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AMC MCQ - You Can Do It!!!!!❤️❤️ > 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

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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

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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
Dr.Cintia.C.Fornaso SURGERY.2023

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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)but expensive

The initial investigation for chronic pancreatitis according to RACGP guidelines typically starts with imaging studies. Abdominal CT scan is often the first choice due to its ability to detect pancreatic calcifications, ductal dilation, and other structural changes indicative of chronic pancreatitis. Additionally, abdominal ultrasound can be used to assess for gallstones or other biliary pathology. These imaging studies are complemented by a thorough history and physical examination to guide diagnosis oai_citation:1,RACGP - Chronic pancreatitis Negotiating the complexities of diagnosis.

For further details, you can access the RACGP guidelines here.

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48
Q

Chronic Pancreatitis treatment

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

The treatment of chronic pancreatitis, according to RACGP guidelines, involves a comprehensive approach tailored to the patient’s symptoms and the progression of the disease. The key aspects of management include:

  1. Pain Management: Pain is a predominant symptom in chronic pancreatitis. Initial treatment typically involves analgesics, and in cases of severe pain, options like celiac nerve blocks or endoscopic procedures may be considered.
  2. Pancreatic Enzyme Replacement Therapy (PERT): For patients with exocrine insufficiency, enzyme supplementation is critical to aid digestion and improve nutrient absorption, which can also help manage associated symptoms like steatorrhea.
  3. Nutritional Support: Dietary modifications, including a high-protein, low-fat diet, are recommended. In cases of severe malnutrition, total parenteral nutrition (TPN) may be necessary.
  4. Alcohol and Smoking Cessation: It’s essential for patients to stop consuming alcohol and smoking, as these are major contributing factors to disease progression and can exacerbate symptoms.
  5. Surgical Interventions: Surgery may be required for complications or when medical management fails to control symptoms. Procedures like the Whipple procedure or total pancreatectomy may be considered depending on the patient’s condition and the severity of the disease.

For more detailed guidelines, you can visit the RACGP website or access resources like the AAFP and Johns Hopkins Medicine websites on chronic pancreatitis.

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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 Sx: 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
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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
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93
Q

Dumping syndrome Management

A
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94
Q

Clinical features of Gouverneur’s Sx
(vesicointestinal fistula)

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

Gouverneur’s syndrome, also known as a vesicointestinal fistula, typically presents with the following clinical features:

  1. Pneumaturia: Passage of gas during urination.
  2. Fecaluria: Presence of fecal material in the urine.
  3. Recurrent urinary tract infections: Due to the presence of bacteria from the intestines entering the urinary tract.
  4. Dysuria: Painful or difficult urination.
  5. Suprapubic pain: Discomfort or pain in the lower abdomen, above the pubic bone.

These symptoms result from an abnormal connection between the bladder and the intestine.

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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 Tratment

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

A

CT Scan

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

A

US

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?

A

E. Coli

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

A

CT Scan

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

A

LMWH

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

A
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

A

2 - 6 mm

251
Q
A
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

A

achalasia

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

A

achalasia

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

A

E. Coli

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

A

genetic

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

A

ERCP

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

A

Dietary

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

A

Albumin

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

A
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?

A

Norovirus

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

A

Diarrhoea

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

A

femoral

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

A

Spigelian

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

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