Block 4 Flashcards
What are some causes of oculogyric crisis?
Phenothiazines
Haloperidol
Metoclopramide
Postencephalitic Parkinson’s disease
Half life of tamoxifen
7 days
Action of tamoxifen
Synthetic partial oestrogen agonist
What are the most common side effects of tamoxifen?
Climateric side effects, 3% stop taking the drug because of these
How do aromatase inhibitors work in breast cancer?
Aromatase inhibitors are an alternative class of drugs, these work by blocking the peripheral aromatization of androgens (post menopausal women produce oestrogens in this way). They may treat cancers for which tamoxifen is no longer effective.
Theme: Thyroid nodules
A.Toxic adenoma
B.Anaplastic carcinoma of thyroid
C.Follicular carcinoma of thyroid
D.Papillary carcinoma of thyroid
E.Medullary carcinoma of thyroid
F.Thyroid lymphoma
G.Multinodular goitre
H.Parathyroid gland tumour
For each scenario please select the most likely underlying diagnosis. Each option may be used once, more than once or not at all.
A 52 year old woman with known Hashimotos thyroiditis presents with a neck swelling. She describes it as rapidly increasing in size over 3 months and she complains of dysphagia to solids. On examination there is an asymmetrical swelling of the thyroid gland.
A 52 year old woman presents with a neck swelling. On examination she is noted to have single nodule on the thyroid gland. A CXR shows two mass lesions.
A 52 year old woman presents with a neck swelling. Her GP reports that her TSH value is low at 0.01. A scintigraphy demonstrates a hot nodule.
Thyroid lymphoma
Thyroid lymphoma (Non Hodgkin’s B cell lymphoma) is rare. It should be considered in patients with a background of Hashimoto’s thyroiditis and a rapid growth in size of the thyroid gland. Diagnosis can be made with core needle biopsy; however an incisional biopsy may be needed. Radiotherapy is the main treatment option.
Follicular carcinoma of thyroid
A solitary nodule with signs of haematogenous spread indicates a follicular tumour. Note that papillary tumours tend to be multinodular and spread via the lymphatic system. Lymphatic spread from a papillary thyroid cancer is nearly always to neck nodes in the first instance and mediastinal lymphadenopathy is vanishingly rare. Lung lesions are typically synonymous with haematogenous metastasis of which a follicular lesion is the most likely culprit.
Toxic adenoma
This lady has thyrotoxicosis (low TSH) and a hot solitary nodule indicating a toxic adenoma. Thyroid cancer rarely causes thyrotoxicosis or hot nodules.
Lung lesion in ?thyroid malignancy
Follicular carcinoma- typically synonymous with haematogenous metastasis
Theme: Tumour markers
A.Invasive ductal carcinoma of the breast
B.Prostate cancer
C.Gastric cancer
D.Ovarian cancer
E.Colorectal cancer
F.Pancreatic adenocarcinoma
G.Seminoma testicular cancer
H.Non-seminomatous testicular cancer
I.Hepatocellular carcinoma
For each tumour marker please select the most likely underlying malignancy. Each option may be used once, more than once or not at all.
50.Raised beta-human chorionic gonadotropin with a raised alpha-feto protein level
Elevated CA 19-9
Raised alpha-feto protein level in a 54-year-old woman
Non-seminomatous testicular cancer
A raised alpha-feto protein level excludes a seminoma
Pancreatic adenocarcinoma
Hepatocellular carcinoma
Which of the following structures lies deepest in the popliteal fossa?
Popliteal artery
Popliteal vein
Tibial nerve
Common peroneal nerve
Popliteal lymph nodes
From superficial to deep:
The common peroneal nerve exits the popliteal fossa along the medial border of the biceps tendon. Then the tibial nerve lies lateral to the popliteal vessels to pass posteriorly and then medially to them. The popliteal vein lies superficial to the popliteal artery, which is the deepest structure in the fossa.
Theme: Management of oesophageal cancer
A.Endo lumenal brachytherapy
B.Chemo-radiotherapy
C.Radiotherapy alone
D.Insertion of expanding metallic stent
E.Ivor-Lewis oesophagectomy
F.Total oesophagectomy
G.Segmental resection of mid oesophagus
H.Endoscopic mucosal resection
Please select the most appropriate intervention for the following patients with oesophageal cancer. Each option may be used once, more than once or not at all.
57.A 58 year old man with long standing Barretts oesophagus is found to have a nodule on endoscopic surveillence. Biopsies and endoscopic USS suggest this is at most a 1cm foci of T1 disease in the distal oesophagus 4 cm proximal to the oesophagogastric junction.
An 82 year old man presents with dysphagia and on investigation is found to have a stenosing tumour of the mid oesophagus with a single mestastasis in the right lobe of the liver (segment VI).
A 56 year old man presents with odynophagia and on investigation is found to have a squamous cell carcinoma of the upper third of the oesophagus. Staging investigations are negative for metastatic disease.
The correct answer is Endoscopic mucosal resection
EMR is an reasonable option for small areas of malignancy occurring on a background of Barretts change. Segmental resections of the oesophagus are not practised and the only resectional strategy in this scenario would be an Ivor- Lewis type resection. The morbidity such a strategy in T1 disease is probably not justified.
Insertion of expanding metallic stent
Distant disease in patients with oesophageal cancer is a contra indication to a resectional strategy and downstaging with chemotherapy is not routinely undertaken in this age group as the results are poor. An expanding stent will provide rapid and durable palliation.
The correct answer is Chemo-radiotherapy
SCC of the oesophagus is treated with chemo-radiotherapy in the first instance.
Surgical options for oesophageal cancer
Endoscopic mucosal resection
Transhiatal oesophagectomy
Ivor Lewis oesophagectomy
McKeown oesophagectomy
Treatment for early localised adenocarcinoma of the distal oesophagus. Survival mirrors that of surgical resection for Tis and T1 disease
Endoscopic mucosal resection
Most commonly used for junctional (type II) (1) tumours where limited thoracic oesophageal resection is required. Less morbidity than two field oesophagectomy
Transhiatal oeosphagectomy
Two stage approach for middle and distal tumours. Very commonly performed, intrathoracic anastomosis will result in mediastinitis in event of anastomotic leak. Lower incidence of recurrent laryngeal nerve injury
Ivor Lewis oesophagectomy
Three field approach, may be useful for proximal tumours. Anastomotic leakage is less serious. Higher incidence of recurrent laryngeal nerve injury
McKeown oesophagectomy
Adjuvant therapy in oesophageal cancer
Neoadjuvent radiotherapy alone prior to resection confers little benefit and is not routinely performed (2)
Preoperative chemotherapy is associated with a survival advantage (OE02 trial)
Peri operative (pre and post operative) chemotherapy confers a survival advantage in junctional tumours
Post operative chemotherapy is not generally recommended following oesophageal resections outside clinical trials
Palliative strategies in oesophageal carcinoma
Combination chemotherapy improves quality of life and survival in non operable disease (3)
Trastuzumab may improve survival in patients with HER 2 positive tumours
Oesophageal intubation with self expanding metal stents is the treatment of choice in patients with occluding tumours >2cm from the cricopharyngeus
Covered metal stents are useful in cases of malignant fistulas
Laser therapy and argon plasma coagulation may be useful as therapies for tumour overgrowth and bleeding
Photodynamic therapy and ethanol injections confer little benefit and should not be routinely used
A 6 year old boy pulls over a kettle and suffers superficial partial thickness burns to his legs. Which of the following will not occur?
Preservation of hair follicles
Formation of vesicles or bullae
Damage to sweat glands
Healing by re-epithelialisation
Pain at the burn site
Partial thickness burns are divided into superficial and deep burns, however, this is often not possible on initial assessment and it may be a week or more before the distinction is clear cut. Dermal appendages are, by definition, intact. Superficial partial thickness burns will typically heal by re-epithelialisation, deeper burns will heal with scarring.
What is the approximate volume of pancreatic secretions in a 24 hour period?
100ml
200ml
500ml
1500ml
3000ml
Typically the pancreas secretes between 1000 and 1500ml per day.
Causes of massive splenomegaly
Myelofibrosis
Chronic myeloid leukaemia
Visceral leishmaniasis (kala-azar)
Malaria
Gaucher’s syndrome
Other causes of splenomegaly
Portal hypertension e.g. secondary to cirrhosis
Lymphoproliferative disease e.g. CLL, Hodgkin’s
Haemolytic anaemia
Infection: hepatitis, glandular fever
Infective endocarditis
Sickle-cell*, thalassaemia
Rheumatoid arthritis (Felty’s syndrome)
Which of the positions listed below best describes the location of the coeliac autonomic plexus?
Anterolateral to the aorta
Posterolateral to the aorta
Anterolateral to the sympathetic chain
Anteromedial to the sympathetic chain
Posterior to L1
Anterolateral to the aorta
The coeliac plexus is the largest of the autonomic plexuses. It is located on a level of the last thoracic and first lumbar vertebrae. It surrounds the coeliac axis and the SMA. It lies posterior to the stomach and the lesser sac. It lies anterior to the crura of the diaphragm and the aorta. The plexus and ganglia are joined by the greater and lesser splanchnic nerves on both sides and branches from both the vagus and phrenic nerves.
Rule of 2s in Meckel’s diverticulum
2% of population
2 inches in length
2 feet from ileocaecal valve
2x more common in men
2 tissue types involved
Arterial supply of Meckel’s diverticulum
Omphalomesenteric artery
Pathology of prostate cancer
95% adenocarcinoma
In situ malignancy is sometimes found in areas adjacent to cancer. Multiple biopsies needed to call true in situ disease.
Often multifocal- 70% lie in the peripheral zone.
Graded using the Gleason grading system, two grades awarded 1 for most dominant grade (on scale of 1-5) and 2 for second most dominant grade (scale 1-5). The two added together give the Gleason score. Where 2 is best prognosis and 10 the worst.
Lymphatic spread occurs first to the obturator nodes and local extra prostatic spread to the seminal vesicles is associated with distant disease.
Treatment options for prostate cancer
Watch and wait
RTx
Surgery
Hormonal therapy
Indications for active surveillance in prostate cancer
In the UK the National Institute for Clinical Excellence (NICE) suggests that active surveillance is the preferred option for low risk men. It is particularly suitable for men with clinical stage T1c, Gleason score 3+3 and PSA density < 0.15 ng/ml/ml who have cancer in less than 50% of their biopsy cores, with < 10 mm of any core involved.
Candidates for active surveillance should:
have had at least 10 biopsy cores taken
have at least one re-biopsy.
If men on active surveillance show evidence of disease progression, offer radical treatment. Treatment decisions should be made with the man, taking into account co-morbidities and life expectancy.
Radiotherapy options in prostate cancer
Radiotherapy (External)- Both potentially curative and palliative therapy possible. However, radiation proctitis and rectal malignancy are late problems. Brachytherapy is a modification allowing internal radiotherapy.
Surgical options for prostate cancer
Radical prostatectomy. Surgical removal of the prostate is the standard treatment for localised disease. The robot is being used increasingly for this procedure. As well as the prostate the obturator nodes are also removed to complement the staging process. Erectile dysfunction is a common side effect. Survival may be better than with radiotherapy (see references).
An intravenous drug user develops a false aneurysm and requires emergency surgery. The procedure is difficult and the femoral nerve is inadvertently transected. Which of the following muscles is least likely to be affected as a result?
Sartorius
Vastus medialis
Pectineus
Quadriceps femoris
Adductor magnus
Adductor magnus is innervated by the obturator and sciatic nerve. The pectineus muscle is sometimes supplied by the obturator nerve but this is variable. Since the question states least likely, the correct answer is adductor magnus
What is the nerve root value of the external urethral sphincter?
S4
S1, S2, S3
S2, S3, S4
L3, L4, L5
L5, S1, S2
The external urethral sphincter is innervated by branches of the pudendal nerve, therefore the root values are S2, S3, S4.
Theme: Management of occlusive vascular disease
A.Aorto-bifemoral bypass graft
B.Femoro-femoral cross over graft
C.Femoro-popliteal bypass graft
D.Femoro-distal bypass graft
E.Axillo-bifemoral bypass graft
F.Bilateral above knee amputation
Please select the most appropriate arterial bypass method for the scenario described. Each option may be used once, more than once or not at all.
72.An 83 year old lady with a significant cardiac history is admitted with rest pain and bilateral leg ulcers. Imaging demonstrates bilateral occlusion of both common iliac arteries that are unsuitable for stenting.
A 54 year old man presents to the vascular clinic with severe rest pain and an ulcer on his right foot that is not healing. On examination he has bilateral absent femoral pulses. Imaging demonstrates a bilateral occlusion of the common iliac arteries that is not suitable for stenting.
A 78 year old man presents with left sided rest pain in his leg and a non healing arterial leg ulcer on the same leg. Imaging shows normal right leg vessels, on the left side there is a long occlusion of the external iliac artery that is unsuitable for stenting. He has a significant cardiac history.
Axillo-bifemoral bypass graft
Theme from January 2012 Exam
In patients with major cardiac co-morbidities the safest option is to choose an axillo-bifemoral bypass graft. The long term patency rates are less good than with aorto-bifemoral bypass grafts, however, the operation is less major.
Aorto-bifemoral bypass graft
In a young patient consideration should be given to aorto-bifemoral bypass grafts as these have the best long term functional outcome compared with an axillo-bifemoral bypass graft.
Femoro-femoral cross over graft
Femoro-femoral cross over grafts are an option for treatment of iliac occlusions in patients with significant co-morbidities and healthy contralateral vessels. In reality the idealised situation presented here seldom applies and the opposite vessels usually have some disease and one must be careful not to damage the “healthy” side.
Factors that must be present for angioplasty to be sucessful
In order for angioplasty to be undertaken successfully the artery has to be accessible. The lesion relatively short and reasonable distal vessel runoff. Longer lesions may be amenable to sub-intimal angioplasty.
Superficial femoral artery occlusion to the above knee popliteal
In the ideal scenario, vein (either in situ or reversed LSV) would the used as a conduit. However, prosthetic material has reasonable 5 year patency rates and some would advocate using this in preference to vein so that vein can be used for other procedures in the future. In general terms either technique is usually associated with an excellent outcome (if run off satisfactory).
Rules in bypass surgery
Vein mapping 1st to see whether there is suitable vein (the preferred conduit). Sub intimal hyperplasia occurs early when PTFE is used for the distal anastomosis and will lead to early graft occlusion and failure.
Essential operative procedure as for above knee fem-pop.
If there is insufficient vein for the entire conduit then vein can be attached to the end of the PTFE graft and then used for the distal anastomosis. This type of ‘vein boot’ is technically referred to as a Miller Cuff and is associated with better patency rates than PTFE alone.
Remember the more distal the arterial anastomosis the lower the success rate.
Key concepts in bypasses for distal vascular disease
Femoro-distal bypass surgery takes longer to perform, is more technically challenging and has higher failure rates.
In elderly diabetic patients with poor runoff a primary amputation may well be a safer and more effective option. There is no point in embarking on this type of surgery in patients who are wheelchair bound.
In femorodistal bypasses vein gives superior outcomes to PTFE.
Theme: Surgical drains
A.Redivac suction drain
B.Corrugated drain
C.Wallace Robinson drain (non suction)
D.Penrose tubing
E.Latex T Tube drain
F.Silastic T Tube drain
G.No drain
Please select the most appropriate surgical drainage system for the indication given. Each option may be used once, more than once or not at all.
75.A 56 year old lady undergoes an open cholecystectomy and exploration of common bile duct. The bile duct is closed over a drain.
A 48 year old lady undergoes a mastectomy and axillary node clearance for an invasive ductal cancer of the breast with lymph node metastasis.
A 75 year old man undergoes a Hartman’s procedure for sigmoid diverticular disease with pericolic abscess and colovesical fistula.
Latex T Tube drain
This will elicit a fibrotic response and encourage a track to form.
Redivac suction drain
The raw tissue exposed from the mastectomy site will often ooze serous fluid and may result in seroma formation when the drain is removed.
Wallace Robinson drain (non suction)
A non suction drain is the preferred option here
Suction type of drain
Closed drainage system
High pressure vacuum system
Redivac
Consist of small systems such as the lantern style drain that may be used for short term drainage of small wounds and cavities
Larger systems are sometimes used following abdominal surgery, they have a lower pressure than the redivac system, which decreases the risks of fistulation
May be emptied and re-pressurised
Low pressure drainage systems
May be shaped (e.g. T Tube) or straight
Usually used in non pressurised systems and act as sump drains
Most often used when it is desirable to generate fibrosis along the drain track (e.g. following exploration of the CBD)
Latex tube drains
May be large or small diameter (depending on the indication)
Connected to underwater seal system to ensure one way flow of air
Chest drains
Thin, wide sheet of plastic, usually soft
Contains corrugations, along which fluids can track
Corrugated drain
A 34 year old lady has just undergone a parathyroidectomy for primary hyperparathyroidism. The operation is difficult and all 4 glands were explored. The wound was clean and dry at the conclusion of the procedure and a suction drain inserted. On the ward she becomes irritable and develops stridor. On examination, her neck is soft and the drain empty. Which of the following treatments should be tried initially?
Administration of intravenous calcium gluconate
Administration of intravenous lorazepam
Removal of the skin closure on the ward
Direct laryngoscopy
Administration of calcichew D3 orally
Exploration of the parathyroid glands may result in impairment of the blood supply. Serum PTH levels can fall quickly and features of hypocalcaemia may ensue, these include neuromuscular irritability and laryngospasm. Prompt administration of intravenous calcium gluconate can be lifesaving. The absence of any neck swelling and no blood in the drain would go against a contained haematoma in the neck (which should be managed by removal of skin closure).
A 45 year old man is stabbed in the abdomen and the inferior vena cava is injured. How many functional valves does this vessel usually have?
0
1
3
2
4
The lack of valves in the IVC is important clinically when it is cannulated during cardiopulmonary bypass, using separate SVC and IVC catheters, such as when the right atrium is to be opened. Note that there is a non functional valve between the right atrium and inferior vena cava.
Mnemonic for the Inferior vena cava tributaries: I Like To Rise So High:
Iliacs
Lumbar
Testicular
Renal
Suprarenal
Hepatic vein
A 24 year old woman presents with a long history of obstructed defecation and chronic constipation. She often strains to open her bowels for long periods and occasionally notices that she has passed a small amount of blood. On examination she has an indurated area located anteriorly approximately 3cm proximal to the anal verge.
Solitary rectal ulcer syndrome
Solitary rectal ulcers are associated with chronic constipation and straining. It will need to be biopsied to exclude malignancy (the histological appearances are characteristic). Diagnostic work up should include endoscopy and probably defecating proctogram and ano-rectal manometry studies.
Brown to black, poorly defined, velvety hyperpigmentation of the skin.
Usually found in body folds such as the posterior and lateral folds of the neck, the axilla, groin, umbilicus, forehead, and other areas.
The most common cause of acanthosis nigricans is insulin resistance, which leads to increased circulating insulin levels. Insulin spillover into the skin results in its abnormal increase in growth (hyperplasia of the skin).
In the context of a malignant disease, acanthosis nigricans is a paraneoplastic syndrome and is then commonly referred to as acanthosis nigricans maligna. Involvement of mucous membranes is rare and suggests a coexisting malignant condition.
Acanthosis nigricans
Theme: Surgical access
A.Gridiron
B.Lanz
C.McEvedy
D.Midline abdominal
E.Rutherford Morrison
F.Battle (abdominal)
G.Lower midline
Please select the most appropriate incision for the procedure required. Each option may be used once, more than once or not at all.
86.A 78 year old lady is admitted with a tender lump in her right groin. It is within the femoral triangle and there is concern that there may be small bowel obstruction developing.
A 45 year old woman with end stage renal failure is due to undergo a cadaveric renal transplant. This will be her first transplant.
A slim 20 year old lady is suffering from appendicitis and requires an appendicectomy.
McEvedy
This is one approach to an obstructed femoral hernia. It is possible to undertake a small bowel resection through this approach. Recourse to laparotomy may be needed if access is difficult.
Rutherford Morrison
This is the incision of choice for the extraperitoneal approach to the iliac vessels which will be required for a renal transplant.
Lanz
Either a Lanz or Gridiron incision will give access for appendicectomy. However, in the case described a Lanz incision will give better cosmesis and can be extended should pelvic surgery be required eg for gynaecological disease.
Which of the following structures does not pass posteriorly to the medial malleolus?
Posterior tibial artery
Tibial nerve
Tibialis anterior tendon
Tendon of flexor digitorum longus
Tendon of flexor hallucis longus
Tibialis anterior tendon
Mnemonic for structures posterior to the medial malleolus:
Tom Dick And Very Nervous Harry
T ibialis posterior tendon
flexor Digitorum longus
A rtery
V ein
N erve
H allucis longus
Which of the following is the most common childhood brain tumour?
Glioblastoma multiforme
Astrocytoma
Medulloblastoma
Ependymoma
Meningioma
Glioblastoma multiforme is rare in childhood. In contrast, astrocytoma is the commonest brain tumour in children. Medulloblastoma is no longer the commonest CNS tumour in children (Cancer research UK)
Which investigation is best for initial assessment of recurrence of follicular carcinoma of the thyroid?
Free T4
Thyroid stimulating hormone
Scintigraphy
Serum thyroglobulin
USS thyroid gland
Elevated thyroglobulin levels raises suspicion of recurrence.
Cardiovascular receptor action
Adrenaline
a1 a2 b1 b2
Cardiovascular receptor action
Norad
a1 (a2) (b1) (b2)
Cardiovascular receptor action
Dobutamine
B1 (B2)
Cardiovascular receptor action
Dopamine
(a1) (a2) (b1) D1 D2
Effects of a1 and 2 adrenoreceptors
Vasoconstriction
Effects of beta 1 adrenoreceptors
Increased cardiac contractility and HR
Affect of beta 2 adrenoreceptors
Vasodilation
Dopamine 1 receptor action
Renal and splenic vasodilation
Dopamine 2 receptor action
Inhibits release of noradrenaline
A 22 year old man presents with an infected sebaceous cyst. The cyst itself is swollen, discharging pus and has some surrounding erythema. What is the most appropriate treatment?
Excision of the cyst of closure of the defect with interrupted 3/0 silk
Excision of the cyst and closure of the defect with subcuticular 4/0 undyed nylon
Incision and drainage with excision of the cyst wall and packing of the defect
Incision and drainage with conservation of the cyst wall and packing of the defect
Administration of oral co-amoxyclav and definitive surgery once the infection has cleared
The correct treatment for an infected sebaceous cyst is incision and drainage with removal of the cyst wall. Conservation of the cyst wall will invariably lead to recurrence. Under no circumstances should an infected wound like this be primarily closed. The administration of antibiotics without drainage of sepsis is futile.
Adrenaline dose in anaphlyaxis
1:1000 0.5 ml IM
Chlorphenamine dose in anaphylaxis
10mg IV
Hydrocortisone dose in anaphylaxis
100-200mg IV
A 16 year old boy develops a painful swelling of his distal femur. An osteoblastic sarcoma is diagnosed. To which of the following sites is this lesion most likely to metastasise?
Inguinal lymph nodes
Common iliac lymph nodes
Liver
Brain
Lung
Lung
Sarcomas often metastasise via the haematogenous route and the lung is a common site for sarcoma metastasis. The liver and brain are often spared (at least initially). A smaller number may develop lymphatic metastasis (see above).
Sarcomas in which Lymphatic Metastasis is seen:
‘RACE For MS’
R: Rhabdomyosarcoma
A: Angiosarcoma
C: Clear cell sarcoma
E: Epithelial cell sarcoma
For: Fibrosarcoma
M: Malignant fibrous histiocytoma
S: Synovial cell sarcoma
What features of a mass should raise suspicion for a sarcoma?
Large >5cm soft tissue mass
Deep tissue location or intra muscular location
Rapid growth
Painful lump
Commoner in males
Incidence of 0.3 / 1, 000, 000
Onset typically between 10 and 20 years of age
Location by femoral diaphysis is commonest site
Histologically it is a small round tumour
Blood borne metastasis is common and chemotherapy is often combined with surgery
Ewings sarcoma
Mesenchymal cells with osteoblastic differentiation
20% of all primary bone tumours
Incidence of 5 per 1,000,000
Peak age 15-30, commoner in males
Limb preserving surgery may be possible and many patients will receive chemotherapy
Osteosarcoma
Malignancy of adipocytes
Rare, approximately 2.5 per 1,000,000. They are the second most common soft tissue sarcoma
Typically located in deep locations such as retroperitoneum
Affect older age group usually >40 years of age
May be well differentiated and thus slow growing although may undergo de-differentiation and disease progression
Many tumours will have a pseudocapsule that can misleadingly allow surgeons to feel that they can ‘shell out’ these lesions. In reality, tumour may invade at the edge of the pseudocapsule and result in local recurrence if this strategy is adopted
Usually resistant to radiotherapy, although this is often used in a palliative setting
Liposarcoma
Tumour with large number of histiocytes
Most common sarcoma in adults
Also described as undifferentiated pleomorphic sarcoma NOS (i.e. Cell of origin is not known)
Four major subtypes are recognised: storiform-pleomorphic (70% cases), myxoid (less aggressive), giant cell and inflammatory
Treatment is usually with surgical resection and adjuvant radiotherapy as this reduces the likelihood of local recurrence
Malignant Fibrous Histiocytoma
Most common sarcoma in adults?
Malignant Fibrous Histiocytoma
Which of the following local anaesthetics is not an amino amide type?
Lignocaine
Xylocaine
Procaine
Bupivacaine
Prilocaine
All local anaesthetics have a chemical bond linking an amine to either an amide or an ester. Most local anaesthetics are of the amino- amide types, these have a more favorable side effect profile and are more stable in solution. Procaine and benzocaine have amino - ester groups, these are metabolised by pseudocholinesterases.
Infection with which of the following micro-organisms may result in a clinical picture resembling achalasia of the oesphagus?
Epstein Barr virus
Wuchereria Bancrofti
Candida Spp
Trypanosoma Cruzi
Helicobacter Pylori
Protozoan
Infection with Trypanosoma Cruzi may result in destruction of the ganglion cells of the myenteric plexus, resulting in a clinical picture similar to achalasia.
Causes Chagas disease
Carried by bugs which infect the skin whilst feeding
Penetrate through open wounds and mucous membranes
Intracellular proliferation
Major infective sites include CNS, intestinal myenteric plexus, spleen, lymph nodes and cardiac muscle
Chronic disease is irreversible, nifurtimox is used to treat acute infection
Next question
You are called to the acute surgical unit. A patient who has short gut syndrome has developed a broad complex tachycardia. You suspect a diagnosis of ventricular tachycardia. What is the most likely precipitant?
Hypoglycaemia
Bisoprolol
Hypomagnesaemia
Dehydration
Hyperthyroidism
Hypomagnesaemia
What are the two main types of VT?
monomorphic VT: most commonly caused by myocardial infarction
polymorphic VT: A subtype of polymorphic VT is torsades de pointes which is precipitated by prolongation of the QT interval. The causes of a long QT interval are listed below
Congenital causes of prolonged QT
Jervell-Lange-Nielsen syndrome (includes deafness and is due to an abnormal potassium channel)
Romano-Ward syndrome (no deafness)
Drugs causing prolonged QT
amiodarone, sotalol, class 1a antiarrhythmic drugs
tricyclic antidepressants, fluoxetine
chloroquine
terfenadine
erythromycin
Other causes of prolonged QT
electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia
acute myocardial infarction
myocarditis
hypothermia
subarachnoid haemorrhage
Based on the current guidelines, which option regarding management of head injuries is false?
Opiates should be avoided
Consider intubation if the GCS is <8 or = 8
Immediate CT head if there is > 1 episode of vomiting
Half hourly GCS assessment until GCS is 15
Contact neurosurgeons if suspected penetrating injury
Opiates should be avoided
Indications for immediate CT head
GCS < 13 on admission
GCS < 15 2 hours after admission
Suspected open or depressed skull fracture
Suspected skull base fracture (panda eyes, Battle’s sign, CSF from nose/ear, bleeding ear)
Focal neurology
Vomiting > 1 episode
Post traumatic seizure
Coagulopathy
Contact neurosurgeon in injury if?
Persistent GCS < 8 or = 8
Unexplained confusion > 4h
Reduced GCS after admission
Progressive neurological signs
Incomplete recovery post seizure
Penetrating injury
Cerebrospinal fluid leak
Failure rates of vasectomy
1 in 2000
Reversal of vasectomy success rates
55% if within 10 years
Which of the following statements relating to the root of the neck is false?
The lung projects into the neck beyond the first rib and is constrained by Sibson’s fascia
The subclavian artery arches over the first rib anterior to scalenus anterior
The roots and trunks of the Brachial plexus lie posterior to the subclavian artery on the first rib
The roots and trunks of the Brachial plexus lie between scalenus anterior and scalenus medius muscles
The thyrocervical trunk is a branch of the subclavian artery
The subclavian artery lies posterior to scalenus anterior, the vein lies in front. Sibson’s fascia is another name for the suprapleural membrane
A 23 year old man presents with blunt abdominal trauma and a splenic bleed is suspected. He is commenced on an infusion of tranexamic acid. Which of the following best describes its mechanism of action?
Inhibition of plasmin
Inhibition of thrombin
Inhibition of factor II
Inhibition of factor Xa
Activation of factor VIII
Tranexamic acid inhibits plasmin and this prevents fibrin degradation.
Tranexamic acid is a synthetic derivative of lysine. Its primary mode of action is as an anti fibrinolytic that competitively inhibits the conversion of plasminogen to plasmin. Plasmin degrades fibrin and therefore rendering plasmin inactive slows this process.
The role of tranexamic acid in trauma was investigated in the CRASH 2 trial and has been shown to be of benefit in bleeding trauma when administered in the first 3 hours.
Facultative anaerobe
Gram positive coccus
Haemolysis on blood agar plates
Catalase positive
20% population are long term carriers
Exo and entero toxin may result in toxic shock syndrome and gastroenteritis respectively
Ideally treated with penicillin although many strains now resistant through beta Lactamase production. In the UK less than 5% of isolates are sensitive to penicillin.
Resistance to methicillin (and other antibiotics) is mediated by the mec operon , essentially penicillin binding protein is altered and resistance to this class of antibiotics ensues
Common cause of cutaneous infections and abscesses
Staphylococcus aureus
Gram positive, forms chain like colonies, Lancefield Group A Streptococcus
Produces beta haemolysis on blood agar plates
Rarely part of normal skin microflora
Catalase negative
Releases a number of proteins/ virulence factors into host including hyaluronidase, streptokinase which allow rapid tissue destruction
Releases superantigens such as pyogenic exotoxin A which results in scarlet fever
Remains sensitive to penicillin, macrolides may be used as an alternative.
Streptococcus pyogenes
Gram negative rod
Facultative anaerobe, non sporing
Wide range of subtypes and some are normal gut commensals
Some subtypes such as 0157 may produce lethal toxins resulting in haemolytic-uraemic syndrome
Enterotoxigenic E-Coli produces an enterotoxin (ST enterotoxin) that results in large volume fluid secretion into the gut lumen (Via cAMP activation)
Enteropathogenic E-Coli binds to intestinal cells and cause structural damage, this coupled with a moderate (or in case of enteroinvasive E-Coli significant) invasive component produces enteritis and large volume diarrhoea together with fever.
They are resistant to many antibiotics used to treat gram positive infections and acquire resistance rapidly and are recognised as producing beta lactamases
Escherichia coli
Curved, gram negative, non sporulating bacteria
One of the commonest causes of diarrhoea worldwide
Produces enteritis which is often diffuse and blood may be passed
Remains a differential for right iliac fossa pain with diarrhoea
Self limiting infection so antibiotics are not usually advised. However, the quinolones are often rapidly effective.
Campylobacter jejuni
Gram negative, helix shaped rod, microaerophillic
Produces hydrogenase that can derive energy from hydrogen released by intestinal bacteria
Flagellated and mobile
Those carrying the cag A gene may cause ulcers
It secretes urease that breaks down gastric urea> Carbon dioxide and ammonia> ammonium>bicarbonate (simplified!) The bicarbonate can neutralise the gastric acid.
Usually colonises the gastric antrum and irritates resulting in increased gastrin release and higher levels of gastric acid. These patients will develop duodenal ulcers. In those with more diffuse H-Pylori infection gastric acid levels are lower and ulcers develop by local tissue damage from H-Pylori- these patients get gastric ulcers.
Diagnosis may be made by serology (approx. 75% sensitive). Biopsy urease test during endoscopy probably the most sensitive.
In patients who are colonised 10-20% risk of peptic ulcer, 1-2% risk gastric cancer, <1% risk MALT lymphoma.
Helicobacter pylori
Infusion with which of the following blood products is most likely to result in an urticarial reaction?
Packed red cells
Fresh frozen plasma
Platelets
Cryoprecipitate
Factor VIII concentrate
Pyrexia is the most common adverse event in transfusing packed red cells
Urticaria is the most common adverse event following infusion of FFP
Systemic AA amyloidosis
long-term complication of several chronic inflammatory disorders - e.g. rheumatoid arthritis, ankylosing spondylitis, Crohn’s disease, malignancies and conditions predisposing to recurrent infections
AL amyloidosis
Results from extra-cellular deposition of fibril-forming monoclonal immunoglobulin light chains (most commonly of lambda isotype). Most patients have evidence of isolated monoclonal gammopathy or asymptomatic myeloma, and the occurrence of AL amyloidosis in patients with symptomatic multiple myeloma or other B-cell lymphoproliferative disorders is unusual. AL type amyloidosis is the most common variant.
A 34 year old male donates a unit of blood. It is stored at 4 oC. After 72 hours which of the following clotting factors will be most affected?
Factor V
Factor II
Factor VII
Factor IX
Factor XI
Factors V and VIII are sensitive to temperature which is the reason why FFP is frozen soon after collection.
What is significant about Beriplex?
- Bereplex 50 u/kg
- Rapid action but factor 6 short half life, therefore give with vitamin K
Cortisol is predominantly produced by which of the following?
Zona fasciculata of the adrenal
Zona glomerulosa of the adrenal
Zona reticularis of the adrenal
Adrenal medulla
Posterior lobe of the pituitary
Relative Glucocorticoid activity:
Hydrocortisone = 1 Prednisolone = 4 Dexamethasone = 25
Cortisol is produced by the zona fasciculata of the adrenal gland.
Theme: Hip fractures
A.Conservative management
B.Percutaneous pinning
C.Fracture reduction and internal fixation
D.Hemiarthroplasty
E.Total hip replacement
F.Dynamic hip screw
G.Intramedullary femoral nail
For each scenario please select the most appropriate management option. Each option may be used once, more than once or not at all.
10.A 60 year old male is admitted to A&E with a fall. He lives with his wife and still works as a restaurant manager. He has a past history of benign prostatic hypertrophy and is currently taking tamsulosin. He is otherwise fit and healthy. On examination there is right hip tenderness on movement in all directions. A hip x-ray confirms an intertrochanteric fracture.
An 86 year old retired pharmacist is admitted to A&E following a fall. She complains of right hip pain. She is known to have hypertension and is currently on bendrofluazide. She lives alone and mobilises with a Zimmer frame. Her right leg is shortened and externally rotated. A hip x-ray confirms a displaced intracapsular fracture.
A 74 year old male is admitted to A&E with a fall. He is known to have rheumatoid arthritis and is on methotrexate and paracetamol. He lives alone in a bungalow and enjoys playing golf. He is independent with his ADLs. He complains of left groin pain, therefore has a hip x-ray which confirms a displaced intracapsular fracture.
Dynamic hip screw
The blood supply to the femoral head may be intact and the fracture should heal with compression type devices such as gamma nails or dynamic hip screws. The latter device being the most commonly performed therapeutic intervention.
Hemiarthroplasty
Hemiarthroplasty is offered to older, less mobile individuals compared to fracture reduction and fixation in younger patients.
Total hip replacement
This patient has pre-existing joint disease, good level of activity and a relatively high life expectancy, therefore THR is preferable to hemiarthroplasty.
NOF mortality
mortality associated with elderly hip fracture is 10% at one month, and 30% at one year. However, this has been improved in the UK with the introduction of multidisciplinary, orthogeriatric lead care and the National Hip Fracture Database and Best Practice Tariff.
Vascular supply to the femoral head
The predominant blood supply to the femoral head and neck is from the medial and lateral femoral circumflex arteries (branches of profunda femoris). These anastomose and pierce the joint capsule at the base of the neck, mainly posteriorly. There is a small vascular contribution from the artery of the ligament teres. Understanding the blood supply is fundamental to the decision making process in treating NOF fractures.
What can be used to classify elderly intracapsular NOF?
Garden classification
Priority in repair of NOF in young?
The priority with the young patient is to retain the femoral head if possible, even with a displaced intracapsular fracture. The risk of avascular necrosis and non-union (and therefore revision surgery) associated with internal fixation needs weighing up against the sequelae of total hip replacement in the
Management of intertrochanteric farctures
Intertrochanteric fractures vary greatly in their stability. If the trochanter (and therefore lateral wall), and medial calcar is in tact, then the fracture configuration bears stability. This can be treated with a DHS, as collapse of the fracture is predictable. Where either or both structures are involved in the fracture, stability becomes compromised and many surgeons will favour using an intramedullary device. This is an ongoing debate, and difficult to test in an exam setting.
Which of the following are not generally supplied by the right coronary artery?
The sino atrial node
The circumflex artery
The atrioventricular node
Most of the right ventricle
The right atrium
The circumflex artery is generally a branch of the left coronary artery.
IVF in XS fluid loss from vomiting
Treated with crystalloid with potassium replacement.
NS if hypochloraemia
IVF in fluid loss from diarrhoea, ileostomy, ileus, obstruction
Hartmann’s
(should also be given in sodium losses 2o to diuretics)
Maintenance fluids
Use 4%/0.18% dextrose saline or 5% dextrose in maintenance fluids. It should not be used in resuscitation or as replacement fluids.
A 44 year old man has a malignant melanoma and is undergoing a block dissection of the groin. The femoral triangle is being explored for intra operative bleeding. Which of the following forms the medial border of the femoral triangle?
Femoral artery
Biceps femoris
Adductor longus
Sartorius
Adductor magnus
Vastus medialis forms the lateral border of the adductor canal. The sartorius muscles forms the roof of the adductor canal.
Adductor longus forms the medial boundary of the femoral triangle (see below).
Contents of the femoral triangle
Femoral vein (medial to lateral)
Femoral artery-pulse palpated at the mid inguinal point
Femoral nerve
Deep and superficial inguinal lymph nodes
Lateral cutaneous nerve
Great saphenous vein
Femoral branch of the genitofemoral nerve
A 45-year-old man presents to surgical outpatients with a long history of recurrent abdominal pain and vomiting. He is noted to have a peripheral motor neuropathy on examination. What is the most likely diagnosis?
Huntington’s disease
Myeloma
Acute intermittent porphyria
Lawrence-Moon-Biedl syndrome
Friedreich’s ataxia
Neurological signs combined with abdominal pain is acute intermittent porphyria or lead poisoning until proven otherwise.
Enzyme deficient in AIP
Porphobilinogen deaminase
A 56 year old man presents with episodic facial pain and discomfort whilst eating. He has suffered from halitosis recently and he frequently complains of a dry mouth. He has a smooth swelling underneath his right mandible. What is the most likely underlying diagnosis?
Stone impacted in Whartons duct
Stone impacted in Stensens duct
Benign adenoma of the submandibular gland
Adenocarcinoma of the submandibular gland
Squamous cell carcinoma of the submandibular gland
The symptoms are typical for sialolithiasis. The stones most commonly form in the submandibular gland and therefore may occlude Whartons duct. Stensens duct drains the parotid gland.
Of the list below, which is not a cause of avascular necrosis?
Steroids
Sickle cell disease
Radiotherapy
Myeloma
Caisson disease
P ancreatitis
L upus
A lcohol
S teroids
T rauma
I diopathic, infection
C aisson disease, collagen vascular disease
R adiation, rheumatoid arthritis
A myloid
G aucher disease
S ickle cell disease
Steroid containing therapy for myeloma may induce avascular necrosis, however the disease itself does not cause it. Caisson disease as may occur in deep sea divers is a recognised cause.
The foramen marking the termination of the adductor canal is located in which of the following?
Adductor longus
Adductor magnus
Adductor brevis
Sartorius
Semimembranosus
The foramen marking the distal limit of the adductor canal is contained within adductor magnus. The vessel passes through this region to enter the popliteal fossa.
Borders of the adductor canal?
Laterally: Vastus medialis
Posteriorly: Adductor longus, adductor magnus
Roof: sartorius
Contents of the adductor canal
Saphenous nerve
Superficial femoral artery
Superficial femoral vein
Interparietal hernia occurring at the level of the arcuate line
Rare
May lie beneath internal oblique muscle. Usually between internal and external oblique
Equal sex distribution
Position is lateral to rectus abdominis
Both open and laparoscopic repair are possible, the former in cases of strangulation
Spigelian hernia
The lumbar triangle (through which these may occur) is bounded by:
Crest of ilium (inferiorly)
External oblique (laterally)
Latissimus dorsi (medially)
Primary lumbar herniae are rare, most are incisional hernias following renal surgery
- Direct anatomical repair with or without mesh re-enforcement is the procedure of choice
Lumbar hernia
Herniation through the obturator canal
Commoner in females
Usually lies behind pectineus muscle
Elective diagnosis is unusual most will present acutely with obstruction
When presenting acutely most cases with require laparotomy or laparoscopy (and small bowel resection if indicated)
Obturator hernia
Condition in which part of the wall of the small bowel (usually the anti mesenteric border) is strangulated within a hernia (of any type)
They do not present with typical features of intestinal obstruction as lumenal patency is preserved
Where vomiting is prominent it usually occurs as a result of paralytic ileus from peritonitis (as these hernias may perforate)
Richters hernia
Occur through sites of surgical access into the abdominal cavity
Most common following surgical wound infection
To minimise following midline laparotomy Jenkins Rule should be followed and this necessitates a suture length 4x length of incision with bites taken at 1cm intervals, 1 cm from the wound edge
Repair may be performed either at open surgery or laparoscopically and a wide variety of techniques are described
Incisional hernia
Jenkin’s Rule
suture length 4x length of incision with bites taken at 1cm intervals, 1 cm from the wound edge
Typically congenital diaphragmatic hernia
85% cases are located in the left hemi diaphragm
Associated with lung hypoplasia on the affected side
More common in males
Associated with other birth defects
May contain stomach
May be treated by direct anatomical apposition or placement of mesh. In infants that have severe respiratory compromise mechanical ventilation may be needed and mortality rate is high
Bochdalek hernia
Rare type of diaphragmatic hernia (approx 2% cases)
Herniation through foramen of Morgagni
Usually located on the right and tend to be less symptomatic
More advanced cases may contain transverse colon
As defects are small pulmonary hypoplasia is less common
Direct anatomical repair is performed
Morgagni Hernia
Hernia through weak umbilicus
Usually presents in childhood
Often symptomatic
Equal sex incidence
95% will resolve by the age of 2 years
Surgery performed after the third birthday
Umbilical hernia
Usually a condition of adulthood
Defect is in the linea alba
More common in females
Multiparity and obesity are risk factors
Traditionally repaired using Mayos technique - overlapping repair, mesh may be used though not if small bowel resection is required owing to acute strangulation
Paraumbilical hernia
Hernia containing Meckels diverticulum
Resection of the diverticulum is usually required and this will preclude a mesh repair
Littres hernia
Theme: Infective organisms
A.Clostridium difficle
B.Cryptosporidium
C.Escherichia coli
D.Streptococcus bovis
E.Staphylococcus epidermidis
F.Clostridium botulinum
G.Staphylococcus aureus
H.Streptococcus pyogenes
Please select the most likely microorganism for the infection scenarios given. Each option may be used once, more than once or not at all.
1.A 56 year old man undergoes a difficult colonoscopy for assessment of a caecal cancer. 48 hours after the procedure he is admitted with septicaemia. His abdomen is soft and non tender. Blood cultures grow gram positive cocci.
Streptococcus bovis
Streptococcus bovis septicaemia is associated with carcinoma of the colon. It also can also cause endocarditis.
Which of the following is the first vessel to branch from the external carotid artery?
Superior thyroid artery
Inferior thyroid artery
Lingual artery
Facial artery
Occipital artery
Mnemonic
The first branch of the external carotid artery is the superior thyroid artery. The inferior thyroid artery is derived from the thyrocervical trunk. The other branches are illustrated below.
(Order in which they branch off)Some (sup thyroid)Attendings (Ascending Pharyngeal)Like (Lingual)Freaking (Facial)Out (Occipital)Potential (Post auricular)Medical (Maxillary)Students (Sup temporal)
Surface marking of the carotid
This is an imaginary line drawn from the bifurcation of the common carotid passing behind the angle of the jaw to a point immediately anterior to the tragus of the ear.
Theme: Electrolyte disorders
A.Hypotonic hypovolaemic hyponatraemia
B.Hypotonic hypervolaemic hyponatraemia
C.Pseudohyponatraemia
D.Syndrome of inappropriate ADH secretion (SIADH)
E.Hypertonic hyponatraemia
F.Over administration 5% dextrose
Please select the most likely reason for hyponatraemia for each scenario given. Each option may be used once, more than once or not at all.
5.A 73 year old man presents to pre operative clinic for an elective total hip replacement. He is on frusemide for hypertension. He is found to have the following blood results:
Na 120
Urine Na 10 (low)
Serum osmolality 280 (normal)
A 67 year old man presents to pre operative clinic for an elective hernia repair. He is on frusemide for heart failure. He is found to have the following blood results:
Na 120
Urine Na 35 (high)
Urine osmolality 520 (high)
Serum osmolality 265 (low)
A 77 year old man presents to pre operative clinic for a total knee replacement. He is on frusemide for hypertension. He is known to have multiple myeloma. He is found to have the following blood results:
Na 120
Serum osmolality 280 (normal)
Urine osmolality normal
Urine Na normal
Hypotonic hypovolaemic hyponatraemia
The blood results reflect extra-renal sodium loss. The body is trying to preserve the sodium by not allowing any sodium into the urine (hence the low Na in the urine). Note with renal sodium loss the Urinary sodium is high.
Syndrome of inappropriate ADH secretion (SIADH)
This blood picture fits with SIADH. SIADH causes retention of fluid from the urine (concentrated urine) into the blood vessels, therefore diluting the fluid in the blood vessels (low osmolality). Management involves removing the cause and fluid restriction.
Pseudohyponatraemia
Hyperlipidaemia and multiple myeloma are known to cause a pseudohyponatraemia.
Causes of pseudohyponatraemia
Hyperlipidaemia and mutliple myeloma are known to cause a pseudohyponatraemia
How can hyponatraemia be classified?
Based on urinary sodium
Causes of hyponatraemia:
Urinary sodium >20mmol/l
Sodium depletion, renal loss
Patient often hypovolaemic
Diuretics (thiazides)
Addison’s
Diuretic stage of renal failure
SIADH (serum osmolality low, urine osmolality high, urine Na high)
Patient often euvolaemic
Causes of hyponatraemia:
Urinary sodium <20mmol/l
Sodium depletion, extra-renal loss
Diarrhoea, vomiting, sweating
Burns, adenoma of rectum (if villous lesion and large)
Causes of hyponatraemia:
Water excess
Secondary hyperaldosteronism: CCF, cirrhosis
Reduced GFR: renal failure
IV dextrose, psychogenic polydipsia
Management of acute hyponatraemia
Acute hyponatraemia with Na <120: immediate therapy. Central Pontine Myelinolisis, may occur from overly rapid correction of serum sodium. Aim to correct until the Na is > 125 at a rate of 1 mEq/h. Normal saline with frusemide is an alternative method.
How can sodium requirement in hyponatraemia be calculated?
(125 - serum sodium) x 0.6 x body weight = required mEq of sodium
Should be replaced at a rate of 1mEq/h
Theme: Feeding options
A.Feeding jejunostomy
B.Percutaneous endoscopic gastrostomy
C.Total parenteral nutrition
D.Naso gastric feeding tube
E.Elemental diet orally
F.Normal oral intake
Please select the most appropriate method of delivering nutrition in each of the following scenarios. Each option may be used once, more than once or not at all.
8.A 28 year old man is comatose, from head injuries, on the neurosurgical intensive care unit. Apart from a parietal fracture there is no bony injury. He is recovering well and should be extubated soon.
A 56 year old man has undergone a potentially curative oesophagectomy for carcinoma
A 43 year old man is recovering from a laparoscopic low anterior resection with loop ileostomy.
The correct answer is Naso gastric feeding tube
The feeding of head injured patients was reviewed in a 2008 Cochrane report. They concluded that the overall evidence base was poor. However, there was a trend for the enteral route, with NG feeding in the later stages following injury. This is contra indicated if there are signs of basal skull fractures.
Feeding jejunostomy
Feeding jejunostomy is the standard of care in most centres. Naso jejunal tubes are preferred by some surgeons. However, if they become displaced the only alternative then becomes TPN.
Normal oral intake
Early feeding in this situation is both safe and will enhance recovery.
Naso gastric feeding
Usually administered via fine bore naso gastric feeding tube
Complications relate to aspiration of feed or misplaced tube
May be safe to use in patients with impaired swallow
Often contra indicated following head injury due to risks associated with tube insertion
Naso jejunal feeding
Avoids problems of feed pooling in stomach (and risk of aspiration)
Insertion of feeding tube more technically complicated (easiest if done intra operatively)
Safe to use following oesophagogastric surgery
Feeding jejunostomy
Surgically sited feeding tube
May be used for long term feeding
Low risk of aspiration and thus safe for long term feeding following upper GI surgery
Main risks are those of tube displacement and peritubal leakage immediately following insertion, which carries a risk of peritonitis
Percutaneous endoscopic gastrostomy
Combined endoscopic and percutaneous tube insertion
May not be technically possible in those patients who cannot undergo successful endoscopy
Risks include aspiration and leakage at the insertion site
Total parenteral nutrition
The definitive option in those patients in whom enteral feeding is contra indicated
Individualised prescribing and monitoring needed
Should be administered via a central vein as it is strongly phlebitic
Long term use is associated with fatty liver and deranged LFT’s
Which of the following cellular types or features is not seen in sarcoidosis?
Reed Sternberg Cells
T lymphocytes
Macrophages
Asteroid bodies
B lymphocytes
Reed Sternberg cells are seen in Hodgkins disease. All of the other cell types are seen in sarcoid.
A 41 year old lady with colicky right upper quadrant pain is identified as having gallstones on an abdominal ultrasound scan. What is the most appropriate course of action?
Laparoscopic cholecystectomy
Open cholecystectomy
Liver function tests
MRCP
ERCP
Liver function testing is part of the core diagnostic work up of biliary colic and surgical planning cannot proceed until this (and the diameter of the CBD on USS) are known.
What proportion of pateints receiving gallbladder surgery will have a stone in the CBD?
12%
What is the composition of the majority of gallstones?
Mixed composition
Pure cholesterol stones account for 20% of cases
The classical symptoms are of colicky right upper quadrant pain that occurs post prandially. The symptoms are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal
Gallstones
Right upper quadrant pain
Fever
Murphys sign on examination
Occasionally mildly deranged LFT’s (especially if Mirizzi syndrome)
Acute cholecystitis
Colicky abdominal pain, worse post prandially, worse after fatty foods
Biliary colic
Usually prodromal illness and right upper quadrant pain
Swinging pyrexia
Patient may be systemically unwell
Generalised peritonism not present
Gallbladder abscess
Patient severely septic and unwell
Jaundice
Right upper quadrant pain
Cholangitis
Patients may have a history of previous cholecystitis and known gallstones
Small bowel obstruction (may be intermittent)
Gallstone ileus
Patients with inter current illness (e.g. diabetes, organ failure)
Patient often systemically unwell
Gallbladder inflammation in absence of stones
High fever
Acalculous cholecystitis
Management of biliary colic
If imaging shows gallstones and history compatible then laparoscopic cholecystectomy
Management of acute cholecystitis
Imaging (USS) and cholecystectomy (ideally within 48 hours of presentation) (2)
Management of gallbladder abscess
Imaging with USS +/- CT Scanning
Ideally surgery, sub total cholecystectomy may be needed if Calots triangle is hostile
In unfit patients percutaneous drainage may be considered
Management of cholangitis
Fluid resuscitation
Broad spectrum intravenous antibiotics
Correct any coagulopathy
Early ERCP
Management of gallstone ileus
Laparotomy and removal of gallstone from small bowel, the enterotomy must be made proximal to the site of obstruction and not at the site of obstruction. The fistula between the gallbladder and duodenum should not be interfered with.
Management of acalculous cholecystitis
If patient fit then cholecystectomy, if unfit then percutaneous cholecystostomy
Treatment of asymptomatic gallstones
Expectant management
Approach to stones in the CBD
During the course of the procedure some surgeons will routinely perform either intra operative cholangiography or laparoscopic USS to either confirm anatomy or to exclude CBD stones. The latter may be more easily achieved by use of laparoscopic ultrasound. If stones are found then the options lie between early ERCP in the day or so following surgery or immediate surgical exploration of the bile duct. When performed via the trans cystic route this adds little in the way of morbidity and certainly results in faster recovery. Where transcystic exploration fails the alternative strategy is that of formal choledochotomy. The exploration of a small duct is challenging and ducts of less than 8mm should not be explored. Small stones that measure less than 5mm may be safely left and most will pass spontaneously.
Risks of ERCP
Bleeding 0.9% (rises to 1.5% if sphincterotomy performed)
Duodenal perforation 0.4%
Cholangitis 1.1%
Pancreatitis 1.5%
Which of the following diseases is not considered a risk factor for gastric cancer?
Polya gastrectomy for antral ulcer
Atrophic gastritis
Intestinal metaplasia of columnar type at the gastric cardia
Patient with polyp showing medium grade dysplasia
Long term therapy with H2 blockers
Although some acid lowering procedures increase the risk of gastric cancer the use of H2 blockers does not, at the present time, seem to increase the risk.
How are tumours of the GOJ classified?
Type 1: True oesophageal cancers
Type 2: Carcinoma of the cardia, arising from cardiac type epthielium or short segments with intestinal metaplsaia.
Type 3: sub cardial cancers that spread across the junction. Involve similar nodal stations to gastric cancer
What symptoms should prompt a referral to endoscopy in patients of any age with dyspepsia
Chronic GI bleeding
Dysphagia
Weight loss
IDA
Upper abdominal mass
What symptoms should prompt a referral to endoscopy in patients without dyspepsia
Dysphagia
Unexplained abdominal pain or weight loss
Vomiting.
Upper abdominal mass
Jaundice
What symptoms should prompt a referral to endoscopy in patients with worsening dyspepsia?
Barretts oesophagus
Intestinal metaplasia
Dysplasia
Atrophic gastritis
Patients >55 with unexplanied or persistent dyspepsia
Staging of gastric cancer
CT scanning of the chest abdomen and pelvis is the routine first line staging investigation in most centres.
Laparoscopy to identify occult peritoneal disease
PET CT (particularly for junctional tumours)
Treatment of proximally sited gastric cancers?
Proximally sited disease greater than 5-10cm from the OG junction may be treated by sub total gastrectomy
Treatment of gastric cancer if tumour is <5cm from OGJ
Total gastrectomy if tumour is <5cm from OG junction
Treatment of type 2 gastric cancers?
For type 2 junctional tumours (extending into oesophagus) oesophagogastrectomy is usual
Lymphadenectomy in gastric cancer
Lymphadenectomy should be performed. A D2 lymphadenectomy is widely advocated by the Japanese, the survival advantages of extended lymphadenectomy have been debated. However, the overall recommendation is that a D2 nodal dissection be undertaken.
D2 esentially suggests that nodal stations 1 and 2 should be excised
CTx in gastric cancer
Most patients will receive chemotherapy either pre or post operatively.
Which of the following is the first radiological change likely to be apparent in a plain radiograph of a 12 year old presenting with suspected Perthes disease
Multiple bone cysts
Sclerosis of the femoral head
Loss of bone density
Joint space narrowing
Collapse of the femoral head
In Catterall stage I disease there may be no radiological abnormality at all. In Stage II disease there may be sclerosis of the femoral head.
Indication for treatment (aide memoire):Half a dozen, half a head
Those aged greater than 6 years with >50% involvement of the femoral head should almost always be treated
Idiopathic avascular necrosis of the femoral epiphysis of the femoral head
Impaired blood supply to femoral head, causing bone infarction. New vessels develop and ossification occurs. The bone either heals or a subchondral fracture occurs.
Perthes disease
Males 4x’s greater than females
Age between 2-12 years (the younger the age of onset, the better the prognosis)
Limp
Hip pain
Bilateral in 20%
Perthes disease
What is used to stage Perthes disease?
Catterall staging
Catterall 1
Clinical and histological features only
Catterall 2
Sclerosis with or without cystic changes and preservation of the articular surface
Catterall stage 3
Loss of structural integrity of the femoral head
Catterall stage 4
Loss of acetabular integrity
Management of Perthes disease
To keep the femoral head within the acetabulum: cast, braces
If less than 6 years: observation
Older: surgical management with moderate results
Operate on severe deformities
A 56 year old man is diagnosed as having a glioma. From which of the following cell types do these tumours usually originate?
Schwann cells
Oligodendrocytes
Ependymal cells
Squamous cells
Neuroglial cells
Gliomas originate from glial (otherwise known as neuroglial) cells. These serve a structural function in the CNS. The tumours produced may resemble a number of CNS cell types. Tumours are therefore named according to the cells they resemble rather than the origin. Where this is not possible they are termed gliomas.
Subtypes of gliomas
Ependymomas- Ependymal cells
Astocytomas- Astrocytes (including glioblastoma)
Oligodendrogliomas- Oligodendrocytes
Mixed- e.g. oligoastrocytomas
Normal anion gap metabolic acidosis
Hyperchloraemic:
Gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula
Renal tubular acidosis
Drugs: e.g. acetazolamide
Ammonium chloride injection
Addison’s disease
Raised anion gap metabolic acidosis
Lactate
Ketones
Urate
Acid poisoning
A 78 year old man presents with unilateral deafness which has been present for the past 3 months. On examination, Webers test localises to the contralateral side and a CT scan of his head shows a thickened calvarium with areas of sclerosis and radiolucency. His blood tests show an elevated alkaline phosphatase, normal serum calcium and normal PTH levels. Which of the following is the most likely underlying diagnosis?
Multiple myeloma with skull involvement
Osteoporosis
Pagets disease with skull involvement
Lung cancer with skull metastasis
Osteopetrosis with skull involvement
Of the conditions listed Pagets disease is the most likely diagnosis (skull vault expansion and sensorineural hearing loss). Multiple myeloma would typically result in multiple areas of radiolucency and usually raised calcium in this setting. Osteopetrosis is a recognised cause of the features described. However, it is a rare inherited disorder and usually presents in children in young adults. Presentation at this stage with no prior symptoms would be extremely rare and therefore this is not the most likelydiagnosis.
Indications for treatment in Paget’s disease?
Bone pain
Skull or long bone deformity
Fracture
Periarticular Paget’s
Cx of Paget’s
Deafness (cranial nerve entrapment)
Bone sarcoma
Fractures
Skull thickening
High output cardiac failure
Theme: Anaesthetic agents
A.Etomidate
B.Ketamine
C.Propofol
D.Sodium thiopentone
E.Methohexitone
F.Metaraminol
G.Midazolam
Please select the most appropriate anaesthetic induction agent for the procedure described. Each option may be used once, more than once or not at all.
7.A 32 year old man is admitted for a trendelenberg procedure for varicose veins. He is known to have porphyria.
A 77 year old lady with unstable ischaemic heart disease requires an emergency femoral hernia repair. She is volume depleted and slightly hypotensive.
A 22 year old man is brought to theatre for an emergency apppendicectomy for generalised peritonitis. He is vomiting.
Propofol
This is a daycase procedure for which propofol is ideal. Sodium thiopentone and etomidate are contraindicated in porphyria.
Ketamine
Ketamine is not negatively inotropic and will not depress cardiac output. Propofol and Sodium thiopentone will produce myocardial depression. Some doctors may also consider etomidate. However, it may cause adrenal suppression and post operative vomiting- which she is at high risk of developing.
Sodium thiopentone
Most anaesthetists would use sodium thiopentone for a rapid sequence induction (which this man will need).
Rapid onset of anaesthesia
Pain on IV injection
Rapidly metabolised with little accumulation of metabolites
Proven anti emetic properties
Moderate myocardial depression
Widely used especially for maintaining sedation on ITU, total IV anaesthesia and for daycase surgery
Propofol
Extremely rapid onset of action making it the agent of choice for rapid sequence of induction
Marked myocardial depression may occur
Metabolites build up quickly
Unsuitable for maintenance infusion
Little analgesic effects
Sodium thiopentone
May be used for induction of anaesthesia
Has moderate to strong analgesic properties
Produces little myocardial depression making it a suitable agent for anaesthesia in those who are haemodynamically unstable
May induce state of dissociative anaesthesia resulting in nightmares
Ketamine
Has favorable cardiac safety profile with very little haemodynamic instability
No analgesic properties
Unsuitable for maintaining sedation as prolonged (and even brief) use may result in adrenal suppression
Post operative vomiting is common
Etomidate
A tall 32 year old lady presents with a diffuse neck swelling a carcinoma of the thyroid medullary type is diagnosed.
This is a case MEN type IIb. It is associated with phaeochromocytomas and is transmitted in an autosomal dominant pattern if inherited. All MEN II tend to have medullary carcinoma of the thyroid as a presenting feature
A 32 year old man is undergoing a splenectomy. Division of which of the following will be necessary during the procedure?
Left crus of diaphragm
Short gastric vessels
Gerotas fascia
Splenic flexure of colon
Marginal artery
During a splenectomy the short gastric vessels which lie within the gastrosplenic ligament will need to be divided. The splenic flexure of the colon may need to be mobilised. However, it will almost never need to be divided, as this is watershed area that would necessitate a formal colonic resection in the event of division.
Theme: Biological therapies
A.Bevacizumab
B.Infliximab
C.Trastuzumab
D.Basiliximab
E.Imatinib
F.Cetuximab
Please select the most appropriate biological agent for the situation described. Each option may be used once, more than once or not at all.
14.A 32 year old lady has previously undergone a wide local excision and axillary node clearance (5 nodes positive) for an invasive ductal carcinoma. It is oestrogen receptor negative, HER 2 positive, vascular invasion is present. She has a lesion suspicious for metastatic disease in the left lobe of her liver.
A 22 year old lady has severe peri anal crohns disease with multiple anal fistulae, the acute sepsis has been drained and setons are in place. She is already receiving standard non biological therapy.
A 63 year old man presents with a locally unresectable gastrointestinal stromal tumour. Biopsies confirm that it is KIT positive.
Trastuzumab
This ladies young age, coupled with ER negativity and extensive nodal disease with suspicion of metastatic disease makes her a candidate for treatment with trastuzumab (herceptin).
Infliximab
Infliximab is a popular choice in managing complex peri anal crohns. It is absolutely vital that all sepsis is drained prior to starting therapy.
Imatinib
Imatinib is licensed for treatment of GIST in the United Kingdom for this situation. The guidance from the National Institute of Clinical evidence is that patients be reviewed at 12 weeks after initiating therapy.
TNF alpha inhibitor
Adalimumab
Infliximab
Etanercept
Anti VEGF (anti angiogenic)
Bevacizumab
HER receptor antagonist
Trastuzumab
Tyrosine kinase inhibitor
Imatinib
IL2 binding site
Basiliximab
Epidermal growth factor inhibitor
Cetuximab
Uses of bevacizumab
Colorectal cancer
Renal
Glioblastoma
Uses of imatinib
Gastrointestinal stromal tumours
Chronic myeloid leukaemia
Use of cetuximab
EGF positive colorectal cancers
Which structure separates the cephalic vein and the brachial artery in the antecubital fossa?
Brachioradialis muscle
Biceps muscle
Origin of flexor digitorum profundus muscle
Pronator quadratus muscle
Origin of flexor digitorum superficialis muscle
Biceps muscle
A 45 year old man presents with symptoms of urinary colic. In the history he has suffered from recurrent episodes of frank haematuria over the past week or so. On examination he has a left loin mass and a varicocele. The most likely diagnosis is:
Renal adenocarcinoma
Renal cortical adenoma
Squamous cell carcinoma of the renal pelvis
Retroperitoneal fibrosis
Nephroblastoma
Renal adenocarcinoma are the most common renal malignancy and account for 75% cases.
Patients may develop frank haematuria and have episodes of clot colic.
A Grawitz tumour is an eponymous name for Renal Adenocarcinoma.
May metastasise to bone.
A 24 year old motor cyclist is involved in a road traffic accident. He suffers a tibial fracture which is treated with an intra medullary nail. Post operatively he develops a compartment syndrome. Surgical decompression of the anterior compartment will relieve pressure on all of the following muscles except?
Peroneus brevis
Peroneus tertius
Extensor digitorum longus
Tibialis anterior
None of the above
The anterior compartment contains:
Tibialis anterior
Extensor digitorum longus
Peroneus tertius
Extensor hallucis longus
Anterior tibial artery
All the muscles are innervated by the deep peroneal nerve.
Contents of the peroneal compartment
Peroneus longus
Peroneus brevis
Innervation of the peroneal compartment
Superficial peroneal nerve
Contents of the superficial posterior compartment
Gastrocnemius
Plantaris (absent in 10%)
Soleus
Innervation of the superficial posterior compartment
Tibial nerve
Contents of the deep posterior compartment
Popliteus
Flexor digitorum longus
Flexor hallucis longus
Tibialis posterior
Innervation of the deep posterior compartment
Tibial
A 43 year old lady underwent an attempted placement of a central line into the internal jugular vein. Unfortunately, the doctor damaged the carotid artery and this necessitated surgical exploration. As the surgeons incise the carotid sheath a nerve is identified lying between the internal jugular vein and the carotid artery. Which of the following is this nerve most likely to be?
Glossopharyngeal nerve
Hypoglossal nerve
Superior laryngeal nerve
Recurrent laryngeal nerve
Vagus
The vagus lies in the carotid sheath. The hypoglossal nerve crosses the sheath, but does not lie within it.
At what level does the carotid divide into the ECA and ICA?
At the upper border of the thyroid
Path of the common carotid
Passes behind the SCJ to the upper border of the thyroid
At what level is the carotid crossed by omohyoid?
C6
What happpens to the carotid after being crossed by the omohyoid
Crossed by thyrohyoid, sternohyoid, sternomastoid
Where is the carotid tubercle?
Transverse process of C6- compression here stops haemorrhage
Relation between the inferior thyroid and CCA?
Inferior thyroid passes posterior to the CCA
A patient has a chest drain insertion. There is fresh blood at the chest drain insertion area. Which vessel has been damaged?
Pericardiophrenic artery
Intercostal vein
Right ventricle
Vagus artery
Intercostal artery
The intercostal vein is more superior than the artery and is thus slightly less susceptible to injury.
Within the intercostal spaces there are thin, strong muscles, intercostal vessels, nerves and lymphatics. There are 3 intercostal muscle layers corresponding to the lateral abdominal wall; external, internal, innermost intercostals. At the mid axillary line there are thin intracostals which is an extension of the internal intercostal muscle. In each intercostal space lies the neurovascular bundle, comprising, from superior to inferiorly; the posterior intercostal vein, artery and nerve, lying protected in the subcostal groove of the rib above and situated between the second and third layer of the intercostal muscles. These blood vessels anastomose anteriorly with the anterior intercostal vessels, which arise from the internal thoracic artery and vein.
Two teenagers are playing with an airgun when one accidentally shoots his friend in the abdomen. He is brought to the emergency department. On examination there is a bullet entry point immediately to the right of the rectus sheath at the level of the 1st lumbar vertebra. Which of the following structures is most likely to be injured by the bullet?
Head of pancreas
Right ureter
Right adrenal gland
Fundus of the gallbladder
Gastric antrum
The fundus of the gallbladder lies at this level and is the most superficially located structure.
Which of the following muscles inserts onto the lesser tuberostiy of the the humerus?
Subscapularis
Deltoid
Supraspinatus
Teres minor
Infraspinatus
With the exception of subscapularis which inserts into the lesser tuberosity, the muscles of the rotator cuff insert into the greater tuberosity.
What is the mechanism of action of macrolides?
Causes misreading of mRNA
Interferes with cell wall formation
Inhibits DNA synthesis
Inhibits RNA synthesis
Inhibits protein synthesis
Macrolides act by inhibiting bacterial protein synthesis. If pushed to give an answer they are bacteriostatic in nature, but in reality this depends on the dose and type of organism being treated. Erythromycin was the first macrolide used clinically. Newer examples include clarithromycin and azithromycin.
Adverse effects of erythromycin
gastrointestinal side-effects are common
cholestatic jaundice: risk may be reduced if erythromycin stearate is used
P450 inhibitor
Inhibit cell wall formation
penicillins
cephalosporins
Abx
Inhibit protein synthesis
aminoglycosides (cause misreading of mRNA)
chloramphenicol
macrolides (e.g. erythromycin)
tetracyclines
fusidic acid
Abx: Inhibit DNA synthesis
quinolones (e.g. ciprofloxacin)
metronidazole
sulphonamides
trimethoprim
Abx inhibiting RNA synthesis
rifampicin
You embark on a laparoscopic appendicectomy and find an appendix mass. There is no free fluid and the patient has no evidence of peritonitis. Which is the best option?
Convert to a midline laparotomy and perform a limited right hemicolectomy and end ileostomy
Convert to midline laparotomy and perform and appendicectomy after taking down the adhesions
Place a drain laparoscopically and administer parenteral antibiotics
Send the patient for CT guided drainage
Wrap omentum around the area and avoid drainage
Attempt conservative management for appendix mass without peritonitis.
Dissection of appendix masses can be associated with a considerable degree of morbidity, the gains of formally dissecting them over simple drainage and antibiotics are minimal.
This was initially described as the Ochsner-Sherren regime and was based on the teachings of Albert Ochsner of Chicago and James Sherren of the London hospital. The key facts of both methods (which essentially consisted of non surgical management and careful observation) were combined and published by Hamilton Bailey in 1930 (Bailey H. The Oschner- Sherren treatment of acute appendicitis. BMJ 1930 Jan 25; 1(3603): 140143.)
Classical history in appendicits
Peri umbilical abdominal pain (visceral stretching of appendix lumen and appendix is mid gut structure) radiating to the right iliac fossa due to localised parietal peritoneal inflammation.
Vomit once or twice but marked and persistent vomiting is unusual.
Diarrhoea is rare. However, pelvic appendicitis may cause localised rectal irritation and some loose stools. A pelvic abscess may also cause diarrhoea.
Mild pyrexia is common - temperature is usually 37.5 -38oC. Higher temperatures are more typical of conditions like mesenteric adenitis.
Anorexia is very common. It is very unusual for patients with appendicitis to be hungry.
Theme: Groin masses
A.Femoral hernia
B.Lymphadenitis
C.Inguinal hernia
D.Psoas abscess
E.Saphenous varix
F.Femoral artery aneurysm
G.Metastatic lymphadenopathy
H.Lymphoma
I.False femoral artery aneurysm
What is the likely diagnosis for groin mass described? Each option may be used once, more than once, or not at all.
A 52 year old obese lady reports a painless grape sized mass in her groin area. She has no medical conditions apart from some varicose veins. There is a cough impulse and the mass disappears on lying down.
A 32 year old male is noted to have a tender mass in the right groin area. There are also red streaks on the thigh, extending from a small abrasion.
A 23 year old male suffering from hepatitis C presents with right groin pain and swelling. On examination there is a large abscess in the groin. Adjacent to this is a pulsatile swelling. There is no cough impulse.
Saphenous varix
The history of varicose veins should indicate a more likely diagnosis of a varix. The varix can enlarge during coughing/sneezing. A blue discolouration may be noted.
Lymphadenitis
The red streaks are along the line of the lymphatics, indicating infection of the lymphatic vessels. Lymphadenitis is infection of the local lymph nodes.
False femoral artery aneurysm
False aneurysms may occur following arterial trauma in IVDU. They may have associated blood borne virus infections and should undergo duplex scanning prior to surgery. False aneurysms do not contain all layers of the arterial wall.
Def: false aneurysm
Do not contain all the layers of the arterial wall
Key questions regarding groin lumps
Is there a cough impulse
Is it pulsatile AND is it expansile (to distinguish between false and true aneurysm)
Are both testes intra scrotal
Any lesions in the legs such as malignancy or infections (?lymph nodes)
Examine the ano rectum as anal cancer may metastasise to the groin
Is the lump soft, small and very superficial (?lipoma)
A 48 year old women suffers blunt trauma to the head and develops respiratory compromise. As a result she develops hypercapnia. Which of the following effects is most likely to ensue?
Cerebral vasoconstriction
Cerebral vasodilation
Cerebral blood flow will remain unchanged
Shunting of blood to peripheral tissues will occur in preference to CNS perfusion
None of the above
Hypercapnia will tend to produce cerebral vasodilation. This is of considerable importance in patients with cranial trauma as it may increase intracranial pressure.
Theme: Causes of arterial occlusion
A.Vasculitis
B.Steal syndrome
C.Thrombosis
D.Foreign body embolus
E.Clot embolus
F.Vasospasm
G.Direct arterial injury
Please select the most likely underlying cause for the scenario provided. Each option may be used once, more than once or not at all.
31.A 73 year old lady develops a cold, pulseless hand 3 days following a myocardial infarction.
A 6 year old child has suffered a displaced supracondylar humeral fracture. On examination, they have a cold and insensate hand with absent pulses.
Clot embolus
The development of mural or atrial appendage thrombi may occur following a myocardial infarct and co-existing atrial fibrillation may contribute to the formation. They tend to present with classical features of an embolic event.
Direct arterial injury
Both vasospasm and arterial injury may complicate supracondylar fractures and are seen in 1% of all cases. Vasospasm is usually transient and more likely when the injury is minor and reduced early. Severely displaced injuries and those with more advanced signs are usually associated with direct arterial injury.
Vasculitis
This is likely to represent Buergers disease. It is commonest in young males who smoke heavily.
Vasculitis affecting aorta and branches
Takayasu’s
Buergers
GCA
Vasculitis affecting large and medium sized arteries
Buerger’s
GCA
PAN
Vasculitis affecting medium sized muscular arteries
PAN
Wegeners
Vasculitis affecting small muscular arteries
Wegeners
Rheumatoid
Inflammatory, obliterative arteritis affecting aorta and branches
Females> Males
Symptoms may include upper limb claudication
Clinical findings include diminished or absent pulses
ESR often affected during the acute phase
Takyasu’s arteritis
Segmental thrombotic occlusions of the small and medium sized lower limb vessels
Commonest in young male smokers
Proximal pulses usually present, but pedal pulses are lost
An acuter hypercellular occlusive thrombus is often present
Tortuous corkscrew shaped collateral vessels may be seen on angiography
Buergers disease
Systemic granulomatous arteritis that usually affects large and medium sized vessels
Females > Males
Temporal arteritis is commonest type
Granulomatous lesions may be seen on biopsy (although up to 50% are normal)
Giant cell arteritis
Systemic necrotising vasculitis affecting small and medium sized muscular arteries
Most common in populations with high prevalence of hepatitis B
Renal disease is seen in 70% cases
Angiography may show saccular or fusiform aneurysms and arterial stenoses
Polyarteritis nodosa
Predominantly affects small and medium sized arteries
Systemic necrotising granulomatous vasculitis
Cutaneous vascular lesions may be seen (ulceration, nodules and purpura)
Sinus imaging may show mucosal thickening and air fluid levels
Wegeners granulomatosis
A 73 year old lady is admitted for a laparoscopic cholecystectomy. During her pre-operative assessment it is noted that she is receiving furosemide for the treatment of hypertension. Approximately what proportion of the sodium that is filtered at the glomerulus will be subsequently excreted?
Up to 25%
Up to 75%
Between 3 and 5%
<2%
Between 1 and 2%
Up to 25%
The loop diuretics can lead to marked increases in the amount of sodium excreted. They act in the medullary and cortical aspects of the thick ascending limb of the loop of Henle. This results in a decreased medullary osmolal gradient and increases free water excretion (as well as loss of sodium). Because loop diuretics result in the loss of both sodium and water they are less frequently associated with hyponatraemia than thiazide diuretics (these latter agents act in the cortex and do not affect urine concentrating ability).
Location of effects: frusemide
Ascending limb
Location of action: distal tubule
Thiazides
Location of action: spironolactone
Cortical collecting tubule
Channel inhibited by frusemide
Na/K/2Cl
Carrier inhibited by thiazides
NaCl
Carrier affected by spironolactone
NA/K ATPase
% of filtered sodium excreted with thiazides
3-5%
% filtered sodium excreted with spironolactone
1-2%
Which of the following nerves is not contained within the posterior triangle of the neck?
Accessory nerve
Phrenic nerve
Greater auricular nerve
Ansa cervicalis
Lesser occiptal nerve
Ansa cervicalis is a content of the anterior triangle of the neck.
Boundaries of the posterior triangle of the neck
Apex: SCM adn trap at the occipital bone
Ant: posterior border of sternocleidomastoid
Post: anterior border of trapezius
Base: middle third of clavicle
Nerves in the posterior triangle of the neck
Accessory
Phrenic
Three trunks of the brachial plexus
Branches of the cervical plexus: supraclavicular, transverse cervical, greater auricular, lesser occipital
Vessels of the posterior triangle of the neck
EJV
Subclavian
Muscles in the posterior triangle of the neck
Inferior belly of omohyoid
Scalene
Lymph nodes in the posterior triangle of the neck
Supraclavicular
Occipital
A 42 year old lady is reviewed in the outpatient clinic following a routine surgical procedure. She complains of diminished sensation at the dorso-lateral aspect of her foot. Which of the following nerves is most likely to be affected?
Sural
Superficial peroneal
Deep peroneal
Medial plantar
Lateral plantar
The sural nerve supplies the lateral aspect of the foot. It runs alongside the short saphenous vein and may be injured in short saphenous vein surgery.
Innervation of the foot:
Lateral planatar
Sural
Innervation of the foot:
Dorsum (not 1st web space)
Superficial peroneal
Innervation of the foot:
1st web space
Deep peroneal
Innervation of the foot:
Extermities of toes
Medial and lateral plantar nerves
Innervation of the foot:
Proximal plantar
Tibial
Innervation of the foot:
Medial plantar
Medial plantar nerve
Innervation of the foot:
Lateral plantar (inferior aspect)
Lateral plantar nerve
Arterial supply of the prostate
Inferior vesical artery (from internal iliac)
Venous drainage of the prostate
Prostatic venous plexus (to paravertebral veins)
Lymphatic drainage of the prostate
Internal iliac nodes
Innervation of the prostate
Inferior hypogastric plexus
Dimensions of the prostate
Transverse: 4cm
AP: 2cm
3cm height
Lobes of the prostate
Posterior lobe: posterior to urethra
Median lobe: posterior to urethra, between ejaculatory ducts.
Lateral lobes x2
Isthmus
Zones of the prostate
Peripheral zone: subcapsular portion- most prostate cancers are here
Central zone
Transition zone
Stroma
Anterior relations of the prostate
Pubic symphysis
Prostatic venous plexus
Posterior relations of the prostate
Denonvilliers fascia
Rectum
Ejaculatory ducts
Lateral relations of the prostate
Venous plexus (on prostate)
Levator ani (immediately below the puboprostatic ligaments)
A 73 year old man has an arterial line in situ. On studying the trace the incisura can be seen. What is the physiological event which accounts for this process?
Atrial repolarisation
Mitral valve closure
Ventricular repolarisation
Elastic recoil of the aorta
Tricuspid valve closure
It is the temporary rise in aortic pressure occurring as a result of elastic recoil.
Adrenoreceptors of the heart?
Beta 1
What are the phases of the cardiac cycle
Mid diastole
Late diastole
Early systole
Late systole
Early diastole
AV valves open. Ventricles hold 80% of final volume. Outflow valves shut. Aortic pressure is high.
Mid diastole
Atria contract. Ventricles receive 20% to complete filling. Typical end diastolic volume 130-160ml.
Late diastole
AV valves shut. Ventricular pressure rises. Isovolumetric ventricular contraction. AV Valves bulge into atria (c-wave). Aortic and pulmonary pressure exceeded- blood is ejected. Shortening of ventricles pulls atria downwards and drops intra atrial pressure (x-descent).
Early systole
Ventricular muscles relax and ventricular pressures drop. Although ventricular pressure drops the aortic pressure remains constant owing to peripheral vascular resistance and elastic property of the aorta. Brief period of retrograde flow that occurs in aortic recoil shuts the aortic valve. Ventricles will contain 60ml end systolic volume. The average stroke volume is 70ml (i.e. Volume ejected).
Late systole
All valves are closed. Isovolumetric ventricular relaxation occurs. Pressure wave associated with closure of the aortic valve increases aortic pressure. The pressure dip before this rise can be seen on arterial waveforms and is called the incisura. During systole the atrial pressure increases such that it is now above zero (v- wave). Eventually atrial pressure exceed ventricular pressure and AV valves open - atria empty passively into ventricles and atrial pressure falls (y -descent )
Early diastole
Laplace’s law:
It states that for hollow organs with a circular cross section, the total circumferential wall tension depends upon the circumference of the wall, multiplied by the thickness of the wall and on the wall tension.
Starlings law
Increase in EDV will produce larger stroke volume
Where are cardiac baroreceptors found?
Baroreceptors located in aortic arch and carotid sinus.
Aortic baroreceptor impulses travel via the vagus and from the carotid via the glossopharyngeal nerve.
They are stimulated by arterial stretch.
Even at normal blood pressures they are tonically active.
Increase in baroreceptor discharge causes:
Where are atrial stretch receptors found?
Located in atria at junction between pulmonary veins and vena cava.
Stimulated by atrial stretch and are thus low pressure sensors.
Increased blood volume will cause increased parasympathetic activity.
Bainbridge reflex
Very rapid infusion of blood will result in increase in heart rate mediated via atrial receptors: the Bainbridge reflex.
A 59 year old man presents with recurrent episodes of urinary sepsis. In his history he mentions that he has suffered from recurrent attacks of left iliac fossa pain over the past few months. He has also notices bubbles in his urine. He undergoes a CT scan which shows a large inflammatory mass in the left iliac fossa. No other abnormality is detected. The most likely diagnosis is:
Ulcerative colitis
Crohns disease
Mesenteric ischaemia
Diverticular disease
Rectal cancer
Diverticular disease is one of the commonest causes of colovesical fistula
Recurrent attacks of diverticulitis may cause the development of local abscesses which may erode into the bladder resulting in urinary sepsis and pneumaturia. This would be an unusual presentation from Crohns disease and rectal cancer would be more distally sited and generally evidence of extra colonic disease would be present if the case were malignant and this advanced.
Def: diverticular disease
Herniation of colonic mucosa through the muscular wall of the colon. The usual site is between the taenia coli, where vessels pierce the muscle to supply the mucosa. For this reason, the rectum is often spared
Complications of diverticular disease
Diverticulitis
Haemorrhage
Development of fistula
Perforation and faecal peritonitis
Perforation and development of abscess
Development of diverticular phlegmon
What can be used to classif the severity of diverticulitis
Hinchey classification
Hinchey 1
Para-colonic abscess
Hinchey 2
Pelvic abscess
Hinchey 3
Purulent peritonitis
Hinchey 4
Faecal peritonitis
Management of diverticulitis
Increase dietary fibre intake.
Mild attacks of diverticulitis may be managed conservatively with antibiotics.
Peri colonic abscesses should be drained either surgically or radiologically.
Recurrent episodes of acute diverticulitis requiring hospitalisation are a relative indication for a segmental resection.
Hinchey IV perforations (generalised faecal peritonitis) will require a resection and usually a stoma. This group have a very high risk of post operative complications and usually require HDU admission. Less severe perforations may be managed by laparoscopic washout and drain insertion.
A 56 year old lady is undergoing an adrenalectomy for Conns syndrome. During the operation the surgeon damages the middle adrenal artery and haemorrhage ensues. From which of the following structures does this vessel originate?
Aorta
Renal artery
Splenic artery
Coeliac axis
Superior mesenteric artery
The middle adrenal artery is usually a branch of the aorta, the lower adrenal artery typically arises from the renal vessels.
Arterial supply of the adrenals
Superior adrenal arteries- from inferior phrenic artery, Middle adrenal arteries - from aorta, Inferior adrenal arteries -from renal arteries
def: cryptorchidism
A congenital undescended testis is one that has failed to reach the bottom of the scrotum by 3 months of age. At birth up to 5% of boys will have an undescended testis, post natal descent occurs in most and by 3 months the incidence of cryptorchidism falls to 1-2%. In the vast majority of cases the cause of the maldescent is unknown. A proportion may be associated with other congenital defects including:
DDx for cryptorchidism
These include retractile testes and, in the case of absent bilateral testes the possibility of intersex conditions. A retractile testis can be brought into the scrotum by the clinician and when released remains in the scrotum. If the examining clinician notes the testis to return rapidly into the inguinal canal when released then surgery is probably indicated.
Reasons for the correction of cryptorchidism
Reduce risk of infertility
Allows the testes to be examined for testicular cancer
Avoid testicular torsion
Cosmetic appearance
Males with undescended testis are 40 times as likely to develop testicular cancer (seminoma) as males without undescended testis
The location of the undescended testis affects the relative risk of testicular cancer (50% intra-abdominal testes)
Prognosis in cryptorchidism
After the age of 2 years in untreated individuals the Sertoli cells will degrade and those presenting late in teenage years may be better served by orchidectomy than to try and salvage a non functioning testis with an increased risk of malignancy.
Why is bupivacaine contraindicated in regional blockade?
It is cardiotoxic and is therefore contra indicated in regional blockage in case the tourniquet fails.
What is used for regional anaesthesia?
Prilocaine
Theme: Ankle brachial pressure index
A.>1.2
B.1.0
C.0.8
D.0.5
E.0.3
Please select the ankle brachial pressure index that is most likely to be present for the scenario given. Each value may be used once, more than once or not at all.
5.A 73 year old lifelong heavy smoker presents to the vascular clinic with symptoms of foot ulceration and rest pain. On examination her foot has areas of gangrene and pulses are impalpable.
A 63 year old man presents with a claudication distance of 15 yards. He is a lifelong heavy smoker. On examination his foot is hyperaemic and there is a small ulcer at the tip of his great toe.
A 77 year old morbidly obese man with type 2 diabetes presents with leg pain at rest. His symptoms are worst at night and sometimes improve during the day. He has no areas of ulceration.
0.3
This is critical limb ischaemia. Values of 0.3 are typical in this setting and urgent further imaging is needed. Debridement of necrosis prior to improving arterial inflow carries a high risk of limb loss.
0.5
Hyperaemia may occur in association with severe vascular disease and is referred to surgically as a “sunset foot”. ABPI is usually higher than 0.3, but seldom greater than 0.5. Especially when associated with hyperaemic changes and ulceration. Urgent further imaging and risk factor modification is needed.
1.2
Type 2 diabetics may have vessel calcification. This will result in abnormally high ABPI readings. Pain of this nature in diabetics is usually neuropathic and if a duplex scan is normal then treatment with an agent such as duloxetine is sometimes helpful.
ABPI
>1.2
Usually due to vessel calcification
ABPI
1.0-1.2
Normal
ABPI 0.8-1.0
Minor stenotic lesion
Initiate risk factor management
ABPI
0.50-0.8
Moderate stenotic lesion
Consider duplex
Risk factor management
If mixed ulcers present then avoid tight compression bandages
ABPI
0.5-0.3
Likely significant stenosis
Duplex scanning to delineate lesions needed
Compression bandaging contra indicated
ABPI
<0.3
Indicative of critical ischaemia
Urgent detailed imaging required
A 73 year old lady suffers a fracture at the surgical neck of the humerus. The decision is made to operate. There are difficulties in reducing the fracture and a vessel lying posterior to the surgical neck is injured. Which of the following is this vessel most likely to be?
Axillary artery
Brachial artery
Thoracoacromial artery
Transverse scapular artery
Posterior circumflex humeral artery
The circumflex humeral arteries lie at the surgical neck and is this scenario the posterior circumflex is likely to be injured. The thoracoacromial and transverse scapular arteries lie more superomedially. The posterior circumflex humeral artery is a branch of the axillary artery.
Shoulder extension
Posterior deltoid
Teres major
Latissimus dorsi
Shoulder flexion
Anterior part of deltoid
Pectoralis major
Biceps
Coracobrachialis
Shoulder adduction
Pectoralis major
Latissimus dorsi
Teres major
Coracobrachialis
Shoulder abduction
Mid deltoid
Supraspinatus
Shoulder medial rotation
Subscapularis
Anterior deltoid
Teres major
Latissimus dorsi
Shoulder lateral rotation
Posterior deltoid
Infraspinatus
Teres minor
Which of the following sutures has the largest diameter?
6/0 Polypropylene
5/0 Silk
3/0 Nylon
1 Polypropylene
0 Polydiaxone
1- polypropylene
The sizes of suture material are not related to the composition of the suture material.
Which of the structures listed below lies posterior to the carotid sheath at the level of the 6th cervical vertebra?
Hypoglossal nerve
Vagus nerve
Cervical sympathetic chain
Ansa cervicalis
Glossopharyngeal nerve
The carotid sheath is crossed anteriorly by the hypoglossal nerves and the ansa cervicalis. The vagus lies within it. The cervical sympathetic chain lies posteriorly between the sheath and the prevertebral fascia.
A 46-year-old woman is referred to endocrine surgery for a possible thyroidectomy. She has a tender neck swelling. Blood results are as follows:
TSH <0.1 mU/l
T4 188 nmol/l
Hb 14.2 g/dl
Plt 377 * 10^9/l
WBC 6.4 * 10^9/l
ESR 65 mm/hr
Technetium thyroid scan shows decreased uptake globally
What is the most likely diagnosis?
Sick thyroid syndrome
Acute bacterial thyroiditis
Hashimoto’s thyroiditis
Subacute thyroiditis
Toxic multinodular goitre
This patient does not need surgery! Subacute thyroiditis is suggested by the tender goitre, hyperthyroidism and raised ESR. The globally reduced uptake on technetium thyroid scan is also typical. This should resolve without any active intervention.
Thought to occur following viral infection and typically presents with hyperthyroidism
Features
Hyperthyroidism
Painful goitre
Raised ESR
Globally reduced uptake on iodine-131 scan
Subacute (de Quervain’s)
immunological disorder in which lymphocytes become sensitised to thyroidal antigens. The three most important antibodies include; thyroglobulin, TPO and TSH-R. During the early phase the thyroglobulin antibody is markedly elevated and then declines.
Hashimoto’s
Hyperthyroidism
Painful goitre
Raised ESR
Globally reduced uptake on iodine-131 scan
Sub acute thyroiditis
Features
Goitre and either euthyroid or mild hypothyroidism
Progressive hypothyroidism (and associated symptoms)
Hashimotos thyroiditis
Management of Hashimoto’s thyroiditis
During the hyperthyroid phase of illness beta blockers may manage symptoms
As hypothyroidism develops patients may require thyroxine
Management of Subacute thyroiditis
Usually self-limiting - most patients do not require treatment
Thyroid pain may respond to aspirin or other NSAIDs
In more severe cases steroids are used, particularly if hypothyroidism develops
A sprinter attends A&E with severe leg pain. He had forgotten to warm up and ran a 100m sprint race. Towards the end of the race he experienced pain in the posterior aspect of his thigh. The pain worsens, localising to the lateral aspect of the knee. The sprinter is unable to flex the knee. What structure has been injured?
Anterior cruciate ligament
Posterior cruciate ligament
Semimembranosus tendon
Semitendinosus tendon
Biceps femoris tendon
The biceps femoris is commonly injured in sports that require explosive bending of the knee as seen in sprinting, especially if the athlete has not warmed up first. Avulsion most commonly occurs where the long head attaches to the ischial tuberosity. Injuries to biceps femoris are more common than to the other hamstrings.
Origin of Long head biceps femoris
Ischial tuberosity
Insertion of Long head bicep femoris
Fibular head
Action of Long head biceps femoris
Knee flexion
Lateral rotation tibia
Extension hip
Innervation of Long head biceps femoris
Tibial division of sciatic nerve (L5-S2
Arterial supply of Long head biceps femoris
Profunda femoris artery, inferior gluteal artery, and the superior muscular branches of popliteal artery
Origin of short head biceps femoris
Lateral lip of linea aspera, lateral supracondylar ridge of femur
Insertion of short head bifceps femoris
Fibular head
Action of short head biceps femoris
Knee flexion, lateral rotation tibia
Innervation of short head biceps femoris
Common peroneal division of sciatic nerve (L5, S1, S2)
Arterial supply of short head biceps femoris
Profunda femoris artery, inferior gluteal artery, and the superior muscular branches of popliteal artery
Which of the following is least likely to occur in association with severe atrophic gastritis?
Gastric ulcers
Gastric cancer
Anaemia
Duodenal ulcers
Gastric polyps
Due to the loss of gastric acid a duodenal ulcer is unlikely. Note that gastric polyps may form
What are the types of gastritis
Type A
Type B
Reflux gastritis
Erosive gastritis
Stress ulceration
Menetrier’s disease
Autoimmune
Circulating antibodies to parietal cells, causes reduction in cell mass and hypochlorhydria
Loss of parietal cells = loss of intrinsic factor = B12 malabsorption
Absence of antral involvement
Hypochlorhydria causes elevated gastrin levels- stimulating enterochromaffin cells and adenomas may form
Type A gastritis
Antral gastritis
Associated with infection with helicobacter pylori infection
Intestinal metaplasia may occur in stomach and require surveillance endoscopy
Peptic ulceration may occur
Type B gastritis
Bile refluxes into stomach, either post surgical or due to failure of pyloric function
Histologically, evidence of chronic inflammation, and foveolar hyperplasia
May respond to therapy with prokinetics
Reflux gastritis
Foveolar hyperplasia
Reflux gastritis
Agents disrupt the gastric mucosal barrier
Most commonly due to NSAIDs and alcohol
With NSAIDs the effects occur secondary to COX 1 inhibition
Erosive gastritis
This occurs as a result of mucosal ischaemia during hypotension or hypovolaemia
The stomach is the most sensitive organ in the GI tract to ischaemia following hypovolaemia
Diffuse ulceration may occur
Prophylaxis with acid lowering therapy and sucralfate may minimise complications
Stress ulceration
Gross hypertrophy of the gastric mucosal folds, excessive mucous production and hypochlorhydria
Pre malignant condition
Menetriers disease
Theme: Lung cancer
A.Adenocarcinoma
B.Small cell lung cancer
C.Large cell lung cancer
D.Squamous cell carcinoma
Please select the most likely lung cancer variant for the scenario described. Each option may be used once, more than once or not at all.
17.A 73 year old heavy smoker presents with haemoptysis. On examination he is cachectic and shows evidence of clubbing. Imaging shows a main bronchial tumour with massive mediastinal lymphadenopathy together with widespread visceral metastases.
A 68 year old female who has never smoked presents with a mass at the periphery of her right lung.
An 85 year old man presents with a cough and haemoptysis. He has a modest smoking history of 15 pack years. He is found to have a tumour located in the right main bronchus, with no evidence of metastatic disease. He decides not undergo any treatment and he remains well for a further 12 months before developing symptomatic metastasis.
Small cell lung cancer
Small cell carcinoma is associated with disseminated disease at presentation in the majority of cases. Most cases occur in the main airways and paraneoplastic features are common.
Adenocarcinoma
Adenocarcinomas are the most common tumour type present in never smokers. They are usually located at the periphery
Squamous cell carcinoma
Squamous cell carcinomas are reported to be more slow growing and are typically centrally located. Small cell carcinomas are usually centrally located. However, small cell carcinomas would seldom be associated with a survival of a year without treatment.
What are the nonsmall cell lung cancers?
These share common features of prognosis and management. They comprise the following tumours:
Squamous cell carcinoma (25% cases)
Adenocarcinoma (40% cases)
Large cell carcinoma (10% cases)
Paraneoplastic features and early disease dissemination are less likely than with small cell lung carcinoma. Adenocarcinoma is the most common lung cancer type encountered in never smokers.
What proportion of lung cancers are accounted for by NSLC
80%
comprised of cells with a neuro endocrine differentiation. The neuroendocrine hormones may be released from these cells with a wide range of paraneoplastic associations. These tumours are strongly associated with smoking and will typically arise in the larger airways. They disseminate early in the course of the disease and although they are usually chemosensitive this seldom results in long lasting remissions.
SCLC
Which of the following is not found on a blood film post splenectomy?
Pappenheimer bodies
Stipple cells
Erythrocyte containing siderotic granules
Howell-Jolly bodies
Target cells
Stipple cells are found in lead poisoning/haemoglobinopathies.
Blood film in hyposplenism:
Howell-Jolly bodies
Pappenheimer bodies
Poikilocytes (Target cells)
Erythrocyte containing siderotic granules
Heinz bodies
What changes may be seen in blood components post splenectomy
In the first few days after splenectomy target cells, siderocytes and reticulocytes will appear in the circulation. Immediately following splenectomy a granulocytosis (mainly composed of neutrophils) is seen, this is replaced by a lymphocytosis and monocytosis over the following weeks.
The platelet count is usually increased and this may be persistent, oral antiplatelet agents may be needed in some patients.
A surgical team wish to conduct a meta analysis of randomised controlled trials of the use of low molecular weight heparins in the prevention of post operative deep vein thrombosis. How would these results be best displayed graphically?
Forest plot
Box Whisker plot
Violin plot
Kaplan Meier graph
None of the above
Data from multiple RCT’s are best displayed using Forest plots. Funnel plots may be used to determine the effect of small studies and their overall effect on the data. Violin plots and Box Whisker plots are often used to graphically display non parametric data from single studies and are not generally used to display data from meta analyses.
A 43 year old man has recurrent episodes of dyspepsia and treatment is commenced with oral antacids. Which of the hormones listed below is released in response to increased serum gastrin levels and decreases intra gastric pH?
Cholecystokinin
Histamine
Somatostatin
Insulin
Vasoactive intestinal peptide
Histamine is released from enterochromaffin cells in the stomach mucosa which stimulates acid secretion. It is usually released in response to increased serum gastrin levels. Histamine blockers (e.g. cimetidine) were extremely popular treatments until the advent of proton pump inhibitors.
Which of the following statements relating to omphalocele is false?
The herniated organs lie outside the peritoneal sac
Cardiac abnormalities co-exist in 25%
The caecum is usually right sided
The defect occurs through the umbilicus
Mortality may be as high as 15%
Gastroschisis: Isolated abnormality, bowel lies outside abdominal wall through defect located to right of umbilicus.
Exomphalos: Liver and gut remain covered with membranous sac connected to umbilical cord. It is associated with other developmental defects.
They are contained within the peritoneal sac and therefore do not have the fluid losses seen in gastroschisis. True malrotation is unusual and minor variants may not result in a requirement for surgery.
A 24 year old man falls and lands astride a manhole cover. He suffers from an injury to the anterior bulbar urethra. Where will the extravasated urine tend to collect?
Lesser pelvis
Connective tissue of the scrotum
Deep perineal space
Ischiorectal fossa
Posterior abdominal wall
Connective tissue of the scrotum
This portion of the urethra is contained between the perineal membrane and the membranous layer of the superficial fascia. As these are densely adherent to the ischiopubic rami, extravasated urine cannot pass posteriorly because the 2 layers are continuous around the superficial transverse perineal muscles.
Theme: Voice disorders
A.Vagus nerve injury
B.Thyroid nerve injury
C.Superior laryngeal nerve injury
D.Unilateral inferior laryngeal nerve injury
E.Bilateral inferior laryngeal nerves injuries
F.Stroke
G.Lacunar infarcts
H.None of the above
Please select the most likely reason for the scenarios given. Each option may be used once, more than once or not at all.
26.A 42 year old singer is admitted for a thyroidectomy. Post operatively she is only able to make a gargling noise. Her voice sounds breathy.
A 42 year old singer is admitted for a thyroidectomy. Post operatively she is unable to sing high pitched notes.
A 42 year old singer is admitted for a thyroidectomy. Post operatively the patient develops stridor and is unable to speak.
Unilateral inferior laryngeal nerve injury
This patient has diplophonia which causes a gargling sound. This is associated with dysphagia. This can also be caused by a vagus nerve lesion, but the recurrent laryngeal nerve is more at risk of damage.
Superior laryngeal nerve injury
SLN lesions cause difficulty in voice pitch.
Bilateral inferior laryngeal nerves injuries
This patient has aphonia due to bilateral damage to the recurrent laryngeal nerve.
What are the two main nerves involved in voice production?
SLN
RLN
SLN innervates?
Cricothyroid muscle
SLN action?
Innervates the cricothyroid muscle
Since the cricothyroid muscle is involved in adjusting the tension of the vocal fold for high notes during singing, SLN paresis and paralysis result in:
a. Abnormalities in pitch
b. Inability to sing with smooth change to each higher note (glissando or pitch glide)
RLN innervates?
Intrinsic larynx muscles
RLN action?
Innervates intrinsic larynx muscles
a. Opening vocal folds (as in breathing, coughing)
b. Closing vocal folds for vocal fold vibration during voice use
c. Closing vocal folds during swallowing
A footballer is injured in a match and is being assessed in the outpatient department. On examination he has a positive valgus stress test and minimal joint effusion. What is the most likely underlying injury?
Injury to the lateral collateral ligament
Injury to the medial collateral ligament
Injury to the anterior cruciate ligament
Injury to the posterior cruciate ligament
Injury to the patellar tendon
A knee injury in the footballer with a positive valgus stress test is usually associated with MCL injury.
Anatomy of the MCL?
The tibial collateral ligament is a broad, flat band. Its upper end has an extensive attachment to the medial epicondyle of the femur with some fibres projecting onto the adductor magnus tendon. The ligament passes downwards and forwards to the medial side of the tibia. The deepest fibres are fused with the medial meniscus.
Anatomy of the LCL?
The fibular collateral ligament is round and cord like and stands clear of the thin, lateral part of the fibrous capsule. It is enclosed within the fascia lata. It passes from the lateral epicondyle of the femur to the head of the fibula in front of its highest point and splits the tendon of biceps femoris. On the lateral side of the joint the fibres are short and weak and bridge the interval between the femoral and tibial condyles. The popliteus tendon intervenes between the lateral meniscus and the capsule.
Action of the collateral knee ligaments?
The tibial and fibular collateral ligaments prevent disruption of the joint at the sides. They are most tightly stretched in extension, and then their direction- the fibular ligament downwards and backwards, the tibial downwards and forwards- prevents rotation of the tibia laterally or the femur medially. Rotation may be demonstrated in the flexed knee.
Which knee collateral is most susceptible to injury?
MCL
Grade 1 collateral knee ligament injury
Minor tearing of ligament fibres
Negative instability tests
Conservative (analgesia and physiotherapy)
Grade 2 knee collateral ligament injury
Ligament laxity (seen with knee in 30oflexion) Knee stable when joint extended
Usually splinting or casting for 4-6 weeks
Grade 3 knee ligament injury
Ligament completely torn
Joint instability
Surgical ligament reconstruction
Theme: Bilious vomiting in neonates
A.Biliary atresia
B.Intestinal malrotation
C.Ileal atresia
D.Necrotising enterocolitis
E.Duodenal atresia
F.Meconium ileus
G.Viral gastroenteritis
H.Pyloric stenosis
Please select the most likely underlying cause of bilious vomiting for the situation described. Each option may be used once, more than once or not at all.
30.A male infant is born prematurely at 26 weeks gestation by emergency cesarean section. Following the birth he develops respiratory distress syndrome and is ventilated. He begins to improve twelve days after birth. Then he becomes unwell and develops abdominal distension and passes bloody stools and vomits a small quantity of bile stained vomit.
A male infant is born by spontaneous vaginal delivery at 39 weeks gestation. He is well after the birth, established on bottle feeding and discharged home. His parents are concerned because he subsequently becomes unwell and vomits a large quantity of bile stained vomit approximately 2 days after discharge home. On examination he looks ill and his abdomen is soft and non distended.
A female infant is born by cesarean section at 38 weeks gestation for foetal distress. The attending paediatricians notice that she has a single palmar crease and a mongoloid slant to her eyes. Soon after the birth the mother tries to feed the child who has a projectile vomit about 10 minutes after feeding. On examination she has a soft, non distended abdomen.
Necrotising enterocolitis
Necrotising enterocolitis often has a delayed presentation and affected infants will typically pass bloody stools. Plain films may show air in the intestinal wall (Pneumatosis).
Intestinal malrotation
Intestinal malrotation with volvulus will typically compromise the vascularisation and lumenal patency of the gut. This will cause bilious vomiting and the vascular insufficiency will produce a clinical picture of illness at odds with the lack of overt abdominal signs. Delay in diagnosis and surgery will result in established necrosis, perforation and peritonitis.
Duodenal atresia
Proximally sited atresia will produce high volume vomits which may or may not be bile stained. Abdominal distension is characteristically absent. Whilst under resuscitated children may be a little dehydrated they are seldom severely ill. The presence of Trisomy 21 (palmar and eye signs) increases the likelihood of duodenal atresia.
Billious vomiting in neonate
1 in 5000 (higher in Downs syndrome)
Few hours after birth
AXR shows “double bubble sign, contrast study may confirm
Duodenal atresia
Treatment of duodenal atresia?
Dudodenoduodenostomy
Billious vomiting in neonate
Usually cause by incomplete rotation during embryogenesis
Usually 3-7 days after birth, volvulus with compromised circulation may result in peritoneal signs and haemodynamic instability
Upper GI contrast study may show DJ flexure is more medially placed, USS may show abnormal orientation of SMA and SMV
Intestinal malrotation with volvulus
Treatment of malrotation with volvulus
Ladd’s procedure
Billious vomiting in neonate
Usually caused by vascular insufficiency in utero, usually 1 in 3000
Usually within 24 hours of birth
AXR will show air-fluid levels
Jejunal/ ileal atresia
Treatment of jejunal/ileal atresia
Laparotomy with primary resection and anastomosis
Billious vomiting in neonate
Occurs in between 15 and20% of those babies with cystic fibrosis, otherwise 1 in 5000
Typically in first 24-48 hours of life with abdominal distension and bilious vomiting
Air - fluid levels on AXR, sweat test to confirm cystic fibrosis
Meconium ileus
Treatment of meconium ileus
Surgical decompression, serosal damage may require segmental resection
Billious vomiting in neonate
Up to 2.4 per 1000 births, risks increased in prematurity and inter-current illness
Usually second week of life
Dilated bowel loops on AXR, pneumatosis and portal venous air
NEC
Treatment of NEC
Conservative and supportive for non perforated cases, laparotomy and resection in cases of perforation of ongoing clinical deterioration
Theme: Diarrhoea
A.Vibrio cholera
B.Yersinia enterocolitica
C.Clostridium difficile
D.Campylobacter jejuni
E.Salmonella spp.
F.E. coli (Enterohaemorrhagic)
G.E.Coli (Enteroinvasive)
What is the most likely infective organism for the scenario given? Each option may be used once, more than once or not at all.
33.A 22 year old chef presents to the medical team with profuse bloody diarrhoea. On further questioning he describes tenesmus. They arrange a sigmoidoscopy which reveals necrosis and ulceration of the descending colon mucosa.
A 22 year old Chef presents with abdominal pain in the right iliac fossa. There is an associated temperature and diarrhoea. The SHO takes the patient to theatre for an appendicectomy, but the appendix appears normal. The terminal ileum appears thickened and engorged.
A 30 year old aid worker becomes unwell whilst helping at the scene of a recent earthquake. He develops vomiting and soon afterwards a diarrhoea that is loose and extremely watery.
E.Coli (Enteroinvasive)
Necrosis and ulcers of the large bowel are a feature of enteroinvasive E.coli. It presents with a dysentery type illness similar to shigellosis.
Yersinia enterocolitica
Yersinia can be mistaken for acute appendicitis due to mesenteric lymphadenitis and ileitis. Yersinia infection of the terminal ileum typically produces more marked clinical changes of this segment of bowel than infection with campylobacter.
Vibrio cholera
The passage of very loose and watery stools distinguishes cholera. Most gastroenteric infections do not produce such watery motions.
Most common cause of acute infective diarrhoea
Spiral, gram negative rods
Usually infects caecum and terminal ileum. Local lymphadenopathy is common
May mimic appendicitis as it has marked right iliac fossa pain
Reactive arthritis is seen in 1-2% of cases
Campylobacterjejuni
Members of the enterobacteriaceae
Gram negative bacilli
Clinically causes dysentery
Shigella soneii is the commonest infective organism (mild illness)
Usually self limiting, ciprofloxacin may be required if individual is in a high risk group
Shigella spp.
Facultatively anaerobic, gram negative, enterobacteriaceae
Infective dose varies according to subtype
Salmonellosis: usually transmitted by infected meat (especially poultry) and eggs
Salmonellaspp
Enteropathogenic
Enteroinvasive: dysentery, large bowel necrosis/ulcers
Enterotoxigenic: small intestine, travelers diarrhoea
Enterohaemorrhagic: 0157, cause a haemorrhagic colitis, haemolytic uraemic syndrome and thrombotic thrombocytopaenic purpura
E. coli
Gram negative, coccobacilli
Typically produces a protracted terminal ileitis that may mimic Crohns disease
Differential diagnosis acute appendicitis
May progress to septicaemia in susceptible individuals
Usually sensitive to quinolone or tetracyclines
Yersinia enterocolitica
Short, gram negative rods
Transmitted by contaminated water, seafood
Symptoms include sudden onset of effortless vomiting and profuse watery diarrhoea
Correction of fluid and electrolyte losses are the mainstay of treatment
Most cases will resolve, antibiotics are not generally indicated
Vibrio cholera
A rapid finger-prick blood test to help diagnosis deep vein thrombosis is developed. Comparing the test to current standard techniques a study is done on 1,000 patients:
DVT present DVT absent
New test positive 200 100
New test negative 20 680
What is the specificity of the new test?
680/880
200/220
680/780
680/700
200/300
Specificity = true negatives / (true negatives + false positives)
= 680 / (680 + 100)
Sensitivity
TP / (TP + FN )
Proportion of patients with the condition who have a positive test result
Specificity
TN / (TN + FP)
Proportion of patients without the condition who have a negative test result
Positive predictive value
TP / (TP + FP)
The chance that the patient has the condition if the diagnostic test is positive
Negative predictive value
TN / (TN + FN)
The chance that the patient does not have the condition if the diagnostic test is negative
Likelihood ratio for a positive test result
sensitivity / (1 - specificity)
How much the odds of the disease increase when a test is positive
Likelihood ratio for a negative test result
(1 - sensitivity) / specificity
How much the odds of the disease decrease when a test is negative
Difference between predictive values and likelihood ratios
Positive and negative predictive values are prevalence dependent. Likelihood ratios are not prevalence dependent
A 22 year old man suffers 20% partial and full thickness burns in a house fire. There is an associated inhalational injury. It is decided to administer intravenous fluids to replace fluid losses. Which of the intravenous fluids listed below should be used for initial resuscitation?
Dextran 40
5% Dextrose
Fresh frozen plasma
Hartmans solution
Blood
In most units a crystalloid such as Hartmans (Ringers lactate) is administered initially. Controversy does remain and some units do prefer colloid. Should this leak in the interstial tissues this may increase the risk of oedema.
Features of fluid resuscitation in burns?
>15% total body area burns in adults (>10% children)
The main aim of resuscitation is to prevent the burn deepening
Most fluid is lost 24 hours after injury
First 8-12 hour fluid shifts are from intravascular to interstitial fluid compartments
Therefore circulatory volume can be compromised. However fluid resuscitation causes more fluid into the interstitial compartment especially colloid (therefore avoided in first 8-24 hours)
Protein loss occurs
Fluid resuscitation formula=
Parkland formula (Crystallod only)
4ml x total burn surface area x body weight
50% in first 8 hours
50% in next 16 hours
What is the resuscitation endpoint for fluids in burns?
Urine output of 0.5-1.0ml/kg/hr
When is the starting point of fluid resuscitation in burns injury?
Time of injury
What should happen after the first 24 hours in fluid resuscitaiton of burns injuries?
Maintenance crystalloid (usually dextrose-saline) is continued at a rate of 1.5 ml x(burn area)x(body weight)
Colloids are rarely used (e.g. albumin)
Antioxidants, such as vitamin C, can be used to minimize oxidant-mediated contributions to the inflammatory cascade in burns
High tension electrical injuries and inhalation injuries require more fluid
Monitor: packed cell volume, plasma sodium, base excess, and lactate
Next question
A 73 year old man presents with symptoms of mesenteric ischaemia. As part of his diagnostic work up a diagnostic angiogram is performed .The radiologist is attempting to cannulate the coeliac axis from the aorta. At which of the following vertebral levels does this is usually originate?
T10
L2
L3
T8
T12
Coeliac trunk branches:
Left Hand Side (LHS)
Left gastric
Hepatic
Splenic
The coeliac axis branches off the aorta at T12.
Anterior relations of the coeliac axis?
Lesser omentum
Right relations of the coeliac axis?
Right coeliac ganglion and caudate process of liver
Left relation of coeliac axis
Left coeliac ganglion and gastric cardia
Inferior relation of coeliac axis
Upper border of pancreas and renal vein
A 45 year old man with long standing ulcerative colitis and rectal dysplasia presents with a DALM lesion in the rectum. What is the most appropriate management option?
Snare polypectomy
Repeat endoscopy in 2 years
Discharge
Anterior resection
Panproctocolectomy
DALM lesions complicating ulcerative colitis should be managed with panproctocolectomy. An anterior resection is inadequate since it will only remove the rectum and ulcerative colitis affects the entire colon. Since many will be associated with invasion a snare polypectomy is not sufficient either.
DALM lesion
The term DALM lesion refers to a Dysplasia Associated Lesion or Mass.
They may complicate dysplasia occurring in patients with longstanding ulcerative colitis.
They have a high incidence of invasive foci.
When they complicate longstanding ulcerative colitis, they should be treated by panproctocolectomy.
Which main group of receptors does dobutamine bind to?
α-1
α-2
ß-1
ß-2
D-1
Dobutamine is a sympathomimetic with both alpha- and beta-agonist properties; it displays a considerable selectivity for beta1-cardiac receptors.
Theme: Open fractures
A.Immediate skeletal stabilisation and application of negative pressure dressing
B.Combined skeletal and soft tissue reconstruction on a scheduled operating list
C.Thorough wound debridement in the emergency department
D.Immediate vascuIar shunting, followed by temporary skeletal stabilisation and vascular reconstruction
E.Intravenous antibiotics, photography and application of saline soaked gauze with impermeable dressing
F.Application of external fixator and conversion to internal fixation after two weeks
G.Fasciotomy with four compartment decompression
H.Skeletal fixation followed by vascular reconstruction
Please select the most appropriate course of action for the scenario described. Each option may be used once, more than once or not at all.
A 30 year old man is admitted overnight, following a road traffic accident. He has an open tibial fracture with a 20 cm wound and extensive periosteal stripping. He is neurovascularly intact and IV antibiotics and wound dressing have been administered in the emergency department.
A 50 year old man is admitted after falling from scaffolding. He has an open fracture of his tibia with a 15 cm wound. He is neurovascularly intact.
A 40 year old woman is admitted after being knocked off her bike. She has an open fracture of her tibia, with a 10 cm wound. No peripheral pulses are palpable. Intravenous antibiotics have been administered in the emergency department and the wound has been dressed.
Combined skeletal and soft tissue reconstruction on a scheduled operating list
This patient has a Gustillo-Anderson Grade 3B open fracture. He will require definitive skeletal and soft tissue reconstruction, which should be performed on a combined ortho-plastic scheduled operating list, as per the BOA/BAPRAS guidelines. The surgery does not have to be performed out of scheduled hours unless there is marine/ sewage contamination, vascular compromise or it is a polytrauma.
Whilst it is reasonable to apply an external fixator prior to definitive skeletal and soft tissue reconstruction, this should be converted to internal fixation within 72 hours.
Intravenous antibiotics, photography and application of saline soaked gauze with impermeable dressing
The initial management of open fractures should include administration of intravenous antibiotics, photography of wound and application of a sterile soaked gauze and impermeable film. The wound should only be handled to remove gross contamination. The patient is then likely to require definitive skeletal and soft tissue reconstruction.
Immediate vascuIar shunting, followed by temporary skeletal stabilisation and vascular reconstruction
This patient has a Gustillo-Anderson Grade 3C open fracture with vascular injury. Vascular impairment requires immediate surgery and restoration of circulation, ideally within 3-4 hours. This should follow the sequence of shunting, temporary skeletal stabilisation and then vascular reconstruction as per BOA / BAPRAS guidelines. Revascularisation using vascular shunts should be performed before skeletal fixation.
def: open fracture
The term open fracture refers to a disruption of the bony cortex associated with a breach in the overlying skin. Any wound that is present in the same limb as a fracture should be suspected as being representative of an open fracture. One of the main problems with open fractures is the associated injuries to the surrounding soft tissues. Whilst the skin is usually relatively resistant to trauma, underlying muscle can be damaged or devitalised, nerves, blood vessels and periosteum may all be disrupted the degree to which this occurs correlates with the severity of the injury and the outcome.
What can be used to grade the severity of open fracutres?
Gustilo and Anderson system
Gustilo and Anderson system
1
Low energy wound <1 cm
Gustilo and Anderson system
2
Greater than 1cm wound with moderate soft tissue damage
Gustilo and Anderson system
3
High energy wound >1cm with extensive soft tissue damage
Gustilo and Anderson system
3A
Adequate soft tissue coverage
Gustilo and Anderson system
3b
Inadequate soft tissue coverage
Gustilo and Anderson system
3C
Associated arterial injury
What can be used to predict the need for primary amputation in Gustilo Andesron 3C injuries?
Mangled extremity scoring system (MESS)
Initial management of open fractures?
Initial management should focus on careful patient examination to check for associated injuries, control of haemorrhage and the extent of injury. The area should be carefully imaged, distal neurovascular status established the wound covered with a dressing and antibiotics administered. Early debridement is the cornerstone of the management of open fractures. The aim of the debridement is to remove foreign material and devitalised tissue. In most cases the wound is left open. The wound should be irrigated, generally, 6 litres of saline is used. The fracture should be stabilised and an external fixator is often used in the first instance
A 43 year old man is diagnosed as having a malignancy of the right adrenal gland. The decision is made to resect this via an open anterior approach. Which of the following will be most useful during the surgery?
Division of the coronary ligaments of the liver
Mobilisation of the colonic hepatic flexure
Division of the right renal vein
Division of the ligament of Trietz
Division of the right colic artery
Mobilisation of the hepatic flexure and right colon are standard steps in open adrenal surgery from an anterior approach. Mobilisation of the liver is seldom required.
Causes of craniomaxillofacial injuries in the UK?
Interpersonal violence (52%)
Motor vehicle accidents (16%)
Sporting injuries (19%)
Falls (11%)
Le Fort fracture
Le Fort fractures are fractures of the midface, which collectively involve separation of all or a portion of the midface from the skull base. In order to be separated from the skull base, the pterygoid plates of the sphenoid bone need to be involved as these connect the midface to the sphenoid bone dorsally. The Le Fort classification system attempts to distinguish according to the plane of injury.
Le Fort 1
The fracture extends from the nasal septum to the lateral pyriform rims, travels horizontally above the teeth apices, crosses below the zygomaticomaxillary junction, and traverses the pterygomaxillary junction to interrupt the pterygoid plates.
Le Fort 2
These fractures have a pyramidal shape and extend from the nasal bridge at or below the nasofrontal suture through the frontal process of the maxilla, inferolaterally through the lacrimal bones and inferior orbital floor and rim through or near the inferior orbital foramen, and inferiorly through the anterior wall of the maxillary sinus; it then travels under the zygoma, across the pterygomaxillary fissure, and through the pterygoid plates.
Le Fort 3
These fractures start at the nasofrontal and frontomaxillary sutures and extend posteriorly along the medial wall of the orbit through the nasolacrimal groove and ethmoid bones. The thicker sphenoid bone posteriorly usually prevents continuation of the fracture into the optic canal. Instead, the fracture continues along the floor of the orbit along the inferior orbital fissure and continues superolaterally through the lateral orbital wall, through the zygomaticofrontal junction and the zygomatic arch. Intranasally, a branch of the fracture extends through the base of the perpendicular plate of the ethmoid, through the vomer, and through the interface of the pterygoid plates to the base of the sphenoid. This type of fracture predisposes the patient to CSF rhinorrhea more commonly than the other types.
Superior orbital fissure syndrome
Severe force to the lateral wall of the orbit resulting in compression of neurovascular structures. Results in :
Complete opthalmoplegia and ptosis (Cranial nerves 3, 4, 6 and nerve to levator palpebrae superioris)
Relative afferent pupillary defect
Dilatation of the pupil and loss of accommodation and corneal reflexes
Altered sensation from forehead to vertex (frontal branch of trigeminal nerve)
Severe force to the lateral wall of the orbit resulting in compression of neurovascular structures. Results in :
Complete opthalmoplegia and ptosis (Cranial nerves 3, 4, 6 and nerve to levator palpebrae superioris)
Relative afferent pupillary defect
Dilatation of the pupil and loss of accommodation and corneal reflexes
Altered sensation from forehead to vertex (frontal branch of trigeminal nerve)
SOF syndrome
Typically occurs when an object of slightly larger diameter than the orbital rim strikes the incompressible eyeball. The bone fragment is displaced downwards into the antral cavity, remaining attached to the orbital periosteum. Periorbital fat may be herniated through the defect, interfering with the inferior rectus and inferior oblique muscles which are contained within the same fascial sheath. This prevents upward movement and outward rotation of the eye and the patient experiences diplopia on upward gaze. The initial bruising and swelling may make assessment difficult and patients should usually be reviewed 5 days later. Residual defects may require orbital floor reconstruction.
Orbital blow out fracture
Features of nasal fracture
Common injury
Ensure new and not old deformity
Control epistaxis
CSF rhinorrhoea implies that the cribriform plate has been breached and antibiotics will be required.
Usually best to allow bruising and swelling to settle and then review patient clinically. Major
Presentation of retrobulbar haemorrhage
PPPPV
Rare but important ocular emergency. Presents with:
Pain (usually sharp and within the globe)
Proptosis
Pupil reactions are lost
Paralysis (eye movements lost)
Visual acuity is lost (colour vision is lost first)
May be the result of Le Fort type facial fractures.
Rare but important ocular emergency. Presents with:
Pain (usually sharp and within the globe)
Proptosis
Pupil reactions are lost
Paralysis (eye movements lost)
Visual acuity is lost (colour vision is lost first)
May be the result of Le Fort type facial fractures.
Retrobulbar haemorrhage
Management of retrobulbar haemorrhage
Mannitol 1g/Kg as 20% infusion, Osmotic diuretic, Contra-indicated in congestive heart failure and pulmonary oedema
Acetazolamide 500mg IV, (Monitor FBC/U+E) Reduces aqueous pressure by inhibition of carbonic anhydrase (used in glaucoma)
Dexamethasone 8mg orally or intravenously
In a traumatic setting an urgent cantholysis may be needed prior to definitive surgery.
Consider
Papaverine 40mg smooth muscle relaxant
Dextran 40 500mls IV improves perfusion
Which of the metastatic bone tumours described below is at the greatest risk of pathological fracture ?
Proximal humeral lesion from a prostate cancer
Vertebral body lesions from a prostate cancer
Peritrochanteric lesion from a carcinoma of the breast
Proximal humeral lesion from a carcinoma of the breast
Peritrochanteric lesion from a prostate cancer
Peritrochanteric lesions have the greatest risks of fracture (due to loading). The lesions from breast cancer are usually lytic and therefore at higher risk rather than the sclerotic lesions from prostate cancer.
Features of metastatic bone disease
Metastatic bone tumours may be described as blastic, lytic or mixed. Osteoblastic metastatic disease has the lowest risk of spontaneous fracture when compared to osteolytic lesions of a similar size.
Lesions affecting the peritrochanteric region are most prone to spontaneous fracture (because of loading forces at that site).
What is the use of the Mirel Scoring system?
The factors are incorporated into the Mirel Scoring system to stratify the risk of spontaneous fracture for bone metastasis of varying types.
Factors scoring 1 point on Mirel system
Upper extremity
Blastic
Less than 1/3 of bone involved
Mild pain
Factors scoring 2 points on Mirel scoring system?
Lower extremity
Mixed
1/3 to 2/3 bone width
Moderate pain
Factors scoring 3 points on Mirel scoring system?
Peritrochanteric
Lytic
More than 2/3 bone width
Pain aggravated by function
Risk of # Mirel >9
Impending (33%)
Risk of # Mirel <7
Not impending (4%)
Risk of fracture Mirel 8
Borderline
Treatment of Mirel >9
Prophylactic fixation
Treatment of Mirel 8
Consider fixation
Treatment of Mirel 7 or less
Non operative management
Features of calcitonin
Secreted by C cells of thyroid
Inhibits intestinal calcium absorption
Inhibits osteoclast activity
Inhibits renal tubular absorption of calcium
A 45 year old man presents with a lipoma located posterior to the posterior border of the sternocleidomastoid muscle, approximately 4cm superior to the middle third of the clavicle. During surgical excision of the lesion troublesome bleeding is encountered. Which of the following is the most likely source?
Internal jugular vein
External jugular vein
Common carotid artery
Vertebral artery
Second part of the subclavian artery
The external jugular vein runs obliquely in the superficial fascia of the posterior triangle. It drains into the subclavian vein. During surgical exploration of this area the external jugular vein may be injured and troublesome bleeding may result. The internal jugular vein and carotid arteries are located in the anterior triangle. The third, and not the second, part of the subclavian artery is also a content of the posterior triangle
Theme: Levels of spinal injury
A.C2
B.C3
C.C4
D.C5
E.C6
F.L1
G.L2
H.L3
I.L4
J.L5
Please select the most likely spinal level for the injury described. Each option may be used once, more than once or not at all.
50.A 62 year old male complains of back pain. He has had a recent fall. Walking causes pain of the left lower leg. On examination he is noted to have reduced sensation over the knee.
A 42 year old woman is found to have a burst fracture of the C5 vertebral body. After a few months where would the level of injury be?
A 56 year old man suddenly develops severe back pain. His pain has a radicular pattern. On examination he is unable to extend his great toe.
L3
Sensation over the knee is equivalent to the L3 dermatome. The four nerves involved include the infrapatellar branch of the saphenous nerve, the lateral cutaneous nerve of the thigh, anterior cutaneous nerve of the thigh (both lateral and medial branches)
C6
A C5 burst fracture usually injures the C6 spinal cord situated at the C5 vertebrae and also the C4 spinal roots that exit the spinal column between the C4 and C5 vertebra. Such an injury should cause a loss of sensations in C4 dermatome and weak deltoids. Due to oedema , the biceps (C5) may be initially weak but should recover. The wrist extensors (C6), however, should remain weak and sensation at and below C6 should be severely compromised. A neurosurgeon would conclude that there is a burst fracture at C5 from the x-rays, an initial sensory level at C4 (the first abnormal sensory dermatome) and the partial loss of deltoids and biceps would imply a motor level at C4 (the highest abnormal muscle level). Over time, as the patient recovers the C4 roots and the C5 spinal cord, both the sensory level and motor level should end up at C6. Such recovery is often attributed to ‘root’ recovery.
L5
Extensor hallucis longus is derived from L5 and loss of EHL function is a useful test to determine whether this level is involved.
Elbow flexors/Biceps
C5
Wrist extensors
C6
Elbow extensors/Triceps
C7
Long finger flexors
C8
Small finger abductors
T1
Hip flexors (psoas)
L1 and L2
Knee extensors (quadriceps)
L3
Ankle dorsiflexors (tibialis anterior)
L4 and L5
Toe extensors (hallucis longus)
L 5
Ankle plantar flexors (gastrocnemius)
S1
The anal sphincter is innervated by
S2,3,4
Which of the following transplants is most susceptible to donor- recipient HLA mismatches?
Autologous skin graft
Renal allograft
Liver allograft
Corneal allograft
Cardiac valve allograft
Autologous transplant- same individual (genetically identical)
Allograft - Genetically different
The kidney is highly susceptible to HLA mismatches and hyperacute rejection may occur in patients with IgG anti HLA Class I antibodies. The liver is at far lower risk of rejection of this nature. Although the heart is sensitive to HLA mismatches this is less than the kidney. Cardiac valves and the cornea incite little immunological response.
Epidemiology of bladder cancer
Bladder cancer is the second most common urological cancer. It most commonly affects males aged between 50 and 80 years of age. Those who are current, or previous (within 20 years), smokers have a 2-5 fold increased risk of the disease. Exposure to hydrocarbons such as 2-Naphthylamine increases the risk. Although rare in the UK, chronic bladder inflammation arising from Schistosomiasis infection remains a common cause of squamous cell carcinomas, in those countries where the disease is endemic.
Histopathology of bladder cancer
Transitional cell carcinoma (>90% of cases)
Squamous cell carcinoma ( 1-7% -except in regions affected by schistosomiasis)
Adenocarcinoma (2%)
Chance of malignancy in females >50 with microscopic haematuria
10% once infection excluded
What proportion of patients with TCC will present with painless macroscopic haematuira?
85%
Staging of bladder cancer
Most will undergo a cystoscopy and biopsies or TURBT, this provides histological diagnosis and information relating to depth of invasion. Locoregional spread is best determined using pelvic MRI and distant disease CT scanning. Nodes of uncertain significance may be investigated using PET CT.
Treatment of bladder cancer
Those with superficial lesions may be managed using TURBT in isolation. Those with recurrences or higher grade/ risk on histology may be offered intravesical chemotherapy. Those with T2 disease are usually offered either surgery (radical cystectomy and ileal conduit) or radical radiotherapy.
Theme: Neck lumps
A.Cystic hygroma
B.Bartonella infection
C.Mycobacterium tuberculosis infection
D.Branchial cyst
E.Thyroglossal cyst
F.Pharyngeal pouch
G.Follicular thyroid cyst
H.Parathyroid adenoma
I.None of the above
Please select the most likely underlying disease process for the scenario given. Each option may be used once, more than once or not at all.
55.A 25 year old cat lover presents with symptoms of abdominal pain, lethargy and sweats. These have been present for the past two weeks. On examination she has lymphadenopathy in the posterior triangle.
A 25 year old lady presents with an swelling located at the anterior border of the sternocleidomastoid muscle. The swelling is intermittent and on examination it is soft and fluctuant.
A 38 year old lady presents with a mass in the midline of the neck immediately below the hyoid bone. It moves upwards on tongue protrusion.
Bartonella infection
Bartonella infection may occur following a cat scratch. The organism is intracellular. Generalised systemic symptoms may occur for a week or so prior to clinical presentation.
Branchial cyst
Branchial cysts are remnants of the branchial cleft. They may become infected.
Thyroglossal cyst
Thyroglossal cysts are usually located in the midline and are linked to the foramen caecum and will thus move upwards on tongue protrusion.
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
Branchial cyst
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
Cystic hygroma
The sciatic nerve lies deep to the following structures except:
Gluteus maximus
The femoral cutaneous nerve
Long head of biceps femoris
Gluteus medius
Branch of the inferior gluteal artery
The gluteus medius does not extend around to the sciatic nerve.
Origin of the sciatic nerve?
Spinal nerves L4 - S3
Articular branches of the sciatic nerve?
Hip joint
Muscular branches of the sciatic nerve in the upper leg?
Semitendinosus
Semimembranosus
Biceps femoris
Part of adductor magnus
Cutaneous sensation carried by the sciatic nerve?
Posterior aspect of thigh (via cutaneous nerves)
Gluteal region
Entire lower leg (except the medial aspect)
Termination of the sciatic nerve?
At the upper part of the popliteal fossa by dividing into the tibial and peroneal nerves
Make up of the upper limb branches of the sciatic nerve?
The nerve to the short head of the biceps femoris comes from the common peroneal part of the sciatic and the other muscular branches arise from the tibial portion.
Bascom theory of pilonidal sinuses
Occur as a result of hair debris creating sinuses in the skin (Bascom theory).
A 22 year old man presents with a discharging area on his lower back. On examination there is an epithelial defect located 6cm proximal to the tip of his coccyx and located in the midline. There are two further defects located about 2cm superiorly in the same position. He is extremely hirsute. What is the most likely diagnosis?
Pre sacral tumour
Sacrococcygeal teratoma
Pilonidal sinus
Fistula in ano
Occult spina bifida
Pilonidal sinuses are extremely common in hirsute individuals and typically present as midline sinuses in the natal cleft
Chronic pilonidal sinus disease may be a risk factor for?
Squamous cell carcinoma
Bascom procedure
Treatment of pilonidal sinus- excision of the pits and obliteration of the underlying cavity
Karydakis procedure
Treatment of pilonidal sinus:
involves wide excision of the natal cleft such that the surface is recontoured once the wound is closed. This avoids the shearing forces that break off the hairs and has reasonable results.
A 67 year old patient is due to undergo a femoro-popliteal bypass graft. Which heparin regime should the surgeon ask for prior to cross clamping the femoral artery?
Single therapeutic dose of low molecular weight heparin on the ward prior to coming to theatre
Single therapeutic dose of low molecular weight heparin the night before surgery
Dose of 10,000 units of unfractionated heparin prior to induction of anaesthesia
Dose of 3,000 units of unfractionated heparin, 3 minutes prior to cross clamping
Dose of 30,000 units of unfractionated heparin, 3 minutes prior to cross clamping
As a rule most vascular surgeons will administer approximately 3,000 units of systemic heparin 3-5 minutes prior to cross clamping to help prevent further intra arterial thromboses. A dose of 30,000 units is given prior to going on cardiopulmonary bypass. Heparin given at induction will cause bleeding during routine dissection.
Action of heparin
Causes the formation of complexes between antithrombin and activated thrombin/factors 7,9,10,11 & 12
What is the half life of insulin in the circulation of a normal healthy adult?
Less than 30 minutes
Between 1 and 2 hours
Between 2 and 3 hours
Between 4 and 5 hours
Over 6 hours
Insulin is degraded by enzymes in the circulation. It typically has a half life of less than 30 minutes. Abnormalities of the clearance of insulin may occur in type 2 diabetes.
Structure of insulin
The human insulin protein is composed of 51 amino acids, and has a molecular weight of 5808 Da. It is a dimer of an A-chain and a B-chain, which are linked together by disulfide bonds.
An 18 year old lady presents with extensive varicose veins of her left leg. There is associated port wine staining. What is the most likely diagnosis?
Type 1 diabetes
Osler syndrome
Gardner’s syndrome
Proteus syndrome
Klippel-Trenaunay-Weber syndrome
A less common cause of venous insufficiency is Klippel-Trenaunay-Weber (KTW) syndrome, which involves port-wine stains, varicose veins, and bony or soft-tissue hypertrophy.
Features of venous insufficiency?
nclude oedema, brown pigmentation, lipodermatosclerosis, eczema
Treatment of venous leg ulcers?
Management: 4 layer compression banding after exclusion of arterial disease or surgery
If fail to heal after 12 weeks or >10cm2 skin grafting may be needed
Causes of venous leg ulcers
Most due to venous hypertension, secondary to chronic venous insufficiency (other causes include calf pump dysfunction or neuromuscular disorders)
Squamous cell carcinoma
Occurring at sites of chronic inflammation e.g; burns, osteomyelitis after 10-20 years
Mainly occur on the lower limb
Marjolin’s ulcer
Occur on the toes and heel
Painful
There may be areas of gangrene
Cold with no palpable pulses
Low ABPI measurements
Arterial ulcers
Commonly over plantar surface of metatarsal head and plantar surface of hallux
The plantar neuropathic ulcer is the condition that most commonly leads to amputation in diabetic patients
Due to pressure
Management includes cushioned shoes to reduce callus formation
Neuropathic ulcers
