Senior surgery Flashcards by B M

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)

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1st line tx for severe UC flare?

IV hydrocortisone 100mg 6 hourly
LMWH
AdCal-D3

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2nd line tx for severe UC flare?

Ciclosporin

infliximab if contraindicated

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Initial ix in someone with ?bowel obstruction?

Basic obs
PR
Supine AXR

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Difference between caecal voluvulus and sigmoid volvulus on axr?

Sigmoid = upside down U
Caecal = U

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Initial mx of volvulus?

Sigmoidoscopy and passage of decompressing flatus tube

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Why does sigmoid volvulus occur?

Due to twisting of the bowel on lax mesentery

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Tx for recurrent sigmoid volvulus?

Sigmoid colectomy

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Which side of colon cancer is more likely to obstruct?

Left

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Which side of colon cancer is more likely to cause anaemia?

Right

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Who is a barium enema contraindicated in?

Patients at risk of perforation

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What does presence of air in the rectum in obstruction suggest?

Left side obstruction unlikely

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How is pseudo-obstruction usually managed?

Conservatively
Correct electrolyte abnormalities
Colonoscopic decompression can be useful acutely

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AXR diameter for small and large bowel obstruction

Small >3cm

Large >5cm

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Most likely cause of peritonitis?

Perforated viscus

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Common causes of free intra-peritoneal air (pneumoperitoneum)?

Laparotomy 24 hours ago
Perforated duodenal ulcer
Perforated diverticulum

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Perforation of which structures can cause air to accumulate retroperitoneally?

3rd part of duodenum
Ascending colon
Descending colon

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Causes of toxic megacolon?

UC
Infective colitis
Crohn’s

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What level does serum amylase need to be to confirm pancreatitis?

> 1000

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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

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How to measure pancreatic insufficiency?

Clinical judgement

Faecal elastase

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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!

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Complications of ERCP?

Perforation
Aspiration pneumonia
Haemorrhage
Acute pancreatitis
Ascending cholangitis

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When might you see porcelain gallbladder?

In chronic cholecystitis and gallstones

Premalignant

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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