AH2 review Flashcards
Indications for surgery- generally
1) Local symptoms
2) Functional and systemic symptoms
3) Malignancy
4) Cosmesis
Also patient factors
Breast cancer Hx
Lump
Breast pain/Mastalgia–> it is cyclic pain or just something abnormal
Nipple changes
Skin changes
Family
Any past investigation–> Any abnormal reports
Mammogram is
X-ray
MRI leads to what in the breast
Overdiagnosis of breast pathology
very sensitive, but not specific so have to do a battery of test
What are the surgical indications of fibroadenoma
- Triple test discordant
- Symptomatic
- Rapid growth or >3cm: DDx Phyllodes(Phyllodes tumours tend to keep growing and does not stop kinda pic)
- Patient request
Management of fibroadenoma
1) Biopsy them at any AGE
2) Review them in 3 months
- stable–> repeat USS and review in 12 months
- –> stable–> discharge from the clinic
- —> growth–> refer to surgical opinion
-Growth–> surgical opinion
If breast pain, we need to rule out what other things
Medical causes of chest pain
- cardio
- gastro
- resp
- gallstones
Breast abscess that is not going away, what are you thinkin?
Inflammatory breast cancer
Breast abscess management algorithm
The first thing to look out for is HOW DOES THE SKIN look
If the skin is normal–> USS guided aspiration and irrigate with Local anaesthetic + oral Abx
- re-aspirate every 2-3 days until there is no more pus
- review for imaging
Thin and necrotized–> Mini Iand D–> irrigate every 2-3 days with saline
Neoadjuvant therapy vs Adjuvant therapy
Neoadjuvant- before surgery
Adjuvant- after surgery
Neoadjuvant therapy, in contrast to adjuvant therapy, is given before the main treatment. For example, systemic therapy for breast cancer that is given before removal of a breast is considered neoadjuvant chemotherapy. The most common reason for neoadjuvant therapy for cancer is to reduce the size of the tumor so as to facilitate more effective surgery.
What is the staging done for breast cancer
TNM staging
2 types of breast cancer surgery
1) Breast conserving therapy (BCT) refers to breast conserving surgery (BCS; ie, lumpectomy) followed by moderate-dose radiation therapy (RT) to eradicate any microscopic residual disease.
2)
Pre-op for breast cancer
Do a triple assessment
Accurate histologic assessment of the primary tumor, including histologic subtype, hormone receptor status, and HER2 status.
Once the diagnosis of cancer is made, multidisciplinary coordination among breast and reconstructive surgeons, radiation and medical oncologists, and radiologists and pathologists facilitates treatment planning and streamlines patient care
In some cases, neoadjuvant chemotherapy is warranted to decrease the tumor size and improve the success rate of breast conservation
Imaging- Preoperative breast imaging to define the extent of disease and identify multifocal or multicentric cancer that could preclude breast conservation or make it difficult to achieve clear surgical margins
What does breast conservative surgery(BCS) involve
BCS involves excision of the primary tumor (ie, lumpectomy) and evaluation of the axillary lymph nodes (most commonly with sentinel lymph node biopsy [SLNB]) for invasive tumors.
What are my options for breast cancer doc? How do I decide my treatment
The surgical approach to the primary tumor depends on the size of the tumor, whether or not multifocal disease is present, and the size of the breast. The options include breast-conserving therapy (breast-conserving surgery plus radiation therapy [RT]) or mastectomy (with or without RT). Both approaches result in equivalent cancer-specific outcomes.
What will happen if my lymph nodes are suspicious on biopsy vs they are not suspicious on biops
For patients presenting with clinically suspicious axillary nodes, a preoperative work-up including ultrasound plus lymph node biopsy can help to determine the best surgical approach. If the lymph node biopsy is positive and the patient proceeds directly to surgery, an axillary node dissection should be performed. If the lymph node biopsy is negative, a sentinel lymph node biopsy (SLNB) at the time of surgery should be performed.
Patients who present with clinically negative axilla do not require a preoperative work-up. These patients should undergo an SLNB at the time of definitive breast surgery. Patients who have <3 pathologically involved sentinel nodes by SLNB might not require an axillary node dissection
Do all patient who undergo BCS need radiation?
Following surgery (with or without neoadjuvant systemic therapy), all patients who undergo breast-conserving surgery should undergo adjuvant RT to maximize locoregional control.
Neoadjuvant chemotherapy for breast cancer
Discuss with MDT
Inflammatory breast cancer always gets neoadjuvant chemotherapy
If breast cancer is has a big tumor size we should do it
Doctor tell me about breast conservative therapy
Breast conserving surgery involves removing the breast cancer and a small amount of healthy tissue around it (called the surgical margin). Some women also have one or more lymph nodes removed from the armpit.
Breast conserving surgery is an option if the breast cancer is small enough compared to the size of the breast to allow removal of the cancer and some healthy tissue around it and still give an acceptable appearance.
Radiotherapy to the breast is usually recommended after breast conserving surgery. Sometimes radiotherapy is also given to lymph nodes in the armpit and/or lower neck.
Triple-negative breast cancer will definitely benefit from what?
Chemotherapy- neoadjuvant
Trastuzumab, what is it and what can it be used to treat
-what side effect do we need to worry about
Monoclonal antibody used to treat breast cancer. Specifically, it is used for breast cancer that is HER2 receptor-positive. It may be used by itself or together with other chemotherapy medication.
Cardiotoxicity with Herceptin
breast cancer-BCS- consent forms tell about
WLE- wide local excision +/- SLN biopsy(sentinel lymph node biopsy)
Most common lump in the thyroid is
Multinodular goitre
What is the most common cause of MNG
The developing world–> iodine deficiency
Australia–> Familial, inbuilt error
Whys is MNG so hard to detect and patient present only when they feel a lump
Because its euthymic
What are the indications of MNG surgery(thyroid cancer)
1) Compressive symptoms--> trachea- stridor oesophagus- dysphagia Major vein inlet sign-Pemberton sign retrosternal extension
2) Cosmetic
3) Hyperthyroidism–> MNG become toxic–> hyperthyroidism increase–> its called Plummer disease
4) Potential malignancy(detectable–> hard to diagnosis if there is a big lump hey)–> do a FNA
Cancer is not common with MNG
MNG what kind of thyroid surgery is done
Total thyroidectomy
When a haematoma is formed post-op or op during thyroid surgery why is it urgent
- what happens if left alone
- what should be done
It does not compress the trachea
It compresses the surrounding veins- one of it being the internal jugular veins–> which drains the head and neck and this can cause you to pass out
- -> basically like a compartment syndrome in the neck
- -> internal oedema of the trachea: not external compression its internal compression
-Incision of the haematoma first cause intubation will be hard. the intubate and then repair
RESPIRATORY DEATH
-Compression neck veins, oedema airway
– Intrinsic obstruction airway
– Release haematoma
Complications of thyroidectomy
1) Bleeding/Haematoma formation
2) Damage to the nerve
- recurrent laryngeal nerve(hoarseness)
- superior laryngeal nerve( affects power of the voice)
4) Parathyroid
- Hypocalcemia
Why do you do FNA in thyroid and not core
The thyroid is very vascular organ, the core will cause too much bleeding
Bethesda system for thyroid is used for
cytopathology of thyroid nodules.
The Bethesda System for Reporting Thyroid Cytopathology is the system used to report whether the thyroid cytological specimen is benign or malignant on fine-needle aspiration cytology (FNAC). It can be divided into six categories
What is the treatment of well-differentiated thyroid (KNOW THIS 3 for exams)
1) Total thyroidectomy + central node dissection +/- block dissection
2) Radioactive iodine
3) Thyroid supplementation
Diffuse goitre
1) Graves disease
2) Hashimoto thyroiditis
Diffuse goitre-2 main causes
1) Graves disease
2) Hashimoto thyroiditis
The most common complication of thyroidectomy
Hypocalcemia as a result of hypoparathyroidism
Symptoms of hypocalcemia post-thyroidectomy
Symptoms of hypocalcemia range from mild (eg, paresthesias around the lips, mouth, hands, and feet) or moderate (eg, muscle twitches or frank cramps) to severe (eg, trismus or tetany
You are at the GP, and you find a thyroid lump. what is the triple assessment you would do for this thyroid lump
●History and physical examination
●Measurement of serum thyroid-stimulating hormone (TSH)–> don’t need to t3 and t4
●Ultrasound to confirm the presence of nodularity, assess sonographic features, and assess for the presence of additional nodules and lymphadenopathy(performed in everyone)
What on physical examination of the thyroid nodule can point towards thyroid cancer-4
The physical examination findings of a fixed hard mass, obstructive symptoms, cervical lymphadenopathy, or vocal cord paralysis all suggest the possibility of cancer.
Thyroid scintigraphy ? what is it
thyroid scintigraphy is used to determine the functional status of a nodule.
After doing a triple assessment for a thyroid nodule, what can be done
FNA
FNA biopsy of thyroid nodules is commonly performed under ultrasound guidance.
What will the FNA tell you
Tell you about cytology
FNA cytology — There are six major categories of results that are obtained from fine-needle aspiration (FNA), each of which indicates different subsequent management. The diagnostic categories (Bethesda classification
Why is FNA of the thyroid so important
FNA biopsy is the most accurate method for evaluating thyroid nodules and selecting patients for thyroid surgery.
Nodules that do not meet sonographic criteria for FNA should be monitored. The frequency of evaluation depends upon the sonographic features of the nodules.
What is the most common cause of a solitary thyroid nodule
Adenoma–> follicular
What are the types of carcinoma of the thyroid
-most prevalent to least
Papillary
Follicular
Medullary
Anaplastic
Treatment of thyroid adenoma
Normally followed up with USS
-red flag with symptomatic and increasing growth
can do Thyroid Lobectomy
» Return for Total if cancer
– Total Thyroidectomy
Assessing the Wound
Cause Location Size Wound colour Tissue Exudate Periwound skin Duration of wound
One of the main complications of bowel surgery is
anastomosis insufficiency, which may lead to abscess formation, peritonitis, and sepsis.
Types of stomas
Temporary and permanent
A permanent stoma is created following a procedure in which continence could not be preserved, whereas a temporary stoma allows for uninterrupted bowel healing (e.g., following surgery).
Hartmann’s procedure- is what? why are we doing it?
tell it to me in 4 steps
Bowel resection and creation of an end stoma with an artificial anus if primary anastomosis is not possible
Surgical re-anastomosis with restoration of intestinal continuity (∼ 6 months following initial operation)
Anastomosis insufficiency (anastomotic leak)- what are the clinical features
Postoperative fever, tachycardia (usually 5–7 days following surgery)
Abdominal distention, pain, and peritoneal signs
Tender incision wound, purulent (or feculent) drainage
Complications: abscess formation, peritonitis, SIRS, sepsis
What are some complications of stoma-3
Stoma retraction (the stoma is drawn below skin level)
Prolapse
Skin maceration, necrosis
Biggest complications you need to br worried about with stoma is fluid management
CAN GO INTO RENAL FAILURE fast
Management of major trauma
“FIND the bleeding, STOP the bleeding”
Rapid and effective restoration of blood volume
Maintain functional blood composition to preserve blood function:
— haemostasis, oxygen carrying capacity, oncotic pressure and biochemistry
“Think SCALPeR when finding the bleeding”
‘Street’: scalp and external sources (especially small children)
Chest
Abdomen
Long bones (especially femurs)
Pelvis
Retroperitoneum
CLASSIFICATION OF STAGES OF HAEMORRHAGIC SHOCK- what is the rule for haemorrhagic shock
Love – 15 – 30 – 40 — game over (>40)
LETHAL TRIAD AND ACUTE COAGULOPATHY OF TRAUMA/ SHOCK
The lethal triad is:
Hypothermia
Coagulopathy
Acidosis
These three factors both cause, and contribute to, acute coagulopathy of trauma/ shock (ACoTS) which leads to, and result from, major hemorrhage.
Q1. What are your main objectives in managing major hemorrhage resulting from trauma?
1) Stop bleeding
2) Rapid and effective restoration of blood volume
3) Maintain functional blood composition to preserve blood function:
— hemostasis, oxygen-carrying capacity, oncotic pressure and biochemistry
Q3. Describe your overall approach to stopping bleeding?
Whenever you think ‘control hemorrhage’, think ‘correct coagulopathy’
What are the indications for emergency laparotomy in penetrating abdominal trauma?
1) Peritonism
2) Free air (in stab wounds may represent the introduction of external air rather than gastrointestinal perforation)
3) Evisceration
4) Hypotension (hemodynamic instability)
5) Gunshot wound traversing peritoneum or retroperitoneum
6) GI bleeding following penetrating trauma
penetrating object is still in situ (risk of precipitous haemorrhage on removal)
Q1. What are the indications for emergency laparotomy in blunt abdominal trauma?
Peritonism
Free air under the diaphragm
Significant gastrointestinal hemorrhage
Hypotension with positive FAST scan
Q13. What are lateralising signs in severe traumatic brain injury?
Lateralising signs in severe traumatic brain injury suggest the presence of a focal lesion (e.g. hematoma) that requires urgent decompression.They include:
unilateral blown pupil (usually ipsilateral to the lesion)
unilateral posturing or seizures (usually contralateral to the lesion)
The most commonly injured organ in blunt abdominal trauma
Spleen
extra info-
Abdominal pain, localized tenderness (LUQ)
Possible hemorrhagic shock
CT abdomen with IV contrast is the investigation of choice (spleen injuries are graded I to V according to severity)
Clinical presentation of spleen trauma
Patients may present with left upper quadrant, left chest pain, left shoulder tip pain (referred from diaphragmatic irritation), and signs of hypotension or shock.
Which imaging is the modality of choice for assessing splenic trauma
CT
Treatment of spleen trauma
Most splenic injuries in haemodynamically-stable patients are treated non-surgically. Splenic artery embolization plays a major role in treating high-grade splenic injuries (both in haemodynamically-stable and -unstable patients; practice varies from institution-to-institution).
If unstable–> lap
Acute colonic pseudo-obstruction also know as
-what specific medication is given for this condition
Ogilvile’s sydrome–> you can seen a massive distention
Acute colonic pseudo-obstruction is characterized by massive dilatation of the cecum (diameter > 10 cm) and right colon on abdominal X-ray.[2][3] It is a type of megacolon, sometimes referred to as “acute megacolon”, to distinguish it from toxic megacolon.
Medication–> neostigmine
Anal fissure, what is the treatment
-what is the best treatment and what is the common side effect from it
CONSERVATIVE, CONSERVATIVE
stool softeners and analgesia
GTN is specific treatment–> HEADACHES is the side effect
Sudden development of lump while popping doc and its painful as hell… what the diagnosis
Perianal haematoma
referral to surgeon
Abscess just lateral to the anal canal
Interspheric abscess/ischiorectal abscess
Which one is worse perianal abscess or ischiorectal abscess
ischiorectal abscess –> Looks deep and some cannot see
Anal fistula
-what can you put
Can be distant from the anal canal
- you can treat with a seton
- crohn’s disease
(Fournier’s gangrene)
Necrotising fasciitis-poorly treated perianal sepsis in a diabetic
Indications for Bariatric surgery
1) Adults with a BMI ≥40 kg/m2 without comorbid illness
2) Adults with a BMI 35.0 to 39.9 kg/m2 with at least one serious comorbidity,
OSA screening-STOP-Bang questionnaire
Snoring Tired Observed Pressure BMI > 35 Age>50 N- neck size G-gender-male
3 surgical operations for bariatric surgery
-which one is gold standard
Sleeve Gastrectomy
Lap/ Gastric band
Gastric bypass(Gold standard)
The common complication of gastric bypass
Leak from the staple line (1 in 20)
Common complications of gastric band/lap band
Band slippage (1 in 20) Band erosion (up to 1 in 100) Oesophageal dilatation (1 in 20)
The common complication of sleeve gastrectomy
Leak from the staple line (1 in 25)
Kehr’s sign
Free blood can irritate the diaphragm and cause a radiating left shoulder pain (known as Kehr’s sign).
What do we need to worry about after splenic rupture
Overwhelming Post-Splenectomy Infection (OPSI)
The spleen is an immunologically active organ, with an active role in destroying encapsulated organisms, such as Pneumococcus, Meningococcus, and H. Influenzae.
These patients–> STRICT BEDREST
INDICATIONS FOR EMERGENCY CHOLECYSTECTOMY
asked in 2017 KFP
Complicated acute cholecystitis, including gallbladder gangrene/necrosis, perforation, and emphysematous cholecystitis, may be fatal without emergency cholecystectomy.
INDICATIONS FOR elective CHOLECYSTECTOMY
asked in 2017 KFP
Acute uncomplicated cholecystitis
3 days within the hospital after assessing the risk
A laparoscopic cholecystectomy is indicated within 1 week, as per NICE guidelines, however this ideally should be done within 72hr of presentation*
Bouveret’s Syndrome and Gallstone Ileus
Inflammation of the gallbladder (typically if recurrent or silent) can cause a fistula to form between the gallbladder wall and the duodenum, allowing gallstones to pass into the small bowel. As a consequence, bowel obstruction can occur
Bouveret’s Syndrome – stone impacts to cause duodenal obstruction
Gallstone Ileus*– stone impacts to cause an obstruction at the terminal ileum (the narrowest part of the adult bowel)
*The term ileus is misleading, as it is actually a bowel obstruction
The choice of treatment for patients with choledocholithiasis
endoscopic retrograde cholangiopancreatography (ERCP).
The gold standard investigation for cholangitis
ERCP, as it is both diagnostic and therapeutic. Many endoscopists may require an MRCP prior to intervention, however, to obtain detailed imaging of the biliary system prior to scoping.
(MRCP is an investigation–> magnetic resonance cholangiopancreatography)
The definitive management of cholangitis is via endoscopic biliary decompression, removing the cause of the blocked biliary tree.
Imaging for cholangitis
An ultrasound scan of the biliary tract will show bile duct dilation. The common bile duct is usually less than 6mm in size (it may be greater in the elderly and those who have had the previous cholecystectomy), so any diameter larger than this suggests dilatation. Ultrasound imaging may also demonstrate the presence of an underlying cause (e.g. gallstones).
Is ERCP an investigation
NOT AN INVESTIGATION
INCREASED RISK OF PANCREATITIS
GET SMASHED
Gallstones
Ethanol (Alcohol)
Trauma
Steroids
Mumps
Autoimmune disease, such as SLE
Scorpion venom (a rare and unlikely cause in most countries)
Hypercalcaemia
Endoscopic retrograde cholangio-pancreatography (ERCP)
Drugs, such as Azathioprine, NSAIDs, or Diuretics
Clinical Signs of retroperitoneal haemorrhage in pancreatitis
A) Cullen’s Sign-periumbilical
(B) Grey-Turner’s Sign-flank ecchymosis
The _____________ is used to assess the severity of acute pancreatitis within the first 48 hours of admission.
modified Glasgow criteria
Management of pancreatic pseudocyst
About 50% will spontaneously resolve, hence conservative management is usually the initial treatment of choice. Cysts which have been present for longer than 6 weeks are unlikely to resolve spontaneously. Treatment options include surgical debridement or endoscopic drainage (often into the stomach).
Pancreatic cyst vs pseudocyst
-treatment
Pancreatic pseudocyst – this is a collection of fluid within the pancreatic tissue, typically forming following pancreatitis
Pancreatic cysts are collections of fluid that form within the pancreas*.
Pancreatic cysts are divided into true cysts (non-inflammatory) and pseudocysts (inflammatory),
MDT meeting
assess if high risk vs low risk
pancreatic resection is ideal
Most common causes of pancreatitis
1) Biliary pancreatitis (e.g., gallstones, constriction of the ampulla of Vater) ∼ 40% of cases
2) Alcohol-induced (∼ 30% of cases)
3) Idiopathic (∼ 15%–25% of cases)
Courvoisier sign/law
Courvoisier sign: enlarged gallbladder and painless jaundice
Painless jaundice (a nontender gallbladder) is the most common initial symptom of pancreatic cancer but usually doesn’t occur when the primary tumour is located in the tail or body of the pancreas. Painless jaundice may also occur in cholangiocarcinoma. Gallstones, on the other hand, cause obstructive jaundice with a painful gallbladder.
ATLS protocol-ABCDE
Airway with C-spine protection Breathing with adequate oxygenation Circulation with haemorrhage control Disability Exposure/Environment
The clinical scoring system used in the diagnosis of appendicitis.
-what is the mnemonic to remember it
Alvarado
MANTRELS
Migration of pain to the right iliac fossa
Anorexia [urinalysis to look for acetone as an indication of anorexia; add urine dipstick for ketonuria >2+]
Nausea/Vomiting
Tenderness in the right iliac fossa
Rebound pain [Can be replaced with other indirect signs such as the Rovsing sign; Dunphy sign; Markle test; or percussion tenderness]
Elevated temperature (fever) [> 37.3 C]
Leukocytosis
Shift of leukocytes to the left
Appendicitis- what not to forget in DDX
Gynaecology
Testicular stuff- look at the junk
Urology stuff- look for stones–> do a urine dipstick
__________ classifies a colonic perforation due to diverticular disease.
Hinchey Classification
Generally, SBO caused by ______ and do they need surgery? _____, generally
adhesion
NO
conservative management is enough
You’re doing a physical exam on somebody for possible SBO. What MUST you look for that you could forget.
HERNIAS (check groin)
Also, as always, do a DRE so as to check for blood.
Name four common causes of small bowel obstruction.
1) Adhesions
Also, hernias, cancer, Crohn’s disease.
The ABCs of small bowel obstruction:
A - adhesions
B - bulges (hernias)
C - cancer, Crohn’s
Children-Intussusception
What is the treatment of someone with complete small bowel obstruction?
vs
What is the treatment of someone with partial small bowel obstruction?
Laparotomy with lysis of adhesions
Conservative treatment (resuscitation, monitoring, NGT compression)
What condition commonly mimics SBO?
Paralytic ileus
What are the symptoms and signs of small bowel obstruction?
Symptoms:
1) Colicky abdominal pain
2) Nausea/vomiting
3) Constipation
Signs:
High-frequency bowel sounds
Distention
Why does volvulus happen in the sigmoid and cecum
Mesenteric twisting
Volvulus treatment? can you an NGT compression?
NGT cannot be done sometimes
If No signs of peritonitis: rigid/flexible sigmoidoscopic detorsion of the volvulus
In any AXR, what warrants as a good AXR
If you can see the diaphragm
Hence you can look for free air
What is the medication used for paralytic ileus
and what is the MoA of the medication
Give them a prokinetic agent like -
Metoclopramide(REMEMBER THIS ONE) or erthromycin
Metoclopramide is given to everyone who has bowel surgery
Domperidone- don’t use it
MoA of metoclopramide–>
dopamine D2 receptors antagonist
–> The antiemetic action of metoclopramide is due to its antagonist activity at D2 receptors in the chemoreceptor trigger zone in the central nervous system — this action prevents nausea and vomiting triggered by most stimuli
CRP greater than what is bacterial
40
Neutropenic fever /sepsis:
Fever 380C over 1 hour or stat temperature of 38.3 when the absolute neutrophil count is <0.5 or(500).
Medical emergency
Need broad spectrum antibiotics- to cover G+, G- esp pseudomonal infections and possibly anaerobes.
Vancomycin only in line sepsis, haemodynamic compromise and history of MRSA
Prostate cancers- 3 options are
Wait and watch vs surgery vs radiotherapy
The most common form of renal stone-which substance is most common
Calcium oxalate- they are radiopaque
If a person has gout, what kind of stones will be present
Uric acid stones
Investigation for nephrolithiasis
1) FBC–> increase in WBC
2) BUN–>↑ Serum urea nitrogen and creatinine- suggests acute kidney injury
3) Urine dipstick and urinalysis –>Gross or microscopic hematuria
4) Urine microscopy: may detect crystals
Imaging
1) X-ray
2) USS
3) CT(GOLD STANDARD)- non-contrast
Intravenous pyelogram (IVP)
Provides a complete outline of the urinary tract system,
What is the cut-off to which the renal stone will pass spontaneously
-what is the pain management for it
less than or equal to 6 mm
The best analgesia for out-of-hospital care is nonsteroidal anti-inflammatory drugs (NSAIDs) suppositories. Importantly, the limitations of peptic ulcer disease and CKD
There are relative and absolute indications for intervention in the setting of renal or ureteric stones.
Absolute indications and Relative indications are:
There are relative and absolute indications for intervention in the setting of renal or ureteric stones. Absolute indications are:
• infection (pyonephrosis)
• renal failure.
Relative indications are:
• ongoing or recurrent pain
• stone larger than 6 mm, unlikely to pass
• occupational/socia
Definitive treatment of ureteric stones
ureteroscopic laser lithotripsy(better than shock)
Shock wave lithotripsy is the least invasive method of eliminating stones, but also the least effective
If calcium oxalate stones are the most common, what kind of advice would you give the patient
General advice for stone prevention consists of:
• increasing fluid intake, especially water, sufficient to maintain dilute
urine output
• avoiding added salt
• SNAP stuff
advised to keep a low oxalate diet.
Common oxalate-rich foods include: tea, chocolate, spinach, beetroot, rhubarb, peanuts, cola, and vitamin C (most supplementary vitamin C is converted to oxalate
What kind of surgery increase kidney stones
associated gastrointestinal pathology (bypass or ileal resection) resulting in fat malabsorption
(After bariatric surgery, patients have an increased risk for kidney stones. Research shows that gastric bypass patients have changes in urine and higher levels of particles, called oxalates, which form kidney stones. … The oxalate can form crystals, which may lead to the formation of kidney stones)
Some interventional procedures of renal stones
Ureteral stenting or percutaneous nephrostomy
Extracorporeal shock wave lithotripsy (SWL)
Ureterorenoscopy (URS)- first line option for 20mm
Percutaneous nephrolithotomy : first-line treatment for renal stones > 20 mm
For stones that enter the drainage system of the urinary tract, there are three natural narrowed points where stones are likely to impact:
Pelviureteric Junction (PUJ), where the renal pelvis becomes the ureter
Crossing the pelvic brim, where the iliac vessels travel across the ureter in the pelvis
Vesicoureteric Junction (VUJ), where the ureter enters the bladder
Criteria for Inpatient Admission for renal stones
Post-obstructive acute kidney injury
Uncontrollable pain from simple analgesics
Evidence of an infected stone(s)
Large stones (>5mm)
Max rate at which potassium can be given
If potassium is greater than 2.5mmol/L - 10mmol/hr
The maximum rate for intravenous potassium chloride administration must not exceed 10mmol per hour
Mini-bags for K what are they
New 10mmol in 100ml Potassium Chloride ( Potassium Chloride (KCl) bags
Any gallbladder surgery what imaging is done after
IOC
Intraoperative cholangiogram
The risks of laparoscopy
carbon dioxide gas –> gas embolism
Damage to other structures
The two most important headings here are bleeding and
infection.
Specific risks of gall bladder surgery
1) The important issue here is injury to the main bile ducts.
2) Stones in the bile duct may be left behind(rarely happens now due to IOC)
Right hemicolectomy
involves removal of the ascending colon and caecum
Left hemicolectomy
involves removal of the splenic flexure and the descending colon
Sigmoid colectomy
involves removal of the sigmoid colon; anterior resection involves removal of the sigmoid colon and rectum
Abdominal-perineal resection (APR)
Involves removal of the sigmoid colon, entire rectum, and anus with the formation of an end colostomy
Procedure: resection of the rectum, sigmoid, and anus with TME and a permanent colostomy
Low anterior resection (LAR)
Procedure: sphincter-preserving resection of the rectum and sigmoid
clinical features of rectal cancer include
Hematochezia ↓ Stool caliber (pencil-shaped stool) Rectal pain Tenesmus Flatulence with involuntary stool loss
Multi-hit theory for the development of colon cancer
Cancer is due to accumulation of genetic insults( loss of tumor suppressor genes and activation of proto-oncogene)
What is the molecular understanding of the adenoma-carcinoma relationship?
- Multi-hit hypothesis
- Accumulation of mutations is more important that the specific order of mutations
The adenoma-carcinoma sequence is the progressive accumulation of mutations in oncogenes (e.g., KRAS) and tumor suppressor genes (e.g., APC, TP53) that results in the slow transformation of adenomas into carcinomas
Given time any polyp can become cancer
How can you grade the depth of invasion of Colorectal Cancer?
T(in situ / IS) = just in mucosa
- T1 = invaded into submuocsa
- T2 = invaded into muscularis propria
- T3 = invaded through serosa
- T4 = invades other organs or structures
Thyroid nodule- what are the indications
1) Malignant FNA
2) USS characteristics- large size, irregular, vascularity calification, mixed cystic/solid
3) Compression symptoms
4) Hyperfunctioning nodules
5) Retrosternal extension
6) Patient preference/cosmesis
What kind of adenoma is most common with primary hyperparathyroidism
Single adenoma
Clinical features of primary hyperparathyroidism
Majority are asymptomatic
Commonest symptoms are polyuria, thirst and
polydypsia, and mental confusion (‘psychic moans’)
“Stones, bones and abdominal groans” Urinary tract calculi Pathological fractures Bone and joint pain Abdominal pain and constipation
Imaging for primary hyperparathyroidism
–> will this help with the diagnosis
USS
Sestamibi Parathyroid Scan
CT–> Highly sensitive in localising single adenomas
Hyperparathyrodism- is a BIOCHEMICAL DIAGNOSIS
What is the surgery for single adenoma causing hyperparathyroidism
Minimally Invasive Parathyroidectomy(MIP)
The most common cause of secondary hyperparathyroidism
CKD
thyroid nodule less than 10mm what should you do
observe and repeat USS in 6 months
what kind diagnosis is hyperparathyroidism
BIOCHEMICAL
Look at the blood tests
Why is removal of the thymus important for hyperparathyroidism
Cause embryologically–> parathyroid hormone remeant can remain
Indications for hernia repair
1) Complicated hernia — Patients who develop strangulation or bowel obstruction should undergo urgent surgical repair. Surgery performed within four to six hours from the onset of symptoms may prevent bowel loss due to one of these complications.
2) Symptomatic hernia — Patients with significant symptoms attributable to an inguinal hernia should undergo elective surgical repair, Such symptoms typically include:
●Groin pain with exertion (eg, lifting)
●Inability to perform daily activities due to pain or discomfort from the hernia
●Inability to manually reduce the hernia (ie, chronic incarceration)
When is watchful waiting for inguinal hernia indicated
Asymptomatic hernia — For patients with minimal or no symptoms from an inguinal hernia, we suggest elective hernia repair, or watchful waiting for those who wish to avoid surgery.
