Pathophysiology

Question 1

Gallstones

1) Types

2) Risk Factors

3) Indications for MRCP

4) Indications for ERCP

Answer 1

1) Mixed, Cholesterol, Pigment, Dark Pigment

2) Risk Factors - Age, Female, Pregnancy, Diabetes, Dyslipidaemia, Obesity, Rapid weight loss,

Specifically pigment - Haemolysis, Cirrhosis, Crohn’s/ileal resection

3) Indications for MRCP - Obstructive jaundice, Chronic pancreatitis, Pancreatic congenital abnormalities, Gallstones, Stricture management, HPV malignancy

4) Indications for ERCP -

i) Post operative cholecystectomy for CBD Clearance
ii) Obstructive Jaundice/cholangitis iii) Stent insertion
iv) Biopsy v) SOD dysfunction vi) stricture dilation

Question 2

1) Indications for cholecystectomy
2) Timing of cholecystectomy
3) Complications of Choleycstectomy

Answer 2

1) Indications - Gallstones, Acalculous cholecystitis, gallbladder polyps, porcelain gallbladder
2) Acute Cholecystitis - Early (<7 days ideally within 72 hours- reduced wound infection, hospitalisation, quicker recovery). Early is technically easier due to deterious effects on the local anatomy recognised >72 hours after onset.

Gallstone pancreatitis - Early

Obstructive jaundice after ERCP - elective

Obstructive jaundice no ERCP - early + CBD exploration

3) Complications - Converstion to open/alternatives to cholecystectomy, Liver Bed Bleeding, Bile Duct Injury (A-E. E is major duct and further subclassified using the bismuth classification), Difficult cystic/R hepatic artery bleeding, Bowel Injury, Bile Spillage

Question 3

1) Goals of perioperative analgaesia
2) “Preventative”
3) Post operative
4) Describe WHO Pain ladder
5) Complications of PCA
6) Pain assessment scales

Answer 3

1) Suffering, lenght of stay, recovery, patient satisfaction
2) Fentanyl with induction, LA infiltration of wound, Paracetamol, NSAIDs, Limb Blocks, Transversus Abdominal Plane Block, Epidural analgaesia
3) Post-Operative:

PRN Opioid for “breakthrough pain”

if large open abdominal surgery/thoracic surgery

consider epidural analgaesia (bupivicaine 0.125% 4-10ml/hour)

and if contraindicated then Paracetamol, NSAID + Breakthrough opioid

if NBM status then - IV Paracetamol + IM NSAID + S/C Opioid. Consider use of PCA device (bolus only 1mg morphine with 10 minute lock out)

4) WHO Pain Ladder
i) Paracetamol +/- Adjuvant
ii) Weak opioid + i)
iii) Strong opioid + i)
5) Complications of PCA - trigger for dependency, pruritis, unsteady plasma levels of drug, usual opioid problems,
6) Visual Analog Scales (Faces), Numerical Rating Scales (score pain 1-10)

Question 4

Describe the main targets of anti-emetics and give some names

Answer 4

M1 (muscaranic) - scopolamine, hyoscine

D2 (Dopaminergic) - Domperidone, prochlorperazine

H1 (Histamine) - Promethazine, Cyclizine

5 HT3 (Serotonin) - Ondansetron

NK1 (Substance P) -

GCs - Dexamethasone

Question 5

1) Purpose of Gastric Acid
2) Gastric Acid secretion phases
3) Gastric acid regulation

Answer 5

1) antimicrobial, activate peptides, denature ingested proteins.
2) Cephalic - External stimulus/ thought/ swallowing (Vagus mediated - 30-50% GA secreted)

Gastric - Intragastric food and gastric distension (Local and gastrin mediated - 50-60% secreted

Intestinal - CCK, Somatostatin mediated negative feedback

3) Secreted by parietal cells which receive:

Positive feedback from - Amino acids, vagal activation (acetylcholine), gastric distension, Gastrin (secreted by Antral G cells and act on enterchromaffin cells[ECL] +parietal cells). Cholecystekinin (but functionally negative feedback - see below) Histamines (autocrine and paracrine - released by ECL cells)

Negative feedback from - Somatostatin (released from D cells - release also enhanced by CCK + gastrin) Prostaglandin (autocrine -inhibited by NSAIds)

Question 6

1) Define DIC

2) Causes of DIC

3) Dx

Answer 6

1) Activation of haemostasis –> fibrin deposition + platelet activation + coag factor consumption –> haemorrhage

2) Causes:

Tissue damage, malignancy, Pregnany (abruption, molar, pre-ecclampsia, eclampsia), Infections, Immunological, Toxins, Liver Disease

3) Dx: Low - platelets, fibrinogem High - fibrin degeneration products, APTT, PT, TT

Question 7

1) Basic stages of haemostasis

2) how are platelets activated

3) Role of platelets in haemostasis

Answer 7

1) Vasoconstriction, Platelet activation, coagulation mechanism, fibrinolytic system

2) platelets are activated when exposed collagen/vwf from endothelial cells bind to platelet glycoproteins

3) i) Vasoconstriction (Relase Thromoxane a and serotonin when activates)

ii) Aggregation - (gpIIb/iiia is activated by thromboxane) gpIIb/iiia binds with vwf or fibrinogen. vwf and fibrinogen act as an intermedium between endothelium - platelets + platelet - platelet.

Platelets also interact with thrombin

Formation of platelet Plug

Question 8

1) Outline coagulation Cascade

Answer 8

Question 9

1) Investigations used to interrogate the coagulation cascade
2) How are platelets produced
3) complications of massive transfusion

Answer 9

APTT - intrinsic and common pathway

PT - Extrinsic Pathway

Bleeding Time - Crudely platelet activity

PFA 100 - platelet activity

2) Platelet production occurs in the bonemarrow. precursor cells are megakaryocytes which then fragment into platelets
3) Cx of Mass Tranf. - Hypocalceamia, Hyperkalaemie, thromboycytopenia, Hypothermia, Coag Fact. Deficiency, Fluid overload

Question 10

Types, mechanisms + presentations of transfusion reactions

Answer 10

IMMUNE

i) Pyrexia - due to white cells fragments/ cytokines in blood - fevers, chills, more common with platelets
ii) Alloimunisation - formation of antibodies 2o to repeat transfusions
iii) TRALI - Antibodies/ white cells/ cytokines interact with pulmonary vasculature - low sats, breathlessness, pul oedema
iv) GvHD - Donor lymphocyte proliferation - fever, rash +multi-organ dysfunction in immunologically compromised patients.
v) Urticaria - foreign plasma proteins - urticaria in isolation
vi) Haemolytic - usually ABO incompatability - fever, pain, dark urine, haemodynamic compromise

NONIMMUNE

i) Overload ii) infection iii) Hyperkalaemia
iv) Hypocalcaemia/hypomagnesaeima (Citrate toxicity)

Question 11

Non-Hodkin Lymphoma

1) Types

2) extra- nodal Sites of predeliction

3) Investigations

4) RFs

5) Tx

Answer 11

1) Broadly - HL + NHL (Agressive - Large B Cell, Burkitt’s, T+B lymphoblastic leukaemia/lymphoma, Adult T Cell Lymphoma amongst others. Indolent - Follicular lymphoma, CLL, Splenic marginal cell lymphoma)

2) High prevalence of extra- nodal disease - Skin, testicles, Bone, paraspinal soft tissue, CNS, Kidney, Bone Marrow

3) Investigations -

Bedside - Bloods (LDH, uric acid, abnormal FBC, hypercalcaemia, protein electrophoresis)

FDG Pet/ CT

Lymph node biopsy - Excision biopsy is best, FNAC is more rapidly performed

4) Risk factors:

• Immunosuppression, Infection (HIV,HTLV, EBV), Autoimmune diseases (SLE, RA, Hashmito’s, Coeliac Disease)

5) Varying regimens but classically

R CHOP - Rituximab, Cyclophosphamide, Doxirubicin, Vincristine, Prednisolone

Question 12

Hodkin’s Lymphoma

1) Type

2) RFs

3) Classical presentation

4) Investigations

5) Rx

Answer 12

B Cells generally speaking

1) Classic- Nodular Sclerosis, Mixed Cellularity, lymphocyte rich, lymphocyte deplete Nodular lymphocyte predominant

2) RFs - Age (Yound adult and older adult), EBV, Other viruses, immunosuppression, smoking, Autoimmune disorders

3) Classical presentation - Constitutional symptoms, lympahdenopathy, mediastinal mass, pruritis

4) Investigations -

Bloods - Hypercalcaemia, FBC abnoramalities, Eosinophilia,

Biopsy - Excision/ FNAC - Reed steenberg cells, CD30 (CD15 commonly seen but absence does not preclude diagnosis)

CT/PET - Staging purposes. Lugano Classification / Ann - Arbor Classification

5) Rx

ABVD - Doxorubicin, Bloemycin, Vinblastine, Dacarbazine

Radiotherapy

Question 13

1) Histological Features of SCC

2) Criteria for melanoma diagnosis

3) Histological features of melanoma

Answer 13

1) Level of differentiation, Perineural invasion, Invasion of absement membrane (by keratinocytes), dysplastic keratinocytes
2) ABCDE - asymmetry, borders, colour, diameter (>6mm), evolution
3) Histological features of melanoma - atypical melanocytes, architectural disorder,

Question 14

Baroreceptors :

i) Where?
ii) How do they communicate with CNS?
iii) Factors influencing Preload/EDV?

Answer 14

i) Present in carotid sinus (dilated segment of ICA

just distal to carotid bifurcation)

ii) via CN IX to the medulla oblongata

iii) EDV is influenced by :

a) Venous Return
b) Venous Blood Pressure (Impaired ventricular contraction, obstruction as in PE)
c) Pumps - Respiratory Pump, Leg Muscle pump

Question 15

Anticoagulants

1) Classes

2) MOA of Heparin + warfarin

Answer 15

1) Vit K Antagonists, Heparins, Antiplatelets, Factor Xa Inhibitors, Factor IIa (thrombin inhibitors)
2) Warfarin - Inhibits Vit K Dependent gamma carboxylation of coag factors II, VII, IX, X, C, S

Heparin - Antithrombin III potentiatior –> inhibits Xa, + IIa (thrombin)

Question 16

Common Peroneal Nerve

I) Features of CPL Lesion

Deep Peroneal Nerve

i) Origin
ii) Deficit produces?

Answer 16

I) Loss of dorsiflexion/foot eversion

Loss of sensation over lateral leg/dorsal foot

Deep Peroneal Nerve (L4-S1)

i) Branch of the common peroneal nerve
ii) Deficit produces:

Motor deficit in anterior compartment (Dorsiflexion)

Sensory deficit in first web space

Question 17

Shoulder Dislocation

i) How can shoulder’s dislocate

Answer 17

i) Anterior - Abduct and externally rotate

Posterior - Adduct and internally rotate

Inferior - Abduct onto onto acromion pushing inferiorly

Question 18

i) What is a carcinoid tumour?
ii) Common sites of carcinoid tumours
iii) What is meant by carcinoid syndrome
iv) Below what size do they not need furhter investigation
v) Ix

Answer 18

i) Carcinoid tumours are well diferrentiatied neuroendrocrine tumours usually in the context of the GI tract.
ii) Ileum>Rectum>Appendix>Colon>Stomach
iii) The syndrome typically refers to metastatic carcinoid tumours as the portal system has been bypassed. the presence of flushing and diarrhoea due to secretion of serotonin + other vasoactive substances being secreted.
iv) Appendix <1cm studies show a low risk of nodal/extra nodal metastases. >1cm the risk increase significantly

Rectum <1cm metastatases are rare. >1cm size associated with mets.

Small intestine and colonic nets all warrant further investigation

v) Ix:

Urinary 5 HIAA + serotonin

Serum serotonin, 5 HIAA, chromogranin A

Imaging - CT, MRI liver, Somatstatin receptor imaging

Endoscopy

Question 19

Cervical Rib Presentation

Answer 19

Vascular - Subclavian artery - thromb./emboli/ Aneurysm

Subclavian vein - thromb.

Cold/Warm Hand

Neurology - Lower trunk Brachial plexus (C8-T1)

Paraesthesia in C8-T1 dermatome.

Hand wasting

Symptoms worse on raising arm

Adson’s Test

Question 20

Features of Tetralogy of Fallot

Answer 20

i) Overarching Aorta
ii) Right Ventricular Hypertrophy
iii) Pulmonary Valve Stenosis
iv) Ventricular Septum Defect

Question 21

ECG Changes - Artery Occluded/ Area of tissue damaged

i) II,III, AVF

ii) V3 + V4

iii) V1 + V2

iv) I, aVL, V5 + V6

v) I, aVL, V2-V6

vi) Tall R Wave in V1

Answer 21

i) RCA

R Atrium + Posterior Interventricular Septum

ii) Distal LAD

Apical (Anterior)

iii) LAD

Septal (Anterior)

iv) Circumflex Artery

L Atrium + L Ventricle

v) LCA

L Atrium, Ventricle, Anterior IVS

vi) RCA

Posterior IVS

Question 22

Hip Fracture Classifications - Outline them

Answer 22

Garden’s Classification:

I - Incomplete/impacted

II - Complete - non-displaced

III - Partial displacement/angulation

IV - Complete displacement

Pauwell’s Classification: (Angle of fracture)

I - 30 degree

II - 50 degree

III - 70 degree

Question 23

Nerve Lesions:

i) Complete Sciatic

ii) High Tibial

iii) Common Peroneal Nerve

Answer 23

i) Loss of power in leg + Post. Thigh

Loss of sensation to post. thigh and lateral leg

ii) Loss of plantar flexion + inversion.

Loss of sensation to sole of foot

iii) Loss of dorsi flexion + Eversion

Loss of sensation over lat. aspect + dorsum of foot

Question 25

**What illnesses does Streptococcus Pyogenes Cause** **What virulence factors does strep pyogenes possess** **What systemic complications of streptococcal infections are there (non-invasive)**

Answer 25

Invasive: Puerperal fever, Nec Fasc, Toxic Shock Syndrome Non-Invasive: Pharyngitis, Erysipelas, Impetigo Virulence Factors: Streptolysins, Hyaluronidase, Streptokinase Pyogenic exotoxins - account for toxic shock syndrome Streptococcal Infections can cause: Rheumatic Fever, glomerulonephritis, scarlet fever

Question 26

**Different types of prion disease**

Answer 26

Creutzfeld Jacob Disease vCJD Kuru Fatal Familial Insomina Gerstmann- Straussler- Scheinker Syndrome

Question 28

What governs interstitial fluid accumulation? Broad causes of oedema

Answer 28

**Starling's Forces:** Capillary Wall permeability Oncotic Pressure (Large proteinaceous plasma components help retain fluid intrasvascularly) Hydrostatic Pressure (in other words stasis is the problem) **Oedema:** Increased hydrostatic pressure (congestion) Oncotic pressure decreasing (loss of protein) Capillary leaking (Inflammation)

Question 29

**Respiration:** i) Where is respiration controlled? ii) What is the Hering-Bruer Reflex? iii) Where does CO2 exert its effect on the respiratory system?

Answer 29

i) Medulla by two bodies of neurones (Ventral and Dorsal) receiving multiple inputs and outputs via phrenic nerve. Dorsal neurones initiate inspiration. Apneustic Centre - Initiates inspiration Pneumotaix centre - Inhibits inspiration ii) Inflation of the lungs \> 800 ml tidal volumes serving to regulate inspiration. iii) CO2 - Carotid body and aortic arch receptors Hydrogen Ions - in the CNS

Question 30

**MOA Dopexamine** **Noradrenaline vs adrenaline therapeutically**

Answer 30

**Adrenergic Agonist -** B2 ( D1 + D2 ) Prevents reuptake of norepinephrine **Adrenaline -** B1 Predominance. Therefore mainly cardiac effects **Noradrenaline -** Alpha agonist - therefore mainly pressor effects

Question 31

**Transplants:** **i) Define a transplant** **ii) What is HLA?**

Answer 31

**i)** Transplantation of a tissue from one anatomical region to another **ii)** HLA is a genetic loci responsible for displaying - Cell surface recognition antigen. Class I - presents endogenous cytoplasmic antigen. A, B + C Class II - presents exogenous antigen. DP, DQ, DR Both present the antigen (peptide) to immune system ( T Cells ) to stimulate an immune response.

Question 32

**Stages of fracture healing:**

Answer 32

1) Haematoma Formation - Granulation Tissue 2) new woven bone formation around the bony collar 3) bridging callus formation 4) Fracture site remodelling + formation of haversian system formation

Question 33

**Common sites of intra-abdominal collection?**

Answer 33

**Morrison's Recess (Hepatorenal)** - Most sensitive in supine patient Paracolic Gutter Between loops of bowel **Pelvis:** Rectovesicular Pouch Pouch Of Douglas

Question 34

**Meckel's Diverticulum?** What is it Associated pathology

Answer 34

**Remnant** of the **vitellointestinal duct** - 2inches long, 2% of people, 2 feet from ileocaecal valve **pathology:** - Appendicitis Mimic - Litter's hernia - Bleeding, Perforation, intessusception, obstruction

Question 35

**Erosions in these parts of the UGI system cause bleeding from which artery?** **1st 2nd part of duodenum?** **3rd or 4th part of duodenum?** **Lesser Curve stomach?**

Answer 35

**1st/2nd duodenum -** Gastroduodenal Artery **3rd/4th duodenum -** Pancreaticoduodenal Artery **Lesser curve stomach -** Left Gastric Artery

Question 36

**Bowel Obstruction:** **Large vs Small** X Ray findings Causes Presentation

Answer 36

Question 37

**Decribe cause of pattern of pain in appnendix**

Answer 37

Central abdominal pain (appendix initially due to visceral pain fibres enterring the spinal cord at T10 level - same level as umbilical dermatome) **to** Right Iliac Fossa type pain (Irritation of parietal peritoneum)

Question 38

**What is the terrible knee injury triad?**

Answer 38

MCL Medial Meniscus ACL

Question 39

**i) Horner's Syndrome Triad** **ii) Causes of Horner's Syndrome**

Answer 39

**i)** Miosis, Ptosis, Anhydrosis **ii)** **Central** - Thalamus, Brainstem, Cervical Cord pathologies (malignancies, stroke, demyelination, haemorrhage, injury) **Pre Ganglionic -** Spine roots, Brachial Plexus, Pulmonary Apex, Anterior Neck pathologies ( pancoast tumour, trauma, acquired nerve damage) **Post Ganglionic -** Superior Cervical Ganglion, ICA, Base of skull/ carotid canal, Middle ear, cavernous sinus pathologies

Question 40

**i) Clinical Features of an orbital blow out fracture?** **ii) Radiological Features of orbital blow out fracture?**

Answer 40

**i) Enopthalmus -** Eye being sucked into brain. **Diplopia -** Extraocular muscle trapped in fracture **Infraorbital Numbness -** Compression of infraorbital n. (V2) **Orbital Emphysema -** signals that there is nearby sinus involved in the fracture **ii)** Fluid in the sinus, tear drop sign (herniated fat into sinus), Orbital emphysema

Question 41

**What does the image show - describe pathology**

Answer 41

**The RIGHT vertebral artery is catheterised -** contrast flows antegrade through the right **VA** and then we see the basilar artery opacifying **and** the **left VA + SCA opacifying.** There is occlusion at **R proximal SCA.** Occlusion of the aortic arch proximal to vertebral artery **leading to :** - Retrograde flow through vertebral artery to subclavian artery - **essentially** blood is being 'stolen' from the contralateral vertebral artery (/circle of willis)

Question 42

**What are the causes of Thoracic Outlet Syndrome?** **How do the subclavian artery, vein and brachial plexus relate to the first rib?**

Answer 42

Compression of the **neurovascular bundle (brachial plexus + Subclavian artery)** between the: i) Anterior and middle scalene muscles ii) Cervical Rib iii) 1st Rib iv) Abhorrent Bands in the thoracic outlet **Subclavian Artery + Brachial PLexus** - Overly the first rib in between anterior and middle scalene muscle. (beneath the clavicle) **Subclavian vein** - Overly the first rib **anterior to the anterior and middle scalene muscle.** (beneath clavicle)

Question 43

**Amylodiosis:** **i) What is amyloidosis** **ii) Histological features** **iii) Types of amyloid protein which sites they favour** **iv) Diagnosis** **v) Rx**

Answer 43

i) Deposition of abnormal fibrillar proteins in extracellular tissue **that cannot be broken down enzymatically** ii) **Microscopy -** Bright pink hyaline material **Congo red stain -** Apple green membranes iii) **AL - Primary** - produced by clonal expansion of plasma cells **favouring** heart, kidney, liver, spleen, peripheral nerves + GI (macroglossia, bleeding), peri orbital purpura **AA - Secondary (RA, IBD, TB, Bronchiectasis, RCC)-** Due to inflammatory **interleukins** stimualting hepatocytes to secrete **amyloid** **precursors**. It **favours** - **liver, kidney + spleen** iv) **Dx** By **Isotope scan** or more commonly **biopsy** of rectum/subcut fat/ affected organs v) **Rx -** Treatment of MM/ Treatment of inflammatory conditions/ Organ transplant

Question 44

**Where can isolates of amyloid tissue be found in the body?**

Answer 44

Larynx Urinary Tract Aorta Pituitary Gland Thyroid ( Medullary Cell Carcinoma)

Question 45

**i) Define Aneurym** **ii) Causes** **iii) Size of normal infrarenal aorta vs aneurysmal** **iv) Pathogenesis of AAA** **v) RFs for AAA** **vi) Aneurysm Cx**

Answer 45

**i)** Aneurysm - Dilation of a blood vessel to 1.5x normal diameter **ii)** **Causes:** Acquires (Atherosclerotic + traumatic), Infective (Syphilitic), Inflammatory, CTDs **iii)** **Infrarenal Aorta** 2cm = Normal \>3cm= Aneurysm **iv)** Atherosclerosis --\> red. elastic recoil, loss of mechanical integrity + ischaemic changes due to occluded vasa vasorum **v)** Age, **Smoking**, HTN, FH, Cholest., DM, Male **vi)** Rupture, Thrombosis, Emboli, Infection, Pressure, Fistula

Question 46

**i) When would AAA be for repair?** **ii) When to screen** **iii) Which arteries may you have to deal with during procedure?** **iv) Complications of EVAR**

Answer 46

**i)** \>4.5 cm/ Growing \>1cm per year/ symptomatic **ii)** 3-4 cm - annual 4-5.4 cm - 6 monthly \>5.5 cm - surgeons **iii)** Posterior - Lumbar arteries (oversewn) Laterally - Renal ARteries (Preserved) Anteriorly - SMA (Reimplanted) IMA (Reimplanted) **iv) EVAR** **cx**: Endoleak, Mesenteric ischeamia, Renal Failure, Infection, MI, Spinal Ischaemia

Question 47

i) **Define: Aortic Dissection** ## Footnote **ii) Aortic Dissection diseae Ax** **iii) Classifiactions**

Answer 47

i) **Tear in intima resulting in separation of arterial wall layers** **ii)** Marfan's, ED, Osteogenesis Imperfecta **iii)** **Stanford -** A( Proximal) B ( Descending only) **Debakey - I** (Arch and descending) **II** (Ascending) **III** (Descending)

Question 48

**i) Causes of Aortic Stenosis** **ii) Pathogenesis of the main variety** **iii) Triad** **iv) Signs** **v) Ix** **vi) Mx** **vii) Causes of IE**

Answer 48

i) Aortic Valve Calfication Congenital Aortic Valve Rhemautic Valve DIsease **Metabolic/Inflammatory -** SLE etc. **ii)** Calcification is caused by - lipid accumulation, inflammation and calcification **iii) Triad -** Syncope, Angina, Dyspnoea **iv) Signs:** **Peripheral -** Slow rising pulse, Narrow pusle pressure, Heart Failure, Anaemia ( Heyde's Syndrome) **Precordial -** ESM R 2nd ICS PS, Soft S2, LV Heave **v)** Ix: ECG - LVH / Ischaemia CXR - HF, Calcified valve, Post Stenotic Dilatation Echo - Valve Assessment, LVH, LVEF Angiogram - Pre operative assessment / intervention Cardiac CT / MRI / Exercise testing **vi) Mx:** conservative, Valve replacement, TAVI, Valvuloplasty **vi)** Infective Endocarditis - SA, Strep (viridans, B & D), E Coli, Pseudomonas, HACEK organisms

Question 49

**Appendicitis:** i) ? Obturator Sign ii) Describe pain seminology iii) Scoring systems iv) Common causes of obstructed lumen v) cx of appendicitis

Answer 49

i) Pain on **hip** **flexion** and **internal** **rotation** due to **obturator** **internus** rubbing against appendix ii) Central pain (**Lesser** **Splanchnic** Afferents - T10/T11)--\> RIF once peritoneal somatic nerves involved iii) **Scoring Systems -** Alvarado, Appendicitis Inflammatory Score iv) Faecolith, tumours, lymphoid, lymphoma intestinal worms v) **Cx -** Rupture, Appendiceal mass, Appendix Abscess

Question 50

**Ascites:** **i) Causes**

Answer 50

**i) Transudates (\<30g protein) Exudates (\>30g/L protein)** **SAAG:** **\>1.1g - Portal Hypertension** Cirrhosis, cardiac failure, Budd Chiari Syndrome, Thoracic Duct Obstruction **\<1.1g - Non-Portal Hypertension** Hypolabuminaemia (Nephrotic Syndrome, GI protein loss), Peritonitis (bacterial or TB), Peritoneal Carcinomatosis, Pancreatitis

Question 51

**Describe starling equation for movement across capillary membrane**

Answer 51

**Arterial End:** **Hydrostatic pressure\> Colloid Oncotic pressure** Net movement of fluid out of capillary **Venous End:** **Colloid Oncotic Pressure \> Hydrostatic Pressure** Net movement into the capillary Therefore fluid is filtered and then reabsorbed

Question 52

**Classify Causes of pitting oedema**

Answer 52

**Increased Hydrostatic Pressure:** Heart Failure, Hypervolaemia, Venous Insufficiency, Pregnancy **Reduced Oncotic Pressure:** Hypoalbuminaemia (nephrotic syndrome, malnutrition, protein losing enteropathy, cirrhosis)

Question 53

**Atherosclerosis:** **i) Definition** **ii) Pathological Process** **iii) RFs**

Answer 53

i) Artery wall thickening as a result of fatty materials accumulating ii) **First -** Endothelial Insult/Dysfunction **Then -** Inflammatory cell migration to stabilise forming a lipid core **Then-** Smooth muscle proliferation to form a fibrous cap iii) **RFs -** Age, Smoking, DM, Hypercholesterolaemia, FH

Question 54

**Benign Breast Disease -** Demographic , Histology, Presentation **i) Fibroadenoma** **ii) Breast Cyst** **iii) True Mastalgia (+ management)** **iv) Breast Abscess ( Classification, ?bacteria, management )** **v) Mondor's Disease**

Answer 54

**i) Fibroadenoma** **Presentation** - Defined/Rubbery/Mobile lesions in outter/upper quadrant **Histology** - Epithelium/ Stromal tissue proliferation **Demographic** - Young women **ii) Breast Cyst** **Presentation** - Distended/ Involuted Lobules **Histology** - Fluid Filled (should **not** be bloody) **Demographic** - Peri-menopausal **iii) True Mastalgia** **Presentation** - Breast enlargement, pain and nodularity **Demographic** - Exaggerated response of breast tissue to hormones **Management** - Caffeine, Gammalinoleic Acid, Danazol, Bromocroptine, Tamoxifen **iv) Breast Abscess** **Lactational** (S. Aureus, S. Epidermydis, Other Staph species) and **non** **lactational** **Presentation -** Breast feeding, Pain, redness, Heat & Swelling **Mx-** Analgaesia, Antibiotics, Cont. Breastfeeding, Drainage **Peri-Ductal Mastitis** **Presentation -** Young, Smokers, Pain, Discharge, Inflammation **Histology -** Inflammation around non dilated sub-areolar ducts **v) Mondor's Disease** **Presentation -** Sudden onset pain with tenderness of tissue in cord like shape **HIstology/Pathology -** Thrombophlebitis of subcutaneous vein **Mx -** NSAIDs

Question 55

**i) Triple Assessment**

Answer 55

**i) Triple Assessment:** Examination Imaging - USS Abdomen / Mammogram Tissue Biopsy - Core Biopsy/FNA

Question 56

**Phylloides Tumour:** **i) Presentation** **ii) Histology** **iii) Treatment**

Answer 56

**i)** **Present -** Large tumours in 40-50s **ii) Histology -** Overgrowth of stromal tissue **iii) Treatment -** WLE / Mastectomy

Question 57

**Gynaecomastia** **i) Causes**

Answer 57

**i) Causes:** **Physiological -** Neonates, Puberty, Elderly **Pathological** - Hepatic Failure, Renal Failure, High Prolactin, Testicular Tumours, Kinefelter's Syndrome **Drug -** Anti Dopaminergic, Spironolactone, ACEi. CCBs, Marijuana

Question 58

**Causes of breast discharge**

Answer 58

**i) Physiological -** Variations in colour. Passive discharge . **ii)Duct Ectasia -** Pathology/ Histology- Shortening and dilating of Sub-areolar ducts Presentation - Mass, Nipple discharge, Nipple Retraction **iii) Intraductal Papilloma -** Presentation - serous/blood stained discharge with lump **iv) Epithelial Hyperplasia** Reddish coloured dicharge **v) Galactorrhoea** Milk Discharge ( Should check prolactin levels) **vi) Cancer** Any lump with discharge should be biopsied

Question 59

**Bladder Cancer:** **i) RFs for TCC** **ii) RFs for SCC** **iii) Other bladder cancers** **iv) Ix** **v) Surgical Mx** **vi) Non- systemic adjuncts**

Answer 59

i) Smoking, Rubber/Textile Industry Worke, Dyes ii) Schistosoma Haematobium - African Countries due to chronic inflammation, indwelling catheters, calculi iii) Adenocarcinomas, Small Cell Carcinoma, Mets iv) Ix - Ultrasound, Urine Cytology, **Cystoscopy + Biopsy**, Staging Cross Sectional Imaging v) **Surgical Mx:** TURBT, Partial Cystectomy, Simple Cystectomy, Radical Cystectomy, Pelvic Exenteration vi) **Non Systemic Adjuncts -** intravesicular BCG/chemotherapy

Question 60

**Bone Tumors:** **i) Benign types** **ii) Malignant types** **iii) Common bone mets**

Answer 60

**i)** Osteochondroma (most common), Enchondroma, giant cell tumour, fibrous dysplasia **ii)** **4 types -** Multiple Myeloma (most common), Osteosarcoma (second most), Ewing's Sarcoma, Chondrosarcoma **iii)** Breast, Lung, Thyroid, Kidney, Prostate

Question 61

**X Ray appearance:** **i) Onion skin appearance & who does it generally effect/presentation characteristics**

Answer 61

**i) Ewing's** **Sarcoma** (Onion skin relates to successive layers of periosteal development. Periosteal lifting) - Children & adolescents - Effects axial and perpendicular skeleton. Pelvic tumours have a worse prognosis.

Question 62

Answer 62

**Osteosarcoma** **-** Sunburst appearance

Question 63

**i) Investigations for ?bone tumour** **ii) When to operate on a benign bone tumour?** **iii) Mx of malignant bone tumours**

Answer 63

**i) Blood -** PTH, Ca++, ALP **Imaging -** Bone films, MRI, Staging scan of CT, whole body technetium scan **Bone biopsy -** Along limb salvage lines so the whole biopsy tract can be removed en block (mitigates tumour seeding) **ii)** Surgery - pain, limitation on movement, rapid growth, local effects **iii)** **Primary -** Surgery (Amputation/Limb Salvage) +/- Chemotherapy +/- radiotherapy- Mx in specialist unit **Secondary -** Radiation +Chemotherapy + surgery **Fracture prophylaxis -** \>50% femoral shaft involvement should have Prophylactic IM nail put in - **only in carcinoma not in sarcoma**

Question 64

**What are the subtypes of surgical resections**

Answer 64

**Intralesional** - tumour is cut into during surgery **Marginal Resection -** Surgical dissection extends into reactive zone surrounding the malignancy **Wide Local Excision -** Surgical dissection remains outside the reactive zone **Radical Excision -** Removal of compartments containing the tumour

Question 65

**Clostridium:** **i) Types** **ii) RFs for C Diff** **iii) Most notable complication? and Mx** **iv) how does C Diff cause pseudomembrane?** **v) What other drugs may increase C Diff Risk?**

Answer 65

**i)** Difficile, Tetani, Perfringens, Botulinim Gram +ve, Anaerobes, Spore producing **ii) Staff, Antibiotics, Elderly** **iii) Toxic Megacolon -** Acute colonic distesnion, fever, pain and shock **Mx -** Resucitate, Decompression (NG+ Flatus), Surgery may be required **iv) Pseudomembrane -** Toxin mediated inflammation of the epithelium leads to production of grey/white exudate Membrane is composed of - neutrophils, bacteria, debris, fibrin and necrotic epithelium **v) PPIs and Beta Agonists** are thought to increase the risk through delayed gut transit times (allowing the toxin more time to exert effect)

Question 66

**Abdo X Ray Method**

Answer 66

Patient details, Film, penetraton, exposure (Lung bases to hernial orifices **Bowel -** SB \>3cm, LB \>6cm, Caecum \>9cm **Gas -** Biliary, subdiaphragmatic, Rigler's **Organs -** Liver, Spleen, Kidneys, Aorta, Psoas **Bone -** Vertebrae, SI joints, Femurs, Inferior Ribs **Other -** Any tubes, pessary, FBs, signs of surgery

Question 67

**i) Most common causes of LBO** **ii) Most common causes of SBO**

Answer 67

i) Tumour, adhesions, Diverticular strictures, Sigmoid / caecal volvulus ii) Adhesions, hernias, Crohn's, Tumour

Question 68

**Hereditary Polyposis Syndromes:** **Names** **INheritance Patterns** **Cancer Risks**

Answer 68

**Familial Adenomatous Polyposis** **-** AD mutation of APC (Ch 5) - FAP (mandibular osteomas) Gardner's (osteomas, desmoids, fibromas, lipomas) / Turcot's (medulloblastoma, GBM) - Need flexi sigs/UGI endoscopy every 1-2 years until you see polyps then colonoscopies every 1-2 years with polypectomy of suspicious polyps - Subtotal colectomy/ Panproctocolectomy + ileoanal pouch formation are often required - Post surgery - UGI endoscopy 3-5 yearly + sigmoidoscopy regularly **Hereditary non Polyposis Coloretal Cancer** **- AD** mutations in DNA mismatch repair (Ch 2+3) - Amsterdam Criteria - Colonic + Extra colonic cancer (gynae, pancreatic, gastic, small bowel) **Peutz Jehger** - **AD** mutations in STK11 (Ch19) - pigmented lesions on face/fingers + hamartamous polyps **Cowden Syndrome** **- AD** mutations in PTEN (Ch10) - Tricholellomas, oral papillomatosis, facial papules

Question 69

**i) Colonic Cancer Classifications** **ii) Adenoma - Carcinoma Sequence** **iii) Common CRC Metastases** **iv) Types of liver resection**

Answer 69

i) TNM or **Duke's** A - Muscularis Propria B - Beyond muscularis propria C - Nodal involvement sparing highest node (apical) D - Involvement of apical node/ distal metastasis ii) **Series of mutations resulting in malignancy** First - APC, Then K-RAS/DCC and then p-p3 TS gene iii) **Mets-** Liver, Lung, Brain, Bone iv) **Right hemihepatectomy** - Counnaud Segment's 5,6,7,8 **Left hemihepatectomy -** Counnaud segment's 2-4 **Total Resection** **Minor -** Wedge, segmental, subsegmental

Question 70

**Layers of the bowel wall**

Answer 70

Mucosa Submucosa Meisner's Plexus Muscularis Propriate Longitudinal Muscle Auerbach's Plexus Circular Muscle Serosa

Question 71

# Define: **i) Adenocarcinoma** **i) Neoplasm**

Answer 71

**i)** Cancer of glandular origin **ii)** Abnormal mass of tissue with uncoordinated growth, exceeding that of normal tissue that persists after cessation of stimulus

Question 72

**Hepatic Tumours**

Answer 72

**Benign -** Haemangioma, Focal nodular hyperplasia, Adenoma **Malignant -** Primary ( HCC, Cholangiocarcinoma, Angiosarcoma, hepatoblastoma) **Mets.**

Question 73

# Define: **i) Absces** **ii) Pus** **iii) Cyst** **iv) Sinus** **v) Stoma**

Answer 73

**i) Abscess** - Collection of a pus walled off and surrounded by granulation/fibrous tissue **ii) Pus -** Neutrophils + dead/dying microorganism **iii)** **Cyst -** Abnormal membranous sac (lined by epithelial/endothelial cells) **iv) Sinus -** Blind ended tract lined by granulation tissue **v)** **Stoma -** Surgical opening into a hollow viscus

Question 74

# Define: ## Footnote **vi) Aneurysm** **vii) Diverticula**

Answer 74

**vi) Aneurysm - An abnormal, permanent dilation of a vessel 1.5x greater than expected diameter** **vii) Diverticula - An abnormal outpouching of a hollow viscus into surrounding tissues**

Question 75

# Define: ## Footnote **viii) Thrombus** **IX) Clot** **X) Embolus**

Answer 75

**viii) Thrombus - Solid material formed from blood constituents in flowing blood** **IX) Clot - As for thrombus but in stationary blood** **X) Embolus - Abnormal mass of undissolved material carrier from one location to another**

Question 76

# Define: ## Footnote **XI) Necrosis** **XII) Hypersensitivity reactions** **XIII) Polyp**

Answer 76

**XI) Necrosis - Abnormal tissue death in life** **XII) Hypersensitivity Reaction - Exagerrated host immune response to specified stimulus** **XIII) Polyp - Abnormal pedunculated mass of tissue rising from an epithelial surface**

Question 77

# Define: ## Footnote **XIV) Hyperplasia** **XV) Hypertrophy** **XVI) Hamartoma** **XVII) Metaplasia** **XVIII) Dysplasia**

Answer 77

**XIV) Hyperplasia - Increase in tissue size due to an increase in the number of normal cells** **XV) Hypertrophy - Increase in tissue size due to an increase in the size of otherwise normal cells** **XVI) Hamartoma - Tumour like malformation composed of disorganised arrangement of tissue found at particular site** **XVII) Metaplasia - Reversible replacement of one differentiated cell type with another** **XVIII) Dysplasia - Abnormal cell population with increased mitosis and pleimorphism. Doesn't penetrate BM/metastasise**

Question 78

**Proportion of thyroid cancers hereditary:** **i) Medullary** **ii) hurthle cell** **iii) Follicular**

Answer 78

**i) Medullary - 25% (MEN 2a/2b. Familial Med. Thyr. Cancer)** **ii) hurthle cell - 7%** **iii) Follicular - 7%**

Question 79

**Cytological Classification of thyroid nodules**

Answer 79

Benign Indeterminate Malignant Inadequate Specimen

Question 80

**Thyroid Cancer:** **Types**

Answer 80

**Medullary** **Follicular** **Papillary (85%)** **Anaplastic (1%)**

Question 81

**What is tertiary hyperparathyroidism**

Answer 81

Development of autonomous PTH secreting nodule in patient with previous secondary hyperparathyroidism

Question 82

**Causes of hypoparathyroidism**

Answer 82

Idiopathic/autoimmune Radioidoine treatment Thyroidectomy

Question 83

**Primary vs Secondary Hyperalodsteronism**

Answer 83

**Primary -** Aldosterone High / Low Renin **Causes -** Aldosterone Secreting Adenoma/adrenocortical carcinoma, Adrenal Hyperplasia, Familial **Secondary -** Aldosterone High/ High Renin **Causes -** Renovascular disease, Renin secreting tumour, Liver cirrhosis

Question 84

**i)Causes of cholangiocarcinoma** **ii) Ix for cholangiocarcinoma**

Answer 84

**i) West - PSC** (chronic inflammation due to refluxing bile) **Developing - Liver flukes** (chronic inflammation due to presence of organisms) Chronic liver disease, HIV, Congenital Liver Diseases **ii)** Imaging - US/ERCP/MRCP Biopsy - MRCP/ Open biopsy Bloods - CEA, CA19-9, Obstructive Jaundice Immunohistochemistry on sample

Question 85

**i) Bacteria commonly found in bile** **ii) Suitable antibiotic cover**

Answer 85

**i) Aerobic** **Negative -** E Coli, Klebsiellus, Proteus, Enterobacter **Positive-** Strep Faecalis. **Anaerobic** Clostridium **ii)** Broad spectrum antibiotic + Anaerobic cover (Cef + Met / Tazocin)

Question 86

**Necrotising Fascitis:** **i) Clinical Presentation** **ii) underlying pathology** **iii) Types** **Iv) Management of post op wound NF**

Answer 86

**i)** Pain out of keeping with clinical picture Violet skin colour (due to necrosis) Sepsis/Shock Oedema **ii)** Necrotising Fascitis is an infection that spreads quickly in the subcutaneous tissue spreading across fascial planes rather than going deep into the muscles. **iii) A - Polymicrobial** - S Aureus, Pseudomonas, Coliforms, Bacterioides, Diptheroids **B - Monomicrobial -** Strep Pyogenes (GAS) Clostridium Perfringens (fourniere's) **iv)** **A-E** **IV Antibiotics / Fluids** **Extensive debridement (emergency) with plastics if possible** **HDU/ITU** **Hyperbaric Oxygen** **VAC dressing**

Question 87

**i) Indications for heart transplant** **ii) Donor Criteria**

Answer 87

**i) NYHA IV Heart Failure (irremediable)** **LVEF \<14 ml/kg** **Deteriorating** **\<1 year prognosis** **No contraindications to transplant in general** **ii) Donor Criteria:** \<55 years old Normal ECG Minimal cardiac risk factors Macrascopically normal heart at organ recovery stage **and** (brainstem death certified, permission from NOK/on organ donor register, ABO compatible, without infectious disease precluding the transplant)

Question 88

**i) Grossly what causes GVHD** **ii) Cancers associated with HIV** **iii) Minimising risk when operatiing on HIV +ve patients**

Answer 88

**i) Donor T Cells** reacting against **Host HLA** **ii) HIV -** Kaposi's Sarcoma, CNS Lymphoma, Anogenital cancer, Cholangiocarcinoma **iii)** HIV Positive Patients: - Experienced Surgeons - Double Glove, Eyeshield, Impervious Gowns, Disposable anaesthetic circuitry

Question 89

H Pylori ## Footnote **i) What is H Pylori?** **ii) Acid evasive techniques?** **iii) How does it cause gastric problems?** **iv) How many H Pylori carriers are asymptomatic?** **v) Malignancy/Disease associations** **vi) Detecting H Pylori** **vii) Treatment of H Pylori**

Answer 89

**i)** Gram Negative, Spiral shaped bacterium **ii) pH detecting -** Has the ability to follow a pH gradient and adhere to neutral epithelial lining **Urease -** Secretes urease which converts urea to CO2 + ammonia. **Ammonia** reacts with **H+** to become **ammonium** thus increasing pH **iii)** **H Pylori produces -** Proteases + Phospholipases + Urease (but problem is ammonia). The three of which **cause** **breakdown** **of** **mucous** covering in stomach. Leaving the epithelium **exposed to gastric acid.** **iv) 80%** **v)** **H Pylori can cause (in 1-2% of carriers) -** **Gastric Adenocarcinomas** and **Gastric MALTomas** **Barrett's, Duodenal + Gastric Ulcers** **vi) Campylobacter Like Organism (CLO Test)**. This test is dependent on urease prodcution by H Pylori **Culture, Histological Examination, Urease Breath** (radiolabelled urea ingestion) **Test, Stool Antigen Test, Serum Antibody Test** **vii) Triple Therapy:** **i)** Amoxicillin, Clari, PPI **ii)** Metronidazole, Clari, PPI

Question 90

**i) Which Cells produce Gastric Acid?** **ii) What is dumping syndrome**

Answer 90

**i) Parietal Cells -** Cephalic/Gastric phase of food ---\> Gastrin secretion by G Cells ---\> Histamine (secreted by enterochromaffin cells due to gastrin stimulation) + Gastrin both **stimulate parietal cells** to produce HCl **PPIs** act on parietal cells to prevent HCl production **ii)** **Dumping Syndrome -** Rapid transmission of undigested gastric contents into the small intestine due to pyloric disruption **Phase I -** Hyperglycaemia and then reactive hypoglycaemia **Phase II** - Hypovolaemia due to fluid shift with a large hyperosmolar load

Question 91

**i) Risk Factors for Gastric Adenocarcinoma** **ii) Two broad categories of Gastric Adenocarcinoma**

Answer 91

i) H Pylori Excessive Salt Smoked Fish Pernicious Anaemia Family History Japanese Origin Men \>50 years old **ii) Lauren Classification -** Intestinal (resembling intestinal adenocarcinoma) **and** Diffuse type

Question 92

**Calcium.** **i) Where are PTH/Calcitonin Produced?** **ii) What does vitamin D do?** **iii) How do surgeons ensure they have removed the parathyroid glands?**

Answer 92

**i) PTH -** Chief Cells (parathyroid gland) **Calcitonin -** Parafollicular C Cells (thyroid gland) **ii) Vitamin D:** 1 25 OH D3 - Hydroxylated form. Usually a) increased intestinal absorption of Ca++ b) increases calcium release from bone c) decreases calcium excretion from kidney **iii)** The specimen is sent for frozen section analysis by pathalogist intraoperatively

Question 93

**Types of hypersensitivity reaction**

Answer 93

**+ ?Type V -** Formulation of stimulatory antibodies

Question 94

**Type 4 Hypersensitivity Reaction:** **Time-Frame?**

Answer 94

It is a delayed reaction that often takes 48-72 hours to manifest. Caused by T Cells

Question 95

**i) 3 Factors contributing to Surgical Infections?** **ii) What factors make for favourable closed spaces for infectious organisms?** **iii) How does infection spread from one site to another?**

Answer 95

**i) Microorganism** **Susceptible Host** **Location (poorly perfused/enclosed)** **ii)** Poor Perfusion, Local Hypoxia Hypercapnia, Acidosis Narrow outlet (GB, Ureter) **iii)** Spread can be: **a)** Haematogenous **b)** Lymphatic **c)** Along fat planes **d)** Enlargement/local movement **e)** Along fascial/subcutaneous planes

Question 96

**Types of immune response to pathogen?**

Answer 96

**Specific Immunity** **Recognise specific pathogens/PAMPS:** **T Cells -** Cell Mediated **B Cells / Plasma Cells -** Antibody production --\> opsonisation and enhanced killing **Non- Specific Immunity :** **Barriers** - Skin, Gastric Acid, Lubricant membranes **Phagocytes -** Migratory capacity, ingestion, killing/attenuating

Question 97

**i) What are the stages of acute inflammation?** **ii) Some chemical inflammatory mediators** **iii) Difference in inflammatory cells in chronic inflammation**

Answer 97

**i) 1 - Vasodilation** **2 - Increased Vascular Permeability** **3 - White cell extravasation** **4 - Phagocytosis** **5 - Resolution/ Chronicity** **ii) Amines-** Histamine, Serotonin **Bradykinin,** **Cytokines, Complement, Coagulation** **Arachidonic Acid products (**leukotrienes, prostaglandins..) **iii)** In chronic inflammation there will be more **lymphocytes** and **macrophages.** In more **acute** inflammation there is a tendency toward neutrophils

Question 98

# Define: **i) Granuloma** **ii) Granulomatous Inflammation** **iii) Classify Granulomas**

Answer 98

i) A granuloma is a collection of **epithelioid** **macrophages** ii) Chronic inflammation characterised by **epithelioid macrophages.** Sometimes evidenced are **Langhan's Cells -** Multinucleate giant cells **iii) Caseating necrosis is typified by the degradation of tissue into a 'cheese like substance'** **Caseating -** TB, Syphilis, **Non - Caseating -** Sarcoid, Crohn's Disease, Leprosy, Rheumatoid Arthritis

Question 99

**IBD:** **i) Most commonly quoted pathogenesis** **ii) Extra Intestinal Manifestations**

Answer 99

**i)** Environmental trigger with a genetic susceptibility **ii)** Perianal disease - crohn's Eyes - Uveitis, Iritis, conjunctivitis, episcleritis Mouth- Apthous Ulcers, Angular stomatis (If concurrent iron deficiency), Glossitis (B12 deficiency) Skin - Erythema Nodosum, pyoderma gangrenosum Joints - Associated inflammatory arthropathy, Ankylosing Spondylitis/Sacroilitis (Crohn's) Biliary - Gallstones (Chron's), Primary Sclerosing Cholangitis (UC), Cholangiocarcinoma (following on from PSC) Urinary Tract Calculi

Question 100

**i) Define naevus** **ii) Main Types of Melanoma** **iii) RFs for melanoma**

Answer 100

**i)** Naevus - benign proliferation of normal skin constituents **ii) Superficial Spreading Melanoma** Nodular melanoma Acral Lentiginous Subungual Lentigo Malgina Melanoma Amelanocytic Melanoma **iii) Congenital -** Skin Type (Fitzpatrick scale), FH, Presence of lots of naevi, Xeroderma Pigmentosum, Albinism, Giant congenital pigmented naevi **Acquired** Sunlight Exposure (radiation in general), Immunosuppresion

Question 101

**i) Characteristics of Melanoma** **ii) Type of biopsy for suspected melanoma** **iii) Classification and recommended margin**

Answer 101

**i) Malingnant proliferation of melanocytes** **A** symmetry Irregular **B** orders Multiple **C** olours **D** iameter \>6mm **E** volution (changing **ii)** They should undergo **excision biopsy with 2mm margin** **iii)** **Breslow Thickness (**from stratum granulosum to the deepest point of tumour involvement) **\<1mm - 1cm Margin** **1-2 mm - 1- 2cm Margin** **2-4mm - 1-2cm Margin** **\>4mm - 2cm Margin**

Question 102

# Define + Locate + Ix/Mx : **i) Branchial Cyst** **ii) Thyroglossal cyst** **iii) Dermoid Cyst** **iv) Sebaceous Cyst**

Answer 102

**i) Branchial Cyst** is stratified squamous epithelium incoorporated into cervical lymphatics (previously thought to be branchial pouch remnant) **Found -** Anterior triangle. Anterior to upper 1/3 of SCM **Ix -** FNA +/- US guidance. CT/MRI to characterise location **Mx -** Excision **ii) Thyroglossal Cyst** is a midline swelling that moves superiorly on tongue protrusion. Remnant of thyroglossal duct containing lymph tissue/ thyroid tissue. **Ix -** US neck/ Cross-sectional imaging (sometimes patients dont have thyroid gland) **Mx -** Sistrunk's procedure - removal of cyst, duct, and hyoid bone **iii) Dermoid Cyst** is an epithelial lined cyst lying deep to skin. **Congenital** (angles of eyebrows, midlien nose, midline of neck/trunk) or **acquired**. **Ix -** US in congenital to ensure no communication with underlying structure **Mx -** Excision **iv)** Smooth swellings attached to the skin with a punctum occuring on the scalp,face, neck + trunk **Truly either:** **Epidermoid Cyst (epidermis)** **Pilar Cyst (hair cells)**

Question 103

**i) Define Ludwig's Angina**

Answer 103

**i)** Cellulitis of cervical/floor of mouth soft tissues **usually** secondary to dental infection. - Require resucitation, airway observation/management, antibiotics +/- surgery

Question 104

## Footnote **i) Cystic Hygroma - Define + Mx** **ii) Pharyngeal Pouch - Define + Mx**

Answer 104

i) Congenital cystic malformation of lymphatics often occurring in the **posterior triangle of the neck** **Mx -** Aspiration and Sclerotherapy/ Excision (High recurrence rate for either) ii) **True Diverticulum** through **Killian's Dehiscence (**Weakness between thyropharyngeus and cricopharyngeus). Usual presentation through regurgitation, cough, halitosis in old men. **Ix - Barium Swallow** **Mx -** Endoscopic Stapling / External Excision

Question 105

**What to do when you see neck lump?**

Answer 105

History ENT Exam FNA Imaging

Question 106

**Types of necrosis**

Answer 106

**Coagulative** - most common **Caseous -** TB **Liquefactive -** Brain **Gangrenous -** Wet/Dry **Fat** **Necrosis**

Question 107

# Define: **i) Necrosis** **ii) Apoptosis** **iii) Outline differences between apoptosis and necrosis**

Answer 107

**i)** Abnormal cell death in life. Always accompanied by inflammation. **ii)** Programmed cell death - apoptotic bodies are produced that are phagocytosed. Generally not accompanied by inflammation.

Question 108

**General spread routes of carcinoma vs sarcoma** **Which thyroid cancer variant spreads haematogenously?**

Answer 108

**Carcinoma -** spreads by lymphatics **Sarcoma -** Spreads haematogenously **Follicular thyroid cancers spread haematogenously**

Question 109

**Key differences between benign and malignant neoplasms**

Answer 109

Question 110

**Examples of hyperplasia and hypertrophy**

Answer 110

**Hyperplasia** **Physiological -** Thyroid in pregnancy, Breast tissue in pregnancy **Pathological -** BPH, Adrenals, Parathyroid **Hypertrophy** **Physiolgoical -** Skeletal muscle, Uterus in pregnancy **Pathological -** Cardiomyopathy, Thyroid in grave's

Question 111

**Rheumatic Fever:** **i) What is it?** **ii) What type of hypersensitivity reaction?** **iii) Criteria?**

Answer 111

i) Systemic immune response to untreated Group A Strep ii) Type 2 Hypersensitivity - Antibodies produce against antigen iii) **Jone's Criteria** **Major -** Joints, Myocarditis, Subcutaenous Nodules, Erythema Marginatum, Sydenham's Chorea **Minor -** CRP, Arthralgia, Fever, ESR, Prolonged PR, Anamnesis, Leukocytosis **For Dx -** Positive culture/ ASOT + **2 Major / 1 Major + 2 Minor**

Question 112

**i) Diagnosis of infective endocarditis** **ii) Why is it hard to treat?** **iii) What to do pre-op with IE patients?**

Answer 112

**i) 2 Major, 1 Major + 3 Minor, 5 Minor** **Major - Blood Cultures** 2 Blood Cultures Positive with typical organism Persistently positive blood cultures **Major - Echo** Evidence on echo of IE - Vegatation, abscess, prosthetic valve dehiscence **Minor -** i) Predisposing Factor ii) Fever \>38 iii) Vascular Phenomena - Janeway, Emboli, Pulmonary infarct, Conjunctival Haemorrhage iv) Immunological phenomena - Osler's Nodes, Roth Spots, GLomerulonephritis v) +ve Blood culture vi) Echo findings **ii)** The valves do not have direct blood supply so neither antibiotics/immune system can reach it **iii)** -Echo - Cardio Review - Consider prophylactic antibiotics

Question 113

**Acute Pancreatitis** **i) Definition** **ii) Most important enzyme in the pathogenesis** **iii) Which enzymes are released?** **iv) When do amylase levels began to decline?** **v) Complications** **vi) Blood Supply to the pancreas**

Answer 113

**i)** Acute pancreatitis reversible inflammatory process of the pancreas that can effect multiple organisms **ii)** Activation **of trypsinogen --\> trypsin.** This is thought to begin the activation cascade **iii)** Lipases, Proteases, Elastases, Amylase **iv)** Levels begin to fall between 24-48 hours after initial insult **v) Complications -** **Early** - Hypocalacaemia, ARDS, Abdominal Collection, Infection, Shock, Pleural effusion, Coagulopathy, hypercalcaemia, renal failure **Late** - Pseudocyst, Chronic Pancreatitis, Malnutrition, Pancreatic Necrosis, Abscess, Haemorrhage, Thrombosis **vi) Superior pancreatoduodenal artery** (Branch of the gastroduodenal artery) **Inferior pancreatoduodenal artery** (1st Branch of the SMA) **Splenic Artery**

Question 114

**Parotid Gland:** **i) Causes of bilateral parotid gland swelling** **ii) Unilateral Parotid Gland Swelling** **iii) Are salivary gland stones more common in submandibular or parotid gland?** **iv) Sign of malignancy?** **v) Post Op Complications of paritodectomy**

Answer 114

**i) Bilateral Parotid Gland:** **Local -** Sjogren's, Mumps, Parotitis, **Systemic -** TB, Sarcoid, Alcohol, Cushings **Drugs -** OCP, Thiouracil, Isoprenaline **ii) Unilateral parotid gland:** **Benign -** Sialolithiasis, Duct Compression, Neoplasia (Pleomorphic Adenoma + Warthin's Tumours), Mumps, Parotitis **Malignant -** Mucoepidermoid carcinoma, Adenoid Cystic Carcinoma **iii)** They are more common in the **submandibular** **gland** because the salivary content is more alkaline and mucous containing higher concentrations of calcium and phosphate - **Parotid Calculi -** Small, multiple intraglandular **- Submandibular Calculi -** Large, single intraductal **iv)** Ipsilateral CNVII Palsy **v)** CNVII Palsy, Frey's Syndrome (auriculotemproal nerve fibers reattaching to cutaneous sweat glands), Salivary Fistula, Greater Auricular Nerve Damage (C2-C3 Nerve Roots)

Question 115

**i) Pain history with gastric vs duodenal ulcers** **ii) Cx of PUD** **iii) PUD aetiology**

Answer 115

**i) Gastric -** Pain related to eating **Duodenal -** Pain before meals and relieved by eating **ii)** Bleeding (DU - GDA) Perforation Gastric Outflow Obstruction (scarring/inflammation) Malignant Transformation **iii) Drugs -** NSAIDs, Steroids, Smoking, Alcohol **Infection -** H Pylori **Phsyiological stress**

Question 116

**i) Bilroth Operations** **ii) Vagotomy purpose**

Answer 116

**i) Bilroth I -** Partial gastrectomy with re-anastamosis **Bilroth II -** Partial gastrectomy + duodenal stump + proximal jejunal anastamosis **ii)** **Vagus nerve usually:** **Inhibits** Somatostatin **Stimulates** Gastric acid, gastrin + histamine release **Vagotomy** is useful in preventing peptic acidity related issues

Question 117

**i) Polyp Classification** **ii) Polyp complications**

Answer 117

**i) Neoplastic -** Tubular (most common), Tubulo-villous, Villous (most malignant potential) **Non - Neoplastic -** Metaplastic, hamartamous, Inflammatory psuedopolyps (UC) **ii)** Malignant transformation, ulceration, bleeding, infection, Hypokalaemia/hypoalbuminaemia, intesusseption

Question 118

**Any medications reducing number of polyp in familial polyposis ?**

Answer 118

**Celecocoxib - COX2 NSAID** **Sulindac - A non COX NSAID** Both reduce the numbers and size of polyps

Question 119

i) Define: Dysplasia ii) Define: Metastasis

Answer 119

i) **Dysplasia -** Abnormal cellular development with pre-malignant characteristics such as a abnormal mitosis and pleomorphism **but** no invasive features (membrane intact) ii) **Metastasis -** The survival and growth of cancerous population at a secondary site from original population

Question 120

**BPH:** **i) Aetiology** **ii) Symptoms** **iii) Work-up** **iv) Mx** **v) What is PSA?**

Answer 120

**i)** Age, Metabolic, Androgen, Genetic Susceptibility ii) **Storage** - Frequency, Urgecy, Nocturia **Voiding** - Stream, Dribbling, **iii)** **History/ Exam -** + PR + Voiding Diary **IPSS** **US/TRUS/MRI/IVU** **PSA** **Urodynamic studies** **iv) Mx:** **Lifestyle -** bladder training, reduce night time drinking **Medication -** Alpha antagonist, 5 a reductase **Surgery -** TURP/HOLEP/TULIP, Prostatectomy **v) PSA -** Is a glycoprotein enzyme that usually liquefies semen and dissolves cervical mucous

Question 121

**i) Prostate cancer grading** **ii) Prostate cancer treatment** **iii) Ix** **iv) PSA monitoring post-prostatectomy**

Answer 121

**i) Gleason Score:** First most common pattern scored 1-5 Second most common pattern scored 1-5 **Add them both togethter to give you the overall score** **ii) Prostate cancer treatment:** a) Watchful waiting b) Radiotherapy/ brachytherapy c) Hormonal therapy - Androgen receptor antagonist (flutamide), LHRH agonists (Goserelin) d) Orchidectomy, TURP, Radical Prostatectomy +/- chemotherapy **iii) Ix:** History/ Exam/ PR / Spinal Exam PSA TRUS + Biopsy/ MRI Prostate Spinal Imaging **iv) 6 weeks** after procedure **6 monthly** for **first 2 years** Then **annually** PSA should be undetectable a week after surgery as the half life is 2-3 days

Question 122

**TURP Complications**

Answer 122

Bleeding, UTI, Urinary Retention Retrograde ejaculation Urinary incontinence Urethral strictures Erectile Dysfunction TURP Syndrome

Question 123

**DDx for Voiding/Storage Sx**

Answer 123

**Bladder Outflow Obstructions** Prostate - BPH/Ca, Urethral Stricture, Urethral sphincter dysynergia **Bladder Dysfunction** Oversensitvity, detrussor overactivity, low detrussor contractility

Question 125

**Difference between :** **Staging and Grading**

Answer 125

**Staging -** Assessment of size and spread of tumour **Grading -** Histological assessment of level of cellular differentiation

Question 126

**Complications of ureteric stones**

Answer 126

i) They may not pass ii) Hydroureter + hydronephrosis iii) Infection iv) Haematuria

Question 127

**i) Why do renal calculi form?** **ii) Types and incidence of calculi**

Answer 127

**i) Anatomy -** Kidney ariants, VU Reflux **Infection -** Proteus (struvite) **Stasis -** Atonic bladder, bladder outflow obstruction **Dehydration** **Electrolytes-** Uric acid cycle abnormalities, Cysteinuria, Hypercalcaemia, Hyperuricaemia **ii)** Calcium Oxalate - **75%** Struvite - **15%** Uric Acid - **5%** Cysteine - **2%**

Question 128

**How are protues mirablis + helicobacter pylori similar?**

Answer 128

Both secrete urease enzyme which cleaves urea to ammonia

Question 129

**Differences between smooth muscle and skeletal muscle**

Answer 129

**Smooth -** Non- Striated Uninucleated Calmodulin (Calcium Binding Protein) Absence of T Tubules **Skeletal-** Striated Multinucleated Troponin (Calcium binding protein) T Tubules

Question 130

**i) Micturition Control** **ii) Spinal injury above T12** **iii) Spinal injury below T12**

Answer 130

**i) Parasympathetic** - Contracts bladder and relaxes internal sphincter - **Pelvic Nerve** S2-S4 **Sympathetic** - Relaxes bladder and contracts internal sphincter - **Hypogastric Nerve** T12 - L2 **External Sphincter -** Pudendal Nerve **ii) Above T12 produces a reflex bladder -** Bladder empties as it fills. **No control over external urethral sphincter** (constantly relaxed) / no awareness of filling **iii)** **Below T12 produces an atonic bladder** Detrussor muscle is paralysed and therefore **spinal reflex** doesn't work. **Bladder empties with overflow incontinence**

Question 131

**i) Define AKI** **ii) What is dysequilibrium syndrome**

Answer 131

**i) AKI** a) Creatinine rise \>26 nm/L in 48 hours b) Creatinine increase 1.5x in 1 week c) UO \<0.5 ml hour for 6 hours **ii) Dysequilibrium Syndrome** Cx of dialysis where rapid changes in serum osmolality lead to cerebral oedema

Question 132

**Side effects associated with:** **i) Tacrolimus** **ii) Cyclosporin** **iii) Azathioprine** **iv) Steroids** **Specific to immunologics**

Answer 132

**i) Tacrolimus -** Nephrotoxic, neurotoxic **ii) Cyclosprin -** nephrotoxic, gingival hypertrophy, hypertension, hirsutism **iii) Azathioprine -** Leukopenia **iv)** **Steroids -** Skin- Thin, striae, bruising, poor wound healing Fat - buffalo hump, centripetal obesity, cushing facies Proximal myopathy CV - Hypertension, Fluid retention GI - Pancreatitis, Peptic Ulcers Endocrine - Diabetes Bone - Osteoporsis, Avascular necrosis **Immunologics:** **Infection -** TB reactivation, CMV (Valganciclovir proph.), Pneumocystis Jerovici (co-trimoxazole proph.), JC Virus, **Malignancy -** Cutaenous, Kaposis, Lymphoma

Question 133

**i) Donor Matching - What do you look for?** **ii) Vascular anastamosis in renal tranpslants** **iii) What is in renal perfusion/preservation solution?** **iv) Immunosuppresion regimen for renal transplants** **v) Broad types of rejection** **vi) Confirming rejection**

Answer 133

**i) ABO** Compatibility **HLA** HLA- A, B & DR are the most important **ii)** Donor renal artery/vein transplanted to recipient External iliac artery/vein **iii)** Ice cold solution: impermeable solutes (minimises swelling), pH buffers, free radical scavengers, membrane stabilisers, Adenosine (for ATP) **iv)** At time of surgery: **Steroid** + **One of** Alemtuzumab (CD-52) Basiliximab (CD25), Anti thymocyte globulin (CD3) Afterward: **Triple** **therapy** - Calcineurin inhibitor (Cyclosporin/Tacrolimus - Blocks IL2 mediated T Cell expansion), Purine Synthesis INhibitor ( Azathioprin), Prednisonolone **v) Hyperacute -** Donor antibodies attack graft. Massive complement activation. **Acute -** T Cell mediated within first 100 days. Lymphocyte infiltration **Chronic -** B cell mediated chronic vascular/atrophic changes. **vi) Renal Biopsy**

Question 134

**Complications from renal transplant**

Answer 134

**Rejection -** Hyperacute (minutes), Acute (100 days), Chronic **Delayed Function -** Reperfusion injury, long cold ischaemic time **Vascular -** Anastomatic failure/leak, Torturous vessels, Vascular thrombosis, Vascular Stenosis **Urological -** Urine leak, Ureteric stenosis **Infection -** Wound, Urine **Lymphocele**

Question 135

**i) Cryptorchidism** - define + associated RFs ## Footnote **ii) Where are undescended testes usually found?** **iii) Mx**

Answer 135

**i) Cryptorchidism -** Failure of tested to descend from abdomen into scrotum. Associated with - low birth weight, high pressure abdomen, hormonal abnormalities **RFs -** increased risk of testicular malignancy + infertility (orchidopexy reduces the risk but to that of normal background population **ii)** Usually found in the inguinal canal. But can be found anywhere along the gubernaculum **iii) Mx -** In neonates referral to surgeon after 6 months whereby surgery (orchidopexy) should occur between 6 months - 1 year If in an adult - Orchidectomy if offered to mitigate testicular cancer risk **iv)**

Question 136

**i) Testicular Cancer Types** **ii) Radiotherapy in testicular cancer** **iii) Where do they tend to metastasise to?** **iv) Lymphatic Drainage**

Answer 136

**i) Germ Cell Tumours** Seminomas (Most Common, 30-40 yo) (ALP, b-HCG) Non- Seminomatous Germ Cell Tumours **Non - Germ Cell Tumours** Teratomas (20-30 yo) (B-HCG, AFP, CEA) Choriocarcinoma ( B HCG) Yolk Sac Tumours Embryonal carcinoma Mixed germ cell tumours **ii) Radiotherapy** is useful in seminomas **iii)** Tend to metastasise to Lung, Bladder, Colon and Pancreas **iv)** Lymphatic drainage of the: **testes -** paraortic nodes (therefore incision should be inguinal for cancer operations rather than scrotal so as not to cause tumour seeding to a different lymphatic group) **scrotal skin -** inguinal lymph nodes

Question 137

**Basal Cell Carcinomas** **i) Classical description** **ii) Mx** **iii) What is bowen's disease**

Answer 137

**i)** Pearly Papule/Nodule with rolled edge **ii) Mx -** Surgical Excision 5 FUC Cream, Imiquimod **iii) SCC in situ -** Erythematous slowly growing plaque on skin

Question 138

**i) Cytological Features of malignancy** **ii) Histological Features of malignancy** **iii) Pros and Cons of Cytology** **iv) Pros and cons of histology**

Answer 138

**i) Cytological Features** Increased mitotic figures Abnormal mitoses Hyperchromatic nuclei (increased DNA) Pleomorphism Increased nuclear to cytoplasmatic ratio **ii) Histological Features** Loss of normal tissue architecture Invasion through BM Neovascularisation Necrosis Haemorrhage **iii) Cytology:** **Pros:** Quick, Cheaper, Minimally Invasive **Cons:** Not as much information, not always sensitive/specific for cancer, Often need to repeat sample obtaining for histology **iv) Histology:** **Pros:** Allows staging of cancers, Lots of information about tissue **Cons:** Longer process (tissue fixing), Invasive, Expensive, Seeding,

Question 139

**i) Spleen Functions** **ii) Normal Weight/Size** **iii) Splenic Injury Grading** **iv) Indications for splenectomy** **v) Complications of splenectomy** **vi) Which vaccines**

Answer 139

**i) 1) Immune response** **-** Splenic Macrophages present antigens to lymphocytes - Filters encapsulated organisms **2) Filter Circulation** - Filters more old RBCs **3)** **Storage of platelets** - Stores 30% of body platelets **4) Neonatal Haematopoiesis** **5) Iron Re-utilisation** ii) **Weight -** 100-200g **Size -** 8-13cm **iii)** **Graded 1-5** 1 - Capsular Tear - **\<1cm** 2 - Capsular Tear - **1-3 cm** 3 - **\>3cm** involving **trabecular** **vessels** 4 - **\>25% of spleen** involving segmental/hilar vessels 5 - **Shattered spleen/ Hilar vascular injury** **iv) Indications:** **Trauma** **Hypersplenism -** Sickle Cell, HS, HA **Malignancy -** Primary splenic / Radical surgery for pancreatic/colonic cancer **v) Complications:** **Early -** Haemorrhage, Gastric Stasis, Gastric Necrosis, Subphrenic collection, pancreatitis **Late -** Thrombocytosis, Infection (encapsulated organisms), Pancreatic fistula **vi)** Other than Pen V - Pneumoccocus, haemophillus, Menigitis, Flu

Question 140

**Causes of splenectomy**

Answer 140

**Infection -** EBV, CMV, TB, Malaria, Kala Azar **Portal hypertension** **Haematological -** Haemolytic anaemia, SCD, HE, HS Thalassaemia, CML **Systemic -** Sarcoid, Rheumatoid arthritis, Gaucher's Disease

Question 141

**Duke's Staging**

Answer 141

A - Bowel Wall (**5YS 95%)** B - Through Bowel Wall **(65-75%)** C - Lymph Node Mets (**30-40%)** D - Distant Mets (**5-10%)**

Question 142

**Groin Lump DDx**

Answer 142

**Skin -** Sebaceous Cyst **Subcutaneous -** Lipoma, Lymph Node **Neurovascular -** Saphena Varix, Pseudoaneruysm, Neuroma **Bowel -** Hernia **Other -** Ectopic Testes, Groin Abscess

Question 143

**i) Define: Teratoma** **ii) How is a teratoma linked to gynaecomastia**

Answer 143

**i) Tumour able to form tissues from all three cell layers (Ectoderm, Mesoderm, Endoderm)** **-** Tumour markers B-HCG / AFP **ii)** **Teratomas/Choriocarcinomas** CAN express **B-HCG. B HCG** can mimic Thyrotrophic Releasing Hormone and therefore cause gynaecomastia (through stimulating prolactin secretion)

Question 144

**i) Define: Ulcer** **ii) RFs for PUD** **iii) How does h pylori cause ulceration?** **iv)**

Answer 144

i) An abnormal discontinuation of a mucous membrane ii) **Drugs** - Steroids, NSAIDS, bisphosphonates etc., alcohol, smoking **Infection** - H Pylori **Stress, High Vagal Tone** **Gastrinoma** (ZE syndrome) **Hypercalcaemia** (Ca++ stimulates GA secretion) iii) **H Pylori:** H Pylori produces - Proteases + Phospholipases + Urease (but problem is ammonia). The three of which cause breakdown of mucous covering in stomach. Leaving the epithelium exposed to gastric acid which is hypersecreted due to gastritis cuased by H Pylori.

Question 145

**Ix of painless haematuria**

Answer 145

**History + Examination + PR** **Urine -** MC&S, Cytology **Bloods -** Hb, Renal Function Testing, PSA **US/TRUS +/- Biopsy** **CT pre/post contrast** **Cystoscopy +/- biopsy**

Question 146

**Renal Cancers** **i) Types** **ii) what is VHL** **iii) Treatment for bladder CIS** **iv) Describe ileal conduit**

Answer 146

**i) Renal Cell Carcinoma** (most common), Clear Cell, Sarcoma, Rhabdoid renal cell **ii) von Hippel Lindau Syndrome (AD)** - RCC, Phaeochromocytoma, Pancreatic islet cell tumours, Retinal angiomas, CNS haemangioblastomas **iii)** Intravesicular B-HCG First line. This can be given multiple times and patients are followed up with repeat cystoscopies and biopsies **iv) Urine diversion method:** Small ileal portion resected. Distal/Proximal bowel portions anastamosed together. Ureters anastamosed to this portion of ileum. One end oversown + the other end brought up as urostomy.

Question 147

**Where is b12 absorbed?**

Answer 147

**Terminal ileum:** - Therefore effected in crohn's disease/ UC (backwash ileitis)/ Ileal resections Deficiency can cause: - Macrocytic anaemia, peripheral neuropathy, SACD

Question 148

**What secretes:** **i) Gastric Acid** **ii) Gastrin** **iii) pepsinogen** **iv) mucous** **v) what inhibits gastric acid secretion**

Answer 148

**i) Gastric Acid** - Parietal Cells **ii) Gastrin -** G Cells (antrum) **iii) pepsinogen -** Chief cells **iv) mucous -** mucous cells **v)** **GA secretion inhibited by - Indirect inhibiition of scretion through --\>** Secretin, Cholecystokinin + Somatostatin

Question 149

**MOA of PPI**

Answer 149

Irreversible blocker of **H+/K+ ATPase** **pump** on parietal cells

Question 150

i) 1st line imaging for suspected perforation ii) Mx of bleeding DU

Answer 150

**i) ERECT CXR** **ii) A-E** **IV PPI** **UGI Endoscopy +/-** Injection/ coagulation/ clipping **Surgery -** Underrunning of the bleeding artery and perforation

Question 151

**Gastric Cancer Metastasis**

Answer 151

**Lymphatic -** Local lymphatics, Supraclavicular LNs (Virchow's) **Direct -** Omentum, Pancreas, Diaphragm, Duodenum, Colon **Haematogenous -** Lung, liver

Question 152

**What is virchow's triad?**

Answer 152

**Altered Flow** - stasis/ turbulence **Altered Constituents** - hypercoaguable - infection/platelets/RBCs/drugs AntithrombinIII/ Protein C/S Deficiency pregnancy, trauma, surgery **Vessel wall** - endothelial injury

Question 153

**Thyroid Cancer:** **i) Presentation** **ii) Classify thyroid tumours** **iii) Investigating thyroid masses in clinic**

Answer 153

i) Neck Lump, Odynophagia, Hoarse voice, lymphadenopathy ii) **Benign -** Follicular Adenoma, cysts, nodules **Malignant (primary)-** **Papillary Carcinoma, Follicular Adenocarcinoma,** **Anaplastic, Medullary** (MEN IIA/B)**,** **Lymphoma** **Malignant (Secondary) - Direct invasion usually** (oesophagus, larynx) iii) Triple Ax - Examination, Imaging, Biopsy

Question 154

**MEN**

Answer 154

**Multiple Endocrine Neoplasia -** AD inherited conditions characterised by hyerplasia/neoplasia in various endocrine tissues **MEN1 (Chromosome 11)** Pituatry Adenoma Pancreatic Islet Tumours Parathyroid Hyperplasia **MEN2a** Parathyroid Hyperplasia Phaeochromocytoma Medullary Thyroid Cancer **MEN2B** Phaeochromocytoma Medullary Thyroid Cancer Marfanoid type body habitus Mucosal Neuromatosis

Question 155

**TB** **i) What are mycobacterium** **ii) Atypical mycobacterium** **iii) What is miliary TB?** **iv) Diagnosis**

Answer 155

**Mycobacterium Tuberculosis** i) Non-motile, non-sporulating, Weak Gram +ve rods. (Actinomycetales) ii) Mycobacterium Avium, Mycobacterium bovis, mycobacterium leprae, mycobacterium marinum iii) **Miliary TB -** widespread **lymphatic** + **haematogenous** **spread** of **TB** seen as small 2mm deposits in **immunocompromised** patients v) AFB (Ziehl - Neelson Staining), Quantiferon/Elispot Lowensten-Jensein Culture MEdia

Question 156

**i) Define: Tumour Marker** **ii) Examples**

Answer 156

**i)** Tumour markers are circulating substances found in patients with neoplasm. Not always proportional to tumour burden **ii) CEA -** Colonic, Cholangio, Teratoma **Ca19-9 -** Pancreatic, Cholangio **CA125 -** Ovarian **AFP -** HCC, Teratoma **b-HCG -** Teratoma, Seminoma **Calcitonin -** Medullary Thyroid **PSA-** Prostate Adenocarcinoma **Chromogranin/ Urinary 5HIAA -** Carcinoid **Placental Alk Phos -** Seminoma

Question 157

**i) Types of Wound Healing** **ii) Types of scarring**

Answer 157

i) **Primary -** Re-approximation of wound edges **Secondary -** No direct closure allowing for granulation tissue to form over wound (VAC Dressings, Packing with kaltostat) **Tertiary -** Delayed primary closure (re-approximation) with initial intentional leaving of wound open **ii) Hypertrophic -** Does not extend beyond edges of initial wound **Keloid -** Extends beyond edges of initial wound

Question 158

**Stages of wound healing (6)**

Answer 158

1) Haemostasis / Coagulation 2) Inflammation 3) Granulation (Fibroblasts, macrophages, epithelial cells) 4) Angiogenesis 5) Epitheliasation --\> Fibroblast proliferation --\> Wound contraction (myofibroblasts) 6) Maturation and remodelling (up to 1 year to beyond 1 year)

Question 159

**Causes of impaired wound healing**

Answer 159

**Patient -** Steroid use, age, diabetes, poor nutrition, hypoxia, other co-morbidities, Drugs **Pathology -** Infection, Tumour, **Site -** Pressure bearing sites, Radiotherapy, Wound closure technique (tension on sutures), compromised blood supply (PVD)

Question 160

**Describe the clotting cascade**

Answer 160

**Intrinsic Pathway-** XII -\> XI-\> IX -\> VIII -\> common pathway **Extrinsic Pathway-** VII **Common pathway** X -\> V -\> Thrombin -\> Fibrin

Question 161

**What is FISH**

Answer 161

**FLuorescent in situ hybridisation** - Cytogenetic method of analysis allowing for the detection of mutagenic DNA - With reference to cancers it can help identify types of mutations associated with cancers and there for assess suitability for certain immunological treatments

Question 162

**What is CRP**

Answer 162

**Capsular Polysaccharide - Reactive Peptide** Released from the **liver** in response to IL-6 secreted from macrophages/T Cells. **Function** - Binds to surface of dead/dying cells to mark them for **complement** **system**

Question 163

**Fever mechanism**

Answer 163

Pyrogen --\> PGE2 secretion --\> acts on hypothalamus which increases "thermal set point" --\> Thus causing various thermal regulating factors (shivering, adrenaline secretion, vasoconstriction)

Question 164

**Types of omental tumours**

Answer 164

Leiomyosarcomas, Fibrosarcoma, Liposarcoma, Haemangiopericytoma

Question 165

**How are clots degraded**

Answer 165

**Plasmin** is produced by the **liver**. It is **converted** to **Plasminogen** by: Urokinase, tissue plasminogen activator **Plasminogen** breaks down fibrin

Question 166

**How do Tyrosine Kinase inhibitors work**

Answer 166

**They are small molecule inhibitors:** Bring about their action by preventing the downstream signalling pathway. Actions: - Allosteric binding of receptor domains - Competition for substrate (ATP) - Prevent maturation of the kinase domain proteins themselves

Question 167

**Adhesive Capsulitis:** **i) Presentation** **ii) Pathophysiology** **iii) Treatment**

Answer 167

**i)** **presentaiton -** I - freezing phase (insidious reduction in ROM and pain) II - Frozen phase **ii)** **Inflammation** of **joint** **capsule** followed by a **chronic inflammatory and fibrotic phase** **iii)** **Conservative -** Physiotherapy **Medical -** Analgaesia, Anti inflammatories, Intra-articular steroid injections, short term oral steroids **Intervention** - External coroporeal shockwave therapy, Joint MUA, Capsule Release, Scalene block

Question 168

# Define: **i) Sequestrum** **ii) Involucrum**

Answer 168

i) **Sequestrum -** Piece of dead bone within alive bone usually in the setting of osteomyelitis **ii) Involucrum -** Piece of living bound surrounding dead bone usually in the setting of osteomyelitis

Question 169

**Categories of biohazard**

Answer 169

**1- 4 Classification** **1-** Well known organisms that are not a threat to healthy humans **2-** Mild diseases can be caused in healthy humans - Chicken Pox, Influenza **3-** Severe/Fatal diseases can be caused in healthy humans **but** treatment/vaccination exists - TB, anthrax, malaria **4-** Severe/Fatal diseases can be caused in healthy humans **for which no treatment/vaccine exists -** Ebola, Marburg, Mers, Sars, Coronavirus

Question 170

**Steps for contact tracing**

Answer 170

**1 Contact Identification** Detailing patient 0s activitities can help elucidate who likely contacts can be (friends, colleagues, healthcare professionals) **2 Contact Listing** Contacts should be contacted: - Explained symptamtology - High risk may be quarantined - preventative measures **3 Contact Follow Up** - Follow up for symptoms/ testing

Question 171

**Serological Tests for TB**

Answer 171

Interferon Gamma Assays: - Whole blood is taken and exposed to various TB Antgiens - Quantitative analysis of interferon gamma is conducted ---\> High levels are sensitive for TB TB PCR Antibody Detection Assays: - These tests depend on there being an active TB infection whereby anti-TB antibodies are being actively secreted

Question 172

**Mechanism of paradoxical aciduria**

Answer 172

**Occurs in the context of metabolic alkalosis:** Hypovolaemia (vomiting, diarrhoea etc) leads to fluid and electrolyte losses. Activation of RAAS (Hypovolaemia, hyponatraemia). Increased Na+ Retention and K+ excretion In the context of **hypokalaemia,** instead of K+ being excreted, H+ is excreted leading to acidic urine

Question 173

**Causes of papilloedema**

Answer 173

**Primary -** Idiopathic Intracranial Hypertension **Secondary -** **Raised intracranial pressure** **Space Occupying Lesion** (Tumour, abscess) **Diffuse oedema** (Hypoxia, Head injury, Toxins) **Haemorrhage** (Sub arachnoid haemorrhage) **Venous sinus thrombosis (**Cavernous) **Inflammation -** Meningitis, encephalitis

Question 174

**Oxygen Dissociation Curve** **i) Causes of left shift** **ii) Causes of right shift**

Answer 174

**i) Left Shift (INCREASED affinity for O2)** DECREASED - Co2, pH, 2-3 DPG, Temperature **ii) Right Shift (DECREASED affinity for O2)** Increased - CO2, pH, 2-3 DPG, Tempeature

Question 175

**Abdominal Compartment Syndrome** **i) What mmHg?** **ii) Causes?**

Answer 175

**i) \>20 mmHg** **ii)** **Retroperitoneal -** AAA rupture, pancreatitis, Retroperitoneal bleeding, Retroperitoneal abscess **Intraperitoneal -** Haemorrhage, AAA rupture, Bowel/gastric obstruction/dilation, pneumoperitoneum, abdominal packing, abscess, SIRS **Abdominal Wall -** Burns, laparotomy closure under tension, abdominal binders, **Chronic -** central obesity, pregnancy, ascites

Question 176

**Describe the Hypothalamopituitary Axis**

Answer 176

**Hypothalamus** (Blood enters via the **superior hypophyseal artery)**: **Parvicellular neruones** secrete **neurotrophic hormones in hypothalamus into the superior hypophysealartery** which travels in the **portal vessels** to the **pituitary gland:** Gonadotrophin RH, Corticotrophin RH, Thyroid RH, Growth Hormone RH **Pituitary Gland:** **Anterior (Adenohypophysis):** TSH, Growth Hormone, Lutenising Hormone, Follicle Stimulating Hormone, Adrenocorticotrphic Hormone, Prolactin **Posterior (Neurohypophysis):** Antidiuretic Hormone, Oxytocin

Question 177

**i) Risk factors for nasopharyngeal carcinoma** **ii) what type of cancer is it?** **iii) What other differentials would you have?**

Answer 177

i) Male Age Salt Cured Food Eppstein Barr Virus Family history Alcohol Smoking Tobacco **ii) Squamous cell carcinoma** **iii) SCC, MALT-oma, Lymphoma, TB, Tonsillitis, Tonsillar Abscess**

Question 178

**Life span of :** **Neutrophil** **Lymphocyte** **RBC** **Platelet**

Answer 178

**Neutrophil - 7 Hours in blood (5 days in tissue)** **Lymphocyte - Variable (Days to years)** **RBC - 120 days** **Platelet - 7-10 days**

Question 179

**Endometriosis:** **i) Locations** **ii) Histology** **iii) Rx**

Answer 179

Presence of ectopic endometrial tissue. Adenomyosis is the presence of endometrial tissue in the myometrium **RFs -** FH, Early Menarche, Dysmenorrhoea, Menorrhagia, **i) Locations -** Ovaries, Broad ligament, uterosacral ligament, colon, bladder **ii) Histology** - Endometrial glands and stromal elements **iii) Rx -** COCP, GnRH Analogue, Danazol Surgery - Conservative / Radical

Question 180

**Causes of obstructive jaundice**

Answer 180

**Intrahepatic** - Hepatitis - Viral, Alcoholl, Drug Induced, - Cirrhosis - Drug induced stasis - PBC/ PSC - Malignancy - Infections **Extrahepatic** - Malignancy - Stricture - Stone - SOD Dysfunction - Infections / Abscess (Histoplasma, Ascaris, Flukes) - PBC/PSC

Question 181

**Enteroehepatic receycling** **i) Method** **ii) Why is it important** **iii)** **What is bilirubin conjugated to?**

Answer 181

**i)** Bile acids are secreted by the liver into the bile ducts and stored in the gallbladder. Secreted in bursts throughout the day in concjunction with mealtimes. They are then re-absorbed by enterocytes in the terminal ileum enterring the portal circulation for re-secretion into the duodenum. **ii) -** The liver is only capable of synthesising 3g of bile acids a day. Through cycline 24g of bile acids a day are excreted into the liver to cope with the 100g of fat the average person consumes. **-** Downstream effects of bile acids (beyond the ileum) can contribute to steattorhoea, impaired water and electrolyte absorption - Important in absorption of fat soluble vitamins **iii)** Conjugated to **Glucoronic Acid** by **Glucoronyltransferase** in the liver

Question 182

**Explain the signs of obstructive jaundice**

Answer 182

**Icterus -** Elevated **conjugated bilirubin** in blood deposits extracellularly. **Pale Stools -** **Conjugated** **bilirubin** does **not** enter the intestine. Usually when it does it is broken down by bacteria to **stercobilin** which gives the stools their brown colour. **Dark Urine -** **Conjugated** **bilirubin** **accumulates** in the blood and is **excreted** through the **urine** thus making it dark. **Itching -** Bile Acids/Salts or Opioid release

Question 183

**i) How do bile acid aid fat absorption?** **ii) How much bile is produced a day?**

Answer 183

**i) Form Micelles -** Hydrophilic layer outside and hydrophobic centre where the lipid is contained. Provides a large surface area for the action of lipases **ii) 400-800ml**

Question 184

**i) What is a pseudoaneurysm?** **ii) Management**

Answer 184

**i)** A false aneurysm where an artery has been punctured: - Incomplete haemostatic plug - Extravasation of blood outside of artery leading to capsule formation **ii) Management:** **Non - Surgical -** Ultrasound guided compression, Endovascular Embolisation, Endovasular stenting **Surgical -** Repair of artery +/- Bovine Patch closure

Question 185

**Cholangiocarcinoma:** **i) Type** **ii) Where does it spread**

Answer 185

**i) Adenocarcinoma** **ii)** Liver, Stomach, Duodenum + Peritoneum

Question 186

**Common Causes of Post Operative Bloody Diarrhoea**

Answer 186

Ischaemic Colitis Infective Colitis Pseudomembranous Colitis Ulceration FIstulation

Question 187

**Wet vs Dry Gangreen**

Answer 187

**Wet Gangrene -** presence of bacteria in necrotic tissue -\> high propensity for systemic spread - Venous Cause - Worse prognosis - unclear line of demarcation - commonly in bowel **Dry Gangrene** - Purely caused by ischaemia to tissue - Arterial Cause - Better prognosis - Clear line of demarcation - commonly in limbs

Question 188

**Crystal Arthropathies**

Answer 188

**Gout - Uric Acid** (Negative birefringence) **Chondrocalcinosis** **- Calcium Pyrophosphate** (Positive birefringence)

Question 189

**Broadly outline pancreatic development**

Answer 189

**Pancreatic Development** The pancreas is formed from two buds from the **foregut.** **It is endodermal in origin** **Ventral + Dorsal Pancreatic Buds** join together to form the pancreas.

Question 190

**What is TNF?**

Answer 190

TNF is a pro-inflammatory cytokine released by macrophages involved in the acute phase response: Induces phagocytosis Chemoattractant for neutrophils amongst other functions

Question 191

**WHere is the vertebral venous plexus?** **Why is it important?**

Answer 191

**Vertebral Venous Plexus -** Is in the extradural space **Importance :** - Provides alternative routes of venous drainage when there is Jugular/ IVC Compression

Question 192

**What leads to cyst development in ADPKD?**

Answer 192

**Germ Line Mutation in PKD1/PKD2:** - Regulates the morphology of epithelial cells - In PKD renal tubular cells replicate until they form sac - The sac fills with transepithelial secretions (Water / NaCl) **Secondary changes are seen in the kidney:** Fibrosis of the interstitium, THickening of the basement membrane, macrophage infiltration, Neovascularisation **leading to a bleeding propensity +**

Question 193

**Grossly describe phagocytosis**

Answer 193

Pathogen is detected by immune cells (neutrophils via PAMP): Neutrophils/Macrophages/ Monocytes encoutnering these pathogens bind them via recognising certain receptors (Mannose) --\> Phagocytosed and undergo apoptosis (release of granules that breakdown the microorganism in a cotnrolled manner --\> Then cell fragmentation in a controlled manner) --\> These then begin to signal through cytokines to attract more immune cells (dendritic cells, neutroophils, monocytes) ---\> Complement, CRP and other factors are involved in the phagocytosis of other **Dendritic Cells -\>** APCs. BRidge between innate and adaptive immunity

Question 194

**Insulin effects**

Answer 194

Increases GLUT4 Mediated glucose uptake Glycogen Sythesis Fatty Acid Synthesis Protein Synthesis

Question 195

**What is sign of Hertoghe?**

Answer 195

Loss of lateral third eyebrow in hypothyroidism

Question 196

**Management of pituitary tumours?**

Answer 196

**Observe** **DA (cabergoline, bromicriptine) -** If Prolactin Secreting **Octreotide** - If GH producing **Surgery -** Transphenoidal

Question 197

**Types of Knot**

Answer 197

Square Knot Surgeon's Knot Granny Knot

Question 198

**Variants of sciatic nerve**

Answer 198

**Usually -** Inferior to piriformis **Sometimes:** Through Piriformis Upper and lower portion go around priiformis

Question 199

**What is a baker's cyst?**

Answer 199

Often related to degnerative disease of the knee. Accumulation of synovial fluid in the gatrocnemio- semimembranosus bursa

Question 200

**What is a choriocarcinoma?**

Answer 200

**Tumour** usualy seen in women originating from the placenta (rarely testicle). **Trophoblastic tumour** consisting of syncitotrophoblasts and expressing B HCg. **High Cure Rate in placenta -** Treatment with methotrexate **Terrible cure rate when found in the testes**

Question 201

**Stages of heamatoma resolutsion**

Answer 201

**Hyperacute -** Oxygenated Blood **Acute -** Platelet plugging/aggregation stable. Blood is deoxyhemoglobin/mmethemoglobin **Subacute -** Red Cell Lysis + expansion due to water being drawn in **Chronic -** Phagoyctic Phase. White cell migration occurs and phagocytosis of lysed red cells etc.

Question 202

**What is group and save / Cross Match**

Answer 202

**Group and Save:** Confirmation of patients blood group and presence of antibodies in their serum **Crossmatch:** Performed when issuing blood where a small amount of patient serum is mixed with the donor red cells to check for comaptibility

Question 203

**Complications of resuscitation with IV Fluids?**

Answer 203

**Volume Overload** **Hyperchloraemic Metabolic Acidosis** **Hypokalaemia** **Hypocalcaemia** **Dilution Coagulopathy**

Question 204

**What is the borrman classification for gastric cancer?**

Answer 204

**Type I :** Polypoid or Fungating **Type II :** Ulcerated with elevated edges **Type III :** Ulcerated with infiltration at edges **Type IV :** Diffuse (linitis plastica)

Question 205

**TNM Classification**

Answer 205

**Tumour** **T0-** No tumour **Tis -** Carcinoma in situ **T1 -** Invades mucosa/submucosa **T2 -** Invades Musclaris Propria **T3 -** Through Muscularis Propria **T4 -** Invades Local structures **Nodes** **N0 -** No LN involvmenet **N1 -** LN Involvement **Metastases** **M0 -** No Mets **M1 -** Distant Mets

Question 206

**i) Perforated PU - Mx options?** ## Footnote **iii) Definitive Ulcer Surgery**

Answer 206

**i) Gastric Ulcer** **Conservative -** If barium swallow no evidence of contrast extravasation/not peritonitic than can watch and wait **Oversewing of Ulcer** **ii) Duodenal Ulcer** **Graham Patch repair** **Modified Grahm Patch Repair** **Cellen Jone's Repair** **iii) Definitive Ulcer Surgery:** If patient is stable - **Vagotomy** + **Antrectomy** - **Highly Selective Vagotomy** - Truncal **Vagotomy** + **Pyloroplasty** **-** Excision of ulcer **+** Frozen Section **+ Bilroth** Procedure

Question 207

**How do the 'caine' local anaesthetics work?**

Answer 207

They're intraneuronal sodium channel blockers therefore preventing propagation of action potentials thus interfering with pain signal transmission

Question 208

**Hypothermia** **Causes** **Complications - intraoperative / postoperative**

Answer 208

**Causes:** Preoperative Hypothermia Co-Morbidities Combined General + Local Anaesthetic Long Operative time Poor Cardiac Function **Complications:** - Altered tissue perfusion ( due to increased affinity for oxygen) --\> Impaired wound healing, Organ ischaemia Platelet Dysfunction Coagulopathy Peripheral Vasoconstriction Arrhyhthmias Low Cardiac Output ALtered Enzyme Function Altered Drug Metabolism

Question 209

**i) Genes associated with familial melanoma** **ii) How does UV light cause cancer?**

Answer 209

i) CDKN2A (p16 TS Gene) CDK4 (Oncogene) ii) **Most data is correlatory:** **UVB -** thought to be the culprit leading to gain / loss of function mutations associated with melanocyte/keratinocyte proliferation

Question 210

**WHy do B12 and FOlate deficiency lead to macrocytic anaemia?**

Answer 210

There is an inhibition of DNA synthesis --\> Arresting of maturation of the RBCS This leads to larger RBCs as they are not completely mature

Question 211

**Functions of Calcium**

Answer 211

i) Muscle Contraction ii) Pre-Synaptic Neurotransmitter Release iii) Cardiac Myocytes iv) Bone Mineralisation v) Coagulation

Question 212

**Definition of false localising sign**

Answer 212

**In the context of neurology are signs that are distant from the expected anatomical locus.**

Question 213

**Calculate Sensitivity / Specificity**

Answer 213

**Sensitivity :** **True Postive / (True Positive + False Negative)** **Specificity:** **True Negative / (True Negative + False Positive)**

Question 214

**Define: Pleomorphism**

Answer 214

**Pleomorphism refers to the variability in cell: Size, Shape, Staining of cells and their nuclei**

Question 215

**Complications of immobility**

Answer 215

**Disuse Atrophy of Muscles** **Disuse Osteoporosis** (Reduced mechanical stress leads to osteoclast mediated bone resorption) **Flexion Contractures** **Pressure Sores** **Increased risk of other infections** **Reduced muscle mass/ Increased fat**

Question 216

**Causes of carpal Tunnel Syndrome**

Answer 216

**Endocrine -** Diabetic Mononeuropathy, Hypothyroidism, Acromegaly **Systemic -** pregnancy**,** Oedema **Bone -** Lunate dislocation, Colles Fracture

Question 217

**Causes of chronic rectal bleeding**

Answer 217

**Infectious** - Amoebiasis, Intestinal SPirochetosis, Bacilliary Dystnery **Diverticulosis (right sided)** **Angiodysplasia** **Inflammatory -** Inflammatory Bowel Disease **Malignancy**

Question 218

**Vicryl - What is it? What is it made from? When is it absorbed?** **Benefits of braided over non braided**

Answer 218

**Vicryl:** **Synthetic, Braided, Absorbable** **Polyglycolic Acid** **Approximately 60 days** **Benefit of braided:** - Good knots, Good Handling - Soft and pliable - Good tensile strength **Disadvantages:** - Tissue Trauma - Infection risk

Question 219

**i) Synthetic Nonabsorbable Monofilament Sutures** **ii)** **LA with + without adrenaline**

Answer 219

**i) Prolene, Nylon** **ii) With:** - Improves length of time of action - Permits a larger dose to be used if warranted (reduced toxicity) - Reduced bleeding **Without:** - Extremities - May be dangerous if CVD, HTN - May be dangerous if injected into a blood vessel directly

Question 220

**Risk factors for hypertrophic / keloid scarring?**

Answer 220

**Site -** Mandible, Posterior neck, sternum, earlobe **Trauma** **Infection** **High Tension Areas** **Keloid - Ethnicity**

Question 221

**Causes of post transplant lymphoproliferative disease**

Answer 221

**Immunosuppression** leading to CMV/EBV infection in patients who have had solid organ transplants **Mx -** Reduce Immunpsuppresion, IVIG, Monoclonal Antibodies against B Cells (Rituximab),

Question 222

**What are pleural plaques?**

Answer 222

**Deposits of collagen and fibrosis** that **may/may not** be **calcified.** **Associated with Chronic Asbesos exposure**

Question 223

**Causes of gastric outlet obstruction** **Metabolic abnormality** **Why are they hyponatraemic?**

Answer 223

**Benign -** Peptic Ulcer Disease Crohn's Disease Polyps Pyloric Stenosis Pancreatic Pseudocyst Bezaor Diabetic Gastroparesis **Malignant -** Pancreatic Cancer Gastric Cancer Cholangiocarcinoma **Hypokalaemic Hypochloraemic Metabolic Alkalosis** **Hyponatraemic** secondary to ADH secretion leading to water retention.

Question 224

**Pancreas:** **Embryology (again)** **Ductal Drainage** **Which parts retropertioneal**

Answer 224

**Embyology.** Proliferation of teh ventral and doral panreatic bud + the duodenal bud (endodermal origin) **Ductal Drainage:** Major Pancreatic Duct - body,, tail + part of head Accessory Pancreatic Duct - Part of head and uncus **Tail + uncinate are intraperitoineal. Rest is retropertioneal**

Question 225

**Causes of positive trendelenberg test**

Answer 225

**SGN Palsy/ Damage** ## Footnote **Hip Fracture** **Gluteual muscle weakness** **Radiculopathy/ Disc Herniation** **Hip Dislocation**

Question 226

**i) Structure at risk in supracondylar femur fracture** **ii) Causes of mass in popliteal fossa**

Answer 226

i) Popliteal Artery (Deepest structure) ii) **Popliteal Vein Varicosity** **popliteal Artery Aneurysm** **Baker's Cyst - Other tendon related bursas** **Neuroma**

Question 227

**RFs for oesophageal cancer:** **SCC** **Adenocarinoma**

Answer 227

**SCC:** Tobbaco, Alcohol, Genetic, Nitrosamine, Achlasia, HPV, radiation **ADC:** Barret's, GORD, Tobacco, FH, H Pylori

Question 228

**Sciatic Nerve Surface Anatomy**

Answer 228

Midway between the greater trochanter and the ischial tuberosity under the cover of gluteus maximus

Question 229

**How do glucocorticoids mediate effects?**

Answer 229

**Cytoplasmic Glucocorticoid Receptor:** On binding to steroid it enters the nucleus and causes gene transcription at many points which brings about the many and varied effects of steroids

Question 230

**How does urinary alkalanisation work in the context of rhabdomyolysis?**

Answer 230

**Attempts to alkalanise the urine to help prevent the formation of casts and damage to tubules.**

Question 231

**What does lymph drain?** **What does lymph system do?**

Answer 231

**Lymphatic Vessels drain the interstitial fluid to regional lymph nodes.** **Lymph:** **Absorbs fat** **Adaptive Immune system -** recognising foreign antigens and help stimulating a clonal resposne to the antigen to clear it

Question 232

**Where else might you find parathyroid glands?**

Answer 232

**Thymus** (also from 3rd pharyngeal arch)

Question 233

**What is in the vertebral canal beneath L1?** **Importance of the venous plexus from question above?**

Answer 233

**CSF, FIlum Terminale, Cauda Equina, Paravertebral venous plexus** **Paravertebral venous plexus:** - Important as a route of metastasis - Site of collateralisation in IVC Obstruction

Question 234

**Why erythema surrounding skin cancers?**

Answer 234

Neoangiogenesis Reactive Capillary Formation Immune cells - lymphocytes causing local vasodilation

Question 235

**Echo findings in endocarditis**

Answer 235

Vegitation Dehiscence of prosthetic valves Regurgitation

Question 236

**how does EBV cause lymphoma**

Answer 236

EBV infects B Lymphocytes --\> Can cause mutations within lymphocytes leading to loss of function/gain of function mutations

Question 237

**What is the coeloemic metaplasia thoery**

Answer 237

**Respect to Endometriosis** Coleoemic epithelium lines abdominal organs and in embryogenesis is the precursor to endometrium. It is thought that this can undergo metaplasia and become endometrial tissue

Question 238

**Pott's Fracture** **Trimalleolar Fracture**

Answer 238

**Pott's** **Fracture -** Bimalleolar Fracture **Trimalleolar Fracture -** Bimalleolus + Posterior Distal Tibia

Question 239

**Phases of fracture healing**

Answer 239

**Haemorrhage + Stabilisation** **Granulation -** Inflammatory Cells phagocytose blood and dead bone **Callus/ Woven bone Formation -** Proliferation of osteocytes and osteoblasts from osteoid progenitor cells in a haphazard manner. Angiogenesis also occurs **Lamellar Bone formation and fracture remodelling -** Occurs over a long period of time in response to shear stress and load.

Question 240

**Sickle Cell Disease** **Genetics** **Mx** **Surgicl Mx**

Answer 240

**Genetics -** Chr 11. AR mutatuion in gene encoding Beta Haemoglobin 1x Trait 2x Diseae **Mx -** Genetic Counselling, Keep hydrated, Pain killers when having crises, Prophylactic antibioitcs (Hyposlplenism) **Surgical Problems:** Avascular Necrosis Gallstones