General surgical cases Flashcards
Case 1:
45y/o male carpenter.
1yr history of intermittent upper abdominal pain.
‘my stomach is always worse when I’m hungover’.
A&E with worsening abdominal pain over 3hrs and one vomit of gastric contents.
PMHx: lower back pain.
SHx: smoker.
DHx: ibuprofen PRN past 2yrs.
O/E: afebrile, HR 75, BP 130/75, abdomen soft, tender in epigastrium.
No J/ Cl/ An/ Cy.
CVS, RS, CNS, PNS: NAD.
Urine: NAD.
WCC 13.4; Hb 15.1; Plts 250; INR & APTR normal; LFTs normal; CRP 15; amylase 71.
ECG: sinus rhythm.
What is the next investigation for this patient?
a) CXR & AXR
b) USS
c) CT
d) MRI
e) laparoscopy
f) laparotomy
CXR & AXR
What are the causes of upper abdominal pain?
Surgical:
- PUD/GORD
- pancreatitis
- biliary pathology
- abdominal wall
- vascular: AAA
- small bowel
- large bowel
Non-surgical:
- cardiac
- gastroenterological
- musculoskeletal
- diabetes
- dermatological
Case 1:
45y/o male carpenter.
1yr history of intermittent upper abdominal pain.
‘my stomach is always worse when I’m hungover’.
A&E with worsening abdominal pain over 3hrs and one vomit of gastric contents.
PMHx: lower back pain.
SHx: smoker.
DHx: ibuprofen PRN past 2yrs.
O/E: afebrile, HR 75, BP 130/75, abdomen soft, tender in epigastrium.
No J/ Cl/ An/ Cy.
Patient reports improvement of pain with paracetamol and IV fluids.
Wants to go home to watch football.
Diagnosed with gastritis.
Discharged home with no follow-up.
Represents 2 days later.
Been taking double dose ibuprofen as the pain has not improved.
Worsening epigastric pain, now constant.
Vomiting.
O/E: looks unwell, sweating; temp 37C, HR 110, BP 100/60; abdomen rigid with 4 quadrant tenderness.
CVS, RS, CNS, PNS: NAD.
Urine: NAD.
WCC 16.4; Hb 15.1; Plts 250; INR & APTR normal; LFTs normal; CRP 180; amylase 105.
ECG: sinus tachycardia.
CXR & AXR requested. AXR shows free intraperitoneal air and Rigler’s sign. CXR shows free subdiaphragmatic gas.
Diagnosis?
a) gastritis
b) pancreatitis
c) pneumonia
d) small bowel obstruction
e) large bowel obstruction
f) perforated viscus
Perforated viscus.
A patient is diagnosed with perforated viscus. He responds well to IV fluids and antibiotics. Afebrile, HR 85, BP 120/75. Abdomen still rigid with maximal tenderness in epigastrium. Likely perforated organ? a) duodenum b) stomach c) sigmoid diverticular disease d) appendix e) small bowel f) colon from colitis
Duodenum.
What are the basic operative principles regarding acute peritonitis?
Identification of aetiology of peritonitis.
Eradication of the peritoneal source of contamination.
Peritoneal lavage ++++ & drainage.
Treatment for perforated ulcer ranges from conservative (Taylor’s approach) to radical surgery (vagotomy, gastrectomy).
What are the types of peritonitis?
Primary peritonitis: bacterial origin, but no visceral perforation; spontaneous; tuberculosis; peritoneal dialysis catheterisation.
Secondary peritonitis: bacterial origin with visceral perforation; perforated ulcer, perforated appendicitis.
Tertiary peritonitis: persistence/recurrence of intra-abdominal infection following apparently adequate therapy of primary or secondary peritonitis; either fungal or without known pathogens.
What is the usual site of perforation in duodenal ulcer disease?
Usually anterior/superior surface of first part of duodenum or pylorus (rarely on pre-pyloric antrum).
Less frequently found in the stomach (lesser curvature, fundus).
Rarely found on the posterior surface of the first part of the duodenum or stomach.
What is the incidence of duodenal ulcer disease?
Duodenal perforation 8-10x > gastric perforation.
Acute ulcers occur in patients with no history of ulceration in 25-30%.
What are the macroscopic features of duodenal ulcer disease?
Shape of small ring.
5-10mm in diameter.
Slightly indurated edges.
Case 1: post-operatively. Stable and normal observations for first 48hrs. Day 3 post-op: complaining of SOB, O2 sats drop from 99% to 87% on 2L nasal specs; spike of temperature to 38C; sinus tachycardia 100 (no ECG changes); bibasal creps on auscultation R>L; pO2 8.2 on FiO2 of 0.35. CXR shows consolidation. Differential diagnosis: a) pulmonary oedema b) pneumonia c) pulmonary embolism d) leak/collection
Post-operative pneumonia and respiratory failure.
Case 1: post-operatively.
Stable and normal observations for first 48hrs.
Day 3 post-op: complaining of SOB, O2 sats drop from 99% to 87% on 2L nasal specs; spike of temperature to 38C; sinus tachycardia 100 (no ECG changes); bibasal creps on auscultation R>L; pO2 8.2 on FiO2 of 0.35.
CXR shows consolidation. Diagnosed pneumonia.
Clinically improves with IVABx.
Discharged home post-op day 6.
Represents 2 days later with abdominal pain and vomiting.
Febrile 38, HR 110, BP 100/60, sats 98% RA.
Abdomen soft but tender and guarding in epigastrium.
Hb 14.1, WCC 18, CRP 209, LFTs & U&Es normal.
ECG sinus tachycardia.
CXR &AXR unremarkable.
Differential diagnosis?
a) leak from repair site
b) persistent pneumonia
c) constipation
d) intraabdominal collection
Intraabdominal collection requiring drainage and IVABx.
Case 2: 45y/o female. 1yr Hx intermittent upper abdo pain, especially after eating mars bars. Now, 2/7 severe upper abdominal pain associated with vomiting. Overweight but otherwise fit and well. O/E: temp 37.8C, HR 100, BP 110/65; tender and guarding in epigastrium; no J/ Cl/ An/ Cy; CVS, RS, CNS: NAD. Urine: NAD. WCC 20, neutrophilia; Hb 14; Plts 230; MCV 80; INR & APTR normal; LFTs: bilirubin 35, alk phos 366; CRP 150; amylase 2150. ECG: sinus tachycardia 100. CXR erect: no free air. AXR: nil diagnostic. Most likely diagnosis? a) appendicitis b) biliary colic c) cholecystitis d) perforated duodenal ulcer e) gallstone pancreatitis f) gastritis
Gallstone pancreatitis.
Case 2:
45y/o female.
1yr Hx intermittent upper abdo pain, especially after eating mars bars.
Now, 2/7 severe upper abdominal pain associated with vomiting.
Overweight but otherwise fit and well.
O/E: temp 37.8C, HR 100, BP 110/65; tender and guarding in epigastrium; no J/ Cl/ An/ Cy; CVS, RS, CNS: NAD.
Urine: NAD.
WCC 20, neutrophilia; Hb 14; Plts 230; MCV 80; INR & APTR normal; LFTs: bilirubin 35, alk phos 366; CRP 150; amylase 2150.
ECG: sinus tachycardia 100.
CXR erect: no free air.
AXR: nil diagnostic.
Most likely diagnosis gallstone pancreatitis.
What is the next investigation?
a) CTAP
b) USS abdo
c) MRCP
d) HIDA scan
e) ERCP
USS abdomen, then MRCP, then ERCP.
Patient diagnosed with gallstone pancreatitis, has ERCP. Day 2 of in-patient admission on HDU. In pain. Urine output 10mL/hr despite +ve fluid balance of 3L daily. pO2 8.3 on FiO2 0.35. HR 110, BP 110/65. Modified Glasgow Criteria score of 3 (LDH, WCC, pO2). What is the next investigation? a) CTAP b) USS abdomen c) MRCP d) HIDA scan e) ERCP
CT abdomen/pelvis.
What is the modified Glasgow criteria?
3 or more of the following detected within 48hrs of admission suggestive of severe pancreatitis and may require ITU input. PaO2 <8kPa. Age >55yrs. Neutrophilia: WCC >15x10^9/L. Calcium <2mmol/L Renal function: urea >16mmol/L Enzymes: LDH ?600iU/L, AST >200iU/L. Albumin <32g/L (serum). Sugar: blood glucose >10mmol/L.
Patient with gallstone pancreatitis. Day 7 of in-patient admission. Clinically much improved. Good urine output. All vital signs normal. No supplementary oxygen. Pain free. All blood tests normalised. Discharged home with elective laparoscopic cholecystectomy set for 6/52. Readmitted 10 days later following discharge. Severe constant RUQ pain 3/7. Sweats and riggers. O/E: temp 37.9C, HR 115, BP 100/60; abdomen soft, tender and guarding RUQ; Murphy's sign +ve. Bloods: WCC 18; Bili 17, ALP 130, AST 100, amylase 75; CRP 95. Most likely diagnosis? a) biliary colic b) cholecystitis c) pancreatitis d) perforated duodenal ulcer e) hepatitis f) gastritis
Cholecystitis.
What is the management of cholecystitis?
Analgesia and antipyretics. Blood cultures. Antiemetics. IV access and fluids. ABx. DVT prophylaxis. Surgery? cholecystectomy.
What are the typical CT findings of a patient with cholecystitis?
Inflamed gallbladder wall.
Pericholecystic fluid.
Multiple calculi in gallbladder.
Dilated intrahepatic and common bile duct.
Free air in bile ducts due to previous intervention.
What is the commonest site of intraabdominal visceral perforation?
Usually anterior/superior surface of first part of duodenum or pylorus (rarely on pre-pyloric antrum).
Which are the 2 structures that need to be identified and divided during a laparsocopic cholecystectomy?
Cystic duct and cystic artery.
