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Year 3 > surgery > Flashcards

surgery Flashcards

1
Q

Define Appendicitis

A

inflammation of appendix

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2
Q

Cause of appendicitis

A

lumen obstruction => distended appendix => increased mucus production + bacterial overgrowth => impaired lymphatic/venous drainage => leading to oedema, ischaemic necrosis and perforation.

Lumen obstruction caused by:

  • faecolith (hard fecal mass matter)
  • lymphoid hyperplasia after infection
  • impacted stool
  • foreign body
  • FHx
  • worms
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3
Q

Presenting symptoms of appendicitis

A
  • periumbilical pain that moves to right iliac fossa
  • pain worsened by movement (cough)
  • anorexia - loss of appetite
  • nausea + vomiting
  • constipation +/- diarrhoea
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4
Q

Atypical presentations of appendicitis

A
  • children- non-specific abdominal pain/ withdrawn/ not eating fave food
  • older - minimal pain/ fever + acute confusion
  • pregnant women (displaced appendix) later stages can be RUQ pain, nausea/vomiting mistaken for pregnancy problems
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5
Q

Examination findings of appendicitis

A
  • facial flushing, halitosis, dry tongue
  • Right iliac fossa tenderness (max over Mcburney’s point- 2/3 from umbilicus => ASIS)
  • palpable abdominal mass (appendix mass/ abscess)
  • Rovsing’s sign (palpation of LLQ => pain in RLQ)
  • Psoas sign (right hip extension in left lateral position => pain in RLQ)
  • Obturator sign (internal rotation of flexed right thigh => pain in RLQ)
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6
Q

Why does appendicitis initially present with periumbilical pain?

A

initial pain is visceral peritoneum inflammation => is poorly localised but as pain spreads to parietal peritoneum somatic more localised (RLQ)

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7
Q

Investigations + findings for appendicitis

A

*usually only to exclude other causes

  • Bloods:
    1. FBC- neutrophil leucocytosis (high WCC)
    2. raised C-reactive protein (inflammatory marker)
  • Urine dipstick (exclude UTI)
  • Pregnancy test (exclude ectopic pregnancy)
  • US/ CT (less common- as delay is fatal rules out ovarian torsion
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8
Q

Management for appendicitis

A
  1. Laparoscopic Appendicectomy (SURGERY)
  2. Conservative Antibiotics (cefuroxime, metronidazole)
  3. Exploratory Laparoscopy (diagnostic/ therapeutic for progressive/ persistant pain)

Immediate (pre surgery)

  • pain relief
  • fluids + NBM (surgery)
  • prophylaxis ABs => for peritonitic signs (as could be perforated appendix)
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9
Q

Differentials for appendicitis (RIF pain)

A
  • ovarian pathology (torsion/ cysts)
  • ectopic pregnancy
  • UTI
  • STI (pelvic inflammatory disease)
  • IBD flare up
  • Meckel’s diverticulitis (elderly- terminal ileum)
  • renal colic
  • mesenteric adenitis (children)
  • testicular torsion
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10
Q

Complications of appendicitis

A
  • appendix perforation => peritonitis signs (rigid, tender abdomen + rebound tenderness)
  • gangrenous appendix
  • appendix mass (inflamed appendix covered in omentum)
  • appendix abscess (pus around appendix)
  • surgical complications (small bowel obstruction, wound infection, abscess, stump leakage)
  • sepsis
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11
Q

prognosis of appendicitis

A
  • uncomplicated => most recover with no long-term problems
  • ruptured appendix => more complications/ death
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12
Q

Define acute pancreatitis

A

inflammation of pancreas due to uncontrolled enzyme release => autodigestion +/- local tissue or organ involvement

mild: minimal organ dysfunction, uneventful recovery
severe: organ failure (necrosis, abscesses)

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13
Q

Pathophysiology of acute pancreatitis

A
  • obstruction in pancreas => increases ductal pressures
  • build up of enzyme rich juice => acinar cell damage
  • lysozymes convert trypsinogen => trypsin which activates enzymes
  • => auto-digestion of pancreas => necrosis
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14
Q

causes of acute pancreatitis (I GET SMASHED)

A
  • Idiopathic
  • Gallstones - obstruction of pancreatic duct => activates pancreatic enzymes => auto-digestion of pancreas => inflammation
  • Ethanol misuse - alcohol toxic to pancreatic cells causing inflammation/ cell destruction + increased protein deposition => increased ductal pressure => intra-pancreatic enzyme activation.
  • Trauma
  • Steroids
  • Mumps/ HIV/ Coxsackie/ Malignancy
  • Autoimmune
  • Scorpion venom
  • Hypertriglyceridaemia/ hypercalcaemia
  • ERCP
  • Drugs (sodium valproate, steroids, thiazides, azathioprine)
  • pregnant, neoplasia
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15
Q

presenting symptoms of acute pancreatitis

A
  • sudden epigastric/ central abdominal pain
  • pain radiating to back
  • pain relieved by sitting forward
  • anorexia
  • nausea
  • vomiting
  • Hx of high alcohol intake/ gallstones
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16
Q

Examination signs of acute pancreatitis

A
  • epigastric pain
  • fever
    -shock (tachycardia, tachypnoea)
  • jaundice
  • decreased bowel sounds (ileus)
    In severe haemorrhagic pancreatitis
  • Cullen’s sign (periumbilical bruising)
  • Grey-Turner (flank bruising)
  • Fox’s sign (ecchymosis over inguinal ligament area)

hypocalcemia

=> Chvostek (touch facial nerve=> ipsilateral face contracts as low Ca2+)

=> trousseau’s (hand contraction when bp cuff)

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17
Q

Investigations + findings for acute pancreatitis

A

Bedside:

  • ECG- rule out cardiac causes (MI)
  • Urinalysis- infection
  • pregnancy test

Bloods:

  • VERY HIGH serum amylase
  • High Serum lipase (more sensitive)
  • FBC - Hb, High WCC
  • U&Es
  • high glucose
  • high CRP
  • low Ca2+ (lipase => FFA => chelate calcium => SOAPIFICATION => Ca2+ complex deposits)
  • LFTs (abnormal if gallstone/alcohol pancreatitis)
  • ABG (metabolic acidosis => to determine severity)
  • *USS** - check for gallstones
  • *CXR**- exclude pleural effusion (due to ARDS)
  • *CT abdomen pelvis** with contrast - exclude pseudocyst, abscess, necrosis

MRCP

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18
Q

Management of acute pancreatitis

A

MEDICAL:

  • fluid + electrolyte resuscitation (3L)- Ca2+/Mg
  • NG tube for vomiting
  • analgesia (WHO pain ladder) / anti-emetics
  • blood sugar control
  • prophylactic antibiotics to reduce mortality
  • enteral feeding

For gallstone pancreatitis => SURGERY: ERCP + early cholecystectomy

If signs of sepsis => image guided fine needle aspiration

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19
Q

complications of pancreatitis

A
  • early: VASODILATION + HYPOTENSION, shock, renal failure, ARDS (pleural effusion) (cytokine mediated), sepsis, DIC

Late:

  • pancreatic necrosis
  • pseudocyst (>4 weeks, painful)- drain with endoscopic US
  • peripancreatic collection
  • pancreatic haemorrhage / bleeding (shock + blood loss)
  • abscess (pain + fever/septic signs)

Long term problems:

  • diabetes
  • chronic pancreatitis (longer pain Hx worse after alcohol/meals, weight loss)
  • enteropancreatic fistula (pancreas => gut)
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20
Q

How to calculate Prognosis of acute pancreatitis (PANCREAS)

A

Modified Glasgow score

PaO2 <7.9

Age >55

Neutrophils (WCC>15)

Calcium (<2mmol/L)

uRea (>16mmol/L)

Enzymes

Albumin

Sugar (>10mmol/L)

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21
Q

Define intestinal obstruction

A

blocked movement of intestinal contents typically common in elderly

  • small/ large bowel
  • partial/ complete obstruction
  • strangulated (blood supply cut) /simple

*closed loop (obstructed both ways -no movement)

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22
Q

causes of bowel obstruction

A

Small

  • adhesions (post-op WESTERN)
  • hernias
  • strictures (CROHN’S)
  • neoplasms

Large

  • colorectal carcinoma
  • volvulus
  • diverticulitis
  • Hirschsprung’s disease- genetic in babies -poor neuron development in colon so poor peristalsis
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23
Q

presenting symptoms of bowel obstruction (Hx)

A
  • abdominal distension
  • colicky abdominal pain
  • absolute constipation - early large bowel sign, late small bowel sign
  • vomiting- early small bowel sign (billious large amounts), late large bowel sign (faecal vomiting)
  • Previous surgery
  • previous hernias
  • cancer symptoms- anaemia? weight loss? anorexia?lethargy?
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24
Q

examination findings of bowel obstruction

A

inspection

  • signs of dehydrations- dry mucous membranes, low bp, high HR
  • distended abdomen
  • scars from previous surgery ADHESIONS
  • check for hernias
  • Jaundice

Paplation

  • peritonitis signs (rebound tenderness, guarding, absent bowel sounds Auscultations
  • tinkling bowel sounds (early), absent bowel sounds (late)
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25
Q

investigations for bowel obstruction

A
  1. Bedside: urine dip (haematuria-kidney stones)
  2. Bloods- FBC- Hb (anaemia), WCC (infection), amylase (pancreatitis), CRP, U&Es- urea&creatinine (AKI), lactate (if strangulation => ISCHAEMIA)
  3. Venous blood gas - check for low K+ (vomiting)
  4. Imaging: Abdominal X-ray (small bowel dilated >3mm), water soluble contrast enema (X-ray with contrast), barium follow through, CT abdomen (shows ischaemia + site of obstruction)
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26
Q

Differences in X-ray of small bowel and large bowel

A

small- central dilation, valvulae conniventes (across whole width),

large- peripheral dilation, haustra (pouches)

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27
Q

Management of bowel obstruction

A
  • conservative:
  1. NBM
  2. NG tube for decompression + IV fluids
  3. analgesia, urinary catheter, electrolyte replacement (monitor urinary output)
  • surgical- depends on cause
  • fecal evacuation
  • rigid sigmoidoscope decompression -to untwist volvolus
  • gastrograffin- resolve adhesions
  • exploratory laparotomy + sigmoid colectomy (resect dead bowel) + end colostomy/ ileostomy (Hartmann’s procedure- bowel connected to skin=> stoma)
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28
Q

Complications of bowel obstruction

A
  • peritonitis
  • bowel perforation
  • dehydration => ACUTE KIDEY INJURY
  • toxaemia
  • gangrene of ischaemic bowel wall
    *
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29
Q

Define bowel ischaemia

A

blockage of mesenteric vessels => bowel ischaemia (lack of oxygen) + necrosis

  1. acute mesenteric ischameia- affects small bowel + SMA
  2. chronic mesenteric ischaemia- small bowel
  3. ischaemic colitis - large bowel inflammation + IMA => ischaemia
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30
Q

risk factors for bowel ischaemia

A
  • >65
  • AF/ cardiac arrythmias
  • endocarditis
  • CVD risk factors: hypertension, hypercholesteremia, diabetes, smoking
  • thrombophillia (hypercoagulable)
  • vasculitis
  • shock => sepsis
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31
Q

causes of acute mesenteric ischaemia

A

arterial (SMA occlusion)

  • emboli
  • thrombosis
  • non-occlusive (hypotension, septic shock, hypoperfusion after cardiac surgery)

Venous (SMV occlusion)

  • portal hypertension
  • sickle cell
  • portal pyaemia - pus in portal vein => inflammation
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32
Q

presenting symptoms of bowel ischaemia

A
  • sudden crampy CENTRAL/RIF abdominal pain
  • signs of shock (hypotension, tachycardia, dehydration)
  • fever
  • loose bloody stools
  • nausea/ vomiting
  • Hx of CVD/ liver disease

AMI- sudden severe abdominal pain, shock

Chronic mesenteric ischaemia - central colicky abdominal pain, worse on eating, +/- PR bleeding, weight loss

Ischaemic colitis - LIF pain +/- bloody diarrhoea

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33
Q

examination findings of bowel ischaemia

A
  • diffuse abdominal tenderness
  • signs of shock (tachycardia, hypotension, dehydration)
  • absent bowel sounds
  • abdominal distension
  • palpable mass
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34
Q

Investigations for bowel ischaemia

A
  1. bedside: ECG (AF)
  2. Bloods: FBC- Hb, WCC- infection, CRP-inflammation, serum lactate (ISCHAEMIC), LFTs, U&Es, clotting screen,
  3. ABG- lactic acidosis
  4. Imaging - AXR-bowel obstruction, mesenteric angiography (if stable), CT/MRI angiography (narrowed vessels)
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35
Q

Gold standard investigation for ischaemic colitis

A

Colonoscopy + biopsy

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36
Q

Management for bowel ischaemia

A
  • conservative: NBM, NG tube for decompression, IV fluids, broad spectrum ABs, treat cause
  • surgical:
  1. Emergency exploratory laparotomy + resect non-viable bowel
  2. restore SMA blood supply (embolectomy, SMA arterial bypass)
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37
Q

Indications for surgery in bowel ischaemia

A
  • haemodynamically unstable
  • massive bleeding
  • toxic megacolon
  • peritonitis/ sepsis
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38
Q

Define diverticular disease

A
  1. diverticulosis- presence of diverticulum
  • true = outpouching contains all layer
  • false = oupouches of only mucosa/submucosa
  1. diverticular disease- diverticulosis + complications (infection/fistulae/ haemorrhage) VERY COMMON
  2. diverticulitis - acute inflammation + infection of diverticulum
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39
Q

What is diverticulum?

A

diverticulum are outpouches of GI wall mucosa/submucosa through muscle layers at points of weakness (entry of arteries)

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40
Q

How to classify acute diverticulitis

A

Hinchley classification

  • I- with pus
  • Ia/II- abscess
  • III- perforation + peritonitis
  • IV- fecal peritonitis (due to large bowel perforation)
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41
Q

Causes of diverticular disease

A
  • low fibre diet causes increased intraluminal pressures in large bowel => increased force of muscle contraction => herniation of gut mucosa/submucosa through gut muscle layers.
  • older age
  • decreased physical activity
  • smoking
  • alcohol
  • obesity
  • NSAIDs
  • Genetics (connective tissue disorder-more stretched, marfan’s)
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42
Q

Presenting symptoms of

  1. diverticular disease
  2. diverticulitis + complications
A
  1. MAINLY asymptomatic
  2. diverticulitis =>
  • LIF pain
  • fever
  • +/- PR bleeding
  • constipation, diarrhoea, abdominal mass
  • peritonitis (rigidity/ guarding)
  1. diverticular fistualation => pneumaturia (gas in urine), faecaluria, recurrent UTIs
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43
Q

Examination findings of diverticulitis

A
  1. LIF tenderness
  2. signs of peritonitis (rigid, guarding, rebound tenderness)
44
Q

Investigations for diverticular disease/ diverticulitis

A

Bedside:

  • stool culture (infection) + faecal calprotectin (bowel inflammation)
  • urinalysis (UTI)
  • DRE - rule out

Bloods

  • FBC - Hb (anaemia), WCC (infection)
  • raised CRP
  • clotting/ cross match if bleeding
  • U&Es- exclude UTI/renal colic
  • amylase - exclude pancreatitis
  • LFTs- exclude cholecystitis

Imaging

  • barium enema with contrast (like X-ray)
  • Flexible sigmoidoscopy/ colonoscopy (see diverticulae + exclude polyps/tumours)
  • CT abdo + pelvis (ACUTE)
  • CXR - rule out perforatation (air under diaphragm)
45
Q

Management of diverticular disease

A

If asymptomatic => high-fibre diet (fruit, veg), stop smoking, weight loss

laxatives (osmotic- more fluid in bowel, bulk-forming - more fluid in stools, stimulant- peristalsis)

GI bleeding (PR bleeding)=> IV fluids, transfusion, antibiotics

acute diverticulitis: => IV fluids, antibiotics, bowel reset (NBM), drainage of abscess, analgesia (avoid opioids => constipation)

SURGERY for perforation/ peritonitis

  • Hartmann’s (end colostomy + leave rectum stump)
  • Sigmoid resection + anastomosis
  • Laprascopic drainage
46
Q

Complications of diverticular disease

A
  1. acute diverticulitis (abscess => Abx + drainage, perforation, peritonitis, fecal peritonitis)
  2. colonic obstruction
  3. haemorrhage
  4. fistulae (vagina, bladder, small bowel)
47
Q

Define volvulus

A

loop of bowel rotates around it’s mesentery => closed loop bowel obstruction + ischaemia

  • mainly sigmoid colon + cecum
48
Q

Causes/ risk factors of volvulus

A

adult

  • long sigmoid colon + long mesentery
  • adhesions (previous abdo surgery)
  • chronic constipation
  • neuropsychiatric disorders (parkinsons, MS, spinal chord injury)
  • elderly
  • parasite infection + chagas disease (kissing bugs spread parasite)
49
Q

Presenting symptoms of volvulus

A
  • sudden colicky abdominal pain (early sign)
  • absolute constipation (early sign)
  • vomiting (late sign)
50
Q

examination findings of volvulus

A
  • abdominal distension
  • dehydration (dry mucous membranes, tachycardia)
  • fever
  • tinkling/ absent bowel sounds (bowel obstruction)
51
Q

investigations for volvulus

A
  • Bloods: FBC, Ca2+/ TFT (exclude pseudo-perforation)
  • AXR- see bowel obstruction (coffee bean sign)
  • CXR- check for perforation
  • water soluble contrast enema (X-ray with contrast => show structure)
  • CTAP - site + cause of bowel obstruction (whirl sign)
52
Q

Management for volvulus

A

Immediate

  • analgesia
  • IV fluids (for dehydration)

conservative:

  • decompression by sigmoidoscope - tube to locate obstruction and once in correct position => relieve obstructed contents + gas
  • insertion of flatus tube => allows normal passage of bowel contents

Surgical (perforation/ ischaemia /necrotic signs)

  • laparotomy (incision)=> Hartmann’s procedure (resect dead bowel + colostomy)
53
Q

Complications of volvulus

A
  • bowel obstruction
  • bowel perforation
  • bowel ischaemia
  • complications from stoma
54
Q

Define acute cholangitis

A

infection of the bile duct

55
Q

presenting symptoms of acute cholangitis

A
  • Charcot’s triad (fever, RUQ pain=> spread to right shoulder, jaundice)
  • Reynold’s pentad (charcot’s + mental confusion + septic shock/hypotension)
  • pruritus (itching)
56
Q

investigations for acute cholangitis

A

Bloods

  • FBC- high WCC
  • high CRP
  • LFTs - obstructive picture (raised GGT + ALP)
  • U&Es- check for renal dysfunction
  • slightly elevated amylase if stone in lower CBD
  • blood culture- check for sepsis

Imaging

  • US KUB- check for stones
  • Abdominal ultrasound - check for gallstones/ biliary tree dilation/obstruction
  • CXR- exclude perforation
  • contrast CT/MRI - check for cholangitis
  • MRCP- check for non-calcified stones
57
Q

Causes of acute cholangitis

A
  • gallbladder/ bile duct obstruction by stones
  • ERCP
  • tumours (pancreatic, cholangiosarcoma)
  • parasites (ascariasis)
  • bile duct stricture/ stenosis
  • cholecystectomy => dilate common bile duct
58
Q

Management of acute cholangitis

A

Immediate

  • ABC
  • analgesia, IV fluid, antibiotics
  • endoscopic billiary drainage

Surgical

  • ERCP (Endoscopic retrograde cholangiopancreatography) + sphincterectomy
  • Open bile duct exploration is a last resort due to a high mortality risk
59
Q

complications of ERCP

A
  • infection
  • pancreatitis
  • aspiration pneumonia
  • duodenal perforation
  • haemorrhage
  • ascending cholangitis
60
Q

presenting symptoms of acute cholangitis

A
  • Charcot’s triad (fever, RUQ pain=> spread to right shoulder, jaundice)
  • Reynold’s pentad (charcot’s + mental confusion + septic shock/hypotension)
  • pruritus (itching)
61
Q

Complications of acute cholangitis

A
  • liver abscess
  • liver failure
  • AKI
  • septic shock => organ dysfunction

endoscopic drainage can lead to=> Intra-abdominal or percutaneous bleeding, sepsis, fistulae and bile leakage

62
Q

Examination signs of acute cholangitis

A
  • fever
  • RUQ pain
  • jaundice
  • mental confusion
  • sepsis
  • hypotension
  • tachycardia
  • mild hepatomegaly
  • Murphy’s sign +ve
63
Q

Causes of acute cholangitis

A
  • gallbladder/ bile duct obstruction by stones
  • ERCP
  • tumours (pancreatic, cholangiosarcoma)
  • parasites (ascariasis)
  • bile duct stricture/ stenosis
  • cholecystectomy => dilate common bile duct
64
Q

Define acute cholangitis

A

infection of the bile duct

65
Q

Examination signs of acute cholangitis

A
  • fever
  • RUQ pain
  • jaundice
  • mental confusion
  • sepsis
  • hypotension
  • tachycardia
  • mild hepatomegaly
  • Murphy’s sign +ve
66
Q

investigations for acute cholangitis

A

Bloods

  • FBC- high WCC
  • high CRP
  • LFTs - obstructive picture (raised GGT + ALP)
  • U&Es- check for renal dysfunction
  • slightly elevated amylase if stone in lower CBD
  • blood culture- check for sepsis

Imaging

  • US KUB- check for stones
  • Abdominal ultrasound - check for gallstones/ biliary tree dilation/obstruction
  • CXR- exclude perforation
  • contrast CT/MRI - check for cholangitis
  • MRCP- check for non-calcified stones
67
Q

Management of acute cholangitis

A

Immediate

  • ABC
  • analgesia, IV fluid, antibiotics
  • endoscopic billiary drainage

Surgical

  • ERCP (Endoscopic retrograde cholangiopancreatography) + sphincterectomy
  • Open bile duct exploration is a last resort due to a high mortality risk
68
Q

complications of ERCP

A
  • infection
  • pancreatitis
  • aspiration pneumonia
  • duodenal perforation
  • haemorrhage
  • ascending cholangitis
69
Q

Complications of acute cholangitis

A
  • liver abscess
  • liver failure
  • AKI
  • septic shock => organ dysfunction

endoscopic drainage can lead to=> Intra-abdominal or percutaneous bleeding, sepsis, fistulae and bile leakage

70
Q

Define anal fissures

A

tear in the squamous lining of the lower anal canal

  • 90% posterior to anus
  • some anterior (usually after childbirth)
71
Q

Causes of anal fissures

A
  • hard faeces
  • anal sphincter spasm => constricts infeior rectal artery => ischaemia + impaired healing
  • syphillis
  • HIV
  • Crohn’s
72
Q

Presenting symptoms of anal fissures

A
  • tearing pain on defecation
  • PR bleeding/ blood on wiping
73
Q

Examination findings of anal fissures

A
  • PR exam - tear on squamous lining
74
Q

Management of anal fissures

A
  1. Conservative (high fibre diet, laxatives to soften stool, hydration)
  2. Medical
  • lidocaine (local anaesthtic)
  • GTN + diltiazem (sphincter relaxants + improves healing)
  • botulinum toxin
  1. Surgical (last resort)
    * internal sphincterectomy (relaxes sphincter but has complications= anal incontinence)
75
Q

complications of anal fissures

A

chronic anal fissures

76
Q

Define hernias

A

internal body part pushes through weakness in muscle or surrounding tissue wall

77
Q

types of hernias

A
  • indirect (stangulates easily -if ischaemia occurs, blood supply is compromised)
  • direct- usually reducable (pushed back in)
  • epigastric
  • paraumbilical
  • incisional -from muscle breakdown after surgery
  • spigelian - arcuate line and transverse abdominus)
  • lumbar
  • richters hernia- bowel wall only
  • inguinal
  • femoral
  • sciatic
  • sliding
  • hiatus
78
Q

causes of femoral hernias

A
  • enlarged prostate
  • pregnancy
  • frequent cough
  • chronic constipation
  • intense workouts
  • elderly
  • obesity
79
Q

causes of inguinal hernias

A
  • chronic cough
  • constipation
  • urinary obstruction
  • heavy lifting
  • ascites
  • past abdominal surgery
  • infants: prematurity, male sex
80
Q

presenting symptoms of hernias

A

femoral

  • mass in upper medial thigh
  • lower abdomen pain

inguinal

  • swelling palpable on coughing
81
Q

examinations signs of hernias

A

femoral

  • cough impulse
  • hernia appears on cough/straining
  • hernia reduces on relaxation/ laying flat

inguinal

  • look for previous scars
  • ask patient to cough if no lump is visible => hernia above pubic tubercle
  • no lump visible feel for impulse
82
Q

How to differentiate between direct/ indirect inguinal hernias?

A
  1. reduce hernia
  2. press on the mipoint of the inguinal ring (deep ring) and ask patient to cough
  3. direct hernia will re-emerge
83
Q

How to repair hernias?

A
  • stop smoking
  • watch diet

Surgical:

  1. laproscopic repair (bilateral/ recurrent hernias)
  2. open repair

*mesh repair (fix to posterior abdo wall but risk of infection)

84
Q

Define hiatus hernia

A
  • upper part of the stomach comes up through the diaphragmatic oesophageal hiatus
85
Q

Types of hiatus hernias

A
  • sliding - hernia moves up and down in the chest => less competent LOS => acid reflux
  • rolling - hernia goes through an adjacent part of the diaphragm
  • mixed
86
Q

risk factors for hiatus hernias

A
  • obesity
  • oesophagitis
  • pregnancy
  • ascites
  • low-fibre diet
    *
87
Q

Presenting symptoms of hiatus hernia

A
  • can be asymptomatic
  • GORD symptoms (heartburn, waterbrash) + painless regurgitation = hiatus hernia
88
Q

Investigations for hiatus hernia

A
  • Bloods - FBC (anaemia)
  • Imaging- CXR (see gastric air bubble)
  • Imaging- Barium swallow
  • Endoscopy - exclude oesophagitis
89
Q

Management for hiatus hernia

A
  • Lifestyle- lose weight
  • PPIs- reduce acid production
  • reduce gastric motility

Surgical (for minority + rolling hernias as can get strangulated)

  • Nissen fundoplication - wrap upper part of stomach around oesophagus to reduce herniation
  • Hill repair - cardia attached to posterior abdominal wall
  • Belsley IV fundoplication - 270 wrap
90
Q

complications of hiatus hernia

A
  • Barrett’s oesophagus
  • oesophagitis
  • oesophageal strictures
  • intermittent bleeding
  • Incarceration of hiatus hernia => strangulation
91
Q

define mesenteric adenitits

A

self-limiting inflammatory process causing swollen mesenteric lymph nodes

*MIMICS APPENDICITIS

*more common in teens/ adolescents

92
Q

presenting symptoms of mesenteric adenitis

A
  • abdominal pain (central/RIF)
  • abdominal tenderness
  • fever
  • mesenteric lymph node enlargement
  • +/- diarrhoea
  • +/- nausea/vomiting
  • more common in children/teens
93
Q

Causes of mesenteric adenitis

A
  • gastroenteritis
  • bacterial infection (Yersinia enterocolitica, helicobacter, campylobacter jejuni, shigella, salmonella, mycobacterium tuberculosis)
  • lymphoma
  • IBD
94
Q

Differentials for mesenteric adenitis

A
  • appendicitis
  • interssusseption
  • Meckel’s diverticulitis (of the terminal ileum)
95
Q

Investigations for mesenteric adenitis

A

Bloods

  • FBC
  • ESR/CRP
  • LFTs
  • U&Es

Imaging

  • Ultrasound (as mainly children) - see enlarged lymph nodes, bowel wall thickening, normal appendix
  • CT (for older patients)
96
Q

Management of mesenteric adenitis

A
  • usually self-limiting
  • getting it during childhood, reduces risk of getting UC in adulthood
97
Q

Complications of mesenteric adenitis

A
  • ischaemic colitis
98
Q

define varicose veins

A

dilation of superficial veins

99
Q

Risk factors for varicose veins

A
  • Female
  • obesity
  • elderly
  • Family Hx
  • caucasian
100
Q

Causes of varicose veins

A
  1. Primary (idiopathic)- 90%
  2. Secondary
  • venous outflow obstruction (pregnancy, ascites, ovarian cysts, pelvic malignancy)
  • DVT
  • AV malformations
101
Q

symptoms + signs of varicose veins

A

symptoms:

  • dilated veins
  • aching/swelling
  • itching
  • bleeding

signs:

  • hard/painful veins
  • tap test- finger over SFJ and press on varicose vein if a thrill is felt = valve incompetance
  • auscultation for bruits
  • trendelenberg test
102
Q

describe trendelenburg test

A
  1. Patient flat + Lift the patient’s leg up to empty the superficial veins by milking the leg towards the groin (SFJ).
  2. Place a tourniquet over the saphenofemoral junction (SFJ) – this is found approximately 2-3cm below and lateral to the pubic tubercle.
  3. Ask the patient to stand and observe for filling of the veins

Results:

  • If the veins have not filled and remain collapsed incompetent valve was at the level of the SFJ.
  • If the veins have filled up again, it indicates the incompetent valve are inferior to the SFJ
  • Repeat the test
103
Q

Investigations for varicose veins

A
  • Doppler US (location of valve incompetence)
104
Q

Management for varicose veins

A

Conservative:

  • compression stockings
  • lifestyle (lose weight)

Endovascular

  • radiofrequency ablation
  • endovenous laser ablation
  • sclerotherapy

Surgery (rarely)

105
Q

complications of varicose veins (venous insufficiency)

A
  • venous ulcers
  • lipodermatosclerosis (champagne bottle)
  • haemociderin deposits
  • stasis eczema

Year 3 (27 decks)

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