General points 7

Question 1

Fasciola hepatica

Answer 1

Also known as the common liver fluke (parasitic trematode)
Infects humans as part of a plant/ food trematode infection - “enthusiastic watercress farmer”
Found throughout the world
There are two illness phases
Acute phase - the immature worms begin penetrating the gut, causing symptoms of fever, nausea, swollen liver, skin rashes, and extreme abdominal pain
Chronic phase - occurs when the worms mature in the bile duct, and can cause symptoms of intermittent pain, jaundice, and anemia
Diagnosis is either by stool sample or serology
Treatment is with triclabendazole
Some patients may need ERCP

Question 2

Septic arthritis

Answer 2

Staph aureus commonest organism
Urgent washout and IV antibiotics otherwise high risk of joint destruction

Diagnosis
Plain x-rays
Consider aspiration
Utilise the Kocher criteria

Kocher criteria:

1. Non weight bearing on affected side
2. ESR > 40 mm/hr
3. Fever
4. WBC count of >12,000 mm3
   - when 4/4 criteria are met, there is a 99% chance that the child has septic arthritis

Question 3

When assessing the HLA matching between donor and recipient what is the most important HLA antigen to match?

Answer 3

DR is the most important

Question 4

Hyperacute acute rejection

Answer 4

Due to antibodies against donor HLA type 1 antigens

Rarely seen due to HLA matching

Question 5

Acute graft failure (< 6 months)

Answer 5

Usually due to mismatched HLA
Other causes include cytomegalovirus infection
Management - give steroids, if resistant use monoclonal antibodies

Question 6

Causes of chronic graft failure (> 6 months)

Answer 6

Chronic allograft nephropathy
Ureteric obstruction
Recurrence of original renal disease (MCGN > IgA > FSGS)

Question 7

Oculogyric crisis

Answer 7

An oculogyric crisis is a dystonic reaction to certain drugs or medical conditions

Features
Restlessness, agitation
Involuntary upward deviation of the eyes

Causes
Phenothiazines
Haloperidol
Metoclopramide
Postencephalitic Parkinson's disease

Management - Procyclidine

Question 8

Fistula management

Answer 8

They will heal provided there is no underlying inflammatory bowel disease and no distal obstruction, so conservative measures may be the best option
Where there is skin involvement, protect the overlying skin, often using a well fitted stoma bag- skin damage is difficult to treat
A high output fistula may be rendered more easily managed by the use of octreotide, this will tend to reduce the volume of pancreatic secretions.
Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal) these may necessitate the use of TPN to provide nutritional support together with the concomitant use of octreotide to reduce volume and protect skin.
When managing perianal fistulae surgeons should avoid probing the fistula where acute inflammation is present, this almost always worsens outcomes.
When perianal fistulae occur secondary to Crohn’s disease the best management option is often to drain acute sepsis and maintain that drainage through the judicious use of setons whilst medical management is implemented.
Always attempt to delineate the fistula anatomy, for abscesses and fistulae that have an intra abdominal source the use of barium and CT studies should show a track. For perianal fistulae surgeons should recall Goodsall’s rule in relation to internal and external openings.

Question 9

Goodsall’s rule

Answer 9

It states that if the perianal skin opening is posterior to the transverse anal line, the fistulous tract will open into the anal canal in the midline posteriorly, sometimes taking a curvilinear course. A perianal skin opening anterior to the transverse anal line is usually associated with a radial fistulous tract.
Essentially, it means that anterior-opening fistulas tend to follow a simple, direct course while posterior-opening fistulas may follow a devious, curving path with some even being horseshoe-shaped before opening in the posterior midline.

Question 10

Osteogenesis imperfecta

Answer 10

Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine.
Failure of maturation of collagen in all the connective tissues.
Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.

Subtypes
Type I The collagen is normal quality but insufficient quantity.
Type II- Poor collagen quantity and quality.
Type III- Collagen poorly formed. Normal quantity.
Type IV- Sufficient collagen quantity but poor quality.