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Generalsurgery andperioperative care MCQ questions and discussions around high yield topics Overviewofthesession ● MCQquestions ○ TakenfromPassmedicine ○ Coversmajorthemes ● Polls ○ Willshowquestiononscreen+pollstoanswerthequestions ○ Willbegivenaround60sectoanswerthequestions ○ Iwon’tpickanyoneouttoansweranyquestions! ● Learningpoints ○ OncetheanswerisrevealedwewilltalkthroughthemAbdominalpain ● Very commonpresenting ● SOCRATESnt ● Whataretheregionsofthe stomach? Righthypochondrium Epigastrium Lefthypochondrium ● Acutecholecystitis ● Pepticulcer ● Splenicabscess ● Ascendingcholangitis ● Pancreatitis ● Splenicrupture ● Hepatitis ● GORD ● Pneumonia ● Pneumonia ● ACS Diffuseabdominalpain/umbilical Rightflank ● Peritonitis Left flank ● Renalcolic ● Ischemicbowel ● Renalcolic ● Pyelonephritis ● Pyelonephritis ● Polycystickidneydisease ● Obstruction ● Polycystickidneydisease ● RupturedAAA ● IBS ● IBD Rightiliacfossa Suprapubic Leftiliacfossa ● Appendicitis ● Cystitis(UTI) ● Diverticulitis ● Uretericcolic ● Gastroenteritis ● Uretericcolic ● Ectopicpregnancy ● Urinaryretention ● Ectopicpregnancy ● Inguinalhernia ● Endometriosis ● Inguinalhernia ● Crohn’sdisease ● Pelvicinflammatorydisease ● Ulcerativecolitis ● Ovariantorsion ● InguinalherniaGuarding vs rebound tenderness? Whatisguarding? Whatisreboundtenderness? ● Thereisvoluntaryandinvoluntary ● Whenrapidlyremovingyourhandafter ● Voluntaryguardingisvoluntarycontraction deeppalpationincreasespain oftheabdominalmuscleswhenthereis ● Canbeanothersignofperitonealirritation pain ● Involuntaryguarding(alsocalledrigidity), occurswhenpalpatingcausestenderness andrigidity,oftenduetoinflammationof theparietalperitoneum ● Theseincludeperforationswhichcause abdominalcontentstoirritatethe peritoneum,andappendicitisQuestion 1Answer 1 ● Whatarewerulingoutwiththepregnancytest? ● Ectopicpregnancy ● Eveniftheydenybeingsexuallyactive,ALWAYS do apregnancytestinawomanofchildbearing agewithabdominalpainregardlessofonset ● Whywouldshehaveperitonitisinthiscase? ● Possiblerupturedectopic,causingabdominal organcontentstoirritatetheparietalperitoneum ● Alltheothertestsarereasonablebutapregnancy testshouldalwaysbedonefirst ● Whataretheotherpossibledifferentialsforthis lady? Keypoint: Alwaysdoapregnancytestin ○ Ovariantorsion anyfemalepatientof ○ Renalcolic? child-bearingagepresenting ○ Ulcerativecolitis? withabdominalpainQuestion 2Answer 2● Thenegativeurinarypregnancytestand dipstickrulesoutectopicpregnancyandUTI ● Notopeningbowelsfor24hoursisnot necessarilyasignofobstructionbecauseits just24hours ● Appendicitiscancausesomedysuria ● Sheisnotintheagegroupthatusuallyget diverticulitis ● Mittelschmerzispainonovulationwhich usuallyoccursmid-cycle(forsomeonewitha 28daycycle,itwillbeday14)AppendicitisAppendicitis Symptoms: Diagnosis: ● Howdoesthepainclassicallypresent? ● Usuallyclinical ○ Periumbilicalpainwhichthenmigratesto ● Mayshowraisedinflammatorymarkerson theRIF bloods ○ Painworseoncoughingandmovement ● Bloodsmayalsoshowhighneutrophils ○ Nauseaandvomitingcommon ○ Mildpyrexia(37.5-38) ● Dopregnancytestandurinediptoruleout ● Whatisasignspecifictoappendicitis? othercauses ○ Rovsing’ssign Treatment: ○ WhenpalpatingtheLIFelicitspaininthe RIF ● Appendicectomy+prophylacticIVabxQuestion 3Answer 3Inguinalvsfemoralhernias ● Inguinalherniasaresuperiorandmedial tothepubictubercle ● Femoralherniasareinferiorandlateralto thepubictubercle Incarceratedvsstrangulatedhernias ● Inanincarceratedhernia,contentsare notreducible ● Inastrangulatedhernia,contentsarenot reducibleandischaemicduetoacutoff bloodsupply,oftenpresentswithpainand erythemaQuestion 4Answer4Inguinal canal ● Whatistheinguinalcanal? ○ Passagewaythattransmitsstructuresfromthe abdomentotheexternalgenitaliaandpelvis ● Bordersoftheinguinalcanal:MALT ○ Muscles(roof),aponeurosis(anteriorwall), ligaments(floor),tendon(posteriorwall) ● Inguinalcanalstartatthedeepinguinalring andendsatthesuperficialinguinalring ○ Deepring:midpointoftheinguinalligament, betweentheASISandPT ○ Superficialring:abovethepubictubercle ● Contentsoftheinguinalcanal ○ Ilioinguinalnerve(L1),genitalbranchof genitofemoralnerve(L2),roundligamentofthe uterus(females),spermaticcord(males)Direct vs indirect inguinal hernia ● Abdominalcontentsforced‘directly’througha ● Abdominalcontentsentertheinguinalcanal defectintheposteriorwalloftheinguinalcanal throughthedeepringandtravelalongtheentire ● ThisareaofweaknessisalsocalledHesselbach’s lengthofthecanalbeforeexitingthroughthe triangle superficialring ● Theherniaenterstheinguinalcanalthroughthe defectwhichismedialtothedeepringandfurther downthecanalHowto tell the difference in clinical examination? ● Askpatienttoliedownflat ● Tryandreducetheherniabyapplyingpressure andpushingtheherniaupallthewaytothe midpointoftheinguinalligament ● Whichisthelocationofthedeepring ● Withhandpressedonthedeepinguinalring,if theherniaisstillreduced,mostlikelyitsan indirecthernia ● Iftheherniaprotrudes,thismeansthatthe herniais‘directly’protrudingthroughthedefect ontheposteriorwall,henceadirectherniaQuestion 5Answer 5● Whatispatientpresentingwith? ● Anasymptomaticinguinalhernia ● Currentguidelinesrecommendtreatmentevenif patientisasymptomatic ● Forunilateralhernias,anelectiveopenrepair withmeshisrecommended ● Forbilateralhernias,alaparoscopicapproachis recommendedQuestion 6Answer 6● Whatpartofthehistorymakeusthinkobstruction? ○ Notpassingwindin12hours,notjustfaeces ● Amylasecanberaisedinalotofpathologyandinthis caseitisn’thighenoughforpancreatitis(3xupper limit),alsotheclinicalpictureofnotpassingwindand faecesdoesnotfit ● Howtodifferentiatelargeandsmallbowel obstruction? ○ Vomitinginsmallbowelobstructioncanbe biliousbutitdoesnotstateinthiscase ○ Insmallbowelobstruction,vomitingiscommon whileinlargebowelobstruction,vomitingisa latesign ○ Anotherpartofthehistoryiskeybutwewill discussthatinthenextquestionQuestion 7Answer 7Bowel obstruction Smallbowel Largebowel Symptoms: Symptoms: ● Diffuse,centralabdopain ● Constipationwithlackofflatulence ● N&V(typicallybilious) ● N&V(usuallyalatesign) ● Constipationwithlackofflatulence ● Abdominalpain ● Abdodistentionpossible ● ‘Tinkling’bowelsoundsonauscultation ● Abdominaldistention ● Featuressuggestingcoloncancer Causes: (weightloss,rectalbleedingetc) ● Adhesions Causes: ● Hernias ● Tumour ● Volvulus ● DiverticulitisBowel obstruction Thingstothinkaboutwhenpatientpresentingwithobstruction: ● Considertheclinicalcontextineverysituation ● Lookforhistoryofprevioussurgeries(especiallyofthesmallbowel),thatwouldsuggestadhesions ● Lookforsignsofcolorectalcanceraswell(weightloss,rectalbleeding,etc) ● Ageplaysaroleaswell,alwaysthinkofcancerinolderpatientspresentingwithobstruction ● Seriouscomplicationofobstructionisperforation,soifpatientisinalotofpainandtherearesignsof peritonitis,considerinvestigatingforperforationQuestion 8Answer 8Question 9Answer 9Bowel obstruction investigations ● Abdominalx-rayisstillcommonlyusedfirst-lineforbothsmallandlargebowelobstruction ● Onx-ray,whatdiametersofsectionsofbowelissignofobstruction? ○ Smallbowel:>3CM ○ Largebowel: ■ >10-12cmforcaecum ■ >8cmforascendingcolon ■ >6.5cmforrectosigmoid ● Definitiveinvestigation:CTscan ○ Highsensitivityandspecificityforobstruction ○ Canalsoidentifyaetiology ● AXRcanalsoidentifyperforationandfreeairintheabdomen.Whatarethesesigns? ○ Pneumoperitoneum ○ Rigler’ssign ○ LucentliversignQuestion 10Answer 10● Thisquestionistoremindusnottoforgetabout otherimportantdifferentialinpatientspresenting withabdominalpain ● PatienthasriskfactorsforACS-obesity,smoking, hypertension,hypercholesterolaemia ● Sweatingnauseaandbreathlessnessalsopoint towardsACS ● Alltheotherinvestigationswouldbeappropriate tolookforothercausesofabdominalpainbut wouldnobefirst-lineinthiscaseQuestion 11Answer 11Dysphagia/dyspepsia referral criteria ● AllpatientspresentingwithdysphagiarequireanupperGIendoscopyunder the2WWreferralregardlessofage ● Otherteststhatshouldbedoneincludebloodsandabariumswallowbutthis shouldnotdelaytheendoscopy ● Othersymptomsthatmeet2WWcriteriaforupperGIendoscopy: ○ Patientswithupperabdominalmassconsistentwithstomachcancer ○ Patientsaged>=55withweightlossANDanyofthefollowing: ■ Upperabdopain ■ Reflux ■ DyspepsiaQuestion 12Answer 12● Thekeyhereisdysphagiaaffectingbothsolids andliquidsfromthestart ● Achalasiaisthefailureofrelaxationofthe loweroesophagealsphincter ● Oesophagealcancerwouldtypicallypresent withdysphagiathatstartswithsolidsandlater progressestoliquids ● Pharyngealpouchwouldclassicallyhave gurglingsoundsandhalitosis(badbreath) ● Oesophagealstricturealsousuallystartswith solidsandthencanprogresstoliquidsQuestion 13Answer 13● Patientispresentingwithdysphagiathatis progressivelygettingworse,startingwithsolids ● Althoughthereisnoweightlossthebariumswallow showsandirregularnarrowingoftheoesophagus ● Achalasiawouldtypicallypresentwithanexpanded oesophagus,fluidlevelandbird'sbeakappearance.Dysphagia causes Neuromuscular causes ● Stroke (usually presents with difficulty ● MND initiating swallowing) ● Myasthenia gravis ● Parkinson’s Obstructive causes ● Oesophageal cancer (usually presents with difficulty ● Oesophageal stricture swallowing solids, then may progress to ● Pharyngeal pouch liquids too, feels like something stuck)● External oesophageal compression ● Hiatus hernia Motility dysfunction causes ● Achalasia (usually presents with difficulty ● CREST syndrome swallowing both solids and liquids from the start)Pre-operative preparation Whatdoweneedtothinkaboutandprepareforapatientbeforetheygointo surgery? ● DVTprophylaxis ○ VTEriskassessment+SCDaltaperin ● Infectionprevention ○ Someoperationsrequireprophylacticabx:prosthesisorvalve,contaminated surgeries ● NBMbeforesurgery ● Diabetesandinsulin ● SpecificmedicationMedications pre-op Whataresomeoftheimportantmedicationsweneedtothinkaboutbefore surgery? ● Anticoagulants ● COCP ● Long-termcorticosteroidsQuestion 14Answer 14WhydowestoptheCOCP4weeks prior? ● ToreducetheriskofVTEQuestion 15Answer 15● Patientisonlong-termsteroidstotreather GCA ● 30daysormoreisusuallyconsidered long-term ● Long-termsteroidssuppressthe hypothalamic-pituitary-adrenalaxis,soat timesofstresslikeduringsurgery,theadrenals can’trespondappropriately ● ThereforehydrocortisoneIV isgivenfor moderatetomajorsurgeryMedications pre-op Whataresomeoftheimportantmedicationsweneedtothinkaboutbefore surgery? ● Anticoagulants ○ Warfarin:monitorINRandensurenormalbeforeop,otherwisecanusevitK ○ DOAC:stopped24-72hrsbeforesurgery ○ LMWHcanbeusedtobridgethegapinhighriskpatients(recentVTW,mechanicalvalve) ● COCP ○ Stop4weekspriortoop ● Long-termcorticosteroids ○ Needtodealwithadditionalstressfromsurgery ○ AdditionalIVhydrocortisoneatanaesthesiainductionandimmediatepost-opperiodQuestion 16Answer 16Whydopatientsneedtofastbeforesurgery? ● Toreducerefluxandaspirationduringop ● Non-clearliquidsorfood:atleast6hoursbeforesurgery ● Clearfluids:atleast2hoursbeforesurgery ● Generalrule:alwaysconsiderkeepinganacutelyunwellsurgicalpatientnil-by-mouth withIVmaintenancefluidsincasetheyrequireanemergencyoperationThank you! Anyquestions→ joshua.williams@student.manchester.ac.uk luqman.aizan@student.manchester.ac.uk Pleasefilloutthefeedbackform! NextsessionisthisThursday onNeurosurgery!