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92 Cards in this Set

  • Front
  • Back

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

Describe the 3 surgical management options for achalaisa?

Balloon dilation

Heller’s cardiomyotomy

Injection of botox into the LOS under USS

What GI condition quite closely mimics ACS? How is it managed?

Diffuse oesophageal spasm

Nifedipine and reassurance

What presents similarly to achalasia and is caused by chronic infection with Trypanosoma cruzi?

Chagas disease

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

How should oesophageal rupture be managed?

Resus, NBM, Broad-spectrum Abx, Parenteral nutrition, PPIs and analgesia

Surgical repair if high risk of contamination, peritonitis

What structures are at risk during oesophagectomy?

Azygos vein, intercostal vessels,aorta, tracheobronchial tree and recurrent laryngeal nerve.

Where is the most common site for PUD?

Duodenum - pain relieved by food

What are the S&S of PUD?

Epigastric pain, anorexia,weight loss, haematemesis, melena

Risk factors for PUD





Zollinger Ellison syndrome


Stress (inc burns, surgery & head injury)

What are the 2 most common causes of acute pancreatitis?



What are the other causes of pancreatitis?


Iatrogenic trauma eg post ERCP

Inefction: mumps, cocksakie

Metabolic: hyperglycaemia, hyperlipidaemia

Drugs eg steroids

Pancreatic duct obstruction

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.

What clinical signs might suggest a retroperitoneal bleed?

Cullen's: periumbilical bruising

Grey Turner's: flank bruising

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


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

What Glasgow score would suggest a pt needs ITU care?


How should acute pancreatitis be managed?


Fluids & correct electrolyte abnormalities


NBM or clear fluids only

UO monitoring

Abx if septic or evidence of collection/necrosis

Insulin sliding scale if erratic BMs

How does chronic pancreatitis present?

Abdo pain, weight loss, nausea, malnourished, DM, jaundice, steatorrhoea

How should chronic pancreatitis be managed?


Dietary modification, low fat, ETOH cessation

Supplements, creon

May require insulin

Endo dilatation/stent if stricture/obstruction

What is the most common type and site of pancreatic cancer?

Ductal adenocarcinoma (90%)


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)

What is jaundice?

Yellow discolouration of skin & sclera due to abnormally high levels of serum bilirubin (>40mmol)

What are the 3 types of jaundice?

Prehepatic (haemolytic) - Un-conjugated

Hepatic - Conjugated & Unconjugated -

Post-hepatic (obstructive) - Conjugated

- Pale stools, dark urine

3 causes of pre-hepatic jaundice

Congenital eg sickle

Autoimmune destruction

Iatrogenic: drug toxicity, transfusion reaction

3 causes of hepatic jaundice

Inherited: Gilberts, Crigler-Najar

Infection - Viral, bacterial,parastitic abscess

Drugs - OD paracetamol, ETOH

3 causes of obstructive jaundice

Intraluminal - gallstones

Mural - cholangiocarcinoma, congenital atresia, PSC, PBC

Extrinsic - pancreatitis, pancreatic tumour, lymphadenopathy at porta hepatis

Why are there clotting defects in obstructive jaundice?

Impaired fat absorption so impaired fat soluble vitamin absorption (Vit K)

What are the causes of portal HTN?


- Congenital portal vein atresia

- Portal vein thrombosis

- Occlusion by tumour or pancreatitis


- Cirrhosis

- Hepatitis

Post hepatic

- Budd-chiari - hepatic vein thrombosis

- Blockage of hepatic veins by tumour

Transudate and Exudate causes of ascites

Transudate: Cirrhosis, heart failure, renal failure

Exudate: Neoplasm, TB, Budd-chiari syndrome, pancreatitis

Which scoring system incorporates ascites as a measure of prognosis of CLD?

Child Pugh score

At what sites do varices typically develop?




How should an acute variceal bleed be managed?


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

How should recurrent variceal bleeding be managed?

Transjugular intrahepatic portosystemic shunt (TIPSS)

liver transplant

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

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

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

What is Murphy's sign?

Tender RUQ & localised peritonism

Pt catches breath when RUQ palpated during inspiration

How should acute cholecystitis be managed?

ABCDE, IV fluids, IV abx, analgesia

Lap chole <72 hours or 6 weeks after settled

What are the complications of acute cholecystitis?

Perforation, gallbladder empyema, abscess

What is the triad in ascending cholangitis?


Requires: urgent ERCP or PTC

Main pathological findings in UC

Rectum & colon

Superficial & continuous

No granulomas, no fistulae


Crypt abscesses

Lead pipe colon

Main pathological findings in Chrons

Mouth to Anus, ++terminal ileum

Transmural & patchy “skip lesions”

Granulomas, fistulae, sinuses

Deep fissures


Cobblestone mucosa

What are the main medical management options in IBD?

5-AA, Mesalazine, Sulphasalazine, steroids, Azothioprine, Anti TNF

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

Which vessels do you ligate in a right hemicolectomy? Left hemicolectomy

Right: Iliocolic, Right colic, Right branch of middle colic

Left: IMA

Which tumours should have anterior resection and which AP resection?

Anterior: Tumours >5cm anal verge

AP: Tumours <5cm anal verge

Define: Diverticulum

Abnormal outpouching of hollow viscus into surrounding tissues

What are the complications of Diverticular disease?







Management of diverticulitis

Uncomplicated = Abx + fluids

Surgery if perf/abscess/obstruction ++Hartmanns

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

What condition is there an increased risk of with rectal prolapse?

Solitary rectal ulcer

What condition is most likely in a pt presenting with:

- Pain on defecation

- Minor bright-red bleeding on the paper

- Pruritis ani

Anal fissure

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)

What are haemorrhoids and what are the most common locations of haemorrhoids?

Prolapsed anal canal submucosal cushions

3, 7, 11 o’clock

Management of haemorrhoids

Conservative - high fibre, ice packs

Medical - anusol, laxatives

Surgical - 1-2nd degree: banding/sclerotherapy.

3-4th (manual reduction or irreducible) haemorrhoidectomy.

4 causes of fistula in ano

Most a result of abscess

May also be secondary to Chrons, TB, cancer.

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

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

What is a pilonidal sinus?

Subcutaneous sinus that contains hair, commonly at the natal cleft

Often presents when infected as an abscess

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

Pathology and risk factors for anal cancer


People who practise anal sex, Hx of genital warts, HPV

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

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

What are the advantages of an implant reconstruction?

Simpler procedure, can be done immediate or delayed

When would a flap reconstruction be better?

Following extensive surgery with little skin/muscle left

Can provide preferred cosmesis

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

What are the complications of thyroidectomy?

Anaesthetic risk

Bleeding/Haematoma - (NB airway obstruction from laryngeal oedema)



Bilateral laryngeal nerve palsy can result in airway obstruction (uni = hoarse)

Thyroid storm



Main metabolic derangement in Conns

↑ Na+, ↓ K+

Aetiology in arterial aneurysms


Also mycotic, congenital, traumatic, connective tissue

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.

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

What is the 2nd most common site of athersclerotic aneurysms?

Popliteal artery

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

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

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

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)

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

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

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)

How should an amputation level be decided?

Proximal enough for good healing, distal enough for outcome & rehab potential

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

What would a stroke in the area of the carotid territory present as?

Contralateral hemiparesis, dysphasia if dominant hemisphere

What is the main indication for carotid endarterectomy?

Patients with ipsilateral stenoses >70%, symptomatic in the previous 6 months

What is a chemodectoma?

A tumour of the carotid body, presents as pulsatile neck lump in anterior triangle

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.

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

How are varicose veins managed?

Conservative - compression stockings, injection sclerotherapy, weight loss

Surgical - saphenous vein ligation or stripping

Location & appearance of arterial vs venous ulcers

Arterial: toes, deep, shiny hairless skin

Venous: ankle, superficial, irregular edges, purple discolouration of skin

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

Investigation of suspected VTE

DVT - urgent compression USS

PE - ABG, CXR, CTPA (or VQ scan)

Calculate wells score

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