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Surgical Review Flashcards

1
Q

Common presentation of pancreatitis

A

Epigastric pain radiating to the back
Relieved by sitting forward
Vomiting
Signs: Tachycardia, fever, jaundice, shock, rigid abdomen, tenderness, Cullen’s sign, Grey Turner’s sign

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2
Q

Ix for acute pancreatitis

A

FBC - WCC, esp. neutrophilia
Serum amylase (up to 24hrs), serum lipase (>72hrs)
CRP - elevated, predictor for severe
ABG - deoxygenation, acid-base disturbance
UEC - Hypocalcaemia, renal function, glucose
LFTs - hypoalbuminaemia, AST, LDH
Imaging: AXR, CXR, CT, MRI, USS if gallstones suspected
ERCP

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3
Q

Management of acute pancreatitis

A 
Conservative is mainstay (80% will resolve)
IV Fluids +++
NBM - NG tube or parenteral nutrition
Analgesia - Morphine, fentanyl 
Monitor vital signs and urine output
Daily bloods - FBC, UEC, Calcium, glucose, amylase, ABG
Treat underlying cause/complications
ERCP for gallstones
Repeat CT to monitor progress and look for complications.
Antibiotic prophylaxis if 
Surgical--> if worsening
Laparotomy with debridement
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4
Q

Ix of diverticular disease

A

CT abdomen, AXR to identify obstruction or perforation
FBC- WCC
CRP, ESR

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5
Q

Common presentation of diverticular disease

A

Hard stools alternating with diarrhoea
Colicky pain (suprapubic or in left iliac fossa)
Local tenderness, guarding or rigidity ‘left-sided appendicitis’
Sometimes a palpable mass
Constipation, distension, diarrhoea, rectal bleeding
Diverticulitis: fever, localised/genralised peritonism

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6
Q

Management of diverticulitis and complications

A

Diverticulitis - mild attack can be managed outpatient w/ bowel rest and ABs + analgesia
Analgesia
NBM
IV FLuids
ABs
Abscess - CT guided drainage
Perforation – surgery (Hartmann’s procedure or primary anastomosis)
Haemorrhage - ABC, transfusion may be needed - bleeding usually stops with bed rest, but may need embolisation or colonic resection

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7
Q

Presentation of complications of diverticulitis

A

Abscess - swinging fever, leucocytosis, boggy rectal mass
Perforation - ileus, peritonitis, shock
Haemorrhage - sudden and painless, common cause of big PR bleed

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8
Q

What is Meckel’s Diverticulum (rule of 2s)

Management?

A 
Most common GI anomaly - presents with bleeding, ulcer, infection, torsion, hernia, obstruction
2% of the population
2cm long
2 ft from the ileocaecal junction
2 years old
Mx- Laparotomy
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9
Q

Common presentations of PUD

A 
Chronic - relapse and remission
Epigastric pain related to meals
Heartburn/indigestion/reflux
Halitosis
Melaena
Haematemesis
Vomiting
Bloating, fullness
Fatigue (anaemia)
Swallowing difficulties
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10
Q

Management of PUD

A

Usually medical - Triple therapy
-H pylori eradication - amoxycillin, clarithromycin
- PPI (esomeprazole)
Lifestyle - avoid aggravating food, stress, smoking, NSAIDs, alcohol

Surgical if haemorrhage, perforation or pyloric stenosis or not responsive to med therapy.

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11
Q

Management of GORD

A
  • Antacids and PPI
  • 2nd Line - H2 receptor antagonist (ranitidine)

Surgery - laparoscopic fundoplication, repair hiatus hernia

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12
Q

GORD - when to send for endoscopy?

A
  • Alarm symptoms - dysphagia, odynophagia, wt loss, persistent vomiting, haematemesi/melaena, signs of anaemia
  • Refractory GORD
  • Uncertain Dx
    Consider endoscopy with RF for complications
  • Male gender
  • Older age
  • severe/frequent sx
  • change in sx
  • obesity
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13
Q

Complications of GORD

A 
Oesophagitis
Ulcers
Strictures
Iron deficiency
Malignancy
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14
Q

Post-operative complications

A 
Fever
Confusion - common in elderly
Dyspnoea/hypoxia
Hypotension
Hypertension
Oliguria
N+V
Hyponatraemia
Bleeding
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15
Q

Post-operative Fever

A 
Immediate (POD 1) - inflammatory reaction, reaction to blood products, malignant hyperthermia
POD 1-2
- atelectasis
- early wound infection from C. diff or GAS
- aspiration pneumonia
POD 3-7 likely infectious
- UTI
- Surgical site
- IV site, catheter
- Septic thrombophlepbitis
- Leakage of bowel anastamosis
POD 8+
- Intra-abdominal abscess
- DVT/PE
- C. difficule colitis
-Endocarditis
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16
Q

Specific complications of biliary surgery

A
  • Retained stones
  • CBD stricture
  • Cholangitis
  • Haemobilia
  • Jaundice
  • Haematemesis
  • Pancreatitis
  • Bile leak –> peritonitis
  • Hepatorenal syndrome (cirrhosis, ascites, renal failure)
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17
Q

Specific complications of laparotomy

A

Wound breakdown –> burst abdomen (early warning sign = pink serous abdomen)
Infection/haematoma
Incisional hernia

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18
Q

Specific complications of mastectomy

A

Arm lymphoedema (in node sampling/dissection)

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19
Q

Specific complication in arterial surgery

A 
Bleeding
Thrombosis
Embolism
Graft infection
MI
AV fistula formation
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20
Q

Specific complication in aortic surgery

A 
Gut ischaemia
Renal failure
Respiratory distress
Trauma to ureters
Trauma to anything
Ischaemic events from distal trash from dislodged thrombus
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21
Q

Specific complication in colonic surgery

A 
Sepsis
Ileus
Fistula
Anastomotic leak
Obstruction from adhesions
Haemorrhage
Trauma to ureters or spleen
22
Q

Specific complications of small bowel surgery

A

Short-gut syndrome - diarrhoea and malabsorption, weight loss, renal stones

23
Q

Specific complications of a splenectomy

A

Increased infections - need extra vaccines (HIB, meningococcal, pneumococcal, pre-op is better)
Sepsis
Acute gastric dilatation
Thrombocytosis
Will need life-long prophylactic ABs - phenoxymethylpenicillin or erythromycin
Should carry card/medical bracelet

24
Q

Main indications for splenectomy

A

Hypersplenism
Splenic trauma
Haemolysis (particularly WAHA)
Congenital haemolytic anaemias

25
Causes of massive splenomegaly
``` CML Malaria Myelofibrosis Leishmaniasis Gaucher's disease ```
26
Specific complications of gastrectomy
Recurrent ulceration Abdominal fullness/early satiety (take small frequent meals, improves with time) Diarrhoea Gastric tumour (rare complication of decreased acid production) Metabolic complicatons - Dumping syndrome (fainting and sweating after eating due to hypoglycaemia) -Weight loss - Blind loop syndrome (bacterial overgrowth and malabsorption) -Anaemia - osteomalacia
27
Specific complications of prostatectomy
``` Haematuria Haematospermia Urethral stricture/trauma Infection- prostatitis Erectile dysfunction Urinary incontinence Retrograde ejaculation Hypothermia ```
28
management of haemorrhoids
``` Medical mx of 1st degree - Increase fluid - High fibre diet - +/- topical analgesics and stool softener Use topical steroids for flare-ups for short courses 2nd-3rd degree - as above + - rubber band ligation - sclerosants - infrared coagulation 4th degree or failure of previous mx - excisional haemorrhoidectomy ```
29
Classification of haemorrhoids
1. Remain in the rectum 2. Prolapse through the anus on defecation, but spontaneously reduce. 3. As per second degree, but require digital reduction 4. Remain persistently prolapsed
30
Complications of stomas
``` Best prevention is pre-op stoma care/education Early complications - Haemorrhage at stoma site - stoma ischaemia - High output --> hypokalaemia - obstruction 2ndry to adhesions - stoma retraction Delayed complications - Obstruction - Dermatitis around stoma site - Stoma prolapse - Stomal intussusception - Parastomal hernia - Fistula - Psychological problems ```
31
Signs and sx of refeeding syndrome
- Rhabdomyolysis - Red and white cell dysfunction - Respiratory insufficiency - Arrhythmias - Cardiogenic shock - Seizures - Sudden death
32
How to prepare a T2DM for surgery. NIDDM
- Tight glycaemic control HbA1c <7% - Give usual medication the night before surgery (except long-acting sulfonylurease) omit morning medication - Restart meds after surg - Check serum glucose levels hourly during surg -- may need SC insulin if persistent hyperglycaemia
33
How to prepare IDDM for surgery
- Place patient 1st on list - Give all usual insulin night before surgery - continue long acting basal insulin - don't give bolus on morning of surg. - monitor BSL and give dextrose infusion if hypo
34
DDx neck lumps
Lymph node - reactive or infiltrative --reactive is normally infectious --> Viral (URTI, EBV, CMV, HIV)or bacterial (syphilis, brucella) -non-infectious causes--> sarcoidosis, amyloidosis, CTD, SLE, RA - Infiltrative = malignant (haematological or metastatic) Thyroid lumps Skin - cysts, lipoma Don't miss carotid artery aneurysm Salivary glands pathology Mumps, parotid tumour
35
Lumps in the thyroid.
Diffuse goitre - iodine deficiency, congenital, autoimmune, acute thyroiditis, physiological in preg. Nodular goitre - multinodular goitre, solitary thyroid nodule (toxic, non-toxic) Thyroid cancer -papillary, follicular, medullary, lymphoma, anaplastic
36
Indications for thyroid surgery
Pressure sx - difficulty breathing, stridor Failed medical management Carcinoma Cosmetic reasons Symptomatic patients planning pregnancy (thyroid function increases in preg.)
37
Specific complications of thyroid surgery
``` Recurrent laryngeal nerve palsy Haemorrhage Hypoparathyroidism (check Ca daily) Thyroid storm Hypothyroidism ```
38
Risk factors for breast cancer
Family hx- BRCA 1 and 2 --> age of onset, bilaterality, ovarian cancer Age Unopposed oestrogen activity -Early menarche Late menopause, nulliparity, HRT, not breastfeeding, obesity, OCP Previous radiation exposure Previous breast ca
39
Types of breast cancer
DCIS (Ductal carcinoma in situ) Invasive ductal carcinoma (70%) Invasive lobular carcinoma (10-15%) Medullary carcinoma (5%, associated with BRCA 1)
40
Staging of breast cancer (Stage 1-4)
Stage 1 - confined to the breast, mobile Stage 2 - confined to the breast, mobile with lymph nodes in ipsilateral axilla Stage 3 - fixed to the muscle, but not the chest wall, ipsilateral lymph nodes matted and may be fixed Stage 4 - complete fixation of tumour to chest wall, distant mets
41
Staging of breast cancer (TNM)
``` T1 - under 2cm T2 - 2-5cm T3 - >5cm T4 - FIxed to the chest wall, peau de orange N1 - mobile ipsilateral nodes N2 - fixed nodes M0 - no mets M1 - mets ```
42
AAA common presentation
Abdominal pain radiating to the back Expansile, pulsatile mass If ruptured --> shock Risk of rupture increases with age
43
Risk factors for AAA
``` Age Male gender Smoking Family hx Atherosclerosis Hypertension Hypercholesterolaemia Other vascular aneurysm Connective tissue disorders ```
44
Indications for AAA repair
Male with AAA>5.5cm Female with AAA >5.0cm Rapid growth >1cm/year Symptomatic AAA
45
Management of ruptured AAA
- Vascular surgeon, anaesthetist, theatre ASAP - cross-match 10-40 units - Catheter - Large bore cannula - Keep systolic BP <100 to contain leak - Prophylactic ABs cephazolin, metronidazole - Surgery: p Ix - Hb and amylase, ECG
46
Management of non-emergent AAA
EVAR - endovascular repair (stenting)
47
Cardinal features of critical limb ischaemia
Ulceration, gangrene and foot pain at rest | Requires revascularation within 4-6 hrs to save the limb
48
SIgns of PVD
``` Pulseless Punched out/painful ulcers Postural colour change Pale Perishingly cold Pain Parasthaesia ```
49
Management of PVD
1. Risk factor modification - Quit smoking - vital! - HTN control - Cholesterol control 2. Prescribe clopidogrel 3. Management of claudication - Supervised exercise programs to improve collateral blood flow - Vasoactive drugs (recommended in those who don't want to undergo surg.) 4. Surgical - Percutaneous transluminal angioplasty (PTA) --> Balloon and stent - Bypass - Amputation
50
Management of varicose veins
Treat underlying cause Education - avoid prolonged standing, elevate legs where possible, lose weight, regular walks, support stockings, Surgical - endovascular treatment

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