General Surgery Flashcards
1
Q
What does Boas sign indicate?
A
cholecystitis
2
Q
Risk factors for abdominal hernias:
A
- obesity
- ascites
- increasing age
- surgical wounds
3
Q
Features of abdominal hernias:
A
- palpable lump
- cough impulse
- pain
- obstruction: more common in females
- strangulation: may compromise bowel blood supply leading to infarction
4
Q
Inguinal hernia:
A
- 75% of abdominal wall hernias
- 95% male
- men have 25% risk of developing inguinal hernia
- above and medial to pubic tubercle
- strangulation rare
5
Q
Femoral hernia:
A
- below and lateral to pubic tubercle
- more common in women (especially multiparous)
- high risk obstruction and strangulation
- surgical repair required
6
Q
Umbilical hernia:
A
symmetrical bulge under umbilicus
7
Q
Paraumbilical hernia:
A
- asymmetrical bulge
- half sac is covered by skin of abdomen directly above or below ubilicus
8
Q
Epigastric hernia:
A
- lump in midline between umbilicus and xiphisternum
- most common in men 20-30yo
9
Q
Incisional hernia:
A
up to 10% of abdominal surgery
10
Q
Spigelian hernia:
A
- also lateral ventral hernia
- rare
- older patients
- hernia through spigelian fascia (aponeurotic layer between rectus abdomens muscle medially and semilunar line laterally)
11
Q
Obturator hernia:
A
- through obturator foramen
- more common in females
- presents with bowel obstruction
12
Q
Richter hernia:
A
- rare
- only anti mesenteric border of bowel herniates through fascial defect
- can present with strangulation symptoms without symptoms of obstruction
13
Q
Abdominal hernias in children:
A
- congenital inguinal
- infantile umbilical
14
Q
Congenital inguinal hernia:
A
- indirect
- from patent processus vaginalis
- 1% term babies (more common preterm)
- 60% right sided
- surgically repaired asap as at risk of incarceration
15
Q
Infantile umbilical hernia:
A
- symmetrical bulge under umbilicus
- more common in premature and afro-caribbean
- resolve without intervention before 4-5years
- complications rare
16
Q
Features and treatment of fissures in ano:
A
- painful, bright red rectal bleeding
- stool softeners, topical diltiazem or GTN, botulinum toxin, sphincterotomy
17
Q
Features and treatment of haemorrhoids:
A
- painless, bright red rectal bleeding following defecation
- stool softeners, avoids straining, surgery
18
Q
Features and treatment of fistula in ano:
A
- abscess then persisting discharge onto perineum
- lay open if low, no sphincter or IBD - if complex, high or IBD - insert seton and consider other options
19
Q
Features and treatment of peri anal abscess:
A
- peri anal swelling and surrounding erythema
- incision and drainage, leave cavity open to heal by secondary intention
20
Q
Features and treatment of pruritus ani:
A
- peri anal itching, occasional mild bleeding
- avoid scented products, wet wipes, avoidance of scratching
21
Q
Surgical treatment of haemorrhoids:
A
- stapled haemorrhoidopexy (does not address skin tags)
- large with substantial external component: Milligan Morgan style conventional haemorrhoidectomy
22
Q
What is seborrhoeic keratosis?
A
- > 50yo, idiopathic
- multiple lesions over face and trunk
- flat, raised, filiform and pedunculate subtypes
- variable colours and surface may have greasy scale
- leave alone or simple shave excision
23
Q
Types of melanocytic naevi:
A
- congenital melanocytic naevi
- junctional melanocytic naevi
- compound naevi
- spitz naevus
- atypical naves syndrome
24
Q
What is congenital melanocytic naevi?
A
- typically at or soon after birth
- usually >1cm
- increased risk of malignant transformation (greatest for large lesions)
25
What are junctional melanocytic naevi?
- circular macules
- heterogenous colour even within same lesion
- most naevi of palms, soles and mucous membranes
26
What are compound naevi?
- domed pigmented nodules up to 1cm diameter
| - arise from junctional naevi, usually uniform colour and smooth
27
What is a spitz naevus?
- develop over few months in children
- may be pink or red in colour, most common on face and legs
- up to 1cm and growth can be rapid, usually excision
28
What is atypical naevus syndrome?
- atypical melanocytic naevi that may be autosomal dominantly inherited
- some at increased risk melanoma (mutations CDKN2A gene)
- many people with atypical naevus syndrome AND parent sibling with melanoma will develop melanoma
29
What are epidermoid cysts?
- common and affect face and trunk
- central puncture, small quantities sebum
- cyst lining either normal epidermis (epidermoid) or outer root sheath of hair follicle (pilar cyst)
30
What is a dermatofibroma?
- solitary dermal nodules
- extremities of young adults
- lesions feel larger than they appear
- proliferating fibroblasts merging with sparsely cellular dermal tissues
31
Painful skin lesions:
- eccrine spiradenoma
- neuroma
- glomus tumour
- leimyoma
- angiolipoma
- neurofibroma (rarely painful) and dermatofibroma (rarely painful)
32
What are adalimumab, infliximab and etanercept and what are they used for?
- TNF alpha inhibitors
- Crohns
- RA
33
What is bevacizumab and what is it used for?
- anti VEGF
- CRC
- renal
- gioblastoma
34
What is trastuzumab and what is it used for?
- targets HER receptor
| - breast cancer
35
What is imatinib and what is it used for?
- tyrosine kinase inhibitor
- GI stromal tumours
- chronic myeloid leukaemia
36
What is basiliximab and what is it used for?
- targets IL2 binding site
| - renal transplants
37
What is cetuximab and what is it used for?
- epidermal growth factor inhibitor
| - EGF positive CRC
38
What is thyroid peroxidase antibodies assay used for?
autoimmune disease affecting thyroid
- Hashimotos
- Graves
39
What are the antibodies to TSH receptor assay used for?
individuals with Graves disease
40
What is the thyroglobulin antibodies assay used for?
- not useful for distinguishing between thyroid disease
| - thyroid cancer follow up
41
What is calcitonin assay used for?
- released from parafollicular cells
| - patients with medullary carcinoma of thyroid
42
What is cryptorchidism?
- congenital undescended testis
- failed to reach bottom of scrotum by 3 months
- 5% at birth
43
Congenital defects associated with cryptorchidism:
- patent processus vaginalis
- abnormal epididymis
- cerebral palsy
- mental retardation
- Wilms tumour
- abdominal wall defects (e.g. gastroschisis, prune belly syndrome)
44
Reasons for correction of cryptorchidism:
- reduce risk of infertility
- allows testes to be examined for testicular cancer (40 times as likely to develop seminomas)
- avoid testicular torsion
- cosmetic appearance
45
Treatment cryptorchidism:
- orchidopexy at 6-18 months
- inguinal exploration, mobilisation of testis and implantation into dartos pouch
- intra abdominal testis - laparoscopically evaluated and mobilised
46
What is Scheuermann's disease?
- epiphysitis of vertebral joints
- predominantly adolescents
- back pain and stiffness
- x-ray: epiphyseal plate disturbance and anterior wedging
- progressive kyphosis
- minor cases: physio and analgesia
- surgical stabilisation and bracing
47
Types of structural scoliosis:
- idiopathic
- congenital
- neuromuscular
48
What is spina bifida?
- non fusion of vertebral arches during embryonic development
- categories: myelomeningocele, spina bifida, occulta and meningocele
- myelomeningocele most severe associated with neuro defects
- spina bifida occulta: birth mark/hair patch
- incidence reduced by folic acid during pregnancy
49
What is spondylolysis?
- congenital or acquired deficiency of pars interarticularis of neural arch
- most commonly L4/5
- may be asymptomatic (no treatment)
- commonest cause of spondylolisthesis in children
50
What is spondylolisthesis?
- one vertebra displaced relative to immediate inferior vertebral body
- stress fracture or spondylolysis
- traumatic cases: scotty dog appearance plain films
- treatment depends on extent of deformity and assoc neuro symptoms
- radicular symptoms or signs: spinal decompression and stabilisation
51
Patients identified as being malnourished:
- BMI <18.5kg/m2
- unintentional weight loss of >10% over 3-6/12
- BMI <20kg/m2 and unintentional weight loss of >5% over 3-6/12
52
At risk of malnutrition:
- eaten little for >5 days
- poor absorptive capacity
- high nutrient losses
- high metabolism
53
Where is the femoral canal?
lies at medial aspect of femoral sheath (fascial tunnel containing femoral artery laterally and femoral vein medially
54
Borders of femoral canal:
- laterally: femoral vein
- medially: lacunar ligament
- anteriorly: inguinal ligament
- posteriorly: pectineal ligament
55
Contents femoral canal:
- lymphatic vessels
| - cloquet's lymph node
56
Physiological and pathological significance of femoral canal:
- physiological: allows femoral vein to expand to allow for increased venous return to lower limbs
- pathological: site of femoral hernias (relatively high neck places these at high risk of strangulation)
57
Four types of fistulae:
- enterocutaneous
- enteroenteric or enterocolic
- enterovaginal
- enterovesicular
58
What is an enterocutaneous fistula?
- links intestine to skin
- high output >500ml (duodenal/jejunal)
- low output <250ml
- suspect if there is excess fluid in the drain
59
What is an enter-enteric or enterocolic fistula?
- large or small intestine
- originate similarly to enterocutaneous fistulae
- bacterial overgrowth may precipitate malabsorption syndromes
- particularly serious in IBD
- enterovaginal same aetiology
60
What is an enterovesicular fistula?
- to bladder
| - may result in frequent UTIs or the passage of gas from the urethra during urination
61
Management fistulae:
- heal provided no underlying IBD and no distal obstruction
| - high output fistula
62
Direct inguinal hernia (anatomy, cause, risk of strangulation, age, gender)
- protrudes through Hesselback triangle
- medial to inferior epigastric artery
- caused by defects or weakness in transversalis fascia area of triangle
- low risk strangulation
- adults
- more in males
63
Indirect inguinal hernia (anatomy, cause, risk of strangulation, age, gender)
- through inguinal ring
- lateral to inferior epigastric artery
- caused by failure of processus vaginalis to close
- low risk strangulation
- infants
- males
64
Femoral hernia (anatomy, risk of strangulation, age, gender)
- below inguinal ligament
- lateral to pubic tubercle
- high risk strangulation
- adults
- females
65
Groin masses:
- hernia
- lipomas
- lymph nodes
- undescended testis
- femoral aneurysm
- saphena varix
66
Malignant causes of haematuria:
- renal cell carcinoma
- urothelial malignancies (transitional cell mostly)
- squamous cell carcinoma and adenocarcinoma (rare bladder)
- prostate cancer
- penile cancers
67
Structural abnormalities causing haematuria:
- BPH
- cystic renal lesions
- vascular malformations
- renal vein thrombosis due to renal cell carcinoma
68
What is a hiatus hernia?
- herniation of stomach above diaphragm
- sliding: 95%, GO junction moves above diaphragm
- rolling (paraoesophagheal): GO junctions stay below diaphragm but separate part of stomach herniates through oesophageal hiatus
69
What are hydatid cysts?
- tapeworm parasite echinoccus granulosus
- outer fibrous capsule formed containing multiple daughter cysts
- precipitates type 1 hypersensitivity reaction
70
Features of hydatid cysts:
- 90% in liver and lungs
- asymptomatic or symptomatic if cysts >5cm
- morbidity caused by cyst bursting, infection and organ dysfunction
- biliary rupture, triad: biliary colic, jaundice, urticaria
71
Investigation and treatment of hydatid cysts:
- US first line
- CT to differentiate from amoebic and pyogenic cysts
- serology: primary diagnosis and follow up
- surgery - cyst walls must not be ruptured and contents sterilised first
72
Small bowel/large bowel on abdominal film bowel obstruction:
- small: max normal diameter 35mm, valvular conniventes extend all way across
- large: 55mm, haustra extend about third of the way across
73
Male lifetime risk of developing in inguinal hernia:
25%
74
Features inguinal hernia:
- groin lump - disappears with pressure or lying down
- discomfort and ache - worse with activity
- strangulation rare
75
Management inguinal hernia:
- hernia truss if not fit for surgery
| - mesh repair
76
Most common primary liver tumours:
- cholangiocarcinoma
| - HCC
77
All primary liver tumours:
- cholangiocarcinoma
- HCC
- hepatoblastoma
- sarcomas (rare)
- lymphomas
- carcinoids
78
What else can raise AFP apart from liver tumours?
testicular tumours
79
Factors raised with liver tumours:
- CA19-9
- CEA
- CA125
80
Causes of lower GI bleeding:
- colitis
- diverticular disease
- cancer
- haemorrhoidal bleeding
- angiodysplasia
81
Management lower GI bleeding:
- first line supportive
- haemorrhoidal: proctosigmoidoscopy
- unstable: angiogram
- UC: subtotal colectomy
82
Consider admission acute lower GI bleeding:
- >60yo
- heamodynamically unstable or profuse
- on aspirin or NSAID
- significant co morbidity
83
Definition of massive haemorrhage:
- one blood volume in 24 hours or loss of 50% of blood in 3 hours
- 150ml/minute
84
How long does lidocaine last?
1 hour
85
Maximum safe does lidocaine?
3mg/kg or 200mcg
86
Where must lidocaine with adrenaline not be used?
near extremities due to risk of ischaemia
87
Non absorbable suture material:
- silk
- novafil
- prolene
- ethilon
88
Absorbable suture material:
- vicryl
- dexon
- PDS
89
When should non absorbable sutures be removed?
7-14 days
| face 3-5
90
When do absorbable sutures disappear?
7-10 days
91
Management haemothorax:
- wide bore 36F chest drain
| - thoracotomy if more than 1.5L blood lost or ongoing >200ml per hour for >2 hours
92
Features and management of cardiac contusion:
- cardiac arrhythmias
- echo to exclude pericardial effusions and tamponade
- risk of arrhythmias falls after 24 hours
93
Transpant types:
- allograft - form other non identical donor of same species
- isograft - genetically identical individuals
- autograft
- xenograft
94
What does total parenteral nutrition consist of:
- bags contain combinations of glucose, lipids, electrolytes
- can be infused peripherally but may cause thrombophlebitis
- longer term infusions: central vein (PICC line)
- complications: sepsis, re feeding syndrome, hepatic dysfunction
95
What is an incarcerated hernia?
a hernia that cannot be reduced (pushed back into place)
96
What is hernial strangulation?
- surgical emergency
- blood supply to herniated tissue compromised
- ischaemia or necrosis
- inguinal: can accuse bowel tissue to be permanently lost or perforated
97
Indications that a hernia is at risk of strangulation:
- episodes of pain in hernia that was perviously asymptomatic
- irreducible hernias
98
Symptoms of strangulated hernia:
- pain
- fever
- increase in size of hernia or erythema of overlying skin
- peritonitic features
- bowel obstruction (distension, nausea, vomiting)
- bowel ischaemia (bleeding)
99
Investigations for suspected strangulated hernia:
- obstruction: abdominal x ray or CT
- perforation: erect CXR
- FBC and ABG for diagnosis (leukocytosis, raised lactate)
100
Repair of strangulated hernia:
- surgery open or laparoscopic
- same technique used in elective hernia repair
- dead bowel removed
- not recommended to manually reduce strangulated hernias prior to surgery as it can cause more generalised peritonitis
101
Conservative management of splenic trauma:
- small sub scapular haematoma
- minimal intra abdominal blood
- no hilar disruption
102
Laparotomy with conservation management of splenic trauma:
- increased amounts of intraabdominal blood
- moderate haemodynamic compromise
- tears or lacerations affecting <50%
103
Resection management of splenic trauma:
- hilar injuries
- major haemorrhage
- major associated injuries
104
What is the most common cause of small bowel obstruction?
intra abdominal adhesions (followed by hernias)
105
Features small bowel obstruction:
- central abdominal pain
- nausea and vomiting
- constipation with complete obstruction
- abdominal distension may be apparent, particularly with lower levels of obstruction
- abdominal film: small bowel loops with fluid levels
106
Causes of right iliac fossa pain:
- appendicitis
- Crohn's
- mesenteric adenitis
- diverticulitis
- Meckel's diverticulitis
- perforated peptic ulcer
- incarcerated right inguinal or femoral hernia
- bowel perforation secondary to caecal or colon carcinoma
- gynaecological
- urological
107
What is Meckel's diverticulitis?
- congenital abnormality in 2% of pop
- 2 feet proximal to ileocaecal valve
- lined by ectopic gastric mucosal tissue and produce bleeding
108
What is mesenteric adenitis?
- mainly children
- caused by adenoviruses, EBV, strep, staph, e coli
- higher temp than appendicitis
- if laparotomy performed, enlarged mesenteric lymph nodes present
109
How can you see pneumoperitoneum on an erect CXR?
- free air
| - Rigler's sign: double wall sign
110
Post gastrectomy syndromes:
- small capacity
- dumping syndrome
- bile gastritis
- afferent loop syndrome
- efferent loop syndrome
- anaemia (B12)
- metabolic bone disease
111
Features of FAP, management and associated disorders:
- 100 colonic adenomas
- cancer risk 100%
- 20% new mutations
- annual flexible sigmoidoscopy from 15yo
- if none, 5 yearly colonoscopy at 20
- resectional surgery
- assocaited: gastric fundal polyps, duodenal polyps, if severe duodenal polyposis cancer risk 30% at 10 years
- abdominal dermoid tumours
112
Features, management, associations MYH associated polyposis:
- multiple colonic polyps
- later onset
- right sided more than FAP
- 100% cancer by 60
- resection and ileana pouch
- attenuated phenotype: regular colonoscopy
- associations: duodenal polyposis, increased risk breast cancer
113
Features, management and associations of Peutz Jeghers syndrome:
- multiple benign intestinal hamartomas
- episodic obstruction and intussusception
- increased risk GI cancer, breast, ovarian, cervical, pancreatic, testicular
- pan intestinal endoscopy every 2-3 years
- malignancies at other sites, pigmentation
114
Features, management and associations of Cowden disease:
- macropcephaly, multiple intestinal hamartomas, trichilemmomas, 89% cancer, 16% risk CRC
- targeted individualised screening
- associations: breast cancer, thyroid cancer and non toxic goitre, uterine cancer
115
Features, management and associations HNPCC (lynch syndrome)
- CRC 30-70%
- endometrial cancer 30-70%
- gastric cancer
- scanty colonic polyps may be present
- colonic tumours likely to be right sided and mucinous
- colonscopy every 1-2 years from 25, consider prophylactic surgery, extra colonic surveillance
- associated with extra colonic cancers
116
What is a pilonidal sinus?
- hair debris creating sinuses in skin
- usually natal cleft of males after puberty
- lined by squamous epithelium and consists of granulation tissue
- can get squamous cell carcinomas
- acute inflammation - abscess
- Bascom procedure, excision of pits and obliteration underlying cavity, Karydakis procedure
117
Metastatic bone tumours come from:
- breast
- lung
- thyroid
- renal
- prostate
118
Local benign conditions leading to fractures
- chronic osteomyelitis
| - solitary bone cyst
119
Primary malignant tumours of bone:
- chondrosarcoma
- osteosarcome
- Ewing's
120
Main antigens giving rise to rejection:
- ABO blood group
- HLA
- minor histocompatibility antigens
121
4 most important HLA alleles:
-HLA A
-HLA B
-HLA C
-HLA DR
(ideal organ match would have all 8 alleles matched)
