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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
Q

How is acute diverticulitis managed?

A

Conservatively - abx, IV fluids, analgesia

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26
Q

When is surgery required for acute diverticulitis?

A

Perforation with peritonitis, sepsis

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27
Q

What surgery is done for acute diverticulitis?

A

Hartmann’s procedure - sigmoid colectomy, may be able to reverse end colostomy

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28
Q

What are some causes of upper GI haemorrhage?

A

Peptic ulcer, oesophageal varices
Malignancy
Oesophagitis, gastritis, Mallory-Weiss tear

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29
Q

How can upper GI haemorrhage present?

A

Haematemesis - bright red vomiting blood, active haemorrhage
Coffee ground vomit - vomiting black material, not active bleeding
Malaena - black, tarry stool

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30
Q

What investigations should be done for an upper GI bleed?

A 
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
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31
Q

What scoring systems can be used to assess upper GI bleeds?

A

Rockall Score - predicts risk of death and rebleeding, two parts: pre- and post-endoscopy
Blatchford Score - predicts need for intervention

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32
Q

What is the initial management of an upper GI bleed?

A

Fluid resuscitation

Pt may require blood, platelet or clotting factor transfusion

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33
Q

How is a peptic ulcer causing haematemesis managed?

A

Injecting adrenaline and cauterisation on OGD
IV omeprazole
H pylori eradication if necessary

34
Q

How are oesophageal varices managed?

A

Done at same time as resuscitation
Endoscopic banding
Terlipressin and IV abx
Long term: repeated banding, beta blockers

35
Q

How does a lower GI bleed present?

A

Haematochezia - fresh PR blood

36
Q

What are some causes of lower GI bleeds?

A

Diverticulosis
Haemorrhoids
Infective
Malignancy

37
Q

How do haemorrhoids present?

A

Pruritis, PR bleed
Blood on surface of stool or on wiping
Can be painful if large

38
Q

What investigations are done for lower GI bleeds?

A

PR
FBC, U&Es, LFT, coagulation profile, group and save
Flexible sigmoidoscopy/colonoscopy

39
Q

How is an acute lower GI bleed managed?

A

2 large bore cannula, IV fluid, blood transfusion as required

Most people investigated as an outpatient

40
Q

How does a direct inguinal hernia occur?

A

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
Q

How does an indirect inguinal hernia occur?

A

Bowel enters the inguinal canal through the deep inguinal ring
Results from a patent processus vaginalis

42
Q

What are the borders of the inguinal canal?

A

Anterior - aponeurosis of external oblique
Superior - internal oblique
Posterior - transversalis fascia
Inferior - inguinal ligament

43
Q

What are the positions of inguinal hernias?

A

Direct - medial to inferior epigastric vessels

Indirect - lateral to inferior epigastric vessels

44
Q

How does an inguinal hernia present?

A

Lump in groin - protrudes with coughing, disappears when laying down/minimal pressure
May have discomfort with activity or standing

45
Q

What is the management of an inguinal hernia?

A

Open or laparoscopic repair

Laparoscopic if at risk of chronic pain or female

46
Q

How does an incarcerated hernia present?

A

Painful, tender, irreducible

47
Q

What is a strangulated hernia?

A

Compression of hernia => compromised blood supply => ischaemic bowel
Irreducible, tender lump
Features of small bowel obstruction

48
Q

What are complications of an inguinal hernia?

A

Incarceration, strangulation, obstruction

49
Q

What are complications of hernia repair?

A

Pain, bruising, urinary retention, infection
Recurrence
Chronic pain

50
Q

How are gallstones formed?

A

Bile is formed from cholesterol, phospholipids and bile pigments
Most stones are formed from excess cholesterol

51
Q

What are risk factors for gallstone formation?

A

5 F’s - fair, fat, female, forty, family history

Haemolytic anaemia, pregnancy

52
Q

What is biliary colic?

A

Gallstone becomes impacted in the neck of the gallbladder
Contraction of the gallbladder causes pain
No inflammation

53
Q

What are complications of gallstones?

A

Biliary colic
Acute cholecystitis
Ascending cholangitis
Acute pancreatitis

54
Q

How does biliary colic present?

A

Dull, colicky pain
Nausea and vomiting
Precipitated by fatty foods - fatty acids stimulate release of CCK => contraction of gallbladder

55
Q

How does acute cholecystitis present?

A

Constant RUQ pain
Signs of inflammation
Positive Murphy’s sign

56
Q

What is Murphy’s sign?

A

Pt inspires while applying pressure on RUQ

Halt in inspiration due to pain => inflamed gallbladder

57
Q

What is acute cholecystitis?

A

Blockage of cystic duct by stone => stasis of bile => infection

58
Q

What is ascending cholangitis?

A

Obstruction of CBD

59
Q

How does ascending cholangitis present?

A

Charcot’s triad: fever, RUQ pain, jaundice

60
Q

What imaging is done for gallstones?

A

USS - shows stones, thickened gallbladder wall, bile duct dilatation
MRCP

61
Q

What is the management for biliary colic?

A

Analgesia
Lifestyle modification - weight loss, stop smoking, low fat diet

Laparoscopic cholecystectomy

62
Q

What is the management of acute cholecystitis?

A

IV abx

Laparoscopic cholecystectomy

63
Q

What is gallstone ileus?

A

Inflammation of gallbladder => formation of a fistula between gallbladder and terminal ileum => small bowel obstruction

64
Q

What is the pathogenesis of acute pancreatitis?

A

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
Q

How does acute pancreatitis present?

A

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
Q

What are causes of acute pancreatitis?

A 
Alcohol
Gallstones 
ERCP 
Trauma
Drugs eg steroids
67
Q

What bloods are done in acute pancreatitis?

A

Serum amylase - must be 3x the limit
LFTs - raised ALT indicates gallstones
Serum lipase - more accurate

68
Q

What is the Glasgow criteria for acute pancreatitis?

A 
pO2 <8kPa
Age >55yrs
Neutrophils >15
Calcium <2 
Renal function (urea) >16
Enzymes (LDH) >600
Albumin - low
Sugar - raised
69
Q

How is acute pancreatitis managed?

A 
Supportive treatment 
IV fluid resuscitation 
NG tube if vomiting profusely 
Monitor fluid output - catheter 
Opioid anlgesia

Treat underlying cause eg ERCP if gallstones

70
Q

What are local complications of acute pancreatitis?

A

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
Q

What are systemic complications of acute pancreatitis?

A 
DIC
ARDS
Hypocalcaemia - due to fat necrosis 
Hyperglycaemia - destruction of islets of Langerhans
Multiorgan failure
72
Q

What does a colostomy look like?

A

Usually LIF, flush to skin

73
Q

What does an ileostomy look like?

A

Usually on right side, spouted

Frequent fluid motions with active enzymes

74
Q

When is a loop ileostomy formed?

A

Defunction colon as a temporary measure in order to control Crohn’s

75
Q

When is an end ileostomy formed?

A

Colectomy

Can do ileal pouch-anal anastomosis => reversal by joining ileum to anus

76
Q

When is a right hemi-colectomy done?

A

Caecal/ascending colon tumour

77
Q

When is a left hemicolectomy done?

A

Descending colon tumour

78
Q

When is an anterior resection done?

A

High rectal tumours
Protects anal sphincter
Also form a loop ileostomy, which is later reversed

79
Q

When is an abdominoperineal resection done?

A

Low rectal tumour

Involves excision of distal colon, results in permanent colostomy

80
Q

When is the Hartmann’s procedure done?

A

Emergency - ca, diverticulitis

Resection of recto-sigmoid, with end colostomy and closure of rectal stump

Year 3 Surgery (6 decks)

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