Surgery - General Flashcards

Question

How would you investigate and manage a hiatus hernia?

Answer 1

Investigations * **_OGD_** is gold standard Management * **PPI** like omeprazole * Weight loss, smaller meal portions with low fat content, sleeping with head of bed raised * Smoking cessation, reduce alcohol * Surgery like **cruroplasty or fundoplication**

Answer 2

* Rolling ones are prone to **incarceration and strangulation** * **_Gastric volvulus_** can occur and cause obstruction and tissue necrosis * **Borchardt’s triad** of severe epigastric pain, _retching without vomiting_, _inability to pass an NG tube_

Answer 3

* A break in the lining of the GI tract extending through to the muscularis mucosae * Most commonly in the **lesser curvature of the proximal stomach** or the **first part of the duodenum** * Normal protective mechanisms = hco3- ions and mucous secretion by the gi mucosa

Answer 4

* Hpylori, Nsaids, corticosteroids, physiological stress, head trauma, Zollinger Ellison syndrome * Hpylori * Produces **urease** to break down urea into co2 and ammonia (neutralises stomach acid to create an alkaline environment) * Sets off inflammatory response * Zollinger Ellison syndrome * Triad of **severe peptic ulcer disease + gastric acid hypersecretion + gastrinoma** * Characteristic finding is a _fasting gastrin level of \>1000pg/ml_ * Associated with _Multiple Endocrine Neoplasia Type 1 syndrome_

Answer 5

* Retrosternal or epigastric pain * **Gastric is worse on eating**, **duodenal is worse 2-4 hours after** eating or even alleviated by eating * Nausea, bloating, post-prandial discomfort, early satiety

Answer 6

Investigations * Nice says to do an **urgent ogd** for people with… * New onset dysphagia * \>55 years old with weight loss and upper abdo pain/reflux/dyspepsia * New dyspepsia not responding to ppi * Ogd usually for older pts or red flag symptoms. * **_Biopsy_** any peptic ulceration for histology and **_rapid urease test_** * Most young low risk pts just need **Non invasive h pylori testing** * **_Carbon 13 urea breath test_** * Serum antibodies to h pylori * Stool antigen test Management * Conservative * Smoking cessation, weight loss, reduce alcohol * Stop nsaids * Start on **_PPI_** for 4-8 weeks then reassess * Triple therapy for hpylori +ve (**_PPI + oral amoxi + clarithro_** OR metronidazole for 7 days) * Surgery for Emergencies like perf or severe relapsing disease = partial gastrectomy or selective vagotomy

Answer 7

* Typically **Adenocarcinomas** * Risk factors = male, hypylori, old age, smoking, alcohol Typically present really late * Dyspepsia * Dysphagia * Early satiety * Vomiting * Melaena * Epigastric mass, Anorexia, weight loss, anaemia in late stage * Troisier sign = palpable left supraclavicular node (Virchows)

Answer 8

Investigations * **_OGD and biopsy_** for histology, CLO test and HER2/neu protein expression * CT CAP and staging laparoscopy Management * **Nutritional assessment** and support * **Peri-op chemo and surgery** (gastrectomy of some sort) * SE of gastrectomy = anastomotic leak, dumping syndrome, vit b12 deficiency * Early t1 tumours may have endoscopic mucosal resection * Palliative for late presentation (chemo, stenting, supportive)

Answer 9

Presentation * Diarrhoea = 3 or more loose stools per day (WHO) * Acute \<14 days, chronic \>14 days * vomiting, night sweats, weight loss * Dehydration and pyrexia * **crampy** abdo pain * typical hx = affected fam or friends, hx of travel, antibiotics within 4 weeks (c diff) Investigations * Stool culture

Answer 10

Viral = norovirus, rotavirus (kids), adenovirus (kids) Bacterial * **Campylobacter** = G-ve bacillus * Food poisoning from chicken, eggs milk * Can result in reactive arthritis, GBS, HUS, TTP * **EColi** = G-ve bacillus * Most common cause of travellers diarrhoea * **Salmonella** = G-ve flagellated bacillus * Uncooked poultry or raw eggs * _Bloody_ diarrhoea * **Shigella** = G-ve bacillus * Contaminated dairy or water * _Bloody_ diarrhoea

Answer 11

Commonly travellers diarrhoea * Cryptosporidium * Entamoeba hystolytica = metronidazole * Giardia intestinalis = metronidazole * Schistosomas = praziquantel

Answer 12

Hospital acquired = C. difficile (G+ve) * Following broad spec antibiotics that disrupt normal microbiota in bowel * C diff overgrow and produce **excess exotoxin A and B** * Results in inflammatory response in colonic mucosa = **severe bloody diarrhoea** * Complications = toxic megacolon if untreated Investigate with stool culture + Cdiff toxin testing Manage with **_IV fluids and oral metronidazole_**

Answer 13

* When abdo cavity contents enter the inguinal canal * Most common hernia Direct (20%) = bowel enters inguinal canal through **_Hesselbach’s triangle_** * Typically in older patients due to increased intra abdo pressure or abdo wall laxity * **Medial** to _inferior epigastric vessels_ Indirect (80%) = bowel enters inguinal canal via **_deep inguinal ring_** * Typically due to **incomplete closure of processes vaginalis** * **Lateral** to _inferior epigastric vessels_

Answer 14

* Lump in the groin that **disappears when lying down** * Incarcerated hernia = painful, tender, erythematous * Signs of bowel obstruction if bowel lumen is blocked * Features of strangulation if blood supply is compromised * Strangulation = _irreducible, tender, tense, pain out of proportion to signs_ * Inguinal hernias are **_superomedial to the pubic tubercle_**, femoral is inferolateral

Answer 15

Investigations * **_Ultrasound_** first line * Obstruction or strangulation = **ct imaging** Management * Symptomatic is offered surgical intervention * Strangulation = urgent surgical exploration * Primary inguinal hernias = **open mesh repairs (Lichenstein technique)** * Bilateral or recurrent inguinal hernias, or younger active patients with PIH = laparoscopic approach * Mesh repair has a risk of chronic pain * Non symptomatic = conservative

Answer 16

**Incarceration** = contents cannot return to original cavity **Obstruction** = lumen of bowel is obstructed **Strangulation** = compression of hernia has compromised its blood supply leading to ischaemia

Answer 17

* Less common but really high rate of strangulation!! * Rigid borders of femoral ring eg. lacunar ligament * More common in women due to **wider bony pelvis** * abdominal visceral **pass through femoral ring** into potential space of femoral canal * Risks = female, pregnant, high intra abdo pressure, old age

Answer 18

* Small lump in groin (**inferolateral to pubic tubercle**, medial to femoral pulse) * Usually **_not reducible_** due to tight borders of femoral ring * Differentials = inguinal hernia, saphena varix, femoral artery aneurysm * Saphena varix will _disappear when lying flat_, _palpable thrill when coughing_, varicose veins

Answer 19

****Investigations * **_Ultrasound_** Or **_CT abdo pelvis_** (high strangulation risk) * Surgical exploration Management * All are **managed surgically within 2 weeks** of presentation due to risk of strangulation * Reduce hernia and narrow femoral ring

Answer 20

**Epigastric hernias** * Occurs in upper midline through fibres of **linea alba** * Due to chronic raised intra abdo pressure **Paraumbilical hernia** * Through **linea alba around umbilical region** * Due to chronic raised intra abdo pressure **Spigelian hernia** * At semilunar line around level of arcuate line **Obturator hernia** * Hernia of pelvic floor **through the obturator foramen** into obturator canal * **Mass in upper medial thigh** and features of **small bowel obstruction** * compression of obturator nerve causes +ve howship-romberg sign **Richters hernia** * Partial herniation of bowel where anti-mesenteric border becomes strangulated * Tender irreducible mass + obstruction

Answer 21

* Arteriovenous malformations between previously healthy blood vessels * Commonly in **caecum** and **ascending colon** * Can be acquired or congenital Presentation * 10% asymptomatic = diagnosed on colonoscopy * majority are **_Painless occult PR bleeding_** * 10-15% is acute haemorrhage

Answer 22

Investigations * Group and save or crossmatch and other routine tests * Haematinics as some have iron def anaemia * Exclude malignancy with an **_OGD or colonoscopy_** * **_Wireless capsule endoscopy_** to identify small bowel bleeds * **_Mesenteric angiography_** to find location of bleed Management * Minimal bleeding = bed rest, IV fluids, **tranexamic acid** * Severe bleeding where site is identified * 1^st line = **_argon plasma coagulation + endoscopy_** * **Mesenteric angiography** for small bowel lesions that cannot be treated endoscopically * Last resort is surgical (only for severe life threatening bleeds with multiple lesions etc)

Answer 23

* Inflammation of the appendix * Luminal obstruction (secondary to faecolith, stool, caecal tumour) * Commensal bacteria multiply and cause acute inflammation * Obstruction causes reduced venous drainage and localised inflammation, resulting in increased pressure in the appendix * This can result in ischaemia and necrosis = perforation

Answer 24

* Initially **dull poorly localised periumbilical pain** (visceral peritoneum inflammation) * Becomes **well localised sharp RIF pain** (parietal peritoneum inflammation) * **Vomiting** that comes on after the pain * Anorexia, nausea, diarrhoea or constipation * Rebound tenderness and percussion pain over **_McBurney’s point_** * Guarding (esp in perforation) * Severe = sepsis (hypotensive, tachy) * On examination = * **_Rovsings_** (RIF pain on LIF palpation) * **_Psoas_** (RIF pain on right hip ext) * Remember presentation can be atypical in kids and with boys check for _testicular torsion or epididymitis_ too. Also rule out _intussusception and acute mesenteric adenitis_

Answer 25

Investigations * **Urinalysis** to rule out renal/urological causes (uti, pyelo, stones, TT etc) * **Pregnancy test** for women +serum bhcg * Routine bloods (fbc, u&es, lfts, crp, esr, clotting) * Ultrasound or CT not very conclusive, typically clinical diagnosis * Risk stratification scores * Men = Appendicitis inflammatory response score * Women = adult appendicitis score * Children = Shera score Manage * **_Laparoscopic appendectomy_** is gold standard * Send to histopathology for malignancy * Appendiceal mass (appendiceal abscess?) = antibiotics then interval appendectomy 6 weeks later

Answer 26

Diverticulum = outpouching of bowel wall commonly in sigmoid colon Diverticulosis = presence of diverticula Diverticular disease = symptomatic diverticula Diverticulitis = inflammation of diverticula Diverticular bleed = diverticulum erodes into a vessel and causes large vol painless bleeding

Answer 27

* **Aging bowel** walls becomes weak and stool moving through the lumen increases luminal pressure * Therefore outpouchings of mucosa will form through weaker areas of bowel (typically where **blood vessels penetrate** or at **junctions of muscle sheets**) * Bacteria can overgrow in the outpouchings = diverticulitis * This can then cause perforation = peritonitis, sepsis, death

Answer 28

Diverticulosis = Typically asymptomatic and incidentally found on routine colonoscopy Diverticular disease * Intermittent **colicky** lower abdo pain, **relieved by defecation** * **Altered bowel** habit, nausea, flatulence * No systemic features Diverticulitis * Acute **sharp abdo pain** localised to **LIF**, **worsened by movement** * Localised tenderness * **Systemic** features eg. decreased appetite, pyrexia, nausea * Perforation = localised peritonism or generalised peritonitis * People on corticosteroids or immunosuppressants may have atypical symptoms * Diverticular abscess can form as a complication (IV antibiotics +/- radiological drainage for big ones)

Answer 29

Investigations * Routine bloods * Faecal calprotectin to rule out differentials * Diverticulitis = group and save, VBG, urine dipstick * **_CT abdo pelvis_** for **diverticulitis** = thickened colonic wall, _pericolonic fat stranding_, abscesses, localised air bubbles, free air * **Hinchey classification** to stage acute diverticulitis (Based on CT findings) * **_Flexible sigmoidoscopy_** for **diverticular disease** * ***Do not do this in diverticulitis as can risk perf*** Management * Diverticular disease * Outpatient management = simple **_analgesia_** and oral **_fluids_** * Outpatient colonoscopy to exclude malignancies * Diverticular bleeds can also be managed conservatively or else with embolization and surgical resection * Acute diverticulitis * Conservative = **_antibiotics, iv fluids, analgesia_** * Surgical = for perf with faecal peritonitis or overwhelming sepsis * Typically **Hartmann’s** procedure

Answer 30

* Recurrence * Diverticular **stricture** due to repeated inflammation * can cause **large bowel obstruction** (needs sigmoid colectomy) * **Fistula** due to repeated inflammation * Colovesical between bowel and bladder (recurrent utis, faeces in urine, pneumoturia) * Colovaginal between bowel and vagina (copious vag discharge, recurrent vag infections)

Answer 31

* Dilation of the **colon** due to an **_adynamic bowel in the absence of mechanical obstruction_** * Due to interruption of autonomic nervous supply to colon resulting in absence of smooth muscle action Presentation = abdo pain, distension, constipation, vomiting is a late sign

Answer 32

* Electrolyte imbalance eg. _hypercalcaemia, hypothyroid, hypomagnesium_ * Meds eg. _opioids, CCB, antidepressants_ * Recent surgery, illness, trauma * Neuro eg. parkinsons, ms, hirschsprungs

Answer 33

Investigations * Routine bloods, u&es, **ca2+, mg2+, tfts** * AXR for bowel distension (but will show similar to mechanical) * **_CT abdo pelvis with iv contrast_** will show dilation and exclude mechanical obstruction and assess for complications like perf Management * Conservative * Treat underlying cause * **NBM and iv fluids**, **ng** if vomiting * **_Endoscopic decompression_** if not resolved in 48 hours * Involves insertion of **flatus tube** * If limited resolution, use **iv neostigmine** * Nutritional support and review * Surgery is sometimes required for non responding cases, perf or ischaemia

Answer 34

**Foregut** (stomach, duodenum, biliary, liver, pancreas, spleen) = **_coeliac artery_** **Midgut** (distal duodenum, 1^st half of transverse colon) = **_superior mesenteric artery_** **Hindgut** (2^nd half of the transverse colon to rectum) = **_inferior mesenteric artery_**

Answer 35

Mesenteric ischaemia is the lack of bloodflow through the mesenteric vessels supplying the intestines = ischaemia. Pathophysiology: * Narrowing of the mesenteric vessels due to **_atherosclerosis_** * Presentation is essentially like _angina_ but with your abdo ie _pain when the blood supply can’t keep up with demand_ Presentation: * **Central colicky abdo pain** starting **30mins after eating** * Weight loss due to food avoidance * **Abdominal bruit** on auscultation

Answer 36

Diagnosis = **_CT angiography_** Management: * Reduce **risk factors** eg smoking, diabetes, htn, cholesterol * Secondary prevention eg statins, antiplatelets * Revascularisation * 1^st line is endovascular like **_percutaneous mesenteric artery stenting_** * 2^nd line is open surgery like endarterectomy

Answer 37

* Rapid blockage in blood flow through **_superior mesenteric artery_** due to a **thrombus** in the artery (either a thrombus or an embolus) * Risk factors eg. AF Presentation: * Acute, **non specific abdo pain** * Pain is **_disproportionate_** to exam findings * Can go into shock, peritonitis, sepsis * Eventually ischaemia --\> necrosis of bowel tissue --\> **perf**

Answer 38

Investigations: * **_Contrast CT_** * Metabolic Acidosis * Raised Lactate Management: * Remove necrotic bowel * Remove or bypass thrombus (open surgery or endovascular)

Answer 39

* **_Twisting of intestine around its mesenteric attachment_** resulting in a closed loop bowel obstruction * Can compromise bowel supply and cause ischaemia, necrosis, perf * Typically in **sigmoid colon** due to long mesentery (increases with age). * Therefore this segment of bowel is more prone to twisting on its mesenteric base * Risk factors = old age, neuropsych disorders, nursing home resident, chronic constipation or laxative use, male, prev abdo operations

Answer 40

* Bowel obstruction= colicky pain, abdo distension, absolute constipation. Vomiting late * Onset is pretty **rapid** (over hours) * Abdo is tympanic to percussion

Answer 41

Investigations * Routine bloods (incl ones to exclude pseudo-obstruction) * **_Ct abdo pelvis with contrast_** = **whirl sign** * **_AXR_** = **coffee bean sign** in LIF Management * Conservative * **_decompression with sigmoidoscope_** and **_flatus tube insertion_** * monitor for ischaemia * fluid resus * Surgical = laparotomy for **hartmanns** * Indications = ischaemia or perf, repeated failed decompression, necrotic bowel on endoscopy

Answer 42

* Abnormal swellings or enlargements of the anal vascular cushions * There are 3 Anal vascular cushions that help maintain continence (3, 7, 11oclock positions) Classification * 1^st degree remain in rectum * 2^nd degree = prolapse through anus on defecation but _spontaneously reduces_ * 3^rd degree = prolapse through anus on defecation but _requires digital reduction_ * 4^th degree = remains _persistently prolapsed_

Answer 43

Risk factors = excessive straining (chronic constipation), old age, raised intra abdo pressure, portal hypertension Presentation * Painless **bright red rectal bleeding after defecation** on _paper or surface of stool_ * **Pruritus**, rectal fullness or anal lump, **soiling** * Large prolapsed haemorrhoids can thrombose = painful, purple/blue oedematous tense tender perianal mass

Answer 44

Investigations * **Proctoscopy** * Routine bloods * **Flexi sigmoidoscopy or colonoscopy** to rule out malignancy Management * Conservative * Increased **fibre and fluid** * **laxatives** if necessary * Topical analgesia (**lignocaine gel**) * **_Rubber band ligation_** for symptomatic 1^st and 2^nd degree haemorrhoids * Surgical * **Haemorrhoidal artery ligation** for 2^nd or 3^rd degree haemorrhoids * **Haemorrhoidectomy** for 3^rd or 4^th degree or symptomatic and not responding to conservative therapies

Answer 45

* Collection of pus in anal/rectal region due to plugging of anal ducts, resulting in fluid stasis and infection * Commonly ecoli, bacteriodes spp, enterococcus spp * Classified as perianal, ischiorectal, intersphincteric or supralevator

Answer 46

* Pain in perianal region _exacerbated by sitting_ * Localised **swelling, itching, discharge** * Severe abscess = systemic like fever, rigors, malaise, sepsis * O/E = erythematous fluctuant tender perianal mass

Answer 47

Investigations * DRE * Examination _under anaesthesia_ * Some need ct or mri Management * Antibiotic therapy and analgesia * **Incision and drainage** of abscess under GA * Heal by **secondary intention** * **Proctoscopy** afterwards to check for fistula-in-ano * Insert a **seton** if fistula is identified

Answer 48

* **Tear in the mucosal lining** of the anal canal typically due to trauma from hard stool defecation * Acute is \<6 weeks, chronic is \>6 weeks * Risk factors = constipation, dehydration, IBD, chronic diarrhoea

Answer 49

* Intense **pain post defecation** * **Bleeding** (bright red on wiping) or **itching** _post defecation_ * O/E fissures are visible and palpable on dre * Most fissures are on the _posterior midline_ * Often DRE is too painful so do _examination under anaesthesia_ * Fissures within anal canal can be seen with _proctoscopy_

Answer 50

* Reduce risk factors = fluids, fibre, stool softening laxatives like **Movicol or lactulose** * Topical analgesia like **lidocaine or hot baths** * 2^nd line is gtn cream or diltiazem cream Surgery for chronic fissures where med has not worked * **Botox injections into internal anal sphincter** * Or lateral sphincterotomy

Surgery - General Flashcards

(76 cards)