General Surgery Flashcards
what is an enterocutaneous fistula?
link intestine to skin
may be high (>500ml) or low (<250ml) output depending on source
duodenal/ jejunal fistulae tend to be high vol, electrolyte rich secretions -> severe excoriation of the skin
colo-cutaneous fistulae -> leak faeculant material
what is an enterovesicular fistula?
fistula between intestine and bladder
- > frequent UTIs
- > passage of gas from urethra during urination (bubbly urine ie. pneumaturia)
Mx of high output fistula?
octreotide -> reduces the vol of pancreatic secretion
nutritional complicatoins common -> may necessitate use of TPN
protect overlying skin using a well fitted stoma bag
What is Goodsall’s rule?
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
mx of inguinal hernias?
clinical consensus is treat medically fit patients even if they are asymptomatic
- mesh repair assoc w lowest recurrence rate
a hernia truss: for pts not fit for surgery
pigmented gallstones assoc w?
sickle cell anaemia
-> results in increased red cell haemolysis and thus pigmented gallstone
pigmented gallstones are primarily made of bilirubin
A 65-year-old man with a history of dyspepsia is found to have a gastric MALT lymphoma on biopsy. What treatment should be offered?
Eradicate H pylori
In meckel’s diverticulitis, why is pain worse after meals?
contain ectopic gastric mucosa which may secrete acid with subsequent bleeding and ulceration.
what happens in Dumping syndrome?
early: food of high osmotic potential moves into small intestine -> fluid shift into the lumen, can cause pain due to lumen distension and diarrhoea
later: surge of insulin following food of high glucose value in small intestine - 2-3h later the insulin overshoots and causes hypoglycaemia
features of oesophagitis causing oesophageal bleeding?
small vol of fresh blood, often streaking vomit
often ceases spontaneously.
usually +ve hx of antecedent GORD type symptoms
features of oesophageal ca causing bleeding?
usually small vol of blood, except as pre terminal event w erosion of major vessels
often assoc w symptoms of dysphagia and constitutional symptoms (FLAWS)
may be recurrent until malignancy managed
features of Mallory Weiss tear causing bleed?
typically brisk small to mod volume of bright red blood following bout of repeated vomiting
melaena rare
usually ceases spontaneously
features of oesophageal varices?
usually large vol of fresh blood
swallowed blood can cause melaena
often assoc w haemodynamic compromise
may stop spontaneously but rebleeds are common until appropriately managed
feautres of gastric cancer causing bleed?
may be frank haematemesis or altered blood mixed w vomit
usually prodromal features of dyspepsia and may have constitutional symptoms
amount of bleeding variable but erosion of major vessel may produce considerable haemorrhage
features of Dielafoy lesion causing bleed?
often no prodromal features
this AV malformation may produce considerable haemorrhage and may be difficult to detect endoscopically
features of diffuse erosive gastritis causing bleeding?
usually haematemesis and epigastric discomfort
usually underlying cause such as NSAID use
large vol haemorrhage may occur w considerable haemodynamic compromise
Upper GI bleed in pt with previous hx of AAA surgery?
aorto-enteric fistulation
- rare but impt cause of major haemorrhage assoc w high mortality
most common cause of major haemorrhage from upper GI bleed?
posteriorly sited duodenal ulcer
when should pts admitted w upper GI bleed undergo upper GI endoscopy?
ideally ALL should undergo endoscopy within 24h of admission
in those who are unstable, this should occur immediately after resus or in tandem w it.
may be safer to perform endoscopy in theatre w an anaethetist present.
Mx of suspected oesophageal varices?
should receive terlipressin before endoscopy
during endoscopy: varices banded or subjected to sclerotherapy
if this is not possible due to active bleeding -> Sengstaken-Blakemore tube inserted
portal pressure should be lowered by combination of medical therapy +/- TIPSS
what to rmb about sengstaken blakemore tube?
gastric balloon inflated first then oesophageal balloon
balloon needs deflating after 12 h (ideally sooner) to prevent necrosis
mx of upper GI bleed due to erosive oesophagitis/ gastritis?
Proton Pump Inhibitor
Identifiable bleeding points should receive combination therapy of injection of adrenaline and either a thermal or mechanical treatment
pts w diffuse erosive gastritis who cannot be managed endoscopically and cont to bleed may require gastrectomy
mx of bleeding ulcers that cannot be controlled endoscopically?
laparotomy and ulcer underrunning
Blatchford and Rockall scores in Upper Gi bleeds?
Blatchford score assesses severity of upper GI bleed, and thus need for admisison and timing of endoscopic intervention
(1 or more = high risk)
Rockall score: determined following endoscopy to assess risk of rebleeding and mortality
duodenal ulcer has caused upper GI bleed, if bleeding is brisk and ulcer is posteriorly sited, what artery is affected?
gastroduodenal artery
surgical mx of bleeding gastric ulcer?
- Under-running of the bleeding site
- Partial gastrectomy-antral ulcer
- Partial gastrectomy or under running the ulcer- lesser curve ulcer (involving left gastric artery)
- Total gastrectomy if bleeding persists
Post cystectomy
Which investigation should you order to offer the most definitive result to assess whether the bladder suture line has healed?
Cystogram:
passing radiopaque dye into the bladder, then performing radiographs to assess the course of the bladder contents. This provides evidence of whether there is any radiopaque fluid that has escaped the bladder and is free in the abdominal cavity.
mutation of PTEN gene
macrocephaly
multiple intestinal hamartomas
multiple trichilemmomas
high risk of cancer (breast, thyroid, uterine, colorectal)
Cowden disease
mx of haemothorax when >1.5L blood loss initially or losses of >200ml per hour for >2 hours?
thoracotomy (surgical incision into chest wall)
- allow for surgical exploration and closure of any actively bleeding sites.
what is Parklands formula for burns?
4ml * % body surface area * weight (kg) = ml of Hartmann’s to be given in first 24 hours
give first half in 8h
what are the boundaries of the Hesselbachs triangle?
Boundaries of Hesselbach’s Triangle
Medial: Rectus abdominis
Lateral: Inferior epigastric vessels
Inferior: Inguinal ligament
Hernias occurring within the triangle tend to be direct and those outside - indirect.
what nerve is at risk during carotid endarterectomy?
ipsilateral hypoglossal nerve.
The hypoglossal nerve supplies ipsilateral motor component to the tongue and the hyoid depressors.
tongue will deviate towards the affected side
what nerve is at risk during posterior approach to hip for transplant?
sciatic nerve
what nerve is at risk during inguinal hernia surgery?
ilioinguinal nerve
what nerve is at risk of damage following varicose vein surgery?
sural and saphenous nerves
what nerve is at risk of damage following Axillary node clearance?
long thoracic nerve, thoracodorsal nerve and intercostobrachial nerve.
what nerve is at risk of damage during Anterior resection of rectum?
hypogastric autonomic nerve
what nerve is at risk of damage following thyroidectomy?
laryngeal n
what nerve is at risk of damage with Lloyd Davies stirrups?
common peroneal nerve
what nerve is at risk of damage following Posterior triangle lymph node biopsy?
accessory n
best ix for hydatid cyst?
CT is the best investigation to differentiate hydatid cysts from amoebic and pyogenic cysts.
Surgery is the mainstay of treatment (the cyst walls must not be ruptured during removal and the contents sterilised first).
what would result in hyperacute rejection of an organ transplant?
ABO incompatibility
- due to pre existing antibodies to other groups
- renal transplants at greatest risk
what would cause acute rejection of organ transplant?
all organs may undergo this.
occurs during first 6 months, usually T cell mediated.
usually mononuclear cell infiltrates
increased risk if HLA mismatching
what causes chronic rejection of organ transplant?
any.
occurs > 6 months
vascular changes predominate -> organ ischaemia
HLA mismatch increases risk
how is donor kidney transplanted into recipient?
operation performed under GA
- Rutherford-Morrison incision
- > provides excelled extraperitoneal access to iliac vessels
the external iliac artery and vein are dissected out and following systemic heparinisation are cross clamped
vein and artery are anastamosed to the iliacs and the clamps removed
-> ureter then implanted into bladder and stent placed to maintain patency
in the immediate phase, what common problem is encountered in cadaveric kidneys which tends to resolve?
acute tubular necrosis
what are graft survival times like from live donors vs cadaveric donors?
live donors: 25 yrs
cadaveric donors: 9 yrs
mx of Infantile umbilical hernia
vast majority resolve without intervention before age 4-5
what is the first major branch of the abdominal aorta?
celiac trunk
what does the coeliac trunk supply?
supplies liver, stomach, abdominal oesophagus, spleen and superior half of duodenum and pancreas
what does the coeliac trunk divide into?
3 branches
- left gastric -> oesophagus, stomach
- common hepatic artery -> liver, + gastroduodenal artery (duodenum)
- splenic artery -> spleen, pancreas
what is the second major branch of the abdominal aorta?
superior mesenteric artery
what does the superior mesenteric artery supply?
intestine from lower part of duodenum to 2/3rds of transverse colon
+ pancreas
what are the branches of the superior mesenteric artery?
inferior pancreaticoduodenal artery: head of pancreas + inferior parts of duodenum
intestinal arteries: branches to ileum and jejunum
ileocolic artery: last part of ileum, caecum and appendix
right colic artery: to ascending colon
middle colic artery: transverse colon
what is the third major branch of the abdominal aorta?
inferior mesenteric artery
what does the inferior mesenteric artery supply?
large intestine from splenic flexure to upper part of the rectum
what are the watershed areas in the colon?
splenic flexture (between IMA and SMA)
sigmoid colon and rectum
during times of systemic hypoperfusion, such as in disseminated intravascular coagulation or heart failure, these regions are particularly vulnerable to ischemia because they are supplied by the most distal branches of their arteries, and thus the least likely to receive sufficient blood
mx of splenic trauma?
if major haemorrhage, and hilar injuries
splenic resection
mx of splenic trauma if mod haemodynamic compromise, tears or lacerations affecting < 50% of spleen, increased amounts of intra abdo blood?
laparotomy with conservation
mx of splenic trauma w no hilar disruption, minimal intra abdo blood, small subcapsular haematoma?
conservative
mx of congenital inguinal hernia?
Indirect hernias resulting from a patent processus vaginalis
Should be surgically repaired soon after diagnosis as at risk of incarceration
what is spondylolisthesis?
spontaneous displacement of a lumbar vertebral body upon the segment below it
usually displacement forward at the L4/5 or L5/S1 level
may be asymptomatic or -> chronic pain w sciatica, worse on standing
palpable step of the displaced vertebral body will be felt on examination of spine
mx of spondylolisthesis?
if asymptomatic: no tx required
severe pain is indication for surgical release of affected nerves w fusion of the spinal column
what is spondylosis?
osteoarthritis of the spine
disc degeneration -> lumbar instability
aching pain worse on activity and in mornings
O/E may be some restrictions of spinal movements
what is marjolins ulcer?
development of a squamous cell carcinoma occuring in an area of scarred or traumatized skin e.g. burns, chronic wounds, venous ulcers
lesions appear as raised, fleshy, firm papules that grow slowly
tx: wide local excision
risk factors for Basal cell carcinomas ie. rodent ulcer?
UV light exposure
xray exposure
chronic scarring
genetic predisposition
male sex
small, skin coloured papules w telangiectasia and a pearly edge w central necrosis?
Basal cell carcinoma
locally invasive, destroying soft tissue, cartilage ad bone
metastasis is v rare
mx via surgical excision
what is a cystic hygroma?
congenital benign proliferation of lymph vessels found in posterior triangle of the neck
multicystic swelling that is fleshy and compressible and contains clear fluid
transilluminates brightly
what is frozen shoulder?
adhesive capsulitis
relatively common
frequently follows hx of minor trauma
long hx of aching pain and restriction of all glenohumeral movements
external rotation is first to be restriction
three characteristic phases: freezing (pain), frozen (stiffness), thawing
impingement syndrome -> pain on abduction between which angles?
60 to 120
what is the most common site for rotator cuff tear?
‘critical zone’ of the supraspinatus tendon, a relatively avascular region near its insertion
-> shoulder tip pain and inability to abduct the arm
localised tenderness at lateral margin of the acromion
popeye sign
elbox flexion produces unusual bulge
-> long tendon of biceps rupture
mx of myxoedema coma?
intensive care for fluids, gentle rewarming and IV thyroid hormones
mx of thyroid storm?
mx in intensive care with fluids, gentle cooling and intravenous beta-blockers (propranolol)
Sodium iopodate (which inhibits thyroxine release) and carbimazole (inhibits synthesis of thyroxine) are also administered.
Histological analysis demonstrates a characteristic ‘Orphan Annie eye’ appearance nuclei
papillary thyroid ca
route of spread of thyroid cancers?
Papillary -> Yellow -> Lymph
Follicular -> Red -> Blood
Medullary -> Yellow -> Lymph
Anaplastic -> Combined -> Lymph and blood
what side do diaphragmatic ruptures typically occur on?
L side
-liver protective on the right
Following diaphragmatic rupture, the abdominal contents herniate into the thorax. Features therefore include respiratory compromise.
ix of suspected ruptured spleen?
Stable patients can undergo CT, whereas unstable patients require urgent laparotomy.
post splenectomy prophylaxis?
vaccinations for the three main encapsulated organisms that are usually destroyed by the spleen (Streptococcus pneumoniae, Haemophilus influenzae B and Neisseria meningitides), with boosters at 10 years
what are the Lanz and Giridion incisions used for?
to access theappendix, predominantly for appendicetomy
Both incisions are made at McBurney’s point (two-thirds from the umbilicus to the ASIS)
Lanz incision is a transverse incision, whilst the Gridiron incision is oblique
Due to its continuation with Langer’s lines, the Lanz incision produces much more aesthetically pleasing results with reduced scarring.
midline incision what surgery?
wide array of abdominal surgery, as it allows the majority of the abdominal viscera to be accessed.
A midline laparotomy can run anywhere from the xiphoid process to the pubic symphysis, passing around the umbilicus
this incision causes minimal blood loss or nerve damage, and can be used for emergency procedures. Its positioning however does make it susceptible to significant scars.
what is a paramedian incision used for?
rare
used to access much of the lateral viscera, such as the kidneys, the spleen, and the adrenal glands.
incision runs 2-5cm lateral to the midline
A paramedian incision can damage the muscles’ lateral blood and nerve supply, which may result in the atrophy of the muscle medial to the incision.
what is a Kocher incision used for?
subcostal incision used to gain access for the gall bladder the biliary tree.
incision is made to run parallel to the costal margin, starting below the xiphoid and extending laterally
2 extensions possible: rooftop/ mercedes benz
Left- sided incisions are used for splenectomy.
The incision cannot be extended medially and, if it is extended too far laterally, many intercostal nerves can be damaged.
what is a rooftop incision used for?
oesophagectomy, gastrectomy, bilateral adrenalectomy, hepatic resections, or liver transplantation
what are langers lines?
Langer’s lines mark the principle axis of orientation of the collagen fibres of the dermis and form the natural creases of the skin. Incisions that are made parallel to these lines offer the best cosmetic outcome.
pain, erythema and palpable cord-like structure around a cannula?
superficial thrombophlebitis
mx by removing the cannula, elevate limb and NSAIDs for pain
surgical mx of varicose veins along the long saphenous vein?
saphenofemoral ligation:
long saphenous vein stripped to knee and all its branches ligated
surgical mx of varicose veins along short saphenous vein?
saphenopopliteal ligation
***surgery for varicose veins only work if deep venous system is intake
what layers are cut during a midline incision?
Skin -> Campers fascia -> Scarpa’s fascia -> linea alba -> transversalis fascia -> extraperitoneal fat -> peritoneum
e.g.s of emergency midline laparotomy?
perforated duodenal ulcer
trauma
ruptured AAA
Hartmann’s
e.g.s of elective midline laparotomy?
colectomy
AAA
Hiatus hernia repair
advantages of midline laparotomy?
good access
almost bloodless line as relatively avascular
no muscle fibres divided
minimal nerve + muscle injury
can be quickly made and closed
disadvantages of midline laparotomy?
long midline scar crossing Langer’s lines so poor cosmetic appearance
more painful than transverse incisions
lower midline incision lacks posterior rectus sheath so urinary bladder may be injured
what is Jenkin’s rule of closure?
length of suture = 4 x length of incision, 1cm bite, 1cm apart -> lower risk of dehiscence
what is a paramedian scar?
scar resulting from vertical incision 2.5cm from midline L/R
can extend from costal margin to pubis
advantages of paramedian incision?
provides access to lateral structures
rectus muscle not divided (rectus sheath cut, rectus displaced laterally)
secure closure
can be extended by a curvilinear incision towards xiphoid process if required (Mayo-Robson incision)
disadvantages of paramedian scar?
longer to make and close
incision needs to be closed in layers
tends to strip muscles of lateral blood and nerve supply resulting in atrophy of muscle medial to incision
what is a Battle’s incision? why is it not used anymore?
not used due to damage to nerves entering rectus sheath and poor healing
causing incisional hernias
what is a Mercedes Benz incision classically used for?
liver transplantation and diaphragmatic hernia repair
what layers are cut in Giridions/ McBurney’s incision?
skin -> Carper’s fascia -> Scarpa’s fascia -> external oblique -> internal oblique -> transversus -> transversalis fascia -> pre peritoneal fat -> peritoneum
disadvantages of Lanz incision or Giridions?
risk of injury to ilioinguinal and iliohypogastric nerves
may predispose to inguinal hernia post op (esp w Lanz)
laparoscopy scars?
generally 3-4 incisions
1 always at umbilicus to allow port for camera
others located in 1 of 4 quadrants for tools e.g. griper, cutting, dissecting scissors etc
Loin (lumbar) incision?
used for nephrectomy
what is a McEvedy’s incision?
transverse incision, 1cm above pubic symphysis and extends from midline laterally
gives access to Hesselbach’s triangle
-> emergency femoral hernia
*modified version replaced original incision which had a v high incisional hernia rate
what is an inguinal incision used for?
scar from oblique incision 1cm above and parallel to inguinal ligament, from inner to outer inguinal ring
for open inguinal hernia repair, orchidectomy, varicoceles, testicular ca
adv: follows Langer’s Lines
disadv: high rates of chronic neuropathic pain
what should the ideal incision allow for?
ease of access to desired structures
can be extended if needed
ideally muscles should be split rather than cut
heals quickly w minimal scarring
cosmetically pleasing
venous ulcers vs arterial ulcers?
venous:
shallow and flat
mildly painful
bleed
medial gaiter area
arterial:
deep
painful
do not bleed
1st line mx for venous ulceration?
4 layer compression bandaging w prior excision of necrotic tissue
*must check ABPI is > 0.8 before
mx of venous ulcer which has failed to improve after 12 wks of compression bandaging or is > 10cm2
split skin grafting
- involves removing a partial thickness layer of skin
(containing the epidermis and a part of the dermis) from another part of the pt’s body and grafting it to the ulcerated area
What is a normal CVP?
2-6 mmHg
what is transfusion related lung injury?
Acute onset non cardiogenic pulmonary oedema
Leading cause of transfusion related deaths
Greatest risk posed with plasma components
Occurs as a result of leucocyte antibodies in transfused plasma ->
Aggregation and degranulation of leucocytes in lung tissue accounts for lung injury
what are the five anatomical sites where a stone might impact in the renal tract?
ureteropelvic junction
where the iliac artery crosses the ureter
the juxtaposition with the vas deferens (males) or the broad ligament (females)
where the ureter enters the bladder wall
and finally the ureteric orifice.
how do bladder calculi present?
triad of dysuria, haematuria and freq
intermittent halting of urinary flow as the stone blocks the urethral meatus in the bladder
pain is suprapubic and radiates to perineum and tip of the penis
pain + haematuria worse at the end of micturation as bladder contracts against the stone
stones that occur in the bladder are due to stasis, infectionb or the presence of a long term indwelling catheter.
what is the most common type of renal tumour?
renal cell adenocarcinoma
how does renal cell carcinoma present?
triad of haematuria, flank pain, palpable abdo mass
new left sided varicocele may occur in men due to obstruction of left testicular vein (which drains into renal vein)
HTN (from hyperaldosteronism)
polycythaemia (excess EPO)
hyperCa (surplus hydroxylation of vit D)
if obstruction of IVC occurs -> bilat leg oedema
renal cell carcinoma + phaeochromocytoma + central nervous system haemangiomas
von hippel lindau
multisystem tumours + developmental delay + seizures + characteristic skin lesions (adenoma sebaceum, shagreen patch, ash-leaf macules and subungual fibromas)
tuberous sclerosis
which histological subtype of RCC is most common?
clear cell carcinoma
Nerve entrapment causes pain or a burning sensation in the lateral thigh (known as meralgia paraesthetica) with no motor abnormality.
obese people or pregnant women
Pain is often caused by long periods of standing.
Lateral femoral cutaneous nerve
can become trapped beneath the inguinal ligament where it attaches to the anterior superior iliac spine
loss of toe flexion, ankle inversion and the ankle jerk
vulnerable to damage during posterior dislocations of the knee
or compressed in the posterior tarsal tunnel behind the medial malleolus
Sensation over the plantar surface of the foot is lost
tibial n palsy
A branch of the sciatic nerve, the tibial nerve supplies the flexor compartment of the leg (calf muscles) It also gives rise to the medial and lateral plantar nerves, which supply the intrinsic muscles of the foot as well as plantar sensation.
Affected patients walk with a shuffling gait, as the take-off phase of walking is impaired
There is loss of the lateral longitudinal arch of the foot, and atrophy of the intrinsic foot muscles eventually results in a claw-foot.
which nerve can be damaged during long saphenous vein surgery, particularly when the vein is stripped below the knee, resulting in loss of sensation to the medial aspect of the calf?
saphenous nerve
loss of hip adduction and loss of sensation to the upper inner thigh
obturator n
which nerve can be damaged during short saphenous vein surgery?
sural nerve - a cutaneous sensory branch of the tibial nerve
Lesions of the sural nerve result in a loss of sensation to the lateral side of the foot and little toe.
loss of hip abduction and a pelvic dip on walking (Trendelenburg gait)
Superior gluteal nerve lesions
loss of hip extension and buttock wasting?
Inferior gluteal nerve lesions
(gluteus maximus)
first line mx of bleeding ulcer seen at endoscopy?
injection of the ulcer with 1:10 000 adrenaline to achieve haemostasis
diagnosis of fat necrosis?
must be confirmed by core biopsy, as presenting features may be similar to those of carcinoma
what is Mondor disease?
thrombophlebitis of the superficial veins of the breast and anterior chest wall
characterised by painful, inflamed subcutaneous cord that is tethered to the skin
when arm on affected side is raised, a shallow groove becomes apparent alongside the cord
tx w rest and analgesia
adrenaline use on a finger?
what is a bier block?
A Bier block is performed by first squeezing the blood out of the limb, then inflating a tourniquet around the upper arm and injecting intravenous prilocaine into the arm distal to the tourniquet. The tourniquet prevents LA from leaving the arm and blood from entering.
Prilocaine is the best local anaesthetic to use for this procedure as it is the least cardio- toxic.
idiopathic fibrosis of the thyroid
slow-growing goitre that is firm and irregular, and it is difficult to distinguish this from cancer without a biopsy
Complications of the fibrosis include tracheal/oesophageal compression and recurrent laryngeal nerve palsy
Riedel thyroiditis
-> no tx but palliative surgery can be performed if there are compressive symptoms
Causes of spontaneous Subarachnoid haemorrhage?
Intracranial aneurysm* (saccular ‘berry’ aneurysms): this accounts for around 85% of cases. Conditions associated with berry aneurysms include adult polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta
Arteriovenous malformation
Pituitary apoplexy
Arterial dissection
Mycotic (infective) aneurysms
Perimesencephalic (an idiopathic venous bleed)
Diagnosis of subarachnoid haemorrhage?
CT head:
Acute blood (hyperdense/bright on CT) is typically distributed in the basal cisterns, sulci and in severe cases the ventricular system.
LP to confirm SAH if CT -ve.
performed at least 12 h following onset of symptoms to allow development of xanthochromia
Mx of subarachnoid haemorrhage?
referral to neurosurgery immediately
ix causative pathology: CT intracranial angiogram (to identify a vascular lesion e.g. AVM or aneurysm) +/- digital subtraction angiogram
Vasospasm is prevented using a 21-day course of nimodipine
hydrocephalus: external ventricular drain or if required, long term ventriculo-peritoneal shunt
Mx of Intracranial aneurysm -> subarachnoid bleed?
coil by interventional neuroradiologists
minority require a craniotomy and clipping by a neurosurgeon
Until the aneurysm is treated: strict bed rest, well controlled BP and avoid straining in order to prevent a re-bleed
Vasospasm is prevented using a 21-day course of nimodipine
hydrocephalus: external ventricular drain or long term VP shunt
Intestinal obstruction + bilious vomiting
few hours after birth
assoc w Downs Syndrome
AXR shows double bubble sign
Duodenal atresia
mx: duodenoduodenostomy
Complications of aneurysmal subarachnoid haemorrhage?
Re-bleeding (in around 30%)
Vasospasm (also termed delayed cerebral ischaemia), typically 7-14 days after onset
Hyponatraemia (most typically due to syndrome inappropriate anti-diuretic hormone (SIADH))
Seizures
Hydrocephalus
Death
Intestinal obstruction + bilious vomiting
Usually 3-7 days after birth
Upper GI contrast study may show DJ flexure is more medially placed, USS may show abnormal orientation of SMA and SMV
Malrotation w volvulus
Tx: Ladd’s procedure
tx of Duodenal atresia?
Duodenoduodenostomy
Intestinal obstruction + bilious vomiting
Typically in first 24-48 hours of life with abdominal distension
assoc w cystic fibrosis
Meconium Ileus
tx: surgical decompression, serosal damage may require segmental resection
Intestinal obstruction + Bilious vomiting
Usually within 24 hours of birth
AXR will show air-fluid levels
Usually caused by vascular insufficiency in utero, usually 1 in 3000
Jejunal/ ileal atresia
Mx: Laparotomy with primary resection and anastomosis
Intestinal obstruction + Bilious vomiting
Usually second week of life
risks increased in prematurity and inter-current illness
Dilated bowel loops on AXR, pneumatosis and portal venous air
Necrotising enterocolitis
mx:
Conservative and supportive for non perforated cases, laparotomy and resection in cases of perforation of ongoing clinical deterioration
mx of Papillary and follicular carcinomas
thyroid surgery
lifelong thyroxine to suppress endogenous TSH secretion and reduce risk of recurrence
most common organism causing necrotizing fasciitis?
Group A strep e.g. strep pyogenes
Mx of necrotizing fasciitis?
IV broad spectrum abx w extensive surgical debridement of infected tissues
What should u image in a L sided varicocele?
US varicocele + L Kidney
Cancers of the left kidney can present with a left-sided varicocele, as the presence of the tumour can impair venous return from the testicle.
swelling on left thigh, below and lateral to the pubic tubercle. On examination, the swelling is bluish, non- tender, non-pulsatile and compressible.
Saphena varix
dilatation of the long saphenous vein that occurs due to valvular incompetence at the SFJ. A saphena varix often has a bluish tinge, is soft and compressible, disappears on lying down, has a cough impulse and exhibits a fluid thrill when the long saphenous vein is tapped distally (Schwart test).
purpose of a double lumen cuffed endotracheal tube?
developed for lung and other intra-thoracic surgery. It allows for one lung to be ventilated while the other is collapsed to make surgery easier.
what type of endotracheal tube is preferred in children?
Single-lumen uncuffed endotracheal tube
An uncuffed endotracheal tube is preferred in children, as the trachea is not as strong as in adults, and the use of a cuff increases the risk of tracheal damage with resulting stenosis.
Mx of gastroparesis?
medical:
prokinetic drugs, incl metoclopramide, erythromycin, domperidone
surgical:
gastric pacing device
small reddish papules arranged in a ring
assoc w diabetes mellitus
usually occurs on backs of hands or feet
Granuloma annulare
features of Slipped upper femoral epiphysis?
posterolateral displacement of the femoral head, following a fracture through the growth plate
-> external rotation of hip and shortening of limb
assoc w obesity
presents w limp + hip pain referred to knee
may follow minor trauma
may be restriction in abduction and internal rotation of the hip
Diagnosis and mx of SUFE?
Diagnosis confirmed on lateral X ray of affected hip
Mx; surgical pinning of the epiphysis
complications of a SUFE?
premature epiphyseal fusion, avascular necrosis and early-onset arthritis
diagnosis of perthes disease?
ateral X-ray of the affected hip, which shows an increased density and reduced size of the femoral head. The femoral head later becomes fragmented and irregular.
Mx of perthes disease?
mild: bed rest and traction
severe: placing child in Gallows traction or surgical femoral osteotomy
Mx of transient synovitis?
analgesia, bed rest and skin traction
risk factors for Developmental dysplasia of hip?
positive family history, breech delivery, spinal/ neuromuscular abnormalities (e.g. spina bifida, talipes equinovarus) and oligohydramnios.
female, first born
Mx of DDH? (hip dysplasia)
if early: conservative tx
- PAvlik harness or Craig splint
(placing hips in abduction)
progress monitored by US or X ray
if conservative measures fail, open reduction and femoral osteotomy
what procedure can you do for prostate cancer with minimal risk to impotence?
Brachytherapy
- implantation of radioactive ‘seeds’ into the prostate gland
- temporary brachytherapy, involves the insertion of thin tubes through the perineal skin (usually under GA) into the prostate.
The ionizing radiation damages DNA and increases apoptosis.
lower rate of complications (30% impotence, 1% incontinence)
Thenar space located on lateral half of palm
mid palmar space on medial side
Mx of Colles fracture?
Manipulation under anaesthesia (internal reduction)
Fracture of clavicle -> appearance?
Clavicles most often break at the junction of the middle and outer 1/3. If displacement occurs, the lateral fragment is displaced downward and medially by the weight of the arm and the medial fragment is held up by the sternomastoid muscle.
mx of clavicle fracture?
Broad arm sling for 2 wks
with active exercises after 1 week
Operative fixation may occasionally be indicated in comminuted fractures or those which are widely displaced (showing signs of skin tenting)
congenital vascular malformation that presents with multiple port-wine stains, varicose veins on the lateral aspect of the thigh and hypertrophy of the bones and soft tissues of one leg. Patients are predisposed to multiple deep vein thromboses
Klippel–Trénaunay syndrome
Ix of diffuse oesophageal spasm?
barium swallow in active disease will show diffuse spasm, known as the ‘corkscrew oesophagus’
manometry: prolonged, powerful oesophageal contractions induced by swallowing
features of a bulbar palsy?
LMN lesion of the cranial nerves of the medulla (9, 10, 11 and 12)
hypotonicity and hyporeflexia
dysphagia, dysarthria, a weak fasciculating tongue and a diminished jaw jerk
Causes of a bulbar palsy include motor neurone disease, Guillain- Barré syndrome and myasthenia gravis
Mx of flail chest?
respiratory support and adequate analgesia
such as an epidural or intercostal nerve block.
Operative intervention is rarely required.
blood at the urethral meatus, an inability to micturate and a palpable bladder.
butterfly bruising of the perineum
Anterior urethral trauma
ix of Anterior urethral trauma?
immediate anterograde urethrogram
by inserting a catheter just inside the urethral meatus and then injecting water-soluble contrast
if urethral injury -> suprapubic catheter
ix for actively bleeding lesion of angiodysplasia?
can be detected by mesenteric angiography, as contrast leaks into the bowel lumen
diagnosis is made by colonoscopy.
tx: diathermy of lesions
what tumour marker is assoc w malignant melanoma?
S-100
Neurone-specific enolase tumour marker?
small cell lung cancer
thyroglobulin tumour marker?
thyroid tumours (follicular/papillary)
what is Peyronie disease?
haracterized by progressive fibrosis of the tunica albuginea covering the corpus cavernosum of the penis
assoc w Dupuytrens contracture
symptoms: pain on erection, followed by deviation of erection and a ventral curvature of the penis
Deformity can progress until sexual inter- course becomes impossible
surgical options: incision/ excision of the fibrotic plaque or graft placement
what is priapism?
a prolonged, painful erection that is not associated with sexual desire
Prolonged erection leads to hypoxia and ischaemia within the corpora of the penis, and pain begins after 3–4 hours
After 12 hours, intersti- tial oedema develops, and smooth muscle necrosis occurs after 24 hours.
mx: conservative (exercise, ice), medical (oral terbutaline/ Intracavernosal phenylephrine) or surgical (vascular shunts)
mx of nephrogenic DI?
improved by thiazide diuretics
Talbot’s test?
the patient is asked to follow your finger with their eyes as you move it towards them
In anterior uveitis, the eye pain increases as the eyes converge and the pupils constrict
tx of anterior uveitis?
prednisolone drops to reduce inflammation
atropine drops - to keep pupils dilated and prevent adhesions from forming
slow-growing malignant tumour of the cartilage
chondrosarcoma
X-rays show localized bone destruction with areas of calcification within the tumour.
Treatment is by chemotherapy with wide local excision.
features of Ewing sarcoma?
rare malignant tumour of the bone
most common in the 5- to 15-year age
small cell carcinoma that most commonly occurs in the legs or pelvis
painful swelling and fever
XR: lytic lesion with a laminated periosteal reaction, known as ‘onion skinning’
Treatment is by neoadju- vant chemotherapy and/or radiotherapy with surgical excision
xray findings of osteosarcoma?
cortical destruction, periosteal elevation (Codman triangle)
calcification within the tumour but outside the bone (sunray spicules)
X-rays show a radiolucent nidus surrounded by a dense area of reactive bone.
presents with intense pain that is characteristically worse at night and is relieved by NSAIDs
osteoid osteoma
Osteoid osteomas are caused by a nidus of osteoblasts that become trapped in the cortex of the bone
bone tumours from prostate mets vs other mets e.g, breast, lung, kidney
prostate: osteosclerotic
Others: osteolytic
Exomphalos
sac is known as an omphalocele
Gastroschisis
budd chiari syndrome presentation?
classic triad of abdominal pain + ascites + hepatomegaly
diagnosis of budd chiari?
Doppler ultrasound
which shows obliteration of hepatic vein flow and reversal of flow in the hepatic portal vein
tx of budd chiari?
thrombolysis or anticoagulation
but 70% of cases die within the year
causes of non pitting oedema in the lower limb?
lymphoedema
pretibial myxoedema (Graves)
mx of acute attacks of hereditary angioedema?
IV C1 esterase inhibitor concentrate
Long-term man- agement with anabolic steroids (e.g. danazol) help promote synthesis of C1-esterase inhibitor.
elephantiasis - which organism?
Wuchereria bancrofti
features of elephantiasis?
cause of secondary lymphoedema. Elephantiasis is characterized by thickening of the skin and subcut tissues, often of the legs and genitals.
what is Milroy disease?
inherited autosomal dominant congenital lymphoedema, caused by a failure of lymph vessels to develop in utero
Isotope lymphography, where a radioactive tracer is injected subcut into the foot and its progress monitored, can be performed. A delayed transit time confirms the diagnosis.
Mx of primary lymphoedema?
compression, elevation, aggressive antibiotic therapy for infections and debulking surgery (indicated when conservative treatment has failed).
significance of weber classification of ankle fractures?
The more proximal the fracture is, the higher the risk of syndesmotic injury and instability.
faecal elastase test?
cystic fibrosis
chronic pancreatitis
port-wine stain is associated with seizures, mental retardation and eye abnormalities (glaucoma and optic atrophy) due to underlying cranial malformations
Sturge- Weber syndrome
port-wine stain in the distribution of the ophthalmic or maxillary division of the trigeminal nerve.
presence of multiple painful lipomas
dercum disease
what is proctalgia fugax?
Proctalgia fugax is a benign condition that affects young, anxious men. It is characterized by brief attacks of rectal pain that usually occur at night and are unrelated to defecation.
mx of proctalgia fugax?
excluding organic disease, reassurance, analgesia and topical smooth muscle relaxants (e.g. GTN cream)
features of otosclerosis?
conductive Deafness is progressive and usually begins with low frequencies
Patients can often hear better in noisy surroundings (paracusis)
treatment of otosclerosis?
stapedotomy (replacement of the abnormal stapes with a prosthesis)
OA, Rheumatoid arthritis
Valgus or varus?
OA: valgus
RA: varus
what is Takayasu arteritis?
granulomatous inflammation of the aorta and its major branches
HTN, arm claudication, absent pulses, bruits and visual disturbance (transient amblyopia and blindness)
+/- FLAWS
diagnosis of takayasu arteritis?
Diagnosis is by angiography, which shows narrowing of the aorta and its major branches
Mx of takayasu arteritis?
steroids
but the condition is progressive and death occurs within a few years.
what is McCune-Albright Syndrome?
at least two of the following three features:
(1) polyostotic fibrous dysplasia (PFD)
(2) café-au-lait skin pigmentation
(3) autonomous endocrine hyperfunction (eg, gonadotropin-independent precocious puberty)
indications for colostomy?
Hartmanns
anterior resection
Abdomino-perineal resection
indications for ileostomy?
total colectomy e.g. UC, FAP
indications for loop ileostomy?
usually temporary
- defunction distal bowel e.g. crohns
- relieve distal obstruction e.g. prior to definitive surgery in rectal ca
- protect distal anastomoses
lesions appear as brown, firm, translucent nodules which give a characteristic ‘apple jelly’ appearance on diascopy.
Lupus vulgaris
cutaneous manifestation of TB
1st line medical mx of BPH?
alpha1 antagonist
e.g. tamsulosin, alfuzosin
decreases smooth muscle tone (prostate and bladder)
improves symptoms in around 70% of men
how to confirm diagnosis of acute urinary retention?
bladder US
- vol of >300 ml confirms the diagnosis
Imatinib tyrosine kinase inhibitor may be used for?
CML
GI stromal tumour
Cetuximab Epidermal growth factor inhibitor may be used for/
EGF positive colorectal cancers
Bevacizumab Anti-VEGF may be used for?
colorectal cancer
renal cancer
glioblastoma
what is the ASA physical status classification system?
system for assessing the fitness of patients before surgery
- Healthy person.
- Mild systemic disease.
- Severe systemic disease.
- Severe systemic disease that is a constant threat to life.
- A moribund person who is not expected to survive without the operation.
- A declared brain-dead person whose organs are being removed for donor purposes.
E for emergency after the number
what is suxamethonium apnoea?
auto dom mutation: lack of acetylcholinesterase which breaks down suxamethonium, terminating its muscle relaxant effect.
patient needs to be mechanically ventilated and observed in ITU until the effects of suxamethonium wear off
suxamethonium: inhibits action of Ach @NMJ
where is intraosseous access most commonly obtained?
proximal tibia
however, the distal femur and humeral head can also be used
what nerves are at risk in a McBurneys / Lanz incision?
ilioinguinal and iliohypogastric nerves
-> may predispose to inguinal hernia
Predominantly affects adolescents
Symptoms include back pain and stiffness
X-ray changes include epiphyseal plate disturbance and anterior wedging
Clinical features include progressive kyphosis (at least 3 vertebrae must be involved)
Scheuermann’s disease
Minor cases may be managed with physiotherapy and analgesia, more severe cases may require bracing or surgical stabilisation
what fluid do you use to clean wounds post surgery?
Use sterile saline for wound cleansing up to 48 hours after surgery.
Advise patients that they may shower safely 48 hours after surgery.
Use tap water for wound cleansing after 48 hours if the surgical wound has separated or has been surgically opened to drain pus.
drugs that cause malignant hyperthermia?
halothane
suxamethonium
other drugs: antipsychotics (neuroleptic malignant syndrome)
features of malignant hyperthermia?
characterised by hyperpyrexia and muscle rigidity
cause by excessive release of Ca2+ from the sarcoplasmic reticulum of skeletal muscle
CK raised
mx: dantrolene
- prevents Ca2+ release from the sarcoplasmic reticulum
mx of overactive bladder?
conservative measures include moderating fluid intake
bladder retraining should be offered
antimuscarinic drugs inc oxybutynin, tolterodine and darifenacin
mx of nocturia?
advise about moderating fluid intake at night
furosemide 40mg in late afternoon may be considered
desmopressin may also be helpful
mx of voiding symptoms due to large prostate?
conservative measures: pelvic floor muscle training, bladder training, prudent fluid intake and containment products
if ‘moderate’ or ‘severe’ symptoms: alpha-blocker
if the prostate is enlarged and the pt is ‘considered at high risk of progression’ then a 5-alpha reductase inhibitor should be offered
enlarged prostate + ‘moderate’ or ‘severe’ symptoms -> both alpha-blocker and 5-alpha reductase inhibitor
medication to tx delirium in pt with Parkinsons?
1st line Lorazepam
mx of terminal restlessness?
Midazolam
Which is the most appropriate method for providing analgesia during the early postoperative period?
Epidural anaesthesia
Epidural is best because it can be topped up and titrated
what artery is a fav target for laparoscopic ports and surgical drains?
inferior epigastric artery
what nerve is at risk in posterior approach to hip?
sciatic n
what nerve is at risk in Posterior triangle lymph node biopsy?
Accessory n
what nerve is at risk when Legs in Lloyd Davies position?
Common peroneal n
what nerve is at risk w Axillary node clearance?
Long thoracic n
what nerve is at risk for Pelvic cancer surgery?
Pelvic autonomic nerves
what n is at risk During thyroid surgery?
Recurrent laryngeal nerves
what nerve is at risk During carotid endarterectomy?
Hypoglossal nerve
what nerve is at risk during parotidectomy?
facial n
Post splenectomy blood film features?
Howell- Jolly bodies
Pappenheimer bodies
Target cells
Irregular contracted erythrocytes
What is the acceptable upper limit of residual urine in patients < 65 years old?
Post-void volumes <50 ml are normal
What is the acceptable upper limit of residual urine in patients > 65 years old?
< 100ml
Chronic urinary retention is defined by the presence of how much fluid within the bladder after voiding?
>500ml
what metabolic complication may ensue from delivering many Litres of 0.9% NaCl into pt?
hyperchloraemic acidosis
what VTE prophylaxis is used in chronic kidney disease?
Unfractionated heparin
which types of shock will cause warm peripheries?
distributive shock
ie. sepsis, anaphylaxis, neurogenic
what should be coprescribed in the first 2-3 wks of goserelin treatment?
antiandrogen e.g. cyproterone acetate
start 3 days before
goserelin - for breast and prostate ca
initial stimulation of luteinising hormone release by the pituitary gland resulting in increased testosterone levels.
Solitary dermal nodules
Usually affect extremities of young adults
Lesions feel larger than they appear visually
Histologically they consist of proliferating fibroblasts merging with sparsely cellular dermal tissues
Dermatofibroma
epidermoid vs pilar cyst?
Common and affect face and trunk
They have a central punctum, they may contain small quantities of sebum
The cyst lining is either normal epidermis (epidermoid cyst) or outer root sheath of hair follicle (pilar cyst)
. What is the most appropriate advice to give pt about eating and drinking before the operation under GA?
no food for 6h and no clear fluids for 2h before op
side effects of inhaled anaesthetic halothane?
Hepatotoxicity, myocardial depression malignant hyperthermia
Which anatomical landmark will allow the categorisation of a bleed as Upper or Lower GI bleed during urgent endoscopy?
ligament of Treitz
found at the duodenojejunal flexure. It marks the boundary between the first and second parts of the small intestine and is the formal boundary between the upper and lower GI tracts.
What is psoas stretch sign?
Acute retrocaecal appendicitis is indicated when the right thigh is passively extended with the patient lying on their side with their knees extended.
Most common organism causing ascending cholangitis?
E. coli
Commonest cause of chronic pancreatitis?
80% alcohol excess
Investigation of chronic pancreatitis?
AXR: pancreatic calcification in 30%
CT: more sensitive at detecting pancreatic calcification. preferred diagnostic test
functional tests: faecal elastase may be used to assess exocrine function if imaging inconclusive
Mx of ascending cholangitis?
intravenous antibiotics
endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction
Mx of acute cholecystitis?
intravenous antibiotics + early laparoscopic cholecystectomy within 1 week of diagnosis
when assessing trauma patients, what arterial pressure is needed to generate a palpable femoral pulse?
>65 mmHg
B12 deficiency post-gastrectomy?
a consequence of removing of the intrinsic factor secreting cells that reside in the fundus and body of the stomach.
What is Pseudomyxoma peritonei?
most commonly arises from appendix
accumulation of large amounts of mucinous material in the abdominal cavity.
mx of pseudomyxoma peritonei?
usually surgical and consists of cytoreductive surgery (and often peritonectomy) combined with intra-peritoneal chemotherapy with mitomycin C.
Most common organism found in central line infections?
Staphylococcus epidermidis
What is melanosis coli?
disorder of pigmentation of the bowel wall.
Histology demonstrates pigment-laden macrophages
associated w laxative abuse, esp senna
mx of sigmoid volvulus w peritonitis?
urgent midline lap
- to avoid bowel necrosis or perforation
features of acute diverticulitis?
Usually LIF pain
N+V
Change in bowel habit
Urinary freq, urgency, dysuria
PR bleeding
Pneumaturia, faecaluria: colovesical fistula
Most common organism causing perianal abscess?
E. coli
from superficial to deep, what structure runs in the parotid gland?
Facial nerve
Retromandibular vein
External carotid artery
