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253 Cards in this Set
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Direct inguinal hernia is
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A direct inguinal hernia is when abdominal contents press through the posterior inguinal wall of the inguinal triangle (aka Hesselbach's triangle)
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What are the 2 components of BPH
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1) Static: transitional zone (epithelial cell hyperplasia due to 5-alpha-reductase conversion of testosterone to DHT)
2) Dynamic: due to smooth muscle |
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What are the boundaries of Hesselbach's triangle (aka inguinal triangle, through which occurs a direct hernia) ?
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Lateral: lateral rectus
Superior: inferior epigastrics Inferior: Inguinal ligament |
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What Hx should be taken in assessing LUTS
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1) HPC:
Q: (hesitancy, frequency, dribbling, incomplete voiding, nature of pain) L: location of any pain. LUTS pain S: severity of pain D: Modifying factors: worse supine (LVF) Context: nocturnal polyuria or difficulty voiding A: haematuria, pain, weight loss, fever, malaise T: insidious or sudden PMH: previous acute LUTS, diabetes or neuropathies, sexual dysfunction (Sexual Hx) FH: BPH, prostate cancer SR: lumbosacral pain or surgery, IHD, CHF, COPD, neurological (MS, Parkinson's, antidepressents or neuroleptics, other anticholinergics), diabetes SHx: spinal, prior prostatic or bladder surgery |
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Compare causes of a direct vs indirect inguinal hernia.
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direct hernias are more likely in older men, cause is due to increased pressure, no true sac, the least likely hernia to incarcerate.
An indirect hernia is usually congenital due to a patent processes vaginalis. It has a true sac which is a remnant of the processes vaginalis which must be excised. An indirect hernia is the most likely to incarcerate |
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What examinations should be performed for the LUTS patient
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1) Abdominal: tenderness, masses
2) DRE: sphincter tone, midline groove, size and texture 3) Urinalysis 4) Frequency volume log over 2 days |
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What is a femoral hernia?
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Due to enlarged femoral ring due to short attachment of transversus abdominalis to Coopers ligament. Is acquired.(Between last rib and iliac crest)
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What possible Ix might be needed for LUTS
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1) Imaging: bladder scan for residual volume, TRUS +/- biopsy
2) Culture and sensitivity 3) Uroflowmetry and post void volume (< 10mL/sec for 150mL = 80% probability BOO) 4) Cystoscopy 5) PSA (>1.5ng/mL or increase indicates possible deterioration) |
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Compare omphalocele vs gastrochisis.
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Both are the incomplete closure of abdominal wall in newborns. In an omphalocele there is a thin membrane of peritoneum and amion while in gastrochisis there is no covering and the abdominal contents are open to the outside world.
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Risk factors for acute urinary retention
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What are the management options for BOO and explain how the two main medical treatments work
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Watchful waiting
Medical (5-alpha-reductase inhibitors reducing DHT, alpha blockade, anticholinergics to reduce detruser activity) Surgical: TURP. TUIP, Laser prostatectomy |
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Where does a lumbar hernia occur?
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A Grynfelt's hernia aka lumbar hernia occurs in the superior lumbar triangle (sacrospinalis, internal oblique, 12th rib)
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Anteriormedial thigh paresthesias can be due to what kind of hernia?
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An obturator hernia which protruds through the obturator canal can cause intermittant bowel obstruction and thigh paresthesisas.
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What are the post surgical complications of TURP
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Retrograde ejaculation (most)
Voiding urge 30% for 1st 6 weeks Bleeding, clot retention, Infection, TURP syndrome (2%) Impotence, neck stricture (6%) Retreatment need 10% |
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Describe the epidaemiology of hyperparathyroidism
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1) Incidence 1:1000
2) 90% parathyroid adenoma, mostly solitary adenomas 3) 4% adenocarcimnoma 4) Can be associated with MEN1 (pancreas, pituitary (prolactin), parathyroid) and MEN2 (para/thyroid, adrenals) |
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What is a Spigelian hernia?
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Herniation through the semilunar line (lateral connection of rectus muscle). Is superior to the inferior epigastric vessels.
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Secondary hyperparathyroidism due to renal failure mechanism
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Decreased calcitriol plus dec phosphate excretion causes decreased ionised Ca++ stimulating Car, PTH and hyperplasia
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What are the layers of the abdominal wall?
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Skin
Superficial fascia (Camper's fascia and Scarpas fascia-deep) External Oblique Internal Oblique Transversalis Transversalis fascia Preperitoneal fat |
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What are the reference ranges for Calcium
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Normal total: 2-2.5 mmol/L
Normal ionised: 1.4-2 mmol/L Crisis level: > 3.5mmol/L |
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What are the layers of the spermatic cord:
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3 facial layers: external, internal, cremasteric
3 arteries: cremasteric, testicular, artery to the ductus deferens 3 other structures: ductus deferens, pampiniform plexus, lymphatics 3 nerves: genitofemoral, afferents and ilioinguinal |
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What are the clinical effects of bowel obstruction
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1. Bowel distension 2. Bowel wall oedema 3. Bacterial proliferation:
‘FAECULENT” vomiting 4. Abdominal distension: Impaired respiration 5. Above lead to:-Hypovolemia, renal insufficiency Shock - - - DEATH |
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Compare the incidence of femoral vs inguinal vs ventral hernias?
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5% of people will have a hernia repair (500,000- 1mil a year). 50% indirect, 25% direct, 10% ventral, 6% femoral W>M.
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What percentage of acute bowel obstruction occurs in the SI v SI. What are the 3 main causes of bowel obstruction?
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Small bowel - 80%, colon - 20%
Different ages, different causes Overall :- - Neonates - Infants - Middle-age - Elderly - Adhesions 37% - Cancer 27% - Hernia 10% |
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Define acute abdomen.
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Signs and symptoms of intra abdominal disease usually treated best by surgical operation.
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What HPC should be taken when patient presents with abdominal pain
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1. LOCATION
Visceral vs parietal Sensory levels Referred pain Shifting pain 2. MODE OF ONSET 3. CHARACTER OTHER SYMPTOMS 1. Anorexia / weight loss 2. Nausea and vomiting M-W tear Boerhaave syndrome Presence of bile Feculent / faecal 3. Constipation / diarrhoea 4. Blood per rectum 5 Pale or dark stools Other aspects 1. Menstrual Hx 2. Drugs Anticoagulants O.C.P. Steroids / NSAIDS 3. Family Hx 4. Travel Hxe or dark stools |
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Define referred pain.
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Organs that share DRG fibers with somatic innervation the somatic fibers have the highest priority and thus pain in an organ can be felt in another area of the body ie pancreatitis and shoulder pain.
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Causes and relative incidences of large bowel obstruction
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Carcinoma of colon 65% Diverticulitis 20%
Volvulus 5% Miscellaneous 10% |
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Define visceral pain:
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Visceral pain is mediated by afferent C fibers in viscera of organs. This pain is slow, dull, localized and protracted. In comparison parietal pain has A delta fibers which has more acute sharp, well localized pain.
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What are the signs of small bowel ischaemia or strangulation
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1) Hypovolaemic Shock: hypotension, tachycardia, tachypnoea, ARDS (difficulty breathing)
2) Acute abdominal signs: guarding, rebound tenderness |
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How do you evaluate abdominal pain?
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WILDA: words to describe it, intensity, location, duration, aggravating and alleviating factors. Is the mode of onset explosive or slowly progressive. Is it colicy. Is there associated anorexia, N/V/D, constipation, blood. What is the menstrual history. Drugs? FH? Travel?
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What investigations strongly indicate acute small bowel ischaemia
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1) Elevated WCC > 15,000
2) Elevated lactic acid levels |
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Intense involuntary guarding resulting in a pathoneumonic "board abdomen" is characteristic of what?
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Boardlike abdomen..... think perforated duodenal ulcer.
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What Ix should be performed for suspected small bowel obstruction
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1) FBC, lactic acid
2) U&E 3) LFT 4) CRP |
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What do you look for on O/E to determine peritonitis?
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Rebound
Guarding |
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What is the immediate management of a bowel obstruction
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1) Prevent shock: large volume fluid replacement
2) Decompress the stomach: nasogastric tube 3) IDC 4) Vitals q4h |
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The absence of bowel sounds makes you think of ?
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complete obstruction (partial gives high pitched sounds)
volvulus ischaemia perforation |
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List the 7 types of hernias and describe their locations
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Note: the epigastric, umbilical and Spigelian hernias are caused by defects in the rectus sheath
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What ddx would you think of with a positive iliopsoas sign with the flexing of the hip?
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+ iliopsoas sign can indicate retrocecal appendix or psoas abscess.
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Describe Hesselbach's triangle
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Site of direct abdominal wall hernias bounded by the rectus muscle, the inguinal ligament and the inferior epigastric artery
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How do you test for obturator's sign?
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Move the hip in internal or external rotation.
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Describe PE findings in appendicitis?
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Rebound tenderness at McBurney's point
Rovsing's sign- pressure in LLQ causes pain in RLQ Psoas sign- pain on flexion/ext of R hip Obturator sign- passive rotation of flexed R thigh causes pain Rebound tenderness |
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What are the DDx
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Femoral hernia
Lymphadenopathy/lymphadenitis Femoral aneurism Cold (TB) abcess Lipoma Ganglion |
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What is the presentation of acute appendicitis and what further studies would you order?
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Abdominal pain in periumbilical area migrating to McBurney's point. Nausea / vomiting, fever, anorexia.
Get CBC- look for leukocytosis Xray - not generally useful, can occasionally 10% of time show fecalith US- good sensitivity CT- useful if case is not clear cut |
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What type of hernia is mistaken for a peptic ulcer. Describe it
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Epigastric hernis - painful protrusion of fatty tissue after meals within the diverication of the rectus muscles within the linea alba
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What are the 5 causes of abdominal pain
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1) Obstruction
2) Ischaemia 3) Perforation 4) Inflammation 5) Haemorrhage into the peritoneal cavity |
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Most common age group for appendicitis?
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Children 5-10 get appendicitis more frequently as they have a high # of lymphoid follicles and increased secretions leading to blockage and inflammation.
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A patient with severe right upper quadrant pain has bruising around the umbilicuc. What is this sign?
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Cullen sign of acute pancreatitis (causing periumbilical bleeding)
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Where do you have pain in a pregnant woman with appendicitis?
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Appendix will be displaced above fundus, which is now in RUQ.
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What are the recommended steps, in sequence, for the examination of the acute abdomen
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1) Inspection
2) Auscultation 3) Cough tenderness 4) Check hernial orifices during cough 5) Palpation 6) Percussion 7) Rebound tenderness 8) PV and PR |
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Give a differential for acute appendicitis?
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PID, pylonephritis, gastroenteritis, IBD, endometriosis, ovulatory pain, ovarian cyst, Meckel's diverticulitis, acute ileitis, cholecystitis, perforated PUD, kidney stones, UTI, hepatitis, PNA
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First line Ix for acute abdomen
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FBC, WCC, CRP
U&Es, pancreatic lipase, LFT's Urinalysis (blood, pus) Simple x-rays initially |
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Abx for acute appendicitis?
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2nd or 3rd gen ceph, piperacillin + metronidazole, AG, ampicillin or clindamycin.
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What treatment is urgently needed if an acute bowel obstruction has been diagnosed
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IV fluid rehydration because of 3rd spacing oedema due to massive inflammation
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How frequuenty is an appendix tumor carcinoid? What % of carcinoid tumors in the GI tract are in the appendix?
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Carcinoid tumors are 0.5% of all appendix tumors. These account for 50% of all carcinoid tumors of the GI tract. However only 3% are malignant.
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What are the 4 primary malignant tumors of teh appendix?
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1. carcinoid tumor
2. adenocarcinoma 3. malignant mucocele 4. carcinoma |
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A factory worker was exposed to hot gasses at workand suffers difficulty breathing, is ataxic and appears to be delirious with difficulty breathing. What is the immediate concern
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Below larynx CO chemical burn. Symptoms are immediate to 5 days
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Describe the anatomy of the biliary system.
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There are R and L hepatic ducts which join to form the common hepatic duct. The common hepatic duct and the cystic duct from the gallbladder form to make the common bile duct, which later joins the pancreatic duct. The CBD then enters the duodenum at the spinctor of Oddi.
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What is likely to happen to a burn wound on a diabetic
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wound conversion: chronic illness, poor blood flow contribute to widening and deepening of the wound ie conversion from hyperaemia to stasis to coagulation
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What are some causes of increased indirect bilirubin?
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Newborns
Crigler Najiar (glucuronyl transferase deficency) Hemolysis |
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Name the locations of internal hernias
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Paraduodenal fossa
Paracaecal fossa Epiploic foramen Mesocolon and diaphragm defects |
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What are some causes of increased direct bilirubin?
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Obstructive
See increased Alk phosphatase and GGT from biliary tree obstruction Increased in AST.ALT- hepatocellular disease |
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What are the 4 main hernia types in order of incidence
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Inguinal
Incisional Femoral Umbilical |
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Treatment for CBD obstruction?
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ERCP with excision of stones.
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Why are Richter's hernias insidious
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Only part of the circumference protrudes through the defect. No obstruction or symptoms until ischamia and rupture
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What are the complications of hernias in order of severity
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Progression
Irreducibility Obstruction Strangulation |
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What are the 4 major risk factors that increase risk 4x for breast cancer.
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1. Family history (BRCA 1/2)
2. Atypical hyperplasia 3. Personal history of prior Breast CA 4. DCIS(ductal carcinoma in situ)/LCIS (lobular carcinoma in situ) dx as they have high rate of recurrance |
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What are the predisposing factors for a hernia
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Increased IOP:Vomiting, Straining, Pregnancy, Obesity, ascites
Abdominal wall weakness: congenital (patent processes vaginalis) anatomical (umbilical ligament, oesophageal hiatus) Acquired (scar, stoma) |
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How does an intraductal papilloma usually present?
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bloody nipple discharge is seen with intraductal papillomas
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Describe hernia strangulation and clinical signs
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Obstruction of VENOUS and lymphatic outflow causing congestion and oedema. Ischaemia -> necrosis.
clinical signs: excuisite tenderness, tense herneal sack, erythema, signs of peritonitis (guarding, rebound tenderness) |
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You palpate a breast mass, what do you do?
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If <30 do u/s if >30 do mammogram.
If mass is cystic and simple, reexamine in 2-3 mo If mass is cystic and complex- aspirate, if fluid is bloody then bx If mass is solid do FNA or core biopsy. If nondiagnositc bx then reassess with mammogram. |
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What are the classifications of an indirect hernia
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1) bubonocoele (just entering the inguinal canal)
2) funicular (fills the inguinal canal) 3) complete (enters the scrotum or labium) |
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How do you treat 0-1 stage breast CA
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Treat 0-1 stage BCA with lumpectomy either alone or with radiation
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Describe Hesselbach's Triangle
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weakness of the medial inguinal canal causing the hernial sac to protrude into the muscle layers
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How do you treat 2-3 stage breast CA
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Treat Stage 2-3 BCA with lumpectomy or masectomy, then radiation therapy, systemic chemo, treatment with tamoxifen or aromatase inhibitor tx if Estrogen receptive and possibly herceptin if HER2+
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What are the two main hernial repair procedures
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1) Herniorraphy
2) Hernioplasty |
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How do you tx stage 4 BCA?
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Treat stage 4 BCA with systemic chemo and surgery.
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Treatment of DCIS entails?
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lumpectomy + radiation or simple mastectomy
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For DCIS you have to Do something for LCIS you can Leave it alone.
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What are the two main causes of bowel obstruction in adults
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1) Carninoma (65%)
2) Diverticulitis (20%) |
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Treatment of Paget's?
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Excision of nipple, radiation, if diffuse do mastectomy
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Contrast the 3 types of mastectomies:
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1. simple- breast removal with pectoralis major fascia removed
2. modified radical- simple with axillary dissection 3. radical- removal of breast as well as pectoralis muscles, axillary contents and overlying skin. |
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Describe survival rates for the 4 stages of BCA?
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Stage I – 96% 5 year survival
Stage II – 82% Stage III – 53% Stave IV – 18% |
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How large a tumor is lumpectomy appropriate for?
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<4cm in size... no metastatic disease. Must follow with radiation.
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How frequently must a woman have a mammogram in her CL breast after a radical masectomy? How about after a lumpectomy?
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1. With masectomy get mammo in CL breast every 3-6 mo for 3 years then annually.
2. With lumpectomy get bilateral mammos Q6 months after radiation completed and then yearly. |
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What is BRCA1?
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BRCA1 is a protein that maintains stability after DNA damage, it activates p53 which mediates apoptosis. BRCA1 lesions are often aneuploid, high grade lesions. It is responsible for about 5% of cancers.
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Most common site of colon obstruction and most common cause?
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Sigmoid colon is most commonly obstructed... due to adenocarcinoma, scaring from diverticulitis or volvulus.
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Contrast hemorrhoids, anal fissure and anal abscess.
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anal abscess- infection of anal crypt presenting with pain, fever, swelling, pus/ discharge (need I&D)
Hemorrhoids- engorged veins, painful, occurs in the anal canal anal fissure- horrific pain, tearing in anal canal below the dentate line resulting from sphincter spasm. |
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What is the Na/ K/ HCO3/ Cl of the following:
Serum |
Na 135-150
K 3.5-5.0 HCO3 22-30 Cl 98-106 |
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What is the Na/ K/ HCO3/ Cl of the following:
Gastric aspirate |
Na 10-150
K 4-12 HCO3 0 Cl 120-160 |
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What is the Na/ K/ HCO3/ Cl of the following:
Bile |
Na 120-170
K 3-12 HCO3 30-40 Cl 80-120 |
Think of bile as very alkalotic. Bicarb is increased while other values are around normal. Bicarb and pancreatic juices are coming out of the spinctor of oddi together... recall the pancreas makes a ton of bicarb.
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What is the Na/ K/ HCO3/ Cl of the following:
Ileostomy aspirate |
Na 80-150
K 2-8 HCO3 20-40 Cl 70-130 |
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How do you calculate TBW?
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0.6 x body weight in kg.
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How do you calculate ECF and ICF?
How do you calculate IVF? |
ECF = 1/3 x TBW
ICF = 2/3 x TBW IVF = 8% x ECF Recall TBW = kg x 0.6 |
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What are the fluid losses for 24 hours:
urine sweat respiratory feces total insensible losses |
urine 1200-1500 ml
sweat 200-400 ml respiratory 500-700ml feces 100-200ml Total: 2000-2800 ml/ day |
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Causes of hypernatremia?
-hypovolemic -euvolemic -hypervolemic |
-hypovolemic: Renal causes (osmotic diuresis), extra renal (diarrhea, fever, sweat)
-euvolemic: DI -hypervolemic: hypertonic saline, cirrhosis, heart failure |
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Calculate H20 deficit:
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H20 deficit= TBW x (serum Na-140)/140
TBW = 0.6 x body weight (0.85 if elderly or female) |
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Causes of hyponatremia:
hypovolemic euvolemic hypervolemic |
hypovolemic- renal losses(diuretics, adrenal insufficiency)
euvolemic- SIADH, polydypsia hypervolemic- CHF, cirrhosis, nephrotic syndrome, renal failure. |
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Treatment of hyponatremia and daily max?
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Na needed = (140-Na ) x TBW
Give 1/2 needed Na in first 12 hours and remaining over 48 hours not to exceed 12 mEQ/L / day |
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DDx of hyperkalemia and tx?
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Hyperkalemia:
renal failure, crush injuries, hemolysis, catabolism, acidosis, dig toxicity EKG shows peaked T waves, long PR, flat P waves, wide QRS, sine wave Tx: insulin with glucose, bicarbonate, Ca gluconate, hemodialysis |
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Ddx for hypercalcemia and tx
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hyperparathyroidism, malignancies, milk-alkali syndrome, Williams syndrome, Vit A intoxication
treatment of hypercalcemia- loop diuretics, bisphosphonates, corticosteroids |
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Ddx hypocalcemia
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PTH deficiency, pancreatitis, vit D deficiency, hypoalbuminemia (Correct for albumin).
Treat with Ca gluconate, chloride IV, thiazide iduretics |
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Normal ABG values
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pH 7.4
pO2 100 pCO2 40 O2 sat >95% HCO3 25 Base -2 to +2 |
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Name 4 endogenous factors that control Na and H20.
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aldosterone from adrenal cortex
ADH from posterior pituitary Renin-angiotensin axis osmole receptors sensing volume balance. |
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What is the content of NS?
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NS contains:
Na 154 Cl 154 |
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Content of D5W?
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D5W only has 50 mg of glucose.
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What is the primary cause of the electrolyte imbalance?
Na 140 K 3.0 HCO3 22 Cl 90 pH >7.45 |
Loss of bicarb and Cl points toward GI losses ie vomiting causing alkalosis.
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A high volume pancreatic fistula would present with what electrolyte imbalance?
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Excessive loss of HCO2 ie 15 instead of 25.
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What electrolyte disturbance would you see with diarrhea?
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Na 140
K 3.0 slightly low HCO3 22 low Cl 95 slightly low ph <7.35 Main point... isotonic losses, everything can be slightly low with slight acidosis if prolonged. |
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What electrolyte disturbance would you see with closed head injury?
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Na 130 low!
K 3.5 normal HCO3 20 low! Cl 90 low pH acidotic |
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Normal values for pH, PCO2, pO2, HCO3
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pH 7.4, PCO2 40, pO2 100, HCO3 25
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ACh is released by what never to stimulate stomach contractions?
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vagus n activates peristalsis to the stomach via ACh.
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What type of cancer is associated with Chron's Disease?
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Adenocarcinoma of the ileum.
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What are the pharmacological treatments of Crohn's diseas?
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Sulfasalazine and mesalazine are antiinflammatory drugs.
Corticosteroids and metronidazole are also helpful. |
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Name 4 indications for surgery for Crohn's disease?
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abscess
perforation bleeding fistula |
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What is the most common congenital anomaly of teh small itnestine? hing it's a failure of the vitelline duct to close from the umbilicus.
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Meckel's diverticulum. heterotopic tissue is found in 30-50% including gastric of pancreatic tissue that can secrete hormones.
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Rule of 2's in Meckel's diverticulum.
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2 feet from ileocecal valve
2% of population 2 in long contains 2 types of heterogenous tissue most common cause of painless rectal bleeding in children <2 yr old |
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What are the 4 types of tumors that affect the small bowel
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adenocrcinoma, GI stromal tumors, carcinoid and lyphoma
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Most common endocrine tumor of the GI tract? What are the associated symptoms?
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carcinoid tumors are the most common and they secrete serotonin primarialy although they can secrete histamine, dopamine, peptides and prostaglandins. They are all considered malignant. Symptoms include flushing, diarrhea, sweating and wheezing. Most common site is the appendix.
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Medical treatment of carcinoid syndrome?
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injections of octreotide, the somatostatin analogue inhibits the serotonin release.
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3 layers of a true divericulum
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submucosa
mucosa muscularis propria |
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Most common location of carcinoid tumors?
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the appendix.
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Your patient presents as follows, what do you do? Syncope, tachycardia, hypotension, hematemesis, acute abdomen.
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First get 2 large bore IVs and stabilize with isotonic fluids ie NS. Check Hct and prep blood. Get CXR to check for perf. NG can be placed for suction. Endoscopy can be performed, if unhelpful consider angiography. IF serial Hcts continue to decline transfuse. if >6 units in 12 hrs then go to OR emergently. Long term tx with PPI or H2 blocker. Band varices, electrocautery, embolization or resection.
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3 branches of the celiac artery?
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Common hepatic, splenic, L gastric are all branches of the celiac artery.
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innervation of the stomach is through the?
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vagus nerve innervates the stomach
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3 types of gastric ulcers?
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type I: in lesser curvature of stomach, transition zone of antrum
type II: gastric and duodenal ulcers. typeIII: pyloric type II and III are due to acid hypersecretion. |
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symptoms of ulcer?
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epigastric pain radiating to back that increases with food, weight loss. Type I with normal or low gastric acid secretion is the most common type of ulcer.
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What two different complications arise depending on where the duodenal ulcer is located?
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anterior duodenal ulcer can spill out into the abdomen.
posterior duodenal ulcer can erode the gastroduodenal artery. The gastroduodenal artery is from the common hepatic artery and bifurcates into the pancreatoduodenal artery and the gastroepiploic artery. |
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which improves with food a gastric or a duodenal ulcer?
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gastric gets worse with food more gastrin while duodenal improves with food.
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Most common gastric tumor and gold standard diagnosis?
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Most common gastric tumor is adenocarcinoma. Dx with upper endoscopy. Cause is usually H pylori.
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2nd most common primary tumor of stomach?
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lymphoma is the second most common ca of stomach. Do barium swallow test to look for lesion, gastroscopy and biopsy for dx, CT can then be done for staging of nodes. In 50% of patients you can palpate epigastric mass.
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GIST tumors- grow intraluminally and are CT tumors, most are benign and most occur in the stomach. How do you diagnose them.
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SBFT, barium swallow (aka upper GI series) or CT used for dx. These tumors are usually CD117 or kit positive and have spindle cells. It is the most common type of sarcoma (CT tumor)
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Free intraperitoneal air indicates....
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perforation
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What is the significance of anatomic locations of ulcers in the stomach and duodenum:
posterior duodenum anterior duodenum pyloric channel gastric |
gastric- risk for malignancy
pyloric channel- risk for obstruction posterior duodenal - risk for bleeding anterior duodenal- risk for perforation |
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Describe vagotomy in terms of PUD treatment.
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Resect distal vagal nerve as it enters the abdomen at teh distal esophagus. However the decrease in vagal tone leads to decrese in emptying so therefore patient has issues with gastric emptying.
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What is an antrectomy?
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Antrectomy is a distal gastrectomy which removes gastrin producing cells.
It inhances vagotomy. |
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What is a pyloroplasty?
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Pylorus is cut vertically and restitched horizontally to improve gastric emptying.
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What is dumping syndrome and when does it occur?
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Dumping syndrome occurs with rapid gastric emptying where osmotic balance is skewed causing tachycardia, anxiety, palpitations, borborygmi and diarrhea. It is seen with anterectomy.
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What distinguishes the BAO vs MAO of ZE vs duodenial ulcers.
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In Zollinger Ellison the basal acid output is elevated but and because it is so high the maximal acid output is about the same. In contrast gastric and duodenal ulcers have higher maximal acid outputs
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What is Charcot's triad in relation to cholangitis?
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jaundice, fever/chills, RUQ pain
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What two additional markers are added to Charcot's triad for cholangitis making it Reynold's pentad.
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Charcot's triad for cholangitis: RUQ pain jaundice, fever
Reynold's pentad: confusion and hypotension indicating ascending cholangitis or sepsis. |
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What are the 5 components of Child's criteria to rate the severity of cirrhosis.
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Child's criteria
serum bilirubin, albumin, ascites, encephalopathy, PT/INR Classifies pt into A, B, C with C being a poor surgical candidate. |
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What is Ranson's criteria and how does it affect a patient's odds of recovery from pancreatitis?
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Ranson's criteria is as follows:
age>55, WBC >16000, glucose >200, LDH >350, AST >250. Having 3 or more criteria increases the risk for major complications during an episode of pancreatitis. |
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How do you stage for pancreatic ca?
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do CT, MRCP, ERCP, endoscopic US. Looking for liver mets, vascular invasion.
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What secretory substances does the pancreas make and what activates them.
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bicarbonate, insulin, lipase, amylase and trypsin.Trypsin is activated by enterokinase in the intestine.
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Most common benign tumor of the liver?
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You are thinking cyst which is true but if it's not a cyst hemangiomas are the most common. Cysts are concerning if the walls are thick, if there are many septations or calcifications. Hemangiomas are usually congenital.
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What is the most common type of primary liver malignancy?
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Hepatomas are the most common primary liver malignancy. >90%. Associated with Hep B and C. AFP is elevated.
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In what group do hepatic adenomas occur?
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Adenomas occur in women age 30-50. It is usually estrogen related. Small risk for cancer but remove due to risk of rupture.
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3 Indications for splenectomy?
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1. splenic rupture due to trauma/injury
2. hypersplenism- hemolytic anemia ie hereditary spherocytosis, hemoglobinopathies, G6PD hyposplenism- asplenia or infarct of spleen 2/2 sickle cell 3. Hematologic malignancy ie chronic leukemia causing splenomegaly |
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What 3 immunizations would you recommend to an individual before splenectomy and why?
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Spleen is responsible for removing encapsulated organisms.
Vaccinate against N. meningitis, H flu S. pneumo |
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Causes of pancreatitis?
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Metabolic- alcohol
Mechanical- Gallstone pancreatitis from obstruction Ischemic- hypotension. |
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cause of pancreatitis?
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diffuse inflammation of the pancreas due to release and activation of pancreatic enzymes into the parenchyma. Treat by NPO, possibly by NG tube, ERCP for stone
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Most common type of pancreatic cancer?
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Adenocarcinomas are the most common pancreatic cancer. They originate from the ductal epithelium.
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What is normal urine output in ml/kg/day?
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Urine output should be 3ml/kg/day. Ie 70 kg male shoudl put out minimum of 210/day.
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basic rule for UOP in children?
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1000 ml for the first 10 kg + 50 ml/kg/day for each additional kg.
ie 15 kg child makes 1250 ml/day. |
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Determine blood volume in infants. When do you start to replace?
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Blood volume is 75 ml/kg. Start repletion when >10% lost
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Non billious, projectile vomiting, with visible epigastric olive indicates what? What metabolic abnormality will also likely be present?
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pyloric stenosis.
also common to note hypocholremic hypokalemic metabolic alkalosis. |
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polyhydramnios, vomiting, abdominal distension and failure to pass meconium signify?
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SBO in neonate.
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Dds for SBO in newborn?
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meconium ileus, intrasusception, malrotation, intestional atresia/stenosis, hirschprung's disease, annular pancreas.
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You suspect a child has intrasusseption. They have current jelly stools and have episodes where they cry and double up in pain. What test would you use to confirm? Where is the intrasusseption most likely located?
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Most common location at ileocecal junction.
Do barium enema to look for obstruction and get CBC which will show PMNs. |
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What is the atomical defect in hirschprungs disease?
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Hirschsprung's is an absence in the ganglion cells of the colon. The parasympathetic mysenteric and submucosal plexi did not migrate.
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Where do most diaphramatic hernias occur?
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left posterior
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describe the most common type of esophageal atresia? How does the child present?
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85% the esophagus dead ends. Then the inferior esophagus anastamoses with the trachea forming a tracheoesophageal fistula. Childpresents with coughing and choking with feeding, cyanosis,gas below the diaphram seen on CXR
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Describe when and how the neonatal intestine rotates?
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AT 10 weeks of gestation the intestine rotates around the SMA 270 degrees counterclockwise.
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how do you treat necrotizing enterocollitis and when do you have to operate?
Recall NEC occurs in the first 2 weeks of life in premature infants whose bowels become ischemic. |
Treat with broad spectrum abx, NG decompression, fluid resuscitation and blood transfusions if necessary. OR intervention is indicated if there is acidosis, or perforation.
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What is the difference between claudication and rest pain?
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Rest pain is more advanced peripheral ischemia. It is usually relieved by dangling the limb over the side of the bed. Both represent PVD and can progress to skin ulceration and gangrene in the most severe form.
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3 Methods of testing for PVD?
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1 Doppler ultrasounds- triphasic wave form becomes biphasic
2. Ankle Brachial Index <0.8 is claudication, <0.4 is rest pain/tissue loss. Ratio is the highest brachial /ankle SBP. 3. Arteriography: radioopaque dye is injected in the abdominal aorta to map the vascular tree. |
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Describe a few of the pharmaceutical approaches to managing claudication.
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1. BB (these people will die of MI not claudication, protect their heart)
2. Statin reduce cholesterol 3.ACEI prevent atherosclerotic progression. 4. Cilostazol (Phosphodiesterase inhibitor) All of these along with exercise, healthy diet, good diet Also can consider decreasing BP |
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6 Ps of major arterial occlusion?
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pallor, pain , paresthesias, paralysis, pulselessness, poikilothermia
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Presentation and tools for dx of AAA?
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AAA presents as pulsatile mass on exam, if ruptured acute back pain, hypotension.
Diagnose by u/s, CT. |
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Cutoff for operation for AAA
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Must be >5 cm. Otherwise mortality from operation outweighs mortalilty from possible rupture
Can use graft to bypass eneurysm or stent. |
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Signs of PE
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pleuritic chest pain, dyspnea, tachypnea, tachycardia, cough, hemoptysis.
Get D dimer, VQ scan or pulm angiogram |
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Compare TIA vs RIND
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TIA- transient ischemic attack , <24 h attack usually involving MCA resulting in stroke liek symptoms.
RIND- Reversible ischemic neurologic defect. Stroke like defect lasting 24-72 hours up to 3 weeks. |
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Treatment of cerebrovascular incidents?
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anticoagulation, thrombolytics ie TPa if thrombotic stroke within 3-4.4 hrs. Carotid endarectomy (CEA), angioplasty, with stent placement.
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Virchow's Triad for DVT
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venous stasis, endothelial injury, hypercoagulable state.
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What is Homans sign and what does it indicate?
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Homan's sign is calf pain with dorsiflexion of the foot indicating DVT.
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PE finding in chronic venous insufficiency?
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hyperpigmentation (orange brown skin from hemosiderin from hemoglobin breakdown) and chronically swollen legs, as well as venous stasis ulcers.
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Symptoms of chronic intestinal ischemia.
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postprandial abdominal pain, bloating, weight loss, early satiety.
Cause is occlusion of vessels at watershed areas, colaterals- gastroduodenal and marginal s. |
Recall that the asc colon = ileocolic and transverse colon = middle colic both from SMA. The desc colon = left colic from IMA. Between at splenic flexure is watershed area.
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Triad that indicates surgical therapy for Crohn's disease
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Perforation (abdo pain, peritonitis, shock)
Obstruction Abcess |
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6 causes of small bowel obstruction.
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hernia, adhesions, volvulus, intrassusception, chron's, gallstone ileus.
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Contrast SBO vs. paralytic ileus.
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SBO: increased risk with prior abdominal surgeries, hernias, vague abdominal sx. exam shows n/v/, abdominal distension, normal/increased BS. XR shows gas only in small intestine
Paralytic ileus: history of narcotic use, bed rest, trauma, sepsis, hypothyroidism, anesthesia. Exam shows minimal pain, n/v/, distension, absent BS. XR shows gas in both small intestine and colon. |
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Contrast SBO and colonic obstruction etiologies and diagnostic procedures.
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SBO etiologies: hernia, adhesions, volvulus, gallstone ileus, chron's disease,
vs colonic etiologies of adenocarcinoma, diverticular scarring and inflammatory disorders. Dx. SBO with CT, endoscopy with small bowel follow through. Dx. colonic obstruction with barium enema and colonoscopy. |
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Diagnosis and treatment for SBO
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Diagnose with plain x-ray (coiled spring sign for SBO v string of beads for LBO). CXR to look for gas under diaphragm. FBC, LFT, U&E, lipase, amylase, USS to look for stones, CT to find location of obstruction. IV fluids mandatory. NG placement for decompression. NPO. Surgery in 24-48H if no improvement. Give abx. preoperatively.
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s/s and causes of peritonitis.
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acute abdomen with fever, leukocytosis, board like abdominal rigidity. Tx with volume resuscitation. Abx or aerobic, anaerobic and Gram neg bacteria.
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Most common sitres of intra abdominal abscesses.
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pelvis, morrison's pouch (betwen liver and kidney), subphrenic, paracolic gutters, periappendiceal, lesser sac.
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Woman presenting with T 38.5, BP 105/50, tachycardia, epigastric pain + yellow Abdomen.What is this constellation of signs called
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Charcot’s Triad (biliary colic, jaundice, fevers/chills) complicated by septicaemia or septic shock
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Woman presenting with T 38.5, BP 105/50, tachycardia, abdominal pain + yellow Abdomen. What is the diagnosis?
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Cholangitis +/- biliary obstruction
hepatitis acute pancreatitis (Cullen’ sign?) perforated peptic ulcer (extravasation causing yellow abdo?) chronic renal failure |
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Woman presenting with T 38.5, BP 105/50, tachycardia, abdominal pain + yellow Abdomen. What is the Pathophysiology of this sign
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Blockage of the biliary tract (esp the CBD) causes
•buildup of pressure within the biliary tree (causing the pain of biliary colic) •overgrowth of normal CBD flora -> infection. Bacteria escape into the systemic circulation via the hepatic sinusoids-> septicaemia and septic shock->pyrexia, tachycardia and hypotension. •The blockage also causes leakage of bilirubin into the systemic circulation, causing yellow abdomen |
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What is the Pathophysiology of acute cholangitis
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Is due to bacterial infection of the bile ducts and is always secondary to bilary obstruction. The common causes are common duct stones, biliary strictures, neoplasms or following ERCP in the presence of large duct symptoms
Not all obstructing lesions are followed by cholangitis. The likelihood of cholangitis is greatest when the obstruction occurs after the duct has acquired a resident bacterial population. |
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Acute cholangitis symptoms
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•fever, often with a rigor
•upper abdominal pain •jaundice •all three symptoms (Charcot’s triad) are present in 70% of cases. When all three symptoms are present the diagnosis is not difficult, but the patient may present with only a fever and accompanying leukocytosis. •Older patients can present with collapse and gram negative septicaemia. •Specific signs may be minimal but tenderness over the liver occurs |
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Acute cholangitis investigation findings
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•Leukocytosis
•Elevated serum bilirubin and alkaline phosphatase levels •Blood cultures are often positive. Predominant organisms are E.coli, klebsiella, pseudomonas, enterococci, and proteus. Anaerobes can be detected in about 25% of cases and their presence correlates with multiple previous biliary operations, severe symptoms and high incidence of postoperative suppurative complications. Two species of bacteria can be cultured in about 50% of cases. |
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Acute cholangitis treatment
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• 6 hourly IV amoxicillin 1g, along with IV gent 2-5mg/kg daily in divided doses for severe cases.
•Suppurative cholangitis - fever continues and shock develops despite adequate antibiotics. The diagnostic pentad is: abdominal pain, jaundice, fever and chills, confusion or lethargy and shock. Urgent decompression of the duct should be perfomed, ususally endoscopically. •After the acute disease is controlled, Dx by USS, transhepatic cholangiography, and ERCP. |
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Toe ulcer: 1st MTP- black, chunky base; ?sharply demarcated edge, surrounding oedema. Describe the ulcer
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•Site: anatomical location, relation to other structures
•Exterior: size, shape, surface, colour, tenderness, temperature •Edge: flat sloping – Venous, septic. indicates that the ulcer is shallow and that epithelium is growing in from the edge inan attempt to heal it. The new skin around the edge is red/blue and almost transparent o punched out – diabetic neuropathy, ischaemia. Follows rapid death and loss of the whole thickness of the skin without much attempt of the body to repair the defect. Most often seen on the foot due to pressure on an insensitive pice of skin eg ulcer secondary to a neurological defect. o Undermined - pressure necrosis. When an infection in an ulcer affects the subcut tissues more than the skin, the edge becomes undermined. Commonly seen in the buttock as a result of pressure necrosis, because the subcutaneous fat is more susceptible to pressure than the skin. o Rolled – BCC. Develops when there is slow growth of tissue in the edge of the ulcer. Typical and almost diagnostic of BBC. Edge is usually pink/white, which clumps and clusters of cells visible through the paper-thin superficial covering of squamous cells o Everted – develops when the tissue in the edge of the ulcer is growing quickly and spilling out of the ulcer. Typical of carcinoma, on the skin - SCC •Base: -remove scab to examine ulcer properly o Depth - mm and anatomically by describing the structures it has penetrated or reached, o floor covering (slough, granulation tissue, eschar, malignancy), oSolid brown, or grey dead tissue indicates full-thickness skin death. oIschaemic ulcers often contain no granulation tissue and tendons and other structures may lie bare in their base. oredness of the granulation tissue reflects the underlying vascularity and indicates the ability to heal odischarge - serous, serosanguinous, purulent, malodorous o always take swab o erosion •Surrounding tissue: o induration, o local blood supply o inflammation, o sensory loss, o lymph node involvement |
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Foot ulcer - . What questions would you ask?
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•Symptoms? – painful? interfere with daily acitivities such as walking? Record a history of each symptom.
•How has the ulcer changed since it first appeared? Size, shape, edge, depth, base, discharge and pain •Has the patient ever had a similar ulcer on the same site or elsewhere? – obtain complete history of each one •What does the patient think caused the ulcer? Most patients believe they know the cause of their ulcer, and are often right. The commonest initiating cause is trauma. If so, try and assess the severity and type of injury. A large ulcer following a minor injury suggests that the skin was abnormal before the injury. •Systemic symptoms? eg fever, weight loss •Systems: Diabetes? Trauma? Vascular disease? Smoker? High cholesterol? |
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Causes of tongue ulceration
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•Aphthous ulcer – unknown aetiology.
o Minor – most common. Less than 10mm, have a grey/white centre within a erythematous halo. Heal within 14 days without scarring o Major - >20mm, often persist for weeks or months and heal with scarring o Herpetiform – multiple 2-3cm lesions. • Trauma – due to ill-fitting dentures, toothbrushing or lacerations by sharp teeth • Non specific glossitis • Generalised disease – crohns, ulcerative colitis, coeliac disease, lupus erythematosus • Tuberculosis and syphilis • Carcinoma – lateral borders. Early tumours may be painless, but advanced tumours are easily recognisable as indurated aphthous ulcers with raised and rolled edges. Aetiological agents include tobacco, heavy alcohol consumption, and areca nut. Intra-oral lesions which undergo malignant transformation include leukoplakia, lichen planus, submucous fibrosis and erythroplakia. |
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List the parts of the biliary tree
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Describe the path of the large intestine
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Ascending colon ascends from the iliocoecal valve to the hepatic flexure. It is attached to the posterior abdominal wall.
The transverse colon hangs from the mesentary of the transverse mesocolon to the splenic flexure. Decending colon, sigmoid, rectum |
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Describe the pathogenesis of appendicitis
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1) Progressive obstruction (faecolith, tumour, parasites, lymphatic congestion)
2) Venous stasis and congestion, bacterial proliferation 3) Acute inflammation 4) Ischaemia, necrosis, perforation |
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Pathology of cholecystitis
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1) cholesterol/bile imbalance and cholesterol precipitates into a cholesterol stone
2) Pigment stones due to haemolysis or infection 3) Neck of gall bladder obstructed 4) Venous congestion, inflammationm ischaemia, wall thickening and fibrosis, perforation and possible fistula formation |
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Name the major organs and blood vessels
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What are the upper GI alarm symptoms
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Dysphasia
Haemtemesis Odynophagia Weight loss |
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What are the four broad management strategies of reflux
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Lifestyle
Medical Surgical Endoscopic |
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What is the normal daily fluid output
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Urine output 0.5-1mL/kg/hr = 1000-1500mL/day
Insensible losses: around 1L/day (faeces, respiration, perspiration) |
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What is the daily fluid requirement for a normal male and female
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Around 2.5L for a 70kg male and 1.6L for a 45kg female
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What is the daily sodium and potassium requirement
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K+ - 1 mmol/kg/day
Na+ 1 mmol/kg/day |
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What are examples of 3rd space losses contributing to dehydration
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Oedema, pleural effusions, ascites, surgical drains
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What are examples of GI fluid losses in the surgical patient that need replacing
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Upper: vomiting, NG tube
Lower: diarrhoea, stoma, fistula |
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A patient suffers from post operative stress response and has been inappropriately given 5% dextrose. Explain the problems that can arise and the mechanism
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Post operative stress causes SIADH resulting in dilution hyponatremia. Addition of hypotonic fluids such as 5% dextrose can result in severe hyponatremia causing cerebral oedema, sezures, coma and death.
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List 6 medical causes of hyponatremia
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1) diuretics
2) CHF 3) Addison's disease 4) Renal failure 5) Polydipsia 6) Cirrhosis |
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What metabolic abnormalities can result in hypernatremia
|
Diabetes insipidus. 2 mechanisms:
1) Central - no production of ADH 2) Renal - no response to ADH |
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What adrenal disorder causes hypokalaemia? Explain
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Conn's Syndrome: aldosterone secreting adrenal adenoma increasing production of Na/K ATPases in renal tubules causing hypokalaemia
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Describe the regimen of potassium replacement
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Oral: 1-2 slow K or chlorvescent tds
IV: 20-40 mmol k+ in 1L saline every 4-6 hrs |
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An ECG shows ST depression leading to a peaking T wave. QRS is broad. What is the cause and what is the 3 treatment alternatives?
|
Hyperkalaemia.
Cause: renal failure, adrenal failure (Addison's), high intake, K+ sparing diuretics, ACEI's Treatment: 1) 100mL 50% dextrose with 20 units of Actrapid 2) Resonium 15G tds 3) Dialysis |
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What 4 considerations need to be taken into account when administering IV fluid supplementation of the surgical patient?
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1) Age
2) Cardiac output eg CHF 3) Renal failure 4) The surgical state: inguinal hernea repair vs bowel resection vs burns patient |
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Post surgery, how much fluid should be administered and why?
|
"Run them dry" at 1-2L/day because of post surgical stress, increased SIADH, cortisol and aldosterone resulting in fluid retention
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What are 4 indicators of poor nutritional states
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1) Serum alb < 35 mmol/L
2) low WCC 3) low ferritin 4) 10% unintentional weight loss or 85% IBW |
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In deciding whether do choose and enteral route over a parenteral route, what considerations are taken
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Enteral is preferred because of: Secretion of gastric hormones, maintenance of intestinal mucosal integrity and immune function, allows processing via portal circulation, cost.
Enteral is contraindicated (hence use parenteral) when there is vomiting, obstruction, chronic diarrhoea, malabsorption |
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What are the neurological symptoms of thyrotoxicosis
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1) Lid lag
2) Exopthalmos 3) Proptosis |
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What are the "compression signs" of thyrotoxicosis
|
1) Compression of trachea, oesophagus (stridor, dysphagia)
2) Horse voice - compression of RLN, sign of malignancy |
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How is a midline neck lump identified as normal thyroid on examination
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1) Thyroglossal cyst moves on tongue protrusion
2) Thyroid only moves on swallowing and not tongue protrusion |
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What is the treatment for papillary cancer and why is this method used
|
Total thyroidectomy because easy to monitor rise in thyroid hormone due to metastatic spread
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What are the complications of a total thyroidectomy
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1) Damage to SLN, horseness, stridor.
2) Parathyroid gland damage (temporary 30%, permanent 3%) - calcium must be administered post surgery 3) Haematoma compresses venous drainage and causes congestion 4) Perforation of oesophagus |
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How can hyperactive parathyroids be identified radiographically?
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1) USS
2) Sestamibi scan (small radionucleotide tagged protein) plus calcium. The calcium switches off normal PT glands. |
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What are the causes of acute pancreatitis
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1) gallstones (60%)
2) alcohol (30%) 3) ERCP, trauma, drugs, infections, hypertriglyceraemia |
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List the Ix for suspected acute pancreatitis and explain rationale for each test
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1) CRP (inflammation)
2) lipase (activated enzyme 3xnormal seeping into bloodstream) 3) PO2 (ARDS, resp failure common) 4) urea, Cr, eGFR (renal failure common) 5) Haematocrit (distributive shock caused by massive sequestration into peritoneal cavity) 6) ALT, AST, ALP, GGT 7) CT to determine severity index. Must wait for necrosis to develop 2 days after onset. 8) MRCP to detect biliary sludge 9) ERCP 10) Secretin stimulation test of function: bolus of secretin and volume of bicarb produced |
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List the treatment steps for acute pancreatitis
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1) Analgesia
2) Fluids 3) Respiratory support 4) GIT rest 5) Monitoring: urine, BGL, PO2, WCC |
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A 59 YO male presents with haematuria. What are the DDx
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1) TCC
2) calculus 3) prostatitis/prostate cancer 4) Renal cancer |
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Which is more serious: microscopic or macroscopic haematuria
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Microscopic: 95% benign
Macroscopic: 50% pathological |
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59YO male with haematuria. Hx questions
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1) Pain? (nature, severity, duration, associated symptoms)
2) Duration, frequency of haematuria 3) Stream questions: initial (hesitancy, clear or bloody?), total stream (bladder likely), terminal drops (ureteric, renal) 4) Clots (indicates larger volume of blood) 5) Risk factors for TCC (smoking industrial dyes and solvents) |
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List the BREAST mnemonic
|
B - BRAC1&2
R - RBG E - E-Cadherin (tumour suppressor gene) A - APC S - Syndromic T - tumour suppressor (P53) |
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What Hx is needed for a lump in teh breast
|
1st & 2nd deg relatives
Age at 1st pregnancy (< 30 protective) OCP HRT Breast feeding Is swelling associated with cycles (fibrocystic disease) Discharge (papiloma bloody) Exposure to oestrogen: early menarch, late menopause Bone pain? (mets) |
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What is peu de orange?
|
Coopers ligament tethering due to lymphatic blockage by tumour cells
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What examination features are indicative of BC
|
1) Dimpling due to fixation by deep tumour
2) Fixation to underlying fascia or muscle (moves when liftuing arms) 3) Lymphatic palpation |
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How is definitive diagnosis of BC made
|
Triple test
1) Examination 2) Imaging (USS<40, mamogram >40) 3) Core biopsy (needle used if difficult site eg deep to nipple |
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When is a mastectomy performed
|
1) Cannot preserve nipple
2) High risk: BRAC1 or 2 3) Tumour > 5cm, multiple tumours |
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When is a mastectomy performed
|
1) Cannot preserve nipple
2) High risk: BRAC1 or 2 3) Tumour > 5cm, multiple tumours |
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What vertebral levels is kidney pain referred to
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T10 to T12: referred all the way from the flanks to the pubis and testes or labia.
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Sharp pain in the bladder region is referred to from what?
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Distal ureter S2-S4
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What size stones require cystoscopy?
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6mm+
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Explain Courvoisier's law
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A palpable gall bladder and jaundice is due to cancer (pancreatic or gall bladder) and not cholesystitis.
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A patient presents with a palpable, painful gall bladder. What is the management
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USS to detect stone
Mucocoele often followed by pyelocoele with gram -ve infection and septic shock. Monitor CVP, treat with AB's and fluids, monitor for pancreatitis, renal function |
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How is acute PVD investigated and treated. What about chronic?
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Acute: arterial due to ventricular source (valvular vegetations, LV thrombus). Ix by CT Angiogram. Tx: TPA, stent, thrombectomy.
Chronic: due to thrombus. Ix by ankle/brachial index. Normal >1. Tx stenting |
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What is Buerger's Disease
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Occlusion by thrombosis of small and medium arteries in extremities. Ass. with tobacco.
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A patient shows a +ve Homan's sign. What further questions should you ask?
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Questions relating to Virchow's triad:
1) Stasis: hospitalisation, immobility, air travel, heart failure 2) Vascular injury: surgery (esp ortho hip or knee), tobacco smoking, diabetes, hypercholesterolaemia, hypertension, kidney disease, trauma 3) hypercoagulability: protein C deficiency, antithrombin III def, family Hx of clotting disorders, cancer |
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A patient presents with varicose veins and says it is due to standing at work. Explain aetiology and treatment
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Aetiology: idiopathic, pregnancy, hereditary, obesity, liver disease
Treatment: compression stockings, stripping, ligation |
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Describe how the LOS maintains its tone
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1) Acute angle of cardioesophageal hunction acts as a valve. fundus produces a definite angle.
2) Crura of the diaphragm |
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A patient presents with new reflux symptoms. What broad aspects must be investigated
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1) Pump: hyper or hypo motility of the oesophagus
2) Valve: tone of the LOS 3) Reservoir: capacity and emptying of the stomach |
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What investigations are performed for patients presenting with gastric reflux? What are red flag history questions?
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1) 24 hr pH monitoring
2) Manometry test Red Flags: dysphagia, odynophagia, chest pain, weight loss |
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What is the management of GORD
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1) Lifestyle: weight loss, dietary changes, smoking cessation
2) If oesophagus mobility is normal, LOS tone is low and stomach emptying is normal then fundoplication. If young and high grade Barrett's dysplasia then oesophagectomy (incidence is 1/200) |
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What are the locations of peptic ulcers? What are the specific stressors
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Locations
1) Antrum 2) Meckel's diverticulum Stressors: burns (due to ischaemia of GI tract), neurosurgery and head trauma, ICU stress |
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What is the management of a bleeding peptic ulcer
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1) Transfusions, PPI's, watchful waiting (up to 70% resolve spontaneously)
2) Endoscopic ligation: clips or cauterisation 3) Abdominal surgery: antrectomy |
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What tumour marker is monitored in colon cancer and how is it used
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CEA (carcinoembryonic antigen). Not sensitive or specific and only used once colon cancer is diagnosed. Used as a prognostic marker once bowel has been resected. If still high then mets are likely.
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How is colon and rectal cancer staged.
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Colon cancer: Ct - cannot MRI because of moving bowel
Rectal: distal rectum is fixed, hence, MRI possible but only before resection. After that, small bowel drops into pelvic cavity. Same reasoning for radiation therapy. |
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Which arteries supply the caecum, ascending and transverse colons
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Branches of the superior mesenteric artery:
Iliocolic - caecum Right colic - ascending Middle colic - transverse |
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In resecting the sigmoid colon containing cancer, what precautions must be taken regarding blood supply
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1) Marginal artery must be patent
2) IMA must be resected proximally to remove as much of lymphatics as possible |
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