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General Surgery Flashcards

Includes: Acute abdomen Rectal/anal pathologies

1
Q

There are surgical and medical causes of constipation.

Broadly, what are the different groups of causes of constipation?

A
  1. GENERAL- low fibre, poor fluid intake, immobility, elderly, environment, post-op
  2. ANORECTAL DISEASE - fissures, abscess, stricture, HSV, prolapse etc
  3. INTESTIONAL OBSTRUCTION - CRC, strictures, foetus, faeces, fibroids, diverticulois, peudo. LI vs SI
  4. METABOLIC/ENDOCRINE - hypercalcaemia, hypokalaemia, hypothyroid, porphyria
  5. DRUGs - opiates*, abx, anti-cholingergic, iron, antacids, chronic laxatives etc
  6. NEUROMUSCULAR - spinal/pelvic injury, hrichsprungs, systemic sclerosis, diabetes
  7. OTHER - idiopathic slow transit
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2
Q

Constipation + Rectal bleeding = ? A
Constipation + mennorhagia = ? B
Constipation + distention = ? C

A 
A = CRC
B = hypothyroid
C = obstruction
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3
Q

Name the 3 cardinal signs of intestional obstruction

A

Abdo distention
Constipation
Vomitting

+/- Abdo pain
+/- No flatus

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4
Q

In what circumstances would you do further investigations for constipation?

Which investigations would you do after performing PR?

A

> 40yrs, change in bowel habit, weight loss. PR mucus or blood, tenesmus.

BLOODS: FBC, U&Es, ESR, Ca, TFTs
IMAGING: AXR + erect-CXR, Colonoscopy

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5
Q

To treat simple constipation:

Laxatives –> Suppositories –> Enema
(step-up after 3 days if no response + repeat PR)

List the types of laxatives and examples

A

Softener: Lactulose: 15-30ml BD. Docusate

Stimulant: Senna

Mixed: Movicol = Laxido - 1 sachet in 125mls
Co-danthramer (turns urine red)

Bulk-forming: Fybogel

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6
Q

A pt who has trialed laxatives for 3 days and hasnt opened bowels should have repeat PR then step-up to ______

A

Glycerol suppositories

Next step-up:
Phosphate enemas
…

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7
Q

Urinary retention can cause constipation.

True or False

A

False

Constipation can cause urinary retention

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8
Q

Hiatus hernias = protrusion of stomach into chest cavity via oesophageal opening.

Who does it tend to affect?

Name the 2 types

A

30% >50yrs
Obese women

  • Sliding (80%) = GOJ slides into chest - GORD
  • Rolling = GOJ remains in abdo but buldge of stomach herniates into chest. Less GORD
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9
Q

Hiatus hernias are diagnosed by _______ _______ (50% asymptomatic)

Which type requires surgery?

What is the conservative/medical mx?

A

BARIUM SWALLOW

Rolling - risk of strangulation

Conservative and medical mx: same as GORD

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10
Q

Oesophageal cancer is uncommon. What are the 2 types?

Which one has a preceeding Barrett’s oesophagus?

A
  • Adenocarcinoma - Barrett’s (long-term GORD changes)

- Squamous cell carcinoma

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11
Q

List the risk factors for squamous cell carcinoma of oesophagus.

Often upper/middle oesophagus

A 
Male
Black
Smoking
Alcohol
Coeliac
Thermal injury
Achlasia
HPV
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12
Q

A 67 y/o comes to you with DYSPHAGIA, WEIGHT LOSS, ANOREXIA, PERSISTENT GORD.

What is the most likely diagnosis?

Investigations?

A

Oesophageal cancer

Bloods: FBC
Imaging: OGD + biopsy, CT

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13
Q

Peptic ulcers can be acute or chronic.

The most common site is ________

The 2 top causes are: _____ and _____

A

Duodenal

H.pylori - 90%
NSAIDs

Other (gastric) -
Duodenal-gastro reflux, hyperacidity, smoking/alcohol, stress

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14
Q

Peptic ulcers often present with: _________

If < 55yrs –> Test ___
If >55yrs + new dyspepsia or ALARM symptoms –. Do _____

A

Epigastric/LUQ pain +/- radiation to back
Dyspepsia
GORD-like

H.pylori - stool antigen test

Urgent OGD

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15
Q

The ALARM Symptoms are…..

A 
Anaemia
Loss of weight
Anorexia
Recent onset
Malaena/haematemesis
Swallowing difficulty
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16
Q

Peptic ulcers are treated with __________

The complications are perforation - upper GI bleed, peritonitis, gastric adenocarcinoma (H.pylori)

A

Triple therapy:
Amoxicillin
Metronidazole OR Clarithromycin
PPI

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17
Q

The 3 top causes of acute pancreatitis are ____?

A
  1. Alcohol
  2. Gall stones
  3. Idiopathic
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18
Q

Acute pancreatitis presents with _________.

A

Acute epigastric pain +/- radiation to the back - better sitting forward
Vomitting +++
Fever

Signs:
OBS: tachycardia, shock
Grey turners/ cullens, (jaundice), tender epigastrium. Peritonitic

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19
Q

How would you manage a pt with acute pancreatitis?

Mx is to support body to recover from this episode.

A

BEDSIDE: NBM, IV fluids, analgesia, NG tube, ABG*, catheter

LABS: Tests based on cause. Standard + Amlyase

IMAGING: USS (stones), CT (complications), If perf: Erect CXR + AXR

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20
Q

[amylase] can predict severity of acute pancreatitis.

True or False/

A

False!

Do Glasgow score (need ABG, U&Es, LFTs to score)

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21
Q

Why is an ABG done in acute pancreatitis?

A

Used to calculate Glasgow score

Complication is ARDS
Also sepsis, shock, aKI, DIC

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22
Q

Perforation of a peptic ulcer / gall bladder / diverticulum / appendix /bowel or ectopic can cause which presentation?

A

Peritonitis

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23
Q

Signs of peritonitis?

A

Lying still
+ve cough test

Rigid abdo men
Pain on superficial palpation
Rebound tenderness
Guarding

Percussion pain

Absent bowel sound

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24
Q

Before a pt goes for an exloratory laparatomy for any peritonitis - what bloods and imaging is needed?

A

BLOODS: FBC, U&Es, LFTs, CRP, Clotting, INR, Group & Save

IMAGING: Erect-CXR, AXR

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25
The 4 most common causes of acute abdomen are...?
Acute appendicitis Acute pancreatitis Acute cholecystitis Bowel obstruction others: acute pyelonephritis, ectopic pregnancy, gastroenteritis, acute urinary retention etc
26
Acute appendicitis is the most common surgical emergency. True or False? The classic presentation is.......
True ``` RIF pain radiating to the umbilicus Fever N/V Anorexia (Constipation, dysuria - inflammed appendix can irritate surroudnign organs) ```
27
Name the signs you could illict in an appendicitis
+ve cough test RIF guarding Rebound tenderness Rovsigns sign = pain in RIF when press in LIF)
28
Appendicitis tends to affect M>F, paeds - 30yrs Complications are a mass, abscess or perforation. How would you manage the pt to try prevent this?
BEDSIDE: NBM, IV fluids, Analgesia, Anti-emetic, Antibiotics LABS: standard - raised WCC, raised CRP + Amylase, Clotting, INR, Group & Save IMAGING - USS
29
Appendicitis tends to affect M>F, paeds - 30yrs Complications are a mass, abscess or perforation. How would you manage the pt to try prevent this?
BEDSIDE: NBM, IV fluids, Analgesia, Anti-emetic, Antibiotics LABS: standard - raised WCC, nuetrophilia, raised CRP + Amylase, Clotting, INR, Group & Save IMAGING - USS
30
20% of surgical admissions are bowel obstruction! The 3 cardinal features are.....?
Abdo distention Vomitting Constipation No flatus, colicky abdo pain, anorexia
31
Causes of bowel obstruction can be intra-luminal, luminal or extra-luminal
Intra-liminal - malignancy, constipation, foreign body Luminal - volvulus, ileus, galls stones, Diveritcular stricture Extra-luminal - Adhesions, Hernias, Trauma
32
The commonest causes of SI obstruction are_____ The commonest causes of LI obstruction are _____________
SI: ADHESIONS, HERNIAS Pres: vomit earlier, less abdo distention, pain high in abdo LI: CONSTIPATION (60%), Malignancy, Volvulus, Diverticular stricture Pres: less vomiting (+/- faeculent), abdo distention, lower abdo pain
33
Anyone with abdo pain needs a PR. Initial mx of bowel obstruction is the same for any surgical pt. How do you manage a SI obstruction?
Riles tube - "Drip & Suck"
34
What signs of bowel obstruction can you see on a AXR & Erect-CXR? What rules for diameter of bowel is used?
AXR: Coffee-bean = sigmoid volvulus Riglers = see both edges of lumin (free gas so perforation) 3, 6, 9cm
35
what are the 5 F's for abdo distention?
``` Fat Flatus Faeces Foetus Fluid ```
36
~15% of the population have gall stones but most are symptomatic with ~20% presenting with symptoms. List the different presentations of gall stones
``` Biliary colic Chronic cholecystitis Acute cholecystitis Acute pancreatitis Acute cholangitis Empyema of GB Gall stone ileus ```
37
Risk factors for gall stones are ________ State the 3 main types of gall stones
"Fair, fat, fourties, female", Diabetes, Hyperlipidaemia, Rapid weight loss, IBD, FH - Cholesterol - Pigmented (haematological D) - Mixed
38
State the diagnoses: 1. Sudden constant epigastric or RUQ pain, radiating to the shoulder. N/V. Spontaneously resolves up to 24hrs later. 2. Vague abdo pain after eating fatty food, bloating, nausea, wind, +/- jaundice 3. RUQ pain + fever + jaundice (can become septic) 4. RUQ or epigastric pain, radiating to the shoulder + fever + vomitting
1. Biliary colic 2. Chronic cholecystitis - USS: thick-walled shrunken GB 3. Acute cholangitis 4. Acute cholecystitis
39
What are signs specific to cholecystitis?
Murphy's sign = pain when palpate GB on inspiration
40
Any obstructive jaundice presents with _________
Dark urine | Pale stools
41
Management of acute cholecystitis is:
BEDSIDE: NBM, IV fluids, Analgesia, Antibiotics (Cef) LABS: FBC, U&Es, LFTs, Amylase, CRP, Clotting, Group & Save IMAGING: USS TREATMENT: ERCP --> Elective cholecystectomy
42
The investigations of choice in biliary pathology is _________
USS | MRCP
43
With all the biliary pathologies with gall stones - eventually all would need an elective cholecystectomy even if had ERCP to move impacted stones. True or False?
True
44
Diverticular disease is common and affected ~ 30% of >60s. Lack of fibre --> high intraluminal pressures --> force muscosa to herniate through weak points It tends to affect ________ Diagnosis if often ___________
Sigmoid colon (95%) Incidental finding on colonoscopy
45
# Define the following terminology in Diverticular disease 1. Diverticulum 2. Diverticulosis 3. Diverticular disease 4. Diverticulitis
1. Diverticulum = outpouching of the bowel at weak points 2. Diverticulosis = presence of diverticulae 3. Diverticular disease = diverticulosis + symptomatic 4. Diverticulitis = inflam of diverticulae
46
Diverticular disease is often asymptomatic but can present with ____________
Left iliac fossa colicky-pain, relieved by defecation Alternating bowel habits Nausea Flatulence Rectal bleeding
47
Management for diverticular disease is:
Conservative: high-fibre diet Medical: antispasmodics - Mebeverine or Buscopan
48
Complications of diverticular disease are rectal bleeding, perforation, inflammation, bowel obstruction. What investigations would indicate divertulitis? How do you manage it?
Raised WCC, Raised CRP + pyrexial Management: BEDSIDE: NBM, IV fluids, analgesia, Antibiotics IMAGING/TREATMENT: CT-guided abscess drainage
49
The 3rd most common cancer in UK is _____ Usually adenocarcinoma Peak: 65-85 years State risk factors
Colorectal Cancer (CRC) >60yrs Lifestyle: smoking, alcohol, low-fibre, red meat Genetics: FH, IBD, FAP, HNPCC
50
List the ways that CRC can present
Symptoms: Rectal bleeding, anorexia, weight loss, change in bowel habit eg constipation, tenesmus Bowel obstruction Bowel perforation Mass on PR Unexplained anaemia Infective endocarditis - Strep. Bovis Mets - RUQ pain, bone pain, SOB Bowel cancer screening - every 2 years for 60-75yrs
51
A 70 y/o is fast-track by his GP after a 1 month hx of rectal bleeding, constipation and weight loss. What investigations should be ordered? Treatment?
LABS: FBC, U&Es, LFTs IMAGING: Colonoscopy or Barium enema --> CT/ PET/MRI, Liver USS Treatment: Surgical resection +/- chemo/RT
52
Rectal prolapse is associated with chronic neurological or psychological disorders. It can be classified into 2 catagories, namely:
Partial / Type 1 = mucosa Complete / Type 2 = all layers (more common)
53
75% with those with rectal prolapse present with _________ What are the signs?
Incontinence Signs: protrusion through anus rectocele = bulge in posterior wall of vagina
54
Management of rectal prolapses is surgical - what approaches can be used?
Abdominal approach - rectopexy +/- mesh Perineal approach - delmorme's procedure
55
Abscesses tend to occur in sweaty areas eg axillae, groin, peri-anal. It is more common in females. 8F>M What are risk factors?
``` Diabetes Crohn's IVDU Insect bite Malignancy ```
56
Abscesses on examination can be organised (hard) or fluctuant (bouncy from pus) What is the management?
If fluctuent: incise and drain under GA If organised: Abx
57
Anal fissure is a painful tear in the squamous epithelium lining the lower anal canal. 90% are posterior What is it associated with? what are the causes?
Haemorrhoids Causes: Hard stools* Rare: Crohn's, trauma, anal cancer, syphilis, herpes
58
What is the management of anal fissures?
CONSERVATIVE: High fibre diet, fluids, exercise, hygiene MEDICAL: Stool softener, Lidocaine + GTN ointment (Surgical)
59
Haemorrhoids aka piles = dirsupted and dilated anal vessels from chronic increased anal tone and straining when passing stool. What are the causes?
* CONSTIPATION with prolonged straining | rare: Pelvic tumour, pregnancy, CHF, portal HTN
60
Wha are the symptoms of: 1. Haemorrhoids 2. Thrombosed haemorrhoids
1. Rectal bleeding - fresh blood when wipe/coat stools/ dripping --> anaemia Painless lump +/- pruritus / mucous discharge 2. Painful lump
61
You perform a protoscopy and sigmoidoscopy to investigate fresh rectal bleeding and you see a haemorrhoid inside the rectum. What degree of haemorrhoid is this? What degree prolapses through anus on defecation and requires digital reduction?
1st degree 3rd degree 2nd degree = prolapse through anus but spontaneously reduces 4th degree = remains persistently prolapsed
62
Conservative mx for haemorhoids is only for 1st degree. What are the concervative and surgical mx?
Consrvative: topical analgesia, stool softener, topical steriods for short periods ``` Surgical: Rubber-band ligation Infrared coagulation Excisional haemorhoidectomy Stapled ```
63
Prolapsed thrombosed haemorrhoids can present acutely. The mx is analgesia, ice-packs and stool softeners. How many weeks can it take for pain to resolve?
2-3 weeks
64
Until proven otherwise "painless jaundice" +/- weight loss, anorexia = ?
Pancreatic carcinoma
65
IBD flare-ups are under Surgery or Gastro team?
Surgery - incase esculation to surgerical mx (closely mx with gastro team)
66
New dyspepsia in >55yrs or dyspepsia + ALARM symptoms could indicate gastric carcinoma. How would you manage them?
Urgent OGD - 2ww (If <55yrs + dyspepsia - think GORD or peptic ulcer so test H.Pylori 1st. Trial PPI for 1 month and if not resolved then OGD)
67
Hernias are a common cause of acute abdomen. ALWAYS EXAMINE IN ANYONE WITH LOWER ABDO-GROIN PAIN OR LUMPS! List the types of hernias.
Hiatus Incisional Umbilical Inguinal - direct vs indirect Femoral
68
Risk factors for incisional hernia are previous open abdo surgery (11-20%) and obesity. 1. What is the cause? 2. How is it managed?
1. Breakdown of muscle closure in abdo wall (often above umbilical area) 2. Urgent mesh repair 50% recurrence if large
69
Umbilical hernias form 10-30% of all hernias. They can be congenital (omphalocele or prematurity) or acquired in adulthood. What are acquired causes?
Women: pregnancy, difficult labour General: ascites, obesity (Enlarges over tume. contains omentum +/- bowel) Treat cause then surgical repair
70
Femoral hernias are uncommon being 1 in 20 hernias. What population does it tend to affect? How is it investigated? Why does it required urgent surgical repair?
Elderly women USS Risk of strangulation
71
State the risk factors for inguinal hernias.
``` 8M>F Chronic cough Heavy lifting Constipationg with straining Urinary obstruction Ascites Past abdo surgery ```
72
Any hernia is examined by inspection, palpation, ausculation. What happens in each step?
Inspection - see visible lump Palpation - ask pt to cough, ask to lean forward. See if reducible when push up to contralateral shoulder or strangulated** Ausculation - hear bowel sound in hernia
73
Which type of inguinal hernia is more common?
INDIRECT (85%) - esp children. Herniation through deep inguinal ring and travels down inguinal canal (often failure of inguinal canal to close properly in utero) DIRECT - esp elderly. Herniation through superficial inguinal ring defect in abdo wall
74
You would differentiate between indirect and direct inguinal hernias on examination by pressing on the hernia, asking pt to cough and seeing where you feel buldge. If bulge directly on hand then = direct If bulge lateral to hand = indirect How are they managed?
If small then reassure If associated with tenderness, irreducible, incarceration --> Lichtenstein repair (mesh) Can recurr!

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