1
Q
What is the definition of a hernia?
A
Protrusion of viscera through it’s covering to an abnormal location
2
Q
What is the definition of an emboli?
A
Solid or gas which has been carried in the bloodstream to a location different to its origin
3
Q
What is the function of the ilioinguinal nerve?
A
Sensory supply of upper anteromedial thigh
4
Q
What is the function of the genitofemoral nerve?
A
Sensory innervation of the upper thigh (anterior scrotum, mons pubis and labia majora)
5
Q
What are things to look for on inspection during a DRE examination?
A
Skin tags Pilonidal sinus Abscess Anal warts Fissures Fistulas Excoriation External haemorrhoids
6
Q
What are four potential causes of a right iliac fossa mass?
A
Caecal carcinoma, appendix abscess, Crohn’s disease, ovarian tumour/cyst
7
Q
What would be the first investigation if you are considering an oesophageal carcinoma?
A
Uppper gastro-intestinal endoscopy
8
Q
Manometry can be used to diagnose what condition which causes dysphagia?
A
Achalasia
9
Q
What would achalasia look like on a barium swallow?
A
‘Bird’s beak’ appearance with a smooth tapering distally and possible oesophageal dilation above the lesion
10
Q
How would a peptic stricture appear on barium swallow?
A
As a short pinch point (small area of narrowing)
11
Q
How would oesophageal spasm appear on barium swallow?
A
One or more smooth areas of contraction in the oesophagus
12
Q
What three investigations are used in staging oesophageal carcinoma?
A
Endoscopic ultrasound, PET scan, CT chest, abdomen and pelvis
13
Q
Where are metastatic lesions likely to spread in oesophageal malignancy?
A
Liver and lung
14
Q
What can commonly cause free intra-peritoneal air?
A
Perforated duodenal ulcer, perforated diverticulum, laparotomy 24 hours ago
15
Q
Perforation of what structures cause gas to accumulate in the retroperitoneum?
A
Ascending colon, descending colon, 3rd part of the duodenum
16
Q
What initial management is used for a volvulus of the sigmois colon?
A
Sigmoidoscopy and passage of decompressing flatus tube
17
Q
What surgery may be required for recurrent sigmoid volulus?
A
Sigmoid colectomy
18
Q
What causes a sigmois volulus?
A
Twisting of the bowel on lax mesentery
19
Q
Which patients are more commonly affected by sigmoid volvulus?
A
Elderly or psychiatric patients
20
Q
What percentage of colonic obstructions are from sigmoid volvulus?
A
1-2%
21
Q
What are the six criteria for acute severe colitis established by Truelove and Witts?
A
- Frequency of stool >6 daily
- Overtly bloody stool
- Fever (>37.5)
- Tachycardia (>90)
- Anaemia (Hb<105)
- Raised ESR (>30)
22
Q
In acute severe disease of UC why would a sigmoidoscopy be used over colonoscopy?
A
Colonoscopy increases risk of perforation
23
Q
Why would you give heparin to a patient with acute severe colitis, what would make you not give it?
A
Patients with acute severe colitis are at high risk of thromboembolic events
Would give unless there is a significant haemorrhage
24
Q
What medication is used in treatment of acute severe colitis?
A
Intravenous hydrocortisone 100mg every 6 hours
Bone protection from high steroids
Heparin as prophylactic
25
Why do patinets with long-standing ulcerative colitis need surveillance colonoscopies?
They are at increased risk of colonic carcinoma and need to be screened regularly with colonoscopy
26
What is thumbprinting on abdominal X-ray?
Radiographic sign of large bowel wall thickening from oedema or inflammation, the normal haustra become tickened appearing like thumbprint projections into lumen
27
What conditions are associated with toxic megacolon?
UC, Crohn’s, infective colitis
28
What is included in the standard trauma X-ray series?
Chest X-ray, lateral cervical spine, X-ray pelvis
29
What imaging modality is best for detection of splenic injuries?
CT
30
What is the most commonly injured solid organ in the abdomen?
The spleen
31
What precautions would you advice a patient about following splenectomy?
Vaccination (pneumococcal, meningococcal, haemophilus influenzae), long term penicillin V prophylaxis, caution with travel to areas of endemic malaria
32
Is achlasia associted with oesophageal malignancy?
Yes
33
What is achalasia?
Disease due to failure of normal peristalsis and relaxation of the lower oesophgeal sphincter
34
What tropical disease may cause similar clinical and imaging appearances to achalasia?
Chaga’s disease (trypanosomiasis)
35
Can achalasia cause painful dysphagia?
Yes
36
Can achalasia cause aspiration pneumonia?
Yes
37
What are treatments frequently used for achalasia?
Balloon dilatation, botox injections, Heller’s myotomy
38
What are the different types of gallstones?
Cholesterol stones, pigment stones, mixed stones
39
Haemolytic anaemia is associated with which type of gallstone?
Pigment
40
Which two ducts come together to form the common bile duct?
The cystic duct and common hepatic duct
41
What are common risk factors for gallstone disease? (The 5 Fs)
```
Fat
Female
Fertile (being pregnant)
Forty (peak age for women to present)
Family history
```
42
What causes biliary colic?
Impaction of gallbladder neck by a gallstone, there is no inflammation but pain on contraction of gallbladder
43
Why do patients often experience biliary colic after a fatty meal?
Fatty acids stimulate the duodenum endocrine cells to produce CCK which stimulates the gallbladder to contract
44
How does pain usually differ between biliary colic and acute cholecystitis?
Biliary colic: sudden, dull, colicky
| Acute cholecystitis: constant
45
What is a positive Murphy’s sign?
Whilst applying pressure to the RUQ, ask the patient to inspire. There will be a halt in inspiration due to pain with a positive test
46
What can a positive Murphy sign indicate?
An inflamed gallbladder
47
What are three things to look for on abdominal ultrasound when suspecting gallstone disease?
Gallbladder wall thickening, presence of gallstones/sludge, bile duct dilatation
48
What is charcot’s triad?
Jaundice, fever and RUQ pain
49
What is Reynold’s pentad?
Jaundice, fever, RUQ pain, hypotension, confusion
50
What is Alvarado scoring system used to help diagnose?
Appendicitis
51
What are some categories in alavadro scoring system?
Pain moving to RIF, anorexia, N+V, RIF tenderness, fever, raised WCC
52
Which out of biliary colic, acute cholecystitis and cholangitis will caise jaundice?
Cholangitis
53
What is often observed on ultrasound when cholangitis is present?
Common bile duct dilatation
54
What is the most common cause of cholangitis?
Gallstones- blocking biliary tract
55
Following an open appendectomy would you be concerned if there was free air beneath the diaphragm?
This is a normal finding after surgery
56
What are the 4HTs for reversible causes of cardiac arrest?
Hypovolaemia, hypo/hyperkalaemia, hypothermia, hypoxia
| Toxins, cardiac Tamponade, Thrombus, Tension pneumothorax
57
What are indications for dialysis in patient with AKI using mneumonic AEIOU?
```
Acidosis
Electrolytes
Intoxications
Overload
Uraemia
```
58
What causes the majority of acute pancreatitis cases?
Gallstones and excess alchol consumption
59
What are causes of pancreatitis? (GET SMASHED)
```
G-gallstones
E- ethanol
T- trauma
S- steroids
M- mumps
A- autoimmune
S- scorpion sting
H- hypercalcaemia
E- ERCP
D- drugs (e.g azathioprine, NSAIDs, diuretics)
```
60
What is pancreatitis?
Inflammation of the pancreas
61
What is the pathophysiology of acute pancreatitis?
Digestive enzymes are activated within the pancreas resulting in an inflammatory response
62
How does fat necrosis occur in acute pancreatitis?
Enzymes released from the pancreas into ystemic circulation causing autodigestion of fats which results in fat necrosis
63
Why can you get hameorrhage in retroperitoneal space with acute pancreatitis?
Enzymes released from pancreas into systemic circultion autodigest blood vessels
64
How do patients typically present with acute pancreatitis?
Severe epigastric pain which can radiate to the back, with nausea and vomiting
65
What do Cullen’s and Grey Turner’s signs suggest?
Retroperitoneal haemorrhage
66
Where does bruising occur with Cullen’s and Grey Turner’s signs?
Cullen’s: peri umbilical
| Grey Turner’s: the flanks
67
What are some causes of abdominal pain which radiates to the back?
AAA, renal calculi, chronic pancreatitis, aortic dissection, peptic ulcer disease
68
Do serum amylase levels directly correlate with acute pancreatitis disease severity?
No
69
What intial labatory test would you consider for acute pancreatitis?
Serum amylase, LFTs, serum lipase (if available at the hospital)
70
What is the management of acute pancreatits?
IV fluid resuscitation, analgesia, NG tube if vomiting profusely, encourage oral intake as soon as tolerated
71
What level of serum amylase is diagnostic of acute pancreatitis?
3 times the normal upper limit
72
What is a pancreatic pseudocyst?
A collection of fluid containg pancreatic enzymes, blood and necrotic tissue, forming typically a few weeks post acute pancreatitis episode
73
What surgery may be required for pancreatic necrosis?
Necrosectomy
74
What is an adhesion?
Fibrous tissue that binds two surfaces of the body which are usually separate
75
What is a fistula?
An abnormal connection between two epithelial surfaces
76
What is tenesmus?
The sensation of needing to open bowels without being able to produce stools
77
What happens in a hemicolectomy?
Removal of a portion of the colon
78
What is a Hartmann’s procedure?
Proctosigmoidectomy- removal of the rectosigmoid colon with closure of the anorectal stump and formation of a colostomy
79
What is an anterior resection in general surgery?
Removal of the rectum
80
What is a Whipple procedure?
Pancreaticoduodenectomy- removal of the head of the pancreas, duodenum, gallbladder and bile duct
81
What type of diathermy would you use for surgery on a patient with a pacemaker?
Bipolar diathermy
82
What is the ASA grading system?
ASA grading system classifies physical status of the patient for anaesthesia from 1 (normal healthy) to 6 (brain-dead undergoing organ donation)
83
Where is the most common area of duodenal ulceration?
The cap (first section) which ascends superiorly from pylorus of stomach
84
How are the different sections of the duodenum categorised?
D1- superior
D2- descending
D3- inferior
D4 ascending
85
What are the two most common causes of duodenal ulcers?
H. Pylori infection and chronic NSAID therapy
86
What are some ways to reduce post op ileus?
Limit bowel handling and opiate use
Mobilise ASAP
Avoid fluid overload (bowel oedema)
87
Extensive small bowel resections for Crohn’s disease can lead to what syndrome?
Short bowel syndrome
88
What is a Hartmann’s procedure?
Complete resection of the rectum and sigmoid colon with the formation of an end colostomy and closure of rectal stump
89
How should abdominal wound dehiscence initially be managed?
Cover wound with saline-soaked gauze and give Iv broad-spectrum antibiotics
90
What is wound dehiscence?
When a surgical wound reopens
91
What is the management of anal fissure?
(1st line) GTN ointment or diltiazem cream applied topically
Botulinum toxin
Then internal sphincterotomy if fail to respond to others
92
What are some typical spinal features seen in ankylosing spondylitis?
Loss of lumbar lordosis and progressive kyphosis of cervical-thoracic spine
93
What are the 3 categories of spina bifida?
Myelomeningocoele, spina bifida occulta and meningocoele
94
What are features of anal fissures?
Painful, bright red rectal bleeding
| Most commonly on posterior midline (if in other location consider underlying cause)
95
What are some general risk factors for VTE?
Cancer/chemo, over 60, high BMI, dehydration, clotting disorder, HRT or COCP, pregnant, varicose veins, significant medical comorbidity
96
What are two types of mechanical VTE prophylaxis?
Compression stockings
| Intermittent pneumatic compression device
97
What are some pharmacological options for VTE prophylaxis?
Low molecular weight heparin (e.g enoxiparin)
Unfractionated heparin
Fondaparinux sodium
98
How long would you advice women to stop their COCP before surgery?
4 weeks before surgery
99
What test is helpful to assess the exocrine function in chronic pancreatitis?
Faecal elastase
100
Patients with a cholangiocarcinoma may have a raise in which tumour marker?
CA 19-9
101
Levels of what enzyme are best for investigating suspected acute pancreatitis of a late presentation >24 hours
Serum lipase (has a longer half life than amylase)
102
Where are diverticula most commonly found in the bowel?
Sigmoid colon
103
What are the four different disease manifestations of diverticulum?
Diverticulosis, diverticular disease, diverticulitis, diverticular bleed
104
What is diverticulitis?
Inflammation of a diverticula from bacterial overgrowth within the outpouching
105
What is a diverticular bleed?
When a diverticula erodes into a vessel and causes a large volume painless bleed
106
What are some risk factors for the formation of diverticula?
Low fibre diet, smoking, obesity, family history, NSAID use
107
What are some clinical features of diverticular disease?
Intermittent lower abdo pain (typically colicky and relieved by defecation)
May also have associated change in bowel habit, nausea and flatulence
108
What drugs that a patient may be taking can mask symptoms of diverticulitis?
Corticosteroids or immunosuppressants
109
What is obturator sign when looking for appendicitis?
Pain with right knee flexed and right hip rotated internally
Positive sign indicates potential appendicitis
110
What is psoas sign when looking for appendicitis?
Pain on extension of the hip (if retrocaecal appendix)
111
What investigation would you request to rule out a post-operative intra-abdominal collection?
CT
112
What size would a diverticular/pericolic abscess need to be for you to consider radiological drainage over IV antibiotics?
5cm
113
What are some findings on CT that may been seen with diverticulitis?
Thickening of colonic wall, pericolonic fat stranding, abscesses, free air
114
Would you do a colonoscopy for a presenting case of suspected diverticulitis?
No because of the risk of perforation
115
How would you manage a patient with uncomplicated diverticular disease?
Simple analgesia, encourage oral fluid intake
116
If a diverticular bleed fails to respond to conservative management, what are the surgical options?
Embolisation, surgical resection
117
How would you manage acute diverticulitis conservatively?
Fluids, antibiotics, analgesia- should improve in a few days
118
What surgical procedure may be required in diverticulitis patients with perforation with faecal peritonitis or overwhelming sepsis?
Hartmann’s procedure: sigmoid colectomy with formation of end colostomy
119
How may a colovesical fistula present?
Recurrent UTIs, pneumoturia, or faecal matter in urine
120
What are the most common complications of diverticular disease?
Strictures and fistula formation
121
What is a peptic ulcer?
a break in the lining of the GI tract extending to the muscularis mucosae
122
Where are peptic ulcers most likely to occur?
The lesser curvature of the stomach and 1st part of duodenum
123
How does H-pylori infection lead to peptic ulcer disease?
Induces release of histamine which cause parietal cells to produce more acid
Down-regulates bicarbonate production
124
What symptoms may a patient have with peptic ulcer disease?
Epigastric/retrosternal pain, nausea, bloating, post-prandial discomfort, early satiety
125
With regards to eating when is the pain worse for gastric ulcers and duodenal ulcers?
Pain from gastric ulcers exacerbate by eating
| Pain from duodenal ulcers are worse 2-4 hours after eating or are alleviated by eating
126
When would you consider an urgent referral for upper oesophageal-gastro-duodenoscopy?
New-onset dysphagia
>55 with weight loss and abdo pain/reflux/dyspepsia
New onset dyspepsia not responding to PPI
127
What is Zollinger-Ellison syndrome?
A triad of severe peptic ulcer disease, gastric acid hypersecretion, gastrinoma
128
What is the characteristic finding in Zollinger-Ellison syndrome?
Fasting gastrin of >1000 pg/ml
129
What should patients do about their current medication before a H.Pylori test?
Stop any current medical therapy for their symptoms 2 weeks prior to investigation
130
What lifestyle advice would you give a patient with peptic ulcer disease?
Smoking cessation, reduce alcohol intake, weight loss, avoid NSAIDs
131
What medication would we give a patient with peptic ulcer disease (not caused by H.Pylori)?
PPI e.g omeprazole
132
What is the triple therapy we use for H.pylori infection?
PPI with oral amoxicillin and clarithromycin/metronidazole for 7 days
133
What is the most common organism to cause cholangitis?
E Coli
134
Where is McBurney’s point?
Two thirds of the way from the umbilicus to the ASIS
135
What is the howship-Romberg sign and what pathology is this specific to?
Pain extending from the inner thigh to the knee when the hip is internally rotated.
This is due to compression of the obturator nerve e.g obturator hernia
Surgery Block
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