General Surgery

Question 1

Summarise the managment of an upper GI bleed.

Answer 1

• Admission to hospital
  
  • Careful monitoring
  • Cross match blood (if haemodynamically unstable, likely to require ONeg)
  • FBC, LFTs, U&Es
  • Clotting
• If varicose Souspected, give terlipressin
• Upper GI endoscopy within 24 hours, or immediately after resuscitation (may be performed in theatre with an naesthetist present)
  
  • Varices should be banded or sclerotherapy. If this is not possible, then a Sengaksten-Blakemore Tube (Minnesota Tube) should be inserted.
  • Patients with erosive oesophagitis should receive a PPI IV
  • Mallory-Weiss tear will resolve spontaneously
• Pateitns that cannot be managed endoscopically may require laparoscopic surgery (e.g. for ulcer underfunding)

Question 2

Summarise the indications for surgery (as opposed to endoscopic treatment) with haematemesis?

Answer 2

• Age >60
• Continued bleeding despite endoscopic intervention
• Recurrent bleeding
• Known cardiovascular disease with poor response to hypotension

Question 3

What is a piloidal sinus?

Answer 3

They occur as a result of hair debris creating sinuses in the skin.

They are usually found in the midline in very hairy individuals

Question 4

What is the management for an asymptomatic inguinal hernia?

Answer 4

Routine referral to surgery.

Studies have shown that many patients would eventually become symptomatic and therefore surgery is advised.

Question 5

What type of hernias are common in children?

Answer 5

Congenital inguinal hernia: indirect hernias resulting from a patent processus vaginalis. Should be repaired surgically soon after diagnosis due to high risk of incarceration.

Infantile umbilical hernia: usually self resolving by age 4-5.

Question 6

What is dumping syndrome?

Answer 6

Dumping syndrome is the result of a hyperosmolar load rapidly entering the proximal Jejunum. Osmosis drags water into the lumen, resulting in luminal distension and diarrhoea.

Excessive insulin release also occurs and results in hypoglycaemic symptoms.

Question 7

What is a dieulafoy lesion?

Answer 7

This is caused by a large tortuous arterielle most commonly located in the stomach wall - these can rupture and bleed.

Question 8

What is Boas’ sign?

Answer 8

Boas’ sign is the phenomenon of hyperparaesthesia beneath the scapula with cholecstitis.

This is due to abdominal wall innervation from the spinal root that lies at this level.

Question 9

What tumour marker is raised in hepatocellular carcinoma?

Answer 9

Alfa feto protein, AFP.

Question 10

What is the annual risk of strangulation with inguinal hernias?

Answer 10

< 5%.

Question 11

Which mAb is anti-VEGF?

Answer 11

Bevacizumab. It is used in colorectal cancer, as well as renal cancers and glioblastoma.

Question 12

Talk yourself through the interpretation of hepatitis B serology.

Answer 12

Hep B surface antibody is what provides immunity.

Hep B core antibody is what shows exposure to the actual virus.

Hep B surface antigen means there is virus in the bloods with potential infectivity.

Question 13

What do the classes of haemorrhagic shock indicate?

Answer 13

Class I:

• <15% blood loss.
• Pulse < 100
• BP normal
• UO normal

Class II: (pt feels anxious)

• 15-30% blood loss.
• Pulse > 100
• BP normal
• UO 20-30 mL

Class III:

• 30-40% blood loss
• Pulse >120
• BP Decreased
• Urine output 5-15 mL/hr

Class IV:

• >40% blood loss
• Pulse >140
• BP Decreased
• Urine output neglegible

Question 14

What is an abdominal wall haematoma?

Answer 14

Abdominal wall/rectus sheath haematoma can occur following trauma, either directly to the abdominal wall or iatrogenic trauma from surgery, or can be spontaneous following excessive strainign of the rectus muscle.

It is more common in people on anticoagulation.

Question 15

What does this AXR show?

Answer 15

It shows small bowel obstruction (valvulae conniventes) as well as a perforation (Rigler’s sign - you can see the bowel wall on both sides of the lumen).

Question 16

What type of transplant would a twin donating a kidney to their other twin be?

Answer 16

Isograft.

Question 17

What is the likely cause of recurrent UTIs and bubbly urine?

Answer 17

An enterovesical fistula. This can frequently be due to a colorectal malignancy.

Question 18

What anatomical landmark demarcates upper from lower GI?

Answer 18

The ligament of Treitz.

It is found at the duodenojejunal flexure. It marks the boundary between the first and second parts of the small intestine and is the formal boundary between the upper and lower GI tracts.

Question 19

What are pilar cysts?

Answer 19

Pilar cysts are epidermoid cysts with the outer lining being a sheath of a hair follicle.

Question 20

What are dermatofibromas?

Answer 20

These are solitary dermal nodules that usually affect the extremities of young adults.

Lesions characteristically are larger than they appear and histologically consist of proliferating fibroblasts merging with sparsely cellular dermal tissues.

Frequently appear at sites of previous trauma.

Question 21

Which blood vessel is often responsible for bleeding that occurs together with a posterior duodenal ulcer?

Answer 21

Posteriorly sited duodenal ulcer are most likely to cause major upper GI haemorrhage and the offending artery is the gastroduodenal artery as it travels behind the second part of the duodenum.

Question 22

What scoring system is used to assess the severity of upper GI bleeds?

Answer 22

The Blatchford Score. It looks at the patients sex,. Hb, blood urea nitrogen level and systolic BP.

In addition, it considers the presence of malaria and syncope and past history of liver disease or cardiac failure.

Score of 0 indicates the patient can be managed as an outpatient, and the higher the score the grater the chances for intervention are.

Question 23

What are differentials for liver abscesses?

Answer 23

Cycstic liver lesions have many potential underlying causes.

• Simple cysts
• Cancers (cystic lhepatocellular carcinoma or metastases)
• Amoebic abscesses
• Hydatic cysts (caused by echinococcus)
• Pyogenic abscesses
• Fungal microabscesses

Question 24

What is the best investigation for a liver cyst?

Answer 24

CT scan is indicated whenever a hydratisier cyst is suspected - they should never be drained due to the risk of anaphylactic reactions.

If a cancer is likely, tumour markers are a useful investigation as well.

Question 25

What is flail chest injury?

Answer 25

A flail chest is when there are ≥2 rib fractures in more than 2 ribs. **Chest movements are irregular**. Associated with **pulmonary contusion**.

Question 26

What does this image of a barium swallow show? What symptoms does this patient likely suffer from?

Answer 26

A hiatus hernia. This is when part of the stomach herniates above the diaphragm. * Sliding: 95% of hiatus hernias. The gastro-oesophageal junction moves above the diaphragm * Rolling: Gastro-oesophageal junction remains below the diaphragm, but a seperate part of the stomach herniates through the oesophageal hiatus. Symptoms include persistent heartburn.

Question 27

Summarise when surgery is indicated for splenic trauma.

Answer 27

Conservative: * Recommended for **small subcapsular haematoma** with **minimal intra abdominal blood** and **no hilar disruption** Laparotomy with conservation: * Indicated if there are increased amounds of intra-abdominal blood with moderate haemodynamic compromise. Overall tears/lacerations affect \<50% Resection: * Indicated if there are **hilar injuries** or **major haemorrhage** or **major associated injuries**

Question 28

What type of analgesic drugs should be avoided in patients with renal transplants?

Answer 28

NSAIDs. As they interfere with prostaglandin synthesis, which is key in regulating renal blood flow*.* Morphine is generally safe to give, but it is partially metabolised in the kidneys and should therefore be given at reduced doses.

Question 29

What ist the most sensitive blood test for diagnosis of acute pancreatitis?

Answer 29

Lipase.

Question 30

What are the most common benign tumour of the liver?

Answer 30

Haemagioma. They are present in ~8% of patients on autopsy. Clinically, they appear as **reddish purple hypervascular lesions**, and they are usually **sepereated from normal liver by fibrous tissue**.

Question 31

What are the USS features of a haemangioma?

Answer 31

Hyperechoic lesions in the liver on USS.

Question 32

What is the investigation of choice for assessing potential leaks after bladder surgery?

Answer 32

**Cystogram**. A cystogram involves passing radiopaque dye into the bladder, then performing radiographs to assess the course of the bladder contents. This provides evidence of whether there is any radiopaque fluid that has escaped the bladder and is free in the abdominal cavity.

Question 33

What is spondylolisthesis?

Answer 33

Spondylolisthesis is the displacement of one verterbae compared to another.

Question 34

Which nerve can be damaged during total hip replacement? How can you test for damage to this nerve?

Answer 34

The sciatic nerve. This manifests as inability to dorsiflex (via common peroneal/fibular nerve) and plantarflex (tibial nerve).

Question 35

What does this abdominal radiograph show?

Answer 35

Small bowel obstruction.

Question 36

What is the diagnosis of choice to characterise the course of fistulas, e.g. an anal fistula in Crohn's disease?

Answer 36

MRI.

Question 37

# Define hernia. What are risk factors for abdominal wall hernias?

Answer 37

Definition: The classical surgical definition of a hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it. Risk factors for abdominal wall hernia: * Obesity * Ascites * Increasing age * Surgical wounds

Question 38

What is Boedhaave Syndrome? Summarise main symptoms, diagnosis and management.

Answer 38

* **Spontaneous ruptue of the oesophagus** * Usually due to **episodes of repeated vomiting** * **Severe chest pain, epigastric pain** * Diagnosis **CT and contrast studies** * Mx: Urgent surgery.

Question 39

What is the most appropriate **initial** scan to assess for the presence of of free fluid in the abdomen and thorax?

Answer 39

**FAST scans** (USS) can be used to assess the presence of fluid in the abdomen and thorax, e.g. in trauma patients.

Question 40

Which form of oesophageal cancer is more comon in patients with achalasia?

Answer 40

Squamous cell carcinoma. It presents with wosening dysphagia on top of a diagnosis of achalasia.

Question 41

Which electrolyte is used in the severity scoring of acute pancreatitis?

Answer 41

Calcium. **Hypocalcaemia** is indicative of severe disease.

Question 42

What are complications of total parenteral nutrition?

Answer 42

* Thrombophlebitis * **Hepatic dysfunction** (abnormal LFTs) * Sepsis (related to continuous IV often via central line) * Re-feeding syndrome

Question 43

Summarise the pharmacological/surgical treatment of anal fissures.

Answer 43

First line: * Relaxation of the sphincter with topical therapies. * **Diltiazem** or **GTN** for 6 weeks (both topical) Second Line: * **Botox injection** Third line: * The most efficient and definitive treatment is **sphincterotomy**. (30% left with flatus incontinence)

Question 44

What is a Richter's Hernia? How does it present?

Answer 44

A Richter's Hernia is when the antimesenteric wall of the intestine protrudes through a defect in the abdominal wall. Only 1 intestinal wall protrudes through the defect, such that the lumen of the intestine is incompletely contained in the defect. Presentation: * Absence of symptoms of obstruction even in the presence of strangulation, as the bowel lumen is patent * Acidosis (metabolic acidosis) and raised lactate * Overlying skin may show signs of necrosis/ischaemia

Question 45

What is Beck's Triad?

Answer 45

Beck's Triad suggests the presence of cardiac tamponade: * Hypotension * Muffled/quiet heart sounds * Raised JVP

Question 46

Other than appendicitis, which other condition can cause RIF pain in young males?

Answer 46

In young men the two most common causes of lower abdominal pain are **appendicitis** and **testicular problems** (infection and torsion). Therefore it is **imperative to examine the testes** to ensure you do not miss a source of referred pain.

Question 48

What is the name of the classification used for the severity of diverticulitis?

Answer 48

Hinchey classification

Question 49

Define cyst. (and pseudocyst whilst we are at it)

Answer 49

Cysts are abnormal sac collection of fluid, gas or semi-solid material that is **completely enclosed in epitheliall lining**. Psudoysts are like cysts, but **lack the epithelial lining**.

Question 50

# Define abscess. What is the usual treatment of abscesses?

Answer 50

An abscess is a **localised collection of pus** and **necrotic** **tissue** anywhere in the body, surrounded and walled of by **damaged and inflammed tissues**. Standard treatment is incision and drainage, often left open afterwards to prevent reaccumulation.