General Surgery

Question 1

Diagnosis?
Why?

Answer 1

SBO

1. dilated loops of bowel
2. multiple fluid levels
3. small bowel - central/3mm/valvular coneventes

Question 2

what are the common causes of SBO obstruction and their examination findings?

Answer 2

• adhesions - old scars
• hernias - hernia on exam
• malignancy - systemic sx

Question 3

what are the metabolic complications of SBO and why?

Answer 3

• metabolic alkalosis - loss of HCL from vomming
• hypoK - vomiting
• hypoNa - 3rd spacing to gut
• lactic acidosis - from iscahemia and hypoperfusion

Question 4

abdo pain and guarding:
What ate the abnormalities?

Diagnosis?

Answer 4

IP free fluid
IP free air
fat stranding around stomach
gallstones
thick walled stomach

diagnosis
Perforated peptic ulcer

Question 5

what is the initial management of perforated abdominal viscous?

Answer 5

IV fluid - bolus and aim over 100
Anagelsea eg fent
IV abx
urgent surgical input

Question 6

diagnosis?

3 positive and two neg findings

Answer 6

gastric volvulus

Pos:
* hiatus hernia
* multiple bowel loops in intrathoraic region
* air fluid in lower loop suggesting obstruciton
* mediastinal shift

Neg
* no pneumothorax
* no free air under diaphragm

Question 7

management priorities?

Answer 7

analgesia
antiemetic
fluid
abx
surgical input

?GOC

Question 8

what clinical features of history and exam make appendicitis more likely in a child?

Answer 8

RIF pain
pain migrating to RIF
pain less than 3 days
anorexia
pain on coughing/moving/hopping

Question 9

with suspected appendicits in child what tests could you do to rule out other things?

Answer 9

urine - UTI
US - mesenteric adenitis
CXR - LRTI
lipase - pancreatitis
glucose - DM

Question 10

what is the maintennce fluid for kids?

Answer 10

normal saline plus 5% dextrose

4:2:1

• For the first 10 kilograms (3-10 kg) — 4 ml/kg/h.
• For the next 10 kilograms (11-20 kg) — 2 ml/kg/h.
• For weights above 20 kilograms — 1 ml/kg/h

Question 11

what are the pros and cons of CT/US for RUQ pain?

Answer 11

Question 12

key findings

Diagnosis

Answer 12

• high glob and low alb- in infection/inflammation, high glob and low albumin in negative acute phase reaction
• jaudince from biliary obstuction
• ductal enzymes high than intrahepatic suggesting post hepatic pathology

Diagnosis
Cholangitis with biliary obstruction

Question 13

diagnosis and abnormal radiological findings

Answer 13

Sigmoid volvulus

• massively dilated sigmoid colon - coffee bean sign
• no rectal gas - dilated proximal large bowel
• Axis to LIF

Question 13

what are the management options for sigmoid volvulus?

Answer 13

1. PR deflation eg sigmoidoscope
2. percutaneous deflation
3. laparatomy

Question 14

with elderly and bowel obstructions what are the considerations for treatment plans?

Answer 14

1. Patients wishes if competent
2. advanced care directive
3. substitute decision maker if competent
4. patients QOL
5. reversibility of condition
6. nature of intervention
7. access to intervention eg in the sticks

Question 15

interpretation of wound

Answer 15

midline laparatomy wound with significant dehiscence

Question 16

list three patient and surgical factors that could contribute to post op wound dehiscence

Answer 16

Patient
* Smoker
* steroid use
* obesity
* immunocompromised
* diabetic
* poor self care
* over 65
* anaemia

Surgical
too much wound tension
inappropriate sutures
inappropriate technique
haematoma at site
FB
non sterile procedure

Question 17

what are the advantages and disadvantages of common methods of wound closure in ED

Answer 17

Question 18

what are the two most common causes of pancreatitis

Answer 18

GS
Alcohol

GETSMASHED

Question 19

What is a common scoring system for pancreatitis and its components

Answer 19

Glasgow >3 severe
glucose over 10
calcium under 2
wcc over 15
ast over 200
ldh over 600
urea over 16
albumin less than 32

Question 20

what are the local and systemic compliations of pancreatitis?

Answer 20

Local
* pancreatic pseudocyst
* abscess
* ileus
* splenic vein thrombosis
* chronic pancreatitis
* duodenal obstruction

Systemic
* Shock
* ARDS
* hypocalcaemia
* metaolic acidosis
* pleural effusion
* multi organ failure

Question 21

what CT featues of pancreatitis are associated with severe disease?

Answer 21

focal or diffuse enlargement
fat stranding
single or multiple fluid collections
necrosis

Question 22

1. Diagnosis?
2. Imprtant investigations?
3. Management

Answer 22

1. Ascending cholangitis
2. LFTs,lipase, cultures, US
3. IV abx (cef 1g BD), fluid(NaCl 1l 4/24), surgical opinion, analgesia( paracetamol, fentanul or bupe)

Question 23

two positives and two negatives?

Answer 23

Positives
* dilated small bowel loops
* thumbprinting

Negatives
* no fecal loading
* no free air
* no rigleers sign

Question 24

what is the mangement of mesenteric ischaemia/bowel infarct?

Answer 24

1. Analgesia 2. NBM and IV fluid 3. heparin infusion 4. early sirgical input

Question 25

What is this?

Answer 25

Pneumatosis intestinalis (presence of gas within wall of bowel)

Question 26

what can cause pneumatosis intestinalis?

Answer 26

submucosal cysts infective enteritis coeliac COPD AIDS sarcoid post chemo

Question 27

what could indicate a bad prognosis in mesenteric infarct/bowel ischaemia

Answer 27

metabolic acidosis bloody diarrheoa portal venous gas thickened bowel wall on imaging

Question 28

if a patient is NBM what are the analgesia options in ED?

Answer 28

**ketamine 0.2mg/kg** fentanyl 25mcg aliquts IV panadol PR indomethacin

Question 29

what are the complications of SBO with management principles?

Answer 29

perforation - abx and surgery hypovoaemia - fluid replacement hypok - replacement aspiration - cxr

Question 30

3 year old in abdo pain describe abnormalities and diagnosis

Answer 30

dilated bowel loop with telescoping Intersusscpetion

Question 31

what is the management of intersussception?

Answer 31

* Analgesia - IV morphine 1mg aliquots or fentanyl * IV fluid - 20ml/kg aiming for pulse under 120 * urgent surgical paeds referral

Question 32

what are the mangement options for intersusscpetion and when would you use them?

Answer 32

gas insufflation PR - first line when uncomplicated Surgical - if first line fails or complicated eg perforation

Question 33

what are the complications of intersussception?

Answer 33

perforation sepsis intestinal ischaemia