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Y4 > General Surgery Block > Flashcards

General Surgery Block Flashcards

1
Q

Describe Munchausen’s syndrome

A

a psychological disorder where someone pretends to be ill or deliberately produces symptoms of illness in themselves.
Eg a drug seeker so that they get medications

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2
Q

What is absolute constipation?

A

Absence of passing wind

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3
Q

Describe Rosvig’s sign?

A

Press on LIF and in a patient with appendicitis, they will get pain in RIF

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4
Q

In which condition may bowel sounds be absent?

A

Ileus

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5
Q

When may bowel sounds be tinkling?

A

Obstruction

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6
Q

Looking at a patient from end of bed check, if they are rocking around the bed and can’t sit still what condition would this suggest?

A

Renal colic

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7
Q

Looking at a patient from the end of bed check, if they are lying still and not moving with ‘board like rigidity’ what would this suggest?

A

Perforated duodenal ulcer

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8
Q

What is cullen’s sign and what condition does it point you towards?

A

Cullen’s sign - peri-umbilical bruising

Sign of pancreatitis

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9
Q

What is Grey Turner’s sign and what condition does it point you towards?

A

Flank bruising

Sign of pancreatitis

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10
Q

When taking a set of bloods in general surgery, why should you always remember to do amylase?

A

To check for pancreatitis

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11
Q

Why is an erect CXR useful?

A

If it shows free air under the diaphragm

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12
Q

What are the 3 main uses of an AXR and why should you generally try to avoid it?

A 
Avoid it where possible - expose patient to lots of radiation
Use if
?obstruction
?colitis
?perforation
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13
Q

What is the gold standard investigation for acute abdomen?

A

CT scan

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14
Q

What is the gold standard investigation for RUQ pain?

A

Ultrasound

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15
Q

MRI is very useful in the acute abdomen. True or false?

A

False

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16
Q

What is pretty much the only use for MRI in the acute abdomen?

A

pregnant appendices

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17
Q

In the setting of the acute abdomen, who needs to go to theatre right away

A

Ischaemic gut

Faecal peritonitis

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18
Q

Board like rigidity on abdominal examination and free air under the diaphragm on erect CXR. What does this make you think of?

A

Perforated duodenal ulcer

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19
Q

Name 4 colonic emergencies

A

Obstruction
Perforation
Volvulus
Colitis

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20
Q

If someone has a volvulus, how do you manage it?

A

Urgent flexible/rigid sigmoidoscope

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21
Q

Management of acute diverticulitis

A

Either a spectrum of antibiotics or Hartmann’s operation

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22
Q

Which classification is used for diverticulitis

A

Hinchey classification

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23
Q

Explain what a Hartmann’s procedure is?

A

Remove sigmoid colon, leave the rectum, bring out colostomy

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24
Q

For emergency surgery in IBD, subtotal colectomy is used for crohn’s / UC ?

A

Ulcerative colitis

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25
Q

For emergency surgery in IBD, resection is used for crohn’s / UC ?

A

Crohn’s

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26
Q

ileostomy is which shape?

A

Rose

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27
Q

Young patient with UC gets a proctocolectomy. Would they most likely want:

  • end ileostomy
  • pouch
  • ileorectal anastamosis
A

Pouch

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28
Q

What are the disadvantages of having a pouch?

A

Increased bowel movements

Increased faecal nocturnal incontinence

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29
Q

Most likely to develop colorectal cancer if you have crohn’s disease / UC ?

A

UC

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30
Q

What is most likely to be cured by surgery: crohn’s or UC?

A

UC

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31
Q

All inguinal hernias should be fixed. True or false?

A

False

- some can be managed conservatively

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32
Q

All femoral hernias should be fixed. True or false?

A

True

- Femoral = FIX

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33
Q

Femoral hernias:

Below/Above and medial/lateral to pubic tubercle

A

Below and lateral to pubic tubercle

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34
Q

indirect inguinal hernia vs direct inguinal hernia

A

Direct inguinal hernia - pops out when pt coughs

Indirect inguinal hernia - does not pop ot when patient coughs

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35
Q

Triad of the following makes you think of what condition:
fever
back pain
limp

A

Psoas abscess

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36
Q

Where is McBurney’s point?

A

1/3rd of the way along the right ASIS and umbilicus

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37
Q

In young adults, appendicitis is most common in males or females?

A

Males

3:2 male:female

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38
Q

Why is the greater ommentum known as the ‘police officer’ in the abdomen

A

if there is an area of inflammation, the greater ommentum is attracted and sticks onto it

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39
Q

Appendicitis can lead to peritonitis. True or false?

A

True

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40
Q

Patient with colicky central abdominal pain which migrates to RIF, nausea, off food, hasn’t passed bowel movement that day. What does this make you think of?

A

Acute appendicitis

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41
Q

Specific sign of appendicitis

A

Rosvig’s sign

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42
Q

Periumbilical abdominal pain which was colicky that then goes away. Flushed, bad breath.

A

Retrocaecal appendicitis

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43
Q

Scoring system for appendicitis

A

Alvarado score

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44
Q

Appendicitis is diagnosed radiologically. True or false?

A

False - clinical diagnosis but US can be helpful

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45
Q

What is the management of appendix mass?

A

Antibiotics first line

Theatre only if symptoms persist

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46
Q

Describe an ileus

A

When the bowels effectively go on strike and dont work for a few days

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47
Q

What does carcinoid of the appendix stain for

A

Stains heavily for chromagrannin

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48
Q

If a patient’s terminal ileum has to be removed, what must you replace?

A

B12 and folate

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49
Q

What is the most common cause of small bowel obstruction

A

Adhesions

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50
Q

Causes of small bowel obstruction - within the lumen (2)

A

Food

Gallstones

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51
Q

Causes of small bowel obstruction - within the wall of the small bowel (2)

A

Crohn’s disease

tumour

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52
Q

Central colicky abdominal pain, nausea, very awful smelling vomit, absolute constipation, burping, abdominal distention. What is the likely diagnosis?

A

Small bowel obstruction

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53
Q

Bowel sounds will be noisy / quiet in small bowel obstruction?

A

Noisy

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54
Q

Management of small bowel obstruction

A

Drip and suck

  • put the patient on a drip to get fluids into them
  • suck out the fluids and air with an NG tube (Ryles tube)
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55
Q

Only drip and suck adhesional small bowel obstruction. True or false?

A

True

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56
Q

How do you define an adhesional small bowel obstruction?

A

A patient must have had a previous abdominal operation

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57
Q

Elderly frail patient with colicky abdominal pain and pretty unimpressive bloods, abdo XR normal, huge amount of analgesia. essentially pain out of proportion to clinical findings. What is the likely diagnosis?

A

Mesenteric ischaemia of the small bowel

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58
Q

Meckel’s diverticulum location

A

2ft above the ileo-caecal valve

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59
Q

Meckel’s diverticulum usually presents in childhood / adulthood ?

A

Childhood

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60
Q

Which needs immediate theatre small bowel obstruction or small bowel mesenteric ischaemia?

A

small bowel mesenteric ischaemia

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61
Q

The appendix is supplied by which dermatome?

A

T10

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62
Q

Referred pain for RUQ goes where and why is this?

A

RUQ pain can be referred to right shoulder

This is because phrenic nerve (C3,4,5) supplies diaphragm but is found at the neck. Shared nerve supply

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63
Q

A patient with epigastric pain and raised amylase makes you think of what diagnosis?

A

Pancreatitis

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64
Q

Lipase is raised and specific to which condition

A

Pancreatitis

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65
Q

Which imaging modality is carried out in pregnant females with acute abdominal pain: CT or MRI?

A

MRI

- do NOT CT in pregnancy

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66
Q

Dilated bowel loops on AXR makes you think

A

Obstruction

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67
Q

How would you manage an AXR which shows dilated bowel loops and faecal impaction?

A

Constipation - Laxative to get things moving

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68
Q

How would you manage an AXR which shows dilated bowel loops and NO faecal impaction?

A

Bowel obstruction

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69
Q

Stepladder pattern on AXR suggests what?

A

small bowel obstruction

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70
Q

which looks more central on AXR: small bowel obstruction or large bowel obstruction?

A

Small bowel obstruction

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71
Q

Describe the stepladder pattern on AXR

A

Central dilation of small bowel (obstruction)

straight lines are seen going all the way through the calibre of the small bowel)

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72
Q

Small bowel / large bowel has valvae conientes?

A

small bowel

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73
Q

Small bowel / large bowel has haustra ?

A

Large bowel

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74
Q

What is the investigation of choice for a 23 year old female with suspected appendicitis ?

A

US

- any female US abdo

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75
Q

What is the investigation of choice for a male OR female over 40 with suspected appendicitis?

A

CT scan

- must have CT to rule out malignancy

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76
Q

What is the investigation of choice for a male UNDER 40 with suspected appendicitis?

A

No investigation required

Operate on clinical diagnosis

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77
Q

Which vessels is the deep inguinal ring marked by?

A

Inferior epigastric vessels

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78
Q

What are the 3 borders of the femoral triangle

A 
Inguinal ligament (superior) 
Adductor longus 
Sartorius
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79
Q

What are the contents of the femoral triangle from medial to lateral?

A 
Medial -> lateral: 
Deep inguinal lymph nodes 
Vein (femoral)
Artery (femoral)
Nerve (femoral)

VANS drive OUT (from medial to lateral)

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80
Q

What 2 components make up the femoral sheath?

A

Femoral artery and femoral vein

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81
Q

Why are femoral hernias more of a worry than inguinal hernias?

A

The femoral canal has tough walls and there is not much room for expansion. So increased risk of strangulation or obstruction if bowel gets stuck in there

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82
Q

What is the definition of the mid inguinal point?

A

Where you feel the femoral pulse

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83
Q

What is the midpoint of the inguinal ligament?

A

Deep inguinal ring

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84
Q

Irreducible hernia

A

Cannot be pushed back in

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85
Q

Incarcerated hernia

A

Hernia is stuck in its sack

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86
Q

Strangulated hernia

A

Blood supply is cut off

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87
Q

Which of the following is IN the inguinal canal

  • indirect inguinal hernia
  • direct inguinal hernia
A

Indirect inguinal hernia

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88
Q

If a hernia is in scrotum it must be a direct/indirect inguinal hernia??

A

Indirect inguinal hernia

- since the spermatic cord passes through the inguinal ring

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89
Q

Which types of hernia strangulate/obstruct more frequently?

  • indirect inguinal hernia
  • direct inguinal hernia
A

Indirect inguinal hernia

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90
Q

Which features in the history would specifically suggest ADHESIONAL bowel obstruction

A

Previous surgeries

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91
Q

Management of sigmoid volvulus with no signs of strangulation

A

Rigid/flexible sigmoidoscope detorsion

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92
Q

Who gets intusuception

A

children, age 3-4

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93
Q

Briefly describe intusucception and explain the most common location for it to occur

A

Telescoping of the bowel in on itself

Most commonly occurs at the ileo-caecal junction

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94
Q

Failure of passing any stool in the first 24 hours after birth is called

A

Meconium ileus

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95
Q

Coffee bean shape on AXR suggests

A

Volvulus

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96
Q

Name the 2 most common causes of small bowel obstruction?

A

Hernia

Adhesions

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97
Q

Name the 2 most common causes of large bowel obstruction?

A

Malignancy

Volvulus

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98
Q

Volvulus is most common in the small/large bowel?

Why?

A

Volvulus most common in large bowel.
Small bowel is full of fluid so less likely to volv. Whereas large bowel has more semi-solid substances and more likely to volv.

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99
Q

Vomiting causes which ABG

A

Metabolic alkalosis

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100
Q

Dehydration causes which ABG

A

Metabolic acidosis

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101
Q

Vomiting occurs early/late in large bowel obstruction

A

Late

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102
Q

Constipation occurs early/late in large bowel obstruction

A

Early

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103
Q

Clinical features of large bowel obstruction (4)

A

Colicky peripheral abdominal pain
Constipation
Abdominal distention
Vomiting (bile -> faecal)

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104
Q

Clinical features of small bowel obstruction (4)

A

Colicky central abdominal pain
Vomiting early, large volume (bile)
Constipation

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105
Q

Clinical examination findings of bowel obstruction

A 
Distended abdomen 
Diffuse abdominal tenderness
Tympanic percussion
Tinkling bowel sounds (early)
Absent bowel sounds (late)
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106
Q

Name 3 symptoms/signs which indicate complication in bowel obstruction

A

Change in the nature of pain
Rebound tenderness
Signs of sepsis

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107
Q

Name 2 of the most common complications of bowel obstruction

A

Bowel ischaemia

Bowel perforation

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108
Q

First line imaging investigation in suspected bowel obstruction

A

AXR

  • small bowel = central
  • large bowel = peripheral
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109
Q

Lumen above Xcm indicates dilation of small bowel

A

3cm

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110
Q

Lumen above Xcm indicates dilation of large bowel

A

6cm

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111
Q

Initial management of bowel obstruction

A

Urgent resuscitation

  • drip and suck
  • drip: fluid resuscitation, re-balance electrolytes
  • suck: NG tube for intestinal decompression
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112
Q

Management of bowel obstruction caused by adhesions

A

Conservative

  • drip and suck
  • active monitoring
  • usually don’t need surgery
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113
Q

Management of bowel obstruction with ischaemia / perforation

A

Surgery - laparotomy

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114
Q

Define paralytic ileus

A

When the peristaltic engine of the bowel is not working. THere is limited power to push things forward in the intesting.
There is NO mechanical obstruction

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115
Q

Name 5 causes of paralytic ileus (5Ps)

A 
Post operative 
low Potassium 
Pelvic or spinal fracture 
Peritonitis 
Partuition (child birth)
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116
Q

Paralytic ileus - blood test findings

A

HYPOKALAEMIA

Hypomagnesia

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117
Q

Paralytic ileus - what does imaging show

A

uniformly distended loops with no transition point and no mechanical cause

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118
Q

Male over 55 presenting with symptoms like renal colic. What should you be wary of and consider?

A

AAA

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119
Q

Define aneurysm

A

Permanent dilation of artery by over 50% of normal diameter

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120
Q

True aneurysm

A

All 3 layers of artery wall involved

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121
Q

False / pseudo aneurysm

A

Only the outermost layer (tunica externa) is involved

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122
Q

Name 3 congenital causes of aneurysm

A

PKD
Marfan’s syndrome
Ehlers danlos syndrome

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123
Q

Risk factors for aneurysm

A 
Male gender 
Over 65 
Obesity 
Smoking 
Hypertension 
FH
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124
Q

Features of AAA rupture

A 
Epigastric/umbilical pain 
- sudden onset
- radiates to back 
Collapse 
Hypotension 
Expansile pulsatile mass
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125
Q

Best imaging for AAA rupture

A

CT angiogram

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126
Q

Repair an asymptomatic AAA when it reaches what size?

A

5.5cm

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127
Q

Why should you not give the patient lots of IV fluids to restore BP in AAA rupturee

A

Will be a retroperitoneal rupture so don;t want to disrupt the tamponade. BP only needs to be ensuring the patient is getting their brain perfused

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128
Q

7 month old child crying and bringing legs up to chest, vomiting and diarhoea, target sign on US. WHat is the likely diagnosis?

A

Intusucception

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129
Q

When you have a patient with a neck lump, there are 3 situations:
Lump does not move on swallowing
Lump moves on swallowing
Lump moves on swallowing and moves when tongue stuck out
Describe the likely causes for each

A

Lump does not move on swallowing
- lymph node or salivary gland issue

Lump does move on swallowing
- thyroid issue

Lump does move on swallowing and moves when tongue stuck out
- thyroglossal cyst

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130
Q

Young 18 year old female complains of neck lump. In the midline, moves on swallowing and when she sticks her tongue out. What is the likely diagnosis?

A

Thyroglossal cyst

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131
Q

When taking a history from a patient with a neck lump, what are the 2 important points you need to ascertain?

A

Previous radiation exposure

FH of thyroid problems

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132
Q

When examining a patient with a neck lump, what are the 2 most important things to check for?

A

Hoarse voice

Lymphadenopathy

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133
Q

Thyroid nodule + neck lymphadenopathy is ____ until proven otherwise

A

Papillary thyroid cancer

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134
Q

When it comes to neck lumps, what is the 5% rule

A

5% of females will have a thyroid lump at some point
5% will be malignant
5% will be on thyroxine at some stage

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135
Q

First line imaging investigation for patient with thyroid nodule?

A

US guided FNA

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136
Q

For thyroid pathology, when should you use an uptake (isotope) scan?

A

If TSH level is suppressed, use it to see if it is a solitary toxic adenoma

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137
Q

In graves disease, what would an uptake (isotope) scan look like?

A

Hot all over

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138
Q

Bile which overspills into the bloodstream causes

A

Jaundice

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139
Q

Which US findings would suggest cholecystitis?

A

Thickened GB wall (inflammation)
Presence of gallstones
Peri-cholecystic fluid

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140
Q

Transient RUQ pain, worse after eating meals (esp fatty meals), radiates to back, pain goes away after a few hours. What does this suggest?

A

Biliary colic

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141
Q

Crampy RUQ pain radiates to back, tender, fever, vomiting. What are the differentials

A

Acute cholecystitis
Ascending cholangitis
Pyelonephritis
Acute pancreatitis

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142
Q

Which LFT will likely be raised in acute cholecystitis ?

A

Raised ALP and bilirubin

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143
Q

Which LFT will be raised in liver problems?

A

AST (T = trauma to the liver)

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144
Q

Investigations for patient presenting with acute cholecystitis

A

Bloods
US
MRCP
Erect CXR

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145
Q

Someone with obstructive jaundice. How do you manage it?

A

ERCP

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146
Q

Name 2 causes of obstructive jaundice

A

Ascending cholangitis

Pancreatic cancer

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147
Q

pt with Amylase 400 and pt with amylase 1000. Which pt has the most severe case of pancreatitis?

A

Can’t tell

- amylase doesnt tell you how severe pancreatitis is

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148
Q

Will billirubin be conjugated or unconjugated in obstructive jaundice

A

Conjugated

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149
Q

Diagnosis and treatment of ascending cholangitis

A

Diagnosid: MRCP
Treatment: ERCP / cholecystectomy

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150
Q

What is the best investigation for ?gallstones

A

abdominal US

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151
Q

Management of pancreatitis

A

IV fluids and analgesia

DO NOT give antibiotics routinely

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152
Q

Cullen’s sign - how do you get this

A

Pancreatitis

Bruising around umbilicus arises from blood travelling down the falciform ligament

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153
Q

What is the best imaging investigation for pancreatitis?

A

CT scan

  • but not used routinely
  • only if diagnosis not clear (ie amylase <300)
  • if patient not improving after couple of days
154
Q

Pancreatic pseudocyst - how does it form and what is the best investigation

A

Patient with pancreatitis -> fluid around the pancreas.

Pseudo cyst arises with fluid within lesser sac

155
Q

What is regarded the most important treatment of pancreatitis?

156
Q

Describe Gallstone ileus

A

Calcified gallstone erodes through the gallbladder wall and finds way to small bowel

157
Q

Which part of the small bowel does gallstone ileus usually occur?

A

Near ileocaecal valve

158
Q

Increased WCC and CRP in biliary colic / acute cholecystitis?

A

Acute cholecystitis

159
Q

Name 2 medications which can cause pancreatitis?

A

Methotrexate

Azathioprine

160
Q

US shows thickened wall of GB. What is the likely diagnosis?

A

Acute cholecystitis

161
Q

What is a cholecystostomy and when may it be used?

A

Makes connection with the skin. Used to drain pus and infected bile from GB in elderly patient not fit for surgery

162
Q

Elderly patient, LIF pain, blood in stool, loose stool. Name top 3 differentials

A

Diverticular disease (diverticulitis)
Colorectal cancer
Ischaemic colitis

163
Q

Which tumour marker is raised in colon cancer?

164
Q

Which tumour marker is raised in ovarian cancer?

165
Q

Drain a diverticular abscess if greater than what size?

166
Q

AXR findings of faecal impaction or constipation?

A

Dilated bowel loops above the area of impaction / constipation

167
Q

Which classification system is used for diverticular disease?

A

Hinchey classification

168
Q

3 complications of diverticular disease

A

Diverticulitis
Fistula
Stricture

169
Q

Which imaging investigation is best for ?diverticulitis

170
Q

Which invasive investigation is best for ?diverticulitis

A

Flexible sigmoidoscopy

171
Q

Sigmoid volvulus

- AXR appearance and location

A

Appearance: coffee bean shape
Location: RUQ (sigmoid colon twists around and goes to RUQ)

172
Q

Caecal volvulus

- AXR appearance and location

A

Appearance: coffee bean shape
Location: LUQ (caecum twists around and goes to LUW)

173
Q

Name 2 causes of toxic megacolon

A

C diff

Ulcerative colitis

174
Q

Treatment of toxic megacolon

A

decompression

If no improvement in 24 hours, surgery required

175
Q

Toxic megacolon risks

A

Rupture (perforation)

Sepsis

176
Q

barium/gastrograffin MEAL examines which parts of the GI tract

A

Oesophagus
Stomach
Duodenum (stops here)

177
Q

Gastrograffin follow through is used to look for what

A

Small bowel obstruction

178
Q

Toxic megacolon there is usually severe dilatation of the RIGHT / LEFT side of colon?

179
Q

Which patients should you NOT do barium studies with?

A

Patients with peritonitis

- can cause chemical peritonitis

180
Q

Patient has ?perforation. Which is best to use

  • barium studies
  • gastrograffin studies
A

Gastrograffin studies

181
Q

Mainstay of treatment for acute pancreatitis

A

Fluid resuscitation

IV analgesia

182
Q

Every patient with ?pancreatitis gets what imaging investigation and why is this?

A

US

- to check for gallstones

183
Q

Why does jaundice occur?

A

Due to hyperbilirubinaemia (when serum bilirubin is over 50 umol/L)

184
Q

Intrahepatic jaundice will be conjugated / unconjugated?

185
Q

Pseudocyst form how long after pancreatitis

186
Q

Name 3 severity scoring systems for acute pancreatitis

A

APACHE
Glasgow
Ranson

187
Q

When is apache score for pancreatitis used?

A

If presentation is within 24 hours symptom onset

188
Q

What is P-POSUM

A

Surgical scoring system to assess risk

Compare morbidity and mortality in a wide range of general surgical procedures

189
Q

Where is the most common location for ischaemic colitis?

A

Junction between midgut and hindgut (around 2/3rd point of the transverse colon)

190
Q

Parietal / visceral peritoneum has nerve endings?

A

Parietal peritoneum has nerve endings

191
Q

Define peritonism

A

Localised area of peritonitis

192
Q

When examining the acute abdomen, how do you check for peritonism?

A

Cough tenderness - get pt to cough, this shifts parietal peritoneum. If pt winces when coughs, peritonism likely present

Percussion tenderness 
Rebound tenderness (unpleasant for patient)
193
Q

Colostomy is RHS / LHS abdo and spouted / flush with skin

A

Colostomy

  • LHS abdo
  • flush with skin
194
Q

Ileostomy is RHS / LHS abdo and spouted / flush with skin?

A

Ileostomy

  • RHS abdo
  • spouted
195
Q

Why is an ileostomy spouted?

A

Ileum contains lots of enzymes which could cause surrounding skin irritation if left flushed with skin

196
Q

Who gets mesenteric adenitis ?

197
Q

If patient in theatre gets cholangiogram which shows stones in the CBD, what is done?

A

IV glucagon opens the sphincter of odi and saline flushed through CBD. Hopefully any stones will pass through to duodenum

198
Q

3 main complications of ERCP

A 
Pancreatitis 
Duodenal perforation (since duodenum fixed)
Duodenal haemorrhage (due to gastroduodenal artery)
199
Q

Name 2 main indications for AXR in general surgery?

A

?obstruction

? toxic megacolon

200
Q

Riglers sign on AXR

A

A sign of perforation (free gas on inside and outside of bowel wall)

201
Q

How do you know if NG tube insertion is correct?

A

X-ray to confirm correct placement

  • must pass carina in the midline and continue down the midline
  • must end up beneath the diaphragm
202
Q

Where is the correct positioning of an endotracheal tube

A

insert via mouth and go to about 2-3cm above carina

- do not want it to extend into the R or L main bronchus

203
Q

If endotracheal tube accidentally ends up in the R main bronchus, what is the risk?

A

Contralateral (L bronchus) lung collapse as only the R lung is getting inflated.

204
Q

Patient with ?rupture AAA. What is the best imaging investigation

  • MRI
  • AXR
  • US
  • CT without contrast
  • CT with contrast
  • CT angiogram
A

CT with contrast

205
Q

If patient has suspected appendicitis, should you give them antibiotics?

A

no, only give antibiotics once you’re sure the patient has appendicitis

206
Q

Young woman with RIF pain. What do you need to exclude

A

Ectopic pregnancy

Ovarian torsion

207
Q

What is the best investigation for ?ovarian torsion ?

208
Q

Where is a common location for crohn’s disease?

A

Ileo-caecal junction

209
Q

Urinalysis: blood and protein. What do you suspect?

A

Renal stones

210
Q

If you suspect a patient has renal stones after urinalysis, what imaging investigation is good?

211
Q

Explain the pathophysiology of venous disease

A

there is reflux, obstruction or a combination of both

The venous system is unable to retain blood flow in the right direction causing a pooling of blood and subsequently increased venous pressure

212
Q

Dilated
Torturous
Elongated
These three words make you think of what

A

Varicose veins

213
Q

investigation of choice for venous disease

214
Q

Conservative management of venous disease

A

Compression stockings

- create what would be a normal venous system (high pressure in the foot)

215
Q

In what situation are compression stockings contraindicated

A

If the person has arterial disease

- ABPI must be above 0.8

216
Q

Explain surgical management of venous disease

A

Essentially you thrombose the superficial vein so that there is no longer any reflux. Now, the only way the leg drains is through the deep venous system.

Over time the body will clear up the thrombosed superficial vein

Options:

  • foam sclerotherapy
  • endothermal ablation
217
Q

Red flags to ask in Hx if suspecting colorectal cancer?

A

Weight loss
Night sweats
Feeling of fullness
PR bleed

218
Q

If a patient has a Hx of bleeding, what should you always screen for in the history?

A

? malignancy

? anaemia

219
Q

Suspect haemorrhoids is diagnosis, how do you go about PR exam

A 
Initial inspection
- may see external haemorrhoids 
Palpation
- for masses (but will not feel haemorrhoids on palpation) 
Proctoscopy 
- to look for internal haemorrhoids
220
Q

You can usually feel haemorrhoids on palpation during PR exam. True or false ?

A

False

- usually can’t feel them

221
Q

A patient with Hx of recurrent perianal abscess and pain. What would you suspect?

A

Fistula

- look / feel for an internal opening

222
Q

Anal pain + fresh red blood on toilet paper. Think?

A

Anal fissure

223
Q

Topical management of anal fissure

A

Diltiazem cream

224
Q

Painless fresh red bleeding on background of constipation makes you think

A

Haemorrhoids

225
Q

85 year old female with right sided lower abdominal pain. Name top 3 differentials

A

Diverticulitis
- usually presents with L sided abdo pain (as sigmoid colon affected) but some patients have large sigmoid colon so could flop over

UTI

Ovarian mass

226
Q

Young male with RIF pain.
Diagnosis?
Investigations?
Management?

A

Appendicitis
No investigations required
Tx surgery (laparoscopic appendicetomy)

227
Q

70 year old male, Left sided colicky loin-groin pain, can’t sit still. What is at front of your mind to exclude?

A

Ruptured AAA

228
Q

Best imaging for diverticular disease / diverticulitis ?

229
Q

DIAGNOSTIC imaging tool for appendicitis

A

CT scan

- usually only use if over 40 y/o

230
Q

Bowel cancer often/rarely present with pain

231
Q

Apart from rectal cancer, what can CEA tumour marker also be raised in?

232
Q

CEA tumour marker is a good screening tool for rectal cancer. True or false?

A

False

- can be raised in people without cancer (eg smokers)

233
Q

Patient with lower abdo pain. If ?gynae pathology what is best imaging investigation to get?

A

US + TVUSS

234
Q

Patient with lower abdominal pain and you request a CT. Should you request with or without contrast?

A

With contrast

235
Q

Mainstay of treatment for diverticulitis?

A

Antibiotics

236
Q

Mainstay of treatment for toxic megacolon?

237
Q

What is mittelshmerz pain?

A

Ovulation pain. Occurs mid cycle, lower abdominal pain.

238
Q

23 year old female with lower abdominal pain (severe). No other symtpoms, no PV discharge, last period 2 weeks ago. Normal bloods and no inflammatory markers raised. What is the likely diagnosis? and how would you manage?

A

Mittelshmerz pain

- self limiting

239
Q

Elderly patient, 2 month Hx food stuck in throat, discomfort in upper part of throat, feels an odd sensation there. Gets a cough at night when he lies down. No weight loss.
What is the most likely diagnosis and what is the pathophysiology of this condition?

A

Pharyngeal pouch

  • weakening in the UPPER part of the oesophageal wall causes an outpouching of mucosa. This puts pressure on the oesophageal lumen and causes it to collapse
240
Q

Suspected pharyngeal pouch. What is the best imaging investigation?

A

Barium swallow

241
Q

Management of pharyngeal pouch

A

Surgical resection

242
Q

Barrett’s oesophagus predisposes to

A

Adenocarcinoma

243
Q

35 year old alcoholic comes to A+E with vomit with red streaks in it. Tachy, hypotensive. What is likely diagnosis and how do you manage?

A

Mallory Weiss Tear

  • keep overnight in hosptial for observation
  • PPI infusion and fluid replacement
  • no other management required
244
Q

Patient presents with burning retrosternal pain and sometimes regurgitation of acidic fluid. Do you need to investigate?
What is managment?

A

No investigation - emperical treatment initially
4-6 weeks PPI
If patient improves, great
If no improvement or worsening in symptoms, order OGD

245
Q

Best investigation for ?Barrett’s oesophagus?

246
Q

Patient with initial dysphagia to solids but now also dysphagia to liquids. Feels discomfort in lower oesophagus. What is likely diagnosis and how would you investigate to confirm diagnosis?

A

Likely diagnosis: Achalasia

Investigation: Barium swallow -> oesophageal manometry is diagnostic

247
Q

Initial treatment of achalasia?

A

Conservative
- diltiazem (CCB)
to try and relax the sphincter and let it open up

248
Q

Definitive treatment for achalasia? (2 options)

A

Endoscopic balloon dilatation

Heller’s myotomy

249
Q

Patient with pain along the entire length of oesophagus, barium swallow shows corkscrew appearance. What is likely diagnosis?

A

Diffuse oesophageal spasm

250
Q

Chronic acid reflux can cause 2 main things

A

Barrett’s oesophagus

Hiatus hernia

251
Q

What is the condition associated with rupture of the oeesophagus?

A

Boerhaave syndrome

252
Q

Oesophageal rupture which results from a sudden increased intraoesophageal pressure (which occurs through vomiting). What is this called?

A

Boerhaave syndrome

253
Q

a patient with a history of overindulgence in food or drinks who, after severe or repeated vomiting, experiences excruciating chest pain and develops subcutaneous emphysema. What is the likely diagnosis?

A

Boerhaave syndrome

254
Q

Pancreatic pseudocyst management (patient has no signs of infection)

A

Conservative

255
Q

2 commonest places of colorectal cancer metastasis?

A

Liver

Lungs

256
Q

Why is blood mixed in with stool more common in left sided colorectal cancer than right sided colorectal cancer presentation?

A

Left sided: stool is mostly formed, blood shows up more

Right sided: contents are more liquid. blood is still there but it gets mixed better and more difficult to distinguish in the stool. However if you do FOB test (qFIT test) then blood will show up

257
Q

Gold standard investigation for ?colorectal cancer

A

Colonoscopy

258
Q

If ?rectal cancer, what is the best imaging ?

A

MRI scan of rectum

259
Q

What is the name of the staging used for colorectal cancer?

A

Duke’s staging

260
Q

Name 4 causes of upper GI bleeding

A

Peptic ulcer disease
Varices
Malignancy
Mallory weis tear

261
Q

Malena is a sign of upper/lower GI bleeding?

A

Upper GI bleeding

262
Q

If a patient presents with fresh PR bleeding, it could not be due to upper GI bleeding. true or false?

A

False
- if patient is having a massive bleed, it won’t have time to oxidise and become ‘malena’ (black and tarry). So you can still get fresh bleeding even if upper GI bleed

263
Q

Most imoportant investigation in upper GI bleed

A

OGD endoscopy

264
Q

What is the treatment of a bleeding peptic ulcer?

A 
Resuscitate 
Endoscopic therapy 
- heater probe 
- clips 
- inject adrenaline (1:10000) 
High dose PPI infusion
265
Q

What is the treatment of oesophageal varices?

A

Vasoconstrictors (somatostatin, terlipressin, ocreotide)
Endoscopy with band ligation
Balloon tamponade

266
Q

Which medication makes ulcerative colitis worse?

267
Q

Higher risk of colorectal cancer if you have UC / Crohn’s ?

268
Q

Name 2 associated conditions related to UC ?

A

Toxic megacolon

PSC

269
Q

This structure is contained within the FEMALE inguinal canal ?

A

Round ligament

270
Q

A patient with Large bowel obstruction. IF X is present they must go to theatre immediately?

A

Closed loop bowel obstruction

271
Q

Patient with UC has abdominal pain + distention. WHat are you concerned about?

A

Toxic megacolon

272
Q

Leadpipe colon on X-ray (distension and loss of haustra)

A

Toxic megacolon

273
Q

Why should you not give metochlopromide in bowel obstruction?

A

It is a prokinetic

274
Q

Increased creatinine, Decreased eGFR think

275
Q

direct inguinal hernia is medial/lateral to inferior epigastric vessels?

276
Q

Patient has an extremely painful groin hernia. In extreme pain when you try to reduce it. What do you do?

A

Give morphine, analgesia to help with the pain and then you try and push it again to see whether it is reducible or not.

If reducible –> send home

If irreducible –> ?obstruction ?incarceration

277
Q

Patient bleeding and you send off bloods.
Creatinine normal
Urea elevated (20)
What should you be thinking and what investigation will you order?

A

Thinking ?upper GI bleed

Order OGD endoscopy

278
Q

Coffee ground vomit indicates upper or lower GI bleed?

A

Upper GI bleed

279
Q

M2 anti-mitochondrial antibodies on biopsy are diagnostic of which condition?

A

Primary Biliary Cholangitis

280
Q

sudden onset abdominal pain, ascites, and tender hepatomegaly makes you think

A

Budd Chiari syndrome

281
Q

Sever eflare up of UC should be treated with

A

IV steroids in hospital

282
Q

corkscrew appearance on barium swallow

A

Diffuse oesophageal spasm

283
Q

12 hours Hx abdominal pain and bloody diarrhoea. Pain out of proportion of clinical findings (soft, non tender abdo) makes you think of what diagnosis?

A

Acute mesenteric ischaemia

284
Q

First line investigation for acute mesenteric ischaemia

A

Serum lactate

- raised: lack of blood supply causes anaerobic metabolism

285
Q

Extradural haematoma usually due to which artery?

A

Middle meningialartery

286
Q

Strongest risk factor for anal cancer

287
Q

In suspected acute cholecystitis, why should a patient be fasted?

A

So that on US investigation, it is easier to assess whether that is the problem.
If patient is fasted it will be easier to see the GB more clearly, it will not be contracted as all the bile will have accumulated in the GB

288
Q

Patient with acute cholecystitis. Symptoms started 1 day ago. What is the management

A

IV antibiotics + cholecystectomy acute (since pain present less than 72 hours)

289
Q

Patient with acute cholecystitis. Symptoms started 4 days ago but they present to hospital now. What is the maangement

A

IV antibiotics + DELAYED cholecystectomy (since pain present over 72 hours, the gallbladder will be at a later stage of inflammation so more risk of complications during the surgery)

290
Q

Patient with acute cholecystitis. Symptoms started 4 days ago so no urgent cholecystectomy required. However, the patient becomes increasingly unwell and acutely deteriorates. What could be the problem?

A

Necrosis and gangrene of the GB -> rupture

291
Q

What is the best investigation to assess a ?perforated gallbladder?

292
Q

Differential diagnosis of haematemesis after forceful vomiting (2)

A 
Mallory weiss tear 
Oesophageal rupture (boor Haave syndrome)
293
Q

Signs of chronic liver disease combined with massive haematemesis suggest

A

Oesophageal varices

294
Q

Gallstone impacts in the cystic duct and the gallbladder epithelium continues to secrete mucus resulting in distention. What is this called?

295
Q

Diaphragmatic splinting

A

Diaphragm can’t move down as much due to pain receptors -> patient takes short shallow breaths -> collapsed lung

296
Q

PaO2 and PaCO2 in type 1 vs type 2 resp failure

A

Type 1 resp failure: decreased PaO2 normal PaCO2

Type 2 resp failure: decreased PaO2 INCREASED PaCO2

297
Q

Management of mild UC

A

Topical 5-ASA

  • local anti-inflamatory
  • eg pentasa
298
Q

Management of mild UC flare up

A

Oral Steroids

299
Q

Management of moderate UC

A

Oral 5-ASA, high dose, capsule

300
Q

Management of severe UC

A

Start on steroids 40mg week 1

gradually reduce 5mg / week

301
Q

If patient has severe UC and has been started on steroids (gradually decreasing dose) but this is ineffective, which are the 2 next medications to try:

A

Azathioprine

Methotrexate

302
Q

Last line medical management for UC before surgery

A

Ciclosporin

303
Q

More likely to get peri anal disease in

  • crohns
  • UC
304
Q

Tumour in the lower rectum, near the anal margin. Which surgery should be done?

  • anterior resection
  • abdominoperineal resection
  • hartmans procedure
  • pan total colectomy
A

Abdominoperineal resection

- this involves removing the anus, rectum and part of the descending colon, resulting in an end colostomy (permanent)

305
Q

Tumour in the upper/middle part of rectum. Which surgery should be done?

  • anterior resection
  • abdominoperineal resection
  • hartmans procedure
  • pan total colectomy
A

Anterior resection

306
Q

What is the most common hepatic malignancy?

A

Hepatocellular carcinoma HCC

307
Q 
Inflammatory markers: normal
LFTs: AST, ALT, bilirubin all raised 
Albumin and PT: decreased 
AFP +ve 
What is likely to be going on
A

Hepatocellular carcinoma

308
Q

What is the tumour marker for HCC

309
Q

Patient with liver lesions seen on CT and +ve CEA. Describe this

A

Metastatic colorectal cancer

- commonly metastasises to liver

310
Q

What is the BEST imaging investigation for ?HCC

A

CT with contrast

311
Q

What are the 2 best management options for HCC

A

Surgery (liver resection)

Liver transplant

312
Q

What is the most common benign liver tumour?

A

Haemangioma

313
Q

Management of haemangioma

A

Do nothing

314
Q

It is common practice to biopsy liver cancer

A

False

- can make diagnosis from imaging ofter

315
Q

How to diagnose H. Pylori

A

FAT stool antigen test

Urease breath test

316
Q

Duodenal ulcer
- aggravated by eating
- relieved by eating
Why?

A

Relieved by eating
When you have food, acid in the stomach is utilised for the digestion of food and so less acid makes its way into the duodenum.

317
Q

Investigation of choice for ? gastric carcinoma ?

A

OGD + biopsy

318
Q

What is the triad for ascending cholangitis?

A

Fever
RUQ pain
Jaundice

319
Q

In ascending cholangitis, do you give antibiotics and if so, when?

320
Q

Investigation of choice for ascending cholangitis

A

MRCP to visualise site of obstruction

321
Q

What is the significance of the dentate line?

A

Change from mucosa to anal skin, the line at which sensation is mostly lost

322
Q

Lymphatic drainage of the breast (2)

A

Axillary lymph nodes 97%

Internal mammary lymph nodes 2%

323
Q 
In triple assessment for breast pathology, under 40 year olds get 
- US 
- mammogram 
and what else if required
- FNA 
- vaccum biopsy
- core needle biopsy
A

Under 40

  • US
  • core needle biopsy
324
Q 
In triple assessment for breast pathology, over 40 year olds get 
- US 
- mammogram 
and what else if required
- FNA 
- vaccum biopsy
- core needle biopsy
A

Over 40

  • mammogram
  • core needle biopsy
325
Q

What is fibroadenosis

A

Breast cyst

326
Q

Name the 3 most common chemotherapies used for adjuvant / neo-adjuvant breast cancer treatment?

A
  1. Anthracyclines (doxorubicin)
  2. Taxanes (pacletaxil)
  3. 5-fluorouracil
327
Q

Non tender hepatomegaly + itch + jaundice makes you think

328
Q

Chronic pancreatitis

- cause

A

Alcohol

Due to persistent and repeated damage of the pancreas

329
Q

There is a role for prophylactic antibiotics in uncomplicated pancreatitis. True or false?

330
Q

When would you use antibiotics in pancreatitis?

A

If necrosis present

331
Q

if ?necrotic pancreatitis, which imaging investigation should be carrried out?

A

CT with contrast

- contrast goes to areas with living blood supply

332
Q

Alcoholic pancreatitis. What should you give to prevent alcohol withdrawal?

A

Benzodiazepines

333
Q

A patient with gallstone pancreatitis must get a cholecystectomy. True or false?

334
Q

When is cholecystectomy carried out for patient with gallstone pancreatitis?

A

Either on admission of within 2 weeks of admission

335
Q

A pseudocyst can be necrotic. True or false?

A

False

- long term collections of fluid around a pancreas which does not have any necrosis, has a capsule round about it

336
Q

Is amylase sensitive and/or specific?

A

No

- neither

337
Q

Metochlopromide should not be given to which 2 groups of people

A

Bowel obstruction - as it is a prokinetic

young women - tardive dyskinesia

338
Q

If you do a CT scan and it shows gas in the pancreas, what does this suggest?

A

Infection present

339
Q

Sudden onset unilateral leg pain with absence of pulses makes you think

A

Acute limb ischaemia (due to embolus)

340
Q

Initial investigation of choice for ?coeliac disease

341
Q

When checking Anti-TTG, what should you also check?

A

IgA levels

- anti-TTG wont raise in patients with IgA deficiency

342
Q

Inherited condition which results in a defect in conjugation of bilirubin

A

Gilbert’s syndrome

343
Q 
RUQ pain 
Palpable GB 
Swinging fever 
US shows distended GB with stone impacted in neck.
What is the likely diagnosis? 
- mucocele
- acute cholecystitis 
- ascending cholangitis 
- empyema 
- mirizzi syndrome
A

GB empyema

344
Q

Most common cause of infective colitis

345
Q

Surgery has a better outcome in UC or crohn’s?

346
Q

What is the normal length of small bowel?

347
Q

At what length of small bowel do you risk getting short bowel syndrome?

A

less than 1m

348
Q

People with short bowel syndrome are reliant on what?

349
Q

Define fistula

A

An abnormal connection between 2 epithelial surfaces

350
Q

Some patients with Crohn’s disease get really bad anal fistula. How is this usually managed?

A

Surgery with seton sutures

351
Q

What is the difference between incarcerated and obstructed hernia?

A

Incarcerated hernia doesn’t cause bowel obstruction.

352
Q

IVDU with painful groin lump. What are the differentials

A 
Groin abscess 
Pseudoaneurysm 
Lymphoedema 
Psoas abscess 
Inguinal hernia
353
Q

What is the best investigation for ?pseudoaneurysm?

A

CT angiogram

354
Q

In an IVDU with groin lump, why is it so important to rule out pseudoaneurysm?

A

If you put a needle into pseudoaneurysm (ie if you think you are draining an abscess) then blood will go EVERYWHERE

355
Q

Best imaging investigation for femoral hernia?

356
Q

most common cause of acute limb ischaemia?

A

Embolism (ie from AF)

357
Q

Clinical features of acute limb ischaemia

A 
Pain
Pallor
Perishingly cold 
Pulseless
Paraesthesia
Paralysis 
Contralateral limb will be normal 
No preceeding problems
358
Q

List investigations you would order for a patient with acute limb ischaemia

A 
Bloods
ECG - ?MI ?arrhythmia 
CXR - ?malignancy 
Duplex US 
CT angiogram
359
Q

Acute limb ischaemia with salvageable limb. What is the management ?

A

Anticoagulate
Embolectomy (fish out clot from leg)
Fascieciotomy

360
Q

Why should you do fasciectomy at time of embolectomy?

A

Due to risk of compartment syndrome

361
Q

Acute limb ischaemia and limb is NOT salvageable. What are your options?

A

Amputation

Paliation

362
Q

Compartment syndrome clinical features

A

Pain out of proportion
Pain on passive stretch
Pulses are PRESENT

363
Q

What is the definition of critical limb ischaemia

A

end stage peripheral vascular disease

patient has pain at rest for over 2 weeks

364
Q

Patient hangs leg out of bed at night is a tell tale sign for what?

A

Critical limb ischaemia

365
Q

intermittent claudication is

  • peripheral vascular disease
  • peripheral arterial disease
A

Peripheral arterial disease

366
Q

What is the most important initial out patient management of claudication?

  • lifestyle modification and exercise
  • lifestyle modification, exercise, statin, antiplatelets
  • antiplatelet therapt
A

Lifestyle modification
Exercise
Statin
Antiplatelets

367
Q

The AAA programme uses what imaging to assess aortic diameter?

A

Abdominal US

368
Q

Circle of willis is supplied by which of the following arteries

  • bilateral internal carotids + posterior cerebral arteries
  • bilateral internal carotids + bilateral vertebral arteries
  • bilateral external carotids + bilateral vertebral arteries
  • bilateral external carotids + posterior cerebral arteries
A

Bilateral internal carotids + bilateral vertebral arteries

369
Q

What is the initial out patient management of a non infected venous ulcer

A

ABPI +/- graduated compression stocking

370
Q

Primary varicose veins care caused by

  • arterial insufficiency
  • DVT
  • hypertension
  • incompetent venous valves
A

Incompetent venous valves

371
Q

Name 3 surgical treatment options for varicose veins

A

Foam sclerotherapy
Endothermal ablation
Open surgery

372
Q

Buerger’s test assesses for

A

Arterial insufficiency

373
Q

ANY patient who has had wide local excision for breast cancer should have radiotherapy. True or false?

374
Q

Who is tamoxifen used in

A

Pre- and peri- menopausal women who are ER+ve

375
Q

Post-menopausal woman with breast cancer that is ER+ve. What is the hormonal treatment?

A

Anastrazole

376
Q

What is spontaneous bacterial peritonitis associated with?

A

Liver disease

- infection of ascitic fluid

377
Q

Which type of obstruction requires emergency surgery?

A

Closed loop obstruction

378
Q

When is the most common time you will see an ileus

A

Following abdominal surgery

379
Q

What is first line medical treatment for anal fissures? And how does it work?

A

Anusol

- chemical which shrinks the haemorrhoids

380
Q

Management of uncomplicated acute diverticulitis in primary care

A

Oral co-amoxiclav 5 days
Analgesia
Clear liquids

381
Q

In those diagnosed with anal fisula, which investigation is best to characterise the course of the fistula?

Y4 (23 decks)

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