General Surgery

Question 1

What clinical signs are consistent with Pancreatic Cancer?

Answer 1

Trousseau’s sign

Courvoisier’s sign

Question 2

What is Courvoisier’s sign?

Answer 2

A painless palpable gallbladder

Jaundice

Question 3

What is Trousseau’s sign?

Answer 3

Migrator thrombophlebitis

Question 4

What is a Zenker’s diverticulum?

Answer 4

Pharyngeal pouch - small bump in the pharynx, most common in the elderly

It occurs through a weakness in the muscle layer called the Killian dehiscence

Question 5

How does a pharyngeal pouch usually present?

Answer 5

Dysphagia 
Chronic cough 
Weight loss 
Regurgitation 
Aspiration

Question 6

How is a pharyngeal pouch diagnosed?

Answer 6

Barium swallow

Question 7

Following initial resuscitation what should be given to patients awaiting endoscopy after an oesophageal varicie bleed?

Answer 7

IV Abx

Terlipressin

Question 8

How should a perinatal abscess be managed?

Answer 8

Incision and drainage

Question 9

Features of Lynch syndrome?

Answer 9

Strong familial prevealence of colorectral, endometrial cancer and ovarian cancer

Question 10

Best initital management for patients with output stomas?

Answer 10

Restrict oral hypotonic fluid intake
Advise dextrose-saline solution
Prescribe oral loperamide and omeprazole

Question 11

What is offered at the age of 55 as part of the NHS screening programme for colorectal cancer?

Answer 11

One-off flexible sigmoidoscopy

Detect and remove polyps

Question 12

What type of colorectal tumours are suitable for anterior resection?

Answer 12

Anterior resection for tumours >8 cm from the anal canal or involving the proximal 1/3 of the rectum.

Question 13

What tumours are a left hemicolectomy suitable for?

Answer 13

A left hemicolectomy is suitable for tumours of the distal transverse colon and descending colon

Question 14

What are the components of Dukes staging of colorectal canceR?

Answer 14

A: limited to the bowel wall (i.e. not beyond the muscularis).
B: extending through the bowel wall (i.e. beyond the muscularis).
C: regional lymph node involvement.
D: distant metastaseis.

Question 15

What diagnostic investigation is most sensitive for a hiatal hernia?

Answer 15

Barium swallow

Will demonstrate if the stomach is partially or completely intrathroacic

Question 16

What drugs commonly cause cholestasis?

Answer 16

Coamoxiclav 
Flucloxacillin
Nitrofurintonin 
Steroids 
Sulphonylurea
Prochlorperazine

Question 17

How is bilirubin conjugated and excreted?

Answer 17

Bilirubin is conjugated with glucuronic acid by glucronyltransferase and is then excreted in the bile.
In the bowel, bilirubin is converted to stercobilin by gut flora, which is then excreted in the faeces as well as urobilinogen, which is reabsorbed and converted into bile, excreted in the faeces or excreted in the urine.

Question 18

What cancer is most associated with Barrets oesophagus?

Answer 18

Oesophogeal adenocarcinoma

Question 19

What type of calcium distrubance is most commonly associated with abdominal pain#?

Answer 19

Hypercalcemia

If calcium is low suspect acute pancreatitis

Question 20

What drug is used for acute management of a variceal haemorrhage?

Answer 20

Terlipressin

Question 21

How does a pharangeal pouch present?

Answer 21

Dysphagia
Aspirtation pneumonia
Halitosis

Question 22

What is the most common kind of stomach ulcer?

Answer 22

Duodenal

Gastric are less common

Question 23

What kind of stomach ulcers are more likely to have associated weight loss?

Answer 23

Gastric ulcers

Question 24

What kind of stomach ulcers have epigastric pain worsened by eating?

Answer 24

Gastric ulcers

Question 25

What type of ulcer may occur at a stoma sight?

Answer 25

Pyoderma gangrenosum, a deep, painful, ulcer

Question 26

Initial management of acute limb ischemia?

Answer 26

Analgesia IV heparin Vascular review

Question 27

Common conseuqence of terminal ileus resection

Answer 27

Bile acid malabsorption

Question 28

What is Mirrizi's syndrome?

Answer 28

Causes an obstructive jaundice due to compression of the common bile duct secondary to presence of gallstones in the cystic duct itself or in Harmanns pouch Conjugated hyperbilirubinaemia Diagnosis confirmed by MRCP Management laproscopic cholecystectomy

Question 29

Definitive diagnostic test for acute mesenteric ischemia?

Answer 29

CT angiography

Question 30

What is meant by the acute abdomen?

Answer 30

Recent, rapid onset of urgent abdominal or pelvic pathology, usually presenting with abdominal pain

Question 31

Causes of generalised abdominal pain?

Answer 31

Peritonitis Ruptured AAA Intestinal obstruction Ischemic colitis

Question 32

Causes of right upper quadrant pain?

Answer 32

Bilary colic Acute cholecystitis Acute cholangitis

Question 33

Causes of epigastric pain?

Answer 33

Acute gastritis Peptic ulcer disease Pancreatitis Ruptured AAA

Question 34

Causes of central abdominal pain?

Answer 34

Ruptured AAA Intestinal obstruction Ischemic colitis Early stage of appendicitis

Question 35

Causes of RIF pain?

Answer 35

``` Acute appendicitis Ectopic pregnancy Ruptured ovarian cyst Ovarian torsion Meckel's diverticulitis ```

Question 36

Causes of LIF pain?

Answer 36

Diverticulitis Ectopic pregnancy Ruptured ovarian cysts Ovarian torsion

Question 37

What is suprapubic pain?

Answer 37

Lower urinary tract infection Acute urinary retention PID Prostatitis

Question 38

Causes of loin to groin pain?

Answer 38

Renal colic (kidney stones) Ruptured AAA Pyelonephritis

Question 39

Causes of testicular pain?

Answer 39

Testicular torsion | Epididymo-orchitis

Question 40

What is peritonitis?

Answer 40

Inflammation of the peritoneum (lining of the abdomen)

Question 41

Signs of peritonitis?

Answer 41

Guarding (involuntary tensing of the abdominal wall muscles when palpated to protect the painful area below) Rigidity (involuntary persistent tightness of abdominal wall muscles) Rebound tenderness (releasing pressure causes more pain than the pressure itself) Coughing test (coughing results in pain) Percussion tenderness Reduced/absent bowel sounfs (suggestive of paralytic illeus)

Question 42

What causes localised peritonitis?

Answer 42

Underlying organ inflammation | Appendicitis, cholecystitits

Question 43

What causes generalised peritonitis?

Answer 43

Perforation of an abdominal viscous(e.g. perforated duodenal ulcers, ruptured appendix) releasing contents into the peritoneal cavity and causing generalised inflammation of the peritoneum

Question 44

What causes spontaneous bacterial peritonitis?

Answer 44

Spontaneous infection of ascities in patients with liver disease. Treated with broad spectrum antibiotics, carries a poor prognosis

Question 45

How might you investigate the acute abdomen?

Answer 45

FBB: hb, WBC U&E - electrolyte imbalance, kidney functions, prior to CT LFTs give and indication of the bilary and hepatic systems CRP - gives an indication of inflammation and infection Amyalse gives an indication of inflammation of the of the pancreas INR - synthetic liver fucntion, plus prep for procedure Serum calcium - scoring acute pancreatitits Beta-HCG in females of child bearing age ABG - lactate (ischema) and pO2 (acute pancreatitis scoring) Group and save - may req blood transfusion Abdominal x ray: can show evidence of bowel obstruction (dilated loops) Erect CXR: air under diaphragm when intra-abdominal perforation (pneumoperitoneum, air in abdominal cavity) Abdominal USS: gallstones, billary duct dilation, gynae pathology CT scans: identify the cause of an acute abdomen and determine management Urine dip: UTI, haematuria

Question 46

Initital management of a bowel obstruction?

Answer 46

``` NBM NG tube IV fluids Analgesia Anit-emetics ```

Question 47

Causes of acutte abdomen that could lead to hypovolemic shock?

Answer 47

AAA Ruptured ectopic pregnancy Bleeding gastric ulcer Trauma

Question 48

Signs of hypovolemic shock?

Answer 48

``` Tachycardia Hypotension Pale Clammy Cool to touch ```

Question 49

What, until proven otherwise, should be suspected in a patient with severe abdominal pain out of proprotion to their clinic signs? What other signs might be present?

Answer 49

Ischemic bowl Acidaemic Raised lactate Diffuse, constant pain

Question 50

What is colic?

Answer 50

Abdominal the crescendos to become very severe and then completely goes away - billary - ureteric - bowel obstruction

Question 51

What is peritonism?

Answer 51

Localised inflamation of the peritoneum, usually due to inflammation of a ciscus that then irritates the visceral (and subsequently, parietal peritoneum) before localising to another area or becoming generalised

Question 52

What is looked for on USS KUB?

Answer 52

Hydronephrosis | Cortico-medullary differentiation

Question 53

What is looked for in billary tree USS?

Answer 53

Presence of gallstones Gallbladder thickening Duct dilation

Question 54

Why should patients with abdominal pain have an ECG?

Answer 54

Exclude cardiac pain (reffered)

Question 55

Where do the vast majority of gastric cancers arise from?

Answer 55

Gastric mucosa (adenocarcinoma)

Question 56

Adenocarcinoma makes up 90% of stomach cancers, what are the other types?

Answer 56

Conncective tissue, lymphoid or neuroendocrine mallignancy

Question 57

Risk factors for gastric cancer?

Answer 57

``` H pylor infection Male gender INcreasing age Smoking Alcohol consumption High salt diet, positive family history, pernicious anaemia ```

Question 58

What is H. Pylori?

Answer 58

H. Pylori is a gram negative helical bacterium that produces the urease enzyme Breaks down urea into CO2 and ammonia Ammonia neutralises stomach acid allowing the bacteria to to create an alkaline microenvironment

Question 59

How does H pylori lead to gastric neoplasia?

Answer 59

Sets off a cycle of repeated damage to the epithelial cells, leading to inflammation, ulceration and ultimately gastric neoplasia.

Question 60

What are the presenting symptoms of gastric cancer?

Answer 60

``` Dyspepsia (new onset, non-responsive to PPI) Dysphagia Early satiety Vomiting Melena Heametemisis Constitutional symptoms (late stage) ```

Question 61

How can H pylori be diagnosed?

Answer 61

Blood antigen test Stool antigen test Urea breath test

Question 62

How is H pylori erradicated?

Answer 62

PPI Clarithromycin Amoxocillin

Question 63

What clinical signs may be present in late stage gastric cancer?

Answer 63

``` Palpable epigastric mass Troisier signs (palpable left supraclavicular (Virchow) node) in metastatic abdominal malignancy ``` Mets: Hepatomegaly, ascites, jaundice, acanthosis nigricans

Question 64

Differentials for gastric cancer?

Answer 64

Peptic ulcer disease GORD Gallstone disease Pancreatic cancer

Question 65

How is suspected gastric cancer investigated?

Answer 65

FBC LFTs Upper GI endoscopy (OGD) +/- biopsy CT chest-abdo-pelvis and staging laparoscopy (peritoneal mets) to stage

Question 66

Why are PET scans rarely used in staging gastric cancers?

Answer 66

Gastric cancers to not take up the radioactive tracer well

Question 67

How are gastric cancers staged?

Answer 67

TNM

Question 68

What should biopsies from gastric mallignancies be sent for?

Answer 68

Histology - grading of any neoplasia CLO test - H pylroi HER2/neu protein expression - allows target monotherapies if present

Question 69

What is the mainstay of curative treatment in gastric cancer?

Answer 69

Surgery (+ adjuvant and neoadjuvant chemotherapy if tolerated) Proximal gastric cancer - total gastrectomy Distal gastric cancer (antrum or pylorus) - subtotal gastrectomy

Question 70

What may patients with early T1a gastric tumours be offered as an alternative to total or sub-total gastrectomy?

Answer 70

Endoscopic Mucosal Resection (EMR) is suitable for tumours confined to the muscularis mucosa and has reduced morbidity and mortality

Question 71

What is the most commonly used method in reconstruction the alimentary anatomy following gastrectomy?

Answer 71

Roux-en-Y reconstruction (best functional result, less bile reflux) Distal oeosphagus is end to end anatsomosed with the small bowel Proximal small bowel is end- to - side anastamosed to the small bowel

Question 72

Complications of gasterectomy?

Answer 72

``` Anastomotic leak Re-operation Dumping syndrome Vitamin B-12 deficiency Death (3-5%) ```

Question 73

What injection do patients require 3 monthly following gastrectomy?

Answer 73

Vitamin B12

Question 74

What is the palliative management of gastric cancer?

Answer 74

Chemotherapy Stention Surgery (distal gastrectomy or bypass surgery, gastro-jejunostomy) if stenting fails or unavailable, or in palliation of bleeding gasrtic tumours Best supportive care

Question 75

Most common complications of gastric cancer?

Answer 75

Gastric outlet obstruction, iron-deficiency anaemia, perforation, malnutrition

Question 76

What is gastric dumping syndrome?

Answer 76

Common following gastric bypass surgery Early (10-30 mins post prandial) - Sudden and large passage of hypertonic gastric contents into the small intestine, resulting in an intraluminal fluid shift and subsequent intestinal distention Late (1-3 hours post prandial) Surge in insulin production following the 'dumping' of food results in hypoglycemia

Question 77

Presentation of gastric dumping syndrome~?

Answer 77

Early (10-30 mins post prandial): nausea, vommiting, diarrhoea, hypovolemia, leading to synpathetic response predominating with tachycardia and diaphoresis Late (1-3 hours post prandial) - hypoglycemia

Question 78

How can gastric dumping syndrome be managed?

Answer 78

Small volume and more frequent meals, avoidence of simple carbohydrates, separation of eating and drinking to reduce load on stomach. Refer these patients to a dietician? Treat hypoglycemia, intra-operative glucose management

Question 79

Most common symptoms of dumping syndrome?

Answer 79

``` Sweating Tingling lips or extremities Tremor Dizziness Slurred speech ```

Question 80

When should a patient be referred under the urgent pathway for OGD?

Answer 80

New onset dysphagia or aged >55 years presenting with weight loss and either upper abdominal pain, reflux, or dyspepsia

Question 81

What are the main two types of oesophageal cancer?

Answer 81

Squamous cell carcinoma (developing world) | Adenocarcinoma (developed world)

Question 82

Where does SCC typically occur in the oesophagus?

Answer 82

Middle and upper thirds

Question 83

What is oesophageal SCC associated with?

Answer 83

``` Smoking Excessive alcohol consumption Chronic achalasia Low vitamin A levels Iron def ```

Question 84

What is oesophageal adneocarcinoma associated with?

Answer 84

Metaplastic epithelium - Barrett's oesophagus (progressing to dysplasia) GORD Obesity High fat intake

Question 85

Where in the oesophagus does adenocarcinoma typically occur?

Answer 85

Lower thirds

Question 86

What vasculature runs near the oesophagus?

Answer 86

Inferior thyroid artery Azygous vein Thoracic aorta and oesophogeal branches

Question 87

How does oesophageal cancer present?

Answer 87

Late stage usually Dysphagia, progressive, starting with solids progressing to liquids Odynophagia Hoarseness Cachexia, dehydration Supracavicular lymphandenopathy Signs of metastatic disease: jaundice, heaptomgealy, asicities)

Question 88

How is dysphagia investigated?

Answer 88

Upper GI endoscopy (OGD) within two weeks +/- biopsy for histology CT chest-abdomen-pelvis if OGD abnormal to search for mets PET-CT for " Staging laparoscopy for junctional tumours with an intra-abdominal component to look for intra-peritoneal metasteses FNA of any palpable cervical lymph nodes Bronchoscopy if hoarseness or haemoptysis

Question 89

How is oesophageal SCC managed?

Answer 89

Usually palliative | Curative: chemo-radiotherapy

Question 90

How is oesophogeal adenocarcinoma managed?

Answer 90

Mostly palliatively, but if curative treatment: Neo-adjuvant chemothreapy or chemo-radiotherapy followed by oesophageal resection (oesophagectomy or EMR if high grad Barret's or early stage cancer)

Question 91

Oesphagectomy involved removing the tumour, top of stomach and surrounding lymph nodes. The stomach is made into a conduit and borugh up the chest to replace the oesophagus. One lung needs to be deflated during surgery for aprox two hours, and patients will not recover fully for 6-9 months. What surgical approaches may be taken?

Answer 91

Right thoracotomy with laparotomy - Ivor-Lewis procedure Right thoracotomy with abdominal and neck incision - MecKeown procedure Left thoracotomy with or without neck incision Left thoraco-abdominal incision (starting above umbilicas extending round back to below left shoulder blade)

Question 92

Palliative options for oesophogeal cancer?

Answer 92

Oesophageal stent Radiotherapy and or chemotherapy can be used to reduce tumour size and bleeding Nutritional support: thicken fluids, nutritional supplements, RIG if enteral feeds not tolerated

Question 93

At what vertebral level does the oesophagus originate?

Answer 93

C6

Question 94

Aetiology of acute pancreatitits?

Answer 94

``` Gallstones Ethanol Trauma Steroids Mumps Autoimmune (SLE, Sjorgen's) Scorpion venom Hypercalcemia ERCP Drugs ```

Question 95

What drugs may cause acute pancreatitis?

Answer 95

Azathioprine NSAIDs Diuretics

Question 96

How is acute pancreatitis distinguished from chronic pancreatitis?

Answer 96

Extent of damage to the secretory function of the gland - no gross structual damage in acute

Question 97

Pathogenisis of acute pancreatitis?

Answer 97

Premature and exaggerated activation of digestive enzymes within the pancreas Pancreatic inflammatory response causes and increase in vascular permeability Subsequent fluid shifts (third spacing) Enzymes released from pancreas into the systemic circultion Autodigestion of fats and blood vessels (fat necrosis, bleeding into retroperitoneal space) Release of free fatty acides reacts with serum calcium to cause chalky depsosits in the fatty tissue, resulting in hypocalcemia

Question 98

What does severe end-stage pancreatitis result in?

Answer 98

Partial or complete necrosis of the pancreas

Question 99

How does pancreaitits present?

Answer 99

Sudden onset of severe epigastric pain which can radiate through to the back Nausea and vommiting Epigastric tenderness +/- gaurding Cullen's sign, Grey turner's sign Tetany (from hypocalcemia) Concurrent obstructive jaundice (if gallstone aeitiology)

Question 100

WHat is Cullen's sign?

Answer 100

Bruising around the umbilicus

Question 101

What is Grey Turner's sign?

Answer 101

Flank brusing

Question 102

Why does Cullen's and Grey Turner's signs occur?

Answer 102

Retroperitoneal haemmorhage

Question 103

Causes of abdominal pain radiating to the back?

Answer 103

``` Pancreatiitis (chronic or acute) AAA Renal calculi Aortic dissection Peptic ulcer disease ```

Question 104

How should you investigate acute pancreatitis (excluding routine bloods as per abdominal pain)

Answer 104

Serum amylase LFTs - concurrent cholestatic elemant to the clinical pictutre Serum lipase Abnominal USS - ?gallstone Contract CT if USS inconclusive, and also 6-10 days after admission in patient with features of persistent inflammatory response or organ failure

Question 105

Whilst not routinely performed for acute pancreatitis, an AXR can show what?

Answer 105

Sential loop sign - dilated proximal bowel loop adjacent to the pancreas, which occurs secondary to the localised inflammation

Question 106

When should a CXR be performed in acute pancreatitits?

Answer 106

Look for pleural effusion or ARDS

Question 107

What serum amylase is diagnostic of acute pancreatitits?

Answer 107

3x the upper limit of normal, although not related to disease severity

Question 108

What ALT level strongly suggest gallstone ateiology in acute pancreatitits?

Answer 108

>150

Question 109

What is the most accurate blood test for acute pancreatitis and why is it not used?

Answer 109

Serum lipase Remains elevated longer than amylase Not available our routinely performed in many hospitals

Question 110

What is used to asses the severity of acute pancreatitits within the first 48 hours of admission?

Answer 110

Modified glasgow criteria

Question 111

What is the modified Glasgow criteria?

Answer 111

``` pO2 <8kPa Age > 55 Neutrophiles (WCC>15) Calcium <2 Renal (urea>16) Enzymes LDH>600 or AST>200 Albumin <32 Sugar > 10 ```

Question 112

What does it mean if a patient has 3 or more factors within the first 48 hours of admission of the modified Glasgow criteria?

Answer 112

Severe pancreatitis, high dependency care referral warrented

Question 113

What will a contrast-enhanced CT scan show after 48hr of initial presentation of acute pancreaitits?

Answer 113

Pancreatic odema and swelling | Non-enhancing areas suggestive of pancreatic necrosis

Question 114

How is acute pancreatitits managed?

Answer 114

IV fluid resucitation - balanced crystalloid O2 as required NG tube if vomiting profusely Catheterisation to monitor urine out put (aim >0.5ml/kg/hr) Opiod analgesia If gallstones ERCP and spinchterotomy

Question 115

When should a borad-spectrum antibiotic such as imipenem be considered for prophalaxis against infection in acute pancreatitits?

Answer 115

confirmed pancreatic necrosis

Question 116

What should be advised once a patient with pancreatitis secondary to gallstones has been stablised?

Answer 116

Early laparoscopic cholecystectomy

Question 117

What complications of pancreatitis tend to occur within days of initial onset?

Answer 117

``` Systemic complications such as: Disseminated Intravascular Coagulation DIC Acute Respiratory Distress Syndrome Hypocalcemia Hyperglycemia ```

Question 118

Why might hyperglycemia occur secondary to pancreatitits?

Answer 118

Destruction of islets of Langerhans and subesquent disturbances to insulin metabolism

Question 119

What should be suspected in patients with evidence of persistent systemic inflammation for more than 7-10 days after the onset of pancreatitis?

Answer 119

Ischemic infarction of the pancreatic tissue, confirmed by CT imaging

Question 120

How is pancreatic necrosis managed?

Answer 120

``` Pancreatic necrosectomy (open or endoscopic) Broad spectrum abx ```

Question 121

Definitive diagnosis of infected pancreatic necrosis can be confirmed by what?

Answer 121

FNA

Question 122

What is a pancreatic pseudocyst?

Answer 122

Collection of fluid containing pancreatic enzymes, blood and necrotic tissue, can occur anywhere within or adjacent to the pancreas Lack an epithelial lining, instead have a vascular and fiboritic wall surrounding the collection

Question 123

Where to pancreatic pseudocysts typically occur?

Answer 123

Lesser sac obstructing the gastro-epiploic foramen by inflammatory adhesions

Question 124

How long after the initial acute pancreatitis episode do pancreatic pseudocyts tend to occur?

Answer 124

Weeks

Question 125

How are pancreatic pseudocyts managed?

Answer 125

About 50% will spontaneously resolve, hence conservative management is usually the initial treatment of choice. Cysts which have been present for longer than 6 weeks are unlikely to resolve spontaneously. Treatment options include surgical debridement or endoscopic drainage N.B. prone to haemorrhage or rupture, can become infected

Question 126

What is a stoma?

Answer 126

Surgically created opening into a hollow organ

Question 127

What does a colonostomy open into?

Answer 127

Large bowel

Question 128

What does an ileostomy open into?

Answer 128

The ileum

Question 129

What does a urostomy open into?

Answer 129

The urinary system

Question 130

What are colostomy stomas situated?

Answer 130

Left illiac fossa

Question 131

Where are ileostomys siutated?

Answer 131

Right iliac fossa

Question 132

What stomas will be spouted?

Answer 132

Ileostomy | Urostomy

Question 133

What stoma is flush to the skin?

Answer 133

Colonoscopy

Question 134

What with the conistency of an ileostomy be?

Answer 134

Watery, greener

Question 135

What is to consistency of a colonostomy contents?

Answer 135

Thick and sludgey

Question 136

What will urostomy output look like?

Answer 136

Urine

Question 137

How many lumens does a loop stoma have?

Answer 137

Two

Question 138

How many lumens does an end stoma have?

Answer 138

One

Question 139

Potential complications of a stoma?

Answer 139

``` Parastomal hernia (colostomy) Prolapse Retraction Infarction (turns jet black) Ulceration Fistulation Local skin irritation Loss of bowel length leading to high output dehydration and malnurtition Granulomas causing raised red lumps around the stoma Stenosis Constipation (colostomies) ```

Question 140

Where are urostomies usually located?

Answer 140

RIF

Question 141

What is an end colostomy?

Answer 141

Removal of a section of bowel, where the end part of the proximal bowel is brough onto the skin. The other open end of remaining bowel (distal part) is sutured and left in the abdomen. It may be reversed at a later date, were the two ends are sutured together, creatining an anastomisis

Question 142

When are end colostomies permanent?

Answer 142

End colostomies are permanent after resection of abdomino-perineal resection (APR) because the entire rectum and anus have been removed. These are usually located in the lower left abdomen.

Question 143

What procedure forms an end illeostomy?

Answer 143

Panproctocolectomy End ileostomies are permanent after a panproctocolectomy (total colectomy with removal of the large bowel, rectum and anus)

Question 144

What is a panproctocolectomy?

Answer 144

Total collectomy with removal of the large bowel, rectum and anus

Question 145

What is a panproctocolectomy used to treat?

Answer 145

IBD | Familial adenmoatous polyposis (FAP)

Question 146

Alternative to panproctocolectomy?

Answer 146

Ileo-anal anastomosis (J-pouch)

Question 147

What does a loop colostomy/ileostomy allow?

Answer 147

Distal portion of the bowel and anastomosis to heal after the surgery, allow faeces to bypass the distal, healing portion of the bowel until healed and ready to restart normal function, they are usually reveresed 6-8 hours. The bowel is partially opened and folder so that there are two opening on the skin side-by-side, attached in the middle. Proximal end is turned outside to form a spout, distal and is flatter.

Question 148

How is a urostomy formed?

Answer 148

Creation of an ileal conduit. Section of illeum removed and end-to-end anastomisis is screated so bowel in coninous. Ends of ureters are anatsomosed and separated to section the ileum. The end of the section is brough out onto the skin as a stoma and drains directly from the ureters into a urostomy bag.

Question 149

What do gallstones form from?

Answer 149

Concentrated bile in the bile duct, most are made from cholesterol

Question 150

Complications of gallstones?

Answer 150

Acute cholecystitits Acute cholangitis Pancreatitis (if blocking the pancreatic duct) Obstructive jaundice

Question 151

Basic anatomy of the bile duct system

Answer 151

Right and left hepatic ducts leave the liver and join together to become the common hepatic duct. Cystic duct from gallbladder joins the common hepatic duct halfway along. Pancreatic duct from the pancreas joints with the common hepatic duct further along. Common bile duct and pancreatic duct join to become the ampulla of Vater, which opens into the duodenum.

Question 152

What is the sphincter of Oddi?

Answer 152

Ring of muscle surrounding the ampulla of Vater that controls the flow of bile and pancreatic secretions in the duodenum.

Question 153

What is cholestasis?

Answer 153

Blockage to flow of bile

Question 154

What is cholelithiasis?

Answer 154

Presence of gallstones

Question 155

What is choledocholithiasis?

Answer 155

Gallstones in the bile duct

Question 156

What is billary colic

Answer 156

intermittent right upper quadrant pain caused by gallstones irritating bile ducts

Question 157

What is cholecystitits?

Answer 157

Inflammation of the gallbladder

Question 158

What is cholangitis?

Answer 158

Inflammation of the bile ducts

Question 159

What is gallbladder empyema?

Answer 159

Pus in the gallbladder

Question 160

What is a cholecystostomy?

Answer 160

Insertion of a drain into the gallbladder

Question 161

What are the risk factors for gallstones?

Answer 161

Fat Fair Female Forty

Question 162

Typical presentation of gallstones (if symptomatic)

Answer 162

Billary colic Severe, colicky epigastric or right upper quadrant pain Often triggered by meals (particularly high fat meals) Lasting between 30 minutes and 8 hours May be associated with nausea and vomiting

Question 163

What does raised jaundice, raised serum bilirubin, pale stools and dark urine represent?

Answer 163

Obstruction caused by a gallstone in the bile duct or an external mass pressing on the bile ducts (e.g. cholangiocarcinoma or tumour of head of pancreas)

Question 164

What can a raised ALP indicated?

Answer 164

``` Liver pathology Bone pathology (Paget's, bone malignancy) Pregnancy (production by the placenta) Billary obstruction Billary chirrosis ```

Question 165

What are ALT and AST helpful markers of?

Answer 165

Hepatocellular injury

Question 166

What does a higher ALP compared to AST and ALT?

Answer 166

Obstructive picture

Question 167

What do a higher ALT and AST compared to ALP indicate?

Answer 167

Hepatic picture

Question 168

First line investigation for suspected gallstone disease?

Answer 168

USS

Question 169

What is USS of the bilary tract limited by?

Answer 169

Patient weight Gaseous bowel obstructing the view Discomfort from the probe

Question 170

What might be found on USS of the billary tract?

Answer 170

Gallstones in the gallbladder Gallstones in the ducts Bile duct dilatation (normally less than 6mm diameter) Acute cholecystitis (thickened gallbladder wall, stones or sludge in gallbladder and fluid around the gallbladder) The pancreas and pancreatic duct

Question 171

What is a magnetic resonance cholangio-pancreatography?

Answer 171

MRI scan with a specific protocol that produces a detailed image of the biliary system. It is very sensitive and specific for biliary tree disease, such as stones in the bile duct and malignancy.

Question 172

When does gallstone disease warrent MRCP?

Answer 172

If USS does not show stones in the duct but there is bile duct dilation or raised bilirubin suggestive of obstruction

Question 173

Key complications of ERCP

Answer 173

Excessive bleeding Cholangitis (infection in the bile ducts) Pancreatitis

Question 174

The main indication for ERCP

Answer 174

Clear stones in the bile duct

Question 175

What can be done during an ERCP?

Answer 175

Inject contrast and take x-rays to visualise the biliary system and diagnose pathology (e.g., stones or strictures) Perform a sphincterotomy on the sphincter of Oddi if it is dysfunctional (blocking flow) Clear stones from the ducts Insert stents to improve bile duct drainage (e.g., with strictures or tumours) Take biopsies of tumours

Question 176

Complications of cholecystectomy?

Answer 176

Bleeding, infection, pain and scars Damage to the bile duct including leakage and strictures Stones left in the bile duct Damage to the bowel, blood vessels or other organs Anaesthetic risks Venous thromboembolism (deep vein thrombosis or pulmonary embolism) Post-cholecystectomy syndrome

Question 177

What are the to approaches to cholecystectomy?

Answer 177

Laparoscopic | Open - Kocher incision

Question 178

What is post-choecystectomy syndrome?

Answer 178

``` Diarrhoea Indigestion Epigastric or right upper quadrant pain and discomfort Nausea Intolerance of fatty foods Flatulence ```

Question 179

Why does post-cholecystectomy syndrome?

Answer 179

Attributed to changes in the bile flow after removal of the gallbladder

Question 180

What is cutaneous wound healing?

Answer 180

Process by which the skin repairs itself after damage?

Question 181

Types of wound healing?

Answer 181

Primary intention | Secondary intention

Question 182

What are the four stages that occur in wound healing?

Answer 182

Haemostasis Inflammation Proliferation Remoddeling

Question 183

What happens in the hameostasis phase of primary intention

Answer 183

Action of platelets and cytokines forms a haematoma and Causes vasconstriction, limiting blood loss at the affected area The close proximity of the wound edges allows for ease of clot formation and prevents infection by forming a scab

Question 184

What happens in the proliferation phase of primary intention healing?

Answer 184

Cytokines released by inflammatory cells drive the proliferation of fibroblasts And formation of granulation tissue Angiogenesis is promoted by the presence of growth mediators (e.g. VEGF) Allows for further maturation of the granulation tissue Production of collagen by fibroblasts Allows for closure of wound within about a week

Question 185

What happens in the inflammation phase of primary intention?

Answer 185

A cellular inflammation response acts to remove any cell debris and pathogens present

Question 186

What is the remodelling phase of healing by primary intention?

Answer 186

Collagen fibres are deposited within the wound to provide strength in the region, with fibroblasts subsequently undergoing apoptosis

Question 187

What is typically the end result of healing by primary intention?

Answer 187

Completed return to function with mininmal scaring and loss of skin appendages

Question 188

Why is correct suture tension important?

Answer 188

Too loose and the wound edges will not be properly opposed, limiting the primary intention healing and reducing the wound strength Too tight and the blood supply to the region may become compromised and lead to tissue necrosis and wound breakdown

Question 189

What happens during haemostasis in secondary intention healing?

Answer 189

A large fibrin mesh forms which fills the wound

Question 190

What happens in the inflammation phase of secondary intention?

Answer 190

An inflammatory response acts to remove and cell debris and pathogen present Larger amount of cell debris present, and the inflammatory reaction tends to be more intense than in primary intention

Question 191

What happens in the proliferation phase of secondary intention and why is it an important step?

Answer 191

Granulation tissue forms at the bottom of the wound Important as the epithelia can only proliferate and regenerate once granulation tissue fills the wound to the level of the original epithelium, once the granulation tissue reaches this level the epithelia can completely cover the wound

Question 192

What happens in the remoddeling stage of secondar intention healing?

Answer 192

Inflammatory response resolves, wound contraction occurs

Question 193

When does healing by primary intention occur?

Answer 193

Wounds with dermal edges that are close together

Question 194

When does healing occur by secondary intention?

Answer 194

When the sides of the wound are not opposed, therefore healing must occur from the bottom of the wound upwards?

Question 195

What cells are vital in secondary intention?

Answer 195

Myofibroblasts - modified smooth muscle cells, that contain actin and myosin, and act to contract the wound; decreasing the space between the dermal edges. They also can deposit collage for scar healing.

Question 196

What are keloid scars?

Answer 196

An uncommon complication from wound healing (particularly in people with darker skin) whereby there is excessive collage production, leading to extensive scarring. This can occur in both primary and secondary intention healing.

Question 197

Local factors that affect wound healing?

Answer 197

``` Type, size, location of wound Local blood supply Infection Foreign material or contamination Radiation damage ```

Question 198

What systemic factors affect wound healing?

Answer 198

Increasing age Co-morbidities, especially CV disease or DM Nutritional deficiencies (especially vitamin C) Obestity

Question 199

Four classes of surgical contamination?

Answer 199

Clean Clean-contaminated Contaminated Dirty

Question 200

What is clean contamination?

Answer 200

Elective, non-emergency, non-traumatic, and primary closed, with GI, biliary and GU tracts remaining intact

Question 201

What is clean contamination?

Answer 201

Urgent or emergency case that is otherwise clean Elective opening of respiratory tract, GI, bililary or GU tract with minimal spillage and not encountering infected urine or bile

Question 202

What does contaminated mean?

Answer 202

Gross spillage from GI tract or entry into biliary or GU tract (in presence of infected bile or urine) Penetrating trauma < 4 hours old or a chronic open wound to be grafted or covered

Question 203

What is a dirty wound?

Answer 203

Purulent inflammation | Preoperative perforation of respiratory, GI, biliary, or GU tract, or a penetration trauma >4 hours old

Question 204

Basic principals of management of a wound or laceration?

Answer 204

``` Haemostasis Cleaning the wound Analgesia Skin closure Dressing and follow-up advise ```

Question 205

Methods to aid haemostasis?

Answer 205

Pressure Elevation Torniquet Suturing

Question 206

The five aspects of wound cleaning?

Answer 206

Disinfect - antiseptic Decontaminate - removal forigen bodies Debride devitalised tissue Irrigate with saline (low perrsure as long as no obvious contamination) Antibiotics for high risk wounds or signs of infection

Question 207

Whats the maximum level of lidocan alone?

Answer 207

3mg/kg

Question 208

Whats tha maximum level of lidocane with the addition of adrenaline?

Answer 208

7mg/kg

Question 209

What's the maximum level of lidocaine with the addition of adrenaline?

Answer 209

7mg/kg

Question 210

When should adrenaline not be used with local anaesthetic?

Answer 210

If administering in or near appendages (e.g. a finger)

Question 211

Methods of skin closure (manually opposed)?

Answer 211

Skin adhesive strips (if no risk factors for infection present) Tissue adhesive glue (small laccerations with easily opposable edges) Sutures (laceration greater than 5cm, deep dermal wounds, locations prone to flexion tension or wetting) Staples (scalp wounds)

Question 212

What should patients be advised following initial wound management?

Answer 212

Following initial wound management, advise patients to: Seek medical attention for any signs of infection Take simple analgesia (e.g. paracetamol) Keep the wound dry as much as possible, even if wearing a waterproof dressing

Question 213

How do you dress a wound to a non-infected laceration?

Answer 213

When applying a wound dressing to a non-infected laceration, the first layer should be non-adherent (such as a saline-soaked gauze), followed by an absorbent material to attract any wound exudate, and finally soft gauze tape to secure the dressing in place.

Question 214

When should sutures or adhesive strips?

Answer 214

10-14 days after initial wound closure (or 3-5 days if on the head)

Question 215

After how long will tissue adhesive flue naturally slough off?

Answer 215

1-2 weeks

Question 216

Why do malnourished patients make poor surgical candiates?

Answer 216

Surgery causes physiological stress with a resultant hyper-metabolic state and catabolic response. Malnourished patients have reduced nutritional reserves

Question 217

How is BMI calculated?

Answer 217

Weight / Height2

Question 218

What should be done with a patient with a MUST score of 1 (medium risk)

Answer 218

Document dietary intake for 3 days If adequete repeat screening (hospital weekly, care home monthly, community 2-3monthly) If inadequete clinical concern follow local policy

Question 219

What should be done about a MUST score of 2 or more?

Answer 219

Dietician ref Sets goals to improve and increase overall nutritional intake Monitor and review care plan (weekly if in hospital otherwise monthly)

Question 220

What BMI scores on a MUST calculation?

Answer 220

18.5-20 = 1 | Under 18.5 = 2

Question 221

What unplanned weight loss across 3-6 months scores on MUST?

Answer 221

5-10% = 1 | Over 10 % = 2

Question 222

What will be added to a patients MUST score if they are acutely ill and there has been or is likely to be no nutritional intake for >5 days?

Answer 222

2 points

Question 223

Hiearchy of Feeding?

Answer 223

``` Oral nutritional supplements NGT PEG/RIG Jeujunostomy Paraentral nutrition ```

Question 224

When should oral nutritional supplements be introduced?

Answer 224

If unable to eat sufficient calories

Question 225

What should NGT feeding be used?

Answer 225

If unable to intake sufficient calories orally or dysfunctional swallow

Question 226

When should gastostomy feeding (PEG/RIG) be used?

Answer 226

If oesophagus blocked/dysfunctional

Question 227

When should jejunal feeding be used?

Answer 227

If stomach inaccessible or outflow obstruction

Question 228

When should parentral nutrition be used?

Answer 228

If jejunum inaccessible or intestinal failure

Question 229

What is the snap pneumonic for management of intestinal failure undergoing surgery?

Answer 229

Sepsis – Any overwhelming infection present must be corrected otherwise feeding will be largely useless Nutrition – Once the infection is corrected, suitable nutritional support should be provided Anatomy – Define the anatomy of the GI tract so that surgery can be planned Procedure – Definitive surgery once any infection eradicated, the patient nourished, and the anatomy defined

Question 230

What does a low serum albumin reflect?

Answer 230

A low serum albumin reflects either chronic inflammation, protein losing enteropathy, proteinuria, or hepatic dysfunction, but does not reflect malnutrition (as witnessed by the fact that patients with severe anorexia nervosa have a normal serum albumin).

Question 231

Up to what point pre surgery can patients have clear fluids?

Answer 231

2 hours

Question 232

From what period before surgery must a patient be NBM (excluding clear fluids)?

Answer 232

6 hours

Question 233

Why should paients with entero-cutaneous fistulae avoid PN straight away ?

Answer 233

The proportion of ECF that will heal with PN is small.

Question 234

How should patients with an entero-cutaneous fistula have their nutrition managed?

Answer 234

``` High fistula (jejunal): enteral or parentral nutrition Low fistula (ileum/colon): treated with low fibre diet ```

Question 235

How is a high output stoma managed?

Answer 235

Reduction in hypotonic fluids to 500ml/day Reduction in gut motility with high dose loperamide and codeine phosphate Reduction in secretions with high dose PPI BD Use of WHO solution to reduce sodium losses Low fibre diet to reduce intraluminal retention of water

Question 236

Complications of TPN

Answer 236

``` Catheter placement and maintenance: Pneumothorax Thromboembolisim Infections IV nutrition Fluid balance Hyperglycemia/Hypoglycemia Electrolyte imbalance (K, Phosp, Mg) Hepatic toxicity Bleeding ```

Question 237

What is a fistula?

Answer 237

An abnormal connection between two epithelial surfaces

Question 238

What does Hartmann's procedure involve?

Answer 238

Removal of the rectosigmoid colon with closure of the anorectal stump and formation of a colostomy

Question 239

What does Whipple's procedure involve?

Answer 239

Removal of: Head of pancreas, duodenum, gallbladder, bile duct

Question 240

What incision is used for renal transplant?

Answer 240

Hockey-stick incision

Question 241

What might cause haematemisis?

Answer 241

``` Bleeding from part of the upper GI tract: Oesophageal Varicies Gastric ulceration Mallor-Weiss Tear Oesophagitis Gastritis Gastric mallginancy Meckel's diverticulum Dieulafoy lesions (vascular lesion) ```

Question 242

Key facts to ascertain from a history and examination of upper Gi bleed?

Answer 242

Timing, frequency, volume of bleeding History of dyspepsia, dysphagia or odynophagia PMH and smoking and alcohol status Steroids, NSAIDs, anticoagulants or bisphosphonates Peritonism Epigastric tendernies Varacies of liver stigmata

Question 243

What are oeasophageal varacies?

Answer 243

Dilations of the porto-systemic venous anastomses in the oesophagus. Dilated veins are swollen, thin-walled, and pront to rupture with the potential to cause a catastrophic haemmorhage Most commonly caused by portal HTN secondary to alcoholic liver disease

Question 244

Where do gastric ulcers most commonly errode into the blood vessels supplying the upper GI tract?

Answer 244

Lesser curve of the stomach | Posterior duodenum

Question 245

What is a Mallory-Weiss tear?

Answer 245

Typified by episodes of severe or recurrent vomiting, then followed by haematemesis. Forceful vomiting causes a tear in the epithelial lining of the oseophagus resulting in a small bleed Benign

Question 246

What is oesophagitis?

Answer 246

Inflammation of the intraluminal epithelial layer of the oesophagus, most often due to gastric acid reflux or infections (Candida Albicans), medication (bisphosphonates), radiotherapy, injegstions of toxic substances or Crohn's disease

Question 247

How should and upper GI bleed be investigated?

Answer 247

FBC (low Hb, although may not show intitially in an acute bleed) U&Es (drop in urea:creatinine ratio very indicative of upper GI bleed) LFTs (?liver damage cause) Clotting VBG/ABG - pH, base excess, lactate, signs of tissue hypoperfusion Group and save (+cross match if suspected variceal bleed) OGD is the definitive investigation and can form management erect CXR if suspected peptic ulcer (pneumoperitoneum) GT abdo with IV contrast (triple phase) assesing active bleeding if endoscopy unremarkable/too invasive

Question 248

What scoring system is used to risk stratify patients admitted with an upper GI bleed?

Answer 248

Glasgow-Blatchford score

Question 249

What score is used to asses the severity of GI bleeding post endoscopy?

Answer 249

Rockall

Question 250

What Glasgow-Blatchford score is associated with a >50% risk of needing intervention?

Answer 250

Greater than or equal to 6

Question 251

Definitive management of perforated peptic ulcer after initial resusitation?

Answer 251

Injections of adrenaline and cauterisation of the bleeding. High dose intravenous PPI therapy should be administered (e.g. IV 40mg omeprazole) to reduce acid secretion +/- H. Pylori eradication therapy if necessary

Question 252

Definitive management of oesophageal alongside initial resusitation and prophylactic abx?

Answer 252

``` Endoscopic banding Somatostatin analogues (octreotide) or vasopressers (terlipressin) acting to reduce splanchic blood flow ```

Question 253

Long term management of oesophageal varicies?

Answer 253

Repeated banding | Beta-blocker therapy

Question 254

What is a Sengstaken-Blakemore tube and when is it used?

Answer 254

In severe oesophageal varices, inserted to level or varacies and inflated to compress the bleeding

Question 255

What is the most common artery affected by erosion due to a peptic ulcer?

Answer 255

This is most commonly the gastro-duodenal artery which is eroded into by an ulcer at the back of the first part of the duodenum.

Question 256

What plain film radiographic sign may indicate a perforated gastric ulcer?

Answer 256

Subdiaphragmatic free gas - suggest pneumoperitoneum

Question 257

How might an upper GI bleed present?

Answer 257

Haematemesis (vomiting blood) “Coffee ground” vomit. This is caused by vomiting digested blood that looks like coffee grounds. Melaena, which is tar like, black, greasy and offensive stools caused by digested blood Haemodynamic instability occurs in large blood loss, causing a low blood pressure, tachycardia and other signs of shock. Bear in mind that young, fit patients may compensate well until they have lost a lot of blood.

Question 258

What does the Glasgow-Blatchford score take into account?

Answer 258

``` Drop in Hb Rise in urea Blood pressure Heart rate Melaena Syncopy ```

Question 259

What does a Glasgow-Blatchford score of more than 0 indicate?

Answer 259

High risk for upper GI bleed

Question 260

What factors does the Rockall score take into account?

Answer 260

Age Features of shock (e.g. tachycardia or hypotension) Co-morbidities Cause of bleeding (e.g. Mallory-Weiss tear or malignancy) Endoscopic stigmata of recent haemorrhage such as clots or visible bleeding vessels

Question 261

Management of an upper GI bleed (ABATED)

Answer 261

A – ABCDE approach to immediate resuscitation B – Bloods A – Access (ideally 2 large bore cannula) T – Transfuse E – Endoscopy (arrange urgent endoscopy within 24 hours) D – Drugs (stop anticoagulants and NSAIDs)

Question 262

What do NICE reccomend regarding PPIs in relation to OGD for oesophageal varicies?

Answer 262

Against PPI prior to endoscopy

Question 263

What causes melena to be tarry, offensive smelling and difficult to flush away?

Answer 263

Alteration and degration of blood by intestinal enzymes

Question 264

Most common causes of melena?

Answer 264

``` Peptic ulcer disease Variceal bleeds Upper GI mallignancy (ulcerating oesophageal or gastric malignancies) Mallory-Weiss tear Meckel's diverticulum Vascular malformations ```

Question 265

When should peptic ulcer disease be suspected as the cause of an Upper GI Bleed?

Answer 265

Known active peptic ulcer disease History of NSAIDs or steroid use Previous dyspepsia-like symptoms H.pylori positive

Question 266

When does the most significant bleeding occur in gastric ulcer disease?

Answer 266

When the ulcer erodes through the posterior gastric wall into the gastroduodenal artery

Question 267

What examination must be performed to confirm melena?

Answer 267

DRE

Question 268

Management of bleeding peptic ulcer?

Answer 268

Adrenaline injections Cauterisation of bleeding High dose PPI (e.g. IV 4omg omperazole)

Question 269

Below what Hb should blood products be transfused?

Answer 269

<70g/L or <80 if hx of CVD

Question 270

Why is a rise in the urea:creatinine ratio an indicator of an upper GI bleed?

Answer 270

Digested blood produces urea as a by-product

Question 271

What is haematochezia?

Answer 271

Passage of fresh blood PR

Question 272

Causes of rectal bleeding?

Answer 272

``` Diverticular disease Ischemic of infective collitis Haemorrhoids Mallignancy Angiodysplasia Crohn's disease UC Radiation proctitis Large upper GI bleed ```

Question 273

What are diverticula?

Answer 273

Outpouchings of the bowel wall composed only of muscosa

Question 274

Where are diverticula most commonly found?

Answer 274

Descending sigmoid colon

Question 275

Diverticular disease bleeds vs diverticulitis associated bleeds?

Answer 275

Diverticular disease - painless | Diverticulitis - painful (secondary to localised inflammation)

Question 276

What are haemorrhoids?

Answer 276

Pathogically engorged vascular cusions in the anal canal

Question 277

How might haemorrhoids present?

Answer 277

PR mass Pruritis Fresh red rectal bleed, on toilet pan or stool surface Painful if large haemorrhoids thrombose

Question 278

In patients with PR bleeding, what key aspects should be ascertained from history and examination?

Answer 278

Nature of bleeding, including duration, frequency, colour of the bleeding, relation to stool and defecation Associated symptoms, including pain (especially association with defaecation), haematemesis, PR mucus, or previous episodes Family history of bowel cancer or inflammatory bowel disease Localised tenderness in the abdomen Abdominal mass palpable DRE - assess for rectal masses and ongoing presence of blood

Question 279

What score is used to help stratify patients presenting with a lower GI bleed to determine if outpatient management is feasible?

Answer 279

Oakland score

Question 280

What factors determine Oakland score?

Answer 280

``` Age Sex Previous admissions for lowe GI bleed PR findings HR Systolic BP Hb ```

Question 281

What investigations should be performed on stable patients with rectal bleeding?

Answer 281

FBC LFT Clotting U&Es ?Stool culture Flexible sigmoidoscopy or colonoscopy (if inconclusive) to exclude left-colonic pathology (outpatient) If no abnormality identified on flexi sig or colonoscopy - OGD If OGD also inconclusive: capsule endoscopy, MRI small bowel

Question 282

Risk factors of adverese outcomes from acute rectal bleeding?

Answer 282

``` Haemodynamic instability Ongoing haematochezia Age > 60 Serum creatnine >150umol/L Significant co-morbidities ```

Question 283

What investigations should be performed on unstable patients with rectal bleeding?

Answer 283

``` FBC LFT Clotting U&Es ?Stool culture Urgent CT angiogram to find ource of bleeding (+/- theraputic intervention:emoblisation) ```

Question 284

How are PR bleeds managed if unstable?

Answer 284

IV fluids and blood transfusion of packed RBC as required Urgent reversal of anticoagulants Endoscopic haemostasis methods Arterial embolisation (patients with an identified bleeding point (blush) of sufficient size on angiogram

Question 285

What are possible methods of endoscopic haemostasis?

Answer 285

Injection (diluted adrenaline) Contact and non contact thermal devices (bipolar electrocoagulation or argon plasma coagulation) Mechanical therapies (endoscopic clips and band ligation)

Question 286

What is the blood supply to the ileum?

Answer 286

Superior mesenteric artery

Question 287

Which value in clotting screen is most affected by warfarin?

Answer 287

Prothrombin time

Question 288

What is diverticulosis

Answer 288

The presence of diverticula (asymptomatic, incidental on imaging)

Question 289

What is diverticular disease/diverticulosis?

Answer 289

Symptoms arising from diverticula

Question 290

What is diverticulitis?

Answer 290

Inflammation of the diverticula

Question 291

What is a diverticular bleed?

Answer 291

The diverticulum erodes into a vessel and causes a large volume painless bleed

Question 292

What is a diverticular abscess?

Answer 292

A diverticular abscess (often termed a pericolic abscess) occurs as a sequelae in complicated diverticulitis Those that are around <5cm can generally be managed with conservatively with intravenous antibiotics, as this is effective in ~90% of cases. If the abscess is any bigger, then radiological drainage is first-line treatment. Complicated multi-loculated abscesses (or patients who clinically deteriorate) will need surgical intervention, either with a laparoscopic washout or a Hartmann’s procedure.

Question 293

Investigation of choice for suspected diverticulitis?

Answer 293

CT abdo pelvis

Question 294

Indications for surgical intervention in diverticulitis?

Answer 294

Intestinal bleeding Failure of percutaneous drainage Septic shock

Question 295

How can 1st and second degree haemorrhoids be managed if symptomatic?

Answer 295

Rubber band ligation

Question 296

Why are external haemorrhoids painful (unlike internal)?

Answer 296

They are below the dentate line/pectinate line Superior to the pectinate line – visceral innervation is from the inferior hypogastric plexus. Inferior to the pectinate line – somatic innervation derived from the inferior anal (rectal) nerves, branches of the pudendal nerve. This part of the anal canal is sensitive to pain, touch, and temperature

Question 297

Conservative management of haemorrhoids?

Answer 297

Increase dietary fiber Increase fluid intake Laxatives if necessary Topical analgesia (lignocaine gel)

Question 298

What is haemorrhoidal artery ligation suitable for?

Answer 298

2nd or 3rd degree haemorrhoids

Question 299

What is Haemorrhoidectomy suitable for?

Answer 299

3rd degree and 4th degree haemorrhoids

Question 300

Describe 1st degree haemorrhoids?

Answer 300

Remain in the rectum

Question 301

Describe 2nd degree haemorrhoids?

Answer 301

Prolapse through the anus on defecation but spontaneously reduce

Question 302

Describe 3rd degree haemorrhoids?

Answer 302

Prolapse through the anus on defecation but require digital reduction

Question 303

Describe 4th degree haemorrhoids?

Answer 303

Remain persistently prolapsed

Question 304

What is Charcot's triad and when does it appear?

Answer 304

Right upper quadrant pain Fever Jaundice (raised bilirubin) Acute cholangitis

Question 305

How and why will excessive vommiting affect pH?

Answer 305

Vomiting leads to the loss of the hydrogen ions secreted by the stomach. Hydrogen ions are needed to create acidity within the body, so a loss of these ions will lead to alkalosis. This results in metabolic alkalosis.

Question 306

Why do direct inguinal hernias occur?

Answer 306

Direct inguinal hernias occur due to weakness in the abdominal wall at Hesselbach’s triangle.

Question 307

What is an indirect inguinal hernia?

Answer 307

An indirect inguinal hernia is where the bowel herniates through the inguinal canal.

Question 308

What is the inguinal canal

Answer 308

The inguinal canal is a tube that runs between the deep inguinal ring (where it connects to the peritoneal cavity), and the superficial inguinal ring (where it connects to the scrotum). In males, the inguinal canal is what allows the spermatic cord and its contents to travel from inside the peritoneal cavity, through the abdominal wall and into the scrotum.

Question 309

How, on examination, can you differentiate between a direct and indirect inguinal hernia?

Answer 309

When an indirect hernia is reduced and pressure is applied (with two fingertips) to the deep inguinal ring (at the mid-way point from the ASIS to the pubic tubercle), the hernia will remain reduced.

Question 310

Where is the deep inguinal ring?

Answer 310

The mid-way point from the ASIS to the pubic tubercle

Question 311

What do femoral hernias involve?

Answer 311

Femoral hernias involve herniation of the abdominal contents through the femoral canal. This occurs below the inguinal ligament, at the top of the thigh.

Question 312

What are obturator hernias?

Answer 312

Obturator hernias are where the abdominal or pelvic contents herniate through the obturator foramen at the bottom of the pelvis.

Question 313

Where does a spigelian hernia occur?

Answer 313

A Spigelian hernia occurs between the lateral border of the rectus abdominis muscle and the linea semilunaris. This is the site of the spigelian fascia, which is an aponeurosis between the muscles of the abdominal wall.

Question 314

What is paralytic illeus?

Answer 314

Condition affecting the small bowel, where the normal peristalsis that pushes the contents along the length of the intestines, temporarily stops

Question 315

What causes paralytic illeus?

Answer 315

Injury to the bowel Handling of the bowel during surgery (most common) Inflammation or infection in, or nearby, the bowel (e.g., peritonitis, appendicitis, pancreatitis or pneumonia) Electrolyte imbalance (e.g., hypokalaemia or hyponatraemia)

Question 316

Why is biliary colic particularly associated with fatty meals?

Answer 316

Meals high in fat stimulate the release of cholecystokinin (CCK) from the duodenum. This peptide hormone stimulates the contraction of the muscles of the gallbladder. When the gallbladder is full of stones, this causes pain as the gallbladder contracts against the stones.

Question 317

What is Rovsing's sign?

Answer 317

In acute appendicitis, palpation of the left iliac fossa causes pain in the RIF

Question 318

Where will be particularly tender in the abdomen in acute appendicitis?

Answer 318

McBurney's point

Question 319

Where is McBurney's point?

Answer 319

A specific area one-third of the distance from the anterior superior iliac spine (ASIS) to the umbilicus.

Question 320

What is tenesmus?

Answer 320

Tenesmus: the sensation of needing to open bowels without being able to produce stools (often accompanied by pain)

Question 321

What does a sigmoid volvulus show on XR?

Answer 321

Coffee bean sign

Question 322

What surgical procedure can be used to manage sigmoid volvulus?

Answer 322

Hartman's

Question 323

Which anti-emetics are suitable in bowel obstruction secondary to mechanical obstruction and which are not?

Answer 323

Prokinetic antiemetics such as metoclopramide should be avoided in a bowel obstruction secondary to a mechanical obstruction, as they stimulate peristalsis. Cyclizine would be an appropriate choice of antiemetic.

Question 324

Risk factors for acute mesenteric ischemia?

Answer 324

``` Female Older age AF HTN Hypercholestrolaemia ```

Question 325

What ABG abnormalities may be present in acute mesenteric ischemia?

Answer 325

High lactate | Metabolic acidosis

Question 326

What is the gold standard for diagnosis of acute mesenteric ischemia?

Answer 326

Contrast CT scan

Question 327

Contraindications to liver transplant?

Answer 327

Significant co-morbidities (e.g., severe kidney, lung or heart disease) Current illicit drug use Continuing alcohol misuse (generally 6 months of abstinence is required) Untreated HIV Current or previous cancer (except certain liver cancers)

Question 328

Causes of microcytic anaemia?

Answer 328

``` T – Thalassaemia A – Anaemia of chronic disease I – Iron deficiency anaemia L – Lead poisoning S – Sideroblastic anaemia ```

Question 329

What is Courvoisier's law and what does it suggest?

Answer 329

Courvoisier’s law states that a palpable gallbladder along with jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic cancer.

Question 330

What is the most applicable tumour marker for bowel cancer?

Answer 330

Serum carcinoembryonic antigen (CEA)

Question 331

What is Carbohydrate antigen 19-9 (CA 19-9) most associated with?

Answer 331

Pancreatic cancer and colangiocarcinoma?

Question 332

What is a Meckel's diverticulum?

Answer 332

Meckel’s diverticulum is a malformation of the distal ileum that occurs in around 2% of the population. It is usually asymptomatic and does not require any treatment. However, it can bleed, become inflamed, rupture or cause a volvulus or intussusception. An inflamed Meckel’s diverticulum (Meckel’s diverticulitis) may mimic the presentation of appendicitis.

Question 333

What Gi cancer is alfapetoprotein associated with?

Answer 333

Liver

Question 334

What is sigmoid volvulus?

Answer 334

Sigmoid volvulus is more common than caecal volvulus and tends to affect older patients. The twist affects the sigmoid colon. A key cause is chronic constipation and lengthening of the mesentery attached to the sigmoid colon. The sigmoid colon becomes overloaded with faeces, causing it to sink downwards, resulting in a twist. It is also associated with a high fibre diet and the excessive use of laxatives. Neuropsychiatric disorders (e.g., Parkinson’s) and being a nursing home resident are also risk factors.

Question 335

What is the preferred management of rectal tumours over 8 cm from the anal margin?

Answer 335

Anterior resection

Question 336

What does anterior resection involve?

Answer 336

Removal of diseased segment, formation of a primary anastomosis between the remaining proximal colon and distal rectum. Temporary loop ileostomy is typically performed to allow the distal anastomoses to heal.

Question 337

What is the preferred management of rectal tumours less than 8 cm from the anal margin?

Answer 337

Abdomino-perianal resection with temporary loop ileostomy

Question 338

What does AP resection involve?

Answer 338

Removal of anus, rectum and proximal sigmoid colon through both abdominal and perineal acesss The remaining section of the colon is brought out to the surface in a permanent end colostomy

Question 339

If a patient has a colostomy and no anus what procedure are they likely to have?

Answer 339

AP resection

Question 340

If a patient has a colostomy and an anus what procedure are they likely to have?

Answer 340

Emergency Hartmann's procedure

Question 341

Where might an epigastric hernia be found and what causes them?

Answer 341

Protusion of extra-peritoneal fat or omentum through a defect in the linea alba vetween the xiphisternum and umbilicus

Question 342

How are epigastric hernias managed?

Answer 342

Asymptomatic: address risk factors such as obesity | Symptomatic or cosmetic concerns: Surgical repair

Question 343

What level of rapid unintentional weight loss is suspicious for mallignancy?

Answer 343

>5%

Question 344

Which cancer is most strongly associated with a history of primary sclerosing cholangitis?

Answer 344

Cholangiocarcinoma

Question 345

What side is colonic cancer most common on?

Answer 345

Left-sided colonic cancer

Question 346

Why is right sided colon cancer more likely to be severe?

Answer 346

Later presentation, insidious in nature

Question 347

Why does right sided colon cancer rarely cause obstructive symptoms?

Answer 347

Stool in right sided colon is semi-liquid

Question 348

What is the treatment for Plummer Vinson what triad of symptoms does it present with?

Answer 348

Iron def anaemia Glossitis Dysphagia Endoscopy shows oesophageal webs Treated with iron supplements and mechanical dilation of the oesophagous

Question 349

What does an enlarged Virchow's node suggest?

Answer 349

GI malignancy

Question 350

What is Virchow's node?

Answer 350

Left supraclavicular lymph node

Question 351

What is a hernia?

Answer 351

Weak point in a cavity wall (usually muscle or fascia) which allows a body organ normally contained within that cavity to pass through that cavity wall

Question 352

Typical features of abdominal wall hernias?

Answer 352

A soft lump protruding from the abdominal wall The lump may be reducible (it can be pushed back into the normal place) The lump may protrude on coughing (raising intra-abdominal pressure) or standing (pulled out by gravity) Aching, pulling or dragging sensation

Question 353

What are the three key complications of a hernia?

Answer 353

Incarceration Obstruction Strangulation

Question 354

What is meant by incarceration of a hernia?

Answer 354

The hernia cannot be reduced back to its proper position (it is irreducible) Bowel is trapped in the herniated position (may lead to obstruction or strangulation)

Question 355

What is meant by obstruction of a hernia?

Answer 355

Causes blockage in the passage of feaces through the bowel. | Obstruction presents with vomiting, generalised abdominal pain and absolute constipation

Question 356

What is strangulation of a hernia?

Answer 356

Hernia is NON-REDUCIBLE and the base of the hernia become so tight that it cuts off the blood supply leading to ISCHEMIA

Question 357

What makes a hernia at lower risk of complication?

Answer 357

Size of neck/defect - wide neck - less complications

Question 358

How will strangulation of a hernia present?

Answer 358

Significant pain and tenderness at hernia site | Clinical features of mechanical obstruction: absolute constipation, N&V

Question 359

Why is hernia strangulation a surgical emergency?

Answer 359

Bowel will die (infarct) within hours if not corrected surgically

Question 360

What is a Richter's hernia?

Answer 360

A Richter’s hernia is a very specific situation that can occur in any abdominal hernia. This is where only part of the bowel wall and lumen herniate through the defect, with the other side of that section of the bowel remaining within the peritoneal cavity. They can become strangulated, where the blood supply to that portion of the bowel wall is constricted and cut off. Strangulated Richter’s hernias will progress very rapidly to ischaemia and necrosis and should be operated on immediately.

Question 361

What is a Maydl's hernia?

Answer 361

Maydl’s hernia refers to a specific situation where two different loops of bowel are contained within the hernia.

Question 362

General management options of all abdominal hernias?

Answer 362

``` Conservative management (wide neck hernias) Tension free repair - mesh over the defect in the abdominal wall is sutured into the muscles and tissues on the other side of the defect, covering it and preventing herniation. Tissues eventually grow over the mesh and provide extra support. Tensions repair: suturing of the muscles and tissues on either side of the defect back together - pain and high recurrence - rarely used ```

Question 363

Advantages and disadvantages of tension-free hernia repair?

Answer 363

Lower recurrence rate compared with tension repair, but there may be complications associated with the mesh (e.g., chronic pain).

Question 364

Diferntials for a lump in the inguinal region?

Answer 364

``` Indirect or direct inguinal hernia Femoral hernia Lymph node Saphena varix Femoral aneurysm Abscess Undecended/ectopic testes Kidney transpant ```

Question 365

What is saphena varix and what might it be mistaken as?

Answer 365

DIlation of saphenous vein at junction with femoral vein in groin Inguinal hernia

Question 366

What anatomical abnormality can lead to indirect inguinal hernias?

Answer 366

After embryological development, in some patients, the inguinal ring remains patent, and the processus vaginalis remains intact. This leaves a tract or tunnel from the abdominal contents, through the inguinal canal and into the scrotum. The bowel can herniate along this tract, creating an indirect inguinal hernia.

Question 367

What are the borders of Hesselbach's triangle?

Answer 367

``` Rectus abdominis muscle - medial boarder Inferior epigastric vessels - superior/lateral border Pouparts ligament (inguinal ligament) inferior border ```

Question 368

Relationship of a direct inguinal hernia to the inferior epigastric vessels?

Answer 368

Direct inguinal hernias protrude anteromedial and inferior to the course of the inferior epigastric vessels

Question 369

Relationship of an indirect inguinal hernia to the inferior epigastric vessels?

Answer 369

Indirect inguinal hernias protrude posterolateral and superior to the course of the inferior epigastric vessels

Question 370

Why should femoral hernias be managed surgically, ideally within two weeks of presentation?

Answer 370

High risk of strangulation as femoral ring leaves only a narrow opening

Question 371

Where do femoral hernias occur?

Answer 371

(Potrusion of abdominal contents through the femoral ring) below the inguinal ligament at the top of the thigh

Question 372

What are the boundaries of the femoral canal?

Answer 372

Femoral vein - laterally Lacunar ligament medially Inguinal ligament posteriorly Pectineal ligament posteriorly

Question 373

What are incisional hernias, when do they occur and how are the managed?

Answer 373

Incisional hernias occur at the site of an incision from previous surgery. They are due to weakness where the muscles and tissues were closed after a surgical incision. The bigger the incision, the higher the risk of a hernia forming. Medical co-morbidities put patients at higher risk due to poor healing. Incisional hernias can be difficult to repair, with a high rate of recurrence. They are often left alone if they are large, with a wide neck and low risk of complications, particularly in patients with multiple co-morbidities.

Question 374

In which patients do umbilical hernias tend to occur in?

Answer 374

Neonates (usually resolve spontaneously) Older people due to a defect in the muscle around the umbilicus

Question 375

What is the spigelian fascia?

Answer 375

Aponeurosis between the muscles of the abdominal wallk

Question 376

How can diagnosis of a spiglian hernia be established?

Answer 376

USS

Question 377

What kind of base to spigelian hernias tend to have?

Answer 377

Narrow base, increased risk of complications

Question 378

Why does anastomotic leak cause fever?

Answer 378

Free fluid causes irritation of the peritoneum

Question 379

What is diastasis recti?

Answer 379

Widening of the linea alba, forming a larger gap between the rectus muscles. It is not technically a hernia. Gap becomes most prominent when the patient lies on their back and lifts their head There is a protuding buldge along the middle of the abdomen Congenital, pregnancy, obesity Normally no treatment but surgical repair is possible

Question 380

What is an obturator hernia?

Answer 380

Abdominal or pelvic contents herniate through the obturator foramen at the bottom of the pelvis, due to a defect in the pelvice floor. More common in older women who have had pregnancies and vaginal deliveries.

Question 381

Obturator hernias are usually asymptomatic, if they do have symptoms, what might they be?

Answer 381

Irritation to the obturator nerve, causing pain in the groin or medial thigh

Question 382

What is the Howship-Romberg sign?

Answer 382

Pain extending to the inner thigh to the knee when the hip is internally rotated due to compression of the obturator nerve

Question 383

What are the four types of hiatus hernia?

Answer 383

Type 1 - Sliding Type 2 - Rolling Type 3 - combination of sliding an rolling Type 4 - large opening with additional abdominal organs entering the thorax (e.g. bowel, pancreas, omentum)

Question 384

What is a hiatus hernia?

Answer 384

An hiatus hernia refers to the herniation of the stomach up through the diaphragm. The diaphragm opening should be at the level of the lower oesophageal sphincter and should be fixed in place. A narrow opening helps to maintain the sphincter and stop acid and stomach contents refluxing into the oesophagus. When the opening of the diaphragm is wider, the stomach can enter through the diaphragm and the contents of the stomach can reflux into the oesophagus.

Question 385

What is a sliding hiatus hernia?

Answer 385

Stomach slides up through the diaphragm with the gastro-oesophageal junction passing up into the thorax

Question 386

What is a rolling hiatus hernia?

Answer 386

Seperate portion of the stomach (ie. fundus) folds around and enters through the diaphragm opening, alongside the oesophagus

Question 387

How might a hiatus hernia present?

Answer 387

``` Dyspepsia Heartburn Acid reflux Reflux of food Burping Bloating Halitosis (bad breath) ```

Question 388

Why might hiatus hernias not be picked up by investigation'?

Answer 388

They can be intermittent

Question 389

How can hiatus hernias be investigated?

Answer 389

Chest c ray CT scan Endoscopy Barium swallow testing

Question 390

How are hiatus hernias treated?

Answer 390

Conservative (with GORD treatment) | Surgical repair if high risk of complications or symptoms are resitant to medical treatment

Question 391

How is hiatus hernia manage surgically?

Answer 391

Laparoscopic fundoplication - fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter

Question 392

What is a bowel obstruction?

Answer 392

A bowel obstruction refers to when the passage of food, fluids and gas, through the intestines becomes blocked. Small bowel obstruction is more common than large bowel obstruction. Obstruction results in a build up of gas and faecal matter proximal to the obstruction (before the obstruction). This causes back-pressure, resulting in vomiting and dilatation of the intestines proximal to the obstruction. Bowel obstruction is a surgical emergency.

Question 393

What is third-spacing?

Answer 393

Fluid loss from the intravascular space into the gastrointestinal tract. Less bowel over which fluid can be reabsorbed. Leads to hypovalemia and shock

Question 394

Causes of small bowel obstruction?

Answer 394

Adhesions (small bowel) Hernias (small bowel) Malignancy (large bowel)

Question 395

Causes of large bowel obstruction?

Answer 395

Volvulus (large bowel) Diverticular disease Strictures (e.g., secondary to Crohn’s disease) Intussusception (in young children aged 6 months to 2 years)

Question 396

Main causes of intestinal adhesions?

Answer 396

Abdominal or pelvic surgery (especially open) Peritonitis Adominal or pelvic infections (e.g. PID) Endometriosis

Question 397

What is meant by closed loop obstruction?

Answer 397

Two points of obstruction along the bowel

Question 398

What might cause a closed loop obstruction?

Answer 398

1. Adhesions that compress two areas of bowel 2. Hernias that isolate a section of bowel blocking either end 3. Volvulus where the twist isolates a section of intestine 4. A single point of obstruction in the large bowel, with an ileocaecal valve that is competent

Question 399

Why does a competent ilecaecal valve cause problems?

Answer 399

A competent ileocaecal valve does not allow any movement back into the illeum from the caecum. LBO and competent ileocacel valve, a section of bowel becomes isolated and the contents cannot flow in either direction

Question 400

Why does a close-loop obstruction of the bowel require emergency surgery?

Answer 400

Contents of obstruction cannot do not have an open end where they can drain and decompress. Therefore, the closed loop section will inevitably continue to expand, leading to ischemia and perforation.

Question 401

Key features of bowel obstruction?

Answer 401

Vomiting (particularly green bilious vomiting) - earlier in SOB Abdominal distention Diffuse abdominal pain Absolute constipation and lack of flatulence “Tinkling” bowel sounds may be heard in early bowel obstruction

Question 402

Upper limits of the normal diameter of bowel?

Answer 402

The upper limits of the normal diameter of bowel are: 3 cm small bowel 6 cm colon 9 cm caecum

Question 403

Key finding on abdominal x ray of bowel obstruction?

Answer 403

Distended bowel loops

Question 404

Investigation of choice for chronic bowel ischemia? What will it demonstrate?

Answer 404

Mesenteric angiography | Demonstrate a proximal occlusion of mesenteric vessels or vasoconstriction of all the mesenteric arcades

Question 405

How does chronic pancreatitis typically present?

Answer 405

Epigastric pain that radiates through the back (exaccerbated by fatty food or alcohol, relieved by sitting forwards) Steratohorea Weight loss Diabetes melitus (Polydyspia, polyuria)

Question 406

What is Borhaave's syndrome?

Answer 406

Oesophageal rupture secondary to forceful vomiting Triad of: Vomiting, chest pain and subcutaneous emphysema (Epigastric back pain may occur)

Question 407

What HPB complication might co-amoxiclav cause?

Answer 407

Cholestatic jaundice

Question 408

How will small bowel vs large bowel appear on X ray?

Answer 408

Small bowel: 3cm, vavulae conniventes (muscosal folds) for lines extending the full width of the bowel. Central Large bowel: 6cm (9cm ceacam), hasutra (pouches formed by muscle wall) extending partial width of the bowel, peripheral

Question 409

Reasons why a patient with a bowel obstruction may be haemodynamically unstable?

Answer 409

Hypovolaemic shock due to fluid stuck in the bowel rather than the intravascular space (third-spacing) Bowel ischaemia Bowel perforation Sepsis

Question 410

Key blood test findings in bowel obstruction?

Answer 410

U&Es- electrolyte imbalance | VBG - Metabolic alkalosis, raised lactate (bowel ischemia)

Question 411

Initial management of bowel obstruction?

Answer 411

NBM IV fluids to hydrate and correct electrolyte imbalances NG tube insertion with free drainage, reduces risk of vomiting and apsiration Anti-emetics if NG aspirate minimal -NOT metoclopramide

Question 412

Initital imaging for bowel obstruction?

Answer 412

Abdominal X ray OR CT scan if signs and symptoms are clear CXR demonstrates air under diagphragm if intra-abdominal perforation Contrast CT to confirm diagnosis, site and cause of obstruction. Also diagnose any intra-abdominal perforation

Question 413

Indications for surgical intervention in bowel obstruction?

Answer 413

``` Failed conservative managemet after 48hrs Closed loop bowel obstruction Strangulater hernia, obstruction tumour Intestinal obstruction Virgin abdomen (never had surgery) ```

Question 414

Complications of bowel obstruction?

Answer 414

Bowel ischaemia Bowel perforation leading to faecal peritonitis (high mortality) Dehydration and renal impairment

Question 415

What should be done when a SBO is not resolving within 24 hours of conservative treatment?

Answer 415

A water soluble contrast study should be performed in cases that do not resolve within 24 hours conservative management. If contrast does not reach the colon by 6 hours then it is very unlikely that it will resolve and the patient should be taken to theatre.

Question 416

What are the surgical options in treating bowel obstruction?

Answer 416

Laparoscopy or lapaotomy to correct underlying cause Emergency resection of the obstruction tumour Adhesiolysis Hernia repair Explorative surgery if unclear cause During colonoscopy stent can be inserted if obstruction due to tumour

Question 417

What is appendicitis and when is the peak incidence?

Answer 417

Inflammation of the appendix (small, thin tube arising from the caecum, with a single dead end opening to the bowel) 10 - 20 years (second smaller peak around 60-70)

Question 418

What is the pathophysiology of acute appendicitis?

Answer 418

Pathogens get trapped due to obstruction at the point where the appendix meets the bowel (where the three teniae coli meet) Trapping of pathogens leads to inflammation Inflammation may proceed to gangrene and rupture When the appendix ruptures, faecal contents and infective material are released into the peritoneal cavity, leading to peritonitits, which is inflammation of the peritoneal lining

Question 419

Signs and symptoms of appendicitis?

Answer 419

``` Central abdominal pain that localised to RIF within 24 hrs Tenderness at McBurney's point (refers to a specific are one third of the distance from the ASIS to the umbilicus) Anorexia N&V Low grade fever Rovsings signs (Psoas sign) Guarding on abdominal palpation Rebound tenderness in the RIF Percussion tenderness ```

Question 420

What findings upon abdominal examintation suggest peritonitis?

Answer 420

Rebound tenderness | Percussion tenderness

Question 421

How is appendicitis diagnosed?

Answer 421

``` Usually only: Raised inflammatory markers Clinical presentation Diagnostic laparoscopy + appendectomy (if indicated) Diagnosis can be further confirmed by: USS to exclude ovarian pathology CT scan confirms appendicitis ```

Question 422

Key differential diagnoses of appendicitis?

Answer 422

Ectopic pregnancy Ovarian cyst rupture/torsion Meckel's Diverticulum Mesenteric adenitits

Question 423

What is mesenteric adenitis?

Answer 423

Mesenteric adenitis describes inflamed abdominal lymph nodes. It presents with abdominal pain, usually in younger children, and is often associated with tonsillitis or an upper respiratory tract infection. No specific treatment is required.

Question 424

What is Meckel's diverticulum?

Answer 424

Meckel’s diverticulum is a malformation of the distal ileum that occurs in around 2% of the population. It is usually asymptomatic and does not require any treatment. However, it can bleed, become inflamed, rupture or cause a volvulus or intussusception.

Question 425

What is an appendix mass and how is it managed?

Answer 425

Mass occuring when the omentum surrounds and sticks to the inflamed appendix, forming a mass in the RIF Managed conservatively with supportive treatment and abx, then once condition has resolved definitive appendectomy.

Question 426

Complications of Appendicetomy?

Answer 426

``` Bleeding, infection, pain and scars Damage to bowel, bladder or other organs Removal of a normal appendix Anaesthetic risks Venous thromboembolism (deep vein thrombosis or pulmonary embolism) ```

Question 427

What is a volvulus?

Answer 427

Condition where bowel twists itself around the mesentery that it is attatched too

Question 428

What is meant by bowel mesentery?

Answer 428

Membranous potential tissue that creates a conncetion between the bowel and the posterior abdominal wall, through which the mesenteric arteries supply blood to the bowel

Question 429

What kind of bowel obstruction does a vovulus?

Answer 429

Close loop large bowel obstruction

Question 430

How can volvulus cause bowel ischemia and what can this cause?

Answer 430

Blood vessels that supply the bowel can be involved, cutting off the blood supply to the bowel, which leads to bowel ischemia, which can lead to necrosis and bowel perforation

Question 431

What type of volvulus is most common?

Answer 431

Sigmoid volvulus

Question 432

What kind of volvulus affects older patients?

Answer 432

Sigmoid volvulus

Question 433

Key cause of sigmoid volvulus and pathophysiology?

Answer 433

Chronic constipation and lengthening of the mesentery attatched to the sigmoid colon. Sigmoid colon becomes overloaded with faeces, causing it to sink downwards causing a twist. It is also associated with a high fibre diet and the excessive use of laxatives

Question 434

Which type of volvulus tends to affect younger patients?

Answer 434

Caecal volvulus

Question 435

Risk factors of volvulus?

Answer 435

``` Neuropsychiatric disorders (e.g., Parkinson’s) Nursing home residents Chronic constipation High fibre diet Pregnancy Adhesions ```

Question 436

Investigation of choice to confirm volvulus and identify other pathology?

Answer 436

A contrast CT scan

Question 437

How is caecal volvulus managed surgically?

Answer 437

Ileocaecal resection or right hemicolectomy for caecal volvulus

Question 438

How is sigmoid volvulus managed surgically?

Answer 438

Hartmann's procedure

Question 439

Which surgical option can be used to manage any kind of volvulus?

Answer 439

Laparotomy

Question 440

Conservative management of sigmoid volvulus?

Answer 440

Conservative management with endoscopic decompression can be attempted in patients with sigmoid volvulus (without peritonitis) A flexible sigmoidoscope is inserted with the patient lying in the left lateral position, correcting the volvulus, a flatus tube is left in place (decompress) and later removed

Question 441

What sign may be present on CT IV contrast in a volvulus?

Answer 441

The whirlpool sign of the mesentery, also known as the whirl sign, is seen when the bowel rotates around its mesentery leading to whirls of the mesenteric vessels

Question 442

Disadvanatge to conservate management of volvulus?

Answer 442

High risk of recurrence

Question 443

How do diverticula form?

Answer 443

Circular muscle in LI is penetrated at points by blood vessels - area of weakness INcreased pressure inside the lumin over time causes a gap to form in these areas of circular muscle These gaps allow muscose to herniate through the muscle layer and pouches to form diverticula

Question 444

Why do divertiucula nor form in the rectum?

Answer 444

It has outer longitudinal muscle layer completely surrounding its diameter adding extra support

Question 445

Which areas of colon are susseptible to formation of diverticula?

Answer 445

Areas not covered by tenia coli (strips formed by three longitudinal muscles running along the colon)

Question 446

Most uncommon type of diverticula?

Answer 446

Small bowel | Sigmoid most common

Question 447

Risk factors for diverticulosis?

Answer 447

Increased age (wear and tare) Low fiber diet Obesity Use of NSAIDs (increases risk of diverticular haemorrhage)

Question 448

How is diverticulosis found incidently?

Answer 448

Colonoscopy or CT

Question 449

How should asymptomatic diverticula be managed?

Answer 449

High fiber diet and weight loss if appropriate

Question 450

If diverticulosis causes LIF pain, constipation, or rectal bleeding, how is it managed?

Answer 450

1. Bulk forming laxatives (ispaghula husk, methylcellulose) 2, Increased fibre intake 3. AVOID stimulant laxatives such as Senna 4. If symptoms are significant and persistant, surgery to remove affected area

Question 451

How might acute diverticulitis present?

Answer 451

Pain and tenderness in the left iliac fossa / lower left abdomen Fever Diarrhoea Nausea and vomiting Rectal bleeding Palpable abdominal mass (if an abscess has formed) Raised inflammatory markers (e.g., CRP) and white blood cells

Question 452

How is uncomplicated diverticulitis managed in primary care?

Answer 452

Oral co-amoxiclav (at least 5 days) Analgesia (avoiding NSAIDs and opiates, if possible) Only taking clear liquids (avoiding solid food) until symptoms improve (usually 2-3 days) Follow-up within 2 days to review symptoms

Question 453

How is diverticulitis with severe pain or complications, warrenting hospital admission, treated?

Answer 453

``` NBM/clear fluids only IV abx IV fluids Analgesia Urgent investigation - CT Urgent surgery to treat complications as required ```

Question 454

What are the potential complications of acute diverticulitis?

Answer 454

Perforation Peritonitis Peridiverticular abscess Large haemorrhage requiring blood transfusions Fistula (e.g., between the colon and the bladder or vagina) Ileus / obstruction

Question 455

What three main branches of the abdominal aorta supply the abdominal organs?

Answer 455

Coeliac artery Superior mesenteric artery INferior mesnetric artery

Question 456

Which section of gut does the coeliac artery supply?

Answer 456

Foregut Distal end of the esophagus, the stomach, and a first half of the descending portion of the duodenum, biliary system, liver, pancreas, spleen

Question 457

What section of gut does the superior mesenteric artery supply?

Answer 457

Midgut - distal part of the duodenum to first part of transverse colon

Question 458

What section of gut does the inferior mesenteric artery supply?

Answer 458

Hind gut - second half of transverse colon to the rectum

Question 459

What is chronic mesenteric ischemia also known as?

Answer 459

Intestinal angina

Question 460

What does chronic mesenteric ischemia result from?

Answer 460

Narrowing of the mesenteric blood vessels by atherosclerosis

Question 461

What is the main presenting feature of chronic mesnteric ischemia?

Answer 461

Intermittent abdominal pain, when the blood supply cannot keep up with the demand

Question 462

Triad of symptoms in chronic mesenteric ischemia?

Answer 462

``` Central colicky abdominal pain after eating (starting around 30 minutes after eating and lasting 1-2 hours) Weight loss (due to food avoidance, as this causes pain) Abdominal bruit may be heard on auscultation ```

Question 463

Risk factors for chronic mesenteric ischemia?

Answer 463

``` Increased age Family history Smoking Diabetes Hypertension Raised cholesterol ```

Question 464

Management of chronic mesenteric ischemia?

Answer 464

Reduce modifiable risk factors Secondary CVD prevention - statins, antiplatelet medication Revascularisation to improve blood flow to the intestines

Question 465

How can revascularisation be performed in chronic mesenteric ischemia?

Answer 465

Endovascular procedures - first line (Percutaneous mesenteric artery stenting) Open surgery - second line (endarectomy, re-implantation, bypass grafting)

Question 466

What causes acute mesenteric ischemia?

Answer 466

Acute mesenteric ischaemia is typically caused by a rapid blockage in blood flow through the superior mesenteric artery. This is usually caused by a thrombus (blood clot) stuck in the artery, blocking blood flow. The blood clot may be a thrombus that has developed inside the artery or an embolus from another site that has got stuck in the artery.

Question 467

Which condition is a key risk factor for acute mesenteric ischemia and why?

Answer 467

AF Thrombus forms in left atrium, thromboembolises down the aorta to the superior mesenteric artery where it becomes stuck and cuts of the blood supply

Question 468

How does acute mesenteric ischemia present?

Answer 468

acute, non-specific abdominal pain. The pain is disproportionate to the examination findings

Question 469

The mortality of acute mesenteric ischemia is over 50%, what potential complications can arise from it??

Answer 469

``` Shock Peritonitis Sepsis Bowel ischemia leading to necrosis leading to perforation Metabolic acidosis Raised lactate ```

Question 470

What abnormality will be present on VBG in a patient with acute mesenteric ischemia?

Answer 470

Metabolic acidosis with raised anion gap | Raised lactate

Question 471

Goal of surgical management in acute mesenteric ischemia?

Answer 471

Remove necrotic bowel | Remove or bypass the thrombus in the blood vessel (open surgery or endovascular procedures may be used)

Question 472

Risk factors for bowel cancer?

Answer 472

Family history of bowel cancer Familial adenomatous polyposis (FAP) Hereditary nonpolyposis colorectal cancer (HNPCC), also known as Lynch syndrome Inflammatory bowel disease (Crohn’s or ulcerative colitis) Increased age Diet (high in red and processed meat and low in fibre) Obesity and sedentary lifestyle Smoking Alcohol

Question 473

What is familial adenomatous polyposis (FAP)?

Answer 473

Autosomal dominant condition Malfunctioning of tumour superssion genes (adenomatous polyposis coli - APC) Polyps - adenomas - develop along large intestine, have potential to become cancerous (before pt is 40) Pt advised to undergo prophylactic panproctocolectomy

Question 474

What is Lynch syndrome?

Answer 474

Hereditary nonpolyposis colorectal cancer (HNPCC) is also known as Lynch syndrome. It is an autosomal dominant condition Results from mutations in DNA mismatch repair (MMR) genes. Patients are at a higher risk of a number of cancers, but particularly colorectal cancer. Unlikely FAP, it does not cause adenomas and tumours develop in isolation.

Question 475

Red flags for bowel cancer?

Answer 475

Change in bowel habit (usually to more loose and frequent stools) Unexplained weight loss Rectal bleeding Unexplained abdominal pain Iron deficiency anaemia (microcytic anaemia with low ferritin) Abdominal or rectal mass on examination

Question 476

What is the criteria for bowel cancer two week wait referral in a patient over 40 years?

Answer 476

Abdominal pain and unexplained weight loss

Question 477

What is the criteria for bowel cancer two week wait referral in a patient over 50 years?

Answer 477

Unexplained rectal bleeding

Question 478

What is the criteria for bowel cancer two week wait referral in a patient over 60?

Answer 478

Change in bowel habit or iron def anaemia

Question 479

What screening test is used to look for bowel cancer and who is it offered to?

Answer 479

In England, people aged 60 – 74 years are sent a home FIT test to do every 2 years. If the results come back positive they are sent for a colonoscopy. People over 50 with unexplained weight loss and no other symptoms who do not meet 2ww criteria Under 60s with a change in bowel habit who do not meet criteria for 2ww

Question 480

Who is offered colonscopy at regular intervals without a FIT test?

Answer 480

Patients with risk factors such as FAP HNPCC IBD

Question 481

What do Faecal immunochemical tests look for specifically?

Answer 481

Human haemoglobin in the stool

Question 482

Gold standard investigation for bowel cancer?

Answer 482

Colonoscopy +/- biopsy or tattoo suspicious lesion

Question 483

What is sigmoidoscopy, what is it used for and what is the weakness of using it?

Answer 483

Sigmoidoscopy involves an endoscopy of the rectum and sigmoid colon only. This may be used in cases where the only feature is rectal bleeding. There is the obvious risk of missing cancers in other parts of the colon.

Question 484

What may be used in diagnosis of bowel cancer in patients not fit for colonoscopy?

Answer 484

CT colonography is a CT scan with bowel prep and contrast to visualise the colon in more detail. This may be considered in patients less fit for a colonoscopy but it is less detailed and does not allow for a biopsy.

Question 485

What is used when investigating staging in a patient with bowel cancer?

Answer 485

Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP). This is used to look for metastasis and other cancers. It may be used after a diagnosis of colorectal cancer, or as part of the initial workup in patients with vague symptoms (e.g., weight loss) in addition to colonoscopy as an initial investigation to exclude other cancers.

Question 486

What tumour marker can be used in prediciting relapse in patinets previously treated for bowel cancer?

Answer 486

Carcinoembryonic antigen (CEA)

Question 487

What is, from A-D Duke's classification of bowel cancer?

Answer 487

Dukes A – confined to mucosa and part of the muscle of the bowel wall Dukes B – extending through the muscle of the bowel wall Dukes C – lymph node involvement Dukes D – metastatic disease

Question 488

What classification has replaced Dukes' classification of bowel cancer?

Answer 488

TMN classification

Question 489

T of TNM?

Answer 489

TX – unable to assess size T1 – submucosa involvement T2 – involvement of muscularis propria (muscle layer) T3 – involvement of the subserosa and serosa (outer layer), but not through the serosa T4 – spread through the serosa (4a) reaching other tissues or organs (4b)

Question 490

N of TNM?

Answer 490

NX – unable to assess nodes N0 – no nodal spread N1 – spread to 1-3 nodes N2 – spread to more than 3 nodes

Question 491

N of TNM?

Answer 491

NX – unable to assess nodes N0 – no nodal spread N1 – spread to 1-3 nodes N2 – spread to more than 3 nodes

Question 492

M of TMN?

Answer 492

M0 – no metastasis | M1 – metastasis

Question 493

Factors MDT will consider when managing colorectal cancer?

Answer 493

``` Clinical condition General health Stage Histology Patient wishes ```

Question 494

Management of bowel cancer?

Answer 494

Surgical resection Chemotherapy Radiotherapy Palliative care

Question 495

What does, generally, surgical management of bowel cancer involve?

Answer 495

Identifying the tumour (it may have been tattooed during an endoscopy) Removing the section of bowel containing the tumour, Creating an end-to-end anastomosis (sewing the remaining ends back together) Alternatively creating a stoma (bringing the open section of bowel onto the skin)

Question 496

What is removed in a right hemicolectomy?

Answer 496

Caecum Ascending Proximal transverse colon

Question 497

What does a left hemicolectomy involve removing?

Answer 497

Distal transverse and descending colon

Question 498

What is removed and what is psared in a low anterior resection?

Answer 498

Removal of sigmoid colon and upper rectum | Sparing of the lower rectum and anus

Question 499

What does a high anterior resection involve removal of?

Answer 499

Sigmoid colon (including anus and all of the rectum)

Question 500

What does an abdomino-perineal resection inolve?

Answer 500

Involves removing the rectum and anus (plus or minus the sigmoid colon) and suturing over the anus. It leaves the patient with a permanent colostomy.

Question 501

What is Hartmann's procedure?

Answer 501

Usually an emergency procedure that involves removal of the RECTOSIGMOID COLON and creating of a colosotmy. The rectal stump is sutured closed Colonostomy may be reversed later

Question 502

What is low anterior resection syndrome and what does it involve?

Answer 502

Low anterior resection syndrome may occur after resection of a portion of bowel from the rectum, with anastomosis between the colon and rectum. It can result in a number of symptoms, including: Urgency and frequency of bowel movements Faecal incontinence Difficulty controlling flatulence

Question 503

Potential complications of surgery for bowel cancer?

Answer 503

``` Bleeding, infection and pain Damage to nerves, bladder, ureter or bowel Post-operative ileus Anaesthetic risks Laparoscopic surgery converted during the operation to open surgery (laparotomy) Leakage or failure of the anastomosis Requirement for a stoma Failure to remove the tumour Change in bowel habit Venous thromboembolism (DVT and PE) Incisional hernias Intra-abdominal adhesions ```

Question 504

Follow up of bowel cancer post surgery?

Answer 504

Patients will be followed up for a period of time (e.g., 3 years) following curative surgery. This includes: Serum carcinoembryonic antigen (CEA) CT thorax, abdomen and pelvis

Question 505

What are the two main causes of acute cholangitis?

Answer 505

Obstruction in the bile ducts causing bile stasis (e.g. gallstones) Infection introduced during an ERCP

Question 506

Most common caustive organisims of acute cholangitis?

Answer 506

Escherichia coli Klebsiella species Enterococcus species

Question 507

What is Charcot triad in acute cholangitis?

Answer 507

RUQ Jaundice Fever

Question 508

Management of acute cholangitis?

Answer 508

``` NBM IV fluids Blood culture Antibiotics as per local guidelines Involvement of seniors and potentially HDU or ICU ```

Question 509

Gold standard investigation for cholangitis?

Answer 509

ERCP (+interventional)

Question 510

How should a patient with acute cholangitis who has not responded to abx in the first 24hrs be managed?

Answer 510

Urgent billiary drainage

Question 511

Interventions that can be done during ERCP?

Answer 511

Cholangio-pancreatography: retrograde injection of contrast into the duct through the sphincter of Oddi and x-ray images to visualise biliary system Sphincterotomy: making a cut in the sphincter to dilate it and allow stone removal Stone removal: a basket can be inserted and pulled through the common bile duct to remove stones Balloon dilatation: a balloon can be inserted and inflated to treat strictures Biliary stenting: a stent can be inserted to maintain a patent bile duct (for strictures or tumours) Biopsy: a small biopsy can be taken to diagnose obstructing lesions

Question 512

What is percutaneous transhepatic cholangiogram (PTC) used to manage?

Answer 512

Radiologically guided insertion of a drain through the skin and liver into the bile ducts, relieving immediate obstruction. Stent can be used to give longer lasting relief Used when ERCP has failed or for patients not suitable for ERCP

Question 513

How might acute cholecystitis present

Answer 513

RUQ pain, potentially radiating to right shoulder Fever Nausea Vomiting Tachycardia (fast heart rate) and tachypnoea (raised respiratory rate) Right upper quadrant tenderness Murphy’s sign Raised inflammatory markers and white blood cells

Question 514

Signs of acute choleycystitis on USS

Answer 514

Thickened gallbladder wall Stones or sludge in gallbladder Fluid around the gallbladder

Question 515

What is Murphy's sign and why and when does it occur?

Answer 515

Place a hand in RUQ and apply pressure Ask the patient to take a deep breath in The gallbladder will move downwards during inspiration and come in contact with your hand Stimulation of the inflamed gallbladder results in acute pain and sudden stopping of inspiration Acute cholecystitis

Question 516

If USS is not sufficient to visualised the billary tree what can be used?

Answer 516

Magnetic resonance cholangiopancreatography (MRCP)

Question 517

Management of gallbladder empyema?

Answer 517

Gallbladder empyema refers to infected tissue and pus collecting in the gallbladder. Management involves IV antibiotics and one of two main options: ``` Cholecystectomy (to remove the gallbladder) Percutaneous cholecystostomy (inserting a drain into the gallbladder to allow the infected contents to drain) ```

Question 518

Complications of cholecysitis?

Answer 518

Sepsis Gallbladder empyema Gangrenous gallbladder Perforation

Question 519

How is gallbladder empyema diagnosed?

Answer 519

USS | CT scan

Question 520

What does chronic cholecystitis increase the risk of?

Answer 520

Gallbladder carcinoma | Biliary enteric firstula

Question 521

How is chronic cholecystitis typically diagnosed?

Answer 521

CT imaging

Question 522

What is Bouveret’s Syndrome?

Answer 522

Inflammation of the gallbladder causes a fistula to form between the gallbladder wall and small bowel (cholecystoduodenal fistual) A stone impacts in the proximal duodenum, causing a gastric outlet obstruction

Question 523

What is Gallstone Ileus?

Answer 523

Inflammation of the gallbladder causes a fistula to form between the gallbladder wall and small bowel (cholecystoduodenal fistual) Stone impacts at the terminal illeum causing SBO?

Question 524

Cholangiocarcinoma is a type of cancer that originates in the bile duct, what is the most common?

Answer 524

Adenocarcinomas

Question 525

Where might cholangicarcinoma affect?

Answer 525

Intrahepatic bile ducts Extrahepatic bile ducts Perihiliar region most common (where right and left hepatic duct have joined to become the common hepatic duct)

Question 526

Key risk factor for cholangiocarcinoma?

Answer 526

Primary sclerosing cholangitis (risk factor for this is UC) | Liver flukes

Question 527

What is obstructive jaundice associated with?

Answer 527

Pale stools Dark urine Generalised itching

Question 528

What is the narrowest part of the small bowel?

Answer 528

Terminal ileum

Question 529

How might cholangiocarcinoma?

Answer 529

``` Jaundice (obstructive) Unexplained weight loss Right upper quadrant pain Palpable gallbladder (swelling due to an obstruction in the duct distal to the gallbladder) - painless Hepatomegaly Pale stools Dark urine Generalised itching ```

Question 530

How is cholangiocarcinoma diagnosed?

Answer 530

Diagnosis is based on imaging (CT or MRI) plus histology from a biopsy.

Question 531

Why might MRCP and ERCP be used in cholangiocarcinoma?

Answer 531

Magnetic resonance cholangio-pancreatography (MRCP) may be used to assess the biliary system in detail to assess the obstruction. Endoscopic retrograde cholangio-pancreatography (ERCP) can be used to put a stent in and relieve the obstruction, and also obtain a biopsy from the tumour.

Question 532

What tumour marker may be raised in cholangiocarcinoma?

Answer 532

CA 19-9

Question 533

If caught in the early stages, cholangiocarcinoma may be curatively treated - how?

Answer 533

Curative surgery +/- raidotherapy and chemotherapy

Question 534

Most cases of cholangiocarcinoma can not be cured, how is it managed palliatively?

Answer 534

Stents inserted to relieve the biliary obstruction Surgery to improve symptoms (e.g., bypassing the biliary obstruction) Palliative chemotherapy Palliative radiotherapy End of life care with symptom control

Question 535

Pancreatic cancer is often diagnosed late and has a very poor prognosis. The vast majority are what type of cancer?

Answer 535

Adenocarcinoma

Question 536

Pancreatic cancer is often diagnosed late and has a very poor prognosis. The vast majority are occur where?

Answer 536

Head of pancreas (as opposed to body and tail)

Question 537

The average survival of pancreatic cancer when diagnosed with advanced disease is only 6 months, why is prognosis so poor?

Answer 537

Pancreatic cancers spread and metastisise early

Question 538

Where do pancreatic cancers metastisise to?

Answer 538

Liver Peritoneum Lungs Bones

Question 539

Why does pancreatic cancer cause obstructive jaundice?

Answer 539

Can compress the bile ducts when a tumour in head of pancreas grows large enough

Question 540

Presenting features of pancreatic cancer?

Answer 540

``` Yellow skin and sclera Pale stools Dark urine Generalised itching Non-specific upper abdominal or back pain Unintentional weight loss Palpable mass in the epigastric region Change in bowel habit Nausea or vomiting New‑onset diabetes or worsening of type 2 diabetes ```

Question 541

Pancreatic cancer 2ww referal criteria?

Answer 541

Over 40 with jaundice – referred on a 2 week wait referral Over 60 with weight loss plus an additional symptoms (Diarrhoea, back pain, abdo pain, nausea, vomiting, constipation – referred for a direct access CT abdomen)

Question 542

How is pancreatic cancer diagnosed?

Answer 542

Diagnosis is based on imaging (usually CT scan) plus histology from a biopsy.

Question 543

What investigations are used to stage pancreatic cancer?

Answer 543

Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP). This is used to look for metastasis and other cancers.

Question 544

What tumour marker might be raised in pancreatic cancer?

Answer 544

CA 19-9 (carbohydrate antigen) is a tumour marker that may be raised in pancreatic cancer. It is also raised in cholangiocarcinoma and a number of other malignant and non-malignant conditions.

Question 545

What is the role of ERCP and MRCP in pancreatic cancer?

Answer 545

Magnetic resonance cholangio-pancreatography (MRCP) may be used to assess the biliary system in detail to assess the obstruction. Endoscopic retrograde cholangio-pancreatography (ERCP) can be used to put a stent in and relieve the obstruction, and also obtain a biopsy from the tumour.

Question 546

How is biopsy taken in pancreatic cancer?

Answer 546

Percutaneous under ultrasound or CT guidance During an endoscopy under ulrasound guidance DUring ERCP

Question 547

Surgery may be used in early pancreatic cancer with small tumour size, what are the options?

Answer 547

Total pancreatectomy Distal pancreatectomy Pylorus-preserving pancreaticoduodenectomy (PPPD) (modified Whipple procedure) Radical pancreaticoduodenectomy (Whipple procedure)

Question 548

Palliative treatment of pancreatic cancer?

Answer 548

``` Stents inserted to relieve the biliary obstruction Surgery to improve symptoms (e.g., bypassing the biliary obstruction) Palliative chemotherapy (to improve symptoms and extend life) Palliative radiotherapy (to improve symptoms and extend life) End of life care with symptom control ```

Question 549

What is Whipple Procedure?

Answer 549

``` Pancreaticoduodenectomy Removal of: Head of pancreas Pylorus of stomach Duodenum Gallbladder Bile duct Relevant lymph nodes ```

Question 550

What differs in a modified Whipple procedure?

Answer 550

A modified Whipple procedure involves leaving the pylorus in place. It is also known as a pylorus-preserving pancreaticoduodenectomy (PPPD).

Question 551

What does the gastrodudenal artery supply?

Answer 551

The gastroduodenal artery (GDA) is a terminal branch of the common hepatic artery which mainly supplies the pylorus of the stomach, proximal duodenum, and the head of the pancreas.

Question 552

Contraindications to liver transplant?

Answer 552

Significant co-morbidities (e.g., severe kidney, lung or heart disease) Current illicit drug use Continuing alcohol misuse (generally 6 months of abstinence is required) Untreated HIV Current or previous cancer (except certain liver cancers)

Question 553

What incision is used in liver transplant?

Answer 553

“rooftop” or “Mercedes Benz” incision along the lower costal margin for open surgery.

Question 554

What is an intra-abdominal abscess?

Answer 554

Intra-abdominal abscess is an intra-abdominal collection of pus or infected material, usually due to a localised infection inside the peritoneal cavity. It can involve any intra-abdominal organ or be located in between bowel loops, or be free within the peritoneal cavity itself.

Question 555

How do intra-abdominal abscess' present?

Answer 555

``` Commonly presents with abdominal pain, fever, and leukocytosis Also: Fever or hypothermia Abdominal pain History of IBD Tachycardia Change in bowel habits/abnormal bowel function Prolonged ileus Anorexia.lack of apetite ```

Question 556

What are intra-abdominal abscess' usually secondary to?

Answer 556

Innoculation, commonly from complicated intra-abdominal infection (ie. bowel perforation, anastomtic leak, trauma)

Question 557

How is an intrabdominal abcess diagnosed?

Answer 557

USS, CTAP (usually more reliable and provided better delineation of anatomical location and abscess size)

Question 558

What are risk factors for an intraabdominal abscess?

Answer 558

diabetes malignancy recent surgery or trauma, appendicitis, diverticulitis, or perforated ulcer male sex

Question 559

What investigations should be ordered first for intra abdominal abscess?

Answer 559

WBC count drainage culture abdominal CT scan ``` Also consider: serum CRP serum erythrocyte sedimentation rate (ESR) Gram stain of abscess fluid serum glucose ```

Question 560

How do anorectal abscess' typically present?

Answer 560

Perianal pain and swelling | PR bleeding is uncommon - more suggestive of anal fissure

Question 561

What will an anorectal abscess appear like on examination?

Answer 561

Fluctuant tender peri-anal swelling

Question 562

If a anorectal abscess causes further infection what features might be present?

Answer 562

Pyrexia Tachycardia Sepsis - haemodynamic compromise

Question 563

Which patients typically present with a anorectal abscess?

Answer 563

Anorectal abscesses typically occur in men age 20-40 years old.

Question 564

What are the risk factors for anorectal abscess?

Answer 564

Anal fistulae Crohn's disease Male sex

Question 565

How are anorectal abscesses managed?

Answer 565

Drainage, to prevent spread of infection and sepsis Either in A&E under local anaesthetic Or in theatre if deep with sphincter extension

Question 566

What causes a pilonidal abscess?

Answer 566

Pilonidal disease is caused by insertion of hairs into the skin of the natal cleft, at the sacrococcygeal region. This causes a chronic inflammatory response, with formation of a discharging sinus. Infection of the region may precipitate abscess formation.

Question 567

How does pilonidal abscess usually present?

Answer 567

Pilonidal disease typically occurs in male patients age 15-40 and is more common in the presence of thick stiff body hair (especially patients who sit down a lot e.g. lorry drivers) Patients typically present with offensive discharge from the natal cleft and discomfort, especially when seated. On physical examination sinus tracts may be visible around the natal cleft. If superinfection occurs, there may be abscess formation which results in a tender fluctuant swelling and low-grade fever.

Question 568

What is a subcutaneous abscess?

Answer 568

A subcutaneous abscess is a kind of soft tissue abscess and a manifestation of a spectrum of skin and soft tissue infections which also includes cellulitis and necrotizing fasciitis. It is a form of abscess which lies within the dermis and subdermal cutaneous layers. Along with dental abscesses, the subcutaneous layer is the most common site for abscess formation.

Question 569

How does a subcutaneous abscess typically present?

Answer 569

Patients typically present with an acute or subacute history of a focal swelling or lump in the affected skin with accompanying signs of cellulitis. If there is bacteremia, the patient may present with systemic signs of sepsis such as fever, rigours, and raised inflammatory markers.

Question 570

What is the most common caustive pathogen of a subcutaneous abscess?

Answer 570

Steptococcus species

Question 571

Pathology of subcutaneous abscess formation?

Answer 571

Skin abscesses are overwhelmingly caused by bacteria that spread into the subcutaneous tissues through breaches in the epidermis. In some cases sterile abscess formation has been described where an irritant drug or substance is injected into the skin, resulting in aseptic inflammation and abscess formation.

Question 572

Subcutaneous abscess is usually diagnosed clinically, why might imaging be used and what imaging is the prefered modaility for the evaluation of more deep soft tissue abscess?

Answer 572

If radical surgical treatment is being considered imaging may be undertaken to determine the extent of soft tissue involvement. MRI USS can also be useful for differntiating cellulitis with gross cutaneous swelling from a true abscess

Question 573

Differential diagnosis for subcutaneous abscess?

Answer 573

``` lymph node enlargement sebaceous cyst seroma lymphocele hematoma herniated bowel blood vessel ```

Question 574

Risk factors for subcutaneous abscess?

Answer 574

``` Advanced age Trauma DM Mallignancy Immunocompromised state Obesity ```

Question 575

How do you manage subcutaneous abscess?

Answer 575

Incision and drainage is the definitive treatment of a soft tissue abscess. However, premature incision before localization of pus will not be curative and may be deleterious. In cases of immature abscesses or cellulitis, oral antibiotics and warm compresses may be of value in helping the infection to coalesce.

Question 576

How is Meckel's diverticulum most accurately diagnosed?

Answer 576

99 Technetium scan

Question 577

What incision is used in an emergency c section?

Answer 577

Pfannenstiel's

Question 578

What incision is used in bile duct exploration?

Answer 578

Kocher's

Question 579

What incision is used in Whipple procedure

Answer 579

: Rooftop or Midline

Question 580

What is Rigler's sign?

Answer 580

Rigler's sign: 2 lines of the intestinal surface is seen on abdominal x ray

Question 581

How might a minor internal haemorrhoid be managed?

Answer 581

The correct answer is: Topical dilti

Question 582

Initial management of an anal fissure?

Answer 582

Initial therapy should be with pharmacological agents to relax the sphincter and facilitate healing. This is particularly true in females presenting for the first time.

Question 583

How should recurrent episodes of natal cleft pain with discharge be managed?

Answer 583

Pilonidal cystectomy

Question 584

How does a strangulated femoral hernia present?

Answer 584

colicky abdominal pain and a tender mass in the groin.

Question 585

How should a thrombosed haemorrhoid be managed if it presents after 72 hours?

Answer 585

Following the first 72 hours of acute thrombosis, the thrombus is likely to organise and contract- lessening symptoms and typically self-resolving within a few weeks. In such scenario, it is more appropriate to offer conservative management options including analgesia, stool softeners and using ice-packs to reduce pain.

Question 586

How should a thrombosed haemorrhoid be managed in the first 72 hrs?

Answer 586

If a patient with thrombosed haemorrhoids presents within 72 hours of onset of the pain, NICE recommends offering admission for surgical management of the piles. This provides immediate pain relief.

Question 587

How do thrombosed haemorrhoids present?

Answer 587

Thrombosed haemorrhoids are characterised by anorectal pain and a tender lump on the anal margin

Question 588

What can a gastrectomy lead to subacute combined degeneration of the spinal cord (loss of vibration sense, hyperreflexia, and absent reflexes)

Answer 588

Gastrectomy may result in vitamin B12 deficiency

Question 589

Why do post-gastrectomy patients not immediatley suffer vitamin deficiency?

Answer 589

B12 stores can last a couple years. | Folate lasts couple months

Question 590

What imbalances might a high output stoma cause?

Answer 590

These patients may develop significant volume depletion, electrolyte and acid-base disturbances (metabolic acidosis) if the ileostomy output increases or if dietary intake is disrupted or altered. Hence, it is important to monitor fluid balance including stoma output in these patients.

Question 591

Inestigatio of choice for Boerhaaves syndrome?

Answer 591

CT contrast swallow is the investigation of choice for suspected Boerhaave's syndrome

Question 592

How is a pancreatic pseudocyst usually managed?

Answer 592

Conservatively

Question 593

Causes of pancreatitits?

Answer 593

Gallstones Ethanol Trauma Steroids Mumps (other viruses include Coxsackie B) Autoimmune (e.g. polyarteritis nodosa), Ascaris infection Scorpion venom Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia ERCP Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)

Question 594

Most commonly performed operation for rectal tumour?

Answer 594

Anterior resection is the most commonly performed operation for rectal tumours, except in lower rectal (tumours abdominoperineal excision of rectum is for low rectal or anal tumours)

Question 595

Diverticulitis symptoms + vaginal passage of faeces or flatus suggest what?

Answer 595

Diverticulitis symptoms + vaginal passage of faeces or flatus → ?colovaginal fistula

Question 596

What type of cannula does a haemodynamically stable pt require?

Answer 596

only require intravenous access temporarily a 20 G (pink) peripheral cannula will suffice.

Question 597

Pigmented gallstones are associated with which conditon?

Answer 597

Pigmented gallstones are associated with sickle cell

Question 598

How does gastric volvulus present?

Answer 598

Gastric volvulus- triad of vomiting, pain and failed attempts to pass an NG tube

Question 599

What is the first-line medication for primary biliary cholangitis?

Answer 599

Ursodeoxycholic acid

Question 600

Surgical management of splenic flexure tumour?

Answer 600

Left hemicolectomy

Question 601

Surgical management of UPPER RECTAL TUMOURS?

Answer 601

Anterior resection and colo-rectal anastomosis

Question 602

Surgical management of lower rectal tumour?

Answer 602

Abdomino-perineal excision of rectum

Question 603

Organisms causing post splenectomy sepsis?

Answer 603

Streptococcus pneumoniae Haemophilus influenzae Meningococci

Question 604

If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year they should be given what to maintain remission?

Answer 604

either oral azathioprine or oral mercaptopurine