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Phase II > Surgery > Flashcards

Surgery Flashcards

1
Q

Describe diathermy

A

Blue - coagulation
Yellow - cutting
Monopolar - most effective but CI if they have metalwork or pacemaker. Needs pad.
Bipolar - current runs between two foreceps

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2
Q

Describe different tools to manage risk

A

ASA - American society of anaesthesiologists:
1 - normal healthy patient
2 - mild systemic disease
3 Patient with severe systemic disease
4 Patient with severe systemic disease that is a constant threat to life
5 Moribund patient that will not survive without surgery
6 brain dead - organ transplant

Also PPOSSUM score
More in depth
looks at medical conditions and difficulty of proceedure

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3
Q

Name of pain that moves?

A

Migratory pain

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4
Q

What signs would you find of examination of appendicitis?

A

Rosving’s sign - palpation of LLQ causes RLQ pain
Temperature, tachycardia
Abdominal tenderness- mcburneys point
pain on lifting right leg

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5
Q

How do you tell the difference between an ileostomy and a colonostomy?

A

Sprouted on iliostomy to prevent acid

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6
Q

Describe DDX and investigations of appendicitis

A

Pancreatitis (amylase, lipase, CT), renal colic (clinical or CT)
Ileocoaecal - CD, diverticulitis, Meckles (Klein’s sign, Technetium-labelled red blood cell scan)
Ovarian - Ectopic, cyst, PID (US)
Elderly - cecal tumour (colonoscopy)

Investigations:
Clincical diagnosis
US in women
CT if imaging needed or over 65

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7
Q

Management

A

Resuscitation if septic or hypotensive - fluids, FBC, U&E, CRP
Laporotomy if unsure
Catheterise
NBM
Open or laporoscopic appendicectomy with IV abx on induction

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8
Q

Complications of appendicitis

A

Perforation
RIF appendix mass - adhering to omentum and caecum
Pelvic abscess (2o to perf)

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9
Q

Symptoms of acute appendicitis

A

Darrhoea common
Pain migratory - increased on coughing and moving
Nausea
Malaise, anorexia and fever

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10
Q

Symptoms of acute panc

A

Epigastric pain radiating to back
Severe N/V
Malaise
Sterratorhea

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11
Q

Signs of acute panc

A 
Tachy, fever, hypotension, dehydration
Epigastric tenderness
Guarding
Grey-Turners - left flank ecchymosis
Cullens - periumbilical eccymosis
Both eccymosis is rare.
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12
Q

Investigations in pancreatitis

A 
Serum amylase (3x normally 300) IU/L
Serum lipase, more specific, less sensitive
Calcium (low is an early complication)
Blood gases
AXR
CT
US - Gall stone
U&Es - hypocalcaemia
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13
Q

Causes of raised serum amylase

A

intestinal ischaemia, leaking aneurysm, perforated ulcer, cholecystitis

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14
Q

AXR and CT findings in pancreatitis

A

AXR:
Sentinel loop sign - dilated jejunal loop adjacent to the pancreas due to ileus
Absent psoas shadows
Colon cut off sign - Air in colon from ileocaecal valce to mid-transverse colon with no air distally (due to pancreas blocking it).
May see gall stones or pancreatic calcification

CT:
Loss of pancreatic adipose
Pancreatic oedema/ swelling
Haemorragic or necrotic complications

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15
Q

How do you differentiate between Meckles and Appendicitis

A

Klein’s sign - RIF pain that moves to left when patient lies on their left - also associated with mesenteric adenitis.

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16
Q

Difference between jejunum and ileum

A 
Jejunum vs ileum
Dark red vs paler pink
Dense plicae circulares vs sparse/ non
Few arcade loops vs Many
Dense BV vs Sparse
Thick and heavy wall vs thin 
Large (2-4 vs 2-3
Less fat vs more
No Peyers patches vs PP
Liquid vs rlq
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17
Q

Complications of acute pancreatitis

A

Pseuo-cyst - haemorrhage, obstruction, rupture, infection
Haemorrhage
Sepsis
70% - oedematous (phlegmon =spreading diffuse inflammatory process whihc is suppurative)
25% Necrotising - causes pseudocyst
5% haemorrhagic

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18
Q

What is intussusception

A

Kiddies
Part of bowl herniates into another part like a telescope
Emergency

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19
Q

Causes of anorectal pain

A

Fissure in ano- knife like pain on defication. Deep throbbing pain for a few hours following due to pelvic floor spasm. streaky/ spotted blood on tissue

Perianal abscess - slow onset, constant pain. fever too

anorectal haematoma - obvious, swelling, discolouration

Haemorroids - spontaneous, perianal lump, soreness and irritation, profuse bright red bleeding possible

Rectal prolapse - spontaneous, occasionally causes pain, obvious large perineal lump, dark red blue surgace and occasionally ulceration

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20
Q

Investigations into anorectal pain

A

Rigid sigmoidoscopy - very painful (flexible not indicated)

DRE

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21
Q

Managment of anorectal pain

A

Anal fistula - Analgesia, anal spincter relaxants e.g. GTN, diltiazem, LAs

Perianal abcess - emergency, needs drainage particularly if immunocomprimised or diabetic

Anorectal haematoma - Incision to allow decompresion (topical LA)

Haemorroids - topical analgesia and coolants, supportive, rarely do surgery due to overexcision of anal tissue. Bed rest. Can do anal dilation under GA

Rectal prolapse - Coolants, dessication (icing sugar), elevation, supportive, surgery is last resort

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22
Q

Pathophysiology of anal fistulas

A

Infected anal glands along dentate line.
Form abscess in ischiorectal fat pad.
May burst or be surgically drained forming a fistula.

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23
Q

Describe Technetium-labelled red blood cell scan

A

Finds gastric mucosa - finds 50% of meckles diverticulum

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24
Q

Describe angiodysplasia

A

Endoscopy and mesenteric angiography - resembles telangiectasia - related to strain and age, degenerative
Symptoms
GI bleed - melena (faecal occult blood test)
Anaemia
Multiple vascular malformations
Often in cecum or ascending colon
Treatment
Angiography and embolization
Tranexamic acid or estrogens
Endoscopic treatment is an initial possibility with cautery or argon plasma coagulation

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25
Q

Commonest causes of rectal bleeding

A 
Piles
UC
Cancer
Anorectal fissure
Angiodysplasia
Diverticular disease
Ischaemic collitis
Meckles
Intersusseption
Massive Upper GI bleed
CD
trauma
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26
Q

Investigations to detect ischaemic collitis

A

Barium enema (thumb printing), colonoscopy

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27
Q

Risk factors for gall stones (cholelithiasis)

A 
Female
Fair (caucasian)
Forties
Fat (or rapid weight loss)
Fertile (pre menopause, multiparity, OCP)
Previous surgery
TPN`
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28
Q

Explain how cholelithiasis form and the problems that gall stones cause

A

Cholesterol and bile salts precipitate in lithogenic bile.
Stasis or gallbladder dysfunction may increase risk.
Nidus of infection (site) contributes.
In gall bladder or CBD = cholethiasis, choledocholithiasis = one or more stones in CBD, cholecystitis = inflam in gall bladder, in cystic duct = cholangitis, pancreatitis

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29
Q

Presentation of cholelithiasis

A

Asymptomatic.
Biliary colic - upper right quadrant pain, steadily increasing for 30mins -hours. Often after a fatty meal or drink and at night. May radiate to shoulder tip or back.
May be sporadic and unpredictable.
No systemic response e.g. WCC or pyrexia.
N/V.
Murphy’s sing - more typical of acute cholecystitis

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30
Q

Describe murphy’s sign

A

Place hand on middle inferior boarder of the liver and ask patient to inspirate deeply. This will cause pain and they wont be able to breath in fully.

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31
Q

How is acute cholecystits different from cholethiasis

A

Always pain - more severe and lingers. - often radiates to right flank and back.
Pyrexia, sweating and WCC.
More likely to see murphy’s sign.
Often anorexia.
Cholelithiasis is less well-localised. No guarding or rebound tenderness.

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32
Q

Complications of acute cholecystitis

A

Mucocele of the gall bladder - swinging fever and sever pain.
Perforation and biliary peritonitis
Cholecystoenteric fisula and gall stone ileus.
Jaundice due to compression of CBD - MIrizzi syndrome.

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33
Q

Investigations into acute colecystitis

A 
FBC, bilirubin, serum alkaline phosphotase (higher than LFTs signifies obstruction)
Serum amylase to rule out pancreatitis
CRP
UEs
USS
CT normally useless
MRCP
Hepatobiliary iminodiacetic acid (HIDA) scan or cholescintigraphy if US unconclusive - dye into vein, absorbed by liver and excreted into bile.
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34
Q

Management of cholelithiasis and cholecstitis

A

Cholelithiasis - analgesia
Acute chole - IV antibiotics (E coli or Kleb)
Laporoscopic cholecystectomy for all with symptoms or those asymptomatic and at risk of complications.

Non surgical:
Percutaneous drainage.
CT or US guided.
If unsuitable for surgery
Once inflam has gone stones are removed percutaneously.
Used for empyema

Dissol

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35
Q

Risk of laparoscopic cholecystectomy

A

5-10% risk of open operation
Bile duct injury
Bleeding
Bile leak

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36
Q

What is a gall bladder mucocele?

A

Stone in neck of bladder (Hartman’s pouch), bile absorbed but mucus sections continue forming a mass

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37
Q

How does CBD gall stones present

A 
Obstructive jaundice:
, sterattorhea, dark urine + Itching are distinguishing features
Pain more epigastric/ central
N/V, anorexia
Palpable distended gall bladder is rare

Ascending cholangiis
Sever RUQ pain, obstructive jaundice, high swinging fever - Charcots triad

Acute panc

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38
Q

Investingations CBD gall stones

A

Routine bloods:
Liver function (bilirubin +alk phosphotase), FBC, U&Es, cholesterol (WCC increased in cholan and panc), amylase, clotting
Non invasive:
US - low accuracy if distal, acute, obese or gassy.Dilation to >1mm).
MRCP if US fails
Invasive:
ERCP - diagnosic if MRCP not tolerated
-stent insertion for unextractable stone
- spincterotomy and stone extractin or lithotryspy

If not then PTC - percutaneous transhepatic cholangiography - dye injected into liver bile duct and X rays but risks of sepsis, movement, leakage and dehydration

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39
Q

Management CBD gall stones

A 
NBM
Analgesia
Abx IV
ERCP (can be combined with PTC)
Can be 'softened' with urso.
If recurrent cholecystectomy or T tube track - removed radiogically (percutaneous via basket extraction)
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40
Q

Risks of ERCP

A

Perforation and peritonitis
Haemorrhage
Acute panc
Ascending infection

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41
Q

What is Reynolds pentad?

A 
Charcots triad (Jaundice, RUQ pain and high swinging fever)
\+ shock and mental disturbance (obtundation)
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42
Q

Describe PEEP and why it is a pathological finding

A

Peak end-expiratory pressure.
In a normal person the pressure in the lungs = pressure of atmosphophere at the end of expiration.
If COPD then there is incomplete exhallation and so so the pressure of the lungs is still > than the atmospheric (not all have come out yet). This progressively leads to hyperexpansion.

Patient hads resistence to outflow to keep airways patent so they can expell more (as less resistence) and decrease PEEP?

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43
Q

How common is bowel cancer

A

2nd most common

1/20 people

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44
Q

Describe screening in bowel cancer

A

Every 2 years from 60-74
Faecal occult blood test
If positive then invited for colonoscopy

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45
Q

Symptoms of bowel cancer

A

Change in stool habits (particularly left as its thinner) normally diarrhoea.
->6 weeks, >40years, no infection
PR Bleeding (particularly right/ caecum as its longer until symptoms)
Anaemia
Constitutional symptoms e.g. anorexia, weight loss, malaise

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46
Q

Describe the location of colorectal cancers

A

Most in rectum then sigmoid then caecum

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47
Q

Explain genetic risk factors for bowel cancer

A

FAP - familial adenomatous polyposis. 100% of people have cancer by 40yrs so propylactic colonectomy AD

HNPCC - Hereditary non-polypoposis colorectal cancer/ Lynch syndrome - other cancers too AD (suspect if cancer

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48
Q

Describe the pathogenesis of colorectal cancer

A

Adenoma - carcinoma change`

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49
Q

Describe how screened polyps are followed up

A

Removal during colonoscopy

>1cm or 2-3 polyps then 1yr follow up if not then 3yrs (depends on other factors too e.g. histology).

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50
Q

Investiations into colorectal cancer

A

Routine bloods:
FBC (anaemia), U&Es,
Colonoscopy
- if patient can’t tolerate then do CT colonogram with contrast or a barium enema

CT chest, abdo and pelvis/ Xray for mets/ staging (chest, abdominal, pelvic)
Clotting, group and save
If rectal then MRI to look for stage
CEA - not diagnostic but to track progress/ success of operation

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51
Q

Spread of colorectal cancer

A

Direct - normally through wall, may affect other structures such as other bowel, bladder, uterus
Lymph - mesentary, paracolic, para aortic, pre aortic
Vascular - liver and then lung

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52
Q

Describe staging of colorectal cancer

A 
Dukes
A - Mucosa, submucosa, MP
B - Serosa
C 1- Lymph - paracolic
2 - Lymph terminal
TNM
T1-mucosa
2- submucosa
3- MP
4- Serosa
N1 -  3 nodes
M1 - mets
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53
Q

Management of colorectal cancer

A

Right/ transverse up to splenic = extended right hemicolectomy
Sigmoid = high anterior resection
Rectum = anterior resection
Lower rectum/ anus= abdominoperineal resection APER

Neo/adjuvant chemo if mets or rectall
Hepatic or lung resection possible

If not fit for surgery then

  • chemo-radio
  • Defunctioning colostomy if obstructive and palliative
  • stenting
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54
Q

Prognosis of colorectal cancer

A

A - 85%
B - 70%
C - 40%

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55
Q

Risks of surgery

A 
Bleed
Leak
Stoma prolapse
Ureter damage
Bowel damage
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56
Q

Difference between colonoscopy and flexible sigmoid

A

Flex sig finds 70%
Colonoscopy needs bowel prep - 4L viscous salty vanila liquid - not good for renal disease or cardiac failure or immobile (cant get to loo as it causes dehydrate and phosphate nephropathy.
Flex sig only needs phophate enema

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57
Q

What is endoscopic mucosal resection

A

Inject dye into submucosa

Ligate polyp

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58
Q

Describe CT cologram

A

Gasgraphin to drink the day before (also laxative)

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59
Q

Causes for raised unconjugated billirubin

A

Hepatitis
Cirrhosis
Drugs - amoxicillin, flucloxiciilin, cough medicine

Sickel cell anaemia
B Thalassemias
Burn/ trauma?
Spherocytosis - haemolysis
Gilberts
Cigler-Nagler
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60
Q

What is gilberts syndrome?

A

10% of pop have
Deficiency of glucuronyltransferase which conjugates bilirubin
Jaundice

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61
Q

What is Crigler Najjar?

A

Enzyme difficience

High unconj bilirubin (causes brain damage and often fatal)

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62
Q

Causes of raised conjgated billibrubin

A 
Cholelithiasis
Cholangitis 
Adenocarcinoma of pancreas
Cholangioadenocarcinoma
Gall bladder/ duodenal malignancies
Iatrogenic
Pancreatitis (swelling) - transient
Billiary stricture - infection, panc, malig
Sclerosis cholangitis
Congenital - choledochal cyst
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63
Q

Treatment of CBD cancers

A 
Hilar then liver resenction
Middle third then resection of duct
Periampullary then peri-pancreatoduodenectomy
Palliative - ERCP/ stent
Percutaeous drainage
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64
Q

Muscle in oesophagus

A

Upper 1/3 is skeletal

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65
Q

What is the acute angle called

A

Angel of his

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66
Q

Oesophageal sphincter made of

A

Folds of mucosa,

Angel of his

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67
Q

Blood supply of oesopagus

A

Neck region - inferior thyroid artery, thyrocervical trunk, subclavian
Chest - branches of aorta
Abdomen - left gastric (Caeliac) and inferior phrenic (AA)

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68
Q

Branches of external carotis

A 
Superior thyroid 
Ascending pharyngeal
Lingual
Facial
Occipital 
post auricular
Maxillary
Superficial temporal
Some aggressive lovers find odd positions more stimulating
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69
Q

Innervation of oesophagus

A

Recurrent pharyngeal - parasymp for upper 1/3

lower 2/3 - Vagus

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70
Q

Treatment for Hiatus hernia

A

Medically - stomach stuff
Surgery - Nissen’s fundoplication (complete or partial)
Linx - beads

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71
Q

DDX pancreatitis

A 
Perforated peptic ulcer
Mesenteric infarction
MI
AAA
Cholecystitis
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72
Q

Prognosis for acute pancreatitis

A

90% resolve in a few days
others have complications - often fatal (sepsis)
Normally sterile necrosis so no abx unless abcess
Drain pseudocyst

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73
Q

Management of acute pancreatitis

A 
Supportive
Anti emetics
Fluids
IV abx if abcess
Give food (low volume) to reduce stress ulceration and bacterial translocation
HDU/ITU
Treat cause
avoid surgery
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74
Q

How is a severe attack of acute pancreatitis diagnosed?

A

3 positive criterea within 48h of admission of the Glasgow Imrie criterea

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75
Q

Assessment of airway

A 
Speak?
see:
-chest movement
-see saw- admoinal distention
- sternal recession in kids
- cyanosis (late)
- redness (early)
- tracheal tug (late)
Hear:
- gurgling
- snoring (bad)
- crowing
Feel 
-breath on cheek
- chest movement

Suction around not down throat if object
Roll onto side if vomit
Jaw thrust/ head chin lift

Use Geudel/ oropharyngeal airway - insert and twist, measure angle of jaw to insisors.

If they gag then use nasopharyngeal airway - length from tragus to naris, lubricate, right nose first
Give O2

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76
Q

Assessment of breathing

A

e

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77
Q

When is a nasopharyngeal airway indicated/ contraindicated?

A

Fits, atrismus (rigid jaw)

CI:
Fracture base of skull
- battle sign - mastoid ecchymosis.
- Panda eyes
- CSF nose
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78
Q

Describe giving O2 on airway

A

Laryngeal mask airway (links to bag valve mask) or Igel

  • If cant intubate and not breathing
  • Head tilt chin lift and insert

If low sats:

CPAP - continuous postive applied pressure only good for O2

Nasal specs
35%, 4L

Venturi mask
No bag
24-60% (variable nozzel) - better for lower %
24% =2L --- blue
28% = 4L

Hudson mask
with bag
max 60%
5L

Non re breath mask
with bag
90% (lady said 60-80)
15L/min

High flow oxygen system/ anaesthetic circuit
100%
humidified
50-60L flow rates

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79
Q

Reasons for hypoxic drive

A

Obstructive Sleep apnoea
Obesity hypoventilation
COPD

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80
Q

When could O2 delivery be harmful

A

Straight after MI, stroke or COPD/ hypoxic drive

Clin sig - titrate O2 down to prescribed/ target %

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81
Q

How long does an O2 cylinder last?

A

30mins at 15L/min (450L total)

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82
Q

What is involved in the pre op assessment

A 
Risk assessment
-ASA/ PPOSSUM
Plan
-LA/GA
-Level of monitoring e.g. cardiac invasive
-Recovery, routine or contact HDU/ITU
Inform 
-Risks of operation
-PONV and pain
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83
Q

How is risk reduced in anaestetics?

A

IV access for fluids
Reduce trauma
Keep patient at correct body temperature

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84
Q

Drugs given by anaethatist and when

A

Induction IV - propofol 1 mg/ml

Muscle relaxant
Depolarising
-Suxamethonium
Non depolarising
-everything else
Need for intubation
Monitor via nerve stimulator

Analgesia
-Opioids

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85
Q

How can you be opioid sparing?

A

Augment with LA perioperatively, give as epidural

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86
Q

Phases of anaesthesia and short description of what happens

A

Induction
-Location down to preference (easier in theatre if unfit to reduce transfer however more anxiety)

Maintainence

  • ECG
  • Pulse oximeter
  • Capniography
  • Volative or TIVA, analgesia and NMB
Emergence
- wearing off of anaesthetic and NMB
- withdraw volitile/TIVA
- may need to reverse NMB
- antagonise e.g. nalocone or flumazanil
- reverse physiological support
--breathing
--CVS
wake in order of C then B then A
- COughing with tube can be bad - venous engorgement and raised ICP

Recovery
- 30-40minutes until awake, no bleeding, no pain

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87
Q

Problem with reliance on pulse oximetry?

A

About a minute behind actual sats

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88
Q

Describe capniography

A

Shows (by shape) if patient is in bronchospasm
Shows if end of tube is in the right place
RR
Info on CO2 shows lung function e.g. hypoperfusion
Attached to breathing tube and onto gas analyser

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89
Q

How can you reverse NMB

A

Neostigmine

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90
Q

Define pain

A

An unpleasant sensory and emotional experience associated with acutal or potential tissue damage or described in terms of damage

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91
Q

Define chronic pain

A

> 3 months
No underlying physical damage.
May not have an identifiable cause

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92
Q

Define nociception

A

Transmission of painful stimulus without consciousness.

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93
Q

Describe the pain pathway

A

Transduction
Transmission
Modulation
Perception

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94
Q

Types of pain transmission

A 
Mechanical
Thermal
Chemical (internal & external?)
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95
Q

Difference between a delta fibres and C fibres

A

A delta is sharp pain

C fibres are for duller pain

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96
Q

Describe modulation of pain and at what levels doctors can affect this

A 
Brain 
Water therapy (drinking loads upon waking)
Hypnosis
Paracetamol
Opioids
Spinal cord
TENS
Opioids
LA
Opioids 
Capsaicin

Periphery
NSAIDs
LA

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97
Q

What is the WHO pain ladder

A

Non opioid

  • Paracetamol
  • NSAISs
  • single or combines

Add Weak opioid

  • codeine
  • tramadol

Substitute for stong opioid

  • Morphine
  • Diamorphine
  • Fentanyl
  • Remi/ Alfentanyl
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98
Q

Cautions for paracetamol

A

Liver failure and

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99
Q

Describe common types of NSAIDs and CIs

A

Ibuprofen, diclofenac, paracoxib, keterolac, asirin

CIs: Renal failure, fluid retention, bronchospasm (10% of asthmatics), GI disturbance
COX1- stomach and clotting
COX2 - pain, fever and inflmmation

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100
Q

How much less potent is codeine than morphine

A

10 times

Variable metabolism

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101
Q

How many times less potent is tramadol than morphine?

A

5-10 times less potent

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102
Q

CIs with tramadol

A

Inhabits Na and 5HT uptake so SSRIS and TCAs,
Lowers seizure threshold
Elderly caution

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103
Q

Describe the control of vomiting including afferents and efferents

A

Postrema - chemoreceptors on the floor of the fifth ventricle (in the blood). Controlled by dopamine.

Vomiting centre in the medulla. Ach, H1 and 5HT. (across BBB).

Inputs to vomiting:

  • Postrema
  • Middle ear - e.g. sea sickness - vestibular stuff, Ach in particular
  • Cortex - anxiety
  • Pain
  • GI via vagus nerve

Efferents:

  • Abdominal muscles
  • Diaphragm
  • Pyloric sphincter
  • Stomach mucles
  • Pharynx
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104
Q

Describe antisickness medications that target the postrema. Side effects

A

Dopamine so metoclopramide (partially- also 5HT and anti cholin also blocks vagal 5HT afferent) and domperidone.

Both can cause prolactin problems and EPSE.

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105
Q

Describe antisickness medications that directly affect the central vomiting centre and side effects

A

Metaclopramide (everythign but histamine) - dopamine effects
Cyclizine (histamine) - QT prolongation, sedative
Ondansterol/on - 5HT - decrease vagal stim.
Hyoscine and Buscopan - anti muscurinic - Ach/ motion sickness more inner ear.

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106
Q

Potencies of strong opioids

A 
Morphine
Diamorphin x2-4
Alfentanyl x10-25
Fentayl x80-100
Remifentanyl x100-200
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107
Q

Describe onset of strong opioids and features

A

Morphine - metab to M6G - 4 hours half life.

Diamorphine

Alfentanyl - short term pain relief e.g. fractures, obtunds stim of laryngoscopy, stays in fat and can give delayed depression

Fentanyl - longer lasting in higher doses, spinal or epidural, patches and lozenges chronic pain, onset in 3.5mins

Remifentanyl - can be used as TIVA

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108
Q

How do you tell the difference between a direct and an indirect hernia?

A

get patient to cough whilst covering the deep ring

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109
Q

Decribe uses of LA

A 
EMLA cream, eumatetic mixture of LA - procaine/ lidocaine - topical
Subcut or intra dermal
Peripheral nerve block
Epidural
Spinal anaesthetic
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110
Q

Difference between epidural and spinal anaesthetic

A

Spinal anaesthetic - into CSF, lasts 2-3 hours, faster onset and offset. Stops all nerve roots below.

Epidural - not through dura, longer, can put in a catheter for constant relief. Not as effective, primary works on nerve roots not CSF. Stops band of nerve roots surrounding

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111
Q

Decribe PCA

A

50mg morphine/ 50ml saline syringe - computer controlled
1mg bolus given (otherwise patient will think it’s not working)
5 min lockout
Plasma levels vary less
Higher satisfaction scores

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112
Q

Describe the treatment for piles

A

Conservative:

  • Avoid straigning
  • Eat fibre
  • softners

Medical

  • Short hydrocortisone
  • LA
  • Rubber band ligation - especially if prolapsing
  • Inject with sclerosising agent - phenol injections

Sugical

  • Haemorrhoidectomy
  • Haemorroidal artery ligation (HALO
  • Stapled anopexy (PPH) - if prolapsing
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113
Q

Describe the finction of the endoanal cushions and why they can become a problem

A

Sensory and closing - solid, liquid and gas
Upper 2/3 is highly vascular and heals well.
Lower 1/3 is oppositie.
Determines if internal or external

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114
Q

Features of piles

A

Bleeding
Perianal itch
Prolapse symptoms
External piles may become thrombosed and become very painful

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115
Q

What is infiltration anaesthesia?

A

Injection locally - infiltrates into tissues.

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116
Q

What can happen in anorecal prolapse and why?

A

Post menopause - lack of pelvic floor, constipation, slow transit. Multi parity.

Internal prolapse - (intersusseption)

Muscosal prolapse

Full thickness prolapse

Get inflammation, ulceration and thickening (collagen deposition).

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117
Q

Clinical features of anorectal prolapse

A

Mucosal - bleeding (sometimes), pruritis ani, mucosal discharge

Internal - feeling of incomplete defication, frequency

External full thickness - prolapsing mass, mucus and faecal soiling, may be bleeding

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118
Q

Treatment for anorectal prolapse

A

Medical:

  • Avoid constipation
  • Facal softners

Surgical:

  • Banding
  • Phenol injection of excess mucosa
  • Mucosal excision
  • stapled anopexy (PPH - procedure for prolapse and haemorroids)

Full thickness:

  • Perineal rectopexy - mucosal excision with sutured plication - like a sphincter
  • Perineal rectal resection
  • Transabdominal rectopexy
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119
Q

What is a pelvic organ prolapse? e.g. anterior

A 
Buldge into vagina
anterior prolapse (cystocele) - bladder buldging into vagina
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120
Q

Describe EUS

A

endoscopic ultra sound.
Can be added with doppler
Upper GI or pulmonary system

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121
Q

When is a GIST

A

Gastrointestinal stromal tumour

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122
Q

What is ischaemic collitis? What are the features?

A

Normally an acute occlusion of IMA. Splenic flexture
May be microscopic
Bloody diarhea and abdo pain.

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123
Q

Investigation into ischaemic collitis/ to differentiate

A

Stool sample for CD, microscopy, culture, sensitivity
Abdo Xray and thickened haustrae
CT and thickening
Endoscopy and biopsy*

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124
Q

Causes of ischaemic collitis

A

Low BP
Constriction of BVs
Thromboembolism
Idiopathic

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125
Q

Treatment of ischaemic collitis

A 
Supportive
IV fluids
Analgesia
Bowl rest
Anticoag if thromboembolic
Emergency - surgery
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126
Q

What is cholestyramine

A

Bile acid sequestrnt

Prevents bile irritating large bowl if terminal ileum has been removed

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127
Q

Types of leg ulcer and distinguishing features

A

Arterial - distal and bony prominences, lateral shin, dorsum of foot, toes. painful (venous and neuropathic are painless). May be black eschar

Venous - gator region (medial shin). Check for varicose veins (standing). Friable, red and bleeding base suggests venous or traumatic

Others can be anywhere:

Tumour - often from long term ulcers. SCC. Did it start as a lump? Rolled edge (Sloping is conventional ulcer)

Infection - is there history e.g. bone? Verticle edge suggests syphilis or chronic infection. Erythematous surrounding tissue

Trauma

Neuropathic

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128
Q

What does the popliteal artery divide into?

A

Ant tib and tibiofibular trunk

Fib and post tib.

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129
Q

What is critical limb ischaemia?

A

Rest pain for >2 weeks.
Necrosis/ ulceration (arterial).
BP

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130
Q

Diagnosis and investigation of critical limb ischaemia

A

Typically clinical

Routine bloods
FBC - polycythemia, anaemia
UEs -
Cholesterol
ESR - Vasculitis
Clotting

Non invasive:

Doppler/ Duplex US (flow greater than 250 is considered treatable)
MRA if they cant tolerate dye
(CO2 angiography)
ABPI - ankle brachial pressure index - uses doppler,

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131
Q

Treatment of critical limb ischaemia

A

Modify risk factors
Nursing care
Analgesia
Surgical:
Angioplasty +- stent
Cant do stent in groin due to bending so ma have to perform an endarterectomy.
Subintimal angioplasty creates a new channel outside the intima.
Bypass graft antatomical e.g. aorto-iliac, femoro-popliteal ect.
extra-anatomical e.g. axillo-femoral or femoro-femoral
Amputation - below or above knee, forefoot, toe, rarely ankle
Needs rehab

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132
Q

What is guttering

A

Raising the limb causes veins to empty and they can be seen as indentation- varicose veins?

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133
Q

What is neurogenic claudication?

A

Pain relieved by sitting down
Radiates from spine
Lifting legs using hip flexors is painful. - passive should be ok
Normal pulses

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134
Q

What is beurger’s test and when and why would you perform this?

A

Raise leg at hip, once it appears pale, let it back down. (in a normal individual it will stay pink). Ankle less than 20 deg to become pale indicates severe ischaemia. Time how long it takes to become red/ refill. If it becomes a dusky red (sunset rubor) then there is reactive hyperaemia. May be painful. Good in diabetics how may have false low ABPI

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135
Q

Common sources of vascular grafts

A

Autograft - Cephalic, Basillic, Long/ short saphenous. Have seen radial arteries.
Allograft
Synthetic - PTFE (gortex) or Decron (polyester)

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136
Q

Causes of venous ulcers

A

Varicose veins

DVT hisotry

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137
Q

Presentation of Venous ulcers

A

Oedema
Lipoderatosclerosis
Often over medial melleolus in the gaiter region

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138
Q

Treatment of venous ulcers

A

Four layer bandaging

Maggots to clear slough

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139
Q

Arterial ulcers presentation

A

Pressure points e.g. heels or malleoli
Distally over and between the toes.
History of claudication
May develop cellulitis or wet gangrene (staph or strep)

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140
Q

Treatment of arterial ulcers

A

Stent
By pass graft
Amputation (level of demarcation in cellulitis)

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141
Q

What joint malformation occurs in DM

A

Charcot’s joints

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142
Q

Aetiology of varicose veins

A

Hypertension
Occupation e.g. surgeons
DVT
Trauma

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143
Q

Presentation of varicose veins

A 
Heavy legs
Swelling
Ache
Pigmentation, hardening
Tortuous dilated vein
Comps:
Ulceration
Venous eczema and puritis 
Haemorrhage and inflammation
Thrombophlebitis
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144
Q

Examination of varicose veins

A

Examine standing
Which vessel? Based on anatomy - most at SFJ
Is the deep vein also incompetent?
Trendelenberg test - Tournique SFJ when patient is supine - patient stands, if blood fills then perforating veins are incompetent.
Tap test - using doppler at superior site of saphenous, squeeze calf, will register sound as blood flow increases then will hear a longer sound as blood flow backwards

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145
Q

Investigations into varicose veins

A

ABPI - rule out arterial
If outpatinet then hand held doppler over SFJ and SPJ with calf compression.
Duplex - Doppler and US.
Find patent veins

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146
Q

Treatment into varicose veins

A

Stockings (may be prophylactic) - pulls veins together
Microsclerotherapy - lasers
Foam sclerotherapy- injection into wall (washing up liquid)

Surgical:
Tie off vein
embolise with burning (coolant surrounding),. Removal of vein.
Long saphenous vein stripping
Endovenous laser therapy (EVLT)
Radiofrequency ablation (endoluminal heating)
Subfascial endoscopic perforator ligation

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147
Q

Surface anatomy of long saphenous vein

A

Starts anterior to the medial malleous, goes posterior to left femoral condyle at knee, enters the femoral vein at the saphenofemoral junction - sapphenous opening just a couple of cm inferior to midinguinal point.

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148
Q

Surface anatomy of short saphenous vein

A

Starts posterior to the lateral malleolus, travels up posterio-lateral part of lower leg into the popliteal vein.

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149
Q

Difference between dysphagia and odynophagia

A

Difficulty vs pain swallowing

Often point to particular part in dysphagia

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150
Q

Diagnostic techniques in dysphagia

A

Barium swallow/ oesophagram
OGD - oesophago-gastro-duodeno
Oesophageal manomety (pressure)

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151
Q

Causes of dysphagia

A

Achalasia
Pharyngeal pouch
Carcinoma

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152
Q

Causes of odynophargia

A

DES
Esophogitis
Mallory-Weiss tear

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153
Q

Alarm symptoms of dysphagia

A

Blood in stool
>60 years
Weight loss
Anaemia

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154
Q

Pathophysiology and causes of achalasia

A

Problem in oesophageal muscle coordination. Disorder of peristalsis and LOS opening.
Results in food stuck at LOS and mechanical obstruction.

Idiopathic

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155
Q

Symptoms of achalasia

A

Dysphagia for solids and liquids (points lower)

Weight loss

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156
Q

Dx achalasia

A

Barium oesophogram.
Bird beak sign
Often clinical
Manometry gold standard

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157
Q

Tx achalasia

A

Pneumatic dilation
BoTox into LES
Lower sphincter myotomy

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158
Q

Sx oesophageal cancer

A

dysphagia - solids more than fluids
Anaemia
Weightloss
Blood in stool

disseminated:
Cervical lymph
Hepatomegaly
Epigastric mass due to para-aortic lymphagenopathy
Dysphonia -RLN
Horner's
Neck swelling - SVC compression
haemoptysis and cough -tracheal
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159
Q

Dx oesophageal cancer

A 
OGD - biopsy
If positive needs staging
EUS - local spread
CT abdo - liver
Bronchoscopy - local
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160
Q

Types of oesophageal cancer, risk factors and presentation

A

Clinically the same.
SCC- anywhere, age, alcohol, smoking
ACC- GORD, dietary nitrosamines - (acid, frying, beer), Barretts, lower 1/3

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161
Q

Tx oesophageal cancer

A

Rarely resectable surgically

Palliative chemo 5FU of neoadjuvant

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162
Q

Pharyngeal pouch pathophys

A 
weakeness - killian's dihiscence
Uncoordinated contraction of the cricopharyngeus. 
Occurs posteriorly
Not a true diverticulum
(Zenker's diverticulum)
Older patients
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163
Q

Symptoms of pharyngeal pouch

A

Dysphagia - point to pharynx
Palpable lump - right or left due to vertebrae
Regurg
Hallotosis
Nocturnal aspiration - waking up coughing

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164
Q

Dx pharyngeal pouch

A

Barium oesophagram

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165
Q

Tx pharyneal pouch

A

Surgical criocpharyngotomy

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166
Q

Causes of oesophageal stricture

A

Oeophagitis,
Hiatus hernia
GORD

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167
Q

Similar pathology to oesphageal stricture

A

Post cricoid web or ring

Barium oesophagram shows narrowing

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168
Q

Diffuse oesophageal spasm (DOS) pathophysiology and causes

A

Uncoordinated spasm of oesophagus

Stimuli include hot or cold but can occur anytime most often on ingestion

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169
Q

Sx DES

A 
Pain (not techically odynophagia
-crushing
-sub sternal
-radiates to back
Potentially dysphagia
Potential regurg
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170
Q

Dx DES

A

ECG - DDX MI
Barium oesophagram - corkscrew
Manometry - gold

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171
Q

Treatment DES

A 
Nitrates
CCB (best) diltiazem
Benzos
widespread pneumatic dilation
Long surgical open myotomy (rare)
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172
Q

Prep for ERCP

A

NBM 4 hours
Sedation IV
LA spray
LFTs and INR needed

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173
Q

Causes oesophagitis

A

Infection - candida in immunosuppressed or ABX
GORD
Irritation - pill stuck e.g. NSAIDs

174
Q

Sx oeophagitis

A

Odynophagia

175
Q

Dx oesophagitis

A

OGD if not obvious

176
Q

Tx oesophagitis

A

Treat cause
fluconazole if candidal
Acyclovir or antiviral

177
Q

Pathophysiology of GORD

A 
Failure of LOS e.g. hiatus hernia.
Leads to oesophagitis, Barretts and ACC.
Excess acid
Gullet cant clear - motility problem
Incomplete emptying - outlet obstructuon
Duodenal reflux
Increased intagastric pressure - coughing, delayed gastric empyting, large meal
178
Q

Symptoms of GORD

A 
Oesophagus:
Heartburn/ pain, radiates up oesophagus, epigastric, sub sternal.
Regurg
Metalic taste
Dyspepsia
Vomiting
Chronic:
Dental erosion - risk of BO
Resp: (suggests erosion)
Hoarsness
Cough
Sore throat
Dysphonia
179
Q

Red flag in GORD/ dyspepsia and investiations

A 
>45
Dysphagia
Weight loss
anaemia.
Can do:
24 hour pH monitoring
manometry
OGD if >45
180
Q

Epidemiology of GORD and risk factors

A 
Western
Smoking
Alcohol
Caffeine
Chocolate
Genetics
181
Q

Treatment of gord

A

PPI
H2 antagonist
Avoid triggers/ eating before bed
Increase emptying with promotilant e.g. metoclopramide

Surgical:
- Nissen’s fundoplication
- toupet fundoplication or posterior partial wrap.
Linx:
New band of titanium magnets laporoscopic
Stretta:
Radiofrequency into sphincter to cause hypertropy

182
Q

Management of Barrets

A

If high grade dysplasia then you can do a distal oesophagectomy

183
Q

Complcations of GORD

A

Oesophagitis
Stricture - fibrosis - shortening - further reflux

Barretts

184
Q

Types and presentation of hiatus hernia

A

I = sliding - stretch of phrenico-oesophageal membrane, axial displacement of upper stomach through oesophageal hiatus

  • Oesophagitis - stricture and dysphagia
  • GORD
  • Barrets

II = rolling - herniation through weakness in phrenico-oesophageal member (separate axis), lies along side a normal oesophagus

  • less common
  • also hiccough
  • ‘pressure’ in chest
  • odynophagia
  • volvulus, incarceration, obstruction

III= mixed

185
Q

Diagnosis of hiatus hernia

A

OGD
Barium swallow
CT scan of thorax if acute presentation

186
Q

Describe 24hr pH study

A

Probe 5cm above LOS
Patient presses button with symptoms
See if they collerate

187
Q

Treatment of hiatus hernia

A

Medical
same as GORD, PPI, lifetyle, promotion

Surgical

  • Rare
  • Nissens fundoplication
  • Gastropex (fixation of ernia)
  • acutely may need partial gastrectomy
  • most laporoscopic
  • linx bands
  • Stretta
188
Q

Causes of large bowel obstruction[

A

Cancer
Diverticulitis
Sigmoid vulvulus - constipation, hypothyroidism, congential abnormality
Caecal volvulus

189
Q

Causes of small bowel obstruction

A

Adhesions
Hernia
Large bowel cancer
CD

Rarer
Volvulus
Intersussception
Mesenteric infarction
Gallstone ileus
190
Q

Symptoms of small bowel obstruction

A

Absolute constipation
Abdominal distension
Abdominal pain
+/- vomiting (faeculent)

191
Q

Signs of small bowel obstruction

A 
Visible peristalsis
Visible hernias
Tinkling
dehydration
Tachycardia
Hypotension
Fever
Tenderness
192
Q

Investigations into small bowel obstruction

A

Routine bloods - CRP, K, WCC, clotting, group and save, LFT, ABG
Non invasive - AXR, CXR, CT, barium meal? MRI

193
Q

Managment of Small bowl obstruction

A

Medical
Resusictation - fluids and Parenteral nutrition
NBM
Urinary catheter
60-70% of adhesional obstructions resolve spontaneously
Operative - fever, peritonitis, failure to resolve

194
Q

How is presentation of large bowel obstruction different from small bowel?

A

Rarely vomiting unless ileocaecal valve dysfunction

Interval between pain is longer

195
Q

Radiological sign for sigmoid vulvulus?

A

Coffee bean

196
Q

What is toxic megacolon

A

abdominal distension and dilated colon (megacolon)

Seen in UC and sometimes CD

197
Q

How to resolve a sigmoid volvulus

A

90% with colonoscopy

198
Q

Treatment of toxic megacolon

A

Decompress bowel

Colectomy

199
Q

Diverticulitis causes

A 
Diverticulosis with infection e.g. facal impaction
RFs:
Low fibre diet
Obesity
Smoking 
NSAIDs
Western
200
Q

Diverticulitis symptoms

A 
Change in bowel habit
Acute sudden pain (often LLQ)
Fever
Nausea
Bleeding
201
Q

Diverticulitis investigations

A

abdominal CT with contrast

Not barium enema or colonscopy due to risk of perf

202
Q

Management of diverticulitis

A 
Medical:
Mild - liquid diet, abx
Severe - NBM, abx
Surgery rarely indicated
Mesalazine and rifaximin to prevent future attacks
Probiotics?
203
Q

DDX diverticulitis

A

Colon cancer
IBD
Gynae
Ischamic collitis

204
Q

Complications of diverticulitis and treatment

A

Abcess - radiologically guided drianage
Peritonitis
Fistula
—surgery

205
Q

Types of peptic ulcers

A

Type 1 - Body or neck (peak at 50yrs)
Type 2 - duodenal or pre pyloral (25-30yrs)
Atypical e.g. meckles or hypergastrinoma (failure to respond)

206
Q

Clinical features of peptic ulcers

A 
N/V
Anaemia
Melena
1 - Food makes worse, anorexia and weight loss
2 - Food relieves pain (hunger pains)
207
Q

Investigation of peptic ulcers

A

Gastroscopy
Barium meal
Urease testing - on OGD or as CO2 breast test
Fasting serum gastrin (hypergastrinaemia)

208
Q

Complications of PUD

A

Pyloric outlet obstruction - distension and vomiting
Bleed
Anaemia
Perforation

209
Q

Treatment PUD

A

Medical
PPI, H2, Topical antacids, H pylori (metro, PPI, clarythro)

Surgerical
If stenosis - pyloroplasty or partial gastrectomy
Or failure of medical - partial gastrectomy

210
Q

Name of hypergastrinaemia?

A

Zollinger-Ellison syndrome

Most often pancreatic gastrinoma

211
Q

Questions ask in pre op

A 
Complete history
Function capacity e.g. exercise
Hypertension
Asthma
Diabetes
Fx
Smoking Drinking
212
Q

Which drugs do you stop before surgery?

A

Warfarin stopped 5 days before or converted to heparin
Oral hypoglycaemics stopped day of
Clopodigrel 7 days before

213
Q

Principles of DVT prophylaxis - when?

A

If at risk e.g. >90 minute op then
AES - anti emb stockings
Deltaparin - 12hours before and 6-12 hours post wound closure
Not

214
Q

Managing pre op diabetes

A

Take insulin as normal - reduce on day, depends on types but often continue after
Most oral miss on morning (hyoiglycaemics)
Warfarin can take unless contrast dye
Restart instantly

215
Q

Causes of post operative confusion

A 
Ketamine
Elderly
Previous history
Infection
Electrolyte imbalance
216
Q

Management of post-operative confusion

A 
Fluids
Infection prevention
Walks
Orient patient
Minimise medication
217
Q

Symptoms of DVT

A

Pain, swelling, redness, warmness, engorged superficial veins, PE

218
Q

Risk factors for PONV

A

Patient - child, anxiety, history, motion sickness
Surgical - Gynae, GI, middle ear, squint (eye), breast, long duration
Anaesthetics - pain, opioids, gas, dehydration

219
Q

Non pharmacological ways to prevent PONV?

A

Reduce anxiety - acupunture, IV fluids (dehydration), peppermint oil and ginger

220
Q

Risk factors for Postoperative cognitive disorder (POCD)

A

Hypoxia, drugs, hypoxia, age, major (cardiac) surgery

221
Q

Things covered in informed consent

A

Diagnosis and prognosis
Options
Purpose and side effects (positives and negatives)

222
Q

Surgical incision for Liver or gallbladder surgery

A

Kocher/ subcostal/ rooftop

223
Q

Surgical incision for appendix

A

Lanz

224
Q

Surgical incision for gyaenae

A

Pfannenstiel (bakini)

225
Q

Surgical incision for discovery

A

Upper or lower midline or paramedian (rare)

226
Q

Sounds in small bowl obstruction and in gastric outlet obstruction

A

Tinkling and gastric succusion splash (LUQ and patient shaken)

227
Q

Percussion of abdomen findings and meaning

A

Tympanitic (resonant) - gaseaous distension e.g. perforation or large bowel obstruction
Dull flanks - free fluid or ascites

228
Q

How to treat DVT

A

Compression - 4 layer bandaging if ABPI >.85%
Elevation bed rest
Graded compression hosiery depending on pressure/
Hydration
Uncomp - LMWH, oral anti coag
Comp - UFH or LMWH, thrombolysis
VEna caval fiter - percutaneously inserted via jugular or femoral vein to catch if recurrent PE

Surgery:
acute - surgical thrombectomy
Chronic venous insufficiency often secondary to DVT:
Skin grafts
Ulcer bed clearence of slough
Arterial revascularisation
229
Q

Investigations into DVT

A 
Routine
Minimally 
Duplex
VQ scan
CT pulmonary angiography
230
Q

Warfarin management for AF, DVT/PE and Prosthetic

A

AF stop
DVT/PE prophylactic LMWH
Prostetic UFH IV in hospital

231
Q

Vitamin K time to reverse warfarin

A

4-6 hours

232
Q

What does resuscitation involve?

A

O2 aand ventilation
Shock management, IV lines
Management of life threatening problems

233
Q

Outline response to critically ill patient

A 
ABCD
Resuscitation
Monitoring and investifations
Secondary Survery - exam and history
Adjuncts to secondary survey
234
Q

How is circulation assessed in critically ill patients?

A 
4 factors
Cap refill
Pulse 
Skin colour/ temp
BP
235
Q

Circulatory changes in shock

A

HR >100 2 seconds
Cool peripharies
Blood pressure drop is a very late sign

236
Q

How to treat hypoglycaemia acutely

A

Dextrose 10% 250-500ml

237
Q

Acute causes of oligourea post op

A

fluid/ blood loss

Adrenal response to stress via aldosterone and ADH

238
Q

Acute causes of dyspnea post op

A

Hospital aquired pneumonia
Shock
PE
pulmonary (basal) atelactasis - collapse due to diaphragm dysfunction and decreased surfactant production due to anaesthesia and surgical manipulation
left ventricular failure - may be a result of myocardial infarction of fluid overload
pneumothorax - may occur as a complication of insertion of a central venous line or use of intercostal anaesthetic block - also may occur spontaneously

239
Q

Acute causes hypotension post op

A 
Infection and sepsis
cardiogenic shock following MI
Anaphylaxis
Haemorrhage
Dehydration
240
Q

Describe volplex

A

Coloid, like NaCl 0.9%

241
Q

How many ml, na and K does someone need per hour/day

A

ml 2/hour or 40ml/kg/day
2mmol Na mmol/kg/day
1 K mmol/kg/day

242
Q

Explain fluid requirements in children

A

20 20ml/kg/day

Same Na and K

243
Q

Good maintainence regime for a 70kg man

A

Need:
Water - 70x 40 = 2800ml
Na - 70x2 = 120mmol
K - 70x1 = 70

Give
2L .9% saline 40 KCl (unless Na >145mmol)
1L 5% dex (due to osmolarity)
both over 8 hours
Gives
3L
Na 200
K 80

This is was book says and figures dont add up but wouldn’t worry too much (Na 300??)

244
Q

In surgery what are third space losses? other losses?

A

Evaporative losses
Measurable losses
Third space - sequesters ECF proportional to tissue damage (ongoing after surgery) - does not participate in dynamic fluid exchange

245
Q

boarders of the inguinal canal

A 
Superior = conjoint (IO and transversalis)
Anterior = Transversalis fascia
osterior = EO
Inferior = Inguinal ligament
246
Q

Differences between direct and indirect hernia

A 
I vs D
Early, old
Uni, Bi (if they have weak muscles then likely to be weak in both)
More likely scrotum, less
Smaller, larger
more likely strangulate vs less
Non eaily reducible vs easily
247
Q

Specific tests to inguinal herniae

A

Finger invagination test and cough - not done as it causes discomfort.
Ring occlusion test - just above mid inguinal point
Cough impulse better seen than felt
Reducible? - ask patient to reduce if not do slowl to remove air

248
Q

Difference between fem and inguinal location

A

Inguinal is medial and superior to inguinal ligament

249
Q

Differentiate between inguinal hernea and hydrocele in infants

A

Transilluminate

250
Q

Who gets incisional hernias?

A

surgical factors - larger wound
patient factors - cough, immunocomp
Post op - infection, haematoma,

251
Q

Treatment of incisional hernias

A

Same same

252
Q

What is a burst abdomen?

A

Abdominal wound opens / dehiscence

Often fatal

253
Q

Rules for distance between stitches

A

Maximum of 1cm apart!

254
Q

Who cant give blood?

A
255
Q

Indications for giving O- blood?

A

Pregnant
O- type
Emergency

256
Q

Indications for transfusion

A

Hb 7-9

Old Hb 9-10 or if CVS comp

257
Q

What is a massive blood transfusion?

A

> 1 blood in 24hrs or .5 in 4hrs

258
Q

Difference between FFP, cryoprecipitate

A

FFP = everything but cells

Cryprecipitate has clotting factors removed

259
Q

Ways to raise Hb pre operatively

A

Transfusion
IR (takes a week
Vit B12/folate

260
Q

Why can steroids with NSAIDs be dodgy

A

Prevent healing - stomach ulcers

261
Q

NSAIDs and warfarin

A

Contraindicated

262
Q

Warfarin side effect

A

Rectus sheath haematoma
Intraperitoneal hernia
Retroperitoneal haematoma

263
Q

Surgical risks of OCP

A

Mesenteric VT
DVT/ PE
Ectopic if prog
Stopped 4 weeks before surgery

264
Q

Common drugs that can cause pancreatitis

A

DMARDs
Metronidazole
Alchol

265
Q

what is small bowel enteropathy and what causes it?

A

Altered function often mucosal.
Hypoalbuminaemia and iron deficiency
NSAIDs

266
Q

How may steroids can mask intraperitoneal pathology?

A

Temp, WCC diminished

267
Q

Risk of sudden stopping BBs

A

Rebound angina, infarct

268
Q

Risk of suddenly stopping corticosteroids?

A

addisonian crisis

269
Q

Drug for immediate warfarin reversal

A

Beriplex = synthetic factors and protein C

FFP but infection risk

270
Q

Herbal medicines and surgery

A

Stop 2 weeks before as often anticoagulants

271
Q

Who doesnt get LMWH?

A
272
Q

Surgical antibiotics used

A

Clean =

Dirty = Metronidazole and co amiclav (or gentamicin)

273
Q

Why surgical steroids

A

Reduce inflam and some evidence for organ dysfunction and blood loss

274
Q

Causative organism of bacterial endocarditis?

A

Laryngeal intubation - strep viridans so amoxicilin

GI, GU add in gentamicin

275
Q

Stematil (prochlorpermaxine) uses

A

Antiemetic (dopamine)
Atypical antipsychotic
BPPV

EPSE

276
Q

Clinical presentation of carotid disease

A

Stroke/ TIA
Crescendo TIA - rappidly recurring with increased frequency due to unstable plaque with ongoing platelet aggregation and small emboli
Completed stroke - the stable end result of an acute stroke lasting over 24hours
Stroke in evolution - progressive deficit over hours/ days.
Amaurosis fugax - transient monocular visual loss - curtain coming down lasting a few seconds or minutes to being permanent.

277
Q

Diagnosis and investigation into carotid disease

A

Colour duplex scan

If it fails then MRA or CTA

278
Q

Treatment of carotid disease

A

Medical

  • Optimise
  • anticoagulate and statin

Surgical
CEA

279
Q

Indications for CEA

A

> 70% stenosis and symptoms

>50% and asymptomatic (NNTT = 22)

280
Q

Proceedure of CEA

A

Most LA and awake - heparinise before clamp - if circle of willis in tact dont need to shunt - most GAs get shunted unless using cerebral monitoring e.g. pressure and doppler
Incision anterior to sternocleidomastoid
Patch closure of the arteriotomy needed

281
Q

Complications of CEA

A 
Death or major disabling stroke
Minor stroke with recovery 3-6%
MI
wound haematoma
Damage to hypoglossal or glossopharyngeal, facial numbness.
282
Q

What is pithidine and how potent is it?

A

Synthetic opioid 10% as potent as morphine

283
Q

Alpha feto protein from which cancers

A

Hepatocellular carcinoma

Teratoma

284
Q

Predisposing features of mesenteric ischaemia

A 
Age
CVS factors
Cocaine
AF
Emboli
285
Q

Features of mesenteric ischaemia

A 
Sudden pain (often at splenic fecture)
Rectal bleeding
Vomiting
Diarrhoea
Fever
286
Q

Ectasia vs aneuysm

A

both permanent localised dilation but >/

287
Q

Do you need to stop POP prior to surgery?

A

No

288
Q

Symptoms of cholangitis

A 
Jaundice
RUQ pain (can be epigastric)
Fever = charcot triad
289
Q

Difference between Biliary colic and acute cholecystitis

A

cholecystitis is more sever, anorexia and pyrexia and does not settle. More likely to have murohys sign. may get Jaunice

290
Q

Difference between mirizzi and ascending cholangitis

A

Both constant sever RUQ pain and obstructive jaundive but more severe. pain and fever more common.
High swingin fever in ascending cholangitis

291
Q

What is courvoisier’s law

A

jaundicand palpable RUQ mass (gall bladder) is not due to gall stones - pancreatic carcinoma most common

292
Q

Presentation of cholangiocarcinoma

A

Gradual onset

Obstruction directly and via lymph nodes at porta hepatis

293
Q

Types of stomas

A

Loop
End
Double barrel

294
Q

How would you manage a large bowel obstruction from a lower rectal cancer (below peritoneal reflection)

A

defunctioning loop colosctomy

Later an APER

295
Q

Difference betwee total clectomy and subtotal

A

Leave rectum e.g. UC (get a loop ileostomy)

296
Q

When do you stop clopodigrel?

A

7 days before

297
Q

What is subcutaneous emphysema

A

Common with laporoscopic
Air under skin
Often over pec major
Gives ginko leaf sign on CXR

298
Q

90% of colon cancer is what type?

A

ACC

299
Q

Difference between panc and cholangitis

A

In oanc its more epigastric radiating to the back
Severe n/v
both have fever but also dehydration, hypotension, tachycardia
Guarding
Ecchymoisis possible

300
Q

Do you treat arterial or venous ulcers first?

A

Arterial and you cannot compress without

301
Q

If patient is allergic to contrast can you still do angioplasty?

A

Yes with CO2

302
Q

Why would a patient have a arteriovenous fistula tied off?

A

Stopped working due to aneurysm

Patient recieved a transplant and no longer needs it

303
Q

Reynaulds causes

A

Primary most common – idiopathic. If secondary then it is called a secondary vasospastic disorder e.g. ax disease, drug induced or neurological disease

304
Q

Treatment for Raynaurds?

A

Medical
CCBs (the -pines) – causes side effects e.g. headache
Prostacyckin IV if severe with tissue loss potential
Surgical – sympathectomy lumbar or cervical

305
Q

What type of skin cancer can cause ulcers and where?

A

SCC and anywhere

306
Q

What is Allens’s test?

A

Patient makes fist. Occlude radial and ulnar. Release ulnar. Check perfusion. Used before cannulation

307
Q

Causes of varicose veins

A

Idiopathic
Peliv mass e.g. fibroids, cancer, pregnancy
DVT

308
Q

Clinical features of varicose veins

A 
Distended tortuous veins
Pain
Venous eczema
Discolouration
Sclerosis and skin changes
Venous ulceration
Heaviness and swelling worse at end of day, hot, premenstruation
Phlebitis is also a complication
309
Q

What is atrophie blanche?

A

White lesion as a result of poor blood supply. – venous insufficiency

310
Q

Investigations into varicose veins

A

Examination e.g. tap test and trendelenberg.
Handheld Doppler and squeeze calf to listen for reflux lasting 1-2s
Colour duplex – gold standard

311
Q

How can post-declamp shock/ reperfusion snyndrome be avoided?

A

Radual reprofusion with fluid resuscitation and vasopressor treatment
Mannitol as a free radical scavenger

312
Q

What is a whipples proceedure?

A

pancreato-duodenectomy (head of the pancreas) also part of CBD and gall bladder. Often distal stomach too.
Treat pancreatic cancers on head, CBD malignancies or duodenum. Some cases of pancreatitis and rarely severe trauma

313
Q

Risk of high volume of blood transfusion?

A

Hyperkalaemia

314
Q

When to give LMWH before surgery vs after?

A

Periop says that even with routine patinets you give a dose 12 hours before?

315
Q

When to stop IV UFH before surgery?

A

6 hours before

316
Q

Is Vicryl soluble?

A

Yes - used on surface

317
Q

Describe prolene?

A

Thick one - biggest - used deep on the rectus sheath

318
Q

Describe the effects of a VIPoma

A 
Diarrhea
Dehydration
Hypokalaemia
Achlorhydria - low acid in stomach
Acidosis
Flushing and hypotension (vasodilation)
Hyperglycaemia
319
Q

What i carcinoid syndrome

A 
Serotonin  and vasoactive substances
Flushing 
diarrhea
heart failure
Bronchoconstrictioj
320
Q

Should you be worried about a post op temperature spike?

A

If no infection then no - caused by basal atelectasis

321
Q

Treatment for basal atelectasis

A

Chest physio, breathing exercises and physio

322
Q

Water and clear fluids how long before op?

A

Stop at 2 hours - food=6

323
Q

Pancreatic marker cancer

A

CA19-9

324
Q

Pancreatic cancer gold standard diagnosis

A

CT

325
Q

What is dumping syndrome

A

Weakness, discomfort and loads of shits that are rapid

Risk of a Whipples (other is PUD)

326
Q

When do you get petechiae?

A

DIC

Fat embolism syndrome

327
Q

what is Fat embolism syndrome

A

Normal clotting, thrombocytopenia, normocytic anaemia
Resp failure (acute resp distress syndrome), cerebral dysfunction and petechial rash
Microembolism

328
Q

Test in women before assuming appendicitis?

A

Pregnancy test - urine hCG to rule pregnancy and ectopic

329
Q

Pancreatic cancer presentation

A

Painless jaundice

Bigger raise in ALP and GGT than ALT

330
Q

Why use adrenaline with a local?

A

Keeps it local

331
Q

What is eltrombopag and when would you use it?

A

Thrombopoietin receptor agonist. Used if they have low platelets

332
Q

Can achalasia cause pain?

A

Yes it can, very severe

333
Q

Symptoms of chronnic mesenteric ischaemia

A

Weightloss, smoking history, ischaemic angina - brought on by eating with n/v. Other vascular features

334
Q

What virus causes pancreatitis?

A

Coxsakie

335
Q

What is a Mcevedy incision?

A

Outdated
Paramedian
along lateral boarder of rectus sheath

336
Q

What is a rooftop incision used for?

A

whipple’s

337
Q

What is the psoas stretch?

A

Extetend the thigh when knee is extended

338
Q

What Boas’ sign?

A

Cholecystitis

Pain/ hypersensitivity below the right scaouka

339
Q

Sodum thiopentone describe

A

Rapid induction, depresses cardiac output, prone to accumulation
barbiturate used before propofol - IV

340
Q

Kartagener’s syndrome describe

A

Immogile cillia syndrome (sinusitis) and situs invertus.
Infertilitiy
Hearing loss
Recesive

341
Q

What is Gardener’s syndrome

A

GI polyps, osteoma, epidermoid cysts

aut dom

342
Q

What is metaraminol?

A

Alpha 1 agonist - first line in vasopressors

343
Q

Dobutamine?

A

Beta 1 receptor agonist - positive ionotrope e.g. Cardiogenic shock

344
Q

Myasthenia gravis patients a resistant to which drug?

A

Suxamethonium (need less rocuronium)
Maybe becoause sux is depolarising blocker you need more conc to get the same % binding at receptors? - hy not this exlaination for roc though?

345
Q

What is US FAST for?

A

AAA

346
Q

What drug reverses heparin?

A

Protamine sulphate

347
Q

How does CD normally present?

A 
Weight loss
Pain (RIF often)
fever malaise
Change in bowl habuit (diarroeah)
Failure to thrive
If fistula then tender abdominal mass with para enteric abscess formation
If stenosis then colicky abdo pain and distended bowl
Anal disease can occur rarely
348
Q

CD and UC extra intestinal symptoms

A 
Arthritis
Episcleritis (CD)
Osteoporosis
Ivelitits
Pyoderma gangrenosum - large ulcers on foot and leg.
Clubbing
Primary sclerosing cholangitis
349
Q

Absolute CI to regional anaesthesia

A

Warfarin

350
Q

what is Chagras disease

A 
Tropical disease - potorzoan
Fever
Lymph
Headaches
Bite
Later causes ventricular magaly, HF, enlarged oesophagus and colon
Erythema nodosum (CD)
Ank spond (CD)
Chronic active hepatits (CD)
Some with disease some not with.
351
Q

Disgnosis of CD and UC

A

Both have high WCC and CRP and low Hb and albumin

UC:
AXR - thumb printing, oedema
flex sig and biopsy with histology

CD:

abdominal CT if acute
Small bowl contrast study showing mucosal irregularity
Endoscopy and biopsy

352
Q

Tretment for CD

A 
5ASA
Steroids for acute (or chronic for high first pass metab e.g. budesonide)
6 MP
Azathioprin
infliximab
diet changes

surgery if:
acute - perf, haemorrhage, severe colitis, co obstruction
subacute e.g. precursors to above or fistulation
chronic if failure to thrive or complications of treatment or cancer prevention

353
Q

Treatment of UC

A

Proctilis with topical steroids and 5ASA supps

Collitis with steroid enemas, 5asa enemas or oral pred

Pancolitis with oral steroid and 5ASA
Aza or 6MP
Cyclosporin A and anti TND

354
Q

What is Boerhaave’s syndrome?

A

Eosuophageal rupture that is not idiopathic (10%) e.g. pill oesophagitis, stricture, vomiting (alcohol).

355
Q

Symptoms of Boerhaave’s

A

upper abdo pain, odynphagia, tachypnoea, shock, fever
Comp = mediastinitis
Pneumomediastinum

356
Q

Treatment of boerhaave’s

A

NBM
Scope
IV abx
Needs surgical repair!!

357
Q

What is dextrocardia?

A

Everything is mirrored in thorax (gastric bubble)

Situs invertusis everything is reversed

358
Q

Bats wing appearence on CXR?

A

Pulmonary oedema

359
Q

What does interstitial shadowing suggest?

A

Fibrosis

360
Q

What does the holly leaf sign show?

A

calcified pleural plaques? front and back of diaphragm e.g. asbestososis

361
Q

Describe appearance of a mesothelioma

A

Thickening of pleural tissue on one side

-frozen lung - shell of malignnat tisse so cant expand

362
Q

How far should ET tube be from the carina?

A

2cm to prvenet ventilation occuring more in one lung than the other

363
Q

What is Rapid sequence induction

A

Risk of aspiration
No ventilation between induction of anaesthesia and intubation.
Pre fill lungs with high O2, apply cricoid pressure.
Used if they have eaten, are preggers or have extreme GORD or if they have neurological defecit

364
Q

Difference between sterilisation and asepsis

A

No bugs including spores on sterile

asepsis = abscence if pathogenic microorganisms

365
Q

What type of imaging used to insert an NJ tube?

A

Fluroscopy

366
Q

Treatment C diff?

A

Stop Abx
Vancomycin
Faecal microbiota transplant

367
Q

Risks involved in TPN

A 
Infection
Mucosal breakdown
Liver damage
Thrombosis
Vascular damage
Pneumothorax
Haemothorax
Refeeding syndrome
Electrolyte imbalance
368
Q

What is refeeding syndrome

A 
Severely malnourished people
Can get cardiac arrhythmias
Celluklar dysfunction 
Give K, PO, Mg and potentionally Ca,
Stop feeding
369
Q

How to calculate circulating vol?

A

70ml/kg so 5l

370
Q

Highest conc of SO and PO4?

A

Intracellular

371
Q

Explain the different types of plastic surgery

A

Graft - tissue taken and uses blood supply of new site
Pedical flap - uses existing blood supply
Free flap -blood supply taken with it but needs reanastomosing.

372
Q

Pathological features of pancreaitis

A 
May affect whole or part (focal).
Features of acute e.g. oedema intraparenchymal haemorrhage
Chronic:
Parenchymal distruction
Gland atrophy and duct ectasia
May be stones and occlusion
Microcalcification
373
Q

Causes of chronic pancreatitis

A

Recurrent acute especially alcohol cause
Congenital idiopathic
Ax e.g. sclerosing cholangitis or primary billiary cirrhosis
Secondary to pancreatic duct obstruction e.g. iatrogenic, ERCP, (forming a stricture), CF, pancreatic head tumours

374
Q

Signs and symptoms of chronic pancreatitis

A 
Abdominal pain (epigastric radiating to back) chronically - associated with eating and alcohol.
Exocrine:
Weight loss and anorexia
Sterattorheao
Endocrine:
Insulin 2DM
375
Q

Investigations of chronci pancreatitis

A 
US- if cysts or duct dilation
AXR - calcification
CT (best) -id causes e.g. genetic variants, tumours, cysts, may show extent of disease
MRI (same as CT)
ERCP
376
Q

Treatment of chronic pancreatitis

A 
Medical:
Treat cause
Pancreatic enyme (creon)
Diet rich in antioxidants
Analgesia
Insulin if DM
Surgery
Whipples (pancreaticoduodenectomy))
Frey (Partial head pancreatectomy or of tail which is a distal 
-pancreatectomy

All resectional surgery linked with increasing risk of failure both exo and endo and risk of recurrence or progression. Only doen if very bad symptoms or treatable cause

377
Q

Complications of chronic pancreatitis

A

Pseudocyst, obstruction, fistula, infections, portal hypertension

378
Q

Pathological features of pancreaitis

A 
May affect whole or part (focal).
Features of acute e.g. oedema intraparenchymal haemorrhage
Chronic:
Parenchymal distruction
Gland atrophy and duct ectasia
May be stones and occlusion
Microcalcification
379
Q

Causes of chronic pancreatitis

A

Recurrent acute especially alcohol cause
Congenital idiopathic
Ax e.g. sclerosing cholangitis or primary billiary cirrhosis
Secondary to pancreatic duct obstruction e.g. iatrogenic, ERCP, (forming a stricture), CF, pancreatic head tumours

380
Q

Signs and symptoms of chronic pancreatitis

A 
Abdominal pain (epigastric radiating to back) chronically - associated with eating and alcohol.
Exocrine:
Weight loss and anorexia
Sterattorheao
Endocrine:
Insulin 2DM
381
Q

Investigations of chronci pancreatitis

A 
US- if cysts or duct dilation
AXR - calcification
CT (best) -id causes e.g. genetic variants, tumours, cysts, may show extent of disease
MRI (same as CT)
ERCP
382
Q

Treatment of chronic pancreatitis

A 
Medical:
Treat cause
Pancreatic enyme (creon)
Diet rich in antioxidants
Analgesia
Insulin if DM
Surgery
Whipples (pancreaticoduodenectomy))
Frey (Partial head pancreatectomy or of tail which is a distal 
-pancreatectomy

All resectional surgery linked with increasing risk of failure both exo and endo and risk of recurrence or progression. Only doen if very bad symptoms or treatable cause

383
Q

Complications of chronic pancreatitis

A

Pseudocyst, obstruction, fistula, infections, portal hypertension

384
Q

How far above diaphragm to be a hiatus hernia?

A

Gastric mucosal fold 2-3cm above (30% aged 50 have)

385
Q

What is Valentinos syndrome?

A

RLQ pain due to perforation duodenal posteriorly.

Often have shock

386
Q

Management of Valentinos syndrome

A 
Medical normal stuff
PPI and H pylori
Surgical
Open or lap
Omentum tied over
387
Q

How is chlamydia relevant to bowel surgery?

A

Proctits

388
Q

Treatment of Pilonidal sinus disease?

A

Medical
Sahveing and washing
Abx if septic
Abcess need draining
If recurrent sepsis then surgery:
Excision of sinus openings
Obliteration of all infected tissues
obliteration of the natal cleft by flattening
e.g. primary excision with lay open and secondary intention (rare)
Normally tension free apposition of edges e.g. flapsr

389
Q

Anatomy of appendix

A

Base and tip - tip nectroses first

390
Q

Cuases of appendiciits

A

Kids - lymph from virus,
Young - faecoliths
Adults?

391
Q

Normal water

A

300ml for 70kg

.5/kg/hr = oligo?? check nexus

392
Q

Nitrates or leukocytes more sensitive to UTI

A

Nitrate - leuko from infalm

393
Q

What do you still take out an appendic if you find it looks normal during surgery?

A

Can be microscopic appendicitis

394
Q

Treatment of Pilonidal sinus disease?

A

Medical
Sahveing and washing
Abx if septic
Abcess need draining
If recurrent sepsis then surgery:
Excision of sinus openings
Obliteration of all infected tissues
obliteration of the natal cleft by flattening
e.g. primary excision with lay open and secondary intention (rare)
Normally tension free apposition of edges e.g. flapsr

395
Q

Commenest site for lower limb vascular disease?

A

Adductor canal (hence calf) 80% SFA

396
Q

Femoral rupture and signs?

A

Blood can go retroperitoneal which can hold a lot of space and cant be stopped from outside

397
Q

DDX intermittent claudication

A

neuropathic claudication
arthritis
musculoigamentous straign

398
Q

What is leriche syndrome

A

Blockage of AA at bifurcation

Erectile disfunction
Claudication of buttocks, thigh and calf

Absent fem pulses

399
Q

What is significant finding on duplex?

A

x3 normal or 75% narrowing

400
Q

Why might vasc disease make leg red instead of pale?

A

sunset foot - inflammation

401
Q

Likely causes of a popliteal rupture?

A

high tibial bumper facture - knees hit bumber

402
Q

Femoral rupture and signs?

A

Blood can go retroperitoneal which can hold a lot of space and cant be stopped from outside

403
Q

Types of gastric tumours

A

Adenocarcinoma
CT - GIST (stromal)
Neuroendocrine - carcinoid
Lymph - lymphomas

404
Q

May ant to do small bowl see xford handbook of surgery

A

m

405
Q

Signs of adenoarcinoma stomach

A

Weight loss
epigastric ass
palpable supraclavicular nodes (Troisier’s sign) if diseminated disease

406
Q

Staging and diagnosis of gastric cancer

A

OGD
Thoraco-abdominal CT for mets
Endoluminal US for local
Laproscopy - peritoneal masses

407
Q

TNM staging for gastric cancers

A 
T same as bowl but T4 = other organs
N0 no lymph
N1 nodes within 3cm of primary
N2 more than 3
P - peritoneal
P0 1/2/3 if more extet
H01/2/3 - hepatic
408
Q

Treatment gastric cancer

A

Often palliative
Pre and post chemo
radical gastrectomy
local ablation for symptom control if palliative

409
Q

Treatment of lymphomas

A

H pylori eradication

410
Q

May ant to do small bowl see xford handbook of surgery

A

m

411
Q

Keloid scar vs hypertrophic

A

No nodules vs nodules
Beyond scar vs contain to scar
Does not regress and recurs vs ?

412
Q

Type of panc scoring

A

Ranson also glasgow imrie

413
Q

Causes of high output stoma

A 
Obstruction
Inflammation
Infection
Excess gastric acid
Malnutrition
Adaptation
414
Q

Name of Adhesions between liver and abdominal caused PID

A

Violin string

415
Q

Differentiatie pancreatitis, perforated ulcers

A

Chest CXR - air under diaphragm

416
Q

Mesenteric ischamia when do you get pain

A

After eating

417
Q

Test mesenteric ischaemia

A

MR angio

418
Q

When would you use gastrografin enema instead barium?

A

If there is risk of a leak e.g. After an anastomosis to check.

419
Q

Most likely to cause gangrene pathogen

A

Clostridium perfringens

420
Q

Lactational mastitis pathogen?

A

Staph aureus

421
Q

Can soiling occur in haemorrhoids?

A

Yes if stage 3 or 4

422
Q

Screening for AAA at 65, how long fo rfollow up?

A

Single only or 2 years if suspect?

423
Q

Fluid challenge amount used?

A

500 saline stat-

424
Q

Comps off pancreatitid and timeline?

A

Pseudo at 4-5 weeks, raied SA

Abcess at 10 - infected pseudocyst

425
Q

HNPCC gene defect?

A

Mismatch repair

426
Q

FAP gene?

A

APC on chromo 5 a TSG

427
Q

What is elemental diet?

A

Break down of aas

428
Q

What does coomb’s test do?

A

Confirms haemolysis - normally rh reactive

429
Q

Likely polypp to become malignat?

A

Villous polyp

430
Q

What is a littres hernia?

A

Herniea containing MD

431
Q

What is Spligelian

A

Hernia lateral to the rectus muscle at level of the arcuate line

432
Q

Classes and features of Haemorrhagic shock

A

Class 1 <15% normal HR
Cl;ass 2 15-30% loss tachycardia
Class 3 30-40, Tachy adn hypotensive, confusion
Class 4 >40% adn LOC sever hypotension

Phase II (18 decks)

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