General surgery Flashcards
(68 cards)
1
Q
Preoperative preparations
A
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
Q
Post-op Fever
A
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
Q
Post-op drugs
A
6 A's Analgesia Anti-emetic Anti-coagulation Antibiotics Anxiolytics All other patietn meds
4
Q
Post-op drugs
A
6 A's Analgesia Anti-emetic Anti-coagulation Antibiotics Anxiolytics All other patient meds
5
Q
Post-op wound complications
A
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
Q
Surgical site infection
A
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
Q
Wound hemorrhage/hematoma
A
Inadequate surgical control of hemostasis.
Rx: pressure dressing, open drainage + wound packing for large hematoma
8
Q
Seroma
A
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
Q
Wound dehiscence
A
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
Q
Post-op urinary and renal complications
A
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
Q
Post-op respiratory complications
A
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
Q
Post-op cardiac complications
A
Common asshythmias: SVT, AF (secondary to fluid overload, PE, MI)
MI
- increased risked post-surgery
13
Q
Hiatus hernia
A
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
Q
Esophageal perforation
A
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
Q
Esophageal cancer
A
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
Q
Thoracic outlet syndrome
A
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
Q
Tube thoracostomy
A
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
Q
Peptic ulcer disease
A
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
Q
Gastric carcinoma
A
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
Q
Bariatric surgery
A
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
Q
Gastric surgery complications
A
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
Q
Meckel’s diverticulum
A
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
Q
Small intestine tumours
A
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
Q
Hernia terminology
A
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
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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
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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
