General surgery Flashcards
1
Q
what diseases can occur in right upper quadrant pain?
A
- Bilary Colic
- Cholecystitis/Cholangitis
- Duodenal Ulcer
- Liver abscess
- Portal vein thrombosis
- Acute hepatitis
- Nephrolithiasis
- RLL pneumonia
2
Q
what diseases can occur with epgastrium pain?
A
- Acute gastritis/GORD
- Gastroparesis
- Peptic ulcer disease/perforation
- Acute pancreatitis
- Mesenteric ischaemia
- AAA (Abdominal Aortic Aneurysm) Aortic dissection
- Myocardial infarction
3
Q
what diseases can occur with left upper quadrant pain?
A
- Peptic ulcer
- Acute pancreatitis
- Splenic abscess
- Splenic infarction
- Nephrolithiasis
- LLL Pneumonia
4
Q
what diseases can occur with right lower quadrant pathology?
A
- Acute Appendicitis
- Colitis
- IBD
- Infectious colitis
- Ureteric stone/Pyelonephritis
- PID/Ovarian torsion
- Ectopic pregnancy
- Malignancy
5
Q
what diseases can occur with suprapubic/central pathology?
A
- Early appendicitis
- Mesenteric ischaemia
- Bowel obstruction
- Bowel perforation
- Constipation
- Gastroenteritis
- UTI/Urinary retention
- PID
6
Q
what diseases can occur with left lower quadrant pathology?
A
- Diverticulitis
- Colitis
- IBD
- Infectious colitis
- Ureteric stone/Pyelonephritis
- PID/Ovarian torsion
- Ectopic pregnancy
- Malignancy
7
Q
what is the presentation of bowel ischemia?
A
- Sudden onset crampy abdominal pain
- Severity of pain depends on the length and thickness of colon affected
- Bloody, loose stool (currant jelly stools)
- Fever, signs of septic shock
8
Q
what is the presentation of acute mesenteric ischaemia?
A
small bowel
usually occlusive due to thromboemboli
sudden onset (presentation and severity varies)
abdominal pain out of proportion of clinical signs
9
Q
what is the presentation of ischaemic colitis?
A
large bowel
usually due to non-occlusive low flow states or atheroscelerosis
more mild and gradual
moderate pain and tenderness
10
Q
what are the risk factors for bowel ischaemia?
A
- Age >65 yr
- Cardiac arrythmias (mainly AF), atherosclerosis
- Hypercoagulation/thrombophilia
- Vasculitis
- Sickle cell disease
- Profound shock causing hypotension
11
Q
what investigations can be done for suspected bowel ischaemia?
A
bloods
imaging
endoscopy
12
Q
what are the bloods seen in bowel ischaemia?
A
FBC: neutrophilic leukocytosis
VBG: lactic acidosis
13
Q
what imaging can be done in bowel ischaemia?
A
- Imaging-CTAP/CT angiogram
- Detects:
- Disrupted flow
- Vascular stenosis
- ‘pneumatosis intestinalis’ (transmural ischaemia/ infarction)
- Ischaemic colitis: Thumbprint sign (unspecific sign of colitis)
- Detects:
14
Q
when is endoscopy done in bowel ischaemia?
A
for mild/moderate cases of ischaemic colititis (oedema, cyanosis, ulceration mucosa)
15
Q
what conservative management can be used for bowel ischaemia?
A
- Mild to moderate cases of ischaemic colitis (not suitable for Small Bowel/acute mesenteric ischaemia)
- IV fluid resuscitation
- Bowel rest (Nil by mouth)
- Broat spectrum Abx- colonic ischaemia can result in bacterial translocation & sepsis
- NG tube for decompression- in concurrent ileus
- Anticoagulation
- Treat/manage underlying cause
- Serial abdominal examination and repeat imaging
16
Q
what are the indications for surgery in bowel ischaemia?
A
- Small bowel ischaemia
- Signs of peritonitis or sepsis
- Haemodynamic instability
- Massive bleeding
- Fulminant colitis with toxic megacolon
17
Q
what surgery can be done for bowel ischaemia?
A
- Exploratory laparotomy
- Resection of necrotic bowel +/- open surgical embolectomy
- Or mesenteric arterial bypass
- Endovascular revascularisation
- Balloon angioplasty/ thrombectomy
- In patients without signs of ischaemia
18
Q
what is the presentation of acute appendicitis?
A
- Initially periumbilical pain that migrates to RLQ (within 24 hrs)
- Anorexia, nausea +/- vomiting, low grade fever, change in bowel habit
- Important clinical signs
- McBurney’s point:
- Tenderness in RLQ (lateral 1/3 of a hypothetical line drawn from right ASIS to umbilicus)
- Blumberg sign
- Rebound tenderness especially in RIF
- Rovsing sign
- RLQ pain elicited on deep palpation of the LLQ
- Psoas sign
- RLQ pain elicited on flexion of right hip against resistance
- Obturator sign
- RLQ pain on passive internal rotation of the hip with hip and knee flexion
- McBurney’s point:
19
Q
what blood results are present in acute appendicitis?
A
- FBC: neutrophilic leukocytosis
- ↑ed CRP
- Urinalysis: possible mild pyuria/haematuria
- Electrolyte imbalances in profound vomiting
20
Q
what imaging is used in acute appendicitis?
A
- CT: gold standard in adults esp. if age > 50
- USS: children/pregnancy/breastfeeding
- MRI: in pregnancy if USS inconclusive
21
Q
what is done if suspected appendicitis with persistent pain and inconclusive imaging?
A
diagnostic laparoscopy
22
Q
how is the likelihood of appendicitis calculated?
A
23
Q
what is the conservative management for appendicitis?
A
- IV fluids, analgesia, IV or PO antibiotics
- In abscess, phlegmon or sealed perforation
- Resuscitation + IV Abx +/- percutaneous drainage
- CT guided drainage
- Consider interval appendectomy- rate recurrence after conservative management of abscess/ perforation is 12-14%
24
Q
what are the indications for conservative management?
A
- After -ve imaging in selected patients with clinically uncomplicated appendicitis
- In delayed presentation with abscess/ phlegmon formation
25
what surgical management is used for appendicitis?
* appendectomy
* Usually laparoscopically
* Less pain
* Lower infection
* Decreased hospital stay
* Earlier return to work
* Overall costs
* Better quality of life scores
26
what is a bowel obstruction?
intestinal obstruction- restriction of normal passage of intestinal contents
27
what are the types of bowel obstruction?
* Paralytic (adynamic) ileus
* Mechanical
28
how is mechanical obstruction classified?
speed of onset
site
nature
aetiology
29
what are the possible speed of onsets of mechanical obstruction?
acute
chronic
acute on chronic
30
what are the possible sites of mechanical obstruction
high or low
roughly synonymous with small or large bowel obstruction
31
what are the possible nature of mechanical obstruction
* Simple vs strangulation
* Simple: bowel is occluded without damage to blood supply.
* Strangulating: blood supply of involved segment of intestine is cut off (e.g. in strangulated hernia, volvulus, intussusception)
32
what are the possible aetiologies of bowel obstruction?
* Causes in lumen- faecal impaction, gallstone ‘ileus’
* Causes in the wall- Crohn’s disease, tumours, diverticulitis of colon
* Causes outside wall
* Strangulated hernia (external or internal)
* Volvulus
* Obstruction due to adhesions or bands
33
what are the possible causes of small bowel obstruction?
adhesions- history previous abdo surgry
neoplasia (primary, metastatic, extraintestinal)
incarcerated hernia(external- abdo wall, internal-mesenteric defect)
crohn's disease (acute-oedma, chronic-strictures)
other ( intussusception, intraluminal (foreign body, bezoar)
34
what are the causes of large bowel obstruction?
colorectal carcinoma
volvulus
diverticulitis
faecal impaction
Hirschsprung disease
35
what is the presentation differences between small and large bowel obstruction?
36
how is bowel obstruction diagnosed?
* Diagnosed by presence of symptoms
* Examination should always include search for hernias & abdominal scare, including laparoscopic port holes
* Is it simple or strangulation?
37
what are the features suggesting strangulation?
* Change character pain from colicky to continuous
* Tachycardia
* Pyrexia
* Peritonism
* Bowel sounds absent or reduced
* Leucocytosis
* Increase CRP
38
is a large or small hernia more dangerous?
large is less dangerous as less change obstruction and ischaemic bowel
39
what are the common hernial sites?
epigastric
umbillical
incisional
inguinal
femoral
40
how does a hernia cause obstruction?
neck of sack forms strangulated hernia -\> richter's hernia
41
what are the blood results for hernia?
* WCC/CRP usually normal (if raised suspicion of strangulation/perforation)
* U&E: electrolyte imbalance
* VBG if vomiting: HypoCl-,HypoK+ metabolic alkalosis
* VBG if strangulation: Metabolic Acidosis (lactate)
42
what imaging is done for hernias?
* Erect CXR/ AXR
* **SBO:** Dilated small bowel loops **\>3cm** proximal to the obstruction (central)
* **LBO:** Dilated large bowel **\>6cm** (if caecum **\>9cm**) predominantly peripheral
* **CT abdo/pelvis** → Transition point, dilatation of proximal loops – IV +/- oral contrast if possible
43
what is seen in a Abdo XRay for small bowel obstruction?
* Ladder pattern of dilated loops & their central position
* Striations that pass completely across the width of the distended loop produced by the circular mucosal folds
44
what is seen on an Xray for large bowel obstruction?
* Distended large bowel tends to lie peripherally
* Show haustrations of taenia coli - do not extend across whole width of the bowel.
45
what can a CT scan show about a bowel obstruction?
* Can localise site of obstruction
* Detect obstruction lesions & colonic tumours
* May diagnose unusual hernias (e.g obturator hernias)
46
when is conservative management used for bowel obstruction?
* In patients with no signs of ischaemia/no signs of clinical deterioration
* supportive management combined with conservative treatment
47
what are the supportive managements for bowel obstruction?
* NBM (nil by mouth), IV peripheral access with large bore cannula - IV Fluid resuscitation
* IV analgesia, IV antiemetics, correction of electrolyte imbalances
* NG tube for decompression (also stop aspiration pneumonia), urinary catheter for monitoring output
* Introduce gradual food intake if abdominal pain and distention improve
48
what are the options for conservative treatment for bowel obstruction?
* Faecal impaction: stool evacuation (manual, enemas, endoscopic)
* Sigmoid volvulus: rigid sigmoidoscopic decompression
* SBO: oral gastrograffin (highly osmolar iodinated contrast agent) can be used to resolve adhesional small bowel obstruction
49
what are the indications for surgical management in bowel obstruction?
* Haemodynamic instability or signs of sepsis
* Complete bowel obstruction with signs of ischaemia
* Closed loop obstruction
* Persistent bowel obstruction \>2 days despite conservative management
50
what operation is done for bowel obstruction?
* Exploratory laparotomy/ laparoscopy
* Restoration of intestinal transit (depending on intra-operational findings)
* Bowel resection with primary anastomosis or temporary/ permanent stoma formation
* Endoscopic stenting if obstruction is distal is always an option
51
What is the presentation for GI perforation?
* Sudden onset severe abdominal pain associated with distention
* Diffuse abdominal guarding, rigidity, rebound tenderness
* Pain aggravated by movement
* Nausea, vomiting, absolute constipation
* Fever, Tachycardia, Tachypnoea, Hypotension
* Decreased or absent bowel sounds
52
what are the signs of a perforated peptic ulcer?
sudden epigastric or defuse pain
referred shoulder pain
history of NSAIDs, steroids, recurrent epigastric pain
53
what are the signs of perforated appendix?
migratory pain
anorexia
gradual worsening RLQ pain
54
what are the signs of perforated diverticulum?
LLQ pain
constipation
insidious onset
55
what are the signs of perforated malignancy?
change in bowel habit
weight loss
anorexia
PR bleeding
56
what are the bloods in someone with GI perforation?
* FBC: neutrophilic leucocytosis
* Possible elevation of urea, creatinine
* VBG: lactic acidosis
57
what is seen in imaging in someone with GI perforation?
* **Erect CXR** → subdiaphragmatic free air (pneumoperitoneum)
* **CT abdo/pelvis** → Pneumoperitoneum, free GI content, localised mesenteric fat stranding
Can exclude common differential diagnoses such as pancreatitis
58
what are the differential diagnosis of GI perforation?
* Acute cholecystitis, appendicitis
* Myocardial infarction, acute pancreatitis (check analyse)
59
what are the conservative managements for GI perforation?
* NBM & NG tube
* IV peripheral access with large bore cannula - IV Fluid resuscitation
* Broad spectrum Abx
* IV PPI
* Parenteral analgesia & antiemetics
* Urinary catheter
60
what is the conservative management in localised peritonitis without signs of sepsis?
* IR - guided drainage of intra-abdominal collection
* Serial abdominal examination & abdominal imaging for assessment
61
when is surgical management used in GI perforation?
* In generalised peritonitis +/- signs of sepsis
62
what surgery is done in GI perforation?
* Exploratory laparotomy/laparascopy
* Primary closure of perforation with or without omental patch (most common in perforated peptic ulcer)
* Resection of the perforated segment of the bowel with primary anastomosis or temporary stoma
* Obtain intra-abdominal fluid for MC&S, peritoneal lavage
63
what surgery is done for perforated appendix?
laparoscopic or open appendectomy
64
what is done on GI perforation if malignancy?
intraoperative biopsies if possible
65
what are the symptoms of biliary colic?
* Postprandial RUQ pain with radiation to the shoulder.
* Nausea
66
what are the symptoms of acute cholecystitis?
* Acute, severe RUQ pain
* Fever
* Murphy's sign
67
what are the symptoms of acute cholangitis?
Charcot's triad: jaundice, RUQ pain, fever
68
what are the symptoms for acute pancreatitis?
* Severe epigastric pain radiating to the back
* Nausea +/- vomiting
* Hx of gallstones or EtOH use
69
what are the investigation results for biliary colic?
* Normal blood results
* USS: cholelithiasis
70
what is the management for biliary colic?
* Analgesia, Antiemetics, Spasmolytics
* Follow up for elective cholecystectomy
71
what are the investigation results for acute cholecystitis?
* Elevated WCC/CRP
* USS: thickened gallbladder wall
72
what is the management for acute cholecystitis?
* Fluids, ABx, Analgesia, Blood cultures
* Early (\<72 hours) or elective cholecystectomy (4-6 weeks)
73
what is the investigation results for acute cholangitis?
* Elevated LFTs, WCC, CRP, Blood MCS (+ve)
* USS: bilary dilatation
74
what is the management for acute cholangitis?
* Fluids, IV Abx, Analgesia
* ERCP (within 72hrs) for clearance of bile duct or stenting
75
what is the investigation results for acute pancreatitis?
* Raised amylase/lipase
* High WCC/Low Ca2+
* CT and US to assess for complications/cause
76
what is the management for acute pancreatitis?
* Admission score (Glasgow-Imrie)
* Aggressive fluid resuscitation, O2
* Analgesia, Antiemetics
* ITU/HDU involvement
