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Colorectal and general surgery Flashcards

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1
Q

Name the main scars found from abdominal surgeries

A

Paramedian scar: Used for spleen, kidney, and adrenal operations
Pfannenstiel scar: Incision along pubic hairline – seen in Caesarean section, pelvic, bladder, and prostate surgery
Kocher scar: Gallbladder and biliary tract operations, with an incision inferior and parallel to the costal margin
Chevron (rooftop) scar: Inferior and parallel to both costal margins – associated with gastrectomy, oesophagectomy, bilateral adrenalectomy, hepatic resections, pancreatic operations. A Mercedes-Benz scar is an extension of this incision superiorly and is used for liver transplants
Lanz scar: Made at McBurney’s point and is a horizontal scar. Associated with open appendicectomy. A Gridiron (a.k.a. McBurney’s) scar is parallel to the inguinal ligament and present at McBurney’s point
Rutherford-Morrison (hockey stick) incision: More common in kidney transplants and colonic resections
Mercedes Benz scar: For liver transplant or Whipple’s (in pancreatic cancer)
Midline scar: For major intra-abdominal surgery, typically in an emergency setting (e.g., perforation)

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2
Q

What is the aetiology of burns?

A
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3
Q

What are the types of burns?

A
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4
Q

What are the treatments for burns?

A

Refer if >5% body coverage if full thickness and >10% if partial thickness.

Airway
Breathing and pain management - opioids
IV fluids using Parkland’s formula if >10% coverage in children and 15% in adults
Tetanus nurse
Wound management nurses/ specialists - debridement
Referral

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5
Q

What is the Parkland formula?

A

4 x burn % x weight

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6
Q

What is Mirizzi syndrome?

A
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7
Q

What are the types of cholecystitis?

A
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8
Q

What are the symptoms of cholecystitis?

A
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9
Q

What is first line investigation for cholecystitis?

A

FBC, LFTs and CRP
US
HIDA

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10
Q

How is cholecystitis treated?

A

Depends if calculous or acalculous.
If calculous (90%) use IV fluids, antibiotics and surgery depending on if acute
If acalculous surgery is indicated as an emergency

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11
Q

What is the difference between hot elective and cold elective surgery?

A

> or < 6 weeks

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12
Q

What are the complications of a cholecystectomy?

A

Haemorrhage
Infection
post-cholecystectomy syndrome

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13
Q

What are the complications of cholecystitis?

A

Empyema, gangrenous cholecysititis, perforation, abscess formation, bile duct obstruction

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14
Q

What are the symptoms of ascending cholangitis?

A

Fever, jaundice, and RUQ pain (Reynolds = shock + confusion)

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15
Q

How is ascending cholangitis managed?

A

Gentamicin, routine antibiotics, percutaneous drainage, endoscopic drainage

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16
Q

How is chronic mesenteric ischaemia managed?

A

PTA = percutaneous transluminal angioplasty

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17
Q

What is chronic pancreatitis?
What causes chronic pancreatitis?
What are the symptoms?
What investigations can be done for chronic pancreatitis?

A

Endocrine and exocrine tissue damage of the pancreas caused by calcifications and cysts

80% of cases are caused by alcohol, but can be linked with CF, pancreatic cancer and metabolic causes like hypertryglicrides.

Epigastric pain 15-30 minutes after eating which is relieved by sitting forward. Bloating and weight loss due to malnourishment. Loss of fat soluble vitamins i.e. KADE and high sugars/ endocrine dysfuynction leading to thirst and fatigue.

Glucose, faecal elastase, imaging with CT to show calcification.

Manage pain - coeliac plexus block
Manage malnourishment - CREON
Manage the diabetes - insulin
Reduce alcohol and fatty foods

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18
Q

How are patients with FAP managed if found early?

A

Total colectomy and then ileo-anal pouch formation

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19
Q

What are colonic polyps?

A

Small, benign growths in the intestine.
Can be genetic such as linked to FAP or lynch syndrome, although may be due to a sendentary lifestyle.
Can cause mucus or bleeding in stool, mild abdominal pain.
Endoscopic resection can be done.

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20
Q

What are some risk factors for colorectal factors?

What are some signs of colorectal cancer?

What is TNM staging?

What is the screening for colorectal cancer?

What is the 2WW guideline for colorectal cancer?

What are the investigations for colorectal cancer?

What is the medical management for bowel cancers?

A

Family history like Peutz Jeugherz, FAP, lynch syndrome.
Obesity
Processed meat
Smoking
Alcohol

Bleeding, change in bowel habits, weight loss, IDA, bowel obstruction

T1 = submucosa, T2 = muscularis, T3 = serosal and T4 = outside of bowel. Nodes N1 = 1-4 nodes, N2 = >4 nodes, M0 or M1 if metasteses

60-74, FIT testing, reduces risk of dying by 16%

At 40 or above with Weight or Pain
At 50 or above with weight pain or bleeding
At 60 or above with iron deficiency anaemia

FBC, iron studies and colonoscopy

For patients unsuitable for surgery management is with chemotherapy (FOLFOX or FOLFIRI i.e. oxaliplatin/irinotecan plus folinic acid plus fluorouracil are the preferred regimens). New monoclonal antibody therapies are becoming available. Note that NICE concluded that cetuximab (anti-EGFR),

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21
Q

What determines whether an AP resection or anterior resection is done for rectal cancer?

A

For patients with rectal cancer suitable for surgery: Anterior resection for tumours >8 cm from the anal canal or involving the proximal 2/3 of the rectum. Abdomino-perineal (AP) resection for tumours <8 cm from the anal canal or involving the distal 1/3 of the rectum.

Patients with stage III disease benefit from adjuvant chemotherapy.

Patients with stage IV disease benefit from adjuvant chemoradiotherapy

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22
Q

How is colon cancer treated surgically?

A

Stage I-III disease: surgical resection ± adjuvant chemotherapy.
Stage IV - neoadjuvant as well

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23
Q

What is Gardener’s syndrome?

A

Gardener’s syndrome is a variant of FAP in which patients may also develop epidermal cysts, supernumerary teeth, osteomas, and thyroid tumours.

Pancolectomy before 20

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24
Q

What is Lynch syndrome?

A

Is caused by a mutation in the mismatch repair genes MLH1/MSH2 and has an autosomal dominant inheritance pattern.

Patients have an 80% risk of developing colorectal cancer by their 30s.

There is increased risk of additional cancers such as gastric, endometrial, breast, and prostate cancer.

Patients are managed with regular endoscopic surveillance.

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25
What is Peutz Jeugherz?
Is caused by a mutation in the STK11 gene and has an autosomal dominant inheritance pattern. Patients typically present in their teens with mucocutaneous pigmentaiton and hamartomatous polyps.
26
How are anal fistulas managed?
Fistulotomy and seton placement
27
What are the types of bowel resection?
28
What are absolute contraindications for laproscopic surgery?
Obvious indication for open therapeutic intervention – Perforation, peritonitis, known intra-abdominal injury, complications of previous surgery, shock, evisceration or abdominal wall dehiscence Acute intestinal obstruction associated with a massive (>4 cm) bowel dilatation – Can obscure the view making intervention harder. Uncorrected coagulopathy – INR should be corrected to at least < 1.5, although some surgeons prefer INR to be even lower than this. Tense or distended abdomen – Suspected intra-abdominal compartment syndrome Trauma with hemodynamic instability Clear indication of bowel injuries (e.g. presence of bile or evisceration
29
Compare and contrast direct and indirect inguinal hernias.
Direct is more commonly seen in older men and is linked to a hernia within Hesselbach's triangle. Indirect is more common in young males and is linked with a patent processus vaginalis.
30
What are the features of a strangulated hernia?
Strangulated hernias are more painful (due to ischaemia), and present with nausea and vomiting and fever. They may present with bowel obstruction, and there can be reduced/absent bowel sounds.
31
How are hernias managed?
All hernias, irrespective of whether they are symptomatic or asymptomatic, should be referred for surgical repair. This typically involves open or laparoscopic mesh repair. Indirect hernias particularly require intervention due to the risk of strangulation. Strangulated hernias are a surgical emergency and require prompt treatement with laparoscopic/open repair to avoid necrosis (death of bowel tissue).
32
How are children with inguinal hernia managed?
If there is a suspected serious complication such as strangulation or intestinal obstruction, arrange emergency hospital admission. If hospital admission is not needed: For children and young people aged less than 18 years: Arrange urgent referral to a paediatric surgeon, preferably to be seen within 2 weeks.
33
How are adults with inguinal hernia managed?
Arrange urgent referral to paediatric or general surgery to consider surgical management if the hernia is irreducible, or only partially reducible. Offer routine referral to paediatric or general surgery to consider surgical management if the hernia is symptomatic but reducible, depending on clinical judgement.
34
What are the symptoms of diverticulitis?
Left lower quadrant abdominal pain Fever Nausea/vomiting Pyrexia and left lower quadrant tenderness/guarding on physical examination Diffuse abdominal tenderness suggestive of perforation or generalised peritonitis.
35
What are risk factors for diverticulitis?
Age, Obesity Low fibre diet Sedentary NSAIDs
36
Outline some complications of diverticulitis.
Short-term complications include: Abscess formation: Initially managed with bowel rest, broad-spectrum antibiotics ± CT-guided percutaneous drainage. Surgical management is considered if medical management fails. Perforation: A surgical emergency suspected in cases of generalised peritonitis. Free air on the abdominal x-ray and high clinical suspicion necessitate urgent exploratory laparotomy. Long-term complications include: Fistula formation: Most commonly colovesical fistulas, presenting with pneumaturia, faecaluria, and recurrent UTIs. Diagnosed with cystoscopy or cystography and require surgical repair. Colovaginal, coloenteric, colouterine, and colourethral fistulas may also occur. Fibrosis: Secondary to inflammation, resulting in strictures and large bowel obstruction.
37
What is the Hinchey classifcation?
38
How is diverticulitis managed?
Colonoscopy FBC antibiotics, hydration and analgesia i.e. paracetemol
39
What are some differentials for dysphasia?
Solid not liquids - Pain Initiating swallow Neck bulge Spasms
40
What are some investigations for dysphagia?
Oesophageal/gastric cancer - Offer urgent OGD (to be performed within 2 weeks) in people with dysphagia or those aged 55 years and over with weight loss and any of the following: upper abdominal pain, reflux, or dyspepsia. Additional investigations may include: Blood tests for associated conditions (e.g. iron studies in suspected Plummer-Vinson syndrome) Barium swallow (looking for a pharyngeal pouch; bird-beak tapering in achalasia; corkscrew appearance in oeseophageal spasm) Manometry (gold standard for achalasia) 24-hour pH monitoring
41
What conservative management should always be considered for dysphagia?
SALT assessment and swallowing therapy with a speech-language specialist This may result in introduction of thickening agents in food and drinks to aid swallowing Psychological support for globus
42
How are femoral hernias treated?
Given the high risk of strangulation, which can lead to bowel ischemia and necrosis, urgent surgical management of femoral hernias is generally required.
43
What are ALARM symptoms?
anaemia, loss of weight, anorexia, recent onset of symptoms, malaena/haematemesis
44
Outline the main causes of gastric cancer.
Atrophic gastritis Achlorydia H pylori Smoking Nitrosamines High alcohol use
45
How are thrombosed haemorrhoids treated?
For thrombosed haemorrhoids, which present as painful, purple protrusions, conservative measures such as ice packs, laxatives, and lidocaine gel are first-line treatments. If these measures fail, haemorrhoidectomy may be required.
46
How are internal haemorrhoids managed?
Grade 1: Conservative management, including potential use of topical corticosteroids to alleviate pruritus Grade 2: Management may involve rubber band ligation (preferred), sclerotherapy, or infrared photocoagulation Grade 3: Rubber band ligation is the treatment of choice Grade 4: Surgical haemorrhoidectomy may be necessary In all cases, patients should be advised to maintain a diet rich in fibre and fluids to reduce the risk of constipation, thereby limiting exacerbation of haemorrhoids.
47
How is HCC managed?
Curative treatment options for HCC include hepatic resection if the lesion is < 3cm Percutaneous radiofrequency ablation and tumour embolisation are additional options, with sorafenib one of the few licensed medications that may be used. Liver transplantation may be required. Palliative care may be required for patients with advanced disease. Regular follow-up and monitoring are essential for all patients. Due to a lack of treatment options, prevention is key, with important preventative measures including HBV vaccination, needle exchange programmes, blood transfusion screening and reducing aflatoxin exposure
48
What are some less common hernias?
Epigastric hernia Spligenian hernia Richter's hernia Obturator hernia
49
What is the Howship-Romberg sign?
(paraesthesia along the medial thigh - the 'Howship-Romberg sign')
50
What are the 5Ws?
Post-operative pyrexia, or fever following surgery, can be the result of several causes, commonly remembered by the "5 Ws" mnemonic: Wind (pneumonia and atelectasis), Water (urinary tract infection), Wound (infection), Wonder drugs (anesthetic reactions), and Walking (deep vein thrombosis).
51
What is a sign of severe pancreatitis?
Whilst hypercalcaemia can cause pancreatitis, hypocalcaemia is an indicator of pancreatitis severity
52
How is acute cholecystitis treated?
Acute cholecystitis treatment: intravenous antibiotics + early laparoscopic cholecystectomy within 1 week of diagnosis
53
What is a Richter's hernia?
54
What is Littre's diverticulum?
55
What is dumping syndrome?
Dumping syndrome, which can be divided into early and late, may occur following gastric surgery. It occurs as a result of a hyperosmolar load rapidly entering the proximal jejunum. Osmosis drags water into the lumen, this results in lumen distension (pain) and then diarrhoea. Excessive insulin release also occurs and results in hypoglycaemic symptoms.
56
How is acute cholecystitis measured?
Acute cholecystitis treatment: intravenous antibiotics + early laparoscopic cholecystectomy within 1 week of diagnosis
57
How is ascending cholangitis managed?
The majority of patients diagnosed with ascending cholangitis will undergo ERCP after 24-48 hours to relieve any obstruction
58
What is a contraindication to laproscopic surgery?
Acute intestinal obstruction with dilated bowel loops is a contraindication to laparoscopic surgery
59
T or F, the vast majority of umbilical hernias will resolve naturally?
T
60
What is a sphincterotomy used for?
To manage fissures
61
What is the rule with giving fluids in burns?
The Parkland formula is used to calculate the amount of fluid to give in the first 24 hours after burns, with half being given in the first 8 hours
62
T or F, Raised CA 19-9 levels may be seen in patients with cholangiocarcinoma - may be useful for patients with PSC
T
63
What can cause pain and jaundice following cholecystectomy?
Gallstones may be present in the CBD causing ongoing jaundice and pain after cholecystectomy
64
How is a fissure treated in less than a week?
Acute anal fissure (< 1 week): soften stool, dietary fibre, analgesia and topical anaesthetic cream if necessary
65
How is a fissure treated in more than a week?
Diltiazem and GTN
66
How should patients with diverticulitis be managed?
Patients with diverticulitis flares can be managed with oral antibiotics at home. If they do not improve within 72 hours, admission to hospital for IV ceftriaxone + metronidazole is indicated
67
What is the link between fibromuscular obliteration and solitary rectal ulcer?
These patients require careful diagnostic work up to elicit the underlying cause of their altered bowel habit. The histological appearances of solitary rectal ulcers are characteristic and extensive collagenous deposits are often seen. This is usually termed fibromuscular obliteration.
68
When is a femoral hernia treated?
Within 2 weeks
69
How is a sigmoid volvulus managed when there is peritonitis?
In patients with sigmoid volvulus who have bowel obstruction with peritonitis, skip the flexible sigmoidoscopy and treat with urgent midline laparotomy. Urgent laparotomy is needed to avoid bowel necrosis or perforation.
70
What is the most common cause of large bowel obstruction?
Bowel cancer is the most common cause of large bowel obstruction
71
What are useful prognostic factors for acute pancreatitis?
Blood glucose and calcium
72
What is the risk of strangulation with inguinal hernias?
The annual probability of strangulation is up to 3% and is more common in indirect hernias.
73
What is needed for a diagnosis of acute pancreatitis?
The most helpful investigation is a serum lipase, looking for an elevation of more than 3 times the upper limit of normal
74
What are some indications for a splenectomy?
Indications for splenectomy include: Uncontrollable splenic bleeding Hilar vascular injuries Devascularised spleen
75
What is shown here?
Calcifications of pancreas
76
What types of shock cause warm peripheries?
Neurogenic, septic, and anaphylactic shock (together are all distributive shock) will cause warm peripheries, with the others causing cool peripheries
77
What imaging is required for a bowel obstruction?
CT Gastrograffin
78
When is drip and suck not indicated for a bowel obstruction?
If strangulation has occurred
79
What is Ogilvie syndrome?
Pseudo-obstruction
80
What are the types of bowel obstruction?
Mechanical Non mechanical: paralytic ileus and pseudoobstruction (Ogilvie)
81
What is Richter's hernia?
Involves the bowel wall, not the lumen
82
How are inguinal hernias repaired?
Weight loss Smoking cessation Lichenstein's repair Rest for four weeks

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