Surgical Finals

Question 1

Hiatus hernia

Answer 1

Sliding 90% - GOJ slides up into thorax- -> incompetent and acid reflux. Conservative: lose wt to ⬇️ intra abdo pressure, and raising bed head.
Med- PPI or H2 antagonists
Surg- nissen fundoplication- GOJ pulled back into abdo and fundus of stomach rolled back on it.

Rolling/ para oesophageal -10%, obese females.
Fundus rotates in front of oesophagus and herniates through hiatus into mediastinum. Oesophageal shincter not affected
❌ NO REFLUX. Asx but Stomach can strangulate tho

Question 2

How do u manage a pt with haed trauma?

Answer 2

ABC
Immobilise neck during rescusitation
Hypovolaemia- tachycardia and hypotension.
Groaning with eyes open- glascow scale 11
Hypotension and bradycardia- raised ICP
Pain can cause ⬆️BP and tachy cardia
Careful neuronexam
I100, BP N or ⬇️, RR raised or norm, PC- cool, pale

III 30-40% HR raised >120, BP ⬇️⬇️, RR raised 30-40, cool pale

III>40% >140, ⬇️⬇️, RR >40, cool, clammy, SHOCK❌❌❗️‼️

Question 3

GCS- what is it

Answer 3

Eye response 1. No respone. 2. Open to pain. 3. Open to command. 4. Open spontaneously

Verbal: 1. No sounds. 2. Incomprehensible sounds. 3. Inappropriate words. 4. Confuesed conv. 5. Orientation

Motor response- 1. No response. 2. Decerebate- extension to pain
3. Decorticate- abdo flexion to pain 4. Flexion withdrawal respinse to pain. 4. Localises pain. 6.obeys command

Incased severity- loss of consiousness and retrograde amnesia.
Neuro signs= CT scan.m

Question 4

Acute appendicitis

Answer 4

Pain epigastric then RIF when peritoneum inflamed. (midgut structure)
Sx- N+V, anorexia, RIf pain.
Signs- tachy, flushed peripheries esp face, purexia 37.5, mildly raised WCc.

If unsure, lap appendicectomy.

Question 5

DDx of RIF pain

Answer 5

Ovulation/ ovarian cyst rupture,
PID .
USS or CT to asses dx.
In kids:
URTI may cause mesenteric adentitis - RIF pain .
Other conditions similar-
Meckels diverticulitis, crohns ileitis, gastroenteritis.

Question 6

Breast cancer

Answer 6

Pagets- nipple disease- eczematous, bleeding lesion of nipple. Malignant epithelium change of nipple- pagets cells- 50% assc intraduct carcinoma

Breast cancer may be hormone dependnt
Estrogen receptor (ER) - endocrine tx- tamoxifen or anastrozole.
Lumphectomy,mmastectomy for large ones, central tumours or preferance.

Question 7

Chest drain

Answer 7

Penumothorax tx:
Aspiration, intercostal tube drainage,mpleurodesis in recurrent.

Local anaesthetic. GA not essential. Incision just above rib by
Artery forceprs. CXR to confirm postition. Movement of fluid in tube during breathing = correct placement.
‼️ place after emeergency relief of tension pneumotharax.
Tension- insert cannula in 2 ICs in midclavicular line.

Question 8

Carcinoid syndrome

Answer 8

Can be found: Appendix tumour, GI and lungs tumour. They may secrete 5HT–> sx-> Xs normally metabolised by liver .
Tx- resection . Liver metastasis- chemo.
Octreotide- inhibits 5HT

Question 9

Hip OA

Answer 9

OA - degenerative condition- wear and tear - articular cartilage damage
Elderly, hips, knees, interP joints. Pain- NSAIDS, analgesia. Steroids not helpful. Mobilisation and wt loss helpful.
Surgery- progressive dx when movement minimised.
Deformities.
Surgicalrod oprions:
Arthrodesis- joint in fixed position, stiff joint result. Usually when movement not required.
Realignment osteotomy: weight bearing surfaces are realigned. Useful when joint space intact.
Prosthesis replacement: tx of choice im elderly: total hip replacement.

NOF fractures: hemiarthroplasty.

Question 10

Hyperthyroidism

Answer 10

Thyroid gland: enlarged or normal, single or multinodular goitre.
Hyperthyroidism causes: 1.nervousness, anxiety/tremor
2. ⬆️ apetite,
3. Wt loss
4. Preferance for cold weather
5. Palpitations.
Eye signs:
Exopthalmos (Graves disease) , lid retraction, lid lag, dilated pupils, opthalmoplegia.

Hand signs:
Tremor, sweating, clubbing, onycholysis.

CVS signs: tachycardia, rapid sleeping pulse, HF, AF‼️

Question 11

Clinical features of prolapsed intervertebral disc at L5/S1

Answer 11

Back pain, pain on straight leg raising,loss of sensation on outer foot, weakness of foot inversion.
Acute prolapse: severe back pain,
Sciatica- pain in the buttock and the back of leg.

Clinical F:
Muscle weakness and wasting,
Reduced ankle reflex, outer border of foot sensory loss.

Herniation at L4/5 will compress the 5th nerve root, and at L5/S1 the first sacral root.
L5 signs:
Knee flexion + big toe extension weakness, increased knee jerk due to weak antagonists, sensory loss on outer leg and dorsum of foot.

S1 signs:
Weak plantar flexion + eversion of foot. Depressed ankle jerk, sensory loss on lateral foot border.

Cauda enquina compression- urinary retention + sensory loss near sacrum .

‼️ acute disc prolapse may cause paravertebral muscle spam causing pain and restriction on straight leg raising.
Inv:
Xray, CT, MRI, myelography.
Tx: heat, analgesia, exercise, rest, reduction(bed rest and traction)
❗️ removal of the disc prolapse by laminectomy or discectomy.

Rehab will be required.

Question 12

Carpal tunnel syndrome

Answer 12

Thenar eminance wasting, Tinels sign, paresthesia of thumb and index finger, pain in hand worse at night 🌙✨.

CTS- median nerve passing deep to flexor retinaculum.
Causes: idiopathic, pregnancy, Rheumatoid arthritis, amyleoid, collagen disorders (je kolla pupite alopos) , hypothyroidism, oedema.

Median nerve: supplies muscles of radial two lumbricals.
Also carries sympathetic nerve fibers to hand.
Supplies forearm muscles except flexor carpi ulnaris and the ulnar half of flexor digitorum profondus.
CF:
1. Thenar eminance wasting, 2. pain worse at night assc w/ burning and tingling sensations.
3. Loss of blanching of the lateral fingers on cold exposure.
4. Tinels sign: tingling in hand produced by continious tapping over the flexor retinaculum.
5. Paresthesia/numbness of thumb and lateral 2 and a half fingers.
6. Weakness of thumb abduction.

Median nerve roots:
C6,7,8,T1
Lies on medial aspect of brachial artery.

Question 13

Obesity

Answer 13

Choice tx- conservative, wt loss, diet improvement and exercise plans.
Complications of surgery:
Operative:
1. General anaesthesia- intubation diff, requiring rapid sequence induction, difficult cannulation.
2. Drug metabolism is altered, higher doses Iv required.
3. Surgery- obscure access, takes longer

Post op:

1. DVT/PE risk is ⬆️ esp due to slow mobilisation.
2. Wound infx + dehiscence.
3. Haematoma formation.

Medical: predisposition to:
CVS eg HTN, IHD, 
Resp- inadequate resp effort
Diabetes(too musch glucose) 
Gall stones(cholesterol) 

Laparoscopic surgery can be advanrageous but requires skill.
BMI>28 ⬆️ risks of surgery. Gross obesity doubles the risk of morbidity and mortality.

Question 14

Hiatus hernias

Answer 14

Sliding-90% , GOJ slides upwards into thorax, rendering it incompetent-> acid reflux + its complic.
Conservative: 1. wt reduction to ⬇️ intra abdo pressure, 2. Raise bed head. (Gia na katevenei kato)
Medical tx- PPIs and H2 antagonists
Surgical: Nissens fundoplication. GOJ pulled back to abdomen and fundus of stomach wrapped around it.

Rolling- para-oesophageal -10% - commoner- OBESE FEMALES.
Fundus rotates infornt of the oesophagus and herniates through hiatus up to mediastinum. GOsphincter not affected. No reflux.
Asx but stomach can strangulate.

Question 15

PErforated duodenal ulcer

Answer 15

Perforation: w/o Abdo signs in elderly on steroids.
Present w/ peritonitis-1. Absolute constipation, ( no bowel sounds) 2. Severe constant pain- cant move, 3. rebound tenderness, 4. guarding, 5.rigidity
⬆️ HR, ⬇️BP, pyrexia. : Also
Inv- leukocytosis, raised amylase( not as high as pancreatitis)
CXR- air under diaphragm in 90%
AXR- signs of gas in bowel - bowel gas shadows.

Mx- conservative- elderly or unfit for surgery.
Sx relief- while healing occurs and omentum seals off the perforation.
Surgery: laparotomy w/ simple oversewingf the perforation.

Question 16

Dukes staging for colorectal cancer

Answer 16

Made by pathological assesment of bowel and lymph nodes.
NOT❌ an assesment of distal spread.
A. Growth limited to wall of colon- not through serosa
B. Extension through wall and surrounding tissue but no local lymph nodes.
C. Metastases in lymph nodes.
D. Distant metastasis.

Staging useful to predict prognosis, amd further mx, eg chemo, radiotherapy, hormonal therapy, surgery.
In colorectal. Surgery may be curative for stage A.
Stages B+ C chemo added.

5 year survival after operation:
Dukes A- 95%
Dukes B- 70%
Dukes C- 40%

50% incurative, so radical surgery. Die within 5 years.

Question 17

UC

Answer 17

Inflammation of mucosa and submucosa of large colon.
Complicated by systemic features:
Anaemia (of chronic disease or iron deficiency due to rectal bleeding).
Seronegative arthropathy 20% ,
uveitis + iritis,
skin lesions (eruthema nodosum and pyoderma ganreonosum)
Occasionally sclerosing cholangitis. (PSC)

Inv:
Bloosds: FBC for anaemia, U+Es, ESR as a measure of disease activity (thick blood due to ⬆️WCC?) rectal exam folowed by proctoscopy and sigmoidoscopy with biopsy if necessary.
AXR- colonic dilatation of toxic megacolon.
Stool culture to exclude infectious cause.
Contrast study: Urgent enema- barium follow through- performed w/o bowel prep i.e. Instant enema only if NO ‼️❌ dilatation on plain film. - 1. Loss of haustra, 2. A lead pipe colon.
3. Fillinf defects due to polyps or carcinoma.
Flexible colonoscopy- permits excision of lesions like polyps, ipuswd for surveillance.

Fulminant cases- risk of perforation.
Young pts w/ total coliti for 10years- 10% risk of developing colon or rectal neoplasia.

Question 18

Small bowel obstruction

Answer 18

Commonest causes:
‼️ Adhesions and strangulated hernias.
and intussusception (segment of bowel becomes invaginated into the bowel distal to it- telescoping. ❌ Kids more.
Meckels divericulum assc w/ congenital band–> inflammation.

Question 19

Achlasia

Answer 19

Oesophageal mobility disorder,-> contractions of lower oesophageal sphincter.
Proximal segment becomes dilated,so pts cant tolerate FOODS AMD FLUIDS❌❌😠
Dysphagia as presentation. Aspiration pneumonias happen due to spillage of fluids into the trachea.
Vomitting and retrosternal pain: severe cases
CXR- widened mediastinum and maybe a fluid level in oesophagus.
Barium swallow- beak appearance w/ oesophag dialataion and tapering constriction (prevents air from going into stomach.

Assc b/w achlasia and oesophageal cancer.

Question 20

1st degree haemorrhoids

Answer 20

Piles- abnormally dilated cushions of veins in lower end of anal mucosal columns.
Sx: 1. Perianal irritation, 2. Pruritus ani( itching) 3. Prolapse 4. Bleed, 5.Pain.
Classification: according to position:
1st degree- not visible, bleed AFTER defecation, ❌ No pain.
2nd degree- prolapse after defecation, but then reduce spontaneously
3rd degree- prolapse and remain external
4th degree- thrombose after prolapse.

Ussually located at 3’, 7’ and 11’ o’clock.
They are situated above the dentate line so can be injected painlessly.

Mx-
Conservative- high fibre diet, avoidance of straining, good anal hygeine.
Medical- local anaesthetic agents, steroids and sx relief.
Surgical- 1st degree + 2nd degrees submocosal injection,banding and anal dilatation.
3rd + 4th degree- haemorrhoidectomy

Question 21

Femoral hernia

Answer 21

Passage of peritoneum (fat or bowel) into femoral canal. Likley to become strangulated or obstructed cz femoral canal/ring= narrow.
Irreducable, obstructed- luminal contents obstructed but bowel viable.
Strangulated- blood supply is cut off. –> infraction.

F>M , less common than inguinal hernias.
Arises BELOW AND LATERAL TO PUBIC TUBERCLE.
Usually small. If it enlarges it deflects upwards.
Might be confused with enlarged lymph node.
Lie flat back, cough implulse. Difficult.

Question 22

Investigation of biliary tree:

Answer 22

AXR- only 10% of GS are radio-opaque
USS- useful for GS- dilatation of bile duct. Cant see gall stone
ERCP: imaging biliary tree and pancreatic ducts. Injection of contrast.
Ampullatory region visualised, pancreatic ducts outlined.
Helpful for identifying stones, strictures of pancreatic ducts, and tumours that cause obstruction.
As well as therapeutic intervention; stone extraction or stent insertion if blocked.
Endoscopic sohincterotomy can be performed. Esp useful in jaundiced pts or unfit for surgery.

PTC: percutaneous transhepatic cholangiography
Used where ERCP fails, more invasive tho ❗️ . Entry via skin into liver, then injection of contrast into ducts. ❌ no visualisation of pancreas.
Stents can be placed during PTC but sphincterotomy No ❌.

Cholangiography - can be done operatievly or via T-tube.

Question 23

Gall stones

Answer 23

Formed in GB, by bile orecipitation.
5% pigmented,20% cholesterol, 75% mixed.

Predisposing Fs:

1. High bile conc
2. Bile stasis
3. Infx.

90% radiolucent. If it passes to duodenum–> can be found in stool.
Chronic inflammation of GB due to GS implicated to GB carcinoma.
GS present in almost every case of Gb cancer.
If lodges to ampulla of Vater- acute pancreatitis.
Lodged in CBD- obstructive jaundice , ascending cholangitis or acute pancreatitis.

Question 24

Obstructive jaundice

Answer 24

Bile duct drainage obstruction: preventing its normal flow into duodenum. “Extrahepatic jaundice”
⬆️ in conjugated bilirubin (liver fx okay) . Urine is dark- Xs bilirubin (urobilinogen increased in urine in hepatocyte damage and haemolytic anaemia) excreted by kidneys. Initially colourless but darkens after time.
Faeces pale- lack of stercobilin.
LFTs:
Bilirubin ⬆️
ALP ⬆️
Transaminases( mild to medarate rise)

Acid phosphatase is raised in prostatic carcinoma.
Amylase(pancreatic enzyme) may be raised.
Hep B- intrahepatic jaundice- causes infective hepatitis.

Question 25

Spleen

Answer 25

Lymphoid organ. Highly vascular, needed for WBC maturation amd RBC destruction (120d)
Splenectomy indicated:
1. Splenomegaly/ hypersplenis
2. Staging of lymphoma
3. Excision of tumours, cysts or abscess.

Splenectomy may be useful in following conditions:
Autoimmune thrombocytosis (very thick blood) , congenital spherocytosis.
Autoimmune haemolysis - breakdown Xs RBCs.
Portal HTN - gastric arteries - varices.
Splenic vein HTN
Gaucher’s disease
Myelofibrosis
Trauma.

Splenic rupture- splenectomy indication. Rib injuries, blunt trauma, peri-op injury. Certain Infx : EBV, malaria + infectious mononucleosis–> render spleen susceptible to rupture but splenectomy wont alter disease.
Agranulocytosis: WBCs deficient, somsplenectomy would be fatal.

Question 26

Skin cysts

Answer 26

Dermoid cysts- arise from epithelium along lines of embryologic development. May arise in MIDLINE of neck and head, may have Hair.

Sebaceous cysts- MOST COMMON SKIN CYSTS. - stratified squamous epithelium filled w/ keratin. Covered by normal epithelium and have punctum. Can occur ANYWHERE, usually, where hair follicles are present.

Thyroglossal cyst- MIDLINE. beneath hyoid bone along thyroglossal tract. Its the embryological tract of descent of the thyroid gland from the foramen caecum to its position of neck.
‼️Moves on swalloning or protrusion of tongue.

Branchial cyst: arises from remnants of 2nd pharyngeal pouch. Painless soft swelling, deep into sternocleidomastoid muscle- bulging foward at anterior border.

Cystic hygromas: lymphangiomas. Present at birth, might be huge.
Occur below angle of Louis, on side of neck. ❌ No midline.

So neck lump- dermoid, sebaceous, thryroglossal.

Question 27

Breast carcinoma.

Answer 27

Lump, nipple disvharge/ inversion, skin changes like lymphoedema.

Pagets- eczematous change around nipple. Locally advanced tumours may cause skin ulceration or even necrosis.

Axillary or supraclavivular lymphadenopathy- presenting features.
Lymphoedema on arm cause by:
1. Surgery for breast neoplesia, 2. Radiotherapy to axilla for breast cancer, 3. Axillary node disease.

Distant spread- bone(sclerotic and lytic lesions)- fracture as PC- liver-lungs(metastasis or lymphangitis) - brain.

PC: sob, peau d’orange,lymphoedema of arm, bone fracture, nipple inversion

Question 28

Ureteric obstruction- IV urogram - what will it show?

Answer 28

Normal excretion in not-affected kidney, and delayed in affected, also enlarged, site of obstruction.
Urinary tract proximal to obstruction: dilated and swollen. Visualised on IVU (IV urogram) - a control abdo film (KUB= kidney, ureter and bladder) taken to look for opacities.
90% kidney stones radioopaque.
1. Control film. 2. iV contrast, 3 more films.
Info about:
Renal size and shape
Speed of excretion of contrast
Ureters
Filling defects, obstruction site,
Bladder.

In acute obstruction: unaffected kidney should prompt urine excretion.

Question 29

Urinary catheters:

Answer 29

Asceptic technique,
14Fr or 16Fr - male urethra.
Size/3 indicated the diameter mm.
Advice asked: recent prostate surgery, previous diff in catheter, urethral stricture.

Question 30

Renal carcinoma

Answer 30

Commonly metastises into bone, can give rise to cannonball metastasis
M>F, >40Ys. Adenocarcinoma- hypernephroma- under miscroscope- adrenal tissue resemblance.

Presenting features:

1. Haematuria- painless usually- micro or macroscopic.
2. Loin pain, 3. abdo mass, 4. pyrexia of unknown origin,
3. HTN due to Xs renin,
4. Polycythaemia- from Xs erythroprotein
5. Hypercalcaemia
6. Secondaries–> cannonball metastasis in lung on CXR or bone,.
7. Left sided varicocele- cz left testicular vein drains into left renal vein- on obstruction to venous drainage by left sided tumour will cause back pressure-> varicosities of left testicular vein, –> left sided varicocele.

Right testiculr vein- IVC.

Question 31

Tension penumothorax

Answer 31

Severe SOB, + shock.
RHS pneumothorax- .1. decreased chest wall movements, 2.tracheal deviation to left, 3. hyper-resonance on RHS,
4. Abscent breath sounds.
EMERGENCY‼️‼️ cannula insertion into 2nd ICS on affected side.
After this, CXR obtained.
NO CXR TO DX PNEUMOTHORAX.

Question 32

Horners syndrome- what is it? Disease framework

Answer 32

Features:
1. Enopthalmos
2. abscent sweat in affected side of face- anhydrosis
3. ptosis of ipsilateral eye.
4. Miosis
Due to damage in sympathetic chain in neck+head.
Nerves involved: from T1 + postganglionic connections, which synapse in cervical ganglia.

Causes of horner syndrome:
1. Brachial plexus injury
2. Iatrogenic- cervical syplathectomy
3. Lung tumours- Pancoast tumour- in lung apex
4. Syringiomyalgia or spinal cord lesion
5. Tumours in neck 
,

Question 33

What does Interruption of sympathetic nerve supply causes?

Answer 33

1. Pupil constriction
2. Vasodilatation
3. Reduced sweating
4. Dropping of levator palpebrae superioris- muscle supplied by sympathetic nerves as well as III cranial nerve.
   Interruption of sympathetic nerve fx = partial ptosis.

Question 34

Acute appendicitis

Answer 34

Fetor oris, fever, anorexia.
Common surgical emergency.
Sx:- classic: pain- central, then RIF pain.
Anorexia (b4 pain), N+V, constipation, but diarrhoea can occur.

Signs:
Pt is flushed, esp in kids- tongue furred w/ fetor oris,
Rebound tenderness and guarding in RIF
Pyrexia- apyrexia might occur-> >38 consider perforation.
Rectal examination may reveal tenderness in RPelvic area.

Usually obstructed by faecolith.

Question 35

Bells palsy

Answer 35

Impairment in taste + inulateral facial weakness.
LMN lesion of facial nerve (VII) .
CF:
1. Loss of facial expression of affected side;
A. Dropping of lower eyelid + lip. B. Pt unable to smile , whistle, frown.
On attempted closrue of eye- lid goes upwards, so complete eye closure is NOT possible. ‼️ pt requires protective eye patch + eye droops - keep moist.

2. Loss of lacrimation
3. Loss of tatse in anterior 2/3 of tongue.
4. Pain around ear due to inflammation
5. Hyperacusis if nerve to stapedius affected.

LMN lesion = entire side of face paralysed.
UMN lesion= upper facial muscles not affected cz occipitofrontalis has Bilateral innervation- so pt can raise eyebrows.

Cause: idiopathic although prex Hx viral illness might.
Tx: conservative; sx resolve w/ time.
Steroids might be given- controversial. 40% never recover.

Question 36

What does the facial nerve supply?

Answer 36

1. Facial expression muscles
2. Sensation to external auditory meatus
3. Salivary and lacrimal glands
4. • supplies a branch to the stapedius.

Question 37

What is Ramsay Hunt syndrome?

Answer 37

A 7th nerve lesion in the external auditory meatus caused by herpes zoster virus.m

Question 38

Medial meniscus tear

Answer 38

Quardiceps wasting, recurrent haemarthrosis, limitation of knee flexion, locking of knee, intermittent effusions.
Medial > lateral cz medial meniscus attached to capsule of knee joint. = less mobile so trauma more likely.

If cartilage jammed between articular surfaces of femur and tibia->
“Locking” of the knee felt, where full knee extension not felt. Full flexion is still possible.

May complain of knee” gives way”. Hx-> twisting injury -> pain ams swelling due to recurrent effusions which may be haemarthrosis.
Long standing cases- quardiceps wasting also.

Investigations: artthroscopy + MRI.

Tx: conservative: lef put in plaster foe 3-4 w - full extension.
Operative- can be done at arthroscopy e.g suturibg. Or partial meniscectomy.

Question 39

Avascular necrosis

Answer 39

• fracture of scaphoid waist,
  2. dislocation of lunate
  3. Subcapital NOF
  4. Steroids
  5. Caisson disease

Ischaemic necrosis of bone. 
Well known complications of:
1. Trauma- fracures- scaphoid, NOF (subcapital), humeral head, lunate and talus, or dislocation; eg of lunate. 
2. Infx e.g. TB
3. Neoplastic lesions
4. Metabolic disease- Gaucher's disease
5. Connective tissue disease
6. Drugs- high dose steroids
7. Alcohol abuse
8. Vascular disease like sickle cell 
9. Idiopathic- perthes disease

Question 40

CAUSES FOR ANY CONDITION PNEUMONIC

Answer 40

TIN MAN CAN DRIVE
Trauma
Infection
Neoplasia

Metabolic
Autoimmune
Nutrition

Connective tissue
Ageing
Neurological

Drugs
Radiotherapy
Idiopathic
Vascular
Endocrine

Question 41

Neuromuscular blockers

Answer 41

Muscle relaxantas- during surgery- 2 types.
1. Completitive inhibitors:
Tubocurarine, pancuronium, atracuronium, vecuronium.
Reversible agents: act by competing with ACh for receptor site.
In neuromuscular junctions ACh acts on Muscarinic receptors.
Their action is terminated by an anticholinesterase - neostigmine.

2. Depolarising blockers
   - suxamethonium- irriversible agent. Rapid onset, short acting.
   Initial cause- to cause stimulation and hence muscle fasciculation may be seen.
   ❗️ pts complain of muscle ache when used, after surgery.
   Normallu metabolised by oseudocholinestarase.
   ‼️❌ some have deficiency of this enzyme- devastating effects.
   Deficiency = familial, ‼️‼️FHx.

Question 42

Carcinoma of the stomach

Answer 42

.
Usually adenocarcinoma.
Aetiology unknown. Associations include:
Genetics- 1st degree relatives
Blood group A - duodenal ulcers occur more frequently in Bloof group O.
Ethnicity- Japan- environment??
Social class- incidence higher in lower classes.
Gastric mucosa atrophy - predisposes to carcinoma. E.g. In gastritis and pernicious anaemia.
Polycyclic hydrocarbons and nitrosamines in diet implicated.
Cigarette smoking.

Rare before 50. M>F. Spread occurs locally via blood and lymphatics.

Question 43

What are Krunkenberg tumours?

Answer 43

Transcolelomic spread to ovaries from gastric cancer.

Question 44

Minimally invasive surgery

Answer 44

Procedures w/ minimal access. E.g. Laparoscopic or USS guided abscess drainage.
Laparoscopy- common for cholecystectomy + hernia repair + appendicectomy, funduplication, hemicolectomy, symphAthectomy + nephrectomy. (Leave the kidney in)
Advantages:
Less operative trauma, ⬇️ post-op complications, quicker recovery + restoration of normality.

Disadvantages:
Longer esp for inexperienced surgeons.
Costly, limited exposure
Risks e.g. Bowel injury during Verres needle or ⬆️ risk of bile duct injury during cholecystectomy.

Question 45

Sarcoma

Answer 45

Fleshy growth- Greek.
Malignant tumour arising in tissue of mesenchymal origin eg skeletal tissue.
Sarcoma~ malignancy. Eg osteosarcoma- usually in metaphysis of femur. Idiopathic.
Smooth muscle- leiomyosarcoma.

Several assc
Inherited conditions- neurofibromatosis
Ionising radiation
Scars from thermal or acid burns. 
Kaposis sarcoma seen in AIDS. 

Sarcomas tend to grow rapidly- spread- local, bloodstream - predominant, lymphatics.

Stomach- via peritoneal fluids- transcelomic spread.
Tx-: surgery + radio
Use of adjuvant chemo- controversial.

Question 46

Prostate carcinoma

Answer 46

Commonest over 65.
Sx- asymptomatic, bladder outflow obstruction- i.e. Hesitancy, poor stream, frequency, nocturia, post-micturition dribbling.

Produces osteosclerotic 2o bone deposits.
Modes of spread:
Local spread- rectum - may cause a stricture- change of bowel habit.
May cause major DVT of lower limp by obstructing venous return.

Distant spread: via blood stream- esp to pelvis and vertebrae- lesions are typically sclerotic. Pts present w/ bone pain and pathological fractures.
Rate of growth= testosterone concentration.

Tx:
1. Hormonal manipulation- orchidectomy, oestrogen, Luteinising hormone releasing hormone,
Anti-androgens- cyproterone acetate (CPA)
2. Transurethral resection of the prostate- early tumours.
3. Radio

Question 47

Pathology pneumonic

Answer 47

In a Surgeons Gown A Physician May Make Some Terribly Clever Progress.

Incidence
Age
Sex
Geography
Aetiology
Predisposition
Macroscopic features
Microscopic f
Spread
Tx
Complications
Prognosis

Question 48

Post op complications

Answer 48

Early: up to 24hrs

1. Atelectasis- resp distress
2. Reactionnary haem
3. Urinary retention

B) intermediate; 2nd day- 2w

1. Lungs- atelectasis, infx, PE
2. bladder: urinary retention, UTI.
3. Wound- infx, dehiscence.

C) Late; weeks later

1. Wound dehiscence
2. Incisional hernia
3. Recurrent condition

Anastomotic leak in bowel s
Nutritional complications following gastrectomy
Paralytic ileus + sunphrenic abscess after abdo s.

Question 49

Gas gangrene

Answer 49

Develops when wound infected with Clostridium perfeingens, a Gram +ve rod found in soil.
Its an obligate anaerobe- proliferates anaerobically.
Exotoxins destroy tissue–> necrosis.
Produces gases- felt as crepitus.
RAPID ❗️ tissue destruction-> 1 blackening of skin, 2- breaks down to become purulent. –> Necrosis occurs.

Tx- excision of necrotic tissue- wound left open to allow drainage and NOT ❌ sutured- fressing packs used to facilitate healing from inside out.
IV benylpenicillin- should be given prophylactically in injury or b4 limp amputation.
Hyperbaric 02 therapy.
Antitoxin administration.

Question 50

Benign breast change

Answer 50

Abnormal response of tissue growth due to hormonal cycle. May be xtreme normal range.
Not pre-cancerous but cancer may co exist+ misdiagnosed.
Benign breast change aka fibrocyctic disease or painful nodularity :
PC:
1 or more areas of lumpiness, cysts, diffuse nodularity, pain or tenderness.

These tend to occur in a cyclical fashion.
Tx:
Reasuarance, lymphectomy, mastectomy- RARE- debilitating cases.

Question 51

Gynaecomastia

Answer 51

Benign condition, enlargement of male breast.
Causes:
Physiological: neonatal or pubertal
Idiopathic: commonest, unilateral or bi.
CHronic liver disease: alcoholism, cirrhosis.
Hormonal- oestogens- in testicular atrophy hormonal abnormality may occur- hormone producing tumours.
Drugs: 1. oestogens- diethylstilbestrol- given in prostatic carcinoma,
2. Spironolactone
3. Digoxin
4. Cimetidine
5. Steroids.

Question 52

AAA

Answer 52

Aneurysm: localised dilatation of an artery involving all layers of wall. May be fusiform or saccular. Commonest cause: atherosclerosis.

Other:
Congenital aneurysms, trauma, syphillis,
collagen disease( Marfans syndrome or Ehlers Danlos syndrome)

Genetic disposition found.
Incidence ⬆️ M >60Y. Assc w/ HTN + smoking. May be asx or produce a pulsatile mass in abdo.
Abdo pain radiates to back (retroperitoneal vessel) .
Shock can develop if leak or rupture.

Aneurysms most commonly found in abdo and below renal arteries.
Calcification along arterial wall allows visualisation on plain abdo film.
USS, CT, aortography - asses size.

Size- monitorred with serial USS scans.
Elective surgery when aortic diameter >5cm, prosthetic graft.

Question 53

NGT

Nasogastric tube.

Answer 53

In severe head injury , where there is loss of the gag reflex, airway meeds to be protected by an cuffed endotracheal tube.
Insertion CI in basal skull fractures as tube might be pushed into brain.

Small or large bowel obstruction- 1st line tx- “drip and suck”- ie IV fluid ,aintenance and suction of stomach contents by NGT.
Relieves vomitting, protects airway + protects bowel from further fluid or air.
Conservative measures- may be enough, if not-> surgery.

‼️ nasogastric aspiration NOT ❌ useful for upper GI bleed as a lot might be lost to lumen and appear as melaena.

A fine- bore NGT used for enteral bleeding.

Question 54

Pleomorhpic adenoma ( mixed parotid tumour)

Answer 54

Adenoma of salivary glands
Painless growing mass in parotid. Its a benign tumour.
Capsule is incomplete and tumour may penetrate to surrounding tissue. It may then recur or undergo malignancy.
So enucleation not enough, excision required.

Surgical risk
Facial nerve damage!

Question 55

When does guastatoey sweating happen?

Answer 55

Freys syndrome - when parasympathetic secretomotor nerve fibres to the gland are divided and then regenerate in the skin.
Causing sweating on stimulation of th salivary gland.

Question 56

Paralytic ileus.

Answer 56

Causes:
Laparotomy- handling of bowel prolonges ileus
Hypokalaemia
Peritonitis
Renal F
Trauma- fracture of lumbar vertebrate) 

Calcium not implicated.
Lumbar sympathectomy seems to prevent paralytic ileus.

Question 57

Oesophagus carcinoma

Answer 57

Most: squamous type in middle 1/3 of oesophagus
RFs: alcohol, smoking, diet (nitrosamines)
Assc w/ structural abnormalities;
Achlasia, oesophageal webs, strictures, pharyngeal pouch + Barretts.

Plummer- Vinson syndrome- dysphagia due to oesoph webs w/ Fe deficiency anaemia + assc w/ carcinoma of oesop.

Question 58

Acute cholecystitis tx

Answer 58

Uncomplicated will resolve conservativley- ie bed rest, IV Fluids, IV antibiots and analgesia.
Cholecystectomy may be done early or late, about 6w after acute attck has settled. laparoscopy may be used.

Also, immediate cholecystectomy may be performed laparotomically.