general

Question 1

fistula define

Answer 1

abnormal connection between 2 epithelial surfaces

Question 2

can fistula resolve spontaneously

Answer 2

• as a general RULE, all fistulae will RESOLVE SPONTANEOUSLY as long as there is no DISTAL OBSTRUCTION
• especially true for intestinal fistulae

Question 3

what ABs can be used to screen for thyroid cancer reccurence

Answer 3

thyroglobulin ABs

• this is the major constituent of colloid + precursor of thyroid hormones
• can be elevated in those with mets or recurr thyroid C

Question 4

Boas’s sign in acute cholecystitis

Answer 4

hyperaesthesia beneath right scapula in acute cholecystitis

-occurs as abdo wall innervation of this region is from SPINAL ROOTS that LIE at this LEVEL

Question 5

epigastric pain that worsens on lying down + radiates to back is typical of what

Answer 5

pancreatitis

Question 6

what are the 3 primary malignant tumours of bone causing pathological #

Answer 6

1. Chondrosarcoma
2. Osteosarcoma
3. Ewing’s tumour

Question 7

inguinal hernia define

Answer 7

protrusion of viscera or abdominal contents through the superficial inguinal ring
-either INDIRECTLY through deep inguinal ring OR DIRECT ING H protruding through defect in posterior wall of inguinal canal

Question 8

what is it called if a hernia cannot be reduced

Answer 8

INCARCERATED

-these hernias are at risk of strangulation = surg emergency

Question 9

strangulated hernia presentation

Answer 9

SURG EMERG - where blood supply to herniated T is compromised –> ischaemia or necrosis
-Sx: pain, F, incr in size of hernia or erythema of overlying skin, peritonitis, bowel obstruction eg N, V, distension, bowel ischaemia eg bloody stools

Question 10

MW tear features

Answer 10

• usu antecedent vomiting
• then vomit small am of blood
• usu little systemic disturbance or prior sx

Question 11

Hiatus hernia of gastric cardia features

Answer 11

• often longstanding hx of dyspepsia, pts often OVERWEIGHT

- uncomplicated hiatus H should not be assoc with dysphagia or haematemesis

Question 12

Oesophageal rupture features

Answer 12

• complete disruption of oesophageal wall in absence of pre-existing pathology
• left postero-lateral oesophagus is commonest site (2-3cm from OG jtn)
• sx: severe CP without cardiac dx + signs suggestive of pneumonia without convincing hx, where there is hx of vomiting
• erect CXR shows infiltrate or effusion in 90% cases

Question 13

SCC of oesophagus features

Answer 13

History of PROGRESSIVE DYSPHAGIA

• Often signs of W.LOSS
• Usually little or NO hx of previous GORD type sx

Question 14

Adenocarcinoma of oesophagus features

Answer 14

PROGRESSIVE DYSPHAGIA, may have previous Sx of GORD or Barretts oesophagus

Question 15

Peptic stricture features

Answer 15

• Longer hx of dysphagia, often not progressive
• Usually sx of GORD
• Often lack systemic feat seen with malignancy

Question 16

Dysmotility disorder features

Answer 16

• May have dysphagia that is EPISODIC and NON-PROGRESSIVE

- Retrosternal pain may accompany the episodes.

Question 17

when to request a NON-URGENT OGD in pts

Answer 17

=Patients with HAEMATEMESIS

=Patients aged >= 55Y who’ve got:

• -treatment-resistant dyspepsia or
• -upper abdo pain with low haemoglobin levels or
• -raised platelet count with any of: N, VOM, W.LOSS, reflux, dyspepsia, upper abdominal pain
• -N or VOM with any of the following: W.LOSS, REFLUX, DYSPEPSIA, upper abdominal pain

Question 18

MX pts who do not meet referral criteria = UNDIAGNOSED DYSPEPSIA

Answer 18

DYSPEPSIA = complex of UGI tract sx which are typically pres for 4+ weeks, including upper abdo pain or discomfort, heartburn, acid reflux, N and/or V

Mx: step wise

1. review meds for poss cause
2. lifestyle advice
3. trial of full dose PPI for 1m OR a test + treat approach for H.Pylori - if sx persist after either of the above approaches then try alt

Question 19

red flags requiring urgent OGD - within 2weeks

Answer 19

1-ALL patients who’ve got DYSPHAGIA
2-ALL pts who’ve got an upper abdominal mass consistent with STOMACH C
3-Patients aged >= 55 years who’ve got W.LOSS, AND any of the following:
–upper abdominal pain
–reflux
–dyspepsia

Question 20

SBO sx + raised amylase, what is dx

Answer 20

SBO

• amylase can be raised in SBO not just pancreatitis
• another differentiator is that in pancreatitis you wouldn’t get problems passing stools or flatus

Question 21

wehn to do a thoracotomy in haemothorax

Answer 21

> 1.5L blood initially or losses of >200ml per hour for >2 hours

Question 22

when to do a thoracotomy in haemothorax

Answer 22

> 1.5L blood initially or losses of >200ml per hour for >2 hours

Question 23

blockage of which ducts commonly does NOT cause jaundice and WHY

Answer 23

Blockage of CYSTIC DUCT or GALLBLADDER does NOT cause jaundice

• bile can still flow down from liver (where it is made) to the common hepatic duct, to common bile duct and then to sphincter of Oddi –> secreted into duodenum
• This is why CHOLECYSTITIS is RARELY assoc with JAUNDICE

Question 24

gastric volvulus triad

Answer 24

1/VOMITING
2/PAIN
3/failed attempts to pass an NGT

Question 25

Haemorrhoids locations + tx

Answer 25

PAINLESS BRIGHT RED RECTAL BLEEDING 3,7, 11 o clock internal or external tx: conservative, rubber band ligation, haemorrhoidectomy

Question 26

Anal fissure pres + location

Answer 26

PAINFUL rectal bleeding -location: midline 6 (90%) + 12 o clock position distal to dentate line

Question 27

chronic anal fissure triad

Answer 27

>6/52 | 1.ulcer 2.sentinel pile 3.enlarged anal papillae

Question 28

proctitis causes x3

Answer 28

Chrons UC C.Diff

Question 29

ano rectal abscess organisms + posoitions

Answer 29

- org's: E.coli, Staph aureus - positions: perianal, ischiorectal, pelvirectal, intersphincteric - present with fever + severe ano-rectal pain - mx: Examination under GA + drainage of sepsis

Question 30

anal fistula

Answer 30

Fistulas usually occur following previous ano-rectal sepsis - The discharge may be foul smelling and troublesome - Mx: Pts should be listed for EUA. Fistulas which are low and have little or no sphincter involvement are usually laid open. - goodsalls rule determines location (use MRI to figure out path)

Question 31

rectal prolapse

Answer 31

Associated with childbirth and rectal intussceception | -May be internal or external

Question 32

pruritis ani

Answer 32

v. common | - in children often related to worms, in adults, idiopathic or related to other causes eg haemorrhoids

Question 33

anal neoplasm

Answer 33

SCC commonest unlike adenocarcinoma in rectum

Question 34

solitary rectal ulcer

Answer 34

- Assoc with chronic straining and constipation - Histology shows mucosal thickening, lamina propria replaced with collagen and smooth muscle (fibromuscular obliteration)

Question 35

Surgical Jaundice: Gallstones - features

Answer 35

Typically hx of biliary colic or ep of chlolecystitis | -Obstructive type hx + test results

Question 36

Surgical Jaundice: Gallstones - pathogenesis

Answer 36

Usually small calibre gallstones which can pass through the cystic duct -In Mirizzi syndrome the stone may compress the bile duct directly- one of the RARE times that cholecystitis may present with jaundice

Question 37

Surgical Jaundice: Cholangitis

Answer 37

Features - Usually obstructive and will have Charcots triad of symptoms (pain, fever, jaundice) -patho: Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile.

Question 38

Surgical Jaundice: pancr C - features

Answer 38

Typically painless jaundice with palpable gallbladder (Courvoisier's Law)

Question 39

Surgical Jaundice: pancr C - pathogenesis

Answer 39

Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatis may be the culprit in which case the bile duct may be of normal calibre.

Question 40

Surgical Jaundice: TPN associated jaundice featurs + pathogenesis

Answer 40

features - Usually follows long term use and is usually painless with non obstructive features patho - Often due to hepatic dysfunction and fatty liver which may occur with long term TPN usage.

Question 41

Surgical Jaundice: Bile Duct Injury features + patho

Answer 41

Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive type -patho: Often due to a difficult cholecystectomy when anatomy in CALOTS triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice offers rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury.

Question 42

Surgical Jaundice: Cholangiocarcinoma features + patho

Answer 42

feat - gradual onset obstructive pattern | patho: Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis.

Question 43

Surgical Jaundice: Septic surgical patient - feat + patho

Answer 43

usu hepatic features | patho - Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis.

Question 44

metastatic disease - feat + patho

Answer 44

feat - mixed hepatic+ post-hepatic patho -Combination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier)

Question 45

how to mx pt with sigmoid volvulus with sx of peritonitis

Answer 45

skip flexi sig | treat with urgent midline laporotomy - to avoid bowel necrosis or perforation

Question 46

modified GLASGOW scofe - use acronym PANCREAS

Answer 46

``` Po2 <8 AGE >55 Neutrophilia WBC>15x10^9 Calcium <2 Renal ftn Urea>16 Enzymes - LDH>600, AST>200 Albumin <32 Sugar (bl gl) >10 ```

Question 47

what procedure in acutely unwell UC pt with fulminant disease that has developed TMColon

Answer 47

SUB TOTAL COLECTOMY | -safest - rectum left in situ as resection of rectum in acutely unwell pts --> high risk of complications

Question 48

what procedure is best for severe rectal chrons with complications

Answer 48

PROTECTOMY | -Not with ileoanal pouch best to use ileostomy

Question 49

what is a useful test of exocrine function of chronic pancreatitis

Answer 49

faecal elastase

Question 50

red flags for colon c requiring 2 WW referral x5

Answer 50

1. Weight loss 2. Persistent change in bowel habits 3. Unexplained rectal bleeding 4. IDA 5. Abdo mass on examination

Question 51

what to do if concerns about new sx of possible colorectal c but not meeting 2 WW criteria

Answer 51

FIT TEST can request in: >= 50 years with unexplained abdominal pain OR weight loss < 60 years with changes in their bowel habit OR iron deficiency anaemia >= 60 years who have anaemia even in the absence of iron deficiency

Question 52

thrombosed haemorrhoids

Answer 52

SIGNIF PAIN + TENDER LUMP - O/E: purple, oedematous, tender SC perianal mass - if pts present within 72h then referral should be considered for EXCISION - otherwise Mx pts with STOOL SOFTNERS, ICE packs + ANALGESIA - sx usu settle wtihin 10d

Question 53

Hiatus Hernia define + types + RF

Answer 53

# define = herniation of part of stomach above the diaphragm ``` sliding = 95% - GOJ moves aboves D rolling = paraoesophageal = GOJ remains below D but seperate part of stomach herniates through oesophagela hiatus ``` RF: Obesity, incr intraabdominal pressure eg ascites, multiparity

Question 54

Hiatus Hernia features, Ix + Mx

Answer 54

``` Features: heartburn dysphagia regurgitation chest pain ``` Ix: - barium swallow is the most sensitive test - given the nature of the symptoms many patients have an endoscopy first-line, with a hiatus hernia being found incidentally Mx: - all patients benefit from conservative management e.g. weight loss - medical management: PPI therapy - surgical mx: only really has a role in symptomatic paraesophageal hernias