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EXAM PREP > Surgical Review > Flashcards

Surgical Review Flashcards

1
Q

Common presentation of pancreatitis

A

Epigastric pain radiating to the back
Relieved by sitting forward
Vomiting
Signs: Tachycardia, fever, jaundice, shock, rigid abdomen, tenderness, Cullen’s sign, Grey Turner’s sign

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2
Q

Ix for acute pancreatitis

A

FBC - WCC, esp. neutrophilia
Serum amylase (up to 24hrs), serum lipase (>72hrs)
CRP - elevated, predictor for severe
ABG - deoxygenation, acid-base disturbance
UEC - Hypocalcaemia, renal function, glucose
LFTs - hypoalbuminaemia, AST, LDH
Imaging: AXR, CXR, CT, MRI, USS if gallstones suspected
ERCP

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3
Q

Management of acute pancreatitis

A 
Conservative is mainstay (80% will resolve)
IV Fluids +++
NBM - NG tube or parenteral nutrition
Analgesia - Morphine, fentanyl 
Monitor vital signs and urine output
Daily bloods - FBC, UEC, Calcium, glucose, amylase, ABG
Treat underlying cause/complications
ERCP for gallstones
Repeat CT to monitor progress and look for complications.
Antibiotic prophylaxis if 
Surgical--> if worsening
Laparotomy with debridement
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4
Q

Ix of diverticular disease

A

CT abdomen, AXR to identify obstruction or perforation
FBC- WCC
CRP, ESR

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5
Q

Common presentation of diverticular disease

A

Hard stools alternating with diarrhoea
Colicky pain (suprapubic or in left iliac fossa)
Local tenderness, guarding or rigidity ‘left-sided appendicitis’
Sometimes a palpable mass
Constipation, distension, diarrhoea, rectal bleeding
Diverticulitis: fever, localised/genralised peritonism

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6
Q

Management of diverticulitis and complications

A

Diverticulitis - mild attack can be managed outpatient w/ bowel rest and ABs + analgesia
Analgesia
NBM
IV FLuids
ABs
Abscess - CT guided drainage
Perforation – surgery (Hartmann’s procedure or primary anastomosis)
Haemorrhage - ABC, transfusion may be needed - bleeding usually stops with bed rest, but may need embolisation or colonic resection

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7
Q

Presentation of complications of diverticulitis

A

Abscess - swinging fever, leucocytosis, boggy rectal mass
Perforation - ileus, peritonitis, shock
Haemorrhage - sudden and painless, common cause of big PR bleed

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8
Q

What is Meckel’s Diverticulum (rule of 2s)

Management?

A 
Most common GI anomaly - presents with bleeding, ulcer, infection, torsion, hernia, obstruction
2% of the population
2cm long
2 ft from the ileocaecal junction
2 years old
Mx- Laparotomy
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9
Q

Common presentations of PUD

A 
Chronic - relapse and remission
Epigastric pain related to meals
Heartburn/indigestion/reflux
Halitosis
Melaena
Haematemesis
Vomiting
Bloating, fullness
Fatigue (anaemia)
Swallowing difficulties
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10
Q

Management of PUD

A

Usually medical - Triple therapy
-H pylori eradication - amoxycillin, clarithromycin
- PPI (esomeprazole)
Lifestyle - avoid aggravating food, stress, smoking, NSAIDs, alcohol

Surgical if haemorrhage, perforation or pyloric stenosis or not responsive to med therapy.

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11
Q

Management of GORD

A
  • Antacids and PPI
  • 2nd Line - H2 receptor antagonist (ranitidine)

Surgery - laparoscopic fundoplication, repair hiatus hernia

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12
Q

GORD - when to send for endoscopy?

A
  • Alarm symptoms - dysphagia, odynophagia, wt loss, persistent vomiting, haematemesi/melaena, signs of anaemia
  • Refractory GORD
  • Uncertain Dx
    Consider endoscopy with RF for complications
  • Male gender
  • Older age
  • severe/frequent sx
  • change in sx
  • obesity
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13
Q

Complications of GORD

A 
Oesophagitis
Ulcers
Strictures
Iron deficiency
Malignancy
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14
Q

Post-operative complications

A 
Fever
Confusion - common in elderly
Dyspnoea/hypoxia
Hypotension
Hypertension
Oliguria
N+V
Hyponatraemia
Bleeding
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15
Q

Post-operative Fever

A 
Immediate (POD 1) - inflammatory reaction, reaction to blood products, malignant hyperthermia
POD 1-2
- atelectasis
- early wound infection from C. diff or GAS
- aspiration pneumonia
POD 3-7 likely infectious
- UTI
- Surgical site
- IV site, catheter
- Septic thrombophlepbitis
- Leakage of bowel anastamosis
POD 8+
- Intra-abdominal abscess
- DVT/PE
- C. difficule colitis
-Endocarditis
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16
Q

Specific complications of biliary surgery

A
  • Retained stones
  • CBD stricture
  • Cholangitis
  • Haemobilia
  • Jaundice
  • Haematemesis
  • Pancreatitis
  • Bile leak –> peritonitis
  • Hepatorenal syndrome (cirrhosis, ascites, renal failure)
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17
Q

Specific complications of laparotomy

A

Wound breakdown –> burst abdomen (early warning sign = pink serous abdomen)
Infection/haematoma
Incisional hernia

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18
Q

Specific complications of mastectomy

A

Arm lymphoedema (in node sampling/dissection)

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19
Q

Specific complication in arterial surgery

A 
Bleeding
Thrombosis
Embolism
Graft infection
MI
AV fistula formation
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20
Q

Specific complication in aortic surgery

A 
Gut ischaemia
Renal failure
Respiratory distress
Trauma to ureters
Trauma to anything
Ischaemic events from distal trash from dislodged thrombus
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21
Q

Specific complication in colonic surgery

A 
Sepsis
Ileus
Fistula
Anastomotic leak
Obstruction from adhesions
Haemorrhage
Trauma to ureters or spleen
22
Q

Specific complications of small bowel surgery

A

Short-gut syndrome - diarrhoea and malabsorption, weight loss, renal stones

23
Q

Specific complications of a splenectomy

A

Increased infections - need extra vaccines (HIB, meningococcal, pneumococcal, pre-op is better)
Sepsis
Acute gastric dilatation
Thrombocytosis
Will need life-long prophylactic ABs - phenoxymethylpenicillin or erythromycin
Should carry card/medical bracelet

24
Q

Main indications for splenectomy

A

Hypersplenism
Splenic trauma
Haemolysis (particularly WAHA)
Congenital haemolytic anaemias

25
Q

Causes of massive splenomegaly

A 
CML
Malaria
Myelofibrosis
Leishmaniasis
Gaucher's disease
26
Q

Specific complications of gastrectomy

A

Recurrent ulceration
Abdominal fullness/early satiety (take small frequent meals, improves with time)
Diarrhoea
Gastric tumour (rare complication of decreased acid production)
Metabolic complicatons
- Dumping syndrome (fainting and sweating after eating due to hypoglycaemia)
-Weight loss
- Blind loop syndrome (bacterial overgrowth and malabsorption)
-Anaemia
- osteomalacia

27
Q

Specific complications of prostatectomy

A 
Haematuria
Haematospermia
Urethral stricture/trauma
Infection- prostatitis
Erectile dysfunction
Urinary incontinence
Retrograde ejaculation
Hypothermia
28
Q

management of haemorrhoids

A 
Medical mx of 1st degree
- Increase fluid
- High fibre diet
- +/- topical analgesics and stool softener
Use topical steroids for flare-ups for short courses
2nd-3rd degree - as above +
- rubber band ligation
- sclerosants
- infrared coagulation
4th degree or failure of previous mx
- excisional haemorrhoidectomy
29
Q

Classification of haemorrhoids

A
  1. Remain in the rectum
  2. Prolapse through the anus on defecation, but spontaneously reduce.
  3. As per second degree, but require digital reduction
  4. Remain persistently prolapsed
30
Q

Complications of stomas

A 
Best prevention is pre-op stoma care/education
Early complications
- Haemorrhage at stoma site
- stoma ischaemia
- High output --> hypokalaemia
- obstruction 2ndry to adhesions
- stoma retraction
Delayed complications
- Obstruction
- Dermatitis around stoma site
- Stoma prolapse
- Stomal intussusception
- Parastomal hernia
- Fistula
- Psychological problems
31
Q

Signs and sx of refeeding syndrome

A
  • Rhabdomyolysis
  • Red and white cell dysfunction
  • Respiratory insufficiency
  • Arrhythmias
  • Cardiogenic shock
  • Seizures
  • Sudden death
32
Q

How to prepare a T2DM for surgery. NIDDM

A
  • Tight glycaemic control HbA1c <7%
  • Give usual medication the night before surgery (except long-acting sulfonylurease)
    omit morning medication
  • Restart meds after surg
  • Check serum glucose levels hourly during surg – may need SC insulin if persistent hyperglycaemia
33
Q

How to prepare IDDM for surgery

A
  • Place patient 1st on list
  • Give all usual insulin night before surgery
  • continue long acting basal insulin
  • don’t give bolus on morning of surg.
  • monitor BSL and give dextrose infusion if hypo
34
Q

DDx neck lumps

A

Lymph node - reactive or infiltrative
–reactive is normally infectious –> Viral (URTI, EBV, CMV, HIV)or bacterial (syphilis, brucella)
-non-infectious causes–> sarcoidosis, amyloidosis, CTD, SLE, RA
- Infiltrative = malignant (haematological or metastatic)
Thyroid lumps
Skin - cysts, lipoma
Don’t miss carotid artery aneurysm
Salivary glands pathology
Mumps, parotid tumour

35
Q

Lumps in the thyroid.

A

Diffuse goitre - iodine deficiency, congenital, autoimmune, acute thyroiditis, physiological in preg.
Nodular goitre - multinodular goitre, solitary thyroid nodule (toxic, non-toxic)
Thyroid cancer -papillary, follicular, medullary, lymphoma, anaplastic

36
Q

Indications for thyroid surgery

A

Pressure sx - difficulty breathing, stridor
Failed medical management
Carcinoma
Cosmetic reasons
Symptomatic patients planning pregnancy (thyroid function increases in preg.)

37
Q

Specific complications of thyroid surgery

A 
Recurrent laryngeal nerve palsy
Haemorrhage
Hypoparathyroidism (check Ca daily)
Thyroid storm
Hypothyroidism
38
Q

Risk factors for breast cancer

A

Family hx- BRCA 1 and 2 –> age of onset, bilaterality, ovarian cancer
Age
Unopposed oestrogen activity -Early menarche
Late menopause, nulliparity, HRT, not breastfeeding, obesity, OCP
Previous radiation exposure
Previous breast ca

39
Q

Types of breast cancer

A

DCIS (Ductal carcinoma in situ)
Invasive ductal carcinoma (70%)
Invasive lobular carcinoma (10-15%)
Medullary carcinoma (5%, associated with BRCA 1)

40
Q

Staging of breast cancer (Stage 1-4)

A

Stage 1 - confined to the breast, mobile
Stage 2 - confined to the breast, mobile with lymph nodes in ipsilateral axilla
Stage 3 - fixed to the muscle, but not the chest wall, ipsilateral lymph nodes matted and may be fixed
Stage 4 - complete fixation of tumour to chest wall, distant mets

41
Q

Staging of breast cancer (TNM)

A 
T1 - under 2cm
T2 - 2-5cm
T3 - >5cm
T4 - FIxed to the chest wall, peau de orange
N1 - mobile ipsilateral nodes
N2 - fixed nodes
M0 - no mets
M1 - mets
42
Q

AAA common presentation

A

Abdominal pain radiating to the back
Expansile, pulsatile mass
If ruptured –> shock
Risk of rupture increases with age

43
Q

Risk factors for AAA

A 
Age
Male gender
Smoking
Family hx
 Atherosclerosis
Hypertension
Hypercholesterolaemia
Other vascular aneurysm
Connective tissue disorders
44
Q

Indications for AAA repair

A

Male with AAA>5.5cm
Female with AAA >5.0cm
Rapid growth >1cm/year
Symptomatic AAA

45
Q

Management of ruptured AAA

A
  • Vascular surgeon, anaesthetist, theatre ASAP
  • cross-match 10-40 units
  • Catheter
  • Large bore cannula
  • Keep systolic BP <100 to contain leak
  • Prophylactic ABs cephazolin, metronidazole
  • Surgery: p
    Ix - Hb and amylase, ECG
46
Q

Management of non-emergent AAA

A

EVAR - endovascular repair (stenting)

47
Q

Cardinal features of critical limb ischaemia

A

Ulceration, gangrene and foot pain at rest

Requires revascularation within 4-6 hrs to save the limb

48
Q

SIgns of PVD

A 
Pulseless
Punched out/painful ulcers
Postural colour change
Pale
Perishingly cold
Pain 
Parasthaesia
49
Q

Management of PVD

A
  1. Risk factor modification
    - Quit smoking - vital!
    - HTN control
    - Cholesterol control
  2. Prescribe clopidogrel
  3. Management of claudication
    - Supervised exercise programs to improve collateral blood flow
    - Vasoactive drugs (recommended in those who don’t want to undergo surg.)
  4. Surgical
    - Percutaneous transluminal angioplasty (PTA) –> Balloon and stent
    - Bypass
    - Amputation
50
Q

Management of varicose veins

A

Treat underlying cause
Education - avoid prolonged standing, elevate legs where possible, lose weight, regular walks, support stockings,
Surgical - endovascular treatment

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