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Y3 Surgery > GI surgery > Flashcards

GI surgery Flashcards

1
Q

What is the difference between paralytic ileus and large bowel obstruction?

A

One way to differentiate from mechanical obstruction is that there will be a complete absence of bowel sounds in paralytic ileus, compared to the tinkling bowel sounds heard in mechanical obstructions.

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2
Q

How can you tell the difference between small bowel obstruction and gastric volvulus?

A

While the distended abdomen suggests obstruction, and the vomiting seems to localise this to the small bowel, the main clue is in the failed attempts to pass an NG tube. This can be remembered with Borchardt’s triad of severe epigastric pain, retching and inability to pass an NG tube, which together suggest a gastric volvulus.

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3
Q

What is the most common GI surgical emergency?

A

Appendicitis

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4
Q

What do you have to bear in mind with any general surgical patient?

A

They could be septic

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5
Q

What is one test you have to do for all general surgical female patients?

A

Pregnancy test

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6
Q

What is the gold standard investigation for cholecystitis?

A

Laparoscopy

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7
Q

What is the difference between the pain in pancreatitis and gall stones?

A

Gall stones- pain starts in the RUQ and radiates to the back

In pancreatitis, the pain is epigastric and goes straight to the back

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8
Q

What score in the modified glasgow criteria for acute pancreatitis warrants admission to ITU?

A

3 or more
Indicates severe pancreatitis

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9
Q

What is more sensitive amylase or lipase for acute pancreatitis?

A

Serum amylase is more sensitive in the first 48 hours

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10
Q

What is the most common cause for diverticulitis?

A

Stool caught in the outpouchings
Avoid constipation
Fibrogel, water and high fibre diet

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11
Q

What are the symptoms of diverticulitis?

A

Severe pain in Left lower quadrant
Fever
PR bleeding
Constipation
Nausea and vomiting

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12
Q

What are causes of bowel obstruction?

A

Volvulus
Tumor
Adhesions
Hernia

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13
Q

What is the gold standard for bowel obstruction?

A

CT

Should also check hernial orifices and DRE

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14
Q

What lymph nodes are inflamed in testicular pathology?

A

Para-aortic

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15
Q

What should you look at on blood tests if suspecting ischemic bowel?

A

Lactate

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16
Q

What is Rovsing’s sign?

A

Rovsing sign—pain elicited in the right lower quadrant with palpation pressure in the left lower quadrant—is a sign of acute appendicitis. Muscle guarding, manifested as resistance to palpation, increases as the severity of inflammation of the parietal peritoneum increases.

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17
Q

What is the psoas sign?

A

Psoas sign (RLQ pain with extension of the right hip or with flexion of the right hip against resistance): Suggests that an inflamed appendix is located along the course of the right psoas muscle.

Suggests it is retro-caecal

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18
Q

What scoring system predicts likelihood of acute appendicitis?

A

Alvarado

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19
Q

What is Dunphy sign?

A

Dunphy sign (sharp pain in the RLQ elicited by a voluntary cough): Suggests localized peritonitis.

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20
Q

What are causes for RLQ pain?

A
  • Meckel’s diverticulum
  • Referred testicular pain
  • Undescended testicle
  • Kidney stones
  • Mesenteric adenitis
  • Salpingitis
  • Ectopic
  • Crohn’s
  • Ovarian torsion
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21
Q

What is the gold standard imaging for appendicitis?

A

CT scan

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22
Q

What specific question should you ask about pain with appendicitis?

A

Worse on coughing?
Worse going over speed bumps?
Ask them to blow out their tummy as much as they can (make themselves as fat as possible)
Then suck in as much as they can

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23
Q

Why do you get metallic bowel sounds with obstruction?

A

Metallic clinks or tinkling bowel sounds occur in bowel obstruction due to turbulent flow of fluid and gas within the obstructed bowel loops.
Increased peristalsis to overcome obstruction

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24
Q

What radiographic sign is seen with achalasia?

A

The “bird beak sign” is a radiological finding seen on barium swallow studies or contrast esophagography in patients with achalasia, a motility disorder of the esophagus.

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25
Q

Can carcinoma of the colon present without any symptoms?

A

Yes
Colon cancer, also known as colorectal cancer, can sometimes develop without causing noticeable symptoms, especially in its early stages. This is why regular screening for colon cancer is recommended, even for individuals who feel well and have no apparent symptoms. However, as the cancer progresses, it may eventually lead to symptoms that can affect a person’s well-being

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26
Q

What is the difference between FAP, HNPCC and Peutz-Jeghers?

A

Familial adenomatous polyposis (FAP): This condition causes lots of small growths in the colon, which can turn into cancer if not treated.

Hereditary nonpolyposis colorectal cancer (HNPCC): In this condition, colorectal cancer can happen without many of these growths in the colon, often affecting people at a younger age.

Peutz-Jeghers syndrome: People with this syndrome develop polyps in the gut and dark spots on their skin, and they have a higher chance of getting different types of cancers like colon, breast, or ovarian cancer.

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27
Q

Important investigation when you suspect a surgical emergency

A

Group and save
Crossmatch

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28
Q

Choice of investigation in a young female with RIF pain

A

Ultrasound

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29
Q

Should you do an abdominal ultrasound in a patient with a high BMI?

A

No- CT

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30
Q

How to manage peritonitis

A

Are they fit for surgery?
Air, faeces, bile, blood in the abdominal cavity- surgery

IF they are not fit for surgery, inform the family, get DNAR in place

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31
Q

What is the modality of choice for a gastrointestinal perforation?

A

CT scan

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32
Q

Cut off for egfr using contrast

A

<40 egfr

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33
Q

What are the key principles of surgical intervention with a perforated bowel?

A

The key aspects of any surgical intervention for a GI perforation are:

Identification of the underlying cause
Appropriate management of perforation
Thorough washout

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34
Q

When would you not do surgery for bowel perforation and keep it conservative?

A

Select physiologically well patients with a gastrointestinal perforation may be managed conservatively, including patients with:

Localised diverticular perforation with only localised peritonitis and tenderness, and no evidence of generalised contamination

Patients with a sealed upper GI perforationon CT imaging without generalised peritonism

Elderly frail patients with extensive co-morbidities who would be very unlikely to survive surgery

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35
Q

Findings from CT with contrast for a bowel obstruction

A

Free intra-abdominal air

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36
Q

How do you know where the perforation is coming from on a CT?

A

Thickening/inflammatory changes to the anatomy around the perforation

Whether it is small bowel, stomach, sigmoid

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37
Q

Should all abdominal CTs be with contrast?

A

Yes (regardless of contra-indications)

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38
Q

When would you do a CT without contrast?

A

Kidney stones
Acute head injury
Calcifications- blood vessels, kidneys

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39
Q

What perianal infection particularly in men can cause sepsis?

A

Fournier’s gangrene (necrotizing fascitis in the perineum)

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40
Q

What is the management of fournier’s gangrene

A

The definitive management is urgent surgical debridement and this should not be delayed. Debridement can often be extensive, however ensuring adequate removal of all necrotic tissue is key; debrided tissue should be sent for both tissue histology and culture separately (MC&S) and any pus sent for fluid culture (MC&S) too

Patients should be started on broad-spectrum antibiotics (to cover Gram-positive, Gram-negative, Aerobic and Anaerobic bacteria, and an anti-MRSA agent) and transferred to a high-dependency setting. Antibiotics can be tailored accordingly, depending on culture sensitivities. Further surgical relooks and debridement are required, until the patient is free of necrotic tissue.

Secondary closure with skin grafts can be a long process, therefore early involvement of plastic surgeons is key. Post-operative outcomes vary, depending on disease extent and tissue involvement.

*The surgical debridement may also encompass partial or total orchiectomy, depending of the size of expansion of the process, with the wound usually left open.

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41
Q

Why would you suspect necrotizing fascitis?

A

Sudden- hours, gas forming bacteria (clostridium perfringens), you can see this with CT with contrast.

Cellulitis- more progressive

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42
Q

What is the first line imaging for abdominal emergencies

A
  • Abdominal CT scan. Non-contrast CT.
    Renal function?- Theoretical risk of long term kidney injury.

Instead of an x-ray.

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43
Q

What are x-ray signs of pneumoperitoneum

A
  • Triple density
  • Rigler sign
  • Bowel wall is visible
  • Slithers of gas and lucency, triangles
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44
Q

X-ray features of small bowel obstruction

A
  • Clustering of the bowel in one part of the abdomen
  • Folds that run through the diameter
  • Frequently spaced apart
  • Central
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45
Q

CT features of small bowel obstruction

A
  • Distension
  • Fluid level- gas above as the patient will be lying down
  • Dilated loops of bowel
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46
Q

How to tell between sigmoid and caecal volvulus?

A

No normal caecum- sigmoid bowel will be normal (caecal volvulus)

Sigmoid- normal caecum

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47
Q

Features of lead-pipe colon (UC)

A
  • Fold pattern is not there
  • Repeated episodes of inflammation
  • Thumbprinting
48
Q

Gastric band and fallopian tube on an x-ray

A

Google

49
Q

How does a gastric band work?

A

A gastric band works by restricting the amount of food that can enter the stomach, leading to a feeling of fullness with smaller amounts of food. Here’s how it works:

Placement: The gastric band is placed around the upper part of the stomach, creating a small pouch at the top.
Adjustability: The band is connected to a port placed just under the skin of the abdomen. This port allows for adjustments to be made to the tightness of the band by inflating or deflating it with saline solution.
Restriction: The band creates a narrow passage between the small pouch and the rest of the stomach, limiting the amount of food that can pass through at one time.

50
Q

What CT do you use without contrast?

A

CTKUB- don’t need contrast when looking for stones (kidney stones)

51
Q

Inflamed gallbladder (acute cholecystitis) on a CT

A

Google
- Oedema, increased wall density, fat stranding in the abdomen

Need to use an ultrasound (you can’t see gall stones on an X-ray or a CT)

MRCP- to look for gallstones, also in the bile ducts. If you only remove the gallbladder, they could still have stones in their cystic ducts.

52
Q

Air in the bile ducts- CT (fistula)

A

Google. You should be able to clearly differentiate the gall bladder to the duodenum.

Gallstone ileus

53
Q

Cystogram

A

Bladder perforation, urine leaked into the peritoneal space

54
Q

What post-op complications are malnourished patients at risk of?

A

Malnourished patients are at increased risk of post-operative complications, such as reduced wound healing, increased infection rates, and skin breakdown.

55
Q

Risk factors for patients becoming malnourished

A

High energy expenditure- parkinson’s tremor
Dysphagia
Long term help conditions
Substance misuse
Live alone- socially isolated

56
Q

When do you refer a patient to a dietcian?

A

When their MUST score is 2 or above

Refer to dietitian, Nutritional
Support Team or implement local
policy
Set goals, improve and increase
overall nutritional intake
Monitor and review care plan
Hospital – weekly
Care Home – monthly Community
– monthly
* Unless detrimental or no benefit is
expected from nutritional support e.g.
imminent death.

57
Q

What are the 3 factors that are taken into account in a MUST calculation?

A
  1. BMI
  2. Weight loss score
  3. Acute disease affect score
58
Q

What are the principles of ERAS (Enhanced recovery after surgery)

A

Reduction in ‘Nil By Mouth’ times (clear fluids up to 2 hours pre-surgery)
Pre-operative carbohydrate loading
Minimally invasive surgery
Minimising the use of drains and nasogastric tubes
Rapid reintroduction of feeding post-operatively
Early mobilisation

59
Q

Different types of feeding tubes

A
  • Naso-gastric tubes
  • naso-jejunal tubes
  • Gastrostomy tubes
  • Jejunostomy tubes
60
Q

What is Gardasil?

A

HPV vaccine

61
Q

How do you narrow down a population to screen for bowel cancer?

A

Those with positive FIT tests will have colonoscopy

62
Q

Most common presenting complaint for patients with right sided colonic cancer

A

Fatigue- secondary to anaemia

63
Q

What are the 4 steps to diagnose a cancer?

A
  1. Clinical
  2. Endoscopic
  3. Image
  4. Histology
64
Q

How often are you offered colonscopy if you are diagnosed with Lynch syndrome?

A

Every 2 years

65
Q

What is the T section of the TNM staging system?

A

Like many cancers, colorectal cancer is staged according to the TNM system. This stages the cancer according to the depth the tumour invades the bowel wall (T stage), the extent of spread to local lymph nodes (N stage), and whether or not there are distant metastasis (M stage).

Whilst the Duke’s staging system has now been largely superseded, it is still used at some centres for additional staging detail.

Stage Description 5 Year Survival
A Confined beneath the muscularis propria 90%
B Extension through the muscularis propria 65%
C Involvement of regional lymph nodes 30%
D Distant metastasis <10%

66
Q

Steps of treating a rectal cancer

A
  • MRI
  • Neoadjuvant chemol/radio
  • Resection
  • Contact radiotherapy and external radio/chemo
  • Anterior resection
  • APER
67
Q

No recurrent disease of colon cancer with surveillance

A
  • Colonoscopy
  • CEA
  • CT/PET/MRI
  • Cure discharge in 5 years
68
Q

What are two genetic predispositions for colorectal cancer?

A

Certain genetic mutations have been implicated in predisposing individuals to colorectal cancer, most notably:

Adenomatous polyposis coli (APC)
A tumour suppressor gene, mutation of the APC gene results in growth of adenomatous tissue, such as Familial Adenomatous Polyposis (FAP)
Hereditary nonpolyposis colorectal cancer (HNPCC)
A DNA mismatch repair gene, mutation to HNPCC leads to defects in DNA repair, such as Lynch syndrome

69
Q

Peutz-Jeghers

A

Peutz-Jeghers syndrome (PJS) is a rare inherited disease that is characterised by gastrointestinal polyps in association with pigmentation affecting skin and mucous membranes.

PJS polyps are hamartomas i.e. benign tumours made up of a mixture of mature cells normally found in that tissue. They can show benign (non-cancerous) or malignant (cancerous) changes. The risk of developing some form of internal cancer is 15 times greater for patients with PJS compared with the general population.

70
Q

Gardner syndrome

A

Gardner syndrome is a variant of familial adenomatous polyposis (FAP) that is associated with extra-colonic features. It is an inherited disease that is characterised by gastrointestinal polyps, multiple osteomas (benign bone tumours), and various skin and soft tissue tumours.

Polyps tend to form at puberty with the average age of diagnosis around 25 years of age. Polyps have an almost 100% risk of undergoing malignant transformation resulting in colorectal cancer, therefore timely detection of Gardner syndrome is essential.

71
Q

What is characteristic of gardner syndrome?

A

CHRPE

Gardner syndrome can also present with ocular manifestations that include the presence of multiple patches of congenital hypertrophy of the retinal pigment epithelium (CHRPE)

72
Q

Characteristics of hematuria in urological cancer

A
  • Total haematuria
  • Painless
  • Recurrent
73
Q

What is the definition of severe acute pancreatitis?

A

Associated with organ failure and/or local complications such as necrosis (with infection), pseudocyst or abscess.

74
Q

Common drugs to cause acute pancreatitis

A

Azathioprine, thiazides, sulfonamides,

75
Q

What is the criteria to stratify acute pancreatitis?

A

Modified glasgow criteria

  • Clinical picture
  • Age
  • WCC
  • Glucose
  • Urea
  • PaO2
  • Calcium
  • Albumin
  • LDH
  • AST/ALT
  • CRP
  • CXR of pleural effusion
  • BMI
76
Q

How much fluid do patients lose with severe acute pancreatitis?

A

2nd shock
3rd space fluid loss

8L loss

All patients will need a catheter

77
Q

Where should patients with acute severe pancreatitis be managed?

A

Always on the high dependency unit. The patients should not be on the ward.

78
Q

What is the difference between a cyst and a pseudocyst?

A

A true cyst is a localized fluid collection that is contained within an epithelial lined capsule. In contrast, a pseudocyst is a fluid collection that is surrounded by a non-epithelialized wall made up of fibrous and granulation tissue, hence the name “pseudo” cyst.

79
Q

What is the use of a sphincterotomy in ERCP?

A

This involves making a small cut in the papilla of Vater to enlarge the opening of the bile duct and/or pancreatic duct.

80
Q

Where is biliary empyema?

A

Cystic duct

81
Q

What should surgeons look at when performing cholecystectomy?

A

Calot’s triangle

In this procedure, the triangle is carefully dissected by the surgeon, and its contents and borders identified.

This allows the surgeon to take into account any anatomical variation and permits safe ligation and division of the cystic duct and cystic artery. Of particular importance is the right hepatic artery – this must be identified by the surgeon prior to ligation of the cystic artery.a

82
Q

Structures supplied by the coeliac trunk

A
  • Upper GI
  • Up to the ligament of treitz
  • Duodenum, pancreas, liver
83
Q

Causes of oesophageal bleeding

A
  • Oesophagitis
  • GORD
  • Mallory-weiss tear
  • Ulcer
  • Malignancy
  • Oesophageal varices
84
Q

Features of upper GI bleed

A
  • Coffee ground vomit
  • Hematemesis
  • Hypotension
  • Abdominal pain
  • LOC
  • Malena
85
Q

Causes of oesophagitis

A
  • Eosinophilic esophagitis (viral infection)
  • Radiation induced
  • Reflux
  • Infection: yeast, viral, fungal
  • Medication induced- aspirin
86
Q

Mallory Weiss tear

A
  • Cardiac sphincter is closed
  • Severe vomiting, associated with chronic alcoholism
  • Lifting and straining
  • Tear in the oesophageal mucosa
87
Q

Difference between Boerhaave’s syndrome and mallory weiss tear

A

Mallory weiss tear is a partial tearing of the wall.

Boerhaave’s is a full thickness tear.

88
Q

What is the histology of malignancy in the oesophagus?

A

Upper 2/3= SCC
- OGD/biopsy
- Staging
- MDT
- DXT

Lower 13= Adenocarcinoma
- OGD and biopsy
- Staging
- MDT
- Resection

89
Q

Difference in swallowing between achalasia and malignancy

A

Achalasia- more dysphagia to liquids

Malignancy- more dysphagia to solids

90
Q

Other causes of oesophageal varices apart from portal hypertension

A
  • Granuloma- schistosomiasis, budd-chiari syndrome
  • Constrictive pericarditis
  • Autoimmune hepatitis
91
Q

Pressure changes during a breath in- blood flow

A

Take a deep breath in- intrathoracic pressure is low- increases venous return to the heart

92
Q

Common cause of budd-chiari syndrome?

A

COCP

93
Q

Treatment of oesophageal varices

A
  1. A-E
  2. IV fluids
  3. Blood transfusion
  4. Mechanical ventilation
  5. Variceal band ligation
  6. IV terlipressin and antibiotics
  7. PPI
  8. Octreotide, vasopressin and somatostatin
  9. Beta blockers
  10. TIPS (long term treatment, between the portal vein and the hepatic vein)
  11. Sengstaken-Blakemore tube
94
Q

Side effect of TIPS

A

Hepatic encephalopathy- food/toxins have not been metabolised by the liver

95
Q

Gastric causes of bleeding

A
  • Peptic ulcer disease
  • Dieulafoy’s Lesion:
  • Cancer
  • Leomyoma/sarcoma
  • Carcinoid
96
Q

What is Dieulafoy lesion?

A

Dieulafoy lesion is an abnormally large artery (a vessel that takes blood from the heart to other areas of the body) in the lining of the gastrointestinal system. It is most common in the stomach but can occur in other locations, including the small and large intestine.

97
Q

What is a gastric leiomyoma?

A

Gastric leiomyoma is an uncommon gastric neoplasia. These are rare tumors and usually asymptomatic on clinical presentation. The laparoscopic technique may treat different gastric tumors, including benign leiomyoma by wedge resection without opening the abdomen.

98
Q

Common sites for carcinoid tumors

A
  • Lungs
  • Appendix
  • Small intestine
99
Q

Common cause of hemobilia

A
  • Trauma
  • Iatrogenic- cholecystectomy, blood in the gall bladder, liver
  • Vascular Causes: Vascular abnormalities such as hepatic artery aneurysms, arteriovenous malformations (AVMs), or pseudoaneurysms can lead to hemorrhage into the biliary system.
  • Tumors: Hepatocellular carcinoma, cholangiocarcinoma, liver metastases, or other hepatic tumors can erode into blood vessels, causing bleeding into the biliary system.
100
Q

Causes of lower GI bleeding

A
  • Crohn’s disease
  • Meckel’s diverticulum
  • SB tumor
  • Vascular malformation
  • Colonic cancer
  • Hemorrhoids
  • Fissure
101
Q

How to diagnose meckel’s diverticulum?

A
  • Technetium scan
  • Capsule endoscopy- concealed GI bleeding
102
Q

Most common location of ischaemic colitis

A

LUQ pain
Splenic flexure of the superior and inferior mesenteric artery

103
Q

How do you investigate an anal/rectal ulcer

A
  • Defacating proctogram
  • To see if there is intussception
  • Chronic straining may cause intussusception of the rectal mucosa, which in turn can develop into a full-thickness rectal prolapse. A prolapse may cause excessive stitching of the rectal mucosa and cause mucosal injury and ultimately a rectal ulcer.
104
Q

Malignancy ulcers characteristic

A

Everted edges
Base is firm and edge- not mobils

105
Q

Sloping edge

A

Inflammatory

106
Q

Undermined edge

A

TB

107
Q

Deep ulcers

A

Neuropathic

108
Q

Most common type of rectal cancer

A

Squamous- responds to radiotherapy very well

109
Q

When do you see bleeding in hemorrhoids?

A

Bleeding comes at the end of defacation

110
Q

Causes of obscure GI bleeding

A
  • Vascular ecatsia
  • Von-Willebrand disease
  • CREST
  • Hemobilia
  • Valvular heart disease
111
Q

Cause of an aortic-duodenal fistula

A
  • Pulsation of the abdominal aorta to the posterior aspect of the duodenum
  • Pressure necrosis
  • Creates a fistula

WCC is VERy high. Communication of the bowel with the circulatory system.

CT scan would show the fistula- straight to surgery.

112
Q

When can you feel the gall-bladder on examination?

A

Empyema or cholangiocarcinoma
Make sure you are palpating away from the rectus muscles

113
Q

What on the spleen can you palpate?

A

The splenic notch
Dull percussion
You cannot put your hand above the spleen

114
Q

Should you offer antibiotics to patients with acute pancreatitis?

A

No
They should NOT be offered prophylactically unless acute severe pancreatitis.

These are the key aspects of the care:
fluid resuscitation
aggressive early hydration with crystalloids. In severe cases 3-6 litres of third space fluid loss may occur
aim for a urine output of > 0.5mls/kg/hr
may also help relieve pain by reducing lactic acidosis
analgesia
pain may be severe so this is a key priority of care
intravenous opioids are normally required to adequately control the pain
nutrition
patients should not routinely be made ‘nil-by-mouth’ unless there is a clear reason e.g. the patient is vomiting
enteral nutrition should be offered to anyone with moderately severe or severe acute pancreatitis within 72 hours of presentation
parental nutrition should only be used if enteral nurition has failed or is contraindicated

115
Q

What are two important drugs to give a patient with severe colitis?

A

IV hydrocortisone
Low molecular weight heparin (at increased of VTE)

Y3 Surgery (7 decks)

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