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What is the surgical Mx of GORD?
only if not repsonding to medical Mx
- Temporary dysphagia
- gas-bloat syndrome [cant burp]
- rare -> slipped wrap
Dysphagia -> dificulty swallowing, indicates oesophageal disease [solids vs liquids]
Odynophagia -> pain on swallowing
Achalasia -> dificulty swallowing fluids -> functional narrowing + peristaltic failure, spluttering + chronic chest infections
give 3 causes of Dysphagia?
- Peptic oesophagitis [hiatus hernia], Ca Oesophagus or cardia
- Subcarinal lymph node secondaries from bronchial Ca
- Candida oesophagitis [post-major surgery]
- Myasthenia Gravis
How would you investigate Dysphagia? Give 3 examples.
- Plain CXR -> exclude Bronchial Ca
- Flexi pharyngeoscopy
- Barium swallow
- Oesophageal manometry
- 24h pH measure
What are the pathological types of Oesophageal Ca and how does it present? Give 2 risk factors.
Pc -> dysphagia [insiduous] -> invade out, then fungate in
RF -> age >50, ^^ETOH, Smoking [SCC]
Outline the Mx fo oesopageal Ca?
Resection only if curative
[neo-adjuvant to shrink tumour initially]
- Ablate tumour w alcohol/laser
- Oesophageal stenting
Look at this nice photo of stuff.
What is Courvousiers law?
So, for jaundice patient, either gallbladder is palpable or not.
not palpable; dilated biliary tree chronic thickened gallbladder [cant dilate] -> likely stones
Palpable; dilated biliary tree, dilated palpable bladder -> pancreatic head/ampullary Ca obstructing
Give 3 Ix for the Jaundiced patient?
- Urine -> urobilinogen
- Bloods -> Hep serology, LFT [obstructive = ^^conj bili + ^^AlkPhos, transaminases normal]
- Liver USS -> ?dilated biliary tree
What are the types of gallstones? 
- Mixed [common] -> abn bile constituents, stasis/infection -> 10% radio-opaque
- Cholesterol [10%] -> radiolucent [transparent]
- Pigment -> haemolysis, malaria, infection
What are the Pc of Gallstones?
- Billiary colic [RUQ pain, no fever]
- Acute cholecystitis -> RUQ + shoulder tip pain, ?fever
- Chronic obstruction -> atrophic mucosa, subsersoal fibrosis
Mx of Gallstones?
conservative -> chenodeoxycholic acid [slow dissolution of cholesterol stones]
Surgical -> Cholecystectomy [lap vs open]
Give 3 complications of gallstones?
- Acute -> acute cholecystitis -> empyema + perforation
- Chronic -> Gallbladder Ca
- Biliary colic [pain no fever]
- acute pancreatitis
- intermittent jaundice
-> Gallstone ileus
Give 3 CF of acute Pancreatitis?
- Acute severe epigastric pain [radiating to back]
- pain relieved by sitting
- tachycardic, fever, jaundice, shock, peritonism
- Cullens sign [periumbilical bruising]
- Grey-Turners sign [flank bruising]
Give 5 causative factors for Acute Pancreatitis?
- Trauma -> seatbelts
- Scorpion venom
- Hyperlipidaemia, hypercalcaemia, hypothermia
- Drugs -> steroids, AZA, NSAIDs
How do you assess the severity of Pancreatitis?
Imrie [Glasgow] Score
- PaO2 <8
- Age >55
- Calcium <2
- Renal function -> urea >16
- Enzymes -> AST >200
- Albumin -> <32
- Sugar -> BM >10
Give 3 investigations for suspected acute pancreatitis?
- serum amylase [>1000]
- Serum Lipase
- ALT + AST
- LFT -> cholestatic obstruction
- Abdo XR -> sentinel loop [dilated adynamic small bowel]
- USS Biliary tree -> ?ductal stones
- CT Abdo -> limited -> ?necrosis
Outline the Mx of acute pancreatitis?
Expert help, NBM, NGT
Analgesia -> pethidine [morphine + sphincteric contraction]
monitor closely, worseing -> ICU ?ARDS
Give 2 early complications of acute pancreatitis?
Give 3 late complications of acute pancreatitis? [>1week]
- Pancreatic necrosis + pseudocyst formation
- bleeding [elastase erodes major vessels]
- thrombosis + bowel necrosis
- Recurrent oedematous pancreatitis
Outline the CF, Ix + Mx of chronic pancreatitis?
CF -> severe upper gI pain + ^^^amylase [no other features of AP]
Pancretic calcification on AXR
surgical only if structural abn found -> sphincterotomy, total pancreatectomy, partia pancreatectomy
Outline the pathology + Natural history of Pancreatic Ca
Exocrine vs endocrine
most common = ductal adenocarcinoma, well differentiated
70% head of pancreas
early mets to local lymph nodes, haematogenous spread via portal vein
Give 3 RF for Pancreatic Ca
- previous resectional gastric surgery
- ingestion of nitrosamines [beer, fish, tobacco smoke]
Give 4 CF of Pancreatic Ca
- Painless jaundice
- Weight loss
- Gnawing abdominal pain
- pale stools, dark urine, priritis, Palpable gallbladder
- Acute Pancreatitis
- Gastric outlet obstruction
Give 3 Ix for suspected Pancreatic Ca?
- USS -> dilated ducts
- CT scan -> primary imaging, CT guided biopsy
- Cytology -> endoscopic USS guided FNA
Outline the Mx of Pancreatic Ca? [Radical vs palliative]
Late presentation -> prognosis = poor
- Whipples -> pancreaticoduodenectomy
- +/- post op adjuvant chemo therapy
- Pain relief -> block coeliac ganglion
- Obstructive jaundice -> stenting of strictures
Define Small bowel ischaemia, give 3 CF and briefly outline the Mx.
Occlusiuon of SMA [in elderly] -> necrosis + gangrene of midgut -> poor prognosis
- Abdo pain [central, severe and constant]
- Resus -> ABCDE
- Resect necrotic bowel -> early embolectomy/thrombolisation
Define rectal prolapse and classify it.
Protusion of rectum through anus. 3 kinds;
Complete -> >5cm, 2 layers of rectal wall, old age females with weak pelvic floors
Incomplete [Mucosal] -> limited to mucosa in children CF -> straining etc
Concealed -> intussuception of upper into lower rectum
Mx of rectal prolapse?
Bulk laxatives + manual reduction
Look at this nice picture
Protrusion of viscus outside normal body cavity
Revision of inguinal anatomy:
Iguinal canal = oblique passage in lower badominal wall through which spermatic cord passes [round ligaminet in fems]
indirect = patent prcessus vaginalis
internal [deep ring] - opening in transversalis fascia 1cm above mid-inguinal point [ASIS -> Pubic symphysis]
Superficial ring -> end -point of canal 1cm medial + superior to pubic tubercle
Describe an indirect inguinal hernia?
- Patent processus vaginalis
- contents enter inguinal ring and into scrotum
-> hydrocele, inguinal hernia, scrotal hernia
- Incarcerated = non-reducible ^^risk of strangulated [nb venous occlusion = first]
Describe a direct inguinal hernia?
- Weakness of abdominal wall
- Precipitated by ^^IA pressure -> lifting
- protrusion through transversalis fascia
- wide neck -> not much worry about incarceration/strangulation
Describe a femoral hernia
- More common in women
- Protrusion through femoral ring, down femoral canal
- dificult to reduce
Important features in lump Hx?
- ?systemic upset
Describe a lump?
- TranSilluminable -> fluid filled
Give 4 causes for rectal bleeding?
- nb fresh vs occult [red v black]
- ?Painful defaecation
- Colorectal Ca
- Inflammatory BD
- Perianal Disease
Rare -> trauma, Ischaemic colitis, radiation proctitis, Aorto-enteric fistula
Give 3 colonic neoplasms
Adenoma -> all malignant potential [adenoma-carcinoma sequence]
rare -> lymphoma, lipoma carcinoid, Leiomyoma
What are the types of colon adenoma and where are they found? [Polyps]
75% within rectum + sigmoid colon
Tubular adenoma -> pedunculated/ sessile, retain tubular form similar to gastric mucosa, least likely to transform
Villous adenoma -> sessile [no stalk] + frond like, secrete mucuous, more dysplastic ^^risk of change
Tubulo-villous -> most common, pedunculated stalk = normal mucosa [effect of pullng of jobbies creates stalk
What are the Pc of Polyps?
- Rectal bleeding
- ^^Mucus production
- Hypokalaemia [villous adenoma]
- polyp prolapse
What are the Pc of Colon carcinoma?
- Change in bowel habit
- Large bowel obstruction
- Rectal bleeding
- obstructive jaundice [hepatic secondaries]
- Systemic features -> malaise, anorexia, weight loss
Give 4 risk factors for colon carcinoma
- Diet -> processed meats, low fibre, low antioxidants
- Genetic -> FAP, HNPCC, Peutz-Jegher syndrome
Outline the pathophysiology of Colon cancer?
- Adenoma-carcinoma sequence
- exophytic [protrude into lumen] can cause obstruction
- met via lymph and haematogenous
- haem -> liver & lungs [cannon ball mets]
- Lymph -> para-aortic nodes
Outline TNM staging of colon cancer?
- T1 = submucosa
- T2 = Muscularis Propria
- T3 = subserosal
- T4 = peritoneal invasion
- N1 = 1-3 regional Lymph nodes
- N2 = >4 LN
M = distal mets
Outline the surgical managment of a colon based tumour [not rectal]
Principles -> as minimally invasive as possible, clear resection margin, pre-op ABx [cefuroxime + metronidazole]
Caecal/Ascending colon -> Right hemicolectomy -> Ileo-colic artery + right colic artery
Transverse colon -> transverse colectomy -> middle colic artery
Descending colon -> left hemicolectomy -> left colic artery [branch of inf mesenteric]
Outline resection of rectal/Sigmoid tumour
Sigmoid = sigmoid colectomy -> left lower colic + sigmmoid arteries
For rectum -> resection of superior rectal artery + mesorectum [fat + LN] -> preferably anus sparing
- Ant resection -> 1-2cm from anus
- J-Pouch -> same as AR, but pouch reduces urgency
- APR -> sphincter invasion, proximal colostomy
- Hartmanns -> emergency resection of rectosigmoid lesions, anastamosis at later date
Give 3 CF of bowel obstruction
- Vomiting with relief
- Colic abdo pain
- Abdominal distension
How do you discrn between small and large bowel obstruction?
- Small = vomit earlier, less distension, pain higher
- Large -> Pain = constant
- Small = central gas shadows, valvulae conniventaes completely cross lumen
- Large = gas proximal to blockage, not in rectum, Haustra = incomplete
Give 3 causes for obstruction?
- Post-op ileus [bowel sounds absent, no pain]
rare -> crohns, gallstone, intussuception
Outline the Mx of Obstruction
Drip + suck -> NGT, Fluids, NBM
- Further investigation
- Flatus -> sigmoid volvulus
Look at this picture of causes of abdo pain!
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