Surgery - General Surgery (Abdomen) Flashcards

Question

Complications of IO

Answer 1

Hypovolaemic shock due to fluid stuck in the bowel rather than the intravascular space (third-spacing) Bowel ischaemia Bowel perforation Sepsis

Answer 2

Nil by mouth IV fluid resuscitation NG tube with free drainage Abdominal x-ray Erect chest x-ray Contrast abdominal CT scan

Answer 3

Conservative management as first instance in stable patients with obstruction secondary to adhesions or volvulus Exploratory surgery in patients with an unclear underlying cause Adhesiolysis to treat adhesions Hernia repair Emergency resection of the obstructing tumour

Answer 4

Injury to the bowel Handling of the bowel during surgery Inflammation or infection in, or nearby, the bowel (e.g., peritonitis, appendicitis, pancreatitis or pneumonia) Electrolyte imbalance (e.g., hypokalaemia or hyponatraemia)

Answer 5

Vomiting (particularly green bilious vomiting) Abdominal distention Diffuse abdominal pain Absolute constipation and lack of flatulence Absent bowel sounds (as opposed to the “tinkling” bowel sounds of mechanical obstruction)

Answer 6

Nil by mouth or limited sips of water NG tube if vomiting IV fluids to prevent dehydration and correct the electrolyte imbalances Mobilisation to helps stimulate peristalsis Total parenteral nutrition (TPN) may be required whilst waiting for the bowel to regain function

Answer 7

Sigmoid volvulus | Caecal volvulus

Answer 8

chronic constipation and lengthening of the mesentery attached to the sigmoid colon. The sigmoid colon becomes overloaded with faeces, causing it to sink downwards causing a twist.

Answer 9

``` Neuropsychiatric disorders (e.g., Parkinson’s) Nursing home residents Chronic constipation High fibre diet Pregnancy Adhesions ```

Answer 10

Vomiting (particularly green bilious vomiting) Abdominal distention Diffuse abdominal pain Absolute constipation and lack of flatulence

Answer 11

Abdominal x-ray can show the “coffee bean” sign in sigmoid volvulus contrast CT scan for Dx

Answer 12

Laparotomy (open abdominal surgery) Hartmann’s procedure for sigmoid volvulus (removal of the rectosigmoid colon and formation of a colostomy) Ileocaecal resection or right hemicolectomy for caecal volvulus

Answer 13

Incarceration of bowel > obstruction and strangulation of the hernia Obstruction > vomiting, generalised abdominal pain and absolute constipation Strangulation > ischemic bowel

Answer 14

Conservative management: hernia has a wide neck (low risk of complications) Tension-free repair (surgery): mesh over the defect in the abdominal wall, sutured to the muscles and tissues on either side of the defect, tissues grow into the mesh Tension repair (surgery): surgical operation to suture the muscles and tissue on either side of the defect back together

Answer 15

``` Femoral hernia Lymph node Saphena varix (dilation of saphenous vein at junction with femoral vein in groin) Femoral aneurysm Abscess Undescended / ectopic testes Kidney transplant ```

Answer 16

Hesselbach’s triangle: (RIP mnemonic): R – Rectus abdominis muscle – medial border I – Inferior epigastric vessels – superior / lateral border P – Poupart’s ligament (inguinal ligament) – inferior border Pressure over the deep inguinal ring will not stop the herniation

Answer 17

Involves herniation of bowel content through femoral canal Opening of femoral ring is narrow, and femoral canal is long and narrow

Answer 18

Boundaries of the femoral canal (FLIP mnemonic): F – Femoral vein laterally L – Lacunar ligament medially I – Inguinal ligament anteriorly P – Pectineal ligament posteriorly

Answer 19

SAIL mnemonic: S – Sartorius – lateral border A – Adductor longus – medial border IL – Inguinal Ligament – superior border

Answer 20

NAVY-C mnemonic ``` N – Femoral Nerve A – Femoral Artery V – Femoral Vein Y – Y-fronts C – Femoral Canal (containing lymphatic vessels and nodes) ```

Answer 21

Spigelian hernia occurs between the lateral border of the rectus abdominis muscle and the linea semilunaris. At the site of the spigelian fascia, which is an aponeurosis between the muscles of the abdominal wall

Answer 22

widening of the linea alba, the connective tissue that separates the rectus abdominis muscle congenital (in newborns) weakness in the connective tissue, for example following pregnancy or in obese patients

Answer 23

through the obturator foramen at the bottom of the pelvis defect in the pelvic floor and are more common in women, particularly in older age, after multiple pregnancies and vaginal deliveries may present with irritation to the obturator nerve: Howship–Romberg sign: pain extending from the inner thigh to the knee when the hip is internally rotated

Answer 24

Hiatus hernias present with dyspepsia (indigestion), with symptoms of: ``` Heartburn Acid reflux Reflux of food Burping Bloating Halitosis (bad breath) ```

Answer 25

laparoscopic fundoplication tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter

Answer 26

pregnancy, obesity, increased age and increased intra-abdominal pressure (e.g., weightlifting or chronic coughing), constipation

Answer 27

1st degree: no prolapse 2nd degree: prolapse when straining and return on relaxing 3rd degree: prolapse when straining, do not return on relaxing, but can be pushed back 4th degree: prolapsed permanently

Answer 28

onstipation and straining. painless, bright red bleeding, typically on the toilet tissue or seen after opening the bowels. The blood is not mixed with the stool Sore / itchy anus Feeling a lump around or inside the anus

Answer 29

External (prolapsed) haemorrhoids are visible on inspection as swellings covered in mucosa Internal haemorrhoids may be felt on a PR exam Prolapse if the patient is asked to “bear down” during inspection

Answer 30

``` Haemorrhoids Anal fissures Diverticulosis Inflammatory bowel disease Colorectal cancer ```

Answer 31

``` Anusol (contains chemicals to shrink the haemorrhoids – “astringents”) Anusol HC (also contains hydrocortisone – only used short term) Germoloids cream (contains lidocaine – a local anaesthetic) Proctosedyl ointment (contains cinchocaine and hydrocortisone – short term only) ```

Answer 32

Rubber band ligation (fitting a tight rubber band around the base of the haemorrhoid to cut off the blood supply) Injection sclerotherapy (injection of phenol oil into the haemorrhoid to cause sclerosis and atrophy) Infra-red coagulation (infra-red light is applied to damage the blood supply) Bipolar diathermy (electrical current applied directly to the haemorrhoid to destroy it)

Answer 33

Haemorrhoidal artery ligation - involves using a proctoscope to identify the blood vessel that supplies the haemorrhoids and suturing it to cut off the blood supply. Haemorrhoidectomy - involves excising the haemorrhoid. Removing the anal cushions may result in faecal incontinence. Stapled haemorrhoidectomy - involves using a special device that excises a ring of haemorrhoid tissue at the same time as adding a circle of staples in the anal canal. The staples remain in place long-term.

Answer 34

Thrombosed Haemorrhoids caused by strangulation at the base of the haemorrhoid, resulting in thrombosis appear as purplish, very tender, swollen lumps around the anus.

Answer 35

diverticulum (plural diverticula) is a pouch or pocket in the bowel wall Diverticulosis refers to the presence of diverticula, without inflammation or infection. Diverticulitis refers to inflammation and infection of diverticula

Answer 36

increased age. Low fibre diets, obesity and the use of NSAIDs

Answer 37

Presentation: lower left abdominal pain, constipation or rectal bleeding Mx: increased fibre in the diet and bulk-forming laxatives, weight loss

Answer 38

Pain and tenderness in the left iliac fossa / lower left abdomen Fever Diarrhoea Nausea and vomiting Rectal bleeding Palpable abdominal mass (if an abscess has formed)

Answer 39

Perforation Peritonitis Peridiverticular abscess Large haemorrhage requiring blood transfusions Fistula (e.g., between the colon and the bladder or vagina) Ileus / obstruction

Answer 40

The foregut includes the stomach and part of the duodenum, biliary system, liver, pancreas and spleen. This is supplied by the coeliac artery. The midgut is from the distal part of the duodenum to the first half of the transverse colon. This is supplied by the superior mesenteric artery. The hindgut is from the second half of the transverse colon to the rectum. This is supplied by the inferior mesenteric artery.

Answer 41

Cause: narrowing of the mesenteric blood vessels by atherosclerosis - Central colicky abdominal pain after eating (starting around 30 minutes after eating and lasting 1-2 hours) - Weight loss (due to food avoidance, as this causes pain) - Abdominal bruit may be heard on auscultation Diagnosis is by CT angiography.

Answer 42

``` Increased age Family history Smoking Diabetes Hypertension Raised cholesterol ```

Answer 43

``` Endovascular procedures first-line (i.e. percutaneous mesenteric artery stenting) Open surgery (i.e endarterectomy, re-implantation or bypass grafting) ```

Answer 44

rapid blockage in blood flow through the superior mesenteric artery, thrombus or embolus acute, non-specific abdominal pain shock, peritonitis and sepsis, necrosis of the bowel tissue and perforation, metabolic acidosis and raised lactate Contrast CT is the diagnostic test

Answer 45

Family history of bowel cancer Familial adenomatous polyposis (FAP) Hereditary nonpolyposis colorectal cancer (HNPCC), Inflammatory bowel disease (Crohn’s or ulcerative colitis) ``` Increased age Diet (high in red and processed meat and low in fibre) Obesity and sedentary lifestyle Smoking Alcohol ```

Answer 46

Change in bowel habit (usually to more loose and frequent stools) Unexplained weight loss Rectal bleeding Unexplained abdominal pain Iron deficiency anaemia (microcytic anaemia with low ferritin) Abdominal or rectal mass on examination

Answer 47

Faecal immunochemical tests (FIT)

Answer 48

Colonoscopy is the gold standard Sigmoidoscopy (for rectal bleeding only presentation) CT colonography Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP) - metastasis Carcinoembryonic antigen (CEA) - tumour marker

Answer 49

Open or Laparoscopic

Answer 50

Right hemicolectomy - removal of the caecum, ascending and proximal transverse colon. Left hemicolectomy - removal of the distal transverse and descending colon. High anterior resection - removing the sigmoid colon (may be called a sigmoid colectomy). Low anterior resection - removing the sigmoid colon and upper rectum but sparing the lower rectum and anus. Abdomino-perineal resection (APR) - removing the rectum and anus (plus or minus the sigmoid colon) and suturing over the anus

Answer 51

``` Bleeding, infection and pain Damage to nerves, bladder, ureter or bowel Post-operative ileus Anaesthetic risks Laparoscopic surgery converted during the operation to open surgery (laparotomy) Leakage or failure of the anastomosis Requirement for a stoma Failure to remove the tumour Change in bowel habit Venous thromboembolism (DVT and PE) Incisional hernias Intra-abdominal adhesions ```

Answer 52

Colostomy - LIF, flush to skin, solid stool Ileostomy - RIF, sprouted, liquid stool Gastrostomy (PEG) - feeding directly into stomach Urostomy - RIF, ileal conduit, after cystectomy

Answer 53

End colostomies are permanent after resection of abdomino-perineal resection (APR) - entire rectum and anus removed End ileostomies are permanent after a panproctocolectomy (total colectomy with removal of the large bowel, rectum and anus)

Answer 54

temporary stoma used to allow a distal portion of the bowel and anastomosis to heal after surgery “covering” or “defunctioning” loop colostomy or ileostomy, as they allow faeces to bypass the distal, healing portion of bowel until healed and ready to restart normal function.

Answer 55

Psycho-social impact Local skin irritation Parastomal hernia Loss of bowel length leading to high output, dehydration and malnutrition Constipation (colostomies) Stenosis Obstruction Retraction (sinking into the skin) Prolapse (telescoping of bowel through hernia site) Bleeding Granulomas causing raised red lumps around the stoma

Answer 56

F – Fat F – Fair F – Female F – Forty

Answer 57

biliary colic Severe, colicky epigastric or right upper quadrant pain Often triggered by meals (particularly high fat meals) Lasting between 30 minutes and 8 hours May be associated with nausea and vomiting

Answer 58

Acute cholecystitis Acute cholangitis Obstructive jaundice (if the stone blocks the ducts) Pancreatitis

Answer 59

Ultrasound (first-line) - diagnostic only A magnetic resonance cholangio-pancreatography (MRCP) - diagnostic only endoscopic retrograde cholangio-pancreatography (ERCP) - diagnostic and therapeutic Cholecystectomy (open or laproscopic) - therapeutic only

Answer 60

Excessive bleeding Cholangitis (infection in the bile ducts) Pancreatitis

Answer 61

Inject contrast and take x-rays to visualise the biliary system and diagnose pathology (e.g., stones or strictures) Perform a sphincterotomy on the sphincter of Oddi if it is dysfunctional (blocking flow) Clear stones from the ducts Insert stents to improve bile duct drainage (e.g., with strictures or tumours) Take biopsies of tumours

Answer 62

Bleeding, infection, pain and scars Damage to the bile duct including leakage and strictures Stones left in the bile duct Damage to the bowel, blood vessels or other organs Anaesthetic risks Venous thromboembolism (deep vein thrombosis or pulmonary embolism) Post-cholecystectomy syndrome

Answer 63

Symptoms after cholecystectomy, may be attributed to changes in the bile flow after removal of the gallbladder ``` Diarrhoea Indigestion Epigastric or right upper quadrant pain and discomfort Nausea Intolerance of fatty foods Flatulence ```

Answer 64

gallstones (calculous cholecystitis) - 95% acalculous cholecystitis - functional disability due to TPN or long fasting periods right upper quadrant (RUQ). This may radiate to the right shoulder. Fever Nausea Vomiting Tachycardia (fast heart rate) and tachypnoea (raised respiratory rate) Right upper quadrant tenderness Murphy’s sign Raised inflammatory markers and white blood cells

Answer 65

Murphy’s sign is suggestive of acute cholecystitis: - Place a hand in RUQ and apply pressure - Ask the patient to take a deep breath in - The gallbladder will move downwards during inspiration and come in contact with your hand - Stimulation of the inflamed gallbladder results in acute pain and sudden stopping of inspiration

Answer 66

1) abdominal ultrasound scan: Thickened gallbladder wall Stones or sludge in gallbladder Fluid around the gallbladder 2) Magnetic resonance cholangiopancreatography (MRCP)

Answer 67

``` Conservative management involves: Nil by mouth IV fluids Antibiotics (as per local guidelines) NG tube if required for vomiting ``` Endoscopic retrograde cholangio-pancreatography (ERCP) Cholecystectomy

Answer 68

Sepsis Gallbladder empyema Gangrenous gallbladder Perforation

Answer 69

Obstruction in the bile ducts Infection introduced during an ERCP procedure Escherichia coli Klebsiella species Enterococcus species

Answer 70

Right upper quadrant pain Fever Jaundice (raised bilirubin)

Answer 71

1) Acute management of sepsis and acute abdomen, including: Nil by mouth IV fluids Blood cultures IV antibiotics (as per local guidelines) Involvement of seniors and potentially HDU or ICU 2) Imaging to diagnose common bile duct (CBD) stones and cholangitis Magnetic resonance cholangio-pancreatography (MRCP) Endoscopic ultrasound

Answer 72

endoscopic retrograde cholangio-pancreatography (ERCP): contrast, stone removal, balloon dilatation, stenting, biopsy Percutaneous transhepatic cholangiogram (PTC) involves radiologically guided insertion of a drain through the skin and liver, into the bile ducts

Answer 73

adenocarcinomas inside the liver (intrahepatic ducts) or outside the liver (extrahepatic ducts) most common site is in the perihilar region Ulcerative colitis Primary sclerosing cholangitis Liver flukes (a parasitic infection)

Answer 74

Obstructive jaundice: Pale stools Dark urine Generalised itching Unexplained weight loss Right upper quadrant pain Palpable gallbladder (swelling due to an obstruction in the duct distal to the gallbladder) Hepatomegaly

Answer 75

palpable gallbladder along with jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic head cancer.

Answer 76

Diagnosis is based on imaging (CT or MRI) plus histology from a biopsy. Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP) CA 19-9 (carbohydrate antigen) is a tumour marker that may be raised in cholangiocarcinoma. It is also raised in pancreatic cancer Magnetic resonance cholangio-pancreatography (MRCP) Endoscopic retrograde cholangio-pancreatography (ERCP)

Answer 77

Stents inserted to relieve the biliary obstruction Surgery to improve symptoms (e.g., bypassing the biliary obstruction) Palliative chemotherapy Palliative radiotherapy End of life care with symptom control

Answer 78

``` - Painless obstructive jaundice: Yellow skin and sclera Pale stools Dark urine Generalised itching ``` - other presenting features: Non-specific upper abdominal or back pain Unintentional weight loss Palpable mass in the epigastric region Change in bowel habit Nausea or vomiting New‑onset diabetes or worsening of type 2 diabetes

Answer 79

refers to migratory thrombophlebitis as a sign of malignancy, particularly pancreatic adenocarcinoma

Answer 80

imaging (usually CT scan) plus histology Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP) CA 19-9 (carbohydrate antigen) Magnetic resonance cholangio-pancreatography (MRCP) Endoscopic retrograde cholangio-pancreatography (ERCP) Biopsy under US or CTG

Answer 81

Total pancreatectomy Distal pancreatectomy Pylorus-preserving pancreaticoduodenectomy (PPPD) (modified Whipple procedure) Radical pancreaticoduodenectomy (Whipple procedure)

Answer 82

Stents inserted to relieve the biliary obstruction Surgery to improve symptoms (e.g., bypassing the biliary obstruction) Palliative chemotherapy (to improve symptoms and extend life) Palliative radiotherapy (to improve symptoms and extend life) End of life care with symptom control

Answer 83

Whipple procedure (pancreaticoduodenectomy) ``` Head of the pancreas Pylorus of the stomach Duodenum Gallbladder Bile duct Relevant lymph nodes ```

Answer 84

pylorus-preserving pancreaticoduodenectomy (PPPD). ``` Removing: Head of the pancreas Duodenum Gallbladder Bile duct Relevant lymph nodes ```

Answer 85

Gallstones (bile reflux back into pancreas) Alcohol (direct toxicity) Post-ERCP ``` Others: S – Steroids T – Trauma A – Autoimmune M – Mumps ```

Answer 86

``` Severe epigastric pain Radiating through to the back Associated vomiting Abdominal tenderness Systemically unwell (e.g., low-grade fever and tachycardia) ```

Answer 87

``` - Glasgow score: FBC (for white cell count) U&E (for urea) LFT (for transaminases and albumin) Calcium ABG (for PaO2 and blood glucose) ``` - Severity: serum amylase 3x upper limit of normal CRP Ultrasound CT abdomen for complications (such as necrosis, abscesses and fluid collections)

Answer 88

PANCREAS mnemonic (1 point for each answer): ``` P – Pa02 < 8 KPa A – Age > 55 N – Neutrophils (WBC > 15) C – Calcium < 2 R – uRea >16 E – Enzymes (LDH > 600 or AST/ALT >200) A – Albumin < 32 S – Sugar (Glucose >10) ```

Answer 89

Management involves: Initial resuscitation (ABCDE approach) IV fluids Nil by mouth Analgesia Careful monitoring Treatment of gallstones in gallstone pancreatitis (ERCP / cholecystectomy) Antibiotics if there is evidence of a specific infection (e.g., abscess or infected necrotic area) Treatment of complications (e.g., endoscopic or percutaneous drainage of large collections)

Answer 90

``` Necrosis of the pancreas Infection in a necrotic area Abscess formation Acute peripancreatic fluid collections Pseudocysts (collections of pancreatic juice) can develop 4 weeks after acute pancreatitis Chronic pancreatitis ```

Answer 91

``` Chronic epigastric pain lack of pancreatic enzymes Loss of insulin, leading to diabetes strictures resulting in obstruction of pancreatic juice and bile pseudocysts or abscesses ```

Answer 92

Abstinence from alcohol and smoking Analgesia Replacement pancreatic enzymes (Creon) Subcutaneous insulin regimes ERCP with stenting Surgery for complications (chronic pain, biliary obstruction, abscess...)

Answer 93

Significant co-morbidities (e.g., severe kidney, lung or heart disease) Current illicit drug use Continuing alcohol misuse (generally 6 months of abstinence is required) Untreated HIV Current or previous cancer (except certain liver cancers)