Block 32 Week 5 Flashcards
1
Q
gastric cancer incidence?
A
- more common in men
- highest indicence in far east
- > 90% are adenocarcinomas
2
Q
RF for gastric cancer?
A
- H. Pylori infection (secondary to inducing atrophic gastritis)
- Excessive intake of salted food
- Smoking
- Pernicious anaemia
- Menetrier’s disease
- Gastric polyps
3
Q
gastric cancer symptoms?
A
- Usually presents late with symptoms of dyspepsia
- Weight loss, anorexia, nausea
- Upper GI bleed/anaemia
- Maybe outflow obstruction if tumour near pylorus
4
Q
gastric cancer - palpable?
A
- Palpable epigastric mass
- Virchow’s node – palpable lymph node in supraclavicular fossa
5
Q
Blood tests for gastric cancer?
A
- FBC - iron def anemia
- LFT - evidence of mets
6
Q
CT for gastric cancer?
A
- staging
- mets
7
Q
Endoscopy for gastric cancer?
A
- Visualisation for histology
8
Q
BARRETS?
A
- Prescence of columnar epithelium in LO
- Results from long-standing acid reflux with metaplasia from squamous to columnar epithelium in the lower oesophagus
- Its a premalignant condition for oesophageal adenocarcinoma – 30 fold increase in risk
9
Q
Decision to treat?
A
- the date a patient agrees a treatment plan, may not be the day consent is signed
- Can change if the treatment plan changes and the patient needs to agree the change
10
Q
symptoms of GOJ cancer?
A
- Atypical upper abdominal pain.
- Dyspepsia
- Nausea and vomiting.
- Anorexia.
- Early satiety.
11
Q
dysphagia in GOJ cancer?
A
- Progressive dysphagia initially solids (bread)
- The dysphagia may be accompanied by a steady, boring pain, which often signals mediastinal involvement & inoperability.
- Obstruction (occurs when cancer is far advance)
12
Q
Signs of GOJ cancer?
A
- Anaemia.
- Weight loss
- Palpable mass (liver metastases)
- Virchow’s node
- Ascites
13
Q
History for GOJ cancer?
A
- B’s O
- years of dysphagia
- h pylori
- prev gastric surgery
- known perinicious anemia
14
Q
CRC tumour markers?
A
CEA
15
Q
Prostate cancer tumour marker?
A
PSA
16
Q
CA125 tumour marker?
A
ovarian
17
Q
pancreatic cancer tumour marker?
A
CA19.9
18
Q
hepatocellular cancer tumour marker?
A
AFP -germ cell, ovary/ testis
19
Q
Which sites are more commonly affected by CRC?
A
caecum and ascending colon most affected
20
Q
LNs CRC spreads to?
A
- spreads to local paracolic, para-aortic lymph nodes
21
Q
gastric cancer risk factors?
A
- H. Pylori increases HR to 4.5.
- Smoked foods.
- Tobacco, alcohol.
- Pernicious anaemia, achlorhidria.
- Blood group A.
22
Q
gender and age inc risk for gastric cancer?
A
- Male sex.
- Age 50- 70 yrs.
23
Q
pres of gastric cancer - other?
A
- Anorexia.
- Early satiety.
- Nausea and vomiting.
24
Q
diagnosis of gastric cancer?
A
- virchows node
- FBC: anaemia, plasma proteins: malnutrition.
- Endoscopy biopsy, CT scan chest and abdomen.
25
hernias are generally caused by?
increased intra-abd pressure, weak or damaged tissues or comb of both
26
causes of increased abd pressure - cough?
* Chronic cough: COPD, long-term smoking, bronchiectasis, cystic fibrosis
27
causes of inc abd pressure - abd distension?
pregnancy, ascites, peritoneal dialysis, obesity (ventral hernias)
28
causes of inc abd pressure - straining?
chronic constipation, prostatism, heavy lifting during work or exercise
* Kyphoscoliosis
29
weakened tissues leading to hernias?
* Congenital defects: patent processus vaginalis, patent umbilical ring
* Collagen disorders: Ehlers-Danlos syndrome, vitamin C deficiency, family history of hernias
* Trauma: including surgery
* Ageing
* Chronic malnutrition
* Long-term corticosteroid use
30
most common type of hernias?
inguinal hernias
31
inguinal hernia?
* abnormal protrusion of abdominopelvic contents through the superficial inguinal ring into the groin.
32
Inguinal canal contents?
* in men, the inguinal canal contains the spermatic cord to the testis and the round ligament in women
* carries the illioinguinal nerve and genital branch of the genitofemoral nerve in both
33
direct inguinal hernia?
* caused by a weakness in the posterior wall of the inguinal canal - Hesselbach's triangle
* abd contents (usually just fatty tissue, sometimes bowel) are forced directly through this defect into the inguinal canal
34
direct hernia enters through the
deep ring and exits via superficial
35
indirect inguinal hernia?
* Instead of piercing the posterior wall, the abdominal contents enter medial to the deep ring, pass along the length of the inguinal canal and exit via the superficial ring,
36
indirect inguinal hernia?
* Instead of piercing the posterior wall, the abdominal contents enter medial to the deep ring, pass along the length of the inguinal canal and exit via the superficial ring,
37
indirect vs direct inguinal hernias?
* if you place your finger over the deep inguinal ring (just above the mid-point of the inguinal ligament), then you can control an indirect inguinal hernia which has been reduced.
* If when you press the deep ring, the hernia still protrudes, then the hernia is emerging via a defect in the posterior wall medial to this point and is, therefore, a direct hernia.
38
IH RFs?
* IH are more common in men
* incidence peaks at 70
* low BMI RF for inguinal hernias
39
CFs of an inguinal hernia?
* Patients often present with a lump in the groin that comes and goes and has slowly increased in size over time.
* the lump may have popped out suddenly, for example after heavy lifting.
40
symptoms of an inguinal hernia?
* symptomatic hernias present w groin pain or discomfort, espec after coughing, bending over or standing for long periods
* pain/ altered sensation over scrotum or inner thigh due to compression of illioinguinal nerve
* changes in bowel habit or US depending on hernia contents
41
inguinal hernias are often?
asymptomatic other than the lump
42
diagnosis of an inguinal hernia?
* palpable swelling located above and medial to pubic tubercle
* Larger hernias may extend down into the scrotum.
43
diagnostic uncertainty w hernias?
* Where there is diagnostic uncertainty, an ultrasound scan of the groin can help differentiate between other possible causes such as enlarged lymph nodes, fatty lumps, or vascular pathology.
44
femoral hernias?
* less common type of hernia
* freq present w bowel obstruction
45
what is a femoral hernia?
* abnormal protrusion of abdominopelvic contents through the femoral canal into the medial upper thigh.
* the femoral canal is a narrow space bordered by the lacunar ligament so they are at a high risk of obstruction or strangulation
46
who are femoral hernias more common in?
* more common in women
* incidence inc w age - higher risk over 50
* low BMI - less fat in femoral canal
47
protective factors with femoral hernias?
laparoscopic inguinal hernia repair
48
Cfs of a femoral hernia?
- lump in groin
* sig prop present as an emergency w symptoms of bowel obstruction or strangulation
* bowel can perforate
49
inguinal vs femoral hernias?
* inguinal hernias are situated above and medial to the pubic tubercle
* femoral hernias are located below and lateral to the pubic tubercle
* Femoral hernias are usually quite small and are not always easily palpable, especially in overweight patients.
50
management of femoral hernias?
* high risk of complications so always need to be repaired
* laparscopic mesh repair the best method
51
obturator hernia?
* very rare
* An obturator hernia is an abnormal protrusion of abdominopelvic contents through the obturator foramen of the bony pelvis into the medial upper thigh.
52
RF for an obturator hernia?
* 'little old lady hernia'
* mostly affect elderly multiparous women
* more common in people who are v thin or have recently lost weight like femoral hernias
53
why does pregnancy increase risk of an obturator hernia?
* changes to pelvis and pelvic floor in pregnancy means herniation is easier
* sharp angles of female obturator foraman also mean structures herniate through it
54
how do obturator hernias present?
* more than 90% present as an emergency w an acute abdomen and features of bowel obstuction/ strangulation
* This usually occurs suddenly, but some patients may report self-limiting episodes of subacute obstruction at home previously.
55
episodes of obstruction with obturator hernias?
* These are characterised by attacks of colicky abdominal pain, bloating and nausea/vomiting which resolved within a few hours.
56
lump w obturator hernias?
* deep position means there's hardly ever a lump to feel
57
how can patients also present w obturator hernias?
* patients can also present w pain and altered sensation along the inner thigh due to compression of the obturator nerve by the hernia,
- which is relieved by flexing the hip and worsened by internally rotating it - howship romberg sign
58
howship romberg sign?
- pain that is relieved by flexing the hip and made worse by internally rotating it
- obturator hernia
59
test for undifferentiated acute abdomen?
* gold standard: CT abdo pelvis with portal venous contrast
60
management of obturator hernias?
* generally require emergency surgery
61
umbilical hernia?
* most common ventral hernia
* An umbilical hernia is an abnormal protrusion of intra-abdominal contents through a fascial defect in or around the umbilical ring.
62
RFs for umbilical hernias?
* women especially during or after pregnancy
* Down’s syndrome and Beckwith-Wiedemann syndrome have been associated with umbilical hernias in children.
* chronically raised intra-abd pressure due to obesity or ascites
63
20% of ? patients develop umbilical hernias?
- cirrhosis patients, secondary to ascites.
- Umbilical hernias can be lethal to these patients, as they often develop large hernias containing bowel and do not have the physiological reserve to survive an acute complication.
64
CFs of umbilical hernias?
* usually asymptomatic
* symptomatic patients usually have a lump in their belly button
* hernias containing bowel are at risk of obstruction or strangulation
65
umbilicus in umbilical hernias?
* palpable swelling in or around umbilicus
* The umbilicus itself may be everted or distorted by the hernia. It is important to note the condition of the overlying skin, which can become stretched and thin and may start to break down, posing a risk of infection.
66
management of umbilical hernias?
* low risk of complications and can safely be managed conservatively
* majority of symptomatic umbilical hernias should undergo open repair with a mesh to reduce the risk of recurrence.
67
complications of hernias?
obstruction and strangulation
68
obstruction from hernias signs?
* abd pain
* distension and vomiting may occur
* hernia will tense tender and irreducible
69
strangulation from hernias?
* become red and tender
* irreducible
* no impulse on cough
* if contains bowel -> signs of obstruction
70
causes of RIF pain?
- appendicitis
- meckles divertiuculm
- UTI
- PID
- Ectopic pregnancy
- mesenteric lymphadenitis
71
Appendicitis pain?
* acute appendicitis - pain origininally epigastric and then right lowe quadrant.
* accompanied by nausea, vomiting, loss of appetite and low grade fever
72
meckle's diverticulum?
* meckles's diverticulum - GI bleeding, intestinal obstruction (symptoms usually before age of 2)
73
PID?
* PID - bilateral lower abd and pelvic pain - dull
* fever, headache, lassitude
* abn vaginal discharge
* usually appear at the time and immediately after menstruation
74
mesenteric lympahdenitis?
75
peritonitis common causes?
* most commonly caused by perforation of an abd viscera e.g. colon, appendix, GB
76
primary peritonitis?
spontaneous bacterial invasion of the peritoneal cavity. Also known as spontaneous bacterial peritonitis. Seen in patients with pre-existing ascites (mainly chronic liver disease)
77
secondary peritonitis?
* Secondary: peritoneal infection due to loss of integrity of the gastrointestinal or urogenital tracts. This leads to contamination of the peritoneal space. This is the cause in perforation
78
tertiary peritonitis?
* Tertiary: recurrent or persistent infection of the peritoneal cavity that typically occurs after secondary peritonitis.
- Less well defined and usually seen in patients who are immunocompromised
79
localised peritonitis?
* Localised: this refers to a focus of infection that is usually walled-off or contained by adjacent organs
80
generalised peritonitis?
also known as diffuse, this refers to an infection that has spread throughout the entire cavity
81
what can lead to SP - oesophagus perf?
* Oesophagus: penetrating injury (trauma), rupture (Boerhaave syndrome), malignancy
82
what can lead to SP - stomach perf?
* Stomach: malignancy, peptic ulcers
83
Pancreas issue leading to secondary peritonitis?
pancreatitis
84
hepatobiliary issues leading to secondary peritonitis?
gallstones, cholecystitis, malignancy
85
small intestine issues leading to secondary peritonitis?
ischaemic bowel, strangulated hernias
86
large intestine issues leadong to secondary peritonitis?
diverticulitis, colorectal cancer
87
localised infection to generalized peritonitis?
A localised infection may develop because the infection becomes walled-off or is contained by the positioning of adjacent organs. In this situation, an abscess may develop in an attempt to control the spread of infection. If the infection spreads throughout the peritoneal cavity this leads to generalised peritonitis
88
cfs of peritonitis?
* cardinal feature: acute, severe abd pain
* Peritonitis should be suspected in any patient with sudden onset, severe abdominal pain.
89
accompanying features of peritonitis?
* Accompanying features are usually fever, nausea, vomiting, and systemic upset (e.g. tachycardia, hypotension). Patients may be extremely unwell with shock.
90
abd pain w peritonitis?
* Abdominal pain is often dull and poorly localised initially due to inflammation of the visceral peritoneum.
- As the parietal peritoneum becomes involved, pain becomes more severe, sharp, and localised
91
symptoms of peritonitis?
* Abdominal pain: may be localised or generalised
* Pain worse on movement: patients often described as wanting to stay rigid to prevent aggravating the inflammation
* Abdominal distension
92
signs of peritonitis?
- guarding
- tendernerness
- rigidity
93
guarding?
voluntary contraction of the abdominal muscles (to protect from the pain)
94
rigidity?
* Rigidity: involuntary muscle contraction due to underlying inflammation
* rebound tendernes
95
what else might you get with peritonitis?
* absent/ reduced bowel sounds
* inflammatory mass: may suggest abscess
- features of septic shock
96
features of septic shock?
- hypotension,
- oliguria/anuria,
- confusion,
- mottled skin
97
what must be excluded with peritonitis?
make sure you check the hernial orifices in a patient with suspected peritonitis to exclude a strangulated hernia.
98
perforated stomch causes
99
benign causes of bowel obstruction?
* volvulus
* stricture
* incarcerated hernia
* tuberculosis
* fecal impaction
100
malignant causes of bowel obstruction?
* CRC
* metastatic disease
101
causes of small bowel obstruction?
post op adhesions or hernia
102
causes of large bowel obstruction?
malignancy, diverticular disease, or volvulus
103
cardinal features of bowel obstruction?
- abd pain
- vomiting
- abd distension
- absolute constipation
104
abd pain in BO?
colicky or cramping in nature (secondary to the bowel peristalsis)
105
Vomiting in bowel obstruction?
occurring early in proximal obstruction and late in distal obstruction
106
absolute constipation in bowel obs?
* Absolute constipation – occurring early in distal obstruction and late in proximal obstruction
107
SBO features?
* early vomiting
* billous and watery, little to no odour
* pain is an early symptom, peri-umbilical
* abd distention may be absent
108
what is almost always present w SBO?
anorexia
109
LBO?
* small volumes, later vomiting
* foul odour vomiting
* localised, deep pain
* often described as crampy
* abd distention present
110
SBO vs LBO vomiting?
SBO: early vomiting, late vomiting in LBO
SBO: little odor, LBO - foul odour
111
complications of stomas?
* parastomal hernia - incisional hernia
* stoma bleeding
* skin irritation
* necrosis
112
where are colostomies found?
* hallmark: found in left iliac fossa
113
contents of colostomy bag?
* The contents of a colostomy bag should be solid or semisolid as the faeces have had time to travel through the colon, undergoing water absorption.
114
appearance of a colostomy?
* Colostomies are positioned flush to the skin (i.e. no spout) because the enzymes present in large bowel contents are less alkali and, therefore, less irritating to the skin.
115
ileostomy?
* uses small bowel
* typically located in RIF
116
contents of an ileostomy?
* Less water is absorbed in the small bowel, so the contents of the stoma bag tend to have a liquid or mushy consistency.
117
which type of stoma is spouted?
ileostomy to allow faces to drain w/o touching skin
118
Outline how clinicians should act with others to control food poisoning and infective diarrhoea?
* isolate the patient
* accurate fluid balanxe management
* onset of SIGHT acronym
119
tests for constipation?
* stool tests - calprotectin, FIT test
* bloods - to exclude secondary causes or red flag features e.g. anaemia
* thyroid function tests, HbA1c, renal profile
120
management of constipation?
* Lifestyle modifications - whole fruit, grains, vegges
* First-line laxatives (osmotic, bulk-forming, softeners)
121
second line laxatives for constipation?
* Second-line laxatives (stimulants, suppositories and/or enemas)
122
primary vs secondary causes of constipation?
123
RF for iBS?
* Female sex
* Younger age
* Stressful life events
* Anxiety and/or depression
* Gastrointestinal infection (post-infectious IBS)
* Somatic symptoms (e.g. joint pain, migraine)
* Endometriosis
* Family history of mental illness
124
abd pain of IBS?
* often lower abd
* typically cramping pain
* pain is frequently related to defecation. May improve or worsen
* food and stress may worsen symptoms
125
Other GI features of IBS?
* Bloating/Distention
* Belching
* Nausea
* Others: IBS may overlap with other functional GI disorders
126
Celiac disease?
* 2x as common in womem
* intolerance to prolamin proteins - wheat, barley and rye
127
genetics of celiac?
HLA-DQ2
128
what inc risk of celiac disease?
recurrent rotavirus infections
129
3 classifical features of coeliac disease?
* Villous atrophy (reduced absorptive surface).
* Crypt hyperplasia (increased cellular proliferation).
* Inflammatory infiltration (increased IEL, influx of immune cells into lamina propria)
130
CFs of celiac disease?
* Patients classically present with gastrointestinal manifestations of malabsorption including bloating, abdominal pain, loose stools and steatorrhoea.
131
symptoms of celiac disease?
* Weight loss
* Fatigue
* Weakness
* Abdominal pain
* Bloating
* Flatulence
* Loose stools
* Steatorrhoea
* Failure to thrive (babies and young children)
132
Signs of celiac disease?
* Mouth ulcers
* Angular stomatitis
* Abdominal distension
* Ecchymosis
* Muscle wasting
* Neuropathy
133
EIM of celiac disease?
* anaemia - mixed megaloblastic/ microcytic
* osteoporosis
* dermatitis herpetiformis
134
achalasia?
* Achalasia is a primary motility disorder of the oesophagus that is characterised by failure to relax of the lower oesophageal sphincter.
* cardinal symptom: dysphagia
135
how do motor disorders like achalasia typically present?
* Motility disorders, such as achalasia, typically present with dysphagia to both solids and liquids.
136
how do cancers causing dysphagia present?
A physical obstruction (e.g. cancer) typically occurs with solids first and progresses to liquids as the narrowing becomes tighter.
137
Symptoms of achalasia?
* Dysphagia: solids and liquids
* Regurgitation of undigested food
* Vomiting
* Difficulty belching (poor opening of upper oesophageal sphincter)
- aspiration and heartburn
138
aspiration w achalasia?
coughing and choking due to content passing into airways
139
heartburn w achalasia?
irritation of the oesophagus due to uncleared food rather than reflux events through the LOS
140
Gastric cancer RF
141
SBO?
* bilious vomiting of SBO (abd distented)
* adhesions mostly cause SBOs
142
Non bilous vomiting in obstructions proximal to?
ampulla of vater
143
faceulent vomiting in obstructions in?
distal small gut obst, LBO, strangulation
144
gallstone ileus?
* gallstone ileus -> stone causes perforation passing from GB into duodenum
* stops in the terminal ileum -> overflow and reflux -> pain and diarrhoea, scar tissue forms around the stone narrowing it
* can get perforations from it
145
Drug history in acute surgical abdomens?
* AC - can lead to an intramural haematoma of the gut causing obs
* espec elderly
146
Acute abdomen - oral contraceptives?
rupture of hepatic adenomas
147
acute abdomens - NSAIDS?
erosive gastritis and peptic ulcers
148
anxious patient lying motionless - think?
* acute appendicitis
* peritonitis
149
rolling in bed and restless ppt?
think colic
150
patient writhing in pain?
writhing in pain: mesenteric ischemia (older patient w vascular history, soft abdomen)
very severe pain - out of proportion to clinical findings
151
patient bending forwards =
chronic panc
152
guarding and rigidity?
* guarding = involuntary spasm of muscles during palpation
* rigidity = when abd muscles are tense and board like -> peritonitis
153
rosvings sign for appedicitis?
pain elicited in the right lower quadrant with palpation pressure in the left lower quadrant
154
test for appendicitis?
* test for appendictis - psoas test
* obturator sign
155
right renal angle pain, over 70 ->
consider AA
156
Murphys sign for cholecystsitis?
- asking the patient to take in and hold a deep breath while palpating the right subcostal area.
- If pain occurs when the inflamed gallbladder comes into contact with the examiner's hand, Murphy's sign is positive.
157
Large vs small bowel on scan?
* can see whole circ = SBO
* large bowel - can't see full circle, just lines and is on the outsides
158
pre-op assessments - history?
* 2-4 weeks prior (elective)
* history - surgeries, AC, allergies, identifying potential risks, FH - malignant hyperthermia
159
pre-op assessment Ix?
* bloods - FBC, platelets, WBC, U&Es - kidney function (opiods), LFT, clotting, group ans save +/- cross match
* imaging - ecg, CXR (not routine), echo - aortic stenosis - limits cardiac output
* other tests - swabs, spirometry, pregnancy test, urinanalysis, carotid doppler
160
pre-op prep - aspiration risk?
1) nil by mouth for 6 hours before - aspiration risk
161
preop prep - stop drugs?
- CHOW
- clopirodgrel stopped 7 days prior
- other platelets like aspirin can continue
- OC/ HRT/ 4 weeks prior
- warfarin 5 days prior (INR less than 1.5) may need vit k if emergency operation
162
pre-op prep - altering drugs
* subcutaneous insulin -> variable rate insulin infusion
* long term steroids -> switch to IV - consider inc dose
163
pre-op prep - start drugs?
* LMWH and or stockings
* antibiotics prophylaxis
* IV fluids
* bowel products and blood products if needed
164
informed consent?
1. Nature of procedure
2. risks of harm and benefits
3. reasonable altns including harms and benefits
4. assessment of ppt's understanding
5. must not be forced
* must be written consent for operation and minor procedures
165
blood transfusions?
* group and save
* valid for 3 months
* identifying blood gr and saving it on the system
* also identifies abn ab
166
cross match?
* lab provides blood products which have been checked to be compatible
* can't be done w/o group and save
* Crossmatching involves physically mixing of patient’s blood with the donor’s blood, in order to see if any immune reaction occurs
167
G&S and cross match samples?
* take a G&S sample then take a cross match sample 1 hr later
168
reactions from transfusions?
* pyrexia
* anaphylaxis
* blood reactions
* infective shock - bacteria from donor blood, can become septic and shock
169
acute haemolytic reaction from transfusions?
fever, rigors, hbureia, blood hasn't been properly crossmatched
170
delayed infection from transfusion?
* infection - non toxin producing bacteria
* usually a day later
171
G v H disease from transfusion?
* G v H disease - rash on hands and feet first sign
* generalised abd pain, enlarged liver, jaundice etc later
172
iron overload?
* iron overload - usually from regular/ multiple tranfusions
* gets deposited in liver -> liver failure and raised liver enzymes
173
what can be done to avoid G v H disease?
* irradiated blood to avoid G v H disease - destroys all DNA in lymphocytes, safe to transfuse to IC patients
* cancer patients, bone marrow malignancies, donated/ received bone marrow recently
174
Indications for transfusions?
* active bleeding
* <70 hb in stable
* <80 stable and ACS
* chronic transfusion dependent anemia
* radiotherapy - higher hb needed >100
175
PVD RF?
* older age - men more at risk
* AF is a risk factor
* fontaine's and rutherfords classifications
176
PVD - popliteal artery entrapment?
* popliteal artery entrapment - young patients who may have normal pulses
177
PVD - venous claudication?
* venous claudication - (may turner syndrome) bursting pain on walking w previous history of DVT - compression of ilac vein by iliac artery
178
PVD - burger's disease?
* burger's disease - young males, heavy smokers, usually leads to digital ischeamia
179
Ix of PVD?
* APBI
* arterial duplex scan
* MR angiography - contrast enhanced
* Ct angiography
180
pharm for claudication?
* pentoxifylline
* cilostazol
* naftidrofuryl
181
procedures for claudication?
* angioplasty - stenting
* bypass grafting
182
complications of PAD
* Sepsis
* major adverse cardiac events
* major adverse limb events - amputations e.g.
183
ALI?
* surg emergency
* sudden decrease in limb perfusion that threatens viability of the limb
* 3 causes: thrombosis in situ, embolisation (E.g. from anyuerysm or prosthetic heart valve) and trauma
184
rutherford classification of acute ischemia?
185
painful white foot in ischemia?
* painful white foot = reversible
* 0-6 hs
186
mottled skin in ischemia?
* 6-12 hrs: mottled skin due to capillary pooling
* blanches on digital pressure
187
ALI Ix?
* CT angiogram
* lactate levels
* bloods and blood gases
188
ALI Tx?
* high flow O2
* IV heparin - bolus initially then infusion
189
ALI of embolic cause management
* embolectomy
* intra-arterial thrombolysis - if the clot has had time to harden e.g alteplase
* bypass surgery
190
ALI of thrombotic cause management?
* intra-arterial thrombolysis
* angioplasty
* bypass procedure
191
referusion injury?
* potassium and h+ builds up in the area of reduced perfusion
* myoglobin -> rhabdo -> AKI and MOF
192
compartment syndrome?
* sudden rush of blood
* caused by inc cap permeability and resultant oedema following reperfusion of the limb
* inc in pressure
* may impair blood flow or cause damage to the muscle directly - risk of ischemia again
193
signs of CS?
* disprop pain compared to signs - characteristic sign
* paraesthesia
* swelling
* prolonged cap refill
194
Raynaurd's syndrome?
* mostly affects women
* usually bilateral - fingers affected more than toes
* numbness, pain, tingling and throbbing
195
what happens in raynaurds?
* pallor -> cyanosis -> hyperaemia
* vasospasm of artery, often triggered by cold
* can be assoc w occupations - use of vibrating tools
196
what worsens raynaurds?
* worsened by smoking and BBs
197
Management of raynaurds?
* avoid cold
* CCBs - vasodilators
* sympatholytic agents - e.g. alpha blockers
* chemical sympathectomy - blocking sympathetic chain usually stellate ganglion
198
aneurysm =
* abn dilatation of the lumen
199
true anureysm?
wall of artery forms wall of A
200
false anueurysm?
* false - lumen of artery is in continuity with the space surrounded by compressed CT - false lumen
* inner layer can block off an artery
201
common areas of aneurysm?
* AA
* femoral arteries
* circle of willis - assoc w subarachnoid haemorrhages
* popliteal etc
202
AAA?
* >65 most common
* infections like syphilis and E coli
* trauma
203
Symptoms of AAA
* tearing abd pain radiates to the back
* hypotension
* tachycardia
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Signs of AAA
* pulsatile expansile mass in the abd
* tenderness on deep palpation if impending rupture
205
Ix of AAA?
* US - screening
* CT whole aortogram
206
Management of venous ulcers?
* raising leg and inc exercise
* emollients for dry skin
* compression therapy
* endovenous ablation - surgery
207
varicose veins?
* incompetent valves
* leading to tortous dilated veins
* results in venous hypertension and superficial dilatation of veins
208
varicose veins rF?
* pregnancy
* prolonged standing
* Fhx
* obesity
209
VVs CFs?
* visible veins
* skin discoloration
* pain,aching
* swelling - after long periods of standing
* oedema
* ulcers
* lipodermatosclrosis
* varicose eczema or thrombophlebitis
210
varicose veins Ix?
* duplex US
* CT venogram
211
Tx of varicose veins?
* compression
* thermal ablation - burning to close the vein off
* foam sclerotherapy - inflammatory resp closes off vein
* vein ligation, stripping and avlsion
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CFs of DVTS?
* pain and swelling in calf
* redness
* engorded superficial veins
* signs of PE - breathlessness, pleuritic chest pain
213
Ix of DVT?
* Wells score
* D dimer
* Doppler US
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RF for DVTs?
* Obesity
* active cancer
* smoking
* age >60
* pregnancy, HRT/ COCP
* Fhx
* clotting disorder
215
preventon of DVTs?
* stockings, encourage mobilisation, prophylatic LMWH for at risk patients
216
management of DVTs?
* anticoagulation - DOAC or warfarin (for 3 months)
* thrombolysis/ thrombectomy
* IVC FILTER - cancer patient
217
Most common type of liver cancer?
HCC
218
Diagnosis of HPB cancer?
* bloods
* tumour markers
* imaging
* histopathology
219
GB cancer?
* found incidentally at routine cholecystectomy
* non-incidental - RUQ pain
* palpable GB - hard
220
biliary obstruction - signs?
* obst jaundice
* yellow sclera
* dark urine + pale stools
* pruitus
221
222
constitutional symptoms of cancer?
* fatigue
* weight loss
* anorexia
* abd pain
* night sweats
223
4 features of obst jaundice?
* dark urine
* pruitus - itching
* jaundice
* clay coloured stools
224
ascites from cancer means
the disease has metastised
225
PC pain?
radiates to back - late symptom
226
GB cancer - pain?
* GB cancer is painless initially, becomes painful when it stretches capsule of liver
* jaudiced patient with palpable GB = dilated biliary tract from tumour - distal to the duct
227
which site does pancreatic cancer most commonly affect?
head
228
CA19-9?
CA19-9: likely cholangiocarcinoma - pancreatic tumour marker
229
AFP?
testicular tumours and liver
230
Liver imaging?
* triple phase CT
* one arterial, one portal, one hepatic venous phase
231
Oesophageal cancer?
* 95% squamous cell or adenocarcinoma
* SCC are sensitive to radiotherapy, adenos need chemo and surgery
232
Oesophageal cancer RF?
* smoking
* Barrets oesophagus
* obesity
* nitrosamines - preservatives
* hiatal hernia
* FHx
* alcohol
* stasis
233
Presentation of oesophageal cancer?
* dysphagia - progressive - liquids to solids
* regurgitation
* retrosternal pain
* haemoptysis
* maleana
* intractable hiccups
* hoarseness
234
Ix of OC?
* OGD - endoscopy
* barium swallow
* CT chest and abdomen
* PET-CT
235
Gastric cancer?
* 90% squamous or adenocarcinoma
* 5th most common cancer, present late
* most common pres anemia
236
gastric cancer epidemiology?
* M:F 2:1
237
RF for gastric cancer?
* BOG
* obesity smoking
* ETOH
* H pylori
* salt/ nitrosamines
238
pres of gastric cancer?
* dyspepsia in early disease
* vomiting
* gastric outlet obs - move epigastric will hear splash - succussion splash
* anemia
239
advanced gastric cancer symptoms?
* early satiety
* bloating
* distension
240
what should be given for variceal bleeding?
Prophylactic antibiotics should be given in addition to terlipressin in anyone with suspected variceal bleeding. The prophylactic antibiotics of choice are usually quinolones.
241
Side effects of mesalazine?
Mesalazine, in particular, can cause agranulocytosis, which may present with sudden onset rigors, fever and sore throat.
242
first line for constipation in IBS?
A bulk-forming laxative such as isphagula husk is the first-line recommended treatment
243
omeprazole and ? interact
clopidogrel so use lansoprazole instead
244
gastric carcinoma symptoms?
- fatigue
- weight loss
- anemia
- elevated urea
245
gastric cancer and upper GI bleed?
Gastric cancer can present with an upper gastrointestinal (GI) bleed which would result in raised urea due to digestion of blood. The patient's dark, foul-smelling stools are indicative of digested blood being passed in the stool.
246
perf PUD -> Ix ?
erect chest XR
247
Diarrhoea, fatigue, osteomalacia → ?
?coeliac disease
248
iron def anemia vs anemia of chronic disease
TIBC is high in IDA, and low/normal in anaemia of chronic disease
249
Metabolic ketoacidosis with normal or low glucose: think?
alcohol
250
CURB scoring?
- Confusion = 1,
- Urea > 7 mmol/L = 1,
- Respiratory rate > 30 = 1,
- Diastolic BP < 60 mmHg = 1,
- Age > 65 = 1
251
UC - patterns seen?
- Proctitis - most common pattern
- pseudopolyps
252
What is the best thing to check for liver failure?
INR
253
What is useful in the management of crohns in patients who develop a perianal fistula?
Oral metronidazole
254
renal cell carcinoma can metastaise to ?
to the lungs, causing 'cannonball metastases, lesions like this can also be due to endometrial cancer
255
what is the most common cause of exudative pleural effusion?
pneumonia
256
transudate vs exudate pleural effusions?
transudate: less than 30g protein
exudate: more than 30g protein
257
transudate pleural effusions examples?
- hypoalbuminaemia - nephrotic syndrome
- hypothyroidism
- HF
258
What is the most common cause of transudate pleural effusions?
HF
259
Causes of exudative pleural effusions?
- pneumonia - most common
- TB
- RA
- lung cancer
- mesothelioma
- pancreatitits
- PE
260
What is the most common causative agent of bronchiectasis?
haemophilus infleunza
261
Mx of infective exacerbation of COPD?
first-line antibiotics are amoxicillin or clarithromycin or doxycycline
262
Which ab should be avoided w long QT?
clarithromycin
263
Tb can cause ? lymphadenopathy
bilateral
264
Young male smoker with symptoms similar to limb ischaemia - think?
Buerger's disease
265
DABS - ACS management?
He had an ACS, now he DABS
Dual antiplatelet therapy
Ace Inhibitor
Beta blocker
Statin
266
What is normal in an athlete?
Mobitz type 1
267
most common causes of AS in under 65s and over 65S?
* younger patients < 65 years: bicuspid aortic valve
* older patients > 65 years: calcification
268
symptoms of AS?
* slow rising pulse
* dyspnoea on activity
* systolic mumur
269
What is a poor prognostic indicator of ACS?
low systolic BP -> cardiogenic shock -> poor prognostic indicator for ACS
270
Becks triad?
- cardiac tamponade
- hypotension
- raised JVP
- muffled heart sounds
271
what is the definitive management of cardiac tamponade?
- pericardiocentesis—a procedure involving the drainage of fluid from the pericardial sac, thereby permitting normal cardiac contractions.
272
management of paracetamol overdose?
* staggered: NAC immediately
* presents within an hour: activated charcoal
273
lithim - tremor in chronic treatment vs in acute toxicity?
Lithium: fine tremor in chronic treatment, coarse tremor in acute toxicity
of COARSE lithium produces toxicity
274
