Surgery Flashcards
(244 cards)
1
Q
part of bowel most likely to be affected by ischaemic colitis
A
splenic flexure
2
Q
thumbprinting at splenic flexure
A
ischaemic colitis
3
Q
part of bowel usually affected by mesenteric ischaemia
A
small bowel
usually embolism of SMA
4
Q
Usual ABPI in diabetic
A
> 1.2 - causes calcification
5
Q
Ix of mesenteric ischaemia
A
lactate
6
Q
test to confirm H. pylori eradication
A
Urea breath test
7
Q
who gets Hep A
A
travelers
8
Q
transmission of Hep A
A
faecal - oral
9
Q
is there a vaccine for Hep A?
A
Yes
10
Q
Ix of Hep A
A
clotted blood for serology
11
Q
Hepatitis that leads to chronic infection
A
Hep B
Hep C
12
Q
transmission of Hep B
A
sex
mother - to - child
blood
13
Q
HBsAg - what does it indicate
A
earliest marker of infection
14
Q
is there a vaccine for Hep B?
A
yes
15
Q
does vaccination against Hep B result in +ve HBsAg
A
no!!
16
Q
Anti-HBsAg - what does it indicate
A
recovery
absence of infectivity
further immunity from Hep B
17
Q
HBeAg - what does it indicate
A
+++ infectious
18
Q
Anti-HBcAg (IgM) - what does it indicate
A
recent acute infection
19
Q
Anti-HBcAg (IgG) - what does it indicate
A
with +ve HBsAg = chronic Hep B infection
with -ve HBsAg = infection in the remote past
20
Q
autoantibodies in autoimmune hepatitis
A
Type 1 = ASMA, ANA
Type 2 = AMA
21
Q
transmission of Hep C
A
sex
mother - to - child
blood
22
Q
what other type of Hepatitis is hep D found with
A
Hep B
23
Q
transmission of Hep E
A
faecal-oral
24
Q
Where does Hep E come from
A
animals
25
is there a vaccine for Hep E?
no
26
Mx autoimmune hepatitis
short term Tx (<6m):
corticosteroid (pred)
long term Tx (>6m):
corticosteroid + immunosuppression
27
Mx alcoholic hepatitis
1. prednisolone
| 2. pentoxyphylline
28
Mx of hep B
1. pegylated interferon-alpha
| 2. tenofovir or entecavir
29
causes of acute pancreatitis
'GET SMASHED'
```
G = gallstones
E = ethanol
T = trauma
```
```
S = steroids
M = mumps
A = autoimmune
S = scorpion bites
H = hypercalcaemia/hyperparathyroidism
E = ERCP
D = drugs
```
30
drugs causing pancreatitis
mesalazine
| azothioprine
31
Ix pancreatitis
1. serum lipase/amylase
2. CT (gold standard)
3. CXR - to rule out other causes
32
complications of pancreatitis
```
peripancreatic fluid collections
pseudocysts
pancreatic necrosis
abscess
haemorrhage
```
33
presentation of chronic pancreatitis
dull abdo pain, worse 30mins after eating
radiates to back
steatorrhoea
diabetes mellitus
34
Ix chronic pancreatitis
gold standard = CT
also - pancreatic enzymes, HbA1c, ultrasound
35
location of most pancreatic ca
head of the pancreas
36
presentation pancreatic ca
painless jaundice (due to compression of the CBD)
anorexia
wt loss
steatorrhoea
Trousseau's sign (clots in superficial veins in uncommon sites)
37
Ix pancreatic ca
Gold standard = pancreatic protocol CT
38
tumour marker pancreatic ca
ca 19-9
39
Mx pancreatic ca
surgery candidate:
Whipple's procedure - pancreaticoduodenectomy + adjuvant chemo
non-surgical candidate:
ERCP + stenting
40
presentation of colonic polyps
incidental finding on qFIT - most common
- rectal bleeding
- mucus discharge
- tenesmus
- change in bowel habit
41
Mx of colonic polyps
colonoscopy +/- polypectomy
42
what type of ca is the majority of colorectal ca
adenocarcinomas
43
genetic conditions predisposing to colorectal ca
Familial Adenomatous Polyposis (FAP)
- > 100 polyps
- early onset
- autosomal dominant
- ass. with thyroid ca
Hereditary Non-Polyposis Colorectal Ca (HNPCC) (Lynch synd)
- < 100 polyps
- late onset
- autosomal dominant
- ass. with endometrial and gastric ca
44
how often are people screened in Scotland for colorectal ca
ever 2 years aged 50-74 y
45
presentation of colorectal ca
depends on site.
L side =
bleeding/mucus PR, altered bowel habit, tenesmus, mass PR
R side =
wt loss, anaemia, abdo pain
46
screening test for colorectal ca
QFit
47
tumour marker colorectal ca
CEA
48
Ix colorectal ca
1. Colonoscopy
2. CT colonography
3. Double contrast barium enema
staging - CT chest/abdo/pelvis
49
dukes classification of colorectal ca
```
A = confined to mucosa
B = invading bowel wall
C = lymph mets
D = distant mets
```
50
Mx colorectal ca
stage I - III:
colonic resection/colectomy + resection of regional lymph nodes
stage IV:
evaluate whether mets are resectable
if not - palliative
51
what nodes do colorectal ca spread to
mesenteric nodes
52
distant mets for colorectal ca
liver
53
Mx of rectal ca
anterior resection
or
abdomino-perineal excision of rectum
54
hartmann's procedure
- surgical resection of recto-sigmoid colon
- close of anorectal stump
- end colostomy
55
what is diverticular disease
presence of asymptomatic outpouchings of the gut wall
56
most common location of diverticular disease
sigmoid colon
57
cause of diverticular disease
lack of dietary fibre - weak gut wall - mucosal herniation
58
presentation diverticulitis
LIF pain
pyrexia
high WCC
generalized peritonism
59
Ix diverticular disease
colonoscopy
60
Ix diverticulitis
CT abdomen
61
Mx symptomatic diverticular disease
dietary modification = fibre supplements
62
Mx diverticulitis
analgesia + oral or IV Abx
63
Mx recurrent diverticulitis
colectomy
64
cause of pseudomembranous colitis
c. diff
65
presentation of pseudomembranous colitis
```
recent Hx of Abx use
diarrhea
prolonged hospitalization/nursing home resident
abdo pain
fever
n+v
```
66
Mx pseudomembranous colitis
Non severe = Metronidazole
Severe = Vancomycin + Metronidazole
67
cause of ischaemic colitis
low flow in the IMA
68
presentation ischaemic colitis
lower left abdo pain +/- bloody diarrhea
| tenderness
69
Mx ischaemic colitis
conservative - most resolve spontaneously
if gangrenous - resection + stoma
70
complications of ischaemic colitis
toxic megacolon
microscopic colitis
radiative colitis
71
presentation of microscopic colitis
chronic, watery diarrhoea
72
presentation of acute mesenteric ischaemia
+++ pain
biochem:
acidotic BG
increased lactate
increased WCC
73
g/s diagnostic Ix mesenteric ischaemia
CT angiogram
74
Mx acute mesenteric ischaemia
bowel resection
- re-anastomose if poss
- if not, stoma
75
presentation of chronic mesenteric ischaemia
```
post-prandial abdo pain
wt loss (eating hurts0
upper abdo bruit
+/- PR bleeding
```
76
Mx chronic mesenteric ischaemia
surgery - pros v cons, ongoing risk of infection
77
causes of large bowel obstruction
colorectal ca
sigmoid volvulus
caecal volvulus
strictures - diverticula, inflammatory
78
sigmoid volvulus on AXR
coffee bean appearance
79
caecal volvus on AXR
fetal appearance
80
presentation large bowel obstruction
colicky abdo pain
abdo distension
'tinkling bowel sounds'
failure to pass faeces
81
Ix large bowel obstruction
1. AXR (haustration - do not cross lumen's width)
| 2. CT
82
Mx large bowel obstruction is signs of strangulation
straight to theatre - laparotomy + resection of bowel
83
Mx large bowel obstruction if no signs of strangulation
drip + suck
```
NBM
NG tube (suck - to decompress bowel)
IV fluids (drip)
```
84
Mx fissure-in-ano
1. conservative - increase fibre and fluids, bulk forming laxatives
2. topical GTN or Diltiazem
3. Botulinum toxin A
4. Surgery
85
how is the course of a fistula-in-ano predicted clinically
Goodsall Rule:
if posterior to transverse anal line - curved course
if anterior to transverse anal line - straight course
86
how is the course of a fistula-in-ano visualised
MRI
87
Mx rectal prolapse
surgery - rectopexy (abdo approach), or perineal approach
88
stomas that are spouted
small bowel stomas
89
stomas that are flat
large bowel stomas
90
what is a loop stoma
entire loop of bowel is brought through one abdominal incision, with both the proximal and distal openings exteriorized in the same sit
91
what is an end stoma
one end of the colon is brought through the abdominal incision and stitched to the skin
92
use of a loop ileostomy
to defunction the colon e.g. following rectal ca surgery
93
use of an end ileostomy
following complete resection of the colon
94
use of an end colostomy
if anastomosis of the colon is not achievable
95
use of a loop colostomy
defunctioning of a distal segment of colon
96
cause of biliary colic
stone lodged in CBD
97
presentation biliary colic
intermittent RUQ pain
worse on eating fatty foods
no fever
98
Ix biliary colic
```
abdominal US
inflammatory markers (normal)
```
99
Mx biliary colic
outpatient cholecystectomy
100
cause of acute cholecystitis
inflammation of the gallbladder secondary to impacted stones
101
presentation acute cholecystitis
constant RUQ pain
Murphy's +ve
Fever
102
what is murphy's sign
pressing RUQ elicits pain and catches breath on inspiration
| pressing LUQ doesn't elicit pain
103
Mx acute cholecystitis
IV Abx - cefuroxime or ciprofloxacin+met
+
Early laparoscopic cholecystectomy
104
what is ascending cholangitis
infection of the biliary tree
105
cause of ascending cholangitis
E.coli
106
presentation ascending cholangitis
Charcot's Triad:
RUQ pain
fever
jaundice
107
Ix ascending cholangitis
abdominal US
| inflammatory markers
108
Mx ascending cholangitis
sepsis 6
| ERCP (after 24-48h)
109
presentation bowel perforation
severe, generalized abdo pain
guarding
firm, peritonitic abdo
rebound and percussion tenderness
110
Ix bowel perforation
```
erect CR (air under diaphragm)
urgent CT
```
111
Mx bowel perforation
urgent surgical repair
112
mechanism of enzyme inducers
these REDUCE the availability of drugs
113
mnemonic for enzyme inducers
CRAPS out drugs
```
Carbamazepine
Rifampicin
bArbituates
Phenytoin
St John's Wort
```
114
mechanism of enzyme inhibitors
these INCREASE the availability of drugs
115
mnemonic for enzyme inhibitors
Some Certain Silly Compounds Annoyingly Inhibit Enzymes, Grrr
```
Sodium valproate
Ciprofloxacin
Sulphonamides
Cimetidine/Omeprazole
Amiodarone, Antifungals
Isoniazid
Erythromycin/Clarithromycin
Grapefruit juice
```
116
mnemonic for Cytp450 substrates
COWPATS
```
Carbamazepine
Oral contraceptive pill
Warfarin
Phenytoin
Acetylcholinesterase inhibitors
Theophylline
Steroids/Statins
```
117
ALARMS symptoms
```
A = anaemia
L = loss of weight
A = anorexia
R = rapid onset
M = melaena
S = swallowing difficulties
```
118
If ALARMS symptoms are present, what Ix is first line?
urgent OGD
119
If ALARMS symptoms are not present what is the Mx?
1. Lifestyle changes + Antacids & r/v in 2w
120
if anatacids and lifestyle changes do not help dyspepsia, what do you do next?
```
test for H.pylori
options -
C-13 urea breath test
serum antibodies to h. pylori
stool antigen test
```
121
if H. pylori test comes back -ve, what is the Mx?
prescribe PPI
122
if H. pylori test comes back +ve, what is the Mx?
```
triple therapy for H.pylori
1. PPI
2. Amoxicillin or Metronidazole
3. Clarithromycin
for 10-14d
```
123
presentation of gastritis
vomiting
epigastric pain
no suspicious features of malignancy
124
causes of gastritis
1. h. pylori
2. NSAID use
3. alcohol
4. autoimmune
125
non-invasive h. pylori testing
C-13 urea breath test
serum antibodies to h. pylori
stool antigen test
126
presentation gastric ulcer
dyspepsia
epigastric pain
nausea + anorexia
MADE WORSE BY EATING
127
presentation duodenal ulcer
dyspepsia
epigastric pain
MADE BETTER BY EATING
128
most common cell type of gastric cancer
adenocarcinoma
129
risk factors for gastric cancer
```
h. pylori
blood group A
pernicious anaemia
smoking
gastric adenomatous polyps
```
130
types of gastric cancer
intestinal
- more common
diffuse
- younger patients
- worse prognosis
131
invasive testing for H. pylori (at biopsy)
rapid urease "CLO" test
132
presentation gastric cancer
```
dyspepsia
n+v
wt loss
dysphagia
virchows node
```
133
what is virchows node
enlarged left supraclavicular node - Troiser's sign
lymph nodes from the digestiv eviscera drain to the thoracic duct
134
Ix gastric cancer
1. OGD + biopsy
2. staging - CT chest/abod/pelvis
- endoscopic USS
- PET CT
135
histology of gastric cancer
signet ring cells
136
Mx gastric cancer
Localised tumour: endoscopic muscosal resection
<5cm from GOJ: total gastrectomy
>5-10cm from GOJ: subtotal gastrectomy
137
incubation period s. aureus
1-6h
138
transmission s. aureus
cream cakes
139
incubation period bacillus cerus
1-6h
140
transmission bacillus cerus
rice
141
incubation period clostriudium perfringens
1-6h
142
transmission clostridium perfringens
contaminated meat
143
incubation period E.coli 0157
12-48h
144
most common cause of travellers diarrhoea
E.coli
145
presentation E.coli 0157
sudden onset
| severe bloody diarrhoea
146
incubation period salmonella
12-48h
147
transmission of salmonella
poultry
| raw eggs
148
Mx salmonella
ciprofloxacin
149
incubation period shigella
48-72h
150
transmission of shigella
door + toilet handles
| schools
151
Mx shigella
ciprofloxacin & co-trimoxazole
152
incubation period campylobacter
48-72h
153
transmission of campylobacter
dairy
| most common cause of food poisoning
154
complication of campylobacter
guillain barre syndrome
155
Mx campylobacter
ciprofloxacin
156
incubation period cholera
48-72h
157
transmission cholera
food or poor sanitation
158
presentation cholera
profuse watery diarrhoea
159
incubation period giardiasis
> 7 days
160
transmission giardiasis
protozoa
161
incubation period amoebiasis
> 7 days
162
transmission amoebiasis
protozoa
163
incubation period norovirus§
12-48h
164
transmission of norovirus
cruise ships (faecal-oral)
165
incubatio nperiod rotavirus
12-48h
166
transmission of rotavirus
children, winter
167
PBC: M or F more common?
Females
168
what is PBC
chronic liver disorder, causing progressive cholestasis and eventual cirrhosis (damage to interlobular ducts)
169
presentation PBC
```
ITCH
fatigue
cholestatic jaundice
RUQ pain
xanthelasma
clubbing
hepatosplenomegaly
hyperpigmentation (esp over pressure points)
```
170
autoantibody PBC
Anti-mitochondrial antibodies (AMA) - most specifc
171
LFTs in PBC
cholestatic appearance - high bilirubin, high Alk phos, more than ALT
172
Mx PBC
ursodeoxycholic acid
173
Mx itch in PBC
cholecystramine
174
complications of PBC
malabsorption
sicca syndrome
portal HTN
hepatocellular carcinoma
175
what forms the hepatic portal vein
```
superior mesenteric vein
+
gastric vein
+
splenic vein
+
part of the inferior mesenteric vein
```
176
where are the anastomoses of the portal venous system with the systemic venous system
1. oesophageal and gastric venous plexus
2. umbilical vein
3. haemorrhoidal venous plexus
177
what causes hepatic encephalopathy
+++ ammonia (normally removed by the liver), travels to the brain and causes fluid shift
178
asterixis
'liver flap' seen in hepatic encephalopathy
179
Mx hepatic encephalopathy
lactulose - to clear the gut
180
pathology of ascites
renal dysfunction + portal HTN + splanchnic arterial vasodilation, leading to:
RAAS activation, leading to sodium and water retention
181
Ix ascites
abdo USS
182
Mx ascites
1. paracentesis
| 2. intrahepatic portosystemic shunt (TIPSS) - connects hepatic vein to portal vein
183
causes of spontaneous bacterial peritonitis
E.coli
| Klebsiella
184
prophylaxis for SBP
oral ciprofloxacin
185
Mx SBP
mild - PO co-trimoxazole
| severe - IV tazocin
186
what is hepatorenal syndrome
cirrhosis + ascites + renal failure
187
pathology of hepatorenal syndrome
abnormal haemodynamics
| causes splanchnic & systemic vasodilation, but renal vasoconstriction
188
types of hepatorenal syndrome
HRS type 1
- rapidly progressive
- v poor prognosis
HRS type 2
- slowly progressive
- poor prognosis
189
Mx of hepatorenal syndrome
liver transplant
vasopressin analogues (terlipressin)
albumin
TIPPS
190
energy daily requirement
30kcal/kg/day
191
protein daily requirement
0.8-1g/kg/day
192
components of the MUST score
BMI + wt loss score + acute disease effect score
```
0 = low risk
1 = med risk
2> = high risk
```
193
types of enteric feeding
NG tube
NJ tube
PEG tube
194
indications for enteric feeding
oral intake likely to be absent for 5-7d AND gut is functioning
195
purpose of NG tube
short term use
196
purpose of NJ tube
used if there is a problem with reflux or gastric emptying
197
what is a PEG tube
percutaneous gastrostomy
| - tube directly into stomach through abdo wall
198
purpose of PEG tube
longer term feeding is needed (4-6w)
or
a mechanical swallowing obstruction
199
indications for parenteral nutrition
intestinal failure
200
how is parenteral nutrition administered
via central line
201
what is refeeding syndrome
a ++ insulin surge on feeding someone who has been depleted of nutrition. therefore -- potassium
202
how to avoid refeeding syndrome
start feeding at around 10kcal/kg/day
203
causes of hepatocellular carcinoma
cirrhosis - hep B, hep C, alcohol
204
presentation hepatocellular carcinoma
wt loss
RUQ pain
acute liver failure
decompensated cirrhosis
205
tumour marker hepatocellular carcinoma
AFP
206
Mx hepatocellular carcinoma
surgical resection
207
presentation liver haemangioma on US
hyperechoic spot - ring of fibrous tissue around it
208
associations with liver adenoma
OCP
| anabolic steroids
209
Mx liver adenoma
males - excision (irrespective of size)
females - imaging after 6m
- <5cm or decrease in size: annual MRI
- >5cm: excision
210
cause of a liver hyatid cyst
parasite from tapeworms - Echinococcus granulosis
211
Mx liver hyatid cyst
1. albendazole (sterilizes the cyst)
| 2. surgical excision
212
sources of a liver abscess
biliary sepsis
| structures drained by the portal venous system
213
mucosal inflammation only
ulcerative colitis
214
transmural inflammation
crohn's disease
215
characteristic site of UC
rectum, and extends proximally
216
characteristic site of crohn's
can involve anywhere from mouth to anus
217
microscopic changes in UC
crypt abscesses
reduced goblet cells
non-granulomatous
218
microscopic changes in crohn's
skip lesions
fissures
deep ulcers (cobblestoning)
fistula formation
219
smoking - protective or increases risk of UC?
protective
220
smoking - protective or increases risk of crohns?
increases risk
221
genetic ass. with UC and crohns
HLA-B27 +ve
222
presentation UC
```
bloody stool
proctitis
mucus discharge
urgency
tenesmus
abdo pain
```
223
condition associated with UC
PSC
224
presentation of crohns
determined by site of disease
small intestine - abdo cramps, diarrhea, wt loss
mouth - ulcers, angular chelitis
anus - perianal pain, abscesses
225
condition associated with crohns
PBC
226
Ix UC
1. stool studies - faecal calprotectin
2. flexible sigmoidoscopy + biopsy
3. colonoscopy
227
Ix crohns
1. stool studies - faecal calprotectin
| 2. colonoscopy - 'cobblestoning'
228
Ix acute exacerbation of UC
1. abdo x-ray or CT
'lead pipe colon' - loss of haustra
'thumb printing - mucosal oedema
229
Mx UC
1. 5-ASA (sulfasalazine, mesalazine)
2. steroids (prednisolone, hydrocortisone)
3. immunosuppressants (azathioprine, methotrexate)
4. anti-TNF
5. surgery
230
Mx crohns'
1. steroids (prednisolone, hydrocortisone)
2. immunosuppressants (azathioprine, methotrexate)
3. anti-TNF
4. surgery
231
surgery in UC - curative?
yes!
| total protocolectomy with permanent ileostomy or ileo-anal anastomosis
232
surgery in crohn's - curative?
no
| ileocaecal resection
233
types of gallstones
cholesterol (90%)
| pigment (10%)
234
risk factors for gallstones
the 5 F's
```
Fat
Forty
Fertile
Female
Family history
```
235
what is mirizzis syndrome
gallstone in the gallbladder neck presses on the bile duct, causing jaundice
236
complication of gallstones involving the gut
gallstone ileus
237
Ix acute cholecystitiss
1. bloods
| 2. USS (if inconclusive - MRCP)
238
what is cholangiocarcinoma
cancer of the biliary system
239
presentation of cholangiocarcinoma
painless jaundice
wt loss
pruritus
pale stools/dark urine
240
Ix cholangiocarcinoma
1. bloods - LFTs (obstructive pattern)
2. MRCP
3. CT/MRI
241
Mx cholangiocarcinoma
resection, XRT
| palliative
242
inheritance of haemochromatosis
autosomal recessive
243
presentation haemochromatosis
```
fatigue
erectile dysfunction
arthralgia
'bronze diabetic'
liver symptoms
cardiomyopathy
arthritis
```
244
Ix of haemochromatosis
1. iron studies
