General Surgery Flashcards
What is Paget’s Disease of the Nipple?
eczematoid change in the nipple - 50% have underlying mass lesion, usually invasive carcinoma
management of post-op ileus
correct deranged electrolytes - replace intravenously
appearance of sigmoid volvulus
‘coffee bean’ sign, lines of coffee bean converge towards site of obstruction.
associations with sigmoid disease (5)
increasing age chronic constipation chagas disease neurological conditions psychiatric conditions
associations with caecal volvulus (3)
all ages
adhesions
pregnancy
caecal volvulus appearance on x-ray
small bowel obstruction
managmene of volvulus
sigmoid - rigid sigmoidoscopy with flatus tube insertion
caecal - operative, usually right hemicolectomy
what is a breast fibroadenoma
a benign tumour which forms from a whole lobule. mobile and firm.
management of breast fibroadenoma
30% will regress on their own
if >3cm surgical excision usually
post splenectomy blood film features (4)
Howell-Jolly bodies
Pappenheimer bodies
target cells
irregular contracted erythrocytes
features of small bowel obstruction on AXR
diameter >35mm
valvulae conniventes extend all the way across bowel loops
features of large bowel obstruction on AXR
diameter >55mm
haustra extend about a third of the way across the bowel loops
non surgical breast cancer Mx
- radiotherapy - all women with breast conserving surgery or women with T3-T4 tumours who have mastectomy
- hormonal therapy is used for women with hormone positive tumours - tamoxifen in pre/perimenopausal women and anastrozole in post menopausal women
- HER2 positive can use herceptin (CIed in heart disorders)
- Chemotherapy may be used neoadjuvantly or to treat axillary node disease
neurogenic shock
interruption of the autonomic nervous system resulting in reduced sympathetic or increased parasympathetic tone, resulting in decreased peripheral vascular resistance and vasodilation
Presentation of duodenal ulcer
post-prandial pain worst several hours after meals
what is a dieulafoy lesion?
small arterial lesions in the stomach - result in significant haematemesis and malena
clinical features of liver disease (6)
jaundice gynaecomastia spider naevi caput medusae ascites malnourished appearance
classification of haemorrhagic shock
I - compensated
II - tachycardia
III - tachycardia, hypotension and confusion
IV- LOC + severe hypotension
Breast cysts - presentation
smooth, discrete lump which may be fluctuant.
breast cysts - management
aspirate, may be excised if blood stained or persistently refill
sclerosing adenosis -presentation and management
breast lumps or breast pain, mammographic changes mimic carcinoma. Biopsy results, excision optional.
what is angiodysplasia
AV lesions causing lower GI bleeds, which can be massive. No other symptoms.
what is a hepatic haemangioma
most common benign liver tumour, hyperechoic on USS, may be symptomatic if large
Blatchford score
assessment of need for admission and urgency of endoscopy in upper GI bleeds.
Rockall score
post endoscopy for upper GI bleed to estimate rebleeding risk and mortality
bubbly urine is suggestive of …
…enterovesical fistula
Causes of nipple discharge (6)
breast abscess -puss duct ectasia - thick green or brown galactorrhoea - pituitary tumour/ emotional/iatrogenic physiological milk production intraductal papilloma- blood-stained carcinoma - blood-stained
Causes of tender breast lumps (3)
breast abscess
mammary duct ectasia
fibroadenosis
Causes of non-tender breast lumps (3)
fat necrosis
breast cancer
fibroadenoma
Marker for bowel cancer
CEA
Dukes staging
Dukes A - tumour confined to the mucosa
Dukes B - Tumour invaded bowel wall
Dukes C - Local lymph node involvement
Dukes D - distant metastases
Iron deficiency anaemia in over 60s - what you gonna do?
Urgent referral to colorectal surgeon for suspected colon cancer.
Acute Mx of anal fissure
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
Chronic Mx of anal fissure
acute Mx 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 care referral should be considered for surgery (sphincterotomy) or botulinum toxin
Resection and anastomosis for tumours in Caecal, ascending or proximal transverse colon
Right hemicolectomy
Ileo-colic
Resection and anastomosis for tumours in Distal transverse, descending colon
Left hemicolectomy
Colo-colon
Resection and anastomosis for tumours in Sigmoid colon
High anterior resection
Colo-rectal
Resection and anastomosis for tumours in Upper rectum
Anterior resection (TME) Colo-rectal
Resection and anastomosis for tumours in Low rectum
Anterior resection (Low TME) Colo-rectal (+/- Defunctioning stoma)
Resection and anastomosis for tumours in Anal verge
Abdominoperineal excision of rectum
None
Complications of diverticular disease (6)
Diverticulitis Haemorrhage Development of fistula Perforation and faecal peritonitis Perforation and development of abscess Development of diverticular phlegmon
Classification of diverticular disease
I Para-colonic abscess
II Pelvic abscess
III Purulent peritonitis
IV Faecal peritonitis
Management of diverticular disease
Increase dietary fibre intake
Mild attacks - antibiotics.
Peri colonic abscesses should be drained either surgically or radiologically.
Recurrent episodes of acute diverticulitis requiring hospitalisation are a relative indication for a segmental resection.
grade IV perforations (generalised faecal peritonitis) will require a resection and usually a stoma. High risk of postoperative complications and usually require HDU admission. Less severe perforations may be managed by laparoscopic washout and drain insertion
Investigation to ensure no anastomotic leak following colonic anastomosis formation
gastrografin enema
Anal cancer risk factors (7)
- HPV 16 and 18 infection causes 80-85% of SSCs
- Anal intercourse and a high lifetime number of sexual partners increases the risk of HPV infection.
- MSM
- Those with HIV and those taking immunosuppressive medication for HIV are at a greater risk of anal carcinoma.
- Women with a history of cervical cancer or cervical intraepithelial neoplasia (CIN) are also at greater risk of anal cancer.
- Immunosuppressive drugs used in transplant recipients increase the risk of anal cancer.
- Smoking is also a risk factor.
Screening for colon cancer
at 55 one-off flexible sigmoidoscopy to detect polyps
FOB test every 2 years from 60 to 74 (from 50 in Scotland)
peptic ulcer pain
duodenal - several hours after eating / worse when hungry
gastric - worsened by eating
which artery tends to be perforated in duodenal ulcers?
gastroduodenal artery
Congenital Inguinal Hernias
Anatomy
Management
Indirect hernias resulting from a patent processus vaginalis
Should be surgically repaired soon after diagnosis as at risk of incarceration
Bowel obstruction - investigation
AXR initially
if small bowel suggestive then get CT abdomen to confirm
Nere at risk of damage in total hip replacement and symtptoms
sciatic nerve - foot drop
Haemothorax
management
wide bore 36F chest drain.
Indications for thoracotomy include loss of more than 1.5L blood initially or ongoing losses of >200ml per hour for >2 hours.
consider delaying management if likely to cause ongoing bleeding in an unstable patient
lower GI bleed in liver disease patients? likely diagnosis?
rectal varices due to portal hypertension
What causes abdominal wall haematoma?
- trauma, either directly to the abdominal wall or iatrogenic trauma from surgery
- spontaneous following excessive straining due to valsalva manoeuvres, coughing.
Presentation of abdominal wall haematoma
painful, discoloured mass
signs of hypovolemia (tachycardia and hypotension)
Complications of TPN (4)
Thrombophlebitis
liver dysfunction
sepsis
refeeding syndrome
What is Rovsings sign?
appendicitis - palpation of the left iliac fossa causes pain in the right iliac fossa
What is Boas sign?
-cholecystitis - hyperaesthesia beneath the right scapula
What is Murphys sign?
cholecystitis - pain as the inferior liver border is brought down on a palpating hand as the patient inhales, causing a ‘catch’ in their breath.
What is Cullens sign?
peri-umbilical bruising - pancreatitis (other intraabdominal haemorrhage)
What is Grey-Turners sign?
flank bruising - pancreatitis (or other retroperitoneal haemorrhage)
Glasgow PANCREAS score
P - PaO2 <8kPa
A - Age >55-years-old
N - Neutrophilia: WCC >15x10(9)/L
C - Calcium <2 mmol/L
R - Renal function: Urea >16 mmol/L
E - Enzymes: LDH >600iu/L; AST >200iu/L
A - Albumin <32g/L (serum)
S - Sugar: blood glucose >10 mmol/L
Complications of gastrectomy (7)
Dumping syndrome Weight loss, early satiety Iron-deficiency anaemia Osteoporosis/osteomalacia Vitamin B12 deficiency increased risk of gallstones increased risk of gastric cancer
What is Dumping syndrome
post gastrectomy
early: food of high osmotic potential moves into small intestine causing fluid shift
late (rebound hypoglycaemia): surge of insulin following food of high glucose value in small intestine - 2-3 hours later the insulin ‘overshoots’ causing hypoglycaemia
Laproscopy complications (5)
- general risks of anaesthetic
- vasovagal reaction (e.g. bradycardia) in response to abdominal distension
- extra-peritoneal gas insufflation: surgical emphysema
- injury to gastro-intestinal tract
- injury to blood vessels e.g. common iliacs, deep inferior epigastric artery
Causes of raised serum amylase (6)
Acute pancreatitis Pancreatic pseudocyst Mesenteric infarct Perforated viscus Acute cholecystitis Diabetic ketoacidosis
Causes of pancreatitis (GET SMASHED)
Gallstones ** common
Ethanol ** common
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
ERCP
Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)
Diagnostic test for chronic pancreatitis
CT Pancreas with contrast
presentation of biliary colic
Episodic, colicky RUQ or epigastric pain and nausea
no fever, no vomiting
Presentation of cholecystitis
Fever, vomiting, constant RUQ pain
no jaundice
Presentation of cholangitits
Jaundice, fever, RUQ pain (Charcot’s Triad)
+/- Hypotension and confusion (Reynolds Pentad)
Gastric MALT lymphoma Cause Mx Prognosis Associated feature
H. pylori infection in 95% of cases, 80% respond to H. pylori eradication
good prognosis
paraptoteinaemia
