GOO, perfed PU, AF and sepsis

Question 1

What are risk factors for perforation?

Answer 1

-NSAIDs
-H.pylori
-Steroids
-Previous peptic ulcer
-Malignancy

Question 2

How can NSAIDs cause peptic ulceration?

Answer 2

-Topical irritant effect on epithelium
-Suppression of prostaglandin synthesis (inhibition of cyclooxygenase) which are essential in proteting mucosa
-Reduction of gastric mucosal blood flow

Question 3

What are the management oprtions for the perfed duodenal ulcer?

Answer 3

-Omental patch repair
-Good wash out
-Intraabdominal drain

Biopsy if gastric ulcer to rule out malignancy

Question 4

What would you give post op to perfed peptic ulcer?

Answer 4

PPI long term

Question 5

What is mechanism of PPI?

Answer 5

-Binds irreversibly to hydrogen/potassium ATPase enzyme (proton pump) on gastric parietal cells and blocks secretion of hydrogen ions
-These combine with chloride in stomach lumen to form HCL

Question 6

What are the actions of HCL?

Answer 6

-Activates pepsinogen to pepsin which help in proteolysis
-Antimicrobial

Question 7

What are the phases of gastric secretion?

Answer 7

1. Cephalic phase (smell/taste of food)
   –> 30% acid produced
   –> vagal cholinergic stimulation causing secretion of HCL and gastrin release from G cells
2. Gastric phase (distension of stomach)
   –> 60% of acid produced
   –> stomach distension/low H+/peptides cause gastrin release
3. Intestinal phase (food in duodenum)
   –> 10% acid produced
   –> high acidity/distension/hypertonic solutions in duodenum inhibits gastric acid secretion via enterogastrones (CCK, secretin) and neural reflexes

Question 8

NCEPOD classification

Answer 8

1: life or limb threatening (immediate, <2 hrs) (ruptured AAA, torsion, compartment syndrome)

Simultaneous resuscitation and management

2a: urgent: 2-6 hrs: Laparotomy for perforated viscus, critical organ or limb ischaemia

once resustcitation completed

2b Urgent 6-18 hours (appendicitis)

3: expedited >18 hours: repair of tendon and nerve injuries, excision of tumour with potential to bleed/obstruct

4 (elective): lap chole

Question 9

Scenario: lady with vomiting and epigastric fullness. Hyponatremia, ph 7.5

Cause of this clinical picture?

Answer 9

Benign: pyloric stenosis secondary to chronic peptic ulceration

Malignant: gastric or pancreatic carcinoma

Question 10

What will ABG show

Answer 10

Metabolic alkalosis

Question 11

What biochemical abnormalities will there be?

Answer 11

-Hypochloraemia due to loss of chloride in vomitus
-Hypokalaemia due to increased aldosterone in response to hypovolaemia

Question 12

Why is bicarb raised?

Answer 12

-Increased uptake of bicarbonates in renal tubule in response to loss of chloride in order to maintain neutrality
-Reduction of pancreatic juice secretion (due to loss of acid load in duodenum)–> retention of bicarbonate rich pancreatic juice

Question 13

Why is there hyponatraemia?

Answer 13

-In metabolic alkalosis, kidneys excrete more NAHCO3 to reduce blood alkalinity –> hyponatraemia

Question 14

Why is there paradoxical aciduria?

Answer 14

Hyponatraemia –> stimulation of angiotensin aldosterone system –> more Na + and H20 reabsorption in exchange for H+ and K + –> hypokalaemia and the urine becomes acidic due to presence of H+

Question 15

What is the clinical picture of hyponatraemia?

Answer 15

–< confusion
-Agitation
-Fits
-Reduced GCS

Question 16

What are the causes of hyponatraemia?

Answer 16

Hypovolaemia
–> diarrhea
–> diurectic
–> burns

Dilutional
–> heart failure
–> over administration of IV fluids

Euvolaemia
–> addison’s
–» hypothyroidism
–> SIADH

Question 17

What shoiuld be commented on in a chest XR?

Answer 17

Pam Found Peteres Rubber In A CHEST

Patient details

Film details (date, orientation). AP: mediastinal structures magnified)

Penetration: vertebral end plates of mid thoracic vertebrae should be visible behind heart

Rotation: medial ends of clavicles should be equidistant from spinous processes

Inflation: count 6-8 anterior ribs in mid-clavicular line

Air: check for air under the diaphragm, pneumothoraces and subcut emphysema

CHEST: examine lungs

Cardiac and vessels (CT ratio should not be >50%)

Hila (TB, sarcoid)

External devises/objects

Skeleton and soft tissue

Trachea

Question 18

Why is pulse oximeter not accurate in AF?

Answer 18

-Af generates insufficient heart contraction resulting in small volume pulse

Question 19

Management of AF

Answer 19

-Treat the cause (sepsis, electrolyte disturbance, dehydration)
-If haemodynamically unstable: DC cardioversion
-Anticoagulate if persistent AF

Question 20

Differential diagnosis of perforated viscus?

Answer 20

-Ruptured diverticulum
-Perforated DU
-Ischaemic bowel
-Perforated tumour

Question 21

Other causes of abdominal pain in this age group?

Answer 21

MI

Question 22

How would patient with gastric outlet obstruction be optimised for theatre?

Answer 22

-IV fluid resuscitation
-NG tube
-Cardiac monitor if low potassium
-Discussion with ITU

Question 23

What pumps are there in the kidneys?