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Flashcards in Abdominal Surgery Deck (84):
1

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

2

What are the risk factors for SCC of the oesophageal?

Low socioeconomic groups

Smoking

Alcohol

Males

Age +60

HPV infection

3

What are the risk factors for adenocarcinoma of the oesophagus?

Barrett’s oesophagus

GERD

Obesity

4

What are the symptoms of oesophageal cancer?

Dysphagia

Pain

Hoarseness

Cough with swallowing - oesophageal-tracheal fistula

Weight loss

Neck mass

5

What are the signs of oesophageal cancer?

Cervical lymph nodes

Hypercalcaemia - parathyroid hormone production

Dehydration, weight loss and muscle wasting

6

How is oesophageal cancer diagnosed?

History - Risk factors, symptoms

Examination - signs

Barium swallow

Endoscopy - direct visualization

FNA our Biopsy - histology

CT scan

7

What is the management of oesophageal cancer?

Surgical resection - oesophagectomy

Neoadjuvant Radiotherapy

Neoadjuvant Chemotherapy

Intubation - expandable stents insertions

8

What are the contraindications for surgery in oesophageal cancer?

Metastasis

Invasion of adjacent structures

Severe associated co-morbid diseases

9

What is the epidemiology of peptic ulcer disease?

Helicobacter pylori infection

NSAIDs

Acid hypersecretion

Smoking and alcohol

Genetic predisposition

10

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

GERD (Heartburn)

Anorexia, vomiting and weight loss/gain

Epigastric tenderness

11

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

12

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

13

What are the complications of peptic ulcer disease?

Bleeding

Perforation

Stomach outlet obstruction

Penetration

Malignancy

14

What are the indications for surgery for peptic ulcer disease?

Non-healing ulcer

Perforation

Bleeding ulcer

Stomach outlet obstruction

Penetration into adjacent organs

Malignant transformation

Bile duct stricture

Fistulation

15

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

16

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)

17

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

Tachycardia

Guarded abdominal examination

Lessened liver dullness due to free air in peritoneal cavity

Reduced bowel sounds

Raised WCC

X-ray shows free air under diaphragm

18

What is the management of a perforated peptic ulcer?

Keep NPO

NG tube - decreases air in peritoneal cavity

IV fluids

IV antibiotics

IV H2 antagonist or PPIs

Laparotomy with omentopexy OR laparotomy with simple closure

19

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

20

What are the complications of a gastrectomy?

Bleeding

Anastomoses leakage

Obstruction

Ulcer recurrence

Gastro-jejuno-colic fistula

Alkaline reflux gastritis

Dumping syndrome

Chronic gastroparesis

Malabsorption - anaemia

21

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

Genetic predisposition

H. Pylori infection

Prior gastric surgery

Gastric ulcer

Atrophic gastritis

Polyps

Males

22

Describe Lauren’s classification for intestinal gastric adenocarcinoma

Ulcerative

Usually in the Antrum of the stomach

Pre-existing gastric atrophy and intestinal metaplasia

Any blood type

More common in males

Older age

Gland formation

Haematogenous spread

Better prognosis

23

Describe Lauren’s classification for diffuse gastric cancer

No gastric atrophy or intestinal metaplasia usually

Blood group A

More common in females

Younger

Poorly differentiated, signet ring cells

Transmural or lymphatic spread

Poor prognosis

24

How would a patient with a gastric adenocarcinoma present?

Epigastric discomfort / indigestion

Weight loss, vomiting, anorexia

Dysphasia

Gastric outlet obstruction

Early satiety

Anaemia

25

What are the signs of advanced gastric adenocarcinoma?

Palpable abdominal mass

Palpable supraclavicular lymph-node’s (virchows LN / troisiers sign)

Sister Mary Joseph nodule

Irregular hepatomegaly

Ascites

26

How is gastric adenocarcinoma diagnosed?

Gastroscopy with biopsy for histological classification

Barium meal

CXR

FBC, U&E, LFTs, serum albumin

Blood gas

CT scan

27

How do you stage a gastric adenocarcinoma?

TNM staging

28

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

29

Describe the pathophysiology of bowel obstruction

Complete 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

> vomiting

> dehydration

> constipation

30

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

31

What are the causes of large bowel obstruction?

Colorectal Cancer

Faecal Impaction

Sigmoid Volvulus

Diverticular stricture

Adhesions

Foreign body

Hernia

32

What are the most common causes of small bowel obstruction?

Adhesions

Hernias

33

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

34

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

35

What are the four cardinal features of mechanical intestinal obstruction?

Pain

Abdominal distension

Vomiting

Constipation/Obstipation

36

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

37

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

38

What is the initial management of bowel obstruction?

Management is dependent on the cause

Admit to hospital
IV fluids, NPO, NG tube
Analgesia
Correct dehydration/Imbalances
Monitor - BP, HR, urine output

39

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

40

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

41

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
Diverticulitis
Neoplasia

It is managed by diverticulectomy or segmental resection

42

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

43

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

44

What are the consequences of diverticular disease of the colon?

Most are asymptomatic

Left iliac fossa pain

Perforation

Diverticulitis

Bleeding per rectum

45

How is a sigmoid volvulus diagnosed?

Barium enema - birds beak appearance

AXR - dilated bowel loop “Bent inner tube” sign

46

How would you manage an uncomplicated sigmoid volvulus?

Decompression via sigmoidoscope

Leave a flatus tube in place

Prepare bowel and patient for elective sigmoidectomy

47

How would you manage a sigmoid volvulus complicated by necrosis?

Emergency laparotomy to resect the infected bowel without untwisting it

48

Describe the pathogenesis of acute appendicitis

Luminal obstruction
> increased mucus
> stasis
> bacterial overgrowth
> pus formation
> increased luminal pressure
> ischaemia/infarction
> perforation
> generalized peritonitis

49

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

Anorexia

50

What are the laboratory finding of acute appendicitis?

Raised WCC

Differential count shows raised neutrophils

Raised CRP

51

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

52

Provide a DDx for right iliac fossa pain

PID in females

Ectopic pregnancy

Ovarian pathology

Endometriosis

Acute gastroenteritis

Crohn’s enteritis

TB

Meckel’s diverticulum

UTI

53

What are the complications of acute appendicitis?

Perforation

Septic shock

Pylephlebitis

Liver abscess

Death

54

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

55

What are the histological classifications of large bowel polyps?

Neoplastic - malignant/benign

Hamartoma

Inflammatory

Other

56

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

57

List the risk factors / pre-malignant factors for colorectal carcinoma

Western diet - high fat, low fiber

Genetic factors:
Family history
FAP
Lynch syndrome type I/II

Ulcerative colitis

Previous irradiation

Implantation of ureters in colon

Colorectal schistosomiasis

58

How did you diagnose colorectal carcinoma?

History and examination - NB PR Exam

Sigmoidoscopy

Barium enema of colonoscopy

CT abdo

59

Discuss a fungating colorectal adenocarcinoma

Usually in the right colon

Few symptoms
Early: peri umbilical/epigastric discomfort 30mins after a meal

60

Discuss a annular stenosing colorectal adenocarcinoma

Typically left colon/sigmoid

GERD

Increasing Constipation or alternating episodes of constipation and diarrhea

61

Discuss a malignant ulcer colorectal adenocarcinoma

Typically in the rectum

Blood/Mucus per rectum

Tenesmus

Spurious diarrhea

Do NOT diagnose this radiologically

62

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
Barium enema
Tumour markers CEA
FBC for Fe anaemia
CT abdo

Staging
TNM
CXR
LFTs
Abdo US

Surgical resection - colectomy/hemicolectomy with removal of regional lymph nodes

Adjuvant Chemo/radiotherapy

6 monthly follow-ups - Exam, LFTs, CXR, US abdo, CEA levels

2 yearly colonoscopies

63

List the 2 most common causes of obstructive jaundice

Gallstones

Head of pancreas carcinoma

64

Provide a DDx for obstructive jaundice due to luminal obstruction

Gallstones

Parasites
* Ascaris Lumbricoides
* Daughter cyst of Enchinococcus cyst

65

What are the signs of obstructive jaundice?

Yellow skin and sclera

Dark Urine

Pale stools

Itching

RUQ pain and tenderness

66

How would you investigate Obstructive jaundice?

Urine dipstick
* + bilirubin
* - urobilinogen

FBC
* Increased WCC with cholangitis

LFTs
* Low albumin
* Increased Alkaline phosphate and GGT

Ultrasound
* Visualization of obstruction - cystic/solid
* Billiary Dilatation above the obstruction
* Level of obstruction
* Hyperechoic mass > gallstone
* Distended gallbladder + thickened wall > acute cholecystitis

AXR
* Radio-opaque gallstones (10-20%) - Brown and black stones coz' it contains calcium

ERCP
* Filling defect

67

What are the consequences of gallstones in the gallbladder?

Mostly asymptomatic

Gallstone dyspepsia
* Upper abdominal discomfort
* Aversion of fatty foods
* Flatulence

Biliary colic
* Colic-like pain in RUQ - radiates to right scapula
* Nausea and vomiting
* Tenderness over gallbladder

Acute cholocystitis

Carcinoma of the gallbladder

68

What are the symptoms and signs of acute cholecystitis?

BIliary colic > constant pain in RUQ

Pyrexia

Murphy's sign (+)

Raised WCC

Paralytic ileus
*Constipation

69

How would you manage acute cholecystitis due to gallstones?

Admit

IV fluids

NPO

Analgesia - Pethidine

Broad spectrum antibiotics - Cephzol / Amoxicillin + Gentamicin

Cholecystectomy within 3-4 days

70

How is Acute cholecystitis diagnosed?

Ultrasound
* 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

71

What is the management of symptomatic gallstones?

Laproscopic cholecystectomy

Open cholecystectomy if...
* Evidence of severe/perforated acute cholecystitis
* Exploration of bile duct required

72

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

Palpable gallbladder

Liver palpable - congestion

73

How would you diagnose a tumour of the pancreas?

LFTs
* Total bilirubin >10x normal favours malignant obstructive jaundice

Tumour Markers
* Elevated CA19-9

Ultrasound
* Biliary/pancreatic duct dilatation
* Cystic neoplasn

Abdominal CT scan
* Visualize tumour
* Biliary/pancreatic duct dilatation
* Local infiltration
* LN/Liver metastases

ERCP
* Site and form of biliary obstruction
* Displacement/obstruction of pancreas

74

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

Unresectable tumour
* Palliative - Gallbladder/bileduct anastomosis to small bowel

75

What is the prognosis of adenocarcinoma of the pancreas?

Poor :(

Without resection 1 year survival <10%

With resection 1 year survival ± 12%

76

When would you perform surgery for portal hypertension?

(When there's complications)

Bleeding Oesophageal Varices
* Who failed other treatment modalities
* Good operative risk

Ascites

Hypersplenism

77

What are the endoscopic treatment interventions for oesophageal varices?

Sclerotherapy

Rubber band ligation

78

What are the invasive radiological treatment procedures for oesophageal varices?

Embolisation

Transjugular intrahepatic portosystemic shunt (TIPSS)

79

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

80

What are the complications of the surgical treatment for oesophageal varices?

Hepatic encephalopathy

81

What are the risk factors for hepatocellular carcinoma?

Hep B/C infection

Cirrhosis

Aflatoxin contaminated foods

Alcoholic

82

How would you diagnose a hepatocellular carcinoma?

History - suggestive symptoms and risk factors
* RUQ pain
* Abdominal mass
* Loss of appetite and weight loss
* Jaundice

Examination: Palpable mass / jaundice

Macroscopic features
* 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

83

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

Liver transplant
* Cirrhotic patients

84

What is the management of a non-resectable (not organ-confined) hepatocellular carcinoma?

Intralesional injections with 95% ethanol

Chemotherapy via the hepatic artery

Radiofrequency ablation