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DPD 2020 > General surgical cases > Flashcards

General surgical cases Flashcards

1
Q

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

A

CXR & AXR

was gastritis

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2
Q

What are the causes of upper abdominal pain?

A

Surgical:

    • PUD/GORD
  • pancreatitis
  • biliary pathology
    • abdominal wall
    • vascular: AAA -
  • small bowel -
  • large bowel

Non-surgical:

  • cardiac
  • gastroenterological
  • musculoskeletal
  • diabetes
  • dermatological
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3
Q

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.
  • Diagnosis?

a) gastritis
b) pancreatitis
c) pneumonia
d) small bowel obstruction
e) large bowel obstruction
f) perforated viscus

A

Perforated viscus.

  • AXR shows free intraperitoneal air and Rigler’s sign.
  • CXR shows free subdiaphragmatic gas.
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4
Q

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.

Keeping in mind he drinks, takes NSAIDs and has epigastric pain

What is the perforated organ?

a) duodenum
b) stomach
c) sigmoid diverticular disease
d) appendix
e) small bowel
f) colon from colitis

A

Duodenum.

Stomach perforation is rare - duodenum gives away first - have to think of gastric cancer if it does perforate

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5
Q

What are the basic operative principles regarding acute peritonitis?

What are the steps you need to do?

A
  1. Identification of aetiology of peritonitis.
  2. Eradication of the peritoneal source of contamination.
  3. Peritoneal lavage ++++ & drainage.
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6
Q

What are the types of peritonitis?

A

Primary peritonitis: bacterial origin, but no visceral perforation

  • spontaneous;
  • tuberculosis;
  • peritoneal dialysis catheterisation (most common -just wash out and treat with antibiotics)

Secondary peritonitis : bacterial origin with visceral perforation;

  • perforated ulcer, perforated appendicitis.

Tertiary peritonitis: (had peritonitis did not lavage properly)

  • persistence/recurrence of intra-abdominal infection following apparently adequate therapy of primary or secondary peritonitis;
  • either fungal or without known pathogens.
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7
Q

What is the usual site of perforation in duodenal ulcer disease?

A
  • 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.
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8
Q

What is the incidence of duodenal ulcer disease?

A

Duodenal perforation 8-10x > gastric perforation. Acute ulcers occur in patients with no history of ulceration in 25-30%.

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9
Q

What are the macroscopic features of duodenal ulcer disease?

A

Shape of small ring. 5-10mm in diameter. Slightly indurated edges.

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10
Q

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

A

Post-operative pneumonia and respiratory failure.

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11
Q

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

A

Intraabdominal collection requiring drainage and IVABx. (most common)

a) leak from repair site
b) persistent pneumonia
c) constipation - have to have excluded everything else

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12
Q

What is the modified Glasgow criteria?

A

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.

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13
Q

Which are the 2 structures that need to be identified and divided during a laparsocopic cholecystectomy?

A

Cystic duct and cystic artery.

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14
Q

What is the diagnosis?

  1. Choledochal cyst
  2. Pancreatic mucinous cystadenoma
  3. pancreatic pseuodcyst
  4. splenic cyst
  5. mesenteric cyst
  6. Liver cyst
A

Pancreatic mucinous cystadenoma

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15
Q

What is the diagnosis?

  1. Choledochal cyst
  2. Pancreatic mucinous cystadenoma
  3. pancreatic pseuodcyst
  4. splenic cyst
  5. mesenteric cyst
  6. Liver cyst
A

splenic cyst

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16
Q

What is the diagnosis?

  1. Choledochal cyst
  2. Pancreatic mucinous cystadenoma
  3. pancreatic pseuodcyst
  4. splenic cyst
  5. mesenteric cyst
  6. Liver cyst
A

Choledochal cyst

17
Q

What is the diagnosis

Choledochal cyst

Pancreatic mucinous cystadenoma

pancreatic pseuodcyst

splenic cyst

mesenteric cyst

Liver cyst

A

Liver cyst

18
Q

45 yr F

P/C:

  • 1 year of Hx intermittent upper abdo pain
  • especially after eating mars bars
  • NOw: 2 days of severe upper abdominal pain associated with vomitting
  • overweight but otherwise fit and well

O/E

  • temp 37, HR: 100, BP 110/65
  • Tender & guarding in epigastrium
  • CVS, RS, CNS - NAD

INVESTIGATION:

  • Urine: NAD
  • WCC 20, neutrophilia
  • Hb 14
  • Plts 230
  • MCV 80
  • INR and APTR normal
  • LFT’s: bilirubin 35, ALP 366
  • CRP 150
  • Amylase 2150
  • ECG: sinus tachy 100
  • CXR erect- no air
  • AXR- nil

What are the differential diagnosis?

A

cholecystitis

19
Q

45 yr F

P/C:

1 year of Hx intermittent upper abdo pain

especially after eating mars bars

NOw: 2 days of severe upper abdominal pain associated with vomitting

overweight but otherwise fit and well

O/E

temp 37, HR: 100, BP 110/65

Tender & guarding in epigastrium

CVS, RS, CNS - NAD

INVESTIGATION:

Urine: NAD

WCC 20, neutrophilia

Hb 14

Plts 230

MCV 80

INR and APTR normal

LFT’s: bilirubin 35, ALP 366

CRP 150

Amylase 2150

ECG: sinus tachy 100

CXR erect- no air

AXR- nil

What is your next investigation?

A

USS abdomen

20
Q

What does this patient have?

gall bladder uss

21
Q

you have done an ultrasound scan on a patient you suspect has cholecystitis and have seen stones?

What is your next investigation?

22
Q

What would you see on an MRCP in a patient with cholecystitis

A

dilated intrahepatic duct

dilated common bile duct with impacted calculi

calculi in gallbladder

23
Q

Patient with cholecystitis you have confirmed stones with an USS and MRCP and waited for the stone to pass but it hasn’t

THe LFT’s are still deranged

What do you do next ?

24
Q

A patient had an ERCP 4 days ago

NOW

in pain

urine output is 10mls/hr despite fluid balancee of 3L daily

pO2 of 8.3 on FIO2 0.35

HR 110, BP 110/65

Modified glasgow of 3 (LDH, WCC, PO2)

What is your differential diagnosis?

A

CT scan

to exclude pancreatic complication from the ERCP

25
Q

What are criterias of the modified Glasgow scale

A

PaO2
Age over 55
Neutrophils
Calcium
Renal function
Enzymes: LDH, AST
Albumin
Sugar

26
Q

patient

with sever RUQ pain 3 days ago

constant

sweating rigors

O/E

temp 37, HR 115, BP 100/60

abdommen soft, tender and guarding in RUQ

BLoods

WCC 18

BIli 17, ALP 130, AST 100 Amylase 75

CRP 95

What is the Diagnosis?

A

Cholecystitis

Biliary colic doesn#t have any signs just pain in RIGHT upper quadrant

27
Q

What does this CT show

A

cholecystisis

inflammed gallbladder

pericholecystic fluid

multiple calculi in the gallbladder

Dilated intrahepatic and common bile duct

Free air in bile ducts due to previous intervention

28
Q

What is the management for cholecystisis

A
  • Admit-
  • analgesia and antipyretics
  • blood culture
  • at first NBM- sips clear fluid- free fluid-light diet- normal diet (low fat)
  • IV access and fluids
  • ABx
  • DVT prophylaxis
  • surgery - not past 48 hours- too inflammed wait and then do elective laprascopic cholecystictomy
29
Q

What are comlication of a cholecystectomy

A

hepatic artery leak

30
Q

What does this CXR and AXR show?

31
Q

What does this patient have?

A
  • duodenal perforation
  • or gallbladder

What you see in this CT
Free gas:

  • falciform ligament
  • upper abdomen

Fluid

thickend duodenum

32
Q

If someone has peritonitis- what is the investigation you must absolutely do?

A

CT abdomen to locate teh lesion and plan surgery

33
Q

What is the treatment for a perforated ulcer

A

Treatment for perforated ulcer ranges from

  • conservative (Taylor’s approach)
  • radical surgery (vagotomy, gastrectomy).
  • THINK IF THERE IS GASTRIC CANCER
34
Q

How do patient present with a perforation at the posterior part of the duodenum or stomach

A

upper gi bleeding

gastroduodenal ulcer

35
Q

How do you close a duodenal or gastric ulcer

A

wrap a bit of omentum around it

36
Q

What does this CXR show

37
Q

How do you treat a collection of fluid post op?

A

percutaneus drain under local aneathetics

IV antibiotics

DPD 2020 (48 decks)

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