Surgery Flashcards
Name a classification system used to determine ease of intubation
Mallampati classification
Name a classification system used to calculate morbidity and mortality in general surgical patients
POSSUM score
What drugs are stopped before surgery?
CHOW:
- Clopidogrel (7 days)
- Aspirin/dipyridamole can be continued
- Hypoglycaemics (day of surgery)
- OCP/HRT (4 weeks) due to DVT risk
- Warfarin (5 days) due to bleeding risk
- Check INR day before surgery
What drugs should be altered before surgery?
- SC insulin - switched to IV variable rate infusion
- Long term steroids (continued due to Addisonian crisis risk)
What drugs should be started before surgery?
- LMWH (dalteparin) 5000 units if general surgery
- 28 days post-op
- Antibiotics prophylaxis if appropriate
- TED stockings (not vascular surgery)
How is diabetes handled before surgery?
- Commence sliding scale night before
- Stop metformin morning of surgery
- First on list to allow best management of blood glucose while NBM
- 5% dextrose 125 ml/hr while NBM
How is an AAA defined?
Irreversible dilatation of the abdominal Aorta >3cm
- Infrarenal 95%
True = contains all 3 layers of artery wall
False = Only lined by surrounding connective tissue/adventitia
Name some risk factors for developing AAA
- Smoking
- Hypertension
- Hyperlipidaemia
- Family history
- Male
- Age > 65
- Connective tissue disease
What are the clinical features of AAA?
Mainly asymptomatic
- Abdominal / back / loin pain
- Distal embolisation - limb ischaemia
- Pulsatile mass in abdomen (above umbilicus)
What is the screening programme for AAA?
NAAASP = abdominal US for all men aged 65
How is AAA managed?
- AAA < 5.5cm monitored via duplex US
- 3.0-4.4cm = yearly
- 5.0-5.4 = 3 monthly
- Reduce CVS risk factors (smoking, BP/DM control, weight loss, statin, aspirin)
- Surgery if > 5.5cm, explanding >1cm/year or symptomatic
- Open repair = inlay synthetic graft
- Endovascular repair (EVAR) = stent via femoral arteries
Name some complications of AAA
- Rupture
- Retroperitoneal leak
- Embolisation
- Aortoduodenal fistula
What are the clinical features of a ruptured AAA?
- Severe/sudden epigastric/back/loin pain
- Transient hypotension
- Sudden collapse/syncope
- Vomiting
- Pulsatile abdominal mass
- Haemodynamic instability
- Sweating
- Grey-Turner’s sign
How is ruptured AAA managed?
- 2 large bore cannulae - fluids/O neg
- Keep BP < 90 mmHg (permissive hypotension)
- Activate major haemorrhage protocol
- High flow O2
- Bloods - FBC, U&E, clotting, crossmatch 6 units
- Analgesia (morphine 5-10mg)
- Contact vascular surgeon
- If stable - CT with contrast
What is an Aortic dissection?
Tear to intimal layer creates false lumen between layers of the wall
- Acute < 14 days
- Chronic > 14 days
- Anterograde towards iliacs
- Retrograde towards Aortic valve
Name a classification of thoracic Aortic dissection
DeBakey classification:
- I = originates in ascending Aorta and propagates to at least Aortic arch
- II = ascending Aorta only
- III = originates distally to left subclavian artery
- IIIa = extends to diaphragm
- IIIb = extends beyond diaphragm
Name some risk factors for Aortic dissection
- Hypertension
- Male
- Atherosclerosis
- Caucasian
- CTD
- Bicuspid Aortic valve
What are the clinical features of Aortic dissection?
- Tearing / stabbing chest pain
- Radiates to back
- Tachycardia
- Hypotension
- New Aortic regurgitation murmur
- End-organ hypoperfusion
How is Aortic dissection investigated?
- Bloods - FBC, U&E, LFTs, troponin, coagulation, crossmatch 6 units
- ABG
- ECG
- CT angiogram
- Transoesophageal Echo
How is Aortic dissection managed?
- High flow O2
- Catheterise and fluid balance
- 2 large bore cannulae and fluid resuscitation
- permissive hypotension (100mmHg)
- DeBakey I+II = surgery (removal of ascending Aorta and replacement with synthetic graft
- Debakey III = manage hypertension with beta blockers (or CCB)
- Surgery if visceral/limb ischaemia, refractor pain or uncontrolled hypertension
- Endovascular with stent graft
- Lifelong antihypertensives and surveillance
What are the complications of Aortic dissection?
- Rupture
- Aortic regurgitation
- Stroke
- MI
- Cardiac tamponade
How is carotid artery disease investigated?
- Urgent CT - ischaemic or haemorrhagic
- Bloods - FBC, U&E, clotting, lipid profile, glucose
- ECG
- CXR
- Colour duplex scan (degree of stenosis)
- CT angiography
What is the acute management of carotid artery disease?
- High flow oxygen
- Swallow screen assessment
- Ischaemic = IV alteplase (tPA) within 4.5 hours of symptom onset
- 300mg aspirin 14 days
- Haemorrhagic = clot evacuation
What is the long term management of carotid artery disease?
- CVS risk factor reduction - smoking, BP/DM control
- Anti-platelet therapy - aspirin, dipyridamole
- Statin (simvastatin 40mg daily)
- Carotid endarterectomy if symptomatic > 70% stenosis of ICA or > 50% stenosis with recent TIA
- Within 2 weeks
- Removes atheroma and damaged intima with temporary bypass shunt
Name some risks of carotid endarterectomy
- Stroke
- Hypoglossal nerve damage = weak tongue
- Glossopharyngeal nerve damage = swallowing dysfunction
- Vagus nerve damage
- MI
- Bleeding
- Infection
What are varicose veins? What veins do they usually affect/
Tortuous, dilated segments of vein associated with valvular incompetence
- Majority long saphenous vein (ant. medial malleolus to femoral vein)
- Minority short saphenous vein (post. lateral malleolus to popliteal vein)
Name some risk factors for developing varicose veins
- Prolonged standing
- Obesity
- Pregnancy
- Family history
What are the clinical features of varicose veins?
- Cosmetic - skin discolouration, visible veins
- Pain
- Aching
- Swelling/oedema
- Thrombophlebitis
- Ulcers (medial malleolus)
- Lipodermatosclerosis = tapering of legs above ankle (upside down champagne bottle)
- Atrophie blanche
- Saphena varix = dilatation of saphenous vein at sapheno-femoral junction
How are varicose veins investigated?
- Trendelenberg test = patient supine, elevate leg to allow veins to empty, apply tourniquet in high thigh and ask patient to stand
- Release tourniquet - if rapidly fill up then incompetent valve is SFJ
- Doppler (exclude arterial pathology)
- Colour duplex US
How are varicose veins managed?
- Education - avoid prolonged standing, weight loss, exercise
- Compression stockings if interventional treatment inappropriate
- CI in arterial ulcers
- If venous ulcer = four-layer compression bandaging
- Surgery
- Vein ligation, stripping and avulsion
- Foam scleropathy = inject sclerosing agent into vein to close it off
- Thermal ablation = heating vein from inside to close it off
What are the indications for surgery in varicose veins?
- Symptomatic
- Skin changes
- Superficial vein thrombosis
- Venous ulcer
Name some complications of varicose vein surgery
- Bruising
- Recurrence (50%)
- Haemorrhage
- Wound infection
- DVT
- Thrombophlebitis
- Nerve damage - saphenous/sural
What is intermittent claudication?
Muscular pain on exercise associated with early-stage peripheral artery disease
Name some risk factors for intermittent claudication
- Hypertension
- Hyperlipidaemia
- Diabetes
- Smoking
- Family history
- Obesity
- Sedentary lifestyle
- Diet
- Male
What are the clinical features of intermittent claudication?
- Pain with exercise
- Relieved by rest
- Cyanosis
- Pallor
- Weak/absent distal pulses
- Atrophic changes
- Dec hair
- Shiny skin
How is intermittent claudication investigated?
- Buerger’s test = patient supine, elevate legs to 45 degrees for 1-2 mins
- Pallor = ischaemia (peripheral arterial pressure is inadequate to overcome gravity)
- Hang legs over bed - blue to red
- Buerger’s angle
- ABPI (Ankle-brachial pressure index) systolic in leg / highest systolic in either arm (<1 = abnormal)
- BP
- Serum glucose, cholesterol
- Angiography
How is intermittent claudication managed?
- Risk factor modification - smoking, exercise, statins, BP control, DM control, antiplatelet
- Pharmacological (improve blood flow/circulation)
- ACE inhibitor
- Beta blockers
- Naftidrofuryl (vasodilator)
- Pentoxifylline (xanthine)
- Surgery
- Angioplasty (Aorto-iliac or superficial femoral)
- Common femoral endarterectomy
- Graft (Aortobifemoral)
- Bypass (popliteal)
What is acute limb ischaemia?
Sudden decrease in the limb perfusion that threatens the viability of the limb
Name some causes of acute limb ischaemia
- Thrombosis - artheroma in artery ruptures and a thrombus forms on the fibrous cap
- Dehydration
- Hypertension
- Malignancy
- Polycythaemia
- Emboli = thrombus travels distally to occlude the artery
- AF
- MI
- Prosthetic heart valves
- AAA
- Trauma (compartment syndrome)
- Aortic dissection
- Peripheral aneurysm
What are the clinical features of acute limb ischaemia?
6 Ps:
- Pain
- Pallor
- Parasthesia
- Pulselessness
- Paralysis
- Perishingly cold
Irreversible - mottled skin, petechial haemorrhages, hard muscles
How is acute limb ischaemia investigated?
- Bloods - FBC, U&E, troponin, clotting, glucose, G&S, lactate, thrombophilia screen
- ECG (dysrhythmias)
- CXR
- Doppler ultrasound
- CT angiography
How is acute limb ischaemia managed?
Irreversible ischaemia within 6 hours
- 100% O2
- Fluids
- Analgesia (5-10mg morphine IM + anti-emetic)
- Heparin IV bolus (5000 IU unfractionated) + start infusion
- If embolic - embolectomy (Fogarty catheter), local intra-arterial thrombolysis, bypass surgery
- If thrombotic - local intra-arterial thrombolysis, angioplasty, bypass surgery
What are the complications of reperfusing after acute limb ischaemia?
Reperfusion injury (release from damaged muscle cells):
- Hyperkalaemia
- Acidosis
- Rhabdomyolosis
- AKI
What is chronic limb ischaemia?
Peripheral arterial disease that results in symptomatic reduced blood supply to the limbs
- Commonly lower limbs
Name some clinical features of chronic limb ischaemia
- Intermittent claudication
- Ulcers
- Weak/absent pulses
- Gangrene
- Pallor
- Cold limbs
- Skin changes - atrophic, hair loss, thickened nails
Name a chronic limb ischaemia classification system
Fontaine classification:
I: asymptomatic
II: intermittent claudication
III: ischaemic rest pain
IV: ulceration and/or gangrene
What is the criteria for critical limb ischaemia?
- Ischaemic rest pain for > 2 weeks
- Presence of ischaemic lesions or gangrene
- ABPI < 0.5
What is Leriche Syndrome?
Peripheral arterial disease affecting the aortic bifurcation
- Buttock/thigh pain
- Erectile dysfunction
How is chronic limb ischaemia investigated?
- ABPI (normal > 0.9, severe < 0.5)
- Value > 1,2 could represent calcification/hardening due to diabetes
- Buerger’s test (angle when limb goes pale)
- Doppler US - assess severity and anatomical location
- CT/MR angiography
- CVS risk assessment - BP, BM, cholesterol, ECG
How is chronic limb ischaemia managed?
- CVS risk factors modification - smoking, exercise, diet, statins, antiplatelet, BP/DM control
- Surgery if risk factor modification has been discussed and supervised exercise has not improved symptoms
- Angioplasty with stenting
- Bypass graft (diffuse disease)
- Amputation (if unsuitable or gangrenous)
Name some causes of acute mesenteric ischaemia
- Thrombosis - atherosclerosis
- Embolism - arrhythmias, MI, prosthetic heart valves
- Non-occlusive - hypovolaemic/cardiogenic shock
- Venous occlusion - coagulopathy, malignancy
Name some clinical features of acute mesenteric ischaemia
- Generalised abdominal pain (out of proportion)
- Nausea, vomiting
- May perforate
- Potential embolic sources - AF, murmurs, prosthetic valves
- Otherwise unremarkable exam
How is acute mesenteric ischaemia investigated?
- Urgent ABG - acidosis, lactate
- Bloods - FBC, U&E, clotting, amylase, LFTs, group & save
- CT angiography
- If perforated - AXR and eCXR / CT abdo
How is acute mesenteric ischaemia managed?
- IV fluids
- Catheter and fluid balance chart
- Broad spectrum antibiotics
- Senior/ITU escalation
- Surgery
- Excision of necrotic bowel +/- stoma
- Revascularisation - remove thrombus/embolus (angioplasty)
What is chronic mesenteric ischaemia?
Gradual deterioration of blood supply to the bowel due to atherosclerosis in the coeliac trunk, SMA and/or IMA
What are the clinical features of chronic mesenteric ischaemia?
- Post-prandial pain/mesenteric angina
- 10 mins - 4 hrs after eating
- Fear of eating
- Weight loss / malnutrition / anorexia
- Other vascular disease - claudication / renal / coronary
- Change in bowel habit - loose
- Nausea / vomiting
- Abdominal bruits
How is chronic limb mesenteric managed?
- CVS risk factor control
- Surgery if severe disease, progressive or debilitating symptoms
- Endovascular (radiologically guided stenting)
- Open (endarterectomy) or bypass
Describe Virchow’s triad
- Stasis - immobility, operations, varicose veins
- Endothelial injury - hypertension, atherosclerosis
- Hypercoagulability - burns, malignancy, pregnancy, smoking, OCP
What are ulcers?
Abnormal breaks in the skin or mucous membranes
- Venous (most common)
- Arterial
- Diabetic
- Pressure
Describe venous ulcers including cause and anatomy
- Shallow with granulated base and irregular borders
- Caused by venous insufficiency (retrograde flow in superficial venous system - dilatation - pooling of blood - impedes oxygen delivery to skin)
- Paths of short and long saphenous veins
- Lower leg and malleoli
Name some risk factors for developing venous ulcers
- DVT
- Varicose veins
- Trauma
- Pregnancy
Name some clinical features of venous ulcer
- Painful
- Dry/itchy skin
- Distended veins
- Oedema
- Lipodermatosclerosis (inverted champagne bottle)
- Thrombophlebitis
- Haemosiderin skin staining (blood leaking out)
How is a venous ulcer managed?
- Leg elevation
- Exercise
- Emollients
- Antibiotics (if infected)
- 4 layered compression bandaging (only if not arterial)
- Varicose treatment via radiorequency ablation
Describe an arterial ulcer including cause and location
Small, deep lesions with well-defined borders (punched out appearance) and a necrotic base
- Caused by a reduction in arterial blood flow - decreased perfusion and poor healing
- Occurs at sites of trauma and pressure areas (heel, malleoli, shin, toe joints)
What are the clinical features of an arterial ulcer?
- Intermittent claudication
- Critical limb ischaemia (night)
- Painful
- Little granulation tissue
- Cold limbs
- Necrotic toes
- Hair loss
- Reduced pulses
How is an arterial ulcer managed?
- Conservative - smoking, weight loss, exercise
- Medical - statin, anti-platelet, BP/DM control
- Surgical - angioplasty or bypass graft
Describe a neuropathic ulcer including cause and location
Painless ulcer on pressure points
- Caused by peripheral neuropathy - loss of protective sensation - repetitive stress - unnoticed injuries
- Diabetes
- B12 deficiency
How are neuropathic ulcers managed?
- Diabetes control (HbA1c < 7%)
- Refer to diabetic foot clinic
- If infected - antibiotics (flucloxacillin)
- Surgical debridement of necrotic tissue
What is charcots foot?
Neuroarthropathy where a loss of joint sensation results in continual unnoticed trauma and deformity occurring, predisposing to neuropathic ulcers
Describe how to assess if a patient needs fluids
- Systolic BP < 100
- Urine output < 0.5 ml/kg/hr
- Cap refill > 2 secs
- HR > 90
- Cold peripheries
- Resp rate > 20
- Reduced skin turgor
- Dry mucous membranes
Describe the approach to fluid resuscitation
- Fluid bolus of 500ml crystalloid over 15 mins
- Reassess using ABCDE
- Continue fluid boluses
- If > 2000 ml given seek expert help
What is the daily requirements of water, electrolytes and glucose?
- 25-30 ml/kg/day water = 2.5L
- 1 mmol/kg/day Na+, K+, Cl- = 70 mmol
- 50-100g/day glucose
Name some causes of fluid loss
- Vomiting/diarrhoea
- Drain loss
- Haemorrhage
- NG loss
- Preoperative fasting
- Stoma loss
- Evaporative losses from open abdomen
- Paralytic ileus
- Leaking anastamosis
Roughly describe the components and concentrations of some crystalloid and colloid fluis and how that compares to ECF and ICF
How long preop before food, breast milk and clear fluids?
- Food 6 hours
- Breast milk 4 hours
- Clear fluids 2 hours
What physiological problems can poor pain management cause?
- CVS - inc HR, BP, PVR, myocardial O2 consumption
- Resp - diaphragmatic splinting/weakened cough - infections
- GI - delayed emptying, reduced motility
- Urinary retention
- Endocrine - release of vasopressin, RAAS, cortisol, glucagon, reduction of insultin/testosterone
- Reduced wound healing
- Protein breakdown
- Na+/H2O retention
Describe the WHO analgesic pain ladder
- Non-opioid (paracetemol/NSAID)
- Weak opioid (non-opioid + codeine/tramadol)
- Strong opioid (non-opioid + morphine)
Why can NSAIDs be contraindicated?
GRAB:
- GI (peptic ulcer)
- Renal (eGFR < 50)
- Asthma / allergy
- Bleeding disorders
Name some analgesic drugs
- Paracetemol - via prostaglandin, serotonin, opioid paths
- NSAID = COX inhibitor dec. synthesis of prostaglandins, prostacyclines and thromboxane A2 from arachidonic acid
- Dec. platelet aggregation, vasoconstriction, renal blood flow
- Inhalation (entonox = 50% O2, 50% N2O) - quick acting, short duration, potent
- Opioids (MOP, KOP, DOP receptor agonists)
Name some side effects of opioids
- Respiratory depression
- Sedation
- Euphoria
- Nausea and vomiting
- Constipation
- Muscle rigidity
- Bradycardia
- Pruritis
How can morphine be reversed?
Nalaxone (400 micrograms to 800 for up to 2 doses)
What is patient-controlled analgesia?
Self-administration of IV opioids to help overcome post-op pain
- Patient titrates plasma opioid concentration to remain in the therapeutic window
- Delivers boluses up to every 5 mins
- Morphine 1 mg
- Tramadol 10mg
- Better control and faster alleviation of pain, overall less morphine needed
- May not be appropriate for all patients (poor dexterity, critically ill)
Name some complications of epidural analgesia
- Dural puncture
- Headache
- Nerve/cord injury
- Hypotension
- Urinary retention
- Pruritis
Name some patient, surgical and anaesthetic causes of post-op nausea and vomiting
Name some causes of PONV
- Infection
- Ileus
- Obstruction
- Metabolic (inc Ca, DKA)
- Antibiotics
- Opioids
- Raised ICP
- Anxiety
How is PONV managed?
- Prophylaxis
- Reduce opiates and volatile gases
- Avoid spinal anaesthesia
- Dexamethasone at induction
- Conservative
- Adequate fluids
- Adequate analgesia
- Pharmaceutical
- If impaired gastric emptying - metoclopramide/domperidone
- If metabolic/biochemical imbalance - metoclopramide
- If opioid-induced - ondansetron
Name some anti-emetics and their mechanism of action
- Ondansetron - Serotonin (5H3) inhibitor
- Domperidone/metoclopramide - dopamine inhibitor
- Cyclizine - antihistamine
- Hyoscine - anticholinergic
Name the stages of anaesthesia including pupils, BP, RR, HR
- Induction
- Excitement
- Operative
- Medullary depression / overdose
Name the ‘triad’ of anaesthesic drugs
- Unconscious
- Propofol (induction)
- Inhalational agents/sevofluorane (maintenance)
- Immobile (muscle relaxant)
- Atracurium
- Comfortable
- Morphine
How are the effects of neuromuscular blocking agents reversed?
Acetylcholinesterase inhibitors: Increases concentration of acetylcholine in neruomuscular junction
- Neostigmine
Name some tools for assessing nutritional status
- Malnutrition Universal Screening Tool (MUST)
- BMI
- Grip strength
- Triceps skin fold thickness
- Mid arm circumference
What is BMI?
Weight (kg) / height^2 (m)
Name the hierachy of feeding
- Unable to eat sufficient calories = oral nutritional supplement
- Dysfunctional swallow/unable to take sufficient calories orally = NG tube
- Oesophagus blocked / dysfunctional = gastrostomy feeding (PEG/RIG)
- Stomach inaccessible / outflow obstruction = jejunostomy
- Jejunum inaccessible / intestinal failure = Parental (TPN)
Name some advantages of day case surgery
- Shorter inpatient stays
- Reduced waiting list
- Lower infection rate
- Cheaper than overnight
What surgery qualified as day case?
- Minimal blood loss
- < 1 hour operating time
- No expected complications
- No specialist aftercare
Name some causes of post-op pyrexia
- Infections (4 Ws)
- Wind (respiratory) day 1-2
- Water (urinary) day 3-5
- Walking (DVT) day 4-6
- Wound/surgical site day 5-7
- Drugs (days 7+) = antibiotics, anaesthetic agents
- PE
- Transfusion reaction
How is post-op pyrexia investigated?
Septic screen:
- Bloods - FBC, CRP, U&E
- Urine dip
- Cultures - blood/urine/sputum/wound swab
- CXR
- CT (if anastamotic leak)
- Doppler US (if DVT)
Name some risk factors for post-op delirium
- Age > 65
- Co-morbidities
- Dementia
- Renal impairment
- Male
- Sensory impairment
Name some causes of post-op delirium
- Hypoxia
- Infection (UTI/LRTI)
- Drugs - benzos, diuretics, opioids, steroids
- Drug withdrawal
- Dehydration
- Pain
- Constipation/urinary retention
- Endocrine (Na+/Ca2+)
How is post-op delirium investigated?
- Bloods - FBC, U&E, Ca2+, TFT, glucose, B12, folate
- Blood cultures / wound swabs
- Urinanalysis
- CXR
- CT head
- Abbreviated Mental Test (AMT)
How is post-op delirium managed?
- Conservative - fluids, analgesia, antibiotics
- Treat cause
- Haloperidol or olanzapine (< 1 week)
Name the different types of post-op haemorrhage
- Primary = within intra-operative period
- Reactive = within 24 hours of operation
- Secondary = 7-10 days post-op
Describe the different classess of shock/haemorrhage
Rules of tennis
What is sepsis?
Clinical features of organ dysfunction (SIRS) in the presence of a known or suspected infection
- WCC < 4 or > 12
- Temp < 36 or > 38.3
- HR > 90
- RR < 20
How is sepsis managed?
SEPSIS 6
IN:
- 100% O2 (15L non re-breathe mask)
- IV fluid (500-1000ml bolus)
- IV antibiotics (start empirical then targeted)
OUT:
- Blood cultures (before antibiotics)
- Serum lactate (> 4 = escalate)
- Urine output (aim for >0.5ml/kg/hr)
Name some sources of infection
7 Cs:
- Cut (wound)
- Central line
- Catheter (UTI)
- Cannula
- Chest
- Collections (abscess)
- Calves (DVT)
What are the risk factors for anastamotic leak?
- Emergency surgery
- Longer operating time
- Oesophageal-gastric or rectal anastamosis
- Smoking/alcohol excess
- Diabetes
- Obesity
- Drugs - steroids, infliximab, immunosuppressants
What are the clinical features of anastamotic leak?
5-7 days post-op:
- Abdo pain
- Fever
- Tachycardia
- Peritonism
- Faeculant material in wound drain
How is anastamotic leak investigated?
- Bloods - FBC, CRP, U&E, LFT (dec albumin). clotting
- ABG - inc lactate
- CT abdo-pelvis with contrast
How is anastamotic leak managed?
- Broad spectrum antibiotics
- IV fluids
- Urinary catheter
- Minor - bowel rest and observation / percutaneous drainage
- Major - exploratory laparotomy
What are the risk factors for developing post-op ileus?
Patient:
- Old age
- Electrolyte imbalance
- Neurological disorders
- Anti-cholinergic drugs
Surgical:
- Opioids
- Pelvis surgery
- Extensive intestinal handling
- Resection of bowel
- Peritoneal contamination
What are the clinical features of post-op ileus?
- Failure to pass flatus or faeces (absolute constipation)
- Bloating/distension
- Nausea and vomiting / high NG output
- Absent bowel sounds
How is post-op ileus managed?
- Correct electrolyte imbalances
- Encourage mobilisation
- Reduce opiate analgesia
- May need NG tube
Describe a brief overview of the approach to AXR
ABDO X:
- Air - pneumoperitoneum (perforation)
- Bowel
- Distension
- Positioning
- Thickening (thumb print sign of oedema)
- Dense objects
- Bones
- Calcification
- Organs and soft tissue - liver, kidneys, spleen, inguinal hernia
- eXternal objects - leads, clips etc
Describe this AXR
Small bowel obstruction:
- Gas-filled, distended loops of bowel
- Central position
- Valvulae conniventes - across whole circumference
- > 3cm
May represent a post-op ileus or hernia
Describe this AXR
Large bowel obstruction:
- Gas-filled and distended bowel down to sigmoid
- ‘Cut off’ at site of obstruction (sigmoid)
- Peripheral position
- Haustra (not across whole circumference)
- > 6cm
Describe this AXR
Sigmoid volvulus = twist at the base of the sigmoid mesentery
- Fixed in LIF
- Coffee bean sign
Describe this AXR
Caecal volvulus = if caecum is retroperitoneal, it can become mobile and susceptible to twisting.
- Grossly dilated caecum
- Not in RIF like normal
- Caecal embryo sign
What sign is showed on this AXR?
Rigler’s sign = free intra-abdominal gas adjacent to a gas filled loop so both sides of the bowel wall are well defined
- Usually represents bowel obstruction that has perforated
- Also look for triangles of gas outside the bowel
Describe the AXR
Extensive bowel wall thickening throughout the colon
- Thickening of haustral folds = thumb print sign
- Indicative of bowel wall inflammation of ulcerative colitis
Name some causes of post-op breathlessness
- Basal atelectasis
- PE
- Pneumonia
- Pulmonary oedema
- Anaphylaxis
- Hypovolaemia
Name the main causes of post-op abdominal pain
- Paralytics ileus
- Anastamotic leak
- Surgical site infection
How is a DVT managed?
- LMWH or fondaparinux
- if severe renal disease - UFH
- Continue for 5 days or until INR is > 2
- Start warfarin
- 3 months if provoked DVT/PE
- >3 months if unprovoked
- Inferior vena caval filter if anticoagulation not tolerated
- If unprovoked - investigate cancer
Name the surgical procedure needed for cancer in different areas of the colon
- Ascending/proximal transverse = right hemicolectomy with ileo-colic anastamosis
- Distal transverse/descending = left hemicolectomy with colo-colon anastamosis
- Sigmoid = high anterior resection with colo-rectal anastamosis
- Upper rectum = Anterior resection (TME) with colo-rectal anastamosis
- Low rectum = anterior resection (low TME) with colo-rectal +/- defunctioning stoma OR APER
- Anal = Abdomino-perineal excision of rectum (APER)
- Emergency = Hartmanns (sigmoid resection with end colostomy)
