Exam revision Flashcards

Question

How can asbestosis be managed?

Answer 1

Management ``` Smoking cessation Pulmonary rehabilitation Bronchodilators Oxygen therapy if SpO2 ≤89% Lung transplant If a death occurs due to asbestosis, this must be reported to the coroner Compensation ``` see a GP to have the flu vaccination and the pneumococcal vaccination – your lungs will be more vulnerable to infections like flu and pneumonia

Answer 2

Patients who develop asbestos related lung disease following occupational exposure may be eligible to claim compensation If you've been diagnosed with asbestosis, you may be able to claim compensation through: industrial injuries disablement benefit a civil claim for compensation against previous employers a claim for governmental compensation under the Pneumoconiosis etc. (Workers' Compensation) Act 1979 Find out about industrial injuries disablement benefit on GOV.UK. You can also get advice on benefits and compensation on the British Lung Foundation website. Support for people with asbestosis Asbestosis can have a big impact on your life, but help is available. Support services include: Asbestos Victims Support Groups Forum British Lung Foundation – helpline 03000 030 555 Cancer Research UK: mesothelioma – helpline 0808 800 4040 Mesothelioma UK – helpline 0800 169 2409

Answer 3

People with asbestosis also have a higher risk of developing other serious conditions, such as: pleural disease – thickening of the lining covering the lungs (pleura) mesothelioma – cancer that affects the lining of the lungs, tummy, heart or testicles lung cancer

Answer 4

Bile is formed from cholesterol, phospholipids, and bile pigments (products of haemoglobin metabolism). It is stored in the gallbladder, before passing into the duodenum upon gallbladder stimulation. Gallstones form as a result of supersaturation of the bile. There are three main types of gallstones: Cholesterol stones – composed purely of cholesterol, from excess cholesterol production There is a well recognised link between poor diet, obesity, and cholesterol stones Pigment stones – composed purely of bile pigments, from excess bile pigments production Commonly seen in those with known haemolytic anaemia Mixed stones – comprised of both cholesterol and bile pigments

Answer 5

Classically the common risk factors for gallstone disease are colloquially described as the “5 F’s”: Fat, Female, Fertile, Forty, and Family history. Other recognised risk factors include pregnancy and oral contraceptives*, haemolytic anaemia (specifically for pigment stones), and malabsorption (such as previous ileal resection or Crohn’s disease). *Oestrogen causes more cholesterol to be secreted into bile

Answer 6

Biliary Colic Biliary colic occurs when the gallbladder neck becomes impacted by a gallstone. There is no inflammatory response, yet the contraction of the gallbladder against the occluded neck will result in pain. The pain is typically sudden, dull, and colicky in nature. It is often focused in the right upper quadrant although it may radiate to the epigastrium and/or back. The pain may be precipitated by the consumption of fatty foods* and the patient often complains of nausea / vomiting. In general, once pain relief has been started, symptoms often settle quickly. *Fatty acids stimulate the duodenum endocrine cells to release cholecystokinin (CCK), which in turn stimulates contraction of the gallbladder. Acute Cholecystitis Patients with acute cholecystitis will report a constant pain in the RUQ or epigastrium, associated with signs of inflammation, such as fever or lethargy. Patients with acute cholecystitis will be tender in the RUQ and may demonstrate a positive Murphy’s sign. Ensure to check for any guarding (may suggest a gallbladder perforation) and for features of sepsis.

Answer 7

Murphy’s Sign Whilst applying pressure in the RUQ, ask the patient to inspire. Murphy’s sign is positive when there is a halt in inspiration due to pain, indicating an inflamed gallbladder. This can be achieved more accurately with an ultrasound, namely the sonographic Murphy sign.

Answer 8

There are a wide variety of pathologies that can present with RUQ pain. However, differentials to consider include gastro-oesophageal reflux disease, peptic ulcer disease, acute pancreatitis, or inflammatory bowel disease.

Answer 9

Laboratory Test Certain blood tests can help in the initial evaluation of suspected cases: FBC and CRP – assess for the presence of any inflammatory response, which will be raised in cholecystitis LFTs – biliary colic and acute cholecystitis are likely to show a raised ALP (indicating ductal occlusion), yet ALT and bilirubin should remain within normal limits (unless a Mirizzi syndrome, discussed below) Amylase (or lipase) – to check for any evidence of pancreatitis A urinalysis, including a pregnancy test if relevant, should be performed to exclude any renal or tubo-ovarian pathology.

Answer 10

Imaging A trans-abdominal ultrasound (Fig. 2) is one of the most sensitive modalities for visualising gallstone disease and is typically used first line to investigate suspected gallstone pathology. Three specific areas are often visualised on US: The presence of gallstones or sludge (the start of gallstone formation) Gallbladder wall thickness (if thick walled, then inflammation is likely) Bile duct dilatation (indicates a possible stone in the distal bile ducts) If results from US scans are inconclusive, further imaging options are available. The gold standard investigation* for gallstones is Magnetic Resonance Cholangiopancreatography (MRCP), largely replacing ERCP for diagnostic purposes (Fig. 3). MRCP can show potential defects in the biliary tree caused by gallstone disease, with a sensitivity approaching 100%.

Answer 11

Biliary Colic Patients with biliary colic should be prescribed analgesia (regular paracetamol +/- NSAIDs +/- opiates analgesia). The patient should be advised about lifestyle factors that may help control symptoms (and help with future surgery), such as a low fat diet, weight loss, and increasing exercise. Following first presentation of biliary colic, there is a high chance of symptom recurrence or the development of complications of gallstones, therefore an elective laparoscopic cholecystectomy* (Fig. 4) is warranted and should be offered within 6 weeks of first presentation. *The laparoscopic route is preferred for cholecystectomy but is not always possible By User:Pschemp [CC-BY-SA-3.0], via Wikimedia Commons

Answer 12

Acute Cholecystitis Patients with acute cholecystitis should be started on appropriate intravenous antibiotics (such as co-amoxiclav +/- metronidazole). Concurrent analgesia and antiemetics should also be prescribed. A laparoscopic cholecystectomy is indicated within 1 week of presentation, as per NICE guidance, however this ideally should be done within 72hrs of presentation for a likely simpler procedure*. For those not fit for surgery and not responding to antibiotics, a percutaneous cholecystostomy can be performed to drain the infection (although as the gallstones remain in-situ, the risk of recurring disease remains). *A Cochrane review previously demonstrated that earlier cholecystectomies are safe and reduce overall hospital stay Any patient readmitted with RUQ pain post-cholecystectomy, it is important to exclude a retained CBD stone post-operatively. US abdomen scan may be useful, yet if this is unremarkable, then further investigation via MRCP imaging is warranted.

Answer 13

Mirizzi Syndrome A stone located in Hartmanns pouch (an out-pouching of the gallbladder wall at the junction with the cystic duct) or in the cystic duct itself can cause compression on the adjacent common hepatic duct. This results in an obstructive jaundice, even without stones being present within the lumen of the common hepatic or common bile ducts. Diagnosis is confirmed by MRCP and management is usually with laparoscopic cholecystectomy. Gallbladder Empyema A gallbladder empyema is when the gallbladder becomes filled with pus (Fig. 6). Patients will become unwell, often septic, presenting with a similar clinical picture to acute cholecystitis. They are associated with significant morbidity and mortality. The condition is diagnosed by either US scan or CT scan. Treatment is via laparoscopic cholecystectomy* (may require intra-operative drainage if tense gallbladder) or percutaneous cholecystostomy (if unsuitable for surgery). *There is a higher rate of conversion to open cholecystectomy with emypema than with uncomplicated acute cholecystitis Chronic Cholecystitis Patients with chronic cholecystitis will typically have a history of recurrent or untreated cholecystitis, which has led to a persistent inflammation of the gallbladder wall. Patients present with ongoing RUQ or epigastric pain with associated nausea and vomiting. It can be diagnosed typically by CT imaging (or often noted on histology post-cholecystectomy). Management in uncomplicated cases is via elective cholecystectomy. Its main complications are gallbladder carcinoma and biliary-enteric fistula. Bouveret’s Syndrome and Gallstone Ileus Inflammation of the gallbladder (typically if recurrent) can cause a fistula to form between the gallbladder wall and the small bowel (Fig. 7), termed a cholecystoduodenal fistula, allowing gallstones to pass directly into the small bowel (typically at the duodenum) As a consequence, bowel obstruction can occur: Bouveret’s Syndrome – a stone impacts in the proximal duodenum, causing a gastric outlet obstruction Gallstone Ileus*– a stone impacts at the terminal ileum (the narrowest part of the small bowel), causing a small bowel obstruction *The term ileus is misleading, as it is actually a bowel obstruction By Thomas Newman, TeachMeSurgery [CC-BY-NC-ND 4.0]

Answer 14

*Fatty acids stimulate the duodenum endocrine cells to release cholecystokinin (CCK), which in turn stimulates contraction of the gallbladder.

Answer 15

Cholangitis refers to infection of the biliary tract. It is associated with high morbidity and mortality when left untreated, and therefore is an important condition to recognise and manage. It is caused by a combination of biliary outflow obstruction* and biliary infection. During an obstruction, stasis of fluid combined with elevated intraluminal pressure allows the bacterial colonisation of the biliary tree to become pathological. *In patients without outflow obstruction, a bacterial colonisation is unlikely to cause cholangitis Causes Any condition which causes occlusion of the biliary tree has the potential to cause cholangitis. The most common causes are gallstones, ERCP (iatrogenic), and cholangiocarcinoma. Rarer causes include pancreatitis, primary sclerosing cholangitis, ischaemic cholangiopathy, and parasitic infections. The most common infective organisms implicated in cholangitis are Escherichia Coli (27%), Klebsiella species (16%), and Enterococcus (15%).

Answer 16

The common presenting symptoms of cholangitis are right upper quadrant pain, fever,and jaundice (when bilirubin >50 μmol/L). The patient may also complain of pruritus (itching), as a result of bile accumulation, and pale stool with dark urine, from the obstructive jaundice. The patient’s past medical history may include gallstones, recent biliary tract instrumentation (i.e. ERCP/cholecystectomy), or previous cholangitis. Medication including oral contraceptive pill and fibrates can increase the risk, and a lipid-rich diet may be indicative of gallstones (as a potential underlying cause). On examination, patients may have pyrexia (in 90% of cases), rigors, jaundice, right upper quadrant tenderness, confusion, hypotension, and tachycardia may be present. Two common eponymous syndromes associated with cholangitis are: Charcots Triad: Jaundice, Fever, and RUQ Pain Reynold’s Pentad: Jaundice, Fever, and RUQ Pain, Hypotension, and Confusion

Answer 17

Laboratory Tests Routine bloods should be taken, especially FBC (leucocytosis is found in the vast majority of patients) and LFTs (showing a raised ALP ± GGT with a raised bilirubin). Blood cultures should always be taken in suspected cases, despite only being positive in 20% of cases. The best opportunity to obtain a positive blood culture is early, before the start of broad spectrum antibiotics. Imaging An ultrasound scan of the biliary tract will show bile duct dilation. The common bile duct is usually less than 6mm in size (it may be greater in the elderly and those who have had previous cholecystectomy), so any diameter larger than this suggests dilatation. Ultrasound imaging may also demonstrate the presence an underlying cause (e.g. gallstones). The gold standard investigation for cholangitis is ERCP, as it is both diagnostic and therapeutic. Many endoscopists may require an MRCP prior to intervention, however to obtain detailed imaging of the biliary system prior to scoping.

Answer 18

Management Immediate Management Patients with cholangitis may present with sepsis, so should be managed promptly, appropriately and often in a higher level of care. Ensure IV access is gained with sufficient fluid resuscitation, routine bloods, and blood cultures taken early, with broad spectrum IV antibiotic therapy instigated (e.g. co-amoxiclav + metronidazole), as per local guidelines. Definitive Management The definitive management of cholangitis is via endoscopic biliary decompression, removing the cause of the blocked biliary tree. For patients who are deteriorating, this may need to be done earlier than those who are responding well to antibiotic therapy. ERCP, with or without a sphincterotomy and stenting, should clear any obstruction. In patients who may be too sick to tolerate ERCP, percutaneous transhepatic cholangiograpy (PTC) is the second line intervention. In the long-term, patients may require a cholecystectomy if gallstones were the underlying cause. Any other cause for the cholangitis identified should also be managed as appropriate. It is important to remember that there are significant complications of ERCP, including repeated cholangitis, pancreatitis (in 3-5% of patients), bleeding (more common when a sphincterotomy is performed), and perforation (a rare complication yet requires urgent surgical intervention if present)

Answer 19

The mortality of cholangitis is around 5-10% in those who are given antibiotic therapy. Early ERCP and early antibiotic therapy have both been found to improve patient outcomes. Factors which increase the mortality rate include delayed diagnosis, liver failure, cirrhosis, CKD, hypotension, female gender, and >50yrs.

Answer 20

Aetiology The majority of acute pancreatitis cases occur secondary to gallstone disease or excess alcohol consumption. However, causes are wide ranging and a popular mnemonic is ‘GET SMASHED’: Gallstones Ethanol (Alcohol) Trauma Steroids Mumps Autoimmune disease, such as SLE Scorpion venom (a rare and unlikely cause in most countries) Hypercalcaemia Endoscopic retrograde cholangio-pancreatography (ERCP) Drugs, such as Azathioprine, NSAIDs, or Diuretics Unfortunately, no evident cause will be found in 10-20% of patients with acute pancreatitis

Answer 21

Acute pancreatitis refers to inflammation of the pancreas. Its incidence is increasing, with around 30 per 100,000 cases each year in the UK. Mortality figures can range between 5-30%, depending on severity. It can be distinguished from chronic pancreatitis by its limited damage to the secretory function of the gland, with no gross structural damage developing. Repeated episodes of acute pancreatitis can eventually lead to chronic pancreatitis. Pathogenesis Each cause described above will trigger a premature and exaggerated activation of the digestive enzymes within the pancreas. The resulting pancreatic inflammatory response causes an increase in vascular permeability and subsequent fluid shifts (often termed “third spacing”). Enzymes are released from the pancreas into the systemic circulation, causing autodigestion of fats (resulting in a ‘fat necrosis’) and blood vessels (sometimes leading to haemorrhage in the retroperitoneal space). Fat necrosis can cause the release of free fatty acids, reacting with serum calcium to form chalky deposits in fatty tissue, resulting in hypocalcaemia. Severe end-stage pancreatitis will eventually result in partial or complete necrosis of the pancreas.

Answer 22

Patients will classically present with a sudden onset of severe epigastric pain, which can radiate through to the back, with nausea and vomiting. On examination, there is often epigastric tenderness, with or without guarding. In severe cases, there may be haemodynamically instability, due to the inflammatory response occurring. Less common signs that are often described are Cullen’s sign (bruising around the umbilicus, FIg. 2A) and Grey Turner’s sign (bruising in the flanks, Fig. 2B) , representing retroperitoneal haemorrhage. Tetany may occur from hypocalcaemia (secondary to fat necrosis) and, in select cases, gallstone aetiology may also cause a concurrent obstructive jaundice.

Answer 23

There are a wide variety of causes of an acutely painful abdomen, as discussed elsewhere. However causes specifically resulting in abdominal pain that radiates through to the back include abdominal aortic aneurysm, renal calculi, chronic pancreatitis, aortic dissection, or peptic ulcer disease.

Answer 24

Laboratory Tests Routine blood tests, as per investigation of any acute abdomen, are required. Specifically for acute pancreatitis, it is important to consider: Serum amylase – diagnostic of acute pancreatitis if 3x the upper limit of normal* Amylase can also be marginally raised in pathologies such as bowel perforation, ectopic pregnancy, or diabetic ketoacidosis LFTs – assess for any concurrent cholestatic element to the clinical picture Patients with acute pancreatitis noted that an alanine transaminase (ALT) level >150U/L has a positive predictive value of 85% for gallstones as the underlying cause Serum lipase – A raised serum lipase is more accurate for acute pancreatitis (as it remains elevated longer than amylase), yet it is not available or routinely performed in every hospital *Serum amylase levels do not directly correlate with disease severity Imaging An abdominal ultrasound scan may be requested if the underlying cause is unknown; it is typically used to identify any gallstones (as a potential underlying cause) and any evidence of duct dilatation Whilst not routinely performed for acute pancreatitis, an AXR can show a ‘sentinal loop sign’. This is a dilated proximal bowel loop adjacent to the pancreas, which occurs secondary to localised inflammation. A CXR should be undertaken to look for pleural effusion or signs of ARDS. A contrast-enhanced CT scan (Fig. 3) may be required if the initial assessment and investigations prove inconclusive. If performed after 48hrs from initial presentation, it will often show areas of pancreatic oedema and swelling, or any non-enhancing areas suggestive of pancreatic necrosis. Current UK guidelines state that any CT scan used to assess for severity of disease should only be performed 6-10 days after admission in patients with features of persistent inflammatory response or organ failure*. *Prior to this time frame, CT-based severity scoring systems have been shown to be equivocal to clinical scoring systems in predicting severity, whilst increasing length of hospital stay with no improvement in clinical outcome By Hellerhoff (Own work) [CC BY-SA 3.0], via Wikimedia Commons

Answer 25

The modified Glasgow criteria is used to assess the severity of acute pancreatitis within the first 48 hours of admission. Any patient scoring with ≥3 positive factors within the first 48hrs should be considered to have severe pancreatitis and a high-dependency care referral is warranted. Helpfully, the mneumonic to remember the score is PANCREAS: pO2 <8kPa, Age >55yrs, Neutrophils (/WCC) >15×109/L, Calcium <2mmol/L, Renal function (Urea) >16mmol/L, Enzymes LDH>600U/L or AST>200U/L, Albumin <32g/L, Sugar (blood glucose) >10mmol/L Other risk stratification scores that can be used scoring severity of acute pancreatitis include the APACHE II score, the Ranson Criteria, and Balthazar score (CT scoring system).

Answer 26

Management There is no curative management for acute pancreatitis, so supportive measures are the mainstay of treatment. Treat any underlying cause as necessary (e.g. urgent ERCP and sphincterotomy for gallstones) where appropriate. Supportive treatment includes: Intravenous fluid resuscitation, and oxygen therapy as required A balanced crystalloid should be used Nasogastric tube if the patient is vomiting profusely If the patient is able to eat, oral intake can be encouraged as tolerated Catheterisation to accurately monitor urine output and start a fluid balance chart (due to the potential for rapid third space losses) Aim for a urine output of at least >0.5ml/kg/hr Opioid analgesia* Current UK guidelines state that all patients with severe acute pancreatitis should be managed in a high dependency unit or intensive therapy unit (although this is often impractical). A broad-spectrum antibiotic, such as imipenem, should be considered for prophylaxis against infection in cases of confirmed pancreatic necrosis. Treating the underlying cause should be addressed, once the patient has been stabilised. For those caused by gallstones, early laparoscopic cholecystectomy is advised, whilst those secondary to alcohol excess should ensure they have access to the appropriate services made. *A Cochrane review stated there is no current evidence that suggests opioid analgesia should be avoided due to increased risk of pancreatitis complications or other adverse events when compared to other analgesia

Answer 27

Complications Systemic Complications The systemic complications of acute pancreatitis tend to occur within days of the initial onset: Disseminated Intravascular Coagulation (DIC) Acute Respiratory Distress Syndrome (ARDS) Hypocalcaemia Fat necrosis from released lipases, results in the release of free fatty acids, which react with serum calcium to form chalky deposits in fatty tissue Hyperglycaemia Secondary to destruction of islets of Langerhans and subsequent disturbances to insulin metabolism Local Complications Pancreatic Necrosis Ongoing inflammation eventually leads to ischaemic infarction of the pancreatic tissue, hence such progression should be suspected in patients with evidence of persistent systemic inflammation for more than 7-10 days after the onset of pancreatitis. Any suspected pancreatic necrosis should be confirmed by CT imaging and treatment will often warrant pancreatic necrosectomy (open or endoscopic)*. Pancreatic necrosis is prone to infection and should be suspected if there is a clinical deterioration in the patient associated with raised infection markers (or from positive blood culture or changes of low density within the pancreas on CT). Definitive diagnosis of infected pancreatic necrosis can be confirmed by a fine needle aspiration of the necrosis. *General consensus for intervention in cases of confirmed pancreatic necrosis is to be delayed until walled-off necrosis has developed, typically 3-5 weeks after the onset of symptoms Pancreatic Pseudocyst A pancreatic pseudocyst is a collection of fluid containing pancreatic enzymes, blood, and necrotic tissue; they can occur anywhere within or adjacent to the pancreas, however are usually seen in the lesser sac obstructing the gastro-epiploic foramen by inflammatory adhesions.. They are typically formed weeks after the initial acute pancreatitis episode. They lack an epithelial lining, therefore termed pseudocyst, and instead have a vascular and fibrotic wall surrounding the collection. Pseudocysts may be found incidentally on imaging or can present with symptoms of mass effect, such as biliary obstruction or gastric outlet obstruction. They are prone to haemorrhage or rupture, and can become infected. About 50% will spontaneously resolve, hence conservative management is usually the initial treatment of choice. Cysts which have been present for longer than 6 weeks are unlikely to resolve spontaneously. Treatment options include surgical debridement or endoscopic drainage (often into the stomach).

Answer 28

Chronic pancreatitis is a chronic fibro-inflammatory disease of the pancreas, resulting in progressive and irreversible damage to the pancreatic parenchyma. The incidence of chronic pancreatitis is quoted between 2-10 new cases per 100,000 people per year in Western countries. It has a male to female ratio of 4:1 and an average age of onset of 40 years.

Answer 29

Aetiology The main causes of chronic pancreatitis are either chronic alcohol abuse (60%) and idiopathic (30%). Less common causes include metabolic (hyperlipidaemia, hypercalcaemia), infection (both viral (e.g. HIV, mumps, coxsackie) and bacterial (e.g. Echinococcus), hereditary (e.g. cystic fibrosis), autoimmune (e.g. autoimmune pancreatitis (AIP) or SLE), anatomical (malignancy or stricture formation), or congenital anomalies (e.g. Pancreas divisum or Annular pancreas). Chronic pancreatitis can also be categorised as either By TeachMeSeries Ltd (2021)

Answer 30

The major symptom in chronic pancreatitis is chronic pain, which may be complicated by recurring attacks of acute pancreatitis (often termed “acute-on-chronic” pancreatitis). The pain is typically in the epigastrium and back, often associated with nausea and vomiting. Due to the damage that has occurred to the pancreatic parenchyma, patients may also present with: Endocrine insufficiency – secondary to damage to the endocrine tissue of the pancreatic gland (islets of Langerhans), there is subsequent failure to produce insulin, resulting in impaired glucose regulation or eventual diabetes mellitus* Exocrine insufficiency – secondary to damage to the acinar cells, resulting in failure to produce digestive enzymes, causing malabsorption, presenting with weight loss, diarrhoea, or steatorrhoea On examination, the abdomen will be soft, however the patient may be tender in the epigastrium. There may also be signs of cachexia and malabsorption. Often concurrent pseudocysts are present, due to previous recurrent attacks of acute pancreatitis. Patients with pseudocysts may present with symptoms of mass effect, such as biliary obstruction or gastric outlet obstruction. *Type 3c (pancreatogenic) diabetes is the term given to diabetes mellitus secondary to pancreatic disease resulting in endocrine dysfunction.

Answer 31

Investigations Most patients presenting with abdominal pain should have a urine dip and routine bloods, including FBC and CRP. Serum amylase or lipase levels are often not raised in established disease. In suspected cases of chronic pancreatitis, ensure to also check blood glucose (secondary to endocrine dysfunction) and LFTs (to ensure no concurrent obstructive jaundice) A faecal elastase level will be low in most cases of chronic pancreatitis with exocrine insufficiency, often can aid the diagnosis.* *The elastase enzyme is produced by the pancreas, being excreted into the bowel to aid with digestion, and importantly does not undergo any significant degradation during intestinal transit; as such, any exocrine dysfunction in chronic pancreatitis will present with low faecal elastase levels Imaging CT imaging can often show pancreatic atrophy or calcification, as well as any pseudocysts present (Fig. 2). Any overt causes for chronic pancreatitis, such as malignancy or congenital anomalies, may also be seen The anatomy of the pancreas and the biliary tree can be determined using both ultrasound imaging or MRI imaging (specifically MRCP). However, a normal appearance of the pancreas on imaging does not necessarily exclude chronic pancreatitis. Additional specialist tests, such as the secretin stimulation test or endoscopic ultrasound (EUS), may also be employed in cases of diagnostic uncertainty. Adapted from work by Hellerhoff and James Heilman [CC BY-SA 3.0], via Wikimedia Commons

Answer 32

Chronic pancreatitis can only be managed definitively by treating any reversible underlying cause. This can include alcohol cessation or statin therapy for hyperlipidaemia. However, analgesia becomes the mainstay of management for most cases of chronic pancreatitis. Whilst the WHO analgesic ladder should be followed in acute cases, for those with long-term pain, opioid analgesia might be replaced with neuropathic analgesics instead. Patients with malabsorption secondary to exocrine dysfunction may benefit from enzyme replacement (including lipases), such as Creon®, that can be taken with meals to good effect. Patients are also at risk of becoming deficient in fat-soluble vitamins (A, D, E and K), therefore ensure adequate vitamin supplementation and check bone density routinely. Those with pancreatogenic diabetes may benefit insulin regimes, along with annual surveillance with HbA1c. Endoscopic Management Endoscopic management is performed only in a select few patients where there is a targetable underlying cause. Surgical intervention is now rarely performed in cases of chronic pancreatitis, due to high morbidity and mortality, with limited symptomatic improvement. Endoscopic retrograde cholangiopancreatography (ERCP) can be used for diagnostic and therapeutic purposes, including stone removal, stent placement, or sphincterotomy (especially in large duct pancreatitis). Endosonography-guided celiac plexus blockade or thoracoscopic splanchnicectomy are interventions that be be performed purely for analgesic purposes. Steroids Steroids are effective at reducing symptoms in chronic pancreatitis with an autoimmune aetiology only. A high dose of prednisolone is used initially to bring symptoms under control; a low dose maintenance regime is then used.

Answer 33

Chronic pancreatitis is associated with significant morbidity and reduced quality of life, as it can be a challenging condition to manage effectively. In some patients, the disease may eventually ‘burn out’ after many years of pain, leaving residual endocrine and exocrine insufficiencies. Pancreatic malignancy is a risk in those who have had the disease for 20 years or more; new or evolving symptoms should therefore undergo investigation.

Answer 34

Cauda equina syndrome (CES) is a surgical emergency caused by a compression of the cauda equina. If untreated, patients can develop debilitating complications, hence a high level of suspicion and rapid intervention is required. The condition has peak onset between 40-50 years of age. Approximately 4 in every 10,000 patients presenting with lower back pain are ultimately diagnosed with the syndrome. The cauda equina is a bundle of nerves situated inferior to the spinal cord. The spinal cord tapers to an end (known as the conus medullaris), approximately at the first lumbar vertebra, with nerve roots L1-S5 leaving from at this region to pass down the spinal canal (as the cauda equina) to exit at their respective formaina. Consequently, the cauda equina is formed by lower motor neurones, containing motor and sensory impulses to the lower limbs, motor innervation to the anal sphincters, and parasympathetic innervation for the bladder.

Answer 35

Pathophysiology Cauda equina syndrome is caused by compression of the cauda equina: Disc herniation – most common at L5/S1 and L4/L5 level Trauma – including vertebral fracture and subluxation Neoplasm – either primary or metastatic The most common cancers that spread to spinal vertebrae are thyroid, breast, lung, renal and prostate Infection – e.g. discitis or Potts disease Chronic spinal inflammation – e.g. ankylosing spondylitis Iatrogenic – e.g. haematoma secondary to spinal anaesthesia

Answer 36

Cauda equina syndrome results in lower motor neurone signs and symptoms. Symptoms include reduced lower limb sensation (often bilateral), bladder or bowel dysfunction, lower limb motor weakness, severe back pain, and impotence. By Lesion [CC BY-SA 3.0], from Wikimedia Commons Figure 2 – The distribution of saddle anaesthesia An important feature to assess is bladder dysfunction, specifically the presence of retention. Confirmed retention or reduced ability to void (loss of desire, reduced urinary sensation) suggests complete or incomplete CES respectively. On examination, features include perianal (the lower sacral dermatomes, termed “saddle” anaesthesia) or lower limb anaesthesia, loss of anal tone, urinary retention, and lower limb weakness and hypoflexia. If no obvious cause is evident, a thorough history and examination may reveal the pathophysiology, such as weight loss as a sign of metastatic disease or living in an area of endemic tuberculosis. As part of the examination for suspected CES, regardless of symptoms, patients will require a PR examination and a post-void bladder scan.

Answer 37

Classification Cauda Equina Syndrome can be classified into 3 groups: Cauda Equina Syndrome with retention (CESR) – Presents as back pain with unilateral or bilateral sciatica, lower limb motor weakness, sensory disturbance in the saddle region, loss of anal tone, and loss of urinary control Incomplete Cauda Equina Syndrome (CESI) – As above, however only altered urinary sensation (e.g. loss of desire to void, diminished sensation, poor stream, and need to strain); painful retention may precede painless retention in some cases Suspected Cauda Equina Syndrome (CESS) – Cases of severe back and leg pains with variable neurological symptoms and signs, and a suggestion of sphincter disturbance Most cases will be progressive in nature and will not immediately cause complete compression on the cauda equina. This is important for the management, as incomplete cauda equina syndrome has a greater potential for neurological recovery.

Answer 38

Differential Diagnosis Radiculopathy – presents with radiating back pain, however there will be no faecal, urinary, or sexual dysfunction in these patients Cord compression – a surgical emergency with a similar pathophysiology to CES, however is characterised by upper motor neurone signs

Answer 39

Investigations For suspected cases of cauda equina syndrome, an emergency whole spine MRI is the gold standard investigation. However, only 60% of patients suspected to have CES from clinical assessment have an abnormality found on MRI. Further imaging may be required dependent on the underlying cause, however if CES is confirmed, then urgent surgical intervention is the priority.

Answer 40

Prognosis The prognosis of cauda equina syndrome is variable depending on both aetiology and the time taken from symptom onset to surgery. Indeed, a retrospective study examined the case for early surgery and found that patients who were in theatre within 24 hours from onset of autonomic dysfunction had reduced bladder problems at long-term follow up.

Answer 41

As the risk of breast cancer increases with age, breast screening in the UK is offered to all women at the age of 50 who are registered with a GP. They are invited for screening every three years until their 71st birthday. They can choose to continue with the programme after this time period at their own request. The procedure is a bilateral mammogram, taken in a horizontal and vertical plane. Most women will have the same lifetime risk as the general population of developing breast cancer (around 11%) and so will follow the screening schedule as above. Some groups, however, are classified as high-risk and have a more frequent screening schedule: women who have a genetic mutation (BRCA and TP53), and women with a significant family history. Women with a BRCA mutation (both 1 & 2) start screening at the age of 30 with a yearly MRI and possibly a mammogram. Those with a TP53 mutation start screening at the age of 20 with a yearly MRI. More detailed information on breast screening in high-risk groups is available on the NICE website.

Answer 42

**Potential complications of epilepsy include:** - Sudden Unexpected Death in Epilepsy (SUDEP): Occurs in approximately 1:1000 patient years with epilepsy. Patients with a diagnosis of epilepsy need to be counselled about this risk. - Status epilepticus: defined as a seizure that persists for more than 30 minutes. This is associated with a mortality of 15-20% - due to hypoxia and metabolic disturbances occurring during the seizure. - Injuries sustained during a seizure or in the post-seizure period. Accidental injuries of some degree are estimated to occur in 6.5% of patients with epilepsy over 2 years. Injuries are partly culturally determined; e.g. severe injuries from burns sustained when falling into an open fire are particularly common in cultures where open fires are used for cooking and heating. - Mood disorders and anxiety are common – occurring in a third to a half of patients with epilepsy. - Cognitive impairment is common, and usually due either to the underlying brain disease of which seizures are a manifestation, or drug side effects. - Cardiovascular and respiratory disease are more common in patients with epilepsy.

Answer 43

- The brain normally produces tiny electrical signals that come from the brain cells and nerves which send messages to each other. These electrical signals can be detected and recorded by the electroencephalograph (EEG) machine - During EEG – Patient may be asked to blink lots of times, or to breathe deeply. These can sometimes trigger patterns of electrical activity in the brain which are associated with certain types of epilepsy. - Photic stimulation and hyperventilation should remain part of standard EEG assessment. The patient and carer should be inform that such activation procedures may induce a seizure and they have a right to refuse. - Some specialised types of EEG : strobe lighting, Sleep EEG, Sleep-deprived EEG, Ambulatory EEG with video

Answer 44

NICE: start antiepileptics if (1) Neurological deficit (2) Brain imaging shows structural abnormality (3) the EEG shows unequivocal epileptic activity (4) the patient or their family or carers consider the risk of having a further seizure unacceptable Generalised tonic-clonic seizures ● sodium valproate ● second line: lamotrigine, carbamazepine Absence seizures (Petit mal) ● sodium valproate or ethosuximide ● sodium valproate particularly effective if co-existent tonic-clonic seizures in primary generalised epilepsy Myoclonic seizures ● sodium valproate ● second line: clonazepam, lamotrigine Focal seizures (with or without secondary generalisation) ● carbamazepine or lamotrigine ● second line: levetiracetam, oxcarbazepine or sodium valproate *carbamazepine may exacerbate absence seizures and myoclonic seizure

Answer 45

Post- op chemotherapy | ● Palliation of jaundice- endoscopic or percutaneous stent insertion

Answer 46

Ca-19-9 ● Surgery- pancreaticoduodenectomy/ whipple's ● Post- op chemotherapy ● Palliation of jaundice- endoscopic or percutaneous stent insertion ● Palliative care for advance stage

Answer 47

Urgent joint aspiration | ● Start empirical antibiotics flucloxacillin

Answer 48

NICE Clinical Knowledge Summaries recommend we use the Eron classification to guide how we manage patients with cellulitis: Class Features I There are no signs of systemic toxicity and the person has no uncontrolled co-morbidities II The person is either systemically unwell or systemically well but with a co-morbidity (for example peripheral arterial disease, chronic venous insufficiency, or morbid obesity) which may complicate or delay resolution of infection III The person has significant systemic upset such as acute confusion, tachycardia, tachypnoea, hypotension, or unstable co-morbidities that may interfere with a response to treatment, or a limb-threatening infection due to vascular compromize IV The person has sepsis syndrome or a severe life-threatening infection such as necrotizing fasciitis They recommend the following that we admit for intravenous antibiotics the following patients: Has Eron Class III or Class IV cellulitis. Has severe or rapidly deteriorating cellulitis (for example extensive areas of skin). Is very young (under 1 year of age) or frail. Is immunocompromized. Has significant lymphoedema. Has facial cellulitis (unless very mild) or periorbital cellulitis. The following is recommend regarding Eron Class II cellulitis: Admission may not be necessary if the facilities and expertise are available in the community to give intravenous antibiotics and monitor the person - check local guidelines. Other patients can be treated with oral antibiotics. Management The BNF recommends flucloxacillin as first-line treatment for mild/moderate cellulitis. Clarithromycin, erythromycin (in pregnancy) or doxycyline is recommended in patients allergic to penicillin. NICE recommend that patients severe cellulitis should be offered co-amoxiclav, cefuroxime, clindamycin or ceftriaxone.

Answer 49

Diagnosis antibodies to HIV may not be present HIV PCR and p24 antigen tests can confirm diagnosis testing for HIV in asymptomatic patients should be done at 4 weeks after possible exposure after an initial negative result when testing for HIV in an asymptomatic patient, offer a repeat test at 12 weeks HIV antibody test most common and accurate test usually consists of both a screening ELISA (Enzyme Linked Immuno-Sorbent Assay) test and a confirmatory Western Blot Assay most people develop antibodies to HIV at 4-6 weeks but 99% do by 3 months p24 antigen test usually positive from about 1 week to 3 - 4 weeks after infection with HIV sometimes used as an additional screening test in blood banks

Answer 50

Acute confusional state is also known as delirium or acute organic brain syndrome. It affects up to 30% of elderly patients admitted to hospital. ``` Predisposing factors include: age > 65 years background of dementia significant injury e.g. hip fracture frailty or multimorbidity polypharmacy ``` The precipitating events are often multifactorial and may include: infection: particularly urinary tract infections metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration change of environment any significant cardiovascular, respiratory, neurological or endocrine condition severe pain alcohol withdrawal constipation ``` Features - a wide variety of presentations memory disturbances (loss of short term > long term) may be very agitated or withdrawn disorientation mood change visual hallucinations disturbed sleep cycle poor attention ``` Common causes of delirium can be remembered using the mnemonic DELIRIUMS: D - Drugs and Alcohol (Anti-cholinergics, opiates, anti-convulsants, recreational) E - Eyes, ears and emotional L - Low Output state (MI, ARDS, PE, CHF, COPD) I - Infection R - Retention (of urine or stool) I - Ictal U - Under-hydration/Under-nutrition M - Metabolic (Electrolyte imbalance, thyroid, wernickes (S) - Subdural, Sleep deprivation Management treatment of the underlying cause modification of the environment the 2006 Royal College of Physicians publication 'The prevention, diagnosis and management of delirium in older people: concise guidelines' recommended haloperidol 0.5 mg as the first-line sedative the 2010 NICE delirium guidelines advocate the use of haloperidol or olanzapine management can be challenging in patients with Parkinson's disease, as antipsychotics can often worsen Parkinsonian symptoms careful reduction of the Parkinson medication may be helpful if symptoms require urgent treatment then the atypical antipsychotics quetiapine and clozapine are preferred

Answer 51

Factors favouring delirium over dementia impairment of consciousness fluctuation of symptoms: worse at night, periods of normality abnormal perception (e.g. illusions and hallucinations) agitation, fear delusions

Answer 52

Dementia is thought to affect over 700,000 people in the UK and accounts for a large amount of health and social care spending. The most common cause of dementia in the UK is Alzheimer's disease followed by vascular and Lewy body dementia. These conditions may coexist. Features diagnosis can be difficult and is often delayed assessment tools recommended by NICE for the non-specialist setting include: 10-point cognitive screener (10-CS), 6-Item cognitive impairment test (6CIT) assessment tools not recommended by NICE for the non-specialist setting include the abbreviated mental test score (AMTS), General practitioner assessment of cognition (GPCOG) and the mini-mental state examination (MMSE) have been widely used. A MMSE score of 24 or less out of 30 suggests dementia Management in primary care, a blood screen is usually sent to exclude reversible causes (e.g. Hypothyroidism). NICE recommend the following tests: FBC, U&E, LFTs, calcium, glucose, TFTs, vitamin B12 and folate levels. Patients are now commonly referred on to old-age psychiatrists (sometimes working in 'memory clinics'). in secondary care, neuroimaging is performed* to exclude other reversible conditions (e.g. Subdural haematoma, normal pressure hydrocephalus) and help provide information on aetiology to guide prognosis and management

Answer 53

NICE recommend urgent referral for Urology review (and usually cystoscopy) for patients who are - aged 45 and over and have: - [unexplained](https://www.nice.org.uk/guidance/NG12/chapter/terms-used-in-this-guideline#terms-used-in-this-guideline) visible haematuria without urinary tract infection **or** - visible haematuria that persists or recurs after successful treatment of urinary tract infection, **or** - ****aged 60 and over and have unexplained non‑visible haematuria **and** either dysuria or a raised white cell count on a blood test. **** - Consider [non-urgent](https://www.nice.org.uk/guidance/NG12/chapter/terms-used-in-this-guideline#terms-used-in-this-guideline) referral for bladder cancer in people aged 60 and over with recurrent or [persistent](https://www.nice.org.uk/guidance/NG12/chapter/terms-used-in-this-guideline#terms-used-in-this-guideline) unexplained urinary tract infection

Answer 54

Initial management of renal colic Medication the BAUS recommend an NSAID as the analgesia of choice for renal colic whilst diclofenac has been traditionally used the increased risk of cardiovascular events with certain NSAIDs (e.g. diclofenac, ibuprofen) should be considered when prescribing the CKS guidelines suggest for patients who require admission: 'Administer a parenteral analgesic (such as intramuscular diclofenac) for rapid relief of severe pain' BAUS no longer endorse the use of alpha-adrenergic blockers to aid ureteric stone passage routinely. They do however acknowledge a recently published meta-analysis advocates the use of α-blockers for patients amenable to conservative management, with greatest benefit amongst those with larger stones Initial investigations urine dipstick and culture serum creatinine and electrolytes: check renal function FBC / CRP: look for associated infection calcium/urate: look for underlying causes also: clotting if percutaneous intervention planned and blood cultures if pyrexial or other signs of sepsis Imaging BAUS now recommend that non-contrast CT KUB should be performed on all patients, within 14 hours of admission if a patient has a fever, a solitary kidney or when the diagnosis is uncertain an immediate CT KUB should be performed. In the case of an uncertain diagnosis, this is to exclude other diagnoses such as ruptured abdominal aortic aneurysm CT KUB has a sensitivity of 97% for ureteric stones and a specificity of 95% ultrasound still has a role but given the wider availability of CT now and greater accurary it is no longer recommend first-line. The sensitivity of ultrasound for stones is around 45% and specificity is around 90% Management of renal stones Stones < 5 mm will usually pass spontaneously. Lithotripsy and nephrolithotomy may be for severe cases. Most renal stones measuring less than 5mm in maximum diameter will typically pass within 4 weeks of symptom onset. More intensive and urgent treatment is indicated in the presence of ureteric obstruction, renal developmental abnormality such as horseshoe kidney and previous renal transplant. Ureteric obstruction due to stones together with infection is a surgical emergency and the system must be decompressed. Options include nephrostomy tube placement, insertion of ureteric catheters and ureteric stent placement. In the non-emergency setting, the preferred options for treatment of stone disease include extra corporeal shock wave lithotripsy, percutaneous nephrolithotomy, ureteroscopy, open surgery remains an option for selected cases. However, minimally invasive options are the most popular first-line treatment. Shockwave lithotripsy A shock wave is generated external to the patient, internally cavitation bubbles and mechanical stress lead to stone fragmentation. The passage of shock waves can result in the development of solid organ injury. Fragmentation of larger stones may result in the development of ureteric obstruction. The procedure is uncomfortable for patients and analgesia is required during the procedure and afterwards. Ureteroscopy A ureteroscope is passed retrograde through the ureter and into the renal pelvis. It is indicated in individuals (e.g. pregnant females) where lithotripsy is contraindicated and in complex stone disease. In most cases a stent is left in situ for 4 weeks after the procedure. Percutaneous nephrolithotomy In this procedure, access is gained to the renal collecting system. Once access is achieved, intra corporeal lithotripsy or stone fragmentation is performed and stone fragments removed. Therapeutic selection Disease Option Stone burden of less than 2cm in aggregate Lithotripsy Stone burden of less than 2cm in pregnant females Ureteroscopy Complex renal calculi and staghorn calculi Percutaneous nephrolithotomy Ureteric calculi less than 5mm Manage expectantly Prevention of renal stones Calcium stones may be due to hypercalciuria, which is found in up to 5-10% of the general population. high fluid intake low animal protein, low salt diet (a low calcium diet has not been shown to be superior to a normocalcaemic diet) thiazides diuretics (increase distal tubular calcium resorption) Oxalate stones cholestyramine reduces urinary oxalate secretion pyridoxine reduces urinary oxalate secretion Uric acid stones allopurinol urinary alkalinization e.g. oral bicarbonate

Answer 55

Renal cell cancer is also known as hypernephroma and accounts for 85% of primary renal neoplasms. It arises from proximal renal tubular epithelium. The most common histological subtype is clear cell (75 to 85 percent of tumours). ``` Associations* more common in middle-aged men smoking von Hippel-Lindau syndrome tuberous sclerosis ``` Features classical triad: haematuria, loin pain, abdominal mass pyrexia of unknown origin left varicocele (due to occlusion of left testicular vein) endocrine effects: may secrete erythropoietin (polycythaemia), parathyroid hormone (hypercalcaemia), renin, ACTH 25% have metastases at presentation paraneoplastic hepatic dysfunction syndrome. Also known as Stauffer syndrome. Typically presents as cholestasis/hepatosplenomegaly. It is thought to be secondary to increased levels of IL-6

Answer 56

Management for confined disease a partial or total nephrectomy depending on the tumour size alpha-interferon and interleukin-2 have been used to reduce tumour size and also treat patients with metatases receptor tyrosine kinase inhibitors (e.g. sorafenib, sunitinib) have been shown to have superior efficacy compared to interferon-alpha

Answer 57

Von Hippel-Lindau (VHL) syndrome is an autosomal dominant condition predisposing to neoplasia. It is due to an abnormality in the VHL gene located on short arm of chromosome 3 Features cerebellar haemangiomas: these can cause subarachnoid haemorrhages retinal haemangiomas: vitreous haemorrhage renal cysts (premalignant) phaeochromocytoma extra-renal cysts: epididymal, pancreatic, hepatic endolymphatic sac tumours clear-cell renal cell carcinoma

Answer 58

PSA levels may also be raised by**: benign prostatic hyperplasia (BPH) prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after treatment) ejaculation (ideally not in the previous 48 hours) vigorous exercise (ideally not in the previous 48 hours) urinary retention instrumentation of the urinary tract

Answer 59

The traditional investigation for suspected prostate cancer was a transrectal ultrasound-guided (TRUS) biopsy. However, recent guidelines from NICE have now advocated the increasing use of multiparametric MRI as a first-line investigation. ``` Complications of TRUS biopsy: sepsis: 1% of cases pain: lasting >= 2 weeks in 15% and severe in 7% fever: 5% haematuria and rectal bleeding ``` Multiparametric MRI is now the first-line investigation for people with suspected clinically localised prostate cancer. the results are reported using a 5‑point Likert scale If the Likert scale is >=3 a multiparametric MRI-influenced prostate biopsy is offered If the Likert scale is 1-2 then NICE recommend discussing with the patient the pros and cons of having a biopsy.

Answer 60

Treatment depends on life expectancy and patient choice. Options include: conservative: active monitoring & watchful waiting radical prostatectomy radiotherapy: external beam and brachytherapy Localised advanced prostate cancer (T3/T4) Options include: hormonal therapy: see below radical prostatectomy: erectile dysfunction is a common complication radiotherapy: external beam and brachytherapy. Patients are at increased risk of bladder, colon, and rectal cancer following radiotherapy for prostate cancer Metastatic prostate cancer disease - hormonal therapy Synthetic GnRH agonist e.g. Goserelin (Zoladex) cover initially with anti-androgen to prevent rise in testosterone Anti-androgen cyproterone acetate prevents DHT binding from intracytoplasmic protein complexes

Answer 61

Pros: it may reassure you if the test result is normal it can find early signs of cancer, meaning you can get treated early PSA testing may reduce your risk of dying if you do have cancer Cons: it can miss cancer and provide false reassurance it may lead to unnecessary worry and medical tests when there's no cancer it cannot tell the difference between slow-growing and fast-growing cancers it may make you worry by finding a slow-growing cancer that may never cause any problems

Answer 62

ALP Osteocalcin N terminal propeptide of type 1 collagen

Answer 63

N terminal telopeptide of type 1 collagen C terminal telopeptide of type 1 collagen Hydroxyproline

Answer 64

Prevention smoking is the most important modifiable risk factor for the development of thyroid eye disease radioiodine treatment may increase the inflammatory symptoms seen in thyroid eye disease. In a recent study of patients with Graves' disease around 15% developed, or had worsening of, eye disease. Prednisolone may help reduce the risk Features the patient may be eu-, hypo- or hyperthyroid at the time of presentation exophthalmos conjunctival oedema optic disc swelling ophthalmoplegia inability to close the eyelids may lead to sore, dry eyes. If severe and untreated patients can be at risk of exposure keratopathy ``` Management topical lubricants may be needed to help prevent corneal inflammation caused by exposure steroids radiotherapy surgery ``` Monitoring patients with established thyroid eye disease For patients with established thyroid eye disease the following symptoms/signs should indicate the need for urgent review by an ophthalmologist (see EUGOGO guidelines): unexplained deterioration in vision awareness of change in intensity or quality of colour vision in one or both eyes history of eye suddenly 'popping out' (globe subluxation) obvious corneal opacity cornea still visible when the eyelids are closed disc swelling Improve these notes

Answer 65

IV propranolol IV digoxin Propylthiouracil through NG tube followed by Lugol's iodine 6 hours later Prednisolone/hydrocortisone

Answer 66

Features of hyperthyroidism or hypothyroidism are not commonly seen in patients with thyroid malignancies as they rarely secrete thyroid hormones Main points Type Percentage Papillary 70% Often young females - excellent prognosis Follicular 20% Medullary 5% Cancer of parafollicular (C) cells, secrete calcitonin, part of MEN-2 Anaplastic 1% Not responsive to treatment, can cause pressure symptoms Lymphoma Rare Associated with Hashimoto's thyroiditis Management of papillary and follicular cancer total thyroidectomy followed by radioiodine (I-131) to kill residual cells yearly thyroglobulin levels to detect early recurrent disease Further information Type Notes Papillary carcinoma Usually contain a mixture of papillary and colloidal filled follicles Histologically tumour has papillary projections and pale empty nuclei Seldom encapsulated Lymph node metastasis predominate Haematogenous metastasis rare Follicular adenoma Usually present as a solitary thyroid nodule Malignancy can only be excluded on formal histological assessment Follicular carcinoma May appear macroscopically encapsulated, microscopically capsular invasion is seen. Without this finding the lesion is a follicular adenoma. Vascular invasion predominates Multifocal disease raree Medullary carcinoma C cells derived from neural crest and not thyroid tissue Serum calcitonin levels often raised Familial genetic disease accounts for up to 20% cases Both lymphatic and haematogenous metastasis are recognised, nodal disease is associated with a very poor prognosis. Anaplastic carcinoma Most common in elderly females Local invasion is a common feature Treatment is by resection where possible, palliation may be achieved through isthmusectomy and radiotherapy. Chemotherapy is ineffective.

Answer 67

Standing behind the person, palpate the different areas of the neck to assess the position of the neck lump(s) and possible cause. Anterior triangle (borders: midline, anterior border of sternocleidomastoid muscle, and the body of the mandible) — thyroid swellings (lobe), pharyngeal pouch, submandibular gland swelling, branchial cyst, lymph nodes (reactive, infective, or malignant), parotid swelling. Posterior triangle (borders: posterior border of sternocleidomastoid muscle, trapezius, and the clavicle) — lymph nodes (reactive or malignant), carotid artery aneurysm, carotid body tumour, cervical rib, lipoma. Midline — thyroid swellings (isthmus), thyroglossal cyst, laryngeal swellings, submental lymph nodes, dermoid cysts.