General Surgery
A revision session for
finals
By Mr Rishi Dhir
MBChB BSc (hons) MRCS
Orthopaedic registrar, Royal London Hospital
CONTENT
The Acute abdomen
General Principles
Conditions causing acute abdominal pain
BREAK
OSCE short cases
Pop quiz
Passing the exam: tips!
Open forum
The Acute Abdomen
The Acute Abdomen
Acute pancreatitis, MI, PUD, AAA
Gastritis, splenic
disorders, LUQ
pneumonia
Cholecystitis, biliary
colic, hepatitis, RUQ
pneumonia
Renal colic
Sigmoid
diverticulitis,gynae
Appendicitis,
caecal diverticulitis,
meckels, mesenteric
adenitis, gynae
Pelvic (PID, ectopic, ovarian
cyst, strangulated hernia,
cystitis, psoas abscess
General principles
Colicky pain: spasms of pain due to peristaltic waves trying to overcome
blockage of hollow viscus e.g. ureter, appendix, bowel, gall bladder
Peritoneum: double layered serous membrane that lines organs (visceral)
and abdominal wall (parietal). Inflammatory process affects visceral first
then parietal
Visceral peritoneum localises to embryological root, parietal is dermatomal
Foregut (mouth to 2nd part duodenum) pain localises to epigastrium
Midgut (2nd part duodenum to transverse colon) to umbilicus
Hindgut (transverse colon to rectum) to suprapubic region
Peritonitis: features
T : Tenderness (and tachycardia)
R : Reflex guarding (progresses to rigidity)
A : Absent (or reduced) bowel sounds
P : Pyrexia
P : Percussion pain (better than rebound)
E : Extremely unwell (shallow resps)
D : Distant-local sign (distant palpation-local tenderness e.g.
Rovsings sign)
Acute appendicitis
Anatomy: Vermiform appendix
Hollow blind-ending tube with end-arterial supply
Majority (>70%) retrocaecal, also pelvic and ileal
Acute appendicitis
Epidemiology
- Sex: more common in men than women
- Age: peaks in adolescence, rare in neonates and geriatrics
Differentials
- Paediatric: Mesenteric adenitis.
- GI: Gastroenteritis, diverticulitis
- Urological: UTI, renal colic
- Gynae: Ectopic pregnancy, PID, dysmenorrhoea, ovarian cysts
Complications
- perforation, peritonitis, appendix abscess
Acute appendicitis
CLINICAL PRESENTATION
SYMPTOMS:
- Pain: (general becomes localised acute), dull colicky)
- Systemic upset: Anorexia, malaise, lethargy, vomiting
SIGNS:
- Rebound, guarding, McBurneys point
- Rovsings Sign, Psoas Sign, Obturator sign
Acute Appendicitis
OBTURATOR SIGN
PSOAS SIGN: pain on hip
extension
Acute Appendicitis
INVESTIGATIONS
Bloods: FBC, U+E, CRP
Urine: bHCG, urine dipstick
Imaging: erect CXR, USS (abdo/pelvic), CT
Laparoscopy
MANAGEMENT
Resucitate, consider antibiotics (caution!)
SURGICAL (Open/laparoscopic)
LANZ / GRID IRON incision
Pancreatitis
Pancreas: endocrine and exocrine organ: AUTODIGESTS ITSELF!
Foregut structure
Acute or chronic
Causes of acute pancreatitis:
GET SMASHED
Gallstones
Steroids
Ethanol
Mumps
Trauma
Autoimmune
Scorpion bite
Hyperlipidaemia, hypercalcaemia, hypothermia
ERCP
Drugs e.g. thiazide diuretics
Acute Pancreatitis
COMPLICATIONS
Local: pancreatic pseudocyst, chronic pancreatitis,
pancreatic abscess
Systemic: Respiratory, Cardiovascular, Renal, Endocrine
CLINICAL PRESENTATION
Symptoms: severe epigastric pain radiating to back,
anorexia, vomiting, unwell
Signs: pyrexia, grey Turners, Cullens sign
Acute pancreatitis
Cullens sign
Grey Turners sign
Acute pancreatitis
Investigations
- Bloods: FBC, U+E, LFTs, serum calcium, amylase and
lipase, ABG
- Imaging: erect CXR, AXR, Abdo USS, CT abdomen
Sentinel loop sign
cut off sign colon
Acute Pancreatitis
MANAGEMENT
-
Resuscitate (fluid balance is key) in correct setting
Essentially supportive: analgesia, rest pancreas, remove cause and allow it to recover
Severity score (GLASGOW Criteria) Mnemonic: PANCREAS
P - pO2 <8kPa
A - Albumin < 32g/l
N - Neutrophil count (WCC) > 15 x 109
C - Calcium < 2mmol/l
R - Raised urea > 16mmol/l
E - Enzymes (AST >200iu/L / LDH > 600iu/L)
A - Age > 55
S - Sugar (glucose) > 10mmol/L
--
Chronic pancreatitis
SYMPTOMS AND SIGNS:
Epigastric pain worse on eating, exacerbating factor
Diarrhoea, nausea, vomiting, malnutrition
Diabetes
Steatorrhea
INVESTIGATIONS:
Bloods: enzymes (amylase, lipase, trypsinogen)
Stool tests: faecal fat test
Imaging: Abdo CT, USS, ERCP, MRCP
MANAGEMENT:
Resuscitate, analgesia, remove underlying cause and allow pancreas to recover
Gall Bladder Anatomy
Stores and concentrates bile
produced by liver
Contracts by CCK
Bile emulsifies fat
Blood supply to gall bladder
= cystic artery
Gallstones
Types: cholesterol (70%), pigment (30% cholesterol mainly bilirubin and calcium salts),
mixed
Risk factors: overweight, age, female sex, haemolytic anaemias
COMPLICATIONS
stones in gall bladder: biliary colic, acute cholecystitis, chronic cholecystitis (porcelain
gallbladder), Mirizzis syndrome
stones in CBD: obstructive jaundice, ascending cholangitis
stones in gut: paralytic ileus (impacts in ileocaecal valve)
Adjacent structures: acute pancreatitis
BILIARY COLIC
Abdo pain: General epigastric pain localises to RUQ, can
radiate to shoulder tip, exacerbated by fatty foods
Associated symptoms: nausea, vomiting
Ix: Bloods (normal WCC, may be abnormal LFTs)
USS: shows gallstones and CBD dilatation
MRCP and ERCP
Mx: resuscitate, rest (nbm), analgesia, tx gallstone
(surgery)
Key: no antibiotics as no superimposed infection
ACUTE CHOLECYSTITIS
Blockage with superimposed infection
CLINICAL
Symptoms: RUQ pain, unwell, shock, jaundice
Signs: Murphys sign, fever
INVESTIGATIONS
Bloods: Raised WCC, CRP, Abnormal LFTs
USS, MRCP, ERCP
MANAGEMENT
Resuscitate, rest (nbm), antibiotics, surgery
Surgery for gallstones
ERCP: extract gallstone (1% risk pancreatitis)
Cholecystectomy
Laparoscopic or open (Kochers incision)
Acute (<72hrs) = hot or interval (>6 wks)
Complications of procedure: bile leak, bile duct injury, bleed
(liver bed/cystic artery), abscess
Cholecystectomy
Identify calots triangle
Cystic artery runs in triangle
Clip cystic artery and cystic duct then
remove gall bladder from liver bed
Diverticulitis
DEFINITIONS
Diverticula : outpouchings of the colon wall
Diverticulosis: presence of diverticula
Diverticulitis : Results if diverticula become inflamed
Diverticulitis: the disease of
Western diet!
AETIOLOGY
Older patients (>40)
Low fibre diet
Increased colonic intraluminal pressure
Weakness where blood vessels perforate taenia coli
Most common site is sigmoid colon
Complications of diverticular
disease
Obstruction
Perforation / peritonitis
Bleeding
Diverticulitis
Diverticular abscess
Fistula (e.g. pneumaturia)
Strictures
Diverticulitis
SIGNS AND SYMPTOMS:
Classical triad: LIF pain, pyrexia, leucocytosis
Complications (PR bleed, peritonitis, obstruction)
INVESTIGATIONS:
Basic Ix: bloods, Erect CXR
CT
Note: sigmoidoscopy and barium enema contraindicated acutely as
risk perforation
Diverticulitis
MANAGEMENT
Initial acute: Resuscitate, rest (nbm) and IV antibiotics
Treat complications
Surgery: Emergency (Hartmans) v Elective (6/52)
Low residue diet after acute episode
Bowel Obstruction
Small v large bowel
Causes: intraluminal, wall, extraluminal
Classical 4: constipation, vomiting, pain and distension
Tympanic abdomen, tinkling / no bowel sounds
Ix: Bloods, AXR, CT, barium enema/follow through
Mx: nbm, drip and suck, surgical (treat cause)
Key: avoid stimulants if mechanical obstruction
In virgin abdomen, strong suspicion for cancer!
Subacute Bowel Obstruction
Inflammatory bowel disease
Crohns
1. Any part of gut (most commonly
terminal ileum)
Ulcerative colitis
1. typically Colon only (can affect
terminal ileum)
2. patchy inflammation (skip)
2. Continuous inflammation
3. Transmural inflammation
3. Shallow, mucosal
4. Perianal involvement common
4. Perianal rare
5. Rectal involvement uncommon
5. Rectal involvement common
6. Terminal ileum common
6. Terminal ileum rare
Inflammatory Bowel disease
COMPLICATIONS
LOCAL
- Crohns: adhesions, strictures, SBO, fistulae, abscesses
- UC: obstruction, perforation, toxic megacolon, colorectal ca
EXTRAINTESTINAL
- arthritis, uveitis, malnutrition, delayed growth, dermatological (pyoderma
gangrenosum), neurological (peripheral neuropathy, seizures)
What is the diagnosis?
What are the main findings on investigation?
How would you manage this?
Ischaemic bowel: the silent
killer!
Definition: ischaemic bowel injury in distribution SMA/SMV.
Range from reversible dysfunction to transmural necrosis
Aetiology: SMA thrombus/embolus, SMV thrombosis, non-occlusive
mesenteric ischaemia (any cause of shock).
3 phases
1. Hyperactive: abdo pain and PR bleed (reversible)
2. Paralytic: increased pain, decreased motility causing ileus
3. Shock: fluid loss through damaged colon (metabolic acidosis)
Ischaemic bowel: the silent
killer!
CLINICAL
Early: non specific abdo pain (out of proportion to tenderness),
PR bleed
Late: abdo distension, malaena, haematemesis, shock
INVESTIGATIONS
Bloods (raised WCC), ABG (lactic acidosis)
Imaging: AXR: thumbprinting, CT
Colonoscopy / flexi-sigmoidoscopy +biopsy
Laparotomy
Ischaemic bowel
MANAGEMENT
Supportive: ABC, nbm, IV fluids, oxygen
Medical: antibiotics, trial of anticoagulant or thrombolytic (if
no signs infarction)
Surgical: laparotomy (if signs infarction) and bowel
resection and anticoagulate post-op
Renal colic
Types: calcium oxalate (75%) and uric acid (5-10%)
Loin to groin pain, colicky, vomiting, haematuria, UTI
Complications: UTI, ARF, hydronephrosis and stricture
Ix: Bloods: FBC, urate, ca, CRP
Urine dipstick: UTI, haematuria
Imaging: IVU, CTKUB
Mx: conservative: analgesia, rehydrate, diet control
Medical: tamsulosin
Surgical: ESWL, Ureteroscopy +/-stent, nephrostomy
OSCE SHORT CASES
SURGICAL SCARS
STOMAS
HERNIAS
GROIN LUMPS
SCROTAL LUMPS
NECK LUMPS
NAME THAT SCAR!
NAME THAT SCAR
STOMAS
Definition: Greek for mouth
Classify by type: colostomy, ileostomy, urostomy
Classify by function: end v loop; temporary v permanent
Uses of stoma: FLEDD Mnemonic
Feeding, Lavage, Exteriorisation, Decompression, Diversion
Complications: electrolyte disturbance, prolapse, necrosis,
obstruction, stricture, retraction, psychosexual
Good stoma care with stoma nurse, education and
counselling vital
COMPLICATIONS OF
STOMAS
What are the differences between ileostomy and colostomy?
Differences between
colostomy and ileostomy
Ileostomy
Colostomy
1. Small calibre
1. Large calibre
2. Spouted
2. Flush with skin
3. Contents of effluent- watery
3. Semi-solid/faecal contents
4. Continuous output
4. Intermittent output
5. Site- RIF
5. Site- LIF
HERNIAS
Definition: protrusion of viscus and coverings through defect
in abdo wall from containing compartment to another
Types: umbilical, paraumbilical, inguinal, femoral, epigastric,
spigellian, richter, incisional, diaphragmatic
HERNIAS
AETIOLOGY: congenital and acquired
Acquired: intra-abdo pressure (pregnancy, obesity, lifting/straining, COPD) or
weakening of wall (previous surgery, age, Ehlers-Danlos, malnutrition)
Symptoms and signs: pain, lump on coughing, complications (severe pain, fever,
nausea and vomiting)
COMPLICATIONS: bowel obstruction, strangulation or incarceration
DIAGNOSIS: clinical
MANAGEMENT: surgical (usually elective, emergency if complications or early repair
if at risk e.g. femoral)
INGUINAL HERNIAS
75% of abdominal hernias
Anatomy of anterior abdominal wall
Recti enclosed in rectus sheath
formed by aponeuroses of 3 flat
muscles
Sheath becomes deficient posteriorly
below arcuate line of Douglas
Anatomy of inguinal canal
4 walls
Contents: ilioinguinal nerve (L1) and spermatic cord or
round ligament
Contents of spermatic cord (rule of 3s)
Inguinal hernias
Direct
Indirect
1. More common in elderly
1. More common in younger
2. Caused by defect in wall
2. Caused by PPV
3. Reduces straight back
3. Reduced upwards and lateral
4. Not controlled by pressure
4. Controlled by pressure over
over deep ring
5. Medial to inf epigastric a
deep ring
5. Lateral to inf epigastric
6. May extend to scrotum
6. Doesnt extend to scrotum
Differential of groin lumps
Think: GROIN ANATOMY LAYERS
1. Skin : sebaceous cyst
2. SC Fat : lipoma
3. Muscle : psoas abscess
4. Arteries : femoral artery aneurysm
5. Veins : saphena varix
6. Nerves : neuroma
7. Lymph : lymph nodes
8. Testis : ectopic testis
Scrotal Lumps
1. Inguinoscrotal hernia
2. Testicular tumour
3. Hydrocele
4. Varicocele
5. Epididymal cyst
Key Qs:
Can you get above it? No = hernia
Can palpate it separately from testis? Yes = epididymal cyst
Does it transilluminate? Yes = hydrocele
Neck Lumps
Neck Lumps
Midline
Lateral
1. Sebaceous cysts
1. Sebaceous cysts
2. Lipomas
2. Lipomas
3. Lymph nodes
3. Lymph nodes
4. Goitre
4. Multinodular goitre
5. Thyroglossal cyst / dermoid
5. Branchial cyst / cystic hygroma
cyst
6. Pharyngeal pouch
6. Vascular: aneurysm / tumour
7. Nerve: neurofibroma
Case 1
What is the diagnosis?
What are the potential complications?
How would you manage it?
Case 2
How would you manage this?
How would patient present?
What are complications?
What are the causes?
Case 3
What are the causes of this?
How would you manage it?
What are the symptoms and signs?
Case 4
What is the main x-ray
finding?
What does it indicate?
How do you manage it?
Case 5
What is the main CT finding?
What condition causes this?
Case 6
What is the diagnosis?
How would you manage it?
What is a life-threatening
complication of this?
How would you manage it?
Passing the exam: revision tips!
Preparation: revision partner, daily OSCE practice; clinics
examinations, histories, investigations
Persistence: Keep going. Its a marathon. Its not too late!
Presentation: compartmentalise your answers! Look the part!
- ABC Conservative, medical, surgical
- Surgical sieve
- Present the x ray not just the finding!
Dont memorise, learn basic principles so can work things out
Schematic for history taking
Introduction: name, age and presenting complaint
HPC: Develop symptom in detail e.g. SOCRATES
PMH: relevant medical and surgical
Drug hx and relevant FH
Social: relevant (occupation, support, risk factors)
Systemic enquiry
Common surgical history
scenarios
Acute abdominal pain: think socrates!
Change in bowel habit- nature, tensemus, PR bleed, mucous,
weight loss, time, FH
- Differential: cancer, diverticular disease, IBD, haemorrhoids
Vascular: peripheral vascular disease
Thyroid disease
Jaundice
Take a history of intermittent
claudication
HPC: is it claudication? claudication distance? Level?
Severity (Fontaine classification), Leriches syndrome
PMH: CV risk factor, interventions
Drug Hx: aspirin, statins FHx: CV disease
Social: smoking
Schematic for examinations
Introduction and wash hands, ask permission
General (end of bed, clues)
Start with hands unless specifically told
Inspection, palpation, percussion, auscultation
Look, Feel, Move (orthopaedics)
Common exam cases
Hernias
Lumps and bumps (breast, groin, testicular, skin, neck)
Varicose veins exam
Arterial disease
Ulcers (size/shape, edge, slope, base and mx)
Ortho- examine hip, knee, shoulder
Hand exam- RA, Peripheral nerves
Surgical scars
Interpretation
ABG, fluid balance chart, ECG
X-rays: chest (some bastard took my pet dog!), AXR
AXR will only be obstruction!
Post op complications: bleeding, infection, DVT/PE (takes
at least 72 hrs), anastamotic leak, collection
Immediate, early, late
Check charts (e.g. end organ perfusion- urine output, BP,
HR, neuro status; drain output and colour)
SHOCK
DEFINITION
Acute circulatory failure resulting in inadequate tissue
perfusion and cellular hypoxia. Supply does not meet
demand!
TYPES
Hypovolaemic
Cardiogenic
Obstructive (massive PE, tension, constrictive
pericarditis, tamponade)
Distributive (vasodilation) e.g. sepsis, neurological,
anaphylactic
SHOCK
Physiological terms explained:
HR (depends on SAN: autonomic control) x SV
(determined by venous return, starlings law) = CO
CO X SVR (arteriole diameter)= BP (perfusion)
3 Factors determine tissue supply: HR, SV, SVR
SHOCK
Classification of hypovolaemic shock
Markers of end-organ perfusion
Management of shock
ABCDE
Treat underlying cause e.g. fluids for hypovolaemic,
antibiotics and inotropes for sepsis, steroids and
inotropes for anaphylaxis
Thanks for listening
