Surgery Flashcards
Causes of poor urine output post-surgery
Pre-renal:
- Hypovolaemia
- Hypotension
- Dehydration
Renal:
- Acute tubular necrosis
Post-renal:
- BPH
- Anticholinergics or adrenoreceptor agonists - often used in anaesthetics
- Pain
- Psychological inhibition
- Opiate analgesia
Which tests should be arranged for COPD patients prior to having surgery?
COPD pts are at higher risk of post-complications due to impaired resp function, so arrange:
- Lung function tests
- CXR
- ABG (if pt is known to retain CO2)
How long should Clopidogrel be stopped before surgery?
7 days
How long should Warfarin be stopped before surgery?
5 days - then switch them to a LMW heparin until the night before
How long should ACE inhibitors be stopped before surgery?
The day before
How long should the COCP be stopped before surgery?
4-6 wks and restarted at least 2 wks afterWH
How are steroids optimised peri-operatively?
Steroid demand increases during surgery, but pt on long-term steroids cannot do this due to suppressed renal function, thus:
- Switch oral steroids to 50-100mg IV hydrocortisone
- If there is any associated hypotension then add fludrocortisone
- For minor ops then oral pred can be restarted immediately post-op, but if major then pts may require IV hydrocortisone for up to 72 hrs
How are diabetic medications optimised peri-operatively?
- Metformin (OD) = take in the morning of the surgery
- DDP-4 inhibitors = take the morning of the surgery
- GLP-1 analogues = take the morning of the surgery
- SGLT-2 inhibitors = omit the day of the surgery due to DKA risk
Insulin rules:
- Schedule pt as early in the morning as possible to reduce the length of time their NBM
- If on long-acting insulin = continue but reduce by 20%
- Stop any other insulin and begin a sliding scale insulin infusion from when the pt is NBM
- Continue infusion until pt is able to eat post-op
- Switch to normal regime after first full meal
Absolute contraindications for laparoscopic surgery
- Obvious indication for open surgery
- Acute intestinal obstruction associated w/ a >4cm bowl dilation - can obscure the view
- Uncorrected coagulopathy = INR corrected to < 1.5
- Suspected intra-abdominal compartment syndrome
- Trauma w/ haemodynamic instability
- Clear indication of bowel injury
Relative contraindications for laparoscopic surgery
- ICU pts who are too ill to tolerate pneumoperitoneum
- Presence of anterior wall infection
- Laparoscopy w/in 4-6 wks
- Extensive adhesions
- Aorto-iliac aneurysmal disease due to risk of rupture
- Pregnancy
- Cardiopulmonary compromise
- Morbid obesity
Define Achalasia
A rare neuromuscular disorder characterised by the inability of the lower oesophageal sphincter to relax during swallowing and impaired peristalsis in the oesophagus - due to the degeneration of ganglion cells w/in the myenteric plexus
Achalasia features
- Dysphagia
- Regurgitation of undigested food
- Aspiration pneumonia
- Retrosternal chest pain/heartburn - often unresponsive to PPI’s
- WL
Achalasia investigations
- Endoscopy = may reveal a dilated oesophagus w/ residual food/fluid (primarily used to rule out other pathologies)
- Oesophageal manometry (gold standard) = demonstrates a high resting pressure and incomplete relaxation of the LOS
- Barium swallow = may show bird beak appearance in advanced cases
Achalasia management
Medical (for pts unsuitable for surgery):
- Botox injections
- CCBs or nitrates
Surgical:
- Oesophageal dilation
- Heller’s myotomy = cutting the LOS to loosen it
Define Acute mesenteric ischaemia
A life-threatening surgical emergency where there is abrupt onset of hypoperfusion to a portion of the small intestine - can either be occlusive (thrombus) or non-occlusive (low flow states e.g. HF, shock, major surgery) and most commonly affects the superior mesenteric artery
Acute mesenteric ischaemia features
- Sudden severe abdo pain w/ guarding
- N&V
- Signs of shock (hypotension, tachycardia, altered mental state)
- Metabolic acidosis on ABG
- Rectal bleeding in advanced ischaemia
Acute mesenteric ischaemia investigations
CT angiography
Acute mesenteric ischaemia management
- Resuscitation
- Anti-coagulation typically w/ IV heparin
- Surgery = embolectomy, arterial bypass or bowel resection if necrosis
- Intra-arterial vasodilators
- Thromboembolic therapy
- Supportive care
What is Grey-Turners sign?
Bruising along the flank indicating retroperitoneal bleeding in acute pancreatitis
What is Cullen’s sign?
Bruising around the peri-umbilical area associated w/ pancreatitis
Acute pancreatitis investigations
- FBC, U&E, LFTs
- Lipase and amylase
- USS
- MRCP to detect obstructive pancreatitis
- Endoscopic retrograde cholangiopancreatography (ERCP) - also therapeutic
- CT after resolution to detect pseudocysts or necrotising pancreatitis
How is Acute pancreatitis graded?
Using the modified Glasgow criteria to predict the severity - usually done on admission and 48hrs after admission, w/ a score of 3 or more +ve factors indicating a transfer to ITU
List the modified Glasgow criteria for pancreatitis
PANCREAS
PaO2 < 8kPa
Age > 55
Neutrophils - WBC >15
Calcium < 2
Renal function - urea >16
Enzymes - AST/ALT >200 or LDH >600
Albumin <32
Sugar - glucose >10
Acute pancreatitis management
- A-E
- Aggressive fluid resuscitation w/ crystalloids to maintain urine output > 30mL/hr
- Catheterisation
- Analgesia - strong opioids often needed
- Anti-emetics
Local complications of Acute pancreatitis
- Peripancreatic fluid collection = accumulation of fluid around the pancreas which may lead to infection, abscess formation or progress
- Pseudocyst = fluid-filled sac that lacks true epithelial lining, can rupture, become infected or compress adjacent structures
- Abscess
- Pancreatic necrosis = requires necrosectomy
- Haemorrhage
Systemic complications of Acute pancreatitis
- ARDS
- Hypovolaemia
- DM
- Sepsis
Anal fissure management
- Treat constipation
- Lodcaine cream/jelly
- Topical vasodilators to aid healing = e.g. nifedipine or nitro-glycerine
- 2nd line = topical diltiazem (CCB) or oral nifedipine
- Screen for IBD
Define Anal fistula
An abnormal connection between the epithelialized surface of the anal canal and perianal skin that is itself epithelialized - typically begins as an infection in the anal glands, which progresses to an anorectal abscess and then becomes a fistula
Anal fistula causes
- Crohn’s (most common)
- Malignancy
- Trauma
- TB
Anal fistula features
- Anal discharge - blood/purulent
- Anal discomfort or pain, exacerbated by sitting or defecation
- Open fistula on examination
Anal fistula management
- Analgesia
- Fistulotomy (opening of the track) to enable healing
- In advanced cases - Seton placement or advancement flap procedure may be used
What is Goodsall’s law?
A rule to predict the course of a perianal fistula:
- If the external opening is anterior to the transverse anal line, the fistula is straight and opens internally anterior to the transverse line
- If the external opening is posterior to the transverse anal line (or anterior but >3cm from the anus), the tract curves and opens at the 6 o’clock position internally
Define Angiodysplasia
A vascular malformation of the GI tract characterised by the formation of fragile, leaky vessels - often in the caecum and ascending colon
Angiodysplasia features
- Chronic, intermitent painless lower GI bleeding
- Can be fresh PR (if lesions in the colon) or melaena (if lesions in upper GI tract)
Angiodysplasia management
- Endoscopic treatments = thermal coagulation, argon plasma coagulation, endoscopic band ligation
- Angiographic embolization
- Octreotide or oestrogen-progesterone replacement
Anorectal abscess features
- Perianal pain and swelling
- Low-grade pyrexia
- Tachycardia
- Sepsis if severe
Anorectal abscess management
- Drainage in A&E under local
- Incision and drainage under GA = if degree of tissue dmg unknown, or in cases of deep abscess w/ sphincter involvement
- Abx if immunosuppressed pt or sepsis
Appendicitis aetiology
Develops due to obstruction w/in the appendix (from fibrous tissue, foreign body or hardened stool) - subsequent bacterial multiplication and infiltration of the appendix wall leads to tissue damage, pressure-induced necrosis and the potential for perforation
Appendicitis complications
- Local abscess formation
- Perforation
- Gangrene
- Post-op wound infection
- Peritonitis
Appendicitis management
- Prophylactic abx
- Laparoscopic appendicectomy is 1st line following abx
- Open appendicectomy + lavage indicated if evidence of perforation
- If there is -ve imaging = non-op management w/ IV fluids and abx
Define Ascending cholangitis
Severe, acute infection and inflammation of the biliary tree - due to obstruction (gallstones, strictures, malignancy) in the common bile duct, leading to bile stasis, bacterial overgrowth and ascending infection
Ascending cholangitis features
Charcot’s triad:
- RUQ pain
- Fever
- Jaundice
Ascending cholangitis investigations
- Bloods = deranged LFTs, elevated CRP and WCC
- Imaging = abdo USS 1st line looking for bile duct dilation - the use CT/MRCP/ERCP
Ascending cholangitis management
- Resuscitation
- Biliary drainage = via ERCP (+/- stent), Percutaneous transhepatic cholangiography (PTC), surgical drainage
Define Boerhaave syndrome
A full-thickness rupture of the oesophagus which occurs due to sudden increases in intraoesphageal pressure (usually repeated episodes of vomiting)
Boerhaave syndrome features
- Severe tearing chest pain that worsens on swallowing
- Minimal or no haematemesis
- Signs of shock
- Subcutaneous emphysema
- X-ray signs = pneumomediastinum, pleural effusions, pneumothorax
Boerhaave syndrome investigations
- CXR
- CT w/ contrast
- Avoid OGD as this may exacerbate the issue
Boerhaave syndrome management
- IV fluid resus
- IV abx to cover for potential mediastinitis
- Surgical correction of rupture
What is the rule of 9’s for burns?
Method for approximating the body SA affected by a burn:
- Head = 9%
- Torso (front) = 18%
- Torso (back) = 18%
- Whole arm = 9%
- Hand = 1%
- Whole leg = 9%
Classification of burns
- Superficial epidermal (1st degree) = affects just the epidermis
- Superficial partial (2nd degree) = affects the epidermis and upper layer of dermis
- Deep partial (2nd degree) = affects the epidermis, upper and deeper layers of the dermis
- Full thickness (3rd degree) = affects all layers of the skin to subcut tissue, can extend into muscle and bone (4th degree)
Burns features
- Superficial = painful, doesn’t blister or scar
- Partial thickness =Blisters and weeps, painful, increased risk of infection and scaring
- Full thickness = dry, insensate to light touch and pin prick, high risk of infection
Burns management
- A-E
- Pain management, usually w/ opiates
- IV fluids are required for children w/ burns >10% or BSA, and adults w/ burns >15% of BSA
- Fluid resus using the Parkland formula = %BSA burnt x weight x 4, half the fluid given over 8 hrs, the rest over 16
- Wound care
- Tetanus prophylaxis
- Refer to burns unit
- Skin graphs for full thickness burns
Burns complications
- Curling ulcer = stress-induced gastric ulcers due to psychological stress response
- Airway compromise from smoke inhalation
Cholangiocarcinoma risk factors
- Hx of gallstone or chronic cholecystitis
- Porcelain gallbladder
- Smoking
- Obesity
- PSC
- IBD
- Oestrogen exposure
- Occupational = pesticides, radiation, heavy metals and vinyl chloride
Cholangiocarcinoma features
- Abdo pain
- Jaundice
- Anorexia
- WL
- Courvoisier’s sign = painless, palpable gallbladder w/ jaundice is unlikely to be gallstone - more likely to be pancreatic or gallbladder cancer
Cholangiocarcinoma investigations
- Bloods
- USS 1st line
- CT
- ERCP for direct visualisation and biopsies
Define Cholecystitis
Acute/chronic inflammation of the gallbladder, usually due to gallstone obstruction - common organisms = E.coli (most common), klebsiella, enterococcus
Classification of Cholecystitis
- Acute = sudden onset inflammation, usually due to blockage of the cystic duct by gallstones, leading to bile build-up and inflammation
- Chronic = long-term inflammation due to repeated irritation by gallstones, overtime this causes thickening if the gallbladder wall and decrease in function - has milder symptoms than acute
- Calculous = cholecystitis caused by gallstone
- Acalculous = cholecystitis w/out gallstones - associated w/ critical illness, severe trauma or prolonged fasting which can lead to gallbladder stasis and ischaemia
Cholecystitis features
- RUQ/epigastric pain, which can radiate to the right shoulder
- Fever
- N&V
- +ve Murphy’s sign (pain on inspiration during palpation of the RUQ)
Cholecystitis management
Acute calculous:
- Conservative = in mild cases pt may be managed w/ bowel rest, fasting and IV fluids
- Abx
- Laparoscopic cholecystectomy - recommended to be during the same hospital admission or w/in a week
Chronic:
- Elective cholecystectomy
- Symptomatic management -= e.g. dietary modifications
Acalculous:
- Prompt cholecystectomy
Cholecystitis complications
- Empyema (gallbladder filled w/ pus)
- Gangrenous cholecystitis
- Perforation
- Abscess formation
- Bile duct obstruction
- Fibrosis
Define Chronic mesenteric ischaemia
A pathological condition presenting in elderly pts where there is insufficient blood flow to the intestines, usually due to a gradual blockage or narrowing of the mesenteric arteries
Chronic mesenteric ischaemia features
- Diffuse, colicky abdo pain, which worsens after eating
- Sig WL as pts avoid eating due to the pain
- Diarrhoea
- GI bleeding secondary to mucosal sloughing
- Abdo tenderness
- Epigastric bruit due to turbulent flow in the narrowed vessels
Chronic mesenteric ischaemia investigations
- ABG to check for raised lactate
- Duplex USS
- CT angiography (gold standard)
- Mesenteric angiography
Chronic mesenteric ischaemia management
- Risk factor management = stop smoking, diabetic control, statins
- Symptomatic relief = vasodilators
- Revascularization = percutaneous transluminal angioplasty
Chronic pancreatitis causes
- Primarily chronic alcoholism
- CF
- Pancreatic cancer
- Elevated triglycerides
Acute pancreatitis causes
Gallstones
Ethanol
Trauma
Steroids
Mumps
AI disease
Scorpion bites
Hypercalcaemia, hypertriglyceridemia, hypothermia
ERCP
Drugs (FATSHEEP below)
Furosemide
Azathioprine
Thiazide/tetracycline
Statins/sulphonamides/sodium valproate
Hydrochlorothiazide
Estrogens
Ethanol
Protease inhibitors
Chronic pancreatitis features
- Epigastric pain exacerbated by eating fatty foods (comes on after 15-30 min) and relieved by sitting forwards
- Bloating
- WL
- Symptoms of exocrine dysfunction (malabsorption and steatorrhea)
- Symptoms of endocrine dysfunction (e.g. DM)
- Epigastric tenderness
Chronic pancreatitis investigations
- Bloods = glucose, faecal elastase (low of exocrine insufficiency)
- Imaging = CT/X ray to show pancreatic calcification
Chronic pancreatitis management
- Analgesia
- Endocrine replacement (insulin)
- Exocrine replacement (Creon = amylase, lipase and protease)
- Invasive = coeliac plexus block and pancreatectomy
TNM staging for colorectal cancer
T:
- Tis = carcinoma in situ
- T1 = extends through the mucosa into submucosa
- T2 = extends through the submucosa into the muscularis
- T3 = extends through the muscularis into the subserosa
- T4 = extends into neighbouring organs and tissues
N:
N0 = no regional lymph node involvement
- N1 = 1-3 regional lymph nodes
- N2 = 4 or more regional lymph nodes
M:
- M0 = no distant mets
- M1 = distant mets
Colorectal cancer screening program
FIT tests every 2 years form men and women 60-74 - if +ve then referred for colonoscopy
Colon cancer management
Stage I-III (no mets) = surgical resection +/- adjuvant chemo
Stage IV (mets) = neoadjuvant chemo + surgical resection
Rectal cancer management
- Tumours > 8cm from the anal canal, or involving proximal 2/3 of the rectum = anterior resection
- Tumours <8cm from the anal canal or involving the distal 1/3 of the rectum = Abdominal-perineal resection
Stages III-Iv benefit from adjuvant chemo
Which hereditary conditions predispose pts to colorectal cancer?
- FAP - need a prophylactic proctocolectomy or virtually guaranteed to have cancer by 20s
- HNPCC/Lynch syndrome = regular endoscopic surveillance, 80% develop cancer by 30s
- Peutz-Jeghers syndrome = present w/ mucocutaneous pigmentation and hamartomatous polyps
Define Indirect inguinal hernias
Hernias which follow the path of the decent of the testes, via the processus vaginalis during foetal development - typically congenital
Define Direct inguinal hernias
Hernias which protrude through a weakness in the abdo wall, specifically the inguinal triangle
Define Incarcerated hernia
A hernia which cannot be reduced - prone to strangulation
Inguinal hernia features
General = groin swelling, pain, palpable mass
Indirect = may decent into scrotum, is reducible , more prone to strangulating
Direct = usually irreducible
Define Diverticulosis
The presence of diverticula in the small intestine - most commonly in the sigmoid colon
Define Diverticulitis
When diverticula become inflamed/infected
Diverticulitis features
- LLQ pain
- Fever
- N&V
- Diffuse abdo pain suggestive of perforation
Dysphagia causes
- Neuro = cerebrovascular disease, Parkinson’s, MND, myasthenia gravis, bulbar palsy
- Motility disorders = achalasia, diffuse oesophageal spasm, systemic sclerosis
- Mechanical/obstructive causes = benign strictures, malignancy, pharyngeal pouch, extrinsic pressure from LC/mediastinal lymph nodes
- Other = oesophagitis, Plummer-Vinson syndrome
How do distinguish dysphagia causes based on the dysphagia features
- Motility disorders = liquids and solids equally affected from the start
- Strictures = progressive dysphagia or solids then liquids
- Neuro = difficulty in making the swallowing motion
- Candida = odynophagia
- Pharyngeal pouch = bulging neck on swallow, gurgling, halitosis
- Plummer-Vinson’s syndrome = upper oesophageal web, post cricoid dysphagia, iron def anaemia
- Diffuse oesophageal spasm = intermittent dysphagia
Define Femoral hernia
A hernia on the femoral canal - an irreducible lump in the groin located inferior to the inguinal ligament and inferior and lateral to the pubic tubercle
Femoral hernia management
Urgent surgery due to the high risk of strangulation - ether open or laparoscopic repair w/ mesh placement
Factors that contribute to gallstone formation
1) Super-saturation of bile w/ cholesterol
2) Gallbladder dysmotility leading to stasis
3) Excessive bilirubin excretion
Types of gallstones
1) Pigment (<10%) = associated w/ haemolysis, stasis and infection
2) Cholesterol (90%) = associated w/ female sex, increasing age and obesity
3) Mixed
Biliary cholic features
Colicky RUQ pain, worse after eating
Define Mirizzi’s syndrome
RUQ pain and intermittent jaundice caused by extrinsic compression of the common hepatic duct by an impacted stone in the cystic duct or gallbladder neck
Which imaging modality is most accurate for detecting gallstones?
MRCP
Gastric cancer features
Dyspepsia + ALARM:
- Anaemia
- Loss of weight
- Anorexia
- Recent onset of symptoms
- Malena/haematemesis
Lymphadenopathy = Virchow’s node, Sister Mary Joseph nodule
Gastric cancer investigations
- OGD + biopsy under 2WW
- Staging USS and CT
Gastric cancer management
Locally invasive disease = partial or total gastrectomy + neoadjuvant chemo
Advanced disease = palliative +/- surgery for symptomatic relief
5yr survival of 20%
Groin lump differentials
Superficial structures:
- Lipomas = soft, movable mass under the skin
- Sebaceous cysts = skin lumps that may be filled w/ keratin and can become infected and tender
- Psoas abscess = groin pain, fever, difficulty moving the hip
NAVY structures:
- Neuroma = localised pain and tenderness, often hx of prior trauma
- Femoral artery aneurysm = pulsatile mass, w/ possible limb ischaemia if ruptures
- Saphena varix = visible and palpable lump, often bluish and varicose-vein like
- Lymphadenopathy
Canals:
- Femoral hernia
- Inguinal hernia
Undescended testes
Causes of haematemesis
- Peptic ulcers (esp duodenal which may erode into blood vessels)
- Oesophageal varices
- GI tumours
- Mallory-Weiss tears
- Coagulopathies
- NSAIDs
- Post-tonsillectomy bleeding
Haematemesis management
- Resuscitation
- Endoscopic haemostasis = sclerotherapy, band ligation or coagulation therapy to stop active bleeding
- PPIs
- Surgery
Haemorrhoid grades
1) No prolapse
2) Prolapse on straining which spontaneously reduces
3) Prolapse on straining and requires manual reduction
4) Prolapse on straining and can’t be manually reduced, external haemorrhoids, or lower grade haemorrhoids failing to respond to less invasive measures
Define Haemorrhoids
When the vascular cushions w/in the anal canal abnormally expand and can protrude outside the anal canal
Haemorrhoid features
- Bright red PR bleeding, associated w/ defecation and on wiping
- Absence of pain
- Anal pruritus
- Palpable mass
Haemorrhoids management
- Grade 1 = conservative - dietary advice, topical corticosteroids to alleviate itching, lidocaine gels
- Grade 2 = rubber band ligation (preferred), sclerotherapy or infrared photocoagulation
- Grade 3 = Rubber band ligation
- Grade 4 = Surgical haemorrhoidectomy
Hepatocellular carcinoma investigations
Bloods:
- LFTs
- U&Es
- CRP
- FBC
- AFP (tumour marker)
Imaging = USS 1st line, staging CT
Liver biopsy is gold standard for diagnosis
Hepatocellular carcinoma management
- Radical hepatic resection if lesion is < 3cm
- Percutaneous radiofrequency ablations and tumour embolization can be used as adjuvant therapies
- Palliative care for most pts
Large bowel obstruction features
- Cramping abdo pain
- Bloating
- Absolute constipation (even to flatus)
- N&V late signs - including feculent vomiting
Large bowel obstruction investigations
- Abdo X ray is diagnostic (shows dilated loops of bowel)
- CT abdo to identify the cause (e.g. cancer)
Large bowel obstruction management
- NG tube insertion + drip and sick to help decompress the bowel
- IV fluids
- Anti-emetics
- Decompress sigmoid volvulus (of that’s the cause) = flexible sigmoidoscopy
- Surgical intervention = colonic resection w/ anastomosis or stoma formation - required in 70% of cases
Define Epigastric hernia
A hernia located in the midline between the umbilicus and xiphisternum - caused by a protrusion of extraperitoneal fat or omentum though a defect in the line alba
Define Richter’s hernia
A hernia where only the antimesenteric part of the bowel wall herniates, w/out compromising the whole bowel - can be inguinal or femoral - because the whole lumen is not involved, they can strangulate or necroes w/out obstruction
Define Spigelian hernia
Herniation through the transversus abdominis aponeurosis along the semilunar line - typically affects middle aged women
Define Obturator hernia
Herniation through a defect in the neurovascular bundle which passes though the obturator foramen (in the hip) - presents w/ paraesthesia along the medial thigh or bowl obstruction
Define Lower GI bleeding
Bleeding which originates from the GI tract distal the ligament of Treitz = distal duodenum and beyond - anything above that results in haematemesis and melaena as apposed to haematochezia and PR bleeding
Causes of PR bleeding
- Vascular = angiodysplasia, ischaemic colitis
- IBD
- Infective colitis
- Neoplasm = colorectal cancer, anal cancer
- Anatomical = anorectal haemorrhoids, anal fissure, diverticular disease, Meckel’s diverticulum, polyps
- Upper GI bleed w/ rapid transit
- Endometriosis
Define Wound dehiscence
A post-op complication when there is partial or complete separation of the layers of the surgical wound - most commonly occurs post abdo surgery
Wound dehiscence features
- Sudden sharp pain at wound site
- Serous drainage from the wound
- Fever
- Visible internal tissue or organs
-Increased abdo girth - Often occurs w/in 1 week post-op, but timing can vary
Wound dehiscence management
- Immediately cover the wound w/ sterile gauze soaked in saline solution
- Transfer the pt promptly to theatre for wound repair which may involve re-suturing, wound vacuum therapy, other surgical interventions
- Address underlying systemic issues e.g. poor nutrition or DM
Mesenteric adenitis features
- Often comes on post-viral infection
- Diffuse abdo pain - mimics appendicitis
- Generalised abdo tenderness
- Pharyngitis/sore throat
- Unaltered appetite
Define Necrotising fasciitis
Life-threatening infection characterised by rapidly progressing inflammation and necrosis of the fascia and subcut tissue - it spreads along the fascial planes and typically spares the underlying muscle
Necrotising fasciitis causative organisms
- Group A strep
- Staph aureus
- Clostridium perfringens (causes gas gangrene)
Define Fournier’s gangrene
Necrotising fasciitis of the perineum - SGLT-2 inhibitors are a RF
Necrotising fasciitis features
- Pain disproportionate to clinical signs
- Minimal inflammation at the early stages
- Crepitus upon palpation and potential visibility of gas on imaging
- As disease progresses, skin changes may occur = dark discolouration, blistering and necrosis
- Pain subsides as nerves are destroyed
- Widespread oedema extending beyond the area of erythema
- Systemic illness
Necrotising fasciitis classification
Type 1 = polymicrobial - frequently involving anaerobes
Type 2 = monomicrobial - usually Strep pyogenes or Staph aureus
Types 3 = gas gangrene - usually Clostridium perfringens
Necrotising fasciitis management
- Urgent surgical debridement = wide margin excision of the necrotic tissue to control the infection
- Broad spectrum abx = IV clindamycin, meropenem or vancomycin
- Haemodynamic support = IV fluids, vasopressors, ICU admission
Which type of carcinomas are found in the oesophagus?
Upper 2/3rds = SCC
Lower 1/3 = adenocarcinoma
Oesophageal carcinoma features
- Progressive dysphagia
- WL
- Odynophagia
- Hoarseness
Oesophageal carcinoma investigations
Urgent OGD w/in 2wks for pts w/ dysphagia or those aged 55 and over w/ WL and any of: upper abdo pain, reflux or dyspepsia
Oesophageal carcinoma management
- Surgical resection (best choice for localised disease)
- Endoscopic therapies = endoscopic mucosal resection or endoscopic submucosal dissection of early-stage disease
- Non-surgical = radio/chemotherapy
Pancreatic cancer features
Early-stage is usually non-specific symptoms:
- Malaise
- Abdo pain
- Nausea
- WL
- Painless jaundice
- Courvoisier’s sign
Advanced disease can present w/ complications:
- Obstructive jaundice = tumour on the head of the pancreas
- New-onset DM = tumour of the body/tail of the pancreas
- Unexplained pancreatitis
- Exocrine dysfunction and steatorrhea
- Paraneoplastic syndromes = Trousseau’s syndrome (migratory thrombophlebitis) or marantic endocarditis
- DIC
Metastasises early to lung, liver and bowel
Pancreatic cancer investigations
- Initial assessment w/ abdo USS to detect tumours >2cm, liver mets and any dilation of the common bile duct
- CT abdo-pelvis
- MRCP
- Endoscopic USS to detect small lesion (2-3mm)
- PET-FDG
Pancreatic cancer management
- Surgical resection (Whipple procedure = pancreaticoduodenectomy) is only curative treatment - only 15-20% of pt present w/ resectable disease
- Palliative care for the rest of the pts = stenting the bile duct, chemo, radiotherapy
Define Parenteral feeding
The provision of nutrients directly to a pts bloodstream when oral or enteral intake is no possible or sufficient, there are 2 types:
1) total parenteral nutrition (TPN) = provides all essential nutrients via a central venous catheter
2) Peripheral parenteral nutrition (PPN) = a less concentrated solution delivered via peripherally inserted central catheter (PICC line)
Complications of Parenteral feeding
- Thrombosis
- Sepsis from an infected line
- Electrolyte imbalances
- Hyperglycaemia
- Metabolic acidosis
- Villous atrophy
- Infective endocarditis
What is the most common type of peptic ulcer?
Duodenal
Peptic ulcer causes
Duodenal:
- H. pylori
- NSAIDs
- Long-term steroids
- SSRIs
- Increased secretion of gastric acid
- Smoking
- Blood group O
- Accelerated gastric emptying
Gastric:
- NSAIDs
- H. pylori
- Smoking
- Delayed gastric emptying
- Severe stress
How can you distinguish between duodenal and gastric ulcers based on symptoms?
Duodenal ulcer pain is relieved on eating = closure of pyloric sphincter, less acid irritating the ulcerated surface
Gastric ulcer pain is worsened by eating = increased acid production in response to food
Peptic ulcer investigations
- Pts >55 w/ WL and dyspepsia should have an OGD under 2ww
- C-13 urea breath test for H. pylori (ensure pt hasn’t had a PPI for 2wks or abx for 4wks)
- Endoscopy +/- biopsy is gold standard for diagnosis
Peptic ulcer management
H. pylori +ve = 7 days of triple therapy (PPI + amoxicillin + clari/metro) and then continue the PPI for another 7wks (8 in total)
H. pylori -ve = PPI for 4-8 wks + lifestyle advice
Repeat OGD/C-13 urea test 6-8 wks later to ensure ulcer is healing
Causes of Peritonitis
- Perforation of a hollow viscus = Boerhaave’s, peptic ulcers, intestinal perforations
- Infections
Peritonitis features
- Severe abdo pain - pt will lie completely still to not trigger the pain
- Systemic symptoms
- N&V
- Abdo rigidity + involuntary guarding (to protect inflamed organs)
- Rebound tenderness (pain is worse as the peritoneum bounces back into place)
- Percussion tenderness
Define Pilonidal disease
A chronic inflammatory condition characterised by the penetration of hairs into the skin, commonly occurring at the natal cleft - this can result in a discharge sinus which can leak fluid, or become infected to form an abscess
Pilonidal disease features
- Offensive discharge from the natal cleft
- Discomfort, esp whilst seated
- Visible sinus tract around the natal cleft
- Visible abscess
Pilonidal disease
- Conservative = meticulous hygiene, hair removal, warm baths
- Abx’s of infected
- Incision and drainage of abscesses
- If persistent can do surgery = sinus tract excision, marsupialization
Define Post-op pyrexia
The development of a fever >38 following a surgical procedure
Causes of Post-op pyrexia
5 W’s:
- Wind = pneumonia and atelectasis (1-2 days post-op)
- Water = UTIs (>3 days)
- Wound = infections (>5 days)
- Wonder drugs = malignant hyperthermia due to halothane or suxamethonium anaesthesia
- Walking = DVT (>1 week)
Surgical site infection management
Mild (erythema, no fever):
- Analgesia
- Oral abx
- Regular wound dressing changes
Severe (discharge, fever, evidence of abscess):
- Wound swaps for culture
- IV abx
- If abscess is present = reopening of wound for drainage and debridement
- Allow wound to heal by secondary intention (open, not stitched closed)
Causes of small bowel obstruction
- Adhesions
- Intra-abdominal hernias
- Crohn’s disease (strictures)
- Appendicitis
- Malignancy
- Foreign body
- Gallstone ileus
- Intussusception
- Volvulus
- Intestinal atresia
Small bowel obstruction features
- Abdo pain w/ distention - colicky pain that becomes continuous
- Bloating
- N&V (early sign)
- Failure to pass flatus or stool (later sign)
- Tympanic, high pitched bowel sounds on auscultation
Small bowel obstruction management
- ABCDE resuscitation
- NG tube + fluids for drip and suck to decompress the bowel
- Gastrografin
- Surgery to relieve the obstruction if conservative management fails
Causes of massive splenomegaly
All have M:
- Malaria
- LeishManiasis
- CML
- Myelofibrosis
Splenomegaly features
- Abdo discomfort or fullness
- Early satiety
- Easy bruising/bleeding due to thrombocytopenia
- Anaemia
- Enlarged spleen on palpation
Ileostomy VS Colostomies
Ileostomy = stoma from the ileum:
- Location = RIF
- Stoma appearance = spouted to keep irritating SB content from the skin
- Output = liquid
Colostomy = stoma from the colon:
- Location = LIF
- Stoma appearance = Flush to the skin
- Output = Solid or semi-solid content
Patient has an ileostomy and no anus, what procedure did they have?
Panproctocolectomy (e.g. for UC)
Patient has an colostomy and no anus, what procedure did they have?
Abdominoperineal resection (e.g. for low rectal cancer)
Stoma complications
- Early mechanical = bowel ischaemia/necrosis, para-stomal abscess
- Early functional = poor/high stoma output
- Late mechanical = para-stomal hernia, bowel stenosis and prolapse, bowel obstruction, para-stomal dermatitis
- Late functional = bowel dysmotility, malabsorption (esp Vit B12 if terminal ileum is removed)
- Psychological
Types of absorbable sutures
Synthetic = vicryl, monocryl, PDS
Natural = catgut, collagen
Types of non- absorbable sutures
Synthetic = nylon, prolene, polyester
Natural = surgical silk
How does the diameters of sutures work?
1-0 is thick and used for closing the skin in procedures such as laparotomies
7-0 is much thinner and is used in facial lacerations
Define Abdominoperineal (AP) resection
The removal of the proximal sigmoid colon, rectum and anus using both abdominal and perineal incision. The bowel end is exteriorised to form a permanent end colostomy - used for tumours <8cm from the anal margin
Define Anterior resection
The resection of the tumour and formation of a primary anastomosis between the 2 ends of bowel - used for tumours >8cm from the anal margin
Define Left hemicolectomy
Removal of the splenic flexure (distal end of the transverse colon), descending colon and proximal sigmoid colon
Define Right hemicolectomy
Removal of the caecum, ascending colon and hepatic flexure (proximal end of the transverse colon)
Define Sigmoid colectomy
Removal of the sigmoid colon
Define Panproctocolectomy
Removal of the entire colon and formation of a permanent end ileostomy - usually done for refractive UC
Define Hartmann’s procedure
A sigmoid colectomy, with the proximal colon exteriorised to form a temporary end colostomy, and the distal bowel over sewn as a rectal stump - this is used in emergencies and an later be anastomosed
Define Volvulus
The abnormal twisting or rotation of the GI tract around its mesenteric axis - leads to bowel obstruction and potential vascular compromise
Typically occurs at the caecum or sigmoid colon
Volvulus investigations
- Bloods = may show raised inflammatory markers and raised lactate if ischaemia
- Abdo X-ray = coffee bean sign or birds beak sign
- CT scan
Volvulus management
- Endoscopic detorsion = using a rigid sigmoidoscopy w/ rectal tube inserted to untwist the bowel
- Surgical intervention if that doesn’t work
- Fluids, analgesia and abx (if ischaemia suspected)
