Surgery

Question 1

How to assess capacity?

Answer 1

Four criteria required:
*Understand the decision
*Retain the information long enough to make the decision
*Weigh up pros and cons
*Communicate their decision

It is assessed based on each individual decision
It may fluctuate so sometimes decisions should be delayed so they can make the decision for themselves at a later time

Question 2

What to do when somebody does not have capacity to make this decision?

Answer 2

Decisions are made in their best interest, taking into account their wishes and values
LPA - legally nominated person allowed to make decisions on someone’s behalf; only comes into effect if patient lacks capacity to decide for themselves
Deprivation of liberty safeguards - application made by hospital or care home for patients who lack capacity to allow them to provide care and treatment

Question 3

What is acute resuscitation?

Answer 3

Cardiopulmonary resuscitation- chest compressions with artificial respiration; performed to maintain blood circulation and oxygenation in a person who has suffered cardiac arrest

Question 4

When would you acutely resuscitate somebody?

Answer 4

After cardiac arrest

Question 5

How to fluid resuscitate somebody.

Answer 5

Give fluid bolus of 500ml of crystalloid [0.9&NaCl] over less than 15m
Reassess with ABCDE
Give up to 2L in 250-500ml boluses, then seek expert advice

Question 6

When to use blood when resuscitating somebody?

Answer 6

When a pt is losing blood
Replace like for like

Question 7

How do you give blood to a patient?

Answer 7

Two large bore cannulae - grey cannula 16G

Question 8

When would you keep a patient NBM?

Answer 8

Bowel obstruction
Surgery expected for treatment
Some scans may require patient to fast

Question 9

What is VTE assessment?

Answer 9

Assesses a patient’s risk of forming a clot/VTE
If at high risk, then should receive prophylaxis [LMWH or compression stockings]

Question 10

How do you complete a VTE assessment?

Answer 10

Follow local guidelines
Risk factors [any of these, must be given LMWH unless contraindicated]:
*anaesthetic + surgery time >90m
*>60 having minor surgery
*BMI >30
*history of VTE or 1st relative history of VTE
*thrombophilia
*malignant/infective or inflammatory disease
*varicose veins
*dehydrated
*totally immobile for >3days
*>60 and partially mobile for >3days
*taking/has taken oestrogen containing contraceptive/HRT in last 4weeks
*pregnant or <6wks post-partum

Question 11

What steps do you undertake after completing a VTE assessment?

Answer 11

Prescribe prophylaxis [LMWH]
Prescribe compression stockings

Question 12

What are some operation specific preparations?

Answer 12

Bowel prep

Question 13

What is bowel prep?

Answer 13

Medical technique to cleanse the bowel
Performed by oral ingestion of medication or by enema

Question 14

Name some types of bowel prep and how do they work?

Answer 14

Moviprep, Klean-Prep, CitraFleet or Picolax [sodium picosulphate] - all laxatives

Question 15

When would you ask for an anaesthetics review pre-operatively?

Answer 15

All patients having an operation under general or regional anaesthetic require a pre-operative assessment
Pts are assessed to determine if they are fit enough to undergo the specific operation- explores their co-morbidities, risk from anaesthesia, frailty status, cardiorespiratory fitness

Question 16

IV fluids - types

Answer 16

Crystalloids:
*0.9% sodium chloride
*5% dextrose
*0.18% sodium chloride in 4% glucose
*Hartmann’s solution
*Plasma-Lyte 148

Colloids
*Human albumin solution

Question 17

Antibiotics given pre-op/intra-op/post-op

Answer 17

Mainly cefazolin; vancomycin; gentamicin

Question 18

Analgesia - intra-/post-op

Answer 18

Morphine is used, alongside propofol, to help during the procedure
Many types of analgesia are used to control pain post operatively

Question 19

Anti-emetics - why are they given

Answer 19

To help post-operative nausea and vomiting
Helps to put patients at ease

Question 20

Anti-emetics - medications

Answer 20

Ondansetron [5HT3 receptor antagonist]; 4mg
Prochlorperazine [D2 receptor antagonist]; 3-6mg
Cyclizine [H1 receptor antagonist]; 50mg
Dexamethasone [unknown site of action]; 4mg

Question 21

Anti-emetics - side effects

Answer 21

Ondansetron - risk of prolong QT interval, constipation
Prochlorperazine - extrapyramidal s/e - dystonic reaction

Question 22

Thromboprophylaxis - medications

Answer 22

LMWH [enoxaparin]
DOACs [apixaban/rivaroxaban]
Anti-embolic compression stockings

Question 23

Thromboprophylaxis - dose

Answer 23

LMWH - enoxaparin - 20-40mg/day

Question 24

Thromboprophylaxis - side effects

Answer 24

Haemorrhage, heparin-induced thrombocytopenia, skin reactions, haemorrhagic anaemia, headache, hypersensitivity, thrombocytosis

Alopecia, hyperkalaemia, osteoporosis, spinal haematoma

Question 25

What is the pre-operative surgical checklist?

Answer 25

It is a checklist aimed to reduce the risk of human error before/during/after surgery It is checked before induction of anaesthesia, before first skin incision, before patient leaves theatre

Question 26

Why is the pre-operative surgical checklist completed?

Answer 26

The aim is to reduce the risk of human error before/during/after surgery

Question 27

What kinds of things are checked in the pre-operative surgical checklist?

Answer 27

Involves multiple members of the team [theatre nurse, anaesthetist and surgeon] checking essential factors, such as: *Patient identity *Allergies *Operation about to be performed/just been performed *Risk of bleeding *Introductions of all team members *Anticipated critical events *Counting the number of sponges, needles, other equipment to ensure nothing is left inside the patient

Question 28

Name some devices used for airway management.

Answer 28

Endotracheal tube Laryngeal mask airway i-gel Oropharyngeal airway Nasopharyngeal airway

Question 29

Endotracheal Tube - when to use

Answer 29

Ensuring airway patency for ventilation Preventing aspiration Inability to protect own airway and/or ventilate

Question 30

Endotracheal Tube - when is it not appropriate?

Answer 30

Severe trauma or airway obstruction proximal to the point at which tube will be passed [pharyngeal foreign body, massive swelling of the pharynx]

Question 31

Endotracheal Tube - complications

Answer 31

Damage to lips, teeth and oropharynx Over-inflation of the cuff may cause high pressure on tracheal wall - ischaemia Under-inflation of the cuff may lead to a circuit leak Misplacement/dislodgement of ET tube may lead to hypoxia and death

Question 32

Endotracheal Tube - how to check it is working/in the correct space

Answer 32

Auscultate chest Visualisation of thoracic movement Fogging of the tube CO2 end-tidal detector

Question 33

Laryngeal Mask Airway - when to use and when not to use

Answer 33

Mainly used for inhalational anaesthesia Supporting the airway sparing tracheal intubation Don't use when definitive airway is indicated; perioperative airway management when there's risk of aspiration, muscle relaxation required and prone position in surgery

Question 34

I-Gel - when to use and when not to use

Answer 34

Mainly used for inhalational anaesthesia Quick and easy to use, able to provide high seal pressures, less trauma, routine gastric port for NGt insertion to reduce aspiration risk -- trismus, airway trauma/abscess/mass, obstruction below glottis, conscious/semi-conscious patients with in-tact gag reflex

Question 35

Oropharyngeal airway [Guedel] - when to use and when not to use

Answer 35

Unconscious pts to maintain airway patency and to facilitate bag-mask ventilation; allows passage of other devices into trachea -- stimulates gag reflex, induces vomiting, abnormal facial or oropharyngeal anatomy, oral trauma, loose teeth, foreign bodies in the upper airway

Question 36

Nasopharyngeal airway - when to use and when not to use

Answer 36

Airway patency required in unconscious/semiconscious pt; seizing pts when patent airway and adequate oxygenation needed in short term; better tolerated than a Guedel; trismus/maxillofacial surgery opt for these are mouth is not required --head/facial trauma [basal skull fracture], trans-sphenoidal surgery; rhinoplasty/septoplasty; coagulopathy and anticoagulated patients due to severe epistaxis and haemorrhage

Question 37

Name some common drugs used for anaesthesia

Answer 37

Premedication- benzodiazepines can be used [midazolam] Induction- IV Propofol; inhalation isoflurane or sevoflurane Maintenance- muscle relaxants [vecuronium; suxamethonium]; IV Propofol; inhalation isoflurane Reversal- anticholinesterases [neostigmine]; atropine is given to prevent excess effect of acetylcholine

Question 38

What are the three principles of anaesthesia?

Answer 38

[premedication - relieve anxiety, reduce discomfort, cause amnesia] Induction Maintenance Reversal

Question 39

Propofol - use

Answer 39

Induction and maintenance of anaesthesia

Question 40

Propofol - side-effects

Answer 40

apnoea; arrhythmias; headache; hypotension; localised pain; nausea/vomiting

Question 41

Propofol - moa

Answer 41

Positive modulation of the inhibitory function of GABA through GABA-A receptors Increases affinity of GABA to GABA-A receptors

Question 42

Isoflurane - side-effects

Answer 42

agitation; apnoea; arrhythmias; chills; cough; dizziness; headache; hypersalivation; hypertension; hypotension; nausea/vomiting; respiratory disorders

Question 43

Isoflurane - moa

Answer 43

Decreases gap junction channel opening times; increases gap junction closing times Activates calcium dependant ATPase Binds to GABA receptor, glutamate and glycine receptors too

Question 44

How are patient's vital signs monitored during surgey?

Answer 44

ECG monitoring on at all times O2 and CO2 monitored through the intubation Pulse oximetry and heart rate are monitored transcutaneously BP is measured with a cuff or through an arterial line [very accurate, measures BP every heart beat]

Question 45

What are some common problems that occur with regards to the vital signs?

Answer 45

Can get hypo/hyperthermic Can get low blood pressure due to medications or other things during the surgery Can become tachy/brady O2/CO2 can become too high or low if airway problems occur

Question 46

How are changes to vitals managed?

Answer 46

++ temp: be wary of malignant hyperthermia; give dantrolene if MH is suspected; cold IV fluids and ice packs — temp: warming blankets are provided; temperature measured every half an hour O2CO2: anaesthetist will monitor and adjust amount of oxygen is administered through the insulation tube ++bp: medications to lower blood pressure can be given —bp: medications lowering blood pressure can be dropped; fluids can be given if due to hypovolaemia; blood pressure is monitored regularly ++hr: fluids can be given if due to hypovolaemia —hr: assess for the cause and treat appropriately

Question 47

What is a post-operative assessment?

Answer 47

Assessment of patient after the surgery Particularly important in patients developing or at risk of developing post-op complications

Question 48

What is the EWS?

Answer 48

A score that determines the degree of illness of a patient using Resp rate; o2 sats; requirement for oxygen; temperature; blood pressure; heart rate; AVPU score

Question 49

How to calculate EWS?

Answer 49

Respiratory rate Oxygen saturation Requirement of oxygen Heart rate Blood pressure AVPU Temperature

Question 50

Name some common post-operative complications

Answer 50

Anaemia; atelectasis; infections; wound dehiscence; ileus; haemorrhage; DVT/PE; shock [hypovolaemia, sepsis, heart failure]; arrhythmias; ACS/CVA; AKI; urinary retention; delirium; N/V

Question 51

What is the daily requirement of water?

Answer 51

25-30ml/kg/day 30 * 70 = 2100ml/day for average 70kg man

Question 52

What is the daily requirement of sodiumm?

Answer 52

1mmol/kg/day 1 * 70 = 70mmol/day for average 70kg man

Question 53

What is the daily requirement of potassium?

Answer 53

1mmol/kg/day 1 * 70 = 70mmol/day for average 70kg man

Question 54

What is the daily requirement of glucose?

Answer 54

50-100g/day of glucose to prevent ketosis, not to meet their nutritional needs

Question 55

What is an appropriate daily fluid chart/prescription for an average 70kg man?

Answer 55

1L of 0.18% sodiuim chloride in 4% glucose with 27mmol/L potassium over 8hr -twice

Question 56

Consequences of hyponatraemia

Answer 56

Mild- anorexia, headache, nausea, vomiting, lethargy Moderate- personality change, cramping and weakness of muscles, confusion, ataxia Severe- seizures

Question 57

Consequences of hypernatraemia

Answer 57

Polydipsia, polyuria, lethargy, weakness, confusion, irritability, myoclonic jerks, seizures, dry mouth, abnormal skin turgor, oliguria, tachycardia, orthostatic hypotension

Question 58

Consequences of hypokalaemia

Answer 58

Mild- asymptomatic More severe [<3.0mmol/L]- lethargy, generalised weakness and muscle pain, constipation K <2.5mmol/L- severe muscle weakness and paralysis, respiratory failure, ileus, paraesthesia, tetany

Question 59

Consequences of hyperkalaemia

Answer 59

Often nonspecific symptoms- weakness, fatigue, muscular paralysis or sob, palpitations or chest pain Signs- occasional bradycardia due to heart block, or tachypnoea from respiratory muscle weakness; muscle weakness and flaccid paralysis; depressed or absent tendon reflexes

Question 60

Consequences of hypovolaemia

Answer 60

Hypotension [systolic <100mmHg]; tachycardia; CRT >2s; cold peripheries; raised respiratory rate; dry mucous membranes; reduced skin turgor; reduced urine output; sunken eyes; reduced body weight from baseline; feeling thirsty

Question 61

Consequences of hypervolaemia

Answer 61

Peripheral oedema; pulmonary oedema; raised JVP; increased body weight from baseline

Question 62

Consequences of hypoglycaemia

Answer 62

Sweating, palpitations, shaking, feeling hungry - autonomic symptoms Confusion, drowsiness, odd behaviour, speech difficulty, in coordination - neuroglycopenic symptoms Headache, nausea - general symptoms

Question 63

Consequences of hyperglycaemia

Answer 63

In diabetics- DKA risk; hyperosmolar hyperglycaemic state

Question 64

How to manage nutrition balance in a patient?

Answer 64

Should be individualised ABCDEF format Anthropometry - aka body composition Biochemical and haematological tests Clinical examination Dietary requirements Environmental, behavioural and social factors Functional Use a MUST tool to assess for risk of malnutrition and be aware of refeeding

Question 65

What is a MUST score?

Answer 65

It is a score assigned to a person based on their weight, illness, percentage weight loss Helps to identify undernutrition and other forms of malnutrition If a high risk, refer to dietitians for review and assistance

Question 66

Types of enteral feed

Answer 66

Gastric feeding: food enters the stomach via NG tube or other forms of tube Post-pyloric feeding: food is delivered after the stomach via ND/NJ tube or a jejunostomy tube

Question 67

Types of parenteral feed

Answer 67

Administration of nutrients via the intravenous route

Question 68

Why would you use enteral feeds?

Answer 68

Indicated when oral feeding is insufficient or unsafe Commonly used in patients with the following: unconscious; neuromuscular swallowing disorders; physiological anorexia; upper GI obstruction; GI dysfunction or malabsorption; increased nutrient requirements; psychological problems

Question 69

Why would you use parenteral feeds?

Answer 69

Considered when a patient is malnourished or at risk of unsafe or inadequate oral/enteral intake; nonfunctional GI tract

Question 70

What is pain?

Answer 70

An unpleasant sensory and emotional experience, associated with, or resembling that associated with, actual of potential tissue damage Always a personal experience that is influenced by many factors

Question 71

How to manage pain?

Answer 71

Analgesia Therapies

Question 72

What is the WHO pain ladder?

Answer 72

Step wise approach to managing pain with analgesia

Question 73

What are the steps of the pain ladder?

Answer 73

1) non-opioids (paracetamol/NSAIDs) 2) as necessary, mild opioids (codeine) 3) strong opioids (morphine or hydromorphone)

Question 74

Different drugs used for pain management

Answer 74

Paracetamol NSAIDs - ibuprofen, naproxen, diclofenac Weak opioids - codeine, co-codamol Strong opioids -morphine, hydromorphone

Question 75

How to prevent venous thromboembolism

Answer 75

LMWH [enoxaparin] DOACs [apixaban/rivaroxaban] Intermittent pneumatic compression [inflated cuffs around the legs] Anti-embolic compression stockings

Question 76

Management of venous thromboembolism

Answer 76

Anticoagulation - apixaban or revaroxaban; started immediately Long term anticoagulation- 3/12 if reversible cause >3/12 if unclear cause 3-6/12 if active cancer, then review

Question 77

S/S of thromboembolism

Answer 77

Unilateral symptoms calf swelling/leg swelling dilated superficial veins tenderness to the calf oedema colour changes to the leg

Question 78

Surgical patient on anticoagulants/anti-platelets - mx

Answer 78

Anticoags are stopped before major surgery; INR is monitored to ensure it returns to normal before surgery Warfarin can be rapidly reversed with vitamin K LMWH or unfractionated heparin infusion may be used to bridge the gap between stopping warfarin and surgery DOACs are stopped 24-72hr before surgery, depending on half-life, procedure and kidney function

Question 79

Surgical patient on oestrogen-containing contraception/HRT - mx

Answer 79

COCP or HRT needs to be stopped 4 weeks before surgery ot reduce risk of VTE

Question 80

Surgical patient with Diabetes Mellitus - mx

Answer 80

Stress of surgery may lead to hyperglycaemia, however fasting may lead to the opposite - in general hypos are more dangerous than hypers Some oral medications need to be omitted or altered around surgery: *Sulfonylureas [gliclazide] cause hypos, stopped until pt is eating/drinking *Metformin is associated with lactic acidosis *SGLT2 inhibitors [dapagliflozin] can cause DKA in dehydrated/unwell patients Insulin users continue on a lower dose of long-acting insulin [80%] Short-acting insulin is stopped while fasting/not eating- until eating/drinking again Variable rate insulin infusion alongside a glucose, sodium chloride, potassium infusion [sliding scale] to carefully control metabolites and glucose

Question 81

Surgical patient with hypertension - mx

Answer 81

Patients should be continued as significant hypotension may result during anaesthesia

Question 82

Surgical patient taking steroids - mx

Answer 82

Long-term steroids cause adrenal suppression, which prevents them from creating the extra steroids they require to deal with stress of surgery *Additional IV hydrocortisone at induction and immediate post-op period [first 24hr] *Doubling of normal dose once eating/drinking for 24-72hr depending on the operation

Question 83

Use of antibiotics in theatre

Answer 83

Antibiotics can be given pre-op, intra-op, and post-op All of these help to limit/minimise the risk of infection after surgery

Question 84

How to manage nausea post-op.

Answer 84

Ondansetron [5HT-3 receptor antagonist] Dexamethasone Cyclizine [histamine 1 receptor antagonist] Usually given as prophylaxis at the end of the operation Ondansetron, prochlorperazine, cyclizine can also be given post-op if N/V occurs

Question 85

How to manage infection post-op.

Answer 85

Identify the source of infection and treat appropriately Urine dip and culture, swabs of wounds/ENT FBC, U&Es, LFTs, cultures, CRP CXR, CT

Question 86

What are some common anaesthesia complications?

Answer 86

Accidental awareness; aspiration; dental injury [mostly when laryngoscope is used for intubation]; anaphylaxis; cardiovascular events [MI, stroke, arrhythmias]

Question 87

What are some rarer, but important, anaesthesia complications?

Answer 87

Malignant hyperthermia and death

Question 88

When to give blood intra-op?

Answer 88

Massive haemorrhage Anaemia

Question 89

How to transfuse blood in a surgical patient.

Answer 89

Through a large bore cannula [16G grey needle] in antecubital fossa

Question 90

Sepsis- definition

Answer 90

Condition where the body launches a large immune response to an infection that causes systemic inflammation and organ dysfunction

Question 91

Sepsis- s/s

Answer 91

hypoxia; oliguria; AKI; thrombocytopenia; coagulation dysfunction; hypotension; hyperlactaemia temperature, hr, rr, o2 sats, bp, conscious level

Question 92

Sepsis - ix

Answer 92

FBC, U&Es, LFTs, CRP, clotting, blood cultures, blood gas urine dipstick, CXR, CT, lumbar puncture- identify source of infection

Question 93

Sepsis - mx

Answer 93

BUFALO Blood cultures/bloods Urine output Fluids Antibiotics- broad spec abx Lactate Oxygen to maintain o2 sats 94-98

Question 94

Sepsis - complications

Answer 94

Death kidney failure gangrene [tissue death] permanent lung damage permanent brain damage

Question 95

Massive haemorrhage - definition

Answer 95

Definition of acute massive haemorrhage varies It can be defined as a 50% blood loss within 3 hours or a rate >150ml/minute

Question 96

Massive haemorrhage - s/s

Answer 96

Bleeding Altered mental state Hypotension Weakness, fatigue

Question 97

Massive haemorrhage - management

Answer 97

Initiate massive haemorrhage protocol Call for help Stop bleeding Send blood samples- crossmatch; FBC; clotting screen; ABG Give blood as soon as available through large bore peripheral cannula [16G grey cannula]

Question 98

Post-operative shock - definition

Answer 98

Severe drop in blood pressure that causes dangerous reduction of blood flow trough the body/perfusion to organs

Question 99

Post-operative shock - s/s

Answer 99

Low blood pressure Altered mental state, including reduced alertness and awareness, confusion, and sleepiness Cold, moist skin; hands and feet may be blue or pale Weak or rapid pulse Rapid breathing and hyperventilation Decreased urine output

Question 100

Post-operative shock - ix

Answer 100

Blood cultures ABG FBC, U&Es

Question 101

Post-operative shock - mx

Answer 101

Abx breathing support- ventilation IV fluids/blood Oxygen Adrenaline

Question 102

Abdominal mass or swelling - differentials

Answer 102

Cancer IBD Appendicitis bowel obstruction ascites hepatomegaly/splenomegaly urinary retention 6F's: fat; fluid; foetus; flatus; faeces; 'filthy' big tumour/'fatal' growth

Question 103

Abdominal mass or swelling - history questions

Answer 103

How long has it been there? Pain? Solid mass? Better/worse? Tried anything for it? Always there? Associated symptoms? fever, nausea, vomiting, flatulence, DHx? SHx? FHx? PMHx?

Question 104

Abdominal mass or swelling - examination

Answer 104

Abdominal examination -DRE -hernial orifices -external genitalia if indicated [pregnancy]

Question 105

Abdominal mass or swelling - investigations

Answer 105

Bed- DRE, beta hcg Blood- FBC, U&Es, LFTs, CRP Imaging- Ultrasound, CT abdo/pelvis w/contrast, colonoscopy[?], abdo XR, CXR

Question 106

Abdominal mass or swelling - initial management

Answer 106

A-E if acutely unwell pain- analgesia; IV paracetamol, codeine, NSAIDs constipation/bowel obstruction- laxative ascites- drain

Question 107

Lump in the groin - differentials

Answer 107

Inguinal hernia, femoral hernia, aneurysm, sebaceous cyst, epididymitis, testicular torsion, lipoma, ectopic testicle, undescended testicle, lymphadenopathy

Question 108

Lump in the groin - history

Answer 108

Pain? SQITARS previous infection? had anything similar before? issues at puberty?

Question 109

Lump in the groin - examination

Answer 109

Reducible? tenderness? abdominal examination; examine external genitalia

Question 110

Lump in the groin - investigations

Answer 110

bloods- crp, fbc, u&es imaging- CT abdo/pelvis with contrast

Question 111

Lump in the groin - initial management

Answer 111

A-E if acutely unwell pain- analgesia [iv paracetamol, codeine] NBM

Question 112

Abdominal pain - differentials

Answer 112

cholecystitis, gallstones, pud, gastritis, kidney stones, pyelonephritis, ruptured aaa, appendicitis, ischaemic colitis, pancreatitis, ectopic pregnancy, ovarian torsion, ovarian cyst, acute urinary retention, UTI, diverticulitis, gastroenteritis, ibd, ibs, peritonitis -aka, a lot

Question 113

Abdominal pain - history

Answer 113

SQITARS DHx, SHx, FHx, PMHx

Question 114

Abdominal pain - examination

Answer 114

abdominal examination, dre external hernial orifices external genitalia if required cardio if indicated [could be MI presenting abnormally]

Question 115

Abdominal pain - investigations

Answer 115

bed- ecg, beta hcg, urine dip/mc&s, bp, obs bloods- fbc, u&e, lfts, crp, amylase, g&s, abg imaging- CT abdo/pelvis with contrast, ultrasound abdomen, ERCP[if indicated], CXR [if indicated], AXR [if indicated]

Question 116

Abdominal pain - initial management

Answer 116

A-E if acutely unwell; treat as you find analgesia and fluids IV abx IV if indicated NBM

Question 117

Change in bowel habit - differentials

Answer 117

Infection, IBD, IBS, stress/anxiety, thyroid problems, exercise/diet changes, anal fissure, cancers

Question 118

Change in bowel habit - history

Answer 118

Describe the changes How often? Consistency? Colour? Blood or mucus? Any recent changes to diet or exercise or medications? Any other symptoms? Nausea? Vomiting. Fever? Cough? Tenesmus? Eye/skin/joint problems? Medication history Past medical history Family history Social history

Question 119

Change in bowel habit - red flags

Answer 119

Weight loss Night sweats Fever Family history of cancer IBD hx - risk of colon cancer in UC Anaemia, malabsorption

Question 120

Change in bowel habit - examination and investigations

Answer 120

Bed: DRE, stool sample for culture and microscopy, faecal cal protection, FIT test Blood: FBC, U&E, LFT, TFT, CRP, bio markers (?) Imaging: AXR, flex sig with colonoscopy at some point if indicated, CT abdo/pelvis with contrast (+thorax if cancer is suspected)

Question 121

Change in bowel habit - initial treatment

Answer 121

ABCDE if acutely unwell Monitor with obs if admitted Reassurance Escalate and refer for imaging appropriately

Question 122

Change in stool colour - differentials

Answer 122

Medication side effect - particularly oral iron tablets Blood- infection, cancer, haemorrhoids, anal fissure, diverticulitis, IBD

Question 123

Change in stool colour - history

Answer 123

Similar to change in bowel habit hx

Question 124

Change in stool colour - red flags

Answer 124

Similar to change in bowel habit

Question 125

Change in stool colour - examination and investigations

Answer 125

Same as change in bowel habit

Question 126

Change in stool colour - initial management

Answer 126

Reassure Review medication Arrange imaging and escalate Admit if unwell

Question 127

Jaundice - differentials

Answer 127

Pre-hepatic - haemolytic anaemia, malaria, Gilbert’s syndrome Intra-hepatic - liver cancer, liver cirrhosis, hepatitis Post-hepatic - gallstones, compression of the biliary tree, pancreatitis

Question 128

Jaundice - history

Answer 128

When did it come on? Travel hx Social history - alcohol, smoking, sexual history is suspecting hep b maybe? IVDU Hx of gallstones PMHx, DHx

Question 129

Jaundice - examination and investigations

Answer 129

Full abdominal examination Bed: Blood: FBC, U&E, LFT, blood film, blood cultures, split bilirubin (conjugated vs unconjugated) Imaging: ultrasound, CT, MRCP

Question 130

Jaundice - initial management

Answer 130

Anti-histamine for itch Fluids Pain relief if required Admit for investigations Discover the source and treat appropriately

Question 131

Weight loss - differentials

Answer 131

Can be many different things Cancers; IBD; stomas; medication side effect; diet and exercise change

Question 132

Weight loss - history

Answer 132

How much and over how long? Any other symptoms Family history Social history - any recent changes Mental health history - eating disorder? Depression?

Question 133

Weight loss - examination and investigations

Answer 133

Abdominal examination and DRE if indicated Stool sample - faecal cal protection, FIT test Blood: FBC, LFT, U&E, TFT, HIV serology Imaging: CT thorax/abdo/pelvis is cancer if suggested, thyroid imaging, flex sig/colonoscopy if indicated

Question 134

Weight loss - red flags

Answer 134

Unintentional weight loss Blood in stool Change in bowel habit Anaemia Abdominal mass

Question 135

Weight loss - investigations

Answer 135

o

Question 136

Weight loss - initial management

Answer 136

Reassure Arrange imaging and other investigations Supportive treatment in the mean time

Question 137

Acute abdomen - initial assessment

Answer 137

A-E, stabilise and treat as you find Refers to a recent, rapid onset of urgent abdominal or pelvic pathology Common presentation; wide variety of causes

Question 138

Acute abdomen - generalised abdominal pain causes

Answer 138

Peritonitis Ruptured AAA Intestinal obstruction Ischaemic colitis

Question 139

Acute abdomen - epigastric causes

Answer 139

Acute gastritis Peptic ulcer disease Pancreatitis Ruptured AAA

Question 140

Acute abdomen - RUQ causes

Answer 140

Biliary colic Acute cholecystitis Acute cholangitis

Question 141

Acute abdomen - L lumbar causes

Answer 141

Renal colic [kidney stones] Ruptured AAA Pyelonephritis

Question 142

Acute abdomen - Testicular pain causes

Answer 142

Testicular torsion Epididymo-orchitis

Question 143

Acute abdomen - umbilical causes

Answer 143

Ruptured AAA Intestinal obstruction Ischaemic colitis Early stages of appendicitis

Question 144

Acute abdomen - L iliac fossa causes

Answer 144

Diverticulitis Ectopic pregnancy Ruptured ovarian cyst Ovarian torsion

Question 145

Acute abdomen - Loin to groin pain causes

Answer 145

Renal colic [kidney stones] Ruptured AAA Pyelonephritis

Question 146

Acute abdomen - supra-pubic/hypogastric causes

Answer 146

Lower UTI Acute urinary retention Pelvic inflammatory disease Prostatitis

Question 147

Acute abdomen - investigations

Answer 147

Bedside- ECG, urine dip, beta-hcg Bloods- FBC, U&Es, LFTs, CRP, amylase, calcium, coag, ABG, lactate, G&S, blood cultures Imaging- CXR, abdo XR, CT abdo/pelvis with contrast

Question 148

Acute abdomen - initial management

Answer 148

A-E assessment Alert senior of unwell pt NBM [if surgery required or bowel obstruction] NG tube [bowel obstruction] IV fluids [resus and/or maintenance] IV abx [infection] Analgesia Arrange investigations VTE assessment Prescribe regular medications

Question 149

GI obstruction - s/s

Answer 149

Colicky abdominal pain Abdominal distension Vomiting Obstipation - intractable constipation caused by prolonged retention of hard, dry feces Fever, malaise, thirst, lethargy, may also be in septic shock

Question 150

GI obstruction - differentials

Answer 150

Biliary colic - area of pain would be different Ruptured AAA - intenser pain Appendicitis Urinary retention MI abnormal presentation Pancreatitis

Question 151

GI obstruction - investigations

Answer 151

Blood: FBC, U&E, LFT, cultures (septic), amylase, ABG (acutely unwell), G&S Imaging: plain film abdominal X-ray, CT

Question 152

GI obstruction - typical history

Answer 152

SBO- previous surgical history, Crohn’s, malignancy LBO - older patient, volvulus, malignancy, diverticula disease

Question 153

GI obstruction - initial management

Answer 153

Drip and suck Admit; NBM; IVF; NGT; oxygen; analgesia; obs; re-examine regularly

Question 154

GI obstruction - definitive management

Answer 154

Exploratory laparotomy- decompress bowel, correct causing factor, resect non-viable bowel

Question 155

GI haemorrhage - s/s

Answer 155

Hypovolaemic shock if very bad bleed Pallor, anaemia, cold/clammy, anxious, hypoxic

Question 156

GI haemorrhage - differentials

Answer 156

Ruptured AAA Sepsis Any other kinds of shock

Question 157

GI haemorrhage - causes

Answer 157

Ruptured AAA Anastomotic leak (?)

Question 158

GI haemorrhage - investigations

Answer 158

Bed: Blood: ABG, FBC, U&E, CRP, G&S, CM, coag/INR/clotting Imaging: ultrasound, CT (not if unstable)

Question 159

GI haemorrhage - initial management

Answer 159

ABCDE if deteriorating/acutely unwell/unstable Two large bore cannula 16G 500mls of 0.9% NaCl in 15m Activate massive haemorrhage protocol if patient severely unwell Replace lost fluids like for like

Question 160

GI haemorrhage - definitive management

Answer 160

Fix the cause - if ruptured AAA - urgent surgery for repair of the aorta

Question 161

Acute pancreatitis - s/s

Answer 161

Epigastric pain - pain through to the back, relieved by sitting forward; though pain may be widespread in severe disease Nausea + vomiting +/- fever Altered mental status - altered consciousness

Question 162

Acute pancreatitis - investigations

Answer 162

Abdominal exam FBC, U&E, LFT, bone profile, random glucose, ABG, amylase/lipase, CRP, lipid profile CXR erect - ?pneumoperitoneum Ultrasound - ?gallstones; ?pseudocysts/abscess/necrosis ERCP for gallstones

Question 163

Acute pancreatitis - causes

Answer 163

Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion sting Hyperlipidaemia/hypercalcaemia/hypothermia ERCP/emboli Drugs

Question 164

Acute pancreatitis - differentials

Answer 164

Gastritis PUD Acute cholecystitis Peritonitis Abnormal MI Bowel obstruction

Question 165

Acute pancreatitis - initial treatment

Answer 165

Fluid resuscitation Analgesia IVF NBM PPI IV abx Insulin sliding scale

Question 166

Acute pancreatitis - definitive management

Answer 166

No definitive management; just supportive treatment mainly Monitor for complications - pseudocyst, necrosis, coagulation disorders, abscess, haemorrhage secondary to pancreatic necrosis

Question 167

Acute appendicitis - s/s

Answer 167

Generalised abdominal pain, later moves to the RIF Nausea and vomiting Anorexia Tenderness and guarding on examination - McBurney’s point Rovsing’s sign - palpation of LIF causes pain in RIF Tachycardia, fever

Question 168

Acute appendicitis - investigations

Answer 168

Bed: pregnancy test in women, urine dip Blood: FBC, U&E, CRP, LFT Faecal calprotectin (?IBD) Imaging: ultrasound is often unhelpful/inconclusive, ultrasound for ectopic pregnancy

Question 169

Acute appendicitis - differentials

Answer 169

RIF differentials Caecal abscess Ovarian pathology Hernia Ectopic pregnancy Infection IBD/IBS Ischaemic mesentery

Question 170

Acute appendicitis - initial treatment

Answer 170

Admit NBM IVF and analgesia and abx Consent for surgery

Question 171

Acute appendicitis - definitive management

Answer 171

Appendicectomy - if non-ruptured If ruptured, treat collection/infection then take out

Question 172

Name some common oesophageal disorders

Answer 172

Achalasia Oesophageal Cancer GORD Barrett's Oesophagus Oesophagitis

Question 173

Achalasia - s/s

Answer 173

Symptoms- dysphagia of solids and liquids; regurgitation of undigested food; vomiting; difficulty belching; weight loss; chest pain; aspiration; heartburn Signs- clinical examination is typically normal, but may be evidence of weight loss and observed regurgitation/vomiting events after oral intake

Question 174

Achalasia - investigations

Answer 174

OGD Barium swallow High-resolution manometry

Question 175

Achalasia - management

Answer 175

Pneumatic dilatation Peroral endoscopic myotomy (POEM) Surgical myotomy interventions aim to improve the lower oesophageal opening

Question 176

Achalasia - complications

Answer 176

Significant chest pain, fatigue, malnutrition, weight loss Aspiration pneumonia

Question 177

Oesophageal cancer - s/s

Answer 177

Symptoms- constitutional symptoms [fever, anorexia, weight loss, lethargy]; dysphagia; weight loss; bleeding [haematemesis, melaena]; retrosternal pain; aspiration [cough, sob, fever], hoarseness [if extended to involve recurrent laryngeal nerve] Signs- lymphadenopathy; cachexia; pallor; hepatomegaly [metastatic spread]

Question 178

Oesophageal cancer - types

Answer 178

Squamous cell carcinoma - upper/middle oesophagus; >90% cases Adenocarcinoma - lower oesophagus; due to chronic reflux and development of columnar metaplasia [precursor lesion known as Barrett's oesophagus]

Question 179

Oesophageal cancer - investigations

Answer 179

Diagnosed using upper GI endoscopy and biopsies of suspected lesions Bloods- FBC, U&Es, LFTs, Bone profile, Clotting screen, Renal function, serum iron, transferrin sats, total iron binding capacity Imaging- CT chest/abdomen/pelvis; abdominal ultrasound; PET-CT Special- Gastroscopy; endoscopic ultrasound, diagnostic laparoscopy

Question 180

Squamous Cell Carcinoma of Oesophagus - risk factors

Answer 180

Smoking; alcohol consumption; previous partial gastrectomy; atrophic gastritis; HPV

Question 181

Adenocarcinoma of Oesophagus - risk factors

Answer 181

Majority arise from Barrett's oesophagus Chronic reflux; Barrett's oesophagus; smoking; obesity; Zollinger-Ellison syndrome

Question 182

Oesophageal cancer - management

Answer 182

Options include: surgery, endoscopic techniques, radio/chemotherapy, palliative car, best supportive care Choice of treatment depends on whether cancer is limited, locally advanced or advanced/metastatic

Question 183

Oesophageal cancer - complications

Answer 183

Prognosis is poor 5y survival rate is 16% Depends on stage of cancer Oesophagectomy is a major operation with significant morbidity and mortality

Question 184

GORD - s/s

Answer 184

Heartburn; regurgitation; dyspepsia; chest pain; dysphagia; odynophagia; cough; hoarse voice; nausea/vomiting

Question 185

GORD - investigations

Answer 185

Gastroscopy and pH monitoring

Question 186

GORD - management

Answer 186

Lifestyle- weight loss, stop smoking, dietary modifications Medical- PPIs Surgical- Nissen fundoplication

Question 187

Barrett's Oesophagus - s/s

Answer 187

Heartburn, regurgitation, chest discomfort, dyspepsia, nausea/vomiting, dysphagia

Question 188

Barrett's Oesophagus - investigations

Answer 188

Diagnosed on endoscopy with biopsies If evidence of metaplastic columnar epithelium >=1cm above the gastro-oesophageal junction; biopsies should be taken to confirm diagnosis of BO

Question 189

Barrett's Oesophagus - management

Answer 189

PPIs- reduces risk of high grade dysplasia and oesophageal carcinoma Surveillance- endoscopic surveillance to detect dysplasia and/or adenocarcinoma at an earlier stage Endoscopic therapy

Question 190

Barrett's Oesophagus - complications

Answer 190

High grade dysplasia Adenocarcinoma

Question 191

Mallory Weiss Tear - GI bleed

Answer 191

Linear mucosal laceration Typically occur at the GOJ or within gastric cardia Classical description- episode of haematemesis precipitated by repeated episodes of retching

Question 192

Peptic Ulcer Disease - s/s

Answer 192

Symptoms- epigastric pain; dyspepsia; heartburn Signs- epigastric tenderness

Question 193

Peptic Ulcer Disease - investigations

Answer 193

Bedside- obs; H.pylori testing; ECG Bloods- FBC, LFTs Imaging- Upper GI endoscopy

Question 194

Peptic Ulcer Disease - causes

Answer 194

Majority are related to H.Pylori infections- 95% of DU; 75% of GU Medications- NSAIDs, SSRIs, alcohol, corticosteroids Alternative- Zollinger-Ellison syndrome,. acute stress, malignancy, inflammatory [e.g. Crohn's]

Question 195

Peptic Ulcer Disease - management

Answer 195

Avoid triggers; lose weight; stop smoking; reduce alcohol; manage mental health H.Pylori- without NSAIDs- first-line eradsication therapy H.Pylori- with NSAIDs- two months PPI, then first-line eradication therapy Negative H.Pylori- 4-8wks full-dose PPI

Question 196

Peptic Ulcer Disease - complications

Answer 196

Perforation Haemorrhage Gastric outlet obstruction

Question 197

Helicobacter Pylori - s/s

Answer 197

PUD; heartburn; dyspepsia; chest pain; GI bleed can be asymptomatic

Question 198

Helicobacter Pylori - investigations

Answer 198

Non-invasive: *13C Urea breath test *Stool antigen test Invasive: *Urease test *Histology *Microbiology

Question 199

Helicobacter Pylori - management

Answer 199

1st line eradication: 7/7 course of triple therapy: PPI + amoxicillin + clarithromycin/metronidazole 2nd line eradication: longer course, different abx No response to second-line or unexplained symptoms- specialist referral

Question 200

Helicobacter Pylori - complications

Answer 200

Cancer; PUD; perforation; haemorrhage

Question 201

Gastric Cancer - s/s

Answer 201

Symptoms- fever, lethargy, anorexia, weight loss, dysphagia, indigestion, dyspepsia, nausea/vomiting, haematemesis/melaena, post-prandial fullness Signs- [usually absent unless late presentation with metastases] pallor, cachexia, lymphadenopathy [Virchow's node, left supraclavicular node], metastatic lesions [hepatomegaly]

Question 202

Gastric Cancer - red flags

Answer 202

Upper abdominal mass consistent with gastric cancer, OR dysphagia, OR >55 with weight loss and one of [upper abdo pain, reflux, dyspepsia]

Question 203

Gastric Cancer - investigations

Answer 203

Diagnosed using upper GI endoscopy and biopsies of suspected lesions Bloods- FBC, iron/transferrin/TIBC, U&Es, LFTs, bone profile, clotting screen, renal function Imaging- CT chest/abdo/pelvis, abdominal ultrasound, PET-CT Special- gastroscopy, endoscopic ultrasound, diagnostic laparoscopy

Question 204

Gastric Cancer - causes/risk factors

Answer 204

H.Pylori Smoking High salt intake Inadequate intake of fruit/vegetables Meat consumption Genetics

Question 205

Gastric Cancer - management

Answer 205

Depends on extent of cancer and patient's fitness Surgery [resection]; Endoscopic techniques [mucosal resection]; Radio/chemotherapy; targeted cancer drugs; palliative care; best supportive care

Question 206

IBD - types

Answer 206

Ulcerative Colitis Crohn's Disease

Question 207

Ulcerative Colitis - CLOSE-UP mnemonic

Answer 207

CLOSE-UP Continuous inflammation Limited to colon and rectum Only superficial mucosa affected Smoking is protective Excrete blood and mucus Use amino salicylates Primary Sclerosing Cholangitis

Question 208

IBD - investigations

Answer 208

routine bloods for anaemia, infection, thyroid, kidney and liver function CRP Faecal calprotectin Endoscopy [OGD and colonoscopy] with biopsy for diagnosis Imaging with ultrasound, CT, MRI can be used to look for complications such as fistulas, abscesses and strictures

Question 209

Ulcerative Colitis - management

Answer 209

Inducing remission: *MILD-MODERATE: mesalazine [2nd line corticosteroids] *SEVERE: IV corticosteroids [2nd line IV ciclosporin] Maintaining remission: mesalazine, azathioprine, mercaptopurine Surgery: pan proctocolectomy; pt left with ileostomy or ileo-anal anastomosis

Question 210

Ulcerative Colitis - complications

Answer 210

Colorectal cancer Primary Sclerosing Cholangitis

Question 211

Crohn's Disease - management

Answer 211

Inducing remission: steroids [oral prednisolone; IV hydrocortisone]; azathioprine; methotrexate; infliximab; adalimumab Maintaining remission: azathioprine, mercaptopurine, methotrexate, infliximab, adalimumab Surgery: when disease is isolated to distal ileum, surgical resection is an option; surgery to treat strictures and fistulas is also an option

Question 212

Crohn's Disease - NESTTS mnemonic

Answer 212

No blood or mucus Entire GI tract Skip lesions seen on endoscopy Transmucosal inflammation Terminal ileum commonly affected Smoking is a risk factor Also associated: weight loss, fistulas and strictures

Question 213

Colon Cancer - s/s

Answer 213

Change in bowel habit [frequency, consistency, quality]; PR bleeding [particularly if blood is mixed in with stool]; tenesmus; mucus in stool; melaena; bowel obstruction; unexplained anaemia; abdominal mass; weight loss; anorexia; weakness

Question 214

Colon Cancer - red flags

Answer 214

Changes to bowel habit Blood in stools Tenesmus Stomach pain/bloating

Question 215

Colon Cancer - screening

Answer 215

NHS bowel cancer screening checks if you could have bowel cancer. It's available to everyone aged 60 to 74 years. Faecal immunochemical test (FIT) - at home test kit Any abnormalities, pt will be asked/invited back to the GP to discuss and will receive an appt for a colonoscopy to check for malignancy/other causes of blood in stools

Question 216

Colon Cancer - investigations

Answer 216

DRE Faecal occult blood test Flex sig or colonoscopy Barium enema CT chest/abdo/pelvis

Question 217

Colon Cancer - management

Answer 217

Aim to resect tumour fully with a good clearance margin Remove mesentery attached as well as lymph nodes and blood vessels Biopsy and exam lymph nodes microscopically to accurately grade/stage tumour to determine whether there's a need for adjuvant therapy

Question 218

Diverticula Disease - definition

Answer 218

Presence of diverticula [out pouchings of the bowel] is symptomatic, causing abdominal pain or inflammation

Question 219

Diverticula Disease - s/s

Answer 219

intermittent abdo pain; may start on eating; relieved after passing stool or wind have constipation/diarrhoea or a general change to bowel habits blood or mucus from rectum

Question 220

Diverticula Disease - investigations

Answer 220

Barium enema or lower GI endoscopy is indicated - cross over with symptoms of colorectal cancer

Question 221

Diverticula Disease - management

Answer 221

Generally requires no treatment; ++fibre; ++fluids bulk-forming laxative

Question 222

Diverticula Disease - complications

Answer 222

Fistulas; abscesses; perforation; colonic obstruction

Question 223

Diverticulitis - s/s

Answer 223

Low-grade fever; abdo pain [LIF]; PR bleeding with diarrhoea; excessive flatulence; bloating

Question 224

Diverticulitis - investigations

Answer 224

Barium enema or lower GI endoscopy is indicated - cross over with symptoms of colorectal cancer

Question 225

Diverticulitis - management

Answer 225

Low-residue diet; IV fluids; antibiotics Outpatients barium enema/colonoscopy to confirm the cause if not alrerady been done

Question 226

Diverticulitis - complications

Answer 226

Fistulas; abscesses; perforation; colonic obstruction

Question 227

Colon Polyps - s/s

Answer 227

Usually asymptomatic, but may be present with rectal bleeding

Question 228

Colonic Polyps - investigations

Answer 228

Colonoscopy

Question 229

Colonic Polyps - management

Answer 229

They are usually benign; although they are routinely removed as this reduces the risk of developing cancer in the future

Question 230

Haemorrhoids - s/s

Answer 230

Bright red fresh blood, passed on defecation; appear blue-red engorged swellings just inside the anus [3, 7 and 11 o'clock]

Question 231

Haemorrhoids - investigations

Answer 231

DRE; proctoscope; flex sig; colonoscopy

Question 232

Haemorrhoids - management

Answer 232

Sitz baths, cold compresses, topical analgesia, dietary advice Banding, sclerosing injections Surgery may be discussed depending on severity; haemorrhoidectomy

Question 233

Haemorrhoids - complications

Answer 233

Anaemia Blood clots in external haemorrhoids Infection Skin tags Strangulated haemorrhoids

Question 234

Rectal Abscess - s/s

Answer 234

Perianal discomfort, pain exacerbated by movement/sitting/defecation May present septic- fever, tachycardia, neutrophilia O/E - erythematous, fluctuant, well-defined mass, sometimes indurated and pointing

Question 235

Rectal Abscess - investigations

Answer 235

Diagnosed on examination, although check obs for signs of systemic infection

Question 236

Rectal Abscess - management

Answer 236

Incision and drainage Curettage and lavage often performed before closing the wound - packing allows the wound to heal from the bottom up, preventing another abscess from forming Antibiotics are required in severe cases, large areas of cellulitis, diabetic/immunocompromised patients

Question 237

Rectal Abscess - complications

Answer 237

Recurrence, sepsis, continuing pain, scarring, fistula

Question 238

Proctitis - s/s

Answer 238

Anorectal pain; LLQ pain; blood/mucus in stool; swelling/fullness in rectum; tenesmus; constipation; diarrhoea

Question 239

Proctitis - causes

Answer 239

IBD; STIs; gastroenteritis; food allergies; radiation therapy; anorectal trauma

Question 240

Proctitis - investigations

Answer 240

Investigate for causes -faecal calprotectin -stool culture -proctoscopy -flex sig

Question 241

Proctitis - management

Answer 241

Can self-resolve Stop medications causing irritation/inflammation Abx Immunosuppressants for autoimmune-related inflammation

Question 242

Proctitis - complications

Answer 242

Usually responds well If linked to IBD, may flare up

Question 243

Anal Fissure - s/s

Answer 243

Cracks in squamous layer of anal canal Excruciating pain on defecation; rectal bleeding

Question 244

Anal Fissure - investigations

Answer 244

Examination; DRE imaging if concerned about other causes

Question 245

Anal Fissure - management

Answer 245

++fluids; ++fibre; laxatives topical diltiazem lateral sphincterotomy may be necessary after BD 3/12 application of topical tx

Question 246

PR bleeding - causes

Answer 246

Colorectal cancer; haemorrhoids; anal fissures; infection; IBD; polyps; diverticula disease

Question 247

PR bleeding - investigations

Answer 247

Bloods- FBC, U&Es, LFTs, CRP, TFTs, calcium Stool- Faecal occult blood Direct visualisation- proctoscopy and sigmoidoscopy; flex sig; colonoscopy; OGD [melaena] Imaging- CT abo/pelvis; MRI

Question 248

Hernias - types

Answer 248

Inguinal - direct and indirect Femoral Incisional Umbilical

Question 249

Inguinal Hernia - s/s

Answer 249

Inguinal lump/swelling

Question 250

Direct Inguinal Hernia - route

Answer 250

Medial to inferior epigastric artery Passes through Hesselbach’s triangle [I-inguinal ligament; L-inferior epigastric artery; M-lateral border of rectus abdominis muscle]

Question 251

Indirect Inguinal Hernia - route

Answer 251

Lateral to inferior epigastric artery Enters inguinal canal through deep ring and transverses canal within patent processus vaginalis

Question 252

Inguinal Hernia - investigations

Answer 252

Good examination CT to show contents of the hernia

Question 253

Inguinal Hernia - management

Answer 253

Conservative - a belt (truss) to apply pressure over inguinal defect - reserved for patients unfit for surgery Surgical - elective or emergency depends on whether hernia is obstructed/strangulated or not. Herniorrhaphy (repair) laparoscopic or open with mesh

Question 254

Femoral Hernia - s/s

Answer 254

Swelling/lump at femoral canal

Question 255

Femoral Hernia - route

Answer 255

Below and lateral to the pubic tubercle

Question 256

Femoral Hernia - investigations

Answer 256

Good examination, imaging?

Question 257

Femoral Hernia - management

Answer 257

All surgical options. Surgical repair of the femoral hernia

Question 258

Incisional Hernia - defintion

Answer 258

Herniation through a site of previous surgery

Question 259

Incisional Hernia - s/s

Answer 259

Lump where there is a surgical wound/scar

Question 260

Incisional Hernia - investigations

Answer 260

Examination

Question 261

Incisional Hernia - management

Answer 261

Mesh repair surgically

Question 262

Umbilical Hernia - s/s

Answer 262

Hernia/lump/swelling through a weakness in the actual umbilicus

Question 263

Umbilical Hernia - investigations

Answer 263

Examination

Question 264

Umbilical Hernia - management

Answer 264

Mesh repair surgically

Question 265

Hiatus Hernia - definition

Answer 265

A herniation of part of the stomach through the oesophageal hiatus of the diaphragm

Question 266

Hiatus Hernia - s/s

Answer 266

Usually asymptomatic May have symptoms of GORD Rarely - dysphagia Nothing found on examination

Question 267

Hiatus Hernia - investigations

Answer 267

Barium swallow/meal is usually diagnostic If GORD is present, may have OGD

Question 268

Hiatus Hernia - management

Answer 268

Surgical management - oesophageal lengthening and Nissen’s fundoplication

Question 269

Strangulated Hernia - defintion

Answer 269

A hernia containing ischaemic bowel

Question 270

Strangulated Hernia - s/s

Answer 270

Tense, tender, irreducible hernia with absent bowel sounds

Question 271

Strangulated Hernia - investigations

Answer 271

Examination

Question 272

Strangulated Hernia - management

Answer 272

Surgical repair

Question 273

Incarcerated Hernia - defintion

Answer 273

An irreducible, non-obstructed hernia Caused by adhesions forming around the sac

Question 274

Incarcerated Hernia - s/s

Answer 274

Irreducible lump Present bowel sounds

Question 275

Incarcerated Hernia - investigations

Answer 275

Examination

Question 276

Incarcerated Hernia - management

Answer 276

Surgical repair- risk of obstruction and strangulation

Question 277

Name some HPB disorders requiring surgical intervention

Answer 277

Acute cholecystitis Hepatic carcinoma Gallstones Cholangitis

Question 278

Acute Cholecystitis - defintion

Answer 278

Acute inflammation of the gallbladder Obstruction of the cystic duct leads to inflammation

Question 279

Acute Cholecystitis - s/s

Answer 279

Constant RUQ pain, referred to epigastrum and scapula Fever, n/v Hx of gallstones - RUQ discomfort particularly after fatty meal, jaundice/dark urine/pale stools Murphy’s sign - palpation of RUQ causes pain on inspiration as inflamed gallbladder moves downwards and ‘hits’ the palpating hand

Question 280

Acute Cholecystitis - investigations

Answer 280

Bed: ECG Blood: FBC, U&E, LFT, Amylase Imaging: ultrasound confirms presence of inflammation and gallstones

Question 281

Acute Cholecystitis - management

Answer 281

Admit for investigations, NBM, IVF, IV abx, analgesia Arrange for cholecystectomy as prophylaxis for future episodes

Question 282

Acute Cholecystitis - complications

Answer 282

Empyema- abscess in the gallbladder Gallbladder perforation Obstructive jaundice Cholecystenteric fistula (between gallbladder and small bowel) and gallstone ileus

Question 283

Gallstones - s/s

Answer 283

RUQ discomfort, particularly after greasy/fatty meal Biliary colic pain - caused by contraction of gallbladder against stone Can have jaundice, pale stools, dark urine

Question 284

Gallstones - investigations

Answer 284

Ultrasound is imaging modality of choice Shows acoustic shadow caused by stones

Question 285

Gallstones - management

Answer 285

Cholecystectomy due to complications associated with cholecystitis ERCP to remove stones + place stent

Question 286

Gallstones - complications

Answer 286

Cholecystitis Mirizzi’s syndrome - large gallstone compressing part of biliary duct of which it is not currently in Porcelain gallbladder Obstructive jaundice Cholangitis

Question 287

Hepatitis - types

Answer 287

ABCDE

Question 288

Hepatitis - s/s

Question 289

Hepatitis - investigations

Answer 289

Serology/virology screen for Hepatitis viruses FBC, LFT, clotting, U&E

Question 290

Hepatitis - management

Answer 290

***REVIEW*** Same as infectious diseases unit - medicine ***REVIEW***

Question 291

Hepatitis - complications

Answer 291

p

Question 292

Biliary Colic - defintion

Answer 292

RUQ intermittent pain caused by contraction of the gallbladder pressing against a gallstone

Question 293

Biliary Colic - s/s

Answer 293

RUQ pain, particularly after greasy food may have obstructive jaundice, dark urine, pale stools

Question 294

Biliary Colic - investigations

Answer 294

Ultrasound - confirms presence of gallstones

Question 295

Biliary Colic - management

Answer 295

Cholecystectomy - usually laparoscopic

Question 296

Ascending Cholangitis - defintion

Answer 296

A severe infection complicating CBD obstruction, spreading proximally Usually caused by gram negative bacilli (Escherichia Coli)

Question 297

Ascending Cholangitis - s/s

Answer 297

Charcot’s triad -fever with rigors -jaundice -RUQ pain In severe infection there may be signs of shock (/sepsis) and altered mental status/confusion ^ this is known as Reynold’s pentad

Question 298

Ascending Cholangitis - investigations

Answer 298

Blood: FBC, U&E, LFT, clotting, blood cultures Imaging: ultrasound

Question 299

Ascending Cholangitis - management

Answer 299

NBM, IVF, correct electrolyte imbalances, IV abx, analgesia, arrange ERCP for stone extraction +/- stenting

Question 300

Ascending Cholangitis - complications

Answer 300

Endotoxic shock Suppurative Cholangitis (pus in biliary tree)

Question 301

Gallstone Ileus - defintion

Answer 301

Small bowel obstruction caused by large intraluminal gallstone

Question 302

Gallstone Ileus - s/s

Answer 302

Symptoms of small bowel obstruction Generalised colicky abdominal pain Vomiting/nausea Constipation (late symptom) Regurgitation of food Abdomen distension Pyrexia, tachycardia High pitched tinkling bowel sounds

Question 303

Gallstone Ileus - investigations

Answer 303

X-ray - dilated loops of bowel, radioopaque gallstone distal to obstruction (usually at ileocaecal valve), air in biliary tree CT can also be used, shows the same things ^

Question 304

Gallstone Ileus - management

Answer 304

Laparotomy with enterotomy and stone removal +/- cholecystoenteric fistula repair or cholecystectomy

Question 305

Cholangiocarcinoma - definition

Answer 305

Carcinoma of the biliary tree Anywhere from the originating biliary ducts in the liver to ampulla of Vater Typically adenocarcinoma

Question 306

Cholangiocarcinoma - s/s

Answer 306

Presents as obstructive jaundice with weight loss

Question 307

Cholangiocarcinoma - investigations

Answer 307

Blood: FBC, U&E, LFT Imaging: ultrasound (shows large tumours and biliary dilation), CT (show tumour, important step for staging), ERCP (can be used for biopsies, palliative stenting)

Question 308

Cholangiocarcinoma - management

Answer 308

Depends on where in biliary tree it is Proximal- tumour resection with hepaticojejunostomy Distal- Whipple’s procedure

Question 309

Hepatocellular Carcinoma - definition

Answer 309

Primary liver cancer, arises from hepatocytes

Question 310

Hepatocellular Carcinoma - s/s

Answer 310

Late presentation - weight loss, anorexia, n/v, abdominal pain in right hypochondrium radiating to the back Signs- cachexia, jaundice, palpable liver, ascites

Question 311

Hepatocellular Carcinoma - investigations

Answer 311

Blood: FBC, U&E, LFT, clotting screen, tumour markers Imaging: ultrasound, CT, MRI, angiography

Question 312

Hepatocellular Carcinoma - management

Answer 312

Surgical - resection; if there’s no extrahepatic spread then transplant can be considered Adjunctive - both chemo and radiotherapy Palliative - symptomatic relief if tumour unrepeatable, patient choice to not treat surgically/medically

Question 313

Pancreatic Cancer - definition

Answer 313

A common, fatal, metastasising adenocarcinoma of the pancreatic ducts Affects head 70%; body 20%; tail 10%

Question 314

Pancreatic Cancer - s/s

Answer 314

Head of pancreas - painless jaundice (classic sign); pruritus; distended gallbladder (as per Courvoisier’s law); weight loss Body + tail - weight loss and pain with migratory thrombophlebitis (Trousseau’s sign) Jaundice occurs in <10% cases

Question 315

Pancreatic Cancer - investigations

Answer 315

Blood: FBC, U&E, LFT, clotting Imaging: ultrasound, CT scan, ERCP, selective angiography

Question 316

Pancreatic Cancer - management

Answer 316

Surgical depends on location -head: Whipple’s procedure -body/tail: distal pancreatic resection Palliative in incurable disease to alleviate symptoms

Question 317

Chronic Pancreatitis - definition

Answer 317

Continuing inflammatory process characterised by irreversible morphological change, pain +/- loss of function

Question 318

Chronic Pancreatitis - s/s

Answer 318

Unremitting epigastric pain, weight loss and steatorrhoea

Question 319

Chronic Pancreatitis - investigations

Answer 319

Blood: FBC, U&E, LFT, bone profile, blood sugar, ABG, amylase, CRP, lipid profile Imaging: ADR, ultrasound/CT

Question 320

Chronic Pancreatitis - causes

Answer 320

Same as acute pancreatitis, alcohol being the most common cause Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion sting Hyperlipidaemia/hypercalcaemia ERCP Drugs - medications

Question 321

Chronic Pancreatitis - management

Answer 321

Conservative - stop alcohol, pancreatic enzyme replacement Surgical - removal of pancreatic duct stones, partial pancreatectomy of body and tail, sphincteroplasty of pancreatic duct opening, total pancreatectomy

Question 322

Stomas - types

Answer 322

Gastrostomy Jejunostomy Ileostomy Caecostomy Colostomy

Question 323

Stomas - indications

Answer 323

FLEDD F - feeding L - lavage (rare) E - exteriorisation (bringing out the end of the bowel after removal of distal parts) D - decompression (also rare) D - diversion

Question 324

Stomas - complications

Answer 324

Mnemonic - STOMA BAGS HELP Stenosis Tight defect Overflow Maintenance problems Anaemia Bloating Aroma Gall/kidney stones Short gut syndrome Hernia - parastomal Excoriation Leakage Prolapse

Question 325

Pancreatic Pseudocyst - defintion

Answer 325

Encapsulated collection of pancreatic fluid and necrotic material which usually collects in the lesser sac Usually occurs in chronic alcoholic pancreatitis

Question 326

Pancreatic Pseudocyst - s/s

Answer 326

Symptoms - same as pancreatitis; suspect in cases of acute pancreatitis whose pain doesn’t resolve Signs - palpable epigastric mass

Question 327

Pancreatic Pseudocyst - investigations

Answer 327

Amylase (persistently elevated) Ultrasound of the abdomen

Question 328

Pancreatic Pseudocyst - management

Answer 328

Depends on size <5cm close follow up to see if it is resolving >5cm percutaneous uss-guided aspiration or surgical marsupialisation of pseudocyst into posterior wall of stomach

Question 329

Bowel Perforation - causes

Answer 329

Bowel obstruction Toxic mega colon

Question 330

Bowel Perforation - s/s

Answer 330

Peritonitis - fever, guarding, severe generalised abdominal pain, malaise, n/v, unwilling to move due to pain Tachycardia, pyrexia, generalised tenderness, board-like rigidity, rebound tenderness and guarding Rebound tenderness to percussion Absent bowel sounds

Question 331

Bowel Perforation - investigations

Answer 331

Blood: FBC, U&E, LFT, CRP, lactate, ABG, cultures Imaging: AXR, CT

Question 332

Bowel Perforation - management

Answer 332

Surgery for washout and definitive management (closing of perforation) Sepsis 6 - oxygen, fluids and antibiotics (other 3 are in previous flashcard) Analgesia Fluid resuscitation NBM

Question 333

Bowel Perforation - complications

Answer 333

Sepsis Peritonitis Death

Question 334

Peritonitis - causes

Answer 334

Bowel perforation - peptic ulcer, tmc, appendix rupture Spontaneous bacterial peritonitis Bile leaking from ruptured gallbladder

Question 335

Peritonitis - definition

Answer 335

Inflammation of peritoneum

Question 336

Peritonitis - investigations

Answer 336

Blood: FBC, U&E, LFT, CRP, amylase, blood cultures, lactate, ABG Imaging: CT abdo/pelvis with contrast

Question 337

Peritonitis - management

Answer 337

Find the cause and treat it Antibiotics, fluids, oxygen Surgery may be required so keep patient NBM NG tube? If bowel obstruction Analgesia

Question 338

Peritonitis - complications

Answer 338

Sepsis Death

Question 339

Ascites - causes

Answer 339

Liver disease

Question 340

Ascites - s/s

Answer 340

Swelling of the abdomen

Question 341

Ascites - investigations

Answer 341

Ascetic tap LFTs, FBC, U&Es, albumin

Question 342

Ascites - management

Answer 342

Antibiotics if infected Drain fluid, with albumin cover if due to liver malfunctioning Supportive treatment

Question 343

Wound Infection - causes

Answer 343

Poor cleaning Poor wound dressing Causative organism is typically Staphylococcus aureus

Question 344

Wound Infection - s/s

Answer 344

Purulent wound, erythema, swelling, warm to touch, odorous

Question 345

Wound Infection - investigations

Answer 345

Skin swab for culture and sensitivities Blood: FBC, U&Es, clotting, glucose, blood cultures, lactate, VBG Imaging: X-ray for osteomyelitis

Question 346

Wound Infection - management

Answer 346

Antibiotics according to local guidelines - flucloxacillin, dose depends on severity

Question 347

Haematuria - causes

Answer 347

infection in or inflammation of the bladder, kidney, urethra, prostate trauma BPH UT stones UT procedure recently vigorous exercise sexual activity endometriosis cancer of the bladder, kidney, prostate haemophilia or other blood-clotting disorders sickle cell disease kidney disease involving glomeruli

Question 348

Haematuria - ix

Answer 348

urinalysis - good for identifying microscopic haematuria DRE or pelvic exam [M/F] bloods: FBC, U&Es, eGFR, antibodies for SLE [ANA], tumour markers imaging: CT, cystoscopy, MRI, ultrasound KUB special: biopsy may be required

Question 349

Haematuria - mx

Answer 349

Manage underlying cause infection- abx stones- lithotripsy, e.g. BPH- alpha-blocker cancer- supportive/palliative/chemo or radio therapy clotting disorders- medications to reverse this?

Question 350

Oliguria - causes

Answer 350

AKI CKD kidney dysfunction: *prerenal [hypovolaemia, third-spacing, renal artery stenosis] *intrarenal [acute tubular necrosis, systemic disorders] *postrenal [prostatic disorders, tumours, kidney stones]

Question 351

Oliguria - s/s

Answer 351

Urine output <500ml/day or <0.5ml/kg/hr shock - tachycardia, hypotension, reduced skin turgor, cool extremities obstructive ureteral kidney stones - extreme flank pain or abdominal pain acute kidney failure or injury - peripheral oedema, hyperkalaemia, severe metabolic acidosis, uremia

Question 352

Oliguria - ix

Answer 352

Measurement of urine via a urinary catheter Basic metabolic panel - FBC, U&Es, CRP, eGFR, kidney function Urinalysis Abdominal ultrasound CT KUB

Question 353

Oliguria - mx

Answer 353

Manage underlying cause pre-renal/intrarenal - manage fluid intake carefully while kidneys recover, steroids [lupus?] post-renal - remove obstruction/manage obstruction [cancer/stones/BPH] end stage kidney disease/acute injury - renal replacement therapy

Question 354

Anuria - causes

Answer 354

Kidneys stop producing urine - CKD Blockage in outflow of urine from kidneys - BPH, urinary retention, cancer, stones

Question 355

Anuria - ix

Answer 355

measure urine output via a catheter [can be pain relieving as well if there is acute urinary retention] blood: FBC, U&Es, kidney function, eGFR imaging: KUB ultrasound, CT KUB urinalysis

Question 356

Anuria - mx

Answer 356

manage fluids carefully - don't overload, esp in kidney failure remove obstruction to allow urine to flow normally catheterise - can help with pain in acute urinary retention renal replacement therapy - dialysis or kidney transplant

Question 357

Renal Colic - patho

Answer 357

multifactorial - no single cause ureteric calculi produce colicky pain due to reflex spasms of the ureter as the stone passes through micro-abrasions can cause microscopic haematuria ureter lies close to the genitofemoral nerve - can cause referred testicular pain 80% are calcium based

Question 358

Renal Colic - s/s

Answer 358

symptoms - loin-to-groin pain; n/v; haematuria; dysuria; urgency signs - flank tenderness; haematuria; fever; rigors

Question 359

Renal Colic - ix

Answer 359

Imaging of choice for diagnosing acute renal colic is a non-contrast CT KUB scan ultrasound is reserved for patients who aren't suitable for a CT scan - children/young adults/ pregnant women X-ray can be used to identify calcium stones; mostly used to check stent placement bed: obs, urinalysis, ECG, urine culture bloods: FBC, U&Es, CRP, LFTs, amylase, bone profile, uric acid

Question 360

Renal Colic - mx

Answer 360

Majority can be managed with analgesia and adequate hydration Surgery: *shockwave lithotripsy [shockwaves to break up stones; stones <20mm] *ureteroscopy with laser lithotripsy [energy devices used to break up stones, 10-20mm, where SWL is contraindicated] *percutaneous nephrolithotomy [nephroscope passed into collecting system and breaks up stones; >20mm stones]

Question 361

Pyelonephritis - patho

Answer 361

Infection of the kidney - upper urinary tract infection Typically E.coli [gram negative anaerobic rod bacteria]

Question 362

Pyelonephritis - s/s

Answer 362

Typical triad - fever; loin/back pain; nausea and vomiting can also have systemic illness [fever, +hr, -bp, +rr] loss of appetite haematuria renal angle tenderness on examination

Question 363

Pyelonephritis - ix

Answer 363

urine dipstick MSU for MC&S bloods: FBC, U&Es, CRP, kidney function, LFTs imaging: ultrasound or CT KUB

Question 364

Pyelonephritis - mx

Answer 364

Referral to hospital if septic/unsafe to manage in community Cefalexin for 7-10d

Question 365

Prostatitis - patho

Answer 365

acute bacterial - rapid onset of symptoms chronic - 3m of symptoms typically an infection; although chronic prostatitis may not have a clear underlying cause

Question 366

Prostatitis - s/s

Answer 366

Chronic- pelvic pain, LUTS, sexual dysfunction, pain with bowel movements, tender and enlarged prostate Acute - more acute ^ symptoms, may also be systemic symptoms [i.e. fever, myalgia, nausea, fatigue, sepsis]

Question 367

Prostatitis - ix

Answer 367

Urine dipstick Urine MC&S Chlamydia and gonorrhoea screening

Question 368

Prostatitis - mx

Answer 368

Acute - hospital admission, oral abx [ciprofloxacin], analgesia, laxatives Chronic - alpha-blockers [tamsulosin], analgesia, psychological treatment, abx if <6m of symptoms or a hx of infection [trimethoprim for 4-6wks], laxatives

Question 369

Urinary Incontinence - patho

Answer 369

Overflow - urethral blockage; bladder unable to completely empty Stress - relaxed pelvic floor, increased abdominal pressure causes leakage Urge - bladder oversensitivity from infection, neurological disorders

Question 370

Overflow Urinary Incontinence - mx

Answer 370

Bladder training Don't delay urination Scheduled toilet trips Double voiding

Question 371

Stress Urinary Incontinence - mx

Answer 371

Pelvic floor exercises Lifestyle adjustments Duloxetine can help with symptoms Vaginal mesh Tension free vaginal tape - sling of tape to support urethra and bladder neck Colposuspension

Question 372

Urge Urinary Incontinence - mx

Answer 372

Lifestyle adjustments Bladder retraining Medications Sacral nerve stimulation Botulinum toxin A injection to the bladder Surgery - augmentation cystoplasty

Question 373

Testicular pain - causes

Answer 373

Testicular torsion Epididymo-orchitis Testicular cancer - not always painful Referred pain from ureteric stones

Question 374

Testicular Torsion - patho

Answer 374

twisting of the spermatic cord with rotation of the testicle Urological emergency Delay in treatment ++risk of ischaemia and necrosis Typically teenage boys

Question 375

Testicular Torsion - s/s

Answer 375

Acute rappid onset of unilateral testicular pain May be associated ith abdominal pain and vomiting o/e - firm, swollen testicle; elevated/retracted testicle; absent cremasteric reflex; abnormal testicular lie; rotation so epididymis is not in normal posterior position

Question 376

Testicular Torsion - ix

Answer 376

Good history and examination urgent management is required don't delay treatment for investigations ultrasound can show a whirlpool sign - but not recommended if it would delay going to theatre

Question 377

Testicular Torsion - mx

Answer 377

NBM in prep for surgery analgesia as required Urgent senior urology assessment Surgical exploration of the scrotum Orchiopexy - correcting the position of the testicle Orchidectomy - removal of testicle if there is necrosis or surgery is delayed

Question 378

Epididymo-orchitis - patho

Answer 378

Epididymitis - inflammation of epididymis Orchitis - inflammation of the testicle Caused by E.coli; chlamydia trachomatis; Neisseria gonorrhoea; mumps

Question 379

Epididymo-orchitis - s/s

Answer 379

Gradual onset, minutes-hours Unilateral testicular pain; dragging/heavy sensation; swelling of testicle and epididymis; tenderness on palpation; urethral discharge [think STIs]; systemic symptoms [fever, potentially sepsis]

Question 380

Epididymo-orchitis - ix

Answer 380

urine dipstick; MC&S chlamydia and gonorrhoea screening saliva swab for mumps serum antibodies for mumps ultrasound of scrotum can be helpful

Question 381

Epididymo-orchitis - mx

Answer 381

Referral to hospital is very unwell/septic STI? refer to GUM for assessment and treatment caused by E.coli - Ofloxacin for 14d caused by STI - IM ceftriaxone; doxycycline analgesia; supportive underwear; reduce physical activity; abstain from sexual intercourse

Question 382

Testicular Cancer - patho

Answer 382

arise from germ cells two types: seminomas and non-seminomas RF: undescended testes; male infertility; fhx; increased height

Question 383

Testicular Cancer - s/s

Answer 383

Painless lump on the testicle; sometimes with pain lump: non-tender/reduced sensation; arising from testicle; hard; irregular; not fluctuant; no transillumination gynaecomastia can be a presenting symptom - particularly for Leydig cell tumours

Question 384

Testicular Cancer - ix

Answer 384

Scrotal ultrasound confirms diagnosis Tumour markers: *alpha-fetoprotein [may be raised in teratomas] *beta-hCG [may be raised in teratomas and seminomas] *LDH [very non specific marker] CT staging scan can be used to look for areas of spread and stage the cancer

Question 385

Testicular Cancer - mets

Answer 385

Common places include lymphatics, lungs, live, brain

Question 386

Testicular Cancer - mx

Answer 386

guided by an MDT Mx can include: *surgery to remove affected testicle *chemo/radiotherapy *sperm banking to save sperm for future use - tx can cause infertility

Question 387

Causes of Scrotal Lump

Answer 387

hydrocele varicocele epididymal cyst testicular cancer epididymo-orchitis inguinal hernia testicular torsion

Question 388

Hydrocele - patho

Answer 388

a collection of fluid within the tunica vaginalis surrounding the testes

Question 389

Hydrocele - s/s

Answer 389

Painless soft scrotal swelling o/e - testicle is palpable within the hydrocele; soft, fluctuant, may be large; irreducible and has no bowel sounds; transilluminated by shining torch through the skin, into the fluid [testicle floats in the fluid]

Question 390

Hydrocele - mx

Answer 390

Exclude serious causes [cancer, torsion] idiopathic hydroceles can be managed conservatively Surgery, aspiration, scleropathy may be required in large or symptomatic cases

Question 391

Varicocele - patho

Answer 391

Veins in the pampiniform plexus become swollen Common - affect 15% of men Can cause impaired fertility [possibly due to temperature changes]; can cause testicular atrophy As a result of increased resistance in the testicular vein Typically right sided; left sided can indicate a renal cell carcinoma

Question 392

Varicocele - s/s

Answer 392

Throbbing/dull pain or discomfort, worse on standing Dragging sensation Sub-fertility or infertility o/e- scrotal mass that feels like a bag of worms; more prominent on standing; disappears when lying down; asymmetry in testicular size if varicocele has caused atrophy

Question 393

Varicocele - ix

Answer 393

Ultrasound with Doppler imaging to confirm diagnosis if it does not disappear when lying down - further urological investigation required as this may be a sign of retroperitoneal tumours obstructing the renal vein Semen analysis if concerned with fertility Hormonal testing if concerned about function

Question 394

Varicocele - mx

Answer 394

Uncomplicated are managed conservatively Surgery or endovascular embolisation may be indicated for pain, testicular atrophy or infertility

Question 395

Epididymal Cyst - patho

Answer 395

A fluid-filled sac at the head of the epididymis If it contains sperm, it is a spermatocele

Question 396

Epididymal Cyst - s/s

Answer 396

Usually asymptomatic; found incidentally on ultrasound for another indication o/e- soft, round lump; typically at the top of the testicle; associated with the epididymis; separate from the testicle; may be able to transilluminate large cysts

Question 397

Epididymal Cyst - mx

Answer 397

Usually harmless and not associated with infertility or cancer May cause pain or discomfort, so removal may be considered Very rarely, there may be torsion of the cyst, causing acute pain and swelling

Question 398

Obstructive Uropathy - patho

Answer 398

a blockage preventing urine flow through the ureters, bladder and urethra Leads to back-pressure in the urinary system [hydronephrosis when the kidney becomes swollen] Vesicoureteral reflux refers to urine refluxing from the bladder back into ureters When it leads to an acute reduction in kidney function, it is a post-renal AKI

Question 399

Obstructive Uropathy - causes

Answer 399

Upper: kidney stones; tumours pressing on ureters; ureter strictures; retroperitoneal fibrosis; bladder cancer; ureterocoele Lower: BPH; prostate cancer; bladder cancer; urethral strictures; neurogenic bladder [causes: MS, diabetes, stroke, parkinson's, brain/spinal cord injuru, spina bifid]

Question 400

Obstructive Uropathy - s/s

Answer 400

Upper: *loin to groin pain or flank pain on the affected side *reduced or no urine output *non-specific systemic symptoms [vomiting for example] *impaired renal function on blood tests Lower: *difficulty/inability to pass urine [poor flow, difficulty initiating urine flow, terminal dribbling] *urinary retention, with increasingly full bladder *impaired renal function on blood tests

Question 401

Obstructive Uropathy - ix

Answer 401

Ultrasound KUB can be helpful in diagnosing

Question 402

Obstructive Uropathy - mx

Answer 402

Removing or bypassing the obstruction Nephrostomy - bypass upper urinary tract; thin tube inserted through skin and kidney and into ureter to drain urine into a bag Urethral or supra-pubic catheter - bypass lower urinary tract; urethral is inserted to the urethra into the bladder; suprapubic is inserted through the skin just above pubic bone directly into bladder

Question 403

Hydronephrosis - ix and mx

Answer 403

ultrasound, CT or IV urogram mx- percutaneous nephrostomy [tube through the skin and kidney into the ureter under radiological guidance] antegrade ureteric stent [stent through the kidney into the ureter under radiological guidance]

Question 404

Erectile Dysfunction - patho

Answer 404

sexual arousal disorder characterised by inability to obtain and maintain erection during sexual intercourse

Question 405

Erectile Dysfunction - causes

Answer 405

cardiovascular disease/peripheral artery disease drug side effects - ssris, antihypertensives, nicotine, ethanol psychogenic - performance anxiety, depression neurological problems - prostatectomy surgery trauma, MS penile disorder - Peyronie's disease, priapism

Question 406

Erectile Dysfunction - RF

Answer 406

increasing age htn smoking hyperlipidaemia diabetes alcohol/drug abuse hypogonadism [--testosterone levels]

Question 407

Erectile Dysfunction - s/s

Answer 407

inability to achieve erection suitable for penetration -libido -erection rigidity inability to achieve orgasm and/or ejaculation early ejaculation -peripheral pulses -sensation small testicles penile abnormalities nocturnal erections present in psychogenic erectile dysfunction, absent in organic erectile dysfunction

Question 408

Erectile Dysfunction - ix

Answer 408

bed: BP bloods: testosterone, FSH/LH, glucose, lipids imaging: duplex ultrasound [measures blood flow before/after injection of vasodilators]

Question 409

Erectile Dysfunction - mx

Answer 409

first line - phosphodiesterase type 5 inhibitors [sildenafil citrate] 30-60m before intercourse other medical options - intracavernosal injections of vasodilators; hormone replacement in individuals with hypogonadism surgical mx - revascularisation, implantation of prosthetic devices psychotherapy - reduce performance anxiety other interventions - external facilitating devices [vacuum/constriction devices]; treat underlying cause

Question 410

Benign Prostatic Hyperplasia - patho

Answer 410

characterised by nodular prostatic hyperplasia not premalignant most common prostatic disease biologically males over 50 RF - increasing age, fhx, heart disease, b-blocker use, obesity, diabetes, erectile dysfunction

Question 411

Benign Prostatic Hyperplasia - s/s

Answer 411

urinary symptoms - frequency, urgency, nocturia, dysuria, emptying bladder feels incomplete, difficulty starting/stopping urine flow, weak stream - small amounts of urine passed

Question 412

Benign Prostatic Hyperplasia - ix

Answer 412

bed: urinalysis, urine culture, DRE bloods: PSA often raised, U&Es, BUN [urea and nitrogen] imaging: ultrasound to evaluate bladder, prostate size, degree of hydronephrosis; cystoscopy to reveal bladder dysfunction before scheduled invasive treatment

Question 413

Benign Prostatic Hyperplasia - mx

Answer 413

medical - alpha receptor blocker [tamsulosin]; 5-alpha reductase inhibitors [finasteride] surgical - transurethral resection of prostate [TURP]; open prostatectomy other - mild cases can be managed conservatively

Question 414

Priapism - patho

Answer 414

involuntary, persistent erection unrelated to sexual stimulation, unrelieved by ejaculation Urological emergency low flow [ischaemic] and high flow [non-ischaemic]

Question 415

Priapism - causes

Answer 415

often idiopathic low flow - hypercoagulable state; neurological disease; metastatic disease; medications relaxing smooth muscle high flow - penile/perineum trauma

Question 416

Priapism - s/s

Answer 416

persistent erection usully lasting 30 minutes to three hours low flow - painful, rigid erection; corporeal aspiration would show dark blood high flow - not painful, may be episodic, trauma evidence

Question 417

Priapism - ix

Answer 417

bloods: penile blood gas; FBC imaging: doppler ultrasound; CT scan to detect underlying cause [i.e. malignancy]

Question 418

Priapism - mx

Answer 418

medication low flow - intracavernosal injection of phenylephrine surgery low flow - surgical decompression others - treat underlying condition

Question 419

Phimosis - patho

Answer 419

inability to retract the foreskin because of a narrow preputial ring 1` = physiological phimosis; congenital 2` = pathological; due to scarring from conditions such as balanitis, traumatic retraction of foreskin

Question 420

Phimosis - s/s

Answer 420

poor stream ballooning of foreskin on micturition spraying on micturition recurrent attacks of balanitis pain on intercourse - adults in severe cases, hydronephrosis

Question 421

Phimosis - mx

Answer 421

physiological - foreskin will become retractable with age so conservative management; watchful waiting; topical steroids may be useful pathological - circumcision; short course of mild topical steroids may be beneficial in scarring

Question 422

Paraphimosis - patho

Answer 422

inability to pull forward a retracted foreskin often caused by presence of tight constricting band as part of foreskin as paraphimosis remains, glans becomes increasingly oedematous due to reduced venous return may lead to penile ischaemia and worsening infection [inc Fournier's gangrene] it is a urological emergency that requires urgent reduction

Question 423

Paraphimosis - RF

Answer 423

phimosis indwelling catheter poor hygiene prior paraphimosis

Question 424

Paraphimosis - s/s

Answer 424

typically presents with progressive pain and swelling in glans or distal prepuce following retraction of foreskin and inability to return to normal position

Question 425

Paraphimosis - mx

Answer 425

reduction asap: -manual pressure to the glans to reduce oedema before applying force to the glans to reduce it into the foreskin [use lubricant as required] -application of dextrose-soaked gauze to have an osmotic effect, drawing fluid out of the glans, reducing oedema and allowing for reduction -"Dundee Technique" involves needle punctures to drain oedematous fluid from the glans before reduction ensure suitable analgesia; a penile block via local anaesthetic [without adrenaline] if manual reduction fails, then a dorsal slit or an emergency circumcision may be required

Question 426

Fournier's Gangrene - patho

Answer 426

form of necrotising fasciitis that affects the perineum urological emergency - mortality of 20-40% causative organisms - group a strep, e.coli testes and epididymis are not affected by the fasciitis, usually

Question 427

Fournier's Gangrene - RF

Answer 427

diabetes mellitus excess alcohol intake poor nutritional status excess steroid use haematological malignancies recent trauma to the region

Question 428

Fournier's Gangrene - s/s

Answer 428

early stages may have severe pain [out of proportion] or pyrexia often non-specific until significant deterioration, most commonly seen in those not quite right for a simple cellulitis as it progresses - crepitus, skin necrosis, haemorrhagic bullae, sensory loss may also occur patients will rapidly deteriorate and become significantly unwell with sepsis, often entering septic shock

Question 429

Fournier's Gangrene - ix

Answer 429

diagnosis is largely clinical bloods: FBC, U&Es, CRP, LFTs, blood cultures, HbA1c imaging: CT imaging can show fascial swelling and soft tissue gas however should not delay surgical intervention

Question 430

Fournier's Gangrene - mx

Answer 430

urgent surgical debridement often extensive to remove all of the necrotic tissue debrided tissue is sent for tissue histology and culture and pus sent for fluid culture as well broad spec abx and transferred to a HDU; tailor abx when sensitivities return further surgical relooks and debridement are required until patient is free of necrotic tissue Secondary closure with skin grafts - early involvement of plastic surgeon

Question 431

Acute Urinary Retention - patho

Answer 431

new onset inability to pass urine -may have small amounts of urine passed but have significant residual volumes and ongoing discomfort

Question 432

Acute Urinary Retention - causes

Answer 432

BPH urethral strictures prostate cancer UTIs constipation severe pain medications - anti-muscarinics or spinal/epidural anaesthesia neurological causes - peripheral neuropathy, iatrogenic nerve damage during pelvic surgery, upper motor neurone disease [MS, Parkinson's]

Question 433

Acute Urinary Retention - s/s

Answer 433

acute suprapubic pain and an inability to micturate may be associated with symptoms of an underlying cause o/e - may have palpable bladder with suprapubic tenderness; fevers/rigors/lethargy may suggest an infective cause

Question 434

Acute Urinary Retention - ix

Answer 434

bed: DRE, CSU [catheterised specimen of urine] should be sent for MC&S blood: FBC, U&Es, CRP imaging: post-void bedside bladder scan will show volume of retained urine; ultrasound to assess for hydronephrosis

Question 435

Acute Urinary Retention - mx

Answer 435

immediate catheter to resolve retention; ensure to measure volume drained underlying cause must be treated accordingly if infective, treat with appropriate abx

Question 436

Chronic Urinary Retention - patho

Answer 436

when the bladder does not empty completely or at all can lead to hydronephrosis and renal impairment, puts patient at risk of acute on chronic retention most common cause is bladder outlet obstruction [BPH, prostate cancer, urethral strictures for example]

Question 437

Chronic Urinary Retention - s/s

Answer 437

urinary frequency, urgency, hesitancy poor urinary stream post-micturition dribbling nocturia new onset enuresis [urinary incontinence] a sense of incomplete voiding after micturition 'double' or recurrent voiding of urine symptoms consistent with UTI increasing abdominal discomfort acute urinary retention lethargy, pruritus, recurrent infections, hypertension due to CKD

Question 438

Chronic Urinary Retention - ix

Answer 438

bed: abdo exam, neurological exam, BP, exam of external genitalia, DRE in males, urinalysis and MC&S blood: FBC, U&Es, creatinine, glucose, PSA imaging: ultrasound/bladder scan can be useful; CT of the urinary tract special: urodynamic studies; post-voiding residual volume determination through catheterisation; voiding diaries can be useful

Question 439

Chronic Urinary Retention - mx

Answer 439

treat the underlying cause consider self-catheterisation before offering indwelling catheter or surgery impaired renal function/hydronephrosis? catheterise provide active surveillance stop aggravating medications lifestyle advice - regulate fluid intake, reduce alcohol/tea/coffee, prepare access for toilet needs while out bladder retraining and regular voiding

Question 440

Arterial Insufficiency - patho

Answer 440

inadequate arterial blood supply to a limb occurs over hours [acute] or months/years [chronic] acute is frequently caused by an embolism that lodges at a bifurcation of an artery - often severe and limb threatening ischaemia

Question 441

Intermittent Claudication

Answer 441

inadequate arterial supply to muscles during exercise causes muscle pain on walking, quickly relieved by rest

Question 442

Chronic Severe Ischaemia

Answer 442

arterial supply is inadequate even at rest with relative ischaemia of all tissues; risk of pressure ulceration; healing is severely impaired rest pain in foot, worse at night; onset over weeks/months; skin is pale/red/purple

Question 443

Acute-on-chronic Ischaemia

Answer 443

Limb is critically ischaemic; risk of limb necrosis in 6-8hr unless urgently revascularised thrombotic occlusion of atherosclerotic artery; clinical features are the same as acute limb ischaemia sudden onset [within 2wk] of acute ischaemia in patient with previous history of chronic ischaemia

Question 444

Acute Severe Ischaemia [of upper/lower limb; brain; intestine]

Answer 444

masses of thrombus detach and impact at arterial bifurcations, occluding flow emboli from heart [mitral stenosis, AF, endocarditis, recent MI] or from aortic aneurysm 6 P's - pain, pallor, perishingly cold, pulseless, paralysis, paraesthesia

Question 445

'Diabetic Foot'

Answer 445

accelerated atherosclerosis and neuropathy; loss of sensation predisposes to injury and ulceration and failure to heal because of ischaemia foot lesions [often painless] - deep ulceration in pressure areas, necrotic toes assume atherosclerotic ischaemia unless foot pulses are felt infection spreads rapidly, with potential limb-threatening necrosis and systemic sepsis needs early recognition and vigorous treatment

Question 446

'Diabetic Foot' infection

Answer 446

Lesions are often complicated by strep pyogenes response to infection is impaired in diabetics

Question 447

Acute DVT - patho

Answer 447

spontaneous thrombosis in deep veins of calf/thigh; obstructs venous return causing swelling and warmth venous gangrene in serious cases, which requires early treatment often with thrombolysis

Question 448

Acute DVT - s/s

Answer 448

pain and swelling of calf and ankle calf tenderness erythema of calf oedema asymmetrical prominent superficial veins cyanosis

Question 449

Acute DVT - ix

Answer 449

bed: ECG blood: D-dimer; FBC; U&Es, creatinine; LFTs, clotting screen imaging: CT venography; venous ultrasound further investigations may be required for unprovoked DVT

Question 450

Acute DVT - mx

Answer 450

apixaban or rivaroxaban are first line treatment; if unsuitable LMWH or dabigatran anti-coagulate for at least 3m

Question 451

Peripheral Arterial Disease - patho

Answer 451

caused by atherosclerosis most pts are symptomatic and require aggressive risk factor control

Question 452

Peripheral Arterial Disease - s/s

Answer 452

presence of RF: diabetes, smoking, hyperlipidaemia, hx of coronary artery disease or cerebrovascular disease intermittent claudication - pain on exertion, relieved by rest diminished/absent pulses ED leg pain at rest gangrene non-healing wound/ulcer muscle atrophy loss of hair thickened toenails shiny/scaly skin pale extremity nerve loss/loss of sensation

Question 453

Peripheral Arterial Disease - ix

Answer 453

ABPI duplex ultrasound Doppler can be useful angiography

Question 454

Peripheral Arterial Disease - ALI mx

Answer 454

urgent assessment for revascularisation or amputation antiplatelet therapy [clopidogrel] analgesia anticoagulation [LMWH] risk factor modification endovascular or surgical revascularisation, intra-arterial thrombolysis amputation

Question 455

Peripheral Arterial Disease - Claudication mx

Answer 455

not lifestyle-limiting: antiplatelet therapy [clopidogrel] + exercise + risk factor modification lifestyle-limiting: antiplatelet therapy [clopidogrel] + exercise + symptom relief + risk factor modification + consider revascularisation

Question 456

Peripheral Arterial Disease - Critical Limb Ischaemia mx

Answer 456

assess for revascularisation + antiplatelet therapy [clopidogrel] + risk factor modification consider: endovascular revascularisation or surgical revascularisation; spinal cord stimulation; bone marrow stem cell transplant; amputation

Question 457

Varicose Veins - patho

Answer 457

subcutaneous, permanently dilated veins 3mm+ in diameter when measured standing exact cause is unknown

Question 458

Varicose Veins - s/s

Answer 458

presence of RF: +age; fhx; female sex; pregnancy [more common the more pregnancies/births you have]; DVT dilated tortuous veins leg fatigue or aching with prolonged standing leg cramps restless legs haemosiderin deposition itching lipodermatosclerosis ankle swelling ulceration bleeding from varices

Question 459

Varicose Veins - ix

Answer 459

Duplex ultrasound

Question 460

Varicose Veins - mx

Answer 460

not all varicose veins require treatment compression stockings endothermal ablation radiofrequency ablation endovenous laser treatment ultrasound-guided foam - sclerotherapy surgery - ligation and stripping to remove the affected veins transilluminated powered phlebectomy [new treatment]

Question 461

Abdominal Aortic Aneurysm - patho

Answer 461

abnormal dilatation of the abdominal aorta with a diameter >3cm vast majority are infrarenal RF: male sex, increasing age, atherosclerotic disease, fhx, smoking, htn, connective tissue disorders

Question 462

Abdominal Aortic Aneurysm - s/s

Answer 462

frequently asymptomatic, symptoms tend to indicate rupture or impending rupture may have back pain or ureteric obstruction Rupture: symps- abdo/back/loin pain signs- hypotension, tachycardia, collapse, pulsatile abdominal mass

Question 463

Abdominal Aortic Aneurysm - screening

Answer 463

men 65+ get an abdominal ultrasound to screen for AAA <3cm: no further follow up required 3-4.5: yearly screening, lifestyle advice, refer to vascular seen within 12wk 4.5-5.5: 3m screening, lifestyle advice, refer to vascular seen within 12wk >5.4: urgent 2ww referral to vascular surgery

Question 464

Abdominal Aortic Aneurysm - ix

Answer 464

bed: obs/monitoring; ECG; urine dip bloods: FBC, U&Es, LFTs, clotting screen, A/VBG, G&S/CM [surgery may be imminent] imaging: AXR; abdo USS; MRI/CT pre-op

Question 465

Abdominal Aortic Aneurysm - elective mx

Answer 465

conservative: follow healthy lifestyle and diet; smoking cessation; treat risk factors if present surgery: open surgical repair elective is indicated in: *diameter >5.4cm *symptomatic aneurysms *asymptomatic, >4cm and grown 1+cm in a year endovascular aneurysm repair is available - iliofemoral access to deploy an aortic graft; can be used in elective or emergency setting

Question 466

Abdominal Aortic Aneurysm - emergency mx

Answer 466

Acute rupture is a medical emergency Fluid resuscitation/blood transfusion - aim for sBP 100-120 analgesia Surgical repair should be performed: either open or EVAR [endovascular aneurysm repair]

Question 467

Venous Leg Ulcer - s/s

Answer 467

occur in the gaiter area [between the top of the foot and the bottom of the calf muscle] associated with chronic venous changes - hyperpigmentation, venous eczema, lipodermatosclerosis occur after a minor injury to the leg larger than arterial ulcers more superficial than arterial ulcers irregular, sloping borders more likely to bleed less painful than arterial ulcers pain is relieved by elevation and worse on lowering the leg

Question 468

Arterial Leg Ulcer - s/s

Answer 468

occur distally, affecting toes r dorsum of the foot associated with peripheral artery disease, absent pulses, pallor and intermittent claudication smaller than venous ulcers deeper than venous ulcers well defined borders have a 'punched-out' appearance pale colour due to poor blood supply less likely to bleed painful pain worse at night or when laying horizontally pain worse on elevating nd improved by lowering the leg

Question 469

Diabetic Leg Ulcer - patho

Answer 469

common in patients with diabetic neuropathy patients who have lost sensation in their feet are less likely to realise they have injured their feet or have poorly fitting shoes damage to small and large blood vessels impairs blood supply and wound healing raised blood sugar, immune system changes and autonomic neuropathy also contribute to ulceration and poor healing osteomyelitis is an important complication

Question 470

Leg Ulcer - ix

Answer 470

ABPI used to assess for arterial disease bloods: FBC, CRP, U&Es, HbA1c, albumin charcoal swabs may be helpful where infection is suspected skin biopsy may be required where skin cancer is suspected as a differential diagnosis - this will require a 2ww referral to dermatology

Question 471

Arterial Leg Ulcer - mx

Answer 471

mx is the same as for peripheral arterial disease - urgent referral to vascular to consider surgical revascularisation if underlygin arterial disease is effectively treated, ulcer should heal rapidly

Question 472

Venous Leg Ulcer - mx

Answer 472

vascular surgery where mixed ulcers are suspected tissue viability/specialist leg ulcer clinics in complex or non-healing ulcers pain clinics where pain is difficult to manage patients require input from experienced nurses [i.e. district nurses] good wound care involves: *cleaning the owund *debridement *dressing the wound compression therapy is used to treat venous ulcers after arterial disease is excluded ab for infection analgesia to manage pain [no NSAIDs]