General Surgery + HPB Flashcards
What is an anal fissure and what is a haemorrhoid?
What are the differences in presentation?
Fissure = tearing of the squamous lining of the distal anal canal. Painful, bright red, rectal bleeding.
Haemorrhoid = mucosal vascular cushions that become congested and therefore enlarged. Painless rectal bleeding and pruritus. Might become painful if thrombosed.
What is the management of haemorrhoids?
soften stools: increase dietary fibre and fluid intake
topical local anaesthetics and steroids may be used to help symptoms
outpatient treatments: rubber band ligation is superior to injection sclerotherapy
What is the management of an anal fissure?
soften stool - diet or bulk forming laxative. then try lactulose
lubricants such as petroleum jelly may be tried before defecation
topical anaesthetics
analgesia
Topical GTN if chronic
Define Mirizzi Syndrome
External compression of the common bile duct by the neck of the gallbladder due to impaction with a gallstone
leads to an obstructive jaundice picture
what is the triad of symptoms seen in ascending cholangitis?
Jaundice
RUQ pain
Fever/rigors
Charcot’s triad
What is a gallstone Ileus?
A gallstone passes into the duodenum via a fistulae and gets stuck at the ileocaecal valve causing a small bowel obstruction
Which anti-hypertensives should be stopped on the day of surgery?
ACEI/ARB
Spironolactone
can have day before but not on day of
can’t have it night before
essentially has to be 24hrs
CCB, B Blocker and diuretics can all be taken as normal
Which oral hypoglycaemics should be stopped in the peri-operative period?
Metformin - DONT TAKE MORNING OF (can take if eGFR is >60)
Sulphonylureas e.g. Gliclazide
SGLT2I e.g. Empagliflozin
When should hypoglycaemics be restarted after surgery?
When patient is able to eat and drink without vomiting
When should a variable rate insulin be used for someone with T2DM?
if >1 meal missed + hyperglycaemic
If HbA1C is >8.5 i.e. poorly controlled
How should insulin be managed peri-operatively?
Keep long acting insulin at 80% and stop any short actings
Put on a variable rate infusion and do BMs every hour
convert back to subcut insulin once eating and drinking without vomiting
How should oral anticoagulants be managed peri-operatively?
Aspirin - don’t stop
Clopidogrel - stop 7 days before surgery
Warfarin - stop 5 days before surgery and bridge with LMWH
DOAC - stop 48 hours before surgery
What is the target INR for surgery?
1.5
anything above then give vitamin k if surgery will be next day
if surgery is emergency then give prothrombin complex
