Gastro history
• Pain
• Location
• Radiation
• Nature
• Duration
• Constant or colicky: constant might be more serious but colicky is more of obstruction
• Aggravating or relieving actors
• Any associated features: fevers sweats etc
• Systemic symptoms:
o LOA
o LOW
• Drugs/medicstion xt
• Smoking, alcohol
• Family history
• Past surgical history
Bowel habit history:
• Don’t ask what is normal. Everyone is different.
• What do they mean by change in bowe habit?
• Duration? Since when?
• What do they mean by diarrhoea or constipation?
• Is there urgency? Incontinence?
• Is there tenesmus?
Acetyl CoA carboxylase is the protein in the liver that is subject to control by high
insulin/glucagon ratio to favour conversion of glucose to fatty acid
Glucose is the only sugar that stimulates active absorption of salts and water in the
small intestine
Ivermectin is NOT effective against hookworms: Use against strongyloides, ascaris
lumbricoides
Albendazole can be used for many parasitic infection, but usually less severe
ALL UPPER/LOWER GIT BLEED WITH MALENA NEEDS TO HAVE DRE DONE TO SEE
WHETHER THERE IS MALAENA/FRESH BLOOD!
• Labelled red blood cell scan (technetium 99 scintigraphy) is a good non
invasive way to look for active bleeding and localization of the bleeding site,
especially for lower GIT bleeds
Blowing abdomen up is a good test for peritonism. If there is pain and patient unable
to do it or pain worsens, there is peritonism.
A bridle is a device that keeps the nasogastric tube in place to reduce NG tube pullouts
and improving patient outcomes. It is placed with a tiny catheter ounted magnets that
goes behind the nasopharynx and holds the nasogastric tube, making it painful when
you try to pull it out, and essentially you cannot pull out the NGT.
Analgesia for bowel patients, ALWAYS use PCA! They shouldn't eat just after post op
GLP-1 released from intestinal L cells can lead to delayed gastric emptying, increased post-
prandial insulin release and improved satiety
Glucagon binds with plasma membrane-bound G-protein coupled receptor, leading to
increased glycogenolysis
Note: Abdominal U/S need to fast becaue you want to see the Gallbladder and
sometimes might need to have a full bladder
,Post op management:
• Patient E&D
• YES/NO for clexane/anticoagulation
• Ongoing antibiotics
• Discharge instructions:
o Keep dressing dry for 3 days then can remove, shower, gentle pat dry
o Laparoscopic/abdominal surgeries: nil driving 1/52, nil heavy lifting >5kg for
4-6/52
o Dissolvable sutures vs GP to remove at ____ days (approx date written is
useful)
SNAP
• Sepsis
• Nutrition
• Anatomy
• Plan/procedure
Discharge summaries:
• State clear diagosis if known
• List operation and name surgeons
• Summarise recovery (rotine vs complicated)
• Other unit consulttions including A/H
• Med changes
• Plan for r/v
• Plan for wound
• Specific unstructions for GP
• Few illsitrative test resitls, esp histology results
Pre-admission clinic
• What is your role?
• Know local protocols/handbook
• Remind them to bring XR
• Anesthetic review
• Opportunity to clarify indication for surgery
• Not your role to consent patient or speak in detail about sugery or risk: defer to
registrar
Hypotensive post surgical patient is bleeding until proven otherwise
Dyspnoic tachycardic surgical patient is likely to be septic until proven otherwise
Neck swelling in post thyroidectomy may progress rapidly to death: if you open the
wound on the ward, open the deep layer as well
Retroperitoneal fibrosis is an uncommon condition and its aetiology is poorly
understood. In a significant proportion the ureters are displaced medially. In most
retroperitoneal malignancies they are displaced laterally. Hypertension is another
common finding. A CT scan will often show a para-aortic mass
Principles of surgical abdomen:
1. DRS ABC
a. Vitals
b. Oxygen: 2L/min Nasal prongs
c. 2 16G cannula: take bloods, fluid resuscitation +/- transfusion +/- inotrope
2. NBM +/- NGT +/- catheter
3. Initial investigatiosn
a. FBE, UEC, LFT, Coags, G&H +/- cross match
b. AXR
4. Symptomatic relief
a. IV morphine
b. +/- anti emetics: metoclopramide, Ondansetron
, 5. Prophylactic antibiotic:
a. –it is: IV Ampicillin + IV gentamicin
b. Perforation: IV ampicillin + IV gentamicin + IV metronidazole
c. Bleeding varices: IV ceftriaxone 1g
6. Specific therapy:
a. Laparotomy
b. Urgent OGD
c. IV PPI
In surgical history for clinic:
• Presenting complaint
• Symptoms
• Current management
• Fitness for surgery:
o Past medical history
o Past surgical history
o Medications
o Allergies
o Social: smoking, occupation, home environment
• Examination to confirm findings/diagnose
• Discussion about options and diagnostic investigations
• Discussion about Procedure and risks and diagnostic investigations
Live screen tests:
• Gastrograffin swallow: esophageal
• Gastrograffin meal: stomach
• Gastrograffin follow through: small intestine
GI surgery emergency:
• 10 days to do initial surgery
• Do NOT go in again within 100 days if possible as the adhesions are still friable and
will cause tears in the intestinal walls when you meddle with the intestines
Ileostomy: bag to ileum
Colostomy: bag to colon
Laparostomy: bag to peritoneal cavity
• Mainly for abdominal compartment syndrome, abdominal sepsis, severe acute
pancreaitits, major abdominal trauma, patients likely for re-laparotomies within short
periods of time
EUS: Endoscopic ultrasound
• Combines both scope and ultrasound from mouth to duodenum
• Ultrasound transducer at the end of the scope can form good image of the duodenum
and the surrounding organs
• Usually can do FNA as well because of very specific and accurate test.
• Very good for:
o Pancreatic masses/tumours
o Cysts
o Acute and chronic pancreatitis
o Autoimmune pancreatitis
o Other cancers in upper GIT
• Indications:
o Evaluate abnormal CT, MRI, U/S
o Evaluation of Pancreatic lesions or tumours
o Further evaluation of cystic lesions
o Drain pancreatic and peripancreaitc fluid collections
o Suspected or establish chronic pancreatitis
• Potential risks
o Bleeding
, o Infection
o Perforation
o Anestic
o Acute pancreatitis
o Dysphagia
o Sore throat
NOTE: Fistulas are inflammatory granulation abnormal connection between 2 epithelial
surfaces. Very common causes by intraperitoneal abscess trying to release the pressure and
hence form a fistula.
• Causes:
o Abscess
o Crohn’s disease
o Malignancy (invasion)
• Colovesical fistula:
o Surgery: fistulotomy, defunctioning ileostomy, reversal after CT colonogram
(give air and contrast shows no leak from anastomosis)
NOTE: PPI theoretically has better acid suppression than H2 antagonists, but patients say H2
antagonists work better: probably placebo effect
• HOWEVER, there is SYNERGISTIC effect when used in conjunction.
o Pleitrophic effect: Pulmonary fibrosis treated with PPI to reduce
inflammation/fibrosis of lungs, pleiotropic effect (when 1 thing influences 2 or
more seemingly unrelated things)
GASTROGRAFFIN VS BARIUM SWALLOW
• GASTROGRAFFIN: used when you suspect a tear/leak only as it causes LESS
tissue irritation than barium if it actually leaks
• BARIUM: still gold standard as it is better in telling the structure. Also used In
preference to avoid aspiration
Apronectomy: mini tummy tuck/abdominoplasty
• Often needed for patients after a massive weight loss post bariatric surgery or
pregnancy etc
• Excess abdominal wall skin is removed and the rectus abdominis sutured and
cinched together in the middle to put tem back closer to where they started
• Some doctors may use liposuction as Well to improve skin tighterning and reduce
blood loss
• Skin is then stitched together
• Only issue is whether belly button is to be kept or not. Sometimes it may be too
difficult to preserve the belly button.
NOTE: Always assume all non-healing ulcer to be CANCER, biopsy will be needed to ensure
that the lesion is benign/malignant for further workup.
3 most common conditions:
• Reflux/GORD
• Divertulosis
• Gallstones/choledocolithiasis
On OGD, multple white dots are hypertrophied stratified squamous mucosa with glycogen/fat
deposition in mucosa, called acanthosis
NOTE: Lesser omentum membrane is called plus plasidis
Do NOTE that a low lying pacemaker lead can irritate the phrenic nerve and cause chronic
hiccups!
Types of approaches for laparoscopic access
• Pain
• Location
• Radiation
• Nature
• Duration
• Constant or colicky: constant might be more serious but colicky is more of obstruction
• Aggravating or relieving actors
• Any associated features: fevers sweats etc
• Systemic symptoms:
o LOA
o LOW
• Drugs/medicstion xt
• Smoking, alcohol
• Family history
• Past surgical history
Bowel habit history:
• Don’t ask what is normal. Everyone is different.
• What do they mean by change in bowe habit?
• Duration? Since when?
• What do they mean by diarrhoea or constipation?
• Is there urgency? Incontinence?
• Is there tenesmus?
Acetyl CoA carboxylase is the protein in the liver that is subject to control by high
insulin/glucagon ratio to favour conversion of glucose to fatty acid
Glucose is the only sugar that stimulates active absorption of salts and water in the
small intestine
Ivermectin is NOT effective against hookworms: Use against strongyloides, ascaris
lumbricoides
Albendazole can be used for many parasitic infection, but usually less severe
ALL UPPER/LOWER GIT BLEED WITH MALENA NEEDS TO HAVE DRE DONE TO SEE
WHETHER THERE IS MALAENA/FRESH BLOOD!
• Labelled red blood cell scan (technetium 99 scintigraphy) is a good non
invasive way to look for active bleeding and localization of the bleeding site,
especially for lower GIT bleeds
Blowing abdomen up is a good test for peritonism. If there is pain and patient unable
to do it or pain worsens, there is peritonism.
A bridle is a device that keeps the nasogastric tube in place to reduce NG tube pullouts
and improving patient outcomes. It is placed with a tiny catheter ounted magnets that
goes behind the nasopharynx and holds the nasogastric tube, making it painful when
you try to pull it out, and essentially you cannot pull out the NGT.
Analgesia for bowel patients, ALWAYS use PCA! They shouldn't eat just after post op
GLP-1 released from intestinal L cells can lead to delayed gastric emptying, increased post-
prandial insulin release and improved satiety
Glucagon binds with plasma membrane-bound G-protein coupled receptor, leading to
increased glycogenolysis
Note: Abdominal U/S need to fast becaue you want to see the Gallbladder and
sometimes might need to have a full bladder
,Post op management:
• Patient E&D
• YES/NO for clexane/anticoagulation
• Ongoing antibiotics
• Discharge instructions:
o Keep dressing dry for 3 days then can remove, shower, gentle pat dry
o Laparoscopic/abdominal surgeries: nil driving 1/52, nil heavy lifting >5kg for
4-6/52
o Dissolvable sutures vs GP to remove at ____ days (approx date written is
useful)
SNAP
• Sepsis
• Nutrition
• Anatomy
• Plan/procedure
Discharge summaries:
• State clear diagosis if known
• List operation and name surgeons
• Summarise recovery (rotine vs complicated)
• Other unit consulttions including A/H
• Med changes
• Plan for r/v
• Plan for wound
• Specific unstructions for GP
• Few illsitrative test resitls, esp histology results
Pre-admission clinic
• What is your role?
• Know local protocols/handbook
• Remind them to bring XR
• Anesthetic review
• Opportunity to clarify indication for surgery
• Not your role to consent patient or speak in detail about sugery or risk: defer to
registrar
Hypotensive post surgical patient is bleeding until proven otherwise
Dyspnoic tachycardic surgical patient is likely to be septic until proven otherwise
Neck swelling in post thyroidectomy may progress rapidly to death: if you open the
wound on the ward, open the deep layer as well
Retroperitoneal fibrosis is an uncommon condition and its aetiology is poorly
understood. In a significant proportion the ureters are displaced medially. In most
retroperitoneal malignancies they are displaced laterally. Hypertension is another
common finding. A CT scan will often show a para-aortic mass
Principles of surgical abdomen:
1. DRS ABC
a. Vitals
b. Oxygen: 2L/min Nasal prongs
c. 2 16G cannula: take bloods, fluid resuscitation +/- transfusion +/- inotrope
2. NBM +/- NGT +/- catheter
3. Initial investigatiosn
a. FBE, UEC, LFT, Coags, G&H +/- cross match
b. AXR
4. Symptomatic relief
a. IV morphine
b. +/- anti emetics: metoclopramide, Ondansetron
, 5. Prophylactic antibiotic:
a. –it is: IV Ampicillin + IV gentamicin
b. Perforation: IV ampicillin + IV gentamicin + IV metronidazole
c. Bleeding varices: IV ceftriaxone 1g
6. Specific therapy:
a. Laparotomy
b. Urgent OGD
c. IV PPI
In surgical history for clinic:
• Presenting complaint
• Symptoms
• Current management
• Fitness for surgery:
o Past medical history
o Past surgical history
o Medications
o Allergies
o Social: smoking, occupation, home environment
• Examination to confirm findings/diagnose
• Discussion about options and diagnostic investigations
• Discussion about Procedure and risks and diagnostic investigations
Live screen tests:
• Gastrograffin swallow: esophageal
• Gastrograffin meal: stomach
• Gastrograffin follow through: small intestine
GI surgery emergency:
• 10 days to do initial surgery
• Do NOT go in again within 100 days if possible as the adhesions are still friable and
will cause tears in the intestinal walls when you meddle with the intestines
Ileostomy: bag to ileum
Colostomy: bag to colon
Laparostomy: bag to peritoneal cavity
• Mainly for abdominal compartment syndrome, abdominal sepsis, severe acute
pancreaitits, major abdominal trauma, patients likely for re-laparotomies within short
periods of time
EUS: Endoscopic ultrasound
• Combines both scope and ultrasound from mouth to duodenum
• Ultrasound transducer at the end of the scope can form good image of the duodenum
and the surrounding organs
• Usually can do FNA as well because of very specific and accurate test.
• Very good for:
o Pancreatic masses/tumours
o Cysts
o Acute and chronic pancreatitis
o Autoimmune pancreatitis
o Other cancers in upper GIT
• Indications:
o Evaluate abnormal CT, MRI, U/S
o Evaluation of Pancreatic lesions or tumours
o Further evaluation of cystic lesions
o Drain pancreatic and peripancreaitc fluid collections
o Suspected or establish chronic pancreatitis
• Potential risks
o Bleeding
, o Infection
o Perforation
o Anestic
o Acute pancreatitis
o Dysphagia
o Sore throat
NOTE: Fistulas are inflammatory granulation abnormal connection between 2 epithelial
surfaces. Very common causes by intraperitoneal abscess trying to release the pressure and
hence form a fistula.
• Causes:
o Abscess
o Crohn’s disease
o Malignancy (invasion)
• Colovesical fistula:
o Surgery: fistulotomy, defunctioning ileostomy, reversal after CT colonogram
(give air and contrast shows no leak from anastomosis)
NOTE: PPI theoretically has better acid suppression than H2 antagonists, but patients say H2
antagonists work better: probably placebo effect
• HOWEVER, there is SYNERGISTIC effect when used in conjunction.
o Pleitrophic effect: Pulmonary fibrosis treated with PPI to reduce
inflammation/fibrosis of lungs, pleiotropic effect (when 1 thing influences 2 or
more seemingly unrelated things)
GASTROGRAFFIN VS BARIUM SWALLOW
• GASTROGRAFFIN: used when you suspect a tear/leak only as it causes LESS
tissue irritation than barium if it actually leaks
• BARIUM: still gold standard as it is better in telling the structure. Also used In
preference to avoid aspiration
Apronectomy: mini tummy tuck/abdominoplasty
• Often needed for patients after a massive weight loss post bariatric surgery or
pregnancy etc
• Excess abdominal wall skin is removed and the rectus abdominis sutured and
cinched together in the middle to put tem back closer to where they started
• Some doctors may use liposuction as Well to improve skin tighterning and reduce
blood loss
• Skin is then stitched together
• Only issue is whether belly button is to be kept or not. Sometimes it may be too
difficult to preserve the belly button.
NOTE: Always assume all non-healing ulcer to be CANCER, biopsy will be needed to ensure
that the lesion is benign/malignant for further workup.
3 most common conditions:
• Reflux/GORD
• Divertulosis
• Gallstones/choledocolithiasis
On OGD, multple white dots are hypertrophied stratified squamous mucosa with glycogen/fat
deposition in mucosa, called acanthosis
NOTE: Lesser omentum membrane is called plus plasidis
Do NOTE that a low lying pacemaker lead can irritate the phrenic nerve and cause chronic
hiccups!
Types of approaches for laparoscopic access
