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MBBS Surgery > Misc > Flashcards

Misc Flashcards

1
Q

Post splenectomy vaccination

A

Spleen protects against capsulated bacteria

  1. pneumococcal
  2. gonococcal (neisseria)
  3. Haemophilus
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2
Q

Causes of mesenteric adenitis

A

Pri: post viral/bac - recent GE
- CT findings: >3 RLQ LN >5mm, +- mild term ileum wall thickening <5mm

Sec: underlying inflammatory dz (Crohns, SLE, diverticulitis)

ddx: cancer

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3
Q

Cx of massive blood transfusion

A
  1. Fluid overload and APO
  2. immune
    - TRALI
    - acute febrile haemolytic rxn
    - non haemolytic febrile transfusion risk
    - allergic rxn/ anaphylaxis
  3. infn
    - bacterial
    - viral: hepb/c/ hiv
  4. metabolic
    - hyperK
    - citrate toxicity
    - dilution of clotting factors
    - thrombocytopenia
    - hypocalcemia
  5. hypothermia
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4
Q

Classes of wound infection

A

Clean
Clean contaminated
Contaminated
Dirty

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5
Q

Causes of post op fever

A

DAY 0-2

  • basal atelectasis
  • tissue damage/ necrosis
  • drug fever
  • blood transfusion

DAY 3-7 (5Ws)

  • wind: pneumonia
  • water: drip site, UTI, drain
  • walk: DVT/ PE
  • wound infx
  • wonder drug: drug fever, blood transfusion

> 7 DAYS:

  • wound infection
  • DVT/ PE
  • Drugs: antibiotics, febrile drug run

> 1 MTH:

  • IE
  • sx site infection
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6
Q

Approach to HyperK

A
  1. Check drugs (diuretics)/ drips containing K – consider stopping
  2. 10ml, 10% Ca gluconate, 10min (mb stabilisers) – slow bolus
  3. Actrapid 10u with 40ml of Dex 50%
  4. oral resonium
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7
Q

What is Rigler’s triad

A

Gall stone ileus

  • small bowel obstruction
  • Gallstone outside GB
  • Air within bile duct (aerobilia)
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8
Q

What is the toxic dose of lignocaine

A

3mg/kg

7mg/kg with adrenaline

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9
Q

how much is circulating blood volume in adults?

A

70ml/kg

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10
Q

Abx associated with pseudomembranous colitis

A

C.difficile overgrowth due to recent abx use (ampicillin, clindamycin, fluroquinolones, cephalosporins) - broad spectrum

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11
Q

Parts of the adrenal and what is produces?

A

Adrenal cortex (GFR>MGS/ACS)

  • Zona Glomerulosa: mineralocorticoid - aldosterone
  • Zona Fasciculata - glucocorticoid - cortisol
  • Zona Reticularis - sex hormones

Adrenal medulla: epinephrine and NE

  • alpha: peripheral vasoconstiction
  • beta 1: HR/contractility
  • beta 2: relaxation of smooth muscles
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12
Q

Differentials for adrenal mass

A 
Cortex
- benign: adrenocortical adenoma (Cushing - cortisol, conn - ald)
- malignant
Medulla
- benign: phaeochromocytoma
- malignant: neuroblastoma
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13
Q

Mgx of adrenal mass

A

rule out CA > sx

Immediate adrenalectomy for tumour >4cm OR hyper functioning mass

<3cm: follow up imaging CT

  • no further growth: no further test
  • grow within 1 year - adrenaectomy
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14
Q

Causes of hyperaldosteronism

A

Primary (renin independent)

  • adrenal hyperplasia (70%)
  • adenoma (conn) 25%
  • ca 5%
Secondary (extra renal, renin dependent)
(dec renal perfusion, intravascular vol depletion)
- renal artery stenosis
- chronic heart failure
- cirrhosis
- nephrotic syndrome
- diuretic use
- renin secreting tumour
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15
Q

Investigation for suspected hyperaldosteronism

A

Screening: AM plasma renin and aldosterone lvl

  • low renin, ald: non ald mineralocorticoid excess (e.g. Cushing syndrome)
  • low renin, high ald: primary hyperald
    (if renin undetectable and ald >30: confirm)
  • high renin, high ald: secondary hyperald

Diagnosis:
salt suppression test

Localising for Pri ald:
adrenal CT/MRI
- unilateral lesion: adenoma
- bilateral/no lesions: adrenal vein sampling

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16
Q

Hypercortisolism diagnosis

A

Screening (2/3 positive)
- urinary free cortisol 24h x2 (positive if 3x upper limit)
- low dose 1mg dexamethasone suppression test
(either overnight 11pm dexa and 8am cortisol OR 48hrDST with 24hr UFC)
- 11pm Late night salivary cortisol x2 (not for shift workers)

Localise (ACTH dependent/ independent)
- serum basal ACTH
> low: do ADRENAL ct/mri (adrenal tumour/hyperplasia
> normal/high: high dose DST OR CRH test
--> pit: suppressed 8am serum cortisol, urinary cortisol (do gadolinium enhanced pit MRI)
----> lesion seen: likely Cushing dz
---> neg: BIPSS
--> ectopic: failure of suppression
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17
Q

confirmation for pituitary tumours

A

contrast MRI - macroadenomas

BIPSS (bilateral inferior petrosal sinus sampling: measure ACTH) - micro adenomas

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18
Q

tx of hyperaldosteronism

A

lesion - adrenalectomy (with pre and post op glucocorticoid replacement)
spironolactone
KIV K replacement
eplerenone - for HTN

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19
Q

Etiology of hypercortisolism

A

Cushing syndrome

  • Iatrogenic (exogenous)
  • Pituitary adenoma/ hyperplasia: Cushing disease
  • Adrenal adenoma/ carcinoma
  • Ectopic ACTH: SCLC, medullary thyroid CA, islet cell tumour, carcinoid, phaeo
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20
Q

Manifestations of hypercortisolism

A

DM, HTN, obesity
oligomenorrhea
osteoporosis, fractures

central obesity, peripheral wasting, dorsocervical fat pad, rounded facies

bruising, proximal myopathy, striae, hirsutism

hyperpigmentation (if ACTH high)
immunocomp: fungal skin infection

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21
Q

Tx Cushing dz

A

trans-sphenoidal resection of ACTH producing pituitary tumour

22
Q

Rule of 10 in phaeochromocytoma

A

10%

  • malignant
  • in children
  • bilateral/ multiple
  • recur
  • incidentaloma
  • extra-adrenal (aka paraganglioma)
  • familial (MEN2, VHL, NF1)
23
Q

Clinical features of pheochromocytoma and diagnostic criteria

A 
pressure - HTN
pain - headache, CP
palpitation - tachy, tremor, low, fever
perspiration
pallor
24
Q

Investigations of phaeochromocytoma

- associations)

A

24h urinary fractionated metanephrines and catcholamines

plasma free metanephrine

adrenal CT/MRI, KIV MIBG scintigraphy

KIV genetic testing (VHL, MEN2a/2b, NF1, TS)

25
Q

Tx of phaeochromocytoma crisis

A

alpha blockade first (phenoxybenzamine)
beta blocker

definitive - adrenalectomy

26
Q

Triad of phaeo

A

episodic headache
sweating
tachycardia

(but most common sign is sustained or paroxysmal HTN)

27
Q

screening investigations for adrenal mass

A

24h urinary fractionated metanephrine, catecholamine, vanillymandelic acid (VMA)

24h urine free cortisol, low dose dexa suppression 1mg, late night salivary cortisol

AM plasma renin, aldosterone (look at ratio)

28
Q

what is a

  • kocher scar
  • pfannestiel scar
  • lanz
  • gridiron
A

kocher - R subcostal
Pfannestiel - suprapubic
Lanz - horizontal appendectomy scar
Gridiron - slanted RIF scar

29
Q

origin of bone metastasis

A

bilobed organs

  • breast, lung, kidneys
  • thyroid, prostate
30
Q

Examples of paraneoplastic syndromes

A 
Cushing syndrome 
SIADH
hypercalcaemia of malignancy
carcinoid syndrome
trousseau sign (thrombophlebitis migrant)
dermatomyositis
membranous glomerulonephritis
31
Q

Layers of anterior abdominal wall

A 
skin
subcutaneous tissue
fascia - camper, scarpa
muscle - rectus abdominis, ext oblique, int oblique, transversus abdominal
transversalis fascia
extraperitoneal fat
parietal peritoneum
32
Q

what do you call the separation of rectus abdominis muscle

A

Diastasis recti

33
Q

Positions of appendix

A

most common - retrocecal

others: pelvic, subpecal, paracecal

34
Q

What is

  • Mc Burney’s point
  • Cough sign
  • Rovsing sign
  • Obturator sign
  • Psoas sign
A
  • 1/3 of distance from R ASIS to umbilicus
  • RIF pain on cough (localised peritonitis)
  • rov: RLQ pain with palpation of LLQ
  • Ob: RIF pain with int rotation of a flexed right hip (spasm of obturator internus)
  • Psoas: pain on hyperextension of R hip
35
Q

Organisms for ruptured/ gangrenous appendicitis

A

E coli, peptostreptococcus, bacillus fragilis, pseudomonas

36
Q

Cx of appendectomy

A

local stump: retained fecalith, stump appendicitis, leak, fistula
Haemorrhage: intra-ab, ab wall hematoma, scrotal hematoma
Infx/ sepsis: wound infx, abscess
Paralytic ileus

post op: DVT/PE, atelectasis, pneumonia

subsequent adhesion IO, right inguinal hernia

37
Q

mgx of appendicitis

A

non perf: immediate op within 12 h
if perf
- unstable: immed op
- stable: conservative then interval appendectomy 6-8w later + colonoscopy TRO appendices neoplasms (Ochsner-sherren regimen)

38
Q

Causes of ischemic colitis

A

Arterial

  • thrombotic: chronic atherosclerosis
  • embolic: AF, post MI, LV thrombus, infective endocarditis, valve dz
  • trauma - aortic dissection

Venous
- VTE: virchow triad

Hypoperfusion

  • shock, low EF, IO - compression and strangulation (CRC, hernia), dialysis
  • post CABG, AAA repair
  • vasoconstrictive meds (alpha agonist)
39
Q

Clinical features of mesenteric ischemia

  • triad
  • progression
  • x ray features
A

Triad:
acute severe ab pain
no physical signs
rapid hypovolemia > shock

Progression from
hyperactive (colicky pain, bloody diarrhea) > paralytic (distension, no bowel sound) > shock

Thumbprinting on x ray
portal venous gas

40
Q

causes of portal venous gas

A

alteration in bowel wall: ischemic bowel, CRC, IBD
bowel luminal distension: paralytic ileus
intra ab sepsis: cholecystitis, pancreatitis
others: pneumatosis intestinalis

41
Q

causes of portal venous gas

air in portal vein

A

alteration in bowel wall: ischemic bowel, CRC, IBD
bowel luminal distension: paralytic ileus
intra ab sepsis: cholecystitis, pancreatitis
others: pneumatosis intestinalis

42
Q

Causes of aerobilia

air in biliary tree

A
  • recent biliary instrumentation: ERCP, PTC
  • incompetent sphincter of Oddi: sphincterotomy
  • sx anastomosis between biliary and enteric: Whipple
  • spontaneous biliary-enteric fistula: gallstone ileus
  • infx: cholangitis, liver abscess, emphysematous cholecystitis
43
Q

Mgx of acute intestinal ischemia

A

supportive: analgesia, anticoag, broad spec abx, NBM, drip suck - wait for collaterals to resupply

immed sx if hemo unstable/ with complication (e.g. gangrene/ perforation/ peritoneal signs)

Mesenteric art occ: Surg lap with embolectomy/ local infusion of thrombolytic agent

Mes venous occ: anticoag/ venous thrombolysis

NOMI: removing inciting factors, tx underlying cause, hemodynamic support and monitoring, infusion of vasodilators if necessary

44
Q

Causes of functional IO

A
  1. Paralytic bowel(no bowel sounds)
    - post op (significant if >72h, no bowel sound, no flatus, distension)
    - infx (intra ab sepsis)
    - infarction: ischemic bowel
    - metabolic (uraemia, hypok, hypoNa, hypothyroid, DKA)
    - reflex: trauma, spinal cord injury above T5, #spine/rib, retroperitoneal haemorrhage
    - drugs: opiates
  2. Pseudo-obstruction
    - small intestine
    - acute colonic: toxic megacolon, Ogilvie syndrome
    - chronic colonic: Hirschsprung, paraneoplastic (SCL Ca), infx (chagas dz)
45
Q

Mgx of surgical wound dehiscence

A

suspect wound infection
- take wound swab, send for cultures

heal by secondary intention
apply thin layer of petrolatum with cotton tip to create non adherent gauze over wound

daily dressing change until complete re-epithelization

46
Q

Clean wound definition

A

An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tract is not entered.

47
Q

clean-contaminated wound definition

A

An operative wound in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination.

48
Q

triad of VIPoma

A

WDHA syndrome

  • watery diarrhoea (metabolic acidosis, dehydration)
  • hypokalemia
  • achlorhydria

other non specific symptoms: lethargy, weakness, N&V, crampy abdominal pain

secretion of VIP (vasoactive intestinal peptide)

49
Q

What are the various pancreatic endocrine tumors

A
  • ACTHoma (cushing syndrome)
  • gastrinoma
  • glucagonoma (assoc with rash - necrolytic migratory erythema)
  • GRFoma (acromegaly)
  • Insulinoma
  • Somatostatinoma
  • VIPoma
50
Q

What is Sepsis, Severe Sepsis

A

Previous Definition

  • Sepsis = 2 of SIRS criteria + infection source
  • Severe sepsis = sepsis + organ dysfunction
  • Septic shock = severe sepsis + persistent organ dysfunction, refractory to fluid resus or requiring inotropes

Current Definition

  • Early sepsis: q sofa more than 2 (AMS - GCS <15, Resp Rate >22, SBP<100), or NEWS
  • Sepsis: organ dysfunction (>2 of SOFA score) + infection source
  • Severe sepsis = sepsis + refractory to fluid resus or requiring inotropes

MBBS Surgery (18 decks)

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