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Year 4 > Acute surgery > Flashcards

Acute surgery Flashcards

1
Q

What is the peak age of incidence for appeenicitis

A

early teens to early twenties

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2
Q

What are the three types of appendicitis

A
  • mucosal
  • phlegmonous
  • necrotic
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3
Q

Describe the symptoms of appendicitisi

A
  • anorexia, fever, malaise
  • abdominal pain which starts centrally and localises to the RIF
  • diarrhoea is common
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4
Q

What are the clinical signs of appendicitis

A
  • fever, tachycardia
  • abdominal tenderness +/- peritonitis if perforated
  • tenderness over McBurney’s point
  • Rovsing’s sign
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5
Q

What is Rovsing’s sign

A

Palpation of LIF causes pain worsening over RIF

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6
Q

Give some differentials for appendicitis

A
  • Meckel’s diverticulum
  • tubo-ovarian pathology
  • ectopic pregnancy
  • crohn’s
  • gastroenteritis
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7
Q

How would you investigate ?appendicitis

A
  • diagnosis is usually clinical and investigations are usually unneccessary
  • CT is appropriate if needed
  • USS if ?tubo-ovarian pathology
  • Bloods (FBC, WCC, CRP, amylase, G+S, U&Es)
  • laparoscopy
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8
Q

What surgery is indicated in acute appendicitis

A

open or laparoscopic appendicectomy

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9
Q

What abx are given for appendix mass or abscess

A

metronidazole 500mg IV tds + cefuroxime 750mg IV tds

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10
Q

What is the sole blood supply of the appendix

A

appendicular artery - a terminal branch of the ileocolic)

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11
Q

Give some conditions which predispose to gall stone formation

A
  • hypercholesterolaemia
  • obesity
  • chronic haemolytic disorders
  • long-term parenteral nutrition
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12
Q

Describe biliary colic

A

intermittent severe epigastric and RUQ pain usually with n + v
tenderness may localise to gall bladder

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13
Q

What clinical sign is indicative of cholecystitis? Describe the sign

A

Murphy’s sign

- tenderness over gallbladder during inspiration

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14
Q

Descibe some complications of acute cholecystitis

A
  • formation of empyema or abscess of the gallbladder
  • perforation with biliary peritonitis
  • cholecystontri fistula formation (may la to gallston ileus)
  • jaundice due to compression of the adjacent common bile duct
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15
Q

What is Mirizzi syndrome

A

jaundice due to compression of the common bile duct

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16
Q

What investigations should be ordered for ?biliary colic

A
  • bloods (FBC, U&Es, amylase, LFTs, CRP, blood culture)

* ultrasound

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17
Q

What is the procedure of choice for diagnosis of biliary colic

A

ultrasound

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18
Q

How is cholecystectomy usually performed

A

laparoscopically

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19
Q

What management option may be used if the patient is too unwell for cholecystectomy

A

cholecystostomy

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20
Q

What are the commonest causes of pancreatitis

A
  • gallstones
  • alcohol
  • hyperlipidaemia
  • trauma
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21
Q

What does the acronym IGETSMASHED stand for in regards to causes of acute pancreatitis

A 
Idiopathic
Gallstones
Ethanol
Trauma (to pancreas)
Steroids
Mumps
Autoimmune
Scorpion sting!
Hyperlipidaemia + hypercalcaemia
ERCP
Drugs
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22
Q

What are the three types of acute pancreatitis

A
  • oedematous
  • severe/necrotising
  • haemorrhagic
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23
Q

What is the most common type of acute pancreatitis

A

Oedematous

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24
Q

What are some symptoms of acute pancreatitis

A
  • severe epigastric pain radiating to the back
  • severe nausea and vomiting
  • fever, dehydration, hypotension, tachycardia
  • epigastric tenderness associated with guarding +/- rigidity in severe cases
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25
Q

What are the two clinical signs associated with haemorrhagic pancreatitis

A
  • cullen’s sign - periumbilical ecchymosis

* grey-turner’s sign - left flank ecchymosis

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26
Q

What bloods should be saved in ?acute pancreatitis

A
  • FBC, CRP, WCC
  • amylase
  • U&Es
  • LFTs
  • coag
  • group and save
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27
Q

What score is used to assess severity of an acute pancreatitis attack

A

Glasgow Imrie criteria

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28
Q

What level of serum amylase is diagnostic of acute pancreatitis

A

> 1000U (but may be normal even in severe cases)

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29
Q

What other causes may there be for elevated serum amylase

A
  • intestinal ischaemia
  • leaking aneurysm
  • perforated ulcer
  • cholecystitis
  • ovarian tumours can also elevate amylase
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30
Q

What imaging must be ordered - in which order of importance - for ?acute pancreatitis

A
  • USS
  • AXR
  • CT
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31
Q

How is acute pancreatitis treated?

A
  • maybe antibiotics
  • CT scan to identify development of phlegmon, necrosis, or haemorrhage
  • fluid and nutritional support
  • surgical debridement may be required in infected necrotic pancreatitis but is associated with a very poor prognosis
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32
Q

What predicts mortality in acute pancreatitis

A
  • pancreatic necrosis

* presence of sepsis, including MODS`

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33
Q

What is the only absolute indicate for surgery for acute pancreatitis

A

infected pancreatic necrosis

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34
Q

What is acute peritonitis defined as

A

acute inflammation in th peritoneal cavity

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35
Q

What is primary peritonitis

A

typically a streptococcal infection

36
Q

What are common causes of secondary peritonitis

A
  • perforated appendicitis
  • perforated peptic ulcer
  • perforated diverticular disease
  • pancreatitis
  • perforated ischaemic bowel or tumour
  • post-surgical intervention
37
Q

What are symptoms of acute peritonitis

A
  • anorexia and fever
  • severe generalised abdominal pain radiating to shoulders and back
  • abdo pain worse when moving, coughiing, sneezing
38
Q

What signs might you find on examination of a patient with acute peritonitis

A
  • guarding, abdominal tenderness, tenderness on percussion, board-like rigidity
  • fever, tachycardia
39
Q

What bloods should you order for acute peritonitis

A 
FBC (WCC, Hb)
CRP
U&Es (Na, K)
LFTs
group + save
Coag
Amylase
40
Q

Most causes of acute peritonitis require surgery - in which case is surgery usually contraindicated?

A

acute pancreatitis

41
Q

What is the imaging investigation of choice for diagnosing most peritonitis

A

CT abdo

42
Q

What IV antibiotics should be started especially if surgery is likely in peritonitis

A

metronidazole 500mg IV tds + cefuroxime 750mg IV tds

43
Q

What is diverticular disease

A

development of outpouchings of colonic mucosa which can become inflamed

44
Q

What age group of diverticulosis common in

A

50-70 - although it is inreasing in frequency in younger patients

45
Q

How does acute diverticuliris present

A
  • sudden onset left iliac fossa pain with fever, nausea and frquntly with loos stools
  • tachycardia common
46
Q

What are the main concerning complications of diverticular disease

A
  • paracolic/pericolic mass/abscess
  • fistula
  • peritonitis (2* to perforation)
  • striture formation
47
Q

Where does diverticular disease commonly form a fistula?

A

typically the vagina in females or bladder in both sexes

colovaginal/colovesical

48
Q

How is diverticular disease usually diagnosed?

A

double contrast barium enema

49
Q

How are acute complications of diverticular disease diagnosed

A

usually with CT scan

50
Q

What IV abx should you give for acute diverticulitis

A

metronidazole 500mg IV tds + cefuroxime 750mg IV tds

51
Q

What preventitive abx can you give for recurrent episodes of acute diverticulitis

A

ciprofloxacin 500mg PO od (6 week course)

52
Q

What does melaeena imply

A

bleeding proximal to the splenic flexure of the colon

53
Q

Give some common causes of upper GI bleeding

A
  • peptic ulcer
  • gastritis/oesophagitis
  • Mallor-Weiss tear
  • NSAIDs, steroids, thrombolytics, anti-coagulants
54
Q

What might a history of heavy alcohol use or stigmata of liver disease indicate in UGIB

A

Bleeding oesophgeal varices or gastritis

55
Q

How is UGIB managed

A
  • cross-match blood
  • 2 wide bore IVs if haemodynamically unstable
  • endoscopy often indicated
56
Q

Which scoring system can be used to determine risk and indication for endscopy in UGIB

A

Glasgow-Blatchford score

57
Q

Give some common causes of lower GI bleeding

A
  • diverticulitis
  • bleeding vascular ectasias
  • colorectal cancer
  • haemorrhois
  • IBD
  • Meckel’s diverticulum
58
Q

Which bloods should be ordered for a LGIB

A 
FBC
LFTs
U&Es
CRP
Glucose
Amylase
Coagulation
Group and save
59
Q

What imaging might you order for LGIB

A
  • erect CXR?

* upper endoscopy may be indicated if there is haemodynamic instability

60
Q

What fluid managment should be set up for LGIB

A
  • 2 wide bore IV
  • fluid challenge crystalloid
  • urinary cath and monitor output
61
Q

What IV abx might you commence in LGIB with ?sepsis or perforation?

A

metronidazole 500mg IV tds + cefuroxime 750mg IV tds

62
Q

If a patient with an LGIB feels the need to get out of bed to pass stool, why should you not allow them to get out of bed?

A

It may be another large bleed which could result in collapse if they try to walk

63
Q

What does SIRS stand for

A

systemic inflammatory response syndrome

64
Q

What is SIRS

A

a pro-inflammatory state that does not include a documented source of infection

65
Q

What is MODS?

A

multiple organ dysfunction syndrome

66
Q

What signs in a normal set of obs may indicate sepsis?

A
  • tachycardia >90bpm
  • tachypnoea
  • pyrexia
67
Q

What is the ‘take 3 give 3’ rule for sepsis?

A

Take cultures, measure urine output, and lactate

Give oxygen, fluid challnge, an IV abx

68
Q

At what diameter is surgery indicated for AAA

A

> 5.5cm

69
Q

What are the three broad groups in ruptured AAAs

A
  • those who are unsuitable for surgery
  • contained leak
  • free rupture
70
Q

What symptoms are suggestive of ruptured AAA

A
  • sudden severe epigastric pain radiating to back or loin

* collapse due to hypotension

71
Q

Why should you not immediately give fluids/blood in ruptured AAA?

A

permissable hypotension

72
Q

What is the ‘drapd aorta’ sign indicative of on CT

A

impending AAA ruptur or contained leakage

73
Q

What is the basic principles of AAA rupture repair surgery

A
  • clamp superior abdominal aorta
  • introduce graft
  • close sac over graft
  • revascularise
74
Q

What are possible complications of AAA rupture surgery

A
  • lower limb embolism
  • gut ischaemia/infarct
  • renal failure
  • death
75
Q

Is a AAA usually above or below the level of the renal arteries

A

below

76
Q

What are the 6 Ps of acute limb ischaemia

A 
Pulseless
Pallor
Perishingly cold
Paraesthesia
Paralysis
Pain
77
Q

What are the two main causes of acute limb ischaemia

A
  • emboli

* acute thrombosis in a vessel with pre-existing atherosclerosis

78
Q

What are rare causes of acute limb ischaemia

A
  • aortic dissection
  • intra-arterial drug use
  • trauma
  • peripheral aneurysm (particularly popliteal)
    Iatrogenic injury
79
Q

What are the two main complications of acute limb ischaemia

A

death

limb loss

80
Q

In what time period does acute limb ischaemia cause irreversible damage

A

6 hours

81
Q

What bloods should be taken in acute limb ischaemia

A 
FBC
Troponin
Glucose
Clotting
Group and Save
82
Q

What dose and analgesia is recommended for acut limb ischaemia

A

5-10mg morphine IM

83
Q

What clinical signs indicate that the limb ischaemia is irreversible? What does this mean?

A
  • fixed mottling
  • woody muscles painful to touch
  • petechial haemorrhages in skin
  • the limb cannot be saved, so amputation is the only option
84
Q

What are the three categories of limb viability

A
  • irreversible
  • complete
  • incomplete
85
Q

What systemic complications will arise from failing to amputate an irreversibly ischaemic limb

A
  • hyperkalaemia
  • acidosis
  • acute renal failure
  • cardiac arrest

Year 4 (13 decks)

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