Principles of Surgery Flashcards
Causes of RUQ Abdominal Pain (5)
- Biliary Colic
- Cholecystitis
- Cholangitis
- Hepatitis
- Right Lower Lobe Pneumonia
Causes of Epigastric Pain (5)
- Radiations
- Relieving Factors
Pancreatitis (Acute/Chronic)
Peptic Ulcer Disease/Gastritis
GORD
Cardiac – Inferior MI / Pericarditis
Ruptured AAA
Causes of LUQ Pain (4)
Splenic abscess/infarct
Gastric Ulcer
Gastritis
Left Lower Lobe Pneumonia
Causes of Right/Left Flank Pain (3)
Renal Colic
Pyelonephritis
MSK: lumbar disc / sciatica / bony metastases
Causes of Umbilical Pain (3)
Appendicitis
Small Bowel Obstruction
UTI
Causes of RIF Pain (7)
Appendicitis
Ovarian Cyst Rupture/Torsion
PID
Inguinal Hernia
IBD
Renal Colic
Psoas Abscess
Causes of Suprapubic Pain (6)
- PID - infection of the upper reproductive organs, including the uterus, fallopian tubes, and ovaries
- UTI/Cystitis
- Urinary retention
- Prostatitis
- IBD
- Osteitis pubis inflammation in the joint between your left and right pubic bones (pubic symphysis)
Causes of LIF Pain (7)
Diverticulitis
Ovarian Cyst Rupture/Torsion
PID
Inguinal Hernia
IBD
Renal Colic
Psoas Abscess
Things to always consider in presentations of adults with Acute Abdomen?
- Always consider a ruptured abdominal aortic aneurysm in any adult presenting with abdominal pain
- In a female of childbearing age presenting with abdominal pain, always consider a ruptured ectopic pregnancy.
Biliary causes of RUQ pain (3)
- Signs
- Etiologies
Triad of symptoms associated with Ascending Cholangitis
Charcot’s Triad:
- Fever/Rigors
- Jaundice
- RUQ Abdominal Pain
Hepatic causes of RUQ pain (3)
- Signs
- Etiologies
Triad of symptoms associated with Budd-Chiari Syndrome
Caused by occlusion of the hepatic veins:
- Abdominal Pain
- Ascites
- Hepatomegaly
Causes of Lower Abdominal Pain (7)
- Pain Localization
- Clinical Features
Investigations/Indications for Acute Abdomen
Bedside Investigations for Acute Abdomen?
Urine investigations for Acute Abdomen?
Blood investigations for Acute Abdomen?
Imaging/Invasive Investigations for Acute Abdomen?
5 R’s of IV Fluids
o Resuscitation
o Routine Maintenance
o Replacement
o Redistribution
o Reassessment
Fluid Resuscitation Protocol
o Initial fluid bolus – 500ml Crystalloid solution (e.g. Hartmann’s) within 15 minutes
o Reassess – ABCDE
o Repeat process up to 2000ml of fluid
Fluid Maintenance Therapy
- Water
- Na/K/Cl
- Glucose
Maintenance Therapy to replace ongoing losses of water and electrolytes under normal physiological conditions – sweat, urine, respiration, stool.
Fluid Replacement Therapy
Replacement therapy – corrects existing water and electrolyte deficits
Causes of Abnormal FLuid/Electrolyte Losses
Vomiting/NG Tube Loss
Biliary Drainage Loss
Diarrhoea/Excess Colostomy Loss
High/Low Volume Ileal Stoma Loss
Ongoing Blood Loss (Malaena)
Urinary Loss e.g. Polyuria, Post AKI
Pancreatic/Jejunal Fistula/Stoma Loss
Sweating/Fever/Dehydration
How to decide on fluid replacement type?
Complications of Drains/When they are withdrawn
Complications
o Infection
o Haemorrhage
o Hernia formation
o Kinking
o Damage to surrounding structures if migration occurs
Drains are left in place until drainage has decreased to <25-30mL per day for two consecutive days
Indications for T-Tubes
■ Placed in common bile duct following CBD exploration with choledochotomy or post repair of CBD damage
■ Facilitates external drainage of bile to allow healing
■ Drains ~600ml a day and then reduces
■ Before removing should be clamped for 24 hours and patient monitored for signs of
obstructive jaundice
■ Generally has been superseded by ERCP
What are complications of poor nutrition generally/surgically?
Poor nutrition results in:
o Impaired albumin production
o Skeletal muscle weakness
o Impaired wound healing
o Reduced neutrophil, macrophage and lymphocyte function
Malnutrition in surgical patients is associated with:
o Poor wound healing
o Increased risk of infection
o Increased frequency of decubitus ulcers
o Overgrowth of bacteria in the GI tract
o Abnormal nutrient loss through stool
When is Malnutrition Diagnosed?
Malnutrition is diagnosed if a patient has two or more of the following:
o Insufficient energy intake
o Loss of muscle mass
o Weight loss
- <18.5 Kg/m2 – Underweight
- 18.5 – 24.9 Kg/m2 – Normal
- > 25 Kg/m2 – Overweight
o Loss of subcutaneous fat
o Localised or generalised fluid accumulation
o Diminished functional status (handgrip strength)
Enteral vs. Parenteral Nutrition
Enteral Nutrition
■ Oral
■ Feeding tube – nasogastric/nasojejunal
■ Gastrostomy/Jejunostomy
- Gastrostomy: for patients who have a functioning gastrointestinal tract but are unable to swallow
- Jejunostomy: used when stomach needs to be bypassed e.g. due to ulcers, or after major oesophagogastric surgery
Parenteral Nutrition
■ Oral/NG/NJ routes not possible e.g. bowel resection, fistula
■ Can be given peripherally or centrally
■ Peripheral parental nutrition should be given via a large diameter venous catheter
■ Parental nutrition should be given via a central venous catheter if indicated for more than a few days, as high osmotic load is not tolerated by peripheral veins and extravasation can lead to tissue damage
- PICC Line (Peripherally inserted central venous catheter)
- Hickman line (dedicated tunneled catheter)
Complications of Total Parentaeral Nutrition?
Monitoring?
