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Surgery - Year 3 > Surgery - General Surgery > Flashcards

Surgery - General Surgery Flashcards

1
Q

Nutrition

  • Define Malnutrition
  • What scoring system is used to measure malnutrition?
  • Name two types of enteral feeding
A
  • An imbalance of energy, protein and other nutrients causing measurable effects on the body
  • MUST score - malnutrition universal screening tool
  • PEG and NG
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2
Q

Name 3 indications and 3 contraindications of NG tubes

What tests should be done after placing?

A

Indications: Functioning gut, unable to meet nutritional requirements with food, unintentionally lost >10% of weight
Contraindications: Basal skull fractures, Hiatus hernia, Pharyngeal Pouch, Oesophageal Varices
Tests: X-ray, pH check <5.5

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3
Q

What does PEG stand for?

Name 3 indications and 3 contraindications for PEG placement.

A
  • Percutaneous endoscopic gastrostomy
    Indications: Enteral feed already established for > 3 weeks, SALT assessment showed no expected swallowing improvement, Long-term care required
    Contraindications: Cardiac disorders, Pregnancy, Hiatus Hernia
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4
Q

What is Parenteral Nutrition?

A

Supplements given through a central line, IV - given if gastric system not working eg. Crohn’s

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5
Q

What is Re-feeding syndrome? What electrolytes are affected

A

Severe fluid and electrolyte imbalance shifts - phosphate, potassium, magnesium

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6
Q

What are the differences between an ileostomy and a colostomy?

A
  • Ileostomy = spouted, liquid effluent

- Colostomy = flushed to the skin, solid effluent

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7
Q

Describe the difference between an end and loop ileostomy

A 
End = permanent unless Hartmann's - single opening onto the skin
Loop = temporary, figure of 8 onto the skin (two openings) - sometimes used to rest the distal gut before anastomosis, or to decompress the colon
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8
Q

Name 3 short term complications and 3 long term complications of stomas

A

Short term:

  • Bleeding
  • Oedema
  • Ischaemia/necrosis
  • Separation of the edges of the stoma from the skin
  • High output (>1.5L in 24 hours) - treated with loperamide and fluid restriction
  • Fistula formation (particularly in Crohn’s)

Long term:

  • Retraction (below the skin level, particularly in obese patients)
  • Parastomal hernia
  • Stoma prolapse - bowel protrudes out of abdomen
  • Stenosis of the stoma
  • Granuloma formation
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9
Q

What are the red flags for dysphagia?

What are the red flags with jaundice?

A

Dysphagia: ALARM - anaemia, loss of weight, anorexia, recent onset of progressive symptoms, masses
Jaundice: Painless jaundice, Hepatomegaly, Unintentional weight loss, Ascites

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10
Q 
Oesophageal Cancer
Types:
Symptoms:
Risk factors:
Investigations:
A

Types: Squamous cell carcinoma - developing world, alcohol + smoking. Adenocarcinoma (stratified squamous to columnar) - most common in developed world. Barret’s.

Symptoms: Progressive dysphagia, weight loss, fluid regurgitation, hoarseness of voice from laryngeal nerve impingement

Risk factors: Smoking, chewing paan, male, obesity

Investigations: PGD, CT, endoscopic USS

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11
Q 
Gastric Cancer
Pathophysiology:
Causes:
Symptoms:
Signs:
Risk factors:
Investigations:
A

Pathophysiology: Adenocarcinomas.

Causes: Chronic gastritis, stomach ulcers.

Symptoms: Dyspepsia, anaemia, weight loss, early satiety, vomiting

Signs: Virchow’s node, palpable mass

Risk factors: H. Pylori, Smoking, Alcohol, High Salt diet, Obesity, FH

Investigations: OGD with biopsy, CT for staging, Urease breath test, laparoscopy for staging

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12
Q 
Liver Cancer
Pathophysiology:
Causes:
Symptoms:
Signs:
Risk factors:
Investigations:
Tumour marker?
Complications:
A

Pathophysiology: Hepatocellular carcinoma - rare, primary cancer. 90% from mets.

Causes: Breast, Colorectal, Lung, Pancreatic

Symptoms: High alcohol, Smoking, Hep B/C, PBC, Aflatoxin, FH

Signs: Jaundice, right sided abdominal pain, SOB, weight loss, bloating

Risk factors:

Investigations: LFTs, liver screen (antibodies for hep), USS - gold standard, CT for staging

Tumour marker: AFP

Complications: Paraneoplastic syndromes - hypercalcaemia, polycythaemia, hypoglycaemia

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13
Q 
Pancreatic cancer
Pathophysiology:
Symptoms:
Courvoisier's law?
Signs:
Risk factors:
Investigations:
Management:
Complications:
A

Pathophysiology: Ductal adenocarcinomas, most commonly affects pancreatic head, affects >60 years old.

Symptoms: Painless jaundice, abdominal pain that radiates to back, weight loss, anorexia, fatigue, diabetes (new-onset), pruritus due to bile deposition in skin, yellowing of sclera

Courvoisier’s law: Painless jaundice + palpable gall bladder = pancreatic cancer

Signs: Jaundice, Icteric sclera (yellow sclera)

Risk factors: Age > 60 years old, chronic pancreatitis, diabetes, smoking, obesity

Investigations: Ca-19-9, LFTs, FBCs, USS, CT scan (gold standard), EUS (endoscopic ultrasound to get fna for biopsy)

Management: Whipple’s - pancreaticoduodenectomy, most palliative

Complications: Acanthosis nigricans

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14
Q 
Cholangiocarcinoma
Pathophysiology:
Symptoms:
Risk factors:
Investigations:
Management:
A

Pathophysiology: Biliary system cancer - most commonly Klatskin tumours (right/left hepatic duct) - adenocarcinomas

Symptoms: Post-hepatic jaundice, pruritus, pale stools, dark urine

Risk factors: Primary sclerosing cholangitis, UC, hepatitis, HIV, alcohol, diabetes

Investigations: MRCP, CT for staging, ERCP for biopsy, Ca-19-9 and CEA

Management: Whipple’s/Stenting

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15
Q 
Bowel Cancer
Pathophysiology:
Symptoms:
Which side is fungating vs stenosing:
Signs:
Risk factors (important):
Investigations:
Management:
A

Pathophysiology: Adenocarcinomas, specifically in caecum, sigmoid (30%), rectum (50%), asc/desc colon

Symptoms: Bowel obstruction, PR bleeding, change in bowel habit, weight loss, abdominal pain, tenesmus

Stenosing vs fungating: fungating = right, stenosing = left (tenesmus)

Signs: Anaemia

Risk factors: Polyposis syndromes (FAP, HNPCC), IBD, Diabetes, Diet (obesity, smoking, alcohol)

Investigations: Flexible sigmoidoscopy/colonoscopy with biopsy, CT colon/staging, LFTs, CEA to track tumour

Management: Right/left hemicolectomy, Abdominoperineal resection, high anterior etc.

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16
Q

Name 7 causes of PR bleeding

A
  • Diverticulitis
  • Haemorrhoids - rarely
  • Anal fissure - most common
  • Ulcerative colitis
  • Infective gastroenteritis eg. shigella, campylobacter
  • Angiodysplasia
  • Colorectal cancer
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17
Q

Define “significant weight loss”

A

10% loss in last 6 months

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18
Q

Describe the bowel cancer screening programme

A 
FIT testing (faecal immunochemical testing) every 2 years for people 60-74 years old
One-off sigmoidoscopy for 55 years old if at risk
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19
Q 
Upper GI bleeding
Name 6 causes of upper GI bleeds:
Risk factors:
Presentation:
Examination:
Investigations:
Scoring systems used:
Management:
- Short term:
- What specialised item can be used in short term lower GI bleeding management?
- Long term:
A

Causes: Peptic ulcer disease, Varices, Mallory-Weiss tear, Boerhaave’s syndrome, Upper GI malignancy, Epistaxis, Gastritis ->

Risk factors: Liver disease, NSAIDs, Alcohol, Helicobacter pylori, repeated vomiting

Presentation: Haematemesis (frank/coffee-ground), melaena, Shock

Examination: OGD, CT angiogram if identifying bleed, PR exam

Investigations: OGD, FBC, U+E, Urea, Group and Save + Cross match, CT abdo, Liver USS

Scoring: ROCKALL - patient risk of an adverse outcome following a completed endoscopy
Glasgow-Blatchford - likelihood of a patient with an upper GI bleed needing intervention

Management:
Short term: IV fluids, Oxygen, NG tube suction, IV PPIs, Terlipressin if varices, catheterise to check output
Minnesota-sengsteken tube used in massive bleeds
Long term: Endoscopic therapy via band ligation, NG lavage, 6-8 week endoscopy

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20
Q

Lower GI bleed
Name 7 causes of lower GI bleeds
Investigations:

A

Causes: Diverticulitis, Haemorrhoids, Anal fissure, Colorectal cancer, UC, Angiodysplasia, Gastroenteritis eg. shigella/campylobacter

Investigations: DRE, colonoscopy/flexible sigmoidoscopy, CT urogram, group and save, urea levels/Hb, stool culture (infective cause)

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21
Q

Angiodysplasia
Pathophysiology:
Symptoms:
Investigations:

A

Pathophysiology: Arteriovenous malformations occur, commonly in the caecum and ascending colon. Very common cause of bleeding.

Symptoms: Rectal bleeding (painless), anaemia

Investigations: FBC, Group and Save/Crossmatch if acute, Haematinics, Colonoscopy/Endoscopy, Mesenteric angiography to identify bleed

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22
Q 
Boerhaave's syndrome
Pathophysiology:
Causes:
Symptoms:
Investigations:
Management:
Complications:
A

Pathophysiology: Full-thickness rupture of the oesophageal wall due to spontaneous increase in pressure - leads to stomach contents in mediastinum and inflammatory response

Causes: Iatrogenic - most, vomiting

Symptoms: Sudden onset retrosternal chest pain, respiratory distress, subcutaneous emphysema

Investigations: Group and save, CXR, CT chest - gold standard, endoscopy

Management: Oxygen + IV saline, thoracotomy, endoscopy, NG drainage, large bore chest drain

Complications: Sepsis

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23
Q

Mallory Weiss tear

Pathophysiology:

A

Pathophysiology: Laceration of the mucosal layer, usually after profuse vomiting.

24
Q 
Gall stones
Name 6 risk factors for gall stones
Can gall stones be seen on an X-ray?
How else can they be diagnosed?
What are they mainly made out of?
A

Risk factors: Fair, Forty, Female, Fat, Family history, IBD

Cannot be seen on an X-ray - radiolucent

They are mainly made out of cholesterol, bile pigments and phospholipids

25
Q 
Biliary Colic
Pathophysiology:
Causes:
Symptoms:
Signs:
Risk factors:
Investigations:
A

Pathophysiology: Temporary obstruction of a gallstone in the cystic duct/CBD.

Symptoms: RUQ pain, radiates to back or shoulder blades

Signs: No signs of infection

Risk factors: Eating fatty foods (releases CCK - gall bladder contraction)

Investigations: USS, LFTs

26
Q 
Acute cholecystitis
Pathophysiology:
Symptoms:
Signs:
Investigations:
Management:
Complications:
A

Pathophysiology: Impaction of stone within the cystic duct, causing inflammation in the gall bladder and thickening of the gall bladder wall.

Symptoms: Fever, RUQ pain, NO JAUNDICE

Signs: Murphy’s sign positive

Investigations: USS

Management: Conservative -> Lap chole

Complications: Empyema of the gall bladder

27
Q 
Ascending Cholangitis
Pathophysiology:
Causes:
Symptoms:
Risk factors:
Investigations:
Management:
Complications:
A

Pathophysiology: Blockage of the CBD causing biliary tree infection

Causes: Gallstones, ERCP, Cholangiocarcinoma

Symptoms: Fever, RUQ pain, Jaundice (Charcot’s triad), Confusion and Hypotension = Reynaud’s pentad

Risk factors:

Investigations: USS, MRCP after (gold standard usually, but ERCP in ascending cholangitis) FBCs, CRP, Amylase (always), Coagulation profile (reduced Vit K absorption)

Management: If gallstones in GB - lap chole, if gallstones in CBD, ERCP then lap chole
Also give Vit K in obstructive jaundice, antibiotics, IV fluids and analgesia

Complications: Empyema, Chronic cholecystitis, gallstone ileus

28
Q

Calcot’s triangle - define the 3 borders and what it is useful for

A

Medial - Common Hepatic Duct
Inferior - Cystic Duct
Superior - Inferior of Liver
Used to locate cystic artery and common bile duct in chole and not cut right hepatic artery

29
Q 
Pancreatitis
Pathophysiology:
Causes:
Symptoms:
Signs:
Risk factors:
Investigations:
Scoring system:
Management:
Complications - local and systemic:
A

Pathophysiology: Acinar cell necrosis due to premature activation of enzymes. Causes autolysis and third spacing. Causes hypocalcaemia due to fat necrosis by released enzymes into bloodstream.

Causes: Gall stones, Ethanol, Steroids, Trauma, ERCP, Steroids, Idiopathic, Malignancy, Autoimmune

Symptoms: Epigastric pain, radiates to back, aggravated when lying flat, vomiting and nausea, tachy, distension tetany from hypocalcaemia

Signs: Grey Turner’s (flanks), Cullen’s (umbilical)

Risk factors:

Investigations: USS, Amylase/Lipase levels, CT/MRI for necrosis after 24 hours, LFTs, urinary catheter to monitor urine output, ABG to check for respiratory failure

Scoring system: Glasgow Imrie

Management: Fluids, Oxygen, Analgesia, NG tube if vomiting, Antibiotics, CXR, no antibiotics unless abscess, urine output monitoring

Complications:
Local: Psudocysts, Necrosis, Abscesses
Systemic: ARDS, DIC, Hypocalcaemia, Hyperglycaemia, AKI

30
Q

IBD - general
What ages are affected in IBD?
What are causes of IBD?

A

Ages: 15-30 and 60+
Causes: Genetics, NSAIDs, HLA-B27, immune response to triggers eg. smoking/infection

31
Q 
Differences between Crohn's and UC:
Location:
Bleeding:
Peri-anal disease:
Fistulas: 
Malnutrition:
Pathological changes - 
Wall thickness affected:
Granulomas:
(Crypt) Abscesses: 
Endoscopic changes -
Ulcers:
Cobblestone appearance:
Fistula formation:
A
  • UC = only affects rectum/colon, Crohn’s anywhere, including mouth (skip lesions), crohn’s does not affect rectum
  • Bleeding: Mainly in UC, with mucous
  • Peri-anal disease: In Crohn’s
  • Fistulas: Crohn’s
  • Malnutrition: In Crohn’s
  • Wall thickness: Transmural in Crohn’s, Mucosal Ulceration in UC
  • Granulomas: Crohn’s
  • Abscesses: UC
  • Ulcers: Crohn’s
  • Cobblestone: Crohn’s
  • Fistulas: Crohn’s
32
Q 
Crohn's Disease
Pathophysiology:
Symptoms:
Signs:
Risk factors:
Investigations:
Gross pathological changes:
Management:
Complications:
A

Pathophysiology: Affects anywhere in the GI tract, most commonly distal ileum, transmural, commonly forms fistulas (perianal fistula)

Symptoms: 6 weeks of 5x diarrhoea/day, non bloody, RLQ pain, joint pain, perianal disease, anaemia, aphthous ulcers, fever

Signs: Erythema nodosum, pyoderma gangrenosum, Uveitis, PSC, nail clubbing

Risk factors: FH, smoking, white, appendicectomy

Investigations: Bloods for anaemia, faecal calprotectin, colonoscopy with biopsy (gold standard)

Gross pathological changes: Skip lesions, cobblestone appearance, fistulae, structures, hyperaemia, transmural inflammation, mucosal oedema

Management: Corticosteroids + azathioprine (monotherapy in remission), avoid loperamide as can cause toxic megacolon, heparin, gradual bowel resection

Complications: Fistulas, strictures and SBO, perianal abscesses, malignancy, malabsorption

33
Q 
Ulcerative Colitis
Pathophysiology:
Causes:
Symptoms:
Signs:
Risk factors:
Investigations:
Gross pathological changes:
Management:
Complications:
A

Pathophysiology: Always begins in rectum, continuous pattern of inflammation, mucosal inflammation only

Causes:

Symptoms: Blood diarrhoea, mucous in stools, proctitis (PR bleeding), Weight loss, Tenesmus, no fever

Signs: Enterohepatic arthritis of the SI joint, nail clubbing, erythema nodosum, PSC, Uveitis

Risk factors:

Investigations: Colonoscopy with biopsy or sigmoidoscopy, CT to assess for toxic megacolon risk, AXR for thumbprinting and mural thickening, lead-pipe colon seen in chronic UC

Gross pathological changes: Chronic inflammatory infiltrate of the lamina propria, Crypt abscesses, gland dysplasia, reduced goblet numbers, pseudopolyps, loss of haustra

Management: Same as Crohn’s - Corticosteroids or sulfasalazine + azathioprine, can do total proctocolectomy curatively, azathioprine/sulfasalazine monotherapy on remission, monitor via colonoscopy, give lifestyle advice

Complications: Toxic Megacolons and Perforations, Malignancy, Osteoporosis, PSC

34
Q 
Ulcers
Pathophysiology:
Commonly affected locations:
Causes:
Symptoms:
Signs:
Risk factors:
Investigations:
Management:
Complications:
A

Pathophysiology: Breach that extends through the muscularis mucosa

Commonly affected locations: Antrum (exit) and Fundus (near entry) of Stomach and 1st part of Duodenum

Causes: H. Pylori - almost all, NSAIDs, Alcohol, Stomach acid excess, Smoking, Stress

Symptoms: Epigastric pain (relieved immediately eating in duodenal and worse after 2 hours, or worse immediately in gastric), bleeding/anaemia, weight loss, early satiety

Signs:

Risk factors:

Investigations: OGD, urease breath test

Management: H. Pylori test and treat (PP + 2 antibiotics - amox and clarithromycin, PPIs, Ranitidine, Antacids, Endoscopy if weight loss and/or >55 years

Complications: Malignancy, haemorrhage/perforation (splenic artery or gastroduodenal artery)

35
Q

Name the layers of the abdominal wall

A 
Skin
Subcutaneous tissue 
Superficial Fascia
External oblique
Internal oblique
Transversus abdominis muscle
Transversalis fascia
Adipose
Peritoneum
36
Q 
Name the components of the Inguinal Canal:
Floor:
Roof:
Posterior:
Anterior:
A

Floor: Inguinal Ligament + lacunar ligament
Roof: Internal oblique + Transversus abdominis
Posterior: Transversalis fascia (with deep ring laterally) and conjoint tendon
Anterior: Aponeurosis of external oblique

37
Q

Define:
Incarcerated:
Strangulated:

A

Incarcerated: Irreducible
Strangulated: Blood supply disrupted

38
Q 
Inguinal Hernias
Location:
Types and majority:
Symptoms:
Risk factors:
Investigations:
What is the special test called? What is it for?
Management:
Complications:
A

Location: Superior to the inguinal ligament and medial to the pubic tubercle

Types and majority: Can be direct or indirect. Indirect most common.
Indirect exits lateral to the inferior epigastric vessels via deep inguinal ring. Direct exits medial to the inferior epigastric vessels via Hesselbach’s triangle. Both exit via superficial inguinal ring, medially.
Both can potentially enter the scrotum if processus vaginalis was not obliterated.

Symptoms: Lump, not usually painful unless incarcerated or strangulated (can cause bowel obstruction too)

Risk factors: Male, increasing age, heavy lifting causing raised intra-abdominal pressure

Investigations: Check cough impulse - hernia will expand when coughing. If scrotal, check if can “get above” the lump. Check reducibility.

Special test: Zieman’s test. Identifies indirect vs direct hernias. Reduce hernia, place finger above deep inguinal ring and ask to cough. Direct if still protrudes.

Management: Any patient with a symptomatic hernia should get surgery. Open mesh repair.

Complications: Incarceration, strangulation, obstruction.

39
Q 
Femoral Hernia
Location:
Pathophysiology:
Symptoms:
What is this commonly mistaken for?
Risk factors:
Investigations:
Management:
Complications:
A

Location: Inferior to the inguinal ligament and lateral to the pubic tubercle.

Pathophysiology: Abdominal viscera passes through femoral ring into femoral canal.

Symptoms: Most present as emergency.

Commonly mistake for: Saphena Varix, dilatation of the saphenous vein at the femoral junction in the groin area - also has a cough reflex.

Risk factors: Female, pregnancy, raised intra-abdominal pressure, increasing age.

Management: All need surgical intervention.

Complications: Very high strangulation risk due to rigidity of femoral ring borders and lacunar ligament.

40
Q 
Hiatus Hernia
Pathophysiology:
Types:
Causes:
Symptoms:
Signs:
Risk factors:
Investigations:
Management:
Complications:
A

Pathophysiology: Protrusion of the stomach through the oesophageal hiatus. Very common.

Types: Sliding (80%), Rolling (20%) (basically only the fundus goes up)

Causes:

Symptoms: Mostly asymptomatic, but GORD, vomiting, weight loss

Signs:

Risk factors: Age (-related loss of diaphragmatic tone), Obesity

Investigations: OGD, urgent CT if obstruction symptoms

Management: PPIs, lifestyle modification
Surgical indicated if medical treatment failure/obstruction - Fundoplication. Can lead to bloating/dysphagia if too tight.

Complications: Incarceration and strangulation. Gastric volvulus.

41
Q

Abdominal X-rays in Obstruction

Describe the defining features of the small and large bowel on an X-ray

A

Small: Valvulae conniventes that go all the way across
Large: Haustra only go partially across

42
Q

What is the expected diagnostic width for sbo and lbo on an X-ray

A 
3cm = SBO
6cm = LBO
9cm = Sigmoid/Caecum
43
Q 
Small Bowel Obstruction
Causes:
Symptoms:
Investigations:
Management:
Complications:
A

Causes: Adhesions (eg. from Crohn’s), Hernias, Cancers, IBD-based narrowing from repeated inflammation

Symptoms: Nausea and vomiting early, Peri-umbilical pain (colicky, every 3-5 mins), Distension (with high-pitched bowel sounds), Absolute constipation (late)

Investigations: CT, history, physical examination (increased pitch/absent bowel sounds)

Management: “Drip and suck” - Drip - IV fluids - Suck - NBM and NG tube lavage, urinary catheter, analgesia, laparotomy if needed

Complications: Third spacing leading to dehydration. Perforation.

44
Q 
Large Bowel Obstruction
Causes:
Symptoms:
Risk factors:
Investigations:
Management:
Complications:
A

Causes: Colon cancer, Strictures (eg. from Diverticular disease), Volvulus, Hernias

Symptoms: Change in bowel habit, distension, crampy pain (10-15 mins in between), vomiting (late), absolute complication

Investigations: Group and save, FBC + U+Es (for third space loss monitoring), VBG to check lactate for ischaemia

Management: IV fluids, surgery if necessary.

Complications: Ischaemia, perforation.

45
Q 
Volvulus
Pathophysiology:
Name the two types of Volvulus:
Risk factors:
Investigations:
Management:
Complications:
A

Patho: Twisting of a loop of intestine around its mesentery, leading to a closed-loop bowel obstruction.

Types: Caecal and Sigmoid (most)

Risk factors: Increasing age, constipation (chronic), previous operations

Investigations: Bloods and electrolytes (exclude pseudo-obstruction), CT abdomen-pelvis (“whirl sign”) or CXR (“Coffee bean”)

Management: Rigid sigmoidectomy + air + flatus tube - do Hartmann’s if cannot decompress. If caecal volvulus, do laparotomy and ileocaecal resection.

Complications: Perforation, ischaemia

46
Q 
Pseudo-obstruction
Pathophysiology:
Causes:
Investigations:
Management:
Complications:
A

Pathophysiology: Dilatation of the colon due an adynamic bowel, in the absence of a mechanical obstruction. Commonly affects caecum.

Causes: Electrolytes imbalance/endocrine imbalance eg. hypercalcaemia, hypothyroidism, hypomagnesemia, medication (opioids), recent surgery, neurological diseases

Investigations: CT scan with IV contrast - gold standard, blood tests for electrolytes

Management: Neostigmine IV, Mostly conservative, NBM, IV fluids, NG tube lavage

47
Q 
LFTs
What is ALT specific for?
What is ALP + Gamma-GT specific for?
What is Gamma-GT on its own specific for?
What does a raised INR indicate?
A

ALT = liver specific eg. viral hepatitis, paracetamol
ALP + Gamma-GT = bile duct blockage and bone mets
Gamma-GT = alcoholic liver disease
INR/PT high = liver failure

48
Q 
Appendicitis
Where is the appendix?
Pathophysiology:
Causes:
Symptoms:
Signs (including special signs):
Risk factors:
Investigations:
Management:
Complications of surgery:
A

Where is the appendix: Caecum

Pathophysiology: 20-30 year olds affected. Blockage of lumen leads to increased pressure. This increases venous pressure, causing oedema and reducing arterial supply. Ischaemia and bacterial invasion then occurs.

Causes:

Symptoms: Start - peri-umbilical pain, progresses to RIF pain. Pain is worse over “McBurney’s point” - 2/3rds of the way from the umbilicus to the ASIS. Nausea, vomiting, fever, anorexia.

Signs: Illness, tachycardia, guarding, rebound tenderness, Rovsing’s sign (press opposite iliac fossa, get pain on not pressed side), Psoas sign (life leg, causes increased pain)

Risk factors: Age - 15-30, FH, female

Investigations: Clinical diagnosis, urine dip to rule out pregnancy, urinalysis for UTI, USS and CT to rule out other conditions

Management: Lap appendicectomy. Must avoid lifting for 4 weeks, work for 2 weeks, not drive until can emergency stop.

Complications of surgery: Adhesions, perforation, abscess, fistula formation, hernias, thromboembolism.

49
Q 
Diverticular disease
Types:
Pathophysiology:
Causes:
Symptoms:
Signs:
Risk factors:
Investigations:
Management:
Complications:
Staging:
A

Types:

  • Diverticulosis
  • Diverticular disease - pain but no inflammation or infection
  • Diverticulitis - acute infection/inflammation/perforation

Pathophysiology: Outpouchings of 2 layers of muscularis mucosa (not 3, not true diverticula). Occurs mostly in sigmoid colon. Occurs along where vasa recta penetrate bowel wall.

Causes: Increased intra-luminal pressure due to low fibre diet.

Symptoms: Diverticular disease: Colicky abdominal pain, altered bowel habit, nausea, flatulence
Diverticulitis: Diverticula inflame/perforate -> abdominal pain (left lower quadrant), fever, bloating, constipation, haematochezia (MOST COMMON cause of GU bleeding)

Signs: Abdominal distension, tenderness, reduced bowel sounds, peritonitis if perforated

Risk factors: > Age, constipation, low fibre, obesity, FH, NSAIDs

Investigations: CT abdomen pelvis, NOT COLONOSCOPY to avoid perforation, Group and Save

Management: Antibiotics, fluid resus, analgesia, if perforated may need Hartmann’s + wash out

Complications: Perforation, Diverticular abscess, Structures (LBO)(, Colovesical fistula, Cancer

Staging: Hinchney Classification - describes the levels of perforation of acute diverticulitis

50
Q 
Haemorrhoids
Pathophysiology:
Symptoms:
Classification:
Signs:
Risk factors:
Investigations:
Management:
Complications:
A

Pathophysiology: Vascular anal cushions that help control continence. Internal and external anal haemorrhoids, above and below the dentate line.

Symptoms: Bright red bleeding, prolapse, discharge, pruritus, pain (not always - usually an anal fissure if painful), rectal fullness

Classification: 1st - 4th degree - 1st = remain in the rectum, 2nd = prolapse on defecation, but reduce spontaneously, 3rd = prolapse and require reduction, 4th cannot be reduced

Risk factors: Straining (from chronic constipation), increasing age, pregnancy

Investigations: PR exam, proctoscopy to diagnose, with flexible sig to rule out cancer

Management: Conservative - give fybogel, increase fluid, avoid straining, topical treatments, laxatives. Band ligation - avoid further surgery as can cause stenosis.

Complications: Thrombosis, ulceration, gangrene, perianal sepsis

51
Q 
Anorectal Abscess
Pathophysiology:
Symptoms:
Risk factors:
Signs:
Investigations:
Management:
Complications:
A

Pathophysiology: Anal ducts/glands become plugged, leading to stasis and bacterial infection.

Symptoms: Pain in anorectal area, swelling, pruritus, discharge, sepsis, spiking temperature.

Risk factors: IBD, Diabetes, diverticulitis, colitis

Signs: Perianal mass, discharging

Investigations: DRE if cannot see mass

Management: Antibiotics (IV co-amox and Gent), incision and drainage under GA, do proctoscopy to identify any fistulas for seton placement

Complications: Anorectal fistulae

52
Q 
Anorectal Fistula
Pathophysiology:
Causes:
Symptoms:
Risk factors:
Investigations:
Management:
A

Pathophysiology: Abnormal connection between the anal canal and the perianal skin

Causes: Anorectal abscess formation precedes usually

Symptoms: Recurrent discharge onto the perineum, fibrous opening visible

Risk factors: Peri-anal abscess, IBD (Crohn’s particularly)

Investigations: Proctoscopy

Management: Conservative usually, can use a seton to allow healing or a fistulotomy

53
Q 
Anal Fissure
Pathophysiology:
Symptoms:
Signs:
Risk factors:
Investigations:
Management:
A

Pathophysiology: Tear in the mucosal lining of the anal canal, most commonly due to hard stool.

Symptoms: Intense pain on defecation which can last several hours, bleeding, pruritus

Signs: Most present on posterior midline

Risk factors: Constipation, dehydration, IBD, chronic diarrhoea

Investigations: EUA and DRE, maybe proctoscopy

Management: Analgesia + lifestyle (fybogel, laxatives, topical analgesia eg. ligocaine, GTN cream to relax sphincter and increase blood supply)

54
Q 
Anal Cancer
Pathophysiology:
Symptoms:
Risk factors:
Investigations:
Management:
A

Pathophysiology: SCC below the dentate line = most.

Symptoms: Rectal pain, rectal bleeding, discharge, palpable mass

Risk factors: HPV, HIV, Age, Smoking, Crohn’s, Anal intraepithelial neoplasia (linked to HPV)

Investigations: Proctoscopy, Screen peri-anal region for warts, PR exam (EUA), check inguinal lymph nodes for lymphadenopathy, smear test in women, FNA of lymph nodes with CT abdomen for staging

Management: First choice: Chemo, Abdominoperineal resection (as within 8 cm of the exit)

55
Q

Describe the lymphatic drainage from:
Below the dentate line:
Above the dentate line and the rectum:

A

Below the dentate line: Superficial inguinal nodes

Above: Mesorectal, paraaortic, paravertebral

56
Q

Name the referral criteria for Colorectal Cancer

A

<40 and unexplained weight loss and pain
<50 and unexplained rectal bleeding
<60 and iron deficiency anaemia or change in bowel habit

Surgery - Year 3 (6 decks)

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