WBUHS (2008-2020) rd 3 Prof. M.B.B.S, Part - II Paper I – Answers of Surgery Question Papers for M.B.B.S Students Dr. Arkaprovo Roy ASSOCIATE PROFESSOR DEPARTMENT OF GENERAL SURGERY MEDICAL COLLEGE, KOLKATA The West Bengal University of Health Sciences M.B.B.S. 3rd Professional Part – II Examination, 2020 Subject: Surgery Time: 21/2 hrs. Paper: I Marks: 60 Group – A 1. What are Hospital Acquired Infections (HAI) and Surgical Site Infections (SSI)? Define Bacterimia and Systemic Inflammatory Response Syndrome. How will you prevent infections (broad outline only). 21/2+21/2+21/2+21/2+5 Group – B 2. a) A middle aged gentleman presents with profuse haematemesis following analgesic intake. How will you investigate and manage this patient? What are the complications of chronic peptic ulcer? 5+5+5 Or b) A lactating woman presents to emergency with painful lump in the right breast which is associated with fever. Write down the clinical examination, investigations and treatment of this patient. 5+5+5 Group – C 3. Answer in brief on any three of the following: 3x5 a) Parotid fistula b) Cold abscess c) Volvulus d) Idiopathic Thrombocytopenic Purpura (ITP) e) Acute necrotizing pancreatitis. Group – D 4. Write short notes (any three): 3x5 a) Sequestrum b) Pott’s paraplegia c) Tennis elbow d) Avascular necrosis e) Dupuytren’s contracture Answers. 1. Hospital-acquired infections, also known as healthcare-associated infections (HAI), are nosocomially acquired infections that are typically not present or might be incubating at the time of admission. These infections are usually acquired after hospitalization and manifest 48 hours after admission to the hospital. A surgical site infection (SSI) is an infection that occurs after surgery in the part of the body where the surgery took place. Bacterimia: Bacteremia is the presence of viable bacteria in the circulating blood.This may or may not have any clinical significance because harmless, transient bacteremia may occur following dental work or other minor medical procedures; however, this bacteremia is generally clinically benign and self-resolving in children who do not have an underlying illness or immune deficiency or a turbulent cardiac blood flow. The concern with occult bacteremia is that it could progress to a more severe local or systemic infection if left untreated. Most episodes of occult bacteremia spontaneously resolve, and serious sequelae are increasingly uncommon. However, serious bacterial infections occur, including pneumonia, septic arthritis, osteomyelitis, cellulitis, meningitis, brain abscesses, and sepsis, possibly resulting in death. Systemic inflammatory response syndrome. Criteria for Four Categories of the Systemic Inflammatory Response Syndrome Systemic Inflammatory Response Syndrome (SIRS) Two or more of the following: ▪ Temperature (core) >38°C or <36°C ▪ Heart rate >90 beats/min ▪ Respiratory rate of >20 breaths/min for patients spontaneously ventilating or a PaCO2 <32 mm Hg White blood cell count >12,000 cells/mm3 or <4000 cells/mm3 or >10% immature ▪ (band) cells in the peripheral blood smear Sepsis Same criteria as for SIRS but with a clearly established focus of infection Severe Sepsis Sepsis associated with organ dysfunction and hypoperfusion Indicators of hypoperfusion: ▪ Systolic blood pressure <90 mm Hg ▪ >40 mm Hg fall from normal systolic blood pressure ▪ Lacticacidemia ▪ Oliguria ▪ Acute mental status changes Septic Shock Patients with severe sepsis who ▪ Are not responsive to intravenous fluid infusion for resuscitation ▪ Require inotropic or vasopressor agents to maintain systolic blood pressure Prevention of infection: Best Strategies for Infection Prevention and Control Hand Hygiene. Environmental hygiene. Screening and cohorting patients. Vaccinations. Surveillance. Antibiotic stewardship Care coordination Following the evidence Strategies for infection prevention & control (1) Hand hygiene: hand washing should be the cornerstone of reducing healthcare associated infections. This is the simplest approach to preventing the spread of infections and needs to be incorporated into the culture of the organization. Wash hands with warm water and soap vigorously for at least 20 seconds. Also, all staff members and visitors in the facility should be encouraged to wash their hands before drinking, eating, providing care and between caring for patients. (2) Use gloves: health care professionals may not always wear gloves when interacting with patients. But, if any contact with blood or bodily fluids is possible, such as when changing sheets or emptying trash, gloves should be worn. (3) Disinfect and keep surfaces clean: between patients, every room in a facility should be cleaned thoroughly with a us epa approved healthcare grade disinfectant. This helps to prevent accidental transmission of infections as new patients are admitted. (4) Use personal protective equipment: appropriate personal protective equipment (PPE), such as gowns, gloves, masks and face shields, should be readily available to staff for usage. (5) Provide infection control education: staff members need to know how to identify common infections and help prevent their spread. In addition, your organization should provide continued, recurring education on infection control. This includes training on blood borne pathogen and droplet-borne infections. (6) Develop an infection prevention and control policy: the facility must establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (7) Antibiotic stewardship: the misuse and overuse of antibiotics can put patients at a risk of contracting infections. Inappropriate antibiotic use may also result in patients becoming resistant to some drugs. If those patients contract an infection, it becomes harder to treat them and the risk of it spreading increases. 2. a) This is a case of analgesic induced peptic ulcer bleeding: Aspirin and paracetamol (acetaminophen) are the most commonly used minor analgesics, but their effects on the gastrointestinal tract differ widely. The effects of other non-steroidal anti-inflammatory drugs (NSAIDs), including phenylbutazone, are intermediate. Aspirin is significantly associated with major upper gastrointestinal haemorrhage, whereas paracetamol is not. Short term use of aspirin produces erythema, erosions and occasionally ulcers; paracetamol does not, while other NSAIDs do so to varying degrees. Complications of chronic peptic ulcer: Internal bleeding: If a peptic ulcer develops near the site of a blood vessel, it can damage the vessel and cause bleeding. Internal is one of the most common complications of a peptic ulcer occurring in between 15-20% of cases. Risk factors for bleeding include: Continued use of non-steroidal anti-inflammatory drugs (nsaids), and Being 60 years of age, or over. Depending on the site and type of the blood vessel, this could cause moderate but long-term bleeding which can lead to anaemia (a condition where the body does not have enough oxygen-carrying red blood cells). Symptoms of anaemia include: Fatigue, Breathlessness (dyspnoea), Pale skin, and Irregular heart beats. Alternatively, the bleeding can be rapid and massive, causing you to: Vomit blood, and/or Pass stools that are very dark or tar-like. If the bleeding is moderate, it can usually be treated by giving you injections of proton pump inhibitors (PPIs). Research has found that lowering the amount of acid around the site of the bleeding makes the blood more likely to clot so that the bleeding will stop. Massive bleeding can be treated using blood transfusions to replace any blood loss. Surgery can be used to repair the blood vessels. Once you are in a stable condition, an endoscopy will be carried out to determine whether there is a high risk of the bleeding recurring. If your risk is thought to be high, you will be given a further course of eradication therapy and PPIs. Perforation Perforation means that the ulcer has eaten through all of your stomach lining. It occurs in an estimated 2-10% of all cases. Perforation is potentially very serious because bacteria that live in your stomach can move out of your stomach and infect the lining of your abdomen (peritoneum). This is known as peritonitis. Peritonitis is a medical emergency because tissue of the peritoneum is usually sterile (germ- free) so unlike other parts of the body, such as the skin, it does not have an inbuilt defence mechanism for fighting off infection. In peritonitis, an infection can rapidly spread into the blood (sepsis) before spreading to other organs. This carries the risk of multiple organ failure and, if left untreated, death. The most common symptom of peritonitis is the sudden onset of abdominal pain that then gets steadily worse. Peritonitis requires admission to hospital where you will be treated with injections of antibiotics to get rid of the infection. Surgery is then used to seal the hole in the stomach wall. Gastric obstruction In some cases, a peptic ulcer can produce inflammation (swelling) and /or scar tissue that can obstruct the normal passage of food through your digestive system. This is known as gastric obstruction. Gastric obstruction occurs in an estimated 5-8% of cases of peptic ulcers. Symptoms of gastric obstruction include: Repeated episodes of vomiting, with large amounts of vomit that contain undigested food, A persistent feeling of bloating, or fullness, Feeling very full after eating less food than usual, and Unexplained weight loss. If a diagnosis of gastric obstruction is suspected, an endoscopy will be used to determine the type and site of the obstruction. If the obstruction is due to inflammation, PPIs or H2-receptor antagonists can be used to reduce the inflammation. If the obstruction is due to scar tissue, surgery will be required to treat it. One option is to pass a small balloon through an endoscope and then inflate it in order to widen the site of the obstruction. In more severe cases of scarring, it may be necessary to surgically remove the affected section of stomach, before and reattaching the remainder of the stomach.