Gen surg Flashcards
laparotomy:
opening up of abdo
laparoscopy:
keyhole surgery on the abdo
adhesions:
scar tissue in the abdo that attach contents together
volvulus:
twisting of colon
tenesmus:
symptom of full rectum/needing to open bowels after emptying bowels
hemicolectomy:
removal of a portion of the bowel
hartmann’s procedure:
removing rectum and or sigmoid colon and forming a colostomy
three main causes of intestinal adhesions:
previous surgery
peritonitis
intra-abdominal infection
kocher incision:
open cholecystectomy
mercedes benz incision?
liver transplant
young female with generalised abdo pain which becomes RIF pain over a few days - important ddx:
sounds like apendicitis
in this demographic - preg ix
gynae causes
set of acute abdominal investigations:
FBC, U&E, LFTs, cultures, amylase, VBG, CRP, clotting, 2xG&S, b-hCG
preg ix
urine dip
what does air under the diaphragm on an erect CXR indicate?
perforation
“tinkling bowel sounds” on auscultation =?
obstruction buzzword
what needs ruling out in elderly male with epigastric pain?
MI - do an ECG
on abdominal X-ray - thresholds for obstruction on each region of bowel?
small bowel - >3cm. central regions
large bowel - >6cm. peripheral region
cecum - >9cm.
elderly male man with AF, smoker, generalised abdo pain 10/10 pain minus guarding disproporationate to exam findings with a raised lactate.
pain can be in umbilical region - dx?
mesenteric ischemia
pathology of mesenteric ischemia?
clot in vessels supplying bowel -> ischemia
set management plan for acute abdomen (5+1):
analgesia (can still give opioids if ?obstr) anti-emetic IVI monitor urine output + cath NBM pending snr rv (Abx)
key cx of pancreatitis?
necrosis, ARDS, DIC, pseudocysts
which condition requires aggressive IV fluid resus?
pancreatitis - due to massive 3rd space losses
1st line (and sequential ix) for billiary pathology:
USS abdo
IF shows CBD dilatation => MRCP
IF shows gallstones => ERCP (to remove)
2 commonest causes of pancreatitis?
gallstones
ethanol
increased amylase and deranged LFTs: dx:
gallstone pancreatitis
when to CT in ?billiary pathology?
if ?perforation
or very septic
causes of small bowel obstruction:
adhesions (post-sx) hernias tumours IBD intussusception
causes of large bowel obstruction:
tumours
volvulus
diverticular disease
mx obstruction:
IVI, NG - drip and suck
what is pseudo-obstruction?
“ileus”
adynamic bowel minus mechanical obstruction
causes of ileus:
hypocalcaemia, other electrolyte imbalances
hypothyroid
MS
post-surgical
differentiating between types of shock by temperature of peripheries?
neurogenic, septic and anaphylactic (together called distributive) -> warm peripheries
rest cause cool peripheries
28-m BIBA to ED. RTA. wearing his seatbelt during the accident, and did not exit the vehicle as a result of the collision. Appears confused, has bruising and pulsatile swelling over the right side of his neck and eventually becomes unresponsive. He also appears to have a fractured nose and has multiple lacerations across his face including his lips. dx?
carotid artery laceration
pulsatile mass and swelling would suggest ?
carotid artery laceration
discoloured purple non-demarcated area to the left of the umbilicus. Palpation of the abdomen demonstrates tenderness localised to a firm non-pulsatile mass just to the left of the midline at the level of the umbilicus. There is no guarding or rigidity. Bowel sounds are present.
What is the most likely cause of this mans symptoms?
abdo wall haematoma
In those diagnosed with anal fistula, what is best ix to characterise the course of the fistula?
MRI pelvis
A 74-year-old male is in recovery following carotid endarterectomy for an 80% stenosis of the carotid artery. Following an uneventful period in recovery the registrar assessed this gentleman’s cranial nerves. When asked to poke his tongue out there is deviation to the right toward the right side of the patient. What nerve has been affected?
right hypoglossal
26-f ED sudden onset lower abdominal pain past 2 hours. sexually active and not having used condoms. She has not had a sexual health screen but has a long-term partner. On examination, she is tender in the right iliac fossa with a heart rate of 100 bpm, blood pressure 120/75mmHg and temperature 37.8ºC. Which investigation should be performed first?
urine pregnancy test
congenital inguinal hernia - mx?
surgical repair immediately
congenital umbilical hernia - mx?
conservative mx
resolves 4-5yo
A 22-year-old man suffers 20% partial and full thickness burns in a house fire. There is an associated inhalational injury. It is decided to administer intravenous fluids to replace fluid losses. Which of the intravenous fluids listed below should be used for initial resuscitation?
hartmanns or NS
A 19-year-old student falls from a 2nd-floor window. He is persistently hypotensive. A chest x-ray shows a widened mediastinum with depression of the left main bronchus and deviation of the trachea to the right. What is the most likely injury?
aortic rupture
Valvulae conniventes (haustra) extend all the way across in?
small bowel obstruction
Haustra extend about a third of the way across in?
large bowel obstruction
A 19-year-old female presents with severe anal pain and bleeding which typically occurs post defecation. On examination she has a large posteriorly sited fissure in ano.
tx?
topical diltiazem
A 43-year-old male has been troubled with symptoms of post defecation bleeding for many years. On examination he has large prolapsed haemorroids, colonoscopy shows no other disease.
tx?
haemorrhoidectomy
A 20-year-old man presents with a 24 hour history of anal pain. On examination he has a peri anal abscess.
tx?
incision and drainage
would have fevers
A 42-year-old lady has suffered from hepatitis C for many years and has also developed cirrhosis. On routine follow up, an ultrasound has demonstrated a 2.5cm lesion in the right lobe of the liver.
dx?
HCC
A 25-year-old man from the far east presents with a fever and right upper quadrant pain. As part of his investigations a CT scan shows an ill defined lesion in the right lobe of the liver.
dx?
amoebic abscess
tx amoebic abscess?
metronidazole
A 42-year-old lady presents with right upper quadrant pain and a sensation of abdominal fullness. An ultrasound scan demonstrates a 6.5 cm hyperechoic lesion in the right lobe of the liver. Serum AFP is normal.
dx?
haemangioma
A 17-year-old male is admitted with lower abdominal discomfort. He has been suffering from intermittent right iliac fossa pain for the past few months. His past medical history includes a negative colonoscopy and gastroscopy for iron deficiency anaemia. The pain is worse after meals. Inflammatory markers are normal.
dx?
meckels diverticulum
A 14-year-old female is admitted with sudden onset right iliac fossa pain. She is otherwise well and on examination has some right iliac fossa tenderness but no guarding. She is afebrile. Urinary dipstick is normal. Her previous menstrual period two weeks ago was normal and pregnancy test is negative.
dx?
mittelschmerz
A 21-year-old male is admitted with a 3 month history of intermittent right iliac fossa pain. He suffers from episodic diarrhoea and has lost 2 kilos in weight. On examination he has some right iliac fossa tenderness and is febrile.
dx?
crohns disease
A 72-year-old woman who takes regular laxatives comes to surgery. Over the past two days she has developed progressively worse pain in the left lower quadrant. On examination she has a low-grade pyrexia and is tender on the left side of the abdomen
dx?
diverticulitis
sigmoid colon
A 37-year-old attends surgery due to a one day history of severe central abdominal pain radiating through to the back. He has vomited several times and is guarding on examination. Parotitis and spider naevi are also noted.
dx?
acute pancreatitis
early IVI
A 49-year-old woman presents with pain in the right upper quadrant. This has been occurring for the past 3 months and is often precipitated by a heavy meal. When the pain comes it is typically lasts around 1-2 hours. Clinical examination is unremarkable other than mild tenderness in the right upper quadrant.
biliary colic
class III shock is?
tachycardia, hypotension and confusion
class I shock is?
fully compensated for
Class II shock is?
tachy
class IV shock is?
LOC , severe hypotension
18-f ED 2 days lower abdominal pain, nausea and vomiting, and has not opened her bowels for 24 hours. She has mild dysuria and her last menstrual period (LMP) was 21 days ago. Smokes 20/day and drinks 15 alcohol/wk. On examination she is haemodynamically stable, with pain in the right iliac fossa. Urinary pregnancy and dipstick are both negative. Which one of the following is the most likely diagnosis?
appendicitis
ddx mittleschmertz (if mid-cucle and normal inflammatory markers)
A patient undergoes a right total hip arthroplasty (THA) via a posterior approach. Post operatively she complains of inability to dorsiflex her right foot.
What nerve may have been injured during the procedure?
sciatic nerve
A 40-year-old women is being investigated for haematuria. She was living with her sister who has just died from a sub arachnoid haemorrhage. The haematuria is painless and she has mild renal impairment.
dx?
PKD
A 75-year-old lady is investigated for episodes of painless haematuria. Apart from COPD from long term smoking she is otherwise well. She has no other urinary symptoms.
dx?
transitional cell carcinoma of the bladder
90%
A 78-year-old man has a long history of nocturia, urinary frequency and terminal dribbling. He was admitted with urinary retention and was catheterised. On removal of the catheter he has noticed some haematuria.
dx?
BPH
where does the duodenum become the jejenum?
ligament of treitz
which branch of the aorta supplies the oesophagus-duodenum (including liver and gallbladder):
coeliac trunk
which branch of the aorta supplies the duodenum- first 2/3 of the transverse colon?
superior mesenteric artery (SMA)
which branch of the aorta supplies the final 1/3 of the transverse colon - rectum?
inferior mesenteric artery (IMA)
what is murphy’s sign and what does it indicate?
tender on inspiration in RUQ
inflammation of the gallbladder
what is Rosvig’s sign and what does it indicate?
tender RIF when press on LIF
appendicitis
what is the psoas strech a sign of and how is it illicited?
appendicitis
RIF pain when straight leg raise
what is rebound tenderness and what does it indicate?
pain when take hand away -
peritonitis / abdo wall pathology
what are tinkling bowel sounds and what do they indicate?
high pitch bowel sounds
obstruction
gallstones + deranged LFTs =
ascending cholangitis (doesn't necessarily present as jaundiced skin/eyes)
what is biliary colic?
pain due to gallstones WITHIN the gallbladder minus infection minus LFT derangement
what is cholecystitis?
infection of the gallbladder - due to gallstones
what abx is usually added to coamox when suspected ascending cholangitis?
gentamycin
what is the minimum EGFR for a CT-AP? (contrast obvs come on lad)
30
mx faecal impaction?
PR then phosphate enema if stool felt in rectum on PR
mx volvulus?
flatus tube
poonami
coffee bean sign on x-ray?
sigmoid volvulus
red flags for hernias:
red, pain, irreduceable, obstruction, peritonism, if the hernia contains bowel
why should you avoid metaclopramide in obstruction?
it is a pro-kinetic - will make things worse la
16M severe groin pain after kicking a football. Imaging confirms a pelvic fracture. A previous pelvic x-ray performed 2 weeks ago shows a lytic lesion with ‘onion type’ periosteal reaction. dx?
Ewing’s sarcoma
52F Pakistani ethnicity has a lumbar vertebral crush fracture. She has hypocalcaemia and a low urinary calcium. dx?
osteomalacia
30F pain and swelling of the left shoulder. There is a large radiolucent lesion in the head of the humerus extending to the subchondral plate. dx?
giant cell tumour
soap bubble’ appearance - mets to lungs
should be considered in patients with portal hypertension and lower gastrointestinal bleeding on hx of alcohol misuse and high ALP (405), high ALT (95) and low albumin (31):
rectal varices
X has typical features of portal hypertension including ascites, splenomegaly and caput medusae.
portal hypertension
73F brisk rectal bleed. She is otherwise well and the bleed settles. On examination her abdomen is soft and non tender. Elective colonoscopy shows a small erythematous lesion in the right colon, but no other abnormality.
dx?
angiodysplasia
A 23-year-old man complains of passing bright red blood rectally. It has been occurring over the past week and tends to occur post defecation. He also suffers from pruritus ani. dx?
haemorrhoids
A 63-year-old man presents with episodic rectal bleeding the blood tends to be dark in colour and may be mixed with stool. His bowel habit has been erratic since an abdominal aortic aneurysm repair 6 weeks previously. dx?
ischemic colitis
A 35-year-old man is admitted with an episode of collapse and passage of malaena. He has been suffering from post prandial abdominal pain for 5 weeks and this is most marked several hours after eating.
dx?
duodenal ulcer
72M episode of brisk haematemesis. Following resuscitation an upper GI endoscopy is performed and a prominent blood vessel is identified in the mucosa approximately 6 cm from the O-G junction on the lesser curve of the stomach. dx?
Dieulafoy lesion
A 56-year-old man is admitted with a profuse upper gastro intestinal haemorrhage. He is relatively malnourished and has evidence of gynaecomastia.
dx?
oesophageal varices
6-wk boy ->clinic by his mother. Right testis is absent. She reports that it is sometimes palpable when she bathes the child. Right testis is palpable at the level of the superficial inguinal ring. What is the most appropriate management?
reassess in 6/12
HCC tumour marker?
AFP
The Parkland formula for fluid resuscitation in burns is:
Volume of fluid =
total body surface area of the burn % x weight (Kg) x 4ml
amount to be given in first 24h with half being given in first 8h
what exam confirms indirect inguinal hernia?
After reducing the hernia, indirect hernia can be controlled by applying pressure over the deep inguinal ring
-> no reappearance with cough after inguinal ring covered
Reappearance of the lump during coughing when covering the deep inguinal ring would indicate the hernia is?
direct
herniated bowel does not pass through the deep inguinal ring in direct hernias.
Inguinal herniae occur due to a hole in the?
internal oblique and transverse muscles
inguinal hernia. What is the most appropriate management?
routine referral for surgery
The definition of an Upper GI Bleed is a haemorrhage with an origin proximal to the???
ligament of treitz
A 56-year-old lady presents with a 6 month history of dysphagia to solids. She has a long history of retrosternal chest pain that is worse on lying flat and bending forwards. She undergoes an upper GI endoscopy where a smooth stricture is identified.
dx?
peptic stricture
76M 5/52 hx progressive dysphagia. Upper GI endoscopy: changes that are compatible with Barretts oesophagus. The oesophagus is filled with food debris that cannot be cleared and the endoscope encounters a resistance that cannot be passed.
dx?
adenocarcinoma of oesophagus
A 22-year-old man presents with a 5 month history of episodic retrosternal chest pain together with episodes of dysphagia to liquids. An upper GI endoscopy is performed and no mucosal abnormality is seen. dx?
motility disorder
strangulation without symptoms of obstruction:
firm mass over the abdominal wall. The overlying skin is dusky with signs of ischaemia and necrosis. dx?
richter’s hernia
50F right-sided medial thigh pain for the past week. There has been no change in her bowels. On examination you noticed a grape sized lump below and lateral to the right pubic tubercle which is difficult to reduce. dx?
femoral hernia
high risk strangulation - repair urgently
Pfannenstiel’s incision which op?
c-section
Kocher’s incision which op?
cholecystecomy
Rooftop or Midline incision - which op?
whipple’s
An 18-year-old student is involved in a car crash, with another car crashing into the side of the car. A chest x-ray shows an indistinct left hemidiaphragm. dx?
diaphragm rupture
A 19-year-old motorcyclist is involved in a road traffic accident. His chest movements are irregular. He is found to have multiple rib fractures, with 2 fractures in the 3rd rib and 3 fractures in the 4th rib.
flail chest
A 19-year-old student falls from a 2nd floor window. He is persistently hypotensive despite fluid resuscitation. A chest x-ray shows depression of the left main bronchus and deviation of the trachea to the right. Lung markers can be seen in the peripheries of both thoraces. dx?
aortic rupture
A syndrome consisting of a PTEN mutation and intestinal hamartomas. dx?
cowden disease
A syndrome which may be present in a patient with multiple intestinal hamartomas and pigmentation spots around the mouth dx?
peutz-jegher’s syndrome
A syndrome likely to be present in a 28-year-old man who presents with a locally advanced mucinous carcinoma of the caecum. There are scanty polyps in the remaining colon. His father died from colorectal cancer aged 34. dx?
lynch syndrome
23Freferred to the surgical assessment unit. She complains severe, slow onset, left iliac fossa pain. On examination left iliac fossa pain is confirmed. She denies being sexually active. There is some clinical evidence of peritonitis. Investigations should you ask for next?
pregnancy test - still have to in woman of child bearing age with acute abdomen
A 72-year-old man is recovering from an inguinal hernia repair when he suffers from an extensive ischaemic stroke. He is managed on the rehabilitation unit. However, he is still not able to feed safely and repeated swallowing assessments have shown that he tends to aspirate. Which of the following is the best option for long term feeding?
PEG tube
