24- Upper GIT Explains Flashcards
What is the prevalence of BPH in men over the age of 60?
BPH is present in 50% of men over the age of 60.
Where does hyperplasia occur in the prostate gland in BPH?
Hyperplasia occurs in the periurethral glands in the transitional zone of the prostate.
What role do androgens play in the development and progression of BPH?
Androgens, such as testosterone, stimulate the growth and proliferation of prostatic and stromal cells, leading to BPH.
What is the end result of androgen stimulation in prostatic stromal cells?
Androgen stimulation leads to proliferation and growth of these cells.
What are the clinical features used to diagnose BPH?
Clinical diagnosis of BPH involves lower urinary tract symptoms (LUTS), palpable prostatic enlargement, and evidence of impaired voiding on urodynamic assessment.
What are the two main groups of LUTS in BPH?
LUTS in BPH can be divided into obstructive symptoms (hesitancy, poor stream, straining) and irritation symptoms (pain during bladder filling, frequency, urgency, nocturia).
What are the conservative management options for BPH?
Conservative management options include alpha-adrenergic antagonists and 5-alpha reductase inhibitors.
What is the gold standard surgical treatment for BPH?
Transurethral resection of the prostate (TURP) is the gold standard surgical treatment for BPH.
When might an open retropubic prostatectomy be considered for BPH?
An open retropubic prostatectomy may be considered for BPH in cases of a large gland.
What are the two main types of germ cell tumors in testicular cancer?
Seminoma and nonseminomatous germ cell tumors
What is the most common malignancy in men aged 20-30 years?
Testicular cancer
What percentage of testicular cancer cases are germ-cell tumors?
Around 95%
What are the key features of seminoma, the most common subtype of germ cell tumor?
Average age at diagnosis is 40, even advanced disease has a 5-year survival rate of 73%
What tumor markers are associated with seminomas?
HCG (elevated in 10% of cases) and lactate dehydrogenase (elevated in 10-20% of cases)
What tumor markers are commonly elevated in nonseminomatous germ cell tumors?
They include teratoma, yolk sac tumor, choriocarcinoma, and mixed germ cell tumors. They present at a younger age (20-30 years) and advanced disease has a worse prognosis (48% at 5 years).
What are the key features of nonseminomatous germ cell tumors?
They include teratoma, yolk sac tumor, choriocarcinoma, and mixed germ cell tumors. They present at a younger age (20-30 years) and advanced disease has a worse prognosis (48% at 5 years).
What tumor markers are commonly elevated in nonseminomatous germ cell tumors?
AFP (elevated in up to 70% of cases) and HCG (elevated in up to 40% of cases)
What is the characteristic texture of nonseminomatous germ cell tumors?
They have a heterogeneous texture with occasional ectopic tissue, such as hair.
What are the risk factors for testicular cancer?
Cryptorchidism, infertility, family history, Klinefelter’s syndrome, and mumps orchitis
What is the most common presenting symptom of testicular cancer?
A painless lump
What is the first-line diagnostic test for testicular cancer?
Ultrasound
What are other possible features of testicular cancer?
Pain (in a minority of men), hydrocele, and gynecomastia
What imaging is used for staging testicular cancer?
CT scanning of the chest, abdomen, and pelvis
What should be measured as tumor markers in testicular cancer?
HCG, AFP, and lactate dehydrogenase
What is the management for testicular cancer?
Orchidectomy (inguinal approach), chemotherapy, and radiotherapy (depending on staging)
What surgical procedure may be required for abdominal lesions following chemotherapy?
Retroperitoneal lymph node dissection
What is the 5-year survival rate for seminomas if Stage I?
Around 95%
What is the 5-year survival rate for teratomas if Stage I?
Around 85%
What is another name for epididymo-orchitis?
Acute epididymitis
What is the usual cause of epididymo-orchitis in men under 35 years of age?
Gonorrhea or chlamydia
What medication is a non-infective cause of epididymitis?
Amiodarone
What are the distinguishing features of epididymo-orchitis compared to testicular torsion?
Tenderness usually confined to the epididymis, pain does not affect the entire testis
What is testicular torsion?
Twist of the spermatic cord resulting in testicular ischemia and necrosis
What is the peak incidence of testicular torsion?
Males aged between 10 and 30, with a peak incidence at 13-15 years
What are the symptoms of testicular torsion?
Severe and sudden onset of pain, loss of cremasteric reflex, and elevation of the testis does not ease the pain
What is the treatment for testicular torsion?
Surgical exploration and fixation of both testes
What is a hydrocele?
A mass that transilluminates and can be examined above
How should a hydrocele in younger men be investigated?
With an ultrasound to exclude tumor
What is the treatment for hydrocele in children?
Transinguinal ligation of the patent processus vaginalis
With an ultrasound to exclude tumor
Lords or Jabouley procedure
What is the most common cause of bladder injuries?
Blunt trauma
What percentage of bladder injuries are associated with pelvic fractures?
85%
Why are bladder injuries easily overlooked during trauma assessment?
They can be easily missed or overshadowed by other injuries
What percentage of male pelvic fractures are associated with urethral or bladder injuries?
Up to 10%
What are the two types of urethral injury in males?
Bulbar rupture and membranous rupture
What is the most common cause of bulbar rupture?
Straddle-type injury, such as bicycles
What are the signs of bulbar rupture?
Urinary retention, perineal hematoma, and blood at the meatus
What are the signs of membranous rupture?
Penile or perineal edema/hematoma, displaced prostate on PR examination
What imaging is used to investigate urethral injuries?
Ascending urethrogram
What is the management for urethral injuries?
Suprapubic catheter (surgical placement, not percutaneously)
What are the causes of external genitalia injuries?
Penetration, blunt trauma, continence or sexual pleasure-enhancing devices, and mutilation
Is bladder injury rupture intra or extraperitoneal?
It can be either intra or extraperitoneal
How can bladder injury be indicated if a Foley catheter is used to irrigate the bladder?
Inability to retrieve all the fluid used for irrigation
What are the common presentations of bladder injury?
Hematuria or suprapubic pain, history of pelvic fracture, and inability to void
What imaging is used to investigate bladder injuries?
Intravenous urography or cystogram
What is the management for bladder injuries?
Laparotomy if intraperitoneal, conservative if extraperitoneal
Why do treatments for squamous cell carcinomas (SCC) and adenocarcinomas of the esophagus differ?
Positive outcomes observed with radical chemoradiotherapy for localized SCC, particularly in the proximal esophagus, make surgery unnecessary
Who should be considered for surgery in esophageal cancer?
Only patients with negative staging investigations for metastatic disease
What is the surgical option for early localized adenocarcinoma of the distal esophagus?
Endoscopic mucosal resection
Which surgical approach is commonly used for junctional (type II) tumors with limited thoracic resection required?
Transhiatal esophagectomy
What is the advantage of Ivor Lewis esophagectomy for middle and distal tumors?
Lower incidence of recurrent laryngeal nerve injury
Which surgical approach may be useful for proximal tumors and has a lower risk of anastomotic leakage?
McKeown esophagectomy
What is the disadvantage of McKeown esophagectomy compared to Ivor Lewis esophagectomy?
Higher incidence of recurrent laryngeal nerve injury
What is associated with a survival advantage in esophageal cancer?
Preoperative chemotherapy
What is the risk associated with anastomotic leakage in intrathoracic anastomosis?
The risk of mediastinitis
What is the benefit of neoadjuvant radiotherapy alone prior to resection?
It confers little benefit and is not routinely performed
In which type of tumors does perioperative chemotherapy confer a survival advantage?
Junctional tumors
Is postoperative chemotherapy generally recommended after esophageal resections?
No, it is not generally recommended outside of clinical trials
Which treatment may improve survival in patients with HER2 positive tumors?
Trastuzumab
What is the effect of combination chemotherapy in non-operable esophageal cancer?
It improves quality of life and survival
What is the preferred treatment for patients with occluding tumors >2cm from the cricopharyngeus?
Oesophageal intubation with self-expanding metal stents
When are covered metal stents useful?
In cases of malignant fistulas
Which therapies may be useful for tumor overgrowth and bleeding?
Laser therapy and argon plasma coagulation
Should photodynamic therapy and ethanol injections be routinely used in esophageal cancer?
No, they confer little benefit and should not be routinely used
What condition presents with inguinoscrotal swelling that cannot be ‘get above it’ on examination?
Inguinal hernia
What are the symptoms of testicular tumors?
Discrete testicular nodule, may have associated hydrocele, and symptoms of metastatic disease
What tests are required to evaluate testicular tumors?
USS scrotum and serum AFP and β HCG
What are the common symptoms associated with acute epididymo-orchitis?
History of dysuria and urethral discharge
What can ease the swelling in acute epididymo-orchitis?
Elevating the testis
What is the usual cause of most cases of acute epididymo-orchitis?
Chlamydia infection
At what age do epididymal cysts usually occur?
Over 40 years of age
What may be associated with epididymal cysts?
Single or multiple cysts that may contain clear or opalescent fluid (spermatoceles)
What is a characteristic feature of hydrocele?
Non-painful, soft fluctuant swelling that transilluminates
What condition should be considered if hydrocele is the presenting feature in young men?
Testicular cancer
What is a characteristic feature of testicular torsion?
Severe, sudden onset testicular pain
Which side do varicoceles typically occur on?
Left side (due to the testicular vein draining into the renal vein)
What condition may be associated with varicoceles and affect fertility?
Bilateral varicoceles, and it may be a presenting feature of renal cell carcinoma
What is the recommended treatment for testicular torsion?
Urgent surgery and fixation of the contralateral testis
What is the treatment for testicular malignancy?
Orchidectomy via an inguinal approach
Why is orchidectomy performed via an inguinal approach for testicular malignancy?
It allows high ligation of the testicular vessels and avoids exposing another lymphatic field to the tumor
What is the treatment for testicular torsion?
Prompt surgical exploration and testicular fixation, achieved through sutures or placement in a Dartos pouch
Which age group is most commonly affected by testicular torsion?
Young teenagers
How should varicoceles be managed?
Usually managed conservatively, but surgery or radiological management can be considered if there are concerns about testicular function or infertility
What is the recommended approach for excising epididymal cysts?
Scrotal approach
How are hydroceles managed in adults?
Scrotal approach, with excision or plication of the hydrocele sac
How are hydroceles managed in children?
Inguinal approach, ligating the underlying patent processus vaginalis
Which gender is most commonly affected by urinary incontinence?
Females (80% of cases)
What is the prevalence of urinary incontinence in those aged greater than 65 years?
11%
What are the common variants of urinary incontinence?
Stress urinary incontinence (50%), urge incontinence (15%), and mixed incontinence (35%)
What anatomical factors contribute to urinary incontinence in males?
Males have two powerful sphincters, one at the bladder neck and the other in the urethra. Damage to the bladder neck mechanism can occur following prostatectomy and may cause retrograde ejaculation. The segment of the urethra passing through the urogenital diaphragm has both striated and smooth muscle, with the latter maintaining continence after prostatectomy.
How is urinary incontinence in females different from males?
The sphincter complex at the level of the bladder neck is poorly developed in females. The external sphincter complex is functionally more important in females, similar to males.
How can obstetric events in females lead to stress urinary incontinence?
Obstetric events may cause neuropathy, compromising the innervation of the pudendal nerve, which can lead to stress urinary incontinence.
What is the most common type of urinary incontinence?
Stress urinary incontinence, especially in females (50% of cases)
What are the innervation pathways involved in bladder control?
Somatic innervation is via the pudendal, hypogastric, and pelvic nerves. Autonomic nerves also travel in these fibers. Sympathetic innervation leads to detrusor relaxation and sphincter contraction, while parasympathetic innervation causes detrusor contraction and sphincter relaxation.
What can cause stress urinary incontinence?
Damage to the supporting structures surrounding the bladder, often from obstetric events, can lead to urethral hypermobility. Other cases may be due to sphincter dysfunction, usually from neurological disorders such as pudendal neuropathy or multiple sclerosis.
What are the two mechanisms that can result in involuntary passage of urine in stress urinary incontinence?
Urethral mobility, where pressure is not transmitted appropriately to the urethra during episodes of raised intra-abdominal pressure, and sphincter dysfunction, where the sphincter fails to adapt to compress the urethra, resulting in involuntary passage of urine. Complete failure of the sphincter can lead to continuous passage of urine.
What is urge incontinence?
Involuntary passage of urine accompanied by a sense of urgency
What is the main characteristic of the detrusor muscle in patients with urge incontinence?
Unstable and overactive detrusor muscle
What can urodynamic investigation reveal in patients with urge incontinence?
Overactivity of the detrusor muscle at inappropriate times, such as during bladder filling
What are the possible causes of urge incontinence?
Both patients with overt neurological disorders and those without can experience urgency. The exact pathophysiology is not well understood, but poor coordination of events during bladder filling is thought to be the main process.
What is the recommended assessment for patients with urge incontinence?
Careful history and examination, including vaginal examination for cystocele. Bladder diary for at least 3 days. Consider flow cystometry if symptoms are unclear or if surgery is being considered and the diagnosis is unclear. Exclude other organic diseases such as stones, UTI, and cancer.
What is the initial management approach for urge incontinence?
Conservative measures should be tried first. Patients with stress urinary incontinence or mixed symptoms should undergo 3 months of pelvic floor exercises. Patients with an overactive bladder should undergo 6 weeks of bladder retraining.
What drug therapy can be offered to women with overactive bladder if conservative measures fail?
Oxybutynin (or solifenacin if elderly)
What treatment options are available for women with detrusor instability who fail non-operative therapy?
A trial of sacral neuromodulation may be considered, with conversion to a permanent implant if there is a good response. Alternatively, augmentation cystoplasty can be considered, but this will involve long-term intermittent self-catheterization.
What procedure may be undertaken for women with stress urinary incontinence?
A urethral sling-type procedure
What are the NICE guidelines for the assessment and management of urinary incontinence?
Initial assessment should classify urinary incontinence as stress/urge/mixed. At least 3 to 7 days of bladder diary should be used if classification is not easy. Conservative treatment should be started before urodynamic studies if the diagnosis is obvious from the history. Urodynamic studies should be considered if surgery is planned. Pelvic floor exercises should be offered to all women in their first pregnancy.
What percentage of the worldwide population is affected by urolithiasis?
Up to 15%
What are the classic features in the history of urolithiasis?
Sudden onset loin to groin pain that is colicky in nature, associated with haematuria (visible or detectable on urine dipstick testing)
What is the most sensitive and specific investigation for suspected renal stones?
Helical, non-contrast, computerised tomographic (CT) scanning
What is the typical management for renal stones measuring less than 5mm in maximum diameter?
They will typically pass within 4 weeks of symptom onset.
When is more urgent treatment indicated for renal stones?
In the presence of ureteric obstruction, renal developmental abnormalities (such as horseshoe kidney), and previous renal transplant.
What are the options for treating ureteric obstruction together with infection as a surgical emergency?
Nephrostomy tube placement or ureteric stent placement via cystoscopy
What are the preferred options for the non-emergency treatment of renal stones?
Extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), and ureteroscopy (URS)
What are the potential complications of extracorporeal shock wave lithotripsy (ESWL)?
Solid organ injury and fragmentation of larger stones resulting in ureteric obstruction.
What is the principle behind extracorporeal shock wave lithotripsy (ESWL)?
Shock waves generated externally lead to stone fragmentation through cavitation bubbles and mechanical stress.
When is extracorporeal shock wave lithotripsy (ESWL) contraindicated?
In pregnant females and patients with significant vascular calcification.
How is a ureteroscope passed during ureteroscopy?
Retrograde via the urethra, bladder, and into the ureter and renal pelvis
What methods are used for stone fragmentation during ureteroscopy?
Laser or pneumatic fragmentation (lithoclasty) using the ureteroscope
What is done with the stone fragments during ureteroscopy?
They are extracted
How is percutaneous access gained during percutaneous nephrolithotomy?
Through percutaneous access to the renal collecting system
What procedures are performed to fragment and remove stones during percutaneous nephrolithotomy?
Endoscopic intra-corporeal lithotripsy, lithoclasty, or laser stone fragmentation
What is the purpose of percutaneous nephrolithotomy?
To remove stone fragments
What is the first-line option for renal stones measuring less than 5mm and asymptomatic?
Watchful waiting
What is the first-line option for renal stones measuring less than 10mm?
Extracorporeal shock wave lithotripsy (ESWL)
What are the first-line options for renal stones measuring 10-20mm?
ESWL or ureteroscopy
What is the first-line option for renal stones measuring greater than 20mm (including staghorn calculi)?
Percutaneous nephrolithotomy (PCNL)
What is the first-line option for ureteric stones measuring 10-20mm?
Ureteroscopy
What is the first-line option for ureteric stones measuring less than 5mm?
Watchful waiting
What is the first-line option for ureteric stones measuring 5-10mm?
Extracorporeal shock wave lithotripsy (ESWL)
What is vasectomy?
A commonly performed technique for permanent sterilization
What is the failure rate of vasectomy?
1 in 2000
How is vasectomy typically performed?
Under local anesthesia
What are the success rates for vasectomy reversal within 10 years of the procedure?
Approximately 55%
Is vasectomy considered a permanent procedure?
Yes, for counseling purposes
What is the standard technique for vasectomy?
Small bilateral incisions and formal dissection of the vas
What is the ‘no scalpel’ technique for vasectomy?
A technique involving the use of haemostats for skin puncture
Is it necessary to routinely send the vas for histology after vasectomy?
No
Who should be cautious when considering vasectomy?
Childless, single men under the age of 30
What are the risks associated with vasectomy?
Chronic scrotal pain, haematomas, and sperm granulomas
When should clearance be granted after vasectomy?
After a negative sperm sample is available, usually taken 12-16 weeks post-procedure
Can recanalization occur after vasectomy?
Yes, in 0.04% of cases
What is the criteria for ‘special clearance’ to stop contraception after vasectomy?
Less than 10,000 non-motile sperm/mL found in a fresh specimen examined at least 7 months after vasectomy
Do the risks of sexually transmitted infections (STIs) change after vasectomy?
No, the risks of STIs remain unchanged
What is a Mallory-Weiss Tear?
A tear in the oesophagus usually caused by antecedent vomiting, followed by the vomiting of a small amount of blood
What are the features of a Mallory-Weiss Tear?
Little systemic disturbance or prior symptoms
What is a Hiatus Hernia of gastric cardia?
A longstanding condition associated with dyspepsia, often seen in overweight patients
Can uncomplicated hiatus hernias be associated with dysphagia or haematemesis?
No
What is Oesophageal Rupture?
A complete disruption of the oesophageal wall in the absence of pre-existing pathology, commonly occurring at the left postero-lateral oesophagus
What are the signs of Oesophageal Rupture?
Severe chest pain without cardiac diagnosis, signs suggestive of pneumonia without convincing history, history of vomiting
What is Squamous Cell Carcinoma of the oesophagus?
A type of oesophageal cancer characterized by progressive dysphagia and weight loss
Is there a history of previous GORD symptoms in Squamous Cell Carcinoma of the oesophagus?
Usually little or no history of previous GORD symptoms
What is Adenocarcinoma of the oesophagus?
Another type of oesophageal cancer characterized by progressive dysphagia, may have previous symptoms of GORD or Barrett’s oesophagus
What is Dysmotility Disorder?
A condition characterized by episodic and non-progressive dysphagia, may be accompanied by retrosternal pain
What are the features of Peptic Stricture?
Longer history of dysphagia, often not progressive, symptoms of GORD, lack systemic features seen with malignancy
How can most oesophageal diseases be accurately diagnosed?
Through upper GI endoscopy, pH and manometry studies, and radiological contrast swallows
How many types of metaplastic processes are recognized in Barrett’s oesophagus?
Three types: intestinal (high risk), cardiac, and fundic
What is Barrett’s oesophagus characterized by?
The metaplastic transformation of squamous oesophageal epithelium to columnar gastric type epithelium
What is the most concrete diagnosis for Barrett’s oesophagus?
Presence of endoscopic features of Barrett’s oesophagus and a deep biopsy demonstrating goblet cell metaplasia and oesophageal glands
How is Barrett’s oesophagus classified based on the length of the affected segment?
Short (<3cm) and long (>3cm)
What is the correlation between the length of the affected segment and the chances of identifying metaplasia?
Strong correlation
What is the overall prevalence of Barrett’s oesophagus?
Difficult to determine, but may be around 1 in 20
What proportion of patients with metaplasia may progress to dysplasia?
A proportion of patients
How often should endoscopic surveillance be done for individuals with Barrett’s oesophagus?
Every 2-5 years
Why should individuals with Barrett’s oesophagus undergo endoscopic surveillance?
To detect dysplasia
What kind of biopsies should be taken during endoscopic surveillance?
Quadrantic biopsies taken at 2-3cm intervals
What should be considered when mass lesions are present in Barrett’s oesophagus?
Endoscopic submucosal resection
What is the recommended treatment for Barrett’s oesophagus?
Long-term proton pump inhibitor therapy
In younger patients, what additional studies may be considered for treatment?
pH and manometry studies to consider anti-reflux procedures
How frequently should endoscopic monitoring be done for individuals with moderate dysplasia?
More frequently
What precaution should be taken when severe dysplasia is present in Barrett’s oesophagus?
To be wary of small foci of cancer
What are the features of calcium oxalate stones?
Hypercalciuria, hyperoxaluria, hypocitraturia, radio-opaque
What is a major risk factor for calcium oxalate stones?
Hypercalciuria
Why are calcium oxalate stones radio-opaque?
Due to their composition
What increases the risk of calcium oxalate stones?
Hyperoxaluria and hypocitraturia
What can cause uric acid stones to form along with calcium oxalate?
Hyperuricosuria
What is the percentage of all calculi accounted for by calcium oxalate stones?
85%
What are the features of cystine stones?
Inherited recessive disorder, multiple stones, radiodense (contain sulfur)
What causes cystine stones to form?
Decreased absorption of cystine due to transmembrane cystine transport disorder
What is the percentage of all calculi accounted for by cystine stones?
1%
What are the features of uric acid stones?
Formed from purine metabolism, precipitate in low urinary pH, more common in children with inborn errors of metabolism, radiolucent
What is the percentage of all calculi accounted for by uric acid stones?
5-10%
What is the percentage of all calculi accounted for by calcium phosphate stones?
10%
What are the features of calcium phosphate stones?
Associated with renal tubular acidosis, high urinary pH increases supersaturation of urine with calcium and phosphate, radio-dense (composition similar to bone)
What are the features of struvite stones?
Formed from magnesium, ammonium, and phosphate, associated with urease-producing bacteria and chronic infections, slightly radio-opaque
What is the percentage of all calculi accounted for by struvite stones?
2-20%
What is the mean urine pH for calcium phosphate stones?
Normal to alkaline (>5.5)
How does urine pH affect stone formation?
Urine pH can vary from acidic to alkaline, and different stone types are associated with different urine pH levels
What is the mean urine pH for calcium oxalate stones?
Variable (around 6)
What is the mean urine pH for uric acid stones?
Acidic (around 5.5)
What is the mean urine pH for struvite stones?
Alkaline (>7.2)
What is the mean urine pH for cystine stones?
Normal (around 6.5)
What is renal cell carcinoma?
An adenocarcinoma of the renal cortex believed to arise from the proximal convoluted tubule
What are the characteristics of renal cell carcinoma?
Usually solid lesions, up to 20% may be multifocal, 20% may be calcified, and 20% may have a cystic component or be wholly cystic
How are renal cell carcinomas often circumscribed?
By a pseudocapsule of compressed normal renal tissue
How does renal cell carcinoma spread?
Direct extension into the adrenal gland, renal vein, or surrounding fascia, or via the haematogenous route to lung, bone, or brain
What percentage of all renal malignancies does renal cell carcinoma comprise?
Up to 85%
Who is more commonly affected by renal cell carcinoma?
Males (typically in their sixth decade)
What are common symptoms of renal cell carcinoma?
Haematuria (50%), loin pain (40%), mass (30%), and symptoms of metastasis (up to 25%)
What is the recommended imaging modality for investigating renal masses?
Multislice CT scanning
What should be done to detect distant disease in renal cell carcinoma?
CT scanning of the chest and abdomen
When should a biopsy be performed in renal cell carcinoma?
Before any ablative therapies are undertaken
What is the management approach for T1 lesions in renal cell carcinoma?
Partial nephrectomy, which gives equivalent oncological results to total radical nephrectomy
When is radical nephrectomy performed in renal cell carcinoma?
For T2 lesions and above
What should be done during surgery for renal cell carcinoma?
Early venous control to avoid shedding of tumour cells into the circulation
Do patients with completely resected renal cell carcinoma benefit from adjuvant therapy?
No, adjuvant therapy is not beneficial
What is the recommended treatment for transitional cell cancer?
Nephroureterectomy with disconnection of the ureter at the bladder
What is a DMSA scan?
A scintigraphy using dimercaptosuccinic acid (DMSA)
Which part of the kidney does DMSA localize to?
Renal cortex
How does DTPA provide information about glomerular filtration rate (GFR)?
It is filtered at the level of the glomerulus
What can a DMSA scan help identify?
Cortical defects and ectopic or aberrant kidneys
What is DTPA used for?
Assessing renal function
Does a DMSA scan provide information on the ureter or collecting system?
No, it does not
Can image quality be affected in patients with chronic renal impairment?
Yes, it may be degraded in such cases
What is used for a MAG 3 renogram?
Mercaptoacetyle triglycine (MAG 3)
How is MAG 3 primarily excreted?
By tubular cells instead of being filtered at the glomerulus
In which patients is MAG 3 the preferred agent for kidney imaging?
Patients with existing renal impairment
What does an MCUG scan provide information about?
Bladder reflux
How is an MCUG scan performed?
By filling the bladder with contrast media and asking the child to void
What can be calculated based on the images obtained during an MCUG scan?
The degree of reflux
What can intravenous urography provide evidence of?
Renal stones or other structural lesions
What is intravenous urography?
An examination using intravenous iodinated contrast media
Is intravenous urography commonly used for assessing renal function?
No, it is now rarely used due to non-contrast CT scan protocols for detecting urinary tract calculi
When is PET/CT used in renal imaging?
To evaluate structurally indeterminate lesions in the staging of malignancy
What can be used to supplement oral intake?
Calorie-rich dietary supplements
When may naso gastric feeding be safe to use?
In patients with impaired swallow
When is naso gastric feeding often contraindicated?
Following head injury due to risks associated with tube insertion
What problem does naso jejunal feeding avoid?
Feed pooling in the stomach and the risk of aspiration
How is the feeding tube inserted for naso jejunal feeding?
More technically complicated, easiest if done intraoperatively
When is naso jejunal feeding safe to use?
Following oesophagogastric surgery
What is a feeding jejunostomy?
A surgically sited feeding tube
How long can feeding jejunostomy be used for?
Long-term feeding
What are the main risks associated with feeding jejunostomy?
Tube displacement and peritubal leakage immediately following insertion, which carries a risk of peritonitis
How is percutaneous endoscopic gastrostomy performed?
Combined endoscopic and percutaneous tube insertion
When may percutaneous endoscopic gastrostomy not be possible?
In patients who cannot undergo successful endoscopy
How should total parenteral nutrition be administered?
Via a central vein
What are the risks associated with percutaneous endoscopic gastrostomy?
Aspiration and leakage at the insertion site
When is total parenteral nutrition used?
In patients in whom enteral feeding is contraindicated
What is needed for total parenteral nutrition?
Individualized prescribing and monitoring
Are resections offered to patients with distant metastasis or N2 disease?
No, in general, resections are not offered to those patients
What are the long-term risks associated with total parenteral nutrition?
Fatty liver and deranged liver function tests
Is local nodal involvement a contraindication to resection?
No, local nodal involvement is not a contraindication to resection
What is the mainstay of treatment for esophageal cancer?
Surgical resection
When is neoadjuvant chemotherapy given in the treatment of esophageal cancer?
In most cases, prior to surgery
How may in situ disease be managed?
By endoscopic mucosal resection
What type of procedure is commonly performed for lower third lesions of the esophagus?
Ivor-Lewis procedure
What type of procedure is required for more proximal lesions of the esophagus?
Total esophagectomy (Mckeown type) with anastomosis to the cervical esophagus
Why is a transhiatal procedure an attractive option for very distal tumors?
Because the penetration of two visceral cavities required for an Ivor-Lewis procedure increases the morbidity considerably
What options are available for patients with unresectable esophageal cancer?
Local ablative procedures, palliative chemotherapy, or stent insertion
What incision is made to access the stomach and duodenum in the Ivor-Lewis procedure?
A rooftop incision
What is the first step in laparotomy to mobilize the stomach?
Incising the greater omentum along the greater curvature of the stomach
What is done after incising the greater omentum?
Ligating and detaching the short gastric vessels from the spleen
How is the lesser omentum incised?
How is the lesser omentum incised?
What attachments of the duodenum are incised to allow the pylorus to reach the oesophageal hiatus?
Retroperitoneal attachments in the second and third portions
What additional procedure may be performed to facilitate gastric emptying?
Pyloroplasty
Where is the incision made for right thoracotomy?
Through the 5th intercostal space
At what point is the dissection performed?
10cm above the tumor
What is done after removing the oesophagus with the stomach?
Creating a gastric tube and performing an anastomosis
What may be transected during the dissection?
The azygos vein
Where do patients typically recover initially postoperatively?
In the Intensive Care Unit (ITU)
What must remain in place during the early phases of recovery?
The nasogastric tube
What is the risk of anastomotic leakage?
Relatively high, especially due to the devascularization of the stomach
What are some potential complications postoperatively?
Atelectasis, anastomotic leakage, and delayed gastric emptying
How is delayed gastric emptying often managed?
By performing a pyloroplasty
How many men are diagnosed with prostate cancer each year?
Up to 30,000
How many men die from prostate cancer in the UK per year?
Up to 9,000
What are the possible presentations of metastatic prostate cancer?
Bone pain
How does locally advanced prostate cancer present?
Pelvic pain or urinary symptoms
What tests are used for the diagnosis of prostate cancer?
Prostate specific antigen measurement, digital rectal examination, transrectal ultrasound (with or without biopsy), MRI/CT and bone scan for staging
What is the normal upper limit for prostate specific antigen (PSA)?
4ng/ml
What can cause false positives in PSA tests?
Prostatitis, UTI, BPH, vigorous digital rectal examination (DRE)
How can the percentage of free: total PSA help distinguish benign disease from cancer?
Values of <20% are suggestive of cancer and biopsy is advised
What is the most common type of prostate cancer?
Adenocarcinoma (95%)
How is prostate cancer graded using the Gleason grading system?
Two grades are awarded, one for the most dominant grade and one for the second most dominant grade. The grades are added together to give the Gleason score
Where does lymphatic spread occur first in prostate cancer?
To the obturator nodes
What is the standard treatment for localized prostate cancer?
Radical prostatectomy (surgical removal of the prostate)
What alternative treatment options are available for prostate cancer?
Watchful waiting, radiotherapy, hormonal therapy
What is the preferred option for low-risk men according to NICE?
Active surveillance
What are the criteria for candidates of active surveillance?
Clinical stage T1c, Gleason score 3+3, PSA density < 0.15 ng/ml/ml, cancer in less than 50% of biopsy cores, <10 mm of any core involved
What should be offered if men on active surveillance show evidence of disease progression?
Radical treatment
How should treatment decisions be made for prostate cancer?
In consultation with the patient, considering co-morbidities and life expectancy
What is renal cell carcinoma?
An adenocarcinoma of the renal cortex believed to arise from the proximal convoluted tubule
What are the characteristics of renal cell carcinoma?
Usually solid lesions, may be multifocal, calcified, or have a cystic component. Often circumscribed by a pseudocapsule of compressed normal renal tissue
What percentage of renal malignancies do renal cell carcinomas comprise?
Up to 85%
How does renal cell carcinoma spread?
Direct extension into the adrenal gland, renal vein, or surrounding fascia, and via the haematogenous route to lung, bone, or brain
Who is more commonly affected by renal cell carcinoma?
Males
What are the common symptoms of renal cell carcinoma?
Haematuria, loin pain, mass, symptoms of metastasis
What imaging modality is used to investigate renal masses?
Multislice CT scanning
What additional phases may be added to the CT scan for renal masses?
Arterial and venous phases to demonstrate vascularity and evidence of caval ingrowth
Is routine bone scanning necessary for renal masses?
No, unless there are symptoms suggestive of bone involvement
When is biopsy not performed for renal masses?
When a nephrectomy is planned
What is the standard treatment for T1 renal lesions?
Partial nephrectomy
What is the standard treatment for T2 renal lesions and above?
Radical nephrectomy
How do calcium oxalate stones appear on x-ray?
Opaque
Do patients with completely resected renal cell carcinoma benefit from adjuvant therapy?
No, adjuvant therapy is not beneficial unless part of a clinical trial
What is the management approach for transitional cell cancer?
Nephroureterectomy with disconnection of the ureter at the bladder
What is the frequency of calcium oxalate stones?
40%
What is the frequency of mixed calcium oxalate/phosphate stones?
25%
How do triple phosphate stones appear on x-ray?
Opaque
How do mixed calcium oxalate/phosphate stones appear on x-ray?
Opaque
What is the frequency of triple phosphate stones?
10%
What is the frequency of calcium phosphate stones?
10%
How do calcium phosphate stones appear on x-ray?
Opaque
What is the frequency of urate stones?
5-10%
How do urate stones appear on x-ray?
Radio-lucent
What is the frequency of cystine stones?
1%
How do cystine stones appear on x-ray?
Semi-opaque, ‘ground-glass’ appearance
What is the frequency of xanthine stones?
<1%
How do xanthine stones appear on x-ray?
Radio-lucent
What are the causes of unilateral hydronephrosis?
Pelvic-ureteric obstruction (congenital or acquired), aberrant renal vessels, calculi, tumours of the renal pelvis
What are the causes of bilateral hydronephrosis?
Stenosis of the urethra, urethral valve, prostatic enlargement, extensive bladder tumour, retro-peritoneal fibrosis
What imaging modality can identify the presence of hydronephrosis and assess the kidneys?
USS (Ultrasound)
What imaging modality can assess the position of the obstruction?
IVU (Intravenous Urogram)
What type of pyelography allows for treatment?
Antegrade or retrograde pyelography
What imaging modality is used if renal colic is suspected?
Non-contrast CT scan
What is the management approach for acute upper urinary tract obstruction?
Nephrostomy tube placement
What is the management approach for chronic upper urinary tract obstruction?
Ureteric stent or pyeloplasty
What is the increased risk of bladder cancer for current or previous smokers?
2-5 fold
What is the second most common urological cancer?
Bladder cancer
What is a common cause of squamous cell carcinomas in regions where Schistosomiasis is endemic?
Chronic bladder inflammation arising from Schistosomiasis infection
What is the most common type of bladder malignancy?
Transitional cell carcinoma (>90% of cases)
Are benign tumours of the bladder common?
No, they are uncommon
Who does bladder cancer most commonly affect?
Males aged between 50 and 80 years of age
What is the prevalence of squamous cell carcinoma in regions affected by Schistosomiasis?
1-7%
What growth patterns are seen in transitional cell carcinomas?
Papillary (up to 70% of cases), mixed papillary and solid, or pure solid growths
Do superficial transitional cell carcinomas have a better prognosis?
Yes
TNM Staging
Stage Description
T0 No evidence of tumour
Ta Non invasive papillary carcinoma
T1 Tumour invades sub epithelial connective tissue
T2a Tumor invades superficial muscularis propria (inner half)
T2b Tumor invades deep muscularis propria (outer half)
T3 Tumour extends to perivesical fat
T4 Tumor invades any of the following: prostatic stroma, seminal vesicles,
uterus, vagina
T4a Invasion of uterus, prostate or bowel
T4b Invasion of pelvic sidewall or abdominal wall
N0 No nodal disease
N1 Single regional lymph node metastasis in the true pelvis (hypogastric,
obturator, external iliac, or presacral lymph node)
N2 Multiple regional lymph node metastasis in the true pelvis (hypogastric,
obturator, external iliac, or presacral lymph node metastasis)
N3 Lymph node metastasis to the common iliac lymph nodes
M0 No distant metastasis
M1 Distant disease
What is the most common presentation of bladder cancer?
Painless, macroscopic hematuria
What percentage of females aged over 50 with incidental microscopic hematuria may have a malignancy?
Up to 10%
What is the risk of regional or distant lymph node metastasis for T3 bladder cancer or worse?
30% or higher
What increases the risk of bladder cancer?
Exposure to hydrocarbons such as 2-Naphthylamine
What is the recommended diagnostic procedure for bladder cancer?
Cystoscopy and biopsies or TURBT (Transurethral Resection of Bladder Tumor)
What imaging modalities are used to determine locoregional spread and distant disease?
Pelvic MRI and CT scanning
What is the prevalence of adenocarcinoma in bladder malignancies?
2%
How are nodes of uncertain significance investigated?
PET-CT (Positron Emission Tomography - Computed Tomography)
What treatment option is available for superficial lesions?
TURBT (Transurethral Resection of Bladder Tumor)
What treatment option is offered to those with recurrences or higher grade/risk on histology?
Intravesical chemotherapy
What treatment options are available for T2 disease?
Surgery (radical cystectomy and ileal conduit) or radical radiotherapy
What is the 5-year survival rate for T1 bladder cancer?
90%
What is the 5-year survival rate for T2 bladder cancer?
60%
What is the 5-year survival rate for T3 bladder cancer?
35%
What is the 5-year survival rate for T4a bladder cancer?
10-25%
What is the 5-year survival rate for any T stage with N1-N2 lymph node involvement?
30
What is the major health problem in the Western world that bariatric surgery aims to address?
Obesity
What have randomized controlled trials shown regarding weight loss after surgical interventions compared to standard medical therapy?
Dramatic weight loss can be achieved following surgical interventions
Is weight loss more durable following surgical interventions or non-surgical interventions?
Weight loss is more durable following surgical interventions
What are the case selection criteria for bariatric surgery?
BMI ≥ 40 kg/m² or between 35-40 kg/m² with other significant diseases that could be improved with weight loss
What are the prerequisites for bariatric surgery according to NICE UK Guidelines?
Non-surgical measures have failed for at least 6 months, will receive intensive specialist management, fit for anesthesia and surgery, commit to long-term follow-up
What is the surgical procedure of adjustable gastric band?
Laparoscopic placement of an adjustable band around the proximal stomach that can be filled or adjusted
What is the first-line option for adults with a BMI > 40 kg/m² for whom surgical intervention is appropriate?
Adjustable gastric band or consider orlistat if there is a long waiting list
What is the surgical procedure of gastric bypass?
Combines changes to reservoir size with a malabsorptive procedure for enduring weight loss
What are the complications associated with adjustable gastric band surgery?
Rare complications include band erosion, slippage, or loss of efficacy
What are the risks associated with gastric bypass surgery?
Technically more challenging with risks related to anastomoses, including a 2% leak rate. Up to 50% may become B12 deficient
What is the surgical procedure of sleeve gastrectomy?
Resection of the stomach using stapling devices
Why is sleeve gastrectomy less popular now?
Initial promising results have not been sustained
What are some post gastrectomy syndromes that may occur?
Small capacity (early satiety), dumping syndrome, bile gastritis, afferent loop syndrome, efferent loop syndrome, anemia (B12 deficiency), metabolic bone disease
Which reconstruction method generally provides the best functional outcomes?
Roux en Y reconstruction
In reconstruction following distal gastrectomy, what can improve gastric emptying?
Tunneling the jejunal limbs in the retrocolic plane
What is the characteristic symptom of small capacity post gastrectomy syndrome?
Early satiety
What is dumping syndrome?
A syndrome characterized by rapid emptying of undigested food from the stomach into the small intestine, leading to symptoms such as diarrhea, nausea, and lightheadedness
What is bile gastritis?
Inflammation of the stomach lining caused by the reflux of bile into the stomach
What is efferent loop syndrome?
Obstruction or distention of the efferent loop, the portion of the small intestine that carries food from the stomach after a gastrectomy
What is afferent loop syndrome?
Obstruction or distention of the afferent loop, the portion of the small intestine that carries bile and pancreatic juices to the stomach after a gastrectomy
What deficiency may lead to anemia following gastrectomy?
B12 deficiency
What is metabolic bone disease?
A condition characterized by the loss of bone density and increased risk of fractures due to malabsorption of nutrients after gastrectomy
What are the functions of the stomach in relation to gastric emptying?
Mechanical function and immunological function
What happens to solid and liquid material in the stomach during gastric emptying?
Repeated peristaltic activity against a closed pyloric sphincter causes fragmentation of food bolus material
How does gastric acid contribute to gastric emptying?
Gastric acid helps neutralize any pathogens present
What factors affect the amount of time material spends in the stomach?
Composition and volume of the material
Give an example of how composition affects gastric emptying.
A glass of water will empty more quickly than a large meal. The presence of amino acids and fat will delay gastric emptying
Which neuronal stimulation mediates gastric motility?
Vagus nerve (parasympathetic nervous system)
Why do individuals who have undergone truncal vagotomy require pyloroplasty or gastro-enterostomy?
Truncal vagotomy causes delayed gastric emptying
What hormonal factors are involved in gastric emptying?
Gastric inhibitory peptide (delays emptying), Gastrin (increases emptying), Cholecystokinin, Enteroglucagon
How can diseases affecting gastric emptying impact the stomach?
They may result in bacterial overgrowth, retained food, formation of bezoars, dyspepsia, reflux, and foul-smelling belches of gas
How can gastric surgery affect gastric emptying?
Gastric surgery, especially procedures that disrupt the vagus nerve, can cause delayed emptying. Procedures like vagotomy, oesophagectomy, and distal gastrectomy can impact gastric emptying
In a gastro-enterostomy, which type of anastomosis empties better?
A posterior, retrocolic gastroenterostomy empties better than an anterior one
What is the main cause of diabetic gastroparesis?
Neuropathy affecting the vagus nerve
What is the characteristic symptom of diabetic gastroparesis?
Poor stomach emptying and episodes of repeated and protracted vomiting
Why are drugs like metoclopramide less effective in treating diabetic gastroparesis?
They exert their effect via the vagus nerve, which is affected by neuropathy
How is the diagnosis of diabetic gastroparesis made?
Upper GI endoscopy, contrast studies, and sometimes a radio nucleotide scan
What is a prokinetic drug that can be used to treat diabetic gastroparesis?
Erythromycin, an antibiotic that works differently
How can distal gastric cancer and pancreatic malignancies affect gastric emptying?
They can obstruct the pylorus or cause extrinsic compression of the duodenum, leading to delayed emptying
What are the treatment options for gastric emptying delay caused by malignancies?
Gastric decompression using a wide bore nasogastric tube, insertion of a stent, or surgical gastroenterostomy
At what age does congenital hypertrophic pyloric stenosis typically present?
Around 6 weeks of age
What other procedure may be done in cases of malignant disease that is being palliated?
Roux en Y bypass, although the increased number of anastomoses is usually not justified
Where are gastroenterostomies usually placed for bypassing malignancies, despite emptying less well?
On the anterior wall of the stomach
How is the diagnosis of congenital hypertrophic pyloric stenosis usually made?
Careful history, examination, and ultrasound showing hypertrophied pylorus
What is the characteristic symptom of congenital hypertrophic pyloric stenosis?
Projectile non bile stained vomiting
What is the treatment for congenital hypertrophic pyloric stenosis?
Pyloromyotomy, either open or laparoscopic
Are there any long-term sequelae after treating congenital hypertrophic pyloric stenosis?
No, there are no long-term complications or effects
