Periop Flashcards
General surgical management for diabetics
• 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
Pre op blood investigations
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.
If female what test needs to be done pre op?
PREGNANCY
VTE prophylaxis
• LMWH - Dalteparin
TED stockings - if ABPI is >0.9 and no history of arterial disease
Causes of hyperkalaemia
• AKI
• Repeated blood transfusions
• K-sparing diuretics, ACEi, spironolactone
Excessive K treatment
ECG of hyperkalaemia
• Tall tented T waves
• Flattened P wave
Widening of QRS
Tx of hyperkalaemia
• Stabilise myocardium ○ IV calcium gluconate • Reduce serum K ○ Salbutamol nebs and insulin with dextrose • Reduce total body K Oral calcium resonium
S&S of hyperK
• Non specific pains • Parasthesia • Muscle Weakness • N&V Palpitations
Investigations of hyperK
• Bloods - FBC, U&E, CRP
• VBG
• ECG
Catheterisation for fluid status
Causes of hypoK
• Diuretics esp thiazides
Hyperaldosteronism
Symptoms of hypoK
• Muscle weakness
Atrial and ventricular ectopic beats
tx of hypoK
• Treat cause
IV K replacement
Where is spinal and epidural given?
Epidural - given anywhere
Spinal - given below L2
S&S of hiatus hernia?
• Vomiting • Weight loss • Bleeding and anemia • Hiccups and palpitations Swallowing problems
Types of hiatus hernia?
• Rolling
Sliding
Surgical indications for hiatus hernia
• Remains symptomatic
• Increased risk of strangulation
Nutritional failure
Surgical tx for hiatus hernia
Fundoplicaiton
Patho of peptic ulcer disease
• Most commonly on lesser curvature of stomach or first part of duodenum
Caused by H pylori or NSAIDs
Red flags for gastric cancer and investigation
Gastric cancer red flags - ALARMS: A - Anaemia L - Lost weight A - Anorexia R - Recent rapid onset M - Meleana S - Swallowing difficulty
Immediate Endoscopy + biopsy
S&S of gastric and duodenal ulcer
• Gastric: ○ Epigastric pain - worse after eating ○ Nausea ○ Weight loss • Duodenal: Epigastric pain - worse 2 hrs after eating
Investigations for peptic ulcer and tx
• H pylori test - Stool antigen • +ve H pylori test - Tx: ○ PPI + amoxicillin + clarithromycin for 7 days • -ve H pylori test - Tx: PPI
RFs for gastric cancer
• H Pylori • Male • Age • Smoking • Japan/Korean Alcohol
S&S for gastric cancer
• Presentation is non specific: ○ Haematemesis ○ Dyspepsia ○ Dysphagia ○ N&V • Advanced S&S: ○ Anaemia signs ○ Jaudnice and hepatmegaly - Liver mets Enlarged Vircows node
Investigations for gastric cancer
Investigations:
• Routine bloods
• Endoscopy + biopsy
• If biopsy confirms - CT CAP to stage disease
commonest causes of SBO
- Adhesions -50+%
- Hernias - 25%
Tumours - 15%
- Hernias - 25%
Causes of adhesion
• Previous surgery
• Idiopathic
• Abdo infection
Trauma
Patho of crohns
• 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
RFs of crohns
- FHx
Smoking
Tx of crohns
- Induce remission:
a. Methotrexate + prednisolone- Maintain remission:
a. Azathioprine
Surgery if medical tx fails - ileocaecal resection
- Maintain remission:
S&S of crohns
• Episodic abdo pain • Diarrhoea - possible blood • Malaise, anorexia, low fever • Oral ulcers Perianal disease
Investigations for crohns
• Routine bloods
Colonoscopy with biopsy
Complicaitons of crohns
• Stricture formation • Fistula • Perianal abscesses • GI malignancy Malabsorption
Signs on xray crohns
thumbprinting
Site involvement, inflammation, micro and macro changes of crohns vs ulcerative
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
UC patho
• Diffuse mucosal inflammation, beginning in rectum going proximally
• Crypt abscess
• Goblet cell hypoplasia
Pseudopolyps
RFs UC
- Smoking = protective
* Bimodal distribution - 15-25 yr old and 55-65 yr old
Tx of UC
- Induce remission:
a. Mild to moderate - sulfasalazine
b. Severe - IV prednisolone- Maintain remission:
a. Sulfasalazine
Surgery if medical tx fails - total proctocolectomy (rectum + colon removal)
- Maintain remission:
S&S of UC
• Bloody diarrhoea - More bloody than Crohns
• Tenesmus
• Increased frequency and urgency of defecation
• Systemic symptoms - malaise, anorexia, low grade fever
Toxic megacolon = severe
Ix of UC
• Routine bloods - anaemia. Raised CRP and WCC
• Colonscopy with biopsy
• AXR if toxic megacolon suspected
Lead pipe colon seen in chronic UC
Complications of UC
• Toxic megacolon
Carcinoma
signs of UC on AXR
lead pipe colon, toxic megacolon
RFs of appendicitis
• FHx
• White
Environmental - summer bigger risk
S&S of appendicitis
• Abdo pain poorly localised --> RIF • N&V • Change in bowel habits • Pyrexia Guarding - if perf
Ix of appendicitis
• Urinalysis - UTI exclusion
• Pregnancy test
• Routine bloods - raised WCC and CRP
Abdo USS - diagnosis
Tx appendicitis
Laparoscopic appendectomy
Complications of appendicitis
• Perf
• SSI
Pelvic abscess - after perf
Patho of Diverticular disease
• 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
3 manifestations of diverticular disease
• Diverticulosis - Presence of diverticulum
• Diverticular disease - symptomatic diverticulum
Diverticulitis - inflammation of diverticulum
RFs of diverticular disease
• Low fibre intake • Obesity • Smoking • FHx NSAIDs
S&S of diverticular diseaase
○ Colicky pain - exacerbated by food and relieved by defecating
○ Altered bowel habits
○ Nausea
Flatulence
S&S of diverticulitis
○ Abdo pain and local tenderness - usually LIF
○ PR bleeding
Sepsis - if perf
Ix of diverticular diseaes
• Routine bloods - anaemia if bleeding • ABG - lactate if ischemic • Sigmoidoscopy in diverticular disease: ○ NOT IN DIVERTICULITIS - risk of perf AXR to exclude obstruction
Tx of diverticulitis. Indications for surgery?
• Diverticulitis: ○ IV abx ○ IV fluids ○ Bowel rest ○ Analgesia • Surgical washout indications: ○ Perf with fecal peritonitis ○ Sepsis Failure to improve with medical tx
Genes involved in colorectal cancers
• Adenomatous polyposis coli (APC) gene
Hereditary nonpolyposis colorectal cancer (HNPCC)
S&S of left and right sided colorectal cancer
○ Right = occult (hidden) bleeding. Left is frank.
○ Left = tenesmus. Right = weight loss.
Right = RIF mass. Left = LIF mass
Dukes staging and 5 yr survival
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
Ix of colorectal cancer
• FBC - anemia if right sided.
• LFTs - liver mets
• Cancer marker carcinoembryonic antigen (CEA)
Colonoscopy with biopsy.
Tx of colorectal cancer
• 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
S&S of hemorrhoids
• PAINLESS fresh bleeding
• Palpable mass
• Pruritic
Soiling - mucus or impaired continence
RFs of hemorrhoids
• Chronic constipation
• Age
Raised intra-abdo pressure eg pregnancy, chronic cough, ascites
Classification of hemorrhoids
- 1st degree - in rectum
- 2nd degree - prolapse through anus on defecation but spontaneously reduce
- 3rd - degree - prolapse on defecation but require digital reduction
4th degree - persistently prolapsed
Ix of hemorrhoids
• Proctoscopy
• FBC - anemia due to bleeding
Colonoscopy to exclude malginancy
Tx of hemorrhoids
• Conservative:
○ 1st and 2nd degree treated with rubber band ligation
• Surgical:
Hemorrhoidectomy if symptomatic
Rectal carcinoma S&S
• Pain and fresh bleeding • Mucus and discharge from anus • Palpable mass • Pruritis Tenesmus and fecal incontinence possible
Ix of rectal carcinoma
• FBCs - anemia of chronic disease • DRE • Biopsy • USS guided FNA of inguinal lymph nodes • CT-thorax-abdo-pelvis for mets MRI pelvis - local invasion
What is hartmanns procedure. used for?
• 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
patho of anal fissure
• Tears in lining of anal canal
• <6 wks - acute
>6wks - chronic
Acute anal fissure tx
• High fibre high fluid
• Bulk forming laxative - Ispaghula husk
• Topical anasthesia
Analgesia
chronic anal fissure tx
• Same as acute + the following
• 1st line - Topical GTN
2nd line - surgery or botulinum toxin referral
RFs of inguinal hernia
male
S&S of inguinal hernia
• Groin lump - reducible on pressure and lying down
Discomfort and ache on activity
Tx of inguinal hernia
• Conservative if few symptoms
• Surgery - if symptomatic:
Mesh repair - open or lapascopic
Femoral hernia RF
female
S&S of femoral hernia
• Most are Asymptomatic
• Emergency presentation if strangulated
Irreducible
Tx of femoral hernia
surgery
Ix of femoral hernia
USS
RFs of incisional hernia
• Obesity • Midline incision • Wound infection • Age Pregnancy
how to assess dilatation on axr of GI?
3/6/9 Rule to assess if there is dilatation:
• >3 cm for small bowel
• >6 cm for large bowel
>9 cm for caecum
signs of pneumoperitoneum on axr
cupola (air under diaphragm), riglers (double wall of bowel visible),
assess hernia on axr
• There is never any bowel below the pelvic line
Hernia if there is.
sign of sigmoid volvulus on axr
coffee bean sign
sign of caecal volvulus on axr
caecum moves from RIF to central abdo and distends
Approach to AXR
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
Prep for surgery?
○ NBM ○ IV access ○ VTE prophylaxis • Analgesia + antiemetics • IV fluids + monitor balance
Acute abdomen in URQ
cholecystitis, pyelonephritis, ureteric colic, hepatitis, pneumonia
acute abdomen in ULQ
pyelonephritis, ureteric colic, pneumonia, gastric ulcer
acute abdomen in LRQ
appendicitis, ureteric colic, inguinal hernia, IBD, UTI, gyne, testicular torsion
acute abdo in LLQ
Diverticulitis, ureteric colic, inguinal hernia, IBD, UTI, gyne, testicular torsion
acute abdo in periumbilical reguin
appendicitis, SBO, LBO, AAA
acute abdo in epigastric region
PUD, cholecystitis, pancreatitis, MI
Ix for acute abdomen
• 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
Peritonitis S&S
• Abdo tenderness • Rigidity • Guarding • Rebound Tenderness EXTREME stillness
Tx of peritonitis
○ Surgery to repair viscus
○ Abx to cover
?peritoneal lavage
Ix of peritonitis
• Bloods - FBC, U&E, LFT, CRP, amylase • ABG - bleeding • Pregnancy test • Blood cultures AXR
S&S of AAA ruptured
• Abdo pain and back pain
• Syncope
• Vomiting
Hemodynamically compromised with pulsatile abdo mass and tenderness
Tx of AAA ruptured and stable
• 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
causes of acute limb ischemia
• Thrombosis in situ
• Embolism
Trauma inc compartment syndrome
S&S of acute limb ischemia
Early S&S: • EXTREME Pain or tenderness ○ Worse on passive movement ○ Worsening despite analgesia • Swelling Parasthesia
Initial tx of acute limb ischemia
• Oxygen
• IV access
Heparin
Surgical and conservative tx of acute limb ischemia
Conservative:
• LMWH
Surgical:
• Bypass surgery if completely occluded
• Angioplasty and stenting
If limb non salvagable, amputate.
Ix of acute limb ischemia
• Bloods - FBC, clotting, U&E (electrolyte imbalances), serum lactate (ischemia), thrombophilia screen
• ECG - AF
• Doppler USS both limbs
Consider CT angiography
RFs of chronic limb ischemia
• Smoking • Diabetes • Hypertension • Hyperlipidemia • Age Family Hx
Classification of chronic limb ischemia
Stage I Asymptomatic
Stage II Intermittent claudication
Stage III Ischaemic rest pain
Stage IV Ulceration or gangrene, or both
definition of critical limb ischemia
• Ischemic rest pain for 2wks+, needing opiate analgesia
• Presence of gangrene
ABPI <0.5
What causes falsely high ABPI?
calcification and hardening of arteries
Ix of chronic limb ischemia
• 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
tx of chronic limb ischemia - medical and surgical
Medically: • Lifestyle advice • Statins • Aspirin or clopidogrel • Optimise diabetes control
Surgically:
• Angioplasty
• Bypass grafting
Amputation
Test for chronic limb ischemia
Buerger’s test
• Raise pts legs while supine
• They go pale until theyre lowered again
Angle of <20 degs indicates severe ischemia
S&S of carotid artery disease
Presents with TIA or stroke
Ix of carotid artery disease
• Bloods - FBC, U&E, clotting, lipid profile, glucose
• ECG - AF (source of clot)
• If pt high risk:
Duplex USS of carotids to assess stenosis
Acute tx of carotid artery disease
• High flow Oxygen
• Optimise blood glucose (4-11 mmol)
• Ischemic stroke - IV alteplase and 300mg OD for 14 days
Hemorrhagic stroke - referral to neurosurgery
Long term tx of carotid artery disaease
• Clopidogrel • Statin • Treat diabetes or hypertension • Smoking cessation • Exercise • Surgical revascularisation if stenosis is above 50% Consider Carotid endarterectomy
S&S and location of total anterior circulation stroke
Middle or anterior cerebral arteries All of - HHHH: • Hemiparesis + Hemiataxia • Homonymous Hemianopia High cortical dysfunction (dysphagia, dyspraxia, neglect)
S&S and location of partial anterior circulation stroke
Middle or anterior cerebral arteries
2/3 of HHHH or just Higher cortical dysfunction
S&S and location of lacunar stroke
Deep penetrating arteries
lacunar - motor or sensory or motor-sensory or ataxic hemiparesis
S&S and location of posterior circulation stroke
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
Investigations for stroke
• URGENT CT head • Bloods - FBC, U&E, clotting, Lipid profile, glucose • ECG - AF CXR Once diagnosis made: • Duplex USS of carotids Assess degree of stenosis
Acute tx for stroke
• ABCDE • High flow o2 • Optimise BM • Ischemic stroke: ○ IV alteplase if within 4.5 hrs of symptoms ○ 300mg Aspirin • Hemorrhagic stroke: Neurosurgery referral
LT tx for stroke
• Antiplatelets - clopidogrel • Statin • Treat HTN and DM • Smoking cessation • Regular exercise • If stenosis >70% or symptomatic, refer for surgery: Carotid endarterectomy
Causes of acute mesenteric ischemia
a. 25% - Thrombus eg AF or aneurysms.
b. 50% - Atherosclerosis
c. 20% - Shock
10% - Venous occlusion eg malignancy, coagulopathy
S&S of acute mesenteric ischemia
• Generalised abdo pain - EXTREME
• N&V++
• Late stage can present as bowel perforation
BE WARY OF EMBOLIC SOURCES EG AF, HEART MURMURS
Ix of acute mesenteric ischemia
• 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
Tx of acute mesenteric ischemia
• Initial: ○ Fluid resus + catheterisation ○ IV abx due to feces ○ Surgery prep • Surgery: ○ Excise necrotic bowel revascularise bowel.
Patho of chronic mesenteric ischemia
• Atherosclerosis of SMA, IMA or celiac trunk
When demand for blood increases, eg after food, transient ischemia results
S&S of chronic mesenteric ischemia
- Post eating pain - 10 mins to 4 hrs later
- Weight loss - malabsorption + reduced intake due to pain + fear
- Concurrent vascular co-morbs
Ix of chronic mesenteric ischemia
• Routine bloods
• Imaging:
CT angiography - reveals stenosis of arteries
Tx of chronic mesenteric ischemia
• Medical: ○ Clopidogrel and statin ○ Weight loss, increase exercise ○ Smoking cessation • Surgical: Stent
Define AAA
Dilatation >3cm
S&S of AAA
• 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
Ix of AAA
• USS
Follow up CT scan with contrast
Tx of AAA - medical and surgical
• 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.
AAA and driving?
> 6cm AAA disqualifies from diriving
S&S of upper GI hemorrhage
• Haematemesis +/or malaena
• Epigastric discomfort
Sudden collapse
Oeseophagus causes of upper GI hemorrhage and S&S
○ 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
Duodenum cause of upper GI hemorrhage
Ulcer
Gastric cause and S&S for upper GI hemorrhage
• Cancer - Blood mixed with vomit. Cancer symptoms
Ulcer - Presents as iron deficiency anaemia. Can erode into major vessel
Tx of upper GI hemorrhage
• ABCDE • Routine bloods + cross match • Endoscopy • Surgery indications: ○ >60 yr ○ Recurrent bleeding Non resolving
Patho of venous ulceration
• 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
RFs for venous ulceration
• DVT • Venous incompetence eg varicose veins • Trauma • Pregnancy Obesity
S&S of venous ulceration
• 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
Ix of venous ulceration
Confirm insufficency with duplex USS
Tx of venous ulceration
• Conservative: ○ Emollients for dry skin ○ Increased exercise ○ Leg elevation ○ Abx if infection Surgery - if conservative fails
Patho of arterial ulceration
• 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
S&S of arterial ulceration
• History of limb ischemia • Painful ulcer with little healing (therefore no granulation) • Hair loss in area • Cold limbs Absent pulses
Tx of arterial ulceration
• Conservative: ○ Smoking cessation ○ Weight loss ○ Increase exercise • Medical: ○ CVS risk modification • Surgical Angioplasty or bypass
Patho of varicose veins
• Incompetent valves
Venous HTN and dilatation of superficial system
Causes of varicose veins
• 98% primary idiopathic
• Secondary:
○ DVT
Pregnancy
RFs of varicose veins
• Obesity
• Prolonged standing
• FHx
Pregnancy
S&S of varicose veins
• Unsightly • Varicose eczema - dry and itchy • Pain • Ulcers • Hemosiderin skin staining Lipodermatosclerosis
Ix for varicose veins
Duplex USS
Tx of varicose veins and surgical indications
• 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
Define VTE
Term used to describe both DVT and PE
RFs of VTE
• Age • Previous VTE • Smoking • Pregnancy • Immobility • HRT • Malignancy • Obesity Thrombophilia disorder
DVT S&S
• Most are asymptomatic
• Unilateral leg pain and swelling
• Low fever
Pitting oedema
Ix of DVT
• If DVT likely - Duplex USS:
○ If result is -ve, perform D dimer to exclude
If DVT unlikely - D dimer to exclude
Tx of DVT
Tx:
LMWH cover for 5 days with warfarin for 3 months
Length of anticoag for DVT?
• 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
State the 2 level DVT wells score and what score = likely DVT?
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
S&S of SBO
• 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
Causes of abdo distension?
6Fs: • Fluid • Fat • Flatus • Feces • Fetus Fucking big tumour
Ix for SBO
• 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
Ischemia red flags for SBO
• FOCAL TENDERNESS
PAIN WAS COLICKY NOW CONSTANT
Tx for SBO
• 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
Causes of LBO
- Malignancy (until proven otherwise)
- Diverticular disease
Volvulus
- Diverticular disease
S&S of LBO
• Similar to SBO • More gradual onset • May have cancer symptoms: ○ Rectal bleeding ○ FHx Weight loss
S&S of bowel adhesions
• Colicky pain
• Constipation
• Fecal vomiting
Abdo distension
Ix for bowel adhesions
• Bloods - FBC, U&E, Clotting, group and save, Crossmatch
• ABG - serum lactate for ischemia signs
Imaging - Abdo Xray, abdo CT
Tx for bowel adhesions
• 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
Assessing pain objectively?
tachycardia, tachypnoea, HTN, sweating, flushing
WHO pain ladder?
Step 1 - non opioid +/- adjuvant
Step 2 - weak opioid + previous
Step 3 - Strong opioid + previous
RFs for post op N&V
• Female • Previous PONV • Opioid analgesia • Longer op • Poor pain control Propofol use
When are the 2 antiemetics used
• Gastric stasis - metoclopramide
Opioid induced - ondasteron
Prophylaxis for post op N&V
• Reduce opiate use and propofol • Antiemetic use Dexamethasone at induction • Adequate fluid hydration Adequate analgesia
3 types of post op hemorrhage?
- Primary - during op
- 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
- Reactive - 24 hrs after op. Due to intraop hypotension and vasoconstriction that means bleeding from some vessels only occurs once BP normalises
S&S of post op hemorrhage
• Most sensitive sign - tachypnoea
• Tachycardia and hypotension are late signs
Oligouria
Tx of post op hemorrhage
• ABCDE
• Fluid resus
Referral
Causes of post op pyrexia
• Infection
• Iatrogenic
VTE
Infection sources post op?
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+.
Tx of post op pyrexia?
• ABCDE
• Is pt septic?
• Examine for line infections, and DVTs
UO >0.5ml/kg/hr?
S&S of acute pancreatitis
• Sudden onset Epigastric pain, may radiate to back
• N&V
• Severe pancreatitis - guarding and rigid abdomen
Grey turners and cullens sign
Tx of acute appendicitis
• High flow O2 • IV fluids - 500ml/hr of crystalloid • Nasogastric tube if pt vomiting • Catheterisation to monitor urine output Opioid analgesia
Ix of aacute ppendicitis
• Serum amylase - 3x upper limit of normal
• LFTs - gallstones can cause pancreatitis
• Serum lipase
Imaging - USS AP and CT scan
Causes of acute pancreatitis?
GET SMASHED:
GallstonesEthanolTraumaSteroidsMumpsAutoimmune disease eg SLEScorpionHypercalcemiaERCPDrugs eg diuretics or NSAIDS
Causes of chronic pancreatitis
alcohol, idiopathic
S&S of chronic pancreatitis
• Chronic epigastric pain: ○ eased by leaning forward ○ May radiate to back • Recurrent acute pancreatitis N&V
Ix of chronic pancreatitis
• Glucose - raised • Serum calcium - hypercalcemia • Imaging: ○ Abdo USS - first line CT scan - pancreatic calcification or pseudocyst
Tx of chronic pancreatitis
• Analgesia
ERCP to extract stones
Complications of chronic pancreatitis
• Pseudocyst
• Steatorrhoea and malabsorption - enzyme replacement tx
Diabetes
RFs of biliary cholic
Risk Factors:
5 Fs - Fair, Fat, Forty, Fertile, Family history
S&S of biliary colic
- No inflammatory response
- Sudden pain, dull, colicky (waxes and wanes, not true colick)
- RUQ focus
- N&V
- Fatty foods make worse
- Settles with analgesia
Ix of biliary colic
• 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.
Tx of biliary colic
• Analgesia eg morphine.
• Elective cholecystectomy can avoid future recurrence with worse consequences
Offer lifestyle advice
Gallstone ileus patho
If colic is long standing can erode through gallbladder into small bowel and cause obstruction in terminal ileus (smallest point of bowels)
Patho of cholecystitits
Inflammation of gallbladder
Ix of cholecystitis
• 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.
Tx of cholecytsitits
• Antibiotics - IV coamox and metronidazole
• Fluid resus pathway if signs of sepsis evident
• NG tube if pt vomiting
Cholecystectomy necessary
S&S of cholecytsitits
• RUQ pain, sudden, dull colicky • N&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.
Patho of cholangitis. CauseS?
Infection of biliary tracts, potentially caused by any condition that occludes biliary tree.
Common causes are gallstones, ERCP, cholangiocarcinoma.
What must you remember about cholangitis
CHOLANGITIS IS NOT A COMPLETE DIAGNOSIS - There is always an underlying cause that must be treated
S&S of cholangitis
• RUQ pain - Charcots triad
• Fever - Charcots triad
• Jaundice - Charcots triad
Pruritis
Tx of cholangitis
• Fluid resus pathway if septic signs
• Broad spectrum IV antibiotics - Coamox and metronidazole
ERCP to remove biliary obstruction. Can also place stent
Ix of cholangitis
• FBC - raised WCC
• LFTs - raised Alp and bilirubin
Blood cultures
• USS AP - bile duct dilatation, ERCP is diagnostic and therapeutic but invasive
Patho of cholangiocarcinoma
Cancer of bile duct system. Most common area is bifurcation of right and left hepatic ducts (klatskin tumours)
Ix of cholangiocarcinoma
• 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.
S&S of cholangiocarcinoma
• Asymptomatic until late stage • Jaundice, pruritis • Pale stools • Dark urine Courvoisiers law - presence of jaundice and enlarged/palpable gallbladder, suspect biliary or pancreatic cancer
Tx of cholangiocarcinoma
• Complete surgical resection • Radiotherapy • Palliative most likely needed: ○ Stent to get rid of obstructive symptoms Radiotherapy to prolong survival
S&S of pancreatic cancer
• Pain in abdomen radiating to back
• Obstructive Jaundice
• Steatorrhoea - pale and floating
Weight loss, cachexia
• Abdo mass palpable Jaundiced.
What is courvoisiers law
Courvoisier’s Law - If gallbladder palpable and jaundice, it’s a cancer of biliary tree or pancreas.
Ix of pancreatic cnacer
- FBC - anemia of chronic disease
- Pancreatic amylase
- LFTs - Raised ALP, gamma-GT, bilirubin (obstructive jaundice)
- CA19-9 tumour marker for pancreatic cancer
• CT scan - disease staging.
Endoscopic USS used for fine needle aspiration biopsy
Tx of pancreatic cancer
• Surgery - Whipples: ○ 40% mortality ○ Due to risk of forming pancreatic fistula • Chemotherapy: ○ After surgery use 5-FU • Palliative Care: Biliary stenting
Liver cancer most common primary? Cause?
Hepatocellular carcinoma caused by viral hepatits
S&S of liver cancer
• Liver cirrhosis presenting: ○ Ascites ○ Jaundice ○ Portal venous HTN • Fatigue • Fever • Weight loss Lethargy
Ix of liver cancer
• LFTs
• Cancer marker alpha fetoprotein (AFP)
USS - mass of >2cm with raised AFP = diagnostic
Tx of liver cancer
• Surgery
Image guided ablation if early
Patho of GORD
• Lower oeso sphincter relaxes and allows reflux of gastric contents
Pain and mucosal damage results
RFs of GORD
• Age • Obesity • Alcohol • Smoking • Caffeine Fatty or spicy foods
Tx of GORD
• 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
S&S of GORD
• Chest pain: ○ Burning ○ Worse after meals ○ Worse lying down, bending over or strainign ○ Relieved by antacids • Excess belching Chronic cough or nocturnal cough
Ix of GORD. Indications for urgent endoscopy?
• 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
Complications of GORD?
• Barretts oeseophagus –> oseophageal cancer
• Oesophagitis
Aspiration pneumonia
Conservative Tx of hiatus hernia
○ PPI
Lifestyle modification
Patho of barretts oesophagus
• Metaplasia of oesophageal epithelial lining:
Stratified squamous to simple columnar
RFs of barretts oesophagus
• White • Male • >50yo • Smoking • Obesity • Hiatus hernia FHx
Ix of barretts oesophagus
Histological diagnosis via biopsy
Tx of barretts
• PPI
• Regular routine endoscopy to ensure no neoplasia
Resection of premalignant lesions via endoscopy.
Types of oeseophageal cancer and where found
• Squamous cell: ○ Middle and upper third of oesophagus ○ RF - smoking, alcohol • Adenocarcinoma: ○ Lower third Due to barretts
S&S of oesophageal cancer
• Dysphagia
• Weight loss
• Haematemesis
Lymphadenopathy
Tx of oesophageal cancer
• Curative: ○ Surgery with neoadjuvant chemotherapy • Palliative: ○ Oesophageal stent if dysphagia Radiochemotherapy to improve symptoms
Patho of achalasia
• Motility disorder. Failure of smooth muscle to relax.
• Due to destruction of myenteric plexus
Progressive disease.
S&S of achalsia
• Progressive dysphagia
• Weight loss
Food regurgitation
Tx of achalasia
• Conservative: ○ Sleep with many pillows ○ Eat slowly + plenty of fluids • Surgical: Myotomy - division of myofibres that fail to relax
Ix for GI perf
• Routine bloods - give idea on how it perforated
• Imaging:
○ Erect CXR - free gas under diaphragm
CT scan
