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Finals > Surgery > Flashcards

Surgery Flashcards

1
Q

List some causes of generalised abdominal pain

A

Peritonitis
Ruptured abdominal aortic aneurysm
Intestinal obstruction
Ischaemic colitis

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2
Q

List some causes of right upper quadrant pain

A

Biliary colic
Acute cholecystitis
Acute cholangitis

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3
Q

List some causes of epigastric pain

A

Acute gastritis
Peptic ulcer disease
Pancreatitis
Ruptured abdominal aortic aneurysm

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4
Q

List some causes of right iliac fossa pain

A

Acute appendicitis
Ectopic pregnancy
Ovarian torsion
Meckel’s diverticulitis

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5
Q

List some causes of left iliac fossa pain

A

Diverticulitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion

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6
Q

List some causes of suprapubic pain

A

Lower urinary tract infection
Acute urinary retention
Pelvic inflammatory disease
Prostatitis

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7
Q

List some causes of loin to gorin pain

A

Renal colic
Ruptured aortic aneurysm
Pyleonephritis

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8
Q

List some causes of testicular pain

A

Testicular torsion

Epididymo-orchitis

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9
Q

What is peritonitis

A

Inflammation of the peritoneum

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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

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11
Q

What is local peritonitis

A

Caused by underlying organ inflammation

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12
Q

What is generalised peritonitis

A

Caused by perforation of the abdominal contewnts into the peritoneal cavity

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13
Q

What is spontaneous bacterial peritonitis

A

Associated with spontaenous infection of ascites in liver disease patients

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14
Q

How is spontaneous bacterial peritonitis treated

A

Broad spectrum antibiotics and supportive care

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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

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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

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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

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18
Q

What does the suffix -ostomy mean?

A

Creating a new opening

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19
Q

What are adhesions

A

Scar like tissue inside the body that bidns surfaces together

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20
Q

What is a fistula

A

Abnormal connection between two epithelial surfaces

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21
Q

What is tenesmus

A

The sensation of needing to open the bowels without being able to produce stool. Often accompanied with pain

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22
Q

Define hemicolectomy

A

Removing a portion of the large intestine (colon)

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23
Q

Define hartmann’s procedure

A

Proctosigmoidectomy - removal of the rectosigmoid colon with closure of the anorectal stump and formation of colostomy

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24
Q

What is an anterior resection

A

Removal of the rectum

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25
Q

What is a Whipples procedure

A

Pancreaticoduodenectomy -

Removal of the head of the pancreas, duodenum, gallbladder and bile duct

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26
Q

What is a Kocher incision for

A

Open cholecystectomy

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27
Q

What is a Chevron/rooftop incision for

A

Liver transplant, whipple procedure, pancreatic surgery or upper GI surgery

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28
Q

What is a Mercedes Benz incision for

A

Liver transplant

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29
Q

What is a midline incision for

A

General lapartomy

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30
Q

What is a paramedian incision for

A

Laparotomy

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31
Q

What is a hockey stick incision for

A

Renal transplant

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32
Q

What is a battle incision for

A

Open appendicetomy

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33
Q

What is a McBurney incision for

A

Open appendicetomy

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34
Q

What is a Lanz incision for

A

Open appendicetomy

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35
Q

What is a rutherford morrison incision for

A

Open appedicetomy and colectomy

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36
Q

Describe a pfannelstiel incision

A

Curved incision two fingers above pubic symphysis

C-section

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37
Q

Describe a Joel-Cohen incision

A

Straight incision slightly higher - recommended

C-section

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38
Q

Describe the incisions in laparoscopic surgery

A

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

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39
Q

Describe diathermy

A

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

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40
Q

Describe absorbable sutures

A

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

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41
Q

Describe non-absorbable sutures

A

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

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42
Q

How is the surface of skin closed

A

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

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43
Q

Describe drains

A

Tubes in body to allow air and fluid to drain away preventing build up of air, pus, blood or other fluid collecting

Chest drain

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44
Q

How do you know if a chest drain is in the right place

A

Swinging - water in the drain will rise and fall due to normal pressure changes in the chest

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45
Q

When is the WHO surgical safety checklist performed

A

3 stages

  • Before induction of anaesthesia
  • Before the first skin incision
  • Before the patient leaves theatre
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46
Q

List the factors checked in the WHO surgical checklist

A 
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
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47
Q

Describe what happens in pre-operative assessment

A 
Past medical problems 
Previous surgery 
Previous adverse responses to anaesthesia 
Medications 
Allergies 
Smoking
Alcohol use 
Malnourished - dietician and additional nutritional support
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48
Q

Describe the ASA grade

A

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

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49
Q

List some pre-op investigations

A

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

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50
Q

How long must patients fast for before surgery

A

6 hrs of no food or feeds before operation

2 hours of clear fluids (fully NBM)

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51
Q

How long before an operation should the COCP and HRT be stopped?

A

4 Weeks

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52
Q

What can be given to rapidly reverse anticoaglation in patients taking warfarin

A

Vitamin K

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53
Q

How long before surgery are DOACs stopped

A

24-72hrs

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54
Q

Describe the medication change before surgery in patients who take long term corticosteroids

A

Additional IV hydrocortisone at induction and for immediate postop period
Doubling of normal dose for 24-72hrs after operation

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55
Q

Describe insulin use in surgery

A

Reduce their ling acting insulin
Omit their short acting insulin
Place on variable rate insulin infusion alongside glucose, sodium and potassium

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56
Q

Describe the VTE prophylaxis during surgery

A

LMWH - enoxaparin
DOACs - apixaban, rivaroxaban
Intermittent pneumatic compression
Anti-embolic compression stockings

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57
Q

What is the extracellular space

A

Intravascular space - inside blood vessels

Interstitial space - functional tissue space between and around cells

Third space - third extracellular space

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58
Q

What is the third space

A

Areas of the body which do not usually contain fluid

Peritoneal cavity - ascites
Pleural cavity - pleural effusion
Pericardial cavity - pericardial effusion
joint - joint effusions

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59
Q

What are the two categories of fluid spaces in the body

A

Intracellular space

Extracellular space

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60
Q

Describe the process of third spacing

A

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

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61
Q

List some sources of fluid intake

A

Oral fluids
NG or PEG feeds
IV fluids
Total parenteral nutrition

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62
Q

List some sources of fluid output

A 
Urine output
Bowel or stoma output 
Vomit or stomach aspiration
Drain output
Bleeding
Sweating
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63
Q

What are insensible fluid losses

A

Fluid output that is difficult to measure - respiration, stools, burns and sweat - estimated

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64
Q

What are some signs of hypovolaemia

A 
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
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65
Q

What are some signs of hypervolemia

A

Peripheral oedema
Pulmonary oedema - SOB, raised JVP, reduced O2 sats, bibasal crackles
Raised JVP
Increased body weight from baseline

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66
Q

Describe the clinical picture of someone with third spacing

A

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

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67
Q

List the main indications for IV fluid

A

Resuscitation
Replacement
Maintenance

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68
Q

Name the two main types of fluid

A

Crystalloids

Colloids

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69
Q

Describe crystalloids

A 
Water with added salt or glucose 
- 0.9% sodium chloride
5% dextrose
0.18% sodium chloride 4% glucose 
Hartmann's solution 
Plasma lyte 148
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70
Q

What does 1 L normal 0.9% saline contain

A

1L water
154mmol Na
154mmol Cl

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71
Q

What does 1L 5% dextrose contain

A

1 L water
No electrolytes
50g glucose

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72
Q

What can too much normal saline cause

A

Hypernatraemia

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73
Q

What can too much 5% dextrose cause

A

Oedema and hyponatraemia - hypotonic fluid

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74
Q

What does 1L Hartmanns solution contain

A 
1L water
131mmol Na
111 mmol Cl 
5 mmol K 
2 mmol Ca 
29mmol lactate - buffer the solution - reduce the risk of acidosis
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75
Q

Describe colloids

A

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

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76
Q

What does tonicity refer to

A

The osmotic pressure gradient between two fluids across a membrane - determines whether water molecules will move across the membrane by osmosis

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77
Q

Describe how you give a fluid bolus in resus situation

A

500ml bolus over 15mins (stat)
Reassess ABCDE
Repeat boluses 250-500ml if required followed by reassement each time

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78
Q

How much water does a person need a day in terms of maintenance

A

25-30ml/kg/day

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79
Q

How much sodium, potassium and chloride does a person need in a day for maintenance

A

1mmol/kg/day

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80
Q

How much glucose does a person need a day for maintenance

A

50-100g/day

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81
Q

What is appendicitis

A

Inflammation and infection of the appendix

Can rupture

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82
Q

Describe the pain in appendicitis

A

Starts as central abdominal pain that moves down to become localised at the right iliac fossa in the first 24hrs

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83
Q

List some features other than abdominal pain which present in appendicitis

A 
Loss of appetite
Nausea and vomiting
Low grade fever 
Guarding 
Rebound tenderness on RIF
Percussion tenderness
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84
Q

What is Rovsing’s sign?

A

Appendicitis - Palpation of the LIF causes pain in the RIF

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85
Q

Where is McBurney’s point

A

1/3 From the ASIS to the umbilicus

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86
Q

What is rebound tenderness a sign of

A

Peritonitis

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87
Q

How is appendicitis diagnosed

A

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

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88
Q

List some differentials of appendicitis

A

Ectopic pregnancy

Meckel’s diverticulum

Ovarian cysts

Mesenteric adenitis

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89
Q

Describe an appendix mass

A

Where the omentum surrounds and sticks to the inflamed appendix, forming a mass in the right iliac fossa.

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90
Q

How is an appendix mass managed

A

Conservatively with supportive treatment and antibiotics followed by appendicectomy once the acute condition has resolved

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91
Q

What is the management of appendicitis

A

Appendicectomy - laparoscopic is preferred to open

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92
Q

Which bowel obstruction is most common

A

Small bowel

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93
Q

Describe third spacing in bowel obstruction

A

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

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94
Q

List some causes of bowel obstruction

A

Adhesions (small bowel)
Hernias (small bowel)
Malignancy (large bowel)

Others: Volvulus (large bowel), diverticular disease, strictures, intussusception in children

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95
Q

List the main causes of intestinal adhesions

A

Abdominal or pelvic surgery
Peritonitis
Abdominal or pelvic infection
Endometriosis

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96
Q

What is meant by closed loop obstruction

A

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

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97
Q

List some causes of closed loop obstruction

A

Adhesions
Hernia
Volvulus - twist
Single point of obstruction and competent ileocaecal valve

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98
Q

What is meant by a competent ileocecal valve in terms of obstruction

A

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

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99
Q

List some key features in bowel obstruction

A

Vomiting - bilious green vomit

Abdominal distension

Diffuse abdominal pain

Absolute constipation and lack of flatulence

Tinkling bowel sounds heard early in obstruction

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100
Q

What might be seen on abdominal X-ray in bowel obstruction

A

Distended loops of bowel

3cm small bowel
6cm colon
9cm caecum

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101
Q

What are valvulae conniventes

A

Small bowel mucosal folds

Extend the full width of the small bowel

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102
Q

What are haustra

A

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

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103
Q

Describe the inital management of bowel obstruction

A

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)

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104
Q

What investigations might be useful in bowel obstruction

A

Abdominal Xray
Contrast abdominal CT scan - confirm diagnosis, establish site and cause. Also used to diagnose intra-abdominal perforation
Erect CXR - air under diaphragm

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105
Q

Describe the management of bowel obstruction after initial management

A

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

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106
Q

Describe ileus

A

Normal peristalsis of the small bowel temporality stops

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107
Q

Describe pseudo-obstruction

A

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

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108
Q

List some causes of ileus

A

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

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109
Q

List the signs and symptoms of bowel obstruction

A

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

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110
Q

Describe the management of ileus

A 
NBM
NG tube if vomiting 
IV fluids - prevent dehydration and correct electrolyte imbalances
Mobilisation 
Total parenteral nutrition
111
Q

What is volvulus

A

Where the bowel twists round itself and the mesentery it is attached to

112
Q

What is mesentery

A

Membranous peritoneal tissue that creates a connection between the bowel and the posterior abdominal wall

113
Q

What does a volvulus cause

A

Closed loop obstruction

114
Q

How does volvulus affect the blood vessels supplying the bowel

A

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
Q

Name the two types of volvulus

A

Sigmoid

Caecal

116
Q

Describe sigmoid volvulus

A

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
Q

Describe caecal volvulus

A

Less common

Affects younger patients

118
Q

List some risk factors for volvulus

A 
Neuropsychiatric disorders - PD
Nursing home residents
Chronic constipation
High fibre diet
Pregnancy 
Adhesions
119
Q

Describe the presentation of volvulus

A

Green bilious vomiting
Abdominal distension
Diffuse abdominal pain
Absolute constipation and lack of flatulence

120
Q

How is volvulus diagnosed

A

Abdominal Xray

Contrast CT scan

121
Q

What is the pathognomonic sign of volvulus

A

Coffee bean sign

122
Q

Describe the management of volvulus

A

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
Q

What is Rigler’s sign

A

Double wall sign

Signifies free air in the abdomen

124
Q

What is the Borchardt’s triad of gastric volvulus

A

Vomiting
Severe epigastric pain
Failed NG tube attempts

125
Q

What are the features of gallstone ileus

A

Small bowel obstruction

Pneumobilia - air in the biliary tree

126
Q

What is a hernia

A

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
Q

Describe the presenting features of a hernia

A

Soft lump protruding from abdominal wall
Lump may be reducible
Lump may protrude on coughing or standing
Aching, pulling or dragging sensation

128
Q

List the three complications of hernias

A

Incarceration
Obstruction
Strangulation

129
Q

Describe what is meant by incarceration of a hernia

A

Irreducibility of the hernia - can lead to obstruction and strangulation

130
Q

Describe what is meant by obstruction of a hernia

A

Blockage in passage of faces through the bowel

Vomiting, generalised abdominal pain and absolute constipation

131
Q

Describe what is meant by a strangulated hernia

A

Non-reducible hernia and the base becomes so tight it cuts off the blood supply causing ischemia

132
Q

How does a strangulated hernia present

A

Significant pain and tenderness at the hernia site

Mechanical obstruction

133
Q

Describe what affects the risk of obstruction and strangulation of a hernia

A

The size of the neck - hernias with a large neck at lower risk
If the hernia is reducible

134
Q

Describe Richters hernia

A

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
Q

Describe a Maydl’s hernia

A

2 different loops of bowel are contained within the hernia

136
Q

Describe the management of hernias

A 
Conservative - do nothing 
Tension free repair (surgery) - mesh 
Tension repair (surgery) - sutures
137
Q

What is found in the inguinal canal

A

Spermatic cord - males

Round ligament - females

138
Q

What is the inguinal canal

A

Tube that runs between the deep inguinal ring and superficial inguinal ring

139
Q

Describe an indirect hernia and how to examine one

A

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
Q

Describe a direct inguinal hernia and how to examine one

A

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
Q

List the boundaries of Hesselbach’s triangle

A

Rectus abdominis muscle - medial border

Inferior epigastric vessels - superior and lateral border

Pouparts ligament (inguinal ligament) - inferior border

142
Q

Describe a femoral hernia

A

Herniation of the abdominal contents through the femoral canal

Below the inguinal ligament at the top of the thigh

143
Q

List the boundaries of the femoral canal

A

Femoral vein laterally

Lacunar ligament medially

Inguinal ligament anteriorly

Pectineal ligament posteriorly

144
Q

Describe the contents of the femoral triangle from lateral to medial

A

Femoral nerve
Femoral artery
Femoral vein
Femoral canal

145
Q

Describe incisional hernias

A

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
Q

Describe an umbilical hernia

A

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
Q

Describe epigastric hernias

A

Hernia in epigastric area

148
Q

Describe diastasis recti

A

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
Q

Who is more at risk of diastasis recti

A

Pregnancy
Obesity
Connective tissue disease
Can be congenital

150
Q

Describe an obturator hernia and its sign

A

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
Q

What is a hiatus hernia

A

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
Q

List some risk factors for hiatus hernias

A

Increasing age
Pregnancy
Obesity

153
Q

List the symptoms of hiatus hernias

A 
Heartburn 
Acid reflux
Reflux of food 
Burping 
Bloating 
Halitosis
154
Q

List some investigations for hiatus hernias

A

CXR
CT scan
Endoscopy
Barium swallow test

155
Q

How is hiatus hernia treated?

A

Conservative - medical management of GORD

Surgical repair - high risk of complications or symptoms resistant to medical Rx- fundoplication

156
Q

Describe haemorrhoids

A

Enlarged anal vascular cushions

157
Q

List some risk factors for haemorrhoids

A

Pregnancy
Obesity
Increased age
Increased abdominal pressure - weigh lifting and constipation

158
Q

What are the anal cushions

A

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
Q

Describe the classification of haemorrhoids

A

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
Q

List some symptoms of haemorrhoids

A 
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
Q

Describe the examination of haemorrhoids

A

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
Q

Describe the management of haemorrhoids

A

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
Q

What are thrombosed haemorrhoids

A

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
Q

What is diverticulosis

A

Presence of diverticula with or without inflammation or infection

165
Q

What is diverticulitis

A

Inflammation and infection of diverticula

166
Q

How does diverticulosis occur

A

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
Q

List some risk factors for diverticulosis

A

Increased age
Low fibre diet
Obesity
Use of NSAIDs

168
Q

What symptoms may diverticulosis present with

A

Lower left abdominal pain
Constipation
Rectal bleeding

169
Q

Describe the management of diverticulosis

A

High fibre diet
Bulk forming laxatives
Stimulant laxatives

170
Q

Describe how patients with acute diverticulitis present

A 
Pain and tenderness in the LIF 
Fever
Diarrhoea 
Nausea and vomiting 
Rectal bleeding 
Palpable abdominal mass 
Raised inflammatory markers and WBC
171
Q

Describe the management of uncomplicated diverticulitis

A

Oral co-amoxiclav
Analgesia
Only taking clear liquids until symptoms improve
Follow up within 2 days to review symptoms

172
Q

Describe the management of complicated diverticulitis

A 
NBM 
IV antibiotics
IV fluids
Analgesia 
Urgent investigations
Urgent surgery may be required for complications
173
Q

List some complications of acute diverticulitis

A 
Perforation 
Peritonitis
Peri diverticular abscess
Large haemorrhage requiring blood transfusions 
Fistula 
Ileus/obstruction
174
Q

What is mesenteric ischaemia

A

Lack of blood flow through the mesenteric vessels supplying the intestines, resulting in ischaemia

175
Q

Which artery supplies the foregut

A

Coeliac artery

176
Q

Describe what is meant by the foregut

A

Stomach, part of duodenum, biliary system, liver, pancreas and spleen

177
Q

Which artery supplies the midgut

A

Superior mesenteric artery

178
Q

What comprises the midgut

A

Distal duodenum to the first half of the transverse colon

179
Q

Which artery supplies the hindgut

A

Inferior mesenteric artery

180
Q

What comprises the hindgut

A

Second half of the transverse colon to the rectum

181
Q

Describe chronic mesenteric ischaemia

A

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
Q

List some risk factors for chronic mesenteric ischaemia

A 
Increased age
Family history 
Smoking
Diabetes
Hypertension 
Raised cholesterol
183
Q

How is chronic mesenteric ischaemia diagnosed?

A

CT angiography

184
Q

Describe the management of intestinal angina

A

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
Q

Describe acute mesenteric ischaemia

A

Rapid blockage in blood flow through the superior mesenteric artery - thrombus

186
Q

What is a key risk factor for acute mesenteric ischaemia

A

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
Q

How does acute mesenteric ischaemia present

A

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
Q

How is acute mesenteric ischaemia diagnosed

A

Contrast CT

Metabolic acidosis
Raised lactate

189
Q

Describe the treatment of mesenteric ischaemia

A

Remove the necrotic bowel

Bypass or remove the thrombus in the blood vessel

190
Q

List some risk factors of bowel cancer

A 
Family history
Age
Smoking
Familial adenomatous polyposis 
Hereditary nonpolyposis colorectal cancer - lynch syndrome 
Obesity 
Alcohol
191
Q

Describe familial adenomatous polyposis

A

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
Q

Describe hereditary nonpolyposis colorectal cancer

A

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
Q

List some red flags for bowel cancer

A 
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
Q

List the people referred under the 2 week wait pathway for bowel cancer

A

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
Q

Describe the FIT test

A

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
Q

Describe bowel cancer screening

A

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
Q

List the investigations for bowel cancer

A 
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
Q

Describe the Dukes staging system for bowel cancer

A

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
Q

Describe the TNM classification for bowel cancer

A

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
Q

Describe the management of bowel cancer

A

Surgical resection - laparoscopic surgery
Chemotherapy
Radiotherapy
Palliative care

201
Q

Describe bowel cancer surgery

A

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
Q

List the complications of surgery for bowel cancer

A 
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
Q

What can a low anterior resection cause

A

Urgency
Frequency
Faecal incontinence
Difficulty controlling flatulence

204
Q

Describe the follow up for bowel cancer

A

Serum carcinoembryonic antigen (CEA)

CT thorax, abdomen and pelvis

205
Q

What are stomas

A

Artificial openings of hollow organ

206
Q

What is a colostomy

A

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
Q

What is an ileostomy

A

Located in RIF
Have a spout
Drain liquid contents

208
Q

What is a gastrostomy

A

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
Q

What is a PEG

A

When gastrostomy inserted by endoscopy procedure

210
Q

What is a urostomy

A

Creating an opening from the urinary system onto the skin - spout and located in RIF

211
Q

Describe an ileoanal anastomosis

A

J pouch

Ileum folded back on itself and fashioned into a larger pouch that functions like a rectum

212
Q

What are loop -ostomys

A

Temporary stoma used to allow a distal portion of the bowel and anastomosis to heal after surgery

213
Q

List some complications of stomas

A 
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
Q

What are gallstones

A

Stones made from cholesterol

215
Q

What are some risk factors for gallstones

A

Fat
Fair
Female
Forty

216
Q

Describe biliary colic

A

Stones temporarily obstruct drainage of bile and when the stones fall back into the gallbladder the symptoms resolve

217
Q

Describe the symptoms of biliary colic

A

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
Q

What is triggered by fat entering the digestive system

A

Cholecystokinin (CKK)

Triggers contraction of the gallbladder, leading to biliary colic

219
Q

Describe the liver function tests in gallstone disease

A

Bilirubin - high, obstructive jaundice
ALP - high
AST/ALT < ALP - high

220
Q

What symptoms may a patient experience with obstructive jaundice

A

Jaundice
Pale stool
Dark urine

221
Q

Give some causes of raised ALP

A 
Liver or bone malignancy 
Primary biliary cirrhosis 
Pagets disease of the bone 
Pregnancy
Any fracture
222
Q

What is the first line investigation for gallstone diseasee

223
Q

What may be seen on USS in gallbladder disease

A

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
Q

What might ultrasound in gallbladder disease be limited by?

A

Patients weight
Gaseous bowel obstructing view
Discomfort from probe

225
Q

What imaging procedure is used to clear stones in the bile ducts and to investigate the biliary disease further

A

ERCP (endoscopic retrograde cholangio-pancreatography)

226
Q

List some complicatons of ERCP

A

Excessive bleeding
Cholangitis - infection in bile ducts
Pancreatitis

227
Q

Name a 2nd line imaging technique in gallstone disease

A

MRCP

Magnetic resonance cholangio-pancreatography

228
Q

Describe the management of gallstone disease

A

Conservative management if asymptomatic

Cholecystectomy if symptomatic - surgical removal of gallbladder - laparoscopic sugery is preferable to open

229
Q

List some complications of cholecystectomy

A

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
Q

What is post-cholecystectomy syndrome

A

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
Q

What is acute cholecystitis

A

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
Q

Describe the presentation of acute cholecystitis

A 
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
Q

Describe Murphy’s sign

A

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
Q

What are the ultrasound findings of acute cholecystisi

A

Thickened gallbladder wall
Stones/sludge in gallbladder
Fluid around gallbladder

235
Q

Describe the management of acute cholecystitis

A 
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
Q

List some complications of acute cholecystitis

A

Sepsis
Gallbladder empyema
Gangrenous gallbladder
Peroration

237
Q

Describe gallbladder empyema

A

Infected tissue and pus collecting in the gallbladder

238
Q

Describe the management of gallbladder empyema

A

Cholecystectomy - removal of gallbladder

Cholecystostomy - drain for contents to drain out

239
Q

What is acute cholangitis

A

Inflammation and infection in the bile ducts

240
Q

What are the two main causes of acute cholecystitis

A

Obstruction in bile duct due to stones

Infection introduced by ERCP procedure

241
Q

List the most common organisms of acute cholangitis

A

E.coli
Klebsiella
Enterococcus

242
Q

Describe the presentation of acute cholangitis

A

Charcot’s triad
RUQ
Fever
Jaundice

243
Q

Describe the management of acute cholangitis

A 
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
Q

What type of cancer is cholangiocarcinoma

A

Adenocarcinoma

245
Q

What is cholangiocarcinoma a cancer of?

A

The bile ducts - intra/extrahepatic ducts

246
Q

Where is the most common site for cholangiocarcinoma

A

Perihilar region - where right and left hepatic duct have joined to become the common hepatic duct just after leaving the liver

247
Q

List two risk factors for cholangiocarcinoma

A

Primary sclerosing cholangitis

Liver flukes - parasitic infection

248
Q

Describe the presentation of cholangiocarcinoma

A 
Obstructive jaundice - pale stool, itching, dark urine 
Unexplained weight loss
RUQ pain 
Palpable gallbladder
Hepatomegaly
249
Q

Describe Courvoisier’s law

A

Palpable gallbladder along with jaundice is unlikely to be gallstones - cause is usually a cancer

250
Q

Describe the investigations for cholangiocarcinoma

A

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
Q

Describe the management of cholangiocarcinoma

A

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
Q

What type of cancer is pancreatic cancer

A

Adenocarcinoma

253
Q

Which part of the pancreas is most often affected by cancer

254
Q

Where do pancreatic cancers metastasise to

A

Liver
Peritoneum
Lungs
Bone

255
Q

Describe the presentation of pancreatic cancer

A

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
Q

Who should you refer when suspecting pancreatic cancer

A

> 40 with jaundice - 2 week wait

>60 with weight loss and additional symptom - GP referral for direct access CT abdomen

257
Q

Describe trousseau’s sign of malignancy

A

Migratory thrombophlebitis - blood vessels inflamed with associated blood clot in that area - reoccurring in different locations over time

258
Q

List some investigations for pancreatic cancer

A 
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
Q

Describe the management of pancreatic cancer

A

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
Q

What does a Whipple procedure involve the removal of

A 
Head of pancreas
Pylorus of the stomach
Duodenum
Gallbladder
Bile duct
Relevant lymph nodes
261
Q

List the causes of pancreatitis

A 
Idiopathic
Gallstones
Ethanol 
Trauma
Steroids
Mumps
Autoimmune
Scorpion sting
Hyperlipidaemia
ERCP
Drugs - furosemide, thiazide diuretics and azathioprine
262
Q

List the investigations for pancreatitis

A 
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
Q

Which scoring system is used for severity of pancreatitis

A

Glasgow score

264
Q

List the criteria of the Glasgow score

A 
PaO2 <8
Age >55
Neutrophils (WBC>15)
Calcium <2
uRea >16
Enzymes (LDH >600 or AST/ALT >200)
Albumin <32
Sugar >10
265
Q

Describe the Glasgow score results

A

0 or 1 - mild pancreatitis
2 - moderate pancreatitis
>3 - severe pancreatitis

266
Q

Describe the management of acute pancreatitis

A 
Initial resusitiation 
IV fluids
NBM 
Analgesia
Careful monitoring 
Treatment of gallstone pancreatitis
Antibiotics if evidence of infection
Treatment of complications
267
Q

What is the prognosis for acute pancreatitis

A

most improve within 3-7 days

268
Q

List some complications of acute pancreatitis

A 
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
Q

Describe chronic pancreatitis

A

Chronic pancreatic inflammation resulting in fibrosis and reduced function of pancreatic tissue

270
Q

What is the most common cause of chronic pancreatitis

271
Q

List some symptoms of chronic pancreatitis

A

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
Q

Describe the management of chronic pancreatitis

A

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
Q

What test is a marker of pancreatic insufficiency

A

Faecal elastase

Finals (18 decks)

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