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Periop Flashcards

1
Q

General surgical management for diabetics

A

• First on morning list
• Urinalysis in morning
• Admitted 2 days prior for assessment and prep
• Avoid hartmanns IV
Insulin to be infused throughout the surgery

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2
Q

Pre op blood investigations

A

FBCs - To find undiagnosed anemia and correct pre surgery

U&Es - susceptibility to AKI to control fluids

LFTs - Directs medication choice and dosing if liver cannot correctly metabolise drugs

Clotting - Identify and correct pre surgery

Group and Save - determines pt blood group and screens for atypical antibodies. Done if blood loss not anticipated but MAY be needed. Takes 40 mins

Cross Match - Physically mixes pt blood with donor blood to see if immune reaciton takes place. Takes 40 mins on top of G&S which must be done first. Done if blood likely will be needed.

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3
Q

If female what test needs to be done pre op?

A

PREGNANCY

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4
Q

VTE prophylaxis

A

• LMWH - Dalteparin

TED stockings - if ABPI is >0.9 and no history of arterial disease

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5
Q

Causes of hyperkalaemia

A

• AKI
• Repeated blood transfusions
• K-sparing diuretics, ACEi, spironolactone
Excessive K treatment

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6
Q

ECG of hyperkalaemia

A

• Tall tented T waves
• Flattened P wave
Widening of QRS

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7
Q

Tx of hyperkalaemia

A 
• Stabilise myocardium
		○ IV calcium gluconate
	• Reduce serum K
		○ Salbutamol nebs and insulin with dextrose
	• Reduce total body K
Oral calcium resonium
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8
Q

S&S of hyperK

A 
• Non specific pains
	• Parasthesia
	• Muscle Weakness
	• N&V
Palpitations
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9
Q

Investigations of hyperK

A

• Bloods - FBC, U&E, CRP
• VBG
• ECG
Catheterisation for fluid status

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10
Q

Causes of hypoK

A

• Diuretics esp thiazides

Hyperaldosteronism

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11
Q

Symptoms of hypoK

A

• Muscle weakness

Atrial and ventricular ectopic beats

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12
Q

tx of hypoK

A

• Treat cause

IV K replacement

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13
Q

Where is spinal and epidural given?

A

Epidural - given anywhere

Spinal - given below L2

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14
Q

S&S of hiatus hernia?

A 
• Vomiting
	• Weight loss
	• Bleeding and anemia
	• Hiccups and palpitations
Swallowing problems
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15
Q

Types of hiatus hernia?

A

• Rolling

Sliding

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16
Q

Surgical indications for hiatus hernia

A

• Remains symptomatic
• Increased risk of strangulation
Nutritional failure

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17
Q

Surgical tx for hiatus hernia

A

Fundoplicaiton

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18
Q

Patho of peptic ulcer disease

A

• Most commonly on lesser curvature of stomach or first part of duodenum
Caused by H pylori or NSAIDs

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19
Q

Red flags for gastric cancer and investigation

A 
Gastric cancer red flags - ALARMS:
A - Anaemia
L - Lost weight
A - Anorexia
R - Recent rapid onset
M - Meleana
S - Swallowing difficulty

Immediate Endoscopy + biopsy

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20
Q

S&S of gastric and duodenal ulcer

A 
• Gastric:
		○ Epigastric pain - worse after eating
		○ Nausea
		○ Weight loss
	• Duodenal:
Epigastric pain - worse 2 hrs after eating
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21
Q

Investigations for peptic ulcer and tx

A 
• H pylori test - Stool antigen
	• +ve H pylori test - Tx:
		○ PPI + amoxicillin + clarithromycin for 7 days
	• -ve H pylori test - Tx:
PPI
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22
Q

RFs for gastric cancer

A 
• H Pylori
	• Male
	• Age
	• Smoking
	• Japan/Korean
Alcohol
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23
Q

S&S for gastric cancer

A 
• Presentation is non specific:
		○ Haematemesis
		○ Dyspepsia
		○ Dysphagia
		○ N&V
	• Advanced S&S:
		○ Anaemia signs
		○ Jaudnice and hepatmegaly - Liver mets
Enlarged Vircows node
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24
Q

Investigations for gastric cancer

A

Investigations:
• Routine bloods
• Endoscopy + biopsy
• If biopsy confirms - CT CAP to stage disease

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25
Q

commonest causes of SBO

A
  1. Adhesions -50+%
    1. Hernias - 25%
      Tumours - 15%
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26
Q

Causes of adhesion

A

• Previous surgery
• Idiopathic
• Abdo infection
Trauma

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27
Q

Patho of crohns

A 
• Can affect any part of GI but most common in distal ileum or proximal colon
	• Trasmural inflammation
	• Cobblestoning
	• Ulcers and fissures
Skip lesions

Tranny Granny Skips on Cobblestones

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28
Q

RFs of crohns

A
  1. FHx

Smoking

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29
Q

Tx of crohns

A
  1. Induce remission:
    a. Methotrexate + prednisolone
    1. Maintain remission:
      a. Azathioprine
      Surgery if medical tx fails - ileocaecal resection
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30
Q

S&S of crohns

A 
• Episodic abdo pain
	• Diarrhoea - possible blood
	• Malaise, anorexia, low fever
	• Oral ulcers
Perianal disease
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31
Q

Investigations for crohns

A

• Routine bloods

Colonoscopy with biopsy

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32
Q

Complicaitons of crohns

A 
• Stricture formation
	• Fistula
	• Perianal abscesses
	• GI malignancy
Malabsorption
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33
Q

Signs on xray crohns

A

thumbprinting

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34
Q

Site involvement, inflammation, micro and macro changes of crohns vs ulcerative

A

UC - large bowel. Crohns - Entire GI
Inflammation UC - mucosa only. Crohns is transmural
Micro changes UC - crypt abscess, reduced goblet cells, non granulomatous. Crohns is granulomatous.
Macro changes UC - continuous inflammation. Pseudopolyps and ulcers. Crohns - Discontinuous inflammation (skip lesions), cobblestoning, fistula formation

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35
Q

UC patho

A

• Diffuse mucosal inflammation, beginning in rectum going proximally
• Crypt abscess
• Goblet cell hypoplasia
Pseudopolyps

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36
Q

RFs UC

A
  • Smoking = protective

* Bimodal distribution - 15-25 yr old and 55-65 yr old

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37
Q

Tx of UC

A
  1. Induce remission:
    a. Mild to moderate - sulfasalazine
    b. Severe - IV prednisolone
    1. Maintain remission:
      a. Sulfasalazine
      Surgery if medical tx fails - total proctocolectomy (rectum + colon removal)
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38
Q

S&S of UC

A

• Bloody diarrhoea - More bloody than Crohns
• Tenesmus
• Increased frequency and urgency of defecation
• Systemic symptoms - malaise, anorexia, low grade fever
Toxic megacolon = severe

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39
Q

Ix of UC

A

• Routine bloods - anaemia. Raised CRP and WCC
• Colonscopy with biopsy
• AXR if toxic megacolon suspected
Lead pipe colon seen in chronic UC

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40
Q

Complications of UC

A

• Toxic megacolon

Carcinoma

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41
Q

signs of UC on AXR

A

lead pipe colon, toxic megacolon

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42
Q

RFs of appendicitis

A

• FHx
• White
Environmental - summer bigger risk

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43
Q

S&S of appendicitis

A 
• Abdo pain poorly localised --> RIF
	• N&V
	• Change in bowel habits
	• Pyrexia
Guarding - if perf
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44
Q

Ix of appendicitis

A

• Urinalysis - UTI exclusion
• Pregnancy test
• Routine bloods - raised WCC and CRP
Abdo USS - diagnosis

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45
Q

Tx appendicitis

A

Laparoscopic appendectomy

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46
Q

Complications of appendicitis

A

• Perf
• SSI
Pelvic abscess - after perf

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47
Q

Patho of Diverticular disease

A

• Outpouching of bowel wall due to weakening over time
• Movement of stool increases luminal pressure leading to outpouching
Bacteria can accumulate in this pocket –> perforation

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48
Q

3 manifestations of diverticular disease

A

• Diverticulosis - Presence of diverticulum
• Diverticular disease - symptomatic diverticulum
Diverticulitis - inflammation of diverticulum

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49
Q

RFs of diverticular disease

A 
• Low fibre intake
	• Obesity
	• Smoking
	• FHx
NSAIDs
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50
Q

S&S of diverticular diseaase

A

○ Colicky pain - exacerbated by food and relieved by defecating
○ Altered bowel habits
○ Nausea
Flatulence

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51
Q

S&S of diverticulitis

A

○ Abdo pain and local tenderness - usually LIF
○ PR bleeding
Sepsis - if perf

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52
Q

Ix of diverticular diseaes

A 
• Routine bloods - anaemia if bleeding
	• ABG - lactate if ischemic
	• Sigmoidoscopy in diverticular disease:
		○ NOT IN DIVERTICULITIS - risk of perf
AXR to exclude obstruction
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53
Q

Tx of diverticulitis. Indications for surgery?

A 
• Diverticulitis:
		○ IV abx
		○ IV fluids
		○ Bowel rest
		○ Analgesia
	• Surgical washout indications:
		○ Perf with fecal peritonitis
		○ Sepsis
Failure to improve with medical tx
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54
Q

Genes involved in colorectal cancers

A

• Adenomatous polyposis coli (APC) gene

Hereditary nonpolyposis colorectal cancer (HNPCC)

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55
Q

S&S of left and right sided colorectal cancer

A

○ Right = occult (hidden) bleeding. Left is frank.
○ Left = tenesmus. Right = weight loss.
Right = RIF mass. Left = LIF mass

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56
Q

Dukes staging and 5 yr survival

A 
Stage	Description	5 yr survival (%)
A	Muscle layer not penetrated	90
B	Muscle layer penetrated	70
C	Lymph node mets	30
D	Distal mets	10
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57
Q

Ix of colorectal cancer

A

• FBC - anemia if right sided.
• LFTs - liver mets
• Cancer marker carcinoembryonic antigen (CEA)
Colonoscopy with biopsy.

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58
Q

Tx of colorectal cancer

A 
• Surgery - if localised:
		○ Laparascopic Bowel resection:
			§ Right hemicolectomy - right colon cancer
			§ Left hemicolectomy - left colon cancer
			§ Sigmoidcolectomy - sigmoid cancer
			§ Anterior resection - high rectal cancer
			§ AP resection - low rectal cancer
			§ Hartmanns - emergency resection
	• Chemo if mets
	• Radio for rectal cancer
	• Palliative:
Stenting
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59
Q

S&S of hemorrhoids

A

• PAINLESS fresh bleeding
• Palpable mass
• Pruritic
Soiling - mucus or impaired continence

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60
Q

RFs of hemorrhoids

A

• Chronic constipation
• Age
Raised intra-abdo pressure eg pregnancy, chronic cough, ascites

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61
Q

Classification of hemorrhoids

A
  1. 1st degree - in rectum
    1. 2nd degree - prolapse through anus on defecation but spontaneously reduce
    2. 3rd - degree - prolapse on defecation but require digital reduction
      4th degree - persistently prolapsed
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62
Q

Ix of hemorrhoids

A

• Proctoscopy
• FBC - anemia due to bleeding
Colonoscopy to exclude malginancy

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63
Q

Tx of hemorrhoids

A

• Conservative:
○ 1st and 2nd degree treated with rubber band ligation
• Surgical:
Hemorrhoidectomy if symptomatic

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64
Q

Rectal carcinoma S&S

A 
• Pain and fresh bleeding
	• Mucus and discharge from anus
	• Palpable mass
	• Pruritis
Tenesmus and fecal incontinence possible
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65
Q

Ix of rectal carcinoma

A 
• FBCs - anemia of chronic disease
	• DRE
	• Biopsy
	• USS guided FNA of inguinal lymph nodes
	• CT-thorax-abdo-pelvis for mets
MRI pelvis - local invasion
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66
Q

What is hartmanns procedure. used for?

A

• Rectosigmoid resection with formation of an end colostomy and closure of rectal stump
• Anastomosis with reversal of colostomy may be possible later
Used to treat obstructive cancers in rectosigmoid

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67
Q

patho of anal fissure

A

• Tears in lining of anal canal
• <6 wks - acute
>6wks - chronic

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68
Q

Acute anal fissure tx

A

• High fibre high fluid
• Bulk forming laxative - Ispaghula husk
• Topical anasthesia
Analgesia

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69
Q

chronic anal fissure tx

A

• Same as acute + the following
• 1st line - Topical GTN
2nd line - surgery or botulinum toxin referral

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70
Q

RFs of inguinal hernia

A

male

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71
Q

S&S of inguinal hernia

A

• Groin lump - reducible on pressure and lying down

Discomfort and ache on activity

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72
Q

Tx of inguinal hernia

A

• Conservative if few symptoms
• Surgery - if symptomatic:
Mesh repair - open or lapascopic

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73
Q

Femoral hernia RF

A

female

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74
Q

S&S of femoral hernia

A

• Most are Asymptomatic
• Emergency presentation if strangulated
Irreducible

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75
Q

Tx of femoral hernia

A

surgery

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76
Q

Ix of femoral hernia

A

USS

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77
Q

RFs of incisional hernia

A 
• Obesity
	• Midline incision
	• Wound infection
	• Age
Pregnancy
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78
Q

how to assess dilatation on axr of GI?

A

3/6/9 Rule to assess if there is dilatation:
• >3 cm for small bowel
• >6 cm for large bowel
>9 cm for caecum

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79
Q

signs of pneumoperitoneum on axr

A

cupola (air under diaphragm), riglers (double wall of bowel visible),

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80
Q

assess hernia on axr

A

• There is never any bowel below the pelvic line

Hernia if there is.

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81
Q

sign of sigmoid volvulus on axr

A

coffee bean sign

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82
Q

sign of caecal volvulus on axr

A

caecum moves from RIF to central abdo and distends

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83
Q

Approach to AXR

A

A - Air - Look through GI tract starting at rectum

B - Bone - fractures. Beware the owl that winks

C - Circulation - look for calcification and psoas muscle, absence indicates AAA

D - Disability (soft tissue/organs) - most visible is bladder

E - Everything else

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84
Q

Prep for surgery?

A 
○ NBM
		○ IV access
		○ VTE prophylaxis
	• Analgesia + antiemetics
	• IV fluids + monitor balance
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85
Q

Acute abdomen in URQ

A

cholecystitis, pyelonephritis, ureteric colic, hepatitis, pneumonia

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86
Q

acute abdomen in ULQ

A

pyelonephritis, ureteric colic, pneumonia, gastric ulcer

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87
Q

acute abdomen in LRQ

A

appendicitis, ureteric colic, inguinal hernia, IBD, UTI, gyne, testicular torsion

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88
Q

acute abdo in LLQ

A

Diverticulitis, ureteric colic, inguinal hernia, IBD, UTI, gyne, testicular torsion

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89
Q

acute abdo in periumbilical reguin

A

appendicitis, SBO, LBO, AAA

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90
Q

acute abdo in epigastric region

A

PUD, cholecystitis, pancreatitis, MI

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91
Q

Ix for acute abdomen

A

• Bloods - FBC, U&E, LFT, CRP, amylase
• ABG - bleeding
• Pregnancy test
• Blood cultures
• Imaging:
○ USS
○ AXR - erect CXR if bowel perforation suspected. Normal if bowel obstruction suspected

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92
Q

Peritonitis S&S

A 
• Abdo tenderness
	• Rigidity
	• Guarding
	• Rebound Tenderness
EXTREME stillness
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93
Q

Tx of peritonitis

A

○ Surgery to repair viscus
○ Abx to cover
?peritoneal lavage

94
Q

Ix of peritonitis

A 
• Bloods - FBC, U&amp;E, LFT, CRP, amylase
	• ABG - bleeding
	• Pregnancy test
	• Blood cultures
AXR
95
Q

S&S of AAA ruptured

A

• Abdo pain and back pain
• Syncope
• Vomiting
Hemodynamically compromised with pulsatile abdo mass and tenderness

96
Q

Tx of AAA ruptured and stable

A

• High flow O2, IV access
• Bloods - FBC, U&E, clotting, cross match
• Fluids and O- Blood. Keep systolic below 100mmHg (permissive hypotension)
• Unstable pt - immediate open surgical repair
Stable pt - CT angiogram to see if EV repair is possible

97
Q

causes of acute limb ischemia

A

• Thrombosis in situ
• Embolism
Trauma inc compartment syndrome

98
Q

S&S of acute limb ischemia

A 
Early S&amp;S:
	• EXTREME Pain or tenderness
		○ Worse on passive movement
		○ Worsening despite analgesia
	• Swelling
Parasthesia
99
Q

Initial tx of acute limb ischemia

A

• Oxygen
• IV access
Heparin

100
Q

Surgical and conservative tx of acute limb ischemia

A

Conservative:
• LMWH

Surgical:
• Bypass surgery if completely occluded
• Angioplasty and stenting
If limb non salvagable, amputate.

101
Q

Ix of acute limb ischemia

A

• Bloods - FBC, clotting, U&E (electrolyte imbalances), serum lactate (ischemia), thrombophilia screen
• ECG - AF
• Doppler USS both limbs
Consider CT angiography

102
Q

RFs of chronic limb ischemia

A 
• Smoking
	• Diabetes
	• Hypertension
	• Hyperlipidemia
	• Age
Family Hx
103
Q

Classification of chronic limb ischemia

A

Stage I Asymptomatic
Stage II Intermittent claudication
Stage III Ischaemic rest pain
Stage IV Ulceration or gangrene, or both

104
Q

definition of critical limb ischemia

A

• Ischemic rest pain for 2wks+, needing opiate analgesia
• Presence of gangrene
ABPI <0.5

105
Q

What causes falsely high ABPI?

A

calcification and hardening of arteries

106
Q

Ix of chronic limb ischemia

A 
• ABPI - 
		○ <0.9 mild. <0.8 moderate. <0.5 severe.
		○ >1.2 - calcification and hardening of arteries can cause falsely high ABPI
	• Doppler USS
	• CVS risk assessment:
		○ Blood pressure
		○ Blood glucose
		○ Lipid profile
ECG
107
Q

tx of chronic limb ischemia - medical and surgical

A 
Medically:
	• Lifestyle advice
	• Statins
	• Aspirin or clopidogrel
	• Optimise diabetes control

Surgically:
• Angioplasty
• Bypass grafting
Amputation

108
Q

Test for chronic limb ischemia

A

Buerger’s test
• Raise pts legs while supine
• They go pale until theyre lowered again
Angle of <20 degs indicates severe ischemia

109
Q

S&S of carotid artery disease

A

Presents with TIA or stroke

110
Q

Ix of carotid artery disease

A

• Bloods - FBC, U&E, clotting, lipid profile, glucose
• ECG - AF (source of clot)
• If pt high risk:
Duplex USS of carotids to assess stenosis

111
Q

Acute tx of carotid artery disease

A

• High flow Oxygen
• Optimise blood glucose (4-11 mmol)
• Ischemic stroke - IV alteplase and 300mg OD for 14 days
Hemorrhagic stroke - referral to neurosurgery

112
Q

Long term tx of carotid artery disaease

A 
• Clopidogrel
	• Statin
	• Treat diabetes or hypertension
	• Smoking cessation
	• Exercise
	• Surgical revascularisation if stenosis is above 50%
Consider Carotid endarterectomy
113
Q

S&S and location of total anterior circulation stroke

A 
Middle or anterior cerebral arteries
All of - HHHH:
	• Hemiparesis + Hemiataxia
	• Homonymous Hemianopia
High cortical dysfunction (dysphagia, dyspraxia, neglect)
114
Q

S&S and location of partial anterior circulation stroke

A

Middle or anterior cerebral arteries

2/3 of HHHH or just Higher cortical dysfunction

115
Q

S&S and location of lacunar stroke

A

Deep penetrating arteries

lacunar - motor or sensory or motor-sensory or ataxic hemiparesis

116
Q

S&S and location of posterior circulation stroke

A

Vertebrobasilar or PCA circulation. Affects brainstem, cerebellum or occipital lobe
• Bilateral motor or sensory deficits
• Cerebellar dysfunction
• Ipsilateral CN palsy with contralateral motor or sensory defects
• Isolated homonymous hemianopia

117
Q

Investigations for stroke

A 
• URGENT CT head
	• Bloods - FBC, U&amp;E, clotting, Lipid profile, glucose
	• ECG - AF
CXR
Once diagnosis made:
	• Duplex USS of carotids
Assess degree of stenosis
118
Q

Acute tx for stroke

A 
• ABCDE
	• High flow o2
	• Optimise BM
	• Ischemic stroke:
		○ IV alteplase if within 4.5 hrs of symptoms
		○ 300mg Aspirin
	• Hemorrhagic stroke:
Neurosurgery referral
119
Q

LT tx for stroke

A 
• Antiplatelets - clopidogrel
	• Statin
	• Treat HTN and DM
	• Smoking cessation
	• Regular exercise
	• If stenosis >70% or symptomatic, refer for surgery:
Carotid endarterectomy
120
Q

Causes of acute mesenteric ischemia

A

a. 25% - Thrombus eg AF or aneurysms.
b. 50% - Atherosclerosis
c. 20% - Shock
10% - Venous occlusion eg malignancy, coagulopathy

121
Q

S&S of acute mesenteric ischemia

A

• Generalised abdo pain - EXTREME
• N&V++
• Late stage can present as bowel perforation
BE WARY OF EMBOLIC SOURCES EG AF, HEART MURMURS

122
Q

Ix of acute mesenteric ischemia

A

• ABG - serum lactate + acidosis
• FBC - raised WCC due to inflammation
• U&E
• Clotting
• Amylase - Rises in mesenteric ischemia (not just pancreatitis)
LFTs - occlusion of celiac trunk can affect liver too

Imaging:
• Erect CXR - if suspected perf
• CT abdo with contrast - Thickened and oedematous bowel

123
Q

Tx of acute mesenteric ischemia

A 
• Initial:
		○ Fluid resus + catheterisation
		○ IV abx due to feces
		○ Surgery prep
	• Surgery:
		○ Excise necrotic bowel
revascularise bowel.
124
Q

Patho of chronic mesenteric ischemia

A

• Atherosclerosis of SMA, IMA or celiac trunk

When demand for blood increases, eg after food, transient ischemia results

125
Q

S&S of chronic mesenteric ischemia

A
  • Post eating pain - 10 mins to 4 hrs later
    • Weight loss - malabsorption + reduced intake due to pain + fear
    • Concurrent vascular co-morbs
126
Q

Ix of chronic mesenteric ischemia

A

• Routine bloods
• Imaging:
CT angiography - reveals stenosis of arteries

127
Q

Tx of chronic mesenteric ischemia

A 
• Medical:
		○ Clopidogrel and statin
		○ Weight loss, increase exercise
		○ Smoking cessation
	• Surgical:
Stent
128
Q

Define AAA

A

Dilatation >3cm

129
Q

S&S of AAA

A 
• Asymptomatic mostly
	• Can have abdo pain, back pain
	• Pulsatile mass felt above umbilicus
	• If ruptured:
		○ grey turners or cullens
		○ Shock
Abdo, back or loin pain
130
Q

Ix of AAA

A

• USS

Follow up CT scan with contrast

131
Q

Tx of AAA - medical and surgical

A 
• Medical:
		○ Duplex USS:
			§ <4.5cm - every year
			§ 4.5 - 5.5cm - every 3 months
		○ Reduce risk:
			§ Smoking cessation
			§ HTN control
			§ Statin + aspirin
			§ Weight loss and exercise
	• Surgery:
		○ Indications:
			§ >5.5cm
Open - young pts. EVAR - older pts.
132
Q

AAA and driving?

A

> 6cm AAA disqualifies from diriving

133
Q

S&S of upper GI hemorrhage

A

• Haematemesis +/or malaena
• Epigastric discomfort
Sudden collapse

134
Q

Oeseophagus causes of upper GI hemorrhage and S&S

A

○ Oesophagitis - vomiting blood proceeds GORD symptoms
○ Cancer - vomiting blood. comes with cancer symptoms
○ Mallory weiss - following repeated vomiting
Varices - Large volumes of fresh blood vomit. Can compromse hemodynamics

135
Q

Duodenum cause of upper GI hemorrhage

A

Ulcer

136
Q

Gastric cause and S&S for upper GI hemorrhage

A

• Cancer - Blood mixed with vomit. Cancer symptoms

Ulcer - Presents as iron deficiency anaemia. Can erode into major vessel

137
Q

Tx of upper GI hemorrhage

A 
• ABCDE
	• Routine bloods + cross match
	• Endoscopy
	• Surgery indications:
		○ >60 yr
		○ Recurrent bleeding
Non resolving
138
Q

Patho of venous ulceration

A

• Shallow ulcers with irregular borders and granulating base
○ Classically over medial malleolus
Occur when retrograde flow causes venous dilatation and pooling of blood. This leads to impaired oxygen delivery to skin –> ulcer

139
Q

RFs for venous ulceration

A 
• DVT
	• Venous incompetence eg varicose veins
	• Trauma
	• Pregnancy
Obesity
140
Q

S&S of venous ulceration

A

• Dry itchy skin
• Varicose veins
• Haemosiderin staining - Red/brown staining of skin:
○ Caused by RBCs breaking down in skin
• Telangiectasia
Lipodermatosclerosis - Upside down champagne bottle appearance

141
Q

Ix of venous ulceration

A

Confirm insufficency with duplex USS

142
Q

Tx of venous ulceration

A 
• Conservative:
		○ Emollients for dry skin
		○ Increased exercise
		○ Leg elevation
		○ Abx if infection
Surgery - if conservative fails
143
Q

Patho of arterial ulceration

A

• Reduction in arterial blood flow leading to decreased perfusion of tissues and poor healing
• Small deep lesions with well defined borders and necrotic base
Occur at sites of trauma and pressure areas

144
Q

S&S of arterial ulceration

A 
• History of limb ischemia
	• Painful ulcer with little healing (therefore no granulation)
	• Hair loss in area
	• Cold limbs
Absent pulses
145
Q

Tx of arterial ulceration

A 
• Conservative:
		○ Smoking cessation
		○ Weight loss
		○ Increase exercise
	• Medical:
		○ CVS risk modification
	• Surgical
Angioplasty or bypass
146
Q

Patho of varicose veins

A

• Incompetent valves

Venous HTN and dilatation of superficial system

147
Q

Causes of varicose veins

A

• 98% primary idiopathic
• Secondary:
○ DVT
Pregnancy

148
Q

RFs of varicose veins

A

• Obesity
• Prolonged standing
• FHx
Pregnancy

149
Q

S&S of varicose veins

A 
• Unsightly
	• Varicose eczema - dry and itchy
	• Pain
	• Ulcers
	• Hemosiderin skin staining
Lipodermatosclerosis
150
Q

Ix for varicose veins

A

Duplex USS

151
Q

Tx of varicose veins and surgical indications

A 
• Conservative:
		○ Pt education about risk factors
		○ Exercise (calf action)
	• Surgery indications:
		○ Symptomatic
		○ Skin changes
		○ Venous leg ulcer
	• Surgical options:
		○ Vein ligation and stripping
		○ Thermal ablation
		○ Foam sclerotherapy:
Sclerosing agent injected directly into vein, closing it off
152
Q

Define VTE

A

Term used to describe both DVT and PE

153
Q

RFs of VTE

A 
• Age
	• Previous VTE
	• Smoking
	• Pregnancy
	• Immobility
	• HRT
	• Malignancy
	• Obesity
Thrombophilia disorder
154
Q

DVT S&S

A

• Most are asymptomatic
• Unilateral leg pain and swelling
• Low fever
Pitting oedema

155
Q

Ix of DVT

A

• If DVT likely - Duplex USS:
○ If result is -ve, perform D dimer to exclude
If DVT unlikely - D dimer to exclude

156
Q

Tx of DVT

A

Tx:

LMWH cover for 5 days with warfarin for 3 months

157
Q

Length of anticoag for DVT?

A

• If PE precipitated by known event - 3 to 6 months
• If due to unknown event - 6 months minimum.
If due to malignancy - 6 month anticoag

158
Q

State the 2 level DVT wells score and what score = likely DVT?

A 
Feature	Points
Cancer	1
Paralysis of legs	1
Bedridden 3+ days or surgery in past 12 weeks	1
Local tenderness alone Deep venous system	1
Leg swelling	1
Unilateral Calf swelling 	1
Pitting oedema on symptomatic leg	1
Previous DVT	1
Other diagnoses likely	-2
Score of 2+ = likely DVT
159
Q

S&S of SBO

A

• Colicky abdo pain - True waxing and waning
• Vomiting - Gastric contents –> bile –> feces
• Abdo distension
• Absolute constipation - no flatus or feces
• Tinkling or absent bowel sounds
• Tympanic (hollow) sound on percussion
FOCAL TENDERNESS = ISCHEMIA

160
Q

Causes of abdo distension?

A 
6Fs:
	• Fluid
	• Fat
	• Flatus
	• Feces
	• Fetus
Fucking big tumour
161
Q

Ix for SBO

A 
• ABG - serum lactate
	• Routine bloods - high urea and hypokalaemia may be present
	• AXR:
		○ Dilated bowel >3cm
		○ Visible valvulae conniventes
		○ Erect xray for free gas
CT abdo - find cause of obstruction
162
Q

Ischemia red flags for SBO

A

• FOCAL TENDERNESS

PAIN WAS COLICKY NOW CONSTANT

163
Q

Tx for SBO

A 
• Conservative - first line if no ischemia:
		○ NBM
		○ IV fluids + catheter
		○ Analgesia + metoclopromide (failure of peristalsis) in mechanical use cyclizine or dexamethasone
	• Laparotomy indicated for:
		○ Ischemia
		○ SBO in virgin abdomen
No improvement in 48 hrs
164
Q

Causes of LBO

A
  1. Malignancy (until proven otherwise)
    1. Diverticular disease
      Volvulus
165
Q

S&S of LBO

A 
• Similar to SBO
	• More gradual onset
	• May have cancer symptoms:
		○ Rectal bleeding
		○ FHx
Weight loss
166
Q

S&S of bowel adhesions

A

• Colicky pain
• Constipation
• Fecal vomiting
Abdo distension

167
Q

Ix for bowel adhesions

A

• Bloods - FBC, U&E, Clotting, group and save, Crossmatch
• ABG - serum lactate for ischemia signs
Imaging - Abdo Xray, abdo CT

168
Q

Tx for bowel adhesions

A

• Conservative:
○ Tube decompression - tube passed into stomach and allows built up pressure to be released
○ Pt to be NBM and given IV fluids and analgesia
• Surgical:
Laparoscopic adhesiolysis

169
Q

Assessing pain objectively?

A

tachycardia, tachypnoea, HTN, sweating, flushing

170
Q

WHO pain ladder?

A

Step 1 - non opioid +/- adjuvant
Step 2 - weak opioid + previous
Step 3 - Strong opioid + previous

171
Q

RFs for post op N&V

A 
• Female
	• Previous PONV
	• Opioid analgesia
	• Longer op
	• Poor pain control
Propofol use
172
Q

When are the 2 antiemetics used

A

• Gastric stasis - metoclopramide

Opioid induced - ondasteron

173
Q

Prophylaxis for post op N&V

A 
• Reduce opiate use and propofol
	• Antiemetic use
Dexamethasone at induction
	• Adequate fluid hydration
Adequate analgesia
174
Q

3 types of post op hemorrhage?

A
  1. Primary - during op
    1. Reactive - 24 hrs after op. Due to intraop hypotension and vasoconstriction that means bleeding from some vessels only occurs once BP normalises
      Secondary - 7-10 days post op. Due to erosion of vessel from infection
175
Q

S&S of post op hemorrhage

A

• Most sensitive sign - tachypnoea
• Tachycardia and hypotension are late signs
Oligouria

176
Q

Tx of post op hemorrhage

A

• ABCDE
• Fluid resus
Referral

177
Q

Causes of post op pyrexia

A

• Infection
• Iatrogenic
VTE

178
Q

Infection sources post op?

A

4Ws of Pyrexia:
• W - Wind, days 1-2. Resp source infection
• W - Water, days 3-5. UTI source infection
• W - Wound, days 5-7. SSI or abscess
W - Wonder about drugs, 7+.

179
Q

Tx of post op pyrexia?

A

• ABCDE
• Is pt septic?
• Examine for line infections, and DVTs
UO >0.5ml/kg/hr?

180
Q

S&S of acute pancreatitis

A

• Sudden onset Epigastric pain, may radiate to back
• N&V
• Severe pancreatitis - guarding and rigid abdomen
Grey turners and cullens sign

181
Q

Tx of acute appendicitis

A 
• High flow O2
	• IV fluids - 500ml/hr of crystalloid
	• Nasogastric tube if pt vomiting
	• Catheterisation to monitor urine output
Opioid analgesia
182
Q

Ix of aacute ppendicitis

A

• Serum amylase - 3x upper limit of normal
• LFTs - gallstones can cause pancreatitis
• Serum lipase
Imaging - USS AP and CT scan

183
Q

Causes of acute pancreatitis?

A

GET SMASHED:

GallstonesEthanolTraumaSteroidsMumpsAutoimmune disease eg SLEScorpionHypercalcemiaERCPDrugs eg diuretics or NSAIDS

184
Q

Causes of chronic pancreatitis

A

alcohol, idiopathic

185
Q

S&S of chronic pancreatitis

A 
• Chronic epigastric pain: 
		○ eased by leaning forward
		○ May radiate to back
	• Recurrent acute pancreatitis
N&amp;V
186
Q

Ix of chronic pancreatitis

A 
• Glucose - raised
	• Serum calcium - hypercalcemia
	• Imaging:
		○ Abdo USS - first line
CT scan - pancreatic calcification or pseudocyst
187
Q

Tx of chronic pancreatitis

A

• Analgesia

ERCP to extract stones

188
Q

Complications of chronic pancreatitis

A

• Pseudocyst
• Steatorrhoea and malabsorption - enzyme replacement tx
Diabetes

189
Q

RFs of biliary cholic

A

Risk Factors:

5 Fs - Fair, Fat, Forty, Fertile, Family history

190
Q

S&S of biliary colic

A
  • No inflammatory response
    • Sudden pain, dull, colicky (waxes and wanes, not true colick)
    • RUQ focus
    • N&V
    • Fatty foods make worse
    • Settles with analgesia
191
Q

Ix of biliary colic

A

• FBC and CRP for inflammation
• U&Es - assess for dehydration
• LFTs - damage to liver can occur
Amylase - damage to pancreas can occur

Use USS AP. Look for:
• Presence of gallstones
• Gallbladder wall thickness - thicker = inflamed
• Bile duct dilatation

Can also use a CT scan with higher sensitivity. MRCP is gold standard.

192
Q

Tx of biliary colic

A

• Analgesia eg morphine.
• Elective cholecystectomy can avoid future recurrence with worse consequences
Offer lifestyle advice

193
Q

Gallstone ileus patho

A

If colic is long standing can erode through gallbladder into small bowel and cause obstruction in terminal ileus (smallest point of bowels)

194
Q

Patho of cholecystitits

A

Inflammation of gallbladder

195
Q

Ix of cholecystitis

A

• FBC and CRP for inflammation
• U&Es - assess for dehydration
• LFTs - damage to liver can occur
Amylase - damage to pancreas can occur

Use USS AP. Look for:
• Presence of gallstones
• Gallbladder wall thickness - thicker = inflamed
• Bile duct dilatation

Can also use a CT scan with higher sensitivity. MRCP is gold standard.

196
Q

Tx of cholecytsitits

A

• Antibiotics - IV coamox and metronidazole
• Fluid resus pathway if signs of sepsis evident
• NG tube if pt vomiting
Cholecystectomy necessary

197
Q

S&S of cholecytsitits

A 
• RUQ pain, sudden, dull colicky
	• N&amp;V
	• Inflammatory response
	• More persistent despite analgesia
Positive murphys sign - Apply pressure on RUQ and ask to inspire, will result in halt in inspiration due to pain.
198
Q

Patho of cholangitis. CauseS?

A

Infection of biliary tracts, potentially caused by any condition that occludes biliary tree.

Common causes are gallstones, ERCP, cholangiocarcinoma.

199
Q

What must you remember about cholangitis

A

CHOLANGITIS IS NOT A COMPLETE DIAGNOSIS - There is always an underlying cause that must be treated

200
Q

S&S of cholangitis

A

• RUQ pain - Charcots triad
• Fever - Charcots triad
• Jaundice - Charcots triad
Pruritis

201
Q

Tx of cholangitis

A

• Fluid resus pathway if septic signs
• Broad spectrum IV antibiotics - Coamox and metronidazole
ERCP to remove biliary obstruction. Can also place stent

202
Q

Ix of cholangitis

A

• FBC - raised WCC
• LFTs - raised Alp and bilirubin
Blood cultures

• USS AP - bile duct dilatation,  ERCP is diagnostic and therapeutic but invasive
203
Q

Patho of cholangiocarcinoma

A

Cancer of bile duct system. Most common area is bifurcation of right and left hepatic ducts (klatskin tumours)

204
Q

Ix of cholangiocarcinoma

A

• Elevated bilirubin, ALP, gamma-GT
• Tumour markers CEA and CA19-9
Deranged LFTs

• USS to confirm obstruction
• CT to stage disease MRCP to diagnose if unsure by CT.
205
Q

S&S of cholangiocarcinoma

A 
• Asymptomatic until late stage
	• Jaundice, pruritis
	• Pale stools
	• Dark urine
Courvoisiers law - presence of jaundice and enlarged/palpable gallbladder, suspect biliary or pancreatic cancer
206
Q

Tx of cholangiocarcinoma

A 
• Complete surgical resection
	• Radiotherapy
	• Palliative most likely needed:
		○ Stent to get rid of obstructive symptoms
Radiotherapy to prolong survival
207
Q

S&S of pancreatic cancer

A

• Pain in abdomen radiating to back
• Obstructive Jaundice
• Steatorrhoea - pale and floating
Weight loss, cachexia

• Abdo mass palpable Jaundiced.
208
Q

What is courvoisiers law

A

Courvoisier’s Law - If gallbladder palpable and jaundice, it’s a cancer of biliary tree or pancreas.

209
Q

Ix of pancreatic cnacer

A
  • FBC - anemia of chronic disease
    • Pancreatic amylase
    • LFTs - Raised ALP, gamma-GT, bilirubin (obstructive jaundice)
    • CA19-9 tumour marker for pancreatic cancer
    • Abdo USS - Pancreatic mass, dilated biliary tree
    • CT scan - disease staging.
    Endoscopic USS used for fine needle aspiration biopsy
210
Q

Tx of pancreatic cancer

A 
• Surgery - Whipples:
		○ 40% mortality
		○ Due to risk of forming pancreatic fistula
	• Chemotherapy:
		○ After surgery use 5-FU
	• Palliative Care:
Biliary stenting
211
Q

Liver cancer most common primary? Cause?

A

Hepatocellular carcinoma caused by viral hepatits

212
Q

S&S of liver cancer

A 
• Liver cirrhosis presenting:
		○ Ascites
		○ Jaundice
		○ Portal venous HTN
	• Fatigue
	• Fever
	• Weight loss
Lethargy
213
Q

Ix of liver cancer

A

• LFTs
• Cancer marker alpha fetoprotein (AFP)
USS - mass of >2cm with raised AFP = diagnostic

214
Q

Tx of liver cancer

A

• Surgery

Image guided ablation if early

215
Q

Patho of GORD

A

• Lower oeso sphincter relaxes and allows reflux of gastric contents
Pain and mucosal damage results

216
Q

RFs of GORD

A 
• Age
	• Obesity
	• Alcohol
	• Smoking
	• Caffeine
Fatty or spicy foods
217
Q

Tx of GORD

A 
• Medical:
		○ PPI - life long
	• Surgery (fundoplication) indications:
		○ Fail to respond
		○ Pt cant deal with life long meds
Pt has complications of GORD eg recurrent pneumonia
218
Q

S&S of GORD

A 
• Chest pain:
		○ Burning
		○ Worse after meals
		○ Worse lying down, bending over or strainign
		○ Relieved by antacids
	• Excess belching
Chronic cough or nocturnal cough
219
Q

Ix of GORD. Indications for urgent endoscopy?

A

• Endoscopy not needed if PPI trial resolves symptoms
• URGENT endoscopy if:
○ Dysphagia or upper abdo mass
○ Aged >55 yrs with weight loss + abdo pain, reflux or dyspepsia
• Non urgent endoscopy if:
○ Tx resistant dyspepsia
N&V with weight loss

220
Q

Complications of GORD?

A

• Barretts oeseophagus –> oseophageal cancer
• Oesophagitis
Aspiration pneumonia

221
Q

Conservative Tx of hiatus hernia

A

○ PPI

Lifestyle modification

222
Q

Patho of barretts oesophagus

A

• Metaplasia of oesophageal epithelial lining:

Stratified squamous to simple columnar

223
Q

RFs of barretts oesophagus

A 
• White
	• Male
	• >50yo
	• Smoking
	• Obesity
	• Hiatus hernia
FHx
224
Q

Ix of barretts oesophagus

A

Histological diagnosis via biopsy

225
Q

Tx of barretts

A

• PPI
• Regular routine endoscopy to ensure no neoplasia
Resection of premalignant lesions via endoscopy.

226
Q

Types of oeseophageal cancer and where found

A 
• Squamous cell:
		○ Middle and upper third of oesophagus
		○ RF - smoking, alcohol
	• Adenocarcinoma:
		○ Lower third
Due to barretts
227
Q

S&S of oesophageal cancer

A

• Dysphagia
• Weight loss
• Haematemesis
Lymphadenopathy

228
Q

Tx of oesophageal cancer

A 
• Curative:
		○ Surgery with neoadjuvant chemotherapy
	• Palliative:
		○ Oesophageal stent if dysphagia
Radiochemotherapy to improve symptoms
229
Q

Patho of achalasia

A

• Motility disorder. Failure of smooth muscle to relax.
• Due to destruction of myenteric plexus
Progressive disease.

230
Q

S&S of achalsia

A

• Progressive dysphagia
• Weight loss
Food regurgitation

231
Q

Tx of achalasia

A 
• Conservative:
		○ Sleep with many pillows
		○ Eat slowly + plenty of fluids
	• Surgical:
Myotomy - division of myofibres that fail to relax
232
Q

Ix for GI perf

A

• Routine bloods - give idea on how it perforated
• Imaging:
○ Erect CXR - free gas under diaphragm
CT scan

Z IPE (15 decks)

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