Surgery/AH2 Flashcards
AAA-definition
Abdominal aortic aneurysm (AAA) is a focal dilatation of the abdominal aorta to more than 1.5 times its normal diameter.
State some risk factors for AAA-major ones are
Advanced age Smoking (most important risk factor) Atherosclerosis Hypercholesterolemia and arterial hypertension Positive family history Trauma
Best initial test to diagnose USS
abdominal ultrasound is the best initial and confirmatory test to diagnose AAAs and determine their extent.
Where is the most common location for AAA to occur at
Below the renal arteries- Infrarenal
Because there is less collagen in this area
Why do you get autonomic symptoms- sweating and feeling calmy after rupture of AAA
Since the celiac, sup., and inf. ganglia runs throughout the AA, a bulging aneurysm or a ruptured aneurysm causing a bleed into the peritoneal space (ant or post) will result in compression of said ganglia leading to sympathomimetic symptoms, like sweating, anxiety, anorexia, constipation.
Classic triad for ruptured AAA
- Hypotension/collapse
- Back/abdominal pain
- Palpable, pulsatile abdominal mass (caution
in patients with raised BMI)
State some investigations you would want to order and the reason for it
- bloodwork: CBC, electrolytes, urea, creatinine, PTT, INR, type and cross
- abdominal U/S- screening and surveillance
- CT with contrast(accurate visualization, size determination, EVARplanning)
- peripheral arterial doppler/duplex (rule out aneurysms elsewhere, e.g. popliteal)
What is the medical management of AAA which is less than 5.5cm- 4 things
Smoking cessation (reduces rate of expansion and risk of rupture)
Improve blood pressure control
Commence statin and aspirin therapy
Weight loss and increased exercise
What are the indications for surgery in AAA-4 things
- Surgery should be considered for an AAA >5.5cm in diameter,
- AAA expanding at >1cm/year
- symptomatic AAA in a patient who is otherwise fit.
- Rupture
What are the mainstay treatment options for AAA repair
Open repair involves a midline laparotomy or long transverse incision, exposing the aorta, and clamping the aorta proximally and the iliac arteries distally, before the segment is then removed and replaced with a prosthetic graft
The endovascular repair involves introducing a graft via the femoral arteries and fixing the stent across the aneurysm –> EVAR(remember the complication is endoleaks)
The patient has a ruptured AAA, if the patient is stable vs unstable what do you do
If the patient is unstable, they will require immediate transfer to theatre for open surgical repair
If the patient is stable, they will require a CT angiogram to determine whether the aneurysm is suitable for endovascular repair*
However
Treatment: open emergency surgery (gold standard) or endoscopic treatment
What are some of the physical signs you may see in a pt. with a ruptured AAA which is contained
Throbbing abdominal or low back pain radiating to the flank, buttocks, legs, or groin Grey turner sign (ecchymosis of the affected flank area) Cullen sign (periumbilical ecchymosis)
Definition of a dissection
Dissections are a separation of the arterial wall layers caused by blood entering the intima-media space after a tear in the internal layer occurred.
What are the characteristic clinical features in an aortic dissection
- Sudden and severe tearing/ripping pain in the anterior chest, interscapular area, the neck, jaw or abdomen depending on the site of dissection
- Syncope
- Asymmetrical pulse and BP readings
What is the treatment for aortic dissection
A- needs help
B- conservative
Open or endovascular stent grafting repair (Stanford A dissections, which involve the ascending aorta, require immediate surgery)
Control hypertension (Stanford B dissections, which do not involve the ascending aorta, are generally treated conservatively)
STI and Aneurysm connection
Tertiary syphilis (due to obliterative endarteritis of the vasa vasorum)
CXR of an aortic dissection will show
widened mediastinum
What some causes of aortic dissection
- HTN
- Trauma
- Syphilis
- Connective tissue disease
- Use of amphetamines and cocaine
- Atherosclerosis
Location of aortic dissection, and its classification
Standford classification
Stanford A = Affects ascending aorta
Stanford B = Begins beyond brachiocephalic vessels.
6Ps of acute limb ischemia
6 Ps – all may not be present
Pain: absent in 20% of cases
Pallor: within a few hours becomes mottled cyanosis
Paresthesia: light touch lost first then sensory modalities
Paralysis/Power loss: most important, heralds impending gangrene
Polar/Poikilothermia/ Perishing cold’ Pulselessness: not re iable
What are the difference between embolus and thrombus causing acute limb ischemia
The embolus is an acute onset compared to the thrombus- which is chronic- hence there can be hx of claudication and thrombosis
examples of conditions that predispose to embolism are: arrhythmias, endocarditis, and arterial
aneurysms
existing atherosclerotic plaques (i.e. chronic PAD) can rupture causing thrombosis
Leriche syndrome (aortoiliac occlusive disease)-triad is
Pain in both legs and the buttocks
Bilaterally absent femoral, popliteal, and ankle pulses
Erectile dysfunction
Shock
What is the initial test for ALI and then diagnostic test,
what other tests can be done
Best initial test: arterial and venous Doppler
Diminished or absent Doppler flow signal distal to site of occlusion.
Confirmatory test: angiography (DSA, CTA, MRA)
Digital subtraction angiography (DSA) is the imaging modality of choice.
Should only be performed if delaying treatment for further imaging does not threaten the extremity
-can consider ECHO if embolic
Acute limb ischemia due to thromboembolism- treatment
- Leg is viable
- Emergency
- Leg is unviable
Acute limb ischaemia is a surgical emergency. Complete arterial occlusion will lead to irreversible tissue damage within 6 hours. Early senior surgical support is vital.
Start the patient on high-flow oxygen and ensure adequate IV access. A therapeutic dose heparin or preferably a bolus dose then heparin infusion should be initiated as soon as is practical.
Systemic anticoagulation with an IV heparin bolus followed by continuous infusion unless a contraindication is present
Viable, non-threatened limb
Urgent angiography to localize the site of the occlusion
Revascularization procedure (open or catheter-directed thrombectomy or thrombolysis) within 6–24 hours
Threatened limb: emergent revascularization procedure within 6 hours
Non-viable limb: limb amputation
Acute limb ischemia due to compartment syndrome: fasciotomy (see compartment syndrome)
Acute limb ischemia due to a dissecting aneurysm: stenting and/or surgical repair
Reperfusion injury (postischemic syndrome)-ALI
Following reperfusion, detached metabolites may trigger further complications, especially after prolonged occlusion (more than 6 h).
Possible complications
Acidosis, hyperkalemia → cardiac arrhythmia
Rhabdomyolysis → myoglobinemia → crush syndrome
Ischemia-reperfusion injury → compartment syndrome
Massive edema → hypovolemic shock
Severe complications: DIC (disseminated intravascular coagulation), multiorgan dysfunction
amputation–> if leg is not viable
Cold and pale limb leg
Acute limb ischemia
Hot and swollen leg
DVT
Chronic arterial insufficiency-what does that mean and characteristics features
chronic ischemia due to inadequate arterial supply to meet cellular metabolic demands(during walking (claudication) or at rest (limb threat/critical limb ischemia)
What must you if you suspect the patient has claudication
claudication:must differentiate vascular from neurogenic claudication or MSK
What is CLI
. includes rest pain, night pain, tissue loss (ulceration or gangrene)
. pain most commonly over the forefoot, waking person from sleep, and often relieved by hanging foot off bed
ABI <0.40
◆ pulses may be absent at some locations, bruits may be present
◆ signs of poor perfusion: hair loss, hypertrophic nails, atrophic muscle, ulcerations and infections,
slow capillary refill, prolonged pallor with elevation and rubor on dependency, venous troughing (collapse of superficial veins of foot)
What are the treatment options for CLI
1)Conservative
2) Pharmacology
- antiplatelet agents
- cilostazol
3) Surgical
- endovascular (angioplasty ± stenting)
- bypass endarterectomy
- amputation-if not suitable for revascularization, persistent serious infections/gangrene, unremitted rest pain poorly controlled with analgesics
Three main causes of acute limb ischemia
1) Emboli
2) Thrombus in-situ
3) Trauma
Should I do a lactate in ALI
Yes to assess for ischemia
Should I do lactate in ALI
Yes to assess for ischemia
What is the classification for CLI
Stage I Asymptomatic
Stage II Intermittent claudication
Stage III Ischaemic rest pain
Stage IV Ulceration or gangrene, or both
Fontaine classification of chronic leg ischaemia
What is Buerger’s test and angle
Buerger’s test involves lying the patient supine and raising their legs until they go pale and then lowering them until the colour returns (or even becoming hyperaemic). The angle at which limb goes pale is termed Buerger’s angle; an angle of less than 20 degrees indicates severe ischaemia.
What is the difference between chronic limb ischemia(peripheral vascular disease) and critical limb ischemia
Critical limb ischaemia is the advanced form of chronic limb ischaemia.
It can be clinically defined in three ways:
- Ischaemic rest pain for greater than 2 weeks duration, requiring opiate analgesia
- Presence of ischaemic lesions or gangrene objectively attributable to the arterial occlusive disease
- ABPI less than 0.5
On examination, the limbs may be pale and cold, with weak or absent pulses.
Other signs include limb hair loss, skin changes (atrophic skin, ulceration, or gangrene), and thickened nails.
What are two BIG ddx you need to exclude in chronic limb ischemia
- Spinal stenosis (‘neurogenic claudication’)
Typically have pain from the back radiating down the lateral aspect of the leg (tensor fascia lata), often have symptoms on initial movement or symptoms that are relieved by sitting rather than standing - Acute limb ischaemia
Clinical features that are less than 14 days duration, often presenting within hours. - Diabetic neuropathy is the other one- but patient needs to have T2DM
What assessment should be done is ALI and CLI patient
Cardiovascular risk assessment
-since it is basically like a heart attack of the leg
What is another name of peripheral vascular disease
chronic limb ischemia
What is the most important risk factor for PAD
smoking
In PAD, which artery gets most commonly blocked
The superficial femoral artery is commonly occluded (in the Hunters canal).
What are the 4 main characteristic features of chronic limb ischemia/peripheral vascular disease
- Intermittent claudication
- Absent or diminished pulses
- Trophic changes in the skin
- Rest pain- worse at night
Critical limb ischemia is indicated in PVD/Chronic limb ischemia when
Critical limb ischemia
The presence of any one of the following:
1.Resting pain
2.Ulcer
3.Tissue loss (gangrene)
Indicative of limb-threatening arterial occlusion
Fever, malaise, arthralgia
Syncope, angina pectoris
Impaired vision
15-40 Asian female
Takayasu’s disease
Migratory thrombophlebitis
Intermittent claudication, often limited to feet, calves and/or hands
Raynaud’s syndrome
Obliterating thromboangiitis
Moa of aspirin
Aspirin: irreversible cyclooxygenase inhibition → decreased thromboxane A2 synthesis → decreased platelet aggregation
MoA of clopidogrel
inhibition of the P2Y12 ADP receptor → decreased platelet activation and platelet-fibrin crosslinking
Venous ulcers
- Irregular border and shallow
- granulated base
- venous insufficiency
Venous leg ulcers are the most common type of leg ulcer; they are prone to infection and can present with associated cellulitis
Ulcer is painful usually end of the day
Venous
Venous ulcers can be painful (particularly worse at the end of the day) and are often found in the gaiter region of the legs. Associated symptoms of chronic venous disease, such as aching, itching, or a bursting sensation, will be present often before venous leg ulcers appear.
What are the other associated features with venous ulcers
varicose veins with ankle or leg oedema varicose eczema thrombophlebitis haemosiderin skin staining lipodermatosclerosis atrophie blanche.
Venous ulcer management
leg elevation and increased exercise
regular lifestyle changes
Antibiotics should only be prescribed with clinical evidence of a wound infection (most wounds are colonized, therefore swab results should only be acted upon if evidence of infection).
Multicomponent compression bandaging
What is the mainstay treatment for venous ulcers
Multicomponent compression bandaging
Features of arterial ulcers
- small deep lesions
- well-defined borders
- necrotic base
- painful
- absent pulses
- limbs will be cold
They most commonly occur distally at sites of trauma and in pressure areas (e.g the heel).
A patient with a suspected arterial ulcer is likely to give a preceding history of intermittent claudication (pain when they walk) or critical limb ischaemia (pain at night).
Where do you see arterial ulcers
Pressure loading points on the foot
- toes
- heel
Imaging for arterial ulcers
USS doppler
CT/MR angiography (CTA/MRA)
What are the 2 most common causes of neuropathic ulceration
Diabetes and vitamin b12 deficiencies
Features of neuropathic ulcers
neuropathic ulcers are variable in size and depth, with a “punched out appearance”
Painless
Remember a ddx for stroke is
Carotid artery disease
Varicose vein definition
Varicose veins are tortuous dilated segments of vein associated with valvular incompetence.
What is the main cause of varicose veins
Idiopathic(98%)
What are some risk factors for Varicose veins-4
Prolonged standing
Pregnancy
Obesity
Family Hx
Gold standard for varicose vein investigations is via
duplex ultrasound (best done by a trained technician)
assessing valve incompetence at the great/short saphenous veins and any perforators. Deep venous incompetence, occlusion (deep venous thrombosis) and stenosis must also be actively looked for.
What are the surgical indications for varicose veins
1) Symptomatic–>Worsening varicose veins may then cause pain, aching, swelling (often worse on standing or at the end of the day), or itching. Subsequent complications may include skin changes, ulceration, thrombophlebitis or bleeding.
2) Lower‑limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufficiency
3) Superficial vein thrombosis (characterised by the appearance of hard, painful veins) with suspected venous incompetence
4) A venous leg ulcer (a break in the skin below the knee that has not healed within 2 weeks)
What are the 3 surgical options for varicose veins
1) Vein ligation, stripping and avulsion
2) Foam sclerotherapy
3) Thermal ablation
In young woman, if secondary hypertension is suspected think of these 1st
1) Renal artery stenosis
2) Fibromuscular dysplasia
What is the blood supply to the GIT
coeliac trunk, superior mesenteric artery (SMA), and/or inferior mesenteric artery (IMA).
What are the watershed areas of the gut and what is the arterial supply present there
The splenic flexure and the rectosigmoid junction are at high risk for colonic ischemia because they are “watershed areas”.
The SMA and IMA anastomose via the marginal artery of the colon (artery of Drummond)
SMA supplies
supplies the distal duodenum, jejunum, ileum, and the right colon from the cecum to the splenic flexure
IMA supplies
supplies the left colon from the splenic flexure to the rectum
What is a classic presentation of a mesenteric ischemia patient
A classic case of ischemic colitis is a patient who presents with bloody diarrhea and severe abdominal pain after an abdominal aortic aneurysm repair!
What are the two conditions in the umbrella term of chronic venous disease
- Varicose veins
2. Chronic venous insufficiency:increased venous pressure resulting in alterations of the skin and veins
Venous ulcers are mostly found in the
Most frequently occur just above the ankle (gaiter region)
Shallow ulcer with irregular borders
Usually only mild pain, pruritic
What are causes
1) Hypercoagulability: increased platelet adhesion, increased clotting tendency (thrombophilia)
2) Endothelial damage: inflammatory, traumatic
3) Stasis (venous): varicosis, external pressure on the extremity, immobilization, local application of heat
To remember the three pathophysiological components of thrombus formation, think: “HE’S Virchow”: H-Hypercoagulability, E-Endothelial damage, S-Stasis.
What is Homan’s sign
Homan sign: calf pain on dorsal flexion of the foot
What are some of the criteria for Well’s score for DVT
-what is the cutoff for criterion
Active cancer
Previously documented DVT
Paralysis or recent (cast) immobilization of lower extremity
Recent bedridden or major surgery
clinical symptoms
Swelling of the entire leg
Calf swelling ≥ 3 cm compared to asymptomatic calf
Unilateral pitting edema in symptomatic leg
< 2: DVT unlikely (low risk)
≥ 2: DVT likely (high risk)
What is your ddx for DVT
- Muscle or soft tissue injury (i.e., posttraumatic swelling or hematoma)
- Lymphedema
- Venous insufficiency
- Ruptured popliteal cyst
- Cellulitis
- Compartment syndrome
Post-op AAA repair, what are you worried about in the abdomen
Acute mesenteric ischemia
Acute abdomen-R) shoulder or scapula
Biliary colic
Acute abdomen- to the groin
Renal colic
Acute abdomen- Periumbilical to right lower
quadrant (RLQ)
Appendicitis
What anatomical landmark differentiates upper GI bleeding vs lower GI bleeding
bleeding from a source proximal to the ligament of Treitz and bleeding from a source distal to the ligament of Treitz
What is the most common cause of UGIB
PUD
What is the most common cause of LGIB in an old person
Colon cancer
What should not be performed in LGIB
Barium enema
LGIB-what is the thing you are going to do
Initial management with colonoscopy to detect and potentially stop the source of bleeding
How do you differentiate the different types of jaundice biochemical
- hepatocellular
- cholestatic
- haemolysis
Hepatocellular: Elevated bilirubin + elevated ALT/AST
Cholestatic Elevated bilirubin+elevated ALP/GGT ± duct dilatation upon biliary U/S
Hemolysis: decrease haptoglobin increased LDH
What are the 5Ws of post-op fever
Wind POD#1-2 (pulmonary – atelectasis, pneumonia)
Water POD #3-5 (urine – UTI)
Wound POD #5-8 (wound infection - if earlier think streptococcal or clostridial infection)
Walk POD #8+ (thrombosis – DVT/PE)
Wonder drugs
POD #1+ (drug)
7A’s of medications of surgery
Analgesia Anti-emetic Anticoagulation Antibiotics Anxiolytics Anticonstipation All other patient meds(home meds, stress dose steroids, and β-blockers)
What is the most common cause of post-op oliguria/anuria
-state some causes of it
pre-renal vs renal vs post-renal
Most common post-operative cause is prerenal ± ischemic ATN
external fluid loss: hemorrhage, dehydration, and diarrhea
internal fluid loss: third-spacing due to bowel obstruction, and pancreatitis
The most common cause of post-op dyspnea
ATELECTASIS
What is the treatment options for atelectasis in surgery
-pre and post
pre-operative prophylaxis
■ smoking cessation (best if >8 wk pre-operative)
• post-operative prophylaxis
■ incentive spirometry, deep breathing exercise, chest physiotherapy, and intermittent positive-
pressure breathing
■ minimize use of respiratory depressive drugs, appropriate pain control, and early ambulation
New onset of “asthma” and wheezing in the elderly is___________ until proven otherwise
cardiogenic
-pulmonary edema
Pulmonary edema-LMNOP
Lasix Morphine Nitrates Oxygen Position
What are the common MI complications post-op
Common arrhythmias: supraventricular tachycardia, atrial fibrillation (secondary to fluid overload,PE, and MI)
What are the 6S of SCC’s
Smoking Spirits (alcohol) Seeds (betel nut) Scalding (hot liquid) Strictures Sack (diverticula)
What are the CXR findings you will see with oesophageal rupture
pneumothorax pneumomediastinum pleural effusion subdiaphragmatic air and widened mediastinum
Barrett’s oesophagus usually precedes
-Barrett’s is a complication of ___
Adenocarcinoma
GERD
What are the early and late stages of oesphgeal cancer
Early stages: Often asymptomatic but may present with swallowing difficulties or retrosternal discomfort
Late stages Common 1. Progressive dysphagia (from solids to liquids) with possible odynophagia 2. Weight loss 3. Retrosternal chest or back pain 4. Anemia
Less common
- Hematemesis, melena
- Hoarsenes
Triad of Borehaave syndrome
- Vomiting and/or retching
- Severe retrosternal pain that often radiates to the back
- Subcutaneous or mediastinal emphysema → crepitus in the suprasternal notch or “crunching” or “crackling” sound on chest auscultation (Hamman’s sign), respectively
What is the most common cause of esophageal perforation
Iatrogenic esophageal perforation: most common cause of esophageal perforation
What is the number you should be concerned about in urine-ouput in surgical patients
If a patient has a urine output < 0.5 mL/kg/hour for > 6 hours: Check catheter patency.
Post-op nausea and vomitting- state 2 causes which are procedure or treatment-related
Volatile general anesthetics including nitrous oxide
Perioperative opiate use
PONV-<1 week after surgery, the cause is
< 1 week after surgery: self-limiting gastric or intestinal atony, or a more severe paralytic ileus
PONV- > 1 week after surgery, the cause is
> 1 week after abdominal surgery: early mechanical bowel obstruction
What are the 4 clinical features of paralytic ileus
Failure to pass flatus
Nausea and vomiting may be present.
Abdominal distention may be present.
Absence of bowel sounds on auscultation
What are the main symptoms of bowel obstruction(5)
nausea vomiting abdominal pain abdominal distention, constipation or obstipation.
Bowel sounds are absent think
Paralytic ileus
the high-pitched tinkling sound would be heard in the early phase of a
Mechanical sound obstruction
What is third spacing
In medicine, the term is often used with regard to loss of fluid into interstitial spaces, such as with burns or edema, but it can also refer to fluid shifts into a body cavity (transcellular space), such as ascites and pleural effusions.
In paralytic ileus, what do you see in CT/AXR- like how do you differentiate where the obstruction is
In paralytic ileus, findings include generalized dilatation of bowel loops with no transition point and air that is visible in the rectum.
On MMG, what type of pattern is most common of breast cancer
spiculated/ star burst pattern
Mammogram findings suspicious for
breast cancer:
Mass- especially spiculated (90% are maligant)
Distortion
Microcalcifications
Concerning USS features for breast lump-5
Taller than wide Calcifications Irregular Invasion Acoustic shadowing Hypoechoic Not compressible and not mobile Feeding vessel or increased vascularity
DCIS
Ductal carcinoma in situ (DCIS) is the presence of abnormal cells inside a milk duct in the breast. DCIS is considered the earliest form of breast cancer. DCIS is noninvasive, meaning it hasn’t spread out of the milk duct and has a low risk of becoming invasive
What are some management options for breast cancer patients
1) Surgical (Breast)
◦ Breast-conserving surgery vs mastectomy
◦ Reconstruction (implant vs flaps)
2) Surgical (Axilla)
◦ Sentinel Lymph node biopsy
◦ Axillary clearance for proven involved LN
3)Radiation therapy
◦ Adjuvant or neoadjuvant
Chemotherapy
◦ Adjuvant or neoadjuvant
Hormone therapy for endocrine receptive tumours–> Herceptin for HER2 overexpression
What are the surgical options for hernia repair
- Surgical mesh repair (hernioplasty)
- Surgical hernia repair (herniorrhaphy)
Open vs lap
What are the different types of colorectal procedures
-right hemicolectomy
-left hemicolectomy
- sigmoid colectomy
- anterior resection(AR) – (for low sigmoid OR high rectal tumours)
- Abdominoperineal resection(APR) – (permanent colostomy & removal of rectum & anus)
- Hartman procedure – (surgical resection of rectal-sigmoid
colon with the closure of rectal stump & colostomy)
small bowel is opened to the skin- what is the surgical procedure
ileostomy
when the large bowels are opened to the skin-hat is the surgical procedure
colostomy
What are the bowel sounds in bowel obstruction heard:
early and then late
High-pitched, tinkling bowel sounds (early)
Absent bowel sounds (late)
Why is tympanic percussion seen in bowel obstruction
Due to gaseous distention of the bowel
What is the conversation management of bowel obstruction
Fluid resuscitation, correction of electrolyte imbalance
Intestinal decompression: nasogastric tube insertion
Bowel rest (NPO)
Administration of IV analgesics and antiemetics
Gradual increase of oral intake, starting with clear fluids, can be initiated once the abdominal pain and distention subside and bowel sounds return to normal.
Old patient, not popping, what is the cause of bowel obstruction
Fecal impaction, is a cause of LBO
What are 4 indications for a surgical approach to bowel obstruction
- Suspected bowel obstruction and hemodynamic instability or features of sepsis
- Complete bowel obstruction with signs of ischemia/necrosis or clinical deterioration
- Persistent partial obstruction (> 3–5 days)
- Closed-loop obstruction
The common causes of paralytic ileus can be memorized using “5 Ps”:
Peritonitis, Postoperative, low Potassium, Pelvic and spinal fractures, and Parturition
What are the 2 main reasons for surgical indication any bowel obstruction-paralytic or mechanical
1) Sepsis
2) Haemodynamically instability
What is the most common site of volvulus, and what is the second most common site
Sigmoid colon
Cecum
What is the treatment for sigmoid volvulus
1)Initial resuscitation: IV fluids; acid-base and electrolyte imbalance correction; nil per oral; placement of a nasogastric tube
2) Evaluation
No signs of peritonitis: rigid/flexible sigmoidoscopic detorsion of the volvulus → inspection of the mucosa for signs of ischemia
No signs of mucosal ischemia → placement of a soft rectal tube (for bowel decompression) → semi-elective surgery within 72 hours of detorsion
Signs of mucosal ischemia → emergency surgery
Signs of peritonitis/unsuccessful endoscopic detorsion → broad-spectrum IV antibiotics and emergency surgery
3) Surgery
Sigmoid colectomy and primary anastomosis: indicated in hemodynamically stable patients with viable bowel
Hartmann’s procedure: indicated in hemodynamically unstable patients or those with ischemic/gangrenous bowel
Why is Hartmann’s procedure done in some people
Hartmann’s procedure is faster to perform than sigmoid colectomy with anastomosis and is the preferred procedure in hemodynamically unstable patients. Primary anastomosis is avoided in patients with gangrenous bowel because of the high risk of anastomotic leak.
-basically if making an anastomosis is unsafe–> then you should do Hartmann
you can decide on rejoining them later
Absent cough impulse indicates
An obstructed or strangulated hernia
Congenital umbilical hernia, what is the treatment
Conservative: ∼ 90% will spontaneously close by 5 years of age(The likelihood of spontaneous closure decreases with increasing age and size of the umbilical hernia)
What are some causes of anal abscess and then anal fistula(abscess become fistula over time)
Most common cause: flow obstruction and infection of the anal crypt glands (90% of cases)
Less common causes
Chronic inflammatory bowel disease (IBD): Crohn’s disease, ulcerative colitis (less commonly)
Acute infections of the gastrointestinal tract: e.g., complicated diverticulitis, acute appendicitis
Radiation-induced proctitis
Iatrogenic
Foreign body
Malignancy: e.g., colorectal cancer
What are the treatment options for fistula(in general too)
Fistulotomy (standard approach)
Possible seton placement (enables adequate drainage and fibrosis)
Possible fibrin glue or fistula plug
What is the treatment for anal abscess, what can you do post-op for anal abscess
Early surgical incision and drainage
Postoperative
Sitz baths
Analgesics and stool softeners
bright red blood per rectum is called
(hematochezia)
What is the treatment for anal fissures
NEED TO EXCLUDE IBD
Conservative
Dietary improvement (e.g., adequate ingestion of dietary fiber and water)
Stool softeners (e.g., docusate)
Anti‑inflammatory and analgesic creams and/or suppositories (e.g., 2% lidocaine jelly)
Sitz baths
Local anesthetic injection
Topical vasodilator therapy: calcium channel blocker gel (e.g., nifedipine) or glyceryl trinitrate ointment (GTN)
What medication can be given for anal fissures
Topical vasodilator therapy: calcium channel blocker gel (e.g., nifedipine) or glyceryl trinitrate ointment (GTN)
What are the features of rectal cancer(Which is a kind of CRC)
Hematochezia ↓ Stool caliber (pencil-shaped stool) Rectal pain Tenesmus Flatulence with involuntary stool loss
Which modality of therapy is not used a treatment option for colorectal cancer
Radiation therapy is not a standard modality in the treatment of colon cancers!
What are the surgical approaches for rectal cancer
Transanal excision–> Procedure: minimally invasive excision of small superficial tumours
Low anterior resection (LAR)
Abdominoperineal resection (APR)
What is the 1st sign of Crohn’s Disease
Perianal fistulas and abscesses are often the first signs of Crohn disease!
What is the treatment for CD- acute
- minor
- major
Acute minor–> Predsinolone PO ( for 12 to 16 weeks)
Acute severe–> Hydrocordisone IV (4-7 days and then switch to oral)
What is the maintenance therapy for Crohn’s disease
Azathioprine PO (immunosuppresant) PLUS: Prophylactic heparin and anti-embolic stockings (due to the prothrombotic state of IBD flares).
What is the criterion used for Ulcerative colitis to assess severity
Truelove and Witts’ severity index
YES eTG uses this criterion, thus Australia recognized!!
Example, Acute severe ulcerative colitis is defined (according to the Truelove and Witts criteria) by the presence of 6 or more bloody stools per day, plus at least one of the following:
temperature more than 37.8ºC
heart rate more than 90 beats/minute
haemoglobin less than 105 g/L
erythrocyte sedimentation rate more than 30 mm/hour.
What are the 4 main intestinal symptoms of UC
- Bloody diarrhea with mucus
- Fecal urgency
- Abdominal pain and cramps
- Tenesmus
If UC thinks(whats the other condition)
PSC
Treatment for UC- acute
-mild-moderate
Oral Sulfasalazine + Mesalazine rectal
moderate to severe- Oral Azathioprine
Treatment fo UC- a medical emergency
IV Hydrocortisone(3 to 5 days) PLUS: Prophylactic heparin and anti-embolic stockings (due to the prothrombotic state of IBD flares).
What is the maintenance therapy for UC
oral 5-aminosalicylates: Oral Sulfasalazine
Modified Hinchey classification of diverticulitis I II III IV
Stage Description
I Diverticulitis with a confined pericolic abscess
II Diverticulitis with distant abscess formation
III Perforated diverticulitis with generalized purulent peritonitis
IV Perforated diverticulitis, free communication with the peritoneum, generalized fecal peritonitis
What investigation should not be performed in acute inflammation of diverticulitis
Not indicated during an acute episode → ↑ risk of perforation and exacerbating diverticulitis
Performed once the inflammation has subsided (after 6 weeks) to assess extent of diverticulitis and rule out malignancy
What is the treatment for diverticula that is present
No treatment can reverse the growth of existing diverticula
How do you guide your management of diverticulitis
eTG
Management depends on if complicated or un-complicated
Complicated (severe) diverticulitis refers to diverticulitis with a positive blood culture result, perforation, peritonitis, sepsis or septic shock, or an abscess larger than 5 cm in diameter. Diverticulitis without any of these features is considered uncomplicated—see Uncomplicated (nonsevere) diverticulitis
Uncomplicated Diverticulitis Management
No antibiotics required unless-
immune compromise
right-sided diverticulitis
failure to improve after 72 hours of conservative treatment (ie no antibiotic therapy)
Amoxicillin+clavulanate
Complicated Diverticulitis Management
Bowel rest, IV Anti-biotics, IV fluids and respective surgical management
Gentamicin + Metronidazole + Amoxicillin
6-8 weeks later- colonoscopy to rule out bowel cancer (no colonoscopy in the acute inflammatory stage as may lead to perforation)
Pre-Operative Management mnemonic
RAPRIOP
Reassurance, Advice, Prescription, Referral, Investigations, Observations, Patient understanding and follow-up:
Commonly stopped medications can be remembered as ‘CHOW’.
Clopidogrel – stopped 7 days prior to surgery due to bleeding risk. Aspirin and other anti-platelets can often be continued and minimal effect on surgical bleeding
Hypoglycaemics
Oral contraceptive pill (OCP) or Hormone Replacement Therapy (HRT) – stopped 4 weeks before surgery due to DVT risk. Advise the patient to use alternative means of contraception during this time period.
Warfarin – usually stopped 5 days prior to surgery due to bleeding risk and commenced on therapeutic dose low molecular weight heparin
Surgery will often only go ahead if the INR <1.5, so you may have to reverse the warfarinisation with PO Vitamin K if the INR remains high on the evening before
Bowel prep required or not
-go through the different general surgery procedures
Upper GI, HPB, or small bowel surgery: none required
Right hemi-colectomy or extended right hemi-colectomy: none required
Left hemi-colectomy, sigmoid colectomy, or abdo-peroneal resection: Phosphate enema on the morning of surgery
Anterior resection: 2 sachets of picolax the day before or phosphate enema on the morning of surgery
Is anorectal varices and haemorrhoids the same thing
NO
Hemorrhoids are not varicose veins (widening of the veins)! However, anorectal varices do exist and may occur, e.g., as a result of portal hypertension. The terms anorectal varices and hemorrhoids are often used interchangeably, but this is incorrect.
What is the treatment for haemorrhoids and what does it depend on
Depends on the staging Grade I-II–> conservative management
Grade III-IV–> surgical management is warranted
What is the procedure used for resection of cancer of the head of the pancreas
Whipple procedure
The most commonly used surgical technique is the pancreaticoduodenectomy (“Whipple procedure”).
What is the treatment approach for cholangitis
supportive therapy, intravenous antibiotics → urgent biliary decompression → prevention of recurrence with interval cholecystectomy if there is concurrent cholelithiasis
ERCP–> therapeutic and diagnostic
ERCP is the treatment of choice, possibly in combination with Percutaneous transhepatic cholangiography (PTC) if ERCP is unsuccessful or unavailable(look if the bile ducts are consistent)
Treatment of choice for Cholelithiasis
cholecystectomy
supportive therapy and dietary modifications → elective cholecystectomy only for symptomatic patients who are surgical candidates or asymptomatic patients at risk of gallbladder cancer
Treatment of choice for choledocholithiasis
Endoscopic retrograde cholangiopancreatography (ERCP)
Both diagnostic and therapeutic
Surgical approach for cholecystitis- the severity of symptoms
In mild cases: elective cholecystectomy within 24–72 hours
If complications are present (e.g., gangrene, perforation) or condition worsens despite conservative therapy → emergency cholecystectomy
In severe, high-risk cases: delayed elective cholecystectomy (> 2 weeks)
On USS for cholecystitis, what will you see-4
Gallbladder wall thickening > 4 mm (postprandial > 5 mm)
Gallbladder wall edema (double wall sign)
Possible free fluid surrounding the gallbladder
Sonographic Murphy sign
Presence of concrement or gallstones
Treatment of choice for cholecystitis
broad-spectrum antibiotics and supportive therapy → surgical management with cholecystectomy
Fluid management- maintenance guidelines
Current NICE guidelines suggest the following:
Water: 25 mL/kg/day
Na+: 1.0 mmol/kg/day
K+: 1.0 mmol/kg/day
Glucose: 50g/day
low K+, low Cl–, and alkalosis indicated
Diarrhea
low K+ and acidosis
Vomiting
What is the most common cause of hyperkalaemia
renal impairment or iatrogenic(so post-op surgery)
Which two substances move insulin intracellular
1) Insulin
2) Salbutamol
What are some ECG changes with hypokalaemia
1) Elongated PR interval
2) T wave flattening* or T wave inversion
3) Prominent U wave*
4) ST-segment depression
Why should you not correct hypernatremia levels too quickly
Increase the risk of cerebral edema
Most common post-op electrolyte imalance
Hyponatremia
In individuals with a chronic hyponatraemia, rapid sodium correction can cause
Central pontine myelinolysis
Anastomotic leak- clinical features
abdominal pain and fever.
They usually present between 5-7 days post-operatively. Other features* may include delirium or prolonged ileus.
Twinkling bowel sounds
Mechanical bowel obs- SBO and LBO
Absent bowel sounds
Functional bowel obs/paralytic ileus
The mainstay treatment for paralytic ileus
The mainstay of management is NBM +/- NG tube, IV fluids, mobilisation, correct electrolyte abnormalities, and avoid bowel mobility reducing medication(pain medication)
What is the common histological type of breast cancer, and which tissue does it arise
Most breast cancers are adenocarcinomas, arising from ductal tissue (80%) or lobular tissue (20%).
What breast cancer is the most
Invasive ductal carcinoma
What is Paget’s disease of the breast
a ductal carcinoma (usually adenocarcinoma- either in situ or invasive) that infiltrates the nipple and areola
What are some clinical features of Paget’s disease of the breast
Erythematous, scaly, or vesicular rash affecting the nipple and areola
Pruritus, burning sensation, nipple retraction
The lesion eventually ulcerates → blood-tinged nipple discharge
What ddx should be considered in Paget’s disease of the breast
Mamillary eczema
Peau d’orange which cancer does it appear in
Inflammatory breast cancer
Erythematous and edematous (peau d’orange) skin plaques over a rapidly growing breast mass
Inflammatory breast cancer-what is it?
It is a rare form of advanced, invasive carcinoma, characterized by dermal lymphatic invasion of tumor cells. Most commonly a ductal carcinoma.
What is the most common benign condition in breast condition
Fibrocystic changes in the breast–> Premenstrual bilateral breast pain
Tender breast nodules
Solitary, well-defined, non-tender, rubbery and mobile mass
Well-defined mass
Possibly popcorn-like calcifications
What do you think
Fibroadenoma
Most common breast mass in women < 35 years
Fibroadenoma
Bloody nipple discharge in breast condition
Intraductal papilloma
Perimenopausal woman
Unilateral greenish or bloody discharge
Nipple inversion
Firm, stable, painful mass under the nipple
Mammary duct ectasia
Premenstrual bilateral breast pain
Tender or non-tender breast nodules
Clear or slightly milky nipple discharge
Fibrocystic changes in the breast
greenish discharge from the breast
Mamillary duct ectasia
Phyllodes tumour- should we be concerned
Commonly benign, however, 25% can be malignant
Painless, smooth, multinodular lump in the breast
Variable growth rate: may grow slowly over many years, rapidly, or have a biphasic growth pattern
Average size 4–7 cm
USS/Mammography
Focal mass or density with poorly defined margins
Spiculated margins
Clustered microcalcifications
Benign or malignant?
Malignant features :(
A rapidly growing breast mass
Tenderness, burning sensation
Axillary lymphadenopathy
Blood-tinged
Inflammatory breast cancer
Trastuzumab
Trastuzumab is a monoclonal antibody that inhibits tumor growth by binding to the epidermal growth factor HER2
Triple-negative breast cancer
Estrogen receptor, progesterone receptor, and HER2 negative
All negative
Paraneoplastic syndrome of breast cancer, what can you get
Paraneoplastic syndrome: hypercalcemia of malignancy
What are the prognostic factors for breast cancer
1) Axillary lymph node status (most important prognostic factor)
2) Tumour size
3) Patient’s age
4) Receptor status (ER/PR-negative and triple-negative disease are associated with a worse prognosis)
- Histologic grade and subtype
What are the common postoperative complications with a thyroidectomy-4
Postoperative complications include
- hematoma formation
- hypoparathyroidism
- nerve palsy (recurrent/superior laryngeal nerve)
- hypothyroidism.
What are some things some the advice you can give a patient who is booked in for a thyroidectomy
-pre-op advice
Achieve euthyroid status preoperatively.
In hyperthyroidism to minimize the risk of thyroid storm
Thioamides
Iodides (potassium iodide)
Beta blockers (e.g., propranolol)
In hypothyroidism: thyroid hormone replacement
Preoperative oral calcium and vitamin D supplementation
Preoperative direct/indirect laryngoscopy
Just say this as well :)
The approach to surgery is very individualized. The conversation with your surgeon will include the type of operation, type of anesthesia, risks of the operation, expected length of hospitalization, and the follow up that will be necessary after your operation
What is the most common post-op complication with thyroidectomy
Transient/permanent postoperative hypoparathyroidism (most common) or hypothyroidism
Most common malignant thyroid nodule
Papillary carcinoma
Which inguinal hernia are common
Indirect
What is the cause of an indirect inguinal hernia
Congenital or acquired condition
Due to patent processus vaginalis-Outpouching of the parietal peritoneum that extends through the inguinal canal; normally obliterated by birth
What is the main idea of surgical intervention in inguinal hernia repair
Main idea: reinforcement of the posterior wall of the inguinal canal with synthetic mesh or primary tissue approximation
What are the complications of inguinal hernia surgery
1) Vas deferens injury
2) Spermatic vessels injury, dissection, or constriction, which may lead to testicular necrosis
3) Injury to femoral nerve, artery, or vein
4) Chronic inguinal pain
5) Bladder injury
6) General risks of surgery (see laparoscopic surgery and perioperative management)
What is the difference between inguinal hernia and femoral hernias
In contrast to indirect inguinal hernias, which may occur congenitally, femoral hernias are almost always acquired.
DDx for femoral hernia
Direct or indirect inguinal hernias Femoral pseudohernia Lipoma Lymph node enlargement Femoral artery aneurysm Saphenous varix Psoas abscess
Treatment of femoral hernia
Non-complicated femoral hernia: early elective surgical repair with mesh hernioplasty (tension-free repair)
Complicated femoral hernia: herniorrhaphy (non-mesh repair)
All femoral hernias should be surgically repaired because of the high risk of complications.
Should you reduce a strangulated femoral hernia
Strangulation: ischemic necrosis of contents within the hernia sac as blood flow is compromised due to incarceration
Warm, tender, and erythematous/discoloured swelling
Features of mechanical bowel obstruction
Reduction of a strangulated hernia should not be attempted because generalized peritonitis would occur following reduction of strangulated bowel loops!
A femoral hernia should be considered among 40–70-year-old women presenting with signs of mechanical bowel obstruction!
In liver disease why does INR go up
INR increased due to malabsorption of Vit K
PRESENTATIONS IN OBSTRUCTIVE JAUNDICE
Pain- Probably Benign Painless- Probably Malignant Icterus/ Courvoisier Cholangitis- Charcot Dark urine and Pale Stools/ Floaters Cachexia and weight loss Abdominal distension Pruritis Depression
Investigation of the jaundiced patient-
• Two tests central to differentiation
From these tests-what is pathognomic for obstructive jaundice
- Serum bilirubin, conjugated or not
- Ultrasound- Ducts dilated or not. May also suggest the diagnosis
• Thus conjugated hyperbilirubinaemia with dilated ducts, is pathognomonic of obstructive jaundice.
Breast cancer comes back positive for these receptors
1) ER and Progesterone
2) HER-2
Which drugs can we give them
-which women gets what?
1) Tamoxifen or aromatase
SERM if premenopausal (e.g. tamoxifen) or aromatase inhibitors if postmenopausal (e.g.
anastrozole); optimal duration 5-10 yr
2) HER-2–> herceptin
Why don’t you use tamoxifen in post-menopause woman
The side effect profile equal menopausal symptoms–> hence their menopausal symptoms get exacerbated
Endometrial cancer risk factors
