Surgery Flashcards
Size of aortic aneurysm before you need surgical repair
> 5.4cm
when would you urgently repair aortic aneurysm
high risk of rupture e.g. symptomatic or rapid expansion
if an aortic aneurysm doesn’t meet criteria for elective repair what should you do?
USS every 1y if 3-4.4cm
USS every 3m if 4.4-5.4cm
define bulbar (and pseudobulbar palsy)
problems with impaired lower cranial nerves (either the lower motor neurons or to the lower cranial nerve itself)
pseudo = upper motor neurone damage, also have emotional lability
how do you repair AAA
CT to assess extent of leak
synthetic grafting or endovascular repair
management of cholangitis
IV fluid resus
lactate
Antibiotics
pigtail drain (cholecystostomy) until ERCP
two causes of acute limb ischaemia
embolus (very acute, AF)
thrombosis of atherosclerotic plaque (more gradual, intermittent claudication history)
CT scan shows swirled appearance of mesentery. What is the diagnosis
Internal herniation of bowel, sometimes after gastric bypass
what vein is usually affected in varicose veins
Superficial venous system, most likely long saphenous
Could be short saphenous in the posterior/lateral leg
X ray changes and clinical picture of diaphragmatic hiatal hernia
gastric air-fluid level behind mediastinum
Epigastric pain, SOB and reduced air entry
Signs of bowel obstruction
colicky abdo pain, distension, vomiting, absolute constipation
hyper-resonance, high-pitched tinkling
Signs of pancreatitis
vomiting, severe abdo pain better leaning forward
gallstone clues, jaundice
What cholangitis is UC associated with
primary sclerosing cholangitis
signs of acute decompensated liver disease
encephalopathy, increased jaundice, deteriorating transaminases
charcot’s triad
+2 for Reynold’s pentad
1) fever
2) jaundice
3) RUQ pain
hypotension and altered mental status
6 P’s of limb ischaemia
PARAESTHESIA PARALYSED pulseless pallor perishingly cold painful
antibodies in PBC
Anti-mitochondrial
findings of extrahepatic cholestasis
high ALP
high conj bilirubin and unconj bilirubin
caused by gallstones, bile duct strictures, tumours blocking bile flow
definitive treatment for PSC
liver transplant
before this they need fat soluble vitamin supplements
Arterial ulcer management
ABPI, optimal diabetic control, angioplasty, antiplatelet and statin
what is achalasia
rare motility disorder from oesophageal ganglion degeneration.
Difficulty swallowing liquids and solids, regurgitation of food, retrosternal chest pain
diagnosis confirmed via oesophageal manometry
management: surgical myotomy or pneumatic dilation
oesophageal cancer and chagas disease are risks
glasgow score criteria
age >55 pO2 <8 WCC >15 Calcium <2 ALT >100 LDH >600 glucose >10 urea >16 albumin <32
features of arterial ulcers vs neuropathic ulcers
arterial: painful, sharply defined, loss of pulses, dusky and loss of hair
neuropathic: painless, sites of trauma/weight bearing, loss of sensation and reflexes, present pulses
what is Rockall score
Upper GI bleed severity score Shock signs Age Likely Diagnosis Co-morbidities stigmata of acute bleeding
Investigations for pancreatic cancer
Ca19-9 USS and CT ERCP Cytology on pancreatic juice and bile needle biopsy
Treatment options for pancreatic cancer
Supportive
palliation by endoscopic/transhepatic stenting of malignant stricutre
Surgical palliation by biliary bypass
Whipple’s procedure
causes of jaundice post abdo surgery
haemorrhage wound infection wound dehiscence delayed wound healing renal failure
What liver pathology is associated with COCP
hepatocellular adenoma
what other organ gets cysts in ADPKD
liver, well-demarcated round cysts
will not enhance with IV contrast
What is amputation through the ankle joint called
Syme’s amputation
what is a gallbladder empyema
complication of cholecystitis where abscess forms. Swinging fevers and palpable gallbladder
will need cholecystectomy or cholecystostomy
may come from infected mucocoeles
Define Mirizzi syndrome
gallstone impacted in neck of gallbladder causes extrinsic compression of CBD resulting in obstructive jaundice
what is gallstone ileus
mechanical SBO as a result of fistulous connection between gallbladder and SB. Gallstone enters the small bowel, impacting the ileocaecal valve
Define following signs Cullens Murphy's Rigler Sister Joseph's
Cullens = periumbilical bruising in retroperitoneal haemorrhage
Murphy’s = pain on expiration when hand is over gallbladder
Rigler’s = air on both sides of intestine in pneumoperitoneum
Sister Joseph’s = nodule at umbilicus assoc with intra-abdominal neoplastic disease
which two cancers usually spread to form cannonball mets
renal cell carcinoma
choriocarcinoma
how would you treat venous ulcers
limb elevation, wound toilet and nonstick dressing, split-skin graft if required
treat varicose veins after ulcer
What is Peutz-Jegher’s syndrome
multiple intestinal hamartomatous polyps
freckles
small bowel tumours, stomach, pancreas and colon
AD inheritance
how to treat bleeding gastric ulcer
stabilise and resuscitate with major haemorrhage protocols
upper GI endoscopy then IV PPI
which 3 tests can you assess varicose veins
Simple tourniquet: lying down, raise legs and milk veins so all blood is gone. tie tourniquet around thigh (sapheno-femoral junction) and ask to stand and assess if fill (no filling is incompetent)
Trendelenberg: same but with a finger at the junction
Doppler: reflux assessment. place over sapheno-femoral junction and squeeze calf. 2 sounds heard in incompetence
indications for surgical treatment of varicose veins
oedema
skin changes
venous eczema and ulceration
what is the BP target for resuscitating AAA
<100 to prevent re-bleeding if initial leak is sealed
which two infections can cause Right Iliac Fossa mass
Tuberculosis, yersinia
investigations for oesophageal carcinoma
OGD
CT CAP - nodal spread
endoscopic ultrasound - T and local N staging
PET scan - staging and distal mets and small lymph nodes which are still involved
treatment for metastatic oesophageal cancer in non-regional node
palliative chemo
radiological insertion of oesophageal stent (severe dysphagia)
laser treatment
treatment for oesophageal cancer with mets in regional node
curative oesphagectomy
risk factors for oesophageal carcinoma
GORD (adeno)
smoking (SCC)
achalasia
pancreatitis investigations
serum amylase (diagnostic if over 1000)
contrast CT diagnostic
USS to look for gallstones
pancreatitis management
IV fluids (5L in 2-3h)
analgesia
BG
oral feeding within 24h - consider NG and slow enteral feeding
ABx only if septic
ERCP only if gallstone expected
what complications may follow resolved pancreatitis
pseudocysts - may lead to pancreatic ascites
pancreatic abscess - features of sepsis
management of pseudocyst
conservatively
drained percutaneously at endoscopic ultrasound
think about how pseudocyst formed - may need ERCP to identify any leak/insert stents
investigations for pancreatic exocrine insufficiency
faecal elastase
clinical judgement
management of pancreatic exocrine insufficiency
oral pancreatic enzyme replacement (Creon, pancreas V, nutrizyme)
treatment for PBC
UCDA
causes of free intra-peritoneal air
laparotomy within 24h
perforated duodenal ulcer
perforated diverticulum
causes of free retro-peritoneal air
perforated 3rd part duodenum, ascending colon or descending colon
stress-induced ulcer after burns
Where is it?
Curling’s ulcer
stomach/duodenum
ulcer after raised icp
Cushings ulcer
what is zollinger ellison syndrome
peptic ulceration secondary to gastrin-secreting tumours
assoc with men1
treatment for gallstone ileus
enterolithotomy and fistula repair
what is a Marjolin ulcer
chronic venous ulcer undergoes SCC malignant change. Edges become raised/thickened and it becomes more painful
investigation for renal stone
non-contrast of CT
cytology finding on fibrocystic disease
cell debris and no malignant cells
best analgesia for people with severe COPD
do not use opioids or NSAIDs
can use epidural
when do leaking anastamoses usually present after surgery
day 3-5
investigations for people with thyroid nodule and are euthyroid
USS neck
investigation for people with thyroid nodule and are hyperthyroid
antibodies and scintigraphy
best investigation for right sided hearing loss with normal tympanometry
MR internal acoustic meatus
management for acute cholecystitis with normal LFTs and normal common bile duct
laparoscopic cholecystectomy
ERCP only if you’re worried about common bile duct issues
fasting times before general anaesthetic
2h clear liquids, 6h foods
management for stone causing obstruction, hydronephrosis and sepsis
nephrostomy as you need to drain the pus otherwise abx won’t work
then lithotripsy or stone extraction
what nodes do the ovarian lymphatics drain to
para-aortic
referral of pain from originally foregut structures
epigastrium
referral of pain from originally midgut structures
umbilical
referral of pain from originally hindgut structures
hypogastric
radiation of pain from retroperitoneal structures
back
what is rovsing’s sign
pain in right IF when left felt
appendicitis
scoring for appendicitis
alvorado
>4 = likely appendicitis
which neck lump moves with tongue protrusion but not swallowing
thyroglossal mass
which neck lump moves with swallowing but not tongue protrusion
thyroid
how to tell the difference between indirect and direct hernia
reduce hernia, occlude the deep ring and ask them to cough
indirect hernia will not come back
how to tell difference between inguinal and femoral hernia
femoral is below crease of groin, low and lateral to pubic tubercle
do hernias need to be surgically treated?
yes if complications or femoral
