Surgery Flashcards
Signs of Cardiac Tamponade
Becks triad:
- Elevated venous pressure —> Distended neck veins
- reduced arterial pressure —> Decreased BP
- reduced heart sounds —> Distant heart sounds
Pulses paradoxus
Management of cardiac tamponade
Fluid resuscitation
Pericardiocentesis
Difference between cardiac tamponade and pericardial effusion
Cardiac tamponade = a pericardial effusion large enough to raise the pericardial pressure
—> reduced filling of the heart during diastole —> decreased CO during systole
DDx for Painful scrotal lump
Epididymis-orchitis
Testicular torsion
Varicocele
Epididymal cyst
Strangulated inguinal hernia
DDx for painless scrotal lump
Hydrocele
Testicular tumour
DDx for a perinatal lump
Abscess
Pilonidal Sinus
Fistula
Anal Fissure
Sebaceous cyst
Crohn’s disease
External haemorrhoids
What is Seton Suture drainage?
Treatment for Anal fistula
Piece of thread remains in fistula tract to keep it open and allow drainage
Gradually tightened to enable healing and closure
Conditions predisposing to anal fistula
Crohns
Diverticula’s disease
TB
Malignancy
Locations of anal cushions
3 o’clock (Left lateral)
7 o’clock (right posterior)
11 o’clock (right anterior)
Epithelium type below dentate line / above dentate line
Below = squamous
Above = columnar
Management of Haemorrhoids (conservative, non-surgical, surgical)
- Conservative: Fluid&fibre, laxatives, topical analgesia, toileting advise
- Non-surgical: rubber band ligation / injectable sclerosants
- surgery: haemorrhoid artery ligation / haemorrhoidectomy
ACUTELY PAINFUL THROMBOSED HAEMORRHOID: analgesia + ice pack + instillagel + laxative
Causes of unilateral hydronephrosis
Pelvic - ureteric obstruction
Aberrant renal arteries
Calculi
Tumours of renal pelvis
Causes of Bilateral Hydronephosis
Stenosis of urethra
Urethral valve
Prostatic enlargement
Bladder tumour
Retro-peritoneal fibrosis
Most common type of colorectal cancer
Adenocardinoma
Which bladder cancer does Schisotosoma infection increase risk of ?
Squamous cell carcinoma
Glad standard imaging for suspected renal colic
Non-contrast CT KUB
Surgical causes of Right Upper Quadrant pain
Gallstone disease
- biliary colic
- cholecystitis
- cholangitis
Hepatitis
Liver abscess
Causes of Epigastric pain
Pancreatitis
Peptic ulcer
Inferior MI
Oesophagitis/GORD
Causes of Left Upper Quadrant pain
Spenic abscess
Splenic rupture
Causes of Flank pain
Renal calculi
Pyelonephritis
UTI
Causes of umbilical region pain
Early appendicitis
Bowel obstruction
Strangulated umbilical hernia
Causes of Right iliac fossa pain
Late appendicitis
Ureteric colic
Crohns
Testicular torsion
Ectopic pregnancy
Meckel’s diverticulitis
PID
Ovarian Cyst
Salpingitis
Hernia
Causes of hypogastric region pain
Testicular torsion
Urinary retention
Cystitis
PID
Causes of Left iliac fossa pain
Diverticulitis
Ulcerative colitis
Testicular torsion
Ectopic pregnancy
Sigmoid volvulus
Constipation
PID
Ovarian cyst
Salpingitis
Hernia
When to consider mesenteric ischemia?
Out of proportion pain +/- metabolic acidosis
Medical causes of acute abdominal pain
DKA
UTI
Basal lobe pneumonia
Poisoning / OD
Addison’s disease
Hypercalcaemia
Bacterial peritonitis
Mesenteric adenitis
Constipation
What is Mesenteric adenitis?
a syndrome characterized by right lower quadrant pain secondary to an inflammatory condition of mesenteric lymph nodes.
Commonly mistaken for acute appendicitis
Character of peritonitic pain
Worse on inspiration
pt often lies still, shallow breaths
Rigidity / guarding
Difference between MRCP and ERCP?
Magnetic resonance cholangiopancreatography (MRCP) is an alternative to diagnostic endoscopic retrograde cholangiopancreatography (ERCP) for investigating biliary obstruction.
MRCP = non-invasive procedure
Both used in suspected pancreatic cancer, pancreatitis, gallstones and bile duct problems
Causes of Acute Appendicitis
I GET SMASHED
Idiopathic (20%)
Gallstones (40%)
Ethanol (35%)
Trauma (15%)
Steroids
Mumps (CMV, EBV)
Autoimmune (SLE, polyarteritis nodosa)
Scorpion venom (lol)
Hyperlipidaemia, hypercalacemia, hypothermia
ERCP
Drugs (thiazides, sulphonamides, ACEi, NSAIDs)
Investigations in Acute pancreatitis
Routine bloods - FBC, U&Es, LFTs, clotting, calcium, lipids
Pregnancy test
Serum lipase/amylase
Erect CXR - to rule out perf.
ABG - monitor the acid-base status
USS - if gallstones suspected
MRCP/CT - extent of damage
Endoscopic USS - if other imaging negative
Scoring system for severity of acute pancreatitis
Modified Glasgow Score (MGS)
or
Ranson’s criteria
Why is pancreatitis caused by hypercalcaemia and causes hypocalcemia
Hypercalcaemia - calcium deposition in the pancreatic duct and calcium activation of trypsinogen in the pancreas.
Enzymes released from the pancreas -> autodigestion of fats and blood vessels –> fat necrosis and sometimes hemorrhage
Fat necrosis –> release of fatty acids –> react with serum calcium –> hypocalcemia
APACHE II Score
Assesses disease severity in patients admitted to ICU
Early complications of acute pancreatitis
Hypovolaemic shock —> renal failure
Hyperglycaemia / hypocalacemia
DIC & Sepsis
Acute respiratory distress syndrome
Late complications of pancreatitis
Pseudocyst (= collection of necrotic tisssue and fluid forming 4-6 weeks after acute pancreatitis)
Abscess
Splenic/duodenal/SMA infarct
Chronic pancreatitis –> cancer
Management of pancreatitis
- ABCDE: IV fluids, O2, catheter, analgesia
- Identify and treat the cause e.g. cholecystectomy for gallstones
- Close monitoring
- only NBM if very unwell (consider NG tube)
What is third space fluid loss?
third-spacing occurs due to decreased oncotic pressure in the intravascular space –> fluid will “leak out” of the intravascular space into the interstitial space
(this can include the interstitial spaces in the brain leading to cerebral oedema!)
Causes of third-spacing
Decreased protein levels
Heart Failure
Increased capillary permeability
Liver failure
Lymphatic obstruction
Major Surgery
Pancreatitis
Sepsis syndrome
Severe Burns
Trauma
Viral and Bacterial infections
What is meckel’s diverticulum?
One of most common GI congenital disorders
May have ectopic acid-secreting gastric or pancreatic tissue
Remnant of embryological vitello-intestinal duct
Located in the distal ileum
Meckel’s diverticulum: Rule of 2s
2% of population
2 years old = peak presentation
2:1 ratio M:F
2 inches long
2 feet proximal to ileocaecal valve
2 types of ectopic tissue (gastric/pancreatic)
Meckel’s diverticulum: Presentation/complications
Could be asymptomatic for whole life
General inflammation: presents similar to acute appendicitis
GI Bleeding
- bright red blood in stools
Obstructive symptoms (Abdo pain, vomiting, constipation)
- Intussuseption
- Caecal volvulus
Pain = RIF
Meckels diverticulum: Investigations
Technetium Scan
CT
(USS)
What is +ve Rovsing’s Sign?
Pain in RIF when LIF is pressed
Suggests acute appendicitis
What is +ve Psoas sign?
Pain on right hip extension
Elicited by having the patient lie on his or her left side while the right thigh is flexed backward. Pain may indicate an inflamed appendix overlying the psoas muscle
What is +ve Obturator sign?
Pain on internal hip rotation
Discomfort felt by the subject/patient on the slow internal movement of the hip joint, while the right knee is flexed. It indicates an inflamed pelvic appendix that is in contact with the obturator internus muscle
Where is McBurney’s Point?
1/3 of the way between anterior, superior iliac spine and umbilicus
Difference between:
- Diverticula
- Diverticulum
- Diverticulosis
- Diverticular disease
- Diverticulitis
Diverticular (Pleural) and Diverticulum (Singular) = outpouching of bowel wall at areas of high pressure
Diverticulosis = asymptomatic presence of diverticula
Diverticular disease = Diverticulosis + symptoms
Diverticulitis = inflammation of diverticula (due to stagnated contents)
Complications of diverticular disease
Perforation
Obstruction
Fistula
Pericolonic abscess (Pus in bowel wall)
Common site for diverticulum
Sigmoid colon
Risk factors for diverticular disease
Diet: Low fibre, high fat (constipation)
Age: >50yrs, male gender
Obesity
Connective tissue disease e.g. Marfan’s, Ehlers danlos (weak bowel wall)
Management of diverticular disease
Conservative: fluids & fibre, smoking cessation & weight loss
Medical: Analgesia, bulk-forming laxatives
Management of diverticulitis
ABCDE
Analgesia
Broad spectrum Abx if unwell
IV fluids
Presentation of diverticular disease
Left sided colicky pain
Relief with defecation
Altered bowel habit
Sudden Painless bleed - bright read
mimics colorectal cancer
Presentation of diverticulitis
Severe LIF pain - acute, worse with movement
Localised guarding and tenderness in LIF
Systemic upset
Causes of Paediatric bowel obstruction
Intussusception
Faecal impaction
Hernia
Malrotation/atresia
Hirschsprung’s
Pyloric stenosis
Adhesions
Imperforate anus
Tumour marker for colorectal cancer
Carcinoembryonic antigen (CEA)
Management of a reducible femoral hernia
Surgical repair within 2 weeks
All femoral hernias needs to be repaired - regardless of whether they are symptomatic
High risk of strangulation
Define incarcerated hernia
Non-reducable
Define strangulated hernia
Can follow incarceration
It is where the arterial supply is compromised
Common causes of acute mesenteric ischaemia
- EMBOLISM (50%) (Acute Mesenteric Arterial Embolism, AMAE) - cardiac causes
- Thrombus-in-situ (Acute Mesenteric Arterial Thrombosis, AMAT) - atherosclerosis
- Non-occlusive cause (Non-Occlusive Mesenteric Ischemia, NOMI) - e.g. hypovolaemia shock, cardiogenic shock
Clinical features of acute mesenteric ischaemia
Generalised abdominal pain, out of proportion to the clinical findings
Diffuse and constant pain, with associated nausea/vomiting
non-specific tenderness
Late stages - globalised peritonism from perf
Acute mesenteric ischemia: ABG results
Increased Lactate
Acidosis
Imaging for acute mesenteric ischemia
CT with IV contast (oral contrast avoided)
Acute mesenteric ischaemia - findings on CT
Oedematous bowel (secondary to the ischaemia and vasodilatation)
Then may progress to a loss of bowel wall enhancement and then to pneumatosis (gas within the wall)
Acute mesenteric ischemia - management
Urgent resusitation
Broad spectrum antibiotics
Definitive management:
- revascularisation of the bowel
- Excision of necrotic or non-viable bowel
Acute mesenteric ischaemia definitive diagnosis
CT angiography
Equation for serum osmolality
(2 x Na+) + glucose + Urea
Normal urine output
0.5-1.5 mL/kg/hour
Type of urine sample for suspected epididymo-orchitis
Guided by age
sexually active younger adults: NAAT for STIs (first catch)
older adults with a low-risk sexual history: MSSU
Function of a loop ileostomy
= defunctioning stoma, diverts bowel contents away from the entire colon
Easier to reverse than a loop colostomy
