Perioperative Flashcards
1
Q
Define a fistula
A
Abnormal tract between two epithelial surfaces
2
Q
Define a sinus
A
A blind ended cavity lined with epithelium
3
Q
Define a hernia
A
An abnormal protrusion of an organ through the wall of the cavity it is contained in.
4
Q
Which types of hernia are usually asymptomatic?
A
Hiatus and umbilical
5
Q
What are the signs of limb ischaemia? Indicate which are early and which are late signs.
A
Early - Pale, Parasthesia, Pain, Perishingly cold
(if compartment, passive stretch pain, palpable swelling)
Late - Pulseless, Paralysis
6
Q
What is the rule of 2s for meckels diverticulum?
A
2% of population Presents before 2 years 2:1 male:female 2 inches long 2 ft above ileocaecal valve (In small intestine)
7
Q
What is a meckels diverticulum?
A
Remnant of the vitelline duct (yolk sac to midgut)
Contains 2 different types of mucosa, can include pancreatic or gastric.
8
Q
How can a meckels diverticulum cause complications?
A
- Vitelline fistula (poo at umbilicus soon after birth)
- Haemorrhage - (Gastric mucosa - peptic ulcer)
3 Small bowel obstruction (adhesions, stones, torsion) - Diverticulits
- Intussusception
9
Q
How do you differentiate between the 3 main causes of acute RUQ pain?
A
All colicky pain, provoked by fatty meal.
Biliary colic - No fever, no CRP
Acute cholecystitis - +fever, CRP, Murphy’s sign (stop breathing when press RUQ)
Ascending cholangitis - +jaundice
(Charcot’s triad of pain, fever and jaundice is ascending cholangitis)
10
Q
How do you differentiate between the 3 main causes of acute epigastric pain?
A
Peptic ulcer - NSAID use, alcohol, reflux
Gastric - worse when eating
Duodenal - relieved by eating
Acute pancreatitis - radiates to back, alcohol, gallstones, fever.
11
Q
How do you differentiate between the main causes of acute central abdominal pain?
A
Early appendicitis - pain on palpation RIF, anorexia, tachy, fever
Acute pancreatitis - radiates to back, alcohol, gallstone, fever
IBD flare - diarrhoea/constipation, blood in stool, joint pains, skin signs, mouth ulcers
Obstruction - vomiting (small), complete constipation (large), tinkling bowel sounds. Hx adhesions or Ca.
Ectopic - repro age, amenorrhoea
AAA - elderly man, radiates to back, hypotensive, tachy, IHD
Mesenteric ischaemia - AF/ cardio disease, diarrhoea, metabolic acidosis from the latate produced by necrosis.
12
Q
How do you differentiate between the main causes of acute RIF pain?
A
Appendicitis - anorexia, tachy, fever, moved from early central pain
Ectopic - repro age, amenorrhoea
IBD flare - diarrhoea/constipation, blood in stool, joint pains, skin signs, mouth ulcers
13
Q
How do you differentiate between the main causes of acute LIF pain?
A
Diverticulitis - elderly, colicky, diarrhoea, fever, CRP, white cells
Ectopic - repro age, amenorrhoea
14
Q
How do you differentiate between the main causes of supra pubic pain?
A
UTI - female, dysuria, frequency
Urinary retention - male with history of BPH
Torsion - absent cremasteric reflex
15
Q
How do you differentiate between the main causes of acute abdo pain radiating to the back?
A
AAA - elderly man, hypotensive, tachy, IHD
Acute Pancreatitis - alcohol, gallstones, fever.
Pyelonephritis - loin to groin pain, fever, rigors
Renal colic - colicky, severe pain, haematuria
16
Q
When would it be appropriate to prescribe Hartmann’s fluid?
A
When replacing isotonic fluid loss.
eg after surgery, diarrhoea and vomiting, blood loss
17
Q
When would it be appropriate to prescribe a dextrose - saline fluid regimen?
A
When replacing hypotonic fluid loss
eg dehydration, diabetes insipidus
18
Q
When is it especially important to avoid pure saline? (ie 0.9% normal saline only)
A
Post op and in sepsis.
Because cell lysis and leaky capillaries respectively lead to increased electrolytes. Pure saline will lead to Na overload.
19
Q
How should you treat a fluid overloaded heart or renal failure patient?
A
Reverse with furosemide
Start fluid chart
Catheterise
20
Q
What is the universal recipient blood type?
A
AB+
21
Q
What is the universal donor blood type?
A
O-
22
Q
What is a massive haemorrhage?
A
100% blood volume (5L) in 24 hours
50% blood volume in 3hrs
or
150ml/min
23
Q
What are the signs and symptoms of acute haemolysis in reaction to a blood transfusion?
A
Shock - fever, AKI, respiratory distress, hypotension, tacchycardia, restless.
Chest pain radiating to the back.
24
Q
What is the pathophysiology of an acute haemolytic reaction to a blood transfusion?
A
Host antibodies IgG and and IgM respond to the antigen (A or B) on the donor blood cells.
They bind to the donor cells, activate complement and lead to haemolysis.
They can also opsonise the rbcs so that they clump together and are captured by macrophages and the RES system.
Massive lysis of rbcs leads to acute anaemia and shock.
25
What is FFP? When is it used?
Fresh frozen plasma - contains clotting factors, albumin and immunoglobulin.
Therefore used in patients with hepatic failure before surgery as they can't produce these things well.
Or a massive haemorrhage in a patient on warfarin/ raised INR.
26
What is tranexamic acid? When is it used?
Blocks plasminogen to plasmin. Less plasmin means clots last longer.
Within 3hrs of an injury to boost the effectiveness of natural clotting.
27
What is the name of the score to calculate VTE risk in surgical patients? What does it include?
Caprini score
2. Age over 60
2. Recent stroke or MI
2. Hx VTE
2. Thrombocytopenia
1. CCF/AF
1. Obesity
1. Hormonal contraceptive/pregnancy
2. Type of surgery - arthroplasty, cancer, longer than 45 mins
2. Bed bound for 72 hours post op
If 2 points use thromboprophylaxis.
28
What is the name of the score to calculate PE risk? What does it include?
Well's score
3. Clinical DVT
3. PE is number 1 diagnosis or equally likely
1. 5 HR >100
1. 5 Surgery within 4 weeks or immobile 3 days
1. 5 Previous DVT or PE
1. Haemoptysis
1. Malignancy
If greater than 4 PE likely
29
What is the sensitivity and specificity of the d dimer? What does this mean?
High sensitivity but low specificity.
Means it can be used to rule out VTE but not a diagnostic tool.
Positive predictive value low
Negative predictive value high
30
What does the d dimer measure?
Breakdown product of fibronlysis.
| Direct measure of plasmin mediated fibrinolysis
31
What pathological conditions can cause a raised d dimer?
VTE
Acute coronary syndrome
Stroke
Aortic dissection
AF
```
DIC
Sickle cell
Infection
Superficial thrombophlebitis
GI haemorrhage
```
Malignancy
Pre-eclampsia
Trauma
32
What non pathological conditions can cause a raised d dimer?
```
Age
Smoking
Post-operatively
Pregnancy
Race (e.g. African Americans)
```
33
What is the mechanism of action of warfarin?
Inhibits vitamin k reuctase therefore producing ineffective clotting factors (2,7,9 and 10)
34
What are all of the options when reversing warfarin?
```
Prothrombin complex
FFP
Vitamin k oral
Vitamin k IV
Stop warfarin
```
35
How would you reverse warfarin in an active bleed?
```
Prothrombin complex (specific clotting factors 2,7,9 and 10)
Give with vitamin k due to short half life.
```
Add FFP if ineffective (less specific blood product full of clotting factors, albumin and immunoglobulin)
36
How would you reverse warfarin for an operation within 24 hours?
Oral vitamin k
37
How would you reverse warfarin for an operation within 6-8 hours?
IV vitamin k
38
How would you reverse warfarin for an elective operation?
Stop warfarin 5-7 days before
Operation goes ahead when INR is below 1.5
Consider heparin bridging
39
What is the advantage of LMWH over normal heparin?
Low risk of HIT (heparin induced thrombocytopenia) longer half life, no APTT monitoring.
(Normal heparin required in renal failure)
40
What is the thromboprophylactic dose of LMWH for a 70kg man? When should it be started around surgery?
Dalteparin - 2500 units SC BD
Enoxaparin - 40mg SC OD
6-12 hours post operative
41
When should a woman stop taking the COC before surgery?
4 weeks before
42
When should clopidogrel be stopped before surgery?
7-10 days
| Unless prosthetic valve, in which case continue dual antiplatelet with aspirin
43
When should aspirin be stopped before surgery?
On the day
| Unless prosthetic valve, in which case continue dual antiplatelet with clopidogrel/prasugrel/ticagrelor
44
How should hypoglycaemics be adapted before surgery in a well controlled diabetic on oral medication?
Sulphonylureas - stop on the morning (risk of hypo)
Continue metformin and pioglitazone
Monitor BM throughout periop period and place first on the list
45
How should hypoglycaemics be adapted before surgery in an insulin dependent diabetic?
Sliding scale throughout peri op period (risk of hypo)
46
Which antibiotics should be used for surgical prophylaxis?
IV Gentamicin and metronidazole
| 1 hr prior to surgery
47
Which surgical procedures require prophylactic antibiotics?
```
Anything except clean surgery eg.
GI - eg appendix
Caesarean
Cataract
MSK
```
48
Which surgical procedures do not require prophylactic antibiotics?
Inguinal hernia repair
Lap chole
Tonsillectomy
49
What are the risk factors for post operative nausea and vomiting?
Female
Gynae and ENT
Hx N and V
General anaesthetic
50
What are the types of anti emetic?
H1 antagonists - cyclizine
5HT antagonists - ondansetron
Dopamine antagonists (prokinetic) - domperidone, metoclopramide
51
What is the mechanism of action of cyclizine?
H1 antagonist. (antihistamine)
| Blocks action of histamine from brain and middle ear on the vomiting centre in the medulla.
52
What is the mechanism of action of ondansetron?
5HT antagonist.
Blocks lots of actions on vomiting centre in the medulla.
From brain and middle ear, from the chemoreceptor trigger zone in the area postrema in the floor of 4th ventricle and from GI tract.
53
What is the mechanism of action of pro kinetic antiemetics? Can you give 2 examples?
Dopamine antagonists.
Domperidone and metoclopramide.
Block action on vomiting centre in the medulla from the chemoreceptor trigger zone in the area postrema in floor of the 4th ventricle and the GI tract.
54
What is the mechanism of loperamide?
Opioid agonist that doesnt cross the bbb
55
What is the major side effect of loperamide?
Risk of toxic megacolon in IBD
56
What are the types of laxative?
Bulk - Fybogel (methylcellulose + ispaghula husk)
Stimulant - senna
Osmotic - lactulose, movicol, phosphate enema
Stool softener - arachis oil
57
What is the mechanism of action of fybogel (methyl cellulose + ispaghula husk)?
Bulk forming by undigested hydrophillic substance that increases volume of stool.
Can help in both constipation (by increasing peristalsis and softening stool) and diarrhoea (by solidifying stool)
Therefore very good in IBS where there may be both symptoms
58
What is the mechanism of action of senna?
Stimulates intestinal muosa to produce water.
59
What is the mechanism of action of lactulose?
Osmotic agent.
| Undigestible starch that draws water into the lumen by osmosis
60
What should be prescribed as an initial fluid challenge for a maintenance regime?
500ml 0.9% saline at 30ml/kg/24hr
Therefore for a 75kg man needs 500ml at a rate of 100ml per hour
61
What should be prescribed as a fluid challenge in a replacement regime?
500ml 0.9% saline stat
62
Describe the ASA classes of risk for anaesthesia.
ASA I No systemic disease
ASA II A patient with mild systemic disease
ASA III A patient with severe systemic disease
ASA IV A patient with severe systemic disease that is a constant threat to life
ASA V A moribund patient who is not expected to survive without the operation
63
What is the electrolyte disturbance seen in an addissonian crisis?
With vomiting, Low sodium high potassium think addissonian
64
What reverses heparin? When is it routinely administered?
Protamine sulphate.
| When coming off cardiac bypass because lots of heparin has been used.
65
What imaging is required before a patient with rheumatoid arthritis has a general anaesthetic?
AP and lateral C spine x rays to check for atlantoaxial subluxation.
66
What are the most common post op complications in timeline order?
```
1- 4 days
atelectasis + or - pyrexia
stroke
MI
paralytic ileus
addissonian crisis
```
1-7 days
Urinary retention
AKI
5-10 days
delirium
7-10 days
Infection - chest, wound, UTI
Secondary haemorrhage
10-14 days
VTE
Wound dehiscience
67
Which groups of patients require a pre op ecg?
Over 65
Renal disease
Diabetes
Cardiovascular disease
68
What routine bloods are required pre op?
Fbc - for baseline for infection/anaemia
U and e's - for baseline in case of AKI
Crossmatch and clotting in case of bleed
69
For a patient on steroids, what should happen to their medication over surgery? Why?
Steroid cover
Hydrocortisone IV at induction then normal dose 8 hourly for 72 hours.
Otherwise risk of addissonian crisis.
70
What is the appropriate crossmatching for the following types of surgery?
```
Appendicectomy
Total hip replacement
AAA repair
Cystectomy
Lap Chole
```
```
Appendicectomy - group and save
Total hip replacement - x match 2
AAA repair - x match 4-6
Cystectomy - x match 4-6
Lap Chole - group and save
```
Unlikely bleed - group and save
Likely bleed - x match 2
Definite bleed - x match 4-6
71
What is the test for an acute haemolytic reaction to a blood transfusion?
Direct coomb test
| Can also measure unconjugated (indirect) bilirubin, or serum and urine bilirubin.
72
What are the contraindications for day surgery?
```
severe dementia
severe learning disabilities
ASA III and above
BMI 32 and above
diabetes type I (if sliding scale commenced)
infection at the site of surgery
social factors
uncontrolled pain or nausea expected post-operatively
```
73
What is the anatomy of a direct inguinal hernia?
Protrudes through Hesselbach's triangle
| Passes medial to the inferior epigastric artery
74
What is the anatomy of an indirect inguinal hernia?
Protrudes through the inguinal ring (inguinal canal is ex processus vaginalis)
Passes lateral to the inferior epigastric artery
75
What is the anatomy of a femoral hernia?
Protrudes below the inguinal ligament, lateral to the pubic tubercle
76
Which type of groin hernia is common in infants?
Indirect. Due to failure of processus vaginalis to close.
77
Which type of groin hernia is common in females?
Femoral. (Although inguinal still more common than femoral in females. Out of all femoral hernias, more are women)
78
Which type of groin hernia has a high risk of strangulation?
Femoral
79
What causes a direct inguinal hernia?
Weakness in the transversalis fasica around Hesselbach's triangle
80
What causes an indirect inguinal hernia?
Failure of processus vaginalis to close
81
What are the borders of the femoral triangle?
Inguinal ligament
Sartorius
Adductor longus
82
What are the borders of the femoral canal?
Femoral vein
Lymph
Lacunar ligament
Think NAVEL
83
What are the the borders of Hesselbach's triangle?
Inguinal ligament
Inferior epigastric vessels
Lateral border of the rectus sheath
84
What are the borders of the inguinal canal?
Diagonally through the abdominal wall
Anterior - External and internal obliques
Posterior - transversalis fascia
Floor - inguinal and lacunar ligaments
Roof - transversalis fascia and transversalis abdominis
85
Describe the layers of the abdominal wall
External oblique
Internal oblique
Transveralis abdominis
Transversalis fascia
Above arcuate line all 3 aponeuroses go around both sides pf the rectus muscle to form rectus sheath
Below the arcuate line they travel anterior to the rectus mucles only
86
What is a Spigelian hernia?
A hernia through the spigelian fascia
| the aponeurosis between the rectus muscle and the arcuate line
87
What is a Richter's hernia?
A rare hernia where only one wall of the bowel herniates through the defect
Can occur at laparoscopic port sites.
88
What is the arcuate line? What is its relevance?
The line below which the rectus sheath no longer travels posterior to the rectus muscle.
Where the inferior epigastric vessels perforate the rectus muscle
Location of spigelian hernias
89
What first line treatment should be recommended for a patient with peripheral arterial disease?
Antiplatelet (aspirin) and a statin
| Plus exercise and stop smoking
90
What treatment should be offered to a patients with peripheral arterial disease in whom first line (antiplatelet and a statin) treatment is not effective?
Angioplasty or stenting
91
Describe the signs and symptoms of peripheral arterial disease
intermittent claudication
limb ischaemia: foot pain at rest, often made worse by elevation e.g. at night
ulceration
loss of foot pulses
92
What syndrome is associated with bilateral peripheral arterial disease and impotence? Why?
Leriche's syndrome
| Atheroma at the bifurcation of the aorta into the iliac arteries
93
What are the risk factors for periperal arterial disease?
Smoking
Diabetes
Obesity
94
How would you examine a patient with intermittent claudication?
check the femoral, popliteal, posterior tibialis and dorsalis pedis pulses
check ankle brachial pressure index (ABPI)
duplex ultrasound is the first line investigation
Buerger's test - lie on back, waggle legs, sit up and watch colour change like Reynaud's in abnormal leg.
95
What is pathophysiology of varicose veins?
Valve incompetence in the superficial veins or the perforators causing inefficient drainage and venous hypertension.
96
Where is the most common site of incompetent valves in varicose veins?
Sapheno- femoral junction
| second is sapheno-popliteal
97
How would you examine a patient with varicose veins?
Look feel for thrombophlebitis/ ulcerative changes
Check femoral, popliteal, posterior tibialis and dorsalis pedis pulses
Trendelenberg test to find incompetent valve
Duplex ultrasound
98
What are the indications for surgical removal of varicose veins?
1. Ulcer
2. Pre-ulcer changes - skin pigmentation, lipodermatosclerosis
3. Thrombophlebitis
99
What is the mainstay treatment for varicose veins?
Stockings
100
What are the branches of the coeliac trunk?
Left gastric
Common hepatic
Splenic
101
What are the branches of the SMA?
Right colic
Middle colic
Ileocolic
Jejunoileal
102
What are the branches of the IMA?
Left colic
Sigmoid
Superior rectal
103
Where do the inferior epigastric vessels travel?
Off externl iliac above the inguinal ligament, it pierces the transversalis fascia at the arcuate line
104
What are the branches of the abdominal aorta in order?
```
Phrenic
Coeliac trunk
SMA
Renal
Gonadal
IMA
Common iliacs
```
105
How should an ABPI be interpreted?
1 Normal
0.6-0.9 Claudication
0.3-0.6 Rest pain
<0.3 Impending
106
What are the borders of Calot's triangle? What is its significance?
Inferior border of the liver
Cystic duct
Common hepatic duct
Contains the cystic artery so identify during lap chole and make sure not to clip it.
107
What is the tumour marker for pancreatic cancer?
CA 19-9
108
What is the tumour marker for bowel cancer?
CEA
109
What is the tumour marker for liver cancer?
AFP
110
What is the tumour marker for ovarian cancer?
CA125
111
What is the tumour marker for testicular cancer?
HCG
112
Describe the scoring system used for acute pancreatitis
```
Glasgow score. 3 points predicts severity
P aO2 <8
A ge >55
N eutrophils >15
C alcium <2
R enal - urea >16
E nzymes - AST >200 LDH>600
A lbumin <32
S ugar >10
```
113
What is the management for asymptomatic gallstones?
Reassurance
114
Which type of cancer is likely to be present in the lower third of the oesophagus? Which type is in the middle third?
Lower third of oesophagus - adenocarcinoma
| Middle third with achalasia - squamous cell carcinoma
115
Describe the pathophysiology of Barrett's oesophagus
Recurrent GORD irritates the epithelia of the lower oesophagus. This leads to a metaplasia from stratified squamous non keratinised to simple columnar with goblet cells.
116
What is whipple procedure? How commonly is it performed?
Removal of the head of the pancreas and the first part of the duodenum, (plus a portion of the common bile duct, gallbladder, and sometimes part of the stomach.)
Rarely performed because pancreatic cancer presents so late.
117
What are the common sequelae of acute pancreatitis?
Pseudocyst - weeks afterwards, defined border, non epithelial wall filled with enzyme fluid. Minimal symptoms. Can drain if required.
Acute fluid collection - less defined wall, immediate, filled with serosanguinous fluid. Self resolve.
Necrosis - symptomatic. Risk of deterioration, call ITU. Necrosectomy.
118
What signs would you look for in a barium swallow?
bird beak - achalasia
| apple core - oesophageal cancer
119
What histological finding indicates gastric cancer?
Signet ring cells filled with mucus that push the nucleus to the side.
120
What signs are specific to pancreatitis?
Grey Turner and Cullen signs
Bleeding into the peritoneum (GT is round the flank, C is round the umbilicus)
121
Which part of the pancreas is usually affected by pancreatitis?
Exocrine (head) of the pancreas
122
How does pancreatic cancer present?
Painless jaundice
123
What is the differential for painless jaundice?
Pancreatic cancer
Increased production - Haemolytic anaemia, transfusion reaction, sepsis
Decreased conjugation - Cirrhosis, hepatitis, GIlberts
Impaired excretion into bile - chronic pancreatitis, PSC
124
What is the differential for painless jaundice?
Pancreatic cancer
Increased production - Haemolytic anaemia, transfusion reaction, sepsis
Decreased conjugation - Cirrhosis, hepatitis, GIlberts
Impaired excretion into bile - chronic pancreatitis, PSC
125
What tests would you order for suspected pancreatitis?
Amylase (diagnostic)
FBC (neutrophils for infective cause and for glasgow score)
U+E (expect dehydration from 3rd space losses, urea for glasgow score)
LFT (look for obstructive pattern of gallstones, gamma GT for alcohol, enzymes for glasgow)
LDH (glasgow)
Calcium (causative and for glasgow)
USS abdo (look for gallstones)
126
How would you treat acute pancreatitis?
Supportive unless infective cause (rare)
| Fluids, analgesia. ERCP if gallstones
127
What tests would you order for suspected gallstones?
FBC - leucocytes - ?cholecystitis and haemolytic anaemia risk factor
U+E - dehydration
LFT - obstructive pattern and bilirubin for ?ascending cholangitis
Lipids- causative
USS abdo
ERCP if USS positive for removal of CBD stones
128
What are the risk factors for gallstones?
Cholesterol stones-
Fat - hyperlipidaemia, obesity, diabetes,
Female - pregnancy
Forty
Pigment stones-
Crohns
Haemolytic anaemia
129
What are the most common gallstones made of?
Cholesterol
| other type is bilirubin
130
What are the most common renal stones made of?
Calcium oxalate
| others include uric acid and cystine
131
What are the indications for a lap chole?
Symptomatic biliary colic
Uncomplicated chronic cholecystitis
Early acute cholecystitis (within 72 hours is a hot gallbladder)
132
What sign is specific to gallstones?
Murphy's sign
| Press under the ribs in the RUQ and ask to breathe in, pain.
133
What is a general rule about obstructive jaundice in the presence of a palpable gallbladder?
Courvoisier's law:
obstructive jaundice in the presence of a palpable gallbladder is unlikely to be due to stones. This is due to the fibrotic effect that stones have on the gallbladder.
Therefore think cancer
134
What is surgical emphysema?
Air trapped in the fascia, often following surgery. Feels like crepitations under the skin like rice krispies.
Usually benign.
Shows up on xray. Especially look at the pectoralis muscles.
135
What is surgical emphysema?
Air trapped in the fascia, often following surgery. Feels like crepitations under the skin like rice krispies.
Usually benign.
Shows up on xray. Especially look at the pectoralis muscles.
136
What are the risk factors for gastric cancer?
```
Japanese or Chinese
H. pylori infection
blood group A: gAstric cAncer
gastric adenomatous polyps
pernicious anaemia
smoking
diet: salty, spicy, nitrates
may be negatively associated with duodenal ulcer
```
137
How is gastric cancer diagnosed?
Endoscopy
138
What type of bacteria is H Pylori?
Gram negative rod
139
What is the initial test for H pylori?
Urease breath test
140
What is H pylori associated with?
GORD
Peptic ulcers
Gastric cancer
B cell lymphoma of MALT tissue
141
How is H pylori eradicated?
7 days triple therapy
a proton pump inhibitor + clarithromycin + metronidazole/amoxicillin
142
Give some extramural causes of intestinal obstruction
Adhesions
Incarcerated Hernia
Volvulus
Tumour
143
Give some intramural causes of intestinal obstruction
IBD
Paralytic ileus
Stricture
Intussusception
144
Give some lumenal causes of intestinal obstruction
Faecal
Bezoar
Gallstone ileus
Parasites
145
What are the most common causes of small bowel obstruction?
Adhesions
| Hernia
146
What are the most common causes of large bowel obstruction?
Colon cancer
| Strictures from IBD and diverticulitis
147
What are the signs and symptoms of small bowel obstruction?
Symptoms
Colicky pain
Early vomiting
Rapid onset
Signs
Distension
Tinkling bowel sounds
Shock
148
What are the signs and symptoms of large bowel obstruction?
Symptoms
Colicky pain
Absolute constipation
Gradual onset
Signs
Distension
Empty rectum
Shock
149
What are the radiological differences between small and large bowel obstruction?
Small - valvulae conniventes lines cross all the way
| Large - haustra do not cross all the way
150
What is the radiological sign of a sigmoid volvulus?
coffee bean shape on abdo xray
151
What is the radiological sign of colonic carcinoma?
Apple core stricture
152
What is absolute constipation?
Constipation with no flatus
| Indicates large bowel obstruction
153
What investigations would you order for a suspected bowel obstruction?
FBC
U and E
Group and save
Chest x ray
Abdo x ray
Consider CT abdo and or gastrograffin study
154
What happens to fluid and electrolytes in bowel obstruction? Why?
3rd space losses of everything.
End up with acidosis and AKI
Fluid builds up at the blockage. This causes osmotic pressure into interstitium.
It also causes stasis and an overgrowth of gut flora. These release toxins that lead to leaky epithelia.
155
What is your initial management of bowel obstruction?
Decompress with NG tube
Replace fluid and electrolytes
Monitor fluid balance
Antibiotics only if in shock
156
What sign is specific to appendicitis?
Psoas stretch
| Pain when right thigh is passively extended with the patient lying on their side with their knees extended.
157
What pathogen is most likely to be associated with gangrene?
Strep pyogenes
158
What is the tumour marker for breast cancer?
CA 15-3
159
What type of surgery is appropriate for a patient with cancer in the splenic flexure?
Left hemicolectomy
160
What type of surgery is appropriate for a patient with cancer in the upper rectum?
Anterior resection (consider TME total mesorectal excision if low/borderline)
161
What type of surgery is appropriate for a patient with cancer in the lower rectum, close to the anal verge (within 6cm)?
Abdomino-perineal excision of rectum (includes TME total mesorectal excision)
162
What are the risk factors for Mesenteric ischaemia?
```
Age
AF
other causes of emboli: endocarditis
CVS: smoking, hypertension, diabetes
Cocaine
```
163
How does mesenteric ischaemia present?
```
abdominal pain
rectal bleeding
diarrhoea
fever
bloods typically show an elevated WBC associated with acidosis
```
164
What is the treatment for mesenteric ischaemia?
Surgical removal of ischaemic bowel
165
Where is mesenteric ischaemia most likely to occur?
Splenic flexure
166
Where is mesenteric ischaemia most likely to occur?
Splenic flexure
167
What nerve is at risk during inguinal hernia surgery? What effect will it have?
Ilioinguinal nerve
| Pain in groin. Illicited on palpation of the inguinal ligament
168
What nerve is at risk during anterior resection of rectum ? What effect will it have?
hypogastric autonomic nerves.
169
What nerve is at risk during Carotid endarterectomy? What effect will it have?
hypoglossal nerve
170
What nerve is at risk during thyroidectomy? What effect will it have?
recurrent laryngeal
171
What is the minimum abpi value for safely using compression bandages?
0.8
172
What are the post op complications which occur immediately?
```
atelectasis + or - pyrexia
stroke
MI
paralytic ileus
addissonian crisis
```
173
What are the post op complications which occur in the first 1-7 days?
1-7 days
Urinary retention
AKI
174
What are the post op complications which occur in the first 5-10 days?
5-10 days
| delirium
175
What are the post op complications which occur in the first 7-10 days?
7-10 days
Infection - chest, wound, UTI
Secondary haemorrhage
176
What are the post op complications which occur in the first 10-14 days?
10-14 days
VTE
Wound dehiscience
