Surgery Flashcards
pain Mx (eg. pt controlled anaesthesia); anastomotic leak; breast cyst
1
Q
Medical management of SBO?
A
IV fluids and gastric decompression, or ‘drip-and-suck’
2
Q
Neutrophil predominant leucocytosis suggests what?
A
Appendicitis
3
Q
Why is appendicitis pain felt in umbilical first?
A
- Inflammation of the visceral peritoneum is felt in T10 which corresponds to periumbilical region -> no somatic sensation here
4
Q
Why does appendicitis pain move to RIF?
A
Parietal peritoneum becomes involved which receives somatic innervation therefore pain is localised to area affected
5
Q
What is a diverticulum?
A
Outpouching of the gut mucous through the muscle wall
6
Q
Which part of the colon is diverticula common in?
A
Sigmoid - as majority of water has already been reabsorbed by this stage therefore high intraluminal pressures
7
Q
Diverticulosis vs Diverticulitis vs Diverticular disease
A
Diverticulosis - presence of diverticula
Diverticular disease - symptomatic diverticula
Diverticulitis - inflammation of the diverticula
8
Q
What is the possible complications of diverticulitis?
A
- Perforation
- Bleeding
- Abscess
- Fistulas
9
Q
What are the 6 Ps of limb ischaemia?
A
Pallor, pain, pulseless, paraesthesia, perishingly cold, paralysis
10
Q
Acute limb ischaemic vs critical limb ischaemia?
A
Critical - last longer than 2 weeks and foot will be warm with pink appearance
11
Q
What is the management of acute limb ischaemia?
A
Immediate referral to vascular
Thrombotic cause - angio/surgery
Embolic cause - embolectomy
12
Q
What is initially added with GnRH agonists for metastatic prostate cancer?
A
Anti-androgens to prevent tumour flare which can cause bone pain, bladder obstruction and other symptoms
13
Q
fever, hypotension and a rash → desquamation
A
Staph toxic shock syndrome
14
Q
Different surgical signs
A
Rosving - appendicitis
Boas - cholecystitis
Murphy’s - cholecystitis
Cullens - pancreatitis
Grey-Turner - pancreatitis
15
Q
What are risk factors for abdominal wall hernias?
A
- Obesity
- Ascites
- Increasing age
16
Q
What are features of abdominal wall hernias?
A
- Palpable lump
- Cough impulse
- Pain
- Obstruction
- Strangulation
17
Q
What is the most common hernia and who is it common in?
A
Inguinal - men
18
Q
Lump in the midline between the umbilicus and xiphisternum?
A
Epigastric hernia -> common in those doing extensive physical training/chronic cough
19
Q
Management of congenital inguinal hernias?
A
Surgical repair ASAP as risk of incarceration
20
Q
What is abdominal wound dehiscence?
A
- When the layers of abdominal mass closure fail and the viscera protrude out
- RF include malnutrition, jaundice and poor surgical technique
21
Q
What is the management of sudden full dehiscence?
A
- Coverage of wound with saline gauze
- IV Abx
- Analgesia
- Fluids
- Return to theatre
22
Q
What blood test would point to appendicitis?
A
Neutrophil-predominant raised WCC
23
Q
Investigations for Appendicitis?
A
Thin, male patients - clinical
Women - US useful to rule out pelvic pathology
24
Q
How to reduce wound infection rates in appendicectomy?
A
Prophylactic IV Abx
25
What is cryptorchidism?
Undescended testis which fails to reach bottom of scrotum by 3 months
26
What is the major complication of undescended testes?
Testicular cancer - massive increased risk
27
What is the treatment of cryptoorchidism?
Orchidopexy at 6-18 months
28
A sinusoidal ECG pattern is indicative of what?
Severe hyperkalaemia
29
What are common complications of enteral feeding?
Diarrhoea
30
What is a femoral hernia?
When a section of the bowel passes into the femoral cancel - more common in females
31
How to differentiate a femoral vs inguinal hernia?
Femoral - inferolateral to the pubic tubercle below the inguinal ligament
Inguinal - super media to the pubic tubercle
32
What is the management of inguinal hernias?
Surgical repair due to the high risk of strangulation
33
Direct vs indirect inguinal hernia?
Direct - Through Hesselback triangle medial to the inferior epigastric artery
Indirect - Through inguinal ring, lateral to the inferior epigastric artery -> more common in infants
34
What causes direct and indirect inguinal hernias?
Direct - defect/weakness in the transversalis fascia area of the Hesselback triangle
Indirect - Failure of the processus vaginalis to close
35
What is a hiatus hernia?
Herniation of part of the stomach above the diaphragm
36
What is the most common type of hiatus hernia?
Sliding - gastroesophageal junction moves above the diaphragm
37
How does a hiatus hernia present?
- Heartburn
- Dysphagia
- Regurg
- Chest pain
38
How to manage hiatus hernia?
- Barium swallow
- Conservative: weight loss
- Medical: PPI
- Surgical: only for symptomatic
39
How to manage inguinal hernias?
- Refer and treat even if asymptomatic
- Unliteral: open surgery
- Bilateral/recurrent: laparoscopy
40
What are the 2 most common liver cancers?
- Hepatocellular carcinoma
- Cholangiocarcinoma
41
What are HCC tumours?
- Common in liver cirrhosis and chronic Hep B infections
- CT/MRI
- Elevated AFP
- Examine testes to rule out testicular tumours
- Surgical resection
42
What is cholangiocarcinoma?
- Tumour of bile ducts
- Presents with jaundice
- Associated with PSC
- Obstructive liver picture with elevated CA19-9, CEA, CA-125
- CT/MRI/MRCP
- Surgical resection
43
Admission criteria for acute lower GI bleed?
- Over 60
- Unstable
- On aspirin/NSAIDs
- Significant co-morbidities
44
What are complications of massive haemorrhage?
- Hypothermia
- Hypocalcaemia
- Hyperkalaemia
- Delayed transfusion reactions
45
Which nerve can be damaged in carotid endardectomy?
Hypoglossal
46
Where is the most common site of oesophageal rupture?
Left postero-lateral oesophagus
47
What is the name for free air in the abdomen?
Pneumoperitoneum - Rigler's sign
48
What is haemorrhagic shock?
- Occurs following trauma
- Control bleeding and then transfuse if needed
49
What is neurogenic shock?
- Occurs following spinal cord transection
- Decreases peripheral vascular resistance causing shock
- Decreases CO -> shock
50
What is cardiogenic shock?
- Caused by IHD
- Supportive treatment plus echo needed
51
What is the most common cause of SBO?
- Adhesions
- Hernias
52
How does SBO present?
- Diffuse abdo pain
- Vomiting then constipation
- Lack of flatulence
- Abdo distension and tinkling bowel sounds
53
How is SBO managed?
- Abdo X ray
- CT - gold standard
- Patients need to be NBM, IV Fluids and NG tube with free drainage
54
What is a strangulated hernia?
Blood supply to the hernia is compromised causing episodes of pain and an irreducible hernia
55
Management of strangulated hernias
- Immediate surgery
- Do not manually try to reduce whilst waiting for surgery
56
What line divides internal and external haemorrhoids?
Dentate line
57
What are symptoms of haemorrhoids?
- Itching
- Rectal fullness
- Soiling
- Pain
58
What are investigations for haemorrhoids?
FBC
Proctoscopy
Sigmoidoscopy
59
What are conservative options to manage haemorrhoids?
- Increase fluid/fibre intake
- Analgesia
- Bed rest
- Topical steroids/anaesthetics
60
What are medical/surgical management options to manage haemorrhoids?
- Rubber band ligation
- Cryotherapy
- Haemorrhoidectomy
- Stapled haemorrhoidopexy
61
What are complications of haemorrhoids?
- Ulceration
- Strictures
- Thrombosis
- Infection
- Anaemia
62
How would acute mesenteric ischaemia show on ABG?
Metabolic acidosis
63
What bloods can indicate AMI?
Raised WCC, raised lactate, raised Hb
64
What is the management of AMI?
- Laparotomy
- Fluids, Abx, Analgesia, Heparin
65
What does red pulp and white pulp of spleen do?
Red - filter and destroys RBC
White - Lymphoid tissue which acts on immune system
66
What are indications for splenectomy?
- Trauma
- Spontaneous rupture
- Hypersplenism
- Abscess
- Neoplasia
67
What are Howell-Jolly bodies?
RBC where the nuclear remnant is still seen
68
What are complications of pancreatitis?
Early - shock, sepsis, DIC, renal failure
Late - necrosis, abscess, thrombosis of arteries, chronic pancreatitis
69
Where is pain in small bowel vs large bowel?
Small - pain is higher as midgut structure
70
Ileus vs mechanical obstruction
Absence of bowel sounds - ileus
Tinkling bowel sounds - mechanical obstruction
71
What is the management of bowel obstruction?
Bowel rest - drip and suck: NBM with NG tube
72
What are types of gallstones?
- Pigment stones
- Cholesterol stones
- Mixed stones
73
What is Murphy's sign?
- 2 fingers in RUQ and patient breathes in which causes pain and they stop breathing in fully
- Repeat test in left which does not cause pain
74
What are causes of HCC?
- Viral hepatitis
- Cirrhosis
- Parasites
- Steroids
- COCP
75
What tumour marker is associated with HCC?
AFP
76
C-KIT gene mutation
Gastrointestinal stromal tumour
77
Bruising to flanks?
Grey-Turners -> Pancreatitis
78
Iron deficiency anaemia, dysphagia, pallor?
Plummer-Vinson syndrome
79
What is Mirizzi syndrome?
A complication of gallstones where a duct is compressed by a gallstone
80
What are complications of obstructive jaundice?
- Sepsis
- Encephalopathy
- Coagulopathy
- Hepatic failure
81
What bacteria are people with obstructive jaundice susceptible to?
Gram neg sepsis
82
What is the bilirubin pathway?
- By product of haem metabolism
- Excreted through bile into the bowel
- Metabolised to urobilinogen and stercobilinogen
83
Treatment of metastatic oesophageal cancer with recurrent vomiting?
Stenting to allow food to pass and relieve symptoms
84
What bacteria are post splenectomy patients susceptible to?
- Strep pneumoniae
- H influenzae
- E coli
- Klebsiella pneumoniae
85
Gastric vs Duodenal ulcer
- Both more common in men
- Duodenal in younger patients
86
Investigation for suspected bowel perforation?
Erect CXR
87
What is Hartmann's procedure?
Sigmoid colon is removed and stoma created
88
Medical management of anal fissure?
Acute
- High fibre and fluid
- Bulk forming laxatives
Chronic
- Topical GTN
- Sphincterotomy if GTN does not help
89
What can be used to defunction the colon to prevent an anastomosis?
Loop ileostomy
90
What drugs can cause pancreatitis?
- Azathioprine
- Mesalazine
91
Large volume paracentesis for ascites requires what to reduce mortality risk?
IV human albumin solution
92
Why is it important to assess airway of someone with burns?
Thermal injury to the airway can lead to airway oedema and obstruction so intubation may be needed
93
How to assess extent of burns?
- Wallace Rule of Nines
- Lund and Browder chart
94
What are signs of superficial burns?
Red, painful, dry and no blisters
95
What are signs of partial thickness superficial burns?
Pale pink, blistered with slow capillary refill
96
What are signs of partial thickness dermal burns?
White with reduced sensation and painful for deep pressure
97
What are signs of full thickness burns?
White/black burns, no blisters with no pain
98
What are indications of referral to secondary care for burns?
- All deep dermal and full thickness burns
- Superficial burns of more than 3% of body surface area in adults or more than 2% of body area in children
- Electrical/chemical burns
- NAI
99
What is the Parkland formula for calculating fluids?
TBSA of burn x Weight (kg) x 4
100
Management of burns
- ABCDE
- Analgesia/emollients for superficial burns
- Catheterise
101
Rectal cancer on the anal verge
Abdomino-perineal excision of the rectum
102
Why is the epidural analgesia good post abdominal surgery?
Accelerates the return of normal bowel function
103
Isolated fever in well patient in first 24 hours following surgery
Normal physiological reaction to operation
104
How should patients taking steroids be managed before surgery?
Switch to IV hydrocortisone
105
What is psoas sign?
Extending right hip causes pain in RIF -> appendicitis
106
What is Courvosier's sign?
Painless jaundice with a palpable gallbladder is usually indicative of pancreatic/gallbladder cancer
107
What do you not do in emergency settings with bowel obstructions caused by tumours?
Resect the bowel -> do colostomy
108
What is migratory thrombophlebitis?
Trousseau sign -> pancreatic cancer
109
Ascending cholangitis definitive management?
ERCP
110
What is the gold standard investigation for diverticulitis?
CT abdomen pelvis with contrast
111
How to distinguish between femoral and inguinal hernias?
Femoral - inferior + lateral to the pubic tubercle
Inguinal - superior + medial to the pubic tubercle
112
Recurrent UTIs + passing gas in urine in someone with diverticular disease?
Colovesical fistula formation -> cystoscopy
113
When should ACE inhibitors be stopped before surgery?
Day before
114
Management of post op poor urine output?
- Fluid challenge to assess whether hypovolaemic
- Manage underlying causes
- Catheterise if persisting to assess urine output
115
Most common organism which causes cholecystitis?
E coli
116
Indications of all the different colonic resections
AP resection - tumours <8cm from anal margin
Anterior resection - tumours >8cm from anal margin
Left hemicolectomy - tumours of descending colon, proximal sigmoid
Right hemicolectomy - tumours of caecum, ascending colon and hepatic flexure
Sigmoid colectomy - tumours of sigmoid colon
Hartmann's - used in an emergency to form temporary end colostomy
117
Hernias - men vs women
Inguinal - men
Femoral - women
118
When should Clopidogrel be stopped before surgery?
7 days before
119
High risk ingested objects such as batteries must be managed how?
Immediate endoscopy for removal
120
What is a diagnostic paracentesis?
Ascitic tap -> should be done for anyone with SBP
121
Prophylaxis of colon polyps in patient with strong FH to prevent cancer?
Panproctoprolectomy
122
What is important to check in post operative ileus?
Electrolytes
123
Colostomy ve ileostomy?
Colostomy - flat to the skin
Ileostomy - spouted
124
Indications for thoracotomy in haemothorax?
- >1.5L of blood loss initially
- >200ml per hour for >2 hours
125
What is left vs right hemicolectomy used for?
Left - tumour in distal transverse colon/descending
Right - tumour in proximal transverse/ascending
126
Acute pancreatitis Mx= Patients with acute pancreatitis due to gallstones should undergo?
early cholecystectomy
127
Acute pancreatitis Mx= Patients with obstructed biliary system due to stones should undergo?
early ERCP
128
Acute pancreatitis Mx= Patients who fail to settle with necrosis and have worsening organ dysfunction may require?
debridement, fine needle aspiration is still used by some
129
Acute pancreatitis Mx= Patients with infected necrosis should undergo?
either radiological drainage or surgical necrosectomy. The choice of procedure depends upon local expertise
130
Mx of acute anal fissure (<1w)?
soften stool:
- dietary advice: high-fibre diet with high fluid intake
- bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried
lubricants such as petroleum jelly may be tried before defecation
topical anaesthetics
analgesia
131
Mx of chronic anal fissure (>1w)?
acute Mx continued plus...
topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure
if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin
132
What is usually required when a patient presents with acute upper abdominal pain?
erect (upright CXR)
if perforated peptic ulcer will have free air under diaphragm (pneumoperitoneum)
133
Volvulus?
torsion of the colon around it's mesenteric axis resulting in compromised blood flow and closed loop obstruction.
134
Sigmoid volvulus?
Sigmoid volvulus (around 80% of cases) describes large bowel obstruction caused by the sigmoid colon twisting on the sigmoid mesocolon.
A similar problem may also occur at the caecum (20% of cases).
In most people (around 80%) the caecum is a retroperitoneal structure so not at risk of twisting.
In the remaining minority there is however developmental failure of peritoneal fixation of the proximal bowel putting these patients at risk of caecal volvulus.
135
Sigmoid volvulus associations?
older patients
chronic constipation
Chagas disease
neurological conditions e.g. Parkinson's disease, Duchenne muscular dystrophy
psychiatric conditions e.g. schizophrenia
136
Caecal volvulus associations?
all ages
adhesions
pregnancy
137
Features of volvulus?
constipation
abdominal bloating
abdominal pain
nausea/vomiting
138
Ix for volvulus?
usually diagnosed on the abdominal film
sigmoid volvulus= large bowel obstruction (large, dilated loop of colon, often with air-fluid levels) + coffee bean sign
caecal volvulus= small bowel obstruction may be seen
139
Mx of sigmoid volvulus?
rigid sigmoidoscopy with rectal tube insertion
140
Mx of caecal volvulus?
management is usually operative. Right hemicolectomy is often needed
141
Postoperative ileus (paralytic ileus)?
common complication after surgery involving the bowel, especially surgeries involving extensive handling of the bowel. There is reduced bowel peristalsis resulting in pseudo-obstruction.
142
Postoperative ileus (paralytic ileus) features?
abdominal distention/bloating
abdominal pain
nausea/vomiting
inability to pass flatus
inability to tolerate an oral diet
143
Postoperative ileus (paralytic ileus) = what is it important to check?
Deranged electrolytes can contribute to the development of postoperative ileus, so it is important to check potassium, magnesium and phosphate.
144
Postoperative ileus (paralytic ileus) = Mx?
nil-by-mouth initially, may progress to small sips of clear fluids
nasogastric tube if vomiting
IV fluids to maintain normovolaemia; additives to correct any electrolyte disturbances
total parenteral nutrition
occasionally required for prolonged/severe cases
145
abdominal distention/bloating
abdominal pain
nausea/vomiting
inability to pass flatus
inability to tolerate an oral diet
presents 2-3d following surgery eg. extensive handling of bowel?
?Postoperative ileus
if lasts >3d then prolonged ileus needs further evalutation
146
Postoperative ileus (paralytic ileus) = when does it normally happen?
normally 2-3d following surgery eg. extensive handling of bowel
if lasts >3d then prolonged ileus needs further evalutation
147
