Surgery Flashcards
Peptic ulcer disease:
-Which is most common ulcers?
-Describe the pain felt in duodenal ulcer vs gastric ulcer
-What other features may be seen?
Duodenal ulcers: more common than gastric ulcers, epigastric pain relieved by eating
Gastric ulcers: epigastric pain worsened by eating
Features of upper gastrointestinal haemorrhage may be seen (haematemesis, melena etc)
Appendicitis
-Describe the pain
-Give 3 other features
-What is the clinical sign suggestive of appendicitis?
Pain initial in the central abdomen before localising to the right iliac fossa
Anorexia is common
Tachycardia, low-grade pyrexia, tenderness in RIF
Rovsing’s sign: more pain in RIF than LIF when palpating LIF
Is acute appendicitis common? Who does this most commonly affect? what is the pathogenesis?
Acute appendicitis is the most common acute abdominal condition requiring surgery. It can occur at any age but is most common in young people aged 10-20 years.
Pathogenesis
lymphoid hyperplasia or a faecolith → obstruction of appendiceal lumen → gut organisms invading the appendix wall → oedema, ischaemia +/- perforation
Features of appendicitis:
-Describe the pain?
-Is there vomiting or diarrhoea?
-Is the pyrexia?
-Will the patient be hungry
Abdominal pain is seen in the vast majority of patients:
peri-umbilical abdominal pain (visceral stretching of appendix lumen and appendix is midgut structure) radiating to the right iliac fossa (RIF) due to localised parietal peritoneal inflammation.
the migration of the pain from the centre to the RIF has been shown to be one of the strongest indicators of appendicitis
patients often report the pain being worse on coughing or going over speed bumps. Children typically can’t hop on the right leg due to the pain.
Other features:
-vomit once or twice but marked and persistent vomiting is unusual
diarrhoea is rare. However, pelvic appendicitis may cause localised rectal irritation of some loose stools. A pelvic abscess may also cause diarrhoea
-mild pyrexia is common - temperature is usually 37.5-38oC. Higher temperatures are more typical of conditions like mesenteric adenitis
-anorexia is very common. It is very unusual for patients with appendicitis to be hungry
-around 50% of patients have the typical symptoms of anorexia, peri-umbilical pain and nausea followed by more localised right lower quadrant pain
Give 4 examination findings of acute appendicitis? what are 2 classical signs
Examination
-generalised peritonitis if perforation has occurred or localised peritonism
-rebound and percussion tenderness, guarding and rigidity
-retrocaecal appendicitis may have relatively few signs
-digital rectal examination may reveal boggy sensation if pelvic abscess is present, or even right-sided tenderness with a pelvic appendix
classical signs
-Rovsing’s sign (palpation in the LIF causes pain in the RIF) is now thought to be of limited value
-psoas sign: pain on extending hip if retrocaecal appendix
Diagnosis of appendicitis
-What is seen on bloods?
-What is seen on urinalysis?
-What imaging can be used?
Diagnosis
-typically raised inflammatory markers coupled with compatible history and examination findings should be enough to justify appendicectomy
-a neutrophil-predominant leucocytosis is seen in 80-90%
-urine analysis: useful to exclude pregnancy in women, renal colic and urinary tract infection. In patients with appendicitis, urinalysis may show mild leucocytosis but no nitrites
-there are no definite rules on the use of imaging and its use is often determined by the patient’s gender, age, body habitus and the likelihood of appendicitis
-thin, male patients with a high likelihood of appendicitis may be diagnosed clinically
-ultrasound is useful in females where pelvic organ pathology is suspected. Although it is not always possible to visualise the appendix on ultrasound, the presence of free fluid (always pathological in males) should raise suspicion
-CT scans are widely used in patients with suspected appendicitis in the US but this practice has not currently reached the UK, due to the concerns regarding excessive ionising radiation and resource limitations
Describe the management of appendicitis
Management
-appendicectomy
can be performed via either an open or laparoscopic approach
-laparoscopic appendicectomy is now the treatment of choice
-administration of prophylactic intravenous antibiotics reduces wound infection rates
-patients with perforated appendicitis (typical around 15-20%) require copious abdominal lavage.
-patients without peritonitis who have an appendix mass should receive broad-spectrum antibiotics and consideration given to performing an interval appendicectomy
-be wary in the older patients who may have either an underlying caecal malignancy or perforated sigmoid diverticular disease.
-trials have looked at the use of intravenous antibiotics alone in the treatment of appendicitis. The evidence currently suggests that whilst this is successful in the majority of patients, it is associated with a longer hospital stay and up to 20% of patients go on to have an appendicectomy within 12 months.
Acute pancreatitis
-what is this usually due to
-What 2 symptoms does this cause
-What may be seen on examination?
Usually due to alcohol or gallstones
Severe epigastric pain
Vomiting is common
Examination may reveal tenderness, ileus and low-grade fever
Periumbilical discolouration (Cullen’s sign) and flank discolouration (Grey-Turner’s sign) is described but rare
Give 10 causes of pancreatitis?
Popular mnemonic is GET SMASHED
Gallstones Ethanol Trauma Steroids Mumps (other viruses include Coxsackie B) Autoimmune (e.g. polyarteritis nodosa), Ascaris infection Scorpion venom Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia ERCP Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)
Give 3 clinical features of biliary colic?
-Pain in the RUQ radiating to the back and interscapular region, may be following a fatty meal. Slight misnomer as the pain may persist for hours
-Obstructive jaundice may cause pale stools and dark urine
-It is sometimes taught that patients are female, forties, fat and fair although this is obviously a generalisation
Acute cholecystitis - give 4 clinical features?
History of gallstones symptoms (see above)
Continuous RUQ pain
Fever, raised inflammatory markers and white cells
Murphy’s sign positive (arrest of inspiration on palpation of the RUQ)
What is ascending cholangitis?
Ascending cholangitis is a bacterial infection (typically E. coli) of the biliary tree. The most common predisposing factor is gallstones.
What is charcots triad of ascending cholangitis? What is seen on bloods?
Charcot’s triad of right upper quadrant (RUQ) pain, fever and jaundice occurs in about 20-50% of patients
fever is the most common feature, seen in 90% of patients RUQ pain 70% jaundice 60% hypotension and confusion are also common (the additional 2 factors in addition to the 3 above make Reynolds' pentad)
Other features
raised inflammatory markers
What is the imaging modality used first line for ascending cholangitis?
Investigation
ultrasound is generally used first-line in suspected cases to look for bile duct dilation and bile duct stones
What is the management of ascending cholangitis?
Management
intravenous antibiotics endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction
Diverticulitis:
-describe the nature and the site of pain
-What is seen on blood tests? Is there a pyrexia
Colicky pain typically in the LLQ
Fever, raised inflammatory markers and white
Describe the pain felt in abdominal aortic aneurysm? what may the presentation of this look like? what may be in the past medical history?
Severe central abdominal pain radiating to the back
Presentation may be catastrophic (e.g. Sudden collapse) or sub-acute (persistent severe central abdominal pain with developing shock)
Patients may have a history of cardiovascular disease
What is an AAA? what is the normal diameter of the infrarenal aorta in females vs males? what is considered aneurysmal? what is the pathophysiology of AAA?
Abdominal aortic aneurysms occur primarily as a result of the failure of elastic proteins within the extracellular matrix. Aneurysms typically represent dilation of all layers of the arterial wall. Most aneurysms are caused by degenerative disease. After the age of 50 years the normal diameter of the infrarenal aorta is 1.5cm in females and 1.7cm in males. Diameters of 3cm and greater, are considered aneurysmal. The pathophysiology involved in the development of aneurysms is complex and the primary event is loss of the intima with loss of elastic fibres from the media. This process is associated with, and potentiated by, increased proteolytic activity and lymphocytic infiltration.
Give 5 causes of AAA
Major risk factors for the development of aneurysms include smoking and hypertension. Rare but important causes include syphilis and connective tissues diseases such as Ehlers Danlos type 1 and Marfan’s syndrome.
Give the interpetation and action for each aorta width:
<3cm
3-4.4cm
4.5-5.4cm
=>5.5
Aorta width Interpretation Action
< 3 cm Normal No further action
3 - 4.4 cm Small aneurysm Rescan every 12 months
4.5 - 5.4 cm Medium aneurysm Rescan every 3 months
≥ 5.5cm Large aneurysm Refer within 2 weeks to vascular surgery for probable intervention
Only found in 1 per 1,000 screened patients
When should an AAA be referred urgently within 2 weeks to vascular surgery?
high rupture risk
symptomatic, aortic diameter >=5.5cm or rapidly enlarging (>1cm/year) refer within 2 weeks to vascular surgery for probable intervention treat with elective endovascular repair (EVAR) or open repair if unsuitable. In EVAR a stent is placed into the abdominal aorta via the femoral artery to prevent blood from collecting in the aneurysm. A complication of EVAR is an endo-leak, where the stent fails to exclude blood from the aneurysm, and usually presents without symptoms on routine follow-up.
Intestinal obstruction:
-what may be in the past medical history
-What 2 symptoms will be complained of?
-What will be found oe
History of malignancy/previous operations
Vomiting
Not opened bowels recently
‘Tinkling’ bowel sounds
What 2 factors point towards pregnancy in abdo swelling?
Young female
Amenorrhoea
Give 2 risk factors which would point towards ascites as a cause of abdo swelling?
History of alcohol excess, cardiac failure
What 2 features would be assoc with urinary retention as a cause of abdo swelling?
History of prostate problems
Dullness to percussion around suprapubic area
Give 6 clinical features which would point towards ovarian cancer as a cause of abdominal swelling?
Older female
Pelvic pain
Urinary symptoms e.g. urgency
Raised CA125
Early satiety, bloating
What is a hydatid cyst?
Hydatid cysts are endemic in Mediterranean and Middle Eastern countries. They are caused by the tapeworm parasite Echinococcus granulosus. An outer fibrous capsule is formed containing multiple small daughter cysts. These cysts are allergens which precipitate a type 1 hypersensitivity reaction.
Give 4 clinical features of hydatid cysts?
Clinical features are as follows:
Up to 90% of cysts occur in the liver and lungs Can be asymptomatic, or symptomatic if cysts > 5cm in diameter Morbidity caused by cyst bursting, infection and organ dysfunction (biliary, bronchial, renal and cerebrospinal fluid outflow obstruction) In biliary rupture, there may be the classical triad of; biliary colic, jaundice, and urticaria
What investigations are used for hydatid cysts?
Investigation
imaging
ultrasound if often used first-line
CT is the best investigation to differentiate hydatid cysts from amoebic and pyogenic cysts
serology
useful for primary diagnosis and for follow-up after treatment
wide variety of different antibody/antigen tests available
What is the management of a hydatid cyst?
Surgery is the mainstay of treatment (the cyst walls must not be ruptured during removal and the contents sterilised first).
what is a hernia? Give 4 risk factors?
The classical surgical definition of a hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it.
Risk factors for abdominal wall hernias include:
obesity ascites increasing age surgical wounds
Give 5 features of hernia
Features
palpable lump cough impulse pain obstruction: more common in femoral hernias strangulation: may compromise the bowel blood supply leading to infarction
inguinal hernia:
-Are these common?
-where are these located?
-Is strangulation common?
Inguinal hernias account for 75% of abdominal wall hernias. Around 95% of patients are male; men have around a 25% lifetime risk of developing an inguinal hernia.
Above and medial to pubic tubercle
Strangulation is rare
give 3 clinical features of inguinal hernia
Features
groin lump
superior and medial to the pubic tubercle
disappears on pressure or when the patient lies down
discomfort and ache: often worse with activity,
severe pain is uncommon
strangulation is rare
Describe the management of inguinal hernia
Management
the clinical consensus is currently to treat medically fit patients even if they are asymptomatic
a hernia truss may be an option for patients not fit for surgery but probably has little role in other patients
mesh repair is associated with the lowest recurrence rate
-unilateral inguinal hernias are generally repaired with an open approach
-bilateral and recurrent inguinal hernias are generally repaired laparoscopically
When can a patient return to work after repair of inguinal hernia? what are early and late complications of repair of inguinal hernia?
The Department for Work and Pensions recommend that following an open repair patients return to non-manual work after 2-3 weeks and following laparoscopic repair after 1-2 weeks
Complications
early: bruising, wound infection late: chronic pain, recurrence
Femoral hernia
-Where is this located?
-who is this most commonly found in?
-what is the management and why?
-Below and lateral to the pubic tubercle
-More common in women, particularly multiparous ones
-High risk of obstruction and strangulation
-Surgical repair is required
What is the difference between umbilical and para-umbilical hernia?
Umbilical hernia Symmetrical bulge under the umbilicus
Paraumbilical hernia Asymmetrical bulge - half the sac is covered by skin of the abdomen directly above or below the umbilicus
Descibe where an epigstric hernia is found? what are 3 risk factors?
Lump in the midline between umbilicus and the xiphisternum
Risk factors include extensive physical training or coughing (from lung diseases), obesity
How common are incisional hernia?
May occur in up to 10% of abdominal operations
Spigelian hernia
-What is this AKA
-What is this?
Also known as lateral ventral hernia
Rare and seen in older patients
A hernia through the spigelian fascia (the aponeurotic layer between the rectus abdominis muscle medially and the semilunar line laterally)
What is an obturator hernia?
A hernia which passes through the obturator foramen. More common in females and typical presents with bowel obstruction
What is a richter hernua?
A rare type of hernia where only the antimesenteric border of the bowel herniates through the fascial defect
Richter’s hernia can present with strangulation without symptoms of obstruction
Congenital inguinal hernia
-What is this caused by
-How common is this?
-what is the management?
Indirect hernias resulting from a patent processus vaginalis
Occur in around 1% of term babies. More common in premature babies and boys
60% are right sided, 10% are bilaterally
Should be surgically repaired soon after diagnosis as at risk of incarceration
What is an infantile umbilical hernia? who is this most common in? what is the management?
Symmetrical bulge under the umbilicus
More common in premature and Afro-Caribbean babies
The vast majority resolve without intervention before the age of 4-5 years
Complications are rare
What screening exists for colorectal cancer in the UK?
Overview
most cancers develop from adenomatous polyps. Screening for colorectal cancer has been shown to reduce mortality by 16% the NHS offers home-based, Faecal Immunochemical Test (FIT) screening to older adults
the NHS now has a national screening programme offering screening every 2 years to all men and women aged 60 to 74 years in England, 50 to 74 years in Scotland. Patients aged over 74 years may request screening
how does a FIT test work? Wjhat is the advantage over FOB?
eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post
a type of faecal occult blood (FOB) test which uses antibodies that specifically recognise human haemoglobin (Hb)
used to detect, and can quantify, the amount of human blood in a single stool sample
dvantages over conventional FOB tests is that it only detects human haemoglobin, as opposed to animal haemoglobin ingested through diet
only one faecal sample is needed compared to the 2-3 for conventional FOB tests
whilst a numerical value is generated, this is not reported to the patient or GP, who will instead be informed if the test is normal or abnormal
patients with abnormal results are offered a colonoscopy
What are the rates of cancer found at colonoscopy post a positive FIT test
At colonoscopy, approximately:
5 out of 10 patients will have a normal exam 4 out of 10 patients will be found to have polyps which may be removed due to their premalignant potential 1 out of 10 patients will be found to have cancer
Stomas - give location / appearance / output of ileostomy
Location - RIF
Appearance - spouted
Output - liquid
Stomas - give location / appearance / output of colostomy
Location - varies, more likely on left side
Appearance - flushed
Output - solid
Stomas - give use and common sites of:
gastrostomy
USE:
-Gastric decompression or fixation
-Feeding
Common site:
Epigastrium
Stomas - give use and common sites of:
loop jejunostomy
use:
-Seldom used as very high output
-May be used following emergency laparotomy with planned early closure
Common site:
any location according to need
Stomas - give use and common sites of:
percutaneous jejunostomy
USE:
Usually performed for feeding purposes and site in the proximal bowel
Common site:
Usually left upper quadrant
Stomas - give use and common sites of:
Loop ileostomy
USE:
Defunctioning of colon e.g. following rectal cancer surgery
Does not decompress colon (if ileocaecal valve competent)
Common site:
Usually RIF
Stomas - give use and common sites of:
end ileostomy
USE:
-Usually following complete excision of colon or where ileocolic anastomosis is not planned
-May be used to defunction colon, but reversal is more difficult
Common site:
RIF
Stomas - give use and common sites of:
end colostomy
USE
Where a colon is diverted or resected and anastomosis is not primarily achievable or desirable
SITE
Either left or right iliac fossa
Stomas - give use and common sites of:
loop colostomy
USE
To defunction a distal segment of colon
Since both lumens are present the distal lumen acts as a vent
SITE
May be located in any region of the abdomen, depending upon colonic segment used
Stomas - give use and common sites of:
Caecostomy
USE
Stoma of last resort where loop colostomy is not possible
SITE
Right iliac fossa
Stomas - give use and common sites of:
Mucous fistula
USE
To decompress a distal segment of bowel following colonic division or resection
Where closure of a distal resection margin is not safe or achievable
Common SITE
May be located in any region of the abdomen according to clinical need
Haemorrhoids
-common location
-treatment
Location: 3, 7, 11 o’clock position
Internal or external
Treatment: Conservative, Rubber band ligation, Haemorrhoidectomy
What are haemorrhoids? Give 4 clinical features1
Haemorrhoidal tissue is part of the normal anatomy which contributes to anal continence. These mucosal vascular cushions are found in the left lateral, right posterior and right anterior portions of the anal canal (3 o’clock, 7’o’clock and 11 o’clock respectively). Haemorrhoids are said to exist when they become enlarged, congested and symptomatic
Clinical features
-painless rectal bleeding is the most common symptom
-pruritus
-pain: usually not significant unless piles are thrombosed
-soiling may occur with third or forth degree piles
What is internal vs external haemorrhoid
External
originate below the dentate line
prone to thrombosis, may be painful
Internal
originate above the dentate line
do not generally cause pain
Give the grading of internal haemorrhoids
Grading of internal haemorrhoids
Grade I Do not prolapse out of the anal canal
Grade II Prolapse on defecation but reduce spontaneously
Grade III Can be manually reduced
Grade IV Cannot be reduced
Give 5 management points for haemorrhoids
Management
-soften stools: increase dietary fibre and fluid intake
-topical local anaesthetics and steroids may be used to help symptoms
-outpatient treatments: rubber band ligation is superior to injection sclerotherapy
-surgery is reserved for large symptomatic haemorrhoids which do not respond to outpatient treatments
newer treatments: Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy
Acutely thrombosed external haemorrhoids:
-How do these usually present?
-What is found on examination?
-Describe the management
Acutely thrombosed external haemorrhoids
typically present with significant pain examination reveals a purplish, oedematous, tender subcutaneous perianal mass if patient presents within 72 hours then referral should be considered for excision. Otherwise patients can usually be managed with stool softeners, ice packs and analgesia. Symptoms usually settle within 10 days
Anal fissue
-How does this commonly present
-common site
-what is a chronic fissure?
Typically presents with painful rectal bleeding
Location: midline 6 (posterior midline 90%) & 12 o’clock position. Distal to the dentate line
Chronic fissure > 6/52: triad: Ulcer, sentinel pile, enlarged anal papillae
What are anal fissures?
Give 3 risk factors
Anal fissures are longitudinal or elliptical tears of the squamous lining of the distal anal canal. If present for less than 6 weeks they are defined as acute, and chronic if present for more than 6 weeks.
Risk factors
constipation inflammatory bowel disease sexually transmitted infections e.g. HIV, syphilis, herpes
Give 3 clinical features of rectal fissures?
Features
-painful, bright red, rectal bleeding
-around 90% of anal fissures occur on the posterior midline.
-if the fissures are found in alternative locations then other underlying causes should be considered e.g. Crohn’s disease
Give 4 management points of acute anal fissure
Management of an acute anal fissure (< 1 week)
soften stool
dietary advice: high-fibre diet with high fluid intake
bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried
lubricants such as petroleum jelly may be tried before defecation
topical anaesthetics
analgesia
Give 3 management points for chronic anal fissures
Management of a chronic anal fissure
Continue management as per acute fissure topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure
if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin
Ano rectal abscess
-Common organisms 2
-Give 4 positions
E.coli, staph aureus
Positions: Perianal, Ischiorectal, Pelvirectal, Intersphincteric
Anal fistula
-What is this usually due to?
-give 4 locations
Usually due to previous ano-rectal abscess
Intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric. Goodsalls rule determines location
Rectal prolapse:
-What two things is this assoc with?
Associated with childbirth and rectal intussceception. May be internal or external
Pruritus ani
-What is this most commonly caused by in adults vs children?
Extremely common. In children is often related to worms, in adults may be idiopathic or related to other causes such as haemorrhoids.
What is the commonest anal neoplasm?
Squamous cell carcinoma commonest unlike adenocarcinoma in rectum
solitary rectal ulcer:
-What is this assoc with?
-What is seen on histology?
Associated with chronic straining and constipation. Histology shows mucosal thickening, lamina propria replaced with collagen and smooth muscle (fibromuscular obliteration)
Scrotal swelling:
what are 3 features of inguinal hernia?
If inguinoscrotal swelling; cannot ‘get above it’ on examination
Cough impulse may be present
May be reducible
Scotal swelling - testicular tumours
-what does this feel like?
-what other symptoms may be present?
-What 3 investigations are necessary?
Often discrete testicular nodule (may have associated hydrocele)
Symptoms of metastatic disease may be present
USS scrotum and serum AFP and β HCG required
Acute epididymo-orchitis
Scrotal swellings, epididymal cysts
-What are these?
-When do these occur?
-Is this painful?
-What site do these occur in and what is found on examination?
-Single or multiple cysts
-May contain clear or opalescent fluid (spermatoceles)
-Usually occur over 40 years of age
-Painless
-Lie above and behind testis
-It is usually possible to ‘get above the lump’ on examination
Epididymal cysts:
-Are these common?
-Give 3 associated conditions
-How may this be diagnosed?
-what is the management?
Epididymal cysts are the most common cause of scrotal swellings seen in primary care.
Features
separate from the body of the testicle found posterior to the testicle
Associated conditions
polycystic kidney disease cystic fibrosis von Hippel-Lindau syndrome
Diagnosis may be confirmed by ultrasound.
Management is usually supportive but surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts.
Scrotal swellings, hydrocele
-What does this feel like on examination?
-What other tests can be done at the bedside?
-what may this indicate in young men?
-Non painful, soft fluctuant swelling
-Often possible to ‘get above it’ on examination
-Usually contain clear fluid
-Will often transilluminate
-May be presenting feature of testicular cancer in young men
What is a hydrocele? what is communicating vs non-communicating? What may hydroceles develop secondary to?
A hydrocele describes the accumulation of fluid within the tunica vaginalis. They can be divided into communicating and non-communicating:
communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life non-communicating: caused by excessive fluid production within the tunica vaginalis
Hydroceles may develop secondary to:
epididymo-orchitis testicular torsion testicular tumours
Give 4 features of hydrocele? How is this diagnosed?
Features
-soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
-the swelling is confined to the scrotum, you can get ‘above’ the mass on examination
-transilluminates with a pen torch
-the testis may be difficult to palpate if the hydrocele is large
Diagnosis may be clinical but ultrasound is required if there is any doubt about the diagnosis or if the underlying testis cannot be palpated.
Testicular torsion
-How does this present?
-Who does this typically affect?
-what is found on examination?
-What is the management?
-Severe, sudden onset testicular pain
-Risk factors include abnormal testicular lie
-Typically affects adolescents and young males
-On examination testis is tender and pain not eased by elevation
-Urgent surgery is indicated, the contra lateral testis should also be fixed
What is a varicocele? Where do these most commonly occur? what may this indicate?
-Varicosities of the pampiniform plexus
-Typically occur on left (because testicular vein drains into renal vein)
-May be presenting feature of renal cell carcinoma
-Affected testis may be smaller and bilateral varicoceles may affect fertility
What are varicoceles classically described as?
A varicocele is an abnormal enlargement of the testicular veins. They are usually asymptomatic but may be important as they are associated with infertility.
Varicoceles are much more common on the left side (> 80%). Features:
classically described as a 'bag of worms' subfertility
What is the diagnosis and management of varicocele?
Diagnosis
ultrasound with Doppler studies
Management
usually conservative occasionally surgery is required if the patient is troubled by pain. There is ongoing debate regarding the effectiveness of surgery to treat infertility -A solitary right-sided varicocele requires urgent referral to a urologist
Describe the management of testicular malignancy?
Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour.
Describe the management of epididymal cysts
Epididymal cysts can be excised using a scrotal approach
Describe the management of hydrocele
Management
-infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years
-in adults a conservative approach may be taken depending on the severity of the presentation. Further investigation (e.g. ultrasound) is usually warranted however to exclude any underlying cause such as a tumour
Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated
Testicular cancer:
-is this common?
-How are these categorised?
Testicular cancer is the most common malignancy in men aged 20-30 years. Around 95% of cases of testicular cancer are germ-cell tumours. Germ cell tumours may essentially be divided into:
seminomas non-seminomas: including embryonal, yolk sac, teratoma and choriocarcinoma
Non-germ cell tumours include Leydig cell tumours and sarcomas.
When is the peak incidence of teratomas / seminomas? give 5 risk factors
The peak incidence for teratomas is 25 years and seminomas is 35 years. Risk factors include:
infertility (increases risk by a factor of 3) cryptorchidism family history Klinefelter's syndrome mumps orchitis
Give 4 features of testicular cancer
Features
a painless lump is the most common presenting symptom
pain may also be present in a minority of men
hydrocele
gynaecomastia
-this occurs due to an increased oestrogen:androgen ratio
-germ-cell tumours → hCG → Leydig cell dysfunction → increases in both oestradiol and testosterone production, but rise in oestradiol is relatively greater than testosterone
- leydig cell tumours → directly secrete more oestradiol and convert additional androgen precursors to oestrogens
What are the tumour markers found in germ cell tumours?
Tumour markers in germ cell tumours
seminomas: hCG may be elevated in around 20%
non-seminomas: AFP and/or beta-hCG are elevated in 80-85%
LDH is elevated in around 40% of germ cell tumours
what is the diagnosis and management of testicular cancer?
Diagnosis
ultrasound is first-line
Management
-treatment depends on whether the tumour is a seminoma or a non-seminoma
-orchidectomy
-chemotherapy and radiotherapy may be given depending on staging and tumour type
Describe the prognosis of seminomas and teratomas in testicular cancer
Prognosis is generally excellent
5 year survival for seminomas is around 95% if Stage I 5 year survival for teratomas is around 85% if Stage I
Acute bacterial prostatitis - what is this typically caused by? give 4 risk factors?
Acute bacterial prostatitis is typically caused by gram-negative bacteria entering the prostate gland via the urethra.
Escherichia coli is the most commonly isolated pathogen.
Risk factors for acute bacterial prostatitis include recent urinary tract infection, urogenital instrumentation, intermittent bladder catheterisation and recent prostate biopsy.
Give 3 features of acute bacterial prostatisis? what is found on DRE?
Features
-the pain of prostatitis may be referred to a variety of areas including the perineum, penis, rectum or back
-obstructive voiding symptoms may be present
-fever and rigors may be present
-digital rectal examination: tender, boggy prostate gland
What is the management of acute bacterial prostatitis?
Management
Clinical Knowledge Summaries currently recommend a 14-day course of a quinolone consider screening for sexually transmitted infections
What is the management of chronic prostatitis?
A prolonged course of a quinolone is often recommended. There has been some debate as to whether prostatic massage has improved outcomes, though no conclusive data published to date.
What are 2 risk factors of BPH?
Benign prostatic hyperplasia (BPH) is a common condition seen in older men.
Risk factors
-age
around 50% of 50-year-old men will have evidence of BPH and 30% will have symptoms
around 80% of 80-year-old men have evidence of BPH
-ethnicity: black > white > Asian
BPH LUTS:
-Give 5 voiding symptoms
Voiding symptoms (obstructive):
weak or intermittent urinary flow straining hesitancy terminal dribbling incomplete emptying
BPH LUTS:
-Give 4 storage symptoms
-Give 1 post-micturition symptom
storage symptoms (irritative)
urgency frequency urgency incontinence nocturia
Post-micturition dribbling
Give 3 complications of BPH
complications
urinary tract infection retention obstructive uropathy
What are 5 components of assessment of BPH?
Assessment
dipstick urine
U&Es: particularly if chronic retention is suspected
PSA: should be done if there are any obstructive symptoms, of if the patient is worried about prostate cancer
urinary frequency-volume chart
should be done for at least 3 days
International Prostate Symptom Score (IPSS)
tool for classifying the severity of lower urinary tract symptoms (LUTS) and assessing the impact of LUTS on quality of life
Score 20–35: severely symptomatic
Score 8–19: moderately symptomatic
Score 0–7: mildly symptomatic
Give 6 management options of BPH
Management options
-watchful waiting
-alpha-1 antagonists e.g. tamsulosin, alfuzosin
-5 alpha-reductase inhibitors e.g. finasteride
-the use of combination therapy (alpha-1 antagonist + 5 alpha-reductase inhibitor) was supported by the Medical Therapy Of Prostatic Symptoms (MTOPS) trial and is also supported by NICE: ‘If the man has bothersome moderate-to-severe voiding symptoms and prostatic enlargement’
-if there is a mixture of storage symptoms and voiding symptoms that persist after treatment with an alpha-blocker alone, then an antimuscarinic (anticholinergic) drug such as tolterodine or darifenacin may be tried
-surgery
transurethral resection of prostate (TURP)
BPH - Alpha-1-antagonists:
-How do these work?
-When are these used?
-What are 4 adverse effects?
alpha-1 antagonists e.g. tamsulosin, alfuzosin
decrease smooth muscle tone of the prostate and bladder considered first-line: NICE recommend if moderate-to-severe voiding symptoms (IPSS ≥ 8) improve symptoms in around 70% of men adverse effects: dizziness, postural hypotension, dry mouth, depression
5-alpha-reductase inhibitors:
-How do these work?
-What blood test can this affect?
-what are 4 adverse effects?
-block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH
-indicated if the patient has a significantly enlarged prostate and is considered to be at high risk of progression
-unlike alpha-1 antagonists causes a reduction in prostate volume and hence may slow disease progression. This however takes time and symptoms may not improve for 6 months
-may also decrease PSA concentrations by up to 50%
-adverse effects: erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia
Describe the cut-off for PSA?
Age-adjusted upper limits for PSA were recommended by the PCRMP:
Age PSA level (ng/ml)
50-59 years 3.0
60-69 years 4.0
> 70 years 5.0
However, NICE Clinical Knowledge Summaries currently suggest a different cut-off:
men aged 50-69 years should be referred if the PSA is >= 3.0 ng/ml OR there is an abnormal DRE note this is a lower threshold than the PCRMP 60-69 years limits recommended above
Give 5 factors that may increase PSA?
PSA levels may also be raised by*:
-benign prostatic hyperplasia (BPH)
-prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after treatment)
-ejaculation (ideally not in the previous 48 hours)
-vigorous exercise (ideally not in the previous 48 hours)
-urinary retention
-instrumentation of the urinary tract
Is PSA a good test?
Poor specificity and sensitivity
around 33% of men with a PSA of 4-10 ng/ml will be found to have prostate cancer. With a PSA of 10-20 ng/ml this rises to 60% of men around 20% with prostate cancer have a normal PSA various methods are used to try and add greater meaning to a PSA level including age-adjusted upper limits and monitoring change in PSA level with time (PSA velocity or PSA doubling time)
Give 4 risk factors for prostate cancer?
Prostate cancer is now the most common cancer in adult males in the UK and is the second most common cause of death due to cancer in men after lung cancer.
Risk factors
increasing age obesity Afro-Caribbean ethnicity family history: around 5-10% of cases have a strong family history
Give 4 possible features of prostate cancer
Localised prostate cancer is often asymptomatic. This is partly because cancers tend to develop in the periphery of the prostate and hence don’t cause obstructive symptoms early on. Possible features include:
-bladder outlet obstruction: hesitancy, urinary retention
-haematuria, haematospermia
-pain: back, perineal or testicular
-digital rectal examination: asymmetrical, hard, nodular enlargement with loss of median sulcus
What is the first line investigation for prostate cancer?
The traditional investigation for suspected prostate cancer was a transrectal ultrasound-guided (TRUS) biopsy. However, recent guidelines from NICE have now advocated the increasing use of multiparametric MRI as a first-line investigation.
Give 4 complications of TRUS biopsy?
Complications of TRUS biopsy:
-sepsis: 1% of cases
-pain: lasting >= 2 weeks in 15% and severe in 7%
-fever: 5%
-haematuria and rectal bleeding
How are the results of multiparametric MRI interpreted for those with suspected clinically localised prostate ca
Multiparametric MRI is now the first-line investigation for people with suspected clinically localised prostate cancer.
the results are reported using a 5‑point Likert scale
If the Likert scale is >=3 a multiparametric MRI-influenced prostate biopsy is offered
If the Likert scale is 1-2 then NICE recommend discussing with the patient the pros and cons of having a biopsy.
Describe the management of localised prostate cancer? T1/T2
Localised prostate cancer (T1/T2)
Treatment depends on life expectancy and patient choice. Options include:
-conservative: active monitoring & watchful waiting
-radical prostatectomy
-radiotherapy: external beam and brachytherapy
Descibe the management of localised advanced prostate cancer? T3/T4
Localised advanced prostate cancer (T3/T4)
Options include:
-hormonal therapy
-radical prostatectomy: erectile dysfunction is a common complication
radiotherapy
-external beam and brachytherapy
-patients may develop proctitis and are also at increased risk of bladder, colon, and rectal cancer following radiotherapy for prostate cancer
Management of metastatic prostate cancer:
-Give 6 anti-androgen therapies
-What else can be used?
One of the key aims of treating advanced prostate cancer is reducing androgen levels. A combination of approaches if often used.
Anti-androgen therapy
-synthetic GnRH agonist or antagonists
-interestingly, GnRH antagonists such as degarelix are being evaluated to suppress testosterone while avoiding the flare phenomenon
-bicalutamide
-cyproterone acetate
-abiraterone
-bilateral orchidectomy (used to rapidly reduce testosterone levels)
Chemotherapy with docetaxel
synthetic GnRH agonist or antagonists use in prostate Ca:
-How does this work?
-What is given additionally?
-GnRH agonists: e.g. Goserelin (Zoladex)
-paradoxically result in lower LH levels longer term by causing overstimulation, resulting in disruption of endogenous hormonal feedback systems. The testosterone level will therefore rise initially for around 2-3 weeks before falling to castration leves
-initially therapy is often covered with an anti-androgen to prevent a rise in testosterone - ‘tumour flare’. The resultant stimulation of prostate cancer growth may result in bone pain, bladder obstruction and other symptoms
Bicalutamide in prostate ca treatment: what is this and how does this work?
non-steroidal anti-androgen
blocks the androgen receptor
Cyproterone acetate in Prostate Ca treatment - what is this and how does this work?
Cyproterone acetate
-steroidal anti-androgen
-prevents DHT binding from intracytoplasmic protein complexes
-used less commonly since introduction of non-steroidal anti-androgens
Abiraterone in Prostate Ca treatment
-How does this work?
-Who is this an option for?
abiraterone
-androgen synthesis inhibitor
-option for the treatment of hormone-relapsed metastatic prostate cancer in patients who have no or mild symptoms after androgen deprivation therapy has failed, and before chemotherapy is indicated
How is prognosis predicted in patients with prostate ca?
The Gleason score is used to predict prognosis in patients with prostatic cancer. The grading system is based on the glandular architecture seen on histology following hollow needle biopsy
The most prevalent and the second most prevalent pattern seen are added to obtain a Gleason score. The Gleason grade ranges from 1 to 5 meaning the Gleason score ranges from 2 to 10 (i.e. two values added)
The higher the Gleason score the worse the prognosis
What is balanitis?
Balanitis is inflammation of the glans penis and sometimes extends to the underside of the foreskin which is known as balanoposthitis. There are a number of causes of balanitis and the most common causes are infective (both bacterial and candidal) although there are a number of other autoimmune causes that are important to know. Simple hygiene is a key part of the treatment of balanitis and both improper washing under the foreskin and the presence of a tight foreskin can make balanitis worse. The presentation can either be acute or more chronic and children and adults are affected by the causes differently.
Balanitis due to candida
-Frequency
-Acute or chronic
-Features on assessment
-Occurring in children or adults?
-Management
Very common Acute
Usually occurs after intercourse and associated with itching and white non-urethral discharge
Both
In the case of candidiasis the treatment is with topical clotrimazole which has to be applied for two weeks to fully treat the infection.
Balanitis due to dermatitis (contact or allergic)
-Frequency
-Acute or chronic
-Features on assessment
-Occurring in children or adults?
-Treatmnet
Very common Acute
Itchy, sometimes painful and occasionally associated with a clear non-urethral discharge. Often there is no other body area affected Both
Dermatitis and circinate balanitis are managed with mild potency topical corticosteroids (e.g. hydrocortisone)
Balanitis due to dermatitis (eczema or psoriasis)
-Frequency
-Acute or chronic
-Features on assessment
-Occurring in children or adults?
-Treatmnet
Very common Both
Very itchy but not associated with any discharge and there will be a medical history of an inflammatory skin condition with active areas elsewhere on the body
Both
Dermatitis and circinate balanitis are managed with mild potency topical corticosteroids (e.g. hydrocortisone)
Balanitis due to bacterial infections
-Frequency
-Acute or chronic
-Features on assessment
-Occurring in children or adults?
-Treatment
Common
Acute
Painful and can be itchy with yellow non-urethral discharge and most often due to Staphylococcus spp. Both
Bacterial balanitis is most often due to Staphylococcus spp. or Group B Streptococcus spp. and can be treated with oral flucloxacillin or clarithromycin if penicillin allergic.
Balanitis due to anaerobic infection
-Frequency
-Acute or chronic
-Features on assessment
-Occurring in children or adults?
-Treatment?
Common
Acute
May be itchy but is most associated with a very offensive yellow non-urethral discharge Both
Anaerobic balanitis is managed with saline washing and can also be managed with topical or oral metronidazole if not settling.
Balanitis due to lichen planus
-Frequency
-Acute or chronic
-Features on assessment
-Occurring in children or adults?
Uncommon
Both
May be itchy, the main diagnostic feature is the presence of Wickham’s striae and violaceous papules
More commonly adults
Balanitis due to lichen sclerosus
-Frequency
-Acute or chronic
-Features on assessment
-Occurring in children or adults?
Treatment?
balanitis xerotica obliterans
Rare
Chronic May be itchy, associated with white plaques and can cause significant scarring Both
Lichen sclerosus and plasma cell balanitis of Zoon are managed with high potency topical steroids (e.g. clobetasol). Circumcision can help in the case of lichen sclerosus.
Zoons Balanitis
-Frequency
-Acute or chronic
-Features on assessment
-Occurring in children or adults?
-Treatmnet?
Plasma cell balanitis of Zoon
Rare
Chronic
Not itchy with clearly circumscribed areas of inflammation
Both
Lichen sclerosus and plasma cell balanitis of Zoon are managed with high potency topical steroids (e.g. clobetasol).
Circinate balanitis
-Frequency
-Acute or chronic
-Features on assessment
-Occurring in children or adults?
-Treatment?
Uncommon
Both
Not itchy and not associated with any discharge. The key feature is painless erosions and it can be associated with reactive arthritis
Adults
Dermatitis and circinate balanitis are managed with mild potency topical corticosteroids (e.g. hydrocortisone)
What are the investigations for balanitis?
-The majority of conditions are diagnosed clinically based on the history and physical appearance of the glans penis.
-In the cases of suspected infective causes a swab can be taken for microscopy and culture which may demonstrate bacteria or Candida albicans.
-When there is a doubt about the cause and there is extensive skin change, then a biopsy can be helpful in confirming the diagnosis.
What is the general management of balanitis?
General treatment:
There are three things which form the basis of management of all causes of balanitis; gentle saline washes, ensuring to wash properly under the foreskin, and in the case of more severe irritation and discomfort then 1% hydrocortisone can be used for a short period. When the cause is not clear, these measures can often resolve the condition alone.
Can you get circumcision for religious/cultural reasons with the NHS?
Circumcision has been performed in a variety of cultures for thousands of years. Today it is mainly people of the Jewish and Islamic faith who undergo circumcision for religious/cultural reasons. Circumcision for religious or cultural reasons is not available on the NHS.
Give 3 benefits of circumcision
he medical benefits of routine circumcision remain controversial although some evidence has emerged that it:
reduces the risk of penile cancer reduces the risk of UTI reduces the risk of acquiring sexually transmitted infections including HIV
Give 4 medical indications for circumcision
Medical indications for circumcision
phimosis recurrent balanitis balanitis xerotica obliterans paraphimosis
It is important to exclude hypospadias prior to circumcision as the foreskin may be used in surgical repair. Circumcision may be performed under a local or general anaesthetic.
Give 3 factors of erectile dysfunction that favour an organic cause?
Gradual onset of symptoms
Lack of tumescence
Normal libido
Give 7 factors in erectile dysfunctions that favour a psychogenic cause?
-Sudden onset of symptoms
-Decreased libido
-Good quality spontaneous or self-stimulated erections
-Major life events
-Problems or changes in a relationship
-Previous psychological problems
-History of premature ejaculation
Give 3 risk factors for erectile dysfunction?
Other than increasing age, risk factors include:
cardiovascular disease risk factors: obesity, diabetes mellitus, dyslipidaemia, metabolic syndrome, hypertension, smoking alcohol use drugs: SSRIs, beta-blockers
what investigations should be done for patients who present with erectile dysfunction?
As part of the assessment for erectile dysfunction Clinical Knowledge Summaries (CKS) recommend that all men have their 10-year cardiovascular risk calculated by measuring lipid and fasting glucose serum levels.
Free testosterone should also be measured in the morning between 9 and 11am. If free testosterone is low or borderline, it should be repeated along with follicle-stimulating hormone, luteinizing hormone and prolactin levels. If any of these are abnormal refer to endocrinology for further assessment.
Opinion on testosterone measurement differs between some experts but CKS advises universal measurement of testosterone in men with erectile dysfunction as recommended by the British Society for Sexual Medicine and the European Association of Urology.
Describe the management of erectile dysfunction
PDE-5 inhibitors (such as sildenafil, ‘Viagra’) have revolutionised the management of ED
they should be prescribed (in the absence of contraindications) to all patients regardless of aetiology sildenafil can be purchased over-the-counter without a prescription.
Vacuum erection devices are recommended as first-line treatment in those who can’t/won’t take a PDE-5 inhibitor.
Other points
for a young man who has always had difficulty achieving an erection, referral to urology is appropriate people with erectile dysfunction who cycle for more than three hours per week should be advised to stop
What is priapism?
Priapism is a persistent penile erection, typically defined as lasting longer than 4 hours and is not associated with sexual stimulation. Priapism can be described as either ischaemic or non-ischaemic with both categories having a different pathophysiology. Ischaemic priapism is typically due to impaired vasorelaxation and therefore reduced vascular outflow resulting in congestion and trapping of de-oxygenated blood within the corpus cavernosa. Non-ischaemic priapism is due to high arterial inflow, typically due to fistula formation often either as the result of congenital or traumatic mechanisms.
Who does priapism most commonly affect?
Epidemiology
Age at presentation has a bimodal distribution, with peaks between 5-10 years and 20-50 years of age incidence has been estimated at up to 5.34 per 100,000 patient-years
Give 5 causes of priapism?
Causes
-Idiopathic
-Sickle cell disease or other -haemoglobinopathies
-Erectile dysfunction medication (e.g. Sildenafil and other PDE-5 inhibitors), this also includes intracavernosal injected therapies.
-Other drugs both prescribed (anti-hypertensives, anticoagulants, antidepressants etc) and recreational (specifically cocaine, cannabis and ecstasy).
-Trauma
Describe the presentation of priapism? 5
Patients typically present acutely with:
-A persistent erection lasting over 4 hours
-Pain localised to the penis
-Often a history of either known haemoglobinopathy or use of medications listed above
-Patients may, more rarely, present with either a non-painful erection or an erection that is not fully rigid: these are both suggestive of non-ischaemic priapism.
-History of trauma to the genital or perineal region: also suggestive of non-ischaemic priapism.
Give 4 investigations for priapism
Investigations:
-Cavernosal blood gas analysis to differentiate between ischaemic and non-ischaemic: in ischaemic priapism pO2 and pH would be reduced whilst pCO2 would be increased.
-Doppler or duplex ultrasonography: this can be used as an alternative to blood gas analysis to assess for blood flow within the penis.
-A full blood count and toxicology screen can be used to assess for an underlying cause of the priapism.
-Diagnosis of priapism is largely clinical, with investigations helping to categorise into ischaemic and non-ischaemic as well as assessing for the underlying cause.
Describe the management of priapism
Ischaemic priapism is a medical emergency and delayed treatment can lead to permanent tissue damage and long-term erectile dysfunction.
-If the priapism has lasted longer than 4 hours, the first-line treatment is aspiration of blood from the cavernosa, this is often combined with injection of a saline flush to help clear viscous blood that has pooled.
-If aspiration and injection fails, then intracavernosal injection of a vasoconstrictive agent such as phenylephrine is used and repeated at 5 minute intervals.
-If medical therapy fails then surgical options can be considered.
Non-ischaemic priapism is not a medical emergency and is normally suitable for observation as a first-line option.
Male sterilisation
-What is the failure rate? What needs to be done before the patient can have UPSI
Male sterilisation - vasectomy
-failure rate: 1 per 2,000 - male sterilisation is a more effective method of contraception than female sterilisation
-simple operation, can be done under LA (some GA), go home after a couple of hours
-doesn’t work immediately
-semen analysis needs to be performed twice following a vasectomy before a man can have unprotected sex (usually at 12 weeks)
What are 5 complications of vasectomy? what is the reversal success rate?
complications: bruising, haematoma, infection, sperm granuloma, chronic testicular pain (affects between 5-30% men)
the success rate of vasectomy reversal is up to 55%, if done within 10 years, and approximately 25% after more than 10 years
what is a fibroadenoma of breast? give 5 features? What is the management
-Develop from a whole lobule
-Mobile, firm breast lumps
-12% of all breast masses
-Over a 2 year period up to 30% will get smaller
-No increase in risk of malignancy
Management:
If >3cm surgical excision is usual, Phyllodes tumours should be widely excised (mastectomy if the lesion is large)
Common in women under the age of 30 years
Often described as ‘breast mice’ due as they are discrete, non-tender, highly mobile lumps
give 3 clinical features of breast cysts? what is the management?
-7% of all Western females will present with a breast cyst
-Usually presents as a smooth discrete lump (may be fluctuant)
-Small increased risk of breast cancer (especially if younger)
Cysts should be aspirated, those which are blood stained or persistently refill should be biopsied or excised
Give 4 clinical features of sclerosing adenosis of breast?
(radial scars and complex sclerosing lesions)
What is the management?
-Usually presents as a breast lump or breast pain
-Causes mammographic changes which may mimic carcinoma
-Cause distortion of the distal lobular unit, without hyperplasia (complex lesions will show hyperplasia)
-Considered a disorder of involution, no increase in malignancy risk
-Lesions should be biopsied, excision is not mandatory
Give 3 clinical features of epithelial hyperplasia of breast? what is the management of this?
-Variable clinical presentation ranging from generalised lumpiness through to discrete lump
-Disorder consists of increased cellularity of terminal lobular unit, atypical features may be present
-Atypical features and family history of breast cancer confers greatly increased risk of malignancy
-If no atypical features then conservative, those with atypical features require either close monitoring or surgical resection
Give 3 clinical features of fat necrosis breast? what is the management?
-Up to 40% cases usually have a traumatic aetiology
-Physical features usually mimic carcinoma
-Mass may increase in size initially
Imaging and core biopsy
More common in obese women with large breasts
May follow trivial or unnoticed trauma
Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
Rare and may mimic breast cancer so further investigation is always warranted
Give 4 clinical features of duct papilloma of breast? what is the manageemnt?
-Usually present with nipple discharge
-Large papillomas may present with a mass
-The discharge usually originates from a single duct
-No increase risk of malignancy
Microdochectomy
Local areas of epithelial proliferation in large mammary ducts
Hyperplastic lesions rather than malignant or premalignant
May present with blood stained discharge
What is Fibroadenosis (fibrocystic disease, benign mammary dysplasia) of breast?
Most common in middle-aged women
‘Lumpy’ breasts which may be painful. Symptoms may worsen prior to menstruation
What is mammary duct ectasia?
Dilatation of the large breast ducts
Most common around the menopause
May present with a tender lump around the areola +/- a green nipple discharge
If ruptures may cause local inflammation, sometimes referred to as ‘plasma cell mastitis’
What is benign cyclical mastalgia and give 3 clinical features
Benign cyclical mastalgia is a common cause of breast pain in younger females.
Clinical features
It varies in intensity according to the phase of the menstrual cycle Cyclical mastalgia is not usually associated with point tenderness of the chest wall (more likely to be Tietze's syndrome). The underlying cause is difficult to pinpoint, examination should focus on identifying focal lesions (such as cysts) that may be treated to provide symptomatic benefit.
Describe the management of cyclical mastalgia
Management
-Women should be advised to wear a supportive bra
-Conservative treatments include standard oral and topical analgesia
-flaxseed oil and evening primrose oil are sometimes used but neither are recommended by NICE Clinical Knowledge Summaries
-If the pain has not responded to conservative measures after 3 months, and is affecting the quality of life or sleep, then referral should be considered
-Hormonal agents such as bromocriptine and danazol may be more effective. However, many women discontinue these therapies due to adverse effects.
What does breast cancer characteristically present as? what is pagets disease of breast?
Characteristically a hard, irregular lump. There may be associated nipple inversion or skin tethering
Paget’s disease of the breast - intraductal carcinoma associated with a reddening and thickening (may resemble eczematous changes) of the nipple/areola
How does pagets disease of breast differ from eczema of breast? how is this diagnosed? what is the treatment?
Paget’s disease differs from eczema of the nipple in that it involves the nipple primarily and only latterly spreads to the areolar (the opposite occurs in eczema).
Diagnosis is made by punch biopsy, mammography and ultrasound of the breast.
Treatment will depend on the underlying lesion.
Who is offered screening in breast cancer?
he NHS Breast Screening Programme is offered to women between the ages of 50-70 years. Women are offered a mammogram every 3 years. After the age of 70 years women may still have mammograms but are ‘encouraged to make their own appointments’.
The effectiveness of breast screening is regularly debated although it is currently thought that the NHS Breast Screening Programme may save around 1,400 lives per year.
Referrals for patients with a family history breast cancer - who gets referred if they have 1 first-degree or second-degree relative diagnosed with breast ca?
If the person concerned only has one first-degree or second-degree relative diagnosed with breast cancer they do NOT need to be referred unless any of the following are present in the family history:
age of diagnosis < 40 years bilateral breast cancer male breast cancer ovarian cancer Jewish ancestry sarcoma in a relative younger than age 45 years glioma or childhood adrenal cortical carcinomas complicated patterns of multiple cancers at a young age paternal history of breast cancer (two or more relatives on the father's side of the family)
Which women are offered breast ca screening from a younger age?
Women who are at an increased risk of breast cancer due to their family history may be offered screening from a younger age. The following patients should be referred to the breast clinic for further assessment:
one first-degree female relative diagnosed with breast cancer at younger than age 40 years, or one first-degree male relative diagnosed with breast cancer at any age, or one first-degree relative with bilateral breast cancer where the first primary was diagnosed at younger than age 50 years, or two first-degree relatives, or one first-degree and one second-degree relative, diagnosed with breast cancer at any age, or one first-degree or second-degree relative diagnosed with breast cancer at any age and one first-degree or second-degree relative diagnosed with ovarian cancer at any age (one of these should be a first-degree relative), or three first-degree or second-degree relatives diagnosed with breast cancer at any age
Give 11 risk factors for breast ca?
Predisposing factors
-BRCA1, BRCA2 genes - 40% lifetime risk of breast/ovarian cancer
-1st degree relative premenopausal relative with breast cancer (e.g. mother)
-nulliparity, 1st pregnancy > 30 yrs (twice risk of women having 1st child < 25 yrs)
-early menarche, late menopause
-combined hormone replacement therapy (relative risk increase * 1.023/year of use), -combined oral contraceptive use
-past breast cancer
-not breastfeeding
-ionising radiation
-p53 gene mutations
-obesity
-previous surgery for benign disease (?more follow-up, scar hides lump)
What are 4 common types of breast ca?
Most breast cancers arise from duct tissue followed by lobular tissue, described as ductal or lobular carcinoma respectively. These can be further subdivided as to whether the cancer hasn’t spread beyond the local tissue (described as carcinoma-in-situ) or has spread (described as invasive). Therefore, common breast cancer types include:
-Invasive ductal carcinoma. This is the most common type of breast cancer. To complicate matters further this has recently been renamed ‘No Special Type (NST)’. In contrast, lobular carcinoma and other rarer types of breast cancer are classified as ‘Special Type’
-Invasive lobular carcinoma
-Ductal carcinoma-in-situ (DCIS)
-Lobular carcinoma-in-situ (LCIS)
What is pagets disease of the nipple? what is the likelihood of underlying malignancy?
Paget’s disease of the nipple is an eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer. In half of these patients, it is associated with an underlying mass lesion and 90% of such patients will have an invasive carcinoma. 30% of patients without a mass lesion will still be found to have an underlying carcinoma. The remainder will have carcinoma in situ.
what is inflammatory breast cancer?
Inflammatory breast cancer where cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast. This accounts for around 1 in 10,000 cases of breast cancer.
Describe who warrants USOC breast referral, who should be considered for USOC breast referral and who should be referred non-urgently
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:
aged 30 and over and have an unexplained breast lump with or without pain or aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people:
with skin changes that suggest breast cancer or aged 30 and over with an unexplained lump in the axilla
Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain.
Surgery for breast cancer
-What is the management if there are no palpable lymph nodes at presentation?
-What is the management if there are palpable lumph nodes?
Prior to surgery, the presence/absence of axillary lymphadenopathy determines management:
women with no palpable axillary lymphadenopathy at presentation should have a pre-operative axillary ultrasound before their primary surgery
if negative then they should have a sentinel node biopsy to assess the nodal burden
in patients with breast cancer who present with clinically palpable lymphadenopathy, axillary node clearance is indicated at primary surgery
this may lead to arm lymphedema and functional arm impairment
Give 4 factors of breast cancer that would indicate mastectomy?
-Multifocal tumour
-Central tumour
-Large lesion in small breast
-DCIS >4cm
Give 4 factors of breast cancer that would indicate wide local excision?
-Solitary lesion
-Peripheral tumour
-Small lesion in large breast
-DCIS <4cm
Who is offered radiotherapy after surgical management of breast ca?
Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds. For women who’ve had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes
What hormonal therapy is used in breast cancer and who is given what?
Adjuvant hormonal therapy is offered if tumours are positive for hormone receptors. For many years this was done using tamoxifen for 5 years after diagnosis. Tamoxifen is still used in pre- and peri-menopausal women. In post-menopausal women, aromatase inhibitors such as anastrozole are used for this purpose*. This is important as aromatisation accounts for the majority of oestrogen production in post-menopausal women and therefore anastrozole is used for ER +ve breast cancer in this group.
Important side effects of tamoxifen include an increased risk of endometrial cancer, venous thromboembolism and menopausal symptoms.
What is tamoxifen? Give 4 adverse effects?
Selective oEstrogen Receptor Modulators (SERM)
Tamoxifen is a SERM which acts as an oestrogen receptor antagonist and partial agonist. It is used in the management of oestrogen receptor-positive breast cancer.
Adverse effects
menstrual disturbance: vaginal bleeding, amenorrhoea hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects venous thromboembolism endometrial cancer
What biological therapy is used in patient with breast ca?
The most common type of biological therapy used for breast cancer is trastuzumab (Herceptin). It is only useful in the 20-25% of tumours that are HER2 positive.
Trastuzumab cannot be used in patients with a history of heart disorders.
Describe what aromatase inhibitors are used in breast ca and who is this used in? what are 4 side effect?
Anastrozole and letrozole are aromatase inhibitors that reduces peripheral oestrogen synthesis. This is important as aromatisation accounts for the majority of oestrogen production in postmenopausal women and therefore anastrozole is used for ER +ve breast cancer in this group.
Adverse effects
osteoporosis
NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer
hot flushes
arthralgia, myalgia
insomnia
What cytotoxic therapy is used in patients with breats ca?
Cytotoxic therapy may be used either prior to surgery (‘neoadjuvanant’ chemotherapy) to downstage a primary lesion or after surgery depending on the stage of the tumour, for example, if there is axillary node disease - FEC-D is used in this situation.
Nipple discharge:
what features point to galactorrhoea?
Commonest cause may be response to emotional events, drugs such as histamine receptor antagonists are also implicated
Nipple discharge due to hyperprolactinaemia
-Give 4 features
Commonest type of pituitary tumour
Microadenomas <1cm in diameter
Macroadenomas >1cm in diameter
Pressure on optic chiasm may cause bitemporal hemianopia
Give 4 features of mammary duct ectasia
Dilatation breast ducts.
Most common in menopausal women
Discharge typically thick and green in colour
Most common in smokers
What would point towards carcinoma causing nipple discharge?
Often blood stained
May be underlying mass or axillary lymphadenopath
Nipple dischareg - give 3 features of intraductal papilloma
Commoner in younger patients
May cause blood stained discharge
There is usually no palpable lump
Describe the reporting of investigations for nipple dischagre and a mass lesion is suspected
Where a mass lesion is suspected or investigations are requested these are prefixed using a system that denotes the investigation type e.g. M for mammography, followed by a numerical code as shown below:
1 No abnormality
2 Abnormality with benign features
3 Indeterminate probably benign
4 Indeterminate probably malignant
5 Malignant
Give 4 management points for benign nipple discharge
Exclude endocrine disease
Nipple cytology unhelpful
Smoking cessation advice for duct ectasia
For duct ectasia with severe symptoms, total duct excision may be warranted.
What is mastitis and give 2 clinical features
Mastitis refers to inflammation of the breast tissue and is typically associated with breastfeeding, where it develops in around 1 in 10 women.
Features
painful, tender, red hot breast fever, and general malaise may be present
Describe the management of mastitis?
Management
the first-line management of mastitis is to continue breastfeeding.
simple measures
analgesia
warm compresses
the BNF advises treating 'if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection'
the first-line antibiotic is oral flucloxacillin
for 10-14 day
reflects the fact that the most common organism causing infective mastitis is Staphylococcus aureus
breastfeeding or expressing should continue during antibiotic treatment.
If left untreated, mastitis may develop into a breast abscess. This generally requires incision and drainage.
Is bladder cancer common? Give 2 risk factors
Bladder cancer is the second most common urological cancer. It most commonly affects males aged between 50 and 80 years of age. Those who are current, or previous (within 20 years), smokers have a 2-5 fold increased risk of the disease. Exposure to hydrocarbons such as 2-Naphthylamine increases the risk. Although rare in the UK, chronic bladder inflammation arising from Schistosomiasis infection remains a common cause of squamous cell carcinomas, in those countries where the disease is endemic
What are 3 types of bladder malignancies?
Bladder malignancies
Urothelial (transitional cell) carcinoma (>90% of cases) Squamous cell carcinoma ( 1-7% -except in regions affected by schistosomiasis) Adenocarcinoma (2%)
Urothelial carcinomas may arise as solitary lesions, or may be multifocal, owing to the effect of ‘field change’ within the urothelium. Up to 70% of TCC’s will have a papillary growth pattern. These tumours are usually superficial in location and accordingly have a better prognosis. The remaining tumours show either mixed papillary and solid growth or pure solid growths. These tumours are typically more prone to local invasion and may be of higher grade, the prognosis is therefore worse. Those with T3 disease or worse have a 30% (or higher) risk of regional or distant lymph node metastasis.
how is bladder cancer staged?
TNM
Most will undergo a cystoscopy and biopsies or TURBT, this provides histological diagnosis and information relating to depth of invasion. Locoregional spread is best determined using pelvic MRI and distant disease CT scanning. Nodes of uncertain significance may be investigated using PET CT.
What is the most common presentations of bladder cancer?
Most patients (85%) will present with painless, macroscopic haematuria. In those patients with incidental microscopic haematuria, up to 10% of females aged over 50 will be found to have a malignancy (once infection excluded).
What is the management of bladder ca?
Those with superficial lesions may be managed using TURBT in isolation. Those with recurrences or higher grade/ risk on histology may be offered intravesical chemotherapy. Those with T2 disease are usually offered either surgery (radical cystectomy and ileal conduit) or radical radiotherapy.
What is the prognosis of bladder ca? T1/2/3/4a/any
T1 90%
T2 60%
T3 35%
T4a 10-25%
Any T, N1-N2 30%
Renal cell cancer:
-Is this common
-what is the most common type?
Renal cell cancer is also known as hypernephroma and accounts for 85% of primary renal neoplasms. It arises from proximal renal tubular epithelium. The most common histological subtype is clear cell (75 to 85 percent of tumours).
Give 5 associations of renal cell cancer?
Associations
-more common in middle-aged men
-smoking
-von Hippel-Lindau syndrome
-tuberous sclerosis
-incidence of renal cell cancer is only slightly increased in patients with autosomal dominant polycystic kidney disease
What is the classical triad of renal cell cancer? give 5 other clinical features?
Classical triad:
haematuria loin pain abdominal mass
-pyrexia of unknown origin
endocrine effects
-may secrete erythropoietin (polycythaemia)
-parathyroid hormone-related protein (hypercalcaemia), renin
-ACTH
-25% have metastases at presentation
-paraneoplastic hepatic dysfunction syndrome
varicocele
majority are left-sided
caused by the tumour compressing veins
What is stauffer syndrome in renal cell cancer?
Stauffer syndrome
a paraneoplastic disorder associated with renal cell cancer typically presents as cholestasis/hepatosplenomegaly it is thought to be secondary to increased levels of IL-6
Describe the T categories of renal cell carcinoma?
T category Criteria
T1 Tumour ≤ 7 cm and confined to the kidney
T2 Tumour > 7 cm and confined to the kidney
T3 Tumour extends into major veins or perinephric tissues, but not into the ipsilateral adrenal gland and not beyond Gerota’s fascia
T4 Tumor invades beyond Gerota’s fascia (including contiguous extension into the ipsilateral adrenal gland)
Give 3 management points of renal cell cancer
Management
-for confined disease a partial or total nephrectomy depending on the tumour size
-patients with a T1 tumour (i.e. < 7cm in size) are typically offered a partial nephrectomy
-alpha-interferon and interleukin-2 have been used to reduce tumour size and also treat patients with metatases
-receptor tyrosine kinase inhibitors (e.g. sorafenib, sunitinib) have been shown to have superior efficacy compared to interferon-alpha
Describe the medical and acute management of renal colic
Pain management and medical therapy
both BAUS and NICE recommend an NSAID as the analgesia of choice for renal colic NICE
whilst diclofenac has been traditionally used the increased risk of cardiovascular events with certain NSAIDs (e.g. diclofenac, ibuprofen) should be considered when prescribing
if NSAIDs are contraindicated or not giving sufficient pain relief NICE recommend IV paracetamol
the CKS guidelines suggest for patients who require admission: 'Administer a parenteral analgesic (such as intramuscular diclofenac) for rapid relief of severe pain'
alpha blockers NICE
promote smooth muscle relaxation and dilation of the ureter. potentially easing stone passage
NICE recommend these are considered for distal ureteric stones less than 10 mm in size
BAUS don't formally recommend but do however acknowledge a recently published meta-analysis advocates the use of α-blockers for patients amenable to conservative management, with the greatest benefit amongst those with larger stones
Give 6 initial investigations for renal colic?
Initial investigations
-urine dipstick and culture
-serum creatinine and electrolytes: check renal function
-FBC / CRP: look for associated infection
-calcium/urate: look for underlying causes
-stone analysis should be considered once the stone has passed
-also: clotting if percutaneous intervention planned and blood cultures if pyrexial or other signs of sepsis
what imaging is used in renal colic?
Imaging
non-contrast CT KUB should be performed on all patients, within 24 hours of admission NICE
if a patient has a fever, a solitary kidney or when the diagnosis is uncertain an immediate CT KUB should be performed. In the case of an uncertain diagnosis, this is to exclude other diagnoses such as ruptured abdominal aortic aneurysm
CT KUB has a sensitivity of 97% for ureteric stones and a specificity of 95%
ultrasound should be used for pregnant women and children
the sensitivity of ultrasound for stones is around 45% and specificity is around 90%
What is the management of renal stone?
Renal stones
-watchful waiting if <5mm and asymptomatic
- 5-10mm shockwave lithotripsy
-10-20 mm shockwave lithotripsy OR ureteroscopy
-> 20 mm percutaneous nephrolithotomy
what is the management of ureteric stones?
Uretic stones
-<10mm shockwave lithotripsy +/- alpha blockers
-10-20 mm ureteroscopy
How can calcium renal stones be prevented?
Calcium stones may be due to hypercalciuria, which is found in up to 5-10% of the general population.
high fluid intake add lemon juice to drinking water avoid carbonated drinks limit salt intake potassium citrate may be beneficial NICE thiazides diuretics (increase distal tubular calcium resorption)
How can oxalate renal stones be prevented?
Oxalate stones
cholestyramine reduces urinary oxalate secretion pyridoxine reduces urinary oxalate secretion
How can uric acid renal stones be prevented?
Uric acid stones
allopurinol urinary alkalinization e.g. oral bicarbonate
Give 5 voiding LUTS
Hesitancy
Poor or intermittent stream
Straining
Incomplete emptying
Terminal dribbling
Give 4 storage LUTS
Urgency
Frequency
Nocturia
Urinary incontinence
Give 2 post-micturition LUTS
Post-micturition dribbling
Sensation of incomplete emptying
What is examination and the assessment of a patient presenting with LUTS
Examination
urinalysis: exclude infection, check for haematuria digital rectal examination: size and consistency of prostate a PSA test may be indicated, but the patient should be properly counselled first
It is useful to get the patient to complete the following to guide management:
urinary frequency-volume chart: distinguish between urinary frequency, polyuria, nocturia, and nocturnal polyuria. International Prostate Symptom Score (IPSS): assess the impact on the patient's life. This classifies the symptoms as mild, moderate or severe
Give 5 management points for predominately voiding LUTS
Predominately voiding symptoms
-conservative measures include: pelvic floor muscle training, bladder training, prudent fluid intake and containment products
-if ‘moderate’ or ‘severe’ symptoms offer an alpha-blocker
-if the prostate is enlarged and the patient is ‘considered at high risk of progression’ then a 5-alpha reductase inhibitor should be offered
-if the patient has an enlarged prostate and ‘moderate’ or ‘severe’ symptoms offer both an alpha-blocker and 5-alpha reductase inhibitor
-if there are mixed symptoms of voiding and storage not responding to an alpha blocker then a antimuscarinic (anticholinergic) drug may be added
Give 4 management points for predominately overactive bladder
Predominately overactive bladder
conservative measures include moderating fluid intake bladder retraining should be offered antimuscarinic drugs should be offered if symptoms persist. NICE recommend oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily preparation) mirabegron may be considered if first-line drugs fail
What is the management of nocturia
Nocturia
advise about moderating fluid intake at night furosemide 40mg in late afternoon may be considered desmopressin may also be helpful
Describe the interpretation of ABPI
Interpretation of ABPI
> 1.2: may indicate calcified, stiff arteries. This may be seen with advanced age or PAD 1.0 - 1.2: normal 0.9 - 1.0: acceptable < 0.9: likely PAD. Values < 0.5 indicate severe disease which should be referred urgently
The ABPI is a good test, values less than 0.90 have been shown to have a sensitivity of 90% and a specificity of 98%* for PAD.
Compression bandaging is generally considered acceptable if the ABPI >= 0.8.
What is the management of PAD that is not severe/critical limb ischaemia?
Peripheral arterial disease (PAD) is strongly linked to smoking. Patients who still smoke should be given help to quit smoking.
Comorbidities should be treated, including
hypertension diabetes mellitus obesity
As with any patient who has established cardiovascular disease, all patients should be taking a statin. Atorvastatin 80 mg is currently recommended. In 2010 NICE published guidance suggesting that clopidogrel should be used first-line in patients with peripheral arterial disease in preference to aspirin.
Exercise training has been shown to have significant benefits. NICE recommend a supervised exercise programme for all patients with peripheral arterial disease prior to other interventions.
What is the manageemnt of severe PAD or critical limb ischaemia? What drugs are licensed of PAD?
Severe PAD or critical limb ischaemia may be treated by:
endovascular revascularization
percutaenous transluminal angioplasty +/- stent placement
endovascular techniques are typically used for short segment stenosis (e.g. < 10 cm), aortic iliac disease and high-risk patients
surgical revascularization
surgical bypass with an autologous vein or prosthetic material
endarterectomy
open surgical techniques are typically used for long segment lesions (> 10 cm), multifocal lesions, lesions of the common femoral artery and purely infrapopliteal disease
Amputation should be reserved for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty of bypass surgery.
Drugs licensed for use in peripheral arterial disease (PAD) include:
naftidrofuryl oxalate: vasodilator, sometimes used for patients with a poor quality of life cilostazol: phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects - not recommended by NICE
Give 4 risk factors for varicose veins?
Risk factors
increasing age
female gender
pregnancy
the uterus causes compression of the pelvic veins
obesity
Why may patients present with varicose veins?
For many patients, the cosmetic appearance may prompt presentation. However other patients may complain of symptoms:
aching, throbbing itching
Other patients may present with complications of varicose veins:
a variety of skin changes may be seen: -varicose eczema (also known as venous stasis) -haemosiderin deposition → hyperpigmentation -lipodermatosclerosis → hard/tight skin -atrophie blanche → hypopigmentation
bleeding
superficial thrombophlebitis
venous ulceration
deep vein thrombosis
What is the investigations of varicose veins?
Investigation
venous duplex ultrasound: this will demonstrate retrograde venous flow
Give 4 conservative treatments for varicose veins?
Management
the majority of patients with varicose veins do not require surgery. Conservative treatments include:
leg elevation
weight loss
regular exercise
graduated compression stockings
Give 5 reasons for referral of patients for varicose veins?
reasons for referral to secondary care include:
significant/troublesome lower limb symptoms e.g. pain, discomfort or swelling previous bleeding from varicose veins skin changes secondary to chronic venous insufficiency (e.g. pigmentation and eczema) superficial thrombophlebitis an active or healed venous leg ulcer
Give 3 possible treatments for varicose veins?
possible treatments:
endothermal ablation: using either radiofrequency ablation or endovenous laser treatment foam sclerotherapy: irritant foam → inflammatory response → closure of the vein surgery: either ligation or stripping
What is scheuermann’s disease?
-Who does this affect?
-give 2 symptoms
-What is seen on xray
-What is a clinical feature?
-What is the management?
Epiphysitis of the vertebral joints is the main pathological process
Predominantly affects adolescents
Symptoms include back pain and stiffness
X-ray changes include epiphyseal plate disturbance and anterior wedging
Clinical features include progressive kyphosis (at least 3 vertebrae must be involved)
Minor cases may be managed with physiotherapy and analgesia, more severe cases may require bracing or surgical stabilisation
What is scoliosis? what are the two different types and how can you differentiate? how is this managed?
Consists of curvature of the spine in the coronal plane
Divisible into structural and non structural, the latter being commonest in adolescent females who develop minor postural changes only. Postural scoliosis will typically disappear on manoeuvres such as bending forwards
Structural scoliosis affects > 1 vertebral body and is divisible into idiopathic, congential and neuromuscular in origin. It is not correctable by alterations in posture
Within structural scoliosis, idiopathic is the most common type
Severe, or progressive structural disease is often managed surgically with bilateral rod stabilisation of the spine
What is spina bifida?
-What are 3 categories
-What is the most severe type?
-What is used during pregnancy to reduce the incidence of this?
Non fusion of the vertebral arches during embryonic development
Three categories; myelomeningocele, spina bifida occulta and meningocele
Myelomeningocele is the most severe type with associated neurological defects that may persist in spite of anatomical closure of the defect
Up to 10% of the population may have spina bifida occulta, in this condition the skin and tissues (but not not bones) may develop over the distal cord. The site may be identifiable by a birth mark or hair patch
The incidence of the condition is reduced by use of folic acid supplements during pregnancy
What is spondylolysis? Where does this usually affect?
Congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/ L5
May be asymptomatic and affects up to 5% of the population
Spondylolysis is the commonest cause of spondylolisthesis in children
Asymptomatic cases do not require treatment
Spondylolisthesis - what is this? what may be seen on plain films?
This occurs when one vertebra is displaced relative to its immediate inferior vertebral body
May occur as a result of stress fracture or spondylolysis
Traumatic cases may show the classic ‘Scotty Dog’ appearance on plain films
Treatment depends upon the extent of deformity and associated neurological symptoms, minor cases may be actively monitored. Individuals with radicular symptoms or signs will usually require spinal decompression and stabilisation
Extradural haematoma:
-What is this and what does this often result from?
-Give 2 clinical features
Bleeding into the space between the dura mater and the skull. Often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of epidural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery.
Features
features of raised intracranial pressure some patients may exhibit a lucid interval
Subdural haematoma:
-What is this and where does this most commonly occur?
-Give 3 risk factors
-Give the clinical features
Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes.
Risk factors include old age, alcoholism and anticoagulation.
Slower onset of symptoms than a epidural haematoma. There may be fluctuating confusion/consciousness
Subarachnoid haemorrhage:
-What is the classic symptom?
-What does this usually occur from?
Classically causes a sudden occipital headache. Usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury
Intracerebral haematoma:
-give causes/risk factors
-How do patients present?
-What is seen on CT
-What is the treatment
n intracerebral (or intraparenchymal) haemorrhage is a collection of blood within the substance of the brain.
Causes / risk factors include: hypertension, vascular lesion (e.g. aneurysm or arteriovenous malformation), cerebral amyloid angiopathy, trauma, brain tumour or infarct (particularly in stroke patients undergoing thrombolysis).
Patients will present similarly to an ischaemic stroke (which is why it is crucial to obtain a CT in head in all stroke patients prior to thrombolysis) or with a decrease in consciousness.
CT imaging will show a hyperdensity (bright lesion) within the substance of the brain.
Treatment is often conservative under the care of stroke physicians, but large clots in patients with impaired consciousness may warrant surgical evacuation.
Who gets a CT head within 1 hr post head injury according to NICE?
CT head within 1 hour
GCS < 13 on initial assessment GCS < 15 at 2 hours post-injury suspected open or depressed skull fracture any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign). post-traumatic seizure. focal neurological deficit. more than 1 episode of vomiting
Who gets a CT head within 8 hours post head injury?
CT head scan within 8 hours of the head injury - for adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury:
age 65 years or older any history of bleeding or clotting disorders including anticogulants dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs) more than 30 minutes' retrograde amnesia of events immediately before the head injury
What is the max safe dose of lidocaine?
Lidocaine is the most widely used LA. It has a rapid onset of action and anaesthesia lasts for around 1 hour.
the maximum safe dose is 3mg/kg. The BNF states 200mg (or 500mg if given in solutions containing adrenaline), which equates to 3mg/kg for a 66kg patient. This is the equivalent of 20ml of 1% solution or 10ml of 2% solution lidocaine is available pre-mixed with adrenaline. This increases the duration of action of lidocaine and reduces blood loss secondary to vasoconstriction. It must never be used near extremities due to the risk of ischaemia
Suture material - absorbable or non-absorbable?
Silk
Novafil
Prolene
Ethilon
non-absorbable
Suture material - absorbable or non-absorbable?
Vicryl
Dexon
PDS
Absorbable
How long does it take for sutures to disappear?
Non-absorbable sutures are normally removed after 7-14 days, depending on the location. Absorbable sutures normally disappear after 7-10 days.
What is removal time for sutures on:
Face
Scalp/limbs/chest
Hand/foot/back
Area Removal time (days)
Face 3 - 5
Scalp, limbs, chest 7 - 10
Hand, foot, back 10 - 14
When are patients referred to bariatric surgery?
Obesity - NICE bariatric referral cut-offs
with risk factors (T2DM, BP etc): > 35 kg/m^2 no risk factors: > 40 kg/m^2
What are 3 primarily restrictive types of bariatric surgery?
Primarily restrictive operations
laparoscopic-adjustable gastric banding (LAGB)
it is normally the first-line intervention in patients with a BMI of 30-39kg/m^2
produces less weight loss than malabsorptive or mixed procedures but as it has fewer complications
sleeve gastrectomy
stomach is reduced to about 15% of its original size
intragastric balloon
the balloon can be left in the stomach for a maximum of 6 months
What is the primarily malabsorptive bariatric operation?
Primarily malabsorptive operations
biliopancreatic diversion with duodenal switch
usually reserved for very obese patients (e.g. BMI > 60 kg/m^2)
Which bariatric operation is mixed both malabsorptive and restrictive?
Mixed operations
Roux-en-Y gastric bypass surgery
is both restrictive and malabsorptive in action
VTE prophylaxis:
-How long after elective hip replacement is this advised?
LMWH for 10 days followed by aspirin (75 or 150 mg) for a further 28 days
or
LMWH for 28 days combined with anti-embolism stockings until discharge
or
Rivaroxaban
VTE prophylaxis:
-How long after elective knee replacement is this advised?
Aspirin (75 or 150 mg) for 14 days
or
LMWH for 14 days combined with anti-embolism stockings until discharge
or
Rivaroxaban
VTE prophylaxis:
-How long after fragility fracture of pelvis/hip/proximal femur is this advised?
The NICE guidance states the following (our bolding):
Offer VTE prophylaxis for a month to people with fragility fractures of the pelvis, hip or proximal
femur if the risk of VTE outweighs the risk of bleeding. Choose either:
LMWH , starting 6–12 hours after surgery or fondaparinux sodium, starting 6 hours after surgery, providing there is low risk of bleeding.
VTE prophylaxis: what advice is given to women prior to surgery and to all patients after surgeyr?
Pre-surgical interventions:
Advise women to stop taking their combined oral contraceptive pill/hormone replacement therapy 4 weeks before surgery
Post-surgical interventions:
Try to mobilise patients as soon as possible after surgery Ensure the patient is hydrated
