General Surgery

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Author:
mewinstanley@googlemail.com
ID:
260700
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General Surgery
Updated:
2014-02-08 08:22:56
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finals
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genereal surgery for finals
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  1. What is the surgical Mx of GORD?
    only if not repsonding to medical Mx

    Nissen Fundoplication

    A/E;

    • Temporary dysphagia
    • gas-bloat syndrome [cant burp]
    • rare -> slipped wrap
  2. Define;
    -Dysphagia
    -Odynophagia
    -Achalasia
    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
  3. give 3 causes of Dysphagia?
    Common;

    • Peptic oesophagitis [hiatus hernia], Ca Oesophagus or cardia
    • Subcarinal lymph node secondaries from bronchial Ca

    Uncommon;

    • Candida oesophagitis [post-major surgery]
    • Achalasia
    • Myasthenia Gravis
  4. How would you investigate Dysphagia? Give 3 examples.
    • Plain CXR -> exclude Bronchial Ca
    • Flexi pharyngeoscopy
    • Barium swallow
    • CT
    • OGD
    • Oesophageal manometry
    • 24h pH measure
  5. What are the pathological types of Oesophageal Ca and how does it present? Give 2 risk factors.
    • Adenocarcinoma -> 70%
    • SCC

    Pc -> dysphagia [insiduous] -> invade out, then fungate in

    RF -> age >50, ^^ETOH, Smoking [SCC]
  6. Outline the Mx fo oesopageal Ca?
    Resection only if curative [neo-adjuvant to shrink tumour initially]

    Palliation;

    • Ablate tumour w alcohol/laser
    • Oesophageal stenting
  7. Look at this nice photo of stuff.
  8. 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
  9. Give 3 Ix for the Jaundiced patient?
    • Urine -> urobilinogen
    • Bloods -> Hep serology, LFT [obstructive = ^^conj bili + ^^AlkPhos, transaminases normal]
    • Liver USS -> ?dilated biliary tree
    • ERCP/MRCP
  10. What are the types of gallstones? [3]
    • Mixed [common] -> abn bile constituents, stasis/infection -> 10% radio-opaque
    • Cholesterol [10%] -> radiolucent [transparent]
    • Pigment -> haemolysis, malaria, infection
  11. 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
  12. Mx of Gallstones?
    conservative -> chenodeoxycholic acid [slow dissolution of cholesterol stones]

    Surgical -> Cholecystectomy [lap vs open]
  13. Give 3 complications of gallstones?
    Inflammation

    • Acute -> acute cholecystitis -> empyema + perforation
    • Chronic -> Gallbladder Ca

    Obstruction

    • Biliary colic [pain no fever]
    • acute pancreatitis
    • intermittent jaundice

    Fistulation -> Gallstone ileus
  14. Give 3 CF of acute Pancreatitis?
    • Acute severe epigastric pain [radiating to back]
    • vomiting
    • pain relieved by sitting
    • tachycardic, fever, jaundice, shock, peritonism
    • Cullens sign [periumbilical bruising]
    • Grey-Turners sign [flank bruising]
  15. Give 5 causative factors for Acute Pancreatitis?

    [GET SMASHED]
    • Gallstones
    • Ethanol
    • Trauma -> seatbelts
    • Steroids
    • Mumps
    • Autoimmune
    • Scorpion venom
    • Hyperlipidaemia, hypercalcaemia, hypothermia
    • ERCP
    • Drugs -> steroids, AZA, NSAIDs
  16. How do you assess the severity of Pancreatitis?
    [PANCREAS]
    Imrie [Glasgow] Score

    • PaO2 <8
    • Age >55
    • Neutrophilia
    • Calcium <2
    • Renal function -> urea >16
    • Enzymes -> AST >200
    • Albumin -> <32
    • Sugar -> BM >10
  17. Give 3 investigations for suspected acute pancreatitis?
    Bloods

    • serum amylase [>1000]
    • Serum Lipase
    • ALT + AST
    • Ca
    • LFT -> cholestatic obstruction

    Imaging

    • Abdo XR -> sentinel loop [dilated adynamic small bowel]
    • USS Biliary tree -> ?ductal stones
    • CT Abdo -> limited -> ?necrosis

    Endoscopy -> ERCP
  18. Outline the Mx of acute pancreatitis?
    Expert help, NBM, NGT

    ABCDE

    Analgesia -> pethidine [morphine + sphincteric contraction]

    monitor closely, worseing -> ICU ?ARDS

    Treat cause
  19. Give 2 early complications of acute pancreatitis?
    • Shock
    • ARDS
    • AKI
    • DDIC
    • Hypocalcaemia
    • Hyperglycaemia
  20. Give 3 late complications of acute pancreatitis? [>1week]
    • Pancreatic necrosis + pseudocyst formation
    • abscess
    • bleeding [elastase erodes major vessels]
    • thrombosis + bowel necrosis
    • Fistulation
    • Recurrent oedematous pancreatitis
  21. Outline the CF, Ix + Mx of chronic pancreatitis?
    CF -> severe upper gI pain + ^^^amylase [no other features of AP]

    Pancretic calcification on AXR

    Mx

    surgical only if structural abn found -> sphincterotomy, total pancreatectomy, partia pancreatectomy
  22. 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
  23. Give 3 RF for Pancreatic Ca
    • >65yo
    • Smoking
    • previous resectional gastric surgery
    • ingestion of nitrosamines [beer, fish, tobacco smoke]
  24. Give 4 CF of Pancreatic Ca
    • Painless jaundice
    • Weight loss
    • Gnawing abdominal pain
    • pale stools, dark urine, priritis, Palpable gallbladder

    • Acute Pancreatitis
    • DM
    • Gastric outlet obstruction
  25. Give 3 Ix for suspected Pancreatic Ca?
    • USS -> dilated ducts
    • CT scan -> primary imaging, CT guided biopsy
    • Cytology -> endoscopic USS guided FNA
  26. Outline the Mx of Pancreatic Ca? [Radical vs palliative]
    Late presentation -> prognosis = poor

    Curative intent;

    • Whipples -> pancreaticoduodenectomy
    • +/- post op adjuvant chemo therapy

    Palliative;

    • Pain relief -> block coeliac ganglion
    • Obstructive jaundice -> stenting of strictures
  27. Define Small bowel ischaemia, give 3 CF and briefly outline the Mx.
    Occlusiuon of SMA [in elderly] -> necrosis + gangrene of midgut -> poor prognosis

    CF

    • Abdo pain [central, severe and constant]
    • ?AF

    Mx

    • Resus -> ABCDE
    • Resect necrotic bowel -> early embolectomy/thrombolisation
  28. 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
  29. Mx of rectal prolapse?
    Bulk laxatives + manual reduction

    surgical rectoplexy
  30. Look at this nice picture
  31. Define hernia
    Protrusion of viscus outside normal body cavity
  32. 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
  33. Describe an indirect inguinal hernia?
    • Patent processus vaginalis
    • contents enter inguinal ring and into scrotum

    Pc -> hydrocele, inguinal hernia, scrotal hernia

    • Incarcerated = non-reducible ^^risk of strangulated [nb venous occlusion = first]
    • Children
  34. 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
  35. Describe a femoral hernia
    • More common in women
    • Protrusion through femoral ring, down femoral canal
    • dificult to reduce
  36. Important features in lump Hx?
    Hx

    • Duration
    • pain
    • number
    • ?^^size
    • ?Travel
    • ?systemic upset
  37. Describe a lump?
    7essesssesess

    • Site
    • Size
    • Shape
    • Smoothness?
    • Surface
    • Sorroundings
    • TranSilluminable -> fluid filled
  38. Give 4 causes for rectal bleeding?
    • nb fresh vs occult [red v black]
    • ?Painful defaecation

    • Diverticulitis
    • Colorectal Ca
    • Haemorrhoids
    • Inflammatory BD
    • Perianal Disease
    • Angiodysplasia

    Rare -> trauma, Ischaemic colitis, radiation proctitis, Aorto-enteric fistula
  39. Give 3 colonic neoplasms
    Adenoma -> all malignant potential [adenoma-carcinoma sequence]

    early carcinoma

    rare -> lymphoma, lipoma carcinoid, Leiomyoma
  40. 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
  41. What are the Pc of Polyps?
    • Rectal bleeding
    • IDA
    • ^^Mucus production
    • Hypokalaemia [villous adenoma]
    • tenesmus
    • polyp prolapse
    • Intussuception/obstruction
  42. What are the Pc of Colon carcinoma?
    • IDA
    • Change in bowel habit
    • Large bowel obstruction
    • Rectal bleeding
    • Tenesmus
    • obstructive jaundice [hepatic secondaries]
    • Systemic features -> malaise, anorexia, weight loss
  43. Give 4 risk factors for colon carcinoma
    • ^age
    • Diet -> processed meats, low fibre, low antioxidants
    • DM
    • IBD
    • Genetic -> FAP, HNPCC, Peutz-Jegher syndrome
  44. 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
  45. 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
  46. 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]
  47. Look at this picture
  48. 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
  49. Give 3 CF of bowel obstruction
    • Vomiting with relief
    • nausea
    • anorexia
    • Colic abdo pain
    • Constipation
    • Abdominal distension
  50. How do you discrn between small and large bowel obstruction?
    • Clinically?
    • Small = vomit earlier, less distension, pain higher
    • Large -> Pain = constant

    • AXR
    • Small = central gas shadows, valvulae conniventaes completely cross lumen
    • Large = gas proximal to blockage, not in rectum, Haustra = incomplete
  51. Give 3 causes for obstruction?
    Typical

    • Constipation
    • Hernia
    • Adhesions
    • Tumour
    • Post-op ileus [bowel sounds absent, no pain]

    rare -> crohns, gallstone, intussuception
  52. Outline the Mx of Obstruction
    Drip + suck -> NGT, Fluids, NBM

    • Further investigation
    • Flatus -> sigmoid volvulus
  53. Look at this picture of causes of abdo pain!

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