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Surgery Block > General Surgery > Flashcards

General Surgery Flashcards

1
Q

Acute pancreatitis-
Aetiology
Differentials

A 
Commonly due to gallstones or ethanol. But 
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion bite
HyperCa
ERCP
Drugs

Leads to premature and increased release of pancreatic enzymes, increased permeability and third spacing. Enzymes in systemic lead to autodigestion of fats- increased FA react with Ca- hypoCa.

Differntials incldue AAA, renal stones, chronic pancreatitis, peptic ulcer.

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2
Q

Acute pancreatitis- Features

A

Acute central epigastric pain radiating to the back, with nausea and vomiting. Epigastric tenderness. Tetany (HypoCa)

May get Cullens/Grey Turner’s sign.

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3
Q

Acute pancreatitis- Investigations

A 
Serum amylase (X3 upper limit), serum lipase, LFTs.
Abdominal USS for diagnosis. Only do a contrast CT if unsure of diagnosis- can indicate necrosis.
Assess severity (few days after admission) with CT.
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4
Q

Acute pancreatitis- Management

A

Manage conservatively, in HDU/ITU. Treat underlying cause i.e. gallstones- lap chole when stable.
IV fluid resus, NG tube (if vomiting), catherisation to monitor urine output, opioid analgesia.
Give broad spectrum Abx for infection prophylaxis if confirmed necrosed pancreas.

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5
Q

Acute pancreatitis- Complications

A

Occurring within days; DIC, ARDS, HypoCa, HyperG.
Local; Ongoing inflammation- ischaemic infarction.
Necrosis- prone to infection. Suspect if deterioration and raised inflam markers.
Pancreatic pseudocyst- containing blood, enzymes and necrotic tissue. Formed within weeks, can spontaneously resolve or will rupture.

Repeated acute pancreatitis can lead to chronic pancreatitis

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6
Q

Acute abdomen- Need urgent intervention

A

Bleeding; Commonly AAA rupture, but also perforated peptic ulcer, ruptured ectopic or trauma.

Perforated organ; Get generalised peritonitis- lie still, involuntary guarding, rigid abdomen, reduced/absent bowel sounds.

Ischaemic bowel; Present with pain but clinical signs unremarkable- raised lactate and compromised, need IV contrast CT.

Bowel obstruction

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7
Q

Acute abdomen- Less acute

A

Colic- Renal/biliary

Peritonism; pain in generalised area which is then referred.

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8
Q

Acute abdomen- Investigations

A

Bloods- FBC, LFTs, U+Es, amylase, G+S, CRP
Urine dip (pregnancy for women)
Erect CXR for free air- suggest perforation
USS- KUB, biliary tree and liver, transvaginal.
CT

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9
Q

Acute abdomen- Management

A

Surgical emergency in some cases
Treat cause
All require IV access, NMB (incase surgery), NG tube, analgaesia +/- antiemetics, catheter, IV fluids.

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10
Q

Surgical Incisions

A

Lanz- @McBurneys point- horizontal, aesthetically better.
Gridiron- @McBurneys point- oblique
Midline- From xiphoid till PS, around umbilicus.
Paramedian- Not really used in UK- Spleen, kidney.
Kocher- Gallbladder, biliary tree
Laparoscopic sign commonly at the umbilicus

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11
Q

Haematemesis- Causes

A

Oesophageal varices
Gastric ulcer perforation

Non emergency;
Oesophagitis- inflammation mainly due to
Mallory-Weiss tears (persistent vomiting- damages oesophagus epithelium)

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12
Q

Haematemesis- History

A

Frequency, volume and timing
Smoking/Alcohol history
NSAIDs, anticoagulants, steroids
History of dyspepsia, dysphagia or odynophagia

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13
Q

Haematemesis- Investigations

A

OGD
Bloods- FBC, LFTs, U+Es, clotting, G+S
Erect CXR (perforation)
CT with IV contrast- look for active bleeding

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14
Q

Haematemesis- Management

A

ABCDE assessment
Fluid Resus + crossmatch blood
Oesophageal varices; endoscopy guided band ligation, also give terlipressin/somatostatin analogues.
Ulcer perforation; Give adrenaline and cauterise the bleed. Follow with PPI +/- H.pylori eradication.

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15
Q

Dysphagia

A

Oesophageal cancer until proven otherwise.
Need endsocopy +/- biopsy.
Manage by treating the underlying cause.

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16
Q

Dysphagia 2ww referral

A

Urgent if:
Dysphagia
>55 with weight loss + dyspepsia/reflux/upper abdominal pain.

Non urgent if:
Haematemesis/ >55yrs with treatment resistant dyspepsia/upper ab pain.

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17
Q

Bowel obstruction

A

Gross dilation-> third spacing (fluid depletion)
Small bowel causes; adhesions, hernias
Large bowel causes; mass and volvulus
4 cardinal signs

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18
Q

Bowel obstruction differentials

A

Pseudo obstruction
Paralytic ileus
Toxic megacolon
Constipation

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19
Q

Bowel obstruction-
Investigations
Management

A

Routine bloods, G+S
CT with contrast (increasingly used as first line)
AXR- SB>3cm, LB>6cm (9cm @ caecum)

Conservative;
NBM and NG tube- 'suck' (decompress bowel)
IV- 'drip'- fluid resus
Catheter and fluid balance
Analgasia +/- antiemetics

Surgery if ischemia, closed loop obstruction or strangulated hernia.

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20
Q

Bowel Obstruction- Complications

A

Bowel ischaemia
Bowel perforation
Dehydration/renal impairment

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21
Q

GI perforation

A

Perforation of peptic ulcer and diverticular (commonly), also due to trauma, infection, ischaemia, colitis, iatrogenic.
Features of sepsis, acute painful abdomen, peritonitis, systemic features also.
Investigate with CT (free air indicates perforation site)
Manage with broad spectrum Abx, NMB (give nasogastric), IV resus, surgical repair- locate the site and treat underlying, thorough washout.
Conservative in frail pts, localised/contained perforation.

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22
Q

Maleana

A

Caused usually by peptic ulcer, varices and upper GI malignancy.
Do DRE, FBC, LFTs, U+Es, clotting, G+S, do ABG etc. Drop in Hb and rise in urea:creatinine suggests GI bleed.
OGD for definitive cause
Manage with A-E. Peptic ulcer- adrenaline and cauterise, follow with IV PPI. Varices; banding and terlipressin. Malignancy- biopsy to guide treatment.

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23
Q

Rectal bleeding

A

Diverticulosis- most common, painless bleeding. (Diverticulitis is painful bleeding).
Haemorrhoids
Malignancy (colorectal cancer)
Can also be a massive upper GI bleed (esp if unstable), IBD
Investigate with bloods, stool cultures, unstable warrants urgent CT angiogram, stable warrants OGD.
Most resolve spontaneously, otherwise consider adrenaline injections, banding, arterial embolisation.

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24
Q

GORD

A

Inefficient LOS. RF: smoking, obesity, PPI, alcohol, age, male. Differentials; peptic ulcer disease, biliary colic, ACS, malignancy, oesophagitis, oesophageal motility disorders.
It is a clinical diagnosis but can do endoscopy if complicated case or suspected malignancy. If resolves with change in lifestyle and PPI- likely GORD. Cessation of PPI can restart symptoms hence take life long.
Manage conservatively. Unless pt not fully responsive to treatment, pt not wanting lifelong meds, pt has complications. Either fundoplication- wrap fundus around GOJ, radiofrequency waves to thicken the LOS or magnetic string to tighten LOS.

25
Q

Barrett’s oesophagus

A

Common cause- chronic GORD.
Diagnosis relies on histology and biopsy.
Look out for red flags.
Treat with PPI, stop NSAIDs (or harmful meds to stomach), lifestyle advice.
If no dysplasia then regular endoscopy every 2-5yrs, low dysplasia needs every 6 months, high dysplasia needs every 3 months + resection.

26
Q

Oesophageal cancer

A

SCC- Upper and middle thirds. RF- smoking, alcohol
AC- Lower third. RF- Barretts, high fat diet
Most present really late since no specific signs.
Any dysphagia warrants OGD
Investigate with OGD and biopsy. Follow with CT chest-abdo-pelvis and PET-CT for mets. If lymph node involvement do fine needle aspiration and biopsy.
Management- Usually palliative. SCC chemo/radio therapy. AC-chemo neoadj or chemo/radio ajd but can also resect the oesophagus although risk of anastomosis leak, reop, pneumonia.
Nutritional support important.

27
Q

Oesophageal perforation

A

Full thickness, either iatrogenic or spontaneous due to severe vomiting (Boerhaave’s). Leads to stomach contents leaking into mediastinum and pleural cavity.
Features include retrosternal chest pain, resp distress and can find subcut emphysema (usually pts septic).
Investigate with routine bloods, G+S, CXR, followed by oral and IV contrast CT adbo.
Spontaneous usually haem unstable- Urgent operation and wash out of chest, give IV resus and sepsis 6.
Iatrogenic are more stable- conservative- give IV resus, NBM, feeding tube (@jejunum), Abx etc.

28
Q

Mallory-Weis Tears

A

Not a full thickness tear, only of oesophageal mucosa.
Due to prolonged period of forced vomiting.
Haematemesis
Investigate and manage as other upper GI bleeds.

29
Q

Achalasia

A

Progressive dysphagia of both solids and liquids due to failure of LOS relaxation.
Clinically look for weight loss, regurgitation, dysphagia.
Investigate with OGD, and manometry- shows loss of LOS tone, failure of LOS relaxing and absent oesophageal peristalsis.
Manage conservative- Fluids with meals, chew food extra, sleep with a few pillows, CCB/nitrates, Botox (temporary)
Surgical- Endoscopic balloon dilatation or dividing away the unresponsive fibres of LOS.

30
Q

Diffuse Oesophageal spasms

A

Lots of contraction of the oesophagus due to dysfunctional inhibitory neurones. Solid and liquid dysphagia. Chest pain relieved by nitrates.
Investigate with manometry.
Manage conservative with CCB/nitrates.
Surgical with pneumatic dilatation (balloon separates fibres of tight LOS) or myotomy.

31
Q

Hiatus hernia

A

Sliding or rolling, usually asymptomatic but can have features of GORD (retrosternal pain, worse on lying).
Investigate with endoscopy.
If symptomatic give PPIs, advice alcohol and smoking reduction, sleep with head raised etc.
If symptoms persists, risk of strangulation or poor nutrition then surgery via fundoplication or cruroplasty (move hernia and insert a mesh).

32
Q

Gastric cancers

A

Present at the later stages, symptoms vague and non-specific. Include dyspepsia, dysphagia, weight loss etc.
RF; smoking, H.P, male, increasing age.
Investigate with FBC, LFTs. Upper GI endoscopy + biopsy.
CT C-A-P for staging.
Need nutritional support, see dietician, NG/feeding.
Most managed palliatively with chemo and supportive.
Some surgically; if really early then endoscopic mucosal resection (good prognosis). Otherwise if proximal- total gastrectomy, distal- subtotal gastrectomy, SB anastomosed to oesophagus. Give neoadjuvant chemo prior.

33
Q

Complications of a hernia

A

Bowel obstruction
Strangulation (More common in femoral due to narrow neck- therefore all are surgically treated)
Incarceration

34
Q

Femoral canal

A

Medial-Lacunar ligament
Lateral-Femoral vein
Posterior-Pectineus
Anterior-Inguinal Ligament

35
Q

Other hernias

A

Epigastric hernia- Through linea alba at the midline.
Paraumbilical hernia-Through LA at umbilical level.
Consider rectus divarication as differential- physiological separation of rectus muscle at LA during pregnancy.

Spigelian hernia- At lateral border of rectus muscle (high risk of strangulation).

36
Q

Angiodysplasia

A

Common cause of painless GI bleeding (PR bleeding main presentation).
Diagnose- endoscopy, wireless capsule endoscopy, or mesenteric angiography
Mainly manage either conservatively, via endoscopic management, or radiological approach.
Can also surgically resect affected area and anastomose remainder segments.

37
Q 
Small bowel tumours-
Presentation
RF
Investigations
Management
A

Very rare, benign are likely adenomas, malignant either adenocarcinomas or neuroendocrine tumours.
Usually asymptomatic, until large enough to cause obstruction. Commonly affect duodenum.
RF: Afro-car, Crohn’s, coeliac, smoking, alcohol, genetics.
Investigations unremarkable- esp. in early stages.
Manage with resection of the bowel, if malignant resect the associated mesentery and give adjuvant chemo if lymph nodes involved.

38
Q

Neuroendocrine tumours-

A

Associated with MEN1 (inherited disorder)
Present non specifically but can develop carcinoid syndrome; increased serotonin, gastrin, prostaglandins- leads to flushing, palpitations, diarrhoea, ab pain, wheezing.
Surgery is curative, but most present with mets.

39
Q

Acute Appendicitis-
Pathophysiology
Presentation
Signs

A

Blocked appendix lumen (likely faecolith)- overgrowth of commensal bacteria- inflammation- ischaemia- if necrosis then can get perforation.

Present with peri-umbilical pain, then radiates to the RIF. N+V, anorexia, weight loss etc.

Examinations- Rebound tenderness and guarding over McBurneys point, +ve Rovsings, + Psoas sign.

40
Q

Acute Appendicitis-
Investigations
Management
Complications

A

Routine bloods + pregnancy test for women.
Imaging only in women or older population. Women- transvaginal USS, older- CT abdomen.
Manage with laparoscopic appendicectomy. Can treat conservatively with Abx but will likely recur.

Complications; perforation, surgical site infection, appendix mass (small bowel and omentum join appendix) or pelvic abscess.

41
Q

Colon cancer-
Aeitology
RF
Left vs Right sided

A

Normal epithelia- adenoma (polyp)- adenocarcinoma
Mainly sporadic but increased risk if FHx, FAP, HNPCC), age, male, IBD, low fibre diet.
Right sided- Early presentation, mass at RIF, ID anaemia, ab pain.
Left sided- Late presentation, rectal bleeding, tenesmus, mass at LIF/DRE, change in bowel habit.

42
Q

Colon cancer-
Referral guidelines
DDx

A

Refer for investigations if:
≥40yrs- unexplained weight loss and abdominal pain
≥50yrs- unexplained rectal bleeding
≥60yrs- iron‑deficiency anaemia or change in bowel habit
Positive occult blood screening test

Differentials- IBD, haemorrhoids

43
Q

Colon cancer-
Investigations
Management

A

Screen 60-75yrs every 2 years with FIT.
Routine bloods, LFTs, clotting (shows ID anaemia), colonoscopy + biopsy (gold standard for diagnosis). Also chest-abdo-pelvis CT (mets), MRI rectum (invasion).
Curative management is surgery. With chemo in advanced disease and radio/chemo at rectum. Radio at rectum only since at risk of damaging SI.

44
Q

Colorectal cancer surgery options-

A

Right Hemi-colectomy- If caecal, ascending or some transverse affected.
Left Hemi-colectomy- If descending affected.
Sigmoid colectomy- If sigmoid
Anterior resection- If high rectal tumour- preserves sphincter.
Abdominoperineal resection- If low rectal tumour, wont preserve the sphincter.

Either anastomose ends or stoma bag.

NB. Hartmann’s procedure- emergency resection at descending colon- end colostomy + rectal stump.

45
Q 
Diverticula-
Nomenclature
RF
DDx
Investigations
A

Diverticulosis- Present of diverticula
Diverticular disease- Symptomatic diverticula- ab pain, change in bowel habit, nausea.
Diverticulitis- Inflammation of diverticula- Think of appendicitis but in LIF. Can also perforate.

RF- low fibre diet, FHx, NSAIDs, age, smoking, obesity.
Differentials include IBD, malignancy.

Investigate with routine bloods. G+S and VBG, urine dip if suspected diverticulitis. Diverticular disease view with flexi-sig. Diverticulitis view with CT Abdo-pelvis.

46
Q

Diverticula-
Management
Complications

A

Diverticular disease- As outpatient, analgesia and increased oral fluid intake.
Diverticulitis- Conservative- Abx, analgesia, IV fluids. Will improve in 2-3 days.
If septic or perforation then Hartmann’s procedure (reversal of stoma at later date).

Complications include strictures, fistulas (with bladder/vagina).

47
Q

Crohns

A

Microscopic- non-caseous granulomas (granulomatous)
Macroscopic- Fistula, skip lesions, deep ulcers and fissures (cobblestone).

Induce remission- Steroids/mesalazine/azathioprine.
Maintaining remission- Azathioprine

Complications include fistulas, malignancy and strictures.

48
Q

UC

A

Microscopic- non-granulomatous, crypt abscesses and reduced goblet cells.
Macroscopic- Continuous, may get pseudopolyps/ulcers

Induce remission-
Mild/moderate- Topical sulfa/mesalazine +/- pred.
Mild/moderate extensive- High dose oral sulfa/mesalazine +/- pred.
Severe- IV corticosteroids- assess need for surgery!
Maintain remission- Mesalazine/sulfasalazine.

Complications; toxic megacolon, bowel perforation, malignancy.

49
Q

IBD-
Investigations
Extra-intestinal manifestations

A

Routine bloods, faecal calprotectin- not present in IBS.
Gold standard diagnosis is colonoscopy + biopsy, so long as not in acute attack.
Acute attack- AXR

Erythema nodosum, eye infections, polyarthritis, renal stones, primary sclerosing cholangitis (more in UC).

50
Q

Pseudo-obstruction-
Causes
DDX
Presentation

A

Due to reduced autonomic simulation of the bowel therefore reduced smooth muscle activity.

Causes; electrolyte imbalance (hyperCa, hypoT, hypoMg), medications (opioids, CCB), recent surgery, neurological (Parkinson’s’, MS).

DDx- Mechanical BO, paralytic ileus, toxic megacolon.

Cardinal signs of BO.

51
Q

Pseudo-obstruction-
Investigations
Management
Complications

A

Investigations- Routine bloods, U+Es, Ca, Mg, TFTs.
CT Abdo-pelvis with IV contrast to differentiate from mechanical.
Management- NBM, IV fluids (balance chart), NG tube. If not resolved within 48hrs then endoscopic decompression with flatus tube.
Complications- bowel perforation, bowel ischaemia, toxic megacolon.

52
Q 
Sigmoid volvulus-
Presentation
RF
Investigations
Management
Complications
A

Sigmoid bowel twists around its own mesentery.
Symptoms of BO, along with severe acute pain.
RF: old, nursing home, male, chronic constipation, dementia.
Investigations- Routine bloods, Ca, TFTs- exclude pseudo-O. CT Abdo-pelvis with IV contrast- whirlpool.
Manage as any other BO. Also decompress with flatus tube or sigmoidoscopy (faeces will squirt out fast!)
Surgery indicated if perforation/ischaemia, necrotic, repeated failed attempts at decompression.
Complications- bowel ischaemia, bowel perforation.

53
Q 
Haemorrhoids-
Presentation
RF
Investigations
Management
Complications
A

Painless rectal bleeding, also pruritis, rectal fullness/lump.
RF: straining, increased IAP, reduced fibre, older age.
Investigate with proctoscopy. If suspect malignancy then sigmoidoscopy.
Manage with reassurance, increased fluid and fibre especially if asymptomatic. Analgesia (not opioids).
May also consider band ligation or surgery.
Complications- thrombosis, ulceration, gangrene.

54
Q

Anal fistula-
Causes
Investigations
Management

A

Abnormal connection between the anal canal and the perianal skin. Usually following a perianal abscess but also IBD, trauma, TB etc.
Investigate with proctoscopy, if complex then MRI.
Any patient with an anal fistula or recurrent peri-anal abscesses should be investigated for possible Crohn’s disease.
Asymptomatic- conservative management, otherwise surgery; (1)fistulotomy- open the fistula and allow healing by secondary intention, or (2)seton placement.

55
Q

Anorectal abscess
Aetiology
Presentation
Management

A

Form due to block of the anal glands (in between anal sphincter)- stasis of mucus- infection (usually E.coli).
Red, swollen, fluctuant, tender perianal mass. May have itching, discharge or even systemic features. Deeper abscesses won’t have external features, do DRE under anaesthetics.
Manage with Abx, surgical incision and drainage under GA, heal by SI. Then use proctoscopy to look for fistula-insert senton.

56
Q 
Anal fissure-
Causes
Presentation
Investigation
Management
A

Tear in mucosal lining of anal canal, commonly at posterior midline. (Constipation, IBD, dehydration, chronic diarrhoea).
Extreme pain post defecation (several hrs), rectal bleed, can’t tolerate DRE, palpable/visible fissure.
DRE and proctoscopy under anaesthetics.
Manage conservatively; hot bath, analgesics, stimulant laxatives, increase fibre and fluid.
Surgery if chronic and non-resolving.

57
Q

Rectal prolapse

A

Partial or full thickness.
Present rectal mucus discharge, faecal soiling, or rectal bleeding
Definitive management is via surgical repair, either by an abdominal or perineal approach

58
Q 
Anal cancer-
RF
Symptoms
Investigation 
Management
A

Rare cancer. Commonly SCC below dentate line, but also AC above line.
RF; HPV, HIV, Crohns, age, smoking.
Common symptoms; Pain and bleeding.
Need proctoscopy and biopsy EUA.
Chemo-radiotherapy is first line curative treatment for the majority of patient

Surgery Block (7 decks)

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