Phase 4 > Acute Surgery > Flashcards

Acute Surgery Flashcards

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1
Q

What symptoms: investigations should be conducted in suspected appendicitis?

A

Localising LQ pain
Fever
Anorexia - key sign
Rovsing’s sign

Investigations:
FBC
- WCC

CRP

Pregnancy test

Urine dipstick testing

+/-
Ultrasound
CT

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2
Q

Contrast between mesenteric adenitis and appendicitis:

A

Mesenteric Adenitis:

  • background of URTI
  • Pain doesn’t move - located to same place
  • high fever
  • Red/ flushed child
  • High CRP
  • child feels unwell then pain starts

Appendicitis:

  • no background of infection
  • pain is general then RLQ
  • Lowish fever
  • Anorexia
  • child looks pale
  • abdominal pain started first

**it is important to appreciate that mesenteric adenitis can become appendicitis due to swelling of the lymph nodes causing blockage

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3
Q

What is the history of someone with Mittelschmerz syndrome?

what investigations are done?

A
  • Occurs 2 weeks following last period
  • Supra pubic region pain
  • 24-48 hour pain

Investigations:
- normal

  • US may show small amount of fluid in abdomen
  • due to a small amount of blood entering the peritoneum following ovulation
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4
Q

50 year old male present with sudden onset abdominal pain, which pain radiating to the back. What is the immediate worrying diagnosis? what investigation should be done?

A

Rupture AAA

CT Scan - if hemodynamically stable (they will have a haematoma)
*this should only be done if patient is stable. otherwise it is straight to theatre.

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5
Q

What transfusion reactions can take place?

A
  1. Acute Haemolytic reaction:
    - sudden onset hypotension
    - tachycardia
    - pyrexia
    - Back pain (due to kidney injury)
    - bilirubinemia
  • stop transfusion
  • Fluids
  • furosemide - to filter
  • dialysis
  1. Allergic reactions - 2-3 hours
    - erythematous papular rashes
    - angioedema
    - pyrexia
    - wheals
  • stop transfusion
  • chlorphenamine 10mg IV
  1. Anaphylactic reaction
    - allergic reaction symptoms
    - bronchospasm
    - angioedema
    - blood pressure drop

*Adrenaline 0.5mg + chlorphenamine 10mg + Iv steroid 100mg

  1. Non - haemolytic febrile reaction
    - Fever
    - Rigors
    - N&V

*paracetamol

  1. Acute lung injury
    - respiratory collapse
    - pulmonary oedema
    - inflammation
  2. Delayed Extravascular Haemolysis reaction
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6
Q

What is the definitive diagnostic investigation for small bowel obstruction? and what other investigations are wanted?

A

Bloods:

  • FBC
  • U&Es
  • ABG/ VBG - lactate (assess for ischemia)
  • G&S
  • Amylase

Imaging:

  • CT abdomen with contrast
  • Gastrograffian studies

Special tests:
- colonoscopy

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7
Q

What would the outcome of bowel perforation be?

A

Septic Shock
Multiorgan failure
Death

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8
Q

What are some causes to bowel perforation?

A

Peptic ulcer

Diverticulitis

Appendicitis

Severe ischemia
- mesenteric ischemia

Obstructing lesion

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9
Q

What non - bowel related causes may lead to peritonitis with air under the diaphragm?

A

Rupture ovarian cyst

Ectopic pregnancy

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10
Q

What investigations should be done into potential bowel perforation?

A

Bloods:

  • FBC - WCC high
  • U&Es
  • Group and Save
  • CRP
  • ABG

Urinalysis
- exclude urological causes

Erect chest x-ray
CT - this is gold standard

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11
Q

In a Bowel perforation, what signs may be seen on xray?

A

Free air under the diaphragm
- pneumoperitoneum

Rigler’s sign
- Both sides of the bowel can be seen - really highlighting th bowel

Psoas Sign
- Loss of the demarcation psoas sign seen

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12
Q

What is the management of Perforated bowel?

A 
Broad spectrum antibiotics 
Fluids 
Analgesia 
Oxygen 
NIL by mouth/ NG tube

Surgical consult

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13
Q

What is the surgical management of a perforated bowel?

A

Source the cause

Repair the rupture - usually with an omental seal
or
Removal - Hartman’s procedure - diverticulitis

Peritoneal lavage - wash out to remove any contents

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14
Q

In a bowel perforation, what is the most important aspect of laparoscopic surgery?

A

Peritoneal lavage to wash out any substances.

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15
Q

What are some differentials do bowel perforation?

A

M.I
Pancreatitis
AAA
Tubulo-ovarian pathology

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16
Q

What are the causes of bowel obstruction?

A

Small bowel:

  • adhesions
  • Hernia
  • ileus
  • gallstone ileus

Large bowel:

  • Malignancy
  • diverticulum
  • Volvulus
  • faceal impactaction
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17
Q

What are some differentials to bowel obstruction?

A

Toxic megacolon
ileus
Constipation

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18
Q

What are the cardinal features of bowel obstruction?

A

Colicky pain

Bowel distention

Vomiting
- Biliary > Feculent vomit

Absolute constipation

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19
Q

What are the radiological findings of small bowel obstruction?

A

Centrally located
>3cm
Plicae circulares are visible - seen as lines all the way across the bowel

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20
Q

How is large bowel obstruction seen on an xray?

A

> 6cm (>9cm at caecum)
Peripherally located
Haustra present - usually seen as small line half way

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21
Q

What are the complications of bowel obstruction?

A

Ischemia
Perforation with faecal peritonitis
Dehydration - AKI

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22
Q

How is bowel obstruction treated, broadly?

A

Conservative management

Surgical:

  • Closed loop obstruction
  • signs of sepsis or perforation
  • Malignancy
  • Failure of conservative management >48 hours
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23
Q

What is the conservative approach to bowel obstruction?

A

Drip and Suck

  • NIL by mouth
  • NG tube - remove content
  • Analgesia
  • IV fluid - need a lot of this
  • Electrolyte replacement
    +/-
    Gastrografian studies
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24
Q

What key investigations should be done into bowel obstruction?

A

Bloods

  • FBC
  • CRP
  • Group and save
  • U&Es - AKI
  • ABG

X-rays

  • CT contrast - gold standard
  • ABX
  • CXR - erect

Water soluble contrast study
- done in conservative management after 24 hours

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25
What is the physical examination that can be done into cholecystitis?
Murphy's sign | - halting of inspiration when compressing the edge of the rectus abdominis at the 11th intercostal margin
26
What are the differential diagnoses to cholecystitis?
GORD Peptic ulcer Acute pancreatitis Inflammatory bowel disease
27
What investigations should be done into biliary colic/ Cholecystitis?
Bloods: - FBC - U&Es - LFTs - CRP - Amylase *always do an amylase Orifices: - Pregnancy test - this should always be done to rule out any cause Imaging: - Ultrasound - MRCP +/- ERCP
28
What may be seen on ultrasound of the gallbladder pathology?
Gall bladder sludge - start of gallstones Thickening of gallbladder wall - inflammation Dilated biliary ducts
29
How is Biliary Colic managed?
Lifestyle changes Analgesia - Paracetamol/ NSAIDs + Antiemetics Elective cholecystectomy - within 6 weeks
30
How is cholecystitis managed?
``` NIL by mouth IV antibiotics - Co-amoxiclav + metronidazole IV fluids Analgesia *sepsis 6 if patient is septic ``` Laparoscopic cholecystectomy should be ideally performed within 72 hours or within 1 week **if a patient is not fit enough for surgery then percutaneous drainage can be done
31
What are the complications of cholecystitis?
Gallbladder empyema - abscess formation - septic - CT diagnosis Chronic cholecystitis Bouveret's syndrome - fistula forms to duodenum allowing stone blockage there Gallstone ileus - fistula formation allows gallstone through and block the ileum
32
What are the causes of appendicitis?
Faecolith impaction Lymphoid hyperplasia Caecal tumour
33
Outwith McBurney's point what other sign may be seen in acute appendicitis?
Rovsing's sign Psoas Sign - extension of the hip compresses the appendix against the psoas muscle causing pain
34
What are some differentials to appendicitis pain?
Gynecological causes - ectopic pregnancy - Rupture cyst Urological causes - renal colic - pyelonephritis G.I - Crohn's disease - Mesenteric adenitis - Merkel's diverticulum - Diverticulitis Male: - Testicular torsion
35
What investigations should be done into appendicitis?
Bloods: - FBC - WCC - CRP - U&Es - Amylase - B- hCG Orifices: - urine dipstick - rule out urological causes - B- hCG X-rays: - Transabdominal US - if uncertain diagnosis - CT abdominal - in older patients to rule out malignancy S-
36
How should a patient with appendicitis be managed?
IV fluids IV analgesia Catheterisation Appendectomy - laparoscopically is preferred choice. +/- Prophylactic antibiotics *there is debate that some can be treated with antibiotics alone.
37
What are some of the complications of appendicitis?
Perforation - Bowel perforation management Appendix mass - becomes adherent to omentum - antibiotics Pelvis Abscess - presents with continual pain and fever conservative management with antibiotics is advised - follow up with CT scan *large amount can be due to malignancy
38
What are some causes of abdominal distention?
``` F's: Fat Fluid Flatus Faeces Fotus Fulminant mass ```
39
What signs may be seen when visually inspecting a patient that they have pancreatitis?
Cullen's sign - bruising epiastrically Grey Turner's Sign - Flank bruising
40
What investigations want to be done into acute pancreatitis?
Bloods: - FBC - WCC - U&Es - LFTs - CRP - Blood glucose - Ca2+ - ABG ** - PaO2, LDH - Amylase ** - **serum lipase following >24 hours Orifices: - Urine analysis - B- hCG X-ray: - Ultrasound - of biliary tract to look for stones - Abdominal CT scan if the diagnosis is uncertain - ERCP - done 24 hours after to assess for blockage ECG Special test - Lipase - most sensitive but rarely done
41
What is the criteria for the risk assessment of pancreatitis?
``` PaO2 <8 Age >55 Neutrophils >15 Calcium <2 Renal Urea >15 Enzymes LDH >600 Albumin <32 Sugar >10 ``` >3 or more admit to ICU
42
Broadly speaking what is general management of pancreatitis?
There is no cure to pancreatitis, so the management is supportive, and organ support. if there is evidence of gallstones or bile duct blockage then an ERCP should be done when reasonable to do so.
43
What is the management of pancreatitis?
Severe >3 should be managed in ICU NIL BY MOUTH NG tube IV fluids - Hartmanns Analgesia - opioids Organ support in HUD - renal dialysis Further treatment: - ERCP - Alcohol abstinence - 3 months - Cholecystectomy
44
What are the systemic complications of acute pancreatitis?
Within early days: - DIC - ARDS - Hypocalcemia - Pleural effusion - Hypoglycaemia - Hypovolemic shock
45
What are the local complications of acute pancreatitis?
Pancreatic necrosis Pancreatic pseudocyst
46
How does a AAA rupture present?
Abdominal Pain Back pain Vomiting Syncope Classic triad is: - Abdominal pain - Back pain - Pulsatile abdominal mass
47
What immediate investigation should be done for ruptured AAA?
Bloods: - FBC - U&;Es - Cross Match If patient is stable: - CT *this is to assess if the patient is suitable for EVAR If patient is unstable: - Surgery Contact: - local vascular unit - anaesthetist - Vascular surgeon
48
What is the management during a ruptured AAA?
ABCDE - High flow oxygen - IV access - Bloods taken off - Modest amount of morphine - IV Fluids - do not raise pressure quickly or chase normal blood pressure as not to dislodge clot. Transfer to Vascular surgical theatre immediately
49
In the setting of an upper G.I bleed what question do you want to the patient?
Episodes like this before? Evidence of melena? - if so how was it managed Drugs - any anti-coagulation Alcohol use? Know liver disease? Dyspepsia pains?
50
What can be used to predict the risk of rebleeding?
Age Shock Comorbidities Endoscopic findings - spurting blood?
51
What other scoring system can be used for acute pancreatitis other than glasgow criteria?
APACHE II
52
When is ERCP recommended following pancreatitis?
72 hours
53
Name 4 causes of acute abdomen in RLQ in a young male:
acute appendicitis meckel's diverticulum adenitis testicular torsion
54
What features of appendicitis can be found clinically?
Furred tongue Fotor Mcburney's point Rovsing's sign Psoas sign
55
What signs would suggest perforated viscus?
Rigid abdomen Absent bowel sounds Percussion tenderness Erect CXR needed
56
What pain medication is contraindicated in acute pancreatitis and why?
Morphine - causes spasm of sphincter of oddi
57
Following an upper G.I bleed, the patient should be started on what medication after the scope and what protocol is used to manage this?
PPI - omeprazole Hong Kong Criteria
58
On a scope if there is found to be ulceration, what additional tests/ treatment should be conducted?
Urea breath test Withhold of NSAIDs, Aspirin, Anti-coagulants (if safe) PPI
59
On discharge of an upper G.I bleed, what should be done?
Arrange urea breath test Continue PPIs for 6 weeks, then consider switching to H2 antagonist Repeat scope 8 weeks
60
What is the general management for an acute abdomen:
``` ABCDE NIL by mouth Oxygen +/- NG tube IV access IV fluids IV antibiotics - this is true for any suspicion of infection - For organ perforation IV Antiemetics Catheterise - monitor fluid output Obtain results from investigations Escalate as needed - surgery/ consultant ```
61
What are some indications that that a bowel is no longer viable following an obstruction?
Lack of peristalsis Loss of sheen Lack of pulsation Black colour
62
What signs may be seen on x-ray of a perforation?
Pneumoperitoneum Rigler's sign - both on both sides of the diaphragm
63
What is the definitive management for a perforated gastric ulcer?
Laparotomy - Repair ulcer +/- Partial gastrectomy Send specimens for sampling of cancer
64
A patient with bowel obstruction what things may you look for on the abdomen to give clues to the aetiology?
Surgical Scars Hernias
65
What radiological study can be done into bowel obstruction, which may also have a therapeutic effect?
Gastrograffin
66
What are the surgical procedures that are done for bowel obstruction?
Small bowel: - Adhesiolysis Large Bowel: - Hartman's - Colectomy - Palliative bypass
67
What are the cardinal signs of gastric obstruction and how is it managed?
Retching - salvia brought up not vomit Abdominal pain Unable to pass NG tube down - Endoscopic manipulation - Emergency laparoscopy
68
What are some of the causes of an ileus?
``` Post surgery - bowel being handled Ischemia Electrolyte abnormalities - Hypo K+, Hyper Ca Peritonitis Pancreatitis ```
69
What imaging do you want in diverticulitis?
Acute: - Erect chest x-ray - look for perforation - CT abdomen and pelvis Chronic: - Gastrograffin enema - Flexible sigmoidoscope - Colonoscopy * sigmoidoscopy and colonoscopy are contraindicated in acute flares
70
What is the management of severe diverticulitis?
Bed rest NBM IV fluids IV antibiotics +/- Surgical - Hartmann's procedure
71
Which way does cecal and sigmoid volvulus twist?
Caecal - clockwise Sigmoidal: Anti-clockwise
72
How is an appendicitis abscess managed and how does it present clinically?
Low quadrant mass that doesn't get better with patient deterioration NIL by mouth IV antibiotics IV fluids +/- CT drainage
73
Following bloods - what is the most appropriate investigation in diverticulitis?
CT Abdo/ Pelvis
74
What are the risk factors for gastric carcinoma?
Gastritis - H.Pylori - Autoimmune Blood group Type A Smoking Nitrates Partial Gastrectomy
75
Biggest symptom of gastric cancer?
Dyspepsia
76
Name the tumours found in the small bowel:
Adenocarcinoma MALT Lymphoma Carcinoid Gastrointestinal stromal tumours
77
How does Gastro-intestinal tumour present and how is it treated?
Arises from Cajal cells Presents: - abdominal fullness - Bleeding Treatment: - Imatinib - Resection
78
When an abdominal mass is felt, what do you want to know about it?
``` Site Consistency Mobile Painful Superficial/ Deep Associated with Lymph nodes ```
79
What are some causes of abdominal masses?
Upper: - Stomach carcinoma - Hepatomegaly - AAA - Cholecystitis Lower: - AAA - Appendicitis - Colorectal cancer - Ovarian mass - Pregnancy/ fibroid
80
List some causes of obstructive jaundice other than stone and pancreatic cancer:
External compression of lymph nodes Cholangiocarcinoma Stricture formation - congenital PSC
81
In the setting of a lower G.I bleed, what investigations do you want? and what would be the definitive surgery?
FBC Mesenteric angiography Colonoscopy/ sigmoidoscopy Radiolabeled Red cell Scan Surgical resection of the bleeding area or if that can't be identified then colectomy or Embolisation at angiography
82
How is gastric outlet obstruction treated?
Endoscopic dilation PPIs Gastric by pass Malignant: - pyloric stenting - Gastric bypass
83
How is acute cholecystitis treated?
IV Antibiotics NIL by mouth Antiemetics Elective cholecystectomy Drainage of empyema if develops
84
What investigations should be done into large PR bleeding and what is the treatment?
Colonoscopy/ Sigmoidoscopy Mesenteric Angiography Radiolabeled Red Blood Cell Scan Treatment: - Colonoscopic control of bleeding - Surgical removal of bowel if source can't be found
85
If suspected pancreatitis has been going on for >24 hours what is the most sensitive test?
Serum Lipase
86
What is the surgery that is conducted for failed endoscopic management of varices?
Trans- Intrahepatic Portal Systemic Shunt - TIPSS
87
What is the preferred scoping method for severe active ulcerative colitis?
Flexible sigmoidoscopy | - because there is increased risk of perforation with colonoscopy
88
What is the management of severe UC?
IV steroids IV fluids LMWH Calcium and Vitamin D supplementation (due to risk from steroids) 3-5day: - rescue therapy - infliximab or ciclosporin 10days: - sub- total colectomy or - total Proctocolectomy
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