Specific hx/exam. and investigations and management Flashcards
indications for ERCP?
choledocholithiasis-gallstones in CBD e.g. as noted on US following acute cholecystitis presentation-RISK of acute pancreatitis
acute pancreatitis due to biliary obstruction or sphincter of Oddi dysfunction or idiopathic recurrent cases
diagnosis of pancreatic and biliary malignancy
palliative tment for inoperable pancreaticobiliary malignancies
dilatation of benign strictures
chronic pancreatitis-may dilate strictures or stent insertion
In patients with CBD gallstones, who will benefit most from ERCP?
the high risk patients- those with recent cholangitis, acute pancreatitis, jaundice, abnormal LFTs-ALP more than twice normal, and dilated CBD to more than 10mm.
Role of ERCP in acute pancreatitis?
should be urgently performed if evidence of biliary tract obstruction e.g. pt is jaundiced
sphincterotomy may be performed during ERCP to remove the obstruction
sphincterotomy can also treat sphincter of Odd dysfunction which usually occurs in women following cholecystectomy
ERCP complications?
acute pancreatitis
duodenal perforation and acute abdomen
infection
bleeding
failure to retrieve GS so may need to revert to an open or more invasive procedure
prolonged pancreatic stenting assoc. with increased risk of stent occlusion, pancreatic duct obstruction and pseudocyst formation.
advantages and disadvantages of ERCP over MRCP?
ERCP has therapeutic advantage
similar sensitivites for diagnosing CBD gallstones
however, invasive, with higher assoc morbidity and mortality than MRCP, and use of contrast which can cause renal impairment
similar sensitivities in diagnosing pancreatic Cas
MRCP patients may have to go on and have an ERCP anyway.
what is the paul bunnell test?
a rapid blood antibody test for EBV, a positive test is diagnostic of infectious mononucleosis-glandular fever. the splenomegaly and lymphadenopathy assoc. with this can cause NSAP.
what is a markedly raised LDH associated with in terms of abdominal pathology?
severe acute hepatitis
what 1 test would strongly suggest a ruptured ectopic pregnancy in a female of child bearing age presenting with lower abdo pain and signs of hypovolaemic shock?
pregnancy test! (hCG)
Management of any condition, surgical or not, should take into account what components?
conservative e.g. smoking cessation, alcohol, diet, exercise, surveillence endoscopies
medical management-drugs-treat condition, treat symptoms, stop drugs that may be causing symptoms of disease
surgical treatment
referral
psychological considerations
further advice e.g. make them aware of red flag symptoms that should encourage them to present again to GP
investigations to aid diagnosis of ascending cholangitis?
bloods: FBC-raise WCC, CRP raised, Us and Es-renal function may be abnormal with septic shock
LFTs-suggestive of obstructive jaundice-bilirubin raised, ALT/AST raised ALP raised-to greater extent than ALT/AST values
blood culture
bile culture if fluid available e.g. biliary drainage through intervention has occurred
serum amylase may be raised and then often indicates involvement of lower part of CBD
AXR
abdominal USS-gallstones
CT-biliary dilatation, strictures, stent
MRI
MRCP
how is pancreatic necrosis diagnosed? And how does infected necrosis become apparent and how is this managed?
abdominal CT with IV contrast: pancreatic necrosis will not enhance
usually within 2wks of acute pancreatitis, infected necrosis is apparent with leucocytosis, fever, deteriorating renal and resp function, and painful abdo mass.
extensive debridement, abscess requires percutaneous or formal open drainage
how to examine an inguinal hernia?
must examine BOTH inguinal regions
ask pt to STAND up, look at lump from in front-exact site and shape? descends into scrotum?-indirect inguinal, any other scrotal swellings and any swellings on asymptomatic side.
look for scars-prev abdo surgery increases risk
ask pt if can reduce it themselves, if cannot make sure not scrotal lump
if not visible, ask to cough-appears medial and superior to pubic tubercle, feel for cough impulse if no lump visible
palpate from front-examine scrotum and its contents, not uncommon to find epididymal cyst or hydrocele, males? if lump true scrotal lump by seeing if can get above it-if can’t-so no upper edge, then hernia as it passes into inguinal canal
feel from side- with 1 hand on pt’s back to support them, assess position, temperature, tenderness, shape, size, tension, composition and reducibility
expansile cough impulse: compress lump gently and ask pt to cough, if becomes tense and expands then has a cough impulse
reducibility? compress lower part of swelling, as lump gets softer lift it up towards external (superficial) ring, then move upwards and laterally to internal (deep) inguinal ring*direct vs indirect-if pressure over deep inguinal ring allows reduced hernia to remain in that position e.g. when asking pt to cough again, then indirect (as indirect travels through deep inguinal ring), if it cannot be controlled by pressure over this area, it is direct. if very large, easier to ask pt to lie down to help reduction.
examine other side-even if no obvious lump or swelling,ask pt to cough to see if hernia appears whilst palpating that inguinal region
differences between an inguinal and femoral hernia on examination?
inguinal-occurs superior and medial to the pubic tubercle
femoral-occurs inferior and lateral to the pubic tubercle
differentials for a groin lump?
inguinal hernia
femoral hernia
lymphadenopathy e.g. testicular Ca, uterine Ca-fundus drains to superficial inguinal LNs due to passage of round ligament of uterus through inguinal canal
femoral artery aneurysm
saphena varix-dilatation in saphenous vein at its confluence with the femoral vein (the SFJ-about 5cm below and medial to femoral pulse), it transmits a cough impulse, may have a bluish tinge on closer inspection.
features of skin ulceration to note o/e?
site?-above medial malleolus commonly those due to venous disease, if on sacrum, greater trochanter or heel-indicative of pressure sores
shape?-oval, circular-cigarette burns
surface area?-quantify and time any healing, wound more than 4wks old is a chronic ulcer
temp?-cold in ischaemic ulcer
edge?-eroded-active and spreading, shelved/sloping-healing, punched-out-DM, syphilis or ischaemic, rolled/everted-malignant, undermined-TB
base?-slough and granulation tissue
depth-use a probe
discharge-culture before starting Abx, bleeding may indicate malignancy
assoc lymphadenopathy-infection or malignancy
sensation
