Senior surgery Flashcards
Truelove and Whitt’s criteria for acute severe colitis?
Frequency of stool >6 Overtly bloody stool Fever (>37.5) Tachycardia (>90) Anaemia (Hb<105) Raised ESR (>30)
1st line tx for severe UC flare?
IV hydrocortisone 100mg 6 hourly
LMWH
AdCal-D3
2nd line tx for severe UC flare?
Ciclosporin
infliximab if contraindicated
Initial ix in someone with ?bowel obstruction?
Basic obs
PR
Supine AXR
Difference between caecal voluvulus and sigmoid volvulus on axr?
Sigmoid = upside down U Caecal = U
Initial mx of volvulus?
Sigmoidoscopy and passage of decompressing flatus tube
Why does sigmoid volvulus occur?
Due to twisting of the bowel on lax mesentery
Tx for recurrent sigmoid volvulus?
Sigmoid colectomy
Which side of colon cancer is more likely to obstruct?
Left
Which side of colon cancer is more likely to cause anaemia?
Right
Who is a barium enema contraindicated in?
Patients at risk of perforation
What does presence of air in the rectum in obstruction suggest?
Left side obstruction unlikely
How is pseudo-obstruction usually managed?
Conservatively
Correct electrolyte abnormalities
Colonoscopic decompression can be useful acutely
AXR diameter for small and large bowel obstruction
Small >3cm
Large >5cm
Most likely cause of peritonitis?
Perforated viscus
Common causes of free intra-peritoneal air (pneumoperitoneum)?
Laparotomy 24 hours ago
Perforated duodenal ulcer
Perforated diverticulum
Perforation of which structures can cause air to accumulate retroperitoneally?
3rd part of duodenum
Ascending colon
Descending colon
Causes of toxic megacolon?
UC
Infective colitis
Crohn’s
What level does serum amylase need to be to confirm pancreatitis?
> 1000
How can a pancreatic pseudocyst be managed?
1st line = Conservative - Admit for bowel rest (nil by mouth), parenteral nutrition (TPN), regular imaging, and observation (up to 12 weeks)
2nd line = Endoscopic ultrasound guided drainage
3rd line = cystogastrostomy
How to measure pancreatic insufficiency?
Clinical judgement
Faecal elastase
Glasgow Imrie Score for acute pancreatitis? When do you use it?
PaO2< 7.9kPa Age >55y/o Neutrophils (WBC > 15) Calcium < 2mmol/L Renal function: Urea > 16 mmol/L Enzymes LDH > 600IU/L Albumin < 32g/L (serum) Sugar (blood glucose) > 10 mmol/L
Use it 48 hours after admission!
Complications of ERCP?
Perforation Aspiration pneumonia Haemorrhage Acute pancreatitis Ascending cholangitis
When might you see porcelain gallbladder?
In chronic cholecystitis and gallstones
Premalignant
Signs of pyogenic liver abscess?
Liver enlargement
RUQ pain
Sepsis
CIs to liver biopsy?
INR >1.3
Platelets <100×109/L
Acute confusional state
Extensive ascites
Common cause of increased bowel sounds?
small bowel obstruction
Common cause of decreased bowel sounds?
Post-op ileus
What value do you aim for K to be above in ileus?
K+ >4mmol (maximise chance of peristalsis starting)
What do you need to give before administering TPN?
IV pabrinex
Most common type of inguinal hernia?
Indirect (80%)
Anatomical landmark for inguinal hernia?
Superior and medial to pubic tubercle
Anatomical landmark for femoral hernia
Inferior and lateral to pubic tubercle
How would you differentiate clinically between a direct or indirect hernia?
Reduce hernia and place 2 fingers above deep ring
Get pt to cough
If the hernia is controlled (suggesting that it commences at the deep ring) it is an indirect one; if it protrudes it is direct
Contents of spermatic cord?
3 arteries: testicular, cremasteric and artery to the vas deferens
3 nerves: genitofemoral nerve, sympathetics (and ilioinguinal – not actually in cord, but in canal)
3 other structures: vas deferens, veins (pampiniform plexus) and lymphatic
Most common surgical mx of inguinal hernias?
Lichtenstein mesh repair
Ix for achalasia?
Barium swallow
Upper GI endoscopy
Oesophageal manometry
Seminoma histology?
“cut potato”
mixture of large round tumour cells with clear cytoplasm and normal small mature lymphocytes
Where do testicular seminomas spread to first?
Para aortic lymph nodes
What does a seminoma produce?
placental alkaline phosphatase (PLAP)
What does a teratoma produce?
AFP
Retroperitoneal organs? SAD PUCKER
S: suprarenal (adrenal) gland A: aorta/IVC D: duodenum (second and third part) P: pancreas (except tail) U: ureters C: colon (ascending and descending) K: kidneys E: (o)oesophagus R: rectum
Fundoscopy findings in dry macular degeneration?
Drusen - yellow round spots in Bruch’s membrane
Which line is best for long term chemo?
Hickman line
indications for surgical involvement in sigmoid volvulus ?
repeated failed attempts at decompression
necrotic bowel noted at endoscopy
suspected (or proven) perforation or peritonitis
first-line option for adults with a BMI >50 trying to lose weight?
Refer for bariatric surgery consideration
Fundoscopy findings in wet macular degeneration?
choroidal neovascularisation
Causes of tunnel vision?
papilloedema glaucoma retinitis pigmentosa choroidoretinitis optic atrophy secondary to tabes dorsalis hysteria
What drug should be given in SAH and why?
Nimodipine is used to prevent vasospasm in aneurysmal subarachnoid haemorrhages
Most likely causes of blown right pupil (third cranial nerve compression)?
Extradural haemorrhage
trans tentorial herniation
flexible sigmoidoscopy a lesion is biopsied and reported as showing ‘fibromuscular obliteration’ - what is it most likely to be?
Solitary rectal ulcer syndrome
Cause for ongoing jaundice and pain after cholecystectomy?
Gallstones may be present in the CBD
When not to check a serum PSA?
Following: 6 weeks of a prostate biopsy 4 weeks following a proven urinary infection 1 week of digital rectal examination 48 hours of vigorous exercise 48 hours of ejaculation
Medical tx in peripheral arterial disease?
Atorvastatin 80mg
Clopidogrel
SE of Aromatase inhibitors (e.g. anastrozole)?
Osteoporosis
Drugs which can be dialysed out? BLAST
Barbiturates Lithium Alcohol Salicylates Theophylline
What condition are pigmented gallstones associated with?
Sickle cell disease
What surgical tx is used for rectal prolapse?
Delorme procedure
Which anaesthetic agent can cause an addisonian crisis?
Etomidate
Which cyst is anterior to the sternocleidomastoid?
Branchial cyst (don’t transilluminate)
How might orbital fractures present?
Infra-orbital/upper lip numbness
Diplopia
Features of proctitis (UC)?
Rectal bleeding
Constipation/diarrhoea
Nocturnal incontinence
What tx is typically used for aneurysm after SAH?
Aneurysm coiling
