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
Define volvulus
Where the bowel twists around itself and the mesentery that it is attached to
26
Types of volvulus
Sigmoid and caecal Sigmoid is common and affects older patients
27
What is the presentation of volvulus
Green bilious vomiting Abdominal distention Diffuse abdominal pain Absolute constipation and lack of flatulence
28
What is the diagnosis of volvulus?
Abdominal x-ray showing "coffee bean" sign in sigmoid volvulus Contrast CT confirms diagnosis
29
What is the management of volvulus?
Conservative management with endoscopic decompression Laparotomy Hartmann's procedure Iliocaecal resection or R hemicolectomy
30
What is a direct inguinal hernia
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)
31
What is hiatus hernias and the treatment?
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
32
What are the classifications of haemorrhoids?
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
33
What are the topical treatments of haemorrhoids?
Anusol Anusol HC Germoloids cream (lidocaine and LA) Proctosedul ointment
34
What are the non-surgical treatments for haemorrhoids?
Rubber band ligation Injection sclerotherapy Infra-red coagulation Bipolar diathermy
35
What are the surgical treatment options for haemorrhoids?
Haemorrhoidal artery ligation Haemorrhoidectomy Stapled haemorrhoidectomy
36
What are the definitions of: Diverticulum Diverticulosis Diverticulitis
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
37
What is the presentation of acute diverticulitis?
``` Pain in LIF Fever Diarrhoea N+V Rectal bleeding Palpable abdo mass Raised CRP and WCC ```
38
What is the management of diverticulitis?
Oral Co-amoxiclav Analgesia Only taking clear liquids until symptoms improve Follow up within 2 days to review
39
What is familial adenomatous polyposis?
Condition involving malfunctioning tumour suppressor gene called APC. Results in many polyps forming along large intestine Polyps have potential to become cancerous
40
What is hereditary nonpolyposis colorectal cancer?
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
41
What are the criteria for a two week wait referral for colorectal cancer?
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
42
When are FIT tests used in the UK>
for bowel cancer screening programme - people aged 60-74 every 2 years
43
What are the investigations for bowel cancer/
``` Colonoscopy Sigmoidoscopy CT colonography Staging CT CEA in blood ```
44
What is the management of bowel cancer?
Surgical resection Chemotherapy Radiotherapy Paliative care
45
What are the risk factors for gallstones?
Fat Fair Female Forty
46
What is the investigation in gallstones?
First line: USS Diagnostic: MRCP CT scan
47
What is the management of gallstones?
Asymptomatic: conservative Symptomatic: cholecystectomy
48
Give the definitions of the following: Biliary colic Cholecystitis Chollangitis
Biliary colic: intermittent RUQ pain caused by gallstones irritating bile ducts Cholecystitis: inflammation of the gallbladder Cholangitis: inflammation of the bile ducts
49
What are the causes of acute cholangitis?
Obstruction in the bile ducts stopping bile flow Infection introduced during an ERCP
50
What are the most common organisms that cause acute cholangitis?
1. E.coli 2. Klebsiella species 3. Enterococcus species
51
What is the presentation of acute cholangitis?
Charcot's triad: RUQ pain Fever Jaundice
52
What is the diagnosis and management of acute cholangitis?
Imaging to diagnose: 1. Abdo USS 2. CT scan 3. MRCP ERCP Percutaneous transhepatic cholangiogram
53
What is a fibroadenoma
Small and mobile Benign tumours of stromal/epithelial breast duct tissue Common in younger patients Smooth
54
What is a breast abscess?
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
What is the criteria for a two week wait referral for breast cancer?
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
What are the causes of acute liver failure?
Acute viral hepatitis | Paracetamol overdose
57
What are the prophylaxis antiemetics given post operatively?
Ondansteron (avoid in prolonged QT interval) Dexamethasone (caution in diabetic or immunocompromised patients) Droperidol (avoid in parkinsons)
58
What are the rescue antiemetics used post op?
Ondansterone (avoid in prolonged QT interval) Prochloperazine (avoid in parkinsons) Cyclizine (caution in HF and elderly)
59
What is the management of post operative anaemia?
Hb <100g/l - start oral iron Hb <70-80g/l - blood transfusion in addition to oral iron
60
What is the presentation of an upper urinary tract obstruction?
(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
What is the presentation of lower urinary tract obstruction?
(in the bladder or urethra) Difficulty or inability to pass urine Urinary retention Impaired renal function on bloods
62
What are the causes of upper urinary tract obstruction?
``` Kidney stones Tumours pressing on ureters Ureter strictures Retroperitoneal fibrosis Bladder cancer Ureterocele ```
63
What are the causes of lower urinary tract obstruction?
``` BPH Prostate cancer Bladder cancer Urethral strictures Neurogenic bladder ```
64
What is the management of obstructive uropathy?
Upper: NEPHROSTOMY Lower: URETHRAL OR SUPRAPUBIC CATHETER
65
What is hydronephrosis?
Swelling of the renal pelvis and calyces in the kidney due to obstruction of the urinary tract
66
What is the cause and management of idiopathic hydronephrosis?
Result of narrowing at pelviureteric junction (PUJ) Can be treated with an operation to correct narrowing (pyeloplasty)
67
What is the treatment of hydronephrosis?
Treat underlying cause. PERCUTANEOUS NEPHROSTOMY ANTEGRADE URETERIC STENT
68
What are the assessments for BPH?
``` PR Abdominal exam Urine dipstick Urinary frequency chart PSA ```
69
What are common causes of raised PSA?
``` Prostate cancer Benign prostatic hyperplasia Prostatitis Urinary tract infections Vigorous exercise (notably cycling) Recent ejaculation or prostate stimulation ```
70
What is the management of BPH?
Medical: Tamsulosin: relaxes smooth muscle (Hypotension) Finnesteride: shrinks prostate over time (impotence) Surgical: TURP
71
What is the presentation of prostatitis?
``` Pelvic pain Lower urinary tract sy Sexual dysfunction Pain with bowel movements Tender and enlarged prostate ```
72
What are the investigations for prostatitis?
Urine dipstick Urine culture and sensitivity Chlamydia and gonorrhoea NAAT testing
73
What is the management of prostatitis?
Hospital admission and supportive Laxatives Alpha blockers Antibiotics
74
What is epididymo-orchitis?
The result of infection in the epididymis and testicle on one side
75
Which organisms cause epididymo-orchitis?
E-coli Chlamydia trachomatis Neisseria gonorrhoea Mumps
76
What is the presentation of epididymo-orchitis?
Gradual onset and unilateral: - testicular pain - dragging/heavy sensation - swelling of testicle and epididymis - urethral discharge - systemic symptoms
77
What are the investigations in epididymo-orchitis?
``` Urine culture and sensitivity Chlamydia and gonorrhoea test Charcoal swab Saliva swab Serum antibodies USS ```
78
What is the management of epididymo-orchitis?
Urgen GUM referral Antibiotic according to local guideline (Quinolone antibiotics - beware of Achilles tendon rupture)
79
What are the examination findings in testicular tortion?
``` Firm swollen testicle Elevated testicle Absent cremasteric reflex Abnormal testicular lie Rotation ```
80
What is seen on urine dipstick in UTI?
Nitrates or leukocytes plus red blood cells indicate likely UTI If only leukocytes, no UTI treatment
81
What is the presentation of pyelonephritis?
Triad of symptoms: Fever Loin/back pain Nausea/vomiting plus UTI symptoms
82
What is the management of pyelonephritis?
Cefalexin Co-amoxiclav Trimethoprim Ciprofloxacin
83
What are the types of bladder cancers?
``` Transitional cell (90%) Squamous cell (5%) ```
84
What is the presentation of bladder cancer?
Painless haematuria
85
What are the referal guidelines for bladder cancer?
2 week >45 with unexplained visible haematuria >60 with microscopic haematuria plus dysuria or raised WBC
86
What are the types of renal stones?
``` Calcium oxalate (common) Calcium phosphate Uric acid (not visible on xray) Struvite (infection) Cystine ```
87
What is the presentation of renal stones?
Unilateral loin to groin pain Colicky Restless
88
What are the investigations in renal stones?
``` Urine dipstick Blood tests Abdominal x-ray Non-contrast CTKUB US KUB ```
89
What is the medical management of renal stones?
``` IM diclofenac Anti-emetics Antibiotics Supportive Tamsulosin Surgical for stones >5mm ```
90
What is the surgical management of renal stones?
Extracorporeal shock wave lithotripsy 0.5-2cm (can't use if obese) Ureteroscopy and laser lithotripsy: pregnancy Percutaneous nephrolithotomy 2-3cm Open
91
What is an anal fissure?
passage of hard stools causes a tear in the mucosa leading to more pain and bleeding when passing stools
92
What is the presentation of anal fissures?
Severe pain when passing stools Associated with fresh blood on wiping Constipation
93
What is the diagnosis of anal fissures?
History Rectal examination Visualisation of anal fissure
94
What is the treatment of anal fissures?
Stool softeners Encourage fluid intake Sitz bath Simple analgesia Topical GTN Surgical refer - botox injection or sphicterotomy
95
What is a complication of a small bowel resection?
Nephrolithiasis
96
Which area commonly involved in chronic mesenteric ischaemia?
Splenic flexure
97
What position do you put the knee for aspiration?
Knee extended
98
Where does the cystic artery branch from?
Right hepatic artery
99
Where do the left and right testicular arteries arise from?
Directly from the aorta
100
What is the risk factors for incisional hernias?
Obesity | Wound infection
101
What are the uses of a central venous line?
``` Administration of adrenaline infusion and other drugs Parenteral nutrition Blood products Fluids Measurement of central venous pressure ```
102
What is the difference between a hydrocele and an epidydimal cyst?
Hydrocele surrounds the testis Epidydimal cyst - you can get above the cyst
103
What is the first line management of superficial thrombophlebitis?
NSAIDs
104
How does the frequencies in US work?
Penetration is increased at lower frequencies but these have poor resolution
105
What are the classification of risk and advised management of patients with colorectal carcinomas?
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
What are the timings for AAA screening?
``` 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
What is the difference between acute and chronic graft rejection?
Acute is within the first 6 months, anything more is chronic
108
What is the presentation of fat embolism?
Multiple fractures followed by early onset (within 24 hours): Hypoxia Dyspnea Tachypnea
109
What is the complication of a TURP?
Excessive fluid absorption (relative hyponatraemia)
110
Why is albumin given when treating large volume ascites?
Reduce postparacentesis circulatory dysfunction
111
What is given post surgical removal of breast cancer?
Radiotherapy
112
What is the management of small bowel obstruction?
``` intial steps: NBM IV fluids nasogastric tube with free drainage some patients settle with conservative management but otherwise will require surgery ```
113
What is the management of large bowel obstruction?
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
What is the treatment for mild varicocele?
Does not need treatment