GI Surgery Flashcards
What are some of the causes of spontaneous oesophageal perforation
Violent vomiting
Malory Weiss tear
What are some of the metastatic disease signs seen in patients with oesophageal cancer
enlarged cervical lymph nodes, jaundice, hepatomegaly, hoarseness of voice, chest pain
What are the palliative treatments for oesophageal cancer
Endoscopic stent
Palliative chemo/radiotherapy
Which channel do PPIs inhibit
H+-K+-ATPase
What are the clinical features of upper GI bleed
Haematemesis +/- melena
What is dieulafoy syndrome
Where a large arteriole in the stomach lining erodes and bleeds
What are the steps in the management of an acute upper GI haemorrhage
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
What are the symptoms of gastric neoplasia
Indigestion, Dyspepsia Flatulence Weight loss Vomiting Epigastric or back pain Epigastric mass present
How is GI neoplasia diagnosed
History and examination Upper GI endoscopy Biopsy Staging CT endoscopic ultrasound Laparoscopy Pet-ct
What is the treatment with curative intent for gastric neoplasia
Gastrectomy + node removal +/- preop chemo
What is the palliative treatment for gastric neoplasia
Supportive care
Palliative chemo/radiotherapy
Stenting
Bypass surgery
If a patient has abnormal LFTs and no evidence of biliary disease on USS, what do you investigate next
- exclude drug reaction
- hepatitis serology
- immunoglobulins
- autoantibodies
- copper and iron studies
What is the next step in investigating/managing a patient with abnormal LFTs and biliary obstructio on USS, but no gallstone disease
MRCP
Ct
Biliary stent/surgery indicated
What is the next step in managing/investigating a patient with biliary obstruction, abnormal LFTs and gallstone disease
Ercp/sphincterectomy
Lap cholecystectomy
How is variceal bleeding managed
Endoscopic ligation banding
Injection sclerotherapy
Surgical portosystemic shunts
What is cavernous hemangioma
Benign tumour found in lover
Do you resect a cavernous haemangioma
Only if large and symptomatic
How do patients with liver cell adenoma present
Left hypochondrial pain
What is the danger with liver cell adenoma
Can undergo malignant transformation
How may hepatocellular carcinoma present
Not until late often Decrease in liver function Progression of existing liver problems Abdo pain Weight loss Fever Intraperitoneal haemorrhage
What are the results of blood investigations for hcc
Deranged LFTs
Alpha fetoprotein raised
How do you confirm a hcc
Percutaneous needle aspiration biopsy and cytology
What imaging techniques can be used to diagnosed hcc
USS
CT, MRI
What is the management of hcc
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
What are the presenting features of cholangiocarcinoma
Jaundice, pain, enlarged liver
What is charcots triad in cholangitis
1) pain
2) pyrexia
3) jaundice
What types of stones can be found in gallstones
Cholesterol or pigment stones (calcium bicarbonate)
List some of the pathological effects of gallstones
- acute cholecystitis
- chronic cholecystitis
- mucocoele
- gallstone ileus
- biliary colic
- cholangitis
What is acute cholecystitis
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
What is chronic cholecystitis
Repeated bouts of biliary colic or acute cholecystitis culminating in fibrosis. The gallbladder ceases to function. RUQ pain, no pyrexia
What is mucocoele
Distension of a hollow cavity or organ with mucus
Why does much ele occasionally develop in patients with gall stones
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
If gall stones become stuck, what conditions can they result in
Jaundice
Cholangitis
Acute pancreatitis
What is cholangitis
Infection of the bile duct caused by bacteria ascending from its junction with the duodenum
What is gallstone ileus
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
What is biliary colic
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
What are the symptoms of acute cholecystitis
RUQ pain
Radiates to right subscapsular region
Tachycardia, pyrexia, nausea, vomiting, leucocytosis
What test may be positive in a patient with acute cholecystitis on examination
Murphy’s
What is primary biliary cirrhosis
Autoimmune condition of the liver, where interlobular bile ducts are damaged by chronic granulomas.
What are the consequences for primary biliary cirrhosis
Progressive cholestasis
Cirrhosis
Portal hypertension
What liver marker is raised in primary biliary cirrhosis
ALK PHOS
How does primary biliary cirrhosis present
Lethargy
Pruritus
Hepatomegaly
What are some of the complications of primary biliary cirrhosis
Portal hypertension
Ascites
Hepatic encephalopathy
HCC
What does biopsy of the liver of patients with primary biliary cirrhosis show
Granulomas around the bile ducts, progressing to cirrhosis
How is primary biliary cirrhosis treated
Symptomatic treatment for pruritus with colestyramine
Ursodeoxycholic acid
Liver transplant last resort
What is primary sclerosing cholangitis
A non malignant, non bacterial inflammation, fibrosis and strictures of intra and extra-hepatic bile ducts
What does primary sclerosing cholangitis lead to
Liver failure and death
What are the symptoms of primary sclerosing cholangitis
Often found incidentally
Jaundice, pruritus, abdo pain, fatigue
Which liver enzyme is increased in primary sclerosing cholangitis
ALK PHOS
Wht re the signs of primary sclerosing cholangitis
Jaundice, hepatomegaly, portal hypertension
What do patients with primary sclerosing cholangitis have a huge risk of developing
Cholangiocarcinoma
What is the management of primary sclerosing cholangitis
Liver transplant is the only effective treatment
Colestyramine for pruritus
Ursodeoxycholic acid improves cholestasis
What are the clinical features of tumours of the biliary tract
Progressive obstructive jaundice Mucocoele Empyema Pruritus Anorexia and weight loss
What is the management for rumours of the biliary tract
Whipped procedure if in lower CBD
Palliative stents in some cases
Where does the pancreas lie anatomically
Retroperitoneally, behind the lesser sac and the stomach . The head lies in the loop of the duodenum
What is the blood supply to the pancreas
Coeliac and superior mesenteric artery
What is the blood supply to the tail of the pancreas
Splenic arteries (lies in front of splenic artery)
What are the most common causes for pancreatitis
Alcohol and gallstones
What is the effect of gall stones impacting on the pancreatic duct
Leads to intracellular activation of pancreatic enzymes, acinar cell damage, pancreatic inflammation
What are the GET SMASHED aetiological causes of pancreatitis
Gallstones Ethanol Trauma Scorpion venom Mumps Autoimmune Steroids Heryperlipidaemia/hypercalcaemia ERCP Drugs
What is more common - sliding or rolling hernia
Sliding (stomach cardia involved)
How would you distinguish between gallstone and alcoholic cause of pancreatitis
Ultrasound scan
What is ercp used for
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)
What are the clinical features of acute pancreatitis
- severe epigastric pain, or right hypochondrium
- radiates to back
- nausea, vomiting, retching
- tachycardia, tachypnoea
- jaundice may be present
How is acute appendicitis diagnosed
Measuring serum amylase (3x upper reference), serum lipase
Ct abdo if doubt
Lost two severity score for acute pancreatitis
- APACHE II
- Glasgow prognostic score
What is the conservative management for acute pancreatitis
Iv fluids, analgesia, gradual reintroduction of diet
Antibiotic prophylaxis
Treat underlying cause e.g. gallstones
What are the possible complications of pancreatitis
- infected pancreatic necrosis
- pancreatic pseudocyst
- abscess
- GI bleeding
- GI ischaemia, fistula
How is infected pancreatic necrosis treated
Surgical debridement or Percutaneous drainage
What is a pancreatic pseudocyst
Collections of pancreatic secretion and inflammatory exudate enclosed in a wall of fibrous or granulation tissue
What is chronic pancreatitis
Chronic inflammatory condition characterised by fibrosis and destruction of exocrine pancreatic tissue. Blockage of flow of pancreatic juices
What is the most common aetiological cause of chronic pancreatitis
Alcohol
What are the clinical features of chronic pancreatitis
Characteristic epigastric pain, radiating to back and often relived by leaning forward
Hot water bottles may help relive pain
What are some of the other manifestations of chronic pancreatitis except the usual symptoms
Steatorrhoea
Diabetes mellitus
What imaging investigations can you do to diagnose chronic pancreatitis
CT - may see speckled calcification
MRCP - to look at pancreatic duct
Which non-imaging investigations can you ror form on a patient with chronic pancreatitis
Blood glucose
Faecal fat content
What is MRCP
Imaging technique which uses MRI to visualise the biliary and pancreatic ducts non-invasively
Which blood tests in particular are important for the investigation of a patient with gallstones
FBC - ?neutrophilia
Bilirubin increased
Alkaline phosphatase increased
When is gas seen surrounding the billiary tree
If fistula is present
How is amo pen cholecystectomy performed
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
How is laparoscopic cholecystectomy performed
Cannulae inserted into anterior abdo wall and co2 insufflation
Same structures ligated as in cholecystectomy
What are some of the complications that may occur in cholecystectomy
Infective complications - strep faecalis, e. Coli
Bile leakage
How is infection from organisms such as E. coli prevented in cholecystectomy patients
Prophylaxis with cephalosporin
How is acute cholecystitis managed conservatively initially
Iv fluids, analgesia, broad spectrum antibiotic such as a cephalosporin, nbm
Is the non surgical approach to acute cholecystitis effective
No - gall stone dissolution
How is acute cholangitis managed
Resusc, administration of appropriate antibiotics, decompression of biliary tree with ercp, cholecystectomy
What is the conservative management for chronic pancreatitis
Abstinence from alcohol
Pain relief
Treat endocrine and exocrine insufficiency - supplements
What are the endoscopic and surgical treatments for chronic pancreatitis
Endoscopic duct stents if there is a stricture
Surgical drainage
of obstructed pancreatic duct
What is Courvoisier’s law?
In the presence of a non tender palpable gall bladder, painless jaundice is unlikely caused by gallstones
What are some of the neuronendocrine tumours found in the pancreas
Gastrinomas (Zollinger Ellison syndrome), insulin as, glucagonomas, somatostatinoma
What histological type of cancer is cholangiocarcinoma
Adenocarcinoma
Where do pancreatic Adenocarcinomas tend to metastasise commonly
Liver and lung
What are some of the symptomatic features of pancreatic cancer
Painless jaundice, weight loss, poor appetite
What is the management of pancreatic cancer
Surgical resection via whipped procedure (pancreaticoduodenectomy)
Palliative treatment with relief from obstructive jaundice, pruritus, biliary drainage, chemo
What does pancreaticoduodenectomy/whipples procedure involve
Resection of head of pancreas, distal half of stomach, duodenum, gallbladder, CBD
What does the red pulp of the spleen contain
Macrophages
What does the White pulp of the spleen contain
Lymphoid tissue - lymphocytes, macrophages and plasma cells
How is a splenectomy performed
Via left subcostal incision, with division of the short gastric vessels and mobilisation from surrounding structures
List the indications for splenectomy
- trauma
- haemolytic anaemia
- hyperslenism
- ITP
- abscess
- splenic artery aneurysm
- as part of resection of other organs
What are the lifelong prophylactic antibiotics given to patients who have had a splenectomy
Erythromycin or phenoxymethylpenicillin
What immunisation is given to patients who have had a splenectomy
Pneumococcal, H influenzae type B, meningococcal group c infection immunisation
What are some of the causes of appendicitis
Inflammation may be due to faecoliths, lymphoid hyperplasia, foreign bodies, carcinoid tumours, strictures
List some begging tumours of the small intestine
- adenomatous polyps
- hamartomas
- lipomas
- haemangiomas
What is a hamartoma
Abnormal formation of normal tissue
What is peutz-jehgers syndrome
Inherited disorder where there are multiple hamartomatous polyps in the GIT, as well as pigmentation in the patients lips
List some malignant tumours of the small intestine
- GIST - GI stromal tumour
- Adenocarcinoma of the small bowel
- lymphoma
- carcinoid tumour
What is Lynch Syndrome also known as
Hereditary non-polyposis colorectal carcinoma
What is the inheritance pattern of lynch syndrome/hereditary nonpolyposis colorectal carcinoma
Autosomal dominant
What is the risk that comes with HNPCC/lynch syndrome
High risk of colon cancer
As well as endometrial cancer
What hereditary conditions may be associated with small bowel Adenocarcinoma
FAP, Lynch syndrome
Which cancers are patients with peutz jehgers syndrome susceptible to
Colorectal, gastric, pancreatic, breast, ovarian tumours
What is the management of peutz jehgers syndrome
Laparotomy, polypectomy
What is me kelps diverticulum
Remnant of Vitello-intestinal duct
How may me kelps diverticulum cause problems in affected patients
Intusussecption, volvulus, obstruction
How is me kelps diverticulum treated
Excised if symptomatic, if not, should be left alone
What are the symptoms of radiation enteritis
Watery diarrhoea, lower abdo pain, tenesmus, rectal bleeding, mucous discharge
What may diverticulae in the jejunum cause in terms of symptoms
Inflammation, malabsorption, occasionally perforation and impaction of material in the diverticulae
If small bowel diverticulae are symptomatic, how should they be treated
Iv fluid resuscitation, antibiotics
What is small bowel ishcaemia usually due to
Atheromatous occlusion and thrombosis in the superior mesenteric artery
What are spathe predisposing factors for small bowel ishcaemia
Thrombophilia Hyperviscosity Dehydration Hypovolaemia Hypoperfusion of gut
List some causes of Hypoperfusion of the gut
Trauma, cardiogenic shock, cardiac arrhythmia, septic shock, arterial emboli,
What does small bowel ishcaemia progress to
Necrosis of all the bowel layers with gangrene and perforation
How is small bowel ishcaemia managed
Resusc, resection of gangrenous bowel; and anticoagulation; In some instances, can be restored by embolectomy, thomobolectomy
What is chronic mesenteric ischaemia
Repeated bouts of colicky Central abdo pain typically 20-30 mins after eating, weight loss. Angiogrpaphy
What are the clinical feature of small bowel ischaemia
- Central abdo pain and tenderness
- previous weight loss
- guarding and rigidity (late signs)
What may plain films show in painted with small bowel ischaemia
Calcified atheroma in mesenteric arteries,
Dilated Andy hi kneed small bowel loops
What are the most common causes of small bowel obstruction
- adhesions (60%)
- obstructed hernia (20%)
- malignancy
What are the most common causes of large bowel obstruction
- colorectal cancer (>70%)
- stricturing diverticular disease (10%)
- sigmoid volvulus
What are the signs and symptoms of obstruction in the proximal jejunum
Anorexia, vomiting, severe upper abdo pain, minimal distension, limited (if any) change in bowel habit
What are the symptoms and signs of distal small bowel obstruction
Colicky midgut pain, distension, vomiting, recent absolute constipation
What are the signs and symptoms with colonic obstruction
- insidious
- hindgut abdo pain and discomfort
- weight loss
- pronounced abdo distension
- altered bowel habit with little or no vomiting
How does gut motility change with obstruction
Initially the bowel proximal to he obstruction contracts vigorously in an attempt to overcome impedance
Eventually peristalsis subsides and paralytic ileus ensues
Why may a patient with paralytic ileus become toxic
Bacteria enter the portal system if ileus not resolved
What are some of the possible consequences to paralytic ileus
Perforation
Strangulation
Peritonitis
How do you manage bowel obstruction
Iv and electrolyte therapy
Erect CXR, AXR
Laparotomy
What are some for eh causes of paralytic ileus
- after surgery
- secondary to peritonitis
- electrolyte imbalances
- tca’s, lithium, opiates
Which electrolyte ambormalities can cause paralytic ileus
Hypokalaemia Hyponatraemia Diabetic ketoacidosis Uraemia Hypocalcaemia
How is paralytic ileus managed
Correction of blood electrolytes
Stimulant enemas
Iv erythromycin
Laparotomy
Whatis the definition of a hernia
Abnormal protrusion of a cavity’s contents (e.g. Viscera) through a weakness in the wall of the cavity that usually contains it.
What is the risk in hernias that are irreducible
May strangulate or become obstructed
What passes through the inguinal canal
In males the spermatic cord, and in females, the round ligament
Which embryonic structure failing to close properly may predispose to inguinal hernias
Processus vaginalis
In which structure is the deep inguinal ring
Transversalis fascia
Where is the deep inguinal ring
About 1 cm above the mid point of the inguinal ligament
What is medial to the deep inguinal ring
Inferior epigastric vessels
Where does an indirect inguinal hernia enter to herniate
The deep inguinal ring
Can pass down into the scrotum
Where is an inguinal hernia usually found in relation to the pubic tubercle
Above and medial
What are the clinical features of inguinal hernias
Discomfort in groin, esp when lifting or straining
Lump, especially visible when coughing or standing up
Where does an direct femoral hernia go through
Hesselbachs triangle- weakness in abdominal wall, protrudes through transversalis fascia
What is the a agreement for inguinal hernias
Surgical
herniotomy and tightening of the deep ring for indirect hernias, and mobilisation of hernia for direct hernias which is strengthened by sutures
Where do femoral hernias project through
Femoral ring and pass down the femoral canal, may progress down to the saline ours opening in the deep fascia of the thigh
What is medial and lateral to the femoral canal
Medial - lacunar ligament
Lateral - femoral vein
What do femoral hernias usually contain
Small bowel or omentum
Where are femoral hernias seen
Inner upper aspect of the thigh
Where are femoral hernias in relation to the pubic tubercle
Below and lateral to pubic tubercle
What is the repair for femoral hernias
Surgical
What causes parImbilical hernias
Gradual weakening of tissues around the umbilicus - obese, multiple pregnancies etc.
When may groin pain be felt in patients with femoral hernias
During exercise
How is para stromal hernia best treated
With reversal of stoma if possible
What are the obstructive symptoms of hernias that indicate surgical repair is needed
Abdo pain, vomiting, distension
What is dysphagia
Difficulty swallowing
What does sudden onset dysphagia indicate
Foreign body
Which conditions have dysphagia to solids and which to liquids
Solids - carcinoma
Liquids - achalasia, motility disorders, stroke
What is odynophagia
Pain on swallowing
What may cause odynophagia
Oesophagitis
Oesophageal spasm
What is dyslepsia
Describes symptoms of indigestion - epigastric pain, belching, heartburn, nausea, early satiety, reduced appetite
What are alarm symptoms in dyspepsia
Weight loss Progressive dysphagia Iron deficiency Mass Vomiting
Where in the world is diverticular disease prevalent
Developed countries
Which component of the diet is related to diverticular disease
Low fibre
Wh in part of the GI system is most commonly affected by diverticular disease
Sigmoid colon (related to intraluminal pressure)
What are the symptoms of diverticular disease
- intermittent lower abdo/left iliac fossa pain
- altered bowel habit
- rectal bleeding
- urgency of defaecation
List some of the imaging investigations for diverticular disease
- barium enema
- colonoscopy/sigmoidoscopy
- CT
How do you manage uncomplciTed diverticular disease
High fibre diet, bulk laxatives, antispasmodics such as mebeverine
When is surgical resection of affected segment indicated in patients with diverticular disease?
Persistent symptoms or when cancer cannot be excluded
What symptoms may you find in a patient with colonic diverticular disease which has perforated
Septic shock Dehydration Marked abdo pain Tenderness Distension
How is perforated diverticular disease treated
Resuscitation, iv broad spectrum antibiotics, reception of affcted bowel + peritoneal lavage
What complications can persistent infections in diverticular disease due to still stasis etc, lead to
Necrosis and formation of abscess. This may go on to perforate
What are the symptoms and clinical features of diverticulitis
Pyrexia, leucocytosis, nausea, vomiting, altered bowel habit
Pain and tenderness in LIF
How is diverticulitis diagnosed
CT
How is an episode of diverticulitis treated
Fasting, clear fluids, bed rest
Iv fluids
Broad spectrum antibiotics
Certain circumstances may require surgery, e.g. Abscess
Give some examples of broad spectrum antibiotics used in the treatment of diverticulitis
Cephalosporins, gentamicin, metronidazole
What are some of the complications of diverticular disease a
- strictures
- obstruction
- infection and inflammation
- fistula
- bleeding
What is a common organ that diverticulae form fistulas with
The bladder - colovesicular fistula
If a colovesicular fistula is preset in a patient with diverticulosis, what are some of the urinary symptoms that may be present
Dysuria, passage of cloudy urine, bubbling on micturition (pneumoturia)
How is a fistula in diverticular disease diagnosed
Barium enema
Cystoscopy if colovesicular fistula
How is a colovesicular fistula treated
Sigmoid colectomy with synchronous repair of the bladder
What are the differentials of pe bleeding in diverticular disease
Haemorrhoids, polyps, IBD, cancer,angiodysplasia
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
Resection or affected bowel, even total colectomy
What is the pathophysiology of large intestinal ischaemia
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
What are the clinical features and symptoms of ischaemic colitis or the large intestine
Lower abdo pain, nausea, vomiting, bloody diarrhoea
Tenderness and guarding
Pyrexia and leucocytosis
What is seem or radiography of a patient with ischaemic colitis of the large bowel
Thickened segment of colon and “thumb printing” due to oedema.
How does gangrenous ishcaemic colitis present
Localised or generalised peritonitis
How is gangrenous ischaemic colitis treated
Surgery - resection + colostomy
How does ischaemic stricture of the colon present
Colicky abdominal pain, constipation and distension following history of an attack of bloody diarrhoea or documented episode of ischaemic colitis.
What is IBS
Mixed group of abdominal symptoms for which no organic cause can be found. Most due to disorders of intestinal motility but enhanced visceral perception
What are the diagnostic criteria for IBS
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
Which part of the git is commonly affected by volvulus
Sigmoid colon
Which mart of the git is rarely affcted by volvulus, but still can be
Caecum
What is a volvulus
Twisting of bowel around a narrow origin in the mesentery
What is the presentation of a sigmoid volvulus
Presentation as per large bowel obstruction:
- lower abdo pain
- abdo distension
- nausea and vomiting
- absolute constipation
How may a patient with perforation due to sigmoid volvulus present
With sepsis
What is seen on radiography of a patient with sigmoid volvulus
Coffee bean sign, with a grossly distended colon arising out of pelvis
What is the conservative treatment of sigmoid volvulus
Reduction and deflation using rigid or flexible sigmoidoscope + placement of large bore tube into the sigmoid
What is the surgical management of sigmoid volvulus
sigmoid colectomy following fill bowel prep
Which anatomical landmark does a faecalis volvulus occur around
Superior mesenteric artery
What does radiography show in a caudal volvulus
Anticlockwise rotation of dilated small bowel loops, around a grossly distended caecum
How can bleeding due to angiodysplasia in the colon be treated
Angiographic embolisation, laser treatment, injection sclerotherapy, resection in emergency laparotomy
What is the responsible organism for pseudo membranous colitis
C. difficile
What usually is the cause of pseudo membranous colitis
Almost always healthcare related infection due to over use of broad spectrum antibiotics
How is C. difficile infection detected
Stool culture or assays for presence of C. difficile toxin in stool or blood
What do stools of those affected by C. difficile infection look like
Watery, green, blood stained, foul smelling, often containing fragments of mucosal slough
What are the signs and symptoms of pseudo,em famous colitis/c difficile infection
Patient profoundly unwell Fever Colitis Sepsis Dehydration
How do you manage C. difficile infection
Resusc, iv fluids, side room isolation
Oral metronidazole or vancomycin for 10 days
What severe complication may patients with severe cases of C. difficile infection encounter
Toxic megacolon
How is toxic megacolon treated
Emergency Colectomy + ileostomy (ileorectal anastomosis ca be performed at a later date)
List the drugs most commonly associated with C. difficile / pseudo,membranous colitis
- ciprofloxacin
- amoxicillin
- clindamycin
- cephalosporins
What class of antibiotic is ciprofloxacin
Quinolone
What are the features of microscopic colitis on biopsy
Increase in inflammatory cells (esp. Lymphocytes) with an otherwise normal appearance and architecture of colon
What is the main presentation of microscopic colitis, and are there any radiological or histological changes
Chronic diarrhoea, normal radiological findings, typical histological findings
How is microscopic colitis treated
Avoid caffeine and orb we known aggravators
5-ASA agents in non responders
Anti diarrhoeal agents
What causes hirschprungs disease
Absence of ganglion cells in Auerbachs and Meisseners plexuses
How does hirschprungs diseases usually present
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
What diagnostic investigation confirms hirschprungs disease
Biopsy - confirms lack of ganglia
How is ileostomy formed
By bringing out ileum through the abdominal wall, through the rectus muscle in the RIF
Spout fashioned to allow appliances to be fitted
Why may an ileostomy be performed
As an adjunct to resectional surgery or as a temporary stoma to allow distal anastomosis to heal
When is an end-ileostomy used
When the colon has been removed +/- small part of distal ileum has been removed.
Why does colostomy not require a spout like an ileostomy does
The faeces extruded here are not usually irritant to skin
Which emergency procedure involves colostomy formation
Hartmanns procedure
Liz some indications for colostomy
Hartmanns procedure
Resectional surgery for colon cancer
Faecal incontinence surgery to divert faeces from disease anorectum
Palliation for cancer
What is a Hartmann procedure
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
What are the distinguishing features between ileostomy and colostomy
Ileostomy - RIF, spout of mucosa
Colostomy - LIF, closer to the skin and sutured to it
What are the indications for nasojejunal feeding
When the patient cannot tolerate feeding into the stomach - severe reflux, vomiting, impaired motility
When is gastrostomy (surgical or peg) indicated
Long term - for problems with swallowing e.g. Stroke, oesophageal atresia, tracheosophgaeal fistula
When is jejune stormy indicated
Long term, for problems with poor gastric motility, chronic vomiting, high risk of aspiration
How may polyps oak syndromes present, considering often they are asymptomatic
Rectus bleeding, large bowel colic, rectal polyps may occasionally prolapse, severe watery diarrhoea, dehydration
How cam polyps is syndromes be managed
Colonoscopic polypectomy, electrocautery snare,
What is the risk associated with familial adenomatous polyps is
Predisposes to cancer - malignant transformation
What is the inheritance pattern for familial adenomatous polypsis
Autosomal dominant
There is an >90% chance of colorectal cancer risk in patients with familial adenomatous polypsis, which prophylactic procedure can be undertaken to prevent this
Prophylactic Colectomy
What are the extra colonic features of familial adenomatous polyposis
Gastric polyps, ileal adenomas, long bone osteomas
How is FAP diagnosed
Sigmoidoscopy/colonoscopy, biopsy, gene mutation screening
Where else should be screened in patients with familial adenomatous polyposis
Upper git - polyps and adenomas may also be present here as extra colonic features
List some autosomal recessive differentials for FAP, which also have hih risk of colorectal cancer
Meta plastic hyperplasia polyposis
MUTYH-associated polyposis
Which parts of the colon are particularly common sites for colorectal cancer
Sigmoid colon and rectum
What are the aetiological factors for colorectal Adenocarcinoma
Male gender, older age, family history, westernised diet, (smoking)
Which diets are associated with increased risk of colorectal cancer
Low fibre, high red meat content, high fat
What are protective factors against colorectal cancer
No smoking/excess alcohol
Dietary calcium and vitamin d supplements
Hugh fibre diet
Aspirin/other NSAIDs
List some gee tic conditions associated with increased risk of colorectal Adenocarcinoma
Hnpcc
Fap
Peutz jehgers
Juvenile polyposis syndrome
Which gene function is affcted in HNPCC
Gene participating in ENA mismatch repair
What are the clinical features of colorectal carcinoma
- 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
What are is the current UK programme for bowel cancer screening
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
What imaging investigations would you perform on a patient with ?colorectal cancer
Colonoscopy
Ct colonography
Barium enema
What is the treatment with curative intent for colorectal carcinoma
Colorectal resection, excision of colonic mesentery, ligation of arterial supply, lymph node excision, formation of colonic j pouch
List some macroscopic appearance types of colorectal Adenocarcinoma
Stenosing
Ulcers ting
Polypoidal
What is t1-4 of colorectal cancer
T1- invades submucosal
T2- muscularis propria
T3- subserosa
T4- invades adjacent organs/peritoneum
What is n0-3 in colorectal cancer staging
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
What is M0 and M1 in TNM staging of colorectal cancer
T0- no distant metastasis
T1- distant metastasis
Why is radiotherapy a good adjuvant therapy
Reduces recurrence rates
How are fixed, inoperable colorectal tumours managed
Radical radiotherapy, combined with chemotherapy such as 5-FU
How does 5-fu chemo generally work
Inhibit thymidylate synthesis
What is the palliative therapy for colorectal cancer
- colostomy to divert faecal stream
- palliative stent
- control pain, mucous discharge, altered bowel habit, bleeding, incontinence
- palliative chemo
How is lymphoma of the large intestine treated
Resection followed by chemo and radiotherapy if primary lymphoma
Systematic therapy and targeted radiotherapy if secondary lymphoma
What are the two muscle layers in the anorectum
Internal and external sphincterectomy
The inner layer of anorectum muscle is a continuation of the git, therefore what inner ages it
Sympathetic and parasympathetic nervous system, arising from the nerve plexuses
What function does the continuous inner action of the internal muscle of the anorectum have
Maintains tone and continues to resting pressure inside canal
What type of muscle is the external sphincter of the anorectum
Striated
What is the inner action of the external anal sphincter
Voluntary
Which nerve supplies the external anorectum sphincter
Internal pudendal nerves
What type of epithelium lines the internal and external zones of the anal canal
Internal - columnar
External - stratified squamous (keratinised)
What are anal cushions
Specialised vascular structures that lie in the submucosa of the anal canal, above the dentate line
What is the function of anal cushions
Aide in fine control of continence
What is the lymphatic drainage of the anal canal
Inferior mesenteric, aortic, internal iliac
Which lymph nodes does anal cancer frequently metastasise to
Inguinal lymph nodes
What are first degree haemorrhoids
Bleed, don’t prolapse, seen on proctoscopy
What are second degree haemorrhoids
Propose during defaecation but reduce spontaneously
What are third degree haemorrhoids
Constantly prolapse but can be reduced manually
What are fourth degree haemorrhoids
Irreducibly prolapsed
How would you manage first degree haemorrhoids
Encourage patient to not strain during defaecation and avoid constipation
How do you manage 2nd degree haemorrhoids
Banding, injection sclerotherapy, haemorrhoidectomy
How are third degree haemorrhoids managed
Haemorrhoidectomy
Los some causes of severe acute anal pain
- perianal abscess
- anal fissure
- thrombosed haemorrhoids
- perianal haematoma
- anorectal cancer
What are haemorrhoids
Enlarged prolapsed anal cushions due to the degeneration of the supporting fibroelastic tissue and smooth muscle (unknown cause)
What are the clinical features of haemorrhoids
prolapse
Intermittent bleeding seen on wiping or in the pan
Aching or discomfort on defaecation
Pruritus
Is it common for patients with haemorrhoids to present with incontinence
No
What are emergency complications of heart hoods
- thrombosed (blue/black) prolapsed piles
- torrential haemorrhage
What is the generic management for piles
- high fibre diet
- bulk laxatives + stool softeners
- band ligation/sclerosant injection/ photocoagulation/ haemorrhoidectomy
What is an adverse functional side effect of haemorrhoidectomy
Incontinence
What is a fissure-in-ano
A tear in the squamous lining of the lower anal canal, often with a sentinel pile or mucosal tag at the external aspect
What is the cause of anal fissures
Hard faeces, making defaecation difficult; spasm may construct inferior rectally artery causing ischaemia and making healing difficult as well as perpetuating the problem
Which GI condition are anal fissures often associated with
Crohns disease
What is the management for anal fissures
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
Lost some conditions that may predispose to perianal abscess
CD, UC, immunosuppression, DM, chemo
How do perianal abscesses arise
Initiated by blockage of anal gland ducts,a nd the anal gland becomes secondarily infected with large bowel organisms
What are the clinical features of perianal abscesses
Acute anal pain and tenderness, difficulty sitting
Pus can track and patient may become toxic and pyrexial
How are perianal abscesses managed
If it doesn’t respond to antibiotics alone, requires surgical drainage under general anaesthetic. Send pus for bacteriological asses,sent for causative organism
Which antibiotics are given if a patient with perianal abscess also has ex festive cellulitis
Cephalosporins and metronidazole
What is the pathogens is of fistula
Preceded by perianal abscesses,w chin have formed due to blockage of anal gland.
What are the clinical features of fistula in ano
- chronically discharging opening perianally
- pruritus
- perianal discomfort
What other condition should be excluded when a patient present with fistula in ano
Crohns
What is the a management of fistula in ano
- examination under anaesthetic to trace the tract
- seton passed through length of fistula, GRADUALLY laid open + allowed to drain and heal behind the seton
Why is important to gradually lay open a fistula rather than in one operation
It would lead to incontinence; it cuts through the sphincters and gradual lay open allows the sphincter muscle to heal behind it
What is the aetiology of fistula in ano
Crohns disease, anorectal trauma, iatrogenic, anorectal carcinoma
What are the symptoms of anal warts
Discomfort, pain, pruritus ani
Why is there an increased risk of SCC in patients with anal warts
Associated with HPV
How are anal warts that do not resolve spontaneously managed
Podophyllotoxin, surgical excision
Are anal skin tags usually managed by surgery
No, not unless they cause significant symptoms and complications
What are anal skin tags usually a comsquence of
Haemorrhoids
Which epithelium does anal cancer usually arise form
Keratinised squamous epithelium of anal margin or non keratinised sum sous epithelium of transitional zone immediately above the dentate line
Very few adenocaricnomas
Which types of HPV are strongly associated with anal cancer
16; 18
What is the premalignant lesion to anal cancer
Anal Intraepithelial neoplasia (AIN)
What are the signs and symptoms of anal cancer
Anal pain, bleeding, discomfort, discharge into underwear, pruritus ani
What symptom will a patient with anal cancer wh in has spread to anal sphincters experience
Incontinence
How is anal cancer diagnosis confirmed
biopsy
What is the management for anal cancer
Lower stage - wide surgical excision
Later stages - radiotherapy to anal canal + inguinal lymph; surgery in radiotherapy failure
What is rector prolapse
Abnormal protrusion of all (fully thickness) or part of the rectal wall (mucosa)
What are the most common aetiological factors for rectally prolapse in young people
Chronic constipation, straining, childbirth
How is rectus prolapse managed in children (self limiting)
Maintain regular bowel habit, stool softeners, digital reduction by parents
How is mucosal (partial) rectal prolapse managed
Submucosal sclerosant injection, photocoagulation, application of bands, limited excision
How is full thickness rectal purpose managed
Surgery
What are the causes of anal incontinence
- structural muscle damage
- disruption of nerve supply
- urgency e.g. UC
- damage to sphincters e.g. Childbirth
- nerve injury during childbirth
- neurodegenerative disease
What questions are import at to ask about she taking a history form a patient presenting with incontinence
- past surgery
- obstetric history
- coexisting disease
- urinary incontinence
- defaecation history
What do you examine for in a patient with rental prolapse
Sphincter tone, previous scars, sensation
Sigmoidoscopy/colonoscopy to exclude other cases
What is the conservative management for rectal prolapse?
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
What is the surgical management for rectal prolapse?
Implants graciloplasty
Permanent colestomy
Give some causes for pruritus ani?
Haemorrhoids, fistulae, fissures, incontinence, anal carcinoma, rectal prolapse, dermatological conditions
How do you treat pruritus ani?
Treat underlying condition,
discourage scratching, use of perfumed soaps, antiseptics
Gentle cleaning habits
Barrier cream
What is pilonidal disease?
Chronic inflammation in one or more sinuses in the midline of the natal cleft that contain hair and debris
What is the histology of pilonidal sinuses?
Lined with squamous epithelium but tracts are lined with granulation tissue from chronic infection
What are the clinical features of pilonidal disease?
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
What is management for pilonidal disease?
Natal cleft hygiene Depilation Antibiotics, if abscess Drainage Surgery to lay tracts open and remove granulomas Closure with sutures
What is the APACHE scoring system
Classification system which rates the severity of patients risk of dying in hospital
Give some examples of factors taken into account in the APACHE scoring system
Core temp, he, BP, creat, age, chronic illness…
List some conditions which may increase risk in surgery
Resp - asthma, COPD Diabetes Cardiac - ihd, HF, arrhythmia Alcoholism Obesity Neuro - myasthenia, CVA, Parkinson's, guillain barre, malignant hyperthermia
Which drugs may people with alcoholism be tolerant to in anaesthesia
BZDs
Why is obesity a problem in surgery, what is different in managing these patients
May require high oxygen concentrations
BP measurements less reliable
If access may be more difficult to obtain
What is the preop management of diabetes
Measure HbA1C, BP, BMI
Details of complications
Optimise glycemic control
Make plan for surgery
How are diabetic patients managed PERIoperatively e.g. Medicine changes
- 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
How do you change the following diabetes drugs for surgery:
- oral hypoglycaemics
- long acting insulin
- 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
How often do you check blood glucose in surgery and post op in patients with diabetes
Surgery - hourly
Post op - every 2 hours
What is the mechanism of action of cyclizine
Anticholinergic / antihistamine
What is the dose of cyclizine
50mg tds
What is the mechanism of action of ondansetron
5HT3 antagonist
What is the mechanism of action of metoclopramide
D2 antagonist
What Is the dose of metoclopramide
10mg tds
What is the mechanism of action of prochlorperazine
D2 antagonist
What is the mechanism of action. Of hyoscine bromide
Anticholinergic
What are some of the side effects of 5HT3 antagonists
Dizziness, confusion, tachycardia
What is a PICC line
Central venous catheter. Form of iv access used for prolonged period of time e.g. Chemo, abx
Los the three types of reasons for confusions in patients undergoing surgery
- delirium
- dementia
- post operative cognitive dysfunction
What is post operative cognitive dysfunction
Short term decline in cognitive function lasting few days. Does not have all the typical features of delirium, not the same
What is the most common post op arrhythmia
AF
What are the characteristics of septic shock initially, then how does this chnage later
Initially - hyperdynamic circulation, fever, rigors, warm dilated peripheries, bounding pulse
Later - BP decreases, peripheral vasoconstriction, Oliguria, multisystemic failure
What is a specific complication of endarterectomy
Stroke
What are the medical treatments for delirium
Diazepam, vit b
If extreme agitation - diazepam or haloperidol
What Re the features of UTI which may be seen in post op patients
Frequency, dysuria, mild fever, flank pain
What are the three components of virchows triad
- increased coagulability
- stasis
- endothelial damage
What are the risk factors for venous thrombosis
- obesity
- age
- prolonged immobility
- hip/pelvic surgery
- prolonged surgery
- prev DVT/PE
- malignancy
- pregnancy
- OCP
What is the policy for those who take the OCP preop
Stop 4 weeks before surgery and offer alternative contraceptive advice for that time
Describe epidural anaesthesia
Continuous local anaesthetic +/- opioid infusion into the epidural space, set to run at a certain rate
How many days can an epidural catheter remain in situ before it has to be removed post op
5 days
What are the causes for epidural failure
Misplacment, displacement, inadequate analgesia, intolerable side effects, very very rarely permanent neurological damage
Why may respiratory distress occur with epidural anaesthesia
Cephalosporins spread of anaesthetic
Describe patient controlled analgesia
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
What is the maximum dose of PCA analgesia
1 mg morphine at 5 min intervals
What are some of the drawbacks to PCAs
Lack of patient understanding to use it and lack of patient dexterity, correct programming
List some agents that may be used for neuropathic pain
- tricyclic antidepressants
- gabapentin/pregabalin
- lidocaine
Why do patients get acute renal failure post op
Inadequate perfusion to kidneys; hypovolaemia, water depletion, drugs, sepsis
How can acute renal failure be prevented in surgery
Adequate fluid replacement perioperatively
What is the MINIMUM urine output
0.5ml/kg/hour
Which invasive method can be used to monitor circulating volume and heart preload
CVP line
What is the a management of a patient in an extreme case where conservative management persistently fails
Renal replacement therapy
Why may airway obstruction occur perioperatively
Decreased level of consciousness and reduced muscle tone
List some causes of airway obstruction perioperatively
- decreased muscle tone
- obstruction by tongue
- foreign bodies e.g. Dentures
- laryngeal spams
- laryngeal oedema e.g, traumatic attempts at intubation
- bronchospasm/bronchial obstruction
Which particular operation has an increased risk of tracheal compression
Thyroid tony- compression by haemorrhage
What is the management for airway obstruction
Chin life, jaw thrust, removal of objects, oropharnygeal airway, O2 administration
How is the appropriate size chosen for oropharnygeal airways
Measured between first incisors and angle of the jaw
What is the definition of reps failure
Inability to maintain normal O2 and co2 pressures in arterial blood,
What is normal pa02
> 13 kpa
What is pao2 is considered resp failure
Less than 6.7 kpa
Which post op complications are common in the first four pays after surgery
Acute MI, pyrexia due to atelectasis, CVA
Which post op complications are common in the first 7 days after surgery
Renal impairment, post op urinary retention
Which complication is common in days 5-10 post op
Delirium tremens
Which post op complications are common in days 7-10 after surgery
Chest/wound infection, UTI, secondary haemorrhage
Which post op complications are common in patients over 10 days after surgery
DVT, PE, wound dehiscence
What is late secondary haemorrhage usually due to post operatively
Infection eroding a blood vessel
How are late secondary haemorrhages manged
Re exploration surgery
List some Respiraotyr post op complications
- pulmonary collapse
- infection
- resp failure
- ARDS
- pleural effusion
- pneumothorax
How are Respiraotyr post op complications managed
Treat underlying cause, administer oxygen, supported ventilation
What are some of the complications in iv administration of anaesthesia - what local damage is done
Bruising, haematoma, phlebitis, venous thrombosis, air embolus, site infection
How is a post op DVT treated
SC LMWH and warfarin. LMWH is stopped once fully anticoagulated with warfarin. Warfarin continues for 3-6 months and inr maintained at 2-3
What Are the clinical characteristics of acute reosiratory distress syndrome
Impaired oxygenation, diffuse lung opacification on CXR, decreased lung compliance
List some causes of ARDS Periop
Pulmonary or systemic sepsis, massive blood transfusion, gastric contents aspiration
What are the signs and symptoms of ARDS
Tachypnoea, increased ventilators effort, restlessness, confusion
What is the pathophys of ARDS
Unclear, but thought to be due to inflammatory reaction with release of cytokines, damaged vascular endothelium, capillary leakage. Leads to interstitial and alveolar oedema
How are post of pleural effusions managed
Small ones are usually left alone to reabsorb if they don’t interfere with inspiration, but large ones require pleural fluid aspiration
How do you manage ARDS
Cventilatory support - positive end exploratory pressure (PEEP), treat underlying condition
What is a common cause of surgical emphysema
CVP line insertion
What are some of the effects anaesthetic agents have witch contribute to pulmonary collapse
- paralysis of cilia
- impaired diaphragmatic movement
- over sedation
- abdominal distension
- wound pain causing patient to not breathe deeply
How post op lung collapse be prevented
Breathe deeply, cough, mobilise, regular analgesia, chest physio,
O2, salbutamol, assisted ventilation if hypoxia severe
How are patients with post op chest infections due to aspiration managed
Encouraging them to cough, prescribing antibiotics, send sputum for bacteriology,
oxygen if hypoxic, assisted ventilation if resp function deteriorates
What are the three steps of the WHO pain ladder
1- non opioids +/- adjuncts
2- mild opioids +/- non opioids, +/- adjuvant
3- opioid +/- non opioids, +/- adjuvant
List some opioid analgesics
Morphine, pethididne, sia morohine, codeine phosphate, tramadol
List some step 1 WHO ladder analgesics
Aspirin, NSAIDs, paracetamol, selective cox-2 inhibitors
List some step 2 WHO ladder analgesics
Codeine phosphate, tramadol, cocodamol
What are step 3 WHO ladder analgesics
Morphine, fentanyl
What are spathe symptoms of massive PE
Severe chest pain, pallor, shock
What agents do you use for fibrinolysis in a massive PE
Streptokinase or urokinase
What drug should be started for 6 months after a patient suffers a massive PE
Warfarin
If a PE patient cannot be coagulated or sustains further PE despite management, what next step should be considered
Inferior vena caval filter
What is evisceration in wound dehiscence
Extrusion of abdo viscera through abdo wound dehiscence
What is the total body water content
42 L
What is the total ECF and ICF body fluid content
ECF - 14 L
ICF - 28 L
How much ECF is interstitial a pond how much is intravascular
Interstitial - 11-12L(4/5)
Intravascular - 3L (1/5)
What is the total daily fluid input and output into adults
2.6 L input and 2.6 output
How much fluid is lost in the urine, faeces, lungs and skin respectively
Urine -1.5 L
Faeces - 100 ml
Lungs - 400 ml
Skin - 600ml
List crystalloid fluids
Normal saline, dextrose, combinations, hartmanns
Name some colloids
Gelofusin/volplex , starch, albumin, blood products
What are the ion requirements in adults
Adults
Na+ 2mmol/kg/day
K+ 1mmol/kg/day
Hey are the dialup water reuqirements in adults
40ml/kg/day
What is the intracellular and extra cellular potassium requirements
Intracellular - 135 mmol
Extra cellular - 5 mmol
What are the intracellular and extra cellular sodium levels
Intracellular - 9 mmol
Extra cellular - 143 mmol
What are he intracellular and extramedullary cl- levels
Intracellular - 9 mmol
Extra cellular - 193 mmol
What are the intracellular and extra cellular hco3- levels
Intracellular - 9 mmol
Extra cellular - 24 mmol
How would a 5% dextrose fluid solution distribute in the fluid compartments of the body, and how much remains intravascularly
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)
How would 0.9% saline distribute within the body fluid compartments, and what volume would therefore remain intravascularly
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
How would colloids distribute throughout the body fluid component,s therefore how many ml would remain within the intravascular space
Would remain entirely intravascularly therefore 1L would remain intravascularly
What are the daily sodium and potassium fluids requirements in a 70kg male
Na+ = 2x70= 140mmol/day K+ = 1x70= 70mmol/day
Calculate the daily fluid requirements of a 70kg male
40x70= 2800 ml/day
What three things are taken into account when calculating an adults fluid requirements
Maintenance requirements + pre existing deficit + replacement of ongoing losses
Calculate a 22kg child’s daily fluid requirements
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
List some causes of ongoing looses in fluid
Vomiting, diarrhoea, ugh output stoma, enterocutaneous fistula
Which electrolytes Apis diarrhoea rich in
K+ and HCO3-
Which electrocutes is vomit rich in
K+, H+, cl-
Which antibody and which antigen is present I group a blood
Antibody - b
Antigen - a
Which antibody and which antigen is present in group b blood
Antibody - a
Antigen - b
Which antibody and which antigen is presentin group ab blood
Antibody - none
antigen - ab
Universal receiver
Which antibody and which antigen is present in group o blood
Antibody - ab
Antigens - none
universal donor
How much is one unit of blood in pints and most
1 unit = 1 pint
1 pint = ~450 mls
How many units of blood are there the body, therefore how many L
10 units therefore 4.7-5.5 L
What is defined as a massive blood transfusion
Transfusing 10units of blood in 24 hours or >50% of patients blood volume in 4 hours in response to massive uncontrolled haemorrhage
What are the different type of blood components that can be transfused
- red cells
- platelets
- FFP
- cryoprecipitate
- human albumin
- factor IX and VIII
- prothrombin complex concentrate (berriplex)
When is FFP used
Multiple coagulation factor deficiencies
severe bleeding; those who are over coagulated e,g, warfarin sometimes
Which coagulation factors are found in cryoprecipitate
Fibrinogen, factor VIII, XIII, vWf, fibronectin
What su the function of factor XIII
Cross links fibrin
When is cryoprecipitate transfusion used
When fibrin levels are low e.g. DIC
When is human albumin transfused
Conditions with increased vascular permeability e.g. Burns, oedema or ascites resistant to diuretics
When are factor IX and VIII infusions used
Haemophilia treatment
What factors does prothrombin complex contain (beriplex)
II, IX, X, +/- VII (vit K dependent)
When is prothrombin complex concentrate (beriplex) used
Reverse anticoag effect of warfarin when there is major bleeding
What tests are performed on blood used for transfusion before use
Grouping
Antibody screening
Cross matching if urgent
Group and save
Which liver enzyme is increased in patients with pancreatitis
ALT
When are gallstones treated symptomatic ally
If symptomatic
What is the “acute abdomen”?
Conditions of the abdomen requiring hospital admission, investigation and treatment and of less than 1 week duration. Primary symptom is abdo pain.
What are the 2 main pathological processes involved in the acute abdomen
Inflammation
Obstruction
What is the most common cause of generalised peritonitis?
Perforation of an intra-abdominal viscus
What is a hiatus hernia
Abnormal protrusion of the stomach through the diaphragm into the thorax. Can be sliding (more common) or rolling
What are the clinical features of hiatus hernia
Heartburn Oesophagitis Epigastric and lower chest pain Palpitations Hiccups (irritation of pericardium and diaphragm)
How would you manage a hiatus hernia
As per GORD
obstructive symptoms should be considered for surgical repair, ng tube and endoscopy
What are obstructive symptoms for hiatus hernia
Vomiting
Regurg
Breathlessness due to reduced lung capacity
What is achalasia
failure of the lower oesophageal sphincter to relax- the oesophagus dilates and peristalsis becomes uncoordinated. Can be due to degeneration of the myenteric plexus
What are the clinical features of achalasia
Progressive dysphagia (both solids and liquids) Regurg retrosternal pain Weight loss Regurg Aspiration pneumonia
How do you go about managing achalasia
Balloon dilatation of LOS
Surgical myotomy
Laparoscopic Hellers myotomy
How does GORD present
Heartburn Acid regurg Nausea Hypersalivation (waterbrash) Epigastric pain Occasionally vomiting
What anatomical or physiological factors usually prevent acid reflux
Angle at which oesophagus joins stomach
LOS
Diaphragmatic crus
How do you gain a diagnosis of GORD
History
Endoscopy
Ph study
What is the lifestyle treatment for GORD
Weight loss Stop smoking Eat less fatty food Eat less spicy food Drink less caffeine and alcohol
What is the medical treatment of GORD
PPIs
Metoclopramide, to promote gastric emptying and prevent nausea
How is barretts oesophagus diagnosed
Endoscopic biopsy
When is antireflux surgery indicated in a patient with GORD
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
What does surgery for GORD involve
Reducing hiatus hernia if it is present and some form of fundoplication/wrapping fungus of stomach around the oesophagus
How does fundoplication/antireflux surgery work to prevent acid reflux
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
What is diffuse oesophageal spasm
A condition caused by repetitive irregular peristalsis
How is diffuse oesophageal spasm diagnosed
Oesophageal manometry
How is diffuse oesophageal spasm treated
CCB, sublingual GTN, PPIs
What is Plummer Vinson syndrome
A condition where a web forms, which results in dysphagia
What causes is Plummer Vinson syndrome related to
Iron deficiency
Congenital
In a patient with Plummer Vinson syndrome caused by iron deficiency anaemia, what would you expect to see on performing bloods
Hypochromic microcytic anaemia
Low serum ferritin
What investigation can demonstrate a Plummer Vinson syndrome web
Barium swallow demonstrates narrowing in the upper oesophagus
Confirm with endoscopy
How do you manage a Plummer Vinson syndrome web
Dilating web endoscopically
Oral Iron therapy as needed
What are oesophageal pouches
Protrusions of mucosa through weak areas in the oesophageal wall
What is a common area for oesophageal pouches
Through Killians dehiscence
Where is Killians dehiscence in the oesophagus
Between the thyropharyngeus and cricopharyngeus muscle
Lis some of the symptoms of a pharyngeal pouch
Regurg Halitosis Dysphagia Gurgling in throat Aspiration
How would you investigate pharyngeal pouches
With a barium swallow
How are pharyngeal pouches managed
Myotomy of cricopharyngeus and resection of pouch
What are the aetiological factors for peptic ulcers
H pylori
NSAIDs
Smoking
Genetic factors
What is Zollinger Ellison syndrome
Gastrinoma (gastrin secreting tumour), normally found in pancreas, but also in duodenum and stomach
How is Zollinger Ellison syndrome diagnosed
Ct and mri to localise tumour
How is Zollinger Ellison syndrome managed
Remove tumour
What are the clinical features of peptic ulcers
Well localised epigastric pain
Gastric ulcers painful when eating
Duodenal ulcers painful when hungry/at night
What factors may patients with peptic ulcer disease say relieve their pain
Food, milk, antacids and vomiting
How are peptic ulcers diagnosed
Endoscopy and biopsy
How are peptic ulcers managed
Avoid NSAIDs, smoking, excessive alcohol
Triple therapy of PPIs and amoxicillin/metronidazole and clarithromycin
Give some intraluminal causes of oesophageal
Perforation
Foreign body
Rigid endoscopy
Give some external causes of oesophageal perforation
Penetrating injury
What is a Malory Weiss tear
Spontaneous perforation of the oesophagus, usually caused by violent vomiting. Results in haematemesis and pain
What are the clinical features of oesophageal perforation
Pain in neck
Vocal tenderness
Surgical emphysema
Mediastinitis and septic shock may result
What are some of the investigations for oesophageal perforation
Erect CXR
Ct scan
Contrast swallow
How is oesophageal perforation managed
Surgically, with prophylactic antibiotics and antifungals
What are the histological types of oesophageal tumour
Benign leiomyomas
Squamous cell carcinoma
Adenocarcinoma
What are the clinical features of oesophageal cancer
Progressive dysphagia to solids
May have metastatic disease signs
What are the investigations for oesophageal cancer
Initially barium swallow, blood tests
Endoscopy and biopsy
Staging with ct and pet scans and laparoscopy
What is the management of oesophageal cancer
Surgical resection + jejunostomy post op
Radiotherapy and chemo
Palliative - most are non operable
What clinical symptoms may you encounter in a patient with perforated duodenal ulcer into the gastro duodenal artery
Acute onset unremitting epigastric pain
Shoulder tip pain
Vomiting
Symptoms of shock
What investigations would perform in a patient with perforated ulcer
CXR to show free air under diaphragm
Ct contrast barium meal
How do you manage a perforated ulcer
Resusc O2 Fluids Broad spectrum abx Ng tube IV opiates PPIs Urinary catheter Surgery to close ulcer
Iist some causes of an upper GI bleed
Peptic ulcers Gastritis Duodenitis Erosions Malory Weiss tear Reflux oesophagitis Varices Angiodysplasia Carcinoma Aortoduodenal fistula Dieulafoy syndrome Caogulopathies
What does a FBC show in a patient with haematemesis
Normal initially
Anaemia if bleeding is chronic
Urea high
How are gi bleeds investigated
Endoscopy
Angiography
How are gi bleeds treated/managed
Surgically
Injection sclerotherapy
Band ligation
Give an example of a benign gastric neoplasm
Adenomatous polyps
What is the most common type of gastric carcinoma
Adenocarcinoma
What are some less common gastric carcinomas, following Adenocarcinoma
Lymphoma
Carcinoids (neuronendocrine)
Gi stromal tumours
Give some aetiological factors for gastric neoplasia
Diet H pylori Infection Hereditary Gastric polyps Chronic strophic gastritis Intestinal metaplasia Gastric dysplasia
How is gastric neoplasm diagnosed, following history and examination
Upper gi endoscopy Biopsy Ct staging Endoscopic USS Laparoscopy Pet ct
How do you manage gastric cancer with curative intent
Gastric tony and removal of nodes +/- preop chemo
How would you treat a patient with oesophageal cancer with palliative intent
Chemo and radiotherapy
Stenting
Surgical bypass
What are stages t1-t4 of gastric neoplasia
T1- invades lamina propria or submucosa
T2- muscularis propria or subserosa
T3- serosa
T4- adjacent structures
How are gastric neoplasms diagnosed
Endoscopy
Endoscopic ultrasound scan
What investigations could you do in a patient with Plummer Vinson syndrome
Bloods - anaemia, ferritin and iron levels
Barium swallow
Endoscopy
At which Hb conc is transfusion considered
What steps should be taken before transiting blood into a patient
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
List some acute effects of blood transfusion
1) acute haemolytic reaction
2) TRALI
3) febrile non haemolytic transfusion reaction
4) allergic reaction
5) bacterial contamination
6) transfusion related circulatory overload
What are some of the delayed transfusion reactions
1) delayed haemolytic transfusion reaction
2) alloimmunisation
3) post transfusion purpura
4) graft vs host disease
5) transfusion transmitted reaction
6) iron overload
Why may acute haemolytic transfusion reaction occur
ABO incompatible, intravascular haemolysis
What are the signs and symptoms of acute haemolytic transfusion reaction
Chills, fevers, rigors
Hypotension, shock, DIC
ARF
Why does TRALI occur
Antibodies in donor blood reacts with recipients leucocytes
What are the signs and symptoms of TRALI
Dyspnoea, cough, fever, hypoxia, pulmonary infiltrates
Why does febrile M&m haemolytic transfusion occur
Antibodies in patients blood react with blood donors leucocytes
What are the signs and symptoms of allergic reactions to transfusion
Urticaria, itch, severe anaphylaxis
Why does transfusion related circulatory overload occur
Too much blood affects LV function - failure
What are the signs and symptoms of fleshed haemolytic transfusion reactions
Jaundice, fever, haemoglobinuria
How do patients with post transfusion haemolysis present
Thrombocytopenia and bleeding
How do patients with graft vs host disease after transfusion present
Fever, rash, abnormal LFTs, pancytopenia
Which organs can iron accumulate in with iron overload
Liver, heart, pancreas
What are the different types of autologous transfusion
- pre op donation
- isovolaemic haemodilution
- cell salvage
How does preop donation work in autologous transfusion
Collected from patient prior to surgery and stored for up to 35 days preop. Not very effective, reserved for those with rare blood groups
How does isovolaemic haemodilution work
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
What is cell salvage
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.
When is cell salvage not used
Malignancy or sepsis
Give some reasons for direct arterial pressure monitoring
- failure of indirect monitoring
- arterial blood sampling
- continuous reactive monitoring
List some complications of direct arterial monitoring
Distal ischaemia
Why is a central venous catheter used
For monitoring CVP, prolonged drug administration, parenteral administration
How can you reduce the risk of damaging collateral structures when inserting a CVP line
Ultrasound scan
What are common insertion sites for Central Venous Catheters
SVC, subclavian vein, internal jugular, occasionally peripheral vein in antecubital fossa (PICC)
the pressure in which chamber of the heart does a central venous catheter give an indication for
RA
What are some of the complication of inserting a central venous catheter
Arterial puncture, haematoma, haemothorax, nerve injury, air embolism, sepsis, PE, cardiac tamponade
List the different types of airway ventilation used in surgery and anaesthesia
- jaw thrust, chin lift
- bag and mask ventilation
- LMA
- endotracheal intubation
- surgical airway
- oropharnygeal (Guedel)
- nasopharyngeal
Wh in membrane is a surgical airway created through
Cricothyroid membrane
What are. The two types of surgical airway
- needle cricothyroidectomy (plastic cannula)
- surgical cricothyroidectomy (inserting tracheostomy tube)
Why would you choose an nasopharyngeal airway over an oropharnygeal airway
Nasopharyngeal used when patient ja co so out and oropharnygeal airway would induce a gag reflex
When is an oropharnygeal airway used in cardiac emergency
Airway adjunct in mi
Where is the mid inguinal point
Half way between the public symphysis and ASIS
Where is the mid point of the inguinal ligament
Half way between the pubic tubercle and ASIS
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Where does the deep inguinal ring lie anatomically
Mid point of inguinal ligament
What anatomical structures are found at the mid inguinal point
Femoral artery
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
What is the difference in location of the inguinal and femoral hernias in relation to the pubic tubercle
Femoral - below and lateral to the pubic tubercle
Inguinal - above and medial to the public tubercle
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
What are the borders of the femoral triangle
- inguinal ligament superiorly
- sartorius muscle laterally
- adductor longus medially
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
List conditions in he right hypochondrium
- acute cholecystitis
- duodenal ulcer
- hepatitis
- hepatomegaly
- pyelonephritis
List the conditions presenting in the epigastric.
- peptic ulcers
- GORD
- gastritis
- epigastric hernia
- MI
- pancreatitis
- AAA
List the conditions presenting in the left hypochondrium
- splenomegaly
- splenic rupture
- pancreatitis
- peptic ulcer
- AAA
- perforated colon
- pneumonia (L)
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
List some of the conditions in the right flank
- renal calculi
- UTI
- lumbar hernia
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
List some of the conditions presenting in the peri umbilical region
- initial appendicitis
- gastritis
- small bowel obstruction
- umbilical hernia
- IBD
- AAA
List some of the conditions presenting in the left flank
- renal calculi
- UTI
- IBD
- diverticular disease
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
List some of the conditions presenting in the right iliac fossa
- appendicitis
- inguinal hernia
- pelvic pain
- salpingitis
- ruptured ectopic pregnancy
- renal calculi
- Crohns
- mesenteric adenitis
- ovarian abscess
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
Which infections does splenectomy predispose patients to
Infections from encapsulated bacteria e.g. Strep. pneumoniae, H. Influenzae
What is mesenteric adenitis
Inflammation of mesenteric lymph nodes
List some of the conduit a presenting in the supra public region
- UTI
- cystitis
- IBD
List some of the conditions in the left iliac fossa
- rectal mass
- diverticulitis
- obstruction of large bowel
- inguinal hernia
- diverticular disease
- UC
- ovarian abscess
- ruptures ectopic pregnancy
- saying its
- strangulated hernia
- CD