Surgery - General Flashcards
1
Q
What are the most common causes of small and large bowel obstruction?
A
- Most common small bowel causes = adhesions, hernia
- Most common large bowel causes = malignancy, diverticular disease, volvulus
2
Q
How does bowel obstruction present?
A
- Presentation
- Abdo pain (colicky or crampy)
- Vomiting (early in proximal, late in distal)
- Abdo distension
- Absolute constipation (early in distal, late in proximal)
- O/E
- Surgical scars (adhesions etc), hernia, abdo distension
- Assess fluid status
- Tympanic on percussion
- Tinkling bowel sounds on auscultation
- Abdo tenderness (but if there is guarding/rebound tenderness then suspect ischaemia!!! Do vbg for lactate)
3
Q
How would you investigate and manage bowel obstruction?
A
- Investigations
- Definitive = ct abdo pelvis with iv contrast
- Differentiates between pseudo-obstruction and mechanical too
-
AXR
- S bowel = dilated >3cm, central, valvulae conniventes (lines totally across bowel)
- L bowel = dilated >6cm or >9cm in caecum, peripheral, haustra visible (incomplete lines across bowel)
- In perforation you can see Riglers sign (both sides of bowel visible) or psoas sign (loss of sharp delineation of psoas muscle border)
- Erect CXR if suspected bowel perf = pneumoperitoneum
- Definitive = ct abdo pelvis with iv contrast
- Management
- Conservative = “drip and suck”
- NBM + NG tube to decompress bowel
- IV fluids and correct electrolytes
- Urinary catheter, fluids
- Analgesia, anti-emetics
- Adhesions = usually conservative unless strangulated/ischaemic
- Do water soluble contrast study if not resolved in 24 hours
- If contrast does not reach colon in 6 hours then take to theatre as it is unlikely to resolve
- Conservative = “drip and suck”
- Surgical = generally a laparotomy, sometimes resection + stoma
- For ischaemia or closed loop bowel obstruction
- Or if patients treated conservatively don’t improve
4
Q
What two ways does an upper GI bleed present as?
A
Melena (black tarry offensive smelling stools)
Haematemesis (vomiting blood)
5
Q
What are some differentials for an upper GI bleed?
A
-
Peptic ulcer disease
- Most signif bleeding if ulcer erodes through posterior gastric wall into gastroduodenal artery (also common in lesser curve of stomach)
- Suspect in nsaids or steroids, dyspepsia like hx, h pylori positive
-
Variceal bleeds
- Commonly Oesophageal varices due to alcoholic liver disease
- Upper gi malignancy
-
oesophagitis
- inflammation of intraluminal epithelial layer of the oesophagus
- due to GORD (most common), or infections (candida albicans), meds (bisphosphonates), radiotherapy, crohns
-
Mallory Weiss tear
- Recurrent vomiting then haematemesis
- Forceful vomiting causes a tear in the epithelial lining of the oesophagus
- Meckels diverticulum
- Vascular malformations eg. dieulafoy lesion
6
Q
How would you investigate an upper GI bleed generally?
+ scoring systems
A
- Investigations
- Oesophagogastroduodenoscopy is definitive
- CT abdo with iv contrast to assess any active bleeding
- Fbc, u&es, lfts, clotting, group and save, abg
- Erect cxr if perforated peptic ulcer suspected
- Glasgow-Blatchford Bleeding score for upper gi bleeds
- Rockall severity score for GI bleeding post endoscopy
- AIMS65 score for risk of in-hospital mortality from upper gi bleed
7
Q
How would you manage an upper GI bleed generally?
(peptic ulcer and varices too)
A
- Peptic ulcer
- During OGD, give adrenaline injection** and **cauterise bleeding.
- High dose ppi eg. iv 40mg omeprazole
- Active bleeding can be treated with angio-embolisation
- Oesophageal varices
- Endoscopic banding
- Prophylactic antibiotics
- Somatostatin analogues (eg. octreotide) or vasopressors (eg terlipressin) to reduce splanchnic blood flow
- Sengstaken-Blakemore tube for uncontrollable/severe
- Longterm = repeated banding and long term BB
- Blood products for hb<70g/L
- FFP+/- platelets for impaired liver function
- Reversal agents for anticoagulants
8
Q
What are some differentials for a lower GI bleed?
A
-
Diverticular disease
- Outpouchings of bowel wall consisting of mucosa
- Commonly in descending and sigmoid colon
- Diverticular disease bleeds are painless
- Diverticulitis bleeds are painful
- Ischaemic/infective colitis
-
Haemorrhoids
- Engorged vascular cushions in anal canal
- Blood on surface of stool not mixed
-
Malignancy
- In elderly, always suspect colorectal cancer
- Angiodysplasia
- Crohns
- UC
- Radiation proctitis
9
Q
How would you investigate and manage a lower GI bleed? and scoring systems
A
Investigations
- Oakland score (stratifies if pt with lower gi bleed can be managed as outpatient)
- Fbc,u&es, lfts, clotting, group and save, stool cultures
- Urgent ct angiogram for haemodynamically unstable (can embolise during)
-
Flexi sigmoidoscopy
- Full colonoscopy if nothing on flexi sig
- OGD if nothing on colonoscopy
- Capsule endoscopy or mri small bowel can also be done
Management
- A-e resus
- Packed rbc for hb<70, reverse anticoagulation
- Endoscopic haemostasis methods eg. adrenaline injection
- surgical
10
Q
What are risk factors of GORD?
A
- male, old age, obesity, alcohol, smoking, caffeine, spicy food
11
Q
How dose GORD present?
A
-
Burning retrosternal chest pain (worse after meals, lying down, bending over, straining)
- Relieved by antacids
- Excessive burping
- Odynophagia
- chronic/nocturnal cough
12
Q
How would you investigate and manage GORD?
A
Investigations
- Los Angeles classification of reflux oesophagitis
-
OGD to rule out red flags for upper gi malignancy
- Dysphagia
- >55 with weight loss, upper abdo pain, dyspepsia, reflux
- OGD also investigates oesophagitis, structuring, barretts
- Gold standard for GORD = 24 hour pH monitoring
- Oesophageal manometry to rule out oesophageal dysmotility
Management
- Conservative
- Avoid alcohol, coffee, fatty foods
- Weight loss
- Smoking cessation
- PPIs
- Surgical
- Fundoplication (se = bloating, dysphagia, inability to vomit)
13
Q
What are the two kinds of oesophageal cancer?
How would they present?
A
Squamous cell = middle and upper 1/3 of oesophagus
- Risk factors = smoking, alcohol, low vit a, chronic achalasia
Adenocarcinoma = lower 1/3 of oesophagus
- Risk factors = barretts (metaplastic epithelium that progresses to dysplasia), GORD, obesity, high fat intake
Presentation
- Progressive dysphagia (solids first)
- Weight loss, cachexia, supraclavicular lymphadenopathy
- Odynophagia
14
Q
How would you investigate and manage oesophageal cancer?
A
Investigations
-
Urgent OGD in 2weeks
- Biopsy and send to histology
- CT CAP and PET CT for mets
- Endoscopic US to assess penetration into oesophageal wall (T stage)
- Staging laparoscopy for intraperitoneal mets
- Fine needle aspiration of palpable cervical lymph nodes
- Bronchoscopy for hoarseness or haemoptysis
Management
- Definitive
- SCC = difficult to operate on so usually chemoradiotherapy
- Adenocarcinoma = neoadjuvant chemo or chemoradiotherapy, followed by oesophageal resection
- Most will need a feeding jejunostomy after surgery to aid nutrition
- Surgery risks = anastomotic leak, pneumonia etc
- Palliative
- Oesophageal stent for difficulty swallowing
- Radiotherapy/chemotherapy to reduce tumour size/bleeding
- Nutritional support = thickened fluid and nutritional supplements
- Radiological inserted gastrostomy (RIG) tube insertion for severe dysphagia
15
Q
Oesophageal tears:
Boerhaave’s Syndrome is full thickness, Mallory Weiss is lacerations of the mucosa.
How does Boerhaave’s present?
A
- Stomach contents leak into mediastinum and pleural cavity
- Severe inflammatory response and multi organ failure
- Causes = iatrogenic like endoscopy or forceful vomiting
- Presentation
- Severe sudden onset retrosternal chest pain, resp distress, subcutaneous emphysema
- Hx of severe vomiting and retching
- Mackler’s triad = vomiting, chest pain, subcut emph
16
Q
How would you investigate and manage Boerhaaves?
A
Investigations
- Fbc, u&es, lfts, clotting
- Definitive = urgent ct abdo pelvis with iv and oral contrast
- Cxr for pneumomediastinum or intrathoracic air fluid levels
- If high clinical suspicion, just do urgent endoscopy in theatre
Management
- A-e resus
- Surgical
- Endoscopy to determine site of perf
- Thoracotomy to Control leak and wash out chest
- Do a contrast ct at 10 days before starting oral intake as leaking is common
- Insert feeding jejunostomy in surgery for nutrition
- Non operative (iatrogenic perfs usually more suitable as they are more stable)
- Resus and transfer to icu/hdu
- Antibiotics and antifungal cover
- NBM for 1-2 weeks, ng tube insertion on drainage
- Large bore chest drain insertion
- TPN or feeding jejunostomy insertion
17
Q
How would a Mallory Weiss tear present?
A
- Typically at gastro-oeosphgeal junction
- Presentation
- Hx of profuse vomiting then short period of haematemesis
- Usually fine unless clotting abnormalities or anti-coag drugs
18
Q
What is Achalasia? How would it present?
A
Achalasia = failure of LOS to relax, progressive failure of contraction of proximal oesophageal smooth muscle
- Due to progressive destruction of ganglion cells in the myenteric plexus
Presentation
- Progressive dysphagia with solids and liquids
- Regurgitation
- Coughing especially at night
- Chest pain
- Weight loss
19
Q
How would you investigate and manage Achalasia?
A
Investigations
- Barium swallow
-
oesophageal manometry is gold standard for motility disorders
- shows absence of oesophageal peristalsis, failure of relaxation of LOS, high resting LOS tone
- urgent OGD to rule out oesophageal cancer
Management
- Conservative
- Sleeping on pillows
- Eating slowly
- Chewing food thoroughly
- More fluids with meals
- CCB or nitrates (temporary)
- Botox injections in LOS by endoscopy (temporary)
- Surgical
- Endoscopic balloon dilation
- Laparoscopic heller myotomy
20
Q
What is diffuse oesophageal spasm?
How would it present
A
Diffuse oesophageal spasm = multi focal high amplitude contractions of the oesophagus
- Due to dysfunction of oesophageal inhibitory nerves
Presentation
- Severe dysphagia to solid and liquids
- Central chest pain exacerbated by food
- Responds to nitrates
21
Q
How would you investigate and manage diffuse oesophageal spasm?
A
Investigations
- Manometry shows repetitive, simultaneous and ineffective contractions of the oesophagus
- Barium swallow can show corkscrew appearance
Management
- Nitrates or CCB to relax smooth muscle
- Pneumatic dilation
- Myotomy for severe
22
Q
What is a hiatus hernia and what are the two types?
A
Hernia = Protrusion of a whole or part of an organ through the wall of the cavity that contains it into an abnormal position
Hiatus hernia = protrusion of an organ from the abdo cavity into the thorax through the oesophageal hiatus (usually stomach)
- They can be classified into sliding or rolling
- Sliding = Gastro-oesophageal junction + abdo part of oesophagus + cardia of stomach slides up through diaphragmatic hiatus into the thorax
- Rolling = upward moving of gastric fundus so it lies beside a normal GOJ, resulting in a “bubble” of stomach in the thorax
23
Q
What are some risk factors of a hiatus hernia?
A
- old age (loss of diaphgragmatic tone), increased abdo pressure (eg. coughing, obesity, pregnancy, ascites)
24
Q
How would a hiatus hernia present?
A
- Mainly asymptomatic
- Reflux eg. burning epigastric pain worse on lying flat
- Hiccups or palpitations (large hernias can irritate diaphragm or pericardial sac)
- Swallowing difficulties (oesophageal stricture formation)
- Vomiting and weightloss
- Bleeding/anaemia (oesophageal ulceration)
25
Q
How would you investigate and manage a hiatus hernia?
A
Investigations
- OGD is gold standard
Management
- PPI like omeprazole
- Weight loss, smaller meal portions with low fat content, sleeping with head of bed raised
- Smoking cessation, reduce alcohol
- Surgery like cruroplasty or fundoplication
26
Q
What are some complications of a hiatus hernia?
A
- Rolling ones are prone to incarceration and strangulation
-
Gastric volvulus can occur and cause obstruction and tissue necrosis
- Borchardt’s triad of severe epigastric pain, retching without vomiting, inability to pass an NG tube
27
Q
What is peptic ulcer disease?
A
- A break in the lining of the GI tract extending through to the muscularis mucosae
- Most commonly in the lesser curvature of the proximal stomach or the first part of the duodenum
- Normal protective mechanisms = hco3- ions and mucous secretion by the gi mucosa
28
Q
What are some risk factors of peptic ulcer disease?
A
- Hpylori, Nsaids, corticosteroids, physiological stress, head trauma, Zollinger Ellison syndrome
- Hpylori
- Produces urease to break down urea into co2 and ammonia (neutralises stomach acid to create an alkaline environment)
- Sets off inflammatory response
- Zollinger Ellison syndrome
- Triad of severe peptic ulcer disease + gastric acid hypersecretion + gastrinoma
- Characteristic finding is a fasting gastrin level of >1000pg/ml
- Associated with Multiple Endocrine Neoplasia Type 1 syndrome
29
Q
How does peptic ulcer disease present?
A
- Retrosternal or epigastric pain
- Gastric is worse on eating, duodenal is worse 2-4 hours after eating or even alleviated by eating
- Nausea, bloating, post-prandial discomfort, early satiety
30
Q
How would you investigate and manage peptic ulcer disease?
A
Investigations
- Nice says to do an urgent ogd for people with…
- New onset dysphagia
- >55 years old with weight loss and upper abdo pain/reflux/dyspepsia
- New dyspepsia not responding to ppi
- Ogd usually for older pts or red flag symptoms.
- Biopsy any peptic ulceration for histology and rapid urease test
- Most young low risk pts just need Non invasive h pylori testing
- Carbon 13 urea breath test
- Serum antibodies to h pylori
- Stool antigen test
Management
- Conservative
- Smoking cessation, weight loss, reduce alcohol
- Stop nsaids
- Start on PPI for 4-8 weeks then reassess
- Triple therapy for hpylori +ve (PPI + oral amoxi + clarithro OR metronidazole for 7 days)
- Surgery for Emergencies like perf or severe relapsing disease = partial gastrectomy or selective vagotomy
38
Q
How would an inguinal hernia present?
A
- Lump in the groin that disappears when lying down
- Incarcerated hernia = painful, tender, erythematous
- Signs of bowel obstruction if bowel lumen is blocked
- Features of strangulation if blood supply is compromised
- Strangulation = irreducible, tender, tense, pain out of proportion to signs
- Inguinal hernias are superomedial to the pubic tubercle, femoral is inferolateral
41
Q
What is a femoral hernia? What are some risk factors?
A
- Less common but really high rate of strangulation!!
- Rigid borders of femoral ring eg. lacunar ligament
- More common in women due to wider bony pelvis
- abdominal visceral pass through femoral ring into potential space of femoral canal
- Risks = female, pregnant, high intra abdo pressure, old age
70
Q
What is an anorectal abscess? What are the different classifications?
A
- Collection of pus in anal/rectal region due to plugging of anal ducts, resulting in fluid stasis and infection
- Commonly ecoli, bacteriodes spp, enterococcus spp
- Classified as perianal, ischiorectal, intersphincteric or supralevator
