General Surgery Flashcards
(126 cards)
1
Q
What is a colostomy?
A
A surgical opening into the large bowel
2
Q
Where are colostomy bags usually found?
A
In the left iliac fossa
3
Q
What should the contents of a colostomy be like?
A
Thick and solid as it has already been through the small bowel and had water reabsorbed
4
Q
Which type of stoma has a spout and why?
A
An ileostomy
As the enzymes in faeces are toxic to the skin so a spout must be made from the section of bowel so the faeces can drain without touching the skin
5
Q
What is a common complication of a stoma that will present with a palpable mass?
A
Parastomal hernia
More common with colostomy rather than ileostomy
6
Q
Where are ileostomies usually found?
A
In the right iliac fossa
7
Q
What is an ileostomy?
A
A surgical opening into the small bowel
8
Q
What should the contents of an ileostomy be like?
A
Watery
9
Q
What are some examples of when an ileostomy may be made?
A
In UC/ Crohn’s
FAP
10
Q
What is the different between:
i) diverticulosis
ii) diverticular disease
iii) diverticulitis
A
i) presence of diverticula
ii) symptomatic diverticula
iii) inflammation/ infection of diverticula
11
Q
What are some risk factors for GORD?
A
Age Male Obesity Smoking Alcohol Spicy or fatty foods Caffeinated drinks
12
Q
What are some symptoms of GORD?
A
Burning retrosternal chest pain (worse on lying down and after eating)
Dysphagia
Chronic cough
Belching
13
Q
How can GORD be managed?
A
Conservative: avoid precipitants e.g. coffee, avoid eating a few hours before bed, smoking cessation, weight loss
Pharmacological: PPI
Surgical: fundoplication
14
Q
What is Barrett’s oesophagus?
A
Metaplasia of normal oesophageal lining from stratified squamous to simple columnar
15
Q
Where does Barrett’s oesophagus usually occur?
A
Distal oesophagus
16
Q
How is Barrett’s oesophagus managed?
A
PPI
Stop any NSAIDs
Routine endoscopy due to risk of progression to adencarcinoma (respect any premalignant lesions, if carcinoma an oesophagectomy may be indicated)
17
Q
Which type of oesophageal cancer is more common in the developed world?
A
Adenocarcinoma
18
Q
Where in the oesophagus does adenocarcinoma occur and why?
A
Lower third of the oesophagus, occurring when Barrett’s oesophagus become dysplasic and becomes malignant
19
Q
How should a patient with ?oesophageal carcinoma be investigated?
A
Urgent OGD within 2 weeks
Biopsy any malignancy and send for histology
20
Q
What is a Mallory Weiss tear and how are they often caused?
A
Rupture to the superficial mucosa of the oesophagus
Usually at the GOJ
Usually occur after a period of profuse vomiting
OGD
Usually self limiting
21
Q
What is the difference between a sliding and rolling hiatus hernia?
A
Sliding: when the GOJ, abdominal part of the oesophagus and often the cardia of the stomach slide upwards through the oesophageal hiatus of the diaphragm
Rolling: when the funds of the stomach creates a pouch that sits next to a normal GOJ
22
Q
What are some risk factors for a hiatus hernia?
A
Age
Pregnancy
Obesity
Ascites
23
Q
How could a hiatus hernia be managed?
A
Conservatively: PPI, weight loss, dietary advice (smaller portion, alcohol reduction), smoking cessation
Surgical: fundoplication (wraps part of funds around the LOS), cruroplasty (reduces hernia back from thorax into abdomen)
24
Q
Where are peptic ulcers most common?
A
In the first part of the duodenum (duodenal ulcer) or fundus of the stomach (gastric ulcer)
25
How would the symptoms differ between a gastric ulcer and a duodenal ulcer?
Epigastric pain in both.
Gastric ulcer pain would be exacerbated by eating.
Duodenal ulcer pain would occur a few hours after eating. It is often worst when fasting and is alleviated by eating.
26
Which vessels could a gastric ulcer erode?
Left gastric and splenic
27
Which vessels could a duodenal ulcer erode?
Gastroduodenal artery
28
How would you investigate a px with a suspected peptic ulcer?
If red flag symptoms: OGD and biopsy (can send biopsy for histology and H Pylori test)
If OGD not needed, test for H Pylori via urease breath test, stool antigen test, serum antibodies test
29
What is the cause of peptic ulcers?
Impaired defence of stomach through H Pylori/ alcohol excess/ prolonged NSAID use
30
How would a peptic ulcer be managed?
Conservative: weight loss, smoking cessation, reduce NSAID use, reduce alcohol use
If H Pylori +ve: amoxicillin, clarithromycin and PPI
If H Pylori -ve: PPI for 8 weeks
31
What are some signs for gastric cancer that would be visible on examination?
```
Enlarged Virchow’s node
Hyperpigmentation of skin creases
Palpable epigastric mass
Signs of anaemia e.g. pale conjunctiva
Jaundice/ hepatomegaly (can indicate liver mets)
```
32
What is Troiser’s sign?
Enlarged Virchow’s node
33
What are some symptoms of gastric cancer?
```
Dyspepsia
Dysphagia
Nausea
Malena
Vomiting
Non specific cancer signs e.g. weight loss, anorexia, Anaemia (markers of late disease)
```
34
What is the difference between a direct and indirect hernia?
Direct: occurs within Hesselbachs triangle when bowel enters superficial ring by a weakness in the abdominal wall, medial to the epigastric vessels
Indirect: goes through the deep inguinal ring, lateral to epigastric vessels, outside Hesselbachs triangle
35
Indirect inguinal hernias are due to failure of which embryological part to close?
Processus vaginalis
36
What are some risk factors for an inguinal hernia?
Male
Age
Obesity
Increased intra abdominal pressure eg heavy lifting, chronic cough, constipation
37
What are the boundaries of Hesselbachs triangle?
Medial: rectum abdominus
Inferior: inguinal ligament
Lateral: inferior epigastric vessels
38
What are some risk factors for a femoral hernia?
Female
Age
Pregnancy
Increased intra abdominal pressure
39
What are the borders of the femoral triangle?
Superior: inguinal ligament
Medial: lateral border of adductor longs
Lateral: medial border of sartorius
40
What type of organism is Clostridium difficile?
Gram positive bacillus
Anaerobic
Spore forming
Produces exotoxins A and B which cause an inflammatory response in the bowel
41
How does a C Diff infection usually occur?
Following treatment by broad spectrum antibiotics
42
How is a C Diff infection treated?
Fluids
| Oral metronidazole
43
If C Diff is unresponsive to metronidazole after 72 hours, which antibiotic could be used?
Vancomycin
44
What are some differentials for abdominal pain common in children?
Appendicitis
| Mesenteric adenitis
45
What is Rovsing’s sign?
When RIF pain is elicited on palpating of the LIF
| Seen in appendicitis
46
What is Psoas sign?
When RIF pain is elicited on extension of the right hip
| Seen in appendicitis
47
What is an important first line investigation to do for any woman of child bearing age with abdominal pain/ symptoms?
Beta hCG
48
How do colorectal carcinoma usually form?
Adenocarcinoma sequence
| Normal mucosa becomes an adenoma which can then become a carcinoma
49
What are some risk factors for colorectal cancer?
```
High red meat and processed intake
Male
IBD
Low fibre diet
Age
Male
```
50
How is colorectalcancer screened for?
Every 2 years for men and women aged 60 to 75 using home stool testing kits for faecal occult blood
If they are positive, they are offered a colonoscopy
51
What is the tumour marker for colorectal cancer and when is it used?
CEA
| Not secreted by all tumours and also raised in IBD so mainly used to monitor response to tx
52
How is colorectal cancer staged?
Dukes Staging
53
What is the classification of Dukes Staging?
```
A = confined to muscularis mucosa
B = through muscularis mucosa
C = regional lymph nodes involved
D = distant mets
```
54
How does treatment differ if a rectal tumour is high or low?
High can undergo anterior resection
| Low would have to abdominoperineal resection resulting in colostomy
55
What are common causes of small bowel obstruction?
Adhesions
| Herniae
56
What are common causes of large bowel obstruction?
Malignancy
Diverticular Disease
Volvulus
57
What signs and symptoms can be seen with bowel obstruction?
```
Abdominal pain
Absolute constipation
Abdominal distension
Vomiting
Tinkling bowel sounds
Rebound tenderness if ischaemic
```
58
Why would a venous blood gas be ordered in cases of possible bowel obstruction?
As high lactate indicates ischaemia
| Px often acidaemic
59
How will small and large bowel differ on abdominal x Ray?
Small bowel: central, dilated more than 3cm, plicae circulares present
Large bowel: peripheral, dilated more than 6cm, haustra visible
60
How is bowel obstruction managed?
Conservative if no signs of ischaemia: drip and suck (IV fluids and NG tube), analgesics, fluid balance
Surgery: indicated if virgin abdomen, signs of ischaemia, closed loop obstruction, tumour
61
What is a Volvulus?
When the large bowel twist around its mesentery resulting in a closed loop obstruction
62
How will a sigmoid Volvulus typically appear on AXR?
Coffee bean sign arising from LIF
| Signs of large bowel obstruction
63
What types of patients are associated with Volvulus?
Older patients
With constipation
And neurological conditions e.g. Parkinson’s
Or psychiatric conditions e.g. schizophrenia
64
How are volvuli managed?
Sigmoidoscope decompression
| If this fails, or if perforated, then surgery is indicated (primary anastamosis or Hartmanns)
65
Where in the bowel is diverticular Disease most common?
Sigmoid colon
66
What is the difference between diverticulosis, diverticulitis and diverticular Disease?
Diverticulosis= presence of diverticula
Diverticulitis = inflammation of diverticulum
Diverticular Disease = symptomatic diverticulum
67
What is important in a patient on immunosuppressants or steroids who may have abdominal pathology?
Immunosuppressants and steroids can mask the symptoms of diverticulitis, even when perforated
68
What are some symptoms are diverticular Disease?
```
LIF colicky pain relived by defecation
Flatulence
Nausea
Altered bowel habit
PR bleeding
```
69
How would you want to investigate a px with diverticular Disease?
Routine bloods
Blood gas to assess lactate level (for sepsis or bowel ischaemia
Flexible sigmoidoscopy (NOT if suspected diverticulitis due to risk of perforation)
AXR to exclude bowel obstruction
CXR to exclude perforation
70
What is Hartmann’s procedure?
Emergency surgical procedure
Where the sigmoid colon is resected
End colostomy and closure of the rectal stump is formed
Anastomosis with reversal of end colostomy may be possible later
71
How can diverticular disease be managed?
Uncomplicated: at home with analgesic (paracetamol 1st line as opioids lead to constipation)! Abx, encourage fluids
Conservative: Broad spectrum Abx, fluids, analgesics, bowel rest (only clear fluids orally)
Surgery: only is unresponsive to conservative methods, have perforation or sepsis unresponsive to Abx
Elective surgery may be indicated if chronic disease or if immunosuppressed
72
What is the difference between an anorectal abscess, anal fissure and anal fistula?
Anorectal abscess is a collection of pus in the anal or rectal region thought to be due to plugging of the anal ducts causing bacteria overgrowth
Anal fissure is a tear in the mucosal lining of the anal canal
Anal fistula is an abnormal connection between the anal canal and perianal skin
73
Wheat are some risk factors for an anal fissure?
Constipation (as usually due to defecation of hard stool)
IBD
STIs
74
How would you manage an anal fissure?
```
Increased patients fibre intake
Increase fluids
Analgesia
Stool softening laxatives
GTN cream (to relax internal anal sphincter and increase blood supply to the area to promote healing)
Surgery only if chronic
```
75
What are haemorrhoids?
Abnormal swelling or enlargement of anal vascular cushions
76
What is the most likely differential of passage of painless bright red blood (not mixed in with stool) in an elderly patient?
Haemorrhoids
77
How are haemorrhoids managed?
95% can be conservatively managed (increased fibre and fluid intake, laxatives, topical analgesics)
Rubber band ligation
Haemorrhoidectomy if symptomatic or haemorrhoid has prolapsed through so cannot be banded
78
Why should opioid analgesics be avoided for a patient with haemorrhoids?
As they can compound constipation
79
Are most liver cancers primary or metastatic?
Metastatic
80
What are the most common cancers that metastasise to the liver?
```
Bowel
Breast
Pancreas
Stomach
Lung
```
81
What is indicated by an AST: ALT ratio >2?
Alcoholic liver disease
82
What is indicated by an AST: ALT ratio of ~1?
Viral hepatitis likely
83
What are some causes of acute pancreatitis?
```
GET SMASHED
Gallstones
Ethanol
Trauma
Steroids
Mumps/ malignancy
Autoimmune
Scorpion bits
Hyperlipidaemia/ hypercalcaemia/ hyperparathyroidism
ERCP
Drugs
```
84
What is Cullen’s sign?
Periumbilical bruising sometimes seen in pancreatitis, indicates retroperitoneal haemorrhage
85
What is Grey Turners sign?
Flank discolouration that can be seen in pancreatitis, indicates retroperitoneal haemorrhage
86
How much would you expect amylase to be raised by in pancreatitis?
At least 3x the upper limit of normal
87
Other than pancreatitis, what else can amylase be raised in?
Ectopic pregnancy
Mesenteric ischaemia
Bowel perforation
DKA
88
What criteria can be used to assess the severity of a patients pancreatitis?
Modified Glasgow criteria
| Does not use amylase in its score!
89
Sudden onset sever epigastric pain radiating to the back with nausea and vomiting is characteristic of what condition?
Acute pancreatitis
90
Why are Cullen’s sign and Grey Turners sign seen in acute pancreatitis?
Due to retroperitoneal haemorrhage as the inflamed pancreas can release its enzymes into the systemic circulation and this can lead to auto digestion of blood vessels
91
Why do hypocalcaemia form in cases of acute pancreatitis?
Enzymes are released from the inflamed pancreas which can cause autodigestion of fats, resulting in fat necrosis
Fat necrosis causes the release of free fatty acids which reacts with serum calcium to form chalky deposits, hence the hypocalcaemia
92
How would you manage a px with acute pancreatitis?
Supportive treatment of O2, fluids IV, NG tube if vomiting, analgesia
Treat any underlying causes e.g. urgent ERCP if gallstones are present
93
What local complications can acute pancreatitis lead to?
Pseudocyst
| Pancreatic necrosis
94
What is the most common cause of chronic pancreatitis?
Alcohol
95
How would chronic pancreatitis appear on USS/ AXR/ CT?
Will have pancreatic calcifications
96
How is chronic pancreatitis managed?
Pancreatic enzyme supplements
Fat soluble vitamin supplements
Analgesia (TCAs recommended due to opioid dependence)
No alcohol and low fat diet
ERCP to extract any pancreatic duct stones
Endoscopic USS to drain any pseudocysts
97
What investigations would you do for chronic pancreatitis and what would they show?
```
BM for hyperglycaemia
LFTs
Amylase and lipase (raised but not as much as in acute disease)
Faecal elastase will be low
Abdominal USS
Ct chest abdo pelvis
ERCP can assess pancreatic duct
```
98
What are the fat soluble vitamins?
A, D, E, K
99
What are most types of pancreatic cancer?
Adenocarcinoma
100
What tumour marker can be used to assess response to tx for pancreatic cancer?
CA19-9
101
What is a Whipple’s procedure?
Removal of head of pancreas, antrum of the stomach, 1st and 2nd part of the duodenum, gallbladder and CBD
(As they are all supplied by the gastroduodenal artery)
102
How is pancreatic cancer treated?
Whipples proceudre
Adjuvant chemo
Palliative stenting and ERCP
103
What are some risk factors for gallstones?
5 F’s
Female, fertile, forty, fat, family hx
104
How do gallstones present?
Mostly asymptomatic
| If synaptic: biliary colic
105
What is biliary colic?
Sudden, dull, colicky pain in the RUQ that may radiate to the right shoulder tip
Associated with nausea and vomiting
Precipitated by fatty foods
106
How does cholecystitis differ to biliary colic?
Cholecystitis is more constant, even despite pain relief
| May also show signs of inflammation e.g. fever, raised WCC
107
What is Murphys sign?
Positive in cholecystitis
Pain elicited when pressure is applied in RUQ as the px inspires (this causes the diaphragm to come down and irritate the inflamed gallbladder)
108
What liver enzyme pattern on LFTs indicate obstruction of the biliary duct?
When ALP and bilirubin and higher than ALT
109
What imaging modality is 1st line in suspected cholecystitis?
USS
| This will show gallstones and can also show gallbladder thickening and bile duct dilation
110
How is biliary colic managed?
Lifestyle: low fat diet, weight loss
Analgesia (NSAID with PRN opioid)
Antiemetic (eg cyclizine, metoclopramide)
Elective cholecystectomy
111
How is cholecystitis managed?
```
IV abx (co-amoxiclav, metronidazole)
Fluids
Analgesia
Antiemetic
Laparoscopic cholecystectomy
```
112
What is ascending cholangitis?
Bacterial infection of the biliary tree combined with biliary obstruction
113
What are the organisms commonly involved in ascending cholangitis?
E Coli
Klebsiella
Enterococcus
114
What is Charcot’s triad?
RUQ pain, fever and jaundice
Seen in ascending cholangitis
115
What is Reynold’s pentad?
For ascending cholangitis
Charcot’s triad + hypotension + confusion
116
What will indicate ascending cholangitis on a FBC and LFT?
Raised WCC, CRP
Raised bilirubin and ALP and GGT
117
What is the gold standard imaging for cholangitis?
ERCP
118
How is ascending cholangitis managed?
IV Abx (co amoxiclav + metronidazole)
Fluids
Bloods and cultures
ERCP to relieve any obstruction
119
What is the most common organism causing cholangitis?
E Coli
| Then klebsiella, streptococcus, psuedonomas
120
In which type of jaundice (pre hepatic, hepatic and post hepatic) will ALT and AST be highest?
Hepatic
| High ALT specific to intracellular hepatic damage
121
ALP will be most elevated in which type of jaundic: pre hepatic, hepatic or post hepatic?
```
Post hepatic
(Raised most in biliary obstruction)
```
122
What is Reynolds pentad and what does it indicate?
Charcot’s triad (fever+jaundice+RUQ pain) + confusion and hypotension
Indicates biliary sepsis
123
What are some drug causes of acute pancreatitis?
```
Steroids
Mesalazine
Azathioprine
Furesomide
Bendroflumethiazide
Sodium valproate
```
124
Whereabouts in the abdomen is pain usually felt in ischaemic colitis?
Left iliac fossa
125
Barium enema showing thumb printing is indicative of which pathology
Ischaemic colitis
126
How is mild to moderate ischaemic colitis managed?
Analgesia
Bowel rest (NBM)
IV Fluids
