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Year 4 > Surgery - Acute > Flashcards

Surgery - Acute Flashcards

1
Q

Where is McBurney’s point?

A

1/3 of the way along the line from the ASIS to the umbilicus - point where the appendix is found anatomically

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2
Q

What are the 9 layers of the anterior abdominal wall from external -> internal?

A
  • skin
  • subcutaneous fat
  • superficial fascia (campers and scarpas)
  • external oblique muscle
  • internal oblique muscle
  • transverse abdominus muscle
  • transversalis fascia
  • pre-peritoneal fat
  • peritoneum
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3
Q

Describe the pathophysiology of appendicitis

A

OBSTRUCTION -> due to faecolith/tumour/worms

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

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4
Q

Describe the pain felt in appendicitis and the pathophysiology behind it:

A
  • 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
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5
Q

What is Rosving’s sign?

A

Pain in RIF when LIF is pressed (appendicitis)

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6
Q

What is Psoas sign?

A

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

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7
Q

Name some differentials of RIF pain

A 
Appendicitis
Crohn's disease
Ovarian pathology
Renal stones
Meckel's diverticulum
Mittelschmertz
UTI
Ectopic pregnancy
Mesenteric adenitis
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8
Q

How is appendicitis investigated?

A
  • 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

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9
Q

What are the 4 ways in which gallstones can present?

A
  • biliary colic
  • acute cholangitis (bile duct infection)
  • acute cholecystitis (GB infection)
  • chronic cholecystitis (GB infection)
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10
Q

What types of gallstones are there?

A
  • 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)
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11
Q

RFx for gallstones?

A 
female
forty
fertile
fat
fair
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12
Q

Name some complications of Gallstones?

A
  • 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
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13
Q

What are the features of gallstone ileus on AXR?

A

Rigler’s triad:

  • pneumobilia
  • SB obstruction
  • stone seen in RLQ
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14
Q

What are differentials of RUQ pain?

A

R lower lobe pneumonia
Hepatitis
Gallstone issues

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15
Q

What is Charcot’s triad?

A

fever, jaundice and RUQ pain

Seen in cholangitis

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16
Q

What is Reynauld’s pentad?

A

fever, jaundice, RUQ pain, sepsis and confusion

seen in cholangitis

17
Q

What is the imaging modality of choice for gallstones?

A

USS

Majority of gallstones are radio-opaque

18
Q

How are biliary colic and ascending cholangitis managed?

A
  • conservative (fluids, analgesia, NBM to rest the GB)

- surgery (lap cholecystectomy if recurrence of pain and stones is an issue)

19
Q

What is Murphy’s sign?

A

tenderness over GB on inspiration (cholecystitis)

20
Q

What is Boas’ sign?

A

hyperaesthesia below the R scapulae

21
Q

How is cholecystitis managed

A
  • conservative (fluids, analgesia, NBM to rest the GB)

- surgery (lap cholecystectomy if recurrence of pain and stones is an issue)

22
Q

Why is gallbladder pain worse with eating?

A

fatty chyme in SI causes CCK (cholecystikinin release from SI cells) which causes GB contraction

23
Q

What are the causes of acute pancreatitis?

A 
Idiopathic
Gallstones
Ethanol
Toxins
Steroids
Mumps
Autoimmune
Scorpion sting
Hyperlipidaemia/hypercalcaemia/hyperparathyroid
ERCP
Drugs (thiazide/loop diuretics, tetracycline antibiotics)
24
Q

What are Grey Turners and Cullens signs?

A

Cullens = periumbilical bruising
Grey turners = flank bruising

Due to pancreatitis (haemorrhagic)

25
Q

Describe the components of the modified Glasgow Criteria for acute pancreatitis

A

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
26
Q

What are the retroperitoneal organs (lined by adventitia)

A 
Suprarenals (adrenals)
Aorta/IVC
Duodenum (distal 2/3rds)
Pancreas
Ureters
Colon (ascending and descending)
Kidneys
oEsophagus
Rectum
27
Q

What is the definition of diverticulum?

A

An acquired out-pouching of the colonic mucosa/connective tissue through the bowel wall

(a false diverticulum has no muscle protruding)

28
Q

Name 3 common causes of visceral perforation

A

peptic ulcer
acute appendicitis
diverticulitis

29
Q

Name some causes of upper GI bleeding:

A

peptic ulcer
oesophageal varices
mallory weiss tear (tear where stomach meets oesophagus)
gastric carcinoma

30
Q

What are the two scores used to assess upper GI bleeding?

A

Glasgow Blatchford score - used pre-endoscopy to predict need for intervention

Rockall score - used after endoscopy and predicts mortality and need for surgery

31
Q

How are upper GI bleeds managed?

A

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

32
Q

Name some causes of lower GI bleeding:

A 
IBD
Infective gastroenteritis
Diverticulitis
Large upper GI bleed
Colonic polyps
Rectal (haemorrhoids, fissures)
Neoplasia
33
Q

What is the investigation and management of a lower GI bleed?

A
  • bloods
  • stool (microscopy)
  • imaging (AXR, erect CXR)
  • colonoscopy/sigmoidoscopy
  • A-E
  • fluid resuscitation/blood transfusion
  • antibiotics ?sepsis
    endoscopic treatment/surgical resection
34
Q

What is the definition of an aneurysm? (and a true and false aneurysm)

A

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

35
Q

What is the management of a ruptured AAA?

A
  • 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
36
Q

Name 5 causes of acute testicular pain

A
  • testicular torsion
  • torsion of testicular appendage
  • acute epididymo-orchitis
  • scrotal oedema
  • inguinal lymphadenopathy
37
Q

What is the blue dot sign?

A

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

38
Q

What is the presentation of testicular torsion

A

sudden moderate/severe constant unilateral pain

  • associated N&V
  • high riding testes with absent ipsilateral cremasteric reflex

Year 4 (28 decks)

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