General Surgery
General surgery tests the acute abdomen, hernia anatomy, gallstone disease, bowel obstruction and common post-operative problems.
Acute abdomen
- Appendicitis: periumbilical pain migrating to the right iliac fossa, McBurney tenderness; the Alvarado score combines symptoms, signs and leukocytosis.
- Acute cholecystitis: right upper quadrant pain, Murphy sign, fever, ultrasound showing stones, wall thickening and pericholecystic fluid.
- Ascending cholangitis: Charcot triad of fever, jaundice and right upper quadrant pain; Reynolds pentad adds hypotension and confusion. Requires biliary drainage plus antibiotics.
Obstruction
- Small bowel obstruction: adhesions and hernia are commonest; look for vomiting, distension, absolute constipation and air-fluid levels.
- Large bowel obstruction: colorectal cancer and sigmoid volvulus; volvulus shows a coffee-bean sign.
Hernia
Indirect inguinal hernia passes lateral to the inferior epigastric vessels through the deep ring; direct hernia passes medial to them through the posterior wall.
Post-operative fever
Timed causes: atelectasis in the first 48 hours, urinary infection, wound infection, then deep vein thrombosis, and drugs.
Worked example
A 70-year-old has fever, jaundice and right upper quadrant pain with a dilated common bile duct. This is ascending cholangitis; give antibiotics and resuscitate, and arrange urgent endoscopic biliary drainage, because antibiotics alone fail when the duct is obstructed.
Traps
Operating on cholangitis before drainage, confusing direct and indirect hernia anatomy, and missing strangulation in a patient with pain out of proportion.