Surgery Flashcards
pain Mx (eg. pt controlled anaesthesia); anastomotic leak; breast cyst
Medical management of SBO?
IV fluids and gastric decompression, or ‘drip-and-suck’
Neutrophil predominant leucocytosis suggests what?
Appendicitis
Why is appendicitis pain felt in umbilical first?
- Inflammation of the visceral peritoneum is felt in T10 which corresponds to periumbilical region -> no somatic sensation here
Why does appendicitis pain move to RIF?
Parietal peritoneum becomes involved which receives somatic innervation therefore pain is localised to area affected
What is a diverticulum?
Outpouching of the gut mucous through the muscle wall
Which part of the colon is diverticula common in?
Sigmoid - as majority of water has already been reabsorbed by this stage therefore high intraluminal pressures
Diverticulosis vs Diverticulitis vs Diverticular disease
Diverticulosis - presence of diverticula
Diverticular disease - symptomatic diverticula
Diverticulitis - inflammation of the diverticula
What is the possible complications of diverticulitis?
- Perforation
- Bleeding
- Abscess
- Fistulas
What are the 6 Ps of limb ischaemia?
Pallor, pain, pulseless, paraesthesia, perishingly cold, paralysis
Acute limb ischaemic vs critical limb ischaemia?
Critical - last longer than 2 weeks and foot will be warm with pink appearance
What is the management of acute limb ischaemia?
Immediate referral to vascular
Thrombotic cause - angio/surgery
Embolic cause - embolectomy
What is initially added with GnRH agonists for metastatic prostate cancer?
Anti-androgens to prevent tumour flare which can cause bone pain, bladder obstruction and other symptoms
fever, hypotension and a rash → desquamation
Staph toxic shock syndrome
Different surgical signs
Rosving - appendicitis
Boas - cholecystitis
Murphy’s - cholecystitis
Cullens - pancreatitis
Grey-Turner - pancreatitis
What are risk factors for abdominal wall hernias?
- Obesity
- Ascites
- Increasing age
What are features of abdominal wall hernias?
- Palpable lump
- Cough impulse
- Pain
- Obstruction
- Strangulation
What is the most common hernia and who is it common in?
Inguinal - men
Lump in the midline between the umbilicus and xiphisternum?
Epigastric hernia -> common in those doing extensive physical training/chronic cough
Management of congenital inguinal hernias?
Surgical repair ASAP as risk of incarceration
What is abdominal wound dehiscence?
- When the layers of abdominal mass closure fail and the viscera protrude out
- RF include malnutrition, jaundice and poor surgical technique
What is the management of sudden full dehiscence?
- Coverage of wound with saline gauze
- IV Abx
- Analgesia
- Fluids
- Return to theatre
What blood test would point to appendicitis?
Neutrophil-predominant raised WCC
Investigations for Appendicitis?
Thin, male patients - clinical
Women - US useful to rule out pelvic pathology
How to reduce wound infection rates in appendicectomy?
Prophylactic IV Abx
What is cryptorchidism?
Undescended testis which fails to reach bottom of scrotum by 3 months
What is the major complication of undescended testes?
Testicular cancer - massive increased risk
What is the treatment of cryptoorchidism?
Orchidopexy at 6-18 months
A sinusoidal ECG pattern is indicative of what?
Severe hyperkalaemia
What are common complications of enteral feeding?
Diarrhoea
What is a femoral hernia?
When a section of the bowel passes into the femoral cancel - more common in females
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
What is the management of inguinal hernias?
Surgical repair due to the high risk of strangulation
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
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
What is a hiatus hernia?
Herniation of part of the stomach above the diaphragm
What is the most common type of hiatus hernia?
Sliding - gastroesophageal junction moves above the diaphragm
How does a hiatus hernia present?
- Heartburn
- Dysphagia
- Regurg
- Chest pain
How to manage hiatus hernia?
- Barium swallow
- Conservative: weight loss
- Medical: PPI
- Surgical: only for symptomatic
How to manage inguinal hernias?
- Refer and treat even if asymptomatic
- Unliteral: open surgery
- Bilateral/recurrent: laparoscopy
What are the 2 most common liver cancers?
- Hepatocellular carcinoma
- Cholangiocarcinoma
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
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
Admission criteria for acute lower GI bleed?
- Over 60
- Unstable
- On aspirin/NSAIDs
- Significant co-morbidities
What are complications of massive haemorrhage?
- Hypothermia
- Hypocalcaemia
- Hyperkalaemia
- Delayed transfusion reactions
Which nerve can be damaged in carotid endardectomy?
Hypoglossal
Where is the most common site of oesophageal rupture?
Left postero-lateral oesophagus
What is the name for free air in the abdomen?
Pneumoperitoneum - Rigler’s sign
What is haemorrhagic shock?
- Occurs following trauma
- Control bleeding and then transfuse if needed
What is neurogenic shock?
- Occurs following spinal cord transection
- Decreases peripheral vascular resistance causing shock
- Decreases CO -> shock
What is cardiogenic shock?
- Caused by IHD
- Supportive treatment plus echo needed
What is the most common cause of SBO?
- Adhesions
- Hernias
How does SBO present?
- Diffuse abdo pain
- Vomiting then constipation
- Lack of flatulence
- Abdo distension and tinkling bowel sounds
How is SBO managed?
- Abdo X ray
- CT - gold standard
- Patients need to be NBM, IV Fluids and NG tube with free drainage
What is a strangulated hernia?
Blood supply to the hernia is compromised causing episodes of pain and an irreducible hernia
Management of strangulated hernias
- Immediate surgery
- Do not manually try to reduce whilst waiting for surgery
What line divides internal and external haemorrhoids?
Dentate line
What are symptoms of haemorrhoids?
- Itching
- Rectal fullness
- Soiling
- Pain
What are investigations for haemorrhoids?
FBC
Proctoscopy
Sigmoidoscopy
What are conservative options to manage haemorrhoids?
- Increase fluid/fibre intake
- Analgesia
- Bed rest
- Topical steroids/anaesthetics
What are medical/surgical management options to manage haemorrhoids?
- Rubber band ligation
- Cryotherapy
- Haemorrhoidectomy
- Stapled haemorrhoidopexy
What are complications of haemorrhoids?
- Ulceration
- Strictures
- Thrombosis
- Infection
- Anaemia
How would acute mesenteric ischaemia show on ABG?
Metabolic acidosis
What bloods can indicate AMI?
Raised WCC, raised lactate, raised Hb
What is the management of AMI?
- Laparotomy
- Fluids, Abx, Analgesia, Heparin
What does red pulp and white pulp of spleen do?
Red - filter and destroys RBC
White - Lymphoid tissue which acts on immune system
What are indications for splenectomy?
- Trauma
- Spontaneous rupture
- Hypersplenism
- Abscess
- Neoplasia
What are Howell-Jolly bodies?
RBC where the nuclear remnant is still seen
What are complications of pancreatitis?
Early - shock, sepsis, DIC, renal failure
Late - necrosis, abscess, thrombosis of arteries, chronic pancreatitis
Where is pain in small bowel vs large bowel?
Small - pain is higher as midgut structure
Ileus vs mechanical obstruction
Absence of bowel sounds - ileus
Tinkling bowel sounds - mechanical obstruction
What is the management of bowel obstruction?
Bowel rest - drip and suck: NBM with NG tube
What are types of gallstones?
- Pigment stones
- Cholesterol stones
- Mixed stones
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
What are causes of HCC?
- Viral hepatitis
- Cirrhosis
- Parasites
- Steroids
- COCP
What tumour marker is associated with HCC?
AFP
C-KIT gene mutation
Gastrointestinal stromal tumour
Bruising to flanks?
Grey-Turners -> Pancreatitis
Iron deficiency anaemia, dysphagia, pallor?
Plummer-Vinson syndrome
What is Mirizzi syndrome?
A complication of gallstones where a duct is compressed by a gallstone
What are complications of obstructive jaundice?
- Sepsis
- Encephalopathy
- Coagulopathy
- Hepatic failure
What bacteria are people with obstructive jaundice susceptible to?
Gram neg sepsis
What is the bilirubin pathway?
- By product of haem metabolism
- Excreted through bile into the bowel
- Metabolised to urobilinogen and stercobilinogen
Treatment of metastatic oesophageal cancer with recurrent vomiting?
Stenting to allow food to pass and relieve symptoms
What bacteria are post splenectomy patients susceptible to?
- Strep pneumoniae
- H influenzae
- E coli
- Klebsiella pneumoniae
Gastric vs Duodenal ulcer
- Both more common in men
- Duodenal in younger patients
Investigation for suspected bowel perforation?
Erect CXR
What is Hartmann’s procedure?
Sigmoid colon is removed and stoma created
Medical management of anal fissure?
Acute
- High fibre and fluid
- Bulk forming laxatives
Chronic
- Topical GTN
- Sphincterotomy if GTN does not help
What can be used to defunction the colon to prevent an anastomosis?
Loop ileostomy
What drugs can cause pancreatitis?
- Azathioprine
- Mesalazine
Large volume paracentesis for ascites requires what to reduce mortality risk?
IV human albumin solution
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
How to assess extent of burns?
- Wallace Rule of Nines
- Lund and Browder chart
What are signs of superficial burns?
Red, painful, dry and no blisters
What are signs of partial thickness superficial burns?
Pale pink, blistered with slow capillary refill
What are signs of partial thickness dermal burns?
White with reduced sensation and painful for deep pressure
What are signs of full thickness burns?
White/black burns, no blisters with no pain
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
What is the Parkland formula for calculating fluids?
TBSA of burn x Weight (kg) x 4
Management of burns
- ABCDE
- Analgesia/emollients for superficial burns
- Catheterise
Rectal cancer on the anal verge
Abdomino-perineal excision of the rectum
Why is the epidural analgesia good post abdominal surgery?
Accelerates the return of normal bowel function
Isolated fever in well patient in first 24 hours following surgery
Normal physiological reaction to operation
How should patients taking steroids be managed before surgery?
Switch to IV hydrocortisone
What is psoas sign?
Extending right hip causes pain in RIF -> appendicitis
What is Courvosier’s sign?
Painless jaundice with a palpable gallbladder is usually indicative of pancreatic/gallbladder cancer
What do you not do in emergency settings with bowel obstructions caused by tumours?
Resect the bowel -> do colostomy
What is migratory thrombophlebitis?
Trousseau sign -> pancreatic cancer
Ascending cholangitis definitive management?
ERCP
What is the gold standard investigation for diverticulitis?
CT abdomen pelvis with contrast
How to distinguish between femoral and inguinal hernias?
Femoral - inferior + lateral to the pubic tubercle
Inguinal - superior + medial to the pubic tubercle
Recurrent UTIs + passing gas in urine in someone with diverticular disease?
Colovesical fistula formation -> cystoscopy
When should ACE inhibitors be stopped before surgery?
Day before
Management of post op poor urine output?
- Fluid challenge to assess whether hypovolaemic
- Manage underlying causes
- Catheterise if persisting to assess urine output
Most common organism which causes cholecystitis?
E coli
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
Hernias - men vs women
Inguinal - men
Femoral - women
When should Clopidogrel be stopped before surgery?
7 days before
High risk ingested objects such as batteries must be managed how?
Immediate endoscopy for removal
What is a diagnostic paracentesis?
Ascitic tap -> should be done for anyone with SBP
Prophylaxis of colon polyps in patient with strong FH to prevent cancer?
Panproctoprolectomy
What is important to check in post operative ileus?
Electrolytes
Colostomy ve ileostomy?
Colostomy - flat to the skin
Ileostomy - spouted
Indications for thoracotomy in haemothorax?
- > 1.5L of blood loss initially
- > 200ml per hour for >2 hours
What is left vs right hemicolectomy used for?
Left - tumour in distal transverse colon/descending
Right - tumour in proximal transverse/ascending
Acute pancreatitis Mx= Patients with acute pancreatitis due to gallstones should undergo?
early cholecystectomy
Acute pancreatitis Mx= Patients with obstructed biliary system due to stones should undergo?
early ERCP
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
Acute pancreatitis Mx= Patients with infected necrosis should undergo?
either radiological drainage or surgical necrosectomy. The choice of procedure depends upon local expertise
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
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
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)
Volvulus?
torsion of the colon around it’s mesenteric axis resulting in compromised blood flow and closed loop obstruction.
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.
Sigmoid volvulus associations?
older patients
chronic constipation
Chagas disease
neurological conditions e.g. Parkinson’s disease, Duchenne muscular dystrophy
psychiatric conditions e.g. schizophrenia
Caecal volvulus associations?
all ages
adhesions
pregnancy
Features of volvulus?
constipation
abdominal bloating
abdominal pain
nausea/vomiting
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
Mx of sigmoid volvulus?
rigid sigmoidoscopy with rectal tube insertion
Mx of caecal volvulus?
management is usually operative. Right hemicolectomy is often needed
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.
Postoperative ileus (paralytic ileus) features?
abdominal distention/bloating
abdominal pain
nausea/vomiting
inability to pass flatus
inability to tolerate an oral diet
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.
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
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
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
