Orthopaedics, gen surg Flashcards

Question

What is the Garden classification used for?

Answer 1

The Garden classification is used for intra-capsular neck of femur fractures: Grade I – incomplete fracture and non-displaced Grade II – complete fracture and non-displaced Grade III – partial displacement (trabeculae are at an angle) Grade IV – full displacement (trabeculae are parallel)

Answer 2

Hemiarthroplasty involves replacing the head of the femur but leaving the acetabulum (socket) in place. Cement is used to hold the stem of the prosthesis in the shaft of the femur. This is generally offered to patients who have limited mobility or significant co-morbidities.

Answer 3

Shortened, abducted and externally rotated leg

Answer 4

Shenton’s line can be seen on an AP x-ray of the hip. It is one continuous curving line formed by the medial border of the femoral neck and continues to the inferior border of the superior pubic ramus. Disruption of Shenton’s line is a key sign of a fractured neck of femur (NOF).

Answer 5

Acute compartment syndrome presents with the 5 P’s: P – Pain “disproportionate” to the underlying injury, worsened by passive stretching of the muscles P – Paresthesia P – Pale P – Pressure (high) P – Paralysis (a late and worrying feature) Note that pulseless is not a feature, differentiating it from acute limb ischaemia. The pulses may remain intact depending on which compartment is affected.

Answer 6

Chronic compartment syndrome (also called chronic exertional compartment syndrome) is usually associated with exertion. During exertion, the pressure within the compartment rises, blood flow to the compartment is restricted, and symptoms start. During rest, the pressure falls, and symptoms begin to resolve. It is not an emergency. Symptoms are usually isolated to a specific location at the affected compartment. Symptoms include pain, numbness or paresthesia (pins and needles). They are made worse by increasing activity and resolve quickly with rest.

Answer 7

Needle manometry can be used to measure the pressure in the compartment before, during and after exertion to confirm the diagnosis. It may be treated with a fasciotomy.

Answer 8

Periosteal reaction (changes to the surface of the bone) Localised osteopenia (thinning of the bone) Destruction of areas of the bone Nothing in early disease

Answer 9

Surgical debridement of the infected bone and tissues Antibiotic therapy

Answer 10

Staph auerus

Answer 11

Haematogenous osteomyelitis refers to when a pathogen is carried through the blood and seeded in the bone. This is the most common mode of infection. Alternatively, osteomyelitis can occur due to direct contamination of the bone, for example, at a fracture site or during an orthopaedic operation.

Answer 12

Osteosarcoma

Answer 13

The spinal nerves L4 – S3 come together to form the sciatic nerve.

Answer 14

The sciatic nerve supplies sensation to the lateral lower leg and the foot. It supplies motor function to the posterior thigh, lower leg and foot. Sciatica causes unilateral pain from the buttock radiating down the back of the thigh to below the knee or feet.

Answer 15

Cauda equina syndrome

Answer 16

The sciatic stretch test can be used to help diagnose sciatica. The patient lies on their back with their leg straight. The examiner lifts one leg from the ankle with the knee extended until the limit of hip flexion is reached (usually around 80-90 degrees). Then the examiner dorsiflexes the patient’s ankle. Sciatica-type pain in the buttock/posterior thigh indicates sciatic nerve root irritation. Symptoms improve with flexing the knee.

Answer 17

Emergency MRI scan within four hours

Answer 18

Inflammatory markers (CRP and ESR) X-ray of the spinal and sacrum (may show a fused “bamboo spine” in later-stage disease) MRI of the spine (may show bone marrow oedema early in the disease)

Answer 19

The STarT Back tool was developed by Keele University to stratify the risk of a patient presenting with acute back pain developing chronic back pain.

Answer 20

Benzodiazepines (e.g., diazepam) for muscle spasm (short-term only – up to 5 days)

Answer 21

Mostly the same as acute low back pain. No opioids They suggest considering a neuropathic medication if symptoms are persisting or worsening at follow up, but not gabapentin or pregabalin, leaving at the main choices of: Amitriptyline Duloxetine

Answer 22

The cauda equina (translated as “horse’s tail”) is a collection of nerve roots that travel through the spinal canal after the spinal cord terminates around L2/L3. The spinal cord tapers down at the end in a section called the conus medullaris. The nerve roots exit either side of the spinal column at their vertebral level (L3, L4, L5, S1, S2, S3, S4, S5 and Co).

Answer 23

Saddle anaesthesia (loss of sensation in the perineum – around the genitals and anus) Loss of sensation in the bladder and rectum (not knowing when they are full) Urinary retention or incontinence Faecal incontinence Bilateral sciatica Bilateral or severe motor weakness in the legs Reduced anal tone on PR examination

Answer 24

MSCC presents similarly to cauda equina, with back pain and motor and sensory signs and symptoms. A key feature is back pain that is worse on coughing or straining.

Answer 25

When a metastatic lesion compresses the spinal cord (before the end of the spinal cord and the start of the cauda equina), this is called metastatic spinal cord compression (MSCC). This is different to cauda equina, which specifically refers to compression of the cauda equina.

Answer 26

Cauda equina presents with lower motor neuron signs (reduced tone and reduced reflexes). The nerves being compressed are lower motor neurons that have already exited the spinal cord. When the spinal cord is being compressed higher up by metastatic spinal cord compression, upper motor neuron signs (increased tone, brisk reflexes and upping plantar responses) will be seen.

Answer 27

Meralgia paraesthetica refers to localised sensory symptoms of the outer thigh caused by compression of the lateral femoral cutaneous nerve. It is a mononeuropathy, meaning it only affects a single nerve.

Answer 28

Patients present with abnormal sensations (dysaesthesia) and loss of sensation (anaesthesia) in the lateral femoral cutaneous nerve distribution. The skin of the upper-outer thigh is affected. Patients may describe symptoms of: Burning Numbness Pins and needles Cold sensation Often aggravated by walking or standing for a long duration and improve on sitting down

Answer 29

Symptoms are often worse with extension of the hip on the affected side. This can be used to reproduce symptoms on examination.

Answer 30

Trochanteric bursitis refers to inflammation of a bursa over the greater trochanter on the outer hip. It produces pain localised at the outer hip, referred to as greater trochanteric pain syndrome.

Answer 31

Bursae are sacs created by synovial membrane filled with a small amount of synovial fluid. They are found at bony prominences (e.g., at the greater trochanter, knee, shoulder and elbow). They act to reduce friction between the bones and soft tissues during movement.

Answer 32

The typical presentation is a middle-aged patient with gradual-onset lateral hip pain (over the greater trochanter) that may radiate down the outer thigh. The pain is described as aching or burning. It is worse with activity, standing after sitting for a prolonged period and trying to sit cross-legged. It may disrupt sleep and be difficult to find a comfortable lying position.

Answer 33

Tenderness over the greater trochanter

Answer 34

The Trendelenburg test involves asking the patient to stand one-legged on the affected leg. Normally, the other side of the pelvis should remain level or tilt upwards slightly. A positive Trendelenburg test is when the other side of the pelvis drops down, suggesting weakness in the affected hip.

Answer 35

Trendelenburg test Resisted abduction of the hip Resisted internal rotation of the hip Resisted external rotation of the hip

Answer 36

R – Rest I – Ice C – Compression E – Elevation

Answer 37

Osgood-Schlatter disease is caused by inflammation at the tibial tuberosity where the patella ligament inserts. It is a common cause of anterior knee pain in adolescents. It typically occurs in patients aged 10 – 15 years and is more common in males. Osgood-Schlatter disease is usually unilateral, but it can be bilateral.

Answer 38

The patella tendon inserts into the tibial tuberosity. In patients with Osgood-Schlatter disease, multiple minor avulsion fractures occur where the patella ligament pulls away tiny pieces of the bone. This leads to growth of the tibial tuberosity, causing a visible lump below the knee. Initially, this lump is tender due to inflammation. As the bone heals and inflammation settles, the lump becomes hard and non-tender. A hard, non-tender lump is then permanently present at the tibial tuberosity.

Answer 39

Baker’s cysts are also called popliteal cysts. A Baker’s cyst is a fluid-filled sac in the popliteal fossa, causing a lump.

Answer 40

Degenerative changes in the knee joint. Synovial fluid is squeezed out of the knee joint and collects in the popliteal fossa. A connection between the synovial fluid in the joint and the Baker’s cyst can remain, allowing the cyst to continue enlarging as more fluid collects there.

Answer 41

On examination, the lump will be most apparent when the patient stands with their knees fully extended. The lump will get smaller or disappear when the knee is flexed to 45 degrees

Answer 42

Ultrasound is usually the first-line investigation to confirm the diagnosis. It is also used to rule out a DVT.

Answer 43

The Achilles tendon connects the calf muscles (gastrocnemius and soleus) to the heel (the calcaneus bone). Flexion of the calf muscles pulls on the Achilles and causes plantar flexion of the ankle.

Answer 44

Fluoroquinolone antibiotics (e.g., ciprofloxacin and levofloxacin)

Answer 45

The patient is positioned prone or kneeling with the feet hanging freely off the end of the bench or couch. When squeezing the calf muscle in a leg with an intact Achilles, there will be plantar flexion of the ankle. Squeezing the calf pulls on the Achilles. When the Achilles is ruptured, the connection between the calf and the ankle is lost. Squeezing the calf will not cause plantar flexion of the ankle in a leg with a ruptured Achilles. A lack of plantar flexion is a positive result.

Answer 46

The plantar fascia is thick connective tissue. It attaches to the calcaneus at the heel, travels along the sole of the foot and branches out to connect to the flexor tendons of the toes.

Answer 47

Morton’s neuroma refers to the dysfunction of a nerve in the intermetatarsal space (between the toes) towards the top of the foot. The abnormal nerve is usually located between the third and fourth metatarsal. It is caused by irritation of the nerve relating to the biomechanics of the foot. High-heels or narrow shoes may exacerbate it.

Answer 48

Pain at the front of the foot at the location of the lesion The sensation of a lump in the shoe Burning, numbness or “pins and needles” felt in the distal toes

Answer 49

Deep pressure applied to the affected intermetatarsal space on the dorsal foot causes pain Metatarsal squeeze test – squeezing the forefoot with one hand to create a concave shape to the plantar aspect while using the other hand to press the affected area on the plantar side of the foot causes pain Mulder’s sign – a painful click is felt when using two hands on either side of the foot to manipulate the metatarsal heads to rub the neuroma

Answer 50

Painful phase – shoulder pain is often the first symptom and may be worse at night Stiff phase – shoulder stiffness develops and affects both active and passive movement (external rotation is the most affected) – the pain settles during this phase Thawing phase – there is a gradual improvement in stiffness and a return to normal

Answer 51

Supraspinatus tendinopathy involves inflammation and irritation of the supraspinatus tendon, particularly due to impingement at the point where it passes between the humeral head and the acromion. The empty can test (AKA Jobe test) can be used to assess for supraspinatus tendinopathy.

Answer 52

This involves the patient abducting the shoulder to 90 degrees and fully internally rotating the arm as though they are emptying a can of water. The examiner pushes down on the arm while the patient resists. The test is positive if there is pain or the arm gives way.

Answer 53

Acromioclavicular (AC) joint arthritis can be demonstrated on examination by: Positive scarf test – pain caused by wrapping the arm across the chest and opposite shoulder

Answer 54

The rotator cuff is made of four muscles, each with a specific action at the shoulder (mnemonic is SITS): S – Supraspinatus – abducts the arm I – Infraspinatus – externally rotates the arm T – Teres minor – externally rotates the arm S – Subscapularis – internally rotates the arm

Answer 55

Electric shocks and seizures

Answer 56

More than 90% of shoulder dislocations are anterior dislocations. This is where the head of the humerus moves anteriorly (forward) in relation to the glenoid cavity.

Answer 57

Axillary nerve damage is a key complication. The axillary nerve comes from the C5 and C6 nerve roots. Damage causes a loss of sensation in the “regimental badge” area over the lateral deltoid. It also leads to motor weakness in the deltoid and teres minor muscles.

Answer 58

Olecranon bursitis refers to inflammation and swelling of the bursa over the elbow. The olecranon is the bony lump at the elbow, which is part of the ulna bone. Olecranon bursitis is sometimes called “student’s elbow”

Answer 59

Repetitive strain injury is an umbrella term that refers to soft tissue irritation, microtrauma and strain resulting from repetitive activities

Answer 60

Epicondylitis refers to inflammation at the point where the tendons of the forearm insert into the epicondyles at the elbow. It is a specific type of repetitive strain injury.

Answer 61

The tendons of the muscles that insert into the: Medial epicondyle act to flex the wrist Lateral epicondyle act to extend the wrist

Answer 62

Lateral epicondylitis is often called tennis elbow. Lateral epicondylitis causes pain and tenderness at the lateral epicondyle (outer elbow). The pain often radiates down the forearm. It can lead to weakness in grip strength.

Answer 63

Medial epicondylitis is often called golfer’s elbow. Medial epicondylitis causes pain and tenderness at the medial epicondyle (inner elbow). The pain often radiates down the forearm. It can lead to weakness in grip strength.

Answer 64

De Quervain’s tenosynovitis is a condition where there is swelling and inflammation of the tendon sheaths in the wrist.

Answer 65

Finkelstein’s test (or maybe Eichhoff’s test) involves the patient making a fist with their thumb inside their fingers. Then, the wrist is adducted (ulnar deviation), causing strain on the APL and EPB tendons. If this movement causes pain at the radial aspect of the wrist, the test is positive, indicating De Quervain’s tenosynovitis.

Answer 66

Trigger finger is a condition causing pain and difficulty moving a finger. It is also known as stenosing tenosynovitis.

Answer 67

The typical presentation is with a troublesome finger, that: Is painful and tender (usually around the MCP joint on the palm-side of the hand) Does not move smoothly Makes a popping or clicking sound Gets stuck in a flexed position Symptoms are often worse in the morning and improve throughout the day

Answer 68

The table-top test is a straightforward test for Dupuytren’s contracture. The patient tries to position their hands flat on a table. If the hand cannot rest completely flat, the test is positive, indicating Dupuytren’s contracture.

Answer 69

In Dupuytren’s contracture, the fascia of the hands becomes thicker and tighter and develops nodules. Cords of dense connective tissue can extend into the fingers, pulling the fingers into flexion and restricting their ability to extend (contracture).

Answer 70

Carpal tunnel syndrome is caused by compression of the medial nerve as it travels through the carpal tunnel in the wrist, causing pain and numbness in the median nerve distribution on the hand.

Answer 71

Ganglion cysts are sacs of synovial fluid that originate from the tendon sheaths or joints. They commonly occur in the wrist and fingers but can occur anywhere there is a joint or tendon sheath. Ganglion cysts are thought to occur when the synovial membrane of the tendon sheath or joint herniates, forming a pouch. Synovial fluid flows from the tendon sheath or joint into the pouch, forming a cyst (a fluid-filled sac).

Answer 72

The American Society of Anesthesiologists (ASA) grading system classifies the physical status of the patient for anaesthesia. Patients are given a grade to describe their current fitness prior to undergoing anaesthesia/surgery: ASA I – normal healthy patient ASA II – mild systemic disease ASA III – severe systemic disease ASA IV – severe systemic disease that constantly threatens life

Answer 73

Fasting for an operation typically involves: 6 hours of no food or feeds before operation 2 hours no clear fluids (fully “nil by mouth”)

Answer 74

Oestrogen-containing contraception (e.g., the combined contraceptive pill) or hormone replacement therapy (e.g., in perimenopausal women) need to be stopped 4 weeks before surgery to reduce the risk of venous thromboembolism (NICE guidelines 2010).

Answer 75

Sulfonylureas (e.g., gliclazide) can cause hypoglycaemia and are omitted until the patient is eating and drinking Metformin is associated with lactic acidosis, particularly in patients with renal impairment SGLT2 inhibitors (e.g., dapagliflozin) can cause diabetic ketoacidosis in dehydrated or acutely unwell patients

Answer 76

Continue a lower dose (BNF recommends 80%) of their long-acting insulin Stop short-acting insulin whilst fasting or not eating, until eating and drinking again Have a variable rate insulin infusion alongside a glucose, sodium chloride and potassium infusion (“sliding-scale”) to carefully control their insulin, glucose and potassium balance

Answer 77

Removal of a catheter is called a trial without catheter (TWOC). It is called this as there is a risk the patient will find it difficult to pass urine normally and go into urinary retention, and the catheter may need to be reinserted for a period before removal can be tried again. This is quite common, more so in male patients.

Answer 78

Total parenteral nutrition (TPN) involves meeting the full ongoing nutritional requirements of the patient using an intravenous infusion of a solution of carbohydrates, fats, proteins, vitamins and minerals. This is used where it is not possible to use the gastrointestinal tract for nutrition.

Answer 79

TPN is very irritant to veins and can cause thrombophlebitis, so is normally given through a central line rather than a peripheral cannula.

Answer 80

Peritonitis Ruptured abdominal aortic aneurysm Intestinal obstruction Ischaemic colitis

Answer 81

Biliary colic Acute cholecystitis Acute cholangitis

Answer 82

Acute gastritis Peptic ulcer disease Pancreatitis Ruptured abdominal aortic aneurysm

Answer 83

Acute appendicitis Ectopic pregnancy Ruptured ovarian cyst Ovarian torsion Meckel’s diverticulitis

Answer 84

Diverticulitis Ectopic pregnancy Ruptured ovarian cyst Ovarian torsion

Answer 85

Lower urinary tract infection Acute urinary retention Pelvic inflammatory disease Prostatitis

Answer 86

Renal colic (kidney stones) Ruptured abdominal aortic aneurysm Pyelonephritis

Answer 87

Guarding – involuntary tensing of the abdominal wall muscles when palpated to protect the painful area below Rigidity – involuntary persistent tightness / tensing of the abdominal wall muscles Rebound tenderness – rapidly releasing pressure on the abdomen creates worse pain than the pressure itself Coughing test – asking the patient to cough to see if it results in pain in the abdomen Percussion tenderness – pain and tenderness when percussing the abdomen

Answer 88

The lining of the abdomen

Answer 89

Gives an indication of inflammation of the pancreas in acute pancreatitis.

Answer 90

Serum lactate gives an indication of tissue ischaemia. It is a product of anaerobic respiration and can also be raised in dehydration or hypoxia.

Answer 91

Palpation of the left iliac fossa causes pain in the RIF

Answer 92

Increased pain when suddenly releasing the pressure of deep palpation

Answer 93

Meckel’s diverticulum is a malformation of the distal ileum that occurs in around 2% of the population. It is usually asymptomatic and does not require any treatment. However, it can bleed, become inflamed, rupture or cause a volvulus or intussusception.

Answer 94

Mesenteric adenitis describes inflamed abdominal lymph nodes. It presents with abdominal pain, usually in younger children, and is often associated with tonsillitis or an upper respiratory tract infection. No specific treatment is required.

Answer 95

The gastrointestinal tract secretes fluid that is later absorbed in the colon. When there is an obstruction, and fluid cannot reach the colon, it cannot be reabsorbed. As a result, there is fluid loss from the intravascular space into the gastrointestinal tract. This leads to hypovolaemia and shock. This abnormal loss of fluid is referred to as third-spacing. The higher up the intestine the obstruction, the greater the fluid losses as there is less bowel over which the fluid can be reabsorbed.

Answer 96

Adhesions Hernias Malignancy

Answer 97

The key x-ray finding in bowel obstruction is distended loops of bowel. The upper limits of the normal diameter of bowel are: 3 cm small bowel 6 cm colon 9 cm caecum A contrast abdominal CT scan is usually required to confirm the diagnosis of bowel obstruction and establish the site and cause of the obstruction. It can also be used to diagnose an intra-abdominal perforation, if present.

Answer 98

Electrolyte imbalances (U&Es) Metabolic alkalosis due to vomiting stomach acid (venous blood gas) Bowel ischaemia (raised lactate – either on a venous blood gas or laboratory sample)

Answer 99

Ileus is a condition affecting the small bowel, where the normal peristalsis that pushes the contents along the length of the intestines, temporarily stops.

Answer 100

Sigmoid volvulus is more common and tends to affect older patients. Caecal volvulus is less common and tends to affect younger patients. The twist occurs in the caecum.

Answer 101

Coffee bean sign, where the dilated and twisted sigmoid colon looks like a giant coffee bean

Answer 102

Endoscopic decompression can be attempted in patients with sigmoid volvulus (without peritonitis). A flexible sigmoidoscope is inserted carefully, with the patient in the left lateral position, resulting in a correction of the volvulus. A flatus tube / rectal tube is left in place temporarily to help decompress the bowel and is later removed. There is a risk of recurrence (around 60%).

Answer 103

Haemorrhoids are enlarged anal vascular cushions. It is not clear why they become enlarged and swollen, but they are often associated with constipation and straining.

Answer 104

The anal cushions are specialised submucosal tissue that contain connections between the arteries and veins, making them very vascular. They are supported by smooth muscle and connective tissue. They help to control anal continence, along with the internal and external sphincters. The blood supply is from the rectal arteries.

Answer 105

1st degree: no prolapse 2nd degree: prolapse when straining and return on relaxing 3rd degree: prolapse when straining, do not return on relaxing, but can be pushed back 4th degree: prolapsed permanently

Answer 106

Haemorrhoids may be asymptomatic. They are often associated with constipation and straining. A common presentation is with painless, bright red bleeding, typically on the toilet tissue or seen after opening the bowels. The blood is not mixed with the stool

Answer 107

Anal fissures Diverticulosis Inflammatory bowel disease Colorectal cancer

Answer 108

Anusol (contains chemicals to shrink the haemorrhoids – “astringents”)

Answer 109

Prevent and tx constipation

Answer 110

Management is with increased fibre in the diet and bulk-forming laxatives (e.g., ispaghula husk). Stimulant laxatives (e.g., Senna) should be avoided. Surgery to remove the affected area may be required where there are significant symptoms.

Answer 111

Pain and tenderness in the left iliac fossa / lower left abdomen Fever Diarrhoea Nausea and vomiting

Answer 112

Oral co-amoxiclav (at least 5 days) Analgesia (avoiding NSAIDs and opiates, if possible) Only taking clear liquids (avoiding solid food) until symptoms improve (usually 2-3 days) Follow-up within 2 days to review symptoms

Answer 113

Contrast CT is the diagnostic test of choice, allowing the radiologist to assess both the bowel and the blood supply.

Answer 114

Acute mesenteric ischaemia presents with acute, non-specific abdominal pain. The pain is disproportionate to the examination findings. Patients can go on to develop shock, peritonitis and sepsis.

Answer 115

Over 40 years with abdominal pain and unexplained weight loss Over 50 years with unexplained rectal bleeding Over 60 years with a change in bowel habit or iron deficiency anaemia

Answer 116

An indication for a “two week wait” cancer referral for colonoscopy and gastroscopy (“top and tail”) for GI malignancy. This is because GI malignancies such as bowel cancer can cause microscopic bleeding (not visible in bowel movements) that eventually lead to iron deficiency anaemia.

Answer 117

Faecal immunochemical tests (FIT) look very specifically for the amount of human haemoglobin in the stool.

Answer 118

A colostomy is where the large intestine (colon) is brought onto the skin. Colostomies drain more solid stools, as much of the water is reabsorbed in the remaining large intestine. They can be flatter to the skin (compared with ileostomies which have a spout), as the solid contents are less irritating to the surrounding skin. They are typically located in the left iliac fossa (LIF).

Answer 119

An ileostomy is where the end portion of the small bowel (ileum) is brought onto the skin. Ileostomies drain more liquid stools, as the fluid content is normally reabsorbed later, in the large intestine. They have a spout, which allows them to drain directly into a tightly fitting stoma bag without the contents coming into contact with the surrounding skin. They are typically located in the right iliac fossa (RIF).

Answer 120

Fat Fair Female Forty

Answer 121

Fat entering the digestive system causes cholecystokinin (CCK) secretion from the duodenum. CCK triggers contraction of the gallbladder, which leads to biliary colic. Patients with gallstones and biliary colic are advised to avoid fatty foods to prevent CCK release and gallbladder contraction.

Answer 122

Biliary obstruction

Answer 123

US MRCP ERCP (removes the stones)

Answer 124

Diarrhoea Indigestion Epigastric or right upper quadrant pain and discomfort Nausea Intolerance of fatty foods Flatulence

Answer 125

Murphy’s sign is suggestive of acute cholecystitis: Place a hand in RUQ and apply pressure Ask the patient to take a deep breath in The gallbladder will move downwards during inspiration and come in contact with your hand Stimulation of the inflamed gallbladder results in acute pain and sudden stopping of inspiration

Answer 126

Acute cholangitis presents with Charcot’s triad: Right upper quadrant pain Fever Jaundice (raised bilirubin)

Answer 127

Cholangiocarcinoma is a type of cancer that originates in the bile ducts. The majority are adenocarcinomas.

Answer 128

Primary sclerosing cholangitis Liver flukes (a parasitic infection)

Answer 129

Obstructive jaundice Pale stools Dark urine Generalised itching

Answer 130

Courvoisier’s law states that a palpable gallbladder along with jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic cancer.

Answer 131

Painless jaundice should make you think of cholangiocarcinoma or cancer of the head of the pancreas. Pancreatic cancer is more common, so this is likely the answer in your exams.

Answer 132

Diagnosis is based on imaging (CT or MRI) plus histology from a biopsy. Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP). This is used to look for metastasis and other cancers. CA 19-9 (carbohydrate antigen) is a tumour marker that may be raised in cholangiocarcinoma. It is also raised in pancreatic cancer and a number of other malignant and non-malignant conditions.

Answer 133

Painless obstructive jaundice

Answer 134

Over 40 with jaundice – referred on a 2 week wait referral Over 60 with weight loss plus an additional symptom (see below) – referred for a direct access CT abdomen

Answer 135

? pancreatic cancer

Answer 136

Gallstones, alcohol, post-ERCP

Answer 137

Severe epigastric pain Radiating through to the back Associated vomiting Abdominal tenderness Systemically unwell (e.g., low-grade fever and tachycardia)

Answer 138

Amylase is raised more than 3 times the upper limit of normal in acute pancreatitis. In chronic pancreatitis it may not rise because the pancreas has reduced function. Lipase is also raised in acute pancreatitis. It is considered more sensitive and specific than amylase. C-reactive protein (CRP) can be used to monitor the level of inflammation. Ultrasound is the initial investigation of choice in assessing for gallstones.

Answer 139

The Glasgow score is used to assess the severity of pancreatitis. It gives a numerical score based on how many of the key criteria are present: 0 or 1 – mild pancreatitis 2 – moderate pancreatitis 3 or more – severe pancreatitis

Answer 140

Often given in chronic pancreatitis Replacement pancreatic enzymes (Creon) may be required if there is a loss of pancreatic enzymes (i.e. lipase). Otherwise, a lack of enzymes leads to malabsorption of fat, greasy stools (steatorrhoea), and deficiency in fat-soluble vitamins.

Answer 141

Acute viral hepatitis and paracetamol overdose

Answer 142

Hernias occur when there is a weak point in a cavity wall, usually affecting the muscle or fascia. This weakness allows a body organ (e.g., bowel) that would normally be contained within that cavity to pass through the cavity wall.

Answer 143

Incarceration Obstruction Strangulation

Answer 144

A Richter’s hernia is a very specific situation that can occur in any abdominal hernia. This is where only part of the bowel wall and lumen herniate through the defect, with the other side of that section of the bowel remaining within the peritoneal cavity. They can become strangulated, where the blood supply to that portion of the bowel wall is constricted and cut off. Strangulated Richter’s hernias will progress very rapidly to ischaemia and necrosis and should be operated on immediately.

Answer 145

Maydl’s hernia refers to a specific situation where two different loops of bowel are contained within the hernia.

Answer 146

Tension-free repair involves placing a mesh over the defect in the abdominal wall - can lead to chronic pain. Tension repair sutures the muscles and tissue on either side of the defect back together - higher recurrence rate.

Answer 147

An indirect inguinal hernia is where the bowel herniates through the inguinal canal.

Answer 148

The inguinal canal is a tube that runs between the deep inguinal ring (where it connects to the peritoneal cavity), and the superficial inguinal ring (where it connects to the scrotum).

Answer 149

When an indirect hernia is reduced and pressure is applied (with two fingertips) to the deep inguinal ring (at the mid-way point from the ASIS to the pubic tubercle), the hernia will remain reduced.

Answer 150

Direct inguinal hernias occur due to weakness in the abdominal wall at Hesselbach’s triangle. The hernia protrudes directly through the abdominal wall, through Hesselbach’s triangle (not along a canal or tract like an indirect inguinal hernia). Pressure over the deep inguinal ring will not stop the herniation.

Answer 151

R – Rectus abdominis muscle – medial border I – Inferior epigastric vessels – superior / lateral border P – Poupart’s ligament (inguinal ligament) – inferior border

Answer 152

An hiatus hernia refers to the herniation of the stomach up through the diaphragm.

Answer 153

Heartburn Acid reflux Reflux of food Burping Bloating Halitosis (bad breath)

Answer 154

Chest x-rays CT scans Endoscopy Barium swallow testing