Miscellaneous 3 Flashcards
Differentials for leukoplakia?
Candidiasis SCC Lichen planus Mouth ulcers Frictional keratosis Geographic tongue
Describe leukoplakia?
White patch/plaque on oral mucosa that is a little riased, not painful but can’t be scraped off
What is the significance of leukoplakia?
Pre-malignant for SCC
Stop smoking and alcohol
Commenest head and neck cancer in UK?
SCC
RFs for SCC of the oral cavity?
Smoking, alcohol HIV, EBV, HPV Poor dental hygiene Radiation Betel nut chewing Wood/nickel dust Preserved food intake Being Asian
Common sites of SCC?
Oral cavity Anus Penis/vulva Lung Oesophagus
Lymph drainage of tongue?
Tip = submental nodes
Anterior 2/3 = submandibular nodes
Posterior 1/3 = superior/inferior deep cervical lymph nodes
What are the 4 extrinsic muscles of the tongue? Innervation?
Genio, hyo, stylo and palatoglossus
All hypoglossal except pglossus which is pharyngeal branch of vagus
4 kinds of intrinsic muscles of tongue? Innervation?
Superior and inferior longitudinal
Transverse
Vertical muscles
Hypoglossal
What constitutes a radical neck dissection?
Removal of level 1-5 LNs as well as SCM, IJV and CN11
Nerve supply to anterior and posterior belly of digastric?
Anterior = CN5 - mandibular, inferior alveolar nerve Posterior = CN7 digastric branch
What does the marginal mandibular nerve innervate?
Ipsilateral depressor anguli oris
Ipsilateral labii inferioris
Nerve supply to tongue?
Ant 2/3 - general = lingual nerve from CNV3 mandibular, special = chorda tympani of CN7
Post 1/3 all = glossopharyngeal
Is chemo or radio better for head/neck SCC?
Radio
Define a flap?
Unit of tissue moved from donor to recipient site with its own blood supply intact
What are the 4 muscles of mastication?
Medial and lateral pterygoids
Masseter
Temporalis
Define an ulcer?
Abnormal discontinuatino of a mucous membrane
What do parietal cells of stomach secrete?
HCl
Intrinsic factor
What cells secrete pepsinogen?
Chief cells
What cells secrete gastrin?
G Cells
What cells secret mucous in stomach?
Mucous cells
What stimualtes release of gastric acid?
Vagus activity - PNS
Gastrin from G cells
Histamine from mast cells
What inhibits the release of gastric acid?
Somatostatin, cholecystokinin and secretin
How does H Pylori survive in the stomach? What is it and how is it pathogenic?
Uses flagella to keep away from lumen (and flow), buries through mucosa and into epithelial lining
Produces urease which alkalinizes its microenvironment (ammonia binds H+ to ammonium)
Gram negative bacilus
By infecting the gastric mucosa it creates inflammation and causes hypersecretion of gastric acid via G-cell and gastrin overactivity, also ammonium is toxic
3 tests for H Pylori?
CLO - campylobacter like organisms - at biopsy (organisms converts urea to ammonia and CO2)
C13 breath test - similar principle
Stool antigen
Treatment for H Pylori?
Tripel therapy - PPI, 2 abx e.g. amox and met/met and clari depending on local senstivities
Why might someone with hyperparathyroidism get peptic ulceration?
‘Groans’ - causes acid stimulation
How do PPIs work?
Blockc action of H/K ATPase in parietal cells
Treatment for low grade MALT lymphoma?
H Pylori edrication
RFs for gastric cancer?
H Pylori
Chronic atrophic gastritis with intestinal metaplasia
Prev gastric adenomatous polyps or prev gastrectomy, nitrosamines
Spread of gastric cancer?
Lymph - local then supraclavic incl virchow
Directly to omenta, pancreas, diaphragm, duodenum, transverse colon
Blood - lung/liver
For what lesions is a subtotal gastrectomy useful?
Distal gastric lesion
3 red flag criteria for 2ww endoscopy ?gastric/oesophageal cancer?
New dysphagia
Upper abdominal mass
Over 55 with weight loss and at least 1 of upper abdominal pain, dyspepsia or reflux
Is H Pylori more commonly associated with gastric or duodenal ulcers?
Duodenal
Where does gastroduodenal artery come from and what are its terminal branches?
Common hepatic artery
Right gastroepiploic artery, and superior pancreaticoduodenal artery
What are Bilroth 1 and 2 operations?
Reconstructive surgery post antrectomy/partial gastrectomy
1 - gastroduodenostomy
2 - gastrojejunostomy
What effect does vagotomy have on gastric emptying?
Increases it
What epithelium lines biliary ducts?
Columnar
What is the most common cancer of biliary tree? What is it histologically?
CholangioCa
Adenocarcinoma (from columnar ep)
Most common causes of cholangioCa in UK?
PSC
Chronic liver diease
HIV
Most common causes of cholangioCa in developing world?
Liver fluke
What is a Klatskin tumour?
Cholangiocarcinoma originating at junction of left and right hepatic ducts
Difference between PBC and PSC?
PBC = associated with AMA, affects interlobular bile ducts. chronic granulomatous inflammation. PSC = inflammation and strictures of intra and extrahepatic biliary tree. associated with IBD (UC) and HIV
5 functions of the spleen?
Immune response - white pulp Circulatory filtration - red pulp Storage of platelets Haematopoeisis in fetus Iron reutilisation
How big is a normal spleen?
10cm, 150g
Grading system for splenic injury?
AAST
1 - less than 1cm or haemtoma less than 10% SA
2 - 1-3cm or 10-50%
3 - over 3cm, over 50% or involving trabecular vessels
4 - involving hilar/segmental vessels
5 - shattered spleen, intraperitoneal haemorrhage or devasculrisation
Complications of splenectomy?
Immediate - haemorrhage
Early - gastric necrosis or ileus, subphrenic abscess, pancreatitis
Late - pancreatic fistula, immunosuppression, thrombocytosis and clot risk
Antibiotics prophylaxis post splenectomy?
For at least 2 years or until age 16; lifelong if imunosupressed
Give pen V or amox, or clari if pen allergic
+ ‘rescue’ broad spec abx
Vaccines for post splenectomy patients? Timing?
Pneumococcal HiB vasccine Meningococcal Annaul flu At least 2 weeks before if elective, or at least 2 weeks after if emergency
4 blood film features post splenectomy?
Increased platelets count
Howell Jolly - red cell remantns w platelets
Pappenheimer bodies - granules of siderocytes containing iron
Target cells
4 areas of differentials for splenomegaly?
Infective - EBV, CMV, HIV, malaria, TB
Increased portal pressure - cirrhosis, portal vein thrombosis
Haem disease - haemolytic anaemias, myeloprolifertive disorders, sickle cell, thalassaemia, leukaemia/lymphoma
Systemic disease - Gaucher, amyloid, sarcoid, RA (Feltys)
Lifetime risk of ulcer disease if you have H Pylori? Lifetime risk of cancer with H Pylori?
10-20%
1-2%
Tumour markers for seminoma?
Placental ALP
sometimes BhcG
5 uses of tumour markers?
Screening - e.g. AFP in cirrhotics
Diagnosis - e.g. Ca125
Monitoring response to treatment e.g. thyroglobulin post thyroidectomy
Measuring for recurrence e.g. PSA
Severity of underlying disease e.g. CA15-3 rarely elevated in localised breast Ca but often high ni metastatic Ca
3 point immobilsation for C spine?
Sandbags/blocks
Tape
Hard collar
What are the 5 areas of haemrroahge as per ATLS?
Chest Abdomen Pelvis Long bones Floor
Define shock?
Inadequate tissue perfusion to meet metabolic requirements
Discuss classes of haemorrhagic shock?
Class 1 = 0-15% circulation loss, normal obs
Class 2 = 15-30%, tachypnoae and tachycardia but normal BP
Class 3 = 30-40%, hypotensive with pulse less than 140
Class 4 = over 40%, hypotensive, tachy over 140, confused/lethargic and anuric
Normal circulating volume of e.g. 70kg man?
5L
What causes TURP syndrome? Why does it happen?
Dilutional hyponatraemia from large volume hypotonic glycine-rich irrigation system
Because can’t use saline as it limits diathermy use
Pathophysiology of TURP syndrome?
Dilutional hyponatraemia occurs due to large volume hypotonic irrigation
Hyponatraemia causes cerebral oedema
Also as glycine is broken down it is turned into ammonia and can cause encephalopathy
How to prevent and manage TURP syndrome?
Reduce glycine time to 1 hour max
If op going longer than this, change irrigation fluid to 0.9% NACl and insert 3 way catheter
Also minimise exposure to open venous sinuses during surgery
Consider fluid restrcition and ICU support
How and where does furosemide work?
Loop diuretic acting on thick ascending loop of Henle, blocking Na/K/2Cl pump and preventing Na resorption (therefore preventing concentration of urine)
2nd line management of significant GI bleed secondary to varices if endoscopic first line fails?
Sengstaken Blakemore tube
Terlipressin/ocrtreotide - vasoconstric mesenteric vessels - not in severe hypovollaemia or cardiovascular disease
How long does a Sengstaken Blakemore tube stay in?
Deflate and assess after 24 hours - if bleeding stops remove 48 hours after insertion
Leave inflated for another 24 hours if not controlled
3 complications of Sengstaken Blakemore tube?
Oesophageal perforation
Ischaemic necrosis of oesophageal mucosa
Aaspiration pneumona
Normal portal system pressure?
Less than 10mmHg
Rule of 2/3 in portal hypertension?
2/3 of cirrhotics get portal hypertension
2/3 of portal hypertensives get oesophageal varices
2/3 of oesophageal varices present with acute bleeding
6 areas of portosystemic anastomosis?
Lower oesophageus Umbilicus Bare area of liver Retroperitoneum Patent ductus venosus Upper anal canal
Rectal blood supply?
SRA = from IMA MRA = from internal iliac IRA = from internal pudendal
Venous drainage of rectum?
SRV to IMV then splenic vein then portal vein
Middle/distal to iliac vein then IVC
Hence is a site of portocaval anastomosis
4 options for uncontrolled variceal bleeding?
Repeat sclerotherapy, conservative management
TIPS - transjugular intrahepatic portosystemic shunt
Surgical shunt
Liver transplant
Describe TIPS procedure?
Transjugular intrahepatic portosystemic shunt
IJV cannulated using US and hepatic vein accessed
Stent inserted between hepatic vein and branch of portal vein to reduce portal pressure
Problems associated with TIPS procedure?
Encephalopathy - due to diversion of portal contents away from liver
Stent blockage - 50% after 1 year
Role of terlipressin in variceal bleed?
Can be started at presentation as long as not in severe hypovolaemic shock or severe heart failure
Continue until definitive haemostasis or after 5 days
Role of prophylactic antibiotics in variceal bleed?
Give - reduces mortality
Define sepsis?
Life-threatending organ dysfunction due to dysregulated host response to infection
Define septic shock?
Sepsis plus MAP less than 65mmHg and lactate over 2, despite adequate fluid resuscitation
Pathophysiology of DIC?
Pathological activation of coagulation cascade and consumption of clotting factors, causing diffuse thrombosis and end vessel occlusion alongside increased bleeding tendency e.g. from mucosa
How does aspirin work?
Cyclo-oxygenase inhibitor, reducing thromboxane A2 and subsequent platelet aggregation
How does clopidogrel work?
Inhibits ADP receptor on platelet membranes to reduce platelet aggregation
Differentials for abdo pain in elderly?
Cancer Diverticulitis, abscess, stricture etc. Obstruction due to above or volvulus Perforation Inflammatory bowel disease
When are diverticular abscesses managed conservatively vs surgically?
3cm or less = conservative with abx
Larger than 3cm = drainage - radiologically/percutaneously or open/lap
Triad of fat embolism?
Respiratory distress, cerebral features and petechial rash
Non-traumatic causes of fat embolism syndrome?
Bone marrow transplant Liposuctionn Acute pancreatitis Bypass Fat necrosis of omentum Sickle cell crisis Bone tumour lysis Parenteral lipid infusion Surgery - IM nailing
When does fat embolism syndrome present?
Within 12-72 hours post injury
Brain imaging of choice for fat embolism syndrome?
MRI - normal MRI essentially rules out
What fluid is useful in fat embolism syndrome?
Albumin solution
Sometimes IV ethanol, dextran 40, heparin
What measures may present development of fat embolism syndrome?
EArly fixation/immobilisation of long bone fractures within 24 hours of onset
Early steroids and CPAP
Specific orthopaedic surgical measures
Equation governing acid base balance? What mediates it?
Henderson Hasselbach, mediated by carbonic anhydrase
3 ways CO2 is transported in blood?
Dissolved in solution
Buffered with water as carbonic acid (Henderson Hasselbach)
Bound to proteins - Hb
What is the chloride shift?
Shift occuring in cells whereby Cl is slighly higher in arterial blood than venous, as it is substituted for bicarb to facilitate CO2 excretion
What is a buffer and what are the 2 most common blood buffers?
Mixture of weak acid and weak base, which can resist changes in pH
In blood these are bicarbonate and haemoblobin
6 causes of normal AG acidosis?
Renal tubular acidosis Tubular damage Diarrhoea Ileostomy high output HyperPTH Hypoaldosterone
Causes of metabolic alkalosis?
Vomiting Use of diuretics Low chloride states Renal loss of H Excess antacids
What is ARDS?
Clinical syndrome of acute respiratory failure and non-cardiogenic pulmonary oedema, leading to hypoxaemia and reduced lung compliance refractory to oxygen therapy
Criteria for ARDS?
Diffuse bilateral pulmonary infiltrates on CXR
Normal pulm art wedge pressure
Reduced Pa/FiO2 ratio
Causes of ARDS?
Lung vs non-lung
Lung = pneumonia, aspiration, pulmonary contusions, fat embolism, smoke inhalation, near drowning
Non-lung = acute pancreatitis, polytrauma, sepsis, massive transfusion, DIC, bypass
Management of ARDS?
Treat underlying cause
ICU - high PEEP if I+V
Proning - reduces atelectasis and improves V/Q
Query drugs e.g. steroids
Biochemical findings suggestive of gastric outlet obstruction?
Hyponatraemia, hypokalaemia, hypochloraemic metabolic alkalosis
AKI
Causes of gastric outlet obstruction?
Benign vs malignant
Benign e.g. pyloric stenosis, ulcer disease, foreign body
Malignant - gastric or duodenal cancer, pancreatic cancer
ECG changes in hypokalaemia?
Flat/inverted T waves
U waves
ST depression
Prolonged PR interval
Indications for renal replacement therapy?
Persistent hyperkalaemia Anuria Severe acidosis Refractory fluid overload Uraemic complications e.g. pericarditis, encephalopathy Drug overdose (rarely) temperature control
HLA matching minimses the risk of what type of tranplant reaction?
Acute
Types of transplant reaction and mechanisms?
Hyperacute - preformed antibodies against tissue
Acute - T cell mediated
Chronic - mechanism unclear
What equivalent dose of steroids mandates cover for surgery?
5mg per day prednisolone
5 things screened for in blood transfusion?
HIV, Hep C/B, syphilis, HTLV (first time)
What does FFP contain?
albumin complement all clotting factors fibrinogen vWF
What does cryyoprcipitate contain?
Factor 8, 13
Fibrinogen
vWF
Red flags when assessing tracheostomy airway?
If cuff up - gurgling, bubbling or vocalisation from mouth
Visibly displaced tube
Respiratory distress
Key components of tracheostomy box?
Trache tube of same size Trache tube 1 size smaller Spare inner tubes Resus bag and mask Suction and suction catheters 0.9% NaCl and syringe to moiisten plug Scissors and tape
How do you manage a trache with no air coming out of it?
2222, airway emergency
High flow O2 over mask and face
Remove speaking valve/cap and inner tube if present
Try to pass suction catheter and suction if able
Deflate cuff if catheter doesn’t pass
If still obstructed - take out
How would you ventilate a trache patient with intact larynx if trache malfunctinos and unable to clear? How would this differ if trache with laaryngectomy?
Take it out, cover with gauze/tape and ventilate via mouth and nose
If laryngectomy, use LMA/paeds face mask over stoma
5 early complications of tracheostomy paitnets post insertion?
Bleeding Pneumothroax Dislodged tube or false passage Subcutaneous/mediastinal emphysema Tracheooesophageal fistula
Variations of tracheostomy tubes?
Single or double lumen
Fenestrated or unfenestrated
Cuffed or uncuffed
