General surgery Flashcards

Question

_Gastric Ca (\>90% adenocarcinomas, rest: CT, lymphoid, neuroendocrine)_ 1. RF 2. H.pylori fact 3. CF 4. DD 5. Ix 6. Management 7. The type of operation performed depends on the region of the malignancy:

Answer 1

1. male, H. pylori infection, increasing age, and smoking 2. Has the enzyme urease urea -\> CO2 + ammonia (neutralises stomach acid) 3. **Dyspepsia, dysphagia,** N+V, melena, and haematemesis. Non-specific ca symptoms (anorexia, weight loss, or anaemia) are markers of late stage disease. Pt usually present at a late stage O/e: anaemia, jaundice or hepatomegaly (indicating likely metastases to the liver), acanthosis nigricans (hyperpigmentation of the skin creases, a non-specific sign seen in gastric cancer), Troisier’s sign (an enlarged Virchow’s node), or a palpable epigastric mass In the UK, only 40% of patients with gastric cancer are diagnosed via the urgent pathway, the rest are diagnosed after a non-urgent referral, an emergency hospital admission, or were referred by another hospital specialist. 4. PUD, GORD, gallstone disease, and pancreatic cancer. 5. **_Laboratory:_** Routine bloods (esp if have maelena or haematemesis) \*A CEA (carcinoembryonic antigen) is a marker of gastric malignancy and will be positive in 50% of patients with gastric cancer, however as it lacks sufficient sensitivity or specificity, it should not be used as a screening test in suspected cases, only as a monitor of disease progression / treatment response. **_Imaging:_** **Urgent upper GI endoscopy\* -\>** visualisation of malignancy + biopsies taken as needed. Biopsies from suspected gastric malignancies can be sent for: * **Histology** – for classification and grading of any neoplasia present * **CLO test** – for the presence of H. Pylori. * **HER2/neu protein expression** – this will allow for targeted monoclonal therapies if present For staging and in order to plan treatment, all patients need a **CT Chest-Abdomen-Pelvis**\*and a **staging laparoscopy** (to look for peritoneal metastases) 6. equate nutrition -\> nutritional status assessment -\> nutritional support, both pre- or post-treatment, via a NG (nasogastric) or RIG (radiologically-inserted gastrostomy) tube **_Curative Treatment_** * Peri-operative **chemotherapy** (3 cycles of neoadjuvant and 3 cycles of adjuvant\*). Epirubicin, cisplatin and 5-FU (ECF). 5-FU is usually replaced by its oral form, capecitabine. * Proximal Ca– total gastrectomy * Distal Ca (antrum or pylorus) – subtotal gastrectomy * Most common method - Roux-en-Y reconstruction- best functional result e.g. Less bile reflux. * Pt with T1atumours (confined to the muscularis mucosa) may be offered an Endoscopic Mucosal Resection (EMR) Adv: greatly reduced morbidity, mortality, and QoL impact _Gastrectomy Complications (major op)_ * QoL remains poor for up to 6 months after surgery * death (3-5%) * anastomotic leak (5-10%) * re-operation * dumping syndrome * Vitamin B12 deficiency (patients need 3-monthly vitamin B12 injections) _Palliative Management_ Chemotherapy, Supportive care, stenting (if gastric outlet obstruction) Palliative surgery: distal gastrectomy or bypass surgery is best used when stenting fails or is not available, yet can also be used cautiously in the palliation of bleeding gastric tumours. The 10-year survival rate for stomach cancer overall is 15%, yet this will vary depending on staging. Most gastric cancers will present at an advanced stage with metastasis, which have a 5 year survival of \<5%

Answer 2

1. M\>W 2. LOS: episodic sphincter relaxation episodes become more frequent 3. age, obesity, alcohol, smoking, caffeinated drinks, and fatty or spicy foods. 4. chest pain

Answer 3

1. Maj caused by GORD 2. * Caucasian * Male * \>50yrs of age * Smoking * Obesity * Hiatus hernia * Family history of Barrett’s oesophagus 3. * **Histological** diagnosis (endoscopy + biopsy) The **length** (squamo-columnar to GOJ) and **degree** of dysplasia are important in classification, and should be recorded on each endoscopy: * A length \<3cm is classed as short segment and ≥3cm is classified as a long segment * Grades of dysplasia include no dysplasia, indefinite for dysplasia, low grade dysplasia and high grade dysplasia 4. * PPI 2xdaily * Stops NSAIDs * Regular routine endoscopy -\> check for **adenocarcinomas** 5. Premalignant lesions: * **endoscopic mucosal resection** (EMR) or * **endoscopic submucosal dissection** (ESD), * which limits the need for **oesophagectomy** If carcinoma is discovered on routine endoscopy, then oesophagectomy may be indicated.

Answer 4

1. M\>W (3x) * **Squamous cell carcinoma** (~ developing world) ~middle and upper thirds of the oesophagus. Strongly associated with smoking and excessive alcohol consumption, as well as chronic achalasia, low vitamin A levels and, rarely, iron deficiency * **Adenocarcinoma** (~ developed world) typically ~lower third of the oesophagus Arises as a consequence of metaplastic epithelium (termed Barrett’s oesophagus) which progresses to dysplasia, to eventually become malignant Risk factors for this subtype are long-standing GORD, obesity, and high dietary fat intake Other rare subtypes of oesophageal malignancy: **leiomyosarcoma, rhabdomyosarcoma, or lymphoma.** 2. * **Dysphagia** – progressive, initially being to solids (esp meats or breads) then liquids -\> any pt with dysphagia should be assumed to have oesophageal cancer until proven otherwise. * **Significant weight loss** – due to both dysphagia and cancer-related anorexia (this is a marker of late-stage disease) * Other less common symptoms include **odonyphagia** or **hoarseness** 3. * Oesophago-gastro-duodenoscopy, **OGD**, to be performed within 2wks * **Biopsied** and sent for histology _Further Investigations_ Before undergoing curative treatment, patients often require a variety of the staging investigations including: * **CT CAP** and **PET-CT** scan are used together to investigate for distant metastases * **Endoscopic US** to measure the penetration into the oesophageal wall (T stage) and assess and biopsy suspicious mediastinal lymph nodes * **Staging laparoscopy** (for junctional tumours with an intra-abdominal component) to look for intra-peritoneal metastases Any palpable cervical lymph nodes may be investigated via Fine Needle Aspiration (FNA) biopsy and any hoarseness or haemoptysis may warrant investigation via bronchoscopy. 4. Advanced disease -\> treated palliatively 5. _Curative Management_ * **Squamous cell carcinomas** of the upper oesophagus are technically difficult to operate on and definitive **CRT** is therefore usually the treatment of choice SCCs of the middle or lower oesophagus will warrant either definitive CRT or neoadjuvant CRT followed then by surgery * **Adenocarcinomas**– neoadjuvant chemotherapy or chemo-radiotherapy followed by an **oesophageal resection** Pts who are less fit (but still fit enough to undergo surgery) may simply receive surgical treatment alone Surgical Treatment * Both the abdominal and chest cavities need to be opened * One lung deflated for about 2hrs during surgery; 30-day mortality rates are around 4% and it takes 6-9 months for patients to recover to their pre-op QoL * The main complications are **anastomotic leak\* (8%), re-op, pneumonia (30%), and death (4%)** * **Post-op nutrition** is a major problem for these patients as they lose the reservoir function of the stomach. Many centres will routinely insert a feeding tube into the small bowel (a “**feeding jejunostomy**”) to aid nutrition. However, most patients will need to eat 5-6 small meals per day and “graze” to meet their nutritional requirements as they physically cannot fit in 3 normal size but intermittent meals. \*Rates of anastomotic leak are relatively high; any deterioration, even minor, in an oesophagectomy patient should be considered to be an anastomotic leak until proven otherwise _Palliative_ * Difficulty swallowing -\> **oesophageal stent** * reduce tumour size and bleeding -\> **Radiotherapy and/or chemotherapy** * **Photodynamic therapy (PDT)** -\> produces a form of oxygen that kills nearby cells. * **Nutritional support** is essential for this patient group, as progression of the disease can lead to significant dysphagia and cachexia. **Thickened fluid** and **nutritional supplements** should be offered (usually via the nutrition team). * If dysphagia becomes too severe to tolerate enteral feeds, a **Radiologically-Inserted Gastrectomy (RIG)** tube may need to be inserted, to bypass the obstruction. 6. Overall 5 year survival is 5-10%

Answer 5

1. Full thickness rupture of the oesophageal wall; if it is spontaneous (often due to vomiting), it is often called **Boerhaave’s syndrome** - \> leakage of stomach contents into the mediastinum - \> sepsis 2. * iatrogenic (such as endoscopy) * after severe forceful vomiting * most common site of perforation is just above the diaphragm in the **left postero-lateral position** 3. * severe sudden-onset retrosternal chest pain, * respiratory distress, * subcutaneous emphysema 4. * Routine bloods: G&S * CXR may demonstrate evidence of **pneumomediastinum** * **investigation of choice is an urgent CT CAP with IV and oral contrast\*** (air or fluid in the mediastinum and pleural cavity; leakage of oral contrast from the oesophagus into the mediastinum or chest is pathognomonic) 5. * A-E (usually septic& haemodynamically unstable) -\> resus, high flow O2, broad spec Abx (gentamicin) * immediate **surgery** -\> control the leak and wash out of the chest. This is almost always via a thoracotomy * on-table **OGD** to determine the site of perforation * CT scan with contrast at **10-14 days** before starting oral intake. They may therefore warrant a feeding jejunostomy to be inserted at the time of surgery for nutrition. _Non-Operative Management_ Consider: * Pts with iatrogenic perforations as they are often more stable * Pts with minimal contamination, a contained perforation, no symptoms or signs of mediastinitis, or no solid food in pleura or mediastinum. * Pts with spontaneous perforations who are too frail or with extensive comorbidity to undergo surgery may also be candidates for non-operative treatment \*This is because the patient will usually have been NBM before the procedure and therefore there is not the forceful vomiting associated with spontaneous perforations and does not have the associated contamination _Non-operative treatment involves:_ * Initial suitable resuscitation and transfer to Intensive Care / **HDU** * **Antibiotic** and **anti-fungal** cover * **NBM** for 1-2 wks * Endoscopic insertion of an **NG tube** * Large-bore **chest drain** insertion * **TPN** or feeding jejunostomy insertion 6. **Morbidity and mortality** is high (between 50–80%) and therefore early identification and treatment will most influence outcomes.

Answer 6

1. Superficial mucosa tear, usually at GOJ After a period of profuse **vomiting**, and in turn results in a short period of haematemesis small and self-limiting 2. Same as for any other upper GI bleed (as discussed here). Although rare, any patient presenting with hypotensive shock require urgent resuscitation, with fluid resuscitation and bloods taken, including group and save (+/- cross match as needed). Most cases can be managed conservatively, rarely warranting interventional or surgical management.

Answer 7

1. primary motility disorder of the oesophagus, failure of SM relaxation high resting tone and failure of relaxation of the lower oesophageal sphincter diagnosis at ~50 years 2. Poorly understood, but a common histological feature is progressive destruction of the **ganglion cells** in the myenteric plexus. 3. vomiting, discomfort, and an developing poor nutritional status. progressive dysphagia regurgitation of food, coughing (due to overspill and aspiration, especially at night), chest pain, and weight loss. The symptom severity frequently varies day-to-day. 4. * Other oesophageal motility disorders * GORD * Oesophageal malignancy * Angina 5. The characteristic feature of achalasia on barium swallow; a bird’s beak appearance caused by failure of relaxation of the lower oesophageal sphincter -\> barium swallows are now rarely performed * Urgent endoscopy (exclude oesophageal ca). This is often normal in achalasia, but rarely a tight LOS can be observed (which may suddenly give way). * **Oesophageal manometry**. Pressure sensitive probe is inserted into the oesophagus (tip placed 5cm above the lower oesophageal sphincter). It measures the pressure of the sphincter, and the surrounding muscle. 6. * Absence of oesophageal peristalsis * Failure of relaxation of the lower oesophageal sphincter * High resting lower oesophageal sphincter tone 7. _Conservative_ * Sleeping with many pillows (minimise regurgitation) * Eating slowly * Chewing food thoroughly * Fluids +++ with meals. * CCB or nitrates can be partly effective for temporary relief, but their action is typically short lived. * Botox injections into the LOS by endoscopy are effective for a few months at most. _Surgical_ * **_Endoscopic balloon dilatation_** – insertion of a balloon into the LOS, which is dilated to stretch the muscle fibres. A **good response in ~75%** of patients but carries the risks of **perforation (~5%)** * **_Laparoscopic Heller myotomy\*_** – the **division** of the specific fibres of the LOS which fail to relax. A long-term **improvement in swallowing is seen in ~85%** of pts, with lower s/e profile compared to endoscopic treatment (although both techniques appear to be approximately equivalent in terms of QoL benefit). \*A recent meta-analysis found that the newer technique, per oral endoscopic myotomy (POEM), when compared to Heller myotomy, is more effective in relieving dysphagia however associated with a very high incidence of pathologic reflux. 8. x8-16 increased risk of oesophageal ca

Answer 8

1. multi-focal, high amplitude contractions of the oesophagus. Thought to be caused by the **dysfunction of oesophageal inhibitory nerves**. **DOS** can progress into **achalasia.** 2. * Severe dysphagia to both solids and liquids * Central chest pain is a common finding, usually exacerbated by food. * Pain from DOS may respond well to nitrates, making it difficult to distinguish from angina (yet this pain is rarely exertional). Examination is often normal 3. * **Oesophageal manometry** (repetitive, simultaneous, and ineffective contractions of the oesophagus. There may also be dysfunction of the lower oesophageal sphincter.) * A barium swallow is rarely performed, but can show a ‘corkscrew’ appearance 4. * Initially: **nitrates or CCBs** -\> relax the oesophageal SM * ffinmThese limit the strongest of the contractions, and so provide a symptomatic improvement, although their long-term efficacy is uncertain. * Patients with diffuse oesophageal spasm and documented hypertension of the lower oesophageal sphincter may benefit from **pneumatic dilatation**. * Myotomy is reserved for the most severe cases and must be used with caution due to the invasive nature. The incision is extensive, involving the entire spasmic segment and the LOS 5. autoimmune and CT disorders are associated with OD e.g. systemic sclerosis (most common), polymyositis, and dermatomyositis. Treatment is directed at the underlying cause (e.g. **immunosupression** in autoimmune-mediated disease), with **nutritional modification** and **PPIs** as required.

Answer 9

1. sudden onset of severe abdominal pain of \<24hrs duration 2. Bleeding -\> AAA, ectopic pregnancy, bleeding gastric ulcer, trauma, Perforated viscus-\> peptic ulceration, small or large bowel obstruction, diverticular disease, IBD * **Rigid** abdomen with **percussion tenderness** * **Involuntary guarding** – the pt involuntarily tenses their abdominal muscles when you palpate the abdomen * Reduced or **absent bowel sounds**, suggesting the presence of a **paralytic ileus** * **Patients often lay completely still,** not to move their abdomen, and look unwell (renal colic pt are constantly moving and cannot get comfortable * **Tachycardia** and potential hypotension Ischaemic bowel -\> severe pain out of proportion to the clinical signs, diffuse and constant pain. Definitive diagnosis is via a CT scan with IV contrast, with early surgical involvement. 3. Colic -\> ureteric obstruction or bowel obstruction -\> pain crescendos then descrescendos Peritonism (localised inflammation of the peritoneum, usually due to inflammation of a viscus that then irritates the visceral (and subsequently, parietal) peritoneum) pain 'migrates' 4. as the pain does not go away completely, instead getting periodically better and worse (colloquially termed ‘waxes and wanes’). 5. image 6. **Urine dipstick** – for signs of infection or haematuria ±MC&S. Include a **pregnancy test** for all women of reproductive age. **ABG** – useful in bleeding or septic patients, especially for the pH, pO2, pCO2, and lactate for signs of tissue hypoperfusion, as well as a rapid haemoglobin. **Routine bloods** – FBC, U&Es, LFTs, CRP, amylase. Consider measuring **serum calcium** in suspected **pancreatitis**. Do not forget a G&S if the patient is likely to need surgery soon. **Blood cultures** – if considering infection as a potential diagnosis _Imaging_ **ECG -** to exclude MI **Ultrasound**: * **KUB** – for suspected renal tract pathology * **Biliary tree and liver** – for suspected gallstone disease * **Ovaries, fallopian tubes and uterus** – for suspected tubo-ovarian pathology **Radiological:** * An **eCXR** – for evidence of bowel perforation * **CT imaging**, often best discussed with a senior depending on the suspected underlying diagnosis 7. * A-E: IV access, bloods, Start IV fluids and monitor fluid balance. * NBM * analgesia +/- antiemetics, * imaging * VTE prophylaxis, * urine dip, * Consider a urinary catheter and/or nasogastric tube if necessary.

Answer 10

1. * Incisions should try to follow **Langer’s lines** where possible, for maximal wound strength with minimal scarring * **Muscles** should be **split** and not cut (where possible) Langers line: correspond to the natural orientation of collagen fibers in the dermis, and are generally perpendicular to the orientation of the underlying muscle fibers. 2. sutures, staples, steri-strips, tissue glue 3. Appendix McBurney’s point (two-thirds from the umbilicus to the ASIS) **Lanz** - transverse incision - continuation with Langer’s lines - reduced scarring **Gridiron** - oblique (superolateral to inferomedial) **4. Run anywhere from the xiphoid process to the pubic symphysis,** passing around the umbilicus. The incision will cut through the skin, subcutaneous tissue, and fascia, the linea alba and tranversalis fascia, and the peritoneum before reaching the abdominal cavity. **Minimal blood loss. Significant scars.** **5.** Rarely performed in the UK. It was originally used to access much of the lateral viscera, such as the kidneys, the spleen, and the adrenal glands. The incision runs 2-5cm lateral to the midline, cutting through the skin, subcutaneous tissue, and the anterior rectus sheath. The anterior rectus sheath is separated and moved laterally, before the excision is continued through the posterior rectus sheath (if above the arcuate line) and the transversalis fascia, reaching the peritoneum and abdominal cavity. The incision will take a long time and is often technically difficult, however it does prevent any division of the rectus muscle and provides access to lateral structures. A paramedian incision **can damage the muscles’ lateral blood and nerve supply,** which may result in the atrophy of the muscle medial to the incision. 6. Subcostal incision used to gain access for the **gall bladder + the biliary tree.** Run parallel to the costal margin, starting below the xiphoid and extending laterally. Two modifications and extensions of the Kocher incision are possible: * **Chevron** / rooftop incision – the extension of the incision to the **other side** of the abdomen. This may be used for oesophagectomy, gastrectomy, bilateral adrenalectomy, hepatic resections, or liver transplantation * **Mercedes Benz incision** – the Chevron incision with a vertical incision and break through the **xiphisternum** This may be used for the same indications as the Chevron incision, however classically seen in **liver transplantation** Whilst open procedures that come with inherent drawbacks, all these subcoastal incisions provide the surgeon with **good exposure** to the abdominal viscera and **tend to heal well.**

Answer 11

1. Umbilicus 2. Scarpa’s membranous fascia, Camper’s subcutaneous fatty layer, and the skin

Answer 12

1. * Skin * Subcutaneous fatty layer (**Camper’s** fascia) * Membranous fascia (**Scarpa’s**) * Linea alba * Transversalis fascia * Preperitoneal fat * Parietal peritoneum 2. * Incision through: skin, subcutaneous fat and fascia, external and internal obliques, transversus abdominis and transversalis fascia * appendectomies * over McBurney’s point two-thirds of the distance between the umbilicus and the R ASIS * incision may be modified to follow the horizontal Langer’s lines for improved cosmesis * Disadvantages: risk of injury to the **ilioinguinal and iliohypogastric nerves** * The arc may be extended cephalad and laterally in order to facilitate access to the ascending colon, which is known as the **Rutherford-Morison incision.** 3. An incision designed to be more cosmetically subtle than the gridiron, with the benefit that it may be hidden beneath the bikini line but the disadvantage of commonly severing the ilioinguinal and iliohypogastric nerves. 4. * obstetricians -\> gravid **uterus** for which a curvilinear incision is made through the skin and subcutaneous fat, then a longitudinal incision made in the linea alba. General and urological surgeons -\> **radical open** **prostatectomy or cystectomy** 5. A useful laparotomy technique for use in paediatric patients who have not yet developed deep subphrenic or pelvic recesses, and in whom the surgeon, therefore, does not need the ability to extend the incision longitudinally as afforded by the midline incision. Vascular surgeons -\> AAA 6. * Incision made parallel to the subcostal margin * Access **liver and biliary tree,** commonly used for open **cholecystectomy**. * **Mirrored** on the contralateral side to provide access to the **spleen** or performed bilaterally as a Rooftop incision to provide efficient access to organs such as the **pancreas and biliary tree** within the transpyloric plane (see below). * Disadvantages include the risk of injuring the **superior epigastric vessels**, and lateral extension of the incision risks disruption of **intercostal nerves.**

Answer 13

1. vomiting blood 2. Oesophageal Varices Gastric Ulceration _Non-Emergencies_ Mallory-Weiss Tear (vomiting -\> tear in the epithelial lining of the oesophagus), resolve spontaneously Oesophagitis -\> inflammation of the intraluminal epithelial layer, either gastric acid reflux (GORD) or less commonly from infections, medication (such as bisphosphonates), radiotherapy, ingestions of toxic substances, or Crohn’s disease. Other Causes: gastritis, gastric malignancy, Meckel’s diverticulum, or vascular malformations (e.g. Dieulafoy lesion) 3. * Timing, frequency, and the volume of bleeding * History of dyspepsia, dysphagia, or odynophagia * Past medical history and smoking and alcohol status * Use of steroids, NSAIDs, anticoagulants, or bisphosphonates On examination, it is important to assess specifically for epigastric tenderness or peritonism, as well as features suggestive of a potential underlying cause, such as evidence of varices or liver stigmata 4. 1. **Bloods** (FBC, U&Es, LFTs, and clotting) and a VBG to be taken * Any acute bleed may not initially show an anaemia in the FBC, whereas LFTs may reveal underlying liver damage as a potential cause. * All patients with haematemesis should have a Group and Save; those with significant haematemesis (especially suspected variceal bleed) should have at least 4 units of blood cross-matched 2. oesophagogastroduodenoscopy (OGD) 3. erect CXR -\> pneumoperitoneum **CT abdomen with IV contrast (triple phase)** can be useful in assessing any active bleeding in an unstable patient\*, especially if endoscopy is unremarkable or the patient is too unwell to undergo invasive investigation \*RBC Scintigraphy is a more sensitive test that can be used to identify active bleeding, however is currently only used routinely in select centres 5. Image **scores ≥6** have been associated with a **\>50%** risk of needing an intervention. Other risk scores are used in the clinical setting, such as the AIMS65 Score (risk score for in-hospital mortality from upper GI bleeding) or Rockall Score (severity score for GI bleeding post-endoscopy) 6. * ABCDE: two large bore IV cannulas, start IV fluid resus if needed and send blood for G&S / X-match. * OGD 1. **Peptic ulcer disease** – **adrenaline + cauterisation** of the bleeding. High dose **intravenous PPI** therapy should be administered (e.g. **IV 40mg omeprazole**) to reduce acid secretion +/- H. Pylori eradication therapy if necessary 1. **Oesophageal varices** – **active resuscitation, endoscopic banding** **Prophylactic Abx** therapy should be initiated **Somatostatin** analogues (e.g. **octreotide**) or **vasopressors** (e.g. **terlipressin**) should also be started, acting to reduce splanchnic blood flow and hence reduce bleeding Long term management: **repeat banding** of the varices and **long-term beta-blocker therapy** \***Sengstaken-Blakemore tube** can be used in severe cases. It is inserted to the level of the varices and inflated to compress the bleeding An actively bleeding patient can also be treated with **angio-embolisation**, in which the bleeding vessel is embolised. This is most commonly the gastro-duodenal artery which is eroded into by an ulcer at the back of the first part of the duodenum.

Answer 14

1. image 2. Pain when swallowing odynophagia ? Is their difficulty in initiating the swallow? Do you cough after you swallow? Do you have to swallow a few times to get food past your throat Oesophagitis: There may be a history of heartburn. Odynophagia but no weight loss and systemically well Oesophageal candidiasis: There may be a history of HIV or other risk factors such as steroid inhaler use Pharyngeal pouch: More common in older men. Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles. Usually not seen but if large then a midline lump in the neck that gurgles on palpation. Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough. Halitosis may occasionally be seen Systemic sclerosis Globus hystericus

Answer 15

1. * **Small bowel** – adhesions and herniae * **Large bowel** – malignancy, diverticular disease, and volvulus (should be considered to be caused by a GI cancer until proved otherwise) * **Intraluminal:** Gallstone ileus, ingested foreign body, faecal impaction * **Mural:** Carcinoma, inflammatory strictures\*, intussusception\*\*, diverticular strictures, Meckel’s diverticulum, lymphoma * **Extramural:** Hernias, adhesions, peritoneal metastasis, volvulus 2. a “**closed-loop**” obstruction. This is a surgical emergency as the bowel will continue to distend, stretching the bowel wall until it becomes **ischaemic and ultimately perforates** 3. * Abdominal **pain** – colicky or cramping in nature, secondary to the bowel peristalsis. Any pain originally colicky that is now constant in nature or worse on movement should be a “red flag” that ischaemia may be developing. * **Vomiting** – initially of gastric contents, before becoming bilious and then eventually faeculent * **Abdominal distension** * **‘Absolute’ constipation** – failure to pass flatus and faeces O/e: (e.g. surgical scars, cachexia from malignancy, or obvious hernia) and abdominal distension. Assess for any clinical signs of dehydration or sepsis. Palpate for focal tenderness\* (including guarding and rebound tenderness on palpation). Percussion may reveal a tympanic sound and auscultation may reveal ‘tinkling’ bowel sounds, both signs characteristic of bowel obstruction. \*Focal tenderness indicates ischaemia and is a key warning sign. Patients with bowel obstruction may be uncomfortable on palpation due to the discomfort from pressing on a distended abdomen, but there should be no focal tenderness, guarding, or rebound tenderness unless ischaemia is developing. 4. * Paralytic ileus * Toxic megacolon * Constipation 5. * FBC, CRP, U&Es (hypokalaemia and high urea may be present), and a Group and Save (G&S). * VBG can be useful to evaluate the signs of ischaemia (high lactate) or for the immediate assessment of any metabolic derangement (secondary to dehydration or excessive vomiting). * **CT imaging** ( (1) more sensitive for bowel obstruction; (2) can differentiate between mechanical obstruction and pseudo-obstruction; (3) can demonstrate the site and cause of obstruction (hence extremely useful for operative planning); and (4) may demonstrate the presence of metastases if caused by a malignancy (which is likewise extremely useful in operative planning). * **Erect CXR** may also be requested to assess for free air under the diaphragm if clinical features suggest a bowel perforation. * **Contrast fluoroscopy** can also be useful in small bowel obstruction caused by adhesions from previous surgery. It has been shown to predict quite reliably whether or not the obstruction will settle and some studies have shown a therapeutic benefit of the contrast itself (although this is controversial) 4. **Small bowel obstruction:** * Dilated bowel (\>3cm) * Central abdominal location * Valvulae conniventes visible (lines completely crossing the bowel) **Large bowel obstruction:** * Dilated bowel (\>6cm, or \>9cm if at the caecum) * Peripheral location * Haustral lines visible (lines not completely crossing the bowel, ‘indents that go Halfway are Haustra’) 6. Ischaemia, perforation, and/or peritonism * A-E: fluid resus (4-5L, first 24 hours) * Most require a urinary catheter * Surgery-\> closed loop bowel obstruction or evidence of ischaemia _Conservative Management_ (no ischemia or strangulation) * **NBM** and insert a nasogastric tube (**NG tube**) to decompress the bowel (‘suck’) * Start **IV fluids** and correct any electrolyte disturbances (‘drip’) * **Urinary catheter** and fluid balance * **Analgesia + anti-emetics** **Adhesional SBO** resulting from previous surgery is treated **conservatively** in the first instance (unless there is evidence of strangulation / ischaemia), with a success rate of around 80%. A **water soluble contrast** study should be performed. If contrast does not reach the **colon** by **6 hrs** then it is very unlikely that it will resolve and the patient should be taken to theatre. **LBO or SBO** in a patient who has **not had previous surgery** (termed a “virgin abdomen”) **rarely settles without surgery.** 7. Surgical intervention is indicated in patients with: * Suspicion of intestinal **ischaemia** or with a **closed loop** bowel obstruction * SBO in a patient with a **virgin abdomen** * A cause that requires surgical correction (e.g. a **strangulated hernia or obstructing tumour**) * If patients **fail to improve** with conservative measures (typically after **≥48 hrs**) 8. * Bowel ischaemia * Bowel perforation, leading to faecal peritonitis (high mortality) * Dehydration and renal impairment

Answer 16

1. **_Inflammatory or Ischaemic_** **Chemical:** PUD, Foreign body (e.g. battery or caustic soda) **Infection:** Appendicitis, Diverticulitis, Cholecystitis, Meckel’s Diverticulum Ischaemia Mesenteric ischaemia Obstructive lesions (e.g. cancer\*, bezoar, or faeces (sterocoral)), resulting in bowel distension and subsequent ischaemia and necrosis Colitis Fistula formation (e.g. Crohn’s Disease) Toxic Megacolon (e.g. Clostridum Difficile or Ulcerative Colitis)

Answer 17

1. **Febrile** reaction (attacking WBC, supportive) 2. **Urticarial** (foreign serum proteins - skin erythema, hives, itching, antihistamines) 3. Acute haemolytic reaction (cold,chest pain, diuretics (manitol)stop the transfusion) 4. Anaphylaxis (adrenaline and corticosteroids) 5. PO 6. Purpura (antiplatelet Ab) (non blanching, plamopheresis to remove Ab) immunological: acute haemolytic, non-haemolytic febrile, allergic/anaphylaxis infective transfusion-related acute lung injury (TRALI) fluid overload other: hyperkalaemia, iron overload, clotting _Acute haemolytic transfusion reaction_ **mismatch** of blood group (ABO) which causes massive intravascular haemolysis. Symptoms begin **minutes** after the transfusion is started and include a fever, abdominal and **chest pain**, agitation and hypotension. Treatment: transfusion termination, generous fluid resuscitation with saline solution and informing the lab Complications: DIC, and renal failure Non-haemolytic febrile reaction Febrile reactions due to white blood cell HLA antibodies often the result of sensitization by previous pregnancies or transfusions _Allergic/anaphylaxis reaction_ Allergic reactions to blood transfusions are caused by hypersensitivity reactions to components within the transfusion. Symptoms typically arise within minutes of starting the transfusion and severity can range from urticaria to anaphylaxis with hypotension, dyspnoea, wheezing, and stridor, or angioedema. Simple urticaria should be treated by discontinuing the transfusion and with an antihistamine. Once the symptoms resolve, the transfusion may be continued with no need for further workup. More severe allergic reaction or anaphylaxis should be treated urgently. The transfusion should be permanently discontinued, intramuscular adrenaline should be administered and supportive care. Antihistamine, corticosteroids and bronchodilators should also be considered for these patients. Infective Transmission of vCJD although the absolute risk is very small, vCJD may be transmitted via blood transfusion a number of steps have been taken to minimise this risk, including: → from late 1999 onward, all donations have undergone removal of white cells (leucodepletion) in order to reduce any vCJD infectivity present →from 1999, plasma derivatives have been fractionated from imported plasma rather than being sourced from UK donors. Fresh Frozen Plasma (FFP) used for children and certain groups of adults needing frequent transfusions is also imported → from 2004 onward, recipients of blood components have been excluded from donating blood

Answer 18

an autosomal dominant ~50% of patients will have died from a gastrointestinal tract cancer by the age of 60 years. Features: * hamartomatous polyps in GI tract (mainly small bowel) * pigmented lesions on lips, oral mucosa, face, palms and soles * intestinal obstruction e.g. intussusception * gastrointestinal bleeding Management: conservative unless complications develop

General surgery Flashcards

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