General surgery Flashcards
CEA is a tumour marker associated with which cancer?
Colorectal
CA125 is associated with…
Ovarian cancer
CA19-9 is associated with…
Pancreatic cancer
CA15-3 is associated with…
Breast cancer
Alpha-feto protein (AFP) is associated with…
Hepatocellular cancer
Teratoma
Gallstones are generally composed of…
Phospholipids
Cholesterol
Bile pigments
Risk factors for gallstones
Female OCP, pregnancy increased age High fat diet and obesity Racial e.g. American Indian tribes Loss of terminal ileum (due to reduced bile salts)
Complications of gallstones
In the gallbladder: Cholecystitis Chronic cholecystitus Biliary colic Mucocele Carcinoma
In the CBD:
Cholangitis
Pancreatitis
Obstructive jaundice
In the gut: gallstone ileus
Presentation of biliary colic
RUQ pain radiating to back N/V Sweating Pallor Precipitated by fatty food and last less than 6 hours Possible jaundice is stone is in the CBD
Presentation of cholecystitis
Severe RUQ. Continuous and radiating to the right scapular and epigastrium Fever Vomiting Possible jaundice Murphy's sign
Presentation of cholecystitis
Severe RUQ. Continuous and radiating to the right scapular and epigastrium Fever Vomiting Possible jaundice Murphy's sign
Thumb printing of the small bowel is seen in
Crohn disease Ulcerative colitis Infection (i.e. pseudomembranous colitis) Ischaemic bowel Diverticulitis Mucosal/submucosal haemorrhage 2 Lymphoma Amyloid
TNM staging of oesophageal tumours
Tumour
T1- the tumour is confined to the submucosa
T2- the tumour has grown into (but not through) the muscularis propria
T3- the tumour has grown into (but not through) the serosa
T4- the tumour has penetrated through the serosa and the peritoneal surface. If extending directly into other nearby structures (such as other parts of the bowel or other organs/body structures) it is classified as T4a. If there is perforation of the bowel, it is classified as T4b.
Nodes
N0- no lymph nodes contain tumour cells
N1- there are tumour cells in up to 3 regional lymph nodes
N2- there are tumour cells in 4 or more regional lymph nodes
Metastases
M0- no metastasis to distant organs
M1- metastasis to distant organs
Management of anal fissure
Management of an acute anal fissure (< 6 weeks)
dietary advice: high-fibre diet with high fluid intake
bulk-forming laxatives are first line - if not tolerated then lactulose should be tried
lubricants such as petroleum jelly may be tried before defecation
topical anaesthetics
-analgesia
topical steroids do not provide significant relief
Management of a chronic anal fissure (> 6 weeks)
the above techniques should be continued
topical glyceryl trinitrate (GTN) is first line treatment for a chronic anal fissure
if topical GTN is not effective after 8 weeks then secondary referral should be considered for surgery or botulinum toxin
Risk factors for pancreatitis
SINED
Smoking Inflammation (e.g. chronic pancreatitis) Nutrition: high fat diet Ethanol Diabetes Mellitus
Causes of acute pancreatitis
I GET SMASHED
Idiopathic Gallstones Ethanol Trauma Steroids Mumps and other infections (e.g. Coxsackie virus) Autoimmune: e.g. PAN Scorpion bite Hyperlipidaemia/hypercalciaemia ERCP Drugs: thiazides, azathioprine
Causes of chronic pancreatitis
AGITS
Alcohol (70%)
Genetic: CF, HH
Immune: lymphoplasmacytic sclerosing pancreatitis
Triglycerides: high levels
Structural: Obstruction by tumour, pancreas divisum
Presentation of chronic cholecystitis
Flatulant dyspepsia. So you get: Bloating and distension Vague upper abdominal discomfort Nausea Flatulence and burping Symptoms exacerbated by fatty foods
Causes of obstructive jaundice
Stones
Cancer of head of the pancreas
Other:
LNs at porta hepatis: TB, Ca
Inflammatory: PBC, PSC
Drugs: OCP, sulfonylureas, flucloxacillin
Neoplastic: Cholangiocarcinoma
Mirizzi’s syndrome: gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the common bile duct (CBD) or common hepatic duct.
Courvoiser’s law
In the presence of a painless obstructive jaundice, a palpable gallbladder is unlikely to be due to stones
Presentation of pancreatic Ca
Male of 60
Painless obstructive jaundice
Epigastric pain radiating to back relieved by sitting forward
Weight loss, reduced appetite, malabsoprtion
Acute pancreatitis
Sudden onset DM in the elderly
Usual pathology of pancreatic cancers
Ductal adenocarcinomas (in head of the pancreas)
Definition of a hernia
Protrusion of a viscus or part of a viscus through the walls of its containing cavity into an abnormal position
Cause of bowel obstruction
Non-mechanical (paralytic ileus) Post op Inflammation e.g. peritonitis, pancratitis Drugs: Anti-MAch Mesenteric ischaemia Metabolic: low K, Na, Mg or uraemia
Mechanical Intra luminal:
Impacted matter e.g. faeces, worms
Intussusception
Gallstones
Mechanical intramural:
Benign stricture e.g. due to IBD, surgery, ischaemic colitis, diverticulitis, radiotherapy
Neoplasia
Congenital atresia
Mechanical extramural : Hernia Adhesions Volvulus (usually sigmoid) Extrinsic compression e.g. tumour, pseudocyst, abscess, haematoma
Definition of a diverticulum
Outpouching of tubular structure
Dukes staging of colorectal cancer
A: Confined to the bowel wall
B: Through the bowel wall but no LNs
C: Regional LNs
D: Distant lymph nodes
TNM staging of colorectal cancer
Tis: carcinoma in situ
T1: Tumour has invaded the submucosa
T2: tumour has invaded the muscularis propria
T3: Tumour has invaded the subserosa
T4: Tumour has invaded through the serosa to the adjacent organs
N1: 1-3 nodes
N2: 4 or more nodes
M0
M1
What is a Hartman’s procedure
A proctosigmoidectomy or Hartmann’s procedure is the surgical resection of the rectosigmoid colon with closure of the anorectal stump and formation of an end colostomy.
Features of familial adenomatous polyposis
Autosomal dominant inheritance
APC gene on 5q21
Affected individuals have 100-1000s of adenomas by age 16
100% develop CRC by age 40
May also have hypertrophy of the retinal pigment epithelium
Features of Peutz-Jegher’s syndrome
Autosomal dominant inheritance
STK11 mutation
Present at 10-15 years
Mucocutaneous hyperpigmentation appearing as macules on palms and buccal mucosa
Multiple GI harmartomatous polyps. Can cause intussusception and haemorrhage
Increased cancer risk: CRC, pancreas, breast, lung, ovarian, uterus
Management of familial adenomatous polyposis
Prophylactic colectomy by age 20:
Colectomy with ileorectal anastamosis: requires life long stump surveillance.
Proctocolectomy plus ileal pouch anal anastamosis: still requires surveillance for gastric and duodenal Ca (endoscopy)
Features of hereditary non-polyposis colorectal cancer
Autosomal dominant
Most common inherited CRC
Mutation of mismatch repair gene
Presentation of mesenteric ischaemia
Nearly always small bowel Triad of: Acute severe abdominal pain with/wo PR bleed Rapid hypovolaemia leading to shock No abdominal signs
Possible AF
Degree of illness is greater than the clinical signs
Gasless abdomen on AXR
Thumprinting on AXR
Raised Hb, amylase, WCC and lactate
Management of mesenteric ischaemia
Fluids Abx: Cef and met NBM LMWH Laparotomy to resect necrotic bowel
Boundaries of the inguinal ligament
The anterior wall is formed by the aponeurosis of the external oblique, and reinforced by the internal oblique muscle laterally.
The posterior wall is formed by the transversalis fascia.
The roof is formed by the transversalis fascia, internal oblique and transversus abdominis.
The floor is formed by the inguinal ligament (a ‘rolled up’ portion of the external oblique aponeurosis) and thickened medially by the lacunar ligament.
Difference between indirect and direct inguinal hernia
Indirect: The peritoneal sac enters the inguinal canal via the deep inguinal ring. Degree to which it herniates depends on the amount of processus vaginalis still present. Sac will have the same 3 coverings as the canal. It enters the canal lateral to the epigastric vessels. Patients usually younger.
Direct: Due to weakening of the abdominal muscles. The periotoneal sac bulges into the canal via the posterior wall (formed by the transversalis fascia) through Hesselbach’s triangle. The sac enters the inguinal canal medial to epigastric vessels.
Boundaries of Hesselbach’s triangle
Medial border: Lateral margin of the rectus sheath, also called linea semilunaris
Superolateral border: Inferior epigastric vessels
Inferior border: Inguinal ligament, sometimes referred to as Poupart’s ligament
Mnemonic RIP (Rectus sheath (lateral border), Inferior epigastric artery, Poupart’s ligament (inguinal ligament)).
Complications of inguinal hernias
Early: Haematoma formation Intraabdominal injury Infection Urinary retention
Late
Recurrence
Ischaemic orchitis
Chronic groin pain
Presentation of femoral hernia
Painless groin lump inferior and lateral to the pubic tubercle
Cough impulse
Often irreducible due to tight borders
Commonly present with obstruction/strangulation:
Tender, red, hot
Abdo pain, distension, vomiting, constipation
50% strangulate within 1 month (urgent surgery)
Diverticulae are most commonly found in which part of the bowel
Sigmoid colon
Important complications following thyroid surgery
Anatomical such as recurrent laryngeal nerve damage.
Bleeding. Owing to the confined space haematoma’s may rapidly lead to respiratory compromise owing to laryngeal oedema.
Damage to the parathyroid glands resulting in hypocalcaemia.
Signs of a basal skull fracture
Battle’s sign – bruising of the mastoid process of the temporal bone.
Raccoon eyes – bruising around the eyes, i.e. “black eyes”
Cerebrospinal fluid rhinorrhea.
Cranial nerve palsy.
Bleeding (sometimes profuse) from the nose and ears.
Hemotympanum.
Conductive or perceptive deafness, nystagmus, vomitus.
Describe the modified Glasgow score (pancreatitis severity)
The Modified Glasgow Score is calculated to predict the severity of pancreatitis. Three or more of the following factors identified within 48 hours of onset indicates severe pancreatitis.
Pa02 <8kPa Age >55 years Neutrophilia WBC >15x10^9 Calcium <2mmol/L Renal function Urea >16mmol/L Enzymes LDH >600 ; AST >200 Albumin <32g/L Sugar Blood glucose >10mmol/L
What is Rovsing’s sign?
Rovsing’s sign is positive if palpation of the left lower quadrant of the abdomen increases the pain felt in the right lower quadrant.
This may be an indicator of appendicitis, although it is not positive in all cases.
Colorectal cancer:
Who should undergo foecal occult blood testing
NHS now has a national screening programme offering screening every 2 years to all men and women aged 60 to 74 years. Patients aged over 74 years may request screening.
In addition FOBT should be offered to:
patients >= 50 years with unexplained abdominal pain OR weight loss
patients < 60 years with changes in their bowel habit OR iron deficiency anaemia
patients >= 60 years who have anaemia even in the absence of iron deficiency
Grading system for internal haemorrhoids
Grade I Do not prolapse out of the anal canal
Grade II Prolapse on defecation but reduce spontaneously
Grade III Can be manually reduced
Grade IV Cannot be reduced
What is the pectinate line
The pectinate line (dentate line) is a line which divides the upper two thirds and lower third of the anal canal. Developmentally, this line represents the hindgut-proctodeum junction.
Haemorrhoids above are internal, below are external.
Lymph drainage: above is internal iliac lymph nodes, below is superficial inguinal lymph nodes.
Arteries: above is superior rectal artery, below is middle and inferior rectal arteries
Borders of the anterior triangle of the neck
Superior: inferior border of the mandible
Lateral: Sternocleidomastoid
Medial: Imaginary sagittal line down midline of the body
Causes of lumps in the anterior triangle of the neck
Pulsatile
Carotid artery aneurism
Tortuous carotid artery
Carotid body tumour
Non-pulsatile Goitre Branchial cysts Laryngocele Parotid tumour (lump in postero-superior area)
Borders of the carotid triangle of the neck
Superior: posterior belly of the digastric muscle
Lateral: Medial border of the sternocleidomastoid muscle
Inferior: Superior belly of the omohyoid muscle
Main contents of the carotid triangle of the neck
Common carotid artery (and its bifurcation)
Internal jugular vein
Hypoglossal nerve
Vagus nerve
Borders of the submandibular triangle
Superiorly: Body of the mandible.
Anteriorly: Anterior belly of the digastric muscle.
Posteriorly: Posterior belly of the digastric muscle.
Contents of the submandibular triangle
Salivary gland
Lymph nodes
Facial artery
Facial vein
Causes of lumps in the submandibular triangle
Salivary stone
Sialadenitis
Salivary tumour
Borders of the posterior triangle of the neck
Anterior: Posterior border of the sternocleidomastoid
Posterior: Anterior border of the trapezius muscle.
Inferior: Middle 1/3 of the clavicle.
Contents of the posterior triangle of the neck
External jugular vein (within the posterior triangle it empties into the subclavian vein.
The distal part of the subclavian artery
Accessory nerve
The cervical plexus forms within the muscles of the floor of the posterior triangle (it forms the phrenic nerve)
The trunks of the brachial plexus cross the floor of the posterior triangle
Causes of lumps in the posterior triangle
Cervical ribs LNs Pharyngeal pouch Cystic hygromas Pancoast's tumour
Causes of midline lumps
<20yrs
Thyroglossal cyst
Dermoid cyst
> 20yrs
Thyroid isthmus mass
Ectopic thyroid tissue
A cystic hygroma is…
Usually congenital Multiloculated lesion Contains lymph Benign but disfiguring Usually occurs in left posterior triangle of neck and armpits
Presentation of branchial cysts
Usually present before 20yrs
Lump along the anterior border of the sternocleidomastoid (junction of middle and upper third)
Can become infected and form an abscess
May be associated with a branchial fistula (may discharge mucus)
Lining and content of a branchial cyst
Squamous epithelium
Granular and keratinaceous cellular debris. Cholesterol crystals may be found in the fluid extracted from a branchial cyst.
Presentation of carotid body tumour
Located at carotid body bifurcation
Just anterior to upper 3rd if sternocleidomastoid
Pulsatile
Moves laterally but not vetically
Pressure may cause dizziness and syncope
Most are benign
Doppler or angiogram will show splaying of the carotid artery bifurcation
Treatment of carotid body tumour
Complete surgical removal
What is a laryngocele
Lump in the anterior triangle of the neck
Cystic dilation of the laryngeal saccule
Cogenital usually but can be acquired e.g. glassblowers
Exacerbated by blowing
Presentation of a laryngocele
Lump in the anterior triangle of the neck
Symptoms vary accordingly to the size and extension of the lesion, and may include: sore throat, dysphagia, stridor, neck lump, and/or airway obstruction.
Presentation of dermoid cyst
Common <20yrs
Found at junctions of embryological fusion e.g. neck midline and under tongue
Contains ectodermal elements e.g. hair follicles and sebaceous glands
Contents of dermoid cyst
Contains ectodermal elements e.g. hair follicles and sebaceous glands
What is a dermoid cyst
A developmental inclusion of epidermis along lines of skin fusion
What is a thyroglossal cyst
Cyst formed from persistant thyroglossal duct
Presentation of thyroglossal cyst
Located anywhere from foramen caecum and the thyroid.
Usually found just inferior to the hyoid or just above the hyoid
Fluctuant lump (sign it contains fluid)
Moves up and down with tongue protrusion
Usually asymptomatic but can cause dysphagia or pain.
Can become infected and form a fistula
Treatment of thyroglossal cyst
Surgical excision of the cyst and the thyroglossal duct.,
Presentation of cervical ribs
Mostly asymptomatic
Hard swelling
Reduced radial pulse on abduction and external rotation of arm
Vascular symptoms: Compress subclavian artery causing:
Raynaud’s
Venous outflow obstruction leading to oedema
Neuro symptoms: compress lower trunk of brachial plexus, or T1 nerve root causing:
Wasting of intrinsic hand muscles
Parasthesia along medial border of the arm
Presentation of pharygeal pouch
Swelling of left side of the neck Regurgitation and aspiration Halitosis Gargling sounds Food debris causes pouch expansion which causes oesophageal compression which in turn causes dysphagia
Birds beak appearance on barium swallow
Treatment of pharyngeal pouch
Excision and cricopharyngeal myotomy
Endoscopic stapling
Presentation of cystic hygroma
Infants
Lower part of posterior triangle but may extend to axilla
Increases in size when the child coughs or cries
Transilluminates brilliantly
Key features to mention when describing cervical lymphadenopathy
Consistency Number Fixation Symmetry Tenderness
Features to assess in a neck lumo
Size – width / height / depth
Location – can help narrow the differential – anterior triangle / posterior triangle / mid-line
Shape – well defined?
Consistency – smooth / rubbery / hard / nodular / irregular
Fluctuance – if fluctuant, this suggests it is a fluid filled lesion – cyst
Trans-illumination – suggests mass is fluid filled – e.g. cystic hygroma
Pulsatility – suggests vascular origin – e.g. carotid body tumour / aneurysm
Temperature – increased warmth may suggest inflammatory / infective cause
Overlying skin changes – erythema / ulceration / punctum
Relation to underlying / overlying tissue – tethering / mobility (ask to turn head)
Auscultation – to assess for bruits – e.g. carotid aneurysm
Causes of cervical lymphadenopathy
LIST
Lymphoma and leukaemia
Infection
Sarcoidosis
Tumours
Infective causes of cervical lymphadenopathy
Bacterial:
TB
Tonsillitis, dental abscess
Bartonella henselae (cat scratch disease)
Viral:
EBV
HIV
Protazoal:
Toxoplasmosis (HIV related)
Causes of thyroid goitre (separate diffuse, multinodular and solitary nodule)
Diffuse:
Simple colloid goitre: endemic (iodine deficiency)
Simple colloid goitre: Sporadic: autoimmune, hereditary, goitrogens (e.g. sulphonylureas, lithium)
Graves
Thyroiditis: Hashimoto’s, De Quervain’s Subacute lymphocytic (e.g. post-partum)
Multinodular with nodules too small to feel
Multinodular
Multinodular colloid goitre (commonest)
Multiple cysts
Multiple adenomas
Solitary Nodule: Dominant nodule in multinodular goitre Adenoma (hot or cold) Cyst Malignancy
Common cause of De Quervain’s thyroiditis
Coxsackie virus
Most common thyroid malignancy type
Papillary
