Surgery - Acute Flashcards by Megan Espie

Where is McBurney’s point?

1/3 of the way along the line from the ASIS to the umbilicus - point where the appendix is found anatomically

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What are the 9 layers of the anterior abdominal wall from external -> internal?

skin
subcutaneous fat
superficial fascia (campers and scarpas)
external oblique muscle
internal oblique muscle
transverse abdominus muscle
transversalis fascia
pre-peritoneal fat
peritoneum

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Describe the pathophysiology of appendicitis

OBSTRUCTION -> due to faecolith/tumour/worms

- gut organisms invade appendix wall causing oedema, ischaemia, necrosis, and then perforation

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Describe the pain felt in appendicitis and the pathophysiology behind it:

early inflammation = visceral pain which is poorly located, only the appendix inflammed, mid-gut pain - initially entire abdomen
later inflammation: parietal peritoneum inflammation as well as appendix, pain localises to RIF

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What is Rosving’s sign?

Pain in RIF when LIF is pressed (appendicitis)

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What is Psoas sign?

Pain on hip extension, as the majority of appendicitises are retrocaecal

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Name some differentials of RIF pain

Appendicitis
Crohn's disease
Ovarian pathology
Renal stones
Meckel's diverticulum
Mittelschmertz
UTI
Ectopic pregnancy
Mesenteric adenitis

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How is appendicitis investigated?

Bloods: FBC, U&E, CRP, LFT, amylase, clotting, lactate, G%S
Urinalysis: B-HCG, infection, ketones
Imaging: Females (USS - rule out gynae pathology), Males (laparotomy immediately)

50yrs+ = CT to rule out cancer

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What are the 4 ways in which gallstones can present?

biliary colic
acute cholangitis (bile duct infection)
acute cholecystitis (GB infection)
chronic cholecystitis (GB infection)

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What types of gallstones are there?

75% mixed stones (cholesterol, calcium and pigment)
20% cholesterol stones (due to Admirand’s triangle = high cholesterol, low bile salts and low lecithin)
Pigment stones (made of calcium bilirubinate and associated with haemolysis)

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RFx for gallstones?

female
forty
fertile
fat
fair

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Name some complications of Gallstones?

biliary colix
cholecystitis
mucocoele
empyema
carcinoma
obstructive jaundice
acute pancreatitis
Mirizzi syndrome -> stone impacted in GG/cystic duct causing CBD compression
gallstone ileus = causing pneumobilia and bowel distention on AXR

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What are the features of gallstone ileus on AXR?

Rigler’s triad:

pneumobilia
SB obstruction
stone seen in RLQ

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What are differentials of RUQ pain?

R lower lobe pneumonia
Hepatitis
Gallstone issues

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What is Charcot’s triad?

fever, jaundice and RUQ pain

Seen in cholangitis

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What is Reynauld’s pentad?

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fever, jaundice, RUQ pain, sepsis and confusion

seen in cholangitis

What is the imaging modality of choice for gallstones?

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USS

Majority of gallstones are radio-opaque

How are biliary colic and ascending cholangitis managed?

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conservative (fluids, analgesia, NBM to rest the GB)

- surgery (lap cholecystectomy if recurrence of pain and stones is an issue)

What is Murphy’s sign?

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tenderness over GB on inspiration (cholecystitis)

What is Boas’ sign?

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hyperaesthesia below the R scapulae

How is cholecystitis managed

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conservative (fluids, analgesia, NBM to rest the GB)

- surgery (lap cholecystectomy if recurrence of pain and stones is an issue)

Why is gallbladder pain worse with eating?

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fatty chyme in SI causes CCK (cholecystikinin release from SI cells) which causes GB contraction

What are the causes of acute pancreatitis?

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Idiopathic
Gallstones
Ethanol
Toxins
Steroids
Mumps
Autoimmune
Scorpion sting
Hyperlipidaemia/hypercalcaemia/hyperparathyroid
ERCP
Drugs (thiazide/loop diuretics, tetracycline antibiotics)

What are Grey Turners and Cullens signs?

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Cullens = periumbilical bruising
Grey turners = flank bruising

Due to pancreatitis (haemorrhagic)

Describe the components of the modified Glasgow Criteria for acute pancreatitis

Used to assess severity and predict mortality: ``` PaO2<8kPa Age >55 Neutrophils high Calcium low Renal (urea >16) Enzymes (high LDH and AST) Albumin low Sugar (BM >10) ``` ``` 1 = mild 2 = moderate 3 = severe ```

What are the retroperitoneal organs (lined by adventitia)

``` Suprarenals (adrenals) Aorta/IVC Duodenum (distal 2/3rds) Pancreas Ureters Colon (ascending and descending) Kidneys oEsophagus Rectum ```

What is the definition of diverticulum?

An acquired out-pouching of the colonic mucosa/connective tissue through the bowel wall (a false diverticulum has no muscle protruding)

Name 3 common causes of visceral perforation

peptic ulcer acute appendicitis diverticulitis

Name some causes of upper GI bleeding:

peptic ulcer oesophageal varices mallory weiss tear (tear where stomach meets oesophagus) gastric carcinoma

What are the two scores used to assess upper GI bleeding?

Glasgow Blatchford score - used pre-endoscopy to predict need for intervention Rockall score - used after endoscopy and predicts mortality and need for surgery

How are upper GI bleeds managed?

ABATED! - A-E - Bloods (FBC, U&E, LFT, coag & cross-match) - Access - Transfuse - Endoscopy (immediately if haem unstable, or within 24hrs if stable) - Drugs (stop NSAIDs and anticoagulants) Additional steps if VARICEAL bleeding: - terlipressin & antibiotics Definitive treatment: banding/sclerotherapy inj/cauterisation

Name some causes of lower GI bleeding:

``` IBD Infective gastroenteritis Diverticulitis Large upper GI bleed Colonic polyps Rectal (haemorrhoids, fissures) Neoplasia ```

What is the investigation and management of a lower GI bleed?

- bloods - stool (microscopy) - imaging (AXR, erect CXR) - colonoscopy/sigmoidoscopy - A-E - fluid resuscitation/blood transfusion - antibiotics ?sepsis endoscopic treatment/surgical resection

What is the definition of an aneurysm? (and a true and false aneurysm)

An artery with >50% dilatation of its original diameter The layers of a blood vessel wall are: - tunica intima - tunica media - adventitia true aneurysm = contains all layers of artery wall false aneurysm = a collection of blood in the adventitia which connects with the lumen after trauma

What is the management of a ruptured AAA?

- high flow O2 - Iv access - FBC, coag, clotting - cross match >6 units transfer to vascular surgeons: - stable = CT angiogram and possible endovascular repair - unstable = open repair

Name 5 causes of acute testicular pain

- testicular torsion - torsion of testicular appendage - acute epididymo-orchitis - scrotal oedema - inguinal lymphadenopathy

What is the blue dot sign?

seen in torsion of testicular appendage also called Hydatid of Morgagni causes a high riding testes with similar presentation to torsion (tender testicle, slightly enlarged) but the cremasteric reflex WILL BE PRESERVED

What is the presentation of testicular torsion

sudden moderate/severe constant unilateral pain - associated N&V - high riding testes with absent ipsilateral cremasteric reflex

Surgery - Acute Flashcards

(38 cards)