General Surgical Topics Flashcards
HPB Urology
What are the risk factors for cholelithiasis?
Female Obesity (>30 BMI) Family history of gallstones drugs (exogenous estrogen, ceftriaxone) Pregnancy Diabetes
What is the classic presentation of gallstones (cholelithiasis)
How is best to investigate gallstones?
What is a differential?
Management if asymptomatic?
Management if symptomatic?
Follow up?
- Pain in the upper abdomen or right upper quadrant, lasting for more than 30 minutes, but less than 8 hours. Biliary colic steady, severe >5/10 - simple should resolve within 5 hours
- May be associated with nausea and vomiting
- Postprandial
- No fever
- No Jaundice
Investigate with
- Abdominal ultrasound
- Liver function test
Though both can be normal
Differential includes:
- peptic ulcer disease
- gastritis
- IBS
- GORD
- Tumour
- Bile duct stricture
- Acute hepatitis
Management:
Asymptomatic
if found in a normal biliary tree - explain very common and no treatment required.
Symptomatic:
Surgical referral
Pain relief - diclofenac 75mg IM
IM opioid if above contraindicated
Paracetamol
Avoid trigger foods - until after surgery
FOLLOW UP:
- follow up 2 weeks after (clinic?)
- symptom check
How does cholelithiasis, cholecystitis, choledocholithasis, cholangits, and acute pancreatitis compare in their presentation?
- Cholelithiasis (gallstones in the gallbladder) RUQ or upper abdominal pain which resolves within 5 - 8 hours. No fever, No Jaundice, no leukocytosis
- Cholecystitis (inflammation of the gallbladder due to stones)- biliary pain lasting more than 5 hours accompanied by fever, marked RUQ pain (Murphy’s sign positive)
Leukocytosis, no jaundice - Choledocholithasis, stone obstructing the bile ducts: biliary pain and jaundice.
- Cholangitis - inflammation of common bile duct and gallbladder: CHARCOT’s triad - biliary pain, jaundice and fever - medical emergency
- Acute pancreatitis - epigastric pain radiating to the back due to bile duct stones obstructing the pancreatitic duct - can be peritonitic.
What is the classic presentation of renal stone disease?
What are the first line investigations?
- Acute, severe flank pain that radiates to the ipsilateral groin, may be asymptomatic
- Previous episodes of renal stones
- Nausea and vomiting
- Urinary frequency/urgency - as stones pass and lodge in the ureter or intramural tunnel, irritating the bladder
- Haematuria - microscopic common and rarely macroscopic
- Testicular pain: due to radiating pain
- Obesity (increased BMI is a risk factor)
- Always consider AAA in those >55
- Urinalysis - microhaematuria. infection
- FBC and differential ? Infection
- U & E - kidney function - high calcium may indicate hyperparathyroidism, or hyperuricaemia: gout
- Urine pregnancy test in women before scans
- non-contract helical CT scan - Always check if they have had a recent scan - if so contact the urology Registrar
- Stone analysis
- Consider a plain film X-ray KUB
What are the risk factors for getting renal stones?
- High protein intake
- High salt diet
- White
- Male (10% lifetime risk for men - 7% for women)
- Dehydration ( 2 - 3 litres a day at least)
- Crystalluria (increased calcium oxalate in the urine, increased cystine, struvite and uric acid.
- Obesity
What is the management of renal stones?
What follow up do patients need?
- Main goal is symptomatic relief and hydration
- Analgesia and anti-emetics
- No infection: opioids (tramadol PO or IV) and NSAIDs (Diclofenac PO or PR):
If they require morphine (give after above trial) they are likely to require admission. - Assess for infection (IV ABX/ sepsis 6 which will require immediate urological review for decompression (ureteric stent, percutaneous nephrostomy, but interventional radiology) to reduce risk of life threatening septic shock.
- ? Medical expulsive therapy - alpha blockers and calcium channel blockers for stones < 10 mm.
Follow up:
Follow in the stone clinic:
? CT KUB or Plain film KUB
What are the symptoms of acute prostatitis
What are the risk factors for prostatitis?
What investigations do you need to do?
Lower Urinary Tract Symptoms (LUTS)
- Dysuria
- Frequency
- Perineal discomfort
- Voiding symptoms - diminished calibre of stream, slowing stream.
- Variable systemic signs - fever, chills & malaise.
- Referred pain to the genitalia, perineum and lower back or suprapubic area which are be extreme.
- Ejaculatory pain
- Intensely tender prostate gland which may also be soft, boggy and warm to the touch on DRE (also rules out an anorectal cause)
2/3 <50 1/3 >50
The greatest risk factor is UTI -
Benign Prostatic Hyperplasia
Investigations:
- urinalysis and culture. [MC&S]
- PSA may be elevated
How do you management Acute Prostatitis?
- ABX - quinolones (ciprofloxacin, ofloxacin, levofloxacin)
What is the most common renal cell carcinoma?
What is the most common symptom?
What are the risk factors?
Clear cell renal cell carcinoma (80%)
most commonly asymptomatic and it occurs sporadically - though +ve family history increases risk 4x
R
Risk factors include: Smoker, Male 55+ black obesity HTN FMHx high parity radiation
Diagnostic factors include:
haematuria, palpable abdominal mass
- though it is commonly asymptomatic.
What is an aneurysm?
A focal, permanent dilation of an artery or vessel to more than 50% of its normal diameter.
What is the natural history of aneurysms?
Asymptomatic growth followed by symptomatic rupture which is often fatal
How is an abdominal aortic aneurysm classified?
A dilation of the infra-renal abdominal aorta greater than 3cm.
Patients with AAA < 5.5 cm are under surveillance. Those at or over 5.5 cm should be considered for surgical repair to prevent rupture.
What are the treatments for AAA?
- Open surgical repair
2. Endovascular Aneurysm Repair (EVAR)
Who is affected more by AAA, men or women?
Men (5%)
Women 0.74%
What is the major risk factor for AAA?
What are other risk factors?
Smoking - which far surpasses genetics and all other modifiable risk factors. (x8 risk compared to never smokers for development and also smoking is related to faster AAA growth)
Hypercholesterolaemia
Hypertension (considered though not proven with randomised evidence)
Diabetes is protective against the development and progression of AAA?
