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Abdominal Surgery Flashcards

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1
Q

What are the most common histological types of oesophageal cancer?

A

Squamous cell carcinoma of the upper oesophagus

Adenocarcinoma of the distal oesophagus - junction of the oesophagus and stomach

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2
Q

What are the risk factors for SCC of the oesophageal?

A

Low socioeconomic groups

Smoking

Alcohol

Males

Age +60

HPV infection

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3
Q

What are the risk factors for adenocarcinoma of the oesophagus?

A

Barrett’s oesophagus

GERD

Obesity

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4
Q

What are the symptoms of oesophageal cancer?

A

Dysphagia

Pain

Hoarseness

Cough with swallowing - oesophageal-tracheal fistula

Weight loss

Neck mass

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5
Q

What are the signs of oesophageal cancer?

A

Cervical lymph nodes

Hypercalcaemia - parathyroid hormone production

Dehydration, weight loss and muscle wasting

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6
Q

How is oesophageal cancer diagnosed?

A

History - Risk factors, symptoms

Examination - signs

Barium swallow

Endoscopy - direct visualization

FNA our Biopsy - histology

CT scan

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7
Q

What is the management of oesophageal cancer?

A

Surgical resection - oesophagectomy

Neoadjuvant Radiotherapy

Neoadjuvant Chemotherapy

Intubation - expandable stents insertions

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8
Q

What are the contraindications for surgery in oesophageal cancer?

A

Metastasis

Invasion of adjacent structures

Severe associated co-morbid diseases

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9
Q

What is the epidemiology of peptic ulcer disease?

A

Helicobacter pylori infection

NSAIDs

Acid hypersecretion

Smoking and alcohol

Genetic predisposition

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10
Q

What are the symptoms of peptic ulcer disease?

A

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

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11
Q

How would you diagnose peptic ulcer disease?

A

Gastroscopy - allows for biopsy to confirm/rule-out H.pylori or malignancy

Barium meal - seldom used

Gastrin levels - zollinger ellison syndrome

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12
Q

Describe the classification of gastric ulcers according to the Gaintree-Johnson classification

A

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

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13
Q

What are the complications of peptic ulcer disease?

A

Bleeding

Perforation

Stomach outlet obstruction

Penetration

Malignancy

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14
Q

What are the indications for surgery for peptic ulcer disease?

A

Non-healing ulcer

Perforation

Bleeding ulcer

Stomach outlet obstruction

Penetration into adjacent organs

Malignant transformation

Bile duct stricture

Fistulation

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15
Q

How do you manage Duodenal ulcers?

A

Truncal vagotomy with antrectomy - most effect acid reducing procedure

Truncal vagotomy with drainage procedure - for ineffective stomach emptying

Highly selective vagotomy

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16
Q

How do you manage gastric ulcers?

A

Type 1: Partial gastrectomy

Type 2: Truncal vagotomy with antrectomy/drainage

Type 3: Truncal vagotomy with antrectomy/drainage

Type 4: Partial gastrectomy (Pauchet procedure)

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17
Q

What are the clinical finding of a perforated peptic ulcer?

A

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

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18
Q

What is the management of a perforated peptic ulcer?

A

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

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19
Q

When can a definitive ulcer operation be performed?

A

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

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20
Q

What are the complications of a gastrectomy?

A

Bleeding

Anastomoses leakage

Obstruction

Ulcer recurrence

Gastro-jejuno-colic fistula

Alkaline reflux gastritis

Dumping syndrome

Chronic gastroparesis

Malabsorption - anaemia

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21
Q

What are the risk factors for gastric cancer?

A

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

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22
Q

Describe Lauren’s classification for intestinal gastric adenocarcinoma

A

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

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23
Q

Describe Lauren’s classification for diffuse gastric cancer

A

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

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24
Q

How would a patient with a gastric adenocarcinoma present?

A

Epigastric discomfort / indigestion

Weight loss, vomiting, anorexia

Dysphasia

Gastric outlet obstruction

Early satiety

Anaemia

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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

General Surgery (7 decks)

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