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Year 6 > Surgery > Flashcards

Surgery Flashcards

1
Q

Causes of poor urine output post-surgery

A

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

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2
Q

Which tests should be arranged for COPD patients prior to having surgery?

A

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)
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3
Q

How long should Clopidogrel be stopped before surgery?

A

7 days

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4
Q

How long should Warfarin be stopped before surgery?

A

5 days - then switch them to a LMW heparin until the night before

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5
Q

How long should ACE inhibitors be stopped before surgery?

A

The day before

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6
Q

How long should the COCP be stopped before surgery?

A

4-6 wks and restarted at least 2 wks afterWH

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7
Q

How are steroids optimised peri-operatively?

A

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
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8
Q

How are diabetic medications optimised peri-operatively?

A
  • 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

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9
Q

Absolute contraindications for laparoscopic surgery

A
  • 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
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10
Q

Relative contraindications for laparoscopic surgery

A
  • 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
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11
Q

Define Achalasia

A

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

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12
Q

Achalasia features

A
  • Dysphagia
  • Regurgitation of undigested food
  • Aspiration pneumonia
  • Retrosternal chest pain/heartburn - often unresponsive to PPI’s
  • WL
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13
Q

Achalasia investigations

A
  • 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
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14
Q

Achalasia management

A

Medical (for pts unsuitable for surgery):
- Botox injections
- CCBs or nitrates

Surgical:
- Oesophageal dilation
- Heller’s myotomy = cutting the LOS to loosen it

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15
Q

Define Acute mesenteric ischaemia

A

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

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16
Q

Acute mesenteric ischaemia features

A
  • 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
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17
Q

Acute mesenteric ischaemia investigations

A

CT angiography

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18
Q

Acute mesenteric ischaemia management

A
  • Resuscitation
  • Anti-coagulation typically w/ IV heparin
  • Surgery = embolectomy, arterial bypass or bowel resection if necrosis
  • Intra-arterial vasodilators
  • Thromboembolic therapy
  • Supportive care
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19
Q

What is Grey-Turners sign?

A

Bruising along the flank indicating retroperitoneal bleeding in acute pancreatitis

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20
Q

What is Cullen’s sign?

A

Bruising around the peri-umbilical area associated w/ pancreatitis

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21
Q

Acute pancreatitis investigations

A
  • 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
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22
Q

How is Acute pancreatitis graded?

A

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

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23
Q

List the modified Glasgow criteria for pancreatitis

A

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

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24
Q

Acute pancreatitis management

A
  • A-E
  • Aggressive fluid resuscitation w/ crystalloids to maintain urine output > 30mL/hr
  • Catheterisation
  • Analgesia - strong opioids often needed
  • Anti-emetics
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25
Q

Local complications of Acute pancreatitis

A
  • 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
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26
Q

Systemic complications of Acute pancreatitis

A
  • ARDS
  • Hypovolaemia
  • DM
  • Sepsis
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27
Q

Anal fissure management

A
  • 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
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28
Q

Define Anal fistula

A

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

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29
Q

Anal fistula causes

A
  • Crohn’s (most common)
  • Malignancy
  • Trauma
  • TB
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30
Q

Anal fistula features

A
  • Anal discharge - blood/purulent
  • Anal discomfort or pain, exacerbated by sitting or defecation
  • Open fistula on examination
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31
Q

Anal fistula management

A
  • Analgesia
  • Fistulotomy (opening of the track) to enable healing
  • In advanced cases - Seton placement or advancement flap procedure may be used
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32
Q

What is Goodsall’s law?

A

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
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33
Q

Define Angiodysplasia

A

A vascular malformation of the GI tract characterised by the formation of fragile, leaky vessels - often in the caecum and ascending colon

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34
Q

Angiodysplasia features

A
  • Chronic, intermitent painless lower GI bleeding
  • Can be fresh PR (if lesions in the colon) or melaena (if lesions in upper GI tract)
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35
Q

Angiodysplasia management

A
  • Endoscopic treatments = thermal coagulation, argon plasma coagulation, endoscopic band ligation
  • Angiographic embolization
  • Octreotide or oestrogen-progesterone replacement
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36
Q

Anorectal abscess features

A
  • Perianal pain and swelling
  • Low-grade pyrexia
  • Tachycardia
  • Sepsis if severe
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37
Q

Anorectal abscess management

A
  • 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
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38
Q

Appendicitis aetiology

A

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

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39
Q

Appendicitis complications

A
  • Local abscess formation
  • Perforation
  • Gangrene
  • Post-op wound infection
  • Peritonitis
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40
Q

Appendicitis management

A
  • 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
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41
Q

Define Ascending cholangitis

A

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

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42
Q

Ascending cholangitis features

A

Charcot’s triad:
- RUQ pain
- Fever
- Jaundice

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43
Q

Ascending cholangitis investigations

A
  • Bloods = deranged LFTs, elevated CRP and WCC
  • Imaging = abdo USS 1st line looking for bile duct dilation - the use CT/MRCP/ERCP
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44
Q

Ascending cholangitis management

A
  • Resuscitation
  • Biliary drainage = via ERCP (+/- stent), Percutaneous transhepatic cholangiography (PTC), surgical drainage
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45
Q

Define Boerhaave syndrome

A

A full-thickness rupture of the oesophagus which occurs due to sudden increases in intraoesphageal pressure (usually repeated episodes of vomiting)

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46
Q

Boerhaave syndrome features

A
  • Severe tearing chest pain that worsens on swallowing
  • Minimal or no haematemesis
  • Signs of shock
  • Subcutaneous emphysema
  • X-ray signs = pneumomediastinum, pleural effusions, pneumothorax
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47
Q

Boerhaave syndrome investigations

A
  • CXR
  • CT w/ contrast
  • Avoid OGD as this may exacerbate the issue
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48
Q

Boerhaave syndrome management

A
  • IV fluid resus
  • IV abx to cover for potential mediastinitis
  • Surgical correction of rupture
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49
Q

What is the rule of 9’s for burns?

A

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%
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50
Q

Classification of burns

A
  • 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)
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51
Q

Burns features

A
  • 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
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52
Q

Burns management

A
  • 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
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53
Q

Burns complications

A
  • Curling ulcer = stress-induced gastric ulcers due to psychological stress response
  • Airway compromise from smoke inhalation
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54
Q

Cholangiocarcinoma risk factors

A
  • Hx of gallstone or chronic cholecystitis
  • Porcelain gallbladder
  • Smoking
  • Obesity
  • PSC
  • IBD
  • Oestrogen exposure
  • Occupational = pesticides, radiation, heavy metals and vinyl chloride
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55
Q

Cholangiocarcinoma features

A
  • 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
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56
Q

Cholangiocarcinoma investigations

A
  • Bloods
  • USS 1st line
  • CT
  • ERCP for direct visualisation and biopsies
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57
Q

Define Cholecystitis

A

Acute/chronic inflammation of the gallbladder, usually due to gallstone obstruction - common organisms = E.coli (most common), klebsiella, enterococcus

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58
Q

Classification of Cholecystitis

A
  • 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
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59
Q

Cholecystitis features

A
  • 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)
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60
Q

Cholecystitis management

A

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

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61
Q

Cholecystitis complications

A
  • Empyema (gallbladder filled w/ pus)
  • Gangrenous cholecystitis
  • Perforation
  • Abscess formation
  • Bile duct obstruction
  • Fibrosis
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62
Q

Define Chronic mesenteric ischaemia

A

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

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63
Q

Chronic mesenteric ischaemia features

A
  • 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
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64
Q

Chronic mesenteric ischaemia investigations

A
  • ABG to check for raised lactate
  • Duplex USS
  • CT angiography (gold standard)
  • Mesenteric angiography
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65
Q

Chronic mesenteric ischaemia management

A
  • Risk factor management = stop smoking, diabetic control, statins
  • Symptomatic relief = vasodilators
  • Revascularization = percutaneous transluminal angioplasty
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66
Q

Chronic pancreatitis causes

A
  • Primarily chronic alcoholism
  • CF
  • Pancreatic cancer
  • Elevated triglycerides
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67
Q

Acute pancreatitis causes

A

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

68
Q

Chronic pancreatitis features

A
  • 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
69
Q

Chronic pancreatitis investigations

A
  • Bloods = glucose, faecal elastase (low of exocrine insufficiency)
  • Imaging = CT/X ray to show pancreatic calcification
70
Q

Chronic pancreatitis management

A
  • Analgesia
  • Endocrine replacement (insulin)
  • Exocrine replacement (Creon = amylase, lipase and protease)
  • Invasive = coeliac plexus block and pancreatectomy
71
Q

TNM staging for colorectal cancer

A

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

72
Q

Colorectal cancer screening program

A

FIT tests every 2 years form men and women 60-74 - if +ve then referred for colonoscopy

73
Q

Colon cancer management

A

Stage I-III (no mets) = surgical resection +/- adjuvant chemo

Stage IV (mets) = neoadjuvant chemo + surgical resection

74
Q

Rectal cancer management

A
  • 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

75
Q

Which hereditary conditions predispose pts to colorectal cancer?

A
  • 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
76
Q

Define Indirect inguinal hernias

A

Hernias which follow the path of the decent of the testes, via the processus vaginalis during foetal development - typically congenital

77
Q

Define Direct inguinal hernias

A

Hernias which protrude through a weakness in the abdo wall, specifically the inguinal triangle

78
Q

Define Incarcerated hernia

A

A hernia which cannot be reduced - prone to strangulation

79
Q

Inguinal hernia features

A

General = groin swelling, pain, palpable mass

Indirect = may decent into scrotum, is reducible , more prone to strangulating

Direct = usually irreducible

80
Q

Define Diverticulosis

A

The presence of diverticula in the small intestine - most commonly in the sigmoid colon

81
Q

Define Diverticulitis

A

When diverticula become inflamed/infected

82
Q

Diverticulitis features

A
  • LLQ pain
  • Fever
  • N&V
  • Diffuse abdo pain suggestive of perforation
83
Q

Dysphagia causes

A
  • 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
84
Q

How do distinguish dysphagia causes based on the dysphagia features

A
  • 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
85
Q

Define Femoral hernia

A

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

86
Q

Femoral hernia management

A

Urgent surgery due to the high risk of strangulation - ether open or laparoscopic repair w/ mesh placement

87
Q

Factors that contribute to gallstone formation

A

1) Super-saturation of bile w/ cholesterol
2) Gallbladder dysmotility leading to stasis
3) Excessive bilirubin excretion

88
Q

Types of gallstones

A

1) Pigment (<10%) = associated w/ haemolysis, stasis and infection
2) Cholesterol (90%) = associated w/ female sex, increasing age and obesity
3) Mixed

89
Q

Biliary cholic features

A

Colicky RUQ pain, worse after eating

90
Q

Define Mirizzi’s syndrome

A

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

91
Q

Which imaging modality is most accurate for detecting gallstones?

A

MRCP

92
Q

Gastric cancer features

A

Dyspepsia + ALARM:
- Anaemia
- Loss of weight
- Anorexia
- Recent onset of symptoms
- Malena/haematemesis

Lymphadenopathy = Virchow’s node, Sister Mary Joseph nodule

93
Q

Gastric cancer investigations

A
  • OGD + biopsy under 2WW
  • Staging USS and CT
94
Q

Gastric cancer management

A

Locally invasive disease = partial or total gastrectomy + neoadjuvant chemo

Advanced disease = palliative +/- surgery for symptomatic relief

5yr survival of 20%

95
Q

Groin lump differentials

A

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

96
Q

Causes of haematemesis

A
  • Peptic ulcers (esp duodenal which may erode into blood vessels)
  • Oesophageal varices
  • GI tumours
  • Mallory-Weiss tears
  • Coagulopathies
  • NSAIDs
  • Post-tonsillectomy bleeding
97
Q

Haematemesis management

A
  • Resuscitation
  • Endoscopic haemostasis = sclerotherapy, band ligation or coagulation therapy to stop active bleeding
  • PPIs
  • Surgery
98
Q

Haemorrhoid grades

A

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

99
Q

Define Haemorrhoids

A

When the vascular cushions w/in the anal canal abnormally expand and can protrude outside the anal canal

100
Q

Haemorrhoid features

A
  • Bright red PR bleeding, associated w/ defecation and on wiping
  • Absence of pain
  • Anal pruritus
  • Palpable mass
101
Q

Haemorrhoids management

A
  • 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
102
Q

Hepatocellular carcinoma investigations

A

Bloods:
- LFTs
- U&Es
- CRP
- FBC
- AFP (tumour marker)

Imaging = USS 1st line, staging CT

Liver biopsy is gold standard for diagnosis

103
Q

Hepatocellular carcinoma management

A
  • Radical hepatic resection if lesion is < 3cm
  • Percutaneous radiofrequency ablations and tumour embolization can be used as adjuvant therapies
  • Palliative care for most pts
104
Q

Large bowel obstruction features

A
  • Cramping abdo pain
  • Bloating
  • Absolute constipation (even to flatus)
  • N&V late signs - including feculent vomiting
105
Q

Large bowel obstruction investigations

A
  • Abdo X ray is diagnostic (shows dilated loops of bowel)
  • CT abdo to identify the cause (e.g. cancer)
106
Q

Large bowel obstruction management

A
  • 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
107
Q

Define Epigastric hernia

A

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

108
Q

Define Richter’s hernia

A

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

109
Q

Define Spigelian hernia

A

Herniation through the transversus abdominis aponeurosis along the semilunar line - typically affects middle aged women

110
Q

Define Obturator hernia

A

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

110
Q

Define Lower GI bleeding

A

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

111
Q

Causes of PR bleeding

A
  • 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
112
Q

Define Wound dehiscence

A

A post-op complication when there is partial or complete separation of the layers of the surgical wound - most commonly occurs post abdo surgery

113
Q

Wound dehiscence features

A
  • 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
114
Q

Wound dehiscence management

A
  • 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
115
Q

Mesenteric adenitis features

A
  • Often comes on post-viral infection
  • Diffuse abdo pain - mimics appendicitis
  • Generalised abdo tenderness
  • Pharyngitis/sore throat
  • Unaltered appetite
116
Q

Define Necrotising fasciitis

A

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

117
Q

Necrotising fasciitis causative organisms

A
  • Group A strep
  • Staph aureus
  • Clostridium perfringens (causes gas gangrene)
118
Q

Define Fournier’s gangrene

A

Necrotising fasciitis of the perineum - SGLT-2 inhibitors are a RF

119
Q

Necrotising fasciitis features

A
  • 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
120
Q

Necrotising fasciitis classification

A

Type 1 = polymicrobial - frequently involving anaerobes

Type 2 = monomicrobial - usually Strep pyogenes or Staph aureus

Types 3 = gas gangrene - usually Clostridium perfringens

121
Q

Necrotising fasciitis management

A
  • 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
122
Q

Which type of carcinomas are found in the oesophagus?

A

Upper 2/3rds = SCC

Lower 1/3 = adenocarcinoma

123
Q

Oesophageal carcinoma features

A
  • Progressive dysphagia
  • WL
  • Odynophagia
  • Hoarseness
124
Q

Oesophageal carcinoma investigations

A

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

125
Q

Oesophageal carcinoma management

A
  • Surgical resection (best choice for localised disease)
  • Endoscopic therapies = endoscopic mucosal resection or endoscopic submucosal dissection of early-stage disease
  • Non-surgical = radio/chemotherapy
126
Q

Pancreatic cancer features

A

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

127
Q

Pancreatic cancer investigations

A
  • 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
128
Q

Pancreatic cancer management

A
  • 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
129
Q

Define Parenteral feeding

A

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)

130
Q

Complications of Parenteral feeding

A
  • Thrombosis
  • Sepsis from an infected line
  • Electrolyte imbalances
  • Hyperglycaemia
  • Metabolic acidosis
  • Villous atrophy
  • Infective endocarditis
131
Q

What is the most common type of peptic ulcer?

A

Duodenal

132
Q

Peptic ulcer causes

A

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

133
Q

How can you distinguish between duodenal and gastric ulcers based on symptoms?

A

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

134
Q

Peptic ulcer investigations

A
  • 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
135
Q

Peptic ulcer management

A

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

136
Q

Causes of Peritonitis

A
  • Perforation of a hollow viscus = Boerhaave’s, peptic ulcers, intestinal perforations
  • Infections
137
Q

Peritonitis features

A
  • 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
138
Q

Define Pilonidal disease

A

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

139
Q

Pilonidal disease features

A
  • Offensive discharge from the natal cleft
  • Discomfort, esp whilst seated
  • Visible sinus tract around the natal cleft
  • Visible abscess
140
Q

Pilonidal disease

A
  • 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
141
Q

Define Post-op pyrexia

A

The development of a fever >38 following a surgical procedure

142
Q

Causes of Post-op pyrexia

A

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)

143
Q

Surgical site infection management

A

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)

144
Q

Causes of small bowel obstruction

A
  • Adhesions
  • Intra-abdominal hernias
  • Crohn’s disease (strictures)
  • Appendicitis
  • Malignancy
  • Foreign body
  • Gallstone ileus
  • Intussusception
  • Volvulus
  • Intestinal atresia
145
Q

Small bowel obstruction features

A
  • 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
146
Q

Small bowel obstruction management

A
  • ABCDE resuscitation
  • NG tube + fluids for drip and suck to decompress the bowel
  • Gastrografin
  • Surgery to relieve the obstruction if conservative management fails
147
Q

Causes of massive splenomegaly

A

All have M:
- Malaria
- LeishManiasis
- CML
- Myelofibrosis

148
Q

Splenomegaly features

A
  • Abdo discomfort or fullness
  • Early satiety
  • Easy bruising/bleeding due to thrombocytopenia
  • Anaemia
  • Enlarged spleen on palpation
149
Q

Ileostomy VS Colostomies

A

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

150
Q

Patient has an ileostomy and no anus, what procedure did they have?

A

Panproctocolectomy (e.g. for UC)

151
Q

Patient has an colostomy and no anus, what procedure did they have?

A

Abdominoperineal resection (e.g. for low rectal cancer)

152
Q

Stoma complications

A
  • 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
153
Q

Types of absorbable sutures

A

Synthetic = vicryl, monocryl, PDS

Natural = catgut, collagen

154
Q

Types of non- absorbable sutures

A

Synthetic = nylon, prolene, polyester

Natural = surgical silk

155
Q

How does the diameters of sutures work?

A

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

156
Q

Define Abdominoperineal (AP) resection

A

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

157
Q

Define Anterior resection

A

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

158
Q

Define Left hemicolectomy

A

Removal of the splenic flexure (distal end of the transverse colon), descending colon and proximal sigmoid colon

159
Q

Define Right hemicolectomy

A

Removal of the caecum, ascending colon and hepatic flexure (proximal end of the transverse colon)

160
Q

Define Sigmoid colectomy

A

Removal of the sigmoid colon

161
Q

Define Panproctocolectomy

A

Removal of the entire colon and formation of a permanent end ileostomy - usually done for refractive UC

162
Q

Define Hartmann’s procedure

A

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

163
Q

Define Volvulus

A

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

164
Q

Volvulus investigations

A
  • Bloods = may show raised inflammatory markers and raised lactate if ischaemia
  • Abdo X-ray = coffee bean sign or birds beak sign
  • CT scan
165
Q

Volvulus management

A
  • 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)

Year 6 (8 decks)

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