random thoguhts

Surgery Notes

surgery notes

  • the point of this document is to have an overview of topics and top level summary of surgery rotation sessions. keep in mind this document is Not extensive to everything you might be asked about during osce or final year exams.
  • due to time constrains there are some errors ... if you like to report it , dm @itsuhaibalrumi on telegram or email me at [email protected]
  • enjoy learning :)

sources

C2 syllabus [[6s-surgery-syllabus-2025.pdf]]

→ [[surgery logbook 2025.pdf]]

/ content
wk1 ---
sun ⏯ Abdominal Pain Hx , PE, General PE
mon Gallbladder disease, Pancreatic disease, Intestinal obstruction (*Operative & Surgical Emergency)
tue ⏯ Wound Mx + Biliary diseases + Ascites Stomas & colostomies + ⏯1 (Inguinal masses) + Patients with abdominal pain (acute abd., appendicitis)
wedn ⏯ Breast : Abscess , Benign & malignant tumors.
Surgical emergency : Peptic ulcer disease, Perforated viscus , Acute appendicitis.
thurs ==Orthopedic Surgery==
wk2 ----
sun Lower Abdominal Pain , Perioperative preparation, cholangitis & obstructive jaundice.
mon ⏯ ATLS
tue ⏯ Anal Pain , Anal Lump , ⏯ (Fluid, electrolytes and acid-base balance , Instruments.)
wedn ⏯ Goiture , Thyrotoxicosis & myxedema , Neck Swelling & Cervical lymphadenopathy.
thurs ==Urosurgery==
wk3 ---
sun Abdominal Pain Hx , PE, General PE
mon ⏯ Surgical Emergency + Upper & Lower GI Bleeding + PUDs
tue Hernias + Divarication of the recti + Surgical Emergency
wedn Surgical Emergency + Burn + Thyroid & Parathyroid Diseases
thurs ==Radiology==
wk4 ---
sun The rectum and anal canal : ano-rectal disease Hx , ano-rectal Exam , Upper & Central abdominal pain - acute and/or chronic. Symptoms and signs resulting from the perforation of a viscus.

==Urosurgery==
mon ==Orthopedic Surgery==
tue ==Radiology==
wedn ==Surgical emergencies in ENT==
thurs ==Vascular - Hemorrhage & Chest trauma==
wk5 ---
sun ==Radiology==
mon ==Urosurgery==
tue ==Orthopedic Surgery==
wedn ==Ophth Sugery==
thurs ==OFF== - Vascular Upper & Lower venous & arterial Circulation Assessment
wk6 ---
sun ==Orthopedic Surgery==
mon ==Radiology==
tue ==OFF== - ==Urosurgery==
wedn ==Orthopedic Surgery==
thurs ==Vascular -Diabetic foot + thoracostomy tube insertion==
wk7 ---
sun ⏯ Wound Mx + Biliary diseases + Ascites Stomas & colostomies + ⏯2 (Inguinal masses) + Patients with abdominal pain (acute abd., appendicitis)
mon ⏯ Breast : Abscess , Benign & malignant tumors.
Surgical emergency : Peptic ulcer disease, Perforated viscus , Acute appendicitis.
tue 〇 Surgical Emergency
〇 Types of skin incisions
〇 Post-operative confusion & fever.
〇 Drains & instruments.
〇 Carcinoma of the thyroid gland & Thyroiditis.
〇 Parathyroid disease
wedn 〇 Lump Hx & PE
〇 Ulcer Hx & PE
〇 Salivary Glands Hx & PE
〇 Inguinal , Femoral Hernia
thurs ==Neurosurgery==
wk8 ---
sun ⏯ Surgical Emergency + Upper & Lower GI Bleeding + PUDs.
mon 〇 Surgical Emergency
〇 Peptic ulcer disease
〇 Perforated viscus.
〇 Acute appendicitis.
〇 Pancreatic diseases.
tue ⏯ Abdominal Pain Hx , PE, General PE
✚ Burns & Operative
wedn ⏯ Anal Pain , Anal Lump , Fluid, electrolytes and acid-base balance , Instruments.
thurs ==Neurosurgery==
wk9 ---
sun ⏯ Goiture , Thyrotoxicosis & myxedema , Neck Swelling & Cervical lymphadenopathy.
⏯ ATLS
mon ⏯3 (Inguinal masses)(RIF&LIF)
⏯ (Fluid, electrolytes and acid-base balance , Instruments.)
tue ⏯ ATLS
wedn ⏯ Breast : Abscess , Benign & malignant tumors.
Surgical emergency : Peptic ulcer disease, Perforated viscus , Acute appendicitis.
thurs ==Neurosurgery==
wk10 ---
Tue & Wedn EXAM (GS + Vascular + Slides) → 1st Day
EXAM (Ortho + Uro + Neuro + Radio) → 2nd Day

General Surgery

S01 : [[2025-11-30]],

A. General Exam

B. Abdominal Exam

C. Abdominal Pain Approach

Acute Abdominal Pain in Adults - Approach to the Patient: https://www.dynamed.com/topic/T912361

Abdominal pain and masses

  1. History (Hx)

A full history is a vital skill in the management of acute abdominal pain.

History Component Key Features to Elicit Supported Sources
General Approach Begin with observation. Use open questions first ("Tell me in your own words how it all started") to gather information, resorting to direct/leading questions only in emergencies. Note past history, especially prior operations (e.g., risk of adhesive obstruction). A full gynecological history should be taken in female patients.
Pain Characteristics Assess the pain using features like Site, Character, Onset, Progression, Severity, and relieving/exacerbating factors.
Site of Pain The site is perhaps the most valuable pointer. Pain from foregut structures (stomach, duodenum, biliary tree, pancreas) is felt in the epigastric area. Pain from midgut (small bowel, appendix, proximal colon) is felt around the umbilicus/central abdomen. Pain from hindgut (distal colon, rectum, bladder) is felt in the hypogastrium/suprapubic area.
Character of Pain Constant pain is associated with inflammation (e.g., appendicitis, cholecystitis), ischemia, infarction, or neoplastic infiltration. Colicky pain (severe, griping pain interspersed with periods of little or no pain) suggests obstruction of a muscular conducting tube (e.g., ureteric colic, biliary colic, intestinal obstruction).
Onset and Progression Sudden onset suggests perforation or vascular rupture/infarction (e.g., perforated viscus, ruptured abdominal aortic aneurysm). Gradual onset suggests inflammation. Movement of pain is classic in acute appendicitis, starting vague/periumbilical (visceral) and moving to the right iliac fossa (somatic).
Associated Symptoms Ask about nausea, vomiting, anorexia (anorexia is the first symptom in >95% of acute appendicitis cases). Profuse vomiting and absolute constipation suggest bowel obstruction. Ask about altered bowel habit, weight loss (suggesting malignancy).
Risk Factors/Drugs Note use of NSAIDs or steroids, which predispose to peptic ulceration and perforation. Alcohol abuse is a risk factor for acute pancreatitis.
  1. Examination (Exam)

General examination should precede abdominal examination.

Examination Step Findings and Significance Supported Sources
General Appearance/Vitals Tachycardia or hypotension indicates serious pathology. Patient position gives clues: those with peritonitis lie motionless, while those with colic may writhe around. Note pallor, jaundice, or sweating (suggesting shock).
Inspection Look for abdominal distension (intestinal obstruction or ascites). Lack of movement with respiration suggests peritonitis. Check for scars (suggesting previous surgery/adhesions) and external hernias. Bruising around the umbilicus (Cullen’s sign) or flank (Grey Turner’s sign) suggests retroperitoneal hemorrhage, often seen in severe acute hemorrhagic pancreatitis or ruptured ectopic pregnancy.
Palpation Palpation should start gently, away from the site of maximum pain, and move toward the tender area.
Tenderness & Peritonism Assess degree of tenderness: Guarding (voluntary muscle contraction) indicates severe tenderness. Rigidity (involuntary, permanent muscle spasm) is characteristic of peritonitis and frank perforation. Asking the patient to cough or performing gentle percussion over the affected area will elicit peritonism and is preferred over performing painful rebound tenderness.
Specific Abdominal Signs Murphy’s sign (tenderness in the RUQ that catches on inspiration) suggests acute cholecystitis. Rovsing’s sign (palpation in the left iliac fossa produces pain in the right iliac fossa) suggests acute appendicitis. Psoas sign (painful extension of the right hip) suggests irritation of the psoas muscle, often seen in retroperitoneal appendicitis.
Deep Structures Palpate for abnormal masses, organomegaly, and check all hernial orifices. A pulsatile and expansile mass in the epigastrium suggests a ruptured abdominal aortic aneurysm.
Percussion/Auscultation Loss of liver dullness suggests pneumoperitoneum/gastrointestinal perforation. Hyperactive bowel sounds may indicate mechanical obstruction, while absent bowel sounds suggest paralytic ileus or generalized peritonitis.
Rectal/Pelvic Exam A rectal examination may be useful to check for pelvic tenderness or masses. A vaginal examination may help differentiate acute appendicitis from acute gynecologic disorders.
  1. Differential Diagnosis (DDx)
Abdominal Region Common Differential Diagnoses Supported Sources
General/Diffuse Pain Peritonitis (often from perforation or ischemia), Intestinal obstruction, Ruptured abdominal aortic aneurysm, Mesenteric vascular ischemia, Diffuse carcinomatosis
Upper Abdomen Acute pancreatitis, Acute cholecystitis, Biliary colic, Perforated peptic ulcer, Acute gastritis, Oesophagitis, Inferior myocardial infarction, Lower lobe pneumonia
Central/Periumbilical Small bowel obstruction, Mesenteric infarction, Intussusception, Meckel's diverticulitis, Early acute appendicitis, Ruptured abdominal aortic aneurysm
Right Iliac Fossa (RLQ) Acute appendicitis (most common cause of acute abdominal pain in the Western world), Meckel’s diverticulitis, Mesenteric adenitis, Crohn’s disease/regional ileitis, Carcinoma of the caecum. In Females: Ectopic pregnancy (must be ruled out), Ovarian torsion, Ovarian cyst rupture, Pelvic inflammatory disease (PID), Mittelschmerz. Urologic: Ureteric colic, Pyelonephritis, UTI.
Left Iliac Fossa (LLQ) Acute diverticulitis, Carcinoma of the left colon/rectum, Salpingitis/PID, Ureteric colic.
Non-Surgical/Systemic Diabetic ketoacidosis, Acute porphyria, Sickle cell crisis, Herpes zoster, Mesenteric adenitis, Non-specific abdominal pain (NSAP).
  1. Investigations (Ix)
Investigation Type Utility and Key Findings Supported Sources
Laboratory Tests CBC, U&Es, LFTs, Serum Amylase/Lipase, CRP: Essential for assessing inflammation (leukocytosis, raised CRP), fluid status (U&Es, creatinine), and excluding pancreatitis (amylase/lipase). Serum Lactate: Raised lactate indicates organ dysfunction, sepsis, or ischemic bowel. HCG: Essential in all women of child-bearing age to rule out ectopic pregnancy. Urinalysis: Check for UTI, stones, or DKA (glucose/ketones). Sterile pyuria may result from an inflamed appendix irritating the ureter.
Plain Radiography Erect Chest X-ray (CXR): Used to detect pneumoperitoneum (free air under the diaphragm), indicative of a perforated viscus. Also rules out lower lobe pneumonia. Abdominal X-rays (KUB): May show dilated bowel loops/air-fluid levels suggesting intestinal obstruction.
Ultrasound (US) Initial investigation of choice for biliary pathology (gallstones, cholecystitis signs like thickened gallbladder wall) and pelvic disease (gynae pathology, ectopic pregnancy). Used often as initial imaging in children and pregnant women suspected of appendicitis.
Computed Tomography (CT) Main diagnostic investigation for acute abdominal pain, highly accurate. Investigation of choice for acute diverticulitis, renal tract calculi (CT KUB), intestinal obstruction (locates transition point), and suspected perforation (especially if plain films are non-diagnostic). Used to exclude a diverticular abscess if patient fails to improve with antibiotics.
Special/Procedural ECG: Essential in upper abdominal pain to exclude inferior myocardial infarction. Diagnostic Laparoscopy: Can improve surgical decision-making, particularly in women of child-bearing age with unclear lower abdominal pain. Endoscopy/Colonoscopy: Used to investigate upper GI pain (after perforation ruled out), obtain biopsies for colitis, or therapeutically decompress sigmoid volvulus.
  1. Management (Mx)

Initial management adheres to the ABC (Airway, Breathing, Circulation) principle for assessment and resuscitation.

  1. Resuscitation and Stabilization:

    • Circulation: Establish large-bore intravenous access. Resuscitate with intravenous fluids and monitor response, ideally by hourly urine output.
    • Analgesia: Administer adequate analgesia, usually small doses of titrated intravenous opiate, as it should not be withheld for fear of masking clinical signs.
    • NPO and Decompression: Keep the patient Nil by Mouth (NPO) if surgery is anticipated or if they have bowel obstruction. Insert a nasogastric tube for decompression in intestinal obstruction or severe vomiting.
    • Antibiotics: Broad-spectrum antibiotics should be given if infection or sepsis is suspected, covering gut flora (Gram-positive, Gram-negative, and anaerobic bacteria).
    • Prophylaxis: Routine deep venous thrombosis prophylaxis should be started unless there is active bleeding.
    • Re-evaluation: Close monitoring and regular clinical review are critical to detect progression or resolution of the condition, especially if the diagnosis is initially uncertain.

  2. Definitive Management (Based on Diagnosis):

    • Acute Appendicitis: Treatment is appendicectomy (open or laparoscopically). Surgery should be carried out promptly in patients with signs of peritonitis.
    • Perforated Viscus (e.g., Perforated PUD): This is a surgical emergency. Operative management is usually indicated, often involving primary closure with an omental patch. Conservative management (NG decompression, antibiotics, PPIs) may be attempted if the perforation is suspected to be sealed and there are no signs of generalized peritonitis, but failure to improve within 12 hours mandates surgery.
    • Acute Cholecystitis: Conservative management with analgesia and antibiotics can lead to settlement. Patients should be admitted, given IV fluids and antibiotics. Urgent cholecystectomy is indicated within 48-72 hours if acute. If managed conservatively, elective cholecystectomy is carried out later (e.g., 6 weeks).
    • Acute Diverticulitis: Initial investigations should include urinalysis, blood tests, blood cultures, and a plain abdominal X-ray. Treatment involves intravenous access, fluids, analgesia, oxygen, broad-spectrum antibiotics, and thromboprophylaxis. Patients who do not improve after 24–48 hours require further investigation with a CT scan to exclude an abscess. A high-roughage diet is recommended once the acute episode resolves to prevent further attacks.
    • Intestinal Obstruction: Initial conservative treatment involves intravenous fluid rehydration, electrolyte replacement, and nasogastric decompression (drip and suck). Surgical intervention is indicated if strangulation, perforation, peritonitis, or failure of conservative management occurs.
    • Ruptured Abdominal Aortic Aneurysm: Urgent operative intervention is mandated, with resuscitation taking place immediately while preparing for surgery.

Abdominal pain is a common medical complaint, while acute abdomen is a term used when there is a rapid onset of severe abdominal pain that can indicate a life-threatening underlying cause. There are many different causes of an acute abdomen; therefore, it is important to focus on the urgent causes that need immediate intervention.

Causes of acute abdomen / Causes of acute abdominal pain

Firstly, we have peritonitis, which refers to inflammation of the peritoneum, the lining of the peritoneal cavity. In cases where this is generalized and involves most of the abdomen, it is called generalized peritonitis. Peritonitic patients can quickly deteriorate, and the peritoneum is a large cavity that can hold several liters of fluid. That, combined with a significant inflammatory response, means that patients can quickly become hypovolemic and enter shock. Additionally, infection is extremely common as the contents of many organs are not sterile; this generates an infective source that can quickly become septic shock.

The most common cause is a perforation of one of the abdominal organs, primarily a bowel obstruction, peptic ulcer disease, diverticular disease, or inflammatory bowel disease.

Acute abdomen generated by a bleed is also an emergency. Bleeding must be kept in the differential in this case; it may be overlooked as the bleeding is not visible externally in many cases. Examples include the rupture of an abdominal aortic aneurysm, a ruptured ectopic pregnancy, trauma, or a bleeding peptic ulcer. These patients will often require immediate surgical intervention. Ischemic bowel is also an emergency, characterized by pain that is disproportionately more severe than the clinical picture.

The other causes can be divided by category, including inflammatory such as acute cholecystitis, pancreatitis, or appendicitis. Other gynecological causes such as a rupture of an ovarian cyst or ovarian torsion. Infections are another cause, featuring intra-abdominal abscesses which pose a risk of developing peritonitis. There are also urological causes such as pyelonephritis, renal stones, or testicular torsion, and other causes include a vaso-occlusive crisis in sickle cell disease and diabetic ketoacidosis.

Diagnosis of acute abdomen / Diagnosis of acute abdominal pain - Causes of acute abdomen by location

In terms of the diagnosis, the clinical history and physical exam will greatly help in narrowing down the possible causes of the acute abdomen. Mnemonics such as SOCRATES are useful in gathering a comprehensive history of the pain. The site of the pain can guide us towards an underlying cause.

Right upper quadrant pain can indicate gallstone disease, acute hepatitis, or even pneumonia, as well as in some instances ureteric colic or pyelonephritis.

Left upper quadrant pain can also suggest many of these pathologies, and in bowel ischemia, can also be a focus of pain as the splenic flexure is a watershed area. Bear in mind that pain in the epigastric region may also include these conditions, as well as peptic ulcer disease, pancreatitis, or even in some cases myocardial infarction.

Pain in the right lower quadrant may indicate appendicitis. Note that appendicitis pain can also depend on the position of the appendix in that particular patient, as well as gynecological issues such as a rupture of an ovarian cyst, ovarian torsion, or an ectopic pregnancy. Others include inguinal hernias or a ureteric stone.

The left lower quadrant may also have similar conditions, this time including diverticular disease. In the western world, diverticulitis is more common on the left side; however, in the Asian population, it is more common to have it on the right side.

Pain in the periumbilical region may be more indicative of an abdominal aortic aneurysm, a bowel obstruction, or the early stages of appendicitis. If there is pain diffusely across the abdomen, this may be more suggestive of ischemia or peritonitis.

Diagnosis of acute abdomen / Diagnosis of acute abdominal pain - History

We then look at the onset of the pain. A longer-standing pain that has worsened can be suggestive of peptic ulcer disease, or if there are previous episodes of a similar pain, that could indicate gallstone disease or diverticular disease. The character of the pain also varies by condition; for example, a cramping colicky pain may point towards renal colic or an obstruction, while aortic dissection is more likely to be a sudden sharp pain.

In addition to the site, the pain may also radiate to other places. Typical examples include from the right upper quadrant to the right scapula in gallstone disease, around the upper abdomen and back like a belt in acute pancreatitis, a progression from the peri-umbilical region to the right iliac fossa in acute appendicitis, and from the flank to the groin or loin to groin in renal stones.

Associated symptoms can provide clues on the severity; for example, the presence of nausea and vomiting, any fevers or rigors, changes in bowel habits, or even the presence of shortness of breath.

The T is for timing; for example, a correlation with food may indicate gallstone disease or peptic ulcer disease.

We then have E which is for the exacerbating or relieving factors. In peritonitis, small movements can exacerbate the pain, causing the patient to lie still, while in renal colic, these patients are often continuously moving because they cannot find a comfortable position.

The last S is for severity, and typically a pain score out of 10 is asked for, but also remember to ask for the severity at its worst and at the time of the examination to gauge any fluctuations and to help guide the need for analgesia. It is also beneficial to ask whether the pain has been generally improving or worsening.

Acute abdomen physical exam / Acute abdominal pain physical exam

To go alongside the history, a physical exam can help narrow down the causes. Following the look, listen, and feel method, a general inspection of the patient can be performed. Are they well colored or pale? Are they struggling to breathe? Are they in visible pain? Are there any abdominal scars that may indicate previous surgery, therefore predisposing to an obstruction? Is there any abdominal discoloration or bruising, or even abdominal distension?

When listening to the chest and abdomen, are the breath sounds and heart sounds present and normal? Are there any bowel sounds? The bowel sounds may be absent in patients with a perforation, peritonitis, or the later stages of an obstruction, or may be tinkling in the case of an early obstruction.

Next comes palpation. A diffuse tenderness with a rigid abdomen with guarding or rebound tenderness may point towards peritonitis, but we may also look for any lumps that may indicate a hernia as the underlying cause. We can also look for Murphy's sign, which is where palpation of the liver when asking the patient to breathe in causes a sharp cessation in inspiration when the liver or gallbladder comes into contact with a palpating hand; this may indicate acute cholecystitis. Percussion may also be done which, if painful, may indicate peritoneal inflammation, but it can also be done to look for dullness in the abdomen which may indicate underlying fluid, or it may be tympanic indicating air.

Diagnosis of acute abdomen / Diagnosis of acute abdominal pain - Labs and Imaging

It's important to remember that the vital signs are crucial, with indicators such as hypotension and tachycardia potentially pointing towards a patient who is critically unwell and possibly shocked or septic.

Lab values are useful, such as the hemoglobin count, white blood cells, electrolytes, and further inflammatory markers like CRP. Other labs may also be useful such as the amylase levels. However, you may not have time to wait for all the lab values to come back; therefore, it's very useful to get a blood gas done which gives some of the other values we mentioned as an immediate result, but crucially also contains lactate which can be a marker for tissue hypoxia or poor perfusion if it is raised and will help to determine how urgent the case is.

It is likely that imaging will also be required, with plain abdominal x-ray being the fastest, which may suggest findings such as an obstruction or the loss of the psoas shadow in the presence of an abdominal aortic aneurysm. An erect chest x-ray may be done to look for air under the diaphragm which would indicate a perforation. But a CT of the abdomen and pelvis is the imaging modality that is done most commonly when evaluating for causes of generalized abdominal pain. Ultrasound is also useful; it may evaluate the gallbladder and biliary system, it can do a FAST scan for the presence of free fluid in the abdomen or the pericardium, as well as being able to look for the rupture of an ectopic pregnancy or ovarian torsion.

Treatment of acute abdomen / Treatment of acute abdominal pain

The treatment and management of patients with an acute abdomen will vary depending on the underlying cause. However, there are some general principles that may be followed. For example, close monitoring of the vital signs, oxygen if necessary, intravenous access, and initiation of fluid or even blood if necessary. In most cases, aggressive fluid management is tolerated, but in cases such as a rupture of an abdominal aneurysm, too much fluid can exacerbate the bleeding, and in patients with comorbidities, they may quickly become overloaded.

Fluid intake and output should also be undertaken, and broad-spectrum antibiotics should be considered if the patient has a suspected infection or perforation. A pregnancy test should also be done if the female is of childbearing age. Analgesia and anti-emetic agents may also be prescribed. Patients with acute abdomens should generally be kept nil by mouth in case they require surgery. Then a surgical review of the patient should also be requested to determine the need for immediate operative management or even exploratory surgery.

Location Potential Causes Mentioned
Right Upper Quadrant (RUQ) Gallstone disease, Acute hepatitis, Pneumonia, Ureteric colic, Pyelonephritis
Left Upper Quadrant (LUQ) Bowel ischemia (Splenic flexure watershed area), Pneumonia, Ureteric colic, Pyelonephritis
Epigastric Peptic ulcer disease (PUD), Pancreatitis, Myocardial infarction, Gallstone disease
Right Lower Quadrant (RLQ) Appendicitis, Inguinal hernia, Ureteric stone, Gynecological: Ruptured ovarian cyst, Ovarian torsion, Ectopic pregnancy
Left Lower Quadrant (LLQ) Diverticular disease (Western population), Inguinal hernia, Ureteric stone, Gynecological: Ruptured ovarian cyst, Ovarian torsion, Ectopic pregnancy
Periumbilical Abdominal Aortic Aneurysm (AAA), Bowel obstruction, Early appendicitis
Diffuse / Generalized Ischemia, Peritonitis, Perforation (Bowel obstruction, PUD, Diverticular, IBD)

Resources

S02 : [[2025-11-30]]

Gallbladder disease, Pancreatic disease, Intestinal obstruction (*Operative & Surgical Emergency)

Below is an exam-oriented summary of Gallbladder Disease strictly from Bailey & Love’s Short Practice of Surgery, 28th edition (Chapter 71) with citations.

GALLBLADDER DISEASE – SUMMARY (Bailey & Love)

Definition

Gallbladder disease encompasses benign and malignant conditions affecting the gallbladder, most commonly gallstones (cholelithiasis), acute/chronic cholecystitis, gallbladder polyps, acalculous cholecystitis, cholecystoses and gallbladder cancer .

Etiology

Gallstones

Pathophysiology

Gallstone formation

Acute cholecystitis

Complications of gallstones

Biliary colic, acute/chronic cholecystitis, empyema, mucocele, perforation, jaundice, cholangitis, pancreatitis, gallstone ileus (fistula to duodenum) .

Clinical Features

Biliary colic

Acute cholecystitis

Acalculous cholecystitis

Gallbladder polyps

Gallbladder cancer

Diagnosis

Imaging

Acute cholecystitis diagnosis (Tokyo Guidelines)

Management

(Educational summary only — not personal medical advice.)

Asymptomatic stones

Symptomatic gallstones / biliary colic

Acute cholecystitis

Acalculous cholecystitis

Cholecystoses

Gallbladder cancer

Clinical Exam Tips (for OSCEs) 🩺📚

Pancreatic disease includes acute pancreatitis, chronic pancreatitis, pancreatic cystic lesions, pancreatic fistulae and pancreatic cancer. Pancreatitis is inflammation of the pancreatic parenchyma and is divided into acute, presenting as an emergency, and chronic, a lifelong disorder with irreversible fibrosis .

Acute pancreatitis is defined by abdominal pain, ≥3× rise in amylase/lipase, or CT evidence of inflammation . The mechanism involves premature enzyme activation causing autodigestion and systemic inflammatory response, leading to oedema, necrosis and possible multiorgan failure . Main causes include gallstones (50–70%), alcohol (25%), post-ERCP, trauma, drugs, hypercalcaemia, hypertriglyceridaemia, pancreas divisum, autoimmune and hereditary pancreatitis . Early phase (first week) is dominated by SIRS with risk of organ failure; late phase involves persistent inflammation, necrosis and sepsis .

Clinically, acute pancreatitis presents with sudden severe epigastric pain radiating to the back, vomiting, tachycardia and variable tenderness. Diagnosis uses serum amylase/lipase (lipase more specific). CT is indicated for diagnostic uncertainty or severe disease to differentiate interstitial vs necrotising pancreatitis (Balthazar grading) . Severity classification (Revised Atlanta) categorises mild, moderately severe and severe based on organ failure duration .

Management (non-patient specific): aggressive early resuscitation, oxygen, analgesia, nutritional support, and treatment of complications; ERCP is indicated urgently only for gallstone pancreatitis with cholangitis or ongoing obstruction . Gallbladder removal is recommended during the same admission once fit in gallstone pancreatitis .

Chronic pancreatitis involves progressive irreversible destruction, usually due to alcohol (60–70%), duct obstruction, hereditary mutations (PRSS1, SPINK1, CFTR), autoimmune disease, tropical pancreatitis and idiopathic causes . Pathology includes fibrosis, duct distortion, strictures, ectasia and intraductal stones; high cancer risk is noted in hereditary and tropical types . Clinical features include chronic epigastric/back pain, weight loss, steatorrhoea and diabetes; complications include pseudocysts, obstruction, fistulae and infection .

Diagnosis uses CT or MRI to show gland damage; MRCP assesses ducts; ERCP defines ductal anatomy and guides therapy. Calcifications on plain film are typical. Sonography may show stones, duct irregularity and hyperechoic changes . Treatment is primarily medical: analgesia, enzyme replacement, diabetes control; endoscopic or surgical decompression is used for duct obstruction or complications .

Pancreatic pseudocysts arise after acute or chronic pancreatitis; differentiation from cystic neoplasms requires imaging and guided fluid analysis (CEA, amylase, cytology) . Management depends on size, symptoms and complications; options include endoscopic, percutaneous or surgical drainage.

Pancreatic fistulae result from trauma, surgery or pancreatitis; diagnosis uses fluid amylase measurement. Management includes fluid/electrolyte correction, skin protection, drainage, nutritional support and octreotide; ERCP with stenting may relieve ductal obstruction .

Pancreatic cancer presents late with weight loss, pain, jaundice (head lesions), and back pain. Many are unresectable; resection is contraindicated when metastases are present. Palliation targets jaundice, gastric outlet obstruction, pain (including coeliac block) and nutritional support. Median survival improvements with chemotherapy are modest .

Clinical exam points include epigastric tenderness, pain radiating to the back, signs of SIRS in acute pancreatitis, and jaundice or palpable gallbladder in malignancy. Grey Turner and Cullen signs indicate haemorrhagic pancreatitis.

I can also provide a rapid exam cheat sheet, flashcards, or tables comparing acute vs chronic pancreatitis.

Intestinal obstruction is classified into dynamic (mechanical) and adynamic (non-mechanical) forms. Dynamic obstruction occurs when peristalsis acts against a physical blockage, whereas adynamic obstruction occurs when peristalsis fails (e.g., paralytic ileus, pseudo-obstruction) .

Causes include intraluminal (faecal impaction, foreign bodies, bezoars, gallstones), intramural (malignancy, strictures, intussusception, volvulus), and extramural (adhesions, hernias). Paralytic ileus and acute colonic pseudo-obstruction are major adynamic causes . Adhesions account for ~40%, followed by malignancy, Crohn’s, hernia and faecal impaction .

Pathophysiology involves proximal dilatation due to gas accumulation (nitrogen-rich from bacterial overgrowth) and fluid sequestration (up to several litres of GI secretions), causing dehydration, electrolyte derangement and shock. Persistent obstruction causes reduced peristalsis and bowel wall ischaemia. Strangulation results from compromised blood flow due to hernias, volvulus, intussusception or closed-loop obstruction and leads to haemorrhagic infarction and sepsis .

Clinical features of dynamic obstruction consist of the classic quartet: colicky abdominal pain, distension, vomiting and absolute constipation . High small bowel obstruction gives early, profuse vomiting with minimal distension; low small bowel obstruction produces marked central distension and later vomiting. Large bowel obstruction causes early, pronounced distension with later vomiting . Severe continuous pain, tachycardia, fever, peritonism or shock suggest strangulation (constant severe pain, tenderness, rigidity, shock) .

Diagnosis begins with clinical assessment and examination of all hernial orifices. Plain radiographs show dilated loops with fluid levels; CT is now the preferred modality for identifying the obstruction site and cause, and signs of ischaemia (reduced bowel wall enhancement, presence of mesenteric fluid) . Water-soluble enema helps differentiate colonic obstruction from pseudo-obstruction; barium follow-through is contraindicated in acute obstruction because of perforation risk.

Management principles are nasogastric decompression, fluid and electrolyte replacement, and relief of obstruction . Surgery is required in most cases but should follow resuscitation unless there are signs of strangulation or closed-loop obstruction. Early surgery is indicated for obstructed external hernia, clinical features of strangulation, and obstruction in a virgin abdomen . Adhesive obstruction without strangulation may be managed conservatively for up to 72 hours.

At laparotomy, assessment includes identifying site, cause and bowel viability. Small bowel obstruction is managed by delivering and supporting distended loops, relieving the cause (adhesiolysis, hernia repair, resection for necrosis). Large bowel obstruction is often due to carcinoma; management includes right hemicolectomy for right-sided lesions, extended hemicolectomy for splenic flexure lesions, or stoma creation when resection is unsafe. Sigmoid volvulus may be relieved endoscopically unless ischaemia is suspected; recurrent cases require definitive surgery .

Pseudo-obstruction and ileus require conservative treatment with correction of underlying causes; mechanical obstruction must be excluded. Chronic obstruction presents with long-standing constipation, distension and later vomiting, often due to strictures, faecal impaction, or functional disorders such as megacolon .

Clinical exam pearls include visible peristalsis in thin patients, hyperactive tinkling bowel sounds early, and peritonism or tachycardia as warning signs of strangulation. Absolute constipation may be absent in Richter’s hernia, gallstone ileus, mesenteric ischaemia and partial obstruction .

If you want, I can also produce a one-page exam cheat sheet, comparison tables (SBO vs LBO, dynamic vs adynamic, strangulated vs simple), or key radiology signs.

Below is a ONE-PAGE, markdown, no-headings, ultra-condensed exam summary of the three topics you requested — Gallbladder Disease, Pancreatic Disease, and Intestinal Obstruction — strictly from Bailey & Love’s Short Practice of Surgery, 28th edition with citations.

Gallbladder disease includes gallstones, acute/chronic cholecystitis, acalculous cholecystitis, cholecystoses and gallbladder cancer. Gallstones form from cholesterol supersaturation, impaired emptying and nucleation factors; pigment stones arise from haemolysis or infection . Risk factors include age, female sex, obesity, haemolysis, ileal disease and pregnancy. Biliary colic causes episodic RUQ pain; acute cholecystitis presents with continuous RUQ pain, fever and Murphy’s sign; complications include empyema, perforation and fistula formation. Diagnosis relies on ultrasonography for stones and wall thickening; HIDA confirms cystic duct obstruction . Management includes supportive care and early laparoscopic cholecystectomy; acalculous disease requires urgent drainage if critically ill. Polyps >1 cm, symptomatic lesions, and those associated with PSC warrant cholecystectomy . Gallbladder cancer presents late with pain, jaundice and weight loss; early T1a lesions may be treated with cholecystectomy, whereas more advanced disease requires extended resection but is often palliative .

Pancreatic disease includes acute and chronic pancreatitis, pancreatic cystic lesions, fistulae and cancer. Acute pancreatitis is diagnosed by characteristic pain, raised enzymes and imaging; gallstones and alcohol account for most cases . Pathophysiology involves premature enzyme activation → autodigestion → SIRS → possible multiorgan failure. Severe cases show persistent organ failure; necrotising pancreatitis may become infected. Management includes aggressive resuscitation, analgesia, early nutrition and ERCP only for biliary obstruction with cholangitis . Chronic pancreatitis causes irreversible fibrosis, duct distortion and stones, typically due to alcohol, hereditary mutations or autoimmune causes; presents with chronic pain, malabsorption and diabetes, with complications such as pseudocysts and obstruction . Management is supportive with enzymes, analgesia and targeted endoscopic or surgical drainage. Pancreatic cancer presents late with weight loss, jaundice and back pain; most are unresectable and require palliative care.

Intestinal obstruction may be dynamic (mechanical) or adynamic (ileus, pseudo-obstruction). Mechanical causes include intraluminal (faecal impaction, bezoars, gallstones), intramural (malignancy, strictures, intussusception, volvulus) and extramural (adhesions, hernias) . Pathophysiology involves proximal dilatation due to gas (nitrogen-rich from bacterial overgrowth) and fluid sequestration, causing dehydration and electrolyte loss; persistent obstruction leads to reduced motility and possible strangulation with ischaemia and necrosis . Clinical features include colicky abdominal pain, distension, vomiting and absolute constipation; in large bowel obstruction, distension is early and pronounced . Severe continuous pain, tenderness, fever or shock suggests strangulation . Diagnosis uses plain radiographs and CT (best for level, cause, and features of ischaemia) . Management consists of nasogastric decompression, fluid resuscitation and relief of obstruction; surgery is urgent for strangulation, obstructed hernia and obstruction in a virgin abdomen . Adhesive obstruction may resolve conservatively within 72 hours; large bowel obstruction often requires resection or stoma depending on tumour site.

S03 [[2025-12-02]] ⏯ Wound Mx + Biliary diseases + Ascites Stomas & colostomies + ⏯1 (Inguinal masses) + Patients with abdominal pain (acute abd., appendicitis)

S04 : ⏯ Breast : Abscess , Benign & malignant tumors. Surgical emergency : Peptic ulcer disease, Perforated viscus , Acute appendicitis.

Topic : Acute appendicitis
2. PUD
3. Perforated viscus

4. Breast Pathology

S05 : [[2025-12-04]] : Ortho : Cast Application

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Radiology

Vascular Surgery

Orthopedic Surgery

Neurosurgery

Urosurgery

ENT Surgery

Ophthalmic Surgery

Footnotes

  1. [[2025-12-02-23-38-baileyandlove-surgery-book|O’Connell, P. Ronan, et al., Bailey & Love’s Short Practice of Surgery, 28th Edition, CRC Press, 2023,https://doi.org/10.1201/9781003106852]] ↩

  2. [[2025-12-02-23-49-browse-introduction-sxandsx-surgicaldisease-book|Gossage, James, et al. “Browse’s Introduction to the Symptoms & Signs of Surgical Disease.” Routledge & CRC Press, https://www.routledge.com/Browses-Introduction-to-the-Symptoms--Signs-of-Surgical-Disease/Gossage-Bultitude-Corbett/p/book/9781138330085.]] ↩

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