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A Grade Surgical Conditions Flashcards

1
Q

What is the acute abdomen?

A

A description of pain in the abdomen that has started in the past 5 days. There are a wide range of differentials

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2
Q

What are the differentials when abdo pain is generalised?

A

Intra-abdo haemorrhage
Viscous organ peforation
Mesenteric Ischaemia
Bowel Obstruction

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3
Q

What is the most serious cause of an intra-abdominal haemorrhage?

A

Ruptured AAA

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4
Q

What are the signs and symptoms of AAA?

A
  • Back/loin pain
  • Collapse
  • Hypotension
  • Pulsatile abdo mass
  • Lower limb ischaemia
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5
Q

What investigations should be performed if AAA is suspected?

A

CT Abdo of pelvis and abdo w/ contrast of arteries

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6
Q

How is a AAA treated?

A

Surgery `

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7
Q

What can viscous organ perforation cause?

A

peritonitis

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8
Q

What are the most common causes of rupture?

A

Gastroduodenal Ulcer

Colonic Diverticulitis

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9
Q

What are the signs of viscus organ perforation?

A

RIGID ABDOMEN
Involuntary guarding
Patient lying completely still
Deranged observations, lactate and inflammatory markers

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10
Q

What investigations should be done if organ perforation suspected?

A

ERECT CXR

CT abdo/pelvis

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11
Q

What is the management for viscus organ perforation?

A

Prompt surgical repair and washout to prevent bowel contents from spilling out into abdo

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12
Q

What are the signs of mesenteric ischaemia?

A

Pain out of proportion to examination

High lactate

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13
Q

What are the risk factors for mesenteric ischaemia?

A

Artertiopaths (angina, previous MI)

AAA, AF, DVT, PE

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14
Q

What can mesenteric ischaemia lead to?

A

necrosis and perforation

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15
Q

What are the causes of mesenteric ischaemia?

A

Mesenteric artery thromboembolism (embolus thrown off from the heart plus chronic atherosclerotic thrombosis)

Non occulusive ischaemia related to hypotension

Mesenteric venous thrombosis

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16
Q

What are the investigations for mesenteric ischaemia?

A

Lactate

CT abdo and pelvis

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17
Q

What is bowel obstruction?

A

A mechanical blockage of bowel = proximal bowel dilates and becomes ischaemic, then necrotic and then it perforates

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18
Q

What are the signs and symptoms of bowel obstruction?

A 
Colicky pain
Nausea and vomiting
ABSOLUTE CONSTIPATION
Distended abdo
Tinkling bowel sounds
Deranged observations and inflammatory markers
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19
Q

What investigations should be requested?

A

CT(differentiates between small bowel and large bowel obstruction)
FBC, UsEs, Renal Function, Coag Panel, Serum amylase/lipase (large bowel suspected)

ABG, FBC, CRP, electrolytes, glucose, u&es, amylase, group and save

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20
Q

What are the causes of small bowel obstruction?

A

Adhesions

Hernia

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21
Q

What are the causes of large bowel obstruction?

A

Tumour

Volvulus

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22
Q

What is the treatment for bowel obstruction?

A

IV fluids, rebalance electrolytes, group and save

Primary resection/laparatomy

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23
Q

What conditions might present with right upper quadrant pain?

A

Cholecystitis and renal colic

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24
Q

What are the signs of cholecystitis ?

A

Sudden onset RUQ pain radiating to back

Charcots Triad (indicates ascending cholangitis)

  • FEVER
  • RUQ pain
  • Jaundice
Reynauds Pentad  (suggests obstruction)
- Charcots Triad + shock and altered mental status
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25
Q

What imaging is performed for cholecystitis?

A

US is performed first to rule other things out and to evaluate any cholecystitis

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26
Q

How is cholecystitis treated?

A

Mild/Moderate

  • Paracetamol/ diclofenac/morphine
  • Plasma-lyte IV infusion
  • Antibiotics if sepsis or infection suspected
  • Cholecystostomy

Severe

  • ITU admission
  • Paracetamol/ diclofenac/morphine
  • Plasma-lyte IV infusion
  • Antibiotics if sepsis or infection suspected
  • Cholecystostomy
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27
Q

What investigations are performed if cholecystitis is suspected?

A

FBC, CRP, bilirubin, LFTs, serum lipase or amylase, blood/bile cultures

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28
Q

What is cholecystitis?

A

Inflammation of the gallbladder

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29
Q

What are the causes of cholecystitis?

A

complete cystic duct obstruction due to an impacted gallstone in the gallbladder neck or cystic duct

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30
Q

What is Renal Colic?

A
  • Colicky loin to gain pain caused by obstruction of flow in ureter leading to increased wall tension in urinary tract
  • Increased prostaglandins synthesis resulting in vasodilatation causing diuresis which further increases pressure
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31
Q

What investigations should be performed if renal colic is suspected?

A

Urinalysis (microscopic haematuria)
24 hr urine collection for recurrent stone formers

FBC, serum electrolytes, urea and creatinine

CT-KUB (kidney,ureter,bladder)

Ultrasound

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32
Q

What is the management for renal colic?

A

Acute renal colic
- conservative management (hydration, pain control, anti-emetics)

Confirmed stone
- conservative management, surgical decompression, medical expulsive therapy (tamsulosin), surgical removal

antibiotic therapy (gentamicin) if infection indicated

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33
Q

What is pancreatitis?

A

Inflammation of the pancreas

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34
Q

What is the diagnostic criteria for pancreatitis?

A

2/3 of:

  • acute onset of severe epigastric pain relieved by bending forward
  • elevated amylase/lipase
  • imaging features consistent on CT/MRI/US
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35
Q

What is the most common subtype of pancreatitis?

A

Interstitial oedematous pancreatitis

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36
Q

What form of imaging should be done if pancreatitis suspected?

A

US (identifies gallstones, vascular complications and necrosis)

CT (focal or diffuse enlargement, oedema, necrosis, abscess, haemorrhage, calcification)

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37
Q

How does a patient with pancreatitis present?

A

sudden-onset mid-epigastric or left upper quadrant abdominal pain, which often radiates to the back

Nausea and vomiting

Signs of hypovolaemia (hypotension, tachycardia, dry mucous membranes, sweating)

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38
Q

What investigations should be done for acute pancreatitis?

A

Serum lipase/amylase, FBC, CRP, LFTs, CXR, pulse oximetry, urea, serum calcium

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39
Q

What is the treatment for pancreatitis?

A 
IV fluids
Ibuprofen/codeine/morphine
O2
Ondansetron
Empiric IV antibiotics if infection suspected
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40
Q

What is gastric ulcer disease?

A

Gastric ulceration due to gastric acid excess

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41
Q

How does an ulcer present?

A

Epigastric pain relieved by eating or antacid

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42
Q

What are the complications of a gastric ulcer?

A

Upper GI haemorrhage –> malaena/haematemesis

Perforation –> generalised acute abdo pain, peritonism, shock

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43
Q

What imaging should be performed if gastric ulcer suspected?

A

CT

Erect CXR

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44
Q

What should be suspected if a patient presents with right lower quadrant pain?

A 
Appendicitis
Urinary Tract Complications
- Pyelonephritis, nephrolithiasis 
Ectopic Pregnancy
Crohns/UC
IBD
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45
Q

What should be suspected if a patient presents with left lower quadrant pain?

A 
Urinary Tract Complications
- pyelonephritis, nephrolithisis 
Ectopic Pregnancy
Diverticulitis
IBS
Crohns/ UC
Hernia
Ovarian cyst/torsion
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46
Q

What should be suspected if a patient presents with left upper quadrant pain?

A

Splenic Rupture
Peptic Ulcer
Nephrolithiasis
Gastritis

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47
Q

What should be suspected if a patient presents with suprapubic pain?

A 
Cystitis 
Acute urinary retention
Appendicitis
IBD
Ovarian Cyst
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48
Q

What does umbilical pain indicate?

A 
Appendicitis
SB/LB obstruction
IBS
IBD
Gastroenteritis
Ischaemic Colitis
AAA
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49
Q

What does left and right lumbar region pain indicate?

A

Nephrolithiasis
Pyelonephritis
Infectious or ischaemic colitis

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50
Q

What are the signs of appendicitis?

A

Central pain that radiates to the right

Nausea,vomiting, anorexia, tachycardia, pyrexia, RLQ tenderness, guarding

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51
Q

What is necrotising fascitis?

A

A rapidly progressive infection of the deep fascia causing necrosis of subcutaneous tissue

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52
Q

What is Type 1 necrotising fascitis?

A

A polymicrobial infection

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53
Q

What is type 2 necrotising fascitis?

A

Nec fasc caused by group a haemolytic strep

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54
Q

What is type 3 necrotising fascitis?

A

NF caused by clostridium (gas gangrene)

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55
Q

What is type 4 necrotising fascitis ?

A

NF caused by MRSA

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56
Q

What are the signs and symptoms of NF?

A 
Anaesthesia or severe pain that is out of proportion to cellulitis 
Fever
Skin discolouration
Sloughing of fascia
Swelling
Palpitations
Tachycardia
Tachypnoea
Hypotension
Lightheadedness 
Nausea and vomiting
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57
Q

What investigations do you want to do in a suspected NF?

A 
FBC
Serum electrolytes (hyponatremia)
U&Es (Raised)
CRP(Raised)
CK (Raised)
Lactate (Raised)
Tissue and Blood cultures
ABG
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58
Q

What scoring system is used to determine NF?

A

LRINEC

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59
Q

What is the management of NF?

A

Surgical debridement plus haemodynamic support
- Excisions should extend beyond the area of visible
necrosis

Empirical Antibiotics
- Flucloxacillin, Benzylpenicillin, Gentamycin, Clindamycin

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60
Q

What are cutaneous burns?

A

A common injury to the skin and superficial tissues caused by heat from hot liquids, flame, or contact with heated objects/electrical current or chemicals

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61
Q

What are thermal burns?

A

Burns from

- heat, hot liquids, flame or contact with heated objects

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62
Q

What are electrical burns?

A

Low, intermediate or high voltage exposure

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63
Q

What are chemical burns?

A

Burns caused by industrial/household chemical products

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64
Q

What are non-accidental burns?

A

Burns from neglect or abuse (20% of paediatric cases)

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65
Q

What are the presentations of burns?

A 
Erythema
Dry and painful/insenate burns
Wet and painful burns
Cellulitis 
Blistering
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66
Q

What investigations can be done when a burns patient presents?

A

FBC
Metabolic panel (increased urea, creatinine, glucose, decreased Na and K)
ABG
Wound biopsy culture, wound histology

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67
Q

What is the management of burns?

A

Outpatients (smaller burns)
- lukewarm water and plain soap. Topical silver sulfadiazine

Inpatient

  • ABCDE
  • Assess % of burns
  • Initial excision and debridement
  • Graft or flap
  • Rehab and reconstruction
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68
Q

What formula is used to assess fluid requirements in a patient with burns >15% BSA?

A

Parkland formula

4 ml of Lactated Ringer’s per kilogram per % BSA over first 24 hours
first half given over first 8 hours
second half given over next 16 hours

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69
Q

How do you assess %BSA?

A

Rule of nine

Hand width = 1%

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70
Q

What is a Erythema/Superficial burn?

A

Burn that only effects epidermis
Pain
Blanchable

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71
Q

What is a Superficial-partial thickness burn?

A

Burn that penetrates the superficial dermis
Pain
Blisters
Blanchable

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72
Q

What is a deep-partial thickness burn?

A

Burn that penetrates the deep dermis
Pain
NOT BLANCHABLE
Soft

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73
Q

What is a full thickness burn?

A

Burn that penetrates muscle, bone
Pain
NOT BLANCHABLE
Hard

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74
Q

When is an escharotomy indicated?

A

When burns are circumferential and deep-partial thickness

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75
Q

What is compartment syndrome?

A

When tissue pressure exceeds perfusion pressure in a limb comparment.

Increased perfusion = swelling and oedema = increased pressure = micro and macrovascular occlusion = myoneural ischaemia

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76
Q

What is the most common site of ACS?

A

Lower leg

followed by forearm and then thigh

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77
Q

What is the most common injury that leads to ACS?

A

Tibial shift fracture

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78
Q

What is the aetiology behind ACS?

A

Fractures, crush injuries, burns, tight dressing, reperfusion injury, extravasation of IV fluids

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79
Q

How does ACS present?

A

Pain (most sensitive sign. Pain out of proportion to injury)
Pulselessness (advanced sign. Indicates amputation)
Pallor
Paraesthesia

Swelling, pink discolouration, tense woody compartment on palpitations

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80
Q

How is ACS diagnosed?

A

Clinical evaluation
X-Ray
Compartment Pressure Monitoring

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81
Q

When is compartment pressure monitoring indicated?

A

If GCS is decreased, in polytrauma or if clinical evaluation is inconclusive

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82
Q

What is the management of compartment syndrome?

A

Morphine
Removal of all casts/occlusive or circumfurential dressings
Fasciotomy

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83
Q

What is osteoarthritis?

A

The loss of cartilage at a joint, resulting in bone remodelling and associated inflammation

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84
Q

What are the risk factors of osteoarthritis?

A

Obesity, repetitive use, trauma, female sex, age, family history

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85
Q

How does osteoarthritis present?

A

Pain on use, easing of pain at rest, decreased function, decreased range of motion, swelling, erythema, joint nodules, crepitus, bony swellings

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86
Q

What investigations are done when osteoarthritis is suspected?

A 
Joint examination
X-Ray
Joint aspiration
FBC (normal)
CRP and ESR (normal)
LFTs and Creatinine (check to see if suitable for NSAID therapy)
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87
Q

How is osteoarthritis managed?

A

Exercise and weight loss
Cold/Heat therapy

NSAID use (naproxen, ibuprofen, diclofenac) - topical or oral 
PRESCRIBE OMEPRAZOLE IF >60

Paracetamol

Topical capsacin

Intra-articular injections (steroids)

Joint replacement therapy

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88
Q

What is septic arthritis ?

A

Infection of one or more joint caused by pathogenic innoculation of microbes

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89
Q

What organisms cause septic arthritis?

A

staphylococcus
streptococcus
MRSA
Gonorrhoea

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90
Q

How does septic arthritis spread?

A

Haematogenous spread to joint

Direct spread to joint

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91
Q

How does septic arthritis present?

A

Hot, swollen, painful restricted joint
An acute onset
Fever

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92
Q

What are the risk factors for septic arthritis?

A 
Underlying joint disease
Prosthetic joint
Age
Immunosuppresion
Tick Exposure
Recent joint surgery
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93
Q

What investigations should be done if septic arthritis is suspected?

A 
Synovial fluid microscopy, culture and WCC
Blood culture
WCC, ESR, CRP
U&Es 
LFTs
Plain X-Ray
US
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94
Q

What is the treatment for septic arthritis is there is systemic involvement?

A

Sepsis treatment

  • Take blood cultures, lactate and urine output
  • Give O2, IV fluids and empirical antibiotics

amoxicillin, metrondiazole and gentamycin

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95
Q

What is the treatment for septic arthritis in a prosthetic joint?

A

surgery (atherocentesis)

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96
Q

What is the treatment for septic arthritis in an inaccessible native joint?

A

Ultrasound guided joint aspiration

Antibiotics

Paracetamol, ibuprofen and diclofenac

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97
Q

What is the treatment for septic arthritis in an accessible native joint?

A

Empirical antibiotics

Paracetamol, ibuprofen and diclofenac

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98
Q

What complications can arise from septic arthritis?

A

Osteomyelitis

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99
Q

What is a femoral shaft fracture?

A

A fracture of the femoral shaft

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100
Q

How does a femoral shaft fracture occur?

A

High energy injuries such as RTAs (often in younger people)

Low impact injuries such as falling from standing or a gunshot (more common in elderly)

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101
Q

What conditions are associated with femoral shaft fracture?

A

Ipsilateral femoral nexk fractures, tibial shaft fractures, cerebral haemorrhage or thoracic injuries

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102
Q

What is the incidence of femoral shaft fracture?

A

37/100,000

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103
Q

What are the fracture patterns of a femoral shaft patterns ?

A

Transverse (pure bending)
Spiral (rotational)
Oblique (uneven bending)
Comminuted (high speed crash)

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104
Q

What is the presentation of a femoral shaft patterns?

A

Pain in thigh
Tense and swollen thigh
Shortened thigh

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105
Q

How do you initially manage a femoral shaft fracture ?

A

ABCDE

Advanced Trauma Life Support

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106
Q

How much blood loss can occur in a femoral shaft fracture?

A

1000-1500ml

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107
Q

What imaging should be done in a femoral shaft fracture?

A

Radiographs

CT

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108
Q

What investigations should be done in a femoral shaft fracture?

A 
ESR
CRP
Lactate
FBC
Urine output
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109
Q

How should a femoral shaft fracture be managed?

A

Anterograde/retrograde intramedullary nails
External fixation
Long limb cast

Abx if wound was open

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110
Q

What are the complications of a femoral shaft fracture

?

A 
Pudendal nerve injury
  Femoral artery/nerve injury
Malunion
Rotational malalignment
Infection
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111
Q

Name some causes of raised ICP?

A 
Localised mass lesions
Neoplasm
Abscess
Focal Oedema secondary to trauma
Diffuse Oedema
Obstructive hydrocephalus
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112
Q

How does raised ICP present?

A

Headache
- can be nocturnal, when waking, worse on coughing

Papilloedema
Vomiting
Changes in mental state
Syncope

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113
Q

What investigations can be done if raised ICP is suspected?

A

CT
MRI
Blood glucose, renal function, electrolytes, ICP monitoring

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114
Q

How should raised ICP be managed?

A

CSF drainage
Head of bed elevation
Analgesia and sedation
Mannitol or hypertonic saline

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115
Q

What is a subarachnoid haemorrhage?

A

Bleeding into the subarachnoid space

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116
Q

What is the aetiology behind a SAH?

A

Rupture of intracranial saccular aneurysm

AV malformations, arterial dissections, anti-coag use

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117
Q

What is the incidence of SAH?

A

6-8 in 100,000 people experience a SAH

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118
Q

What are the risk factors of SAH?

A

Hypertension, smoking, family history, ADPKD

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119
Q

What is the presentation of SAH?

A 
Thunderclap headache
Decrease in consciousness
Neck stiffness and muscle aches
Photophobia
Nausea and vomiting
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120
Q

What investigations should be performed if SAH is suspected?

A

CT Head

FBC, U&Es, Clotting Profile, Troponin, Serum Glucose, ECG

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121
Q

What is the management for SAH?

A

ABCDE (including GCS)

If GCS <8 and Falling
- IV Fluids, nimodipine, surgery and continuous ECG

If GCS >8
- IV fluids, nimodipine, analgesia, surgery

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122
Q

What surgery is performed for a SAH?

A

Endovascular coiling or clipping

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123
Q

What are the complications involved with SAH?

A

Death
Cognitive Impairment
Reoccurrence
Chronic hydrocephalus

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124
Q

What is a subdural haematoma?

A

Collection of blood between dura and arachnoid mater

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125
Q

How does herniation occur in subdural haematoma?

A

Increasing volumes of blood = compression of brain parenchyma = herniation

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126
Q

What is the incidence of Subdural Haematoma?

A

50-60% of all intracranial haematomas

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127
Q

What is the aetiology behind Subdural Haematoma?

A

Trauma (torsional or shearing forces) = disruption of cortical veins = bleeding = haematoma

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128
Q

What is the presentation of a Subdural Haematoma?

A 
Evidence of trauma
Headache, nausea, vomiting
Decrease GCS and consciouness
Confusion
Seizure
Incontinence
Weakness
Speech and vision change
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129
Q

What investigations should be done for a Subdural Haematoma?

A

CT head

FBC, clotting profile

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130
Q

What is the management for a Subdural Haematoma?

A

ABCDE including GCS
Trauma craniotomy
Prophylactic anti-epileptics (phenytoin)
Monitoring

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131
Q

What are the indications for a trauma craniotomy?

A

Haematoma >10mm
Midline shift >5mm
GCS >9
ICP >20mmHg

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132
Q

What are the complications of a Subdural Haematoma?

A 
Neurological deficit
Coma
Death
Stroke
Epilepsy
Infection at surgical site
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133
Q

What is a AAA?

A

An abdominal aortic aneurysm is a permanent pathological dilation of the aorta with a diameter of
>3cm

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134
Q

What is the epidemiology behind a AAA?

A

Incidence is higher M>F
Rupture is higher F>M
Most arise below renal artery level

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135
Q

What are the risk factors for a AAA?

A

Smoking, FH, age, congenital connective tissue disorders

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136
Q

How does AAA present?

A

Usually asymptomatic

Can present with abdo/back pain and a palpable abdo mass

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137
Q

How does a ruptured AAA present?

A

Severe and sudden Abdo and back pain

Syncope/shock and collapse

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138
Q

What investigations should be done if a AAA is suspected?

A

Abdominal US
CT
MRI

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139
Q

Who is screened for AAA’s?

140
Q

What is the management for AAA?

A

Rupture

  • Standard resus (IV fluids, airway, bloods) and ABCDE
  • EVAR

Large AAA
- EVAR or Open Elective Surgery

Small AAA
- observation

141
Q

What complications are associated with AAA?

A 
Death
Abdo compartment syndrome
AKI
Ileus, obstruction, Ischaemic colitis
Graft infection
Aortic neck dilation
142
Q

Define breast cancer

A

A malignancy originating in the breasts and nodal basins

143
Q

What is the aetiology behind breast cancer?

A

Genetic Factors (BRCA1, BRCA2, HER2), Hormonal Factors

144
Q

What is the epidemiology behind breast cancer?

A

Most common female malignancy
25% of diagnosis occur before age 50
15% of all new cancer cases

145
Q

What are the risk factors for breast cancer?

A 
Previous Hx of Breast Cancer
Age
FH of breast cancer
BRCA 1
BRCA2
HER2
Nulliparity
First child after 30
Early menarche, late menopause
HRT
COCP
146
Q

How does breast cancer present?

A 
Breast mass
Nipple discharge
Axillary lymphadenopathy
Skin thickening or contour changes
Nipple changes
147
Q

What are the diagnostic investigations for breast cancer?

A

Triple Assessment
1. History and breast examination

  1. Imaging - mammography and ultrasound. US typically used for men and women under 35
  2. Histology - core biopsy or FNA
148
Q

In the triple assessment, how is the examination score measured?

A 
P1 = Normal
P2 = Benign
p3= uncertain/likely benign
P4 = Malignancy suspicion
P5 = Malignant
149
Q

In the triple assessment, how is the Imaging Score Generated?

A 
M1/U1 = Normal
M2/U2 = Benign
M3/U3= uncertain/likely benign
M4/U4 = Malignancy suspicion
M5/U4 = Malignant
150
Q

In the triple assessment, how is the Histology score generated?

A 
B1 = Normal
B2 = Benign
B3= uncertain/likely benign
B4 = Malignancy suspicion
B5 = Malignant
151
Q

What are the staging diagnostics for breast cancer?

A 
ER and PR receptor status
HER2 status
CXR
LFTs
CT
Bone scintagraphy
152
Q

What treatment is available for breast cancer?

A

Lumpectomy or total mastectomy with SLNB

Chemotherapy
Radiotherapy

Tamoxifen (premenopausal women with hormone receptor postitive disease) Aromatase Inhibitor (Post-menopausal women with hormone receptor positive disease)

Bone Health Support (vitamin D and calcium)

153
Q

What are the complications of breast cancer?

A

Chemo related nausea/neutropenic fever/ovarian failure

Lymphoedema

Treatment related osteopenia

Metastasis

Death

154
Q

What is the prognosis for breast cancer?

A

85% 5 year survival rate

75% 10 year survival rate

155
Q

Define prostate cancer?

A

A malignant tumour of glandular origin situated in the prostate. They are adenocarcinoma

156
Q

What is the cause of prostate cancer?

A

It is unknown but a high fat diet and genetics play a part in its development

157
Q

What is the epidemiology behind prostate cancer?

A

makes up 26% of all male cancer diagnosis in UK

173/100,000 diagnosed

158
Q

What risk factors can predispose you to prostate cancer?

A

Increasing age
Black Men > White Men
First degree relative w/ Hx of prostate cancer

159
Q

What is the presentation of prostate cancer?

A

LUTS
- weak stream, hesitancy, retention, frequency, urge incontinence

Haematuria, dysuria
Impotence
Tenesmus

Bone

Asymmetrical, nodular prostate gland on DRE

160
Q

What investigations should be done if prostate cancer is suspected?

A 
PSA
PCA3 urine test
Urinalysis to exclude renal bladder pathology
Renal function test
Prostate biopsy
Uroflow measurement
161
Q

What grading system is used in prostate cancer?

A

Gleason Grading System
Grade 1: small, uniform glands with minimal nuclear changes.
Grade 2: medium-sized acinii, separated by stromal tissue but more closely arranged.
Grade 3: marked variation in glandular size and organisation and infiltration of stromal and neighbouring tissues.
Grade 4: marked atypical cytology with extensive infiltration.
Grade 5: sheets of undifferentiated cells.

162
Q

How is prostate cancer managed?

A 
MDT lead treatment
Active surveillance
Radical Prostatectomy
Radical Radiotherapy
Androgen deprivation therapy (enzalutamide - to be used in those with metastatic prostate cancer)
Chemotherapy
163
Q

What are the complications of prostate cancer?

A

Urinary tract obstruction
Sexual dysfunction
Metastasis
Death

164
Q

What is acute urinary retention?

A

The sudden inability to pass urine. It is usually painful.

165
Q

What is the structural causes of acute urinary retention?

A

Men = BPH, Meatal Stenosis, Paraphimosis, Penile Contricting Bands, Phimosis, Prostate Cancer

Woman - Prolapse, Pelvic Mass, Retroverted Gravid Uterus

Both = Bladder calculi, bladder cancer, faecal impaction, GI or retroperitoneal malignancy, urethral strictures, foreign bodies, stones

166
Q

What are the infectious and inflammatory causes of acute urinary retention?

A

Men = balanitis, prostatitis, prostatic abscess

Women = acute vulvovaginitis, vaginal lichen planus, llichen sclerosis, vaginal pemphigus

Both = schistomiasis, cystitis, HSV, VZV, peri-urethral abscess

167
Q

What are the drug-related causes of acute urinary retention?

A 
Anticholinergics
Opioid and Anaesthetics
Alpha-adrenoreceptor agonists
Benzodiazepines
NSAIDs
Detrusor Relaxants
CCBs
Antihistamines
Alcohol
168
Q

When is AUR most commonly encountered?

A

Post-operatively due to
- pain, traumatic instrumentation, bladder overdistention, drugs, iatrogenic error, decreased mobility and increased bed rest

169
Q

What is the epidemiology behind AUR?

A

3 in 1000

M>F

170
Q

How does AUR present?

A

Patient uncomfortable and unable to pass urine. Tender and distended bladder.

171
Q

What should you look for in a history and examination when investigating AUR?

A

History
- Associated symptoms (fever, weakness, sensory loss), previous LUTS, PMH, check medication

Examination

  • Abdo = tender, enlarged bladder that is dull to percuss above level of pubis symphysis
  • Genitourinary = phimosis, meatal stenosis, discharge, vaginal inflammation, prolapse
  • Neuro = Look for evidence of disc prolapse or cord compression via testing lower limb power
172
Q

What are the differentials for AUR?

A

Chronic Urinary Retention

Prostatic hyperplasia

173
Q

What investigations should be performed when AUR is suspected?

A 
Urinalysis 
MSU 
Blood Tests (FBC, U&amp;Es, eGFR, Blood Glucose, PSA)
Ultrasound 
CT
174
Q

How is AUR managed?

A

Catheterisation

Investigate cause and treat as per local guidelines

175
Q

What are the complications associated with AUR?

A

UTIs
AKI
Post-retention haematuria

176
Q

What is stress incontinence ?

A

involuntary leakage of urine on effort or exertion, or on sneezing or coughing. This is due to an incompetent sphincter. Stress incontinence may be associated with genitourinary prolapse.

177
Q

What are the risk factors for stress incontinence?

A

Pregnancy, vaginal delivery, diabetes mellitus, oral oestrogen therapy, high BMI, hysterectomy

178
Q

What investigations should be done?

A

Bimanual examination
DRE (men) to assess prostate
Urine dipstick, assess residual urine, urinary flow rate, urodynamic studies,

179
Q

How is stress incontinence managed?

A

Pads or collecting devices
Pelvic floor exercises
Duloxetine
Surgical treatment (open colposuspension, autologous rectus fascial sling)

180
Q

What is an uncomplicated UTI?

A

infection of the urinary tract by a usual pathogen in a person with a normal urinary tract and with normal kidney function.

181
Q

What is a complicated UTI?

A

anatomical, functional, or pharmacological factors predispose the person to persistent infection, recurrent infection or treatment failure - eg, abnormal urinary tract.

182
Q

What pathogens cause UTIs?

A 
E. Coli
Staph saprophyticus
Enterococci
Klebsiella 
Proteus Vulgaris
Candida Albicans
Pseudomonas
183
Q

What are the risk factors for UTI?

A 
Recent instrumentation of renal tract
Stasis of urine
Abnormal renal tract
Not voiding after sex
Catheterisation
Diabetes
Pregnancy
184
Q

How does a UTI present?

A 
Urinary frequency
Dysuria
Haematuria
Foul smelling, cloudy urine
Burning sensation on urination
Urgency
Pyrexia, rigors
Nausea +/- vomiting
Delirium (Elderly)
185
Q

What investigations should be done for a UTI?

A

History
Urinalysis
Urine culture
US of upper urinary tract

186
Q

What is the treatment for UTI?

A

Trimethorprim or nitrofurantoin

Ciproflox if complicated UTI

187
Q

What are the complications of UTI?

A

Ascending infection - pyelonephritis, hydronephrosis, AKI, sepsis

188
Q

What is testicular torsion?

A

Twisting of the testis around the spermatic cord resulting in occlusion of testicular blood vessels and can lead to ischaemia

189
Q

Epidemiology of testicular torsion?

A

Typically effects neonates or post-pubertal bous
L side > R side
Often unilateral

190
Q

What is intravaginal torsion?

A

Occurs when the posterior lateral aspect of the testes is not properly fixated to the tunica vaginalis.

Occurs in 12% of males

191
Q

What is extravaginal torsion?

A

Occurs more often in neonates

Spermatic cord and tunica vaginalis undergo torsion in or below the inguinal canal

192
Q

How does testicular torsion present?

A 
Acute swelling in testis 
Sudden and severe pain in one testis 
Lower abdo pain
Nausea and vomiting
Erythema of scrotal skin
Swollen and tender testis retracted upwards
193
Q

Differentials for testicular torsion?

A

Epididymitis
Orchitis
Hydrocele
Hernia

194
Q

What investigations should be done for testicular torsion?

A

Ultrasound
Doppler
MRI
Urinalysis

195
Q

How is testicular torsion managed?

A

Prompt clinical examination
Emergency urology referral
Orchidopexy or orchiectomy

196
Q

What are the complications of testicular torision?

A

Subfertility

Infertillity

197
Q

What is acute limb ischaemia?

A

A sudden decrease in limb perfusion causing a potential threat to limb viability

198
Q

What is the most common cause of acute limb ischaemia ?

A

acute thrombotic occlusion of a previously partially occluded, thrombosed arterial segment

embolus from a distant site

trauma

Compartment Syndrome

199
Q

What are less common causes of acute limb ischaemia?

A 
Vasculitis
Popliteal entrapment syndrome
Compartment Syndrome
Iatrogenic
Aortic Dissection
Graft Occlusion
200
Q

What are the risk factors for acute limb ischaemia ?

A 
AF
Hypertension 
Smoking
Diabetes
Recent MI
201
Q

What are the 6 Ps of acute limb ischaemia ?

A

Pain (worse distally)
Pallor (white rather than blue)
Pulselessness (doppler)
Paraesthesia
Perishingly Cold (compare to contralateral limb)
Paralysis (poor prognosis of irreversible ischaemia)

202
Q

What examinations should be performed in acute limb ischaemia?

A

CV exam
Abdomen (check for AAA)

The affected limb

  • Inspection (colour, scars)
  • Palpation (temperature, pulses, tenderness, neurological function)
  • Auscultation (Arterial doppler - compare to contralateral limb)
  • Move leg passively and ask patient if they can move affected limb
203
Q

What investigations should be performed if acute limb ischaemia is suspected?

A 
FBC
UsEs
Serum Glucose and Lactate
Clotting Panel
ESR
Group and Save
Cross Match

ECG
Doppler

204
Q

What is the immediate management for acute limb ischaemia?

A 
IV heparin
Analgesia - morphine
Oxygen
CT angiogram if feasible
Call vascular surgeon for review
205
Q

What are the complications of acute limb ischaemia?

A

Myoglobinaemia
Rhabdomyolysis
Acute tubular necrosis
Hyperkalaemia

206
Q

What is infective endocarditis?

A

An infection involving the endocardial surface of the heart and the chordae tendineae

207
Q

What organisms cause endocarditis?

A

Viridans group streptococci
Staph aureus
Enterococci

208
Q

Endocarditis statistics

A

M>F

>60 yrs old = most prevalent

209
Q

What are the risk factors for developing infective endocarditis?

A

Artificial prosthetic heart valves
Congenital Heart Disease
IVDU

210
Q

How does infective endocarditis present?

A 
Fever/chills
Night sweats, fatigue, malaise, weakness
Arthralgia
Headache
SOB
Janeway lesions
Oslers nodes
Roth Spots (fundoscopy)
Splinter haemorrhages
Heart Murmur
Arthritis
Meningism
211
Q

What investigations should be done if infective endocarditis is suspected?

A 
FBC
Serum chemistry 
Urinalysis 
Blood cultures
ECG
Echo
CXR
212
Q

What is the initial management for infective endocarditis?

A

Supportive measures
Amoxicillin (+/- gentamycin)
Surgery

213
Q

What are the complications of infective endocarditis?

A

CHF
Systemic Embolisation
Mitral valve vegetation

214
Q

What is the diagnostic criteria for endocarditis?

A

Duke’s criteria

- 2 major/ 1 major + 3 minor/ 5 minor for diagnosis

215
Q

What are the major criteria of Dukes crtiteria?

A

Positive blood culture for IE

Evidence of endocardial involvement (abscess, valvular regurg, oscillating intracardiac mass on valve, abscess)

216
Q

What are the minor Duke’s criteria

A

predisposing heart condition or intravenous drug use.
Fever
Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial haemorrhage, conjunctival haemorrhages and Janeway’s lesions.
Immunological phenomena: glomerulonephritis, Osler’s nodes, Roth’s spots and rheumatoid factor.
Microbiological phenomena: positive blood culture
PCR: broad-range PCR of 16S
Echocardiographic findings consistent with IE

217
Q

Define ischaemic heart disease?

A

An inability to provide adequate blood supply to the myocardium, is primarily caused by atherosclerosis of the epicardial coronary arteries

218
Q

What is the aetiology behind stable ischaemic heart disease?

A

Atherosclerosis, vasospasm, endothelial dysfunction, embolism, coronary artery dissection, vasculitis/arteritis

219
Q

Statistics behind ischaemic heart disease

A

M>F
1/5 men die every year
1/7 women die every year
Poor > Rich

220
Q

What are the risk factors for ischaemic heart disease?

A 
Increasing Age
Social deprivation
Smoking
Poor nutrition
Stress
Alcohol
HTN
Hypercholesterolaemia 
Obesity 
Diabetes
Family History
221
Q

How does ischaemic heart disease present?

A

Chest pressure lasting several minutes provoked by emotional stress or exercise (relieved by GTN)

222
Q

What investigations should be done if ischaemic heart disease is suspected?

A 
Resting ECG
Haemoglobin 
Lipid profile
Fasting blood glucose
HbA1c
223
Q

How should ischaemic heart disease be managed?

A

Lifestyle education
Antiplatelet therapy (Aspirin, clopidogrel)
Lipid lowering therapy (atorvastatin, simvastatin, rosuvastatin)
Antihyertensive therapy
- B Blocker (metoprolol, bisoprolol)
- ACEi (lisinopril, ramipril, losartan)

Blood Sugar Control
- Metformin, Glimepiride,

CABG or PCI

GTN spray

224
Q

What are the complications of ischaemic heart disease?

A 
Myocardial infarction
Sudden cardiac death
Stroke
Peripheral arterial disease
Ischaemic cardiomyopathy
225
Q

What is unstable angina?

A

An acute coronary syndrome defined by the absence of biochemical evidence of myocardial damage.

226
Q

What is the aetiology behind unstable angina?

A

Coronary artery disease

Vasospasm

227
Q

How does unstable angina present?

A

Increasing frequency and severity of chest pain, retrosternal pain radiating to jaw, arm or neck, dyspnoea

228
Q

What investigations should be done for unstable angina ?

A 
ECG
Cardiac biomarkers (troponin)
FBC
Electrolytes 
Renal function
Blood sugar
Lipid profile 
Coag profile
CXR
Echo 
Myocardial perfusion studdy
CT Chest
Coronary angiography
229
Q

What is the management for cardiac chest pain?

A

Oxygen, nitrates, morphine

Betablockers (metoprolol, lisoprolol, labetalol, atenalol. propranalol, bisoprolol)

230
Q

Define a STEMI?

A

STEMI is an acute myocardial infarction with new and persistent ST segment elevation in two contiguous leads

231
Q

What is an acute myocardial infarction?

A

Cell death that occurs because of a prolonged tissue perfusion/tissue demand mismatch

232
Q

What are the risk factors for developing a STEMI?

A 
Increasing age 
Male
FH
Smoking
Diabetes
Hypertension
Dyslipidaemia
Obesity
233
Q

What is the incidence of STEMI?

A

500/1,000,000
M>F
Younger > Older
Incidence in women increases after menopause

234
Q

How does STEMI present?

A
  • Chest pain (retrosternal, crushing, heavy and diffuse. Can radiate to left arm, neck or jaw)
  • Dyspnoea
  • Pallor
  • Diaphoresis
  • Nausea/vomiting
  • Dizziness or light-headedness
  • Palpitations
  • Distress and anxiety
235
Q

What investigations should be done if STEMI is suspected?

A 
ECG
Cardiac Troponin
Glucose
FBC
Electrolytes, urea, creatinine, eGFR
CRP
Serum Lipids
236
Q

Differentials for STEMI

A 
Unstable Angina
NSTEMI
Aortic Dissection
PE
Pneumothorax
237
Q

How should STEMI be managed?

A 
Aspirin + clopidogrel
Morphine
Ondansentron
Oxygen 
IV GTN

PCI if symptoms presented <12 hours ago

238
Q

What are the complications of a STEMI?

A

Sinus bradycardia, first degree heart block, second degree heart block

Recurrence

Congestive Heart Failure

Death

239
Q

What is an NSTEMI ?

A

Chest pain without ST-segment elevation

but troponin levels are raised

240
Q

How is an NSTEMI assessed?

A

ECG (diagnostic)

Troponin

241
Q

What should be offered if NSTEMI is diagnosis is made?

A

Aspirin
Ticagrelor
Clopidogrel
LMW Heparin

242
Q

What system is used to assess risk of cardiovascular event of NSTEMI patients?

A

GRACE scoring system

243
Q

What is a pneumothorax?

A

Collection of air in the pleural cavity resulting in the affected lung collapsing

244
Q

What are the types of pneumothorax?

A

Primary spontaneous pneumothorax
Secondary Pneumothorax (associated with underlying lung disease)
Traumatic Pneumothorax
Iatrogenic Pneumothorax

245
Q

What is a tension pneumothorax?

A

Life threatening variant of pneumothorax resulting in impaired respiration and haemodynamic instability

246
Q

What are common findings in a tension pneumothorax?

A 
Chest pain
Tachycardia
Tachypnoea
Lowering O2 sats and BP
Tracheal displacement away from affected side
247
Q

How do you manage a tension pneumothorax?

A

Oxygen

Emergency needle decompression (large bore needle through second or third anterior intercostal space)

248
Q

When does a tension pneumothorax tend to arise?

A

In ventilated patient
Trauma
Resucitation patients
In COPD, Asthma
Patients revieving non-invasive ventilation
Patients undergoing hyperbaric oxygen treatment

249
Q

What are the risk factors for developing pneumothorax?

A 
Smoking
Marfans syndrome
Endometriosis 
COPD
CF
Malignanxy
Pulmonary Fibrosis
TB
250
Q

How does a pneumothorax present?

A

Sudden chest pain with shortness of breath
Distressed and sweating patient
Tachycardia
Hypotension
Decreased air entry and chest movements on affected side
Tracheal deviation
Hyperresonance and reduced breath sounds over effected area

251
Q

What investigations should be performed for pneumothorax?

A

Erect CXR
ABG (hypoxia)
O2 sats

252
Q

How is a pneumothorax managed?

A

Supplemental O2
Chest drain / Needle aspiration
Persistent air leak = thoracic surgery referral
Pleurodesis (minocylcline)

253
Q

What is otitis media?

A

Infection of the middle ear

254
Q

What organisms can cause otitis media?

A

Haemophilus Influenzae
Streptococcus pneumoniae
Moraxella catarrhalis

255
Q

What is the pathophysiology behind otitis media?

A

Upper respiratory infecitons can effect the nasal passages and consequently, the effect of the eustachian tube (draining the middle ear). This allows for effusion to develop and nasopharyngeal bacteria will contaminate the effusion.

256
Q

How does otitis media present?

A 
Otalgia
Recent Hx of Upper Resp symptoms
Bulging typanic mebrane
Myringitis 
Fever
Irritability
Sleep Disturbance
257
Q

What investigations are performed for otitis media?

A

None - diagnosis is clinical

258
Q

How is otitis media managed?

A

Paracetamol
Ibuprofen
Amoxicillin (delayed)/ erythromycin (penicillin allergic)

259
Q

What are the complications of acute otitis media?

A 
Otitis media with effusion
Mastoiditis
Acutely perforated tympanic membrane
Facial Nerve Palsy
Meningitis
Encephalitis
260
Q

What is otitis externa?

A

Inflammation of the outer ear

261
Q

What are the risk factors for otitis externa?

A 
Hot and humid climates
Swimming 
Older Age
Immunocompromise
DM 
Wax build up
Eczema
262
Q

What is the pathophysiology behind otitis externa?

A

Disturbance of lipid/acid balance of the ear canal

263
Q

What organisms can cause otitis externa?

A

Staph aureus
P. aeruginosa
Candida

264
Q

What irritants can cause otitis externa?

A 
Topical medications
Hearing aids
Earplugs
Foreign bodies
Water in ear 
Chemicals
265
Q

How does otitis externa present?

A 
Ear canal erythema, oedema and exudate
Mobile tympanic membrane
Pain with movement of tragus or auricle
Pre-auricular lymphadenopathy
Hearing Loss
Cellulitis spreading beyond ear 
Ottorhoea
Aural Fullness
Itching
266
Q

What investigations should be performed if otitis externa is suspected?

A

Otoscopy

Tympanometry

267
Q

How should otitis externa be managed?

A

Ciprofloxacin/dexamethasone drops
OR
Ofloxaxin drops
Paracetamol and ibuprofen

268
Q

What is a Hiatus Hernia?

A

The herniation of a part of the abdominal viscera through the oesophageal aperture of the diaphragm

269
Q

What are the risk factors for a hiatus hernia?

A 
Obesity
Pregnancy 
Ascites
Advancing Age
Genetics
Previous gastro-oesophageal surgery
270
Q

What is the cause of hiatus hernia?

A

Widening of the diaphragmatic hiatus
Oesophageal Shortening
Increased intra-abdominal pressure pushing up the stomach

271
Q

What are the two types of hiatus hernia?

A

Sliding (gastro-oesophageal junction slides into the thoracic cavity - 85-95% of cases)
Para-oesophageal hiatus hernia - the gastro-oesophageal junction remains in place but a part of the stomach herniates into the chest next to the oesophagus

272
Q

What is concerning about para-oesophageal hernias?

A

Risk of obstruction, volvulus or ischaemia

273
Q

How does a hiatus hernia present?

A

Asymptomatic (often with sliding hernias) OR:

  • Retrosternal burning sensation
  • Heartburn when lying or sitting
  • Gastro-oesophageal reflux
  • Difficulty Swallowing

Para-oesophageal hernia

  • chest pain
  • epigastric pain
  • fullness
  • nausea
274
Q

What investigations should be done for hiatus hernias?

A

CXR
Barium swallow
Endoscopy

275
Q

What diseases are associated with hiatus hernia?

A

Reflux oesophagitis
Barrett’s oesophagus
Oesophageal adenocarcinoma
Reflux laryngitis

276
Q

How is a hiatus hernia treated?

A

In absence of symptoms, sliding hernias do not require treatment

LIFESTYLE:
Avoid tight clothing, weight loss, remaining elevated when sleeping, smaller meals

PHARMACOLOGICAL:

  • Omeprazole
  • Lansoprazole

SURGICAL:
Fundoplication

277
Q

What are the indications for surgery?

A

People who are intolerant to/do not comply with therapeutic regimes

People with respiratory complications of reflux

People with symptomatic para-oesophageal hernia

People who require high doses of medication or in whom high doses are not working

278
Q

What is GORD?

A

Gastro-oesophageal Reflux Disease - prolonged exposure to gastric acid in the oesophagus

279
Q

What factors predispose people to GORD?

A 
Increased intra-abdominal pressure
Inadequate cardiac sphincter 
Smoking
Alcohol
Pregnancy
Obesity
Systemic sclerosis 
Hiatus hernia
Drugs (TCA's, ANTI CHOLINERGICS, NITRATES, CCB's)
280
Q

How does GORD present?

A 
Dyspepsia
Retrosternal discomfort
Acid or water brash
Odynophagia 
Chest Pain
Epigastric Pain
281
Q

How is GORD investigated?

A

Endoscopy
FBC
Barium Swallow
Oesophageal pH monitoring

282
Q

How is GORD managed?

A

LIFESTYLE:

  • weight loss
  • smoking cessation
  • reduce alcohol
  • small, regular meals

PHARMACOLOGICAL:
- Omeprazole

Endoscopy

Laproscopic fundoplication

283
Q

What are the complications of GORD?

A

Oesophagitis
Anaemia
Stricture
Barret’s oesophagus

284
Q

When should someone with GORD be referred for investigations into upper GI cancer?

A

Dysphagia - food sticking
Dyspepsia with weight loss/anaemia/vomiting
Dyspepsia with FH of upper GI cancer, Barrett’s oesophagitis, Pernicious Anaemia, Jaundice, Upper Abdo Mass

285
Q

What is Crohn’s disease?

A

A chronic relapsing IBD characterised by transmural granulomatous inflammation that can affect any part of the GI tract

286
Q

What is the most common site of crohn’s?

A

Terminal ileum

287
Q

What are the extra-intestinal manifestations of Crohn’s?

A 
Iritis
Arthritis
Erythema Nodosum
Pyoderma Gangrenosum
Fatty liver
Renal Stones
Osteomalacia
288
Q

Epidemiology of crohn’s?

A

M=F
2 age peaks
- 15-30 years
- 50-70 years

Strong genetic link

289
Q

What are the risk factors for Crohn’s?

A

Genetics

Smoking

290
Q

How does Crohn’s present?

A 
Diarrhoea (often not bloody or mucusy) 
Abdo pain
Weight loss 
Aphthous Ulcers 
Perianal abscess
Anal fissure

Pain etc is intermittent

May have skin, eye or joint problems too.

291
Q

What blood tests are done if Crohn’s is suspected?

A 
FBC
CRP
U&Es
LFTs
Faecal calprotectin
292
Q

What other forms of investigations are done for Crohn’s?

A

Endoscopy
Colonoscopy
+ Biopsy

293
Q

How is Crohn’s managed?

A

Correction of any vitamin/mineral deficiencies

Flare Up:

  • Oral Prednisolone, IV hydrocortisone
  • Azathioprine
  • Infliximab (severe active crohn’s)

Maintaining Remission:

  • Smoking Cessation
  • Azathioprine/ Mercaptopurine
  • Methotrexate (if pt does not tolerate azathioprine etc.)

Surgery

294
Q

What are the indications for surgery in Crohn’s?

A

Stricture formation
Fistula formation

Localised to distal ileum

295
Q

Why are anti-diarrhoeals not given in an active flare?

A

Can cause toxic megacolon

296
Q

What are the complications of Crohns?

A 
Stricutres
Fistulas
Perforation of bowel
Cancer
Osteoporosis (steroid therapy)
Iron, folate and vit b12 deficiency 
Gallstones and oxalate renal stones
297
Q

What is Ulcerative Colitis?

A

Inflammation of the colon with periods of relapse and remission. Limited to colon and rectum. Superficial mucosa only affected.

298
Q

Epidemiology of UC?

A

Most common type of IBD
M=F
Peak incidence = late adolescence, early adulthood

299
Q

What is the cause of UC?

A

Probably autoimmune

300
Q

What are the risk factors for UC?

A

Family History

301
Q

What is protective against UC?

302
Q

What are the symptoms of

A 
Bloody diarrhoea 
Colicky abdo pain
Urgency 
Tenesmus
Rectal bleeding 
Malaise
Fever
Weight Loss 
Tender abdo on examination
303
Q

What extra-intestinal diseases are associated with UC?

A 
Erythema nodosum
Episcleritis
Anterior uveitis
Ankylosing spondylitis
Primary sclerosing cholangitis
304
Q

What blood tests should be performed if UC is suspected?

A 
FBC
Renal function
CRP 
U&Es
LFTs
ESR
Iron studies, Vit B12 and folate
Faecal calprotectin 
p-ANCA testing
305
Q

What other investigations should be done for UC?

A

Sigmoidoscopy and rectal biopsy

Colonoscopy and biopsy

Abdo XRay

306
Q

Truelove and Witt categories for UC?

A

Mild - <4 stools a day, only small amount of blood in stool, no anaemia, no tachycardia, normal ESR and CRP

Moderate - 4-6 stools daily, more blood than mild disease, no anaemia, no tachycardia, no fever, normal esr and crp

Severe - >6 stools daily with visible blood, one or more feature of systemic upset (fever, tachy, anaemia, raised ESR, CRP)

307
Q

When is urgent hospital referral considered for UC patients?

A

Abdo pain with distended abdomen

Failed response to steroids after two weeks

308
Q

How is UC managed?

A

Mesalazine (oral or topical)
Corticosteroids (flare up)
Azathiopurine (pt intolerant to corticosteroids, relapse within 6 weeks of stopping steroids, relapse with small doses of steroids regularly)

Infliximab for moderate to severe disase

Surgery
- total colectomy (ileal pouch-anal anastamosis)

309
Q

When is surgery indicated in UC?

A

Stools >8 daily
Pyrexia
Tachycardia
Colonic dilation on abdo X-RAY

310
Q

What complications are associated with UC?

A

Colorectal cancer
Toxic megacolon
Osteoporosis (due to drug treatment)

311
Q

Colorectal cancer epidemiology

A

2/3 occurs in colon
1/3 occurs on rectum
4th most common cancer overall
Highest incidence in people aged 85-89

312
Q

What are risk factors for developing colorectal cancers?

A 
FH of colorectal neoplasia
PH of colorectal neoplasm
IBD
Polyposis syndromes (Gardner's syndrome, Peutz-Jeghers Syndrome etc)
HNPCC
DM
History of small bowel, endometrial, breast or ovarian cancer
Sedentary Lifestyle
313
Q

How does colorectal cancer present?

A

Right Sided
- weight loss, anaemia, occult bleeding, mass in right iliac fossa

Left Sided
- colicky pain, rectal bleeding, bowel obstruction, tenesmus, mass in left iliac fossa, early change in bowel habit, less advanced disease at presentation

Rectal bleeding

314
Q

What investigations should be performed for suspected colorectal cancer?

A 
Full blood count
Us Es
Liver Function Tests
Iron studies, ferritin, B12, folate
Faecal Occult Blood Test

Colonoscopy

315
Q

What is the referral criteria for colorectal cancer?

A
  • aged 40 and over w/ unexplained weight lorr and abdo pain
  • Aged 50 and over with unexplained rectal bleeding
  • Aged 60 and over with:
    • Iron deficiency anaemia
      OR
    • Changes in bowel habit OR
    • Tests show occult blood
      in faeces
  • Abdo or rectal mass
316
Q

What staging system is used to grade colorectal cancer?

A

Dukes Staging System

317
Q

Dukes Staging System

A

Dukes A - cancer in the innermost lining of bowel/ slight growth into muscle layer

Dukes B - cancer grown through the muscle layer of the bowel

Dukes C - cancer has spread to at least one lymph node close to the bowel

Dukes D - cancer has metastasised to other area

318
Q

What is the management for colorectal cancer?

A

Surgery
Radiotherapy
Chemotherapy

319
Q

Where are the common sites for metastasis in colorectal cancer?

A 
Liver
Lung 
Peritoneum 
Ovaries 
Brain
320
Q

What is the 5 year survival rate for colorectal cancer?

321
Q

What is an inguinal hernia?

A

the protrusion of abdo contents through the fascia of the abdo wall

322
Q

Epidemiology of inguinal hernias

A

M>F
Most common in infants or people aged 75 or above
Indirect more common in children
Direct more common in elderly

323
Q

What is the presentation of an inguinal hernia?

A

Swelling in the groin that may appear with lifting and be accompanied by sudden pain
Pain in scrotum (INDIRECT)
Increased swelling on coughing
Lump that may reduce when lying down

324
Q

What is an indirect hernia?

A

Protrusion through the internal inguinal ring, along the inguinal canal through abdo wall, running laterally to inf epigastric vessels

325
Q

What is a direct hernia?

A

Produces directly through a weakness in posterior wall of inguinal canal, running medially to inf epigastric vessels

326
Q

What investigations are done to diagnose a hernia?

A

Ultrasound

MRI if US unclear

327
Q

How is a hernia managed?

A

In adults, if small - conservative management unless painful, then surgery

Surgery if large, painful or in paediatric cases

328
Q

What complications are associated with hernias?

A 
Recurrence
Infarcted testes (or ovary)
Wound infection
Hydrocele 
Bladder or intestinal injury
329
Q

What are the most common causes of upper GI bleeding?

A

Oesophageal varices
Mallory-weiss tear
Duodenal or gastric ulcers
Gastric or duodenal cancer

330
Q

What is the glasgow-blatchford score?

A

a scoring system used in suspected upper GI bleed on initial presentation. A score >0 indicates a GI bleed

331
Q

What biochemical result would suggest an upper GI bleed?

A

A raised urea level

332
Q

What is the Rockall score?

A

Used for patients that have had endoscopy. Provides percentage risk for mortality.

333
Q

How is an upper GI bleed managed?

A 
ABCDE
Bloods
Access (2 large bore cannula)
Transfuse
Endoscopy
Drugs (stop anticoags and NSAIDs)
334
Q

What blood tests should be done in an upper GI bleed?

A 
FBC
UsEs
Coag panel
LFTs
Crossmatch
335
Q

What are gallstones?

A

A stone formed within gallbladder made of bile components

336
Q

Epidemiology behind gallstones

A

10-15% of adults develop gallstones
Most common presentations = biliary colic and acute cholecystitis
70% of patients with gallstones are asymptomatic at time of diagnosis

337
Q

What are the risk factors for developing gallstones?

A 
Fair
Fat
Female
Fertile
Forty
Increasing age
Sudden weight loss 
Diabetes
338
Q

What are the most common types of gallstone?

A

Cholesterol stone (Radiolucent)
Black pigment stones (Radiolucent)
Mixed stones - calcium salts, bile pigment and cholesterol (radiopaque)
Brown stones (result of stasis and infection within the biliary system)

339
Q

What is the pathophysiology behind biliary colic?

A

gallstone impacting in cystic duct or ampulla of vater

340
Q

Pathophysiology behind acute cholecystitis?

A

Distension of the gallbladder = necrosis and ischaemia of mucosal wall

341
Q

What are the symptoms of biliary colic?

A

Pain in epigastrium or RUQ and might radiate to back (interscapular region)

Nausea or vomiting

Doesn’t fluctuate

342
Q

What investigations should be done for suspected biliary colic?

A

Ultrasound
Urinalysis, ECG and CXR (exclude other things)
LFTs
ERCP

343
Q

How does acute cholecystitis present?

A 
RUQ pain
Vomiting
Fever
Local peritonism
GB mass 
Jaundice (stone moved to common bile duct)
344
Q

What investigations should be done for acute cholecystitis ?

A

FBCs
LFTs
US

345
Q

How is gallstones, colic and cholecystitis managed?

A

Opioids +/- diclofenac
IV antibiotics
Cholecystectomy

Surgical Block (6 decks)

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