paces Flashcards
nail signs of abdominal disease
- clubbing
- leukonychia - whitening of nails in hypoalbuminaemic states (liver synthesis albumin)
- duptyrens - thickening of palmar aponeurosis, bilateral commonly
- koilonychia = spooning of nails, late sign of IDA
causes of clubbing (MIC)
Malignancy
IBD
Chronic liver dis
Kocher’s (rooftop) incision
- along costal margin R or L
- biliary or hepatic surgery
Midline laporotomy
- down middle
- any major abdo surgery
Transverse upper abdo incision
- straight line below costal margin on LHS
- splenic surgery
Grid iron incision
- RIF
- appendicectomy
Umbilical/subumbilical
-hernia repairs
Point incision marks
-laporoscopy ports or drain sites
Rutherford Morrison (hockey stick)
- RIF hooked
- renal transplant
Biliary or hepatic surgery scar
Kocher’s rooftop incision along costal margin
Splenic Surgery scar
Transverse upper abdo incision
-straight line below costal margin on LHS
Renal transplant surgery scar
Rutherford Morrison hockey stick scar
Liver transplant surgery scar
Mercedez-Benz incision
Gynae surgery scar
Pfannestiel incision / low transverse
Hernia repair/vascular access surgery
Inguinal incision
How to differentiate between SPLEEN vs Kidney
- moves down with inspiration
- you cannot get above it
- has a notch
- dull to percussion
- not ballotable
Causes of hepatomegaly - VANNIC
Cancer - mets, HCC
Cirrhosis (early ALD - late cirrhosis –> shrivels)
Cardiac - CCF , Constrictive pericarditis
Infiltration - viral hepatitis, inflammation, NAFLD, haemochromatosis, amyloidosis, sarcoidosis
Causes of splenomegaly - 2 Hs 2 Is
Hypertension (portal) - signs of CLD
Haem- myelofibrosis, CML, haemolytic anaemia, lymphoma
Infection - TB, Malaria, Leishmaniasis, Schisto, Inf Mono
Infiltrative - Sarcoid, Gaucher’s disease
(AI - SLE, Felty’s Syndrome)
Causes of large kidneys
- PKD
- Simple cyst
- Renal Cancer
- Infiltrative - sarcoid, amyloid
signs of Chronic STABLE Liver Disease (A-J)
Asterixis (liver flap) - hepatic encephalopathy Bruising CLUBBING DUPUTYREN'S contracture Erythema (Palmar) - redness Fetor GYNAECOMASTIA Hair loss Jaundice Leuconychia - hypoalbuminaemia (decreased liver function) \+ testicular atrophy \+ SPIDER NAEVI >5
signs of abdo dis - arms, hands, neck
AV fistulae Anaemia Jaundice Skin: excoriation, spider naevi Oral: pigmentation, gum hypertrophy (ciclosp) Lymphad
signs of abdo dis - chest
Gynaecomastia
Hair loss
Excoriation marks
Spider naevi
signs of abdo dis - abdo
abdo distension
caput medusae = distended superficial abdo veins (dtn of flow in veins below umbilicus is towards legs)
Liver failure signs
Jaundice Leuconychia (low protein) Bruising (clotting / fibrinogen) Ascites Encephalopathy (?nitrogenous)
Portal hypertension signs
Splenomegaly
Ascites
Dilated veins on abdo (blood goes away from umbilicus)
(Haematemesis/ maleana)
IVCO signs
Ascites
Dilated veins on abdo (blood travels upwards)
- to differentiate IVCO
Causes of ascites
Transudate & Exudate causes: Exudative - Portal HTN/ thrombosis IVC/ Hepatic vein obstruction Constrictive pericarditis Peritoneal secondaries / TB Ovarian malignancy
Transudate - Hypoproteinaemic states: - nephrotic syndrome - liver failaure - malabsorpiton
signs of cholestasis
itching pale stools dark urine (negative for urobilinogen) jaundice xanthelasmata eg PBC, AMA+, high IgM Chronic active hepatitis, ANF +, IgG
abdo bloods
FBC U+E CRP LFT Amylase Coag G+S Cultures - if septic ABG or VBG for lactate - if req
foregut regions + blood supply
—- lower part of duodenum to first 1/3 of asc colon
midgut regions + blood supply
Ascending colon and proximal 2/3 of the transverse colon
-superior mesenteric artery
–The ascending colon receives arterial supply from two branches of the superior mesenteric artery; the ileocolic and right colic arteries. The ileocolic artery gives rise to colic, anterior cecal and posterior cecal branches – all of which supply the ascending colon.
- -The transverse colon is derived from both the midgut and hindgut, and so it is supplied by branches of the superior mesenteric artery and inferior mesenteric artery:
- Right colic artery (from the superior mesenteric artery)
- Middle colic artery (from the superior mesenteric artery)
- Left colic artery (from the inferior mesenteric artery)
hindgut regions + blood supply
Distal 1/3 of the transverse colon, descending colon and sigmoid colon
-inferior mesenteric artery
–The descending colon is supplied by a single branch of the inferior mesenteric artery; the left colic artery. The sigmoid colon receives arterial supply via the sigmoid arteries (branches of the inferior mesenteric artery).
marginal artery of drummond
The marginal artery (of Drummond) is a clinically important vessel that provides collateral supply to the colon – thereby maintaining arterial supply in the case of occlusion or stenosis of one of the major vessels.
As the terminal vessels of the superior mesenteric and inferior mesenteric artery approach the colon, they split into many branches, which anastomose with each other. These anastomoses form a continuous arterial channel which extends the length of the colon – the marginal artery. Long, straight arterial branches (called vasa recta) arise from the marginal artery to supply the colon
relation between arterial supply + lymphatic supply
both follow same path SO
lymphatic draining of ascending + transverse = SMA
lymphatic drainage of descending + sigmoid = IMA
-then–> intestinal lymph trunks –> on to the cisterna chyli –> THORACIC DUCT
venous drainage of ascending colon
ileocolic and right colic veins, which empty into the superior mesenteric vein.
venous drainage of transverse colon
middle colic vein, which empties into the superior mesenteric vein.
venous drainage of desc colon
left colic vein, which drains into the inferior mesenteric vein.
venous drainage of sigmoid colon
drained by the sigmoid veins into the inferior mesenteric vein
where do sup mesenteric + inf mesenteric veins ultimately empty into
HEPATIC PORTAL VEIN –> TOXINS absorbed from colon processed by liver for detoxification
neurovascular supply of colon
- linked to embryological origin
- Ascending colon and proximal 2/3 of the transverse colon – derived from the midgut.
- Distal 1/3 of the transverse colon, descending colon and sigmoid colon – derived from the hindgut.
Where is the transpyloric plane of addison
horizontal line between the suprasternal notch + pubic symphisis
what lies at the transpyloric plane (classic surgical q)
- End of SC
- L1 vert
- Origin of SMA
- Origin of portal vein
- neck of pancreas
- pylorus of stomach
- D2
- Sphincter of Odii
- Hilum of each K
- DJ flexure
- Fundus of GB
- Tip of 9th costal cartilage
Describing scars
Imagine examiner hasn’t seen the scar before
1.Size
2.Shape - transverse, longitudinal, oblique
3.Site
4.Surgical health + age - ie. well healed/ dehisced/ inf + fresh vs old
SUGGESTIVE OF (name scar)
SURGICAL ACCESS (what organs does it provide access to and to what blood vessels or just say the blood vessels that supply them)
SURGERY + SURGICAL INDICATION
BRING IN OWN KNOWLEDGE
example of describing a kocher incision
1.10cm
2.OBLIQUE scar
3.Under the R costal margin
4.Old + well healed
Suggestive of a Kocher scar
Provides access to the liver + GB + their vascular supply
This may be necessary for an open cholecystectomy eg for cholecystitis or ascending cholangitis or acute pancreatitis secondary to GS
I know that most cholecystectomies are typically performed laparoscopically so reasons to convert to OPEN would be DIFFICULT ANATOMY or a HAEMODYNAMICALLY UNSTABLE PT
if they have an ILEOSTOMY - what are 3 imp things to comment on
- Location - RIF
- Spouted (to prevent irritation from high enzyme contents)
- Watery contents drained
If they have an END (single lumen) ILEOSTOMY what ops have they had
Sub total colectomy (anus intact) Pan proctocolectomy (closed anus)
If they have had a LOOP (double lumen) ILEOSTOMY what ops have they had
Anterior resection (removed part of sigmoid colon and rectum. anus open as anal sphincters not invovled)
- STOMA formed
+ Anastomosis formed !!
if they have a COLOSTOMY - what are 3 imp things to comment on
- Location - LIF
- Not spouted / flat / flush to skin
- Faecal matter drained
If they have an END (single lumen) COLOSTOMY what ops have they had
Hartmann's (sigmoid colectomy) AP resection (sigmoid colectomy + anus closed)
are LOOP COLOSTOMY often seen
V RARE
what are important complications of STOMA
IMMED - infection, bleeding, necrosis (stoma too tight/ under tension <24h often)
EARLY - high output (up to 1.5L normal) , obstruction
LATE - retraction, prolapse, stenosis, parastomal hernias
