Surgery Flashcards
What causes colicky abdominal pain in intestinal obstruction
Increased peristalsis against the obstruction
What is wallaces rule of 9s
For burns Head and neck = 9% Upper limb = 9% Anterior lower limb = 9% Whole lower limb = 18% Anterior torso = 18% Posterior torso = 18% Perineum = 1% Hand = 1%
What is a volvulus
Twisting of a bowel loop around its mesenteric axis
Risk factors for volvulus Development
Long sigmoid,
narrow mesenteric attachment,
constipated loop
What does the coffee bean sign on abdo xr indicate
Volvulus
Management of volvulus
Passage of a flatus tube into the sigmoid colon
Failure - laparotomy
What is gallstone ileus
Gallstone erodes into the duodenum
Forms cholecysto-duodenal fistula
Gallstone then blocks the ileo-caecal valve - obstruction
Air enters the biliary tree - can be seen on xray.
Causes of paralytic ileus
Post op Peritonitis Spinal surgery Hypokalaemia Uraemia Anticholinergic drugs
Presentation for paralytic ileus
Vomiting, distension, absolute constipation
NO pain
Abdominal x-ray findings of paralytic ileus
Gas in the whole small and large bowel
No discrete obstruction
Management of paralytic ileus
Fluids
NG tube
Pethidine for pain (doesnt slow GI motility)
Anti-emetics
What is hartmann’s pouch
The neck of the gallbladder
Why is biliary colic not true colic
The pain is continuous and not in waves
Where is the pain of biliary colic felt
Initially epigastric for right upper quadrant
Then Radiates around both costal margins
Differential diagnosis of severe upper abdominal pain
Biliary colic
Pancreatitis
Perforated peptic ulcer
Ruptured aneurysm
What is a right sub-costal incision used for
Open cholecystectomy
Gas used for insuflation in laparoscopic surgery
CO2
Benefits of laparoscopic surgery
Smaller wounds/scars Less post-operative pain Reduced risk of wound infection Reduced post-operative chest infections Earlier mobilisation Earlier discharge
Contraindications to laparoscopic surgery
Suspected cancer
Bleeding disorders
(Multiple adhesions)
What is a mucocele of the gallbladder
Gallstone impacts the gallbladder neck
Mucus builds up and distends the gallbladder
What is cholangitis
Infection of the biliary tree
Usually associated with obstruction
Presentation of cholangitis
Pain
Jaundice
Pyrexia and rigors
Risk factors for gallbladder carcinoma
Long term gallstones
Gallbladder polyps
Gallbladder calcification
What is a porcelain gallbladder
Calcification of the gallbladder
Types of pancreatic cancer
Ductal adenocarcinoma (poor prognosis)
Ampullary carcinoma
Islet cell tumours
Cystic tumours
Presentation of ductal pancreatic cancer
Obstructive jaundice (if at head of pancreas -80%) Severe upper abdominal pain Weight loss Anorexia Malaise Thrombophlebitis migrans
Management of pancreatic cancer
If too advanced for resection - biliary stent
Surgical resection (15% of ductal ca)
When is whipples procedure done?
Tumours of the head of the pancreas / peri-ampullary
Compenets of the modified Glasgow score
PaO2 < 8kPa Age > 55 years Neutrophils (WBC > 15) Calcium < 2 mmol/L Renal function: Urea > 16 mmol/L Enzymes LDH > 600IU/L Albumin < 32g/L (serum) Sugar (blood glucose) > 10 mmol/L
Define hernia
Protrusion of a viscus, or part of a viscus, through the walls of its containing cavity into an abnormal position
What is the neck of a hernia
The margin of the defect through which it has protruded
What does a ‘reducible’ hernia mean
When the contents of the hernia can be returned to the abdominal cavity.
Either spontaneously or with manipulation
What does an ‘incarcerated’ hernia mean
An irreducible hernia
Which is irreducible due to adhesions within the sac.
Not obstructed or strangulated.
What does an ‘obstructed’ hernia mean?
Bowel within the hernia is obstructed.
Patient may have - pain, distension, vomiting and absolute constipation
What does a ‘strangulated’ hernia mean
The blood supply to the contents of the hernia is occluded by pressure from the neck of the hernia
Usually veins occlude 1st - causing swelling - causing arterial occlusion
What is a richters hernia
Where part of the bowel wall is caught in the sac and may become strangulated.
Where do femoral hernias herniate through
Through the femoral canal - usually contains fat and LN
Appear below and lateral to the pubic tubercle
What hernias are below and lateral to the pubic tubercle
Femoral hernias
When does a femoral hernia need repairing
ALL femoral hernias require repair
High risk of strangulation
Types of inguinal hernia
Direct inguinal hernia
Indirect inguinal hernia
What hernia is above and medial to the pubic tubercle
Inguinal hernia (But they leave the abdominal cavity above and lateral to the pubic tubercle)
Passage of indirect inguinal hernias
Through the deep inguinal ring
Along inguinal canal
Emerge through the superficial inguinal ring
Passage of direct inguinal hernias
Enter the inguinal canal directly via a weakness in its posterior wall.
Emerge from the superficial inguinal ring
What type of hernia often extends into the scrotum
Indirect inguinal hernias
Differential diagnosis of a lump in the groin
Inguinal hernia Femoral hernia Inguinal lymph node Saphena varix Femoral artery aneurysm Encysted hydrocoele Lipoma
Factors leading to the development of incisional hernias
Obesity Old age Chronic cough Straining due to constipation Post-op wound infection Post-op haematoma
What is the normal difference between adult and congenital umbilical hernias
Congenital umbilical hernias herniate through the umbilicus itself.
Adult umbilical hernias are usually para-umbilical.
What is a spigelian hernia
A hernia into the posterior rectus sheath at the point where it becomes deficient.
What is an obturator hernia
V rare hernia.
In pelvic area - into obturator foramen.
Can cause pain to be felt on inner thigh
Old F
What does a modified Glasgow score of 3 or more indicate
Severe pancreatitis
What is fibrocystic breast disease
Aberrations of normal development
Small cyst formation
Fibrosis
Hyperplasia of duct epithelium
Presentation of fibrocystic breast disease
Bilateral, diffuse lumpiness and breast pain.
Often cyclical
Features of a fibroadenoma
Discrete, firm, freely mobile lump
2-3cm in size
Most common aged 15-25
What is a phyllodes tumour
Rapid growing
Tumour of Fibroepithelial stroma of breast
Leaf-like appearance on histology
Usually benign
What is peau d’orange
Orange skin appearance of skin of breast
Can occur in breast cancer
Cutaneous lymphoedema
Skin dimpling
What is a cystic hygroma
Congenital benign proliferation of lymph vessels.
Posterior triangle of neck.
Multi-cystic swelling.
Features of a cystic hygroma
Posterior triangle of neck.
Multi-cystic swelling.
Fleshy and compressible
Trans illuminate brightly
Boundaries of the posterior triangle of the neck
SCM muscle anteriorly
Anterior border of trapezius
Middle 1/3 of clavicle
Features of a salivary duct carcinoma
>50yo Rapid growth Regional lymph node involvement Rapid metastasis Facial nerve involvement --> weakness
What is a branchial cyst
Cystic degeneration of lymphoid tissue
Commoner in M on LHS
Anterior triangle
Features of a branchial cyst
Anterior triangle - anterior to bordere of SCM
Smooth
Non-tender
Fluctuant swelling
Does not trans-illuminate
Aspiration reveals creamy fluid containing cholesterol crystals
What is a thyroglossal cyst
Congenital cystic remnant of the thyroglossal tract
Features of a thyroglossal cyst
Smooth midline lump
Moves on tongue protrusion
What is a sialolithiasis
Salivary gland stone
Presentation of salivary duct stone
Immense pain on salivation
Enlarged gland
Post-hepatic causes of jaundice
Biliary obstruction
- Extrahepatic cholestasis:
> Bile duct strictures (can be benign or malignant).
> Common duct stone.
> Cancer of the head of the pancreas.
> Tumour of the ampulla of Vater.
> Pancreatitis.
> Cancer of the gallbladder.
- Intrahepatic cholestasis:
> Primary biliary cirrhosis
> Drugs (e.g phenothiazines).
> Primary sclerosing cholangitis
> Dubin-Johnson syndrome (autosomal recessive)
> Rotor's syndrome.What type of jaundice causes pale stools and dark urine
Conjugated
Suggests a post-Hepatic cause
What type of incision is used for an appendicectomy?
Gridiron (at right angles to the line between ASIS and umbilicus -1/3 way along)
Lanz (more transverse and closer to ASIS)
Where is McBurney’s point
1/3 way between the ASIS and umbilicus
Tender on palpation in acute appendicitis
When is a midline laparotomy incision used + where is it
For urgent abdominal surgery or exploratory surgery
Upper = Xiphisternum to umbilicus
Lower = umbilicus to pubic symphysis
Trauma cases = Xiphisternum to pubic symphysis
When is a pfannenstiel incision used
Caesarean section
Ovarian operations
Bladder and prostate operations
When is a subcostal (kocher) incision used
Right sided for cholecystectomy
Left sided for splenectomy
Management of thrombophlebitis caused by cannula
Remove cannula
Elevate limb
NSAIDs
If signs of infection start abx
Presentation of the breast cyst
Sudden, painful swelling in the breast
Commonest in 40s
What is mastitis
Infection of a lactiferous duct by staphylococcus aureus
Transmitted by infants nasopharynx in lactation
Presentation of mastitis
Cellulitis of breast
Pyrexia
tachycardia
leucocytosis
Presentation of fat necrosis in the breast
Middle age obese women
History of breast trauma
Painless, irregular, firm lump
+/- Skin thickening, retraction
What is mondor’s disease of the breast
Rare
Thrombophlebitis of superficial veins of bathe breast and anterior chest wall.
Painful, inflamed cord-like structure tethered to skin
Presentation of a cervical rib
Lump in the neck
Paresthesia / pain in T1 distribution
Horners syndrome
Subclavian artery can be pinched - reduced blood flow to arm
Commonest benign tumour of the salivary glands
Pleomorphic adenoma
What is a chemodectoma
Tumour of the carotid body chemoreceptors arising in carotid bifurcation
Slowly enlarging neck mass with carotid pulsation
Presentation of sternocleidomastoid tumour
Tilting of head - torticollis
Painless fibrous mass in SCM muscle
Tx = passive stretching of muscle
When can aorto-enteric fistulas occur
How do they present
Rare complication of abdominal aortic aneurysm repair
Presents as massive GI bleeding, hypovolaemia, collapse
Risk factors for gastric carcinoma
Chronic peptic alteration Helicobacter pylori infection Gastric polyps Pernicious anaemia Ménétrier's disease Blood group A Eating pickled foods Smoking Alcohol
What is Ménétrier’s disease
Rare condition of hyperplasia of mucus producing cells in stomach,
Causes protein losing enteropathy
And reduced gastric acid secretion
What is the most common type of gastric cancer
Adenocarcinoma
What is troisiers sign
Supraclavicular lymphadenopathy on the left hand side = vichows node
Gastric cancer
What is a krunkenburg tumour
Secondary ovarian tumour - From adenocarcinoma of the stomach
What is a sister Joseph nodule
Hard red lump in the umbilicus
Signifies gastric carcinoma
Management of haemorrhoids
Increase dietary fibre Increase water Injections sclerotherapy Banding Surgical haemorrhoidectomy
What is an amyand hernia
Hernia containing the appendix in the sac
Management of achalasia
Balloon dilation of the oesophagus
Hellers cardiomyotomy
What malignancy does achalasia predispose to?
Squamous cell carcinoma of the oesophagus
Symptoms of hiatus hernia
Asymptomatic
Gastro-oesophageal reflux
Dyspepsia
Complications of hiatus hernia
Weight loss Oesophagitis Oesophageal ulceration Oesophageal stricture Aspiration pneumonia
What is the surgical procedure for hiatus hernia
nissen’s fundoplication
Presentation of toxic megacolon
Acute Abdominal pain Abdominal distension Diarrhoea Blood stained stools Fever Tachycardia
Xray findings of toxic megacolon
Colon dilation >6cm
Colonic wall thickening
Multiple air-fluid levels
Disrupted haustral pattern
Management of toxic megacolon
HDU
Fluid rescus
Antibiotics
Corticosteroids
Daily abdominal X-rays to assess progression
If dilation worsening consider collectomy
What is CA-19-9 raised in
Pancreatic cancer
Tumour marker of pancreatic cancer
CA 19-9
Tumour marker of ovarian cancer
CA 125
When is CA 125 raised
Ovarian cancer
What tumour is alpha-fetoprotein raised in
Hepatocellular carcinoma
Liver metastasis
Germ cell tumours
What tumour maker is raised in prostate cancer
PSA
prostate specific antigen
When is CA15-3 raised
Breast cancer
Tumour marker of breast cancer
CA 15-3
What is beta-HCG a tumour marker for
Choriocarcinoma (trophoblastic disease)
Testicular tumours
What is calcitonin a tumour marker for
Medullary thyroid cancer
What is CEA (carcino-embryonic antigen) a tumour marker for
Colorectal cancer
Tumour marker of colorectal cancer
CEA
carcino-embryonic antigen
When is monoclonal immunoglobulin G raised
Multiple myeloma
What is s-100 a tumour Marker for
Malignant melanoma
What cystic neck lump occurs at the lower posterior edge of SCM
Cystic hygroma
Lymph-angioma
What cystic neck lump occurs at the upper anterior edge of SCM
Branchial cyst
When does a cystic hygroma present
Birth / early childhood
When does a branchial cyst present
Adolescence / easily adulthood
What nerve is contained in the posterior triangle of the neck
Accessory nerve
Where can a lipoma NOT form?
Palms
Soles
Scalp
Does a lipoma have a punctum
No
What nerve runs through the parotid gland
5 branches of the facial nerve
Signs of peritonitis
Tenderness Reflex guarding Absent bowel sounds Pyrexia Pain to percussion Extremely unwell Distant palpation pain
Is small of large bowel obstruction more common?
Small
Mechanism of sentinel node identification in breast cancer
Injection of vital blue dye + technetium labelled colloid
To identify sentinel node
Allows histology on single node
What type of drug is herceptin + when is it used
Immunotherapy / biological therapy
Used in breast cancer following chemotherapy
What is tamoxifen
Oestrogen receptor antagonist
Complications of hernias
Irreducibility Obstruction Strangulation Peritonitis Infarction
What % of patients presenting with a hernia have bilateral ones
10%
Presentation of an incisional hernia
Appear months after surgery
Usually abdominal
Exaggerated when lying by lifting head off bed
Wide neck - low risk of obstuction / strangulation
Where is the inguinal ligament
Between the pubic tubercle and the ASIS
What is the difference between the mid-inguinal point and the mid-point of the inguinal ligament
mid-inguinal point = 1/2 way between symphysis pubis and ASIS = location of femoral pulse
Mid-point of inguinal ligament = 1/2 way between pubic tubercle + ASIS = location of deep inguinal ring
What is the process behind dupuytrens contracture
Thickening of the palmar aponeurosis
Doesn’t involve flexor tendons but prevents them working properly.
Is not painful
Risk factors for dupuytrens contracture
Family hx Alcohol excess Cigarette smoking Diabetes Peyronie's disease Phenytoin
