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Clinical Practice > Surgery > Flashcards

Surgery Flashcards

1
Q

what is the treatment of oesophageal varices?

A

sengstaken tube

somatostatin injection

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2
Q

what are the causes, signs and treatment of oesophageal perforation?

A

may follow endoscopy

acute chest/abdominal pain
air in mediastinum and soft tissues

surgery in malignant cases
intubation in benign cases

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3
Q

what are the features and treatment of stomach/duodenum perforation?

A 
abdominal pain
rigidity
peritonism
shock
air under diaphragm (x-ray)
treatment - abx, resuscitate, repair
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4
Q

what are the causes and treatment of stomach/duodenum bleeding?

A

causes - duodenal or gastric ulcer, erosions

treatment - transfusion, inject DU

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5
Q

what are the features and complications of acute pancreatitis?

A

constant pain
vomiting
shock

complications; pseudocyst, phlegmon, abscess

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6
Q

describe meckel’s diverticulum

A

rare
diverticulum of terminal ileum
can be lined by gastric epithelium
can perforate and present like appendicitis

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7
Q

what are the causes, symptoms and treatment of intestinal obstruction?

A

causes; adhesions, hernia, tumour
presentation; colicky abdominal pain, vomiting, constipation
treatment; resuscitate, operate

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8
Q

describe a mesenteric infarct

A

sudden occlusion of small bowel arterial supply
sudden onset of abdominal pain
shock
peritonitis

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9
Q

describe acute diverticulitis

A

maximal in L colon
presentation; LIF pain, fever, tenderness, leukocytosis
treatment; antibiotics, fluids, rest

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10
Q

what are the causes of appendicitis?

A 
obstruction of the appendix
faecolith/mucous
foreign body
tumour
secondary bacterial infection
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11
Q

what are the symptoms and signs of appendicitis?

A 
crampy colicky abdominal pain that begins in the centre of the abdomen
becomes sharper and migrates to the RIF
maximal tenderness of McBurney's point
Rovsing's, psoas and obturator's sign
abdominal mass
nausea
vomiting
pyrexia
anorexia
diarrhoea
urinary symptoms
recent LRTI
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12
Q

what is the differential diagnosis of appendicitis?

A 
mesenteric adenitis
intussusception
meckels diverticulum
Crohn's disease
gastroenteritis
UTI/pyelonephritis/stone
diverticulitis
colorectal cancer
ectopic pregnancy
ovarian cyst
PID
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13
Q

what are the components of the Alvarado score?

A 
migratory RIF pain (1)
anorexia (1)
nausea and vomiting (1)
RIF tenderness (2)
rebound tenderness (1)
fever (1)
leucocytosis (2)
segmented neutrophils (1)
<5 indicates no appendicitis and >7 indicates appendicitis
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14
Q

what investigations are performed to diagnose appendicitis?

A 
predominately clinical diagnosis
WCC
urine
pregnancy test
plain abdo film
US appendix
US abdo/pelvis/renal tracts
CT
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15
Q

what is the treatment of appendicitis?

A

initially observation, analgesia, rest, IV fluids
reassessment
consent for theatre
open/laparoscopic appendectomy

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16
Q

what are the complications of appendicitis/appendectomy?

A 
post-op ileus
infection of wound, abscess (failure of appendix stump ligation)
urinary retention
pneumonia
DVT
PE
long term - hernia, adhesions
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17
Q

what are the 5 R’s of fluid balance?

A 
re(assessment)
fluid resuscitation (if in shock)
routine maintenance
replacement
redistribution
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18
Q

how is extracellular fluid divided?

A

1/5 intravascular

4/5 interstitial

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19
Q

why are fluids given?

A

resuscitate by replacing lost volume
routine maintenance of daily requirements
replacement of deficits and ongoing losses
replace Hb
replace blood component
diluent for drugs
physical effect

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20
Q

what are the daily prescriptions of water, Na and K?

A

water - 25-30 ml/kg/day
Na - 1 mmol/kg/day
K - 1 mmol/kg/day

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21
Q

what are the indicators for fluid resuscitation?

A 
SBP <100mmHg
CRT >2s
HR >90bpm
peripheries cold to touch
RR >20
NEWS >5
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22
Q

what are the principles of fluid resuscitation?

A

identify cause of deficit
give a 500ml/15mins crystalloid fluid bolus (containing 130-154 mmol Na) rapid infusion
continue 250-500ml boluses until >2000ml
monitor immediate response
if the patient is no longer in shock reassess

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23
Q

what are the principles of fluid maintenance?

A

assess fluid and electrolyte needs - history, exam, monitoring, investigations
meet requirements orally/enterally if possible
normal maintenance IV requirements -
25-30 ml/kg/day water
1 mmol/kg/day Na, K, Cl
50-100 mmol/kg/day glucose
reassess and monitor

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24
Q

what are the routine fluid maintenance principles for children?

A

strictly by weight
100 ml/kg/day for first 10kg
50 ml/kg/day for second 10kg
20 ml/kg/day for the rest

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25
Q

what are the daily requirements of Na?

A

1-2 mmol/kg/day
up to a maximum of 150 mmol/day
1L normal saline

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26
Q

what are the daily requirements of K?

A

1 mmol/kg/day
usually about 60-70 mmol/day
maximum infusion rate 10 mmol/hr

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27
Q

what is a fluid script for a normal person with no outlying fluid requirements?

A

1L normal saline (contains 150 mmol Na) with 20 mmol KCl at 84 ml/hr
1L 5% dextrose with 40 mmol KCl at 84 ml/hr

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28
Q

what is a fluid script for a normal person receiving 600ml oral intake and 400 paracetamol IV?

A

500ml normal saline with 20 mmol KCl at 42 ml/hr

500ml 5% dextrose with 40 mmol KCl at 42 ml/hr

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29
Q

how should you reassess to estimate fluid deficit?

A 
symptoms and signs
fluid balance chart
urinary output
biochemistry
postural hypotension
urine - osmolarity >300, Na <10
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30
Q

describe a very severe fluid deficit (>6L)

A 
sunken eyes
anuria
leathery tongue
hypotension
HR >120
grossly disturbed electrolytes
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31
Q

describe a mildly severe fluid deficit (4-6L)

A 
dry mucous membranes
HR >100
low BP
severe oliguria
raised urea and creatinine
veins guttered
peripheries cool
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32
Q

how should excess fluid losses be replaced?

A

calculate estimated volume loss and replace with same volume of appropriate fluid
always within the next 24hrs
normal saline with K as required
Hartmann’s solution if K normal

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33
Q

what products should be used for fluid resuscitation?

A

normal saline
colloids (albumin, mannitol, dextran)
blood products

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34
Q

what products should be used for routine fluid maintenance?

A

normal saline
5% dextrose
hartmann’s
about 30 ml/kg/day

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35
Q

what products should be used for replacement of fluid deficits?

A

normal saline
5% dextrose
hartmann’s
over 24 hours

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36
Q

what products should be used to replace ongoing excessive losses?

A

normal saline; with K as required
hartmann’s; if K normal
over 24 hours

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37
Q

what are the causes of high serum osmolarity?

A

hyperglycaemia
hypertonic infusions (glycerol, glycine, mannitol)
hyperlipidaemia
hyperproteinaemia

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38
Q

what drugs cause hyponatraemia?

A

diuretics
SSRI
SNRI

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39
Q

what are the causes of hypovolaemic hyponatraemia?

A 
vomiting
diarrhoea
fluid shifts (burns, pancreatitis)
diuretics
salt wasting
nephropathy (analgesics, polycystic disease, pyelonephritis)
adrenal insufficiency
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40
Q

what are the causes of isovolaemic hyponatraemia?

A 
H2O intoxication (urine osmolarity <100 mOsm/kg)
SIADH (urinary osmolarity >100 mOsm/kg)
renal failure
adrenal insufficiency
hypothyroidism
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41
Q

what are the causes of hypervolaemic hyponatraemia?

A

cirrhosis
congestive heart failure
nephrotic syndrome

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42
Q

what is the treatment of hypovolaemic hyponatraemia?

A

restore volume - 1L normal saline / 2-4hrs

repeat Na in 1hr and continue if Na rising

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43
Q

what is the treatment of isovolaemic hyponatraemia?

A

symptomatic - hypertonic saline, furosemide diuresis

asymptomatic - water restriction

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44
Q

what is the treatment of hypervolaemic hyponatraemia?

A

treat underlying disorder

water restriction

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45
Q

what are the causes of hyperkalaemia?

A

AKI/CKD
drugs inhibiting RAAS (ACEi, ARBs, NSAIDs, heparin)
drugs inhibiting K excretion (amiloride, spironolactone, eplerenone, trimethoprim)
hyperkalaemic ATN (type IV)
acidosis (lactic)
digoxin poisoning
suxamethonium
exogenous K (K supplements in drugs)
endogenous (burns, rhabdomyolysis, trauma)

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46
Q

what are the causes and features of hypokalaemia?

A

under-prescription
excessive loss

can cause arrhythmias

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47
Q

define a hernia

A

a part of an organ protruding through an opening in the cavity in which it is usually contained

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48
Q

define an inguinal hernia

A

protrusion of the contents of the abdominal cavity or pre-peritoneal fat through a defect in the inguinal area

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49
Q

what are the muscles of the abdominal wall?

A

internal and external oblique

transversus and rectus abdominus

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50
Q

what are the contents of the spermatic cord (inguinal canal)?

A 
vas
testicular artery
pampiniform plexus
arteries to cremaster and vas
genital branch of genitofemoral nerve
lymphatics
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51
Q

describe the deep ring of the inguinal canal

A

40% of the way from the pubic tubercle to the ASIS

medial to the femoral pulse

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52
Q

describe the anatomical relations of the inguinal canal

A 
oblique passage
anterior wall; external oblique
posterior wall; strong conjoint tendon
flattened/closed by muscle contraction
protected by thighs when hips flexed
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53
Q

what are the risk factors for developing an inguinal hernia?

A 
patent processus vaginalis
AAA
collagen disorder
smoking
COPD
ascites
long-term heavy work
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54
Q

how do you examine a groin swelling?

A 
examine supine
inspect
ask the patient to cough
palpate for a swelling if not obvious
attempt to reduce it gently
identify anatomy
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55
Q

what are the features of a hernia?

A

arises in the inguinal/groin region
increases on coughing
can be partially/fully reduced

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56
Q

what is the difference between an inguinal or pubic hernia?

A

inguinal - above the pubic tubercle

pubic - below or lateral to the pubic tubercle

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57
Q

what is the differential diagnosis of a hernia?

A 
lower abdominal mass
scrotal swelling
lymph nodes
femoral aneurysm
saphena varix
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58
Q

what are the complications of hernia surgery?

A 
pain
haematoma
recurrence
infection; wound, chest
urinary retention
thickened cord
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59
Q

what patients have difficulty ventilating a face mask?

A 
obese
beards
elderly >55
snorers
edentulous
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60
Q

what action should be taken for peri-operative medications?

A

NSAIDs - stop 48hrs pre-op
warfarin - stop 5 day pre-op, commence on enoxaparin
aspirin - stop 5 days pre-op
clopidogrel - stop 7 days pre-op
stop herbal medications, diuretics (unless severe HF), ACEi, ARBs (depends on hypotension risk), insulin, oral hypoglycaemics, vitamins, iron

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61
Q

what are the causes of gallstone formation?

A

lithogenic bile
stasis
nidus

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62
Q

what is the composition of gallstones?

A

mixed (cholesterol and calcium salts of bile pigment)
pure cholesterol
pure pigment

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63
Q

describe biliary colic

A

caused by stones temporarily obstructing drainage of the gallbladder
colicky abdominal pain, <24hrs
caused by fatty meals, mucocoele

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64
Q

what are the causes, features and consequences of cholecystitis?

A

physical/chemical irritation
bacterial infection
SIRS
sepsis

RUQ tenderness
local peritonitism

empyema
perforation

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65
Q

describe choledocholithiasis

A

stones in the common bile duct
usually arise in gallbladder
impaction leads to jaundice
can be asymptomatic or lead to ascending cholangitis

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66
Q

describe gallstone pancreatitis and its other causes

A

passing of calculus through the pancreatic head
causes; gallstones, alcohol, trauma, steroids, mumps, autoimmune, scorpion sting, hypercalcaemia, hypertriglyceridaemia, ERCP, drugs

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67
Q

describe gallstone ileus

A

distal small bowel obstruction

gas in biliary tree

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68
Q

what investigations should be performed to diagnosis gallstones?

A 
examination;
tenderness
Murphy's positivity
SIRS
jaundice

USS
MRC

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69
Q

what is the treatment of gallbladder calculi?

A 
ursodeoxycholic acid
multiple small cholesterol calculi
recurrence when stopping treatment
side effects
open, laparoscopic, percutaneous cholecystectomy
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70
Q

what are the complications of a cholecystectomy?

A

bile duct, blood vessels, bowel injury
bleeding
chest, wound infection

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71
Q

what is the treatment of bile duct calculi?

A

ERCP

laparoscopic/open exploration of common bile duct

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72
Q

define shock

A

acute alteration in circulation in which there is inadequate tissue perfusion leading to cellular hypoxia, dysfunction and failure of major organ systems

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73
Q

what are the causes of hypo-perfusion?

A 
inadequate preload
inadequate myocardial contractility
excessive afterload
hypovolaemia
excessive vasodilatation
excessive systemic vascular resistance
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74
Q

what are the causes of cardiogenic shock?

A

MI
myocardial contusion
cardiac failure
arrhythmia

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75
Q

what are the causes of hypovolaemic shock?

A 
vomiting
diarrhoea
burns
pancreatitis
haemorrhage
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76
Q

what are the causes of distributive shock?

A

septic
neurogenic
anaphylactic

loss of regulation of vascular tone
disordered vascular permeability; shifting of intravascular volume to the interstitium

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77
Q

what are the causes of obstructive shock?

A

PE
cardiac tamponade
pneumothorax

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78
Q

what is the pathophysiological response to shock?

A

increased catecholamine release
activation of RAAS
increased glucocorticoid and mineralocorticoid release
activation of sympathetic nervous system

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79
Q

describe the systemic response to shock

A 
vasoconstriction
increased blood flow to major organs
increased CO
increased RR and volume
decreased urine output
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80
Q

what are the symptoms of shock?

A 
anxiety
dizziness
weakness
nausea and vomiting
thirst
confusion
chest pain
fever
rigors
breathlessness
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81
Q

what are the features of compensated shock?

A 
tachycardia
tachypnoea
cold peripheries
oliguria
altered mental status
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82
Q

what are the features of uncompensated shock?

A 
hypotension
rapid thready pulse
peripheral cyanosis
agitation
confusion
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83
Q

what features are specific to cardiogenic and obstructive shock?

A

elevated JVP

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84
Q

what features are specific to distributive shock?

A

septic shock - pyrexia, warm peripheries

neurogenic shock - warm and dry peripheries

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85
Q

what is the specific treatment of cardiogenic shock?

A 
remove the cause of the cardiac shock;
PCI
valve replacement
pacemaker
interventional ablation
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86
Q

what is the specific treatment of distributive shock?

A

antibiotics

vasopressors

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87
Q

what is the specific treatment of obstructive shock?

A

pericardiocentesis

chest drain

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88
Q

what is the specific treatment of hypovolaemic shock?

A

airway
ventilation
IV; crystalloid fluids then blood products
locate bleeding; CT in blunt trauma, ruptured AAA, endoscopy in GI haemorrhage
ICU; ventilation, isotrope administration, invasive BP monitoring

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89
Q

what are the risk factors for colorectal carcinoma?

A 
FAP (APC gene-5q)
HNPCC (MMR gene)
diet
lifestyle
bile acids
ulcerative colitis
crohn's
PSC
gastric surgery
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90
Q

what are the signs and symptoms of a colorectal carcinoma?

A

RC - anaemia, weight loss, RIF mass
rectal - change BO, rectal bleeding, tenesmus, mucous, PR mass
L splenic flexure - change BO, crampy pain, obstruction
sigmoid - change BO, rectal bleeding, obstruction, crampy pain

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91
Q

what are the red flag criteria for colorectal carcinoma?

A

> 60yrs, rectal bleeding or change in habit >6 weeks
40-60yrs, rectal bleeding and change in habit >6 weeks
palpable abdominal mass
palpable rectal mass
anaemia

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92
Q

what investigations are required to diagnose colorectal carcinoma?

A 
FOB test (positive -> colonoscopy)
endoscopy
histopathology
CT cologram
barium enema
CT abdo, pelvis, chest (20% mets at presentation)
MRI pelvis (rectal cancer)
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93
Q

what is the treatment of colorectal carcinoma?

A 
colectomy
resection
APER
liver/lung resection
adjuvant or palliative chemotherapy
short or long course radiotherapy
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94
Q

define an aneurysm

A

abnormal dilatation of a blood vessel >50% of the expected diameter
aorta >3cm
weakness of the arterial wall - dilation of wall, thrombus in sac, perivascular inflammation

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95
Q

what are the causes of aneurysms?

A

genetic and environmental factors
inflammatory cell infiltrate
extracellular matrix degradation by MMPs
elastolysis

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96
Q

what are the risk factors for developing an aneursym?

A 
male
collagen vascular diseases (Marfan's)
age
smoking
HTN
cardiovascular disease; athersclerosis
FHx
other large artery aneurysms; iliac, femoral, popliteal
caucasian
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97
Q

what are the symptoms and signs of an aortic aneurysm?

A 
epigastric mass
pulsatile and expansible
tenderness
abdominal pain
radiates to back/groin
intermittent claudication
chronic/acute limb ischaemia
retroperitoneal fibrosis
malaise
weight loss; inflammatory
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98
Q

what are the symptoms and signs of aortic aneurysm rupture?

A 
abdominal pain
radiates to back/groin
collapse/LOC
abdominal pulsatile mass
lumbar haematoma
acute limb ischaemia
shock
bruits
peripheral pulses
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99
Q

what investigations are required for diagnosis of an aortic aneurysm?

A

abdominal exam
US
CT angiogram

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100
Q

what is the treatment of an aortic aneursym?

A

surveillance
endovascular repair (EVAR); minimally invasive
conventional open repair; gold standard
laparoscopic repair

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101
Q

what are the complications of EVAR?

A 
contrast nephropathy
branch vessel occlusion
limb occlusion
endoleak
late rupture
endotension
endograft migration, fracture, infection or occlusion
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102
Q

what are the complications of AAA surgery?

A

hostile abdomen
blood loss/clamp time
branch vessel ischaemia

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103
Q

what are the effects of poor pain management?

A

increased sympathetic activity (HR, BP, myocardial O2 demand, risk of ischaemia)
poor respiratory function (poor cough, atelectasis, infection, hypoxia)
anxiety
insomnia
immobility (increased DVT risk)
risk of developing chronic pain

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104
Q

describe pain transmission

A

initial trauma
release of pain mediators (PG, bradykinins)
neuronal transmission central through spinal cord
cortical level processing

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105
Q

describe the methods of analgesia

A

peripherally:
NSAIDs - reduce inflammatory mediator production
local anaesthetics - topical, infiltration, nerve block
spinal cord level:
opioids, local anaesthetics - modify/block nociceptive input
cortical level:
opioids, NSAIDs, other analgesics - block pain perception

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106
Q

describe paracetamol

A

analgesic and anti-pyretic

inhibits PG synthesis, acts via serotonin pathways to produce analgesia

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107
Q

describe NSAIDs

A

analgesic, anti-pyretic and anti-inflammatory
inhibit COX to stop production of PG
reduce opioid requirements in severe pain and opioid-related side effects

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108
Q

what conditions require caution with NSAIDs?

A

bleeding disorders
active PUD
asthma
severe renal impairment (renal blood flow helped by PG)
severe hepatic impairment (hepatocellular toxicity)
elderly (reduced elimination)

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109
Q

describe codeine

A

acts on opioid receptors centrally
50% bioavailability in oral administration
often given in combination with paracetamol
prodrug metabolised in liver to morphine

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110
Q

describe tramadol

A

weak opioid agonist
increases noradrenaline and serotonin activity
used as a step down from PCA
side effects - nausea, vomiting, less respiratory depression

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111
Q

describe potent opioid analgesia

A

includes morphine, diamorphine, oxycodone

bind to opioid receptors in brain and spinal cord

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112
Q

what are the side effects of potent opioid analgesia?

A

sedation
respiratory depression - may lead to respiratory arrest
naloxone must be prescribed and available
nausea and vomiting; anti-emetic should be prescribed
pruritis
reduced bowel motility
urinary retention

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113
Q

describe patient controlled analgesia

A

patient controlled pump
small bolus
lockout time

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114
Q

describe the standard PCA regimen

A

morphine sulphate 250mg in 250ml
bolus dose 1g in 1ml
lockout time 5 minutes
4hrly limit 40mg

alternate - fentanyl/oxycodone

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115
Q

describe the problems with PCA

A 
sedation
respiratory depression
nausea and vomiting
itch
pump failure
tissued cannula
unable to use
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116
Q

what features require and contraindicate epidural analgesia?

A 
major surgery
pre-existing medical problems
frail, elderly
cognitively impaired
unable to manage PCA
patient refusal
abnormal coagulation
infection (local or systemic)
previous back surgery
abnormal anatomy
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117
Q

describe epidural analgesia

A

catheter inserted into epidural space
local anaesthetic with added opioid administered
spinal level - blocks incoming pain receptors
controlled by continuous infusion from a pump
can be boosted by bolus request

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118
Q

what are the benefits of opioid analgesia?

A 
better analgesia
reduced sedation
reduced DVT or PE
bowel motility
less atelectasis
less RTIs
less cardiac mobility
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119
Q

what are the disadvantages to opioid analgesia?

A

hypotension (sympathetic block)
leg weakness (motor nerve block)
haematoma (trauma)
infection (CNS, epidural abscess)

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120
Q

what are the causes of jaundice?

A

pre-hepatic - haematoma, haemolytic anaemia, spherocytosis, sickle cell
hepatic - hepatitis, cirrhosis
post-hepatic - gallstones, head of pancreas tumour

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121
Q

what are the signs of jaundice?

A 
yellow skin
sclera
scratch mark
lymphadenopathy
liver disease evidence
abdominal tenderness
abdominal mass
ascites
hepato/splenomegaly
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122
Q

describe ERCP

A

inject dye into the duct in the biliary tree and pancreas so they can been seen on x-rays
used to diagnose and treat gallstones, inflammatory strictures, leaks (trauma or surgery), cancer

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123
Q

what is the management of surgical jaundice on admission?

A

fluids
assess for sepsis
monitor PT
avoid/stop hepatotoxic drugs

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124
Q

what are the causes of surgical jaundice?

A

gallstones
malignant biliary tree tumours (cholangiocarcinoma)
head of pancreas tumours
benign biliary tree lesions (strictures)

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125
Q

what are the causes of post-surgical bleeding?

A

coagulation defects
surgical technique
local factors

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126
Q

what are the direct causes of coagulation-related post-surgical bleeding?

A 
anticoagulation (warfarin)
anti platelet (clopidogrel, aspirin)
thrombocytopenia
severe blood loss/transfusion
obstructive jaundice
long-term steroid therapy
severe sepsis with DIC
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127
Q

what is the management of post-surgical bleeding?

A

check coag and Hb
discontinue anti-thrombotic therapy
reverse coagulation defects (vitamin K, protamine sulphate, FFP, platelets)
identify and control bleeding

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128
Q

what is the prevention of post-surgical bleeding?

A 
be aware of potential coagulation defects
discontinue anti-thrombotic therapy
vitamin K is jaundiced
good surgical technique
control infection
leave drains in at-risk wounds
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129
Q

what are the complications of a PE?

A 
pleuritic chest pain
cough
dyspnoea
haemoptysis
pleural rub
raised JVP
low O2 saturations
sinus tachycardia
S1Q3T3
check blood gas
confirm with CTPA
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130
Q

what are the risk factors for developing respiratory post-surgical complications?

A 
old age
smoking
obesity
immobility
sedation
pre-existing lung disease
myocardial disease
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131
Q

what are the types of respiratory post-surgical complications?

A 
atelectasis
chest infection
PE
aspiration
pleural effusion
ARDS
pneumothorax
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132
Q

what are the risk factors for infectious post-surgical complications?

A 
hypoxia
diabetes
immunosuppression
malnutrition
jaundice
corticosteroid therapy
obesity
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133
Q

what are the signs of wound infection?

A

wound discharge
erythema
cellulitis

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134
Q

what are the signs of intra-abdominal infection/abscess?

A

abdominal distension
prolonged ileus
increasing pain

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135
Q

what are the signs of a post-surgical wound breakdown?

A

7-10 days post-op
serous discharge
superficial dehiscence
abdominal contents protruding through wound

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136
Q

what are the causes of post-surgical oliguria?

A

blocked catheter
stress response to surgery
renal hypoperfusion
inadequate fluid intake

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137
Q

define IBD

A

an abnormal immune response to gut organisms

ulcerative colitis and Crohn’s disease

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138
Q

describe ulcerative colitis

A

affected the mucosa and superficial mucosa of the large bowel only
starts in rectum (always involved), extending upwards for a variable distance
terminal ileum involvement; back wash ileitis

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139
Q

describe Crohn’s disease

A

may affect any part of the GI tract
20% - distal small bowel
25% - large bowel
45% - both

patchy, discontinuous
wall thickening
discrete, deep ulcers, often linear
cobblestone mucosa
fistulae and anal disease common
granulatoma and fissure ulcers
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140
Q

what are the acute and chronic complications of colitis?

A

acute toxic colitis
toxic dilatation/perforation
bleeding
malignancy

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141
Q

what are the clinical features of ileitis (CD)?

A

abdominal pain (cramps, worse after eating)
weight loss
diarrhoea
mass in RIF

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142
Q

what are the clinical features of anal/perianal disease (CD)?

A

skin tags
fissures
fistula
abscess

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143
Q

what are the extraintestinal manifestations of IBD?

A 
arthropathy
sacroiliitis
ankylosing spondylitis
episcleritis/uveitis
erythema nodosum
pyoderma gangrenosum
aphthous oral ulceration
sclerosis cholangitis
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144
Q

what is the management of IBD?

A 
diet
fe/B12/folate
vitamins
anti-diarrhoeals
osteoporosis prophylaxis
antibiotics
aminosalicylates (sulfasalazine, olsalazine, mesalazine, balsalazide)
oral/rectum administration
corticosteroids (systemic; IV/oral, topical; enema/suppositories)
immunomodulators (ciclosporin to induce remission, azathioprine and mercatopurine to maintain remission)
anti-TNF alpha antibodies (infliximab, adalimumab)
resection
strictureplasty
abdominal colectomy
segmental resection
ileorectal anastomosis
proctocolectomy and ileostomy
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145
Q

what are the causes of upper GI bleeding?

A 
peptic ulcer
oesophagitis
gastritis/erosions
erosive duodenitis
varices
portal hypertensive gastropathy
malignancy
mallory-weiss tear
vascular malformation
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146
Q

describe the pathology and treatment of duodenal ulcer

A

strong association with helicobacter pylori
triple therapy reduces the risk of recurrent ulcers and bleeding; clarithromycin, metronidazole, PPI
NSAIDs - inhibit the action of cyclooxygenase, impaired mucosal defence against acid

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147
Q

describe oesophageal varices

A

chronic liver disease

portal hypertension leads to portal-systemic shunting

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148
Q

describe the management of haematemesis and melaena

A

treat hypovolaemia and shock (ABC)
estimate the amount of blood loss
treat the underlying cause

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149
Q

what are the components of the Rockall score?

A 
age
shock
comorbidity
diagnosis
major stigmata of recent haemorrhage
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150
Q

what is the initial treatment of GI bleeding?

A 
ABC
IV fluids
urinary catheter and hourly urometer
transfuse as necessary
correct coagulopathy
PPI (maintain pH > 6, protects ulcer clot from fibrinolysis)
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151
Q

describe endoscopic strategies

A

injection - adrenaline or sclerosant
thermal - coagulation using heater probe
mechanical - endoscopic clips

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152
Q

what is the treatment of rebleeding?

A

repeat endoscopy
radiology
surgery (laparotomy and haemorrhage control); underrunning vessel, gastrectomy

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153
Q

what is the management of variceal bleeding?

A

endoscopy; variceal band ligation, injection scleropathy
pharmacology; vasoactive drugs (reduction in portal blood flow), antibiotics
balloon tamponade; sengstaken, temporary salvage

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154
Q

what re the types of varicose veins and varicose disorders?

A 
primary trunk varicose veins
secondary trunk varicose veins
reticular veins
spider veins/venous flares
venous malformations
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155
Q

what is the pathophysiology of primary valve failure?

A

primary degenerative changes in the valve leaflets

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156
Q

what is the pathophysiology of secondary valve failure?

A

developmental weakness in vein wall and secondary vein widening and valve incompetence

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157
Q

what are the complications of varicose veins?

A 
superficial thrombophlebitis
lipodermatosclerosis and pigmentation
varicose eczema
ulceration
haemorrhage
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158
Q

describe the examination of varicose veins

A 
standing and adequately exposed
inspection:
distribution of varicose veins (GSV/SSV)
chronic venous insufficiency
scars
trendelenberg's test
perthes test
hand held doppler
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159
Q

what is the treatment of varicose veins?

A 
reassurance
compression hoisery
foam scleropathy
endovenous ablation
conventional surgery
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160
Q

describe foam scleropathy

A

sodium tetra decyl sulphate mixed with air in ratio 1:4
causes phlebitis and vein occlusion
injection of foam into truncal vein or varicose vein

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161
Q

describe endovenous ablation

A

radio frequency ablation
endovenous laser ablation
both damage the vein wall causing subsequent thrombosis

pass guide wire/catheter
position catheter
tumescent anaesthesia
catheter withdrawn

analgesia - NSAIDs

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162
Q

describe conventional varicose vein surgery

A

gold standard

saphenofemoral ligation and stripping GSV
saphenopopliteal ligation
phlebectomies

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163
Q

what are the complications of conventional varicose vein surgery

A 
bruising
bleeding
wound infection
nerve injury
DVT
164
Q

which groups are at risk of requiring a transfusion?

A

nutritional deficiencies
malabsorption syndromes
inflammatory bowel conditions
chronic low grade bleeding conditions (haemorrhoids, haematuria, menorrhagia, bowel cancer)

165
Q

what is the treatment of anaemia?

A

oral iron
if intolerant - IV iron
cause unknown - refer to specialist

166
Q

what are the causes of a decreased red cell count?

A

decreased red cell production - marrow failure
increased red cell destruction - haemolytic problems
increased red cell loss - bleeding

167
Q

when should a patient who is <65, stable and no cerebro/cardiovascular problems be transfused?

A

<7 g/dL

168
Q

when should a patient who is >65, stable and no cerebro/cardiovascular problems be transfused?

A

<8 g/dL

169
Q

when should a patient who has cerebro/cardiovascular problems be transfused?

A

<9 g/dL

170
Q

in what circumstances should transfusion <10 g/dL be considered?

A

appropriately symptomatic (dyspnoea, angina, tachycardia, orthostatic hypotension, syncope)
or
bone marrow failure/receiving chemo/radiotherapy
or
obvious evidence of ongoing significant bleeding (>500ml/hr)

171
Q

define overtransfusion

A

transfusing to a Hb level >2g/dL above the transfusion threshold for that patient

172
Q

what are the complications of blood transfusion?

A

febrile reaction
delayed haemolytic reaction
wrong blood incident
infection; HIV, hepatitis B

173
Q

how should a patient receiving a blood transfusion be monitored?

A

baseline HR, BP, temperature before transfusion
check 15 minutes into transfusion
check at the end of transfusion
clinical observations during transfusion

174
Q

what are the symptoms and signs of a transfusion reaction?

A 
fever
urticaria
rash
pruritus
pyrexia
rigors
hypotension
loin/back pain
increasing anxiety
pain at infusion site
dark urine
respiratory distress
severe tachycardia
unexpected bleeding (DIC)
175
Q

what is the management of a mild acute transfusion reaction?

A

stop transfusion
appropriate treatment (antipyretic/antihistamines)
reassess patient
if signs and symptoms worsen in 15 minutes, treat as severe reaction

176
Q

what is the management of a severe transfusion reaction?

A

stop transfusion
IV maintained with normal saline infusion
resuscitation/drugs trolley may be required
monitor and reassess frequently
inform the lab and return the component
document in patient case notes
report event to monitoring body

177
Q

what are the principles of ANTT?

A

always wash hands effectively
non-touch technique
take appropriate equipment precautions
take steps to protect key parts at all times

178
Q

what is the treatment of a mild diabetic foot ulcer?

A

flucloxacillin 1g 6hrly PO

MRSA - doxycycline 100mg BD PO

179
Q

what is the treatment of a severe diabetic foot ulcer?

A

co-amoxiclav 625mg 8hrly
MRSA - add vancomycin 1g BD IV or teicoplanin 10mg/kg IV 12hrly (3 doses) then maintenance dose 10mg/kg daily (serum levels)

180
Q

what is the treatment of a diabetic foot ulcer in osteomyelitis?

A

flucloxacillin 2g 6hrly + fusidic acid 500mg 8hrly PO

MRSA - teicoplanin or vancomycin + fusidic acid

181
Q

what are the exceptions to single dose prophylactic antibiotics?

A

duration of surgery >4hrs
blood loss >1.5L
emergency surgery for dirty/contaminated wounds
infection already present

182
Q

describe general surgery prophylaxis

A

co-amoxiclav 1.2g IV
or
gentamicin 2mg/kg IV plus metronidazole 500mg
MRSA - above + teicoplanin 400mg IV

183
Q

what are the consequences of overnutrition?

A 
hypertension
T2DM
hyperlipidaemia
coronary artery disease
osteoarthritis
obstructive sleep apnoea
gallbladder disease
cancer
184
Q

what are the causes of undernutrition?

A 
reduced food intake (anorexia, fasting, pain on swallowing, handicap)
malabsorption (impaired digestion, impaired absorption, excess losses from the gut)
modified metabolism (trauma, burns, sepsis, surgery)
185
Q

what are the consequences of undernutrition?

A

organ function - reduced strength, motility, impaired respiration, apathy, impaired immunity
increased peri-operative morbidity and mortality

186
Q

describe types of enteral nutrition

A 
sip feeds
tube feeds (NGT, PEG, PEG-jej, gastrostomy, jejunostomy, button)
187
Q

what are the indications for parenteral nutrition?

A 
malnourished
or 
likely to become malnourished
and
GI tract not functional or not accessible
188
Q

what are the components that decide the amount of calories require in parenteral nutrition?

A

BMI
stress factor
activity
energy stores

189
Q

what is the amount of different substances required in parenteral feeding?

A 
fluids - 30 ml/kg/day
calories - 30 cal/kg/day
fat - 30% total
protein - 1 g/day
Na - 1 mmol/kg/day
K - 1 mmol/kg/day
Cl - 1 mmol/kg/day
190
Q

describe the embryology of the thyroid gland

A

endodermal invagination of tongue at foramen caecum at week 4 of gestation
descends anterior to hyoid and larynx
thyroglossal duct degenerates
secreting thyroid hormone by 12th week
contribution from 5th pharyngeal pouch (ultimobranchial body - C cells)

191
Q

what questions are required from a history of a thyroid nodule?

A 
age (50% >14yrs malignant)
sex (men)
growth rate
pain
voice changes
pressure symptoms
hypo/hyperthyroidism
previous irradiation (20-50% malignant)
FHx
192
Q

describe MEN 2A

A

medullary thyroid carcinoma
hyperparathyroidism
phaeochromocytoma

193
Q

describe MEN 2B

A

medullary thyroid carcinoma
hyperparathyroidism
neuroma (lips and tongue)

194
Q

what are the symptoms and signs of hypothyroidism?

A 
tiredness
moodiness
slower thinking
depression
inability to concentration
thinning hair/hair loss
dry, patchy skin
weight gain
cold intolerance
elevated cholesterol
puffy eyes
goitre
hoarseness
persistent dry/sore throat
throat deepening
difficulty swallowing
irregular/heavy periods
bradycardia
infertility
constipation
muscle weakness/cramps
195
Q

what are the signs and symptoms of hyperthyroidism?

A 
nervousness/tremor
irritability
difficulty sleeping
eye bulging
irregular/light periods
frequent bowel movements
first-trimester miscarriage
persistent vomiting in pregnancy
hoarseness/deepening of voice
persistent dry/sore throat
difficulty swallowing
tachycardia
palpitation
impaired fertility
weight loss/gain
heat intolerance
increased sweating
sudden paralysis
FHx of thyroid disease or diabetes
196
Q

what is looked for in an examination of the thyroid?

A 
size
solitary/dominant nodule in MNG
consistency
lymphadenopathy
signs of hypo/hyperthyroidism
antibodies to thyroglobulin and TPO
TSH receptor autoantibodies
thyroglobulin/calcitonin and CEA
US
FNA
197
Q

what is the differential diagnosis of a thyroid nodule?

A

benign; colloid nodule, simple cyst, focal thyroiditis, follicular adenoma, Hurthle cell adenoma
malignant; papillary, follicular, anaplastic, medullary carcinoma, lymphoma, Hurthle cell carcinoma

198
Q

what is the treatment of a thyroid nodule?

A

surgery; hemithyroidectomy (including isthmus and pyramidal lobe), total thyroidectomy

199
Q

what are the complications of thyroid surgery?

A 
haematoma
nerve damage;
external SLN (voice changes, loss of high-pitch phonation)
RLN (unilateral) - hoarse, weak voice
RLN (bilateral) - loss of phonation, stridor, tracheostomy
hypocalcaemia
scar
infection
recurrent hypercalcaemia
200
Q

what are the indications for a hemithyroidectomy?

A

recurrent cysts
follicular lesions
colloid nodule
<1cm papillary carcinoma

201
Q

what are the indications for a total thyroidectomy?

A

papillary carcinoma (with nodes)
follicular carcinoma
medullary carcinoma (with nodes)
multi nodular goitre with compressive symptoms

202
Q

what factors indicate the prognosis of a thyroidectomy?

A 
metastases
age
completeness of resection
invasion
size
203
Q

what is the treatment/follow-up post-thyroidectomy?

A 
T3 20mcgs TID
radioactive I at 6 weeks
thyroxine replacement
clinical examination
TFTs
serial thyroglobulin (calcitonin/CEA)
204
Q

what are the indications for sub/total thyroidectomy for goitre?

A

cosmesis
compression
MNG
grave’s (diffuse toxic goitre); relapse on antithyroid drugs, large goitre, difficult control, high T4 conc, eye signs

205
Q

describe atherosclerosis

A

damages arterial wall by; endothelial injury, lipid deposition, inflammatory cell infiltrate, smooth muscle cell infiltration
disrupts blood flow by; stenosis, complete occlusion, plaque rupture, embolisation

206
Q

what are the consequences of atherosclerosis?

A 
ischaemic stroke
TIA
myocardial infarct
angina (stable and unstable)
peripheral arterial disease
renovascular disease
207
Q

what are the consequences of peripheral arterial disease?

A

indicator of overall cardiovascular risk

5 year mortality - 30% die from MI/stroke, 50% critical limb ischaemia

208
Q

what are the risk factors for developing peripheral arterial disease?

A 
age
gender
smoking
HTN
hyperlipidaemia
diabetes mellitus
209
Q

describe critical limb ischaemia

A

pain at rest >2 weeks
at night (woken up)
not relieved by simple analgesia
relief from hanging foot out of bed (gravity/reduction in metabolic activity)

210
Q

describe acute limb ischaemia

A 
sudden onset
surgical emergency (6hr window)
often embolism, thrombosis and trauma
is the patient in AF?
previous Hx of claudication?
6 P's
211
Q

name the 6 P’s

A 
pain
pallor
parasthesia
paralysis
pulselessness
perishingly cold
212
Q

what are the signs of PVD that would be present on examination?

A 
supra-aortic (rate, rhythm, character, volume)
BP both arms
carotid/renal bruits
cardiac murmurs
AAA
absent/weak pulses
pallor
cool
muscle atrophy
loss of hair growth
brittle crumbly nails
neuropathy
213
Q

what are the symptoms and signs of the “critically ischaemic foot?”

A 
tissue necrosis (dry and wet gangrene; superimposed infection, cellulitis)
absent pulses
venous guttering
positive Buerger's test
pallor increased with elevation
214
Q

describe a popliteal pulse

A

midline between heads of gastrocnemius
press neuromuscular bundle against tibia
thumbs apply counter pressure
prominent - popliteal aneurysm

215
Q

what investigations are required to diagnose PVD?

A

ankle-brachial pressure index (confirms the diagnosis)
duplex ultrasonography (grayscale US measures architecture and colour doppler visualises flow)
MRA (no radiation, ferrous metals (pacemakers)
CTA (radiation, contrast nephrotoxicity, iodine)
digital subtraction angiography (DSA, gold standard, radiation, contrast allergy, nephrotoxicity, more commonly 2nd line)

216
Q

what is the treatment of PVD?

A 
smoking cessation
weight reduction
total cholesterol <4.4 mmol/L
LDL cholesterol <1.8 mmol/L
glycaemic control
BP control exercise therapy
pharmacotherapy
endovascular intervention (angioplasty/stents, better for proximal aorta-iliac disease)
surgery - bypass/endarterectomy (invasive, better long-term results)
217
Q

what is the treatment of critical limb ischaemia?

A 
endovascular intervention (angioplasty, stents)
surgical (bypass, endarterectomy)
amputation
218
Q

define pancreatic necrosis

A

focal or diffuse development of non-viable parenchyma which have become infected

219
Q

what are the causes of pancreatitis?

A 
gallstones
alcohol
idiopathic
trauma (ERCP, blunt abdominal)
drugs (steroids, thiazide diuretics)
metabolic (hyperlipidaemic, hypercalcaemia)
infection (mumps, coxsackie)
hereditary
nutritional (anorexia, bulimia, malnutrition)
hypothermia
scorpion venom
220
Q

what are the symptoms and signs of pancreatitis?

A 
severe epigastric pain and tenderness
nausea
vomiting
shallow breathing
flank bruising (grey-turner's sign)
peri-umbilical bruising (Cullen's sign)
221
Q

what are the components of the Glasgow (imrie) system?

A 
age
WCC
serum glucose
PaO2
albumin
Ca
LDH
AST
222
Q

what is the initial management of pancreatitis?

A 
pain relief
IV fluid resus
anti-emetic
NBM
NG suction if severe vomiting)
mild - treatment/removal of etiological factor
severe - treatment of complications
223
Q

what is the management of gallstone pancreatitis?

A

US
gallstones removed within 2-4 weeks of acute attack
laparoscopic cholecystectomy or ERCP + sphincterotomy
MRCP or intra-op cholangiogram to exclude CBD stones

224
Q

what are the complications of acute pancreatitis?

A 
pseudocyst
necrosis
abscess
exocrine insufficiency (steatorrhoea)
endocrine insufficiency (diabetes)
chronic pancreatitis
225
Q

describe a pancreatic pseudocyst

A

collection of fluid in lesser sac
may be palpable per abdomen
abdominal pain
delayed gastric emptying

226
Q

what is the management of necrotic pancreatitis?

A

initially conservative
ICU support for organ failure
minimally invasive resection of pancreas (MIRP)
open surgical debridement (necrosectomy)

227
Q

describe chronic pancreatitis

A 
fibrosis of pancreas
structuring and dilatation of pancreatic duct
pseudocyst formation
mainly due to chronic alcohol abuse
increased risk of pancreatic cancer
calcification in gland on x-ray or CT
chronic abdominal pain
exocrine insufficiency (steatorrhoea, managed by Creon)
endocrine insufficiency (diabetes)
228
Q

what are the risk factors for developing breast cancer?

A 
increasing age
environment factors > genetic
menstrual onset and end
age at first pregnancy
BMI
alcohol
diet
previous breast disease (CIS, atypical hyperplasia)
exogenous oestrogen (HRT, OCP)
genetics (BRCA-1, BRCA-2)
229
Q

what is the presentation of breast cancer?

A 
lump
nipple discharge or retraction
skin changes - rash, scaling, puckering
pain
mammography screening
FHx
230
Q

what are the characteristics of a suspicious breast lump?

A 
single lesion
hard
immovable
irregular border
skin dimpling
>2cm
231
Q

describe a fine need aspiration of a breast lump

A

simple cyst - clear fluid aspirated and swelling cyst resolves
bloody fluid - send for cytology and consider further assessment

232
Q

how is a breast lump diagnosed?

A

triple diagnosis; exam, imaging and FNA
0.7% cancer if all 3 benign, 99.4% cancer if all 3 malignant

bilateral mammograms
US of breast and axilla
CXR
routine bloods

233
Q

describe the surgical procedures available for breast cancer

A

modified radical mastectomy
simple mastectomy
partial mastectomy

axillary clearance vs sentinel node biopsy

234
Q

how is the sentinel node detected?

A

blue dye injected around the areola and will drain into the lymph nodes (the sentinel node first)

235
Q

what is the post-operative management of breast cancer?

A

chemotherapy (best results in node positive young women)
hormonal therapy (tamoxifen/aromatase inhibitor)
radiotherapy
monoclonal antibody (Herceptin in HER2 positive women)

236
Q

what are the complications of breast surgery?

A 
anaesthesia complications
DVT, PE, LRTI
wound infections
nerve damage (long thoracic)
chronic wound pain
cosmetic
psychological
lymphoedema
237
Q

what are the reconstructive techniques in breast surgery?

A

TRAM flap
latissimus dorsi flap
prosthetic implants

238
Q

what are the types of intestinal obstruction?

A

mechanical; partial/complete, simple/strangulation

function; paralytic ileus, pseudo-obstruction

239
Q

what are the causes of intestinal obstruction?

A 
foreign object in body; food, bezoar gallstones
parasites
adhesions
hernia (primary or secondary)
tumour (primary or secondary)
inflammation (IBD)
diverticular disease
stricture
vasculitis
240
Q

what are the symptoms and signs of intestinal obstruction?

A 
abdominal pain
distention
vomiting
constipation
tachycardia
hypotension
fever
scars
hernias
auscultation (no bowel sounds)
dilatation on scans
241
Q

what is the management of intestinal obstruction?

A

fluid resuscitation (saline, K)
urinary catheter
NG tube
analgesia
operative - post-resuscitation, antibiotics, DVT prophylaxis
non operative - paralytic ileus, known adhesions, metastatic disease, inflammatory

242
Q

define sepsis

A

life-threatening organ dysfunction cause by a dysregulated host response

243
Q

describe septic shock

A

hypovolaemia, vasodilation, impaired cardiac function and mitochondrial dysfunction
lactate >2mmol/L
persistent hypotension requiring vasopressors to keep MAP above 65mmHg

244
Q

what are the non-infectious causes of sepsis?

A 
pancreatitis
tissue ischaemia
trauma
burns
thromboembolism
vasculitis
drug reactions
autoimmunity
neoplasia
245
Q

what are the infectious causes of sepsis?

A

lungs
intra-abdominal
GU
bloodstream

246
Q

what is the pathophysiology of sepsis?

A 
CO increase
systemic vascular resistance decrease
serum lactate increase (hypo perfusion/hypoxia, aerobic glycolysis through enhanced adrenergic tone)
increased leucocyte adhesion
increased coagulation
vasodilatation
loss of barrier function
hypercytokinaemia
247
Q

what are the consequences of sepsis?

A 
DIC
bacterial translocation
ARDS
AKI
encephalopathy
hepatic failure
248
Q

describe the sepsis cycle

A

ARDS - lung injury
sedative - reduced mobility, progressive catabolism, severe neuromuscular weakness
intestinal barrier dysfunction - ongoing bacterial translocation and malnutrition
immune dysfunction - secondary infections

249
Q

describe sepsis pathophysiology on a cellular/molecular level

A

endotoxins, macrophage, cytokine production
inflammatory signalling
potent cytokine response
pyroptosis - caspase mediated plasma membrane rupture
early damage pathway (RO species, complement activation, immunothrombosis)
metabolic dysfunction
resolution pathways (anti-inflammatory pathways)

250
Q

what is the treatment of sepsis?

A

6; IVI (crystalloids), BS antibiotics, O2, urine measurement, blood cultures, serum lactate

early and effective antimicrobial therapy
resus; colloids and crystalloids
vasopressors; vasopressin, adrenaline, noradrenaline
lung protective ventilation
insulin therapy
enteral feeding
urinary catheter
reduced sedation
251
Q

what drugs are useful in sepsis?

A

anti-cytokines; etanercept, afelimomab, anakinra
anti-virulence factors; HA-1A, ES, eritoran
anti-coagulopathy; activated protein C, antithrombin III, heparin
immune stimulation; G-CSF, GM-CSF

252
Q

define diverticulosis

A

presence of diverticula in bowel wall

253
Q

define diverticulitis

A

inflammation of diverticula

254
Q

define diverticular disease

A

entire spectrum of clinical consequences

255
Q

what is the pathogenesis of diverticular disease?

A

mucosal herniations
points of weakness - vasa recta beside taeniae
false diverticula
present in sigmoid column, none in rectum
areas of high pressure - segmentation

256
Q

what are the signs and symptoms of diverticular disease?

A 
asymptomatic
crampy lower abdominal pain
LIF discomfort, tenderness and guarding
pyrexia
rabbit-like stools
increased WCC, CRP
must exclude sinister pathology
257
Q

what is the treatment of diverticular disease?

A

high fibre diet (20-30g bran)
fibre supplements
anti-spasmodics
reduces pain not complications

258
Q

what are the complications of diverticulitis?

A

phlegmon (stricture)
perforation (localised abscess, generalised peritonitis)
fistula (colovesical, colovaginal, coloenteric, colocutaneous)
bleeding

259
Q

what is the treatment of diverticulitis?

A

oral fluids
IV antibiotics (broad spectrum penicillin and metronidazole)
oral antibiotics if resolving
BE or colonoscopy in 4-6 weeks

260
Q

how do an abscess present?

A

failure to resolve
temperature spiking
obvious mass

261
Q

what is the management of an abscess?

A

broader spectrum antibiotics (tazobactam and piperacillin)
CT
percutaneous drainage
sigmoid colectomy
failure to resolve - surgery
hartmann’s; safe, 50% not resolved
sigmoid colectomy + loop ileostomy; higher risk, easier reversible

262
Q

what are the signs and symptoms of intestinal perforation?

A 
severe, generalised abdominal pain
sudden onset
shock
tender, guarding, rebound
seen on erect CXR
263
Q

what is the management of intestinal perforation?

A 
resus IV fluid
broad spectrum IV antibiotics
emergency Hartmann's procedure
extensive lavage; large bore drains
high mortality
264
Q

what are the symptoms, signs and management of a colovesical fistula?

A

recurrent UTIs, pneumoturia, faecoturia

BE (80%), Bournes test, cystoscopy, CT

265
Q

what are the symptoms, signs and management of a colovaginal fistula?

A

prior hysterectomy
flatus, foul-smelling discharge, faeces PV

BE, vaginal exam

266
Q

what are the symptoms and signs of a colocutaneous fistula?

A

cellulitis
induration
perforation

267
Q

what are the symptoms, signs and management of a stricture?

A 
crampy abdominal pain
constipation
diarrhoea
thin stools
abdominal distension

exclude malignancy
barium enema
colonoscopy
sigmoid colectomy

268
Q

what are the symptoms, signs and management of bleeding?

A

sudden and significant
bright red/maroon
haemodynamic upset
anaemia

resuscitation (70% resolve)
OGD
technetium red cell scan
angiography - vasopressin, embolisation
surgery
269
Q

describe a perianal examination

A 
inspection
digital rectal examination
rigid sigmoidoscopy
proctoscopy
flexible sigmoidoscopy
colonoscopy
270
Q

what investigations are performed in diagnosing perianal disease?

A 
endo-anal US
barium studies
ano-rectal manometry
defaecating proctogram
fistulogram
MRI
rectal muscosa biopsy
271
Q

describe the classification of haemorrhoids

A

1st degree; bleeding
2nd degree; prolapse and reduce spontaneously
3rd degree; remain prolapsed

272
Q

what is the management of haemorrhoids?

A 
avoid constipation and straining
adjust diet
use faecal softeners
rubber band ligation
injection
infra-red photocoagulation
transfixion and excision
circular stapling
273
Q

name other perianal diseases

A 
anal fistula (Seton encircling)
perianal CD
anal fissure
thrombosed external pile
perianal haematoma
perianal warts
anal cancer
rectal prolapse
pruritus ani
274
Q

what is included on the sign-in surgical safety checklist?

A 
correct patient
correct site
anaesthetic check
monitoring check
allergy status
airway risk (including aspiration)
anticipated blood loss
275
Q

what is included on the time-out surgical safety checklist?

A 
team member introduction
correct patient and site
antibiotic prophylaxis
anticipated critical events
imaging displayed
276
Q

what is included on the sign-out surgical safety checklist?

A 
procedure
instrument/swab count
specimen labelling
any equipment problems
any recovery concerns
277
Q

name some high-risk medications

A 
anticoagulants
opiates
injectable sedatives
insulin
antibiotics
chemotherapy
infusion fluids
antipsychotics
drugs requiring monitoring of levels; digoxin, vancomycin, lithium, theophylline, warfarin
278
Q

define systemic inflammatory response syndrome (SIRS)

A 
2 or more of the following;
temperature >38.3 or <36.0
HR >90 (unless AF)
RR >20
WCC <4 or >12 x109/L
glucose >8.3mmol/L (unless diabetic)

only significant if new to an individual patient

279
Q

define sepsis

A

SIRS + infection (presence bacterial, viral, fungi, parasitic in normally sterile tissue)

infection has led to systemic sirs-like effects

280
Q

define severe sepsis

A

sepsis + one or more organ dysfunction

sepsis + tissue hypo perfusion

281
Q

what are the signs of respiratory dysfunction?

A

new/increased O2 requirement to maintain spO2 >90%

282
Q

what are the signs of renal dysfunction?

A

creatinine >177mmol/L
or
UO >0.5ml/kg/hr for 2hrs

283
Q

what are the signs of hepatic dysfunction?

A

bilirubin >34mmol/L

284
Q

what are the signs of coagulation dysfunction?

A

PLT <100
INR >1.5
aPTT >60s

285
Q

what are the causes of SIRS?

A

pancreatitis
trauma
burns
other

286
Q

what is the management of severe sepsis?

A

medical emergency
requires a fluid challenge to avoid irreversible organ damage
fluid challenge should reverse the tissue hypo perfusion parameters just described

287
Q

define septic shock

A

if, following the immediate administration of fluid challenges,
the patient retains signs of tissue hypoperfusion
or
has a repeat lactate of >4mmol/L

288
Q

what are the functions of calcium?

A 
muscle contraction
nerve impulse conduction
intracellular signalling
blood clotting
glandular secretions
preservation of bone density
regulation of digestion, energy and fat metabolism
regulates insulin secretion
regulates PTH and calcitonin secretion
289
Q

describe parathyroid hormone

A

t1/2 3 minutes
responds to changes in extracellular Ca
parathyroid chief cells have cell surface Ca sensing receptor

290
Q

describe calcitriol (1,25-dihydroxyvitamin D)

A

vitamin D from diet/skin hydroxylated in liver

PTH controls 2nd hydroxylation in kidney

291
Q

describe Ca homeostasis

A

calcitriol controls absorption from GI tract
PTH increases osteoclastic activity
calcitriol and PTH control Ca excretion from kidney
decreased intake/absorption - PTH increases Ca release from bone, Ca reabsorption from distal nephron and calcitriol production

292
Q

what are the signs and symptoms of hypercalcaemia?

A 
polyuria
polydipsia
dyspepsia
vage depressive complaints
mild cognitive impairment
apathy
weakness
nausea
anorexia
constipation
dehydration
abdominal pain
seizures
lethargy
coma
becomes more symptomatic the high the Ca levels are
293
Q

what are the renal symptoms (stones) of hypercalcaemia?

A

polyuria
polydipsia
nephrolithiasis
nocturia

294
Q

what are the skeletal symptoms (bone) of hypercalcaemia?

A

joint pain
bone pain
increased risk of fracture
gout

295
Q

what are the neurological symptoms (psychiatric overtones) of hypercalcaemia?

A

fatigue
weakness
depression
memory loss

296
Q

what are the GI symptoms (moans) of hypercalcaemia?

A 
anorexia
constipation
heartburn
PUD
pancreatitis
297
Q

describe non-parathyroid related hypercalcaemia

A

malignancy associated
granulomatous (sarcoid, TB)
endocrinopathies (hyperthyroidism, adrenal insufficiency)
drugs (thiazides, Ca supplements, vitamin D)
immobilisation

298
Q

describe parathyroid mediated hypercalcaemia

A

primary hyperparathyroidism; parathyroid adenoma, hyperplasia, carcinoma
tertiary hyperparathyroidism
familial hypocalcuric hypercalcaemia
lithium therapy

299
Q

what investigations are required to diagnose hyperparathyroidism?

A 
corrected Ca
PTH
phosphate
24hr urine Ca excretion
bone densitometry
sestimibi scan
US
300
Q

what are the complications of hyperparathyroidism?

A 
renal disease
bone loss
HTN
neuropsychiatric disorders
glucose intolerance
301
Q

when is surgery required for hyperparathyroidism?

A

serum Ca >0.5mmol/dL above reference range
24hr urinary Ca excretion >400mg/day
30% decreased in creatinine clearance
T score

302
Q

what surgery is required in renal disease?

A

sub-total
total and autotransplant
total parathyroidectomy

all patients with renal disease should have a thymectomy

303
Q

describe the pathophysiology of appendicitis

A

luminal obstruction with resultant inflammation
increased pressure resulting in abdominal pain from visceral nerve fibres
accumulation of E. coli and bacteroides

304
Q

what is the location of McBurney’s point?

A

1/3 from the ASIS to the umbilicus

305
Q

describe Rovsing’s sign

A

pressing on the LIF elicits pain in the RIF

present in appendicitis

306
Q

what groups of people are most likely to develop appendicitis?

A

young males
women of child-bearing age
older patients >30yrs

307
Q

what is the differential diagnosis of appendicitis in young males?

A

mesenteric adenitis
acute appendicitis
inflamed meckel’s diverticulum
Crohn’s disease

308
Q

what is the differential diagnosis of appendicitis of women of child-bearing age?

A 
ovarian torsion
ovarian cyst rupture
ectopic pregnancy
UTI
pyelonephritis
renal colic
acute appendicitis
acute diverticulitis
terminal ileal Crohn's disease
colitis
meckel's diverticulum
309
Q

what is the differential diagnosis of acute appendicitis in older patients?

A 
caecal tumours
terminal ileal Crohn's disease
acute diverticulitis
renal colic
ovarian/uterine malignancy
310
Q

what investigations are required to diagnose acute appendicitis?

A 
USS
CTAP
bloods; WCC, CRP
urinalysis
beta CG
history and examination
311
Q

what are the complications of appendicitis surgery?

A

early; bleeding, visceral injury (small bowel, caecum)
immediate; ileus, wound infection, intrabdominal collections
late; adhesions obstruction, incisional hernia

312
Q

describe the distribution of infused fluids

A

colloids; plasma
0.9% NaCl; interstitial fluid
5% dextrose; intracellular fluid

313
Q

what are the causes of existing fluid/electrolytes deficits and excesses?

A

dehydration
fluid overload
hypo/hyperkalaemia

314
Q

what are the causes of ongoing fluid/electrolyte deficits and excesses?

A 
vomiting and NG tube loss
biliary drainage loss
high/low volume ileal stoma loss
diarrhoea/excess colostomy loss
ongoing blood loss sweating, fever, dehydration
pancreatic, jejunal fistula, stoma loss
urinary loss; post-AKI polyuria
315
Q

what are the causes of fluid redistribution issues?

A 
gross oedema
severe sepsis
hypo/hypernatraemia
renal, liver, cardiac impairment
post-operative fluid retention and redistribution
malnourishment and refeeding issues
316
Q

what are the symptoms and signs of hypovolaemia?

A 
sunken skin
reduced turgor
fluids out; drains, GI losses
diuretics
fever
tachycardia
decreased pulse pressure
postural hypotension
low vascular tone
B-blockade
autonomic neuropathy
sunken eyes
dry mucous membranes
no JVP visible
increased CRT
raised creatinine (AKI)
raised lactate
317
Q

what are the symptoms and signs of hypervolaemia?

A 
dyspnoea
increased RR
oedema
fluids in; IV fluids, infusions
raised JVP
apex beat displacement
3rd HS
pulmonary oedema in lung bases
ascites
peripheral oedema
raised BNP (HF)
CXR; overload signs
echocardiogram; LV function, HF signs, overload
318
Q

describe pre-renal AKI

A

hypovolaemia and hypotension compromised the normal perfusion
mostly due to hypotension associated with sepsis and/or fluid depletion
exacerbated by ACE inhibitors or NSAIDs
will often respond to fluid replacement and drug withdrawal
avoid nephrotoxins; radio contrast, high dose aminoglycoside

319
Q

define an established AKI

A

creatinine rise >26mmol/L in 48hrs
>50% from baseline value within 7 days
UO <30ml/hr for 6hrs

320
Q

what is the management of an established AKI?

A 
bloods, urinalysis, urinary Na
renal USS; if upper tract obstruction or no response to treatment
resuscitation fluids
optimise blood pressure
stop NSAIDs, COX II, ACEi, ARBs, metformin
avoid antihypertensives, diuretics
correct dosing to eGFR level
maintenance fluids; rate = UO + 30ml/hr
avoid Hartmann's if K >5.5mmol/L
321
Q

what are the indications of AKI for referral to nephrology?

A

suspected intrinsic renal disease; blood and protein on urinalysis with suspected glomerulonephritis, unclear aetiology of AKI
potential need for dialysis; refractory hyperkalaemia, pulmonary oedema, severe metabolic acidosis, progressive AKI
AKI in; renal transplant patients, baseline GFR <30ml/min

322
Q

what questions should be asked in a hernia history?

A 
bulging/lump
pain; type, onset, site, when, where
standing vs lying down
previous treatment
smoking
diabetes
occupation
323
Q

what are the general principles of a hernia examination?

A 
exposure of abdomen fully including groin
standing vs lying down
reducibility
tenderness
overlying skin
bowel sounds
324
Q

what are the risks of a hernia?

A

incarceration
obstruction
strangulation and necrosis

325
Q

what are the features of a primary acquired hernia?

A

weakness of muscles/fascia

genetic
diabetes
smoking
obesity
pregnancy
occupation?
326
Q

describe an epigastric hernia

A

above umbilicus
midline
x2 in males
fixed with sutures or mesh

327
Q

describe (para)umbilical hernias

A

acquired paraumbilical; associated with age, obesity, pregnancy, females x3, fix

congenital umbilical; usually leave alone

328
Q

describe hesselbach’s triangle

A

an area of potential weakness in the abdominal wall; herniation of abdominal contents can occur
between the inguinal ligament, inferior epigastric vessel and lateral border of the rectus abdominis muscle

329
Q

describe the treatment methods of hernias

A

herniotomy division of sac (paediatric)
herniorraphy repair
hernioplasty repair with mesh

330
Q

what is the composition of calcium in the body?

A

1kg in average human body
99% in skeleton
60% albumin bound, or complexed with phosphate and citrate

331
Q

describe the calcium phosphate ratio

A

calcium:phosphate normally 2:1

increase in plasma calcium causes corresponding decreased in phosphate absorption

332
Q

describe the hormonal control of calcium and phosphate metabolism

A 
4 integrated systems;
endocrine; vitamin D, PTH, calcitonin
gut
bone
kidney
333
Q

describe calcium absorption

A

derived through dietary sources as calcium phosphate, carbonate, tartrate and oxalate
absorbed from the GI tract; simple diffusion, active transport, and distributed
99% is filtered in the glomerulus
only a small quantity is excreted through urine
calcium may be deposited or resorbed in the bone depending on the level of calcium in the plasma

334
Q

what are the actions of PTH with calcitriol?

A

bone; act on osteoclasts to promote bone resorption and increase calcium concentration
small intestine; stimulates calcium reabsorption via vitamin D activation
renal; PTH stimulates renal 1 alpha hydroxylase to stimulate intestinal calcium absorption

335
Q

describe calcitonin

A

released by the parafollicular or C cells

actions;
decreased absorption of bone by osteoclasts
decreased formation of new osteoclasts and decreased in the number of osteoblasts

336
Q

what are the causes of hypercalcaemia?

A

PTH mediated; primary hyperparathyroidism, lithium FHH, tertiary hyperparathyroidism

cancer; multiple myeloma, PTHrp mediated, renal cancer, bone metastases

calcitriol mediated; granulomatous disease, lymphoma, milk alkali syndrome, exogenous vitamin D
dialysis

vitamin A toxicity, thyrotoxicosis, Paget’s disease, adrenal insufficiency, thiazide use

337
Q

what are the causes of hyperparathyroidism?

A

80-85%; pituitary adenoma
5%; double adenoma
carcinoma; <1%
hyperplasia; more common in familial syndromes

338
Q

what are the major features of hyperparathyroidism?

A 
progressive mild decline in renal function
decreased bone density
fatigue and muscle pain
nausea, constipation and heartburn
nocturia
brain fog
depression, anxiety, poor sleep
neuropsychiatric features
339
Q

what are the symptoms and signs of osteoporosis?

A

decrease in height over time
hunched or stooped posture
back pain; particularly lower back secondary to a collapsed vertebra
bones fracturing easily

340
Q

describe familial hypocalciuric hypercalcaemia

A 
rare genetic disorder; calcium receptor in kidney
AD
mild hypercalcaemia
low urinary calcium
genetic testing
PTH may be normal
341
Q

what investigations are required to diagnose hyperparathyroidism?

A 
calcium
PTH
serum phosphate
creatinine
24hr urinary calcium
vitamin D levels; all patients should be vitamin D deplete
USS; may locate adenoma
sestamibi scan
4D CT scan
342
Q

what are the indications for thyroid surgery?

A

history of renal stones
osteoporosis; lowest T score on scan
<50yrs
calcium >2.75
neurocognitive and neuropsychiatric symptoms
considered in CVD, persistent GORD, fibromyalgia

343
Q

what are the consequences of thyroid surgery?

A 
cure
calcium normalises quickly
PTH takes longer to normalise
reverses osteoporosis
decreases risk of hip fracture
reduces renal stone risk
increased life expectancy
feel better; less weak, fatigue, depression, thirst
344
Q

what is the management of hypocalcaemia?

A

drink of milk or cheese
calcium supplements
start 1g elemental TID and monitor response
vitamin D can be added

10ml 10% calcium gluconate IV
never IM

345
Q

describe the features of post-operative neck haematoma

A

worsening wound swelling after neck surgery

respiratory distress; tachypnoea, stridor, low saturation

346
Q

what is the management of post-operative neck haematoma?

A 
sit up
start 100% O2 by mask
monitor closely
100mg IV hydrocortisone
open the wound and pack closely; SCOOP
347
Q

describe primary hyperparathyroidism

A

raised serum calcium and PTH in the setting of normal renal function
measure these and calcitriol and 24hr urinary calcium
consider familial hypocalciuric hypercalcaemia causing secondary hyperparathyroidism
assess for end organ damage; nephrolithiasis, osteoporosis, reduced renal function
surgery; only curative treatment

348
Q

what is the treatment of hypercalcaemia?

A

avoid calcium containing foods and supplements
volume expansion and rehydration
normal saline at 200-300ml/hr
consider steroids for known malignancy
loop diuretic only if fluid overloaded
IV bisphosphate; zolendronic (4mg IV / 15 mins) or pamidronate (60-90mg / 2hrs)
or
denosumab (120mg every 4 weeks) in renal impairment

349
Q

describe the pathogenesis of gallstones

A

components of bile get out of correct concentrations

loss of gallbladder motility/excessive sphincter contraction; bile stasis, sludge/stones

350
Q

what does bile consist of?

A

bilirubin, cholesterol, fatty acids and various minerals

351
Q

what are the risk factors for developing gallstones?

A 
FHx
white european/North American, asians, black africans
female
pregnancy
morbid obesity/rapid weight loss
total parenteral nutrition
drugs; fibrates
diet high in fats and carbohydrates
sedentary lifestyle
T2DM
dyslipidaemia
352
Q

what are the causes of black gallstones?

A 
excess unconjugated bile/increased enterohepatic circulation of bilirubin
haemolytic anaemia
ineffective erythropoiesis
liver cirrhosis
ileal disease
353
Q

describe brown gallstones

A

predominate in other areas of biliary tract; intrahepatic ducts, gallbladder
SE asia; parasite infestation, e. coli

354
Q

what are the clinical features of gallstones?

A

contraction of GB smooth muscle
activation of visceral nerve fibres in the GB wall
sensation of referred pain in the T9 dermatome
poorly localised pain
often associated with nausea and vomiting
local cytokine release; irritation to parietal peritoneum in RUQ
biliary pain; >few hours, localised to RUQ, tender RUQ, increased WBC, CRP, ESR, deranged LFTs, mucocele, empyema

355
Q

what is the pathophysiology of acute pancreatitis?

A

CBD stones pass out of the bile duct

impacted gallstone in distal bile duct obstructs Pd, increasing pancreatic pressure, damaging ductal and acinar cells

356
Q

what investigations are required to diagnose bile duct stones?

A 
faecal sampling
LFTs; GGT, ALP, transaminases, bilirubin
USS
MRCP
ERCP; therapeutic only
EUS
357
Q

describe Charcot’s triad

A 
jaundice
high temperature (39-40)
RUQ pain
indicates cholangitis; E. coli, klebsiella, enterobacter, enterococcus
treatment; antibiotics and ERCP
358
Q

describe mirizzi syndrome

A

stone impacted in hartmann’s pouch produces an inflammatory process resulting in adherence of hartmann’s pouch to CBD
obliterates hepatocystic triangle
resulting in partial obstruction of CBD and cholecysto-choedochal fistula

359
Q

what is the treatment of gallstones?

A

laparoscopic cholecystectomy
cholecystostomy tube
open cholecystectomy

360
Q

what is the management of CBD stones?

A

ERCP; sphincterotomy, remove stones, insert stent, take brushings of bile duct strictures
complications; acute pancreatitis, haemorrhage, death
laparoscopic; choledochoscope used
T tube

361
Q

describe gallstone ileus

A

mechanical obstruction caused by a large gallstone
typically inflamed gallbladder erodes into duodenum
usually impacts the terminal ileum
once the stone has passed the fistula will usually close

362
Q

describe porcelain gallbladder

A

extensive calcium deposited in the gallbladder wall

usually asymptomatic

363
Q

describe acute acalulous cholecystitis

A

often seen in sick patients in ICU; burns, trauma, post cardiac surgery
gallbladder ischaemia

364
Q

describe gallstones in children

A

rare

associated with underlying disease; haemolytic anaemia, Crohn’s, genetic disorders, liver disease, obesity

365
Q

describe hypovolaemic shock

A

inadequate organ perfusion caused by loss of intravascular volume
usually acute
drop of cardiac preload to a critical level
haemorrhagic/non-haemorrhagic

366
Q

describe haemorrhagic hypovolaemic shock

A

blood loss; vasoconstriction
increased HR to preserve CO
endogenous catecholamines; nor/adrenaline
contraction of the venous system to increase venous return
cellular; conversion to anaerobic metabolism (lactic acidosis)
prolonged; multi organ dysfunction

367
Q

what are the signs of hypovolaemic shock?

A 
tachycardia
reduced BP
increased RR
reduced UO
decreased mental status
increased CRT
368
Q

describe distributive shock

A

a state of relative hypovolaemia resulting from pathological redistribution of intravascular volume

369
Q

describe qSOFA

A

identifies patients with suspected infection who are at greater risk for a poor outcome outside ICU;
SBP <100mmHg
RR >22
GCS <15

370
Q

what is the treatment of septic shock?

A 
oxygen
IV fluids
bloods including ABG (lactate)
urinary catheter
blood cultures
abscess drainage sample
IV antibiotics; empirical, may need micro consult
HDU/ICU consult
source ontrol; radiological, surgery (GI perforation)
371
Q

define anaphylactic shock

A

massive histamine mediated vasodilation with shift of fluid from the intra to extravascular space
triggers; food products, insect venom
treatment; adrenaline injection. fluids, steroids

372
Q

describe neurogenic shock

A

SBP <100mmHg
HR <60
obtunded consciousness
high spinal cord injury; loss of spinal reflexes

373
Q

describe cariogenic shock

A

disorder of cardiac function
critical reduction of the hearts pumping capacity
systolic or diastolic dysfunction; reduced ejection fraction or impaired ventricular filling

374
Q

what are the symptoms of cariogenic shock?

A

agitation
disturbed consciousness
cool extremities
oliguria

375
Q

describe obstructive shock

A

due to extra cardiac causes of cardiac pump failure and often associated with poor RV output
pulmonary vascular; RV failure from a haemodynamically significant PE or severe pulmonary hypertension
mechanical; decreased preload, reduced venous return to RA, tension pneumothorax, pericardial tamponade contrastive pericarditis, cardiomyopathy

376
Q

what is the cause of cardiac tamponade

A

penetrating or blunt injuries that cause the pericardium to fill with blood from the heart, great vessels or pericardial vessels

377
Q

what is the classic clinical triad of cardiac tamponade?

A

muffled heart sounds
hypotension
distended veins

378
Q

what is the treatment of cardiac tamponade?

A

thoracotomy; drain the pericardial sac

379
Q

what is the treatment of an adenocarcinoma of distal sigmoid colon?

A

laparoscopic panproctocolectomy

restorative proctocolectomy ileal J-pouch

380
Q

name the inherited CRCs

A

Lynch syndrome
polyposis syndrome; FAP, AFAP, MAP
familial

381
Q

what cancers is Lynch syndrome associated with a greater risk?

A

colorectal
endometrial
ovarian
stomach

382
Q

what are the treatment options of a rectal adenocarcinoma?

A

surgery; low anterior resection
radiotherapy; pre-operative
watch and wait; chemoradiotherapy with monitoring and follow up

383
Q

what is the treatment of a rectosigmoid adenocarcinoma?

A

surgery; hartmann’s operation, colostomy

colonic stent; endoscopically placed, morbidity and mortality equal to surgery

384
Q

what are the indications for AAA surgical repair?

A

rupture; emergency
symptomatic; urgent, regardless of size
>5.5cm
rapid expansion; >1cm over 12 months

385
Q

what are the post-operative complications of AAA surgery?

A 
cardiac complications
renal insufficiency
respiratory problems
lower extremity ischaemia/emboli
post-operative haemorrhage
colonic ischaemia
paraplegia

late;
false aneurysm
graft limb thrombosis
graft infection enteric fistula

386
Q

what is the classical triad of AAA rupture?

A

abdominal/back pain
hypovolaemic shock
elderly patient

387
Q

what are the signs, symptoms and investigations required to diagnose a leaking AAA?

A

abdominal, back or groin pain
pulsatile expansile abdominal mass
hypotension/shock

contrast enhanced CT
USS

388
Q

what is the differential diagnosis of a ruptured AAA?

A 
MI
acute pancreatitis
renal/ureteric colic
acute cholecystitis
perforated peptic ulcers
intestinal obstruction
ischaemic gut
389
Q

what is the management of a ruptured AAA?

A

large bore cannula
urgent bloods; FBC, U&E, coag, G&X 6 units
analgesia, oxygen, urinary catheter, haemodynamic monitoring
permissive hypotension
urgent transfer to theatre for surgery

390
Q

what are the complications specific to ruptured AAA?

A 
bowel ischaemia
abdominal compartment syndrome
leg ischaemia
renal failure
cardiac complications
391
Q

describe the stress response system

A

CRH is released from the hypothalamus
CRH acts on the pituitary gland to release ACTH
ACTH acts on the adrenal gland to produce cortisol

392
Q

what are the actions of cortisol?

A 
promotes fat breakdown
reduces bone formation
increases glucose generation from the liver
decreases amino acid uptake by muscle
counteracts the actions of insulin
393
Q

what are the actions of cytokines?

A

maintain the stress response
release of inflammatory mediators
may be harmful response

394
Q

what is the initial management of suspected ACS (acute chest pain)?

A 
MONA;
morphine
oygen
nitrate
aspirin 300mg
395
Q

what is the treatment of an NSTEMI?

A 
morphine
oxygen; only <90%
nitrates
aspirin
clopidogrel
enoxaparin
396
Q

what is the management of hypovolaemic shock due to haemorrhage?

A 
permissive hypotension
get help
wide bore access; 2 16G cannula
XIM 6 units to theatre ASAP
massive transfusion protocol
cardiac monitor
397
Q

describe the pathogenesis of sepsis

A

local infection caused by bacteria
bacteria enter the bloodstream
immune system responds to fight infection
bacteria and immune cells spread throughout the body causing uncontrolled inflammation
leads to organ damage and death if left untreated

398
Q

what are the aims or urine output?

A

adults; 0.5-1.0 ml/kg/hr

children <30kgs; 1ml/kg/hr

399
Q

what are the causes of AKI?

A 
recent infection
certain drugs
severe dehydration
exposure to heavy metals or toxic solvents
blood loss
shock
parenchymal disease
400
Q

what is the treatment of an AKI?

A 
low grade temperature
stop DAMN drugs
fluid resuscitation
aim SBP >100 and UO >0.5 ml/kg/min
consider sepsis and treat accordingly
stop antihypertensives if hypotensive
avoid contrast if possible
discuss with renal team if at stage 3
401
Q

what are the risk factors for developing ulcerative colitis?

A

high fat intake
sleep deprivation; flare ups
gastroenteritis
smoking and appendectomy decrease risk

402
Q

what is the pathophysiology of ulcerative colitis?

A

mucosal ulcers and crypt abscess formation
intact and oedematous mucosa projects in the bowel lumen
chronic inflammation leads to loss of haustra
predisposition to dysplastic change

403
Q

what are the clinical features of ulcerative colitis?

A 
blood diarrhoea
tenesmus
weight and appetite loss
electrolyte imbalance; hypokalaemia
systemically unwell
toxic megacolon
extra-intestinal manifestations
404
Q

what are the signs of ulcerative colitis on endoscopy?

A

mucosal inflammation of colon and rectum

biopsy shows typical pathological features of UC

405
Q

what are the signs of ulcerative colitis on barium enema?

A

loss of haustra
pseudopolyps
lead pipe colon

406
Q

what are the signs of ulcerative colitis on CT?

A

diffusely thickened colonic walls

407
Q

what are the risk factors for Crohn’s disease?

A 
smoking
high fat intake
low vitamin D intake
gastroenteritis
physical activity and high fibre intake decreases risk

Clinical Practice (14 decks)

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