Surgery - Acute Flashcards
Where is McBurney’s point?
1/3 of the way along the line from the ASIS to the umbilicus - point where the appendix is found anatomically
What are the 9 layers of the anterior abdominal wall from external -> internal?
- skin
- subcutaneous fat
- superficial fascia (campers and scarpas)
- external oblique muscle
- internal oblique muscle
- transverse abdominus muscle
- transversalis fascia
- pre-peritoneal fat
- peritoneum
Describe the pathophysiology of appendicitis
OBSTRUCTION -> due to faecolith/tumour/worms
- gut organisms invade appendix wall causing oedema, ischaemia, necrosis, and then perforation
Describe the pain felt in appendicitis and the pathophysiology behind it:
- early inflammation = visceral pain which is poorly located, only the appendix inflammed, mid-gut pain - initially entire abdomen
- later inflammation: parietal peritoneum inflammation as well as appendix, pain localises to RIF
What is Rosving’s sign?
Pain in RIF when LIF is pressed (appendicitis)
What is Psoas sign?
Pain on hip extension, as the majority of appendicitises are retrocaecal
Name some differentials of RIF pain
Appendicitis Crohn's disease Ovarian pathology Renal stones Meckel's diverticulum Mittelschmertz UTI Ectopic pregnancy Mesenteric adenitis
How is appendicitis investigated?
- Bloods: FBC, U&E, CRP, LFT, amylase, clotting, lactate, G%S
- Urinalysis: B-HCG, infection, ketones
- Imaging: Females (USS - rule out gynae pathology), Males (laparotomy immediately)
50yrs+ = CT to rule out cancer
What are the 4 ways in which gallstones can present?
- biliary colic
- acute cholangitis (bile duct infection)
- acute cholecystitis (GB infection)
- chronic cholecystitis (GB infection)
What types of gallstones are there?
- 75% mixed stones (cholesterol, calcium and pigment)
- 20% cholesterol stones (due to Admirand’s triangle = high cholesterol, low bile salts and low lecithin)
- Pigment stones (made of calcium bilirubinate and associated with haemolysis)
RFx for gallstones?
female forty fertile fat fair
Name some complications of Gallstones?
- biliary colix
- cholecystitis
- mucocoele
- empyema
- carcinoma
- obstructive jaundice
- acute pancreatitis
- Mirizzi syndrome -> stone impacted in GG/cystic duct causing CBD compression
- gallstone ileus = causing pneumobilia and bowel distention on AXR
What are the features of gallstone ileus on AXR?
Rigler’s triad:
- pneumobilia
- SB obstruction
- stone seen in RLQ
What are differentials of RUQ pain?
R lower lobe pneumonia
Hepatitis
Gallstone issues
What is Charcot’s triad?
fever, jaundice and RUQ pain
Seen in cholangitis
What is Reynauld’s pentad?
fever, jaundice, RUQ pain, sepsis and confusion
seen in cholangitis
What is the imaging modality of choice for gallstones?
USS
Majority of gallstones are radio-opaque
How are biliary colic and ascending cholangitis managed?
- conservative (fluids, analgesia, NBM to rest the GB)
- surgery (lap cholecystectomy if recurrence of pain and stones is an issue)
What is Murphy’s sign?
tenderness over GB on inspiration (cholecystitis)
What is Boas’ sign?
hyperaesthesia below the R scapulae
How is cholecystitis managed
- conservative (fluids, analgesia, NBM to rest the GB)
- surgery (lap cholecystectomy if recurrence of pain and stones is an issue)
Why is gallbladder pain worse with eating?
fatty chyme in SI causes CCK (cholecystikinin release from SI cells) which causes GB contraction
What are the causes of acute pancreatitis?
Idiopathic Gallstones Ethanol Toxins Steroids Mumps Autoimmune Scorpion sting Hyperlipidaemia/hypercalcaemia/hyperparathyroid ERCP Drugs (thiazide/loop diuretics, tetracycline antibiotics)
What are Grey Turners and Cullens signs?
Cullens = periumbilical bruising
Grey turners = flank bruising
Due to pancreatitis (haemorrhagic)
Describe the components of the modified Glasgow Criteria for acute pancreatitis
Used to assess severity and predict mortality:
PaO2<8kPa Age >55 Neutrophils high Calcium low Renal (urea >16) Enzymes (high LDH and AST) Albumin low Sugar (BM >10)
1 = mild 2 = moderate 3 = severe
What are the retroperitoneal organs (lined by adventitia)
Suprarenals (adrenals) Aorta/IVC Duodenum (distal 2/3rds) Pancreas Ureters Colon (ascending and descending) Kidneys oEsophagus Rectum
What is the definition of diverticulum?
An acquired out-pouching of the colonic mucosa/connective tissue through the bowel wall
(a false diverticulum has no muscle protruding)
Name 3 common causes of visceral perforation
peptic ulcer
acute appendicitis
diverticulitis
Name some causes of upper GI bleeding:
peptic ulcer
oesophageal varices
mallory weiss tear (tear where stomach meets oesophagus)
gastric carcinoma
What are the two scores used to assess upper GI bleeding?
Glasgow Blatchford score - used pre-endoscopy to predict need for intervention
Rockall score - used after endoscopy and predicts mortality and need for surgery
How are upper GI bleeds managed?
ABATED!
- A-E
- Bloods (FBC, U&E, LFT, coag & cross-match)
- Access
- Transfuse
- Endoscopy (immediately if haem unstable, or within 24hrs if stable)
- Drugs (stop NSAIDs and anticoagulants)
Additional steps if VARICEAL bleeding:
- terlipressin & antibiotics
Definitive treatment: banding/sclerotherapy inj/cauterisation
Name some causes of lower GI bleeding:
IBD Infective gastroenteritis Diverticulitis Large upper GI bleed Colonic polyps Rectal (haemorrhoids, fissures) Neoplasia
What is the investigation and management of a lower GI bleed?
- bloods
- stool (microscopy)
- imaging (AXR, erect CXR)
- colonoscopy/sigmoidoscopy
- A-E
- fluid resuscitation/blood transfusion
- antibiotics ?sepsis
endoscopic treatment/surgical resection
What is the definition of an aneurysm? (and a true and false aneurysm)
An artery with >50% dilatation of its original diameter
The layers of a blood vessel wall are:
- tunica intima
- tunica media
- adventitia
true aneurysm = contains all layers of artery wall
false aneurysm = a collection of blood in the adventitia which connects with the lumen after trauma
What is the management of a ruptured AAA?
- high flow O2
- Iv access
- FBC, coag, clotting
- cross match >6 units
transfer to vascular surgeons: - stable = CT angiogram and possible endovascular repair
- unstable = open repair
Name 5 causes of acute testicular pain
- testicular torsion
- torsion of testicular appendage
- acute epididymo-orchitis
- scrotal oedema
- inguinal lymphadenopathy
What is the blue dot sign?
seen in torsion of testicular appendage
also called Hydatid of Morgagni
causes a high riding testes with similar presentation to torsion (tender testicle, slightly enlarged) but the cremasteric reflex WILL BE PRESERVED
What is the presentation of testicular torsion
sudden moderate/severe constant unilateral pain
- associated N&V
- high riding testes with absent ipsilateral cremasteric reflex
