General Surgery Flashcards
1
Q
How can an anastomotic leak present?
A
New onset atrial fibrillation, fever and feculent material present in the abdominal wound drain
2
Q
IVDU groin swellings
A
May be pseudoaneurysms (CT to exclude) Psoas abscess (triad of fever, back pain, limp)
3
Q
Presentation of Psoas abscess
A
Fever, back pain, limp
usually in immunocompromised individuals
4
Q
Positions of femoral and inguinal hernias
A
Femoral - below and lateral to pubic tubercle
Inguinal - above and lateral to pubic tubercle
5
Q
Structures in femoral triangle (medial to lateral)
A
Lymphatics
Femoral Vein
Femoral Artery
Femoral Nerve
6
Q
Lateral border of femoral triangle
A
Sartorius muscle
7
Q
Medial border of femoral triangle
A
Adductor longus muscle
8
Q
Superior border of femoral triangle
A
Inguinal ligament
9
Q
Difference between mid-inguinal and midpoint of inguinal canal
A
Mid inguinal is midpoint between pubic SYMPHYSIS and ASIS
Midpoint of the inginal canal (is more lateral as it) lies between the pubic TUBERCLE and ASIS
10
Q
Anterior border of inguinal canal
A
Aponeurosis of external oblique
11
Q
Posterior wall of inguinal canal
A
Transversalis fascia
12
Q
Roof of inguinal canal
A
transversalis fascia, internal oblique and transversus abdominis
13
Q
Floor of inguinal canal
A
inguinal ligament
14
Q
Which two horizontal anatomical planes are used to divide the abdomen into 9 regions
A
Transpyloric
Transtubular
15
Q
Pain worse on eating
A
Peptic ulcer
16
Q
Food relives pain
A
Duodenal ulcer
17
Q
Abdominal pain that is relieved by leaning forward
A
Think pancreatitis
18
Q
Patients with abdominal pain that refuses to be examined and move
A
Think peritonism
19
Q
Indications of abdominal X-ray
A
complicated constipation, foreign body, complicated colitis
20
Q
Air under which hemidiaphragm is more worrying
A
Right-sided air is more sensitive for free abdominal gas
Left-sided is normal due to stomach gas
21
Q
Diagnosing hernia
A
Clinical
If needed USS is first line
If there are features of obstruction or strangulation then CT
22
Q
Coffee-ground vomiting
A
Non-active (bleeding has stopped) haematemesis
23
Q
Malaena vs iron-tablet stools
A
Malaenia - black foul smelling stool
Iron-tablets cause black stool with lack of distinctive smell
24
Q
UGI bleed with recent history of aortic graft or AAA repair
A
Aortoenteric fistula
25
Difference between MW tear and Boerhaave's syndrome
MW tear - superficial mucosal tear
| Boerhaave's syndrome - full thickness tear
26
Management of complicated/ruptured gastric ulcers
Repair, biopsy, OGD in 6-8 weeks
Non-healing risk of malignancy
27
Which artery is involved in major haemorrhages following peptic ulcer disease?
gastroduodenal artery
28
Anatomy relevant to an indirect inguinal hernia
Protrudes through the inguinal ring
| Passes lateral to the inferior epigastric artery
29
Anatomy relevant to femoral hernias
Protrudes below the inguinal ligament, lateral to the pubic tubercle
30
Cause of direct inguinal hernia
weakness of transversalis fascia in Hesselbach triangle
31
Cause of direct inguinal hernia
failure of processus vaginalis to close
32
Which type of hernia is an emergency due to its high risk of strangulation?
Femoral
33
Classification of direct and indirect inguinal hernias wrt Hesselbach triangle
Hernias occurring within the triangle tend to be direct and those outside - indirect.
34
Boundaries of Hesselbach Triangle
Medial - rectus abdominis
Lateral - inferior epigastric vessels
Inferior - inguinal ligament
35
When is laparoscopic repair favoured in inguinal hernia repair?
Recurrent hernias and those which are bilateral
36
What type of inguinal hernia is common in children?
Indirect - through inguinal canal due to patent processus vaginalis
37
What type of inguinal hernia is common in adults?
Direct - through Hesselbach's triangle
38
Return to work following hernia repair
open repair - non-manual work after 2-3 weeks
laparoscopic repair - 1-2 weeks
39
Hernias that cannot be reduced
Incarcerated
40
Should strangulated hernias be reduced when awaiting surgery
No - may precipitate generalised peritonitis
41
Associations of umbilical hernia in children
Associations
Afro-Caribbean infants
Down's syndrome
mucopolysaccharide storage diseases
42
Inguinal hernia in children
<1 year very high risk of strangulation so emergency procedure required
>1 year lower risk so elective fix
43
Sign. colicky pain after eating a fatty meal
Biliary colic - gallstone lodged in bile duct
Differentiated from acute cholecystitis by lack of fever and inflammatory markers
44
Sign. Murphy's positive
Acute cholecystitis
45
Sign. Rovsings
appendicitis
46
Sign. Boas
cholecystitis
47
Cullens sign
Pancreatitis or intra-abdominal haemorrhage
48
Grey-Turners sign
Pancreatitis or retroperitoneal haemorrhage
49
Features of ascending cholangitis
RUQ pain
Fever
Jaundice
This is known as Charcot's triad
50
Which is more common; gastric ulcer or duodenal ulcer?
Duodenal Ulcer
51
What is Rovsing's sign in appendicitis?
Rovsing's sign: more pain in RIF than LIF when palpating LIF
52
Presentation of acute diverticulitis
Colicky pain typically in the LLQ
Diarrhoea, sometimes bloody.
Fever, raised inflammatory markers and white cells
53
Buzzword. 'Tinkling' bowel sounds
Intestinal obstruction
54
Features of renal colic
loin pain radiating to groin
restlessness
haematuria
55
Features of pylonephritis
fever
rigors
vomiting
loin pain
56
Features of ruptured AAA
Acute - sudden collapse
| Sub-acute - central abdominal pain radiating to back with developing shock
57
Features of acute mesenteric ischaemia
Pain out of proportion to symptoms
History of atrial fibrillation or other cardiovascular disease
Diarrhoea, rectal bleeding may be seen
A metabolic acidosis is often seen (due to 'dying' tissue)
58
Features of oesophagitis
Haematemesis - small volume of blood often streaking vomit
Malaena rare
History of GORD
59
Features of oesophageal cancer
Dysphagia an earlier sign , followed by haematemesis of small amounts of blood
Associated with weight loss and history of GORD
60
Features of Mallory-Weis tear
Small transient bleeding following repeated vomiting
usually self-resolving
Malaena rare
61
Features of oesophageal varices
Haematemesis with large volume of blood
Possible malaena
Associated with haemodynamic compromise
62
Dieulafoy Lesion
Often no prodromal features prior to haematemesis and malaena, but this arteriovenous malformation may produce quite considerable haemorrhage and may be difficult to detect endoscopically
63
Management of bleeding oesophageal varices prior to endoscopy
terlipressin prior to endoscopy
64
Management of stable UGI bleeding
OGD within 24 hours
If unstable, perform immediate OGD in theatre with anaesthetist present
65
Management of bleeding oesophageal varices
```
Terlipressing
Endoscopy
Banding or Sclerotherapy
Sengaksten-Blakemore Tube
Gastric ballooning followed by oesophageal ballooning (deflate within 12 hours to avoid necrosis)
TIPS procedure
```
66
UGI bleeding
- Scoring for determining who needs to be admitted
- Scoring to determine rebleeding risk
Blatchford score ≥1 admit
| Rockall score ≤4 is low risk
67
Which artery is involved in major haemorrhages following peptic ulcer disease?
gastroduodenal artery
68
When should platelets, FPP and prothrombin complex be given in cases of acute bleeding?
platelet transfusion if actively bleeding platelet count of less than 50 x 10*9/litre
fresh frozen plasma to patients who have either a fibrinogen level of less than 1 g/litre, or a prothrombin time (international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal
prothrombin complex concentrate to patients who are taking warfarin and actively bleeding
69
Antibiotic prophylaxis for ascites with <15g/L protein
Oral Ciprofloxacin
70
Symptoms of osmotic demyelination syndrome
speech disturbances, swallowing dysfunction, limb paralysis, movement disorders, and behavioural and psychiatric disturbances
71
Risk factors of breast cancer
HRT, Combined Hormonal Contraceptives
Higher exposure to oestrogen
- Early menarche
- Late menopause
- No children/breastfeeding
Positive FHx ?BRCA1/2
Obesity
SHx - alcohol intake
Previous breast or ovarian cancer
72
Breast biopsy gold standard
Core needle biopsy - US guided by interventional radiologist
73
Breast examination - Hands above head
- flatten pec major to assess for tethering to chest wall --> Skin dimpling
74
Fibroadenoma differentials
Phyllodes tumour - rapidly growing and occurs in slightly older group (30-40)
Breast cyst
Lipomas
75
Difference between wide-local excision and excisional biopsy?
Excision biopsy -> benign lesions e.g. lumpectomy
Wide-Local Excision -> lesions with metastatic potential (in breast at least 1cm)
76
Spread of Phyllodes breast tumour
Haematogenous - no need for sentinel node examinations
77
Breast Cancer Treatments and Hormone Receptors
```
ER+ = Tamoxifen (SERM - used for pre-menopausal as oestrogen mostly from ovaries) or Letrozole (Aromatase Inhibitors - blocks peripheral aromatisation of oestrogens in fat)
PR+ = manage as ER+ with SERMs (pre-menopausal) and AI (post-menopausal)
HER2+ = Herceptin (Trastuzumab)
```
78
Where does breast cancer spreads to?
Bone esp. spine
Liver
Lungs
79
Why are aromatase inhibitors first line in ER+ breast cancers in post-menopausal women?
Letrozole - blocks peripheral aromatisation of oestrogens in fat
In pre-menopausal women ostrogens are made in ovaries mostly (give tamoxifen to block this)
80
Triple Negative Hormonal Breast Cancer
Very aggressive
| Needs urgent chemotherapy prior to surgery - refer to oncology
81
Presentation of haemorrhoids
Painless bright red rectal bleeding
82
Features of a chronic anal fissure
>6week fissure
| Triad of ulcer, sentinel pile, enlarged anal papillae
83
Most common anal cancer
Squamous cell carcinoma
84
Normal position of anal fissures
posterior midline 90%
if elsewhere suspect other pathology e.g. Crohn's
85
First-line and Second-line for chronic anal fissure
Topical GTN for 8 weeks
| If not resolved then Sphincterotomy or BOTOX
86
Management of acute anal fissure
```
Stool softening with diet and laxatives
- bulk-forming laxatives are first line
- lactulose is second line
Topical lubricants e.g. petroleum jelly
Topical anaesthetic
Analgesia
```
87
Food and drink prior to surgery
Clear fluids up to 2 hours before surgery
| Non-clear fluids and food for a minimum 6 hours before surgery
88
Which patients should be at the beginning of the elective surgical list?
Diabetics
89
Which marker is used to identify parathyroid gland?
Methylene blue
90
Prep for phaeochromocytoma surgery
alpha and beta blockade
91
Carcinoid tumour removal prep
Octreotide
92
Risk factors for AAA
```
FHx
Smoking
Male
Age >65
Hypertension
Syphilis
CTDs - Ehlers Danlos and Marfans
```
93
Breast Screening
50-70 every 3 years (will be expanded to 47-73)
94
Increased risk of Familial Breast Cancer
First or Second degree relative
- diagnosis <40yo
- bilateral breast cancer
- male breast cancer
- Jewish ancestry
- sarcoma in <45yo
- glioma or childhood adrenal cortical carcinomas
- childhood with multiple cancers
- ≥2 paternal family members with breast cancer
95
Breast cancer and lymph node management
Palpable lymphadenopathy -> axillary node clearance at primary surgery
No palpable lymphadenopathy -> pre-operative axillary lymph node
If Axillary US positive -> Sentinel node biopsy to assess nodal burden
96
Management of breast cancer
Neoadjuvant Chemotherapy - used in some tumours to downstage lesion allowing more conservative excision e.g. FEC-D for axillar node disease
Surgery - mastectomy or wide-local excision
+ reconstruction
Radiotherapy - following wide-local excision (reduces recurrence by 2/3), mastectomy of T3 or 4 tumour and those with ≥4 positive lymph nodes
Hormone Therapy ER+/PR+ - Tamoxifen (pre or peri - menopausal women) and Anastrozole (AI in post-menopausal women)
Hormone Therapy HER+ - Herceptin (Trastuzumab) - contraindicated in heart disorders
97
Risks of Tamoxifen
Endometrial Cancer
VTE
Menopausal symptoms
98
Most common breast cancer
Invasive Ductal Carcinoma
99
Mastectomy vs Wide-Local Excision for DCIS
<4cm - WLE
| >4cm - Mastectomy
100
Index for indication of survival at 5 years with Breast cancer
Nottingham Prognostic Index
101
Calculating Nottingham Prognostic Index for breast cancer
Tumour Size x 0.2 + Lymph node score + Grade Score
Lymph Node Score: 0 nodes = 1; 1-3 nodes = 2; >3 nodes = 3
102
Nottingham Prognostic Index for Breast Cancer and Survival Rates
2.0-2.4 = 93%
2.5-3.4 = 85%
3.5-5.4 = 70%
>5.5 = 50%
103
Suspicion of breast cancer referral
2 weeks for triple assessment
- aged ≥30 with unexplained breast lump
- aged ≥50 with nipple discharge, skin retraction or other changes
non-urgent referral in <30 with unexplained breast lump
104
Features of breast fibroadenosis
Middle-aged
"Lumpy" breasts
Worse symptoms before menstruation
105
Features of duct ectasia
Peri-menopausal
Tender lump around areola
If infected - known as plasma cell mastitis
- Green nipple discharge
106
Breast cancer. blood-stained discharge
Duct papilloma
107
Ascites SBP prophylaxis after having 1 episode
Long term Ciprofloxacin
108
Pre-operative staging for rectal cancer
Rectal MRI and CT Chest/Abdo/Pelvis
109
Pre-operative staging for colon cancer
CT Chest/Abdo/Pelvis
110
Rectal Cancer showing invasion of mesorectal fascia on MRI
Neoadjuvant - chemoradiotherapy
| Then Surgical resection
111
Difference between Sigmoid colorectal cancer surgical options?
Sigmoid colectomy - descending colon and rectum anastamoses
Hartman's procedure - L-sided colostomy + rectum kept in - used in emergency e.g. perforation - can be reversed in future once stable
112
Which colorectal cancers benefit from radiotherapy?
Rectal cancers only
113
Surgical excision of rectal cancers
Total Mesorectal Excision
114
What is the most common gene affected in colorectal cancer?
APC
115
Where do HNPCC individuals get CRC?
Proximal Colon
116
Features of Gardner's Syndrome
```
FAP Colorectal Cancer
Osteomas of the skull and mandible
Retinal Pigmentation
Thyroid Carcinomas
Epidermoid Cysts
```
117
Colorectal Cancer Screening
England: 60-74
Scotland: 50-74
FIT every 2 years
If abnormal invited for colonoscopy
118
Flexible Sigmoidoscopy Screening
New - being rolled out
Once-off between 55-60
Allow the detection and treatment of polyps, reducing the future risk of colorectal cancer
119
Turcots Syndrome
Polyposis and colonic tumours and CNS tumours
120
Peutz-Jeghers syndrome
Hamartomatous polyps in GI tract and increased risk of GI malignancy
121
Cowden Disease
Rare autosomal dominant condition
Multiple hamartoma syndrome
Associated with breast carcinoma, colon cancer, thyroid cancer, oral papillomas and acral keratosis.
122
Triad of Plummer-Vinson Syndrome + Treatment
dysphagia (secondary to oesophageal webs)
glossitis
iron-deficiency anaemia
iron supplementation and dilation of the webs
123
Management of acute pancreatitis
1. Fluid resuscitation with crystalloids
2. Enteral nutrition offered to moderately severe or severe cases that present within 72 hours
3. If cause is stones then cholecystectomy, if necrosis then debridement
124
Safe area for insertion of a chest drain
The triangle of safety for chest drain insertion involves the base of the axilla, lateral edge pectoralis major, 5th intercostal space and the anterior border of latissimus dorsi
125
Management of Alcoholic Liver Disease in patients with first presentation of Ascites
1. Avoid Alcohol
2. Good Nutrition (correct vitamin deficiencies)
3. Restrict Dietary Salt
4. If hyponatraemic then fluid restrict
