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Year 3 > Surgery > Flashcards

Surgery Flashcards

1
Q

How to assess capacity?

A

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

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2
Q

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

A

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

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3
Q

What is acute resuscitation?

A

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

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4
Q

When would you acutely resuscitate somebody?

A

After cardiac arrest

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5
Q

How to fluid resuscitate somebody.

A

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

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6
Q

When to use blood when resuscitating somebody?

A

When a pt is losing blood
Replace like for like

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7
Q

How do you give blood to a patient?

A

Two large bore cannulae - grey cannula 16G

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8
Q

When would you keep a patient NBM?

A

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

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9
Q

What is VTE assessment?

A

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

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10
Q

How do you complete a VTE assessment?

A

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

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11
Q

What steps do you undertake after completing a VTE assessment?

A

Prescribe prophylaxis [LMWH]
Prescribe compression stockings

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12
Q

What are some operation specific preparations?

A

Bowel prep

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13
Q

What is bowel prep?

A

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

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14
Q

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

A

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

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15
Q

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

A

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

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16
Q

IV fluids - types

A

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

Colloids
*Human albumin solution

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17
Q

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

A

Mainly cefazolin; vancomycin; gentamicin

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18
Q

Analgesia - intra-/post-op

A

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

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19
Q

Anti-emetics - why are they given

A

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

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20
Q

Anti-emetics - medications

A

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

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21
Q

Anti-emetics - side effects

A

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

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22
Q

Thromboprophylaxis - medications

A

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

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23
Q

Thromboprophylaxis - dose

A

LMWH - enoxaparin - 20-40mg/day

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24
Q

Thromboprophylaxis - side effects

A

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

Alopecia, hyperkalaemia, osteoporosis, spinal haematoma

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25
Q

What is the pre-operative surgical checklist?

A

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

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26
Q

Why is the pre-operative surgical checklist completed?

A

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

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27
Q

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

A

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

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28
Q

Name some devices used for airway management.

A

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

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29
Q

Endotracheal Tube - when to use

A

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

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30
Q

Endotracheal Tube - when is it not appropriate?

A

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

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31
Q

Endotracheal Tube - complications

A

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

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32
Q

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

A

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

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33
Q

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

A

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

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34
Q

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

A

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

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35
Q

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

A

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

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36
Q

Nasopharyngeal airway - when to use and when not to use

A

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

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37
Q

Name some common drugs used for anaesthesia

A

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

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38
Q

What are the three principles of anaesthesia?

A

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

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39
Q

Propofol - use

A

Induction and maintenance of anaesthesia

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40
Q

Propofol - side-effects

A

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

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41
Q

Propofol - moa

A

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

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42
Q

Isoflurane - side-effects

A

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

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43
Q

Isoflurane - moa

A

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

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44
Q

How are patient’s vital signs monitored during surgey?

A

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]

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45
Q

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

A

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

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46
Q

How are changes to vitals managed?

A

++ 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

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47
Q

What is a post-operative assessment?

A

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

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48
Q

What is the EWS?

A

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

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49
Q

How to calculate EWS?

A

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

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50
Q

Name some common post-operative complications

A

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

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51
Q

What is the daily requirement of water?

A

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

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52
Q

What is the daily requirement of sodiumm?

A

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

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53
Q

What is the daily requirement of potassium?

A

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

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54
Q

What is the daily requirement of glucose?

A

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

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55
Q

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

A

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

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56
Q

Consequences of hyponatraemia

A

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

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57
Q

Consequences of hypernatraemia

A

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

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58
Q

Consequences of hypokalaemia

A

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

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59
Q

Consequences of hyperkalaemia

A

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

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60
Q

Consequences of hypovolaemia

A

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

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61
Q

Consequences of hypervolaemia

A

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

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62
Q

Consequences of hypoglycaemia

A

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

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63
Q

Consequences of hyperglycaemia

A

In diabetics- DKA risk; hyperosmolar hyperglycaemic state

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64
Q

How to manage nutrition balance in a patient?

A

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

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65
Q

What is a MUST score?

A

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

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66
Q

Types of enteral feed

A

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

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67
Q

Types of parenteral feed

A

Administration of nutrients via the intravenous route

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68
Q

Why would you use enteral feeds?

A

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

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69
Q

Why would you use parenteral feeds?

A

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

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70
Q

What is pain?

A

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

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71
Q

How to manage pain?

A

Analgesia
Therapies

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72
Q

What is the WHO pain ladder?

A

Step wise approach to managing pain with analgesia

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73
Q

What are the steps of the pain ladder?

A

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

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74
Q

Different drugs used for pain management

A

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

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75
Q

How to prevent venous thromboembolism

A

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

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76
Q

Management of venous thromboembolism

A

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

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77
Q

S/S of thromboembolism

A

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

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78
Q

Surgical patient on anticoagulants/anti-platelets - mx

A

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

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79
Q

Surgical patient on oestrogen-containing contraception/HRT - mx

A

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

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80
Q

Surgical patient with Diabetes Mellitus - mx

A

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

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81
Q

Surgical patient with hypertension - mx

A

Patients should be continued as significant hypotension may result during anaesthesia

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82
Q

Surgical patient taking steroids - mx

A

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

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83
Q

Use of antibiotics in theatre

A

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

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84
Q

How to manage nausea post-op.

A

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

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85
Q

How to manage infection post-op.

A

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

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86
Q

What are some common anaesthesia complications?

A

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

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87
Q

What are some rarer, but important, anaesthesia complications?

A

Malignant hyperthermia and death

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88
Q

When to give blood intra-op?

A

Massive haemorrhage
Anaemia

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89
Q

How to transfuse blood in a surgical patient.

A

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

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90
Q

Sepsis- definition

A

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

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91
Q

Sepsis- s/s

A

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

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92
Q

Sepsis - ix

A

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

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93
Q

Sepsis - mx

A

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

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94
Q

Sepsis - complications

A

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

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95
Q

Massive haemorrhage - definition

A

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

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96
Q

Massive haemorrhage - s/s

A

Bleeding
Altered mental state
Hypotension
Weakness, fatigue

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97
Q

Massive haemorrhage - management

A

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]

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98
Q

Post-operative shock - definition

A

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

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99
Q

Post-operative shock - s/s

A

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

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100
Q

Post-operative shock - ix

A

Blood cultures
ABG
FBC, U&Es

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101
Q

Post-operative shock - mx

A

Abx
breathing support- ventilation
IV fluids/blood
Oxygen
Adrenaline

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102
Q

Abdominal mass or swelling - differentials

A

Cancer
IBD
Appendicitis
bowel obstruction
ascites
hepatomegaly/splenomegaly
urinary retention

6F’s:
fat; fluid; foetus; flatus; faeces; ‘filthy’ big tumour/’fatal’ growth

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103
Q

Abdominal mass or swelling - history questions

A

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?

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104
Q

Abdominal mass or swelling - examination

A

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

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105
Q

Abdominal mass or swelling - investigations

A

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

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106
Q

Abdominal mass or swelling - initial management

A

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

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107
Q

Lump in the groin - differentials

A

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

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108
Q

Lump in the groin - history

A

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

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109
Q

Lump in the groin - examination

A

Reducible?
tenderness?
abdominal examination; examine external genitalia

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110
Q

Lump in the groin - investigations

A

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

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111
Q

Lump in the groin - initial management

A

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

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112
Q

Abdominal pain - differentials

A

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

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113
Q

Abdominal pain - history

A

SQITARS
DHx, SHx, FHx, PMHx

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114
Q

Abdominal pain - examination

A

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

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115
Q

Abdominal pain - investigations

A

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]

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116
Q

Abdominal pain - initial management

A

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

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117
Q

Change in bowel habit - differentials

A

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

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118
Q

Change in bowel habit - history

A

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

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119
Q

Change in bowel habit - red flags

A

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

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120
Q

Change in bowel habit - examination and investigations

A

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)

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121
Q

Change in bowel habit - initial treatment

A

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

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122
Q

Change in stool colour - differentials

A

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

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123
Q

Change in stool colour - history

A

Similar to change in bowel habit hx

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124
Q

Change in stool colour - red flags

A

Similar to change in bowel habit

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125
Q

Change in stool colour - examination and investigations

A

Same as change in bowel habit

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126
Q

Change in stool colour - initial management

A

Reassure
Review medication
Arrange imaging and escalate
Admit if unwell

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127
Q

Jaundice - differentials

A

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

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128
Q

Jaundice - history

A

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

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129
Q

Jaundice - examination and investigations

A

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

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130
Q

Jaundice - initial management

A

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

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131
Q

Weight loss - differentials

A

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

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132
Q

Weight loss - history

A

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

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133
Q

Weight loss - examination and investigations

A

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

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134
Q

Weight loss - red flags

A

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

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135
Q

Weight loss - investigations

A

o

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136
Q

Weight loss - initial management

A

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

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137
Q

Acute abdomen - initial assessment

A

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

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138
Q

Acute abdomen - generalised abdominal pain causes

A

Peritonitis
Ruptured AAA
Intestinal obstruction
Ischaemic colitis

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139
Q

Acute abdomen - epigastric causes

A

Acute gastritis
Peptic ulcer disease
Pancreatitis
Ruptured AAA

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140
Q

Acute abdomen - RUQ causes

A

Biliary colic
Acute cholecystitis
Acute cholangitis

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141
Q

Acute abdomen - L lumbar causes

A

Renal colic [kidney stones]
Ruptured AAA
Pyelonephritis

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142
Q

Acute abdomen - Testicular pain causes

A

Testicular torsion
Epididymo-orchitis

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143
Q

Acute abdomen - umbilical causes

A

Ruptured AAA
Intestinal obstruction
Ischaemic colitis
Early stages of appendicitis

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144
Q

Acute abdomen - L iliac fossa causes

A

Diverticulitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion

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145
Q

Acute abdomen - Loin to groin pain causes

A

Renal colic [kidney stones]
Ruptured AAA
Pyelonephritis

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146
Q

Acute abdomen - supra-pubic/hypogastric causes

A

Lower UTI
Acute urinary retention
Pelvic inflammatory disease
Prostatitis

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147
Q

Acute abdomen - investigations

A

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

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148
Q

Acute abdomen - initial management

A

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

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149
Q

GI obstruction - s/s

A

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

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150
Q

GI obstruction - differentials

A

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

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151
Q

GI obstruction - investigations

A

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

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152
Q

GI obstruction - typical history

A

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

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153
Q

GI obstruction - initial management

A

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

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154
Q

GI obstruction - definitive management

A

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

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155
Q

GI haemorrhage - s/s

A

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

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156
Q

GI haemorrhage - differentials

A

Ruptured AAA
Sepsis
Any other kinds of shock

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157
Q

GI haemorrhage - causes

A

Ruptured AAA
Anastomotic leak (?)

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158
Q

GI haemorrhage - investigations

A

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

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159
Q

GI haemorrhage - initial management

A

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

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160
Q

GI haemorrhage - definitive management

A

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

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161
Q

Acute pancreatitis - s/s

A

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

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162
Q

Acute pancreatitis - investigations

A

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

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163
Q

Acute pancreatitis - causes

A

Idiopathic

Gallstones
Ethanol
Trauma

Steroids
Mumps
Autoimmune
Scorpion sting
Hyperlipidaemia/hypercalcaemia/hypothermia
ERCP/emboli
Drugs

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164
Q

Acute pancreatitis - differentials

A

Gastritis
PUD
Acute cholecystitis
Peritonitis
Abnormal MI
Bowel obstruction

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165
Q

Acute pancreatitis - initial treatment

A

Fluid resuscitation
Analgesia
IVF
NBM
PPI
IV abx
Insulin sliding scale

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166
Q

Acute pancreatitis - definitive management

A

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

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167
Q

Acute appendicitis - s/s

A

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

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168
Q

Acute appendicitis - investigations

A

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

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169
Q

Acute appendicitis - differentials

A

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

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170
Q

Acute appendicitis - initial treatment

A

Admit
NBM
IVF and analgesia and abx
Consent for surgery

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171
Q

Acute appendicitis - definitive management

A

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

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172
Q

Name some common oesophageal disorders

A

Achalasia
Oesophageal Cancer
GORD
Barrett’s Oesophagus
Oesophagitis

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173
Q

Achalasia - s/s

A

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

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174
Q

Achalasia - investigations

A

OGD
Barium swallow
High-resolution manometry

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175
Q

Achalasia - management

A

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

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176
Q

Achalasia - complications

A

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

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177
Q

Oesophageal cancer - s/s

A

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]

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178
Q

Oesophageal cancer - types

A

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]

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179
Q

Oesophageal cancer - investigations

A

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

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180
Q

Squamous Cell Carcinoma of Oesophagus - risk factors

A

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

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181
Q

Adenocarcinoma of Oesophagus - risk factors

A

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

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182
Q

Oesophageal cancer - management

A

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

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183
Q

Oesophageal cancer - complications

A

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

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184
Q

GORD - s/s

A

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

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185
Q

GORD - investigations

A

Gastroscopy and pH monitoring

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186
Q

GORD - management

A

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

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187
Q

Barrett’s Oesophagus - s/s

A

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

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188
Q

Barrett’s Oesophagus - investigations

A

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

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189
Q

Barrett’s Oesophagus - management

A

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

190
Q

Barrett’s Oesophagus - complications

A

High grade dysplasia
Adenocarcinoma

191
Q

Mallory Weiss Tear - GI bleed

A

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

192
Q

Peptic Ulcer Disease - s/s

A

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

193
Q

Peptic Ulcer Disease - investigations

A

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

194
Q

Peptic Ulcer Disease - causes

A

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]

195
Q

Peptic Ulcer Disease - management

A

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

196
Q

Peptic Ulcer Disease - complications

A

Perforation
Haemorrhage
Gastric outlet obstruction

197
Q

Helicobacter Pylori - s/s

A

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

198
Q

Helicobacter Pylori - investigations

A

Non-invasive:
*13C Urea breath test
*Stool antigen test

Invasive:
*Urease test
*Histology
*Microbiology

199
Q

Helicobacter Pylori - management

A

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

200
Q

Helicobacter Pylori - complications

A

Cancer; PUD; perforation; haemorrhage

201
Q

Gastric Cancer - s/s

A

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]

202
Q

Gastric Cancer - red flags

A

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

203
Q

Gastric Cancer - investigations

A

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

204
Q

Gastric Cancer - causes/risk factors

A

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

205
Q

Gastric Cancer - management

A

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

206
Q

IBD - types

A

Ulcerative Colitis
Crohn’s Disease

207
Q

Ulcerative Colitis - CLOSE-UP mnemonic

A

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

208
Q

IBD - investigations

A

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

209
Q

Ulcerative Colitis - management

A

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

210
Q

Ulcerative Colitis - complications

A

Colorectal cancer
Primary Sclerosing Cholangitis

211
Q

Crohn’s Disease - management

A

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

212
Q

Crohn’s Disease - NESTTS mnemonic

A

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

213
Q

Colon Cancer - s/s

A

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

214
Q

Colon Cancer - red flags

A

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

215
Q

Colon Cancer - screening

A

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

216
Q

Colon Cancer - investigations

A

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

217
Q

Colon Cancer - management

A

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

218
Q

Diverticula Disease - definition

A

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

219
Q

Diverticula Disease - s/s

A

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

220
Q

Diverticula Disease - investigations

A

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

221
Q

Diverticula Disease - management

A

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

222
Q

Diverticula Disease - complications

A

Fistulas; abscesses; perforation; colonic obstruction

223
Q

Diverticulitis - s/s

A

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

224
Q

Diverticulitis - investigations

A

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

225
Q

Diverticulitis - management

A

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

226
Q

Diverticulitis - complications

A

Fistulas; abscesses; perforation; colonic obstruction

227
Q

Colon Polyps - s/s

A

Usually asymptomatic, but may be present with rectal bleeding

228
Q

Colonic Polyps - investigations

A

Colonoscopy

229
Q

Colonic Polyps - management

A

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

230
Q

Haemorrhoids - s/s

A

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

231
Q

Haemorrhoids - investigations

A

DRE; proctoscope; flex sig; colonoscopy

232
Q

Haemorrhoids - management

A

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

233
Q

Haemorrhoids - complications

A

Anaemia
Blood clots in external haemorrhoids
Infection
Skin tags
Strangulated haemorrhoids

234
Q

Rectal Abscess - s/s

A

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

235
Q

Rectal Abscess - investigations

A

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

236
Q

Rectal Abscess - management

A

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

237
Q

Rectal Abscess - complications

A

Recurrence, sepsis, continuing pain, scarring, fistula

238
Q

Proctitis - s/s

A

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

239
Q

Proctitis - causes

A

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

240
Q

Proctitis - investigations

A

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

241
Q

Proctitis - management

A

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

242
Q

Proctitis - complications

A

Usually responds well
If linked to IBD, may flare up

243
Q

Anal Fissure - s/s

A

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

244
Q

Anal Fissure - investigations

A

Examination; DRE
imaging if concerned about other causes

245
Q

Anal Fissure - management

A

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

246
Q

PR bleeding - causes

A

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

247
Q

PR bleeding - investigations

A

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

248
Q

Hernias - types

A

Inguinal - direct and indirect
Femoral
Incisional
Umbilical

249
Q

Inguinal Hernia - s/s

A

Inguinal lump/swelling

250
Q

Direct Inguinal Hernia - route

A

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

251
Q

Indirect Inguinal Hernia - route

A

Lateral to inferior epigastric artery

Enters inguinal canal through deep ring and transverses canal within patent processus vaginalis

252
Q

Inguinal Hernia - investigations

A

Good examination
CT to show contents of the hernia

253
Q

Inguinal Hernia - management

A

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

254
Q

Femoral Hernia - s/s

A

Swelling/lump at femoral canal

255
Q

Femoral Hernia - route

A

Below and lateral to the pubic tubercle

256
Q

Femoral Hernia - investigations

A

Good examination, imaging?

257
Q

Femoral Hernia - management

A

All surgical options. Surgical repair of the femoral hernia

258
Q

Incisional Hernia - defintion

A

Herniation through a site of previous surgery

259
Q

Incisional Hernia - s/s

A

Lump where there is a surgical wound/scar

260
Q

Incisional Hernia - investigations

A

Examination

261
Q

Incisional Hernia - management

A

Mesh repair surgically

262
Q

Umbilical Hernia - s/s

A

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

263
Q

Umbilical Hernia - investigations

A

Examination

264
Q

Umbilical Hernia - management

A

Mesh repair surgically

265
Q

Hiatus Hernia - definition

A

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

266
Q

Hiatus Hernia - s/s

A

Usually asymptomatic
May have symptoms of GORD
Rarely - dysphagia

Nothing found on examination

267
Q

Hiatus Hernia - investigations

A

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

268
Q

Hiatus Hernia - management

A

Surgical management - oesophageal lengthening and Nissen’s fundoplication

269
Q

Strangulated Hernia - defintion

A

A hernia containing ischaemic bowel

270
Q

Strangulated Hernia - s/s

A

Tense, tender, irreducible hernia with absent bowel sounds

271
Q

Strangulated Hernia - investigations

A

Examination

272
Q

Strangulated Hernia - management

A

Surgical repair

273
Q

Incarcerated Hernia - defintion

A

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

274
Q

Incarcerated Hernia - s/s

A

Irreducible lump
Present bowel sounds

275
Q

Incarcerated Hernia - investigations

A

Examination

276
Q

Incarcerated Hernia - management

A

Surgical repair- risk of obstruction and strangulation

277
Q

Name some HPB disorders requiring surgical intervention

A

Acute cholecystitis
Hepatic carcinoma
Gallstones
Cholangitis

278
Q

Acute Cholecystitis - defintion

A

Acute inflammation of the gallbladder

Obstruction of the cystic duct leads to inflammation

279
Q

Acute Cholecystitis - s/s

A

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

280
Q

Acute Cholecystitis - investigations

A

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

281
Q

Acute Cholecystitis - management

A

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

282
Q

Acute Cholecystitis - complications

A

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

283
Q

Gallstones - s/s

A

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

284
Q

Gallstones - investigations

A

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

285
Q

Gallstones - management

A

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

286
Q

Gallstones - complications

A

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

287
Q

Hepatitis - types

A

ABCDE

288
Q

Hepatitis - s/s

A
289
Q

Hepatitis - investigations

A

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

290
Q

Hepatitis - management

A

REVIEW Same as infectious diseases unit - medicine
REVIEW

291
Q

Hepatitis - complications

A

p

292
Q

Biliary Colic - defintion

A

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

293
Q

Biliary Colic - s/s

A

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

294
Q

Biliary Colic - investigations

A

Ultrasound - confirms presence of gallstones

295
Q

Biliary Colic - management

A

Cholecystectomy - usually laparoscopic

296
Q

Ascending Cholangitis - defintion

A

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

297
Q

Ascending Cholangitis - s/s

A

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

298
Q

Ascending Cholangitis - investigations

A

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

299
Q

Ascending Cholangitis - management

A

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

300
Q

Ascending Cholangitis - complications

A

Endotoxic shock
Suppurative Cholangitis (pus in biliary tree)

301
Q

Gallstone Ileus - defintion

A

Small bowel obstruction caused by large intraluminal gallstone

302
Q

Gallstone Ileus - s/s

A

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

303
Q

Gallstone Ileus - investigations

A

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 ^

304
Q

Gallstone Ileus - management

A

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

305
Q

Cholangiocarcinoma - definition

A

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

Typically adenocarcinoma

306
Q

Cholangiocarcinoma - s/s

A

Presents as obstructive jaundice with weight loss

307
Q

Cholangiocarcinoma - investigations

A

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)

308
Q

Cholangiocarcinoma - management

A

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

309
Q

Hepatocellular Carcinoma - definition

A

Primary liver cancer, arises from hepatocytes

310
Q

Hepatocellular Carcinoma - s/s

A

Late presentation - weight loss, anorexia, n/v, abdominal pain in right hypochondrium radiating to the back

Signs- cachexia, jaundice, palpable liver, ascites

311
Q

Hepatocellular Carcinoma - investigations

A

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

312
Q

Hepatocellular Carcinoma - management

A

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

313
Q

Pancreatic Cancer - definition

A

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

314
Q

Pancreatic Cancer - s/s

A

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

315
Q

Pancreatic Cancer - investigations

A

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

316
Q

Pancreatic Cancer - management

A

Surgical depends on location
-head: Whipple’s procedure
-body/tail: distal pancreatic resection

Palliative in incurable disease to alleviate symptoms

317
Q

Chronic Pancreatitis - definition

A

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

318
Q

Chronic Pancreatitis - s/s

A

Unremitting epigastric pain, weight loss and steatorrhoea

319
Q

Chronic Pancreatitis - investigations

A

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

320
Q

Chronic Pancreatitis - causes

A

Same as acute pancreatitis, alcohol being the most common cause

Idiopathic

Gallstones
Ethanol
Trauma

Steroids
Mumps
Autoimmune
Scorpion sting
Hyperlipidaemia/hypercalcaemia
ERCP
Drugs - medications

321
Q

Chronic Pancreatitis - management

A

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

322
Q

Stomas - types

A

Gastrostomy
Jejunostomy
Ileostomy
Caecostomy
Colostomy

323
Q

Stomas - indications

A

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

324
Q

Stomas - complications

A

Mnemonic - STOMA BAGS HELP
Stenosis
Tight defect
Overflow
Maintenance problems
Anaemia

Bloating
Aroma
Gall/kidney stones
Short gut syndrome

Hernia - parastomal
Excoriation
Leakage
Prolapse

325
Q

Pancreatic Pseudocyst - defintion

A

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

326
Q

Pancreatic Pseudocyst - s/s

A

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

327
Q

Pancreatic Pseudocyst - investigations

A

Amylase (persistently elevated)
Ultrasound of the abdomen

328
Q

Pancreatic Pseudocyst - management

A

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

329
Q

Bowel Perforation - causes

A

Bowel obstruction
Toxic mega colon

330
Q

Bowel Perforation - s/s

A

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

331
Q

Bowel Perforation - investigations

A

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

332
Q

Bowel Perforation - management

A

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

333
Q

Bowel Perforation - complications

A

Sepsis
Peritonitis
Death

334
Q

Peritonitis - causes

A

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

335
Q

Peritonitis - definition

A

Inflammation of peritoneum

336
Q

Peritonitis - investigations

A

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

337
Q

Peritonitis - management

A

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

338
Q

Peritonitis - complications

A

Sepsis
Death

339
Q

Ascites - causes

A

Liver disease

340
Q

Ascites - s/s

A

Swelling of the abdomen

341
Q

Ascites - investigations

A

Ascetic tap
LFTs, FBC, U&Es, albumin

342
Q

Ascites - management

A

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

343
Q

Wound Infection - causes

A

Poor cleaning
Poor wound dressing

Causative organism is typically Staphylococcus aureus

344
Q

Wound Infection - s/s

A

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

345
Q

Wound Infection - investigations

A

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

346
Q

Wound Infection - management

A

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

347
Q

Haematuria - causes

A

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

348
Q

Haematuria - ix

A

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

349
Q

Haematuria - mx

A

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?

350
Q

Oliguria - causes

A

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

351
Q

Oliguria - s/s

A

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

352
Q

Oliguria - ix

A

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

353
Q

Oliguria - mx

A

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

354
Q

Anuria - causes

A

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

355
Q

Anuria - ix

A

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

356
Q

Anuria - mx

A

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

357
Q

Renal Colic - patho

A

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

358
Q

Renal Colic - s/s

A

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

359
Q

Renal Colic - ix

A

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

360
Q

Renal Colic - mx

A

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]

361
Q

Pyelonephritis - patho

A

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

362
Q

Pyelonephritis - s/s

A

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

363
Q

Pyelonephritis - ix

A

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

364
Q

Pyelonephritis - mx

A

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

365
Q

Prostatitis - patho

A

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

366
Q

Prostatitis - s/s

A

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]

367
Q

Prostatitis - ix

A

Urine dipstick
Urine MC&S
Chlamydia and gonorrhoea screening

368
Q

Prostatitis - mx

A

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

369
Q

Urinary Incontinence - patho

A

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

370
Q

Overflow Urinary Incontinence - mx

A

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

371
Q

Stress Urinary Incontinence - mx

A

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

372
Q

Urge Urinary Incontinence - mx

A

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

373
Q

Testicular pain - causes

A

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

374
Q

Testicular Torsion - patho

A

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

375
Q

Testicular Torsion - s/s

A

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

376
Q

Testicular Torsion - ix

A

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

377
Q

Testicular Torsion - mx

A

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

378
Q

Epididymo-orchitis - patho

A

Epididymitis - inflammation of epididymis
Orchitis - inflammation of the testicle

Caused by E.coli; chlamydia trachomatis; Neisseria gonorrhoea; mumps

379
Q

Epididymo-orchitis - s/s

A

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]

380
Q

Epididymo-orchitis - ix

A

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

381
Q

Epididymo-orchitis - mx

A

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

382
Q

Testicular Cancer - patho

A

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

383
Q

Testicular Cancer - s/s

A

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

384
Q

Testicular Cancer - ix

A

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

385
Q

Testicular Cancer - mets

A

Common places include lymphatics, lungs, live, brain

386
Q

Testicular Cancer - mx

A

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

387
Q

Causes of Scrotal Lump

A

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

388
Q

Hydrocele - patho

A

a collection of fluid within the tunica vaginalis surrounding the testes

389
Q

Hydrocele - s/s

A

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]

390
Q

Hydrocele - mx

A

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

391
Q

Varicocele - patho

A

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

392
Q

Varicocele - s/s

A

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

393
Q

Varicocele - ix

A

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

394
Q

Varicocele - mx

A

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

395
Q

Epididymal Cyst - patho

A

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

396
Q

Epididymal Cyst - s/s

A

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

397
Q

Epididymal Cyst - mx

A

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

398
Q

Obstructive Uropathy - patho

A

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

399
Q

Obstructive Uropathy - causes

A

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]

400
Q

Obstructive Uropathy - s/s

A

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

401
Q

Obstructive Uropathy - ix

A

Ultrasound KUB can be helpful in diagnosing

402
Q

Obstructive Uropathy - mx

A

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

403
Q

Hydronephrosis - ix and mx

A

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]

404
Q

Erectile Dysfunction - patho

A

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

405
Q

Erectile Dysfunction - causes

A

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

406
Q

Erectile Dysfunction - RF

A

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

407
Q

Erectile Dysfunction - s/s

A

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

408
Q

Erectile Dysfunction - ix

A

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

409
Q

Erectile Dysfunction - mx

A

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

410
Q

Benign Prostatic Hyperplasia - patho

A

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

411
Q

Benign Prostatic Hyperplasia - s/s

A

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

412
Q

Benign Prostatic Hyperplasia - ix

A

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

413
Q

Benign Prostatic Hyperplasia - mx

A

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

414
Q

Priapism - patho

A

involuntary, persistent erection unrelated to sexual stimulation, unrelieved by ejaculation
Urological emergency

low flow [ischaemic] and high flow [non-ischaemic]

415
Q

Priapism - causes

A

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

416
Q

Priapism - s/s

A

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

417
Q

Priapism - ix

A

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

418
Q

Priapism - mx

A

medication
low flow - intracavernosal injection of phenylephrine

surgery
low flow - surgical decompression

others - treat underlying condition

419
Q

Phimosis - patho

A

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

420
Q

Phimosis - s/s

A

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

421
Q

Phimosis - mx

A

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

422
Q

Paraphimosis - patho

A

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

423
Q

Paraphimosis - RF

A

phimosis
indwelling catheter
poor hygiene
prior paraphimosis

424
Q

Paraphimosis - s/s

A

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

425
Q

Paraphimosis - mx

A

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

426
Q

Fournier’s Gangrene - patho

A

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

427
Q

Fournier’s Gangrene - RF

A

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

428
Q

Fournier’s Gangrene - s/s

A

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

429
Q

Fournier’s Gangrene - ix

A

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

430
Q

Fournier’s Gangrene - mx

A

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

431
Q

Acute Urinary Retention - patho

A

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

432
Q

Acute Urinary Retention - causes

A

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]

433
Q

Acute Urinary Retention - s/s

A

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

434
Q

Acute Urinary Retention - ix

A

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

435
Q

Acute Urinary Retention - mx

A

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

436
Q

Chronic Urinary Retention - patho

A

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]

437
Q

Chronic Urinary Retention - s/s

A

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

438
Q

Chronic Urinary Retention - ix

A

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

439
Q

Chronic Urinary Retention - mx

A

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

440
Q

Arterial Insufficiency - patho

A

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

441
Q

Intermittent Claudication

A

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

442
Q

Chronic Severe Ischaemia

A

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

443
Q

Acute-on-chronic Ischaemia

A

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

444
Q

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

A

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

445
Q

‘Diabetic Foot’

A

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

446
Q

‘Diabetic Foot’ infection

A

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

447
Q

Acute DVT - patho

A

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

448
Q

Acute DVT - s/s

A

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

449
Q

Acute DVT - ix

A

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

450
Q

Acute DVT - mx

A

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

451
Q

Peripheral Arterial Disease - patho

A

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

452
Q

Peripheral Arterial Disease - s/s

A

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

453
Q

Peripheral Arterial Disease - ix

A

ABPI
duplex ultrasound
Doppler can be useful
angiography

454
Q

Peripheral Arterial Disease - ALI mx

A

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

455
Q

Peripheral Arterial Disease - Claudication mx

A

not lifestyle-limiting:
antiplatelet therapy [clopidogrel] + exercise + risk factor modification

lifestyle-limiting:
antiplatelet therapy [clopidogrel] + exercise + symptom relief + risk factor modification + consider revascularisation

456
Q

Peripheral Arterial Disease - Critical Limb Ischaemia mx

A

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

457
Q

Varicose Veins - patho

A

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

458
Q

Varicose Veins - s/s

A

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

459
Q

Varicose Veins - ix

A

Duplex ultrasound

460
Q

Varicose Veins - mx

A

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]

461
Q

Abdominal Aortic Aneurysm - patho

A

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

462
Q

Abdominal Aortic Aneurysm - s/s

A

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

463
Q

Abdominal Aortic Aneurysm - screening

A

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

464
Q

Abdominal Aortic Aneurysm - ix

A

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

465
Q

Abdominal Aortic Aneurysm - elective mx

A

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

466
Q

Abdominal Aortic Aneurysm - emergency mx

A

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]

467
Q

Venous Leg Ulcer - s/s

A

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

468
Q

Arterial Leg Ulcer - s/s

A

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

469
Q

Diabetic Leg Ulcer - patho

A

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

470
Q

Leg Ulcer - ix

A

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

471
Q

Arterial Leg Ulcer - mx

A

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

472
Q

Venous Leg Ulcer - mx

A

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]

Year 3 (5 decks)

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