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Scott's Notes > GI Surgery (upper, HPB, lower, perianal) > Flashcards

GI Surgery (upper, HPB, lower, perianal) Flashcards

1
Q

What are the causes of dysphagia?

A

Inflammatory
Pharyngitis, tonsillitis, oesophagitis

Motility disorders
Local: Achalasia, Diffuse spasm, Bulbar palsy
Systemic: CREST, MG

Mechanical
Luminal: FB
Mural: Benign stricture, web, malignancy, pouch
Extramural: Retrosternal goitre, rolling hiatus hernia, lung Ca, LNs

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2
Q

What is the area of weakness which gives to form a pharyngeal pouch?

A

Killian’s dehiscence

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3
Q

What is the surgical management of achalasia?

A

Heller’s cardiomyotomy

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4
Q

When would you see a corkscrew oesophagus?

A

Diffuse oesophageal spasm

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5
Q

What are the features of Plummer Vinson syndrome?

A

IDA
Webbing
Glossitis/cheilosis

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6
Q

What are the two types of oesophageal cancer and where do they affect?

A

Adenocarcinoma - 65%
Lower 3rd
Derived from GORD and Barretts

SCC - 35%
Upper and middle 3rd
Assoc with EtOH and smoking

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7
Q

What are the different surgical approaches to oesophagectomy and what incisions are used for each?

A

Ivor-Lewis - Vertical abdo incision with right sided thoracotomy

McKeown - Vertical abdo ioncision with right sided thoracotomy and a left neck incision

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8
Q

What extra GI symptoms might GORD cause?

A

Nocturnal asthma
Chronic cough
Sinusitis/laryngitis

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9
Q

What features would make you do an OGD in a patient?

A

55ALARMS

>55
Anaemia
Loss of weight
Anorexia
Recent onset progression
Melaena
Swallowing difficulty
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10
Q

What is the surgical management of GORD?

A

NIssen Fundoplication

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11
Q

What are the complications of a Nissen Fundoplication?

A

Dysphagia

Inability to belch or vomit

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12
Q

Which type of hiatus hernia should be operated on even if symptomatic and why?

A

Rolling - as it may strangulate

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13
Q

What are the complications following antrectomy/vagotomy for PUD?

A 
Physical
Gastric cancer risk
Reflux
Abdo fullness
Stricture
Stump leakage

Metabolic
Dumping syndrome - Distension, flushing, N/V, fainting
Blind loop syndrome - malabsorption and diarrhoea
Vitamin deficiency due to parietal cell loss
Weight loss

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14
Q

What is the Rockall score used for and what are its constituent parts?

A

Used to assess risk of rebleeding in upper GI bleeds

Age (old is worse)
Shock
Comorbidities
Diagnosis
Signs of recent haemorrhage
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15
Q

What are some causes of portal hypertension?

A

Pre-hepatic - Portal vein thrombosis
Hepatic - cirrhosis, schisto, sarcoid
Post hepatic - Budd Chiari, RHF, constrictive pericarditis

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16
Q

What is the process and aim of the TIPSS procedure?

A

Transjucular intrahepatic portosystemic shunt

Shunt formation between hepatic and portal veins to reduce portal pressure

Used prophylactically or acutely if endoscopic therapy fails to control a variceal bleed

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17
Q

What sign would you see on AXR in a ruptured peptic ulcer?

A

Rigler’s sign - pneumoperitoneum

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18
Q

What would be seen on the ABG of a gastric outlet obstruction?

A

Hypochloraemic hypokalaemic metabolic alkalosis

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19
Q

What type of cancer does H.ylori predispose to?

A

MALToma

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20
Q

What do Zollinger Ellison tumours secrete, and what neurocutaneous syndrome are they associated with?

A

Gastrin

MEN1

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21
Q

What is the surgical management of ZE syndrome?

A

Tumour resection OR

Roux en Y gastric bypass

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22
Q

What criteria must be met for bariatric surgery to be considered?

A

BMI>=40 with significant scope for improvement with weight loss
Failure of non surgical techniques
Fit for surgery
Integrated post op programme

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23
Q

What are the complications of gallstones?

A

In the gallbladder - colic, a/c cholecystitis, mucocele

In the CBD - obstructive jaundice, pancreatitis, cholangitis

In the gut - gallstone ileus

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24
Q

What is the pathogenesis of biliary colic?

A

Gallbladder spasm against a stone impacted in the neck of the gallbladder or CBD

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25
What is the presentation of biliary colic?
RUQ pain radiating to the back Sweating, N/V Precipitated by fatty food Jaundice only if stone is in CBD
26
What investigations and results would you do for biliary colic?
``` Urine - bilirubin, urobiliinogen Bloods - standards AXR - 10% are radioopaque Erect CXR - look for perforation USS - dilated ducts and GB wall oedema If dilated ducts seen then do MRCP ```
27
What is the pathogenesis of acute cholecystitis?
Stone impaction in Hartmann's leading to chemical or bacterial inflammation
28
What is the presentation of acute cholecystitis?
Severe RUQ pain that is continuous (unlike biliary colic) Fever Vomiting
29
WHat are the examination findings in acute cholecystitis?
``` Local peritonism Tachycardia May be jaundiced Murphy's positive Boas sign - hyperaesthesia below right scapula ```
30
What is the non-surgical management of acute cholecystitis?
``` NBM Fluid resuscitation Analgesia Cef and met The majority of cases will settle over 1-2 days ```
31
What are the features of chronic cholecystitis?
``` Flatulence Dyspepsia Upper abdo discomfort Distension Nausea Exacerbated by fatty foods ```
32
What is going on in a gallstone ileus, and what is Rigler's triad?
Large stone erodes through GB to duodenum through an inflammatory fistula, impacting the distal ileum leading to an obstruction Rigler's triad describes: Pneumobilia SBO Gallstone in RLQ
33
What (numerically) causes obstructive janudice?
30% stones 30% pancreatic head Ca 30% other - LNs, PBC, PSC, OCP, cholangiocarcinoma
34
What are the features of ascending cholangitis?
Charcots 3 - fever, RUQ pain, jaundice Reynolds 5 - Charcot3, shock, confusion
35
What are the risk factors for pancreatic cancer?
SINED ``` Smoking Inflammation Nutrition (high fat) EtOH DM ```
36
What is the commonest type of pancreatic carcinoma, and where are they most commonly found?
90% ductal adenocarcinoma, 60% in the head
37
Cause of acute pancreatitis?
GET SMASHED ``` Gallstones EtOh Trauma Steroids Mumps Autoimmune Scorpions Hyperlipidaemia ERCP ~Drugs - thiazides, azathioprine ```
38
When would you see Grey Turner's and Cullen's signs?
Acute pancreatiutis
39
What is the Modified Glasgow Criteria and its component parts?
Assess severity and predict mortality of acute pancreatitis PANCREAS ``` PaO2 Age >55 Neutrophils Ca2+ (low) Renal function Enxymes Albumin Sugar ```
40
What are the complications of acute pancreatitis?
Early - ARDS, shock, renal failure, DIC, hypocalcaemia, hyperglycaemia Late - Panc necrosis/infection/abscess, splenic artery bleed, thrombosis (BUDCHIARI), pancreato-cutaneous fistula
41
When and how might a pancreactic pseudocysts present?
4-6 weeks after an attack with persistent abdo pain and early satiety
42
Which causes chronic pancreatitis - alcohol or gallstones?
Alcohol
43
What are the risk factors for cholangiocarcinoma?
PSC (/UC) | Hep B/C
44
WHat is the rpesentation of cholangiocarcinoma?
Progressive painless obstructive jaundice with steatorrhoea and weight loss
45
What is the management of a cholangiocarcinoma?
No curative treatemtn | Palliative ERCP stentinig
46
What is a hydatid cyst?
Calcified liver cyst due to parasitic infection presenting commonly silently or with pressure effects
47
What are the different types of small bowel neoplasms?
Benign - Lipoma, leiomyoma, neurofibroma, haemangioma, adenomatous polyps Malignant - Adenocarcinoma Carcinoid Lymphoma
48
What is the origin cell of carcinoid tumours?
Enterochromaffin cells
49
What are the commonest sites that carcinoid tumours are found at?
Appendic - 45% Ileum - 30% Colorectum - 20%
50
What is the presentation of carcinoid syndrome?
FIVE HT ``` Flushing Intestinal - diarrhoea Valve fibrosis whEEze Hepatic involvement Tryptophan deficiency (Pelagra) ```
51
What would you measure to diagnose carcinoid syndrome>
Urinary 5-Hydrozyindoleacetic acid
52
What is the management of carcinoid syndrome?
Symptoms - Octreotide or loperamide Curative - Resection
53
What is a carcinoid crisis and how should it be managed?
The tumour outgrows its blood supply resulting in massive mediator release - Vasodilation, hypotension, bronchoconstriction, hyperglycaemia Manage with high dose octreotide
54
What is the commonest cause of appendicitis?
Faecolith
55
What are the classical features of appendicitis?
``` Umbilical -> RIF pain Anorexia Nausea Bowel disturbance Pyrexia ```
56
What specific signs might be seen in appendicitis?
Rovsigs - Pressure in LIF increases pain in RIF Psoas - Pain on hip extension Cope - Flexion and internal rotation of the right hip causes pain
57
What are the complications of acute appendicitis?
Appendix mass Appendx abscess Perforation
58
What are the complications of UC?
``` Toxic megacolon Bleeding Malignancy (CRC) Cholangiocarcinoma Strictures-> Obstruction VTE ```
59
What are the complications of Crohns?
Fistulae Obstructive strictures Abscesses Malabsorption (Fat, B12, Vit D, protein)
60
What is the Truelove and Witts classification and what are its component parts?
Assesses severity of UC flare up ``` Daily bowel motions PR bleed Temperature HR Hb ESR ```
61
What is the acute management of severe UC flare?
Resuscitate 100mg IV hydrocortisone LMWH Monitoring
62
What should be done following initial management of an UC flare?
If improvement -> Switch to tapering oral pred and a 5-ASA If no improvement then rescue therapy - Medical - immunosuppressants Surgical options considered
63
When would you use topical therapy for UC and what are the options?
Mainly in left sided disease Use suppositories for proctitis and enemas or foams for more proximal disease
64
What is the medical management for remission maintenance in UC?
1st - 5ASAs PO 2nd - Axathioprine/mercaptopurine (Measure TPMT first) 3rd - Infliximab/Adalimumab
65
What proportion of UC and Crohns' patients will require surgery at some point>
20% of UC patients | 50-80% of Crohn's patients
66
What is a total colectomy?
Resection of the large bowel and anastamosis of the ileum to the rectum
67
What is an end ileostomy
When, after removal of the large bowel the ileum is brought to the surface of the abdomen to form a stoma. This may be temporary or permanent
68
What is a proctectomy?
Removal of all or part of the rectum
69
What is a panprotocolectomy?
Removal of the entire large bowel, rectum and anal canal resulting in a permanent ileostomy
70
What is an ileal pouch anal anastomosis?
The restoration of GI continuity after a proctectomy. Also known as a J pouch, the procedure involves pouch formation of the small intestine to recreate the removed rectum
71
What are the emergency surgical options for UC?
Total/subtotal colectomy with end ileostomy followed 3 months later by a complete proctectomy and ileal pouch anal anastomosis Panproctocolectomy with permanent end ileostomy
72
What are the elective surgical options for UC?
Panprotocolectomy with end ileostomy or ileal pouch anal anastomosis Total colectomy with ileorectal anastomosis
73
What are the complications of UC surgery?
Abdo - SBO, anastomotic stricture, pelvic abscess Stoma - retraction, stenosis, prolapse, dermatitis Pouch - pouchitis (met + Cipro_, faecal leakage
74
What is the main difference in acute management of Crohns's flare up vs. UC?
Antibiotics (metronidazole) are advised in Crohns but not in UC
75
What drugs are used for inducing remission in Crohn's?
``` 1st - ileocaecal - budesonide 1st - colitis - sulfasalazine 2nd - tapering pred 3rd - methotrexate 4th - infliximab/adalimumab ```
76
What drugs are used in maintaining remission in Crohns?
1st - Azathioprine or mercaptopurine 2nd - Methotrexate 3rd - Adalimu/Infliximab
77
What surgical procedures are commonly used in Crohns?
Limited resection e.g. ileocaecal Stricturoplasty Temporary loop ileostomy
78
What is a loop ileostomy?
When a loop of small bowel is brought to the surface to form a stoma, but the distal protion of bowel is not resected
79
What are the features of short gut syndrome?
Steatorrhoea ADEK and B12 malabsorption Gallstones Renal stones
80
``` Define the following: Diverticulum Diverticulosis Diverticular disease Diverticulitis ```
Diverticulum - out pouching of a tubular structure Diverticulosis - the presence of diverticula Diverticular disease - symptomatic diverticulosis (Altered bowel habit, nausea, flatulence) Diverticulitis - Inflammation of diverticula
81
What is the conservative management of diverticular disease?
Promote high fibre diet
82
What is the management of acute diverticulitis?
Mild - at homw with bowel rest (fluid only) and Abx Admit if unwell and unable to tolerate fluids/pain Medical - NBM, IV fluids, analgesia, cefnmet Surgical - Hartmann's procedure to resect diseased bowel
83
What are the indications for surgical management of diverticulitis?
Perforation Large haemorrhage Strictural obstrucion
84
What is a Hartmann's procedure?
AKA - proctosigmoidectomy Resection of the rectosigmoid colon with closure of the rectal stump and formation of an end colostomy.
85
What are the complications of acute diverticulitis?
``` Perforation (free air on CXR) Haemorrhage Abscess Fistulae Strictures ```
86
What are the commonest causes of small and large bowel obstructions?
SBO - adhesions | LBO - CRC
87
What are the causes of a mechanical bowel obstruction?
Intraluminal - Impacted faeces, intusussception, gallstones Intramural - benign stricture, neoplasm Extramural - hernia, adhesions, volvulus, extrinsic compression
88
How would you investigate a bowel obstruction?
``` Bloods - FBC - raised WCC UnE - off Amylase - raised if strangulated VBG - lactate if strangulated C+S and clotting for surgery ``` Imaging Erect CXR AXR CT Gastrograffin studies Looks for mechanimcal obstruction Colonoscopy
89
What are the AXR findings in SBO and LBO?
LBO is larger diameter LBO usually peripheral whereas SBO more central Valvulae conniventes in SBO go completely across, whereas haustra in LBO go partially across Gas is seen in LBO not SBO Many loops in SBO vs LBO many short fluid levels in SBO vs few longer ones in LBO
90
What is the medical management of bowel obstruction?
Drip and suck - NGT to decompress the bowel and IV fluids for rehydration. Also catheterise Analgesia ABx Gastrograffin study
91
What is a typical presentation of sigmoid volvulus?
Elderly constipated male presents with massive distension Coffee bean sign
92
What are the causes of a paralytic ileus?
``` Post op Peritonitis Pancreatitis Poisons - Anti-AchM Pseudo obstruction Metabolic Mesenteric ischaemia ```
93
What are colonic adernomata, and what are the different types?
Benign precursors to CRC with dysplastic epithelium Tubular - less malignant potential Tubulovillous Villous - more malignant potential
94
What factors contribute to risk of CRC?
``` Diet - low fibre and high animal I BD Familial - FAP, HNPCC, P-J Smoking Genetics NSAIDs are protective ```
95
What is the commonest type of CRC and where is it most commonly found?
95% adenocarcinoma 35% rectum 25% sigmoid 20% caecum/ascending colon
96
What tumour marker is used in CRC?
CEA
97
What is a high anterior resection?
Essentially just a sigmoidectomy with removal of the upper rectum. Treatment for upper rectal carcinoma
98
WHat is a low anterior resection
Similar to a high anterior resection but more is removed distally
99
What is an AP resection?
Abdominoperitoneal resection is a procedure which removes CRC which crosses the anal verge - more distal than an anterior resection
100
What is the NHS screening programme for CRC?
FOB testing aged 60-75 every 2 years -> colonoscopy if +ve Flexi sig one off for 55-60 year olds
101
WHat is the inheritance pattern of FAP?
AD - APC gene on 5q21
102
What is the incidence of CRC in FAP patients?
Near 100% by age of 40
103
What is the management of FAP?
Prophylactic total colectomy before age of 20
104
What is the inheritance pattern and pathology of HNPCC?
AD Mutated mismatch repair genes
105
What is the 3,2,1 rule for HNPCC diagnosis?
>=3 family members affected over 2 generation with 1 under the age of 50
106
WHat is the inheritance pattern and presenting picture of Peutz-Jehgers?
AD 10-15 year old Mucocutaneous hyperpigmentation GI hamartomatous polyps CRC, pancreas, other Cas
107
What are the causes of acute mesenteric ischaemia?
Arterial - thrombotic or embolic Splanchnic vasoconstriction 2ary to shock Venous thrombosis Trauma, vasculitis
108
What is the classical presentation of acute mesenteric ischaemia?
Triad of: Acute severe abdo pain +_bleeding Rapid hypovolaemic shock No abdo signs Often in AF
109
What is the presentation of chronic small bowel ischaemia?
Gut claudication PR bleeding Malabsorption Weight loss
110
Lower GI bleed differentials?
``` Haemorrhoids Fissures Diverticulitis Cancer IBD Infection Polyps Ischaemic colitis ```
111
What are the different degrees of haemorrhoids?
1st deg - Never prolapse 2nd - prolapse on defecation but spontaneously reduce 3rd - prolapse on defecation but require digital reduction 4th - permanent prolapse
112
What is the management of haemorrhoids?
Conservative - increase fibre and fluid intake ``` Medical - Topical hydrocortisone Topical analgesics Lactulose Fybogel ``` Interventional - banding/cryo Surgical - haemorrhoidectomy

Scott's Notes (21 decks)

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