General Surgery

only if not repsonding to medical Mx

Nissen Fundoplication

A/E;

• 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

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

• Plain CXR -> exclude Bronchial Ca
• Flexi pharyngeoscopy
• Barium swallow
• CT
• OGD
• Oesophageal manometry
• 24h pH measure

• Adenocarcinoma -> 70%
• SCC

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

RF -> age >50, ^^ETOH, Smoking [SCC]

Resection only if curative [neo-adjuvant to shrink tumour initially]

Palliation;

• Ablate tumour w alcohol/laser
• Oesophageal stenting

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

• Urine -> urobilinogen
• Bloods -> Hep serology, LFT [obstructive = ^^conj bili + ^^AlkPhos, transaminases normal]
• Liver USS -> ?dilated biliary tree
• ERCP/MRCP

• Mixed [common] -> abn bile constituents, stasis/infection -> 10% radio-opaque
• Cholesterol [10%] -> radiolucent [transparent]
• Pigment -> haemolysis, malaria, infection

• Billiary colic [RUQ pain, no fever]
• Acute cholecystitis -> RUQ + shoulder tip pain, ?fever
• Chronic obstruction -> atrophic mucosa, subsersoal fibrosis

conservative -> chenodeoxycholic acid [slow dissolution of cholesterol stones]

Surgical -> Cholecystectomy [lap vs open]

Inflammation

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

Obstruction

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

Fistulation -> Gallstone ileus

• 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]

• Gallstones
• Ethanol
• Trauma -> seatbelts
• Steroids
• Mumps
• Autoimmune
• Scorpion venom
• Hyperlipidaemia, hypercalcaemia, hypothermia
• ERCP
• Drugs -> steroids, AZA, NSAIDs

Imrie [Glasgow] Score

• PaO2 <8
• Age >55
• Neutrophilia
• Calcium <2
• Renal function -> urea >16
• Enzymes -> AST >200
• Albumin -> <32
• Sugar -> BM >10

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

Expert help, NBM, NGT

ABCDE

Analgesia -> pethidine [morphine + sphincteric contraction]

monitor closely, worseing -> ICU ?ARDS

Treat cause

• Shock
• ARDS
• AKI
• DDIC
• Hypocalcaemia
• Hyperglycaemia

• Pancreatic necrosis + pseudocyst formation
• abscess
• bleeding [elastase erodes major vessels]
• thrombosis + bowel necrosis
• Fistulation
• Recurrent oedematous 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

Exocrine vs endocrine

most common = ductal adenocarcinoma, well differentiated

70% head of pancreas

early mets to local lymph nodes, haematogenous spread via portal vein

• >65yo
• Smoking
• previous resectional gastric surgery
• ingestion of nitrosamines [beer, fish, tobacco smoke]

• Painless jaundice
• Weight loss
• Gnawing abdominal pain
• pale stools, dark urine, priritis, Palpable gallbladder

• Acute Pancreatitis
• DM
• Gastric outlet obstruction

• USS -> dilated ducts
• CT scan -> primary imaging, CT guided biopsy
• Cytology -> endoscopic USS guided FNA

Late presentation -> prognosis = poor

Curative intent;

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

Palliative;

• Pain relief -> block coeliac ganglion
• Obstructive jaundice -> stenting of strictures

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

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

Bulk laxatives + manual reduction

surgical rectoplexy

Protrusion of viscus outside normal body cavity

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

• 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

• Weakness of abdominal wall
• Precipitated by ^^IA pressure -> lifting
• protrusion through transversalis fascia
• wide neck -> not much worry about incarceration/strangulation

• More common in women
• Protrusion through femoral ring, down femoral canal
• dificult to reduce

Hx

• Duration
• pain
• number
• ?^^size
• ?Travel
• ?systemic upset

7essesssesess

• Site
• Size
• Shape
• Smoothness?
• Surface
• Sorroundings
• TranSilluminable -> fluid filled

• 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

Adenoma -> all malignant potential [adenoma-carcinoma sequence]

early carcinoma

rare -> lymphoma, lipoma carcinoid, Leiomyoma

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

• Rectal bleeding
• IDA
• ^^Mucus production
• Hypokalaemia [villous adenoma]
• tenesmus
• polyp prolapse
• Intussuception/obstruction

• IDA
• Change in bowel habit
• Large bowel obstruction
• Rectal bleeding
• Tenesmus
• obstructive jaundice [hepatic secondaries]
• Systemic features -> malaise, anorexia, weight loss

• ^age
• Diet -> processed meats, low fibre, low antioxidants
• DM
• IBD
• Genetic -> FAP, HNPCC, Peutz-Jegher syndrome

• 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

• T1 = submucosa
• T2 = Muscularis Propria
• T3 = subserosal
• T4 = peritoneal invasion

• N1 = 1-3 regional Lymph nodes
• N2 = >4 LN

M = distal mets

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]

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

• Vomiting with relief
• nausea
• anorexia
• Colic abdo pain
• Constipation
• Abdominal distension

• 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

Typical

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

rare -> crohns, gallstone, intussuception

Drip + suck -> NGT, Fluids, NBM

• Further investigation
• Flatus -> sigmoid volvulus