Surgery - General Surgery Flashcards
(259 cards)
1
Q
define a fistula
A
an abnormal connection between 2 epithelial surfaces
2
Q
what does a “mercedes benz” scar on the abdomen indicate?
A
liver transplant
3
Q
what does a hockey stick scar indicate?
A
renal transplant
4
Q
at which 3 stages is the surgical safety checklist carried out?
A
NAME?
5
Q
what is the ASA grade?
A
a scoring system to classify the physical status of a patient for anaesthesia
6
Q
indications for a pre-op ECG?
A
- possible CVD| - aged >65
7
Q
how long should the patient have been nil by mouth for pre-surgery
A
6 hours of no food and 2 hours of no fluids (true NBM)
8
Q
pre-op management of pts on warfarin?
A
NAME?
9
Q
when should contraception with oestrogen in it be stopped pre-op?
A
4 weeks before surgery
10
Q
peri-op management of pts on long term steroids?
A
- additional IV hydrocortisone at induction| - double normal steroid dose post-op
11
Q
drugs to be stopped pre-op?
A
NAME?
12
Q
diabetes drugs and their complications peri-op?
A
NAME?
13
Q
management of insulin peri-op?
A
- long acting: reduce dose- short acting: stop - start “sliding scale”
14
Q
what is a “sliding scale”?
A
variable rate insulin infusion along with glucose, NaCl and K+ infusions
15
Q
what are the options for VTE prophylaxis?
A
NAME?
16
Q
what are the 4 components of having the capacity to make a decision?
A
NAME?
17
Q
what is a lasting power of attorney (LPA)?
A
when a person legally nominates someone to make decisions on their behalf IF they lack mental capacity
18
Q
in which settings is a deprivation of liberty safeguards (DoLS) valid? what does this mean?
A
NAME?
19
Q
what are the 4 types of consent form?
A
- 1: pt consenting - 2: parent consenting on behalf of child- 3: pt will not lose consciousness for the procedure- 4: pt lacks capacity
20
Q
NSAIDs are contraindicated in….
A
NAME?
21
Q
what is patient controlled analgesia (PCA)?
A
NAME?
22
Q
examples of strong opiates?
A
NAME?
23
Q
risk factors for post-op nausea and vomiting (PONV)?
A
NAME?
24
Q
which anti-emetics can be used prophylactically post-op?
A
NAME?
25
MOA of ondansetron? it should be avoided in....
- serotonin receptor antagonist| - pts at risk of long QT interval
26
dexamethasone drug class? it should be used with caution in...
- corticosteroid| - diabetes, immunocompromised pts
27
MOA of cyclizine? it should be used with caution in....
- histamine receptor antagonist| - HF, elderly
28
which antiemetics can be used for episodes of PONV?
#NAME?
29
MOA of prochloperazine? it must be avoided in...
- dopamine receptor antagonist| - parkinson's!!!!
30
non-drug management of PONV?
pressure on P6 acupuncture point of wrist
31
3 methods of enteral feeding?
#NAME?
32
what is total parenteral nutrition (TPN)?
- IV infusion of all nutrients| - done via central line
33
potential post-op complications?
#NAME?
34
what is a "third space"? give some examples
- space in body where there shouldn't be any fluid- peritoneal cavity (ascites)- pleural cavity (pleural effusion)- pericardial cavity (pericardial effusion)- joints (effusion)
35
which pts require fluid restriction?
- HF- CKD- hyponatraemia (low Na+)
36
examples of insensible fluid loss?
#NAME?
37
signs of hypovolaemia?
- systolic BP <100- HR >90- CRT >2 secs- RR >20- cold peripheries- dry mucous mems, loss of skin turgor, sunken eyes- reduced body weight - reduced UO
38
signs of fluid overload?
#NAME?
39
signs O/E of pulmonary oedema?
#NAME?
40
what are the 3 main indications for IV fluids?
#NAME?
41
indications for fluid resuscitation?
- sepsis| - hypotension
42
examples of indications for fluid replacement?
- vomiting| - diarrhoea
43
example of indication for maintenance fluids?
NBM due to bowel obstruction
44
what are the 2 types of IV fluid?
- crystalloid| - colloid
45
examples of crystalloid fluids?
- 0.9% NaCl (normal saline)- 5% dextrose- hartmann's solution - plasma-lyte 148
46
which condition benefits from being given human albumin solution?
decompensated liver disease
47
what type of fluid is used in resuscitation? give some examples
isotonic ones:- 0.9% saline - hartmann's solution- plasma-lyte 148
48
how is fluid resuscitation carried out?
- A-E assessment to find out fluid status- initial 500ml fluid bolus over 15 mins (stat)- repeat A-E assessment - repeat fluid bolus if necessary- seek expert help if no response after 2L of fluid
49
which fluids can never be infused rapidly?
- any containing high K+ conc| - risk of arrhythmia or cardiac arrest
50
principles of using maintenance fluids?
#NAME?
51
examples of when maintenance fluids would be needed?
negative fluid balance unable to take PO fluids:- NBM waiting for surgery- bowel obstruction
52
what should be included in maintenance fluids?
- 25-30ml / kg / day water- 1 mmol / kg / day Na+, K+ and Cl- - 50-100g / day glucose
53
why is glucose included in maintenance fluids?
- to prevent ketosis| - NOT to meet nutritional needs
54
how is overprescribing of maintenance fluids in obese patients prevented?
use ideal body weight instead of BMI
55
monitoring requirements of maintenance fluids?
to be done at least daily: - fluid status assessment - look at fluid balance chart- UEs
56
in which patient groups should maintenance fluids be prescribed with caution?
#NAME?
57
differentials for generalised abdominal pain?
#NAME?
58
differentials for RUQ pain?
#NAME?
59
differentials for epigastric pain?
#NAME?
60
differentials for central abdominal pain?
#NAME?
61
differentials for RIF pain?
- appendicitis (later)- ectopic pregnancy- ruptured ovarian cyst- ovarian torsion- meckel's diverticulitis
62
differentials for LIF pain?
#NAME?
63
differentials for suprapubic pain?
#NAME?
64
differentials for loin to groin pain?
#NAME?
65
differentials for testicular pain?
- testicular torsion| - epididymo-orchitis
66
signs of peritonitis?
#NAME?
67
how can peritonitis be classified?
#NAME?
68
prognosis in SBP?
poor
69
management of the acute abdomen patient?
#NAME?
70
pre-surgical management of acute abdomen?
#NAME?
71
peak incidence of appendicitis?
- ages 10-20| - less common in young children and >50s
72
where is the appendix found?
- arises from caecum| - where the 3 teniae coli meet (longitudinal colon muscles)
73
what happens when the appendix ruptures?
#NAME?
74
presentation of appendicitis?
- abdo pain which starts off central, then moves to RIF within 24h- tenderness at mcburney's point - anorexia, N+V- low-grade fever- rovsing's sign- guarding - rebound tenderness- tender to percuss
75
where is mcburney's point
1/3 of the way from the ASIS to the umbilicus
76
describe rovsing's sign. where is this seen?
- palpating the LIF causes pain in the RIF| - appendicitis
77
how is appendicitis diagnosed?
#NAME?
78
key differentials for appendicitis?
- ectopic pregnancy (check bHCG)- ovarian cysts- meckel's diverticulum - mesenteric adenitis
79
describe meckel's diverticulum. which complications could it cause?
#NAME?
80
what is mesenteric adenitis? which conditions is it associated with?
#NAME?
81
what causes an appendix mass?
- when the omentum sticks to the inflamed appendix| - forms mass in RIF
82
management of appendicitis?
#NAME?
83
advantages of laparoscopic surgery over open surgery for appendicitis?
- fewer risks| - faster recovery
84
complications of appendicectomy?
#NAME?
85
which type of bowel obstruction is more common, small or large?
small
86
how does bowel obstruction result in fluid loss? what determines the severity of this?
- colon should be absorbing fluid but the fluid cannot reach it because of blockage- results in "third spacing"- higher up the obstruction, the worse the third spacing
87
3 main causes of bowel obstruction?
#NAME?
88
less common causes of bowel obstruction?
- volvulus (large bowel)- diverticular disease- strictures secondary to Crohn's- intusussception
89
causes of adhesions?
#NAME?
90
presentation of bowel obstruction?
- green, bilious vomiting- abdo distension- diffuse abdo pain- obstipation- "tinkling" bowel sounds in early stages
91
initial investigation of choice and findings in bowel obstruction?
#NAME?
92
complications of bowel obstruction?
#NAME?
93
findings on bloods in bowel obstruction?
#NAME?
94
initial management of a bowel obstruction?
#NAME?
95
investigations for bowel obstruction?
#NAME?
96
surgical management of bowel obstruction?
- exploratory surgery if cause unclearotherwise depends on cause:- adhesiolysis- hernia repair- emergency resection - stent to move tumour out of way if Ca cause
97
pathophysiology of ileus?
temporary cessation of peristalsis in the small bowel
98
causes of ileus?
#NAME?
99
which electrolyte imbalances could cause ileus?
- hypokalaemia| - hyponatraemia
100
commonest time to have ileus? prognosis?
- straight after abdo surgery| - self-resolves within a few days
101
presentation of ileus?
literally identical to that of BO: - green, bilious vomiting- abdo distension- diffuse abdo pain- obstipation- ABSENT bowel sounds instead of tinkling
102
management of ileus?
#NAME?
103
pathophysiology of volvulus?
- bowel twists around on itself and surrounding mesentery| - causes closed-loop obstruction
104
what is a closed loop bowel obstruction?
when an area of bowl is isolated by obstruction on either side of it
105
types of volvulus? hint: where they happen
- sigmoid volvulus| - caecal volvulus
106
most common type of volvulus? typical demographic affected?
- sigmoid volvulus| - elderly
107
risk factors for volvulus?
- parkinson's - being a nursing home resident- chronic constipation - high fibre diet- pregnancy- presence of adhesions
108
presentation of volvulus? hint: same as BO
#NAME?
109
how is volvulus diagnosed?
- abdo XR shows "coffee bean" sign in sigmoid volvulus| - confirmed with contrast CT
110
initial management of volvulus?
same initial management as BO:- make NBM- NG tube- IV fluids
111
conservative management of volvulus?
endoscopic decompression
112
surgical management of volvulus?
- laparotomy - hartmann's procedure- ileocaecal resection / right hemicolectomy if caecal
113
presentation of abdominal wall hernia?
#NAME?
114
complications of hernias?
#NAME?
115
how does a strangulated hernia present? what's the significance of this?
- pain and tenderness over lump| - needs emergency surgery, bowel will be dead in hours
116
describe a maydl's hernia
a hernia with 2 different loops of bowel in it
117
describe a richter's hernia
#NAME?
118
management options for a hernia?
#NAME?
119
which hernias can be managed conservatively?
- hernias with a wide neck (low risk of complications)| - where pts have too many comorbidities for surgery
120
how can inguinal hernias be classified?
- direct| - indirect
121
differentials for lump in inguinal region?
#NAME?
122
what is an indirect inguinal hernia?
bowel herniating through the inguinal canal
123
what is the inguinal canal? where does it run between?
#NAME?
124
describe the course of the round ligament in females?
#NAME?
125
where is the deep inguinal ring found?
halfway between ASIS and pubic tubercle
126
how can an indirect inguinal hernia be differentiated from a direct one?
#NAME?
127
what causes direct inguinal hernias to form?
weakness of the abdo wall at hesselbach's triangle
128
RIP: borders of hesselbach's triangle?
- rectus abdominis- inferior epigastric vessels- poupart's (inguinal) ligament
129
describe a femoral hernia
abdo contents herniating through the femoral canal
130
FLIP: boundaries of the femoral canal?
#NAME?
131
what is the femoral triangle?
large area at top of thigh which contains the femoral canal
132
where do incisional hernias occur?
at the site of incision of past surgery
133
typical demographic affected by umbilical hernias? prognosis?
- neonates| - good, self-resolving
134
describe a hiatus hernia
stomach herniating through hole in diaphragm
135
4 types of hiatus hernia?
#NAME?
136
risk factors for hiatus hernia?
#NAME?
137
presentation of hiatus hernia?
#NAME?
138
investigations for hiatus hernia?
#NAME?
139
management of hiatus hernia?
- conservative| - surgical laparoscopic fundoplication
140
what is a haemorrhoid?
an enlarged anal vascular cushion
141
risk factors for haemorrhoids?
#NAME?
142
give examples of how intra-abdominal pressure could be raised
- weightlifting| - chronic coughing
143
how can haemorrhoids be classified?
- 1st deg: no prolapse- 2nd deg: prolapse when straining, disappears on relaxing- 3rd deg: prolapse when straining and does NOT disappear on relaxing, but can be pushed back- 4th deg: prolapsed permanently
144
presentation of haemorrhoids?
#NAME?
145
signs O/E of haemorrhoids?
- external ones are visible on inspection| - internal ones may be felt on PR exam
146
differentials for rectal bleeding?
#NAME?
147
non-surgical management of haemorrhoids?
#NAME?
148
surgical management of haemorrhoids?
#NAME?
149
what causes a haemorrhoid to become thrombosed?
when there is strangulation at the base of the haemorrhoid
150
presentation of thrombosed haemorrhoid?
- purplish, very tender lumps around anus| - PR impossible due to pain
151
what is a diverticulum?
a pouch in the bowel wall
152
what is the difference between diverticulosis / diverticular disease and diverticulitis?
#NAME?
153
which parts of the bowel wall are most susceptible to diverticula forming?
areas where there are no teniae coli
154
most commonly affected portion of the bowel in diverticulosis?
sigmoid colon
155
risk factors for diverticulosis?
#NAME?
156
how is diverticulosis diagnosed?
usually asymptomatic, incidental finding on colonoscopy / CT scans
157
how could diverticulosis present?
#NAME?
158
management of diverticulosis?
#NAME?
159
how does acute diverticulitis present?
#NAME?
160
management of uncomplicated diverticulitis?
- no need for admission- PO co-amox for 5 days- analgesia, but avoid NSAIDs and opiates- clear liquid diet until symptoms improve - follow up in 2 days to review symptoms
161
management of severe diverticulitis?
#NAME?
162
complications of acute diverticulitis?
#NAME?
163
3 main arteries supplying abdominal arteries?
#NAME?
164
presentation of chronic mesenteric ischaemia? hint: triad
#NAME?
165
describe the abdo pain felt in chronic mesenteric ischaemia
- central- colicky- comes on 30 mins after eating- lasts 1-2 hours
166
how does chronic mesenteric ischaemia result in weight loss?
food avoidance due to pain after eating
167
risk factors for chronic mesenteric ischaemia?
same as any other cardiovascular disease:- ageing- FHx- smoking- DM- HTN- raised cholesterol
168
how is chronic mesenteric ischaemia diagnosed?
on CT angiography
169
management of chronic mesenteric ischaemia?
#NAME?
170
how is revascularisation performed for chronic mesenteric ischaemia?
either:- endovascular (percutaneous mesenteric artery stenting), 1st line- open surgery (endarterectomy or bypass)
171
key risk factor for acute mesenteric ischaemia?
AF (basically an embolic stroke but in the gut)
172
early presentation of acute mesenteric ischaemia?
#NAME?
173
later presentation of acute mesenteric ischaemia?
#NAME?
174
first line investigation in acute mesenteric ischaemia?
contrast CT
175
findings on bloods in acute mesenteric ischaemia?
- metabolic acidosis| - raised lactate
176
management of acute mesenteric ischaemia?
surgery to remove bowel and remove / bypass thrombus in artery
177
prognosis in acute mesenteric ischaemia?
- poor| - >50% mortality rate !
178
risk factors for bowel Ca?
#NAME?
179
which aspects of diet can increase risk of bowel Ca?
#NAME?
180
what does FAP result in? pattern of inheritance?
- adenomas (polyps) develop in the large intestine- polyps can become malignant, usually before age of 40- autosomal dominant
181
how can bowel Ca be prevented in someone with FAP?
entire large intestine removed
182
which familial conditions increase the risk of bowel Ca?
- FAP| - HNPCC (esp colorectal Ca)
183
presentation of bowel Ca?
#NAME?
184
2WW criteria for bowel Ca?
- >40 with abdo pain and unexplained weight loss- >50 with unexplained PR bleeding- >60 with change in bowel habit or Fe def anaemia
185
what does FIT testing look for? what is it used for?
- amount of human Hb in stool| - to screen for bowel Ca
186
why is the FOB test for bowel Ca not very accurate?
- just detects any form of blood| - false positives from red meat blood
187
who gets screened for bowel Ca? how often is this done?
- those aged 60-74| - they get sent a FIT test every 2 years
188
how is the FIT test result interpreted?
if positive, invite them to colonoscopy
189
investigations for bowel Ca?
- colonoscopy (gold standard)- sigmoidoscopy- CT colonography - CT TAP (thorax, abdo, pelvis - done for staging)- CEA tumour marker on bloods
190
how is bowel Ca classified?
TNM system or using dukes' classification:- A: confined to mucosa of bowel wall- B: extends through muscle of wall- C: lymph nodes- D: metastatic disease
191
management of bowel Ca?
#NAME?
192
what is low anterior resection syndrome? how does it present?
#NAME?
193
investigations following curative surgery for bowel Ca?
- serum CEA levels| - CT TAP
194
what are most gallstones made of?
cholesterol
195
complications of gallstones?
#NAME?
196
4Fs: risk factors for gallstones?
#NAME?
197
presentation of gallstones?
- "biliary colic":- severe RUQ colicky pain- triggered by meals (esp fatty ones)- lasts 30 mins - 8 hours- associated N+V
198
findings on LFTs in gallstones?
#NAME?
199
first line investigation in gallstones?
USS
200
findings on USS in gallstones?
- stones in GB / ducts- bile duct dilatation (should be <6mm diameter)- acute cholecystitis
201
findings on USS indicative of acute cholecystitis?
#NAME?
202
management of gallstones in bile duct?
ERCP
203
complications of ERCP procedure?
#NAME?
204
management of gallstones?
#NAME?
205
what is post-cholecystectomy syndrome? features?
#NAME?
206
what is acute cholecystitis?
inflammation of gallbladder
207
causes of acute cholecystitis?
anything compressing cystic duct:- gallstones- tumour- infection- fasting (GB not stimulated to move)
208
presentation of acute cholecystitis?
- RUQ pain+/- radiates to R shoulder- fever- N+V
209
findings O/E of acute cholecystitis?
- high HR- high RR- RUQ tenderness- murphy's sign
210
findings on bloods in acute cholecystitis?
- raised inflamm markers| - raised WCC
211
describe murphy's sign
#NAME?
212
first line investigation in acute cholecystitis?
abdo USS
213
findings on USS in acute cholecystitis?
#NAME?
214
management of acute cholecystitis?
- needs emergency admission- make NBM- IV fluids- ABx- NG tube insertion if vomiting - ERCP to remove stones stuck in CBD - cholecystectomy if <72h of symptom onset
215
complications of acute cholecystitis?
#NAME?
216
what is GB empyema? how is it managed?
#NAME?
217
what is acute cholangitis?
- infection and inflammation of bile ducts| - surgical emergency
218
2 main causes of acute cholangitis?
- obstruction (e.g. stones) in bile ducts stopping slow| - infection from ERCP procedure
219
commonest causative organisms in acute cholangitis?
#NAME?
220
presentation of acute cholangitis? hint: triad
charcot's triad:- RUQ pain- fever- jaundice
221
management of acute cholangitis?
#NAME?
222
key complications of acute cholangitis?
#NAME?
223
which procedures can be carried out in ERCP for acute cholangitis?
#NAME?
224
what is a cholangiocarcinoma? what is the most common type?
- Ca of bile ducts| - adenocarcinoma
225
risk factors for cholangiocarcinoma?
- PSC| - liver flukes (parasitic infection)
226
presentation of cholangiocarcinoma?
#NAME?
227
signs of obstructive jaundice?
#NAME?
228
what is courvoisier's law? what is the significance of this?
- a palpable GB with jaundice is unlikely to be gallstones| - makes cholangiocarcinoma / pancreatic Ca more likely
229
investigations for cholangiocarcinoma?
- CT TAP for staging- CA 19-9 (tumour marker, raised)- MRCP- ERCP to put stent in and relieve obstruction
230
management of cholangiocarcinoma?
- curative surgery in early cases| - rest is palliative
231
commonest site for a pancreatic Ca?
head of pancreas
232
prognosis of pancreatic Ca?
- very poor- avg survival = 6m- 5YS = <25%
233
presentation of pancreatic Ca?
- painless obstructive jaundice - non-specific upper abdo / back pain- unintentional weight loss- palpable mass in epigastric region- change in bowel habit- N+/-V- new onset / worsening T2DM
234
describe trosseau's sign of malignancy. where is it seen?
- migratory thrombophlebitis in someone with Ca| - seen in pancreatic Ca
235
investigations in pancreatic Ca?
- diagnosed on CT with histology from biopsy- CT TAP for staging- CA 19-9- MRCP- ERCP to put stent in- biopsy
236
management of pancreatic Ca?
- 90% of cases are palliative - 10% can have a form of surgery- total / distal pancreatectomy- whipple procedure
237
palliative care options in cholangiocarcinoma and pancreatic Ca?
#NAME?
238
which structures are removed in whipple procedure?
#NAME?
239
3 key causes of acute pancreatitis?
#NAME?
240
which demographics are more likely to get gallstone pancreatitis?
- women| - older pts
241
which demographics are more likely to get alcohol-induced pancreatitis?
- men| - younger pts
242
presentation of acute pancreatitis?
- severe epigastric pain- radiates to back- associated vomiting - abdo tenderness- systemic signs (low-grade fever, tachycardia)
243
how is acute pancreatitis diagnosed?
- clinically| - plus raised amylase level on bloods
244
investigations for acute pancreatitis?
#NAME?
245
which score can be used to assess severity of acute pancreatitis?
- Glasgow score| - 2 = moderate, 3 = severe
246
management of acute pancreatitis?
#NAME?
247
complications of acute pancreatitis?
- necrosis of pancreas- infection - abscess - pseudocysts (up to 4w after pancreatitis)- chronic pancreatitis
248
commonest cause of chronic pancreatitis?
alcohol
249
complications of chronic pancreatitis?
#NAME?
250
how does chronic pancreatitis result in diabetes?
#NAME?
251
management of chronic pancreatitis?
#NAME?
252
how does chronic pancreatitis result in steatorrhoea?
#NAME?
253
indications for liver transplant?
#NAME?
254
who gets priority in liver transplants?
- acute ones| - chronic ones get put on a list, wait approx 5m
255
which patient factors suggest they may not be suitable for a liver transplant?
- severe comorbidities (e.g. bad CKD, HF)- excessive weight loss / malnutrition- active hep B / C- end-stage HIV- active alcohol use
256
how long should a patient have been abstinent for before a liver transplant?
at least 6m
257
after care / advice following a liver transplant?
#NAME?
258
drugs used for immunosuppression post-liver transplant?
#NAME?
259
signs of liver transplant rejection?
#NAME?
