General Surgery Flashcards
Formula for calculating fluid volume for resuscitation after burns?
Volume of fluid = total body surface area of the burn % x weight (Kg) x 4ml
What is the spectrum of gallbladder disease?
- Biliary colic
- Cholecystitis
- Ascending cholangitis
- ?Pancreatitis
What is biliary colic?
Results from transient cystic duct blockage from impacted stones, can have transient ALT rise.
Biliary colic presentation?
RUQ pain, can radiate to shoulder, can come on spontaneously, may be related to fatty food, can last from 15mins to 24 hours.
Biliary colic investigations?
USS is really good at seeing stones, MRCP is next stage and then ERCP can be diagnostic and treatment.
Biliary colic and cholecystitis management?
Manage patient symptoms - pain control.
Abx if needed
Cholecystectomy
Sphincterectomy
Consider biliary stent if stones are irretrievable
Most common cause of rectal bleeding?
Haemorrhoids
Typical causes of rectal bleeding?
Benign:
- Haemorrhoids
- Anal fissures
- Fistulae
Diverticulosis/itis
Colonic polyps
Colorectal/anal cancer
Investigations for rectal bleeding?
Flexible sigmoidoscopy
Colonoscopy
CT colonography
Red flags for colorectal cancer?
Main
- PR bleeding
- Anaemia
- Change in Bowel habit
Others:
- Weight loss
- Abdo discomfort
- Mass
Suspected colorectal cancer investigations?
Colonoscopy with biopsy is gold standard
Would also do FBC and LFT
CT colonoscope
Different surgery available for colorectal cancer, according to location?
Resection, depends on affected region:
- Hemicolectomy (right or left)
- Sigmoid colectomy
- Anterior resection
When is the bowel screening programme offered?
Offered flexible sigmoidoscopy at 55
Home testing kit every 2 years from 60 to 74 years old (and can do after 75 too)
What is the home testing kit of the bowel cancer screening programme looking for?
Occult blood in the sample
Tumour marker for colorectal cancer?
CEA
Q’s for a bowel habit history?
- How are they generally?
- Are you going everyday?
- Are they formed movements?
- Has anything changed?
What is the role of the tunica (processus) vaginalis in men?
Forms a capsule around the testes
In what tissue do hydrocele’s form?
The tunica vaginalis
What are LUTS? Examples?
Lower Urinary Tract Symptoms:
- Frequency
- Dysuria
- Hesitancy
- Urgency
What is urinary hesitancy?
Delay in initial urination.
Types/classifications of haematuria?
Blood can arise from anywhere in the renal tract.
Classed as visible and non-visible
Non-visible further into:
- Symptomatic (LUTS)
- Non-symptomatic
What type of urinary sample is more sensitive to haematuria?
Dipstick of fresh urine (rather than MSU)
Painless haematuria is indicative usually of what?
Bladder cancer
Transient causes of Haematuria?
UTI, Vigorous exercise, menstruation
Renal causes of haematuria? (non-transient)
neoplasia, glomerulonephritis, tubulointerstitial nephritis, PCKD, Papillary necrosis, pyelonephritis, trauma
ExtraRenal causes of haematuria?
Renal stones
infection
neoplasia
trauma (e.g. catheter)
Some drugs e.g. cephalosprins, NSAIDS
What is polycythaemia?
Larger than usual concentration of haemoglobin in the blood.
Increases chance of blood clot formation and can have unpleasant symptoms such as a headache
Normal PSA range for men through their life?
40-50: <2
50-60: <3
60-70: <4
> 70: <5
Role of LH and FSH in men?
LH stimulates testosterone production and FSH testicle enlargement
Anaemia definition?
Low haemoglobin concentration (<135 in Men and <115 in women)
Types of anaemia?
Microcytic (low MCV), normocytic and macrocytic (high MCV)
Haemolytic
Causes of Microcytic anaemia?
Iron deficiency anaemia (most common)
Thalassaemia, Sideroblastic anaemia
Causes of Normocytic anaemia?
Acute blood loss, anaemia of chronic disease
Bone marrow failure, renal failure, Hypothyroidism, Haemolysis, pregnancy
Causes of Macrocytic anaemia?
B12 or folate deficiency
Alcohol excess
Reticulocytosis
Cytotoxics
hypothyroidism
Maximum lidocaine dose?
500 micrograms (if given with Adrenaline)
Appendicitis presentation?
Early periumbilical pain that moves to the RIF, MOVEMENT makes it WORSE
N&V
RIF guarding and rebound tenderness (pain upon removal of pressure - indicative of peritonitis (blumbergs sign))
Causes of acute pancreatitis?
GET SMASHED
Gallstones
Ethanol
Trauma
Steroids Mumps/malignancy Autoimmune Scorpion sting Hypercalcaemia ERCP Drugs e.g. azothioprine
Key features of bowel obstruction?
Vomiting, nausea and anorexia.
Colic, constipation and distension
Can have tinkling bowel sounds
Common causes of palmar erythema?
Primary idiopathic
Pregnant (high oestrogen)
Liver cirrhosis
Rheumatoid arthritis
SLE
Causes of bowel obstruction?
Small Bowel
- Adhesions
- Hernias
- Gallstone ileus
Large bowel
- Colon Cancer
- Diverticular stricture
- Volvulus
Action of warfarin, how long does it take to work?
Antagonises Vit k, takes 2-3 days to take effect.
Difference between Heparin and Warfarin?
Warfarin antagonises vit K. Warfarin needs monitoring of the INR. It is a once daily dose.
Heparin is more fast acting.
Unfractionated heparin (UFH) works very fast and has a short half life. Needs some monitoring
LMWH (e.g. dalteparin), also works fast and does not require monitoring. It works by inactivating factor Xa. It has a longer half life than UFH
What are functional bowel disorders?
Functional bowel disorders are functional gastrointestinal disorders with symptoms attributable to the middle or lower gastrointestinal tract.
These include the IBS, functional bloating, functional constipation, functional diarrhoea, and unspecified functional bowel disorder.
Must have occurred for the first time ≥6 months before the patient presents, and their presence on ≥3 days a month during the last 3 months indicates current activity
Bloods to check in functional bowel disorders?
Calcium, thyroid, coeliac test.
What is an anterior resection?
Resection of an area of rectum, remaining parts are then anastamosed
What is low anterior resection syndrome?
The collection of symptoms resulting from a low anterior resection (or abdominal perineal resection). Symptoms include incontinence obstructed defecation and constipation.
What are haemorrhoids, what are the two types?
Haemorrhoids are abnormally enlarged vascular mucosal cushions (the mucosal cushions are normally present)
Internal haemorrhoids originate above the dentate line and external below
They can prolapse:
- grade 1 is no prolapsing,
- 2 is prolapsing on straining but spontaneously reducing
- 3rd degree prolapse on straining and manually reduce
- 4th degree permanently prolapse and cannot be reduced
What blood test can help to differentiate upper GI bleeding from lower?
Urea - high then upper is likely
Gastritis symptoms?
Epigastric pain
Loss of appetite
Bloating
Retching
Nausea and Vomiting
What are the different types of laxatives?
Bulk laxatives
- Bran
- Ispaghula (fibre)
Osmotic (also increase bulk - but water)
- MgSO4
- Lactulose
Stimulants:
- Senna
- Bisocodyl
- Docusate
- Glycerol
- Suppositories
Faecal softeners
- Docusate
- Arachis oil
What is c diff infection?
Normally after people have taken Abx, normally causing D, N & V. Can range from mild to severe gastroenteritis.
What is a hiatus hernia?
Hernia of the abdominal viscera through the diapragm at the oesophageal level, causing GORD, heartburn and can cause dysphagia.
What is tenesmus typically consistent with?
A rectal prolapse or rectal mass
What are synchronous and metachronous cancers?
Synchronous - two or more cancers occurring at the same time
Metachronous - Two or more cancers occurring one after the other
What is mammary duct ectasia, how does it present, how do you diagnose?
Benign breast condition that mimics invasive carcinoma. Characterised by dilatation of subareola duct dilatation
Presents with:
- Discharge - can be blood stained
- Non-cyclical mastalgia
Diagnose with ultrasound or can do others such as cytology of lavage
Can leave alone, or if persistent do microductectomy
Types of breast cancer?
Cancer from epithelial lining of mammary ducts is DUCTAL
Cancer from epithelial lining of terminal ducts of the lobules (deeper)
Breast cancer risk factors?
COCP
HRT
Never having borne a child/post 30
Not having breast fed
Early menarche and late menopause
Family history and genetic factors
Breast cancer presentation?
Lump - painful or painless
Nipple change
Nipple discharge
Skin contour/changes
Pain alone is a very uncommon presentation
What is hepatic encephalopathy?
A spectrum of neuropsychiatric abnormalities in patients with liver failure. Either covert or overt.
Covert:
- Subclinical encephalopathy, requires psychometric testing.
Includes:
- Personality changes, intellectual impairment and reduced levels of consciousness. Pathogenesis uncertain but may be due to the passage of neurotoxins to the brain.
Causes of post-operative fever?
- Day 1-2: ‘Wind’ - Pneumonia, aspiration, pulmonary embolism
- Day 3-5: ‘Water’ - Urinary tract infection (especially if the patient was catheterised)
- Day 5-7: ‘Wound’ - Infection at the surgical site or abscess formation
- Day 5+: ‘Walking’ - Deep vein thrombosis or pulmonary embolism
- Any time: Drugs, transfusion reactions, sepsis, line contamination.
Becks triad indicating cardiac tamponade?
- Hypotension
- Muffled heart sounds
- Raised JVP
5 W’s causing fever post-operatively?
Wind - Atelectasis, pneumonia
Water - UTI, urosepsis, (remove catheter up to 1 month)
Wound - infection at site - Sterile site, Abx prophylaxis given?
Walking - DVT, Day 5 is most common complication
What we done - ADR
What does the PCT blood test function as?
Blood test specific for sepsis
Antibiotic regime for sepsis?
Amoxicillin
Metronidazole
Gentamicin (if renal function okay)
Normal stoma output?
10mls/kg per day
Pancreatitis presentation?
Tachy, hypotensive, fever, oliguria
Widespread tenderness and guarding
Bruising paraumbilicus - cullers sign
Flank bruising - Grey turners sign
Amylase level in pancreatitis?
> 300
Investigations in pancreatitis?
Amylase (>300)
Lipase - more specific
GCS
Oxygen sats, White cells, glucose
Pancreatitis management?
Analgesia
IV fluids
Catheter
NG tube
ERCP
CVP monitoring - Central venous pressure (assess vol. status
Pancreatitis complications?
Pseudocyst
- Communicating or non-communication w/ pancreatic duct
Pancreatic necrosis
Pancreatic infection
On a CT scan how can you tell if the AAA has ruptured?
If there is blood in retroperitoneum then AAA has ruptured.
Presentation and causes of a bowel perforation?
Presentation depends on anatomical location:
Intraperitoneal presents with crescendo abdo pain, progressing to peritonitis and distension
Retroperitoneal has less symptoms, may be insidious in onset, right shoulder-tip pain, back or RIF pain.
On imaging there will be pneumoperitoneum (air under right diapragm), or riglers sign (air in peritoneum so you can see both sides of the bowel.
Causes:
Infection: Cholecystitis, DIverticulitis, Appendicitis.
Ischaemia: Obstructive lesions e.g. cancer,
Colitis: Fistula formation in Crohns, toxic megacolon
Trauma: iatrogenic, penetrating trauma, excess vomiting.
What is toxic megacolon?
Very dilated colon (megacolon), accompanied by abdominal distension (bloating), and sometimes fever, abdominal pain.
Usually as a complication of Inflammatory bowel disease
What is an incarcerated and what is a strangulated hernia?
Incarcerated hernias are irreducable, they may BECOME strangulated which can lead to ischaemia and bowel obstruction.
What is the ankle brachial pressure index?
Simple method for quantifying the level of arterial occlusion in the leg, do pressure in arm and ankle and if the ratio is below it shows peripheral artery disease, if higher it is likely a calcified artery (>1.3)
Symptom free = 1 or more
Intermittent claudication = 0.95 - 0.5
Rest pain = 0.5 - 0.3
Gangrene and ulceration = <0.2
What type of medication is clopidogrel?
Anti-platelet.
What is spinal stenosis?
Narrowing of the spinal canal often caused by a combination of loss of disc space, osteophytes and a hypertrophic ligamentum flavum (connects spinal vertebrae to each other).
Cholangitis management?
Broad-spectrum intravenous antibiotics and correction of fluid/electrolyte disturbance.
Surgical decompression of the GB may be required.
Endoscopic drainage
Can you do a sphincterotomy for gallstones?
Yes - small gallstones
Three radiological techniques to image the kidneys?
USS
CT KUB (kidneys, ureters and bladder)
CT urogram - less commonly used
What would bleeding from the urethra and perineal ecchymosis (bruising) represent?
Urethral trauma, urethral perforation.
What Neuromuscular junction blockers can you not use if the pt has hyperkalaemia?
Suxamethonium - and other depolarising junction blockers
What are the ASA (anaesthetic) classifications for patients?
1-6
1 is a healthy patient
2 is a patient with mild systemic disease e.g. controlled diabetes, also includes smokers and alcohol drinkers and pregnant women
3 is a patient with severe systemic disease e.g. poorly controlled diabetes, COPD, BMI >40.
4 is a patient with severe disease that is a constant threat to life e.g. recent MI or stroke
5 is a patient who wouldn’t survive without the classification, e.g. Major trauma, ruptured AAA
6 is a brain dead patient (organ donation)
What are the different anaesthetic agents, and other drugs given in anaesthesia, and their characteristics?
Propofol (induction) - IV
- Rapid anaesthesia
- IV injection pain
- Myocardial depression, but only mild,
- Suitable for maintenance
Fentanyl or alfentanyl
Sodium thiopentone (induction) - Really rapid - rapid sequence induction, pretty much only this
Ketamine (induction)
- Not much myocardial depression, so can be used for haemodynamically unstable patients, for induction.
- Also strong effect so can be used outside of hospital for emergency.
Inhaled is generally not used anymore (unless needle phobia)
Most commonly would be sevfluorane
Suxamethonium is the muscle relaxant of choice, not always given though.
If a surgery is unlikely/likely/definitely going to have blood loss what is the guidance regarding pre-operative blood products?
Unlikely
- Group and save
Likely
- Cross-match 2 units
Definitely
- Cross match 4-6
What do you usually use FFP for?
Correcting clotting deficiencies in those with hepatic failure.
What blood product can be ABO incompatible in adults?
Platelets
What is a central line and a PICC line?
Essentially a PICC line is a central line (i.e. internal jugular) but inserted peripherally therefore reducing the risk of infection.
Doses of Local anaesthetics?
Lignocaine (same as lidocaine)
3mg/Kg - without adrenaline
7mg/Kg - with adrenaline
What can cause malignant hyperthermia?
Halothane (inhaled GA)
Suxamethonium (depolarizing)
How would malignant hyperthermia present?
Hyperthermia, hyperrigidity (similar to neuroleptic malignant syndrome)
How do you manage malignant hyperthermia?
Dantrolene (not in neuroleptic though usually)
S/Es of suxamethonium?
Malignant hyperthermia and hyperkalaemia
How would you reverse vecuronium?
Neostigmine
Difference in a feeding jejunostomy and a PEG?
PEG is endoscopically inserted and Feeding jejunostomy is surgically. Obviously in different places too.
Generally favoured fluid types for post-surgical patients?
Hartmanns or Ringers lactate.
Not 0.9% NaCl as it is associated with hyperchloraemic acidosis
What are the 4 Ws in post operative pyrexia, what causes are within them and when would they present?
Wind (lungs)
Wound (infection)
Water (UTI)
Walking (VTE)
Day 1-2: ‘Wind’ - Pneumonia, aspiration, pulmonary embolism
Day 3-5: ‘Water’ - Urinary tract infection (especially if the patient was catheterised)
Day 5-7: ‘Wound’ - Infection at the surgical site or abscess formation
Day 5+: ‘Walking’ - Deep vein thrombosis or pulmonary embolism
Pre op workup for elective surgical patients?
Consider pre admission clinic to address medical issues.
Blood tests including FBC, U+E, LFTs, Clotting, Group and Save
Urine analysis
Pregnancy test
Sickle cell test
ECG/ Chest x-ray
Emergency surgical case pre-op workup? (4)
Stabilise and resuscitate where needed.
Consider whether antibiotics are needed and when and how they should be administered.
Inform blood bank if major procedures planned particularly where coagulopathies are present at the outset or anticipated (e.g. Ruptured AAA repair)
Don’t forget to consent and inform relatives.
What are the three phases of surgery?
1) Before the induction of anaesthesia (sign in)
2) Before the incision of the skin (time out)
3) Before the patient leaves the operating room (sign out).
What are the main stages of wound healing?
Haemostasis
- Minutes to hours
- Clotting and vasospasm
Inflammation
- Days 1-5
- Neutrophils and fibroblasts
Regeneration
- Days 7-56
- Fibroblasts causing collagen matrix
- Angiogenesis
Remodelling
- 6 weeks - a year
- Fibroblasts become myofibroblasts and contract
- Microvessels regress and collagen remodelled leaving a pale scar
What drugs impair wound healing?
Non steroidal anti inflammatory drugs
Steroids
Immunosupressive agents
Anti neoplastic drugs
How long do you need to stop taking the COCP before surgery?
28 days
How do you manage a patient with paralytic ileus?
NG tube and Nil by mouth
Advice for food and water prior to an operation?
No food for 6 hours before the induction of general anaesthesia. Patients should be allowed to drink water or other clear fluids until 2 hours before the induction of general anaesthesia.
6 and 2 rule
What are the airway options in anaesthesia?
LMA or Endotracheal
LMA is preferred, but can’t be at risk of aspiration (e.g. reflux disease, or full stomach)
Endotracheal for when muscle relaxants are required or reflux risk. Relaxants are required for major open abdo surgery.
What do you use to visualise an anastomotic leak?
CT abdo
How long can cannulas stay in?
3 days
