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71 Cards in this Set
- Front
- Back
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What 4 areas are most commony injured in a stab wound to the abdomen? |
Liver Small bowel Diaphragm Colon |
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What areas does blunt abdominal trauma most commonly affect? |
Organs that are fixed by ligaments/mesentery that can sheer off: Spleen Liver Small bowel |
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What are the components of an AMPLE history? |
A - allergies M - medications P - past hx L - last ate E - events leading up to injury |
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Which areas are investigated by FAST scan and when should this be repeated? |
Pericardial sac Hepatorenal fossa Splenorenal fossa Pelvis/pouch of douglas Repeat after 30 mins to see any progression |
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What are indications that a laparotomy is required in abdominal trauma? |
Refractory Hypotension Clinical evidence of intraperitoneal bleeding, Positive FAST Peritonitis or Evisceration Penetrating trauma & active bleeding from stomach, rectum or GU trac |
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What organ is classically at risk from a direct blow from a bicycle handlebar? |
Duodenum |
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4 differentials for epigastric pain |
Oesophagitis PUD/ruptured ulcer Pancreatitis Chest pain: cardia/resp |
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2 differentials for flank pain |
Ureteric colic Pyelonephritis |
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Differentials for RUQ pain |
Gallstones Cholangitis Hepatitis/hepatomegaly Liver abscess |
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Differentials for LUQ pain |
Splenic abscess, rupture or splenomegaly |
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3 differentials for umbilical pain |
Early appendicitis Meckels diverticulum Mesenteric adenitis |
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3 differentials for suprapubic pain |
Cystitis Urinary retention Testicular torsion |
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5 differentials for RIF pain |
Appendicitis Chrons Ovarian cyst Ectopic pregnancy Hernia |
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5 differentials for LIF pain |
Diverticulitis Ovarian cyst UC Constipation Hernias |
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5 causes of abdominal distension |
Fat Flatus Foetus Fluid Faeces |
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5 S's when describing masses |
Site Size Shape Skin changes & Scars Symmetry |
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What is rebound tenderness? |
Pain upon removal of pressure more than on application - sign of peritonitis (rigidity is more specific sign of peritonitis) |
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How does an ischaemic abdomen present? |
Diffuse abdominal pain, bowel distention, and bloody diarrhea |
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What are the 2 most common presentations of functional bowel obstruction and how do they present? |
Paralytic ileus: Post op typically day 2-3, effortless vomiting, no faeces or flatus, absent bowel sounds. Treatment: drip & suck Pseudo-obstruction, often elderly/inferm, gradual distension, little pain. Manage: fluid/electrolyte replacement & nutritional support. May do sig to decompress |
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What are the most common cause of mechanical bowel obstruction? |
Adhesions Also hernias or neoplasia |
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How can you classify mechanical bowel obstruction? Give examples. |
Extrinsic - adhesions, hernia, volvulus Intrinsic - Chrons, Cancer, TB, congenital atresia Luminal - Gallstones, FB, parasite |
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How might bowel obstruction lead to perforation? |
Venous compromise leads to oedema, which in turn results in arterial compression, ischaemia and intestinal necrosis |
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Which features occur earliest in: - Small bowel obstruction - Large bowel obstruction |
SBO: vomiting LBO: constipation, distension |
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Why is the caecum the most likely part to rupture? |
Laplace’s law: as pressure rises, tension in the wall is maximal at the point where the diameter of a tube is greatest (caecum has largest radius of any part of bowel) |
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What investigations would you do for bowel obstruction? |
Bloods, AXR (+/- erect chest), +/- CT abdo |
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What is the initial management for bowel obstruction? |
Drip & suck 48 hours then surgery if not settled NBM, NG decompression, analgesia, O2, fluid resus, monitoring including ABGs |
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When should primary anastomosis of resected bowel NOT be carried out? |
Ischaemia of either of the bowel ends Tension on the anastomosis Peritoneal soiling with faeces or pus Gross inflammatory disease, eg Crohn’s disease |
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What is volvulus and where does it occur? |
Segment of bowel twists through 360° Sigmoid++ - usually elderly from nursing home Caecum |
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What are the 3 most common causes of peritonitis? |
Postop complication Acute appendicitis Perforated peptic ulcer |
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Hiccoughing and swinging pyrexia a few weeks after an abdominal perforation is a classic Hx of...? |
Subphrenic abscess |
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What are the parameters of a Rockall score? |
Age Shock Co-morbidity Diagnosis Stigmata of recent hemorrhage Anything >0 should have endoscopy |
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How would you manage a bleeding peptic ulcer? |
ABCDE & resus (RBCs if >30% volume loss) Endoscopy +/- • Injections: Adrenaline, Ethanol, sclerosants • Heater probe • Clips • Bipolar electrocoagulator • Nd:YAG laser When haemostasis has been achieved:• Acid suppression, Tranexamic acid, H. pylori eradication |
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When might you operate on a bleeding peptic ulcer and how is haemostasis achieved? |
If not controlled endoscopically or mssive transfusion requirements Stop bleeding by under-running bleeding vessel with a suture Definitive treatment may involve resection of ulcer to prevent rebleed & exclude malignancy |
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Define: hernia |
A protrusion of all or part of a viscus outwith its normal position |
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What is the difference between the types of hernias that men and women get? |
M: Direct inguinal > indirect inguinal > femoral F: Indirect inguinal > femoral > direct inguinal |
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What is the aetiology of inguinal hernias? |
Congenital eg persistent process vaginalis Acquired: aging, previous surgery, high intra-abdominal pressure eg chronic cough, heavy lifting, ascites |
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4 states a hernia may be in |
Reducible Incarcerated - part of the contents cannot be reduced Obstructed - bowel loop contained is kinked & obstructed Strangulated - blood supply compromised |
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Describe inguinal and femoral hernias in relation to the pubic tubercle |
Inguinal: lie above and medial to pubic tubercle Femoral hernia - lie below and lateral to pubic tubercle, medial to femoral pulse |
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Describe the difference between direct and indirect inguinal hernias |
Direct - straight through weakness in anterior abdominal wall. NOT controlled by occluding deep inguinal ringAt surgery: neck lies medial to IEA Indirect - through deep & superficial rings along entire length of inguinal canal (Remnant of patent processus vaginalis. At surgery neck lies lateral to IEA |
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How should hernias be managed? |
Repair: - Open or laparoscopic - General or local anaesthesia - Suture or mesh |
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How should the risk of incisional hernias be minimised when closing a laparotomy wound? |
Jenkins Rule should be followed: - Use a suture length 4x length of incision - Take bites at 1cm intervals, 1 cm from the wound edge |
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What are the risk factors for incisional hernias? |
Pt: Age, immunocompromised, obesity, abdominal distension, malnutrition Op: poor technique, poor incision placement Post-op: wound infection, haematoma, early mobilisation, chest infection & cough |
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What is a Spigellian hernia? |
Hernia occurring at the level of the arcuate line |
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What is the nme given to a hernia where just part of the wall of the small bowel is strangulated within a hernia? |
Richters |
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What is a Littres hernia? |
Hernia containing Meckels diverticulum |
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How should fistulas be managed? |
S - Sepsis control - treat infection, remove FBs N - nutritional support A - adequate fluid and electrolyte replacement and assess anatomy P - protect skin and plan for excision/drainage |
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Define: stoma |
Communication between a hollow viscus and the skin |
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What are the 3 outcomes for the distal portion of bowel in an end colostomy? |
Resected (AP resection) Closed and left in abdomen (Hartmann’s) Exteriorised (Mucus fistula) |
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Where is an end colostomy most commonly located? Ileostomy? |
Colostomy: LIF Ileostomy: RIF |
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How should a stoma site be marked? |
With pt standing Away from clothing waistline or bony prominences, skinfolds, scars or umbilicus |
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What is the main indication for Gastrostomy and how is this usually achieved? |
Feeding Commonly percutaneous endoscopic gastrostomy |
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Describe some indications for a temporary and a permanent ileostomy |
Temporary: - To protect ileorectal anastomosis - Persistent low intestinal fistula - Right colonic trauma Permanent - Panproctocolectomy for UC, severe Crohn’s, FPC or multiple colonic cancer |
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What are the complications of stoma formation? |
Psychosexual Nutritional deficincy, diarrhoea (fluid/electrolyte) Ischaemia Bleeding Hernia/Prolapse/intussusception Stenosis Skin excoriation |
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Describe the difference in surface and contents of an ileostomy and a colostomy |
Ileostomy: spouted & liquid contents Colostomy: flush & solid contents |
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Where does the spleen lie? |
Between ribs 9-11, left |
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What is the blood supply and venous drainage of the spleen? |
Blood supply: splenic artery (from coeliac axis) Venous drainage: splenic vein to portal system |
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In splenic trauma what should occur if the pt is conservatively managed? |
Pt should be closely observed for at least 7–10 days due to the risk of secondary rupture |
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What are the causes of splenomegaly? |
Infection Cellular infiltration: eg Amyloidosis Collagen diseases: eg Felty syndrome Autoimmune disorders: eg RA, SLE Haematological Venous Congestion Infarction Space-occupying lesions eg cysts Neoplasia |
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What are the normal blood changes post op after Splenectomy? |
A transient neutrophilia Increased size and number of platelets Presence of nucleated red cells and target cells |
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What is the complication of splenectomy with the highest mortality and what is it due to? |
Overwhelming infection due to: Streptococcus pneumoniae, Neisseria meningitidis or Haemophilus influenzae |
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How is overwhelming post splenectomy infection risk minimised? |
Elective splenectomy pt’s should have immunisations 2-4 weeks pre-op Post op Abx prophylaxis & immunisations (& boosters) |
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What is the difference between dysphagia and odonophagia? |
Dysphagia: difficulty swallowing Odonophagia: pain on swallowing |
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How can difficulty swallowing be classified? |
Intrinsic Extrinsic Functional: neurological or dysmotility |
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What is progressive dysphagia from solids to liquids indicative of? |
Oesophageal cancer |
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What is the mainstay of investigating dysphagia and what special tests can also be used? |
OGD +/- biopsy Barium swallow, CT, Manometry, pH studies |
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What is a pharyngeal pouch and how is it investigated & managed? |
A pseudo-diverticulum of the mucosa of the pharynx, just above the cricopharyngeal muscle Investigation: contrast swallow Treatment: Conservative management or endoscopic stapling |
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How should a pt presenting with GORD be investigated/managed? |
Aged <55 Urease breath test & trial of PPI. Investigate further if Hx of weight loss, anaemia, anorexia, FHx or Barrett’s oesophagus Aged >55 : Endoscopy is 1st line However pH monitoring is the gold standard for diagnosing reflux (90% sensitive) |
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What is the mainstay of management of GORD? |
Conservative: lifestyle factors Medical: PPI & H.pylori eradication |
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What operation may be used in refractory cases of GORD? |
Nissen fundoplication of hiatus hernia |
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What is the most common cause of an oesophageal stricture and how is this treated? |
+++GORD NB also TB, Chrons, NSAIDs Management: treat cause & serial balloon dilatations |
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What cell changes occur in Barrets oesophagus? |
Normal squamous lining has been replaced by metaplastic columnar epithelium |
