Core Content Flashcards
Acute DKA management
A-E, senior, admit
- Fluids resuscitation (0.9% saline)
- Insulin (0.1 unit/kg/hour)
- Potassium and glucose replacement
Monitor - VBG (pH and electrolytes), capillary glucose, capillary ketones
DKA diagnostic criteria
PH < 7.3
Glucose > 11
Ketones > 3 serum, ++ urine
Acute stroke (ischaemic)
- A-E, alert stroke team (stroke call)
- CT Head, BP, ECG, bloods (esp. clotting)
- Aspirin 300mg
- Thrombolysis if within 4.5 hours +/- thrombectomy
If > 4.5 hours supportive treatment on specialist stroke ward
Acute stroke (haemorrhagic)
- A-E, stroke call/senior
- CT head, ECG, BP, bloods (esp. clotting)
- BP control if HTN, aim 130-140
- Reverse coagulation if patient on
- Surgical decompression if severe, else supportive care
Acute ACS management - STEMI
- A-E, cardio bleep
- ECG, trop, BP, bloods incl. VBG, CXR
- MONA - morphine + anti-emeric , oxygen, nitrate, aspirin 300mg
- Ticareglol 180mg
- PCI or thrombolysis (alteplase, if no PCI)
Acute ACS management - NSTEMI
- A-E, cardio bleep
- ECG, trop, BP, bloods incl. VBG, CXR
- MONA - morphine + anti-emeric , oxygen, nitrate, aspirin 300mg
- Fondaparinux (LMWH)
- Calculate GRACE score (6 month mortality)
How does GRACE score change treatment of NSTEMI patients?
GRACE - 6 month mortality score, considered high if > 3%
HIGH - second anti-platelet (ticagrelol), PCI within 72 hours
LOW - can be d/c once stable, likely elective OP PCI
Long term post MI management
Conservative
- Lifestyle - smoking, diet, activity
- Cardiac rehabilitation programme
Medicine - BADS
Beta blocker
ACEi
Dual antiplatelet - aspirin 75mg (lifelong) + ticagrelol 90mg (1 year)
Statin - high dose
Complications of MI
DARTH VADAR
Death
Arrythmia
Rupture - V wall, papillary muscle (MR)
Tamponade
Heart failure
Valve disease
Aneurysm of ventricle
Dressler’s syndrome (pericarditis)
thromboEmbolism
Recurrence
Acute management of heart failure
POD MAN
Position - sit up
Oxygen
Diuretics - furosemide 50mg IV
Morphine
Anti-emetic
Nitrates
Long term management of heart failure
CONSERVATIVE
- Cardiology MDT
- Lifestyle - smoking, execise
MEDICAL
Treat the underlying cause if possible
- ACEi + beta blocker + loop diuretic if oedema
- Add spironolactone
- Specialist Tx such as ibravadine, sacubitral-valsartan
SURGICAL
- Cardiac resynchronisation
- ICD
Interpreting NT pro BNP
> 2000 ng/L - 2 week referral to cardio
400-2000 - 6 week referral to cardio
< 400 - unlikely heart failure
Acute management of PE
A-E assessment, breif history for RF, alert seniors
Calculate wells score
- low - D.Dimer
- high - CTPA
CXR, ECG, BP, bloods incl. clotting
Unstable - thrombolysis with alteplase
Stable - anti-coagulation with apixaban
Acute management of asthma
A-E
O SHIT ME
Oxygen
Salbutamol nebs
Hydrocortisone
Ipratropium nebs
Theophylline IV
Magnesium sulphate IV
Escalation - intubation and ventilation
Acute management of COPD
O SHIT
Oxygen - titrate with venturi
Salbutamol nebs
Hydrocortison
Ipratropium nebs
Theophylline
If infection + antibiotics e.g. doxy
If not responding - NIV (BiPaP)
When do you use BiPap vs CPAP?
Type 1 RF - 1 thing wrong (hypoxic) - CPAP
Type 2 RF - 2 things wrong (hypoxic, hypercapnic) - BiPaP
Acute management of pneumothorax
A-E assessment
CXR, sats, RR, tracheal deviation, BP
Stop NIV if running and high suspicion of pneumo
Tension - needle decompression 2nd ICS MCL then chest drain
Non tension - assess size of rim of air on CXR, if patient is symptomatic and if primary/secondary
Management of a non tension pneumothorax (after A-E)
Primary
- < 2cm and no SOB - d/c, repeat CXR in 2-3 weeks
- > 2cm or Sx - needle aspirate
- failure of aspiration - chest drain
Secondary - always admit
- <1cm + no SOB - 24 hours oxygeb
- 1-2cm + no SOB - needle aspiration
- > 2cm, SOB or failed aspiration - chest drain
Management of sepsis
A-E, senior input
Sepsis 6
Urine output, IV fluids
Blood cultures, IV antibiotics
Lactate (Blood gas), Oxygen
Assess for source - CXR, urine dip, cultures, assess neuro/CNS
Management of meningitis and/encephalitis
- A-E approach, senior input
- CT head, lumbar puncture
- IV antibiotics (ceftriaxone +/- amoxicillin)
- Anti-viral if ?encephalitis/viral → IV aciclovir
- Sepsis 6 if unstable/septic
Long term stroke management (ischaemic specific?
Reducing recurrence risk
- CVD RF modification
- look for emboli - ECG and ECHO
- look for carotid stenosis (doppler)
Conservative
- SALT, OT/PT
- lifestyle - smoking, alcohol, etc
Medical
- aspirin 300mg for 2 weeks then life long clopidogrel
- BP control
- high dose statin
- glycaemic control if DM
Acute management of upper GI bleed
- A-E, if shocked major haemorrhage call
- Fluid resusciation +/- blood
- Fastbleep gastro for endoscopy consideration
- NBM
- IV Abx
- Analgesia + anti-emetic
- Terlipressin if likely/known varicela bleed
- Stengstaken-blakemore if life-threatening
Acute management of anaphylaxis
- A-E, if stridor - anaesthetics, stop ?offending drugs, IV access
- IM Adrenaline 0.5ml 1 in 1000 (500mcg)
- IV fluids - manage hypotension
- Repeat IM adrenaline if 5 minutes if no change
After 2 doses = refractory - set up IV infusion adrenaline via central line, goes to ITU
Acute management of status epilepticus
- A-E, start timing, follow status protocol, alert seniors
- Reversible causes - VBG, glucose, blood panel
- 5 minutes - IV lorazepam or buccal midazolam
- After 10 minutes - repeat benzo, ensure ITU/anaesthetics attending
- After another 10 minutes - IV phenytoin + cardiac monitoring
- After another 10 minutes - RSI with propofol, ITU + EEG
components of A in A-E
airway
- assessment
- talking = patent
- stridor
- sounds of upper airway obstruction
- interventions
- head tilt + chin lift
- jaw thrust
- oro/nasopharyngeal airway
- LMA
- ET/tracheostomy
components of B in A-E
breathing
- assessment
- RR + sats
- Auscultate, percuss, expansion, trachea
- CXR
- ABG
- interventions
- 15L non-rebreathe mask
- ventilation in severe
components of C in A-E
circulation
- assessment
- BP, HR
- heart sounds
- fluid status - JVP, mucus membranes, CRT, UO
- ECG
- bloods - VBG + specific for scenario
- interventions
- 2 x large bore IV cannula
- fluid challenge if hypotensive
- blood transfusion if major bleed
components of D in A-E
disability
- assessment
- capillary blood glucose
- GCS calculation
- Pupils - equal/reactive to light
- CT head if reduced GCS
- intervention
- glucose replacement
- head up, neuro + mannitol for raised ICP
components of E in A-E
exposure/everything else
- assessment
- limbs - neurovascular status
- skin - rash
- abdo - SNT?
- orifices for other sites of bleeding
Acute management of hypoglycaemia
- conscious + moderate - glucogel
- unconscious/severe + IV access - 75ml 10% glucose
- unconscious, no access - IM glucagon
acute management of bradycardia with life-threatening signs
- A-E with IV access, seniors
- monitor BP, sats + cardiac monitoring, ECG
- Atropine 500mcg IV - repeat up to 6 doses
- Transcutaneous pacing or IV adrenaline or IV isoprenaline
- Transvenous pacing
what are the life-threatening signs in arrhythmias?
HISS
- heart failure
- ischaemia (MI)
- shock
- syncope
acute management of bradycardia without life-threatening signs
- A-E approach
- monitor BP, ECG, sats, cardiac monitoring
- observe and urgent cardio review
what are the shockable rhythms of arrest?
ventricular fibrillation
pulseless ventricular tachycardia
what are the non-shockable rhythms of arrest?
PEA
asystole
management of regular narrow complex tachycardia
no life-threatening features
- A-E, cardiac monitoring, sats, BP
- Vagal manoeuvres
- IV adenosine - up to 3 doses
- verapamil if asthmatic
- beta-blocker or verapamil
- synchronised DC cardioversion
management of regular narrow complex tachycardia
with life-threatening features
- A-E, senior support
- synchronised DC cardioversion
management of narrow complex, irregular tachycardia
no life-threatening features
- A-E, senior input, likely AF
- beta-blocker
- if evidence of HF - digoxin or amiodarone
- anticoagulation if > 48 hours, consider DC if < 48 for rhythm control
management of polymorphic broad complex tachycardia
no life-threatening features
- A-E, senior
- IV magnesium sulphate
- assess for reversible causes - drug review, electrolytes
management of broad complex tachycardia
with life threatening features
- synchronised DC cardioversion
management of regular broad complex tachycardia
no life-threatening signs
- A-E, senior input, monitoring
- 300mg IV amiodarone over 10-20 minutes, then 900mg over 24 hours
- consider DC cardioversion if no response
via central line
ALS algorithm for shockable rhythms
- Defibrillation shock
- CPR - 30:2
- Reassess rhythm
- Repeat steps 1-3 provided rhythm remains shockable
Drugs
- after 3rd shock
- 1mg adrenaline IV/IM
- 300mg IV amiodarone bolus
- after
- continue adrenaline every 3-5 mins
- another 150mg amiodarone after 5th shock
ALS algorithm for non-shockable rhythms
- Start CPR - 30:2
- Adrenaline 1mg IM - give every other cycle of CPR
- Atropine 3mg IV if rate < 60bpm
what type of hypersensitivity reaction is asthma?
type 1
Ix for diagnosing asthma
- bedside
- Peak flow diary
- sats + RR + resp examination
- bloods - FBC, IgE
- imaging - CXR
- special
- spirometry + bronchodilator - improvement of FEV1 > 12% or volume > 200
- FeNO > 40 parts per billion
aims of asthma treatment?
- no daytime symptoms
- no night time waking due to symptoms
- no need for rescue medications
- no attacks
- no limitations on daily activities
- normal lung function
CXR features of bronchiectasis
- tram lines
- ring shadows
describe the CURB-65 score
- confusion (AMTS < 8)
- urea ( > 7)
- respiratory rate (>30)
- blood pressure (low, SBP < 90 or DBP < 60)
- age ( >65)
what are the drugs used to treat TB?
RIPE
rifampicin, isoniazid, pyrazinamide, ethambutol
SE of rifampicin
orange secretions e.g. urine
hepatitis
induces liver enzymes
SE of isoniazid?
hepatitis
peripheral neuropathy
SE of pyrazinamide
hepatitis
photo sensitivity
gout
SE of ethambutol
optic neuritis
causes of upper lobe fibrosis?
A TEA SHOP
- A - allergic bronchopulmonary aspergillosis
- T - TB
- E - extrinsic allergic alveolitis
- A - ankylosing spondylitis
- S - sarcoidosis
- H - histiocytes
- O - occupation (silicosis, berylliosis)
- P - pneumoconiosis (coal worker’s)
causes of lower lobe fibrosis
IPAS - BM
- IP - infection, interstitial pneumonia
- A - alpha-1 anti-trypsin deficiency, asbestosis
- S - systemic sclerosis, CTD e.g. RA
- B - bronchiectasis
- M - medications
causes of exudative pleural effusion
- Infection
- Malignancy
- Inflammation e.g. RA, SLE, acute pancreatitis
- Pulmonary infarct e.g. secondary to PE
causes of transudative pleural effusion
- ↑ capillary hydrostatic pressure
- Heart failure
- ↓ capillary oncotic pressure
- Cirrhosis
- Nephrotic syndrome
- CKD
- GI malabsorption or malnutrition e.g. Crohn’s
medications that cause fibrosis
BANS ME
- Bleomycin
- Amiodarone
- Nitrofurantoin
- Sulfasalazine
- MEthotrexate
PEF criteria for grading asthma attack
- 50-70 = moderate
- 33-49 - severe
- < 33 - life-threatening
who does ABPA tend to effect? what does it lead to?
asthmatics
poor control
Allergic bronchopulmonary aspergillosis management
- oral glucocorticoids
- itraconazole
NICE treatment ladder for asthma (long-term)
- SABA, salbutamol
- SABA + ICS e.g. budesonide
- SABA + ICS + LTRA e.g. Montelukast, PO
-
SABA + ICS + LABA (salmeterol) + LTRA
- Continue LTRA if responsive
- Switch LABA/ICS → maintenance and reliever herapy with low-dose ICS
- SABA + MART + LRTA
- Increase ICS to medium dose - SABA + MART with medium dose ICS + LRTA
- Referral to specialist - biologic, high dose ICS
drugs contraindicated in asthma
beta-blockers
NSAIDs
ACEi
adenosine
conservative management of COPD
- smoking cessation
- flu + pneumococcal vaccines
- pulmonary rehabilitation/chest physio
long term medical management of COPD
- 1st - SABA or SAMA
- 2nd - Asthmatic features → add LABA + ICS
-
2nd - No asthmatic features → add LABA and LAMA
- if on SAMA → SABA
- 3rd line - LAMA + LABA + ICS
what are the asthmatic features of COPD?
PEDS
- PMHx atopy/asthma
- Eosinophils high
- Diurnal variation PEFR
- Steroid responsive before
what are the specialist medical interventions for COPD?
- prophylactic antibiotics (azithromycin) - multiple exacerbations/year
- LTOT
what is the criteria for LTOT in all resp conditions (COPD, fibrosis)
- non smoker
- PaO2 < 7.3 kPa on 2 ABG 3 weeks apart
- PaO2 7.3 - 8 kPa with 1 of:
- polycythaemia
- peripheral oedema
- pulmonary HTN
what are the surgical options for COPD?
bullectomy
lung volume reduction surgery
diagnostic test for pulmonary fibrosis?
high resolution CT
honeycombing
management of idiopathic pulmonary fibrosis
best supportive care pathway, respiratory MDT.
-
Conservative
- Chest physiotherapy
- Pulmonary rehabilitation
- Smoking cessation
-
Medical
- Anti-fibrotic - Pirfenidone,
- LTOT
-
Surgical
- Transplant
features of small cell lung cancer
- central
- associated with smoking
- paraneoplastic syndromes - ACTH, lambert-eaton
features of squamous cell lung cancer
- associated with smoking
- central tumours
- cavitating lesions
- paraneoplastic - high calcium, PTHrP secreting
features of adenocarcinoma of the lung
- non-smokers
- peripherally located
investigations for suspected lung cancer
CXR
CT chest
then if confirmed- imaging to stage
common pneumonia CAP organisms
- Streptococcus pneumoniae (70% of CAP)
- Haemophilus influenzae (2nd most common)
- Morexalla catarrhalis
- Group A streptococci
- Klebsiella pneumoniae
- Staphylococcus Aureus
what are the common atypical pathogens of CAP?
- Chlamydia pneumonia
- Mycoplasma pneumoniae
- Legionella
- Chlamydia psittaci
what pathogen of pneumonia:
- rusty coloured sputum
- lobar on CXR
- +ve diplococci
s. pneumoniae
what pathogen of pneumonia:
- smoking + COPD
- gram -ve cocco-baccili
haemophilus influenzae
what pathogen of pneumonia
- following recent viral infection/flu
- cavitation on CXR
- +ve cocci
s. aureus
who gets klebsiella pneumonia?
alcoholics and elderly
treatment of pneumonia
admit if high CURB
-
medical treatment
-
Typical CAP
- Mild → (amoxicillin)
- Moderate-severe → penicillin + macrolide
-
Atypical CAPs
- generally = clarithromycin or doxycycline
-
Typical CAP
-
supportive treatment
- Oxygen, IV fluids, Analgesics
- NIV/ventilation
- Drainage of abscess or empyema
acute abdomen core principles
NBM
IV fluids
analgesia
antiemetic
Abx (cef + met)
investigations for the surgeon
- CT abdo
- FBC + CRP
- U&E, LFTs
- clotting + G&S
- amylase
- calcium
definition of AAA?
Abdominal aorta develops a permanent localised dilation of > 50% of expected artery diameter (>3cm)
cardiovascular RF
- HTN
- Hyperlipidaemia
- Smoking
- Previous CVD disease
- DM
- Male
- Older
what conditions in which to screen/consider for CVD RF?
- stroke
- ACS
- AAA/aneurysms
- peripheral vascular disease
- CKD
- DM
describe screening for AAA
- men one off USS at 65
- women at high risk USS at 70
- (RF - vascular disease, FHx AAA, high risk of CVD)
describe the monitoring of AAA
- 3-4.4cm - yearly USS
- 4.4 - 5.4cm - USS every 3 months
indications for elective repair of AAA
- symptomatic
- asymptomatic + > 5.5 cm
- asymptomatic + growing > 1cm/year
acute management of ruptured AAA
- A-E assessment, major haemorrhage call, vascular
- CT with contrast, G&S + X-match, IV access + resuscitate
- permissive hypotension (< 100mmHg)
- surgery - open repair usually
management of unruptured AAA
- active monitoring
- conservative - stop smoking
- medical - HTN Tx, statin, aspirin
- surgery - EVAR or open procedure
- EVAR for older/frail
- open for younger
6 P’s of acute limb ischaemia
- Pain - constant, persistent
- Pulseless - ankle pulses absent
- Pallor (or cyanosis or mottling)
- Perishingly cold
- Paraesthesia or ↓ sensation or numbness
- Paralysis or power loss
key vascular investigations
-
bedside
- vascular examination
- BP, HR
- ECG
- ABPI
- handheld doppler USS
-
bloods
- FBC, lipids, HbA1c
- clotting
-
imaging
- doppler USS
- CT angiogram
- digital subtraction angiography
-
special
- carotid dopplers
acute management of acute limb ischaemia
- A-E, vascular review urgent
- Limb down (promote blood flow)
- Heparin IV
- Assess if salvageable → if yes revascularisation (embolectomy, thrombolysis or bypass)
what are the revascularisation options for acute limb ischaemia?
- emboli
- embolectomy (balloon, Fogarty catheter)
- thrombus
- bypass grafting (usually if incomplete occlusion)
- thrombolysis + stent
how to assess limb viability in acute ischaemia?
- neurosensory deficit → time critical, late stage ischamia
- paraesthesia + paralysis
- skin appearance
- mottling → suggests non-salvageable
options for non-salvageable limbs
- amputation
- palliation - supportive measures until auto-amputation
what are the risks of revascularisation?
- reperfusion injury → hyperkalaemia, acidosis, rhabdomyolysis, acute renal failure, sepsis
- compartment syndrome
describe IV maintenance fluid guidance
- daily requirements
- water - 30ml/kg/day if fit; 25ml/kg/day if old, kidney or heart failure
- 1 mmol/kg per day of K+, Na+, Cl-
- 50g-100g of glucose each day
how you could estimate surface area of burns?
rule of 9s
acute management of burns (A-E)
- severe → Burns centre
- A - assess for inhalation injury, consider pre-emptive intubation if high risk
- B - 100% O2, ABG, check carboxyhaemoglobin levels
-
C - 2 large bore IV
- routine bloods, G&S, clotting, CK
- aggressive fluid therapy - Parkland’s formula, 0.9% NaCl warmed
- IV analgesia (morphine)
- D - GCS, temperature (risk of hypothermia), PEARL
- E - estimate % burns + wound care
describe Parkland’s formula for burns fluid resuscitation in adults
- Parklands = fluid volume for 1st 24 hrs after major burns
- Adults - 4mL (Hartmann’s) x weight (kg) x % TBSA burned
- Give 50% calculated in 8 hours post burn and 50% in remaining 16 hours
differentials for life-threatening chest injuries
ATOMIC
- airway obstruction
- tension pneumothorax
- open pneumothorax (sucking)
- massive haemothorax
- intercostal disruption + pulmonary contusion
- cardiac tamponade
what is the management of variceal bleeding?
- acute upper GI management
- acute specific
- Terlipressin + IV Abx pre-op
- endoscopy - variceal banding, endoscopy ligation, endoscopic injection
- long term
- beta-blocker (propanolol)
- TIPSS procedure
- address chronic liver disease
causes of cauda equina syndrome
- disc prolapse (most common, L4/5, L5/S1)
- trauma - #
- malignancy
- infection - discitis, Pott’s
- iatrogenic - haematoma after spinal anaesthetic
red flags for cauda equina syndrome?
- Bilateral sciatica
- Progressive evolving neurology, rapid
- Saddle anaesthesia
- Urinary symptoms - incontinence, loss of urge or retention
- Bowel symptoms - unable to open bowels, incontinence
acute management of spinal compression/CES
- Urgent MRI and urgent referral to neurosurgery
- Pre-op measures → Analgesia + NBM + G&S
- Catheterisation - prevent post-renal AKI
-
Metastatic spinal cord compression
- Dexamethasone 16mg in divided doses PO (high dose corticosteroids) + PPI
definitive management of spinal compression/cauda equina syndrome
-
surgical
- Surgical decompression - within 48 hours, laminectomy, posterior decompression
- Radiotherapy + chemotherapy if cancer
- Steroids - if cancer, some inflammation e.g. AS
-
post-operative
- PT/OT
- treat any underlying/contributive cause
causes of encephalitis?
-
infection
- viruses → herpes simplex virus 1 (most common)
- bacteria - N. meningitides
- fungal
- autoimmune encephalitis
cord compression vs cauda equina
differentiating by: tone, power, reflex, clonus, plantars, bowel, bladder and sensation
what are the CSF findings in bacterial infection?
variables: appearance; WCC, protein, glucose
what are the CSF findings in virus infection?
variables: appearance; WCC, protein, glucose
what are the CSF findings in GBS infection?
variables: appearance; WCC, protein, glucose
what are the CSF findings in SAH infection?
variables: appearance; WCC, protein, glucose
what are the CSF findings in TB infection?
variables: appearance; WCC, protein, glucose
describe the components of GCS (broad categories + total score) ?
eye - 4
verbal - 5
motor - 6
detailed GCS score
what are the signs of basal skull #?
- haemotympanum
- “panda” eyes
- CSF leak from ear or nose
- Battle’s sign
what are the indications for CT head within 1 hour ADULT?
- consciousness related
- Initial A&E GCS < 13
- GCS < 15 at 2 hours after the injury
- injury related
- Suspected open or depressed skull fracture
- Any sign of basal skull #
- concerning neurology
- Focal neurological deficit
- Post-traumatic seizure
- > 1 episode of vomiting
what are the indications for CT head within 8 hours in ADULTS?
- over 65 years
- Hx of bleeding or clotting disorder
- On anti-coagulants
- Dangerous mechanism of injury
- > 30 minutes retrograde amnesia of events immediately prior to head injury
acute management of raised ICP
- A-E
- Urgent neurosurgical referral
- Head up 40 degrees
- If intubated → hyperventilate (↓ PaCO2 → cerebral vasoconstriction → ↓ ICP)
- Osmotic agents e.g. mannitol
- Steroids - if ↑ ICP due to malignancy
what are the common organisms of meningitis in neonates?
- group B streptococci
- listeria monocytogenes
- Escherichia coli
what are the common organisms of meningitis overall?
NHS
- N. meningitides
- H. influenza B
- S. pneumoniae,
what are encapsulated bacteria that are clinically important after splenectomy?
NHS
- N. meningitides
- H. influenza B
- S. pneumoniae
what are the common organisms of meningitis older and immunocompromised?
- s. pneumoniae
- L. monocytogenes
- TB
- gram negative organisms
what is the prophylaxis for meningococcal meningitis?
ciprofloxacin to close household contacts
what are the causes of spinal cord compression?
- metastatic cord compression (most common)
- lung, breast, prostate
- traumatic
- infective - abscess, TB, discitis
- disc prolapse (rare in upper spine)
what # are most commonly associated with compartment syndrome?
supracondylar
tibial
key features of compartment syndrome
- pain out of proportion to injury
- sensation of pressure
- paraesthesia
- paralysis of muscle group
management of compartment syndrome
- Dressing release
- Analgesia + urgent T&O/surgery review
- Fasciotomy
- Monitor for rhabdomyolysis and renal impairment
- Surgical intervention - if frankly necrotic muscle is seen on fasciotomy → debridement + amputation
what is the diagnostic criteria of creatine kinase?
5 x the upper limit of normal
what are some causes of rhabdomyolysis?
- Trauma
- long lie - elderly after falls
- Ischaemia - compartment syndrome, reperfusion
- Medical causes - seizure, infections, metabolic abnormalities
- Drug induced - cocaine, diuretics (severe K+ depletion), statin, anti-psychotics, DDP-4 inhibitors (e.g. sitagliptin)
- Toxins - cyanide, copper, CO
management of rhabdomyolysis
- IV fluids + correct electrolyte abnormalities
- Urine alkalinisation - IV sodium bicarbonate
-
Haemodialysis - refractory raised K+ or acidosis
- Helps with ↑ K+ and acidosis
- Indicated if anuric with severe acidosis and hyperkalaemia
management of acute alcohol withdrawal?
- seizure prevention - reducing dose of chlordiazepoxide
- Wernicke-Korsakoff prevention - IV thiamine
- screen for liver disease
- involve alcohol services
features of salicyclate/aspirin OD?
- flushed
- fever
- hyperventilation
- tinnitus, dizziness
- Respiratory alkalosis → lactic acidosis (mixed pH disturbance)
management of salicyclate OD?
- IV sodium bicarbonate
- emergency haemodialysis if life-threatening OD or coma due to OD
treatment of opiate OD?
naloxone 400mcg IM/IV
can repeat if unresponsive
risks of hepatotoxicity after paracetamol OD?
- enzyme inducing medication (PC BRASS)
- malnourish - anorexia, chronic ETOH
- staggered OD
- delayed presentation
what is the management of paracetamol OD?
- N-acetylcysteine
- anti-emetic + fluids, monitor electrolytes + LFTS
- liver transplant - acute liver failure
who should get an immediate NAC infusion? what is usually done?
- single OD → bloods at 4 hours, nomogram to see if needs NAC
- immediate NAC at presentation if:
- staggered, unsure of time of ingestion
- high risk of toxicity e.g. alcoholic
benzodiazepine antidote
flumazenil
management of beta blocker OD
- atropine for bradycardia
- anti-dote = glucagon
antidote to digoxin
digifab
antidote for ethylene glycol poisoning
fomepizole
antidote for local anaesthetic overdose
intralipid
management of TCA overdose
- cardiac monitoring - risk of QTc prolongation and ventricular arrhythmias
- sodium bicarbonate
*
features + treatment of duct ectasia
- older woman
- characterised by dilation of ducts
- nipple discharge - green/brown
- management
- conservative - reassurance
- surgical - if persistent Sx - duct excision
most common type of breast cancer
ductal carcinoma (either in situ or invasive)
RF for breast cancer
- genetic - BRCA 1 or 2
- high oestrogen exposure
- nulliparity
- early menarche, late menopause
- COCP/HRT
- PMHx breast, ovarian, endometrial, colorectal cancer
- obesity
what is the triple assessment for breast cancer?
- clinical examination
- imaging - USS < 35; mammogram if > 35
- histology - FNA or core biopsy
what is the screening program for breast cancer?
mammogram every 3 years (2 views) from 50-70
general description of cancer treatment
- MDT
- treatment combination based on patient factors, tumour staging and patient wishes
- curative or palliative intent
- conservative - psychological support
- medical - chemotherapy, radiotherapy, immunotherapy
- surgical - resection
management of breast cancer
-
general
- MDT
-
surgical resection
- wide local excision - if small, localised
- mastectomy
- + axillary LN clearance
-
adjunct treatment
- radiotherapy
- chemotherapy
- hormonal treatment
- tamoxifen (SERM) if pre-menopausal
- anastrozole (aromatase inhibitor) if post-menopausal
- reconstruction - prosthetic or flap
complications of mastectomy
- Pain
- Infection
- Bleeding
- Lymphoedema of the arm if axillary clearance conducted
- Phantom breast pain
- Seroma
common cause of mastitis/breast abscess?
flucloxacillin
management of mastitis
- anti-pyretic
- antibiotics - flucloxacillin PO, if severe IV Abx
management of breast abscess
- anti-pyretic
- antibiotics - flucloxacillin PO, if severe IV Abx
- needle aspiration - LA, USS, send for MC&S
- Incision and drainage - if failed multiple aspiration, very large or multi-loculated
classification of aortic dissection (stanford)
-
Type A - dissection of the ascending aorta or arch of the aorta
- Most common
- Type B - dissection of aorta distal to the left subclavian aorta (descending)
diagnostic test for aortic dissection
CT angiogram
acute management of aortic dissection
- A-E assessment, major haemorrhage protocol, vascular referral
- haemodynamically unstable
- theatre - graft or repair
- haemodynamically stable
- type A - surgery, graft repair
- type B - strict BP control (IV labetalol), bed rest, EVAR/open if develop end organ damage
RF for aortic dissection
- HTN
- CTD (EDS, SLE, Marfan’s)
- aortitis
- trauma/iatrogenic
- cocaine/amphetamines
- valvular heart disease
common secondary causes of AF
- ischaemic heart disease
- rheumatic heart disease
- thyrotoxicosis
- pneumonia
- PE
- sepsis
- alcohol
- mitral valve disease
investigations for AF
-
Bedside
- ECG - diagnostic. Irregularly irregular rhythm, No P waves
-
Bloods
- Exclude contributing cause - FBC + CRP, TFTs, U&Es
-
Imaging
- Echocardiogram - structure heart disease
-
Specialist or scoring
- CHA2DS2-VASc stroke risk score
- ORBIT bleeding risk score
what is the CHADsVASc and how to interpret?
- > 2 F - should be anticoagulated
- > 1 M - should be
- C - congestive cardiac failure (1)
- H - HTN (1)
- A2 - > 75 (2)
- D - DM (1)
- S2 - Stroke/TIA (2)
- V- Vascular disease (1)
- A - 65-74 (1)
- Sc - female (1)
new-onset AF - guidance for DC cardioversion?
< 48 hours - can cardiovert
48+ hours - TOE to exclude thrombus + DC or anti-coagulate for 3/52 then elective cardiovert
management of AF
-
conservative
- cardiovascular RF modification
- education about AF + stroke signs
-
medical
- rate control
- rhythm control
- stroke prevention
-
surgical
- atrial ablation - refractory, identifiable originating loci
detailed medical management of AF?
-
rate control
- beta-blocker (bisoprolol)
- rate-limiting CCB (verapamil)
- digoxin - if hypotension, heart failure
-
rhythm control
- elective electrical cardioversion
- pharmacological - flecainide (pill in pocket), amiodarone
- stroke prevention - DOAC (apixiban), warfarin + LMWH bridging (always if valvular AF)
what is atrial flutter?
- re-entrant atrial tachycardia
- atrial rate 250-320 bpm
- fixed or variable AV condition, narrow QRS
- saw-tooth pattern on ECG
management of atrial flutter
- haemodynamically unstable → DC cardioversion
- stable
- rate control - beta-blocker, CCB
- rhythm control - elective cardioversion
- VTE prophylaxis e.g. apixiban
- catheter radiofrequency ablation - 1st line if normal/mild enlarged LA
- pacemaker (atrial if refractory to Tx)
causes of high output failure?
anaemia
sepsis
pregnancy
Paget’s
hyperthyroidism
what is a reduced EF?
< 45%
features of LV heart failure
- pulmonary congestion - SOB, PND, orthopnoea
- hypotension/syncope - low CO
- S3 gallop
- functional MR
CXR features of heart failure
- A - alveolar oedema (“batwing” perihilar shadowing)
- B - Kerley B lines, interstitial oedema
- C - Cardiomegaly (> 0.5)
- D - upper lobe blood diversion
- E - pleural effusions (usually bilateral, transudates)
- F - fluid in the horizontal fissure
types of cardiomyopathy
- dilated
- hypertrophic
- restrictive
Dilated cardiomyopathy summary
- description
- causes
- management
Dilated cardiomyopathy summary
- description- systolic dysfunction, dilation of heart
- causes - idiopathy (majority), post-viral, alcoholism, post-partum
-
management
- symptomatic support + HF management
- ICD if arrhythmias
- heart transplant
Ix for cardiomyopathy
- bedside - ECG
- bloods - NT pro-BNP, lipids, HBA1c, U&Es, FBC
- imaging - CXR, echo
-
specialist
- endomyocardial biopsy
- genetic analysis
- cardiac catheterisation
Hypertrophic cardiomyopathy summary
- description
- causes
- management
Hypertrophic cardiomyopathy summary
- description - thickened heart tissue, diastolic dysfunction, preserved EF till end
- causes - genetic, AD
-
management
- ICD - high risk of sudden cardiac death
- exercise restriction
- reducing outflow obstruction
- beta-blocker, verapamil
- surgical myomectomy
- alcohol septal ablation
- screening of relatives
Restrictive cardiomyopathy summary
- description
- causes
- management
Restrictive cardiomyopathy summary
- description - diastolic dysfunction, reduced compliance of heart tissue, RARE
- causes - familial, infiltrative (sarcoid, amyloid), storage (haemochromatosis), radiation induced fibrosis
-
management
- symptomatic + HF
- ICD if arrhythmia
- heart transplant
DVT well’s score
- 2+ - likely, 1 or less - unlikely.
- Criteria are:
- Active cancer 1
- Paralysis, paresis or recent plaster immobilisation of lower extremities 1
- Recently bedridden for > 3 days, or major surgery within 3/12 = 1
- Tenderness along deep vein system = 1
- Entire leg swollen = 1
- Calf swelling at least 3 cm = 1
- Pitting oedema = 1
- Collateral superficial veins (non-varicose) = 1
- Previously documented DVT = 1
- An alternative diagnosis is at least as likely as DVT = -2
management if high DVT Well’s score (> 2)
- USS to confirm diagnosis within 4 hours
- anticoagulation if +ve USS → DOAC (apixiban), LMWH
- mechanical intervention - thrombectomy + IVC filter only if can’t anticoagulate
how long to anti-coagulate for in VTE?
3 months if provoked
6 months if unprovoked
management if low DVT Well’s score
D-dimer test within 4 hours
- If cannot get result within 4 hr → offer interim anticoagulation
- If negative - consider alternative diagnosis
- If positive - offer USS (if within 4 hours) + interim anticoagulation
what to do if D-dimer +ve and USS negative in DVT?
stop anti-coagulation
repeat USS in 1 week
what is the primary prevention statin choice?
20mg atorvastatin
what is the secondary prevention statin of choice?
80mg of atorvastatin
indications for amputation
- Death → tissue death most commonly due PAD
- Dangerous → infected or malignancy in limb
- Damage → trauma, burns, frostbite
- Damn annoying → pain, etc, refractory to other treatment
what are the types of heart block?
- first degree - consistent PR prolongation, no loss of QRS
-
Second degree - prolonged PR with loss of QRS complexes in a predictable manner
- Mobitz type 1 - progressive lengthening of the PR interval until P wave with failed conduction of QRS
- Mobitz type 2 - intermittent non-conduction of P to QRS with a fixed constant PR interval
- Third degree - complete heart block, atrial impulses fail to be conducted to ventricles
causes of 1st degree heart block?
- athletes - high vagal tone (not pathological)
- acute inferior MI
- electrolyte abnormalities
- meds
what medications can cause heart block?
- beta-blockers
- CCB
- digoxin
- amiodarone
what is a major cause of second and third degree heart block?
myocardial infarction
management of 1st degree heart block?
benign, doesn’t require treatment
screen for any underlying cause, if found treat
management of second degree heart block
-
Mobitz type 1
- asymptomatic - no Tx
- symptomatic - most no Tx, ECG monitoring, review medication, consider pacemaker
-
Mobitz type 2
- pace maker as high risk of complete high block
management of third degree heart block
permanent pacemaker
what is malignant HTN
> over 180/120
secondary causes of HTN
- Renal: renal artery stenosis, PCKD, CKD
- Endocrine: hyperthyroidism, Cushing’s, Conn’s syndrome, pheochromocytoma, acromegaly
- Cardiovascular: coarctation of aorta
- Drugs: sympathomimetics, corticosteroids, COCP
investigations of HTN
- diagnosis
- clinic + confirmed with ambulatory (1st line) or home BP readings
- assess for complications
- urine dipstick - protein
- ECG
- bloods - U&E (renal function), HbA1c (CVD risk), lipids (CVD risk)
- fundoscopy
medical management of HTN
management of severe HTN (> 180/120)
- asymptomatic
- urgent assessment for end organ damage - headache, eyes, renal, heart
- initiate oral HTN treatment
- symptomatic
- hospital assessment + admission
- IV labetalol
what are the HTN retinopathy stages
- Silver wiring
- Silver wiring + arteriovenous nipping
- Silver wiring, arteriovenous nipping, flame haemorrhages and cotton wool exudates
- Silver wiring, arteriovenous nipping, flame haemorrhages, cotton wool exudates + papilloedema
complications of HTN
- cardiac - HF, coronary artery disease, PVD
- neuro - CVA, HTN encephalopathy
- renal - HTN nephropathy, CKD
- eyes - hypertensive retinopathy
Duke’s criteria for infective endocarditis
-
major
- +ve blood cultures (2 +ve, 12 hours apart, different site)
- echocardiogram findings - vegetations
-
minor
- RF e.g. IVDU
- fever > 38
- immune complex - haematuria/glomerulonephritis, osler’s, roth spots
- embolic phenomena - stroke/PE, splinter, janeway
- +ve echo not meeting criteria
pathogens seen in IE
- subacute - Strep. viridans
- acute - S. Aureus, S. epidermis
what valves are most common affected in IE?
mitral and aortic, unless IVDU then RH valves
management of infective endocarditis
- Admit
- A-E
- IV antibiotics - 4-6 week course, should respond within 48 hours of initiation treatment
- Surgical intervention - severe cases, uncontrolled infection
management of stable angina
-
conservative
- education
- lifestyle and RF modification
-
medical
- short term nitrate PRN
- anti-anginal medication
- 1st - beta blocker or CCB
- 2nd - ivabradine
- secondary prevention - 75mg aspirin, 80mg statin, HTN management
-
surgical
- CT angiography 1st line to assess suitability for surgery
- PCI + stenting
- CABG
management of intermittent claudication
-
conservative
- RF - smoking, lifestyle
- supervised exercise program
-
medical
- secondary prevention - 75mg clopidogrel
- vasodilator
-
surgical
- revascularisation - angioplasty + stenting; bypass
what does ABPI tell you?
- high - calcification, seen in DM
- < 0.9 = PAD
- 0.9-0.8 - mild; 0.8-0.5 - moderate; < 0.5 - severe/critical
what is the management of critical limb ischaemia?
- urgent referral vascular
-
medical
- analgesia
- secondary prevention - clopidogrel
-
surgical
- revascularisation - bypass
- amputation if gangrene
what is rheumatic fever?
Rheumatic fever is a systemic inflammatory condition following group A beta-haemolytic streptococcal infection
what is the Jones criteria
Infection + 2 major or 1 major + 2 minor
- Evidence of recent streptococcal infection
- Major criteria
- Arthritis
- Pancarditis
- Sydenham’s chorea
- Erythema marginatum
- Subcutaneous nodules
- Minor criteria
- Fever
- Arthralgia - unless arthritis met as major
- ↑ acute phase proteins (ESR, CRP)
- Prolonged PR interval on ECG
which valves are most commonly affected in rheumatic fever?
most common = mitral
2nd most common = aortic
treatment of rheumatic fever
- eradicate group A beta-haemolytic strep - IV benzypenicillin
- bed rest
- analgesia
- cardiac assessment - may require valve replacement
general ulcer management
- treat any underlying contributing cause
- wound care
- treat any complicating infection
- severe wounds - assessment by plastics for ?debridement + grafting
features of arterial ulcers
- lower legs, areas of trauma or pressure
- small, deep lesions
- painful
- clear edges
- features of peripheral arterial disease - cold peripheries, thick nails, hair loss, long CRT
features of venous ulcers
- gaiter region
- large and shallow
- sloped edges
- sloughing ulcer
- painful
- features of venous insufficiency e.g. varicose veins
4 main types of ulcers
- arterial
- venous
- neuropathic
- pressure
features of neuropathic ulcers
- bony areas e.g. heel, plantar aspect
- deep, clear edges
- painless
- surrounding features - dry, cracked, insensate, calluses, charcot joint
- associated with peripheral neuropathies (DM, B12)
treatment of arterial ulcers
- general ulcer principles
- refer to vascular as sign of critical limb ischaemia
- CVD risk factor modification
- surgery - revascularisation (stenting or bypass)
treatment of venous ulcers
-
conservative
- leg elevation, increased exercise, weight reduction
-
medical
- general ulcer principles
- compression bandaging - check ABPI first
-
surgical
- treat concurrent venous insufficiency
management of neuropathic ulcers
- wound care
- optimise factors affecting peripheral neuropathy - e.g. glycaemic control in DM
causes of aortic regurgitation
- acute
- IE
- aortic dissection
- trauma
- chronic
- rheumatic heart disease
- bicuspid valve
- IE
- CTD
key clinical features of AR
- early diastolic murmur, LLSE, expiration
- wide pulse pressure
- collapsing pulse
- LH failure - SOB
eponymous signs of aortic regurgitation
- Corrigans - exaggerated carotid
- Quinke’s - nailbed pulsation
- De Musset’s - head nodding
- Traube’s sign - “pistol shot” at femoral
investigating valve disease
-
bedside
- cardio examination, ECG
- bloods - FBC, U&E, lipids, glucose
- imaging - echo, CXR
- special - angiogram if for open repair
management of aortic regurgitation
-
conservative
- RF modification
- regular review by cardio
-
medical
- reducing afterload → beta-blocker, ACEi, diuretics
- treat underlying cause
-
surgical
- open aortic valve replacement + aortic root graft
general indications for valve replacement (R heart)
- symptomatic
- features of heart failure
- severe valve disease on echo
causes of aortic stenosis
- bicuspid valve
- senile calcification
- rheumatic heart disease
clinical features of aortic stenosis
- ejection systolic murmur, aortic region, 2nd ICS
- S4
- heaving, non-displaced apex beat
- slow rising pulse, narrow pulse pressure
- quiet S2 (severe)
what are the key symptoms of aortic stenosis?
syncope
angina
dyspnoea
management of aortic stenosis
-
conservative
- monitoring, severe 6-12 monthly
- RF modification
-
medical
- symptomatic treatment if features of HF
-
surgical
- open aortic valve repair
- TAVI (preferred in older/frail)
causes of mitral regurgitation
- acute
- ischaemic - papillary muscle rupture
- IE
- rheumatic heart disease
- chronic
- degeneration of valve (age)
- CTD
- dilated cardiomyopathy
clinical features of mitral regurgitation
- pansystolic murmur at the apex, radiate to axilla, expiration
- quiet/soft S1
- parasternal heave
- irregularly irregular pulse
- prolapse - mid-systolic click
management of mitral regurgitation
- conservative- monitoring and RF
-
medical
- AF management
- HF management if present
-
surgery
- valve repair (1st)
- valve repalcement (2nd)
causes of mitral stenosis
- rheumatic heart disease (most common)
- mitral calcification
- carcinoid syndrome
clinical features of mitral stenosis
- rumbling mid-diastolic murmur over apex, bell, expiration, left lateral
- tapping + non-displaced apex
- parasternal heave
- loud S1
- malar flush
- AF
management of mitral stenosis
- conservative - monitoring and RF
-
medical
- manage AF
- consider diuretics (reduce pre-load)
-
surgical
- transcatheter valvotomy (rheumatic MS)
- mitral valve replacement
complications of varicose veins
- bleeding
- superficial vein thrombosis
- skin ulceration
- depression
- reduced QOL
RF for varicose veins
- older age
- FHx
- female
- pregnancy
- obesity
- prolonged sitting/standing
- Hx of DVT
management of varicose veins
-
conservative
- reduce standing, elevate stocking, weight loss
-
medical
- compression stocking
-
interventional
- radiofrequency ablation
- injection sclerotherapy
-
surgery
- ligation
- stripping
what are the indications for interventional or surgical treatment of varicose veins?
bleeding, symptomatic, venous insufficiency chronic changes, venous ulcers
pathology of vasovagal syncope
- neural mediated reflex syncope
- excessive vagal discharge causing reflex bradycardia + peripheral vasodilation.
management of vagal attack
- education about triggers
- if impending syncope → lie down, legs up, volume expansion (more fluids, salt)
- severe/unpredictable → tilt training, isometric counterpressure manoeuvres
what is wolff-Parkinson white?
WPW is a syndrome characterised by a congenital abnormality which predisposes to supraventricular tachycardia secondary to an accessory pathway
clinical features of WPW
- bundle of kent (congenital)
- syncope, palpitation, dizzy
- short PR
- delta wave on ECG
management of WPW
-
acute
- unstable - cardiovert
- stable - IV adenosine, if feature of flutter amiodarone
-
chronic
- medication review
- ablation of accessory pathway - radiofrequency or surgical
indications for carotid endarterectomy
- Carotid artery disease - in prevention of ischaemia stroke
- Symptomatic carotid stenosis of 50-99%
- > 50% stenosis and > 1 TIA in last six months provided stenosis on side accounting for TIA
clinical features of cluster headache
- trigger - ETOH, smoking, exercise
- severe, unilateral headache, rapid, clustered, night
- associated - red, teary eye, rhinorrhoea, lacrimation, facial vasodilation
management of cluster headache
-
conservative
- avoid trigger, good sleep hygiene
-
acute
- high flow O2
- sumatriptan SC
-
long term
- verapamil
what are the types of seizure?
- focal
- simple
- complex - impaired consciousness
- generalised
- absence
- tonic
- myoclonic
- tonic-clonic
- atonic
features of temporal lobe seizure
- automatism e.g. lip smacking
- deja vu
- emotional disturbance
- hallucination (sensory e.g. olfactory)
features of frontal lobe seizure
motor
jacksonian march, Todd’s paresis
features of parietal lobe seizures
sensory - tingling, numbness
can develop into motor as electrical activity spreads into frontal lobe
management of alzheimer’s dementia
- bio
- acetylcholinesterase inhibitor (donepezil)
- NMDA antagonist (memantine)
- psycho
- managing psychological symptoms e.g. mood disturbance
- social
- support at home + carers
- home safety
features of Miller Fisher syndrome
ataxia + opthalmoplegia + areflexia
subtype of GBS
key features of Guillain-Barre syndrome
- ascending symmetrical paralysis (LMN)
- risk of T2RF
- anti-ganglioside antibodies
- LP - raised protein, normal cell count + glucose
- reduced nerve conduction studies
what are the main triggers for GBS?
respiratory or GI infection (Campylobacter, mycoplasma, EBV)
management of GBS?
- serial ABG + spirometry for resp. function
- IVIG + plasmapheresis
- ventilation of required
causes of horner’s syndrome
- central
- stroke, MS, tumour
- pre-ganglionic
- Pancoast, trauma, cervical rib
- post-ganglionic
- carotid dissection, endartectomy, cavernous sinus thrombosis
triad of Horner’s
- ptosis
- miosis
- anhidrosis
what is the genetics of Huntingtons?
trinucleotid repeat (CAG, Chr 4, huntingtin protein)
AD condition
what are the clinical features of Huntington?
- choreoathetosis (chorea)
- dementia
- familial condition
what are the types of hydrocephalus?
- Non-communicating/obstructive where the flow of CSF is blocked
- Communicating - is an issue with reduced absorption or blockage of the venous drainage system
causes of obstructive hydrocephalus
- obstructing tumour or cyst
- congenital
causes of communicating hydrocephalus
- infective meningitis
- SAH
- normal pressure hydrocephalus
management of hydrocephalus
- medical - acetazolamide (limited use)
- surgical - ventriculo-peritoneal shunt
What bleeds in an extradural?
Middle meningeal artery (most common)
Key features of extradural
- blood collects between bone and dura - lucid period then reduced GCS - features of raised ICP
What is the appearance of an extradural on CT?
Hyperdense biconvex/lentiform haematoma
Management of extradural
General principles - A-E - neurosurgery - raised ICP management Definitive - surgery (burr holes, craniotomy) if GCS < 8, large, midline shift, focal neuro deficits - conservative - everyone else - neurorehab
What bleeds in a subarachnoid haemorrhage?
Aneurysm - e.g Berry AV malformations
Key features of SAH
- blood accumulating in subarachnoid space - sudden onset thunderclap headache - associated with PCKD
Diagnosing SAH
- CT head - blood in SA space often around circle Willis - CT angiogram/DSA - LP 12 hours after Sx onset - xanthochromia
Management of SAH
- A-E, neurosurgical review 2. Nimodipine 4hrl to prevent vasospasm 3. BP control < 180 systolic 4. Surgical - coiling or clipping of aneurysm 5. Neuro-obs + rehab
What is bleeding in a subdural?
Briding veins between cortex and venous sinuses
Types of subdural haemorrhage
Acute - <72hrs, associated with trauma Subacute - 3-20 days Chronic - > 3 weeks
Key features of subdural
- bleeding between dura mater and brain surface
- fluctuating consciousness
- may have long hx
- gait deterioration
- psych symptoms / CI
appearance of a subdural haemorrhage on CT?
- crescent shaped
- acute - homogenous hyperdensity
- subacute/chronic - varying density
management of subdural haemorrhage
- A-E, neurosurgical review
- anti-convulsant for 1 week (seizure prophylaxis)
- surgical intervention - large, midline shift, neurological deficit
- trauma craniotomy
- burr hole + drain
- conservative otherwise
classical migraine features
- unilateral throbbing headache, hours
- aura
- N&V
- photophobia
- phonophobia
- still/reduction in function
acute management of migraine
- oral triptan e.g. sumitriptan
- analgesia - OTC
- anti-emetic e.g. metoclopramide
long term management of migraine
-
conservative
- trigger avoidance
- OCP CI (meds r/v)
-
medical
- indicated - multiple episodes in month
- 1st line - propranolol (F), topiramate
- 2nd - amitriptyline
what is motor neurone disease
Motor neurone disease refers to a spectrum of heredodegenerative disease of the peripheral and central motor neurones
has UMN and LMN features
what are the 4 types of MND?
- amyotrophic lateral sclerosis
- bulbar amyotrophic lateral sclerosis
- progressive muscular atrophy
- progressive lateral sclerosis
what is the most common form of MND?
amyotrophic lateral sclerosis
key features of bulbar amyotrophic lateral sclerosis
- early bulbar involvement
- dysarthria, dysphagia, wasted fasciculation tongue
- poor prognosis
investigations for MND
- bedside - neuro examination
- bloods - CK, ESR, anti-ganglioside AB (Exclude GBS)
- imaging - MRI head and spine
-
special
- nerve conduction studies
- spirometry
management of MND
- neurology MDT
-
conservative
- PT/OT
- education
- psych
-
medical
- riluzole
- respiratory support e.g. NIV
- symptom management
- cramps → quinine
- spasticity → baclofen
- pain Tx
what is the medication used to treat/prolong life in MND?
riluzole
what is MS?
MS is an autoimmune condition whereby T cell mediated immune response leads to discrete areas of demyelination within the CNS.
what are the types of MS?
- Relapsing-remitting - 80% at PC
- Primary progressive
- Progressive-relapsing disease
- Secondary progressive
what criteria is used to diagnose MS?
McDonald
what investigations for MS?
- bedside - neuro + eye exam
- blood - exclude other causes
-
imaging
- MRI brain + spine with contrast (plaques of demyelination)
-
special
- LP - IgG oligoclonal bands, electrophoresis
management of acute MS relapse?
- high dose glucocorticoids
- plasma exchange if no response to steroids
long term management of MS
- MDT neuro
-
conservative
- PT/OT, psych, education
-
medical - disease modifying
- beta-interferon (glatiramir) - 1st line
- biologic - natalizumab
-
medical - symptoms
- spasticity - baclofen
- clonazepam - tremor
- anti-cholinergic/catheter = bladder dysfunction
what is the 1st line disease modifying drug for MS?
beta-interferon (glatiramir)
what is a biologic used in MS?
natalizumab
prevents migration of leucocytes over BBB by blocking receptor
what are the key Ab in myasthenia gravis?
anti-acetylcholine receptor Ab
what is myasthenia gravis associated with? how to assess?
thymoma
CT chest
what are complications of myasthenia gravis?
- myasthenic crisis (respiratory failure)
- reduced QOL
how to differentiate myasthenia gravis from lambert eaton?
MG - worse with repetition
LE - better with repetition
management of acute myasthenia gravis crisis
- A-E
- serial FVC monitoring + ventilatory support
- steroids
- IVIG or plasmapheresis if severe/steroid unresponsive
long term management of myasthenia gravis
- thymectomy if thymoma +
- anti-cholinesterase inhibitor - pyridostigmine
core features of parkinson’s
rest tremor
rigidity
bradykinesia
postural instability
what are the parkinson plus syndromes?
- progressive supranuclear palsy - impaired downgaze
- multiple system atrophy - autonomic + cerebellar signs
- corticobasal degeneratoin
- lewy-body - fluctuating consciousness, hallucination
what is the underlying issue in parkinsons (pathology)
loss of DA neurons in substantia nigra
medical management of parkinson’s disease
- Levodopa + COMT inhibitor
- inhibitor - prevent peripheral metabolism
- Levodopa - boost DA levels
key features of tension headache
- mild
- bilateral, non pulsatile headache
- tight band
- often end of day/associated with stress
management of tension headache
- OTC pain relief - advice r.e. overuse
- stress management
- reassure benign condition
TIA vs stroke?
TIA refers to focal neurology which resolves with no evidence of infarct on scans (MRI)
what are the Ix for TIA
-
bedside
- neuro exam + cardio
- BP
- ECG
-
bloods
- FBC, U&E, LFTs, lipids, glucose
-
imaging
- CT head (acute, current neurology)
- diffusion weight MRI - assess for ischemia
- carotid USS
what is the initial management of TIA?
- 300mg aspirin
- referral
- ongoing neuro Sx → A&E
- TIA in last 7 days → TIA clinic within 24 hours
- TIA > 7 days → TIA clinic within a week
long term management of TIA
- CVD risk reduction
- anti-platelet - clopidogrel
- treat AF if present
- consider carotid endarterectomy
key features of trigeminal neuralgia
- severe sharp pain in trigeminal distribution
- unilateral
- triggers - light touch, wind, shaving
what is the treatment for trigeminal neuralgia?
-
medical
- 1st line - carbamazepine
-
surgical
- microvascular decompression
what is Wernicke’s encephalopathy?
triad of: mental status change + ophthalmoplegia + gait dysfunction
what causes Wernicke’s encephalopathy?
B12 deficiency
what is the management of Wernicke’s encephalopathy
- acute
- IV pabrinex (thiamine)
- long term
- reduce drinking if alcoholic
- manage liver disease if present
definition of achalasia
oesophageal motility disorder of impaired muscle activity leading to failure/incomplete relaxation of the lower oesophageal sphincter
gold standard test for achalasia
oesophageal manometry
- shows:
- Absence of oesophageal peristalsis
- Failure of relaxation of lower oesophageal sphincter
- High resting lower oesophageal sphincter tone
management of achalasia
-
conservative
- reflux management strategies
- nutritional support if required
-
medical
- botulinum toxin injection
- CCB/nitrates - short lasting effect
-
surgical
- oesophageal endoscopic balloon dilatation
- Heller’s myotomy - division of lower oesophageal sphincter
stages of alcoholic liver disease
fatty liver → alcoholic hepatitis → alcoholic cirrhosis
what LFT would suggest alcoholic liver disease?
- LFTs - ↑ AST + ALT, AST:ALT > 2 → indicative of alcoholic liver disease; ↓ albumin
- GGT - ↑↑
what is seen on biopsy of alcoholic liver disease?
- centrilobar hepatocyte balooning
- Mallory-Denk bodies (mallory-hyaline inclusion)
- evidence of inflammation and fibrosis
management of alcoholic liver disease
-
acute
- acute withdrawal - chlordiazepoxide + pabrinex
- manage liver decompensation as appropriate
-
conservative
- reduce ETOH
-
medical
- prednisolone
-
surgical
- liver transplant - abstinent for 3/12
causes of anal fissure
- primary
- secondary
- constipation
- IBD
- STI
- rectal malignancy
- birth
management of anal fissure
-
conservative
- high fibre diet + good hydration
-
medical
- laxatives - bulk forming (ispaghula husk)
- local anaesthetic ointment
- GTN ointment if > 1 week + no improvement
- Topical 2% diltiazem, specialist guidance
-
surgical
- lateral sphincterotomy - unresponsive to medical Tx
management of anal fissure
-
conservative
- high fibre diet + good hydration
-
medical
- laxatives - bulk forming (ispaghula husk)
- local anaesthetic ointment
- GTN ointment if > 1 week + no improvement
- Topical 2% diltiazem, specialist guidance
-
surgical
- lateral sphincterotomy - unresponsive to medical Tx
what are the signs associated with appendicitis?
- periumbilical pain → RIF
- Rovsing’s sign - palpation of LIF produces pain in RIF
- Psoas sign - RIF pain with extension of right hip
- Cope sign - pain on flexion + internal rotation of hip (occurs if appendix near obturator internus)
differentials for appendicitis?
- Gynae - ovarian cyst accident, ectopic, PID
- Renal - ureteric stone, UTI
- GI - obstruction, strangulated hernia, IBD
- Urological - testicular torsion, epididymo-orchitis
- Other - DKA, pneumonia, porphyria
what score is used for appedicitis?
Alvarado
what is the management of appendicitis?
-
Medical
- Septic 6 - if required
- IV antibiotics - cefuroxime, metronidazole
- NBM + IVF + analgesia + anti-emetic
-
Surgery
- Laparoscopic appendicectomy (1st line)
antibodies associated with autoimmune hepatitis
- type 1 - anti-smooth muscle Ab, ANA
- type 2 - anti liver/kidney microsomal Ab type 1
what are the nerves for the ankle reflex?
S1/S2
nerves for patella reflex?
L3/L4
nerve for triceps reflex?
C7-C8
nerve for biceps reflex?
C5/C6
supinator reflex (brachioradialis) nerve root
C5/C6
management of autoimmune hepatitis
-
Medical
- Induction → steroids
- Maintenance therapy → azathioprine
- Vaccinate against hepatitis A and B, test prior to vaccination
- surveillance for HCC → USS + serum AFP
-
Surgical
- Liver transplant - terminal stages, recurrence after transplant occurs in some
what is Barret’s oesophagus?
Barrett’s oesophagus refers metaplasia of squamous epithelium to columnar epithelium following chronic acid exposure
Ix for Barret’s
- Gi examination
- H. pylori testing
- endoscopy + biopsy - histological diagnosis
complications of Barret’s oesophagus
Oesophageal adenocarcinoma, oesophageal stricture
management of Barret’s oesophagus
-
Conservative - all
- ↓ ETOH intake, normal weight
- meds r/v - ↓ gastric protection or affecting oesophageal motility
- Reflux prevention
-
No dysplasia
- Endoscopy every 2-5 years
-
Low grade dysplasia
- High dose PPI (BD)
- Endoscopic surveillance every 6/12, quandrantic biopsies every 1cm
-
High grade dysplasia
- Endoscopy every 3/12
- Treat any visible lesions → resection (photodynamic, radiofrequency or laser)
what is cholangiocarcinoma?
- cancer of biliary tree - usually extrahepatic
- most common at bifurcation of hepatic duct
- 95% adenocarcinoma
what is the tumour marker for cholangiocarinoma?
CA19-9
management of cholangiocarcinoma
- Management under MDT
-
Curative treatment
-
Surgical
- Complete surgical resection - gives definitive treatment
- Intrahepatic and tumours at hepatic bifurcation → partial hepatectomy and reconstruction of biliary tree
- Distal common duct tumours - pancreaticoduodenectomy (Whipple’s procedure)
- Radiotherapy
-
Surgical
-
Palliative treatment
- ERCP stenting - dilate bile duct to relieve obstruction
- Surgical bypass procedures
- Chemotherapy
what is cirrhosis?
Cirrhosis refers to the diffuse fibrosis and structural abnormality of liver characteristic of chronic liver disease
- impairment of Liver function
major causes of cirrhosis
Alcoholic liver disease
- Non-alcoholic fatty liver disease
- Chronic viral hepatitis
- Autoimmune hepatitis
- Biliary causes - PBC, PSC
- Genetic causes - haemochromatosis, Wilson’s disease, alpha-1 antitrypsin deficiency,
- Medications
- Budd-Chiari syndrome
liver panel bloods
- LFTs
- bone profile + albumin
- FBC + clotting
- U&E - hepatorenal
- cause:
- viral hepatitis serology
- iron studies
- auto-antibodies - smooth muscle, anti-mitochondrial, etc
- aceruloplasmin
- alpha-1 anti-trypsin
what are the components of the Child Pugh score?
- Albumin
- Bilirubin
- Clotting - PT/INR
- Distended abdomen - Ascites
- Encephalopathy
graded A-C with C most severe, high risk for variceal bleed if B/C
what is coeliac disease?
T cell mediated inflammation AI disease due to sensitivity to gluten components (prolamin) resulting in villous atrophy + malabsorption
investigations for coeliac disease
-
bedside
- stool MC&S - exclude infection
-
bloods
- total IgA
- IgA anti-TTG, and IgA anti-endomysial
- FBC, U&E/bone profile, LFT, iron, B12, folate
- imaging
-
specialist
- jejunal/duodenal biopsy - villous atrophy, crypt:villous ratio < 2:1
what are the biopsy features of coeliac?
- villous atrophy, ↑ intraepithelial lymphocytes, crypt hyperplasia
- ↓ crypt: villous ratio ( < 2:1)
what do patients going for endoscopy for coeliacs need to do?
eat gluten for 6 weeks
management of coeliac
-
conservative
- gluten exclusion
-
medical
- screening for other AI disease
- management malnutrition complications e.g. Fe2+ supplements
what cancer is coeliac a RF for?
T cell lymphoma (enteropathy associated T cell lymphoma)
what are the familial syndrome associated with colorectal cancer?
- familial adenomatosis polyposis - APC gene
- Gardner’s
- Peutz-Jegher’s
- hereditary non-polyposis colorectal cancer (NPCC/Lynch syndrome)
what runs through the cavernous sinus?
- Abducens nerve (CN VI)
- Carotid plexus (post-ganglionic sympathetic nerve fibres)
- Internal carotid artery (cavernous portion)
what runs lateral to the cavernous sinus?
- Oculomotor nerve (CN III)
- Trochlear nerve (CN IV)
- Ophthalmic (V1) and maxillary (V2) branches of the trigeminal nerve
investigations for colon cancer?
-
bedside
- GI examination + DRE
- faecal immunohistochemistry test
-
bloods
- CEA - tumour marker
- routine
-
imaging
- barium enema - apple core stricture
- CT colonoscopy - if unable to do actual
- Staging CT (CAP)
-
specialist
- colonoscopy + biopsy = gold standard for diagnosis
what is the tumour marker for colon cancer?
carcinoembryonic antigen (CEA)
describe the 2WW for colorectal cancer
- > 40 + unexplained weight loss + abdominal pain
- > 50 + unexplained PR bleeding
- > 60 with IDA or changes in bowel habit
- +ve occult blood in faeces
describe the screening for colorectal cancer
- Kit sent at: 56 years, then every 2 years from 60-74
- Colonoscopy if +ve
- ↓ risk of dying from bowel cancer by 16%
- Offer another FIT to those with PR bleeding, IDA, CIBH who don’t meet 2WW
describe the Duke’s criteria for colorectal cancer
what is the management of colorectal cancer?
- Management under MDT
-
curative
-
surgery → Resection
- Type of surgery is depending on region affected by malignancy
- + chemotherapy (before or after depends on staging)
- + neoadjuvant radiotherapy - rectal cancers
-
surgery → Resection
-
Non-surgical treatments
- FOLFOX or FOLRIR chemotherapy regime - unsuitable for surgery
- Stenting - palliative procedure for symptomatic relief
what are the surgeries for colorectal cancer?
-
No rectal-disease
- Right hemicolectomy - caecum + ascending colon
- Left hemicolectomy - distal transverse colon descending colon
- Sigmoid colectomy - sigmoid colon
-
Rectal disease
- Anterior resection - tumour > 8cm from anal canal or involving proximal 2/3 of rectum
- Abdomino-perineal resection - tumour < 8cm from anal canal or involves distal 1/3 of rectum
key histological features of Crohn’s
- transmural inflammation
- goblet cells
- non-caseating granulomas
features of crohn’s
- mouth → anus
- skip lesions
- bowel obstruction
- fistula
- usually non bloody diarrhoea
- arthritis
- erythema nodosum
- pyoderma gangrenosum
features of UC
- continuous disease
- no inflammation beyond submucosa
- crypt abscess
- bloody diarrhoea
- PSC
- uveitis
- colorectal cancer
- erythema nodosum
- pyoderma gangrenosum
what is the genetic link with crohn’?
CARD15
Ix for Crohn’s
-
bedside
- GI examination + PR
- faecal calprotectin
-
bloods
- FBC, CRP, ER, LFT, bone, TPMT
-
imaging
- CT abdomen
-
specialist
- ileocolonoscopy + biopsy - gold standard Dx
management of Crohn’s
-
conservative
- smoking cessation
- education + IBD nurse, nutrition
-
medical
- remission - corticosteroids
- maintenance (>2/yr) - azathioprine, methotrexate
- biologic - TNF-alpa (infliximab)
- symptomatic Mx
-
surgical
- resection + stoma as required
treatment of pyoderma gangrenosum?
topical or systemic steroids
ciclosporin if resistant
types of diverticular disease
- diverticula - outpouching of gut wall
- diverticulosis - asymptomatic
- diverticular disease - symptomatic
- diverticulitis - inflammation + bleeding
RF for diverticulitis
older age, low dietary fibre, obesity
complications of diverticulitis
- recurrence
- perforation
- haemorrhage
- abscess
- stricture/obstruction
- fistula
management of diverticulosis?
high fibre diet + fluid intake
laxatives if ongoing constipation
management of diverticular disease
- high fibre diet
- bulk forming laxatives
- analgesia
- anti-spasmodic - relief cramping if required
management of diverticulitis
- admission if severe
- antibiotics
- co-amoxiclav (IV or PO)
- cef + met IV (2nd)
- transfusion if required
- angiography + embolectomy for haemorrhage if distal branch
- surgical
- Hartmann’s - emergency
- resection + stoma elective
what are the types of gallstone?
- cholesterol (90%)
- pigment - associated with haemolysis
- mixed stones
RF for gallstone disease
fat, fair (Caucasian), fertile, forties, female, FHx
management of biliary colic
- Analgesia
- Lifestyle advice - Low fat diet, maintain normal weight, ↑ exercise
- Elective laparoscopic cholecystectomy - within 6 weeks of 1st PC
acute cholecystitis vs ascending cholangitis
- acute cholecystitis - no jaundice
- ascending cholangitis - jaundice, transaminases deranged, CBD obstruction
what is mirizzi syndrome?
stone in Hartmann’s pouch of gallbladder or in cystic duct → can compressed adjacent common hepatic duct causing an obstructive jaundice despite no stone in the CBD
what is gallstone ileus?
after formation of a cholecystoduodenal fistula → gallstone passes into bowel and impacts terminal ileum → small bowel obstruciton
what are features of mild vs moderate vs severe cholecystitis
- mild - stable, short Hx
- moderate - majority, raised WCC, palpable mass in RUQ, > 72hrs, localised inflammation
- severe - resistant hypotension, lowered GCS, oliguria, hepatic dysfunction, hypoxia
management of mild cholecystitis
- oral antibiotics
- analgesia (OTC)
- early laparoscopic cholecystectomy - 1 week within 1st PC
management of moderate cholecystitis
- A-E + admit + general surg. pt Tx
- IV antibiotics
- laparoscopic cholecystectomy - within 1 week (NICE)
- percutaneous cholecystostomy - IR, unfit for surgery + not responding to Abx, drain insertion + delayed cholecystectomy (6 weeks)
management of severe cholecystitis
- as moderate + ICU
- more likely for drain + delayed cholecystectomy
- open cholecystectomy if: mass, sig. inflammation or bleeding, pregnant
major organisms of ascending cholangitis?
E. coli, klebsiella, enterococcus
what is Charcot’s triad? what for?
RUQ pain + fever + jaundice
ascending cholangitis
management of ascending cholangitis
- A-E, resuscitation
- IV antibiotics
- ERCP (1st line)
- percutaneous transhepatic cholangiography - T-tube for drainage (2nd)
- cholecystectomy - definitive
indications for ERCP
- Choledocholithiasis
- Acute pancreatitis
- Chronic pancreatitis (dilatation or stent placement)
- Lesion within biliary system that requires biopsy
- Dilatation of benign stricture
- Manometry reading for sphincter of Oddi dysfunction
types of gastric cancer
- adenocarcinoma (95%)
- intestinal type - smoking, chronic gastritis, lesser curve
- diffuse type - signet cell CA, leather bottle stomach
- SCC
- lymphoma/MALT - H.pylori
what are some associated conditions with gastric cancer
- GI - pernicious anaemia, H. pylori, atrophic gastritis, adenomatous polyps
- blood group A
- smoking
- diet - high nitrates, high salt, low Vit C
- nitrosamine exposure
where does gastric cancer usually affect?
antrum
investigations for gastric cancer
-
bedside
- GI examination
-
bloods
- FBC, LFTs
-
imaging
- endoscopic USS - assess depth
- CT CAP
-
specialist
- gastroscopy + biopsy
2WW for gastric cancer
2WW appointment:
- Upper abdominal mass
Urgent upper GI endoscopy with 2/52 if:
- Dysphagia
- > 55 + weight loss + one of: upper abdominal pain, reflux, dyspepsia
management of gastric cancer
- MDT
- surgical
- early T1a - endoscopic mucosal resection
- locally invasive - partial/total gastrectomy + reconstruction + neoadjuvant chemo
- medical - nutritional
- palliative - majority by time diagnosed
causes of GORD
- Lower oesophageal sphincter incompetence
- Hiatus hernia
- Loss of oesophageal peristaltic function
- obesity
- Gastric factors - gastric acid hypersecretion, slow gastric emptying
- Patient factors - smoking, alcohol, pregnancy
- medications (TCA, anti-cholinergic, nitrates)
- Associated conditions - systemic sclerosis, H. pylori infection
Ix for GORD
- bedside- GI exam
- bloods - FBC
- imaging
-
specialist
- endoscopy (OGD) + biopsy
- H. pylori (urea breath, stool antigen)
- barium swallow - if ? hernia
- 24 hour pH monitoring - gold standard, uncommon
management of GORD
-
conservative
- medication r/v
- raise bed
- smoking cessation, low fat, smaller meals
- avoid triggers
-
medical
- acute - anti-acid, alginate
- PPI
management of dyspepsi
- dyspepsia = reflux, no OGD, clinically diagnosed
- review meds
- trial full dose PPI 4 weeks or “test and treat” H. pylori
- treatment resistant → non urgent OGD
what should be done after H. pylori eradication treatment in ulcer patients?
test of cure 6-8 weeks after treatment
what is the treatment of H. pylori
- PPI + amoxicillin + clarithromycin/metronidazole BD 7 days
- pen allergic = PPI + clarithromycin + metronidazole BD 7 days
management of GORD
- reflux + histological Dx after OGD
- full dose PPI 4-8 weeks
- recurrent → high dose PPI
- refractory + sever → Nissen fundoplication
treatment of C. Diff
- 1st line - oral vancomycin 10/7 or oral fidaxomicin
- 2nd line - oral vancomycin + IV metronidazole (1st if severe, life-threatening)
key facts of haemochromatosis including issue
- hereditary, AR
- increased intestinal iron absorption → iron overload
- HFE C282Y Chr 6
key Ix for haemochromatosis
- FBC
- iron studies - raised ferritin, transferrin saturation, low transferrin, low TIBC
- LFTs - deranged
- CRP - exclude acute ferritin
- HbA1c, hormone levels
complications of haemachromatosis
- Liver fibrosis, cirrhosis, hepatocellular carcinoma
- Severe myocardial siderosis, cardiac dysfunction
- DM
- Skin hyperpigmentation
- Arthropathy
management of haemochromatosis
- venesection - 500mg (450mg iron) 1-2 x week; aim ferritin < 50 ug/L
- desferrioxamine
- liver transplant
- screening for HCC, monitor ferritin levels
what are the types of haemorrhoid?
internal - above dentate
external - below dentate line
what are the grades of haemorrhoids?
- Project into lumen of canal but don’t prolapse
- Prolapse on straining but spontaneously reduce
- Prolapse on straining, require manual reduction
- Prolapsed and incarcerated, cannot be reduced
what is the management of haemorrhoids?
- conservative - minimise straining, fibre + fluid
-
medical
- laxative
- analgesia - LA + steroid
-
minor procedure
- rubber band ligation
- injection sclerotherapy
- photocoagulation
-
surgical
- haemorrhoidectomy
RF for hepatocellular carcinoma
- hep B and hep C - chronic
- alcoholism
- haemochromatosis
- PBC
- aflatoxins
- cirrhosis
Ix for hepatocellular carcinoma
- LFT
- clotting
- liver screen
- AFP
- abdominal USS + biopsy
tumour marker for hepatocellular carcinoma
alfa-fetoprotein
how to differentiate groin hernia using pubic tubercle?
superior + medial → inguinal
inferior and lateral → femoral
hernia superior + medial to pubic tubercle
inguinal
hernia inferior and lateral to pubic tubercle
femoral hernia
differentiating inguinal hernias related to inferior epigastric vessels
direct = medial
indirect = lateral
differentiating indirect vs direct clinically
pressure on deep inguinal ring and assess cough impulse
- direct = protrudes
- indirect - no protrusion
descriptions of hernia
- Reducible hernia - uncomplicated
- Irreducible or incarcerated - contents of hernia cannot be returned to their original cavity
- Obstruction - bowel lumen becomes obstructed
- Strangulated - compression of hernia which cannot be reduced leads to blood supply compromise, leading to the bowel becoming ischaemia
RF for femoral hernia
female, pregnancy, raised intra-abdominal pressure, older age
RF for inguinal hernia
male, increasing age, raised intra-abdominal pressure, obesity
management of inguinal hernia
-
non-surgical/conservative
- small + no sx → watchful wait
- RF modification
-
surgical
- open mesh repair - primary unilateral
- laparoscopic repair - bilateral, recurrent, primary unilateral, female
management of femoral hernia
-
surgical - urgent, within 2 weeks
- low or high approach repair relative to inguinal ligament
- repair defect with suture or mesh
- high approach preferred for emergencies
types of hiatus hernia
-
sliding
- 80%, gastro-oesophageal junction moves up into chest
-
rolling
- 20%, stomach herniates into chest (upward movement of fundus)
management of hiatus hernia
-
conservative
- elevate head at night, small meals, avoid alcohol, smoking cessation
-
medical
- PPI
-
surgical
- Nissen fundoplication
what is acute mesenteric ischaemia?
- acute compromise to blood flow, usually emboli in arteries, usually small bowel
- Life-threatening, surgical emergency
- Sudden onset intestinal hypoperfusion
- Most common site → superior mesenteric artery
what is chronic mesenteric ischaemia
- “intestinal angina”, ↓ blood supply which gradually deteriorates over time, usually due to atherosclerosis
- Common sites - coeliac trunk, SMA, IMA
what is ischaemic colitis?
acute but transient compromise in blood flow to large bowel. Can result in inflammation, ulceration and haemorrhage
causes of acute mesenteric ischaemia
- thrombus due to atherosclerotic plaque
- emboli - AF, aneurysm
- non-occlusive e.g. cardiogenic shock
- venous occlusion + congestion
definitive diagnostic test for acute mesenteric ischaemia>
CT abdomen with IV contrast (CT angiogram) - triple phase scan with thin slices in arterial phase → definitive diagnosis of acute mesenteric
management of acute mesenteric ischaemia
- A-E, admit, surgical Tx + referral
- surgical
- necrotic bowel resection
- re-vascularisation - IR + angioplasty 1st line
management of chronic mesenteric ischaemia
- conservative - cardio RF modification
-
medical
- anti-platelet + statin
- nutritional optimisation
-
surgical
- EVAR - angioplasty and stenting of mesenteric vessels
- open re-vascularisation (endartectomy or bypass)
management of ischaemic colitis
- supportive care incl. transfusion
- broad spec IV Abx
- surgery - if generalised peritonitis, perforation, ongoing bleeding, failed conservative Tx
causes of small bowel obstruction?
HAT
Hernia
Adhesions
Tumour
causes of large bowel obstruction?
CVS
cancer
volvulus
strictures (diverticular > IBD)
pathophysiology in SBO
The blockage → proximal dilation → perforation. In acute cases hyperperistalsis distal to obstruction occurs leading to diarrhoea.
pathophysiology of LBO
Colon proximal to obstruction dilates → increased colonic pressure → mesenteric blood flow reduced → mucosal oedema. If arterial supply is compromised → ulceration and necrosis. Perforation eventually occurs
management of sigmoid volvulus
- decompression with flexible sigmoidoscope
- open/laparoscopic repair if fails
management of SBO
- conservative
- dip + suck
- water soluble contrast study - if no contrast in colon after 6 hrs → surgery
- surgery
- adhesionlysis, resection, hernia repair
what are the functional bowel obstructions?
paralytic ileus
pseudo-obstruction (large bowel)
what is the criteria for IBS?
Manning criteria for IBS - NICE recommended
- At least 6/12
- Abdominal discomfort of pain relieved by defecation or associated with altered bowel habit or stool form
- At least 2 of:
- Altered stool passage e.g. straining or urgency
- Abdominal bloating
- Symptoms made worse by eating
- Passage of mucus
how to diagnose IBS?
- diagnosis of exclusion
- conservative
- diet, review fibre, low FODMAP
- medical - symptomatic
- anti-spasmodic - buscopan
- prokinetic (metoclopramide)
- anti-diarrhoea - loperamide
- laxative
- psych - CBT, relaxation
what is the most common cause of amoebic liver abscess? + treatment
Entamoeba histolytica
metronidazole + drainage/resection
what scores are used to assess for liver transplant?
MELD score - chronic liver disease
King’s college hospital criteria - acute liver failure
factors in Child Pugh score
Albumin
Bilirubin
Clotting (INR)
Distended abdomen (ascites)
Encephalopathy (present, grade)
A-C, associated with life expectancy
complications of liver failure
- infection - usually bacterial
- cerebral oedema + high ICP
- bleeding
- hypoglycaemia
- SBP
- portal HTN
- variceal bleeding
- hepatorenal syndrome
management of ascites?
- dietary salt + fluid restrict
- spironolactone + furosemide
- therapeutic paracentesis
- IV albumin
- < 15 g/L prophylactic Abx (ciprofloxacin)
- TIPSS procedure
when to give ABx in ascites? and which?
< 15 g/L protein in ascitic fluid or previous SBP
ciprofloxacin
management of SBP
broad spectrum IV Abx
describe serum-ascites albumin gradient
> over 11g/L = transudate
< 11 g/L = exudate
causes of ascitic transudate
- > 11g/L SAAG
- portal HTN
- cirrhosis, acute liver failure, liver met/cancer
- RH failure
- constrictive pericarditis
- budd-chiari
- portal vein thrombosis
causes of ascitic exudate
- SAAG < 11g/L
- low albumin - nephrotic, malnutrition
- peritoneal cancers
- TB peritonitis
- pancreatitis
- biliary ascites
- post-op lymphatic leak
management of hepatic encephalopathy
- conservative
- avoid sedatives
- 30 degree head tilt
- medical
- lactulose
- rifaximin (secondary prophylaxis)
- IV mannitol
management of variceal bleeding
- A-E resuscitation
- Blood transfusion
- Vitamin K, FFP and platelet transfusions as required
- Terlipressin - splanchnic vasoconstriction, ↓ portal pressure and bleeding
- Broad spectrum Abx
- Sengstaken-Blakemore tube -
- Urgent OGD ideally within 24 hrs (band, sclerotheraoy)
long term prophylaxis of variceal bleeding
propranolol (beta blocker)
stages of non-alcoholic liver disease
steatosis → steatohepatitis (NASH) → liver fibrosis → cirrhosis
what test is used to assess for liver fibrosis?
enhanced liver fibrosis blood test
hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1
gold standard for diagnosis of NASH
USS guided liver biopsy (histological diagnosis)
management of NASH
- refer to HBP team if fibrosis/end stage liver disease
- healthy weight (weight loss)
- healthy diet
- avoid ETOH and hepatotoxic drugs
- CVD risk factor modification
types of oesophageal cancer?
- squamous cell - upper oesophagus, aggressive
- adenocarcinoma - most common UK, lower ⅓, reflux
1st line for focal seizures
carbamazepine or lamotrigine
1st line for absence seizure
sodium valproate or ethiosuximide
1st line for tonic clonic seizures
sodium valproate or lamotrigine
1st line for myoclonic seizures
sodium valproate
1st line for atonic seizures
sodium valproate or lamotrigine
what is oesophageal adenocarcinoma associated with?
barrett’s oesophagus, GORD, smoking, high fat intake
Ix for oesphageal cancer
- bedside
- blood - baseline bloods
-
imaging
- endoscopic USS - assess depth of invasion
- staging CT CAP + neck
-
specialist
- OGD + biopsy - gold standard, diagnostic
- staging laparoscopy - junctional tumor for intra-peritoneal metastases
2WW rules for urgent OGD for oesophageal cancer
- Dysphagia
- > 55 years + weight loss + 1 of: abdominal pain, reflux, dyspepsia
management of oesophageal cancer
- MDT
-
curative
- adenocarcinoma - surgery + chemo/radiotherapy
- oesophagectomy with reconstruction
- SCC - chemoradiotherapy
- intense nutritional support - jejunostomy
- adenocarcinoma - surgery + chemo/radiotherapy
-
palliative - majority
- stent
- chemo/radiotherapy
- nutritional support including RIG
types of pancreatic cancer
- ductal adenocarcinoma = 90%, from exocrine region
- exocrine tumours
- endocrine tumours - derived from islet cell, better prognosis
where is the most common site for pancreatic cancer?
head
Rf for pancreatic cancer
- smoking
- chronic pancreatitis
- diet - high red meat
- FHx - MEN, HNPCC, FAP, VHL
- late onset DM
Ix for pancreatic cancer
- bedside
-
bloods - baseline
- CA19-9 (tumour marker), clotting
-
imaging
- abdominal USS
- CT imaging with panreatic protocol (HR) - gold standard for prelim diagnosis
- endoscopic USS + biopsy
2WW for pancreatic cancer
> 40 + jaundice
management of pancreatic cancer
- MDT
-
curative
- radial resection
- adjuvant chemotherapy
-
palliative - majority
- chemotherapy
- symptom control - biliary stenting, Creon, pain management (coeliac plexus block)
what are the radical resections for pancreatic cancer?
-
Pancreaticoduodenectomy (Whipple’s) + regional lymphadenectomy → if head of pancreas cancer
- Remove head of pancreas, antrum of stomach, 1st + 2nd part of duodenum, CBD, gallbladder
-
Distal pancreatectomy + splenectomy + regional lymphadenectomy → if body/tail of pancreas cancer
- High morbidity associated
causes of acute pancreatitis
GET SMASHED (mnemonic)
- Gallstones
- Ethanol
- Trauma
- Steroids
- Mumps
- Autoimmune (PAN, SLE)
- Scorpion bite
- Hyperlipidaemia, hypothermia, hypercalcaemia
- ERCP and emboli
- Drugs - azathioprine, NSAIDs, diuretics
ix for pancreatitis (acute)
- bedside - exam
-
blood
- VBG
- bone profile - Calcium
- LFT + albumin
- clotting
- serum amylase/lipase
- lipase - more sensitive
-
imaging
- abdominal USS - ?gallstones
-
specialist
- calculate glasgow score
when should a contrast enhanced CT be done in pancreatitis and why?
6-10 days after PC
assess for severity - indicated if persistent inflammatory response or organ failure
e.g. detect pseudocyst
describe the glasgow criteria for pancreatitis
- PaO2 < 8kPa on ABG
- Age > 55 years
- Neutrophilia – WBC > 15x 109/L
- Calcium <2mmol/L
- Renal function – urea >16mmol/L
- Enzymes – LDH >600iu/L or AST > 200 iu/L
- Albumin < 32 g/L (serum)
- Sugar – blood glucose > 10mmol/L
complications of acute pancreatitis
- Chronic pancreatitis
- DIC, ARDs, hypocalcaemia, hyperglycaemia
- Pancreatic necrosis, pancreatic pseudocyst, pancreatic abscess, haemorrhage
management of acute pancreatitis
- A-E, admit, glasgow > 3 ITU
- conservative
- UO
- medical
- treat underlying e.g. ERCP
- aggressive IV fluid resuscitation
- NG if sig. vomit else oral intake as tolerated
- opioid analgesia
- broad spec Abx if confirmed necrosis
- surgical
- pancreatic debridement
management of pancreatic pseudocyst
- 50% spontaneously resolve, give up to 12 weeks to resolve
- If there after 6/52 unlikely to resolve → surgical debridement or endoscopic drainage often into stomach
causes of chronic pancreatitis
- Chronic alcohol excess (80%)
- Idiopathic (15-20%)
- Cystic fibrosis
- Obstruction - pancreatic cancer
- Recurrent acute pancreatitis
- Metabolic - ↑ triglycerides, hypercalcaemia
- Autoimmune - autoimmune pancreatitis, SLE
what is chronic pancreatitis?
caused by chronic inflammation and fibrosis of both the exocrine and endocrine components of the pancreas
Ix for chronic pancreatitis
- baseline bloods
- glucose/HbA1c
- faecal elastase
- AXR/CT - pancreatic calcification
- secretin stimulation test - only if dx uncertain
management of chronic pancreatitis
-
conservative
- reduce alcohol
-
medical
- analgesia + coeliac plexus block
- insulin
- Creon - exocrine enzyme replacement
- A, D, E, K vitamin supplement
-
surgical
- pancreatectomy
duodenal vs gastric ulcer
- duodenal more common 4:1
- worse after eating - gastric
- better with food, worse with fast/night → duodenal
tests for peptic ulcer disease
-
bedside
- H. pylori carbon 13 urea breath test
- H. pylori stool antigen
- blood - FBC, CRP
-
imaging
- erect CXR in acute
-
specialist
- upper GI endoscopy
prep urea breath test for h. pylori what can’t patients do?
No Abx or bismuth products for 4 weeks and no PPI for 2 weeks before H. Pylori diagnosis
complications of peptic ulcer disease
gastric outlet obstruction, upper GI bleed, perforation
acute management of peptic ulcer disease
- A-E approach
- Urgent endoscopy
- PPI after endoscopy
- Urgent intervention angiography with trans-arterial embolization or surgery
- If endoscopic procedures fail or too unstable for endoscopy
management of peptic ulcer disease
-
conservative
- stop smoking, less ETOH
- diet - avoid trigger, healthy, weight loss
- medication r/v
- stress management
-
medical
- 4-8 weeks full dose PPI
- H. pylori eradication if +ve
-
surgical
- partial gastrectomy in severe/emergencies
what drugs are associated with peptic ulcer disease
NSAIDS, steroids, bisphosphonates, potassium supplements, SSRIs, cocaine
management of peri-anal fistula
- asymptomatic - watch and wait
- surgical
- drainage seton (1st line if trans-sphinteric)
- fistulotomy (1st line if low, submucosal fistula)
definition of portal hypertension
portal HTN is abnormally high pressure in hepatic portal vein > 10 mmHg
causes of portal HTN
-
pre-hepatic
- thrombosis (splenic vein)
- extrinsic compression
-
intra-hepatic
- cirrhosis
- idiopathic portal HTN
-
post-hepatic
- Budd-chiari
- right heart failure
- constrictive pericarditis
management of portal HTN
-
conservative
- salt restriction _ fluid
-
medical
- spiro + furo
- non-selective beta blocker - propranolol
- terlipressin - acute
-
surgical
- transjugular intrahepatic portosystemic shunt (TIPSS)
- liver transplant
definition of primary biliary cirrhosis
Autoimmune inflammatory destruction of the intrahepatic bile ducts which results in cholestasis and progressive development of cirrhosis over many years.
antibody for primary biliary cirrhosis
anti-mitochondrial
treatment of PBC
- conservative
- avoid systemic oestrogen
- medical
- ursodeoxycholic acid - can induce remission
- cholestyramine - itch tx
- surgical - transplant (liver)
what is primary sclerosing cholangitis?
chronic cholestatic disorder characterised by inflammation and fibrosis of intrahepatic and extrahepatic bile ducts, resulting in multifocal biliary strictures
what is PSC associated with?
IBD esp. UC
antibodies associated with PSC
pANCA
anti-smooth muscle
Ix for PSC
- LFT
- anti-smooth muscle, pANCA
- biliary tree USS - duct dilation
- ERCP/MRCP - beading of bile ducts
- biopsy - onion skinning fibrosis
management of PSC
- yearly screening for malignancy
- cholestyramine - manage pruritus
- stricture dilation via ERCP
- liver transplant
what is ulcerative colitis?
Ulcerative colitis is the most common form of inflammatory granulomatous bowel disease
- Characterised by diffuse continual mucosal inflammation of the large bowel, beginning in rectum and spreading proximally
investigations of UC
- bedside - faecal calprotectin
- bloods - FBC, CRP, U&Es, LFTs, clotting
-
imaging
- AXR - lead pipe colon, thumbprinting, toxic megacolon
- barium - lead-pipe
-
specialist
- colonoscopy + biopsy = diagnostic
how is UC severity graded in acute?
truelove and witt score
management of UC
-
Medical
-
Inducing remission - severe disease
- IV fluid resuscitation
- Nutritional support
- Prophylactic heparin - VTE prevention
- IV corticosteroids + immunosuppression (ciclosporin or 5-ASA suppositories)
-
Inducing remission - mild-moderate
- topical/oral 5-ASA (aminosalicylates)
- + oral prednisolone
- Oral tacrolimus
-
Maintaining remission
- 1st line - 5-ASA’s e.g. mesalazine or sulfasalazine
- 2nd line - azathioprine
-
Inducing remission - severe disease
- Colonoscopic surveillance - if > 10 yrs with > 1 segment of bowel affected
-
Surgical
- Segmental bowel resection + stome
- Total proctocolectomy - curative, forms end-ileostomy
what is the most common renal stone?
calcium oxalate
what stone is associated with haemolysis?
uric acid
renal stone
what bacteria is associated with staghorn calculus
proteus
made of struvite