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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
Commonest causes of rectal bleeding
``` Piles UC Cancer Anorectal fissure Angiodysplasia Diverticular disease Ischaemic collitis Meckles Intersusseption Massive Upper GI bleed CD trauma ```
26
Investigations to detect ischaemic collitis
Barium enema (thumb printing), colonoscopy
27
Risk factors for gall stones (cholelithiasis)
``` Female Fair (caucasian) Forties Fat (or rapid weight loss) Fertile (pre menopause, multiparity, OCP) Previous surgery TPN` ```
28
Explain how cholelithiasis form and the problems that gall stones cause
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
29
Presentation of cholelithiasis
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
30
Describe murphy's sign
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.
31
How is acute cholecystits different from cholethiasis
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.
32
Complications of acute cholecystitis
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.
33
Investigations into acute colecystitis
``` 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. ```
34
Management of cholelithiasis and cholecstitis
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
35
Risk of laparoscopic cholecystectomy
5-10% risk of open operation Bile duct injury Bleeding Bile leak
36
What is a gall bladder mucocele?
Stone in neck of bladder (Hartman's pouch), bile absorbed but mucus sections continue forming a mass
37
How does CBD gall stones present
``` 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
38
Investingations CBD gall stones
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
39
Management CBD gall stones
``` 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) ```
40
Risks of ERCP
Perforation and peritonitis Haemorrhage Acute panc Ascending infection
41
What is Reynolds pentad?
``` Charcots triad (Jaundice, RUQ pain and high swinging fever) + shock and mental disturbance (obtundation) ```
42
Describe PEEP and why it is a pathological finding
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?
43
How common is bowel cancer
2nd most common | 1/20 people
44
Describe screening in bowel cancer
Every 2 years from 60-74 Faecal occult blood test If positive then invited for colonoscopy
45
Symptoms of bowel cancer
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
46
Describe the location of colorectal cancers
Most in rectum then sigmoid then caecum
47
Explain genetic risk factors for bowel cancer
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
48
Describe the pathogenesis of colorectal cancer
Adenoma - carcinoma change`
49
Describe how screened polyps are followed up
Removal during colonoscopy | >1cm or 2-3 polyps then 1yr follow up if not then 3yrs (depends on other factors too e.g. histology).
50
Investiations into colorectal cancer
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
51
Spread of colorectal cancer
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
52
Describe staging of colorectal cancer
``` 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 ```
53
Management of colorectal cancer
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
54
Prognosis of colorectal cancer
A - 85% B - 70% C - 40%
55
Risks of surgery
``` Bleed Leak Stoma prolapse Ureter damage Bowel damage ```
56
Difference between colonoscopy and flexible sigmoid
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
57
What is endoscopic mucosal resection
Inject dye into submucosa | Ligate polyp
58
Describe CT cologram
Gasgraphin to drink the day before (also laxative)
59
Causes for raised unconjugated billirubin
Hepatitis Cirrhosis Drugs - amoxicillin, flucloxiciilin, cough medicine ``` Sickel cell anaemia B Thalassemias Burn/ trauma? Spherocytosis - haemolysis Gilberts Cigler-Nagler ```
60
What is gilberts syndrome?
10% of pop have Deficiency of glucuronyltransferase which conjugates bilirubin Jaundice
61
What is Crigler Najjar?
Enzyme difficience | High unconj bilirubin (causes brain damage and often fatal)
62
Causes of raised conjgated billibrubin
``` Cholelithiasis Cholangitis Adenocarcinoma of pancreas Cholangioadenocarcinoma Gall bladder/ duodenal malignancies Iatrogenic Pancreatitis (swelling) - transient Billiary stricture - infection, panc, malig Sclerosis cholangitis Congenital - choledochal cyst ```
63
Treatment of CBD cancers
``` Hilar then liver resenction Middle third then resection of duct Periampullary then peri-pancreatoduodenectomy Palliative - ERCP/ stent Percutaeous drainage ```
64
Muscle in oesophagus
Upper 1/3 is skeletal
65
What is the acute angle called
Angel of his
66
Oesophageal sphincter made of
Folds of mucosa, | Angel of his
67
Blood supply of oesopagus
Neck region - inferior thyroid artery, thyrocervical trunk, subclavian Chest - branches of aorta Abdomen - left gastric (Caeliac) and inferior phrenic (AA)
68
Branches of external carotis
``` Superior thyroid Ascending pharyngeal Lingual Facial Occipital post auricular Maxillary Superficial temporal Some aggressive lovers find odd positions more stimulating ```
69
Innervation of oesophagus
Recurrent pharyngeal - parasymp for upper 1/3 | lower 2/3 - Vagus
70
Treatment for Hiatus hernia
Medically - stomach stuff Surgery - Nissen's fundoplication (complete or partial) Linx - beads
71
DDX pancreatitis
``` Perforated peptic ulcer Mesenteric infarction MI AAA Cholecystitis ```
72
Prognosis for acute pancreatitis
90% resolve in a few days others have complications - often fatal (sepsis) Normally sterile necrosis so no abx unless abcess Drain pseudocyst
73
Management of acute pancreatitis
``` 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 ```
74
How is a severe attack of acute pancreatitis diagnosed?
3 positive criterea within 48h of admission of the Glasgow Imrie criterea
75
Assessment of airway
``` 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
76
Assessment of breathing
e
77
When is a nasopharyngeal airway indicated/ contraindicated?
Fits, atrismus (rigid jaw) ``` CI: Fracture base of skull - battle sign - mastoid ecchymosis. - Panda eyes - CSF nose ```
78
Describe giving O2 on airway
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
79
Reasons for hypoxic drive
Obstructive Sleep apnoea Obesity hypoventilation COPD
80
When could O2 delivery be harmful
Straight after MI, stroke or COPD/ hypoxic drive Clin sig - titrate O2 down to prescribed/ target %
81
How long does an O2 cylinder last?
30mins at 15L/min (450L total)
82
What is involved in the pre op assessment
``` 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 ```
83
How is risk reduced in anaestetics?
IV access for fluids Reduce trauma Keep patient at correct body temperature
84
Drugs given by anaethatist and when
Induction IV - propofol 1 mg/ml ``` Muscle relaxant Depolarising -Suxamethonium Non depolarising -everything else Need for intubation Monitor via nerve stimulator ``` Analgesia -Opioids
85
How can you be opioid sparing?
Augment with LA perioperatively, give as epidural
86
Phases of anaesthesia and short description of what happens
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
87
Problem with reliance on pulse oximetry?
About a minute behind actual sats
88
Describe capniography
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
89
How can you reverse NMB
Neostigmine
90
Define pain
An unpleasant sensory and emotional experience associated with acutal or potential tissue damage or described in terms of damage
91
Define chronic pain
>3 months No underlying physical damage. May not have an identifiable cause
92
Define nociception
Transmission of painful stimulus without consciousness.
93
Describe the pain pathway
Transduction Transmission Modulation Perception
94
Types of pain transmission
``` Mechanical Thermal Chemical (internal & external?) ```
95
Difference between a delta fibres and C fibres
A delta is sharp pain | C fibres are for duller pain
96
Describe modulation of pain and at what levels doctors can affect this
``` Brain Water therapy (drinking loads upon waking) Hypnosis Paracetamol Opioids ``` ``` Spinal cord TENS Opioids LA Opioids Capsaicin ``` Periphery NSAIDs LA
97
What is the WHO pain ladder
Non opioid - Paracetamol - NSAISs - single or combines Add Weak opioid - codeine - tramadol Substitute for stong opioid - Morphine - Diamorphine - Fentanyl - Remi/ Alfentanyl
98
Cautions for paracetamol
Liver failure and
99
Describe common types of NSAIDs and CIs
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
100
How much less potent is codeine than morphine
10 times | Variable metabolism
101
How many times less potent is tramadol than morphine?
5-10 times less potent
102
CIs with tramadol
Inhabits Na and 5HT uptake so SSRIS and TCAs, Lowers seizure threshold Elderly caution
103
Describe the control of vomiting including afferents and efferents
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
104
Describe antisickness medications that target the postrema. Side effects
Dopamine so metoclopramide (partially- also 5HT and anti cholin also blocks vagal 5HT afferent) and domperidone. Both can cause prolactin problems and EPSE.
105
Describe antisickness medications that directly affect the central vomiting centre and side effects
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.
106
Potencies of strong opioids
``` Morphine Diamorphin x2-4 Alfentanyl x10-25 Fentayl x80-100 Remifentanyl x100-200 ```
107
Describe onset of strong opioids and features
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
108
How do you tell the difference between a direct and an indirect hernia?
get patient to cough whilst covering the deep ring
109
Decribe uses of LA
``` EMLA cream, eumatetic mixture of LA - procaine/ lidocaine - topical Subcut or intra dermal Peripheral nerve block Epidural Spinal anaesthetic ```
110
Difference between epidural and spinal anaesthetic
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
111
Decribe PCA
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
112
Describe the treatment for piles
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
113
Describe the finction of the endoanal cushions and why they can become a problem
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
114
Features of piles
Bleeding Perianal itch Prolapse symptoms External piles may become thrombosed and become very painful
115
What is infiltration anaesthesia?
Injection locally - infiltrates into tissues.
116
What can happen in anorecal prolapse and why?
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).
117
Clinical features of anorectal prolapse
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
118
Treatment for anorectal prolapse
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
119
What is a pelvic organ prolapse? e.g. anterior
``` Buldge into vagina anterior prolapse (cystocele) - bladder buldging into vagina ```
120
Describe EUS
endoscopic ultra sound. Can be added with doppler Upper GI or pulmonary system
121
When is a GIST
Gastrointestinal stromal tumour
122
What is ischaemic collitis? What are the features?
Normally an acute occlusion of IMA. Splenic flexture May be microscopic Bloody diarhea and abdo pain.
123
Investigation into ischaemic collitis/ to differentiate
Stool sample for CD, microscopy, culture, sensitivity Abdo Xray and thickened haustrae CT and thickening Endoscopy and biopsy*
124
Causes of ischaemic collitis
Low BP Constriction of BVs Thromboembolism Idiopathic
125
Treatment of ischaemic collitis
``` Supportive IV fluids Analgesia Bowl rest Anticoag if thromboembolic Emergency - surgery ```
126
What is cholestyramine
Bile acid sequestrnt | Prevents bile irritating large bowl if terminal ileum has been removed
127
Types of leg ulcer and distinguishing features
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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What does the popliteal artery divide into?
Ant tib and tibiofibular trunk | Fib and post tib.
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What is critical limb ischaemia?
Rest pain for >2 weeks. Necrosis/ ulceration (arterial). BP
130
Diagnosis and investigation of critical limb ischaemia
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,
131
Treatment of critical limb ischaemia
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
132
What is guttering
Raising the limb causes veins to empty and they can be seen as indentation- varicose veins?
133
What is neurogenic claudication?
Pain relieved by sitting down Radiates from spine Lifting legs using hip flexors is painful. - passive should be ok Normal pulses
134
What is beurger's test and when and why would you perform this?
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
135
Common sources of vascular grafts
Autograft - Cephalic, Basillic, Long/ short saphenous. Have seen radial arteries. Allograft Synthetic - PTFE (gortex) or Decron (polyester)
136
Causes of venous ulcers
Varicose veins | DVT hisotry
137
Presentation of Venous ulcers
Oedema Lipoderatosclerosis Often over medial melleolus in the gaiter region
138
Treatment of venous ulcers
Four layer bandaging | Maggots to clear slough
139
Arterial ulcers presentation
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)
140
Treatment of arterial ulcers
Stent By pass graft Amputation (level of demarcation in cellulitis)
141
What joint malformation occurs in DM
Charcot's joints
142
Aetiology of varicose veins
Hypertension Occupation e.g. surgeons DVT Trauma
143
Presentation of varicose veins
``` Heavy legs Swelling Ache Pigmentation, hardening Tortuous dilated vein Comps: Ulceration Venous eczema and puritis Haemorrhage and inflammation Thrombophlebitis ```
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Examination of varicose veins
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
145
Investigations into varicose veins
ABPI - rule out arterial If outpatinet then hand held doppler over SFJ and SPJ with calf compression. Duplex - Doppler and US. Find patent veins
146
Treatment into varicose veins
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
147
Surface anatomy of long saphenous vein
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.
148
Surface anatomy of short saphenous vein
Starts posterior to the lateral malleolus, travels up posterio-lateral part of lower leg into the popliteal vein.
149
Difference between dysphagia and odynophagia
Difficulty vs pain swallowing | Often point to particular part in dysphagia
150
Diagnostic techniques in dysphagia
Barium swallow/ oesophagram OGD - oesophago-gastro-duodeno Oesophageal manomety (pressure)
151
Causes of dysphagia
Achalasia Pharyngeal pouch Carcinoma
152
Causes of odynophargia
DES Esophogitis Mallory-Weiss tear
153
Alarm symptoms of dysphagia
Blood in stool >60 years Weight loss Anaemia
154
Pathophysiology and causes of achalasia
Problem in oesophageal muscle coordination. Disorder of peristalsis and LOS opening. Results in food stuck at LOS and mechanical obstruction. Idiopathic
155
Symptoms of achalasia
Dysphagia for solids and liquids (points lower) | Weight loss
156
Dx achalasia
Barium oesophogram. Bird beak sign Often clinical Manometry gold standard
157
Tx achalasia
Pneumatic dilation BoTox into LES Lower sphincter myotomy
158
Sx oesophageal cancer
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 ```
159
Dx oesophageal cancer
``` OGD - biopsy If positive needs staging EUS - local spread CT abdo - liver Bronchoscopy - local ```
160
Types of oesophageal cancer, risk factors and presentation
Clinically the same. SCC- anywhere, age, alcohol, smoking ACC- GORD, dietary nitrosamines - (acid, frying, beer), Barretts, lower 1/3
161
Tx oesophageal cancer
Rarely resectable surgically | Palliative chemo 5FU of neoadjuvant
162
Pharyngeal pouch pathophys
``` weakeness - killian's dihiscence Uncoordinated contraction of the cricopharyngeus. Occurs posteriorly Not a true diverticulum (Zenker's diverticulum) Older patients ```
163
Symptoms of pharyngeal pouch
Dysphagia - point to pharynx Palpable lump - right or left due to vertebrae Regurg Hallotosis Nocturnal aspiration - waking up coughing
164
Dx pharyngeal pouch
Barium oesophagram
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Tx pharyneal pouch
Surgical criocpharyngotomy
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Causes of oesophageal stricture
Oeophagitis, Hiatus hernia GORD
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Similar pathology to oesphageal stricture
Post cricoid web or ring | Barium oesophagram shows narrowing
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Diffuse oesophageal spasm (DOS) pathophysiology and causes
Uncoordinated spasm of oesophagus | Stimuli include hot or cold but can occur anytime most often on ingestion
169
Sx DES
``` Pain (not techically odynophagia -crushing -sub sternal -radiates to back Potentially dysphagia Potential regurg ```
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Dx DES
ECG - DDX MI Barium oesophagram - corkscrew Manometry - gold
171
Treatment DES
``` Nitrates CCB (best) diltiazem Benzos widespread pneumatic dilation Long surgical open myotomy (rare) ```
172
Prep for ERCP
NBM 4 hours Sedation IV LA spray LFTs and INR needed
173
Causes oesophagitis
Infection - candida in immunosuppressed or ABX GORD Irritation - pill stuck e.g. NSAIDs
174
Sx oeophagitis
Odynophagia
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Dx oesophagitis
OGD if not obvious
176
Tx oesophagitis
Treat cause fluconazole if candidal Acyclovir or antiviral
177
Pathophysiology of GORD
``` 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 ```
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Symptoms of GORD
``` 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
Red flag in GORD/ dyspepsia and investiations
``` >45 Dysphagia Weight loss anaemia. Can do: 24 hour pH monitoring manometry OGD if >45 ```
180
Epidemiology of GORD and risk factors
``` Western Smoking Alcohol Caffeine Chocolate Genetics ```
181
Treatment of gord
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
Management of Barrets
If high grade dysplasia then you can do a distal oesophagectomy
183
Complcations of GORD
Oesophagitis Stricture - fibrosis - shortening - further reflux Barretts
184
Types and presentation of hiatus hernia
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
Diagnosis of hiatus hernia
OGD Barium swallow CT scan of thorax if acute presentation
186
Describe 24hr pH study
Probe 5cm above LOS Patient presses button with symptoms See if they collerate
187
Treatment of hiatus hernia
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
Causes of large bowel obstruction[
Cancer Diverticulitis Sigmoid vulvulus - constipation, hypothyroidism, congential abnormality Caecal volvulus
189
Causes of small bowel obstruction
Adhesions Hernia Large bowel cancer CD ``` Rarer Volvulus Intersussception Mesenteric infarction Gallstone ileus ```
190
Symptoms of small bowel obstruction
Absolute constipation Abdominal distension Abdominal pain +/- vomiting (faeculent)
191
Signs of small bowel obstruction
``` Visible peristalsis Visible hernias Tinkling dehydration Tachycardia Hypotension Fever Tenderness ```
192
Investigations into small bowel obstruction
Routine bloods - CRP, K, WCC, clotting, group and save, LFT, ABG Non invasive - AXR, CXR, CT, barium meal? MRI
193
Managment of Small bowl obstruction
Medical Resusictation - fluids and Parenteral nutrition NBM Urinary catheter 60-70% of adhesional obstructions resolve spontaneously Operative - fever, peritonitis, failure to resolve
194
How is presentation of large bowel obstruction different from small bowel?
Rarely vomiting unless ileocaecal valve dysfunction | Interval between pain is longer
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Radiological sign for sigmoid vulvulus?
Coffee bean
196
What is toxic megacolon
abdominal distension and dilated colon (megacolon) | Seen in UC and sometimes CD
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How to resolve a sigmoid volvulus
90% with colonoscopy
198
Treatment of toxic megacolon
Decompress bowel | Colectomy
199
Diverticulitis causes
``` Diverticulosis with infection e.g. facal impaction RFs: Low fibre diet Obesity Smoking NSAIDs Western ```
200
Diverticulitis symptoms
``` Change in bowel habit Acute sudden pain (often LLQ) Fever Nausea Bleeding ```
201
Diverticulitis investigations
abdominal CT with contrast | Not barium enema or colonscopy due to risk of perf
202
Management of diverticulitis
``` Medical: Mild - liquid diet, abx Severe - NBM, abx Surgery rarely indicated Mesalazine and rifaximin to prevent future attacks Probiotics? ```
203
DDX diverticulitis
Colon cancer IBD Gynae Ischamic collitis
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Complications of diverticulitis and treatment
Abcess - radiologically guided drianage Peritonitis Fistula ---surgery
205
Types of peptic ulcers
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
Clinical features of peptic ulcers
``` N/V Anaemia Melena 1 - Food makes worse, anorexia and weight loss 2 - Food relieves pain (hunger pains) ```
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Investigation of peptic ulcers
Gastroscopy Barium meal Urease testing - on OGD or as CO2 breast test Fasting serum gastrin (hypergastrinaemia)
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Complications of PUD
Pyloric outlet obstruction - distension and vomiting Bleed Anaemia Perforation
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Treatment PUD
Medical PPI, H2, Topical antacids, H pylori (metro, PPI, clarythro) Surgerical If stenosis - pyloroplasty or partial gastrectomy Or failure of medical - partial gastrectomy
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Name of hypergastrinaemia?
Zollinger-Ellison syndrome | Most often pancreatic gastrinoma
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Questions ask in pre op
``` Complete history Function capacity e.g. exercise Hypertension Asthma Diabetes Fx Smoking Drinking ```
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Which drugs do you stop before surgery?
Warfarin stopped 5 days before or converted to heparin Oral hypoglycaemics stopped day of Clopodigrel 7 days before
213
Principles of DVT prophylaxis - when?
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
Managing pre op diabetes
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
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Causes of post operative confusion
``` Ketamine Elderly Previous history Infection Electrolyte imbalance ```
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Management of post-operative confusion
``` Fluids Infection prevention Walks Orient patient Minimise medication ```
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Symptoms of DVT
Pain, swelling, redness, warmness, engorged superficial veins, PE
218
Risk factors for PONV
Patient - child, anxiety, history, motion sickness Surgical - Gynae, GI, middle ear, squint (eye), breast, long duration Anaesthetics - pain, opioids, gas, dehydration
219
Non pharmacological ways to prevent PONV?
Reduce anxiety - acupunture, IV fluids (dehydration), peppermint oil and ginger
220
Risk factors for Postoperative cognitive disorder (POCD)
Hypoxia, drugs, hypoxia, age, major (cardiac) surgery
221
Things covered in informed consent
Diagnosis and prognosis Options Purpose and side effects (positives and negatives)
222
Surgical incision for Liver or gallbladder surgery
Kocher/ subcostal/ rooftop
223
Surgical incision for appendix
Lanz
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Surgical incision for gyaenae
Pfannenstiel (bakini)
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Surgical incision for discovery
Upper or lower midline or paramedian (rare)
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Sounds in small bowl obstruction and in gastric outlet obstruction
Tinkling and gastric succusion splash (LUQ and patient shaken)
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Percussion of abdomen findings and meaning
Tympanitic (resonant) - gaseaous distension e.g. perforation or large bowel obstruction Dull flanks - free fluid or ascites
228
How to treat DVT
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
Investigations into DVT
``` Routine Minimally Duplex VQ scan CT pulmonary angiography ```
230
Warfarin management for AF, DVT/PE and Prosthetic
AF stop DVT/PE prophylactic LMWH Prostetic UFH IV in hospital
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Vitamin K time to reverse warfarin
4-6 hours
232
What does resuscitation involve?
O2 aand ventilation Shock management, IV lines Management of life threatening problems
233
Outline response to critically ill patient
``` ABCD Resuscitation Monitoring and investifations Secondary Survery - exam and history Adjuncts to secondary survey ```
234
How is circulation assessed in critically ill patients?
``` 4 factors Cap refill Pulse Skin colour/ temp BP ```
235
Circulatory changes in shock
HR >100 2 seconds Cool peripharies Blood pressure drop is a very late sign
236
How to treat hypoglycaemia acutely
Dextrose 10% 250-500ml
237
Acute causes of oligourea post op
fluid/ blood loss | Adrenal response to stress via aldosterone and ADH
238
Acute causes of dyspnea post op
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
Acute causes hypotension post op
``` Infection and sepsis cardiogenic shock following MI Anaphylaxis Haemorrhage Dehydration ```
240
Describe volplex
Coloid, like NaCl 0.9%
241
How many ml, na and K does someone need per hour/day
ml 2/hour or 40ml/kg/day 2mmol Na mmol/kg/day 1 K mmol/kg/day
242
Explain fluid requirements in children
20 20ml/kg/day | Same Na and K
243
Good maintainence regime for a 70kg man
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
In surgery what are third space losses? other losses?
Evaporative losses Measurable losses Third space - sequesters ECF proportional to tissue damage (ongoing after surgery) - does not participate in dynamic fluid exchange
245
boarders of the inguinal canal
``` Superior = conjoint (IO and transversalis) Anterior = Transversalis fascia osterior = EO Inferior = Inguinal ligament ```
246
Differences between direct and indirect hernia
``` 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
Specific tests to inguinal herniae
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
Difference between fem and inguinal location
Inguinal is medial and superior to inguinal ligament
249
Differentiate between inguinal hernea and hydrocele in infants
Transilluminate
250
Who gets incisional hernias?
surgical factors - larger wound patient factors - cough, immunocomp Post op - infection, haematoma,
251
Treatment of incisional hernias
Same same
252
What is a burst abdomen?
Abdominal wound opens / dehiscence | Often fatal
253
Rules for distance between stitches
Maximum of 1cm apart!
254
Who cant give blood?
255
Indications for giving O- blood?
Pregnant O- type Emergency
256
Indications for transfusion
Hb 7-9 | Old Hb 9-10 or if CVS comp
257
What is a massive blood transfusion?
>1 blood in 24hrs or .5 in 4hrs
258
Difference between FFP, cryoprecipitate
FFP = everything but cells | Cryprecipitate has clotting factors removed
259
Ways to raise Hb pre operatively
Transfusion IR (takes a week Vit B12/folate
260
Why can steroids with NSAIDs be dodgy
Prevent healing - stomach ulcers
261
NSAIDs and warfarin
Contraindicated
262
Warfarin side effect
Rectus sheath haematoma Intraperitoneal hernia Retroperitoneal haematoma
263
Surgical risks of OCP
Mesenteric VT DVT/ PE Ectopic if prog Stopped 4 weeks before surgery
264
Common drugs that can cause pancreatitis
DMARDs Metronidazole Alchol
265
what is small bowel enteropathy and what causes it?
Altered function often mucosal. Hypoalbuminaemia and iron deficiency NSAIDs
266
How may steroids can mask intraperitoneal pathology?
Temp, WCC diminished
267
Risk of sudden stopping BBs
Rebound angina, infarct
268
Risk of suddenly stopping corticosteroids?
addisonian crisis
269
Drug for immediate warfarin reversal
Beriplex = synthetic factors and protein C | FFP but infection risk
270
Herbal medicines and surgery
Stop 2 weeks before as often anticoagulants
271
Who doesnt get LMWH?
272
Surgical antibiotics used
Clean = | Dirty = Metronidazole and co amiclav (or gentamicin)
273
Why surgical steroids
Reduce inflam and some evidence for organ dysfunction and blood loss
274
Causative organism of bacterial endocarditis?
Laryngeal intubation - strep viridans so amoxicilin | GI, GU add in gentamicin
275
Stematil (prochlorpermaxine) uses
Antiemetic (dopamine) Atypical antipsychotic BPPV EPSE
276
Clinical presentation of carotid disease
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
Diagnosis and investigation into carotid disease
Colour duplex scan | If it fails then MRA or CTA
278
Treatment of carotid disease
Medical - Optimise - anticoagulate and statin Surgical CEA
279
Indications for CEA
>70% stenosis and symptoms | >50% and asymptomatic (NNTT = 22)
280
Proceedure of CEA
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
Complications of CEA
``` Death or major disabling stroke Minor stroke with recovery 3-6% MI wound haematoma Damage to hypoglossal or glossopharyngeal, facial numbness. ```
282
What is pithidine and how potent is it?
Synthetic opioid 10% as potent as morphine
283
Alpha feto protein from which cancers
Hepatocellular carcinoma | Teratoma
284
Predisposing features of mesenteric ischaemia
``` Age CVS factors Cocaine AF Emboli ```
285
Features of mesenteric ischaemia
``` Sudden pain (often at splenic fecture) Rectal bleeding Vomiting Diarrhoea Fever ```
286
Ectasia vs aneuysm
both permanent localised dilation but >/
287
Do you need to stop POP prior to surgery?
No
288
Symptoms of cholangitis
``` Jaundice RUQ pain (can be epigastric) Fever = charcot triad ```
289
Difference between Biliary colic and acute cholecystitis
cholecystitis is more sever, anorexia and pyrexia and does not settle. More likely to have murohys sign. may get Jaunice
290
Difference between mirizzi and ascending cholangitis
Both constant sever RUQ pain and obstructive jaundive but more severe. pain and fever more common. High swingin fever in ascending cholangitis
291
What is courvoisier's law
jaundicand palpable RUQ mass (gall bladder) is not due to gall stones - pancreatic carcinoma most common
292
Presentation of cholangiocarcinoma
Gradual onset | Obstruction directly and via lymph nodes at porta hepatis
293
Types of stomas
Loop End Double barrel
294
How would you manage a large bowel obstruction from a lower rectal cancer (below peritoneal reflection)
defunctioning loop colosctomy | Later an APER
295
Difference betwee total clectomy and subtotal
Leave rectum e.g. UC (get a loop ileostomy)
296
When do you stop clopodigrel?
7 days before
297
What is subcutaneous emphysema
Common with laporoscopic Air under skin Often over pec major Gives ginko leaf sign on CXR
298
90% of colon cancer is what type?
ACC
299
Difference between panc and cholangitis
In oanc its more epigastric radiating to the back Severe n/v both have fever but also dehydration, hypotension, tachycardia Guarding Ecchymoisis possible
300
Do you treat arterial or venous ulcers first?
Arterial and you cannot compress without
301
If patient is allergic to contrast can you still do angioplasty?
Yes with CO2
302
Why would a patient have a arteriovenous fistula tied off?
Stopped working due to aneurysm | Patient recieved a transplant and no longer needs it
303
Reynaulds causes
Primary most common – idiopathic. If secondary then it is called a secondary vasospastic disorder e.g. ax disease, drug induced or neurological disease
304
Treatment for Raynaurds?
Medical CCBs (the -pines) – causes side effects e.g. headache Prostacyckin IV if severe with tissue loss potential Surgical – sympathectomy lumbar or cervical
305
What type of skin cancer can cause ulcers and where?
SCC and anywhere
306
What is Allens’s test?
Patient makes fist. Occlude radial and ulnar. Release ulnar. Check perfusion. Used before cannulation
307
Causes of varicose veins
Idiopathic Peliv mass e.g. fibroids, cancer, pregnancy DVT
308
Clinical features of varicose veins
``` 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
What is atrophie blanche?
White lesion as a result of poor blood supply. – venous insufficiency
310
Investigations into varicose veins
Examination e.g. tap test and trendelenberg. Handheld Doppler and squeeze calf to listen for reflux lasting 1-2s Colour duplex – gold standard
311
How can post-declamp shock/ reperfusion snyndrome be avoided?
Radual reprofusion with fluid resuscitation and vasopressor treatment Mannitol as a free radical scavenger
312
What is a whipples proceedure?
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
Risk of high volume of blood transfusion?
Hyperkalaemia
314
When to give LMWH before surgery vs after?
Periop says that even with routine patinets you give a dose 12 hours before?
315
When to stop IV UFH before surgery?
6 hours before
316
Is Vicryl soluble?
Yes - used on surface
317
Describe prolene?
Thick one - biggest - used deep on the rectus sheath
318
Describe the effects of a VIPoma
``` Diarrhea Dehydration Hypokalaemia Achlorhydria - low acid in stomach Acidosis Flushing and hypotension (vasodilation) Hyperglycaemia ```
319
What i carcinoid syndrome
``` Serotonin and vasoactive substances Flushing diarrhea heart failure Bronchoconstrictioj ```
320
Should you be worried about a post op temperature spike?
If no infection then no - caused by basal atelectasis
321
Treatment for basal atelectasis
Chest physio, breathing exercises and physio
322
Water and clear fluids how long before op?
Stop at 2 hours - food=6
323
Pancreatic marker cancer
CA19-9
324
Pancreatic cancer gold standard diagnosis
CT
325
What is dumping syndrome
Weakness, discomfort and loads of shits that are rapid | Risk of a Whipples (other is PUD)
326
When do you get petechiae?
DIC | Fat embolism syndrome
327
what is Fat embolism syndrome
Normal clotting, thrombocytopenia, normocytic anaemia Resp failure (acute resp distress syndrome), cerebral dysfunction and petechial rash Microembolism
328
Test in women before assuming appendicitis?
Pregnancy test - urine hCG to rule pregnancy and ectopic
329
Pancreatic cancer presentation
Painless jaundice | Bigger raise in ALP and GGT than ALT
330
Why use adrenaline with a local?
Keeps it local
331
What is eltrombopag and when would you use it?
Thrombopoietin receptor agonist. Used if they have low platelets
332
Can achalasia cause pain?
Yes it can, very severe
333
Symptoms of chronnic mesenteric ischaemia
Weightloss, smoking history, ischaemic angina - brought on by eating with n/v. Other vascular features
334
What virus causes pancreatitis?
Coxsakie
335
What is a Mcevedy incision?
Outdated Paramedian along lateral boarder of rectus sheath
336
What is a rooftop incision used for?
whipple's
337
What is the psoas stretch?
Extetend the thigh when knee is extended
338
What Boas' sign?
Cholecystitis | Pain/ hypersensitivity below the right scaouka
339
Sodum thiopentone describe
Rapid induction, depresses cardiac output, prone to accumulation barbiturate used before propofol - IV
340
Kartagener's syndrome describe
Immogile cillia syndrome (sinusitis) and situs invertus. Infertilitiy Hearing loss Recesive
341
What is Gardener's syndrome
GI polyps, osteoma, epidermoid cysts | aut dom
342
What is metaraminol?
Alpha 1 agonist - first line in vasopressors
343
Dobutamine?
Beta 1 receptor agonist - positive ionotrope e.g. Cardiogenic shock
344
Myasthenia gravis patients a resistant to which drug?
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
What is US FAST for?
AAA
346
What drug reverses heparin?
Protamine sulphate
347
How does CD normally present?
``` 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
CD and UC extra intestinal symptoms
``` Arthritis Episcleritis (CD) Osteoporosis Ivelitits Pyoderma gangrenosum - large ulcers on foot and leg. Clubbing Primary sclerosing cholangitis ```
349
Absolute CI to regional anaesthesia
Warfarin
350
what is Chagras disease
``` 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
Disgnosis of CD and UC
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
Tretment for CD
``` 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
Treatment of UC
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
What is Boerhaave's syndrome?
Eosuophageal rupture that is not idiopathic (10%) e.g. pill oesophagitis, stricture, vomiting (alcohol).
355
Symptoms of Boerhaave's
upper abdo pain, odynphagia, tachypnoea, shock, fever Comp = mediastinitis Pneumomediastinum
356
Treatment of boerhaave's
NBM Scope IV abx Needs surgical repair!!
357
What is dextrocardia?
Everything is mirrored in thorax (gastric bubble) | Situs invertusis everything is reversed
358
Bats wing appearence on CXR?
Pulmonary oedema
359
What does interstitial shadowing suggest?
Fibrosis
360
What does the holly leaf sign show?
calcified pleural plaques? front and back of diaphragm e.g. asbestososis
361
Describe appearance of a mesothelioma
Thickening of pleural tissue on one side | -frozen lung - shell of malignnat tisse so cant expand
362
How far should ET tube be from the carina?
2cm to prvenet ventilation occuring more in one lung than the other
363
What is Rapid sequence induction
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
Difference between sterilisation and asepsis
No bugs including spores on sterile | asepsis = abscence if pathogenic microorganisms
365
What type of imaging used to insert an NJ tube?
Fluroscopy
366
Treatment C diff?
Stop Abx Vancomycin Faecal microbiota transplant
367
Risks involved in TPN
``` Infection Mucosal breakdown Liver damage Thrombosis Vascular damage Pneumothorax Haemothorax Refeeding syndrome Electrolyte imbalance ```
368
What is refeeding syndrome
``` Severely malnourished people Can get cardiac arrhythmias Celluklar dysfunction Give K, PO, Mg and potentionally Ca, Stop feeding ```
369
How to calculate circulating vol?
70ml/kg so 5l
370
Highest conc of SO and PO4?
Intracellular
371
Explain the different types of plastic surgery
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
Pathological features of pancreaitis
``` 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
Causes of chronic pancreatitis
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
Signs and symptoms of chronic pancreatitis
``` Abdominal pain (epigastric radiating to back) chronically - associated with eating and alcohol. Exocrine: Weight loss and anorexia Sterattorheao Endocrine: Insulin 2DM ```
375
Investigations of chronci pancreatitis
``` 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
Treatment of chronic pancreatitis
``` 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
Complications of chronic pancreatitis
Pseudocyst, obstruction, fistula, infections, portal hypertension
378
Pathological features of pancreaitis
``` 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
Causes of chronic pancreatitis
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
Signs and symptoms of chronic pancreatitis
``` Abdominal pain (epigastric radiating to back) chronically - associated with eating and alcohol. Exocrine: Weight loss and anorexia Sterattorheao Endocrine: Insulin 2DM ```
381
Investigations of chronci pancreatitis
``` 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
Treatment of chronic pancreatitis
``` 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
Complications of chronic pancreatitis
Pseudocyst, obstruction, fistula, infections, portal hypertension
384
How far above diaphragm to be a hiatus hernia?
Gastric mucosal fold 2-3cm above (30% aged 50 have)
385
What is Valentinos syndrome?
RLQ pain due to perforation duodenal posteriorly. | Often have shock
386
Management of Valentinos syndrome
``` Medical normal stuff PPI and H pylori Surgical Open or lap Omentum tied over ```
387
How is chlamydia relevant to bowel surgery?
Proctits
388
Treatment of Pilonidal sinus disease?
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
Anatomy of appendix
Base and tip - tip nectroses first
390
Cuases of appendiciits
Kids - lymph from virus, Young - faecoliths Adults?
391
Normal water
300ml for 70kg | .5/kg/hr = oligo?? check nexus
392
Nitrates or leukocytes more sensitive to UTI
Nitrate - leuko from infalm
393
What do you still take out an appendic if you find it looks normal during surgery?
Can be microscopic appendicitis
394
Treatment of Pilonidal sinus disease?
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
Commenest site for lower limb vascular disease?
Adductor canal (hence calf) 80% SFA
396
Femoral rupture and signs?
Blood can go retroperitoneal which can hold a lot of space and cant be stopped from outside
397
DDX intermittent claudication
neuropathic claudication arthritis musculoigamentous straign
398
What is leriche syndrome
Blockage of AA at bifurcation Erectile disfunction Claudication of buttocks, thigh and calf Absent fem pulses
399
What is significant finding on duplex?
x3 normal or 75% narrowing
400
Why might vasc disease make leg red instead of pale?
sunset foot - inflammation
401
Likely causes of a popliteal rupture?
high tibial bumper facture - knees hit bumber
402
Femoral rupture and signs?
Blood can go retroperitoneal which can hold a lot of space and cant be stopped from outside
403
Types of gastric tumours
Adenocarcinoma CT - GIST (stromal) Neuroendocrine - carcinoid Lymph - lymphomas
404
May ant to do small bowl see xford handbook of surgery
m
405
Signs of adenoarcinoma stomach
Weight loss epigastric ass palpable supraclavicular nodes (Troisier's sign) if diseminated disease
406
Staging and diagnosis of gastric cancer
OGD Thoraco-abdominal CT for mets Endoluminal US for local Laproscopy - peritoneal masses
407
TNM staging for gastric cancers
``` 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
Treatment gastric cancer
Often palliative Pre and post chemo radical gastrectomy local ablation for symptom control if palliative
409
Treatment of lymphomas
H pylori eradication
410
May ant to do small bowl see xford handbook of surgery
m
411
Keloid scar vs hypertrophic
No nodules vs nodules Beyond scar vs contain to scar Does not regress and recurs vs ?
412
Type of panc scoring
Ranson also glasgow imrie
413
Causes of high output stoma
``` Obstruction Inflammation Infection Excess gastric acid Malnutrition Adaptation ```
414
Name of Adhesions between liver and abdominal caused PID
Violin string
415
Differentiatie pancreatitis, perforated ulcers
Chest CXR - air under diaphragm
416
Mesenteric ischamia when do you get pain
After eating
417
Test mesenteric ischaemia
MR angio
418
When would you use gastrografin enema instead barium?
If there is risk of a leak e.g. After an anastomosis to check.
419
Most likely to cause gangrene pathogen
Clostridium perfringens
420
Lactational mastitis pathogen?
Staph aureus
421
Can soiling occur in haemorrhoids?
Yes if stage 3 or 4
422
Screening for AAA at 65, how long fo rfollow up?
Single only or 2 years if suspect?
423
Fluid challenge amount used?
500 saline stat-
424
Comps off pancreatitid and timeline?
Pseudo at 4-5 weeks, raied SA | Abcess at 10 - infected pseudocyst
425
HNPCC gene defect?
Mismatch repair
426
FAP gene?
APC on chromo 5 a TSG
427
What is elemental diet?
Break down of aas
428
What does coomb's test do?
Confirms haemolysis - normally rh reactive
429
Likely polypp to become malignat?
Villous polyp
430
What is a littres hernia?
Herniea containing MD
431
What is Spligelian
Hernia lateral to the rectus muscle at level of the arcuate line
432
Classes and features of Haemorrhagic shock
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

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