GENERAL SURGERY Flashcards
1
Q
What is the ‘acute abdomen’
A
Sudden onset of severe abdominal pain of less than 24 hrs duration
2
Q
What can cause an acute abdomen?
A
Ruptured AAA
Ruptured Ectopic pregnancy
Peritonitis (perforation of abdominal viscus) = rigid abdomen
Ischaemic bowel (pain out of proportion to clinical sign)
Gastric ulcer
Pancreatitis
MI
Small / large bowel obstruction
3
Q
What are the investigations for an acute abdomen?
A
- Urine dipstick (signs of infection)
- Pregnancy test
- ABG (bleeding / septic patients - lactate signs of tissue hypoperfusion)
- Routine bloods: FBC, U&Es, LFTs, CRP, amylase
- Serum calcium (pancreatitis)
4
Q
What Amylase level is required for a diagnosis of pancreatitis?
A
3x the upper limit
5
Q
What is the imaging in acute abdomen?
A
- ECG
- Ultrasound: KUB - renal tract pathology, biliary tree and liver - gallstones
- CXR for bowel perforation
6
Q
What is the general management of the acute abdo?
A
- IV access
- NBM
- Analgesia
- Antiemetic
- Imaging
- VTE prophylaxis
- Urine dip
- Bloods
- Urinary catheter
7
Q
What is Barrett’s oesophagus?
A
Metaplasia from stratified squamous epithelium to simple columnar epithelium
8
Q
Is metaplasia reversible?
A
Yes
9
Q
What typically causes Barretts oesophagus?
A
GORD
10
Q
What are the risk factors for Barrett’s?
A
Being Caucasian
>50 y/o
Smoking
Male
11
Q
What are the presenting features of Barrett’s?
A
Retrosternal chest pain
Belching
Chronic cough
REMEMBER TO CHECK RED FLAGS
12
Q
What are investigations for Barrett’s oesophagus?
A
Histological diagnosis
13
Q
What is the management of Barretts?
A
High dose PPI
NSAIDs stopped
Lifestyle advice
Regular follow up endoscopy
14
Q
What type of cell is in the upper third and lower third of the oesophagus respectively?
A
Upper = Skeletal
Lower = Smooth muscle
15
Q
What are the differentials for oesophageal motility disorders?
A
GORD
Malignancy
Achalasia
Oesophageal spasm
16
Q
What is achalasia?
A
Failure of relaxation of the LOS (pathophysiology poorly understood)
17
Q
What are the symptoms of achalasia?
A
Regurgitation of food
Chest pain
Weight loss
18
Q
What is the investigation in achalasia?
A
Endoscopy
Oesophageal manometry
Barium swallow - birds beak appearance
19
Q
What is the management of achalasia?
A
Sleeping with many pillows (stops regurg)
Chew food thoroughly
Botox injections at LOS (only effective for a few months)
Surgical endoscopic ballon dilatation
20
Q
What is diffuse oesophageal spasm?
A
Multifocal high amplitude contractions of the oesophagus
21
Q
How does diffuse oesophageal spasm present?
A
Severe dysphagia to both solids and liquids
Central chest pain
22
Q
How is diffuse oesophageal spasm diagnosed?
A
Manometry (simultaneous and ineffective contractions of oesophagus)
23
Q
What is the management of DOS?
A
Nitrates / CCBs (relax muscles)
24
Q
What is Boerhaave’s syndrome?
A
Oesophageal perforation
25
Why is oesophageal rupture an emergency?
Leakage of stomach contents into mediastinum triggers an **inflammatory response** - leading to death
26
What are the causes of oesophageal rupture?
**Iatrogenic** (endoscopy)
Severe **forceful vomiting**
27
How does an oesophageal rupture present?
Sudden **retrosternal chest pain**
## Footnote
**Respiratory distress**
**Subcutaneous emphysema**
28
What are the investigations for an oesophageal rupture?
**Routine bloods**
**G&S**
**CXR**
CT chest abdo pelvis with contract to demonstrate air
29
What is the management of oesophageal rupture?
**Fluid resus**
High flow **oxygen**
**Abx**
**Surgery**
30
What are Mallory-Weiss tears?
**Laceration in oesophageal mucosa** usually due to forceful vomiting
31
What is the management of Mallory-Weiss tear?
As in other upper GI bleeds
32
What is the most common form of gastric cancer?
**Adenocarcinoma**
33
What are the risk factors for gastric cancer?
**H. Pylori** infection
Increasing age
**Smoking**
**Alcohol** consumption
34
What time of bacteria is H. Pylori?
**G neg helical bacterium**
35
How does H. Pylori exert its effect?
Produces **urease enzyme** breaking down urea into CO2 and ammonium
## Footnote
**Ammonium neutralises the stomach acid**
36
What are the symptoms of gastric cancer?
**Dyspepsia** (indigestion)
**Dysphagia**
Early **satiety**
**Vomiting**
37
What is Troisiers sign?
Presence of a palpable **left supraclavicular node**
38
What are the differentials to consider with dyspepsia?
**Gastric cancer**
**Peptic ulcer** disease
**GORD**
**Gallstones**
39
What is the imaging of choice in gastric cancer?
**Upper GI endoscopy**: direct visualisation
Biopsy’s sent for: **Histology, CLO test (pylori)**
40
What happens in GORD?
**Excessive relaxation of LOS** allowing reflux of acidic gastric contents
41
What are the risk factors for GORD?
**Age**
**Obesity**
**Male gender**
Alcohol
Smoking
Caffeinated drinks
42
What are the symptoms of GORD?
**Burning retrosternal pain after meals**
**Relieved by antacids**
**Cough**
43
What are the red flags for dyspepsia?
**Weight loss**
**Early satiety**
**Malaise**
Loss of appetite
44
How is GORD diagnosed?
Good history, resolution of symptoms after PPI
45
When do NICE suggest endoscopy for upper GI symptoms?
**\>55 years old with weight loss**, dyspepsia or reflux
46
What are the management options for GORD?
**Avoid precipitating food, weight loss, smoking cessation**
**PPI**s
**Surgery** (fundoplication)
47
What are the complications of GORD?
**Aspiration pneumonia**
**Barrett’s oesophagus**
**Oesophageal cancer**
48
What is a hiatus hernia?
**Herniation of part of abdomen into thorax** via oesophageal hiatus (usually the stomach, can be small bowel, mesentery etc)
49
What are some risk factors for hiatus hernia?
**Age**
**Repetitive coughing**
**Pregnancy**
**Obesity**
**Ascites**
50
What are the presenting features of a **hiatus hernia?**
**Reflux symptoms**
**Vomiting**
**Weight loss**
51
What is the gold standard investigation for hiatus hernia?
**Oesophagogastroduodenoscopy** is the gold standard
52
What is the management of hiatus hernia?
**PPI** (first thing)
**Weight loss**, early meals small, smaller portions
**Surgery**
53
What are some complications of hiatus hernia?
**GASTRIC VOLVULUS** - Borchardt’s triad - stomach twists on itself (severe epigastric pain, retching without vomiting, inability to pass NG tube)
54
Where are peptic ulcers commonly seen?
**Lesser curvature of proximal stomach**
**First part of the duodenum**
55
What causes peptic ulcers?
**H.Pylori infection**
**NSAID** use
**Previous gastric bypass surgery**
56
How do patients with peptic ulcers present?
**Epigastric or retrosternal pain**
**Early satiety**
57
What is the triad in Zollinger-Ellison syndrome?
**Triad of:**
Severe **peptic ulcer** disease
**Gastric acid hypersecretion**
**Gastrinoma**
58
What are the investigations for peptic ulcer disease?
**FBC (for anaemia)**
**H. Pylori testing**
**Ongoing symptoms** despite treatment - **OGD**
59
What is the management for peptic ulcer disease?
**Lifestyle advise**: **smoking cessation, weight loss, reduction in alcohol**
## Footnote
**PPI**
**Triple therapy if H. Pylori**
60
What is the triple therapy for H. Pylori?
PPI
Oral amoxicillin
Clarythomycin/metronidazole
61
What type of hernia occurs in the upper midline through fibres of the linea alba, typically in men?
**Epigastric hernia**
62
What are risk factors for epigastric hernia?
**Obesity**
**Pregnancy**
**Ascites**
63
What other kind of hernia can occur in the abdomen?
Paraumbilical hernia
64
When else is serum amylase raised?
**Ectopic pregnancy**
**DKA**
65
What is angiodysplasia?
Arteriovenous malformation between previously healthy blood vessels normally in caecum
66
What are the main features of angiodysplasia?
Rectal **bleeding and anaemia**
67
What are the differentials for lower GI bleeding?
**GI malignancy**
**Diverticular disease**
**Coagulopathies**
68
What blood tests for lower GI bleed?
**FBC** (haemantics for iron deficiency)
**U&Es**
**LFTs**
**Clotting profile**
**G&S**
**Cross match**
69
What is the treatment for angiodysplasia?
**Bed rest and IV fluid** and tranexamic acid
**Surgery** (resection)
70
Why are femoral hernias worrying?
High rate of **strangulation**
71
What are the contents of the femoral canal?
**Lymph** vessels
Lymph nodes
**Loose connective tissue**
72
What are the risk factors for femoral hernia?
**Female**
**Pregnancy**
Raised intra-abdominal pressure
**Increasing age**
73
How to tell the difference between a femoral hernia and inguinal hernia?
**Femoral** = inferno-lateral to the pubic tubercle
**Inguinal** = supero-medial to pubic tubercle
74
How can a femoral hernia be imaged?
**Ultrasound**: operator dependent
**CT** abdo-pelvis
75
How is a femoral hernia managed?
**Surgically**
76
What is gastroenteritis?
**Inflammation of GI tract**
77
What is the most common cause of gastroenteritis?
**Viral infection**
78
What information does the timing of onset give you as to the cause of gastroenteritis?
Bacterial **toxin** = hours
**Virus** = days
**Bacteria** = weeks
**Parasites** = months
79
What is diarrhoea?
3/ more loose stool per day
80
What is acute diarrhoea?
**\< 14 days**
81
What is dysentery
**Gastroenteritis characterised by loose stools** with blood and mucus
82
What are some risk factors for gastroenteritis?
**Poor food prep**
**Poor personal hygiene**
**Immunocompromised**
83
How does gastroenteritis present?
Cramp-like **abdominal pain**
## Footnote
**Diarrhoea**
**Vomiting**
**Night sweats**
84
What should be covered in the history?
**Bowel movements** (blood stained, watery?)
**Affected family / friends?**
Recent **travel abroad?**
Recent **use of abx?**
85
What is the management of gastroenteritis?
**Rehydration**
Education to prevent future episodes
Exclusion from work 24 hours
86
Is food poisoning a notifiable disease?
YES
87
What are some infective causes of gastroenteritis?
**Viruses:** norovirus, rotavirus
**Bacteria**: campylobacter, E.coli, salmonella, shigella
**Bacterial toxins**: Staph aureus, bacillus cereus
**Parasites:** Schistosoma, cryptosporidum
88
How long does norovirus last?
1-3 days of watery diarrhoea
89
What type of bacteria is campylobacter?
**G. Neg bacillus** (from chicken, eggs or milk)
90
What complication can campylobacter infection result in?
**Reactive arthritis**
**Guillan Barre** syndrome
91
Where does Cambylobacter, E. Coli, Salmonella and Shigella all come from?
**Contaminated** foodstuff
92
What kind of organism is C. Diff?
**Gram positive**
93
What is the worrying complication of a C. Diff infection?
Toxic megacolon
94
How does a C. Diff infection present?
**Severe bloody diarrhoea**
95
What are some important causes of dysentery?
**Campylobacter**
**Shigella**
**Salmonella**
**Norovirus**
96
What is a direct inguinal hernia?
Bowel enters **through ‘Hesselbach’s’ triangle**
97
What is an indirect inguinal hernia?
Bowel enters the inguinal canal via **deep inguinal ring**
98
How can direct and indirect hernias be differentiated?
**Indirect**: lateral to the vessels
**Direct**: medial to the vessels
99
What are the risk factors for inguinal hernias?
**Male**
Increasing **age**
**Raised intra-abdominal pressure:** Chronic cough, heavy lifting
Obesity
100
What are the differentials for lump in the groin?
Femoral / inguinal **hernia**
Inguinal **lymphadenopathy**
**Lipoma**
Groin **abscess**
101
How is an inguinal hernia diagnosed?
Clinical diagnosis
102
What is the risk associated with inguinal hernias?
**Strangulation** (bowel ischaemia)
**Incarcerated** hernia (cant return to normal position)
**Obstruction** (bowel obstruction)
103
What are some post op complications of hernia repair?
**Pain, bruising**
**Recurrence**
**Damage to vas deferens** (leading to sub-fertility)
104
What is appendicitis caused by?
**Luminal obstruction:**
Faecolith (stoney faeces)
Lymphoid hyperplasia
105
What are the risk factors for appendicitis?
**FH**
**Caucasian**
**Seasonal** presentation (summer)
106
What are the features of appendicitis?
**Abdo pain**
**Peri-umbilical** (migrating to RIF)
**Vomiting**
**Anorexia**
**Nausea**
Tachycardia
Tachypnoeic
Pyrexial
107
Where is McBurney’s point (where the pain is felt in appendicitis)?
2/3 way between umbilicus and ASIS
108
What ‘signs’ are elicited in appendicitis?
**Rovsing’s sign** (RIF pain on palpagtion of LIF)
**Psoas sign** (RIF pain with extension of the right hip
109
What are the differentials for Lower Right Quadrant pain?
**Gynaecological** (ovarian cyst rupture, ectopic pregnancy, PID)
**Renal** (ureteric stones, UTI, pyelonephritis)
**GI (**Diverticular disease, IBD)
**Urological** (testicular torsion, epididymo-orchitis)
110
What are the investigations for RIF pain?
**Urinalysis** (renal/urological cause)
**Pregnancy test** (or serum b-HCG)
**FBC and CRP**
111
How is appendicitis diagnosed?
Usually a **clinical diagnosis**
Ultrasound can be useful (also rules out gynae problems)
112
What is the definitive treatment of appendicitis?
Laparoscopic appendicectomy
113
What are the complications of acute appendicitis?
**Perforation** (contamination)
**Surgical site infection**
Pelvic **abscess**
114
What is the most common type of colon cancer?
Adenocarcinoma
115
What mutations predispose patients to colon cancer?
**APC**
**HNPCC**
116
What are the risk factors for colon cancer?
**Increasing age**
**FH**
**IBD**
**Low fibre diet**
117
What are the presenting signs of colon cancer?
**Change in bowel habit**
**Rectal bleeding**
**Weight loss**
Abdo pain
118
How do right sided colon cancers present?
Abdo **pain**
**Occult bleeding/anaemia**
**Mass in RIF**
Present late
119
How do left sided colon cancers present?
**Rectal bleed**
**Change in bowel habit**
**Tenesmus**
Mass in LIF
120
What are the main differentials to consider with rectal bleeding and change in bowel habits?
**IBD** (onset 20-40 years old)
## Footnote
**Haemorrhoids**
121
What test is used to detect blood in the faeces?
Faecal Immunochemistry Test **(FIT TEST)**
122
When is the tumour marker CEA used for colorectal cancer?
Monitor **disease progression** (poor diagnostic usage)
123
What is the gold standard for diagnosis of colorectal cancer?
**Colonoscopy with biopsy**
124
What staging is used for colon cancer?
**Dukes** staging
125
What are the surgical options for colon cancer depending on location?
Right Hemicolectomy
Left Hemicolectomy
Sigmoidcolectomy
Anterior resection
Abdominal perineal resection
126
When is an anterior resection used?
**High rectal tumours \> 5cm from anus,** leaving sphincter intact
127
When is an abdominal perineal resection used?
**Low rectal tumour** (excision of the distal colon, rectum and anal sphincters) resulting in permanent colostomy
128
When is Hartmann’s procedure used?
Emergency bowel surgery e.g. obstruction or perforation
129
What is involved in a Hartmann’s procedure?
Complete resection of recto-sigmoid colon
Forming an end colostomy
130
What disease course does Crohn’s take?
**Relapsing, remitting**
131
Where does Crohn’s disease commonly affect?
**Distal ileum**
132
What are the features of the inflammation in Crohn’s?
**Transmural inflammation** (affecting all layers)
**Cobblestone** appearance
Causes **fissures**
Skip lesions
Non-caseating granulomatous inflammation
133
Where is the site of inflammation in UC?
**Mucosa only** (in large bowel)
134
What are some risk factors for Crohn’s?
**FH**
**Smoking**
135
What are the presenting features of Crohn’s?
**Episodic abdo pain**
**Bloody** chronic **diarrhoea**
**Malaise**
**Oral ulcers**
**Peri-anal disease** (skin tags, abscesses)
136
What are the extra-intestinal features of Crohn’s?
**Arthritis** of large joints
**Erythema nodosum**
**Pyoderma gangrenosum** (ulcers on the shins)
Anterior **uveitis**
Renal stones
137
What investigations are there for Crohn’s?
Routine **bloods for anaemia**
**Abdo xray** for toxic megacolon
**Faecal calprotectin** (sensitivity for IBD)
138
What is the gold standard investigation for Crohn’s?
**Colonoscopy with biopsy**
139
How is Crohn’s managed?
**Fluids,** nutritional support, prophylactic heparin
**Inducing remission** - **corticosteroid therapy & immunosuppressive agents** (mesalazine/azathioprine)
**Maintaining remission - azathioprine**
(**Biologics** have been used in acute flare ups e.g. infliximab)
140
What are some complications of Crohn’s disease?
**Fistula**
**Stricture**
141
Where are **diverticulum** (outpouching) usually found?
**Sigmoid colon**
142
What is diverticulosis, diverticulitis and diverticular disease and Diverticular bleed?
**Diverticulosis** = Presence of diverticula
**Diverticulitis** = inflammation of diverticula
**Diverticular disease** = symptoms of diverticula
**Diverticular bleed** = diverticulum erodes into a vessel
143
What are the risk factors for diverticulum?
**Age**
**Low dietary fibre intake**
**Obesity**
**Smoking**
**Family history**
144
How does Diverticular disease present?
**Intermittent low abdo pain**
**Altered bowel habit**
**Flatulence**
NO SYSTEMIC SYMPTOMS
145
How does acute diverticulitis present?
**Acute abdo pain**
Normally **pain in LIF**
**Decreased appetite**
**Pyrexia**
146
What are the differentials for lower abdo pain and bowel symptoms?
**IBD**
Bowel **cancer**
**Mesenteric ischaemia**
**Gynaecological causes**
147
What investigations can be done for those with symptoms of diverticular disease?
Routine **blood tests**
**FBC**
**CRP**
**U&Es**
Faecal calprotectin?
G&S
148
What can be used to image diverticulitis?
CT abdo-pelvis
149
What is the imaging for uncomplicated diverticular disease?
**Flexible sigmoidoscopy**
150
How is diverticular disease managed?
**Analgesia**
Encourage **oral fluid intake**
151
How is acute diverticulitis managed?
**ABx**
**Fluids**
**Analgesia**
152
What is the surgical management of Diverticular disease?
In **perforation** with faecal peritonitis / overwhelming **sepsis**
**HARTMANN’S PROCEDURE** (sigmoid colectomy and formation of end colostomy)
**Anastomosis** with reversal of colostomy may be available at a **later date**
153
What are some complications of diverticular disease?
**Stricture**
**Fistula** (colovesical: UTIs, colovaginal)
154
What is pseudo-obstruction?
**Dilatation of the colon** due to an adynamic bowel (absence of mechanical dysfunction)
155
What are the associated risks of pseudo-obstruction?
**Toxic megacolon**
**Bowel ischaemia**
**Perforation**
156
What things can cause pseudo-obstruction?
**Hypercalcaemia, hypothyroidism**
**Opiods**, CCB
**Recent surgery**
**MS**
157
What are the features of pseudo obstruction?
Abdo **pain**
Abdo **distension**
**Constipation**
**Vomiting** = late feature
158
What are the differentials for bowel obstruction?
**Pseudo-obstruction**
**Paralytic ileus**
**Toxic megacolon**
159
What blood tests should be used for pseudo-obstruction?
**U&E**s
**Ca2+**
**Mg2+**
**TFT**s
160
How should patients with **pseudo-obstruction** be managed?
**Nil-by mouth**
Started on **IV fluids**
**NG tube** (for vomiting)
161
How is the inflammation in UC?
**Diffuse continual mucosal inflammation** from rectum
**Crypt abscesses**
**Smoking** is **protective**
**Non granulomatous**
**Thumbprinting**
162
How does UC present?
**Bloody diarrhoea**
**Mucus discharge**
Increased frequency
163
What are the extra intestinal signs of UC?
**Arthritis**
**Erythema nodosum**
**Uveitis**
**Primary sclerosing cholangitis**
164
What are the investigations for UC?
**Routine bloods:** FBC, U&Es, CRP, LFTs and clotting
Faecal **calprotectin**
165
How is an acute attack of UC treated?
**Corticosteroid** therapy
Prophylactic **heparin**
**Corticosteroid** therapy / immune supppressive agents (azathioprine)
166
What can be used for maintaining remission in UC?
**Mesalazine or Sulfasalazine**
167
What are the life threatening complications of UC?
**Toxic megacolon**
**Bowel perforation**
168
What is a volvulus?
**Twisting of loop of intestine** around its mesentery
169
Where do most volvuli occur?
Sigmoid colon (due to its long mesentery)
170
What are the risk factors for volvulus?
Increasing **age**
Resident in **nursing home**
**Chronic constipation**
171
What are the features of volvulus?
**Colicky pain**
Abdo **distension**
Absolute **constipation**
172
What are the differentials for bowel obstruction?
**Pseudo obstruction**
Severe **constipation**
Sigmoid **diverticular disease**
173
What should be checked in volvulus?
**Bloods** (incl. electrolytes, Ca2+, TFT for pseudo-obstruction)
174
How is UC diagnosed?
**Colonscopy with biopsy**
**Abdo X-ray** for toxic megacolon
175
What does a sigmoid volvulus show on XR?
**Coffee-bean sign**
176
How is a sigmoid volvulus treated?
**Sigmoidoscope** decompression
177
What are the indications for surgery (Hartmann’s) in UC?
**Colonic ischaemia**
Repeated **failed decompressions**
**Necrotic bowel**
178
What are the immediate complications from sigmoid volvulus?
Bowel **ischaemia**
## Footnote
**Perforation**
179
What are the risk factors for anal cancer?
**HPV infection (16&18)**
**HIV**
Increasing **age**
**Immunosuppression**
180
What are the main symptoms of anal cancer?
**Rectal pain**
Rectal **bleeding**
**Anal discharge**
181
Where does lymph drain from below the dentate lines?
**Superficial inguinal nodes**
182
Where does lymph drain from above dentate lines?
Para-aortic
183
What are the differentials for anal cancer?
**Haemorrhoids**
**Anal fissures**
**Fistula in ano**
**Anal warts**
184
What are the initial investigations for anal cancer?
**Proctoscopy**
185
What is the surgery for anal cancer?
**Abdominoperineal resection **
186
What is an anal fissure?
**Tear in the mucosal lining of the anal canal** (Acute \< 6 weeks)
187
What are the risk factors for anal fissures?
**Constipation**
**Dehydration**
**IBD**
**Chronic diarrhoea**
188
How do anal fissures present?
Intense **pain post defecation**
## Footnote
**Bleeding**
**Itching**
189
Where do most anal fissures present?
**Posterior midline**
190
How can anal fissures be managed?
Increasing **fibre and fluid intake**
**Stool softening laxatives**
Topical anaesthetics such as lidocaine
Hot baths (healing process)
191
What is an anorectal abscess?
Collection of **pus in the anal region**
192
What are some common organisms in anorectal abscesses?
E. Coli
Enterococcus spp.
193
What are the features of anorectal abscesses?
**Pain** in perianal region, exacerbated when sitting down
Localised **swelling**
**Itching**
Discharge
194
What is the management for anorectal abscesses?
**Abx**
**Analgesia**
**Incision and drainage**
195
What are haemorrhoids?
Abnormal **swellings of anal vascular cushions**
196
What are the risk factors for haemorrhoids?
Excessive straining (**constipation**)
Increasing **age**
**Raised intra abdo pressure** (pregnancy, chronic cough, ascites)
197
How do haemorrhoids present?
Painless **bright red bleeding** after defecation
**Priritus** (mucus discharge)
Anal **lump**
198
What are some differentials to consider for rectal bleeding?
**Malignancy**
**IBD**
**Diverticular disease**
199
How are haemorrhoids diagnosed?
Proctoscopy
200
How are haemhorroids managed?
Increase daily **fibre** / fluid intake
**Laxatives**
Rubber band **ligation** (only above dentate line)
201
What are some complications of haemhorroids?
**Thrombosis**
**Ulceration**
**Gangrene**
202
What are some risk factors for a perianal fistula?
Perianal **abscess**
**Crohn’s / UC**
Previous **radiation** to anal canal
203
What are some risk factors for rectal prolapse?
Increasing **age**
**Female** gender
**Multiple deliveries**
204
How do rectal prolapses present?
Rectal **mucus discharge**
Faecal **incontinence**
Per rectum **bleeding**
Visible **ulceration**
Prolapse visible on asking patient to strain
205
What is the management of rectal prolapse?
Increase dietary **fibre** and fluid intake
Definitive **surgical** repair
206
What lines should incisions follow?
**Langer’s lines** for wound strength and minimal scarring
207
Where is a midline incision?
Anywhere from xiphoid process to pubic symphysis
208
What incision is used to gain access to the gallbladder along the costal margin
**Kocher** incision
209
Why does bowel obstruction require fluid resuscitation?
Due to secretion of large volumes of electrolyte-fluid into the bowel after increased peristalsis (**3rd spacing**)
210
What commonly causes small bowel obstruction?
Adhesions and herniae
211
What commonly causes large bowel obstruction?
**Malignancy**, **diverticular** disease and **volvulus**
212
What are the clinical features of bowel obstruction?
**Pain**
**Vomiting**
Abdo **distension**
Absolute **constipation**
Tinkling bowel sounds
213
What are the lab tests for bowel obstruction?
**RBC, CRP, U&Es, LFTs, G&S**
Venous blood gas (for high lactate - evidence of ischaemia)
214
What is the imaging of choice in bowel obstruction?
**CT scan** with IV contrast
215
Why is CT better than XR for bowel obstruction?
Differentiate between **mechanical and pseudo-obstruction**
Can find the **site** and cause of obstruction
May show **mets**
216
How do small bowel and large bowel obstruction appear on XR?
**Small** = dilated bowel, central location, lines crossing the bowel
**Large** = dilated, peripheral location, haustra lines visible
217
What is the conservative management of bowel obstruction?
**Drip and suck** =
Start IV fluid and NG tube to decompress the bowel
Urinary catheter and fluid balance
**Analgesia**
218
What are the complications of bowel obstruction?
Bowel **ischaemia**
Bowel **perforation**
**Dehydration** and renal impairment
219
What is dysphagia?
**Difficulty in swallowing**
220
What are some causes of dysphagia?
Oesophageal **malignancy**
Oesophageal **strictures**
Pharyngeal **pouch**
**Achalasia**
Post stroke
Spasm
221
What are the investigations for dysphagia?
**Endoscopy + biopsy**
**FBC, LFTs**
Manometry
222
What are the 2 common causes of GI perforation?
Peptic **ulcer**
Sigmoid **diverticulum**
223
What are the differentials for acute abdominal pain?
Acute **pancreatitis**
**MI**
Ovarian **torsion**
**Ruptured aneurysm**
GI perforation
224
What are the investigations for an acute abdomen?
**Routine blood tests**
**G&S**
**WCC**
**CRP**
225
Name 3 causes for acute mesenteric ischaemia?
**Atherosclerosis**
**Embolus** from AF
**Hypovolaemic** shock
226
How does acute mesenteric ischaemia present?
**Abdo** pain out of proportion to clinical findings
## Footnote
**Nausea**
**Vomiting**
227
What is the definitive diagnosis of acute mesenteric ischaemia informed by?
**CT scan** with IV contrast
228
What is the initial management of acute mesenteric ischaemia?
**Urgent resuscitation**
**Catheter**
**Fluid balance chart**
Broad-spectrum Abx for risk of perforation
229
What is the definitive management of acute mesenteric ischaemia?
**Excision of necrotic bowel**
**Revascularisation**
230
What are the main risks form mesenteric ischaemia?
**Bowel necrosis and perforation**
**Mortality**
231
What is the imaging for gastro perforation?
**eCXR to show air** (70% sensitive)
Gold standard = **CT**
232
What is the management of GI perforation?
**Broad spectrum Abx**
IV **fluid** support
**Nasogastric tube**
233
What can cause haematemesis?
* Oesophageal **varices** (urgent OGD)
* Gastric **ulceration** (lesser curve of stomach)
* **Mallory-Weiss tear**
* **Oesophagitis** (bisphosphonates)
234
What are the investigations for haematemesis?
FBC
U&Es
LFTs (liver cause?)
Clotting
VBG
G&S
Erect chest x ray (pneumoperitoneum)
235
What scoring system can be used to risk stratify pts with upper GI bleed?
Glasgow-Blatchford Bleeding Score
236
What is the management of patients with an upper GI bleed?
**A-E** assessment
Insert **2 large bore IV cannulas**
**Fluid** resuscitation
**Crossmatch** blood
237
How is a peptic ulcer bleed managed?
Inject **adrenaline**
**Cauterise** bleed
High dose **PPI**
238
How should oesophageal varies be managed?
Endoscopic banding
Terlipressin (reduce splanchnic blood flow)
239
What can cause melena?
Peptic **ulcer** disease
* *Variceal bleeds**
* *Upper GI malignancy**
240
What artery is eroded in peptic ulcer disease?
Gastroduodenal
241
What are the investigations for melena?
* **Routine bloods**
* **FBC**
* **U&Es**
* LFTs (liver problems )
* Clotting
* Raised urea is indicative of an upper GI bleed (digested Hb)
* ABG
* OGD
242
What causes fresh rectal bleeding?
* Diverticular disease
* Ischaemic colitis
* Haemorrhoids
* Malignancy
* Angiodysplasia
* Crohns
* UC
243
What are the investigations for a GI bleed?
FBC
U&Es
LFT
Clotting
G&S
Stool culture (for infective cause)
244
How are patients with a lower GI bleed managed if they are stable/unstable?
* *Unstable** = Urgent CT angiogram (source of bleeding)
* *Stable** = flexible sigmoidoscopy
245
How are unstable rectal bleeds managed?
* **Fluid resuscitation**
* **Hb \< 70** transfusion of packed RBCs
* **Anti-coag stopped**
246
What can cause an acute abdomen?
* Ruptured AAA
* Ruptured ectopic
* Bleeding gastric ulcer
* Trauma
* Peritonitis
247
How do patients with generalised peritonitis present?
Completely **still** (not to move abdomen)
**Tachycardia**
Involuntary guarding
Reduced / absent bowel sounds (paralytic ileus)
248
What can cause RUQ pain?
Cholecystitis
Pyelonephritis
Ureteric colic
Hepatits
Pneumonia
249
What can cause LUQ pain?
Pyelonephritis
Gastric ulcer
Ureteric colic
Pneumonia
250
What can cause RLQ pain?
Appendicitis
Ureteric colic
Inguinal hernia
IBD
UTI
Gynae
251
What can cause LLQ pain?
Diverticulitis
Ureteric colic
Inguinal hernia
IBD
UTI
Gynae
Testicular torsion
252
What are the investigations in acute abdomen?
**Urine dipstick (infection)**
**Pregnancy** test
**ABG** (for sepsis)
**FBC, U&Es, LFTs, CRP, amylase**
**Serium calcium (pancreatitis)**
**G&S**
**Blood cultures**
ECG (for MI)
Ultrasound KUB for renal pathology, biliary tree for gallstones
eCXR (bowel perforation)
253
What is the general management of the acute abdomen?
* IV access
* NBM
* Analgesia
* VTE prophylaxis
* Urine dip
* Bloods
254
What is the small bowel usual diameter upper limit?
Large bowel?
Caecum?
3cm
6cm
9cm
255
What is the "Top and Tail" investigation for GI malignancy?
OGD and Colonoscopy
256
What is a covering loop ileostemy
A temporary ileostomy created to protect a distal anastomosis
257
When is ultrasound better than CT for imaging the abdo?
Ovarian cysts
Cholecystitis
258
What stimulates contraction of the gallbladder?
CCK from the duodenum
259
What term describes the process of **making an incision into the abdomen** to explore as an **open procedure** the contents of the abdomen?
Laparotomy
260
What might a surgeon use a Rutherford Morrison incision for?
**Renal transplant**
261
what factors normally prevent reflux?
262
what are the investigations for a suspected upper GI malignancy?
OGD
CT chest abdo pelvis and PET- CT for mets
Endoscopic ultrasound to measure penetration into oesophageal wall
263
What is the main complication follow oesophageal carcinoma treatment?
anastomotic leak, pneumonia, death
264
what is the removal of the oesophagus called?
Oesophagectomy - removes tumour, top of stomach and surrounding lymph nodes, stomach is then made into a tube to replace the oesophagus (Ivor-Lewis procedure does this by laparotomy)
265
when can a patient eat after oesophagectomy?
2 weeks
266
What is the consequence of poorly controlled post op pain?
slower recovery
reluctance to mobilise
Inadequate ventilation and subsequent atelectasis
267
What is atelectasis?
Partial collapse of the small airways due to impairment of surfactant production causing hypoxaemia, pulmonary infections
Diagnosed CLINICALLY
268
What is the treatment for atelectasis?
Deep breathing exercises and chest physio, adequate pain control
269
On what cells do PPIs work?
Gastric parietal cells
270
what causes EPIGASTRIC PAIN?
271
what causes EPIGASTRIC PAIN?
peptic ulcer disease
Cholecystitis
Pancreatitis
Myocardial Infarction
272
How to interpret LFTs ?
is ALT raised more than 10 times? (Hepatocyte injury)
Is ALP raised more than 3 times? (Cholestasis indicator)
Is GGT raised? (Biliary obstruction / alcohol)
Isolated raised ALP (non-hepatobiliary = bony mets, vit D deficiency, fracture)
Isolated raised bilirubin? (Pre hepatic cause e.g. gilberts, haemolysis)
Ratio between AST/ALT (AST\> then alcoholic/cirrhosis or if ALT\>AST then chronic liver disease)
273
What can cause acute hepatocellular injury?
Poisoning (paracetamol)
Infection (hep A/B)
Liver ischaemia
274
What is a Whipple's procedure?
Removal of head of pancreas, start of duodenum, gallbladder
## Footnote
**Tail of pancreas and hepatic duct are then attached to the jejunum**
275
What is courvisiers law?
Pesence of jaundice and enlarged gallbladder = pancreatic cancer
**Treatment** = radical resection
