Misc Flashcards
Post splenectomy vaccination
Spleen protects against capsulated bacteria
- pneumococcal
- gonococcal (neisseria)
- Haemophilus
Causes of mesenteric adenitis
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
Cx of massive blood transfusion
- Fluid overload and APO
- immune
- TRALI
- acute febrile haemolytic rxn
- non haemolytic febrile transfusion risk
- allergic rxn/ anaphylaxis - infn
- bacterial
- viral: hepb/c/ hiv - metabolic
- hyperK
- citrate toxicity
- dilution of clotting factors
- thrombocytopenia
- hypocalcemia - hypothermia
Classes of wound infection
Clean
Clean contaminated
Contaminated
Dirty
Causes of post op fever
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
Approach to HyperK
- Check drugs (diuretics)/ drips containing K – consider stopping
- 10ml, 10% Ca gluconate, 10min (mb stabilisers) – slow bolus
- Actrapid 10u with 40ml of Dex 50%
- oral resonium
What is Rigler’s triad
Gall stone ileus
- small bowel obstruction
- Gallstone outside GB
- Air within bile duct (aerobilia)
What is the toxic dose of lignocaine
3mg/kg
7mg/kg with adrenaline
how much is circulating blood volume in adults?
70ml/kg
Abx associated with pseudomembranous colitis
C.difficile overgrowth due to recent abx use (ampicillin, clindamycin, fluroquinolones, cephalosporins) - broad spectrum
Parts of the adrenal and what is produces?
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
Differentials for adrenal mass
Cortex - benign: adrenocortical adenoma (Cushing - cortisol, conn - ald) - malignant Medulla - benign: phaeochromocytoma - malignant: neuroblastoma
Mgx of adrenal mass
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
Causes of hyperaldosteronism
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
Investigation for suspected hyperaldosteronism
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
Hypercortisolism diagnosis
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
confirmation for pituitary tumours
contrast MRI - macroadenomas
BIPSS (bilateral inferior petrosal sinus sampling: measure ACTH) - micro adenomas
tx of hyperaldosteronism
lesion - adrenalectomy (with pre and post op glucocorticoid replacement)
spironolactone
KIV K replacement
eplerenone - for HTN
Etiology of hypercortisolism
Cushing syndrome
- Iatrogenic (exogenous)
- Pituitary adenoma/ hyperplasia: Cushing disease
- Adrenal adenoma/ carcinoma
- Ectopic ACTH: SCLC, medullary thyroid CA, islet cell tumour, carcinoid, phaeo
Manifestations of hypercortisolism
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
Tx Cushing dz
trans-sphenoidal resection of ACTH producing pituitary tumour
Rule of 10 in phaeochromocytoma
10%
- malignant
- in children
- bilateral/ multiple
- recur
- incidentaloma
- extra-adrenal (aka paraganglioma)
- familial (MEN2, VHL, NF1)
Clinical features of pheochromocytoma and diagnostic criteria
pressure - HTN pain - headache, CP palpitation - tachy, tremor, low, fever perspiration pallor
Investigations of phaeochromocytoma
- associations)
24h urinary fractionated metanephrines and catcholamines
plasma free metanephrine
adrenal CT/MRI, KIV MIBG scintigraphy
KIV genetic testing (VHL, MEN2a/2b, NF1, TS)
Tx of phaeochromocytoma crisis
alpha blockade first (phenoxybenzamine)
beta blocker
definitive - adrenalectomy
Triad of phaeo
episodic headache
sweating
tachycardia
(but most common sign is sustained or paroxysmal HTN)
screening investigations for adrenal mass
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)
what is a
- kocher scar
- pfannestiel scar
- lanz
- gridiron
kocher - R subcostal
Pfannestiel - suprapubic
Lanz - horizontal appendectomy scar
Gridiron - slanted RIF scar
origin of bone metastasis
bilobed organs
- breast, lung, kidneys
- thyroid, prostate
Examples of paraneoplastic syndromes
Cushing syndrome SIADH hypercalcaemia of malignancy carcinoid syndrome trousseau sign (thrombophlebitis migrant) dermatomyositis membranous glomerulonephritis
Layers of anterior abdominal wall
skin subcutaneous tissue fascia - camper, scarpa muscle - rectus abdominis, ext oblique, int oblique, transversus abdominal transversalis fascia extraperitoneal fat parietal peritoneum
what do you call the separation of rectus abdominis muscle
Diastasis recti
Positions of appendix
most common - retrocecal
others: pelvic, subpecal, paracecal
What is
- Mc Burney’s point
- Cough sign
- Rovsing sign
- Obturator sign
- Psoas sign
- 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
Organisms for ruptured/ gangrenous appendicitis
E coli, peptostreptococcus, bacillus fragilis, pseudomonas
Cx of appendectomy
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
mgx of appendicitis
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)
Causes of ischemic colitis
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)
Clinical features of mesenteric ischemia
- triad
- progression
- x ray features
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
causes of portal venous gas
alteration in bowel wall: ischemic bowel, CRC, IBD
bowel luminal distension: paralytic ileus
intra ab sepsis: cholecystitis, pancreatitis
others: pneumatosis intestinalis
causes of portal venous gas
air in portal vein
alteration in bowel wall: ischemic bowel, CRC, IBD
bowel luminal distension: paralytic ileus
intra ab sepsis: cholecystitis, pancreatitis
others: pneumatosis intestinalis
Causes of aerobilia
air in biliary tree
- 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
Mgx of acute intestinal ischemia
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
Causes of functional IO
- 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 - Pseudo-obstruction
- small intestine
- acute colonic: toxic megacolon, Ogilvie syndrome
- chronic colonic: Hirschsprung, paraneoplastic (SCL Ca), infx (chagas dz)
Mgx of surgical wound dehiscence
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
Clean wound definition
An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tract is not entered.
clean-contaminated wound definition
An operative wound in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination.
triad of VIPoma
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)
What are the various pancreatic endocrine tumors
- ACTHoma (cushing syndrome)
- gastrinoma
- glucagonoma (assoc with rash - necrolytic migratory erythema)
- GRFoma (acromegaly)
- Insulinoma
- Somatostatinoma
- VIPoma
What is Sepsis, Severe Sepsis
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
