Surgery Flashcards
What are the “3 I’s” of “Thumbprinting” ?
Infection (C.diff or salmonella colitis) / Inflammation (UC or Crohn’s) / Ischaemia (Ischaemic colitis)
Surgical Sieve “TIN CAN BEDs”
Trauma Infection Neoplasm Congenital Acquired Neuro Blood Endocrine Drugs Syphilis
List Dysphagia (difficulty swallowing) differentials
Oesophageal carcinoma (Squamous/ adenocarcinoma)
Achalasia (LES dysfunction)
Oesophageal / peptic stricture
Hyperthyroidism
Oesophageal candidiasis (immunosuppressed patients)
Bulbar Palsy (CN IX - XII)
Trypanosomiasis (Chagas’ disease) tropical disease
GORD
Extrinsic Malignancies (lung/lymph node) can externally compress oesophagus)
Name the 3 Bacteria that can cause life threatening infections in patients with splenectomy.
Neisseria Meningitidis (aka Menigococcus) Streptococcus Pneumonia (aka Streptococcus) Haemophilus Influenza
Most common places for oesophageal metastases
The 2 L’s - Liver and Lungs
List differentials for a RIF mass
Appendix abscess / Mass (omentum envelopes inflammed appendix giving a mass like feeling on palpation)
Hepatomegaly
Crohn’s
Caecal carcinoma
Meckels diverticulum (paeds)
Ileo-ceacal stricture (Yersinia and TB - 2 rare but important differentials to be excluded with CXR)
List the criteria that make a UTI complicated
> 2 in 6 months / > 3 in 1 Year
Pyelonephritis (i.e loin pain and upper UTI)
Men
Anatomical disruption (stent/catheter/stricture)
List the causes of Pancreatitis
I GET SMASHED
Iatrogenic Gall stones Ethanol (alcohol) Trauma Steroids Mumps Autoimmune Scorpion bite Hyperlipidaemia ERCP Drugs (Azothioprine/ Anticonvulsants (ex. sodium valproate) / Antimicrobials (metronidazole) / Diuretics (ex. Thiazides and Furosemide)
Name the two strains of bacteria and the toxin that causes Haemolytic Uraemic Syndrome (HUS). List the classic pathological triad associated with HUS.
E.Coli (0157:H7) and Shigella - Shiga toxin
Anaemia
AKI
Thrombocytopaenia (Low platelets)
List post surgical complications of GI surgery
Infection (Suture site/from laporotomy/UTI/ Hospital acquired pneumonia) DVT/PE Haemorrhage Obstruction Paralytic ileus (bowel goes to sleep) Anastomotic leak
Name the 3 Features of Charcot’s Triad and which condition this indicates.
Fever (usually with rigors)
Jaundice
RUQ pain
Ascending Cholangitis (infection of the biliary tree)
5 risk factors for acute cholecystitis
5F's Female Forty Fat Fertile Family History
Pregnancy / oral contraceptives (oestrogen causes more bile to be secreted into bile duct) / any condition that causes haemolysis (sickle cell disease etc) / Malabsorption (ileal resection / crohns)
What is the normal diameters of the Small bowel / Large bowel / Appendix / Caecum ?
3-6-9 rule
Small bowel <3cm
Large bowel <6cm
Appendix <6mm
Caecum <9cm
What is Murphy’s sign?
Apply pressure to RUQ and ask patient to inhale. Cessation of inspiratory effort due to pain in RUQ is indicative of Gall bladder Inflammation (i.e cholecystitis and not biliary colic).
Name 6 complications of gall stones
Acute Pancreatitis
Gall bladder mucocoele (mucous filled overdistended gall bladder - can become infected and lead to empyema)
Porcelain gall bladder (calcified gall bladder wall)
Small bowel obstruction (lodge at ileo-coecal valve)
Ascending cholangitis (infection of biliary tree)
List the Glasgow-Imrie score criteria that determines the severity of Pancreatitis?
Remember Mnemonic PANCREAS
PaO2 (<60 mmHg) Age (> 55 y/o) Neutrophilia (>15) Calcium (<2) uRea (>16) Enzymes (LDH > 600 AST/ALT > 200) Albumin (<32) Sugar (glucose >10)
Name the synonym for ovulation pain, and the causes.
Mittelschmertz - Endometriosis / Adhesions/ Surgical Scarring/ Scarring from STI’s (ex. Chlamydia).
Mesenteric Adenitis is typically precipitated by which type of infection? It is thus important to perform which examination to rule out mesenteric adenitis as the cause of GI pain.
Respiratory Tract Infection
Ear and Throat examination (sore ears/throat and symptoms of cold predate mesenteric adenitis)
Thiamine (B1) deficiency can lead to which two neurological conditions? Name the triad of symptoms for each.
Remember mnemonic - “COAT RACK”
Wernicke's Encephalopathy (1) Confusion (2) Ophthalamoplegia (3) Ataxia Thiamine deficiency
If left untreated (thiamine reverses condition) can progress to Korsakoff’s Psychosis.
(1) Retrograde Amnesia
(2) Anterograde Amnesia
(3) Confabulation
Korsakoff’s psychosis
State Courvoisier’s Law:
Painless jaundice and palpable RUQ mass is indicative that pathology is not caused by gall stones and thus an obstructing pancreatic or biliary neoplasm until proven other wise. Could also be a gall bladder stricture.
What is a Krukenberg Tumour?
Rare tumours that arise in the ovaries of women as a result of metastases of a gastric malignancy.
At what level of serum bilirubin does jaundice become clinically evident?
2-3 mg/dL or 34-51 µM
Normal Bilirubin: 0-21 µM
Name the most common infective organisms in ascending cholangitis
E.Coli (27%) / Klebsiella (16%) / Enterococcus (15%)
List the Features of Reynad’s Pentad and the pathology this pentad is associated with.
RUQ pain Fever Jaundice Hypotension Confusion
Cholangitis (patients may also present with tachycardia)
List the causes of cholangitis.
Usually due to obstruction of the biliary tree
Gall stones
ERCP
Cholangiocarcinoma
More rarely
Primary sclerosing cholangitis
Ischaemic cholangiopathy (damage/stricturing of biliary tree due to lack of blood flow).
Parasitic infection
What is the mortality rate of Cholangitis?
5-10% when treated with antibiotics
What is the initial steps of management in cholangitis
IV Fluids
Broad spec Antibiotics (do not delay and wait for culture results as these patients can become septic very quickly)
Analgesia
Other investigaitons
LFTs
Bloods (FBC)
Culture
Imaging:
Ultrasound for stones and duct dilatation
MRCP if dilatation but no stone identified on ultrasound
ERCP for biliary decompression sphincterotomy/stenting if stone identified.
Patient may need laparoscopic cholecystectomy in the long term.
If patient too unwell for ERCP then a percutaneous transhepatic cholangiography (PTC) can be performed.
List the common sites of metastases for Colon Cancer.
Remember 3L’s : (oesophageal cancer is 2 L’s)
Liver
Lung
Lymph nodes
Also more rarely: Bone Peritoneum Brain Skin
Colon carcinomas are most likely to be what kind of tumour?
Adenocarcinomas
Which kind of polyps are most likely to become malignant?
Sessile (adhered tightly to mucosal wall)
and
Villous (histological subdivision of polyps with large surface area)
What is the screening process for colorectal cancer in the UK?
Men and Women aged 60-75 are tested every 2 years using a FIT (Faecal Immunochemistry Test) whereby antibodies bind to haemoglobin to detect blood.
If blood detected - specialist nurse carries out colonoscopy.
Give the ages and associated symptoms that need urgent investigation for bowel cancer.
<40 - Unexplained weight loss and abdominal pain
<50 - Unexplained rectal bleeding (haematochezia)
<60 - Iron deficient anaemia or change in bowel habit
Causes of Pseudo-Obstruction
Surgery (orthopaedic)
Severe illness (cardiac ischaemia)
Trauma
Electrolyte imbalance (Hypercalcaemia/Hypomagnesaemia/Hypothyroidism/Hypokalaemia)
Neurological (Parkinsons/MS/Hirschsprung’s disease)
Medications (Opiates/Calcium channel blockers/Anti-depressants)
Pseudo-Obstruction increases the risk of which three pathologies?
Toxic Megacolon
Ischaemic Colitis
Perforation
Identify the management steps of pseudo-obstruction.
Conservative (i.e Nil by mouth/ IV fluids/ NG tube if vomiting)
If this fails to resolve within 48hrs
Endoscopic decompression with flatus tube
Failing this
IV Neostigmine (anticholinesterase) - should be avoided if possible due to complications.
Surgery required if all this fails or evidence of perforation
Which organs are retroperitoneal?
Remember mnemonic SAD PUCKER
Suprarenals (adrenal glands) Aorta/IVC Duodenum (except proximal cap 2cm) Pancreas Ureters Colon (Ascending and Descending) Kidneys Esophagus Rectum
List the main layers of the GI tract
Remember “Marks + Spencers X2” i.e MSMS
Mucosa (3 layers - Epithelium / Lamina propria/ Muscularis interna)
Submucosa
Muscularis propria/externa (circular and longitudinal)
Serosa or adventia (when it is fibrous connective tisseu)
Remember muscularis propria is divided into 2 layers (circularis and longitudinal) by the myenteric/ auerbach plexus.
Submucosal / Meissners plexus (Secretions and dilation of blood vessels)
Myenteric / Auerbach’s plexus (muscle relaxation)
Hirschsprung’s disease is associated with an increased risk of developing which infection?
Clostridium difficile
List the complications of C.difficile Infection
Toxic Megacolon Perforation Peritonitis Sepsis Acute Renal Failure Hypokalaemia Hypoalbuminaemia
List two inflammatory areas associated with C.difficile infection
Iritis (inflammation of the Iris)
Arthritis
Name two classical features of a hernia on examination? And a situation where they cannot be exhibited.
Cough reflex (owing to an increase in intra-abdominal pressure) Can be reduced (i.e pushed back)
If bowel or mesentery gets caught in the hernial orifice (where they have herniated through the abdominal wall for example) then neither the cough reflex or reducibility are elicitable.
This is called an incarcerated/obstructed hernia
Name the contents of the spermatic cord that pass through the processus vaginalis and inguinal canal?
Remember rule of 3’s:
3 Arteries - Testicular / Cremasteric / Vas deferens
3 Nerves - Genitofemoral / Sympathetics / Ilioinguinal (not actually part of the cord but pass through the canal)
3 Other structures - Vas deferens / Veins (pampniform plexus) / Lymphatics
What are the components of Hesselbach’s triangle?
Medial – lateral border of the rectus abdominis muscle.
Lateral – inferior epigastric vessels.
Inferior – inguinal ligament.
Name the classes of medications used to treat Over Active Bladder syndrome (OAB) and examples of each?
Anticholinergics, more specifically antimuscurinics
- Oxybutynin / tolterodine / Solifenacin or darifenacin
Can cause dry mouth/constipation and unfit for eldery as memory loss and increased likelihood of fall.
Beta 3 adrenergic agonist - acts directly on bladder smooth muscle causing it to relax.
Ex. Mirabegron
What are the treatment options for hyperthyroidism?
1st line: Carbimazole
(Titration-block / block and replace)
2nd line: Propylthiouracil (small risk of severe hepatic reaction and death) also preferred option for thyroid storm.
Radioactive iodine also an option (avoid pregnancy for 3 months - avoid children and pregnant women for 3 weeks).
Surgery
Both the latter options require lifelong levothyroxine replacement.
What are the LUTS Storage and Voiding Symptoms?
Remember Mnemonic **FUN WISE Harry*.
Storage:
Frequency
Urgency
Nocturia
Voiding:
Weak Stream
Intermittent Flow
Straining
Emptying incompletely
Hesitancy
