Principles of Surgery

Question 1

Causes of RUQ Abdominal Pain (5)

Answer 1

• Biliary Colic
• Cholecystitis
• Cholangitis
• Hepatitis
• Right Lower Lobe Pneumonia

Question 2

Causes of Epigastric Pain (5)

• Radiations
• Relieving Factors

Answer 2

Pancreatitis (Acute/Chronic)

Peptic Ulcer Disease/Gastritis

GORD

Cardiac – Inferior MI / Pericarditis

Ruptured AAA

Question 3

Causes of LUQ Pain (4)

Answer 3

Splenic abscess/infarct

Gastric Ulcer

Gastritis

Left Lower Lobe Pneumonia

Question 4

Causes of Right/Left Flank Pain (3)

Answer 4

Renal Colic

Pyelonephritis

MSK: lumbar disc / sciatica / bony metastases

Question 5

Causes of Umbilical Pain (3)

Answer 5

Appendicitis

Small Bowel Obstruction

UTI

Question 6

Causes of RIF Pain (7)

Answer 6

Appendicitis

Ovarian Cyst Rupture/Torsion

PID

Inguinal Hernia

IBD

Renal Colic

Psoas Abscess

Question 7

Causes of Suprapubic Pain (6)

Answer 7

• PID - infection of the upper reproductive organs, including the uterus, fallopian tubes, and ovaries
• UTI/Cystitis
• Urinary retention
• Prostatitis
• IBD
• Osteitis pubis inflammation in the joint between your left and right pubic bones (pubic symphysis)

Question 8

Causes of LIF Pain (7)

Answer 8

Diverticulitis

Ovarian Cyst Rupture/Torsion

PID

Inguinal Hernia

IBD

Renal Colic

Psoas Abscess

Question 9

Things to always consider in presentations of adults with Acute Abdomen?

Answer 9

• Always consider a ruptured abdominal aortic aneurysm in any adult presenting with abdominal pain
• In a female of childbearing age presenting with abdominal pain, always consider a ruptured ectopic pregnancy.

Question 10

Biliary causes of RUQ pain (3)

• Signs
• Etiologies

Answer 10

Question 11

Triad of symptoms associated with Ascending Cholangitis

Answer 11

Charcot’s Triad:

• Fever/Rigors
• Jaundice
• RUQ Abdominal Pain

Question 12

Hepatic causes of RUQ pain (3)

• Signs
• Etiologies

Answer 12

Question 13

Triad of symptoms associated with Budd-Chiari Syndrome

Answer 13

Caused by occlusion of the hepatic veins:

• Abdominal Pain
• Ascites
• Hepatomegaly

Question 14

Causes of Lower Abdominal Pain (7)

• Pain Localization
• Clinical Features

Answer 14

Question 15

Investigations/Indications for Acute Abdomen

Answer 15

Question 16

Bedside Investigations for Acute Abdomen?

Answer 16

Question 17

Urine investigations for Acute Abdomen?

Answer 17

Question 18

Blood investigations for Acute Abdomen?

Answer 18

Question 19

Imaging/Invasive Investigations for Acute Abdomen?

Answer 19

Question 20

Answer 20

Question 21

Answer 21

Question 22

5 R’s of IV Fluids

Answer 22

o Resuscitation

o Routine Maintenance

o Replacement

o Redistribution

o Reassessment

Question 23

Fluid Resuscitation Protocol

Answer 23

o Initial fluid bolus – 500ml Crystalloid solution (e.g. Hartmann’s) within 15 minutes

o Reassess – ABCDE

o Repeat process up to 2000ml of fluid

Question 24

Fluid Maintenance Therapy

• Water
• Na/K/Cl
• Glucose

Answer 24

Maintenance Therapy to replace ongoing losses of water and electrolytes under normal physiological conditions – sweat, urine, respiration, stool.

Question 25

Fluid Replacement Therapy

Answer 25

Replacement therapy – corrects existing water and electrolyte deficits

Question 26

Causes of Abnormal FLuid/Electrolyte Losses

Answer 26

Vomiting/NG Tube Loss Biliary Drainage Loss Diarrhoea/Excess Colostomy Loss High/Low Volume Ileal Stoma Loss Ongoing Blood Loss (Malaena) Urinary Loss e.g. Polyuria, Post AKI Pancreatic/Jejunal Fistula/Stoma Loss Sweating/Fever/Dehydration

Question 27

How to decide on fluid replacement type?

Answer 27

Question 28

Complications of Drains/When they are withdrawn

Answer 28

**Complications** o Infection o Haemorrhage o Hernia formation o Kinking o Damage to surrounding structures if migration occurs **Drains are left in place until drainage has decreased to <25-30mL per day for two consecutive days**

Question 29

Indications for T-Tubes

Answer 29

■ Placed in common bile duct following CBD exploration with choledochotomy or post repair of CBD damage ■ Facilitates external drainage of bile to allow healing ■ Drains ~600ml a day and then reduces ■ Before removing should be clamped for 24 hours and patient monitored for signs of obstructive jaundice ■ Generally has been superseded by ERCP

Question 30

What are complications of poor nutrition generally/surgically?

Answer 30

Poor nutrition results in: o Impaired albumin production o Skeletal muscle weakness o Impaired wound healing o Reduced neutrophil, macrophage and lymphocyte function Malnutrition in surgical patients is associated with: o Poor wound healing o Increased risk of infection o Increased frequency of decubitus ulcers o Overgrowth of bacteria in the GI tract o Abnormal nutrient loss through stool

Question 31

When is Malnutrition Diagnosed?

Answer 31

Malnutrition is diagnosed if a patient has **two or more of the following**: o Insufficient energy intake o Loss of muscle mass o Weight loss - <18.5 Kg/m2 – Underweight - 18.5 – 24.9 Kg/m2 – Normal - >25 Kg/m2 – Overweight o Loss of subcutaneous fat o Localised or generalised fluid accumulation o Diminished functional status (handgrip strength)

Question 32

Enteral vs. Parenteral Nutrition

Answer 32

**Enteral Nutrition** ■ Oral ■ Feeding tube – nasogastric/nasojejunal ■ Gastrostomy/Jejunostomy - _Gastrostomy_: for patients who have a functioning gastrointestinal tract but are unable to swallow - _Jejunostomy_: used when stomach needs to be bypassed e.g. due to ulcers, or after major oesophagogastric surgery **Parenteral Nutrition** ■ Oral/NG/NJ routes not possible e.g. bowel resection, fistula ■ Can be given peripherally or centrally ■ Peripheral parental nutrition should be given via a large diameter venous catheter ■ Parental nutrition should be given via a central venous catheter if indicated for more than a few days, as high osmotic load is not tolerated by peripheral veins and extravasation can lead to tissue damage - PICC Line (Peripherally inserted central venous catheter) - Hickman line (dedicated tunneled catheter)

Question 33

Complications of Total Parentaeral Nutrition? Monitoring?

Answer 33