Surgery Flashcards
Clinical features of Appendicitis
Abdo pain - initially central then RIF (<24hrs)
McBurney’s point tenderness
Rosving’s sign = LIF palpation causes RIF pain
PR exam causes pain in RIF
Rebound tenderness/percussion tenderness
Anorexia, N&V, Pyrexia
Diagnostic criteria for Appendicitis
Largely a clinical diagnosis (based on Sx + Raised CRP/ESR).
Consider a USS to rule out gynaecologist pathology or CT scan to rule out other differentials.
if symptoms are present but inflammatory markers are normal = diagnostic laparotomy.
Management of Appendicitis
Urgent admission + surgical referall
Give prophylactic IV antibiotics + appendectomy
Causes of bowel obstruction
Small bowel adhesions (following surgery, endometriosis etc)
Hernia
Malignancy
Volvulus
Diverticular disease
Strictures (crohns)
Intususspetion
At what age does intususseption usually present?
6 months - 2 years
Investigations for suspected bowel obstruction
Abdo Xray - this shows a distended bowel (>3cm small bowel, >6cm colon, >9cm rectum)
Confirmation of diagnosis = CT contrast
What ABG findings are common in bowel obstruction
Metabolic alkalosis (due to vomitting) + Raised lactate (due to bowel ischemia) + Hypokalemia
What investigation should be used to rule out bowel perforation
Erect CXR
Management of a bowel obstruction
- A-E assessment + stabilisation. Think Drip + Suck: Keep patient NBM. Give IV fluids + added K+ if hypokalemic. NG tube with free drainage.
Consider emergency resection / exploratory surgery if patient is unstable
What medication should be avoided in bowel obstruction
Senna
Metaclopramide
Clinical Features of bowel obstruction
Green, bilious vomitting
Abdo pain + distension
Absolute constipation + absence of flatulence
Tinkling bowel sounds (in early obstruction) or absent bowel sounds (in late obstruction/ileus)
What classic sign is seen on Abdo Xray in a volvulus
Coffee bean sign (loss of haustra)
Femoral hernia description
Location = Below + Lateral to pubic tubercle. Through femoral ring into femoral canal
High risk of strangulation
Indirect inguinal hernia
Bowel herniates through deep inguinal ring into inguinal canal
Direct inguinal hernia
Bowel herniates through hesslebach’s triangle into inguinal canal
How to differentiate between indirect + direct inguinal hernias
Reduce the hernia and apply pressure to the deep inguinal ring (midpoint from ASIS to pubic tubercle). An indirect hernia will remain reduced whereas direct will not.
(think - because the indirect one gets pushed back up above the deep inguinal ring so won’t come back down)
Clinical Features of diverticular disease
Lower left abdominal pain
Constipation
Rectal bleeding
May have fever + systemic upset + palpable abdominal mass (particularly in an abscess has formed)
Management of chronic Diverticular disease
High fibre diet + good hydration
Bulk forming laxatives (e.g isphagula hulk)
Avoid stimulant laxatives - Senna
Surgical resection if severe
Management of acute diverticulitis
Uncomplicated = Amoxicillin 5 days + Liquid diet
Severe (or Sx for >72hrs) = Hospital admission for IV Ceftriaxone + Metronidazole
Classification of haemorrhoids
1st degree = no prolapse
2nd degree = prolapse when straining + return on relaxing
3rd degree = prolapse when straining, do not return on relaxing but can be pushed back in
4th degree = permanently prolapsed
Anatomical location of haemorrhoids
Mainly at 3, 7 and 11 o’clock.
Anal Fissue anatomical loation
Usually in the posterior midline (6 or 12 oclock)
Management of anal fissures
Soften stools with bulk forming laxatives
Topical LA
Chronic fissures = Topical GTN and surgery if not responsive in 8 weeks.
Gold standard investigation for peri-anal abscess
Trans-perineal USS
Kochers abdominal scar
Right subcostal margin
Purpose = Cholecystectomy
Lanz abdominal scar
RIF
Purpose = Appendicectomy
Rutherford Morrison scar
Renal transplant
Post-splenectomy prophylaxis
Vaccinations - needed 2 weeks before splenectomy - Hib + Men ACWY + Annual influenza + Pneumococcal 5yrly.
Penecillin V for at least 2 years
Aspirin
UK breast cancer screening programme
Mammogram offered every 3 years to women aged 50-70 (+/-3yrs) based on GP lists.
High risk patients get annual mammograms (age 40-49 if mod risk, 40-59 if high risk, 40-69 if BRCA +ve)
Types of breast cancer
Ductal (invasive or in-situ)
Lobular (invasive or in-situ)
Paget’s disease of the nipple
Eczemoid changes to the nipple secondary to breast cancer (usually invasive carcinoma)
Invx = punch biopsy
BRCA1
Mutation on chromosome 14
70% of pts develop breast cancer & 50% develop ovarian cancer. Also increased risk of bowel and prostate cancer
BRCA2
Mutation on chrosome 13
60% develop breast cancer & 20% ovarian cancer
2ww referall criteria for suspected breast cancer
Age >30 with unexplained breast lump, lump in axilla or skin changes suggestive of BC
Age >50 with unilateral nipple changes
Routine referall for suspected breast cancer
Unexplained lump in pt <30yrs.
Breast cancer tumor marker
Ca15-3
Indications for wide local excision of breast cancer
Solitary lesion
Peripheral location
Tumor <4cm in size
Large breast
DCIS <4cm
Indications for mastectomy in breast cancer
Multifocal tumor
Central tumor
Large lesion
Small breast
DCIS >4cm
Indications for whole breast uniltateral radiotherapy in breast cancer
After wide local excision
After mastectomy for stage T3/4 tumor
Treatment of ER +Ve breast cancer
Premenopausal = Tamoxifen
Postmenopausal = Anastrazole/lenestrazole
Side effects of tamoxifen
Endometrial cancer
VTE
Menopausal symptoms
Weight gain
Discharge
Side effects of Anastrazole
Hot flushes
Vaginal dryness
Bone pain
Skin rash
Hair thinning
indiction for biological therapy in BC
HER2 +ve cancer.
Trastuzumab - contraindicated in heart disorders
Scoring system for prognosis of breast cancer
Nottingham prognostic index
Tumor size x 0.2 + Lymph node score + Grade score
Fibroadenomas
Benign tumor of a whole lobule from stromal/epithelial cells .
Non tender mobile firm breast lumps typically in 15-30yr olds.
Fibroadenoma
Management of Fibroadenoma
If <3cm then watch & wait
If > 3cm = surgical excision
Lumpy breast + Cyclical breast pain in middle aged women
Fibroadenosis
Classic presentation/findings of a breast cyst
Smooth, discrete lump which may fluctuate with menstruation.
Mammogram shows ‘halo’ sign
Irregular firm fixed lump following trauma to the breast
Fat necrosis
Most common cause of nipple discharge (+/- blood) in 20-40yr olds
Intraductal papilloma
Mammary duct ectasia
Dilation of large breast ducts
Sx = thick green nipple discharge. May have tender lump around the areola.
Periductal mastitis
Mammary duct ectasia + infection
Smoking is a risk factor
Management = Antibiotics + drainage
Management of mastitis
Continue breast feeding
+ Flucoxacillin 10-14 days if systemically unwell or if symptoms don’t improve <24hrs.
Management of breast abscess
Antibiotics + USS guided incision/drainage
Abdominal aortic aneurysm
Diameter >3cm
AAA Screening in UK
Men aged 65yrs get a single abdominal USS
If <3cm = no further action
3 - 4.4 cm = Rescan annually
4.5 - 5.4cm = Rescan every 3 months
>5.5cm or if symptomatic / growing by >1cm per year = 2ww referal to vascular surgery
Treatment of AAA
Endovascular repair
If haemodynamically unstable = open repair
Clinical Presentation of Ruptured AAA
Severe central abdo pain radiating to the back
Pulsatile expansile mass in the abdomen
Cardiovascular shock
Aching/burning sensation in the legs precipitated by walking. Symptoms relieved by rest.
Intermittent claudication
ABPI 0.6-0.9
Intermittent claudication
ABPI 0.3 - 0.6
Critical limb ischemia
ABPI >1.2
Calcified / Stiffened arteries (think diabetes)
Pain in foot at rest for > 2 weeks + Ulceration + Gangrene. Pt sleeps with legs hanging out of the bed
Critical limb ischemia
Features of Acute limb threatening ischemia
Pale
Pulseless
Painfull
Paralysed
Paraesthetic
Perishingly cold
ABPI <0.3
Management of intermittent claudication
Lifestyle measures
Supervised exercise programme
Preventative meds = Statin + Clopidogrel
Management of critical limb ischemia
Endovascular revascularisation with angioplasty/stenting
OR
Surgical bypass with vein graft if: Long segment lesion / lesion of femoral artery / infra-popliteal disease
OR
Amputation if unfit
Management of acute limb threatening ischemia
Analgesia (IV opioids)
IV heparin
Immediate vascular review
for thrombolysis/surgery/amputation
Rutherford classification
Scoring system to determine if an ischemic limb is viable or not
1 = viable.
4 = Irreversible. Profound sensory loss + inaudible pulses
Arterial ulcer description
Deep punched out lesion. Pale/Necrotic wound. Located on pressure points.
Surrounding tissue = cold shiny + pale with absent hair, no palpable pulses + prolonged CRT
Shallow, irregular ulcer with granulation, exudative material + brown pigmentation. Located on the gaiter area
Venous ulcer
Deep punched out necrotic lesion on plantar surface of hallux
Neuropathic ulcer
Great saphenous vein vs Small saphenous vein
Both are superficial leg veins
Great saphenous = Medial
Small saphenous = Posterior
Indicators of venous insufficiency
C1: Reticular veins
Indicators of venous insufficiency
C1: Reticular veins
C2: Varicose veins
C3: Oedema
C4: Haemosiderin pigmentation
C5: Active venous ucer
Management of Varicose veins
Conservative = leg elevation + weight loss + exercise + graduated compression stockings
Invasive Tx = Endothermal ablation / Foam sclerotherapy
Surgery = Ligation / Stripping
Burgers disease
Small vessel vasculitis
RF = Smoking
Extremity ischmia + superficial thrombophlebitis + raynauds
(typically young male who smokes with extremity ischemia)
Causes of Upper urinary tract obstruction
Stones
Tumours
Strictures
Bladder tumor
Ureterocoele
Causes of lower urinary tract obstruction
BPH
Prostate tumour
Bladder neck cancer
Urethra strictures
Neurogenic bladder
Symptoms of obstructive uropathy
Upper = Loin - Groin pain + Oliguria / Anuria
Lower = LUTS + Suprapubic pain + Palpable bladder
Impaired renal function tests
Management of obstructive uropathy
Upper = Nephrostomy
Lower = Urethral/suprapubic catheter
Complications of obstructive uropathy
Post renal AKI
CKD
Infection
Retention
Overflow incontinence
Hydronephrosis
Acute urinary retention
Sudden onset of inability to urinate
RF = Male + age >60yrs
Causes = BPH / Urethral obstruction / Medications / Neurological disease / Post-op
Which medications are most likely to cause acute urinary retention
Anticholingergics
TCAs
Antihistamines
Opioids
Benzodiazepines
Classification of haemorrhoids
1st degree = no prolapse
2nd degree = prolapse when straining + returning on relaxing
3rd degree = prolapse when straining, do not return on relaxing
4th degree = permanently prolapsed
Types of Chronic urinary retention
- High pressure = Impaired renal function + bilateral hydronephrosis.
- Low pressure = Normal renal function + no hydronephrosis
Clinical Presentation of Renal cell carcinoma
Haematuria
Flank pain
Palpable mass
Types of renal cell carcinoma
Clear cell - 80%.
Papillary
Chromophobe
Wilm’s tumour
Tumor affecting the kidney in children, typically age <5years
Risk factors for renal cell carcinoma
Smoking
Obesity
HTN
ESRF
Von Hippel-Lindau Disease
Tuberous sclerosis
Where does Renal cell carcinoma tend to spread?
Locally - to gerota’s fascia, adrenals, spleen or colon
Renal vein (causing L sided varicocele) then IVC
Cannonball metastases = mets in lung fields.
Paraneoplastic features of RCC
Polycythemia - due to secretion of EPO
Hypercalcemia
Hypertension
Stauffer’s syndrome = abnormal LFTs without liver mets
1st line investigation for renal cell carcinoma
CT TAP
Management of Renal cell carcinoma
1st line = Nephrectomy
- Partial if <7cm
- Total if >7cm
2nd line = Arterial embolisation / Percutaneous cryotherapy / Radiofrequency ablation / Chemo + Radiotherapy (sunitinib)
Common sites of obstruction in renal stones
Pelvic-ureteric junction
Pelvic brim
Vesico-ureteric junction
Most common renal stone
Calcium oxalate stone
= opaque on radiograph.
Which renal stone is commonly formed due to Alkaline urine
Struvite stones - these appear like opaque staghorn caniculi.
1st line investigation for renal stones
CT KUB
Management of renal stones
IM Diclofenac +/- Abx if infection present
Stone <5mm will pass
Stone <2cm = lithotripsy
Stone <2cm + pregnant = uretoscopy + stents
Complex / staghorn caniculi = percutaneous nephrolithiotomy
Prevention of Oxalate stones
Reduce urinary oxalate secretion using cholestyramine / pyroxidine
Prevention of Uric acid stones
Allopurinol & urinary alkalisation (e.g bicarbonate)
Risk factors for Transitional cell bladder cancer
Smoking
Exposure to aniline dyes / aromatic amines (textile industry / rubber manufacture)
Cyclophosphamide
Thiazolidinediones (PPAR-gamma agonsits)
Risk factors for squamous cell bladder cancer
Schistosomiasis
Smoking
Thiozolidinediones
Clinical Presentation of bladder cancer
Painless microscopic haematuria
2ww referral criteria for bladder cancer
Age >45yrs + unexplained visible haematuria
Age >60 + microscopic haematuria + Dysuria/raised WCC
Investigation for bladder cancer
Cystoscopy +/- biopsy
Management options for bladder cancer
- TUBT - transurethral resection of bladder cancer
+ Adjuvant intravesical chemotherapy - Radical cystectomy - for stages T2 +
What is the occupational risk factor for bladder cancer
Textile/printing industry (due to aline dyes) or Rubber manufacture / rubber factories
Management of Lower urinary tract infection
Simple UTI = 3 days Nitrofuantoin/trimethorpim
Men = 7 days (if recurrent refer to urology)
Pregnant ladies = Nitrofuantoin/amoxicillin 7 days even if asymptomatic
Management of UTI in children
Age <3 months = refer to paediatrics
Age > 3 months + Upper UTI = Consider admission + Oral cefaclor/ceftriazone/co-amox for 10 days
Age > 3 months + lower UTI = Abx for 3 days
Management of pyelonephritis
Cephalosporin (e.g cefaclor/ceftriaxone) or Quinolone (e.g amoxicilln) for 10-14 days
Interstitial cystitis
chronic inflammation of the bladder leading to a chronic lower UTI (> 6 weeks) + suprapubic pain
Cystoscopy findings with interstitial cystitis
Hunner lesions /Granulation
Symptoms of BPH
Voiding - Weak stream / intermittent stream / straining / hesitancy / terminal dribling / incomplete emptying
Storage - urgency / frequency / urge incontinence / nocturia
What should the prostate feel like on examination
Smooth, symettrical + slightly soft with preservation of the central sulcus
Management of BPH
1st line = Tamsulosin
2nd line = Finasteride - indicated if significantly enlarged prostate with high risk of progression
MOA & Side effects of Tamsulosin
Moa = Alpha-1 antagonist. It decreases smooth muscle tone of the prostate/bladder
SEs = Postural hypotension / Drowsiness / Dyspnoea / Cough
*Caution in patients undergoing cataract surgery due to risk of floppy iris syndrome
MOA & Side effects of Finasteride
MOA = 5 alpha reductase inhibitor (essentially stops the conversion of testosterone into dihydrotestosterone which prevents prostatic growth)
SEs = Impotence / Decreased libido / Ejaculation disorders / Gynaecomastia
Symptomatic relief for BPH
Tolterodine (anti-muscarinic) - if overactive bladder
Complications of Transurethral resection of the prostate
TURP syndrome = hyponatremia + hyperammonia (CNS disturbance). Caused by absorption of irrigation fluid during surgery
Urethral strictures
Retrogade ejaculation
Perforation
Histology of Prostate cancer
95% are adenocarcinomas located in the peripheral zone of the prostate
What does prostate cancer feel like?
Hard, craggy, irregular prostate with a loss of the central sulcus
Causes of false +ve BPH
Prostatitis
UTI
BPH
Vigorous DRE
1st line investigation for prostate cancer
Multiparametric MRI
Staging system for prostate cancer
Gleason score
Management of Prostate cancer
Low risk = active surveillence (regular core biopsies)
High risk = External radiotherapy, Brachytherapy, Surgery, Hormonal therapies
Indications for radical prostatectomy
Localised disease
Hormonal therapy options for prostate cancer
GnRH agonists e.g gosrelin (initially causes a 2-3week rise in testosterone so symptoms may worsen at first)
Non-steroidal anti-androgens: Bicalutamide
Androgen synthesis inhibitor: Abiraterone
Chemotherapy agent used in prostate cancer
Docetaxel
What does prostatitis feel like
Tender, enlarged + boggy prostate
Management of prostatitis
Acute = Oral Ciprofloxacin/Trimethoprim for 2-4 weeks
Chronic = Tamsulosin + Abx
Causes of Epididymo-orchitis
E.coli
Chlamydia / Gonorrhoea
Mumps
Clinical Presentation of epididymo-orchitis
Unilateral testicle pain + dragging sensation.
Swelling + tenderness
Pain relieved by testicular elevation
May have urethral discharge if STI present
Management of epididymo-orchitis
Unknown organism = IM Ceftriazone + Doxycycline for 10-14days
Low risk of STI = Ofloxacin 14 days
High risk of STI = refer to GUM
Risk Factors of Testicular torsion
Bell clapper deformity
Teenage boy
USS findings in testicular torsion
Whirlpool sign
Management of Testicular torsion
Bilateral orchiplexy
Orchidectomy if nectrotic
Painless soft scrotal swelling which can be transilluminated
Hydrocoele
What can a left sided varicocele indicate?
Renal cell carcinoma
Scrotal swelling with throbbing pain which is worse on standing. Scrotal mass feels like a bag of worms and dissapears when lying down
Varicocoele
What is concerning about a varicocoele that does not dissapear on lying down
May indicate a retroperitoneal tumour or Renal cell carcinoma
Types of Testicular cancer
Seminomas
Non-seminomas e.g teratomas
Clinical presentation of testicular cancer
Painless, non-tender lump on testes
Hard + irregular + non-fluctuant
No translumination
May have gynaecomastic (may indicate a leydig cell tumor)
Tumor markers in Testicular cancer
Beta-hcg (raised in both types)
Alpha fetoprotein = non-seminomas
LDH = germ cell tumours
Testicular cancer staging system
Royal marsden criteria
