ILOs Flashcards
What are the 9 areas of the abdomen
Common laparotomy incisions (13)
Common laparoscopic incisions (3)
anatomy of the inguinal canal
- which direction does it travel
- it is superior and parallel to ewhich structure
- serves as a pathway between where?
- clinical significance?
- contents of the inguinal canal (4)
- travels inferomedially
- it is superior and parallel to the inguinal ligament
- pathway between abdominal cavity and the external genitalia
- site of potential weakness in the abdo wall, 75% of anterior abdo wall hernias
- spermatic cord (males only), round ligament (females only), iliolinguinal nerve,genital branch of genitofemoral nerve
inguinal hernias can be split into (2)
how do you differentiate between them?
- Indirect – where the peritoneal sac (and potentially loops of bowel) enters the inguinal canal through the deep inguinal ring. More common. Congenital weakness.
- direct- where the peritoneal sac enters the inguinal canal though the posterior wall of the inguinal canal (termed Hesselbach’s triangle). They occur more commonly in older patients, often secondary to abdominal wall laxity or a significant increase in intra-abdominal pressure
Both types of inguinal hernia can present as lumps in the scrotum or labia majora.
Differentiation
differentiated at the time of surgery by identifying the inferior epigastric vessels – indirect hernias will be lateral to the vessels whilst direct hernias will be medial to the vessels.
To differentiate between types of inguinal hernias the examiner must reduce the hernia and then place pressure over the deep inguinal ring (located mid point of the ligament) before asking the patient to cough.
If the hernia protrudes despite occlusion of the deep inguinal ring, this indicates a direct hernia
Whereas if the hernia doesn’t protrude then this indicates an indirect hernia. This assessment is often unrealiable.
6 locations for hernia
Things that increase the risk of incidence in general anaesthesia (13)
- smoking
- diabetes
- COPD
- CKD
- frailty
- cognitive dysfunction
- obesity
- age
- aneamia
- recent cold
- recent heart attack
- recent stroke
- allergies
what test is done to assess fitness for general anaesthesia?
cardiopulmonary fitness test
cycle on bike
For consent to be valid (3)
what is capacity. what are the 4 factors of it
young people are assumed to have capacity to give consent at what age
- patient must UNDERSTAND what the procedure entails
- consent must be given VOLUNTARILY
- the patient must be COMPETENT- i.e. they have capacity
Capacity- the ability to use and understand information to make a decision, and communicate any decision made.
- UNDERSTAND the decision
- RETAIN information relevent to their decision long enough to give consent
- WEIGH UP relevent info
- COMMUNICATE their decision
capacity at 16+, if younger look on a case by case basis
what are some things you should include when gaining consent for surgery
- The patient’s diagnosis and prognosis
- Options for treatment, including non-operative care and no treatment
- The purpose and expected benefit of the treatment
- The likelihood of success
- The clinicians involved in their treatment
- The risks inherent in the procedure, however small the possibility of their occurrence,side effects and complications. The consequences of non-operative alternatives should also be explained.
- Potential follow up treatment
Complications of surgery and anaesthesia (12)
How would you identify them?
- Shock- qSOFA score.
- Haemorrhage- tachycardia, dizziness, agitation, decreased urine output
- Nausea and vomiting
- Pain- - objectively tachycardia, tachypnoea, hypertension, sweating
- Pyrexia- raised body temp above 37.5*
- Wound infection- fever, clammy, sweaty, discolouration
- DVT- pain, swelling, tenderness, redness
- PE- Rapid or irregular heartbeat, Lightheadedness or dizziness, Excessive sweating, Fever, Leg pain or swelling, or both, usually in the calf caused by a deep vein thrombosis, Clammy or discolored skin (cyanosis)
- Urinary retention-
- Reaction to anaesthesia-
- Delirium- disturbed consciousness and altered cogitive function
- Decreased sodium
Complications of abdo surgery (15)
- haematoma amnd seroma (serouds fluid)
- Surgical site infection
- Fascial dehiscence
- nerve injury
- intra-abdominal bleeding
- herniation
- mechanical bowel obstruction
- sepsis
- peritonitis
- c. diff infection
- pneumonia
- urinary retention
- uti
- DVT
- failure of surgery
possible complications of vascular surgery (4)
- Haemorrhage
- Early thrombosis of a graft or vessel nerve injury
- Graft infection
- Renal failure
staging system for colorectal cancer
what are the 2 systems
explain the different stages of them
Duke’s staging system
Stage (A-D), descrption of containment and 5 year survival rate
- A- confined to bowel wall only (75-90)
- B- Through bowel wall (55-70)
- C- Any with +ve lymph node involvement (30-60)
- D- Any with metastases (5-10)
TNM
based on 3 components:
- Extent (size) of the tumour- How far has the tumour grown into the wall of the colon or rectum? T1-4 stages of invasion of bowel wall
- N- spread to nearby lymph nodes- N0/1/2, no/up to 4/more than 4 lymph nodes involved
- M- spread to distant sites- such as lungs or liver
Additional TNM codes
TX- Main tumour cannot be assessed due to lack of information
T0- No evidence of a primary tumour
NX- regional lymph nodes cannot be assessed due to lack of information
Explain the principles of surgical treatments for colorectal cancer
list 6 procedures for general surgery
Curative treatmements are suitable for technically resectable tumours with no evidence of metastases (or metastases potentially curable by liver or lung resection)
Surgery is the mainstay of curative management for localised bowel cancer. The general plan in most surgical management plans is suitable regional colectomy, to ensure the removal of the primary tumour with adequate margins and lymphatic drainage, followed either by primary anastomosis or formation of a stoma
- Right hemicolectomy or extended right hemicolectomy
- Left hemicolectomy
- Sigmoidcolectomy
- Anterior resection
- Abdominoperineal resection
- Hartmann’s procedure
explanation of these procedures:
Right hemicolectomy or extended right hemicolectomy
-Used for caecal tumours or ascending colon tumours, extended version used on transverse colon tumours. During the procedure the ileocolic, right colic and right branch of the middle colic vessels (branches of SMA) are divided and removed w their mesenteries.
Left hemicolectomy
-Used for descending colon tumours. Left branch of the middle colic vessels (branch of SMA/SMV), the inferior mesenteric vein and the left colic vessels (branches of the IMA/IMV) are divided and removed of their mesenteries
Sigmoidcolectomy
-Sigmoid colon tumours. IMA fully dissected out to ensure adequate margins are obtained
Anterior resection
-Used for low rectal tumours, typically <5cm from the anus
Excision of the distal colon, rectum and anal sphincters resulting in permanent colostomy
Abdominoperineal resection
- Used for low rectal tumours, typically <5cm from the anus. Excision of the distal colon, rectum and anal sphincters, resulting in permanent colostomy
Hartmann’s procedure
-Procedure used in emergency bowel surgery (e.g., bowel obstruction or perforation). Complete resection of the recto-sigmoid colon with the formation of an end colostomy and the closure of the rectal stump.
Explain the principles of adjuvant (1) or neoadjuvant treatment (1) of colorectal cancer
Aims to eradicate micro-metastatic cancer cells
Neoadjuvant therapy- given as a first step to shrink a tumour before the main treatment, which is usually surgery. Examples include Chemotherapy, Radiation therapy, Hormone therapy. It is a type of induction therapy. Also lets the MDT see if they respond to that kind of chemotherapy.
Adjuvant therapy: Additional cancer treatment given after the primary treatment to lower the risk that the cancer will come back. Adjuvant therapy may include chemotherapy, radiation therapy, hormone therapy, targeted therapy, or biological therapy.
What is a stoma
Identify the different types of stomas (3)
A stoma is a surgical joining of a lumen onto the anterior abdominal wall., They are red in colour as they are mucous membranes. They don’t have any sensation so shouldn’t be painful to the touch.
- what is a colostomy?
- where are they usually placed?
- what is the output, what is it like?
- what are the 2 types of colostomy?
- A colostomy is created from a part of the colon
- Usually placed on the left-hand side of the navel (descending colon)
- The output is faeces that are usually firm and formed. Stools in this part of the intestine are solid and will need to be collected using a stoma pouch.
1) End colostomy- If parts of your colon or rectum have been removed the remaining colon is brought to the surface of the abdomen to form a stoma. An end colostomy can be temporary or permanent
2) Loop colostomy- Typically, temporary used in acute situations.
- What is an ileostomy?
- usually where is it?
- stool content?
- 2 main kinds?
- In an ileostomy operation, a part of your small bowel called the ileum is brought to the surface of your abdomen to form the stoma. Typically, when the end part of the small bowel is diseased
- Right hand side of the abdomen
- Stools are generally liquid
1) End ileostomy- Often done when part of your large bowel (colon) is removed (or simply needs to rest) and the end of your small bowel is brought to the surface of the abdomen to form a stoma. An end ileostomy can be temporary or permanent.
2) Loop ileostomy
Urostomy aka ____?
when might a urostomy be done?
how is it carried out?
- AKA ileal conduit or a Bricker bladder
- If a problem occurs within the bladder, the bladder may be removed from the body and a new system for urine to be passed from the body must be made
- Surgeon takes 6-8 inches of the small bowel (ileum) and makes it into a conduit (pipeline) for urine. Remainder of the small bowel is reconnected so your bowel will function as it did before surgery. Ureters then connect into the ileum
10 factors of cancer development
- genome instability
- resisting cell death
- sustaining proliferative signalling
- evading growth suppressors
- enabling replicative immortality
- inducing angiogenesis
- activating invasion and metastasis
- reprogramming energy metabolism
- tumour-promoting inflammation
- evading immune destruction
genome instability and how it helps
- occasionally mutations are advantagous
- allows overgrowth and dominance
- instability leads to further istability so rates of mutation increase
6 steps of apoptosis
- produces nuclear fragmentation
- chromosomal condensation
- shrinking of the cell membrane
- cellular fragmentation
- formation of apoptopic bodies
- phagocytosed by neighbouring cells
resisting cell death
removal of survival factors
P53 supressed (increased expression of anti-apoptotic regulators, down-regulation of pro-apoptotic factors, short circuiting of extrinsic ligand-induced death pathway)
sustained proliferative signalling
- overproduction of growth factors
- faulty receptors- e.g., don’t need signal, perpetually on, amplified receptors, increased response
- CDK’s dysregulated
- cancer cells can produce growth factors for itself (EGDR and HER2 overexpresison)
*
4 stages of the cell cycle
- G1 (gap 1)
- S (DNA synthesis)
- G2 (gap 2)
- M (mitosis./ meiosis)
enabling replicative immortality
- normally telomeres shorten progressivley with successive cycles
- prevents cells from dividing after a certain point
- cancer cells ecpress high lvels of telomerase enzyme
*
inducing angiogenesis
blood vessels derived from tumour-mediated signalling VEGF and PDGF
Activation of invasion and metastasis
cadherin-1 expression decreased
reprogramming energy metabolism
cancer cells upregulate GLUT1 glucose transplrter favouring aerobic gyloclysis
tumour promoting inflammation
vasodilation reults in increased blood flow
increased permeability of vessels
exudation of plasma proteins and fluid into tissues
prognostic factors for breast cancer (9)
- Axillary lymph node status
- Tumor size
- Lymphatic/vascular invasion
- Patient age
- Histologic grade
- Histologic subtypes (eg, tubular, mucinous [colloid], or papillary)
- Response to neoadjuvant therapy
- Estrogen receptor/progesterone receptor (ER/PR) status
- HER2 gene amplification or overexpression
what is the triple assessment for?
what is the route for getting one?
what are the 3 stages briefly?
hospital based assessment clinic that allows for early and rapid detectoion of breast cancer and other breast diseases.
Women (and men) can be referred by a ‘one stop’ clinic by their GP if they have signs or symptoms that meet the breast cancer “2 week wait” referral criteria, or if they have early intervention in the treatment of breast cancer.
- history and examination by breast surgeobn or associate specialist
- imaging
- histology
detailed explanation of triple assessment:
- history and examination
- imaging
- histology
history and examination
- Presenting complaint
- Potential risk factors (red flags: night sweats, cachexia, bloody discharge, change to eating habits)
- Family history
- Medication history
- Social history
imaging
Based around either mammography (X-rays) or ultrasound investigations. Which one is used will be determined by patient factors.
- Mammography- X rays- compression views of the breast across 2 views (oblique and craniocaudal), allowing for the detection of mass lesions or microcalcifications
- Ultrasound imaging- more useful in women <35 years and in men, due to density of the breast tissue in identifying anomalies. This form of imaging is also used to guide core biopsies
- _MRI- n_ot used in the mainstay of triple assessment however can be useful in the assessment of lobular breast cancers (and in assessing response to neoadjuvant therapy); whilst it has high sensitivity, it has a low specificity.
histology
- A biopsy is required of any suspicious mass or lesion presenting to the clinic, most commonly obtained via core biopsy.
- A core biopsy provides full histology (as opposed to fine needle aspiration (FNA) which only provides cytology), allowing differentiation between invasive and in-situ carcinoma.
- The test can generate important information about tumour grading and staging, and has a higher sensitivity and specificity than FNA for detecting breast cancer.
at each stage of the triple assessment the suspicion of malignancy is graded to create an overall risk index
explain the principles of surgical treatment of cancer of the breast
- breast conserving
- mastectomy
- axillary surgery
Breast conserving surgery
- Only suitable for individuals with localised operable disease and no evidence of metastatic disease.
- Wide local excision (WLE) is the most common breast conserving treatment and involves excision of the tumour, typically ensuring a 1cm margin of macroscopically normal tissue is taken as well.
- Suitable for smaller focal cancers but is also dependant on the location and relative size of the breast.
- Better asthetics
Mastectomy
- multifocal disease
- high tumour: breast tissue ratio
- disease recurrence or patient choice
- Removes all of the tissue of the affected breast, along with a significant amounts of superficial skin
- Leaves muscle layer intact
Axillary surgery
- Commonly done alongside WLE and mastectomies in order to assess nodal status and remove any nodal disease
- Sentinel node biopsy- removing first lymph node into which tumour drains. They are identified by injecting blue ink and radioisotope.
- Axillary node clearance- removing all nodes in the axilla, ensuring to not damage any associated important structures in the axilla, which are then sent
Explain the relevance of the assessment of the axilla in the management of breast cancer
- Lymphatic fluid drains into lymph nodes, its contents including biomarkers and inflammatory markers.
- Cancer cells can break off from the main tumour and circulate through the lymphatic system or through blood vessels.
- Some of these cells can grow in the lymph nodes or drain to elsewhere in the body.
- Breast is largely drained by the axillary (armpit) lymph nodes.
- Sentinel lymph node, the first lymph node through which a certain area of tissue drains into. If you can rule out sentinel lymph node involvement then you reduce the need for axillary lymph node dissection.
Explain hormonal treatments for cancer of the breast
Name the commonly used hormones
Many cancer cells get an overly strong, uncontrolled signal to proliferate. This often comes in the form of a mutated gene coding for cell receptors.
- Most common are oestrogen (ER) or progesterone (PR) positive tumours. HER2.
- Hormonal therapy aims to stop the growth of hormone sensitive tumours by blocking the body’s ability to produce hormones or by interfering w the effects that the hormones have of the cancerous cells.
1) Blocking ovarian function:
- Ovaries main source of oestrogen in premenopausal women. Blocking ovarian function = ovarian oblation. This is done surgically or radiologically.
2) Block oestrogen production
- Aromatase inhibitors block aromatase enzyme used to create oestrogen
3) Blocking oestrogen’s effect
- Tamoxifen- selective oestrogen receptor modulator used to treat oestrogen receptor positive breast cancer
- Aromatase inhibitors- e.g., letrozole, anastrozole, exemestane
- Goserelin (Zoladex) e.g., synthetic analogue of luteinizing hormone-releasing hormone, reducing secretion of gonadotropins from the pituitary.
- Leuprorelin (Prostap)peptide-based GnRH receptor superagonist
- Fulvestrant (Faslodex)- estrogen receptor antagonist used to treat HR+ breast cancer that may also be HER2-.
which populations are offered breast screening
Anyone registered with a GP as female every 3 years between 50-71
- Trans man/ woman or a non-binary person you may be invited automatically.
- Those over 71 aren’t automatically invited but can still get screened every 3 years.
- advantages
- disadvantages of breast screening
benefits
- allows you to catch a cancer that is too small to find
- catch cancers early- more succesful treatment and breast preservation
drawbacks
- can’t always tell if a tumour is life-threatening or not, therefore you could undergo traumatic treatment for something that wouldn’t have killed you
- false negative- missing a cancer that is there
- flase positive- undergo unneccessary treatment
- exposure to xrays from mammogram
which patients undergo colorectal screening
60-74 year olds get sent a FIT kit every 2 years
some 56 year olds are starting to be sent them in england
What is peripheral vascular disease?
which vessels are included?
what is it a sign of usually?
2 forms of classifying PVD?
Happens when a blood vessel becomes narrowed and there is subsequent reduced blood flow. Arms and legs (usually arms) don’t receive enough BF to meet demand often causing pain.
Any vessels not supplying heart or brain, usually involves the artery
usually a sign of atherosclerosis
fonataine and rutherford classifications
presentation of late stage PAD
- Muscle pain or cramping triggered by activity or at late stages at rest, eased with rest
- Leg numbness
- Leg weakness
- Lack of peripheral pulse
- Coldness in affected leg
- Sores on toes, feet or legs that won’t heal
- Change in colour to the legs (usually go pale)
- Hair loss or slower growth
- Shiny skin on legs
- Erectile dysfunction in men
Symptoms may be worse at night as patients lie down and lose the aid of gravity in perfusing their legs
often asymptomatic at early stages
causes of peripheral vascular disease
Functional- exaggerated dilation in response to sommething
Organic- change in the structure of the blood vessels
- Most often by atherosclerosis (build up of fatty deposits on your artery walls) so they reduce BF
- Blood vessel inflammation
- Injury to your limbs (compartment syndrome)
- Unusual anatomy of ligaments/ muscles
- Radiation exposure
- smoking
- high blood pressure
- diabetes
- high cholesterol
risk factors for PVD
- Smoking
- Diabetes
- Obesity (a body mass index over 30)
- High blood pressure
- High cholesterol
- Increasing age, especially after age 65 or after 50 if you have risk factors for atherosclerosis
- A family history of peripheral artery disease, heart disease or stroke
- High levels of homocysteine, an amino acid that helps your body make protein and to build and maintain tissue
complications of PVD
- Critical limb ischaemia: condition begins as open sores that won’t heal. Infection or injury progresses and causes tissue death, sometimes requiring amputation of affected limb.
- Stroke and heart attack: atherosclerotic plaque can rupture and form thromboembolism
- tissue death, which can lead to limb amputation
- impotence
- pale skin
- pain at rest and with movement
- severe pain that restricts mobility
- wounds that don’t heal
- life-threatening infections of the bones and blood stream
investigations for PVD
ankle brachial index first
colour duplex
ct/ mri angiography
management of PVD (6)
Conservative management
- Supervised exercise programme- reduce symptoms by inrceasing collateral blood flow
- vasoactive drugs- naftidofural oxylate
- percutaneous transluminal angioplasty- for disease limited to one artery (balloon)
- surgical reconstruction
- amputation
- future therapies
· Explain the principles of surgical management of peripheral vascular disease
1) Angioplasty- blocked or narrowed section of artery is widened by inflating a balloon inside the vessel. Used for disease that is confined to one artery.
2) Artery bypass graft- where blood vessels are taken from another part of your body and used to bypass the blockage in an artery. Most common arteries to use are the internal mammary arteries (IMA)
3) Stent with or without graft
4) amputation- try to preserve knee where possible. protects against gangrenous necrosis and sepsis
· Explain the principles of non-surgical management of peripheral vascular disease
Lifestyle changes:
Lowering cholesterol- less fatty diet
Control high blood pressure
Lose weight
Quit smoking
Exercise regularly- increases collateral blood flow to area
Sometimes prescribe blood thinners
Watchful waiting
3 kinds of aortic aneurysm
- abdominal aortic aneursym- most common, characterized by chest and jaw pain, stabbing abdominal or back pain, fainting, difficulty breathing, and weakness on one side of the body. Often asymptomatic at first
- Arterial aneurysm- develop in the portion of the aorta that passes through the chest. Also like abdominal aortic aneurysms, thoracic aortic aneurysms are largely asymptomatic – so you’re unlikely to know that it’s lurking. However, some symptoms to look out for are back pain, hoarseness, shortness of breath, or tenderness or pain in the chest prior to a thoracic aneurysm’s rupture.
- Cerebral- ages 30-60
aRTERIAL ANEURYSMS (3)
Popliteal aneurysms (70-80%)
Femoral artery
Visceral arteries- splenic, hepatic and renal
criteria for surgical intervention for AAA (3)
what are the 2 main surgical treatments for AAA
criteria for surgical intervention for AAA
- >5.5cm in diameter
- Expanding at > 1cm per year
- Symptomatic AAA in a patient who is otherwise fit
a) open repair- involves a midline laparotomy or long transverse incision, exposing the aorta, and clamping the aorta proximally and the iliac arteries distally, before the segment is then removed and replaced with a prosthetic graft
b) Endovascular repair- introducing a graft via the femoral arteries and fixing the stent across the aneursysm shown below
*·* *Principles of non-operative management of abdominal aortic aneurysms (2)*
monitor —–< 5.5cm monitor w duplex USS as surgery before this point offers no survival advantage
- 0-4.4cm yearly ultrasound
- 5- 5.4cm 3 monthly ultrasound
control risk factors:
- Smoking cessation (reduces rate of expansion and risk of rupture)
- Improve blood pressure control
- Commence statin and aspirin therapy
- Weight loss and increased exercise
medication- antihypertensives (beta blockers and ANG II R blockers) and antiplatelets
What is an acute abdomen?
presentations requiring immediate surgical intervention (3)
less immediate presentations that still require swift surgical action (2)
A sudden onset of severe abdominal pain developing over a short time period. It has a large number of possible causes and so a structured approach is required
presentations requiring immediate surgical intervention:
- Bleeding
- Perforated viscus
- Ischaemic bowel
Less severe
- Colic
- peritonism (perforation of ulcer, diverticulum, appendicitis, colecysticis) signs: prostration unable to bend, shock, +ve cough test, no bowel souds
- Obstruction
explain possible causes, risks and presentations of
- Bleeding
- Perforted viscus
- Ischaemic bowel
- Colic pain
- Peritonism
Bleeding
- most serious is a ruptured AAA but also consider ruptured ectopic pregnancy, bleeding gastric ulcer, and trauma.
- Hypovolaemia- Clinical features: tachycardia,pale and clammy on inspection, cool to touch
Perforated viscus (organ)
- peritonitis is caused by inflammation of the peritoneum, generalised peritonitis is most commonly caused by perforated abdominal viscus.
- Causes- peptic ulceration, bowel obstruction small and large, diverticular disease, IBD
- Clinical features: lie completely still to avoid pain, DDX renal colic would be writhing in pain. Tachycardia, rigid abdomen with percussion tenderness, involuntary guarding, reduced or absent bowel sounds
Ischaemic bowel
- Any patient who has severe pain out of proportion to the clinical signs has ischaemic bowel until proven otherwise. They are often acidaemic with a raised lactate and physiologically compromised.
- Patients will often complain of a diffuse and constant pain, however the examination can often otherwise be unremarkable. Definitive diagnosis is via a CT scan with IV contrast, with early surgical involvement.
Colic pain
- A pain that crescendos to become very severe and then disappears. Happens as a tube contracts onto something blocking it. The forms are biliary colic (gall stones), ureteric colic (kidney stones) or bowel obstruction
Peritonism
- Localised inflammation of the peritoneum. Usually starts with viscus inflam– visceral peritoneum and then parietal peritoneum. This pain migrates and becomes more well localised e.g. appendicitis.
differential diagnoses per abdoinal quadrant for acute abdomen
Investigations for an acute abdomen
- Labs (4)
- imaging (2)
- ECG (1)
labs for acute abdomen
- Urine dipstick- signs of infection and haematuria, preg test for wpmen of age
- ABG- septic or bleeding patients
- Routine bloods- FBCs, U&Es, LFTs,CRP and amylase, ,,, group and save for those who might need surgery
- Blood cultures
Imaging
- Erect chest plain film radiography (eCXR)- for evidence of free abdominal air
- Ultrasound- kidneys, ureters and bladder (KUB), biliary tree and liver, transvaginal
- CT imaging
ECG
- rule out heart referred pain
Explain the early non operative management of a patient presenting with an acute abdomen
(9) +2
- Intravenous access
- Nil by mouth status set
- Analgesia +/- anti-emetics
- Initial imaging
- VTE prophylaxis
- Urine dip
- Bloods
- Start IV fluids
- Monitor Fluid balance
Consider
- urinary catheter
- nasogastric tube
Classical presentatin of acute appendicitis
symptoms (6)
signs (4)
Specific signs on examination (2)
Acute appendicitis most common surgical abdominal emergency
- Abdominal pain- peri-umbilical, dull and poorly localised (visceral peritoneum inflam) and then later well localised once it has migrated to the right iliac fossa (parietal peritoneum involvement)
- Vomiting
- Anorexia
- Nausea
- Diarrhoea
- Constipation
On examination:
- Rebound tenderness
- Percussion pain over mcBurney’s point (point 2)
- Guarding
- Features of sepsis when severe
Specific signs of examination:
Rovsing’s sign; RIF pain on palpation of the LIF
Psoas sign; RIF pain with extension of the right hip, specifically suggest an inflamed appendix abutting psoas major muscle into a retrocaecal position
DDx in general (11)
DDX for males (2)
DDX for females (2)
acute appendicitis
DDX appendicitis general
- Renal: ureteric stones, urinary tract infection, pyelonephriti
- Gastrointestinal: inflammatory bowel disease, Meckel’s diverticulum, or diverticular disease
- Paediatrics- acute mesenteric adenitis, gastroenteritis, constipation, intussusception, or urinary tract infection.
DDX appendicitis males
- testicular torsion
- epididymo-orchitis
DDX appendicitis females
- ovarian cyst rupture
- ectopic pregnancy
Acute abdomen posssible causes pneumonic
- B
- A
- D
- G
- U
- T
- Bowel obstruction
- Appendicitis/ adenitis
- Diverticulitis (mesenteric), diabetic ketoacidosis
- Gastroenteritis/ gall stones
- Urinary tract obstruction (stones)/ infection
- T?
DDx for RIF pain
Gastrointestinal (9)
Reproductive female (5)
Reproductive male (2)
Urinary (2)
Nearby areas (5)
DDx for RIF pain
Gastrointestinal
- appendicitis
- Crohn’s disease
- inflamed Meckel diverticulum
- cholecystitis with low gall bladder
- mesenteric adenitis
- epiploic appendagitis
- colon cancer
- constipation
- irritable bowel syndrome
Reproductive female
- ectopic pregnancy
- acute ovarian event (cyst rupture, hemorrhage, torsion)
- Mittelschmerz (ovulation pain mid-cycle)
- Pelvic inflammatory disease
- Endometriosis
Reproductive male
- seminal vesiculitis
- undescended testicle pathology
Urinary
- renal colic
- UTI
Nearby areas
- abdominal: RUQ, central, groin pain
- hip pathology
- psoas abscess
- rectus sheath haematoma
- right lower lobe pneumonia
Investigations for acute appendicitis
lab tests (2)
Imaging (2)
Lab tests for appendicitis
- Urinalysis- exclude renal or urological cause. Pregnancy test in women
- Routine bloods- FBC and CRP to check for inflame markers, pre-op assessment, serum B-hCG to exclude ectopic pregnancy
Imaging for appendicitis
- Ultrasound- helps exclude gynaecological findings
- CT- helps exclude GI or urological causes
treatment options for appendicitis
Definitive treatment is laparoscopic appendicectomy
Some debate over conservative antibiotic therapy in uncomplicated appendicitis.
Laparoscopic appendectomy
- low morbidity
- in females gives you better visualisation of the uterus and ovaries for assessment
- appendix should be sent to histopathology for evidence of malignancy
- entire abdomen should be inspected for evident pathology e.g., meckel’s diverticulum
Complications of acute appendicitis (4)
- Perforation- this will cause a peritoneal contamination- particularly bad in children with a delayed presentation
- Surgical site infection – rates vary depending on simple or complicated appendicitis
- Appendix mass- where omentum and small bowel adhere to the appendix
- Pelvic abscess- presents as fever with a palpable RIF mass, can be confirmed via CT scan for confirmation, management is usually w antibiotics and percutaneous drainage.
- What is acute pancreatitis
- how can it be distinguished from chronic pancreatitis
- investigations for acute pancreatitis a) lab tests (3),,, b) imaging (3)
inflammation of the pancreas
can be distinguished from chronic pancreatitis by its limited damage to the secretpry function of the gland, with no gross structural damage developing
investigations
lab tests
- serum amylase- if 3x above normal limit
- LFTs
- serum lipase
imaging
- abdominal ultrasound
- AXR can show sentinal loop sign
- contrast enhanced CT scan
Causes of pancreatitis
G
E
T
S
M
A
S
H
E
D
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune disease
Scorpion venom
Hypercalcaemia
Endoscopic retrograde cholangio-pancreatopraphy
Drugs
general pathophysiology of pancreatitis
- casues trigger a premature and exaggerated activation of the digestive enzymes within the pancreas
- pancreatic inflammatory response
- increase in vascular permeability
- fluid shifting (third spascing)
- enzymes released into the systemic circulation casuing autodigestion of fats (fat necrosis) and blood cessels
what is the cardinal symptom of pancreatitis
presentations of pancreatitis
*abdominal pain-* sudden onset which gradually intensifies until reaching a steady dull and boring ache. Occurs in the epigastrium but may be felt on the flanks depending on which side of the pancreas is affected. May radiate to back
- bruisinng around umbilicus
- nausea
- anorexia
- vomiting
- diarrhoea
- discomfort lessens when leaning forwards
which symptoms are present on examination of pancreatitis
(5)
in order of frequency
fever and tachycardia
abdominal tenderness, mescular guarding, distension
jaundice
dyspnoea
haemodynamic instability rarely
what is the commonly used scoring system for grading the severity of acute pancreatitis
mneumonic for remembering factors
P
A
N
C
R
E
A
S
grading system for acute pancreatitis
- modified Glasgow criteria assesses severity within the first 48 hours of admission
- any patient with +/>3 should be admitted to ICU with severe pancreatitis
PO2 ,8kPa
Age >55 years
Neutrophils (/WCC)> 15 x 109/L
Calcium <2mmol/L
Renal function (urea) > 16mmol/L
Enzymes LDH> 600 U/L or AST>200U/L
Albumin <32g/L
Sugar (blood glucose) >10 mmol/L
initial management of pancreatitis (6)
Mainly symptom control and not curative
- admit to emergency ward
- Resuscitation with intravenous fluids.
- Supplemental oxygen.
- Intravenous analgesia.
- Intravenous antibiotics for treatment of infected pancreatic necrosis and/or associated cholangitis.
- Early nutritional support which may involve initial parenteral feeding if the person is unable to tolerate oral intake.
longer term management of pancreatitis
- Endoscopic retrograde cholangiopancreatography (ERCP) to relieve the obstruction within 72 hours of the onset of pain, for those with gallstones and cholangitis, jaundice, or common bile duct obstruction.
- Percutaneous or endoscopic drainage of pancreatic collections, and potential surgical management of other complications such as debridement of necrotic tissue.
complications of pancreatitis can be split into 2 categories
systemic complication (4)
local complications (2)
systemic complication
- disseminated intravascular coagulation (DIC)
- acute respiratory distress syndrome
- hypocalcaemia
- hyperglycaemia (secondary to destruction of Langerhans and subsequent disturbances to insulin metabolism
local complications
- Pancreatic necrosis- persisting inflame leads to ischaemic infarct of the pancreatic tissue. Confirm via CT.
- Pancreatic pseudocyst- collection of fluid containing pancreatic enzymes, blood and necrotic tissue
What are gallstones
what are the 2 kinds of gallstones
Gallstones are hardened deposits of digestive fluid that can form in your gallbladder. Your gallbladder is a small, pear-shaped organ on the right side of your abdomen, just beneath your liver.
2 types of gallstones:
1) cholesterol gallstones
- most common type
- appears yellow in colour
- mainly undissolved cholesterol
2) pigment gallstones
* dark brown or black stones that form when bile has too much bilirubin
label the biliary system
A- fundus of gall bladder
B- body of gall bladder
C- neck of gall bladder
D- cystic duct
E- hepatic duct
F- common bile duct
conditions caused by gallstones (4)
- Cholecystitis-inflammation of the gallbladder. A gallstone that becomes lodged in the neck of the gallbladder. Causes severe pain and fever.
- Blockage of the common bile duct- blockage of the tubes through which bile flows from your gallbladder or liver to your small intestine. Severe pain, jaundice and bile duct infection can result.
- Gallstone blockage in the pancreatic duct- which can lead to inflammation of the pancreas (pancreatitis). Pancreatitis causes intense, constant abdominal pain and usually requires hospitalization.
- Gallbladder cancer- People with a history of gallstones have an increased risk of gallbladder cancer.
treatment for
- cholecystitis
- common bile duct obstruction
- blockage of the pancreatic duct causing pancreatitis
- gall bladder cancer
Hospital stay for all
1) cholecystitis (inflam of gallbladder)
control symptoms:
- fasting (nil by mouth)
- fluid through a vein
- antibiotics
- analgesia
- surgery- (endoscopic retrograde cholangiopancreatography) ERCP tube to remove stones
2) common bile duct obstruction
- ERCP
- antibiotics
- stent it up if caused by cancer
3) blockage of the pancreatic duct causing pancreatitis
- cholecystectomy with occasional lymph node removal
4) gall bladder cancer
- normal cancer stuff + add a stent in
- What is diverticula
- What is diverticular disease
- What is diverticulitis
- What is diverticulosis
Diverticula-
- The bulges (pockets) that stick out of the side of the large intestine.
- Often associated with ageing.
- The large intestine becomes weaker with age and the pressure of hard stool passing through the large intestine is thought to cause them.
Diverticular disease-
- 1/4 people woth diverticula experience symtpoms, this is having diverticular disease
Diverticulitis-
- Symptomatic inflammation of the diverticula
- Major risk is the western diet (low fibre)
Diverticulosis
- Asymptomatic inflammation of the diverticula
presentation of patients with diverticular disease (3)
presentation of diverticulitis (3)
- intermittent left lower abdominal pain that is usally colicky and may be relieved by defaecation
- constipation
- rectal bleeding some
many asymptomatic, no systemic features
presentation of diverticulitis
- acute abdo pain (sharp and localised in LIF, worsened by movement)
- localised tenderness on examination
- systemic upset (appeitie, fever, nausea)
Complications of diverticular disease
recurrence of diverticulitis high 10-35%- elective segmental resection
- Abscess formation managed with bowel rest, broad spec antibiotics, with or without CT guided drainage. Surgical management if medical fails.
- stricture (narrowing of lumen)- most common, repeated episodes of inflam leave a fibrotic lump that narrows the lumen
- fistula formation (abnormla connection of passsageway)- surgical intervention required always
- Perforation
management of diverticulosis
non-surgical management of diverticular disease (3)
surgical management (1)
diverticulosis- no treatment needed
diverticulitis- conservative management for majority of patients, symptoms clear within 3 days
- broad spec antibiotics
- IV fluid
- analgesia
- Increase dietary intake of fibre
required for those with perforation, faecal peritonitis or overwhelming sepsis
- Hartmann’s procedure (major)- this is a sigmoid colectomy with formation of an end colostomy, an anastamosis with reversal colostomy may be available later
Other interventions include resection with primary anastomosis and loop ileostomy or laparoscopic peritoneal lavage, however neither option have shown superior outcomes
What type does bowel obstruction most often refer to?
Why is urgent rehydration and fluid balance needed?
what is a closed loop osbtruction?
other types of bowel obstruction
1) mechanical bowel obstruction- structural pathology blocks lumen and passage of intestinal contents
- 15% of acute abdomen= obstruction
- Once bowel segment has been occluded, gross dilation of the proximal limb of bowel occurs resulting in increased peristalsis. Leads to large secretion of large volumes of electrolyte rich fluid into the bowel (often referred to as “third spacing”)
- Closed loop obstruction- when there is another obstruction distally
Causes of mechanical
- Twisted
- Inflamed
- Intussipation
- Scar tissue or hernia
- Tumour or other growth
- Famaged blood vessels
2) Functional obstruction
No physical blockage but bowel can’t move food through lumen i.e. denervation
Futher categorisation of obstructions:
- partial- liquid and gas can pass
- complete- nothing can pass
Bowel obstruction
cardinal features
how to determine of its small or large bowel
is there ileus or mechanical obstruction
vomiting, nausea + anorexia, colic pain, constipation, abdo distension, tinkling bowel sounds
small bowel- vomiting happens sooner, distension less, pain higher in abdomen
large bowel- pain is more constant
in ileus there is essentially paralysis so there will be no or minimal bowel sounds
most common cause of obstruction in
- small intestine (4)
- large intestine
Small intestine obstruction causes;
- adhesions
- herniae
- Intuscuception (children)
- volvulus
Large intestinal obstruction causes;
- malignancy
- diverticular disease
- volvulus
definitive early non-surgical management of small bowel obstruction
(4)
- nil by mouth
- drip and suck- nasogastric tube to (suck) contents, start IV fluids and correct electrolyte distrubances (drip- fluid rescus)
- urinary catheter and fluid balance
- analgesia PRN + anti-emetics
CT
Surgical intervention for bowel obstruction is indicated in patients with:
- Suspicion of intestinal ischaemia or closed loop bowel obstruction
- A cause that requires surgical correction (such as a strangulated hernia or obstructing tumour)
- If patients fail to improve with conservative measures (typically after ≥48 hours)
Surgical options for small bowel obstruction (2)
surgical options for large bowel obstruction
(3)
Specifics alter the surgery but generally a lap
- Laparotomy
- If resection of bowel is required, the re-joining of obstructed bowel is often not possible and a stoma may be necessary.
large bowel obstruction
- fix hernia
- stent
- resection and colostomy
what is peritonitis
types
causes (8)
inflammation of the peritoneum
types
- primary spontaneous peritonitis, an infection that develops in the peritoneum
- secondary peritonitis, which develops when an injury or infection in the abdominal cavity allows infectious organisms into the peritoneum
causes
- a burst stomach ulcer
- a burst appendix
- digestive problems, such as Crohn’s disease or diverticulitis
- pancreatitis
- surgery
- injury to the stomach
- pelvic inflammatory disease
- cirrhosis
Clinical presentations of peritonitis
The first symptoms of peritonitis are:
- typically poor appetite
- nausea
- dull abdominal ache that quickly turns into persistent severe abdominal pain, which is worsened by any movement.
Other signs and symptoms related to peritonitis may include:
- Abdominal tenderness
- Abdo distention
- Chills
Initial management of peritonitis (4)
- Antibiotics
- stop peritoneal dialysis
- supportive care: IV analgesia, oxygen, blood transfusion
- nasogastric feeding?
investigations for peritonitis (4)
- Firstly, physical abdo examination and review of medical history to reveal underlying conditions or medical procedures that may have caused peritonitis.
- Blood test for WBC and and blood film for presence of bacteria
- Peritoneal fluid analysis can also be performed to determine if there is infection or inflammation
- X-rays or CT scans, can show perforation or other trauma in the gastrointestinal tract.
management of peritonitis
- IV antibiotics
- Surgery
- Used to remove infected tissue
- treat underlying cause of infection and prevent infection spread
- especially if peritonitis is due to a ruptured appendix, stomach or colon
ABCDE approach
Airway
Can the patient talk?
If yes then their airway is patent and you can move onto B.
No:
- Look for signs of airway compromise:
- Cyanosis
- See saw breathing
- Use of accessory muscles
- Diminished breath sounds + added sounds
- Open the mouth and inspect look for obstructions:
- Inhaled foreign body SOB and stridor
- Blood in the airway from epistaxis, haematemesis or trauma
- Vomit/ secretions in the airway
- Soft tissue swelling anaphylaxis and infection
- Local mass effect lymphoma
- Laryngospasm asthma, GORD and intubation
Interventions
- Seek immediate expert support
- Head tilt chin lift manoeuvre
- Jaw thrust
- Insert oropharyngeal airway
- Nasopharyngeal airway
- CPR
ABCDE approach Breathing
observation
investigations
interventions
Observations
RR between 12-20?
Bradypnoea sedation, opioid toxicity, COPD exhaustion?
Review SP02 94-98 in healthy 88-92 in COPD
HYpoaxaemia seen in PE, spiration, COPD, asthma and pulmonary oedema
Quick end of bed exam
Investigations
ABG
CXR
Interventions
Oxygen
CPR
Oxygen and nebulisers in asthma
ABCDE approach
Circulation which vitals do you look at?
why may either be high or low
HR
Tachycardia >99 hypovolaemia, arrhythmia, infection, hypoglycaemia, thyrotoxicosis, anxiety, pain, drugs like salbutamol
Bradycardia <60 acute coronary syndrome, ischaemic heart disease, electrolyte abnormalities like hypokalaemia, drugs (B-blockers)
BP
90/60 140/90 is normal
Hypertension hypervolaemia, stroke, Conns syndrome, cushing’s syndrome, pre- eclampsia
Hypotension hypovolaemia, sepsis, adrenal crisis, drugs like hypotensive, diuretics and opiates
Fluid balance assessment
General inspection
Palpation temperature of hands, cap refill, pulses and BP, JVP, auscultation, ankles and sacrum
D of ABCDE
Consciousness AVPU
Pupils size, symmetry, light reflex
Drug chart review
Investigations and procedures
Blood glucose and ketones
Imaging e.g., CT head
E of ABCDE approach
Rashes
Review any IV lines
Assess calves for DVT
Review surgical wounds
Review output of drains and catheters
Assess temperature
Predispsing factors for bowel cancer (7)
- Neoplastic polyps
- IBD
- Altered bowel habit or obstruction
- Diet (low fibre, high in red and processed meat)
- Alcohol
- Smoking
- Previous cancer
presentation of right sided colorectal cancer
Bleeding/ mucous
Altered bowel habit
Tenesmus
Mass PR
presentation of right sided colorectal cancer
decreased weight
decreased Hb
abdo pain
obstruction less lilkey
signs of colorectal cancer (either side)
abdo mass
perforation
haemorrhage
fistula
decreased weight
tests for colorectal cancer
FBC–> microcytic anaemia
FOB
sigmoioscopy/ endoscopy
CEA blood marker
