1
Q
go%
anal fissures in
A
posterior midline
2
Q
Acute Anal fissure
A
< 6 wks
3
Q
. If symptoms persist > 1 week anal fissure
A
1st line: Topical 0.4% glyceryl trinitrate (GTN) ointment BD for 6–8 weeks.
Side effect: Headache (~25% patients).
4
Q
If no significant improvement: anal fissure after GTN
A
Second-line: Topical diltiazem 2%.
Referral to colorectal surgery.
5
Q
Secondary Care Options fissure
A
Botox
Lateral internal sphincterotomy (
6
Q
Rovsing’s sign:
A
RIF pain on palpation of the LIF.
7
Q
Psoas sign:
A
RIF pain when extending the right hip (retrocaecal appendix).
8
Q
Appendicitis . Imaging
A
Ultrasound: 1st line in children and pregnant patients to avoid radiation.
CT abdomen/pelvis: High sensitivity and specificity for diagnosis.
9
Q
Acute Mesenteric Ischaemia Risk factors:
A
Atrial fibrillation, smoking, vasculopathy.
10
Q
Investigations Acute Mesenteric Ischaemia
A
Triple-phase CT scan with IV contrast.
11
Q
Severe abdominal pain, out of proportion to clinical findings.
A
Acute Mesenteric Ischaemia
12
Q
Gut angina
A
Ischaemic pain postprandially due to increased metabolic demand after meals.Atherosclerosis of coeliac trunk, SMA, or IMA causing gradual arterial narrowing <
Chronic Mesenteric Ischaemia
13
Q
(gold standard for diagnosis).Chronic Mesenteric Ischaemia
A
CT angiography
14
Q
Acute onset cramping abdominal pain.
Haematochezia (bloody diarrhoea).
A
?🧬 Ischaemic Colitis
15
Q
AXR: may show thumbprinting, mural thickening.
A
🧬 Ischaemic Colitis
16
Q
PR bleeding with colicky pain in a patient post colonoscopy/with sepsis/HF =
A
think ischaemic colitis.
17
Q
4 Cardinal signs of bowel obstruction:
A
abdominal pain, distension, vomiting, and complete constipation.
18
Q
Causes differ between small and large bowel obstruction:
A
SBO: adhesions/strictures/hernias(IBD)(post-operative)
LBO: colorectal cancer/volvulus.diverticular disease
19
Q
High-pitched ‘tinkling’ bowel sounds Tympanic percussion
A
Bowel Obstruction
20
Q
3-6-9 Rule”:
A
AXR (abdominal X-ray):
“3-6-9 Rule”:
Small bowel > 3 cm
Large bowel > 6 cm
Caecum > 9 cm
21
Q
Valvulae conniventes
A
Small Bowel (lines cross full width of bowel).
22
Q
Gold standard for diagnosis. Bowel Obstruction
A
CT Abdomen with Contrast:
23
Q
Bowel Obstruction Mx
A
Initial:
NGT (nasogastric tube) decompression (‘drip and suck’).
IV fluids and electrolyte correction.
Conservative: Stable patients without signs of peritonitis or ischaemia.
Surgical: Indicated for intestinal ischaemia, perforation, closed-loop obstruction.
24
Q
Peripheral loops + haustra =
A
LB O
25
Risk factors:Diverticular Disease
Obesity
Advancing age
Low dietary fibre intake
Constipation
26
Diverticula associated with symptoms
Diverticular disease:
27
Inflammation of diverticula, often due to microperforation.
Diverticulitis
28
Severe lower abdominal pain, classically sharp and localised to the left iliac fossa (LIF
Acute Diverticulitis
29
First-line imaging Diverticulitis
: CT abdomen-pelvis.
Findings: mural thickening of the colon, pericolic fat stranding, possible abscess formation.
30
Management Acute Diverticulitis
Admit if:
Systemically very unwell
Evidence of complicated diverticulitis (abscess, perforation, sepsis).
Primary care management (mild cases):
PO antibiotics:
1st line: Co-amoxiclav 625 mg TDS for 5 days (NICE recommendation).
Penicillin allergy: Cefalexin 500 mg TDS + Metronidazole 400 mg TDS for 5 days.
31
antibiotics Acute Diverticulitis
1st line: Co-amoxiclav 625 mg TDS for 5 days (NICE recommendation).
Penicillin allergy: Cefalexin 500 mg TDS + Metronidazole 400 mg TDS for 5 days.
32
LIF pain +/- PR bleeding + systemic upset =
think diverticulitis.
33
Topical Treatments haemorrhoids
Steroid + local anaesthetic preparations (e.g., hydrocortisone + lidocaine).
34
Secondary Care Options haemorrhoids
Non-Surgical:
Rubber band ligation – often used 1st-line for 1st/2nd-degree haemorrhoids.
Surgical:
Haemorrhoidectomy – reserved for more severe or persistent cases.
35
NICE CKS - “best available outpatient treatment”haemorrhoids
Rubber band ligation
36
first-line for non-prolapsing or reducible haemorrhoid
Rubber band ligation
37
Borders Inguinal Canal
Roof: Transversus abdominis/internal oblique.
Anterior: External oblique aponeurosis.
Floor: Inguinal ligament.
Posterior: Transversalis fascia.
38
Contents Inguinal Canal
Males: Spermatic cord.
Females: Round ligament.
Ilioinguinal nerve and genital branch of genitofemoral nerve.
39
Investigations hernia
Clinical diagnosis.
Ultrasound if uncertain.
40
lateral to inferior epigastric artery.
Indirect hernia =
41
higher risk of strangulation.
Femoral hernias
42
Aetiology Paralytic Ileus
Post-operative (especially after abdominal surgery).
Intra-abdominal sepsis.
Electrolyte imbalance.
Drugs (e.g., opioids).
43
Investigations Paralytic Ileus
Contrast-enhanced CT abdomen to exclude mechanical obstruction.
44
Pseudo-obstructionAetiology
Electrolyte disturbances (hypomagnesaemia, hypokalaemia, hypercalcaemia).
Drugs (opiates, anticholinergics).
Post-operative states.
Severe systemic illness.
45
Pseudo-obstructionMost commonly affects
caecum and ascending colon.
46
dilatation of colon without a transition point
Pseudo-obstruction
47
If conservative measures fail:Pseudo-obstruction
Endoscopic decompression with flatus tube via flexible sigmoidoscopy.
48
Massive colonic dilatation + no transition point on CT, electrolyte imbalance =
think pseudo-obstruction.
49
IGETSMASHED
Acute Pancreatitis
Idiopathic
Gallstones
Ethanol (alcohol)
Trauma
Steroids
Mumps
Autoimmune (e.g., SLE, Sjögren’s)
Scorpion sting
Hypercalcaemia
ERCP
Drugs (NSAIDs, azathioprine, furosemide)
50
Drugs causing Acute
Pancreatitis
NSAIDs, azathioprine, furosemide)
Mesalazine
51
Cullen’s sign
periumbilical bruising
52
Grey-Turner’s sign (
flank bruising).
53
Imaging Acute Pancreatitis
Ultrasound abdomen (identify gallstones).
Contrast-enhanced CT (assess for oedema/necrosis).
54
Modified Glasgow Criteria (PANCREAS):3 or more = severe pancreatitis (needs HDU care).
Risk Scoring
PaO2 < 8
Age > 55
Neutrophils > 15
Calcium < 2
Renal (Urea > 16)
Enzymes (AST > 200 or LDH > 600)
Albumin < 32
Sugar > 10
55
Antibiotics in Pancreatitis
only if pancreatic necrosis/infection.
56
Persistent inflammation >1 week post-onset. Pancreatitis
Pancreatic Necrosis
57
Pancreatic Necrosis Mx
prophylactic antibiotics to prevent secondary infection.
58
Pancreatic Pseudocysts Mx
Conservative (most resolve).
Drainage if persists >6 weeks or symptomatic.
59
Chronic PancreatitisClinical Features
Chronic epigastric pain, worst post-prandially (15 min after meals).
Steatorrhoea (exocrine insufficiency).
Diabetes mellitus (endocrine insufficiency).
60
Investigations Chronic Pancreatitis
Amylase/lipase often normal.
Low faecal elastase (diagnostic of exocrine insufficiency).
Imaging:
AXR: pancreatic calcifications.
CT: atrophy, calcification, pseudocysts.
61
faecal elastase
Low faecal elastase (diagnostic of exocrine insufficiency). Chronic Pancreatitis
62
Management Chronic Pancreatitis
Lifestyle modification (alcohol cessation, smoking cessation).
Exocrine supplementation:
CREON (pancreatin) 50,000 units with meals + 25,000 with snacks.
Analgesia.
Control diabetes if present.
63
Post-prandial pain + DM + Steatorrhoea =
think chronic pancreatitis
64
bruising signs reflect
retroperitoneal haemorrhage secondary to pancreatic necrosis.
65
first-line treatment for grade II–III haemorrhoids
Rubber ligation
66
Ogilvie’s syndrome
acute colonic pseudo-obstruction
67
Pregnancy haemorrhoids common in
the third trimester.
68
Ascending cholangitis is a bacterial infection (typically
E. coli
69
Management Ascending cholangitis
intravenous antibiotics
endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction
70
Indications for thoracotomy in haemothorax
include >1.5L blood initially or losses of >200ml per hour for >2 hours
71
Tension pneumothorax worsens with
positive-pressure ventilation — decompress urgently.
72
Urinary catheter: avoid if
urethral injury suspected (blood at meatus, high-riding prostate, perineal haematoma).
73
Nasogastric tube: contraindicated in
basal skull fracture — use orogastric tube.
74
Tracheobronchial injury Persistent air leak, surgical emphysema →
urgent bronchoscopy ± surgical repair.
75
Aortic transection
perform CT angiography → endovascular repair (TEVAR).
76
Diagnostic Peritoneal Lavage/Aspiration (DPL/DPA)
For unstable patients when FAST inconclusive; highly sensitive for intra-peritoneal bleeding but misses retroperitoneal injury.
77
if urethral injury suspected.
Retrograde urethrography
78
Mirizzi syndrome
gallstone becomes impacted in the cystic duct or Hartmann's pouch and causes extrinsic compression of the common hepatic duct.
obstructive jaundice with a cholestatic picture on liver function tests - significantly elevated bilirubin and alkaline phosphatas
79
acalculous cholecystitis in immunosuppressed patients
it may develop secondary to Cryptosporidium or cytomegalovirus
80
Liver function tests . Acute cholecystitis
Normal
81
Investigation Acute cholecystitis
ultrasound is the first-line investigation of choice
if the diagnosis remains unclear then cholescintigraphy (HIDA scan) may be used
82
Treatment Acute cholecystitis
intravenous antibiotics
cholecystectomy
NICE now recommend early laparoscopic cholecystectomy, within 1 week of diagnosis
83
most common cause of symptomatic lower gastrointestinal haemorrhage in older patients
Colonic diverticular bleeding
84
sudden onset, painless, brisk bright red rectal bleeding with large volume blood loss.
Colonic diverticular bleeding
85
most common cause of blood loss from the lower GI tract overal
Colorectal carcinoma is
86
Fitz-Hugh-Curtis syndrome
perihepatitis, an inflammation of the liver capsule associated with pelvic inflammatory disease (PID).
87
Caecal, ascending or proximal transverse colon Type of resection nd and Anastomosis
Right hemicolectomy
Ileo-colic Anastomosis
88
Distal transverse, descending colon Type of resection
Left hemicolectomy
Anastomosis Colo-colon
89
Sigmoid colon Type of resectionAnastomosis
High anterior resection Colo-rectal Anastomosis
90
Upper rectum Type of resectionAnastomosis
Anterior resection (TME) Colo-rectal Anastomosis
91
Low rectum Type of resectionAnastomosis
Anterior resection (Low TME)Colo-rectal
(+/- Defunctioning stoma) Anastomosis
92
Anal verge crc Type of resectionAnastomosis
Abdomino-perineal excision of rectum No Anastomosis
93
Chemotherapy crc
FOLFOX and FOLFIRI
Bevacizumab (anti-VEGF) and Cetuximab (anti-EGFR), particularly for metastatic disease
94
Hartmann's procedure.
resection of the sigmoid colon is performed and an end colostomy
95
In an emergency setting, if a colonic tumour is associated with perforation
the risk of an anastomosis is greater --> end colostomy
96
After 24 hours burns injury
Colloid infusion is begun at a rate
Maintenance crystalloid (usually dextrose-saline)
0.5 ml x(total burn surface area (%))x(body weight (kg))
1.5 ml x(burn area)x(body weight)
97
organ rejection
Hyperacute
immediately through presence of pre formed antigens (such as ABO incompatibility
98
organ rejection
acute
during the first 6 months and is usually T cell mediated. Usually tissue infiltrates and vascular lesions.
99
Chronic organ rejection
after the first 6 months. Vascular changes predominate.
100
Rigler's sign
double wall sign)pneumoperitoneum
101
Drugs causing Pancreatitis
azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, sodium valproate
102
key consideration when classifying a case of pancreatitis by severity
presence of any systemic or local complications
103
Mild acute pancreatitis is defined as
with no organ failure, local or systemic complications which usually resolves within 1 week.
104
Severe acute pancreatitis is present when
there is organ failure for over 48 hours.
105
moderately severe acute pancreatitis
transient organ failure, local complications or exacerbation of the patient's existing co-morbidities
106
Nutrition in avute Pancreatitis
patients should not routinely be made 'nil-by-mouth' unless there is a clear reason e.g. the patient is vomiting
enteral nutrition should be offered to anyone with moderately severe or severe acute pancreatitis within 72 hours of presentation
parental nutrition should only be used if enteral nurition has failed or is contraindicated
107
Antibiotics in acutely Pancreatitis
'Do not offer prophylactic antimicrobials to people with acute pancreatitis'
potential indications include infected pancreatic necrosis
108
Patients with obstructed biliary system due to stones should undergo
early ERCP
109
Hypertriglyceridaemia-induced pancreatitis
IV insulin infusion (enhances lipoprotein lipase activity).
plasmapheresis in refractory cases with very high triglyceride levels.
long-term lipid-lowering therapy and strict dietary modification.
110
Post-ERCP pancreatitis
managed similarly to other acute cases, but rectal NSAID prophylaxis (e.g. indomethacin) is often used peri-procedurally in high-risk patients.
111
Autoimmune pancreatitis.
steroid-responsive, associated with IgG4-related disease
112
Haemorrhoids Location:
3, 7, 11 o'clock position
113
Anal fissureLocation
: midline 6 (posterior midline 90%) & 12 o'clock position.
114
Chronic fissure > 6/52: triad:
Ulcer, sentinel pile, enlarged anal papillae
115
Proctitis Causes
Crohn's, ulcerative colitis, Clostridioides difficile
116
Ano rectal abscess causative
E.coli, staph aureus
117
Ano rectal abscess position
Perianal, Ischiorectal, Pelvirectal, Intersphincteric
118
Goodsalls rule
determines location
Anal fistula
Intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric
119
Anal neoplasm commonest
Squamous cell carcinoma
unlike adenocarcinoma in rectum
120
Solitary rectal ulcerHistology
mucosal thickening, lamina propria replaced with collagen and smooth muscle (fibromuscular obliteration)
Associated with chronic straining and constipation.
121
Other than alcohol, causes for chronic Pancreatitis include:
genetic: cystic fibrosis, haemochromatosis
ductal obstruction:
122
episodic epigastric pain relieved by eating, which is characteristic
duodenal ulcer.
123
epigastric pain worsened by eating
Gastric ulcers:
124
Faecal Immunochemical Test (FIT) screening
national screening programme offering screening every 2 years to all men and women aged 50 to 74 years. Patients aged over 74 years may request screening
125
may be used to monitor for recurrence in patients post-operatively or to assess response to treatment in patients with metastatic disease
Carcinoembryonic antigen
126
The Department for Work and Pensions recommend that following an open repair patients return to non-manual work after
2-3 weeks and following laparoscopic repair after 1-2 weeks
127
most commonly injured in hernia repair
ilioinguinal nerve is the most commonly injured and may lead to numbness or tingling over the superomedial thigh, base of penis, or anterior scrotum/labia
128
Pseudocysts typically occur when where
2-4 weeks or more after an attack of acute pancreatitis
Most are retrogastric
129
PseudocystsTreatment
Investigation is with CT, ERCP and MRI or endoscopic USS
Symptomatic cases may be observed for 12 weeks as up to 50% resolve
Treatment is either with endoscopic or surgical cystogastrostomy or aspiration
130
Grade II internal haemorrhoids
Prolapse on defecation but reduce spontaneously
131
Acutely thrombosed external haemorrhoids mx
if patient presents within 72 hours then referral should be considered for excision. Otherwise patients can usually be managed with stool softeners, ice packs and analgesia. Symptoms usually settle within 10 days
132
people with a rectal mass, an unexplained anal mass or unexplained anal ulceration
do not need to be offered FIT before referral is considered.
FIT is not indicated once red-flag criteria for an urgent suspected cancer referral are met, as it should not delay definitive diagnostic colonoscopy.
133
two types:hiatus hernia
sliding: accounts for 95% of hiatus hernias, the gastroesophageal junction moves above the diaphragm
rolling (paraoesophageal): the gastroesophageal junctions remains below the diaphragm but a separate part of the stomach herniates through the oesophageal hiatus
134
Investigation hiatus hernia
barium swallow is the most sensitive test
given the nature of the symptoms many patients have an endoscopy first-line, with a hiatus hernia being found incidentally
135
Management hiatus hernia
conservative management e.g. weight loss
medical management: proton pump inhibitor therapy
surgical management: only really has a role in symptomatic paraesophageal hernias
136
ongoing jaundice and pain after cholecystectomy
Gallstones may be present in the CBD
137
drugs Risk factors gallstones
fibrates, combined oral contraceptive pill
138
complications of cholecystectomy early
: bleeding, bile leak (pain, fever, bilious drainage from a surgical drain), infection, injury to bile ducts
139
complications of cholecystectomy late
postcholecystectomy syndrome - a complex of heterogeneous symptoms, including persistent abdominal pain and dyspepsia. Many biliary and extrabiliary factors can contribute to this
140
Sigmoid volvulus associations
older patients
chronic constipation
Chagas disease
neurological conditions e.g. Parkinson's disease, Duchenne muscular dystrophy
psychiatric conditions e.g. schizophrenia
141
Caecal volvulus associations
all ages
adhesions
pregnancy
142
Management
sigmoid volvulus:
rigid sigmoidoscopy with rectal tube insertion
143
caecal volvulus mx
emergency laparotomy or laparoscopy:
if bowel is viable: right hemicolectomy (removes the redundant mobile caecum and prevents recurrence) followed by primary ileocolic anastomosis
if bowel is non-viable (ischaemia/perforation): right hemicolectomy + stoma (e.g. end ileostomy with mucous fistula).
144
Abdominal wound dehiscence should initially be managed with
coverage of the wound with saline impregnated gauze + IV broad-spectrum antibiotics
145
When sudden full dehiscence occurs the management is as follows:
Coverage of the wound with saline impregnated gauze (on the ward)
IV broad-spectrum antibiotics
Analgesia
IV fluids
Arrangements made for a return to theatre
146
Factors that increase the risk of wound dehiscence
Malnutrition
Vitamin deficiencies
Jaundice
Steroid use
Major wound contamination (e.g. faecal peritonitis)
Poor surgical technique (Mass closure technique is the preferred method-Jenkins Rule)
147
Congenital hernias
inguinal:
umbilical:
repair ASAP
manage conservatively
148
Epigastric herniaRisk factors
extensive physical training or coughing (from lung diseases), obesity
149
spigelian fascia
the aponeurotic layer between the rectus abdominis muscle medially and the semilunar line laterally
150
Richter hernia
rare type of hernia where only the antimesenteric border of the bowel herniates through the fascial defect
151
Congenital inguinal hernia
resulting from a patent processus vaginalis
Should be surgically repaired soon after diagnosis as at risk of incarceration
152
Infantile umbilical hernia More common in
premature and Afro-Caribbean babies
153
used to defunction the colon to protect an anastomosis
loop ileostomy
154
Ileostomy
Location
Appearance
Output
Rif
Spoted
Liquid
155
To defunction a distal segment of colon nd decompress
Loop colostomy
156
Colostomy: prone to
prolapse and hernia
157
Ileostomy: risk of
high output, electrolyte imbalance
158
One differentiating feature between small and large bowel obstruction clinically
onset of nausea and vomiting. Nausea and vomiting are early signs of small bowel obstruction as this suggests a proximal lesion.
159
most common cause of small bowel obstruction,
Adhesions
160
most common cause of large bowel obstruction.
Colorectal cancer
161
definitive investigation and is more sensitive, particularly in early obstruction
CT
(NCEPOD) reports getting an abdominal x-ray first can delay treatment and may contribute to patient harm due to delayed definitive management
162
most commonly performed operation for rectal tumours, except in lower rectal tumours
Anterior resection
163
Colostomies are brought out on
left side of the abdomen, and sewn flush with the skin.
164
haemorrhage shock, BP does not fall until
about 30% of blood volume is lost
Increased sympathetic tone preserves arterial pressure initially
165
4 major classes of haemorrhagic shock
Blood loss ml <750ml 750-1500ml 1500-2000ml >2000ml
Blood loss % <15% 15-30% 30-40% >40%
Pulse rate <100 >100 >120 >140ml
Blood pressure Normal Normal Decreased Decreased
Respiratory rate 14-20 20-30 30-40 >35
Urine output >30ml 20-30ml 5-15ml <5ml
Symptoms Normal Anxious Confused Lethargic
166
Neurogenic shock
This occurs most often following a spinal cord transection, usually at a high level. There is a resultant interruption of the autonomic nervous system. The result is
decreased sympathetic tone or increased parasympathetic tone, the effect of which is a decrease in peripheral vascular resistance mediated by marked vasodilation.This results in decreased preload and thus decreased cardiac output (Starling's law).
167
Congenital inguinal hernias are more common on the
right side
168
Rubber band ligation is the first-line treatment for
grade II–III haemorrhoids
MSRA
flashcards
Decks in class (27)
# Cards
-
MEDICINE228
-
Antibiotics31
-
Ent149
-
Psychiatry59
-
Contraception49
-
Gynae95
-
Ortho1
-
Cardio304
-
Resp120
-
Derma278
-
Ophthal180
-
Endocrine322
-
Metabolic58
-
Gastro343
-
Surgery168
-
Infectious Diseases269
-
Hematology242
-
Rheumat + Musculoskeletal497
-
Rheumat + Musculoskeletal 264
-
Pediatrics389
-
Pharma254
-
Psychiatry168
-
Respiratory247
-
Uro101
-
Renal175
-
Obgyn340
-
Neuro269
