Block 1

Question 1

Which of the following drugs increases the rate of gastric emptying in the vagotomised stomach?

Ondansetron

Metoclopramide

Cyclizine

Erythromycin

Chloramphenicol

Answer 1

Erythromycin

Vagotomy seriously compromises gastric emptying which is why either a pyloroplasty or gastro-enterostomy is routinely performed at the same time.

Chloramphenicol has no effect on gastric emptying. Ondansetron slows gastric emptying slightly. Metoclopramide increases the rate of gastric emptying but its effects are mediated via the vagus nerve. Erythromycin enhances gastric emptying by acting via the motilin receptor in the gut.

Question 2

What factors delay gastric emptying?

Answer 2

Hormonal:

Gastric inhibitory peptide

Cholecystokinin

Enteroglucagon

Question 3

What factors increase gastric emptying?

Answer 3

Gastrin

Parasympathetic stimulation by the vagus nerve

Question 4

What do patients undergoing truncal vagotomy require and why?

Answer 4

Routinely require either a pyloroplasty or gastro-enterostomy or they would otherwise have delayed gastric emptying

Question 5

What may the consequences of diseases affecting gastric emptying be?

Answer 5

Bacterial overgrowth

Retained food-> bezoars that may occlude the pylorus

Fermentation of food may cause dyspepsia, reflux and foul smelling belches of gas

Question 6

Iatrogenic factors impacting gastric emptying

Answer 6

Any procedure that disrupts the vaugs nerve-> depayed emptying. vagotomy not routinely performed but oesophagectomy may also disrupt vagal nervous supply of the stomach.

When a distal gastrectomy is performed, the type of anastomosis performed impacts on emptying. e.g. when a gastro-enterostomy is constructed, posterior retrocolic gastroenterostomy will empty better than an anterior one

Question 7

How does the type of gastro-enterostomy performed affect gastric emptying?

Answer 7

When a distal gastrectomy is performed, the type of anastomosis performed will impact on emptying. When a gastro-enterostomy is constructed, a posterior, retrocolic gastroenterostomy will empty better than an anterior one.

Question 8

Diabetic

Episodes of repeated and protracted vomiting

Answer 8

?Diabetic gastroparesis

Question 9

Pathophysiology of diabetic gastroparesis

Answer 9

Predominantly due to neuropathy affecting the vagus nerve

Question 10

Diagnosis of diabetic gastroparesis

Answer 10

Upper GI endoscopy

Contrast studies

Radio-nucleotide scan may be used rarely to demonstrate abnormality

Question 11

Treatment of diabetic gastroparesis

Answer 11

Drugs such as metoclopramide don’t work as effectively as they exert their effect via the vagus nerve.

Erythromycin is one of the few prokinetic drugs that does as it works via the motilitin receptor

Question 12

Malignancies causing delayed gastric emptying

Answer 12

Distal gastric cancer

Malignancies of the pancreas may cause extrinsic compression of duodenum

Question 13

Treatment of gastric outflow obstruction by malignancy

Answer 13

Gastric decompression with wide bore NG tube (Ryles tube)

Insertion of stent

Or surgical bypass via gastroenterostomy

Question 14

Where is the anatsomosis placed in gastroenterostomy due to malignancy

Answer 14

In the anterior wall despite less good emptying

Question 15

What type of bypass may also be used in obstructing gastric malignancy

Answer 15

Roux en Y bypass

Question 16

Typically a disease of infancy. Most babies will present around 6 weeks of age with projectile non bile stained vomiting. It has an incidence of 2.4 per 1000 live births and is more common in males.

Answer 16

Pyloric stenosis

Question 17

Diagnostic test in in py sten

Answer 17

USS- hypertrophied pylorus

Question 18

Metabolic abnormality in pyloric stenosis

Answer 18

Hypochloraemic hypokalaemic metabolic alkalosis

Question 19

What is the earliest complication that can occur following construction of an ileostomy?

Prolapse

Retraction

Necrosis

Parastomal hernia

Dermatitis

Answer 19

Necrosis

Construction of a stoma may be complicated by several factors. Necrosis may occur because of technical errors in mesenteric division, excessive tension or failure to construct a fascial defect of adequate size to permit safe passage of the mesentery and the bowel.

Question 20

Where are ileostomies generally fashioned?

Answer 20

RIF in the triangle between ASIS, symphysis pubis and umbilicus

Should lie one-third of the distance between the umbilicus and ASIS.

Question 21

Process of ileostomy formation

Answer 21

They should lie one-third of the distance between the umbilicus and anterior superior iliac spine. A 2cm skin incision is made and dissection continued through the rectus muscle. A cruciate incision should be made, and generally dilated to admit two fingers. The ileum is brought through the incisions and should generally be spouted to a final length of 2.5cm. Ileostomies that are too short may cause problems with appliance fixation and those which are too long may cause problems with tension and subsequent ulceration or prolapse.

Question 22

What is the most common complication post-ileostomy

Answer 22

Dermatitis

Question 23

What is the usual ileostomy output?

Answer 23

5-10ml/kg/24h

Question 24

When might ileostomy output require additional IVF

Answer 24

20ml/kg/24h

Question 25

Medical management of high output ileostomy

Answer 25

Oral loperamide

Foods containing gelatine.

Question 26

What proportion of ileostomy patients will respond to conservative management of high output stoma?

Answer 26

50%

Question 27

Which of the following structures is not transmitted by the jugular foramen?

Hypoglossal nerve

Accessory nerve

Internal jugular vein

Inferior petrosal sinus

Vagus nerve

Answer 27

Contents of the jugular foramen:

Anterior: inferior petrosal sinus
Intermediate: glossopharyngeal, vagus, and accessory nerves
Posterior: sigmoid sinus (becoming the internal jugular vein) and some meningeal branches from the occipital and ascending pharyngeal arteries

Question 28

What are the anterior contents of the jugular foramen?

Answer 28

Inferior petrosal sinus

Question 29

What are the intermediate contents of the jugular foramen?

Answer 29

Glossopharyngeal, vagus, accessory nerves

Question 30

What are the posterior contents of the jugular foramen

Answer 30

Sigmoid sinus (becoming the IJV) and some meningeal branches from the occipital and ascending pharyngeal arteries

Question 31

Location of foramen ovale

Answer 31

Sphenoid bone

Question 32

Contents of the foramen ovale

Answer 32

Otic ganglion

V3 (mandibular branch of V)

Accessory meningeal artery

Lesser petrosal nerve

Emissary veins

Question 33

What is the location of the foramen spinosum

Answer 33

Sphenoid bone

Question 34

Contents of the foramen spinosum

Answer 34

MMA

Meningeal branch of mandibular nerve

Question 35

Location of the foramen rotundum

Answer 35

Sphenoid bone

Question 36

Contents of the foramen rotundum

Answer 36

Maxillary nerve V2

Question 37

Location of the foramen lacerum/carotid canal

Answer 37

Sphenoid bone

Question 38

What foramina are found in the sphenoid bone?

Answer 38

Foramen ovale

Foramen spinosum

Foramen rotundum

Foramen lacerum/carotid canal

Superior orbital fissure

Optic canal

Question 39

What are the contents of the foramen lacerum

Answer 39

Base of the medial pterygoid plate

Internal carotid artery*

Nerve and artery of the pterygoid canal

*= In life the foramen lacerum is occluded by a cartilagenous plug. The ICA initially passes into the carotid canal which ascends superomedially to enter the cranial cavity through the foramen lacerum.

Question 40

What is the location of the jugular foramen

Answer 40

Temporal bone

Question 41

Location of the foramen magnum

Answer 41

Occipital bone

Question 42

Contents of the foramen magnum

Answer 42

Anterior and posterior spinal arteries

Vertebral arteries

Medulla oblongata

Question 43

Location of the stylomastoid foramen

Answer 43

Temporal bone

Question 44

Contents of the stylomastoid foramen

Answer 44

Stylomastoid artery

Facial nerve

Question 45

Contents of the superior orbital fissure

Answer 45

III

Recurrent meningeal artery

IV

Larcimal, frontal and nasociliary branches of V1

VI

Superior ophthalmic vein

Question 46

Answer 46

Question 47

At what levels are lumbar punctures best performed?

Answer 47

L3/4 or L4/5

Question 48

At what level does the SC terminate?

Answer 48

L1

Question 49

What does the needle pass through on LP

Answer 49

Supraspinous ligament- connects the tips of the spinous processes and the interspinous ligaments between adjacent borders of the spinous processes

Ligamentum flavum which may cause a give as it is penetrated

A second give represents penetration of the needle through the dura mater into the subarachnoid space.

Clear CSF should be obtained at this point.

Question 50

What do parietal cells secrete?

Answer 50

HCl, Ca, Na. Mg, IF

Question 51

What do chief cells secrete?

Answer 51

Pepsinogen

Question 52

What do gastric surface mucosal cells secrete?

Answer 52

Mucus and bicarbonate

Question 53

Which of the following is not secreted by the parietal cells?

Hydrochloric acid

Mucus

Magnesium

Intrinsic factor

Calcium

Answer 53

Mucus

Question 54

Outline the process of gastric acid secretion

Answer 54

Produced by parietal cells

pH of 2- maintained by H/K ATPase, bicarbonate ions secreted into the surrounding vessels.

Na and Cl are actively secreted from parietal cells into the cannaliculus, this sets up a negative potential across the membrane and as a result sodium and potassium ions diffuse across into the cannaliculus

Carbonic anhydrase forms carbonic acid which dissociates and the hydrogen ions formed by dissociation leave the cell via the H/K antiporter pump

At the same time, Na ions are actively absorbed. This leaves H + Cl ions in the canaliculus, these mix and are secreted into the lumen of the oxyntic gland

Question 55

What are the 3 phases of gastric acid secretion

Answer 55

Cephalic phase (smell/taste of food)

Gastric phase (stomach distension)

Intestinal phase (food in duodenum)

Question 56

Outline the cephalic phase of gastric acid secretion

Answer 56

30% acid produced

Vagal cholinergic stimulation causing secretion of HCl and gastrin release from G Cells

Question 57

Outline the gastric phase of gastric acid secretion

Answer 57

60% acid produced

Stomach distension/low H+/peptides cause gastrin release

Question 58

Outline the intestinal phase of gastric acid secretion

Answer 58

10% of acid produced

High acidity/distension/hypertonic solutions in the duodenum inihibt gastric acid secretion via enterogastrones (CCK, secretin) and neural reflexes

Question 59

What are the factors increasing gastric acid secretion

Answer 59

Vagal nerve stimulation

Gastrin release

Histamine release (indirectly following gastrin release) from enterochromaffin like cells

Question 60

What are the factors decreasing gastric acid production

Answer 60

Somatostatin (inhibits histamine relase)

Cholecystokinin

Secretin

Question 61

Describe the factors affecting gastric acid release

Answer 61

Question 62

Gastrin comes from

Answer 62

G cells in the antrum of the stomach

Question 63

CCK comes from

Answer 63

I cells in the upper small intestine

Question 64

Secretin comes from

Answer 64

S cells in upper small intestine

Question 65

VIP comes from

Answer 65

Small intestine, pancreas

Question 66

Somatostatin comes from

Answer 66

D cells in the pancreas and stomach

Question 67

Action of gastrin

Answer 67

increase HCl

Pepsinogen and IF secretion

Increase gastric motility

Trophic effect on gastric mucosa

Question 68

Action of CCK

Answer 68

Increases secretion of enzyme-rich fluid from pancreas

Contraction of galbladder, relaxation of sphincter of Oddi

Decreases gastric emptying

Trophic effect on pancreatic acinar cells

Induces satiety

Question 69

Action of secretin

Answer 69

Increases secretion of bicarbonate-rich fluid from pancreas and hepatic duct cells

Decreases gastric acid section

Trophic effect on pancreatic acinar cells

Question 70

Action of VIP

Answer 70

Stimulates secretion by pancreas and intestines

Inhibits acid and pepsinogen secretion

Question 71

Action of somatostatin

Answer 71

Decreases acid and pepsin secretion

Decreases gastrin secretion

Decreases pancreatic enzyme secretion

Decreases insulin and glucagon secretion

Inhibits trophic effects of gastrin

Stimulates gastric mucous production

Question 72

Stimulus for gastrin

Answer 72

Distension of stomach

Extrinsic nerves

Inhibited by low antral pH, somatostatin

Question 73

Stimulus for CCK

Answer 73

Partially digested proteins and TGs

Question 74

Stimulus for secretin

Answer 74

Acidic chyme, FAs

Question 75

Stimulus for VIP

Answer 75

neural

Question 76

Stimulus for somatostatin

Answer 76

Fat, bile salts and glucose in the intestinal lumen

Question 77

A 45 year old motor cyclist sustains a tibial fracture and is noted to have anaesthesia of the web space between his first and second toes. Which of the nerves listed below is most likely to be compromised?

Superficial peroneal nerve

Deep peroneal nerve

Sural nerve

Long saphenous nerve

Tibial nerve

Answer 77

The deep peroneal nerve lies in the anterior muscular compartment of the lower leg and can be compromised by compartment syndrome affecting this area. It provides cutaneous sensation to the first web space. The superficial peroneal nerve provides more lateral cutaneous innervation.

Question 78

Origin of the deep peroneal nerve

Answer 78

From the common peroneal nerve at the lateral aspect of the fibula, deep to peroneus longus

Question 79

Nerve roots of the deep peroneal nerve

Answer 79

L4, L5, S1

Question 80

Course of the deep peroneal nerve

Answer 80

Pierces the anterior intermuscular septum to enter the anterior compartment of the lower leg

Passes anteriorly down the ankle joint, midway between the two malleoli

Terminates in the dorsum of the foot

Question 81

Muscles innervated by deep peroneal nerve

Answer 81

Tibialis anterior

EHL

EDL

Peroneus tertius

EDB

Question 82

Cutaneous innervation of deep peroneal nerve

Answer 82

Web spaceof the first and second toes

Question 83

Actions of the deep peroneal nerve

Answer 83

Dorsiflexion of the ankle joint

Extension of all toes (EHL and EDL)

Inversion of the foot

Question 84

Which nerve produces these movements:

Dorsiflexion of the ankle joint

Extension of all toes (EHL and EDL)

Inversion of the foot

Answer 84

Deep peroneal nerve

Question 85

What happens to the deep peroneal nerve after its bifurcation at the ankle joint?:

Answer 85

After its bifurcation past the ankle joint, the lateral branch of the deep peroneal nerve innervates the extensor digitorum brevis and the extensor hallucis brevis
The medial branch supplies the web space between the first and second digits.

Question 86

A 40 year old women presented with a mass on her forehead. On examination, she had a fluctuant pulsatile mass on her head. Examination of her neck revealed a mass inferior to the hyoid with a positive Berry’s sign. What is the most likely underlying diagnosis?

Follicular thyroid cancer

Medullary thyroid cancer

Papillary thyroid cancer

Anaplastic thyroid cancer

Parathyroid gland cancer

Answer 86

Follicular thyroid cancer

Papillary thyroid cancers will tend to spread via lymphatics and present with disease that is nearly always confined to the neck. Follicular carcinomas may metastasise haematogenously and the skull may be the presenting site of disease in between 2 and 8% of patients.

Question 87

Berry’s sign

Answer 87

Absence of carotid pulse due to malignant thyromegaly

Question 88

Commonest sub-type of thyroid malignancy

Answer 88

Papillary carcinoma

Question 89

Histologically, they may demonstrate psammoma bodies (areas of calcification) and so called ‘orphan Annie’ nuclei

Answer 89

Papillary carcinoma

Question 90

How does follicular thyroid carcinoma tend to spread?

Answer 90

Haematogenously-> higher mortality rate

Question 91

What is an issue with follicular thyroid lesions

Answer 91

Cannot be accurately diagnosed on FNA and thus all FNAs (THY 3f) will require at least a hemi-thyroidectomy

Question 92

These are tumours of the parafollicular cells ( C Cells) and are of neural crest origin.

The serum calcitonin may be elevated which is of use when monitoring for recurrence.

Answer 92

Medullary carcinoma

Question 93

Spread of medullary thyroid carcinoma

Answer 93

Spread may be either lymphatic or haematogenous and as these tumours are not derived primarily from thyroid cells they are not responsive to radioiodine.

Question 94

Theme: Result of nerve injury

A.Teres major

B.Brachialis

C.Serratus anterior

D.Trapezius

E.Flexor digitorum profundus

F.Biceps

G.Supinator

H.Adductor pollicis

I.Abductor pollicis brevis

J.Abductor digiti minimi

For each of the nerves listed below, please identify the muscle which is most likely to be affected.

Damage to the accessory nerve during a lymph node excision biopsy.

Damage to the median nerve during a carpal tunnel release.

Injury to the radial nerve in a humeral shaft fracture.

Answer 94

The correct answer is Trapezius

The correct answer is Abductor pollicis brevis

Adductor pollicis and abductor digiti minimi are innervated by the ulnar nerve

The correct answer is Supinator

Question 95

Posterior triangle LN biopsy associated with what nerve lesion

Answer 95

Accessory nerve

Question 96

Llyod davies stirrups and what nerve

Answer 96

Common peroneal

Question 97

Thyrodiectomy what nerve

Answer 97

Laryngeal nerve

Question 98

Anterior resection of rectum- what nerve at risk of injury

Answer 98

Hypogastric autonomic nerves

Question 99

Axillary node clearance, what nerves at risk of injury?

Answer 99

LTN

Thoracodorsal

Intercostobrachial

Question 100

Inguinal surgery, what nerve

Answer 100

Ilioinguinal

Question 101

Varicose vein surgery, what nerve at risk of injury

Answer 101

Sural and saphenous

Question 102

Posterior approach to the hip, what nerve at risk

Answer 102

Sciatic nerve

Question 103

Cartoid endarterectomy and what nerve

Answer 103

Hypoglossal

Question 104

What is the most common cause of mesenteric infarction?

Mesenteric vein thrombosis

Acute embolism affecting the superior mesenteric artery

Acute on chronic thrombus of the superior mesenteric artery

Sub intimal dissection of the superior mesenteric artery

Proximal migration of abdominal aortic aneurysm

Answer 104

Acute embolic events account for up to 50% of cases of mesenteric infarcts. These may occur as a result of long standing atrial fibrillation, ventricular anuerysms and post myocardial infarction.

Question 105

What proportion of surgical admissions is accounted for by mesenteric iscahemia?

Answer 105

1 in 1000 acute surgical admissions

Question 106

What is the primary cause of mesenteric vessel disease and where is it more likely to occur?

Answer 106

Arterial embolism-> colonic infarction

Areas such as the splenic flexure that are located at the borders of arterial territories

Question 107

Sudden onset abdominal pain followed by profuse diarrhoea.

May be associated with vomiting.

Rapid clinical deterioration.

Serological tests: WCC, lactate, amylase may all be abnormal particularly in established disease. These can be normal in the early phases.

Answer 107

Acute mesenteric emboluc (commonest mesenteric vessel disease- 50%)

Question 108

Usually longer prodromal history.

Post prandial abdominal discomfort and weight loss are dominant features. Patients will usually present with an acute on chronic event, but otherwise will tend not to present until mesenteric flow is reduced by greater than 80%.

When acute thrombosis occurs presentation may be as above. In the chronic setting the symptoms will often be those of ischaemic colitis (mucosa is the most sensitive area to this insult).

Answer 108

Acute on chronic mesenteric ischaemia

Question 109

Usually a history over weeks.

Overt abdominal signs and symptoms will not occur until venous thrombosis has reached a stage to compromise arterial inflow.

Thrombophilia accounts for 60% of cases.

Answer 109

Mesenteric vein thrombosis

Question 110

This occurs in patients with multiple co morbidities in whom mesenteric perfusion is significantly compromised by overuse of inotropes or background cardiovascular compromise.

The end result is that the bowel is not adequately perfused and infarcts occur from the mucosa outwards.

Answer 110

Low flow mesenteric infarction

Question 111

Diagnosis of mesenteric ischaemia

Answer 111

Serological tests: WCC, lactate, CRP, amylase (can be normal in early disease).

Cornerstone for diagnosis of arterial AND venous mesenteric disease is CT angiography scanning in the arterial phase with thin slices (<5mm). Venous phase contrast is not helpful.

SMA duplex USS is useful in the evaluation of proximal SMA disease in patients with chronic mesenteric ischaemia.

MRI is of limited use due to gut peristalsis and movement artefact.

Question 112

What is the cornerstone for diagnosis of arterial and venous mesenteric disease?

Answer 112

CT angiography in the arterial phase with thin slices (<5mm). Venous phase contrast is not helpful

Question 113

Management of mesenteric ischaemia

Answer 113

Peritonitic- laparotomy

At operation limited resection of frankly necrotic bowel with view to relook laparotomy at 24-48h. In the interim urgent bowel revascularisation via endovascular (preferred) or surgery.

Question 114

Management of mesenteric vein thrombosis if not peritonitic

Answer 114

IV heparin

Question 115

Px of mesenteric ischaemia

Answer 115

Overall poor. Best outlook is from an acute ischaemia from an embolic event where surgery occurs within 12h. Survival may be 50%. This falls to 30% with treatment delay. The other conditions carry worse survival figures.

Question 116

A patient undergoes a femoral hernia repair and at operation the surgeon decides to enter the abdominal cavity to resect small bowel. She makes a transverse incision two thirds of the way between umbilicus and the symphysis pubis. Which of the structures listed below is least likely to be divided?

Rectus abdominis

External oblique aponeurosis

Peritoneum

Fascia transversalis

Posterior lamina of the rectus sheath

Answer 116

An incision at this level lies below the arcuate line and the posterior wall of the rectus sheath is deficient at this level.

Question 117

Rectus sheath above the costal margin

Answer 117

Anterior sheath: External oblique aponeurosis

Costal cartilages posterior

Question 118

Rectus sheath from the costal margin to arcuate line

Answer 118

External oblique and anterior part of internal oblique aponeurosis

Posterior part of the sheath: posterior internal oblique aponeurosis and transversus abdominis

Question 119

Rectus sheath below the arcuate line

Answer 119

Aponeuroses of all the abdominal muscles lie in anterior aspect of the rectus

Posteriorly lies the transversalis fascia and peritoneum

Question 120

What does the arcuate line represent?

Answer 120

The point at which the inferior epigastric vessels enter the rectus sheath

Question 121

Lymphatic drainage of the ovaries

Answer 121

Para-aortic nodes via gonadal vessels

Question 122

Lymphatic drainage of the uterine fundus

Answer 122

Runs with ovarian vessels-> para-aortic nodes

Some drainage may also pass along the round ligament to the inguinal nodes

Question 123

Lymphatic drainage of the body of the uterus

Answer 123

Lymphatics contained within the broad ligament to the iliac LNs

Question 124

Lymphatic drainage of the cervix

Answer 124

Laterally through the broad ligament to EI nodes

Uterosacral fold to the presacral nodes

Posterolaterally along lymphatics lying alongside uterine vessles to the IA nodes

Question 125

heme: Axillary anatomy

A.Medial pectoral nerve

B.Thoracodorsal nerve

C.Lateral pectoral nerve

D.Intercostobrachial nerve

E.Medial cord of the brachial plexus

F.Long thoracic nerve

G.Axillary nerve

H.Accessory nerve

Please identify the structure that is most likely to be affected in the scenarios described below. Each structure may be used once, more than once or not at all.

A 44 year old lady has undergone a mastectomy and axillary node clearance. Post operatively, she notices a patch of anaesthesia of her axillary skin when she applies an underarm deodorant.

A 44 year old lady has undergone a mastectomy and axillary node clearance to treat breast cancer. Post operatively, it is noted that she has winging of the scapula.

A 44 year old lady who works as an interior decorator has undergone a mastectomy and axillary node clearance to treat breast cancer. Post operatively, she comments that her arm easily becomes fatigued when she is painting walls.

Answer 125

The correct answer is Intercostobrachial nerve

The intercostobrachial nerves traverse the axilla and innervate the overlying skin. These can be injured or divided during axillary surgery and the result is anaesthesia of the overlying skin.

Long thoracic nerve

Injury to the long thoracic nerve (which innervates the serratus anterior) can occur as it lies at the medial aspect of the axilla, winging of the scapula will then result.

The correct answer is Thoracodorsal nerve

The most likely explanation for this is that the thoracodorsal nerve has been injured. This will result in atrophy of latissimus dorsi and this will become evident with repetitive arm movements where the arm is elevated and moving up and down (such as in painting). Injury to the pectoral nerves may produce a similar picture but this pattern of injury is very rare and the pectoral nerves are seldom injured in breast surgery.

Question 126

Medial boundary of the axilla

Answer 126

Chest wall and serratus anterior

Question 127

Lateral boundary of the axilla

Answer 127

Humeral head

Question 128

Floor of the axilla

Answer 128

Subscapularis

Question 129

Anterior aspect of the axilla

Answer 129

Lateral border of pec major

Question 130

Fascia of the axilla

Answer 130

Clavipectoral fascia

Question 131

Contents of the axilla

Answer 131

LTN

Thoracodorsal nerve and thoracodorsal trunk

Axillary vein

inercostobrachial nerves

LNs

Question 132

Derived from C5-C7 and passes behind the brachial plexus to enter the axilla. It lies on the medial chest wall and supplies serratus anterior. Its location puts it at risk during axillary surgery and damage will lead to winging of the scapula.

Answer 132

Long thoracic nerve (of Bell)

Question 133

Innervate and vascularise latissimus dorsi.

Answer 133

Thoracodorsal nerve and thoracodorsal trunk

Question 134

Lies at the apex of the axilla, it is the continuation of the basilic vein. Becomes the subclavian vein at the outer border of the first rib.

Answer 134

Axillary vein

Question 135

Traverse the axillary lymph nodes and are often divided during axillary surgery. They provide cutaneous sensation to the axillary skin.

Answer 135

Intercostobrachial nerves

Question 136

A 25 year old man is shot in the abdomen and is transferred to the operating theatre following arrival in the emergency department, as he is unstable and a FAST scan is positive. At operation there is an extensive laceration to the right lobe of the liver and involvement of the IVC. There is massive haemorrhage. What is the most appropriate approach to blood component therapy?

Use Factor VIII concentrates early

Avoid use of “o” negative blood

Transfuse packed cells, FFP and platelets in fixed ratios of 1:1:1

Transfuse packed cells and FFP in a fixed ratio of 4:1

Perform goal directed transfusion based on the Hb, PT and TEG studies

Answer 136

There is strong evidence to support the use of haemostatic transfusion in the setting of major haemorrhage due to trauma. This advocates the use of 1:1:1 ratios.

Question 137

Def: massive transfusion

Answer 137

Replacement of patient’s total blood volume in <24h or the acute administration of >1/2 of the patient’s estimated blood volume per hour.

Question 138

CRASH 2 study provides evidence of what?

Answer 138

Haemorrhaging patients following trauma- evidence to support initital adminsitration of tranexamic acid.

Question 139

CRASH study

Answer 139

A large simple placebo controlled trial, among adults with head injury and impaired consciousness, of the effects of a 48 hour infusion of corticosteroids on death and neurological disability

.These results show there is no reduction in mortality with methylprednisolone in the 2 weeks after head injury. The cause of the rise in risk of death within 2 weeks is unclear.

Question 140

CRASH-2

Answer 140

CRASH-2 Study of Tranexamic Acid to Treat Bleeding in Trauma Patients

Tranexamic acid vs placebo within 3 hours of head injury

Tranexamic acid was associated with a significant reduction in all cause mortality and deaths from bleeding.

Question 141

A 35 year old farm labourer injures the posterior aspect of his hand with a mechanical scythe. He severs some of his extensor tendons in this injury. How many tunnels lie in the extensor retinaculum that transmit the tendons of the extensor muscles?

One

Three

Four

Five

Six

Answer 141

There are six tunnels, each lined by its own synovial sheath.

Question 142

Attachments of the extensor retinaculum

Answer 142

The pisiform and triquetral medially

The end of the radius laterally

Question 143

Structures superficial to the extensor retinaculum

Answer 143

Basilic vein

Dorsal cutaneous branch of the ulnar nerve

Cephalic vein

Superficial branch of the radial nerve

Question 144

Structures passing deep to the extensor retinaculum

Answer 144

Extensor carpi ulnaris tendon

Extensor digiti minimi tendon

Extensor digitorum and extensor indicis tendon

Extensor pollicis longus tendon

Extensor carpi radialis longus tendon

Extensor carpi radialis brevis tendon

Abductor pollicis longus and extensor pollicis brevis tendons

Question 145

Radial artery passage into the hand

Answer 145

Passes between the lateral collateral ligament of the wrist joint and the tendons of abductor pollicis longus and extensor pollicis brevis

Question 146

A 23 year old man undergoes an orchidectomy. The right testicular vein is ligated; into which structure does it drain?

Right renal vein

Inferior vena cava

Common iliac vein

Internal iliac vein

External iliac vein

Answer 146

The testicular venous drainage begins in the septa and these veins together with those of the tunica vasculosa converge on the posterior border of the testis as the pampiniform plexus. The pampiniform plexus drains to the testicular vein. The left testicular vein drains into the left renal vein. The right testicular vein drains into the inferior vena cava.

Question 147

Where do the sympathetic nerve fibres lie in the spermatic cord?

Answer 147

Lie on arteries

Question 148

Where do the parasympathetic nerve fibres lie in the spermatic cord?

Answer 148

On vas

Question 149

Genital branch of the genitofemoral nerve supplies what muscle?

Answer 149

Cremaster

Question 150

Arterial supply of the scrotum

Answer 150

Anterior and posterior scrotal arteries

Question 151

What is the organisation of the tunica vaginalis

Answer 151

Surround the testes.

Parietal layer of the tunica vaginalis is adjacent to internal spermatic fascia.

Question 152

Testicular arteries arise from?

Answer 152

The aorta, immediately inferior to the renal arteries

Question 153

Which of the muscles listed below is not innervated by the median nerve?

Flexor pollicis brevis

Lateral two lumbricals

Pronator teres

Opponens pollicis

Adductor pollicis

Answer 153

Adductor pollicis is innervated by the ulnar nerve.
Medial two lumbricals innervated by the ulnar nerve.

Question 154

Formation of the median nerve?

Answer 154

The median nerve is formed by the union of a lateral and medial root respectively from the lateral (C5,6,7) and medial (C8 and T1) cords of the brachial plexus; the medial root passes anterior to the third part of the axillary artery. The nerve descends lateral to the brachial artery, crosses to its medial side (usually passing anterior to the artery). It passes deep to the bicipital aponeurosis and the median cubital vein at the elbow.

Question 155

Passage of the median nerve in the lower arm?

Answer 155

Passes between the two heads of pronator teres and runs on the deep surface of flexor digitorum superficialis (within its fascial sheath)

Question 156

Passage of the median nerve into the hand

Answer 156

Near the wrist it becomes superficial between the tendons of the flexor digitorum superficialis and flexor carpi radialis, deep to palmaris longus.

Passes deep to the flexor retinaculum to enter the palm but lies anterior to the long flexor tendons within the carpal tunnel

Question 157

Branches of the median nerve in the upper arm?

Answer 157

No branches, although the nerve commonly communicates with the musculocutaneous nerve

Question 158

Muscles innervated by median nerve in forearm

Answer 158

Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor digitorum superficialis
Flexor pollicis longus
Flexor digitorum profundus (only the radial half)

Question 159

Branches of the median nerve in the distal forearm, proximal to the carpal tunnel

Answer 159

Palmar cutaneous branch

Question 160

Motor function of the median in the hand

LOAF

Answer 160

Lateral 2 lumbricals

Opponens pollicis

Abductor pollicis brevis

Flexor pollicis brevis

Question 161

Sensory function of the median nerve in the hand

Answer 161

Thumb and lateral 2.5 fingers

On the plamar aspect this projects proximally, on the dorsal aspect only the distal regions are innervated. With the radial nerve providing the more proximal cutaneous innervation

Question 162

paralysis and wasting of thenar eminence muscles and opponens pollicis (ape hand deformity)

sensory loss to palmar aspect of lateral (radial) 2 ½ fingers

Answer 162

Median nerve damage at the wrist

e.g. carpal tunnel

Question 163

unable to pronate forearm

weak wrist flexion

ulnar deviation of wrist

Answer 163

Median nerve damage at the elbow

Question 164

Anterior interosseus nerve

Answer 164

Branch of the median nerve, leaves just below elbow.

Results in loss of pronation of forearm and weakness of long flexors of the thumb and index finger.

Question 165

A 45 year old man with recurrent episodes of confusion is found to have a 1.5cm insulinoma of the pancreatic head. What is the most appropriate management?

Whipples procedure

Total pancreatectomy and en bloc splenectomy

Pylorus preserving pancreatico duodenectomy

Enucleation of the lesion

External beam radiotherapy

Answer 165

Enucleation

Most insulinomas are benign and radical resection is therefore not justified.

Question 166

Symptomatic hypoglycaemia during fasting
Concomitant blood glucose of less than 3mmol/L
Relief of hypoglycaemia by use of glucose

Answer 166

Insulinoma

Question 167

Def: insulinoma

Proportion benign?

Answer 167

Insulin producing tumours of the pancreatic beta cells

90% benign

Question 168

What proportion of insulinomas are MEN associated?

Answer 168

5-10% have MEN1

Question 169

What proportion of MEN1 sufferers will develop pancreatic islet cell tumours?

Answer 169

75%

Question 170

Testing in insulinoma

Answer 170

When neuroglycopenic symptoms occur blood is taken for serum insulin levels, serum glucose, C-peptide and pro insulin concentrations. The plasma insulin concentration is >10 micro U/ml in patients with the disorder.

Question 171

What is the most effective method for benign insulinoma localisation

Answer 171

Endoscopic USS (75%)

Question 172

Diagnostic accuracy of MRI for malignant insulinomas?

Answer 172

Near 100%

Question 173

Methods of insulinoma localisation

Answer 173

USS (25% accuracy), endoscopic USS better (75% accuracy)

CT scanning (pancreatic protocol=40% accuracy)

Malignant insulinomas are larger and diagnostic accuracy with MRI is nearly 100% in such cases

Somatostatin receptor scintigraphy (50% accuracy)

Question 174

Treatment of insulinomas

Answer 174

Since the majority of tumours are benign; the blind segmental resection of the pancreas (e.g. Whipples) cannot be justified, this may be considered acceptable for malignant lesions. The best approach at laparotomy is to corroborate pre operative imaging with intraoperative ultrasonography to identify the lesion. Tumours may be close of the pancreatic duct and this must be appreciated by the operating surgeon. The perioperative use of octreotide reduces the amount of pancreatic drainage, but not overall complications.

Question 175

A 39 year old man notices a swelling in his left hemiscrotum. On examination he has a left sided varicocele. The ipsilateral testis is normal on palpation. What is the most appropriate course of action?

Scrotal exploration and ligation of the varicocele

Abdominal ultrasound

Scrotal ultrasound

Left orchidectomy

Discharge

Answer 175

A left sided varicocele is a recognised presenting sign of a renal tumour occluding the renal vein (into which the left testicular vein drains). An abdominal ultrasound should be undertaken to exclude this. Surgery for uncomplicated varicocele is usually unnecessary.

Question 176

Histopathology of RCC

Answer 176

Adenocarcinoma of renal cortex, believed to arise from PCT

Usually solitary lesions, 20% may be multifocal, 20% may be calcified, 20% may have a cystic component or be wholly cystic.

Often circumscribed by a pseudocapsule of compressed normal renal tissue

Question 177

Spread of RCC

Answer 177

Direct extension into the adrenal gland, renal vein or surrounding fascia.

Distal disease is haematogenous to lungs, bone or brain

Question 178

Demographics of RCC

Answer 178

85% of all renal malignancies

Males>females

Sporadic tumours

6th decade

Question 179

Symptoms of RCC

Answer 179

Haematuria (50%), loin pain (40%), mass (30%) and up to 25% may have symptoms of metastasis.Less than 10% have the classic triad of haematuria, pain and mass.

Question 180

Classic triad in RCC?

Answer 180

Haematuria

Pain

Mass

Question 181

Ix in RCC

Answer 181

Many cases will present as haematuria and be discovered during diagnostic work up. Benign renal tumours are rare, so renal masses should be investigated with multislice CT scanning. Some units will add an arterial and venous phase to the scan to demonstrate vascularity and evidence of caval ingrowth.

CT scanning of the chest and abdomen to detect distant disease should also be undertaken.

Routine bone scanning is not indicated in the absence of symptoms.

Biopsy should not be performed when a nephrectomy is planned but is mandatory before any ablative therapies are undertaken.

Assessment of the functioning of the contra lateral kidney.

Question 182

Mx of T1 renal lesions

Answer 182

T1 lesions may be managed by partial nephrectomy and this gives equivalent oncological results to total radical nephrectomy. Partial nephrectomy may also be performed when there is inadequate reserve in the remaining kidney.

Question 183

Mx of T2 renal lesions

Answer 183

For T2 lesions and above a radical nephrectomy is standard practice and this may be performed via a laparoscopic or open approach. Preoperative embolisation is not indicated nor is resection of uninvolved adrenal glands. During surgery early venous control is mandatory to avoid shedding of tumour cells into the circulation.

Question 184

Chemotherapy in RCC

Answer 184

Patients with completely resected disease do not benefit from adjuvant therapy with either chemotherapy or biological agents. These should not be administered outside the setting of clinical trials.

Question 185

Mx of TCC involving kidneys

Answer 185

Patients with transitional cell cancer will require a nephroureterectomy with disconnection of the ureter at the bladder.

Question 186

A 65 year old man is admitted for a below knee amputation. He is taking digoxin. Clinically the patient has an irregularly irregular pulse. What would you expect to see when you examine the jugular venous pressure?

Absent y waves

Slow y descent

Cannon waves

Steep y descent

Absent a waves

Answer 186

Absent a waves = Atrial fibrillation
Large a waves = Any cause of right ventricular hypertrophy, tricuspid stenosis
Cannon waves (extra large a waves) = Complete heart block
Prominent v waves = Tricuspid regurgitation
Slow y descent = Tricuspid stenosis, right atrial myxoma
Steep y descent = Right ventricular failure, constrictive pericarditis, tricuspid regurgitation

Question 187

‘a’ wave =

Answer 187

atrial contraction

large if atrial pressure e.g. tricuspid stenosis, pulmonary stenosis, pulmonary hypertension

absent if in atrial fibrillation

Question 188

Cannon ‘a’ waves

Answer 188

caused by atrial contractions against a closed tricuspid valve

are seen in complete heart block, ventricular tachycardia/ectopics, nodal rhythm, single chamber ventricular pacing

Question 189

‘c’ wave

Answer 189

closure of tricuspid valve

not normally visible

Question 190

‘v’ wave

Answer 190

due to passive filling of blood into the atrium against a closed tricuspid valve

giant v waves in tricuspid regurgitation

Question 191

‘x’ descent =

Answer 191

= fall in atrial pressure during ventricular systole

Question 192

‘y’ descent

Answer 192

= opening of tricuspid valve

Question 193

Draw and label JVP

Answer 193

‘a’ wave = atrial contraction

large if atrial pressure e.g. tricuspid stenosis, pulmonary stenosis, pulmonary hypertension

absent if in atrial fibrillation

Cannon ‘a’ waves

caused by atrial contractions against a closed tricuspid valve

are seen in complete heart block, ventricular tachycardia/ectopics, nodal rhythm, single chamber ventricular pacing

‘c’ wave

closure of tricuspid valve

not normally visible

‘v’ wave

due to passive filling of blood into the atrium against a closed tricuspid valve

giant v waves in tricuspid regurgitation

‘x’ descent = fall in atrial pressure during ventricular systole

‘y’ descent = opening of tricuspid valve

Question 194

A 44 year old lady is undergoing an abdominal hysterectomy and the ureter is identified during the ligation of the uterine artery. At which site does it insert into the bladder?

Posterior

Apex

Anterior

Base

Superior aspect of the lateral side

Answer 194

The ureters enter the bladder at the upper lateral aspect of the base of the bladder. They are about 5cm apart from each other in the empty bladder. Internally this aspect is contained within the bladder trigone.

Question 195

Where does the uretur overlie the transverse processes

Answer 195

L2-L5

Question 196

Relationship of ureturs to the iliac vessels

Answer 196

Anterior to bifurcation

Question 197

Bloody supply of the ureturs

Answer 197

Segmental: renal artery, aortic branches, gonadal branches, common iliac, internal iliac

Question 198

Relationship of ureturs to the uterine artery

Answer 198

Lies below

Question 199

Where does the ureteric muscle coat become three layers?

Answer 199

As it crosses into the bony pelvis

Question 200

What is the correct embryological origin of the stapes?

First pharyngeal arch

Second pharyngeal arch

Third pharyngeal arch

Fourth pharyngeal arch

Fifth pharyngeal arch

Answer 200

The dorsal ends of the cartilages of the first and second pharyngeal arches articulate superior to the tubotympanic recess. These cartilages form the malleus, incus and stapes. At least part of the malleus is formed from the first arch and the stapes from the second arch. The incus is most likely to arise from the first arch.

The ectoderm covering the outer aspect of the second arch originates from a strip of ectoderm lateral to the metencephalic neural fold. The cartilaginous element to this, eponymously known as Reicherts cartilage extends from the otic capsule to the midline on each side. Its dorsal end separates and becomes enclosed in the tympanic cavity as the stapes.

Question 201

When do the pharyngeal arches develop and from what?

Answer 201

Fourth week of embryonic growth from a series of mesodermal outpouchings

Develop and fuse in the ventral midline.

Pharyngeal pouches form on the endodermal side between the arches

Question 202

Muscular contributions of the first pharyngeal arch

Answer 202

Muscles of mastication

Anterior belly of digastric

Mylohyoid

Tensor tympani

Tensor veli palatini

Question 203

Skeletal contributions of the first pharyngeal arch

Answer 203

Maxilla

Meckels cartilage

Incus

Malleus

Question 204

Arterial contributions of the first pharyngeal arch

Answer 204

Maxillary

External carotid

Question 205

Nerve contributions of the first pharyngeal arch

Answer 205

Mandibular

Question 206

Fate of the 5th pharyngeal arch

Answer 206

Does not contribute any useful structures and often fuses with the sixth arch

Question 207

Muscular contributions of the second pharyngeal arch

Answer 207

Buccinator

Platysma

Muscles of facial expression

Stylohyoid

Posterior belly of digastric

Stapedius

Question 208

Skeletal contributions of the second pharyngeal arch

Answer 208

Stapes

Styloid process

Lesser horn and upper body of hyoid

Question 209

Arterial contributions of the second pharyngeal arch

Answer 209

Inferior branch of superior thyroid artery

Stapedial artery

Question 210

Nerve contributions of the second pharyngeal arch

Answer 210

Facial nerve

Question 211

Muscular contributions of the third pharyngeal arch

Answer 211

Stylopharyngeus

Question 212

Endocrine contributions of the third pharyngeal arch

Answer 212

Thymus

Inferior parathyroids

Question 213

Skeletal contributions of the third pharyngeal arch

Answer 213

Greater horn and lower part of hyoid

Question 214

Vascular contributions of third pharygneal arch

Answer 214

Common and internal carotid

Question 215

Nervous contributions of the third pharyngeal arch

Answer 215

Glossopharyngeal

Question 216

Muscular contributions of the fourth pharyngeal arch

Answer 216

Cricothyroid

All intrinsic muscles of the soft palate

Question 217

Skeletal contributions of the fourth pharyngeal arch

Answer 217

Thyroid and epiglottic cartialges

Question 218

Endocrine contributions of the fourth pharyngeal arch

Answer 218

Superior parathyroids

Question 219

Vascular contributions of the fourth pharyngeal arch

Answer 219

Right subclavian artery

Left aortic arch

Question 220

Nerve contributions of the fourth pharyngeal arch

Answer 220

Vagus

Question 221

Muscular contributions of the sixth pharyngeal arch

Answer 221

All intrinsic muscles of the larynx except cricothyroid

Question 222

Skeletal contributions of the sixth pharyngeal arch

Answer 222

Cricoid, arytenoid and corniculate cartilages

Question 223

Vascular contributions of the sixth pharyngeal arch

Answer 223

Right pulmonary artery

Left pulonary artery

Ductus arteriosus

Question 224

Nervous contributions of the sixth pharyngeal arch

Answer 224

Vagus and RLN

Question 225

A 68 year old man with poorly controlled diabetes presents with severe otalgia and headaches. On examination, there is granulation tissue within the external auditory meatus. What is the most likely underlying infective agent?

Pseudomonas aeruginosa

Streptococcus pyogenes

Staphylococcus aureus

Actinomyces

Bacteroides fragilis

Answer 225

Malignant otitis externa is caused by Pseudomonas aeruginosa

Severe pain, headaches and granulation tissue within the external auditory meatus are key features of malignant otitis externa. Diabetes mellitus is one of the commonest risk factors.

Question 226

Uncommon type of otitis externa that is found in immunocompromised individuals (90% cases found in diabetics)

Infective organism is usually Pseudomonas aeruginosa

Infection commences in the soft tissues of the external auditory meatus, then progresses to involve the soft tissues and into the bony ear canal

Progresses to temporal bone osteomyelitis

Answer 226

Malignant otitis externa

Question 227

What are the key features in the history for malignant otitis externa?

Answer 227

DM or immunosuppression

Severe, unrelenting, deep-seated otalgia

Temporal headaches

Purulent otorrhea

Possibly dysphagia, hoarseness and or facial nerve dysfunction

Question 228

Treatment of malignant otitis externa

Answer 228

Antipseudomonal antimicrobial agents

Topical agents

Hyperbaric oxygen may be used in refractory cases

Question 229

Theme: Paediatric gastrointestinal disorders

A.Liver transplant

B.Rectal biopsy

C.Roux-en-Y portojejunostomy

D.Ramstedt pyloromyotomy

E.Abdominal CT scan

F.Upper GI contrast study

G.Laparotomy and formation of stoma

H.Laparotomy

I.Colonoscopy

J.Gastroscopy

What is the best management option for these children? Each option may be used once, more than once or not at all.

2.A male infant, born at term appears well following delivery. Six hours later, he is noted to have bilious vomiting by the paediatricians. On examination he seems well and his abdomen is soft and non tender.

A 2 month old baby presents with jaundice. He has an elevated conjugated bilirubin level. Diagnosis is confirmed by cholangiography during surgery.

A male infant, born at term by normal vaginal delivery is well. However, 72 hours following delivery, he has still not passed meconium. On examination, his abdomen is soft and not particularly distended. He has a normally sited anus.

Answer 229

Upper GI contrast study

Bilious vomiting in neonates is a surgical emergency and is intestinal malrotation and volvulus until otherwise proven. It is investigated with an upper GI contrast study. Contrast should be seen to exit the stomach and the location of the DJ flexure is noted (it lies to the left of the midline). If this is not the case, or the study is inconclusive, a laparotomy is performed.

Roux-en-Y portojejunostomy

This child has biliary atresia. The aim is to avoid liver transplantation (however, most will come to transplant in time).

Rectal biopsy

Delayed passage of meconium is suggestive of Hirschsprung’s disease and the investigation of choice is full thickness suction rectal biopsy. If Hirschprungs is confirmed, then the correct treatment is laparotomy and stoma formation. At between 9 and 12 months of age, definitive surgery (usually resection and primary anastomosis) is performed.

Question 230

Acute appendicitis in <3y/o

Answer 230

Uncommon, may present atypically

Question 231

Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool.

Answer 231

Intussuception

Question 232

Paediatric, central abdominal pain and URTI

Answer 232

Mesenteric adenitis

Question 233

Pathology of intussuception

Answer 233

Telescoping bowel

Proximal to or at the level of ileocaecal valve

6-9 months old

Question 234

Diagnosis of malrotation

Answer 234

Upper GI contrast study and USS

Question 235

Treatment of malrotation

Answer 235

Laparotomy, if volvulus is present or patient at high risk of volvulus than a Ladds procedure is performed

Question 236

Ladd’s procdure

Answer 236

The procedure involves surgical division of Ladd’s bands, widening of the small intestine’s mesentery, performing an appendectomy and correctional placement of the cecum and colon.

Question 237

High caecum at the midline

Features in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia

Answer 237

Malrotation

Question 238

def: Hirschsprung’s

Answer 238

Absence of ganglion cells from myenteric and submucosal plexuses

Question 239

Delayed passage of meconium and abdominal distension

Answer 239

?Hirschsprung’s

Question 240

Dx of Hirschsprung’s

Answer 240

Full thickness rectal biopsy

Question 241

Treatment of Hirschsprung’s

Answer 241

Rectal washouts initially, then anorectal pull through procedure

Question 242

Usually delayed passage of meconium and abdominal distension

Majority have cystic fibrosis

Answer 242

?meconium ileus

Question 243

Ix in meconium ileus

Answer 243

XR may not show a fluid level as meconium is viscid.

PR contrast studies may dislodge meconium plugs

Question 244

Mx of meconium ileus

Answer 244

PR contrast

NG n-acetyl cysteine

Surgery

Question 245

Jaundice >13d

Increased conjugated bilirubin

Neonate

Answer 245

Biliary atresia

Question 246

Treatment of Biliary atresia

Answer 246

Urgent Kasai procedure

Question 247

Kasai proceudre

Answer 247

Hepatoportoenterostomy.

Question 248

Prematurity is the main risk factor

Early features include abdominal distension and passage of bloody stools

X-Rays may show pneumatosis intestinalis and evidence of free air

Increased risk when empirical antibiotics are given to infants beyond 5 days

Treatment is with total gut rest and TPN, babies with perforations will require laparotomy

Answer 248

NEC

Question 249

An injured axillary artery is ligated between the thyrocervical trunk of the subclavian and subscapular artery. Subsequent collateral circulation is likely to result in reversal of blood flow in which of the vessels listed below?

Circumflex scapular artery

Transverse cervical artery

Posterior intercostal arteries

Suprascapular artery

Profunda brachii artery

Answer 249

It’s an easy question really, we just made the wording difficult (on purpose). It is asking about the branches of the axillary artery and knowledge of the fact that there is an extensive collateral network around the shoulder joint. As a result, the occlusion of the proximal aspect of the circumflex humeral inflow (from the axillary artery) ceases and there is then retrograde flow through it from collaterals.

The circumflex scapular artery is a branch of the subscapular artery and normally supplies the muscle on the dorsal aspect of the scapula. In this instance, flow is reversed in the circumflex scapular and subscapular arteries forming a collateral circulation around the scapula.

Question 250

Extent of the axillary artery

Answer 250

Outer border of first rib to the lower border of teres major

Question 251

Where is the first part of the axillary artery

Answer 251

Above pec minor

Question 252

Where is the second part of the axillary artery

Answer 252

posterior to pec minor

Question 253

Where is the third part of the axillary artery?

Answer 253

Inferior to pec minor

Question 254

Relations of the first part of the axillary artery

Answer 254

Enclosed within the cords of the brachial plexus.

Contained with axillary vein in the axillary sheath, a prolongation of the prevertebral fascia.

Posteriomedial to the sheath lies the first intercostal space, the superior aspect of serratus anterior and the LTN.

Within the sheath, the medial cord of the brachial pexus lies behind the aretery.

Anteriorly is the clavipectoral fascia.

Superolaterally lie the lateral and posterior cords of the brachial plexus.

Inferomedially= axillary vein

Question 255

Relations of the second part of the axillary artery

Answer 255

Posterior to it is the posterior cord of the brachial plexus and subscapularis muscle.

Anteriorly lie pectoralis minor and major

Lateral cord of the brachial plexus lies laterally.

Medially lies the medial cord of the brachial plexus, here it separates the artery from the vein

Question 256

Relations of the third part of the axillary aretery

Answer 256

Posterior: subscapularis, lat dorsi, teres major.

Interspersed between the vessel and subscapularis are the axillary and radial nerves.

Anterior to the vessel is the medial root of the median nerve.

Laterally lies the median and musculocutaneous nerves and coarcobrachialis.

Axillary vein is related medially.

Question 257

What are the branches of the axillary artery

Answer 257

Highest thoracic artery

Thoraco-acromial artery

Lateral thoracic artery

Subscapular artery

Posterior circumflex humeral

Anterior circumflex humeral

Question 258

A 20 year old lady presents with pain on the medial aspect of her thigh. Investigations show a large ovarian cyst. Compression of which of the nerves listed below is the most likely underlying cause?

Sciatic

Genitofemoral

Obturator

Ilioinguinal

Femoral cutaneous

Answer 258

The cutaneous branch of the obturator nerve is frequently absent. However, the obturator nerve is a recognised contributor to innervation of the medial thigh and large pelvic tumours may compress this nerve with resultant pain radiating distally.

Question 259

Obturator nerve roots

Answer 259

Ventral parts of L2, L3, L4

L3 forms the main contribution and second lumbar branch is occasionally absent.

Question 260

Course of the obturator

Answer 260

Branches unite in the substance of psoas major and descend vertically in its posterior part to emerge from its medial border at the lateral margin of the sacrum

It crosses the sacroiliac joint to enter lesser pelvis, descending on obturator internus to enter the obturator groove.

Question 261

Relations of obturator in the lesser pelvis

Answer 261

Lateral to the II vessels and uretur.

Joined by obturator vessels lateral to the ovary or ductus deferens

Question 262

Motor functions of obturator

Answer 262

Muscles supplied: external obturator, adductor longus, adductor brevis, adductor magnus (not the lower part- sciatic nerve), gracilis

Question 263

Cutaneous function of obturator

Answer 263

Cutaneous branch often absent.

When present it passes between gracilis and adductor longus near the middle part of the thigh and supplies the skin and fascia of the distal 2/3rds of the medial aspect

Question 264

Contents of the obturator canal

Answer 264

Obturator artery

Vein

Nerve which divides into anterior and posterior nerve

Question 265

A 73 year old man presents with a tumour at the central aspect of the posterior third of the tongue. To which of the following lymph node groups is it most likely to metastasise?

Submental

Submandibular

Ipsilateral deep cervical nodes

Contralateral deep cervical nodes

Bilateral deep cervical nodes

Answer 265

Posterior third tumours of the tongue commonly metastasise to the bilateral deep cervical lymph nodes

Tumours of the posterior third of the tongue will typically metastasise early and bilateral nodal involvement is well recognised, this is most often true of centrally located tumours and those adjacent to the midline as the lymph vessels may cross the median plane at this location.

Question 266

Outline the lymphatic drainage of the anterior 2/3rds of the tongue

Answer 266

Shows only minimal communication of lymphatics so metastasis to ipsilateral nodes is usual

Question 267

Lymphatic drainage of the posterior third of the tongue

Answer 267

Has communicating networks, as a result bilateral nodal metastases are more common in this area

Question 268

Lymphatic drainage of the tip of the tongue

Answer 268

Submental nodes and from there to deep cercival nodes

Question 269

Lymphatic drainage from the mid portion of the tongue

Answer 269

Submandibular nodes and then to the deep cervical nodes.

Mid tongue tumors that are laterally located will usually drain to ipsilateral deep cervical nodes.

Those from more central regions may have bilateral deep cervical nodal involvement

Question 270

A 6 month old child is brought to the surgical clinic because of non descended testes. What is the main structure that determines the descent path of the testicle?

Processus vaginalis

Cremaster

Mesorchium

Inguinal canal

Gubernaculum

Answer 270

The gubernaculum is a ridge of mesenchymal tissue that connects the testis to the inferior aspect of the scrotum. Early in embryonic development the gubernaculum is long and the testis are located on the posterior abdominal wall. During foetal growth the body grows relative to the gubernaculum, with resultant descent of the testis.

Question 271

A 21 year old man undergoes surgical removal of an impacted 3rd molar. Post operatively, he is noted to have anaesthesia on the anterolateral aspect of the tongue. What is the most likely explanation?

Injury to the hypoglossal nerve

Injury to the inferior alveolar nerve

Injury to the lingual nerve

Injury to the mandibular branch of the facial nerve

Injury to the glossopharyngeal nerve

Answer 271

The lingual nerve is closely related to the third molar and up to 10% of patients undergoing surgical extraction of these teeth may subsequently develop a lingual neuropraxia. The result is anaesthesia of the ipsilateral anterior aspect of the tongue. The inferior alveolar nerve innervates the teeth themselves.

Question 272

What is the function of the lingual nerve

Answer 272

Sensory nerve to the mucosa of the presulcal part of the tongue, floor of mouth and mandibular lingual gingivae

Question 273

Whence does the lingual nerve arise?

Answer 273

Posterior trunk of the mandibular nerve (branch of trigeminal)

Question 274

Theme: Transplantation

A.Xenograft

B.Allograft

C.Autograft

D.Isograft

Please select the type of transplantation that has occurred in the situation described. Each option may be used once, more than once or not at all.

A 38 year old lady donates her kidney to her identical twin sibling.

Answer 274

Isograft

Question 275

Theme: Causes of dysphagia

A.Benign oesophageal stricture

B.Globus

C.Carcinoma of the oesophagus

D.Achalasia

E.Hiatus hernia

F.Pharyngeal pouch

G.Oesophageal web

H.Oesophageal atresia

Please select the the most likely cause of swallowing difficulties for the scenarios described. Each option may be used once, more than once or not at all.

13.A 55 year old man presents with a history of progressive dysphagia over the past 4 weeks. For the preceding 5 years he had regularly attended his general practitioner with symptoms of dyspepsia and reflux.

A 40 year old man presents with symptoms of dysphagia that have been present for many months. His investigations demonstrate lack of relaxation of the lower oesophageal sphincter during swallowing.

A 4 year old presents with sudden onset of dysphagia. He undergoes an upper GI endoscopy and a large bolus of food is identified in the mid oesophagus. He has no significant history, other than a tracheo-oesophageal fistula repair soon after birth.

Answer 275

Carcinoma of the oesophagus

Theme from January 2013 Exam
A short history of progressive dysphagia in a middle aged man who has a background history of reflux is strongly suggestive of malignancy. Long standing reflux symptoms may be suggestive of a increased risk of developing Barretts oesophagus. Note that not all patients with Barretts transformation alone are symptomatic.

Achalasia

Patients with dysphagia will usually undergo an upper GI endoscopy as a first line investigation. Where this investigation is normal, the next stage is to perform studies assessing oesophageal motility. These comprise fluroscopic barium swallows and oesophageal manometry and pH studies. Lack of sphincter relaxation suggests achalasia (pressures are usually high).

Benign oesophageal stricture

Children with tracheo-oesophageal fistulas will commonly develop oesophageal strictures following repair. These may require regular dilations throughout childhood.

Question 276

How can the causes of dysphagia be classified?

Answer 276

Extrinsic

Oesophageal wall

Intrinsic

Neurological

Question 277

Extrinsic causes of dysphagia

Answer 277

Mediastinal masses

Cervical spondylosis

Question 278

Oesophageal wall causes of dysphagia

Answer 278

Achalasia

Diffuse oesophageal spasm

Hypertensive LOS

Question 279

Intrinsic causes of dysphagia

Answer 279

Tumours

Strictures

Oesophageal web

Schatzki rings

Question 280

Schatzki ring

Answer 280

A Schatzki ring or Schatzki–Gary ring is a narrowing of the lower esophagus that can cause difficulty swallowing (dysphagia). The narrowing is caused by a ring of mucosal tissue (which lines the esophagus) or muscular tissue.[1] A Schatzki ring is a specific type of “esophageal ring”, and Schatzki rings are further subdivided into those above the esophagus/stomach junction (A rings),[2] and those found at the squamocolumnar junction in the lower esophagus (B rings).[3]

Patients with Schatzki rings can develop intermittent difficulty swallowing or, more seriously, a completely blocked esophagus. The ring is named after the German-American physician Richard Schatzki.

Question 281

Neurgolocial causes of dysphagia

Answer 281

CVA

PD

MS

Brainstem pathology

MG

Question 282

Ix in dysphagia

Answer 282

Upper GI endoscopy

Motility disorders best appreciated with fluorscopic swallowing studies

FBC

Ambulatory oesophageal pH and manometry studies amy be used

Question 283

A 48 year old lady presents with discomfort in the right breast. On examination she has a discrete soft fluctuant area in the upper outer quadrant of her right breast. A mammogram is performed and a “halo sign” is seen by the radiologist.

A.Mondors disease

B.Duct ectasia

C.Periductal mastitis

D.Lactational breast abscess

E.Fibroadenoma

F.Breast cyst

G.Intraductal papilloma

H.Atypical ductal hyperplasia

I.Radial scar

Answer 283

Breast cyst

Lesions such as breast cysts compress the underlying fat and produce a radiolucent area (halo sign). If symptomatic, these cysts should be aspirated.

Question 284

How can fibroadenomas be classified?

Answer 284

Juvenile

Common

Giant

Question 285

Mx of fibroadenomas

Answer 285

>4cm- biopsy

<3cm- consider watch and waiting.

Question 286

Natural history of fibroadenomas

Answer 286

10% increase in size

30% regress

Remainder stay the same.

Changes during pregnancy

Question 287

What proportion of breast lumps are accounted for by fibroadenomas?

Answer 287

13%

Question 288

What propotion of breast lumps are accounted for by breast cysts

Answer 288

15%

Question 289

In what age groups are breast cysts most frequent

Answer 289

Perimenopausal females

Question 290

What is the most important structure involved in supporting the uterus?

Round ligament

Broad ligament

Uterosacral ligaments

Cardinal ligaments

Central perineal tendon

Answer 290

The central perineal tendon provides the main structural support to the uterus. Damage to this structure is commonly associated with the development of pelvic organ prolapse, even when other structures are intact.

Question 291

Blood supply of the uterus

Answer 291

Uterine body is via the uterine artery (branch of IIA), uterine artery passes from the inferior aspect of the uterus (lateral to the cervix) and runs alongsisde the uterus

Frequently anastomoses with ovarian artery superiorly

Question 292

Supporting ligaments of the uterus

Answer 292

Central perineal tendon

Lateral cervical

Round

Uterosacral ligaments

Question 293

A 76 year old woman with a body weight of 50 kg is undergoing an excision of a lipoma from her forehead. It is the first time the senior house officer has performed the procedure. He administers 30ml of 2% lignocaine to the area. The procedure is complicated by bleeding and the patient experiences discomfort, a further 10ml of the same anaesthetic formulation is then administered. Over the following 5 minutes the patient complains of tinnitus and becomes drowsy. Which of the drugs listed below should be administered?

Temazepam

Lorazepam

Naloxone

Intralipid 20%

Sodium bicarbonate 20%

Answer 293

Local anaesthetic toxicity treatment = Intralipid

Intralipid is indicated for the treatment of local anaesthetic toxicity. In this case the safe dose of local anaesthetic has been exceeded and is thus this lady’s symptoms are likely to represent toxicity.

Question 294

Pathophysiology of local anaesthetic toxicity

Answer 294

LA not only exert a membrane stabilising effect on peripheral nerves but also act on excitable membranes within CNS and heart

Sensory neurones in CNS are suppressed before the motor ones

Early symptoms are typically those of circumoral paresthesia and tinnitus-> falling GCS and coma

Question 295

Management of local anaesthetic toxicity

Answer 295

Stop injecting agent

High flow O2

CV monitoring

Lipid emulsion (intralipid 20%) at 1.5ml/kg over 1 minute as a bolus

Consider infusion at 0.25ml/kg/minute

If toxicity due to prilocaine then administer methylene blue

Question 296

Lignocaine dose

Answer 296

3mg/Kg

7mg/Kg with adrenaline

Question 297

Dose of bupivicane

Answer 297

2mg/Kg

2mg/Kg with adrenaline

Question 298

Dose of prilocaine

Answer 298

6mg/kg

9mg/kg with adrenaline

Question 299

Treatment of prilocaine toxicity

Answer 299

Methylene blue

Question 300

A 38 year old lady presents with a recent episode of renal colic. As part of her investigations the following results are obtained:

Corrected Calcium3.84 mmol/l

PTH88pg/ml (increased)

Her serum urea and electrolytes are normal.
What is the most likely diagnosis?

Carcinoma of the bronchus

Secondary hyperparathyroidism

Primary hyperparathyroidism

Tertiary hyperparathyroidism

Carcinoma of the breast

Answer 300

In this situation the most likely diagnosis is primary hyperparathyroidism. The question mentions that serum urea and electrolytes are normal, which makes tertiary hyperparathyroidism unlikely.

Question 301

Most common causes of primary hyperparathyroidism

Answer 301

Solitary adenoma

Question 302

Causes of primary hyperparathyroidsim

Answer 302

80%: solitary adenoma

15%: hyperplasia

4%: mulitple adenoma

1%: carcinoma

Question 303

Polydipsia, polyuria

Peptic ulceration/constipation/pancreatitis

Bone pain/fracture

Renal stones

Depression

HTN

Answer 303

?hypercalcaemia

Question 304

Associations of primary hyperparathyroidism

Answer 304

HTN

MEN1 and 2

Question 305

Raised Ca

Low P

PTH may be raised or normal

Answer 305

?primary hyperparathyroidism

Question 306

Biochemistry of primary hyperparathyroidism

Answer 306

Raised Ca, low P

PTH may be raised or normal

Question 307

Scan in primary hyperparathyroidism

Answer 307

Technetium-MIBI subtraction scan

Question 308

Which Hodgkin’s lymphoma does not have Reed-Sternberg cells?

Answer 308

Nodular lymphocyte predominant Hodgkin lymphoma

Question 309

A 24 year old man is diagnosed as having Hodgkins lymphoma. Which subtype is associated with the most favorable prognosis?

Nodular sclerosing

Lymphocyte depleted

Nodular lymphocyte predominant

Classical lymphocyte predominant

Mixed cellularity

Answer 309

The classical lymphocyte predominant variant has the most favorable prognosis. Nodular lymphocyte predominant disease is a very different disease entity and does not have the same favorable prognosis.

Question 310

Which Hodgkin’s lymphoma subtype has the worst prognosis?

Answer 310

Lymphocyte depleted

Question 311

What are poor prognostic patient demographic factors in Hodgkin’s lymphoma?

Answer 311

Advancing age

Male sex

Advanced stage disease

Question 312

Theme: Proctology

A.Fissure in ano

B.Fistula in ano

C.Rectal prolapse

D.Juvenile polyps

E.Rectal adenoma

F.Intersphincteric abscess

G.Haemorrhoids

Please select the most likely underlying cause for the presentations described. Each option may be used once, more than once or not at all.

A 21 year old female presents with a 24 hour history of increasingly severe ano-rectal pain. On examination she is febrile and the skin surrounding the anus looks normal. She did not tolerate an attempted digital rectal examination.

A 21 year old male presents with a 4 week history of frank, bright red, rectal bleeding. This typically occurs post defecation into the toilet pan. He has a long standing history of constipation and a previous fissure in ano. On examination the skin surrounding the anus is normal and digital rectal examination is normal.

A 21 year old lady presents with a 6 month history of an offensive discharge from the anus. She is otherwise well, but is increasingly annoyed at the need to wear pads. On examination she has a small epithelial defect in the 5 o’clock position, approximately 3cm from the anal verge.

Answer 312

The presence of fever and severe pain makes an abscess more likely than a fissure. Although fissures may be painful they do not, in themselves, cause fever. The usual management for this condition is examination of the ano-rectum under general anaesthesia and drainage of the abscess.

Haemorrhoids are a common cause of bright red rectal bleeding. The bleeding is typically painless. A history of constipation is usual and may have been previously associated with a fissure (though this is less common). Haemorrhoids are not always associated with external features and digital rectal examination is usually unremarkable.

Fistulas usually occur following previous ano-rectal sepsis. The discharge may be foul smelling and troublesome. Patients should be listed for examination under anaesthesia. Fistulas which are low and have little or no sphincter involvement are usually laid open.

Question 313

Location of haemorrhoids?

Answer 313

3, 7, 11 o’clock

Internal or external

Question 314

Location of fissure in ano?

Answer 314

Midline 6 (posterior midine 90%) and 12 o’clock position

Distal to dentate line

Question 315

Triad in chronic fissure

Answer 315

Ulcer

Sentinal pile

Enlarged anal papillae

?6/52

Question 316

Positions of anorectal abscess?

Answer 316

Perianal

Ischiorectal

Pelvirectal

Intersphincteric

Question 317

Location of anal fistula

Answer 317

Usually due to previous ano-rectal abscess

Intersphincteric

Transsphincteric

Suprasphincteric

Extrasphincteric

Question 318

What determines fistula location?

Answer 318

Goodsall’s rule

Question 319

Goodsall’s rule

Answer 319

Fistulas with an external opening in relation to the anterior half of the anus is of the direct type i.e. straight line

Fistulas with external openings in relation to the posterior half of the rectus have a curved track, may be of horseshoe type, open in the midline posteriorly and may present with multiple external opening all connected to a single internal opening

Question 320

What is an issue with external rectal prolapse

Answer 320

Can ulcerate and impair continence in the long term.

Question 321

Associated with chronic straining and constipation

Histology shows mucosal thickening.

Lamina propria replaced with collagen and smooth muscle (fibromuscular obliteration)

Answer 321

Solitary rectal ulcer

Question 322

What is the most common type of anal neoplasm?

Answer 322

Squamous cell carcinoma

Question 323

What are the treatments for rectal prolapse

Answer 323

Reduce it acutely

Delormes procedure

Altmeirs procedure

Rectopexy

Question 324

Delormes procedue

Answer 324

Excision of rectal mucosa and plication (high recurrence rates)

May be used for external prolapse

Question 325

Altmeir proecdure

Answer 325

Resects colon via the perineal route but carries the risk of anastomotic leak

Used for rectal prolapse

Question 326

Rectopexy

Answer 326

Abdominal procedure in which the rectum is elevated and usually supported at the level of the sacral promonotory

Post operative constipation may be reduced by limiting the dissection to the anterior plane

Question 327

Typically painful PR bleeding (bright red).

Nearly always in the posterior midline.

Usually solitary.

Answer 327

Fissure in ano

Question 328

Treatment of fissure in ano

Answer 328

Stool softeners

Topical diltiazem

If treatments fail then botulinum toxin

Females who do not respond to botulinum toxin should under go ano rectal manometry studies and endo anal USS prior to being offered surgery

Question 329

A surgical resection specimen is analysed histologically. The pathologist comments that at the periphery of the resected specimen, oxyphil cells are identified. In which of the structures listed below are these cells typically found?

Thymus

Thyroid gland

Parathyroid gland

Lymph node

Adrenal gland

Answer 329

Oxyphil cells are typically found in parathyroid glands

Question 330

Location of the parathyroid gland

Answer 330

4 glands

Posterior to the thyroid

Lie within the pretracheal fascia

Question 331

Embryology of the parathyroids

Answer 331

Develop from extermitites of the third and fourth pharyngeal pouches

Those derived from the fourth pharyngeal pouch are superior and associated with thyroid gland.

Those derived from third pharyngeal pouch lie more inferiorly and may become associated with thymus

Question 332

Blood supply of the parathyroids

Answer 332

Derived from the inferior and superior thyroid arteries

Rich anastomosis between the two vessels.

Venous drainage into the thyroid veins

Question 333

Lateral relation of the parathyroid

Answer 333

Common carotid

Question 334

Medial relations of the parathyroids

Answer 334

Recurrent laryngeal nerve, trachea

Question 335

Anterior relations of the parathyroid

Answer 335

Thyroid

Question 336

Posterior relations of the parathyroid

Answer 336

Pretracheal fascia

Question 337

Represents the wave of depolarization that spreads from the SA node throughout the atria

Lasts 0.08 to 0.1 seconds (80-100 ms)

The isoelectric period immediately after represents the time in which the impulse is traveling within the AV node

Answer 337

P wave

Question 338

Time from the onset of the P wave to the beginning of the QRS complex

Ranges from 0.12 to 0.20 seconds in duration

Represents the time between the onset of atrial depolarization and the onset of ventricular depolarization

Answer 338

PR interval

Question 339

Represents ventricular depolarization

Duration of is normally 0.06 to 0.1 seconds

Answer 339

QRS

Question 340

Normal P wave length

Answer 340

0.08 to 0.1 seconds

Question 341

Normal PRI

Answer 341

0.12 to 0.2

Question 342

QRS

Answer 342

0.06-0.1

Question 343

Isoelectric period following the QRS

Represents period which the entire ventricle is depolarized and roughly corresponds to the plateau phase of the ventricular action potential

Answer 343

ST segment

Question 344

Represents ventricular repolarization and is longer in duration than depolarization

A small positive U wave may follow the T wave which represents the last remnants of ventricular repolarization.

Answer 344

T wave

Question 345

Represents the time for both ventricular depolarization and repolarization to occur, and therefore roughly estimates the duration of an average ventricular action potential.

Answer 345

QT interval

Question 346

What is the QTc

Answer 346

At high heart rates, ventricular APs shorten in duration, which decreases the QT interval. The QT interval is divided by the square root of the R-R interval.

This allows an assessment of the QT interval that is independent of heart rate

Question 347

Normal QTc

Answer 347

0.44

Question 348

A 45 year old male has alcoholic cirrhosis and decompensated liver failure, which of the following clotting factors is least likely to be affected?

Factor V

Factor VII

Factor IX

Factor VIII

Factor XI

Answer 348

Factor VIII is synthesised in the endothelial cells of the liver rather than the liver itself and therefore is less prone to the effects of hepatic dysfunction.

Question 349

Affects synthesis of factors 2,7,9,10

Answer 349

Warfarin

Question 350

Affects Factors 1,2,5,8,11

Answer 350

DIC

Question 351

Affects Factors 1,2,5,7,9,10,11

Answer 351

Liver disease

Question 352

Prevents activation factors 2,9,10,11

Answer 352

Heparin

Question 353

APTT increased

PT normal

Bleeding time normal

Answer 353

Haemophilia

Question 354

APTT increased

PT normal

Bleeding time increased

Answer 354

vWD

Question 355

APTT increased

PT increased

Bleeding time normal

Answer 355

Vit K deficiency

Question 356

A 53 year old man undergoes a reversal of a loop colostomy. He recovers well and is discharged home. He is readmitted 10 days later with symptoms of vomiting and colicky abdominal pain. On examination he has a swelling of the loop colostomy site and it is tender. What is the most likely underlying diagnosis?

Haematoma

Intra abdominal adhesions

Anastomotic leak

Anastomotic stricture

Obstructed incisional hernia

Answer 356

In this scenario the most likely diagnosis would be obstructed incisional hernia. The tender swelling coupled with symptoms of obstruction point to this diagnosis. Prompt surgical exploration is warranted. Loop colostomy reversals are at high risk of this complication as the operative site is at increased risk of the development of post operative wound infections.

Question 357

A 34 year old lady suffers from hyperparathyroidism. The right inferior parathyroid is identified as having an adenoma and is scheduled for resection. From which of the following embryological structures is it derived?

Second pharyngeal pouch

Third pharyngeal pouch

Fourth pharyngeal pouch

First pharyngeal pouch

None of the above

Answer 357

The inferior parathyroid is a derivative of the third pharyngeal pouch. The superior parathyroid originates from the fourth pharyngeal pouch.

Question 358

A 43 year old lady has recently undergone a wide local excision and sentinel lymph node biopsy for carcinoma of the breast. Of the factors listed below, which will provide the most important prognostic information?

Mitotic number

Grade

Nodal status

Size

Oestrogen receptor status

Answer 358

Nodal status is important because it serves as a marker of tumour metastatic potential. This translates to survival advantages of up to 40% at five years. Both grade and size are of secondary importance as they both less concerning in the absence of nodal involvement.

Question 359

What is the most common breast carcinoma

Answer 359

Invasive ductal carcinomas

Question 360

When might a mastectomy be indicated?

Answer 360

Multifocal tumour

Central tumour (central lesions may be managed using breast conserving surgery although this is rarely the case in small breasts)

Large lesion in small breast

DCIS >4cm

Patient choice

Question 361

When might a wide local excision be indicated

Answer 361

Solitary lesion

Peripheral tumour

Small lesion in large breast

DCIS <4cm

Patient choice

Question 362

How to caclulate NPI

Answer 362

Tumour size x 0.2 + LN score + grade score

Question 363

A 23 year old man falls and slips at a nightclub. A shard of glass penetrates the skin at the level of the medial epicondyle, which of the following sequelae is least likely to occur?

Atrophy of the first dorsal interosseous muscle

Difficulty in abduction of the the 2nd, 3rd, 4th and 5th fingers

Claw like appearance of the hand

Loss of sensation on the anterior aspect of the 5th finger

Partial denervation of flexor digitorum profundus

Answer 363

Injury to the ulnar nerve in the mid to distal forearm will typically produce a claw hand. This consists of flexion of the 4th and 5th interphalangeal joints and extension of the metacarpophalangeal joints. The effects are potentiated when flexor digitorum profundus is not affected, and the clawing is more pronounced.More proximally sited ulnar nerve lesions produce a milder clinical picture owing to the simultaneous paralysis of flexor digitorum profundus (ulnar half).

This is the ‘ulnar paradox’, due to the more proximal level of transection the hand will typically not have a claw like appearance that may be seen following a more distal injury. The first dorsal interosseous muscle will be affected as it is supplied by the ulnar nerve.

Question 364

Origin of the ulnar nerve

Answer 364

C8 T1

Question 365

Muscles supplied by the ulnar nerve

Answer 365

FCU

FDP

FD minimi

Abductor minimi

Opponens digiti minimi

Adductor pollicis

Interossei

Third and fourth lumbricals

Palmaris brevis

Question 366

Path of the ulnar nerve

Answer 366

Posteromedial aspect of the upper arm to flexor compartment of the forearm

Then along the ulnar

Passes beneath the flexor carpi ulnaris muscle, then superficially through the flexor retinaculum into the hand

Question 367

What muscles in the upper arm are supplied by the ulnar nerve?

Answer 367

None

Question 368

What are the branches of the ulnar nerve

Answer 368

Muscular branch

Palmar cutaneous branch (arises near the middle of the forearm)

Dorsal cutaneous branch

Superficial branch

Deep branch

Question 369

Muscular branch of the ulnar supplies?

Answer 369

FCU

Medial half of FDP

Question 370

Palmar cutaneous branch of the ulnar supplies?

Answer 370

Skin on medial part of the palm

Question 371

Dorsal cutaneous branch of the ulnar supplies

Answer 371

Dorsal surface of the medial part of the hand

Question 372

Superifical branch of the ulnar supplies

Answer 372

Cutaneous fibres to the anterior surfaces of the medial 1.5 digits

Question 373

Deep branch of the ulnar supplies

Answer 373

Hypothenar muscles

All of the interoessei

Third and fourth lumbricals

Adductor pollicis

Medial head of flexor pollicis brevis

Question 374

Damage to ulnar, where?

Wasting and paralysis of intrinsic hand muscles (claw hand)

Wasting and paralysis of hypothenar muscles

Loss of sensation medial 1 and half fingers

Answer 374

At the wrist

Question 375

Damage to the ulnar, where

Radial deviation of the wrist

Clawing less in 4th and 5th digits

Answer 375

Damage at the elbow

Question 376

Explain the ulnar paradox

Answer 376

The ulnar nerve also innervates the ulnar (medial) half of the flexor digitorum profundus muscle (FDP). If the ulnar nerve lesion occurs more proximally (closer to the elbow), the flexor digitorum profundus muscle may also be denervated. As a result, flexion of the IP joints is weakened, which reduces the claw-like appearance of the hand.[3] (Instead, the fourth and fifth fingers are simply paralyzed in their fully extended position.) This is called the “ulnar paradox” because one would normally expect a more proximal and thus debilitating injury to result in a more deformed appearance.

Simply put, as reinnervation occurs along the ulnar nerve after a high lesion, the deformity will get worse (FDP reinnervated) as the patient recovers - hence the use of the term “paradox”. A simple way to remember this is: ‘the closer to the Paw, the worse the Claw’.

Question 377

Theme: Abdominal stomas

A.End ileostomy

B.End colostomy

C.Loop ileostomy

D.Loop colostomy

E.End jejunostomy

F.Loop jejunostomy

G.Caecostomy

For each of the following scenarios, please select the most appropriate type of stoma to be constructed. Each option may be selected once, more than once or not at all.

A 56 year old man is undergoing a low anterior resection for carcinoma of the rectum. A primary anastomosis is planned.

A 23 year old man with uncontrolled ulcerative colitis is undergoing an emergency sub total colectomy.

A 63 year old women presents with large bowel obstruction. On examination she has a carcinoma 10cm from the anal verge.

Answer 377

The correct answer is Loop ileostomy

Theme from April 2014 Exam
Colonic resections with an anastomosis below the peritoneal reflection may have an anastomotic leak rate (both clinical and radiological) of up to 15%. Therefore most surgeons will defunction such an anastomosis to reduce the clinical severity of an anastomotic leak. A loop ileostomy will achieve this end point and is relatively easy to reverse.

The correct answer is
Following a sub total colectomy the immediate surgical options include an end ileostomy or ileorectal anastomosis. In the emergency setting an ileorectal anastomosis would be unsafe.

The correct answer is Loop colostomy

Large bowel obstruction resulting from carcinoma should be resected, stented or defunctioned. The first two options typically apply to tumours above the peritoneal reflection. Lower tumours should be defunctioned with a loop colostomy and then formal staging undertaken prior to definitive surgery. An emergency attempted rectal resection carries a high risk of involvement of the circumferential resection margin and is not recommended.

Question 378

Use of gastrostomy

Answer 378

Gasrtic decompression or fixation

Feeding

Question 379

Use of loop jejunostomy

Answer 379

Seldom used as very high output

May be used following emergency laparotomy with planned early closure

Question 380

Use of percutaneous jejunostomy

Answer 380

Usually performed for feeding purposes and site in the proximal bowel

Question 381

Use of loop ileostomy

Answer 381

Defunctioning of colon e.g. following rectal cancer surgery

Does not decompress colon if ileocaecal valve competenet

Question 382

Use of end ileostomy

Answer 382

Usually following complete excision of colon or where ileo-colic anastomosis is not planned.

May be used to defunction colon but reversal is more difficult

Question 383

Use of end colostomy

Answer 383

Where a colon is diverted or resected and anastomosis is not primarily achievable or desirable

Question 384

Use of loop colostomy

Answer 384

To defunction a distal segment of colon.

Since both lumens are present, the distal lumen acts as a vent

Question 385

Use of caecostomy

Answer 385

Stoma of last resort where loop colostomy is not possible

Question 386

Use of mucous fistula

Answer 386

To decompress a distal segment of bowel following colonic diversion or resection

Where closure of distal resection margin is not safe or achievable

Question 387

A 56 year old man is undergoing a superficial parotidectomy for a pleomorphic adenoma. During the dissection of the parotid, which of the following structures will be encountered lying most superficially?

Facial nerve

External carotid artery

Occipital artery

Maxillary artery

Retromandibular vein

Answer 387

Most superficial structure on the parotid gland = facial nerve

The facial nerve is the most superficial structure in the parotid gland. Slightly deeper to this lies the retromandibular vein, with the arterial layer lying most deeply.

Question 388

Location of the parotid gland

Answer 388

Overlying the mandibular ramus, anterior and inferior to the ear

Question 389

Salivary duct of the parotid gland

Answer 389

Crosses the masseter, pierces the buccinator and drains adjacent to the second upper molar tooth (Stensen’s duct)

Question 390

What are the structures passing through the parotid?

Answer 390

Facial nerve

External carotid artery

Retromandibular vein

Auriculotemporal nerve

Question 391

Branches of the facial nerve

Ten Zulus Buggered My Car

Answer 391

Temporal

Zygomatic

Buccal

Mandibular

Cervical

Question 392

Anterior relations of the parotid

Answer 392

Masseter

Medial pterygoid

Superficial temporal and maxillary artery

Stylomandibular ligament

Question 393

Posterior relations of the parotid

Answer 393

Posterior belly of digastric muscle

Sternocleidomastoid

Stylohyoid

ICA

Mastoid process

Styloid process

Question 394

Arterial supply of the parotid

Answer 394

Branches of ECA

Question 395

Venous drainage of the parotid

Answer 395

Retromandibular vein

Question 396

Lymphatic drainage of the parotid

Answer 396

Deep cervical nodes

Question 397

Parasympathetic innervation of the parotid

Stimulation produces

Answer 397

Secretomotor

Water rich, serous saliva

Question 398

Sympathetic innervation of the parotid

Stimulation leads to

Answer 398

Superior cervical ganglion

Secretion of a low volume, enzyme-rich saliva

Question 399

Sensory supply of the parotid

Answer 399

Greater auricular nerve

Question 400

A 43 year old man is stabbed outside a nightclub. He suffers a transection of his median nerve just as it leaves the brachial plexus. Which of the following features is least likely to ensue?

Ulnar deviation of the wrist

Complete loss of wrist flexion

Loss of pronation

Loss of flexion at the thumb joint

Inability to oppose the thumb

Answer 400

Loss of the median nerve will result in loss of function of the flexor muscles. However, flexor carpi ulnaris will still function and produce ulnar deviation and some residual wrist flexion. High median nerve lesions result in complete loss of flexion at the thumb joint.

Question 401

A 78 year old man is due to undergo an endarterectomy of the internal carotid artery. Which of the following nervous structures are most at risk during the dissection?

Recurrent laryngeal nerve

Sympathetic chain

Hypoglossal nerve

Phrenic nerve

Lingual nerve

Answer 401

During a carotid endarterectomy the sternocleidomastoid muscle is dissected, with ligation of the common facial vein and then the internal jugular is dissected exposing the common and the internal carotid arteries. The nerves at risk during the operation include:

Hypoglossal nerve

Greater auricular nerve

Superior laryngeal nerve

The sympathetic chain lies posteriorly and is less prone to injury in this procedure.

Question 402

What nerves are at risk during a carotid endarterectomy

Answer 402

Hypoglossal

Greater auricular

Superior laryngeal nerve

Question 403

Where does the internal carotid form

Answer 403

From the common carotid opposite the upper border of the thyroid cartilage

Extends superiorly to enter the skull via the carotid canal

Question 404

Where does the internal carotid divide into the anterior and middle cerebral arteries

Answer 404

After it passes through the cavernous sinus, above which it divides into the anterior and middle cerebral arteries

Question 405

What are the posterior relations of the carotid in the neck?

Answer 405

Longus capitis

Pre-vertebral fascia

Sympathetic chain

Superior laryngeal nerve

Question 406

What are the medial relations of the ICA in the neck

Answer 406

External carotid

Wall of pharynx

Ascending pharyngeal artery

Question 407

What are the lateral relations of the ICA in the neck

Answer 407

IJV (moves posteriorly at entrance to the skull)

Vagus nerve (most posterolaterally)

Question 408

What are the anterior relations of the ICA in the neck

Answer 408

Sternocleidomastoid

Lingual and facial veins

Hypoglossal nerve

Question 409

What are the relations of the ICA in the carotid canal

Answer 409

Internal carotid plexus

Cochlea and middle ear cavity

Trigeminal ganglion (superiorly)

Leaves canal above the foramen lacerum

Question 410

Path of the ICA in the cranial cavity

Answer 410

Bends sharply forward in the cavernous sinus

Abducens lies close to its inferolateral aspect.

The oculomotor, trochlear, ophthalmic and usually the maxillary nerves lie in the lateral wall of the sinus.

Near the SOF it turns posteriorly and pass posteromedially to pierce the roof of the cavernous sinus inferior to the optic nerve

It then passes between the optic and oculomotor nerves to terminate below the anterior perforated substance by dividing into the anterior and middle cerebral arteries

Question 411

What are the branches of the ICA

Answer 411

Anterior and MCA

Ophthalmic artery

PComm

Anterior choroid artery

Meningeal arteries

Hypophyseal arteries

Question 412

Which of the structures listed below articulates with the head of the radius superiorly?

Capitulum

Trochlea

Lateral epicondyle

Ulna

Medial epicondyle

Answer 412

The head of the radius articulates with the capitulum of the humerus.

Question 413

Upper end of the radius

Answer 413

Articular cartilage covers medial > lateral side

Articulates with radial notch of the ulna by the annular ligament

Muscle attachment: biceps brachii at the tuberosity

Question 414

Muscles attached to the upper third of the body of the radius

Answer 414

Supinator

FDS

FPL

Question 415

Muscles attached to the middle third of the body of the radius

Answer 415

Pronator teres

Question 416

Muscles attached to the lower quarter of the body of the radius

Answer 416

Pronator quadratus

Tendon of supinator longus

Question 417

Relations of the lower end of the radius?

Answer 417

Quadrilateral

Anterior surface: capsule of wrist joint

Medial surface: head of ulna

Lateral surface: ends in the styloid process.

Posterior surface has 3 grooves containing various tendons

Question 418

What are the tendons in the grooves of the radius?

Answer 418

Tendon of ECR longus and brevis

Tendon of EPL

Tendon of extensor indicis

Question 419

Answer 419

Question 420

Theme: Management of urinary tract calculi

A.Nephrectomy

B.Open ureteric exploration

C.Extra corporeal shock wave lithotripsy

D.Percutaneous nephrostomy

E.Pyeloplasty

F.Conservative management

G.Percutaneous nephrolithotomy

Please select the most appropriate management for the scenario given. Each option may be used once, more than once or not at all.

A 23 year old male is admitted with left sided loin pain and fever. His investigations demonstrate a left sided ureteric calculi that measures 0.7cm in diameter and associated hydronephrosis.

A 23 year old man is admitted with left sided loin pain that radiates to his groin. His investigations demonstrate a 1cm left sided calculus within the renal pelvis.

A 30 year old male presents with left sided loin pain. His investigations demonstrate a large left sided staghorn calculus that measures 2.3cm in diameter.

Answer 420

An obstructed, infected system is an indication for urgent decompression. This may be achieved by ureteroscopy or nephrostomy. In addition to this the patient should also receive broad spectrum, intravenous antibiotics.

Stones with a total volume of less than 2cm can be considered for lithotripsy. If it is impacted in the upper ureter then some may consider a ureteroscopy.

Large, proximal stones are generally best managed with a percutaneous nephrolithotomy. The use of lithotripsy has low clearance rates. Where stones remain after the initial procedure a repeat percutaneous nephrolithotomy is generally preferred over follow up lithotripsy.

Question 421

When is urgent treatment of ureteric stones indicated

Answer 421

Ureteric obstruction

Renal developmental abnormality

Previous renal transplant.

Question 422

Process of shockwave lithotripsy

Answer 422

A shock wave is generated external to the patient, internally cavitation bubbles and mechanical stress lead to stone fragmentation. The passage of shock waves can result in the development of solid organ injury. Fragmentation of larger stones may result in the development of ureteric obstruction. The procedure is uncomfortable for patients and analgesia is required during the procedure and afterwards.

Question 423

Ureteroscopy management of stones

Answer 423

A ureteroscope is passed retrograde through the ureter and into the renal pelvis. It is indicated in individuals (e.g. pregnant females) where lithotripsy is contraindicated and in complex stone disease. In most cases a stent is left in situ for 4 weeks after the procedure.

Question 424

Process of PCNL

Answer 424

In this procedure access is gained to the renal collecting system. Once access is achieved, intra corporeal lithotripsy or stone fragmentation is performed and stone fragments removed.

Question 425

Treatment options for stones:

Stone burden of less than 2cm in aggregate

Stone burden of less than 2cm in pregnant females

Complex renal calculi and staghorn calculi

Ureteric calculi less than 5mm

Answer 425

Lithotripsy

Ureteroscopy

Percutaneous nephrolithotomy

Question 426

Theme: Head and neck lumps

A.Branchial cyst

B.Cystic hygroma

C.Carotid body tumour

D.Lymphadenopathy

E.Adenolymphoma of the parotid

F.Pleomorphic adenoma of the parotid

G.Submandibular tumour

H.Thyroglossal cyst

I.Thoracic outlet syndrome

J.Submandibular gland calculus

A 60 year old Tibetan immigrant is referred to the surgical clinic with a painless neck swelling. On examination, it is located on the left side immediately anterior to the sternocleidomastoid muscle. There are no other abnormalities to find.

A 40 year old woman presents as an emergency with a painful mass underneath her right mandible. The mass has appeared over the previous week with the pain worsening as the lump has increased in size. On examination, there is a 4cm mass underneath her mandible, there is no associated lymphadenopathy.

A 73 year old male smoker is referred to the clinic by his GP. On examination he has a 3cm soft mass immediately anterior to his ear. It has been present for the past five years and is otherwise associated with no symptoms.

Answer 426

Carotid body tumours typically present as painless masses. They may compress the vagus or hypoglossal nerves with symptoms attributable to these structures. Over 90% occur spontaneously and are more common in people living at high altitude. In familial cases up to 30% may be bilateral. Treatment is with excision.

The sub mandibular gland is the most common site for salivary calculi. Patients will usually complain of pain, which is worse on eating. When the lesion is located distally the duct may be laid open and the stone excised. Otherwise the gland will require removal.

Warthins tumours (a.k.a. adenolymphoma) are commoner in older men (especially smokers). They are the second commonest benign tumour of the parotid gland, they may be bilateral. They are soft and slow growing and relatively easy to excise. Pleomorphic adenomas typically present in females aged between 40 - 60 years.

Question 427

By far the most common cause of neck swellings. There may be a history of local infection or a generalised viral illness

Answer 427

Reactive lymphadenopathy

Question 428

Rubbery, painless lymphadenopathy
The phenomenon of pain whilst drinking alcohol is very uncommon
There may be associated night sweats and splenomegaly

Answer 428

Lymphoma

Question 429

May be hypo-, eu- or hyperthyroid symptomatically
Moves upwards on swallowing

Answer 429

Thyroid swelling

Question 430

More common in patients < 20 years old
Usually midline, between the isthmus of the thyroid and the hyoid bone
Moves upwards with protrusion of the tongue
May be painful if infected

Answer 430

Thyroglossal cyst

Question 431

More common in older men
Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen, but if large then a midline lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough

Answer 431

Pharyngeal pouch

Question 432

A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side
Most are evident at birth, around 90% present before 2 years of age

Answer 432

Cystic hygroma

Question 433

An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx
Develop due to failure of obliteration of the second branchial cleft in embryonic development
Usually present in early adulthood

Answer 433

Branchial cyst

Question 434

More common in adult females
Around 10% develop thoracic outlet syndrome

Answer 434

Cervical rib

Question 435

Pulsatile lateral neck mass which doesn’t move on swallowing

Answer 435

Carotid aneurysm

Question 436

Which of the following fascial structures encases the apex of the lungs?

Waldeyers fascia

Sibsons fascia

Pretracheal fascia

Clavipectoral fascia

None of the above

Answer 436

Sibson’s fascia overlies the apices of both lungs

The suprapleural fascia (Sibson’s fascia) runs from C7 to the first rib and overlies the apex of both lungs.It lies between the parietal pleura and the thoracic cage.

Question 437

General lung anatomy

Answer 437

Right lung composed of 3 lobes, divided by the oblique and transverse fissures.

Left lung has two lobes divided by the oblique fissure.

Apex is approximately 4cm superior to the sterno-costal joint of the first rib.

Immediately below this is a sulcus created by the subclavian artery.

Question 438

What are the peripheral contact points of the lung

Answer 438

Base: diaphragm

Costal surface: corresponds to the cavity of the chest

Mediastinal surace: contacts the mediastinal pleura. Has the cardiac impression. Above and behind this concavity is a triangular depression where the structures that form the root of the lung enter and leave (i.e. hilum)

These are invested by viscus, which below the hilum and behind the pericardial impression forms the pulmonary ligament

Question 439

Outline the relations of the right lung

Answer 439

Above hilum is the azygos. Superior to this is the groove for the SVC and right inominate vein.

Behind this and nearer the apex is the groove for the inominate artery.

Behind the attachment of the pulmonry ligament is a vertical groove for the oesophagus.

In front and to the right of the lower part of the oesophageal groove is a deep concavity for the extracardiac portion of the IVC.

The root of the right lung lies behind the SVC and the RA and below the azygos vein.

Question 440

Answer 440

Question 441

A 12 year old child is admitted with a 12 hour history of colicky right upper quadrant pain. On examination the child is afebrile and is jaundiced. The abdomen is soft and non tender at the time of examination. What is the most likely cause?

Infectious hepatitis

Acute cholecystitis

Cholangitis

Hereditary spherocytosis

Gilberts syndrome

Answer 441

Cholecystitis is unlikely in the absence of focal tenderness

Theme from September 2012 Exam
The child is most likely to have hereditary spherocytosis. In these individuals there may be disease flares precipitated by acute illness. They form small pigment stones. These may cause biliary colic and some may require cholecystectomy.
Gilbert’s syndrome is an inherited condition causing unconjugated hyperbilirubinaemia. Patients may have jaundice or be asymptomatic. The other LFTs are normal and Gilbert’s may be confirmed with a fasting test or Nicotinic acid test. There is no need for treatment as it is a benign condition.

Question 442

Most common disorder of the red cell membrane, it has an incidence of 1 in 5000. The abnormally shaped erythrocytes are prone to splenic sequestration and destruction. This can result in hyperbilirubinaemia, jaundice and splenomegaly. In older patients an intercurrent illness may increase the rate of red cell destruction resulting in more acute symptoms.
Severe cases may benefit from splenectomy.

Answer 442

Hereditary Spherocytosis

Question 443

Theme: Management of biliary disease

A.Acute laparoscopic cholecystectomy

B.Delayed laparoscopic cholecystectomy

C.Percutaneous cholecystostomy

D.Elective cholecystectomy and intra operative cholangiogram

E.Endoscopic retrograde cholangiopancreatography

F.Choledochoduodenostomy

G.Bile duct excision and hepatico-jejunostomy

H.Operative cholecystostomy

A 72 year old lady underwent an open cholecystectomy 12 years previously. She has been admitted since with 2 episodes of cholangitis and stones were retrieved at ERCP. She has just recovered from a further episode of sepsis and MRCP has shown further biliary stones.

A 26 year old women is admitted with acute cholecystitis of 24 hours duration. LFT’s are normal and Ultrasound shows a thick walled gallbladder containing stones.

A 32 year old lady is seen in the outpatients. She has had multiple episodes of biliary colic and ultrasound shows thin walled gallbladder with multiple calculi. Her ALT is slightly raised but other parameters are normal.

Answer 443

A patient with long standing common bile duct stones is at risk of developing duct fibrosis and ductal disproportion. This can result in impaired biliary drainage. Not only may further stones be formed in the bile that is present, but because of the ductal disproportion the tendency will be for the stones to accumulate (rather than pass spontaneously, as would usually be the case post ERCP and sphincterotomy). A biliary bypass procedure is the standard method dealing with this and a choledochoduodenstomy is one procedure that can be used.

This is an ideal case for an acute cholecystectomy, provided that surgery can be undertaken promptly. After 48 -72 hours the patient should receive parenteral antibiotics and delayed cholecystectomy performed.

The easiest option is to perform an intraoperative cholangiogram. It is unlikely to reveal any stones. If is does then either laparoscopic bile duct exploration or urgent ERCP can be performed. An MRCP pre op is an alternative strategy.

Question 444

Typically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results.

Answer 444

Gallstones

Question 445

Usually obstructive and will have Charcot’s triad of symptoms (pain, fever, jaundice)

Answer 445

Cholangitis

Question 446

Typically painless jaundice with palpable gallbladder (Courvoisier’s Law)

Answer 446

Pancreatic cancer

Question 447

Usually follows long term use of TPN and is usually painless with non obstructive features

Answer 447

TPN (total parenteral nutrition) associated jaundice

Question 448

Depending upon the type of injury jaundice may be of sudden or gradual onset and is usually of obstructive type

Answer 448

Bile duct injury

Question 449

Picture of jaundice in cholangiocarcinoma

Answer 449

Gradual onset of obstructive pattern

Question 450

Aetiology of jaundice in a septic surgical patient

Answer 450

Gradual onset obstructive pattern.

Caused be a combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis

Question 451

Pathophysiology of jaundice in metastatic disease

Answer 451

Combination of liver sythnetic failure (late) and extrinsic compression by nodal disease, anatomical compression of intrahepatic structures (earlier)

Mixed hepatic and post-hepatic picture

Question 452

When may Roikitansky-Aschoff sinuses be seen microscopically

Answer 452

Chronic cholecystitis

Question 453

Pathogenesis of gallstones

Answer 453

Usually small calibre gallstones which can pass through the cystic duct. No jaundice unless Mirizzi syndrome

Question 454

Mirizzi syndrome

Answer 454

Compression of the bile bile duct by gallstones.

One of the rare times that cholecystitis may present with jaundice.

Question 455

Pathophysiology of cholangitis

Answer 455

Ascending infection of the bile ducts usually by E. Coli and by definition occurring in a pool of stagnant bile

Question 456

Bacteria associated with cholangitis?

Answer 456

E. Coli

Question 457

Pathophysiology of pancreatic cancer causing jaundice

Answer 457

Direct occlusion of distal bile duct or pancreatic duct by tumour.

Sometimes nodal disease at the porta hepatis may be the culpirt

Question 458

When may the bile duct be of normal calibre in pancreatic cancer + jaundice?

Answer 458

Nodal disease at the porta hepatis

Question 459

Pathophysiology of jaundice in TPN

Answer 459

Often due to hepatic dysfunction and fatty liver which may occur with LT TPN usage

Question 460

Pathophysiology of bile duct injury

Answer 460

Often due to difficult laparosocopic cholecystectomy when anatomy in Calot’s triangle is not appreciated.

Worst case: bile duct excised and jaundice develops rapidly post-op

More insidious is bile duct stenosis that may be caused by clips or diathermy injury

Question 461

Calot’s triangle

Answer 461

Calot triangle is a small (potential) triangular space at the porta hepatis of surgical importance as it is dissected during cholecystectomy. Its contents, the cystic artery and cystic duct must be identified before ligation and division to avoid damaging them during the operation.

Question 462

Boundaries of the triangle of Calot

Answer 462

Right: cystic duct.

Left common hepatic duct

Superior: inferior suface of the liver (in the original description by Calot, the cystic artery is defined as the superior margin)

Question 463

Contents of the triangle of Calot

Answer 463

Right hepatic artery

Cystic artery

Cystic lymph node of Lund

Connective tissue

Lymphatics

Occasionally accessory hepatic ducts and arteries

Question 464

Which of the structures listed below inserts into the site labelled in the image.

© Image provided by the University of Sheffield

Psoas minor

Psoas major

Sartorius

Obturator externus

Gemellus

Answer 464

Psoas major inserts onto the lesser trochanter.

Question 465

Extent of the femur

Answer 465

From a rounded head which articulates with the acetabulum down to the knee where the two large condyles at its inferior aspect articulate with the tibia.

Question 466

Superior aspect of the femur

Answer 466

Comprises a head and neck which pass inferolaterally to the body and the two trochanters which lie at the junction between the neck and the body.

The neck meets the body of the femur at an angle of 125 degrees.

Question 467

Describe the intertrochanteric crest of the femur

Answer 467

Demarcates the neck of the femur from the body.

Continues inferomedially as a spiral line that runs below the lesser trochanter.

Medially, the intertrochanteric line gives attachments to the inferior end of the iliofemoral ligament.

Neck is covered by a synovial membrane up to the intertrochanteric line.

Posterior aspect of the neck is demarcated from the shaft by the intertrochanteric crest and only its medial aspect is covered by the synovium and the joint capsule

Question 468

Greater trochanter attachments

Answer 468

Form the site of attachment of the gluteal muscles.

Laterally, the greater trochanter overhangs the body and this forms part of the origin of vastus lateralis

Question 469

What is the origin of the vastus intermedius

Answer 469

Surface of the anterior aspect of the body of the femur

Question 470

What attaches to the upper and middle aspects of the linea aspera?

Answer 470

Thigh adductors

Question 471

Course of the linea aspera.

Answer 471

As it continues inferiorly, it spans out to form the bony floor of the popliteal fossa.

At the inferior aspect of the popliteal surface, it curves posteriorly to form the femoral condyles.

Question 472

Structures attached to the inferior aspect of the linea aspera?

Answer 472

Split with it as it approaches the popliteal fossa:

vastus medialis and adductor magnus continue with the medial split.

Biceps femoris and vastus intermedius along the lateral split

Question 473

Answer 473

Question 474

Answer 474

Question 475

As regards the internal jugular vein, which of the following statements is untrue?

It lies within the carotid sheath

It is the continuation of the sigmoid sinus

The terminal part of the thoracic duct crosses anterior to it to insert into the right subclavian vein

The hypoglossal nerve is closely related to it as it passes near the atlas

The vagus nerve is closely related to it within the carotid sheath

Answer 475

The terminal part of the thoracic duct crosses anterior to it to insert into the right subclavian vein

Question 476

Course of the IJV

Answer 476

Begins in the jugular foramen as a continuation of the sigmoid sinus.

Terminate at the medial end of the clavicle where they unite with subclavian vein.

Lies within the carotid sheath throughout its course.

Below the skull, the internal carotid and the last 4 CNs are anteromedial to the vein. Thereafter it is in contact medially with the ICA then CCA. Vagus lies posteromedially.

At its superior aspect, the vein is overlapped by sternocleidomastoid and covered by its inferior aspect

Below the transverse process of the atlas, it is crossed on its lateral side by the accessory nerve.

At its midpoint it is crossed by inferior root of the ansa cervicalis.

Posterior to the vein are transverse processes of the cervical vertebrae. The phrenic nerve as it descends on scalenus anterior and the fist part of subclavian.

On the left side it is also related to the thoracic duct.

Question 477

Theme: Management of ano-rectal disease

A.Excision and primary closure

B.Incision and drainage

C.Topical steroids

D.Topical diltiazem

E.Steroid injections

F.Haemorroidectomy

G.Manual anal dilation

H.Injection with 88% aqueous phenol

I.Sphincterotomy

A 19 year old female presents with severe anal pain and bleeding which typically occurs post defecation. On examination she has a large posteriorly sited fissure in ano.

A 43 year old male has been troubled with symptoms of post defecation bleeding for many years. On examination he has large prolapsed haemorroids, colonoscopy shows no other disease.
A 20 year old man presents with a 24 hour history of anal pain. On examination he has a peri anal abscess.

Answer 477

Initial therapy should be with pharmacological agents to relax the sphincter and facilitate healing. This is particularly true in females presenting for the first time.

Prolapsed haemorroids are best managed surgically if symptomatic. Note that phenol injections are usually only used for minor internal haemorroids. Where used low concentration phenol in oil is used, the phenolic solution above is used to ablate the nail bed in toe nail surgery!

Abscesses require incision and drainage as a first line treatment.

Question 478

Treatment of acutely thrombosed haemorrhoids?

Answer 478

Treatment of this acute condition is usually conservative and consists of stool softeners, ice compressions and topical GTN or diltiazem to reduce sphincter spasm. Most cases managed with this approach will settle over the next 5-7 days. After this period there may be residual skin tags that merit surgical excision or indeed residual haemorroidal disease that may necessitate haemorroidectomy.

Question 479

Treatment of small mild haemorrhoids

Answer 479

Conservatively

Question 480

Core marked symptoms of bleeding and occasional prolapse, where the haemorroidal complex is largely internal may benefit from ?

Answer 480

Stapled haemorroidopexy

Question 481

Stapled haemorroidopexy?

Answer 481

This procedure excises rectal tissue above the dentate line and disrupts the haemorroidal blood supply. At the same time the excisional component of the procedure means that the haemorroids are less prone to prolapse. Adverse effects of this procedure include urgency, which can affect up to 40% of patients (but settles over 6-12 months) and recurrence. The procedure does not address skin tags and therefore this procedure is unsuitable if this is the dominant symptom.

Question 482

Treatment of large haemorrhoids with a substantial external component?

Answer 482

Milligan Morgan haemorroidectomy

Question 483

Milligan morgan haemorroidecctomy

Answer 483

In this procedure three haemorroidal cushions are excised, together with their vascular pedicle. Excision of excessive volumes of tissue may result in anal stenosis. The procedure is quite painful and most surgeons prescribe metronidazole post operatively as it decreases post operative pain.

Question 484

Treatment of fissure in ano?

Answer 484

Definitevely is lateral internal spincterotomy

Permanent and nearly all patients will recover.

Not as readily used in females due to risk of faecal incontinence

Usual first line therapy is topical GTN or diltiazem for 6/52

Failure of topical therapy will usually-> botulinum

Question 485

Typical fissures usually present in the posterior midline, multiple or unusually located fissures should prompt a search for

Answer 485

Underlying cause e.g. IBD or internal prolapse.

Question 486

Treatment for refractory cases of fissure in ano?

Answer 486

?Advancement flaps

Question 487

Treatment of fistula in ano when fistula is below sphincter and uncomplicated?

Answer 487

Fistulotomy

Question 488

What can be used to assess extent of sphincter involvement in fistula in ano?

Answer 488

MRI or endoanal USS

Question 489

Treatment of fistula in in ano in patients with Crohn’s?

Answer 489

LT seton left in situ and medical management as attempts at complex surgical repair nearly always fail

Question 490

Treatment of uncomplicated fistula in ano involving the sphincters?

Answer 490

Draining seton suture

Question 491

Management of fistulas in patients without IBD in whom seton has failed?

Answer 491

Advancement flaps

Newer technique of ligation of intersphincteric tract is reported to have good results in selected centres

Question 492

LIFT technique

Answer 492

LIFT technique is the novel modified approach through the intersphincteric plane for the treatment of fistula-in-ano, known as LIFT (ligation of intersphincteric fistula tract) procedure. LIFT procedure is based on secure closure of the internal opening and removal of infected cryptoglandular tissue through the intersphincteric approach. Essential steps of the procedure include, incision at the intersphincteric groove, identification of the intersphincteric tract, ligation of intersphincteric tract close to the internal opening and removal of intersphincteric tract, scraping out all granulation tissue in the rest of the fistulous tract, and suturing of the defect at the external sphincter muscle.

Question 493

A 21 year old man is involved in a road traffic accident. After a transient period of concussion he is found to have a GCS of 15 by the paramedics. On arrival at hospital he is monitored in a side room of the emergency department. When he is next observed he is noted to have a GCS of 3 and a blown right pupil. Which of the processes below best accounts for this deterioration?

Hydrocephalus

Intraventricular bleed

Sub dural bleed

Trans tentorial herniation

Sub arachnoid haemorrhage

Answer 493

The presence of a blown right pupil is a sign of a third cranial nerve compression. The most likely cause is an extradural bleed. However, since this option is not listed the process of trans tentorial herniation would be the most applicable answer. Intraventricular bleeds are typically more common in premature neonates, deterioration due to hydrocephalus is more chronic.

Question 494

A 28 year old man requires a urethral catheter to be inserted prior to undergoing a splenectomy. Where is the first site of resistance to be encountered on inserting the catheter?

Bulbar urethra

Membranous urethra

Internal sphincter

Prostatic urethra

Bladder neck

Answer 494

The membranous urethra is the least distensible portion of the urethra. This is due to the fact that it is surrounded by the external sphincter.

Question 495

Describe the female urethra

Answer 495

Shorter and more acutely angulated than the male.

Extra-peritoneal and embedded in the endopelvic fascia.

Neck of the bladder is subject to transmitted IAP and therefore deficiency in this area may result in stress urinary incontinence.

Between the layers of the urogenital diaphragm the female urethra is surrounded by the external urethral sphincter.

It ultimately lies anterior to the vagina orifice

Question 496

Innervation of the female external urethral sphincter?

Answer 496

Pudendal nerve

Question 497

Innervation of pre-prostatic urethra and its signficance?

Answer 497

Sympathetic noradrenergic fibres.

Composed of striated muscle bundles that contract and prevent retrograde ejaculation

Question 498

What is the narrowest part of the urethra?

Answer 498

Membranous urethra as it is surrounded by the external sphincter

Question 499

What is the infrabulbar fossa?

Answer 499

Dilatation of the penile urethra at its origin.

Question 500

Urothelium cellular type?

Answer 500

Transitional nearer to the bladder.

Becomes squamous more distally

Question 501

What is the most common abdominal emergency in children under 1 year of age?

Appendicitis

Intussusception

Intestinal malrotation

Pyloric stenosis

Mid gut volvulus

Answer 501

Intussuception

The commonest emergency in this age group is inguinal hernia followed by intussusception. Appendicitis is commoner in those older than 1 year of age.

Question 502

A 28 year old man has a carcinoid tumour identified in his appendix. Blood testing for which of the substances listed below is likely to be helpful during follow up?

CA19-9

Alkaline phosphatase

AFP

CEA

Chromogranin A

Answer 502

It is important to distinguish between blood and urine tests for carcinoid syndrome. Blood tests usually measure chromogranin A,neuron-specific enolase (NSE), substance P, and gastrin. Urine tests usually measure 5 HIAA, which is a metabolite of serotonin. Sometimes blood tests for 5 hydroxytryptamine (serotonin) are also performed.

Question 503

Clinical features of carcinoid syndrome

Answer 503

Onset: insidious

Flushing face

Palpitations

Pulmonary valve stenosis and TR causing dyspnoea

Asthma

Severe diarrhoea (secretory and persists despite fasting)

Question 504

Investigations in carcinoid syndrome?

Answer 504

5-HIAA in 24 hour urine

Somatostatin receptor scintigraphy

CT scan

Blood testing for chromogranin A

Question 505

A 40 year old man presents with obstructive jaundice and dysphagia. Twenty years previously he underwent a right hemicolectomy for a mucinous right sided colonic carcinoma. He was subsequently diagnosed as having Lynch syndrome. A recent colonoscopy was normal. What is the most likely cause of his jaundice?

Hepatocellular carcinoma

Liver metastasis from colonic cancer

Pancreatic carcinoma

Duodenal carcinoma

Gastric carcinoma

Answer 505

Lynch syndrome usually results in colonic cancer which is right sided and mucinous. The next most common site to be affected is the uterus. The stomach is at particular risk and this risk is up to 10 times greater in HNPCC (Lynch) patients than the general population. Duodenal adenomas (and rarely carcinoma) are usually seen in association with FAP. Whilst pancreatic carcinoma is associated with HNPCC it is far less likely to occur than gastric cancer.

Question 506

Genetics of CRC

Answer 506

Lifetime risk of 5%

Up to 5% of newly diagnosed bowel cancers will be in those individuals with genetic component.

Cancers arising in the low-moderate genetic risk group are ~30% of newly diagnosed bowel cancer

Question 507

More than 100 adenomatous polyps affecting the colon and rectum. Duodenal and fundic glandular polyps

Answer 507

FAP

Question 508

Gene in FAP

Answer 508

APC

Question 509

As FAP but with desmoid tumours and mandibular osteomas

Answer 509

Gardner syndrome

Question 510

Autosomal dominant condition, affects 1 in 12,000. Accounts for 0.5% of all CRCs. Lifetime incidence of colorectal cancer in untreated FAP =100%. Up to 25% cases are caused by de-novo germ line mutations and show no prior family history. The APC tumour suppressor gene is affected in most cases.

Answer 510

FAP

Question 511

Inheritance of FAP?

Answer 511

AD

Question 512

Polyposis and colonic tumours and CNS tumours

Answer 512

Turcots syndrome

Question 513

Colorectal cancer without extensive polyposis. Endometrial cancer, renal and CNS

Answer 513

HNPCC

Question 514

Hamartomatous polyps in GI tract and increased risk of GI malignancy

Answer 514

Peutz-Jeghers syndrome

Question 515

Cowden disease

Answer 515

Multiple hamartomas

Question 516

Autosomal recessive, multiple adenomatous polyps in GI tract, those in colon having somatic KRAS mutations

Answer 516

MYH associated polyposis

Question 517

Genes implicated in Turcots?

Answer 517

APC +MLH1 and PMS2

Question 518

Genes implicated in HNPCC?

Answer 518

MSH2, MLH1, PMS2 and GTBP

Question 519

Genes implicated in Peutz-Jeghers?

Answer 519

LKB1 and STK11 (in up to 70%)

Question 520

Genes implicated in Cowden disease?

Answer 520

PTEN (85%)

Question 521

APC in non inherited colorectal cancer

Answer 521

Up to 80% of sporadic colorectal cancers will have somatic mutations that inactivate APC[1]. Both alleles are usually affected. Although the APC protein more than likely has multiple critical cellular functions, the best-established role for APC in the cancer process is as a major binding partner and regulator of the β- catenin protein in the so-called canonical or β- catenin dependent Wnt signaling pathway.

Question 522

How do HNPCC cancers differ from conventional tumours?

Answer 522

In the colon, tumours are more likely to be right sided.

More likely to be mucinous and have dense lymhpocytic infiltrates

Question 523

Genetic pathophysiology of HNPCC?

Answer 523

Stem primarily from microsatellite instaiblity affecting DNA MMR genes.

In HNPCC the mismatch repair genes most commonly implicated include; MSH2 and MLH1 and these occur in up to 70% of people with HNPCC

Question 524

Microsatellite instability in sporadic CRCs?

Answer 524

Unusual

Question 525

What can be used to diagnose HNPCC?

Answer 525

Amsterdam criteria:

HNPCC tumours in at least 3 individuals (one of whom must be first degree relative to the other two)

In two successive generations.

At least 1 cancer < 50y/o

FAP excluded

Question 526

What proportion of inividuals fulfilling Amsterdam criteria will not be found to have MMR defects?

Answer 526

60%

Question 527

Impact of Amsterdam criteria fulfillment on cancer risk?

Answer 527

The risk of developing colorectal cancer in those who have not demonstrated mutation of the mismatch repair genes is increased if they fulfill the Amsterdam criteria, but not to the extent that it is increased in those who fulfill the criteria AND have evidence of mismatch repair gene defects.

Question 528

Also known as multiple hamartoma syndrome. Rare autosomal dominant condition with incidence of 1 in 200,000.. It is characterised by multiple mucocutaneous lesions, trichilemmomas, oral papillomas and acral keratosis. Most often diagnosed in third decade of life. Breast carcinoma may occur in up to 50% of patients and conditions such as fibrocystic disease of the breast may occur in 75% of women. Thyroid disease occurs in 75% and may include malignancy. Endoscopic screening will identify disease in up to 85% although the small bowel is rarely involved. There is a 15-20% risk of developing colorectal cancer and regular colonoscopic screening from age 45 is recommended.

Answer 528

Cowden syndrome

Question 529

KRAS Mutations

Answer 529

The RAS family of small G proteins act as molecular switches downstream of growth factor receptors. KRAS and the other two members of the family; HRAS and NRAS, are the site of mutation in approximately 40% of colorectal cancers. When adenomas are examined the proportion of adenomas less than 1cm showing KRAS mutations was only 10% which contrasts with 50% in those lesions greater than 1cm.

Question 530

p53 mutations

Answer 530

The p53 protein functions as a key transcriptional regulator of genes that encode proteins with functions in cell-cycle checkpoints at the G1/S and G2/M boundaries, in promoting apoptosis, and in restricting angiogenesis . As such, selection for p53 defects at the adenoma-carcinoma transition may reflect the fact that stresses on tumor cells activate cell-cycle arrest, apoptotic, and antiangiogenic pathways in cells with wild-type p53 function. Many colonic tumours will demonstrate changes in the p53 gene that may facilitate tumour progression through from adenoma to carcinoma.

Question 531

Why do cardiac transplant patients have higher resting heartrates?

Answer 531

Spontaneous depolarisationof the SAN is 100bpm.

There is no vagal stimulation

Question 532

What is a typical end diastolic volume?

Answer 532

130-160mL

Question 533

Average stroke volume?

Answer 533

70mL

Question 534

What is the incisura

Answer 534

In early diastole all valves are closed. Isovolumetric ventricular relxation occurs. Pressure wave associated with closure of aortic valve increases aortic pressure. The pressure dip before this rise can be seen on arterial waveforms= incisura.

Question 535

What is significant about negative atrial pressures?

Answer 535

Clinical importance as they can allow air embolisation to occur if neck veins are exposed to air.

Patient positioning is important in head and neck surgery to avoid this occurrence if veins are inadvertently cut or during CVP insertion.

Question 536

What is the Bainbridge reflex?

Answer 536

Atrial stretch receptors.

Very rapid infusion of blood will cause an increase in heart rate mediated by these receptors.

(normally increased blood volume causes increased PNS activity).

Question 537

Consequences of atrial stretch?

Answer 537

Increased BV-> increased parasympathetic activity.

Decreases in receptor stimulation results in increased sympathetic activity-> reduced RBF, decreases GFR, decreases urinary sodium excretion. Renin secreted by JGA-> increased AngII

Increased atrial stretch will also stimulate the release of ANP

Question 538

At the level of the wrist joint, which of the statements below best describes the relationship of the ulnar artery to the ulnar nerve?

It lies on its radial side

It lies deep to it

It lies superficial to it

It lies on its ulnar side

None of the above

Answer 538

It lies on its radial side

In the middle of the forearm, the artery is overlapped by the flexor carpi ulnaris and on the flexor retinaculum it is covered by a superficial layer from that structure. In its distal two-thirds, flexor digitorum superficialis lies on its radial side, and the ulnar nerve is situated on its ulnar side.

Question 539

Where does the ulnar artery start?

Answer 539

Middle of the ACF

Question 540

Passage of the ulnar artery in the forearm?

Answer 540

Passes obliquely downward, reaching the ulnar side of the forearm at a point midway between the elbow and wrist.

Follows the ulnar border to the wrist, crossing over the flexor retinatculum

It than divides into the superficial and deep volar arches

Question 541

Branch of ulnar artery?

Answer 541

Anterior interosseous artery

Question 542

What structures is the ulnar artery deep to?

Answer 542

Pronator teres

Flexor carpi radialis

Palmaris longus

Question 543

Relationship between the ulnar artery and the flexor retinaculum

Answer 543

Superificial to the flexor retinaculum at the wrist

Question 544

What does the ulnar artery lie on?

Answer 544

Brachialis and FDP

Question 545

Relationship between the ulnar artery and the median nerve

Answer 545

Related to the median side of the artery for about 2.5cm. Crosses the vessel, separated from it by the ulnar head of pronator teres

Question 546

Relationship between the ulnar nerve and artery

Answer 546

Ulnar nerve lies medially to the lower two-thirds of the artery

Question 547

Which of the following anatomical structures lies within the spiral groove of the humerus?

Median nerve

Radial nerve

Tendon of triceps

Musculocutaneous nerve

Axillary nerve

Answer 547

The radial nerve lies in this groove and may be compromised by fractures involving the shaft.

Question 548

A 24 year old man falls and sustains a fracture through his scaphoid bone. From which of the following areas does the scaphoid derive the majority of its blood supply?

From its proximal medial border

From its proximal lateral border

From its proximal posterior surface

From the proximal end

From the distal end

Answer 548

The blood supply to the scaphoid enters from a small non articular surface near its distal end. Transverse fractures through the scaphoid therefore carry a risk of non union.

Question 549

A 21 year old man has an inguinal hernia and is undergoing a surgical repair. As the surgeons approach the inguinal canal they expose the superficial inguinal ring. Which of the following forms the lateral edge of this structure?

Inferior epigastric artery

Conjoint tendon

Rectus abdominis muscle

External oblique aponeurosis

Transversalis fascia

Answer 549

The external oblique aponeurosis forms the anterior wall of the inguinal canal and also the lateral edge of the superficial inguinal ring. The rectus abdominis lies posteromedially and the transversalis posterior to this.

Question 550

A 27 year old man is involved in a road traffic accident. He is seen in the emergency department with chest pain. Clinical examination is essentially unremarkable and he is discharged. He subsequently is found dead at home. What is the most likely underlying injury?

Tracheobronchial tree injury

Traumatic aortic disruption

Cardiac laceration

Diaphragmatic rupture

Rupture of the oesophagus

Answer 550

Aortic injuries that do not die at the scene may have a contained haematoma. Clinical signs are subtle and the diagnosis may not be apparent on clinical examination. Without prompt treatment the haematoma usually bursts and the patient dies.

Question 551

Mechanism of thoracic aorta rupture

Answer 551

Decelerating force i.e. RTA, fall from a great height

Most people die at the scene

Survivors have an incomplete laceration at the ligamentum arteriosum of the aorta

Question 552

Clinical features of thoracic aorta rupture

Answer 552

Contained haematoma

Detected mainly by history and CXR changes

Question 553

CXR changes in thoracic aorta rupture

Answer 553

Widened mediastinum

Trachea/oesophagus to the right

Depression of left main stem bronchus

Widened paratracheal stripe/paraspinal interfaces

Space between aorta and pulmonary artery obliterated

Rib#/ left haemothorax

Question 554

Diagnosis of thoracic aorta rupture

Answer 554

Angiography, usually CT aortogram

Question 555

Answer 555

Supine trauma chest radiograph showing widened mediastinum with deviation of the trachea to the right, depression of the left main bronchus, left apical pleural capping and increased density of the left hemithorax consistent with haemothorax. Combination of findings is highly suspicious for traumatic aortic rupture.

Question 556

Treatment of thoracic aorta rupture

Answer 556

Repair or replacement, ideally endovascular repair

Question 557

A 45 year old lady presented with a 2cm mobile breast mass. A mammogram is indeterminate (M3), USS is normal (U2), clinical examination is also indeterminate (P3). What is the next most appropriate course of action?

Re-assure and discharge

Fine needle aspiration cytology

Excision biopsy

Image guided core biopsy

Wide local excision

Answer 557

All discrete breast lumps, including those that seem benign, should have a confirmed histological diagnosis. In this case, a core biopsy has not yet been performed. This may yield a diagnosis that is concordant with imaging findings. In which case, this concludes the investigative process (if benign). If it remains unclear, excision biopsy will be needed.

Question 558

Develop from a whole lobule

Mobile, firm breast lumps

12% of all breast masses

Over a 2 year period up to 30% will get smaller

No increase in risk of malignancy

Answer 558

Fibroadenoma

Question 559

Usually presents as a smooth discrete lump (may be fluctuant)

Small increased risk of breast cancer (especially if younger)

Answer 559

Breast cyst

Question 560

Usually presents as a breast lump or breast pain

Causes mammographic changes which may mimic carcinoma

Cause distortion of the distal lobular unit, without hyperplasia (complex lesions will show hyperplasia)

Considered a disorder of involution, no increase in malignancy risk

Answer 560

Sclerosing adenosis, (radial scars and complex sclerosing lesions)

Question 561

Variable clinical presentation ranging from generalised lumpiness through to discrete lump

Disorder consists of increased cellularity of terminal lobular unit, atypical features may be present

Atypical features and family history of breast cancer confers greatly increased risk of malignancy

Answer 561

Epithelial hyperplasia

Question 562

Up to 40% cases usually have a traumatic aetiology

Physical features usually mimic carcinoma

Mass may increase in size initially

Answer 562

Fat necrosis

Question 563

Usually present with nipple discharge

Large papillomas may present with a mass

The discharge usually originates from a single duct

No increase risk of malignancy

Answer 563

Duct papilloma

Question 564

Treatment of fibroadenoma

Answer 564

If >3cm surgical excision is usual, Phyllodes tumours should be widely excised (mastectomy if the lesion is large)

Question 565

Treatment of breast cyst

Answer 565

Cysts should be aspirated, those which are blood stained or persistently refill should be biopsied or excised

Question 566

Treatment of Sclerosing adenosis, (radial scars and complex sclerosing lesions)

Answer 566

Lesions should be biopsied, excision is not mandatory

Question 567

Treatment of breast epithelial hyperplasia

Answer 567

If no atypical features then conservative, those with atypical features require either close monitoring or surgical resection

Question 568

Treatment of Fat necrosis

Answer 568

Imaging and core biopsy

Question 569

Treatment of duct papilloma

Answer 569

Michododcetomy

Question 570

Which of the following cranial venous sinuses is unpaired?

Transverse sinus

Superior sagittal sinus

Cavernous sinus

Sigmoid sinus

Inferior petrosal sinus

Answer 570

The superior sagittal sinus is unpaired. It begins at the crista galli, where it may communicate with the veins of the frontal sinus and sometimes with those of the nasal cavity. It arches backwards in the falx cerebri to terminate at the internal occipital protuberance (usually into the right transverse sinus). The parietal emissary veins link the superior sagittal sinus with the veins on the exterior of the cranium.

Question 571

Why do the cranial venous sinsuses have a strong potential for spreading sepsis?

Answer 571

They have no valves

Question 572

Theme: Management of colonic polypoidal lesions

A.Reassure and discharge

B.Pan proctocolectomy

C.Hot biopsy

D.Snare polypectomy

E.Segmental colonic resection

F.Repeat endoscopy at 3 years

G.Repeat endoscopy at 1 year

H.Repeat endoscopy at 5 years

Please select the most appropriate management for the scenario given. Each option may be used once, more than once or not at all.

A 43 year old man is investigated for altered bowel habit. At colonoscopy he is found to have a 2cm polyp on a long stalk in the proximal sigmoid colon. The rest of the colonoscopy is normal. It bears no macroscopic features of malignancy.

A 60 year old lady is investigated for abdominal pain. A polyp is identified at the proximal descending colon, three small polyps are also noted in the sigmoid colon. The largest lesion is removed by snare polypectomy and the pathology report states that this polyp is a low grade dysplastic adenoma measuring 3cm in diameter. The remaining lesions are ablated using diathermy.

A 73 year old lady is investigated for anaemia. At colonoscopy she is found to have a flat broad based lesion in the caecum. This is biopsied and the histology report states that these have diagnostic features of an adenoma with high grade dysplasia.

Answer 572

Snare polypectomy

Polyps on long stalks are best managed by snare excision. It is important to retrieve the polyp for histology.

Repeat endoscopy at 1 year

She is at high risk of malignancy and should be closely followed up. Fulguration of polyps without histology is unhelpful.

Segmental colonic resection

Management of right sided colonic polyps such as this is controversial. There is a high liklihood that this lesion will harbor an focus on invasive malignancy (which should generally be managed with resection). This is further suggested by the background history of anaemia. It is for this reason that resection over right sided colonic endoscopic mucosal resection is chosen.

Polypectomy of flat broad lesions in the right colon is difficult and where concern arises a right hemicolectomy is probably the safest option.

Question 573

What is the association in adenomas and risk of malignancy for colonic polyps

Answer 573

Increased since= increased risk. ~10% risk in a 1cm adenoma.

Question 574

Features of low risk colonic polyps

Answer 574

1 or 2 adenomas less than 1cm

Question 575

F/U of low risk colonic polyps

Answer 575

No F/U or repeat colonoscopy at 5 years

Question 576

Features of moderate risk colonic polyps?

Answer 576

3 or 4 small adenomas or 1 adenoma greater than 1cm

Question 577

F/U for moderate risk colonic polyps

Answer 577

Re-scope at 3 years

Question 578

Features of high risk colonic poylps

Answer 578

More than 5 small adenomas or more than 3 with 1 of them >1cm

Question 579

Action in high risk colonic polyps

Answer 579

Re scope at 1 year

Question 580

When should segmental resection or complete colectomy be considered in the context of colonic polyps?

Answer 580

1. Incomplete excision of malignant polyp
2. Malignant sessile polyp
3. Malignant pedunculated polyp with submucosal invasion
4. Polyps with poorly differentiated carcinoma
5. Familial polyposis coli
   - Screening from teenager up to 40 years by 2 yearly sigmoidoscopy/colonoscopy
   - Panproctocolectomy and Ileostomy or Restorative Panproctocolectomy.

Rectal polypoidal lesions may be amenable to trans anal endoscopic microsurgery.

Question 581

Which of the following laryngeal tumours will not typically metastasise to the cervical lymph nodes?

Glottic

Supraglottic

Subglottic

Transglottic

Aryepiglottic fold

Answer 581

Glottic

The vocal cords have no lymphatic drainage and therefore this region serves as a lymphatic watershed. The supraglottic part drains to the upper deep cervical nodes through vessels piercing the thyrohyoid membrane. The sub glottic part drains to the pre laryngeal, pre tracheal and inferior deep cervical nodes. The aryepiglottic and vestibular folds have a rich lymphatic drainage and will metastasise early.

Question 582

What are the paired laryngeal cartilaginous segments?

Answer 582

Arytenoid

Corniculate

Cuneiform

Question 583

What are the unpaired cartilaginous segments of the larynx?

Answer 583

Thyroid

Cricoid

Epiglottic

Question 584

Location of the larynx?

Answer 584

Anterior part of the neck at the levels of C3-C6

Question 585

Extent of the laryngeal cavity?

Answer 585

Extends from the laryngeal inlet to the level of the inferior border of the cricoid cartilage

Question 586

What are the divisions of the laryngeal cavity?

Answer 586

Laryngeal vestibule

Laryngeal ventricle

Infraglottic cavity

Question 587

Extent of the laryngeal vestibule

Answer 587

Superior to the vestibular folds

Question 588

Extent of the laryngeal ventricle

Answer 588

Between vestibular folds and superior to the vocal cords

Question 589

Extent of the infraglottic cavity?

Answer 589

Extends from vocal cords to the inferior border of the cricoid cartilage

Question 590

What is the function and composition of the vocal cords?

Answer 590

Control sound production.

The apex of each fold projects medially into the laryngeal cavity. Each vocal fold includes

vocal ligament

vocalis muscle (most medial part of the thyroarytenoid muscle)

Question 591

Composition of the glottis?

Answer 591

Vocal folds, processes and rima glottidis.

Question 592

What is the rima glottidis?

Answer 592

The narrowest potential site within the larynx, as the vocal cords may be completely opposed, forming a complete barrier

Question 593

What are the muscles of the larynx?

Answer 593

Posterior cricoarytenoid

Lateral cricoarytenoid

Thyroarytenoid

Transverse and oblique arytenoids

Vocalis

Cricothyroid

Question 594

Innervation of the muscles of the larynx

Answer 594

All recurrent laryngeal nerve except cricothyroid (external laryngeal)

Question 595

What is the only muscle of the larynx not innervated by the recurrent laryngeal nerve?

Answer 595

Cricothyroid (external laryngeal)

Question 596

Origin of the posterior cricoarytenoid

Answer 596

Posterior aspect of lamina of cricoid

Question 597

Insertion of posterior cricoarytenoid

Answer 597

Muscular process of arytenoid

Question 598

Action of posterior cricoarytenoid

Answer 598

Abducts vocal fold

Question 599

Origin of lateral cricoarytenoid

Answer 599

Arch of cricoid

Question 600

Insertion of lateral cricoarytenoid

Answer 600

Muscular process of arytenoid

Question 601

Action of lateral cricoarytenoid

Answer 601

Adducts vocal fold

Question 602

Origin of thyroarytenoid

Answer 602

Posterior aspect of thyroid cartilage

Question 603

Insertion of thyroarytenoid

Answer 603

Muscular process of arytenoid

Question 604

Action of thyroarytenoid

Answer 604

Relaxes vocal fold

Question 605

Origin of the transverse and oblique arytenoids

Answer 605

Arytenoid cartilage

Question 606

Insertion of the transverse and oblique arytenoids

Answer 606

Contralateral arytenoid

Question 607

Action of the transverse and oblique arytenoids

Answer 607

Closure of the intercartilagenous part of the rima glottidis

Question 608

Origin of vocalis

Answer 608

Depression between lamina of thyroid cartilage

Question 609

Insertion of vocalis

Answer 609

Vocal ligament and vocal process of arytenoid cartilage

Question 610

Action of vocalis

Answer 610

Relaxes posterior vocal ligament, tenses anterior part

Question 611

Origin of cricothyroid

Answer 611

Anterolateral part of cricoid

Question 612

Insertion of cricothyroid

Answer 612

Inferior margin and horn of thyroid cartilage

Question 613

Action of cricothyroid

Answer 613

Tenses vocal fold

Question 614

Arterial supply of the larynx

Answer 614

Laryngeal arteries, branches of the superior and inferior thyroid arteries

Question 615

Relation of the superior laryngeal artery?

Answer 615

Internal laryngeal nerve

Question 616

Relation of the inferior laryngeal artery?

Answer 616

Related to the inferior laryngeal nerve.

Question 617

Venous drainage of the larynx?

Answer 617

Via superior and inferior laryngeal veins.

Question 618

Superior laryngeal vein drains to?

Answer 618

Superior thyroid vein

Question 619

Inferior thyroid vein drains into

Answer 619

Either middle thyroid vein or thyroid venous plexus

Question 620

Lympathic drainage of the vocal cords?

Answer 620

No lymphatic drainage- this site acts as a watershed

Question 621

Supraglottic lymphatic drainage?

Answer 621

Upper deep cervical nodes

Question 622

Subglottic lymphatic drainage

Answer 622

Prelarygneal and pretracheal nodes and inferior deep cervical nodes

Question 623

What is an issue with malignancies at the aryepiglottic fold and the vestibular folds?

Answer 623

Have a dense plexus of associated lymphatics-> greater propensity for nodal metastasis