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Periop > GI Surgery > Flashcards

GI Surgery Flashcards

1
Q

What are some of the causes of spontaneous oesophageal perforation

A

Violent vomiting

Malory Weiss tear

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2
Q

What are some of the metastatic disease signs seen in patients with oesophageal cancer

A

enlarged cervical lymph nodes, jaundice, hepatomegaly, hoarseness of voice, chest pain

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3
Q

What are the palliative treatments for oesophageal cancer

A

Endoscopic stent

Palliative chemo/radiotherapy

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4
Q

Which channel do PPIs inhibit

A

H+-K+-ATPase

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5
Q

What are the clinical features of upper GI bleed

A

Haematemesis +/- melena

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6
Q

What is dieulafoy syndrome

A

Where a large arteriole in the stomach lining erodes and bleeds

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7
Q

What are the steps in the management of an acute upper GI haemorrhage

A

1) protect airway and give high flow O2
2) 2 large bore cannulae, take bloods
3) IV fluids to restore intravascular pressure while waiting for blood to be cross matched/ O RhD- blood
4) urinary catheter

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8
Q

What are the symptoms of gastric neoplasia

A 
Indigestion, Dyspepsia
Flatulence
Weight loss
Vomiting
Epigastric or back pain 
Epigastric mass present
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9
Q

How is GI neoplasia diagnosed

A 
History and examination
Upper GI endoscopy
Biopsy
Staging CT
endoscopic ultrasound 
Laparoscopy
Pet-ct
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10
Q

What is the treatment with curative intent for gastric neoplasia

A

Gastrectomy + node removal +/- preop chemo

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11
Q

What is the palliative treatment for gastric neoplasia

A

Supportive care
Palliative chemo/radiotherapy
Stenting
Bypass surgery

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12
Q

If a patient has abnormal LFTs and no evidence of biliary disease on USS, what do you investigate next

A
  • exclude drug reaction
  • hepatitis serology
  • immunoglobulins
  • autoantibodies
  • copper and iron studies
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13
Q

What is the next step in investigating/managing a patient with abnormal LFTs and biliary obstructio on USS, but no gallstone disease

A

MRCP
Ct
Biliary stent/surgery indicated

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14
Q

What is the next step in managing/investigating a patient with biliary obstruction, abnormal LFTs and gallstone disease

A

Ercp/sphincterectomy

Lap cholecystectomy

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15
Q

How is variceal bleeding managed

A

Endoscopic ligation banding
Injection sclerotherapy
Surgical portosystemic shunts

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16
Q

What is cavernous hemangioma

A

Benign tumour found in lover

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17
Q

Do you resect a cavernous haemangioma

A

Only if large and symptomatic

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18
Q

How do patients with liver cell adenoma present

A

Left hypochondrial pain

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19
Q

What is the danger with liver cell adenoma

A

Can undergo malignant transformation

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20
Q

How may hepatocellular carcinoma present

A 
Not until late often
Decrease in liver function
Progression of existing liver problems
Abdo pain
Weight loss
Fever
Intraperitoneal haemorrhage
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21
Q

What are the results of blood investigations for hcc

A

Deranged LFTs

Alpha fetoprotein raised

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22
Q

How do you confirm a hcc

A

Percutaneous needle aspiration biopsy and cytology

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23
Q

What imaging techniques can be used to diagnosed hcc

A

USS

CT, MRI

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24
Q

What is the management of hcc

A

1) Liver resection, esp viable if not cirrhotic
2) If less hepatic reserve, limited resection and systemic chemo
3) Percutaneous ablation with microwaves
4) Liver transplant

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25
Q

What are the presenting features of cholangiocarcinoma

A

Jaundice, pain, enlarged liver

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26
Q

What is charcots triad in cholangitis

A

1) pain
2) pyrexia
3) jaundice

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27
Q

What types of stones can be found in gallstones

A

Cholesterol or pigment stones (calcium bicarbonate)

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28
Q

List some of the pathological effects of gallstones

A
  • acute cholecystitis
  • chronic cholecystitis
  • mucocoele
  • gallstone ileus
  • biliary colic
  • cholangitis
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29
Q

What is acute cholecystitis

A

RUQ pain and fever occurring from obstruction of the neck of the gall bladder or cystic duct oedema and occasionally gangrene or perforation of the inflamed gall bladder

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30
Q

What is chronic cholecystitis

A

Repeated bouts of biliary colic or acute cholecystitis culminating in fibrosis. The gallbladder ceases to function. RUQ pain, no pyrexia

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31
Q

What is mucocoele

A

Distension of a hollow cavity or organ with mucus

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32
Q

Why does much ele occasionally develop in patients with gall stones

A

The outlet of the gall bladder can become obstructed in the absence of infection. Clear mucus continues to be secreted into the distended gall bladder,r forming mucocoele

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33
Q

If gall stones become stuck, what conditions can they result in

A

Jaundice
Cholangitis
Acute pancreatitis

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34
Q

What is cholangitis

A

Infection of the bile duct caused by bacteria ascending from its junction with the duodenum

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35
Q

What is gallstone ileus

A

Intestinal obstruction occurring when a a large gallstone becomes impacted in the intestine. Gall stones may have gained access by eroding through the wall of the gallbladder into the duodenum

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36
Q

What is biliary colic

A

Pain due to transient obstruction of the gallbladder from an impacted stone. There is a severe gripping pain often after meals or in the evening. Epigastric / RUQ pain

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37
Q

What are the symptoms of acute cholecystitis

A

RUQ pain
Radiates to right subscapsular region
Tachycardia, pyrexia, nausea, vomiting, leucocytosis

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38
Q

What test may be positive in a patient with acute cholecystitis on examination

A

Murphy’s

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39
Q

What is primary biliary cirrhosis

A

Autoimmune condition of the liver, where interlobular bile ducts are damaged by chronic granulomas.

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40
Q

What are the consequences for primary biliary cirrhosis

A

Progressive cholestasis
Cirrhosis
Portal hypertension

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41
Q

What liver marker is raised in primary biliary cirrhosis

A

ALK PHOS

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42
Q

How does primary biliary cirrhosis present

A

Lethargy
Pruritus
Hepatomegaly

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43
Q

What are some of the complications of primary biliary cirrhosis

A

Portal hypertension
Ascites
Hepatic encephalopathy
HCC

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44
Q

What does biopsy of the liver of patients with primary biliary cirrhosis show

A

Granulomas around the bile ducts, progressing to cirrhosis

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45
Q

How is primary biliary cirrhosis treated

A

Symptomatic treatment for pruritus with colestyramine
Ursodeoxycholic acid
Liver transplant last resort

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46
Q

What is primary sclerosing cholangitis

A

A non malignant, non bacterial inflammation, fibrosis and strictures of intra and extra-hepatic bile ducts

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47
Q

What does primary sclerosing cholangitis lead to

A

Liver failure and death

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48
Q

What are the symptoms of primary sclerosing cholangitis

A

Often found incidentally

Jaundice, pruritus, abdo pain, fatigue

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49
Q

Which liver enzyme is increased in primary sclerosing cholangitis

A

ALK PHOS

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50
Q

Wht re the signs of primary sclerosing cholangitis

A

Jaundice, hepatomegaly, portal hypertension

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51
Q

What do patients with primary sclerosing cholangitis have a huge risk of developing

A

Cholangiocarcinoma

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52
Q

What is the management of primary sclerosing cholangitis

A

Liver transplant is the only effective treatment
Colestyramine for pruritus
Ursodeoxycholic acid improves cholestasis

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53
Q

What are the clinical features of tumours of the biliary tract

A 
Progressive obstructive jaundice
Mucocoele
Empyema
Pruritus
Anorexia and weight loss
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54
Q

What is the management for rumours of the biliary tract

A

Whipped procedure if in lower CBD

Palliative stents in some cases

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55
Q

Where does the pancreas lie anatomically

A

Retroperitoneally, behind the lesser sac and the stomach . The head lies in the loop of the duodenum

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56
Q

What is the blood supply to the pancreas

A

Coeliac and superior mesenteric artery

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57
Q

What is the blood supply to the tail of the pancreas

A

Splenic arteries (lies in front of splenic artery)

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58
Q

What are the most common causes for pancreatitis

A

Alcohol and gallstones

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59
Q

What is the effect of gall stones impacting on the pancreatic duct

A

Leads to intracellular activation of pancreatic enzymes, acinar cell damage, pancreatic inflammation

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60
Q

What are the GET SMASHED aetiological causes of pancreatitis

A 
Gallstones
Ethanol
Trauma
Scorpion venom
Mumps
Autoimmune
Steroids
Heryperlipidaemia/hypercalcaemia
ERCP
Drugs
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61
Q

What is more common - sliding or rolling hernia

A

Sliding (stomach cardia involved)

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62
Q

How would you distinguish between gallstone and alcoholic cause of pancreatitis

A

Ultrasound scan

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63
Q

What is ercp used for

A

Endoscopy + fluoroscopy to diagnose and treat biliary and pancreatic duct system problems, eg gallstones, bile duct tumours etc.
can be used therapeutically to remove stones, insert stents and dilate strictures (PSC)

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64
Q

What are the clinical features of acute pancreatitis

A
  • severe epigastric pain, or right hypochondrium
  • radiates to back
  • nausea, vomiting, retching
  • tachycardia, tachypnoea
  • jaundice may be present
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65
Q

How is acute appendicitis diagnosed

A

Measuring serum amylase (3x upper reference), serum lipase

Ct abdo if doubt

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66
Q

Lost two severity score for acute pancreatitis

A
  • APACHE II

- Glasgow prognostic score

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67
Q

What is the conservative management for acute pancreatitis

A

Iv fluids, analgesia, gradual reintroduction of diet
Antibiotic prophylaxis
Treat underlying cause e.g. gallstones

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68
Q

What are the possible complications of pancreatitis

A
  • infected pancreatic necrosis
  • pancreatic pseudocyst
  • abscess
  • GI bleeding
  • GI ischaemia, fistula
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69
Q

How is infected pancreatic necrosis treated

A

Surgical debridement or Percutaneous drainage

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70
Q

What is a pancreatic pseudocyst

A

Collections of pancreatic secretion and inflammatory exudate enclosed in a wall of fibrous or granulation tissue

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71
Q

What is chronic pancreatitis

A

Chronic inflammatory condition characterised by fibrosis and destruction of exocrine pancreatic tissue. Blockage of flow of pancreatic juices

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72
Q

What is the most common aetiological cause of chronic pancreatitis

A

Alcohol

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73
Q

What are the clinical features of chronic pancreatitis

A

Characteristic epigastric pain, radiating to back and often relived by leaning forward
Hot water bottles may help relive pain

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74
Q

What are some of the other manifestations of chronic pancreatitis except the usual symptoms

A

Steatorrhoea

Diabetes mellitus

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75
Q

What imaging investigations can you do to diagnose chronic pancreatitis

A

CT - may see speckled calcification

MRCP - to look at pancreatic duct

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76
Q

Which non-imaging investigations can you ror form on a patient with chronic pancreatitis

A

Blood glucose

Faecal fat content

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77
Q

What is MRCP

A

Imaging technique which uses MRI to visualise the biliary and pancreatic ducts non-invasively

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78
Q

Which blood tests in particular are important for the investigation of a patient with gallstones

A

FBC - ?neutrophilia
Bilirubin increased
Alkaline phosphatase increased

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79
Q

When is gas seen surrounding the billiary tree

A

If fistula is present

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80
Q

How is amo pen cholecystectomy performed

A

Right subcostal incision with intra operative cholangiography to display the anatomy of Ge duct system
Cystic artery and duct are ligated, gall bladder removed
Abdo drain placed

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81
Q

How is laparoscopic cholecystectomy performed

A

Cannulae inserted into anterior abdo wall and co2 insufflation
Same structures ligated as in cholecystectomy

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82
Q

What are some of the complications that may occur in cholecystectomy

A

Infective complications - strep faecalis, e. Coli

Bile leakage

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83
Q

How is infection from organisms such as E. coli prevented in cholecystectomy patients

A

Prophylaxis with cephalosporin

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84
Q

How is acute cholecystitis managed conservatively initially

A

Iv fluids, analgesia, broad spectrum antibiotic such as a cephalosporin, nbm

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85
Q

Is the non surgical approach to acute cholecystitis effective

A

No - gall stone dissolution

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86
Q

How is acute cholangitis managed

A

Resusc, administration of appropriate antibiotics, decompression of biliary tree with ercp, cholecystectomy

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87
Q

What is the conservative management for chronic pancreatitis

A

Abstinence from alcohol
Pain relief
Treat endocrine and exocrine insufficiency - supplements

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88
Q

What are the endoscopic and surgical treatments for chronic pancreatitis

A

Endoscopic duct stents if there is a stricture
Surgical drainage
of obstructed pancreatic duct

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89
Q

What is Courvoisier’s law?

A

In the presence of a non tender palpable gall bladder, painless jaundice is unlikely caused by gallstones

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90
Q

What are some of the neuronendocrine tumours found in the pancreas

A

Gastrinomas (Zollinger Ellison syndrome), insulin as, glucagonomas, somatostatinoma

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91
Q

What histological type of cancer is cholangiocarcinoma

A

Adenocarcinoma

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92
Q

Where do pancreatic Adenocarcinomas tend to metastasise commonly

A

Liver and lung

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93
Q

What are some of the symptomatic features of pancreatic cancer

A

Painless jaundice, weight loss, poor appetite

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94
Q

What is the management of pancreatic cancer

A

Surgical resection via whipped procedure (pancreaticoduodenectomy)
Palliative treatment with relief from obstructive jaundice, pruritus, biliary drainage, chemo

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95
Q

What does pancreaticoduodenectomy/whipples procedure involve

A

Resection of head of pancreas, distal half of stomach, duodenum, gallbladder, CBD

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96
Q

What does the red pulp of the spleen contain

A

Macrophages

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97
Q

What does the White pulp of the spleen contain

A

Lymphoid tissue - lymphocytes, macrophages and plasma cells

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98
Q

How is a splenectomy performed

A

Via left subcostal incision, with division of the short gastric vessels and mobilisation from surrounding structures

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99
Q

List the indications for splenectomy

A
  • trauma
  • haemolytic anaemia
  • hyperslenism
  • ITP
  • abscess
  • splenic artery aneurysm
  • as part of resection of other organs
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100
Q

What are the lifelong prophylactic antibiotics given to patients who have had a splenectomy

A

Erythromycin or phenoxymethylpenicillin

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101
Q

What immunisation is given to patients who have had a splenectomy

A

Pneumococcal, H influenzae type B, meningococcal group c infection immunisation

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102
Q

What are some of the causes of appendicitis

A

Inflammation may be due to faecoliths, lymphoid hyperplasia, foreign bodies, carcinoid tumours, strictures

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103
Q

List some begging tumours of the small intestine

A
  • adenomatous polyps
  • hamartomas
  • lipomas
  • haemangiomas
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104
Q

What is a hamartoma

A

Abnormal formation of normal tissue

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105
Q

What is peutz-jehgers syndrome

A

Inherited disorder where there are multiple hamartomatous polyps in the GIT, as well as pigmentation in the patients lips

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106
Q

List some malignant tumours of the small intestine

A
  • GIST - GI stromal tumour
  • Adenocarcinoma of the small bowel
  • lymphoma
  • carcinoid tumour
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107
Q

What is Lynch Syndrome also known as

A

Hereditary non-polyposis colorectal carcinoma

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108
Q

What is the inheritance pattern of lynch syndrome/hereditary nonpolyposis colorectal carcinoma

A

Autosomal dominant

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109
Q

What is the risk that comes with HNPCC/lynch syndrome

A

High risk of colon cancer

As well as endometrial cancer

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110
Q

What hereditary conditions may be associated with small bowel Adenocarcinoma

A

FAP, Lynch syndrome

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111
Q

Which cancers are patients with peutz jehgers syndrome susceptible to

A

Colorectal, gastric, pancreatic, breast, ovarian tumours

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112
Q

What is the management of peutz jehgers syndrome

A

Laparotomy, polypectomy

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113
Q

What is me kelps diverticulum

A

Remnant of Vitello-intestinal duct

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114
Q

How may me kelps diverticulum cause problems in affected patients

A

Intusussecption, volvulus, obstruction

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115
Q

How is me kelps diverticulum treated

A

Excised if symptomatic, if not, should be left alone

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116
Q

What are the symptoms of radiation enteritis

A

Watery diarrhoea, lower abdo pain, tenesmus, rectal bleeding, mucous discharge

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117
Q

What may diverticulae in the jejunum cause in terms of symptoms

A

Inflammation, malabsorption, occasionally perforation and impaction of material in the diverticulae

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118
Q

If small bowel diverticulae are symptomatic, how should they be treated

A

Iv fluid resuscitation, antibiotics

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119
Q

What is small bowel ishcaemia usually due to

A

Atheromatous occlusion and thrombosis in the superior mesenteric artery

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120
Q

What are spathe predisposing factors for small bowel ishcaemia

A 
Thrombophilia
Hyperviscosity
Dehydration
Hypovolaemia
Hypoperfusion of gut
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121
Q

List some causes of Hypoperfusion of the gut

A

Trauma, cardiogenic shock, cardiac arrhythmia, septic shock, arterial emboli,

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122
Q

What does small bowel ishcaemia progress to

A

Necrosis of all the bowel layers with gangrene and perforation

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123
Q

How is small bowel ishcaemia managed

A

Resusc, resection of gangrenous bowel; and anticoagulation; In some instances, can be restored by embolectomy, thomobolectomy

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124
Q

What is chronic mesenteric ischaemia

A

Repeated bouts of colicky Central abdo pain typically 20-30 mins after eating, weight loss. Angiogrpaphy

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125
Q

What are the clinical feature of small bowel ischaemia

A
  • Central abdo pain and tenderness
  • previous weight loss
  • guarding and rigidity (late signs)
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126
Q

What may plain films show in painted with small bowel ischaemia

A

Calcified atheroma in mesenteric arteries,

Dilated Andy hi kneed small bowel loops

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127
Q

What are the most common causes of small bowel obstruction

A
  • adhesions (60%)
  • obstructed hernia (20%)
  • malignancy
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128
Q

What are the most common causes of large bowel obstruction

A
  • colorectal cancer (>70%)
  • stricturing diverticular disease (10%)
  • sigmoid volvulus
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129
Q

What are the signs and symptoms of obstruction in the proximal jejunum

A

Anorexia, vomiting, severe upper abdo pain, minimal distension, limited (if any) change in bowel habit

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130
Q

What are the symptoms and signs of distal small bowel obstruction

A

Colicky midgut pain, distension, vomiting, recent absolute constipation

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131
Q

What are the signs and symptoms with colonic obstruction

A
  • insidious
  • hindgut abdo pain and discomfort
  • weight loss
  • pronounced abdo distension
  • altered bowel habit with little or no vomiting
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132
Q

How does gut motility change with obstruction

A

Initially the bowel proximal to he obstruction contracts vigorously in an attempt to overcome impedance
Eventually peristalsis subsides and paralytic ileus ensues

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133
Q

Why may a patient with paralytic ileus become toxic

A

Bacteria enter the portal system if ileus not resolved

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134
Q

What are some of the possible consequences to paralytic ileus

A

Perforation
Strangulation
Peritonitis

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135
Q

How do you manage bowel obstruction

A

Iv and electrolyte therapy
Erect CXR, AXR
Laparotomy

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136
Q

What are some for eh causes of paralytic ileus

A
  • after surgery
  • secondary to peritonitis
  • electrolyte imbalances
  • tca’s, lithium, opiates
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137
Q

Which electrolyte ambormalities can cause paralytic ileus

A 
Hypokalaemia
Hyponatraemia
Diabetic ketoacidosis
Uraemia 
Hypocalcaemia
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138
Q

How is paralytic ileus managed

A

Correction of blood electrolytes
Stimulant enemas
Iv erythromycin
Laparotomy

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139
Q

Whatis the definition of a hernia

A

Abnormal protrusion of a cavity’s contents (e.g. Viscera) through a weakness in the wall of the cavity that usually contains it.

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140
Q

What is the risk in hernias that are irreducible

A

May strangulate or become obstructed

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141
Q

What passes through the inguinal canal

A

In males the spermatic cord, and in females, the round ligament

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142
Q

Which embryonic structure failing to close properly may predispose to inguinal hernias

A

Processus vaginalis

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143
Q

In which structure is the deep inguinal ring

A

Transversalis fascia

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144
Q

Where is the deep inguinal ring

A

About 1 cm above the mid point of the inguinal ligament

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145
Q

What is medial to the deep inguinal ring

A

Inferior epigastric vessels

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146
Q

Where does an indirect inguinal hernia enter to herniate

A

The deep inguinal ring

Can pass down into the scrotum

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147
Q

Where is an inguinal hernia usually found in relation to the pubic tubercle

A

Above and medial

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148
Q

What are the clinical features of inguinal hernias

A

Discomfort in groin, esp when lifting or straining

Lump, especially visible when coughing or standing up

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149
Q

Where does an direct femoral hernia go through

A

Hesselbachs triangle- weakness in abdominal wall, protrudes through transversalis fascia

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150
Q

What is the a agreement for inguinal hernias

A

Surgical
herniotomy and tightening of the deep ring for indirect hernias, and mobilisation of hernia for direct hernias which is strengthened by sutures

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151
Q

Where do femoral hernias project through

A

Femoral ring and pass down the femoral canal, may progress down to the saline ours opening in the deep fascia of the thigh

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152
Q

What is medial and lateral to the femoral canal

A

Medial - lacunar ligament

Lateral - femoral vein

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153
Q

What do femoral hernias usually contain

A

Small bowel or omentum

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154
Q

Where are femoral hernias seen

A

Inner upper aspect of the thigh

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155
Q

Where are femoral hernias in relation to the pubic tubercle

A

Below and lateral to pubic tubercle

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156
Q

What is the repair for femoral hernias

A

Surgical

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157
Q

What causes parImbilical hernias

A

Gradual weakening of tissues around the umbilicus - obese, multiple pregnancies etc.

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158
Q

When may groin pain be felt in patients with femoral hernias

A

During exercise

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159
Q

How is para stromal hernia best treated

A

With reversal of stoma if possible

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160
Q

What are the obstructive symptoms of hernias that indicate surgical repair is needed

A

Abdo pain, vomiting, distension

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161
Q

What is dysphagia

A

Difficulty swallowing

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162
Q

What does sudden onset dysphagia indicate

A

Foreign body

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163
Q

Which conditions have dysphagia to solids and which to liquids

A

Solids - carcinoma

Liquids - achalasia, motility disorders, stroke

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164
Q

What is odynophagia

A

Pain on swallowing

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165
Q

What may cause odynophagia

A

Oesophagitis

Oesophageal spasm

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166
Q

What is dyslepsia

A

Describes symptoms of indigestion - epigastric pain, belching, heartburn, nausea, early satiety, reduced appetite

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167
Q

What are alarm symptoms in dyspepsia

A 
Weight loss
Progressive dysphagia 
Iron deficiency
Mass
Vomiting
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168
Q

Where in the world is diverticular disease prevalent

A

Developed countries

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169
Q

Which component of the diet is related to diverticular disease

A

Low fibre

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170
Q

Wh in part of the GI system is most commonly affected by diverticular disease

A

Sigmoid colon (related to intraluminal pressure)

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171
Q

What are the symptoms of diverticular disease

A
  • intermittent lower abdo/left iliac fossa pain
  • altered bowel habit
  • rectal bleeding
  • urgency of defaecation
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172
Q

List some of the imaging investigations for diverticular disease

A
  • barium enema
  • colonoscopy/sigmoidoscopy
  • CT
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173
Q

How do you manage uncomplciTed diverticular disease

A

High fibre diet, bulk laxatives, antispasmodics such as mebeverine

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174
Q

When is surgical resection of affected segment indicated in patients with diverticular disease?

A

Persistent symptoms or when cancer cannot be excluded

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175
Q

What symptoms may you find in a patient with colonic diverticular disease which has perforated

A 
Septic shock
Dehydration
Marked abdo pain
Tenderness
Distension
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176
Q

How is perforated diverticular disease treated

A

Resuscitation, iv broad spectrum antibiotics, reception of affcted bowel + peritoneal lavage

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177
Q

What complications can persistent infections in diverticular disease due to still stasis etc, lead to

A

Necrosis and formation of abscess. This may go on to perforate

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178
Q

What are the symptoms and clinical features of diverticulitis

A

Pyrexia, leucocytosis, nausea, vomiting, altered bowel habit
Pain and tenderness in LIF

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179
Q

How is diverticulitis diagnosed

A

CT

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180
Q

How is an episode of diverticulitis treated

A

Fasting, clear fluids, bed rest
Iv fluids
Broad spectrum antibiotics
Certain circumstances may require surgery, e.g. Abscess

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181
Q

Give some examples of broad spectrum antibiotics used in the treatment of diverticulitis

A

Cephalosporins, gentamicin, metronidazole

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182
Q

What are some of the complications of diverticular disease a

A
  • strictures
  • obstruction
  • infection and inflammation
  • fistula
  • bleeding
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183
Q

What is a common organ that diverticulae form fistulas with

A

The bladder - colovesicular fistula

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184
Q

If a colovesicular fistula is preset in a patient with diverticulosis, what are some of the urinary symptoms that may be present

A

Dysuria, passage of cloudy urine, bubbling on micturition (pneumoturia)

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185
Q

How is a fistula in diverticular disease diagnosed

A

Barium enema

Cystoscopy if colovesicular fistula

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186
Q

How is a colovesicular fistula treated

A

Sigmoid colectomy with synchronous repair of the bladder

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187
Q

What are the differentials of pe bleeding in diverticular disease

A

Haemorrhoids, polyps, IBD, cancer,angiodysplasia

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188
Q

If a patient with divertcular disease is also bleeding, how do you manage it once you pick up the source of bleeding on ct angiography

A

Resection or affected bowel, even total colectomy

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189
Q

What is the pathophysiology of large intestinal ischaemia

A

Similar to small vowel ischaemia - atheroma at the region of the inferior mesenteric artery resulting in insufficient blood supply from marginal artery.
Progress to gangrene and perforation
Some may have acute bloody diarrhoea

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190
Q

What are the clinical features and symptoms of ischaemic colitis or the large intestine

A

Lower abdo pain, nausea, vomiting, bloody diarrhoea
Tenderness and guarding
Pyrexia and leucocytosis

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191
Q

What is seem or radiography of a patient with ischaemic colitis of the large bowel

A

Thickened segment of colon and “thumb printing” due to oedema.

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192
Q

How does gangrenous ishcaemic colitis present

A

Localised or generalised peritonitis

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193
Q

How is gangrenous ischaemic colitis treated

A

Surgery - resection + colostomy

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194
Q

How does ischaemic stricture of the colon present

A

Colicky abdominal pain, constipation and distension following history of an attack of bloody diarrhoea or documented episode of ischaemic colitis.

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195
Q

What is IBS

A

Mixed group of abdominal symptoms for which no organic cause can be found. Most due to disorders of intestinal motility but enhanced visceral perception

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196
Q

What are the diagnostic criteria for IBS

A 
Diagnosis of exclusion
Abdo pain/discomfort relived by defaecation OR associated with altered stool form OR bowel frequency 
AND there are 2 or more of:
- urgency
- tenesmus
- bloating/distension
- PR mucus
- worsening of symptoms after food
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197
Q

Which part of the git is commonly affected by volvulus

A

Sigmoid colon

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198
Q

Which mart of the git is rarely affcted by volvulus, but still can be

A

Caecum

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199
Q

What is a volvulus

A

Twisting of bowel around a narrow origin in the mesentery

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200
Q

What is the presentation of a sigmoid volvulus

A

Presentation as per large bowel obstruction:

  • lower abdo pain
  • abdo distension
  • nausea and vomiting
  • absolute constipation
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201
Q

How may a patient with perforation due to sigmoid volvulus present

A

With sepsis

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202
Q

What is seen on radiography of a patient with sigmoid volvulus

A

Coffee bean sign, with a grossly distended colon arising out of pelvis

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203
Q

What is the conservative treatment of sigmoid volvulus

A

Reduction and deflation using rigid or flexible sigmoidoscope + placement of large bore tube into the sigmoid

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204
Q

What is the surgical management of sigmoid volvulus

A

sigmoid colectomy following fill bowel prep

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205
Q

Which anatomical landmark does a faecalis volvulus occur around

A

Superior mesenteric artery

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206
Q

What does radiography show in a caudal volvulus

A

Anticlockwise rotation of dilated small bowel loops, around a grossly distended caecum

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207
Q

How can bleeding due to angiodysplasia in the colon be treated

A

Angiographic embolisation, laser treatment, injection sclerotherapy, resection in emergency laparotomy

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208
Q

What is the responsible organism for pseudo membranous colitis

A

C. difficile

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209
Q

What usually is the cause of pseudo membranous colitis

A

Almost always healthcare related infection due to over use of broad spectrum antibiotics

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210
Q

How is C. difficile infection detected

A

Stool culture or assays for presence of C. difficile toxin in stool or blood

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211
Q

What do stools of those affected by C. difficile infection look like

A

Watery, green, blood stained, foul smelling, often containing fragments of mucosal slough

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212
Q

What are the signs and symptoms of pseudo,em famous colitis/c difficile infection

A 
Patient profoundly unwell
Fever
Colitis 
Sepsis
Dehydration
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213
Q

How do you manage C. difficile infection

A

Resusc, iv fluids, side room isolation

Oral metronidazole or vancomycin for 10 days

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214
Q

What severe complication may patients with severe cases of C. difficile infection encounter

A

Toxic megacolon

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215
Q

How is toxic megacolon treated

A

Emergency Colectomy + ileostomy (ileorectal anastomosis ca be performed at a later date)

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216
Q

List the drugs most commonly associated with C. difficile / pseudo,membranous colitis

A
  • ciprofloxacin
  • amoxicillin
  • clindamycin
  • cephalosporins
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217
Q

What class of antibiotic is ciprofloxacin

A

Quinolone

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218
Q

What are the features of microscopic colitis on biopsy

A

Increase in inflammatory cells (esp. Lymphocytes) with an otherwise normal appearance and architecture of colon

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219
Q

What is the main presentation of microscopic colitis, and are there any radiological or histological changes

A

Chronic diarrhoea, normal radiological findings, typical histological findings

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220
Q

How is microscopic colitis treated

A

Avoid caffeine and orb we known aggravators
5-ASA agents in non responders
Anti diarrhoeal agents

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221
Q

What causes hirschprungs disease

A

Absence of ganglion cells in Auerbachs and Meisseners plexuses

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222
Q

How does hirschprungs diseases usually present

A

In childhood, where there is a loss of peristalsis in the affected segment leading to large bowel obstruction with distension of proximal to affcted segment

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223
Q

What diagnostic investigation confirms hirschprungs disease

A

Biopsy - confirms lack of ganglia

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224
Q

How is ileostomy formed

A

By bringing out ileum through the abdominal wall, through the rectus muscle in the RIF
Spout fashioned to allow appliances to be fitted

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225
Q

Why may an ileostomy be performed

A

As an adjunct to resectional surgery or as a temporary stoma to allow distal anastomosis to heal

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226
Q

When is an end-ileostomy used

A

When the colon has been removed +/- small part of distal ileum has been removed.

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227
Q

Why does colostomy not require a spout like an ileostomy does

A

The faeces extruded here are not usually irritant to skin

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228
Q

Which emergency procedure involves colostomy formation

A

Hartmanns procedure

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229
Q

Liz some indications for colostomy

A

Hartmanns procedure
Resectional surgery for colon cancer
Faecal incontinence surgery to divert faeces from disease anorectum
Palliation for cancer

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230
Q

What is a Hartmann procedure

A

A procedure performed in emergency bowel obstruction where part of the sigmoid colon and/or rectum is removed along with local blood vessels + lymph nodes. Followed by colostomy if cannot rejoin bowel

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231
Q

What are the distinguishing features between ileostomy and colostomy

A

Ileostomy - RIF, spout of mucosa

Colostomy - LIF, closer to the skin and sutured to it

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232
Q

What are the indications for nasojejunal feeding

A

When the patient cannot tolerate feeding into the stomach - severe reflux, vomiting, impaired motility

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233
Q

When is gastrostomy (surgical or peg) indicated

A

Long term - for problems with swallowing e.g. Stroke, oesophageal atresia, tracheosophgaeal fistula

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234
Q

When is jejune stormy indicated

A

Long term, for problems with poor gastric motility, chronic vomiting, high risk of aspiration

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235
Q

How may polyps oak syndromes present, considering often they are asymptomatic

A

Rectus bleeding, large bowel colic, rectal polyps may occasionally prolapse, severe watery diarrhoea, dehydration

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236
Q

How cam polyps is syndromes be managed

A

Colonoscopic polypectomy, electrocautery snare,

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237
Q

What is the risk associated with familial adenomatous polyps is

A

Predisposes to cancer - malignant transformation

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238
Q

What is the inheritance pattern for familial adenomatous polypsis

A

Autosomal dominant

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239
Q

There is an >90% chance of colorectal cancer risk in patients with familial adenomatous polypsis, which prophylactic procedure can be undertaken to prevent this

A

Prophylactic Colectomy

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240
Q

What are the extra colonic features of familial adenomatous polyposis

A

Gastric polyps, ileal adenomas, long bone osteomas

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241
Q

How is FAP diagnosed

A

Sigmoidoscopy/colonoscopy, biopsy, gene mutation screening

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242
Q

Where else should be screened in patients with familial adenomatous polyposis

A

Upper git - polyps and adenomas may also be present here as extra colonic features

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243
Q

List some autosomal recessive differentials for FAP, which also have hih risk of colorectal cancer

A

Meta plastic hyperplasia polyposis

MUTYH-associated polyposis

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244
Q

Which parts of the colon are particularly common sites for colorectal cancer

A

Sigmoid colon and rectum

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245
Q

What are the aetiological factors for colorectal Adenocarcinoma

A

Male gender, older age, family history, westernised diet, (smoking)

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246
Q

Which diets are associated with increased risk of colorectal cancer

A

Low fibre, high red meat content, high fat

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247
Q

What are protective factors against colorectal cancer

A

No smoking/excess alcohol
Dietary calcium and vitamin d supplements
Hugh fibre diet
Aspirin/other NSAIDs

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248
Q

List some gee tic conditions associated with increased risk of colorectal Adenocarcinoma

A

Hnpcc
Fap
Peutz jehgers
Juvenile polyposis syndrome

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249
Q

Which gene function is affcted in HNPCC

A

Gene participating in ENA mismatch repair

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250
Q

What are the clinical features of colorectal carcinoma

A
  • intermittent rectal bleeding
  • blood mixed with mucus
  • altered bowel habit
  • iron deficiency anaemia (microcytic)
  • colicky lower abdo pain
  • tenesmus
  • obstructive symptoms in some cases
  • abdo mass
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251
Q

What are is the current UK programme for bowel cancer screening

A

All M+F 60-75 year olds are sent home kit test for Faecal Occult Blood
An additional one-off scope at 55 years is being introduced in the UK currently

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252
Q

What imaging investigations would you perform on a patient with ?colorectal cancer

A

Colonoscopy
Ct colonography
Barium enema

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253
Q

What is the treatment with curative intent for colorectal carcinoma

A

Colorectal resection, excision of colonic mesentery, ligation of arterial supply, lymph node excision, formation of colonic j pouch

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254
Q

List some macroscopic appearance types of colorectal Adenocarcinoma

A

Stenosing
Ulcers ting
Polypoidal

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255
Q

What is t1-4 of colorectal cancer

A

T1- invades submucosal
T2- muscularis propria
T3- subserosa
T4- invades adjacent organs/peritoneum

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256
Q

What is n0-3 in colorectal cancer staging

A

N0 - no regional lymph nodes involved
N1 - metastasis to 1-3 nearby lymph nodes
N2 - to 4 or more nearby lymph nodes
N3 - to lymph nodes near major blood vessels

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257
Q

What is M0 and M1 in TNM staging of colorectal cancer

A

T0- no distant metastasis

T1- distant metastasis

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258
Q

Why is radiotherapy a good adjuvant therapy

A

Reduces recurrence rates

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259
Q

How are fixed, inoperable colorectal tumours managed

A

Radical radiotherapy, combined with chemotherapy such as 5-FU

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260
Q

How does 5-fu chemo generally work

A

Inhibit thymidylate synthesis

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261
Q

What is the palliative therapy for colorectal cancer

A
  • colostomy to divert faecal stream
  • palliative stent
  • control pain, mucous discharge, altered bowel habit, bleeding, incontinence
  • palliative chemo
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262
Q

How is lymphoma of the large intestine treated

A

Resection followed by chemo and radiotherapy if primary lymphoma

Systematic therapy and targeted radiotherapy if secondary lymphoma

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263
Q

What are the two muscle layers in the anorectum

A

Internal and external sphincterectomy

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264
Q

The inner layer of anorectum muscle is a continuation of the git, therefore what inner ages it

A

Sympathetic and parasympathetic nervous system, arising from the nerve plexuses

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265
Q

What function does the continuous inner action of the internal muscle of the anorectum have

A

Maintains tone and continues to resting pressure inside canal

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266
Q

What type of muscle is the external sphincter of the anorectum

A

Striated

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267
Q

What is the inner action of the external anal sphincter

A

Voluntary

268
Q

Which nerve supplies the external anorectum sphincter

A

Internal pudendal nerves

269
Q

What type of epithelium lines the internal and external zones of the anal canal

A

Internal - columnar

External - stratified squamous (keratinised)

270
Q

What are anal cushions

A

Specialised vascular structures that lie in the submucosa of the anal canal, above the dentate line

271
Q

What is the function of anal cushions

A

Aide in fine control of continence

272
Q

What is the lymphatic drainage of the anal canal

A

Inferior mesenteric, aortic, internal iliac

273
Q

Which lymph nodes does anal cancer frequently metastasise to

A

Inguinal lymph nodes

274
Q

What are first degree haemorrhoids

A

Bleed, don’t prolapse, seen on proctoscopy

275
Q

What are second degree haemorrhoids

A

Propose during defaecation but reduce spontaneously

276
Q

What are third degree haemorrhoids

A

Constantly prolapse but can be reduced manually

277
Q

What are fourth degree haemorrhoids

A

Irreducibly prolapsed

278
Q

How would you manage first degree haemorrhoids

A

Encourage patient to not strain during defaecation and avoid constipation

279
Q

How do you manage 2nd degree haemorrhoids

A

Banding, injection sclerotherapy, haemorrhoidectomy

280
Q

How are third degree haemorrhoids managed

A

Haemorrhoidectomy

281
Q

Los some causes of severe acute anal pain

A
  • perianal abscess
  • anal fissure
  • thrombosed haemorrhoids
  • perianal haematoma
  • anorectal cancer
282
Q

What are haemorrhoids

A

Enlarged prolapsed anal cushions due to the degeneration of the supporting fibroelastic tissue and smooth muscle (unknown cause)

283
Q

What are the clinical features of haemorrhoids

A

prolapse
Intermittent bleeding seen on wiping or in the pan
Aching or discomfort on defaecation
Pruritus

284
Q

Is it common for patients with haemorrhoids to present with incontinence

A

No

285
Q

What are emergency complications of heart hoods

A
  • thrombosed (blue/black) prolapsed piles

- torrential haemorrhage

286
Q

What is the generic management for piles

A
  • high fibre diet
  • bulk laxatives + stool softeners
  • band ligation/sclerosant injection/ photocoagulation/ haemorrhoidectomy
287
Q

What is an adverse functional side effect of haemorrhoidectomy

A

Incontinence

288
Q

What is a fissure-in-ano

A

A tear in the squamous lining of the lower anal canal, often with a sentinel pile or mucosal tag at the external aspect

289
Q

What is the cause of anal fissures

A

Hard faeces, making defaecation difficult; spasm may construct inferior rectally artery causing ischaemia and making healing difficult as well as perpetuating the problem

290
Q

Which GI condition are anal fissures often associated with

A

Crohns disease

291
Q

What is the management for anal fissures

A 
May resolve spontaneously so treatment should be reserved for >6 weeks of symptoms 
Stool softeners may help
Diltiazem
Topical nitrates 
Lateral sphincterectomy 
Botulinum toxin injection
292
Q

Lost some conditions that may predispose to perianal abscess

A

CD, UC, immunosuppression, DM, chemo

293
Q

How do perianal abscesses arise

A

Initiated by blockage of anal gland ducts,a nd the anal gland becomes secondarily infected with large bowel organisms

294
Q

What are the clinical features of perianal abscesses

A

Acute anal pain and tenderness, difficulty sitting

Pus can track and patient may become toxic and pyrexial

295
Q

How are perianal abscesses managed

A

If it doesn’t respond to antibiotics alone, requires surgical drainage under general anaesthetic. Send pus for bacteriological asses,sent for causative organism

296
Q

Which antibiotics are given if a patient with perianal abscess also has ex festive cellulitis

A

Cephalosporins and metronidazole

297
Q

What is the pathogens is of fistula

A

Preceded by perianal abscesses,w chin have formed due to blockage of anal gland.

298
Q

What are the clinical features of fistula in ano

A
  • chronically discharging opening perianally
  • pruritus
  • perianal discomfort
299
Q

What other condition should be excluded when a patient present with fistula in ano

A

Crohns

300
Q

What is the a management of fistula in ano

A
  • examination under anaesthetic to trace the tract

- seton passed through length of fistula, GRADUALLY laid open + allowed to drain and heal behind the seton

301
Q

Why is important to gradually lay open a fistula rather than in one operation

A

It would lead to incontinence; it cuts through the sphincters and gradual lay open allows the sphincter muscle to heal behind it

302
Q

What is the aetiology of fistula in ano

A

Crohns disease, anorectal trauma, iatrogenic, anorectal carcinoma

303
Q

What are the symptoms of anal warts

A

Discomfort, pain, pruritus ani

304
Q

Why is there an increased risk of SCC in patients with anal warts

A

Associated with HPV

305
Q

How are anal warts that do not resolve spontaneously managed

A

Podophyllotoxin, surgical excision

306
Q

Are anal skin tags usually managed by surgery

A

No, not unless they cause significant symptoms and complications

307
Q

What are anal skin tags usually a comsquence of

A

Haemorrhoids

308
Q

Which epithelium does anal cancer usually arise form

A

Keratinised squamous epithelium of anal margin or non keratinised sum sous epithelium of transitional zone immediately above the dentate line
Very few adenocaricnomas

309
Q

Which types of HPV are strongly associated with anal cancer

A

16; 18

310
Q

What is the premalignant lesion to anal cancer

A

Anal Intraepithelial neoplasia (AIN)

311
Q

What are the signs and symptoms of anal cancer

A

Anal pain, bleeding, discomfort, discharge into underwear, pruritus ani

312
Q

What symptom will a patient with anal cancer wh in has spread to anal sphincters experience

A

Incontinence

313
Q

How is anal cancer diagnosis confirmed

A

biopsy

314
Q

What is the management for anal cancer

A

Lower stage - wide surgical excision

Later stages - radiotherapy to anal canal + inguinal lymph; surgery in radiotherapy failure

315
Q

What is rector prolapse

A

Abnormal protrusion of all (fully thickness) or part of the rectal wall (mucosa)

316
Q

What are the most common aetiological factors for rectally prolapse in young people

A

Chronic constipation, straining, childbirth

317
Q

How is rectus prolapse managed in children (self limiting)

A

Maintain regular bowel habit, stool softeners, digital reduction by parents

318
Q

How is mucosal (partial) rectal prolapse managed

A

Submucosal sclerosant injection, photocoagulation, application of bands, limited excision

319
Q

How is full thickness rectal purpose managed

A

Surgery

320
Q

What are the causes of anal incontinence

A
  • structural muscle damage
  • disruption of nerve supply
  • urgency e.g. UC
  • damage to sphincters e.g. Childbirth
  • nerve injury during childbirth
  • neurodegenerative disease
321
Q

What questions are import at to ask about she taking a history form a patient presenting with incontinence

A
  • past surgery
  • obstetric history
  • coexisting disease
  • urinary incontinence
  • defaecation history
322
Q

What do you examine for in a patient with rental prolapse

A

Sphincter tone, previous scars, sensation

Sigmoidoscopy/colonoscopy to exclude other cases

323
Q

What is the conservative management for rectal prolapse?

A

Dietary advice to avoid exacerbating factors such as caffeine
Stool bulking agents, e.g. Fybogel plus loperamide to induce a degree of constipation
Regular emptying of rectum stimulant suppositories

324
Q

What is the surgical management for rectal prolapse?

A

Implants graciloplasty

Permanent colestomy

325
Q

Give some causes for pruritus ani?

A

Haemorrhoids, fistulae, fissures, incontinence, anal carcinoma, rectal prolapse, dermatological conditions

326
Q

How do you treat pruritus ani?

A

Treat underlying condition,
discourage scratching, use of perfumed soaps, antiseptics
Gentle cleaning habits
Barrier cream

327
Q

What is pilonidal disease?

A

Chronic inflammation in one or more sinuses in the midline of the natal cleft that contain hair and debris

328
Q

What is the histology of pilonidal sinuses?

A

Lined with squamous epithelium but tracts are lined with granulation tissue from chronic infection

329
Q

What are the clinical features of pilonidal disease?

A

Midline natal cleft pits discharging mucopurulent material with mildly offensive smell and maybe blood
Tenderness on pressure
Avoids sitting for long periods
,any become pilonidal abscess

330
Q

What is management for pilonidal disease?

A 
Natal cleft hygiene
Depilation
Antibiotics, if abscess
Drainage
Surgery to lay tracts open and remove granulomas
Closure with sutures
331
Q

What is the APACHE scoring system

A

Classification system which rates the severity of patients risk of dying in hospital

332
Q

Give some examples of factors taken into account in the APACHE scoring system

A

Core temp, he, BP, creat, age, chronic illness…

333
Q

List some conditions which may increase risk in surgery

A 
Resp - asthma, COPD
Diabetes
Cardiac - ihd, HF, arrhythmia 
Alcoholism
Obesity 
Neuro - myasthenia, CVA, Parkinson's, guillain barre, malignant hyperthermia
334
Q

Which drugs may people with alcoholism be tolerant to in anaesthesia

A

BZDs

335
Q

Why is obesity a problem in surgery, what is different in managing these patients

A

May require high oxygen concentrations
BP measurements less reliable
If access may be more difficult to obtain

336
Q

What is the preop management of diabetes

A

Measure HbA1C, BP, BMI
Details of complications
Optimise glycemic control
Make plan for surgery

337
Q

How are diabetic patients managed PERIoperatively e.g. Medicine changes

A
  • put first on list
  • stop oral hypoglycaemics on day of surgery
  • can take long acting insulin day before but not on day of surgery
  • if late on list, give morning dose with breakfast
  • sliding scale VRIII
  • give 0.45% NaCl, 5% dextrose, KCl
  • measure blood glucose every 1 hour
338
Q

How do you change the following diabetes drugs for surgery:

  • oral hypoglycaemics
  • long acting insulin
A
  • oral hypoglycaemics - stop on day of surgery

- long acting insulin - have dose night before if early on list; if late on list take dose with breakfast as normal

339
Q

How often do you check blood glucose in surgery and post op in patients with diabetes

A

Surgery - hourly

Post op - every 2 hours

340
Q

What is the mechanism of action of cyclizine

A

Anticholinergic / antihistamine

341
Q

What is the dose of cyclizine

A

50mg tds

342
Q

What is the mechanism of action of ondansetron

A

5HT3 antagonist

343
Q

What is the mechanism of action of metoclopramide

A

D2 antagonist

344
Q

What Is the dose of metoclopramide

A

10mg tds

345
Q

What is the mechanism of action of prochlorperazine

A

D2 antagonist

346
Q

What is the mechanism of action. Of hyoscine bromide

A

Anticholinergic

347
Q

What are some of the side effects of 5HT3 antagonists

A

Dizziness, confusion, tachycardia

348
Q

What is a PICC line

A

Central venous catheter. Form of iv access used for prolonged period of time e.g. Chemo, abx

349
Q

Los the three types of reasons for confusions in patients undergoing surgery

A
  • delirium
  • dementia
  • post operative cognitive dysfunction
350
Q

What is post operative cognitive dysfunction

A

Short term decline in cognitive function lasting few days. Does not have all the typical features of delirium, not the same

351
Q

What is the most common post op arrhythmia

A

AF

352
Q

What are the characteristics of septic shock initially, then how does this chnage later

A

Initially - hyperdynamic circulation, fever, rigors, warm dilated peripheries, bounding pulse
Later - BP decreases, peripheral vasoconstriction, Oliguria, multisystemic failure

353
Q

What is a specific complication of endarterectomy

A

Stroke

354
Q

What are the medical treatments for delirium

A

Diazepam, vit b

If extreme agitation - diazepam or haloperidol

355
Q

What Re the features of UTI which may be seen in post op patients

A

Frequency, dysuria, mild fever, flank pain

356
Q

What are the three components of virchows triad

A
  • increased coagulability
  • stasis
  • endothelial damage
357
Q

What are the risk factors for venous thrombosis

A
  • obesity
  • age
  • prolonged immobility
  • hip/pelvic surgery
  • prolonged surgery
  • prev DVT/PE
  • malignancy
  • pregnancy
  • OCP
358
Q

What is the policy for those who take the OCP preop

A

Stop 4 weeks before surgery and offer alternative contraceptive advice for that time

359
Q

Describe epidural anaesthesia

A

Continuous local anaesthetic +/- opioid infusion into the epidural space, set to run at a certain rate

360
Q

How many days can an epidural catheter remain in situ before it has to be removed post op

A

5 days

361
Q

What are the causes for epidural failure

A

Misplacment, displacement, inadequate analgesia, intolerable side effects, very very rarely permanent neurological damage

362
Q

Why may respiratory distress occur with epidural anaesthesia

A

Cephalosporins spread of anaesthetic

363
Q

Describe patient controlled analgesia

A

Use of programmed pump delivers small predetermined dose of drug (usually opiate) with miminum time (lock out period) between doses to minimise risk of reps distress etc

364
Q

What is the maximum dose of PCA analgesia

A

1 mg morphine at 5 min intervals

365
Q

What are some of the drawbacks to PCAs

A

Lack of patient understanding to use it and lack of patient dexterity, correct programming

366
Q

List some agents that may be used for neuropathic pain

A
  • tricyclic antidepressants
  • gabapentin/pregabalin
  • lidocaine
367
Q

Why do patients get acute renal failure post op

A

Inadequate perfusion to kidneys; hypovolaemia, water depletion, drugs, sepsis

368
Q

How can acute renal failure be prevented in surgery

A

Adequate fluid replacement perioperatively

369
Q

What is the MINIMUM urine output

A

0.5ml/kg/hour

370
Q

Which invasive method can be used to monitor circulating volume and heart preload

A

CVP line

371
Q

What is the a management of a patient in an extreme case where conservative management persistently fails

A

Renal replacement therapy

372
Q

Why may airway obstruction occur perioperatively

A

Decreased level of consciousness and reduced muscle tone

373
Q

List some causes of airway obstruction perioperatively

A
  • decreased muscle tone
  • obstruction by tongue
  • foreign bodies e.g. Dentures
  • laryngeal spams
  • laryngeal oedema e.g, traumatic attempts at intubation
  • bronchospasm/bronchial obstruction
374
Q

Which particular operation has an increased risk of tracheal compression

A

Thyroid tony- compression by haemorrhage

375
Q

What is the management for airway obstruction

A

Chin life, jaw thrust, removal of objects, oropharnygeal airway, O2 administration

376
Q

How is the appropriate size chosen for oropharnygeal airways

A

Measured between first incisors and angle of the jaw

377
Q

What is the definition of reps failure

A

Inability to maintain normal O2 and co2 pressures in arterial blood,

378
Q

What is normal pa02

A

> 13 kpa

379
Q

What is pao2 is considered resp failure

A

Less than 6.7 kpa

380
Q

Which post op complications are common in the first four pays after surgery

A

Acute MI, pyrexia due to atelectasis, CVA

381
Q

Which post op complications are common in the first 7 days after surgery

A

Renal impairment, post op urinary retention

382
Q

Which complication is common in days 5-10 post op

A

Delirium tremens

383
Q

Which post op complications are common in days 7-10 after surgery

A

Chest/wound infection, UTI, secondary haemorrhage

384
Q

Which post op complications are common in patients over 10 days after surgery

A

DVT, PE, wound dehiscence

385
Q

What is late secondary haemorrhage usually due to post operatively

A

Infection eroding a blood vessel

386
Q

How are late secondary haemorrhages manged

A

Re exploration surgery

387
Q

List some Respiraotyr post op complications

A
  • pulmonary collapse
  • infection
  • resp failure
  • ARDS
  • pleural effusion
  • pneumothorax
388
Q

How are Respiraotyr post op complications managed

A

Treat underlying cause, administer oxygen, supported ventilation

389
Q

What are some of the complications in iv administration of anaesthesia - what local damage is done

A

Bruising, haematoma, phlebitis, venous thrombosis, air embolus, site infection

390
Q

How is a post op DVT treated

A

SC LMWH and warfarin. LMWH is stopped once fully anticoagulated with warfarin. Warfarin continues for 3-6 months and inr maintained at 2-3

391
Q

What Are the clinical characteristics of acute reosiratory distress syndrome

A

Impaired oxygenation, diffuse lung opacification on CXR, decreased lung compliance

392
Q

List some causes of ARDS Periop

A

Pulmonary or systemic sepsis, massive blood transfusion, gastric contents aspiration

393
Q

What are the signs and symptoms of ARDS

A

Tachypnoea, increased ventilators effort, restlessness, confusion

394
Q

What is the pathophys of ARDS

A

Unclear, but thought to be due to inflammatory reaction with release of cytokines, damaged vascular endothelium, capillary leakage. Leads to interstitial and alveolar oedema

395
Q

How are post of pleural effusions managed

A

Small ones are usually left alone to reabsorb if they don’t interfere with inspiration, but large ones require pleural fluid aspiration

396
Q

How do you manage ARDS

A

Cventilatory support - positive end exploratory pressure (PEEP), treat underlying condition

397
Q

What is a common cause of surgical emphysema

A

CVP line insertion

398
Q

What are some of the effects anaesthetic agents have witch contribute to pulmonary collapse

A
  • paralysis of cilia
  • impaired diaphragmatic movement
  • over sedation
  • abdominal distension
  • wound pain causing patient to not breathe deeply
399
Q

How post op lung collapse be prevented

A

Breathe deeply, cough, mobilise, regular analgesia, chest physio,
O2, salbutamol, assisted ventilation if hypoxia severe

400
Q

How are patients with post op chest infections due to aspiration managed

A

Encouraging them to cough, prescribing antibiotics, send sputum for bacteriology,
oxygen if hypoxic, assisted ventilation if resp function deteriorates

401
Q

What are the three steps of the WHO pain ladder

A

1- non opioids +/- adjuncts
2- mild opioids +/- non opioids, +/- adjuvant
3- opioid +/- non opioids, +/- adjuvant

402
Q

List some opioid analgesics

A

Morphine, pethididne, sia morohine, codeine phosphate, tramadol

403
Q

List some step 1 WHO ladder analgesics

A

Aspirin, NSAIDs, paracetamol, selective cox-2 inhibitors

404
Q

List some step 2 WHO ladder analgesics

A

Codeine phosphate, tramadol, cocodamol

405
Q

What are step 3 WHO ladder analgesics

A

Morphine, fentanyl

406
Q

What are spathe symptoms of massive PE

A

Severe chest pain, pallor, shock

407
Q

What agents do you use for fibrinolysis in a massive PE

A

Streptokinase or urokinase

408
Q

What drug should be started for 6 months after a patient suffers a massive PE

A

Warfarin

409
Q

If a PE patient cannot be coagulated or sustains further PE despite management, what next step should be considered

A

Inferior vena caval filter

410
Q

What is evisceration in wound dehiscence

A

Extrusion of abdo viscera through abdo wound dehiscence

411
Q

What is the total body water content

A

42 L

412
Q

What is the total ECF and ICF body fluid content

A

ECF - 14 L

ICF - 28 L

413
Q

How much ECF is interstitial a pond how much is intravascular

A

Interstitial - 11-12L(4/5)

Intravascular - 3L (1/5)

414
Q

What is the total daily fluid input and output into adults

A

2.6 L input and 2.6 output

415
Q

How much fluid is lost in the urine, faeces, lungs and skin respectively

A

Urine -1.5 L
Faeces - 100 ml
Lungs - 400 ml
Skin - 600ml

416
Q

List crystalloid fluids

A

Normal saline, dextrose, combinations, hartmanns

417
Q

Name some colloids

A

Gelofusin/volplex , starch, albumin, blood products

418
Q

What are the ion requirements in adults

A

Adults
Na+ 2mmol/kg/day
K+ 1mmol/kg/day

419
Q

Hey are the dialup water reuqirements in adults

A

40ml/kg/day

420
Q

What is the intracellular and extra cellular potassium requirements

A

Intracellular - 135 mmol

Extra cellular - 5 mmol

421
Q

What are the intracellular and extra cellular sodium levels

A

Intracellular - 9 mmol

Extra cellular - 143 mmol

422
Q

What are he intracellular and extramedullary cl- levels

A

Intracellular - 9 mmol

Extra cellular - 193 mmol

423
Q

What are the intracellular and extra cellular hco3- levels

A

Intracellular - 9 mmol

Extra cellular - 24 mmol

424
Q

How would a 5% dextrose fluid solution distribute in the fluid compartments of the body, and how much remains intravascularly

A

Distributes to all body fluid components, therefore as the intravascular space only makes up 1/15 of the total body volume, only 1/15 of 1l dextrose remains within the intravascular space (67ml)

425
Q

How would 0.9% saline distribute within the body fluid compartments, and what volume would therefore remain intravascularly

A

It would distribute within the extra dullard compartments but not the intracellular (needs Na+-K+-ATPase), therefore would remain in the 1/5th intravascular compartment - 1/5 of 1L = 200ml

426
Q

How would colloids distribute throughout the body fluid component,s therefore how many ml would remain within the intravascular space

A

Would remain entirely intravascularly therefore 1L would remain intravascularly

427
Q

What are the daily sodium and potassium fluids requirements in a 70kg male

A 
Na+ = 2x70= 140mmol/day
K+ = 1x70= 70mmol/day
428
Q

Calculate the daily fluid requirements of a 70kg male

A

40x70= 2800 ml/day

429
Q

What three things are taken into account when calculating an adults fluid requirements

A

Maintenance requirements + pre existing deficit + replacement of ongoing losses

430
Q

Calculate a 22kg child’s daily fluid requirements

A 
First 10 kg = 4x10 = 40
Up to 20kg = 2x10 = 20
Last 2 kg = 1x2 = 2
Therefore 40+20+2 = 62ml/hour 
62X24= 1488mls a day
431
Q

List some causes of ongoing looses in fluid

A

Vomiting, diarrhoea, ugh output stoma, enterocutaneous fistula

432
Q

Which electrolytes Apis diarrhoea rich in

A

K+ and HCO3-

433
Q

Which electrocutes is vomit rich in

A

K+, H+, cl-

434
Q

Which antibody and which antigen is present I group a blood

A

Antibody - b

Antigen - a

435
Q

Which antibody and which antigen is present in group b blood

A

Antibody - a

Antigen - b

436
Q

Which antibody and which antigen is presentin group ab blood

A

Antibody - none
antigen - ab
Universal receiver

437
Q

Which antibody and which antigen is present in group o blood

A

Antibody - ab
Antigens - none
universal donor

438
Q

How much is one unit of blood in pints and most

A

1 unit = 1 pint

1 pint = ~450 mls

439
Q

How many units of blood are there the body, therefore how many L

A

10 units therefore 4.7-5.5 L

440
Q

What is defined as a massive blood transfusion

A

Transfusing 10units of blood in 24 hours or >50% of patients blood volume in 4 hours in response to massive uncontrolled haemorrhage

441
Q

What are the different type of blood components that can be transfused

A
  • red cells
  • platelets
  • FFP
  • cryoprecipitate
  • human albumin
  • factor IX and VIII
  • prothrombin complex concentrate (berriplex)
442
Q

When is FFP used

A

Multiple coagulation factor deficiencies

severe bleeding; those who are over coagulated e,g, warfarin sometimes

443
Q

Which coagulation factors are found in cryoprecipitate

A

Fibrinogen, factor VIII, XIII, vWf, fibronectin

444
Q

What su the function of factor XIII

A

Cross links fibrin

445
Q

When is cryoprecipitate transfusion used

A

When fibrin levels are low e.g. DIC

446
Q

When is human albumin transfused

A

Conditions with increased vascular permeability e.g. Burns, oedema or ascites resistant to diuretics

447
Q

When are factor IX and VIII infusions used

A

Haemophilia treatment

448
Q

What factors does prothrombin complex contain (beriplex)

A

II, IX, X, +/- VII (vit K dependent)

449
Q

When is prothrombin complex concentrate (beriplex) used

A

Reverse anticoag effect of warfarin when there is major bleeding

450
Q

What tests are performed on blood used for transfusion before use

A

Grouping
Antibody screening

Cross matching if urgent
Group and save

451
Q

Which liver enzyme is increased in patients with pancreatitis

A

ALT

452
Q

When are gallstones treated symptomatic ally

A

If symptomatic

453
Q

What is the “acute abdomen”?

A

Conditions of the abdomen requiring hospital admission, investigation and treatment and of less than 1 week duration. Primary symptom is abdo pain.

454
Q

What are the 2 main pathological processes involved in the acute abdomen

A

Inflammation

Obstruction

455
Q

What is the most common cause of generalised peritonitis?

A

Perforation of an intra-abdominal viscus

456
Q

What is a hiatus hernia

A

Abnormal protrusion of the stomach through the diaphragm into the thorax. Can be sliding (more common) or rolling

457
Q

What are the clinical features of hiatus hernia

A 
Heartburn
Oesophagitis
Epigastric and lower chest pain
Palpitations
Hiccups (irritation of pericardium and diaphragm)
458
Q

How would you manage a hiatus hernia

A

As per GORD

obstructive symptoms should be considered for surgical repair, ng tube and endoscopy

459
Q

What are obstructive symptoms for hiatus hernia

A

Vomiting
Regurg
Breathlessness due to reduced lung capacity

460
Q

What is achalasia

A

failure of the lower oesophageal sphincter to relax- the oesophagus dilates and peristalsis becomes uncoordinated. Can be due to degeneration of the myenteric plexus

461
Q

What are the clinical features of achalasia

A 
Progressive dysphagia (both solids and liquids) 
Regurg
retrosternal pain 
Weight loss
Regurg
Aspiration pneumonia
462
Q

How do you go about managing achalasia

A

Balloon dilatation of LOS
Surgical myotomy
Laparoscopic Hellers myotomy

463
Q

How does GORD present

A 
Heartburn
Acid regurg
Nausea
Hypersalivation (waterbrash)
Epigastric pain
Occasionally vomiting
464
Q

What anatomical or physiological factors usually prevent acid reflux

A

Angle at which oesophagus joins stomach
LOS
Diaphragmatic crus

465
Q

How do you gain a diagnosis of GORD

A

History
Endoscopy
Ph study

466
Q

What is the lifestyle treatment for GORD

A 
Weight loss
Stop smoking
Eat less fatty food
Eat less spicy food
Drink less caffeine and alcohol
467
Q

What is the medical treatment of GORD

A

PPIs

Metoclopramide, to promote gastric emptying and prevent nausea

468
Q

How is barretts oesophagus diagnosed

A

Endoscopic biopsy

469
Q

When is antireflux surgery indicated in a patient with GORD

A

When symptoms cannot be controlled by medical therapy

Patients who do not wish to take acid reflux therapy for a prolonged time or for life, esp if they’re young

470
Q

What does surgery for GORD involve

A

Reducing hiatus hernia if it is present and some form of fundoplication/wrapping fungus of stomach around the oesophagus

471
Q

How does fundoplication/antireflux surgery work to prevent acid reflux

A

When the stomach contracts, the funds wrapped around the lower oesophagus also contracts, so acid isn’t reflexes into the oesophagus as it is momentarily closed off

472
Q

What is diffuse oesophageal spasm

A

A condition caused by repetitive irregular peristalsis

473
Q

How is diffuse oesophageal spasm diagnosed

A

Oesophageal manometry

474
Q

How is diffuse oesophageal spasm treated

A

CCB, sublingual GTN, PPIs

475
Q

What is Plummer Vinson syndrome

A

A condition where a web forms, which results in dysphagia

476
Q

What causes is Plummer Vinson syndrome related to

A

Iron deficiency

Congenital

477
Q

In a patient with Plummer Vinson syndrome caused by iron deficiency anaemia, what would you expect to see on performing bloods

A

Hypochromic microcytic anaemia

Low serum ferritin

478
Q

What investigation can demonstrate a Plummer Vinson syndrome web

A

Barium swallow demonstrates narrowing in the upper oesophagus
Confirm with endoscopy

479
Q

How do you manage a Plummer Vinson syndrome web

A

Dilating web endoscopically

Oral Iron therapy as needed

480
Q

What are oesophageal pouches

A

Protrusions of mucosa through weak areas in the oesophageal wall

481
Q

What is a common area for oesophageal pouches

A

Through Killians dehiscence

482
Q

Where is Killians dehiscence in the oesophagus

A

Between the thyropharyngeus and cricopharyngeus muscle

483
Q

Lis some of the symptoms of a pharyngeal pouch

A 
Regurg
Halitosis
Dysphagia
Gurgling in throat
Aspiration
484
Q

How would you investigate pharyngeal pouches

A

With a barium swallow

485
Q

How are pharyngeal pouches managed

A

Myotomy of cricopharyngeus and resection of pouch

486
Q

What are the aetiological factors for peptic ulcers

A

H pylori
NSAIDs
Smoking
Genetic factors

487
Q

What is Zollinger Ellison syndrome

A

Gastrinoma (gastrin secreting tumour), normally found in pancreas, but also in duodenum and stomach

488
Q

How is Zollinger Ellison syndrome diagnosed

A

Ct and mri to localise tumour

489
Q

How is Zollinger Ellison syndrome managed

A

Remove tumour

490
Q

What are the clinical features of peptic ulcers

A

Well localised epigastric pain
Gastric ulcers painful when eating
Duodenal ulcers painful when hungry/at night

491
Q

What factors may patients with peptic ulcer disease say relieve their pain

A

Food, milk, antacids and vomiting

492
Q

How are peptic ulcers diagnosed

A

Endoscopy and biopsy

493
Q

How are peptic ulcers managed

A

Avoid NSAIDs, smoking, excessive alcohol

Triple therapy of PPIs and amoxicillin/metronidazole and clarithromycin

494
Q

Give some intraluminal causes of oesophageal

Perforation

A

Foreign body

Rigid endoscopy

495
Q

Give some external causes of oesophageal perforation

A

Penetrating injury

496
Q

What is a Malory Weiss tear

A

Spontaneous perforation of the oesophagus, usually caused by violent vomiting. Results in haematemesis and pain

497
Q

What are the clinical features of oesophageal perforation

A

Pain in neck
Vocal tenderness
Surgical emphysema
Mediastinitis and septic shock may result

498
Q

What are some of the investigations for oesophageal perforation

A

Erect CXR
Ct scan
Contrast swallow

499
Q

How is oesophageal perforation managed

A

Surgically, with prophylactic antibiotics and antifungals

500
Q

What are the histological types of oesophageal tumour

A

Benign leiomyomas
Squamous cell carcinoma
Adenocarcinoma

501
Q

What are the clinical features of oesophageal cancer

A

Progressive dysphagia to solids

May have metastatic disease signs

502
Q

What are the investigations for oesophageal cancer

A

Initially barium swallow, blood tests
Endoscopy and biopsy
Staging with ct and pet scans and laparoscopy

503
Q

What is the management of oesophageal cancer

A

Surgical resection + jejunostomy post op
Radiotherapy and chemo
Palliative - most are non operable

504
Q

What clinical symptoms may you encounter in a patient with perforated duodenal ulcer into the gastro duodenal artery

A

Acute onset unremitting epigastric pain
Shoulder tip pain
Vomiting
Symptoms of shock

505
Q

What investigations would perform in a patient with perforated ulcer

A

CXR to show free air under diaphragm

Ct contrast barium meal

506
Q

How do you manage a perforated ulcer

A 
Resusc
O2
Fluids
Broad spectrum abx
Ng tube
IV opiates
PPIs
Urinary catheter
Surgery to close ulcer
507
Q

Iist some causes of an upper GI bleed

A 
Peptic ulcers
Gastritis
Duodenitis
Erosions
Malory Weiss tear
Reflux oesophagitis
Varices
Angiodysplasia
Carcinoma
Aortoduodenal fistula
Dieulafoy syndrome
Caogulopathies
508
Q

What does a FBC show in a patient with haematemesis

A

Normal initially
Anaemia if bleeding is chronic
Urea high

509
Q

How are gi bleeds investigated

A

Endoscopy

Angiography

510
Q

How are gi bleeds treated/managed

A

Surgically
Injection sclerotherapy
Band ligation

511
Q

Give an example of a benign gastric neoplasm

A

Adenomatous polyps

512
Q

What is the most common type of gastric carcinoma

A

Adenocarcinoma

513
Q

What are some less common gastric carcinomas, following Adenocarcinoma

A

Lymphoma
Carcinoids (neuronendocrine)
Gi stromal tumours

514
Q

Give some aetiological factors for gastric neoplasia

A 
Diet
H pylori
Infection
Hereditary
Gastric polyps
Chronic strophic gastritis
Intestinal metaplasia
Gastric dysplasia
515
Q

How is gastric neoplasm diagnosed, following history and examination

A 
Upper gi endoscopy
Biopsy 
Ct staging
Endoscopic USS
Laparoscopy
Pet ct
516
Q

How do you manage gastric cancer with curative intent

A

Gastric tony and removal of nodes +/- preop chemo

517
Q

How would you treat a patient with oesophageal cancer with palliative intent

A

Chemo and radiotherapy
Stenting
Surgical bypass

518
Q

What are stages t1-t4 of gastric neoplasia

A

T1- invades lamina propria or submucosa
T2- muscularis propria or subserosa
T3- serosa
T4- adjacent structures

519
Q

How are gastric neoplasms diagnosed

A

Endoscopy

Endoscopic ultrasound scan

520
Q

What investigations could you do in a patient with Plummer Vinson syndrome

A

Bloods - anaemia, ferritin and iron levels
Barium swallow
Endoscopy

521
Q

At which Hb conc is transfusion considered

A
522
Q

What steps should be taken before transiting blood into a patient

A

1) check correct patient and fully label sample
2) complete blood request form
3) before commencing transfusion, must be checked by two individuals
4) check identity of patient, ABO and RhD-, donation no, expiry date, ensure no leaks/haemolysis
5) check patient vital signs before and 15 mins after each unit, and after completion
6) record

523
Q

List some acute effects of blood transfusion

A

1) acute haemolytic reaction
2) TRALI
3) febrile non haemolytic transfusion reaction
4) allergic reaction
5) bacterial contamination
6) transfusion related circulatory overload

524
Q

What are some of the delayed transfusion reactions

A

1) delayed haemolytic transfusion reaction
2) alloimmunisation
3) post transfusion purpura
4) graft vs host disease
5) transfusion transmitted reaction
6) iron overload

525
Q

Why may acute haemolytic transfusion reaction occur

A

ABO incompatible, intravascular haemolysis

526
Q

What are the signs and symptoms of acute haemolytic transfusion reaction

A

Chills, fevers, rigors
Hypotension, shock, DIC
ARF

527
Q

Why does TRALI occur

A

Antibodies in donor blood reacts with recipients leucocytes

528
Q

What are the signs and symptoms of TRALI

A

Dyspnoea, cough, fever, hypoxia, pulmonary infiltrates

529
Q

Why does febrile M&m haemolytic transfusion occur

A

Antibodies in patients blood react with blood donors leucocytes

530
Q

What are the signs and symptoms of allergic reactions to transfusion

A

Urticaria, itch, severe anaphylaxis

531
Q

Why does transfusion related circulatory overload occur

A

Too much blood affects LV function - failure

532
Q

What are the signs and symptoms of fleshed haemolytic transfusion reactions

A

Jaundice, fever, haemoglobinuria

533
Q

How do patients with post transfusion haemolysis present

A

Thrombocytopenia and bleeding

534
Q

How do patients with graft vs host disease after transfusion present

A

Fever, rash, abnormal LFTs, pancytopenia

535
Q

Which organs can iron accumulate in with iron overload

A

Liver, heart, pancreas

536
Q

What are the different types of autologous transfusion

A
  • pre op donation
  • isovolaemic haemodilution
  • cell salvage
537
Q

How does preop donation work in autologous transfusion

A

Collected from patient prior to surgery and stored for up to 35 days preop. Not very effective, reserved for those with rare blood groups

538
Q

How does isovolaemic haemodilution work

A

Blood drawn preop and put in bag containing anticoagulant and replaced by saline to maintain blood volume. The withdraw blood is red fused during surgery or post op

539
Q

What is cell salvage

A

Blood collected from operation site during surgery, and is processed by a cell salvage machine, where it is anticoagulated and the cells are washed to remove clots and debris. The returned to patient.

540
Q

When is cell salvage not used

A

Malignancy or sepsis

541
Q

Give some reasons for direct arterial pressure monitoring

A
  • failure of indirect monitoring
  • arterial blood sampling
  • continuous reactive monitoring
542
Q

List some complications of direct arterial monitoring

A

Distal ischaemia

543
Q

Why is a central venous catheter used

A

For monitoring CVP, prolonged drug administration, parenteral administration

544
Q

How can you reduce the risk of damaging collateral structures when inserting a CVP line

A

Ultrasound scan

545
Q

What are common insertion sites for Central Venous Catheters

A

SVC, subclavian vein, internal jugular, occasionally peripheral vein in antecubital fossa (PICC)

546
Q

the pressure in which chamber of the heart does a central venous catheter give an indication for

A

RA

547
Q

What are some of the complication of inserting a central venous catheter

A

Arterial puncture, haematoma, haemothorax, nerve injury, air embolism, sepsis, PE, cardiac tamponade

548
Q

List the different types of airway ventilation used in surgery and anaesthesia

A
  • jaw thrust, chin lift
  • bag and mask ventilation
  • LMA
  • endotracheal intubation
  • surgical airway
  • oropharnygeal (Guedel)
  • nasopharyngeal
549
Q

Wh in membrane is a surgical airway created through

A

Cricothyroid membrane

550
Q

What are. The two types of surgical airway

A
  • needle cricothyroidectomy (plastic cannula)

- surgical cricothyroidectomy (inserting tracheostomy tube)

551
Q

Why would you choose an nasopharyngeal airway over an oropharnygeal airway

A

Nasopharyngeal used when patient ja co so out and oropharnygeal airway would induce a gag reflex

552
Q

When is an oropharnygeal airway used in cardiac emergency

A

Airway adjunct in mi

553
Q

Where is the mid inguinal point

A

Half way between the public symphysis and ASIS

554
Q

Where is the mid point of the inguinal ligament

A

Half way between the pubic tubercle and ASIS

555
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

556
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

557
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

558
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

559
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

560
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

561
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

562
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

563
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

564
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

565
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

566
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

567
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

568
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

569
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

570
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

571
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

572
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

573
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

574
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

575
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

576
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

577
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

578
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

579
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

580
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

581
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

582
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

583
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

584
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

585
Q

Where does the deep inguinal ring lie anatomically

A

Mid point of inguinal ligament

586
Q

What anatomical structures are found at the mid inguinal point

A

Femoral artery

587
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

588
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

589
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

590
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

591
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

592
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

593
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

594
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

595
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

596
Q

What is the difference in location of the inguinal and femoral hernias in relation to the pubic tubercle

A

Femoral - below and lateral to the pubic tubercle

Inguinal - above and medial to the public tubercle

597
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

598
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

599
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

600
Q

What are the borders of the femoral triangle

A
  • inguinal ligament superiorly
  • sartorius muscle laterally
  • adductor longus medially
601
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

602
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

603
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

604
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

605
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

606
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

607
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

608
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

609
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

610
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

611
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

612
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

613
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

614
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

615
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

616
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

617
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

618
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

619
Q

List conditions in he right hypochondrium

A
  • acute cholecystitis
  • duodenal ulcer
  • hepatitis
  • hepatomegaly
  • pyelonephritis
620
Q

List the conditions presenting in the epigastric.

A
  • peptic ulcers
  • GORD
  • gastritis
  • epigastric hernia
  • MI
  • pancreatitis
  • AAA
621
Q

List the conditions presenting in the left hypochondrium

A
  • splenomegaly
  • splenic rupture
  • pancreatitis
  • peptic ulcer
  • AAA
  • perforated colon
  • pneumonia (L)
622
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

623
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

624
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

625
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

626
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

627
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

628
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

629
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

630
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

631
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

632
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

633
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

634
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

635
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

636
Q

List some of the conditions in the right flank

A
  • renal calculi
  • UTI
  • lumbar hernia
637
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

638
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

639
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

640
Q

List some of the conditions presenting in the peri umbilical region

A
  • initial appendicitis
  • gastritis
  • small bowel obstruction
  • umbilical hernia
  • IBD
  • AAA
641
Q

List some of the conditions presenting in the left flank

A
  • renal calculi
  • UTI
  • IBD
  • diverticular disease
642
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

643
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

644
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

645
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

646
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

647
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

648
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

649
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

650
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

651
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

652
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

653
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

654
Q

List some of the conditions presenting in the right iliac fossa

A
  • appendicitis
  • inguinal hernia
  • pelvic pain
  • salpingitis
  • ruptured ectopic pregnancy
  • renal calculi
  • Crohns
  • mesenteric adenitis
  • ovarian abscess
655
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

656
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

657
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

658
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

659
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

660
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

661
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

662
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

663
Q

Which infections does splenectomy predispose patients to

A

Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae

664
Q

What is mesenteric adenitis

A

Inflammation of mesenteric lymph nodes

665
Q

List some of the conduit a presenting in the supra public region

A
  • UTI
  • cystitis
  • IBD
666
Q

List some of the conditions in the left iliac fossa

A
  • rectal mass
  • diverticulitis
  • obstruction of large bowel
  • inguinal hernia
  • diverticular disease
  • UC
  • ovarian abscess
  • ruptures ectopic pregnancy
  • saying its
  • strangulated hernia
  • CD

Periop (3 decks)

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