Surgery Review Flashcards
why might a dermatofasciotomy be required following a femoral angioplasty for a patient with critical limb ischaemia?
on revascularisation, there is a rapid increase in blood flow to the patient’s limb, causing a rise in pressure within a limb compartment which may lead to compartment syndrome which is treated with a dermatofasciotomy.
an odd pattern of ischaemic damage is noted in the foot, what is the most likely cause?
embolisation
oesophageal surgery procedure name?
Ivor Lewis procedure
A Hartmann’s procedure is performed when disease affects which part of the bowels?
Sigmoid colon
How is severity of pancreatitis assessed?
CT scan-look for low density changes
CRP monitoring
Modified Glasgow criteria/Imrie scoring: 3 or more positive factors within 48hr of symptom onset suggest severe pancreatitis requiring prompt transfer to ITU/HDU:
PANCREAS: PaO2 less than 8.0 kPa
age over 55yrs
neutrophilia more than 15X10^9 cells per L
calcium less than 2mmol/L
urea more than 16mmol/L
LDH more than 600iu/L, AST more than 200iu/L
albumin less than 32g/L (serum)
blood glucose more than 10mmol/L
cause of pigment GSs?
haemodialysis
when does serum amylase start to fall in acute pancreatitis?
within 24-48hr of onset
if presentation after this time, urinary amylase may still be raised
continuing care required post acute pancreatitis attack?
must advise to stop drinking alcohol even if attack not result of alcoholic ‘binge’
cholecystectomy if GSs were demonstrated once pt fully recovered
acute pancreatitis prognosis?
mortality less than 1% if single episode of mild pancreatitis
mortality of 10% if severe, rising to 30% if severe necrosis and nearly 40% if pancreatic necrosectomy required.
complications that may follow a perforated peptic ulcer?
re-perforation-ensure H pylori eradication therapy given abscess wound infection lung atelectasis PE gastric outlet obstruction-occurs with fibrotic stenosis of dudodenum or gastric antrum, and may follow long standing chronic peptic ulceration, presents with massive and effortless vomiting often containing undigested food. sub-phrenic abscess multi-organ failure
if vomitus contains bile, what causative conditions can we rule out?
anything pathology proximal to the ampulla of Vater
why is melaena usually associated with gastric haemorrhage?
gastric acid turns the Hb to haematin, responsible for the black, tarry and unpleasant smelling stools.
why is the term ‘biliary colic’ not really an appropriate use of the word colic?
despite the intermittent nature of the pain, it does not remit entirely between each spasm, and the bile duct has a very weak muscle layer, in contrast the the small of large bowel.
when is a pt said to have an acute abdomen?
if moderate to severe pain lasting between a few hrs and a few days
a very high WCC in the context of acute abdominal pain supports the diagnosis of which conditions?
severe acute pancreatitis
mesenteric ischaemia
conditions to be met for referral under the 2 week wait for suspected colorectal Ca?
rectal bleeding and change in bowel habit for more than 6 weeks
persistent rectal bleeding without anal symptoms in those aged over 45, with no obvious external evidence of benign anal disease
Fe deficiency anaemia (microcytic, hypochromic), without an obvious cause and Hb less than 10g/dL
palpable abdo or rectal mass
recent onset of looser stools and/or increase frequency of defecation, persisting for more than 6 weeks
most common organisms implicated in ascending cholangitis?
klebsiella spp. E.coli enterobacter spp. enterococci streptococci
what additional features might a pt with ascending cholangitis present with other than charcot’s triad?
hypotension due to septic shock
mental confusion
=Reynold’s pentad
How should the management of a pt proceed if they are suspected of having a non-disabling stroke or TIA, identified as candidate for carotid endarterectomy on specialist assessment, but carotid imaging within 1wk of symptom onset shows non-significant stenosis?
should have best medical management: lifestyle advice-increase exercise, lipid lowering diet and drugs, BP control, antiplatelet agents.
this is carried out rather than carotid endarterectomy if carotid imaging (duplex USS) within 1wk of symptom onset shows stenosis of less than 50% with NASCET criteria, or less than 70% with ECST criteria, in pt with stable neurological symptoms and symptomatic stenosis.
How should the management of a pt proceed if they are suspected of having a non-disabling stroke or TIA, identified as candidate for carotid endarterectomy on specialist assessment, and carotid imaging within 1wk of symptom onset shows significant stenosis?
require best medical management and assess and refer for cartoid endarterectomy within 1wk of symptom onset. Carotid endarterectomy should be performed within 2wks of symptom onset.
this is carried out if carotid imaging within 1 wk of symptom onset shows stenosis of 50-99% according to NASCET criteria or 70-99% according to ECST criteria, and pt has stable neurological symptoms and symptomatic stenosis.
in a pt with sudden onset neurological symptoms, what blood test is important to rule in/out particular differential?
blood glucose-exclude hypoglycaemia
how is TIA defined and how are these patients assessed in hospital?
sudden onset focal neurological defecit with neurological symptoms lasting for no more than 24 hours.
assessment for subsequent stroke risk using ABCD2 scoring tool-score 0-3 mild risk, 4-5 moderate risk and 6-7 high risk.
imaging in suspected TIA or non disabling stroke?
urgent brain scanning required if symptoms of acute stroke
if TIA, pt should have specialist assessment within 1wk of symptom onset before decision on brain imaging made
if TIA and high risk of stroke (ABCD2 score 4 or more) and vascular territory or pathology uncertain, do urgent brain imaging with diffusion-weighted MRI
same if low risk of stroke
if after specialist assessment deemed suitable for carotid endarterectomy, should have carotid imaging within 1 wk of symptom onset.
define buerger’s angle?
the angle to which the leg has to be raised before it becomes white
vascular angle less than 20 degrees indicates severe ischaemia.
how do veins appear in an ischaemic foot?
‘guttering of the veins’: appear as pale blue gutters as veins collapse and sink below the skin surface
components to inspection of lower limb for assessing arterial circulation?
colour
buerger’s angle (vascular angle)-raise both legs to determine vascular angle and compare, then pt should sit up and dangle feet over edge of bed, ischaemic leg will slowly turn from white to pink to purple-red-deoxygen bld filling dilated capillaries.
venous filling
pressure areas
what is palpated on arterial assessment of lower limb?
skin temperature
CRT
pulses-femoral, popliteal, dorsalis pedis, posterior tibial
causes of skin ulceration?
arterial-gangrene-atherosclerosis and AV malformations
venous-DVT-post thrombotic deep vein damage, and varicose vein association, 80-85% of leg ulcers
neuropathic ulceration-DM, tabes dorsalis-tertiary syphilis, syringomyelia, spina bifida, nerve injuries
lymphatic insufficiency
osteomyelitis
vasculitis-RA, SLE, scleroderma, polyarteritis nodosa, wegener’s granulomatosis
squamous or basal cell carcinoma, melanoma
marjolin’s ulcer-malignant change of an ulcer
bowen’s disease-slow growing red/brown scaly plaque e.g. lower legs, carcinoma in situ
sarcoidosis
pyoderma gangrenosum e.g. assoc. with IBD, wegener’s
traumatic e.g. radiation, cold injury, burns, pressure sore
haematological e.g. sickle cell anaemia, polycythaemia rubra vera-somatic mutation in single haemopoietic stem cell causing erythroid hyperplasia, thrombocytosis and myeloid leukocytosis, and splenomegaly, plus risk of transformation to acute myeloid leukaemia, only tested in females as polymorphism on X chromosome taking advantage of its inactivation.
if a pt complains of aching calves, this may be the result of intermittent claudication- should clarify walking distance (claudication distance), however how could a CXR be useful in ruling out an important differential for aching calves?
CXR to look for lung Ca-small cell lung Ca assoc. with the paraneoplastic syndrome of lambert-eaton myasthenic syndrome, for which 1 of the presenting symptoms is aching muscles, in addition to weakness-usually proximal lower limb muscles affecting gait, and autonomic symptoms e.g. dry mouth and postural hypotension.
what are the components of the EWS and which would you be monitoring most closely and why after a pt returns to the ward from theatre when assessing for complications?
BP, HR, RR, SpO2, temperature, conscious level
RR- 1st to change in pt becoming acutely unwell e.g. when assessing hypovolaemia from blood loss, class I with a blood loss of less than 750ml would be unlikely to alter HR, BP or urine output, but RR may be between 14 and 20/min, which might be notable increase if pt normally 12/min.
what important investigation should be carried out on all afro-caribbean patients preoperatively?
sickle cell testing:
importance as heterozygotes (HbAS) have sickle-cell trait, which causes no disability and protects against falciparum malaria, EXCEPT IN HYPOXIA- e.g. in anaesthesia, where vaso-occlusive events may occur e.g. stroke, mesenteric ischaemia, avascular necrosis e.g. of femoral head, and leg ulcers.
gas in the biliary tree on AXR is consistent with what diagnosis?
GS ileus
how can barium enema be used to distinguish between true large bowel obstruction and pseudoobstruction?
barium will pass through proximal dilated bowel in pseudo-obstruction
why should laparoscopy be avoided when bowel obstruction?
dilated bowel loops obscure view and can be perforated during cannulae insertion, espec. if bowel adherent to abdo wall.
caution with IV fluid resuscitation in suspected ruptured aneurysm?
hypotension in this case is homeostatic reducing risk of rebleed
PUD diagnostic confirmation?
upper GI endoscopy (oesophago-gastro duodenoscopy)
how are biopsies taken from gastric ulcers to exclude early malignant change?
from all 4 quadrants
Calot’s triangle components?
cystic artery-from the R hepatic artery (or superior border of triangle formed by inferior liver in term cystohepatic triangle*)
cystic duct
common hepatic duct
*significance in cholecystectomy- cystic artery and duct dissected out and then clipped, or ligated by endosuture and divided. GB dissected off undersurface of liver.
lap cholecystectomy complications?*
residual stones
bile duct damage
cystic duct bile leakage
haemorrhage from cystic artery
acute cholecystitis complications?
obstructive jaundice acute pancreatitis GB empyema mucocele of GB mirizi's syndrome-CBD obstructed by GS in hartman's pouch acute cholangitis cholecysto-enteric fistula and GS ileus
2 presentations of perforated diverticular disease?
purulent peritonitis: diverticulitis has proceeded to form a pericolic abscess that has burst into the peritoneal cavity but does not communicate with the bowel (Hinchey stage 3 classification of acute diverticulitis).
faecal peritonitis: true connection between bowel and peritoneal cavity as orifice of diverticulum patent. Mortality of at least 50%, characterised by septic SHOCK: severe sepsis plus hypotension unresponsive to adequate fluid resuscitation.
why do diverticula NOT form in the rectum?
at rectosigmoid junction, the taeniae join to form a complete outer longitudinal muscle layer.
presentation of acute sigmoid diverticulitis?
LIF pain, colicky if large bowel obstruction from inflammation or stricture predominates
pain may spread across whole abdomen if pericolic abscess or diverticulum ruptures causing generalised peritonitis
usually constipated, a few develop diarrhoea
often accompanying nausea
abdo tenderness
fever
urinary symptoms if inflamed colon lies against bladder
RIF pain if sigmoid loop flops over to R
bleeding PR unlikely as inflammation-oedema*?
3 criteria defining the PAIN in intermittent claudication?
pain in a muscle, usually calf
pain only when muscle is exercised
pain disappears when exercise stops
if restenosis follows therapeutic interventions for chronic leg ischaemia, what is the likely cause?
intimal hyperplasia
NICE recommendations on IC management?
CVS RF reduction: smoking cessation-CVS risk halved within 1 yr of stopping, also improve walking distance and amputation rates.
of managing all RFs, stopping smoking along with exercise training provides most notable improvement in walking distance.
lipid modification with statin-reduce CVS events and stabilise atherosclerotic plaques.
exercise-CVS benefit, improve walking distance. offer supervised or unsupervised if not available exercise programme
HTN-manage to reduce risk of stroke and CVS events
DM-good glycaemic control benefit on CVS disease progression in general
AP treatment-Clopidogrel 75 mg daily is the preferred antiplatelet in PVD. If contraindicated or not tolerated, give low dose aspirin alone. If both contraindicated or not tolerated, give modified-release dipyridamole alone.
Naftidrofuryl oxalate- a peripheral vasodilator via 5-HT antagonism, can be given if exercise unsuccessful, managing RFs has been enforced, and pt does not want consideration for angioplasty or bypass.
complications of surgical treatment for intermittent claudication?
failed angioplasty vessel thrombosis arterial wall dissection restenosis bypass occlusion
causes of visceral pain?
ischaemia-e.g. acute mesenteric ischaemia- may present with periumbilic pain
stretching/distensions e.g. large bowel distension with large bowel obstruction due to a colorectal Ca, presenting with suprapubic pain
tension
hindgut derivatives which are responsible for visceral referred pain to the suprapubic region?
from distal 1/3 of transverse colon to the anal verge
referrred biliary tract pain?
R inferior scapular area
how does pain duration help to determine differentials for the acute abdomen?
sudden onset: rupture or perforation e.g. splenic rupture, AAA rupture, PUD perforation, diverticulum perforation
in onset, ? how long to reach maximal pan?
also ensure rule out cardio/resp pathologies e.g. aortic dissection, PE and pneumothorax
rapidly accelerating: colic-ureteric, biliary, SBO- e.g. adhesions, hernia or strictures e.g. Crohn’s disease
gradual onset (over a few hrs): inflammatory, obstructive processes, mechanical causes
if movement aggravates pain so pt remains as still as possible, what does this indicate in acute abdomen?
generalised peritonitis
features suggestive of malignancy in acute abdomen presentation?
intermittent pain for more than 48 hrs change in bowel habit, may be absolute constipation with LBO abdominal distension mass weight loss
features suggesting perforated viscus in acute abdomen presentation?
sudden onset pain constant severe pain aggravated by movement and coughing diffuse tenderness silent rigid abdomen
important components to abdomen inspection in presentation of acute abdomen?
scars-indicative of previous surgery e.g. Lanz incision-appendicitis, Kocher-gallbladder, maybe prev surgery causes adhesions now presenting as SBO
distension-in flanks and epigastrium suggestive of LBO
bulge, mass-? diverticular abscess, CR Ca
movement-board like rigidity if peritonitis
bruising-periumbilical cullen’s sign and flank grey turner’s sign in acute pancreatitis
the most common cause of SHOCK in a surgical pt is hypovolaemia, how is hypovolaemia resulting from blood loss assessed?
look at patients pulse, BP, pulse pressure, RR, urine output and mental state
Class I: with less than 750mL blood loss (less than 15%), pulse less than 100, BP normal, pulse pressure normal or raised, RR 14-20/min, urine more than 30mL/hr, pt may be slightly anxious, ONLY REAL ABNORMALITY=RR
Class II: 750-1500 mL blood loss (15-30%), PR more than 100, BP normal, pulse pressure decreased, RR 20-30, urine output 20-30, mildy anxious.
Class III: 1500-2000 blood loss (30-40%), pulse more than 120, BP decrease, pulse pressure decrease, RR 30-40, 5-15 mL urine ouput, confused pt.
NOTE BP ONLY DROPS AFTER 30-40% OF BLOOD VOLUME LOSS
Class IV: more than 2000mL (40%) bld loss, pulse more than 140, BP and PP decrease, RR more than 35, negligible UO and pt lethargic- needs blood aswell as crystalloid.
what score is used to risk-score upper GI bleeds?
Rockall score
what is meant by a positive Rovsing’s sign?
palpation of LLQ increases pain felt in RLQ
this is indicative of acute appendicitis
what is ascending cholangitis?
infection of the CBD superimposed on an obstruction e.g. due to a gallstone, or stricture
what is the purpose of bile duct sphincterotomy?
help improve bile drainage*
causes of adhesions other than previous operation?
trauma e.g. RTA, blunt spleen injury
intra-abdominal infection e.g. salpingitis
indications for surgery in small bowel obstruction?
unresolving
fever
marked tenderness indicating peritonitis
evidence of perforation on imaging
what imaging is used to identify gallstone ileus, and what triad is this associated with?
plain AXR- shows pneumobilia, small bowel obstruction and radiolucent gallstone=rigler’s triad
complications of small bowel obstruction?
perforation, producing peritonitis and sepsis*
ischaemia
why is checking for anaemia by performing an FBC as part of the pre-operative assessment so important?
in order to correct the anaemia prior to surgery so as to reduce the risk of cardiovascular events
importance of LFTs as part of the pre-operative assessment?
assess for any coagulopathy that can be corrected
help in determining drug choices and dosages bearing in mind their metabolism by the liver
low albumin or protein level indicative of poor nutritional state that may affect post-operative recovery
what must be done prior to a X match of bloods?
a group and save!
name of syndrome for oesophageal rupture?
Boerhaave’s syndrome
differentials for sudden onset severe abdo pain that rapidly progresses to become generalised and constant?
hollow viscus perforation
ruptured AAA
acute mesenteric ischaemia
pain fibres carrying visceral pain in GI tract?
sympathetic splanchnic nerves
somatic pain from parietal peritoneum and abdominal wall carried by intercostal (spinal) nerves
why might acute cholecystitis present with R scapula pain?
irritation of the diaphragm, referred pain to shoulder.
why might a patient with a PMH of COPD be delayed in waking up post GA?
if patient is a retainer of CO2, they will have compensated for this through HCO3- release by the choroid plexus cells to normalise pH so CO2 conc no longer driving their urge to breathe, hypoxia is, BUT it is hypercarbia which is the stimulus to waking following a GA.
aim of pre-op assessment?
is the patient fit for surgery?
can we optimise the pt prior to surgery, paying close attention to management of pt co-morbidities? ability to postpone or cancel the surgery if necessary.
can we identify and reduce the risk of any complications that might occur?
establish rapport with pt
take hx, examine and investigate
in terms of r/ving the CVS and Resp functioning of a pt pre-op, what specifically should be asked about?
patient’s functional capacity (exercise tolerance)
e.g. are they able to manage a flight of stairs in one attempt?
why is it important to ask a pt pre-op whether they, or anyone in their family, has suffered from a rapid rise in temperature after being given an anaesthetic?
to assess for malignant hyperthermia-potentially lethal condition usually triggered by an anaesthetic and result of genetic defect of the ryanodine receptor causing massive intramyoplasmic increase in Ca2+ from SR, causing muscle rigidity and rhabdomyolysis.
?muscle disorders in the family (assoc. with Duchenne’s and becker’s muscular dystrophy), pt myalgia and muscle cramps. bloods may show persistent raised CK.
in diagnosed patient, can avoid the causative anaesthetics e.g. halothane and suxamethonium. non-depolarising NM blockers e.g. pancuronium are safe, as is NO and barbiturates includ thiopental. check CK before and after surgery, and put pt 1st on the list and flush apparatus through with O2 for 10mins before using.
management of malignant hyperthermia?
switch from volatile anaesthetics to alternatives
give 100% O2 and adjust ventilation according to blood gas and end-expiratory CO2
deepen anesthesia with BZDs, opioids, propofol
monitor blood gas, electrolytes, lactate, myoglobin, CK
stop surgery if elective and signs of masseter spasm or a fulminant crisis
continue surgery if no hyperkalaemia, no acidosis and no triggers
IV DANTROLENE-muscle relaxant
If a fulminant malignant hyperpyrexia crisis occurs:
Sodium bicarbonate may be given according to blood gas analysis.
Arrhythmia may be treated with a beta-blocker or lidocaine.
Stop surgery as soon as possible.
Cool the patient - eg, iced water through a nasogastric tube.
Intensive monitoring including arterial catheter, central venous catheter, Swan-Ganz catheter, urinary catheter. Monitor renal function, check myoglobinuria, coagulation screen, temperature, electrolytes and CK.
Forced diuresis to help protect the kidneys
components to hx of PC and PMH in pre-op assessment?
hx of condition and procedure to be done
confirm site of operation and side
PMH: CVD, including prev. MIs, HTN, and current exercise tolerance-risk of acute cardiac event increased during anaesthesia.
Resp disease e.g. COPD, asthma-control, triggers, med.s e.g. steroids-dose and duration, prev hosp admissions espec. ITU. In peri-op period, adequate oxygenation vital to reduce risk of acute ischaemic events.
Renal disease: surgical complications risk increased with anaemia, coagulopathy and BC disturbance. Signif. disturbance of renal funtion can occur with IV contrast and blood loss.
DM-type, medication, related co-morbidities. thyroid disease.
MSK illness e.g. cervical spondylosis which can make intubation difficult necessitating specific equipment.
also want to check if pt could be pregnant, and if could have undiagnosed sickle cell disease if of african or AC origin.
post-op complications in patients with sickle cell disease?**
acute chest syndrome infection hyperhaemolytic crisis relative aplastic crisis alloimmunisation with delayed transfusion reactions
additions to PMH in a surgical patient?
past surgical history-operations and why
anaesthetic hx-prev anaeasthetic? any complications? PONV? rapid rise in temp-malignant hyperthermia.
how is the airway assessed prior to surgery?
look for facial abnormalities e.g. receding mandible-can cause difficulties in airway insertion
look in the mouth-teeth-present?dentition?loose teeth?crowns? degree of mouth opening-favourable if inter-incisor distance more than 3cm
oropharnyx-Mallampati classification-correlates with difficulty of intubation, classed as I-IV, ask pt to maximally protrude tongue.
neck-flex, extend and lateral flexion, then max extend and measure distance between thyroid cartilage and chin-thyromental distance-less than 7cm suggests difficult intubation.
definition of ASA 3?
severe systemic illness, leading to functional limitation of their activity
importance of Us and Es before surgery?
baseline function of kidneys assessment to indicate susceptibility to AKI
general pre-op investigations?
FBC-anaemia?-correct before surgery to reduce risk of acute cardiac events
Us and Es-baseline
LFTs-correct coagulopathy, determine met of part drugs-appropriate and doses, low albumin-poor nutrition-poor post-op recovery.
clotting-identify abnormalities and correct
G+S- determine pt’s blood group (ABO and RhD) and screen for atypical Abs. recommended if blood loss not anticipated but bld may be required in surgery if greater blood loss than expected.
X match- mix patient’s bld with donor’s bld to see if immune reaction occurs. do if bld loss anticipated. must G and S 1st.
ABG if pt has condition that may cause pulmonary impairment.
ECG-if hx of CVD, undergoing major surgery. indicate underlying pathology and provide baseline if post op signs of cardiac ischaemia.
CXR-indicated if respiratory illness and not had a CXR within 12 months, new cardiorespiratory symptoms, recent travel from areas with endemic tuberculosis or significant smoking history.
spirometry if chronic lung condition-may predict post-op pulm. complications.
preg test
sickle cell testing-HbS
MRSA swabs-nasopharyngeal, perineal, throat. if colonisation isolated, give antiseptic hair and body wash, and topical ointment.
urinalysis-ongoing glycosuria or UTI? undiagnosed diabetes mellitus?-increase complications peri-operatively.
2 potential complications of gastric contents aspiration in pts perioperatively?
aspiration pneumonitis- inflammation causing desquamation
aspiration pneumonia-secondary infection following pneumonitis or direct aspiration of infected material.
presentation of biliary colic?
sudden severe pain across the upper abdomen, may not be able to indicate which side is more affected
constant pain with excruciating exacerbations, pain does not remit in between these
severe pain usually lasts no longer than a few hours unless acute cholecystitis develops
usually N+V
pain relieved only by strong analgesia
jaundice may be present, in this case may be dark urine and pale stools
hx of flatulent dyspepsia-upper abdo pain accompanied by feeling of fullness, with nausea and frequent belching of air
mild tachycardia often present but temp usually normal
abdomen extremely tender, with intense guarding in upper abdomen
acute cholecystitis management (and that of biliary colic)?
pain relief with opioids
admit for bed rest and USS confirmation of dignosis
restrict oral fluids if nauseated or vomiting
commence IV fluids
Abx e.g. cephalosporin such as cefuroxime 1.5g/8h if pt pyrexial or marked leucocytosis
SC LMWH
Cx management if attack lasted several days or pt jaundiced, re-admit for elective lap chole 6-8wk later
early chole if pt fit, US confirmed diagnosis and attack less than 24-48hrs duration.
medication which must be STOPPED before sugery?
clopidogrel-stopped at least 1 week before to reduce risk of profuse bleeding. aspirin can be continued as cardio and cerebroprotective benefits outweigh risks + long t1/2 and minimal effects on surgical bleeding.
warfarin-stopped 5 days before. ensure INR checked day before surgery, may convert to heparin for elective but must stop 6hrs prior to surgery and monitor APTT peri-op. if prev DVT/PE, admit day before surgery and may give high dose prophylactic LMWH. if prosthetic heart valve, admit 2-3days post op, check INR, allow decrease to 2, start IV unfractionated heparin and stop 4hrs pre-op.
OCP and HRT-stopped 4 wks before, advise alternative contraception e.g. barrier, at this time.
don’t give oral hypoglycaemics and most antihypertensives on morning of surgery
