General Surgery Block Flashcards
1
Q
Describe Munchausen’s syndrome
A
a psychological disorder where someone pretends to be ill or deliberately produces symptoms of illness in themselves.
Eg a drug seeker so that they get medications
2
Q
What is absolute constipation?
A
Absence of passing wind
3
Q
Describe Rosvig’s sign?
A
Press on LIF and in a patient with appendicitis, they will get pain in RIF
4
Q
In which condition may bowel sounds be absent?
A
Ileus
5
Q
When may bowel sounds be tinkling?
A
Obstruction
6
Q
Looking at a patient from end of bed check, if they are rocking around the bed and can’t sit still what condition would this suggest?
A
Renal colic
7
Q
Looking at a patient from the end of bed check, if they are lying still and not moving with ‘board like rigidity’ what would this suggest?
A
Perforated duodenal ulcer
8
Q
What is cullen’s sign and what condition does it point you towards?
A
Cullen’s sign - peri-umbilical bruising
Sign of pancreatitis
9
Q
What is Grey Turner’s sign and what condition does it point you towards?
A
Flank bruising
Sign of pancreatitis
10
Q
When taking a set of bloods in general surgery, why should you always remember to do amylase?
A
To check for pancreatitis
11
Q
Why is an erect CXR useful?
A
If it shows free air under the diaphragm
12
Q
What are the 3 main uses of an AXR and why should you generally try to avoid it?
A
Avoid it where possible - expose patient to lots of radiation Use if ?obstruction ?colitis ?perforation
13
Q
What is the gold standard investigation for acute abdomen?
A
CT scan
14
Q
What is the gold standard investigation for RUQ pain?
A
Ultrasound
15
Q
MRI is very useful in the acute abdomen. True or false?
A
False
16
Q
What is pretty much the only use for MRI in the acute abdomen?
A
pregnant appendices
17
Q
In the setting of the acute abdomen, who needs to go to theatre right away
A
Ischaemic gut
Faecal peritonitis
18
Q
Board like rigidity on abdominal examination and free air under the diaphragm on erect CXR. What does this make you think of?
A
Perforated duodenal ulcer
19
Q
Name 4 colonic emergencies
A
Obstruction
Perforation
Volvulus
Colitis
20
Q
If someone has a volvulus, how do you manage it?
A
Urgent flexible/rigid sigmoidoscope
21
Q
Management of acute diverticulitis
A
Either a spectrum of antibiotics or Hartmann’s operation
22
Q
Which classification is used for diverticulitis
A
Hinchey classification
23
Q
Explain what a Hartmann’s procedure is?
A
Remove sigmoid colon, leave the rectum, bring out colostomy
24
Q
For emergency surgery in IBD, subtotal colectomy is used for crohn’s / UC ?
A
Ulcerative colitis
25
For emergency surgery in IBD, resection is used for crohn's / UC ?
Crohn's
26
ileostomy is which shape?
Rose
27
Young patient with UC gets a proctocolectomy. Would they most likely want:
- end ileostomy
- pouch
- ileorectal anastamosis
Pouch
28
What are the disadvantages of having a pouch?
Increased bowel movements
| Increased faecal nocturnal incontinence
29
Most likely to develop colorectal cancer if you have crohn's disease / UC ?
UC
30
What is most likely to be cured by surgery: crohn's or UC?
UC
31
All inguinal hernias should be fixed. True or false?
False
| - some can be managed conservatively
32
All femoral hernias should be fixed. True or false?
True
| - Femoral = FIX
33
Femoral hernias:
| Below/Above and medial/lateral to pubic tubercle
Below and lateral to pubic tubercle
34
indirect inguinal hernia vs direct inguinal hernia
Direct inguinal hernia - pops out when pt coughs
| Indirect inguinal hernia - does not pop ot when patient coughs
35
Triad of the following makes you think of what condition:
fever
back pain
limp
Psoas abscess
36
Where is McBurney's point?
1/3rd of the way along the right ASIS and umbilicus
37
In young adults, appendicitis is most common in males or females?
Males
| 3:2 male:female
38
Why is the greater ommentum known as the 'police officer' in the abdomen
if there is an area of inflammation, the greater ommentum is attracted and sticks onto it
39
Appendicitis can lead to peritonitis. True or false?
True
40
Patient with colicky central abdominal pain which migrates to RIF, nausea, off food, hasn't passed bowel movement that day. What does this make you think of?
Acute appendicitis
41
Specific sign of appendicitis
Rosvig's sign
42
Periumbilical abdominal pain which was colicky that then goes away. Flushed, bad breath.
Retrocaecal appendicitis
43
Scoring system for appendicitis
Alvarado score
44
Appendicitis is diagnosed radiologically. True or false?
False - clinical diagnosis but US can be helpful
45
What is the management of appendix mass?
Antibiotics first line
| Theatre only if symptoms persist
46
Describe an ileus
When the bowels effectively go on strike and dont work for a few days
47
What does carcinoid of the appendix stain for
Stains heavily for chromagrannin
48
If a patient's terminal ileum has to be removed, what must you replace?
B12 and folate
49
What is the most common cause of small bowel obstruction
Adhesions
50
Causes of small bowel obstruction - within the lumen (2)
Food
| Gallstones
51
Causes of small bowel obstruction - within the wall of the small bowel (2)
Crohn's disease
| tumour
52
Central colicky abdominal pain, nausea, very awful smelling vomit, absolute constipation, burping, abdominal distention. What is the likely diagnosis?
Small bowel obstruction
53
Bowel sounds will be noisy / quiet in small bowel obstruction?
Noisy
54
Management of small bowel obstruction
Drip and suck
- put the patient on a drip to get fluids into them
- suck out the fluids and air with an NG tube (Ryles tube)
55
Only drip and suck adhesional small bowel obstruction. True or false?
True
56
How do you define an adhesional small bowel obstruction?
A patient must have had a previous abdominal operation
57
Elderly frail patient with colicky abdominal pain and pretty unimpressive bloods, abdo XR normal, huge amount of analgesia. essentially pain out of proportion to clinical findings. What is the likely diagnosis?
Mesenteric ischaemia of the small bowel
58
Meckel's diverticulum location
2ft above the ileo-caecal valve
59
Meckel's diverticulum usually presents in childhood / adulthood ?
Childhood
60
Which needs immediate theatre small bowel obstruction or small bowel mesenteric ischaemia?
small bowel mesenteric ischaemia
61
The appendix is supplied by which dermatome?
T10
62
Referred pain for RUQ goes where and why is this?
RUQ pain can be referred to right shoulder
| This is because phrenic nerve (C3,4,5) supplies diaphragm but is found at the neck. Shared nerve supply
63
A patient with epigastric pain and raised amylase makes you think of what diagnosis?
Pancreatitis
64
Lipase is raised and specific to which condition
Pancreatitis
65
Which imaging modality is carried out in pregnant females with acute abdominal pain: CT or MRI?
MRI
| - do NOT CT in pregnancy
66
Dilated bowel loops on AXR makes you think
Obstruction
67
How would you manage an AXR which shows dilated bowel loops and faecal impaction?
Constipation - Laxative to get things moving
68
How would you manage an AXR which shows dilated bowel loops and NO faecal impaction?
Bowel obstruction
69
Stepladder pattern on AXR suggests what?
small bowel obstruction
70
which looks more central on AXR: small bowel obstruction or large bowel obstruction?
Small bowel obstruction
71
Describe the stepladder pattern on AXR
Central dilation of small bowel (obstruction)
| straight lines are seen going all the way through the calibre of the small bowel)
72
Small bowel / large bowel has valvae conientes?
small bowel
73
Small bowel / large bowel has haustra ?
Large bowel
74
What is the investigation of choice for a 23 year old female with suspected appendicitis ?
US
| - any female US abdo
75
What is the investigation of choice for a male OR female over 40 with suspected appendicitis?
CT scan
| - must have CT to rule out malignancy
76
What is the investigation of choice for a male UNDER 40 with suspected appendicitis?
No investigation required
| Operate on clinical diagnosis
77
Which vessels is the deep inguinal ring marked by?
Inferior epigastric vessels
78
What are the 3 borders of the femoral triangle
```
Inguinal ligament (superior)
Adductor longus
Sartorius
```
79
What are the contents of the femoral triangle from medial to lateral?
```
Medial -> lateral:
Deep inguinal lymph nodes
Vein (femoral)
Artery (femoral)
Nerve (femoral)
```
VANS drive OUT (from medial to lateral)
80
What 2 components make up the femoral sheath?
Femoral artery and femoral vein
81
Why are femoral hernias more of a worry than inguinal hernias?
The femoral canal has tough walls and there is not much room for expansion. So increased risk of strangulation or obstruction if bowel gets stuck in there
82
What is the definition of the mid inguinal point?
Where you feel the femoral pulse
83
What is the midpoint of the inguinal ligament?
Deep inguinal ring
84
Irreducible hernia
Cannot be pushed back in
85
Incarcerated hernia
Hernia is stuck in its sack
86
Strangulated hernia
Blood supply is cut off
87
Which of the following is IN the inguinal canal
- indirect inguinal hernia
- direct inguinal hernia
Indirect inguinal hernia
88
If a hernia is in scrotum it must be a direct/indirect inguinal hernia??
Indirect inguinal hernia
| - since the spermatic cord passes through the inguinal ring
89
Which types of hernia strangulate/obstruct more frequently?
- indirect inguinal hernia
- direct inguinal hernia
Indirect inguinal hernia
90
Which features in the history would specifically suggest ADHESIONAL bowel obstruction
Previous surgeries
91
Management of sigmoid volvulus with no signs of strangulation
Rigid/flexible sigmoidoscope detorsion
92
Who gets intusuception
children, age 3-4
93
Briefly describe intusucception and explain the most common location for it to occur
Telescoping of the bowel in on itself
| Most commonly occurs at the ileo-caecal junction
94
Failure of passing any stool in the first 24 hours after birth is called
Meconium ileus
95
Coffee bean shape on AXR suggests
Volvulus
96
Name the 2 most common causes of small bowel obstruction?
Hernia
| Adhesions
97
Name the 2 most common causes of large bowel obstruction?
Malignancy
| Volvulus
98
Volvulus is most common in the small/large bowel?
| Why?
Volvulus most common in large bowel.
Small bowel is full of fluid so less likely to volv. Whereas large bowel has more semi-solid substances and more likely to volv.
99
Vomiting causes which ABG
Metabolic alkalosis
100
Dehydration causes which ABG
Metabolic acidosis
101
Vomiting occurs early/late in large bowel obstruction
Late
102
Constipation occurs early/late in large bowel obstruction
Early
103
Clinical features of large bowel obstruction (4)
Colicky peripheral abdominal pain
Constipation
Abdominal distention
Vomiting (bile -> faecal)
104
Clinical features of small bowel obstruction (4)
Colicky central abdominal pain
Vomiting early, large volume (bile)
Constipation
105
Clinical examination findings of bowel obstruction
```
Distended abdomen
Diffuse abdominal tenderness
Tympanic percussion
Tinkling bowel sounds (early)
Absent bowel sounds (late)
```
106
Name 3 symptoms/signs which indicate complication in bowel obstruction
Change in the nature of pain
Rebound tenderness
Signs of sepsis
107
Name 2 of the most common complications of bowel obstruction
Bowel ischaemia
| Bowel perforation
108
First line imaging investigation in suspected bowel obstruction
AXR
- small bowel = central
- large bowel = peripheral
109
Lumen above Xcm indicates dilation of small bowel
3cm
110
Lumen above Xcm indicates dilation of large bowel
6cm
111
Initial management of bowel obstruction
Urgent resuscitation
- drip and suck
- drip: fluid resuscitation, re-balance electrolytes
- suck: NG tube for intestinal decompression
112
Management of bowel obstruction caused by adhesions
Conservative
- drip and suck
- active monitoring
- usually don't need surgery
113
Management of bowel obstruction with ischaemia / perforation
Surgery - laparotomy
114
Define paralytic ileus
When the peristaltic engine of the bowel is not working. THere is limited power to push things forward in the intesting.
There is NO mechanical obstruction
115
Name 5 causes of paralytic ileus (5Ps)
```
Post operative
low Potassium
Pelvic or spinal fracture
Peritonitis
Partuition (child birth)
```
116
Paralytic ileus - blood test findings
HYPOKALAEMIA
| Hypomagnesia
117
Paralytic ileus - what does imaging show
uniformly distended loops with no transition point and no mechanical cause
118
Male over 55 presenting with symptoms like renal colic. What should you be wary of and consider?
AAA
119
Define aneurysm
Permanent dilation of artery by over 50% of normal diameter
120
True aneurysm
All 3 layers of artery wall involved
121
False / pseudo aneurysm
Only the outermost layer (tunica externa) is involved
122
Name 3 congenital causes of aneurysm
PKD
Marfan's syndrome
Ehlers danlos syndrome
123
Risk factors for aneurysm
```
Male gender
Over 65
Obesity
Smoking
Hypertension
FH
```
124
Features of AAA rupture
```
Epigastric/umbilical pain
- sudden onset
- radiates to back
Collapse
Hypotension
Expansile pulsatile mass
```
125
Best imaging for AAA rupture
CT angiogram
126
Repair an asymptomatic AAA when it reaches what size?
5.5cm
127
Why should you not give the patient lots of IV fluids to restore BP in AAA rupturee
Will be a retroperitoneal rupture so don;t want to disrupt the tamponade. BP only needs to be ensuring the patient is getting their brain perfused
128
7 month old child crying and bringing legs up to chest, vomiting and diarhoea, target sign on US. WHat is the likely diagnosis?
Intusucception
129
When you have a patient with a neck lump, there are 3 situations:
Lump does not move on swallowing
Lump moves on swallowing
Lump moves on swallowing and moves when tongue stuck out
Describe the likely causes for each
Lump does not move on swallowing
- lymph node or salivary gland issue
Lump does move on swallowing
- thyroid issue
Lump does move on swallowing and moves when tongue stuck out
- thyroglossal cyst
130
Young 18 year old female complains of neck lump. In the midline, moves on swallowing and when she sticks her tongue out. What is the likely diagnosis?
Thyroglossal cyst
131
When taking a history from a patient with a neck lump, what are the 2 important points you need to ascertain?
Previous radiation exposure
| FH of thyroid problems
132
When examining a patient with a neck lump, what are the 2 most important things to check for?
Hoarse voice
| Lymphadenopathy
133
Thyroid nodule + neck lymphadenopathy is ____ until proven otherwise
Papillary thyroid cancer
134
When it comes to neck lumps, what is the 5% rule
5% of females will have a thyroid lump at some point
5% will be malignant
5% will be on thyroxine at some stage
135
First line imaging investigation for patient with thyroid nodule?
US guided FNA
136
For thyroid pathology, when should you use an uptake (isotope) scan?
If TSH level is suppressed, use it to see if it is a solitary toxic adenoma
137
In graves disease, what would an uptake (isotope) scan look like?
Hot all over
138
Bile which overspills into the bloodstream causes
Jaundice
139
Which US findings would suggest cholecystitis?
Thickened GB wall (inflammation)
Presence of gallstones
Peri-cholecystic fluid
140
Transient RUQ pain, worse after eating meals (esp fatty meals), radiates to back, pain goes away after a few hours. What does this suggest?
Biliary colic
141
Crampy RUQ pain radiates to back, tender, fever, vomiting. What are the differentials
Acute cholecystitis
Ascending cholangitis
Pyelonephritis
Acute pancreatitis
142
Which LFT will likely be raised in acute cholecystitis ?
Raised ALP and bilirubin
143
Which LFT will be raised in liver problems?
AST (T = trauma to the liver)
144
Investigations for patient presenting with acute cholecystitis
Bloods
US
MRCP
Erect CXR
145
Someone with obstructive jaundice. How do you manage it?
ERCP
146
Name 2 causes of obstructive jaundice
Ascending cholangitis
| Pancreatic cancer
147
pt with Amylase 400 and pt with amylase 1000. Which pt has the most severe case of pancreatitis?
Can't tell
| - amylase doesnt tell you how severe pancreatitis is
148
Will billirubin be conjugated or unconjugated in obstructive jaundice
Conjugated
149
Diagnosis and treatment of ascending cholangitis
Diagnosid: MRCP
Treatment: ERCP / cholecystectomy
150
What is the best investigation for ?gallstones
abdominal US
151
Management of pancreatitis
IV fluids and analgesia
| DO NOT give antibiotics routinely
152
Cullen's sign - how do you get this
Pancreatitis
| Bruising around umbilicus arises from blood travelling down the falciform ligament
153
What is the best imaging investigation for pancreatitis?
CT scan
- but not used routinely
- only if diagnosis not clear (ie amylase <300)
- if patient not improving after couple of days
154
Pancreatic pseudocyst - how does it form and what is the best investigation
Patient with pancreatitis -> fluid around the pancreas.
| Pseudo cyst arises with fluid within lesser sac
155
What is regarded the most important treatment of pancreatitis?
IV fluids
156
Describe Gallstone ileus
Calcified gallstone erodes through the gallbladder wall and finds way to small bowel
157
Which part of the small bowel does gallstone ileus usually occur?
Near ileocaecal valve
158
Increased WCC and CRP in biliary colic / acute cholecystitis?
Acute cholecystitis
159
Name 2 medications which can cause pancreatitis?
Methotrexate
| Azathioprine
160
US shows thickened wall of GB. What is the likely diagnosis?
Acute cholecystitis
161
What is a cholecystostomy and when may it be used?
Makes connection with the skin. Used to drain pus and infected bile from GB in elderly patient not fit for surgery
162
Elderly patient, LIF pain, blood in stool, loose stool. Name top 3 differentials
Diverticular disease (diverticulitis)
Colorectal cancer
Ischaemic colitis
163
Which tumour marker is raised in colon cancer?
CEA
164
Which tumour marker is raised in ovarian cancer?
CA-125
165
Drain a diverticular abscess if greater than what size?
>5cm
166
AXR findings of faecal impaction or constipation?
Dilated bowel loops above the area of impaction / constipation
167
Which classification system is used for diverticular disease?
Hinchey classification
168
3 complications of diverticular disease
Diverticulitis
Fistula
Stricture
169
Which imaging investigation is best for ?diverticulitis
CT scan
170
Which invasive investigation is best for ?diverticulitis
Flexible sigmoidoscopy
171
Sigmoid volvulus
| - AXR appearance and location
Appearance: coffee bean shape
Location: RUQ (sigmoid colon twists around and goes to RUQ)
172
Caecal volvulus
| - AXR appearance and location
Appearance: coffee bean shape
Location: LUQ (caecum twists around and goes to LUW)
173
Name 2 causes of toxic megacolon
C diff
| Ulcerative colitis
174
Treatment of toxic megacolon
decompression
| If no improvement in 24 hours, surgery required
175
Toxic megacolon risks
Rupture (perforation)
| Sepsis
176
barium/gastrograffin MEAL examines which parts of the GI tract
Oesophagus
Stomach
Duodenum (stops here)
177
Gastrograffin follow through is used to look for what
Small bowel obstruction
178
Toxic megacolon there is usually severe dilatation of the RIGHT / LEFT side of colon?
Left
179
Which patients should you NOT do barium studies with?
Patients with peritonitis
| - can cause chemical peritonitis
180
Patient has ?perforation. Which is best to use
- barium studies
- gastrograffin studies
Gastrograffin studies
181
Mainstay of treatment for acute pancreatitis
Fluid resuscitation
| IV analgesia
182
Every patient with ?pancreatitis gets what imaging investigation and why is this?
US
| - to check for gallstones
183
Why does jaundice occur?
Due to hyperbilirubinaemia (when serum bilirubin is over 50 umol/L)
184
Intrahepatic jaundice will be conjugated / unconjugated?
Both
185
Pseudocyst form how long after pancreatitis
4-6 weeks
186
Name 3 severity scoring systems for acute pancreatitis
APACHE
Glasgow
Ranson
187
When is apache score for pancreatitis used?
If presentation is within 24 hours symptom onset
188
What is P-POSUM
Surgical scoring system to assess risk
| Compare morbidity and mortality in a wide range of general surgical procedures
189
Where is the most common location for ischaemic colitis?
Junction between midgut and hindgut (around 2/3rd point of the transverse colon)
190
Parietal / visceral peritoneum has nerve endings?
Parietal peritoneum has nerve endings
191
Define peritonism
Localised area of peritonitis
192
When examining the acute abdomen, how do you check for peritonism?
Cough tenderness - get pt to cough, this shifts parietal peritoneum. If pt winces when coughs, peritonism likely present
```
Percussion tenderness
Rebound tenderness (unpleasant for patient)
```
193
Colostomy is RHS / LHS abdo and spouted / flush with skin
Colostomy
- LHS abdo
- flush with skin
194
Ileostomy is RHS / LHS abdo and spouted / flush with skin?
Ileostomy
- RHS abdo
- spouted
195
Why is an ileostomy spouted?
Ileum contains lots of enzymes which could cause surrounding skin irritation if left flushed with skin
196
Who gets mesenteric adenitis ?
Kids
197
If patient in theatre gets cholangiogram which shows stones in the CBD, what is done?
IV glucagon opens the sphincter of odi and saline flushed through CBD. Hopefully any stones will pass through to duodenum
198
3 main complications of ERCP
```
Pancreatitis
Duodenal perforation (since duodenum fixed)
Duodenal haemorrhage (due to gastroduodenal artery)
```
199
Name 2 main indications for AXR in general surgery?
?obstruction
| ? toxic megacolon
200
Riglers sign on AXR
A sign of perforation (free gas on inside and outside of bowel wall)
201
How do you know if NG tube insertion is correct?
X-ray to confirm correct placement
- must pass carina in the midline and continue down the midline
- must end up beneath the diaphragm
202
Where is the correct positioning of an endotracheal tube
insert via mouth and go to about 2-3cm above carina
| - do not want it to extend into the R or L main bronchus
203
If endotracheal tube accidentally ends up in the R main bronchus, what is the risk?
Contralateral (L bronchus) lung collapse as only the R lung is getting inflated.
204
Patient with ?rupture AAA. What is the best imaging investigation
- MRI
- AXR
- US
- CT without contrast
- CT with contrast
- CT angiogram
CT with contrast
205
If patient has suspected appendicitis, should you give them antibiotics?
no, only give antibiotics once you're sure the patient has appendicitis
206
Young woman with RIF pain. What do you need to exclude
Ectopic pregnancy
| Ovarian torsion
207
What is the best investigation for ?ovarian torsion ?
TVUSS
208
Where is a common location for crohn's disease?
Ileo-caecal junction
209
Urinalysis: blood and protein. What do you suspect?
Renal stones
210
If you suspect a patient has renal stones after urinalysis, what imaging investigation is good?
CT KUB
211
Explain the pathophysiology of venous disease
there is reflux, obstruction or a combination of both
The venous system is unable to retain blood flow in the right direction causing a pooling of blood and subsequently increased venous pressure
212
Dilated
Torturous
Elongated
These three words make you think of what
Varicose veins
213
investigation of choice for venous disease
Duplex US
214
Conservative management of venous disease
Compression stockings
| - create what would be a normal venous system (high pressure in the foot)
215
In what situation are compression stockings contraindicated
If the person has arterial disease
| - ABPI must be above 0.8
216
Explain surgical management of venous disease
Essentially you thrombose the superficial vein so that there is no longer any reflux. Now, the only way the leg drains is through the deep venous system.
Over time the body will clear up the thrombosed superficial vein
Options:
- foam sclerotherapy
- endothermal ablation
217
Red flags to ask in Hx if suspecting colorectal cancer?
Weight loss
Night sweats
Feeling of fullness
PR bleed
218
If a patient has a Hx of bleeding, what should you always screen for in the history?
? malignancy
| ? anaemia
219
Suspect haemorrhoids is diagnosis, how do you go about PR exam
```
Initial inspection
- may see external haemorrhoids
Palpation
- for masses (but will not feel haemorrhoids on palpation)
Proctoscopy
- to look for internal haemorrhoids
```
220
You can usually feel haemorrhoids on palpation during PR exam. True or false ?
False
| - usually can't feel them
221
A patient with Hx of recurrent perianal abscess and pain. What would you suspect?
Fistula
| - look / feel for an internal opening
222
Anal pain + fresh red blood on toilet paper. Think?
Anal fissure
223
Topical management of anal fissure
Diltiazem cream
224
Painless fresh red bleeding on background of constipation makes you think
Haemorrhoids
225
85 year old female with right sided lower abdominal pain. Name top 3 differentials
Diverticulitis
- usually presents with L sided abdo pain (as sigmoid colon affected) but some patients have large sigmoid colon so could flop over
UTI
Ovarian mass
226
Young male with RIF pain.
Diagnosis?
Investigations?
Management?
Appendicitis
No investigations required
Tx surgery (laparoscopic appendicetomy)
227
70 year old male, Left sided colicky loin-groin pain, can't sit still. What is at front of your mind to exclude?
Ruptured AAA
228
Best imaging for diverticular disease / diverticulitis ?
CT scan
229
DIAGNOSTIC imaging tool for appendicitis
CT scan
| - usually only use if over 40 y/o
230
Bowel cancer often/rarely present with pain
Rarely
231
Apart from rectal cancer, what can CEA tumour marker also be raised in?
Smokers
232
CEA tumour marker is a good screening tool for rectal cancer. True or false?
False
| - can be raised in people without cancer (eg smokers)
233
Patient with lower abdo pain. If ?gynae pathology what is best imaging investigation to get?
US + TVUSS
234
Patient with lower abdominal pain and you request a CT. Should you request with or without contrast?
With contrast
235
Mainstay of treatment for diverticulitis?
Antibiotics
236
Mainstay of treatment for toxic megacolon?
Surgery
237
What is mittelshmerz pain?
Ovulation pain. Occurs mid cycle, lower abdominal pain.
238
23 year old female with lower abdominal pain (severe). No other symtpoms, no PV discharge, last period 2 weeks ago. Normal bloods and no inflammatory markers raised. What is the likely diagnosis? and how would you manage?
Mittelshmerz pain
| - self limiting
239
Elderly patient, 2 month Hx food stuck in throat, discomfort in upper part of throat, feels an odd sensation there. Gets a cough at night when he lies down. No weight loss.
What is the most likely diagnosis and what is the pathophysiology of this condition?
Pharyngeal pouch
- weakening in the UPPER part of the oesophageal wall causes an outpouching of mucosa. This puts pressure on the oesophageal lumen and causes it to collapse
240
Suspected pharyngeal pouch. What is the best imaging investigation?
Barium swallow
241
Management of pharyngeal pouch
Surgical resection
242
Barrett's oesophagus predisposes to
Adenocarcinoma
243
35 year old alcoholic comes to A+E with vomit with red streaks in it. Tachy, hypotensive. What is likely diagnosis and how do you manage?
Mallory Weiss Tear
- keep overnight in hosptial for observation
- PPI infusion and fluid replacement
- no other management required
244
Patient presents with burning retrosternal pain and sometimes regurgitation of acidic fluid. Do you need to investigate?
What is managment?
No investigation - emperical treatment initially
4-6 weeks PPI
If patient improves, great
If no improvement or worsening in symptoms, order OGD
245
Best investigation for ?Barrett's oesophagus?
OGD
246
Patient with initial dysphagia to solids but now also dysphagia to liquids. Feels discomfort in lower oesophagus. What is likely diagnosis and how would you investigate to confirm diagnosis?
Likely diagnosis: Achalasia
| Investigation: Barium swallow -> oesophageal manometry is diagnostic
247
Initial treatment of achalasia?
Conservative
- diltiazem (CCB)
to try and relax the sphincter and let it open up
248
Definitive treatment for achalasia? (2 options)
Endoscopic balloon dilatation
Heller's myotomy
249
Patient with pain along the entire length of oesophagus, barium swallow shows corkscrew appearance. What is likely diagnosis?
Diffuse oesophageal spasm
250
Chronic acid reflux can cause 2 main things
Barrett's oesophagus
Hiatus hernia
251
What is the condition associated with rupture of the oeesophagus?
Boerhaave syndrome
252
Oesophageal rupture which results from a sudden increased intraoesophageal pressure (which occurs through vomiting). What is this called?
Boerhaave syndrome
253
a patient with a history of overindulgence in food or drinks who, after severe or repeated vomiting, experiences excruciating chest pain and develops subcutaneous emphysema. What is the likely diagnosis?
Boerhaave syndrome
254
Pancreatic pseudocyst management (patient has no signs of infection)
Conservative
255
2 commonest places of colorectal cancer metastasis?
Liver
| Lungs
256
Why is blood mixed in with stool more common in left sided colorectal cancer than right sided colorectal cancer presentation?
Left sided: stool is mostly formed, blood shows up more
Right sided: contents are more liquid. blood is still there but it gets mixed better and more difficult to distinguish in the stool. However if you do FOB test (qFIT test) then blood will show up
257
Gold standard investigation for ?colorectal cancer
Colonoscopy
258
If ?rectal cancer, what is the best imaging ?
MRI scan of rectum
259
What is the name of the staging used for colorectal cancer?
Duke's staging
260
Name 4 causes of upper GI bleeding
Peptic ulcer disease
Varices
Malignancy
Mallory weis tear
261
Malena is a sign of upper/lower GI bleeding?
Upper GI bleeding
262
If a patient presents with fresh PR bleeding, it could not be due to upper GI bleeding. true or false?
False
- if patient is having a massive bleed, it won't have time to oxidise and become 'malena' (black and tarry). So you can still get fresh bleeding even if upper GI bleed
263
Most imoportant investigation in upper GI bleed
OGD endoscopy
264
What is the treatment of a bleeding peptic ulcer?
```
Resuscitate
Endoscopic therapy
- heater probe
- clips
- inject adrenaline (1:10000)
High dose PPI infusion
```
265
What is the treatment of oesophageal varices?
Vasoconstrictors (somatostatin, terlipressin, ocreotide)
Endoscopy with band ligation
Balloon tamponade
266
Which medication makes ulcerative colitis worse?
NSAIDS
267
Higher risk of colorectal cancer if you have UC / Crohn's ?
UC
268
Name 2 associated conditions related to UC ?
Toxic megacolon
| PSC
269
This structure is contained within the FEMALE inguinal canal ?
Round ligament
270
A patient with Large bowel obstruction. IF X is present they must go to theatre immediately?
Closed loop bowel obstruction
271
Patient with UC has abdominal pain + distention. WHat are you concerned about?
Toxic megacolon
272
Leadpipe colon on X-ray (distension and loss of haustra)
Toxic megacolon
273
Why should you not give metochlopromide in bowel obstruction?
It is a prokinetic
274
Increased creatinine, Decreased eGFR think
AKI
275
direct inguinal hernia is medial/lateral to inferior epigastric vessels?
Medial
276
Patient has an extremely painful groin hernia. In extreme pain when you try to reduce it. What do you do?
Give morphine, analgesia to help with the pain and then you try and push it again to see whether it is reducible or not.
If reducible --> send home
If irreducible --> ?obstruction ?incarceration
277
Patient bleeding and you send off bloods.
Creatinine normal
Urea elevated (20)
What should you be thinking and what investigation will you order?
Thinking ?upper GI bleed
Order OGD endoscopy
278
Coffee ground vomit indicates upper or lower GI bleed?
Upper GI bleed
279
M2 anti-mitochondrial antibodies on biopsy are diagnostic of which condition?
Primary Biliary Cholangitis
280
sudden onset abdominal pain, ascites, and tender hepatomegaly makes you think
Budd Chiari syndrome
281
Sever eflare up of UC should be treated with
IV steroids in hospital
282
corkscrew appearance on barium swallow
Diffuse oesophageal spasm
283
12 hours Hx abdominal pain and bloody diarrhoea. Pain out of proportion of clinical findings (soft, non tender abdo) makes you think of what diagnosis?
Acute mesenteric ischaemia
284
First line investigation for acute mesenteric ischaemia
Serum lactate
| - raised: lack of blood supply causes anaerobic metabolism
285
Extradural haematoma usually due to which artery?
Middle meningialartery
286
Strongest risk factor for anal cancer
HPV
287
In suspected acute cholecystitis, why should a patient be fasted?
So that on US investigation, it is easier to assess whether that is the problem.
If patient is fasted it will be easier to see the GB more clearly, it will not be contracted as all the bile will have accumulated in the GB
288
Patient with acute cholecystitis. Symptoms started 1 day ago. What is the management
IV antibiotics + cholecystectomy acute (since pain present less than 72 hours)
289
Patient with acute cholecystitis. Symptoms started 4 days ago but they present to hospital now. What is the maangement
IV antibiotics + DELAYED cholecystectomy (since pain present over 72 hours, the gallbladder will be at a later stage of inflammation so more risk of complications during the surgery)
290
Patient with acute cholecystitis. Symptoms started 4 days ago so no urgent cholecystectomy required. However, the patient becomes increasingly unwell and acutely deteriorates. What could be the problem?
Necrosis and gangrene of the GB -> rupture
291
What is the best investigation to assess a ?perforated gallbladder?
CT scan
292
Differential diagnosis of haematemesis after forceful vomiting (2)
```
Mallory weiss tear
Oesophageal rupture (boor Haave syndrome)
```
293
Signs of chronic liver disease combined with massive haematemesis suggest
Oesophageal varices
294
Gallstone impacts in the cystic duct and the gallbladder epithelium continues to secrete mucus resulting in distention. What is this called?
Mucocele
295
Diaphragmatic splinting
Diaphragm can't move down as much due to pain receptors -> patient takes short shallow breaths -> collapsed lung
296
PaO2 and PaCO2 in type 1 vs type 2 resp failure
Type 1 resp failure: decreased PaO2 normal PaCO2
| Type 2 resp failure: decreased PaO2 INCREASED PaCO2
297
Management of mild UC
Topical 5-ASA
- local anti-inflamatory
- eg pentasa
298
Management of mild UC flare up
Oral Steroids
299
Management of moderate UC
Oral 5-ASA, high dose, capsule
300
Management of severe UC
Start on steroids 40mg week 1
| gradually reduce 5mg / week
301
If patient has severe UC and has been started on steroids (gradually decreasing dose) but this is ineffective, which are the 2 next medications to try:
Azathioprine
Methotrexate
302
Last line medical management for UC before surgery
Ciclosporin
303
More likely to get peri anal disease in
- crohns
- UC
Crohn's
304
Tumour in the lower rectum, near the anal margin. Which surgery should be done?
- anterior resection
- abdominoperineal resection
- hartmans procedure
- pan total colectomy
Abdominoperineal resection
| - this involves removing the anus, rectum and part of the descending colon, resulting in an end colostomy (permanent)
305
Tumour in the upper/middle part of rectum. Which surgery should be done?
- anterior resection
- abdominoperineal resection
- hartmans procedure
- pan total colectomy
Anterior resection
306
What is the most common hepatic malignancy?
Hepatocellular carcinoma HCC
307
```
Inflammatory markers: normal
LFTs: AST, ALT, bilirubin all raised
Albumin and PT: decreased
AFP +ve
What is likely to be going on
```
Hepatocellular carcinoma
308
What is the tumour marker for HCC
AFP
309
Patient with liver lesions seen on CT and +ve CEA. Describe this
Metastatic colorectal cancer
| - commonly metastasises to liver
310
What is the BEST imaging investigation for ?HCC
CT with contrast
311
What are the 2 best management options for HCC
Surgery (liver resection)
| Liver transplant
312
What is the most common benign liver tumour?
Haemangioma
313
Management of haemangioma
Do nothing
314
It is common practice to biopsy liver cancer
False
| - can make diagnosis from imaging ofter
315
How to diagnose H. Pylori
FAT stool antigen test
| Urease breath test
316
Duodenal ulcer
- aggravated by eating
- relieved by eating
Why?
Relieved by eating
When you have food, acid in the stomach is utilised for the digestion of food and so less acid makes its way into the duodenum.
317
Investigation of choice for ? gastric carcinoma ?
OGD + biopsy
318
What is the triad for ascending cholangitis?
Fever
RUQ pain
Jaundice
319
In ascending cholangitis, do you give antibiotics and if so, when?
Yes
| ASAP
320
Investigation of choice for ascending cholangitis
MRCP to visualise site of obstruction
321
What is the significance of the dentate line?
Change from mucosa to anal skin, the line at which sensation is mostly lost
322
Lymphatic drainage of the breast (2)
Axillary lymph nodes 97%
| Internal mammary lymph nodes 2%
323
```
In triple assessment for breast pathology, under 40 year olds get
- US
- mammogram
and what else if required
- FNA
- vaccum biopsy
- core needle biopsy
```
Under 40
- US
- core needle biopsy
324
```
In triple assessment for breast pathology, over 40 year olds get
- US
- mammogram
and what else if required
- FNA
- vaccum biopsy
- core needle biopsy
```
Over 40
- mammogram
- core needle biopsy
325
What is fibroadenosis
Breast cyst
326
Name the 3 most common chemotherapies used for adjuvant / neo-adjuvant breast cancer treatment?
1. Anthracyclines (doxorubicin)
2. Taxanes (pacletaxil)
3. 5-fluorouracil
327
Non tender hepatomegaly + itch + jaundice makes you think
PSC
328
Chronic pancreatitis
| - cause
Alcohol
| Due to persistent and repeated damage of the pancreas
329
There is a role for prophylactic antibiotics in uncomplicated pancreatitis. True or false?
False
330
When would you use antibiotics in pancreatitis?
If necrosis present
331
if ?necrotic pancreatitis, which imaging investigation should be carrried out?
CT with contrast
| - contrast goes to areas with living blood supply
332
Alcoholic pancreatitis. What should you give to prevent alcohol withdrawal?
Benzodiazepines
333
A patient with gallstone pancreatitis must get a cholecystectomy. True or false?
True
334
When is cholecystectomy carried out for patient with gallstone pancreatitis?
Either on admission of within 2 weeks of admission
335
A pseudocyst can be necrotic. True or false?
False
| - long term collections of fluid around a pancreas which does not have any necrosis, has a capsule round about it
336
Is amylase sensitive and/or specific?
No
| - neither
337
Metochlopromide should not be given to which 2 groups of people
Bowel obstruction - as it is a prokinetic
young women - tardive dyskinesia
338
If you do a CT scan and it shows gas in the pancreas, what does this suggest?
Infection present
339
Sudden onset unilateral leg pain with absence of pulses makes you think
Acute limb ischaemia (due to embolus)
340
Initial investigation of choice for ?coeliac disease
Anti-TTG
341
When checking Anti-TTG, what should you also check?
IgA levels
| - anti-TTG wont raise in patients with IgA deficiency
342
Inherited condition which results in a defect in conjugation of bilirubin
Gilbert's syndrome
343
```
RUQ pain
Palpable GB
Swinging fever
US shows distended GB with stone impacted in neck.
What is the likely diagnosis?
- mucocele
- acute cholecystitis
- ascending cholangitis
- empyema
- mirizzi syndrome
```
GB empyema
344
Most common cause of infective colitis
C. diff
345
Surgery has a better outcome in UC or crohn's?
UC
346
What is the normal length of small bowel?
~3m
347
At what length of small bowel do you risk getting short bowel syndrome?
less than 1m
348
People with short bowel syndrome are reliant on what?
TPN
349
Define fistula
An abnormal connection between 2 epithelial surfaces
350
Some patients with Crohn's disease get really bad anal fistula. How is this usually managed?
Surgery with seton sutures
351
What is the difference between incarcerated and obstructed hernia?
Incarcerated hernia doesn't cause bowel obstruction.
352
IVDU with painful groin lump. What are the differentials
```
Groin abscess
Pseudoaneurysm
Lymphoedema
Psoas abscess
Inguinal hernia
```
353
What is the best investigation for ?pseudoaneurysm?
CT angiogram
354
In an IVDU with groin lump, why is it so important to rule out pseudoaneurysm?
If you put a needle into pseudoaneurysm (ie if you think you are draining an abscess) then blood will go EVERYWHERE
355
Best imaging investigation for femoral hernia?
CT scan
356
most common cause of acute limb ischaemia?
Embolism (ie from AF)
357
Clinical features of acute limb ischaemia
```
Pain
Pallor
Perishingly cold
Pulseless
Paraesthesia
Paralysis
Contralateral limb will be normal
No preceeding problems
```
358
List investigations you would order for a patient with acute limb ischaemia
```
Bloods
ECG - ?MI ?arrhythmia
CXR - ?malignancy
Duplex US
CT angiogram
```
359
Acute limb ischaemia with salvageable limb. What is the management ?
Anticoagulate
Embolectomy (fish out clot from leg)
Fascieciotomy
360
Why should you do fasciectomy at time of embolectomy?
Due to risk of compartment syndrome
361
Acute limb ischaemia and limb is NOT salvageable. What are your options?
Amputation
| Paliation
362
Compartment syndrome clinical features
Pain out of proportion
Pain on passive stretch
Pulses are PRESENT
363
What is the definition of critical limb ischaemia
end stage peripheral vascular disease
| patient has pain at rest for over 2 weeks
364
Patient hangs leg out of bed at night is a tell tale sign for what?
Critical limb ischaemia
365
intermittent claudication is
- peripheral vascular disease
- peripheral arterial disease
Peripheral arterial disease
366
What is the most important initial out patient management of claudication?
- lifestyle modification and exercise
- lifestyle modification, exercise, statin, antiplatelets
- antiplatelet therapt
Lifestyle modification
Exercise
Statin
Antiplatelets
367
The AAA programme uses what imaging to assess aortic diameter?
Abdominal US
368
Circle of willis is supplied by which of the following arteries
- bilateral internal carotids + posterior cerebral arteries
- bilateral internal carotids + bilateral vertebral arteries
- bilateral external carotids + bilateral vertebral arteries
- bilateral external carotids + posterior cerebral arteries
Bilateral internal carotids + bilateral vertebral arteries
369
What is the initial out patient management of a non infected venous ulcer
ABPI +/- graduated compression stocking
370
Primary varicose veins care caused by
- arterial insufficiency
- DVT
- hypertension
- incompetent venous valves
Incompetent venous valves
371
Name 3 surgical treatment options for varicose veins
Foam sclerotherapy
Endothermal ablation
Open surgery
372
Buerger's test assesses for
Arterial insufficiency
373
ANY patient who has had wide local excision for breast cancer should have radiotherapy. True or false?
True
374
Who is tamoxifen used in
Pre- and peri- menopausal women who are ER+ve
375
Post-menopausal woman with breast cancer that is ER+ve. What is the hormonal treatment?
Anastrazole
376
What is spontaneous bacterial peritonitis associated with?
Liver disease
| - infection of ascitic fluid
377
Which type of obstruction requires emergency surgery?
Closed loop obstruction
378
When is the most common time you will see an ileus
Following abdominal surgery
379
What is first line medical treatment for anal fissures? And how does it work?
Anusol
| - chemical which shrinks the haemorrhoids
380
Management of uncomplicated acute diverticulitis in primary care
Oral co-amoxiclav 5 days
Analgesia
Clear liquids
381
In those diagnosed with anal fisula, which investigation is best to characterise the course of the fistula?
MRI scan
