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AMC MCQ > Surgery > Flashcards

Surgery Flashcards

1
Q

Autosomal dominant diseases

A
  • Familial adenomatous polyposis
  • Peutz Jeghers syndrome
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2
Q

Autosomal recessive diseases

A

Gilbert’s syndrome

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3
Q

Liver damage enzymes

A
  • ALT 0 - 45 U/L
  • ALP 25–100 U/L
  • AST <40 U/L
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4
Q

Liver function enzymes

A

Bilirubin
- <20 μmol/L (total)
- <3 μmol/L (direct)
Albumin:
- 38–50 g/L
- ALT ( liver specific)
- AST

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5
Q

Normal lipase & amylase levels

A

Lipase: <100 U/L
Amylase: 30–110 U/L

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6
Q

Category 1 Colorectal cancer risk

A

Low risk

1 1st degree relative > 60 years at dx

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7
Q

Category 1 Colorectal cancer SCREENING

A
  • iFOBT every 2 years after 45 to 74 years
  • low-dose (100 mg) aspirin daily should be considered from age 45 to 70 yo
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8
Q

Category 2 Colorectal cancer RISK FACTORS

A

MODERATE RISK

One 1st degree relative < 60 years at diagnose

OR

One 1st degree relative + > 1 2nd degree diagnosed at any age

OR

Two 1st degree relatives diagnosed at any age

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9
Q

Category 2 Colorectal cancer SCREENING

A
  • Colonoscopy every 5 years starting at 10 years younger than the earliest age of diagnosis in 1st degree relative

OR age 50, whichever is earlier, to age 74.

  • CT colonography if clinically indicated (colonoscopy 3 months unsatisfactory)
  • Low dose aspirin (100mg)
  • Update history
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10
Q

Category 3 Colorectal cancer RISK FACTORS

A

HIGH RISK
Two 1st degree relatives + One 2nd degree relative diagnosed < 50 yo

OR

Two 1st degree relatives + > Two 2nd degree relatives diagnosed at ANY age

OR

> Three 1st degree relatives diagnosed at ANY age

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11
Q

Category 3 Colorectal cancer SCREENING

A
  • iFOBT every 2 years after 35 to 45 years
  • Colonoscopy every 5 years starting at 10 years younger than the earliest age of diagnosis of colorectal cancer in a first-degree relative
    OR
    age 40, whichever is earlier, to age 74.
  • CT colonography if clinically indicated (colonoscopy 3 months unsatisfactory)
  • Low dose aspirin (100mg)
  • Update history
  • Refer to cancer clinic
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12
Q

Elective non-cardiac surgery following PCI

A

Defer surgery for 6 weeks - 3 months

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13
Q

Elective surgery with history of drug eluding stents

A

Defer for 12 months

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14
Q

emergency surgery with history of drug eluding stents

A

Withhold clopidogrel for 5-7 days
- continue aspirin

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15
Q

Clinical features of cholangitis
(Charcot’s triad)

A

fever with chills + upper abdominal pain + jaundice

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16
Q

Raynaud’s pentad (Cholangitis)

A

fever with chills + upper abdominal pain + jaundice + sepsis + confusion

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17
Q

Cholangitis initial investigation

A

US

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18
Q

Cholangitis best investigation

A

ERCP (diagnostic & therapeutic)

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19
Q

Cholangitis treatment

A
  1. Fluids
  2. NPO
  3. Analgesics
  4. Antibiotics IV: Gentamycin + Amoxicillin. (If chronic add metronidazole.)
  5. ERCP: Urgent decompression in
    >70yo, DM, comorbid conditions.
  6. Percutaneous cholecystostomy: If
    pt is not fit for Qx and can’t take pt
    off medications. It’s a temporary
    drainage that relieves symptoms
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20
Q

Clinical features of post-cholecystectomy Syndrome

A
  • Diarrhoea (MC symptoms)
  • abdominal pain
  • nausea
  • jaundice
  • bloating
  • dyspepsia

Cause: incomplete surgery or operative complications.

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21
Q

post-cholecystectomy initial investigation

A

US

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22
Q

post-cholecystectomy best investigation

A

ERCP w/ biliary manometry

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23
Q

Clinical features of appendicitis

A
  • Murphy’s triad:
    1. Abdominal Pain: Periumbilical or epigastric pain migrating to the right lower quadrant of the abdomen.
    2. Nausea / Vomiting.
    3. Fever.
  • Retrocecal: Loin tenderness,
    psoas sign (Pain on passive extension of the right thigh)
  • Pelvic: Diarrhoea, tenderness
    on DRE, obturator sign (pain on passive internal rotation of the flexed right thigh).
    1st Ix: US of the pelvis.
    Best Ix: Appendiceal CT.
  • Rovsing Sign: Pain in RIF when
    palpation LIF.
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24
Q

Acute Pancreatitis -cause

A

G: Gallstones
E: Ethanol – alcohol
T: Trauma
S: Steroids
M: Mumps – malignancy
A: Autoimmune
S: Scorpion stings – spider bites
H: Hyperlipidaemia – hypercalcaemia
E: ERCP
D: Drugs

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25
Q

Appendicitis initial investigation

A
  1. WBC: Leukocytosis.
  2. Pelvic US: Noncompressible tubular structure of 7-9 mm in diameter.
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26
Q

Appendicitis best investigation

A
  1. CT in adults
  2. USG in pregnant women/children
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27
Q

Appendicitis management

A
  1. Atb: Genta+Metro+Amoxi
  • Genta CI: Ceftriaxone+Metro or
    Amoxi+clavulanate
  • Penicilin CI: Genta+Clinda
  1. Laparoscopic > Open Qx
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28
Q

Appendiceal cancer treatment

A
  • Do nothing If only in mucosa.
  • If they are a bit more bigger
    then right hemicolectomy
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29
Q

Clinical features of Perforated Peptic Ulcer

A
  • Epigastric pain that doesn’t radiate to back
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30
Q

Perforated Peptic Ulcer initial investigation

A
  1. X-ray (Free gas under diaphragm)
  2. Gastrograffin swallow or meal to identify where the perforation is
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31
Q

Perforated Peptic Ulcer best investigation

A
  1. CT Scan
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32
Q

Perforated Peptic Ulcer treatment

A
  1. Pain relief
  2. NGT
  3. Atbs (which ones?)
  4. Immediate laparotomy
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33
Q

Clinical features of Peritonitis

A
  • Board like rigidity with guarding, no abd distension (reduced bowel sounds)
  • Normal first, then tachycardia, then shock
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34
Q

Peritonitis treatment

A
  1. Genta+Metro+Amoxi
  • Genta CI: Piper Tazo
  • HS to penicilin: Genta+Clinda.
  1. Switch to oral Amoxi+Clavulanate
    for 5d
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35
Q

Clinical features of Acute Pancreatitis

A
  • Epigastric pain that goes to the back
  • Pt feels better bending forward
  • Lack of guarding, rigidity, or rebound
  • Reduced bowel sounds
  • Fever
  • Tachycardia
  • Shock
  • Follows an alcohol binge
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36
Q

Clinical features of severe necrotizing hemorrhagic pancreatitis

A

Cullen sign (superficial edema and bruising around the umbilicus)

Grey turner sign (bruising of the flanks/loins)

Polyarthritis.

Earliest Complications:
Renal failure bc hemorrhage
and ARF

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37
Q

Acute Pancreatitis Causes

A
  1. Gallstones
  2. Ethanol
  3. Trauma
  4. Steroids
  5. Mumps
  6. Autoimmune
  7. Scorpion stings
  8. Spider bites
  9. Hyperlipidaemia
  10. ERCP
  11. Drugs
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38
Q

Acute pancreatitis, Complications:

A
  • Pseudocyst
  • Infected abscess/pseudocyst
  • Pancreatic necrosis
  • Pancreatic cancer
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39
Q

Acute Pancreatitis Initial investigation

A
  1. Lipase (Most sensitive and specific)
    and amylase
  2. Abdominal X-ray:
  • Colon cutoff sign: Dilation of ascending and transverse that abruptly finishes at splenic flexure.
  • Sentinel loop: One or two isolated distended loops of the small bowel.
  1. Abdominal US: Peripancreatic fluid
  2. Abdominal CT: Specific for complications (necrosis, infection, pseudocyst and absesse)
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40
Q

Acute Pancreatitis Initial Management

A
  1. Admit to hospital
  2. NPO
  3. Bed rest
  4. NG suction
  5. IV fluids
  6. Analgesics: Morphine IV
  7. ERCP if obstructive LFTs (MCC of
    acute bile duct obstruction in tertiary hospitals)
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41
Q

Acute Pancreatitis ATBs Indications

A

Only if infected:

  • Pancreatic necrosis
  • Pancreatic abscess.

Empirical: Piper-Tazo IV for 7d.

Allergic to penicillin:
Ceftriaxone+Metro

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42
Q

Acute Pancreatitis Surgery Indications

A
  1. Abscess
  2. Infected pseudocyst
  3. Necrosis
  4. Gallstone-associated pancreatitis
  5. Uncertain in clinical dx
  6. Worsening condition despite tx
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43
Q

Glasgow Score

A

P – Pa02 < 8 KPa
A – Age > 55
N – Neutrophils (WBC > 15)
C – Calcium < 2
R – uRea >16
E – Enzymes (LDH > 600 or AST/ALT >200)
A – Albumin < 32
S – Sugar (Glucose >10)

to access the severity of a pancreatitis

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44
Q

Clinical features of Pancreatic pseudocyst

A
  • Mass in epigastric area in context of pancreatitis
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45
Q

Pancreatic pseudocyst treatment

A

≤4 cm: Observation.

≥5 cm: Endoscopic cyst gastrostomy.

ERCP:
- size > 6cm
- Present for > 6 weeks
- Wall thickness for > 6 mm

Laparotomy:
- ERCP fails.
- Pseudoaneurysm or complicated pseudocyst.

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46
Q

Clinical features of Chronic Pancreatitis

A
  • Alcohol consumption
  • Epigastric pain
  • Weight loss
  • Loss of pancreatic function
  • Diarrhoea
  • Steatorrhea

Serum amylase and lipase and often normal

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47
Q

Chronic Pancreatitis initial investigation

A
  1. CT Scan
  2. US to detect
    obstruction by stone or
    stricture
  3. MRCP (Most
    sensitive)
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48
Q

Chronic Pancreatitis treatment

A
  1. Analgesia: PCM, codeine
  2. Pancreatic enzyme supplements
  3. Tx DM
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49
Q

Gallbladder dilatation, what investigation to do?

A

US

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50
Q

Clinical features of Pancreatic Cancer

A
  • Painless obstructive progressive jaundice
  • Dark urine.
  • Steathorrhoea.
  • Trousseau Syndrom: Recurrent, migratory thrombosis in superficial veins on uncommon sites, such as the chest wall and arms; besides increased thrombus.
  • Superficial thrombophlebitis: Caused by IV infusion (NSAIDs) or
    spontaneous: LMWH for 4w
  • Courvoisier sign: Enlarged gallbladder bc obstruction.
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51
Q

Pancreatic Cancer Risk Factors

A
  1. Smoking
  2. DM
  3. Chronic pancreatitis
  4. Obesity
  5. Inactivity
  6. Non–O blood group
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52
Q

Pancreatic Cancer initial investigation

A
  1. US
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53
Q

Pancreatic Cancer best investigation

A
  1. CT scan with contrast
  2. ERCP if concurrent
    cholangitis
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54
Q

Pancreatic Cancer treatment

A
  1. Pancreaticoduodenectomy (Whipple)
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55
Q

Peri-ampullary Tumors Types

A
  1. Pancreatic ductal adenocarcinoma: - Pancreatic head tumor (most common)
    - Uncinate process tumor
  2. Cholangiocarcinoma
  3. Ampullary tumors (from the ampula of Vater)
  4. Periampullary duodenal carcinoma
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56
Q

Clinical features of Common Bile Duct (CBD) Obstruction

A
  1. Progressive obstructive jaundice
    - pale stools (steatorrhoea)
    - dark urine
  2. Palpable mass (distended gallbladder) in the right upper quadrant that moves with respiration (can be tender or non-tender)
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57
Q

Causes of Common Bile Duct (CBD) Obstruction

A
  1. Stones (most common)
  2. Strictures (injury during surgery)
  3. Periampullary tumors (arise within 2cm of the ampula of Vater)
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58
Q

Clinical features of Pyloric stenosis

A

ADULTS:

  • Non-bilious vomiting occuring intermittently WITHIN 1 HOUR of a meal and contains undigested food particles.

-Bloating.

-Weight loss.

-Decrease appetite.

-Epigastric pain.

CHILDREN:

  • Typically forceful non- bilious vomiting occuring immediately after feeding.
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59
Q

Clinical features of Small Bowel Obstruction (SBO)

A
  • Noisy abdomen (sharp bowel sounds).

– Severe colicky epigastric and periumbilical pain.

– Absolute constipation.

– Nausea and vomiting.

  • High SBO: Mainly pain and dehydration.
  • Low SBO: Mainly distension.
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60
Q

Small Bowel Obstruction Causes

A
  1. Adhesions.
  2. Tumours
  3. Hernias (incarcerated).
  4. Strictures (eg. caused by Crohn’s disease)
  5. intussusception
  6. Bezoars
  7. Gallstone ileus
  8. Superior mesenteric artery syndrome
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61
Q

Small Bowel Obstruction (SBO) initial investigation

A
  1. X-ray erect abdomen (Step ladder air-fluid levels, coin sign)
  2. Gastrograffin meal (Dx and tx)
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62
Q

Small Bowel Obstruction (SBO) best investigation

A

CT

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63
Q

Small Bowel Obstruction (SBO) treatment

A
  1. IV fluids
  2. NGT
  3. Gastrograffin follow through
  4. Laparotomy to remove obstruction
    - Ileotomy & extraction: Best for SBO
    in long hx of cholecystitis
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64
Q

Clinical features of Large Bowel Obstruction (LBO)

A
  1. Distension
  2. Mild pain
  3. Increased bowel sounds
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65
Q

Large Bowel Obstruction Causes

A
  1. Colon Cancer
  2. Sigmoid volvulus (elderly).
  3. Fecal impaction (+ stools on DRE)
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66
Q

Large Bowel Obstruction (LBO) initial investigation

A
  1. X-ray (Irregular haustral folds)
  2. Gastrograffin enema
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67
Q

Large Bowel Obstruction (LBO) best investigation

A
  1. CT scan (Best)
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68
Q

Large Bowel Obstruction (LBO) treatment in steps

A
  1. IV fluids
  2. NGT
  3. Gastrograffin enema
  4. Surgery
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69
Q

Clinical features of Paralytic ileus

A

No pain, no noise, absolute constipation and distension.

Nausea and vomiting.

When solved, accumulated fluid will be reabsorbed and increase diuresis

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70
Q

Paralytic ileus Causes

A

PostQx (resolves after 24–48 h)

Infection (Peritonitis)

Electrolyte imbalance (hypoK [diuretics], hypoCa)

Opioids

Inflammatory bowel diseases (IBD) or diverticulitis

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71
Q

stuttering episodes of nausea and vomiting + air in the biliary tree + hyperactive bowel sounds + dilated loops of bowels

A

gallstone ileus

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72
Q

Clinical features of Sigmoid Volvulus

A
  • It’s a LBO
  • Tympanic abdomen, colicky abd pain, empty rectum.
  • Common in elderly w/ use of laxatives of hx of constipation, or bedridden
  • Parkinson
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73
Q

Sigmoid Volvulus initial investigation

A
  1. X-ray:
  • Coffee bean or jelly bean sign.
  • Dilated U-shaped colon with a cut-off point at the site of obstruction.
  • Distention of the small bowel with air-fluid levels and decompressed colon distal to the point of volvulus.
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74
Q

Sigmoid Volvulus best investigation

A
  1. CT Scan
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75
Q

Sigmoid Volvulus treatment

A
  1. Sigmoidoscopy to relieve pressure
  2. Qx
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76
Q

Caecal Volvulus initial investigation

A

X-ray (dead fetus sign)

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77
Q

Clinical features of Caecal Volvulus

A

Abdominal pain

Constipation/obstipation

Nausea/vomiting

Tympanitic and markedly distended abdomen (more impressive than other causes of bowel obstruction)

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78
Q

Caecal Volvulus best investigation

A

CT Scan

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79
Q

Caecal Volvulus Treatment

A

Right Hemicolectomy???

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80
Q

Clinical features of Pseudo-obstruction

A
  1. Oglivie’s syndrome: Acute colonic pseudo-obstruction (ACPO) without mechanical obstruction. Massive colon dilatation (> 10 cm) usually involves the cecum and right hemicolon, although occasionally colonic dilation extends to the rectum.

Symptoms:
- Abdominal pain and distension.
- Anorexia.
- Nausea and vomiting.
- Bloating and gas.
- Constipation and/or diarrhea.

  1. Assoc w/ Anti-parkinsonian
    drugs, parkinsonisms (Hx of falls), opioids, CCB.
  2. Seen in elderly who are very
    sick
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81
Q

Pseudo-obstruction treatment

A
  1. Neostigmine
  2. Colonoscopic decompression
  3. Laparotomy
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82
Q

Pseudo-obstruction initial investigation

A

X-ray ??

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83
Q

Pseudo-obstruction BEST investigation

A

CT Scan ??

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84
Q

Indications for splenectomy

A
  • Trauma
  • Spontaneous rupture (mononucleosis)
  • Hypersplenism (ITP)
  • Neoplasia
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85
Q

Splenic Injury Complications

A

Infections:

  1. Pneumococcus.
  2. Haemophilus influenzae.
  3. Neisseria.
  4. Malaria.
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86
Q

Splenic Injury Initial investigation

A

FAST Scan is in hemodynamically
unstable pt and not in children

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87
Q

Splenic Injury best investigation

A

CT is the preferred modality
for adults and children with
abdominal blunt trauma

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88
Q

Splenectomy Prophylaxis Treatment

A

Amoxi OR phenoxymethylpenicillin

  1. 2 years after splenectomy.
  2. Until 5 years old in children w/ SCD or congenital hemoglobinopathy (thalassemias, sideroblastic and dyserythropoietic anemia).
  3. After sepsis episode for 6 months
  4. Lifelong for Pts that:
  • Survived post-splenectomy inf (recurrent sepsis)
  • Immunocompromised.
  • Had hematological malignancy.
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89
Q

Splenectomy + Sore Throat ATB Treatment

A

<2 years since splenectomy:
1. Amoxi Oral

> 2 years:
1. Reassure and observe.
2. Fever = Amoxi

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90
Q

bariatric surgery indications

A

– BMI above 40 with no co-morbidities

– BMI above 35 with co-morbidities such as hypertension

– BMI above 30 with poorly controlled type 2 diabetes

– BMI above 30 with increased cardiovascular risk due to multiple risk factors such as hypertension, hyperlipidaemia, strong family history of cardiovascular disease at a young age

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91
Q

bariatric surgery contraindications

A

– Irreversible end-organ dysfunction.

– Cirrhosis with portal hypertension.

– Medical problems precluding general anesthesia???

– Centrally mediated obesity syndromes such as Prader-Willi or Craniopharyngioma.

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92
Q

Clinical features of Dumping syndrome

A

early ( 15-30 min)
* abdominal pain
* osmotic diarrhoea
* bloating nausea
* flush/palpitation

late ( 1-3 hours after meal)
* hypovolaemia
* weakness sweating, dizziness

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93
Q

Dumping syndrome Management

A
  1. conservative/ small simple meals
  2. re op
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94
Q

Clinical features of Gouverneur’s Sx
(vesicointestinal fistula)

A
  • Suprapubic pain
  • Frequency
  • Dysuria
  • Tenesmus
  • Pneumaturia
  • Fecaluria
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95
Q

Gouverneur’s Sx Treatment
(vesicointestinal fistula)

A
  1. Hospitalization
  2. Correct fluids
  3. Diazepam
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96
Q

Clinical features of Pilonidal sinus

A
  • Nest of hairs in hirsute young
    men, cyst or abscess
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97
Q

Pilonidal sinus Treatment

A
  1. Qx
  2. Atbs only if cellulitis is present

-Recurrent: Shave the area and keep it clean

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98
Q

Clinical features of Haemorrhoids (Piles)

A
  • Cx: Constipation.
  • Internal: Bleeding, prolapse, mucoid
    discharge.
  • External: Thrombosis.
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99
Q

Internal Haemorrhoids Stages

A

I above the dentate line

II only during straining

III requires manual replacement

IV prolapse, cannot be reduced

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100
Q

Internal Haemorrhoids Treatment

A

Prevention:
Fiber and fluids to avoid
constipation.

Stage I and II: Conservative tx

Stage III and IV: Refer for rubber
band ligation

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101
Q

External hemorrhoids treatment

A

Thrombosed external hemorrhoid OR perianal hematoma.

within 24 hours of the onset = aspiration of fluid consistency hematoma with large bore needle without local anesthesia.

Between 24 hours to day 5 = A simple incision under local anesthetic over the hematoma with deroofing with a scissor.

After day 6 and onwards, the hematoma is best left alone unless it is very tense, painful, or infected.

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102
Q

Clinical features of Anal Fissure

A
  • Most fissures are at 6 o’clock.
  • Anal pain worse with defecation and small bright red blood from rectum.
  • MCC of bleeding per rectum in
    2,5 yo child.
  • Severe excruciating pain after
    30 mins of pooing + bleeding in
    toilet paper.
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103
Q

Anal Fissure Treatment

A

Acute
- Adults: Glyceryl trinitrate (topic)
- Kids: Anusol 1st, then laxatives.

Chronic
1. Local inj. Of botulinum toxin
2. Qx

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104
Q

Treatment of anal fissure with Crohn’s

A

infliximab

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105
Q

Most common cause of perianal fistula in Crohn’s

A

abscess

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106
Q

Most common cause of multiple or recurrent anal fistulae

A

Crohn’s

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107
Q

Cause of low-lying fistula

A

Crohn’s

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108
Q

Clinical features of Proctalgia fugax

A

Brief self-limited episodes of
sudden short attacks of intense
stabbing pain in the anal sphincter

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109
Q

Proctalgia fugax Management

A

Reassurance

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110
Q

Clinical features of Diverticulitis

A
  • Acute left iliac fossa pain.
  • Increases with change in posture.
  • Tenderness
  • Guarding.
  • Rigidity in LIF.
  • Fever.
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111
Q

Diverticulitis Complications

A
  1. Bleeding (MCC of acute bleeding from large bowel)
  2. Perforation (high mortality)
  3. Fistulas
  4. Abscess
  5. Peritonitis
  6. Intestinal obstruction
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112
Q

Clinical features of Diverticulitis Perforation

A
  1. Abdominal distention
  2. Diffuse tenderness of the abdomen even to light Guarding
  3. Rigidity
  4. Rebound tenderness
  5. Absent bowel sounds
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113
Q

Diverticulitis First Investigation

A

WBC

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114
Q

Diverticulitis Best Investigation

A

CT Scan with oral contrast (To detect fistula, abscess, or perforation)

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115
Q

Diverticulitis Treatment

A
  1. Hospital admission, NPO,
    analgesics.
  2. Atbs:
    - Mild: Amoxy+Clavulanate for 5d
    - Severe: Amoxy + Genta + Metro IV
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116
Q

Indications of Surgery for Diverticulitis

A

Perforation

Abcses

Peritonitis

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117
Q

Diverticulitis Follow up

A

Colon cancer screening

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118
Q

Clinical features of Anorectal abscess

A

Pain caused by inf of anal
glands (above dentate line,
lubricate the poo)

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119
Q

Anorectal abscess Treatment

A
  1. Urgent surgical drainage
  2. Atb:
    - Mild: Amoxi/Clav
    - Severe: Amoxy+Genta+Metro
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120
Q

Clinical features of Perianal Abscess

A
  • Severe, constant, throbbing pain
  • Fever and toxicity
  • Hot, red, tender swelling adjacent to anal margin
  • Non-fluctuant swelling
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121
Q

Parianal abscess vs perianal haematoma

A
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122
Q

Perianal Abscess Treatment

A
  1. Incision under local anesthesia
  2. Atbs
    - metronidazole 400 mg (o) 12 hourly for 5–7 days
    PLUS
    - cephalexin 500 mg (o) 6 hourly for 5–7 days
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123
Q

Clinical features of Perianal Anorectal Fistula

A
  • Hx of Crohn’s,
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124
Q

Perianal Anorectal Fistula Treatment

A
  1. Draining abscess, lay open fistula.
  2. Refer
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125
Q

Hiatal Hernia First Investigation

A

X-ray

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126
Q

Hiatal Hernia Best Investigation

A

Barium X-ray

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127
Q

Clinical features of Incarcerated hernia

A

No pain, no tenderness, no
cough impulse
?????????

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128
Q

Incarcerated hernia Treatment

A

Emergency Surgery

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129
Q

Clinical features of Indirect Inguinal hernia

A
  • Does not touch midline.
  • Goes to testicle (Examiner finger cannot get above swelling bc the hernia is there).
  • More chance to strangulate
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130
Q

Clinical features of Direct Inguinal hernia

A
  • Touches the midline.
  • Less change to strangulate
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131
Q

Inguinal hernia Treatment

A

Birth-6w: Qx in 2d

6w-6m: Qx in 2w

> 6m: Qx in 2m

Irreducible: Urgent Qx

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132
Q

Clinical features of Femoral hernia

A
  • Does not touch midline.
  • Lateral to pubic tubercle.
  • Most likely to strangulate.
  • VAN looking from up to down
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133
Q

Femoral hernia Treatment

A

Qx ASAP bc likely to strangulate

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134
Q

Hernia is LEAST likely to strangulate

A

Direct inguinal hernia

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135
Q

Hernias is MORE likely to strangulate

A
  1. Femoral (most important)
  2. Incisional
  3. Umbilical
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136
Q

Clinical features of Epigastric hernia

A

Pt lies supine and cough and
protrudes but doesn’t move
umbilicus

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137
Q

Epigastric hernia Treatment

A

Qx if > 6 months old

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138
Q

Clinical features of Diastasis Recti

A

Pt lies supine and coughs and
protrudes and moves the umbilicus.

Happy face.

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139
Q

Diastasis Recti Treatment

A
  1. Physio
  2. Qx
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140
Q

Causes of Post-Operative Fever

A

24 hours: Atelectasis

3-5d: Pneumonia, sepsis,
wound inf, abscess, DVT

> 5d: Specific comp of Qx:
Bowel anastomosis, fistula,
wound inf

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141
Q

Post-Operative Fever Treatment

A

Fever at 7d PostQx

  • Superficial: Remove suture, no atbs
  • Cellulitis but no fluctuance: Atbs (which??)
  • Cellulitis, fluctuance: Abscess.
    1. Drain.
    2. Atbs (which??)
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142
Q

Post-surgical Confusion

A

Often secondary to hypoxia.

Causes:

  • Chest infection
  • Over-sedation
  • Cardiac problems
  • Pulmonary embolism
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143
Q

Post-surgical Confusion First Investigation

A
  1. Oxygen saturation.
  2. Blood gases.
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144
Q

Tx of Atelectasis

A
  1. Chest Physio.
  2. Supplemental Oxygen.
  3. Postural drainage w/ bronchoscopy while pt is on CPAP.
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145
Q

Clinical features of Salivary Stone

A

Pain increase after eating

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146
Q

Salivary Stone First Investigation

A

X-ray (80% of
submandibular calculi
are radio-opaque)

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147
Q

Salivary Stone Treatment

A

Excision or Sialendoscopy

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148
Q

Clinical features of Sialadenitis Suppurative

A

MC germ: Staph Aureus.

  • Painful swelling: Glands
    enlarged, hot, tense, with pus.
  • Does not affect facial nerve.
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149
Q

Clinical features of Submandibular
abscess

A
  • Cx by Mycobacterium avium.
  • Painless, cold, abscess that starts
    as lymph node enlargement for
    4-6w at 1-2yo
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150
Q

Submandibular
abscess Treatment

A

Excision of abscess & lymph node

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151
Q

Clinical features of Parotid Gland Tumour

A

Compression of VII CN = Peripheral Facial Paralysis

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152
Q

Parotid Gland Tumour FIRST Investigation

A
  1. CT
  2. MRI
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153
Q

Parotid Gland Tumour BEST Investigation

A

FNA w/ biopsy

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154
Q

Clinical features of Pleomorphic adenoma

A

Affects the salivary glands, particularly parotid glands.

Takes 5-10 years to grow.

Does not cause facial nerve palsy

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155
Q

pleomorphic adenoma BEST Investigation

A

Needle biopsy

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156
Q

pleomorphic adenoma Treatment

A

Surgical excision

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157
Q

Clinical features of Adenoid cystic
carcinoma

A

Painless

Peripheral facial nerve palsy

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158
Q

Adenoid cystic carcinoma BEST Investigation

A

Needle biopsy

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159
Q

Adenoid cystic carcinoma Treatment

A

Surgical excision

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160
Q

Neck Lumps FIRST Investigation

A

CT Scan if suspicion
of neoplasm (>2cm,
fixed, hard, non-tender)

US if suspicion of
inflammatory process
(<2cm, mobile, squishy,
tender)

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161
Q

Neck Anterior Triangle Lumps

A

BCC

  • Branchial cyst: 20-40yo, can get
    infected. Tx: excision
  • Carotid body tumour: Pulsatile
    mass that moves laterally. Tx: Excision
  • Carotid aneurysm
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162
Q

Neck Posterior Triangle Lumps

A

CCP

  • Cystic Hygroma. Transluminal
    mass. Tx Surgery
  • Cervical Rib
  • Pancoast Tumour
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163
Q

Midline Neck Lumps

A

TTD

  • Thyroid Nodule. Next: TSH
  • Thyroglossal duct: Moves
    upwards with protrussion of
    tongue
  • Dermoid cyst: Teratoma
164
Q

Suggested AAA surveillance (w/
US) of Abdominal Aortic
Aneurysm

A

3.0-3.9 cm: e/ 24m

4.0-4.5 cm: e/ 12m

4.6-5.0 cm: e/ 6m

≥5.1 cm: e/3m

If 1st degree rel has it, 20% risk
of getting it. Arrange yearly US from 50yo.

165
Q

Clinical features of Abdominal Aortic
Aneurysm (Ruptured)

A
  • Sudden abd. pain radiating to back.
  • Syncope.
  • Shock.
  • Pulsatile tender abd mass.
  • Gross haematuria
166
Q

Abdominal Aortic Aneurysm FIRST Investigations

A

Screening: US

Emergency: FAST US
- Next bedside ix for ruptured.
- Not reliable in kids bc low volume.
- If it’s positive >800mL fluid loss.

167
Q

Abdominal Aortic Aneurysm BEST Investigations

168
Q

When to refer an Abdominal Aortic
Aneurysm?

A
  • Male w/ AAA >5.5cm
  • Female w/ AAA >5.0cm
  • Male or female in thoracic aortic
    and aortic iliac aneurysms >3.5cm
  • Rapid growth >1cm/year
  • Symptomatic (abdominal, flank, or back pain) AAA = independently of
    the size
169
Q

Abdominal Aortic Aneurysm Treatment

A
  1. No ruptured:
    - Referral to vascular Qx
    - Open repair or endovascular repair
  2. Ruptured:
    IV line (Colloids), not crystalloid
    (NS) bc will dilute coagulation factors, more bleeding.
170
Q

Mortality rate of a ruptured abdominal aortic aneurysm

A

About 80%.

171
Q

Clinical features of Aortic Dissection

A
  • Abrupt chest pain, sharpen,
    migrating / irradiating to the
    back.
  • Unequal or absent pulses.
  • Difference of BP in arms (more than 20mmHg).
  • Diastolic murmur if AR occurred.
172
Q

Aortic Dissection Types

A
  • Type A: Ascending aorta.
  • Type B: Descending aorta.
173
Q

Aortic Dissection FIRST Investigation

A

Transesophageal Echocardiogram

174
Q

Aortic Dissection BEST Investigation

A

CT angiogram

175
Q

Aortic Dissection Treatment

A
  1. BB (to reduce shear stress)
  2. Immediate Qx for type A
    (ascending aorta)
176
Q

Cholelithiasis Treatment

A

Surgery if stones ≥3cm or porcelain
gallbladder

177
Q

Cholelithiasis BEST Investigation

178
Q

Clinical features of Cholecystitis

A

Fever + Jaundice + Murphy’s sign (localized tenderness over
gallbladder)

179
Q

Cholecystitis Types

A
  1. Calculous (90%) caused
    by E. coli (in unstable pts) and
    Kepsiella.
  2. Acalculous (10%)
    emphysematous gallbladder
180
Q

Cholecystitis BEST Investigation

A

HIDA Scan (If the US is not
conclusive)

181
Q

Cholecystitis FIRST Investigation

A

US: Most useful initial
ix for the detection of
gallstones and dilation
of the common bile duct

182
Q

Cholecystitis Treatment

A

Bed rest, IV fluids, NPO, analgesia,
Antibiotics:

  1. Empiric of calculous

Gentamicin IV + Amoxi
- Genta CI: Clavulanate+Amoxi

  1. Empiric of acalculous

Genta+Metro+Amoxi
- Genta CI: Piper+Tazo

183
Q

Pathogen responsible for cholecystitis?

184
Q

when to choose ERCP or cholecystectomy in an acute cholecystitis px?

A

cholecystectomy:
- within 72 hours
- without contraindications
- gallstone pancreatitis
- common bile duct not dilated

ERCP:
- common bile duct is dilated
- elevated ALP

185
Q

Clinical features of Mesenteric Ischaemia

A
  • Context of a patient with: Thrombosis or Embolus from AF.
  1. Central abdominal pain.
  2. Tenderness, rigidity, and absent bowel sounds.
  3. Vomiting with bloody diarrhea.
  4. Confusion
186
Q

Mesenteric Ischaemia risk factors

A
  • Atherosclerosis (acute on chronic)
  • Embolic source (thrombus, vegetations)
  • Hypercoagulable disorders
187
Q

Mesenteric ischaemia lab findings

A
  • Leukocytosis
  • Elevated amylase & phosphate levels
  • Metabolic acidosis (elevated lactate)
188
Q

Mesenteric Ischaemia FIRST Investigation

A

X-ray: Thumbprinting (bowel-wall thickening due to edema)

189
Q

Mesenteric Ischaemia BEST Investigation

190
Q

Mesenteric Ischaemia Treatment

A

Resection of the necrosed gut.

191
Q

severe periumbilical pain + tenderness + vomiting & diarrhoea + diminished/no bowel sounds + AF/atherosclerosis

A

Acute mesenteric ischaemia

192
Q

diffuse tenderness + rebound tenderness (diffuse peritonitis) + few weeks hx of postprandial pain

A

mesenteric ischemia

193
Q

Clinical features of Pseudoaneurysm

A

Hematoma, painful pulsatile
groin mass.

194
Q

Pseudoaneurysm FIRST Investigation

A

Duplex Doppler US

195
Q

Pseudoaneurysm Treatment

A

US-guided thrombin injection

196
Q

Carotid Artery Stenosis Treatment

A
  1. Aspirin
  2. Statin
  3. Endarterectomy Indications:

> 50 and symptomatic
or
70 and asymptomatic

197
Q

Clinical features of Carotid haematoma

A
  • Complication of carotid endarterectomy (CEA).
  • Progressive and quick SOB.
198
Q

Carotid haematoma Treatment

A

Open wound layers in the ER room.

  • Unstable: Intubation
199
Q

Clinical features of Retroperitoneal
hematoma

A

Traumatic (unstable pelvis) or spontaneous (warfarin tx or post-PCI)

Sudden onset of flank or abdominal pain with fullness, and guarding.

Hypotension / Hypovolemic shock (syncope, pallor, and dizziness).

Femoral neuropathy: Pain that radiates from the back and hips into your legs (radicular pain). Leg, ankle or foot numbness, weakness, tingling, paralysis or pain.

200
Q

Retroperitoneal hematoma investigation

A

Contrast-enhanced CT-scan

201
Q

Retroperitoneal Hematoma Treatment

A

Traumatic: Laparotomy.

Spontaneous:

  1. Vit K IV bc besides being the tx of
    warfarin overdose, you can also give
    heparin
  2. Prothrombinex
  3. FFP
202
Q

Risk assessment of venous thromboembolic events (VTE)

A
  • Major surgery: any intra-abdominal operation and all other operations lasting more than 45 minutes
  • Infectious diseases, varicose veins, obesity or general immobility
  • Deficiency of antithrombin, protein C, protein S, Factor V Leiden mutation, hyperhomocysteinemia, and prothrombin 20210A
203
Q

Clinical features of Acute Lower limb
ischemia

A
  • Context of a patient with: Thrombosis (most common cause) or Embolus from AF.
  1. Acute onset of progressive PAIN:
  • Calf: Common femoral art / Superficial femoral art (MC site of occlusion).
  • Buttock: Common
    iliac/external iliac Thrombosis.
  1. Pulselessness.
  2. Pallor.
  3. Paresthesia.
  4. Paralysis:
  • Foot drop = Peroneal nerve paralysis.
  • Most reliable sign requiring Emergency Qx intervention.
204
Q

Acute Lower limb ischemia FIRST investigation

A
  1. Doppler US
  2. CT angiogram (Emergency Qx intervention)
205
Q

Acute Lower limb ischemia BEST investigation

A

Digital subtraction arteriography or just arteriography

206
Q

Acute Lower limb ischemia Treatment

A

Golden time: 4 hrs

  1. IV Unfractionated Heparin: 5000 IU then 1250IU/hour. APTT guides further adjustment.
  2. Surgical treatment:
  • Embolectomy: Can cause
    reperfusion injury (HyperK, metab
    acid, myoglobinuria, increased CK).
    Keep pt hydrated and perfused.
  • Arterial bypass is helpful if it is chronic limb ischemia.
  • Amputation is required only if there are irreversible ischemic changes.
  1. After acute, give warfarin for 3-6m
207
Q

Clinical features of Chronic Lower Limb Ischemia

A
  • Claudication (pain w/ exercise
    and relieved by rest), if pain at
    rest: RED FLAG
  • Shiny hairless legs
  • Muscles atrophied
208
Q

Chronic Lower Limb Ischemia initial investigation

A
  1. Measure ABI
  2. Duplex US (often the only imaging required to plan endovascular interventions)
209
Q

Chronic Lower Limb
Ischaemia best investigation

A

CT Angiography w/
contrast (Contraindicated in RF)

210
Q

Chronic Lower Limb Ischaemia MEDICAL Treatment

A

ABI:

1-1.4: Normal

0.9: Borderline. Nothing

<0.9:
Risk factor management
- Smoke cessation
- Antiplatelets (aspirin or clopidogrel)
- Statins (even in the absence of dyslipidemia)
- ACE Inhibitors or ARBs.
- Supervised exercise program.

The beta-blockers should be avoided until and unless they are commenced for cardioprotection.

For mixed ulcers (Do not use compression bandage if ABI <0.8)

<0.4: Urgent referral

211
Q

Chronic Lower Limb Ischaemia SURGICAL Treatment

A

– Endovascular angioplasty or stenting

– Open surgical reconstruction by bypass or endarterectomy.

212
Q

Chronic Lower Limb Ischaemia referral criteria

A

– Rest Pain

– Ischemic ulceration

– Gangrene

– Claudication symptoms are limiting day to life, work, and there is no improvement with exercises, risk factor modifications and medical management after 6 M.

213
Q

Raynaud Features

A

Bilateral vasospasms, fingers are
white or blue.

Raynaud’s disease (primary Raynaud’s)

Raynaud’s phenomenon (secondary Raynaud’s), a wide variety of other conditions.

INVESTIGATION: Capillaroscopy

214
Q

Raynaud Treatment

A
  1. Avoid cold, triggers, use
    gloves
  2. Nifedipine
215
Q

Pernio (Chilblains)

A
  • Multiple erythrocyanotic lesions, typically macules, papules, or nodules that develop in response to exposure to cold, damp environments. Generally symmetric, affecting particularly the toes and fingers.
  • Burning sensation, fingers are red, blue, or white.
  • More common in women.

TREATMENT:
- Avoid cold exposure. Use gloves or socks.
- Smoking cessation
- Topical corticosteroids.
- Nifedipine.

216
Q

Buerger Disease (thromboangiitis obliterans)

A
  • Young male (20-50 yo), heavy tobacco user.
  • Jewish, Indians, Koreans, and Japanese.
  • Vaso-occlusive inflammatory disease, auto-mutilation, black fingers.
  • Arteriography may show characteristic “pig-tailing” or “corkscrewing” (not specific).
  • Echocardiography should be obtained to exclude a proximal source of emboli.

TREATMENT:
- Smoking cessation.
- NSAIDs for pain.
- Nifedipine.

217
Q

DVT Features

A
  • RFs: Age>60, smoking, flight or
    qx, pregnancy, malignant diseases, CHF, IBD (Crohn’s disease and UC)
  • Varicose veins aren’t on the RFs list.
  • C/F: Tenderness in calf,
    unilateral leg swelling.
218
Q

DVT Initial Investigation

A

duplex u/s

219
Q

DVT Best Investigation

A

Contrast venography

220
Q

DVT Treatment

A
  1. LMWH
  2. Warfarin (within 24-48 hrs)
  3. Cava filters in pts that have CIs to
    anticoagulation or have poor
    compliance or failure of
    anticoagulation.
  4. Any motor or sensory deficit requires emergency intervention.
221
Q

Upper Extremity DVT Features

A

Primary DVT Paget-Schroetter syndrome (PSS):

-Hx of young person trimming a tree, wresting, using a chainsaw. Dominant arm.
-PE: Edema (nonpitting) of shoulder, arm, and hand -> Subclavian thrombosis.
- Urschel’s sign: Limb erythema with visible veins across the chest and upper extremity.

Secondary DVT: Patients with central venous catheterization or malignancy.

The IV line:

If required (e.g., total peripheral nutrition): Remain in place and start on anticoagulation therapy.

Not required: Remove but only after the completion of 3 to 5 days of anticoagulation therapy.

222
Q

Upper Extremity DVT Investigation

A

CXR: PE ??

Confirm a diagnosis: Compression duplex US.

Gold standard: Magnetic resonance venography.

223
Q

SVC Syndrome Features

A

Caused by malignancies
(Pancoast tumor, etc) or by central catheter.

Pt has facial plethora, cough, dyspnea, orthopnea and papilledema

224
Q

SVC Syndrome Initial Investigation

A
  1. Dupplex US for catheter-related
  2. CXR for malignancies
225
Q

SVC Syndrome Best Investigation

A

Contrast Venography

226
Q

SVC Syndrome Treatment

227
Q

Varicose Veins Features

A
  • RF: Female, pregnancy, age, occupation.
  • C/F: 1st symptom: Ankle flare edema (least likely indication for
    referral), pain improves on walking, varicose veins, skin pigmentation, ulcers
228
Q

Varicose Veins Initial/Best Investigation

A

Venous duplex US (Ix of
choice)

229
Q

Varicose Veins Treatment

A
  • ABI ≥0.9: Compression stocking safe
  • ABI≤0.8: Can’t use compression
    stocking.
  • Varicose veins w/ Ulceration:
    Compression bandage
  • Varicose veins w/o ulceration:
    Compression stocking
230
Q

Venous Ulcers Features

A
  • Location: Medial distal leg (just above internal malleolus)
  • Edema, irregular borders
231
Q

Venous Ulcers Initial/Best Investigation

A

Venous duplex US (Ix of
choice)

232
Q

Venous Ulcers Treatment

A
  • Compression bandage
  • Weight reduction
  • Increase exercise
  • If eczema: Topical steroids
  • Non healing ulcer: Wound swab
  • Atbs only if clinical signs of infection
    (But not topical bc delay wound
    healing)
233
Q

Arterial Ulcers Features

A
  • Location: Tops of feet or toes.
  • Painful esp at night, punched-out appearance, loss of leg hair, faint or absent ankle pulses, black eschar, necrotic border.
234
Q

Arterial Ulcers Treatment

A
  1. LSM (low-level laser therapy)

Maybe
2. Wound care
3. Atbs if infection present

235
Q

Diabetic Foot Ulcer Clinical Features

A
  • Location: First metatarsal area
  • Non necrotic border
236
Q

Diabetic Foot Ulcer Initial Investigation

A

Foot X-ray

237
Q

Diabetic Foot Ulcer Best Investigation

A

MRI to r/o osteomyelitis
in an ulcer that doesn’t heal

238
Q

Diabetic Foot Ulcer Treatment

A
  • Uninfected: 1cm odorless ulcer.
    Wet dressing
  • Mild: Purulence, erythema BUT no
    cellulitis/erythema and smaller than 2cm:
    1. Wound debridement.
    2. Swab of wound for cultures.
    3. Atbs: Amoxi+Clavulanate OR
    Cephalexine+Metro
  • Moderate: Infection + Cellulitis
    >2cm.
    1. Wound debridement.
    2. Swab of wound for cultures.
    3. Atbs:
    Dicloxacilin/flucloxacilin. Add metro if
    discharge is odorous
  • Severe: Infection + Systemic symptoms (fever, tachy, hypotension,
    confusion) = Piper-tazo or ticarciclin+clavulanate.

If conservative approach fails: Revascularization with angioplasty and endovascular stenting

239
Q

Marjolin Ulcers Features

A

Cutaneous SCC, an ulcer that persists > 3m at the site of the scar.

Burn scars are the most common inciting condition.
Other Cx: Traumatic wounds, venous stasis ulcers, osteomyelitis, pressure ulcers, radiation dermatitis, and stings/bites.

Locations: Lower limbs (most frequently affected), followed by the scalp, upper extremities, torso, and face.

240
Q

Marjolin Ulcers Initial/Best Investigation

A
  1. Biopsy
  2. MRI can be done to assess the degree of soft tissue and bone involvement.
241
Q

Marjolin Ulcers Treatment

A

Wide excision

242
Q

Breast Discharge Milky

A

-Galactorrhea
-Hyperprolactinemia

243
Q

Breast Discharge Multicoloured/ Sticky/ Toothpaste like

A

-Duct Ectasia
-Comedomastitis

244
Q

Breast Discharge Purulent

A

-Chronic Mastitis
-Breast Abscess
-Plasma cell Mastitits
-Acute puerperal Mastitis

245
Q

Breast Discharge Watery/Serous/Bloody/Serosanguineous

A

-Intraductal Papilloma (bloody)
-Fibrocystic disease
-Advanced duct ectasia
-Breast Cancer

246
Q

Breast Lump

247
Q

NOT PROVEN to increase the risk of developing peptic ulcer

A

-Corticosteroids.

-Alcohol (except for gastric erosion).

-Diet.

248
Q

Risk Factors for peptic ulcer

A

-Male sex.

-Family history of peptic ulcer disease.

-Smoking.

-Stress.

-NSAIDs.

-H.pyelori.

249
Q

Indications for urgent abdominal surgical interventions

A

1-Diffuse peritonitis (localized peritonitis is not always an indication).

2-Severe or increasing localized tenderness.

3-Progressive abdominal distension.

4-Tender mass with fever or hypotension (abscess).

5-Septicemia and abdominal findings.

7-Bleeding and abdominal findings.

8-Suspected bowel ischemia (acidosis, fever, tachycardia).

9-Massive bowel dilatation (>12cm).

250
Q

Common Bile Duct normal size

252
Q

Coeliac disease Symptoms:

A

Chronic diarrhoea

Steatorrhoea

Weight loss

Anorexia

Abdominal distension

Nutritional deficiency: folate, calcium, zinc or iron (in particular)

Grouped blisters around the knees, elbows and buttocks (dermatitis herpetiformis)

Hair loss

Mouth ulcers

253
Q

bariatric surgery contraindications

A

– Irreversible end-organ dysfunction.
– Cirrhosis with portal hypertension.
– Medical problems precluding general anaesthesia.
– Centrally mediated obesity syndromes such as Prader-Willi syndrome or Craniopharyngioma.

254
Q

acute pancreatitis surgery indications

A
  • Uncertainty of clinical diagnosis
  • Worsening clinical condition despite optimal supportive car2
  • Infected pseudocysts
  • Gallstone-associated pancreatitis
255
Q

diarrhoea + abdominal pain + bloating + belching + flatus + nausea and vomiting

A

Giardiasis

256
Q

Giardiasis investigation

A

stool examination for ova and cyst

257
Q

Gallstone surgery indication

A

size > 3 cm
- calcified/porcelain gallbladder

258
Q

gall stone investigation

A

initial:
diagnostic: US/ERCP

259
Q

Diverticultis highest mortality rate complication

A

Perforation 20%

  • Bleeding especially in elderly
    – Intra-abdominal abscess.
    – Peritonitis.
    – Fistula formation.
    – Intestinal obstruction.
260
Q

oesophageal malignant lesions surgical contraindication

A
  • Invasion of tracheobronchial tree
  • Invasion of great vessels
  • lesion more than 10 cm
261
Q

paraesophageal/hiatus hernia investigation

A

Diagnostic: Barium swallow

262
Q

abdominal pain + diarrhoea + Tenderness on DRE

A

Acute appendicitis

263
Q

long hx of vomiting after food + reduced appetite + brackish taste + epigastric pain

A

Gastro-oesophageal reflux disease (GORD)

264
Q

Gastro-oesophageal reflux disease (GORD) investigation

A

Initial:
- Intraoesophageally pH probe monitoring
- Barium swallow unless suspicion of stricture, obstructions

265
Q

Indications for endoscopy for GORD

A

pre-existing GORD now presented with anaemia

266
Q

Most common complication of GORD

A
  • Barrett’s oesophagus
  • Oesophagitis
  • Strictures
  • Iron deficiency anaemia
  • Adenocarcinoma
267
Q

GORD management

A

Lifestyle modification
- weight reduction

Therapeutic trial of PPI for 4 weeks

NOTE: Ranitidine is not given in Australia (lung cancer, MI)

268
Q

Chronic GORD (> 5 years) + LES low tone + mucosal damage

A

Barrett’s oesophagus

269
Q

Barrett’s oesophagus investigation

A
  • endoscopy with biopsy
  • contrast studies if endoscopy unavailable
270
Q

Barrett’s oesophagus monitoring

A

2-5 years by endoscopy and biopsy depending on segment length

271
Q

Barrett’s oesophagus histopathology

A
  • squamous cells forming into ciliated columnar cells

NOTE: precancerous site for adenocarcinoma

272
Q

Barrett’s oesophagus management

A

PPI
Low grade: PPI every 6 months
High grade: radio frequency ablation

273
Q

Dysphagia to solids and liquids + Heartburn unresponsive to PPI + Retained food in the oesophagus on upper endoscopy + Unusually increased esophagogastric junction sphincter tone + failure of muscle relaxation + weight loss + regurgitation getting worse at night/lying down

274
Q

Achalasia initial investigation

A

Plain X -ray
- air fluid levels to see absence of gastric bubble
Barium swallow
- Birds beak/rat tail appearance
OGD endoscopy
- exclude other causes of dysphagia

275
Q

Achalasia diagnostic investigation

A

Manometry
- high tension at lower end of oesophagus
Endoscopy
- exclude carcinoma

276
Q

Most important diagnostic feature of achalasia?

A

Dysphagia for both solids and liquids

277
Q

Achalasia complications

A
  • strictures
  • oesophageal cancer
278
Q

Achalasia management

A

Mild symptoms
- CCB (Nifedipine)
- nitrates

Young px
- Endoscopic Pneumatic dilation of LES
Old px
- Botulinum injection (may need to be repeated every 3 - 12 months) + mild symptoms management

Best
- Laparoscopic Myotomy (Heller’s)

279
Q

most common oesophageal disorder

280
Q

painless + elderly + recurrent pneumonia + dysphagia + solids & liquids undigested food regurgitation + coughing immediately after eating + halitosis

A

Zenker’s diverticulum (pharyngeal pouch)

281
Q

Zenker’s diverticulum investigation (pharyngeal pouch)

A

Initial: Barium swallow/Contrast oesophagography
Best: Upper gastrointestinal endoscopy

282
Q

Zenker’s diverticulum management (pharyngeal pouch)

A

Surgery: cricopharyngeal myotomy ± diverticulectomy
Laparoscopic surgery

283
Q

dysphagia + iron deficiency anaemia + glossitis ‘rings’ (oesophageal webs) + glossitis

A

Plummer Vinson Syndrome/Syderopenic dysphagia

284
Q

Plummer Vinson Syndrome/Syderopenic dysphagia investigation

A

Video fluoroscopy to test iron deficiency
Endoscopy

285
Q

Plummer Vinson Syndrome/Syderopenic dysphagia biggest risk factor

A

Oesophageal SCC

286
Q

Plummer Vinson Syndrome/Syderopenic dysphagia management

A

Treat iron deficiency
Mechanical dilation

287
Q

Progressive dysphagia + Weight loss >10% + Elderly

A

Oesophageal cancer

288
Q

Oesophageal cancer features

A

▪ Dysphagia progressive continuous - first solids then liquids → odynophagia

▪ Striking unintentional weight loss ( >10%)

▪ Hiccoughs (early sign – phrenic nerve irritation)
▪ Hoarseness and cough (upper 1/3 cancer – recurrent
laryngeal nerve irritation – vocal cord palsy)

▪ Progressive chest discomfort or pain in locally invasive cancer

289
Q

Oesophageal cancer types

A

▪ SCC (most common)
▪ Adenocarcinoma

290
Q

Oesophageal cancer investigation

A

1st test: Barium swallow to locate lesion
▪ Narrowing of oesophagus
▪ Irregular oesophageal borders
apple core appearance

THEN

Endoscopy w/biopsies
Oesophagogastroduodenoscopy

291
Q

Oesophageal cancer ddx

A

Dysphagia intermittent = Achalasia

Hoarseness and cough = also in Pancoast tumour but Horner is present and no GI symptoms

292
Q

Oesophageal cancer risk factors

A

SCC:
▪ Smoking & OH → Tripe S
(smoking - spirits – SCC)

Adeno:
▪ Barrett’s oesophagus & smoking

293
Q

prolonged vomiting + small haematemesis ± alcohol excess

A

Mallory-Weiss Tear

294
Q

alcoholic binge + vomiting + hemodynamic instability ± left-sided pleural effusion + hypotension

A

Boerhaave’s Syndrome

295
Q

Boerhaave’s Syndrome investigation

A

Initial: upright chest x-ray
- left unilateral effusion
- free air in the mediastinum or peritoneum
Diagnostic : Oesophagography
- extravasation of contrast material into the pleural cavity

Gastrograffin: It has 90% sensitivity but may have false-negative results in up to 20% of
patients

NOTE: Barium swallow has been associated
with severe mediastinitis

296
Q

Boerhaave’s Syndrome management

A
  • ABCDE – Resus - IV fluid therapy
  • immediate antibiotic therapy to prevent mediastinitis and sepsis
  • surgical repair of the perforation

NOTE: mortality 100%

297
Q

Complete oesophageal rupture causes

A

▪ Iatrogenic - 56% due to an endoscopy or
paraesophageal surgery

▪ Boerhaave’s syndrome- 10%

▪ Spontaneous perforation include:
- Caustic ingestion
- Pill esophagitis
-Barrett’s oesophagus
-Infectious ulcers in patients with AIDS, and following dilation of oesophageal strictures

298
Q

PUD risk factors

A

-Male sex.
-Family history of peptic ulcer disease.
-Smoking.
-Stress.
-NSAIDs.
-H.pylori.

299
Q

infective cholecystitis pathogen

300
Q

hx of ascites+ fever + altered mental status + increased WBC + abdominal pain/discomfort

A

spontaneous bacterial peritonitis

301
Q

spontaneous bacterial peritonitis transmission

A

Bacterial translocation from gut to mesenteric lymph node Bacterial translocation from gut to mesenteric lymph node

302
Q

Left iliac fossa pain + Fever + Tenderness and rebound tenderness + Guarding + Per rectal bleeding + hypotension

A

Acute diverticulitis

303
Q

Coeliac Disease most common age

A
  • children 9-18 months the most common
  • any age
304
Q

Causes of Coeliac Disease

305
Q

Coeliac Disease Investigation GOLD STANDARD

A
  • Duodenal Biopsy

NOTE: atrophic villi, IG Antiendomysial AB, IGA transglutamines, IGA Antigliadin for screening

306
Q

conditions is associated with an increased risk of coeliac disease

A
  • Type I diabetes mellitus
  • Hashimoto’s thyroiditis
  • autoimmune diseases
  • Down’s syndrome
  • Turner’s syndrome
  • IgA deficiency
307
Q

Coeliac Disease management

A
  • Gluten free diet
  • Vitamin replacement
  • Pneumococcal Vaccine
  • Dapsone (for dermatitis herpetiformis)
308
Q

Left supraclavicular lymph node cancer

A
  • abdominal or pelvic
309
Q

hx of cholecystectomy + abdominal pain + dyspepsia + increased liver enzymes and cholesterol

A

post-cholecystectomy syndrome

310
Q

post-cholecystectomy syndrome investigation

311
Q

screening for hepatoma or primary liver cancers with chronic hepatitis

A

Alpha fetoprotein

312
Q

autoimmune hepatitis predictor of poor clinical response to therapy

A

Anti-liver-kidney microsomal antibody (Anti-LKM antibody)

313
Q

high INR + low calcium + hypochromic microcytic anaemia

A

malabsorption syndrome

314
Q

malabsorption syndrome investigation

A

Anti-gliadin antibodies

315
Q

most common cause of large bowel obstruction

A

Colon cancer

316
Q

most common cause of constipation

317
Q

Acute cholangitis poor prognostic determinants

A

1 Age more than 70.
2 Female
3 Failure to respond to conservative management.
4 Concurrent medical conditions:
- liver abscess
- cirrhosis
- hypoalbuminaemia
- thrombocytopenia
- IBD
- malignant strictures

318
Q

high age + progressive dysphagia + decreased contractions + increased tertiary wave activity

A

Presbyoesophagus

319
Q

jaundice, dark urine, and pale stool + palpable gall bladder

A

Periampullary tumor

320
Q

bacterial peritonitis treatment

A

Cefotaxime and albumin
- albumin to reduce the rate of renal failure

321
Q

migratory superficial thrombophlebitis + deep vein thrombosis

A

Trousseau’s syndrome

322
Q

Trousseau’s syndrome associated tumours

A
  1. Pancreas 24%
  2. Lung 20%
  3. Prostate 13%
  4. Stomach 12%
  5. Acute leukaemia 9%
  6. Colon 5%.
323
Q

– Severe colicky epigastric and periumbilical pain
– Absolute constipation.
– Nausea and vomiting.
– Abdominal distension in low small bowel obstruction

A

small bowel obstruction

324
Q

Elevated liver enzymes with normal bilirubin

A

Ischemic hepatitis

325
Q

Pancreatic pseudocyst management

A
  • size > 6cm ERCP
  • Present for > 6 weeks
  • Wall thickness for > 6 mm

NOTE: if ERCP fails, then move on to laporotomy

326
Q

Longstanding cirrhosis or Hep C

A

Form hepatocellular carcinioma

327
Q

Cirrhosis findings

A

PE: spider naevi, palmar erythema, gynecomastia and splenomegaly

LAB:
- Thrombocytopenia
Abnormal coagulation studies including INR and PT
Hypoalbuminemia

328
Q

Small bowel obstruction investigation

A

initial: Abdominal X-ray
Best: CT abdomen

329
Q

GI bleed with weight loss and decreased appetite

A

colon adenocarcinoma

330
Q

hix of gastric bypass + discomfort, including nausea, vomiting, cramps, and diarrhea

A

Dumping syndrome

331
Q

Dumping syndrome management

A
  • Diet modification (high fibre + protein)
  • -Hydrogen breath test positive
  • Barium fluoroscopy
  • radionuclide scintigraphy
    reoperation if diet fails
332
Q

H. Pylori

A

Gram -ve
- corkscrew-shaped, motile bacillus with three to seven flagella
- rapid urease test
- Eradication with colloidal bismuth (Pepto-Bismol), an antibiotic (amoxicillin or ampicillin), and a nitroimi-dazole such as metronidazole.

333
Q

fever + jaundice, + pain in the right upper quadrant + chills

A

Acute cholangitis
Harcot’s triad

334
Q

Acute pancreatitis investigation

A
  • serum lipase (elevated)
335
Q

Meckel diverticulum investigation

A
  • painless large-volume intestinal hemorrhage
    Technetium-99m pertechnetate scintigraphic study
336
Q

Iron deficiency anaemia in elderly

A

colon cancer

337
Q

abdominal surgical interventions

A

D1. iffuse peritonitis(localized peritonitis is not always an indication).
2-Severe or increasing localized tenderness.
3-Progressive abdominal distension.
4-Tender mass with fever or hypotension (abscess).
5-Septicemia and abdominal findings.
7-Bleeding and abdominal findings.
8-Suspected bowel ischemia (acidosis,fever,tachycardia).
9-Massive bowel dilatation more than 12cm.

338
Q

Malignant cells in ascites will spread to

A

Left supraclavicular lymph nodes

339
Q

Pilonidal sinus prevention

A

1-Keep the area clean and dry.
2-Avoid sitting for a long time on hard surfaces.
3-Remove hair from the area

340
Q

Peritonitis investigation

A
  • Ascitic analysis
    (fluid neutrophil count more than 250 cells/mm3)
341
Q

Hepatic hydatid cyst pathogen

A

Echinococcus tape worm

342
Q

Hepatic hydatid cyst investigation

A

Triphasic abdominal CT Triphasic abdominal CT
Cyst aspiration

343
Q

Hepatic hydatid cyst management

A

Albendazole

344
Q

Best indicator for chronic liver disease

345
Q

Indicator for chronic liver disease

A
  • Alanine aminotransferase
  • Aspartate aminotransferase
346
Q

Best predictor of patient livelihood

A

Hypoalbumin
- decrease in osmotic pressure, therefore ANSARCA
leads to CHF

347
Q

Coeliac disease investigation

A

Serum transglutaminase antibodies

348
Q

Splenectomy measures

A
  • Vaccination against:
    streptococcus pneumoniae
    meningococcus
    H. influenza
  • Antibiotics (Penicillin) from 6 months - 2 years
  • target cells (deformed RBCs)
349
Q

Acute confusion post surgery

A

Atelectasis, PR, chest infection
- check pulse oximetry

350
Q

5 F’s of cholecystitis

351
Q

Encephalopathy grades

A

Grade-I involves altered mood/behaviour, sleep disturbance including reversal of sleep cycle.
Grade-II involves increasing drowsiness, confusion and slurred speech
Grade-III involves stupor, incoherence, restlessness and significant confusion
Grade IV is an
ultimate coma

352
Q

Dilated abdominal veins flowing towards head + hepatomegaly

A

Inferior Vena Cava Obstruction

353
Q

Dilated abdominal veins flowing towards legs+ hepatomegaly

A

Caput medusae from cirrhosis and portal hypertension

354
Q

History of recent myocardial infarction. + acute onset of abdominal pain + Metabolic
acidosis.

A

mesenteric ischemia

355
Q

Pancreatic cancer risks

A

-Smoking.
-Long-standing diabetes mellitus.
-Chronic pancreatitis.
-Obesity.
-Inactivity (high cholesterol/obesity?
-Non–O blood group

356
Q

Child-Pugh classification

A

The severity of portal hypertension
1-Increased total bilirubin.
2-Prolonged INR.
3-Low serum albumin.
4-Presence of hepatic encephalopathy.
5-Presence of ascites.

357
Q

chronic gastrointestinal bleeding prevention

A

BB (Propranolol or nadolol)

358
Q

most likely to strangulate hernia

A

indirect inguinal hernia

359
Q

least likely to strangulate hernia

A

Direct inguinal hernia

360
Q

gastroenteritis in Australia?

361
Q

Male + intermittent mild jaundice provoked by stress

(infection, fasting, vigorous exercise, surgery)

A

Gilbert’s syndrome

362
Q

Repeated unconjugated hyperbilirubinemia + No evidence of haemolysis + normal findings on complete blood count, reticulocyte count, and blood smear. + Normal liver function tests except for bilirubin.

A

Gilbert’s syndrome

363
Q

Gilbert’s syndrome features

A

AR or AD mutation in UGT1A1 gene
decreased UDP-glucuronosyltransferase activity leading to increased unconjugated bilirubin

364
Q

most common gastrointestinal complication seen after cholecystectomy

365
Q

infliximab for inflammatory bowel disease

A

Crohn’s disease with perianal fistulas

366
Q

sulfasazine side effects

A
  • agranulocytosis
  • haemolytic anaemia
    rash -
367
Q

Coeliac vitamin defciencies

A
  • iron (most common)
  • B12
  • ADEK
368
Q

bariatric surgery indications

A

– BMI above 40 with no co-morbidities
– BMI above 35 with co-morbidities such as hypertension
– BMI above 30 with poorly controlled type 2 diabetes
– BMI above 30 with increased cardiovascular risk due to multiple risk factors such as hypertension, hyperlipidemia, strong family history of cardiovascular disease at a young age

369
Q

presence of eosinophils + dysphagia

A

eosinophilic esophagitis

370
Q

eosinophilic esophagitis management

A
  1. PPI
  2. Swallowed budesonide
  3. Systemic corticosteroids
371
Q

CEA

A

glycoprotein found in colon - cancer
- CEA assay is a sensitive serologic tool for identifying recurrent disease

372
Q

infant + volvulus + duodenal obstruction + intermittent or chronic + abdominal pain

A

malrotation

373
Q

hernia that follows the path of the spermatic cord within the cremaster muscle

A

Indirect inguinal

374
Q

hernia passes directly beneath the inguinal
ligament at a point medial to the femoral vessels

375
Q

hernia passes through a weakness in the floor of the inguinal canal medial to the inferior epigastric
artery

A

direct inguinal

376
Q

hernia that protrude through an anatomic defect that can occur along the lateral border of
the rectus muscle at its junction with the linea semilunaris

377
Q

thiazide diuretic + beta
blocker

A

hypokalemia

378
Q

haemorrhoiids investigation

A

Proctoscopy

379
Q

dysphagia + coughing and choking + recurrent aspiration pneumonia + stroke

A

Oropharyngeal dysphagia

380
Q

Oropharyngeal dysphagia investigation

A

Videofluoroscopic modified barium swallow study

381
Q

middle-aged women + hyperlipidemia + fatigue + pruritus + elevated alkaline phosphatase

A

cholestasis

382
Q

constipation + fecal ncontinence + hematochezia + hx of pelvic radiation therapy

A

Radiation proctitis

383
Q

Acute pancreatitis worse prognosis

A

Blood urea nitrogen level
- reflect intravascular volume depletion

384
Q

Ursodeoxycholic acid is used to treat

A

Primary biliary cirrhosis
- increases bile acid output and bile flow while reducing
cholesterol absorption

385
Q

primary lymphoma predisposing factors

A

Celiac disease

386
Q

solids dysphagia + breathlessness, cough +
heartburn + wheezing

A

Congenital anomaly of the aortic arch
- presses against the oesophagus causing dysphagic, compression isn’t too harsh as liquids can still pass through

387
Q

long hx of constipation + sudden cut-off + dilated proximal colon + abdominal distension + empty rectum on DRE

A

sigmoid volvulus

388
Q

sigmoid volvulus investigation

A

diagnostic: CT abdomen
NOTE: barium if perforation is suspected

389
Q

mild tenderness on rectal exam + pain localized in the pelvis

A

pelvic appendicitis

390
Q

freckling + gastrointestinal polyposis (polyps in small bowel) + intussusception

A

Peutz Jegers Syndrome

391
Q

Peutz Jegers Syndrome complications

A

high risk of specific cancers:
intestine
colon
pancreas
breasts
cervix
ovaries
testes

392
Q

Disease with strongest association with colorectal cancer

A

Familial adenomatous polyposis
- cancer can develop as early as 20

393
Q

Somalian + anal fissure predisposing factor

A

Rectal schistosomiasis

394
Q

dysphagia + hoarseness + hx of achalasia + thoracic inlet mass

A

Oesophageal cancer

395
Q

hoarseness + dysphagia + neck mass

A

Laryngeal cancer

396
Q

erythematous + well define + fluctuant mass at the anal orifice

A

Perianal abscess

397
Q

most common cause of treatment failure in PUD

A

metronidazole/clarithromycin resistance

398
Q

dyspepsia + belching + abdominal pain + post cholesytectomy

A

Post- cholecystectomy syndrome (PCS)

399
Q

Most common cause of post-cholecystectomy syndrome (PCS)

A

Choledocholithiasis

400
Q

Types or benign renal tumours

A
  • Renal adenoma
  • Oncocytoma
  • Angiolipoma
401
Q

Types or malignant renal tumours

A
  • Renal cell carcinoma (90%)
  • Urothelial carcinoma (5-10%)
  • Wilms tumour/nephroblastoma
  • Sarcomas
402
Q

aniline dye industry ± smoking + haematuria

A

urothelial tumour

403
Q

urothelial tumour features

A
  • papillary tumours of the urinary transitional epithelium
  • incidence increases progressively from renal pelvis to bladder
404
Q

Most common complication of urothelial tumour?

A

Bladder cancer (90%)

405
Q

most common blunt abdominal trauma in children?

A

duodenal haematoma

406
Q

Haemorrhagic shock classes

A

Class II-III:
- systolic BP < 90
- heart rate< 120
- respiratory rate< 30

407
Q

Trousseau syndrom

A

venous thrombosis, migrating thrombophlebitis

Pancreas Ca
Lung Ca

AMC MCQ (59 decks)

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