Surgery Flashcards
What might be seen in x-ray to suggest Boerhaave’s over a Mallory Weiss tear?
Pneumoperitoneum
Management of Boerhaave’s disease
IV fluid resuscitation
IV antibiotics to cover/treat mediastinitis
Surgical correction
Features of Boerhaave’s disease
Severe chest pain, worse on swallowing Vomiting up blood (or not) Signs of shock Subcutaneous emphysema Pneumomediastinum, pleural effusions, pneumothorax on x-ray
Which investigation can help to confirm achalasia after a bird’s beak appearance has been seen on barium swallow?
Manometry
To assess the pressures in the oesophageal sphincters
Most common cause of LARGE bowel obstruction
Colorectal cancer
The way you know its large bowel is that the obstruction will be in the periphery of the abdomen
Most common cause of SMALL bowel obstruction
Adhesions from previous surgeries
Management of large bowel obstruction
Supportive care – analgesia, IV fluids, anti-emetics
Decompression of sigmoid volvulus – using flexible sigmoidoscope
Palliative care – a proportion of patients who present with malignant large bowel obstruction are not candidates for surgery. Palliative stenting of the obstruction can be performed to help relieve symptoms.
The majority of patients (70%) with large bowel obstruction require surgical intervention – laparoscopic or open colonic resection. This can involve a primary anastomosis or stoma formation
Emergency surgery for rectal cancer causing bowel obstruction
Loop colostomy
Too risk to go straight in and remove the cancer at this point, just make that bit of bowel defunctioning
What do you do with varicose veins that are symptomatic despite compression treatment?
Stripping
Single tortuous varicosity present on the postero-lateral aspect of the lower left leg indicates varicose veins of which vein?
Short saphenous
Management of tumour lysis syndrome
Rehydration and haemodialysis
Symptoms of hyponatraemia
Dizziness
Generalised weakness
Diuretics that can cause hyponatraemia
Thiazide diuretics e.g bendroflumethazide
Whirlpool sign on USS indicates…
Ovarian torsion
Which abdominal x-ray finding for caecal volvulus?
Embryo sign
Originates from the right lower zone (where the caecum is)
Which abdominal x-ray finding for sigmoid volvulus?
Coffee bean sign
Surgical options for chronic limb ischaemia
If one obvious artery blocked on CT angiogram, or venous doppler, you can perform percutaneous angioplasty
Other options = bypass and amputation
RF for limb ischaemia
Smoking. Diabetes mellitus. Hypertension. Hyperlipidaemia: high total cholesterol and low high-density lipoprotein (HDL) cholesterol are independent risk factors. Physical inactivity. Obesity.
Conservative/medical approach to chronic limb ischaemia
Antiplatelet therapy: with clopidogrel 75mg once daily. Aspirin is prescribed only if clopidogrel is not tolerated or contraindicated.
Lipid lowering therapy: with atorvastatin 80mg once nightly.
In diabetics, glycaemic control should be optimised.
High blood pressure should be managed appropriately.
Features of gallstone ileus
History of gallstones
Signs of bowel obstruction
Air in the biliary tree
USS signs of intussception
US abdomen reveals concentric echogenic and hypoechogenic bands
“Target sign”
Treatment of schistosomiasis
Praziquantel
Schistosomiasis is linked with which bladder cancer?
Squamous cell carcinoma
Management of ascending cholangitis
Fluid Antibiotics Biliary drainage ERCP and stent insertion SEPSIS protocol
Management of diverticular disease
Patients with asymptomatic diverticulosis (i.e. diverticula are seen incidentally on imaging/endoscopy) do not require treatment.
Patients with symptomatic diverticular disease should be advised to increase dietary fibre intake and hydration.
If there is evidence of inflammation of the diverticula (diverticulitis) e.g. leukocytosis, fever, patients are initially managed with oral antibiotics (e.g. 7 days co-amoxiclav).
Analgesia may also be required. This should be prescribed in a step-wise fashion, starting with oral paracetamol.
A low residue diet should be advised.
If patients fail to improve after 72 hours of oral antibiotics, admission to hospital for intravenous antibiotics (e.g. ceftriaxone and metronidazole) is required.
Which scoring system for head trauma?
Canadian CT head rule
Management of pancreatitis
Aggressive fluid resuscitation
Aim to keep urine output > 30 mL/hour
Start with a 1 litre bolus and try to maintain adequate urine output. This usually amount to a fluid requirement of 3 – 5 ml/kg/hr
Catheterisation
Analgesia
Strong analgesia in the form of opioids are needed
Anti-emetics
IV antibiotics are shown to have no real effect in outcome unless necrotising pancreatitis is present. Necrotising pancreatitis is a complication of severe pancreatitis representing inadequate fluid resuscitation during initial management. It is usually diagnosed by CT scan.
Calcium may be given if hypocalcaemia is present, but is not prescribed prophylactically.
Insulin may also be given in the presence of hyperglycaemia due to the damaged pancreas reducing release of the hormone.
Treatment of epididymo-orchitis
Azathioprine or other antibiotics
How do you treat high output stoma (>1.5L/day)
Restrict oral fluids and prescribe IV dextrose
You can also prescribe loperamide to help reduce output aswell as omeprazole to reduce secretions
Complications of stoma
Complications can be classified into early and late complications.
Early complications can be further classified into mechanical and functional complications.
Early mechanical complications include bowel ischaemia/necrosis, bowel retraction, and para-stomal abscess formation.
Early functional complications include poor stoma function and high output stoma.
Late complications can be further classified into mechanical, functional, and psychosocial complications.
Late mechanical complications include para-stomal hernia formation, bowel stenosis and prolapse, adhesion formation leading to bowel obstruction, and para-stomal dermatitis.
Late functional complications include bowel dysmotility (leading to constipation/diarrhoea) and malabsorption (e.g. if the terminal ileum is removed this can cause B12 deficiency).
The patient may also develop psychosocial complications, relating to difficulties with body image and sexual activity
3 components to MEN1
Para-pan-pit
Ix for Zollinger-Ellison syndrome
Secretin stimulation test
Features of Zollinger-Ellison syndrome
Refractory GORD and abdominal pain despite treatment
Weight loss
Management of Stanford B aortic dissections
Intravenous beta blockade (e.g. with IV labetalol). This reduces the pulsatile force on the intima, preventing propagation of the dissection and aortic rupture.
Intravenous morphine. This provides analgesia and helps maintain haemodynamic stability by reducing sympathetic tone.
If beta blockade is insufficient, alternative antihypertensive vasodilator therapy should be administered (e.g. nitroprusside or diltiazem).
For type B dissection with complication (such as ischaemia, expansion, persistent pain, or aortic rupture), endovascular stent-graft repair is indicated.
Management of Stanford A aortic dissection
Immediate open repair
Ix for aortic dissection
CT angiography
Treatment of acute limb ischaemia
Surgical embolectomy
Angiography to confirm the site
If unsuccessful, can attempt on the table thrombolysis (very risky)
?LMWH, consult senior
Features of Boorhaave’s perforation clinically
Hypotensive
Pneumoperitoneum
Common for the patient to NOT vomit up blood
Difference between Boorhaave’s and oesophageal rupture
Boorhaves is due to increased pressure (e.g. vomiting), rupture could be from a fish bone or something
Pt, post-cholecystectomy, now has increasing abdo pain and the drain is draining bile
There are deranged LFTs
Most likely Dx and what the Ix and Mx?
Bile leak
Dangerous, usually caused by slipped clips or a missed stone
Ix with ERCP and stent it to allow for biliary drainage
Features of post-cholecystectomy syndrome
Presents many weeks/months after the operation
Clinically stable
Recurring abdominal pain and reflux symptoms
Features of cholecystitis
Right upper quadrant/epigastric pain (radiating to right shoulder tip if the diaphragm is irritated) Fever Nausea and vomiting Right upper quadrant tenderness Murphy's sign positive
Mx of mild acute cholecystitis
Antibiotics and simple analgesia
Laparoscopic surgery within 6 weeks
Gene mutation in FAP
APC
Features of Peutz-Jeghers syndrome
Pigmented macules on lips (like freckles)
Multiple benign hamartomatous polyps
What is Trousseau’s sign in regards to pancreatic cancer?
Migratory thrombophlebitis
Risk factors for pancreatic cancer
Smoking
Palliative options for pancreatic cancer
Endoscopic stent insertion into bile duct
Palliative surgery if endoscopic stent insertion fails
Chemotherapy
Radiotherapy (only for localised advanced disease
Causes of post-op pyrexia
Wind (atelectasis and pneumonia) 1-2 Water (UTI) 3-5 Walk 5-6 Wound 5-7 Wonder about drugs 7+
Urine related complication of long standing diverticular disease
Colovesical fistula
Present with gassy urine
Require surgical repair
Dx of chronic mesenteric ischaemia
CT angiography
Usually in the superior mesenteric artery
RF = AF
Sx = recurrent abdo pain after meals
What are the components of severe pancreatitis
PaO2 < 8kPa (60mmHg) Age > 55 years Neutrophils - WBC >15 x109/l Calcium < 2mmol/l Renal function - Urea > 16mmol/l Enzymes - AST/ALT > 200 iu/L or LDH > 600 iu/L Albumin < 32g/l Sugar - Glucose >10mmol/L
Which type of cancer does UC put you at risk of?
Cholangiocarcinoma (because of PSC)
Sx, RF, Mx of pilonidal abscess
Result of blockage of a pilonidal sinus in the anal cavity
RF = Crohn’s disease, excess hair
Can get infected and cause an abscess (often at the base of the back)
Mx = incision and drainage
Presence of tender, palpable mass in the RUQ
1 week history of repeated episodes of RUQp, swinging fevers =>
Gallbladder empyema
Mx of gallbladder empyema
Drainage
RF of gallstones
Fat
Forty
Fertile
Female
Courvoussiers law and Hx of UC =>
Cholangiocarcinoma
Features of rectal prolapse
A mass that extrudes during defecation Rectal mucus discharge Perianal pain Bleeding Faecal incontinence
Valvulae conniventes vs haustra
Valvulae = small bowel and go all the way across
Mx of chronic limb ischaemia
Exercise and diet
Supervised exercise programmes (helps to form collateral blood flow)
What should you do if you detect an AAA >3cm but <5.5cm
12w referral to vascular surgeons
Try not to get mixed up with dates of screening. These are
3-4.5 yearly 4.5-5.5 3 monthly
Mx of shoulder dislocation
Relocation under anaesthesia
Place the arm in a broad arm sling
Is intertrochanteric intracapsular or extracapsular?
Extracapsular
Management of extra-capsular NOF
Open repair and internal fixation (ORIF) with dynamic hip screw placement
Mx of carpal tunnel syndrome
Splinting, local steroid injections and treatment of the underlying cause if it is secondary.
If these fail, then decompression surgery is used- performed by dividing the tunnel roof (flexor retinaculum).
X-ray features of Colle’s fracture
Dorsally angulated radial fracture
Snaps in the way you would expect
How can you differentiate between a meniscal injury and cruciate tear?
Often immediate swelling with cruciate tear
Need an MRI to tell for sure
2mo Hx of increasing pain on the sole of the foot in someone who does parkour =>
Stress fracture
Damage to which nerve causes winging of the scapula?
The long thoracic nerve
Low impact trauma now back pain and tenderness on palpation
Hx of steroid use, old age, female =>
Vertebral wedge fracture
Sx of cubital tunnel syndrome
Tingling in ring finger and little finger when they bend their arm for a while
Mx of cubital tunnel syndrome
Conservative = splint
Surgical decompression if refractory
