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General (Surgery) > Presentations > Flashcards

Presentations Flashcards

1
Q

what are the most common causes of severe intra-abdominal bleeding and what signs indicate this

A

ruptured AAA

ruptured ectopic pregnancy

bleeding gastric ulcer

trauma

these patients typically go into hypovolaemic shock; tachycardia, hypotension, pale and clammy on inspection and cool to touch

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2
Q

sings and symptoms of hypovolaemic shock

A

tachycardia

hypotension

pale and clammy on inspection

cool to touch

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3
Q

what is peritonitis and what is broadly the most common cause

A

inflammation of the peritoneum

most commonly caused by perforation of an abdominal organ

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4
Q

what are some causes of perforation in the abdomen

A

peptic ulceration

small or large bowel obstruction

diverticular disease

inflammatory bowel disease

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5
Q

signs and symptoms of generalised peritonitis

A

lay completely still and look very unwell

tachycardia and potential hypotension

rigid abdomen with percussion tenderness

involuntary guarding (tensing of abdo muscles when palpating the abdomen)

reduced or absent bowel sounds (paralytic ileus)

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6
Q

any patient who presents with severe acute abdomen pain out of proportion to the clinical signs is immediately suspected to have what

A

ischaemic bowel

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7
Q

what do patients with ischaemic bowel usually complain of

A

diffuse severe constant abdo pain - however examination is often unremarkable

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8
Q

what laboratory tests are required in all cases of acute abdominal pain

A

urine dipstick - infection or haematuria

pregnancy test for women of reproductive age

ABG - useful in bleeding and septic patients; pH, pCO2, pO2, lactate (tissue hypoperfusion) and haemoglobin levels

routine bloods - include amylase (pancreatitis) and group and save (surgery)

blood cultures - ?infection

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9
Q

imaging and tests required for all acute abdo pain cases

A

ECG and CXR - ?cardiac pathology or ?free air in abdomen

USS KUB (KUB = kidney, ureters, bladder)

USS of liver and biliary tree

Transvaginal USS - ?tubo-ovarian pathology

CT abdomen

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10
Q

basic management for all cases of acute abdo pain (and severe acute malaise in general) prior to any definitive action

A

IV access, NBM status, analgesia, anti-emetics, initial imaging, VTE prophylaxis, urine dip and routine bloods, catheter or NG tube if required, resus fluids

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11
Q

what is biliary colic

A

RUQ pain, intermittent in nature and worse after eating

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12
Q

what are oesophageal varices

A

dilations of the porto-systemic venous anastamoses in the oesophagus

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13
Q

what are some emergency causes of haematemesis

A

oesophageal varices

gastric ulceration

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14
Q

what is the most common cause (60%) of haematemesis cases

A

gastric ulceration

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15
Q

how does gastric ulceration cause haematemesis

A

ulceration can result in erosion into the blood vessels supplying the upper GI tract - most commonly on the lesser curve of the stomach or posterior duodenum

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16
Q

what is a mallory-weiss syndrome tear and what is the most common history

A

tear in the epithelial lining of the oesophagus - history of severe or recurrent vomiting followed by minor haematemesis

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17
Q

what are some causes of oesophagitis

A

GORD

infection (most commonly candida)

ingestion of toxic substances

medications

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18
Q

what are some non-emergency causes of haematemesis

A

mallory-weiss tear

oesophagitis

gastritis

gastric malignancy

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19
Q

investigations into haematemesis

A

FBC and VBG + group and save

definitive investigation is oesophagogastroduodenoscopy (OGD)

erect CXR if perforated peptic ulcer is suspected - in such a case pneumoperitoneum may be seen

CT abdomen with IV contrast can also be useful if endoscopy is contraindicated

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20
Q

if a patient presents with haematemesis and upon investigation is found to have air in the peritoneum on eCXR - what is the most likely diagnosis

A

perforated peptic ulcer

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21
Q

definitive management of peptic ulcer disease

A

first line; A to E + IV cannulas, start fluid resus and crossmatch blood

OGD needed to visualise

definitive; adrenaline injections and cauterisation of the bleeding followed by high dose IV PPI therapy to reduce acid secretion, and finally H.pylori eradication therapy if necessary

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22
Q

definitive management of oesophageal varices

A

first line; active resus + blood + prophylactic abx

definitive; endoscopic banding, vasopressors to reduce splanchnic blood flow and reduce bleeding

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23
Q

what plain film radiographic sign may indicate a perforated gastric ulcer

A

subdiaphragmatic free gas

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24
Q

what are some mechanical causes of dysphagia

A

oesophageal or gastric malignancy

benign oesophageal strictures

pharyngeal pouch

foreign body

extrinsic compression

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25
Q

what are some neuromuscular causes of dysphagia

A

post-stroke

achalasia

myasthenia gravis

diffuse oesophageal spasm

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26
Q

what are red flag symptoms for dysphagia

A

weight loss

sensation of food becoming stuck

hoarse voice

referred ear or neck pain

27
Q

investigations into dysphagia

A

OGD + biopsy if relevant

routine bloods

28
Q

what is the blood supply to the inferior third of the oesophagus

A

left gastric artery

29
Q

what is the most common neuromuscular cause of acute dysphagia in a 70 year old male

A

stroke

30
Q

what is Gastric Outlet obstruction

A

describes a mechanical obstruction of the proximal GI tract, occurring at some point between the gastric pylorus and the proximal duodenum, resulting in an inability to empty the stomach

31
Q

what are some causes of gastric outlet obstruction

A

gastric or small bowel malignancy

peptic ulcer disease - causing stricture of stomach/duodenum

stricture following surgery

pancreatic cyst

bouveret syndrome

32
Q

what is Bouveret syndrome

A

gastric outlet obstruction secondary to a gallstone impacted at the pylorus or proximal duodenum

occurs in patients with a cholecystoduondenal fistula

33
Q

clinical features of gastric outlet obstruction

A

epigastric pain

vomiting post eating

early satiety

often no change in bowel habit initially

dehydrated due to persistent vomiting and obstruction - also tachycardic and hypotensive (hypovolaemic)

34
Q

investigations into gastric outlet obstruction

A

routine bloods - FBC, CRP, U&Es, clotting, group and save

CT abdo with IV contrast + endoscopy (following decompression of stomach)

35
Q

what is the main first line step in managing gastric outlet obstruction

A

decompress the stomach via NG tube

then start on IV PPI therapy

36
Q

most common causes of small bowel obstruction

A

adhesions and herniae

37
Q

most common causes of large bowel obstruction

A

malignancy, diverticular disease and volvulus

38
Q

what are the cardinal signs of bowel obstruction

A

abdominal pain - colicky or cramping in nature (secondary to peristalsis)

vomiting - early in proximal obstructions and late in distal obstructions

abdominal distension

absolute constipation - early in distal obstructions but late in proximal obstructions

39
Q

what are characteristic signs that an obstructed bowel is becoming ischaemic

A

guarding and rebound tenderness

percussion tenderness

40
Q

tinkling bowel sounds indicate what?

A

bowel obstruction

41
Q

laboratory tests into suspected bowel obstruction

A

routine bloods - important to monitor for electrolyte changes

VBG - check lactate (high = sign of ischaemia)

42
Q

imaging for a suspected bowel obstruction

A

gold standard = CT abdo pelvis with IV contrast

AXR still used in some settings

43
Q

what are the AXR findings that would indicate small bowel vs large bowel obstruction

A

small bowel = dilated >3cm, central location, valvulae conniventes visible (lines completely crossing the bowel)

large bowel = dilated >6cm, peripheral location, haustral lines visible (lines not completely crossing the bowel - go Halfway as they are Haustra)

44
Q

management of bowel obstruction

A

conservative; IV fluids, urinary catheter, analgesia, NBM and insert NG tube to decompress the bowel (non-surgical treatment only suitable in those with no signs of ischaemia or strangulation)

surgical; laparotomy and possible stoma (indicated in those with signs of ischaemia or closed bowel obstruction)

45
Q

what measurement in an ABG is most indicative of bowel ischaemia

A

high lactate levels

46
Q

causes of gastrointestinal perforation

A

diverticulitis

peptic ulcer disease

GI malignancy

iatrogenic e.g. routine endoscopy

trauma

foreign body

appendicitis

mesenteric ischaemia

bowel obstruction

47
Q

clinical features of GI perforation

A

pain - rapid onset and sharp in nature

systemically unwell - malaise, vomiting and lethargy

signs of sepsis

signs of peritonism - rigid abdomen, guarding, etc.

48
Q

imaging in suspected GI perforation

A

gold standard = CT scan

49
Q

management of GI perforation

A

broad spectrum abx, NBM, NG tube, IV fluids and analgesia

surgery - identify, manage and washout

50
Q

what artery provides the blood supply to the ascending colon

A

superior mesenteric artery

51
Q

what is malaena

A

black tarry stools occurring as a result of upper GI bleeding - usually have a very offensive smell

52
Q

what is the most common cause of malaena

A

peptic ulcer disease

53
Q

common causes of maleana

A

peptic ulcer disease

oesophageal varices

upper GI malignancy

gastritis, oesophagitis, mallory-weiss tear

54
Q

investigations into malaena

A

routine bloods + group and save

ABG - pH and lactate

OGD - definitive investigation in most cases of malaena

CT abdo with IV contrast - if contraindications to OGD

55
Q

how does a drop in haemoglobin and rise in urea:creatinine ratio indicate upper GI bleed

A

digested Hb produces urea as a by-product and is readily absorbed by the intestine; therefore urea levels increase

56
Q

what is the role of somatostatin analogues in variceal bleeding

A

reduces splanchnic blood flow to the GI tract - thereby reducing bleeding

57
Q

what is haematochezia

A

passage of fresh blood via the rectum caused by bleeding from the lower GI tract

58
Q

what are some common causes of acute lower GI bleeding

A

diverticular disease

ischaemic or infective colitis

haemorrhoids

malignancy

angiodysplasia

crohn’s disease

ulcerative colitis

59
Q

what is the most common cause of lower GI bleeding

A

diverticulosis

60
Q

what first line examination is essential in any patient presenting with haematochezia

A

DRE

61
Q

investigations into haematochezia

A

routine bloods - baseline

group and save - surgery

stool cultures - ?infection

unstable patients require CT angiogram - to identify location of bleed

stable patients require flexible sigmoidoscopy - to exclude left colonic malignancy

62
Q

what investigations are required in stable vs unstable patients with haematochezia

A

stable = flexible sigmoidoscopy

unstable = CT angiogram

63
Q

what is the blood supply to the ileum

A

superior mesenteric artery

64
Q

what is the first line investigation in an haemodynamically unstable patient presenting with haematochezia

A

CT angiogram

General (Surgery) (7 decks)

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