Lecture on General Surgery Complete

8/10/2019 Lecture on General Surgery Complete

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General SurgeryA revision session for

finals

By Mr Rishi Dhir

MBChB BSc (hons) MRCS

Orthopaedic registrar, Royal London Hospital


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CONTENT The Acute abdomen

General Principles

Conditions causing acute abdominal pain

BREAK

OSCE short cases

Pop quiz

Passing the exam: tips!

Open forum


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The Acute Abdomen


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The Acute Abdomen

Gastritis, splenic

disorders, LUQ

pneumonia

Cholecystitis, biliary

colic, hepatitis, RUQ

pneumonia

Sigmoid

diverticulitis,gynae

Appendicitis,

caecal diverticulitis,

meckels, mesenteric

adenitis, gynae

Pelvic (PID, ectopic, ovarian

cyst, strangulated hernia,

cystitis, psoas abscess

Acute pancreatitis, MI, PUD, AAA

Renal colic


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General principles Colicky pain: spasms of pain due to peristaltic waves trying to overcome

blockage of hollow viscus e.g. ureter, appendix, bowel, gall bladder

Peritoneum: double layered serous membrane that lines organs (visceral)

and abdominal wall (parietal). Inflammatory process affects visceral first

then parietal

Visceral peritoneum localises to embryological root, parietal is dermatomal

Foregut(mouth to 2ndpart duodenum) pain localises to epigastrium

Midgut(2ndpart duodenum to transverse colon) to umbilicus

Hindgut(transverse colon to rectum) to suprapubic region


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Peritonitis: features

T : Tenderness (and tachycardia)

R : Reflex guarding (progresses to rigidity)

A : Absent (or reduced) bowel sounds

P : Pyrexia

P : Percussion pain (better than rebound)

E : Extremely unwell (shallow resps)

D : Distant-local sign (distant palpation-local tenderness e.g.

Rovsings sign)


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Acute appendicitisAnatomy: Vermiform appendix

Hollow blind-ending tube with end-arterial supply

Majority (>70%) retrocaecal, also pelvic and ileal


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Acute appendicitis Epidemiology

- Sex: more common in men than women

- Age: peaks in adolescence, rare in neonates and geriatrics

Differentials

- Paediatric: Mesenteric adenitis.

- GI: Gastroenteritis, diverticulitis

- Urological: UTI, renal colic- Gynae: Ectopic pregnancy, PID, dysmenorrhoea, ovarian cysts

Complications

- perforation, peritonitis, appendix abscess


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Acute appendicitisCLINICAL PRESENTATION

SYMPTOMS:

- Pain: (general becomes localised acute), dull colicky)- Systemic upset: Anorexia, malaise, lethargy, vomiting

SIGNS:

- Rebound, guarding, McBurneys point

- RovsingsSign, Psoas Sign, Obturator sign


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Acute Appendicitis

OBTURATOR SIGN

PSOAS SIGN: pain on hip

extension


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Acute AppendicitisINVESTIGATIONS

Bloods: FBC, U+E, CRP

Urine: bHCG, urine dipstick

Imaging: erect CXR, USS (abdo/pelvic), CT

Laparoscopy

MANAGEMENT

Resucitate, consider antibiotics (caution!)

SURGICAL (Open/laparoscopic)

LANZ / GRID IRON incision


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Pancreatitis Pancreas: endocrine and exocrine organ: AUTODIGESTS ITSELF!

Foregut structure

Acute or chronic

Causes of acute pancreatitis:

GET SMASHED

Gallstones Steroids

Ethanol Mumps

Trauma Autoimmune

Scorpion bite

Hyperlipidaemia, hypercalcaemia, hypothermia

ERCP

Drugs e.g. thiazide diuretics


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Acute PancreatitisCOMPLICATIONS

Local: pancreatic pseudocyst, chronic pancreatitis,pancreatic abscess

Systemic: Respiratory, Cardiovascular, Renal, Endocrine

CLINICAL PRESENTATION

Symptoms: severe epigastric pain radiating to back,anorexia, vomiting, unwell

Signs: pyrexia, grey Turners, Cullens sign


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Acute pancreatitis Investigations

- Bloods: FBC, U+E, LFTs, serum calcium, amylase andlipase, ABG

- Imaging: erect CXR, AXR, Abdo USS, CT abdomen

Sentinel loop signcut off sign colon


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Acute Pancreatitis

MANAGEMENT

- Resuscitate (fluid balance is key) in correct setting

- Essentially supportive: analgesia, rest pancreas, remove cause and allow it to recover

- Severity score (GLASGOW Criteria)Mnemonic: PANCREAS

- P- pO2 15 x 109

- C- Calcium < 2mmol/l

- R- Raised urea > 16mmol/l

- E- Enzymes (AST >200iu/L / LDH > 600iu/L)

- A- Age > 55

- S- Sugar (glucose) > 10mmol/L

--


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Chronic pancreatitis SYMPTOMS AND SIGNS:

- Epigastric pain worse on eating, exacerbating factor

- Diarrhoea, nausea, vomiting, malnutrition

- Diabetes

- Steatorrhea

INVESTIGATIONS:

- Bloods: enzymes (amylase, lipase, trypsinogen)

- Stool tests: faecal fat test

- Imaging: Abdo CT, USS, ERCP, MRCP

MANAGEMENT:

- Resuscitate, analgesia, remove underlying cause and allow pancreas to recover


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Gall Bladder Anatomy

Stores and concentrates bile

produced by liver Contracts by CCK

Bile emulsifies fat

Blood supply to gall bladder

= cystic artery


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Gallstones Types: cholesterol(70%), pigment(30% cholesterol mainly bilirubin and calcium salts),

mixed

Risk factors: overweight, age, female sex, haemolytic anaemias

COMPLICATIONS

stones in gall bladder: biliary colic, acute cholecystitis, chronic cholecystitis (porcelain

gallbladder), Mirizzis syndrome

stones in CBD: obstructive jaundice, ascending cholangitis

stones in gut: paralytic ileus (impacts in ileocaecal valve)

Adjacent structures: acute pancreatitis


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BILIARY COLIC Abdo pain: General epigastric pain localises to RUQ, can

radiate to shoulder tip, exacerbated by fatty foods

Associated symptoms: nausea, vomiting

Ix: Bloods(normal WCC, may be abnormal LFTs)

USS: shows gallstones and CBD dilatation

MRCPand ERCP

Mx: resuscitate, rest (nbm), analgesia, tx gallstone(surgery)

Key: no antibiotics as no superimposed infection


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ACUTE CHOLECYSTITIS Blockage with superimposed infection

CLINICAL

Symptoms: RUQ pain, unwell, shock, jaundice

Signs: Murphys sign, fever

INVESTIGATIONS

Bloods: Raised WCC, CRP, Abnormal LFTs

USS, MRCP, ERCP

MANAGEMENT

Resuscitate, rest (nbm), antibiotics, surgery


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Surgery for gallstones ERCP: extract gallstone (1% risk pancreatitis)

Cholecystectomy

Laparoscopic or open (Kochers incision)

Acute(6 wks)

Complications of procedure: bile leak, bile duct injury, bleed

(liver bed/cystic artery), abscess


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Cholecystectomy

Identify calots triangle

Clip cystic artery and cystic duct then

remove gall bladder from liver bed

Cystic artery runs in triangle


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DiverticulitisDEFINITIONS

Diverticula: outpouchings of the colonwall

Diverticulosis: presence of diverticula

Diverticulitis: Results if diverticula become inflamed

Di ti liti th di f


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Diverticulitis: the disease of

Western diet!AETIOLOGY

Older patients (>40)

Low fibre diet

Increased colonic intraluminal pressure

Weakness where blood vessels perforate taenia coli

Most common site is sigmoid colon

C li ti f di ti l


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Complications of diverticular

disease Obstruction

Perforation / peritonitis

Bleeding

Diverticulitis

Diverticular abscess

Fistula (e.g. pneumaturia)

Strictures


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DiverticulitisSIGNS AND SYMPTOMS:

Classical triad: LIF pain, pyrexia, leucocytosis

Complications (PR bleed, peritonitis, obstruction)

INVESTIGATIONS:

Basic Ix: bloods, Erect CXR

CT

Note: sigmoidoscopy and barium enema contraindicated acutely as

risk perforation


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DiverticulitisMANAGEMENT

Initial acute: Resuscitate, rest (nbm) and IV antibiotics

Treat complications

Surgery: Emergency (Hartmans) v Elective (6/52)

Low residue diet after acute episode


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Bowel Obstruction Small v large bowel

Causes: intraluminal, wall, extraluminal

Classical 4: constipation, vomiting, pain and distension

Tympanic abdomen, tinkling / no bowel sounds

Ix: Bloods, AXR, CT, barium enema/follow through

Mx: nbm, drip and suck, surgical (treat cause)

Key: avoid stimulants if mechanical obstruction

In virgin abdomen, strong suspicion for cancer!


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Subacute Bowel Obstruction


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Inflammatory bowel disease

Crohns

1. Any part of gut (most commonlyterminal ileum)

2. patchy inflammation (skip)

3. Transmural inflammation

4. Perianal involvement common

5. Rectal involvement uncommon

6. Terminal ileum common

Ulcerative colitis

1. typically Colon only (can affectterminal ileum)

2. Continuous inflammation

3. Shallow, mucosal

4. Perianal rare

5. Rectal involvement common

6. Terminal ileum rare


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Inflammatory Bowel disease

COMPLICATIONS

LOCAL

- Crohns: adhesions, strictures, SBO, fistulae, abscesses

- UC: obstruction, perforation, toxic megacolon, colorectal ca

EXTRAINTESTINAL

- arthritis, uveitis, malnutrition, delayed growth, dermatological (pyoderma

gangrenosum), neurological (peripheral neuropathy, seizures)


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What is the diagnosis?

What are the main findings on investigation?

How would you manage this?

Ischaemic bowel: the silent


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killer!

Definition: ischaemic bowel injury in distribution SMA/SMV.

Range from reversible dysfunction to transmural necrosis

Aetiology: SMA thrombus/embolus, SMV thrombosis, non-occlusive

mesenteric ischaemia (any cause of shock).

3 phases

1. Hyperactive: abdo pain and PR bleed (reversible)

2. Paralytic: increased pain, decreased motility causing ileus

3. Shock: fluid loss through damaged colon (metabolic acidosis)



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killer!CLINICAL

Early: non specific abdo pain (out of proportion to tenderness),

PR bleed

Late: abdo distension, malaena, haematemesis, shock

INVESTIGATIONS

Bloods (raised WCC), ABG (lactic acidosis)

Imaging: AXR: thumbprinting, CT

Colonoscopy / flexi-sigmoidoscopy +biopsy

Laparotomy


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Ischaemic bowel

MANAGEMENT

Supportive: ABC, nbm, IV fluids, oxygen

Medical: antibiotics, trial of anticoagulant or thrombolytic (if

no signs infarction)

Surgical: laparotomy (if signs infarction) and bowel

resection and anticoagulate post-op


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Renal colic Types: calcium oxalate (75%) and uric acid (5-10%)

Loin to groin pain, colicky, vomiting, haematuria, UTI

Complications: UTI, ARF, hydronephrosis and stricture

Ix: Bloods: FBC, urate, ca, CRP

Urine dipstick: UTI, haematuria

Imaging: IVU, CTKUB Mx: conservative: analgesia, rehydrate, diet control

Medical: tamsulosin

Surgical: ESWL, Ureteroscopy +/-stent, nephrostomy


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OSCE SHORT CASES

SURGICAL SCARS

STOMAS

HERNIAS

GROIN LUMPS

SCROTAL LUMPS

NECK LUMPS


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NAME THAT SCAR!


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NAME THAT SCAR


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STOMAS Definition: Greek for mouth

Classify by type: colostomy, ileostomy, urostomy

Classify by function: end v loop; temporary v permanent

Uses of stoma: FLEDDMnemonic

Feeding, Lavage, Exteriorisation, Decompression, Diversion

Complications: electrolyte disturbance, prolapse, necrosis,obstruction, stricture, retraction, psychosexual

Good stoma care with stoma nurse, education andcounselling vital

COMPLICATIONS OF


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COMPLICATIONS OF

STOMAS

What are the differences between ileostomy and colostomy?

Differences between


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Differences between

colostomy and ileostomyIleostomy

1. Small calibre

2. Spouted

3. Contents of effluent- watery

4. Continuous output

5. Site- RIF

Colostomy

1. Large calibre

2. Flush with skin

3. Semi-solid/faecal contents

4. Intermittent output

5. Site- LIF


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HERNIAS Definition:protrusion of viscus and coveringsthrough defect

in abdo wall from containing compartment to another

Types: umbilical, paraumbilical, inguinal, femoral, epigastric,

spigellian, richter, incisional, diaphragmatic


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HERNIAS AETIOLOGY: congenital and acquired

Acquired: intra-abdo pressure (pregnancy, obesity, lifting/straining, COPD) or

weakening of wall (previous surgery, age, Ehlers-Danlos, malnutrition)

Symptoms and signs: pain, lump on coughing, complications (severe pain, fever,

nausea and vomiting)

COMPLICATIONS: bowel obstruction, strangulation or incarceration

DIAGNOSIS: clinical

MANAGEMENT: surgical (usually elective, emergency if complications or early repair

if at risk e.g. femoral)


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INGUINAL HERNIAS 75% of abdominal hernias

Anatomy of anterior abdominal wall

Recti enclosed in rectus sheath

formed by aponeuroses of 3 flat

muscles

Sheath becomes deficient posteriorly

below arcuate line of Douglas


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Anatomy of inguinal canal 4 walls

Contents: ilioinguinal nerve (L1) and spermatic cord or

round ligament

Contents of spermatic cord (rule of 3s)


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Inguinal hernias

Direct

1. More common in elderly

2. Caused by defect in wall

3. Reduces straight back

4. Not controlled by pressureover deep ring

5. Medial to inf epigastric a

6. Doesnt extend to scrotum

Indirect

1. More common in younger

2. Caused by PPV

3. Reduced upwards and lateral

4. Controlled by pressure overdeep ring

5. Lateral to inf epigastric

6. May extend to scrotum


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Differential of groin lumpsThink: GROIN ANATOMY LAYERS

1. Skin: sebaceous cyst

2. SC Fat : lipoma

3. Muscle: psoas abscess

4. Arteries : femoral artery aneurysm

5. Veins : saphena varix

6. Nerves : neuroma

7. Lymph: lymph nodes

8. Testis: ectopic testis


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Scrotal Lumps1. Inguinoscrotal hernia

2. Testicular tumour

3. Hydrocele

4. Varicocele

5. Epididymal cyst

Key Qs:

Can you get above it? No = hernia

Can palpate it separately from testis? Yes = epididymal cyst

Does it transilluminate? Yes = hydrocele


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Neck Lumps


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Neck LumpsMidline

1. Sebaceous cysts

2. Lipomas

3. Lymph nodes

4. Goitre

5. Thyroglossal cyst / dermoidcyst

6. Pharyngeal pouch

Lateral

1. Sebaceous cysts

2. Lipomas

3. Lymph nodes

4. Multinodular goitre

5. Branchial cyst / cystic hygroma

6. Vascular: aneurysm / tumour

7. Nerve: neurofibroma


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Case 1

What is the diagnosis?

What are the potential complications?

How would you manage it?


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Case 2

How would you manage this?

How would patient present?

What are complications?

What are the causes?


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Case 3

What are the causes of this?


What are the symptoms and signs?


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Case 4

What is the main x-rayfinding?

What does it indicate?

How do you manage it?


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Case 5

What is the main CT finding?

What condition causes this?


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Case 6What is the diagnosis?


What is a life-threatening

complication of this?



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Passing the exam: revision tips!

Preparation: revision partner, daily OSCE practice; clinics

examinations, histories, investigations

Persistence: Keep going. Its a marathon. Its not too late!

Presentation: compartmentalise your answers! Look the part!

- ABC Conservative, medical, surgical

- Surgical sieve

- Present the x ray not just the finding!

Dont memorise, learn basic principles so can work things out


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Schematic for history taking

Introduction: name, age and presenting complaint

HPC: Develop symptom in detail e.g. SOCRATES

PMH: relevant medical and surgical

Drug hx and relevant FH

Social: relevant (occupation, support, risk factors)

Systemic enquiry

Common surgical history


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Common surgical history

scenarios Acute abdominal pain: think socrates!

Change in bowel habit- nature, tensemus, PR bleed, mucous,

weight loss, time, FH

- Differential: cancer, diverticular disease, IBD, haemorrhoids

Vascular: peripheral vascular disease

Thyroid disease

Jaundice

Take a history of intermittent


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Take a history of intermittent

claudication

HPC: is it claudication? claudication distance? Level?

Severity (Fontaine classification), Leriches syndrome

PMH: CV risk factor, interventions

Drug Hx: aspirin, statins FHx: CV disease

Social: smoking


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Schematic for examinations Introduction and wash hands, ask permission

General (end of bed, clues)

Start with hands unless specifically told

Inspection, palpation, percussion, auscultation

Look, Feel, Move (orthopaedics)


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Common exam cases Hernias

Lumps and bumps (breast, groin, testicular, skin, neck)

Varicose veins exam

Arterial disease

Ulcers (size/shape, edge, slope, base and mx)

Ortho- examine hip, knee, shoulder

Hand exam- RA, Peripheral nerves

Surgical scars


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Interpretation ABG, fluid balance chart, ECG

X-rays: chest (some bastard took my pet dog!), AXR

AXR will only be obstruction!

Post op complications: bleeding, infection, DVT/PE (takes

at least 72 hrs), anastamotic leak, collection

Immediate, early, late

Check charts (e.g. end organ perfusion- urine output, BP,

HR, neuro status; drain output and colour)


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SHOCK

DEFINITION

Acute circulatory failure resulting in inadequate tissueperfusion and cellular hypoxia. Supply does not meetdemand!

TYPES

Hypovolaemic

Cardiogenic Obstructive (massive PE, tension, constrictive

pericarditis, tamponade)

Distributive (vasodilation) e.g. sepsis, neurological,

anaphylactic


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SHOCK Physiological terms explained:

HR(depends on SAN: autonomic control) x SV

(determined by venous return, starlings law) = CO

CO X SVR (arteriole diameter)= BP(perfusion)

3 Factors determine tissue supply: HR, SV, SVR


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SHOCK Classification of hypovolaemic shock

Markers of end-organ perfusion

Management of shock

ABCDE

Treat underlying cause e.g. fluids for hypovolaemic,

antibiotics and inotropes for sepsis, steroids and

inotropes for anaphylaxis


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Thanks for listening

Lecture on General Surgery Complete

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