Surgical Flashcards
Gallstones
W: 10%
- 1/3 will -> symptoms
R: age, weight, F, preg, meds (ocp), FH, rapid weight loss, haemolytic
Sx: 30m-6hr pain, after meal or nocte
IX: bloods and USS, determined by symptoms and severity. Infection -> acute referral
Pregnancy
- risks: pHX, obese, < activity
- ED for suspected biliary Dx
- Fasting, IVF, Abx, analgesia
- Surgical: 2nd trimester
Mx:
- Lifestyle: healthy diet
- NSAIDs PO or IM voltaren
+/- opioid, +/- buscopan
+/- anti-emetic
Lapchole
- 30-90mins, 1-3d stay
- cholecystitis = early surgery
- ?increased risk of GIca later
Anal fissures
W: 15-40, M=F
1o: straining, preg, anal ++, constipation, diarrhoea ++
2o: Ca, IBD, STD, HIV/TB, herpes, anal
Acute: superficial, fresh cut
Chronic >6w. Spasm <heal, raised edge, exposing muscle -> sentinal pile at distal end of fissure
Sx: 30% self-heal 6w
- pain 1-2hr post-poo
- blood on paper
- feel a tear during
Cx: chronic, fistula, abscess, impaction
- ulcer, sentinel pile
Ex: 90% midline
- Rule out hem, abscess, viral ulcer
Mx:
- Fibre, fluids
- Warm bath to hips
- Coloxyl to soften
- Lidocaine x sub $$$
- 3w: top GTN (SA) OD -> TDS 6w. SE: headache
- 2nd top dilt 2% less SE
- Ref surg/ botox under GA if fails
Note Ultraproct soothing only and not curative
GTN - 1 -1.5cm into anal canal 6w
Hemorrhoids
Sx:
- Trio: discom, mucus, itch
+/- fresh red bleeding
- PAIN unusual ?fissure
- Symptom and fx score
Ex:
- Anaemia, mass, nodes
- Int: above dentate line
- ext: below, >pain sens, less likely to bleed
G1 - not prolapsed
G2 - pops back by self
G3 - needs popping back
G4 - can’t pop back
Mx
- Fibre, fluid. NEED BOTH
- Exercise, ETOH, SITZ 30m
- Coloxyl (stim and soften)
- Lactulose/Laxsach (osmo)
- Anusol (soothing, not funded, OTC)
- Ultraproct 1-4w, longer -> atrophy
Surgical (refer 4 internal)
- G1-2 -> sclero
- G2-3 -> band/sclero
- G4 -> removal
- External: usually asymp
Acute Surgical:
- Strangulated -> acute OR conservative. Key: unable to push back, severe pain
- Thrombosed: blue/purple rather than red/purple
- Haematoma -> leave or I&D x local at GP
Also refer if 6w Sx
Diff:
- Haematoma: purple lump separate to ext sphincter, often after hard stool. Resolves over weeks
IBD
W: 18-35, +UC 60-70
Sx
- UC: more bleeding, diarrhoea, mucus, always rectum
- CD: more pain, mass, fever, perianal
- KP: urgency, nocte
- tired, <kg, EN, eye, ulcers, PSC
Ix:
- granulomas rare in UC, more crypts
- CD: patchy, lymphoids, fat wrapping, transmural
Mx:
- Urgent ref: nocturnal, 8x/day, severe pain, <4.5kg, fever/systemic unwell
- UC: ASA SE dyscrasia
- CD: Pred 40 2w
-> AZA (in preg) TPMT, MTX by gastro
-> Inflixi, Adalimumab
CI live vaccines
Surgical:
- 60-80% CD, 20% UC
- lack of response, cx, pre-ca changes,
Long-term
- Colonoscopy 8-10yr post sx. 1-5yr on risk
- UC 50% flare in 2yr
- CD more variable
Lifestyle:
- no smoke, reduce fat
- refer dietician
- stress management
- Regular exercise
Neurogenic vs vascular leg pain
neurogenic claudication
- prox to distal
- worse standing, better sitting or leaning forward
- better up hill
- worse downhill
- no symptom w cycling
vascular claudication
- distal to proximal
- relieved by standing
- worse up hill
- better down hill
- symptoms with cycling
- fixed walking distance
Peripheral arterial disease
Ix:
- ABPI if able
M
- acute -> vascular acute
- non-acute: ABPI <0.4 OR absent pulse + rest pain >2w OR ulcers OR gangrenous change, no improvement 6m risk Mx, QoL, young
- ALL: Green Rx and walking therapy, 1hr 3x per week, up to point of pain, rest, carry on
- ALL: weight, diet, DM mx, HTN mx
- ALL: STATIN, clopidogrel
- angioplasty if QoL impact or acute critical
Lower back pain
W
- Acute <6w
- Sub-acute 6-12w
- Chronic >12w
Acute: often unclear cause
- Non-specific 90%
- radicular 5-10%
- serious pathology 1% (fracture, malignancy, infection, compression)
Hx:
- sudden onset severe red flag
- psychosocial: fear-avoidance, catastrophising, mood/anxiety, support, occupational consideration
- radicular pain = inflammation
- radiculopathy = compressive
- somatic referral w/o nerves
EX
- Positive slump test = radicular
- Femoral stretch = L2-4
- SLR = L4-S2
Mx:
- Acute: movement, gradual increase, stretching, PT, hot/cold, relaxation, distraction. Short course of NSAID. Non-funded topical. Limited evidence for balms. Norlfex can be helpful if spasm but no evidence of above naproxen.
- Radicular: steroid injection can be effective but not spinal stenosis
- Surgery: neuro deficit or pain >4m
- Work, even if work can’t offer, mark on form as light duties - employer and ACC must sort. May be given time off until then
- FU @ 2w. Avoid diary as pain focus
- Chronic: add PT, TCA, CBT, MDT
Differentials:
1. Fracture
- old, midline, ca/OP/steroid, injury
- Xray or referral for CT scan
- Axial spondyloarthritis
- >12w before 45 + Hx, enthesitis, extra-articular, FH, NSAID works
- CRP, HLA, XR, MRI ?sacroiliitis - Cancer
- Hx of Ca, >50, <Kg, rest x help
- PSA if M. MRI best - Cauda Equina
- Most common = disc. Also ca, trauma, infection, spinal stenosis
- Progress rapidly within hrs/days
- Can be slow and without pain
- BL, worsening weakness, sens
- Urinary/bowel Sx TOO LATE
- Mx: surg within 48hrs >prognosis - Infection
- AAA
In summary, spinal cord compression primarily affects motor and sensory function depending on the level of compression, whereas cauda equina syndrome specifically involves lower back pain and loss of bowel/bladder control due to compression of the nerve roots. Prompt recognition and appropriate management are crucial for both conditions, with cauda equina syndrome requiring urgent intervention.
Varicose veins
Sx:
- varicose veins
- Ankle flare (tiny veins on ankle)
- Atrophie blance (lacy white area)
- haemosiderin staining
- lipodermatosclerosis
- venous eczema, oedema, ulcers
CEAP classification:
- C0 no signs
- C1 telangectasias
- C2 varicose veins
- C3 oedema
- C4 pigment, eczema, LDS, blanche
- C5 healed ulcer
- C6 active ulcer
+ A = asymptomatic, S = symptoms
Public Ref: C4-6 + controllable Sx
Ix:
- ABPI <0.5 = severe. To 0.8 mod to 0.9 mild. IF no pulse or 4 compress
Mx
- Co-existing PAD -> refer
- Non acute vasc - ablation + duplex if: C4-6 or bleeding veins AFTER 3m of compression + elevation/walking
- DN for BMI >40 as can do ABPI and then sort compression
- Lifestyle: exercise, diet, smoking, elevation.
- Manage venous eczema as per
- Difficult wounds -> ref assessment
Surgical options:
- open vein surgery
- endovenous ablative treatment
- ultrasound guided slerotherapy
Leg ulcers
W:
- chronic >4w
- venous insufficiency most
- arterial rarer, need revasc
- 10-20% mixed
Sx:
- Arterial: ischaemic pain, gangrene, pulses, pale feet, atrophied nails, hair loss, atrophied shiny skin
- Diabetic: callous, hammer toes, hallux valgus, drop arch, charcot
- Non-healing? Malignancy. Can also be: comorbid, nutrition, <mobile, steroid, anticoag, smoking, infection
Ex: pulses, sensation + TIMES
- T = non-viable tissue e.g. slough (bacterial burden), necrotic tissue
- I = infection: breadown, dehiscence, delay, smell, >pain, >/altered discharge, erythema, induration in peri-wound
- M = too moist then induration, delay, too dry then eschar forms
- E = edge advacement. Shouldn’t role, hypergranulate (red+++), undermine
- S - surrounding skin e.g. colour, warmth, perfusion. Excoriation is injury to skin e.g. scratch or abrasion. Maceration is moisture
Ix:
- ABPI + bloods e.g. CHF, anaemia
Mx:
- Critical ischaemic -> acute vasc
- ABPI <0.8 -> non-acute vasc
- Com podiatry for diabetics
- cellulitis without pulses -> vasc
- wound Ax if fails to heal 6w
venous -> cleanse, eczema Rx, debride eschar or slough, treat any infection, compression therapy ref, walking, treat any cause
arterial -> non-acute vasc for Ax, analgesia, only dry wound in gangrene or necrosis
malignant - biopsy / excise
AAA
W:
- most asymptomatic, die with
- N diam is 2cm, AAA is >3cm
- Predictors: initial size, speed, sex
e.g. >5.5 in men, >5 in women
Risks: >65, M, HTN, smoke, FH, MAPAS, existing vasc disease
- smoking: growth >25%
Sx:
- Tender suggests rupture
Mx:
- Acute AAA -> vascular
- Non-acute -> USS
- BP control, lipids, smoking, DM
- Aspirin 100mg if no CI
- Monitoring on size, 6m to 5yr
- No driving if >5.5 until post-surg
ACTIVITY -> X -> RUPTURE
Diverticular
W: 50% >60
-> 10% of ^ get infection
R: <fibre, cigs, etoh, obese, low exercise, NSAIDS
Sx:
- Disease: bleeding
- Diverticulitis
- R-side > in Asian
- PU/PV if fistulae
Hx:
- When? how Ix? Abx?
- Admission? complication?
Diff:
- CRC, GE, appendix, perf ulcer, ischaemic, pancreas, obstruction, hernia, IBD/S
- Gynae, urinary (stone)
- Vascular
Ix:
- Bld: FBC, fe, U&E, LFT, crp
- Urine + PREG TEST + stool
- Surg if ?CT scan but admit is usually required
Mx:
- Analgesia: para +/- trama
+/- abx
- Review in 48hrs
- Admit ?comps, worsening/no improve
FOB test result
5-15% are CRC
Endoscopy
Stop PPI 2 w prior to endoscopy
Stop PPI 2 w prior to h.pylori test and 4w after antibiotics
Note gluten needs to be started for 3 weeks
