General Surgery Flashcards
(28 cards)
Appendicitis
Pathophysiology: pathogens trapped → inflammation + infx → gangrene + rupture → peritonitis
Sx:
Abdominal pain (umbilical → RIF (< 24 hrs))
Tender at McBurney’s point (1/3rd distance from ASIS to umbilicus)
Rovsing’s sign = palpation of LIF → pain in RIF
PR exam → pain in RIF
Features of general upset: anorexia + N&V + pyrexia
Diagnosis = clinical. Sx but normal inflammatory markers → diagnostic laparoscopy. Consider CT/USS to exclude other diagnoses.
Tx = urgent admission + refer surgery + prophylactic IV ABX + appendicectomy (laparoscopic)
Complications of appendicitis
Appendix mass = omentum sticks to appendix → mass in RIF. Tx = supportive (with ABX) → appendectomy when acute phase resolves
Features of peritonitis
Rebound tenderness in right iliac fossa + Percussion tenderness
Caused by rupture (e.g. appendix)
IX = erect CXR (shows air under diaphragm)
Bowel obstruction
Small bowel intestine more commonly affected.
Pathophysiology: obstruction →↓ passage of food/fluid/gas →↑ proximal pressure → vomiting + dilation of proximal bowel (Surgical emergency) →↓ fluid absorption → hypovolaemic shock (a.k.a. third-spacing).
Causes (>90% due to below):
(1) Adhesion (small bowel) due to abdo/pelvic surgery + peritonitis + infx + endometriosis.
(2) Hernia (small bowel) – think obturator hernia
(3) Malignancy (large bowel)
Symptoms:
o Green bilious vomiting
o Abdominal distention + diffuse pain
o Absolute constipation (absence of flatulence)
o Tinkling bowel sounds (early sign)
diagnosis = AXR showing dilated bowel (small bowel >3cm or colon>6cm or caecum > 9cm)
Other Ix: ABG (metabolic alkalosis due to vomit + raised lactate) + contrast CT + erect CXR (exclude air under diaphragm)
TX = drip and suck = A-E + NBM + IV fluids with added potassium + NG tube with free drainage + pain relief.
o Stable → conservative
o Unstable → surgical therapy (e.g. emergency resection / stent)
Bowel obstruction = CI to metoclopramide
Closed loop obstruction
Definition: 2 points of obstruction in bowel → middle section unable to drain → continuous dilation of middle section → ischeamia → perforation
Causes: adhesions + hernias + volvulus + single obstruction with competent ileocecal valve (ileocecal valve behaves as obstruction if there is additional obstruction in distal colon)
Treatment = emergency surgery
Ileus
Definition:
o Ileus = transient loss of peristalsis in small intestine.
o Pseudo-obstruction = functional obstruction of large bowel (no mechanical cause). Less common than ileus.
Aetiology (anything that disrupts small intestine) = injury + handling of bowel in surgery + inflammation of nearby tissue (e.g. pancreatitis) + electrolyte imbalance.
Clinical features = bowel obstruction Sx + absent bowel sounds
Treat underlying cause + supportive care (NBM + NG tube + IV fluids + parenteral nutrition).
Volvulus
Bowel twists arounds → closed-loop bowel obstruction → ischaemia → necrosis → perforation. 2 types:
Sigmoid volvulus = affecting sigmoid. More common. RF = chronic constipation + elderly + high fibre diet + excessive use of laxatives.
Caecal volvulus = affecting caecum. Less common. Affects younger patients.
Risk factors: neuropsychiatric disorder (e.g. Parkinson’s) + elderly + chronic constipation + high fibre diet + pregnancy + adhesion
Clinical features = bowel obstruction Sx
Ix = AXR (coffee bean sign = sigmoid) + contrast CT (diagnostic)
Tx = A-E + supportive (drip and suck).
Conservative treatment = endoscopic decompression (using flexible sigmoidoscope). Risk of reoccurrence is 60%. Only indicated in sigmoid volvulus.
Surgical = laparotomy / Hartmann’s procedure / ileocecal resection / right hemicolectomy. If bowel obstruction perform emergency laparotomy.
Symptoms and treatment of hernia
Clinical features = Soft lump protruding from abdominal wall. Initially reducible. May protrude on coughing / standing. May be accompanied by aching, pulling or dragging sensation.
Treatment:
o Conservative = hernia is left. Most appropriate if wide neck hernia + not surgical candidate
o Surgical = Tension free repair = mesh placed over defect in abdominal wall (mesh acts as scaffold for new tissue to heal over). Lower rate of recurrence but high rate of complications.
Define:
incarceration of herna
Obstruction of hernia
Strangulation of hernia
Richter’s hernia
Maydl’s hernia
Incarceration = irreducible = hernia cannot be pushed back into place. Bowel trapped in herniated position. The wider the neck the lower the risk of this (important to assess on exam)
Obstruction = blockage to passage of contents within bowel of hernia
Strangulation = compression at neck of irreducible hernia → ischaemia → necrosis (within hrs). Sx = significant pain at herniation site + obstruction. Surgical emergency.
Richter’s hernia = can occur with any abdominal hernia. Rare. Only part of bowel wall herniates through abdominal wall → ischaemia of bowel wall → rapid necrosis. Surgical emergency. Sx = Sx of strangulation without Sx of obstruction.
Maydl’s hernia = 2 different loops of bowel contained within same hernia
Inguinal hernia (indirect vs. direct)
95% are male. Found above and medial to pubic tubercle.
Indirect = bowel herniates through deep inguinal ring and into inguinal canal.
Direct = bowel herniates through Hesselbach’s triangle (in abdominal wall) into inguinal canal
Examination to differentiate indirect vs. direct = reduce hernia and apply pressure at deep inguinal ring (mid-point from ASIS to pubic tubercle):
• Indirect hernia = will remain reduced with pressure at deep inguinal ring
• Direct hernia = will not remain reduced with pressure at deep inguinal ring
Strangulation is rare (~3% per year). More common in indirect hernias.
Femoral hernia
Hernia through femoral ring into femoral canal
below and lateral to pubic tubercle.
High risk of obstruction/strangulation (as femoral ring is narrow). More common in women.
Tx = surgical repair required.
Obturator hernia
Herniation of abdominal/pelvic organ through obturator foramen of pelvis.
RF = defect in pelvic floor (female + older age + pregnancy + vaginal delivery).
Sx = irritation of obturator nerve (→ medial thigh pain). Howship-Romberg sign = pain on inner thigh to knee during hip internal rotation (→ compression of nerve). Commonly present with bowel obstruction.
IX = CT / MRI
Other types of hernia (Incisional + umbilical + epigastric + spigelian + diastasis recti)
Incisional hernia = found at site of previous surgery (due to weakness of previous incision). Difficult to repair and high recurrence (conservative Tx preferred). Seen in 10% of ops.
Umbilical hernia = herniation around umbilicus. Umbilical → symmetric bulge. Paraumbilical → asymmetric bulge. Common in neonates. Resolve spontaneously. Epigastric hernia = hernia in epigastric area. Spigelian hernia = between lateral border of recuts abdominis and linea semilunaris (site of spigelian fascia which is aponeurosis between muscles of abdominal wall). Usually found in lower abdomen. Ix = USS. Narrow neck so high risk of incarceration / strangulation / obstruction. Diastasis recti = widening of linea alba between rectus muscles (not technically a hernia). Can be congenital / pregnancy / obesity. No Tx required.
Hernias in children
Congenital inguinal hernia = indirect hernias resulting from patent processus vaginalis.
Occur in 1%. RF = premature + male. 60% right sided, 10% bilaterally.
Tx = surgical repair ASAP (risk of incarceration)
Infantile umbilical hernia = Symmetrical bulge under umbilicus.
RF = premature + Afro-Caribbean.
Tx = self-resolve before age of 4-5 years. Complications are rare
Hiatus hernia
Definition: herniation of stomach through oesophageal hiatus . Types:
o Type 1 = sliding = stomach slides through diaphragm with gastro-oesophageal junction passing into thorax
o Type 2 = rolling = fundus of stomach folds around and enters through diaphragm
o Type 3 = combination of type 1 and 2
o Type 4 = large hernia allowing additional abdominal organs to pass through diaphragm
Risk factors = old age+ obesity + pregnancy
Sx = heartburn + Dysphagia + regurgitation + chest pain
Ix = endoscopy / barium swallow (most sensitive). Can be intermittent therefore negative investigations does not exclude.
Treatment:
o Conservative (Tx of GORD
o Laparoscopic fundoplication (indicated if high risk of complications / Tx resistant Sx)
Chronic mesenteric ischaemia (intestinal angina)
Atherosclerosis of mesenteric vessels → chronic ischaemia of intestines → intermittent abdo pain
RF = angina RF = age + FMH + smoking + HTN + cholesterol
Clinical features – classic triad:
Central colicky abdominal pain after eating
Weight loss (due to food avoidance)
Abdominal Bruit
Investigation = CT angiography
Tx = Tx modifiable risk factors + secondary prevention of atherosclerosis (e.g. stains + antiplatelet) + revascularisation. Options for revascularisation:
1st line = endovascular procedure (e.g. percutaneous mesenteric artery stenting)
2nd line = open surgery (e.g. endarterectomy / bypass grafting)
Acute mesenteric ischaemia
thrombus/emboli → sudden occlusion of superior mesenteric artery → acute ischaemia of midgut → necrosis → perforation
Risk factors = atrial fibrillation
Clinical feature = Acute, non-specific abdominal pain (pain disproportionate to examination findings) + shock ± peritonitis ± sepsis
Ix = contrast CT. Other findings: metabolic acidosis + raised lactate (due to organ ischaemia)
Treatment = surgery (immediate laparotomy to remove necrotic bowel + thrombus in artery)
Prognosis = mortality >50%
Define:
o Diverticulum
o Diverticulosis
o Diverticular disease
o Diverticulitis
o Diverticulum: pouch or pocket in bowel wall.
o Diverticulosis: presence of multiple diverticula without inflammation / infection.
o Diverticular disease: diverticulosis + symptoms.
o Diverticulitis: inflammation + infection of diverticula.
Diverticular disease
Pathophysiology: weak areas of bowel wall = areas not covered by teniae coli + points where circular muscles are penetrated by blood vessels. ↑ pressure in bowel → hernia of mucosa through weak areas of walls (diverticula). Do not spread into rectum as reinforced by outer longitudinal muscle layer. Most commonly affects sigmoid colon.
Risk factors: age + low fibre + obesity + NSAIDs.
Clinical features:
Lower left abdominal pain
Constipation
Rectal bleeding
Investigations: colonoscopy / CT scan
Management (step wise).
(1) Wt loss + high fibre diet + good hydration.
(2) Bulk forming laxatives (ispaghula hulk). Avoid stimulant laxatives (senna).
(3) Surgical resection if severe symptoms
Acute diverticulitis
Clinical features: severe Sx of diverticular disease (e.g. severe pain in LIF) + systemically unwell (e.g. diarrhoea / N&V) ± Palpable abdominal mass (if abscess formed).
Investigations: bloods (raised inflammatory markers) + CT scan
Management:
Uncomplicated → manage in primary care = ABX (co-amoxiclav 5 days) + liquid diet (i.e. avoid solid foods) + analgesia (avoid NSAIDs / opioids).
Severe pain / Sx > 72 hrs → admit for IV ceftriaxone + metronidazole ± surgery
Complications: Perforation / Peritonitis / Peri-diverticular abscess / Large haemorrhage / Fistula (between colon + bladder/ vagina) / Ileus / obstruction
Haemorrhoids
Enlarged anal vascular cushions. Usually found at 3, 7 and 11 O’clock (with patient in lithotomy position)
RF = age, pregnancy, obesity, constipation, increased straining, increased intra-abdominal pressure (weight-lifting/ chronic coughing).
Classification:
o 1st degree = no prolapse.
o 2nd degree = prolapse when straining + return on relaxing.
o 3rd degree = do not return on relaxing but can be pushed back.
o 4th degree = prolapsed permanently.
Clinical features:
o Painless, bright red bleed (typically on toilet tissue) - blood not mixed in with stool.
o Sore/ itchy anus
o Feeling a lump around or inside anus.
PR findings:
o External (prolapsed) haemorrhoids = visible on inspection as swellings covered in mucosa.
o Internal haemorrhoids = felt upon PR exam / appear when bearing down (grade 2/3)
Investigations = proctoscopy (required for visualisation) + consider testing for anaemia
Management:
o Soften stools: increase dietary fibre and fluid intake
o Topical local anaesthetics + steroids may be used to help symptoms
o Outpatient Tx = rubber band ligation (1st line) / injection sclerotherapy (2nd line)
o Surgery = large symptomatic haemorrhoids which do not respond to outpatient Tx
o Newer treatments = Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy
Thrombosed haemorrhoids
strangulation / thrombosis at base of external haemorrhoids → very painful, tender + purplish, odematous swollen lumps around anus.
PR exam impossible due to pain. Will resolve (can take weeks).
Tx:
< 72hrs since Sx onset → surgery.
> 72 hrs → ice pack + analgesia + stool softeners
Anal fissure
Tear in squamous lining of distal anal canal. Acute = <6 wks. Chronic = >6wks.
90% found in posterior midline – alternative location consider underlying cause (e.g. Crohn’s) and are red flag for bowel cancer (2WW)
RF = constipation + IBD + STI
Sx = painful bright red rectal bleed
Treatment:
Acute = soft stools = diet + bulk forming laxatives ± lubricant / topical anaesthetic
Chronic = topical GTN (1st line). GTN not effective <8wks → refer surgery (sphincterotomy / botulinum toxin)
Perianal abscess
Collection of pus in subcut tissue of anus. Infx may or may not be present (due to E.coli / staph aureus).
Associations = Crohn’s
Sx = pain around anus (worse on sitting) ± pus like discharge
Ix = Clinical diagnosis. Consider trans-perineal USS (gold standard) .
Tx = incision + drainage (1st line). Wound should be left open/packed (heals in 3-4wks).
