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Year 3 - Surgery > General surgery (Upper GI and Colorectal) > Flashcards

General surgery (Upper GI and Colorectal) Flashcards

1
Q

List some common differentials for acute generalised abdominal pain

A
  • Peritonitis
  • Ruptured AAA
  • Ischaemic colitis
  • Intestinal obstruction
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2
Q

List some common differentials for acute epigastric abdominal pain

A
  • Pancreatitis
  • Peptic ulcer disease
  • Acute gastritis
  • Ruptured AAA
  • Peritonitis
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3
Q

List some common differentials for acute right upper quadrant abdominal pain

A
  • Biliary colic
  • Acute cholecystitis
  • Acute cholangitis
  • Hepatitis
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4
Q

List some common differentials for periumbilical abdominal pain

A
  • Intestinal obstruction
  • Ischaemic colitis
  • Ruptured AAA
  • Early appendicitis
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5
Q

List some common differentials for right iliac fossa abdominal pain

A
  • Appendicitis
  • Ruptured ovarian cyst
  • Ovarian torsion
  • Ectopic pregnancy
  • Meckel’s diverticulitis
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6
Q

List some common differentials for left iliac fossa abdominal pain

A
  • Ruptured ovarian cyst
  • Ovarian torsion
  • Ectopic pregnancy
  • Diverticulitis
  • Inflammatory bowel disease
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7
Q

List some common differentials for suprapubic abdominal pain

A
  • Lower UTI
  • Acute urinary retention
  • Pelvic inflammatory disease
  • Prostatitis
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8
Q

List some common differentials for loin to groin abdominal pain

A
  • Renal stones
  • Pyelonephritis
  • Ruptured AAA
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9
Q

List some common differentials for testicular pain

A
  • Testicular torsion
  • Epididymo-orchitis
  • Scrotal hernia
  • Torsion of hydatid of Morgagni
  • Testicular cancer (only 5% of cases)
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10
Q

List 5 signs of peritonitis

A
  • Guarding
  • Rebound tenderness
  • Rigidity
  • Positive coughing test
  • Percussion tenderness
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11
Q

Appendicitis - state the following:
- Pathophysiology and incidence age
- Special tests to do
- Signs and symptoms
- Diagnosis
- Management

A

Pathophysiology and peak incidence age:
- Inflammation of the appendix
- Caused by an obstruction (faecolith, lymph node or foreign object), leading to trapping of bacteria then inflammation
- Inflammation reduces blood flow, with necrosis and rupture
- Peak incidence is between 10-20 years, less common in young children and adults >50 years

Special tests to do:
- McBurney’s sign (tenderness 2/3 from umbilicus to ASIS)
- Rovsing’s sign (press on left, reproduces pain on right)

Signs and symptoms:
- Central abdominal pain, that migrates to RIF within 24 hrs
- Nausea / vomiting
- Loss of appetite
- Fever
- Rebound tenderness (?ruptured)
- Guarding (?ruptured)
- Percussion tenderness (?ruptured)

Diagnosis:
- Mainly medical (Alvarado score) with clinical presentation and raised inflammatory markers
- Generally CT or ultrasound if clinical uncertainty
- Ultrasound best in children / pregnancy / exclude gynae pathology
- May need investigative laparoscopy

Management:
- Appendectomy (laparoscopic first line, laparotomy if there is perforation)
- Prophylactic antibiotics +/- full septic 6 if appropriate

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12
Q

List some common differentials for appendicitis

A
  • Ectopic pregnancy
  • Ovarian cyst including torsion and rupture
  • Meckel’s diverticulum
  • Mesenteric adenitis
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13
Q

Describe how an appendix mass forms in appendicitis and how it’s managed

A
  • Formed when the overlying omentum sticks to the inflamed appendix, forming a mass in the RIF
  • Managed conservatively with supportive treatment and antibiotics
  • Appendectomy when the acute condition has resolved
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14
Q

List some complications of an appendectomy

A

Appendectomy specific:
- Removal of perfectly normal appendix
- Damage to nearby bowel or other structures

General surgery risks:
- Bleeding
- Pain
- Infection e.g. abscess
- General anaesthetic risks
- VTE

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15
Q

Bowel obstruction - state the following:
- Pathophysiology
- Causes
- Presentation
- Investigation
- Initial management

A

Pathophysiology:
- Blockage leading to obstruction
- Obstruction causes a back pressure, leading to vomiting with a reduced capacity to absorb fluids (downstream, in LI)
- SI obstruction is more common than LI obstruction

Causes:
THE BIG 3
1. Adhesions
2. Hernias
3. Tumours
Also, volvulus, diverticular disease, strictures, intussusception

Presentation:
- Vomiting (particularly bilious)
- Diffuse abdominal pain
- Absolute constipation
- Abdominal distention
- Tinkling bowel sounds

Investigation:
- Abdominal x-ray
- Contrast CT scan

Management:
- Initial ABCDE assessment
- Conservative management if stable
- Definitive management is surgery to correct the underlying cause (adhesions, hernia or tumour most likely)

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16
Q

Explain the condition of a closed bowel obstruction, some key causes and it’s significance

A

A closed bowel obstruction is when there are 2 points of obstruction, with bowel trapped in the middle

Key causes:
- Adhesions
- Hernias
- Volvulus
- Obstruction of large bowel WITH competent ileocecal valve

Significant as it means that the bowel content can’t drain and decompress, leading to inevitable expansion leading to ischaemia and perforation

All cases will require emergency surgery

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17
Q

Ileus - state the following:
- Pathophysiology
- Causes
- Presentation
- Management (for post-op ileus and non-surgical ileus)

A

Pathophysiology:
- Ileus is a condition of the small bowel where peristalsis temporarily stops, not associated with a mechanical obstruction
Diagnosis of exclusion (once bowel obstruction has been ruled out)

Causes:
- Abdominal surgery (2-3 days post-surgery)
- Injury
- Inflammation or infection e.g. sepsis
- Electrolyte imbalance

Presentation:
- Vomiting (particularly bilious)
- Diffuse abdominal pain
- Absolute constipation
- Abdominal distention
- ABSENT bowel sounds

Management (for post-op ileus and non-surgical ileus):
Post-op ileus
- Reduce opioid analgesia (replace with non-opioid analgesia)
- Nil by mouth and IV fluids (consider NG tube if repeated vomiting)
- Monitor electrolyte imbalance
Non-surgical ileus
- Reduce any underlying cause e.g. electrolyte imbalance
- Nil by mouth and IV fluids (consider NG tube if repeated vomiting)
- Monitor electrolyte imbalance

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18
Q

Volvulus - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Investigation
- Management

A

Pathophysiology:
- Bowel twists around itself OR the mesentery that it is attached to
- This can reduce the blood supply to the bowel section causing ischaemia, leading to necrosis and bowel perforation

Risk factors:
- High fibre diet
- Chronic constipation
- Neuropsychiatric disorders
- Nursing home residents
- Pregnancy
- Adhesions

Presentation:
- Vomiting (particularly bilious)
- Diffuse abdominal pain
- Abdominal distension
- Absolute constipation

Investigation:
- Contrast CT scan
- Abdominal x-ray (sigmoid volvulus = coffee bean sign)

Management:
Initial / conservative
- Nil by mouth
- Drip and suck (NG tube and IV fluids)
- Endoscopic decompression (for sigmoid volvulus without peritonitis)
Surgical
- Laparotomy
- Hartmann’s procedure (sigmoid volvulus)
- Ileocaecal resection or right hemicolectomy (caecal volvulus)

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19
Q

Outline the 2 main types of volvulus and who they mainly affect - which one is more common?

A

Sigmoid volvulus
- More common
- Involves the sigmoid colon
- Mainly affects older patients

Caecal volvulus:
- Less common
- Involves the caecum
- Mainly affects younger patients

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20
Q

Outline risk factors for developing a volvulus

A

A sigmoid volvulus specifically:
- Chronic constipation
- High fibre diet
- Longer attached mesentery
- Excessive use of laxatives

General risk of developing a volvulus
- Neuropsychiatric disorders
- Nursing home residents
- Pregnancy
- Adhesions
(plus high fibre diet and chronic constipation)

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21
Q

Outline the presenting features of a hernia

A
  • Soft protruding lump
  • May enlarge on coughing/standing
  • May be reducible
  • Aching/dragging sensation
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22
Q

Outline three main complications of a hernia and describe each one

A
  1. Incarceration
    - Becomes non-reducible
    - Can lead to obstruction or strangulation
  2. Obstruction
    - Blockage in the passage of bowel contents
  3. Strangulation
    - Both non-reducible and cut off blood supply
    - Leads to ischaemia and necrosis
    - Surgical emergency
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23
Q

Describe a Richter’s hernia and Maydl’s hernia

A

Richter’s hernia:
- Where only part of the bowel wall and lumen protrude
- Higher risk of strangulating
- Progresses rapidly

Maydl’s hernia:
- Where 2 loops of bowel are contained within the same hernia

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24
Q

Outline general management options for hernias and what is important to consider when deciding

A

Conservative:
- Can do nothing
- If neck is wide or if not good candidate for surgery

Surgical:
- Tension free repair (mesh, prevents herniation)
- Tension repair (suture muscle/tissue back together)

Important to consider the width of the base of the hernia - the wider the base the lower the risk of complications

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25
Q

Explain how to clinically differentiate between a direct and indirect inguinal hernia

A
  • Reduce the inguinal hernia
  • Press on the deep inguinal ring (mid-way between ASIS and public tubercle)

Direct: would fall back down
Indirect: would stay reduced

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26
Q

Outline the 4 types of hiatus hernia

A
  1. Sliding - stomach slides up through hernia
  2. Rolling - separate portion of stomach goes through hernia e.g. fundus
  3. Mixed/combination
  4. Large opening with multiple organs herniating
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27
Q

List some presenting symptoms for hiatus hernia

A
  • Acid reflux
  • Reflux of food
  • Heartburn
  • Bad breath
  • Burping
  • Bloating
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28
Q

Outline some investigations for hiatus hernia

A
  • Chest x-ray
  • Contrast upper GI series (barium oesophagram)
  • OGD to check for oesophagitis (if severe symptoms)
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29
Q

Outline the management for hiatus hernia

A

Conservative:
- Weight loss
- Avoid large meals
- No alcohol
- Avoid acidic foods
- Eat 3-4 hours before bedtime
- Elevate the head of the bed

Medical:
- PPI for 4-8 weeks (assess response)

Surgical:
- Fundoplication (if medication-resistant)

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30
Q

Haemorrhoids - state the following:
- Pathophysiology
- Common distribution (clock face)
- Classification
- Presentation
- Investigation
- Management

A

Pathophysiology:
- Enlargement/swelling of the anal cushions
- Not clear as to why they enlarge, but often associated with constipation and straining

Common distribution (clock face):
- 3, 7, 11 o’clock

Classification:
1st degree - no prolapse
2nd degree - prolapse on straining but goes back
3rd degree - prolapse on straining but only goes back on manual effort
4th degree - permanently prolapsed

Presentation:
- May be asymptomatic
- Painless
- Fresh red PR bleed on toilet paper or surface of stool, not mixed in
- Sore or itchy
- Feeling a protruding mass in or around anus

Investigation:
- Examination will be unremarkable unless thrombosed
- Visualisation with anoscope / proctoscope

Management:
Conservative
- Lifestyle advice on prevention e.g. high fibre diet, regular exercise, increase fluid intake
- Topical treatments e.g. Anusol (reduce swelling)
- Prescribe laxatives if necessary
Non-surgical
- Rubber band ligation (if symptomatic 1st or 2nd degree)
Surgical
- Hemorrhoidal artery ligation (if 2nd or 3rd degree)
- Haemorrhoidectomy (if 3rd or 4th degree)

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31
Q

Outline how a thrombosed haemorrhoid presents (different to an uncomplicated haemorrhoid)

A
  • Very painful perianal mass (normally relatively painless)
  • Purple/blue (normally pink/red)
  • Oedematous (normally not too swollen)
  • Tender
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32
Q

Diverticulosis - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Investigation
- Management

A

Pathophysiology:
- Diverticulum is a pouch in the bowel wall
- Increased pressure in bowel lumen can cause gaps in circular muscle and mucosa prolapses (doesn’t occur in rectum as there is outer longitudinal muscle)
- Particularly prevalent in the sigmoid colon
- No inflammation or infection

Risk factors:
- Low fibre diet
- Obesity
- NSAIDs

Presentation:
- May be an incidental finding (colonoscopy or CT scan)
- Lower left abdominal pain
- Consipation
- Rectal bleeding

Investigations:
- Bloods: FBC, CRP, and U&Es
- CT abdo-pelvis with contrast
- Flexible sigmoidoscopy (if no acute inflammation and patient suitable)
- CT colonography

Management:
- Increase fibre in the diet
- Bulk forming laxatives (avoid Senna)
- Surgery if significant symptoms

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33
Q

Acute diverticulitis - state the following:
- Outline
- Presentation
- Investigations
- Management

A

Outline:
- Inflammation of an existing diverticula

Presentation:
- Pain
- Fever
- Nausea and vomiting
- Rectal bleeding
- Diarrhoea
- Palpable abdominal mass (if abscess)
- Raised inflammatory markers

Investigations:
- Bloods: FBC, CRP, and U&Es
- Group and Save
- Venous blood gas
- CT abdo-pelvis with contrast

Management:
- Analgesia
- Oral Co-Amoxiclav
- Clear liquids
- Follow up in 2 days

34
Q

List some complications of diverticulitis

A
  • Perforation and peritonitis
  • Abscess
  • Haemorrhage
  • Fistula
  • Ileus / obstruction
35
Q

Acute mesenteric ischaemia - state the following:
- Pathophysiology
- Presentation
- Investigation
- Management

A

Pathophysiology:
- Lack of blood flow through the mesenteric vessels (coeliac trunk, SMA, IMA)
- Mainly caused by a thrombus (key risk factor = AF)

Presentation:
- Acute, non-specific abdominal pain disproportionate to clinical findings

Investigation:
- Contrast CT
- Bloods for metabolic acidosis and raised lactate

Management:
- Surgery to remove / bypass the thrombus
- Surgery to resect any necrotic bowel

36
Q

Chronic mesenteric ischaemia - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Investigation
- Management

A

Pathophysiology:
- Lack of blood flow through the mesenteric vessels (coeliac trunk, SMA, IMA)
- Narrowing of the ischaemic vessels by atherosclerosis

Risk factors:
- Generic cardiovascular risk factors

Presentation:
Classic triad
- Collicy abdominal pain, present after eating
- Weight loss
- Abdominal bruit on auscultation

Investigation:
- CT angiography

Management:
- Reduce modifiable risk factors
- Secondary prevention e.g. statins, antiplatelets
- Revascularisation

37
Q

Bowel cancer - state the following:
- Risk factors
- Presentation
- Screening test
- Investigation
- Management

A

Risk factors:
- Smoking
- Alcohol
- Age
- Family history
- Familial adenomatous polyposis (FAP)
- Hereditary non-polyposis colorectal cancer (HNPCC)
- IBD
- Diet
- Obesity / sedentary lifestyle

Presentation:
- Change in bowel habit
- Weight loss
- Rectal bleeding
- Abdominal pain
- Iron deficiency anaemia
- Abdominal/rectal mass
- Obstruction (if tumour is large enough)

Screening test:
- Faecal immunochemical test
- Looks for the presence of human haemoglobin

Investigation:
- Colonoscopy (gold standard)
- Sigmoidoscopy
- CT colonography
- Staging CT scan
- CEA tumour marker for bowel cancer

Management:
- Surgical resection
- Chemotherapy
- Radiotherapy
- Palliative care

38
Q

Explain the root cause of Familial adenomatous polyposis (FAP) and Hereditary non-polyposis colorectal cancer (HNPCC)

A

Familial adenomatous polyposis (FAP)
- Mutation of tumour suppressor gene
- Results in multiple polyps (adenomas) with the potential for them to become cancerous

Hereditary non-polyposis colorectal cancer (HNPCC)
- Mutation of DNA mismatch repair gene

39
Q

Explain the 6 types of bowel resection operations

A
  1. Right hemicolectomy
    - Caecum
    - Ascending colon
    - First part of transverse colon
  2. Left hemicolectomy
    - Second part of transverse colon
    - Descending colon
  3. High anterior resection (sigmoid colectomy)
    - Sigmoid colon
  4. Low anterior resection
    - Sigmoid colon
    - Upper rectum
  5. Abdomino-perineal resection (APR)
    - Rectum
    - Anus (sewn up)
    +/- sigmoid colon
  6. Hartmann’s procedure
    Emergency procedure
    - Remove sigmoid colon and rectum (close rectal stump)
    - Create colostomy
    - May be permanent or reserved later
40
Q

List some complications of bowel cancer surgery

A
  • Post-surgery ileus
  • Bowel perforation
  • Damage to surrounding organs, vessels or nerves
  • Bleeding
  • Infection
  • Incisional hernia
  • VTE (DVT or PE)
  • Failure to remove tumour entirely
  • Failure of anastomosis
  • Anaesthetic risks
41
Q

Describe some features of each stoma:
- Colostomy
- Ileostomy
- Urostomy

A

Colostomy:
- Typically in left iliac fossa
- Typically no sprout (flatter)
- Produces more solid content

Ileostomy:
- Typically in right iliac fossa
- Typically has a sprout
- Produces more liquid content

Urostomy:
- Typically in right iliac fossa
- Typically has a sprout

42
Q

List some early and late complications of stomas

A

Early complications:
Mechanical: ischaemia/necrosis, retraction, abscess
Functional: poor stoma function, high output

Late complications:
Mechanical: hernia, stenosis and prolapse, adhesion leading to bowel obstruction, dermatitis
Functional: bowel dysmotility and malabsorption
Psychosocial: issues with body image and sexual activity

43
Q

Gallstones - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Investigation
- Management

A

Pathophysiology:
- Concentrated bile in the bile duct (mostly made of cholesterol) forming stones

Risk factors:
4 F’s
- Fat
- Forty
- Female
- Fair

Presentation:
- May be asymptomatic
- Severe colicky RUQ pain
- Often triggered by meals (fatty)
- Lasts 30 mins - 8 hrs
- May be associated with nausea and vomiting
- May also present with complications of gallstones

Investigations:
- Ultrasound (first line)
- MR-CP (MRI cholangio-pancreatography)
- ERCP
- Blood tests
- CT

Management:
- Cholecystectomy (laparoscopic > open)
- Conservative treatment if asymptomatic

44
Q

List liver function test findings in gallstones

A
  • Raised bilirubin (due to obstruction)
  • Raised ALP (non-specific)
  • Slightly raised AST or ALT but with a much higher ALP
45
Q

List 3 key complications of ERCP

A
  • Cholangitis
  • Pancreatitis
  • Excessive bleeding
46
Q

List some things that can be done during an ERCP procedure

A
  • Removal of gallstones
  • Stent for obstruction or tumour
  • Inject contrast and visualise/diagnose pathology
  • Sphincterotomy
  • Take biopsies
47
Q

List some complications of a cholecystectomy including outlining post-cholecystectomy syndrome

A
  • Conversion to open (from laparoscopic)
  • Bleeding
  • Infection
  • Anaesthetic risks
  • Damage to local structures
  • Damage to bile ducts
  • Stones remaining in bile duct
  • VTE
  • Post-cholecystectomy syndrome

Post-cholecystectomy syndrome
- Group of non-specific symptoms, due to changes to bile flow post-operation but often improves with time
- Diarrhoea
- Indigestion
- Epigastric/RUQ pain
- Nausea
- Intolerance of fatty foods
- Flatulence

48
Q

Acute cholecystitis - state the following:
- Pathophysiology
- Causes
- Presentation
- Investigation
- Management

A

Pathophysiology:
- Inflammation of the gallbladder
- Caused by blockage of the cystic duct, which prevents the gallbladder from emptying

Causes:
- Main cause: gallstones
- Sometimes other causes, such as reduced use of gallbladder (e.g. if PTN)

Presentation:
- RUQ pain (may radiate to right shoulder)
- Positive Murphy’s sign
- Fever
- Nausea / vomiting
- Tachycardia
- Raised inflammatory markers / WBCs

Investigations:
- Bloods (inflammatory markers / WBCs)
- Abdominal ultrasound
- MRCP (if suspected but no evidence found on USS)

Management:
- Conservative management
- ERCP to remove any gallstones
- Cholecystectomy

49
Q

List some complications of acute cholecystitis

A
  • Sepsis
  • Gallbladder empyema
  • Gangrene / necrosis
  • Perforation
50
Q

Outline ways to manage gallbladder empyema (a complication of acute cholecystitis)

A
  • IV antibiotics
    Plus either:
    1. Cholecystectomy (removal)
    2. Cholecystostomy (drain)
51
Q

Acute cholangitis - state the following:
- Pathophysiology
- Causes
- Presentation
- Investigation
- Management

A

Pathophysiology:
- Infection and inflammation of the bile ducts

Causes:
1. Complication of gallstones
2. Infection during ERCP procedure

Presentation:
Charcot’s triad
1. RUQ pain
2. Fever
3. Jaundice

Investigations:
- Endoscopic ultrasound
- MRCP
- CT
- Abdominal ultrasound

Management:
- Conservative management
- ERCP
- May use PTC (percutaneous transhepatic cholangiogram) in place of ERCP

52
Q

Explain the difference in presentation between biliary colic, acute cholecystitis and acute cholangitis

A

All to do with Charcot’s triad:

Biliary colic (1)
1. RUQ pain

Acute cholecystitis (2)
1. RUQ pain
2. Fever

Acute cholangitis (3 - only one with all 3)
1. RUQ pain
2. Fever
3. Jaundice

53
Q

Cholangiocarcinoma - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Investigations
- Management

A

Pathophysiology:
- Cancer of the bile ducts
- Mostly adenocarcinomas
- Intrahepatic or extrahepatic
- Most commonly affected: perihilar region (Klatskin tumour)

Risk factors:
- Primary sclerosing cholangitis (patients with UC are more at risk of this)
- Family history
- Chronic hepatitis / liver cirrhosis
- Obesity
- Diabetes

Presentation:
- Obstructive jaundice (pale stool, dark urine and generalised itching)
- Unexplained weight loss
- RUQ pain
- Palpable gallbladder
- Hepatomegaly

Investigations:
Diagnosis on imagine PLUS biopsy
- MRCP
- Staging CT
- ERCP (biopsy)
- CA 19-9 (tumour marker)

Management:
- Curative if caught early
- Otherwise palliative care (including stents to relieve any obstruction)

54
Q

Pancreatic cancer - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management

A

Pathophysiology:
- Mostly occurs in the head of the pancreas, leading to compression of the biliary tree
- Mostly adenocarcinomas

Presentation:
- Painless, obstructive jaundice (worrying sign!)
- Pale stool and dark urine
- Generalised itching
- Non-specific abdominal pain
- Weight loss
- Palpable mass
- Nausea and vomiting

Investigations:
- CT scan of thorax, abdomen and pelvis (staging for pancreatic protocol scan)
- Ultrasound abdomen
- May add MRCP or PET scan
- ERCP or endoscopic ultrasound (biopsy)
- CA 19-9 (tumour marker)

Management:
- Partial (distal) removal
- Total removal
- Pylorus-preserving removal of pancreas and duodenum (modified Whipple)
- Radical removal of pancreas and duodenum (Whipple)
In most cases, curative surgery is not possible

55
Q

Explain a Whipple procedure (surgery for pancreatic cancer)

A
  • Remove head of the pancreas
    Also removes:
  • Pylorus of stomach (not done in a modified Whipple)
  • Gallbladder
  • Bile duct
  • Duodenum
  • Associated lymph nodes
56
Q

Outline some palliative interventions for pancreatic cancer (to help with symptom control)

A
  • ERCP stents inserted to relieve biliary obstruction (surgery to relieve obstruction if stent fails)
  • Palliative chemotherapy (to improve symptoms and extend life)
  • Palliative radiotherapy (to improve symptoms and extend life)
  • End of life care with symptom control
57
Q

Acute pancreatitis - state the following:
- Pathophysiology
- Causes
- Presentation
- Investigations
- Severity of pancreatitis criteria
- Management

A

Pathophysiology:
- Inflammation of the pancreas, either acute or chronic
- Acute has a rapid onset of symptoms
- After, normal function usually resolves

Causes:
- Gallstones (prevents release of pancreatic juices)
- Alcohol (directly toxic)
- ERCP

Presentation:
- Severe epigastric pain (radiate to back)
- Vomiting
- Loss of appetite
- Systemically unwell

Severity of pancreatitis criteria:
- Glasgow-Imrie Criteria
- Score out of 8, ranks the severity of pancreatitis
- Either mild, moderate or severe

Investigations:
(Mainly a clinical diagnosis plus raised amylase)
- Bloods (FBC, LFT, UandEs, CRP, ABG, calcium)
- Ultrasound if suspect gallstones
- CT abdomen to see complications

Management:
- Admission to ITU
- Supportive treatment e.g. fluids, NBM, analgesia
- Remove gallstones if possible
- Antibiotics if infection
- Treatment of complications
- Most will improve in 3-7 days

58
Q

List some complications of pancreatitis

A
  • Infection / abscess / necrosis of pancreas
  • Chronic pancreatitis
  • Sepsis
  • Pseudocysts / peripancreatic fluid collections
59
Q

List the causes of pancreatitis (pneumonic)

A

I GET SMASHED

Idiopathic

Gallstones
Ethanol (alcohol)
Trauma

Scorpion sting
Mumps
Autoimmune
Steroids
Hyperlipidaemia
ERCP
Drugs (Furosemide, Thiazide diuretics, Azathioprine)

60
Q

Outline the Glasgow-Imrie Criteria for severity of acute pancreatitis

A

Glasgow-Imrie Criteria establishes the severity of acute pancreatitis

Score given out of 8 gives a marker of the the severity:
- Mild (0-1)
- Moderate (2)
- Severe (3+)

Score given by PANCREAS (8):
PaO2
Age
Neutrophils
Calcium
uRea
Enzymes (LDH and ALT/AST)
Albumin
Sugar (glucose)

61
Q

Outline the Glasgow-Imrie Criteria for severity of acute pancreatitis

A

Glasgow-Imrie Criteria establishes the severity of acute pancreatitis

Score given out of 8 gives a marker of the the severity:
- Mild (0-1)
- Moderate (2)
- Severe (3+)

Score given by PANCREAS (8):
PaO2
Age
Neutrophils
Calcium
uRea
Enzymes (LDH and ALT/AST)
Albumin
Sugar (glucose)

62
Q

Chronic pancreatitis - state the following:
- Pathophysiology
- Most common cause
- Presentation (how it’s different to acute pancreatitis)
- Management

A

Pathophysiology:
- Chronic pancreatitis is chronic inflammation
- Leads to fibrosis and reduced function of the pancreas (exocrine and endocrine)

Most common cause:
- Chronic alcohol

Presentation (how it’s different to acute pancreatitis)
- Similar symptoms to acute pancreatitis, but less intense and longer lasting
- Severe epigastric pain (radiate to back)
- Vomiting
- Systemically unwell

Management:
- Abstinence from alcohol / smoking
- Analgesia
- Replace exocrine enzymes (Creon)
- Replace endocrine hormones (subcutaneous insulin)
- ERCP (stent) to treat any strictures
- Surgery to treat complications

63
Q

List some complications of chronic pancreatitis

A
  • Loss of endocrine function (diabetes)
  • Loss of exocrine function (altered digestion)
  • Chronic epigastric pain
  • Pseudocysts / abscesses
  • Damage / strictures
64
Q

List the 3 types of liver transplant

A

Orthogenic transplant = full liver from deceased donor

Living donor transplant = partial liver from living donor

Split transplant = full liver from deceased donor given to 2 people (split in half)

65
Q

List some reasons to give a liver transplant

A

Acute liver failure (priority)
- Paracetamol overdose
- Acute viral hepatitis

Chronic liver failure (further down list)

Hepatocellular carcinoma

66
Q

List some reasons why someone might not be suitable for a liver transplant

A
  • Multiple/significant comorbidities
  • Excessive weight loss or malnutrition
  • Active hepatitis (B or C) or other active infection
  • Active alcohol use
  • End-stage HIV
67
Q

List some aspects of post-liver transplant care (treatments plus things to monitor)

A

Treatments:
- Lifelong immunosuppression
- Avoid smoking and alcohol
- Treat opportunistic infections

Monitor:
- Disease recurrence
- Cancer
- Evidence of rejection

68
Q

Define a hernia

A

A hernia is a protrusion of an organ/tissue, through the wall of the cavity that normally contains it

69
Q

Define a fistula

A

A fistula is an abnormal connection between two epithelial lined surfaces

70
Q

List 3 common causes of small bowel obstruction

A
  • Adhesions
  • Hernias
  • Tumours
71
Q

List 3 common causes of large bowel obstruction

A
  • Tumours
  • Diverticular disease
  • Volvulus
72
Q

List common complications of total parental nutrition (TPN)
- Line issues
- Metabolic issues

A

Line issues:
- Infection
- Central venous thrombosis
- Air embolus
- Blockage of line
- Damage to line

Metabolic issues:
- Refedding sydrome
- Dehydration and electrolyte imbalances e.g. hyperphosphataemia, hyponatraemia/hypernatraemia
- Hyperglycaemia
- Overnutrition
- Fatty degeneration of the liver and deranged LFTs
- Trace element and folate deficiency

73
Q

List the retroperitoneal structures

A

SAD PUCKER

Supra-renal glands
Aorta / IVC
Duodenum (distal 2/3rds)

Pancreas
Ureters
Colon (ascending and descending)
Kidneys
E(oesophagus)
Rectum

74
Q

List the intra-peritoneal structures

A

Liver
Stomach
Proximal 1/3 duodenum
Spleen

75
Q

Outline the layers of the gut

A

Mucosa
(epithelium)
(lamina propria)
(muscularis mucosa)

Submucosa (contains Meissner’s plexus)
External muscle layers (in between is Auerbach’s plexus)
Serosa

76
Q

Meckel’s diverticulum - state the following:
- Pathophysiology
- Presentation
- Investigation
- Management

A

Pathophysiology:
- Failure of the vitelline duct to regress
- Has all 3 layers (mucosa, submucosa and muscularis propria)
- Often contains abnormal tissue e.g. gastric mucosa

Presentation:
- Rectal bleeding (painless)
- Tenderness near umbilicus
- Small bowel obstruction
- Inflammation could lead to crampy abdominal pain

Investigation:
- Often found incidentally
- Meckel scan
- Angiography

Management:
- Surgical resection if challenging symptoms

77
Q

Outline some indications for surgery in inflammatory bowel disease

A
  • Acute complications e.g. toxic megacolon, bowel perforation or severe flare that is unresolving with medications
  • Failure to respond to more conservative methods
  • Patient preference / unable to manage condition
  • Failure to thrive in children
78
Q

Outline some indications for surgery in diverticular disease (aka. complications of diverticular disease)

A
  • Bowel perforation
  • Bowel obstruction
  • Acute inflammation (diverticulitis)
  • Acute rectal bleeding
  • Abscess formation
  • Fistula
79
Q

Where is McBurney’s point anatomically in appendicitis?

A

2/3 way from the umbilicus to the right ASIS (anterior superior iliac spine)

80
Q

Ascending cholangitis - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management

A

Pathophysiology:
- Bacterial infection of the biliary tree

Presentation:
Charcot’s triad:
- RUQ pain
- Fever
- Jaundice
If septic: hypotension, tachycardia and confusion

Investigations:
- Basic bloods for raised LFTs and WCC / CRP
- May do initial USS abdomen
- MRCP = gold standard

Management:
- IV fluid resuscitation
- Antibiotics
- ERCP for endoscopic drainage or stent
- Percutaneous drainage – PTC (Percutaneous transhepatic cholangiography)
- Surgical drainage

81
Q

Outline 3 common causes of ascending cholangitis

A
  • Gallstones
  • Benign biliary stricture e.g. congenital, post-infectious, or inflammatory
  • Malignancy
82
Q

Outline the general management steps for anal fissures

A

Conservative:
- Reduce underlying constipation
- Advise on keeping area clean and dry
- Can try sitting in a shallow, warm bath several times a day to help with pain

Medical:
- Simple oral analgesia e.g. Paracetamol
- Stool softeners
- Topical rectal GTN cream (alternative topical Diltiazem), twice per day for 6–8 weeks

If unresolving, referral to colorectal surgeons

Year 3 - Surgery (10 decks)

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