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Flashcards in General surgery Deck (68):
1

Preoperative preparations

Informed consent
Screening questionaire + regular medications
Consultation with anesthesia, cardiology
NBM after midnight
Prophylactic antibiotics: cefazolin + metronidazole
Consider DVT prophylaxis
Withhold aspirin for 1 wk prior to operation
Smoking cessation 6wks pre-op

2

Post-op Fever

POD 1-2
- Atelectasis
- Early wound infection
0 Aspiration pneumonitis

POD 3-7
- UTI
- Surgical and IV site infection
- Septic thrombophelbitis
- Bowel anastomosis leakage

POD 8+
- Intra-abdominal abcess
- DVT/PE
- Drug fever

6 W's
Wind (pulmonary)
Water (UTI)
Wound
Walk (DVT/PE)
Wonder drugs
Weins (thrombophlebitis)

3

Post-op drugs

6 A's
Analgesia
Anti-emetic
Anti-coagulation
Antibiotics
Anxiolytics
All other patietn meds

4

Post-op drugs

6 A's
Analgesia
Anti-emetic
Anti-coagulation
Antibiotics
Anxiolytics
All other patient meds

5

Post-op wound complications

Wound care
- Dressing removal POD 2-4
- leave uncovered if wound dry
- remove dressing if wet, signs of infection
- Bath from POD 2-3
- Suture removal POD 7-10 or - Suter removal delayed to POD 14 if elderly, steroid use, under tension

Drains
- Prevent fluid accumulation but can be sources of infection
- Removed if infected or drainage minimal <30-50mL/24hr

6

Surgical site infection

Bacteria: Staph aureus, E. coli, Enterococcus, Strept spp, Clostridium spp

Risk factors:
- Type of procedure
- Patient characteristics
- Other siurgical or progress factors

Presentation
- fever POD 3-6, strept and clostridium can present in 24h
- pain, erythema, induration, pus, warmth

Prophylaxis
- pre-op antibiotics: cefazolin, metronidazole, tobramycin (orthopaedics) 1hr prior to incision
- post-op antibiotics for 24hr
- normothermia
- hyperoxygenation FiO2 >80%
- sterile techniques

Treatment:
- Re-open incision, culture, pack
- Antibiotics and demarcation of erythema
- Debridement of non-viable tissue

7

Wound hemorrhage/hematoma

Inadequate surgical control of hemostasis.
Rx: pressure dressing, open drainage + wound packing for large hematoma

8

Seroma

Fluid collection other than pus or blood. It is secondary to transection of lymphatics and delays healing + increase risk of infection.

Rx: pressure dressing + needle drainage

9

Wound dehiscence

Disruption of fascial layer, suture tearing through the fascia. Present typically POD 1-3 with serosanguinous drainage +/- evisceration. No "healing ridge" at the wound edge.

Risk factors: increase IAP, hematoma, infection, poor blood supply, smoking, malnutrition, immunosuppression, steroids.

Rx: binder dressing on wound or operative closure.

10

Post-op urinary and renal complications

Urinary retention
- may occur after any operation with GA or spinal
- igher likelyhood in older males with BPH or those on anti-cholinergics

Oliguria/anuria
- most common due to pre-renal +/- ischemic ATN
- external fluid loss (hemorrhage, dehydration, diarrhea), internal fluid loss (third-space with bowel obstruction, pancreatitis)

11

Post-op respiratory complications

Atelectasis
- 90% of post-op pulmonary complications
- low grade fever on POD 1, tachycardia, crackles, decreased breath sounds, bronchial breathing

Prophylaxis
- Pre-op: smoking cessation >6wks
- Post-op: minimise respiratory depressant drugs, good pain control, incentive spirometry, deep breathing, chest physio, early ambulation

Pneumonia/pneumonitis
- secondary to aspiration of gastric content with GA and intubation
- productive cough, fever
- Prophylaxis: pre-op NG tube, rapid sequence anesthetic induction
- Rx: IV antibiotics

Pulmonary embolus
- sudden onset SOB, tachycardia, fever POD 7-10
- prophylaxis: SC heparin, TED stockings, aspirin
- Rx: IV heparin, long term warfarin for 3m

Pulmonary edema
- circulatory overload or LV failure
- SOB, crackles at bases, CXR abnormal
- Rx: morphine, nitrates, oxygen, sitting up

Respiratory failure
- dypnea, cyanosis, decrease sats
- Rx: ABCs, O2 +/- intubation, bronchodilators, diuretics, maintain adequate BP

12

Post-op cardiac complications

Common asshythmias: SVT, AF (secondary to fluid overload, PE, MI)

MI
- increased risked post-surgery

13

Hiatus hernia

Sliding hiatus hernia (Type I)
- herniation of both stomach and GE junction
- 90% of esophageal hernias
- risk fx: age, increased intra-abdominal pressure, smoking
- features: GRED
- investigations: barium swallow, endoscopy
- Rx: lifestyle (stop smoking, weight loss, no meals prior to sleeping, avoid alcohol), antacid, PPI, surgical if severe complications

Paraesophageal hiatus hernia (Type II)
- herniation of part of stomach with undisplaced GE junction
- features: asymptomatic, pressure sensation
- complications: hemorrhage, incarceration, stangulation, obstruction, ulcer
- Rx: surgery to prevent severe complications

Mixed hiatus hernia (Type III)
- combination of Types I and II

Type IV hernia
- herniation of other abdominal organs

14

Esophageal perforation

Causes
- iatrogenic: endoscopic, intubation, biopsy, NG tube
- barogenic: trauma, repeated forceful vomiting
- ingestion injury: batteries
- carcinoma

Features
- neck or chest pain
- fever tachycardia, hypotension, dyspnea, respiratory compromise
- pneumothorac, hematemesis

Treatment:
- NPO, vigorous fluid resuscitation, broadspectrum antibiotics
- surgical <24hr with primary closure
- surgical >24hr with diversion and delayed reconstruction

15

Esophageal cancer

Male > female, onset 50-60yrs, most common in lower esophageal.

Risk factors:
- SCC: 4 S's (smoking, spirits, seeds, scalding), underlying esophageal disease (strictures, achalasia)
- Adenocarcinoma: Barrett's eosphagus, smoking, obesity, GERD

Features:
- late presentation
- progressive dysphagia, odynophagia, regurgitation and aspiration
- hemetemesis, anemia, fistulas
- metastasis: trachea, recurrent laryngeal nerves, aortic, liver, lung, bone, lymph nodes

Investigations:
- Barium swallow
- Esophagoscopy
- CT chest

16

Thoracic outlet syndrome

Impingement of subclavian vessels and brachial plexus nerve trunk

Causes:
- congenital cervical rib
- trauma
- degenerative osteoporosis, arthritis

Features:
- neurogenic: ulnar and median nerve motor and sensory deficit
- arterial: fatige, weakness, coldness, pain
- venous: edema, venous distension

Rx:
- PT, posture and behaviour modification
- surgical removal of cervical rib

17

Tube thoracostomy

Insert at 4th or 5th intercostal space in ant axillary or mid-axillary line. Placed with underwater seal

Complications
- malposition
- bleeding
- local infection, empyema
- lung perforation

18

Peptic ulcer disease

Gastric ulcers
- require surgery if unresponsive to medical treatment (H. pylori eradication + PPI)

Duodenal ulcers
- typically on anterior surface on descending duodenum
- perforation presents with sudden acute pain onset, acute abdomen, ileus
- posterior penetration into pancreas creates pain radiating to back
- hemorrhage occurs with posterior penetration to the gastroduodenal artery, requires therapeutic endoscopy

19

Gastric carcinoma

More common in males and in Asian/Latina populations. Most commonly in 50-60 yr olds.

Risk factors:
- H. pylori
- HNPCC, HDGC
- smoking, alcohol, smoked foods
-pernicious anemia, gastric adeomatous polyps, hypertrophic gastropathy
- previous partial gastrectomy

Features:
- non-healing ulcer, lesion on greater curvature of stomach or cardia
- postprandial fullness, vague epigastric pain, anorexia, weight loss, burping, dyspepsia, dysphagia, hematemesis, fecal occult blood, melena, IDA
- signs of metastatic disease
= Virchow's node: left supraclavicular node
= Blumer's shelf: mass in pouch of Douglas
= Krukenberg tumour : metastasis to ovary

Staging
I) mucosa + submucosa
II) muscularis propria
III) regional lymph nodes
IV) distant metastasis

Treatment:
Surgical, chemotherapy, radiation

20

Bariatric surgery

Weight reduction surgery for those BMI >40 or BMI >35 with related comorbidity

Surgery:
- malabsorptive: decrease stomach size and bypass duodenum with Roux-en-Y
- restrictive: gastric banding

21

Gastric surgery complications

Alkaline reflux gastritis
- duodenal contents reflux into stomach

Afferent loop syndrome
- accumulation of bile and pancreatic secretions causes intermittent obstruction

Dumping syndrome
- hyperosmotic chyme released into small bowel, with fluid accumulation and jejunal distention

Blind loop syndrome
- bacterial overgrowth in afferent limb

Postcagotomy diarrhea
- bile salts in colon inhibit water reabsorption

22

Meckel's diverticulum

Remnant of embryonic vitelline duct on border of ileum.

Features:
- only 2% symptomatic
- GI bleed by ectopic gastric mucosa, SBO, diverticulitis

Investigations
- Tec-99 (Meckel's scan)
- AXR

23

Small intestine tumours

Risk factors:
- carsinogen exposure
- familial adenomatous polyposis, Peutz-Jegher syndrome, Gardner's syndrome
- Crohn's disease, celiac disease

Benign
- more common and usually asymptomatic
- polyps: adenomas, hamartomas, familial adenomatous polyposis, juvenile polyps

Malignant
- Adenocarcinoma: develops from polyps, predominance male 50-70yrs.
- Carcinoid: slow growing with <10% carcinoid syndrome (flushing, diarrhea, RHF), elevated 5-HIAA
- Lymphoma: usually NHL, increase risk wit autoimmune disease or immunosuppression
- Sarcoma
- Metastatic: from melanoma, breast, lung, ovary, colon, cervical cancer

24

Hernia terminology

Strangulated - compromised vascular supply
Incarcerated - irreducible
Richter's hernia - only part of the bowel wall has herniated

Anatomical sites
- Groin
- Epigastric: linea alba
- Incisional

25

Groin hernias

Direct inguinal
- acquired weakness of transversalis fascia
- increased intra-abdominal pressure
- medial to inferior epigastric artery

Indirect inguinal
- most common in men and women
- congenital persistence of processus vaginalis in 20% of adults
- lateral to inferior epigastric artery and often descends into scotal sac/labia majorum

Femoral
- affects mostly females
- pregnancy, increased intrabdominal pressure
- into femoral canal, below inguinal ligament

26

Hesselbach's triangle

Lateral - inferior epigastric artery
Inferior - inguinal ligament
Medial - lateral margin of rectus sheath

27

Inguinal ring

Superficial inguinal ring
- Opening: external abdominal aponeurosis, superior and lateral to pubic tubercle
- Medial border: medial crus of external abdominal aponeurosis
- Lateral border: lateral crus of external oblique aponeurosis
- Roof: intercrural fibres

Deep inguinal ring
- Opening: transversalis fascia, superior to mid-inguinal ligament
- Medial border: inferior epigastric vessels
- Superio-lateral borders: internal oblique and transversus abdominis muscles
- Inferior border: inguinal ligament

28

Bowel obstruction

Proximal dilation, distal decompression may take 12-24hrs

Features of bowel obstruction
- colicky abdominal pain
- nausea and vomiting: early bilious with SBO, late feculent with LBO
- abdominal distention greater more distal
- bowel sounds may be normal, increased or absent if secondary ileus
- AXR show air-fluid levels

Paralytic ileus
- nausea + vomting
- minimal pain with mild distension and constipation
- decreased bowel sounds
- air throughout bowels on AXR

Complications
- strangulated obstruction: fever, leukocytosis, peritoneal signs
- perforation
- septicemia
- hypovolemia

Investigations
- upright CXR
- AXR
- CT

Rx:
- ABC's stabilisation
- NG tube to decompress small bowel

29

Small bowel obstruction

Most common causes:
1) Adhesions
2) Hernias
3) Cancer

Other causes:
- Intraluminal: intussusception, gallstones
- Intramural: Crohn's, radiation stricture, adenocarcinoma
- Extramural: adhesions, incarcerated hernia, peritoneal carcinomatosis

Rx:
- adhesions: manage conservatively for 48-72hrs
- strangulation: urgent surgery

30

Large bowel obstruction

Most common causes:
1) Cancer
2) Diverticulitis
3) Volvulus

Other causes:
- Intraluminal: constipation
- Intramural: adenocarcinoma, diverticulitis, IBD strictures, radiation stricture
- Extramural: volvulus, adhesions

Features:
- open loop: incompetent ileocecal valve, similar presentation to SBO
- closed loop: competent ileocecal valve, massive colonic distention, bowel wall ischemia and necrosis

31

Toxic megacolon

Extension of inflammation into smooth muscle layers causing paralysis

Causes:
- IBD
- Infectious colitis: C. difficle, Salmonella, Shigella, Campylobacter, CMV
- Volvulus, diverticulitis, ischemic colitis

Features
- infectious colitis present for >1wk before dilatation
- abdo distention, tenderness

Diagnosis:
- must have both colitis and systemic manifestations
- radiologic evidence of dilated colon
- 3 of: fever, HR >120, WBC >10.5, anemia
- one of: fluid and electrolyte disturbances, hypotension, altered LOC

Rx:
- NBM, NG tube
- broad spectrum antibiotics
- surgery if severe

32

Paralytic ileus

Temporary parlysis of myenteric plexus. Due to post-op, intra-abbdominal sepsis, medications, electrolyte disturbance, C. difficile, inactivity

33

Intestinal ischemia

Etiology:
- arterio-occlusive mesenteric ischemia: thrombotic, embolic, extrinsic compression
- non-occlusive mesenteric ischemia: vasoconstriction secondary to systemic hypoperfusion
- mesenteric venous thrombosis: hypercoagulability, DVT
- chronic due to atherosclerotic disease

Features:
- acute: severe abdominal pain, vomiting, bloody diarrhea, bloating, hypotension, shock, sepsis
- chronic: post-prandial pain, fear of eating
- sites: SMA, splenic flexure, left clon, sigmoid colon

Investigations:
- leukocytosis, lactic acidosis
- AXR, contrast CT
- CT angiography

Rx:
- ABC's, NGT decompression, prophylactiv antibiotics
- exploratory laparotomy

34

Appendicitis

Luminal obstruction causes bacterial overgrowth, inflammation and increased pressure. Can result in localised ischemia, perforation, localised abscess or peritonitis. Can be caused by hyperplasia of lymphoid follicles (children), fibrosis, fecolith, obstructing neoplasm (adult)

Features:
- low grade fever, abdominal pain with anorexia, nausea/vomiting.
- central pain localising over McBurney's point (2/3 along line from umbilicus to right ASIS)

Site
- Inferior appendix: McBurney's sign, Rovsing's sign (palpation pressure on left side causes pain in McBurney's point)
- Retrocecal appendix: psoas sign (pain on hip flexion against resistance)
- pelvic appendix: obturator sign (rotation about right hip causes pain)

Investigations
- B-hCG, urinalysis
- CXR, AXR
- US to rule out gynaecological causes
- CT scan

Treatment:
- ABC's
- Perioperative antibiotics: ampicillin + gentamicin + metronidazole
- Appendectomy: laparoscopic vs open

35

Appendix tumours

Carcinoid tumours - most common
Adenocarcinoma

36

Crohn's disease

Indications for surgery:
- failure of medical management
- SBO
- abcess, fistula, quality of life

Complications of treatment:
- short gut sydrome (diarrhea, steatorrhea, malnutrition)
- fistulas
- gallstones (decreased bile salt resorption, increased cholesterol precipitation)
- kidney stone (loss of calium in diarrhea, increased oxalate absorption)

37

Ulcerative colitis

Indications for surgery:
- failure of medical management
- complication: hemorrhage, obstruction, perforation, toxic megacolon
- reduce cancer risk

Complications of treatment:
- early: bowel obstruction, transient urinary dysfunction, dehydration, anastamotic leak
- late: stricture, anal fistula/abcess, poor anorectal function, reduced fertility

38

Diverticular disease

Diverticulum - sac-like protrusion from the bowel
Diverticulosis - presence of multiple diverticulosis
Diverticulitis - inflammation of diverticula

Diverticulosis
- most common in sigmoid colon
- risk factors: low-fibre diet, inactivity, obesity, muscle wall weakness
- most are asymptomatic but may cause LLQ pain, bloating, flatulence, constipation, diarrhea
- compliations: diverticulitis, painless rectal bleeding, diverticular colitis
- treated by increasing fibre.

Diverticulitis
- 95% left-sided in Western, 75% right sided in Asian
- due to micro or macroperforation from inflammation
- initially walled off by pericolic fat and mesentery ( abscess, fistula), poor containment leads to peritonitis
- LLQ pain for several days prior to admission, constipation, diarrhea, nausea, vomiting, urinary symptoms

Investigations
- CT scan: increased density of pericolic fat secondary to inflammation, diverticula, bowel wall thickening

Treatment
- conservative management for uncomplicated
- outpatient: fluids only until improvement, ciprofloxacin + metronidazole for 7-10d
- inpatient: unable to take oral fluids, treat with NBM, IVF, IV antibiotics
- surgery for unstable patient with peritonitis and those with complications, Hartmann's procedure

39

Colorectal polyps

Sessile or pedunculated, increase with increasing age.
Tubular are more common. They are smaller, pedunculated with low malignant potential.
Villous are large, sessile with higher malignant potential.

Usually discovered during colonoscopy and removed for biopsy.

40

Familial colon cancer syndromes

Familial adenomatous polyposis
- AD inheritance at APC gene
- hundreds of colorectal adenomas by age 20
- 100% life time risk fo colon cancer, surgery indicated by age 17-20 with total proctocolectomy or colectomy
- genetic testing available

Hereditary non-polyposis colorectal cancer (Lynch syndrome)
- AD inheritance, DNA mismatch repair gene
- early age of onset, high rates of endometrial, ovarian, hepatobiliary and small bowel tumours
- genetic testing 80% sensitive, requires annual colonoscopy

41

Colorectal carcinoma

Third most common cancer and second most common cause of cancer deaths
- mean age 70
- increased risk with genetics, UC, previous colorectal cancer, diet, smoking, DM, and acromegaly

Screening with Positive Family History
- Begin at 40 or 10yrs younger than earliest case (colonoscopy every 5yrs): 2 or more second degree relative with CRC, or 1 first degree relative with CRC <60
- Begin at 40: 1 first degree relative with polyp >60

Right colon
- 25%, exophytic lesion with occult bleeding
- IDA, RLQ mass

Left colon
- 35%, annular invasive lesion
- constipation, overflow, LBO

Rectum
- 30%, ulcerating
- obstruction, tenesmus, rectal bleeding, palpable mass on DRE

42

Volvulus

Sigmoid 65%
Cecum 30%
Transverse colon 3%
Splenic flexure 2%

Risk factors:
- age, high fibre diet, chronic constipation, laxative abuse, pregnancy, congenitally hypermobile cecum

Investigations
- Cecal volvulus: central cleft of coffee bean points to RLQ
- Sigmoid volvulus: central cleft of coffee bea points to LLQ

Treatment
- nonsurgical decompression
- surgical if strangulated, perforation of unsuccessful endoscopic decompression

43

Fistula

Etiology
- foreign object erosion
- infection, Crohn's, diverticular disease
- iatrogenic/surgery
- congenital, trauma
- neoplastic

Treatment:
- ABCs
- drain abcess/infection
- skin care

44

Ostomies

Colostomy/ileostomy

Complications
- obstruction: herniation, stenosis, adhesive bands, volvulus
- peri-ileostomy abcess and fistula
- skin irritation
- prolapse/retration
- diarrhea

45

Hemorroids

Internal: superior hemorrhoidal veins, above dentate line, portal circulation
External: inferior hemorrhoidal veins, below dentate line, systemic circulation

Risk:
- increased intra-abdominal pressure: chronic constipation, pregnancy, obesity, portal hypertension

Internal features:
- painless rectal bleeding, prolapse, mucus discharge, pruritus, burning pain, rectal fullness
- 1st: not prolapsed; high fibre, steroid cream, rubber band ligation
- 2nd: prolapse with straining, spontaneous reduction; band ligation, photocoagulation
- 3rd: prolapse, require manual reduction; band ligation
- 4th: permanently prolapsed; closed hemorrhoidectomy

External features:
- pain after bowel motion: dietary fibre, stool softner
- thrombosed hemorroids: resolve within 2 weeks, consider surgical compression if <48hrs

46

Anal fissures

90% posterior midline, 10% anterior midline

Features
- acute: very painful, blood after bowel motion, sphincter spasm on DRE; stool softners, bulking agent
- chronic: fissure, sentinel skin tages, hypertrophied papillae; stool softners, topical nitroglycerin, lateral internal anal sphincterotomy, botullinum

47

Anorectal abscess

Infection in one or more of the anal spaces
- perianal
- intersphinteric
- ischiorectal
- supralevator

Features:
- throbbing pain that worsen with straining and movement
- tender perianal/rectal mass
- recurrent perianal abscesses with Crohn's

Treatment:
- incision and drainage

Complications
- can develop to fitula-in-ano with palpable cord-like tract. Requires fistulotomy

48

Rectal prolapse

Mostly in women, at extremes of age.

Risks:
- gynaecological surgery
- chronic neurologic/psychiatric disorders affecting motility

49

Anal cancers

SCC
- most common tumour of anal canal
- prone to HPV
- anal bleeding, pain, mass, ulceration, pruritus
- treatmetn: chemotherapy, radiation, surgery

Anal canal is 3rd most common site for primary malignant melanoma (after skin, eyes)

50

Liver cysts

Simple cysts
Polycystic liver disease
Choledochal cysts (congenital moalformations of pancreaticobiliary tree)
Hydatid liver cysts (Echinococcus granulosus parasitic infection)
Cystadenoma

51

Liver abscess

Etiology
- Pyogenic: most often polymicrobial - E.coli, Klebsiella, Proteus, Strep. milleri
- Parasitic: Entamoeba histolytica
- Fungal: candida

52

Liver tumours

Hemangiomas
- most common benign tumour
- results from malformation of angioblastic fetal tissue

Adenoma
- benign glandular epithelial tumour
- risk factors: female, estrogen (fertile age, OCP, pregnancy)
- mostly asymptomatic but may have RUQ pain
- stop steroids, excision if large

Focal nodular hyperplasia
- unclear pathogenesis
- risk facots: female, 20-50
- central stellate scar on CT scan

Primary liver malignancy
- usually hepatocellular carcinoma
- risk fx: chronic liver inflammation (Hep B/C, cirrhosis, hemochromatosis, a-anti-trypsin deficiency), COC, steroids, smoking, alcohol
- RUQ pain, right shoulder pain, jaundice, weightloss, fever, hepatomegaly, bruit, ascites, paraneoplastic syndromes, metastasis (lung, bone, brain, peritoneal seeding)
- elevated ALP, bilirubin, a-fetoprotein, imaging, biopsy
- resection, radiofrequency ablation, chemoembolization, chemotherapy, liver transplant

Secondary liver malignancy
- most common liver malignancy
- from: GI, lung, breast, pancreas, ovary, uterus, kigney, gallbladder, prostate
- resection or chemotherapy

53

Liver transplant

Indications
- progressive liver disease not responding to medical therapy
- end-stage liver disease
- progressive jaundice, refractory ascites, spontaneous hepatic encephalopathy, recurrent sepsis, recurrent variceal hemorrhage

Conditions
- Parenchymal disease: chronic Hep B/C (most common in adults), alcoholic cirrhosis, acute liver failure, Budd-Chiari syndrome, congenital hepatic fibrosis, CF
- Cholestatic disease: biliary atresia (most common in children), primary bilary cirrhosis, sclerosing cholangitis
- Inborn errors: a-antitrypsin deficiency, Wilson's disease, hemochromatosis
- HHC

Contraindications:
- active alcohol or substance abuse
- extrahepatic malignancy within 5yrs
- advanced cardiorespiratory disease
- "HIV positive"

Post-op complications
- graft failure
- acute and chronci rejection, ischemia perfusion injury
- vascular: thrombosis, IVC obstruction
- immunosuppression complications
- recurrence of Hep B

54

Cholelithiasis

Formation of gallstones
- imbalance of cholesterol and bile salts/lecithin
- excessive hepatic cholesterol secretion, supersaturated cholesterol can precipitate and form gallstones

Risk factors:
Cholesterol stones:
- obesity
- estrogens
- ethnicity: Polinesians
- terminal ileal resection or disease
- impaired gallbladder emptying: DM, starvation
- rapid weight loss
Pigmant stones
- cirrhosis
- chronic hemolysis
- bilary stasis: strictures, dilation, infection

Features:
- 80% asymptomatic
- biliary colic 10-25%
- cholecystitis
- choledocholithiasis
- cholangitis
- gallstone pancreatitis
- gallstone ileus

Investigations
- US
- ERCP: biliary and pancreatic ducts

55

Biliary colic

Gallstone impacted on cystic duct, no infection
- RUQ pain, crescendo-decresendopain
- worse at night or after fatty meal
- normal bloods, US
- analgesia, rehydration, elective cholecystectomy

56

Acute cholecystitis

Inflammation of gallbladder resulting from sustained gallstone impaction in cystic duct
- biliary colic hx, severe constant epigastric/RUQ pain, anorexia, nausea, fever
- Murphy's sign, palpable tender gallbladder
- elevated inflammatory markers and mildly elevated LFT's, US
- complications: mucocele, gangrene 20%, perforation 2%, empyema, cholecystoenteric fistula, Mirizzi syndrome
- Rx: NBM, IVF, analgesia, abx, cholecystectomy

Acalculous cholecystits
- acute/chronic cholecystitis in absence of stones
- gallbladder ischemia, stasis
- risk fx: DM, immunosuppression, ICU, trauma, TPN, sepsis
- Rx: broad spectrum antibiotics, cholecystectomy

Mirizzi Syndrome
- extrinsic compression of common hepatic duct by gallstone in cystic duct or Hartmann's pouch
- may erode into CHD or CBD creating a fistula
- fever, RUQ pain, jaundice
- elevated ALP, bilirbin, US, CT, ERCP
- Rx: cholecystectomy

57

Choledocolithiasis

Stone in common bile duct
- tenderness in RUQ, pale stool, dark urine, fluctuating jaundice
- normal inflammatory markers, raised LFTs, US, ERCP
- Rx: ERCP

58

Acute cholangitis

Obstruction of CBD leading to biliary stasis, bacterial overgrowth, suppuration and biliary sepsis
- organisms: E.coli, Klebsiella, Pseudomonas, Enterococcus
- Charcot's triad (fever, RUQ pain, jandice), nausea, jaundice, pale stools, dark urine
- raised inflammatory markers, elevated LFTs with obstruction, US
- Rx: NBM, IVF, IV antibiotics, decompression with ERCP + sphincterotomy, laparotomy

59

Gallstone ileus

Cholecystoenteric fistula allows large gallstone to enter gut and impacts at ileocecal valve, causing bowel obstruction
- crampy abdominal pain, nausea, vomiting
- AXR, air fluid levels, radiopaque gallstone, air in biliary tree (Rigler's triad)
- Rx: IVF, NGT, surgical removal of stone and fistula closure, cholecystectomy

60

Gallbladder cancer

Risk factors:
- chronic symptomatic gallstones, old age, female, gallstone polyps, chronic infection
- mainly adenocarcinoma, incidental finding
- vague RUQ pain, palpable RUQ mass, jaundice due to invasion of CBD, early local extension or metastasis
- US mural thickening, calcification, abdo CTq

61

Cholangiocarcinoma

Malignancy of extra-hepatic or intrahepatic bile ducts

Risk factors:
- age 50-70
- UC, primary sclerosing cholangitis, choledocal cyst, chronic intrahepatic stones

Majority are adenocarcinomas
- gradual signs of biliary obstruction: jaundice, pruritus, dark urine
- anorexia, weight loss, RUQ pain, hepatomegaly
- obstructive LFTs, US, ERCP
- Rx: generally palliative

62

Acute pancreatitis

Obstruction of pancreatic duct by gallstones and biliary sludge.
- epigastric pain radiating to back, nausea, vomitng, ileus, peritoneal signs, jaundice, fever, better sitting up
- high amylase, lipase and WBC, elevated LFTs
- Rx: supportive, NBM, IVF, analgesia, antibiotics if severe (most pass spontaneously), may need urgent ERCP + spincterotomy if conservative treatment fails, cholecystectomy electively

63

Chronic pancreatitis

Surgical treatment if failure of medical treatment/acute complication

64

Pancreatic cancer

Fourth most common cause on cancer mortality

Risk factors:
- increased age
- smoking
- high fat diet, heavy alcohol use
- DM, chronic pancreatits
- partrial gastrectomy, cholecystectomy

Features
Head of pancreas 70%
- weight loss, obstructive jaundice, vague constant epigastric pain, painless jaundice, palpable tumour mass
Body or tail of pancreas 30%
- presents later
- weight loss, vague mid-epigastric pain
- sudden onset diabetes

Investigations
- elevated ALP and bilirubin
- CA 19-9
- imaging with contrast CT

Treatment
- resection: Whipple's procedure, distal pancreatectomy +/- splenectomy for tail of pancreas
- may require neo-adjuvant therapy
- non-resectable requires palliative care
- most important factors atr lymph node status, size >3cm, perineural invasion

65

Splenectomy

Indications
- splenic trauma
- hereditary spherocytosis
- primary hypersplenism
- chronic immune thrombocytopeniapurpura,
- splenic vein thrombosis
- TTP
- non-Hodgkin's lymphoma

Complications
Short term
- injury to surrounding structure: gastric wall tail of pancreas
- post-op thrombocytosis, leukocytosis
- thrombosis of portal, splenic, mesenteric veins
- subphrenic abcess
Long term
- post-spenectomy sepsis by encapsulated organism (prophylactic vaccinations for pneumoccocal, H. influenza, meningococcal, prophylactic penicillin in children)

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Benign breast lesion

Fibrocystic changes
- fibrotic and cystic changes of the breast

Fibroadenoma
- smooth rubbery mobile mass
- hormone dependant
- observation, consider excision if growing or large

Intraductal papilloma
- solitary intraductal benign polyp

Fat necrosis
- result of trauma
- tender and firm ill-defined mass

Mammary duct ectasia
- obstruction of subareolar duct leading to dilation, inflammation and fibrosis of duct
- may present with nipple discharge
- resolves spontaneously.
- risk of secondary infection

Abscess
- lactaional vs periductal/subareolar
- unilateral localised pain, erythemia, nipple discharge
- rule out inflammatory carcinoma
- broad-spectrum antibiotics, total duct excision if presitent

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Breast cancer

Second leading cause of cancer mortality in women

Risk factors
- female
- age >40
- family hx
- high estrogen level: nulliparity, early menarche, late menopause, HRT >5yrs
- decreased risk with lactation, early menopause, early childbirth

Investigations
- Mammography: screening every 2yrs from 45-69, features of ill-defined mass, microcalcifications, architectual distortion
- US for cystic vs solid lesions
- Needle aspiration: cystic lesions
- Guided core needle biopsy: most common

Genetic screening for BRCA 1/2:
- patient with ovarian + breast cancer
- strong family hx of breast/ovarian cancer
- male breast cancer
- young patient <35yrs

Staging
- clinical tumour size
- grade
- estrogen and progesterone receptors
- HER2 receptors
- lymphovascular invasion

Pathology
- Ductal carcinoma in-situ DCIS: lumpectomy
- Lobar carinoma in-situ LCIS
- Invasive ductal carinoma 80%: microcalcifications, hard and gritty
- Invasive lobular carcinoma 8-15%: does not form microcalcifications
- Paget's disease: ductal carcinoma that invades nipple with scaling and eczematoid lesion
- Inflammatory carcinoma: invades dermal lymphatics, most aggressive form and causes warm swollen breast.

Surgical treatment
- Breast conserving surgery: lupectomy with wide local incision for stage I and II, recommend radiation
- Mastectomy
- Axillary lymph node clearance: performed if lymph node infiltration, risk of arm lymphedema
- Sentinel lymph node biopsy: technetium-99 + blue dye injected into tumour site

Adjuvant/neoadjuvant therapy:
- Radiation: after BCS and occasionally masectomy
- Hormonal: ER positive cancers, tamoxifen if premenopausal, ovarian ablation
- Chemotherapy: ER negative or young age

Follow-up
- annual mammography

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Pediatric surgery

Hydroceles
- processus vaginalis fails to close
- most spontaneously resolve <1yr
- repair if persistance >2yrs

Hypertrophic pyloric stenosis
- pyloric circular muscle hypertrophy
- non-bilious projectile vomiting 30-60min after feeds
- pyloromyotomy

Meckel's diverticulum
- first 5 years of life
- failure of viteline duct regression
- bright red blood per rectum

Malrotation
- failure of gut to normally rotate around superior mesenteric artery
- bilious emesis
- emergent laparotomy

Umbilical hernias
- incomplete closure of peritoneal and fascical layers within the umbilicus by 5yrs
- surgery only if complicated

Hirschsprung's disease
- defect in migration of neurocrest cells to intestine, failure of peristalsis and relaxation of external sphincter
- delayed passage of meconium >24hrs
- surgical resection

Cryptorchidism
- undescended testes
- orchidopexy if undescended by age 1

Intussusception
- most common bowel obstruction 6-36m
- enlarged Peyer's patches, polyps, Meckel's diverticulum, CF, lymphoma
- currant-jelly stool
- air contrast enema, operative reduction

Inguinal hernias
- mostly indirect, manual reduction ro relieve acute symptoms
- surgical repair at earliest convenience, emergent repair if incarcerated