General Surgery (colorectal) Flashcards
What are the causes of pancreatitis?
Gallstones
Alcohol
Steroids
Other:
- trauma, mumps, SLE, ERCP, hypothermia, hypercalcaemia
Drugs:
- azathioprine and mesalazine, NSAIDs, diuretics, sodium valproate
Brief pathophysiology of pancreatitis
duct obstruction leads to ischaemia and acinar cell injury
- lipase released: fat necrosis with fatty acids binding calcium leading to hypocalcaemia
- islet cells damaged: hyperglycaemia
- protease and elastase released: haemorrhage
All leading to infection and inflammation
Aside from pancreatitis, when else would amylase be raised?
Ectopic pregnancy Renal failure DKA cholecystitis mesenteric ischaemia
Why is serum lipase not accurate in diagnosing pancreatitis?
It takes 8 hours after symptom onset to rise
If you were to do an AXR or CXR in pancreatitis, what might it show?
CXR: pneumoperitoneum or pleural effusion
AXR: sentinel loop sign (dilated proximal bowl)
What are the signs and symptoms of pancreatitis?
Epigastric pain radiating to the back
Guarding
Nausea and vomiting
Tetany (hypocalcaemia)
Tachycardic and hypotensive
Cullens: peri-umbilical brusing
Grey-turners: flank brusing
Left sided pleural effusion
What system would you use to calculate the severity/prognosis? What are some markers used in this score?
Glasgow scoring system
Low sats
>55
Raised neutrophils
Raised Urea
Raised LDH
Raised glucose
Hypoalbuminaemia
Hypocalcaemia
What is the management of pancreatitis?
IV Fluids
Analgesia
Antiemetics
Monitor Blood Glucose
Analgesia
What are some complications of pancreatitis?
Infective necrosis Abscess Pseudocyst Chronic pancreatitis DIC ARDS and pleural effusions
What is the difference between acute and chronic pancreatitis? Therefore, how does chronic pancreatitis present?
In chronic pancreatitis it is the secretory function of the pancreas that is damaged
Diabetes
Steatorrhea
+ pain after eating
What are the causes of chronic pancreatitis?
Alcohol
Cystic fibrosis
Duct obstruction with tumour or stones
How should you investigate chronic pancreatitis? What is seen?
CT
Shows pancreatic calcifications
How is chronic pancreatitis managed?
Fat soluble vitamins
Pancreatic enzymes
Analgesia
Where are pancreatic pseudocysts most commonly located?
Lesser sac
Gastro-epiploic foramen
How do pancreatic pseudocysts present?
Biliary or gastric outlet obstruction
When and how does post-op ileus present?
Few days post-op
!!Hypovolaemia and low electrolytes despite positive fluid balance!!
Distension
N&V
Absolute constipation
What is third spacing?
How is it managed?
obstruction = proximal bowel hugely dilates = increased peristalsis = electrolyte rich secretions move from vascular space to bowel
Fluid resus
How does bowel obstruction present?
Distension + absolute constipation + vomiting + pain + empty rectum
What measurements constitute enlarged small bowel, large bowel and caecum?
small >3cm
large >6cm
caecum >9cm
What causes large bowel obstruction?
Colorectal cancer
Diverticulitis
Volvulus
IBD
What causes small bowel obstruction?
Hernia
Adhesions
Tumours, peritoneal metastasis, lymphomas
Compare what you’d hear on auscultation of large and small bowel obstruction
Large: loud but normal pitch
Small: high pitch tinkling
Percussion of a small bowel obstruction sounds like what?
Tympanic
How is bowel obstruction managed?
Fluid resuscitation
NG tube to decompress
A competent ileo-caecal valve leads to what?
Worsening bowel obstruction as material continues to pass in to the caecum leading to it rupturing
Where are peptic ulcers most commonly found?
lesser curve and antrum of the stomach
anterior proximal duodenum
What are the risk factors for developing peptic ulcers?
H-pylori infection NSAIDs Smoking Alcohol Zollinger Ellison
Briefly, how does H-pylori lead to ulcers?
- reduced bicarbonate production
- reduced mucous production
- increased histamine leading to excessive acid
What is H-pylori?
spiral shaped gram -ve bacteria
How does peptic ulcers present in general?
What features point towards the ulcer being in the stomach vs duodenum?
Epigastric pain
Weight loss due to pain and early satiety
stomach: pain just before and whilst eating
duodenal: improved by eating then pain worse hours after
How would you investigate peptic ulcer disease?
urease breath test
stool antigen test
+/- endoscopy and biopsy
What does H-pylori eradication involve?
Omeprazole
Amoxicillin
Metronidazole or clarithromycin
What are the complications of peptic ulcer disease?
perforation leading to peritonitis anaemia malignancy haemorrhage - stomach = left gastric - duodenum = gastroduodenal
How is haemorrhage resulting from peptic ulcer erosion managed?
inject adrenaline
cauterize
omeprazole
What can cause peritonitis?
GI tract perforation
Spontaneous bacteria peritonitis (seen in ascites)
Peritoneal dialysis
Surgical complication
Non-infectious eg with SLE
How does peritonitis present?
acute abdominal pain
washboard rigidity
fever
shock
What are the complications of peritonitis?
abscess formation
sepsis
fluid and electrolyte disturbances
breathing difficulties if diaphragm irritated or under pressure in abdomen distension
What nerves cause the classic generalised then localising to RIF pain seen in appendicitis?
General: visceral splanchnic
Localised: peritoneal
What are some examination findings in appendicitis?
RIF rebound tenderness Guarding Rosvings: RIF pain when LIF palpated Psoas sign: RIF pain on right hip extension Palpable mass if abscess present
What are some signs, symptoms and blood results that would indicate the need for an appendicectomy?
migration of pain N&V Rebound tenderness Fever neutrophil predominate leukocytosis
Define a hernia
protrusion of viscera from its containing cavity
Describe the anatomy of a direct and indirect inguinal hernia
direct: enters through a defect in the posterior wall of the inguinal canal at Hesselbachs
indirect: enters through the deep ring and travels through the canal exiting at the superficial ring
How do you differentiate between a direct and indirect inguinal hernia?
Direct are found medial to IEVs
Indirect are found lateral to IEVs
How do you differentiate between an inguinal vs a femoral hernia?
inguinal are superior to the pubic tubercle
inguinal head towards the groin
femoral are infero-lateral to the pubic tubercle
femoral head straight down the leg
femoral are medial to the pulse
How would an obturator hernia present?
mass in the upper medial thigh
nerve compression = pain on hip extension, medial rotation and abduction
What are some differentials for hernias?
lymphadenopathy
aneurysm
saphena varix
How are hernias managed?
weight loss
open repair: generally if one off unilateral
laparoscopic repair: generally if recurrent, females, young, bilateral
What are some complications of hernias? Describe briefly what these terms mean
obstructed: bowel contents within the hernia becomes obstructed
incarcerated: contents is stuck inside the sack because of adhesions. The hernia can’t be reduced
strangulated: ischaemia of the tissue within the hernia
How would a strangulated hernia present?
What should you not do whilst awaiting surgery?
Pain out of proportion
Fever
Erythema of the overlying skin
Peritonitic features: guarding
Do not try to reduce it - this can lead to generalised peritonitis
Describe the types of hiatus hernias
sliding: gastroduodenal junction moves above the diaphragm in to the thoracic cavity
rolling: gastroduodenal junction remains in the abdomen but the fundus herniates in to the thoracic cavity
How does a hiatus hernia present?
What examination finding might you find?
reflux dysphagia weight loss hiccups vomiting
How are hiatus hernias managed?
weight loss, stop smoking, stop alcohol
PPIs
fundoplication
What would you see at endoscopy of a hiatus hernia?
upward displacement of the z-line
What are some complications of fundoplication for hiatus hernia?
recurrence of the hernia
dysphagia if done too tightly
bloating - inability to belch
fundal necrosis
What is a complication of a rolling hiatus hernia? How would this present?
gastric volvulus
- Inability to pass an NG tube
- Retching but no vomiting
- Pain
What is diverticulosis, diverticular disease and diverticulitis?
diverticulosis: outpouchings of mucosa between the teniae coli
disease: symptoms arising from the diverticulosis
diverticulitis: inflammation and infection of the diverticulosis often due to faces and food getting stuck in the neck of the outpouching
Where does diverticulosis most commonly occur?
sigmoid colon
can also be descending colon
What are the causes/risk factors for developing diverticulosis?
low fibre diet and constipation
What are the symptoms of diverticular disease?
erratic bowel habits: constipation and diarrhoea
painless bleeding
Colicky LIF pain that is relieved by defecation
How is diverticular disease managed?
How and when is acute diverticulitis managed?
increased fibre
laxatives
analgesia
If >72 hours with no improvement or if severe
- NBM, IV fluids, IV metronidazole + a cephalosporin
How does acute diverticulitis present?
LIF pain N&V Erratic bowel habits Fever Painful bleeding Abdominal distension
What are some complications of diverticular disease?
Fistula - vaginal = brown discharge - bladder = frothy urine and UTIs Perforation Strictures Haemorrhage (erosion in to vessels)
Compare the 2 histological subtypes of oesophageal cancer, their locations and the risk factors for them
squamous cell: upper 2/3rds
- alcohol, smoking, achalasia, reduced vit A
adeno: lower 1/3rd
- obesity, fatty diet, GORD
What are the red flags 2 week wait criteria for oesophageal cancer?
Dysphagia!! +
>55 with dyspepsia and weight loss
Compare Mallory Weiss and Boerhave
Mallory Weiss: superficial mucosa tear
Boerhave: full thickness oesophageal tear
How would an oesophageal tear present?
Retrosternal pain
Respiratory distress
Subcutaneous emphysema
How is oesophageal tear investigated? What would you see?
CT CAP with IV and oral contrast
- can see the oral contrast leaking out
How is oesophageal tear managed?
repair the tear
decontaminate the mediastinum and pleural cavity
abx
feeding via jejunostomy
What is achalasia?
failure of the LOS to relax
eventual failure of the oesophageal smooth muscle
this leads to the food bolus getting stuck
proximal damage of the oesophagus due to force against a blockage
How does achalasia present?
dysphagia to solids and liquids
weight loss
regurgitation
chest pain