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Surgery Flashcards

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1
Q

What is the Modified Glasgow Score?

A

tool to assess severity of acute pancreatitis

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2
Q

In the Modified Glasgow Score, what score indicates severe pancreatitis

A

> =3 within 48hrs onset

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3
Q

What is the tumour marker for pancreatic cancer?

A

Ca 19-9

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4
Q

What is the tumour marker for ovarian cancer?

A

CA 125

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5
Q

What is the tumour marker for hepatocellular carcinoma

A

AFP - alpha-feto protein

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6
Q

What is the tumour marker for colorectal cancer?

A

CEA - carcinoembryonic antigen

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7
Q

What are the key features of Crohn’s disease (macroscopic and microscopic)

A 
macroscopic:
mouth to anus
skip lesions
transmural
mucosal oedema

Microscopic:
epitheloid granulomas`

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8
Q

Which part of the bowel does Crohn’s most commonly affect?

A

terminal ileum

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9
Q

What kind of perianal disease can occur in crohn’s

A 
fistulae
fissure
abscess
skin tags
ulcers
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10
Q

What skin changes can occur in crohn’s

A

erythema nodosum

pyoderma granulosum

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11
Q

What investigations should be carried out in suspected crohn’s

A

FBC, U+E, ESR, CRP, LFT, B12, folate
stool mc+s, c diff toxin
Colonoscopy with biopsies, small bowel enema, capsule endoscopy

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12
Q

What are the expected blood results in chron;s

A

anaemia

raised inflammatory markers

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13
Q

What is the management of crohn’s to induce remission

A

supportive: IV fluids, nutrition

  1. corticosteroids eg IV hydrocortisone
  2. 5-ASA eg. mesalazine
  3. add on mercaptopurine, azathioprine or methotrexate
  4. if no response, consider infliximab or adalimumab
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14
Q

What is the management of crohn’s to maintain remission

A
  1. mercaptopurine or azathioprine
  2. methotrexate
  3. mesalazine
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15
Q

What are indications for surgery in Crohn’s

A 
peritonitis
obstruction
abscess
fistula
not responding to medical therapy
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16
Q

What are the aims of surgery in crohn’s

A

resect worst areas

defunction distal disease

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17
Q

What are the compications of crohn’s

A 
strictures
fistulae
osteoporosis
anaemia
renal stones
gallstones
primary sclerosing cholangitis
cholangiocarcinoma
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18
Q

What age is crohn’s most common

A

15-30

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19
Q

What age is UC most common

A

15-25

55-65

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20
Q

Describe the typical macroscopic and microscopic features of UC

A 
macro:
rectum up
continuous
mucosal
pseudopolyps

micro:
crypt abscesses
reduced goblet cells

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21
Q

What investigations should be done in suspected UC

A

FBC, U+E, LFTs, CRP, ANCA, p-ANCA, ANSA
stool culture and CDT
AXR, erect CXR
colonoscopy

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22
Q

How is the severity of UC classified?

A

mild - <4 stools per day, little blood

moderate - 4-6 stools per day, no systemic upset

severe - >6 stools per day, systemic upset (raised HR, raised inflammatory markers, anaemia, pyrexia)

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23
Q

What is the treatment for UC to induce remission

A

mild/moderate

  1. oral or rectal mesalazine or sulfasalazine
  2. oral or rectal prednisolone

severe
1. IV steroids - hydrocortisone

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24
Q

What is the treatment for UC to maintain remission

A
  1. oral/rectal mesalazine or sulfasalazine (aminosalicylates)
  2. azathioprine or mercaptopurine
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25
What are the complications of UC
toxic megacolon VTE depression and anxiety primary sclerosing cholangitis
26
State seven differences between crohn's and UC
``` transmural, mucosal mouth to anus, rectum up skip lesions, continuous granulomas, crypt abscesses strictures and fistulae, no smoking increases risk, smoking decreases risk ulcers and perianal disease, no no, increased risk colorectal cancer ```
27
State some mechanical ways of preventing VTE in post op patients
Early ambulation after surgery Compression stockings Intermittent pneumatic compression devices
28
State some ways of preventing VTE in post op patients with medications
stop the pill 4 weeks prior to surgery LMWH, unfractionated heparin if patient in renal failure or fondaparinux continued for 5-7days post op or until mobile major cancer or hip/knee replacement for 28days+
29
What is chronic liver disease?
progressive inflammation and destruction of liver parenchyma leading to fibrosis and cirrhosis
30
What are the causes of chronic liver disease
``` alcohol hep B/C non-alcoholic fatty liver disease genetic - Wilson's, haemochromatosis autoimmune - primary biliary sclerosis drugs - methotrexate,isoniazid, amiodarone, sodium valproate vascular - Budd-Chiari ```
31
What is haemochromatosis
autosomal recessive mutations in HFE gene - leading to increased iron uptake and deposition in tissue leads to cirrhosis, heart failure and diabetes hypogonadism
32
How is haemochromatosis treated
venesection
33
What is Wilson's disease
autosomal recessive condition causing increased uptake and decreased excretion of copper, leading to increased Cu2+ in blood and deposition in tissues deposition in liver, brain, cornea leading to cirrhosis, psychiatric problems
34
How is wilson's treated
penicillamine - chelates copper
35
What is Budd-Chiari syndrome
hepatic vein thrombosis venous congestion causes hepatomegaly if hypoxia of tissues, necrosis occurs
36
What is metabolic syndrome
presence of 3/5 of ``` T2DM obesity HTN hypertriglyceridamia hyperlipidaemia ```
37
What non-alcoholic fatty liver disease
in presence of metabolic syndrome insulin resistance leads to increased fat deposition and reduced fatty acid oxidation, increased synthesis fatty acids. leads to steatosis inflammation due to hepatocyte cell death leads to steatohepatitis stellate cells lay down fibrotic tissue leading to cirrhosis
38
define steatosis
abnormal fatty depositis in hepatocytes
39
define steatohepatitis
steatosis plus inflammation causes by hepatocyte necrosis
40
define cirrhosis
degeneration of cells, inflammation, and fibrous thickening of tissue in liver nodules of regenerating hepatocytes surrounded by collagen
41
Why does alcohol cause cirrhosis
alcohol broken down by alcohol dehydrogenase forming acetaldehyde uses NAD+ (decreasing B oxidation of fa) giving NADH (increases fatty acid synthesis) leads to steatosis acetaldehyde is toxic, as are ROS produced by reaction leads to inflammation therefore, steatohepatitis nodular regeneration and fibrosis by stellate cells scar tissue starts to form around veins = cirrhosis!
42
What is a key histological finding in steatohepatitis of alcoholic liver disease
Mallory bodies in cytoplasm of hepatocytes
43
Which hepatitis increased the risk of hepatocellular carcinoma
HBV
44
What are the key serology findings in HBV
HBsAg - presence of disease anti HBs - immune anti HBc - have been exposed to virus
45
What is the treatment for HBV
acute: peginterferon alfa chronic: entecavir
46
What is the treatment for HCV
ribavirin + peginterferon alfa
47
What are the symptoms of chronic liver disease
``` lethargy N+V anorexia pain in RUQ fever easy bruising blood in stools haematemesis ```
48
What are the signs of chronic liver disease
``` jaundice palmar erythema hepatic flap spider naevi caput medusae gynacomastea testicular atrophy loss of body hair ascites hepatomegaly splenomegaly ```
49
What are the complications of chronic liver disease
oesophageal varices hepatic encephalopathy HCC spontaenojus bacterial peritonitis
50
Describe how you would investigate a patient with presumed chronic liver disease
urinalysis FBC, clotting, U+E, LFTs, albumin, viral serology, iron, ferritin, copper USS, endoscopy, transient elastography
51
What are the signs of hepatic encephalopathy
confusion cognitive impairment constructional apraxia liver flap
52
State the stages of hepatic encephalopathy
I - irritability, sleep disturbance, dyspraxia II - confusion, inappropriate behaviour, liver flap III - incoherent, restless, liver flap, stupor IV - coma
53
What causes ascites in cirrhosis
reduced albumin - reduced oncotic pressure | portal hypertension - increased hydrostatic pressure (RAAS activation due to sphlancnic vasodilation)
54
How is ascites treated
fluid restriction spironolactone low salt diet
55
How is encephalopathy treated
referral to ITU manage airway - intubation lactulose
56
What long term monitoring is needed in cirrhosis
6m USS liver and alpha fetoprotein for HCC
57
what causes varicose veins
valvular insufficiency in superficial veins, leading to dilation. tortuous veins
58
what are the risk factors for varicose veins
``` female pregnancies standing up for prolonged time family history obesity ```
59
What are the symptoms of varicose veins
``` purely cosmetic pain (after prolonged standing) itching aching swelling of legs ```
60
What are the signs of varicose veins
tortuous veins along small and great saphenous veins
61
What is deep venous insufficiency?
failure of the venous system, characterised by valvular reflux, venous hypertension and obstruction
62
what are the signs of chronic venous insufficiency
``` peripheral oedema venous eczema lipodermatoclerosis haemosiderin deposition atrophie blanche venous ulcers ```
63
Where are venous ulcers most commonly found
medial malleolus
64
describe the course of the great saphenous vein
dorsal venous arch anterior to medial malleolus posterior to medial condyle of knee inserts into femoral vein inferior to inguinal ligament
65
describe the course of the small saphenous vein
dorsal venous arch posterior to lateral malleolus inbetween heads of gastrocnemius into popliteal vein
66
What investigations need to be done when investigating varicose veins
FBC, U+E, LFTs, BNP, | duplex ultrasound of veins, ABPI
67
What is the conservative management of varicose vein
elevation weight loss not standing for prolonged periods of time compression stocking
68
what are the surgical options for treatment of varicose veins
laser ablation foam sclerotherapy ligation, stripping and avulsion
69
What is a saphena varix
dilatation at the top of the long saphenous vein due to valvular incompetence.
70
How is a saphena varix tested for?
cough impulse at saphenofemoral junction
71
What is trendelenberg's test for varicose veins
raise leg to 45 degrees milk veins tourniquet around thigh lower leg varicose veins return = incompetency below level of tourniquet varicose veins do not return = incompetency above level of tourniquet
72
What is MEN1
inherited parathyroid pancreas - gastrinoma or insulinoma anterior pituitary
73
describe MEN2
2A - phaeochromocytoma, parathyroid, medullary thyroid cancer 2B - MTC, phaeochromocytoma, neuromas, Marfan's
74
Define acute hepatic failure
liver failure occuring suddenly in a previously healthy liver
75
define acute on chronic liver failure
decompensation of chronic liver disease
76
define fulminant hepatic failure
acute liver failure + encephalopathy | due to mass necrosis of liver cells leading to severe impairment of function
77
Define hyperacute, acute and subacute fulminant hepatic failure
hyperacute - less than seven days sinnce onset of jaundice acute - 7-28d subacute - 5-26 weeks
78
Which hepatitis viruses cause acute liver failure
Hep A and E
79
What are the signs of acute liver failure
``` jaundice RUQ pain fever nausea anorexia fatigue ```
80
What are the signs of fulminant hepatic failure
``` hepatic encephalopathy - confusion, constructional apraxia, altered mental state ascites asterixis acidosis hypoglycaemia ```
81
State some investigations you would want to do in acute liver failure
FBC, U+E, LFTs, clotting, albumin, iron studies, viral serology, paracetemol level blood cultures liver USS ascitic tap - MC+S
82
What are the indications for liver transplantation in paracetamol overdose
Arterial pH < 7.3, 24 hours after ingestion or all of the following: prothrombin time > 100 seconds creatinine > 300 µmol/l grade III or IV encephalopathy
83
What are gallstones formed from?
cholesterol bile pigments calcium
84
Define biliary colic
intermittent pain due to movement of gallstones into cystic duct causing transient obstruction
85
define cholecystitis
infection and inflammation of gall bladder due to obstruction of cystic duct
86
define cholangitis
inflammation and infection of common bile duct due to gallstone present in common bile duct
87
What are the symptoms of biliary colic
intermittent RUQ pain worse after meal or at night spontaneous resolution
88
What are the signs and symptoms of cholecystitis
pain in RUQ fever +ve Murphy's sign nausea and vomiting
89
What are the signs and symptoms of cholangitis
``` fever RUQ pain jaundice hypotension confusion deranged LFTs ```
90
What investigations should be done is gallstone pathology
FBC, U+E, LFTs, CRP, amylase | USS, MRCP if USS not diagnostic
91
What are the findings on USS for gallstones
presence of stones thickened gallbladder wall dilated ducts
92
What is the management of biliary colic
analgesia | elective cholecystectomy
93
What is the management of cholecystitis
IV analgesia and fluids broad spectrum antibiotics cholecystectomy within 1 week
94
What is the management of cholangitis
``` IV fluids analgesia Abx ERCP for removal of stones from CBD within 48hours cholecystectomy ```
95
What is the treatment for empyema of gall bladder
cholecystectomy | percutaneous cholecystotomy if not fit for surgery (followed by cholecystectomy if possible at later date)
96
What are the complications of cholecystectomy
may need to convert to open surgery leakage of bile bleeding injury to CBD
97
What are the complications of gallstones
pancreatitis gallstone ileus empyema perforation of gall bladder
98
Why does biliary colic occur after fatty meals?
presence of fatty acids stimulates enteroendocrine cells to release CCK CCK causes contraction of gall bladder
99
Describe the pathophysiology of acute pancreatitis
inflammation of the pancreas due to injury of the acinar (exocrine cells). leads to enzymatic spillage, inflammatory cascade activation and localized oedema
100
What are the symptoms of acute pancreatitis
nausea and vomiting | pain! - radiating to back
101
What are the causes of acute pancreatitis
``` Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion bites Hypercalcaemia ERCP Drugs - azothioprine, thiazides, loop diuretics ```
102
What are the signs of acute pancreatitis
``` tachycardia fever Grey-Turner's/Cullen's epigastric tenderness abdominal distension jaundice ```
103
What is the cause of Grey-Turner's/Cullen's signs
retroperitoneal bleeding due to haemorrhage from necrotic pancreas
104
What investigations should be done in suspected pancreatitis
ECG FBC, U+E, LFTs, amylase, lipase, calcium, ABG, CRP USS, AXR, erect CXR
105
What can causes a raised amylase
``` pancreatitis mesenteric ischaemia ectopic pregnancy perforation DKA cholecystitis ```
106
What sign is seen on AXR in pancreatitis
sentinel loop = dilated proximal jejunal loop due to local inflammation of pancreas
107
What is the differential diagnosis in acute pancreatitis
AAA rupture bowel perforation aortic dissection duodenal ulcer
108
State the management of acute pancreatitis
oxygen - maintain above 95% sats IV fluids analgesia catheter to monitor urine output
109
What are some of the systemic complications of acute pancreatitis
DIC Acute Respiratory Distress Syndrome (ARDS) Hypocalcaemia Hyperglycaemia - secondary to disturbances of insulin metabolism Hypovolemic shock and multiorgan failure
110
What are some of the local complications of acute pancreatitis
pancreatic necrosis pancreatic pseudocyst pancreatic abscess
111
Describe how pancreatic necrosis occurs
Ongoing inflammation eventually leads to ischaemic infarction of the pancreatic tissue, often 7-10 days after the onset of pancreatitis. Any suspected pancreatic necrosis should be confirmed by
112
How is suspected pancreatic necrosis investigated and treated
CT scan, sterile - conservative ?pancreatic necrosectomy (open or endoscopic)
113
What is a pancreatic pseudocyst
pancreatic fluid surrounded by fibrous/granulation tissue often occur 4 weeks after acute pancreatitis
114
What is the treatment for a pancreatic pseudocyst
most resolve spontaneously. if not: surgical debridement or endoscopic drainage (often into the stomach)
115
In IDDM with well controlled diabetes,what is the perioperative insulin management for a patient undergoing a minor procedure
day before: normal doses | day of: reduced once daily long acting to 80% normal dose. continue other short acting doses
116
In IDDM with poorly controlled diabetes or a major operation, what is the insulin management perioperativly
day before: 80% dose once daily long acting insulin ``` day of: 80% dose once daily long acting insulin omit other short acting doses start variable rate IV insulin infusion monitor blood glucose hourly - target 6-10mmol/L ``` once stable eating and drinking: convert back to SC insulin
117
during variable rate IV insulin infusion intraoperatively, what should be done if the blood glucose falls below 6mmol/L
give IV glucose 20% to prevent drop below 4mmol/L
118
What is the perioperative insulin regimen in emergency surgery?
check blood glucose, ketones, HCO3- and U+Es if no ketosis, start variable rate IV insulin infusion
119
Which diabetic drugs can be continued intraoperatively
pioglitazones, DDP-4 inhibitors, GLP-1 agonists
120
Whcih diabetic drugs need to be stopped on the fay of surgery?
metformin (if at risk of AKI or pt going to miss more than 1 meal) sulfonylureas SGLT-2 inhibitors
121
Why is metformin stopped pre-op in diabetics?
risk of lactic acidosis
122
Why are sulfonylureas stopped pre-op in diabetics?
risk of hypoglycaemia
123
Why are SGLT-2 inhibitors stopped pre-op in diabetics?
risk of DKA
124
Which antibiotics are given as prophylaxis in musculoskeletal surgery?
IV co-amoxiclav 1.2g in induction room and then 8 and 16 hours later IV gentamicin and teicoplanin in induction room
125
Describe the pathophysiology of chronic pancreatitis
chronic fibro-inflammatory disease of the pancreas, with progressive and irreversible damage to the pancreatic parenchyma. Calcification of parenchyma there is recurrent and persistent evidence of exocrine and endocrine insufficiency
126
What are the causes of chronic pancreatitis
``` alcohol idiopathic hypercalcaemia CF obstruction pancreatic duct - neoplasm? ```
127
What are the symptoms of chronic pancreatitis
``` pain in epigastrium radiating to back - relived with sitting forwards/hot water bottle N+V weight loss steatorrhoea narcotic abuse ```
128
What are hte signs of chronic pancreatitis
epigastric tenderness | erythema ab igne
129
What investigations should be done in chronic pancreatitis?
urinalysis FBC, U+E, blood glucose, amylase, lipase, LFTs faecal elastase USS
130
What are important differentials to consider in chronic pancreatitis
acute cholecystitis, peptic ulcer disease, acute hepatitis
131
What is the management of chronic pancreatitis
``` analgesia!!! stop alcohol pancreatic enzyme replacement insulin steroids if cause autoimmune surgery: pancreaticoduodenectomy, Whipple'a ```
132
Which vitamins are those with chronic pancreatitis at risk of becoming deficient in?
ADEK
133
What is a Whipple's procedure?
removal of the head of the pancreas, first and second parts of the duodenum, the pyloric antrum, the gallbladder and the bile duct. tail of pancreas anastamosed with duodenum and body of stomach anastamosed with distal duodenum
134
What are hte complications of chronic pancreatitis
``` exocrine insufficiency - malabsorption endocrine insufficiency - diabetes pancreatic cancer pseudocyst biliary obstruction ```
135
What is the pathophysiology of colorectal cancer
adenoma-carcinoma sequence stepwise pattern of mutational activation of oncogenes (e.g. K-ras) and inactivation of tumour suppressor genes (e.g. p53) that results in cancer. epithelium to abnoramal epithelium to adenoma to adenocarcinoma
136
what proportion of adenomas will progress to adenocarcinomas
10%
137
What are the risk factors for colorectal carcinoma
``` sporadic! alcohol smoking high in processed meats diet age (>60yrs), family history, inflammatory bowel disease, low fibre diet, ```
138
What are the symptoms of colorectal cancer
``` change in bowel habits weight loss abdominal pain blood in stools tiredness ```
139
what are the signs of colorectal carcinoma
pale conjunctiva mass in abdomen mass on PR
140
What are the differential diagnoses for colorectal cancer
``` diverticular disease haemorrhoids anal fissure IBD diverticulitis ```
141
What investigations should be done in suspected colorectal carcinoma
FBC, LFTs, U+Es, CEA, clotting stool culture colonoscopy + biopsy
142
Describe the process of colorectal cancer screening
60-75y FOB home testing every 2 years | if +ve invited for colonoscopy
143
What is the most common location for colorectal carcinioma
rectum | sigmoid colon
144
State the Duke's staging of colorectal carcinoma
I - confined beneath muscularis mucosa II - extension through muscularis mucosa III - nearby lymph nodes IV - distant metastasis
145
Describe a right hemicolectomy and what it is used for
ileocolic, right colic, and right branch of the middle colic vessels (branches of the SMA) are divided and removed with their mesenteries. removal of caecum, ascending colon and hepatic flexure right sided cancers
146
Describe a left hemicolectomy
left branch of the middle colic vessels (branch of SMA/SMV), the inferior mesenteric vein, and the left colic vessels (branches of the IMA/IMV) are divided and removed with their mesenteries. removal of splenic flexure and descending colon left sided cancers
147
Describe a sigmoid colectomy
the IMA is fully dissected out removal of sigmoid sigmoid cancers
148
Describe an anterior resection
removal of sigmoid and rectum, formation of anastamosis between descending colon and remaining rectum. leaves the rectal sphincter intact a defunctioning loop ileostomy is performed to protect the anastomosis and reduce complications in the event of an anastomotic leak. This is then reversed electively approximately four to six months later. high rectal cancer
149
Describe an abdominoperineal resection
removal of the distal colon, rectum and anal sphincters, resulting in a permanent colostomy. low rectal tumours
150
Why is laparoscopic surgery preferred to open?
faster recovery times, reduced surgical site infection risk, reduced post-operative pain,
151
Describe a Hartmann's procedure
This operation involves the removal of the sigmoid colon and a variable portion of the upper rectum and left colon colon brought out through the abdominal wall to form colostomy. rectum is closed off with stitches or staples and returned to the pelvis. The procedure is usually reversible by surgery
152
What investigations should be done after the initial diagnosis of colerctal cancer has been made
CTCAP - look for metastasis and local invasion
153
What is neo-adjuvant chemotherapy?
chemotherapy before surgery Reduction of tumor mass decreases the extent and invasiveness of a surgery and makes it easier for the surgeon to distinguish between normal and cancerous tissue
154
What is adjuvant chemotherapy?
chemotherapy after surgery
155
What treatments can be used in palliative care for colorectal cancer
endoluminal stenting - to relieve/prevent obstruction | stoma
156
What are the heriditary causes of colorectal carcinoma?
HNPCC - hereditary non-polyposis colorectal carcinoma | FAP - familial adenomatous polyposis
157
What factors need to be present for an anastamosis to heal
adequate blood supply, mucosal apposition no tissue tension.
158
What is bowel obstruction?
structural block of passage of bowel contents through the bowel due to a mechanical obstruction
159
What is paralytic ileus?
bowel contents not moving due to lack of peristalsis
160
What can cause paralytic ileus
``` post operative chest infections, myocardial infarction, stroke acute kidney injury. ```
161
What are the key differences in examination between true bowel obstruction and paralytic ielus
obstruction - tinkling bowel sounds paralytic ileus - no bowel sounds
162
How is paralytic ileus managed>?
Daily U&Es Encourage mobilisation Reduce opiate analgesia and any other bowel mobility reducing medication Prolonged cases may warrant insertion of a nasogastric (NG) tube on free drainage and catheterising with a fluid balance chart
163
What are some extramural causes of bowel obstruction
external compression by mass adhesions hernias volvulus
164
What are some mural causes of bowel obstruction
``` strictures carcinoma intussception diverticular strictures Meckel's diverticulum ```
165
What are some intraluminal causes of bowel obstruction
faecal impaction foreign bodies - bezoars gallstone ileus
166
What are the most common causes of obstruction in the small bowel?
adhesions | hernias
167
What are the most common causes of obstruction in the large bowel?
tumours diverticular disease volvulus
168
What are the symptoms of bowel obstruction
vomiting - starts gastric contents, then bilious fluids, then faeculant absolute constipation abdominal pain - colicky abdominal distension
169
DEscribe the pathophysiology of bowel obstruction
gross dilatation of the proximal limb of bowel, results in increased peristalsis of the bowel. leads to secretion of large volumes of electrolyte rich fluid into the bowel (sometimes termed ‘third spacing’).
170
Why might vomiting not be present in bowel obstruction
closed-loop obstruction eg. volvulus or large bowel obstruction with competent ileocaecal valve
171
What might you find on examination in bowel obstruction?
``` distended abdomen patient in pain! scars from previous surgery tinkling bowel sounds hernias cachexia - cancer? discomfort on palpation ```
172
What signs might be present on examination if bowel obstruction has lead to bowel ischaemua
focal tenderness - rebound tenderness/guarding
173
What tests should be done in suspected bowel obstruction
``` ECG FBC, U+E, G+S, clotting, ABG AXR, erect CXR CT abdomen contrast fluoroscopy ```
174
Why is a CT abdomen more useful than AXR in bowel obstruction
(1) more sensitive for bowel obstruction; (2) can differentiate between mechanical obstruction and pseudo-obstruction; (3) can demonstrate the site and cause of obstruction (4) may demonstrate the presence of metastases if caused by a malignancy
175
What are the signs on AXR in small bowel obstruction
>3cm dilation valvulae conniventes - whole width bowel wall central location
176
What are the signs on AXR in large bowel obstuction
>6cm dilation haustra - not whole width bowel peripheral location
177
How is sigmoid volvulus seen on AXR
‘coffee bean’ appearance thick 'inner wall' represents the double wall thickness of opposed loops of bowel, with thinner outer walls due single thickness.
178
How does bowel obstruction lead to bowel ischaemia
as the bowel distends, the intramural vessels become stretched and the blood supply is compromised, leading to ischaemia, necrosis and perforation
179
How is bowel obstruction treated conservatively?
``` NBM and insert wide bore NG tube to decompress the bowel IV fluids - 4-5 litres in first 24h correct any electrolyte disturbances Urinary catheter and fluid balance. Analgesia ```
180
What proportion of obstruction due to adhesions resolves with conservative management?
60-70%
181
Why would bowel obstruction need to be managed surgically?
Suspicion of intestinal ischaemia closed loop bowel obstruction Small bowel obstruction in a patient with a virgin abdomen (no prev abdo surgery) A cause that requires surgical correction (e.g. a strangulated hernia or obstructing tumour) If patients fail to improve with conservative measures (typically after ≥48 hours)
182
How can sigmoid volvulus be treated?
colonoscopy! deflates it | 90% resolve!
183
How is volvulus defined?
torsion of the colon around it's mesenteric axis resulting in compromised blood flow and closed loop obstruction.
184
Describe the pathophysiology of peripheral arterial disease
progressive narrowing of the arteries (by atherosclerosis) leading to symptomatic redeced blood supply to the limbs
185
What are the risk factors for peripheral vascular disease?
``` IHD obesity diabetes age HTN hyperlipidaemia FH ```
186
What are the symptoms of PVD
pain on walking in calf/buttock/thigh, relieved by rest
187
What are the signs of PVD
pale limb prolonged capillary refill lack of peripheral pulses arterial ulcers
188
What are the key differentials in PVD
acute limb ischaemia | spinal stenosis
189
What are the key differences between PVD and spinal stenosis
PVD - pain on walking, relieved within by rest stenosis- pain on walking or standing, relieved by sitting down
190
Define the stages of chronic limb ischaemia
Stage I Asymptomatic Stage II Intermittent claudication Stage III Ischaemic rest pain Stage IV Ulceration or gangrene, or both
191
What investigations should be carried out in suspected PVD
ABPI, doppler ultrasound, ECG, BP | FBC, lipids, glucose
192
What is ABPI
ankle brachial pressure index ratio of the systolic blood pressure in the lower leg to that in the arms.
193
What do the findings of the ABPI mean?
>1.2 Abnormally hard vessel (e.g. calcified due to diabetes) 1.0-1.2 Normal 0.8-0.9 Mild arterial disease: mild claudication 0.5-0.79 Moderate arterial disease: severe claudication <0.5 Severe arterial disease: rest pain, ulceration and gangrene (critical ischaemia)
194
Describe the medical management of PVD
``` risk factor modification: stop smoking exercise weight loss diabetic control HTN control lipid lowering antiplatelets - statin/clopidogrel ```
195
What are the options in surgical management of chronic limb ischaemia
revascularisation = angioplasty. used for single lesions | venous graft bypass - used for diffuse disease
196
Which patients with PVD should be considered for surgery?
risk factor modification has been discussed; and supervised exercise has failed to improve symptoms. Any patients with critical limb ischaemia
197
How is critical limb ischaemia defined?
Ischaemic rest pain for greater than 2 weeks duration, requiring opiate analgesia Presence of ischaemic lesions or gangrene objectively attributable to the arterial occlusive disease ABPI less than 0.5
198
What are the signs on examination of critical limb ischaemia
``` pale and cold limb weak or absent pulses. hair loss, atrophic skin, ulceration gangrene thickened nails ```
199
define acute limb ischaemia
sudden decrease in perfusion to a limb hat threatens the viability of the limb
200
What are the causes of acute limb ischaemia
thrombosis - rupture of atherosclerotic plaque embolus trauma
201
Where could be the source of the embolus in acute limb ischaemia
AF, post-MI mural-thrombus, abdominal aortic aneurysm prosthetic heart valves.
202
What are the signs and symptoms of acute limb ischaemia
``` acute onset of: Pain Pallor Pulselessness Paresthesia Perishingly cold Paralysis ```
203
Describe the characteristics of a class I acute limb ischaemia
no sensory loss no motor loss arterial and venous doppler present no threat to limb viability
204
Describe the characteristics of a class IIa acute limb ischaemia
``` minor sensory loss no motor loss arterial doppler not present venous doppler presnt salvageable ```
205
Describe the characteristics of a class IIb acute limb ischaemia
``` moderate sensory loss - more than toes mild motor loss arterial doppler not present venous doppler present salveagable if immediately revascularised ```
206
Describe the characteristics of a class III acute limb ischaemia
``` sensory loss motor loss arterial doppler not present venous doppler not present not salvagable - permanant tissue damage inevitable ```
207
What is the differential diagnosis for acute limb ischaemia
critical chronic limb ischaemia, acute DVT spinal cord compression peripheral nerve compression
208
What investigations should be carried out in acute limb iscahemia
ECG, doppler ultrasound, ABPI FBC, thrombophilia screen, serum lactate CT angiogram, USS abdo
209
How long does it take for acute limb ischaemia to develop into irreversible tissue damage
6 hours
210
What is the initial management of acue limb ischaemia
IV heparin infusion if embolic, the options are: Embolectomy Local intra-arterial thrombolysis Bypass surgery If thrombotic disease, the options are: Local intra-arterial thrombolysis Angioplasty Bypass surgery
211
What are the signs of irreversible limb ischaemia
mottled non-blanching appearance | hard woody muscles
212
What is the management for irreversible limb ischaemia
urgent amputation
213
What is the long term management of acute limb ischaemia after reperfusion
``` modification of risk factors stop smoking weight loss exercise antiplatelet' control HTN statin control diabetes control source of embolus ```
214
What are the complications after reperfusion in acute limb ischaemia
compartment syndrome hyperkalaemia - K+ released from cells AKI from rhabdomyolysis
215
What are the causes of constipation
Post-operative ileus Physiological – low fibre diet or poor fluid intake. Iatrogenic – opioid analgesia, anticonvulsants, or antihistamines. Functional – mainly painful defecation (such as anal fissures). Pathological - bowel obstruction, hypercalcaemia, or hypothyroidism).
216
What examination and investigations need to happen in constipation
DRE abdominal examination - for signs of obstruction or peritonism if no obvious cause or signs of obstruction etc: Ca2+, TFT, AXR
217
Name the four types of laxative
bulk forming osmotic stimulant faecal softeners
218
Which types of laxative are used for hard stools?
bulk forming | osmotic
219
Which types of laxative are used for soft stools?
stimulants
220
Name some bulk forming laxatives
isphagula husk | methylcellulose
221
What is the mechanism of action of bulk forming laxatives
increase bulk and fibre, absorb water | leads to stimulation as the bowel is stretched
222
How long does it take bulk forming laxatives to act
72hrs

Finals (32 decks)

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