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Surgical abdomen Flashcards

1
Q

Differential diagnoses for RUQ pain

A

Biliary Colic
Acute Cholecystitis
Acute Cholangitis

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2
Q

Differentials for RIF pain

A 
Acute Appendicitis
Ectopic Pregnancy
Ovarian Cyst
Meckel’s Diverticulitis
Mesenteric adenitis
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3
Q

Differentials for epigastric pain

A

Pancreatitis
Peptic Ulcer Disease
Abdominal Aortic Aneurysm

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4
Q

Differentials for central/diffuse abdominal pain

A

Abdominal Aortic Aneurysm
Intestinal Obstruction
Ischaemic Colitis

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5
Q

Differentials for LIF pain

A

Diverticulitis
Ectopic Pregnancy
Ovarian Cyst

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6
Q

Differentials for suprapubic pain

A

Acute Urinary Retention

Pelvic Inflammatory Disease

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7
Q

Differentials for loin pain

A 
Renal Colic (kidney stones)
Abdominal Aortic Aneurysm
Pyelonephritis
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8
Q

What is peritonitis

A
  • Inflammation of the peritoneum (the lining of the abdomen)
  • Localised peritonitis is caused by underlying organ inflammation
  • Generalised peritonitis is caused by perforation of an abdominal orga
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9
Q

What must you always get before taking a patient to theatre

A

group and save

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10
Q

What is the management of an acute abdomen

A

ABCDE approach to prioritise resuscitation
Nil by mouth
IV access (the bigger the cannula the better)
IV fluids
IV antibiotics (if evidence of infective cause)
Analgesia and antiemetics
NG tube
Catheterise for fluid balance monitoring
Escalate

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11
Q

When do you place an NG tube

A

vomiting and suspected obstruction

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12
Q

What is appendicitis

A

The appendix is a small, thin tube of bowel sprouting from the caecum
Appendicitis is inflammation of the appendix
Results from obstruction of the appendix and subsequent infection and inflammation of the appendix

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13
Q

What are the symptoms of appendicitis

A

Abdominal pain, typically central then settling in the right iliac fossa (RIF)
Loss of appetite (anorexia), nausea and vomiting.

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14
Q

What are the signs of appendicitis

A

Tender to McBurney’s point
Guarding to RIF
Rebound tenderness and percussion tenderness indicate peritonitis
Rovsing’s sign

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15
Q

Where is McBurneys point

A

(1/3 the distance from the ASIS to umbilicus)

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16
Q

What is rebound tenderness

A

(increased pain when releasing deep palpation to the RIF)

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17
Q

What is Rovsings sign

A

(palpation of the left iliac fossa (LIF) causes pain in the RIF)

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18
Q

How do you diagnose appendicitis

A
  • Often clinical
  • CT: especially if other diagnosis more likely
  • USS: exclude ovarian and gynae pathology
  • If clinically appendicitis but tests are negative may proceed to diagnostic laparoscopy – appendicectomy
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19
Q

What is mesenteric adenitis

A

Abdominal pain caused by inflamed abdominal lymph nodes
Often associated with cough/cold
No treatment required

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20
Q

What is Meckels diverticulitis

A

Malformation of the distal ileum in 2% of the population

Can become inflamed and infected in the same way as the appendix

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21
Q

What may cause an appendendectal mass

A

When the omentum and / or bowel surround and stick to the inflamed appendix
Typically managed conservatively with supportive treatment and antibiotics, with appendicectomy once acute condition has resolved

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22
Q

What are the complications of appendectomy

A 
Bleeding / infection / pain / scars
Damage to bowel, bladder or other organs
Removal of normal appendix
Anaesthetic risk
DVT / PE
- Laparoscopic is associated with fewer risks and faster recovery versus open
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23
Q

What are the main causes of bowel obstructions

A
  • Adhesions (scar tissue from previous surgery causing a kink in the bowel – think watering hose kinking)
  • Hernias
  • Malignancy
  • Strictures
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24
Q

What are the signs and symptoms of obstruction

A

Increasing abdominal distention and diffuse pain
Absolute constipation and lack of flatulence
Vomiting

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25
What is the initial management of Obstruction
'Drip & suck' - Nil by mouth - IV fluids - NG tube on free drainage (to allow stomach contents to freely drain and prevent the need for vomiting)
26
What may you see on abdominal x ray in an obstruction
Distended loops of bowel | Upper limits of normal are: 3 cm small bowel, 6 cm colon, 9 cm caecum
27
How can the small bowel be distinguished from large bowel
presence of valvulae conniventes and haustra.
28
What are Valvulae conniventes
present in small bowel, and are mucosal folds that form lines that extend the full width of the small bowe
29
What are haustra
pouches formed by the muscles in the walls of the large bowel, and form lines that do not extend the full width of the bowel.
30
What investigations should you order for ? obstruction
Abdominal x ray CT scan FBC, U&Es, LFTs, CRP Gas: lactate if ? perf
31
What is a sigmoid volvulus
Counterclockwise twisting | The sigmoid colon becomes overloaded with faeces, causing it to sink downwards causing a twist or torsion
32
What is a caecal volvulus
Clockwise twisting (Caecal – Clockwise)
33
What are the risk factors of a volvulus
``` Psychiatric disorders Neurological disorders Nursing home residents Chronic constipation Pelvic masses (including pregnancy) Adhesions ```
34
what are the complications of a volvulus
Obstruction Ischaemia Perforation
35
How do you diganose a volvulus
Presents as intestinal obstruction Abdominal xray CT scan to confirm diagnosis and identify other pathology
36
What do you see on an abdominal x ray with a volvulus
coffee bean sign (dilated, twisted sigmoid colon that looks like a giant coffee bean)
37
What is the treatment of volvulus
Endoscopic decompression (for sigmoid volvulus with no peritonitis only) Laparotomy Hartmann’s procedure (sigmoid) right hemicolectomy (caecal)
38
What are the symptoms of bowel cancer
``` Change in bowel habit (usually to more loose and frequent stools) Weight loss PR bleeding Tenesmus Iron Deficiency Anaemia Obstruction ```
39
What is tenesmus
(feeling of full rectum even after opening bowels)
40
What type of iron deficiency do you see in bowel ca
(microcytic anaemia with low ferritin)
41
What are the risk factors for bowel ca
In the UK it is the third most prevalent cancer - FH - other cancers - age - IBD - diet (red meat, low fibre)
42
What investigations should be conducted if suspecting a bowel cancer
- Endoscopy to visualize full colon - CT colonography - CT with bowel prep and contrast to visualize the colon (not fit for colonoscopy_ - Staging CT scan: CT TAP - Carcinomembryonic Antigen (CEA)?
43
What is Carcinomembryonic Antigen CEA
Tumour marker blood test for bowel cancer Not useful in screening Useful in predicting relapse of previously treated bowel cancer
44
How do we treat bowel cancers
Decision taken by MDT Based on clinical condition, general health, staging radiography, histology and patient wishes Options are surgical resection, chemotherapy, radiotherapy and palliation in any combination
45
What are the complications of surgery for bowel resections
``` Bleeding / infection / pain Damage to nerves, bladder, ureter or bowel Post op ileus Anaesthetic risks Conversion to open Anastomotic leak / failure Requirement for a stoma Failure to remove the tumour DVT/PE Hernias Adhesions ```
46
What is a covering loop ileostomy
A temporary ileostomy created to protect a distal anastomosis Typically left for 6-8 weeks to allow healing of the anastomosis, after which is it reversed “Loop” refers to it being the two ends (proximal and distal) of a section of small bowel being brought out onto skin Proximal end (the productive side) has turned inside out to form a spout to protect the surrounding skin Usually located lower right side of abdomen
47
what is a right hemicolectomy
remove tumours of the caecum, ascending and proximal transverse colon:
48
What is a left hemicolectomy
remove tumours of the distal transverse and descending colon
49
what is a sigmoid colectomy
remove tumours of the sigmoid colon:
50
What is an anterior resection
remove tumours of the low sigmoid colon or higher rectum
51
What is a Abdominoperineal Resection (APR)
remove tumours of the lower rectum. - removes the rectum and anus (plus or minus the sigmoid colon) and suturing over the anus. It leaves the patient with a permanent colostomy:
52
what is followed up following a curative resection
CT T.A.P. at 1 and 2 or 3 years Colonoscopy at 1 and 5 years CEA 6 monthly for 3 years Thereafter based on local policy
53
What is acute mesenteric ischaemia
Caused by bloods clots blocking blood supply in mesenteric vessels (embolus or thrombus)
54
What are the symptoms of acute mesenteric ischaemia
- non-specific abdominal pain (disproportionate to exam findings) - shock - peritonitis - systemic inflammatory response
55
Risk factors of acute mesenteric adenitis
Older age Atrial fibrillation Atherosclerosis Coagulation disorders
56
What is the management of acute mesenteric adenitis
Fluid resuscitation Thrombolysis Surgical intervention Very poor prognosis
57
What is considered the foregut (blood supply)
Stomach and part of duodenum, biliary system, liver, pancreas Celiac artery
58
What is considered the mid-gut (blood supply)
Duodenum to 1st half of transverse colon | Superior mesenteric artery
59
What is considered the hindgut (blood supply)
2nd half of transverse colon to rectum | Interior mesenteric
60
What is a Permanent (end) Ileostomy
After total colectomy for Inflammatory Bowel Disease (UC/Crohns) or Familial Adenomatous Polyposis (FAP) Most often in lower right abdomen
61
What is a colostomy
After abdomino-perineal resections (APR) for low rectal cancers Permanent Most often in lower left abdomen Produces stools just like an anus
62
What is a urostomy
- To allow draining of urine from kidney, bypassing the ureter, bladder and urethra (e.g cystectomy) - Ileal conduit urinary diversion
63
What is Ileal conduit urinary diversion
Section of ileum (15-20cm) is removed and end to end anastomosis is created Ends of the ureters are anastomosed to this section of ileum The end of the section is brought out onto the skin as a stoma This stoma then works to drain urine directly from the ureters into a bag
64
What are the complications of stomas
``` Psycho-social impact Local skin irritation around stoma Parastomal hernia Loss of bowel length leading to high output, dehydration and malnutrition Constipation (colostomies) Obstruction Retraction Bleeding Granulomas Prolapse (telescoping of bowel through hernia site) Stenosis ```

Gastro (9 decks)

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