GI Surgery Stuff Flashcards
1
Q
What is the most common causative organism of ascending cholangitis?
A
E. coli
2
Q
What is the 2nd most common causative organism of ascending cholangitis?
A
Klebsiella
3
Q
What is the causative organism in Lemierre’s syndrome?
A
Fusobacterium necrophorum
4
Q
What is Lemierre’s syndrome?
A
Thrombophlebitis of internal jugular vein following bacterial throat infection, usually in young healthy adults
5
Q
What is the causative organism of diarrhoea in immunodeficient patients?
A
Mycobacterium avium complex
6
Q
What is the history of a patient with CBD stones post-cholecystectomy?
A
Symptoms will disappear post-cholecystectomy for a few weeks then return as they were prior to removal, including jaundice
7
Q
What is the classical symptom of gallstones?
A
RUQ colicky pain, worse after fatty foods
8
Q
Where is the pilonidal sinus?
A
Midline sinus between buttocks, just above coccyx
9
Q
Who gets pilonidal cysts?
A
Hirsute patients
10
Q
What is the definitive treatment of a pilonidal cyst?
A
Bascom or Karydakis procedures
11
Q
What kind of stoma is required if bowel continuity is the end goal?
A
Loop ileostomy
12
Q
Where are loop ileostomies often located?
A
RIF
13
Q
When are loop ileostomies generally used?
A
Cancer resections and UC colectomies
14
Q
When are end ileostomies generally used?
A
Complete colectomies
15
Q
What is the psoas stretch sign?
A
Extend right hip passively with the knee extended while patient is lying on side
16
Q
What does the poses stretch sign test for?
A
Acute retrocaecal appendicitis
17
Q
How do giant cell tumours appear on X-rays?
A
Radiolucent ‘soap bubble’ appearance
18
Q
What is the calcium profile of someone with osteomalacia?
A
Low calcium
Low urinary calcium
19
Q
What are the features of Ewing’s sarcoma?
A
Lytic lesion with ‘onion type’ periosteal reaction on XR
Most have mets on presentation
5-10% 5yr prognosis
20
Q
Who gets Ewing’s sarcoma?
A
10-25 yr old males
21
Q
What is the treatment for a chronic anal fissure?
A
Topical GTN/Diltiazem
2nd line = botox
3rd line = sphincterectomy
22
Q
What is the classical presentation of diverticulitis?
A
LLQ colicky pain and fever
Raised WCC and CRP
23
Q
Describe a Grade I haemorrhoid
A
No prolapse
24
Q
Describe a Grade II haemorrhoid
A
Prolapse when bearing down
25
Describe a Grade III haemorrhoid
Prolapse requiring manual reduction
26
Describe a Grade IV haemorrhoid
Unreducible
27
What type of cancer makes up the majority of colorectal cancer?
Adenocarcinoma (90%)
28
Where are colorectal cancers most commonly located?
40% rectal
| 30% sigmoid
29
What is the screening programme for colorectal cancer in the UK?
Faecal occult blood 60-74yrs
| One-off flexible sigmoidoscopy at 55yrs
30
What is dumping syndrome?
Gastric contents empty too quickly
| Common post-gastrectomy
31
What are the issues with dumping syndrome?
1. Hyperosmolar load in jejunum draws water into lumen -> swelling and diarrhoea -> cramps pain
2. Large sugar volume stimulates large insulin release -> hypoglycaemic symptoms (eg. dizziness)
32
Which gastrectomy technique gives the best functional outcomes?
Roux en Y reconstruction
33
Describe a Roux en Y reconstruction
Attach the jejunum to small stomach push, therefore bypassing the majority of the stomach and duodenum
The duodenum is attached to allow bile and digestive enzymes etc to drain into jejunum
34
Describe Hartmann's procedure
Removal of rectosigmoid colon with colostomy formation and closure of rectal stump
Non-functioning rectal stump (Hartmann's pouch) is closed and left inside abdomen
35
Is Hartmann's procedure used often?
No
| Rarely used beyond emergencies and terminal patients
36
What is the management of acute cholecystitis? (4)
Analgesia
Fluids
IV Antibiotics
Laparoscopic cholecystectomy within 1 weeks of diagnosis
37
How often is the Faecal Immunochemical Test (FIT) performed?
Every 2yrs 60-74yrs (50-74yrs in Scotland)
38
Is an ileostomy flat or spouted?
Spouted
39
Why is an ileostomy spouted?
Prevents skin coming into contact with alkaline enzyme secretions
40
Is a colostomy flat or spouted?
Flat
41
What is the likely diagnosis for a young female with a history of spondylolysis presenting with sudden severe back pain and bilateral leg weakness?
Spondylolythesis
42
What is the difference between spondylolysis and spondylolythesis?
```
Spondylolysis = separation of pars interarticularis due to stress fracture
Spondylolythesis = spondylolysis with anterior displacement of vertebra
```
43
What are the Dukes' stages?
```
A = mucose
B = wall invasion
C = LNs
D = mets
```
44
What is the Blatchford score used for?
Score the severity of upper GI bleeds and whether to endoscopy
45
What dose a Blatchford score of 0 mean?
Manage as an outpatient
46
What is the Rockall score used for?
Assessing the prognosis of an upper GI bleed at endoscopy
47
What is Charcot's triad?
Fever
Jaundice
RUQ pain
= Ascending cholangitis
48
What is rectal intussusception a symptom of?
Obstructed defecation
49
What investigation is required if rectal intussusception is found?
Defecating proctogram
50
Young man with PAINFUL PR bleeding: what is the diagnosis?
Fissure in ano
51
Where are fissures usually located?
6 and 12 o'clock
| 90% at 6 o'clock
52
Young man with PAINLESS PR bleeding: what is the diagnosis?
Haemorrhoids
53
Where are haemorrhoids usually located?
3, 7 and 11 o'clock
54
What is the surgical management of fulminant UC?
Subtotal colectomy
55
What is the surgical management of medication-resistant UC?
Panproctocolectomy with IPAA
56
What is a requirement for a panproctocolectomy with IPAA?
Symptoms must be well-controlled as this is an elective operation
57
How may a small bowel obstruction appear on AXR?
Valvulae conniventes extend across bowel
58
What is the maximum diameter of small and large bowel?
```
SB = 35mm
LB = 55mm
```
59
What is a large risk factor for anal cancer?
HPV 16 and 18
| Anal intercourse and increased sexual partners increases this risk
60
What percentage of anal cancers are squamous cell carcinomas?
About 80%
61
What percentage of anal SCC are associated with HPV?
80-85%
62
What diagnosis may be indicated by a centrally dilated bowel in a CD patient?
Caecal volvulus
63
What increases the risk of a caecal volvulus?
Adhesions secondary to surgery
64
What diagnosis may be indicated by a dilated bowel in a UC patient?
Toxic megacolon
65
What are the common locations for a volvulus to occur?
80% sigmoid
| 20% caecal
66
Why isn't the caecum at risk of a volvulus in the majority of people?
Caecum is retroperitoneal in 80% of people so can't rotate
67
What are the risk factors for a sigmoid volvulus? (4)
Eldery (Big)
Chronic constipation
Neuro/psych conditions
Chagas disease
68
What is the AXR appearance of a sigmoid volvulus?
Large bowel obstruction with coffee bean sign
69
What is the surgical management of a sigmoid volvulus?
Rigid sigmoidoscopy with rectal tube insertion
70
What are the risk factors for a caecal volvulus? (4)
Occur at all ages
Adhesions
Pregnancy
CD
71
What is the AXR appearance of a caecal volvulus?
Small bowel obstruction - centrally dilated bowel
72
What is the surgical management of a caecal volvulus?
Generally right hemicolectomy
73
What is an abdominoperineal resection?
Removal of anus, rectum and sigmoid colon
74
When is an abdominperineal resection used?
Tumours of distal 1/3 of rectum
75
When is a low anterior resection used?
Tumours in upper 2/3 of rectum
76
When is a high anterior resection used?
Sigmoid tumours
77
What are the advantages and disadvantages of left-sided resections?
More risky
| BUT ileo-colic anastomoses are relatively safe and can often be done, even in emergencies
78
What is Borchardt's triad?
Severe epigastric pain
Retching
Inability to pass NG
= Gastric volvulus
79
What is the most important aspect of haemorrhoid management?
Increased fibre and fluids
| Also stool softeners
80
What score is used to determine the severity of pancreatitis?
Modified Glasgow score
81
What are the components of the Modified Glasgow score?
```
PaO2 <8
Age >55yrs
Neutrophilia, WCC >15
Calcium <2
Renal, urea >16
Enzymes, LDH >600
Albumin <32
Sugar, BM >10
```
82
Is amylase a useful prognostic indicator in pancreatitis?
No
83
What vitamin deficiency may occur post-gastrectomy?
B12
| Due to reduced intrinsic factor (produced in body and fungus)
84
What is a complication of B12 deficiency?
Subacute combined degeneration of the spinal cord
85
What are the features of subacute combined degeneration of the spinal cord?
Bilateral reduced lower limb sensation and wide ataxic gait
86
What are the features of solitary rectal ulcer syndrome?
Altered bowel habit and extensive collagen deposits on flexi-sig. = 'fibromuscular obliteration'
87
Are nocturnal diarrhoea and incontinence features of IBS?
No, they are features of IBD
88
What do you need to do if LFTs show an isolated hyperbilirubinaemia?
FBC - determine whether due to haemolytic or Gilbert's
89
What is ceruloplasmin used for?
Investigating the possibility of Wilson's disease
90
What will LFTs show in Wilson's disease?
Raised ALT and AST
91
What will LFTs show in obstructive jaundice?
Very high ALP
92
What is the management of gastric MALT?
H. pylori eradication - 95% associated with H. pylori
| 80% MALT are low-grade and respond to eradication
93
What does MALT stand for?
Mucosa associated lymphoid tissue
94
What is H. pylori eradication?
PPI
| Amoxicillin/Clarithromycin + Metronidazole 7-14days
95
What is the presentation of cholangiocarcinoma?
Obstructive jaundice and weight loss
96
What other condition increases the risk of cholangiocarcinoma?
Primary sclerosis cholangitis
97
What conditions are pigmented gallstones associated with?
Haemolysis eg. Sickle Cell Disease
98
What investigation is useful if you suspect chronic pancreatitis?
CT pancreas with contrast
| Can identify calcifications
99
What is a pancreatic pseudocyst?
Collection of fluid, typically 4 weeks post-acute pancreatitis
100
Where are pancreatic pseudocysts usually located?
Retrogastric
101
What blood test make indicate a pancreatic pseudocyst?
75% have persistent mildly raised amylase
102
What is the management of pancreatic pseudocysts?
Conservative - 50% resolve within 12 weeks
| After 12 weeks or signs of infection, consider FNA
103
What is the management of a diverticulitis flare?
72hrs oral Abx
| If no improvement, admit for IV ceftriaxone and metronidazole
104
What needs to happen for a 60yr old patient presenting with new iron-deficient anaemia?
Urgent colorectal cancer pathway
105
Does a cystic duct/gallbladder blockage cause jaundice?
No
106
What is a Whipple procedure?
Pancreaticoduodenectomy
| Removes head of pancreas, duodenum, gallbladder and bile duct
107
What is the Whipple procedure primarily used for?
Head of pancreas tumours
108
What are the symptoms of diverticular disease?
Altered bowel habit
PR bleeding
Abdominal pain
Can resemble cancer
109
Where are diverticula usually located?
Sigmoid colon
110
What is a common history for a perianal abscess?
Severe pain and unable to defecate
May be spiking fevers
PMHx of DM or other immunodeficiency
111
Who gets perianal abscesses?
Generally 40yr old men with anorectal abscesses
112
What is the first line management of an unruptured sigmoid volvulus?
Flatus tube insertion on rigid sigmoidoscopy - allows decompression
113
What is the second line management of an unruptured sigmoid volvulus?
Percutaneous colostomy to allow decompression
| Only attempted if flatus tube insertion has failed many times
114
What is one advantage of epidural analgesia in general surgery?
Faster return of normal bowel function
115
Why is a gastrografin enema preferred to barium to check anastomoses?
Less toxic if leaks into the abdominal cavity
116
Other than checking anastomoses, what else can gastrografin be used for?
Oral gastrografin can help in small bowel obstruction secondary to adhesions in conservative management
117
Where are bile salts absorbed?
Terminal ileum
118
Why are CD patients at an increased risk of gallstones?
Terminal ileum is the most common area of inflammation in CD
| Reduced bile salt reabsorption -> increased bile -> increased risk of gallstones
119
What should be done if someone presents with a sigmoid volvulus and signs of peritonitis?
Urgent laparotomy to avoid perforation/necrosis
120
When should a sphincterectomy be considered in the management of fissures in ano?
After 6 week acute management, followed by 8 week trial of topical GTN
121
How does a sphinctectomy aid the management of fissures in ano?
Relieves the spasm of a torn spinster by creating a clean cut to aid healing
122
What are the indications for an OGD? (5)
- Age >55yrs
- Symptoms lasting >4wks despite Tx
- Dysphagia
- Relapsing symptoms
- Weight loss
123
What are the indications for an urgent OGD? (3)
- All dysphagia
- All upper abdominal masses
- >55yrs with weight loss and either abdo pain/reflux/dyspepsia
124
What are the indications for a non-urgent OGD? (4)
- All haematemesis
- >55yrs with Tx-resistant dyspepsia
- Increased platelets and low Hb with abdo pain/ALARM symptoms
- Nausea or vomiting with ALARM symptoms
125
What are the ALARM symptoms?
```
Anaemia
Loss of weight
Anorexia
Recent onset of progressive symptoms
Melaena/Masses
Swallowing difficulty (dysphagia)
```
