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Phase 4 > Surgery > Flashcards

Surgery Flashcards

1
Q

List the types of oesophageal cancer and associated risk factors

A
  • Squamous cell carcinoma
  • Adenocarcinoma

Risk factors: smoking, alcohol, hot beverages, GORD, Barrett’s, obesity, achalasia

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2
Q

Describe the signs and symptoms associated with oesophageal cancer

A
  • Progressive dysphagia (solids then liquids)
  • Weight loss
  • Anaemia
  • Less common – odynophagia, cough, hoarseness, haematemesis, melaena
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3
Q

List differential diagnoses for dysphagia

A

Within lumen
> Food bolus
> Foreign body
> Oesophageal candidiasis

Within wall
> Peptic/caustic stricture
> Schatzki ring
> Pharyngeal pouch
> Achalasia / oesophageal dysmotility
> Oesophageal web
> Oesophageal cancer

Outside oesophagus
> Mediastinal mass
> Lymphoma
> Thoracic aortic aneurysm
> Globus hystericus

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4
Q

Describe the treatment of oesophageal cancer

A

Curative intent – early cancers
> endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD)

> Endoscopic mucosal therapy – Barrett’s oesophagus with dysplasia

Tumours beyond mucosa +/- LN
> Neoadjuvant chemoradiation

> Surgery
> Ivor-Lewis oesophagectomy OR three stage (McKeown) operation

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5
Q

Describe the anatomy, blood supply, nerve supply and lymphatic drainage of the stomach

A

4 sections: cardia, fundus, body, pylorus

Blood supply
> Lesser curvature: left gastric artery (coeliac trunk branch)
> Greater curvature: left & right gastroepiploic arteries
> Fundus: short fastric artery (splenic branch)
> Pylorus: right gastric artery (common hepatic branch)

Venous drainage matches arterial supply

Nerve supply
> Parasympathetic: vagus nerve
> Sympathetic nerve: T6-T9 spinal cord segments

Lymphatics
> Lymph fluid drains into gastric and gastroomental lymph nodes found at curvatures

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6
Q

List risk factors for gastric cancer

A
  • Diet
    > Processed meat
    > Low fruit/veg intake
    > High salt intake
    > Nitrates / nitrites
  • Obesity
  • Smoking
  • H. pylori
  • Age > 50
  • Ethnicity – Asian and Pacific Islanders
  • Male gender
  • Heavy alcohol use
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7
Q

Describe the signs and symptoms of gastric cancer

A

symptoms
- Weight loss
- Abdominal pain
- Nausea
- Dysphagia
- Melaena
- Early satiety
- Ulcer type pain
- Occult GI bleeding more common than overt bleeding

signs
- Palpable abdominal mass
- Palpable lymph node
> Left supraclavicular node (Virchow’s)
> Periumbilical (Sister Mary Joseph)
- Ascites

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8
Q

Describe the different types of gastric cancer and their routes of spread

A

Primary

> Adenocarcinoma (94%)
> Tubular
> Papillary
> Mucinous
> Signet ring

> Lymphoma (4%)

> GI stromal tumour (GIST)
> Type of sarcoma, develops in the connective tissue

> Secondary
> Direct invasion from nearby organs

Routes of spread

> Haematogenous

> Peritoneal seeding
> Krukenberg tumours – ovarian metastasis
> Blumer’s shelf – metastasis in pouch of Douglas

> Lymphatic spread

> Direct – to adjacent organs

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9
Q

Describe the investigations used in gastric cancer

A

Bloods
- FBC – microcytic anaemia
- LFTs – if deranged, possible mets
- No reliable tumour markers but CEA, Ca125 and CA19-9 may be raised

Upper GI endoscopy

CT thorax, abdomen and pelvis – assess for metastatic disease

Staging laparoscopy to look for peritoneal metastases if considering resection

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10
Q

Describe the treatment of gastric cancer

A

> Peri-operative chemotherapy

> Proximal cancers – total gastrectomy

> Distal cancers (antrum or pylorus) - subtotal gastrectomy

> Very early T1 gastric cancers – endoscopic mucosal resection (EMR)

Advanced disease – palliative therapy
> Nutrition – enteral feed, build up drinks
> Treatment of infection
> Maintain lumen patency (stenting or endoscopic laser treatment)
> Palliative surgery (gastro-jejunostomy) to by-pass obstruction

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11
Q

List complications of total gastrectomy

A
  • Anastomotic leak
  • Dumping syndrome
    > Sudden and large passage of hypertonic gastric contents into small intestine
    > Results in an intraluminal fluid shift and subsequent intestinal distention
    > Symptoms of nausea, vomiting, diarrhoea, hypovolaemia
  • Vitamin B12 deficiency – loss of secretion of intrinsic factor
  • MI / stroke / respiratory failure / DVT / PE
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12
Q

Describe the characteristics of Helicobacter pylori and its treatment

A

Gram negative helical bacterium produces urease enzyme

investigations
- urea breath test
- stool antigen test
- H pylori antibody test
- rapid urease test during endoscopy (CLO test)

Eradication – triple therapy, 1 PPI + 2 antibiotics
> Omeprazole 20mg BD (PPI)
> Clarithromycin 500mg BD OR metronidazole
> Amoxicillin 1g BD

test of eradication: urea breath test

no need to test for eradication if asymptomatic following test and treat

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13
Q

Describe the anatomy of the pancreas, including blood supply

A
  • Head
  • Neck
  • Body
  • Uncinate process
  • Tail

Blood supply
- Gastroduodenal artery
- Superior & inferior pancreaticoduodenal artery
- Splenic artery - greater pancreatic artery

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13
Q

Describe the functions of the pancreas

A

Endocrine - islets of Langerhans
> Alpha cells: glucagon
> Beta cells: insulin + amylin (slows gastric emptying)
> Delta cells - somatostatin (regulates alpha & beta)
> Gamma cells: pancreatic polypeptide
> Epsilon cells: ghrelin (appetite)

Exocrine - acinar & duct tissue
- Proteases - trypsinogen and chymotrypsinogen
- Amylase: starch & maltose
- Lipase
- Others: elastase, ribonuclease…

Regulated by vagal innervation

> Acidic chime entering duodenum encourages S cells to release secretin which release alkaline pancreatic juices

> Fatty acids in duodenum release cholecystokinin, leads to secretion of digestive enzymes and bile from gallbladder

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14
Q

List risk factors for pancreatic cancer

A
  • Smoking, diabetes, high BMI, alcohol excess
  • Chronic and hereditary pancreatitis
  • Genetic familial syndromes e.g. Von-Hippel Lindau, MEN1
  • Medical conditions: peptic ulcer disease, IBD
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15
Q

Describe the signs and symptoms and investigations for pancreatic cancer

A

signs and symptoms
- Obstructive jaundice (often painless) or pain radiating through to back
- Cachexia, anorexia and unexplained weight loss
- Pale stools and dark urine
- Loss of endocrine function - type 3c diabetes
- Nausea / vomiting
- Palpable gallbladder (Courvoisier’s sign)
- Acute pancreatitis
- Haematemesis, melaena, IDA

investigations
- high resolution CT scan
- ultrasound
- imaging may demonstrate double duct sign
> simultaneous dilatation of the common bile and pancreatic ducts

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16
Q

List types of pancreatic cancer

A

Solid non-endocrine
> Pancreatic ductal adenocarcinoma (PDAC)
> Adenosquamous
> Acinar cell
> Giant cell
> Pancreatoblastoma

Cystic non-endocrine
> Serous cystic
> Mucinous cystic
> Solid and cystic papillary
> Acinar cell cystadenocarcinoma
> IPMN – intraductal papillary mucinous neoplasm – malignant transformation possible

Neuroendocrine – functional v non-functional

> Gastrinoma - Zollinger-Ellison syndrome
> Increased levels of gastrin and stomach acid leading to ulcers and diarrhoea

> Insulinoma
> Slow growing, can present with hypoglycaemic coma

> Glucagonoma - High BMs

> VIPoma - Vener-Morrison syndrome

> Somatostatinoma

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17
Q

Describe the treatment for pancreatic cancers

A

Head of pancreas cancer
> Whipple’s procedure (pancreaticoduodenectomy) +/- pylorus sparing

Body / tail - distal pancreatectomy / total pancreatectomy

Neoadjuvant / adjuvant chemotherapy

Not for resection
> Palliative intent
> Relieve obstruction via biliary stent or duodenal stent if GOO
> Palliative chemotherapy

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17
Q

Describe Familial Adenomatous Polyposis (FAP)

A

APC gene (chromosome 5), AD inheritance

Gardner’s syndrome (subtype of FAP)

Numerous (>100) polyps

Almost 100% risk by age 40

Total colectomy performed in mid 20s

Still require endoscopic surveillance

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17
Q

List risk factors for CRC

A
  • Dietary – low fibre, high animal fat & red meat
  • Excess bile salts
  • Increasing age: majority >50 years age
  • Previous colon cancers or previous colorectal adenomas
  • Family history
  • IBD (UC > Crohn’s)
  • Familial conditions: FAP, HNPCC, juvenile polyps
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18
Q

Describe Lynch syndrome

A

aka hereditary non-polyposis colorectal carcinoma (HNPCC)

AD inheritance
> due to defects in DNA mismatch repair gene MSH2/MLH1
> most common inherited condition for CRC

clinical features
- predominantly right-sided lesions
- increases risk of endometrial, breast, prostate and gastric cancer

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19
Q

Describe the adenoma-carcinoma sequence

A

Adenoma – benign neoplasm of large bowel glandular epithelium

Adenomas undergo dysplastic change to become carcinomas

Majority left-sided lesions

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20
Q

Describe the presentation of CRC

A

Change in bowel habit
> Bloods / mucus PR
> Lower abdo pain
> LBO / perforation
> Rectal pain / tenesmus
> Fistulate to adjacent structures
> Iron deficiency anaemia
> Weight loss
> Mass in RIF
> SBO or appendicitis in caecal lesions

30% present as an emergency
> Obstruction
> Perforation

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21
Q

How is the severity of ulcerative colitis (UC) classified?

A

Truelove and Witts Criteria

  • Moderate: 4-8 stool a day
  • Severe: 8 stools a day, may have fever or night sweats
  • Fulminant
    >10 stools a day
    Abdo pain, fever
    Hypotension, tachycardia
    Low Hb
    Increased WCC &CRP, lowered albumin
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22
Q

Describe Duke’s classification for CRC

A

A – limited to bowel mucosa

B – infiltrating through muscle wall

C – local lymph node involvement

D – distant spread (lung, liver, bone)

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23
Q

Describe the management of ulcerative colitis (UC)

A

inducing remission

  • Mild acute UC
    > topical (rectal) mesalazine (aminosalicylate)
  • moderate acute UC
    > topical (rectal) + oral mesalazine
    > Prednisolone
  • Severe acute UC
    > IV steroids e.g. hydrocortisone
    > IV ciclosporin if steroids contraindicated
    > if no improvement after 72h
    » Infliximab
    » Surgery

maintaining remission
- after mild/moderate flare: topical mesalazine OR topical + oral mesalazine

  • following a severe relapse or if >=2 exacerbations in the past year: oral azathioprine or oral mercaptopurine
  • Maintaining remission
    > Aminosalicylate, azathioprine or mercaptopurine
  • Predfoam enemas for toxic megacolon
  • Total panproctocolectomy is curative - patient will have a permanent ileostomy or an ileo-anal anastomosis (J-pouch)
    > sub-total colectomy in acute flare due to risk of infection
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24
Q

List investigations for CRC

A
  • Colonoscopy and biopsy
  • Staging CT CAP
  • Bloods, stool qFIT
  • ECG - exclude ischaemic bowel from AF
  • CEA marker - carcinoembryonic antigen
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25
Q

Describe the management of CRC

A
  • Surgical resection
  • Adjuvant chemoradiotherapy
  • Palliative stenting for inoperable lesions; perform bypass surgery or colostomy to avoid obstruction
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26
Q

Which patients should be investigated for CRC?

A

Patients >50 with >6 week history of
- Change in bowel habit
- Rectal bleeding
- IDA

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27
Q

Describe the types and symptoms of anal cancer

A

Most commonly SSC, less commonly adenocarcinoma

Risk factors – HPV types 6 and 11/ anogenital warts or dysplasia / immunosuppression

symptoms
- Can be painful: constant pain suggests invasion into sphincter / sidewall

  • Blood and mucus on wiping
  • Tenesmus

Red flags – weight loss, anorexia, groin nodes

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28
Q

List causes of perforated viscus

A

Upper GI (most common)
> DU/GU, gastric cancer, gallbladder, iatrogenic

Colonic (less common)
> CRC, diverticulum, stercoral, appendicitis, colitis

Small bowel (least common)
> Meckel’s diverticulum, ischaemia, Crohn’s, lymphoma

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29
Q

List risk factors for peptic ulcer disease

A

Infection – H. pylori

Neoplasia – gastric carcinoma

Vascular – inflammatory / autoimmune

Trauma – stab wounds

Iatrogenic – ERCP or OGD

Endocrine – Zollinger-Ellison syndrome: excessive gastrin

Drugs – NSAID use

Chemical – caustic substances/batteries

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30
Q

Define stercoral colitis

A

Stercoral colitis is an inflammatory colitis related to increased intraluminal pressure from impacted faecal material in the colon

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31
Q

Describe the management of a perforated ulcer

A
  • IV antibiotics + IV PPI
  • laparotomy
    > perforated duodenal ulcer - oversew and omental patch
    > gastric ulcer perforation - same or partial gastrectomy
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32
Q

Describe the causes and clinical presentation of a small bowel obstruction

A

clinical features
- faeculent vomiting
- absolute constipation
- colicky abdominal pain
- distended abdomen
- tinkling bowel sounds (BS)

causes
- Intraluminal
> Foreign bodies
> Gallstones
> Meconium

  • Intramural
    > Tumours
    > Crohn’s – inflammatory strictures
  • Extrinsic
    > Adhesions (MOST COMMON)
    > Hernias
    > Cancer

Less common: gallstone ileus, intussusception, volvulus

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33
Q

List investigations used in SBO

A

History and examination

Bloods

AXR +/- CT A/P
> AXR supine will show dilated small bowel loops >3cm, erect AXR will show air-fluid level

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34
Q

Describe the management of SBO

A

Drip and suck
> NG tube + IV fluids
> NG tube decompresses small bowel by draining content upwards
> IV fluids used to catch up with losses

Monitor UO – intake/output chart

Theatre after 48h

Trial of gastrografin if unsuccessful

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35
Q

Describe a sigmoid volvulus and its management

A

Bowel twists on its mesentery and obstructs

Causes massive blockage at location and upstream

risk factors: reduced mobility, psychotropic medications, opiates, antidepressants, chronic laxatives, Parkinson’s, schizophrenia

AXR:
> Coffee bean sign
> Points to LUQ
> Loop arising from LIF twists
> Dilated proximal large bowel + small bowel

management
- Fluid and electrolyte replacement

  • Decompression using flexible sigmoidoscopy
  • Urgent laparotomy in bowel obstruction with signs of peritonitis
  • Elective sigmoid colectomy for recurrent sigmoid volvulus
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36
Q

Describe a caecal volvulus

A

Location is variable

Distended caecum, remainder of colon collapses

Obstruction is where volvulus is

Small bowel can be dilated depending on ileocaecal valve

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37
Q

Describe the presentation of LBO and its management

A

Clinical presentation
> Absolute constipation
> abdominal distension
+/- vomiting (depending on whether ileocaecal valve is open or closed)

Causes
> Stricture
> Malignant (CRC) - MOST COMMON
> Benign (diverticula, ischaemia, IBD)
> External compression; gynaecological malignancy
> Volvulus
> Adhesions

Management
- IV fluids + NG tube

  • Surgery
    > If volvulus: flexible sigmoidoscopy decompression +/- flatus tube
    > Laparotomy (caecal volvulus)
    > Defunctioning colostomy / ileostomy
    > Colonic stent

Closed-loop obstruction (competent ileocaecal valve not relieving pressure) - SURGICAL EMERGENCY

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38
Q

Describe investigations and management of ischaemic colitis

A

clinical features
- abdominal pain out of keeping with abdominal findings
- vomiting (possible altered blood)
- bloody diarrhoea

Risk factors: elderly, vasculopath, AF

investigations
> Very high WCC and CRP
> Lactic acidosis on ABG
> AXR: abnormal/obstructed

Management
- IV fluids, IV antibiotics

  • Small bowel: laparotomy
    > Pan-ischaemia is fatal and non-resectable
    > Segmental ischaemic – resect
  • Colon
    > Conservative treatment
    > If perforates or deteriorating patient may need Hartmanns/colectomy
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39
Q

Describe the clinical presentation of appendicitis

A

clinical features
- periumbilical pain migrates to RIF with guarding, rigidity, rebound tenderness
> Max tender over McBurney’s point, 2/3 of the way along line between umbilicus and ASIS

  • nausea and vomiting
  • anorexia (common feature especially children)
  • flatulence, bowel irregularity, diarrhoea
  • pain on walking / speed bumps / potholes
  • Rovsing’s sign – pain in RIF when LIF is palpated
  • Psoas stretch sign
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40
Q

What is Valentino’s syndrome?

A

Perforated peptic ulcer
> Chemical fluid from ulcer streams along right paracolic gutter to RIF
> Causes peritoneal irritation and consequent chemical appendicitis

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41
Q

Describe the management of appendicitis

A
  • Children: USS abdomen
  • Young man – convincing clinically, proceed to lap/open appendicectomy
  • Young woman – HCG to exclude ectopic, pelvis USS to exclude ovarian pathology, proceed to diagnostic lap +/- appendicectomy
  • Older man/woman - CT A/P to exclude malignancy and confirm appendicitis

IV Abx pre-operatively

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42
Q

Describe the clinical presentation of diverticulitis

A

diverticula are outpouchings of the colonic mucosa through the muscular wall of the colon, predominantly sigmoid colon

site: between taenia coli where vessels pierce the muscle to supply the mucosa

risk factors: low fibre high fat diet, physical inactivity, smokers, use of NSAIDs, steroids, opiates

clinical features
- LIF pain (except Asian, more likely RIF pain)
- Fever
- Change in bowel habit
- Nausea, vomiting
- Urinary symptoms
- PR bleeding

management
- IV antibiotics: IV ceftriaxone + metronidazole
- IV fluids
- Analgesia

Non-improving patients or those with complications require intervention e.g. drainage of abscess, colonic resection if perforation or obstruction

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43
Q

List acute and chronic complications of diverticular disease

A

Acute
> Abscess, perforation, haemorrhage
> Perforation leads to generalised peritonitis, distended abdomen, diffuse tenderness/guarding

Chronic
> Stricture

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44
Q

Describe the composition of bile

A

Bilirubin - pigment - breakdown of haem products

Cholesterol - excreted in bile, requires lecithin and bile salts to solubilise

Bile salts - cholic & chenodeoxycholic acid conjugated to taurine and glycine; fat emulsifiers

Lecithin - fat emulsifier

Inorganic salts - NaCl, NaHCO3 - neutralisation of gastric acid

Water

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45
Q

Describe the pathophysiology of gallstones

A

Mixed stones
> Cholesterol supersaturation
> Gallbladder function (emptying/absorption)
> Reduced bile acid concentration (gut bugs, ileal resection/disease)

Pigment stones
> Accumulation of bilirubin e.g. due to haemolytic anaemia
> Bile stasis
> Biliary tract colonisation (deconjugation of bilirubin diglucuronide)
> Foreign body (stents, parasites)

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46
Q

List risk factors for gallstones

A
  • 5 Fs
    > Female (oestrogen drives stone formation)
    > fair (Caucasian)
    > fertile
    > forties
    > fat
  • Genetics
  • Low calorie diet, rapid weight loss
  • PPI use
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47
Q

Describe the clinical features and management of biliary colic

A

Clinical features
> Colicky RUQ / epigastric pain
> Acute onset, initiated by eating & drinking fatty foods
> Radiating to back
> Nausea and vomiting
> Dyspepsia, flatulence, food intolerance

Duration
> Lasts minutes to hours
> Settles spontaneously
> Well in between episodes

Blood results
> WCC, CRP – normal
> LFTs – normal

Management – analgesia and elective lap chole if severe
> If CBD is cut, hepatojejunostomy is performed; however, lifetime of recurrent biliary sepsis, gallstones

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48
Q

Describe the clinical features and management of acute cholecystitis

A

Obstruction of the cystic duct / Hartmann’s pouch

features
- RUQ pain
- fever
- vomiting
- Murphy’s sign +ve
- Boas sign: hyperaesthesia beneath right scapula

investigations
> WCC, CRP – raised
> LFTs: normal/mildly deranged
> ultrasound abdomen
> if equivocal diagnosis, technetium-labelled HIDA scan

Management
> NBM – low fat diet
> Analgesia
> IV Antibiotics

> early laparoscopic cholecystectomy within 1 week of diagnosis

> Percutaneous cholecystostomy if gangrenous

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49
Q

List complications of cholecystitis

A
  • Gangrene
  • Chronic cholecystitis
  • Emphysema of GB
  • Mucocoele
  • Empyema of GB
  • Perforation
  • Mirizzi syndrome
    > GB stone impacted in Hartmann’s pouch leads to pressure and erosion of common hepatic duct
  • Gallstone ileus
    > seen as small bowel obstruction + air in biliary tree on AXR
  • Carcinoma
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50
Q

Describe the causes, clinical presentation and management of ascending cholangitis

A

Clinical presentation
> Charcot’s triad
» Fevers / rigors
» Jaundice
» RUQ pain

> Raynaud’s pentad
> Charcot’s
> CNS depression
> Shock

Causes: CBD stones, stricture, anastomotic stricture, post-ERCP
> blockage in cystic duct or gallbladder will not cause jaundice

commonly caused by E. coli

Management
- Aggressive resuscitation
- IV Antibiotics - triple therapy: gentamicin, amoxicillin and metronidazole OR piperacillin/tazobactam

  • Urgent ERCP, sphincterotomy +/ stent
  • Percutaneous transhepatic cholangiography
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51
Q

Describe gallstone ileus

A

In older individuals, long-term low-grade inflammation causes a fistula connecting duodenum & GB (sometimes stomach)

Presentation
> Presents as SBO
» Vomiting, distended abdomen, absolute constipation

AXR: stones & air in biliary tree

Management
> Laparotomy
> Enterotomy and removal of stone

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52
Q

List causes of acute pancreatitis

A

I GET SMASHED

  • Iatrogenic
  • Gallstones
  • Ethanol
  • Trauma
  • Steroids
  • Mumps / malignancy
  • Autoimmune (IgG4)
  • Scorpion stings
  • Hypercalcaemia / hypertrygliceridaemia
  • ERCP
  • Drugs
    > azathioprine
    > thiazides
    > oestrogen
    > mesalazine
    > furosemide
    > sodium valproate
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53
Q

Describe the investigations carried out in acute pancreatitis

A

Investigations
- Bloods: AMYLASE or lipase

Imaging
> Erect CXR: exclude pneumoperitoneum or LRTI
> USS abdomen: exclude gallstones & determine CBD diameter
» also demonstrates pancreatic head masses and pancreatic oedema
> MRCP - exclude biliary or pancreatic stones
> ERCP: especially with coexisting cholangitis in gallstone pancreatitis

> EUS: idiopathic pancreatitis

> CT with contrast

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54
Q

Describe complications of acute pancreatitis

A

peripancreatic fluid collections
- may resolve or develop into pseudocysts/abscesses

pancreatic pseudocyst
- organisation of peripancreatic fluid collection, usually retrogastric
- collection is walled by fibrous/granulation tissue and occurs 4 weeks or more after acute pancreatitis
- associated with mild elevation of amylase
- symptomatic cases observed for 12 weeks as up to 50% resolve
- treatment: endoscopic or surgical cystogastrostomy or aspiration

pancreatic necrosis
> sterile necrosis should be managed conservatively initially

pancreatic abscess
> intraabdominal collection of pus in the absence of necrosis
> usually due to infected pseudocyst
> management: transgastric or endoscopic drainage

haemorrhage
> infected necrosis may involve vascular structures leading to haemorrhage
> retroperitoneal: Grey Turner’s sign

acute respiratory distress syndrome (ARDS)

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55
Q

Describe severity scores for acute pancreatitis

A

Glasgow (Imrie) score >=3 within 48h of admission indicates severe, likely to develop complications
> Age, oxygen, WCC, urea, calcium, glucose, albumin, LDH, AST/ALT

Modified Glasgow / PANCREAS score

Revised Atlantic Classification
> Mild – no organ failure, no local/systemic complications
> Moderate – transient organ failure (<48h), local/systemic complications
> Severe – persistent organ failure (>48h)

CRP of >300mg/L 72h after onset of symptoms – necrosis likely

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56
Q

List complications of acute pancreatitis

A

Acute

> Local

> > Acute peripancreatic fluid collection (<4wk) developing into a pseudocyst (>4wk)

> > Acute necrotic collection (<4wk) developing into walled-off necrosis (>4wk)

> > Gastric outlet obstruction

> > Haemorrhage (splenic or GDA pseudoaneurysm)

> > Portal vein thrombosis

> Distant / systemic
> Hypotension / shock / arrhythmias
> Infection
> Respiratory failure: ARDS, atelectasis, pleural effusions, pulmonary oedema
AKI / renal failure
Ileus
Liver failure / ascites
DIC

Chronic
> Chronic pancreatitis (CP) - calcifications, ducts, strictures, stones
> Exocrine failure – malnutrition
> Endocrine failure – type 3c diabetes
> PD stones/strictures

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57
Q

Describe the clinical features and management of acute pancreatitis

A

clinical features
- Epigastric pain radiating to back
- Nausea / vomiting
- Fever
- Periumbilical discolouration (Cullen’s sign)
- Flank discolouration (Grey-Turner sign)
- Ischaemic (Purtscher) retinopathy - temporary/permanent blindness

management
- IV fluids
- Analgesia
- No role for antibiotics in initial setting, consider if infected collection

  • Late – ERCP if required, nutritional support

Collections
> Sterile pseudocyst – no management needed except monitoring
> Walled off necrosis: drainage – cyst gastroscopy or percutaneous cyst drainage

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58
Q

Describe the clinical presentation, pathophysiology and causes of chronic pancreatitis

A

symptoms
> Upper abdominal pain
> Nausea and vomiting
> Steatorrhoea
> Weight loss
> Diabetes

Causes
> Alcohol
> Idiopathic
> Autoimmune
> Hereditary

Diagnosis:
- Calcified / fibrotic pancreas on imaging
- Serum amylase is normal
- Faecal elastase is high
- Autoimmune screen

Treatment
> Medical
» Insulin
» Analgesia
» Diet modification
» Pancreatic enzymes (CREON)

> Surgery
> Resection and drainage procedures

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59
Q

Describe the causes and presentation of oesophageal perforation

A

Causes: caustic substances, OGD, Boerhaaves syndrome, trauma

clinical features
- neck, chest or abdominal pain

Imaging
- Plain CXR - pneumomediastinum, hydropneumothorax
- CT with oral contrast - extraluminal contrast

Management
- Conservative
> Resuscitation, IV antibiotics, NBM

  • Surgical
    > Thoracotomy + surgical repair: thoracic oesophageal perf
    > Laparotomy: intra-abdominal perforation + peritonitis
    > Stents - palliative, contained perforations
    > Percutaneous drainage

High mortality - sepsis leading to shock, multiorgan failure, death

60
Q

List signs of perforation on AXR (pneumoperitoneum)

A
  • Continuous hemidiaphragm with crisp delineation
  • Rigler’s sign - increased delineation of wall of bowel due to free gas
  • Football sign: gas bubble rises to top of abdomen forming a ball, most commonly seen in NEC in babies
  • Air surrounding falciform ligament
  • visible line on AXR
61
Q

Describe the anatomy of the thyroid gland

A

2 lobes connected by isthmus

Blood supply
> Superior thyroid artery – branch of external carotid

> Inferior thyroid artery – branch of thyrocervical trunk (branch of subclavian)

Venous drainage
> Internal jugular vein
> Brachiocephalic veins

Lymph nodes: anterior cervical chain

62
Q

List the types and clinical features of thyroid cancer

A

types
- Papillary: most common
- Follicular
- Medullary: C cells
- Anaplastic: rare, aggressive
- Lymphoma

clinical features
- Palpable single or multiple lumps
- Rapid growth
- Pain
- Cough, hoarse voice, stridor
- Multiple enlarged cervical lymph nodes

management
- Surgery
> Hemi-thyroidectomy
> Total thyroidectomy

  • Non-surgical treatment
    > Radioiodine therapy
    > External beam radiotherapy
    > Chemotherapy
63
Q

List the symptoms of hypercalcaemia

A

GI
> Nausea and vomiting
> Abdominal pain
> Pancreatitis
> Ulcer
> Constipation

CV
> High BP
> Bradycardia
> Heart block
> Arrhythmias

Renal
> Colic
> Polyuria
> Oliguria
> Thirst
> Renal failure

Neuro
> Anxiety
> Depression
> Headaches
> Confusion

64
Q

List causes of hypercalcaemia

A

Malignancy
> Solid tumour
> Metastasis

Haematological
> Myeloma, lymphoma, leukaemia

Hyperparathyroidism
> Lithium, familial (MEN), FHH

High bone turnover
> Paget’s, thiazides, hyperthyroid

Excess vitamin D

Renal failure – secondary HPT

Addisonian crisis

Lab error - haemoconcentration

65
Q

Describe the anatomy of the adrenal gland

A

Blood supply
> Inferior phrenic, renal and aortic branches

Venous drainage
> IVC on right
> Left renal vein on left

Cortex
> Zona glomerulosa – mineralocorticoids
> Zona fasciculata – glucocorticoids
> Zona reticularis – androgens (DHEA)

Medullary
> Noradrenaline, adrenaline

66
Q

Describe the features and management of Cushing’s disease

A

Increased levels of glucocorticoids

Features
> Obesity
> Hirsutism
> Muscle weakness
> Striae
> Acne
> Diabetes
> Bruising
> Fractures
> Buffalo hump
> High BP

Management
> Surgery
» Transsphenoidal pituitary surgery
» Laparoscopic adrenalectomy

67
Q

Describe adrenocortical carcinoma and its management

A

Suspected when mass size is >6cm

Associated with
> MEN1
> Li Fraumeni syndrome (breast, brain, osteosarcoma)

Management
> Medical: mitotane – causes adrenal necrosis
> Surgery: laparoscopic or transabdominal approach

68
Q

List drugs which must be stopped or altered prior to surgery

A

Drugs to stop prior to surgery – CHOW

Clopidogrel
> Stop 7 days prior due to bleeding risk
> Aspirin and other anti-platelets can be continued

Hypoglycaemics

Oral contraceptive pill or HRT
> Stop 4 weeks before surgery due to DVT risk

Warfarin
> Stop 5 days prior due to bleeding risk
> Commence on therapeutic dose LMWH
> If INR >1.5, give PO vitamin K

DOACs will also need to be stopped but duration depends on each one

Drugs to alter

> Subcutaneous insulin
> Switch to variable-rate insulin infusion (VRIII)

> Long-term steroids
> Must be continued due to risk of Addisonian crisis if stopped
> If patient cannot take orally, switch to IV

69
Q

Describe colonic polyps

A

Any growth from lining of large bowel

Can be pedunculated or sessile

Types
> Tubular – smaller, less potential
> Villous – larger, frond-like lesions, greater malignant potential
> Tubulovillous - both

Presentation
> PR bleeding
> Mucous discharge or prolapse if low in rectum

Can be precancerous

70
Q

List causes of PR bleeding

A
  • Anticoagulants
  • Bleeding diathesis / coagulopathy
  • Haemorrhoids
  • Diverticulosis
  • CRC
  • Colitis (Crohn’s / UC / infective / C. diff / ischaemic)
  • Angiodysplasia
  • Meckel’s with ectopic gastric mucosa
71
Q

Describe perianal abscesses

A

associated with Crohn’s disease

clinical features
- acute perianal pain
- purulent discharge
- erythema and swelling
- +/- systemic upset

Mangement
- EUA (examination under anaesthesia)
- incision and drainage (+/- fistulotomy)

Beware the obese diabetic who is unwell – necrotising perianal sepsis

72
Q

Describe fistula in ano

A

Causes: cryptoglandular, Crohn’s, drugs, radiation, tumour

Symptoms
- discharge
- pain
- soiling

Imaging: MRI pelvis

Management
> Crohn’s
- induce remission with glucocorticoids
- enteral feeding can be used
- second-line: mesalazine
- azathioprine and mercaptopurine may be added
- infliximab may be used for refractory / fistulating disease
- Metronidazole if isolated perianal fistula

  • Lay open and remove internal opening - heal by secondary intention
  • Repeated seton until laying open is possible
  • Complex procedures –
    > LIFT procedure - ligation of intersphincteric fistula tract
    > Endoanal advancement flap
73
Q

Describe anal fissures

A

Tear in the epithelial lining of the anal canal

Symptoms
- Acute
> Sharp anal pain: cut glass – during and after defecation
> A little blood on wiping

  • Chronic
    > Symptoms beyond 6-8/52
    > Sentinel tag at the external apex
    > Exposed internal sphincter muscle
    > Hypertrophied anal papilla at the internal apex

posterior is most common site
- if lateral anal fissure, investigate for IBD (uncommon site)

Management
- acute anal fissure (<1 week)
> soften stool
> dietary fibre
> topical anaesthetic e.g. lidocaine
> Sitz baths

  • > 1 week
    GTN / diltiazem ointment
    Diltiazem ointment
    Intersphincteric botox injection
  • If persists at 6/52 consider EUA – exclude sinister pathology
  • surgical management
    > Lateral internal sphincterotomy
    > Anal advancement flap
    > Fissurectomy
    > Defunctioning stoma
74
Q

Describe thrombosed external haemorrhoid

A

Aka perianal haematoma

Symptoms
> Acute severe perianal pain
> Blood on wiping and in pan
> Perianal lump

Either conservative management or incision and evacuation

Symptoms usually last 2/52 regardless

Little evidence that surgery improves pain over this period, although initial relief is usually marked

Conservative Rx
> stool softeners
> Topical local anaesthetic gel
> Cool pack
> refer for excision if <72h

75
Q

Describe rectal prolapse

A

Protrusion of all layers of the rectal wall through anal canal

Symptoms
- A lump coming down on defecation or standing
- Blood and mucus on wiping
- Incontinence
- Usually not painful
- Patient may confuse for prolapsing haemorrhoids

Usually elderly women – pelvic floor / sphincter complex weakness after obstetric injury followed by age and menopause-related muscle weakening

Management
- Initially – push it back in
- Conservative if very unfit
- Perineal repair (Delorme’s / Altmeier’s)
- Abdominal rectopexy

76
Q

Compare colostomy and ilostomy

A

Ileostomy
- usually RIF
- Spouted
- effluent is liquid to semi-liquid
- higher output

Colostomy
- usually LIF
- Flat / flush with skin
- semi-solid to solid effluent
- lower output

77
Q

List symptoms and management of GORD

A

clinical features
- dyspepsia
- heartburn
- nausea
- epigastric / retrosternal pain
- bloating
- anorexia
- early satiety
- unintentional weight loss
- dysphagia
- GI bleeding

Red flags
> Iron deficiency anaemia
> Epigastric mass

Complications
> Oesophagitis
> Ulcers
> Benign stricture
> Barrett’s oesophagus
> Oesophageal adenocarcinoma
> Iron deficiency anaemia

Drug management
> H2 receptor blocker (ECL cells) – cimetidine, ranitidine
> PPI (parietal cells) – omeprazole, esomeprazole

78
Q

List investigations used in oesophageal pathology

A

Upper GI endoscopy

Barium swallow

24h pH monitoring if endoscopy is normal

Oesophageal manometry – if endoscopy is normal
> Need to see transmitted peristalsis of oesophageal muscle and relaxation of lower oesophageal sphincter

79
Q

Describe hiatus hernias

A

Sliding hiatus hernia
> Gastric fundus protrudes into thoracic cavity
> Lower oesophageal sphincter is no longer in contact with diaphragm

Paraoesophageal “rolling” hiatus hernia
> More dangerous, less symptomatic as lower oesophageal sphincter is potentially still functioning
> Rolling hernia means risk of strangulation of gastric fundus

Management
> Weight loss
> Symptomatic relief : PPI, H2 receptor antagonist

Surgery - Nissen fundoplication, Linx procedure

80
Q

Describe achalasia and its management

A

Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter due to degenerative loss of ganglia from Auerbach’s plexus

Clinical features
- dysphagia of BOTH liquids and solids
- variation in severity of symptoms
- heartburn
- regurgitation of food
- may lead to cough, aspiration pneumonia
> aspiration pneumonia is more common in right lower lobe (RLL)

Investigations
- oesophageal manometry: excessive LOS tone which doesn’t relax on swallowing

  • barium swallow: grossly expanded oesophagus, fluid level, ‘bird’s beak’ appearance
    chest x-ray: wide mediastinum, fluid level

Treatment
> pneumatic (balloon) dilation first-line

> surgical intervention: Heller cardiomyotomy

> intra-sphincteric injection of botulinum toxin if high surgical risk

> drug therapy (e.g. nitrates, calcium channel blockers)

complications - squamous cell carcinoma

81
Q

Describe the features and management of abscesses

A

Collection of pus surrounded by a pyogenic membrane

Pus – dead leukocytes, bacteria and tissue debris

Features
> Red, hot, tender swelling
> Fluctuant

Outcomes
> Rupture
> Discharge into another organ – fistula
> Discharge into an epithelial surface – sinus

Management – drainage
> Skin and soft tissue – I&D under LA/GA
> Intra-abdominal abscess – Abx + IR drainage or laparoscopic washout

82
Q

Describe erysipelas and its management

A

Spreading cuticular lymphangitis

Common organisms – streptococcus pyogenes

> Rose-pink rash that extends to adjacent skin
Raised
Sharply defined margins
Vesicles contain serum, not pus

Milian’s ear sign

Management
> Wound swab
> Antibiotics – want to cover gram +ve flucloxacillin

83
Q

Describe cellulitis and its management

A

Spreading inflammation of subcutaneous and fascial layers – suppuration, sloughing or gangrene

Common in diabetic, malnourished patients

Features
> Swollen
> Tender
> Hot
> No definite edge
> Vesicles may contain pus

management
- PO/IV Antibiotics depending on patient and severity

84
Q

Describe necrotising fasciitis and its management

A

A polymicrobial bacterial infection - destruction of the soft tissues and fascia

Surgical emergency

Risk factors
> Diabetes
> Smoking
> Penetrating trauma
> Pressure sores

Clinical features
> Rapidly progressing
> Generally unwell, tachycardic, fever +/- hypotensive
> Oedema stretching beyond visible skin erythema
> Pain out of proportion to affected area
> Crepitus
> Fournier gangrene – nec fasc affecting external genitalia and perineum

Management
> Fluid resuscitation
> IV Antibiotics – covering gram +ve, gram –ve and anaerobes
> Surgical debridement
+/- plastic surgery review for skin graft

85
Q

Describe peritonitis

A

Inflammation of the peritoneum

Causes
> bacterial inflammation
> Gastrointestinal perforation – perforated ulcer, appendix, diverticulum
> Transmural translocation (no perforation) e.g. pancreatitis, ischaemic bowel
> Exogenous contamination e.g. drains, open surgery, trauma
> Female genital tract infection e.g. pelvic inflammatory disease
> Haematogenous spread (rare) e.g. septicaemia
> Chemical – bile, barium
> Ischaemia – strangulated bowel, vascular occlusion

Management
> Resuscitate – IV fluids / Urinary catheter to monitor output
> IV Antibiotics
> CXR +/- CT A/P
> Theatre

86
Q

Describe ulcerative colitis (UC) and its symptoms

A

features
> Involves rectum and extends proximally to involve all or part of colon (left side)
> Continuous spread (no skip lesions)
> Ulcers, pseudopolyps
> Diffuse mucosal inflammation – no transmural ulceration
> Limited to colon

biopsy: crypt abscesses

Symptoms
> Bloody diarrhoea
> Mucus
> Abdominal pain
> Tenesmus and urgency

Most common disease pattern is proctitis

> Extraintestinal
> Erythema nodosum, pyoderma gangrenosum
> Uveitis
> Arthritis
> Aphthous ulcers
> Primary sclerosing cholangitis (PSC)

87
Q

Describe Crohn’s disease

A

Patchy transmural inflammation in any part of GI tract
> skip lesions mouth-anus
> transmural inflammation
> goblet cells
> granulomas
> strictures: Kantor’s string sign
> rose-thorn ulcers

Risk factors – smoking, prior appendicectomy, family history

Defined by
> Location – terminal ileum, ileocolic, upper GI
» terminal ileitis increases gallstone risk

> Disease – inflammatory, stricturing, fistulating

> Cobblestone appearance

> Creeping fat – adhesions and fistula

Diagnosis
> Colonoscopy – cobblestoning
> Histology – discontinuous, granulomatous inflammation
> CT/USS/MRI - abscess/fistulae
> Capsule enteroscopy

88
Q

Describe the management of Crohn’s

A

Inducing remission: glucocorticoids

> Aminosalicylates e.g. mesalazine (second-line to glucocorticoids)

> Immunosuppressants e.g. azathioprine, 6-mercaptopurine, cyclosporin (add-on)

> Biological therapy: infliximab, adalimumab

Maintaining remission - azathioprine or mercaptopurine first-line (methotrexate second-line)

Perianal fistulae: oral metronidazole +/- seton drain

Most patients eventually have surgery
> stricturing terminal ileal disease - ileocaecal resection
> segmental small bowel resections
> stricturoplasty

89
Q

Define haemorrhoids and the causes of haemorrhoids

A

Cushions of highly vascular tissue found within the submucosal space and are considered part of the anatomy of the anal canal

Causes
> Constipation, prolonged straining
> Exercise, gravity
> Nutrition (low fibre diet)
> Pregnancy, increased intra-abdominal pressure
> Irregular bowel habits (constipation / diarrhoea)
> Genetics, absence of valves within the haemorrhoidal veins
> Aging

90
Q

Describe the presentation, grading and treatment of haemorrhoids

A

Acute – thrombosed piles

Chronic
> Internal
» Painless bleeding
» Itch

> External
> Bleeding
> Swelling and discomfort
> Mucous discharge

investigation - PR exam, proctoscopy

Grading
> grade I: do not prolapse out of anal canal
> grade II: prolapse on defecation but reduce spontaneously
> grade III: can be manually reduced
> grade IV: cannot be reduced

Treatment

> Medical
> Dietary / lifestyle: avoid constipation
> Creams
> anusol: astringent to shrink haemorrhoids (short-term)
> topical lidocaine

Non-surgical
> Injection sclerotherapy
> Rubber band ligation (RBL)
> Transanal haemorrhoidal dearterialization (THD)

Surgery
> Open/closed haemorrhoidectomy
> Procedure for prolapse and haemorrhoids (PPH)
> Infrared photocoagulation
> Haemorrhoidal artery ligation operation (HALO)

91
Q

Describe pilonidal sinus & its treatment

A

Acquired condition related to the presence of hair in the natal cleft

Loose hair causes a foreign body reaction leading to midline pit formation

Presentation
> Simple cyst
> Acute abscess with/without cellulitis
> A chronic draining sinus
> May have a tracking sinus or multiple sinuses

Treatment
> Non-operative
» Local hair control – shaving or laser epilation
» Improved hygiene

> Operative
> PNS abscess – incision & drainage
> Karydakis & Bascom’s procedure

92
Q

Describe the pathophysiology, presentation and management of a tension pneumothorax

A

Pathophysiology
- Blunt or penetrating injury
> Results from a one-way air leak which results in trapped air within the thoracic cavity – collapsing the affected lung
> Mediastinal shift results in decreased venous return and compression of the opposite lung
> Decreased venous return reduces cardiac output
> Obstructive shock

Clinical signs
- Respiratory distress
- Deviated trachea
- Distended neck veins
- Absent breath sounds / markedly decreased on the affected side
- Hyperresonant to percuss
- Minimal chest movement

Management
- Oxygen – 15L trauma mask (non-rebreather)
- Grey venflon – second intercostal space mid clavicular line to buy some time
- Chest drain

93
Q

Describe the pathophysiology, clinical signs and management of cardiac tamponade

A

Pathophysiology
> penetrating or blunt
> Cardiac tamponade is the accumulation of pericardial fluid, blood, pus or air within the pericardial space
> Results in an increase in intra-pericardial pressure, restricting cardiac filling and decreasing cardiac output
> Obstructive shock

Clinical signs
> Tachycardia, hypotension
> Distant heart sounds
> Distended neck veins
> Pulsus paradoxus >10 mmHg
> Abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration

Management
> Drainage of the pericardial fluid either by pericardiocentesis or surgical drainage – usually with a thoracotomy in trauma and creation of a pericardial window

94
Q

Describe acute limb ischaemia and its clinical presentation

A

Sudden decrease in limb arterial perfusion with potential threat to limb survival ; onset <2 weeks

Presentation: 6 Ps
- Pain
- Pulseless
- Pallor
- Poikilothermia (perishingly cold)
- Paraesthesia – indicative of neuronal ischaemia
- Paralysis – indicative of neuronal ischaemia

95
Q

List investigations and management for acute limb ischaemia

A

Rutherford classification for staging of severity

Investigations
> ECG, echo
> CT angiography
> Arterial Doppler ultrasound (initial investigation)
> ABPI

Management: surgical emergency

> Resuscitation and analgesia (IV opioids)
IV unfractionated heparin to prevent clot propagation

> Revascularisation options
> Surgical embolectomy +/- fasciotomy
> Endovascular: targeted thrombolysis
Late diagnosis: amputation

96
Q

Describe causes of acute limb ischaemia

A
  • Thrombo-embolus
    > E.g. AF, infective endocarditis, antiphospholipid syndrome
    > Managed via open arteriotomy or catheter-directed thrombectomy
  • Aneurysm
    > Higher amputation rates as no collateral circulation
  • Trauma & iatrogenic injury
  • Dissection
97
Q

Describe the pathophysiology and clinical presentation of chronic limb ischaemia

A

History
- Walking distance aka claudication distance
- Rest pain
> Pain at rest, numbness, paraesthesia – critical limb ischaemia

Examination
- absent / diminished pedal pulses
- cold / shiny / scaly skin
- peripheral hair loss
- ulceration / gangrene
- thickened toenails

critical limb ischaemia
> buerger’s angle <20
> capillary refill time >15s
> diminished/absent pulses
> evidence of gangrene or ulceration

98
Q

Describe findings on inspection in chronic venous insufficiency

A

Haemosiderin deposition
> Erythrocyte leakage & breakdown
> Release of iron

Lipodermatosclerosis
> Inflammation and fibrosis

Venous eczema

> Venous ulceration
> Sloping edges
> Shallow
> Large
> management: compression bandaging, oral pentoxifylline

99
Q

Describe chronic limb threatening ischaemia and its features on examination

A

Peripheral arterial disease combined with
> Rest pain + night pain
> Gangrene
> Limb ulceration / tissue loss >2 weeks

Examination
> Absent peripheral pulses
> Buerger’s test
» Foot blanches on elevation + dependent hyperaemia
» Hyperaemic foot “sunset”
> Arterial ulcers / tissue loss / necrosis
» Classically “punched out”, distal, painful

100
Q

Describe investigations for chronic limb threatening ischaemia

A

Resting + exercise ankle-brachial pressure indices (ABPI)

Arterial duplex ultrasound

Non-invasive angiography – CT / MRI

Conventional needle angiography / DSA (digital subtraction angiography) - best imaging

101
Q

Describe the management of peripheral arterial disease and chronic limb threatening ischaemia

A

Peripheral arterial disease

all patients with PAD should take clopidogrel and atorvastatin 80mg

Conservative: risk modification, patient education, smoking cessation

If claudication: cilostazol – phosphodiesterase 3 inhibitor – vasodilator -

Chronic limb threatening ischaemia

> Revascularise

> > Open surgery: endarterectomy, bypass grafting
> used for long segment stenosis, multifocal lesions, lesions of common femoral artery and purely infrapopliteal disease, low-risk patients

> > Endovascular surgery: balloon angioplasty+/- stent
> used for short segment stenosis, aortic iliac disease, high-risk disease

> If necrosis / gangrene – below or above knee amputation

102
Q

Define abdominal aortic aneurysms and describe their classification

A

True aneurysms involve all layers of the arterial wall, > 50% dilatation of the artery

> False / pseudo aneurysm – bleeding tamponade by surrounding tissue
> Causes – IVDU and cardio procedures due to puncturing vessels

2 types of aneurysm
> Saccular (outpouching), usually subarachnoid
> Fusiform (majority) of AAA
» Related to position of renal arteries: infrarenal, suprarenal…

indications for surgical repair
- rapidly enlarging (>1cm over a year and >4cm)
- repair at 5.5cm

103
Q

List risk factors for AAA

A

Age >65

Male gender

Smoking

Family history of AAA

Atherosclerosis

History of other vascular aneurysms, especially popliteal aneurysm

Arterial hypertension

Greater height

Obesity

COPD

Congenital disorders e.g. Marfan’s, Ehlers-Danlos

104
Q

Describe treatment options for AAA

A

Open repair (consider repair >5.5cm): good long-term outcomes

EVAR (endovascular aneurysm repair): may need reintervention in future

105
Q

Describe the presentation, investigations and treatment of an AAA rupture

A

Presentation
> Sudden onset severe back/lower abdo pain
> Expansile abdominal mass +/- tenderness
> Cardiovascular instability e.g. hypotension / collapse
> Assess peripheral pulses
> Beware “renal colic” in men <50, retroperitoneal fluid can cause flank pain

Surgical emergency, high mortality

Investigations: abdo exam, CT

Management
> Resuscitation
> Permissive hypotension: less chance of disrupting haematoma with lower BP
> Repair – open or EVAR

106
Q

List antiemetics for post-op nausea

A

Serotonin antagonists (5HT) - ondansetron 4mg

Corticosteroid – dexamethasone 4-8mg

Dopamine antagonists (D2) - droperidol 0.625-1.25mg

Metoclopramide – 25-50mg

107
Q

List complications associated with massive transfusion

A

Metabolic acidosis / hypocalcaemia

Coagulopathy – dilutional / consumptive

Hypothermia

Hyperkalaemia

TACO – Transfusion-associated circulatory overload

Transfusion related acute lung injury (TRALI)

108
Q

Describe the classification of severity of UC and its management

A

Truelove & Witts Criteria

Severity
- Mild: <4 stools/day, small amount of blood
- Moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
- Severe: >6 stools/day, features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)

Management

  • Mild to moderate UC
    > topical (rectal) aminosalicylate e.g. mesalazine
    » if remission not achieved within 4 weeks add oral aminosalicylate, if still not achieved, topical/oral steroid
  • severe colitis
    > IV methylprednisolone
    > intravenous ciclosporin if steroids not tolerated

IF toxic megacolon - surgical referral, may need emergent colitis (consider rescue infliximab)

following a severe relapse or >=2 exacerbations in the past year: oral azathioprine or oral mercaptopurine

109
Q

What is the diameter for megacolon?

A

369

3cm - small bowel

6cm - large bowel

9cm - caecum

110
Q

Describe milk-alkali syndrome

A

Triad of hypercalcaemia, metabolic alkalosis and renal insufficiency (AKI).

Associated with excess calcium supplementation e.g. calcium carbonate

lab features: high calcium, low PTH

111
Q

Describe Paget’s disease of the bone and its management

A

Increased bone turnover

Association with age >55, smoking, genetics, paramyxoviruses e.g. measles, RSV, canine distemper virus

Clinical features
> bone pain (Deep, dull, nighttime)
> Skeletal deformities
» increased hat size (skull involvement), hearing loss
» bowed tibias
» kyphosis
» fractures

Lab features
> increased serum ALP
> normal calcium and phosphate

X-ray: localised bone enlargement and deformity, patchy cortical thickening with sclerosis

Bone biopsy is the most sensitive test

Complications
- Neurological: nerve root compression,, spinal stenosis
- Orthopaedic: OA, pathological fractures, enlargement/deformity
- Oncological: osteosarcoma
- Other: HF, secondary hyperparathyroidism
- malignancy: osteosarcoma

management:
> analgesia
> bisphosphonates
> PT/OT
> Corrective surgery, joint replacement

112
Q

Describe multiple myeloma

A

malignant proliferation of plasma cells that secrete monoclonal antibodies and light immunoglobulin chains.

clinical fratures
> lethargy
> bone pain
> pathological fracture
> amyloidosis
> pancytopenia (marrow infiltration)

Diagnosis requires two of the following 3 criteria:
1. Marrow plasmacytosis
2. Serum/urinary immunoglobulin light chains (Bence Jones protein)
3. Skeletal lesions (osteolytic lesions, pepperpot skull and pathological fractures)

If serum / urine monoclonal antibodies but do not fulfil the criteria for multiple myeloma: monoclonal gammopathy of uncertain significance

Management
> analgesia
> bisphosphonates
> orthopaedic interventions
> <55yy: allogeneic stem cell transplantation
> palliative chemo

Complications

> Renal failure (caused by the deposition of light chains within the kidney)
> managed by promoting fluid intake although renal replacement therapy may be required

113
Q

Describe the adverse effects of the following cytotoxic agents

  • cyclophosphamide (alkylating agent)
  • bleomycin (cytotoxic)
  • doxorubicin (anthracycline)
  • methotrexate
  • 5-FU
  • 6-mercaptopurine
  • cytarabine
  • vincristine, vinblastine
  • docetaxel
  • cisplatin
  • hydroxyurea
A

cyclophosphamide
> haemorrhagic cystitis
> myelosuppression
> transitional cell carcinoma

bleomycin
- lung fibrosis

doxorubicin
- cardiomyopathy

methotrexate
- myelosuppression
- mucositis
- liver fibrosis
- lung fibrosis

5-FU
- myelosuppression
- mucositis
- dermatitis

6-mercaptopurine
- myelosuppression

cytarabine
- myelosuppression
- ataxia

vincristine: peripheral neuropathy, paralytic ileus

docetaxel: neutropaenia

cisplatin: ototoxicity, peripheral neuropathy

114
Q

Describe cryptorchidism and its management

A
  • congenital undescended testis by 3 months of age
  • increased risk of testicular cancer

treatment
- orchidopexy at 6-18 months of age

retractile testis: appears in warm conditions or can be brought down on clinical examination and does not immediately retract

115
Q

Describe the investigations and management of renal stones

A

Investigations
- urine dipstick
- Non-contrast CT KUB
- ultrasound for pregnant women and children

Managemenet
Analgesia - NSAIDs, usually IM diclofenac

Renal stones
> watchful waiting if <5mm and asymptomatic (follow-up imaging in 4 weeks)
> 5-10mm: shockwave lithotripsy
> 10-20mm: shockwave lithotripsy OR ureteroscopy
> >20mm: percutaneous nephrolithotomy

Ureteric stones
- distal ureteric stones <10mm
> extracorporeal shockwave lithotripsy + alpha blockers e.g. tamsulosin

  • stones 10-20mm
    > ureteroscopy

Infected Obstructed Urinary System - surgical emergency
> decompression via percutaneous nephrostomy

116
Q

Describe cholangiocarcinoma and its management

A

bile duct cancer, risk factor is primary sclerosing cholangitis

features
- persistent biliary colic symptoms
- anorexia, jaundice, weight loss
- palpable mass in RUQ: Courvoisier sign
- periumbilical lymphadenopathy (Sister Mary Joseph nodes), Virchow node
- raised CA 19-9 levels

117
Q

Describe local anaesthetic agents

A
  • lidocaine
    > affects Na channels in the axon
    > toxicity: due to IV or excess administration
  • cocaine
    > applied topically to nasal mucosa in ENT surgery
  • bupivacaine
    > binds to intracellular portion of sodium channels and blocks sodium influx into cells
    > longer duration than lignocaine
    > cardiotoxic; levobupivacaine is less cardiotoxic
  • prilocaine
    > used for intravenous regional anaesthesia
  • prilocaine
  • lignocaine

Adrenaline may be added to local anaesthetic drugs to prolong duration of action and permit usage of higher doses

118
Q

describe pilonidal disease and its management

A

condition where sinuses and cysts form near the upper part of the natal cleft of the buttocks

clinical features
- abscess
> pain (may be severe)
> purulent discharge
> fluctuant swelling at site

management
- asymptomatic: managed conservatively with local hygiene
- symptomatic
> acute: incision and drainage
> chronic/recurrent: excision of the pits and obliteration of underlying cavity

119
Q

describe TURP syndrome

A

rare and life-threatening complication of transurethral resection of the prostate surgery

pathophysiology - venous destruction and absorption of irrigation fluid (glycine) causes hyponatraemia and hyperammonia

risk factors
- surgical time >1h
- height of bag >70cm
- resected >60g
- large blood loss
- perforation
- large amount of fluid used
- poorly controlled CHF

features
- CNS, respiratory and systemic symptoms
- visual disturbances

other complications
- retrograde ejaculation

120
Q

what investigation can be performed to ensure that a colonic anastomosis is intact

A

gastrografin enema

121
Q

describe prostate cancer

A

adenocarcinoma most common subtype

most cancers lie in the peripheral zone

more common in the Afro-Caribbean population

investigations
- PSA >4
- multiparametric MRI
- Gleason grading system used

treatment
- watch and wait (low Gleason score)

  • radiotherapy / brachytherapy
  • surgery - radical prostatectomy
    > complications: incontinence, erectile dysfunction, urethral stenosis
  • hormonal therapy
    > LHRH analogues
122
Q

list blood film features in hyposplenism and 2 causes of hyposplenism

A

causes: post-splenectomy, coeliac disease

features
- target cells
- Howell-Jolly bodies
- Pappenheimer bodies
- Siderotic granules
- Acanthocytes

123
Q

describe blood film features of the following conditions
- IDA
- myelofibrosis
- intravascular haemolysis
- megaloblastic anaemia

A

IDA
- target cells
- pencil poikilocytes
- if combined B12/folate deficiency: dimorphic film with mixed microcytic and macrocytic cells

Myelofibrosis
- tear drop poikilocytes

Intravascular haemolysis
- schistocytes

megaloblastic anaemia
- hypersegmented neutrophils

124
Q

describe a gastric volvulus

A

Borchardt’s triad of vomiting, severe epigastric pain and failure to pass NG tube

125
Q

describe the management of transplant rejection

A

hyperacute rejection (minute to hours)
- due to pre-existing antibodies against ABO or HLA antigens
- no treatment is possible - graft must be removed

acute graft failure (<6 months)
- mismatched HLA. Cell-mediated (cytotoxic T cells)
- also caused by CMV
- may be reversible with immunosuppression and steroids

chronic graft failure (>6 months)
- antibody and cell-mediated mechanisms cause fibrosis

126
Q

describe a venous ulcer

A

occur due to the pooling of blood and waste products in the skin secondary to venous insufficiency.

occur in the gaiter area (between the top of the foot and bottom of the calf muscle)

associated with chronic venous changes
- haemosiderin deposits
- venous eczema
- lipodermatosclerosis

Occur after a minor injury to the leg

features
- large and shallow
- irregular, gently sloping border
- more likely to bleed
- less painful than arterial ulcers
- pain relieved by elevation and worse on lowering the leg

management
- compression therapy
- cleaning, debridement and dressing of wound
- pentoxifylline
- analgesia (but avoid NSAIDs)
- Tissue viability / specialist leg ulcer clinics in complex or non-healing ulcers

127
Q

describe an arterial ulcer

A

Occur distally, affecting the toes or dorsum of the foot

associated with peripheral arterial disease
> absent pulses, pallor and intermittent claudication

features
- small and deep
- well defined borders
- “punched-out” appearance
- pale colour due to poor blood supply
- less likely to bleed
- painful
- pain worse at night (when lying horizontally)
- pain worse on elevating and improved by lowering the leg (gravity helps the circulation)

management
- urgent referral to vascular to consider surgical revascularisation

128
Q

describe the areas and muscle movements supplied by the following nerves

  • deep peroneal
  • superficial peroneal
  • tibial
A

deep peroneal
- anterior compartment: tibialis anterior, extensor digitorum longus, peroneus tertius, extensor hallucis longus
> actions: dorsiflexion, inversion, eversion, toe extension,

superficial peroneal
- peroneal compartment: peroneus longus, peroneus brevis
> actions: eversion, plantarflexion

tibial
- posterior compartment: gastrocnemius, soleus, flexor digitorum longus, flexor hallucis longus, tibialis posterior
> actions: plantarflexion, toe flexion, inversion

129
Q

describe inguinal and femoral hernias

A

inguinal hernias
- superior and medial to pubic tubercle
- direct:
> cannot be reduced by pressing on deep inguinal ring
- indirect: exit point is the deep inguinal ring
> can be reduced by pressing on deep inguinal ring
> no reappearance during coughing when covering the deep inguinal ring

femoral hernia
- inferior and lateral to pubic tubercle
- more common in multiparous women
- higher risk of strangulation
- refer for surgical repair within 2 weeks

130
Q

describe total parenteral nutrition (TPN)

A

indications
- flare of inflammatory bowel disease
- short bowel syndrome
- bowel obstruction

TPN is very irritant to veins and can cause thrombophlebitis
> normally given through a central line

complications
- sepsis
- hyperglycaemia / hypoglycaemia
- dehydration and electrolyte imbalances

131
Q

describe testicular cancer and its treatment

A

2 types
> non-seminomas (mostly teratomas - terrible twenties)

> seminomas: sucky sirties

in older men
- interstitial tumour
- lymphoma

investigations
- scrotal USS
- bloods: AFP, bHCG, LDH
- staging CT CAP

common sites of metastasis: lymphatics, lungs, liver, brain

treatment
- radical orchidectomy
- chemotherapy / radiotherapy
- sperm banking for future use

132
Q

describe entonox and its use

A

Entonox is 50% O2 and 50% NO anaesthetic gas
> analgesic equivalent of 15mg morphine SC

often used in sports injuries

Contraindications
- impaired consciousness
- confirmed/presumed pneumothorax

133
Q

describe the ERAS protocol

A

key components

  • pre-operative
    > pre-admission education
    > reduced fasting duration
    » normal fasting: no clear liquids 2h before, no solids 6h before
    > VTE prophylaxis
  • operative
    > active warming
    > opioid sparing
    > avoidance of prophylactic NG tubes and drains
  • post-operative
    > early oral nutrition
    > early ambulation
    > early catheter removal
    > pain and nausea management
134
Q

describe a Hartmanns procedure

A

aka proctosigmoidectomy

emergency procedure involving resection of rectosigmoid colon with closure of anorectal stump and formation of colostomy

> colostomy may be permanent or reversed at a later date

> performed in bowel obstruction due to tumour or significant diverticular disease

134
Q

Describe the WHO surgical safety checklist

A

aim is to reduce the risk of human error

checklist is completed at 3 stages:
> Before induction of anaesthesia
> Before first skin incision
> Before patient leaves theatre

involves multiple members of the team checking essential factors, such as:

  • Patient identity
  • Allergies
  • Operation
  • Risk of bleeding
  • Introductions of all team members
  • Anticipated critical events
  • Counting the number of sponges and needles to ensure nothing is left inside the patient
135
Q

describe the interpretation of ABPI values

A

0.9 – 1.3 is normal
0.6 – 0.9 indicates mild peripheral arterial disease
0.3 – 0.6 indicates moderate to severe peripheral arterial disease
Less than 0.3 indicates severe disease to critical ischaemic

ABPI >1 can indicate vessel calcification common in diabetes

136
Q

name the surgeries used for colorectal tumours depending on their location

A

right hemicolectomy
- caecal, ascending or proximal transverse colon tumours

left hemicolectomy
- distal transverse colon or descending colon

Hartmann’s procedure: sigmoid colectomy with end colostomy formation
> used acutely for sigmoid colon perforation or obstruction

High anterior resection
- tumours of sigmoid colon

Anterior resection
- tumours of the upper rectum

abdomino-perineal excision
- tumours of lower rectum and anal verge

137
Q

describe post-op pain management

A
  • give paracetamol and NSAIDs
  • offer opioid if post-op pain is expected to be moderate-severe
    > oral first-line
    > patient-controlled analgesia (PCA) if cannot tolerate oral
  • if severe respiratory disease, do not offer opioid, instead
    > continuous epidural (can be topped up so better than spinal anaesthesia)
    > epidurals help faster return of normal bowel function
138
Q

describe the management of paralytic ileus

A
  • NG tube insertion + NBM
139
Q

describe maintenance fluid prescription

A

prescribe at 30ml/kg/24hr

round up to 500ml and divide by 24 to find hourly rate e.g. 75kg x 30 = 2250mL in 24h

2500/24 = 93.75ml/hr = 100ml/hr

140
Q

describe the management of diabetes in the perioperative period

A
  • insulin with good glycaemic control undergoing minor procedures: adjust usual insulin regimen
  • insulin with poor glycaemic control or prolonged fasting: VRIII
  • long acting insulin: reduce by 20% on day before and day of surgery
  • metformin: take as normal unless taking three times a day; if so, omit lunchtime dose
  • sulfonylureas:
    > morning surgery: omit morning dose
    > afternoon surgery: omit both doses
  • DPP4i and GLP-1 analogues: take as normal
  • SGLT2i: omit on day of surgery
  • twice daily insulins e.g. Novomix 30, Humulin M3: halve the usual morning dose and leave evening dose unchanged
141
Q

describe pre-operative platelet transfusions

A

aim for platelet levels of
- >50 for most patients
- 50-75 if high risk of bleeding
- >100 if surgery at critical site

142
Q

describe preparation for the following types of surgeries
- thyroid
- parathyroid
- sentinel node biopsy
- thoracic duct
- phaeochromocytoma
- carcinoid tumours
- colorectal cases
- thyrotoxicosis

A
  • thyroid: vocal cord check
  • parathyroid: methylene blue to identify gland
  • sentinel node biopsy: radioactive marker / patent blue dye
  • thoracic duct: cream
  • phaeochromocytoma: alpha and beta blockade
  • carcinoid tumours: cover with octreotide
  • colorectal cases: bowel prep
  • thyrotoxicosis: lugols iodine/medical therapy
143
Q

list risk factors and protective factors for post-op nausea and vomiting (PONV)

A

risk factors
- female gender
- younger age
- use of opioid analgesia
- non-smoker
- previous severe post-operative nausea and vomiting
- ENT surgery
- inhaled anaesthetic gases
- ketamine, midazolam
- prolonged operative time

protective
- propofol
- prophylactic antiemetics
- dexamethasone

144
Q

describe AAA screening

A

single abdominal US for men aged 65

145
Q

describe the appearance of renal stones on X-ray

A

calcium phosphate / calcium oxalate: radio-opaque

cystine: semi-opaque

urate / xanthine: radio-lucent

146
Q

describe the management of acute clot retention

A

clots cause bladder outlet obstruction

management:
continuous bladder irrigation via a 3-way urethral catheter

147
Q

list contraindications to laparoscopic surgery

A
  • acute intestinal obstruction with dilated bowel loops
  • haemodynamic instability / shock
  • raised ICP
  • uncorrected coagulopathy
148
Q

describe chronic urinary retention

A

clinical features
- painless and insidious retention
- higher volumes than acute retention, usually >1L

high pressure retention
- impaired renal function and bilateral hydronephrosis
- typically due to bladder outflow obstruction

low pressure retention
- normal renal function and no hydronephrosis

decompression haematuria may occur after catheterisation

149
Q

when should VTE prophylaxis be given for surgery

A

6-12h after surgery

150
Q
A

Phase 4 (14 decks)

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