Surgery teaching (General surgery) Flashcards
1
Q
general surgery emergency presentatons
A
- Acute abdomen (abdominal pain)
- Hernias
- Abscesses
- Lower GI bleeding
- Obstructive juandice
- Trauma
2
Q
the acute abdomen def
A
‘abdo pain of < 1 week duration, requiring admission to hospital, which has not been previously investigated or treated’
3
Q
pathophysiology of abdo pain
A
Visceral vs somatic pain
4
Q
visceral pain
A
- mediated by sympathetic NS
- insensitive to mechanical/chemical/thermal stimuli
- sensitive to tension (e.g. overdistention) and ischaemia
- deep-seated, ill-localised
- colic = visceral pain from hollow viscus with muscle in wall
5
Q
somatic pain
A
- parietal peritoneum. Mediated by somatic nerves - sharp, well-localised pain
- reflex guarding, rigidity
6
Q
two main processes behind abdo pain
A
1) Inflammation
2) Obstruction
7
Q
causes of abdo pain: location
A
- Upper GI/ HPB
- Small boewl/ large bowel
- Urological
- Vascular
- Gynaecological
8
Q
Upper GI/ HPB causes
A
- peptic ulcer disease
- acute cholecystitis
- acute cholangitis
- acute pancreatitis
- biliary colic
9
Q
colorectal causes
A
- IBD
- Mesenteric ischameia
- Meckels diverticulitis
- Acute appendicitis
- Acute colitis
- Acute diverticulitis
- Perforation of strangulated bowel
- Small bowel obstruction
- Large bowel obstruction
10
Q
Urological causes
A
- UTI/ Pyelonephritis
- Ureteric colic
- Retention of urine
11
Q
vascular causes
A
ruptured AAA
12
Q
gynaecological causes
A
- ectopic pregnancy
- ovarian cyst (torion, ruputre, haem, infection)
- PID
- mittelschmerz
- Endometriosis
- Fibroid degeneration
13
Q
Medical causes of abdo pain
A
- Abdo wall – rectus sheath haematoma, costochondritis
- GI – gastritis, gastroenteritis, mesenteric adenitis, hepatitis, Fitz-Hugh-Curtis syndrome CVS /Resp - angina, MI, pneumonia
- Haem – sickle cell, malaria, hereditary spherocytosis
- Endocrine/metabolic – DKA, thyrotoxicosis, Addison’s, uraemia, hyperCa, porphyria Neurol/infective - herpes zoster
14
Q
approach to patient with abdominal pain
A
1) A- E first
2) History (good pain history - SOCRATES)
3) Examination (inspection, palpation, percussion, ausc)
15
Q
Examination: what to remember
A
- Examine the groins, DRE, PV if appropriate, complete systemic examination
- Specific signs: Murphy’s, Rovsing’s, Grey Turner’s/Cullen’s
16
Q
investigations for acute abdomen
A
1) Bloods
2) Urinalysis
3) Radiology
17
Q
Bloods for acute abdomen
A
- FBC, CRP
- U&E
- Amylase – 3x upper limit for acute pancreatitis (AP)
- LFTs
- VBG/ABG (lactate!)
- Serum calcium (hyperCa can cause pain, hypoCa seen in AP) * Sickle cell tests – if abdo pain in at-risk pt
- Blood glucose – DKA, known DM, in acute pancreatitis
18
Q
Urinalysis for acute abdomen
A
- haematuria, glucose/ketones, infection
- bHCG
- urinary porphobilinogen (recurrent, unexplained abdo pain)
19
Q
Radiology for acute abdomen
A
- USS – for appendicitis, gallstones, urinary obstruction, gynae pathology
- CT – for appendicitis (if USS not diagnostic), delineate cause of obstruction/peritonitis
- CXR – for free intraperitoneal air. Largely replaced by CT.
- AXR – for obstruction. Largely replaced by CT.
- Others – contrast radiology, angiography
20
Q
management overview for the acute abdomen
A
1) all require A-E assessment and appropriate resus (O2, fluids +/- antibiotics/sepsis 6)
- if rapid haemorrhage (e.g. AAA, ectopic) resus while arrange intervention.
2) Early analgesia
3) DVT prophylaxis
4) reassessment key – to ensure improving and to monitor for deterioration
5) often keep fasted until diagnosis reached
6) Definitive treatment – ABx, radiological, surgical
21
Q
SCENARIO 1
* 22 y/o female, 48 hour history of RIF pain, nausea/vomiting and anorexia
* O/E - PR 100, BP 120/80, RR 18, 37.8C, ACVPU - peritonism RIF, Rovsing’s positive
- PR – tender on right side
Investigations
* Bloods – U&E/LFT/amylase normal; WCC 14; CRP 58 * Urinalysis – + leuc only, bHCG neg
A
APPENDICITIS
- History/exam suggests appendicitis
- Start resus, NBM
- Historically would have just operated (laparoscopy)
- Currently – vast majority of patients are imaged 1) Ultrasound scan - if positive→theatre
- if equivocal→ 2) Focused CT scan
- Reduces negative laparoscopy rate
22
Q
SCENARIO 2
* 46 y/o female, 5 day history of RIF pain, nausea/vomiting and anorexia
* O/E - PR 100, BP 120/80, RR 18, 37.9C, ACVPU
- tender RIF, mass in RIF (on abdominal exam and PR)
Investigations
* Bloods – U&E/LFT/amylase normal; WCC 16; CRP 62
* Urinalysis – + leuc only, bHCG neg
A
APPENDIX MASS/ABSCESS
CT is key investigation as differentials and treatment here different
* Appendix mass (walled-off appendicitis)
- surgery difficult at this stage
- IV Abx, may offer interval appendicectomy (+/- preceding colonoscopy)
* Appendicitis plus abscess
- if well and no signs of sepsis → radiological drain.
- may then offer interval appendicectomy (+/- preceding colonoscopy)
* Other causes of mass – Crohn’s disease, GI malignancy, ovarian
23
Q
SCENARIO 3
* 34 y/o male, 6 hours ago sudden onset epigastric pain, nausea and vomiting
* recently taking analgesia for ankle injury
* O/E – ACVPU, clammy, cap refill 3 sec, PR 110, BP
100/80, RR 18/min, temp 37.7C
- abdomen – peritonism in epigastrium and RUQ/RIF
Management?
A
- Resus - ABCDE: O2, IV access + fluids, NBM
- Bloods – U&E/LFT/amylase normal, CRP 50, WCC 12.5
Imaging
- ? CXR – generally not nowadays as can miss free gas (e.g. retroperitoneal perf). If negative, will get a CT scan
- CT scan best
24
Q
GI PERFORATION - CAUSES
A
Upper GI
* Perforated peptic ulcer (duodenal > gastric)
* Perforated gastric tumor
* Iatrogenic (OGD, ERCP)
* Small bowel diverticular perforation (jejunal/ Meckel’s)
Lower GI
* Perforated diverticular disease
* Perforated colonic tumour
* Perforation proximal to distal obstruction (e.g. at caecum) * Iatrogenic
25
GI PERFORATION - SURGERY
Depends on
i) the underlying pathology and
ii) the performance status (fitness) of the patient
Upper GI perforations (e.g. DU) are generally closed
Lower GI perforations (e.g. perforated diverticular disease)
are generally resected
* Mortality and morbidity is high
26
causes of small bowel obstruction
Outside the wall
Within the wall
Within the lumen
27
Small bowel obstruction causes: Outside the wall:
* Adhesions (50-75%)
* Hernias (up to 25%)
* Tumours (e.g. peritoneal disease)
28
SBO: Within the wall:
* Tumours (benign, malignant)
* Strictures (e.g. Crohn’s, TB)
29
SBO: Within the lumen
* Foreign bodies, gallstones, bezoars
30
which is more common: LBO or SBO
LBO is 3-4 times less common than SBO, but more likely to need surgery
31
LBO: outside the wall
* Volvulus: sigmoid (3-8%), caecal (1-3%)
* Pelvic tumours
* Hernias (uncommon cause of LBO)
* Adhesions (uncommon cause of LBO)
32
LBO: Within the wall
Malignancy - colorectal cancer (60%)
* Diverticular disease (20%)
* Ischaemic stricture (following ischaemic colitis)
33
LBO: Within the lumen:
* Faecal impaction/faecaloma (e.g. debilitated elderly)
34
BOWEL OBSTRUCTION - SYMPTOMS *
- Colicky pain - constant pain is significant
- Abdominal distention
- Vomiting (prominent in SBO)
- Not opening bowels inc flatulence
35
Clinical signs in obstruction
* Systemic – dehydration, tachycardia, hypotension - fever
* Abdominal
- distension
- visible peristalsis
- high-pitched, tinkling bowel sounds - tenderness
- scars
- hernias
36
MANAGEMENT OF OBSTRUCTION
* ABCDE!
* IVI. Need aggressive fluid resus. Close eye on electrolytes
* NBM, NGT
* catheter
* analgesia
* definitive diagnosis – (AXR) + CT
* definitive management plan (conservative/ operative)
37
Management of Adhesional small bowel obstruction
- period of initial conservative management usual
- if not settling→Gastrografin (water-soluble contrast agent) and delayed AXR. If no contrast into colon → surgery indicated
38
Management of Sigmoid volvulus
- May be suitable for endoscopic decompression
39
HPB EMERGENCIES
* Biliary colic
* Cholecystitis
* Pancreatitis
* Choledocholithiasis (stone in bile duct)
* Ascending cholangitis
* Gallstone ileus
40
GALLSTONES - BACKGROUND
* 8% of males and 17% of females
* Up to 30% of the population may have gallstones (post- mortem studies)
* ‘Fair, fat, fertile, female and forty’ = fairly useless
* 80% of people with gallstones will have no symptoms
41
Biliary colic summary
**Pathophysiology**
* Due to cholecystokinin (CCK) release after meal, which causes the gall bladder contract and push a gallstone up against the neck of the gall bladder- temporary obstruction of biliary duct
* Gall stones happily sitting within gall bladder, but can cause sudden onset of RUQ pain typically a few hours after eating a fatty meal
**Presentation**
* Severe, colicky epigastric or right upper quadrant pain
* Radiates to back
* Often triggered by meals (particularly high fat meals)
* Lasting between 30 minutes and 8 hours
* May be associated with nausea and vomiting
**Treatment**- pain relief and removal
42
Acute cholecystitis summary
Inflammation of gallbladder caused by full impaction of stone in cystic duct- preventing gallbladder draining
**Presentation**
* RUQ pain
* Fever, N and V
* Tachycardia
* Raised CRP
* Positive Murphy sign place a hand on right side of the patients stomach and ask them to take a deep breathe in- will push gall bladder down and cause them to take a sharp breathe in pain (wont happen on left hand side)
* Pain which radiates to shoulder
**Imaging**
- MRCP or US
**Treatment**
- Pain relief and Ab
- Cholecystectomy
43
Gallbladder empyema
– infected tissue and puss in gallbladder- IV antibiotics and surgery
44
Ascending cholangitis
Infection and inflammation in bile duct. High mortality rate due to sepsis.
**Causes**
* Gallstone in CBD or infection due to ERCP
* E.coli, klebsiella
**Presentation**
* Charcots triad-
* Inflammation
* RUQ pain,
* jaundice (when stone reaches common bile duct)
**Management**
* acute management of sepsis and acute abdomen (BUFALO)
* imaging to diagnose CBD stone and cholangitis
* most sensitive MRCP or endoscopic ultrasound
Management
* ERCP required for stone removal
* Percutaneous transhepatic cholangiogram
45
Gallstones- investigations
**Bloods** - FBC, U&E, LFTs and Amylase
- WCC raised in acute cholecystitis, mildly raised ALP common, does not indicate an obstructed biliary tree
**USS** - to confirm diagnosis, 90% sensitive and specific for gallstones
- also allows for evaluation of CBD and intrahepatic duct dilatation
NB10% of gallstones will show up on plain X-ray, but NOT a routine test
46
gallstones management algorithm
47
acute pancreatitis main causes
Gallstones Ethanol Trauma
48
SMASHED- A.pancreatitis
Steriods
Mumps
Autoimmune
Scorpion sting
Hyper –lipidaemia -calcaemia ERCP
Drugs
49
Acute Pancreatitis - Symptoms
* Constant epigastric pain, maximal intensity several hours after onset
* 50% radiates through to the back
* Aggravated by movement
* Relieved by sitting up
* Nausea and vomiting
50
Acute Pancreatitis- Signs
* Epigastric tenderness
* Abdominal distension
* Fever and tachycardia
* Jaundice
* Haemorrhagic pancreatitis (Cullens)
51
Acute Pancreatitis - Investigations
52
Acute Pancreatitis - treatment
- O2, IV fluids, correct electrolytes (incl calcium)
- Catheter to monitor urine output
- No routine antibiotics – use if severe or jaundiced
- Eat and drink if can tolerate
- Alcohol withdrawal meds
- Close obs (i.e. EWS) for signs of deterioration
- Early escalation to HDU/ITU (to treat systemic complications)
- Identify and treat cause – e.g. remove gallbladder urgently if gallstones
53
best marker for acute pancreatitis
lipase, however expensive test so amylase useds
(AMYLASE NEEDS TO BE X3 OVER)
54
potential complications in gen surg
- Haemorrhage (primary, reactionary, secondary)
- Wound (ifection, dehiscence)
- Cardiac (arrhythmia, ischaemia, infarction)
- Respiratory (atelectasis, LRTI)
- Renal (aKI, retention, electrolyte abnormalities)
- GI (paralytic ileus, small bowl obstruction)
- DVT/ PE
- Infection (chest, urine, abdomen (inc anastomotic breakdown), lines, soft tissue/ wound, sepsis)
- Neurological (delirium, CVA)
- Haematological (DIC)
- Anaesthetic reaction
55
General symptoms of complications
pain
SOB
N + V
56
General signs of complications
Thinks NEWS chart
Pyrexia
Low BP/High BP Tachycardia
High/low RR
Low sats
Poor UO
High EWS
Acute confusion Abnormal signs on exam
57
HOW DO I ASSESS AND MANAGE AN UNWELL SURGICAL PATIENT?
1) A - E assessment
2) History
3) Investigations
58
ASSESSMENT/TREATMENT OF THE ACUTELY UNWELL PATIENT
**1) Immediate management **
A – Airway
B – Breathing
C – Circulation
D – Disability
E – Exposure / everything else
- *treat problems in the order they kill*
- assess systematically. Often linked problems in > 1 system
- only once happy with these ^ →
**2) Full patient assessment**
- Simultaneous assessment and resus/Rx throughout!
59
A - AIRWAY
**Signs**
- Look - accessory muscles/abdo breathing, cyanosis
- Listen/feel - ? air entry, tracheal tug
**Treatment**
- high-flow O2- 15l no-rebreathe mask (all pts!)
- no airway → head tilt/chin lift/jaw thrust, suction, adjuncts, bag and mask ventilation. Call senior/anaes/arrest call
60
B - BREATHING
Signs
1) Look – Fi02, O2 saturation.
- speech, RR, equality/depth, acc muscles, cyanosis - decreased GCS (hypoxia, hypercarbia)
2) Listen
3) Feel – air entry, percussion, abdo distention
Treatment
- high-flow O2 (all pts!), positioning
- ID and Rx life-threatening complications (e.g. pneumo)→senior help - if tiring to point of resp arrest → airway, bag and mask until help arrives - Rx depends on cause
61
C – CIRCULATION
1) Signs
– colour, cap refill, PR, BP, UO, level of consciousness
If shocked - of cause – haem (external/in drains, internal), vomiting
2) Treatment
1. O2!
2. Resus – large bore (16G) IV access, bloods incl XM, fluids 3. If haemorrhage→control + senior help
62
D – DYSFUNCTION OF CNS
- Pupils
- ACVPU
* Alert
* Confused
* Verbal stimuli
* Painful stimuli
* Unresponsive
63
E – Exposure/Everything else
- wounds
- drains
- monitoring equipment
64
full patient assessment involves
1) History (pt, case notes, collatersl)- current illness, PMH
2) Examination of all systems
3) Chart review
- EWS
- Fluid balance
4) Drug chart
- Drugs on
- new drugs
- missed doses
5) Review available results
- bloods
- imaging
- microbiology
6) Further investigations
- bloods/cultures
- ECG
- XR
- CT
7) Definitive treatment
- initial resus stabilises
- need to treat cause promptly or may deteriorate
- specialist involvement
8) Reassess after any treatment
65
define shock
acute circulatory failure with inadequate tissue perfusion causing cellular hypoxia
66
causes of shock
➢true hypovolaemic – blood loss, dehydration, plasma loss (e.g. burns)
➢cardiogenic - MI/ischaemia, arrhythmia
➢obstructive - PE, tamponade, tension pneumothorax
➢apparent hypovolaemic (vasodilatation) – sepsis, neurogenic (incl. epidural), anaphylaxis, adrenal insufficiency
67
stages of shcok
68
69
immediate management of shock
A/B - O2!!!
C- initially assess perfusion and not BP
- pallor, temp, delayed CF, tachy, pulse pressure, BP (will be normal until late on), urine output, loss of conscioussness
Initial management
1) Fluid resus - Rx for all shock save cardiogenic!
- large bore IV access, bloods, XM
- fluid challenge - 10ml/kg crystalloid if normotensive, 20ml/kg if hypotensive - assess response +/- rechallenge
2) Rx of cause – bleeding → surgery/OGD/angiogram ASAP.
- no obvious bleeding→full assessment to achieve diagnosis/definitive Rx
70
full patient assessment of patient in shock
1) History
- PMH of cardiac/resp disease, ? intraop events
2) Examination
- concealed haemorrhage (abdomen, GI tract), epidural - ? block too high
3) Chart review
- trends in obs, fluid balance (input, output)
4) Investigations
- Hb, WCC (infection), ABG, cultures (sputum, urine, blood), ECG, CXR
5) Provisional D and definitive treatment
* ongoing resus if hypovolaemia
* Rx of sepsis, Rx of cardiac disease (e.g. of MI, arrhythmia)
71
causes of SoB/ low sats
* Resp – airway, atelectasis, LRTI, COPD, asthma, PE, ARDS
* CVS – LVF (MI, arrhythmia), overload
* Secondary – resp depression by drugs, shock, acidosis (RF, DM)
72
causes of low urine output
Pre-renal
* hypovolaemia
* sepsis
* low cardiac output
Renal
* acute tubular necrosis
* ischaemic injury, nephrotoxic injury (e.g. endotoxin, drugs, contrast)
* abdominal compartment syndrome, hepatorenal syndrome
Post-renal
* bilateral ureteric obstruction
* bladder outflow obstruction (including blocked/malpositioned catheter!)
NB in surgical patients often multifactorial
73
PRINCIPLES OF URINE OUTPUT IN SURGICAL PATIENTS
1.The kidney cannot function without adequate blood pressure (= perfusion)
2. A surgical patient with poor UO usually requires more fluid
3. Absolute anuria is usually due to urinary tract obstruction
4. Poor urine output in a surgical patient is not due to diuretic deficiency!
74
summary management of low urine output
1. Immediate management
* ABCDE - O2, resus
* Urgent investigations – check U&E and treat hyperkalaemia
2. Full patient assessment
Definitive Rx:
- hypovolaemic - restore perfusion
- nephrotoxins - remove/avoid
- sepsis - treat
- obstruction – exclude/treat
- if unresponsive to treatment→call senior help/Renal team
NB low UO in immediate post-op period may be due to stress response – do not overfilll if U&E normal and hydration appears normal
75
define sepsis and septic shock
Sepsis = life-threatening organ dysfunction caused by a dysregulated host response to infection (predicted mortality 10%)
Septic shock = subset with particularly profound circulatory/cellular/metabolic abnormalities (predicted mortality 40%) -> refractory to fluid challenge
76
screening for sepsis
NEWS >5 or risk factors
- >75 yo
- immunosuppressed
- recent trauma/surgery
- indwelling lines
- IVDU
77
sofa score above = sepsis
>2 points (used in ITU)
78
Septic shock
- hypotension despite adequate fluid resuscitation (e.g. need vasopressors to maintain BP)
79
Sepsis 6 care bundle
➢ Give oxygen if required (aim for sats 94-98%)
➢ Give IV broad spectrum antibiotics
➢ Give IV fluids (500ml)
➢ Obtain IV access/take bloods (cultures, glucose, lactate, FBC, U&E, CRP)
➢ Monitor NEWS2, urine output (+/- catheter)
➢ Ensure a senior clinician attends (ST3+)
80
POTENTIAL SOURCES OF POST-OP SEPSIS
* Respiratory
* Abdomen: wound, intra-abdominal
(? small bowel injury, anastomotic leak) * Urine
* Lines/indwelling device
* Other
81
causes of confusion/ unresponsiveness
* Stress – foreign environment, pain, lack of sleep
* Systemic disease – shock, sepsis/SIRS, renal failure, cardiac failure,
* hepatic failure
* Metabolic – hypoxia, hypercarbia, hypoglycaemia, electrolyte disturbance, alcohol withdrawal
* Drugs – opioids, steroids, hypnotics
* Intracerebral disorders – CVA, haematoma, postictal
