Surgery Flashcards
Diabetic medications and surgery
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
Which patients cannot have NSAIDs?
Asthma
Renal impairment
Heart disease
Stomach ulcers
How do you measure maintenance fluid?
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)
What are the main causes of bowel obstruction
Adhesions (small bowel)
Hernias (small bowel)
Malignancy (large bowel)
What are the signs seen in cholecystitis?
Murphy’s
Boas sign - Below scapula
What are the signs seen in Appendicitis?
Rovsing’s sign
Rebound tenderness
Psoas stretch
McBurney’s point tenderness
What are the signs seen in pancreatitis?
Cullens - bruising in peri-umbilicial region
Grey-turners sign - bruised flank
What are the side effects of gentamycin?
Ototoxicity and nephrotoxicity
What is the traid of Meneiere’s?
Vertigo
Tinitus
Hearing loss
What do you have to look out for in gallbladder removal?
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.
What is the blood supply to the abdominal organs?
3 main branches of the abdominal aorta:
- coeliac artery
- superior mesenteric artery
- 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
Give the presentation of chronic mesenteric ischaemia
- central colicky abdominal pain after eating
- weight loss
- abdominal bruit
What is the diagnosis and management of chronic mesenteric ischaemia?
CT angiography
Management:
- reducing modifiable risk factors
- secondary prevention
- revascularisation (stenting/open)
Define cholecystitis
Inflammation of the gallbladder which is caused by a blockage of the cystic duct preventing the gallbladder draining
What is the presentation of acute cholecystitis?
RUQ pain (radiate to R shoulder) Fever N+V Tachycardia Tachypnoea Murphy's sign Raised inflammatory markers Boas sign
What is the investigation for acute cholecystitis?
- Abdominal USS
- thickened gallbladder wall
- stones or sludge in gallbladder
- fluid around gallbladder - MRCP
What is the management of acute cholecystitis?
ERCP
Cholecystectomy
What are the causes of small bowel obstruction?
ADHESIONS HERNIAS Diverticular disease Strictures Intussusception
What are the causes of large bowel obstruction?
MALIGNANCY
Volvulus
Strictures
Intussusception
What is the presentation of bowel obstruction?
Vomiting green bilious Abdominal distention Diffuse abdo pain Absolute constipation and lack of flatulence Tinkling bowel sounds
What are the findings in bowel obstruction?
X-ray: distended loops of bowel
Valvulae conniventes
Haustra
What are the causes of ileus?
Injury to bowel
Handling of bowel
Inflammation or infection
Electrolyte imbalance
What are the signs and symptoms of ileus?
Green bilious vomiting Abdo distention Diffuse abdo pain Absolute constipation and lack of flatulence ABSENT bowel sounds
What is the management of ileus?
Supportive care: Nil by mouth NG tube IV fluids Mobilisation TPN
Define volvulus
Where the bowel twists around itself and the mesentery that it is attached to
Types of volvulus
Sigmoid and caecal
Sigmoid is common and affects older patients
What is the presentation of volvulus
Green bilious vomiting
Abdominal distention
Diffuse abdominal pain
Absolute constipation and lack of flatulence
What is the diagnosis of volvulus?
Abdominal x-ray showing “coffee bean” sign in sigmoid volvulus
Contrast CT confirms diagnosis
What is the management of volvulus?
Conservative management with endoscopic decompression
Laparotomy
Hartmann’s procedure
Iliocaecal resection or R hemicolectomy
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)
What is hiatus hernias and the treatment?
Refers to the herniation of the stomach up through the diaphragm. 4 types:
- Sliding
- Rolling
- Combination of sliding and rolling
- Large opening with additional abdominal organs entering thorax
conservative or laparoscopic fundoplication
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
What are the topical treatments of haemorrhoids?
Anusol
Anusol HC
Germoloids cream (lidocaine and LA)
Proctosedul ointment
What are the non-surgical treatments for haemorrhoids?
Rubber band ligation
Injection sclerotherapy
Infra-red coagulation
Bipolar diathermy
What are the surgical treatment options for haemorrhoids?
Haemorrhoidal artery ligation
Haemorrhoidectomy
Stapled haemorrhoidectomy
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
What is the presentation of acute diverticulitis?
Pain in LIF Fever Diarrhoea N+V Rectal bleeding Palpable abdo mass Raised CRP and WCC
What is the management of diverticulitis?
Oral Co-amoxiclav
Analgesia
Only taking clear liquids until symptoms improve
Follow up within 2 days to review
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
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
What are the criteria for a two week wait referral for colorectal cancer?
- over 40 with abdo pain and unexplained weight loss
- Over 50 with unexplained rectal bleeding
- Over 60 with change in bowel habit or iron deficiency anaemia
When are FIT tests used in the UK>
for bowel cancer screening programme - people aged 60-74 every 2 years
What are the investigations for bowel cancer/
Colonoscopy Sigmoidoscopy CT colonography Staging CT CEA in blood
What is the management of bowel cancer?
Surgical resection
Chemotherapy
Radiotherapy
Paliative care
What are the risk factors for gallstones?
Fat
Fair
Female
Forty
What is the investigation in gallstones?
First line: USS
Diagnostic: MRCP
CT scan
What is the management of gallstones?
Asymptomatic: conservative
Symptomatic: cholecystectomy
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
What are the causes of acute cholangitis?
Obstruction in the bile ducts stopping bile flow
Infection introduced during an ERCP
What are the most common organisms that cause acute cholangitis?
- E.coli
- Klebsiella species
- Enterococcus species
What is the presentation of acute cholangitis?
Charcot’s triad:
RUQ pain
Fever
Jaundice
What is the diagnosis and management of acute cholangitis?
Imaging to diagnose:
- Abdo USS
- CT scan
- MRCP
ERCP
Percutaneous transhepatic cholangiogram
What is a fibroadenoma
Small and mobile
Benign tumours of stromal/epithelial breast duct tissue
Common in younger patients
Smooth
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.
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
What are the causes of acute liver failure?
Acute viral hepatitis
Paracetamol overdose
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)
What are the rescue antiemetics used post op?
Ondansterone (avoid in prolonged QT interval)
Prochloperazine (avoid in parkinsons)
Cyclizine (caution in HF and elderly)
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
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
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
What are the causes of upper urinary tract obstruction?
Kidney stones Tumours pressing on ureters Ureter strictures Retroperitoneal fibrosis Bladder cancer Ureterocele
What are the causes of lower urinary tract obstruction?
BPH Prostate cancer Bladder cancer Urethral strictures Neurogenic bladder
What is the management of obstructive uropathy?
Upper: NEPHROSTOMY
Lower: URETHRAL OR SUPRAPUBIC CATHETER
What is hydronephrosis?
Swelling of the renal pelvis and calyces in the kidney due to obstruction of the urinary tract
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)
What is the treatment of hydronephrosis?
Treat underlying cause.
PERCUTANEOUS NEPHROSTOMY
ANTEGRADE URETERIC STENT
What are the assessments for BPH?
PR Abdominal exam Urine dipstick Urinary frequency chart PSA
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
What is the management of BPH?
Medical:
Tamsulosin: relaxes smooth muscle (Hypotension)
Finnesteride: shrinks prostate over time (impotence)
Surgical:
TURP
What is the presentation of prostatitis?
Pelvic pain Lower urinary tract sy Sexual dysfunction Pain with bowel movements Tender and enlarged prostate
What are the investigations for prostatitis?
Urine dipstick
Urine culture and sensitivity
Chlamydia and gonorrhoea NAAT testing
What is the management of prostatitis?
Hospital admission and supportive
Laxatives
Alpha blockers
Antibiotics
What is epididymo-orchitis?
The result of infection in the epididymis and testicle on one side
Which organisms cause epididymo-orchitis?
E-coli
Chlamydia trachomatis
Neisseria gonorrhoea
Mumps
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
What are the investigations in epididymo-orchitis?
Urine culture and sensitivity Chlamydia and gonorrhoea test Charcoal swab Saliva swab Serum antibodies USS
What is the management of epididymo-orchitis?
Urgen GUM referral
Antibiotic according to local guideline
(Quinolone antibiotics - beware of Achilles tendon rupture)
What are the examination findings in testicular tortion?
Firm swollen testicle Elevated testicle Absent cremasteric reflex Abnormal testicular lie Rotation
What is seen on urine dipstick in UTI?
Nitrates or leukocytes plus red blood cells indicate likely UTI
If only leukocytes, no UTI treatment
What is the presentation of pyelonephritis?
Triad of symptoms:
Fever
Loin/back pain
Nausea/vomiting
plus UTI symptoms
What is the management of pyelonephritis?
Cefalexin
Co-amoxiclav
Trimethoprim
Ciprofloxacin
What are the types of bladder cancers?
Transitional cell (90%) Squamous cell (5%)
What is the presentation of bladder cancer?
Painless haematuria
What are the referal guidelines for bladder cancer?
2 week
> 45 with unexplained visible haematuria
> 60 with microscopic haematuria plus dysuria or raised WBC
What are the types of renal stones?
Calcium oxalate (common) Calcium phosphate Uric acid (not visible on xray) Struvite (infection) Cystine
What is the presentation of renal stones?
Unilateral loin to groin pain
Colicky
Restless
What are the investigations in renal stones?
Urine dipstick Blood tests Abdominal x-ray Non-contrast CTKUB US KUB
What is the medical management of renal stones?
IM diclofenac Anti-emetics Antibiotics Supportive Tamsulosin Surgical for stones >5mm
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
What is an anal fissure?
passage of hard stools causes a tear in the mucosa leading to more pain and bleeding when passing stools
What is the presentation of anal fissures?
Severe pain when passing stools
Associated with fresh blood on wiping
Constipation
What is the diagnosis of anal fissures?
History
Rectal examination
Visualisation of anal fissure
What is the treatment of anal fissures?
Stool softeners
Encourage fluid intake
Sitz bath
Simple analgesia
Topical GTN
Surgical refer - botox injection or sphicterotomy
What is a complication of a small bowel resection?
Nephrolithiasis
Which area commonly involved in chronic mesenteric ischaemia?
Splenic flexure
What position do you put the knee for aspiration?
Knee extended
Where does the cystic artery branch from?
Right hepatic artery
Where do the left and right testicular arteries arise from?
Directly from the aorta
What is the risk factors for incisional hernias?
Obesity
Wound infection
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
What is the difference between a hydrocele and an epidydimal cyst?
Hydrocele surrounds the testis
Epidydimal cyst - you can get above the cyst
What is the first line management of superficial thrombophlebitis?
NSAIDs
How does the frequencies in US work?
Penetration is increased at lower frequencies but these have poor resolution
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
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
What is the difference between acute and chronic graft rejection?
Acute is within the first 6 months, anything more is chronic
What is the presentation of fat embolism?
Multiple fractures followed by early onset (within 24 hours):
Hypoxia
Dyspnea
Tachypnea
What is the complication of a TURP?
Excessive fluid absorption (relative hyponatraemia)
Why is albumin given when treating large volume ascites?
Reduce postparacentesis circulatory dysfunction
What is given post surgical removal of breast cancer?
Radiotherapy
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
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
What is the treatment for mild varicocele?
Does not need treatment
