surgery Flashcards
Define Appendicitis
inflammation of appendix
Cause of appendicitis
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
Presenting symptoms of appendicitis
- periumbilical pain that moves to right iliac fossa
- pain worsened by movement (cough)
- anorexia - loss of appetite
- nausea + vomiting
- constipation +/- diarrhoea
Atypical presentations of appendicitis
- children- non-specific abdominal pain/ withdrawn/ not eating fave food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
Examination findings of appendicitis
- 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)
Why does appendicitis initially present with periumbilical pain?
initial pain is visceral peritoneum inflammation => is poorly localised but as pain spreads to parietal peritoneum somatic more localised (RLQ)
Investigations + findings for appendicitis
*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
Management for appendicitis
- Laparoscopic Appendicectomy (SURGERY)
- Conservative Antibiotics (cefuroxime, metronidazole)
- 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)
Differentials for appendicitis (RIF pain)
- 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
Complications of appendicitis
- 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
prognosis of appendicitis
- uncomplicated => most recover with no long-term problems
- ruptured appendix => more complications/ death
Define acute pancreatitis
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)
Pathophysiology of acute pancreatitis
- 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
causes of acute pancreatitis (I GET SMASHED)
- 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
presenting symptoms of acute pancreatitis
- sudden epigastric/ central abdominal pain
- pain radiating to back
- pain relieved by sitting forward
- anorexia
- nausea
- vomiting
- Hx of high alcohol intake/ gallstones
Examination signs of acute pancreatitis
- 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)
Investigations + findings for acute pancreatitis
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
Management of acute pancreatitis
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
complications of pancreatitis
- 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)
How to calculate Prognosis of acute pancreatitis (PANCREAS)
Modified Glasgow score
PaO2 <7.9
Age >55
Neutrophils (WCC>15)
Calcium (<2mmol/L)
uRea (>16mmol/L)
Enzymes
Albumin
Sugar (>10mmol/L)
Define intestinal obstruction
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)
causes of bowel obstruction
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
presenting symptoms of bowel obstruction (Hx)
- 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?
examination findings of bowel obstruction
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)
investigations for bowel obstruction
- Bedside: urine dip (haematuria-kidney stones)
- Bloods- FBC- Hb (anaemia), WCC (infection), amylase (pancreatitis), CRP, U&Es- urea&creatinine (AKI), lactate (if strangulation => ISCHAEMIA)
- Venous blood gas - check for low K+ (vomiting)
- 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)
Differences in X-ray of small bowel and large bowel
small- central dilation, valvulae conniventes (across whole width),
large- peripheral dilation, haustra (pouches)
Management of bowel obstruction
- conservative:
- NBM
- NG tube for decompression + IV fluids
- 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)
Complications of bowel obstruction
- peritonitis
- bowel perforation
- dehydration => ACUTE KIDEY INJURY
- toxaemia
- gangrene of ischaemic bowel wall
*
Define bowel ischaemia
blockage of mesenteric vessels => bowel ischaemia (lack of oxygen) + necrosis
- acute mesenteric ischameia- affects small bowel + SMA
- chronic mesenteric ischaemia- small bowel
- ischaemic colitis - large bowel inflammation + IMA => ischaemia
risk factors for bowel ischaemia
- >65
- AF/ cardiac arrythmias
- endocarditis
- CVD risk factors: hypertension, hypercholesteremia, diabetes, smoking
- thrombophillia (hypercoagulable)
- vasculitis
- shock => sepsis
causes of acute mesenteric ischaemia
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
presenting symptoms of bowel ischaemia
- 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
examination findings of bowel ischaemia
- diffuse abdominal tenderness
- signs of shock (tachycardia, hypotension, dehydration)
- absent bowel sounds
- abdominal distension
- palpable mass
Investigations for bowel ischaemia
- bedside: ECG (AF)
- Bloods: FBC- Hb, WCC- infection, CRP-inflammation, serum lactate (ISCHAEMIC), LFTs, U&Es, clotting screen,
- ABG- lactic acidosis
- Imaging - AXR-bowel obstruction, mesenteric angiography (if stable), CT/MRI angiography (narrowed vessels)
Gold standard investigation for ischaemic colitis
Colonoscopy + biopsy
Management for bowel ischaemia
- conservative: NBM, NG tube for decompression, IV fluids, broad spectrum ABs, treat cause
- surgical:
- Emergency exploratory laparotomy + resect non-viable bowel
- restore SMA blood supply (embolectomy, SMA arterial bypass)
Indications for surgery in bowel ischaemia
- haemodynamically unstable
- massive bleeding
- toxic megacolon
- peritonitis/ sepsis
Define diverticular disease
- diverticulosis- presence of diverticulum
- true = outpouching contains all layer
- false = oupouches of only mucosa/submucosa
- diverticular disease- diverticulosis + complications (infection/fistulae/ haemorrhage) VERY COMMON
- diverticulitis - acute inflammation + infection of diverticulum
What is diverticulum?
diverticulum are outpouches of GI wall mucosa/submucosa through muscle layers at points of weakness (entry of arteries)
How to classify acute diverticulitis
Hinchley classification
- I- with pus
- Ia/II- abscess
- III- perforation + peritonitis
- IV- fecal peritonitis (due to large bowel perforation)
Causes of diverticular disease
- 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)
Presenting symptoms of
- diverticular disease
- diverticulitis + complications
- MAINLY asymptomatic
- diverticulitis =>
- LIF pain
- fever
- +/- PR bleeding
- constipation, diarrhoea, abdominal mass
- peritonitis (rigidity/ guarding)
- diverticular fistualation => pneumaturia (gas in urine), faecaluria, recurrent UTIs
Examination findings of diverticulitis
- LIF tenderness
- signs of peritonitis (rigid, guarding, rebound tenderness)
Investigations for diverticular disease/ diverticulitis
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)
Management of diverticular disease
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
Complications of diverticular disease
- acute diverticulitis (abscess => Abx + drainage, perforation, peritonitis, fecal peritonitis)
- colonic obstruction
- haemorrhage
- fistulae (vagina, bladder, small bowel)
Define volvulus
loop of bowel rotates around it’s mesentery => closed loop bowel obstruction + ischaemia
- mainly sigmoid colon + cecum
Causes/ risk factors of volvulus
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)
Presenting symptoms of volvulus
- sudden colicky abdominal pain (early sign)
- absolute constipation (early sign)
- vomiting (late sign)
examination findings of volvulus
- abdominal distension
- dehydration (dry mucous membranes, tachycardia)
- fever
- tinkling/ absent bowel sounds (bowel obstruction)
investigations for volvulus
- 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)
Management for volvulus
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)
Complications of volvulus
- bowel obstruction
- bowel perforation
- bowel ischaemia
- complications from stoma
Define acute cholangitis
infection of the bile duct
presenting symptoms of acute cholangitis
- Charcot’s triad (fever, RUQ pain=> spread to right shoulder, jaundice)
- Reynold’s pentad (charcot’s + mental confusion + septic shock/hypotension)
- pruritus (itching)
investigations for acute cholangitis
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
Causes of acute cholangitis
- gallbladder/ bile duct obstruction by stones
- ERCP
- tumours (pancreatic, cholangiosarcoma)
- parasites (ascariasis)
- bile duct stricture/ stenosis
- cholecystectomy => dilate common bile duct
Management of acute cholangitis
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
complications of ERCP
- infection
- pancreatitis
- aspiration pneumonia
- duodenal perforation
- haemorrhage
- ascending cholangitis
presenting symptoms of acute cholangitis
- Charcot’s triad (fever, RUQ pain=> spread to right shoulder, jaundice)
- Reynold’s pentad (charcot’s + mental confusion + septic shock/hypotension)
- pruritus (itching)
Complications of acute cholangitis
- liver abscess
- liver failure
- AKI
- septic shock => organ dysfunction
endoscopic drainage can lead to=> Intra-abdominal or percutaneous bleeding, sepsis, fistulae and bile leakage
Examination signs of acute cholangitis
- fever
- RUQ pain
- jaundice
- mental confusion
- sepsis
- hypotension
- tachycardia
- mild hepatomegaly
- Murphy’s sign +ve
Causes of acute cholangitis
- gallbladder/ bile duct obstruction by stones
- ERCP
- tumours (pancreatic, cholangiosarcoma)
- parasites (ascariasis)
- bile duct stricture/ stenosis
- cholecystectomy => dilate common bile duct
Define acute cholangitis
infection of the bile duct
Examination signs of acute cholangitis
- fever
- RUQ pain
- jaundice
- mental confusion
- sepsis
- hypotension
- tachycardia
- mild hepatomegaly
- Murphy’s sign +ve
investigations for acute cholangitis
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
Management of acute cholangitis
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
complications of ERCP
- infection
- pancreatitis
- aspiration pneumonia
- duodenal perforation
- haemorrhage
- ascending cholangitis
Complications of acute cholangitis
- liver abscess
- liver failure
- AKI
- septic shock => organ dysfunction
endoscopic drainage can lead to=> Intra-abdominal or percutaneous bleeding, sepsis, fistulae and bile leakage
Define anal fissures
tear in the squamous lining of the lower anal canal
- 90% posterior to anus
- some anterior (usually after childbirth)
Causes of anal fissures
- hard faeces
- anal sphincter spasm => constricts infeior rectal artery => ischaemia + impaired healing
- syphillis
- HIV
- Crohn’s
Presenting symptoms of anal fissures
- tearing pain on defecation
- PR bleeding/ blood on wiping
Examination findings of anal fissures
- PR exam - tear on squamous lining
Management of anal fissures
- Conservative (high fibre diet, laxatives to soften stool, hydration)
- Medical
- lidocaine (local anaesthtic)
- GTN + diltiazem (sphincter relaxants + improves healing)
- botulinum toxin
- Surgical (last resort)
* internal sphincterectomy (relaxes sphincter but has complications= anal incontinence)
complications of anal fissures
chronic anal fissures
Define hernias
internal body part pushes through weakness in muscle or surrounding tissue wall
types of hernias
- 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
causes of femoral hernias
- enlarged prostate
- pregnancy
- frequent cough
- chronic constipation
- intense workouts
- elderly
- obesity
causes of inguinal hernias
- chronic cough
- constipation
- urinary obstruction
- heavy lifting
- ascites
- past abdominal surgery
- infants: prematurity, male sex
presenting symptoms of hernias
femoral
- mass in upper medial thigh
- lower abdomen pain
inguinal
- swelling palpable on coughing
examinations signs of hernias
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
How to differentiate between direct/ indirect inguinal hernias?
- reduce hernia
- press on the mipoint of the inguinal ring (deep ring) and ask patient to cough
- direct hernia will re-emerge
How to repair hernias?
- stop smoking
- watch diet
Surgical:
- laproscopic repair (bilateral/ recurrent hernias)
- open repair
*mesh repair (fix to posterior abdo wall but risk of infection)
Define hiatus hernia
- upper part of the stomach comes up through the diaphragmatic oesophageal hiatus
Types of hiatus hernias
- 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
risk factors for hiatus hernias
- obesity
- oesophagitis
- pregnancy
- ascites
- low-fibre diet
*
Presenting symptoms of hiatus hernia
- can be asymptomatic
- GORD symptoms (heartburn, waterbrash) + painless regurgitation = hiatus hernia
Investigations for hiatus hernia
- Bloods - FBC (anaemia)
- Imaging- CXR (see gastric air bubble)
- Imaging- Barium swallow
- Endoscopy - exclude oesophagitis
Management for hiatus hernia
- 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
complications of hiatus hernia
- Barrett’s oesophagus
- oesophagitis
- oesophageal strictures
- intermittent bleeding
- Incarceration of hiatus hernia => strangulation
define mesenteric adenitits
self-limiting inflammatory process causing swollen mesenteric lymph nodes
*MIMICS APPENDICITIS
*more common in teens/ adolescents
presenting symptoms of mesenteric adenitis
- abdominal pain (central/RIF)
- abdominal tenderness
- fever
- mesenteric lymph node enlargement
- +/- diarrhoea
- +/- nausea/vomiting
- more common in children/teens
Causes of mesenteric adenitis
- gastroenteritis
- bacterial infection (Yersinia enterocolitica, helicobacter, campylobacter jejuni, shigella, salmonella, mycobacterium tuberculosis)
- lymphoma
- IBD
Differentials for mesenteric adenitis
- appendicitis
- interssusseption
- Meckel’s diverticulitis (of the terminal ileum)
Investigations for mesenteric adenitis
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)
Management of mesenteric adenitis
- usually self-limiting
- getting it during childhood, reduces risk of getting UC in adulthood
Complications of mesenteric adenitis
- ischaemic colitis
define varicose veins
dilation of superficial veins
Risk factors for varicose veins
- Female
- obesity
- elderly
- Family Hx
- caucasian
Causes of varicose veins
- Primary (idiopathic)- 90%
- Secondary
- venous outflow obstruction (pregnancy, ascites, ovarian cysts, pelvic malignancy)
- DVT
- AV malformations
symptoms + signs of varicose veins
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
describe trendelenburg test
- Patient flat + Lift the patient’s leg up to empty the superficial veins by milking the leg towards the groin (SFJ).
- Place a tourniquet over the saphenofemoral junction (SFJ) – this is found approximately 2-3cm below and lateral to the pubic tubercle.
- 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
Investigations for varicose veins
- Doppler US (location of valve incompetence)
Management for varicose veins
Conservative:
- compression stockings
- lifestyle (lose weight)
Endovascular
- radiofrequency ablation
- endovenous laser ablation
- sclerotherapy
Surgery (rarely)
complications of varicose veins (venous insufficiency)
- venous ulcers
- lipodermatosclerosis (champagne bottle)
- haemociderin deposits
- stasis eczema
