General Surgery

Question 1

What are the big three causes of bowel obstruction?

Answer 1

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

Question 2

What are the main causes of adhesions?

Answer 2

Abdominal/pelvic surgery
Peritonitis
Abdominal/pelvic infections (e.g. PID)
Endometriosis

Question 3

What is a closed loop obstruction?

Answer 3

When there are 2 points of obstruction along the bowel. There is a middle bit sandwiched between the 2 points of obstruction

Question 4

What are the key presenting features of an obstructed bowel?

Answer 4

Vomiting (green bilious)
Abdominal distention
Diffuse abdominal pain
Constipation, lack of flatulence
Tinkling bowel sounds

Question 5

What is the initial management of bowel obstruction?

Answer 5

Drip and suck
- Nil by mouth
- IV fluids
- NG tube with free drainage

Question 6

What is an ileus?

Answer 6

A condition that affects the small bowel - the normal peristalsis stops. Presents the same as a bowel obstruction.

Question 7

How is an ileus managed?

Answer 7

Nil by mouth
NG tube
IV fluids
Mobilisation to help re-initiate peristalsis
TPN

Question 8

What is a volvulus?

Answer 8

Occurs when the bowel twists around itself and the mesentery leading to a closed loop obstruction.
Sigmoid and caecal volvulus

Question 9

What X-ray sign is seen in a sigmoid volvulus?

Answer 9

Coffee bean sign

Question 10

What are the associated with a sigmoid volvulus?

Answer 10

Older patients
Chronic constipation
Chagas disease
Neuropsychiatric conditions (e.g. Parkinson’s, Duchene’s muscular dystrophy, schizophrenia)

Question 11

What is associated with caecal volvulus?

Answer 11

Can occur in all ages
Pregnancy
Adhesions

Question 12

What is the management of a sigmoid volvulus?

Answer 12

Rigid sigmoidoscopy with a rectal tube insertion

Question 13

What is the management of a caecal volvulus?

Answer 13

Right hemicolectomy often needed

Question 14

What is diverticulosis?

Answer 14

The presence of diverticula without infection and inflammation

Question 15

What is diverticulitis?

Answer 15

Inflammation and infection of the diverticula

Question 16

What is the management of uncomplicated diverticulitis?

Answer 16

Oral co-amox
Analgesia (avoid NSAIDs and opiates)
Clear liquids
Follow-up, may require IV antibiotics

Question 17

What is the Hinchey classification?

Answer 17

Determines the severity of acute diverticulitis
I - para-colonic abscess
II - pelvic abscess
III - purulent peritonitis
IV - faecal peritonitis

Question 18

What is mesenteric ischaemia?

Answer 18

Lack of blood flow through the mesenteric vessels that leads to intestinal ischaemia

Question 19

What is the foregut?

Answer 19

Stomach, first part of the duodenum, hepatobiliary system, pancreas and spleen

Question 20

What is the midgut?

Answer 20

Distal part of the duodenum to the first half of the transverse colon

Question 21

What is the hindgut?

Answer 21

Second half of the transverse colon to the rectum

Question 22

What is chronic mesenteric ischaemia?

Answer 22

Also called mesenteric angina
Narrowing of the mesenteric vessels as a result of atherosclerosis
Results in intermittent abdominal pain

Question 23

What is the classical triad of chronic mesenteric ischaemia?

Answer 23

Central colicky abdominal pain that comes on after eating
Weight loss (due to food avoidance)
Abdominal bruit may be heart on auscultation

Question 24

How is chronic mesenteric ischaemia diagnosed?

Answer 24

CT angiography

Question 25

What is the management of acute mesenteric ischaemia?

Answer 25

Reduce modifiable risk factors (e.g. stop smoking) Secondary prevention (statins and antiplatelets) Revascularisation to improve blood flow (1st line is endovascular procedures e.g. percutaneous mesenteric artery stenting)

Question 26

What is acute mesenteric ischaemia?

Answer 26

Typically results from an embolism that occludes artery supplying the small bowel. Typically patients have a history of AF.

Question 27

What is the presentation of acute mesenteric ischaemia?

Answer 27

Severe abdominal pain that is sudden onset and out of keeping with physical exam findings

Question 28

What is the management of acute mesenteric ischaemia?

Answer 28

Immediate laparotomy to remove necrotic bowel or remove/bypass the thrombus

Question 29

What is used to monitor the response of colon cancer to treatment?

Answer 29

CEA (carcinoembryonic antigen)

Question 30

How does an anal fissure present?

Answer 30

Bright red rectal bleeding and pain on defecation

Question 31

What is the management of an acute anal fissure?

Answer 31

Soften stool - dietary advice (high fibre + high fluid intake) - bulk forming laxatives Lubricants before defecation Topical anaesthetics Topical analgesia

Question 32

What is the management of a chronic anal fissure?

Answer 32

Topical GTN If not effective after 8 weeks refer for surgery (sphincterotomy) or botox

Question 33

What are the general rules of thumb for an ileostomy?

Answer 33

R iliac fossa Spouted Liquid

Question 34

What are the general rules of thumb for an colostomy?

Answer 34

L iliac fossa Flat to the skin Solids

Question 35

What is the treatment of a perianal abscess?

Answer 35

Incision and drainage

Question 36

How might a haemorrhoid present?

Answer 36

Usually painless bright red rectal bleeding