General Surgery Flashcards
(265 cards)
1
Q
What is an adhesion?
A
Scar-like tissue binding surfaces together
2
Q
What is a fistula?
A
Abnormal connection between two epithelial surfaces
3
Q
What is tenesmus?
A
Sensation of needing to open bowels without the ability to produce stools
4
Q
What is an anterior resection?
A
Surgical removal of the rectum
5
Q
What is a Hartmann’s procedure?
A
Proctosigmoidoscopy-> removal of rectosigmoid colon + closure of anorectal stump + form colostomy
6
Q
What is a Whipple procedure?
A
Pancreaticoduodenectomy-> head of pancreas, duodenum, gallbladder and bile duct removal
7
Q
What are the 4 criteria for a patient having capacity?
A
- Understand information
- Retain information
- Weigh up the pros and cons of the decision
- Communicate their decision
8
Q
What is a lasting power of attourney (LPA)?
A
A person who is legally nominated to make decisions on behalf of another person if/when they lack capacity
9
Q
What is the deprivation of liberty safeguards (DoLS)?
A
An application made from hospital/care home for a patient when they lack capacity-> means they are unable to leave the place of care
10
Q
What does a pre-operative assessment entail?
A
- Taking a history-> PMH, surgeries, adverse response to previous anaesthesia, medications, allergies, smoking, alcohol, possibility of pregnancy, malnourishment
- American Society of Anaesthesiologist (ASA) grading
- Investigations-> bloods including group + save etc
- Looking at medications for pre-existing conditions and determining if anything needs changing
- Assessment for VTE prophylaxis
11
Q
What is the American Society of Anaesthesiologist (ASA) grading system and what are the different grades?
A
Assessment of physical status/fitness before surgery
- ASA I-> normal + healthy
- ASA II-> mild systemic disease
- ASA III-> severe systemic disease
- ASA IV-> severe + constant threat to life
- ASA V-> moribund + expected to die without op
- ASA VI-> braindead + undergoing organ donation op
- E!-> emergency
12
Q
What investigations may be done as part of a pre-operative assessment?
A
- Bloods-> FBC, U+Es, clotting, HbA1c if diabetic
- Group + save-> when lower risk of needing blood products
- Crossmatching-> when higher risk
- MRSA screening-> all patients
- ABG
- ECG
- Echo if HF/murmurs
13
Q
How long before operations do patients usually need to fast for and why?
A
- 6 hours before-> no food
- 2 hours before-> no clear fluids
- Reduce risk of food reflux + aspiration pneumonia
14
Q
When do contraceptives and HRT (containing oesteogen) need to be stopped pre-op?
A
4 weeks before
15
Q
When should DOACs be stopped before surgery?
A
24-72 hours before depending on operation
16
Q
What should be done in regards to long-term steroid therapy pre-op?
A
- Needs adjustment to prevent adrenal crisis from stress of surgery
- Give additional IV hydrocortisone at induction + 24 hours after op
- Double normal dose once eating + drinking for 24-72 hours
17
Q
What should be done in regards to insulin therapy pre-op?
A
- Short acting should be stopped till eating and drinking
- Continue with lower dose of long-acting insulin
- Add variable rate infusion with glucose, sodium chloride and potassium
18
Q
What should be done in regards to oral hypoglycaemics pre-op?
A
- Should stop
- Metformin-> lactic acidosis risk
- SUs-> can cause hypo
- SGLT2 inhibitors-> can cause DKA
19
Q
How can a patient’s recovery be enhanced after surgery?
A
- Early independence and mobility
- Good nutritional support-> helps with wound healing
- Early catheter
20
Q
When should NSAIDs be avoided?
A
Asthma, renal impairment, heart disease, stomach ulcers
21
Q
How does patient-controlled analgesia work?
A
- IV infusion of strong optiate-> morphine, oxycodone or fentanyl
- Press when pain
- Stops responding for set time-> prevent overuse
- Need access to naloxone (for respiratory depression) + atropine (bradycardia) + antiemetics
22
Q
What are the risk factors for post-op nausea and vomiting?
A
Female, motion sickness history, non-smoker, opiate use post op, younger, volatile anaesthetics
23
Q
What is used for prophylaxis of post-op nausea and vomiting?
A
- Ondansetron-> 5HT3 antagonist + avoided in prolonged QT risk
- Dexamethasone-> steroid, cautioned in diabetes + immunocompromised
- Cyclizine-> H1 receptor antagonist, cautioned in elderly and heart failure
24
Q
What is used to treat post-op nausea and vomiting?
A
- Ondansetron-> 5HT3 antagonist + avoided in prolonged QT risk
- Cyclizine-> H1 receptor antagonist, cautioned in elderly and heart failure
- Prochlorperazine
- P6 acupuncture point (inner wrist)
25
What are the types of enteral feeds?
By mouth, NG tube, PEG (percutaneous endoscopic gastrostomy)
26
What route is used for total parenteral nutrition?
IV infusion of solution
27
What are the risks of total parenteral nutrition?
Irritant-> thrombophlebitis
28
What are some common post-op complications?
- Anaemia
- Atelectasis-> lung collapse when under-ventilated
- Infection
- Wound dehiscence-> separation of wound edges
- Ileus-> peristalsis of bowel reduces
- Haemorrhage
- DVT/PE
- Shock
- Arrythmias
- ACS
- CVA
- AKI
- urinary retention
- Delirium
29
How might post-op anaemia be managed?
- If Hb <100-> oral iron
- Hb <70-80g/L-> transfusion
- Remember Jehovah's witnesses may refuse
30
What are the different compartments of fluids in the body?
Intracellular (2/3)
Extracellular (1/3)
- Interstitial (80%)-> between + around cells
- Intravascular (20%)-> in blood vessels
31
What is 'third spacing'?
- Pathological movement of fluid into spaces/cavities-> ascites, pleural effusions etc
- Excess fluids into interstitial space at expense of intravascular space
- May present with hypovolaemia but signs of overload
32
When should fluids be restricted?
Hyponatraemia, heart failure, renal failure
33
What are insensible losses?
- Fluids lose due to respiration, burns, sweating etc
- Difficult to measure
- Can be 800ml/day+ when diarrhoea/fever
34
What are the signs of hypovolaemia?
- Hypotension
- Tachycardia
- High CRT
- Cold peripheries
- High RR
- Dry mucous membranes
- Reduced skin turgor
- Reduced UO
- Sunken eyes
35
What are the signs of fluid overload?
- Peripheral oedema
- Pulmonary oedema
- Raised JVP
- Increased body weight
36
How much glucose is in 1L of 5% dextrose?
50g glucose
37
How does human albumin solution work and when is it used?
- Increases plasma volume
- Large molecules stay in intravascular space-> increases oncotic pressure to draw in and retain fluids
- Helps correct decompensated liver disease
38
What are the major risks with giving normal saline and why?
- Hypernatraemia-> 154mmol in NaCl (normal conc-> 135-145mmol/L
- Metabolic acidosis-> 154mmol chloride in NaCl
39
What are examples of isotonic solutions?
- Match osmolality of plasma ie concentration of solutes
| - 0.9% saline + Hartmann's
40
What are examples of hypotonic solutions and how do they work?
- Lower concentration than plasma
- If dilute blood then water flows from blood to interstitial space
- 5% dextrose
41
What are examples of hypertonic solutions?
- Higher concentration than plasma
| - 3% saline
42
How quickly should potassium solutions be infused?
<10mmol/hour-> reduce risk of arrhythmia
43
What is the normal requirement of maintenance fluids per day?
25-30ml/kg/day
44
What is the normal requirement of sodium per day?
1mmol/kg/day
45
What is the normal requirement of potassium per day?
1mmol/kg/day
46
What is the normal requirement of chloride per day?
1mmol/kg/day
47
What is the normal requirement of glucose per day?
50-100g per day
48
What does daily monitoring for fluid levels entail?
- Fluid status + balance
- U+Es
- Watch for anaemia + coagulopathy-> diluting blood can cause deficiencies
49
What are the potential differentials for acute generalised abdominal pain?
Peritonitis, obstruction, ruptured AAA, ischaemic colitis
50
What are the potential differentials for acute RUQ pain?
Biliary colic, acute cholecystitis, acute cholangitis
51
What are the potential differentials for acute epigastric pain?
Acute gastritis, peptic ulcer disease, pancreatitis, ruptured AAA
52
What are the potential differentials for acute central abdominal pain?
Ruptured AAA, obstruction, ischaemic colitis, early appendicitis
53
What are the potential differentials for acute RIF pain?
Acute appendicitis, ectopic pregnancy, ruptured ovarian cyst, ovarian torsion, Meckel's diverticulum
54
What are the potential differentials for acute LIF pain?
Diverticulitis, ectopic pregnancy, ruptured ovarian cyst, ovarian torsion
55
What are the potential differentials for acute suprapubic pain?
Lower UTI, urinary retention, pelvic inflammatory disease, prostatitis
56
What are the potential differentials for acute loin to groin pain?
Renal colic, ruptured AAA, pyelonephritis
57
What are the potential differentials for acute testicular pain?
Testicular torsion, epididymo-orchitis
58
What are the potential signs of peritonitis on abdominal examination?
- Guarding-> tensing abdominal wall on palpation
- Rigidity-> persistent tightness
- Rebound tenderness-> rapidly releasing pressure on abdomen creates worse pain than pressure itself
- Coughing test-> if cough get pain in abdomen
- Percussion tenderness
59
What is spontaneous bacterial peritonitis?
Infection of ascitic fluid in liver disease
60
What are the initial investigations performed in acute abdomen?
- Bloods-> FBC, U+Es, LFTs, CRP, amylase, INR (synthetic liver function), serum calcium
- Serum/urine bHCG if indicated
- ABG-> lactate (ischaemia), pO2
- Group and save-> before theatre
- Blood cultures
- AXR-> obstruction
- CXR-> air under diaphragm in perforation
- Abdominal US-> gallstones, BD dilatation etc
- CT scan-> identify cause
61
How should acute abdomen by managed?
- ABCDE + alert seniors
- NBM
- NG tube
- IV fluids + analgesia
- IV antibiotics if indicated
- Medication prescription + review
- Consultant makes plan during post-take ward round
62
What is the appendix?
- Small thin tube arising from caecum
- Where 3 teniae coli meet (longitudinal muscles of large intestine)-> single opening to appendix
- Dead end
63
What is the pathophysiology of appendicitis?
- Pathogens get trapped in appendix due to obstruction
- Infection + inflammation-> can gangrene
- Can rupture-> faecal contents + infective material into peritoneal cavity-> peritonitis
64
What are the signs and symptoms of appendicitis?
- Starts as central abdominal pain
- Moves to RIF + McBurney's point within 24 hours
- Anorexia, N+V, low grade fever
- Signs-> guarding, rebound tenderness in RIF, percussion tenderness, Rovsing's sign
- Might have RIF mass-> when omentum surrounds + sticks to inflamed appendix
65
Where is McBurney's point?
2/3 distance from umbilicus to ASIS
66
What is Rovsing's sign?
- LIF palpation causes RIF pain
| - Present in appendicitis
67
How is appendicitis diagnosed?
- Clinical presentation
- Bloods-> inflammatory markers
- CT scan to confirm
- US-> in kids or to rule out gynae causes
68
How is appendicitis treated>
Diagnostic laparoscopy + appendicectomy
69
What are the potential complications of appendicectomy?
Bleeding, infection, pain, scars, damage to other organs, removal of normal appendix, VTE
70
What is Meckel's diverticulum?
Malformation of distal ilium + can bleed/inflame/rupture-> volvulus or intussusception
71
What is mesenteric adenitis?
Inflamed abdominal lymph nodes
72
How does mesenteric adenitis present?
Abdominal pain + tonsilitis/URTI
73
What type of bowel obstruction is the most common?
Small
74
What is the pathophysiology of bowel obstruction?
- Passage of food, fluids + gas blocked-> due to adhesions, hernias or malignancy etc
- Blockage-> back pressure, vomiting + dilatation of proximal bowel
- Fluid unable to be absorbed in bowel-> fluid loss from intravascular space into GI tract-> hypovolaemia + shock (3rd spacing)
- Higher up-> greater fluid loss (less bowel where fluid can be absorbed)
75
What are the three main causes of bowel obstruction?
- Adhesions (small)
- Hernias (small)
- Malignancy (large)
76
What are some of the causes of bowel obstruction?
- Adhesions (small)
- Hernias (small)
- Malignancy (large)
- Volvulus (large)
- Diverticular disease
- Strictures eg in Crohn's
- Intussusception in kids
77
At what age does intussusception typically present?
6 months to 2 years
78
What are adhesions and what can they cause?
Scar tissue in the abdomen binding contents together-> kink/squeeze-> obstruct (usually small bowel)
79
What can cause adhesions?
Abdominal/pelvic surgery, peritonitis, abdo/pelvic infections, endometriosis, congenital, secondary to radiotherapy
80
What is closed loop bowel obstruction?
- 2 points of obstruction so middle section sandwiched
- If single point in large bowel + competent ileocaecal valve-> not allow movement back to ileum-> section isolated + contents can't flow
- No way to drain section contents-> expansion + ischaemia-> perforation
81
How does bowel obstruction present?
- Vomiting-> green/bilous or faecal
- Abdominal distention
- Diffuse pain
- Constipation
- Lack of flatulence
- Tinkling bowel sounds
82
What are the upper limits of normal when assessing bowel diameters on an AXR?
- Small-> 3cm
- Colon-> 6cm
- Caecum-> 9cm
83
What are the valvulae conniventes?
Mucosal folds that form lines for the full width of the small bowel
84
What are haustra?
Pouches from muscles in large bowel wall-> lines don't extend the full width
85
What is the initial management of bowel obstruction?
- ABCDE + resus
- Bloods-> U+Es, VBG (metabolic alkalosis, lactate)
- Drip + suck-> NBM, IV fluids, NG tube + free drainage
- AXR or abdo CT-> see obstruction site + perforation
- Erect CXR-> air under diaphragm in perforation
- Conservative management if stable
- Consider surgery
86
What are the surgical management options for bowel obstruction?
- Exploratory
- Adhesiolysis
- Hernia repair
- Emergency resection
- Stents during colonoscopy-> when tumour
87
What is ileus?
Paralytic or adynamic temporary stopping of peristalsis in the small bowel
88
What is pseudo-obstruction?
Functional obstruction of the large bowel-> no cause found
89
What causes ileus?
- Usually handling during surgery (post-op)
| - Injury, inflammation, infection, electrical imbalance (hypokalaemia/hyponatraemia)
90
What are the signs and symptoms of ileus?
Vomiting (green + bilious), abdominal distention, diffuse abdominal pain, constipation, lack of flatulence, absent bowel sounds (not tinkling)
91
What might absent bowel sounds indicate?
Ileus
92
How is ileus managed?
- Usually no treatment
| - Supportive-> NBM, NG tube, IV fluids, mobilisation, TPN
93
What is volvulus?
- Bowel twists around itself + mesentery it attached to
- Where mesenteric arteries are-> supply bowel
- Closed loop bowel obstruction-> can cut off vessels-> ischaemia + necrosis
94
What is the mesentery?
Membranous peritoneal tissue
- Connects bowel to posterior abdominal wall
- Mesenterics arteries here-> supply bowel
95
What are the two types of volvulus?
- Sigmoid (most common)
| - Caecal (usually younger)
96
What causes sigmoid volvulus?
- Chronic constipation + lengthening of mesentery
- Overloaded with faeces-> sink downwards + twist
- Excess laxatives of high fibre diet can cause too
97
What are the risk factors for volvulus?
- Chronic constipation
- High fibre diet
- Adhesions
- Pregnancy
- Neuropsychiatric disorder
- Nursing home resident
98
How does volvulus present?
Green bilious vomiting, abdominal distention, diffuse pain, constipation, lack of flatulence
99
How is volvulus diagnosed?
- Coffee bean sign on AXR-> in sigmoid volvulus
| - Contrast CT-> confirm diagnosis + exclude other pathology
100
How is volvulus managed?
- Same as obstruction-> NBM, NG tube, IV fluids etc
- Endoscopic decompression for sigmoid volvulus-> tube left in place to decompress + remove later
- Surgical-> laparotomy, Hartmann's, ileocaecal resection, right hemicolectomy
101
What is a hernia?
When a weak point in a cavity wall (muscle or fascia) lets organ through
102
How does a hernia typically present?
- Soft lumo
- May have aching/pulling/dragging sensation
- May be reducible-> can push back to normal place
- May protrude on coughing-> high intra-abdominal pressure
- May protrude on standing-> pulled by gravity
103
What are the potential complications of a hernia?
- Incarceration-> irreducible
- Obstruction-> blockage
- Strangulation-> non-reducible + base tight so cut off blood supply-> ischaemia + emergency
104
What is important to comment on when examining a hernia?
How wide the neck/defect is-> risk assessment for strangulation
105
What is the general management for a hernia?
- Conservative-> when wide neck/not good for surgery
- Tension-free repair-> mesh over defect + suture to muscle + tissues (grow over time to support)
- Tension repair-> suture muscles + tissue back together, rarely done as high recurrence rate
106
What are the differentials for an inguinal hernia?
Femoral hernia, lymph nodes, saphena varix (dilation of SFJ at junction with femoral vein), femoral aneurysm, abscess, undescended/ectopic testes
107
What is a direct inguinal hernia?
Weakness in the abdominal wall at Hesselbach's triangle (not through canal/tract)
108
What might you find on examination of a direct inguinal hernia?
Pressure over the deep inguinal ring doesn't stop herniation-> doesn't reduce
109
What is Hesselbach's triangle?
RIP
- Rectal abdominis muscle (medial)
- Inferior epigastric vessels (superior/lateral)
- Poupart's ligament (inguinal- inferior)
110
What causes a femoral hernia?
- Abdominal contents through femoral canal
| - Opening in femoral ring (between peritoneal cavity + femoral canal)-> narrow opening so high risk
111
What is the femoral triangle?
- Larger area at top of thigh containing femoral canal
- Sartoris (lateral)
- Adductor longus (medial)
- Inguinal ligament (superior)
- NAVY-C contained within
112
What is contained within the femoral triangle?
NAVY-C (lateral to medial)
- Nerve
- Artery
- Vein
- Y fronts
- Canal-> lymph vessels + nodes
113
What is an incisional hernia?
Weakness where muscles and tissues closed in previous surgery-> hernia
114
How are incisional hernias managed?
- Often left alone if large/low risk
| - Can repair but difficult + high recurrence rate
115
What are the different types of hernia?
- Direct inguinal
- Indirect inguinal
- Femoral
- Incisional
- Hiatus
- Umbilical
- Epigastric
- Spigelian-> between rectus abdominis + linea semilunaris
- Diastasis recti-> linea alba widens + separated rectus abdominis
- Obturator-> bottom of pelvis + irritates obturator nerve
- Ritcher's-> only some of bowel wall + lumen through defect so easy to strangulate
- Maydl's-> 2 different bowel loops in 1 hernia
116
Who are umbilical hernias most common in?
Neonates
117
What is an indirect inguinal hernia?
A herniation through the inguinal canal
118
Where does the inguinal canal run?
- Deep inguinal ring-> connects to peritoneal cavity
| - Superficial inguinal ring-> to scrotum
119
What is the embryological function of the inguinal canal in males?
Allows spermatic cord + contents from inside the peritoneal cavity through the abdominal wall to the scrotum
120
What is the embryological function of the inguinal canal in females?
Round ligament attached to uterus + passes through deep inguinal ring-> through canal-> attach to labia majora
121
How does the inguinal canal develop in utero and how can this cause hernias?
- Processus vaginalis ie pouch of peritoneum from abdominal cavity through inguinal canal
- Allows tested to descend from abdominal cavity
- Deep inguinal ring closes after descent + PV obliterated
- If ring patent + PV intact-> tunnel for abdominal contents-> herniate into scrotum
122
What examination finding would you expect in an indirect inguinal hernia?
Reduce + put pressure on deep inguinal ring with 2 fingertips (between ASIS + pubic tubercle)-> remains reduced
123
What is a hiatus hernia?
Widening in diaphragm at level of lower oesophageal sphincter-> stomach herniates up
124
What are the different types of a hiatus hernia?
- Type 1-> sliding ie stomach slides up with gastro-oesophageal junction
- Type 2-> rolling ie separate portion (eg fundus) folds around + enters diaphragm opening
- Type 3-> 1 + 2
- Type 4-> other organs in too eg pancreas
125
How does hiatus hernia present?
Dyspepsia, reflux, burping, halitosis
126
What are the risk factors for developing a hiatus hernia?
Older age, obesity, pregnancy
127
What are the investigations for hiatus hernia?
- Might not see as intermittent
- CXT
- CT
- Endoscopy
- Barium swallow
128
How are hiatus hernias treated?
- Conservative-> managed GOR
| - Surgical-> when high risk or symptoms eh laparoscopic fundoplication (wrap fundus around lower oesophageal sphincter)
129
What are haemorrhoids?
Enlarged anal vascular cushions
- Submucosal tissue with connections between arteries and veins
- Smooth muscle and connective tissue support
- Help with anal continence
- Strain etc-> enlarged
130
What causes haemorrhoids?
- Constipation + strain
- Pregnancy-> constipation, pressure from baby, hormones relax connective tissue
- Obesity
- Older age
- Increased intra-abdominal pressure
131
Where are haemorrhoids usually found?
- Think of anus as clock face
- Haemorrhoids usually at 3, 7 and 11 oclock when patient on back
- Where cushions are
132
How are haemorrhoids classified?
- 1st degree-> no prolapse
- 2nd degree-> prolapse when strain + return when relax
- 3rd degree-> don't return on relaxing but can push back in
- 4th degree-> permanent prolapse
133
What are the symptoms of haemorrhoids?
- Asymptomatic
- Constipation + straining
- Sore/itchy
- Feel a lump
- Painless bright red bleeding not mixed with stool
134
How are haemorrhoids investigated?
- Inspection- can see prolapsed
- PR exam-> may not be able to see internal ones
- Proctoscopy-> hollow tube in cavity to inspect
135
What are some differentials for haemorrhoids?
Fissures, diverticulosis, IBD, cancer
136
How are haemorrhoids managed (non-surgical)?
- Topical creams/ointments-> anusol +/- hydrocortisone, germoloids cream + lidocaine
- Avoid constipation-> increase fibre, laxatives
- Rubber band ligation-> cut off blood supply
- Injection sclerotherapy
- Infra-red coagulation-> light damages blood supply
- Bipolar diathermy-> electric current
137
How are haemorrhoids managed (surgical)?
- haemorrhoid artery ligation-> suture vessel
- Haemorrhoidectomy-> can cause faecal incontinence
- Stapled haemorrhoidectomy-> excise tissue + add circle of staples
138
What causes a thrombosed haemorrhoid?
Strangulation + clotting
139
How does a thrombosed haemorrhoid present?
Purple, tender, swollen, unable to perform PR exam
140
How is a thrombosed haemorrhoid treated?
- Resolves with time (weeks)
| - May need admission + surgery if painful
141
What is diverticulosis?
Presence of diverticulum-> pouch/pockets in abdominal wall
142
What is diverticulitis?
When diverticulum (pouch/pockets in abdominal wall) become infected + inflamed
143
What is diverticular disease?
When diverticulum (pouch/pockets in abdominal wall) cause problems/symptoms
144
What is the pathophysiology of diverticulosis?
- Points of weakness in large intestine's circular muscle layer where BVs penetrate
- Increased pressure over time-> gaps + herniations through muscle layer
- NOT in rectum as outer longitudinal muscle layer gives support
- Areas not covered in taniae coli (3 longitudinal muscle strips) at risk
145
Where is diverticulosis most common?
Sigmoid colon
146
What are the risk factors for developing diverticulosis?
Older age, low fibre diet, obesity, NSAIDs
147
What are the symptoms of diverticulosis?
- Asymptomatic
- Lower left abdominal pain
- Constipation
- Rectal bleeding
148
How is diverticulosis diagnosed?
Often incidental on colonoscopy or CT
149
How is diverticulosis treated?
- Not needed when asymptomatic
- Weight loss + diet advice
- Bulk-forming laxatives-> isphagula husk
- May need surgery
150
How does acute diverticulitis present?
LIF/LUQ pain, fever, diarrhoea, N+V, rectal bleeding, palpable abdominal mass, raised inflammatory markers?
151
How is uncomplicated acute diverticulitis treated?
- In primary care
- Co-amoxiclav PO 5 days
- Analgesia-> NOT NSAIDs
- Clear liquids + avoid solid foods
- Review in 2 days
152
How is severe acute diverticulitis managed?
Acute abdomen-> NBM, IV fluids, antibiotics, urgent investigations, surgery
153
How are the complications of acute diverticulitis?
Perforation, peritonitis, peridiverticular abscess, haemorrhage, fistula, ileus, obstruction
154
What is mesenteric ischaemia?
Lack of blood flow through mesenteric vessels-> intestinal ischaemia
155
What is included in the foregut?
Stomach, some of the duodenum, biliary, liver pancreas, spleen
156
What is included in the midgut?
Distal duodenum to first 1/2 of transverse colon
157
What is included in the hindgut?
Second half of the transverse colon to the rectum
158
What supplies the foregut?
Coeliac artery
159
What supplies the midgut?
Superior mesenteric artery
160
What supplies the hindgut?
Inferior mesenteric artery
161
What is the pathophysiology of chronic mesenteric ischaemia?
Chronic intestinal angina due to narrowing of vessels by atherosclerosis-> can present as acute ischaemia
162
What is the classic triad of the presentation of chronic mesenteric ischaemia?
- Central colicky abdominal pain after eating
- Weight loss due to pain (food avoidance)
- Abdominal bruit on auscultation
- Symptoms usually intermittent (when can't keep up to demand
163
How is chronic mesenteric ischaemia diagnosed?
CT angiography
164
How is chronic mesenteric ischaemia managed?
- Risk factors and secondary presention
| - Revascularisation-> stenting, bypass
165
What causes acute mesenteric ischaemia?
- Rapid blockage of vessels due to thrombus or emboli
| - Usually AF causing RA thrombus to aorta then superior mesenteric artery
166
How does acute mesenteric ischaemia present?
Acute + non specific pain disproportionate to examination findings-> shock, peritonitis, sepsis
167
How is acute mesenteric ischaemia diagnosed?
- Contrast CT-> gold standard
- Metabolic acidosis
- Raised lactate
168
How is acute mesenteric ischaemia managed?
Surgery to remove necrotic bowel + remove/bypass thrombus-> open or endovascular (stenting)
169
What is the prognosis of acute mesenteric ischaemia?
High mortality of 50%
170
Where in the bowel does cancer most commonly present?
Colon or rectum
171
What are the risk factors for bowel cancer?
Family history, IBD, older age, diet, obesity, smoking, alcohol, familial adenomatous polyposis (FAP), hereditary nonpolyposis colorectal cancer (HNPCC)
172
What is familial adenomatous polyposis (FAP)?
Autosomal dominant condition-> malfunction of APC tumour suppressor genes causing polyps (adenomas) in the large intestine-> can become cancerous
173
How is familial adenomatous polyposis (FAP) managed?
Prophylactic panprocticolectomy-> removal of large intestine
174
What is hereditary nonpolyposis colorectal cancer (HNPCC)?
- Autosomal dominant-> mutation in DNA mismatch repair genes
- High risk of cancers
- AKA Lynch syndrome
175
How does bowel cancer present?
Change in bowel habit, rectal bleeding, unexplained pain, iron deficiency anaemia, weight loss
176
What is the 2-week wait referral criteria for bowel cancer?
Depends on age
40+-> abdominal pain + weight loss
50+-> unexplained PR bleeding
60+-> change in bowel habit or iron deficiency anaemia
177
Who is eligible for the bowel cancer screening programme?
- People aged 60-74
- Age 50+ with weight loss
- Age <60 with bowel habit change
- Any age + risk factors-> FAP, HNPCC, IBD
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How does the bowel cancer screening programme work?
- Faecal immunochemical test (FIT)-> look at Hb level in stool
- If positive-> send for colonoscopy
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What investigations are done for suspected bowel cancer?
- Gold standard-> colonoscopy +/- biopsy or tattoo (for surgery)
- Sigmoidoscopy-> when only PR bleeding
- CT colonography-> CT + bowel prep as alternative to colonoscopy
- Staging CT-TAP
- Carcinoembryonic antigen (CEA)-> tumour marker for relapse prediction
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What 2 methods can be used to stage bowel cancer?
- TMN system
| - Duke's classification
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How does the TNM system for staging bowel cancer work?
- Tx-> unable to assess
- T1-> submucosa
- T2-> involves muscularis propria
- T3-> subserosa + serosa involvement
- T4a-> through serosa
- T4b-> reaches other tissues
- Nx-> unable to assess
- N0-> none
- N1-> spread to 1-3 nodes
- N2-> spread to 3+ nodes
- M0-> no mets
- M1-> mets
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How does the Duke's Classification for bowel cancer work?
- A-> mucosa + part of bowel wall muscle
- B-> extends through muscle
- C-> lymph node involvement
- D-> metastases
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How is bowel cancer managed?
- Depends on health + stage + histology
- MDT involvement
- Surgical resection-> curative/palliative, tumour or section of bowel, may need stoma or anasthamosis
- Options for surgery-> hemicolectomy, high or low anterior resection, abdomino-perineal resection + colostomy, Hartmann's in emergencies
- Follow up-> every 3 years, CEA marker + CT-TAP
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What are the potential complications after bowel cancer surgery?
Bleeding, damage, post-op ileus, leakage/failure of anastamosis, stoma, failure to remove tumour, inciscional hernia, adhesions, low anterior resection syndrome
185
What is low anterior resection syndrome?
- Anastamosis between colon and rectum in surgery
| - Causes urgent + frequent bowel movements and incontinence
186
Where is a colostomy likely to be located?
Left iliac fossa
187
What sort of stool does a colostomy drain?
More solid-> more water reabsorbed in large intestine
188
Is a colostomy spouted?
No- flatter as less irritating to skin
189
Where is an ileostomy likely to be located?
Right iliac fossa
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What sort of stool does an ileostomy drain?
More liquid-> bypasses large intestine
191
Is an ileostomy spouted?
Yes-> more irritant to skin so no contact with skin
192
Where is a gastrostomy located?
Between stomach and abdominal wall
193
What is a percutaneous endoscopic gastrostomy?
Hole in stomach to allow feeding directly
194
Where is a urostomy likely to be located?
Usually right iliac fossa
195
How is a urostomy made?
Ileal conduit
- Section of ileus removed and end-to-end anastamosis made
- Ureters attached to separated section
- Out to skin as stoma + into urostomy
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Is a urostomy spouted?
Yes-> irritant liquid produced so no skin contact
197
Where is an end colostomy located?
Usually lower left abdomen
198
When are end colostomies done?
After abdomino-perineal resection-> rectum and anus removed
199
When are end ileostomies done?
After panproctocolectomy (eg for IBD or FAP)
200
What is a J-pouch?
Ileo-anal anastamosis-> functions like a rectum + attached to anus
201
When are loop colostomies + ileostomies done?
After surgery to allow healing-> 2 openings side by side with productive proximal end-> temporary
202
What are the potential complications of having a stoma?
- Psychosocial implications
- Local skin irritations
- Parastomal hernias
- Dehydration and malnutrition
- Constipation
- Stenosis
- Obstruction
- Prolapse
- Bleeding
- Granulomas
203
What are gallstones made of and why?
Cholesterol-> found in bile + concentration gets too high
204
What causes symptoms in biliary colic?
- Fat in digestive system causes cholecystokinin (CKK) release from duodenum
- Stimulates gallbladder contraction-> colic when stones
205
What is the anatomy of the biliary tree?
- Right and left hepatic ducts leave liver + join-> common hepatic duct
- Cystic duct from gallbladder-> joins CHD halfway along
- Cystic duct + CHD-> CBD
- Pancreatic duct-> joins CBD later on
- Ampulla of Vater in duodenum-> sphincter of Oddi (ring of muscle surrounding AoV to control flow)
206
What is cholestasis?
Blockage of bile flow
207
What is cholethliasis?
Stones present in gallbladder
208
What is choledocholithiasis?
Stones present in bile duct
209
What is biliary colic?
Intermittent RUQ pain due to gallstones in the bide ducts
210
What is cholecystitis?
Gallbladder inflammation due to cystic duct blockage and prevention of drainage
211
What is cholangitis?
Bile duct inflammation
212
What is a gallbladder empyema?
Pus in the gallbladder
213
What are the risk factors for gallstones?
4Fs-> fat, fair, female, forty
214
How do gallstones present?
- Asymptomatic
- Biliary colic
- Signs of complications-> obstructive jaundice etc
215
How does biliary colic present?
Severe colicky epigastric/RUQ pain, triggered by fatty meals, lasts 30 mins to 8 hours, associated N+V
216
What can cause pale stools and dark urine?
- Normally bilirubin drains through liver and bile ducts to intestines
- Obstruction due to gallstone in BD or external mass (pancreas, cholangiocarcinoma)-> flow blocked
- Raises serum level
217
What does a raised bilirubin level indicate?
Obstructive jaundice eg due to gallstone in BD or external mass (pancreas, cholangiocarcinoma
218
What might cause a raised alkaline phosphatase (ALP)?
- A problem with the liver, biliary system or bones
| - Can also be raised in pregnancy
219
What might cause a raised level of aminotransferases (ALT and AST)?
Hepatocellular injury (as are enzymes produced by liver)
220
What LFT blood results would you expect in an obstructive picture?
ALT + AST slightly up but higher ALP and high bilirubin
221
What LFT blood results would you expect in a hepatic picture?
ALT + AST higher compared to ALP
222
What ultrasound findings might you see in gallbladder pathology?
- Stones in gallbladder or ducts
- Bile duct dilatation
- Acute cholecystitis-> thickened walls, fluid surrounding, stones/sludge)
- Pancreatic duct stones
223
When is magnetic resonance cholangio-pancreatography (MRCP) performed?
- When US negative for gallstones
| - In strictures or congenital disease
224
What is Endoscopic Retrograde Cholangio-Pancreatography (ERCP)?
- A procedure to clear stones in the bile duct
- Endoscope into sphincter of Oddi + CBD
- Take X rays and diagnose
- Clear stones, insert stents, sphincterectomy if dysfunctional etc
- May take biopsies
225
What are the potential complications of Endoscopic Retrograde Cholangio-Pancreatography (ERCP)?
Excess bleeding, cholangitis, pancreatitis
226
What is the management of gallbladder pathology (especially stones)?
- Conservative if asymptomatic
| - Laporoscopic cholecystectomy
227
What are the complications of laporoscopic cholecystectomy?
- Bleeding
- Bile duct damage-> leaks + strictures
- Other organ damage
- Post-cholecystectomy syndrome (due to changes in bile flow)
- VTE + anaesthetic risks
228
What is post-cholecystectomy syndrome?
- Complication of laporoscopic cholecystectomy
- Changes in bile flow
- Presents with diarrhoea, indigestion, RUQ pain, epigastric pain, intolerance of fatty food
229
What is calculus cholecystitis?
Caused by gallstones + trapped in cystic duct of GB neck-> 95% of all acute cholecystitis
230
What is acalculous acute cholecystitis?
Gallbladder pressure builds up as not stimulated during food emptying-> eg TPN
231
How does acute cholecystitis present?
- RUQ pain + can radiate to shoulder
- Fever, N+V, tachycardia, tachypnoea, tenderness
- Raised WBCs + inflammatory
- Murphy's sign positive
232
What is Murphy's sign?
- RUQ pressure-> eep breath in-> acute pain + stop inspiration when gallbladder touches hand
- Indicates acute cholecystitis
233
How is acute cholecystitis managed?
- Abdominal US-> thick wall, stones/sludge, fluid around GB
- MRCP-> if CBD stone suspected but not seen on US
- Emergency admission + conservative management
- ERCP if stones in CBD
- Cholecystectomy-> within 72 hours or 6-8 weeks after acute episode
234
When in cholecystectomy performed in acute cholecystitis?
within 72 hours or 6-8 weeks after acute episode
235
What are the potential complications of acute cholecystitis?
- Sepsis
- Gangrenous gallbladder
- Perforation
- Empyema-> infected tissue + pus collects
236
What causes ascending cholangitis?
- Obstruction eg CBD stones
- Infection introduced during ERCP
- Organisms-> E.coli, Klebsiella, Enterococcus
237
How does ascending cholangitis present?
Charcot's triad-> RUQ pain, fever, jaundice (raised bilirubin)
238
In what condition does Charcot's triad (RUQ pain, fever, jaundice) present?
ascending cholangitis
239
How is ascending cholangitis managed?
- Admission + treat as acute abdomen
- Diagnose-> endoscopic US, MRCP, CT scan, abdo US
- ERCP-> eg stone removal, dilation/stenting, biopsy
- Percutaneous transhepatic cholangiogram-> drain through skin + liver into BDs to relieve obstruction + stent inserted
240
What is cholangiocarcinoma?
- Cancer originating in the bile ducts-> usually adenocarcinoma
- Can be intra- or extra-hepatic
241
What are the risk factors for cholangiocarcinoma?
- Primary sclerosing cholangitis (10-20%)
| - Liver flukes-> parasites
242
How does cholangiocarcinoma present?
- Obstructive jaundice-> pale stools, dark urine, itching
- Weight loss
- RUQ pain, palpable GB, hepatomegaly
243
What is Courvoisier's law?
- Palpable gallbladder + jaundice is unlikely stones
| - May be cholangiocarcinoma or pancreatic cancer
244
How is cholangiocarcinoma investigation?
- CT/MRI + biopsy for histology
- Staging CT-TAP
- MRCP or ERCP
- CA19-9-> tumour marker for cholangiocarcinoma and pancreatic cancer
245
How is cholangiocarcinoma managed?
- Curative surgery +/- radio/chemotherapy in early cases
| - Palliative-> stents, chemo, radiotherapy, end of life
246
Where does pancreatic cancer commonly occur?
Head of pancreas-> usually adenocarcinomas
247
Why does pancreatic cancer have a poor prognosis?
- Spread + mets early
- Grows large + compresses bileducts-> obstructive jaundice
- Often presents late
- Average survival 6 months
248
How does pancreatic cancer present?
- Painless obstructive jaundice
- Yellow skin + sclera, pale stools, dark urine, itching
- Abdominal pain, palpable epigastric mass, change in bowels, N+V
- T2DM-> worsening or new onset
249
What is the 2-week wait referral criteria for pancreatic cancer?
- Age 40+ with jaundice
- Age 60+ with weight loss + 1 of diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation, new-onset diabetes
250
What are the signs of pancreatic cancer?
- Courvoisier's law-> Palpable gallbladder + jaundice
| - Trousseau's sign-> migratory thrombophlebitis (different locations over time)
251
What is Trousseau's sign of malignancy and what might it indicate?
- migratory thrombophlebitis (different locations over time)
| - pancreatic cancer
252
What are the investigations for pancreatic cancer?
- Biopsy under US or CT or endoscopy
- MRCP or ERCP
- CA19-9 tumour marker
253
How is pancreatic cancer managed?
- Hepatobiliary MDT
- Surgery when small + isolated to head-> total/distal pancreatectomy, Whipple procedure (pancreaticoduodenectomy)
- Palliative-> stents, bypass obstruction, chemo + radiotherapy, end of life care
254
What are the causes of pancreatitis?
I GET SMASHED
- Idiopathic
- Gallstones
- Ethanol (alcohol)
- Trauma
- Steroids
- Mumps
- Autoimmune
- Scorpion Stings
- Hyperlipidaemia
- ERCP (quite common)
- Drugs-> furosemide, thiazide diuretic, azathioprine
255
What can gallstones cause pancreatitis?
- Stones trapped in ampulla of vater + block flow of pancreatic juices + bile
- Reflux in pancreatic duct
- Inflammation
256
Why does alcohol cause pancreatitis?
Directly causes toxicity + inflammation
257
How does acute pancreatitis present?
- Rapid onset
- Severe epigastric pain + radiated to back
- Vomiting
- Abdominal tenderness
- Systemically unwell-> low grade fever etc
258
What are the investigations for acute pancreatitis?
- FBC, U+E, LFTs, calcium, CRP
- Amylase-> 3x upper limit of normal
- ABG
- US for gallstones
- CT abdomen-> monitor complications (necrosis, abscess, fluid collection)
259
What is the Glasgow score for pancreatitis?
Assesses severity of pancreatitis-> 0-1 (mild), 2 (moderate), 3+ (severe)
- PaO2 <8kPa
- Age >55
- Neutrophils ie WBC >15
- Calcium <2
- Urea >16
- Enzymes ie LDH >600 or AST/ALT >200
- Albumin <32
- Sugar ie glucose >10
260
How is acute pancreatitis managed?
- Admission + supportive-> most improve within 3-7 days
- ERCP or cholecystectomy
- Antibiotics if indicated
261
What are the complications of acute pancreatitis?
Necrosis, infection, abscess, peri-pancreatic fluid collections, pseudocysts, chronic pancreatitis
262
What usually causes chronic pancreatitis?
- Progressive and permanent deterioration-> fibrosis
| - Usually alcohol
263
How does chronic pancreatitis present?
- Longer onset + less intense
- Severe epigastric pain + radiated to back
- Vomiting
- Abdominal tenderness
264
What are the complications of chronic pancreatitis?
- Chronic pain
- Loss of exocrine function-> lipase in GI tract lost
- Loss of endocrine function-> diabetes
- Obstruction due to damage + duct stricture
- Pseudocysts
- Abscess
265
How is chronic pancreatitis managed?
- Alcohol + smoking abstinence
- Analgesia
- Creon-> lipase replacement to prevent malabsoprtion of fats + steatorrhoea
- May need-> SC insulin, ERCP + stents, surgery
