Surgery Flashcards
Define acute cholecystitis
Acute inflammation of the gall bladder, most commonly caused by gall stones
epidemiology of acute cholecystitis
- Develops in 10% of people with symptomatic gall stones
- Gall stones are common - 10% of people over the age of 50y have gall stones
- Females > Males (3:1) before the age of 50 years
- Can occur at any age but most commonly occurs in overweight, middle-aged women
Aetiology of acute cholecystitis
• Calculous Cholecystitis (Gall bladder stones) - 90-95%
⁃ Stone Types:
1. Pure cholesterol stones - 10%
⁃ Often solitary, large and round
⁃ Most common stone in Asia
⁃ Radiolucent
- Pure pigment (bile salts) stones - 10%
⁃ Occasionally associated with haemolytic anaemia due to increased formation of bile
pigment from Hb
⁃ Radiolucent - Mixed stones - 80%
⁃ Combination of calcium salts, cholesterol and pigment stones
⁃ Usually multiple stones
⁃ 10% are radioopaque
• Acalculous Cholecystitis (Others):
⁃ Severe trauma
⁃ Sepsis
⁃ Helminthic infection - common in Asia
⁃ Salmonella associated Typhoid fever –> 2° cholecystitis
⁃ CMV associated with AIDs-related cholecystitis
⁃ Longterm TPN
Risk factor for acute cholecystitis
5Fs of gallbladder disease - fair, forty, female, fat, fertile
- Increasing age
⁃ Female (pregnancy and use of the OCP)
⁃ Obesity or rapid weight loss
⁃ Chronic haemolytic disorders (pigment stones)
⁃ Longterm TPN (alters bile constituents)
⁃ Previous Sx or inflammation (Crohnʼs) affecting the terminal ileum (alters bile constituents as most of
the bile salts are reabsorbed here)
Pathophysiology of acute cholecystitis
Calculous cholecystitis:
1. Obstruction of the GB neck or cystic duct causing a closed-loop obstruction
⁃ Usually by impacted gall stones –> acute inflammation of the GB wall
⁃ Choledocholilithiasis
2. Distention of the GB
⁃ Due to continuing mucus secretion from the cells located at the neck of the GB
⁃ Bacterial multiplication
3. Blood flow and lymphatic drainage compromised
⁃ Due to increased pressure of the closed-loop obstruction
4. Arterial blood flow compromised
⁃ Pressure increases above arterial pressure –> ischaemia, necrosis and perforation
Acalculous cholecystitis:
• Exact mechanism unknown
clinical features of acute cholecystitis
• Hx:
⁃ Severe continuous RUQ abdominal pain lasting >30min
⁃ May begin in the epigastrium and migrate to the RUQ
⁃ Associated nausea, vomiting and anorexia
⁃ Right shoulder tip or scapular pain:
Due to peritoneal irritation involving the diaphragm (phrenic nerve)
⁃ Previous Hx of biliary colic:
Intermittent severe epigastric and RUQ pain that resolves after a few hours
GB tenderness during episodes
• Examination:
⁃ Fever (common)
⁃ Murphyʼs Sign
⁃ Pain on inspiration when two fingers are placed over the RUQ
⁃ RUQ mass - GB may be palpated in 30-40% of cases
⁃ Jaundice (uncommon) - due to obstruction of the common bile duct
investigations for acute cholecystitis
- Bloods:
⁃ FBC - Elevated WBCs (unlike in biliary colic)
⁃ CRP - Elevated (unlike biliary colic)
⁃ LFTs - Elevated GGT, ALP and bilirubin
⁃ Serum amylase - to exclude acute pancreatitis
⁃ Trop T - ECG - rule out MI
- RUQ U/S:
⁃ Distended GB
⁃ Thickened GB wall
⁃ +/- Gall stones
⁃ Positive Murphyʼs Sign
⁃ Pericholecystic fluid (collection of fluid seen around the GB during)
DDx of acute cholecystitis
• Appendicitis - highly situated appendix
• Right basal pneumonia
• Perforated peptic ulcer
• Pancreatitis
• MI
• Biliary colic
• Acute cholangitis - Charcotʼs triad of fever,
jaundice and RUQ pain
Management of acute cholecystitis
Initial management/Supportive care:
⁃ Nill by mouth (NBM)
⁃ IV hydration, correction of electrolyte abnormalities, Analgesia
⁃ Antibiotics (gram negative cover) - 2nd gen cephalosporin + metronidazole
Rx is usually initially conservative unless complicated (e.g. perforation)
⁃ As above
⁃ +/- Cholecystectomy performed after 48 hours (“hot lap chole”)
⁃ or Allow inflammation to settle and GB removal in 2-3 months
Complicated –> Sx
Poor surgical candidates receive a percutaneous cholecystostomy tube
complications and prognosis of acute cholecystitis
Complications:
• Perforation - 10%
⁃ Due to failed conservative management and delayed presentation due to transient symptom relief
from GB decompression
⁃ Leads to generalised biliary peritonitis
⁃ 30% mortality rate with free perforation
• Suppurative cholecystitis
⁃ Thickened GB wall infiltrated with WBCs, intra-wall abscess and necrosis
⁃ May result in perforation
• Gangrenous cholecystitis - 2-30%
⁃ Occurs most commonly at the fundus of the GB due to vascular compromise
Prognosis:
• Gall bladder perforation carries a 30% mortality rate
• Untreated acute acalculous cholecystitis is life-threatening - up to 50% mortality rate
epidemiology and risk factors of gall stones
Epidemiology
⁃ Common - 10% of age>50 years
RF:
⁃ Females, overweight, multiparity, increases with age
clinical features of gall stones
⁃ Often asymptomatic until they obstruct
⁃ “Colicky pain” - Pain that comes and goes in the RUQ due to impaction of the stones into the neck of the GB
⁃ Obstructive jaundice if stones involve the common bile duct
sequelae of gall stones
- Non-obstructive gall stones –> asymptomatic
⁃ Transient obstruction of the cystic duct –> biliary colic
⁃ Recurrent obstruction –> chronic cholecystitis
⁃ Permanent obstruction of the cystic duct –> acute cholecystitis
⁃ Obstructed common bile duct –> obstructive jaundice
⁃ Obstructed ampula –> acute pancreatitis
Ix of gall stones
-LFTs - Obstructive picture
⁃ Increased PTT due to vit K deficiency
⁃ U/S - presence of gall stones
⁃ ERCP - can also be interventional in removing stones near the ampula
⁃ MRCP (magnetic resonance cholangiopancreatography) - visualise the biliary tree but no therapeutic use
⁃ Haemolysis screen if pigmented stones suspected or found
define colorectal cancer
any malignancy arising from the colon or rectum
epidemiology of CRC
- 3rd most common cancer in men and women in the developed world
- Rare before 50 years
- Mortality rates are similar in men and women but increase in men over 50 year
AETIOLOGY of CRC
Risk factors:
Family Hx
Western Diet
Low fibre and high fats –> prolongs colonic transit time
Processed and red meats –> toxic nitrogenous waste fermented in the gut
Risk demonstrated in migrating populations to western countries and adopting western diet
Excess alcohol
T2DM
Ulcerative colitis - Risk increases by 1% per year after 10 years of active disease Smoking
Inherited genetic causes:
FAP (Familial Adenomatous Polyposis)
⁃ Autosomal dominant mutation in the APC gene –> >100 polyps forming by teenage years
⁃ Inevitably 100% will develop colorectal cancer if untreated
HNPCC (Hereditary Non-Polyposis Colorectal Cancer) or Lynch Syndrome
⁃ Defects in mismatch repair genes –> 70% lifetime risk of developing CRC
⁃ Increase risk of other cancers such as endometrial, ovarian, urothelial, small bowel and brain
⁃ Exhibits “incomplete penetration” (not everyone with the defect will develop the disease)
Peutz Jaghers Syndrome
⁃ Causes hamartomatous polyps throughout the GIT
⁃ Typically have freckles around the mouth and on the hands, feet and genitalia
⁃ 50% die by age 50 due to polyp-related complications such as intessusception or cancer
pathophysiology of CRC
• “Adenoma-carcinoma sequence”
• Lesion Characteristics:
⁃ Most lesions are exophytic (protrude into the lumen)
⁃ Later they progressively ulcerate and invade the muscular bowel wall
⁃ Invasion of the serosa and surrounding tissue –> stromal or annular fibrosis –> narrowing & obstruction
metastases of CRC
Direct:
⁃ Tumour directly invades neighbouring tissue and can cause fistulas between adjacent structures such as the stomach, small bowel, bladder,
• Lymphatic:
⁃ Mesenteric LN –> Para-aortic LN
*LN = lymph node
• Haematogenous:
⁃ Liver
⁃ Lungs and brain (uncommon)
Presentation of CRC
• Asymptomatic - in early stages of disease
• Iron-deficiency Anaemia
⁃ Occult bleeding from the tumour surface over time causes iron-deficiency anaemia
⁃ Iron-deficiency anaemia in a patient >50 years is CRC until proven otherwise
⁃ Can be the only presentation of a right-sided CRC
• Rectal bleeding
⁃ Carcinomas distal to the splenic flexure causes visible PR bleeding
⁃ Blood can be mixed into the stool which is a sign of a cancer more proximal
• Change in bowel habit
⁃ Loose stools (in particular) are caused by secretions of blood or mucus into the bowel lumen
⁃ Mucus is secreted by adenomatous lesions and can also cause hypokalaemia if severe
• Bowel Obstruction
⁃ The more distal the tumour, the more likely it is to cause obstruction due to the narrower diameter of the left colon and the formation of harder stools
• Tenesmus
⁃ “The feeling of incomplete evacuation”
⁃ Caused by a tumour in the lower 2/3rds of the rectum causing a sudden urge to defecate
• Bowel Perforation
⁃ Caused by cancer invading completely through the bowel wall –> Acute abdomen with peritonitis
⁃ E.g. Left iliac fossa pain caused by pericolic abscess (collection formed due to perforation)
examination and investigation for CRC
• General: (signs of late disease)
⁃ Cachexia, weight loss, malaise and supraclavicular node enlargement
• Abdo Exam:
⁃ Usually normal
⁃ Mass
⁃ Hepatomegaly (due to liver mets)
• Rectal Exam:
⁃ MUST be performed if CRC is suspected - Most cancers are located in the distal 12cm of the colon
⁃ Assess Pouch of Douglas (through the anterior wall of the rectum)
⁃ Inspect/sample stool/blood/mucus
Ix:
• Bloods
- Anaemia
- Altered liver enzymes - liver mets
• Colonoscopy is gold standard
• Fixed or flexible sigmoidascope can be performed at the time of presentation without bowel prep
- Fixed can reach 50% of CRCs and flexible (75%)
• CXR and CT for analysis of mets
STAGING OF CRC
• Dukes Classification:
⁃ A - Limited to the mucosa
⁃ B - Invaded through the mucosa +/- adjacent tissue but no nodes
⁃ C - Nodal involvement
⁃ D - Distant mets
• TNM:
⁃ Tumour:
⁃ T1 = Tumour invasion of submucosa
⁃ T2 = Muscularis propria
⁃ T3 = Serosa
⁃ T4 = Other adjacent organs
• Nodes:
⁃ Nx - Nodes not assessed
⁃ N0 = No nodal involvement
⁃ N1= Metastasis to 1-3 nodes
⁃ N2 = > 3 nodes
• Metastasis
⁃ N0 = No distant metastasis
⁃ M1 = Metastasis present
management of CRC
• Surgical Resection + Resection of draining lymph nodes
⁃ Depends on the location of lesion
• Radio and chemotherapy play some role in reducing recurrence rates in Duke C tumours
what is VTE
- Venous Thromboembolism (VTE) manifests as DVTs and PEs
- Preventable cause of death in hospital patients
- Many at-risk patients do not receive adequate DVT/PE prophylaxis
- Hospital-acquired DVT/PE usually clinically silent
RF for VTE
• Patient Factors:
⁃ Age > 40 years
⁃ Obesity
⁃ Immobility
⁃ Varicose veins
⁃ Long haul flights
⁃ Previous DVT/PE
⁃ Thrombophilia
⁃ Antithrombin deficiency
⁃ Protein C + S deficiency
⁃ Factor 5 Leiden variant
⁃ Antiphospholipid syndrome/Lupus
⁃ Oestrogen therapy - OCP, HRT
• Disease/Surgical Factors
⁃ Surgery - Especially pelvis, hip, knee or lower limbs
⁃ Trauma
⁃ Malignancy
⁃ Cardiac failure
⁃ Infection or Inflammatory conditions
⁃ IBD
⁃ Nephrotic syndrome
⁃ Polycythemia
⁃ Sickle-cell anaemia
risk stratification for VTE
VTE pharmacology
non pharmacological Rx for VTE
Definition, epidemiology and RF for bladder cancer
Definition: Malignancy derived from the tissue of the urinary bladder
Epidemiology:
• Rare before 50 years
• Males > Females (3:1)
Risk Factors:
• Aniline dyes - used in rubber and cable industries (20-60x increased risk of TCC)
• Smoking
• Cyclophosphomide
• Urachal remnants –> adenocarcinoma
• Urinary schistosomiasis and other chronic bladder infections –> SCCs
classification of bladder cancer
Classification:
• Benign
⁃ Transitional cell papilloma
⁃ Grow inwards into the bladder wall
⁃ Considered low grade carcinomas since they have a tendency to recur after removal
⁃ Regular cystoscopy is recommended due to malignant potential
• Malignant
⁃ Transitional cell carcinoma - 90%
⁃ Most common form of malignancy of the bladder
⁃ Squamous cell carcinoma
⁃ Arises in areas of metaplasia
⁃ Adenocarcinoma (uncommon)
⁃ Occurs in urachal remnants (embryological remnant)
⁃ 2°
⁃ Direct invasion from adjacent structures - e.g. colonic, renal, ovarian, uterine, prostatic Ca
spread of bladder cancer
• Direct invasion:
⁃ Initially through the muscularis propria of the bladder
⁃ Perivesical tissue where it can enter the colon
⁃ The uterus may be involved in women & the prostate may be involved in men
⁃ The carcinoma does not cross the rectovesical pouch
• Distant spread –> lungs, brain, bones and liver
definition, epidemiology and RF of transitional cell carcinoma (bladder cancer)
Definition:
• Malignancy of the transitional cells that line the urinary tract from the renal pelvis to the urethra
Epidemiology:
• Most common cancer of the bladder (90%)
• Males > females (3:1)
• Lowest incidence in Asian countries
• Occupational exposure accounts for 1/4 of cases
Aetiology:
• Risk factors:
⁃ Cigarette smoke
⁃ Age
⁃ Male
⁃ Exposure to carcinogens:
⁃ Analine (aromatic amines) used in dye and rubber industries
⁃ Due to carcinogens like β-naphthyl amine in the urine
⁃ Polycyclic hydrocarbons - coal, aluminium and roofing-industries
⁃ Pelvic radiation
⁃ Chemotherapy with cyclophosphamides
⁃ Chronic inflammation - Schistosomiasis infection and chronic IDCs
pathology and clinical features of transitional cell carcinoma (bladder cancer)
Pathology:
• Malignancies more common at the base, trigone and at the ureteric orifices
• Commonly multiple that can extend from the renal pelvis to the urethra
Clinical Features:
• Painless Haematuria (microscopic or macroscopic)
• Dysuria (common)
• Frequency/urgency of micturition
investigations of transitional cell carcinoma (bladder cancer)
Investigations:
• Urinalysis - haematuria; pyuria can also be present
• Urine cytology - Positive in high-grade carcinomas (90%) and always signifies TCCs
⁃ Urine typically contains transitional cells that are shed from the urinary tract
⁃ Non-invasive method for diagnosing cancer
⁃ Not good for low-grade cancers (30%)
• Imaging:
⁃ Renal/bladder U/S
⁃ CT abdo/pelvis
⁃ IV pyelogram - visualise the kidneys at varying stages after injection of IV contrast ⁃> May see filling defect, obstruction or hydronephrosis
• Cystoscopy
management and prognosis of transitional cell carcinoma (bladder cancer)
Management:
• TNM staging
• Surgical:
⁃ Low risk superficial cancers - Transurethral resection of Bladder Tumour
⁃ High risk - TURBT + post-op intra-vesicular chemo
• Invasive tumours:
⁃ Pre and Post-op chemo or radiotherapy
⁃ Sx - Radical cystectomy with LN disection
• Metastatic disease
⁃ Systemic chemo + Sx + radiotherapy
Prognosis:
• Low grade lesions - high risk of tumour recurrence but low risk of disease progression and death
• High grade lesions - high risk of recurrence and progression
⁃ Overall survival with cystectomy is ~ 50%
types of kidney stones
Definition and epidemiology of urinary retention
Definition:
Impaired urinary flow due to physical obstruction at any level from renal calyces to external urethral meatus.
Epi:
- Male < 60yrs - Renal Calculi
- Male > 60yrs - Benign Prostatic Hypertrophy (BPH)
- Females - Pregnancy & Renal Calculi
pathophysiology of urinary retention
•Intraluminal
- Calculi (Renal Colic)
- Blood clot
- Rupture - traumatic or iatrogenic
•Luminal
- Stricture/stenosis - native or iatrogenic
- Ischaemia
- Haematoma
- Tumour
•External
- Pregnancy
- BPH (Benign Prostatic Hypertrophy)
- Other neoplastic process or mass
when to inflate the catheter baloon?
•1) Ensure IDC all the way to the hilt
2) Ensure Urine Flowing through IDC
3) Watch patients face when inflating the balloon, feel for significant resistance
4) Pull IDC back and feel balloon tug on bladder neck
Haematuria
- Macroscopic vs microscopic
- Differential causes → 20% underlying malignancy and 80% benign causes, infection, stone, inflammation
worry if you see clots, clot retention, fever
Management:
Wash the bladder continuously
Upper and lower tract imaging + Urine cytology + Referral to urologist for cystoscopy
Epidemiology and presentation of renal colic
- Epidemiology:
- 5-15% prevalence
- 30-40 years common, but any age
- 2:1 M:F but changing
Presentation:
- Severe pain - “Loin to groin”
- Restlessness - “Writhing agony”
- Nausea & vomiting
- Haematuria
Diagnosis of renal colic
Diagnosis:
History
Physical exam
Urinalysis
Dipstick
Formal m/c/s
Blood tests (UEC, FBC)
Imaging studies
Imaging:
CT KUB
X-Ray KUB (85% visible)
Indications of urgent treatment for renal colic
Indications for urgent treatment:
- Septic -
- Temperature > 37.80
- Tachycardic
- Hypotensive
- Renal impairment
- Creatinine raised – everyone is different but >200
- Single kidney
- Uncontrolled pain Despite adequate analgesia
- Urgent treatment options:
1. Ureteric stent
2. Nephrostomy tube
definition of Testicular torsion
•DEF: Rotation of the testis on its spermatic cord causing occlusion of its venous drainage and blood supply.
Epidemiology, presentation and Rx of testicular torsion
- Epidemiology:
- Commonly 12-19yo
- 75% cases < 20yo
Presentation:
- Acute onset pain
- Swollen, tender testicle
- Firm texture
- High riding or horizontal lie
- Absence of cremasteric reflex
- Treatment:
- Surgical exploration
- Do not delay surgery for further investigation
Define Fournier’s Gangrene
Necrotising infection involving the soft tissue of the perineum and external genetalia.
Epidemiology and pathophysiology of Fournier’s Gangrene
- Epidemiology:
- Most commonly 60-70yo
- Overall mortality ~ 40%
- Associated sepsis ~ 80% mortality
- Diabetes mellitus ~ 50% cases
- Medically immunosuppression ~ 10% cases
- Pathophysiology:
- Anaerobic and aerobic organisms – polymicrobial
- Aggressive and frequently fatal
E. coli, Klebsiella, enterococci along with anaerobes (Bacteroides, Fusobacterium, Clostridium, anaerobic or microaerophilic streptococci
presentation of Fournier’s Gangrene
- Necrotic perineal tissue
- Rapidly progressive cellulitis
- Immunocompromised:
- Diabetic
- Alcoholic
- Malnutrition
- Medication (steroids, immunosuppressants)
- Malignancy
Crepitus and foul smelling exudate usually with more advanced infection
treatment for fournier’s gangrene
•Broad spectrum antibiotics – polymicrobial infection
Tazocin/Meropenem + vancomycin + clindamycin
- Debridement of all non-viable tissue as urgent as possible
- Often requires several trips to theatre for repeat debridement and eventual reconstruction
clinda has antitoxin effect for strep toxin
define Paraphimosis
Condition where the foreskin becomes trapped behind the glans penis
Usually due to chronic inflammation under the prepuce and development of a phimosis
presentation, complications and management of paraphimosis
- Presentation:
- Uncircumcised male
- Painful, irreducible foreskin
- Swollen glans penis
- Complications:
- Gangrenous glans penis
- Management:
- Reduce foreskin
- Manually
- Shift the oedema – glucose; ice; pressure
- Surgical release (dorsal slit) with local
Penile Priaprism
persistent erection of the penis that is not associated with sexual stimulation or desire
presentation and aetiology of penile priaprism
- Presentation
- Prolonged erection with failure of detumescence
- Ischaemic vs high-flow
- Ischaemic: fully erect and painful
- Aetiology
- Haematological – sickle cell•
Iatrogenic – penile injections
•Medication/Drugs – cocaine
90% of men with erection >24hrs will lose the ability to have intercourse again. Early return to flaccidity usually carries good outcomes
management of penile priaprism
define penile fracture
Rupture or tear of the tunica albuginea of the corpus cavernosum typically occurs when excessive bending force is applied to the erect penis.
presentation, treatment and complications of penile fracture
- Presentation:
- History of risk-taking behavior
- Pop or cracking sound
- Sudden onset pain
- Tumescence
- Haematoma
- Treatment:
- Urgent urology review
- Surgical intervention
- Complications:
- 50% impotence
- Peyronie’s disease
Distal radius # MOI, epi, RF, clinical features
MOI: FOOSH
Epidemiology:
Accounts for 17.5% of all adult fractures
F>M (2-3:1)
Bimodal age distribution
- Younger patients due to high energy mechanisms
- Older patients due to low energy mechanisms
Risk factors:
Osteoporosis, DR# is predictor for subsequent fractures → DEXA
Clinical features:
wrist pain, swelling, deformity, examine skin for open wounds, NV status (motor, sensory of ulnar, rad and med N), radial pulse for perfusion of hand
Colles’ # vs smith’s #
colles’ → Low-energy, dorsally displaced, extra-articular #
smith’s → low energy, volarly displaced, extra articular #
Monteggia injury
- Proximal 1/3 ulna fracture with associated radial head dislocation
- Epidemiology → Rare in adults, common in children 4-10yo
- Clinical presentation→ Pain & swelling at elbow
- Examination:
1. Inspection: ?obvious dislocation, skin integrity
2. ROM & stability
3. NV exam
PIN neuropathy (Wrist extension & radial deviation, Thumb extension, MCP extension)
- Pain & swelling at elbow
Scaphoid # MOI and epidemiology
MOI: FOOSH, high or low energy mechanism
Epidemiology: Account for 60% of carpal bone fractures, 15% of wrist injuries, M>F (2:1), most common in 30s, Waist (65%), proximal 1/3 (25%), distal 1/3 (10%)
Scaphoid # clinical presentation
- Variable level of wrist pain
- Wrist swelling. Rarely any ecchymosis, haematoma or gross deformity
- Pain with resisted pronation
- Provocative tests: 1. Anatomic snuffbox tenderness (dorsal) 2. Scaphoid tubercle tenderness (volar) 3. Scaphoid compression test (scaphoid loading)
scaphoid # imaging and management
- Imaging
- XR: PA, lat, oblique, scaphoid view (20deg wrist ext, 20deg ulnar deviation)
- If radiographs unremarkable (27%), but high clinical suspicion → CT
- Management
- Stable nondisplaced fracture → thumb spica cast
- If unstable, or displaced >1mm → perc screw
Epidemiology, MOI, examination and imaging of humeral shaft #
Epidemiology & MOI:
- Bimodal age distribution (Young patients with high-energy trauma; Elderly, osteopenic patients with low-energy injuries)
Examination
- NV status: radial nerve!
* Imaging - AP & lateral xray with view of joint of above & below
management of humeral shaft #
- Coaptation splint, then functional brace (90% union rate)
-
ORIF
Absolute indications: - Open fracture
- Vascular injury requiring repair
- Brachial plexus injury
- Floating elbow (ipsilateral forearm #)
- Compartment syndrome
Relative indications:
Bilateral humerus #
Polytrauma patient
Pathological #
both bone forearm #
MOI: fall from height e.g. playground equipment
Epidemiology: ??
Clinical presentation:
- Forearm pain & refusing to move arm
- Exam:
Swelling deformity, ecchymosis
Check for open wounds e.g. puncture
Complete examination of ipsilateral limb
for concomitant injury
NV exam, check compartments
Imaging
AP & lat of forearm, wrist & elbow
Management
CR & above elbow cast +/- tens nail
NOF # immediate management
- NOF pathway:
ECG
CXR
IDC & U/A
Bloods
Analgesia
FI block - withhold anticoagulants
- NBM + chart IVF
- call ortho!
definitive management of NOF #
- Non-op?
- Non-ambulatory, minimal pain, high risk surgical candidate
- Very rare!
- Operative management
- Intracapsular vs extracapsular fractures
- Hemi vs total arthroplasty
- Timing of surgery?
- As soon as medically possible
- Should be within 24-48 hours
intracapsular vs extracapsular NOF #
- Intracapsular
- Subcapital, transcervical, basicervical
- More likely to disrupt blood supply to femoral head → AVN, so are treated with arthroplasty in elderly
- Extracapsular
- Intertrochanteric, subtrochanteric
- Treated with internal fixation device e.g. IMN
- Capsule of hip joint attaches along intertrochanteric line on anterior femur & ~1.5cm above intertroch line posteriorly
blood supply of femur
- Profunda femoris a branches off ext iliac artery
- Medial & lateral femoral circumflex arteries branch off this & encircle the base of the femoral neck, giving off retinacular vessels which supply the femoral head in a retrograde manner
- NOF#s can disrupt this blood supply → AVN of femoral head
complications of NOF #
- AVN (10-45%)
- Risk depends on initial degree of displacement, nonanatomical reduction
- Non-union (5-30%)
- Dislocation
- High with THA (~10%, 7x higher than hemi)
- Loss of independence
- Mortality
- 30% at 1 year
- Pre-injury mobility is the biggest determinant of postoperative survival
- Mortality risk is decreased at 30 days & at 1 year post-op when surgical intervention is performed within 24 hours of admission
Define SSI (surgical site infection)
Infection related to an operative procedure
that occurs at or near the surgical incision
within 30 days of the procedure
or
within 90 days if prosthetic material is
implanted at surgery
How do we know a surgical site infection (SSI) has occurred?
Clinical criteria for defining Surgical Site infecton include one or more of the following: -
- A purulent exudate draining from a surgical site
- A positive fluid culture obtained from a surgical site that was closed primarily
- A surgical site that is reopened in the setting of at least one clinical sign of infection (warmth, pain, erythema and swelling,) and is culture positive or not cultured
- The surgeon’s diagnosis of infection
what is the triad that indicates acute cholangitis?
Sudden onset of a triad of symptoms including jaundice, right upper quadrant pain and rigours (Charcot’s triad) indicates acute cholangitis.
Mirizzi’s syndrome
Mirizzi’s syndrome is where a stone impacted in the neck of the gallbladder causes distension of the gallbladder and jaundice due to extrinsic compression of the common hepatic/common bile duct.
Investigations for jaundice
-
Blood test
a. Full blood count along with red cell indices including reticulocyte counts are useful in identifying the presence and type of anaemia (secondary to haemolysis, haemoglobinopathies) and thrombocytopenia (secondary to portal hypertension).
b. bilirubin, albumin and INR convey information on liver function, with platelets conveying information on the level of fibrosis, unconjugated and conjugated bilirubin fractions. The most common cause of an isolated elevated bilirubin concentration is Gilbert’s syndrome.
c. albumin
d. PT time and INR will be raised, clotting factors 2, 5, 7, 9, 10 will eb reduced
e. ALP - ALP is usually high in childhood (bone growth) and pregnancy (placental production)
f. GGT
f. AST, ALT. AST is good for alcohol related liver injury and autoimmune hep
2. IMAGING
a. U/S (preferred) - cyst, steatosis
b. CT - Computed tomography (CT) with oral
and intravenous contrast agents may demonstrate liver, biliary
and pancreatic tumours, portal lymphadenopathy and tumour
spread beyond the organ of origin. It can show biliary dilatation
and the level of obstruction (Figure 4). It may demonstrate a
cirrhotic liver, with a nodular or fine cobblestone appearance of
the margin, liver lobar asymmetry, caudate hypertrophy and
features of portal hypertension such as varices, splenomegaly
and ascites.
c. MRI
D. PET
e. MRCP - Magnetic resonance cholangiopancreatography (MRCP), using T2 weighted sequences, is a non-invasive, non-contrast method of obtaining an accurate ‘road map’ of the biliary tree and has now superseded diagnostic endoscopic retrograde cholangiopancreatography (ERCP)
f. ERCP - ERCP with a side viewing duodenoscope is widely considered to be the gold standard for investigation of biliary and pancreatic duct pathology. It permits direct examination and biopsy of the ampulla in cases of suspected ampullary carcinoma. Cannulation of the ampulla, injection of water-soluble contrast agents and real-time screening permits diagnostic and therapeutic manoeuvres such as endoscopic sphincterotomy, gallstone extraction, biliary brushing for cytology and insertion of plastic or metal endobiliary or pancreatic duct stents.
g. liver biopsy - It is generally not recommended to biopsy a liver tumour if the patient has resectable disease, due to the risk of disease dissemination and such a biopsy should only be performed after multidisciplinary team discussion.
h. Laparoscopy - Laparoscopy is used selectively in the staging of hepaticopancreatico-biliary malignancies, in particular looking for small-volume peritoneal disease, not seen on cross-sectional imaging, which might preclude a major resection.
i. PET CT - staging of hepato-pancreatico-biliary cancers.
define cholangitis +its causes
- Inflammation and/or infection of the biliary tree
- Often referred to as ‘biliary sepsis’
- rare but can be 1-2% after ERCP
Causes of cholangitis:
- Obstruction of biliary tree secondary to gallstones (including Mirizzi’s syndrome, gallstone-related oedema compressing biliary tree as opposed to gallstones themselves) (Commonest cause)
- Infection post-ERCP
- Invasion by tumour (Pancreatic, cholangiocarcinoma, hepatocellular carcinoma, metastases)
- Roundworm or liver fluke infection (common overseas)
- HIV cholangiopathy
presentation and DDx of cholangitis
Presentations of cholangitis
The following make up the classical ‘Charcot’s triad’
- Jaundice
- Fever
- RUQ pain – severe
- Shock (due to sepsis) and confusion added to Charcot’s triad = Reynold’s pentad
- Jaundice may not always be present, especially if a patient already has a biliary stent in situ
- PMHx
- Gallstones
- Cholecystitis
- HIV
- Peritonism is uncommon and suggests alternative cause, e.g. appendix or ruptured gall bladder
Differential diagnosis of cholangitis
- Cholecystitis
- Other causes of acute jaundice
- CBD gallstone causing obstructive jaundice
management of cholangitis
Initial management of cholangitis
- Blood tests:
- Full blood count
- Urea and electrolytes
- Clotting
- Amylase
- Inflammatory markers
- Blood cultures
- Usually gram-negative: E.coli, Klebsiella, Enterobacter
- Imaging:
- AXR – may show ileus or air in biliary tree (e.g. after ERCP; gas-producing organisms; cholecystenteric-fistula)
- USS – gallstones or dilated ducts
- CT abdomen
- Prompt IV fluid resuscitation
- Prompt IV antibiotics
- Broad spectrum with gram-negative cover
- Often IV Tazocin 4.5g three times daily or IV Meropenem 1g three times daily but check local guidelines or guided by culture sensitivities
- Catheterisation for fluid balance
- These patients are often sick and may need HDU or ITU management
Further management of cholangitis
- MRCP (magnetic retrograde cholangiopancreatography)
- ERCP (endoscopic retrograde cholangiopancreatography)
- This can be diagnostic and therapeutic as stones can be removed and a sphincterotomy performed at the Sphincter of Oddi to prevent future episodes
- There is, however, a significant associated morbidity and mortality
- Pancreatitis (up to 5%)
- Cholangitis (up to 3.5%)
- Perforation (up to 0.6%)
- Death (0.2%)
- Biliary scintography
- Radio-active substance secreted in bile
- Can demonstrate an obstruction if diagnosis unsure
- Cholecystectomy
- All patients with an episode of biliary sepsis secondary to gallstones should be referred to the surgeons for consideration of an elective cholecystectomy once recovered.
complications and prognosis of cholangitis
Complications of cholangitis
- Septic shock and death
- Intra-abdominal collection
Prognosis of cholangitis
- Acute cholangitis has a high mortality (7-40%),
- Higher mortality in patients with co-morbidities, e.g. elderly, renal failure, cirrhosis, metastatic disease, failure to respond to antibiotics
What do you need to discuss with the patient to obtain consent?
For a consent to be valid what condi?ons must be sa?sfied?
If patient does not have capacity to consent it can be given by ‘a person responsible’. explain.
Spouse
- Guardian
- ‘carer’ – not paid
- Close relative, friend
- if no person responsible able to be found only then guardianship tribunal will act
what if say patient unconscious and needs emergency treatment?
In an emergency, where the patient is unable to give consent and the treatment is required immediately: (i) to save the person’s life; (ii) to prevent serious injury to a person’s health; (iii) to prevent the patient from suffering or continuing to suffer signiSicant pain or distress; the procedure/treatment may be carried out in the absence of consent.
definition, epi, RF of breast carcinoma
Definition:
• Breast cancer in situ → Cancer that is confined to the duct (DCIS) or lobule (LCIS) in which it originated from & does not
extend beyond the basement membrane
• Primary invasive breast cancer
• Metastatic breast cancer
Epidemiology:
- 1 in 10 women will develop breast cancer
- 2nd most common cancer killer in women after lung cancer
- Rare below the age of 30 years
- 10% have a genetic predisposition
Risk factors:
- Female (100x) • Increasing Age (> 30 years) • FHx
- Hormonal factors:
⁃ Early menarche (< 11yr) and late menopause (>51 yr)
⁃ Exogenous Oestrogen exposure (OCP or HRT)
⁃ Nulliparity
- Radiation exposure - E.g. ionising radiation exposure in adolescence/early adulthood
- Benign breast conditions ⁃ Atypical lobular or ductal hyperplasia (4-5x)
aetiology of breast cancer
pathology of breast cancer
investigations of breast cancer
management of breast cancer
Staging: (Used to guide treatment and prognosis) ⁃ Estimate tumour size ⁃ Histological type ⁃ Estimate tumour spread (Nodes vs. Distant Mets)
• Sx ⁃ Lumpectomy, LN clearance, Mastectomy ⁃ Reconstructive surgery • Radiotherapy - improves loco-regional control
• Chemotherapy - improves systemic control
• Hormonal therapy - only for oestrogen receptor +ve Ca ⁃ (1) Ovarian ablation, (2) oestrogen receptor modulators (tamoxifen), (3) aromatase inhibitors ⁃ Greatest benefit in post-menopausal women
Complications: • Nausea and vomiting from chemotherapy (short-term high) • Osteopenia and osteoporosis ⁃ Due to continued suppression of oestrogen by aromatase inhibitors (long-term high) ⁃ Encourage weight-bearing exercises and Ca2+ supplements • Vasomotor symptoms ⁃ Including hot-flushes, sleep disturbances, irritability and vaginal dryness ⁃ Occurs due to premature ovarian failure due to cytotoxic therapy • Recurrence ⁃ Variable
Prognosis: • Breast cancer survival is calculated from Nottingham Prognostic Index ⁃ Only useful for 10 year survival • Depends on staging
anatomy of breast cancer
epidemiology of breast lump
Epidemiology: • Breast lumps are a common but only ~15% are cancerous • 1 in 10 women develop breast cancer • 2nd most common cancer killer of women • Incidence of breast cancer increases with age • Incidence increases with prolonged exposure to oestrogen: ⁃ Use of OCP or HRT ⁃ Early menarche or late menopause • Male breast cancers account for < 1% of cases • Most common causes of Breast Lump: 1. Carcinoma of the breast 2. Cyst 3. Fibroadenoma 4. Fibroadenosis
DDx of breast lump
Benign Breast Masses:
- Cysts ⁃ Common in the peri-menopausal age ⁃ Uncommon after menopause –> suspect cancer ⁃ Present with a short history as painful,tender swelling in the breast ⁃ Appear as well-defined rounded opacities on mammography and U/S will distinguish solid from cyst ⁃ Newly diagnosed or symptomatic cysts should be aspirated via FNA ⁃ If blood fluid –> send to pathology and perform Core biopsy
- Fibroadenoma ⁃ Most common benign neoplasia of the breasts ⁃ Presents as a discrete, usually solitary, firm masses that are mobile and not attached to the skin ⁃ Arise from the entire breast lobule and have both stromal and epithelial components ⁃ Occur more commonly during the 3rd decade of life ⁃ Cause unknown but thought to be hormonally driven
- Fibrocystic breasts ⁃ Most commonly found in premenopausal and peri-menopausal women ⁃ Relatively uncommon post-menopausal & should raise suspicion of malignancy ⁃ Pathological features include cysts, epithelial hyperplasia, apocrine metaplasia & cystic dilation/ fibrosis ⁃ Pts sometimes present with a discrete mass, when in actual fact it is fibrocystic changes ⁃ Characteristics of cysts: ⁃ Mobile and have distinct borders on examination ⁃ Sometimes fluctuate with the menstrual cycle ⁃ Anechoic on U/S
- Fat necrosis ⁃ Occurs 2° breast trauma ⁃ May be iatrogenic due to breast augmentation or biopsy or trauma (seatbelt injury) ⁃ Lesions present as hard, fixed masses and acoustic shadowing on U/S –> biopsy
- Breast Abscess ⁃ Typically occur in women that are breastfeeding ⁃ Thought to result from ruptured sub-aeriolar ducts that leak into the periductal space ⁃ Must be differentiated from inflammatory breast cancer (does not present as a mass)
- Intraduct Papilloma ⁃ Benign neoplasm that arises from the subareolar ducts ⁃ Present with watery-clear or blood-stained nipple discharge from a single duct ⁃ If papilloma mass may be palpable
Malignant Breast Masses:
- 1° ⁃ (1) Intraduct carcinoma, (2) Invasive carcinoma, (3) Pagetʼs disease of the nipple, (4) Sarcoma
- 2° ⁃ Direct invasion from tumours of the chest wall ⁃ Metastatic deposits from melanoma or others (rare)
DDx: Discharge From the Nipple
Hx of breast lump
examination of breast lump
investigations of breast lump
breast lump flow chart
Definition, epi, aetiology, pathophys of AAA
clinical presentation and management of AAA
random points on acute abdomen pain
definition and aetiology of acute abdomen pain
focussed history on acute abdo pain
surgical sieve for abdo pain
congenital vs acquired
acute vs chronic
- Vascular = Ischaemic colitis, AAA rupture
- Infection = Gastroenteritis
- Neoplastic = Bowel cancer
- Drugs/Iatrogenic = Paracetamol OD
- Inflammation = Appendicitis
- Congenital = Meckelʼs diverticulitis
- Autoimmune = Food allergy
- Trauma = MVA causing ruptured spleen
- Endocrine/Metabolic = DKA
- Mechanical/Anatomical = Volvulus
causes of hollow organ obstruction (dressed from acute abdo pain)
Def, epi, aetiology, pathophysiology of acute appendicitis
diagnosis and ddx of acute appendicitis
structure and function of the appendix and surface anatomy
management, complications and prognosis of acute pancreatitis
acute pancreatitis pathophys flowchart
pancreatitis CT
more CT
more CT 2
Def, epi, RF, classification, spread of bladder cancer
bladder cancer (transitional cell carcinoma/TCC) → def, epi
Definition: • Malignancy of the transitional cells that line the urinary tract from the renal pelvis to the urethra
Epidemiology: • Most common cancer of the bladder (90%) • Males > females (3:1) • Lowest incidence in Asian countries • Occupational exposure accounts for 1/4 of cases
anatomy of skull
traumatic brain injuries
primary brain injuries
secondary brain injuries
secondary brain trauma - subdural haematoma
secondary brain trauma - intracranial and infection
skull #
cerebral herniation
cerebral perfusion pressure
NOF #
classification of burns
burn first aid
estimating % burn
causes of burns
total body water and fluid compartments
water balance
factors that affect h2o requirement
control of water balance
Control of Water Balance:
• Sensors:
- Osmoreceptors ⁃ Specialised cells in the hypothalamus which respond to changes in extracellular tonicity (rather than osmolality) ⁃ Tonicity refers to the osmotic pressure gradient between 2 fluids separated by a semi-permeable membrane ⁃ A hypertonic solution is one that has a higher conc. of solutes outside the cell ⁃ These receptors are very sensitive to changes in [Na+] - respond to 1-2% change in tonicity ⁃ In general, [Na+] can be used as a measure of ECF tonicity ⁃ Note: Cl-, HCO3- & proteins also count towards ECF tonicity
- Baroreceptors ⁃ Baroreceptors are less sensitive (but more potent) than osmoreceptors ⁃ When stimulated the cause a much higher release of ADH than with osmoreceptor stimulation ⁃ Hypovolaemia is a more potent stimulus for ADH release than hyperosmolarity ⁃ Hyovolaemic stimulation will override hypotonic inhibition of ADH release ⁃ Types: ⁃ Volume receptors (low pressure baroreceptors) ⁃ Located in the right atrium and great veins ⁃ Input to the hypothalamus ⁃ High pressure baroreceptors ⁃ Located in the aortic arch and carotid sinus and respond to a change in MAP
- Central controller = Hypothalamus • No anatomically defined centre that is solely responsible for responding to changes in water balance • Key components: ⁃ Osmoreceptors ⁃ Thirst centre ⁃ OVLT (organum vasculosum of the lamina terminalis) & SFO (subfornical organ) ⁃ Respond to Ang-II ⁃ Supraoptic and paraventricular nuclei - ADH synthesis
- Effectors
- Thirst ⁃ Stimuli: ⁃ Hypertonicity: Cellular dehydration acts on osmoreceptors in hypothalamus ⁃ Hypovolaemia: Low volume sensed by low pressure baroreceptors ⁃ Hypotension: Sensed by high pressure baroreceptors ⁃ Ang-II: Released in response to hypotension
- ADH release ⁃ Synthesised in the hypothalamus and transported to the Post. Pituitary ⁃ Actions: ⁃ Increases water reabsorption in the CD of the renal tubules ⁃ Acts on V2 receptors in the cortical and medullary collecting ducts –> synthesis of Aquaporin 2 that increase water reabsorption ⁃ Vasocontrsiction ⁃ Acts on V1, 2 and 3 receptors in blood vessels ⁃ Negative-feedback: ⁃ Reabsorption of water reduces plasma [Na+] and this is detected by the osmoreceptors –> negative-feedback on the hypothalamus
Calculating Daily Fluid Requirements:
Basic IV Fluids:
different IV fluids
MORE IV FLUIDS
Hx, examination and Ix for groin swelling
hiatus hernia - def, epi, aetiology, classification
hiatus hernia: pathophys and clinical features
hiatus hernia: investigation, complications, management, prognosis
hiatus hernia - more on dressed
UC - investigations and DDx
Crohn’s - def, epi, aetiology, pathophys, micro path
Crohn’s - clinical features + Ix
Crohn’s - DDx, prognosis, management, complications
IBD common presentation
crohn’s vc UC
crohn’s vc uc colonoscopy
UC summary
crohn’s summary
Cellulitis and Erysipelas:
Necrotising Fasciitis
SIRS - def, criteria, pathophys
SIRS - sequelae, complications, prognosis
inguinal/femoral hernia - investigations, clinical features, management, DDx, prognosis
inguinal vs femoral hernia
liver neoplasms - classification
Biology of Human Parasitic Fungi - structure and morphology
Human disease caused by fungi
Antifungal Drugs and Treatment:
Groups of Mycoses:
group of mycoses part 2
neck lump examination - anatomy of the neck
⁃ Divided into central vs. lateral compartments
⁃ Central neck: ⁃ Hyoid bone, thyroid and cricoid cartilages, thyroid isthmus and the trachea
⁃ Lateral neck: ⁃ Divided into the anterior and posterior triangles via the SCM muscle (post. border)
neck lump examination location
- Pre-auricular and angle of the jaw = Parotid gland or lymphoid tissue in the parotid system ⁃ Examine the Facial Nerve (CN 7)
- Central neck = Thyroid goitre, thyroglossal cyst or thyroid cancer ⁃ Examine the thyroid by assessing swallowing
⁃ Thyroglossal cyst will move if patient pokes out tongue
- Anterior triangle
⁃ Lymphadenopathy common here in adults (potentially malignant)
⁃ Congenital masses (paeds) - 2nd branchial cleft cyst (remnant of the 2nd pharyngeal arch)
- Posterior triangle
⁃ Masses here should have a high index of suspicion for malignancy ⁃ E.g. Nasopharyngeal carcinomas
- Supraclavicular ⁃ Especially Left sided suggests metastases of the lungs, GIT or gynaecological
neck lump investigations
DDx neck lump
painful red eye
warning features that require specialist referral for eye
DDx for unilateral red eye
management and prognosis of pancreatic cancer
Management:
• Surgical resection - minority of patients are suitable for Sx because pancreatic cancer presents late
⁃ Patients with ampullary carcinoma often present early with jaundice and may be better candidates for Sx ⁃ “Whippleʼs procedure”
- No role for adjuvant chemotherapy
- Palliative procedures may include bypass or stenting procedures for obstructive jaundice
Prognosis: • Without treatment - survival is only a few weeks to months after diagnosis • Post Sx - prognosis is still poor with 5 year survival = 10%
preoperative antibiotic prophylaxis
- Definition: ⁃ The use of antibiotics to prevent infections at the surgical site
- Rational: ⁃ The majority of post-op infections are caused by the patientʼs own bacterial flora ⁃ The antibiotic given should only cover the likely pathogens, NOT all potential organisms ⁃ Important to use a narrow spectrum antibiotic appropriate to the site of surgery ⁃ It is important to achieve high circulating blood levels by the time of operation
⁃ IV - give at the time of anaesthetic induction
⁃ IM - give at pre-op medications ⁃ A single bolus dose is usually sufficient if the duration of the surgery is 4 hours or less ⁃ Inappropriate use of surgical prophylaxis increases both cost and selective pressures on resistant bacteria ⁃ Persistant antibiotics post surgery does not improve efficacy and increases toxicity and cost
- Indications: ⁃ When the surgery is considered “contaminated” or “clean-contaminated” ⁃ When there is insertion of an artificial device or prosthetic material
- Choice of antibiotic: ⁃ Based on: Patient allergy, site of surgery, duration of surgery and narrow spectrum ⁃ 3rd generation cephalosporins should be avoided due their broad cover
commonly used regimen - antibiotic prophylaxis
prostate cancer - def, epi, aetiology
pathophysiology of prostate cancer
pathology of prostate cancer
clinical features of prostate cancer
investigations of prostate cancer
management of prostate cancer
prognosis of prostate cancer
renal tumour - def, epi
renal tumour - classification
renal cell carcinoma - def, epi RF, characteristics
renal cell carcinoma - clinical features, Ix, management, prognosis
small bowel obstruction - def, epi, aetiology
pathophys and classification of small bowel obstruction
small bowel obstruction - clinical features and Ix
small bowel obstruction - DDx, management, prognosis
oesophageal cancer - def, epi, aetiology, pathophys
oesophageal cancer - Ix, DDx, Rx, prognosis
stomach cancer - def, epi, aetiology, pathology, clin features
stomach cancer - Ix, DDx, Rx, prognosis
thoracic trauma
tension pneumothorax
simple vs open pneumothorax
haemothorax
cardiac tamponade
trauma - part 1
trauma part 2
breast cancer types
group + hold vs crossmatch
give the pt O negative while we try to identify the pt’s blood group
FFP
platelets
cryoprecipitate
fibrinogen
Massive transfusion protocol (MTP)
