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GIT Surgery - Topicwise Notes for MBBS Exams

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TOPIC 1: PEPTIC ULCER DISEASE (PUD)

Basics

• "Peptic" implies acid-dependent disease - no acid = no ulcer
• Most are healed by PPIs (render patient virtually achlorhydric)
• Common sites: 1st part of duodenum (most common), lesser curve of stomach, stoma after gastric surgery, oesophagus, Meckel's diverticulum (if ectopic gastric mucosa)
• Ulcer occurs at junction between different epithelia - where resistance to acid is least

Aetiology

• Duodenal ulcer: high acid secretion
• Gastric ulcer: normal acid secretion (mucosal barrier failure)

Key Exam Summary Box (Bailey & Love)

• Duodenal ulcers are more common than gastric ulcers
• Symptoms are indistinguishable clinically
• Gastric ulcers may be malignant - ulcerated gastric cancer can mimic a benign ulcer
• Treatment: H. pylori eradication + PPI - elective surgery is now very rarely performed
• Complications: Perforation, Bleeding (haemorrhage), Stenosis (pyloric stenosis)

Complications (Exam Favourite)

1. Perforation - presents with sudden severe epigastric pain, board-like rigidity, gas under diaphragm on erect CXR; Rx: omental patch repair (Graham patch)
2. Haemorrhage - haematemesis / melaena; Rockford classification for severity; Rx: endoscopic haemostasis, PPIs, surgery if refractory
3. Pyloric stenosis (gastric outlet obstruction) - succussion splash, projectile vomiting, metabolic alkalosis (loss of HCl); Rx: pyloroplasty or gastrojejunostomy

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TOPIC 2: INTESTINAL OBSTRUCTION

Classification

Causes by Location

• Adhesions (post-op) - most common
• Hernias (incarcerated / strangulated)
• Crohn's disease strictures
• Intussusception, volvulus

• Carcinoma of colon - most common
• Sigmoid volvulus
• Diverticular stricture

Pathophysiology

• Small bowel secretes up to 6 litres of salt-rich fluid/day
• Obstruction → accumulation → vomiting → electrolyte imbalance
• Strangulation → loss of blood supply → necrosis, gangrene, perforation

Clinical Features (Exam Mnemonic: ABCV)

• Abdominal distension
• Bowel sounds - high-pitched tinkling (early) → silent (late/strangulation)
• Colic (abdominal pain) - proximal = high-pitched colic + vomiting; distal = distension predominates
• Vomiting (early in proximal, late in distal)
• Absolute constipation (no flatus = complete obstruction)

Diagnosis

• Erect + supine AXR: multiple air-fluid levels (erect); small bowel identified by valvulae conniventes (run across full width, close together); large bowel by haustra (further apart, incomplete)
• CT abdomen: definitive
• Check all hernial orifices - incarcerated hernia is one of the commonest causes

Treatment

• Drip and suck: IV fluids, NG tube decompression
• Treat underlying cause: surgery for adhesive bands, hernias, tumours
• Strangulated bowel = surgical emergency

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TOPIC 3: APPENDICITIS

Key Facts

• Most common surgical emergency in young adults
• Peak age: 10-30 years
• Cause: luminal obstruction (faecolith, lymphoid hyperplasia, foreign body)

Pathological Progression

1. Obstruction → bacterial overgrowth
2. Mucosal inflammation → wall oedema
3. Venous congestion → ischaemia
4. Gangrene → Perforation

Clinical Features

• Begins as central/periumbilical colicky pain → migrates to right iliac fossa (RIF)
• Anorexia, nausea, low-grade fever
• Guarding + rebound in RIF; Rovsing's sign (pressure on LIF causes pain in RIF)
• Psoas sign (retroperitoneal appendix), Obturator sign (pelvic appendix)

Alvarado Score (MANTRELS)

• Score ≥ 7: high probability; Score ≤ 4: appendicitis unlikely

Diagnosis

• WBC elevated with neutrophilia
• USS: non-compressible appendix > 6 mm
• CT: gold standard when in doubt

Treatment

• Appendicectomy - open (grid-iron / Lanz incision) or laparoscopic
• Perforated appendix with peritonitis: IV antibiotics + surgery
• Appendicular mass (Ochsner-Sherren regimen): conservative initially, interval appendicectomy after 6 weeks

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TOPIC 4: HERNIAS

Definition

Types and Key Features

Inguinal Hernia - Exam Focus

• Indirect inguinal hernia: passes through deep inguinal ring → follows the inguinal canal → can enter scrotum; more common; congenital processus vaginalis patent; young males
• Direct inguinal hernia: pushes through posterior wall of inguinal canal (Hasselbach's triangle); acquired; older males; rarely strangulates
• Differentiating from femoral: inguinal hernia is above and medial to pubic tubercle; femoral is below and lateral

Complications

1. Irreducibility - contents cannot be returned
2. Obstruction - bowel obstructed in sac
3. Strangulation - blood supply cut off → ischaemia → emergency surgery
4. Inflammation / Sliding hernia (bladder/colon may be part of sac wall)

Treatment

• Elective: mesh repair (Lichtenstein - most common for inguinal); laparoscopic TEP/TAPP
• Emergency (strangulation): resection of infarcted bowel + repair

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TOPIC 5: COLORECTAL CANCER

Epidemiology

• Greatest cause of cancer mortality in non-smokers in Europe/North America/Australasia
• Incidence increases with age
• Diet high in meat + low in fibre = increased risk
• ~10% have hereditary contribution

Hereditary Forms (Exam Favourite)

• FAP (Familial Adenomatous Polyposis): hundreds/thousands of adenomatous polyps; almost inevitable colorectal cancer → prophylactic colectomy
• HNPCC (Lynch syndrome): mismatch repair gene defect; right-sided CRC predominance

Progression: Adenoma-Carcinoma Sequence

Dukes' Staging (Most Tested)

Presenting Symptoms

• Alteration of bowel habit (most common)
• Rectal bleeding - fresh blood (left-sided/rectal) or dark blood (right-sided)
• Weight loss, anaemia (right-sided CRC often presents with iron deficiency anaemia)
• Intestinal obstruction (late)
• Left-sided: change in stool calibre (pencil stools)

Investigation

• Colonoscopy + biopsy: gold standard
• CEA (carcinoembryonic antigen): for monitoring recurrence, not diagnosis
• CT chest/abdomen/pelvis: staging

Treatment

• Right-sided: Right hemicolectomy
• Left-sided: Left hemicolectomy / Sigmoid colectomy
• Rectal: Anterior resection (high); Abdominoperineal resection (APR) (low) with permanent colostomy
• Adjuvant chemotherapy (FOLFOX) for Stage III/IV

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TOPIC 6: LIVER ABSCESS

Types

Risk Factors

• Elderly, diabetics, immunosuppressed

Clinical Features

• Fever, rigors, anorexia, malaise
• Right upper quadrant pain/discomfort
• Hepatomegaly, raised diaphragm

Diagnosis

• USS: multiloculated cystic mass
• CT: air-fluid level + rim enhancement (pyogenic); confirms extent
• Aspiration: microbiological confirmation ("anchovy sauce" pus = amoebic)

Treatment

• Pyogenic: IV antibiotics (metronidazole + cephalosporin/aminoglycoside) + percutaneous drainage (USS/CT guided); surgery if refractory
• Amoebic: Metronidazole (drug of choice) - surgery rarely needed

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TOPIC 7: ACUTE PANCREATITIS

Aetiology (Mnemonic: GET SMASHED)

Clinical Features

• Severe epigastric pain radiating to the back
• Nausea and vomiting
• Grey Turner's sign: bruising in flanks (retroperitoneal haemorrhage)
• Cullen's sign: periumbilical bruising
• Tender epigastrium; reduced/absent bowel sounds

Investigations

• Serum amylase > 3× upper limit of normal (rises in 2-12 hours, returns to normal in 3-5 days)
• Serum lipase: more sensitive and specific (stays elevated longer)
• CRP: severity marker
• CT abdomen (Balthazar scoring): definitive - necrosis assessment

Severity Assessment - Ranson's Criteria (Exam Favourite)

• Age > 55
• WBC > 16,000
• Blood glucose > 200 mg/dL
• LDH > 350 IU/L
• AST > 250 IU/L

• Haematocrit fall > 10%
• BUN rise > 5 mg/dL
• Ca²⁺ < 8 mg/dL
• PaO₂ < 60 mmHg
• Base deficit > 4 mEq/L
• Fluid sequestration > 6L

Complications

• Local: pancreatic necrosis, pseudocyst, abscess
• Systemic: ARDS, renal failure, DIC, shock
• Chronic: diabetes, malabsorption, steatorrhoea

Treatment

• Conservative (mainstay): IV fluids, bowel rest (NPO), analgesia (pethidine - not morphine, which causes sphincter of Oddi spasm), NG tube, monitor
• ERCP: if gallstone pancreatitis with biliary obstruction
• Surgery: for infected necrosis, abscess, failure of conservative treatment

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TOPIC 8: GASTROINTESTINAL BLEEDING

Upper GI Bleed (source above ligament of Treitz)

1. Resuscitate (IV access, fluids, O₂, cross-match)
2. Urgent endoscopy (within 24 hours; < 12 hours if haemodynamically unstable)
3. Endoscopic haemostasis: injection (adrenaline), thermal coagulation, haemoclips
4. PPI infusion (omeprazole 80 mg bolus → infusion)
5. Surgery if endoscopy fails: underrunning the ulcer, partial gastrectomy

• Sengstaken-Blakemore tube for tamponade
• Terlipressin / Octreotide (vasoconstrictors)
• Endoscopic banding / sclerotherapy
• TIPSS (Transjugular Intrahepatic Portosystemic Shunt) if refractory

Lower GI Bleed (source below ligament of Treitz)

• Causes: haemorrhoids, diverticular disease, angiodysplasia, colorectal cancer, IBD, polyps
• Investigation: colonoscopy, CT angiography if massive
• Treatment: depends on cause; angioembolisation for bleeding angiodysplasia; surgery if massive uncontrolled haemorrhage

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TOPIC 9: HAEMORRHOIDS (PILES)

Classification

• First degree: bleed only, do not prolapse
• Second degree: prolapse on straining, reduce spontaneously
• Third degree: prolapse, require manual reduction
• Fourth degree: permanently prolapsed, irreducible

Positions: 3, 7, 11 o'clock (patient in lithotomy)

Treatment

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TOPIC 10: ANORECTAL CONDITIONS

Anal Fissure

• Tear in anal mucosa, usually at 6 o'clock (posterior midline)
• Causes: constipation, trauma
• Features: severe pain during/after defaecation, bright red blood streaking stool, sentinel pile
• Treatment: stool softeners, GTN ointment / diltiazem (chemical sphincterotomy), lateral internal sphincterotomy (definitive surgical treatment)

Anorectal Abscess and Fistula-in-Ano

• Cryptoglandular origin: infection of anal glands
• Types by position: perianal (most common), ischiorectal, intersphincteric, supralevator
• Goodsall's Rule: fistula with external opening anterior to transverse anal line → straight radial track; posterior → curved track to posterior midline
• Treatment: incision and drainage (abscess); fistulotomy / seton for fistula

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IMPORTANT SURGICAL OPERATIONS - QUICK REFERENCE

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EXAM HOT TOPICS - FREQUENTLY ASKED

1. Complications of PUD: Perforation, Bleeding, Pyloric stenosis
2. Ranson's criteria for pancreatitis severity
3. Dukes' staging of colorectal cancer
4. Alvarado score for appendicitis
5. Goodsall's rule for fistula-in-ano
6. GET SMASHED - causes of pancreatitis
7. Indirect vs Direct inguinal hernia differences
8. Grey Turner's / Cullen's signs in pancreatitis
9. Sengstaken-Blakemore tube - management of oesophageal varices
10. Amoebic vs Pyogenic liver abscess
11. Adenoma-carcinoma sequence in colorectal cancer
12. FAP - prophylactic colectomy indication

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