Surgery Flashcards
What type of pain is colicky?
A squeezing pain which sometimes comes and goes
When suspecting peritonitis, you should ask if it hurts when?
Laughing, coughing or going over speedbumps
What will be the difference in movement of patients with peritonitis or colicky pain?
Peritonitis- completely still
Colicky- move about, can’t be comfortable
Where does gallbladder pain radiate?
Round to back
Where does pancreas pain radiate?
Through to back
The appendix is what kind of structure?
Midgut
Describe pain of appendicitis?
Starts in umbilical region and then shifts to RIF
What is spread pain?
When it starts localised and then spreads all over- different to shift!!
What causes somatic pain?
Area of inflammation
Inflammation from only one structure causes pain where? What is this known as?
In its corresponding area (foregut, midgut, hindgut)- local peritonism
Where is sore to touch in peritonitis?
Everywhere
What is a really important thing to know about the onset of pain?
If it came on suddenly or gradually
What type of pain will inflammation give you?
Throbbing
What kind of pain will an obstruction give you?
Colicky
When does pain make patients unable to breathe?
Peritonitis
What can cause shoulder tip pain?
Gallbladder or liver pain from aggravation of the diaphragm
What is the best pain relief but what is its downside?
IV morphine- all patients who have had this must be admitted
What cases don’t get IV morphine, what do they get instead?
Colic- anti-inflammatory
What causes tenderness to percussion?
Peritonism
What is voluntary guarding?
Patients tense up for first/second exam but this will go away
What is involuntary guarding?
Physiological response to peritonitis- will not go away
What type of pain does cholecystitis cause?
Biliary colic
What type of pain does diverticulitis cause?
LIF pain
What type of pain does an intestinal obstruction cause, what are some associated symptoms?
Colic- nausea and vomiting
What age are people with appendicitis?
Either young or old
What are some other symptoms of appendicitis?
Sick maybe once, fever
What will the CRP on day 1 of appendicitis be?
Normal usually
What should you find out about abdominal masses during a history?
Size (changes), tender, duration, associated symptoms
What are important investigations to do for an abdominal mass?
CXR, AXR, ultrasound, CT, sigmoid/colon/endoscopy + biopsy, ERCP, laparoscopy and biopsy
What is abdominal mass with a history of collapse and pain radiating to the back likely to be? What would be the investigation of choice to confirm?
AAA- CT
What is abdominal mass with a history of weight loss, jaundice and hepatomegaly to the back likely to be? What would be the investigation of choice to confirm?
Hepatic mass- US, CT liver biopsy
What is abdominal mass with a history of trauma and weight loss with splenomegaly likely to be? What would be the investigation of choice to confirm?
Splenic mass- CT, MRI, PET
What is abdominal mass with a history of renal failure and weight loss likely to be? What would be the investigation of choice to confirm?
Renal mass- US, CT
What is abdominal mass with a history of weight loss, alcohol and non-tenderness likely to be? What would be the investigation of choice to confirm?
Pancreatic mass- ERCP, CT, biopsy
What is abdominal mass with a history of weight loss, altered bowel habit and PR bleeding likely to be? What would be the investigation of choice to confirm?
Colorectal cancer- CT, colonoscopy
What is another really important cause of abdominal masses?
Hernias
What type of hernia is caused by an insufficiently healed wound?
Incisional
Where do midline hernias come out between?
The two rectus muscles
What is more sinister than bleeding while defecating?
Bleeding into pants
What is absolute constipation?
No flatus or faeces
What does a tinkling bowel sound mean?
Obstruction
When can bowel sounds be absent?
Very obese people
What are Cullen’s and Grey Turner’s signs suggestive of?
Acute pancreatitis
What is a really important investigation to do for acute pancreatitis?
Amylase
What are cases of people who would not go to theatre immediately?
Pancreatitis or diabetic ketoacidosis
What are examples of patients who would go to theatre immediately?
Faecal peritonitis, ischaemic gut
What can free air under the diaphragm be suggestive of?
Perforated ulcer
What determines if an obstruction is an emergency or not?
Competent ileocaecal valve- emergency
Not competent- not emergency
Incisional and midline hernias will do what on coughing and lying flat?
Coughing- bulge
Lying flat- disappears
Why is there more pain below the pectinate line than above?
That is skin, not mucosa
What are haemorrhoids?
Enlarged vascular cushions in the lower rectum and anal canal
What are symptoms of haemorrhoids?
Painless bleeding, fresh red blood not mixed with the stool
What are common symptoms of bowel problems which are NOT the case in haemorrhoids?
Change in bowel habit and weight loss
Where do the positions of haemorrhoids relate to?
Branches of the superior haemorrhoidal artery occurring at 3, 7 and 11 o clock
What position should the patient be in when looking for haemorrhoids?
Lithotomy
What exams should be done for haemorrhoids?
PR exam, rigid sigmoidoscopy, proctoscopy
What test should be done for >50 with suspected haemorrhoids?
Flexible sigmoidoscopy
When should haemorrhoids be managed?
When symptomatic (normally constipation)
What are different ways of surgically treating haemorrhoids?
Rubber band ligation
Open/stapled haemorrhoidectomy
HALO/THD procedure
What is the HALO procedure?
Use a Doppler to find vessel, tie off the vessel and the haemorrhoid shrinks
What happens to cause partial rectal prolapse?
Prolapse of anterior muscle
What is a rectal prolapse?
Protruding mass from the anus, especially during defaecation
What is it common to pass with a rectal prolapse?
Blood or mucus
How do you treat complete rectal prolapse?
Perianal/abdominal rectopexy
How is an incomplete prolapse treated in children?
Diet advice and treat constipation
How is an incomplete prolapse treated in adults?
Similarly to haemorrhoids
What is an anal fissure?
A tear in the anal margin due to passage of a constipated stool
How is an anal fissure differentiated from haemorrhoids?
Fissure is painful
What could multiple anal fissures suggest?
Crohn’s
Who are anal fissures more common in?
Younger people, particularly women
How long does the pain of an anal fissure last after defaecation?
Half an hour
What type of PR bleeding will anal fissures cause?
Bright red
What is the non surgical treatment for an anal fissure?
Dietary advice and stool softeners
Ointments containing what drugs can be used for anal fissures?
GTN and diltiazem
What is a treatment used to paralyse the internal anal sphincter?
Botox
What is an anal fistula?
Internal opening in the anal canal and one or more on peri-anal skin
What are rare causes of anal fistulae?
Crohn’s, TB and carcinoma
What are treatments for anal fistulae?
Laying open, setons
What are complications of anal fisulae?
Pain, bleeding, incontinence, recurrence
What are cardiovascular surgery complications?
Haemorrhage, MI, DVT
What two types of haemorrhage can occur as a complication of surgery?
Reactionary (during) or secondary (infection- later)
What are some presentations of haemorrhage?
Tachycardia, hypotension, oliguria (low urine output)
How can haemorrhage in surgery be prevented?
Good technique, avoiding sepsis, correction of coagulation disorders
What increases risk of MI in surgery?
Severe angina, previous MI
What is the rule on operating on patients with MI?
Try to avoid 6 months following
How can an MI following surgery present?
Often silent, can be cardiac failure or arrhythmias
What increases risk of DVT?
Age > 40, previous DVT, major surgery, obesity, malignancy
What causes DVT as a complication?
Immobility during surgery and hypercoagulable state
How can a DVT present?
Low grade fever, unilateral ankle swelling, calf/thigh tenderness, shiny skin, pitting oedema
What is a first line rule out test for DVT?
D-dimers (degradation product of fibrin)
What are other tests for DVT?
Doppler ultrasound, venography
How can DVT be prevented?
Compression stockings, low dose subcutaneous heparin, early mobilisation
What are respiratory complications of surgery?
Lung collapse, pneumonia, PE
What does atelectasis/lung collapse during surgery lead to?
Pneumonia
How is there an increased risk of pneumonia in surgery?
Anaesthetic inhibits cilia,, postoperative pain inhibits coughing, aspiration
What is the presentation of a chest infection?
Fever, dyspnoea, productive cough, confusion
How can a chest infection be prevented?
Stop smoking, adequate analgesia, physiotherapy
What causes a PE?
DVT
How does a PE present?
Tachypnoea, dyspnoea, confusion, pleuritic pain, haemoptysis
What is a good test for PE?
V/Q scan or CTPA
What are GI complications of surgery?
Ileus, anastomosis, adhesions
What does ileus mean?
Paralysis of intestinal motility
How does an ileus present?
Vomiting, abdominal distension, dehydration, silent abdomen
How can an ileus be prevented?
Minimal operative trauma, laparoscopy, avoidance of sepsis
What is an adhesion?
Fibrin to fibrous tissue
Where are common adhesions?
Bowel to abdominal wall, lung to chest wall
What can cause adhesions?
Inflammatory response, ischaemia
What can adhesions present as?
An intestinal obstruction
What complications can arise with a wound?
Infection, splitting, hernia
How does a wound infection present?
Pyrexia, redness, pain, swelling, discharge
What are urinary surgical complications?
Acute retention of urine, UTI, urethral stricture, acute renal failure
What are neurological surgical complications?
Confusion, stroke, peripheral nerve lesions
What does confusion occur as a result of?
Hypoxia
