Surgery Flashcards
part of bowel most likely to be affected by ischaemic colitis
splenic flexure
thumbprinting at splenic flexure
ischaemic colitis
part of bowel usually affected by mesenteric ischaemia
small bowel
usually embolism of SMA
Usual ABPI in diabetic
> 1.2 - causes calcification
Ix of mesenteric ischaemia
lactate
test to confirm H. pylori eradication
Urea breath test
who gets Hep A
travelers
transmission of Hep A
faecal - oral
is there a vaccine for Hep A?
Yes
Ix of Hep A
clotted blood for serology
Hepatitis that leads to chronic infection
Hep B
Hep C
transmission of Hep B
sex
mother - to - child
blood
HBsAg - what does it indicate
earliest marker of infection
is there a vaccine for Hep B?
yes
does vaccination against Hep B result in +ve HBsAg
no!!
Anti-HBsAg - what does it indicate
recovery
absence of infectivity
further immunity from Hep B
HBeAg - what does it indicate
+++ infectious
Anti-HBcAg (IgM) - what does it indicate
recent acute infection
Anti-HBcAg (IgG) - what does it indicate
with +ve HBsAg = chronic Hep B infection
with -ve HBsAg = infection in the remote past
autoantibodies in autoimmune hepatitis
Type 1 = ASMA, ANA
Type 2 = AMA
transmission of Hep C
sex
mother - to - child
blood
what other type of Hepatitis is hep D found with
Hep B
transmission of Hep E
faecal-oral
Where does Hep E come from
animals
is there a vaccine for Hep E?
no
Mx autoimmune hepatitis
short term Tx (<6m):
corticosteroid (pred)
long term Tx (>6m):
corticosteroid + immunosuppression
Mx alcoholic hepatitis
- prednisolone
2. pentoxyphylline
Mx of hep B
- pegylated interferon-alpha
2. tenofovir or entecavir
causes of acute pancreatitis
‘GET SMASHED’
G = gallstones E = ethanol T = trauma
S = steroids M = mumps A = autoimmune S = scorpion bites H = hypercalcaemia/hyperparathyroidism E = ERCP D = drugs
drugs causing pancreatitis
mesalazine
azothioprine
Ix pancreatitis
- serum lipase/amylase
- CT (gold standard)
- CXR - to rule out other causes
complications of pancreatitis
peripancreatic fluid collections pseudocysts pancreatic necrosis abscess haemorrhage
presentation of chronic pancreatitis
dull abdo pain, worse 30mins after eating
radiates to back
steatorrhoea
diabetes mellitus
Ix chronic pancreatitis
gold standard = CT
also - pancreatic enzymes, HbA1c, ultrasound
location of most pancreatic ca
head of the pancreas
presentation pancreatic ca
painless jaundice (due to compression of the CBD)
anorexia
wt loss
steatorrhoea
Trousseau’s sign (clots in superficial veins in uncommon sites)
Ix pancreatic ca
Gold standard = pancreatic protocol CT
tumour marker pancreatic ca
ca 19-9
Mx pancreatic ca
surgery candidate:
Whipple’s procedure - pancreaticoduodenectomy + adjuvant chemo
non-surgical candidate:
ERCP + stenting
presentation of colonic polyps
incidental finding on qFIT - most common
- rectal bleeding
- mucus discharge
- tenesmus
- change in bowel habit
Mx of colonic polyps
colonoscopy +/- polypectomy
what type of ca is the majority of colorectal ca
adenocarcinomas
genetic conditions predisposing to colorectal ca
Familial Adenomatous Polyposis (FAP)
- > 100 polyps
- early onset
- autosomal dominant
- ass. with thyroid ca
Hereditary Non-Polyposis Colorectal Ca (HNPCC) (Lynch synd)
- < 100 polyps
- late onset
- autosomal dominant
- ass. with endometrial and gastric ca
how often are people screened in Scotland for colorectal ca
ever 2 years aged 50-74 y
presentation of colorectal ca
depends on site.
L side =
bleeding/mucus PR, altered bowel habit, tenesmus, mass PR
R side =
wt loss, anaemia, abdo pain
screening test for colorectal ca
QFit
tumour marker colorectal ca
CEA
Ix colorectal ca
- Colonoscopy
- CT colonography
- Double contrast barium enema
staging - CT chest/abdo/pelvis
dukes classification of colorectal ca
A = confined to mucosa B = invading bowel wall C = lymph mets D = distant mets
Mx colorectal ca
stage I - III:
colonic resection/colectomy + resection of regional lymph nodes
stage IV:
evaluate whether mets are resectable
if not - palliative
what nodes do colorectal ca spread to
mesenteric nodes
distant mets for colorectal ca
liver
Mx of rectal ca
anterior resection
or
abdomino-perineal excision of rectum
hartmann’s procedure
- surgical resection of recto-sigmoid colon
- close of anorectal stump
- end colostomy
what is diverticular disease
presence of asymptomatic outpouchings of the gut wall
most common location of diverticular disease
sigmoid colon
cause of diverticular disease
lack of dietary fibre - weak gut wall - mucosal herniation
presentation diverticulitis
LIF pain
pyrexia
high WCC
generalized peritonism
Ix diverticular disease
colonoscopy
Ix diverticulitis
CT abdomen
Mx symptomatic diverticular disease
dietary modification = fibre supplements
Mx diverticulitis
analgesia + oral or IV Abx
Mx recurrent diverticulitis
colectomy
cause of pseudomembranous colitis
c. diff
presentation of pseudomembranous colitis
recent Hx of Abx use diarrhea prolonged hospitalization/nursing home resident abdo pain fever n+v
Mx pseudomembranous colitis
Non severe = Metronidazole
Severe = Vancomycin + Metronidazole
cause of ischaemic colitis
low flow in the IMA
presentation ischaemic colitis
lower left abdo pain +/- bloody diarrhea
tenderness
Mx ischaemic colitis
conservative - most resolve spontaneously
if gangrenous - resection + stoma
complications of ischaemic colitis
toxic megacolon
microscopic colitis
radiative colitis
presentation of microscopic colitis
chronic, watery diarrhoea
presentation of acute mesenteric ischaemia
+++ pain
biochem:
acidotic BG
increased lactate
increased WCC
g/s diagnostic Ix mesenteric ischaemia
CT angiogram
Mx acute mesenteric ischaemia
bowel resection
- re-anastomose if poss
- if not, stoma
presentation of chronic mesenteric ischaemia
post-prandial abdo pain wt loss (eating hurts0 upper abdo bruit \+/- PR bleeding
Mx chronic mesenteric ischaemia
surgery - pros v cons, ongoing risk of infection
causes of large bowel obstruction
colorectal ca
sigmoid volvulus
caecal volvulus
strictures - diverticula, inflammatory
sigmoid volvulus on AXR
coffee bean appearance
caecal volvus on AXR
fetal appearance
presentation large bowel obstruction
colicky abdo pain
abdo distension
‘tinkling bowel sounds’
failure to pass faeces
Ix large bowel obstruction
- AXR (haustration - do not cross lumen’s width)
2. CT
Mx large bowel obstruction is signs of strangulation
straight to theatre - laparotomy + resection of bowel
Mx large bowel obstruction if no signs of strangulation
drip + suck
NBM NG tube (suck - to decompress bowel) IV fluids (drip)
Mx fissure-in-ano
- conservative - increase fibre and fluids, bulk forming laxatives
- topical GTN or Diltiazem
- Botulinum toxin A
- Surgery
how is the course of a fistula-in-ano predicted clinically
Goodsall Rule:
if posterior to transverse anal line - curved course
if anterior to transverse anal line - straight course
how is the course of a fistula-in-ano visualised
MRI
Mx rectal prolapse
surgery - rectopexy (abdo approach), or perineal approach
stomas that are spouted
small bowel stomas
stomas that are flat
large bowel stomas
what is a loop stoma
entire loop of bowel is brought through one abdominal incision, with both the proximal and distal openings exteriorized in the same sit
what is an end stoma
one end of the colon is brought through the abdominal incision and stitched to the skin
use of a loop ileostomy
to defunction the colon e.g. following rectal ca surgery
use of an end ileostomy
following complete resection of the colon
use of an end colostomy
if anastomosis of the colon is not achievable
use of a loop colostomy
defunctioning of a distal segment of colon
cause of biliary colic
stone lodged in CBD
presentation biliary colic
intermittent RUQ pain
worse on eating fatty foods
no fever
Ix biliary colic
abdominal US inflammatory markers (normal)
Mx biliary colic
outpatient cholecystectomy
cause of acute cholecystitis
inflammation of the gallbladder secondary to impacted stones
presentation acute cholecystitis
constant RUQ pain
Murphy’s +ve
Fever
what is murphy’s sign
pressing RUQ elicits pain and catches breath on inspiration
pressing LUQ doesn’t elicit pain
Mx acute cholecystitis
IV Abx - cefuroxime or ciprofloxacin+met
+
Early laparoscopic cholecystectomy
what is ascending cholangitis
infection of the biliary tree
cause of ascending cholangitis
E.coli
presentation ascending cholangitis
Charcot’s Triad:
RUQ pain
fever
jaundice
Ix ascending cholangitis
abdominal US
inflammatory markers
Mx ascending cholangitis
sepsis 6
ERCP (after 24-48h)
presentation bowel perforation
severe, generalized abdo pain
guarding
firm, peritonitic abdo
rebound and percussion tenderness
Ix bowel perforation
erect CR (air under diaphragm) urgent CT
Mx bowel perforation
urgent surgical repair
mechanism of enzyme inducers
these REDUCE the availability of drugs
mnemonic for enzyme inducers
CRAPS out drugs
Carbamazepine Rifampicin bArbituates Phenytoin St John's Wort
mechanism of enzyme inhibitors
these INCREASE the availability of drugs
mnemonic for enzyme inhibitors
Some Certain Silly Compounds Annoyingly Inhibit Enzymes, Grrr
Sodium valproate Ciprofloxacin Sulphonamides Cimetidine/Omeprazole Amiodarone, Antifungals Isoniazid Erythromycin/Clarithromycin Grapefruit juice
mnemonic for Cytp450 substrates
COWPATS
Carbamazepine Oral contraceptive pill Warfarin Phenytoin Acetylcholinesterase inhibitors Theophylline Steroids/Statins
ALARMS symptoms
A = anaemia L = loss of weight A = anorexia R = rapid onset M = melaena S = swallowing difficulties
If ALARMS symptoms are present, what Ix is first line?
urgent OGD
If ALARMS symptoms are not present what is the Mx?
- Lifestyle changes + Antacids & r/v in 2w
if anatacids and lifestyle changes do not help dyspepsia, what do you do next?
test for H.pylori options - C-13 urea breath test serum antibodies to h. pylori stool antigen test
if H. pylori test comes back -ve, what is the Mx?
prescribe PPI
if H. pylori test comes back +ve, what is the Mx?
triple therapy for H.pylori 1. PPI 2. Amoxicillin or Metronidazole 3. Clarithromycin for 10-14d
presentation of gastritis
vomiting
epigastric pain
no suspicious features of malignancy
causes of gastritis
- h. pylori
- NSAID use
- alcohol
- autoimmune
non-invasive h. pylori testing
C-13 urea breath test
serum antibodies to h. pylori
stool antigen test
presentation gastric ulcer
dyspepsia
epigastric pain
nausea + anorexia
MADE WORSE BY EATING
presentation duodenal ulcer
dyspepsia
epigastric pain
MADE BETTER BY EATING
most common cell type of gastric cancer
adenocarcinoma
risk factors for gastric cancer
h. pylori blood group A pernicious anaemia smoking gastric adenomatous polyps
types of gastric cancer
intestinal
- more common
diffuse
- younger patients
- worse prognosis
invasive testing for H. pylori (at biopsy)
rapid urease “CLO” test
presentation gastric cancer
dyspepsia n+v wt loss dysphagia virchows node
what is virchows node
enlarged left supraclavicular node - Troiser’s sign
lymph nodes from the digestiv eviscera drain to the thoracic duct
Ix gastric cancer
- OGD + biopsy
- staging - CT chest/abod/pelvis
- endoscopic USS
- PET CT
histology of gastric cancer
signet ring cells
Mx gastric cancer
Localised tumour: endoscopic muscosal resection
<5cm from GOJ: total gastrectomy
> 5-10cm from GOJ: subtotal gastrectomy
incubation period s. aureus
1-6h
transmission s. aureus
cream cakes
incubation period bacillus cerus
1-6h
transmission bacillus cerus
rice
incubation period clostriudium perfringens
1-6h
transmission clostridium perfringens
contaminated meat
incubation period E.coli 0157
12-48h
most common cause of travellers diarrhoea
E.coli
presentation E.coli 0157
sudden onset
severe bloody diarrhoea
incubation period salmonella
12-48h
transmission of salmonella
poultry
raw eggs
Mx salmonella
ciprofloxacin
incubation period shigella
48-72h
transmission of shigella
door + toilet handles
schools
Mx shigella
ciprofloxacin & co-trimoxazole
incubation period campylobacter
48-72h
transmission of campylobacter
dairy
most common cause of food poisoning
complication of campylobacter
guillain barre syndrome
Mx campylobacter
ciprofloxacin
incubation period cholera
48-72h
transmission cholera
food or poor sanitation
presentation cholera
profuse watery diarrhoea
incubation period giardiasis
> 7 days
transmission giardiasis
protozoa
incubation period amoebiasis
> 7 days
transmission amoebiasis
protozoa
incubation period norovirus§
12-48h
transmission of norovirus
cruise ships (faecal-oral)
incubatio nperiod rotavirus
12-48h
transmission of rotavirus
children, winter
PBC: M or F more common?
Females
what is PBC
chronic liver disorder, causing progressive cholestasis and eventual cirrhosis (damage to interlobular ducts)
presentation PBC
ITCH fatigue cholestatic jaundice RUQ pain xanthelasma clubbing hepatosplenomegaly hyperpigmentation (esp over pressure points)
autoantibody PBC
Anti-mitochondrial antibodies (AMA) - most specifc
LFTs in PBC
cholestatic appearance - high bilirubin, high Alk phos, more than ALT
Mx PBC
ursodeoxycholic acid
Mx itch in PBC
cholecystramine
complications of PBC
malabsorption
sicca syndrome
portal HTN
hepatocellular carcinoma
what forms the hepatic portal vein
superior mesenteric vein \+ gastric vein \+ splenic vein \+ part of the inferior mesenteric vein
where are the anastomoses of the portal venous system with the systemic venous system
- oesophageal and gastric venous plexus
- umbilical vein
- haemorrhoidal venous plexus
what causes hepatic encephalopathy
+++ ammonia (normally removed by the liver), travels to the brain and causes fluid shift
asterixis
‘liver flap’ seen in hepatic encephalopathy
Mx hepatic encephalopathy
lactulose - to clear the gut
pathology of ascites
renal dysfunction + portal HTN + splanchnic arterial vasodilation, leading to:
RAAS activation, leading to sodium and water retention
Ix ascites
abdo USS
Mx ascites
- paracentesis
2. intrahepatic portosystemic shunt (TIPSS) - connects hepatic vein to portal vein
causes of spontaneous bacterial peritonitis
E.coli
Klebsiella
prophylaxis for SBP
oral ciprofloxacin
Mx SBP
mild - PO co-trimoxazole
severe - IV tazocin
what is hepatorenal syndrome
cirrhosis + ascites + renal failure
pathology of hepatorenal syndrome
abnormal haemodynamics
causes splanchnic & systemic vasodilation, but renal vasoconstriction
types of hepatorenal syndrome
HRS type 1
- rapidly progressive
- v poor prognosis
HRS type 2
- slowly progressive
- poor prognosis
Mx of hepatorenal syndrome
liver transplant
vasopressin analogues (terlipressin)
albumin
TIPPS
energy daily requirement
30kcal/kg/day
protein daily requirement
0.8-1g/kg/day
components of the MUST score
BMI + wt loss score + acute disease effect score
0 = low risk 1 = med risk 2> = high risk
types of enteric feeding
NG tube
NJ tube
PEG tube
indications for enteric feeding
oral intake likely to be absent for 5-7d AND gut is functioning
purpose of NG tube
short term use
purpose of NJ tube
used if there is a problem with reflux or gastric emptying
what is a PEG tube
percutaneous gastrostomy
- tube directly into stomach through abdo wall
purpose of PEG tube
longer term feeding is needed (4-6w)
or
a mechanical swallowing obstruction
indications for parenteral nutrition
intestinal failure
how is parenteral nutrition administered
via central line
what is refeeding syndrome
a ++ insulin surge on feeding someone who has been depleted of nutrition. therefore – potassium
how to avoid refeeding syndrome
start feeding at around 10kcal/kg/day
causes of hepatocellular carcinoma
cirrhosis - hep B, hep C, alcohol
presentation hepatocellular carcinoma
wt loss
RUQ pain
acute liver failure
decompensated cirrhosis
tumour marker hepatocellular carcinoma
AFP
Mx hepatocellular carcinoma
surgical resection
presentation liver haemangioma on US
hyperechoic spot - ring of fibrous tissue around it
associations with liver adenoma
OCP
anabolic steroids
Mx liver adenoma
males - excision (irrespective of size)
females - imaging after 6m
- <5cm or decrease in size: annual MRI
- > 5cm: excision
cause of a liver hyatid cyst
parasite from tapeworms - Echinococcus granulosis
Mx liver hyatid cyst
- albendazole (sterilizes the cyst)
2. surgical excision
sources of a liver abscess
biliary sepsis
structures drained by the portal venous system
mucosal inflammation only
ulcerative colitis
transmural inflammation
crohn’s disease
characteristic site of UC
rectum, and extends proximally
characteristic site of crohn’s
can involve anywhere from mouth to anus
microscopic changes in UC
crypt abscesses
reduced goblet cells
non-granulomatous
microscopic changes in crohn’s
skip lesions
fissures
deep ulcers (cobblestoning)
fistula formation
smoking - protective or increases risk of UC?
protective
smoking - protective or increases risk of crohns?
increases risk
genetic ass. with UC and crohns
HLA-B27 +ve
presentation UC
bloody stool proctitis mucus discharge urgency tenesmus abdo pain
condition associated with UC
PSC
presentation of crohns
determined by site of disease
small intestine - abdo cramps, diarrhea, wt loss
mouth - ulcers, angular chelitis
anus - perianal pain, abscesses
condition associated with crohns
PBC
Ix UC
- stool studies - faecal calprotectin
- flexible sigmoidoscopy + biopsy
- colonoscopy
Ix crohns
- stool studies - faecal calprotectin
2. colonoscopy - ‘cobblestoning’
Ix acute exacerbation of UC
- abdo x-ray or CT
‘lead pipe colon’ - loss of haustra
‘thumb printing - mucosal oedema
Mx UC
- 5-ASA (sulfasalazine, mesalazine)
- steroids (prednisolone, hydrocortisone)
- immunosuppressants (azathioprine, methotrexate)
- anti-TNF
- surgery
Mx crohns’
- steroids (prednisolone, hydrocortisone)
- immunosuppressants (azathioprine, methotrexate)
- anti-TNF
- surgery
surgery in UC - curative?
yes!
total protocolectomy with permanent ileostomy or ileo-anal anastomosis
surgery in crohn’s - curative?
no
ileocaecal resection
types of gallstones
cholesterol (90%)
pigment (10%)
risk factors for gallstones
the 5 F’s
Fat Forty Fertile Female Family history
what is mirizzis syndrome
gallstone in the gallbladder neck presses on the bile duct, causing jaundice
complication of gallstones involving the gut
gallstone ileus
Ix acute cholecystitiss
- bloods
2. USS (if inconclusive - MRCP)
what is cholangiocarcinoma
cancer of the biliary system
presentation of cholangiocarcinoma
painless jaundice
wt loss
pruritus
pale stools/dark urine
Ix cholangiocarcinoma
- bloods - LFTs (obstructive pattern)
- MRCP
- CT/MRI
Mx cholangiocarcinoma
resection, XRT
palliative
inheritance of haemochromatosis
autosomal recessive
presentation haemochromatosis
fatigue erectile dysfunction arthralgia 'bronze diabetic' liver symptoms cardiomyopathy arthritis
Ix of haemochromatosis
- iron studies
