Finals HH > General Surgery > Flashcards

General Surgery Flashcards

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1
Q

Main causes of pancreatitis?

A

Gallstones
Alcohol
Post-ERCP

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2
Q

Pancreatitis causes pneumonic

A
  • I – Idiopathic
  • G – Gallstones
  • E – Ethanol
  • T – Trauma
  • S – Steroids
  • M – Mumps
  • A – Autoimmune
  • S – Scorpion sting
  • H – Hyperlipidaemia
  • E – ERCP
  • D – Drugs (furosemide, thiazide diuretics, azathioprine)
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3
Q

Investigation for severity of pancreatitis?

A

Glasgow score

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4
Q

Glasgow score pneumonic?

A

(<3 = mild/moderate, >3 = severe):
* P – PaO2 <8kPa
* A – Age > 55
* N – Neutrophils (WBC >15)
* C – Calcium < 2
* R – Renal, Urea >16
* E – Enzymes, LDH >600 or AST/ALT >200
* A – Albumin <32
* S – Sugar (glucose >10)

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5
Q

What is Cullen’s sign?

A

Bluish discolouration around umbilicus

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6
Q

What is Grey-turner’s sign?

A

Bluish discolouration around flank

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7
Q

What is Fox’s Sign?

A

Bluish discolouration around inguinal ligament

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8
Q

What enzymes are replaced in pancreatic enzyme replacement?

A

CREON - Lipase + amylase + protease

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9
Q

What is acute cholangitis?

A

Bile duct inflammation

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10
Q

What is cholecystitis?

A

Gallbladder inflammation

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11
Q

What is cholestasis?

A

Biliary obstruction

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12
Q

Biliary colic px

A
  • Intermittent RUQ/epigastric pain due to bile duct blockage
  • Associated with eating fatty foods
  • Pain may radiate to shoulder tip
  • Pain lasts between 30 mins and 8 hours
  • N&V
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13
Q

What triggers contraction of the gallbladder?

A

Fat -> CKK secretion into duodenum

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14
Q

Ix of biliary colic?

A
  1. LFT (↑bilirubin, ↑ALP, ↑ALT) + ultrasound
  2. MRCP if ultrasound negative but:
    a. Dilated bile duct and/or
    b. Abnormal LFT
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15
Q

Mx of gallbladder stones?

A

1 Asymptomatic -> no treatment
2 Symptomatic -> laparoscopic cholecystectomy (removal of gallbladder)
- Within 1 week if acute cholecystitis
3 Gallbladder empyema + surgery contra-indicated or conservative mx unsuccessful
-> Percutaneous cholecystostomy (drain pus from gallbladder)

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16
Q

Mx of common bile duct stones?

A

Asymptomatic or symptomatic:
-> Clear the bile duct + laparoscopic cholecystectomy

Clear bile duct with ERCP while awaiting laparoscopic cholecystectomy

If ERCP doesn’t work -> temporary stent for drainage

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17
Q

What is ascending cholangitis?

A

Ascending bacterial infection of biliary tree.

The blocking gallstones initiate an inflammatory response -> Toxin release [emergency]

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18
Q

Ix & Mx of ascending cholangitis

A

Ix – FBC (↑WCC, ↑ESR, ↑CRP), serum amylase
* USS
Mx – IV antibiotics, urgent biliary drainage

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19
Q

Appendicitis px:

A
  • Abdo pain – Starts central and moves to RIF over 24h, worse on movement
  • Low grade fever, N&V, loss of appetite
  • Guarding
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20
Q

What is Rovsing’s sign?

A

Left iliac fossa palpation increase pain in RIF

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21
Q

What is McBurney’s point?

A

Maximal tenderness 2/3rds way along a line drawn from umbilicus to the anterior superior iliac spine

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22
Q

Dx of appendicitis?

A

Ultrasound, abdo CT, MRI

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23
Q

Who is at risk of diverticular disease?

A

Elderly, low fibre diet, obese, NSAID use

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24
Q

What is diverticulosis and px?

A

Colonic muscle over-activity -> Herniation of mucosa and submucosa through muscular layer

Asymptomatic

Large, painless rectal bleed

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25
Mx of diverticular disease?
- Increase fibre, avoid NSAIDs - Bulk forming laxatives * Avoid stimulant laxatives (senna) - Anti-spasmodic for abdo cramps - Analgesia (paracetamol)
26
Mx of diverticulitis?
Severe -> hospital assessment Systemically unwell: - Oral Co-amoxiclav Systemically well: - No antibiotics, analgesia only
27
Px of diverticulitis?
Inflammation and infection of diverticula: - Fever - Sudden change in bowel habit & rectal bleeding - LLQ tenderness
28
Diverticular disease complications?
Bleeding, infection, perforation, peritonitis, fistula and obstruction
29
Causes of bowel obstruction?
Adhesions Hernias Malignancy Volvulus Diverticular disease Intussusception Meckel’s divectulum
30
What is a volvulus?
Bowel twists around itself and the mesentery -> closed loop bowel obstruction X-ray – “Coffee bean”
31
What is intussusception?
Bowel telescopes into itself
32
Intussusception px?
- Redcurrant jelly stool - RLQ tenderness - Sausage shape mass
33
Meckel's diverticulum ix?
Best ix – technetium scan Common ix – CTAP
34
Volvulus Ix & Mx?
Dx – contrast CT Mx - Drip & suck, consider surgery
35
Meckel/s diverticulum mx?
Mx – excise diverticulum if symptomatic
36
Bowel obstruction mx?
Initial mx – Drip and suck * Nasogastric decompression & IV fluids Are there any complications? * Hypovolaemic shock, bowel ischaemia, bowel perforation, sepsis Final mx – Surgical intervention or conservative if stable patient?
37
Bowel obstruction Ix?
Bloods * U&Es * VBG – metabolic alkalosis or ^lactate Imaging * Abdo X-ray, are there distended loops of bowel? * CTAP if severe
38
Bowel obstruction px?
* Diffuse abdominal pain & distention * Vomiting (green bilious) * Absolute constipation and lack of flatulence * “Tinkling” bowel sounds
39
What is a closed-loop bowel obstruction?
Two points of obstruction along bowel so there is a sandwiched middle section. Can occur with any bowel obstruction + competent ileocecal valve. - The closed loop section cannot drain -> expansion -> ischaemia + perforation
40
Px of G.I perforation?
Rapid onset of abdo pain + systemically unwell (tachy, hypo) - CXR will show air under diaphragm
41
Dx & Mx of G.I perforation?
Dx – CT with contrast Mx – underlying + resus, fluids, analgesia, antibiotics
42
Types of peritonitis?
Spontaneous bacterial peritonitis – development of infection of ascitic fluid in peritoneum o Liver failure, kidney failure Secondary peritonitis (occurs 24-48 hours after rupture of abdo wall or organs) o Ruptured organ – appendicitis, pancreatitis, diverticulitis, ruptured stomach ulcer, perforated colon
43
Peritonitis px?
Px: - Dull, generalised abdo pain which becomes severe - Guarding and rigidity - Rebound tenderness - Cough test (coughing elicits pain)
44
Types of intestinal ischaemia?
- Acute mesenteric ischaemia - Chronic mesenteric ischaemia - Colonic ischaemia
45
Px of acute mesenteric ischaemia
Non-specific abdo pain -> Shock, peritonitis & sepsis
46
Px of chronic mesenteric ischaemia?
- Colicky abdo pain after eating - Weight loss - Abdo bruit
47
Px of colonic ischaemia?
- Lateral cramping pain - Urgent need to defecate with pain
48
Dx & Mx of intestinal ischaemias
Acute mesenteric ischameia: Dx - Contrast CT Mx - Remove thrombus + necrotic bowel Chronic mesenteric bowel & colonic ischaemia: Dx - CT angiogram Mx: 1.Lifestyle 2. Statins, antiplatelets 3. Revascularisation
49
Rx of colorectal cancer?
Family history FAP Lynch syndrome IBD Smoker High red meat diet
50
Urgent referral criteria for bowel cancer?
Urgent referral (<2 weeks): - >40y with abdo pain and unexplained weight loss - >50y with unexplained rectal bleeding - >60y with iron-deficiency anaemia or change in their bowel habit - Occult blood in faeces
51
Screening Ix for bowel cancer?
QFIT - People aged 50-74 are screened for bowel cancer every two years in Scotland
52
What is removed in a right hemicolectomy?
Caecum, ascending and proximal transverse
53
What is removed in a left hemicolectomy?
Distal transverse and descending
54
What is removed in a high anterior resection?
Sigmoid colon
55
What is removed in a low anterior resection?
Sigmoid + upper rectum
56
What is removed in a abdomino-perineal resection?
Rectum + anus +/- sigmoid
57
What is a Hartmann's surgery?
Can be elective or emergency removal of rectosigmoid and creation of a colostomy
58
What is low anterior resection syndrome?
Anastomosis of colon and rectum
59
Pancreatic cancer common px
Mostly adenocarcinomas at head of pancreas -> compression of bile ducts -> painless obstructive jaundice + weight loss
60
What are the symptoms of painless obstructive jaundice?
Yellow skin and sclera Pale stools Dark urine Itching
61
Referral criteria for pancreatic cancer?
- >40 with jaundice – 2 week wait referral - >60 with weight loss + non-specific symptom (weight loss, abdo pain, epigastric mass, N&V, constipation / diarrhoea, new onset diabetes) -> direct access CT abdomen
62
Rx for cholangiocarcinoma
PSC - primary sclerosing cholangitis
63
Px of cholangiocarcinoma?
- Obstructive jaundice – pale stools, dark urine, generalised itch - Weight loss - RUQ pain - Palpable gallbladder
64
Ix & Mx of cholangiocarcinoma?
Ix – Imaging + history - CA 19-9 tumour marker - MRCP to observe obstruction Mx: - Curative surgery not often possible - Stent insertion by ERCP to relieve biliary obstruction
65
How many weeks for an anal fissure to be chronic?
6 weeks
66
Primary and secondary anal fissure differences on ex?
Primary – singular in posterior midline of anus Secondary – multiple, irregular outline or occur laterally
67
Mx of anal fissure?
- Ensure soft stools fibre diet? - Anal hygiene (cleaning and kept dry, not straining) - Analgesia – paracetamol or ibuprofen o Adult with extreme pain on defecation -> topical anaesthetic (lidocaine 5%) One week without improvement in an adult with primary anal fissure -> rectal GTN 0.4% BID
68
Px of peri-anal abscess?
- Constant throbbing pain in perineum - Intermittent discharge near anal region - Skin lesion near anus - Fever, chills, urinary retentions - IBD (Crohn’s)
69
Mx of peri-anal abscess?
Incision + drainage, consider fistulotomy & antibiotics
70
Location of inguinal hernia?
Superomedial to pubic tubercle
71
Location of femoral hernia?
Inferolateral to pubic tubercle
72
What is an indirect inguinal hernia?
Hernia via incomplete closure of outpouching of peritoneum which allowed testes decent
73
Who gets what type of inguinal hernia?
Direct (20%): - Older patients secondary to abdo wall laxity Indirect (80%): - Congenital - Paediatric cases
74
What is an incarcerated hernia?
Hernia can't be reduced
75
What is a strangulated hernia?
Non-reducible hernia + hernia has cut off blood supply -> ischaemic bowel (significant pain)
76
Hernia mx?
- Small & asymptomatic -> watchful waiting o 1/3rd never have symptoms - Symptomatic hernia -> surgical repair + prophylactic antibiotics
77
Acute mesenteric ischaemia causes?
Rapid blockage of blood vessel * Embolus (50%) * Thrombus (20%) * Hypo-perfusion * Vasculitis
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