Surgery - General Surgery

Question 1

Nutrition

• Define Malnutrition
• What scoring system is used to measure malnutrition?
• Name two types of enteral feeding

Answer 1

• An imbalance of energy, protein and other nutrients causing measurable effects on the body
• MUST score - malnutrition universal screening tool
• PEG and NG

Question 2

Name 3 indications and 3 contraindications of NG tubes

What tests should be done after placing?

Answer 2

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

Question 3

What does PEG stand for?

Name 3 indications and 3 contraindications for PEG placement.

Answer 3

• 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

Question 4

What is Parenteral Nutrition?

Answer 4

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

Question 5

What is Re-feeding syndrome? What electrolytes are affected

Answer 5

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

Question 6

What are the differences between an ileostomy and a colostomy?

Answer 6

• Ileostomy = spouted, liquid effluent

- Colostomy = flushed to the skin, solid effluent

Question 7

Describe the difference between an end and loop ileostomy

Answer 7

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

Question 8

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

Answer 8

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

Question 9

What are the red flags for dysphagia?

What are the red flags with jaundice?

Answer 9

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

Question 10

Oesophageal Cancer
Types:
Symptoms:
Risk factors:
Investigations:

Answer 10

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

Question 11

Gastric Cancer
Pathophysiology:
Causes:
Symptoms:
Signs:
Risk factors:
Investigations:

Answer 11

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

Question 12

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

Answer 12

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

Question 13

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

Answer 13

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

Question 14

Cholangiocarcinoma
Pathophysiology:
Symptoms:
Risk factors:
Investigations:
Management:

Answer 14

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

Question 15

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

Answer 15

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.

Question 16

Name 7 causes of PR bleeding

Answer 16

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

Question 17

Define “significant weight loss”

Answer 17

10% loss in last 6 months

Question 18

Describe the bowel cancer screening programme

Answer 18

FIT testing (faecal immunochemical testing) every 2 years for people 60-74 years old
One-off sigmoidoscopy for 55 years old if at risk

Question 19

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:

Answer 19

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

Question 20

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

Answer 20

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)

Question 21

Angiodysplasia
Pathophysiology:
Symptoms:
Investigations:

Answer 21

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

Question 22

Boerhaave's syndrome
Pathophysiology:
Causes:
Symptoms:
Investigations:
Management:
Complications:

Answer 22

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

Question 23

Mallory Weiss tear

Pathophysiology:

Answer 23

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

Question 24

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?

Answer 24

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

Question 25

``` Biliary Colic Pathophysiology: Causes: Symptoms: Signs: Risk factors: Investigations: ```

Answer 25

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

Question 26

``` Acute cholecystitis Pathophysiology: Symptoms: Signs: Investigations: Management: Complications: ```

Answer 26

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

Question 27

``` Ascending Cholangitis Pathophysiology: Causes: Symptoms: Risk factors: Investigations: Management: Complications: ```

Answer 27

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

Question 28

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

Answer 28

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

Question 29

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

Answer 29

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

Question 30

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

Answer 30

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

Question 31

``` 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: ```

Answer 31

- 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

Question 32

``` Crohn's Disease Pathophysiology: Symptoms: Signs: Risk factors: Investigations: Gross pathological changes: Management: Complications: ```

Answer 32

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

Question 33

``` Ulcerative Colitis Pathophysiology: Causes: Symptoms: Signs: Risk factors: Investigations: Gross pathological changes: Management: Complications: ```

Answer 33

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

Question 34

``` Ulcers Pathophysiology: Commonly affected locations: Causes: Symptoms: Signs: Risk factors: Investigations: Management: Complications: ```

Answer 34

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)

Question 35

Name the layers of the abdominal wall

Answer 35

``` Skin Subcutaneous tissue Superficial Fascia External oblique Internal oblique Transversus abdominis muscle Transversalis fascia Adipose Peritoneum ```

Question 36

``` Name the components of the Inguinal Canal: Floor: Roof: Posterior: Anterior: ```

Answer 36

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

Question 37

Define: Incarcerated: Strangulated:

Answer 37

Incarcerated: Irreducible Strangulated: Blood supply disrupted

Question 38

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

Answer 38

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.

Question 39

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

Answer 39

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.

Question 40

``` Hiatus Hernia Pathophysiology: Types: Causes: Symptoms: Signs: Risk factors: Investigations: Management: Complications: ```

Answer 40

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.

Question 41

Abdominal X-rays in Obstruction | Describe the defining features of the small and large bowel on an X-ray

Answer 41

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

Question 42

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

Answer 42

``` 3cm = SBO 6cm = LBO 9cm = Sigmoid/Caecum ```

Question 43

``` Small Bowel Obstruction Causes: Symptoms: Investigations: Management: Complications: ```

Answer 43

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.

Question 44

``` Large Bowel Obstruction Causes: Symptoms: Risk factors: Investigations: Management: Complications: ```

Answer 44

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.

Question 45

``` Volvulus Pathophysiology: Name the two types of Volvulus: Risk factors: Investigations: Management: Complications: ```

Answer 45

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

Question 46

``` Pseudo-obstruction Pathophysiology: Causes: Investigations: Management: Complications: ```

Answer 46

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

Question 47

``` 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? ```

Answer 47

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

Question 48

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

Answer 48

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.

Question 49

``` Diverticular disease Types: Pathophysiology: Causes: Symptoms: Signs: Risk factors: Investigations: Management: Complications: Staging: ```

Answer 49

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

Question 50

``` Haemorrhoids Pathophysiology: Symptoms: Classification: Signs: Risk factors: Investigations: Management: Complications: ```

Answer 50

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

Question 51

``` Anorectal Abscess Pathophysiology: Symptoms: Risk factors: Signs: Investigations: Management: Complications: ```

Answer 51

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

Question 52

``` Anorectal Fistula Pathophysiology: Causes: Symptoms: Risk factors: Investigations: Management: ```

Answer 52

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

Question 53

``` Anal Fissure Pathophysiology: Symptoms: Signs: Risk factors: Investigations: Management: ```

Answer 53

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)

Question 54

``` Anal Cancer Pathophysiology: Symptoms: Risk factors: Investigations: Management: ```

Answer 54

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)

Question 55

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

Answer 55

Below the dentate line: Superficial inguinal nodes | Above: Mesorectal, paraaortic, paravertebral

Question 56

Name the referral criteria for Colorectal Cancer

Answer 56

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