Surgery Flashcards
What are the 4 key symptoms of bowel obstruction?
Vomiting
Colicky pain
Constipation
Abdominal distention
What gives rise to a ‘coffee-bean’ sign on abdominal x-ray?
Sigmoid volvulus - where the bowel has twisted on it’s mesentery
What are the 2WW guidelines for suspected bowel cancer?
- Age over 40 and unexplained weight loss and abdominal pain
- Age over 50 with unexplained PR bleeding
- Age over 60 with unexplained iron deficiency anaemia
- Any adult with positive faecal occult blood result
- Any adult with abdominal or rectal mass
- Age under 50 with PR bleeding and…unexplained weight loss, change in bowel habit, unexplained abdominal pain, iron deficiency anaemia
What can cause air under the diaphragm on an abdominal x-ray?
Perforation of viscera
Iatrogenic e.g. post-surgery
What is Buerger’s test?
Test for peripheral arterial disease: Patient lies supine and both legs are raised - If one leg becomes pale this is a sign of arterial disease as the arteries cannot work against gravity to supply the limb. If Buerger’s is positive, then hang both legs down by the side of the bed and both legs will become pink…the leg affected by PAD will become even more pink, called ‘ischaemic rubour’
What is a normal value for ABPI?
0.9-1.1
What does an ABPI value of more than 1.1 indicate?
Might be due to calcification of vessels, or severe atherosclerosis e.g. in diabetes
What does an ABPI value of 0.5-0.9 indicate?
Peripheral arterial disease
What does an ABPI value of less than 0.5 indicate?
Likely a degree of critical ischaemia if ABPI less than 0.5
What is the main feature of chronic limb ischaemia?
Intermittent claudication
What are the 6Ps of acute limb ischaemia?
Pain Paralysis Parasthaesia Perishingly cold Pallor Pulseless
What are the 3 manifestations of critical limb ischaemia?
Gangrene
Rest pain
Ischaemic ulceration
What is Courvoisier’s sign?
Palpable, non-tender gallbladder
Painless jaundice
Indicates a problem with the gallbladder but NOT gallstones - likely malignancy
How might you differentiate biliary colic from acute cholecystitis on investigation results?
WCC and inflammatory markers raised in acute cholecystitis but not biliary colic
What is Murphy’s sign?
Pain in RUQ during inspiration on palpation. Sign of an inflamed gallbladder in acute cholecystitis.
What is Charcot’s triad?
Sign of cholangitis - Fevers, RUQ pain, jaundice
If, on examination, you find Murphy’s sign positive in the RUQ, what must you do?
Always check the LUQ as well to make sure this is negative
What is the key investigation in acute cholecystitis?
Ultrasound - Thickened, oedematous gallbladder, stones
What are Cullen’s sign and Grey Turner’s sign?
Cullen’s = Periumbilical bruising
Grey Turner’s sign = Bruising in flank regions
Both seen in acute pancreatitis and caused by retroperitoneal haemorrhage from damaged blood vessels
What is the inheritance pattern of Peutz-Jegher’s syndrome?
Autosomal dominant
What are the clinical features of Peutz-Jegher’s syndrome?
Benign hamartomatous polyps in GI tract
Hyperpigmented macules on lips and oral mucosa
What is a haemorrhoid?
Symptomatic enlargements of ‘anal cushions’ (vascular tissue lining the anus)
What are the normal positions of haemorrhoids?
3, 7, 11 o’clock when the patient is in the lithotomy position
What is the classification of haemorrhoids?
I - Remain in the rectum and do not protrude out of the rectum
2 - Prolapse on defecation or straining but spontaneously reduce
3 - Prolapse on defecation or straining and require manual reduction
4 - Remain continuously prolapsed
True / False: Haemorrhoids are painful
False - They are not usually painful (unless they strangulate or become thrombosed) but patients may experience pruritis
What is a fistula?
‘An abnormal connection between two epithelial surfaces’…commonly an anal fissure connecting the external skin and the anal canal / rectum
How are anal fistulae classified?
Low = Below dentate line High = Above dentate line
What is the treatment of anal fistulae?
Low fistulae = Fistolotomy to lay open the track
High fistulae = Seton stitch (can’t have fistulotomy as sphincters would be damaged)
What is an anal fissure?
A tear in the anal canal
What is the most common cause of an anal fissure?
Hard faeces
What are the possible treatments available for an anal fissure?
Conservative i.e. high fibre diet, avoid straining
Medical:
- Stool softening laxatives
- Topical lidocaine (anaesthetic)
- Topical GTN or diltiazem to promote relaxation of internal anal sphincter
- Botox injection
Surgery: Internal anal sphincterotomy
What are the indications for a stoma?
Inflammatory bowel disease
Diverticulitis
Colon cancer
Bowel obstruction
A stoma in the right iliac fossa is most likely to be a ……?
An ileostomy
A stoma in the left iliac fossa is most likely to be a ……?
A colostomy
A stoma which is spouted is most likely to be a ……?
An ileostomy
A stoma which is flush to the skin is most likely to be a ……?
A colostomy
Why are ileostomies usually spouted?
Small bowel contents are more corrosive to the skin and so the stoma is placed slightly away from the skin
The contents of an ileostomy are most likely to be …….?
Liquid stool
The contents of a colostomy are most likely to be ……..?
Formed, solid faeces
Which procedure is most likely to result in a temporary end colostomy and why?
Hartmann’s procedure e.g. in obstruction from a colon cancer or diverticulitis - to rest the bowel and to be anastamosed later
Which procedure is most likely to result in a permanent end colostomy?
AP resection e.g. in low rectal cancer
What are the 2 procedures likely to result in an end colostomy? Which is usually temporary and which is usually permanent?
Hartmann’s = Usually temporary
Abdominoperineal (AP) resection = Usually permanent
Why is a permanent end colostomy usually performed in an AP resection?
The segment of rectum is too short to be re-anastamosed and so the stoma is permanent
A stoma with 2 lumen is referred to as a …….??
A ‘loop’ ileostomy (or colostomy - less common) has 2 lumen, compared to an ‘end’ stoma which has 1 lumen
Which operations of the bowel involve removal of the anus?
Panproctocolectomy
AP resection
Which procedure is most likely to result in an end ileostomy?
Panproctocolectomy e.g. in inflammatory bowel disease
Which procedure is most likely to result in a loop ileostomy and why?
Anterior resection - Performed e.g. in inflammatory bowel disease, for bowel rest as the distal segment has a much poorer blood supply than the proximal so needs a period of rest before re-anastamosing
List some complications of stomas
High output stoma Peristomal hernia Anastamotic leak Dermatitis - Where the stoma is in contact with the skin Psychological complications Stenosis
List some risk factors for colon cancer
Family history
Age over 65
Diet: Red meats, low fibre, low vegetable
Smoking
Alcohol
Inactivity
Previous colonic disease e.g. ulcerative colitis
Are left or right sided colon cancers more common?
Left - Most cancers affect the distal colon and rectum
How might a patient with a right sided colon cancer present - why?
Faeces is more liquid so less obstruction, more systemic features:
- Bleeding
- Iron deficiency anaemia e.g. breathlessness, fatigue
- Weight loss
How might a patient with a left sided colon cancer present - why?
Faeces more solid and lumen smaller so more likely to present with features of obstruction:
- Abdominal pain
- Altered bowel habit e.g. constipation
- PR mass
What is a key presenting feature if a patient has a tumour affecting the rectum?
Tenesmus
What is the tumour marker for bowel cancer?
CEA (Carcinoembryonic antigen)
What might barium enema show in a patient with bowel cancer?
‘Apple-core’ stricture
What is the significance of the Duke’s staging criteria?
Related to the 5 year survival rate of the stage: Duke's A = 90% 5 year survival Duke's B = 60% 5 year survival Duke's C = 30% 5 year survival Duke's D = 5-10% 5 year survival
List some common sites for bowel cancer to metastasise to
Liver
Lung
Bone
Perineal cavity
Who is invited to bowel cancer screening programme?
Men and women aged 60-69
What is Allen’s test used for?
Assesses whether the patency of the patient’s radial and ulnar arteries are intact and that they have dual blood supply to their hands
What are the 3C’s and 3S’s of inspection in a peripheral arterial examination?
Comfort (pain) Colour Count (any previous amputation?) Scars Stains Skin
Which 2 places must you inspect in an arterial examination?
Groin - for scars
Feet (remove the socks!) to check number of digits!
What are Buerger’s 3 signs?
1st sign - Pallor in leg(s) on elevation
2nd sign - Reperfusion of legs when hung down the end of the bed
3rd sign - Reactive hyperaemia (ischaemic rubour) i.e. redness
List all the pulses which must be tested in an arterial examination
Radial Brachial Carotid Abdominal aorta (aneurysm) Femoral Popliteal Posterior tibial Dorsalis pedis
What is a normal doppler signal in a peripheral arterial examination?
Triphasic
What is Buerger’s disease otherwise called?
Thromboangiitis obliterans
What is thromboangiitis obliterans?
Small vessel disease where clots develop inside these vessels. Often affects young smokers. Vessels cannot be reconstructed once damaged.
What does a monophasic signal on doppler indicate?
Severe arterial stenosis e.g. from calcified arteries
What causes peripheral arterial disease?
Artherosclerosis causing ischaemia to peripheral arteries (in the same way as coronary arteries)
How might you differentiate between arterial and venous claudication?
Arterial claudication = Worse on walking distances
Venous claudication = Improved by walking
What is the management of peripheral arterial disease?
Conservative - Stop smoking - Exercise - Supervised exercise programme e.g. 2hrs weekly for 4/12 Medical - BP control - Diabetic control - Statin - Anti-platelet e.g. Aspirin or Clopidogrel Surgical - Angioplasty ± stent - Reconstruction e.g. bypass - Amputation
How might gangrene be managed?
Analgesia
Broad-spectrum antibiotics
Surgical debridement ± amputation
What are the 2 types of arterial gangrene?
Wet and dry
What is the difference between wet and dry gangrene?
Wet = Necrosis and infection Dry = Necrosis in absence of infection
What is particularly concerning about venous gangrene?
Caused by an iliofemoral DVT and might be a sign of underlying malignancy
What might be useful in the treatment of phantom limb pain following amputation?
Gabapentin
Which vein is likely to be affected in a varicose vein at the lateral calf?
Short saphenous vein
Which vein is likely to be affected in a varicose vein at the medial thigh?
Long saphenous vein
Which vein is likely to be affected in a varicose vein at the medial calf?
Calf perforators (branches of long saphenous)
Where is the sapheno-femoral junction located?
2-4cm inferior and laterally to the pubic tubercle
Why is it important to check the peripheral pulses in a venous examination?
If they are not present it might indicated co-existing arterial disease, which would mean the patient is not appropriate for compression hosiery
How would you perform the ‘tap test’ in a venous examination?
Palpate the saphenofemoral junction and tap the distal end of a varicose vein. If a transmitted thrill is palpated at the SFJ this indicates incompetence of the valves connecting the 2 points.
What is the tourniquet test for in a venous examination?
Tests the competence of the saphenofemoral junction
What is Perthe’s test for in a venous examination?
Tests competency of deep venous system in a patient whose superficial venous system is known to be inadequate
What is the treatment for varicose veins?
- Avoid prolonged standing
- Compression hosiery
- Radiofrequency ablation
- Endovenous laser ablation
- Injection sclerotherapy
- Surgery: Ligation, stripping, avulsions
What is the difference between a true aneurysm and a false aneurysm?
True aneurysm = Involves all layers of the arterial wall
False aneurysm = Blood collects in the outer later of the vessel which communicates with the lumen e.g. after trauma
Describe the screening programme for abdominal aortic aneurysm
Offered to men aged over 65. Ultrasound used to detect diameter of abdominal aorta. If enlarged, patients are regularly monitored.
What is the treatment for an abdominal aortic aneurysm which requires repair?
EVAR (Endovascular Aneurysm Repair)
FEVAR (Fenestrated EVAR)
Open surgery
What is a hernia?
Protrusion of the the abdominal viscus through a weakness in the abdominal wall
Are direct or indirect inguinal hernias more common?
Indirect
What is the difference between diverticulosis, diverticular disease, and diverticulitis?
Diverticulosis = Presence of diverticulum (outpouching of the wall of the gut)
Diverticular disease = Symptomatic
Diverticulitis = Inflammation of the diverticula
What is the treatment for diverticular disease?
Encourage a high fibre diet
Antispasmodics e.g. mebeverine
How is diverticulitis managed?
Mild: At home with encouragement of oral fluids and antibiotics
More severe: Admit, NBM, IV fluids, IV antibiotics (usually Cef and Met), surgery to drain abscess if required
