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