Surgery - Acute Flashcards by Megan Espie

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

Describe the pathophysiology of appendicitis

OBSTRUCTION -> due to faecolith/tumour/worms

- gut organisms invade appendix wall causing oedema, ischaemia, necrosis, and then perforation

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What is Rosving’s sign?

Pain in RIF when LIF is pressed (appendicitis)

How well did you know this?

Not at all

Perfectly

What is Psoas sign?

Pain on hip extension, as the majority of appendicitises are retrocaecal

How well did you know this?

Not at all

Perfectly

Name some differentials of RIF pain

Appendicitis
Crohn's disease
Ovarian pathology
Renal stones
Meckel's diverticulum
Mittelschmertz
UTI
Ectopic pregnancy
Mesenteric adenitis

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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)

How well did you know this?

Not at all

Perfectly

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)

How well did you know this?

Not at all

Perfectly

RFx for gallstones?

female
forty
fertile
fat
fair

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What are the features of gallstone ileus on AXR?

Rigler’s triad:

pneumobilia
SB obstruction
stone seen in RLQ

How well did you know this?

Not at all

Perfectly

What are differentials of RUQ pain?

R lower lobe pneumonia
Hepatitis
Gallstone issues

How well did you know this?

Not at all

Perfectly

What is Charcot’s triad?

fever, jaundice and RUQ pain

Seen in cholangitis

How well did you know this?

Not at all

Perfectly

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