Surgery Flashcards
1
Q
List some causes of generalised abdominal pain
A
Peritonitis
Ruptured abdominal aortic aneurysm
Intestinal obstruction
Ischaemic colitis
2
Q
List some causes of right upper quadrant pain
A
Biliary colic
Acute cholecystitis
Acute cholangitis
3
Q
List some causes of epigastric pain
A
Acute gastritis
Peptic ulcer disease
Pancreatitis
Ruptured abdominal aortic aneurysm
4
Q
List some causes of right iliac fossa pain
A
Acute appendicitis
Ectopic pregnancy
Ovarian torsion
Meckel’s diverticulitis
5
Q
List some causes of left iliac fossa pain
A
Diverticulitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
6
Q
List some causes of suprapubic pain
A
Lower urinary tract infection
Acute urinary retention
Pelvic inflammatory disease
Prostatitis
7
Q
List some causes of loin to gorin pain
A
Renal colic
Ruptured aortic aneurysm
Pyleonephritis
8
Q
List some causes of testicular pain
A
Testicular torsion
Epididymo-orchitis
9
Q
What is peritonitis
A
Inflammation of the peritoneum
10
Q
List some signs of peritonitis
A
Guarding - involuntary tensing of the abdominal wall muscles when palpated to protect the painful area
Rigidity - involuntary perisitent tightness or tensing of the abdominal wall muscles
Rebound tenderness - rapidly releasing pressure on the abdomen creating a worse pain than the pressuure itselg
Coughing test - coughing results in pain
Percussion tenderness - pain and tenderness when percussing the abdomen
11
Q
What is local peritonitis
A
Caused by underlying organ inflammation
12
Q
What is generalised peritonitis
A
Caused by perforation of the abdominal contewnts into the peritoneal cavity
13
Q
What is spontaneous bacterial peritonitis
A
Associated with spontaenous infection of ascites in liver disease patients
14
Q
How is spontaneous bacterial peritonitis treated
A
Broad spectrum antibiotics and supportive care
15
Q
Describe the initial assessment of an acute abdomen patient
A
A to E approach
Airway - ensure secure and patent
breathing - RR, O2 sats, listen to lungs and give O2 if required
Circulation - assess BP, HR, heart sounds and perfusion. Gain IV access, take blood and provide IV bolus fluid if required
Disability - assess consciousness level - GCS/AVPU, check blood glucose
Exposure - examination of abdomen
16
Q
What investigations are useful in obtaining a diagnosis in acute abdomen?
A
FBC - drop in Hb and infection/inflammation high WCC
U&Es - electrolyte imbalance and kidney function - prior to CT scans which require contrast
LFTs - biliary and hepatic system
CRP - inflammation and infection
Amylase - pancreatitis
INR - synthetic state of the liver, establish the coagulation prior to procedures
Serum calcium - score acute pancreatitis
Serum hCG or urine pregnancy test in women of child bearing age
ABG - lactate (tissue ischaemia) and pO2 (used in scoring of acute pancreatitis)
Serum lactate - tissue ischaemia as product of anaerobic respiration and can be raised in dehydration or hypoxia
Group and save - essential prior to theatre in case patient needs a blood transfusion
Blood cultures - infection suspected
Abdominal X-ray - bowel obstruction - dilated bowel loops
Erect CXR - air under diaphragm when there is intra-abdominal perforation - caused by air in the peritoneum
Abdominal USS - gallstones, biliary duct dilation and gynaecological pathology
CT scans - identify the cause of acute abdomen - determine the correct management
17
Q
Describe the initial management of acute abdomen
A
ABCDE
Alert seniors - escalate to reg, consultant and critical care as required
NBM - surgery may be required
NG tube - bowel obstruction
IV fluids - resuscitation or maintenance
IV antibiotics – if infection is suspected
Analgesia 0 pain management
Arrange investigations
Venous thromboembolism risk assessment and prescription if indicated
Prescribe regular medication and see which should be withheld
18
Q
What does the suffix -ostomy mean?
A
Creating a new opening
19
Q
What are adhesions
A
Scar like tissue inside the body that bidns surfaces together
20
Q
What is a fistula
A
Abnormal connection between two epithelial surfaces
21
Q
What is tenesmus
A
The sensation of needing to open the bowels without being able to produce stool. Often accompanied with pain
22
Q
Define hemicolectomy
A
Removing a portion of the large intestine (colon)
23
Q
Define hartmann’s procedure
A
Proctosigmoidectomy - removal of the rectosigmoid colon with closure of the anorectal stump and formation of colostomy
24
Q
What is an anterior resection
A
Removal of the rectum
25
What is a Whipples procedure
Pancreaticoduodenectomy -
| Removal of the head of the pancreas, duodenum, gallbladder and bile duct
26
What is a Kocher incision for
Open cholecystectomy
27
What is a Chevron/rooftop incision for
Liver transplant, whipple procedure, pancreatic surgery or upper GI surgery
28
What is a Mercedes Benz incision for
Liver transplant
29
What is a midline incision for
General lapartomy
30
What is a paramedian incision for
Laparotomy
31
What is a hockey stick incision for
Renal transplant
32
What is a battle incision for
Open appendicetomy
33
What is a McBurney incision for
Open appendicetomy
34
What is a Lanz incision for
Open appendicetomy
35
What is a rutherford morrison incision for
Open appedicetomy and colectomy
36
Describe a pfannelstiel incision
Curved incision two fingers above pubic symphysis
C-section
37
Describe a Joel-Cohen incision
Straight incision slightly higher - recommended
C-section
38
Describe the incisions in laparoscopic surgery
Several 5-10mm incisions to allow the cameras and instruments to be inserted into the abdomen via port sites - site just above or below umbilicus
39
Describe diathermy
High frequency electrical current to cut through tissues or to stop bleeding. It causes localised burning of tissues - targeted incision with minimal bleeding
Monopolar diathermy - grounding plate under leg of patient to form a circuit of electricity. Causes localised burning and tissue damage. The electrical signal passes round the body but becomes weaker so does not damage other tissues
Bipolar diathermy - involves an instrument with two electrodes and current passes between the electrodes affecting the tissues - does not pass to rest of the body
40
Describe absorbable sutures
Slowly absorbed and disappear over time - vicryl and monocryl
Used in tissues that heal well and remain sealed after suture absorbed such as abdominal cavity and closing the tissues beneath the dermis
41
Describe non-absorbable sutures
Remain in place for a long time to provide support
Nylon, silk, polypropylene
Interrupted or mattress suture and removed later once the skin has healed, fixing drains in place and removed later with the drain, connective tissues that heal slowly such as repairing tendons
42
How is the surface of skin closed
Staples
Interrupted suture - series of individual knows
Mattress suture - series of individual sutures that each go from one side of the wound, under and out the other side then back under again to the original side
Continius sutures 0 in and out, spiral shape
Subcuticular sutures - single absorbale suture side to side just below the skin to pull the edges together
43
Describe drains
Tubes in body to allow air and fluid to drain away preventing build up of air, pus, blood or other fluid collecting
Chest drain
44
How do you know if a chest drain is in the right place
Swinging - water in the drain will rise and fall due to normal pressure changes in the chest
45
When is the WHO surgical safety checklist performed
3 stages
- Before induction of anaesthesia
- Before the first skin incision
- Before the patient leaves theatre
46
List the factors checked in the WHO surgical checklist
```
Patient identity
Allergies
Operation
Risk of bleeding
Introductions of all team members
Anticipated critical events
Counting equipment to ensure nothing is still in the patient
```
47
Describe what happens in pre-operative assessment
```
Past medical problems
Previous surgery
Previous adverse responses to anaesthesia
Medications
Allergies
Smoking
Alcohol use
Malnourished - dietician and additional nutritional support
```
48
Describe the ASA grade
American society of anesthiologists grading system classifies the physical status of the patient for anaesthesia
ASA1 - normal healthy patient
ASA 2 - mild systemic disease
ASA 3 - severe systemic disease
ASA 4 - severe systemic disease that constantly threatens life
ASA V - moribund and expected to fie without the operation
ASA VI - declared brain dead and undergoing organ donation
E - emergency operations
49
List some pre-op investigations
ECG - if known or possible CVD
Echo - heart murmurs, cardiac failure or symptoms
Lung function tests - known or possible respiratory disease
HbA1C - within last 3 months in patients with known diabetes
U&Es - at risk of AKI or electrolyte abnormalities due to medication
FBC - anaemia, CVD or kidney disease
Clotting if known liver disease
Group and save - send off sample of patients blood to establish blood group. Sample is saved in case they require blood to be matched to them for blood transfusion and no blood is assigned to them at this stage
Cross matching - acutely take a unit or more of blood and assign it to the patient in case they need it quick
MRSA screening
50
How long must patients fast for before surgery
6 hrs of no food or feeds before operation
| 2 hours of clear fluids (fully NBM)
51
How long before an operation should the COCP and HRT be stopped?
4 Weeks
52
What can be given to rapidly reverse anticoaglation in patients taking warfarin
Vitamin K
53
How long before surgery are DOACs stopped
24-72hrs
54
Describe the medication change before surgery in patients who take long term corticosteroids
Additional IV hydrocortisone at induction and for immediate postop period
Doubling of normal dose for 24-72hrs after operation
55
Describe insulin use in surgery
Reduce their ling acting insulin
Omit their short acting insulin
Place on variable rate insulin infusion alongside glucose, sodium and potassium
56
Describe the VTE prophylaxis during surgery
LMWH - enoxaparin
DOACs - apixaban, rivaroxaban
Intermittent pneumatic compression
Anti-embolic compression stockings
57
What is the extracellular space
Intravascular space - inside blood vessels
Interstitial space - functional tissue space between and around cells
Third space - third extracellular space
58
What is the third space
Areas of the body which do not usually contain fluid
Peritoneal cavity - ascites
Pleural cavity - pleural effusion
Pericardial cavity - pericardial effusion
joint - joint effusions
59
What are the two categories of fluid spaces in the body
Intracellular space
| Extracellular space
60
Describe the process of third spacing
Fluid shifting into the third space
Development of oedema as excessive fluid moves into the intersitital space
Development of ascites, effusions or other non-functional space - hypotension and reduced perfusion of tissue
61
List some sources of fluid intake
Oral fluids
NG or PEG feeds
IV fluids
Total parenteral nutrition
62
List some sources of fluid output
```
Urine output
Bowel or stoma output
Vomit or stomach aspiration
Drain output
Bleeding
Sweating
```
63
What are insensible fluid losses
Fluid output that is difficult to measure - respiration, stools, burns and sweat - estimated
64
What are some signs of hypovolaemia
```
Hypotension
Tachycardia
CRT >2 seconds
Cold peripheries
Raises RR
Dry mucous membranes
Reduced skin turgor
Reduced urine output
Sunken eyes
Reduced body weight from baseline
Feeling thirsty
```
65
What are some signs of hypervolemia
Peripheral oedema
Pulmonary oedema - SOB, raised JVP, reduced O2 sats, bibasal crackles
Raised JVP
Increased body weight from baseline
66
Describe the clinical picture of someone with third spacing
Low level of fluid in the intravascular space but excessive lfuid in other areas (interstitial fluid or peritoneal cavity)
Hypovolaemia signs and signs of fluid overload
67
List the main indications for IV fluid
Resuscitation
Replacement
Maintenance
68
Name the two main types of fluid
Crystalloids
| Colloids
69
Describe crystalloids
```
Water with added salt or glucose
- 0.9% sodium chloride
5% dextrose
0.18% sodium chloride 4% glucose
Hartmann's solution
Plasma lyte 148
```
70
What does 1 L normal 0.9% saline contain
1L water
154mmol Na
154mmol Cl
71
What does 1L 5% dextrose contain
1 L water
No electrolytes
50g glucose
72
What can too much normal saline cause
Hypernatraemia
73
What can too much 5% dextrose cause
Oedema and hyponatraemia - hypotonic fluid
74
What does 1L Hartmanns solution contain
```
1L water
131mmol Na
111 mmol Cl
5 mmol K
2 mmol Ca
29mmol lactate - buffer the solution - reduce the risk of acidosis
```
75
Describe colloids
Larger molecules that stay in the intravascular space longer - help retain the fluid in intravascular space
eg. human albumin solution - used in patients with decompensated liver disease. Increases plasma oncotic pressure drawing in and retaining fluid
76
What does tonicity refer to
The osmotic pressure gradient between two fluids across a membrane - determines whether water molecules will move across the membrane by osmosis
77
Describe how you give a fluid bolus in resus situation
500ml bolus over 15mins (stat)
Reassess ABCDE
Repeat boluses 250-500ml if required followed by reassement each time
78
How much water does a person need a day in terms of maintenance
25-30ml/kg/day
79
How much sodium, potassium and chloride does a person need in a day for maintenance
1mmol/kg/day
80
How much glucose does a person need a day for maintenance
50-100g/day
81
What is appendicitis
Inflammation and infection of the appendix
| Can rupture
82
Describe the pain in appendicitis
Starts as central abdominal pain that moves down to become localised at the right iliac fossa in the first 24hrs
83
List some features other than abdominal pain which present in appendicitis
```
Loss of appetite
Nausea and vomiting
Low grade fever
Guarding
Rebound tenderness on RIF
Percussion tenderness
```
84
What is Rovsing's sign?
Appendicitis - Palpation of the LIF causes pain in the RIF
85
Where is McBurney's point
1/3 From the ASIS to the umbilicus
86
What is rebound tenderness a sign of
Peritonitis
87
How is appendicitis diagnosed
Clinical presenation
Raised inflammatory markers
CT scan if other diagnosis more likely
USS in children and females (exclude gynae problem)
Period of observation if unclear or when clear clinical presentation but negative investigations perform a diagnostic laparoscopy
88
List some differentials of appendicitis
Ectopic pregnancy
Meckel's diverticulum
Ovarian cysts
Mesenteric adenitis
89
Describe an appendix mass
Where the omentum surrounds and sticks to the inflamed appendix, forming a mass in the right iliac fossa.
90
How is an appendix mass managed
Conservatively with supportive treatment and antibiotics followed by appendicectomy once the acute condition has resolved
91
What is the management of appendicitis
Appendicectomy - laparoscopic is preferred to open
92
Which bowel obstruction is most common
Small bowel
93
Describe third spacing in bowel obstruction
The bowel secretes fluid which in normal instances is reabsorbed in the colon. When there is an obstruction, the fluid cannot be reabsorbed so there is fluid loss from the intravascular space into the GI tract. This leads to hypovolaemia and shock. The higher up in the intestine, the greater the fluid loss
94
List some causes of bowel obstruction
Adhesions (small bowel)
Hernias (small bowel)
Malignancy (large bowel)
Others: Volvulus (large bowel), diverticular disease, strictures, intussusception in children
95
List the main causes of intestinal adhesions
Abdominal or pelvic surgery
Peritonitis
Abdominal or pelvic infection
Endometriosis
96
What is meant by closed loop obstruction
Two points of obstruction along the bowel - middle section sandwiched between two points of obstruction
The contents of closed loop section do not have an open end where they can drain and decompress, therefore the section will inevitably continue to expand, leading to ischaemia and perforation
97
List some causes of closed loop obstruction
Adhesions
Hernia
Volvulus - twist
Single point of obstruction and competent ileocaecal valve
98
What is meant by a competent ileocecal valve in terms of obstruction
Ileocaecal valve does not allow any movement back into the ileum from the caecum
When there is a large bowel obstruction and a competent ileocecal valve, a section of bowel becomes isolated and the contents cannot flow in either direction
99
List some key features in bowel obstruction
Vomiting - bilious green vomit
Abdominal distension
Diffuse abdominal pain
Absolute constipation and lack of flatulence
Tinkling bowel sounds heard early in obstruction
100
What might be seen on abdominal X-ray in bowel obstruction
Distended loops of bowel
3cm small bowel
6cm colon
9cm caecum
101
What are valvulae conniventes
Small bowel mucosal folds
| Extend the full width of the small bowel
102
What are haustra
Pouches formed by the muscles in the large bowel walls. They form lines which do not extend the full width - only part of the way across the bowel
103
Describe the inital management of bowel obstruction
ABCDE
Fluids - hypovolaemic shock due to third spacing
U&Es - electrolyte imbalance
Lactate - vowel ischaemia
Metabolic alkalosis - VBG - vomiting stomach acid
Drip and suck - NBM, IV fluids, NG tube with free drainage (allow stomach contents to freely drain and reduce risk of aspiration and vomiting)
104
What investigations might be useful in bowel obstruction
Abdominal Xray
Contrast abdominal CT scan - confirm diagnosis, establish site and cause. Also used to diagnose intra-abdominal perforation
Erect CXR - air under diaphragm
105
Describe the management of bowel obstruction after initial management
Conservative if volvulus or adhesions and patient stable
Laparotomy or laparoscopy - exploratory surgery, adhesolysis, hernia repair, emergency resection of tumour
Colonoscopy - stents in bowel if obstruction due to tumour and not for resection
106
Describe ileus
Normal peristalsis of the small bowel temporality stops
107
Describe pseudo-obstruction
Functional obstruction of the large bowel - patients present with intestinal obstruction but no mechanical cause is found
Less common than ileus affecting the small bowel
108
List some causes of ileus
Injury to the bowel
Handling of the bowel during surgery - most common
Inflammation or infection in or nearby the bowel
Electrolyte imbalance - hypokalaemia and hyponatraemia
109
List the signs and symptoms of bowel obstruction
Vomiting - green bilious vomit
Abdominal distension
Diffuse abdominal pain
Absolute constipation and lack of flatulence
Absent bowel sounds - as opposed to tinkling bowel sounds of mechanical obstruction
110
Describe the management of ileus
```
NBM
NG tube if vomiting
IV fluids - prevent dehydration and correct electrolyte imbalances
Mobilisation
Total parenteral nutrition
```
111
What is volvulus
Where the bowel twists round itself and the mesentery it is attached to
112
What is mesentery
Membranous peritoneal tissue that creates a connection between the bowel and the posterior abdominal wall
113
What does a volvulus cause
Closed loop obstruction
114
How does volvulus affect the blood vessels supplying the bowel
Mesenteric arteries supply the bowel and if involved they can cut off the supply to the bowl leading to ischaemia, necrosis and bowel perforation
115
Name the two types of volvulus
Sigmoid
| Caecal
116
Describe sigmoid volvulus
Most common
Affects older people
Twist affects the sigmoid colon
Caused by chronic constipation where the mesentery lengthens and twists, high protein diet and excessive use of laxatives
117
Describe caecal volvulus
Less common
| Affects younger patients
118
List some risk factors for volvulus
```
Neuropsychiatric disorders - PD
Nursing home residents
Chronic constipation
High fibre diet
Pregnancy
Adhesions
```
119
Describe the presentation of volvulus
Green bilious vomiting
Abdominal distension
Diffuse abdominal pain
Absolute constipation and lack of flatulence
120
How is volvulus diagnosed
Abdominal Xray
| Contrast CT scan
121
What is the pathognomonic sign of volvulus
Coffee bean sign
122
Describe the management of volvulus
NBM
NG tube
IV fluids
Conservative management - endoscopic decompression with sigmoid voluvlus. Flexible sigmoidoscope is inserted with patient in left lateral potion, correction of the volvulus. A flatus tube/rectal tube is left temporarily in place to decompress the bowl and is later removed
Surgical management
- Laparotomy
- Hartmann's procedure - removal of rectosigmoid colon and formation of colostomy
- Ileocaecal resection or right hemicolectomy for caecal volvulus
123
What is Rigler's sign
Double wall sign
| Signifies free air in the abdomen
124
What is the Borchardt's triad of gastric volvulus
Vomiting
Severe epigastric pain
Failed NG tube attempts
125
What are the features of gallstone ileus
Small bowel obstruction
| Pneumobilia - air in the biliary tree
126
What is a hernia
The protrusion of a viscus/part of a viscus through a hole/defect in the wall of its containing cavity into an abnormal position
127
Describe the presenting features of a hernia
Soft lump protruding from abdominal wall
Lump may be reducible
Lump may protrude on coughing or standing
Aching, pulling or dragging sensation
128
List the three complications of hernias
Incarceration
Obstruction
Strangulation
129
Describe what is meant by incarceration of a hernia
Irreducibility of the hernia - can lead to obstruction and strangulation
130
Describe what is meant by obstruction of a hernia
Blockage in passage of faces through the bowel
| Vomiting, generalised abdominal pain and absolute constipation
131
Describe what is meant by a strangulated hernia
Non-reducible hernia and the base becomes so tight it cuts off the blood supply causing ischemia
132
How does a strangulated hernia present
Significant pain and tenderness at the hernia site
| Mechanical obstruction
133
Describe what affects the risk of obstruction and strangulation of a hernia
The size of the neck - hernias with a large neck at lower risk
If the hernia is reducible
134
Describe Richters hernia
Part of the bowel wall and lumen herniate through the defect with the other side of the section of bowel remaining in the peritoneal cavity
Becomes strangulated and rapidly necrotic
135
Describe a Maydl's hernia
2 different loops of bowel are contained within the hernia
136
Describe the management of hernias
```
Conservative - do nothing
Tension free repair (surgery) - mesh
Tension repair (surgery) - sutures
```
137
What is found in the inguinal canal
Spermatic cord - males
| Round ligament - females
138
What is the inguinal canal
Tube that runs between the deep inguinal ring and superficial inguinal ring
139
Describe an indirect hernia and how to examine one
Passage of bowel through the deep inguinal ring
When pressure applied to the deep ring (midway between ASIS and pubic tubercle) the hernia is reduced and remains reduced
140
Describe a direct inguinal hernia and how to examine one
Occur due to weakness in the abdominal wall at Hesselbach's triangle
The hernia protrudes directly through the abdominal wall
Pressure over the deep ring will not stop herniation
141
List the boundaries of Hesselbach's triangle
Rectus abdominis muscle - medial border
Inferior epigastric vessels - superior and lateral border
Pouparts ligament (inguinal ligament) - inferior border
142
Describe a femoral hernia
Herniation of the abdominal contents through the femoral canal
Below the inguinal ligament at the top of the thigh
143
List the boundaries of the femoral canal
Femoral vein laterally
Lacunar ligament medially
Inguinal ligament anteriorly
Pectineal ligament posteriorly
144
Describe the contents of the femoral triangle from lateral to medial
Femoral nerve
Femoral artery
Femoral vein
Femoral canal
145
Describe incisional hernias
Site of an incision from previous surgery
Weakness where the muscles and tissues were closed after a surgical incision
Bigger the incision and if co-morbidities which delay wound healing
146
Describe an umbilical hernia
Occur around the umbilicus due to a defect in the muscle around the umbilicus
More common in neonates and resolve spontaneously, also in older adults
147
Describe epigastric hernias
Hernia in epigastric area
148
Describe diastasis recti
Rectus diastasis and recti divarication
Refers to widening of the linea alba, the connective tissue that separates the rectus abdominis muscle, forming a larger gap between the rectus muscle
Gap becomes more prominent when the patient lies on their back and lifts their head - protruding buldge along the middle of the abdomen
149
Who is more at risk of diastasis recti
Pregnancy
Obesity
Connective tissue disease
Can be congenital
150
Describe an obturator hernia and its sign
Where abdominal or pelvic contents herniate through the obturator foramen at the bottom of the pelvic. They occur due to a defect in the pelvic floor and are more common in women, old age, after multiple pregnancies and vaginal deliveries
Present with irritation of the obturator nerve
Howship-romberg sign - pain extending from the inner thigh to the knee when the hip is internally rotated
151
What is a hiatus hernia
Herniation of the stomach up through the diaphragm
4 types
Sliding - stomach slides up through the diaphragm with the gastro-oesophageal junction passing into the thorax
Rolling hiatus hernia - separate portion of the stomach folds around and enters the diaphragm opening alongside the oesophagus
Type 4 - large hernia that allows other intra-abdominal organs to pass through the diaphragm opening
152
List some risk factors for hiatus hernias
Increasing age
Pregnancy
Obesity
153
List the symptoms of hiatus hernias
```
Heartburn
Acid reflux
Reflux of food
Burping
Bloating
Halitosis
```
154
List some investigations for hiatus hernias
CXR
CT scan
Endoscopy
Barium swallow test
155
How is hiatus hernia treated?
Conservative - medical management of GORD
| Surgical repair - high risk of complications or symptoms resistant to medical Rx- fundoplication
156
Describe haemorrhoids
Enlarged anal vascular cushions
157
List some risk factors for haemorrhoids
Pregnancy
Obesity
Increased age
Increased abdominal pressure - weigh lifting and constipation
158
What are the anal cushions
Specialised submucosal tissue that contain connections between the arteries and veins, making them very vascular. They are supported by smooth muscle and connective tissue. They help to control anal continence along with internal and external sphincters - blood supply is from the rectal arteries
159
Describe the classification of haemorrhoids
1st degree - no prolapse
2nd degree - prolapse when straining and return on relaxing
3rd degree - prolapse when straining, does not return on relaxing but can be pushed back
4th degree - prolapse permanently
160
List some symptoms of haemorrhoids
```
Constipation
Straining
Bright red, painless bleeding - toilet tissue or seen after opening the bowels
Blood is not mixed with stool
Sore/itchy anus
Feeling a lump inside or around anus
```
161
Describe the examination of haemorrhoids
External (prolapsed) haemorrhoids are visible on inspection as swellings covered in mucosa
Internal haemorrhoids may be felt on PR exam
They may appear (prolapse) if the patient is asked to bear down during inspection
Proctoscopy is required for proper visualisation and inspection - visualise the mucosa
162
Describe the management of haemorrhoids
Topical treatment - anusol, germaloid cream
Prevention and treatment of constipation - increase fibre intake, maintain good fluid intake, using laxatives, consciously avoiding straining when opening bowels
Non-surgical options - rubber band ligation, injection sclerotherapy, infra-red coagulation, bipolar diathermy
Surgical - haemorrhoidal artery ligation, haemorrhoidectomy, stapled haemorrhoidectomy
163
What are thrombosed haemorrhoids
Strangulation at base of haemorrhoid and blood clot inside
Painful
Purple, very tender, swollen lumps around anus
Resolve with time although very painful may require admission for surgery if patient presents <72hrs
164
What is diverticulosis
Presence of diverticula with or without inflammation or infection
165
What is diverticulitis
Inflammation and infection of diverticula
166
How does diverticulosis occur
Large instestine contains a layer of muscle called the circular muscle. Points penetrated by blood vessels are areas of weakness. Increased pressure inside the lumen over time causes a gap to form in these areas and allow mucosa to herniate through the muscle layer and pouches to form
167
List some risk factors for diverticulosis
Increased age
Low fibre diet
Obesity
Use of NSAIDs
168
What symptoms may diverticulosis present with
Lower left abdominal pain
Constipation
Rectal bleeding
169
Describe the management of diverticulosis
High fibre diet
Bulk forming laxatives
Stimulant laxatives
170
Describe how patients with acute diverticulitis present
```
Pain and tenderness in the LIF
Fever
Diarrhoea
Nausea and vomiting
Rectal bleeding
Palpable abdominal mass
Raised inflammatory markers and WBC
```
171
Describe the management of uncomplicated diverticulitis
Oral co-amoxiclav
Analgesia
Only taking clear liquids until symptoms improve
Follow up within 2 days to review symptoms
172
Describe the management of complicated diverticulitis
```
NBM
IV antibiotics
IV fluids
Analgesia
Urgent investigations
Urgent surgery may be required for complications
```
173
List some complications of acute diverticulitis
```
Perforation
Peritonitis
Peri diverticular abscess
Large haemorrhage requiring blood transfusions
Fistula
Ileus/obstruction
```
174
What is mesenteric ischaemia
Lack of blood flow through the mesenteric vessels supplying the intestines, resulting in ischaemia
175
Which artery supplies the foregut
Coeliac artery
176
Describe what is meant by the foregut
Stomach, part of duodenum, biliary system, liver, pancreas and spleen
177
Which artery supplies the midgut
Superior mesenteric artery
178
What comprises the midgut
Distal duodenum to the first half of the transverse colon
179
Which artery supplies the hindgut
Inferior mesenteric artery
180
What comprises the hindgut
Second half of the transverse colon to the rectum
181
Describe chronic mesenteric ischaemia
Intestinal angina
Atherosclerosis causing narrowing to the mesenteric blood vessels
Triad
- Central colicky abdominal pain after eating (starting 30 mins after and lasting 1-2hrs)
- Weight loss due to food avoidance
- Abdominal bruit may be heard on auscultation
182
List some risk factors for chronic mesenteric ischaemia
```
Increased age
Family history
Smoking
Diabetes
Hypertension
Raised cholesterol
```
183
How is chronic mesenteric ischaemia diagnosed?
CT angiography
184
Describe the management of intestinal angina
Reducing modifiable risk factors
Secondary prevention - statins and antiplatelet medication
Revascularisation to improve the blood flow to the intestines - endovascular procedures or open surgery
185
Describe acute mesenteric ischaemia
Rapid blockage in blood flow through the superior mesenteric artery - thrombus
186
What is a key risk factor for acute mesenteric ischaemia
AF - thrombus forms in the left atrium, then mobilises (thromboembolism) down the aorta to the superior mesenteric artery where it becomes stuck and cuts off the blood supply
187
How does acute mesenteric ischaemia present
Intense pain that is disproportionate to the examination findings
Patients can go on to develop shock, peritonitis and sepsis and necrosis of the bowel and perforation
188
How is acute mesenteric ischaemia diagnosed
Contrast CT
Metabolic acidosis
Raised lactate
189
Describe the treatment of mesenteric ischaemia
Remove the necrotic bowel
| Bypass or remove the thrombus in the blood vessel
190
List some risk factors of bowel cancer
```
Family history
Age
Smoking
Familial adenomatous polyposis
Hereditary nonpolyposis colorectal cancer - lynch syndrome
Obesity
Alcohol
```
191
Describe familial adenomatous polyposis
Autosomal dominant condition involving malfunctioning of the tumour suppressor genes (adenomatous polyposis coli)
Many polyps forming along the large intestine before age 40
These have the potential to become cancerous
```
Patients have their entire large intestine
removed prophylactically (pan proctocolectomy) `
```
192
Describe hereditary nonpolyposis colorectal cancer
Lynch syndrome
Autosomal dominant
Mutations of DNA mismatch repair genes
Patients are at a higher risk of a number of cancers but particularly colorectal cancer
193
List some red flags for bowel cancer
```
Change in bowel habit - usually more frequent and loose
Unexplained weight loss
Rectal bleeding
Unexplained abdominal pain
Iron deficency anatima
Abdominal or rectal mass on examination
```
194
List the people referred under the 2 week wait pathway for bowel cancer
Over 40 with abdominal pain and unexplained weight loss
Over 50 with unexplained rectal bleeding
Over 60 with change in bowel habit or iron deficiciency anaemia
195
Describe the FIT test
Faecal immunochemical test - amount of human haemoglobin in the stool - replaced the faecal occult test - could detect blood in stool from meat
Used in patients who may have bowel cancer who do not meet requirements for 2 week wait referral
196
Describe bowel cancer screening
FIT testing for people aged 60-74 every 2 years
If positive - referred for colonoscopy
Patients with risk factors such as FAP, HNPCC or inflammatory bowel cancer offered regular colonoscopy
197
List the investigations for bowel cancer
```
Colonoscopy
Sigmoidoscopy
CT colonography
Staging CT - CT TAP
CEA blood test - carcinoembryonic antigen - tumour marker blood test in bowel cancer - not helpful in screening but may be used in predicting relapse in patients previously treated for bowel cancer
```
198
Describe the Dukes staging system for bowel cancer
Dukes classification
Dukes A - confined to mucosa and part of the muscle of the bowel wall
Dukes B - extending through the muscle of the bowel wall
Dukes C - lymph node involvement
Dukes D - metastatic disease
199
Describe the TNM classification for bowel cancer
Tumour
TX - unable to assess size
T1 - submucosa involvement
T2 - involvement of muscularis propria
T3 - Involvement of the subserosal and serosa but not through the serosa
T4 - spread through the serosa reaching other tissues (a) or organs (b)
```
Nodes
NX - unable to assess nodes
N0 - no nodal spread
N1 - spread to 1 or 3 nodes
N2 - spread to more than 3 nodes
```
Metastasises
M0 - no metastasise
M1 - metastasis
200
Describe the management of bowel cancer
Surgical resection - laparoscopic surgery
Chemotherapy
Radiotherapy
Palliative care
201
Describe bowel cancer surgery
Identifying the tumour
Remove the section of bowel containing the tumour
Create an end to end anastomosis
Alternatively create a stoma
Hemicolectomy
High anterior resection - sigmoid colon
Low anterior resection - removing the sigmoid colon and the upper rectum
Abdominal-perineal resection - removing the rectum and anus
Hartman's procedure - emergency procedure involves removal of the rectosigmoid colon and creation of colostomy. The rectal stump is sutured closed. The colostomy may be permanent or reversed at a later date
202
List the complications of surgery for bowel cancer
```
Bleeding, infection and pain
Damage to nerves, bladder, ureter or bowel
Post-op ileus
Anaesthetic risks
Laparoscopic surgery converted to open
Requirement of stoma
Failure to remove tumour
Change in bowel habit
VTE
Incisional hernia
Adhesions
```
203
What can a low anterior resection cause
Urgency
Frequency
Faecal incontinence
Difficulty controlling flatulence
204
Describe the follow up for bowel cancer
Serum carcinoembryonic antigen (CEA)
| CT thorax, abdomen and pelvis
205
What are stomas
Artificial openings of hollow organ
206
What is a colostomy
Large intestine
Drain more solid stool as water reabsorbed by remaining large bowel - flush to the skin as solid stool less irritating to the skin
Located in LIF
207
What is an ileostomy
Located in RIF
Have a spout
Drain liquid contents
208
What is a gastrostomy
Creating an artificical connection between the stomach and abdominal wall
Provide feeds directly into the stomach in patients who can not meet their nutritional needs by mouth
209
What is a PEG
When gastrostomy inserted by endoscopy procedure
210
What is a urostomy
Creating an opening from the urinary system onto the skin - spout and located in RIF
211
Describe an ileoanal anastomosis
J pouch
| Ileum folded back on itself and fashioned into a larger pouch that functions like a rectum
212
What are loop -ostomys
Temporary stoma used to allow a distal portion of the bowel and anastomosis to heal after surgery
213
List some complications of stomas
```
Psycho-social
Local skin irritation
Parastomal hernia
Loss of bowel length - high output, dehydration and malnutrition
Constipation in colostomies
Stenosis
Obstruction
Retraction
Prolapse - telescoping of bowel
Bleeding
Granulomas
```
214
What are gallstones
Stones made from cholesterol
215
What are some risk factors for gallstones
Fat
Fair
Female
Forty
216
Describe biliary colic
Stones temporarily obstruct drainage of bile and when the stones fall back into the gallbladder the symptoms resolve
217
Describe the symptoms of biliary colic
Severe, colicky, epigastric or right upper quadrant pain
Often triggered by meals
Lasting 30mins to 8 hrs
May be associated with nausea and vomiting
218
What is triggered by fat entering the digestive system
Cholecystokinin (CKK)
| Triggers contraction of the gallbladder, leading to biliary colic
219
Describe the liver function tests in gallstone disease
Bilirubin - high, obstructive jaundice
ALP - high
AST/ALT < ALP - high
220
What symptoms may a patient experience with obstructive jaundice
Jaundice
Pale stool
Dark urine
221
Give some causes of raised ALP
```
Liver or bone malignancy
Primary biliary cirrhosis
Pagets disease of the bone
Pregnancy
Any fracture
```
222
What is the first line investigation for gallstone diseasee
USS
223
What may be seen on USS in gallbladder disease
Bile duct dilation (<6mm is normal)
Stones in gallbladder or ducts
Acute cholecystitis - thickened gallbladder wall, stones or sludge in gallbladder and fluid around the gallbladder
Pancreas and pancreatic duct
224
What might ultrasound in gallbladder disease be limited by?
Patients weight
Gaseous bowel obstructing view
Discomfort from probe
225
What imaging procedure is used to clear stones in the bile ducts and to investigate the biliary disease further
ERCP (endoscopic retrograde cholangio-pancreatography)
226
List some complicatons of ERCP
Excessive bleeding
Cholangitis - infection in bile ducts
Pancreatitis
227
Name a 2nd line imaging technique in gallstone disease
MRCP
| Magnetic resonance cholangio-pancreatography
228
Describe the management of gallstone disease
Conservative management if asymptomatic
| Cholecystectomy if symptomatic - surgical removal of gallbladder - laparoscopic sugery is preferable to open
229
List some complications of cholecystectomy
Bleeding, infection, pain and scars
Damage to the bile duct - leakage and strictures
Stones left in the bile duct
Damage to the bowel, blood vessels and other organs
Anaesthetic risks
Venous thromboembolism
Post-cholecystectomy syndrome
230
What is post-cholecystectomy syndrome
Non specific symptoms that can occur after a cholecystectomy - often improves over time
```
Diarrhoea
Indigestion
Epigastric or RUQ pain
Nausea
Intolerance of fatty food
Flatulence
```
231
What is acute cholecystitis
Inflammation of the gallbladder
Caused by gallstones trapped in neck of gallbladder/cystic duct
Can also be caused if patient not eaten for a while and gallbladder not stimulated by food to empty so build up of pressure
232
Describe the presentation of acute cholecystitis
```
RUQ pain - may radiate to right shoulder
Fever
Nausea and vomiting
Tachycardia and tachypnoea
Murphy's sign
RUQ tenderness
Raised inflammatory markers and WBC
```
233
Describe Murphy's sign
Place hand in RUQ and apply pressure
Ask pt to take deep breath in
Gallbladder moves downwards during inspiration and comes into contact with your hand
Stimulation of the inflamed gallbladder results in acute pain and cessation of inspiration
234
What are the ultrasound findings of acute cholecystisi
Thickened gallbladder wall
Stones/sludge in gallbladder
Fluid around gallbladder
235
Describe the management of acute cholecystitis
```
NBM
IV fluid
Antibiotics - local guidelines
NGT if vomiting
ERCP - remove stones
Cholecystectomy - <72hrs of symptoms, may be delayed for 6-8weeks to allow the inflammation o settle
```
236
List some complications of acute cholecystitis
Sepsis
Gallbladder empyema
Gangrenous gallbladder
Peroration
237
Describe gallbladder empyema
Infected tissue and pus collecting in the gallbladder
238
Describe the management of gallbladder empyema
Cholecystectomy - removal of gallbladder
| Cholecystostomy - drain for contents to drain out
239
What is acute cholangitis
Inflammation and infection in the bile ducts
240
What are the two main causes of acute cholecystitis
Obstruction in bile duct due to stones
| Infection introduced by ERCP procedure
241
List the most common organisms of acute cholangitis
E.coli
Klebsiella
Enterococcus
242
Describe the presentation of acute cholangitis
Charcot's triad
RUQ
Fever
Jaundice
243
Describe the management of acute cholangitis
```
NB,
IV fluid
Blood cultures
IV antibiotics
Involve seniors - HDU/ICU
```
Imaging - Abdominal USS, CT, MRCP, ERCP, PTC (percutaneous transhepatic cholangiogram when ERCP failed or unsuitable - drain through the skin)
244
What type of cancer is cholangiocarcinoma
Adenocarcinoma
245
What is cholangiocarcinoma a cancer of?
The bile ducts - intra/extrahepatic ducts
246
Where is the most common site for cholangiocarcinoma
Perihilar region - where right and left hepatic duct have joined to become the common hepatic duct just after leaving the liver
247
List two risk factors for cholangiocarcinoma
Primary sclerosing cholangitis
Liver flukes - parasitic infection
248
Describe the presentation of cholangiocarcinoma
```
Obstructive jaundice - pale stool, itching, dark urine
Unexplained weight loss
RUQ pain
Palpable gallbladder
Hepatomegaly
```
249
Describe Courvoisier's law
Palpable gallbladder along with jaundice is unlikely to be gallstones - cause is usually a cancer
250
Describe the investigations for cholangiocarcinoma
CT/MRI plus histology for diagnosis
CT thorax, abdo and pelvis for staging
CA19-9 - tumour marker for cholangiocarcinoma and pancreatic cancer
MRCP - detail obstruction
ERCP - stent and relive obstruction and obtain biopdy
251
Describe the management of cholangiocarcinoma
MDT
Curative surgery - if early
Radiotherapy and Chemotherapy
Most cases not curable so palliative therapy and stents to relive obstruction, surgery to improve symptoms
252
What type of cancer is pancreatic cancer
Adenocarcinoma
253
Which part of the pancreas is most often affected by cancer
The head
254
Where do pancreatic cancers metastasise to
Liver
Peritoneum
Lungs
Bone
255
Describe the presentation of pancreatic cancer
Painless obstructive jaundice - tumour compresses bile ducts - yellow skin and sclera, pale stool, dark urine, generalised itching
Non-specific upper abdominal or back pain
Unintentional weight loss
Palpable mass in the epigastric region
Change in bowel habit
Nausea and vomiting
New onset diabetes or worsening of type 2 diabetes
256
Who should you refer when suspecting pancreatic cancer
>40 with jaundice - 2 week wait
| >60 with weight loss and additional symptom - GP referral for direct access CT abdomen
257
Describe trousseau's sign of malignancy
Migratory thrombophlebitis - blood vessels inflamed with associated blood clot in that area - reoccurring in different locations over time
258
List some investigations for pancreatic cancer
```
CT plus histology
Staging CT - TAP - mets
CA19-9 - pancreatic, cholangiocarcinoma marker
MRCP - biliary system for obstruction
ERCP - stenting
Biopsy - may be taken percutaenously
```
259
Describe the management of pancreatic cancer
Hepatobiliary MDT
Surgery - when small and isolated - total pancreatectomy, distal pancreatectomy, pylorus preserving pancreaticoduodenectomy (modified Whipples), radical pancreaticoduodenectomy (Whipple procedure)
Most cases surgery is not possible and palliative treatment involving stents, surgery to improve symptoms, palliative chemo and radiotherapy
260
What does a Whipple procedure involve the removal of
```
Head of pancreas
Pylorus of the stomach
Duodenum
Gallbladder
Bile duct
Relevant lymph nodes
```
261
List the causes of pancreatitis
```
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion sting
Hyperlipidaemia
ERCP
Drugs - furosemide, thiazide diuretics and azathioprine
```
262
List the investigations for pancreatitis
```
FBC - WCC
U&Es - Ur
LFT - AST/ALT and albumin
Calcium
ABG - PaO2 and blood glucose
Amylase - raised more than 3 times the upper limit of normal in acute pancreatitis
CRP
US - gallstones
CT abdomen - complications of pancreatitis
```
263
Which scoring system is used for severity of pancreatitis
Glasgow score
264
List the criteria of the Glasgow score
```
PaO2 <8
Age >55
Neutrophils (WBC>15)
Calcium <2
uRea >16
Enzymes (LDH >600 or AST/ALT >200)
Albumin <32
Sugar >10
```
265
Describe the Glasgow score results
0 or 1 - mild pancreatitis
2 - moderate pancreatitis
>3 - severe pancreatitis
266
Describe the management of acute pancreatitis
```
Initial resusitiation
IV fluids
NBM
Analgesia
Careful monitoring
Treatment of gallstone pancreatitis
Antibiotics if evidence of infection
Treatment of complications
```
267
What is the prognosis for acute pancreatitis
most improve within 3-7 days
268
List some complications of acute pancreatitis
```
Necrosis of the pancreas
Infection in necrotic area
Abscess formation
Acute peripancreatic fluid collection
Pseudocyst - collection of pancreatic juice can develop 4 weeks after
Chronic pancreatitis
```
269
Describe chronic pancreatitis
Chronic pancreatic inflammation resulting in fibrosis and reduced function of pancreatic tissue
270
What is the most common cause of chronic pancreatitis
Alcohol
271
List some symptoms of chronic pancreatitis
Chronic epigastric pain
Loss of exocrine function - lack of pancreatic enzymes - fatty, greasy stools and malabsorption
Loss of endocrine function - lack of insulin - diabetes
Damage and strictures to the duct system - obstruction in the excretion of pancreatic juice and bile
Formation of pseudocysts and abscesses
272
Describe the management of chronic pancreatitis
Abstinence from alcohol and smoking
Analgesia
Replacement of pancreatic enzymes - Creon
Subcutaneous insulin regimes
ERCP with stenting
Surgery - severe chronic pain, obstruction to biliary tree, pseudocyst drainage and abscess drainage
273
What test is a marker of pancreatic insufficiency
Faecal elastase
