Surgery Flashcards
1
Q
Autosomal dominant diseases
A
- Familial adenomatous polyposis
- Peutz Jeghers syndrome
2
Q
Autosomal recessive diseases
A
Gilbert’s syndrome
3
Q
Liver damage enzymes
A
- ALT 0 - 45 U/L
- ALP 25–100 U/L
- AST <40 U/L
4
Q
Liver function enzymes
A
Bilirubin
- <20 μmol/L (total)
- <3 μmol/L (direct)
Albumin:
- 38–50 g/L
5
Q
Normal lipase & amylase levels
A
Lipase: <100 U/L
Amylase: 30–110 U/L
6
Q
Category 1 Colorectal cancer risk
A
Low risk
1 1st degree relative > 60 years at dx
7
Q
Category 1 Colorectal cancer SCREENING
A
- iFOBT every 2 years after 45 to 74 years
- low-dose (100 mg) aspirin daily should be considered from age 45 to 70 yo
8
Q
Category 2 Colorectal cancer RISK FACTORS
A
MODERATE RISK
9
Q
Category 2 Colorectal cancer SCREENING
A
- Colonoscopy every 5 years starting at 10 years younger than the earliest age of diagnosis in 1st degree relative
OR age 50, whichever is earlier, to age 74.
- CT colonography if clinically indicated (colonoscopy 3 months unsatisfactory)
- Low dose aspirin (100mg)
- Update history
10
Q
Category 3 Colorectal cancer RISK FACTORS
A
HIGH RISK
Two 1st degree relatives + One 2nd degree relative diagnosed < 50 yo
OR
Two 1st degree relatives + > Two 2nd degree relatives diagnosed at ANY age
OR
> Three 1st degree relatives diagnosed at ANY age
11
Q
Category 3 Colorectal cancer SCREENING
A
- iFOBT every 2 years after 35 to 45 years
- Colonoscopy every 5 years starting at 10 years younger than the earliest age of diagnosis of colorectal cancer in a first-degree relative
OR
age 40, whichever is earlier, to age 74. - CT colonography if clinically indicated (colonoscopy 3 months unsatisfactory)
- Low dose aspirin (100mg)
- Update history
- Refer to cancer clinic
12
Q
Elective non-cardiac surgery following PCI
A
Defer surgery for 6 weeks - 3 months
13
Q
Elective surgery with history of drug eluding stents
A
Defer for 12 months
14
Q
emergency surgery with history of drug eluding stents
A
Withhold clopidogrel for 5-7 days
- continue aspirin
15
Q
Clinical features of cholangitis
(Charcot’s triad)
A
fever with chills + upper abdominal pain + jaundice
16
Q
Raynaud’s pentad (Cholangitis)
A
fever with chills + upper abdominal pain + jaundice + sepsis + confusion
17
Q
Cholangitis initial investigation
A
US
18
Q
Cholangitis best investigation
A
ERCP (diagnostic & therapeutic)
19
Q
Cholangitis treatment
A
- Fluids
- NPO
- Analgesics
- Antibiotics IV: Gentamycin + Amoxicillin. (If chronic add metronidazole.)
- ERCP: Urgent decompression in
>70yo, DM, comorbid conditions. - Percutaneous cholecystostomy: If
pt is not fit for Qx and can’t take pt
off medications. It’s a temporary
drainage that relieves symptoms
20
Q
Clinical features of post-cholecystectomy Syndrome
A
- Diarrhoea (MC symptoms)
- abdominal pain
- nausea
- jaundice
- bloating
- dyspepsia
Cause: incomplete surgery or operative complications.
21
Q
post-cholecystectomy initial investigation
A
US
22
Q
post-cholecystectomy best investigation
A
ERCP w/ biliary manometry
23
Q
Clinical features of appendicitis
A
- Murphy’s triad:
1. Abdominal Pain: Periumbilical or epigastric pain migrating to the right lower quadrant of the abdomen.
2. Nausea / Vomiting.
3. Fever. - Retrocecal: Loin tenderness,
psoas sign (Pain on passive extension of the right thigh) - Pelvic: Diarrhoea, tenderness
on DRE, obturator sign (pain on passive internal rotation of the flexed right thigh).
1st Ix: US of the pelvis.
Best Ix: Appendiceal CT. - Rovsing Sign: Pain in RIF when
palpation LIF.
24
Q
Acute Pancreatitis -cause
A
G: Gallstones
E: Ethanol – alcohol
T: Trauma
S: Steroids
M: Mumps – malignancy
A: Autoimmune
S: Scorpion stings – spider bites
H: Hyperlipidaemia – hypercalcaemia
E: ERCP
D: Drugs
Dr.Cintia.C.Fornaso SURGERY.2023
25
Appendicitis initial investigation
1. WBC: Leukocytosis.
2. Pelvic US: Noncompressible tubular structure of 7-9 mm in diameter.
26
Appendicitis best investigation
1. CT in adults
1. USG in pregnant women/children
27
Appendicitis management
1. Atb: Genta+Metro+Amoxi
- Genta CI: Ceftriaxone+Metro or
Amoxi+clavulanate
- Penicilin CI: Genta+Clinda
2. Laparoscopic > Open Qx
28
Appendiceal cancer treatment
- Do nothing If only in mucosa.
- If they are a bit more bigger
then right hemicolectomy
29
Clinical features of Perforated Peptic Ulcer
- Epigastric pain that doesn’t radiate to back
30
Perforated Peptic Ulcer initial investigation
1. X-ray (Free gas under diaphragm)
2. Gastrograffin swallow or meal to identify where the perforation is
31
Perforated Peptic Ulcer best investigation
1. CT Scan
32
Perforated Peptic Ulcer treatment
1. Pain relief
2. NGT
3. Atbs (which ones?)
4. Immediate laparotomy
33
Clinical features of Peritonitis
- Board like rigidity with guarding, no abd distension (reduced bowel sounds)
- Normal first, then tachycardia, then shock
34
Peritonitis treatment
1. Genta+Metro+Amoxi
- Genta CI: Piper Tazo
- HS to penicilin: Genta+Clinda.
2. Switch to oral Amoxi+Clavulanate
for 5d
35
Clinical features of Acute Pancreatitis
- Epigastric pain that goes to the back
- Pt feels better bending forward
- Lack of guarding, rigidity, or rebound
- Reduced bowel sounds
- Fever
- Tachycardia
- Shock
- Follows an alcohol binge
36
Clinical features of severe necrotizing hemorrhagic pancreatitis
Cullen sign (superficial edema and bruising around the umbilicus)
Grey turner sign (bruising of the flanks/loins)
Polyarthritis.
Earliest Complications:
Renal failure bc hemorrhage
and ARF
37
Acute Pancreatitis Causes
1. Gallstones
2. Ethanol
3. Trauma
4. Steroids
5. Mumps
6. Autoimmune
7. Scorpion stings
8. Spider bites
9. Hyperlipidaemia
10. ERCP
11. Drugs
38
Acute pancreatitis, Complications:
- Pseudocyst
- Infected abscess/pseudocyst
- Pancreatic necrosis
- Pancreatic cancer
39
Acute Pancreatitis Initial investigation
1. Lipase (Most sensitive and specific)
and amylase
2. Abdominal X-ray:
- Colon cutoff sign: Dilation of ascending and transverse that abruptly finishes at splenic flexure.
- Sentinel loop: One or two isolated distended loops of the small bowel.
3. Abdominal US: Peripancreatic fluid
4. Abdominal CT: Specific for complications (necrosis, infection, pseudocyst and absesse)
40
Acute Pancreatitis Initial Management
1. Admit to hospital
2. NPO
3. Bed rest
4. NG suction
5. IV fluids
6. Analgesics: Morphine IV
7. ERCP if obstructive LFTs (MCC of
acute bile duct obstruction in tertiary hospitals)
41
Acute Pancreatitis ATBs Indications
Only if infected:
- Pancreatic necrosis
- Pancreatic abscess.
Empirical: Piper-Tazo IV for 7d.
Allergic to penicillin:
Ceftriaxone+Metro
42
Acute Pancreatitis Surgery Indications
1. Abscess
2. Infected pseudocyst
3. Necrosis
4. Gallstone-associated pancreatitis
5. Uncertain in clinical dx
6. Worsening condition despite tx
43
Glasgow Score
P – Pa02 < 8 KPa
A – Age > 55
N – Neutrophils (WBC > 15)
C – Calcium < 2
R – uRea >16
E – Enzymes (LDH > 600 or AST/ALT >200)
A – Albumin < 32
S – Sugar (Glucose >10)
to access the severity of a pancreatitis
44
Clinical features of Pancreatic pseudocyst
- Mass in epigastric area in context of pancreatitis
45
Pancreatic pseudocyst treatment
≤4 cm: Observation.
≥5 cm: Endoscopic cyst gastrostomy.
ERCP:
- size > 6cm
- Present for > 6 weeks
- Wall thickness for > 6 mm
Laparotomy:
- ERCP fails.
- Pseudoaneurysm or complicated pseudocyst.
46
Clinical features of Chronic Pancreatitis
- Alcohol consumption
- Epigastric pain
- Weight loss
- Loss of pancreatic function
- Diarrhoea
- Steatorrhea
**Serum amylase and lipase and often normal**
47
Chronic Pancreatitis initial investigation
1. CT Scan
2. US to detect
obstruction by stone or
stricture
3. MRCP (Most
sensitive)but expensive
The initial investigation for chronic pancreatitis according to RACGP guidelines typically starts with imaging studies. **Abdominal CT scan** is often the first choice due to its ability to detect pancreatic calcifications, ductal dilation, and other structural changes indicative of chronic pancreatitis. Additionally, **abdominal ultrasound** can be used to assess for gallstones or other biliary pathology. These imaging studies are complemented by a thorough history and physical examination to guide diagnosis [oai_citation:1,RACGP - Chronic pancreatitis Negotiating the complexities of diagnosis](https://www.racgp.org.au/afp/2015/october/chronic-pancreatitis-negotiating-the-complexities).
For further details, you can access the RACGP guidelines [here](https://www.racgp.org.au).
48
Chronic Pancreatitis treatment
1. Analgesia: PCM, codeine
2. Pancreatic enzyme supplements
3. Tx DM
The treatment of chronic pancreatitis, according to RACGP guidelines, involves a comprehensive approach tailored to the patient's symptoms and the progression of the disease. The key aspects of management include:
1. **Pain Management**: Pain is a predominant symptom in chronic pancreatitis. Initial treatment typically involves analgesics, and in cases of severe pain, options like celiac nerve blocks or endoscopic procedures may be considered.
2. **Pancreatic Enzyme Replacement Therapy (PERT)**: For patients with exocrine insufficiency, enzyme supplementation is critical to aid digestion and improve nutrient absorption, which can also help manage associated symptoms like steatorrhea.
3. **Nutritional Support**: Dietary modifications, including a high-protein, low-fat diet, are recommended. In cases of severe malnutrition, total parenteral nutrition (TPN) may be necessary.
4. **Alcohol and Smoking Cessation**: It's essential for patients to stop consuming alcohol and smoking, as these are major contributing factors to disease progression and can exacerbate symptoms.
5. **Surgical Interventions**: Surgery may be required for complications or when medical management fails to control symptoms. Procedures like the Whipple procedure or total pancreatectomy may be considered depending on the patient's condition and the severity of the disease.
For more detailed guidelines, you can visit the RACGP website or access resources like the AAFP and Johns Hopkins Medicine websites on chronic pancreatitis.
49
Gallbladder dilatation, what investigation to do?
US
50
Clinical features of Pancreatic Cancer
- Painless obstructive progressive jaundice
- Dark urine.
- Steathorrhoea.
- Trousseau Sx: Recurrent, migratory thrombosis in superficial veins on uncommon sites, such as the chest wall and arms; besides increased thrombus.
- Superficial thrombophlebitis: Caused by IV infusion (NSAIDs) or
spontaneous: LMWH for 4w
- Courvoisier sign: Enlarged gallbladder bc obstruction.
51
Pancreatic Cancer Risk Factors
1. Smoking
2. DM
3. Chronic pancreatitis
4. Obesity
5. Inactivity
6. Non–O blood group
52
Pancreatic Cancer initial investigation
1. US
53
Pancreatic Cancer best investigation
1. CT scan with contrast
2. ERCP if concurrent
cholangitis
54
Pancreatic Cancer treatment
1. Pancreaticoduodenectomy (Whipple)
55
Peri-ampullary Tumors Types
1. Pancreatic ductal adenocarcinoma: - Pancreatic head tumor (most common)
- Uncinate process tumor
2. Cholangiocarcinoma
3. Ampullary tumors (from the ampula of Vater)
4. Periampullary duodenal carcinoma
56
Clinical features of Common Bile Duct (CBD) Obstruction
1. Progressive obstructive jaundice
- pale stools (steatorrhoea)
- dark urine
2. Palpable mass (distended gallbladder) in the right upper quadrant that moves with respiration (can be tender or non-tender)
57
Causes of Common Bile Duct (CBD) Obstruction
1. Stones (most common)
2. Strictures (injury during surgery)
3. Periampullary tumors (arise within 2cm of the ampula of Vater)
58
Clinical features of Pyloric stenosis
ADULTS:
- Non-bilious vomiting occuring intermittently WITHIN 1 HOUR of a meal and contains undigested food particles.
-Bloating.
-Weight loss.
-Decrease appetite.
-Epigastric pain.
CHILDREN:
- Typically forceful non- bilious vomiting occuring immediately after feeding.
59
Clinical features of Small Bowel Obstruction (SBO)
- Noisy abdomen (sharp bowel sounds).
– Severe colicky epigastric and periumbilical pain.
– Absolute constipation.
– Nausea and vomiting.
- High SBO: Mainly pain and dehydration.
- Low SBO: Mainly distension.
60
Small Bowel Obstruction Causes
1. Adhesions.
3. Tumours
2. Hernias (incarcerated).
3. Strictures (eg. caused by Crohn’s disease)
4. intussusception
5. Bezoars
6. Gallstone ileus
7. Superior mesenteric artery syndrome
61
Small Bowel Obstruction (SBO) initial investigation
1. X-ray erect abdomen (Step ladder air-fluid levels, coin sign)
2. Gastrograffin meal (Dx and tx)
62
Small Bowel Obstruction (SBO) best investigation
CT
63
Small Bowel Obstruction (SBO) treatment
1. IV fluids
2. NGT
3. Gastrograffin follow through
4. Laparotomy to remove obstruction
- Ileotomy & extraction: Best for SBO
in long hx of cholecystitis
64
Clinical features of Large Bowel Obstruction (LBO)
1. Distension
2. Mild pain
3. Increased bowel sounds
65
Large Bowel Obstruction Causes
1. Colon Cancer
2. Sigmoid volvulus (elderly).
3. Fecal impaction (+ stools on DRE)
66
Large Bowel Obstruction (LBO) initial investigation
1. X-ray (Irregular haustral folds)
2. Gastrograffin enema
67
Large Bowel Obstruction (LBO) best investigation
1. CT scan (Best)
68
Large Bowel Obstruction (LBO) treatment in steps
1. IV fluids
2. NGT
3. Gastrograffin enema
4. Surgery
69
Clinical features of Paralytic ileus
No pain, no noise, absolute constipation and distension.
Nausea and vomiting.
When solved, accumulated fluid will be reabsorbed and increase diuresis
70
Paralytic ileus Causes
PostQx (resolves after 24–48 h)
Infection (Peritonitis)
Electrolyte imbalance (hypoK [diuretics], hypoCa)
Opioids
Inflammatory bowel diseases (IBD) or diverticulitis
71
stuttering episodes of nausea and vomiting + air in the biliary tree + hyperactive bowel sounds + dilated loops of bowels
gallstone ileus
72
Clinical features of Sigmoid Volvulus
- It's a LBO
- Tympanic abdomen, colicky abd pain, empty rectum.
- Common in elderly w/ use of laxatives of hx of constipation, or bedridden
73
Sigmoid Volvulus initial investigation
1. X-ray:
- Coffee bean or jelly bean sign.
- Dilated U-shaped colon with a cut-off point at the site of obstruction.
- Distention of the small bowel with air-fluid levels and decompressed colon distal to the point of volvulus.
74
Sigmoid Volvulus best investigation
1. CT Scan
75
Sigmoid Volvulus treatment
1. Sigmoidoscopy to relieve pressure
2. Qx
76
Caecal Volvulus initial investigation
X-ray (dead fetus sign)
77
Clinical features of Caecal Volvulus
Abdominal pain
Constipation/obstipation
Nausea/vomiting
Tympanitic and markedly distended abdomen (more impressive than other causes of bowel obstruction)
78
Caecal Volvulus best investigation
CT Scan
79
Caecal Volvulus Treatment
Right Hemicolectomy???
80
Clinical features of Pseudo-obstruction
1. Oglivie's syndrome: Acute colonic pseudo-obstruction (ACPO) without mechanical obstruction. Massive colon dilatation (> 10 cm) usually involves the cecum and right hemicolon, although occasionally colonic dilation extends to the rectum.
Symptoms:
- Abdominal pain and distension.
- Anorexia.
- Nausea and vomiting.
- Bloating and gas.
- Constipation and/or diarrhea.
2. Assoc w/ Anti-parkinsonian
drugs, parkinsonisms (Hx of falls), opioids, CCB.
3. Seen in elderly who are very
sick
81
Pseudo-obstruction treatment
1. Neostigmine
2. Colonoscopic decompression
3. Laparotomy
82
Pseudo-obstruction initial investigation
X-ray ??
83
Pseudo-obstruction BEST investigation
CT Scan ??
84
Indications for splenectomy
- Trauma
- Spontaneous rupture (mononucleosis)
- Hypersplenism (ITP)
- Neoplasia
85
Splenic Injury Complications
Infections:
1. Pneumococcus.
2. Haemophilus influenzae.
3. Neisseria.
4. Malaria.
86
Splenic Injury Initial investigation
FAST Scan is in hemodynamically
unstable pt and not in children
87
Splenic Injury best investigation
CT is the preferred modality
for adults and children with
abdominal blunt trauma
88
Splenectomy Prophylaxis Treatment
Amoxi OR phenoxymethylpenicillin
1. 2 years after splenectomy.
2. Until 5 years old in children w/ SCD or congenital hemoglobinopathy (thalassemias, sideroblastic and dyserythropoietic anemia).
3. After sepsis episode for 6 months
3. Lifelong for Pts that:
- Survived post-splenectomy inf (recurrent sepsis)
- Immunocompromised.
- Had hematological malignancy.
89
Splenectomy + Sore Throat ATB Treatment
<2 years since splenectomy:
1. Amoxi Oral
>2 years:
1. Reassure and observe.
2. Fever = Amoxi
90
bariatric surgery indications
– BMI above 40 with no co-morbidities
– BMI above 35 with co-morbidities such as hypertension
– BMI above 30 with poorly controlled type 2 diabetes
– BMI above 30 with increased cardiovascular risk due to multiple risk factors such as hypertension, hyperlipidaemia, strong family history of cardiovascular disease at a young age
91
bariatric surgery contraindications
– Irreversible end-organ dysfunction.
– Cirrhosis with portal hypertension.
– Medical problems precluding general anesthesia???
– Centrally mediated obesity syndromes such as Prader-Willi or Craniopharyngioma.
92
Clinical features of Dumping syndrome
93
Dumping syndrome Management
94
Clinical features of Gouverneur's Sx
(vesicointestinal fistula)
- Suprapubic pain
- Frequency
- Dysuria
- Tenesmus
- Pneumaturia
- Fecaluria
Gouverneur’s syndrome, also known as a vesicointestinal fistula, typically presents with the following clinical features:
1. **Pneumaturia**: Passage of gas during urination.
2. **Fecaluria**: Presence of fecal material in the urine.
3. **Recurrent urinary tract infections**: Due to the presence of bacteria from the intestines entering the urinary tract.
4. **Dysuria**: Painful or difficult urination.
5. **Suprapubic pain**: Discomfort or pain in the lower abdomen, above the pubic bone.
These symptoms result from an abnormal connection between the bladder and the intestine.
95
Gouverneur's Sx Treatment
(vesicointestinal fistula)
1. Hospitalization
2. Correct fluids
3. Diazepam
96
Clinical features of Pilonidal sinus
- Nest of hairs in hirsute young
men, cyst or abscess
97
Pilonidal sinus Treatment
1. Qx
2. Atbs only if cellulitis is present
-Recurrent: Shave the area and keep it clean
98
Clinical features of Haemorrhoids (Piles)
- Cx: Constipation.
- Internal: Bleeding, prolapse, mucoid
discharge.
- External: Thrombosis.
99
Internal Haemorrhoids Stages
I above the dentate line
II only during straining
III requires manual replacement
IV prolapse, cannot be reduced
100
Internal Haemorrhoids Treatment
Prevention:
Fiber and fluids to avoid
constipation.
Stage I and II: Conservative tx
Stage III and IV: Refer for rubber
band ligation
101
External hemorrhoids treatment
Thrombosed external hemorrhoid OR perianal hematoma.
within 24 hours of the onset = aspiration of fluid consistency hematoma with large bore needle without local anesthesia.
Between 24 hours to day 5 = A simple incision under local anesthetic over the hematoma with deroofing with a scissor.
After day 6 and onwards, the hematoma is best left alone unless it is very tense, painful, or infected.
102
Clinical features of Anal Fissure
- Most fissures are at 6 o'clock.
- Anal pain worse with defecation and small bright red blood from rectum.
- MCC of bleeding per rectum in
2,5 yo child.
- Severe excruciating pain after
30 mins of pooing + bleeding in
toilet paper.
103
Anal Fissure Treatment
Acute
- Adults: Glyceryl trinitrate (topic)
- Kids: Anusol 1st, then laxatives.
Chronic
1. Local inj. Of botulinum toxin
2. Qx
104
Treatment of anal fissure with Crohn's
infliximab
105
Most common cause of perianal fistula in Crohn's
abscess
106
Most common cause of multiple or recurrent anal fistulae
Crohn's
107
Cause of low-lying fistula
Crohn's
108
Clinical features of Proctalgia fugax
Brief self-limited episodes of
sudden short attacks of intense
stabbing pain in the anal sphincter
109
Proctalgia fugax Management
Reassurance
110
Clinical features of Diverticulitis
- Acute left iliac fossa pain.
- Increases with change in posture.
- Tenderness
- Guarding.
- Rigidity in LIF.
- Fever.
111
Diverticulitis Complications
1. Bleeding (MCC of acute bleeding from large bowel)
2. Perforation (high mortality)
3. Fistulas
4. Abscess
5. Peritonitis
6. Intestinal obstruction
112
Clinical features of Diverticulitis Perforation
1. Abdominal distention
2. Diffuse tenderness of the abdomen even to light Guarding
3. Rigidity
4. Rebound tenderness
5. Absent bowel sounds
113
Diverticulitis First Investigation
WBC
114
Diverticulitis Best Investigation
CT Scan with oral contrast (To detect fistula, abscess, or perforation)
115
Diverticulitis Treatment
1. Hospital admission, NPO,
analgesics.
2. Atbs:
- Mild: Amoxy+Clavulanate for 5d
- Severe: Amoxy + Genta + Metro IV
116
Indications of Surgery for Diverticulitis
Perforation
Abcses
Peritonitis
117
Diverticulitis Follow up
Colon cancer screening
118
Clinical features of Anorectal abscess
Pain caused by inf of anal
glands (above dentate line,
lubricate the poo)
119
Anorectal abscess Treatment
1. Urgent surgical drainage
2. Atb:
- Mild: Amoxi/Clav
- Severe: Amoxy+Genta+Metro
120
Clinical features of Perianal Abscess
- Severe, constant, throbbing pain
- Fever and toxicity
- Hot, red, tender swelling adjacent to anal margin
- Non-fluctuant swelling
121
Parianal abscess vs perianal haematoma
122
Perianal Abscess Treatment
1. Incision under local anesthesia
2. Atbs
- metronidazole 400 mg (o) 12 hourly for 5–7 days
PLUS
- cephalexin 500 mg (o) 6 hourly for 5–7 days
123
Clinical features of Perianal Anorectal Fistula
- Hx of Crohn's,
124
Perianal Anorectal Fistula Treatment
1. Draining abscess, lay open fistula.
2. Refer
125
Hiatal Hernia First Investigation
X-ray
126
Hiatal Hernia Best Investigation
Barium X-ray
127
Clinical features of Incarcerated hernia
No pain, no tenderness, no
cough impulse
128
Incarcerated hernia Tratment
Emergency Surgery
129
Clinical features of Indirect Inguinal hernia
- Does not touch midline.
- Goes to testicle (Examiner finger cannot get above swelling bc the hernia is there).
- More chance to strangulate
130
Clinical features of Direct Inguinal hernia
- Touches the midline.
- Less change to strangulate
131
Inguinal hernia Treatment
Birth-6w: Qx in 2d
6w-6m: Qx in 2w
>6m: Qx in 2m
Irreducible: Urgent Qx
132
Clinical features of Femoral hernia
- Does not touch midline.
- Lateral to pubic tubercle.
- Most likely to strangulate.
- VAN looking from up to down
133
Femoral hernia Treatment
Qx ASAP bc likely to strangulate
134
Hernia is LEAST likely to strangulate
Direct inguinal hernia
135
Hernias is MORE likely to strangulate
1. Femoral (most important)
2. Incisional
3. Umbilical
136
Clinical features of Epigastric hernia
Pt lies supine and cough and
protrudes but doesn’t move
umbilicus
137
Epigastric hernia Treatment
Qx if > 6 months old
138
Clinical features of Diastasis Recti
Pt lies supine and coughs and
protrudes and moves the umbilicus.
Happy face.
139
Diastasis Recti Treatment
1. Physio
2. Qx
140
Causes of Post-Operative Fever
24 hours: Atelectasis
3-5d: Pneumonia, sepsis,
wound inf, abscess, DVT
>5d: Specific comp of Qx:
Bowel anastomosis, fistula,
wound inf
141
Post-Operative Fever Treatment
Fever at 7d PostQx
- Superficial: Remove suture, no atbs
- Cellulitis but no fluctuance: Atbs (which??)
- Cellulitis, fluctuance: Abscess.
1. Drain.
2. Atbs (which??)
142
Post-surgical Confusion
Often secondary to hypoxia.
Causes:
- Chest infection
- Over-sedation
- Cardiac problems
- Pulmonary embolism
143
Post-surgical Confusion First Investigation
1. Oxygen saturation.
2. Blood gases.
144
Tx of Atelectasis
1. Chest Physio.
2. Supplemental Oxygen.
3. Postural drainage w/ bronchoscopy while pt is on CPAP.
145
Clinical features of Salivary Stone
Pain increase after eating
146
Salivary Stone First Investigation
X-ray (80% of
submandibular calculi
are radio-opaque)
147
Salivary Stone Treatment
Excision or Sialendoscopy
148
Clinical features of Sialadenitis Suppurative
MC germ: Staph Aureus.
- Painful swelling: Glands
enlarged, hot, tense, with pus.
- Does not affect facial nerve.
149
Clinical features of Submandibular
abscess
- Cx by Mycobacterium avium.
- Painless, cold, abscess that starts
as lymph node enlargement for
4-6w at 1-2yo
150
Submandibular
abscess Treatment
Excision of abscess & lymph node
151
Clinical features of Parotid Gland Tumour
Compression of VII CN = Peripheral Facial Paralysis
152
Parotid Gland Tumour FIRST Investigation
1. CT
2. MRI
153
Parotid Gland Tumour BEST Investigation
FNA w/ biopsy
154
Clinical features of Pleomorphic adenoma
Affects the salivary glands, particularly parotid glands.
Takes 5-10 years to grow.
Does not cause facial nerve palsy
155
pleomorphic adenoma BEST Investigation
Needle biopsy
156
pleomorphic adenoma Treatment
Surgical excision
157
Clinical features of Adenoid cystic
carcinoma
Painless
Peripheral facial nerve palsy
158
Adenoid cystic carcinoma BEST Investigation
Needle biopsy
159
Adenoid cystic carcinoma Treatment
Surgical excision
160
Neck Lumps FIRST Investigation
CT Scan if suspicion
of neoplasm (>2cm,
fixed, hard, non-tender)
US if suspicion of
inflammatory process
(<2cm, mobile, squishy,
tender)
161
Neck Anterior Triangle Lumps
BCC
- Branchial cyst: 20-40yo, can get
infected. Tx: excision
- Carotid body tumour: Pulsatile
mass that moves laterally. Tx: Excision
- Carotid aneurysm
162
Neck Posterior Triangle Lumps
CCP
- Cystic Hygroma. Transluminal
mass. Tx Surgery
- Cervical Rib
- Pancoast Tumour
163
Midline Neck Lumps
TTD
- Thyroid Nodule. Next: TSH
- Thyroglossal duct: Moves
upwards with protrussion of
tongue
- Dermoid cyst: Teratoma
164
Suggested AAA surveillance (w/
US) of Abdominal Aortic
Aneurysm
3.0-3.9 cm: e/ 24m
4.0-4.5 cm: e/ 12m
4.6-5.0 cm: e/ 6m
≥5.1 cm: e/3m
If 1st degree rel has it, 20% risk
of getting it. Arrange yearly US from 50yo.
165
Clinical features of Abdominal Aortic
Aneurysm (Ruptured)
- Sudden abd. pain radiating to back.
- Syncope.
- Shock.
- Pulsatile tender abd mass.
- Gross haematuria
166
Abdominal Aortic Aneurysm FIRST Investigations
Screening: US
Emergency: FAST US
- Next bedside ix for ruptured.
- Not reliable in kids bc low volume.
- If it's positive >800mL fluid loss.
167
Abdominal Aortic Aneurysm BEST Investigations
CT Scan
168
When to refer an Abdominal Aortic
Aneurysm?
- Male w/ AAA >5.5cm
- Female w/ AAA >5.0cm
- Male or female in thoracic aortic
and aortic iliac aneurysms >3.5cm
- Rapid growth >1cm/year
- Symptomatic (abdominal, flank, or back pain) AAA = independently of
the size
169
Abdominal Aortic Aneurysm Treatment
1. No ruptured:
- Referral to vascular Qx
- Open repair or endovascular repair
2. Ruptured:
IV line (Colloids), not crystalloid
(NS) bc will dilute coagulation factors, more bleeding.
170
Mortality rate of a ruptured abdominal aortic aneurysm
About 80%.
171
Clinical features of Aortic Dissection
- Abrupt chest pain, sharpen,
migrating / irradiating to the
back.
- Unequal or absent pulses.
- Difference of BP in arms (more than 20mmHg).
- Diastolic murmur if AR occurred.
172
Aortic Dissection Types
- Type A: Ascending aorta.
- Type B: Descending aorta.
173
Aortic Dissection FIRST Investigation
Transesophageal Echocardiogram
174
Aortic Dissection BEST Investigation
CT angiogram
175
Aortic Dissection Treatment
1. BB (to reduce shear stress)
2. Immediate Qx for type A
(ascending aorta)
176
Cholelithiasis Treatment
Surgery if stones ≥3cm or porcelain
gallbladder
177
Cholelithiasis BEST Investigation
US
178
Clinical features of Cholecystitis
Fever + Jaundice + Murphy's sign (localized tenderness over
gallbladder)
179
Cholecystitis Types
1. Calculous (90%) caused
by E. coli (in unstable pts) and
Kepsiella.
2. Acalculous (10%)
emphysematous gallbladder
180
Cholecystitis BEST Investigation
HIDA Scan (If the US is not
conclusive)
181
Cholecystitis FIRST Investigation
US: Most useful initial
ix for the detection of
gallstones and dilation
of the common bile duct
182
Cholecystitis Treatment
Bed rest, IV fluids, NPO, analgesia,
Antibiotics:
1. Empiric of calculous
Gentamicin IV + Amoxi
- Genta CI: Clavulanate+Amoxi
2. Empiric of acalculous
Genta+Metro+Amoxi
- Genta CI: Piper+Tazo
183
Pathogen responsible for cholecystitis?
E. Coli
184
when to choose ERCP or cholecystectomy in an acute cholecystitis px?
cholecystectomy:
- within 72 hours
- without contraindications
- gallstone pancreatitis
- common bile duct not dilated
ERCP:
- common bile duct is dilated
- elevated ALP
185
Clinical features of Mesenteric Ischaemia
- Context of a patient with: Thrombosis or Embolus from AF.
1. Central abdominal pain.
2. Tenderness, rigidity, and absent bowel sounds.
3. Vomiting with bloody diarrhea.
4. Confusion
186
Mesenteric Ischaemia risk factors
* Atherosclerosis (acute on chronic)
* Embolic source (thrombus, vegetations)
* Hypercoagulable disorders
187
Mesenteric ischaemia lab findings
* Leukocytosis
* Elevated amylase & phosphate levels
* Metabolic acidosis (elevated lactate)
188
Mesenteric Ischaemia FIRST Investigation
X-ray: Thumbprinting (bowel-wall thickening due to edema)
189
Mesenteric Ischaemia BEST Investigation
CT Scan
190
Mesenteric Ischaemia Treatment
Resection of the necrosed gut.
191
severe periumbilical pain + tenderness + vomiting & diarrhoea + diminished/no bowel sounds + AF/atherosclerosis
Acute mesenteric ischaemia
192
diffuse tenderness + rebound tenderness (diffuse peritonitis) + few weeks hx of postprandial pain
mesenteric ischemia
193
Clinical features of Pseudoaneurysm
Hematoma, painful pulsatile
groin mass.
194
Pseudoaneurysm FIRST Investigation
Duplex Doppler US
195
Pseudoaneurysm Treatment
US-guided thrombin injection
196
Carotid Artery Stenosis Treatment
1. Aspirin
2. Statin
3. Endarterectomy Indications:
>50 and symptomatic
or
>70 and asymptomatic
197
Clinical features of Carotid haematoma
- Complication of carotid endarterectomy (CEA).
- Progressive and quick SOB.
198
Carotid haematoma Treatment
Open wound layers in the ER room.
- Unstable: Intubation
199
Clinical features of Retroperitoneal
hematoma
Traumatic (unstable pelvis) or spontaneous (warfarin tx or post-PCI)
Sudden onset of flank or abdominal pain with fullness, and guarding.
Hypotension / Hypovolemic shock (syncope, pallor, and dizziness).
Femoral neuropathy: Pain that radiates from the back and hips into your legs (radicular pain). Leg, ankle or foot numbness, weakness, tingling, paralysis or pain.
200
Retroperitoneal hematoma investigation
Contrast-enhanced CT-scan
201
Retroperitoneal Hematoma Treatment
Traumatic: Laparotomy.
Spontaneous:
1. Vit K IV bc besides being the tx of
warfarin overdose, you can also give
heparin
2. Prothrombinex
3. FFP
202
Risk assessment of venous thromboembolic events (VTE)
- Major surgery: any intra-abdominal operation and all other operations lasting more than 45 minutes
- Infectious diseases, varicose veins, obesity or general immobility
- Deficiency of antithrombin, protein C, protein S, Factor V Leiden mutation, hyperhomocysteinemia, and prothrombin 20210A
203
Clinical features of Acute Lower limb
ischemia
- Context of a patient with: Thrombosis (most common cause) or Embolus from AF.
1. Acute onset of progressive PAIN:
- Calf: Common femoral art / Superficial femoral art (MC site of occlusion).
- Buttock: Common
iliac/external iliac Thrombosis.
2. Pulselessness.
3. Pallor.
4. Paresthesia.
5. Paralysis:
- Foot drop = Peroneal nerve paralysis.
- Most reliable sign requiring Emergency Qx intervention.
204
Acute Lower limb ischemia FIRST investigation
1. Doppler US
2. CT angiogram (Emergency Qx intervention)
205
Acute Lower limb ischemia BEST investigation
Digital subtraction arteriography or just arteriography
206
Acute Lower limb ischemia Treatment
Golden time: 4 hrs
1. IV Unfractionated Heparin: 5000 IU then 1250IU/hour. APTT guides further adjustment.
2. Surgical treatment:
- Embolectomy: Can cause
reperfusion injury (HyperK, metab
acid, myoglobinuria, increased CK).
Keep pt hydrated and perfused.
- Arterial bypass is helpful if it is chronic limb ischemia.
- Amputation is required only if there are irreversible ischemic changes.
3. After acute, give warfarin for 3-6m
207
Clinical features of Chronic Lower Limb Ischemia
- Claudication (pain w/ exercise
and relieved by rest), if pain at
rest: RED FLAG
- Shiny hairless legs
- Muscles atrophied
208
Chronic Lower Limb Ischemia initial investigation
1. Measure ABI
2. Duplex US (often the only imaging required to plan endovascular interventions)
209
Chronic Lower Limb
Ischaemia best investigation
CT Angiography w/
contrast (Contraindicated in RF)
210
Chronic Lower Limb Ischaemia MEDICAL Treatment
ABI:
1-1.4: Normal
0.9: Borderline. Nothing
<0.9:
Risk factor management
- Smoke cessation
- Antiplatelets (aspirin or clopidogrel)
- Statins (even in the absence of dyslipidemia)
- ACE Inhibitors or ARBs.
- Supervised exercise program.
The beta-blockers should be avoided until and unless they are commenced for cardioprotection.
For mixed ulcers (Do not use compression bandage if ABI <0.8)
<0.4: Urgent referral
211
Chronic Lower Limb Ischaemia SURGICAL Treatment
– Endovascular angioplasty or stenting
– Open surgical reconstruction by bypass or endarterectomy.
212
Chronic Lower Limb Ischaemia referral criteria
– Rest Pain
– Ischemic ulceration
– Gangrene
– Claudication symptoms are limiting day to life, work, and there is no improvement with exercises, risk factor modifications and medical management after 6 M.
213
Raynaud Features
Bilateral vasospasms, fingers are
white or blue.
Raynaud's disease (primary Raynaud's)
Raynaud's phenomenon (secondary Raynaud's), a wide variety of other conditions.
INVESTIGATION: Capillaroscopy
214
Raynaud Treatment
1. Avoid cold, triggers, use
gloves
2. Nifedipine
215
Pernio (Chilblains)
- Multiple erythrocyanotic lesions, typically macules, papules, or nodules that develop in response to exposure to cold, damp environments. Generally symmetric, affecting particularly the toes and fingers.
- Burning sensation, fingers are red, blue, or white.
- More common in women.
TREATMENT:
- Avoid cold exposure. Use gloves or socks.
- Smoking cessation
- Topical corticosteroids.
- Nifedipine.
216
Buerger Disease (thromboangiitis obliterans)
- Young male (20-50 yo), heavy tobacco user.
- Jewish, Indians, Koreans, and Japanese.
- Vaso-occlusive inflammatory disease, auto-mutilation, black fingers.
- Arteriography may show characteristic "pig-tailing" or "corkscrewing" (not specific).
- Echocardiography should be obtained to exclude a proximal source of emboli.
TREATMENT:
- Smoking cessation.
- NSAIDs for pain.
- Nifedipine.
217
DVT Features
- RFs: Age>60, smoking, flight or
qx, pregnancy, malignant diseases, CHF, IBD (Crohn's disease and UC)
- Varicose veins aren't on the RFs list.
- C/F: Tenderness in calf,
unilateral leg swelling.
218
DVT Initial Investigation
duplex u/s
219
DVT Best Investigation
Contrast venography
220
DVT Treatment
1. LMWH
2. Warfarin (within 24-48 hrs)
3. Cava filters in pts that have CIs to
anticoagulation or have poor
compliance or failure of
anticoagulation.
4. Any motor or sensory deficit requires emergency intervention.
221
Upper Extremity DVT Features
Primary DVT Paget-Schroetter syndrome (PSS):
-Hx of young person trimming a tree, wresting, using a chainsaw. Dominant arm.
-PE: Edema (nonpitting) of shoulder, arm, and hand -> Subclavian thrombosis.
- Urschel’s sign: Limb erythema with visible veins across the chest and upper extremity.
Secondary DVT: Patients with central venous catheterization or malignancy.
The IV line:
If required (e.g., total peripheral nutrition): Remain in place and start on anticoagulation therapy.
Not required: Remove but only after the completion of 3 to 5 days of anticoagulation therapy.
222
Upper Extremity DVT Investigation
CXR: PE ??
Confirm a diagnosis: Compression duplex US.
Gold standard: Magnetic resonance venography.
223
SVC Syndrome Features
Caused by malignancies
(Pancoast tumor, etc) or by central catheter.
Pt has facial plethora, cough, dyspnea, orthopnea and papilledema
224
SVC Syndrome Initial Investigation
1. Dupplex US for catheter-related
2. CXR for malignancies
225
SVC Syndrome Best Investigation
Contrast Venography
226
SVC Syndrome Treatment
LMWH
227
Varicose Veins Features
- RF: Female, pregnancy, age, occupation.
- C/F: 1st symptom: Ankle flare edema (least likely indication for
referral), pain improves on walking, varicose veins, skin pigmentation, ulcers
228
Varicose Veins Initial/Best Investigation
Venous duplex US (Ix of
choice)
229
Varicose Veins Treatment
- ABI ≥0.9: Compression stocking safe
- ABI≤0.8: Can't use compression
stocking.
- Varicose veins w/ Ulceration:
Compression bandage
- Varicose veins w/o ulceration:
Compression stocking
230
Venous Ulcers Features
- Location: Medial distal leg (just above internal malleolus)
- Edema, irregular borders
231
Venous Ulcers Initial/Best Investigation
Venous duplex US (Ix of
choice)
232
Venous Ulcers Treatment
- Compression bandage
- Weight reduction
- Increase exercise
- If eczema: Topical steroids
- Non healing ulcer: Wound swab
- Atbs only if clinical signs of infection
(But not topical bc delay wound
healing)
233
Arterial Ulcers Features
- Location: Tops of feet or toes.
- Painful esp at night, punched-out appearance, loss of leg hair, faint or absent ankle pulses, black eschar, necrotic border.
234
Arterial Ulcers Treatment
1. LSM (low-level laser therapy)
Maybe
2. Wound care
3. Atbs if infection present
235
Diabetic Foot Ulcer Clinical Features
- Location: First metatarsal area
- Non necrotic border
236
Diabetic Foot Ulcer Initial Investigation
Foot X-ray
237
Diabetic Foot Ulcer Best Investigation
MRI to r/o osteomyelitis
in an ulcer that doesn’t heal
238
Diabetic Foot Ulcer Treatment
- Uninfected: 1cm odorless ulcer.
Wet dressing
- Mild: Purulence, erythema BUT no
cellulitis/erythema and smaller than 2cm:
1. Wound debridement.
2. Swab of wound for cultures.
3. Atbs: Amoxi+Clavulanate OR
Cephalexine+Metro
- Moderate: Infection + Cellulitis
>2cm.
1. Wound debridement.
2. Swab of wound for cultures.
3. Atbs:
Dicloxacilin/flucloxacilin. Add metro if
discharge is odorous
- Severe: Infection + Systemic symptoms (fever, tachy, hypotension,
confusion) = Piper-tazo or ticarciclin+clavulanate.
If conservative approach fails: Revascularization with angioplasty and endovascular stenting
239
Marjolin Ulcers Features
Cutaneous SCC, an ulcer that persists > 3m at the site of the scar.
Burn scars are the most common inciting condition.
Other Cx: Traumatic wounds, venous stasis ulcers, osteomyelitis, pressure ulcers, radiation dermatitis, and stings/bites.
Locations: Lower limbs (most frequently affected), followed by the scalp, upper extremities, torso, and face.
240
Marjolin Ulcers Initial/Best Investigation
1. Biopsy
2. MRI can be done to assess the degree of soft tissue and bone involvement.
241
Marjolin Ulcers Treatment
Wide excision
242
Breast Discharge Milky
-Galactorrhea
-Hyperprolactinemia
243
Breast Discharge Multicoloured/ Sticky/ Toothpaste like
-Duct Ectasia
-Comedomastitis
244
Breast Discharge Purulent
-Chronic Mastitis
-Breast Abscess
-Plasma cell Mastitits
-Acute puerperal Mastitis
245
Breast Discharge Watery/Serous/Bloody/Serosanguineous
-Intraductal Papilloma (bloody)
-Fibrocystic disease
-Advanced duct ectasia
-Breast Cancer
246
Breast Lump
247
NOT PROVEN to increase the risk of developing peptic ulcer
-Corticosteroids.
-Alcohol (except for gastric erosion).
-Diet.
248
Risk Factors for peptic ulcer
-Male sex.
-Family history of peptic ulcer disease.
-Smoking.
-Stress.
-NSAIDs.
-H.pyelori.
249
Indications for urgent abdominal surgical interventions
1-Diffuse peritonitis (localized peritonitis is not always an indication).
2-Severe or increasing localized tenderness.
3-Progressive abdominal distension.
4-Tender mass with fever or hypotension (abscess).
5-Septicemia and abdominal findings.
7-Bleeding and abdominal findings.
8-Suspected bowel ischemia (acidosis, fever, tachycardia).
9-Massive bowel dilatation (>12cm).
250
Common Bile Duct normal size
2 - 6 mm
251
252
Coeliac disease Symptoms:
Chronic diarrhoea
Steatorrhoea
Weight loss
Anorexia
Abdominal distension
Nutritional deficiency: folate, calcium, zinc or iron (in particular)
Grouped blisters around the knees, elbows and buttocks (dermatitis herpetiformis)
Hair loss
Mouth ulcers
253
bariatric surgery contraindications
– Irreversible end-organ dysfunction.
– Cirrhosis with portal hypertension.
– Medical problems precluding general anaesthesia.
– Centrally mediated obesity syndromes such as Prader-Willi syndrome or Craniopharyngioma.
254
acute pancreatitis surgery indications
- Uncertainty of clinical diagnosis
- Worsening clinical condition despite optimal supportive car2
- Infected pseudocysts
- Gallstone-associated pancreatitis
255
diarrhoea + abdominal pain + bloating + belching + flatus + nausea and vomiting
Giardiasis
256
Giardiasis investigation
stool examination for ova and cyst
257
Gallstone surgery indication
size > 3 cm
- calcified/porcelain gallbladder
258
gall stone investigation
initial:
diagnostic: US/ERCP
259
Diverticultis highest mortality rate complication
Perforation 20%
- Bleeding especially in elderly
– Intra-abdominal abscess.
– Peritonitis.
– Fistula formation.
– Intestinal obstruction.
260
oesophageal malignant lesions surgical contraindication
- Invasion of tracheobronchial tree
- Invasion of great vessels
- lesion more than 10 cm
261
paraesophageal/hiatus hernia investigation
Diagnostic: Barium swallow
262
abdominal pain + diarrhoea + Tenderness on DRE
Acute appendicitis
263
long hx of vomiting after food + reduced appetite + brackish taste + epigastric pain
Gastro-oesophageal reflux disease (GORD)
264
Gastro-oesophageal reflux disease (GORD) investigation
Initial:
- Intraoesophageally pH probe monitoring
- Barium swallow unless suspicion of stricture, obstructions
265
Indications for endoscopy for GORD
pre-existing GORD now presented with anaemia
266
Most common complication of GORD
- Barrett's oesophagus
- Oesophagitis
- Strictures
- Iron deficiency anaemia
- Adenocarcinoma
267
GORD management
Lifestyle modification
- **weight reduction**
Therapeutic trial of PPI for 4 weeks
NOTE: Ranitidine is not given in Australia (lung cancer, MI)
268
Chronic GORD (> 5 years) + LES low tone + mucosal damage
Barrett’s oesophagus
269
Barrett’s oesophagus investigation
- endoscopy with biopsy
- contrast studies if endoscopy unavailable
270
Barrett’s oesophagus monitoring
2-5 years by endoscopy and biopsy depending on segment length
271
Barrett's oesophagus histopathology
- squamous cells forming into ciliated columnar cells
NOTE: precancerous site for adenocarcinoma
272
Barrett's oesophagus management
PPI
Low grade: PPI every 6 months
High grade: radio frequency ablation
273
Dysphagia to solids and liquids + Heartburn unresponsive to PPI + Retained food in the oesophagus on upper endoscopy + Unusually increased esophagogastric junction sphincter tone + failure of muscle relaxation + weight loss + regurgitation getting worse at night/lying down
achalasia
274
Achalasia initial investigation
Plain X -ray
- air fluid levels to see absence of gastric bubble
Barium swallow
- Birds beak/rat tail appearance
OGD endoscopy
- exclude other causes of dysphagia
275
Achalasia diagnostic investigation
Manometry
- high tension at lower end of oesophagus
Endoscopy
- exclude carcinoma
276
Most important diagnostic feature of achalasia?
Dysphagia for both solids and liquids
277
Achalasia complications
- strictures
- oesophageal cancer
278
Achalasia management
Mild symptoms
- CCB (Nifedipine)
- nitrates
Young px
- Endoscopic Pneumatic dilation of LES
Old px
- Botulinum injection (may need to be repeated every 3 - 12 months) + mild symptoms management
Best
- Laparoscopic Myotomy (Heller's)
279
most common oesophageal disorder
achalasia
280
painless + elderly + recurrent pneumonia + dysphagia + solids & liquids undigested food regurgitation + coughing immediately after eating + halitosis
Zenker's diverticulum (pharyngeal pouch)
281
Zenker's diverticulum investigation (pharyngeal pouch)
Initial: Barium swallow/Contrast oesophagography
Best: Upper gastrointestinal endoscopy
282
Zenker's diverticulum management (pharyngeal pouch)
Surgery: cricopharyngeal myotomy ± diverticulectomy
Laparoscopic surgery
283
dysphagia + iron deficiency anaemia + glossitis 'rings' (oesophageal webs) + glossitis
Plummer Vinson Syndrome/Syderopenic dysphagia
284
Plummer Vinson Syndrome/Syderopenic dysphagia investigation
Video fluoroscopy to test iron deficiency
Endoscopy
285
Plummer Vinson Syndrome/Syderopenic dysphagia biggest risk factor
Oesophageal SCC
286
Plummer Vinson Syndrome/Syderopenic dysphagia management
Treat iron deficiency
Mechanical dilation
287
Progressive dysphagia + Weight loss >10% + Elderly
Oesophageal cancer
288
Oesophageal cancer features
▪ Dysphagia progressive continuous - first solids then liquids → odynophagia
▪ Striking unintentional weight loss ( >10%)
▪ Hiccoughs (early sign – phrenic nerve irritation)
▪ Hoarseness and cough (upper 1/3 cancer – recurrent
laryngeal nerve irritation – vocal cord palsy)
▪ Progressive chest discomfort or pain in locally invasive cancer
289
Oesophageal cancer types
▪ SCC (most common)
▪ Adenocarcinoma
290
Oesophageal cancer investigation
1st test: Barium swallow to locate lesion
▪ Narrowing of oesophagus
▪ Irregular oesophageal borders
apple core appearance
THEN
Endoscopy w/biopsies
Oesophagogastroduodenoscopy
291
Oesophageal cancer ddx
Dysphagia intermittent = Achalasia
Hoarseness and cough = also in Pancoast tumour but Horner is present and no GI symptoms
292
Oesophageal cancer risk factors
SCC:
▪ Smoking & OH → Tripe S
(smoking - spirits – SCC)
Adeno:
▪ Barrett’s oesophagus & smoking
293
prolonged vomiting + small haematemesis ± alcohol excess
Mallory-Weiss Tear
294
alcoholic binge + vomiting + hemodynamic instability ± left-sided pleural effusion + hypotension
Boerhaave’s Syndrome
295
Boerhaave’s Syndrome investigation
Initial: upright chest x-ray
- left unilateral effusion
- free air in the mediastinum or peritoneum
Diagnostic : Oesophagography
- extravasation of contrast material into the pleural cavity
Gastrograffin: It has 90% sensitivity but may have false-negative results in up to 20% of
patients
NOTE: Barium swallow has been associated
with severe mediastinitis
296
Boerhaave’s Syndrome management
- ABCDE – Resus - IV fluid therapy
- immediate antibiotic therapy to prevent mediastinitis and sepsis
- surgical repair of the perforation
NOTE: mortality 100%
297
Complete oesophageal rupture causes
▪ Iatrogenic - 56% due to an endoscopy or
paraesophageal surgery
▪ Boerhaave's syndrome- 10%
▪ Spontaneous perforation include:
- Caustic ingestion
- Pill esophagitis
-Barrett's oesophagus
-Infectious ulcers in patients with AIDS, and following dilation of oesophageal strictures
298
PUD risk factors
-Male sex.
-Family history of peptic ulcer disease.
-Smoking.
-Stress.
-NSAIDs.
-H.pylori.
299
infective cholecystitis pathogen
E. Coli
300
hx of ascites+ fever + altered mental status + increased WBC + abdominal pain/discomfort
spontaneous bacterial peritonitis
301
spontaneous bacterial peritonitis transmission
Bacterial translocation from gut to mesenteric lymph node Bacterial translocation from gut to mesenteric lymph node
302
Left iliac fossa pain + Fever + Tenderness and rebound tenderness + Guarding + Per rectal bleeding + hypotension
Acute diverticulitis
303
Coeliac Disease most common age
- children 9-18 months the most common
- any age
304
Causes of Coeliac Disease
genetic
305
Coeliac Disease Investigation GOLD STANDARD
- Duodenal Biopsy
NOTE: atrophic villi, IG Antiendomysial AB, IGA transglutamines, IGA Antigliadin for screening
306
conditions is associated with an increased risk of coeliac disease
- Type I diabetes mellitus
- Hashimoto’s thyroiditis
- autoimmune diseases
- Down’s syndrome
- Turner’s syndrome
- IgA deficiency
307
Coeliac Disease management
- **Gluten free diet**
- Vitamin replacement
- Pneumococcal Vaccine
- Dapsone (for dermatitis herpetiformis)
308
Left supraclavicular lymph node cancer
- abdominal or pelvic
309
hx of cholecystectomy + abdominal pain + dyspepsia + increased liver enzymes and cholesterol
post-cholecystectomy syndrome
310
post-cholecystectomy syndrome investigation
ERCP
311
screening for hepatoma or primary liver cancers with chronic hepatitis
Alpha fetoprotein
312
autoimmune hepatitis predictor of poor clinical response to therapy
Anti-liver-kidney microsomal antibody (Anti-LKM antibody)
313
high INR + low calcium + hypochromic microcytic anaemia
malabsorption syndrome
314
malabsorption syndrome investigation
Anti-gliadin antibodies
315
most common cause of large bowel obstruction
Colon cancer
316
most common cause of constipation
Dietary
317
Acute cholangitis poor prognostic determinants
1 Age more than 70.
2 Female
3 Failure to respond to conservative management.
4 Concurrent medical conditions:
- liver abscess
- cirrhosis
- hypoalbuminaemia
- thrombocytopenia
- IBD
- malignant strictures
318
high age + progressive dysphagia + decreased contractions + increased tertiary wave activity
Presbyoesophagus
319
jaundice, dark urine, and pale stool + palpable gall bladder
Periampullary tumor
320
bacterial peritonitis treatment
Cefotaxime and albumin
- albumin to reduce the rate of renal failure
321
migratory superficial thrombophlebitis + deep vein thrombosis
Trousseau’s syndrome
322
Trousseau’s syndrome associated tumours
1. Pancreas 24%
2. Lung 20%
3. Prostate 13%
4. Stomach 12%
5. Acute leukaemia 9%
6. Colon 5%.
323
– Severe colicky epigastric and periumbilical pain
– Absolute constipation.
– Nausea and vomiting.
– Abdominal distension in low small bowel obstruction
small bowel obstruction
324
Elevated liver enzymes with normal bilirubin
Ischemic hepatitis
325
Pancreatic pseudocyst management
- size > 6cm ERCP
- Present for > 6 weeks
- Wall thickness for > 6 mm
NOTE: if ERCP fails, then move on to laporotomy
326
Longstanding cirrhosis or Hep C
Form hepatocellular carcinioma
327
Cirrhosis findings
PE: spider naevi, palmar erythema, gynecomastia and splenomegaly
LAB:
- Thrombocytopenia
Abnormal coagulation studies including INR and PT
Hypoalbuminemia
328
Small bowel obstruction investigation
initial: Abdominal X-ray
Best: CT abdomen
329
GI bleed with weight loss and decreased appetite
colon adenocarcinoma
330
hix of gastric bypass + discomfort, including nausea, vomiting, cramps, and diarrhea
Dumping syndrome
331
Dumping syndrome management
- Diet modification (high fibre + protein)
- -Hydrogen breath test positive
- Barium fluoroscopy
- radionuclide scintigraphy
reoperation if diet fails
332
H. Pylori
Gram -ve
- corkscrew-shaped, motile bacillus with three to seven flagella
- rapid urease test
- Eradication with colloidal bismuth (Pepto-Bismol), an antibiotic (amoxicillin or ampicillin), and a nitroimi-dazole such as metronidazole.
333
fever + jaundice, + pain in the right upper quadrant + chills
Acute cholangitis
Harcot's triad
334
Acute pancreatitis investigation
- serum lipase (elevated)
335
Meckel diverticulum investigation
- painless large-volume intestinal hemorrhage
**Technetium-99m pertechnetate scintigraphic study**
336
Iron deficiency anaemia in elderly
colon cancer
337
abdominal surgical interventions
D1. iffuse peritonitis(localized peritonitis is not always an indication).
2-Severe or increasing localized tenderness.
3-Progressive abdominal distension.
4-Tender mass with fever or hypotension (abscess).
5-Septicemia and abdominal findings.
7-Bleeding and abdominal findings.
8-Suspected bowel ischemia (acidosis,fever,tachycardia).
9-Massive bowel dilatation more than 12cm.
338
Malignant cells in ascites will spread to
Left supraclavicular lymph nodes
339
Pilonidal sinus prevention
1-Keep the area clean and dry.
2-Avoid sitting for a long time on hard surfaces.
3-Remove hair from the area
340
Peritonitis investigation
- Ascitic analysis
(fluid neutrophil count more than 250 cells/mm3)
341
Hepatic hydatid cyst pathogen
Echinococcus tape worm
342
Hepatic hydatid cyst investigation
Triphasic abdominal CT Triphasic abdominal CT
Cyst aspiration
343
Hepatic hydatid cyst management
Albendazole
344
Best indicator for chronic liver disease
Albumin
345
Indicator for chronic liver disease
- Alanine aminotransferase
- Aspartate aminotransferase
346
Best predictor of patient livelihood
Hypoalbumin
- decrease in osmotic pressure, therefore ANSARCA
leads to CHF
347
Coeliac disease investigation
Serum transglutaminase antibodies
348
Splenectomy measures
- Vaccination against:
streptococcus pneumoniae
meningococcus
H. influenza
- Antibiotics (Penicillin) from 6 months - 2 years
- target cells (deformed RBCs)
349
Acute confusion post surgery
Atelectasis, PR, chest infection
- check pulse oximetry
350
5 F's of cholecystitis
351
Encephalopathy grades
Grade-I involves altered mood/behaviour, sleep disturbance including reversal of sleep cycle.
Grade-II involves increasing drowsiness, confusion and slurred speech
Grade-III involves stupor, incoherence, restlessness and significant confusion
Grade IV is an
ultimate coma
352
Dilated abdominal veins flowing towards head + hepatomegaly
Inferior Vena Cava Obstruction
353
Dilated abdominal veins flowing towards legs+ hepatomegaly
Caput medusae from cirrhosis and portal hypertension
354
History of recent myocardial infarction. + acute onset of abdominal pain + Metabolic
acidosis.
mesenteric ischemia
355
Pancreatic cancer risks
-Smoking.
-Long-standing diabetes mellitus.
-Chronic pancreatitis.
-Obesity.
-Inactivity (high cholesterol/obesity?
-Non–O blood group
356
Child-Pugh classification
The severity of portal hypertension
1-Increased total bilirubin.
2-Prolonged INR.
3-Low serum albumin.
4-Presence of hepatic encephalopathy.
5-Presence of ascites.
357
chronic gastrointestinal bleeding prevention
BB (Propranolol or nadolol)
358
most likely to strangulate hernia
indirect inguinal hernia
359
least likely to strangulate hernia
Direct inguinal hernia
360
gastroenteritis in Australia?
Norovirus
361
Male + intermittent mild jaundice provoked by stress
(infection, fasting, vigorous exercise, surgery)
Gilbert's syndrome
362
Repeated unconjugated hyperbilirubinemia + No evidence of haemolysis + normal findings on complete blood count, reticulocyte count, and blood smear. + Normal liver function tests except for bilirubin.
Gilbert’s syndrome
363
Gilbert's syndrome features
AR or AD mutation in UGT1A1 gene
decreased UDP-glucuronosyltransferase activity leading to increased unconjugated bilirubin
364
most common gastrointestinal complication seen after cholecystectomy
Diarrhoea
365
infliximab for inflammatory bowel disease
Crohn’s disease with perianal fistulas
366
sulfasazine side effects
- agranulocytosis
- haemolytic anaemia
rash -
367
Coeliac vitamin defciencies
- iron (most common)
- B12
- ADEK
368
bariatric surgery indications
– BMI above 40 with no co-morbidities
– BMI above 35 with co-morbidities such as hypertension
– BMI above 30 with poorly controlled type 2 diabetes
– BMI above 30 with increased cardiovascular risk due to multiple risk factors such as hypertension, hyperlipidemia, strong family history of cardiovascular disease at a young age
369
presence of eosinophils + dysphagia
eosinophilic esophagitis
370
eosinophilic esophagitis management
1. PPI
2. Swallowed budesonide
3. Systemic corticosteroids
371
CEA
glycoprotein found in colon - cancer
- CEA assay is a sensitive serologic tool for identifying recurrent disease
372
infant + volvulus + duodenal obstruction + intermittent or chronic + abdominal pain
malrotation
373
hernia that follows the path of the spermatic cord within the cremaster muscle
Indirect inguinal
374
hernia passes directly beneath the inguinal
ligament at a point medial to the femoral vessels
femoral
375
hernia passes through a weakness in the floor of the inguinal canal medial to the inferior epigastric
artery
direct inguinal
376
hernia that protrude through an anatomic defect that can occur along the lateral border of
the rectus muscle at its junction with the linea semilunaris
Spigelian
377
thiazide diuretic + beta
blocker
hypokalemia
378
haemorrhoiids investigation
Proctoscopy
379
dysphagia + coughing and choking + recurrent aspiration pneumonia + stroke
Oropharyngeal dysphagia
380
Oropharyngeal dysphagia investigation
Videofluoroscopic modified barium swallow study
381
middle-aged women + hyperlipidemia + fatigue + pruritus + elevated alkaline phosphatase
cholestasis
382
constipation + fecal ncontinence + hematochezia + hx of pelvic radiation therapy
Radiation proctitis
383
Acute pancreatitis worse prognosis
Blood urea nitrogen level
- reflect intravascular volume depletion
384
Ursodeoxycholic acid is used to treat
Primary biliary cirrhosis
- increases bile acid output and bile flow while reducing
cholesterol absorption
385
primary lymphoma predisposing factors
Celiac disease
386
solids dysphagia + breathlessness, cough +
heartburn + wheezing
Congenital anomaly of the aortic arch
- presses against the oesophagus causing dysphagic, compression isn't too harsh as liquids can still pass through
387
long hx of constipation + sudden cut-off + dilated proximal colon + abdominal distension + empty rectum on DRE
sigmoid volvulus
388
sigmoid volvulus investigation
diagnostic: CT abdomen
NOTE: barium if perforation is suspected
389
mild tenderness on rectal exam + pain localized in the pelvis
pelvic appendicitis
390
freckling + gastrointestinal polyposis (polyps in small bowel) + intussusception
Peutz Jegers Syndrome
391
Peutz Jegers Syndrome complications
high risk of specific cancers:
intestine
colon
pancreas
breasts
cervix
ovaries
testes
392
Disease with strongest association with colorectal cancer
Familial adenomatous polyposis
- cancer can develop as early as 20
393
Somalian + anal fissure predisposing factor
Rectal schistosomiasis
394
dysphagia + hoarseness + hx of achalasia + thoracic inlet mass
Oesophageal cancer
395
hoarseness + dysphagia + neck mass
Laryngeal cancer
396
erythematous + well define + fluctuant mass at the anal orifice
Perianal abscess
397
most common cause of treatment failure in PUD
metronidazole/clarithromycin resistance
398
dyspepsia + belching + abdominal pain + post cholesytectomy
Post- cholecystectomy syndrome (PCS)
399
Most common cause of post-cholecystectomy syndrome (PCS)
Choledocholithiasis
400
Types or benign renal tumours
- Renal adenoma
- Oncocytoma
- Angiolipoma
401
Types or malignant renal tumours
- Renal cell carcinoma (90%)
- Urothelial carcinoma (5-10%)
- Wilms tumour/nephroblastoma
- Sarcomas
402
aniline dye industry ± smoking + haematuria
urothelial tumour
403
urothelial tumour features
- papillary tumours of the urinary transitional epithelium
- incidence increases progressively from renal pelvis to bladder
404
Most common complication of urothelial tumour?
Bladder cancer (90%)
405
most common blunt abdominal trauma in children?
duodenal haematoma
406
Haemorrhagic shock classes
Class II-III:
- systolic BP < 90
- heart rate< 120
- respiratory rate< 30
