General Surgery

Question 1

1: What is an abscess?

Answer 1

An abscess is a collection of pus (dead/dying neutrophils plus proteinacious material) walled off by a zone of acute inflammation.

Question 2

1a) What can cause an abscess?

Answer 2

Acute abscess formation particularly occurs in response to pyogenic organisms that attract neutrophils but are resistant to phagocytosis and lysosomal destruction.
Main pyogenic organisms of surgical relevance are staph aureus, strep pyogenes, e.coli, coliforms and bacteroides.
Abscesses can also form in response to localised tissue necrosis and organic foreign bodies like wood splints and linen sutures.

Question 3

1b) What are the symptoms and signs of an abscess?

Answer 3

localised inflammation- redness, heat, swelling and pain.
swinging fever- usually due to bacteraemia
fluctuant mass
lyphadenopathy

Question 4

1c) If investigations show leukocytosis with more than 80% neutrophils what does this indicate?

Answer 4

pyogenic cause

Question 5

1d) How do you treat an abscess?

Answer 5

Incision and drainage. If it is superficial a scalpel is used, if it is deep then US or CT guided percutaneous aspiration is conducted.

The abscess will be left open but covered with a wound dressing, so if any more pus is produced it can drain away easily. If the abscess is deep, an antiseptic dressing (gauze wick) may be placed inside the wound to keep it open and let it heal via secondary intention.

Surgery may be required if an internal abscess is too large and can’t be safely accessed.

Antibiotics is not indicated if abscess is fully formed.
If the abscess perforates then treat with IV vancomycin.

Question 6

2. What is cancer staging?

Answer 6

Cancer staging is the process of determining the anatomical location, size and extent of spread of the tumor or its malignant process.

The purpose is to:

• provide a description of the anatomic extent of a cancer that can be communicated to others
• assist in treatment decisions
• serve as an indicator of prognosis

Most widely used staging system is TNM.
T= depth of tumor invasion (1-4)
N= extent of nodal involvement (0-3)
M= presence of metastatic disease (0-1)
Once the TNM value is determined an overall stage is assigned.

Specific staging exists for some cancers e.g. Duke stage for colorectal cancer.

Question 7

2a) What is the difference between grading and staging?

Answer 7

Grading is the pathological assessment of a tumor to estimate the level of malignancy based on cytological differentiation and the mitotic activity of the tumor.
It is an indicator of how quickly a tumor is likely to grow and spread. Whereas, staging refers to the actual size and spread of a tumor.

Question 8

3. What modalities are used to stage cancer?

Answer 8

A range of investigations are used. This includes clinical exam, imaging. biochemistry and histopathology.

History and exam can be used to assess signs and symptoms of cancer and its progression. This includes the constitution symptoms like weight loss, fever, malaise, night sweats.
Furthermore, Hx and Ex can reveal evidence of organ dysfn- e.g. jaundice, SOB, changes in bowel, presence of mass.

Structural imaging can help detect the presence of tumors and extent of spread. This can include Xray (bone,lung), CT (tumor vasculature), US (breat,pelvic), MRI.

Functional imaging can detect the presence of metastatic disease in bone and soft tissue. E.g. PET Scan- only useful in metabolically active cancers.

Biochemical Ix such as tumor markers and physiological changes e.g. LFT change in liver cancer.

Histopathology allows for grading to assess the level of cellular differentiation. This includes biopsy and endoscopy.

Question 9

4. What is the purpose of “staging” a patient’s cancer?

Answer 9

Staging can guide management. It can help determine appropriate treatment option and approach. It can assist in identifying surgical candidate, whether there is a need for adjuvant therapy or palliative therapy is better recommended for the patient. Furthermore, it can prevent unnecessary treatment that would provide little benefit to the patient and their family. E.g. Stage IV is inoperable.

Staging can provide prognostic information via comparison to historical data to provide a 5 year relative survival rate.

Staging is used to better describe a cancer when communicating within a multidisciplinary team.

And finally, staging assists in cancer research as it proivdes information on the pattern of the cancer and can help determine eligibility for clinical trials.

Question 10

5. What is a neoplase? Give examples of benign and malignant neoplasms.

Answer 10

Neoplasia is any new and abnormal growth of tissue.

It is a result of unchecked cell proliferation due to a combination of genetic susceptibility and environmental exposures, that results in overactive growth pathways and underactive growth suppression pathways.

The division of neoplasms as benign or malignant is based on a judgement of histological pattern and the tumors clinical behavior.

Benign neoplasia are usually slow growing, well demarcated and encapsulated. They are histologically similar to the tissue of origin and remains localised at site of origin. Examples include fibroma (fibrous tissue), lipoma, adenoma (glandular tissue).

Malignant neoplasms are fast growing, poorly differentiated with an irregular outline and non-encapsulated. Histologically they range from well differentiated to anaplastic. They can present with pleomorphic nuclei and some tumors may have stromal hyperplasia. They are locally invasive and can metastasise.
Examples include; carcinomas (tumor of epithelial tissue), sarcoma (mesenchymal tissue), melanoma (melanocytes) and teratoma (cells from more than one germ layer).

Question 11

6. What is a fistula? Give some examples.

Answer 11

A fistula is an abnormal communication between 2 epithelial surfaces, such as two hollow organs or between a hollow organ and the exterior. The formation of a fistula generally requires inflammation and pressure.

Examples include:

• anal fistula- may be due to abscess rupture
• rectovaginal- due to trauma of childbirth of pelvic cancer treatment
• colovesical- between colon and bladder due to diverticulitis or chrons
• gastrocolic fistula- stomach and colon

Question 12

6a) what are some causes of fistulas?

Answer 12

• inflammation
• infection
• congenital
• iatrogenic- surgery/ radiation
• neoplastic
• trauma

Question 13

6b) what are some causes of a non-healing fistula?

Answer 13

F- foreign body
R- radiation
I- inflammation/infection
E- epithelialisation
N- neoplasia
D- distal obstruction

Question 14

How do you treat a fistula?

Answer 14

• treat any sepsis, fluid imbalance and poor nutrition
• analgesia
• relevant Abx
• good drainage to prevent fistula extension (seton stitch- material looped through the fistula which keeps it open and allows pus to drain out)
• biopsy fistula if indicated

Definitive treatment requires:

• excision of organ of origin or closure of site of origin
• removal of chronic fistula track and surrounding inflammaed tissue
• closure of organ if internal
• drainage of external site if skin

Question 15

7. What is a stoma?

Answer 15

A stoma is an artifical opening of an internal tube that has been brought to the surface.
They can be temporary or permanent.
Permanent stomas are necessary when there is no distal bowel segment remaining.
Temporary stomas are necessary for:
- emergency procedures (e.g. complete bowel obstruction that is about to perforate)
- defunctioning (e.g. to protect a distal anastamosis that is at risk of leakage or breakdown)
- bowel rest (e.g. to allow a distal segment of bowel/perineum to rest from inflammatory process).

Question 16

7a) What are some types of stomas?

Answer 16

• loop stoma- both proximal and distal segments of bowel drain to skin surface. Mainly used for temporary defunctioning.
• split or ‘spectacle’ stoma- defunctioning stoma but has been superceeded by loop stoma. Proximal and distal ends are brought to surface separately.
• end stoma- permanent stoma with the resite of the anus to the abdominal wall.
• Hartmann’s procedure- when primary anastomosis is inadvisable due to obstruction, inflammation, fecal contamination or surgical inexperience. Proximal end is end colostomy and distal end is stapled/sutured and rejoined later.

Question 17

8. What are the potential complications of a surgery?

Answer 17

• complications due to predisposing medical conditions
• anaesthetic complications
• general complications of operating- haemorrage, wound infection, unavoidable tissue damage, inadvertant tissue damage during surgery, impaired wound healing and dehiscence, incisional hernia.
• complications of any surgical conditions- resp complications e.g. pneumonia, atelectasis, ARDS.
  Venous thromboembolism- DVT/PE,
  renal impairment, ABx complications, pressure sores, fluid or electrolyte disturbances.
• complications can also be specific to a particular disorder or surgery.

Question 18

9. What are the risk factors for a superficial wound infection?

Answer 18

A superficial wound infection is one that occurs in 30 days of the surgery and involves only the skin and subcutaneous tissue ad at least one of:

• purulent discharge from surgical site
• purulent discharge from wound or drain placed in wound
• an organism isolated from aseptically obtained wound culture
• at least one sign of infection (redness, heat, pain ,swelling).

Risk factors can be classified into those relating to patients preoperative morbiditiy, intraoperative factors and post operative factors.

Preoperative include age, immunosuppression status, malnutrition, smoking, obesity, PVD

Intra-Op- contamination, poor aseptic technique, open procedures, duration of procedure, ABx prophylaxis adequacy, insertion of devices and blood transfusions.

Post Op- dressing and cleaning of wound, prolonged hospitalisation, glycemic control.

Question 19

10. How do you treat a superficial wound infection?

Answer 19

Inital step- perform primary survey to assess evidence for sepsis or heamodynamic compromise. If so refer to sepsis pathway.

If not, swab wound for microscopy,culture,screen and send bloods for FBC and culture before any ABx therapy.
Then open wound, irrigate and drain pus with 0.9%NaCl, apply a clean dressing and avoid topical ABx.

Relevant ABx can be provided if evidence of systemic involvement such as spreading cellulitis or sepsis.

Question 20

11. What are the principles of antibiotic prophylaxis for surgical patients?

Answer 20

The aim of appropriate antibiotic prophylaxis is to reduce post-operative infections without increasing antimicrobrial resistance.

It is based on three principles: indications, antibiotic selection and timeframe of administration.

Antibiotic prophylaxis should only be used if there is a significant risk of infection or if the post operative infection would have serious consequences.
Indications include:
- insertion of prosthesis or an artifical device like in hip replacements or heart valve replacement.

• clean-contaminated surgery site procedure (when an operative procedure enters into a colonized viscus or cavity of the body, but under elective and controlled circumstances) such as an appendiectomy or cholecystectomy.
• contaminated procedure such as a large bowel resection.

Antibiotic selection should be directed against most likely pathogen and should have a narrower range. The selection may need to be modified according to the patients risk factors (such as pre-exisitng infections, recent antimicrobial use, known colonisatin with multi-drug resistant organisms, prolonged hospitalisation or presence of prosthesis.)

The optimal time for preoperative IV antibiotic administration is within 60minutes before surgical incision. Vancomycin is an exception and needs to be given earlier as it can take an hour to infuse.

A repeat intraoperative dose is only required if the procedure is prolonged and the drug has a short half life.

Postoperative doses of IV ABx are only required in defined circumstances such as some cardiac and vascular surgeries and lower limb amputation.

Prophylaxis should not extend beyond 24 hours regardless of the procedure as extended prophylaxis is associated with an increased risk of adverse effects.

*First line is cephazolin 2g IV

Question 21

12. Why do surgical wounds fail?

Answer 21

Wound healing is achieved through four precisely and highly programmed phases: hemostasis, inflammation, proliferation, and remodeling. For a wound to heal successfully, all four phases must occur in the proper sequence and time frame. Many factors can interfere with one or more phases of this process, thus causing improper or impaired wound healing.

Surgical wound failure, or wound dehiscence, occurs when a wound fails to heal through the progressive stages of healing and possibly reopens after surgery.

Local factors that can affect wound healing include; poor oxygenation, infection, foreign body contamination, arterial or venous insufficiency, patient interference, unsuitable wound sutturing or dressing.

Systemic factors include; age, diabetes, ischemia, malnutrition, vit C or zinc deficiency, anaemia, immunosuppressive drugs or disease, lifestyle factors (like alcohol, smoking, IV drug use, neglect), autoimmune disorders like rheumatoid and collagen disorders like Marfans and cancer.

Question 22

110. How do you categorise abdominal pain?

Answer 22

I categorise abdominal pain based on anatomical location.

If it is right hypochondrium I am thinking of hepatobiliar causes like hepatitis, cholecystitis, cholangitis.

For epigastric, i’m thinking of GIT causes like gastritis, GORD, pancreatitis and cardiovascular conditions like atypical MI and AAA.

In the left hypochondrium I’d be thinking splenic complications like infarcts, abscess or rupture.

In the Right and left lumbar regions I’d be thinking of radiating spinal nerve pain, ureteric colic or pyelonephritis.

In the periumbilical region, I’d be thinking of small bowel obstruction, IBS, IBS, mesenteric ischemia and AAA.

In the right iliac fossa- appendicitis, chrons disease, caecal volvolus, ectopic pregnancy, pelvic inflammatory disease.

suprapubic- cystitis, urinary retention, gynaecological causes in females.

left iliac fossa- diverticulitis, sigmoid volvolus, colorectal cancer, impaction.

Question 23

111. Where is the appendix found?

Answer 23

The appendix is a vestigial structure located in the RIF, more specifically at McBurnys point which is 1/3 the distance from ASIS to the umbilicus.
Internally, it arises from the posteromedial aspect of the caecum and is approximately 2.5 cm below the ileocecal valve and the Tineae coli converge at base of appendix .
The base of the appendix is attached to the caecum but the tip is free to migrate allowing for variation in people- retrocecal, subcecal,other.

Question 24

112. When should you commence antibiotics in a patient who has symptoms and signs of appendicitis?

Answer 24

Surgical drainage and appendicectomy are the mainstays of treatment for appendicitis and antibiotic therapy remains only a bridge to surgery.
Therefore, antibiotics should be given only when the decision to operate has been made.
Empirical IV antibiotic is triple therapy which is the same as peritonitis due to perforated viscus. This includes Gentamicin, Amoxycillin and Metronidazole.

If it is uncomplicated appendicitis in surgery, then the antibiotics should be discontinued after the operation.

If the appendicitis is complicated by perforation or an abscess, then a total treatment duration of 7 days (IV + oral) is recommended.

Once susceptibility results are obtained, antibiotics should be modified appropriately.

Question 25

113. What are the important differential diagnoses to consider when managing a 17 year old woman who has the symptoms and signs of appendicitis?

Answer 25

The differential diagnoses to consider when managing this patient can be categorised into gyneacological and non gynaecological causes. ``` Gynaecological causes could include: - pelvic inflammatory disease which is usually bilateral but may mimic appendicitis if confined to right fallopian tube - Mittleschmerz from right ovary - ovarian torsion which presents with fever and leucocytosis and RLQ pain - endometriosis - STI - salphingitis AND ruptured ectopic pregnancy ``` Non gynaecological causes can include urological causes such as UTI, cystitis, pyelonephritis, renal colic and GIT causes such as gastroenteritis, new onset chrons disease.

Question 26

114. You (the candidate) are an Emergency Department resident. How would you proceed to manage a 22 year-old female patient who presents to you with a 24 hour history of right iliac fossa pain?

Answer 26

If the patient is stable I would take a history to assess the pain and associated symptoms, past medical history including medications and a focussed gynaecological history with appropriate questions about the patient's menstrual cycle, sexual history and pregnancy. On examination I'd assess the patient's vitals, conduct a focussed abdominal exam looking for any signs of peritonism and other abnormalities and a pelvic examination to look for any vaginal bleeding, adnexal tenderness or masses and cervical motion tenderness on bimanual palpation. To investigate further I'd order a FBC (leukocytosis), CRP, UEC, LFTs, Lipase (exclude pancreatitis), VBG (assess for sepsis), lipase, beta HCG and Group and Save if proceeding to surgery. I'd also consider a urine dipstick and urine MCS and stool culture if necessary. I'd consider a chest/abdo Xray if obstruction is suspected, Abdo Ultrasound for a dilated appendix or pelvic US for ectopics and other gynaecological suspicions AND CT abdoment if the pt is not pregnant and if it is indicated. In terms of management, IV access would be important for fluids, analgesia, nil by mouth, IV antibiotics if appendicitis is diagnosed and an appropriate surgical, gynaecological or gastro consult as indicated.

Question 27

115. What is the indication for imaging in suspected appendicitis?

Answer 27

Acute appendicitis is a clinical diagnosis, almost entirely made off history and examination. Imaging should only be used to exclude differential diagnoses and/ or confirm the diagnosis in atypical presentations. The Alvorado Score (MANTRELS) can be used to help guide clinical decisions. Plain Xray films are not indicated unless there is a concern for other pathologies such as an intestinal obstruction, renal calculi or perforated viscus. USS is indicated if there is a suspicion of gynaecological causes or if investigating an atypical presentation especially in pregnant women and young people where exposure to ionising radiation is to be avoided. CT is indicated if there is an atypical presentation of appendicitis in a pt, especially in the elderly and obese, that needs to be confirmed OR in determining alternative diagnoses.

Question 28

116. Why does the pain and discomfort of appendicitis classically ‘migrate’ from generalised abdominal pain to become localised in the RIF?

Answer 28

The mechanoreceptor and chemoreceptors located within the visceral peritoneum detect distention and inflammation due to appendicitis and this stimulus is carried along Type C nerve fibres within the paleospinothalamic tract to the CNS to produce poorly localised, central, dull, generalised pain. The pain presents with these features due to low nociceptor density, bilateral symmetric innervation of the visceral organs , C fibres being unmyelinated and the fact that pain is perceived at the spinal level at which the afferent fibers enter (T10-periumbilical.). As inflammation of the appendix extends to involve the parietal peritoneum there is stimulation of somatic nociceptor and the stimulus of pain is now carried along type A fibres via the neospinothalamic tract to the CNS. As the parietal peritoneum has higher nociceptor density, unilateral innervation and involvement of myelinated type A fibres the pain is now felt localised to the RIF and felt a lot sharper.

Question 29

117. What are the indications for a laparoscopic approach to appendicectomy?

Answer 29

Indications for a laparascopic approach to appendicectomy include: - uncomplicated appendicitis - uncertain diagnosis as it provides more visualisation - obese patients as open requires larger incision - elderly patients, children and patients with comorobities as it is less invasive and there is a faster recovery with a lower incidence of surgical site infection Contraindications include: - haemodynamic instability - lack of surgical expertise - generalised peritonitis - pregnancy - Severe abdominal distention that causes operative view obstruction or complicates abdominal entry and bowel manipulation - if there is known extensive adhesions due to multiple surgeries.

Question 30

118. What are the classical symptoms and signs of acute appendicitis?

Answer 30

classical symptoms include: - abdominal pain that starts of poorly localised, central and colicky which may then migrate to the RIF - anorexia and vomitting Classical signs include: - a fever usually between 37.3 and 38.5 - tacchycardia - abdominal tenderness (worse over mcburnys point) - Rovsings sign- palpation of LIF causes pain in RIF Depending on the position of the appendix you can also see: - Psoas sign - extending the right thigh as the patient lies on their left side and this elicits pain in right lower quadrant - Obturator sign – pain is elicited at the RLQ by internal rotation of the flexed right thigh - diarrhoea or bowel disturbances (if near the rectum) - urinary disturbances (if near bladder) - right costal margin pain (if there is a high retrocecal appendix) - if perforated then signs of peritonitis can be evident including rigidity, guarding and rebound tenderness

Question 31

119. What is a sentinel node biopsy in the management of breast cancer?

Answer 31

The sentinel nodes are the first site of lymphatic drainage from the breast, as such they are the most likely site of metastatic spread from a primary breast tumour. Sentinel Node Biopsy (SNB) involves identifying, excising, and histologically analysing the Sentinel Lymph Nodes for signs of metastatic spread to guide the need for further management. This technique has become the standard of care in the management of the axilla in patients with clinically node-negative disease. The aim is to identify the first node which drains the breast and the method involves radioactive isotope injection 12hrs prior to surgery, and blue dye injection at the start of surgery into the same quadrant as the tumor. The sentinel node is located during surgery with a gamma probe (Geiger counter) and then surgically visualised by the blue dye The blue nodes are excised and examined by a pathologist – this can be done by immediate frozen section, and if the nodes are positive, an axillary clearance can be completed.

Question 32

120. What is a hernia?

Answer 32

A hernia abnormal protrusion of viscus through an acquired or congenital area of weakness or defect in the wall it is contained in. Hernias are classified into: - abdominal wall hernias which include umbilical, epigastric, spigelian and incisional AND - groin hernias which include inguinal and femoral. Many hernias are asymptomatic, but some become incarcerated or strangulated, causing pain and requiring immediate surgery.

Question 33

121. What is the anatomical difference between an inguinal hernia and a femoral hernia?

Answer 33

Inguinal hernias arise from above the inguinal ligament and femoral hernias from below. Inguinal hernias can be either direct or indirect. Direct inguinal hernias protrude through the anterior abdominal wall via the Hesselbach's triangle and is located medially to the epigastric artery. Indirect inguinal hernias enter the inguinal canal at the deep inguinal ring and are located laterally to the inferior epigastric artery. The hernia may then pass inferomedially through the congenitally patent processes vaginalis to emerge via the superficial ring, which may extend into: o Scrotum in males o Labia majora in females Femoral hernias pass through the femoral ring and into the femoral canal which is located below the inguinal canal.

Question 34

121a) What are the borders of the inguinal canal?

Answer 34

anterior border is the external oblique aponeurosis, reinforced by the internal oblique muscle laterally posterior wall is the transversalis fascia laterally and conjoint tendon medially Superiorly is the transverse abdominus Inferior is the inguinal ligament

Question 35

121b) What are the borders of the Hesselbach's Triangle?

Answer 35

Medially is the lateral border of the rectus abdominus. Inferiorly is the inguinal ligament AND Laterally is the inferior epigastric artery.

Question 36

121c) What are the borders of the femoral canal?

Answer 36

Anteriorly is the Inguinal ligament Posteriorly is the Pectineal ligament and pectineus Medialy is the Lacunar ligament AND Laterally is the Femoral vein.

Question 37

122. On examination, what is the difference between an inguinal hernia and a femoral hernia?

Answer 37

On examination: - Inguinal hernias are most commonly found superomedial to the pubic tubercle. - Femoral hernias are typically found infero-lateral to the pubic tubercle (and medial to the femoral pulse). Inguinal hernias are more common in male and femoral hernias are more common in females. Inguinal hernias are larger, whereas femoral hernias are smaller and firmer. Femoral hernias are at high risk of strangulation and obstruction as the space it protrudes through is quite tight, and it is bordered medially by the sharp edge of the lacunar ligament.

Question 38

123. What is the importance of deciding whether a hernia is inguinal or femoral?

Answer 38

Femoral hernias have a higher rate of complication than inguinal hernias – they are more likely to become incarcerated/ strangulated Asymptomatic inguinal hernias may be managed by a watch and wait approach, but femoral hernias should be repaired without delay (as elective is better than emergency) Therefore, the type of hernia determines whether surgery is indicated when the patient is asymptomatic (the watch and wait approach) Indications for surgery: • Symptomatic hernia • Strangulated/ incarcerated hernia • Femoral hernia

Question 39

124. What is the difference between an incarcerated or irreducible hernia, and a strangulated hernia?

Answer 39

A reducible hernia can be pushed back into the right place. An irreducible hernia cannot be pushed back into the right place. This is not a problem for the patient per se but is at risk of causing problems. A hernia may be irreducible because it is: o Incarcerated: stuck in the abnormal position because either there are adhesions between the hernial sac and surrounding structures, or there are adhesions between structures within the sac such that the sac is now wider than its neck and no longer able to pass through the wall defect o Obstructed: the neck of the hernial sac provides an obstruction to the passage of flow through the bowel lumen (but the blood supply of the bowel is still intact) o Strangulated: if the bowel becomes so constricted by the neck of the hernial sac that the blood supply is compromised it is referred to as a strangulated hernia. This is a major problem for the patient as their bowel will necrose rapidly from ischaemia.

Question 40

125.A 75 year-old woman presents to the emergency department with a 24 hour history of vomiting and cramping abdominal pain. She has not passed flatus or stool for 24 hours. She has no relevant previous medical history. On examination, she has a distended abdomen, and a tender, red coloured lump in the right groin. What is the most likely diagnosis and what should be done to help this patient?

Answer 40

The most likely diagnosis is a Bowel obstruction secondary to strangulated femoral hernia. The strangulation is indicated by signs of tenderness and overlying erythema. The obstruction is indicated by distension, vomiting, cramping, abdo pain, constipation and obstipation. First thing I will do is a primary survey to assess if the patient is stable - ABCDE’s - A - B o Check RR, SpO2, ? supplemental O2 - C o Check HR, BP, peripheral perfusion (pallor, temperature, cap refill) o Establish IV access  Send bloods – FBC, UECs, G&S, coagulation studies • IV fluid resuscitation with crystalloids • Analgesia (opioid) • NBM • Anti-emetics (as needed) • NG decompression • Fluid balance chart • Consider urinary catheter • Urgent surgical repair of the hernia and resection of infarcted/ necrotic bowel o I would not try to reduce a painful incarcerated hernia if it has been present for > 4 - 6 hours, otherwise the infarcted/ necrotic bowel may perforated intraperitoneally

Question 41

126. What are the common causes of a lower GI bleed?

Answer 41

Lower GI bleeding is bleeding arising distal to the ligament of Trietz (duodenal-jejunal flexure). ``` Common causes include: • Diverticular disease • Polyps • Carcinoma • Haemorrhoids • Anal fissure • Angiodysplasia • Inflammatory Bowel Disease • Ischaemic Colitis • Infectious Colitis ```

Question 42

127. What are the signs and symptoms of a lower GI bleed?

Answer 42

``` • Haematochezia (maroon or bright red blood PR) • Melaena • Tachycardia • Hypotension (may be orthostatic) • Dizziness/ light-headedness • Chest pain/ SOB/ palpitation (due to anaemia) • Associated Symptoms: o Abdominal pain/ perianal pain o Change in bowel habits o Weight loss o Night sweats o Fevers o Abdominal masses ```

Question 43

128. What is the management of a lower GI bleed?

Answer 43

* Initial assessment and resuscitation * Exclusion of UGI bleeding and Evaluation of source of LGI bleeding via HISTORY AND EXAM * Definitive management of the cause Initial Assessment – ABCDE: • Assess vitals (HR, RR, BP, SaO2, Temperature) • Give supplemental oxygen if hypoxic • Gain IV access (2x Large Bore IV cannulas) and resuscitate with IV crystalloids • Alert ICU/ HDU if required • Bloods: VBG, FBC, UEC, Coagulation studies, LFT, CRP, Group and Hold (or X-match) • Consider the need for blood products to replace lost blood and correct for coagulopathy or thrombocytopaenia • Consider an IDC to monitor urine output • Keep patient NBM • NGT lavage to exclude UGI source of bleeding if moderate to low suspicion of UGI cause (proceed to endoscopy if there is a high suspicion of UGI causes) • Early contact with gastroenterology/ anaesthetics/ general surgery as appropriate Focussed history on bleeding • Associated dizziness or syncope • Other symptoms – pain (abdominal/ rectal), constipation/ diarrhoea, tenesmus, change in bowel habits, weight loss • PMHx – IBD, haemorrhoids, diverticular disease, Angiodysplasia, past colonoscopies? • Meds – aspirin/ NSAIDs, anticoagulants, recent Abx • lifestyle and recent travel Investigation/ Definitive management: • Bloods as listed above • Stool MCS (ova, cysts and parasites if associated with diarrhoea) * Anoscopy – to exclude simple anorectal causes * BUT MORE IMPORTANTLY the Colonoscopy – which requires bowel prep but bleeding can be controlled with cautery, injection of adrenaline, band ligation and/or haemoclips • Radiographic studies: o Radionuclide imaging (Technitium-99m labelled colloid or RBCs) o CT angiography o Mesenteric angiography (with embolisation) • IF it is an Emergency then Laparotomy is the way to go

Question 44

129. What is a Meckel’s Diverticulum?

Answer 44

It it the most common congenital malformation of the small bowel, in which there is an outpouching due to a failure of obliteration of the yolk stalk (normally disappears during embryonic life in the 5th-8th week of gestation). Rule of 2’s: • Occur in 2% of the population • 2% of cases become symptomatic • Most patients with a complication present in the first 2 years of life • Is 2 inches long (approx. 5 cm) • Located 2 feet proximal to the ileocaecal valve (approx. 60cm) • 2/3rd have ectopic mucosa • 2 types of ectopic tissue are commonly present (gastric and pancreatic)

Question 45

130. What symptoms can be caused by a Meckel’s diverticulum and why?

Answer 45

• Most patients remain asymptomatic • PR Bleeding (frank blood or occult blood): o Most common complication o Acid secreting gastric mucosa causes inflammation and ulceration of adjacent small bowel wall • Obstructive Symptoms (abdominal distension, Nausea/Vomitting, cramping periumbilical pain): o 2nd most common complication o Small Bowel Obstruction due to adhesions, volvulus, intussusception (if inverted), herniation, stricture formation- due to chronic inflammation, neoplastic obstruction • Abdominal Pain (epigastric migrating to the RIF): o Meckel diverticulitis due to a narrow neck and inflammation – mimic of appendicitis • Peritonism: o Due to perforation of the diverticulum

Question 46

131. What are the causes of an obstruction of a luminal structure (e.g the bowel, the ureter, biliary tree, or blood vessel)?

Answer 46

The causes of an obstruction can be either mechanical or functional. In mechanical obstructions, it can be classified as: Intraluminal - Impacted faeces - Stones (kidney, ureter, gallbladder) - Foreign objects (stents) - Thrombus or embolism Intramural - Malignancy - Stricture - Congenital atresia Extramural - Herniation - Adhesion - Volvulus - Tumour - Intussusception Functional causes of obstruction includes: - Paralytic ileus - Mesenteric vascular occlusion- loss of bowel fn due to ischemia - Pseudo-obstruction

Question 47

132. What are the signs and symptoms of a large, acute upper GI bleed?

Answer 47

Upper GI bleed is when there is haemorrhage in the GI tract proximal to the ligament of Treitz. Symptoms generally include: - Haematemesis, vomiting - Melaena - Haematochezia- fresh blood in stool - Symptoms of anaemia such asfatigue, dizziness, SOB, tachycardia - Altered consciousness Specific symptoms: - Peptic ulcer disease- epigastric pain, heartburn - Oesophageal varices- jaundice, anorexia, abdominal distention - Malignancy- weight loss, dysphagia Signs: - Haemodynamic compromise, deranged vitals, altered mental state - Signs of anaemia (cool extremities, pallor, tachycardia) - Blood on PR exam

Question 48

133. What is the treatment of an acute upper GI bleed?

Answer 48

Initial treatment: resuscitation (primary survey- airway and breathing maintained, IV access, fluids, analgesia, antiemetics, blood tests) + assessment (hx + exam + risk stratification using Glasglow Batchford score) Therapeutic endoscopy - Patient must be haemodynamically stable - Non-variceal - clips or thermal coagulation + adrenaline injection - Variceal- band ligation, transjugular intrahepatic portosystemic shunt (TIPS) Medical treatment - Non-variceal - PPI, reduces risk of re-bleed - Variceal - vasopressin, prophylactic antibiotics, somatostatin Surgical treatment - Indicated if endoscopic management fails, diagnosis under endoscopic approach is uncertain oR uncontrolled massive haemorrhage.

Question 49

134. What do you do as the intern if you think someone is having an acute UGI bleed?

Answer 49

Call for help from the team and conduct a primary survey and appropriate resuscitation, take a history, conduct an exam and order relevant investigations. If the bleeding is severe I would consider an urgent general surgical/ gastroenterology consult * Important to Assess vitals (HR, BP, RR, Temp, SaO2) to assess if patient is in shock? * Call for help early (ED/ ICU or MET) * Give supplemental oxygen if hypoxic * Gain IV access (2x large bore IV cannulas) and resuscitate with IV crystalloids • Initial investigations: o Bloods: VBG, FBC, UEC, LFT, Coagulations studies, CRP, group and hold (or X-match) o ECG and ?CXR • Consider the need for blood products to replace lost blood and correct for coagulopathy or thrombocytopaenia • Consider an IDC to monitor urine output • Keep patient NBM • Consider placement of NGT

Question 50

135. What are the risk factors contributing to the aetiology of a peptic ulcer?

Answer 50

Peptic ulcer is when there is an erosion or defect in the mucosa of the gastric or duodenal wall that extends to submucosa and muscular layer. It is caused when the acid secretion exceeds the defence mechanism (bicarbonate) which damages the mucosal layer. ``` Risk factors contributing to the aetiology of a peptic ulcer include: • Helicobacter Pylori infection • Aspirin/ NSAIDs use • Smoking • Alcohol • Overproduction of gastrin (Zollinger-Ellison syndrome) • Increasing age • Family History • Steroid use ```

Question 51

136. What are the initial investigations in the ED for a perforated ulcer?

Answer 51

The investigations Following Initial assessment with history, physical examination and resuscitation (as required) include: • Bloods: o VBG o FBC, UEC, LFT, Coags, CRP, Group and hold, lipase, blood cultures • Radiology: o Erect CXR (pneumoperitoneum) o CT abdo/pelvis may be used • Other: o ECG Endoscopy if you were unsure it was a perforation.

Question 52

137. What are the physical signs suggestive of a perforated ulcer?

Answer 52

- Involuntary guarding and rigidity (patient will be lying dead flat, with shallow breathing) - Generalised abdominal tenderness - Rebound tenderness (peritonism) - Absent bowel sounds - Abdominal distention - Signs of shock (tachycardic, hypotensive, febrile)

Question 53

138. What are the symptoms suggestive of a perforated peptic ulcer?

Answer 53

The symptoms mainly include: - Acute onset of severe pain starting in epigastric region that becomes generalised abdominal pain. - The pain may radiate to the shoulder due to diaphragmic involvement. - There may also be associated N/V/A - Haematemesis, melaena, haematochezia. - Symptoms of anaemia (fatigue, dizziness, SOB) If it becomes chronic, the pain might be similar to GORD with heartburn intermittently 2-5 hrs post prandial.

Question 54

139. What is the treatment for a perforated duodenal ulcer?

Answer 54

``` Initial Management: • ABCDE • Supplemental O2 • IV access: o Crystalloid resuscitation o Bloods: VBG, FBC, UEC, LFT, Coags, Group and Hold (? X-match) o Transfusion of blood products if required ``` * NBM * Analgesia (opioid) * Consider IDC (monitor urine output) * Consider NGT * Establish Diagnosis with: Erect CXR/ CT * IV PPI (pantoprazole) * Empirical Abx (triple therapy – ampicillin, gentamicin, metronidazole) * General Surgical Consult Definitive Management: • Surgical Management: o Duodenal perforation is repaired with simple closure by suturing a flap of omentum over the defect (“Graham patch”) – followed by H. Pylori eradication therapy ``` • Conservative Management: o For elderly/ unfit patients that present late and are unable to treated surgically o NGT aspiration o IV fluids o IV PPI o IV Abx (triple therapy) ```

Question 55

140. What are the common skin cancers?

Answer 55

The three main types of skin cancers are Basal cell carcinoma (BCC), Squamous cell carcinoma (SCC) and Melanoma, all these cancers arise from different cells of the epidermis (outer layer of skin). BCC - Is most common cancer of human, 70% of non-melanoma skin cancer. It is a locally invasive keratinocyte cancer from the basal cells of the epidermis. - Skin areas of sun exposed (head, face, neck, arm, shoulder etc) - Slow growing, over months to years - Rarely metastasises - If left untreated, can invade locally - Presents as pearl coloured lump, scaly area, may bleed SCC - 30% of non-melanoma skin cancer. It is an invasive cancer of the keratinocytes from the epidermis - Skin areas of sun exposed (head, face, neck, arm, shoulder etc) - > 90% of cases are association with mutations of p53 tumour suppressor gene - Fast growing, weeks to months - SCC in situ (Bowen disease) is early form of skin cancer but may become invasive SCC - More likely to metastasise especially on lips and ears - Presents as thickened red, scaly or crusted spot Melanoma - Less common than BCC, SCC. It is an invasive cancer of melanocytes - More likely to metastasise to lymph nodes, lungs, liver, brain, bones - Irregular shaped, dark, flat or raised spots - BCC and SCC can be managed with surgical incision which is gold standard. If present on the face, Moh’s micrographic surgery can be performed.

Question 56

143. What features of a mole on the skin would make you concerned that it had become malignant?

Answer 56

To access a skin lesion or mole, I would use the ABCDE approach which is checking for: - Asymmetry (vs symmetry) - Borders (irregular or bleeding) - Colour (multiple colours, variation) - Diameter (>6mm) - Evolving (change in size, colour shape)

Question 57

144. What are the principles of initial treatment of a mole on the skin that you are concerned may have undergone malignant change?

Answer 57

Initial treatment involves the confirmation of diagnosis with histological evaluation of a biopsy (this can be – total excision with a 3 -4mm margin, shave biopsy OR punch biopsy. If suspicious of melanoma perform total excision biopsy). The cancer will be then staged using Breslow’s thickness (if >1mm, sentinel node biopsy is considered but doens't have survival benefit it is just more accurate for prognosis. Risks to be discussed with pt). If skin cancer is confirmed, the lesion will be excised depending on extent and type. Wide local excision to appropriate margins Staging and adjuvant therapy may be required for late stage cancers (III,IV) – chemotherapy, radiotherapy, excision of metastasis. Patient education should also be considered regarding regular skin checks, sun safety and follow ups.

Question 58

145. What is a volvulus of the colon?

Answer 58

A condition in which the bowel becomes twisted on its mesentery, causing partial or complete obstruction and vascular compromise o The sigmoid colon is the most commonly affected due to its long mesentery o The second most common is the caecum Patients with a longstanding history of chronic constipation are at higher risk as the colon becomes elongated and atonic. Occasionally a huge sigmoid loop loaded with faeces and gas becomes twisted on the mesenteric pedicle and produces a closed loop obstruction. The obstruction leads to venous congestion, oedema, strangulation, gangrene and eventually perforation with faeculent peritonitis. Clinical presentation includes: o Abdominal distension o Variable abdominal pain (central and colicky) o Obstipation o Tympanic abdomen o Nausea (maybe vomiting) o If infarct or necrosis the pt will present with severe pain, shock, tachycardia, peritonism/ rebound tenderness and fever Investigations to consider are AXR, CT, FBC, UEC, LFT, VBG, CRP.

Question 59

146. How is a sigmoid volvulus treated (after initial history, examination and investigation)?

Answer 59

Initial management should be primary survey to stabilise the patient (ABCDE) - Airways - O2 - IV access (fluids, antibiotics if perforated, analgesia, blood tests, antiemetics) - NBM * A sigmoidoscope is gently passed as far as possible into the rectum and a flatus tube inserted into the scope * The flatus tube is then gently manipulated through the twisted bowel * If successful there is a gush of liquid faeces and flatus, relieving the obstruction * The flatus tube is left in situ for 24hrs to maintain decompression, discourage re-twisting and allow recovery of the vascular supply to the bowel wall. If the volvulus cannot be released, operative management is performed urgently. Hartmann’s procedure or primary anastomosis

Question 60

147. Refer to Photograph - This 18 year-old man has this lump in his groin. 1. What is the most likely diagnosis? 2. What are the differential diagnoses?

Answer 60

Most likely is an indirect inguinal hernia- which is the passage of abdominal contents , often including bowel through the inguinal canal towards the scrotum ``` Differential Diagnoses: • direct hernia • Femoral Hernia • Inguinal Lymphadenopathy • Saphena Varix- dilation of saphenous vein superficial to deep fascia before it enters femoral vein. • Femoral Artery Aneurysm • Psoas Abscess ```

Question 61

148. Refer to Photograph - This 18 year-old man has this lump in his groin. It is a hernia. What is most likely to be in the hernia?

Answer 61

Contents of hernia can include:  Preperitoneal fat  Peritoneal fat (e.g. mesenteric fat, omental fat etc.)  Small Bowel loops  Mobile large bowel (sigmoid, caecum, appendix)  Rarely other structures – bladder etc. * Most direct hernias do not have a true peritoneal lining (i.e. they have a pseudo-sac formed from the transversalis fascia) and do not contain bowel. They usually contain preperitoneal fat and occasionally bladder * Indirect hernias have a peritoneal sac (i.e. patent processus vaginalis) and most commonly contain mesenteric fat but may also contain small bowel loops or mobile colon segments (sigmoid, caecum, appendix) * Femoral hernias also have a protrusion of peritoneal sac and may contain pre-peritoneal fat, omentum or mesenteric fat, small bowel and rarely other structures.

Question 62

149. What are the common methods of repairing an inguinal hernia in a fit 18 year-old?

Answer 62

If the hernia is asymptomatic, non-complicated, (active infection are contraindications for surgery) it can be managed conservatively, ‘watch and wait’ with elective surgery. Inguinal hernia is less likely to strangulate than femoral (indirect>direct), only 5% becoming incarcerated within next 2 years. Indications for surgery are if they are symptomatic, incarcerated and/or strangulated. The surgical options can be either open or laparoscopic. Both have similar recurrence rate, laparoscopic less likely to damage testicular vessels and ilioinguinal nerves. Open: - More commonly used for inguinal hernia. - May or may not use mesh Laparoscopic: - Indicated for bilateral, recurrent, femoral hernias - Total extraperitoneal surgery (TEPS), more commonly used - Transabdominal pre-peritoneal surgery (TAPS) is another method Prophylactic antibiotics if mesh repair is being done with augmentin IV

Question 63

150. What are the common complications of an inguinal hernia repair, and what are the serious complications of this operation?

Answer 63

Some of the common complications include: - Scrotal haematoma - Seroma formation - Infection of wound site/mesh - Recurrence Serious complications include: ``` Short term - Urinary retention - Division of vas deferens - Visceral and vascular damage - Bowel obstruction - Ischemic orchitis Long term - Mesh rejection/migration/erosion - Dysejaculation - Pelvic adhesion ```

Question 64

151. Refer to Photograph - What is the most significant abnormality in this photo (the photo is a lump in the neck of a 70 year-old man). Where, anatomically, is it, what is the differential diagnosis?

Answer 64

The lump can be classified as anterior triangle or posterior triangle lump. The borders for each triangle: - Anterior = Inferior ramus of the mandible, anterior border of SternoCMastoid, and the midline of the anterior neck - Posterior = posterior border of SternoCleidoMastoid, superior border of the clavicle, and the anterior border of trapeziu DDx: Lymphadenopathy - Infectious  Viral (EBV)  Bacterial (tonsillitis) - Malignant  Lymphoma  Metastasis from local cancer (oropharyngeal, skin, throat) Infectious abscess (dental) Thyroid - Infectious (thyroiditis) - Inflammatory (Grave’s, Hashimoto’s) - Cancer Salivary gland - Stone - Infection - inflammation - Cancer (adenoma, carcinoma) Skin - Benign (keratocanthoma, subcutaneous cyst) - Malignant (BCC/SCC/melanoma) Congenital - Thyroglossal cyst - Branchial cyst - Cystic hygroma

Question 65

152. What specific history and examination will you perform for a 70 year-old man who presents with a lump in the neck that is clearly not in the thyroid or other midline structures?

Answer 65

In adults >40, up to 80% of the lumps are malignant. Hence, if no signs of infection, it is lymphadenopathy due to malignancy (commonly metastasis from SCC) until proven otherwise. In history: - Onset and duration of the lump - Growth of the lump - Painful? - Other lumps or previous lumps - Symptoms of infection (malaise, fever, cough, dental pain etc) - Symptoms of cancer (weight loss, fatigue, night sweats, difficulty swallowing/speaking/breathing, any bloody discharge) - Past history of cancer, autoimmune conditions - Family history of cancer - Social (smoking, alcohol, recent travel, sun exposure) O/E: - Location - Tenderness - Characteristics (tender or warm/ solid or fluctuant/ pulsatile/ mobile) - Examination of mouth and throat - Examination of skin (head and neck) - Palpation for lymph nodes, salivary glands

Question 66

260. This man has complained about a swelling at his umbilicus. Q1. What can you see and what is the diagnosis? Q2. What is the likely contents? Q3. What is the risk of serious complications with this hernia as it stands. Q4. What would be the correct approach if this were to become acutely painful and incarcerated?

Answer 66

1: umbilical hernia 2: peritoneal fat, omentum, small bowel 3: incarceration/strangulation which leads to ischemic necrosis and bowel obstruction 4: Initial approach is resuscitation (ABCDE). If painful and incarcerated (irreducible) or strangulated, urgent surgery should be considered for hernia repair (laparoscopic or open withh tension free mesh or suturing)

Question 67

263. This is the laparoscopic view of the lower abdomen. Q1. What is visible here? Q2. How can the bowel be injured at laparoscopy and what are the consequences?

Answer 67

1. Lower abdomen organs: - Omentum, mesentery - Large/small bowel, sigmoid, rectum, appendix - Ureters - Uterus, fallopian tube, ovaries 2. Bowel injuries: - Thermal injury from cautery - Mechanical injury from dissection/manipulation - Perforation with placement of trocar or pneumoperitoneum needle ``` Consequences can include: • Necrosis • Perforation • Peritonitis • Sepsis • Haemorrhage • Death ```

Question 68

268. This patient has become aware of a skin abnormality for years that has developed hair growth during adolescence. Q1. What is the abnormality? Q2. What is it's significance? Q3. What treatment is needed?

Answer 68

1. The abnormality is an Accessory Nipple One of its primary features is that is occurs along the milk line Significance: - It is usually benign with no pathological significance - They can be affected by hormonal changes which may cause them to enlarge or develop hair growth - They can undergo similar diseases to normal breast tissue incl. fibroadenoma, adenoma, abscess, mastitis, breast ca. - It can be related to a congenital condition e.g. Pollands syndrome, Hay-Wells syndrome Mx: - Usually not required - Surgical removal can be considered for cosmetic purposes or if there significant discomfort from lactation or tenderness

Question 69

270. This is the abdominal photograph of an 80 year-old woman who presents with a painful lump in the right groin. She has had it for 24 hours. Q1. What could it be? She has had generalised colicky abdominal pain from about 12 hours and some vomiting. Q2. What is the most likely diagnosis here? Q3. What is the most appropriate treatment strategy?

Answer 69

``` 1. It could be: • Inguinal Hernia • Femoral Hernia • Inguinal lymphadenopathy • Saphena Varix • Psoas Abscess • Femoral aneurysm • Infected Sebaceous Cyst ``` 2. Dx: Femoral hernia likely incarcerated 3. Initial Resusitation with primary survey - A - B o Supplemental O2 - C o IV access  ABG, FBC, UEC, G&S, coagulation studies  IV fluids  Analgesia  Anti-emetics - Consider: o NG Tube decompression o IDC o NBM • Urgent surgical repair of the hernia and resection of infarcted/ necrotic bowel o Note: do not try to reduce a painful incarcerated hernia if it has been present for > 4 - 6 hours, otherwise the infarcted/ necrotic bowel may perforate intraperitoneally

Question 70

276. This lady had a swelling on the back of her lower neck. It has been present for years. It had slowly enlarged over that time and is producing no other symptoms. Q1. What is the most likely diagnosis? Q2. What tests other than physical examination are likely to be helpful. Q3. What are the common complications of operative removal of this?"

Answer 70

1. The most likely diagnosis is subcutaneous lipoma, ddx of sebaceous cyst, but no punctum (small opening) seen in picture. 2. Useful tests - USS (can differentiate fat and fluid easily) - Biopsy/ FNA - MRI or CT if there is concern about liposarcoma 3. Complications of removal include: - infection - seroma formation - haematoma - scarring

Question 71

277. A 65 year-old woman presents to the ED with vomiting, abdominal distension and colicky pain. She has never had an operation. She has a CT scan. Q1. What does this show? Q2. What does the surgical registrar do the minute he sees this scan? Q3. What does he find? Q4. What is the treatment?

Answer 71

1. Likely diagnosis is a femoral hernia 2. The surgical reg would clinical examine the minute he see the scan this is to distinguish if it is irreducible, incarcerated or strangulated. 3. Findings may present as: - Erythematous, tender mass that is irreducible - May have colour changes - Patient may have bowel obstruction symptoms 4. The treatment is urgent surgery for hernia repair. Until then it is important to primary survey and ensure pt is stable and resuscitate accordingly and also decompress using an NG tube.

Question 72

279. Q1. What is the massive transfusion protocol? Q2. In what circumstances should it be used? "

Answer 72

A Massive Transfusion Protocol is a standardised procedure that, once activated by a senior clinician, allows rapid availability of blood products from the blood bank A Massive Transfusion Protocol should be used in critically bleeding patients anticipated to require massive transfusion When the bleeding is controlled the bank is notified to “cease the MTP” Massive transfusion is defined as: • Replacement of > 1 blood volume in 24 hours • > 50% of blood volume in 4 hours (adult blood volume is approx.. 70mL/kg) 2. Indications include: - Trauma – particularly to thoracic, abdominal, pelvic or long bones - Major obstetric, GI or surgical bleeding - Actual or anticipated loss of 3 units of RBC in <4hrs - Hemodynamically instabiliry OR - anticipated ongoing bleeding EXTRA: In patients who have lost significant amounts of blood, they often have developed a coagulopathy, as they have used all their platelets/fibrinogen/clotting factors in an attempt to stop the bleeding. If fluids/RBCs given alone this could aggravate the situation, hence MTP is used. Consist of: - 4 units packed cells - 4 units fresh frozen platelets (FFP) - 1 unit packed platelets - 5 packs cryopecipitate (prepared from plasma and contains fibrinogen, von Willebrand factor, factor VIII, factor XIII, and fibrinogen)

Question 73

280. A 75 year-old lady was admitted with abdominal pain and vomiting, this Xray was taken. Q1. What are the possible causes of her small bowel obstruction? Q2. What are the priorities in managing her in the ED?

Answer 73

1. Causes of Small Bowel Obstruction: ``` • Intramural: o Tumours o Strictures o Intussusception o Volvulus ``` • Extraluminal: o Adhesions o Hernia’s o Tumours (causing compression of the bowel) • Intraluminal: - Impacted faeces - Gallstone ileus - Intersusseption Note: adhesions and hernia’s are the most common causes ``` 2. The priorities in managing her in ED include: • ABCDE approach • NG tube for decompression • IV access for fluid resuscitation (crystalloids) • Analgesia (opioid) • Anti-emetics if needed • O2 supplementation if hypoxic • Early surgical consultation • NBM • Blood: FBC, UEC, VBG, group and save ```

Question 74

288. Refer to Photograph Q1. What is this structure and what operation is being attempted? Q2. What symptoms would this patient have presented with? Q3. What is the modern management of this condition?

Answer 74

1. Inflammed gallbladder in a cholecystitis ``` 2. • RUQ pain that radiates to the right flank • Anorexia • Nausea /vomiting • Diaphoresis • Fever • Tachycardia • Guarding/ rebound tenderness in the RUQ • Murphy’s sign positive ``` 3.Modern Management is supportive treatment and laporascopic cholecystectomy with 48 hrs. Supportive treament includes: • NBM • IV fluids (crystalloids) • Analgesia • Consider IV Abx (Ampicillin + Gentamicin) The treatment is, however, under contention as to whether a laporascopic cholecystectomy on admission improves morbidity compared to it being done 3mo after.