General and Gastrointestinal Surgery
What the exam tests
This domain tests a systematic approach to the acute abdomen, bowel obstruction, hernia complications, appendicitis, and the principles of gastrointestinal anastomosis and stoma care, including safe source control in intra-abdominal sepsis.
Core rules
- Resuscitate before diagnosing: ATLS ABCDE, two large-bore cannulae, urine output and lactate.
- Small bowel obstruction: colicky pain, vomiting, distension and absolute constipation; examine hernial orifices and previous scars. Constant pain, tachycardia, fever, tenderness and rising lactate suggest strangulation.
- Large bowel obstruction: consider colorectal cancer, sigmoid volvulus and diverticular stricture. A coffee-bean sign supports volvulus; a flatus tube can decompress a stable sigmoid volvulus, but recurrence warrants elective sigmoid colectomy.
- Appendicitis is clinical; Alvarado scoring and imaging support, not replace, assessment. Exclude gynaecological causes in women of childbearing age.
- Anastomosis requires tension-free, well-perfused bowel, accurate apposition and attention to patient factors.
Worked example
A 65-year-old with abdominal distension and absolute constipation has a plain film showing a hugely dilated sigmoid loop. He is stable, without peritonism. The initial step is resuscitation and flatus-tube decompression after excluding perforation. If successful, plan semi-elective sigmoid colectomy during the same admission to prevent recurrence. If there is peritonitis or perforation, proceed to emergency resection, usually with an end colostomy.
Traps
Missing an incarcerated femoral hernia in a virgin abdomen; treating pain out of proportion as constipation; failing to recognise strangulation; and giving oral fluids before excluding obstruction.