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Finals > Surgery > Flashcards

Surgery Flashcards

1
Q

Diabetic medications and surgery

A

Sulfonylureas need to be stopped until patients can eat and drink again - hypoglycaemia

Metformin be aware of lactic acidosis

SGLT2 inhibitors - DKA

Continue long acting insulin and stop short acting when fasting

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2
Q

Which patients cannot have NSAIDs?

A

Asthma
Renal impairment
Heart disease
Stomach ulcers

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3
Q

How do you measure maintenance fluid?

A

25 – 30 ml / kg / day of water

1 mmol / kg / day of sodium, potassium and chloride

50 – 100 g / day of glucose (this is to prevent ketosis, not to meet their nutritional needs)

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4
Q

What are the main causes of bowel obstruction

A

Adhesions (small bowel)
Hernias (small bowel)
Malignancy (large bowel)

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5
Q

What are the signs seen in cholecystitis?

A

Murphy’s

Boas sign - Below scapula

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6
Q

What are the signs seen in Appendicitis?

A

Rovsing’s sign
Rebound tenderness
Psoas stretch
McBurney’s point tenderness

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7
Q

What are the signs seen in pancreatitis?

A

Cullens - bruising in peri-umbilicial region

Grey-turners sign - bruised flank

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8
Q

What are the side effects of gentamycin?

A

Ototoxicity and nephrotoxicity

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9
Q

What is the traid of Meneiere’s?

A

Vertigo
Tinitus
Hearing loss

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10
Q

What do you have to look out for in gallbladder removal?

A

The Calot’s triangle:
Cystic duct laterally
Hepatic duct medially
Inferior edge of liver superiorly

The cystic artery lies within the triangle and have to be careful not to cut it.

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11
Q

What is the blood supply to the abdominal organs?

A

3 main branches of the abdominal aorta:

  1. coeliac artery
  2. superior mesenteric artery
  3. inferior mesenteric artery

Foregut: stomach, part of the duodenum, biliary system, liver, pancreas and spleen = coeliac artery

Midgut: distal part of duodenum to first half of the transverse colon = superior mesenteric

Hindgut: second half of transverse colon to the rectum = inferior mesenteric

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12
Q

Give the presentation of chronic mesenteric ischaemia

A
  1. central colicky abdominal pain after eating
  2. weight loss
  3. abdominal bruit
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13
Q

What is the diagnosis and management of chronic mesenteric ischaemia?

A

CT angiography

Management:

  • reducing modifiable risk factors
  • secondary prevention
  • revascularisation (stenting/open)
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14
Q

Define cholecystitis

A

Inflammation of the gallbladder which is caused by a blockage of the cystic duct preventing the gallbladder draining

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15
Q

What is the presentation of acute cholecystitis?

A 
RUQ pain (radiate to R shoulder)
Fever
N+V
Tachycardia
Tachypnoea
Murphy's sign
Raised inflammatory markers
Boas sign
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16
Q

What is the investigation for acute cholecystitis?

A
  1. Abdominal USS
    - thickened gallbladder wall
    - stones or sludge in gallbladder
    - fluid around gallbladder
  2. MRCP
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17
Q

What is the management of acute cholecystitis?

A

ERCP

Cholecystectomy

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18
Q

What are the causes of small bowel obstruction?

A 
ADHESIONS
HERNIAS
Diverticular disease
Strictures
Intussusception
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19
Q

What are the causes of large bowel obstruction?

A

MALIGNANCY
Volvulus
Strictures
Intussusception

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20
Q

What is the presentation of bowel obstruction?

A 
Vomiting green bilious
Abdominal distention
Diffuse abdo pain
Absolute constipation and lack of flatulence
Tinkling bowel sounds
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21
Q

What are the findings in bowel obstruction?

A

X-ray: distended loops of bowel

Valvulae conniventes

Haustra

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22
Q

What are the causes of ileus?

A

Injury to bowel
Handling of bowel
Inflammation or infection
Electrolyte imbalance

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23
Q

What are the signs and symptoms of ileus?

A 
Green bilious vomiting
Abdo distention
Diffuse abdo pain
Absolute constipation and lack of flatulence
ABSENT bowel sounds
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24
Q

What is the management of ileus?

A 
Supportive care:
Nil by mouth
NG tube
IV fluids
Mobilisation
TPN
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25
Q

Define volvulus

A

Where the bowel twists around itself and the mesentery that it is attached to

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26
Q

Types of volvulus

A

Sigmoid and caecal

Sigmoid is common and affects older patients

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27
Q

What is the presentation of volvulus

A

Green bilious vomiting
Abdominal distention
Diffuse abdominal pain
Absolute constipation and lack of flatulence

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28
Q

What is the diagnosis of volvulus?

A

Abdominal x-ray showing “coffee bean” sign in sigmoid volvulus

Contrast CT confirms diagnosis

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29
Q

What is the management of volvulus?

A

Conservative management with endoscopic decompression

Laparotomy
Hartmann’s procedure
Iliocaecal resection or R hemicolectomy

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30
Q

What is a direct inguinal hernia

A

Occurs due to weakness in the abdominal wall at hesselbach’s triangle (RIP):

Rectus abdominis muscle (medial border)
Inferior epigastric vessels (superior/lateral border)
Poupart’s ligament/inguinal ligament (inferior border)

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31
Q

What is hiatus hernias and the treatment?

A

Refers to the herniation of the stomach up through the diaphragm. 4 types:

  1. Sliding
  2. Rolling
  3. Combination of sliding and rolling
  4. Large opening with additional abdominal organs entering thorax

conservative or laparoscopic fundoplication

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32
Q

What are the classifications of haemorrhoids?

A

1st degree: no prolapse

2nd degree: prolapse when straining and return on relaxing

3rd degree: prolapse when straining but no return on relaxing (can be pushed back)

4th degree: prolapsed permanently

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33
Q

What are the topical treatments of haemorrhoids?

A

Anusol
Anusol HC
Germoloids cream (lidocaine and LA)
Proctosedul ointment

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34
Q

What are the non-surgical treatments for haemorrhoids?

A

Rubber band ligation
Injection sclerotherapy
Infra-red coagulation
Bipolar diathermy

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35
Q

What are the surgical treatment options for haemorrhoids?

A

Haemorrhoidal artery ligation
Haemorrhoidectomy
Stapled haemorrhoidectomy

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36
Q

What are the definitions of:
Diverticulum
Diverticulosis
Diverticulitis

A

Diverticulum is a pouch or pocket in the bowel wall

Diverticulosis refers to presence of diverticula without inflammation or infection (referred to as diverticular disease when patients experience symptoms)

Diverticulitis refers to inflammation and infection of diverticular

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37
Q

What is the presentation of acute diverticulitis?

A 
Pain in LIF
Fever
Diarrhoea 
N+V
Rectal bleeding
Palpable abdo mass
Raised CRP and WCC
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38
Q

What is the management of diverticulitis?

A

Oral Co-amoxiclav
Analgesia
Only taking clear liquids until symptoms improve
Follow up within 2 days to review

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39
Q

What is familial adenomatous polyposis?

A

Condition involving malfunctioning tumour suppressor gene called APC.

Results in many polyps forming along large intestine

Polyps have potential to become cancerous

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40
Q

What is hereditary nonpolyposis colorectal cancer?

A

Also known as lynch syndrome. Autosomal dominant condition that results in mutations in DNA mismatch repair genes

Patients are at higher risk of number of cancers

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41
Q

What are the criteria for a two week wait referral for colorectal cancer?

A
  1. over 40 with abdo pain and unexplained weight loss
  2. Over 50 with unexplained rectal bleeding
  3. Over 60 with change in bowel habit or iron deficiency anaemia
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42
Q

When are FIT tests used in the UK>

A

for bowel cancer screening programme - people aged 60-74 every 2 years

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43
Q

What are the investigations for bowel cancer/

A 
Colonoscopy
Sigmoidoscopy
CT colonography
Staging CT
CEA in blood
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44
Q

What is the management of bowel cancer?

A

Surgical resection
Chemotherapy
Radiotherapy
Paliative care

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45
Q

What are the risk factors for gallstones?

A

Fat
Fair
Female
Forty

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46
Q

What is the investigation in gallstones?

A

First line: USS
Diagnostic: MRCP
CT scan

47
Q

What is the management of gallstones?

A

Asymptomatic: conservative
Symptomatic: cholecystectomy

48
Q

Give the definitions of the following:
Biliary colic
Cholecystitis
Chollangitis

A

Biliary colic: intermittent RUQ pain caused by gallstones irritating bile ducts

Cholecystitis: inflammation of the gallbladder

Cholangitis: inflammation of the bile ducts

49
Q

What are the causes of acute cholangitis?

A

Obstruction in the bile ducts stopping bile flow

Infection introduced during an ERCP

50
Q

What are the most common organisms that cause acute cholangitis?

A
  1. E.coli
  2. Klebsiella species
  3. Enterococcus species
51
Q

What is the presentation of acute cholangitis?

A

Charcot’s triad:
RUQ pain
Fever
Jaundice

52
Q

What is the diagnosis and management of acute cholangitis?

A

Imaging to diagnose:

  1. Abdo USS
  2. CT scan
  3. MRCP

ERCP

Percutaneous transhepatic cholangiogram

53
Q

What is a fibroadenoma

A

Small and mobile
Benign tumours of stromal/epithelial breast duct tissue
Common in younger patients
Smooth

54
Q

What is a breast abscess?

A

Acute bacterial infection of the breast tissue

May be associated with fever, pus discharge from the nipp;e and local erythema, tenderness and heat

Treat with antibiotics. May require incision and drainage surgically.

55
Q

What is the criteria for a two week wait referral for breast cancer?

A

discrete lump with fixation that enlarges and/or with any concerns

Women over 30 with a persistent breast or axillary lump or focal lumpiness after their period

Previous breast cancer with new suspicious symptoms

Skin or nipple changes suggestive of breast cancer

Unilateral bloody nipple discharge

56
Q

What are the causes of acute liver failure?

A

Acute viral hepatitis

Paracetamol overdose

57
Q

What are the prophylaxis antiemetics given post operatively?

A

Ondansteron (avoid in prolonged QT interval)

Dexamethasone (caution in diabetic or immunocompromised patients)

Droperidol (avoid in parkinsons)

58
Q

What are the rescue antiemetics used post op?

A

Ondansterone (avoid in prolonged QT interval)

Prochloperazine (avoid in parkinsons)

Cyclizine (caution in HF and elderly)

59
Q

What is the management of post operative anaemia?

A

Hb <100g/l - start oral iron

Hb <70-80g/l - blood transfusion in addition to oral iron

60
Q

What is the presentation of an upper urinary tract obstruction?

A

(In the ureters)

Loin to groin or flank pain on affected side
Reduced or no urine output
Non-specific systemic sy
Impaired renal function on bloods

61
Q

What is the presentation of lower urinary tract obstruction?

A

(in the bladder or urethra)

Difficulty or inability to pass urine
Urinary retention
Impaired renal function on bloods

62
Q

What are the causes of upper urinary tract obstruction?

A 
Kidney stones
Tumours pressing on ureters
Ureter strictures
Retroperitoneal fibrosis
Bladder cancer
Ureterocele
63
Q

What are the causes of lower urinary tract obstruction?

A 
BPH
Prostate cancer
Bladder cancer
Urethral strictures
Neurogenic bladder
64
Q

What is the management of obstructive uropathy?

A

Upper: NEPHROSTOMY

Lower: URETHRAL OR SUPRAPUBIC CATHETER

65
Q

What is hydronephrosis?

A

Swelling of the renal pelvis and calyces in the kidney due to obstruction of the urinary tract

66
Q

What is the cause and management of idiopathic hydronephrosis?

A

Result of narrowing at pelviureteric junction (PUJ)

Can be treated with an operation to correct narrowing (pyeloplasty)

67
Q

What is the treatment of hydronephrosis?

A

Treat underlying cause.

PERCUTANEOUS NEPHROSTOMY

ANTEGRADE URETERIC STENT

68
Q

What are the assessments for BPH?

A 
PR
Abdominal exam
Urine dipstick
Urinary frequency chart
PSA
69
Q

What are common causes of raised PSA?

A 
Prostate cancer
Benign prostatic hyperplasia
Prostatitis
Urinary tract infections
Vigorous exercise (notably cycling)
Recent ejaculation or prostate stimulation
70
Q

What is the management of BPH?

A

Medical:
Tamsulosin: relaxes smooth muscle (Hypotension)
Finnesteride: shrinks prostate over time (impotence)

Surgical:
TURP

71
Q

What is the presentation of prostatitis?

A 
Pelvic pain
Lower urinary tract sy
Sexual dysfunction
Pain with bowel movements
Tender and enlarged prostate
72
Q

What are the investigations for prostatitis?

A

Urine dipstick
Urine culture and sensitivity
Chlamydia and gonorrhoea NAAT testing

73
Q

What is the management of prostatitis?

A

Hospital admission and supportive
Laxatives
Alpha blockers
Antibiotics

74
Q

What is epididymo-orchitis?

A

The result of infection in the epididymis and testicle on one side

75
Q

Which organisms cause epididymo-orchitis?

A

E-coli
Chlamydia trachomatis
Neisseria gonorrhoea
Mumps

76
Q

What is the presentation of epididymo-orchitis?

A

Gradual onset and unilateral:

  • testicular pain
  • dragging/heavy sensation
  • swelling of testicle and epididymis
  • urethral discharge
  • systemic symptoms
77
Q

What are the investigations in epididymo-orchitis?

A 
Urine culture and sensitivity
Chlamydia and gonorrhoea test
Charcoal swab
Saliva swab
Serum antibodies
USS
78
Q

What is the management of epididymo-orchitis?

A

Urgen GUM referral
Antibiotic according to local guideline
(Quinolone antibiotics - beware of Achilles tendon rupture)

79
Q

What are the examination findings in testicular tortion?

A 
Firm swollen testicle
Elevated testicle
Absent cremasteric reflex
Abnormal testicular lie
Rotation
80
Q

What is seen on urine dipstick in UTI?

A

Nitrates or leukocytes plus red blood cells indicate likely UTI

If only leukocytes, no UTI treatment

81
Q

What is the presentation of pyelonephritis?

A

Triad of symptoms:
Fever
Loin/back pain
Nausea/vomiting

plus UTI symptoms

82
Q

What is the management of pyelonephritis?

A

Cefalexin
Co-amoxiclav
Trimethoprim
Ciprofloxacin

83
Q

What are the types of bladder cancers?

A 
Transitional cell (90%)
Squamous cell (5%)
84
Q

What is the presentation of bladder cancer?

A

Painless haematuria

85
Q

What are the referal guidelines for bladder cancer?

A

2 week

> 45 with unexplained visible haematuria

> 60 with microscopic haematuria plus dysuria or raised WBC

86
Q

What are the types of renal stones?

A 
Calcium oxalate (common)
Calcium phosphate
Uric acid (not visible on  xray)
Struvite (infection)
Cystine
87
Q

What is the presentation of renal stones?

A

Unilateral loin to groin pain
Colicky
Restless

88
Q

What are the investigations in renal stones?

A 
Urine dipstick
Blood tests
Abdominal x-ray
Non-contrast CTKUB
US KUB
89
Q

What is the medical management of renal stones?

A 
IM diclofenac
Anti-emetics
Antibiotics
Supportive
Tamsulosin
Surgical for stones >5mm
90
Q

What is the surgical management of renal stones?

A

Extracorporeal shock wave lithotripsy 0.5-2cm (can’t use if obese)

Ureteroscopy and laser lithotripsy: pregnancy

Percutaneous nephrolithotomy 2-3cm

Open

91
Q

What is an anal fissure?

A

passage of hard stools causes a tear in the mucosa leading to more pain and bleeding when passing stools

92
Q

What is the presentation of anal fissures?

A

Severe pain when passing stools
Associated with fresh blood on wiping
Constipation

93
Q

What is the diagnosis of anal fissures?

A

History
Rectal examination
Visualisation of anal fissure

94
Q

What is the treatment of anal fissures?

A

Stool softeners
Encourage fluid intake
Sitz bath

Simple analgesia
Topical GTN

Surgical refer - botox injection or sphicterotomy

95
Q

What is a complication of a small bowel resection?

A

Nephrolithiasis

96
Q

Which area commonly involved in chronic mesenteric ischaemia?

A

Splenic flexure

97
Q

What position do you put the knee for aspiration?

A

Knee extended

98
Q

Where does the cystic artery branch from?

A

Right hepatic artery

99
Q

Where do the left and right testicular arteries arise from?

A

Directly from the aorta

100
Q

What is the risk factors for incisional hernias?

A

Obesity

Wound infection

101
Q

What are the uses of a central venous line?

A 
Administration of adrenaline infusion and other drugs
Parenteral nutrition
Blood products
Fluids
Measurement of central venous pressure
102
Q

What is the difference between a hydrocele and an epidydimal cyst?

A

Hydrocele surrounds the testis

Epidydimal cyst - you can get above the cyst

103
Q

What is the first line management of superficial thrombophlebitis?

A

NSAIDs

104
Q

How does the frequencies in US work?

A

Penetration is increased at lower frequencies but these have poor resolution

105
Q

What are the classification of risk and advised management of patients with colorectal carcinomas?

A

Low:
1/2 adenomas <10mm
Colonoscopy every 5 years

Intermediate risk:
3/4 <10mm or 1/2 >10mm
Colonoscopy every 3 years

High risk:
>5 measuring <10mm or >3 measuring <10mm
Colonoscopy annually

106
Q

What are the timings for AAA screening?

A 
Starts at age 65:
normal = no further screening
3-4.4cm annual review
4.5-5.4cm 3 monthly review
>5.5cm or if it has grown >1cm between screening: elective surgery
107
Q

What is the difference between acute and chronic graft rejection?

A

Acute is within the first 6 months, anything more is chronic

108
Q

What is the presentation of fat embolism?

A

Multiple fractures followed by early onset (within 24 hours):
Hypoxia
Dyspnea
Tachypnea

109
Q

What is the complication of a TURP?

A

Excessive fluid absorption (relative hyponatraemia)

110
Q

Why is albumin given when treating large volume ascites?

A

Reduce postparacentesis circulatory dysfunction

111
Q

What is given post surgical removal of breast cancer?

A

Radiotherapy

112
Q

What is the management of small bowel obstruction?

A 
intial steps:
NBM
IV fluids
nasogastric tube with free drainage
some patients settle with conservative management but otherwise will require surgery
113
Q

What is the management of large bowel obstruction?

A

initial steps:
NBM
IV fluids
nasogastric tube with free drainage

Can trial conservative management for up to 72 hours, after which further management may be required if there is no resolution

around 75% will eventually require surgery
IV antibiotics will be given if perforation suspected or surgery planned

surgery
if there is any overt peritonitis or evidence of bowel perforation, emergency surgery is necessary

114
Q

What is the treatment for mild varicocele?

A

Does not need treatment

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