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Year 3 Surgery > General Surgery > Flashcards

General Surgery Flashcards

1
Q

What is a closed loop obstruction?

A

When there are two obstructions - volvulus or large bowel obstruction with a competent ileocaecal valve
Bowel will continue to distend => stretching bowel until it becomes ischaemic or perforates

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2
Q

What are common causes of small bowel obstruction?

A

Adhesions

Hernias

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3
Q

What are common causes of large bowel obstruction?

A

Malignancy
Diverticular disease
Volvulus

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4
Q

How can a small bowel obstruction present?

A

Vomiting
Pain
Late constipation

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5
Q

How can a large bowel obstruction present?

A

Absolute constipation
Pain
Abdo distension

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6
Q

What investigations are done for bowel obstruction?

A

FBC, CRP, U&E, LFTs, Group and save
Venous blood gas - high lactate indicates ischaemia
CT abdo and pelvis
CXR - look for air under diaphragm => bowel perforation

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7
Q

What signs are seen on AXR in small bowel obstruction?

A

Dilated small bowel >3cm, centrally located

Valvulae conniventes - lines fully cross bowel

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8
Q

What signs are seen on AXR in large bowel obstruction?

A

Dilated large bowel - >6cm or >9cm at caecum, peripherally located
Haustra - lines don’t fully cross bowel

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9
Q

What is the immediate management for bowel obstruction?

A 
Make pt NBM
Insert NG tube - decompress stomach 
Give IV fluids, correct electrolyte disturbances 
Catheter and fluid balance 
Analgesia and anti-emetics
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10
Q

When is surgery required for bowel obstruction?

A

Iscaemia, closed loop obstruction
Strangulated hernia
Malignancy
If pt fails to recover with conservative management

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11
Q

What are complications of bowel obstruction?

A

Ischaemia
Perforation => peritonitis
Dehydration and renal impairment

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12
Q

How does appendicitis present?

A

Pain - initially peri-umbilical, localises to RIF due to irritation of the parietal peritoneum
Vomiting, constipation

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13
Q

What signs can be seen in appendicitis?

A

Tachycardia, tachypnoea, pyrexia
Rebound tenderness
Guarding if perforated
Rosving’s sign, psoas sign

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14
Q

What is Rosving’s sign?

A

Pain elicited in RIF when palpating LIF

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15
Q

What is psoas sign?

A

Extension of the right hip elicits pain in RIF with retrocaecal appendix

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16
Q

What investigations are required in appendicitis?

A

Urinalysis
FBC, CRP, serum beta hCG
USS
CT

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17
Q

What is the management for appendicitis?

A

Laparoscopic appendicectomy

Occasionally can be treated just with abx

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18
Q

What are complications of appendicitis?

A

Perforation
Appendix mass
Pelvic abscess

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19
Q

What is an appendix mass?

A

Omentum and small bowel adhere to appendix

Conservative management with abx

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20
Q

What is a diverticulum?

A

Outpouching of bowel wall, most commonly found in the sigmoid colon

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21
Q

What are the manifestations of diverticulum?

A

Diverticulosis - asymptomatic, found incidentally
Diverticular disease - symptomatic diverticula
Diverticulitis - inflam of diverticula
Diverticular bleed - diverticulum erodes into vessel

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22
Q

What is the pathophysiology of diverticula formation?

A

Bowel wall weakens with age, movement of stool => increase in luminal pressure
Leads the outpouching and weakening of bowel wall
Bacteria are able to grow in the diverticula => inflam

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23
Q

How does acute diverticulitis present?

A

Sharp LIF pain
Localised tenderness
Altered bowel habit, nausea

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24
Q

What investigations are required for acute diverticulitis?

A 
FBC, U&Es, LFTs, CRP 
Serum beta hCG 
Urinalysis 
Venous blood gas 
CT abdo pelvis

Uncomplicated - flexible sigmoidoscopy

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25
How is acute diverticulitis managed?
Conservatively - abx, IV fluids, analgesia
26
When is surgery required for acute diverticulitis?
Perforation with peritonitis, sepsis
27
What surgery is done for acute diverticulitis?
Hartmann's procedure - sigmoid colectomy, may be able to reverse end colostomy
28
What are some causes of upper GI haemorrhage?
Peptic ulcer, oesophageal varices Malignancy Oesophagitis, gastritis, Mallory-Weiss tear
29
How can upper GI haemorrhage present?
Haematemesis - bright red vomiting blood, active haemorrhage Coffee ground vomit - vomiting black material, not active bleeding Malaena - black, tarry stool
30
What investigations should be done for an upper GI bleed?
``` FBC - monitor Hb and platelets LFTs - underlying liver disease U&Es - AKI, raised urea VBG - Hb levels Coagulation Group and Save, Crossmatch blood Erect CXR - perforated viscus OGD ```
31
What scoring systems can be used to assess upper GI bleeds?
Rockall Score - predicts risk of death and rebleeding, two parts: pre- and post-endoscopy Blatchford Score - predicts need for intervention
32
What is the initial management of an upper GI bleed?
Fluid resuscitation | Pt may require blood, platelet or clotting factor transfusion
33
How is a peptic ulcer causing haematemesis managed?
Injecting adrenaline and cauterisation on OGD IV omeprazole H pylori eradication if necessary
34
How are oesophageal varices managed?
Done at same time as resuscitation Endoscopic banding Terlipressin and IV abx Long term: repeated banding, beta blockers
35
How does a lower GI bleed present?
Haematochezia - fresh PR blood
36
What are some causes of lower GI bleeds?
Diverticulosis Haemorrhoids Infective Malignancy
37
How do haemorrhoids present?
Pruritis, PR bleed Blood on surface of stool or on wiping Can be painful if large
38
What investigations are done for lower GI bleeds?
PR FBC, U&Es, LFT, coagulation profile, group and save Flexible sigmoidoscopy/colonoscopy
39
How is an acute lower GI bleed managed?
2 large bore cannula, IV fluid, blood transfusion as required Most people investigated as an outpatient
40
How does a direct inguinal hernia occur?
Bowel enters inguinal canal through Hesselbach's triangle, a weakness in the posterior wall of the canal Usually due to a laxity in the abdominal wall or increase in intra-abdominal pressure
41
How does an indirect inguinal hernia occur?
Bowel enters the inguinal canal through the deep inguinal ring Results from a patent processus vaginalis
42
What are the borders of the inguinal canal?
Anterior - aponeurosis of external oblique Superior - internal oblique Posterior - transversalis fascia Inferior - inguinal ligament
43
What are the positions of inguinal hernias?
Direct - medial to inferior epigastric vessels | Indirect - lateral to inferior epigastric vessels
44
How does an inguinal hernia present?
Lump in groin - protrudes with coughing, disappears when laying down/minimal pressure May have discomfort with activity or standing
45
What is the management of an inguinal hernia?
Open or laparoscopic repair Laparoscopic if at risk of chronic pain or female
46
How does an incarcerated hernia present?
Painful, tender, irreducible
47
What is a strangulated hernia?
Compression of hernia => compromised blood supply => ischaemic bowel Irreducible, tender lump Features of small bowel obstruction
48
What are complications of an inguinal hernia?
Incarceration, strangulation, obstruction
49
What are complications of hernia repair?
Pain, bruising, urinary retention, infection Recurrence Chronic pain
50
How are gallstones formed?
Bile is formed from cholesterol, phospholipids and bile pigments Most stones are formed from excess cholesterol
51
What are risk factors for gallstone formation?
5 F's - fair, fat, female, forty, family history Haemolytic anaemia, pregnancy
52
What is biliary colic?
Gallstone becomes impacted in the neck of the gallbladder Contraction of the gallbladder causes pain No inflammation
53
What are complications of gallstones?
Biliary colic Acute cholecystitis Ascending cholangitis Acute pancreatitis
54
How does biliary colic present?
Dull, colicky pain Nausea and vomiting Precipitated by fatty foods - fatty acids stimulate release of CCK => contraction of gallbladder
55
How does acute cholecystitis present?
Constant RUQ pain Signs of inflammation Positive Murphy's sign
56
What is Murphy's sign?
Pt inspires while applying pressure on RUQ | Halt in inspiration due to pain => inflamed gallbladder
57
What is acute cholecystitis?
Blockage of cystic duct by stone => stasis of bile => infection
58
What is ascending cholangitis?
Obstruction of CBD
59
How does ascending cholangitis present?
Charcot's triad: fever, RUQ pain, jaundice
60
What imaging is done for gallstones?
USS - shows stones, thickened gallbladder wall, bile duct dilatation MRCP
61
What is the management for biliary colic?
Analgesia Lifestyle modification - weight loss, stop smoking, low fat diet Laparoscopic cholecystectomy
62
What is the management of acute cholecystitis?
IV abx | Laparoscopic cholecystectomy
63
What is gallstone ileus?
Inflammation of gallbladder => formation of a fistula between gallbladder and terminal ileum => small bowel obstruction
64
What is the pathogenesis of acute pancreatitis?
Release of pancreatic enzymes within the pancreas => inflammation of the pancreas Enzymes then released into systemic circulation => autodigestion of fat (fat necrosis => hypocalcaemia) and blood vessels (retroperitoneal haemorrhage)
65
How does acute pancreatitis present?
Severe epigastric pain radiating to back Vomiting Grey-Turner's and Cullen's sign Tetany due to hypocalcaemia from fat necrosis Jaundice if due to gallstones
66
What are causes of acute pancreatitis?
``` Alcohol Gallstones ERCP Trauma Drugs eg steroids ```
67
What bloods are done in acute pancreatitis?
Serum amylase - must be 3x the limit LFTs - raised ALT indicates gallstones Serum lipase - more accurate
68
What is the Glasgow criteria for acute pancreatitis?
``` pO2 <8kPa Age >55yrs Neutrophils >15 Calcium <2 Renal function (urea) >16 Enzymes (LDH) >600 Albumin - low Sugar - raised ```
69
How is acute pancreatitis managed?
``` Supportive treatment IV fluid resuscitation NG tube if vomiting profusely Monitor fluid output - catheter Opioid anlgesia ``` Treat underlying cause eg ERCP if gallstones
70
What are local complications of acute pancreatitis?
Pancreatic necrosis - ongoing inflammation => ischaemic infarction, confirmed by CT Pancreatic pseudocyst - collection of fluid usually in lesser sac, prone to rupture/haemorrhage/infection, will probs resolve spontaneously
71
What are systemic complications of acute pancreatitis?
``` DIC ARDS Hypocalcaemia - due to fat necrosis Hyperglycaemia - destruction of islets of Langerhans Multiorgan failure ```
72
What does a colostomy look like?
Usually LIF, flush to skin
73
What does an ileostomy look like?
Usually on right side, spouted | Frequent fluid motions with active enzymes
74
When is a loop ileostomy formed?
Defunction colon as a temporary measure in order to control Crohn's
75
When is an end ileostomy formed?
Colectomy | Can do ileal pouch-anal anastomosis => reversal by joining ileum to anus
76
When is a right hemi-colectomy done?
Caecal/ascending colon tumour
77
When is a left hemicolectomy done?
Descending colon tumour
78
When is an anterior resection done?
High rectal tumours Protects anal sphincter Also form a loop ileostomy, which is later reversed
79
When is an abdominoperineal resection done?
Low rectal tumour | Involves excision of distal colon, results in permanent colostomy
80
When is the Hartmann's procedure done?
Emergency - ca, diverticulitis Resection of recto-sigmoid, with end colostomy and closure of rectal stump

Year 3 Surgery (6 decks)

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