23/05/2016

General surgery teaching

 Try and see:
o Appendicitis, cholecystitis, biliary colic, diverticulitis, ureteric colic, pancreatitis, PUD
o A&E in DGH
 Abdo pain:
o Site
 Visceral
 Ill-defined
 Foregut/midgut/hindgut regions
o Boundaries: 2nd part of duodenum; 2/3rd along transverse colon
 Somatic
 Parietal peritoneum involved
 Defined, localised pain
 All-over
 Peritonitis  board-like rigidity, any movement hurts (‘car ride here’)
 Abdominal distension 2o to obstruction
o Onset
 Very sudden (immediate)  perforation, infarct
 Infarct / embolic event
o Bowel, mesentery
o MI  can cause epigastric pain
 Perforation / rupture
o Peptic ulcer (GUD, DUD)
o Diverticulum
o Appendicitis
o Ectopic pregnancy ( intraperitoneal bleed)
o (Ruptured AAA)
 Intraperitoneal (die quickly) vs retroperitoneal (slower
progression, tamponade) bleed
 Usually get a gradual backache first
 Sudden  max intensity develops over 10-20 minutes
 Acute pancreatitis
 Biliary colic
 Ovarian torsion
 Moderately sudden  hours to reach peak
 Acute cholecystitis
 Hepatitis
 Pneumonia
o Character
 Burning/stabbing/sharp – not that helpful
 Gastritis, oesophagis, PUD
 Crushing/tight  cardiac
 Deep ‘boring’ pain  pancreatitis
o Radiation
 Biliary problems  phrenic  shoulder tip
 Retrosternal  oesophagitis
 23/05/2016
 Renal  loin to groin
 Retroperitoneal organs  back
 Aorta (dissection, AAA)
 Pancreas (except tail)
 Duodenum (2nd and 3rd parts) – posterior
ulcer perf into the gastroduodenal artery
 Kidneys
 Free intraperitoneal fluid (perforation, bleed) 
shouldertip pain
 ‘When I lie flat, I get pain in my shoulder’
 Get post-laproscopic surgery due to the CO2 left inside
o Associated factors
 GI disturbances (see below)
 N+V
 Diarrhoea
o Timing
 Have you had it before?
 When did it start?
 Were you woken up by it?
 Colicky
 Biliary / renal / gut  ‘hollow viscous’
o Biliary colic, ureteric colic, appendicitis, diverticular disease,
 Tubes with longitudinal and circular muscle  pain derives from muscle
contraction trying to push through
 Biliary colic vs cholecystitis
o Biliary colic
 Ongoing RUQ pain with exacerbations (so not a true colic)
 Exacerbations: fatty food, N+V,
o Cholecystitis
 Inflammatory process (temperature, tachy, sweaty)
 Infective
 Obstructive (usually self-limiting)
 Renal colic
o Clear rise and fall in pain (v characteristic)
o Haematuria, dysuria, frequency
o Pain worse at end of micturition
o Nausea, vomiting
o Exacerbating and relieving factors
 Eating – pain better or worse? Any particular foods?
 Peptic ulcer disease
o Better with milky drinks?
o GUD worse on eating; DUD worse before eating / at night
 GUD stimulating by gastric contractions
 DUD eased by alkaline secretions (hence better on eating) and
worst when high acid (at night)
 Appendicitis  do not eat
 Biliary colic  exac by fatty meals
 Biliary system  fatty meals
 Must directly ask if eating makes it worse, fatty foods in particular
 Peritonitic pain  ‘does it hurt when you cough?’
 Peritonitis or not (emergency)
 23/05/2016
 ‘Was it painful when you go over bumps in the car here?’
 Children  ask them to stand up and hop
 If severe  do not want to move
o Severity
 1-10
 Severe pain = perforated PUD, pancreatitis, ureteric colic

 GI disturbances
o Vomiting
 Frequency
 ‘how many times do you vomit’
 Volume
 ‘When you’re sick, do you fill the bowl?’
 Nauseated  vomit small amounts
 Obstruction  lots of vomit, often quite difficult to control
o Can lose 5L over 24 hours – very dehydrated and compromised
circulation (renal failure and circulatory collapse)
 Blood
 Volume
 Colour (bright vs dark)
o ‘Coffee-brown vomit’  upper GI bleeds
 Do not confuse with faeculant vomit
 When?
o Bloody straight away (varices etc) vs vomit, vomit, vomit and then blood
(MW tear)
 Nature of contents
 Look exactly what you ate yesterday?
o Gastric outlet obstruction (pylorus area)
 Duodenum blocked 
 Head of pancreas tumour
 Peptic ulceration causing stenosis
o Achalasia (lower oesophageal sphincter contracted)
 Nocturnal cough
 Aspiration (when lying down at night)
 Causes:
 Tryanosoma cruzi (infection)
 Neurological
 Unknown (most cases)
 Tx:
 Botox to lower eosophageal sphincter
 Surgical sphincter alteration – balloon dilation, myotomy
 Bilious or Faecal matter (‘faecular vomiting’)
o Usually small bowel contents
o Bowel obstruction
 Hx: ‘started of with normal vomit, then became green (bilious),
now it looks brown’
 Tx: NBM, NG tube, IV fluids, analgesia
 Causes:
 Intraluminal
o Foreign body
 Children swallow button
 23/05/2016
 Bazoas (concretions of fibrous material,
perhaps from vegetables or from eating
hair – ‘phytobazoas’ or ‘trichobazoas’
o Constipation
 Can cause pathological obstruction, even so
much to cause erosion through bowel wall
( stercoral perforation)
o Gall stone ileus (common AXR in exam)
 ‘Small bowel obstruction with air in the
biliary tree’
 Gall stone in bladder  inflammation 
pressure necrosis  fistulation between
duodenum and gall bladder  stone passes
into small bowel
 Rare but common in exams X-ray
 Transmural
o Crohn’s (stricturing) – not UC
o Diverticulitis
o Colon cancer
 R sided malignancy = Fe-def anaemia
 L sided = obstruction (more likely to cause
obstruction on the L due to anatomy
surrounding)
o Lymphoma (small bowel)
 Assoc with Coeliac disease
o Small bowel adenocarcinoma (rare)
o Radiation enteritis and strictures (v difficult to
treat) – post-radiation
o Pyloric stenosis
 6 week year old
o Ischaemic stricturing
 Arteriopath
 Aortic repair (as they have lost inferior
mesenteric artery)
 Most suspectible site = where SMA and
IMA dual supply meet
o Intussuseption (small bowel usually)
 ‘Leading point’ of bowel acts as a piece of
food; peristalsis pulls it down
 Children (prominent Peyer’s patches –
exposure to new pathogens as a child
means active lymphoid tissue; Meckel’s
also can act as leading point)
 Adults (small malignancy or lipoma can act
as the leading point)
 Extramural
o Adhesions (between 2 bits of bowel or bowel and
anterior wall) – MOST COMMON
 ‘Have they had surgery before’
 Note – not all adhesions are post-surgical;
some are congenital
o Hernias
 23/05/2016
 Femoral (less common, more likely in F,
more likely to cause
obstruction/incarceration)
 Inguinal
 Incisional (‘have they had surgery before’)
 Internal (bowel twists around adhesion, or
pushes through a split in mesentery post-
surgery)
 ‘The bigger the hernia, the less likely it is to
cause a problem’
o Volvulus
o Malignancy outside bowel (gastric, ovarian,
uterine)
 Tumour spread: lympthatic, haem, local
invasion, transthelomic (GI only)
 Risks of vomiting:
 Dehydration
 Aspiration pneumonia (hence NG tubes are useful)
 Electrolyte:
o Alkalosis
o Hypokalemia

o Diarrhoea
 Frequency
 Contents
 Colour
 Volume
 Blood
 Colour
o Bright/fresh = lower GI (or massive upper GI)
 Usually local phenomenon – left colon
 Causes:
 Diverticulitis (most likely cause of bright red blood)
o Outpouching of gut mucosa at the site where the
blood vessels go through the wall
 UC
 Malignancy (not often)
o Wt loss
o Tenesmus
o Coffee brown = upper GI (esp PUD)
 Volume
o Intricately linked to colour
 ‘Mixed in’  GI source
 ‘On the tissue’
o Perianal pathology
 Anal fissure
 = mucosal tear in perianal region (‘split’)
 Causes intense spasm of the surrounded muscle leading to
poor healing
o So when open bowels again the ‘healed scar’ tears
again
 23/05/2016
 Haemorrhoids
 Abcesses
 Perianal infections
 Locations: sphincter, ischiorectal fossa,
 Causes:
o Infection within one of the glands around the
rectum/anus
 Can be benign or spectacularly awful
 Anal sphincter:
o Internal and external
o Between the 2 sphincters you have many glands 
if these get blocked/infected = abcess  incise
 Treatment
o Drain/incise abcess
o Risks:
 Perianal Fistulae formation (abnormal
connection between 2 epithelial surfaces)
 N.B. perinal fistulaes are common in
Crohn’s
 Incontinence (if surgical error)
o Constipation

 Appendicitis
o Epidemiology
 Children
 Not elderly usually (think lower GI cancer/diverticulitis more)
 M=F
o Hx
 Periumbilical pain  localises to RIF
 Few hours – localised to RIF
 Onset?
 Colicky?
 Worse on movement
 N+V
 Not eating (will not be hungry!)
o Appearance of pt:
 Pale, clammy
 Fever
o Obs
 HR, BP, RR, Temp, O2 sat, urine dip, pregnancy test, ECG
 Low grade fever
 High grade fever  viral illness usually (URTI in children)
o Mesenteric adenitis
 Common in children
 RIF pain (so confuse with appendicitis)
 Viral
 Assoc with URTI
 Tachycardia
 BP normal usually
 Urine dip
 Rule in/out renal problem (UTI)
 23/05/2016
 NOTE  appendix can be touching the bladder (can be variable in position)
o Examination
 Tender peri-umbilical
 Rosvig’s sign
 Guarding in RLQ
 Rebound tenderness  worse when remove finger
 Will get same information by lightly percussing in the same region
 Furred tongue
 Anorexic
 DRE (always in exam)
 In case they have a purely pelvic appendix (then only way to palpate is via DRE)
o Ix
 Bloods
 CRP (ESR is more chronic inflamm e.g. RA, Crohn’s, SLE)
 FBC (WCC, ?Fe def anaemia push towards cancer esp in elderly)
 U+Es (dehydrated, baseline K level)
 Cultures (if high fever)
 Group and save
o Blood group, historically the serum was saved
o Now serum is also tested to see if you have a Abs vs different RBC Ag
 Amylase
o Pancreatitis can present in v odd ways and the Tx is NOT TO GO TO
THEATRE (hence always do)
o N.B. had to be markedly raised for pancreatitis
 LFTs
o Problems with gall bladder could cause right sided pain…
 N.B. Dx of appendicitis is usually a clinical (Hx, Ex, bloods) diagnosis, not with
imaging – hence need to rule out other things
 Imaging
 CXR
o Perforation (pneumoperitoneum)  erect CXR
o Extremes of age  can present v funnily; may have RIF pain but actually
have R lower lobe pneumonia
 U/S
o Inflamed = hyper-echoic
o May show you pelvic pathology:
 Ruptured ovarian cyst
 Food in the peritoneum
 Gall stones
o Problems:
 Caecum, lots of bowel gas  US not great through gas  hence
not ideal to Dx appendicitis
 CT
o Diagnostic
 MRI
o Pregnant women
 V hard to Dx appendicitis in pregnant women as appendix
changes position (seems subcostal or hypochrondrium region in
3rd trimester)
 Also do not want to operate on an inflamed appendix in pregnant
woman… will precipitate labour
 23/05/2016
o Mx
 Drug chart:
 Pain management (analgesia)
o Don’t want to give oral medication  gut not working optimally!
o Options:
 IV opiate (most appropriate)
 Abx
o Esp if high grade fever
o Treatment (Abx ASAP) VS prophylaxis (Abx during induction before
surgery)
 Clean operation (hop replacement)
 Clean-contaminated (appendisectomy)
 Dirty (colon surgery)
 Abx relevant for all these!
 Fluids (as nil by mouth)
o Hartmann’s
 ‘Physiological solution’  Na, Cl, K, buffers (lactate, HCO3-)
o Saline
 Normal
 5% dextrose
o Average 3L/day
 VTE prophylaxis (anticoagulants)
o LMWH (not reversible, injections)
 ?LMWH makes you less likely to thrombose but not more likely to
bleed
 N.B. warfarin is not suitable for prophlyaxis as takes time to build
up
o TED stockings
 Do not use 
 Peripheral vascular disease
o Harmful
o TED might compromise circulation enough to
cause amputations
 Diabetics (peripheral neuropathy)
o Pressure necrosis  ulceration (esp over malleoli)
o Risk factors for VTE (so increase dose of LMWH):
 Malignancy, oral contraceptive, previous DVT, smoking, obesity,
FHx, pelvic/lower limb surgery, length of surgery
o When to give less LMWH:
 Renal impairment (dialysis patients, poor kidney function)
 Surgery consent
 FY1 can do  you do not have to be part of the surgical team, but have to know
the surgery well enough to give informed consent (so OK for a straightforward
surgery such as appendisectomy)
 Anaesthetise
 Contact
 Book a theatre slot