Flashcards in Abdominal Surgery Deck (84):
What are the most common histological types of oesophageal cancer?
Squamous cell carcinoma of the upper oesophagus
Adenocarcinoma of the distal oesophagus - junction of the oesophagus and stomach
What are the risk factors for SCC of the oesophageal?
Low socioeconomic groups
What are the risk factors for adenocarcinoma of the oesophagus?
What are the symptoms of oesophageal cancer?
Cough with swallowing - oesophageal-tracheal fistula
What are the signs of oesophageal cancer?
Cervical lymph nodes
Hypercalcaemia - parathyroid hormone production
Dehydration, weight loss and muscle wasting
How is oesophageal cancer diagnosed?
History - Risk factors, symptoms
Examination - signs
Endoscopy - direct visualization
FNA our Biopsy - histology
What is the management of oesophageal cancer?
Surgical resection - oesophagectomy
Intubation - expandable stents insertions
What are the contraindications for surgery in oesophageal cancer?
Invasion of adjacent structures
Severe associated co-morbid diseases
What is the epidemiology of peptic ulcer disease?
Helicobacter pylori infection
Smoking and alcohol
What are the symptoms of peptic ulcer disease?
Epigastric pain relieved by food or antacids and worse when hungry
Nocturnal pain causing waking
Persistent pain or pain radiating to the back - penetrating ulcer
Anorexia, vomiting and weight loss/gain
How would you diagnose peptic ulcer disease?
Gastroscopy - allows for biopsy to confirm/rule-out H.pylori or malignancy
Barium meal - seldom used
Gastrin levels - zollinger ellison syndrome
Describe the classification of gastric ulcers according to the Gaintree-Johnson classification
Type 1: At the incisura on the lesser curvature - not associated with acid hypersecretion
Type 2: Gastric and Duodenal ulcer secondary to gastric stasis usually due to acid hypersecretion
Type 3: Prepyloric ulcer usually due to acid hypersecretion
Type 4: High on lesser curvature close to gastro-oesophageal junction not associated with acid hypersecretion
Type 5: Secondary to chronic NSAIDs use
What are the complications of peptic ulcer disease?
Stomach outlet obstruction
What are the indications for surgery for peptic ulcer disease?
Stomach outlet obstruction
Penetration into adjacent organs
Bile duct stricture
How do you manage Duodenal ulcers?
Truncal vagotomy with antrectomy - most effect acid reducing procedure
Truncal vagotomy with drainage procedure - for ineffective stomach emptying
Highly selective vagotomy
How do you manage gastric ulcers?
Type 1: Partial gastrectomy
Type 2: Truncal vagotomy with antrectomy/drainage
Type 3: Truncal vagotomy with antrectomy/drainage
Type 4: Partial gastrectomy (Pauchet procedure)
What are the clinical finding of a perforated peptic ulcer?
Anterior ulcers tends to perforate
Sudden severe upper abdominal pain with/without shoulder pain
Fetal position, motionless, avoids breathing
Guarded abdominal examination
Lessened liver dullness due to free air in peritoneal cavity
Reduced bowel sounds
X-ray shows free air under diaphragm
What is the management of a perforated peptic ulcer?
NG tube - decreases air in peritoneal cavity
IV H2 antagonist or PPIs
Laparotomy with omentopexy OR laparotomy with simple closure
When can a definitive ulcer operation be performed?
The patient is haemodynamically stable
Perforation has to occurred <24hrs ago
No associated risk factors
Failed medical treatment
Very large ulcers associated with severe bleeding, obstruction or repeated perforation
What are the complications of a gastrectomy?
Alkaline reflux gastritis
Malabsorption - anaemia
What are the risk factors for gastric cancer?
Diet - low fat, low protein, high salt, alcohol
Environmental - poor food prep and drinking water, smoking
Poor socioeconomic status
H. Pylori infection
Prior gastric surgery
Describe Lauren’s classification for intestinal gastric adenocarcinoma
Usually in the Antrum of the stomach
Pre-existing gastric atrophy and intestinal metaplasia
Any blood type
More common in males
Describe Lauren’s classification for diffuse gastric cancer
No gastric atrophy or intestinal metaplasia usually
Blood group A
More common in females
Poorly differentiated, signet ring cells
Transmural or lymphatic spread
How would a patient with a gastric adenocarcinoma present?
Epigastric discomfort / indigestion
Weight loss, vomiting, anorexia
Gastric outlet obstruction
What are the signs of advanced gastric adenocarcinoma?
Palpable abdominal mass
Palpable supraclavicular lymph-node’s (virchows LN / troisiers sign)
Sister Mary Joseph nodule
How is gastric adenocarcinoma diagnosed?
Gastroscopy with biopsy for histological classification
FBC, U&E, LFTs, serum albumin
How do you stage a gastric adenocarcinoma?
What is the management of a gastric carcinoma?
Subtotal gastrectomy- distal third tumors
Total gastrectomy - middle and proximal third tumors
Lymph nodes in close proximity are always removed
Describe the pathophysiology of bowel obstruction
> Intestine proximal to obstruction contracts vigorously trying to overcome obstruction
> colicky pain + increased bowel sounds
> abdominal distension
> proliferation of gas producing bacteria
> Further abdominal distension
Describe La Place’s Law in terms of bowel obstruction
If the radius of bowel increases with a constant pressure. Then the tension exerted on the wall will be greater.
Meaning, If the pressure in the bowel is equal the area of bowel with the largest radius will have the greatest force/tension on its wall. The ceacum is the largest area of the bowel and tends to perforate more often
What are the causes of large bowel obstruction?
What are the most common causes of small bowel obstruction?
Describe a closed loop bowel obstruction
It is a complicated intestinal obstruction.
The bowel is obstructed at two points by an adhesive band or volvulus
Decompression can not occur pressure causes the loop to rise
This results in severe constant pain, local tenderness/peritonism
Describe a strangulated bowel obstruction
Requires urgent surgery
The blood supply of the obstructed bowel is occluded
This can result in necrosis/perforation of the involved segment
It can be caused by hernia, adhesions, volvulus and intussusception
It causes severe pain/tenderness/peritonism over the area, fever, tachycardia, leucocytosis
What are the four cardinal features of mechanical intestinal obstruction?
How would you diagnose bowel obstruction?
History - Previous surgery, symptoms
Examination- especial abdominal and rectal examination
Bloods - FBC, U&E
AXR - supine or erect
Single contrast barium enema
How do you distinguish between small bowel and large bowel on erect film?
Small bowel - fluid levels are more wide than high and descend stepwise from left to right
Large bowel - fluid levels are more high that wide
What is the initial management of bowel obstruction?
Management is dependent on the cause
Admit to hospital
IV fluids, NPO, NG tube
Monitor - BP, HR, urine output
Describe the surgical management of bowel obstruction
Right sided obstruction - midline laparotomy with right hemi-colectomy and anastomoses
Left sided obstruction - resection of obstructing lesion and creation of a colostomy followed by eventual closure of the colostomy
What is the difference between a true and false diverticulum?
True - contains all the layers of the intestinal wall which includes the mucosa, submucosa, serousa and muscle layer
False - contains no muscle layer of the instestinal wall
Discuss Meckel’s Diverticulum
Common congenital abnormalities of the GIT
It is a TRUE diverticulum of the small bowel
It is known as the disease of 2’s
2 inches long
2 feet for the ileoceacal valve
2 types of mucosa
2 x more common in males
2% of the population
It is a remnant of the omphalmesenteric duct from the embryological period
It usually doesn’t cause any problems. But it maybe cause:
Mechanical intestinal obstruction
Bleeding per rectum
It is managed by diverticulectomy or segmental resection
Why don’t we find diverticula in the rectum?
The rectum has a completely circumferential longitudinal muscle layer which doesn’t allow for defects which lead to diverticulum
Describe the pathogenesis of diverticulosis
1. Increased intraluminal pressure in the colon cause diverticula through a defect in the muscle wall where small arteries pass
2. Weakness/Degeneration of the musculature of the colon
What are the consequences of diverticular disease of the colon?
Most are asymptomatic
Left iliac fossa pain
Bleeding per rectum
How is a sigmoid volvulus diagnosed?
Barium enema - birds beak appearance
AXR - dilated bowel loop “Bent inner tube” sign
How would you manage an uncomplicated sigmoid volvulus?
Decompression via sigmoidoscope
Leave a flatus tube in place
Prepare bowel and patient for elective sigmoidectomy
How would you manage a sigmoid volvulus complicated by necrosis?
Emergency laparotomy to resect the infected bowel without untwisting it
Describe the pathogenesis of acute appendicitis
> increased mucus
> bacterial overgrowth
> pus formation
> increased luminal pressure
> generalized peritonitis
What is the classic presentation of acute appendicitis?
Vague epigastric/umbilical pain which localizes to the right iliac fossa
Nausea and vomiting
Low grade fever
What are the laboratory finding of acute appendicitis?
Differential count shows raised neutrophils
Describe the radiological finding of acute appendicitis
AXR - faecolith may be visible, ill-defined right psoas margin
Abdo US - dilated non-compressable blind tubular structure
CT abdo - dilated appendix with thick wall, “fat stranding” or abscess
Provide a DDx for right iliac fossa pain
PID in females
What are the complications of acute appendicitis?
How would you manage acute appendicitis?
Admit - if uncertain then re-evaluate every 4 hours
IV fluids and analgesia
Antibiotics - gentamicin (E. Coli) or cephzol
What are the histological classifications of large bowel polyps?
Neoplastic - malignant/benign
Discuss Familial Adenomatous Polyposis (FAP)
Autosomal dominant inherited condition
Very High Pre-malignant condition for colorectal ca
Polyps also occurs in duodenum and small bowel
Management is restorative proctolectomy (all large bowel mucosa is removed)
Need to have annual upper GIT endoscopy post proctolectomy coz patients have a high risk of duodenal carcinoma
List the risk factors / pre-malignant factors for colorectal carcinoma
Western diet - high fat, low fiber
Lynch syndrome type I/II
Implantation of ureters in colon
How did you diagnose colorectal carcinoma?
History and examination - NB PR Exam
Barium enema of colonoscopy
Discuss a fungating colorectal adenocarcinoma
Usually in the right colon
Early: peri umbilical/epigastric discomfort 30mins after a meal
Discuss a annular stenosing colorectal adenocarcinoma
Typically left colon/sigmoid
Increasing Constipation or alternating episodes of constipation and diarrhea
Discuss a malignant ulcer colorectal adenocarcinoma
Typically in the rectum
Blood/Mucus per rectum
Do NOT diagnose this radiologically
Discuss your approach to a patient with colorectal carcinoma
History - suggestive symptoms
Examination - all especially PR exam; looking for signs
Special investigations -
Colonoscopy/Sigmoidoscopy and biopsy
Tumour markers CEA
FBC for Fe anaemia
Surgical resection - colectomy/hemicolectomy with removal of regional lymph nodes
6 monthly follow-ups - Exam, LFTs, CXR, US abdo, CEA levels
2 yearly colonoscopies
List the 2 most common causes of obstructive jaundice
Head of pancreas carcinoma
Provide a DDx for obstructive jaundice due to luminal obstruction
* Ascaris Lumbricoides
* Daughter cyst of Enchinococcus cyst
What are the signs of obstructive jaundice?
Yellow skin and sclera
RUQ pain and tenderness
How would you investigate Obstructive jaundice?
* + bilirubin
* - urobilinogen
* Increased WCC with cholangitis
* Low albumin
* Increased Alkaline phosphate and GGT
* Visualization of obstruction - cystic/solid
* Billiary Dilatation above the obstruction
* Level of obstruction
* Hyperechoic mass > gallstone
* Distended gallbladder + thickened wall > acute cholecystitis
* Radio-opaque gallstones (10-20%) - Brown and black stones coz' it contains calcium
* Filling defect
What are the consequences of gallstones in the gallbladder?
* Upper abdominal discomfort
* Aversion of fatty foods
* Colic-like pain in RUQ - radiates to right scapula
* Nausea and vomiting
* Tenderness over gallbladder
Carcinoma of the gallbladder
What are the symptoms and signs of acute cholecystitis?
BIliary colic > constant pain in RUQ
Murphy's sign (+)
How would you manage acute cholecystitis due to gallstones?
Analgesia - Pethidine
Broad spectrum antibiotics - Cephzol / Amoxicillin + Gentamicin
Cholecystectomy within 3-4 days
How is Acute cholecystitis diagnosed?
* Distended gallbladder
* Thickened gallbladder wall
* Sonographic Murphy's sign - Localised tenderness
Tc-99m HIDA scintigram
* Done under sonar
* Isotope reaches bowel but no activity seen in gallbladder
What is the management of symptomatic gallstones?
Open cholecystectomy if...
* Evidence of severe/perforated acute cholecystitis
* Exploration of bile duct required
What are the clinical features of an adenocarcinoma of the pancreas?
Painless obstructive jaundice
* Preceded by vague, deep-seated abdominal pain + bachache (poor prognostic indicator)
Anorexia, weight loss
Liver palpable - congestion
How would you diagnose a tumour of the pancreas?
* Total bilirubin >10x normal favours malignant obstructive jaundice
* Elevated CA19-9
* Biliary/pancreatic duct dilatation
* Cystic neoplasn
Abdominal CT scan
* Visualize tumour
* Biliary/pancreatic duct dilatation
* Local infiltration
* LN/Liver metastases
* Site and form of biliary obstruction
* Displacement/obstruction of pancreas
What is the treatment for pancreatic tumours?
Surgical resection (whenever possible)
Islet cell tumours / cystadenoma
* Simple enucleation
Head of pancreas / peri-ampullary tumors
* Whipple operation (Pancreaticduodectomy)
Body/tail pancreatic tumour
* Distal pancreaticduodectomy + excision of spleen and splenic vessels
* Palliative - Gallbladder/bileduct anastomosis to small bowel
What is the prognosis of adenocarcinoma of the pancreas?
Without resection 1 year survival <10%
With resection 1 year survival ± 12%
When would you perform surgery for portal hypertension?
(When there's complications)
Bleeding Oesophageal Varices
* Who failed other treatment modalities
* Good operative risk
What are the endoscopic treatment interventions for oesophageal varices?
Rubber band ligation
What are the invasive radiological treatment procedures for oesophageal varices?
Transjugular intrahepatic portosystemic shunt (TIPSS)
What are the surgical treatment procedures for oesophageal varices?
Porto-caval / Meso-caval shunt
* Creation of a communication between the hypertensive portal venous system and low pressure systemic system
* Normalises pressure in portal venous system
* Manages ascites and hypersplenism as well
What are the complications of the surgical treatment for oesophageal varices?
What are the risk factors for hepatocellular carcinoma?
Hep B/C infection
Aflatoxin contaminated foods
How would you diagnose a hepatocellular carcinoma?
History - suggestive symptoms and risk factors
* RUQ pain
* Abdominal mass
* Loss of appetite and weight loss
Examination: Palpable mass / jaundice
* Large - single well-circumscribed
* Nodular - multiple nodules
* Diffuse - ill-defined, wide infiltration, most common in SA
Alpha - Fetoprotein will be raised
U/S - visualise mass
CT scan - Staging
What is the management of an organ-confined hepatocellular carcinoma?
Tumour resection (where possible)
* Most effective
* Not done if there's cirrhosis coz' of bleeding risk and decreased liver function
* Cirrhotic patients