Surgery Flashcards
Breast Abscess/mastitis
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
inflam of breast 2 types
- Lactational mastitis (10% of nursing mothers 2-4 weeks post partum)
- Non-lactational mastitis
Breast abscess: a localised area of infection with a walled-off collection of pus → main complication of mastitis
RF: breast feeding
CLINICAL FEATURES
- Tender, firm, swollen erythematous breast
- Pain during breastfeeding (also decreased milk outflow) → usually a sharp breast pain
- Flu like symptoms: fever, malaise, chills, myalgia
- Nipple Discharge → purulent discharge is associated with infection
Abscess: fluctuant, tender mass with overlying erythema
INVESTIGATIONS
Breast US to show pus collection
More invasive:
- Diagnostic Needle Aspiration Drainage → purulent fluid indicates a breast abscess
- Fine Needle Aspiration
Breast milk culture to check for infective agent
MANAGEMENT
Uncomplicated: advise to breastfeed with alternative breasts every few hours (continue breastfeeding or effective milk removal). Give analgesics
If pain lasts more than 12-24h or systemic signs need ABx
ABx: flucloxacillin 10-14 days (usually s.aureus)
If MRSA: clindamycin (trimethoprim can be used but not if infant is jaundiced or is less than 2 months)
Breast abscess: needle aspiration, incision and drainage, refer to secondary care if suspect abscess
COMPLICATIONS
- cessation of breast feeding
- abscess
- sepsis
- scarring
- fistula
Prognosis:
When treated promptly and appropriately, most breast infections, including abscess, will resolve without serious complications
Resolution of mastitis after 2-3 days of appropriate antibiotic therapy is expected among most patients
Breast Cyst
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
Awell-definedcollection of fluid within thebreast that is influenced by hormonal changes. Very common accounts for 25% of breast masses
Common in perimenopausal women, usually 35-50 years old
CLINICAL FEATURES
Small discrete, soft, fluctuable swelling
- Single or multiple breast masses
- May be painful or tender
- Variable size & texture
- Usually moveable
INVESTIGATIONS
Breast Ultrasound or Mammography → depending on woman’s age (Ultrasound in younger patients, <35)
see halo appearance on mammography
US confirms fluid filled nature of the cyst
(will be round on both scans, if have jagged edges suspect cancer)
MANAGEMENT
Aspiration, if blood stained or persistently refilling then biopsy or excision
If cyst, large painful and has infection signs: US guided fine needle aspirate
Complex cysts (debris floating inside on scan) that may develop into breast cancer= US guided core needle biospy
2 week wait:
- Age ≥30 with unexplained breast lump with or without pain
- Age ≥50 with discharge, retraction or other concerning changes in 1 nipple only
Routine non-urgent referral to breast clinic
- Age <30 with unexplained breast lump with or without pain
Fibroadenoma
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
A benign breast tumour with fibrous and glandular tissue
Women 15-35 years old and is the most common breast tumour in women under 35
Cause: Unknown but increased oestrogen during pregnancy or menstruation may stimulate growth
No increase in risk of malignancy (unlike cyst)
CLINICAL FEATURES
- Well defined, mobile mass
- Smooth
- Most commonly solitary
- Non-tender
- Rubbery consistency
INVESTIGATIONS
- US <35 years → well defined mass
- Mammography >35 years → well defined mass which may have popcorn like calcifications
More invasive:
Core Needle Biopsy or Fine Needle Aspiration
MANAGEMENT
Regular check up
If over 3cm- surgical excision
Prognosis: good no increased risk of breast cancer
Intestinal Obstruction and Ileus
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
Interruption of normal passage of bowel contents through the bowel, either due to a functional or mechanical obstruction
Functional obstruction (paralytic ileus): Temporary disturbance of peristalsis- common complication after bowel surgery
Mechanical obstruction:
Due to a structural barrier e.g. tumour or adhesions
Can be classified as SBO (80%) or LBO (20%)
SBO causes:
- Adhesions
- Incarcerated hernias
- Gallstones (gallstone ileus)
LBO:
- Malignant tumours e.g. colorectal carcinomas
- Diverticular disease (causes strictures)
- Sigmoid/caecal volvulus
CLINICAL FEATURES
Mechanical:
- Colicky abdo pain
- Vomiting
- Constipation
- Abdo distension- worse in LBO than SBO
- Decreased bowel sounds (may be tympanic/high pitched)
SBO mechanical
- Early onset bilious vomiting
- Tinkling bowel sounds (more common in early bowel obstruction)
LBO:
- Late onset vomiting- may progress to faecal vomiting
- Absolute constipation (not passing wind or faeces)
- History of malignant symptoms like change in bowel habit, rectal bleeding and weight loss
After surgery:
- Adhesions- won’t cause symptoms until months/year after surgery
- Post-operative ileus- may occur sooner
Paralytic ileus vs mechanical
- paralytic has no bowel sounds
- mechanical will have tinkling bowel sounds
INVESTIGATIONS
CTAP with IV contrast- definitive investigation that helps establish cause
Hameodynamically unstable: Erect AXR
- SBO: Distended bowel in middle of abdomen with valvulae conniventes (go all the way across)
- LBO: Distended bowel around outside of abdomen with haustra (don’t go all the way across, only halfway)
Post-op
moitor U+Es as deranged can contibute to postop ielus developing (K, Mg and PO4 check)
U+E after vomiting: to check from hyponatraemia and hypokalameic metabolic alkalosis
Erect CXR to look for pneumoperitoneum
Blood tests for bowel ischaemia:
- Elevated lactate and metabolic acidosis
- Leukocytosis
- Amylase can be raised in SBO (not just pancreatitis)
MANAGEMENT
ABCDE approach
Initial management:
- NBM
- IV fluid resus
- Electrolyte replacement
- Insert NG tube (helps decompress bowel)
Supportive
- antiemetics
- analgesics
If doesnt improve with suck and drip method within 18h, consider surgery. If signs of bowel ischameia like high lactate, abo guarding, tenderness then surgery immediately
Not fit for surgery:
Gastrografin
Definitive treatment
Surgical laparotomy if compplicated bowel obstruction aka strangulation or ischaemic bowel signs
Surgery contraindicated if acute intestinal obstruction with dilated bowel loops
COMPLICATIONS
- bowel ischaemia
- bowel perforation
- peritonitis
Avoid metoclopramide
Surgical site infection
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
Infection that occurs in the incision created by an invasive surgical procedure- major cause of morbidity and mortality.
Following a breach in tissue surfaces allowing normal commensals and other pathogens to initiate infection
20% of all healthcare associated infections and 5% of surgica patients will develop
RF
- Old age
- Poor glucose control
- Obesity
- Smoking
- Renal failure
- Immunosuppression
- Preoperative shaving
- Length of operation
CLINICAL FEATURES
- Spreading erythema
- Localised pain
- Pus or discharge from the wound
- Pyrexia
INVESTIGATIONS
Wound swab
Blood test: chek for infection markers
Blood culture: check for sepsis
Cross- sectional imaging: assess for deeper collections or necrotising fasciitis
MANAGEMENT
Remove any sutures or clips to allow pus to drain + empirical antibiotic therapy
Before surgery:
- Don’t remove body hair routinely (if you do, use electrical clippers instead of razors)
- Antibiotics prophylaxis → if placement of prosthesis or valve
- Patient advice- encourage weight loss, smoking cessation, optimise nutrition, and ensure good diabetic control
During surgery
- Prep skin with alcoholic chlorhexidine
- Cover surgical site with dressing
Testicular torsion
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
Sudden twisting of the spermatic cord- surgical emergency
Results in venous outflow obstruction from testicle leading to arterial occlusion and testicular infarction
Usually: first 30 days of life or during puberty (10-18)
After 6-12 hours theres irreversible damage
Common causes
- Bell clapper deformity (horizontal lie of the testes)
- Cryptorchidism (undescended testes)
2 Types:
- Intravaginal torsion- most common- twisting within the tunica vaginalis
- Extravaginal torsion- usually in neonates
CLINICAL FEATURES
- Sudden onset severe unilateral testicular pain
- Swollen and tender scrotum
- High-riding testicle- Affected testicle may appear higher than unaffected
- Absent cremasteric reflex- diagnostic for testicular torsion- elevation of the testicle and scrotum in response to stroking of the ipsilateral inner thigh (if doesnt contract = testicular torsion)
- Negative Prehn sign- no pain relief on elevation of testes (distinguished between torsion and epidiymitis)
- Nausea and vomiting
- Abdo pain
INVESTIGATION:
1st: Duplex US of scrotum (but dont delay surgery only if in doubt)
- Enlarged scrotum
- Twisting of spermatic cord
- Reduced/absent blood flow to/from affected testes
- Whirlpool sign (spiral like pattern)
Other:
Urinalysis, FBC, CRP- if suspect epidiymitis
MANAGEMENT
Treat within 6 hours
1st: emergency scrotal exploration (radical inginal orchidopexy) to untwist affected testes. Fix both testes
2nd: manual testicular detorsion if surgery not available in 6 hours, or attempt prior for pain relief
Pain relief: morphine
Intemittend: refer for consideration of orchidopexy
COMPLICATIONS
- infarction of testicle
- infertility due to loss of testicle
- cosmetic deformity
- recurrent torsion
PROGNOSIS
from onset, testicle may only survive up to 6 hours. Most testicles salvaged with prompt surgical intervention (quicker the surgery is performed, better the prognosis is)
Varicose Veins
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
Subcutaneous, permanently dilated veins ≥3 mm diameter when measured in standing position
Superficial veins of lower limbs due to reflux in great saphenous vein (travels above medial malleolus and medial thigh) and small saphenous vein (originates from lateral malleolus)
RF:
- increasing age
- family history
- female sex
- increasing numbers of births
- obesity
- occupations with prolonged standing
- deep vein thrombosis
Pathway of formation:
Elevated venous pressure → incompetence of venous valves → reflux of blood back into superficial veins → further elevation of venous pressure → formation of varicose veins
CLINICAL FEATURES
- Dilated tortuous veins- examine patients whilst standing and the skin is examined visually and by palpation for irregularities and bulges consistent with varicose veins
- Leg fatigue or aching- worse with prolonged standing
- Leg cramps
- Restless legs
- Swelling
- Skin changes: varcose eczema (venous stasis), Haemosiderin deposition (brown hyperpigmentation), lipodermatoscleorsis (hard, tight skin then champagne bottle appearacnce of leg), atrophie blanche (hypopigmentation)
INVESTIGATIONS
Duplex US → assesses for reversed flow
- Valve closure time >0.5s is indicative of reflux
- Valve closure time >1s is indicative of reflux in deep system
- Helps localise site of valvular incompetence
MANAGEMENT
Consrvative: frequent leg elevation, compresion stockings, lifestyle change (weight loss and exercise)
Endovascular treatment: endovenous lasar ablation
Surgical : stripping of long saphenous vein
PROGNOSIS
resolution in over 95%
COMPLICATIONS
- chronic venous insufficiency
- venous ulcers
- haemorrhage
Volvulus
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
Twisting of a loop of bowel on its mesentery. Common cause of intestinal obstruction
2 common sites:
1) Sigmoid volvulus (65%): old patients, chronic constipation, chagas disease, neurological conditions (parkinsons), psychiatric conditions (schizo)
2) Caecal volvulus (30%): any age, adhesions, pregnancy
In neonates or infancts: midgut volvulus due to intestinal malrotation
CLINICAL FEATURES
- History of abdo pain- decreases after explosive passage of stool/gas
- Slowly progressive symptoms of bowel obstruction → abdo pain, distensions, bilious vomiting
- Constipation
Bowel ischamia signs:
- Tachycardia
- Hypotension
- Peritonitis (rebound tenderness)
Caecal volvulus
- SBO signs (billous vomiting, tinkiling bowel sounds) and recurrent episodes of RLQ abdo pain
Gastric volvulus
- Failure to pass NG tube
- Epigastric pain
- Vomiting
Midgut volvulus in infants:
- Bilious vomiting
- Haematochezia (fresh blood passing through anus)
- Haematemesis
- Hypotension
- Tachycardia
INVESTIGATIONS
AXR:
- sigmoid volvulus: large bowel obstruction, coffee bean sign (2 dilated loops no haustration, LUQ pain that moves to RUG pain)
- Caecal volvulus: small bowel obstruction may be seen, kidney bean/embryo sign, dilation of 1 loop with haustration near the caecum
CT: whirl sign
Barium enema: birds beak sign
MANAGEMENT
Initial resus:
- IV fluids
- NBM
- Placement of NGT
Sigmoid volvulus: Rigid sigmoidoscopy with rectal tube insertion (detorsion)
Do surgery if signs of peritonism or decompression isnt working :
- Sigmoid colectomy (haemodynamically stable patient with viable bowel)
- Hartmann procedure (haemodynamically unstable patients or those with ischaemic bowel)
Caecal Volvulus:
Operative- right hemicolectomy often needed
Intestinal malrotation: Ladd procure (emergency)
