General Surgery 5.3 PDF - Medical Study Zone

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1 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Plab1keys.com Strict Copyrights! General No Sharing or Copying Surgery Allowed by any means Compensations and Penalties Worldwide System is Active Version 5.3 PLAB 1 Keys is for PLAB-1 and UKMLA-AKT (Based on the New MLA Content-Map) Corrected, Updated, Lighter With the Most Recent Recalls and the UK Guidelines PLAB 1 Keys is For PLAB and UKMLA-AKT (Based on the New MLA Content-Map) ATTENTION: This file will be updated online on our website frequently! (example: Version 2.7 is more recent than Version 2.6, and so on) Key Paget’s Disease of the breast and nipple 1 ◙ A rare breast malignancy. ◙ With a better prognosis than the infiltrating ductal carcinoma. ◙ Features: Copyrights @ Plab1Keys.com 2 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) ♠ Dry skin around the areola resembling eczema with scales + erosions. ♠ Itching in the area. ♠ Discharge per nipple sometimes bloody. ♠ Ulcerated and/or inverted nipple. ◙ Diagnosis → Punch Biopsy Differential Diagnoses of Breast Lesions 1 ◙ Painful, fluctuating mass over the breast or near the nipple → Nipple Abscess (Pus Collection). 2 ◙ Brown/ Green/ Coloured discharge per Nipple → Duct Ectasia. 3 ◙ Hx of Trauma to the Breast (redness or bruises around the lump) + firm, round, solitary and localized lump. → Fat Necrosis. 4 ◙ Bleeding per nipple in 20-40 YO ♀ ± skin changes → Ductal Papilloma → Galactogram. Copyrights @ Plab1Keys.com 3 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) 5 ◙ Bleeding discharge per nipple in an Old woman with eczema-like changes in the nipple ± areola ± Ulcers → Paget’s disease (Malignant) → Punch Biopsy 6 ◙ Firm, non-tender, mobile mass in a breast of a young ♀ (15-30 YO) → Fibroadenoma → Clinical + Ultrasound + FNA 7 ◙ Breast pain (Mastalgia), ↑ breast size, lumpiness (nodularity) of the breast, ♀ in the reproductive age ± tend to appear just before or during menstrual cycle and disappear after it → Fibroadenosis. 8 ◙ Fixed, irregular, hard, painless lump ± nipple retraction ± fixed to skin (Peau d’orange) or muscle (+) Local fixed, firm axillary LNs. → Breast Cancer → Core biopsy 9 ◙ Offensive yellow discharge from an area near the nipple + Hx of Abscess near this area → Ductal Fistula (Mamillary Fistula). 10 ◙ Prolonged Redness around the areola. Hx of using antibiotics which improved symptoms slightly. Greenish discharge per nipple. ± nipple retraction ± small lump around the nipple is felt. → Periductal mastitis. (Commonly young age, smoking is a risk factor, treated with antibiotics, if left untreated it may develop into an abscess that needs drainage by fine needle). Copyrights @ Plab1Keys.com 4 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) 11 ◙ Persistent nipple discharge that is non-bloody and occasionally milky or serous fluid. It is spontaneous. No breast masses. No Nipple retraction. No skin changes. → Mamillary duct fistula (abnormal connection between lactiferous ducts of the breast and skin surface → leads to spontaneous nipple discharge that is not purulent nor bloody. It can appear as a milky or serous fluid). Key Dysphagia + Regurgitation of Stale food/fluid + Chronic Cough (esp. 2 Nocturnal) ± Bad mouth breath (Halitosis) ± Aspiration ± Gurgling sounds in the chest on drinking ± Neck lump → Pharyngeal pouch (Zenker’s Diverticulum) Note: Stale food = Decayed, rotten and old food (this is because it has been stored in the pouch until it has become rotten “with bad smell”). Copyrights @ Plab1Keys.com 5 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Endoscopy is Contraindicated as it may perforate the pouch. Instead, perform → Barium Swallow. Old age + Gradually Worsening Dysphagia (initially for solid food and then for soft and liquids) + Longstanding Gastric Reflux → Think of Oesophageal Carcinoma. √ A gift hint that on Barium Swallow → irregular narrowing + Proximal Shouldering. √ Another hint → Weight loss. √ Another hint → Hx of GORD or Barret’s Oesophagus (Risk Factors) ♦ The commonest type → Adenocarcinoma. ♦ Diagnosis is made by → Upper GI Endoscopy + Biopsy. (Adenocarcinoma of the oesophagus is Common in GERD and Barret’s oesoph.). Key Common Tumour Markers 3 Copyrights @ Plab1Keys.com 6 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Breast Cancer CA 15-3 Ovarian Cancer CA 125 Pancreatic Cancer CA 19-9 Colorectal Cancer CEA “Carcinoembryonic Antigen” Prostatic Cancer PSA “Prostate Specific Antigen” Liver (HCC) AFP “Alpha-fetoprotein” Teratoma (e.g. of testicles, ovaries) AFP “Alpha-fetoprotein” Testicular Seminoma LDH (Lactate Dehydrogenase) NOTE → Tumour markers are of the original tumor, not the site of metastasis. For example, if a colon cancer sends metastasis to liver, we follow up the original site tumour marker (Colon) which is CEA, not AFP. Key Gastric Carcinoma 4 ◙ The gift hint is → Left supraclavicular mass (Virchow Node). ◙ Others → Weight loss, Old age, Tiredness, Vomiting, Dyspepsia, Anemia (Palpitations). ◙ If there are associated Hepatomegaly and Ascites → Late stage Gastric Carcinoma that has metastasized to the liver. ◙ Risk Factors → Old age, Blood Group A, H. Pylori, Smoking, Spicy food, Pernicious Anemia. Copyrights @ Plab1Keys.com 7 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Key Hemoglobin Level Before Surgery 5 ◙ Elective Surgery: ♠ If Hb is < 10 → Delay “defer” “Postpone” the surgery and Investigate for the anemia reasons first. ♠ If Hb is < 8 → Transfuse Blood and also Defer the surgery. ◙ Emergency Surgery: ♠ If Hb is < 10 → Proceed with the surgery. ♠ If Hb is < 8 → Transfuse Blood and Proceed with the surgery. Key Hypercalcemia 6 √ (↑ Ca++) presents with many features such as: ↑ Thirst, ↑ Urination, Depression and Confusion. ◙ Pay attention to the history as there might be a Hx of Multiple Myeloma or a Hx of breast/ Prostate/ Lung cancer (SCC). These malignancies can metastasize to the bone, causing → Hypercalcemia. ◙ Hypercalcemia Manifestations: Copyrights @ Plab1Keys.com 8 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Neuro → lethargy, Confusion, Depression. GIT → Constipation. Renal → polyuria (increased urination), Polydipsia (Thirst). CVS → ECG: Short QT interval. ◙ Causes of hypercalcemia: 1ry hyperparathyroidism. Multiple Myeloma, Sarcoidosis, SCC of lung, Breast and prostate cancer. ◙ Management of Hypercalcemia: Initially → IV fluid (NS) Then → Bisphosphonates (e.g. alendronate), (or Calcitonin) Key Sudden onset of severe LEFT lower abdominal pain + develops to generalized 7 abdominal pain, guarding and rigidity + FEVER + Tachycardia. → Perforated Diverticulum. ◙ Diverticulosis (Colon Outpouches) mainly occur on the Sigmoid colon (Left Lower Abdomen). Copyrights @ Plab1Keys.com 9 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) ◙ One of the complications of Diverticulosis is Diverticulitis which may lead to a ruptured diverticulum. ◙ The fact that there is Fever along with the Acute abdomen support the diagnosis of a ruptured diverticulum. Fever and sepsis are caused by the leakage of the colon content into the peritoneum → Peritonitis. ◙ For your knowledge, whenever you see an acute abdomen, think, initially, that something inside has been ruptured. Differential Diagnoses: ♠ Sigmoid Volvulus → Sudden onset colicky lower abdominal pain + Abdominal Distension + Complete Constipation (No flatus or stools pass) + Vomiting. ♠ Intussusception → Recurrent Non-specific Abdominal Pain. ♠ Bowel Ischemia → The pain is not as severe as in a perforated diverticulum (At least initially) + The localization of the pain is poor + Initially, only mild tenderness → No peritonitis “No fever, no severe guarding, rigidity and tenderness” Until late stages + Hx of AF might be given. Key Analgesics Ladder 8 ◙ Simple Analgesics → NSAIDs (Diclofenac), Aspirin, Paracetamol. Copyrights @ Plab1Keys.com 10 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) ◙ Weak Opioids → Codeine, Tramadol. ◙ Strong Opioids → Morphine, Fentanyl, Diamorphine, Oxycodone. ◙ Epidural Nerve Block. ♠ Bone pain due to metastasis → Radiotherapy. ♠ No full response? → add Bisphosphonate e.g. Zoledronic acid ♠ Neuropathic pain → Gabapentin, Amitriptyline, Pregabalin. NOTE: After an Open surgery, give → Patient controlled analgesia with Morphine (it can be weaned off later). Key An elderly with difficulty in swallowing + Chronic Cough + Bad Breath + 9 Regurgitation of food + Weight loss. The initial Investigation? → Barium Swallow Why not Endoscopy? → Although he is old and with Hx of weight loss, the likely diagnosis here is Pharyngeal Pouch “Zenker’s Diverticulum” given the specific features of bad Copyrights @ Plab1Keys.com 11 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) mouth breath (Halitosis) and regurgitation of food along with chronic cough and dysphagia. √ Endoscopy is contraindicated in Pharyngeal Pouch for the fear of perforation of the pouch. Thus, barium swallow is more appropriate. Key Important: 10 All patients with a Hx of MI should not undergo “Elective” Surgery for at least 6 months after their myocardial infarction attack. √ imp. Key Obstructive Jaundice = 11 Acute choledocholithiasis: It results when stones form in the gallbladder and then pass into the common bile duct (CBD), where they may become lodged and cause obstruction. Occurs frequently during pregnancy. Presents with: √ Right Upper Quadrant Pain (sometimes with epigastric pain) + √ Obstructive features ► Jaundice, Dark urine and Pale stools, (and ↑ ALP = serum ALkaline Phosphatase). The most appropriate investigation → Ultrasound of the Abdomen → as it will most likely show the CBD stones” Choledocholithiasis”. Copyrights @ Plab1Keys.com 12 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Note that there are other causes for Obstructive Jaundice such as cancer head of pancreas “painless jaundice”, and periampullary tumour. Key After hemicolectomy, or Rectal Resection and anastomosis, one of the 12 common and feared complications is → Anastomotic Leak (Leakage of luminal contents at the site of anastomosis). - It usually occurs 5 to 10 days after the surgery. - It presents with severe abdominal pain and tenderness over the site of the anastomosis + fever + reduced bowel sounds. - RFs → DM, smoking, immunocompromised (e.g. prolonged use of steroids such as for RA, Asthma, COPD), rectal anastomosis, peritoneal contamination). Important: Anastomotic leakage can lead to Peritonitis or Intrabdominal abscess which needs: → CT scan of Abdomen and Pelvis “with contrast”. Broad spectrum antibiotics should be initiated. An important risk factor for anastomotic leakage is → DM. Key Old age + Painless bleeding per rectum + Altered bowel habits + Anemia ± 13 Weight Loss Copyrights @ Plab1Keys.com 13 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) → Think of Colorectal Carcinoma → Perform Colonoscopy Note, the malignancy might appear as a large fungating mass or just as an isolated ulcer. Do not hesitate to request Colonoscopy in a patient presents with these features or most of them! Notes for Your Knowledge ◙ Left sided colonic cancer usually presents with Obstructive symptoms such as Constipation, Changes in bowel habits, Dark blood “fresh” per rectum along with anemia and weight loss. ◙ Right sided (e.g. Caecal cancer) → Iron Deficiency Anemia mainly. ♠ The right-side colonic diameter is wider than the left side. Therefore, obstructive symptoms are more common in left side colonic cancer. ♠ The right-side bleeding is usually microscopic and tend to mix with stools during the long journey to the rectum; thus, not seen as a fresh dark blood as in the case of the left side colonic cancer. Key ◙ Bleeding discharge per Nipple in a Middle-Aged woman (20-40 YO) With 14 or Without Skin Changes. Copyrights @ Plab1Keys.com 14 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) ♠ Dx → Ductal Papilloma (Benign) ♠ Investigation → Galactogram (The masses are usually too small to be palpated clinically or to be seen on a mammogram) Remember, ◙ Bleeding discharge per nipple in an Old woman with eczema-like changes in the nipple ± areola ± Ulcers ♠ Dx → Paget’s disease (malignant) ♠ Investigation → Punch Biopsy. Common Breast Lesions 1 ◙ Painful, fluctuating mass over the breast or near the nipple → Nipple Abscess (Pus Collection). 2 ◙ Brown/ Green/ Coloured discharge per Nipple → Duct Ectasia. 3 ◙ Hx of Trauma to the Breast (redness or bruises around the lump) + firm, round, solitary and localized lump → Fat Necrosis. Copyrights @ Plab1Keys.com 15 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) 4 ◙ Bleeding per nipple in 20-40 YO ♀ ± skin changes → Ductal Papilloma → Galactogram. 5 ◙ Bleeding discharge per nipple in an Old woman with eczema-like changes in the nipple ± areola ± Ulcers → Paget’s disease (Malignant) → Punch Biopsy 6 ◙ Firm, non-tender, mobile mass in a breast of a young ♀ (15-30 YO) → Fibroadenoma → Clinical + Ultrasound + FNA 7 ◙ Breast pain (Mastalgia), ↑ breast size, lumpiness (nodularity) of the breast, ♀ in the reproductive age, tend to appear just before or during menstrual cycle and disappear after it → Fibroadenosis. 8 ◙ Fixed, irregular, hard, painless lump ± nipple retraction ± fixed to skin (Peau d’orange) or muscle (+) Local, fixed, firm, axillary LNs. → Breast Cancer → Core biopsy 9 ◙ Offensive yellow discharge from an area near the nipple + Hx of Abscess near this area → Ductal Fistula (Mamillary Fistula). 10 ◙ Prolonged Redness around the areola. Hx of using antibiotics which may improve symptoms slightly. Greenish fluid is aspirated from the breast. Copyrights @ Plab1Keys.com 16 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) → Periductal mastitis. 11 ◙ Persistent nipple discharge that is non-bloody and occasionally milky or serous fluid. It is spontaneous. No breast masses. No Nipple retraction. No skin changes. → Mamillary duct fistula (abnormal connection between lactiferous ducts of the breast and skin surface → leads to spontaneous nipple discharge that is not purulent nor bloody. It can appear as a milky or serous fluid). Key Following a closure of a stoma (colostomy), or at the site of 15 surgical wound or skin sutures: → The development of painful fluctuating swelling + fever → indicates a formation of an abscess. → Local Exploration is required. Sometimes followed by → Antibiotics + Drainage. Key U/S Abdomen can diagnose Gallstones and also biliary colic. 16 In a patient with recurrent attacks of biliary colics who presents complaining of right upper quadrant pain → Repeat the U/S as he might be in another attack of biliary colic. Copyrights @ Plab1Keys.com 17 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) ◙ Biliary colic is when a colic (sudden pain) occurs due to a gallstone temporarily blocking the cystic duct. Typically, the pain is in the right upper part of the abdomen. Pain usually lasts from one to a few hours. Often, it occurs after eating a heavy meal, or during the night. Repeated attacks are common. Gallstone formation occurs from the precipitation of crystals that aggregate to form stones. The most common form is cholesterol gallstones. ◙ Cholecystitis is associated with fever + high WBCs ± Peritonitis (Inflammatory elements) as there might be bacterial infection due to the permanent obstruction of the cystic duct by a stone. On the other hand, Biliary colic does not have this inflammatory component as the obstruction is transient (Temporary). ◙ In both cases → Abdomen U/S. Copyrights @ Plab1Keys.com 18 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Ultrasound: A Gallstone impacted in the neck of the gallbladder and leading to cholecystitis. + Gallbladder wall thickening. Important Note: ERCP is now rarely done without a therapeutic intent. Copyrights @ Plab1Keys.com 19 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Biliary Tree Key Remember that: 17 Ascending Cholangitis → Charcot’s Triad (frj) → Fever + Right upper abdominal pain + Jaundice Copyrights @ Plab1Keys.com 20 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Key Complications of Thyroidectomy 18 ◙ Hypocalcemia: Damage or removal of parathyroid glands → Hypoparathyroidism → Hypocalcemia. Copyrights @ Plab1Keys.com 21 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) ♠ Hypocalcemia Features → Tingling of lips and fingertips “initial” SPASMODIC **Neuronal Hyperexcitability** Spasms, Perioral Paraesthesia, Anxious, Seizures, Muscle tones increased in smooth muscles, Orientation impaired and confusion, Dermatitis, Impetigo Herpetiform (rare and serious), Chvostek’s sign, Carpopedal Spasm, Cardiomyopathy (prolonged QT interval on ECG). - Trousseau’s signs → after occlusion of brachial artery → wrist flexion - Chvostek’s sign → Tapping over parotid (Facial nerve) → twitching of facial muscles. Rx → give 10 ml of 10% Calcium Gluconate (initially). ◙ Acute Airway Obstruction (= Compressing Hematoma, Tracheomalacia): - Soon after the operation (in the first 24 hours) → Airway Obstruction. - Rx → Open the surgical incision to evacuate the hematoma. ◙ Nerve Injury: Unilateral Injury to the Recurrent laryngeal nerve → Hoarseness of voice Bilateral Injury to the Recurrent laryngeal nerve → Aphonia and Airway obstruction. Injury to the External branch of (superior) laryngeal nerve → Loss of high- pitched sound = (Dysphonia) = (Mono-toned voice). Copyrights @ Plab1Keys.com 22 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) ◙ Thyroid Storm: Due to manipulation of the thyroid gland during a surgery in a patient with hyperthyroidism. ♠ Features: Tachycardia, palpitation, High body Temperature, Diarrhea, Vomiting reduced consciousness, Tremors. ♠ Treatment: - Beta-blockers (Propranolol) → To control Tachycardia and Tremors. - High dose steroids → it inhibits the conversion of T4 to T3. ◙ Wound Infection (rare: 1-2%). Key Acute Mesenteric Ischemia VS Ischemic Colitis 19 ◙ Acute Mesenteric Ischemia ♠ From its name “Acute” → Sudden onset of SEVERE abdominal pain and tenderness which exceed the physical signs. ♠ Also, Abdominal distension + Absent Bowel Sounds. ♠ Again, from its name “Acute”, there is something that has caused this abruptly, likely AF has caused emboli to occlude the blood supply of a large segment of the mesentery. Another possibility is that a patient with myocardial ischemia has developed Hypotension which has caused low blood reaching the mesentery. ♠ VBG → High Lactate (↑ lactate). Copyrights @ Plab1Keys.com 23 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) ♠ The resulted Gangrene is Irreversible. ♠ Rx → O2, IV fluids, Analgesics, Antibiotics → then, Urgent Surgery. ◙ Ischemic colitis. ♠ Transient interruption of the blood supply to the colon. ♠ “Gradual Onset – Over Hours”. ♠ Abdominal pain and tenderness that are moderate to severe but not as severe as in acute mesenteric ischemia. ♠ The cause is multifactorial e.g. Heart failure, shock, MI. ♠ Pain usually starts at the left iliac fossa. ♠ ± Bloody diarrhea. ♠ Rx → Conservative or Surgical. Acute Mesenteric Ischemia Ischemic Colitis Sudden onset Onset is gradual over hours VERY SEVERE pain and tenderness. Moderately Severe. Hx of AF. Multifactorial (transient interruption of blood supply) e.g. AF → embolization to superior HF ▐ MI leading to HF mesenteric artery → acute mesenteric ischemia. - Usually starts at left iliac fossa VBG → High Lactate (↑ lactate). ± Bloody diarrhea. Rx: Urgent Surgery Conservative or Surgical Copyrights @ Plab1Keys.com 24 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Key A Post-op patient on 100% facemask oxygen develops Respiratory Alkalosis 20 (pH > 7.45), (PaCO2 < 4.7) and (PaO2 >14). The next step should be → Reduce the O2. This is a case of hyperoxemia (Excess of O2 with Low CO2 due to rapid O2 delivery via the oxygen mask). Key ◙ When should we offer Prophylactic Mastectomy? 21 1) Strong Family History of breast cancer. 2) Inherited Mutations in Breast Cancer Susceptibility genes (BRCA1 and/or BRCA2). These genes are Autosomal Dominant. √ imp. 3) Previous breast cancer in one breast. 4) Biopsy that shows → Lobular Carcinoma in Situ and/or atypical hyperplasia. Notes on Mammogram in the UK √ Mammogram is offered for all women aged 50-70 YO every 3 years. √ If there is a strong family history or BRCA mutations → Mammogram should be carried out on Women aged 40-70 every year (Annually). Copyrights @ Plab1Keys.com 25 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Do not forget: Prophylactic bilateral Mastectomy/ Oophorectomy can be offered if the patient has Strong FHx of cancer and genetic markers of that cancer. Key In a suspicious breast mass (e.g. ill defined, spiculated, with palpable LNs), 22 Fine Needle Aspiration Cytology (FNAC) is not enough alone. To confirm the diagnosis → Core Biopsy. Other Notes on Breast: ♠ Paget’s disease or Skin changes → Punch Biopsy. (Punch takes parts of the skin changes). ♠ Suspicious Breast lump → FNA followed by Core biopsy. (Core takes entire tissues not only cells as in FNAC) ♠ Ductal Papilloma (Bleeding per nipple in 20-40 YO ♀) → Galactogram. ♠ Fibroadenoma (firm, non-tender, mobile beast mass in a young ♀) → Clinical + Ultrasound + FNA ♠ ♀ < 35 YO → Ultrasound. ♠ ♀ > 35 YO → Mammogram. ♠ The UK screening for Breast Ca: 50-70 YO → Mammogram every three years. Copyrights @ Plab1Keys.com 26 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) If strong Family Hx, BRCA genes → 40-70 YO Annually. Key In the first few hours after abdominal surgery (e.g. Appendectomy), if there 23 are hypotension, tachycardia, tachypnea and Abdominal pain → Intra-abdominal bleed. It is likely a case “Reactionary” haemorrhage. Remember that: Primary Hemorrhage → bleeding during the surgery. Reactionary Haemorrhage → bleeding within 24 hours after an operation usually due to slipping of ligatures/ dislodgement of clots/ warming up of the patient leading to a rise in BP into normal. Example: Bleeding while in the recovery room. This needs resuscitation with IV fluids and if heavy, packed RBCs + Surgical re- exploration. Secondary Haemorrhage → 1-2 weeks post-op (Usually related to infection) Note that, Appendectomy does not have anastomosis! Just removal. Key Notes on the Histopathology of some breast lesions 24 Invasive intraductal carcinoma of the breast extending to the epithelium → Breast cancer (The commonest form of breast Malignancy) Copyrights @ Plab1Keys.com 27 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) In situ carcinoma involving the nipple epidermis → Paget’s disease. (Rare Malignant) Encapsulated adipocytes within a fibrotic stroma → Hamartoma (Benign). Proliferation and expansion of the stroma with low cellularity → Fibroadenoma (Benign). Another Histological Description of Fibroadenoma that is frequently asked → A well circumscribed lump with clear margins and separate from the surrounding fatty tissue. There are overgrowths of fibrous and glandular tissue. Or: duct-like epithelium surrounded by fibrous bridging. Cystic formations with mild epithelial hyperplasia (Fibrosis, epitheliosis and cystic formations) → Fibrocystic changes [Fibroadenosis] (Benign). Key Important Notes on Post-operative Oliguria 25 ◙ It is known that urine catheter is inserted during surgery and it remains in place for 1-2 days post-op. Copyrights @ Plab1Keys.com 28 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) ◙ However, in the UK, because of the fear of UTI and urinary sepsis that might be caused by a long-time placed urinary catheter, it is recommended that the catheter is removed as early as possible (within 24-48 hours post-op) sometimes immediately in small operations. ◙ The patient is then instructed to report any discomfort during voiding, feeling of bladder fullness, inability to void, urinary retention and so on. Sometimes these symptoms can occur as a result of using epidural analgesia during the operation (e.g. in Caesarean section). ◙ If any of these symptoms develop, BLADDER SCAN is performed to measure the Post Void Residual Volume (PVRV) “the amount of urine remaining in the bladder after one urinates”. ◙ If PVRV is > 500 ml → Re-insert a urine catheter. ◙ Thus, in a post-op patient who has received epidural analgesia and now complains of inability to void/ Feeling of fullness → Perform Bladder Scan (To measure PVRV and decide on re-inserting the urine catheter accordingly). HOWEVER If a healthy patient who still has the urinary catheter in place after surgery and it shows that he has passed small volume of urine within 24 hours post- op, the first “initial” step that should be done is → Check the Urine Catheter! ♠ the urinary catheter might only be kinked (curled) or blocked (needs a simple flush) or mispositioned. So, do not rush and pick “Bladder Scan”! Copyrights @ Plab1Keys.com 29 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) ♠ If there is nothing wrong with the urinary catheter and the patient is hypotensive and oliguric → IV fluid challenge (There might be internal Bleeding or Acute renal injury)! Key A patient with a tender mass near the anus. The lump is tender, swollen, 26 erythematous and with throbbing pain that is worse on sitting. There is also fever and constipation. The patient is diabetic. The likely Dx → Anorectal Abscess Management → Incision + Drainage + Antibiotics Anorectal abscesses tend to develop in patients with DM, Immunocompromised (e.g. prolonged steroids intake), Crohn’s disease. Key A well circumscribed lump with clear margins and separated from the 27 surrounding fatty tissue. There are overgrowths of fibrous and glandular tissue. → Fibroadenoma. Key Axillary Lymph nodes clearance (removal) during radical mastectomy can 28 lead to → Upper Limb Lymphoedema (Redness and Swelling) + Frozen shoulder. Rx → Physiotherapy and arm exercise. Copyrights @ Plab1Keys.com 30 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Key Perianal Fistula Management 29 ◙ Superficial = Simple = Low Fistula → Lay Open (Fistulotomy). ◙ Deep = Complex = High = Fistula that crosses internal and external sphincters → Seton Suture, Ligation of inter-sphincteric fistula tract. Key Fibroadenoma 30 Benign. The commonest breast tumour in Adolescence and Young women. Firm, Painless “Non-tender”, Mobile. Some of them are extremely mobile that they can slip between the examining fingers and are thus called “Breast mice”. Dx → Clinical + U/S + FNAC Key How to Deal with Diabetic Patients Before Surgery? 31 Pre-op Management of DM 2 (on oral hypoglycemics): If Major surgery → Stop oral hypoglycemic before surgery. Copyrights @ Plab1Keys.com 31 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) If Minor surgery → Continue the same routine. Pre-op Management of DM 1 (on insulin): If Major surgery → Start sliding scale IV insulin before surgery and continue until diet per-mouth is re-established. ♠ Another possible Answer for PLAB 1: → Start IV Insulin, Dextrose and Saline pre-op. If Minor surgery: Omit insulin on the day of the surgery. In all cases, restart the previous regimen when per mouth diet is re- established + Check Blood glucose 4 hourly. Key ◙ No gastric Bubbles → Oesophageal Atresia. 32 ◙ Single Bubble → Gastric/ Pyloric Atresia. ◙ Double Bubbles (Double bubble sign: Oesophagus + Stomach) → Duodenal Atresia. ◙ Triple bubble sign → Jejunal Atresia. Key A pregnant woman attends for anomaly scan at 31-week gestation. She has 33 polyhydramnios. U/S → No fetal gastric bubbles. Copyrights @ Plab1Keys.com 32 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) → Oesophageal Atresia. ♠ Polyhydramnios + Absent fetal Gastric Bubbles → Oesophageal Atresia. ♠ Logically, if nothing can pass into the stomach because of the oesophageal atresia, there won’t be bubbles in the stomach! ♠ Important post-natal (after delivery) sign of oesophageal atresia: → inability to pass a catheter into the stomach (X-ray would show the catheter is coiled in the oesophagus). REMEMBER: Coiled NGT after Road Traffic Accident → Diaphragmatic Rupture. Key Tenesmus → a continual or recurrent inclination to evacuate the bowels, 34 caused by disorder of the rectum or other illness. Some RFs of Rectal Carcinoma: ♠ FHx ▐ ♠ Smoking ▐ ♠ Polyposis Syndromes ▐ ♠ Low fibre diet ▐ ♠ IBD Copyrights @ Plab1Keys.com 33 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Key Firm, painless, mobile mass in a young woman’s breast → Fibroadenoma. 35 Investigation → Ultrasound. Key Following surgery, the most common complication in general is 36 ► Post-Operative Infection. It does not matter what the type of the surgery is. Generally, Post-op infection is the most common complication seen, including local (wound) infection, lung infection (Hospital-acquired pneumonia) and so on. Example, After a hemi-arthroplasty: ♠ Post-operative infection is the commonest complication. ♠ Fat necrosis is very rare. ♠ DVT and Pulmonary embolism: can occur but not as common as infection. This is because nowadays, early post-op mobilisation + Heparin/ Enoxaparin are mandatory. ♠ Avascular necrosis cannot occur as the fractured head of the femur has been already replaced. Hemi-arthroplasty = a surgical procedure that involves replacing half of the hip joint. Hemi means “half” and arthroplasty refers to “joint replacement.” Copyrights @ Plab1Keys.com 34 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Replacing the entire hip joint is called total hip replacement (THR). A hemiarthroplasty is generally used to treat a fractured hip. Key A Case Scenario 37 A 60 YO ♀ presents to the ED complaining of passing large amount of bright red blood + Left lower abdominal pain for 2 days that is worse after eating + Nausea but with no vomiting. The patient’s main diet is canned meat. There is localised left lower abdominal tenderness without rigidity or rebound tenderness. On examining the rectum, blood is found on the examiner’s glove. Vital signs: (BP: 85/55), (HR: 105), (Temperature: 38°C), (RR: 19). ◙ The likely diagnosis → Bleeding diverticulitis. ◙ The most appropriate step → Urgent admission to the surgical ward. ◙ The most appropriate “INITIAL” step → IV fluid (she is hypotensive). Diverticulosis ♠ Diverticulosis → Outpouches (outward herniations) of the colonic wall. ♠ Low fibre diet + (age > 50 Years) are common precipitating factors. Patients tend to consume lots of canned food that is low in fibres. ♠ Diverticulosis mainly affects the sigmoid colon (Left Lower Abdomen). ♠ It is Mainly Asymptomatic. Copyrights @ Plab1Keys.com 35 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) ♠ Sometimes, the stools can get impacted inside the diverticulae leading to infection → Acute Diverticulitis → left iliac fossa pain and tenderness, Fever, Constipation. ♠ In the case of acute diverticulitis → Admit patient and give IV antibiotics. ♠ So, the asymptomatic disease is called (Diverticulosis) or (Diverticular disease). When infected, it is called→ Diverticulitis. Important: What is the most likely outcome of acute diverticulitis? The likely outcome of acute diverticulitis after treating with IV antibiotics, IV fluids, observation and keeping the patient NPO → Complete resolution (recovery). Only 20% of acute diverticulitis cases develop complications such as fistula, abscess, bowel obstruction, perforation and or peritonitis. Only 20% of acute diverticulitis cases develop complications such as fistula, abscess, bowel obstruction, perforation and or peritonitis. ♠ Bleeding/ ruptured diverticula are also complications (rare). ♠ If bleeding occurs: → Stabilise the patient by IV fluids, IV antibiotics, Copyrights @ Plab1Keys.com 36 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) → Arrange Urgent Admission to the surgical ward, → Take FBC “Haemoglobin” to see if blood transfusion is required, CRP to confirm the presence of infection (diverticulitis), → Colonoscopy to correct and stop the bleeding source or even surgery if there is a diverticular rupture. ◙ Do not forget: in diverticulosis, profuse bleeding per rectum → urgent admission. Copyrights @ Plab1Keys.com 37 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Key If haemorrhoids (Piles) are Asymptomatic (even if advanced grade) 38 → No surgical treatment is required! Grades of Hemorrhoids Key After abdominal surgery (e.g. Splenectomy), blood supply of the stomach 39 might be affected during the operation → the stomach will be in ileus (non- functioning) → accumulation of air inside the stomach → Acute Gastric Dilatation. Example: Copyrights @ Plab1Keys.com 38 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) On the second day post-splenectomy, a patient develops epigastric fullness, tenderness, nausea and Vomiting, and gradually increasing abdominal distension. He is hypotensive (BP: 75/45) and Tachycardic (135 bpm). ◙ The likely diagnosis → Acute Gastric Distension. ◙ The next step should be → Insertion of NGT (Nasogastric Tube). ♠ The NGT will “deflate the stomach” and thus the signs and symptoms would rapidly improve. ♠ Why is there hypotension? When stomach massively dilates, it compresses the surrounding vessels, sometimes the aorta as well → blood pressure drops. Key ◙ Numbness and Tingling of the thumb, index and middle fingers 40 → Think of Carpal Tunnel Syndrome √ Pregnancy is an important RF for Carpal Tunnel Syndrome (due to fluid retention). √ Tinel Test is not always positive in Carpal Tunnel Syndrome “very low sensitivity”. ◙ The Transverse Carpal Ligament compresses the MEDIAN nerve. Copyrights @ Plab1Keys.com 39 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) ◙ Thus, the treatment would be → Cut the Transverse Carpal Ligament to release the pressure on the median nerve. ♠ Note: Transverse Carpal Ligament is also called = Flexor Retinaculum = Anterior Annular Ligament. Key Anal Fissure 41 ♦ Extremely painful especially on defecation (The patient may refuse rectal examination because of the intense pain)! ♦ There are blood streaks on the stools. ♦ The patient my remember an event when they felt a sharp intense pain while defecating. ♦ The constipation and straining are the precipitating factors. However, the presence of an anal fissure would also cause constipation as the patient would be so afraid to pass stool as it is severely painful! Notes: ♠ Haemorrhoids → Blood + Intermittent, bearable “tolerable” pain or painless/ splashes of blood. ♠ Perianal Abscess → Throbbing pain, swelling, Usually No blood. ♠ Anal fissure → Intense pain (unbearable), streaks of blood. e.g. ◙ A man presents with severe pain in anus especially on defecation, Copyrights @ Plab1Keys.com 40 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) blood streaks on the stools and Hx of constipation. The likely Dx → Anal Fissure. ◙ Management of an acute anal fissure (< 6 weeks): √ Dietary advice: high-fibre diet with high fluid intake. √ Bulk-forming laxatives are first-line – if not tolerated then lactulose should be tried. √ Lubricants such as petroleum jelly may be tried before defecation. √ Topical anaesthetics. √ Analgesia. ◙ Management of a chronic anal fissure (> 6 weeks): √ The above techniques should be continued. √ Topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure. √ If topical GTN is not effective after 8 weeks, then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin. Key Important Notes on Hernias 42 Copyrights @ Plab1Keys.com 41 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) ◙ Inguinal Hernia → ABOVE and Medial (some sources say lateral) to the pubic tubercle. ◙ Femoral Hernia → BELOW and lateral to the pubic tubercle. ◙ Inguinal Hernia → Impulse on cough, reducible ◙ Femoral Hernia → rarely impulse on cough (but it can impulse on cough) + Irreducible as the femoral canal is narrow + tends to occur more in females + easy to strangulate + often irreducible + below inguinal ligament. ◙ Strangulated and Incarcerated hernias → Irreducible, very painful, require urgent surgery. ◙ RFx of Inguinal Hernia → Male sex, Lifting heavy objects, old age, chronic cough, previous abdominal surgery. ◙ Indirect inguinal hernia → Passes through the deep and the superficial inguinal ring (Passes through the entire length of the inguinal canal) and lies LATERAL to the inferior epigastric artery. ◙ Direct inguinal hernia → Passes through the Posterior wall of the inguinal canal “directly” and lies MEDIAL to inferior epigastric artery. Copyrights @ Plab1Keys.com 42 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) It does not pass through the deep and then the superficial ring of the inguinal canal as the indirect hernia does. Key Paralytic ileus 43 = No GIT Motility + Non-functioning Bowel = No Peristalsis ◙ One of the known post-operative complications. ◙ Manipulation and handling of the bowel loops during an intra-abdominal operation → bowel stops functioning “No motility”. ◙ Causes other than surgery → Electrolyte imbalance (HYPOKALEMIA, HYPERCALCEMIA), Anti-cholinergic, Post-trauma, Opiates, Peritonitis, Immobilisation. ◙ Important, even if it is not an abdominal operation (e.g. Hip joint replacement), the prolonged immobilisation alone can cause paralytic ileus. ◙ Features → √ Abdominal Distension “bloating”, No passage of flatus “gases”. √ Absent Bowel Sounds. √ Nausea, Vomiting. √ Percussion → Hyperresonance. Copyrights @ Plab1Keys.com 43 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) ◙ What to do Next? → Abdominal X-ray. ◙ Erect Abdominal X-ray → Gases/ air-fluid levels/ dilated small loops Note, in mechanical obstruction → Noisy (high-pitched) bowel sounds + more intense abdominal pain. ◙ Rx of paralytic ileus → NGT + IV fluids. (Drip and Suck) ♠ Insertion of Nasogastric tube → deflate the gases and sucks the fluids and thus relieve the distension, nausea and vomiting. Copyrights @ Plab1Keys.com 44 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Key 65 YO ♀ with firm, round, painless lump in a breast + Bruises + No discharge 44 → Fat Necrosis Common Breast Lesions 1 ◙ Painful, fluctuating mass over the breast or near the nipple → Nipple Abscess. 2 ◙ Brown/ Green discharge per Nipple ± itching and retracted nipple ± Painful breast ± Hx of smoking → Duct Ectasia. Copyrights @ Plab1Keys.com 45 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) 3 ◙ Hx of Trauma to the Breast (redness or bruises around the lump) + firm, round, solitary and localized lump → Fat Necrosis 4 ◙ Bleeding per nipple in 20-40 YO ♀ ± skin changes → Ductal Papilloma 5 ◙ Bleeding discharge per nipple in an Old woman with eczema-like changes in the nipple ± areola ± Ulcers → Paget’s disease (Malignant) 6 ◙ Firm, non-tender, highly mobile mass in a breast of a young ♀ (15-30 YO) → Fibroadenoma 7 ◙ Breast pain (Mastalgia), ↑ breast size, lumpiness (nodularity) of the breast, ♀ in the reproductive age, tend to appear just before or during menstrual cycle and disappear after it → Fibroadenosis. 8 ◙ Fixed, irregular, hard, painless lump ± nipple retraction ± fixed to skin (Peau d’orange) or muscle (+) Local, fixed, firm, axillary LNs → Breast Cancer 9 ◙ Offensive yellow discharge from an area near the nipple + Hx of Abscess near this area that was surgically treated → Ductal Fistula (Mamillary Fistula). Copyrights @ Plab1Keys.com 46 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) 10 ◙ Prolonged Redness around the areola. Hx of using antibiotics which improved symptoms slightly. Greenish discharge per nipple. ± nipple retraction ± small lump around the nipple is felt. → Periductal mastitis. (commonly young age, smoking is a risk factor, treated with antibiotics, if left untreated it may develop into an abscess that needs drainage by fine needle) 11 ◙ Persistent nipple discharge that is non-bloody and occasionally milky or serous fluid. It is spontaneous. No breast masses. No Nipple retraction. No skin changes. → Mamillary duct fistula (abnormal connection between lactiferous ducts of the breast and skin surface → leads to spontaneous nipple discharge that is not purulent nor bloody. It can appear as a milky or serous fluid). Key After Thyroidectomy: 45 ◙ Unilateral Injury to the Recurrent laryngeal nerve → Hoarseness of voice. ◙ Bilateral Injury to the Recurrent laryngeal nerve → Aphonia ± Airway Obstruction. ◙ Injury to the External branch of (superior) laryngeal nerve → Loss of high-pitched sound = (Dysphonia) = (Mono toned voice). Copyrights @ Plab1Keys.com 47 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Key In the exam, any of the following Histopathological descriptions are for 46 Fibroadenoma: Proliferation and expansion of the stroma with low cellularity. Or: A well circumscribed lump with clear margins and separated from the surrounding fatty tissue. There are overgrowths of fibrous and glandular tissue. Or: Duct-like epithelium surrounded by fibrous bridging. Key ◙ The most common breast lesion in young ♀ (15-35 YO) → Fibroadenoma. 47 ◙ The most common breast lesion in ♀ in reproductive age (Peak incidence: 35-50) → Fibroadenosis. ◙ The most common breast mass in postmenopausal ♀ → Breast carcinoma. Key Itching around the breast + “Greenish” foul nipple discharge 48 → Duct ectasia. Key ♦ Intermittent, Burning or Stabbing Pain in one part of one breast that may 49 radiate to axilla, no palpable masses or lumps and no enlarged LNs → Non-cyclical Mastalgia Copyrights @ Plab1Keys.com 48 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) ♦ If there is a lump → Think of breast Cyst. ♦ If there is a mention of an association with menstruation → Cyclic Mastalgia. Breast pain (Mastalgia), ↑ breast size, lumpiness (nodularity) of the breast, ♀ in the reproductive age, tends to appear just before or during menstrual cycle and disappears after it → Fibroadenosis. Key Post-Abdominal operation (e.g. Sigmoidectomy) → Abdominal discomfort is 50 logical, expected and not a big deal as long as there is no fever and no other signs and symptoms. Even if WBCs and CRP are high, this is expected post-operatively; therefore, all that is needed is to → Repeat WBCs and CRP after 24 hours. Key ◙ It is known that colon and rectum are stores for fecal matters and thus 51 during colectomy, there is a risk of serious infections. ◙ Therefore, prophylactic antibiotics should be given before any surgery that involves colon or rectum. ◙ One common regimen: Copyrights @ Plab1Keys.com 49 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) → Cefuroxime (Cephalosporin) “good coverage against Gram +ve and -ve”. Plus: → Metronidazole “Good coverage against Anaerobic bacteria”. ◙ They are given in the first 30 minutes of the first incision made or: √ At the induction of anaesthesia (Important). ♦ In short, for a patient undergoing colectomy, the prophylactic antibiotics → Cefuroxime + Metronidazole. Key Hepatomegaly + Palpable liver + Weight Loss + Hx of Cirrhosis + 52 Tiredness + Right upper quadrant pain → Suspect Hepatocellular Carcinoma (HCC) → Request the hepatic tumor marker → Alpha-fetoprotein (AFP). ◙ Remember that AFP is also a tumor marker for Teratoma. Key ◙ Throbbing anal pain esp. on defecation and on sitting, the pain is gradually 53 increasing in severity, Tender swelling/mass around the anus that might be erythematous, ± fever, No blood. Copyrights @ Plab1Keys.com 50 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) → Perianal Abscess ◙ Rx → Incision and drainage (immediately to prevent the development of fistula) Perianal hematoma → Analgesics, Self-resolving. Perianal Abscess → Incision and Drainage (Acute Surgical Emergency) ± Post-op Antibiotics. Key Very Important Note! 54 ◙ In Any patient who has just had Thyroid surgery (e.g. thyroidectomy) and develops Shortness of Breath (SOB) and Stridor. The first step to do is to → Cut the subcutaneous Sutures. This is likely a post-thyroidectomy complication called (Hematoma). It compresses the trachea and causes upper airway obstruction. Cutting the sutures would relieve the pressure and improve breathing. If not → Consider intubation. Copyrights @ Plab1Keys.com 51 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Key Remember: 55 ◙ For a patient undergoing colorectal surgery, the prophylactic antibiotics → IV Cefuroxime + Metronidazole ◙ They are given in the first 30 minutes of the first incision made or: √ At the induction of anaesthesia (Important). Key Notes on Diagnosing Appendicitis 56 ◙ Abdominal pain that started centrally (Peri-umbilical) then shifted to the Right iliac fossa → McBurney’s sign. Remember that umbilical region and appendicitis share the same dermatome (T10). However, later on when there is peritoneal irritation, the pain will become localised to its origin (Right iliac fossa). ◙ Nausea, Vomiting, Loose stools. ◙ Tenderness, Rebound Tenderness over the Right iliac fossa. ◙ Fever. ◙ High WBCs and CRP. ◙ +ve Rovsing’s sign → applying pressure on the left iliac fossa → pain is felt on the right iliac fossa. ♦ Note: Do not get tricked by a Hx of Pregnancy in a patient. Copyrights @ Plab1Keys.com 52 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Central Abdominal pain then shifted to Right iliac fossa Pain, Tenderness, Rebound Tenderness + Vomiting, loose stools, High CRP → Think of Appendicitis. Other Appendicitis Signs for your knowledge Key For Colorectal cancer, Old age followed by Family History constitute the 57 greatest risk factors. “do not get tricked and pick smoking”! For Urinary Bladder cancer → Smoking is the most important risk factor. Key A patient with right upper quadrant pain that radiates to the shoulder found 58 to have Gallstones. He is vitally stable. What should be done? → Elective Laparoscopic Cholecystectomy. Copyrights @ Plab1Keys.com 53 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Notes: ♦ As there are symptoms (RUQ pain) → Reassurance is wrong. ♦ As he is vitally stable and no signs of perforation → Emergency Laparotomy is wrong. Key ◙ Old age + Anemia + Bleeding per rectum + Weight loss + Left lower 59 abdominal mass or pain → Sigmoid carcinoma. ◙ Old age + Anemia + Weight loss + Right lower quadrant pain/mass → Caecal Carcinoma. Key Acute Mesenteric Ischemia Ischemic Colitis 60 Sudden onset Onset is gradual over hours VERY SEVERE pain and tenderness. Moderately Severe. Hx of AF Multifactorial (transient interruption AF → embolization to superior of blood supply) e.g. HF. mesenteric artery → acute HF on top of MI. mesenteric ischemia. - Usually starts at left iliac fossa Copyrights @ Plab1Keys.com 54 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) VBG → High Lactate (↑ lactate). ± Bloody diarrhea. Rx: Urgent Surgery Conservative or Surgical Scenario (1) An old patient presents whit 2-hour severe and persistent abdominal pain of an acute onset. There are abdominal dissension, generalised tenderness and absent bowel sounds. Venous blood shows lactate of 6 (Normal: 0.6-2.4) ECG → Atrial Fibrillation. → Acute mesenteric ischemia Scenario (2) An old patient with Heart failure and Diabetes presents complaining of a 16- hour abdominal pain that has begun at the lower left abdominal quadrant. The pain is of a gradual onset. On examination → generalised abdominal tenderness, mild fever and rectal examination shows blood. Copyrights @ Plab1Keys.com 55 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) → Ischemic Colitis. Scenario (3) Recent Question: A 60 YO man presents complaining of severe abdominal pain and bloody stools. The pain is cramp-like and is of a gradual onset. He had MI 2 days ago and was treated with thrombolysis. He also takes azathioprine for crohn’s disease. His HR is 90 and Temperature 37.5 C. What is the likely cause for abdominal pain and bloody stools? Gradual onset pain + Bloody stools + MI → Ischemic colitis. The question also asked about the site. You need to know that Ischemic Colitis is commonest at the Splenic Flexure as this area has fewer collaterals (called: weak spots/ watershed) The answer is: → Ischemic colitis at the splenic flexure Another correct answer: → ischemia at watershed areas of splenic flexure and rectosigmoid. The stem does not mention signs of flare-up of CD. Copyrights @ Plab1Keys.com 56 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Key A child with fluid-filled mass on the midline of his neck below the hyoid bone. 61 It is non-tender and it moves upward on tongue protrusion and on swallowing. The likely Dx → Thyroglossal Cyst. The most appropriate Investigation → ULTRASOUND Not FNAC! Ultrasound alone is sufficient to confirm the diagnosis of thyroglossal cyst in the majority of cases. Key Offensive yellow discharge from an area near the nipple + Hx of Abscess near 62 this area that was surgically treated → Ductal Fistula (Mamillary Fistula). Copyrights @ Plab1Keys.com 57 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Key Dysphagia + Regurgitation of Stale food/fluid + Chronic Cough 63 (esp. Nocturnal) ± Bad mouth breath (Halitosis) ± Aspiration → Pharyngeal pouch (Zenker’s Diverticulum) ♦ Endoscopy is Contraindicated as it may perforate the pouch. Instead, request → Barium Swallow. Old age + Gradually Worsening Dysphagia (initially for solid food and then for soft food and liquids) + Longstanding Gastric Reflux → Think of Oesophageal Carcinoma. ♦ Diagnosis is made by → Upper GI Endoscopy + Biopsy. Key Old age + Earache (Ear pain) + Painful/discomfort swallowing + Lesion/ Ulcer 64 on the mouth (e.g. at the back of the tongue) + Palpable, non-tender Cervical LN. → Think of oropharyngeal Carcinoma ◙ Oropharyngeal Carcinoma presents with: Copyrights @ Plab1Keys.com 58 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) √ a lump or ulcer in the mouth or throat, √ referred otalgia, √ persistent sore throat and painful swallowing, √ in a typically old and smoker patient. Other DDx: Nasopharyngeal Carcinoma Swollen cervical LNs → a painless swelling or lump in the upper neck. Eustachian tube obstruction → Otitis media, Epistaxis “recurrent nose bleeds”, Nasal obstruction. Others: Conductive hearing loss, Tinnitus. RFx: EBV (specific), Smoking, Alcohol. N.B: EBV → Hodgkin’s lymphoma, Nasopharyngeal carcinoma. Tonsil Carcinoma (a form of oropharyngeal carcinoma) Persistent sore throat (over weeks). Progressive Hoarseness of voice. Copyrights @ Plab1Keys.com 59 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Dysphagia and painful swallowing. Feeling of a persistent lump in the throat. Palpable lump on the anterolateral portion of the neck. N.B. the absence of weight loss does not exclude the tonsil cancer! Tonsillar cancer spreads to → Mandible (important) → Pain in the throat + Trismus (spasm of the jaw muscles, causing the mouth to remain tightly closed). ◘ One important differential diagnosis is Quinsy (Peritonsillar abscess) Peritonsillar abscess usually presents after a Hx of tonsillitis or sore throat for several days. ◘ Quinsy “Peritonsillar abscess” presents with: √ severe trismus (which is lockjaw = spasm of jaw muscles), √ Drippling of saliva, √ Otalgia (as CN IX glossopharyngeal nerve supplies both the ears and tonsils), √ Hot potato voice, √ uvular deviation. √ Red and inflamed bulge (or) swelling beside the tonsil (above and lateral to a tonsil) Copyrights @ Plab1Keys.com 60 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) ◙ Plummer Vinson Syndrome: √ Iron Deficiency Anemia (IDA), √ Glossitis, √ Dysphagia (due to post-cricoid oesophageal web). It is a risk factor for oropharyngeal carcinoma It is common in postmenopausal women. Key ◙ A man presents with severe pain in anus especially on defecation. He has 65 a Hx of constipation. The likely Dx → Anal Fissure. ◙ A man presents with severe pain in anus especially on defecation, blood streaks on the stools and Hx of constipation. The likely Dx → Anal Fissure. ◙ Management of an acute anal fissure (< 6 weeks): √ Dietary advice: high-fibre diet with high fluid intake. Copyrights @ Plab1Keys.com 61 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) √ Bulk-forming laxatives are first-line – if not tolerated then lactulose should be tried. √ Lubricants such as petroleum jelly may be tried before defecation. √ Topical anaesthetics. √ Analgesia. ◙ Management of a chronic anal fissure (> 6 weeks): √ The above techniques should be continued. √ Topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure. √ If topical GTN is not effective after 8 weeks, then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin. Key Remember that: 66 ◙ Inguinal Hernia → ABOVE and Medial (some say lateral) to the pubic tubercle. ◙ Indirect inguinal hernia → Passes through the deep and the superficial inguinal ring (Passes through the entire length of the inguinal canal) and lies LATERAL to the inferior epigastric artery. ◙ Direct inguinal hernia → Passes through the Posterior wall of the inguinal canal “directly”. Copyrights @ Plab1Keys.com 62 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) It does not pass through the deep and then the superficial ring of the inguinal canal as the indirect hernia does. So, indirect inguinal hernia passes through the deep inguinal ring. Key A patient who is not breathing after being exposed to burn. Intubation has 67 failed. The next step is: → Cricothyroidotomy The structure to be pierced → Cricothyroid membrane Key Abdominal pain, distension, tenderness, empty rectum, Noisy hyperactive 68 bowel sounds, constipation. The likely Dx → Intestinal Obstruction. If after surgery → “Mechanical bowel obstruction” “due to post-operative adhesions” Chest X-ray would show → multiple air-fluid levels. The next best step → Urgent refer to surgical ward. Imp √ Copyrights @ Plab1Keys.com 63 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) (Note, this resembles paralytic ileus. However, in paralytic ileus, bowel sounds are absent. Also, in paralytic ileus, there is usually a Hx of recent abdominal surgery or immobilisation and it is managed by NGT and IV fluid). ◙ In a patient with intestinal obstructions, the emergency team’s role is to deliver IV fluids and analgesics and order X-ray and then to → send the patient to the surgical team. At surgical ward, they can decide whether the patient needs surgery or conservative management. Key Back pain 69 + WEIGHT LOSS + Hx of smoking/alcohol + Obstructive jaundice (Jaundice = ↑ conjugated and total bilirubin, Pale stool, Dark urine, Pruritus = itching, ↑ ALP) + Abnormal LFT + High blood glucose + Palpable Gallbladder (± Palpable mass at epigastrium) Think → Cancer head of pancreas Copyrights @ Plab1Keys.com 64 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) ◙ Chronic Alcohol intake → Chronic Pancreatitis (Epigastric pain that radiates to the back) → RF of Pancreatic carcinoma. Why not Cholangiocarcinoma? ♦ In cholangiocarcinoma, the pain would be in the Right Upper Quadrant (RUQ), not in the back or epigastrium. ♦ The triad for Cholangiocarcinoma → Jaundice, Weight Loss, RUQ pain. ♦ Also, note that in pancreatic carcinoma, the blood glucose elevates. Why is there obstructive jaundice? This is because as the cancer grows, it blocks the biliary tract. Investigations of cancer head of pancreas. √ Initial → Ultrasound. √ The investigation of choice → High-resolution CT scan. √ Prognosis → CA 19-9 Management of cancer head of pancreas. In patients without metastasis → Whipple’s resection (Pancreaticoduodenectomy). In patients with metastasis → palliative ERCP with Stent. Copyrights @ Plab1Keys.com 65 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Key ◙ While performing laparoscopy, the anatomical structure(s) to be pierced 70 while inserting a port (trocar) at the midway point between umbilicus and anterior superior iliac spine is → Internal oblique muscle and external oblique aponeurosis. ◙ During a laparoscopic cholecystectomy, the midline structure that is pierced is → Linea Alba Key Cancer Screening Programmes available in the UK 71 Colorectal Cancer Screening: √ Fecal Immunochemical Test (FIT). √ 60-74 YO every 2 years in England And 50-74 in Scotland Breast Cancer Screening: √ (Mammogram). √ ♀ 50-70 YO every 3 years. √ Those with high risk → 40-70 YO annually. Copyrights @ Plab1Keys.com 66 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Cervical (Cervix) Cancer Screening: √ (Pap smear: Cytology, HPV) √ 25-49 YO → every 3 years. √ 50-64 → every 5 years. Key Palpable mass at scrotum 72 Reducible Impulse and enlarges on cough → Inguinal Hernia. Note: Only indirect inguinal hernia can descend into the scrotum. Note: Incisional hernias do not exist in scrotum, they develop at the “Incision Site” of a previous wound of surgery. Key ◙ In breast Abscess, the commonest causative organism is 73 → Staphylococcus aureus. Key A lady presents with Dry skin around the areola, Itching in the area, 74 Discharge per nipple sometimes bloody → Paget’s disease Copyrights @ Plab1Keys.com 67 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) (do: Punch biopsy). Key ◙ An old man with abdominal distension and pain, vomiting. O/E, 75 empty rectum and high-pitched exaggerated bowel sounds. → referral to surgery (Bowel Obstruction in managed by a Surgical team). Key A woman presents complaining of hoarseness of voice. Which nerve might 76 be affected? → Recurrent laryngeal nerve. (For knowledge, not every hoarseness is caused by recurrent laryngeal nerve injury. Laryngitis, vocal cord nodules and tiredness are more common causes for hoarseness). Unilateral Injury to the Recurrent laryngeal nerve → Hoarseness of voice Bilateral Injury to the Recurrent laryngeal nerve → Aphonia/ Airway obstruction. Injury to the External branch of (superior) laryngeal nerve → Loss of high- pitched sound = (Dysphonia) = (Mono toned voice). N.B. About 18% of Lung cancer patients experience hoarseness of voice due to compression of the tumour on the recurrent laryngeal nerve. Copyrights @ Plab1Keys.com 68 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Recurrent laryngeal nerve is a branch of the Vagus nerve (10th CN) Key A lady underwent radical mastectomy. Later on, she developed upper limb 77 swelling and redness. The likely Dx → Lymphoedema. Axillary Lymph nodes clearance (removal) during radical mastectomy can lead to → Upper Limb Lymphoedema (Redness and Swelling) ± Frozen shoulder. Rx → Physiotherapy and arm exercise. Key An elderly man presents with Back pain, weight loss, Hx of smoking/alcohol, 78 jaundice, High blood glucose. He has palpable liver and gallbladder Likely Dx → Cancer of Pancreas. An elderly man presents with a 6-month history of jaundice, pale stool, dark urine and weight loss of 10 kg. He has abdominal pain that is worse after eating. He has a palpable mass at the epigastrium. His Bilirubin, ALT, AST and ALP are elevated. Likely Dx → Cancer of Pancreas. Copyrights @ Plab1Keys.com 69 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Key A 55 YO lady was found to have high glucose in urine after surgery. 79 → Stress Hyperglycemia. Stress hyperglycemia: Post-op or stress or post-trauma or some diseases → high cortisol → high glucose → glycosuria (glucose in urine) This subsides on its own in a few days. What to do next as follow up? FASTING blood glucose (although it is a normal phenomenon, we need to make sure of our diagnosis of the Stress hyperglycemia). Copyrights @ Plab1Keys.com 70 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Key A 22 YO female presents with firm, non-tender and mobile mass in her right 80 breast. The likely Dx → Fibroadenoma Key A patient is due for elective hernia repair and his Hb was found to be 8.2. 81 → “Postpone” the surgery and Investigate for the anemia A patient is due for elective hernia repair and his Hb was found to be 10.3. → Proceed with the surgery A patient is due for emergency laparotomy and his Hb was found to be 8.2. → Proceed with the surgery A patient is due for emergency laparotomy and his Hb was found to be 7.2. → Transfuse blood and proceed with the surgery ◙ Elective Surgery: Copyrights @ Plab1Keys.com 71 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) ♠ If Hb is > 10 → Proceed with the surgery ♠ If Hb is between 8-10→ Delay “defer” “Postpone” the surgery and Investigate for the anemia reasons first. ♠ If Hb is < 8 + Symptomatic → Transfuse Blood and also Defer the surgery. ◙ Emergency Surgery: ♠ If Hb is > 10 → Proceed with the surgery ♠ If Hb is between 8-10 → Proceed with the surgery. ♠ If Hb is < 8 → Transfuse Blood and Proceed with the surgery “it is emergency”! Key Hx of Trauma to the Breast (redness or bruises around the lump) + firm, 82 round, solitary and localized lump → Fat Necrosis. Key A 60 YO man presents complaining of severe abdominal pain and bloody 83 stools. The pain is cramp-like and is of a gradual onset. He had MI 2 days ago and was treated with thrombolysis. He also takes azathioprine for crohn’s disease. His HR is 90 and Temperature 37.5 C. What is the likely cause for abdominal pain and bloody stools? Gradual onset pain + Bloody stools + MI → Ischemic colitis. Copyrights @ Plab1Keys.com 72 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) The question asked about the site also, you need to know that Ischemic Colitis is commonest at the Splenic Flexure as this area has fewer collaterals (called: weak spots/ watershed) The answer is: → Ischemic colitis at the splenic flexure Another correct answer: → ischemia at watershed areas of splenic flexure and rectosigmoid. The stem does not mention signs of flare-up of CD. Key Post-hemicolectomy, a patient was commenced on parenteral morphine for 84 pain. 2 days later, he developed SOB with RR of 30 and O2 saturation of 87%. The most appropriate management → Commence O2 by face mask immediately. (ABC: Airways, breathing, circulation). Remember that (opioid toxicity → ↓ RR -resp. depression-). Here, ↑ RR. Key ◙ A stem with long history of a patient after RTA being managed in a critical 85 care unit with an X-ray showing an NGT curled above the hemidiaphragm. Coiled NGT after Road Traffic Accident → Diaphragmatic Rupture. Copyrights @ Plab1Keys.com 73 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Key ◙ Testis cancer → request LDH (lactate dehydrogenase) 86 Key ◙ Woman with breast cancer and widespread metastasis, has developed 87 an increased thirst, Constipation and confusion. What is the likely cause? → Hypercalcemia. Key ◙ Hx of Undescended Testis (Cryptorchidism) increases the risk of testicular 88 cancer by 10 times (Particularly: Seminoma “a germ cell tumor”) for which, we request Lactate Dehydrogenase (LDH). Key ◙ A patient is on warfarin and has surgery in a few days 89 → Stop Warfarin and commence LMWH LMWH = Low Molecular Weight Heparin [e.g. fondaparinux, enoxaparin]. Key A 27yr old woman with redness around her areola of 4 weeks duration. She 90 had used some antibiotics which improved her symptoms slightly. 5ml of greenish fluid was aspirated from the breast. She smokes regularly. What is the most likely diagnosis? A. Breast abscess B. Breast cancer C. Duct papilloma D. Paget’s disease E. Periductal mastitis Copyrights @ Plab1Keys.com 74 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) ’ Periductal mastitis. (commonly young age, smoking is a risk factor, treated with antibiotics, if left untreated it may develop into an abscess that needs drainage by fine needle) Key A man who just had surgery a few hours ago. Urine bag is not draining. 91 Vitals are stable. What to do next? a) check the catheter for blockage b) exploratory laparotomy c) give furosemide D) fluid challenge Key Patient Came back after 7 days of adeno-tonsillectomy, vomiting blood. 92 Temp 38.5. What is the most appropriate step? A. Admit for IV antibiotics B. Admit for FFP and Vit k C. Discharge home with oral antibiotics D. urgent surgical exploration of wound site Tonsillectomy Complications 1ry Bleeding (within the first 24 hours) → Return to the theatre may be required. Usually due to inadequate haemostasis, displacement of a tie, loss of eschar. 2ry or Reactive Bleeding (occurs more than 24 hours post-op = 1-10 days post op, and usually after discharge) Copyrights @ Plab1Keys.com 75 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Usually due to wound infection that leads to vessel erosion; thus, Admit the patient and give IV Antibiotics. (Antibiotics and Antiseptic mouthwashes are also indicated). Key 27-year-old Woman with a 1.5 cm lump, tender, firm in left breast. What is 93 the appropriate Investigation? A. Ultrasound of breast B. mammogram C. FNAC D. excision biopsy E. punch biopsy Generally: ♠ ♀ < 35 YO → Ultrasound. ♠ ♀ > 35 YO → Mammogram. √ Fine needle aspiration may follow (based on the US result). √ Punch biopsy is for Paget’s disease of the breast (eczema like, Dry skin around the areola, Itching in the area, Discharge per nipple sometimes bloody). Key A 21 YO lady presents with positive family hx of breast ca, has a mass that’s 94 firm, painless, mobile, not attached to anything, skin over it is intact. Her mother had breast ca. Most likely diagnosis? a) Paget’s b) Ductal papilloma c) Fibrocystic change Copyrights @ Plab1Keys.com 76 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) d) Fibroadenoma e) Breast cancer Despite the Hx of breast cancer in mother, the features of the mass and the young age are suggestive of fibroadenoma (young age, MOBILE mass, not attached to the underlying structures). ◙ Firm, non-tender, mobile mass in a breast of a young ♀ (15-30 YO) → Fibroadenoma → Clinical + Ultrasound + FNA Key Patient with advanced ovarian carcinoma with gaseous distension and 95 intermittent pain. Management? A. Hyoscine Butylbromide B. SC morphine C. Surgical palliative care with stoma D. NG tube If bowel obstruction occurs due to advanced malignancy or as a complication of chemotherapy, conservative treatment is not an option as in most cases it fails. So, the answer for this question is → C. Palliative colostomy. Key 38 yr old woman who presented with passing of blood per rectum. She 96 complained of occasionally staining of toilet paper for about 3 months with blood. There was an episode when she was just passing blood while trying to defecate. On examination, perineum is normal, no mass felt in the rectum, rectum is empty. Gloved finger not stained with blood. What is the next best investigation? Copyrights @ Plab1Keys.com 77 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) A) Colonoscopy B) proctoscopy C) Fecal calprotectin test D) Faecal occult blood test Proctoscopy is a scope that visualises the Rectum. Based on the age and the features (blood stained toilet tissues), this is likely a case of internal haemorrhoids (Piles). An episode of passing fresh blood only means that the defect is distal (mostly in the rectum). Because internal haemorrhoids are often too soft to be felt during a rectal exam, your doctor might examine the lower portion of your colon and rectum with an anoscope, proctoscope or sigmoidoscope. Kindly note that if this patient was an old age and with other symptoms such as a change in bowel habits, anemia, abdominal pain → colorectal carcinoma should be among the possible differentials and → colonoscopy is to be done. Key A man has just got out of the theatre for cholecystectomy. Vitals are stable 97 except BP which is 90/50. Pulse is 120. What is the next step to carry out? a. Fluid challenge b. Adrenaline c. Dopamine Likely primary hemorrhage. He is hypotensive. The (initial) = (next) step is IV fluid. Copyrights @ Plab1Keys.com 78 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Remember: Types of Surgical Bleeding Primary Bleeding at the time of Rx: Replacing Blood or hemorrhage surgery. return to theatre if severe. Reactionary Bleeding within 24 hours Usually due to slipping of hemorrhage after surgery/ Trauma. ligatures, dislodgement of clots, warming up post-op e.g. a patient bleeding and leading to vasodilatation and hypotensive while in the rising of BP to normal. recovery room. Rx: Replacing blood (IV fluids and Packed RBCs if heavy), wound re-exploration. Secondary 1 to 2 weeks post-op Usually due to necrosis of hemorrhage blood vessels related to the previous repair, and precipitated by wound INFECTION. The patient may require admission and IV antibiotics. But in this stem, it asks about the next step. ABC [C = Circulation → correct the low BP by IV fluid NS first. If still low BP → Packed RBCs]. Copyrights @ Plab1Keys.com 79 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Key A woman with Hx of Crohn’s disease presents complaining of foul-smelling 98 feculent discharge from her vagina. A fistula is suspected. What is the most likely structure that would be involved in the formation of this fistula with vagina? → Rectum “rectovaginal fistula”. If Not in the options, pick → ileum. √ Although the rectum is rarely involved in CD, it is the most common site of fistula (Rectovaginal fistula). √ Ileum is the most common part to be involved in CD; “ileitis” but rarely forms fistula. √ Remember, in males with CD, the fistula is usually between the urinary bladder and the rectum. Key When is the repair of Inguinal Hernia required? 99 ◙ If the inguinal hernia is Reducible + Asymptomatic → No surgery is required “especially in old age”. ◙ If the inguinal hernia is Symptomatic → Repair to prevent the risk of future strangulation. ◙ If the inguinal hernia is Irreducible → Urgent repair to avoid strangulation. Inguinal hernia: Copyrights @ Plab1Keys.com 80 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) √ Above and medial to pubic tubercle. √ Impulse on cough. √ Mostly in Males. ○ Direct inguinal hernia → passes through the posterior wall of the inguinal canal directly. Lies medial to inferior epigastric artery. ○ Indirect inguinal hernia → passes through the superficial and the deep inguinal ring “passes through the whole length of the inguinal canal”. Lies lateral to inferior epigastric artery. Can descend into the scrotum. These descending into the scrotum will not trans-illuminate and it is not possible to ‘get above’ the swelling. Cases that are unclear on examination, but suspected from the history, may be further investigated using ultrasound or by performing a herniogram. Management of Inguinal Hernias (If surgery is required): ◙ First time hernias may be treated by performing an open inguinal hernia repair; the inguinal canal is opened; the hernia is reduced and the defect is repaired. A prosthetic mesh may be placed posterior to the cord structures to reinforce the repair and reduce the risk of recurrence. ◙ Recurrent hernias and those which are bilateral are generally managed with a laparoscopic approach. This may be via an intra or extra peritoneal route. As in open surgery, a mesh is deployed. However, it will typically lie posterior to the deep ring. Copyrights @ Plab1Keys.com 81 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Remember: √ Asymptomatic Gallstones → No surgery required. √ Asymptomatic Hernia (esp. in elderly) → No surgery required. √ Asymptomatic Haemorrhoids at any age and stage → No surgery required. Femoral Hernia √ More common in females. √ Below and lateral to pubic tubercle. √ usually irreducible, and with a high risk of strangulation. √ Careful: Femoral hernias need to be surgically repaired even if asymptomatic! Key A 72 YO man is scheduled to undergo transurethral resection of the 100 prostate. During pre-op examination, the doctors found a small swelling on his right groin. It is reducible, impulses on cough and not tender. The patient does not have abdominal discomfort nor constipation. What is the management of this swelling? → No surgery is required. √ This is likely an inguinal hernia and since it is asymptomatic and particularly, he is old age, no surgery is required as explained in the precious key. Copyrights @ Plab1Keys.com 82 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) √ However, he should be instructed to seek medical advice if symptoms such as pain have developed in the future. Key A 24 YO man has undergone radical orchidectomy 1 month ago for 101 testicular carcinoma. He now presents with a painful swelling in the groin that appears to be located below and lateral to pubic tubercle. What is the likely Dx? → Inguinal hernia. Although anatomically, it should be femoral hernia. However, the approach used in radical orchidectomy in adults is the (inguinal) approach. So, this patient has (inguinal hernia). Kindly note that determining the type of hernia by only physical appearance is very difficult and there are conflicting views. Key A 50 YO man had proctocolectomy 2 weeks ago. He now presents 102 with fever, malaise and abdominal pain. The patient’s history includes DM type 2 and Crohn’s disease. His temperature is 39.4, tachycardic and normal BP. What is the likely Dx? → Pelvic abscess. √ Pelvic abscess has developed here either due to CD or as a post-operative complication. √ Being diabetic increases the risk this complication. Copyrights @ Plab1Keys.com 83 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) √ Investigation → CT scan. (important) √ Rx → Drainage + Antibiotics. Key ◙ A man presents with 2 episodes of passing blood per rectum after 103 defecation. There is no pain. There are splashes of blood around the toilet bowl and streaks of blood on the toilet paper. The likely Dx → Internal haemorrhoids “piles”. To diagnose? → Proctoscopy or rigid sigmoidoscope. ◙ A man presents with severe pain in anus especially on defecation, blood streaks on the stools and Hx of constipation. The likely Dx → Anal Fissure. IMPORTANT NOTES: ♠ Haemorrhoids → Blood + Intermittent, bearable “tolerable” pain or painless, splashes of blood. (internal hemorrhoids are usually painless unless they have started to prolapse out). ♠ Perianal Abscess → Throbbing pain, swelling, Usually No blood. ♠ Anal fissure → Intense pain (unbearable), acute pain, streaks of blood. Copyrights @ Plab1Keys.com 84 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Key Splenectomy Vaccines in the UK 104 ◙ Pre-splenectomy: Pneumococcal + Meningococcal vaccines. ◙ Post-splenectomy: influenza vaccines. This is the regimen: 4-6 weeks before splenectomy, they would receive pneumococcal and meningococcal vaccines. However, if it is an emergency splenectomy and there was no time to give pre-splenectomy vaccines, then, read the following: Very IMPORTANT: What if the patient DID NOT receive pre-splenectomy vaccines? If the patient did not receive pneumococcal vaccine before splenectomy (eg, in emergency splenectomy), the most crucial vaccine to be given post splenectomy (after operation) is → Pneumococcal vaccine. √ Additional notes: √ Pneumococcal and Meningococcal vaccines are also given every 5 years after splenectomy. √ All patients with asplenia or hyposplenia should receive annual influenza vaccine due to the high risk of 2ry bacterial infection. The best time is autumn (October, November) before the onset of the “peak flu season”. Key An elderly patient + Tenesmus (feeling of incomplete defecation) + 105 Altered bowel habits (constipation alternating with diarrhea) + Blood per rectum: Think → Colon or Rectal cancer. Copyrights @ Plab1Keys.com 85 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) In the case of diverticulitis, there is usually lower left abdominal pain + Fever + Tachycardia. Take a look at the following example: A 60 YO ♀ presents to the ED complaining of passing large amount of bright red blood + Left lower abdominal pain for 2 days that is worse after eating + Nausea but with no vomiting. The patient’s main diet is canned meat. There is localised left lower abdominal tenderness without rigidity or rebound tenderness. On examining the rectum, blood is found on the examiner’s glove. Vital signs: (BP: 85/55), (HR: 105), (Temperature: 38°C), (RR: 19). ◙ The likely diagnosis → Bleeding diverticulitis. ◙ The most appropriate step → Urgent admission to the surgical ward. ◙ The most appropriate “INITIAL” step → IV fluid (she is hypotensive). In a case of acute diverticulitis “without rectal bleeding”. E.g., there is fever, tachycardia, left iliac fossa pain, tenderness and guarding, Hx of constipation → Start IV antibiotics. Key A female patient has finished her surgery (cholecystectomy) 7 hours ago and 106 is now the surgical ward. She has nausea, blurred vision, confusion. Her vitals are stable except for hypopnea (7 breaths per minute). What is the likely cause? Copyrights @ Plab1Keys.com 86 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) → Morphine (opiates). √ Morphine overdose can cause all these side effects, including the respiratory depression (low RR). √ Atelectasis, pulmonary embolism and hemorrhage do not present with hypopnea (low respiratory rate). Key ♦ Intermittent, Burning or Stabbing Pain in one part of one breast that may 107 radiate to axilla, no palpable masses or lumps and no enlarged LNs → Non-cyclical Mastalgia → Gabapentin/ Amitriptyline can be useful. Important: ♦ If there is a mention of an association with menstruation (the pain increases a few days before the menstrual cycle and subside after it), No lumps, but there may be swelling and tenderness in both breasts. → Cyclical Mastalgia. → Advise her to wear a supportive bra. √ Another valid answer: → Advise her to wear a better fitting bra during the day and a soft support bra at night. √ Another valid answer: Copyrights @ Plab1Keys.com 87 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) → Advise her to take paracetamol. √ If the pain is unilateral and there are lumps, nodularity, and is related to menstruation, think of Fibroadenosis. If the pain is bilateral, no lumps, and is related to menstrual cycles, think of cyclical Mastalgia. Breast pain (Mastalgia), ↑ breast size, lumpiness (nodularity) of the breast, ♀ in the reproductive age, tends to appear just before or during menstrual cycle and disappears after it → Fibroadenosis. Key Which of the following is an absolute contraindication to elective 108 surgery? A) Recent MI. (within the last 6 months) B) Previous Pulmonary Embolism (done 2 years ago). C) Uncontrolled DM. d) Uncontrolled HTN. e) Anemia. Copyrights @ Plab1Keys.com 88 | P a g e [ G e n e r a l S u r g e r y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Key After hemicolectomy, or Rectal Resection and anastomosis, one of the 109 common and feared complications is → Anastomotic Leak (Leakage of luminal contents at the site of anastomosis). - It usually occurs 5 to 10 days after the surgery. - It presents with severe, generalized abdominal pain and tenderness over the site of the anastomosis + fever + reduced bowel sounds. ± Hypotension. - RFs → DM, smoking, immunocompromised (e.g., prolonged use of steroids such as for RA, Asthma, COPD), rectal anastomosis, peritoneal contamination). Important: Anastomotic leakage can lead to Peritonitis or Intrabdominal abscess which needs → CT scan of Abdomen and Pelvis “with contrast”. Broad spectrum antibiotics should be initiated. An important risk factor for anastomotic leakage and abscess is → DM. Key Iron deficiency anemia + Old age (>60 YO) + No other symptoms (No blood in 110 stool, constipation, or abdominal pain). If colorectal cancer is suspected, the site of the tumor would be → The right colon (Cecum). Copyrights @ Plab1Keys.com 89