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Surgery > General Surgery > Flashcards

General Surgery Flashcards

1
Q

What does Boas sign indicate?

A

cholecystitis

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2
Q

Risk factors for abdominal hernias:

A
  • obesity
  • ascites
  • increasing age
  • surgical wounds
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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
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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
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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
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6
Q

Umbilical hernia:

A

symmetrical bulge under umbilicus

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7
Q

Paraumbilical hernia:

A
  • asymmetrical bulge

- half sac is covered by skin of abdomen directly above or below ubilicus

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8
Q

Epigastric hernia:

A
  • lump in midline between umbilicus and xiphisternum

- most common in men 20-30yo

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9
Q

Incisional hernia:

A

up to 10% of abdominal surgery

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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)
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11
Q

Obturator hernia:

A
  • through obturator foramen
  • more common in females
  • presents with bowel obstruction
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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
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13
Q

Abdominal hernias in children:

A
  • congenital inguinal

- infantile umbilical

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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
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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
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16
Q

Features and treatment of fissures in ano:

A
  • painful, bright red rectal bleeding

- stool softeners, topical diltiazem or GTN, botulinum toxin, sphincterotomy

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17
Q

Features and treatment of haemorrhoids:

A
  • painless, bright red rectal bleeding following defecation

- stool softeners, avoids straining, surgery

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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

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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

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20
Q

Features and treatment of pruritus ani:

A
  • peri anal itching, occasional mild bleeding

- avoid scented products, wet wipes, avoidance of scratching

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21
Q

Surgical treatment of haemorrhoids:

A
  • stapled haemorrhoidopexy (does not address skin tags)

- large with substantial external component: Milligan Morgan style conventional haemorrhoidectomy

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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
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23
Q

Types of melanocytic naevi:

A
  • congenital melanocytic naevi
  • junctional melanocytic naevi
  • compound naevi
  • spitz naevus
  • atypical naves syndrome
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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)
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25
Q

What are junctional melanocytic naevi?

A
  • circular macules
  • heterogenous colour even within same lesion
  • most naevi of palms, soles and mucous membranes
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26
Q

What are compound naevi?

A
  • domed pigmented nodules up to 1cm diameter

- arise from junctional naevi, usually uniform colour and smooth

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27
Q

What is a spitz naevus?

A
  • 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
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28
Q

What is atypical naevus syndrome?

A
  • 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
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29
Q

What are epidermoid cysts?

A
  • 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)
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30
Q

What is a dermatofibroma?

A
  • solitary dermal nodules
  • extremities of young adults
  • lesions feel larger than they appear
  • proliferating fibroblasts merging with sparsely cellular dermal tissues
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31
Q

Painful skin lesions:

A
  • eccrine spiradenoma
  • neuroma
  • glomus tumour
  • leimyoma
  • angiolipoma
  • neurofibroma (rarely painful) and dermatofibroma (rarely painful)
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32
Q

What are adalimumab, infliximab and etanercept and what are they used for?

A
  • TNF alpha inhibitors
  • Crohns
  • RA
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33
Q

What is bevacizumab and what is it used for?

A
  • anti VEGF
  • CRC
  • renal
  • gioblastoma
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34
Q

What is trastuzumab and what is it used for?

A
  • targets HER receptor

- breast cancer

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35
Q

What is imatinib and what is it used for?

A
  • tyrosine kinase inhibitor
  • GI stromal tumours
  • chronic myeloid leukaemia
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36
Q

What is basiliximab and what is it used for?

A
  • targets IL2 binding site

- renal transplants

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37
Q

What is cetuximab and what is it used for?

A
  • epidermal growth factor inhibitor

- EGF positive CRC

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38
Q

What is thyroid peroxidase antibodies assay used for?

A

autoimmune disease affecting thyroid

  • Hashimotos
  • Graves
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39
Q

What are the antibodies to TSH receptor assay used for?

A

individuals with Graves disease

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40
Q

What is the thyroglobulin antibodies assay used for?

A
  • not useful for distinguishing between thyroid disease

- thyroid cancer follow up

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41
Q

What is calcitonin assay used for?

A
  • released from parafollicular cells

- patients with medullary carcinoma of thyroid

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42
Q

What is cryptorchidism?

A
  • congenital undescended testis
  • failed to reach bottom of scrotum by 3 months
  • 5% at birth
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43
Q

Congenital defects associated with cryptorchidism:

A
  • patent processus vaginalis
  • abnormal epididymis
  • cerebral palsy
  • mental retardation
  • Wilms tumour
  • abdominal wall defects (e.g. gastroschisis, prune belly syndrome)
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44
Q

Reasons for correction of cryptorchidism:

A
  • reduce risk of infertility
  • allows testes to be examined for testicular cancer (40 times as likely to develop seminomas)
  • avoid testicular torsion
  • cosmetic appearance
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45
Q

Treatment cryptorchidism:

A
  • orchidopexy at 6-18 months
  • inguinal exploration, mobilisation of testis and implantation into dartos pouch
  • intra abdominal testis - laparoscopically evaluated and mobilised
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46
Q

What is Scheuermann’s disease?

A
  • 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
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47
Q

Types of structural scoliosis:

A
  • idiopathic
  • congenital
  • neuromuscular
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48
Q

What is spina bifida?

A
  • 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
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49
Q

What is spondylolysis?

A
  • 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
Q

What is spondylolisthesis?

A
  • 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
Q

Patients identified as being malnourished:

A
  • 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
Q

At risk of malnutrition:

A
  • eaten little for >5 days
  • poor absorptive capacity
  • high nutrient losses
  • high metabolism
53
Q

Where is the femoral canal?

A

lies at medial aspect of femoral sheath (fascial tunnel containing femoral artery laterally and femoral vein medially

54
Q

Borders of femoral canal:

A
  • laterally: femoral vein
  • medially: lacunar ligament
  • anteriorly: inguinal ligament
  • posteriorly: pectineal ligament
55
Q

Contents femoral canal:

A
  • lymphatic vessels

- cloquet’s lymph node

56
Q

Physiological and pathological significance of femoral canal:

A
  • 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
Q

Four types of fistulae:

A
  • enterocutaneous
  • enteroenteric or enterocolic
  • enterovaginal
  • enterovesicular
58
Q

What is an enterocutaneous fistula?

A
  • links intestine to skin
  • high output >500ml (duodenal/jejunal)
  • low output <250ml
  • suspect if there is excess fluid in the drain
59
Q

What is an enter-enteric or enterocolic fistula?

A
  • large or small intestine
  • originate similarly to enterocutaneous fistulae
  • bacterial overgrowth may precipitate malabsorption syndromes
  • particularly serious in IBD
  • enterovaginal same aetiology
60
Q

What is an enterovesicular fistula?

A
  • to bladder

- may result in frequent UTIs or the passage of gas from the urethra during urination

61
Q

Management fistulae:

A
  • heal provided no underlying IBD and no distal obstruction

- high output fistula

62
Q

Direct inguinal hernia (anatomy, cause, risk of strangulation, age, gender)

A
  • 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
Q

Indirect inguinal hernia (anatomy, cause, risk of strangulation, age, gender)

A
  • through inguinal ring
  • lateral to inferior epigastric artery
  • caused by failure of processus vaginalis to close
  • low risk strangulation
  • infants
  • males
64
Q

Femoral hernia (anatomy, risk of strangulation, age, gender)

A
  • below inguinal ligament
  • lateral to pubic tubercle
  • high risk strangulation
  • adults
  • females
65
Q

Groin masses:

A
  • hernia
  • lipomas
  • lymph nodes
  • undescended testis
  • femoral aneurysm
  • saphena varix
66
Q

Malignant causes of haematuria:

A
  • renal cell carcinoma
  • urothelial malignancies (transitional cell mostly)
  • squamous cell carcinoma and adenocarcinoma (rare bladder)
  • prostate cancer
  • penile cancers
67
Q

Structural abnormalities causing haematuria:

A
  • BPH
  • cystic renal lesions
  • vascular malformations
  • renal vein thrombosis due to renal cell carcinoma
68
Q

What is a hiatus hernia?

A
  • 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
Q

What are hydatid cysts?

A
  • tapeworm parasite echinoccus granulosus
  • outer fibrous capsule formed containing multiple daughter cysts
  • precipitates type 1 hypersensitivity reaction
70
Q

Features of hydatid cysts:

A
  • 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
Q

Investigation and treatment of hydatid cysts:

A
  • 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
Q

Small bowel/large bowel on abdominal film bowel obstruction:

A
  • small: max normal diameter 35mm, valvular conniventes extend all way across
  • large: 55mm, haustra extend about third of the way across
73
Q

Male lifetime risk of developing in inguinal hernia:

A

25%

74
Q

Features inguinal hernia:

A
  • groin lump - disappears with pressure or lying down
  • discomfort and ache - worse with activity
  • strangulation rare
75
Q

Management inguinal hernia:

A
  • hernia truss if not fit for surgery

- mesh repair

76
Q

Most common primary liver tumours:

A
  • cholangiocarcinoma

- HCC

77
Q

All primary liver tumours:

A
  • cholangiocarcinoma
  • HCC
  • hepatoblastoma
  • sarcomas (rare)
  • lymphomas
  • carcinoids
78
Q

What else can raise AFP apart from liver tumours?

A

testicular tumours

79
Q

Factors raised with liver tumours:

A
  • CA19-9
  • CEA
  • CA125
80
Q

Causes of lower GI bleeding:

A
  • colitis
  • diverticular disease
  • cancer
  • haemorrhoidal bleeding
  • angiodysplasia
81
Q

Management lower GI bleeding:

A
  • first line supportive
  • haemorrhoidal: proctosigmoidoscopy
  • unstable: angiogram
  • UC: subtotal colectomy
82
Q

Consider admission acute lower GI bleeding:

A
  • > 60yo
  • heamodynamically unstable or profuse
  • on aspirin or NSAID
  • significant co morbidity
83
Q

Definition of massive haemorrhage:

A
  • one blood volume in 24 hours or loss of 50% of blood in 3 hours
  • 150ml/minute
84
Q

How long does lidocaine last?

A

1 hour

85
Q

Maximum safe does lidocaine?

A

3mg/kg or 200mcg

86
Q

Where must lidocaine with adrenaline not be used?

A

near extremities due to risk of ischaemia

87
Q

Non absorbable suture material:

A
  • silk
  • novafil
  • prolene
  • ethilon
88
Q

Absorbable suture material:

A
  • vicryl
  • dexon
  • PDS
89
Q

When should non absorbable sutures be removed?

A

7-14 days

face 3-5

90
Q

When do absorbable sutures disappear?

A

7-10 days

91
Q

Management haemothorax:

A
  • wide bore 36F chest drain

- thoracotomy if more than 1.5L blood lost or ongoing >200ml per hour for >2 hours

92
Q

Features and management of cardiac contusion:

A
  • cardiac arrhythmias
  • echo to exclude pericardial effusions and tamponade
  • risk of arrhythmias falls after 24 hours
93
Q

Transpant types:

A
  • allograft - form other non identical donor of same species
  • isograft - genetically identical individuals
  • autograft
  • xenograft
94
Q

What does total parenteral nutrition consist of:

A
  • 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
Q

What is an incarcerated hernia?

A

a hernia that cannot be reduced (pushed back into place)

96
Q

What is hernial strangulation?

A
  • surgical emergency
  • blood supply to herniated tissue compromised
  • ischaemia or necrosis
  • inguinal: can accuse bowel tissue to be permanently lost or perforated
97
Q

Indications that a hernia is at risk of strangulation:

A
  • episodes of pain in hernia that was perviously asymptomatic
  • irreducible hernias
98
Q

Symptoms of strangulated hernia:

A
  • pain
  • fever
  • increase in size of hernia or erythema of overlying skin
  • peritonitic features
  • bowel obstruction (distension, nausea, vomiting)
  • bowel ischaemia (bleeding)
99
Q

Investigations for suspected strangulated hernia:

A
  • obstruction: abdominal x ray or CT
  • perforation: erect CXR
  • FBC and ABG for diagnosis (leukocytosis, raised lactate)
100
Q

Repair of strangulated hernia:

A
  • 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
Q

Conservative management of splenic trauma:

A
  • small sub scapular haematoma
  • minimal intra abdominal blood
  • no hilar disruption
102
Q

Laparotomy with conservation management of splenic trauma:

A
  • increased amounts of intraabdominal blood
  • moderate haemodynamic compromise
  • tears or lacerations affecting <50%
103
Q

Resection management of splenic trauma:

A
  • hilar injuries
  • major haemorrhage
  • major associated injuries
104
Q

What is the most common cause of small bowel obstruction?

A

intra abdominal adhesions (followed by hernias)

105
Q

Features small bowel obstruction:

A
  • 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
Q

Causes of right iliac fossa pain:

A
  • 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
Q

What is Meckel’s diverticulitis?

A
  • congenital abnormality in 2% of pop
  • 2 feet proximal to ileocaecal valve
  • lined by ectopic gastric mucosal tissue and produce bleeding
108
Q

What is mesenteric adenitis?

A
  • mainly children
  • caused by adenoviruses, EBV, strep, staph, e coli
  • higher temp than appendicitis
  • if laparotomy performed, enlarged mesenteric lymph nodes present
109
Q

How can you see pneumoperitoneum on an erect CXR?

A
  • free air

- Rigler’s sign: double wall sign

110
Q

Post gastrectomy syndromes:

A
  • small capacity
  • dumping syndrome
  • bile gastritis
  • afferent loop syndrome
  • efferent loop syndrome
  • anaemia (B12)
  • metabolic bone disease
111
Q

Features of FAP, management and associated disorders:

A
  • 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
Q

Features, management, associations MYH associated polyposis:

A
  • 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
Q

Features, management and associations of Peutz Jeghers syndrome:

A
  • 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
Q

Features, management and associations of Cowden disease:

A
  • 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
Q

Features, management and associations HNPCC (lynch syndrome)

A
  • 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
Q

What is a pilonidal sinus?

A
  • 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
Q

Metastatic bone tumours come from:

A
  • breast
  • lung
  • thyroid
  • renal
  • prostate
118
Q

Local benign conditions leading to fractures

A
  • chronic osteomyelitis

- solitary bone cyst

119
Q

Primary malignant tumours of bone:

A
  • chondrosarcoma
  • osteosarcome
  • Ewing’s
120
Q

Main antigens giving rise to rejection:

A
  • ABO blood group
  • HLA
  • minor histocompatibility antigens
121
Q

4 most important HLA alleles:

A

-HLA A
-HLA B
-HLA C
-HLA DR
(ideal organ match would have all 8 alleles matched)

Surgery (10 decks)

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