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92 Cards in this Set
- Front
- Back
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What are the characteristic features of achalasia? |
High LOS pressure and failure of the relaxation of the sphincter Usually presents as difficulty swallowing (liquids and solids equally) and retrosternal chest pain |
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Describe the 3 surgical management options for achalaisa? |
Balloon dilation Heller’s cardiomyotomy Injection of botox into the LOS under USS |
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What GI condition quite closely mimics ACS? How is it managed? |
Diffuse oesophageal spasm Nifedipine and reassurance |
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What presents similarly to achalasia and is caused by chronic infection with Trypanosoma cruzi? |
Chagas disease |
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What is Boorhave's syndrome? What is typically seen on CXR? |
Spontaneous oesophageal rupture: severe chest pain/upper abdominal pain after an episode of vomiting CXR: pneumothorax, mediastinal gas and pleural effusion |
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How should oesophageal rupture be managed? |
Resus, NBM, Broad-spectrum Abx, Parenteral nutrition, PPIs and analgesia Surgical repair if high risk of contamination, peritonitis |
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What structures are at risk during oesophagectomy? |
Azygos vein, intercostal vessels,aorta, tracheobronchial tree and recurrent laryngeal nerve. |
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Where is the most common site for PUD? |
Duodenum - pain relieved by food |
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What are the S&S of PUD? |
Epigastric pain, anorexia,weight loss, haematemesis, melena |
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Risk factors for PUD |
NSAIDs Smoking ETOH H.pylori Zollinger Ellison syndrome FHx Stress (inc burns, surgery & head injury) |
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What are the 2 most common causes of acute pancreatitis? |
Gallstones ETOH |
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What are the other causes of pancreatitis? |
Trauma Iatrogenic trauma eg post ERCP Inefction: mumps, cocksakie Metabolic: hyperglycaemia, hyperlipidaemia Drugs eg steroids Pancreatic duct obstruction |
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What are the S&S of acute pancreatitis? |
Epigastric pain radiating to back, N/V, may have obstructive jaundice Severe may present as shock with pyrexia. |
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What clinical signs might suggest a retroperitoneal bleed? |
Cullen's: periumbilical bruising Grey Turner's: flank bruising |
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What investigations should be done in acute pancreatitis? |
Bloods inc Amylase (>3 times normal value) ABG, CXR, AXR (exclude perf PUD) CT with contrast USS - pancreatic oedema or mass, dilated ducts, gallstones, pseudocyst MRCP/ERCP |
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Describe the Modified Glasgow score for pancreatitis |
P - PaO2 <8 A - Age >55 N - Neutrophils >15 C - Ca - <2 R - Raised Ur - >16 E - Enzymes (LDH) - >600 A - Albumin - <32 S- Sugar - >10 |
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What Glasgow score would suggest a pt needs ITU care? |
>3 |
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How should acute pancreatitis be managed? |
ABCDE Fluids & correct electrolyte abnormalities Analgesia NBM or clear fluids only UO monitoring Abx if septic or evidence of collection/necrosis Insulin sliding scale if erratic BMs |
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How does chronic pancreatitis present? |
Abdo pain, weight loss, nausea, malnourished, DM, jaundice, steatorrhoea |
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How should chronic pancreatitis be managed? |
Analgesia Dietary modification, low fat, ETOH cessation Supplements, creon May require insulin Endo dilatation/stent if stricture/obstruction |
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What is the most common type and site of pancreatic cancer? |
Ductal adenocarcinoma (90%) head>body>tail |
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How would you manage pancreatic cancer? |
Palliative: stenting, radiotherapy or coeliac plexus block for pain Curative:Whipples (for head/ampulla)Distal pancreatectomy (for body/tail) |
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What is jaundice? |
Yellow discolouration of skin & sclera due to abnormally high levels of serum bilirubin (>40mmol) |
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What are the 3 types of jaundice? |
Prehepatic (haemolytic) - Un-conjugated Hepatic - Conjugated & Unconjugated - Post-hepatic (obstructive) - Conjugated - Pale stools, dark urine |
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3 causes of pre-hepatic jaundice |
Congenital eg sickle Autoimmune destruction Iatrogenic: drug toxicity, transfusion reaction |
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3 causes of hepatic jaundice |
Inherited: Gilberts, Crigler-Najar Infection - Viral, bacterial,parastitic abscess Drugs - OD paracetamol, ETOH |
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3 causes of obstructive jaundice |
Intraluminal - gallstones Mural - cholangiocarcinoma, congenital atresia, PSC, PBC Extrinsic - pancreatitis, pancreatic tumour, lymphadenopathy at porta hepatis |
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Why are there clotting defects in obstructive jaundice? |
Impaired fat absorption so impaired fat soluble vitamin absorption (Vit K) |
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What are the causes of portal HTN? |
Pre-hepatic - Congenital portal vein atresia - Portal vein thrombosis - Occlusion by tumour or pancreatitis Hepatic - Cirrhosis - Hepatitis Post hepatic - Budd-chiari - hepatic vein thrombosis - Blockage of hepatic veins by tumour |
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Transudate and Exudate causes of ascites |
Transudate: Cirrhosis, heart failure, renal failure Exudate: Neoplasm, TB, Budd-chiari syndrome, pancreatitis |
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Which scoring system incorporates ascites as a measure of prognosis of CLD? |
Child Pugh score |
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At what sites do varices typically develop? |
Oesophageal Rectal Umbilical |
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How should an acute variceal bleed be managed? |
ABCDE OGD & banding, ligation or sclerotherapy Somatostatin or octreotide: reduce splanchnic and hepatic flow, use for 5 days post bleed. Terlipressin for 48hours to cause vasoconstriction. Temporary measures: Balloon tamponade - Sengstaken–Blakemore |
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How should recurrent variceal bleeding be managed? |
Transjugular intrahepatic portosystemic shunt (TIPSS) liver transplant |
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What are the risk factors for gallstones? What are the S&S? |
Fat, Female, Forty, Fertile, FHx Usually asymptomatic. Bloating, abdo discomfort, flatulence after high fat meal |
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What is biliary colic and how should it be managed? |
When gallstone causing irritation to gallbladder or duct- afebrile and normal inflammatory markers Analgesia, low fat diet, consider elective lap chole |
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What is acute cholecystitis and how does it present? |
Infection & inflammation of the gallbladder S&S = severe, constant RUQ pain, fever, N/V, pyrexia, tachycardia |
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What is Murphy's sign? |
Tender RUQ & localised peritonism Pt catches breath when RUQ palpated during inspiration |
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How should acute cholecystitis be managed? |
ABCDE, IV fluids, IV abx, analgesia Lap chole <72 hours or 6 weeks after settled |
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What are the complications of acute cholecystitis? |
Perforation, gallbladder empyema, abscess |
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What is the triad in ascending cholangitis? |
FEVER + PAIN + JAUNDICE Requires: urgent ERCP or PTC |
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Main pathological findings in UC |
Rectum & colon Superficial & continuous No granulomas, no fistulae Pseudopolyps Crypt abscesses Lead pipe colon |
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Main pathological findings in Chrons |
Mouth to Anus, ++terminal ileum Transmural & patchy “skip lesions” Granulomas, fistulae, sinuses Deep fissures Strictures Cobblestone mucosa |
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What are the main medical management options in IBD? |
5-AA, Mesalazine, Sulphasalazine, steroids, Azothioprine, Anti TNF |
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How is surgery used in management of Chrons vs UC? |
UC: curative intent eg proctocolectomy Chrons: surgery not curative, used to treat complications: fistula, abscess, stricture |
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Which vessels do you ligate in a right hemicolectomy? Left hemicolectomy |
Right: Iliocolic, Right colic, Right branch of middle colic Left: IMA |
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Which tumours should have anterior resection and which AP resection? |
Anterior: Tumours >5cm anal verge AP: Tumours <5cm anal verge |
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Define: Diverticulum |
Abnormal outpouching of hollow viscus into surrounding tissues |
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What are the complications of Diverticular disease? |
Perforation Infection/inflammation Bleeding Fistulae Strictures Malignancy |
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Management of diverticulitis |
Uncomplicated = Abx + fluids Surgery if perf/abscess/obstruction ++Hartmanns |
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Causes of faecal incontinence |
Diarrhoea including overflow, IBD Anal problems: injury eg obstetric, prolapse, radiotherapy, resection, fistula Neurological EG MS, spinal injury Congenital eg spina bifida or Hirschsprungs Severe cognitive impairment |
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What condition is there an increased risk of with rectal prolapse? |
Solitary rectal ulcer |
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What condition is most likely in a pt presenting with: - Pain on defecation - Minor bright-red bleeding on the paper - Pruritis ani |
Anal fissure |
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Management options for anal fissure |
Conservative: high fibre diet Medical: GTN paste 0.2%, Diltiazem cream 2%, Botox to sphincter to break the spasm–fissure cycle Surgical: Lateral sphincterotomy (risk of incontinence) |
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What are haemorrhoids and what are the most common locations of haemorrhoids? |
Prolapsed anal canal submucosal cushions 3, 7, 11 o’clock |
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Management of haemorrhoids |
Conservative - high fibre, ice packs Medical - anusol, laxatives Surgical - 1-2nd degree: banding/sclerotherapy. 3-4th (manual reduction or irreducible) haemorrhoidectomy. |
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4 causes of fistula in ano |
Most a result of abscess May also be secondary to Chrons, TB, cancer. |
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What does Goodsall's rule state? |
An external opening lying anterior to Goodsall’s line is usually associated with a straight tract, whereas an external opening lying posterior to it may not be |
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Managment options for fistula in ano |
Medical treatment of IBD Drain acute sepsis EUA, probe track to identify course Low: Fistulotomy (lay open and leave to heal) High: seton insertion |
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What is a pilonidal sinus? |
Subcutaneous sinus that contains hair, commonly at the natal cleft Often presents when infected as an abscess |
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How should a pilonidal sinus be managed? |
Incision and drainage under GA with f/u to review for further intervention Elective excision of pits and laying open of sinus, pack loosely with a gauze ribbon. Frequent changes of dressing and close supervision postop. Regular rubbing with a finger avoids premature closure. Meticulous hygiene and shaving |
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Pathology and risk factors for anal cancer |
+++SCC People who practise anal sex, Hx of genital warts, HPV |
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To which lymph nodes to cancers of the anal margin and anal canal spread? What is the most common treatment modality? |
Margin: inguinal lymph nodes Canal: internal iliac lymph nodes Management ++radiotherapy |
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What are the methods used for breast reconstruction? |
Tissue expansion & implant - subcutaneous or submuscular Myocutaneous flap - TRAM (transverse rectus abdominis) - DIEP (deep inf epigastric perforator), spares rectus - SIEA (Sup inf epigastric artery) - Latissimus dorsi flap |
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What are the advantages of an implant reconstruction? |
Simpler procedure, can be done immediate or delayed |
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When would a flap reconstruction be better? |
Following extensive surgery with little skin/muscle left Can provide preferred cosmesis |
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What preoperative steps would you take for a pt pre-thyroidectomy? |
Vocal cord check TFTs, if hyperthyroid: cardiac work up & Lugols iodine to reduce vascularity, render euthyroid with medical therapy |
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What are the complications of thyroidectomy? |
Anaesthetic risk Bleeding/Haematoma - (NB airway obstruction from laryngeal oedema) Infection Scar Bilateral laryngeal nerve palsy can result in airway obstruction (uni = hoarse) Thyroid storm Hypocalcaemia Hypothyroidism |
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Main metabolic derangement in Conns |
↑ Na+, ↓ K+ |
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Aetiology in arterial aneurysms |
++Athersclerotic Also mycotic, congenital, traumatic, connective tissue |
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How might a AAA present? |
++present asymptomatic incidental finding May also present as central abdo pain radiating to back (sign of expansion), or severe abdo pain & collapse (rupture). Thrombus from the aneurysm may cause acute limb ischaemia or small trash foot. |
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Describe the screening of AAAs |
Men >65 3.0-4.4 cm: annual ultrasound 4.5-5.4 cm: three-monthly ultrasound 5.5 cm or bigger - consider surgery |
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What is the 2nd most common site of athersclerotic aneurysms? |
Popliteal artery |
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Describe a classification system for aortic dissection and how this affects management |
Stanford classification A - Ascending aorta - usually requires surgery B - Descednding aorta - medically managed with anti-HTN |
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What are the principles of management of acute limb ischaemia? |
• Resuscitation (oxygen and intravenous fluids) • Immediate anticoagulation (5000 units heparin intravenously) • Investigate: Doppler, arteriography • Analgesia • Restore arterial continuity • Identify and correct any underlying source of embolus |
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What is Leriche syndrome? |
Chronic buttock, thigh and calf claudication with erectile dysfunction, and proximal muscle wasting due to distal aortic or proximal iliac stenosis or occlusion |
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How might a pt with an ABPI <0.4 present? |
Critical limb ischaemia Severe rest pain, nocturnal rest pain so pt’s often sleep upright in chair, ulceration at extremities: “punched-out” with sloughy, unhealthy bases. Gangrene (tissue necrosis due to critical ischaemia) |
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Describe 3 types of gangrene |
Dry gangrene; insensate, cold and hard Wet gangrene - associated with infection by putrefactive organisms Gas gangrene - due to clostridia. Crepitus and septicaemia from toxin |
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What are the management options for chronic limb ischaemia? |
Conservative: correct RFs: exercise, smoking cessation, low fat diet Medical: Antiplatelet (aspirin, clopidogrel) Aggressive BP management & BM control. Statins Radiological:Balloon Angioplasty, Stenting Surgical: Graft, Amputation |
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What are the indications for amputation? |
Dying (eg vascular disease(++ in UK), gangrene) Dangerous (eg tumour, severe infection) Damned nuisance (eg useless, painful limb after trauma, neurological damage) |
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How should an amputation level be decided? |
Proximal enough for good healing, distal enough for outcome & rehab potential |
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What types of vascular grafts can be used? |
• Autologous: eg long saphenous vein, used in the reverse direction (flow not impeded by cusps) or used in situ after destruction of the vein cusps • Prosthetic: Dacron or PTFE grafts |
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What would a stroke in the area of the carotid territory present as? |
Contralateral hemiparesis, dysphasia if dominant hemisphere |
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What is the main indication for carotid endarterectomy? |
Patients with ipsilateral stenoses >70%, symptomatic in the previous 6 months |
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What is a chemodectoma? |
A tumour of the carotid body, presents as pulsatile neck lump in anterior triangle |
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What are the 3 layers of an aterial wall? |
Tunica Intima - endothelium, single layer Tunica Media – smooth muscle cells and elastic fibres Tunica Externa or Adventitia – collagen and the external elastic lamina. |
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What are the risk factors for varicose veins? What conditions are associated with varicose veins? |
Age, F>M, prev. DVT, obesity, pregnancy Associations: klippel-trenaunay-weber (varicose veins, port wine stains & limb soft tissue hypertrophy). Parks-Weber: multiple AV fistulae |
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How are varicose veins managed? |
Conservative - compression stockings, injection sclerotherapy, weight loss Surgical - saphenous vein ligation or stripping |
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Location & appearance of arterial vs venous ulcers |
Arterial: toes, deep, shiny hairless skin Venous: ankle, superficial, irregular edges, purple discolouration of skin |
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VTE risk factors |
Surgery: ++ Abdo/pelvic, hip/knee, C section Prolonged immoblity Pt factors: age, Malignancy, dehydration, sepsis, CCF, obesity, polycythaemia Trauma, lower limb or spine Haematological: Deficiency in C/S/Antithrombin III/V Leiden. Antiphospholipid Abs Endocrine: HRT, COCP Vascular: prev DVT, varicose veins |
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Investigation of suspected VTE |
DVT - urgent compression USS PE - ABG, CXR, CTPA (or VQ scan) Calculate wells score |
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Management of VTE |
Medical: LMWH (Dalteparin/fondaparinux). If low GFR or bleeding diathesis commence unfractionated heparin. Commence warfarin simultaneously til INR >2 for 24hours DVT: Catheter directed thrombolysis if symptoms <2 weeks, low bleeding risk and good life expectancy Systemic thrombolysis if acute PE and haemodynamic instability - if contraindicated (high risk of haemorrhage) then IE pulmonary catheterisation Surgical Embolectomy - critically ill pt, thrombolysis contraindicated and/or pulmonary catheterisation failed |
