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

General surgery (Upper GI and Colorectal) Flashcards

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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
Explain how to clinically differentiate between a direct and indirect inguinal hernia
- 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
26
Outline the 4 types of hiatus hernia
1. Sliding (80% cases) - stomach slides up through hernia 2. Rolling or paraoesophageal (15% cases) - separate portion of stomach goes through hernia e.g. fundus 3. Mixed/combination 4. Large opening with multiple organs herniating
27
List some presenting symptoms for hiatus hernia
- Acid reflux - Reflux of food - Heartburn - Bad breath - Burping - Bloating
28
Outline some investigations for hiatus hernia
- Chest x-ray (visualise hiatus hernia) - Barium contrast upper GI series (barium oesophagram) - OGD to check for oesophagitis (if severe symptoms) - Manometry of oesophagus (prior to surgery)
29
Outline the management for hiatus hernia
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)
30
Haemorrhoids - state the following: - Pathophysiology - Common distribution (clock face) - Classification - Presentation - Investigation - Management
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)
31
Outline how a thrombosed haemorrhoid presents (different to an uncomplicated haemorrhoid)
- Very painful perianal mass (normally relatively painless) - Purple/blue (normally pink/red) - Oedematous (normally not too swollen) - Tender
32
Diverticulosis - state the following: - Pathophysiology - Risk factors - Presentation - Investigation - Management
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, group & save if surgery,Venous blood gas - 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
33
Acute diverticulitis - state the following: - Outline - Presentation - Investigations - Management
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
List some complications of diverticulitis
- Perforation and peritonitis - Abscess - Haemorrhage - Fistula - Ileus / obstruction
35
Acute mesenteric ischaemia - state the following: - Pathophysiology - Presentation - Investigation - Management
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
Chronic mesenteric ischaemia - state the following: - Pathophysiology - Risk factors - Presentation - Investigation - Management
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
Bowel cancer - state the following: - Risk factors - Presentation - Screening test - Investigation - Management
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
Explain the root cause of Familial adenomatous polyposis (FAP) and Hereditary non-polyposis colorectal cancer (HNPCC)
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
Explain the 6 types of bowel resection operations
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
List some complications of bowel cancer surgery
- 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
Describe some features of each stoma: - Colostomy - Ileostomy - Urostomy
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
List some early and late complications of stomas
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
Gallstones - state the following: - Pathophysiology - Risk factors - Presentation - Investigation - Management
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
List liver function test findings in gallstones
- Raised bilirubin (due to obstruction) - Raised ALP (non-specific) - Slightly raised AST or ALT but with a much higher ALP
45
List 3 key complications of ERCP
- Cholangitis - Pancreatitis - Excessive bleeding
46
List some things that can be done during an ERCP procedure
- Removal of gallstones - Stent for obstruction or tumour - Inject contrast and visualise/diagnose pathology - Sphincterotomy - Take biopsies
47
List some complications of a cholecystectomy including outlining post-cholecystectomy syndrome
- 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
Acute cholecystitis - state the following: - Pathophysiology - Causes - Presentation - Investigation - Management
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
List some complications of acute cholecystitis
- Sepsis - Gallbladder empyema - Gangrene / necrosis - Perforation
50
Outline ways to manage gallbladder empyema (a complication of acute cholecystitis)
- IV antibiotics Plus either: 1. Cholecystectomy (removal) 2. Cholecystostomy (drain)
51
Acute cholangitis - state the following: - Pathophysiology - Causes - Presentation - Investigation - Management
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
Explain the difference in presentation between biliary colic, acute cholecystitis and acute cholangitis
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
Cholangiocarcinoma - state the following: - Pathophysiology - Risk factors - Presentation - Investigations - Management
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
Pancreatic cancer - state the following: - Pathophysiology - Presentation - Investigations - Management
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
Explain a Whipple procedure (surgery for pancreatic cancer)
- Remove head of the pancreas Also removes: - Pylorus of stomach (not done in a modified Whipple) - Gallbladder - Bile duct - Duodenum - Associated lymph nodes
56
Outline some palliative interventions for pancreatic cancer (to help with symptom control)
- 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
Acute pancreatitis - state the following: - Pathophysiology - Causes - Presentation - Investigations - Severity of pancreatitis criteria - Management
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
List some complications of pancreatitis
- Infection / abscess / necrosis of pancreas - Chronic pancreatitis - Sepsis - Pseudocysts / peripancreatic fluid collections
59
List the causes of pancreatitis (pneumonic)
I GET SMASHED Idiopathic Gallstones Ethanol (alcohol) Trauma Scorpion sting Mumps Autoimmune Steroids Hyperlipidaemia ERCP Drugs (Furosemide, Thiazide diuretics, Azathioprine)
60
Outline the Glasgow-Imrie Criteria for severity of acute pancreatitis
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
Outline the Glasgow-Imrie Criteria for severity of acute pancreatitis
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
Chronic pancreatitis - state the following: - Pathophysiology - Most common cause - Presentation (how it's different to acute pancreatitis) - Management
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
List some complications of chronic pancreatitis
- Loss of endocrine function (diabetes) - Loss of exocrine function (altered digestion) - Chronic epigastric pain - Pseudocysts / abscesses - Damage / strictures
64
List the 3 types of liver transplant
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
List some reasons to give a liver transplant
Acute liver failure (priority) - Paracetamol overdose - Acute viral hepatitis Chronic liver failure (further down list) Hepatocellular carcinoma
66
List some reasons why someone might not be suitable for a liver transplant
- Multiple/significant comorbidities - Excessive weight loss or malnutrition - Active hepatitis (B or C) or other active infection - Active alcohol use - End-stage HIV
67
List some aspects of post-liver transplant care (treatments plus things to monitor)
Treatments: - Lifelong immunosuppression - Avoid smoking and alcohol - Treat opportunistic infections Monitor: - Disease recurrence - Cancer - Evidence of rejection
68
Define a hernia
A hernia is a protrusion of an organ/tissue, through the wall of the cavity that normally contains it
69
Define a fistula
A fistula is an abnormal connection between two epithelial lined surfaces
70
List 3 common causes of small bowel obstruction
- Adhesions - Hernias - Tumours
71
List 3 common causes of large bowel obstruction
- Tumours - Diverticular disease - Volvulus
72
List common complications of total parental nutrition (TPN) - Line issues - Metabolic issues
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
List the retroperitoneal structures
SAD PUCKER Supra-renal glands Aorta / IVC Duodenum (distal 2/3rds) Pancreas Ureters Colon (ascending and descending) Kidneys E(oesophagus) Rectum
74
List the intra-peritoneal structures
Liver Stomach Proximal 1/3 duodenum Spleen
75
Outline the layers of the gut
Mucosa (epithelium) (lamina propria) (muscularis mucosa) Submucosa (contains Meissner's plexus) External muscle layers (in between is Auerbach's plexus) Serosa
76
Meckel's diverticulum - state the following: - Pathophysiology - Presentation - Investigation - Management
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
Outline some indications for surgery in inflammatory bowel disease
- 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
Outline some indications for surgery in diverticular disease (aka. complications of diverticular disease)
- Bowel perforation - Bowel obstruction - Acute inflammation (diverticulitis) - Acute rectal bleeding - Abscess formation - Fistula
79
Where is McBurney’s point anatomically in appendicitis?
2/3 way from the umbilicus to the right ASIS (anterior superior iliac spine)
80
Ascending cholangitis - state the following: - Pathophysiology - Presentation - Investigations - Management
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
Outline 3 common causes of ascending cholangitis
- Gallstones - Benign biliary stricture e.g. congenital, post-infectious, or inflammatory - Malignancy
82
Outline the general management steps for anal fissures
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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