General Surgery Flashcards
What are the signs of appendicitis?
Tender to McBurney’s point
Guarding to RIF
Rosving’s sign (palpation of the LIF causes pain in RIF)
What are some potential DDx of appendicitis?
Ectopic pregnancy
Ovarian cysts
Mittelschmerz syndrome
Meckel’s diverticulitis
Mesenteric adenitis
What is mesenteric adenitis?
Abdominal pain caused by inflamed abdominal lymph nodes
Often associated with cough/cold
No treatment required
What are the signs of an appendix mass?
Signs of appendicitis with palpable mass in RIF
(omentum and/or bowel surround and stick to the inflamed appendix
How should an appendix mass be managed?
Conservatively with supportive treatment and abx
Appendicetomy once acute condition has resolved
What are some of the associated complications of an appendicectomy?
Bleeding Infection Damage to surrounding tissues Removal of normal appendix Anaesthetic risk DVT/PE
Prior to an appendicetomy, what should be given?
Prophylactic IV antibiotics
What are three causes of obstruction?
Adhesions
Malignancy
Hernias
What are symptoms of obstruction?
Abdominal distention and diffuse pain
Absolute constipation and lack of flatulence
Vomiting
How can obstruction be initially managed?
A-E assessment
NBM
IV fluids
NG tube
What investigation should be ordered for a patient with ?obstruction?
AXR
What are the upper limits of normal for parts of the bowel?
3cm small bowel
6cm colon
9cm caecum
What can cause an ileus?
Post abdo surgery Intra-abdominal infection/inflammation Pneumonia Trauma Electrolyte imbalance
What are signs and symptoms of an ileus?
Similar to obstruction Abdominal distension and pain Constipation, no flatulence Sluggish bowel sounds Vomiting
How should an ileus be managed?
NBM NG tube if vomiting Mobilise (stimulate peristalsis) IV fluids Consider parenteral nutrition
In what direction does a sigmoid volvulus twist?
Anti-clockwise
In what direction does a caecal volvulus twist?
Clockwise
What are risk factors for a volvulus formation?
Psychiatric disorders Neurological disorders Nursing home residents Chronic constipation Pelvic masses (inc. pregnancy) Adhesions
What are the complications associated with a volvulus?
Obstruction
ischaemia
Perforation
What sign on AXR is associated with a sigmoid volvulus?
Coffee bean
How can a volvulus be treated?
Endoscopic compression - if sigmoid volvulus
Laparotomy:
Hartmann’s procedure - sigmoid
Right hemicolectomy (caecal)
What is a haemorrhoid?
Vascular cushion that becomes enlarged due to pressure (ie straining during defecation, pregnancy)
How can haemorrhoids be classified?
1st degree: no prolapse
2nd degree: prolapse on straining, return on relaxing
3rd degree: prolapse when straining, does not return on relaxing but can be pushed back
4th degree: prolapsed permanently
What are symptoms of haemorrhoids?
Asymptomatic Constipation Bright red outflow bleeding Sore/itchy anus Feeling a lump around anus
What is a thrombosed haemorrhoid?
Strangulation at the base of the haemorrhoid causing a clot to form
How does a thrombosed haemorrhoid present?
Very painful
Purple, very tender, swollen lump
DRE impossible due to pain
How can haemorrhoids be examined?
External haemorrhoids visible on inspection
Internal haemorrhoids may be hard to feel on DRE
Proctoscopy for proper visualisation and inspection
What are potential Ddx of haemorrhoids?
Fissure
Cancer
IBD
How can haemorrhoids be managed?
Increase fluid and fibre intake
Anusol cream
Laxatives
Band ligation - above dentate line
Surgical haemorrhoidectomy
What complications are associated with diverticulitis?
Haemorrhage Perforation Absces Fistula Ileus/obstruction
Define cholestasis
Blockage to the flow of bile
Define cholelithiasis
Presence of gallstone(s)
Define choledocholithiasis
Gallstone(s) in the bile duct
Define biliary colic
Intermittent RUQ pain caused by gallstones irritating the bile duct
Define cholecystitis
Inflammation of the gallbladder
Define cholangitis
Infection and obstruction of the biliary system
Define gallbladder empyema
Pus in the gallbladder
What limits whether an AUS is able to detect gallstones
Patients weight
Gaseous bowel obstructing the view
Patients discomfort with prone
When is a MRCP indicated in suspected gallstones?
USS doesn’t show ductal stones but there is bile duct dilatation or raised bilirubin
When is an ERCP indicated in ?gallstone?
Established CBD stones
Other than established CBD stones, what are the other indications for ERCP?
Obstructing ductal tumours on USS or MRCP
Treatment of CBD stones
Stricture dilitation
Biopsy of malignant areas
What are the USS findings that are consistent with acute cholecystitis?
Thickened gallbladder wall
Stones/sludge in gallbladder
Fluid around gallbladder
What is the upper limit of normal for size of the bile duct
6mm plus 1mm for every decade after 60
What LFTs indicate pathology in the biliary tree?
Raised bilirubin
Raised ALP
(may have raised AST/ALT)
If a patient has high ALT/AST compared to ALP, what does this indicate?
Hepatocellular process
What is Murphy’s sign
RUQ tenderness exacerbated by deep inspiration
Place hand in RUQ and apply pressure
Ask patient to take a deep breath in
Gallbladder will move downwards under your hand and cause pain
How should acute cholecystitis be managed?
Fasting
Fluids
ABx (if evidence of an infection)
Delayed lap chole
What is a gallbladder empyema?
Infected tissue and pus in gallbladder
Treat with cholecystectomy - drain into gallbladder to drain the empyema
How is acute cholangitis diagnosed?
Charcot’s triad
- RUQ pain
- Fever
- Jaundice
How is acute cholangitis managed?
IV antibiotics
Treat sepsis
ERCP or PTC to relieve obstruction
What is a notable complication of a cholecystectomy?
Chronic diarrhoea
What is acute mesenteric ischaemia?
Blood clots occlude the blood supply in the mesenteric vessels
How does acute mesenteric ischaemia present?
Non-specific abdo pain (out of proportion to exam findings)
Can develop shock and peritonitis
How is acute mesenteric ischaemia diagnosed?
Raised blood lactate
Diagnose with CT angiogram
What can acute mesenteric ischaemia result in?
Gangrene +/- perforation
What are risk factors for acute mesenteric ischaemia?
AF
Older age
Atherosclerosis
Coag disorders
How should acute mesenteric ischaemia be managed?
A-E assessment Fluid resuscitation Thrombolysis Surgical intervention Very poor prognosis
What is the Glasgow Pancreas score?
PaO2 <60 Age >55 Neutrophils (WBC >15) Calcium <2 uRea >16 Enzymes (LDH >600 or AST/ALT >200) Albumin <32 Sugar (glucose >10)
<2 = mild 2 = moderate >2 = severe
What are complications of pancreatitis?
Pancreatic necrosis
Pseudocysts
Chronic pancreatitis
How should pancreatitis be managed?
Careful monitoring IV fluids - third space losses Analgesia Endoscopic drainage of large pseudocysts ABx only if evidence of infected pancreatic necrosis
Escalate care depending on Glasgow score
