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Final Prep > Surg > Flashcards

Surg Flashcards

1
Q

Causes of mechanical bowel obstruction

A

extraluminal: adhesions, herniae, abscess, neoplasm, volvulus
intraluminal: faecolith, intussusception, gallstone ileus, meconium
mural: atresia, inflammatory bowel disease, diverticulosis, neoplasm

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2
Q

Psuedo obstruction of bowel

A

Pseudo-obstruction refers to the presentation of
symptoms and signs mimicking mechanical obstruction but with no obstructing
lesion. It is more common in elderly patients suffering from chronic medical conditions.
Treatment is conservative.

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3
Q

Spiking temperatures

A

abscess/collection formation

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4
Q

Repairing AAA

A

Elective surgical repair of aneurysm
is indicated with an aneurysm diameter greater than 5.5 cm. Operative options include replacement with a prosthetic graft or endovascular stent graft repair.

Mortality from aneurysm rupture without surgery
is 100 per cent; and even if the patient reaches the hospital surgical unit alive, overall mortality is very high (80–95%).

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5
Q

Signs and symptoms of carcinoma of the large bowel vary depending on site

A

Right-sided lesions in the caecum/ascending colon are associated with
weight loss and anaemia, whereas symptoms of change in bowel habit and bleeding
per rectum are more common in the sigmoid colon/rectum.

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6
Q

Pancreatic psudocyst

A

Usually located in the lesser sac adjacent to the pancreas.
Occur due to ductal leakage following inflammation of the pancreas (acute or chronic).
Present non-specifically with abdominal discomfort,
nausea, early satiety etc.

Complications of pancreatic pseudocyst include
infection (most common), obstruction (of common bile duct leading to jaundice)
and perforation.

Rarely erosion of nearby vessels cause pseudoaneurysm formation which can be fatal.

Most pseudocysts resolve spontaneously. CT shows a round/ovoid fluid-filled cavity encapsulated by a fibrous wall. A pseudocyst does not have a true epithelial lining.

Pancreatic pseudocysts can be treated
by drainage if it is felt that there is a high risk of complication

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7
Q

Managing rectal fissure

A

Initially medical with liberal use of stool softeners to break the cycle of pain. GTN/diltiazem ointment may be
applied topically to relax the sphincter. Surgical procedures include lateral internal sphincterotomy and controlled sphincter dilatation.

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8
Q

Abdominoperineal resection

A

Operation of choice for lower rectal tumours
where sphincter preservation is not possible. It involves the removal of the anus, rectum and part of the sigmoid colon, and the formation of a permanent
colostomy.

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9
Q

Indications for a Hartmann’s

A

Hartmann’s procedure involves excision of part of the left colon with end colostomy and closure or exteriorization of the distal remnant.

Relief of obstruction – for example in a patient presenting with obstruction secondary to sigmoid colon carcinoma. The malignancy with appropriate margins can be excised and a colostomy formed. The Hartmann’s procedure can be reversed at a later date.

Perforation of sigmoid colon. The patient presents as an emergency with a perforated sigmoid diverticulum/secondary to undiagnosed malignancy. A primary anastomosis is not possible with the degree of inflammation and peritonitis.

Refractory sigmoid volvulus. Occasionally sigmoid volvulus fails to resolve by conservative measures/passing of flatus tube etc., and emergency surgery is required. If primary anastomosis is deemed likely to fail, then a Hartmann’s procedure is performed in the first instance (can be reversed later depending on
the case).

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10
Q

Shoulder tip pain

A

Referred from peritiontic (eg diaphragm and

gallbladder). Acromion - diaphragm. Angle of scapula - gallbladder

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11
Q

Embryological origins of epigastic pain

A

Mainly foregut structures - stomach, duodenum, liver, gallbladder, spleen and pancreas. T8 T9

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12
Q

Embyrological origins of periumbilical pain

A

Midgut structures - small bowel, ascending colon, appendix. T10 T11

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13
Q

Embryological origins of suprapubic pain

A

Hindgut pain - colon, rectum, bladder, uterus, fallopian tubes, testicular. T12 L1

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14
Q

Body fluid breakdown

A

60% body weight H20, 40% intracellular, 20% extravellular (5% IV, 15% interstitial).
Intracellular ions - High K Low Na
Extracellular ions - Low K High Na (K is 98% IC)
Interstitial - V low protein
IV - High protein

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15
Q

Blood vs Colloids vs Crytalloids vs 5% dextrose

A

Blood - fills up IV space almost exclusively

Colloid - majority stays IV due to high high osmotic potential

Crystalloid - will distribute over entire extravascular compartment (4 times bigger than IV) so 1L hartmans only 250ml stays IV

5% dextrose - will distribute over both IC and EC compartments

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16
Q

Normal daily fluid losses

A

Urine 2000ml + 80-130mmol Na + 60mmol K
Faeces 300ml
Insensible (lungs and skin) 400ml

Total 2700

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17
Q

GIT causes of water and electrolyte imbalances

A

D&V, ileostomy, NG aspiration, fistulous losses, pyloric stenosis, pancreatic fistula

In paralytic ileus and bowel obstruction, several litres of fluid may become acutely sequestered in the gut contributing to hypovolaemia. Resolution of an ileus is marked by diuresis

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18
Q

Is potassium supplementation requires post surgery or trauma?

A

NO, potassium is released from damaged tissue, and can be further increased by transfusion. Supplementary potassium should not be needed in first 48h post

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19
Q

Effect of surgery on fluid balance

A

Activation of vasopressin, catecholamines, RAS and steroids result in oliguria and water retention.

Clinical examination - if euvolaemic, overhydration may dilute blood causing pulmonary oedema and provide a salt load the patient cannot excrete

Potassium is released from damaged tissue, and can be further increased by transfusion. Supplementary potassium should not be needed in first 48h post. Esp watch in RF where excess K cannot be excreted.

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20
Q

Preoperative fluid management in elective case

A

NBM and clear fluids up to 2-3h pre surgery unless gastric emptying is affected (DM, carcinoma of head of pancreas). Pre-op carbohydrate drinks (2-3h pre surg) reduce preoperative anxiety and postop N&V

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21
Q

Electrolyte contents of 0.9% saline (vs human plasma)

A 
Osmolality: 308 (291)
Na: 154 (135-145)
K: 
Ca: 
Mg: 
Cl: 154 (94-111)
Lactate: 
HCO3:
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22
Q

Electrolyte contents of Hartmann’s (vs human plasma)

A 
Osmolality: 278 (291)
Na: 131 (135-145)
K: 5 (3.5-5)
Ca: 2 (2.2-2.6)
Mg: 
Cl: 111 (94-111)
Lactate: 29 (1-2) 
HCO3:
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23
Q

Electrolyte contents of 5% albumin (vs human plasma)

A 
Osmolality: 300 (291)
Na: 150 (135-145)
K: 
Ca: 
Mg: 
Cl: 150 (94-111)
Lactate: 
HCO3:
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24
Q

Electrolyte contents of 4% dextrose + 0.18% saline (vs human plasma)

A 
Osmolality: 283 (291)
Na: 30 (135-145)
K: 
Ca: 
Mg: 
Cl: 30 (94-111)
Lactate: 
HCO3:
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25
Q

Sample fluid replacement of lost fluid in typical adult without co-morbidities and no fluid deficit

A

1.5-3L fluid + Na 50-100mmol + K 40-80mmol / 24h
3 x 1L fluids per 24h
0.4% dextrose + 0.18% saline + 20mmol K in each bag

or

Using hartmann’s Na/K/Cl/Lactate/Ca

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26
Q

Calculating fluid deficit

A

Clinically
<5% No clinical signs
5-10% Dry mucous membranes, loss of skin turgor, tachycardia and postural hypotension, low JV pressure
>15% circulatory collapse

So 70kg man with 10% - 10% x 60% x 70 = 4.2L

If state of fluid depletion is unclear, fluid challenge with 200ml bolus of colloid or balances crystalloid solution

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27
Q

Physiology of malnutrition

A

Depletion of glycogen stores leads to fat catabolism resulting in the primary energy source for the brain to be ketones. IC minerals Mg and PO4 become depleted. Insulin production is halted, and though initially protein is preserved muscle catabolism occurs (occurs earlier with sepsis and trauma). Impaired immune responces lead to infection and worse wound healing.

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28
Q

Anthropometric measurements of malnutrition

A

Triceps skin fold thickness (reflect fat stores)
Midarm muscle circumference (MAMC)
Hand grip strength (non dominant)

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29
Q

Principles of preoperative assessment (3 things to do)

A
  1. History and confirmation of initial indication for surgery still exists
  2. If the patient fit enough for the procedure?
  3. Are co-morbidities managed? (eg if HBA1c 100 probs best to postpone elective surgery)
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30
Q

Taking a pre-op history - PMHx

A

DM - medications. Can result in gastroparesis (gastric stasis) increasing aspiration risk despite fasting.
Resp - nature of disease, how far away from best is patient?
Cardio - what is exercise telerance? Stable/unstable
RA - associated with unstable C spine. XR needed
Rheumatic fever, cardiac heart disease, prosthesis - needs prophylactic Abx
SSD - prone to sickle cell crisis under GA and post op

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31
Q

Taking a pre-op history - PSHx

A

Nature - what has been done, indication, complications (DVT/PE, infection, MRSA, dehiscence)

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32
Q

Taking a pre-op hisotry - Anaesthetics

A 
Difficult intubation
Aspiration
Rare (scoline apnoea - AD pseudocholinesterase deficiency results in prolonged paralysis with short acting muscle relaxants like suxamethonium; malignant hyperpyrexia - AD uncontrolled increase in muscle oxidative metabolism leads to difficult to control pyrexia)
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33
Q

Taking a pre-op history - Social

A

Alcohol and fags
Substance abuse - think hepatitis and HIV
Allergies - latex, anaesthetics, antimicrobials, iodine

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34
Q

Pre op management of DM

A
  1. Diet controlled - nil
  2. Oral hypoglycaemics/SC insulin - stop night before, commenced on glucose+insulin infusion.

Esp avoid long acting insulin which can cause intraoperative hypoglycaemia.
Diabetic - first on list

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35
Q

Pre op management of asthma

A

Peak flow, if possible avoid pollinating months when planning elective surgery

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36
Q

Pre op management of COPD

A

Consider regional anaesthesia, whether pt requires post op ventilation on ICU. Think epidural

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37
Q

Pre op management of CABG/Angioplasty

A

Assess cardiac function - ECG ± Echo

Consider local anaesthesia

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38
Q

Pre op management - oral anticoagulants

A 
Eg Warfarin, Dibigatran, Apixaban
Indication important 
Should be discontinued prior to surgery
Eg. AV prosthesis generally safe to discontinue to a while but MV prothesis not
If needed, switch to SC heparin
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39
Q

Pre op management - oral antiplatelets

A

Discuss with cardio regarding dual antiplatelet therapy

Should ideally be stopped 10 days prior to surgery

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40
Q

Pre op management - COCP

A

Increased risk of DVT/PE - stop 6 weeks before major surgery. POP safe. Counsel need to change to condoms.

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41
Q

Pre op management - Roids

A

Patients who are steroid dependant will require IV hydrocortisone to tide them over perioperative stress

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42
Q

Pre op management - Immunosupression

A

More prone to post op infection and absorbtion of immunosupressants may be affected

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43
Q

Pre op management - diuretics

A

Important to have normal K levels pre op

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44
Q

Pre op management - MOIs

A

Rarely used now, but interact with anaesthetic agents to cause hypotension

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45
Q

Pre op management - obstructive jaundice

A

These pts often have prolonged PTT and require vitK and either human prothrombin complex or FFP. Intraoperatively maintain diuresis with fluid replacement and mannitol as susceptible to AKI (HR syndrome)

46
Q

ASA grades (mortality)

A

I - no cormobidities (<0.1%)
II - mind systemic disease does not limit activity (0.3%)
III - severe systemic disease, not incapacitating (2-4%)
IV - Incapacitating constantly life threatening disease (20-40%)
V - not expected to survive >24h with or without surgery (>50%)

47
Q

Timetable for post op complications

A

<24 hours - LOCAL:haemorrhage, anatomical injury (eg ligation of ureter during pervic surgery) GENERAL asphyxia - aspiration of vomit, obstructed airway

24h-3weeks - LOCAL: paralytic ileus, infection (wound, peritonitis, pelvic, subphrenic), secondary haemorrhage, dehiscence (wound, anastamosis), obstruction due to fibrous adhesions. GENERAL pulmonary collapse, bronchopneumonia, embolus, retention, ATN, enterocolitis, bed sore

Late - LOCAL: obstruction due to fibrosis, incisional hernia, recurrance of lesion (malignancy). GENERAL: anaemia, vitamin deficiency, diarrhoea, OP,

48
Q

Dumping Syndrome

A

A group of symptoms, including weakness, abdominal discomfort, and sometimes abnormally rapid bowel evacuation, occurring after meals in some patients who have undergone gastric surgery.

49
Q

Type of surgery vs infection risk

A

Clean - eg hernia repair. No viscera opened, without inflammation, infection <1%
Clean contaminated - viscous opened with little or no spillage, infection <10%
Contaminated - obvious spillage, obvious inflammatory disease (eg gangrenous appendix), infection 15-20%
Dirty - eg gunshot, frank pus or gross soiling (eg bowel perforation). Infection 40%

50
Q

Gas gangrene

A

Gas gangrene (also known as clostridial myonecrosis and myonecrosis) is a bacterial infection that produces gas in tissues in gangrene. This deadly form of gangrene usually is caused by Clostridium perfringens bacteria. It is a medical emergency. Especially likes poorly vascularized tissue eg amputation stump.

51
Q

Prophylactic Abx in bowel and biliary surgery

A

Depends on what you want to cover. Good choice is 3rd gen cephalosporin with metronidazole to cover anaerobes. Fluconazole for candida may also be required.

52
Q

Antibiotic associated enterocolitis

A

C. Diff is a grap positive spore forming bacteria.
Extensive enterocolitis causes diarrhoea and bowel will show mucosal inflammation with psudomembrane formation. Sigmoidoscopy shows red friable mucosa with whitish/yellow patches which may form psudomembranes.

Feaco-oral transmission associate with PPI use

Id of toxins A & B in stool diagnostic.

Complications of toxic megacolon and rapid dehydration

Good infection control with oral metronidazole 14 days

53
Q

Notable MDR organisms

A 
MRSA
VISA
VRSA
ESBL (extended spectrum B lactamases)
CRE (carbopenem resistant enterobacteriaceae)
VRE (vancomycin resistant enterococci)
54
Q

Basal atelectasis post op

A

Some degree of pulmonary collapse occurs after almost every abdominal or transthoracic procedure. Mucous is retained in bronchial tree, blocking smaller bronchi. The alveolar air is absorbed leading to collapse of the supplied lung segments. While normal, increased risk of infection

55
Q

Post op pulmonary collapse

A

Some occurs normally (basal atelectasis)

Smokers, Chronic pulmonary diseas, chest wall disease increase risk

Anaesthetic drugs increase mucous secretion and depress ciliary action, while post op pain inhibits taking deep breaths and causes mucous retension

Occurs in first 48hours. Dyspnoea, tachypnoea, T, fruity cough, diminished breath sounds that side, basal dullness and air entry depresses with course crackles.

Prevention - postpone surgery until all infections cleared. Pre op breathing exercises and stop smoking

Post op encourage coughing (small dose opiates to limit pain but not high enough to affect coughing reflex) with breathing exercises. Abx if becomes infected.

56
Q

Post op DVT

A

Virchows triad - flow (immobilization on operative table and post op in bed with depression of respiration), vessel wall (damage prompts thrombus formation, can be caused by pressure by matress on calf or direct at op), thrombotic tendency (intraoperative blood loss and platelet consumption leads to new platelets being formed, peaking at 10 days post op. Fibrinogen also rises)

Ascertain other risk factors, incl genetic (eg G20210A prothrombin mutation or fVL

Good prophylaxis (eg COCP), early mobilisation, intermittant calf comression during surgery, TED stockings and elevation, SC LMWH
Wells Score

In established case - LMWH with conversion to warfarin in future

57
Q

Post op PE

A

PE classically occur day 10 post op
Signs - tachyponeoa, pleuritic chest pain, raised JVP (reflecting right heart strain), cyanosis, pleural rub

CTPA, CXR, ECG (may show rhythm changes, right heart strain, S1Q3T3) ABG

Oxygen + LMWH ± Analgesia
Critical options include streptokinase (CI following surgery) or pulmonary embolectomy

58
Q

Factors which impair wound healing

A

Uraemia, cachexia with protein deficiency, vitamin C deficiency, jaundice, obesity, steroids, DM

59
Q

Managing wound dehiscence

A

Reassure with morphine and antiemetic
Cover contents with sterile guaze soaked with saline and prepare for operation.
Resuture under GA using nylon strong sutures passed through all layes of abdominal wall
Prognosis good unless underlying disease takes over
High risk for future incisional hernia

60
Q

Signs of wound dehiscence

A

Abdomen usually day 10
Warning sign if pink fluid discharges through incision - represents serous effusion (always present in abdominal cavity after operation), tinged with blood and which seeps through the hole in wound. If this progresses, patient finds bowel or omentum through wall, usually after cough or strain.

61
Q

Post op hypotension - management

A

In a surgical patient hypotension is hypovolaemia until proven otherwise. Resuscitate with a fluid challenge and monitor clinical response while sending bloods for FBC and clotting

62
Q

Duct of Lushka

A

Duct of Luschka is used to refer to an accessory bile duct. They are small ducts that distinctly enter the gallbladder bed, or small tributaries of minor intrahepatic radicals of the right hepatic ductal system.

63
Q

Common complication post laparoscopy

A

Umbilical port site bleed / haematoma

64
Q

Steroid cover during surgery

A

Minor surgery - if less than 10mg/d no cover needed, if more than 10mg/d give 25mg preop IV hydrocortisone the return to normal steroid use post op

Intermediate surgery - 25mg IV hydrocortisone pre op, then every 8h for 24h until normal resumed

Major surgery - 50mg IV hydrocortisone preop then 50mg IV every 8h for 72h then resume normal

65
Q

Manage: urgent surgery pt on warfarin with INR 3

A

Discontinue warfarin, vit K 2-3mg, monitor INR every 6-8h post op and have FFP, cryoprecipitate and XM blood ready to cover the surgery

66
Q

Insulin sliding scale during surgery

A

Add 50 units of Actarapid to 0.9% saline to total volume 50ml (1ml = 1 unit). Calculated as 1 ml (unit) / h. Blood glucose should be measured hourly and scale adjusted.

BM > 16 - 6 ml/h
BM 13-16 - 4ml/h
BM 10-13 - 3 ml/h
BM 7-10 - 2ml/h
BM 5-7 - 1ml/h
BM 4-5 - 0.5ml/h

Medical staff monitor every 2-4h to ensure glucose within 5-10mmol/L

This needs to be run with 5% dextrose with 20mmol/L KCl supplementation through the same cannula to avoid hypos if cannula blocks

67
Q

Half live of IV insulin

A

2.5 minutes

68
Q

Causes of post op cellulitis

A

Staph Aureus and Strep Pyogenes, if immunocompromised staph epidermidis

69
Q

Initial first line fluid replacement for trauma ATLS

A

2L Hartmann’s

70
Q

Typical daily requirements for adults (H2O, Na, K)

A

1-2.5L H2O
1mmol/kg Na
0.5-1mmol/kg K

71
Q

Electrolytes in ileal fluid (important in high output ileostomies)

A

130 mmol/L Na
110 mmol/L Cl
10 mmol/L K

72
Q

Post op fistula

A

Serious if involves alimentary canal or biliary/pancreatic adnexea following abdominal surgery. Escape of bowel / bile contents through drainage site. If in doubt methylene blue given orally.
Sample of fluid tested for creatinine (urinary), bile (biliary), amylase (pancreatic).
Injection of radio opaque dye at time of ct will visualise size and if distal obstruction.

73
Q

Treating post op fistula

A
  1. Protect skin around fistula - edges covered by Stomadhesive (adheres to moist surfaces) or silicone barier cream. Consider colostomy appliance
  2. Replace loss of fluids, electrolytes, nutrients and vitamins
  3. Reduce sepsis - abx and pus drainage
    On this conservative management fistula may heal but if in site of inflammatory disease (CD) or malignant in origin needs surgery.
    Patient will likely be toxic and rapid catabolism occurs
74
Q

Post op pyrexia

A

Mild pyrexia normal response to surgery.

Examine and exclude infection

75
Q

Risks of Laparoscopic surgery

A

Cannula insertion - perforation of viscus, bladder, aorta
Insufflation - vagal stimulation causing profound bradycardia, CO2 retention, CO2 embolism
Surgery itself - bleeding, trauma
Port closure - inadequate closure leading to hernia

76
Q

Risks of OGD

A

Oesophageal perforation, variceal bleeding

77
Q

Risks of ERCP

A

perforative cholangitis, pancreatitis

78
Q

Risks of Colonoscopy

A

perforation, esp if polypectomy or stenting of stricture

79
Q

Commonest causative agent in cellulitis

A

Group A B haemolytic strep (eg pyogenes)

80
Q

Why do abscesses cause swinging fever?

A

Initially abscess is hard, red and painful. Becomes soften and fluctuant and if not drained discharges into body cavity.
Abscess if established needs drainage

81
Q

True vs False diverticulum

A

True - outpouching covered by all layers of the bowel wall (e.g. Meckel’s)
False - lacking normal muscle coat of the bowel

82
Q

Causes of colonic diverticuli

A

Low fibre diet - disease of western civilisation
Structural abrnomalities - CTD incl Marfans and Ehler Danlos
Abnormal motility and increased intraluminal pressure.

83
Q

Complications of diverticuli

A

Diverticulitis resulting in perforation into either peritioneum (peritonitis) or pericolic tissues (pericolic abscess)
Large bowel obstruction - muscular hypertrophy and inflammatory fibrosis
Haemorrhage - erosion of vessel within diverticular fundus.

84
Q

Managing acute diverticulitis

A

Conservative - fluids, metronidazole + ciprofloxacin / penicillin + gentamycin
Pericolic abscess - percutaneous drainage
If stable, surgery may be avoided. If sepsis controlled, laparotomy and resection of diseased segment.
If emergency usually Hartmann’s

85
Q

Managing chronic diverticular disease

A

Conservative - Milpar (lubricant laxative) plus high roughage diet including F&V, wholemeal bred, bran.

86
Q

Angiodysplasia - investigating and treatment

A

Colonoscopy - GS, bright red submucosal lesions 0.5-1cm with small dilated vessels visible on close inspection. Visible on barium enema
Mesenteric angiogram - actively bleeding angiodysplasias will feature contrast bleeding into bowel.

Treatment - transfuse if severe, colonoscopic electrocoagulation or argon plasma coagulation may be curative. Resection (usually R hemi) may be required.

87
Q

UC and colon cancer

A

5-12% op patients with colitis for 20years duration will develop malignant change. Annual / biannual colonoscopy with biopsies

88
Q

Surgery for refractive severe UC

A

Usually total colectomy and rectum removal with either permanent ileostomy or ileoanal anastamosis with interposed pouch of ileum.
All patients will likely be on high dose steroids - IV hydrocortisone cover

89
Q

Familial history in CRC

A

Baseline lifetime risk CRC - 1/50
1 FDR - 1/17
1FDR <45 - 1/10
Think FAP and HNPCC

90
Q

FAP

A

FAP gene, AD, 0.5% all CRC, 25% de novo

Prophylactic total colectomy with ileoanal pouch befor 25 years olf

91
Q

HNPCC

A

AR, 5% all CRC, MSH2 (60%) MLH1 (30% MMR genes

Tumours favour R colon,

92
Q

Dukes classification CRC (+ 5 yr survival %)

A

A - confined to muscularis mucosae (90%)
B - extends through muscularis mucosae (65%)
C - local lymph nodes (30%)
D - mets (<30%)

  • More likely today to use TNM classification
93
Q

Red flag for CRC

A

Change in bowel habit

Mucous / Blood

94
Q

Screening CRC

A

Faecal occult blood test (screening offered every 2 years to all 60-74 year olds)
Bowel scope screening - this additional one-off test is gradually being introduced in England. It is offered to men and women at the age of 55

95
Q

Investigating suspected CRC

A 
Faecal occult blood tests
Sigmoidoscopy / Colonoscopy (biopsy is able to be taken as well)
CT colonography (virtual colonoscopy) replaced barium enema (which used to show apple core appearance)
CEA levels useful, but baseline important
96
Q

CRC - principles of surgical treatment

A

Wide resection of mass together with regional lymph nodes. If bowel unobstructed, can be prepared beforehand and primary anastamosis possible. If obstructed (anastamosis CI) defunction distal bowel with colostomy or ileostomy for possible anastamosis at a later date.

Even palliatively best scenario is tumour removal to avoid obstruction. If not, try at least stenting

97
Q

Chemotherapy in CRC

A

Adjuvant therapy in CRC includes 5-fluorouracil (5FU) and may reduce recurrance.
Survival prolonging treatments include 5FU + irinotecan, cetuximab (mAb against epidermal growth factor) and bevacizumab (mAb against VEGF)

98
Q

Colostomy - what do think about when you see one?

A

Need to divert faeces to allow healing of more distal bowel anastamosis or fistula
Decompression of a dilated colon, prelude to resection of obstructing lesion
Removal of distal colon and rectum

99
Q

Loop vs End vs Double barreled colostomy

A

Loop - colon bought to surface and antimesenteric border opened. Rod or similar device stops bowel from moving back inside. Temporary measure to divert faeces and rest distal bowel. Easy to reverse and better blood supply to bowel

End - permanent. May be used in a patient undergoing total rectal excision or following perforated diverticular disease where primary anastamosis not viable.

Double barrelled (Paul Mikulicz) - proximal and distal ends both out, kind of like loop but divided fully. Rarely used as distal segment often too short.

100
Q

Complications of colostomy formation

A

Retraction - real (due to tension) or apparent (necrosis of terminal bowel)
Stenosis - due to ischaemia or poor apposition of colonic mucosae
Paracolostomy hernia - peritoneal contents herniate through adbsominal wall defect made to hold stoma
Prolapse
Lateral space bowel obstruction

Then there are complications arising from poor fitting appliances or poorly made stomas

101
Q

Managing a new colostomy

A

In the first few weeks faecal discharge is semi liquid but this gradually reverts to normal solid stools
Appliances are both wind and waterproof
Most patients find they pass one stool a day despite no sphincter (morning shits are the norm)
Large amounts of v&g can cause diarrhoea and flatus

102
Q

AXR - small bowel obstruction

A

Ladder pattern of dilated loops
Central position
Striations - vena conniventes, which pass completely across width of distended loop

103
Q

AXR - large bowel obstruction

A

Bowel tends to lie peripherally, haustrations of taenia coli, not extending the whole width of bowel

Coffee bean sign if sigmoid volvulus

CT with oral gastrograffin contrast to image further

104
Q

Preop management of acute bowel obstruction

A

NG tube + aspiration to decompress bowel and reduce aspiration risk
IV fluids - these pts will sequested huge amounts of fluid in the gut. Hartman’s or Saline with K
Ab

105
Q

Operating principles of bowel obstruction

A

Determine viabilility of bowel:
Loss of peristalsis
Loss of normal sheen
Colour (green/black is non viable, purple may recover)
Loss of arterial pulsation in supplying mesentery

If extensive areas are doubtful reopen 48h (remember Mr Tsohazis case) to reassess

Small bowel can be excised at will, as due to excellent blood supply and cleanliness easy to anastamose.

Large bowel obstruction treated by primary ileocolic anastamosis if lesion proximal to spleinc flexure. Left sided lesions managed with excision, and temporary colostomy with mucus fistula (if distal end will not reach surface fo Hartman’s)

106
Q

Closed loop obstruction

A

Specific form of mechanical bowel obstruction. Combination of distal complete obstruction + competent ileocaecal valve preventing reflux. Highly distended caecum at risk of perforation.

107
Q

Adhesion obstruction

A

Adhesions account for 3/4 of all SB obstructions. Initially conservative with IV fluids and NG suction.
If strangulation, perforation or failure to respond urgent laparotomy

108
Q

Sigmoid volvulus

A

Think elderly, constipated patients. M>W 4:1. 2% of intestinal obstructions in UK. More common in other parts of world.
Loop of sigmoid colon usually anticlockwise from 1/2 to 3 turns

109
Q

Treating sigmoid volvulus

A

Long soft rectal tube passed through sigmoid colon - usually untwists and early volvulus - accompanied by huuge amounts of flatus and liquid shit.

If this fails, laparotomy to untwist followed by tube decompression. If gangrene, excise and both open ends brought to surface (Paul-Mikulewicz procedure) as a double barelled colostomy, subsequently closed

110
Q

Mesenteric oclusion

A

++++ AF
Mural thrombus 2* to MI
Vegetation on valve
Paradoxical embolus from DVT (which crossed to other side via patent foramen ovale)
Atherosclerosis - usually preceding Hx of “angina”, pain after meals as gut struggles to process with limited blood supply

111
Q

Rigler’s sign

A

Radiograph - gas on both sides of the bowel wall

Final Prep (19 decks)

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