Surgery Flashcards
1
Q
List the types of oesophageal cancer and associated risk factors
A
- Squamous cell carcinoma
- Adenocarcinoma
Risk factors: smoking, alcohol, hot beverages, GORD, Barrett’s, obesity, achalasia
2
Q
Describe the signs and symptoms associated with oesophageal cancer
A
- Progressive dysphagia (solids then liquids)
- Weight loss
- Anaemia
- Less common – odynophagia, cough, hoarseness, haematemesis, melaena
3
Q
List differential diagnoses for dysphagia
A
Within lumen
> Food bolus
> Foreign body
> Oesophageal candidiasis
Within wall
> Peptic/caustic stricture
> Schatzki ring
> Pharyngeal pouch
> Achalasia / oesophageal dysmotility
> Oesophageal web
> Oesophageal cancer
Outside oesophagus
> Mediastinal mass
> Lymphoma
> Thoracic aortic aneurysm
> Globus hystericus
4
Q
Describe the treatment of oesophageal cancer
A
Curative intent – early cancers
> endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD)
> Endoscopic mucosal therapy – Barrett’s oesophagus with dysplasia
Tumours beyond mucosa +/- LN
> Neoadjuvant chemoradiation
> Surgery
> Ivor-Lewis oesophagectomy OR three stage (McKeown) operation
5
Q
Describe the anatomy, blood supply, nerve supply and lymphatic drainage of the stomach
A
4 sections: cardia, fundus, body, pylorus
Blood supply
> Lesser curvature: left gastric artery (coeliac trunk branch)
> Greater curvature: left & right gastroepiploic arteries
> Fundus: short fastric artery (splenic branch)
> Pylorus: right gastric artery (common hepatic branch)
Venous drainage matches arterial supply
Nerve supply
> Parasympathetic: vagus nerve
> Sympathetic nerve: T6-T9 spinal cord segments
Lymphatics
> Lymph fluid drains into gastric and gastroomental lymph nodes found at curvatures
6
Q
List risk factors for gastric cancer
A
- Diet
> Processed meat
> Low fruit/veg intake
> High salt intake
> Nitrates / nitrites - Obesity
- Smoking
- H. pylori
- Age > 50
- Ethnicity – Asian and Pacific Islanders
- Male gender
- Heavy alcohol use
7
Q
Describe the signs and symptoms of gastric cancer
A
symptoms
- Weight loss
- Abdominal pain
- Nausea
- Dysphagia
- Melaena
- Early satiety
- Ulcer type pain
- Occult GI bleeding more common than overt bleeding
signs
- Palpable abdominal mass
- Palpable lymph node
> Left supraclavicular node (Virchow’s)
> Periumbilical (Sister Mary Joseph)
- Ascites
8
Q
Describe the different types of gastric cancer and their routes of spread
A
Primary
> Adenocarcinoma (94%)
> Tubular
> Papillary
> Mucinous
> Signet ring
> Lymphoma (4%)
> GI stromal tumour (GIST)
> Type of sarcoma, develops in the connective tissue
> Secondary
> Direct invasion from nearby organs
Routes of spread
> Haematogenous
> Peritoneal seeding
> Krukenberg tumours – ovarian metastasis
> Blumer’s shelf – metastasis in pouch of Douglas
> Lymphatic spread
> Direct – to adjacent organs
9
Q
Describe the investigations used in gastric cancer
A
Bloods
- FBC – microcytic anaemia
- LFTs – if deranged, possible mets
- No reliable tumour markers but CEA, Ca125 and CA19-9 may be raised
Upper GI endoscopy
CT thorax, abdomen and pelvis – assess for metastatic disease
Staging laparoscopy to look for peritoneal metastases if considering resection
10
Q
Describe the treatment of gastric cancer
A
> Peri-operative chemotherapy
> Proximal cancers – total gastrectomy
> Distal cancers (antrum or pylorus) - subtotal gastrectomy
> Very early T1 gastric cancers – endoscopic mucosal resection (EMR)
Advanced disease – palliative therapy
> Nutrition – enteral feed, build up drinks
> Treatment of infection
> Maintain lumen patency (stenting or endoscopic laser treatment)
> Palliative surgery (gastro-jejunostomy) to by-pass obstruction
11
Q
List complications of total gastrectomy
A
- Anastomotic leak
- Dumping syndrome
> Sudden and large passage of hypertonic gastric contents into small intestine
> Results in an intraluminal fluid shift and subsequent intestinal distention
> Symptoms of nausea, vomiting, diarrhoea, hypovolaemia - Vitamin B12 deficiency – loss of secretion of intrinsic factor
- MI / stroke / respiratory failure / DVT / PE
12
Q
Describe the characteristics of Helicobacter pylori and its treatment
A
Gram negative helical bacterium produces urease enzyme
investigations
- urea breath test
> no antibiotics in past 4 weeks, no PPIs in past 2 weeks
- stool antigen test
- H pylori antibody test
- rapid urease test during endoscopy (CLO test)
Eradication – triple therapy, 1 PPI + 2 antibiotics
> Omeprazole 20mg BD (PPI)
> Clarithromycin 500mg BD OR metronidazole
> Amoxicillin 1g BD
test of eradication: urea breath test
no need to test for eradication if asymptomatic following test and treat
13
Q
Describe the anatomy of the pancreas, including blood supply
A
- Head
- Neck
- Body
- Uncinate process
- Tail
Blood supply
- Gastroduodenal artery
- Superior & inferior pancreaticoduodenal artery
- Splenic artery - greater pancreatic artery
13
Q
Describe the functions of the pancreas
A
Endocrine - islets of Langerhans
> Alpha cells: glucagon
> Beta cells: insulin + amylin (slows gastric emptying)
> Delta cells - somatostatin (regulates alpha & beta)
> Gamma cells: pancreatic polypeptide
> Epsilon cells: ghrelin (appetite)
Exocrine - acinar & duct tissue
- Proteases - trypsinogen and chymotrypsinogen
- Amylase: starch & maltose
- Lipase
- Others: elastase, ribonuclease…
Regulated by vagal innervation
> Acidic chime entering duodenum encourages S cells to release secretin which release alkaline pancreatic juices
> Fatty acids in duodenum release cholecystokinin, leads to secretion of digestive enzymes and bile from gallbladder
14
Q
List risk factors for pancreatic cancer
A
- Smoking, diabetes, high BMI, alcohol excess
- Chronic and hereditary pancreatitis
- Genetic familial syndromes e.g. Von-Hippel Lindau, MEN1
- Medical conditions: peptic ulcer disease, IBD
15
Q
Describe the signs and symptoms and investigations for pancreatic cancer
A
signs and symptoms
- Obstructive jaundice (often painless) or pain radiating through to back
- Cachexia, anorexia and unexplained weight loss
- Pale stools and dark urine
- Loss of endocrine function - type 3c diabetes
- Nausea / vomiting
- Palpable gallbladder (Courvoisier’s sign)
- Acute pancreatitis
- Haematemesis, melaena, IDA
investigations
- high resolution CT scan
- ultrasound
- imaging may demonstrate double duct sign
> simultaneous dilatation of the common bile and pancreatic ducts
16
Q
List types of pancreatic cancer
A
Solid non-endocrine
> Pancreatic ductal adenocarcinoma (PDAC)
> Adenosquamous
> Acinar cell
> Giant cell
> Pancreatoblastoma
Cystic non-endocrine
> Serous cystic
> Mucinous cystic
> Solid and cystic papillary
> Acinar cell cystadenocarcinoma
> IPMN – intraductal papillary mucinous neoplasm – malignant transformation possible
Neuroendocrine – functional v non-functional
> Gastrinoma - Zollinger-Ellison syndrome
> Increased levels of gastrin and stomach acid leading to ulcers and diarrhoea
> Insulinoma
> Slow growing, can present with hypoglycaemic coma
> Glucagonoma - High BMs
> VIPoma - Vener-Morrison syndrome
> Somatostatinoma
17
Q
Describe the treatment for pancreatic cancers
A
Head of pancreas cancer
> Whipple’s procedure (pancreaticoduodenectomy) +/- pylorus sparing
Body / tail - distal pancreatectomy / total pancreatectomy
Neoadjuvant / adjuvant chemotherapy
Not for resection
> Palliative intent
> Relieve obstruction via biliary stent or duodenal stent if GOO
> Palliative chemotherapy
17
Q
Describe Familial Adenomatous Polyposis (FAP)
A
APC gene (chromosome 5), AD inheritance
Gardner’s syndrome (subtype of FAP)
Numerous (>100) polyps
Almost 100% risk by age 40
Total colectomy performed in mid 20s
Still require endoscopic surveillance
17
Q
List risk factors for CRC
A
- Dietary – low fibre, high animal fat & red meat
- Excess bile salts
- Increasing age: majority >50 years age
- Previous colon cancers or previous colorectal adenomas
- Family history
- IBD (UC > Crohn’s)
- Familial conditions: FAP, HNPCC, juvenile polyps
18
Q
Describe Lynch syndrome
A
aka hereditary non-polyposis colorectal carcinoma (HNPCC)
AD inheritance
> due to defects in DNA mismatch repair gene MSH2/MLH1
> most common inherited condition for CRC
clinical features
- predominantly right-sided lesions
- increases risk of the followinng cancers
> colorectal
> endometrial
> ovarian
> pancreatic
19
Q
Describe the adenoma-carcinoma sequence
A
Adenoma – benign neoplasm of large bowel glandular epithelium
Adenomas undergo dysplastic change to become carcinomas
Majority left-sided lesions
20
Q
Describe the presentation of CRC
A
Change in bowel habit
> Bloods / mucus PR
> Lower abdo pain
> LBO / perforation
> Rectal pain / tenesmus
> Fistulate to adjacent structures
> Iron deficiency anaemia
> Weight loss
> Mass in RIF
> SBO or appendicitis in caecal lesions
30% present as an emergency
> Obstruction
> Perforation
21
Q
How is the severity of ulcerative colitis (UC) classified?
A
Truelove and Witts Criteria
- Moderate: 4-8 stool a day
- Severe: 8 stools a day, may have fever or night sweats
- Fulminant
>10 stools a day
Abdo pain, fever
Hypotension, tachycardia
Low Hb
Increased WCC &CRP, lowered albumin
22
Describe Duke's classification for CRC
A – limited to bowel mucosa
B – infiltrating through muscle wall
C – local lymph node involvement
D – distant spread (lung, liver, bone)
23
Describe the management of ulcerative colitis (UC)
inducing remission
- Mild acute UC
> topical (rectal) mesalazine (aminosalicylate)
- moderate acute UC
> topical (rectal) + oral mesalazine
> Prednisolone
> mild-moderate flare with demonstrable disease extending past left-sided colon, oral aminosalicylates (enemas only reach splenic flexure)
- Severe acute UC
> IV steroids e.g. hydrocortisone
> IV ciclosporin if steroids contraindicated
> if no improvement after 72h
>> Infliximab
>> Surgery
maintaining remission
- after mild/moderate flare: topical mesalazine OR topical + oral mesalazine
- following a severe relapse or if >=2 exacerbations in the past year: oral azathioprine or oral mercaptopurine
- Maintaining remission
> Aminosalicylate, azathioprine or mercaptopurine
- Predfoam enemas for toxic megacolon
- Total panproctocolectomy is curative - patient will have a permanent ileostomy or an ileo-anal anastomosis (J-pouch)
> sub-total colectomy in acute flare due to risk of infection
24
List investigations for CRC
- Colonoscopy and biopsy
- Staging CT CAP
- Bloods, stool qFIT
- ECG - exclude ischaemic bowel from AF
- CEA marker - carcinoembryonic antigen
25
Describe the management of CRC
- Surgical resection
- Adjuvant chemoradiotherapy
- Palliative stenting for inoperable lesions; perform bypass surgery or colostomy to avoid obstruction
26
Which patients should be investigated for CRC?
Patients >50 with >6 week history of
- Change in bowel habit
- Rectal bleeding
- IDA
27
Describe the types and symptoms of anal cancer
Most commonly SSC, less commonly adenocarcinoma
Risk factors – HPV types 6 and 11/ anogenital warts or dysplasia / immunosuppression
symptoms
- Can be painful: constant pain suggests invasion into sphincter / sidewall
- Blood and mucus on wiping
- Tenesmus
Red flags – weight loss, anorexia, groin nodes
28
List causes of perforated viscus
Upper GI (most common)
> DU/GU, gastric cancer, gallbladder, iatrogenic
Colonic (less common)
> CRC, diverticulum, stercoral, appendicitis, colitis
Small bowel (least common)
> Meckel's diverticulum, ischaemia, Crohn's, lymphoma
29
List risk factors for peptic ulcer disease
Infection – H. pylori
Neoplasia – gastric carcinoma
Vascular – inflammatory / autoimmune
Trauma – stab wounds
Iatrogenic – ERCP or OGD
Endocrine – Zollinger-Ellison syndrome: excessive gastrin
Drugs – NSAID use
Chemical – caustic substances/batteries
30
Define stercoral colitis
Stercoral colitis is an inflammatory colitis related to increased intraluminal pressure from impacted faecal material in the colon
31
Describe the management of a perforated ulcer
- IV antibiotics + IV PPI
- laparotomy
> perforated duodenal ulcer - oversew and omental patch
> gastric ulcer perforation - same or partial gastrectomy
32
Describe the causes and clinical presentation of a small bowel obstruction
clinical features
- faeculent vomiting
- absolute constipation
- colicky abdominal pain
- distended abdomen
- tinkling bowel sounds (BS)
causes
- Intraluminal
> Foreign bodies
> Gallstones
> Meconium
- Intramural
> Tumours
> Crohn's – inflammatory strictures
- Extrinsic
> Adhesions (MOST COMMON)
> Hernias
> Cancer
Less common: gallstone ileus, intussusception, volvulus
33
List investigations used in SBO
History and examination
Bloods
AXR +/- CT A/P
> AXR supine will show dilated small bowel loops >3cm, erect AXR will show air-fluid level
34
Describe the management of SBO
Drip and suck
> NG tube + IV fluids
> NG tube decompresses small bowel by draining content upwards
> IV fluids used to catch up with losses
Monitor UO – intake/output chart
Theatre after 48h
Trial of gastrografin if unsuccessful
35
Describe a sigmoid volvulus and its management
Bowel twists on its mesentery and obstructs
Causes massive blockage at location and upstream
risk factors: reduced mobility, psychotropic medications, opiates, antidepressants, chronic laxatives, Parkinson's, schizophrenia
AXR:
> Coffee bean sign
> Points to LUQ
> Loop arising from LIF twists
> Dilated proximal large bowel + small bowel
management
- Fluid and electrolyte replacement
- Decompression using flexible sigmoidoscopy
- Urgent laparotomy in bowel obstruction with signs of peritonitis
- Elective sigmoid colectomy for recurrent sigmoid volvulus
36
Describe a caecal volvulus
Location is variable
Distended caecum, remainder of colon collapses
Obstruction is where volvulus is
Small bowel can be dilated depending on ileocaecal valve
37
Describe the presentation of LBO and its management
Clinical presentation
> Absolute constipation
> abdominal distension
+/- vomiting (depending on whether ileocaecal valve is open or closed)
Causes
> Stricture
> Malignant (CRC) - MOST COMMON
> Benign (diverticula, ischaemia, IBD)
> External compression; gynaecological malignancy
> Volvulus
> Adhesions
Management
- IV fluids + NG tube
- Surgery
> If volvulus: flexible sigmoidoscopy decompression +/- flatus tube
> Laparotomy (caecal volvulus)
> Defunctioning colostomy / ileostomy
> Colonic stent
Closed-loop obstruction (competent ileocaecal valve not relieving pressure) - SURGICAL EMERGENCY
38
Describe investigations and management of ischaemic colitis
clinical features
- abdominal pain out of keeping with abdominal findings
- vomiting (possible altered blood)
- bloody diarrhoea
Risk factors: elderly, vasculopath, AF
investigations
> Very high WCC and CRP
> Lactic acidosis on ABG
> AXR: abnormal/obstructed
Management
- IV fluids, IV antibiotics
- Small bowel: laparotomy
> Pan-ischaemia is fatal and non-resectable
> Segmental ischaemic – resect
- Colon
> Conservative treatment
> If perforates or deteriorating patient may need Hartmanns/colectomy
39
Describe the clinical presentation of appendicitis
clinical features
- periumbilical pain migrates to RIF with guarding, rigidity, rebound tenderness
> Max tender over McBurney's point, 2/3 of the way along line between umbilicus and ASIS
- nausea and vomiting
- anorexia (common feature especially children)
- flatulence, bowel irregularity, diarrhoea
- pain on walking / speed bumps / potholes
- Rovsing's sign – pain in RIF when LIF is palpated
- Psoas stretch sign
40
What is Valentino's syndrome?
Perforated peptic ulcer
> Chemical fluid from ulcer streams along right paracolic gutter to RIF
> Causes peritoneal irritation and consequent chemical appendicitis
41
Describe the management of appendicitis
- Children: USS abdomen
- Young man – convincing clinically, proceed to lap/open appendicectomy
- Young woman – HCG to exclude ectopic, pelvis USS to exclude ovarian pathology, proceed to diagnostic lap +/- appendicectomy
- Older man/woman - CT A/P to exclude malignancy and confirm appendicitis
IV Abx pre-operatively
42
Describe the clinical presentation of diverticulitis
diverticula: outpouchings of colonic mucosa through muscular wall of colon, predominantly sigmoid colon
site: between taenia coli where vessels pierce the muscle to supply the mucosa
risk factors: low fibre high fat diet, physical inactivity, smokers, use of NSAIDs, steroids, opiates
clinical features
- LIF pain (except Asian, more likely RIF pain)
- Fever
- Change in bowel habit
- Nausea, vomiting
- Urinary symptoms
- PR bleeding
management
- mild cases can be managed at home: oral antibiotics, if no improvement in 72h then admission
> IV antibiotics: IV ceftriaxone + metronidazole
> IV fluids
> Analgesia
Non-improving patients or those with complications require intervention e.g. drainage of abscess, colonic resection if perforation or obstruction
43
List acute and chronic complications of diverticular disease
Acute
- Abscess
- perforation
> leads to generalised peritonitis, distended abdomen, diffuse tenderness/guarding
- haemorrhage
Chronic
- diverticular stricture
44
Describe the composition of bile
Bilirubin - pigment - breakdown of haem products
Cholesterol - excreted in bile, requires lecithin and bile salts to solubilise
Bile salts - cholic & chenodeoxycholic acid conjugated to taurine and glycine; fat emulsifiers
Lecithin - fat emulsifier
Inorganic salts - NaCl, NaHCO3 - neutralisation of gastric acid
Water
45
Describe the pathophysiology of gallstones
Mixed stones
> Cholesterol supersaturation
> Gallbladder function (emptying/absorption)
> Reduced bile acid concentration (gut bugs, ileal resection/disease)
Pigment stones
> Accumulation of bilirubin e.g. due to haemolytic anaemia
> Bile stasis
> Biliary tract colonisation (deconjugation of bilirubin diglucuronide)
> Foreign body (stents, parasites)
46
List risk factors for gallstones
- 5 Fs
> Female (oestrogen drives stone formation)
> fair (Caucasian)
> fertile
> forties
> fat
- Genetics
- Low calorie diet, rapid weight loss
- PPI use
47
Describe the clinical features and management of biliary colic
Clinical features
> Colicky RUQ / epigastric pain
> Acute onset, initiated by eating & drinking fatty foods
> Radiating to back
> Nausea and vomiting
> Dyspepsia, flatulence, food intolerance
Duration
> Lasts minutes to hours
> Settles spontaneously
> Well in between episodes
Blood results
> WCC, CRP – normal
> LFTs – normal
Management – analgesia and elective lap chole if severe
> If CBD is cut, hepatojejunostomy is performed; however, lifetime of recurrent biliary sepsis, gallstones
48
Describe the clinical features and management of acute cholecystitis
Obstruction of the cystic duct / Hartmann's pouch
features
- RUQ pain
- fever
- vomiting
- Murphy's sign +ve
- Boas sign: hyperaesthesia beneath right scapula
investigations
> WCC, CRP – raised
> LFTs: normal/mildly deranged
> ultrasound abdomen
> if equivocal diagnosis, technetium-labelled HIDA scan
Management
> NBM – low fat diet
> Analgesia
> IV Antibiotics
> early laparoscopic cholecystectomy within 1 week of diagnosis
> Percutaneous cholecystostomy if gangrenous
49
List complications of cholecystitis
- Gangrene
- Chronic cholecystitis
- Emphysema of GB
- Mucocoele
- Empyema of GB
- Perforation
- Mirizzi syndrome
> GB stone impacted in Hartmann's pouch leads to pressure and erosion of common hepatic duct
- Gallstone ileus
> seen as small bowel obstruction + air in biliary tree on AXR
- Carcinoma
50
Describe the causes, clinical presentation and management of ascending cholangitis
Clinical presentation
> Charcot's triad
>> Fevers / rigors
>> Jaundice
>> RUQ pain
> Raynaud's pentad
>> Charcot's
>> CNS depression
>> Shock
Causes: CBD stones, stricture, anastomotic stricture, post-ERCP
> blockage in cystic duct or gallbladder will not cause jaundice
commonly caused by E. coli
Management
- Aggressive resuscitation
- IV Antibiotics - triple therapy: gentamicin, amoxicillin and metronidazole OR piperacillin/tazobactam
- Urgent ERCP, sphincterotomy +/ stent
- Percutaneous transhepatic cholangiography
51
Describe gallstone ileus
In older individuals, long-term low-grade inflammation causes a fistula connecting duodenum & GB (sometimes stomach)
Presentation
> Presents as SBO
>> Vomiting, distended abdomen, absolute constipation
AXR: stones & air in biliary tree
Management
> Laparotomy
> Enterotomy and removal of stone
52
List causes of acute pancreatitis
I GET SMASHED
- Iatrogenic
- Gallstones
- Ethanol
- Trauma
- Steroids
- Mumps / malignancy
- Autoimmune (IgG4)
- Scorpion stings
- Hypercalcaemia / hypertrygliceridaemia
- ERCP
- Drugs
> azathioprine
> thiazides
> oestrogen
> mesalazine
> furosemide
> sodium valproate
53
Describe the investigations carried out in acute pancreatitis
Investigations
- Bloods: AMYLASE or lipase if >24h
Imaging
> Erect CXR: exclude pneumoperitoneum or LRTI
> USS abdomen: exclude gallstones & determine CBD diameter
>> also demonstrates pancreatic head masses and pancreatic oedema
> MRCP - exclude biliary or pancreatic stones
> ERCP: especially with coexisting cholangitis in gallstone pancreatitis
> EUS: idiopathic pancreatitis
> CT with contrast
54
Describe complications of acute pancreatitis
peripancreatic fluid collections
- may resolve or develop into pseudocysts/abscesses
pancreatic pseudocyst
- organisation of peripancreatic fluid collection, usually retrogastric
- collection is walled by fibrous/granulation tissue and occurs 4 weeks or more after acute pancreatitis
- associated with mild elevation of amylase
- symptomatic cases observed for 12 weeks as up to 50% resolve
- treatment: endoscopic or surgical cystogastrostomy or aspiration
pancreatic necrosis
> sterile necrosis should be managed conservatively initially
pancreatic abscess
> intraabdominal collection of pus in the absence of necrosis
> usually due to infected pseudocyst
> management: transgastric or endoscopic drainage
haemorrhage
> infected necrosis may involve vascular structures leading to haemorrhage
> retroperitoneal: Grey Turner's sign
acute respiratory distress syndrome (ARDS)
55
Describe severity scores for acute pancreatitis
Glasgow (Imrie) score >=3 within 48h of admission indicates severe, likely to develop complications
> Age, oxygen, WCC, urea, calcium, glucose, albumin, LDH, AST/ALT
Modified Glasgow / PANCREAS score
Revised Atlantic Classification
> Mild – no organ failure, no local/systemic complications
> Moderate – transient organ failure (<48h), local/systemic complications
> Severe – persistent organ failure (>48h)
CRP of >300mg/L 72h after onset of symptoms – necrosis likely
56
List complications of acute pancreatitis
Acute
> Local
>> Acute peripancreatic fluid collection (<4wk) developing into a pseudocyst (>4wk)
>> Acute necrotic collection (<4wk) developing into walled-off necrosis (>4wk)
>> Gastric outlet obstruction
>> Haemorrhage (splenic or GDA pseudoaneurysm)
>> Portal vein thrombosis
> Distant / systemic
>> Hypotension / shock / arrhythmias
>> Infection
>> Respiratory failure: ARDS, atelectasis, pleural effusions, pulmonary oedema
> AKI / renal failure
> Ileus
> Liver failure / ascites
> DIC
Chronic
> Chronic pancreatitis (CP) - calcifications, ducts, strictures, stones
> Exocrine failure – malnutrition
> Endocrine failure – type 3c diabetes
> PD stones/strictures
57
Describe the clinical features and management of acute pancreatitis
clinical features
- Epigastric pain radiating to back
- Nausea / vomiting
- Fever
- Periumbilical discolouration (Cullen's sign)
- Flank discolouration (Grey-Turner sign)
- Ischaemic (Purtscher) retinopathy - temporary/permanent blindness
management
- IV fluids
- Analgesia
- No role for antibiotics in initial setting, consider if infected collection
- Late – ERCP if required, nutritional support
Collections
> Sterile pseudocyst – no management needed except monitoring
> Walled off necrosis: drainage – cyst gastroscopy or percutaneous cyst drainage
58
Describe the clinical presentation, causes and management of chronic pancreatitis
symptoms
- Upper abdominal pain
- Post-prandial pain
- Nausea and vomiting
- Steatorrhoea
- Weight loss
- Diabetes
Causes
- Alcohol
- Idiopathic
- Autoimmune
- Hereditary
- Genetic: CF, haemochromatosis
- Obstructive: tumours, stones, structural abnormalities
Diagnosis:
- CT pancreas: diagnostic test of choice
> shows calcified / fibrotic pancreas
- Serum amylase: normal
- Faecal elastase: elevated
- Autoimmune screen
Management
> Analgesia
> Pancreatic enzymes (CREON)
> Insulin if diabetes
> Antioxidants in diet
59
Describe the causes and presentation of oesophageal perforation
Causes: caustic substances, OGD, Boerhaaves syndrome, trauma
clinical features
- neck, chest or abdominal pain
- surgical emphysema
Imaging
- Plain CXR - pneumomediastinum, hydropneumothorax
- CT with oral contrast - extraluminal contrast
Management
- Conservative
> Resuscitation, IV antibiotics, NBM
- Surgical
> Thoracotomy + surgical repair: thoracic oesophageal perf
> Laparotomy: intra-abdominal perforation + peritonitis
> Stents - palliative, contained perforations
> Percutaneous drainage
High mortality - sepsis leading to shock, multiorgan failure, death
60
List signs of perforation on AXR (pneumoperitoneum)
- Continuous hemidiaphragm with crisp delineation
- Rigler's sign - increased delineation of wall of bowel due to free gas
- Football sign: gas bubble rises to top of abdomen forming a ball, most commonly seen in NEC in babies
- Air surrounding falciform ligament
- visible line on AXR
61
Describe the anatomy of the thyroid gland
2 lobes connected by isthmus
Blood supply
> Superior thyroid artery – branch of external carotid
> Inferior thyroid artery – branch of thyrocervical trunk (branch of subclavian)
Venous drainage
> Internal jugular vein
> Brachiocephalic veins
Lymph nodes: anterior cervical chain
62
List the types and clinical features of thyroid cancer
types
- Papillary: most common
> orphan annie appearance on histology
- Follicular
- Medullary: C cells
- Anaplastic: rare, aggressive
- Lymphoma
clinical features
- Palpable single or multiple lumps
- Rapid growth
- Pain
- Cough, hoarse voice, stridor
- Multiple enlarged cervical lymph nodes
management
- Surgery
> Hemi-thyroidectomy
> Total thyroidectomy
- Non-surgical treatment
> Radioiodine therapy
> External beam radiotherapy
> Chemotherapy
63
List the symptoms of hypercalcaemia
GI
> Nausea and vomiting
> Abdominal pain
> Pancreatitis
> Ulcer
> Constipation
CV
> High BP
> Bradycardia
> Heart block
> Arrhythmias
Renal
> Colic
> Polyuria
> Oliguria
> Thirst
> Renal failure
Neuro
> Anxiety
> Depression
> Headaches
> Confusion
64
List causes of hypercalcaemia
Malignancy
> Solid tumour
> Metastasis
Haematological
> Myeloma, lymphoma, leukaemia
Hyperparathyroidism
> Lithium, familial (MEN), FHH
High bone turnover
> Paget's, thiazides, hyperthyroid
Excess vitamin D
Renal failure – secondary HPT
Addisonian crisis
Lab error - haemoconcentration
65
Describe the anatomy of the adrenal gland
Blood supply
> Inferior phrenic, renal and aortic branches
Venous drainage
> IVC on right
> Left renal vein on left
Cortex
> Zona glomerulosa – mineralocorticoids
> Zona fasciculata – glucocorticoids
> Zona reticularis – androgens (DHEA)
Medullary
> Noradrenaline, adrenaline
66
Describe the features and management of Cushing's disease
Increased levels of glucocorticoids
Features
> Obesity
> Hirsutism
> Muscle weakness
> Striae
> Acne
> Diabetes
> Bruising
> Fractures
> Buffalo hump
> High BP
Management
> Surgery
>> Transsphenoidal pituitary surgery
>> Laparoscopic adrenalectomy
67
Describe adrenocortical carcinoma and its management
Suspected when mass size is >6cm
Associated with
> MEN1
> Li Fraumeni syndrome (breast, brain, osteosarcoma)
Management
> Medical: mitotane – causes adrenal necrosis
> Surgery: laparoscopic or transabdominal approach
68
List drugs which must be stopped or altered prior to surgery
Drugs to stop prior to surgery – CHOW
Clopidogrel
> Stop 7 days prior due to bleeding risk
> Aspirin and other anti-platelets can be continued
Hypoglycaemics
Oral contraceptive pill or HRT
> Stop 4 weeks before surgery due to DVT risk
Warfarin
> Stop 5 days prior due to bleeding risk
> Commence on therapeutic dose LMWH
> If INR >1.5, give PO vitamin K
DOACs will also need to be stopped but duration depends on each one
Drugs to alter
> Subcutaneous insulin
>> Switch to variable-rate insulin infusion (VRIII)
> Long-term steroids
>> Must be continued due to risk of Addisonian crisis if stopped
>> If patient cannot take orally, switch to IV
69
Describe colonic polyps
Any growth from lining of large bowel
Can be pedunculated or sessile
Types
> Tubular – smaller, less potential
> Villous – larger, frond-like lesions, greater malignant potential
> Tubulovillous - both
Presentation
> PR bleeding
> Mucous discharge or prolapse if low in rectum
Can be precancerous
70
List causes of PR bleeding
- Anticoagulants
- Bleeding diathesis / coagulopathy
- Haemorrhoids
- Diverticulosis
- CRC
- Colitis (Crohn's / UC / infective / C. diff / ischaemic)
- Angiodysplasia
- Meckel's with ectopic gastric mucosa
71
Describe perianal abscesses
associated with Crohn's disease
clinical features
- acute perianal pain
- purulent discharge
- erythema and swelling
- +/- systemic upset
Mangement
- EUA (examination under anaesthesia)
- incision and drainage (+/- fistulotomy)
Beware the obese diabetic who is unwell – necrotising perianal sepsis
72
Describe fistula in ano
Causes: cryptoglandular, Crohn's, drugs, radiation, tumour
Symptoms
- discharge
- pain
- soiling
Imaging: MRI pelvis
Management
> Crohn's
- induce remission with glucocorticoids
- enteral feeding can be used
- second-line: mesalazine
- azathioprine or mercaptopurine to maintain remission
-refractory / fistulating disease: infliximab
- isolated perianal fistula: metronidazole
- Lay open and remove internal opening - heal by secondary intention
- Repeated seton until laying open is possible
- Complex procedures –
> LIFT procedure - ligation of intersphincteric fistula tract
> Endoanal advancement flap
73
Describe anal fissures
Tear in the epithelial lining of the anal canal
Symptoms
- Acute
> Sharp anal pain: cut glass – during and after defecation
> A little blood on wiping
- Chronic
> Symptoms beyond 6-8/52
> Sentinel tag at the external apex
> Exposed internal sphincter muscle
> Hypertrophied anal papilla at the internal apex
posterior is most common site
- if lateral anal fissure, investigate for IBD (uncommon site)
Management
- acute anal fissure (<1 week)
> soften stool
> dietary fibre
> topical anaesthetic e.g. lidocaine
> Sitz baths
- >1 week
> GTN / diltiazem ointment
> Diltiazem ointment
> Intersphincteric botox injection
- If persists at 6/52 consider EUA – exclude sinister pathology
- surgical management
> Lateral internal sphincterotomy
> Anal advancement flap
> Fissurectomy
> Defunctioning stoma
74
Describe thrombosed external haemorrhoid
Aka perianal haematoma
Symptoms
> Acute severe perianal pain
> Blood on wiping and in pan
> Perianal lump
Either conservative management or incision and evacuation
Symptoms usually last 2/52 regardless
Little evidence that surgery improves pain over this period, although initial relief is usually marked
Conservative Rx
> stool softeners
> Topical local anaesthetic gel
> Cool pack
> refer for excision if <72h
75
Describe rectal prolapse
Protrusion of all layers of the rectal wall through anal canal
Symptoms
- A lump coming down on defecation or standing
- Blood and mucus on wiping
- Incontinence
- Usually not painful
- Patient may confuse for prolapsing haemorrhoids
Usually elderly women – pelvic floor / sphincter complex weakness after obstetric injury followed by age and menopause-related muscle weakening
Management
- Initially – push it back in
- Conservative if very unfit
- Perineal repair (Delorme's / Altmeier's)
- Abdominal rectopexy
76
Compare colostomy and ilostomy
Ileostomy
- usually RIF
- Spouted
- effluent is liquid to semi-liquid
- higher output
Colostomy
- usually LIF
- Flat / flush with skin
- semi-solid to solid effluent
- lower output
77
List symptoms and management of GORD
clinical features
- dyspepsia
- heartburn
- nausea
- epigastric / retrosternal pain
- bloating
- anorexia
- early satiety
- unintentional weight loss
- dysphagia
- GI bleeding
Red flags
> Iron deficiency anaemia
> Epigastric mass
Complications
> Oesophagitis
> Ulcers
> Benign stricture
> Barrett's oesophagus
> Oesophageal adenocarcinoma
> Iron deficiency anaemia
Drug management
> H2 receptor blocker (ECL cells) – cimetidine, ranitidine
> PPI (parietal cells) – omeprazole, esomeprazole
78
List investigations used in oesophageal pathology
Upper GI endoscopy
Barium swallow
24h pH monitoring if endoscopy is normal
Oesophageal manometry – if endoscopy is normal
> Need to see transmitted peristalsis of oesophageal muscle and relaxation of lower oesophageal sphincter
79
Describe hiatus hernias
Sliding hiatus hernia
> Gastric fundus protrudes into thoracic cavity
> Lower oesophageal sphincter is no longer in contact with diaphragm
Paraoesophageal "rolling" hiatus hernia
> More dangerous, less symptomatic as lower oesophageal sphincter is potentially still functioning
> Rolling hernia means risk of strangulation of gastric fundus
Management
> Weight loss
> Symptomatic relief : PPI, H2 receptor antagonist
Surgery - Nissen fundoplication, Linx procedure
80
Describe achalasia and its management
Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter due to degenerative loss of ganglia from Auerbach's plexus
Clinical features
- dysphagia of BOTH liquids and solids
- variation in severity of symptoms
- heartburn
- regurgitation of food
- may lead to cough, aspiration pneumonia
> aspiration pneumonia is more common in right lower lobe (RLL)
Investigations
- oesophageal manometry: excessive LOS tone which doesn't relax on swallowing
- barium swallow: grossly expanded oesophagus, fluid level, 'bird's beak' appearance
chest x-ray: wide mediastinum, fluid level
Treatment
> pneumatic (balloon) dilation first-line
> surgical intervention: Heller cardiomyotomy
> intra-sphincteric injection of botulinum toxin if high surgical risk
> drug therapy (e.g. nitrates, calcium channel blockers)
complications - squamous cell carcinoma
81
Describe the features and management of abscesses
Collection of pus surrounded by a pyogenic membrane
Pus – dead leukocytes, bacteria and tissue debris
Features
> Red, hot, tender swelling
> Fluctuant
Outcomes
> Rupture
> Discharge into another organ – fistula
> Discharge into an epithelial surface – sinus
Management – drainage
> Skin and soft tissue – I&D under LA/GA
> Intra-abdominal abscess – Abx + IR drainage or laparoscopic washout
82
Describe erysipelas and its management
Spreading cuticular lymphangitis
Common organisms – streptococcus pyogenes
> Rose-pink rash that extends to adjacent skin
> Raised
> Sharply defined margins
> Vesicles contain serum, not pus
Milian's ear sign
Management
> Wound swab
> Antibiotics – want to cover gram +ve flucloxacillin
83
Describe cellulitis and its management
Spreading inflammation of subcutaneous and fascial layers – suppuration, sloughing or gangrene
Common in diabetic, malnourished patients
Features
> Swollen
> Tender
> Hot
> No definite edge
> Vesicles may contain pus
management
- PO/IV Antibiotics depending on patient and severity
84
Describe necrotising fasciitis and its management
A polymicrobial bacterial infection - destruction of the soft tissues and fascia
Surgical emergency
Risk factors
> Diabetes
> Smoking
> Penetrating trauma
> Pressure sores
Clinical features
> Rapidly progressing
> Generally unwell, tachycardic, fever +/- hypotensive
> Oedema stretching beyond visible skin erythema
> Pain out of proportion to affected area
> Crepitus
> Fournier gangrene – nec fasc affecting external genitalia and perineum
Management
> Fluid resuscitation
> IV Antibiotics – covering gram +ve, gram –ve and anaerobes
> Surgical debridement
+/- plastic surgery review for skin graft
85
Describe peritonitis
Inflammation of the peritoneum
Causes
> bacterial inflammation
> Gastrointestinal perforation – perforated ulcer, appendix, diverticulum
> Transmural translocation (no perforation) e.g. pancreatitis, ischaemic bowel
> Exogenous contamination e.g. drains, open surgery, trauma
> Female genital tract infection e.g. pelvic inflammatory disease
> Haematogenous spread (rare) e.g. septicaemia
> Chemical – bile, barium
> Ischaemia – strangulated bowel, vascular occlusion
Management
> Resuscitate – IV fluids / Urinary catheter to monitor output
> IV Antibiotics
> CXR +/- CT A/P
> Theatre
86
Describe ulcerative colitis (UC) and its symptoms
features
> Involves rectum and extends proximally to involve all or part of colon (left side)
> Continuous spread (no skip lesions)
> Ulcers, pseudopolyps
> Diffuse mucosal inflammation – no transmural ulceration
> Limited to colon
biopsy: crypt abscesses
Symptoms
> Bloody diarrhoea
> Mucus
> Abdominal pain
> Tenesmus and urgency
Most common disease pattern is proctitis
> Extraintestinal
>> Erythema nodosum, pyoderma gangrenosum
>> Uveitis
>> Arthritis
>> Aphthous ulcers
>> Primary sclerosing cholangitis (PSC)
87
Describe Crohn's disease
Patchy transmural inflammation in any part of GI tract
> skip lesions mouth-anus
> transmural inflammation
> goblet cells
> granulomas
> strictures: Kantor's string sign
> rose-thorn ulcers
Risk factors – smoking, prior appendicectomy, family history
Defined by
> Location – terminal ileum, ileocolic, upper GI
>> terminal ileitis increases gallstone risk
> Disease – inflammatory, stricturing, fistulating
> Cobblestone appearance
> Creeping fat – adhesions and fistula
Diagnosis
> Colonoscopy – cobblestoning
> Histology – discontinuous, granulomatous inflammation
> CT/USS/MRI - abscess/fistulae
> Capsule enteroscopy
88
Describe the management of Crohn's
Inducing remission: glucocorticoids
> Aminosalicylates e.g. mesalazine (second-line to glucocorticoids)
> Immunosuppressants e.g. azathioprine, 6-mercaptopurine, cyclosporin (add-on)
> Biological therapy: infliximab, adalimumab
Maintaining remission - azathioprine or mercaptopurine first-line (methotrexate second-line)
Perianal fistulae: oral metronidazole +/- seton drain
Most patients eventually have surgery
> stricturing terminal ileal disease - ileocaecal resection
> segmental small bowel resections
> stricturoplasty
89
Define haemorrhoids and the causes of haemorrhoids
Cushions of highly vascular tissue found within the submucosal space and are considered part of the anatomy of the anal canal
Causes
> Constipation, prolonged straining
> Exercise, gravity
> Nutrition (low fibre diet)
> Pregnancy, increased intra-abdominal pressure
> Irregular bowel habits (constipation / diarrhoea)
> Genetics, absence of valves within the haemorrhoidal veins
> Aging
90
Describe the presentation, grading and treatment of haemorrhoids
Acute – thrombosed piles
Chronic
> Internal
>> Painless bleeding
>> Itch
> External
>> Bleeding
>> Swelling and discomfort
>> Mucous discharge
investigation - PR exam, proctoscopy
Grading
> grade I: do not prolapse out of anal canal
> grade II: prolapse on defecation but reduce spontaneously
> grade III: can be manually reduced
> grade IV: cannot be reduced
Treatment
> Medical
>> Dietary / lifestyle: avoid constipation
>> Creams
>> anusol: astringent to shrink haemorrhoids (short-term)
>> topical lidocaine
Non-surgical
> Injection sclerotherapy
> Rubber band ligation (RBL)
> Transanal haemorrhoidal dearterialization (THD)
Surgery
> Open/closed haemorrhoidectomy
> Procedure for prolapse and haemorrhoids (PPH)
> Infrared photocoagulation
> Haemorrhoidal artery ligation operation (HALO)
91
Describe pilonidal sinus & its treatment
Acquired condition related to the presence of hair in the natal cleft
Loose hair causes a foreign body reaction leading to midline pit formation
Presentation
> Simple cyst
> Acute abscess with/without cellulitis
> A chronic draining sinus
> May have a tracking sinus or multiple sinuses
Treatment
> Non-operative
>> Local hair control – shaving or laser epilation
>> Improved hygiene
> Operative
>> PNS abscess – incision & drainage
>> Karydakis & Bascom's procedure
92
Describe the pathophysiology, presentation and management of a tension pneumothorax
Pathophysiology
- Blunt or penetrating injury
> Results from a one-way air leak which results in trapped air within the thoracic cavity – collapsing the affected lung
> Mediastinal shift results in decreased venous return and compression of the opposite lung
> Decreased venous return reduces cardiac output
> Obstructive shock
Clinical signs
- Respiratory distress
- Deviated trachea
- Distended neck veins
- Absent breath sounds / markedly decreased on the affected side
- Hyperresonant to percuss
- Minimal chest movement
Management
- Oxygen – 15L trauma mask (non-rebreather)
- Grey venflon – second intercostal space mid clavicular line to buy some time
- Chest drain
93
Describe the pathophysiology, clinical signs and management of cardiac tamponade
Pathophysiology
> penetrating or blunt
> Cardiac tamponade is the accumulation of pericardial fluid, blood, pus or air within the pericardial space
> Results in an increase in intra-pericardial pressure, restricting cardiac filling and decreasing cardiac output
> Obstructive shock
Clinical signs
> Tachycardia, hypotension
> Distant heart sounds
> Distended neck veins
> Pulsus paradoxus >10 mmHg
> Abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration
Management
> Drainage of the pericardial fluid either by pericardiocentesis or surgical drainage – usually with a thoracotomy in trauma and creation of a pericardial window
94
Describe acute limb ischaemia and its clinical presentation
Sudden decrease in limb arterial perfusion with potential threat to limb survival ; onset <2 weeks
Presentation: 6 Ps
- Pain
- Pulseless
- Pallor
- Poikilothermia (perishingly cold)
- Paraesthesia – indicative of neuronal ischaemia
- Paralysis – indicative of neuronal ischaemia
95
List investigations and management for acute limb ischaemia
Rutherford classification for staging of severity
Investigations
> ECG, echo
> CT angiography
> Arterial Doppler ultrasound (initial investigation)
> ABPI
Management: surgical emergency
> Resuscitation and analgesia (IV opioids)
> IV unfractionated heparin to prevent clot propagation
> urgent specialist assessment for revascularisation
>> Surgical embolectomy +/- fasciotomy
>> Endovascular: targeted thrombolysis
> Late diagnosis: amputation
96
Describe causes of acute limb ischaemia
- Thrombo-embolus
> E.g. AF, infective endocarditis, antiphospholipid syndrome
> Managed via open arteriotomy or catheter-directed thrombectomy
- Aneurysm
> Higher amputation rates as no collateral circulation
- Trauma & iatrogenic injury
- Dissection
97
Describe the pathophysiology and clinical presentation of critical limb ischaemia
Peripheral arterial disease combined with
> Rest pain + night pain
> Gangrene
> Limb ulceration / tissue loss >2 weeks
Examination
- Absent peripheral pulses
- Buerger's test
> Foot blanches on elevation + dependent hyperaemia
- Hyperaemic foot "sunset"
- Arterial ulcers / gangrene / necrosis
>> Classically "punched out", distal, painful
98
Describe findings on inspection in chronic venous insufficiency
Haemosiderin deposition
> Erythrocyte leakage & breakdown
> Release of iron
Lipodermatosclerosis
> Inflammation and fibrosis
Venous eczema
> Venous ulceration
>> Sloping edges
>> Shallow
>> Large
>> management: compression bandaging, oral pentoxifylline
99
Describe peripheral arterial disease and its management
clinical features
- intermittent claudication
> usually affects calves, can affect thighs and buttocks
investigations
- ankle-brachial pressure index (ABPI)
- arterial duplex ultrasound
- non-invasive angiography – CT / MRI
- conventional needle angiography / DSA (digital subtraction angiography): best imaging
management
- conservative: risk modification, patient education, smoking cessation
- exercise training
- clopidogrel 75mg and atorvastatin 80mg
If intermittent claudication:
> medical: cilostazol – phosphodiesterase 3 inhibitor – vasodilator
> surgical: if medical management fails
100
Define abdominal aortic aneurysms and describe their classification
True aneurysms involve all layers of the arterial wall, > 50% dilatation of the artery
> False / pseudo aneurysm – bleeding tamponade by surrounding tissue
>> Causes – IVDU and cardio procedures due to puncturing vessels
2 types of aneurysm
> Saccular (outpouching), usually subarachnoid
> Fusiform (majority) of AAA
>> Related to position of renal arteries: infrarenal, suprarenal...
indications for surgical repair
- rapidly enlarging (>1cm over a year and >4cm)
- repair at 5.5cm
101
List risk factors for AAA
Age >65
Male gender
Smoking
Family history of AAA
Atherosclerosis
History of other vascular aneurysms, especially popliteal aneurysm
Arterial hypertension
Greater height
Obesity
COPD
Congenital disorders e.g. Marfan's, Ehlers-Danlos
102
Describe treatment options for AAA
Open repair (consider repair >5.5cm): good long-term outcomes
EVAR (endovascular aneurysm repair): may need reintervention in future
103
Describe the presentation, investigations and treatment of an AAA rupture
Presentation
> Sudden onset severe back/lower abdo pain
> Expansile abdominal mass +/- tenderness
> Cardiovascular instability e.g. hypotension / collapse
> Assess peripheral pulses
> Beware "renal colic" in men <50, retroperitoneal fluid can cause flank pain
Surgical emergency, high mortality
Investigations: abdo exam, CT
Management
> Resuscitation
> Permissive hypotension: less chance of disrupting haematoma with lower BP
> Repair – open or EVAR
104
List antiemetics for post-op nausea
Serotonin antagonists (5HT) - ondansetron 4mg
Corticosteroid – dexamethasone 4-8mg
Dopamine antagonists (D2) - droperidol 0.625-1.25mg
Metoclopramide – 25-50mg
105
List complications associated with massive transfusion
Metabolic acidosis / hypocalcaemia
Coagulopathy – dilutional / consumptive
Hypothermia
Hyperkalaemia
TACO – Transfusion-associated circulatory overload
Transfusion related acute lung injury (TRALI)
106
Describe the classification of severity of UC and its management
Truelove & Witts Criteria
Severity
- Mild: <4 stools/day, small amount of blood
- Moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
- Severe: >6 stools/day, features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
Management
- Mild to moderate UC
> topical (rectal) aminosalicylate e.g. mesalazine
>> if remission not achieved within 4 weeks add oral aminosalicylate, if still not achieved, topical/oral steroid
- severe colitis
> IV methylprednisolone
> intravenous ciclosporin if steroids not tolerated
IF toxic megacolon - surgical referral, may need emergent colitis (consider rescue infliximab)
following a severe relapse or >=2 exacerbations in the past year: oral azathioprine or oral mercaptopurine
107
What is the diameter for megacolon?
369
3cm - small bowel
6cm - large bowel
9cm - caecum
108
Describe milk-alkali syndrome
Triad of hypercalcaemia, metabolic alkalosis and renal insufficiency (AKI).
Associated with excess calcium supplementation e.g. calcium carbonate
lab features: high calcium, low PTH
109
Describe Paget's disease of the bone and its management
Increased bone turnover
Association with age >55, smoking, genetics, paramyxoviruses e.g. measles, RSV, canine distemper virus
Clinical features
> bone pain (Deep, dull, nighttime)
> Skeletal deformities
>> increased hat size (skull involvement), hearing loss
>> bowed tibias
>> kyphosis
>> fractures
Lab features
> increased serum ALP
> normal calcium and phosphate
X-ray: localised bone enlargement and deformity, patchy cortical thickening with sclerosis
Bone biopsy is the most sensitive test
Complications
- Neurological: nerve root compression,, spinal stenosis
- Orthopaedic: OA, pathological fractures, enlargement/deformity
- Oncological: osteosarcoma
- Other: HF, secondary hyperparathyroidism
- malignancy: osteosarcoma
management:
> analgesia
> bisphosphonates
> PT/OT
> Corrective surgery, joint replacement
110
Describe multiple myeloma
malignant proliferation of plasma cells that secrete monoclonal antibodies and light immunoglobulin chains.
clinical fratures
> lethargy
> bone pain
> pathological fracture
> amyloidosis
> pancytopenia (marrow infiltration)
Diagnosis requires two of the following 3 criteria:
1. Marrow plasmacytosis
2. Serum/urinary immunoglobulin light chains (Bence Jones protein)
3. Skeletal lesions (osteolytic lesions, pepperpot skull and pathological fractures)
If serum / urine monoclonal antibodies but do not fulfil the criteria for multiple myeloma: monoclonal gammopathy of uncertain significance
Management
> analgesia
> bisphosphonates
> orthopaedic interventions
> <55yy: allogeneic stem cell transplantation
> palliative chemo
Complications
> Renal failure (caused by the deposition of light chains within the kidney)
>> managed by promoting fluid intake although renal replacement therapy may be required
111
Describe the adverse effects of the following cytotoxic agents
- cyclophosphamide (alkylating agent)
- bleomycin (cytotoxic)
- doxorubicin (anthracycline)
- methotrexate
- 5-FU
- 6-mercaptopurine
- cytarabine
- vincristine, vinblastine
- docetaxel
- cisplatin
- hydroxyurea
cyclophosphamide
> haemorrhagic cystitis
> myelosuppression
> transitional cell carcinoma
bleomycin
- lung fibrosis
doxorubicin
- cardiomyopathy
methotrexate
- myelosuppression
- mucositis
- liver fibrosis
- lung fibrosis
5-FU
- myelosuppression
- mucositis
- dermatitis
6-mercaptopurine
- myelosuppression
cytarabine
- myelosuppression
- ataxia
vincristine: peripheral neuropathy, paralytic ileus
docetaxel: neutropaenia
cisplatin: ototoxicity, peripheral neuropathy
112
Describe cryptorchidism and its management
- congenital undescended testis by 3 months of age
- increased risk of testicular cancer
treatment
- orchidopexy at 6-18 months of age
retractile testis: appears in warm conditions or can be brought down on clinical examination and does not immediately retract
113
Describe the investigations and management of renal stones
Investigations
- urine dipstick
- Non-contrast CT KUB
- ultrasound for pregnant women and children
types of stone
- UTIs: struvite stones
> Proteus mirabilis will form a staghorn calculus
- cysteine stones: familial syndromes
- urate stones: increased uric acid (e.g. chemotherapy in AML)
- dehydration: calcium stones
Managemenet
Analgesia - NSAIDs
> usually IM diclofenac
Renal stones
> watchful waiting if <5mm and asymptomatic (follow-up imaging in 4 weeks)
> 5-10mm: shockwave lithotripsy
> 10-20mm: shockwave lithotripsy OR ureteroscopy
> >20mm: percutaneous nephrolithotomy
Ureteric stones
- distal ureteric stones <10mm
> extracorporeal shockwave lithotripsy + alpha blockers e.g. tamsulosin
- stones 10-20mm
> ureteroscopy
Infected Obstructed Urinary System - surgical emergency
> decompression via percutaneous nephrostomy
114
Describe cholangiocarcinoma and its management
bile duct cancer, risk factor is primary sclerosing cholangitis
features
- persistent biliary colic symptoms
- anorexia, jaundice, weight loss
- palpable mass in RUQ: Courvoisier sign
- periumbilical lymphadenopathy (Sister Mary Joseph nodes), Virchow node
- raised CA 19-9 levels
115
Describe local anaesthetic agents
- lidocaine
> affects Na channels in the axon
> toxicity: due to IV or excess administration
- cocaine
> applied topically to nasal mucosa in ENT surgery
- bupivacaine
> binds to intracellular portion of sodium channels and blocks sodium influx into cells
> longer duration than lignocaine
> cardiotoxic; levobupivacaine is less cardiotoxic
- prilocaine
> used for intravenous regional anaesthesia
- prilocaine
- lignocaine
Adrenaline may be added to local anaesthetic drugs to prolong duration of action and permit usage of higher doses
116
describe pilonidal disease and its management
condition where sinuses and cysts form near the upper part of the natal cleft of the buttocks
clinical features
- abscess
> pain (may be severe)
> purulent discharge
> fluctuant swelling at site
management
- asymptomatic: managed conservatively with local hygiene
- symptomatic
> acute: incision and drainage
> chronic/recurrent: excision of the pits and obliteration of underlying cavity
117
describe TURP syndrome
rare and life-threatening complication of transurethral resection of the prostate surgery
pathophysiology - venous destruction and absorption of irrigation fluid (glycine) causes hyponatraemia and hyperammonia
risk factors
- surgical time >1h
- height of bag >70cm
- resected >60g
- large blood loss
- perforation
- large amount of fluid used
- poorly controlled CHF
features
- CNS, respiratory and systemic symptoms
- visual disturbances
other complications
- retrograde ejaculation
118
what investigation can be performed to ensure that a colonic anastomosis is intact
gastrografin enema
119
describe prostate cancer
adenocarcinoma most common subtype
most cancers lie in the peripheral zone
more common in the Afro-Caribbean population
investigations
- PSA >4
- multiparametric MRI
- Gleason grading system used
treatment
- conservative: active watch and wait
- surgery - radical prostatectomy
> complications: incontinence, erectile dysfunction, urethral stenosis
- radiotherapy / brachytherapy
- hormonal therapy
> GnRH agonists or antagonists e.g. goserelin
> bicalutamide, cyproterone acetate, abiraterone
120
list blood film features in hyposplenism and 2 causes of hyposplenism
causes: post-splenectomy, coeliac disease
features
- target cells
- Howell-Jolly bodies
- Pappenheimer bodies
- Siderotic granules
- Acanthocytes
121
describe blood film features of the following conditions
- IDA
- myelofibrosis
- intravascular haemolysis
- megaloblastic anaemia
IDA
- target cells
- pencil poikilocytes
- if combined B12/folate deficiency: dimorphic film with mixed microcytic and macrocytic cells
Myelofibrosis
- tear drop poikilocytes
Intravascular haemolysis
- schistocytes
megaloblastic anaemia
- hypersegmented neutrophils
122
describe a gastric volvulus
Borchardt's triad of vomiting, severe epigastric pain and failure to pass NG tube
123
describe the management of transplant rejection
hyperacute rejection (minute to hours)
- due to pre-existing antibodies against ABO or HLA antigens
- no treatment is possible - graft must be removed
acute graft failure (<6 months)
- mismatched HLA. Cell-mediated (cytotoxic T cells)
- also caused by CMV
- may be reversible with immunosuppression and steroids
chronic graft failure (>6 months)
- antibody and cell-mediated mechanisms cause fibrosis
124
describe a venous ulcer
occur due to the pooling of blood and waste products in the skin secondary to venous insufficiency.
occur in the gaiter area (between the top of the foot and bottom of the calf muscle)
associated with chronic venous changes
- haemosiderin deposits
- venous eczema
- lipodermatosclerosis
Occur after a minor injury to the leg
features
- large and shallow
- irregular, gently sloping border
- more likely to bleed
- less painful than arterial ulcers
- pain relieved by elevation and worse on lowering the leg
management
- compression therapy
- cleaning, debridement and dressing of wound
- pentoxifylline
- analgesia (but avoid NSAIDs)
- Tissue viability / specialist leg ulcer clinics in complex or non-healing ulcers
125
describe an arterial ulcer
Occur distally, affecting the toes or dorsum of the foot
associated with peripheral arterial disease
> absent pulses, pallor and intermittent claudication
features
- small and deep
- well defined borders
- “punched-out” appearance
- pale colour due to poor blood supply
- less likely to bleed
- painful
- pain worse at night (when lying horizontally)
- pain worse on elevating and improved by lowering the leg (gravity helps the circulation)
management
- urgent referral to vascular to consider surgical revascularisation
126
describe the areas and muscle movements supplied by the following nerves
- deep peroneal
- superficial peroneal
- tibial
deep peroneal
- anterior compartment: tibialis anterior, extensor digitorum longus, peroneus tertius, extensor hallucis longus
> actions: dorsiflexion, inversion, eversion, toe extension,
superficial peroneal
- peroneal compartment: peroneus longus, peroneus brevis
> actions: eversion, plantarflexion
tibial
- posterior compartment: gastrocnemius, soleus, flexor digitorum longus, flexor hallucis longus, tibialis posterior
> actions: plantarflexion, toe flexion, inversion
127
describe inguinal and femoral hernias
inguinal hernias
- superior and medial to pubic tubercle
- direct:
> cannot be reduced by pressing on deep inguinal ring
- indirect: exit point is the deep inguinal ring
> can be reduced by pressing on deep inguinal ring
> no reappearance during coughing when covering the deep inguinal ring
femoral hernia
- inferior and lateral to pubic tubercle
- more common in multiparous women
- higher risk of strangulation
- refer for surgical repair within 2 weeks
128
describe total parenteral nutrition (TPN)
indications
- flare of inflammatory bowel disease
- short bowel syndrome
- bowel obstruction
TPN is very irritant to veins and can cause thrombophlebitis
> normally given through a central line
complications
- sepsis
- hyperglycaemia / hypoglycaemia
- dehydration and electrolyte imbalances
129
describe testicular cancer and its treatment
2 types
> non-seminomas (mostly teratomas - terrible twenties)
> seminomas: sucky sirties
in older men
- interstitial tumour
- lymphoma
investigations
- scrotal USS
- bloods: AFP, bHCG, LDH
- staging CT CAP
common sites of metastasis: lymphatics, lungs, liver, brain
treatment
- radical orchidectomy
- chemotherapy / radiotherapy
- sperm banking for future use
130
describe entonox and its use
Entonox is 50% O2 and 50% NO anaesthetic gas
> analgesic equivalent of 15mg morphine SC
often used in sports injuries
Contraindications
- impaired consciousness
- confirmed/presumed pneumothorax
131
describe the ERAS protocol
key components
- pre-operative
> pre-admission education
> reduced fasting duration
>> normal fasting: no clear liquids 2h before, no solids 6h before
> VTE prophylaxis
- operative
> active warming
> opioid sparing
> avoidance of prophylactic NG tubes and drains
- post-operative
> early oral nutrition
> early ambulation
> early catheter removal
> pain and nausea management
132
describe a Hartmanns procedure
aka proctosigmoidectomy
emergency procedure involving resection of rectosigmoid colon with closure of anorectal stump and formation of colostomy
> colostomy may be permanent or reversed at a later date
> performed in bowel obstruction due to tumour or significant diverticular disease
132
Describe the WHO surgical safety checklist
aim is to reduce the risk of human error
checklist is completed at 3 stages:
> Before induction of anaesthesia
> Before first skin incision
> Before patient leaves theatre
involves multiple members of the team checking essential factors, such as:
- Patient identity
- Allergies
- Operation
- Risk of bleeding
- Introductions of all team members
- Anticipated critical events
- Counting the number of sponges and needles to ensure nothing is left inside the patient
133
describe the interpretation of ABPI values
0.9 – 1.3 is normal
0.6 – 0.9 indicates mild peripheral arterial disease
0.3 – 0.6 indicates moderate to severe peripheral arterial disease
Less than 0.3 indicates severe disease to critical ischaemic
ABPI >1 can indicate vessel calcification common in diabetes
134
name the surgeries used for colorectal tumours depending on their location
right hemicolectomy
- caecal, ascending or proximal transverse colon tumours
left hemicolectomy
- distal transverse colon or descending colon
Hartmann's procedure: sigmoid colectomy with end colostomy formation
> used acutely for sigmoid colon perforation or obstruction
High anterior resection
- tumours of sigmoid colon
Anterior resection
- tumours of the upper rectum
abdomino-perineal excision
- tumours of lower rectum and anal verge
135
describe post-op pain management
- give paracetamol and NSAIDs
- offer opioid if post-op pain is expected to be moderate-severe
> oral first-line
> patient-controlled analgesia (PCA) if cannot tolerate oral
- if severe respiratory disease, do not offer opioid, instead
> continuous epidural (can be topped up so better than spinal anaesthesia)
> epidurals help faster return of normal bowel function
136
describe the management of paralytic ileus
- NG tube insertion + NBM
137
describe maintenance fluid prescription
prescribe at 30ml/kg/24hr
round up to 500ml and divide by 24 to find hourly rate e.g. 75kg x 30 = 2250mL in 24h
2500/24 = 93.75ml/hr = 100ml/hr
138
describe the management of diabetes in the perioperative period
- insulin with good glycaemic control undergoing minor procedures: adjust usual insulin regimen
- insulin with poor glycaemic control or prolonged fasting: VRIII
- long acting insulin: reduce by 20% on day before and day of surgery
- metformin: take as normal unless taking three times a day; if so, omit lunchtime dose
- sulfonylureas:
> morning surgery: omit morning dose
> afternoon surgery: omit both doses
- DPP4i and GLP-1 analogues: take as normal
- SGLT2i: omit on day of surgery
- twice daily insulins e.g. Novomix 30, Humulin M3: halve the usual morning dose and leave evening dose unchanged
139
describe pre-operative platelet transfusions
aim for platelet levels of
- >50 for most patients
- 50-75 if high risk of bleeding
- >100 if surgery at critical site
140
describe preparation for the following types of surgeries
- thyroid
- parathyroid
- sentinel node biopsy
- thoracic duct
- phaeochromocytoma
- carcinoid tumours
- colorectal cases
- thyrotoxicosis
- thyroid: vocal cord check
- parathyroid: methylene blue to identify gland
- sentinel node biopsy: radioactive marker / patent blue dye
- thoracic duct: cream
- phaeochromocytoma: alpha and beta blockade
- carcinoid tumours: cover with octreotide
- colorectal cases: bowel prep
- thyrotoxicosis: lugols iodine/medical therapy
141
list risk factors and protective factors for post-op nausea and vomiting (PONV)
risk factors
- female gender
- younger age
- use of opioid analgesia
- non-smoker
- previous severe post-operative nausea and vomiting
- ENT surgery
- inhaled anaesthetic gases
- ketamine, midazolam
- prolonged operative time
protective
- propofol
- prophylactic antiemetics
- dexamethasone
142
describe AAA screening
single abdominal US for men aged 65
143
describe the appearance of renal stones on X-ray
calcium phosphate / calcium oxalate (most common): radio-opaque
cystine: semi-opaque
urate / xanthine: radio-lucent
144
describe the management of acute clot retention
clots cause bladder outlet obstruction
management:
continuous bladder irrigation via a 3-way urethral catheter
145
list contraindications to laparoscopic surgery
- acute intestinal obstruction with dilated bowel loops
- haemodynamic instability / shock
- raised ICP
- uncorrected coagulopathy
146
describe chronic urinary retention
clinical features
- painless and insidious retention
- higher volumes than acute retention, usually >1L
high pressure retention
- impaired renal function and bilateral hydronephrosis
- typically due to bladder outflow obstruction
low pressure retention
- normal renal function and no hydronephrosis
decompression haematuria may occur after catheterisation
147
when should VTE prophylaxis be given for surgery
6-12h after surgery
148
describe the management of critical limb ischaemia
- endovascular revascularisation
> percutaneous transluminal angioplasty +/- stent placement
> used for short segment stenosis (<10cm), aortic iliac disease, high-risk diseas
- open revascularisation
> bypass grafting
> endarterectomy
> used for long segment stenosis (>10cm), multifocal lesions, lesions of common femoral artery and purely infrapopliteal disease
- If necrosis / gangrene – below or above knee amputation
149
describe the advice to give patients for vasectomy as a form of contraception
not immediate - semen analysis must be performed and azoospermia confirmed before use as contraception
150
list criteria for referral of patients with dyspepsia
urgent
- dysphagia
- upper abdominal mass
- aged >= 55 years with weight loss, AND:
* upper abdominal pain
* reflux
* dyspepsia
non-urgent
- haematemesis
- aged >= 55 years with:
* treatment-resistant dyspepsia
* upper abdominal pain with anaemia
* thrombocytosis with: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain
* nausea or vomiting with: weight loss, reflux, dyspepsia, upper abdominal pain
151
describe the management of dyspepsia in patients who do not meet criteria for referral
- review medications
- lifestyle advice
- trial of full-dose proton pump inhibitor for one month OR a 'test and treat' approach for H. pylori
> if symptoms persist after either of the above approaches then the alternative approach should be tried
