Surgery Flashcards
What is a Hartmann’s procedure?
Emergency procedure
Resection of the sigmoid colon with an end colostomy.
What is the most appropriate initial action if post-operatively a patient has a urine output of <0.5ml/kg/hr? Why is this?
Consider a fluid challenge (500ml bolus), if there are no contraindications or signs of haemorrhage etc.
Hypovolemia is the most common cause of post-operative oliguria.
What acid-base balance is most associated with prolonged diarrhoea?
Metabolic acidosis associated with hypokalaemia.
DEXA scans: the Z score is adjusted for ……, gender and …… factors
age
ethnic
A high voiding detrusor pressure with a low peak flow rate is indicative of bladder outlet obstruction. Which type of incontinence does this suggest?
Overflow incontinence.
Acute mesenteric ischaemia usually requires an ……., particularly if signs of advanced …….. e.g. peritonitis or sepsis
immediate laparotomy
ischaemia
What imaging is required to diagnose a bowel perforation?
Erect CXR
What is the investigation of choice for suspected achilles tendon rupture?
Ankle USS
How are Renal Cell Carcinomas classified and then managed?
Category Criteria
T1 Less than or equal to 7 cm and confined to the kidney
T2 Over 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 Tumour invades beyond Gerota’s fascia
The management of RCC depends on the T category. T1 tumours are treated with a partial nephrectomy, and T2 with radical nephrectomy (as in this case). T3 and T4 tumours are typically managed surgically with a radical nephrectomy if resectable. Systemic therapies like tyrosine kinase inhibitors are considered for metastatic or unresectable RCC. RCC is typically resistant to radiotherapy and chemotherapy, so these play no role in the management of RCC.
What size parameters require the removal of a fibrodenoma?
> 3cm
Transjugular Intrahepatic Portosystemic Shunt commonly causes an exacerbation of ………………..
hepatic encephalopathy
(Transjugular Intrahepatic Portosystemic Shunt causes blood from the portal system to bypass the liver and enter the systemic circulation without the metabolism of nitrogenous waste products such as ammonia. As these build up in the systemic circulation, increased ammonia is able to cross the blood brain barrier resulting in hepatic encephalopathy.)
What is the most common type inherited colorectal cancer
Lynch syndrome
Hereditary Non-polyposis Colorectal Carcinoma
When is propranolol given in the context of variceal bleeding?
After endoscopic band ligation to reduce bleeding.
Which two medications should be administered before endoscopic band ligation for a patient with variceal bleeding?
IV Terlipressin
Prophylactic antibiotics.
How are liver abscesses commonly managed?
Image-guided drainage and intravenous antibiotics.
What mode of imaging is firstline for a suspected bowel perforation?
Erect CXR
Where is venous ulceration most commonly observed?
Above the medial malleolus
How is necrotising fascitis managed?
Immediate IV antibiotics and surgical debridement.
Kidney stones are an example of a cause of an upper urinary tract obstruction: Name 5 more.
Tumours compressing the ureters
Bladder cancer
Ureteric strictures
Retroperitoneal fibrosis
Ureterocele
Ureterocele: ballooning of the most distal protion of the ureter
BPH is an example of a cause of a lower urinary tract obstruction: Name 4 more.
Prostate cancer
Bladder cancer
Urethral strictures
Neurogenic bladder
What can cause a neurogenic bladder?
Parkinson’s Disease
Multiple Sclerosis
Diabetes
Stroke
Brain or spinal cord injury
Spina bifida
Pain is a complication of untreated obstructive uropathy: Name 6 more.
AKI - post-renal
CKD
Infection
Hydronephrosis
Urinary retention and bladder distention
Overflow incontinence of urine
What is the pathology behind idiopathic hydronephrosis?
How is it treated?
Narrowing of the pelviureteric junction (renal pelvis meeting ureter) - congenital or develop later.
Pyeloplasty.
What are the two treatment options for hydronephrosis?
Percutaneous nephrostomy
Antegrade ureteric stent
Urinary rentention and output monitoring are two indications for urinary catheter insertion: Name 4 more.
Neurogenic bladder
Surgery - during and after
Bladder irrigation
Delivery of medications (e.g. chemotherapy for bladder cancer)
What is the score that is used to assess the severity of LUTS?
International prostate symptom score (IPSS)
Prostate cancer and BPH are two common causes of raised PSA: Name 4 more.
Prostatitis
Recent ejaculation or prostate stimulation
Urinary tract infections
Vigorous exercise
What medications are used to treat BPH?
What do they do?
Alpha blockers (alpha-1 antagonists) - relax smooth muscle sx management
5-alpha reductase inhibitors - gradually reduce the size of the prostate
What are the surgical options for treatment of BPH?
Transurethral Resection of the prostate (TURP)
Transurethral electrovaporisation of the prostate
Holmium laser enucleation of the prostate
Open prostatectomy
Bleeding and infection are two complications of a TURP: Name 5 more.
Urinary incontinence
Erectile dysfunction
Retrograde ejaculation
Urethral strictures
Failure to resolve symptoms
What is proctitis?
How might a patient present with this?
What treatment option can cause this as a complication?
Inflammation of the rectum.
Rectal discomfort, increased bowel movement frequency, and rectal bleeding, along with tenderness in the rectal area and upon examination of the anterior rectal wall.
Radiotherapy for prostate cancer.
Which types of testicular cancer have a raised AFP and Beta HCG and in which testicular cancers are they normal?
Raised: Teratomas and Yolk Sac tumours
Normal: Seminoma
What is the firstline investigation for a man presenting with new erectile dysfunction?
Serum testosterone levels.
What medication can be prescribed to prevent the formation of calcium oxalate stones?
Potassium citrate.
What is the most common causative organism for epididymo-orchitis in younger men?
Chlamydia Trachomatitis
What is the firstline investigation for suspected prostate cancer?
Multiparametric MRI
What causes the formation of varicose veins?
When the valve in the peforator vein between the deep and superficial veins is incompetent - this means that blood flows back into the superficial veins from the deep veins and overloads the superficial veins.
What diameter does a superficial vein need to be in order to term it a varicose vein?
Over 3mm
What are the clinical signs of chronic venous insufficiency?
Haemosiderin staining (broken down Hb).
Venous eczema
Lipodermatosclerosis (tight and fibrosed skin).
Atrophie blanche (white scar patches)
Female and pregnancy are two risk factors for the development of varicose veins: Name 5 more.
Increasing age
Family history
Obesity
Prolonged standing
DVT
How might a patient with varicose veins present?
Asymptomatic
Heavy legs
Aching
Burning
Itching
Restless legs
Muscle aches
Oedema
What tests can be done to determine whether a patient has varicose veins?
Tap test
Cough test
Trendelenburg’s test
Perthes test
Duplex USS
What are the conservative management options for varicose veins?
Weight loss
Exercise
Leg elevation
Compression stockings
What test MUST be carried out before giving a patient compression stockings for the treatment of varicose veins and why?
ABPI to check for any arterial disease. As using compression stockings on these patients will further reduce the blood flow and could result in necrosis of the leg.
What are the surgical options for the treatment of varicose veins?
Endothermal ablation
Sclerotherapy
Stripping
What complications can arise from having varicose veins?
Heavy bleeding following trauma.
Superficial thrombophlebitis
Deep vein thrombosis
Skin changes and ulcers that are associated with chronic venous insufficiency
Other than:
Venous eczema
Haemosiderin staining
Lipodermatosclerosis
Atrophie Blanche
What are some other problems that can arise with chronic venous insufficiency?
Cellulitis
Venous ulceration
Poor healing
Pain
What are the aims of managing chronic venous insufficiency and what are the ways of achieving these?
- Keeping skin healthy
- Avoiding damage, emollients, topical steroids for flares of venous eczema, potent topical steroids for flares of lipodermatosclerosis. - Improving venous return
- Weight loss, exercise, leg elevation, compression stockings. - Managing Complications
- Abx for infection, analgesia and wound care for ulceration.
What are the risk factors for carotid artery stenosis?
Age
Male
Smoking
Lack of exercise
High cholesterol
Hypertension
Poor diet
What are the main complications of carotid artery stenosis?
TIA
Stroke
How is carotid artery stenosis classified?
Mild - less than 50%
Moderate - 50-69%
Severe - more than 70%
What are the non-surgical management options for patients with carotid artery stenosis?
Exercise and healthy eating
Lipid lowering medications (statin therapy)
Antiplatelet therapy
Smoking cessation
Management of co-morbidities
What are the surgical management options for patients with carotid artery stenosis?
Carotid endartectomy
Angioplasty and stenting (increase in likelihood of future events)
What nerves are at risk during a carotid endartectomy and what deficit would this cause?
Facial - facial weakness
Glossopharyngeal - swallowing difficulties
Recurrent laryngeal - hoarse voice
Hypoglossal - unilateral tongue paralysis
What is Beurgers disease?
A type of vasculitis that causes the formation of thrombus in the small and medium-sized vessels of the distal arteries (hands and feet).
How would a patient with Beurgers disease normally present?
Classical presentation is a young man between 25-35 that smokes and has noticed that the tips of his fingers or toes have become painful and have a blue discolouration.
What are the management options for Beurgers?
Stop smoking (partially stopping does not have the desired effect)
IV iloprost can be used (dilate the blood vessels)
What are the complications that can occur if Beurgers disease is not treated?
Ulcers
Gangrene
Amputation
What are the 4 different types of ulcer?
Pressure ulcers
Neuropathic ulcers
Arterial ulcers
Venous ulcers
What investigations are done for a patient presenting with a suspected ulcer?
ABPI
Blood tests - FBC (anaemia or infection), CRP, albumin (malnutrition), HbA1c (diabetes).
Skin swab if infection is suspected
Skin biopsy if skin cancer is suspected.
What is the managment for an arterial ulcer?
Urgent referral to vascular for revascularisation.
The ulcer should heal after the blood flow is restored - NO debridement or compression stockings.
What is the management for a venous ulcer?
Potential referral to vascular if mixed ulcer is suspected.
Pain clinic referral
Tissue viability clinic
Derm referral if cancer suspected
Compression stockings
District nurses clean and debride the wound
Antibiotics for any infection
Analgesia for the pain
What is lymphoedema and what are the types?
Impairment of the drainage of the lymphatic system causing a build-up of lymph.
Primary: Rare, genetic condition normally presenting before 30 which is a result of faulty development of the lymphatic system.
Secondary: Develops later due to a surgical intervention, such as, removal of lymph nodes in a patient with breast cancer.
How is a patient with suspected lymphoedema assessed?
Stemmer’s sign: pinching the skin of the middle finger or toe to see if there is tenting - if there is not tenting then Stemmer’s sign is positive and suggestive of lymphoedema.
Limb volume measurement: circumference, water displacement or perometry.
Bioelectric impedence spectrometry
Lymphoscintography
What are the non-surgical management options for a patient with lymphoedma?
Weight loss
Massage techniques
Specific exercises
Good skin care
Compression stockings
What is the main surgical managment option for a patient with lymphoedema?
Lymphaticovenular anastomosis (attachment of lymphatic vessels to veins to allow lymph to drain through the venous system).
What is lymphatic filariasis?
An infectious disease caused by parasitic worms and spread by mosquitos that can cause severe lymphoedema - most common in Africa and Asia.
What are the three types of peripheral arterial disease?
Intermittent claudication - pain on exertion and relief on rest.
Critical limb ischaemia - pain at rest, ulcers and gangrene.
Acute limb ischaemia - rapid ischaemia in the limb caused by a thrombus.
Older age, family history and male gender are the non-modifiable risk factors for development of atherosclerosis, what are the modifiable risk factors?
Smoking
Alcohol
Poor diet
No exercise
Poor sleep
Stress
Obesity
Hypertension is associated with the development of atherosclerosis: Name 4 other co-morbidities that are associated with atherosclerosis.
Inflammatory conditions e.g. rheumatoid arthritis
Diabetes
CKD
Mental health - atypical antipyschotic medications
What are the potential complications of untreated atherosclerosis?
MI
Stroke
Chronic mesenteric ischaemia
Peripheral arterial disease
TIA
Angina
What are the 6 Ps of acute limb ischaemia?
Pallor
Painful
Pulselessness
Paraesthesia
Paralysis
Perishingly cold
What is Leriche syndrome?
Occlusion in the distal aorta or proximal common ialiac artery resulting in a triad of:
- Thigh or buttock claudication
- Impotence (male)
- Absent femoral pulse
What is Buerger’s Test?
Used to assess for peripheral arterial disease in the leg
1. Lif the patients legs whilst they are lying flat to the angle of 45 degrees one at a time. They should be held there for 1-2 minutes and you are looking for pallor - the angle that the legs begin to go pale due to inadequate blood supply is buergers angle.
2. Once the first part is complete the patient then must sit with their legs hanging over the edge of the bed - their legs will initially go blue and then dark red if they have PAD.
How is intermittent claudication managed?
Lifestyle changes
Exercise training
Atorvastatin 80mg , clopidogrel 75mg and 5-HT2 antagonists (peripheral vasodilation)
Surgical: Endovascular angioplasty and stenting, endartectomy or bypass surgery.
How is critical limb ischaemia managed?
Surgically ASAP to attempt revascularisation of the leg.
If this is not possible then amputation may need to be done.
How is acute limb ischaemia managed?
Initially analgesia, IV heparin and urgent vascular review
Surgically:
- Endovascular thrombolysis or thrombectomy
- Open thrombolysis or thrombectomy
- Endartectomy
- Bypass surgery
- Amputation
What is ABPI and what do the results mean?
Ratio of the systolic blood pressure in the ankle to the systolic blood pressure in the arm.
0.9-1.3 = normal
0.6-0.9 = mild PAD
0.3-0.6 = moderate to severe PAD
<0.3 = severe critical limb ischaemia
more than 1.3 = calcification indicative of diabetes
Immobility and recent surgery are two risk factors for the development of a DVT: Name 7 more.
Hormone therapy with oestrogen
Malignancy
Polycythaemia
Pregnancy
Long haul travel
SLE
Thrombophilias
Apart from a DVT what else can cause a raised d-dimer?
Pneumonia
Malignancy
Heart failure
Surgery
Pregnancy
How long should patients continue with anticoagulation after a DVT?
Provoked - 3 months
Unprovoked - 3-6 months
Cancer - until treatment for cancer has finished
When should an inferior vena cava filter be used?
In patients with recurrent VTE without a reversible or known cause.
How are AAA’s classified?
Under 3cm = normal
3-4.4cm = small aneurysm
4.5-5.4cm = medium aneurysm
Over 5.5cm = large aneurysm
What is the screening programme for AAA in men? When can women be screened?
ALL Men over 65 have an USS of the abdominal aorta.
Men with an aneurysm 3-4.4cm are screened annually.
Men with an aneurysm 4.4-5.4cm are screened every 3 months.
Women over 70 with relevant risk factors can be screeened.
What are the indications for an elective repair of an AAA?
Symptomatic
Growing over 1cm per year.
Over 5.5cm
What are the surgical options for repair of an AAA?
Open repair (via laparotomy)
Endovascular repair (EVAR)
Between what layers does the blood normally gather in an aortic dissection?
Intima and media
What are the two classification systems for aortic dissection?
Stanford and DeBakey
Stanford:
- Type A - ascending aorta
- Type B - descending aorta
DeBakey:
- Type 1 - ascending aorta and can involve the whole aorta
- Type 2 - ascending aorta only
- Type 3a - descending aorta involving only above the diaphragm
- Type 3b - descending aorta involving both above and below the diaphragm
Hypertension is the biggest risk factor for aortic dissection: Name other risk factors (conditions, procedures, lifestyle).
Heavy weight lifting
Use of cocaine
Aortic valve replacement
CABG
Bicuspid aortic valve
Coarctation of the aorta
Ehler’s danlos
Marfans
What investigations are carried out for a suspected aortic dissection?
CT angiogram - firstline
ECG and CXR can be done to exclude other causes (MI can occur alongside dissection)
Bedside USS can be used to look for aortic dissection in A&E
Other than sudden onset ripping and tearing pain, what are the other features that a patient with an aortic dissection may present with?
Hypertension
Differences in blood pressure between the arms (more than 20mmHg)
Radial pulse deficit
Diastolic murmur
Focal neurological defect
Chest and abo pain
Collapse
Hypotension as the dissection progresses
What is the management of an aortic dissection?
Type A: open surgical repair and possible aortic valve replacement
Type B: if haemodynamically stable manage with medication to lower the blood pressure (beat blockers), if it is a complicated dissection then thoracic endovascular aortic repair can be done (TEVAR).
What complications can arise if aortic dissection is left untreated?
MI
Stroke
Cardiac tamponade
Aortic rupture
Paraplegia
Aortic valve regurgitation
Death
How is superficial thrombophlebitis managed?
Compression stockings (after checking ABPI).
For a patient with critical limb ischaemia when is open repair preferred to angioplasty and stenting?
When the lesion is multi-focal/long segment lesions
What is the firstline investigation for a patient with suspected acute limb ischaemia?
Handheld doppler to confirm absence of pulses.
At what length does short segment stenosis become long segment?
10cm
Coarctation of the aorta may occur due to the remnant of the …………………………. acting as a fibrous constrictive band of the aorta. Weak ………… pulses may be seen, ……………………… delay is the classical physical finding. Collateral flow through the intercostal vessels may produce …………………… of the ribs, if the disease is long standing.
ductus arteriosus
arm
radiofemoral
notching
Patients with long saphenous vein superficial thrombophlebitis should have an ultrasound scan to exclude an underlying ………….
DVT
An aneurysm is defined as a persistent abnormal dilatation of an artery to ……… times its normal diameter.
1.5
What are the causes of a thoracic aortic aneurysm?
The main causes of thoracic aneurysm are:
- Connective tissue diseases (e.g. Marfan’s syndrome or Ehlers-Danlos syndrome)
- Bicuspid aortic valve
Other causes include trauma, aortic dissection, aortic arteritis (e.g. Takayasu Arteritis), and tertiary syphilis
What determines the location of the pain experiened with a thoracic aortic aneurysm?
In those that are symptomatic, the most common presenting symptom is chest pain, depending on the location of the anuerysm:
Ascending aorta – anterior chest pain
Aortic arch – neck pain
Descending aorta – posterior thoracic pain
Arterial bowel ischaemia will initially show on CT imaging as ………………. bowel, secondary to the ischaemia and vasodilatation, before progressing to a loss of bowel wall enhancement and then to …………………..
In addition, the CT scan should highlight an acute occlusion of typically the …………………………. artery or ………………… artery with a …………… sign around the occlusion.
oedematous
pneumatosis
superior mesenteric
coeliac
halo
What should be done for a patient with a diagnosis of acute mesenteric ischaemia?
Ensure the patient receives intravenous fluids, a urinary catheter inserted, and a fluid balance chart started. For confirmed cases, broad-spectrum antibiotics should be given, due to the risk of faecal contamination in case of perforation of the ischaemic (and potentially necrotic) bowel and bacterial translocation.
What are the definitive management options for a patient with acute mesenteric ischaemia?
Excision of the necrotic bowel.
Revascularisation.
What are the main complications of acute mesenteric ischaemia?
Bowel necrosis
Perforation
Short gut syndrome
What are the classical sx associated with chronic mesenteric ischaemia?
The classical set of symptoms associated with chronic mesenteric ischaemia are:
- Postprandial pain – classically occurring around 10mins-4hrs after eating
- Weight loss – a combination of decreased calorie intake and malabsorption
- Concurrent vascular co-morbidities, e.g. previous MI, stroke, or PVD
What is the diagnostic investigation of choice for suspected chronic mesenteric ischaemia?
CT angiography
Where are pseudoaneurysms most common?
Femoral artery
(may also occur in the radial artery)
What are the common causes for a pseudoaneurysm?
They typically occur following damage to the vessel wall, such as puncture following cardiac catheterisation or repeated injections to the vessel (e.g. from intravenous drug use (IVDU)); other causes include trauma, regional inflammation, or vasculitis.
What is the gold standard investigation for a suspected pseudoaneurysm?
What will this show?
Duplex USS
Turbulent blood flow forwards and backwards.
What investigations should be done for a suspected infected pseudoaneurysm?
- FBC
- Blood culture
- Pus MC&S
- Group and Save
- Crossmatch (high risk of rupture)
How are pseudoaneurysms managed?
Smaller pseudoaneurysms can be left alone if they are not at high risk for rupture or causing any troublesome sx.
Larger pseudoaneurysms will have ultrasound-guided compression or thrombin injection.
Infected pseudoaneurysms require surgical ligation.
Where are the most common locations for peripheral artery aneurysms?
Femoral and popliteal arteries.
When should an asymptomatic popliteal aneurysm be treated?
What are the treatment options?
When they are greater than 2.5cm
Endovascular repair
Open repair - ligation or bypass
What is the most common type of visceral aneurysm?
Splenic artery aneurysm.
What are the main risk factors for development of a splenic artery aneurysm?
- female sex
- multiple pregnancies
- portal hypertension
- pancreatitis or pancreatic pseudocyst formation.
How may a patient with a splenic artery aneurysm present?
Those that are symptomatic will present with a vague epigastric or left upper quadrant abdominal pain.
Those that rupture will present with severe abdominal pain and haemodynamic compromise.
What is the main investigation done for a suspected splenic artery aneurysm?
CT or MR angiography
How might a patient with a hepatic artery aneurysm present?
Most cases are usually asymptomatic, yet stable symptomatic cases can often present with vague RUQ or epigastric pain; jaundice can less commonly occur if there is any biliary obstruction.
How might a patient with a renal artery aneurysm present?
Patients may present with haematuria, resistant hypertension, or loin pain (including those with renal infarction).
Where does the brachial plexus become compressed in thoracic outlet syndrome?
Which nerve distribution is normally affected?
The brachial plexus can be compressed between the anterior and middle scalene muscles, or against the 1st rib or a cervical rib; typically, it is the lower cord which becomes irritated (resulting in symptoms affecting the ulnar distribution).
What sx may a patient with thoracic outlet syndrome experience?
Neuro, Venous and Arterial
Compression of the brachial plexus can cause paraesthesia and/or motor weakness, which is often in the ulnar distribution; there may be muscle wasting, and pain can radiate to the neck and upper part of the back
Venous compression can lead to deep vein thrombosis and extremity swelling (termed Paget-Schrötter syndrome); in untreated severe cases, there can be prominent veins over the shoulder due to collateralisation
Arterial compression can cause claudication symptoms or acute limb ischaemia through either occlusion, distal embolisation, or aneurysm formation
What investigations should be done for a patient with suspected thoracic outlet syndrome?
Blood tests - FBC and clotting
CXR - to assess for any abnormalities in the ribs or other structures.
Venous or Arterial duplex USS - suspected arterial or venous involvement
Nerve conduction studies - suspected nerve compression
How can TOS be managed?
Neuro = Physio +/- botulinum toxin injections
Venous = thrombolysis and anticoagulation, most cases will also need surgical decompression.
Arterial = urgent vascular review (due to acute limb ischaemia) and possible embolectomy
What are the possible complications of surgery for TOS?
Complications of TOS surgery include:
- the neurological or vascular damage
- haemothorax
- pneumothorax
- chylothorax (particular on the left, the thoracic duct is within the thoracic outlet can is at risk of damage).
What is subclavian steal syndrome?
Subclavian steal is secondary to a proximal stenosing lesion or occlusion in the subclavian artery, typically on the left.
In order to compensate for the increased oxygen demand in the arm, blood is drawn from the collateral circulation, which results in reversed blood flow in the ipsilateral vertebral artery (or less commonly the internal thoracic artery).
How is SSS managed surgically?
Occlusions may be treated either through endovascular or bypass techniques, although these have risks of stroke and damage to the brachial plexus.
Use of percutaneous angioplasty ± stenting has reported success rates upwards of 90%, albeit with higher rate of restenosis with worsening disease severity.
Use of bypass should be considered for longer or distal occlusions; options include carotid-subclavian bypass (5 year patency rates reported at 80%) or axillo-axillary bypass.
What are the some of the causes for secondary hyperhidrosis?
- Pregnancy or menopause
- Anxiety
- Infections: Including tuberculosis, HIV, or malaria
- Malignancy, especially lymphoma
- Endocrine disorders: Including hyperthyroidism, phaeochromocytoma, or carcinoid syndrome
- Medication: Including anticholinesterases, antidepressants, or propranolol
How can you differentiate between primary and secondary hyperhidrosis?
Primary hyperhidrosis - will often present with focal sweating, typically bilateral and symmetrical, occurring at least once a week. It typically onsets before 25yrs of age and should be present for >6months for the diagnosis to be made.
Secondary hyperhidrosis - will often be generalised sweating and in many cases predominantly at night time. It is important to assess for features of underlying secondary causes, such as pyrexia, palpitations, or unexplained weight loss.
What investigations are ususally carried out for suspected hyperhidrosis?
Blood tests, including FBC, CRP, U&Es, TFTs, and glucose
CXR
What are the management options for primary hyperhidrosis?
- topical aluminium chloride preparations are first-line. Main side effect is skin irritation
- iontophoresis: particularly useful for patients with palmar, plantar and axillary hyperhidrosis
- botulinum toxin: currently licensed for axillary symptoms
- surgery: e.g. Endoscopic transthoracic sympathectomy. Patients should be made aware of the risk of compensatory sweating
What is galactorrhoea?
The production and excretion of milk from the breast (nipple) that is not associated with breastfeeding or pregnancy.
Where is prolactin produced?
The anterior pituitary
(also small amounts in the breast and prostate)
What are the key causes of hyperprolactinaemia?
Idiopathic
Prolactinomas
Endocrine disorders (hypothyroidism and PCOS)
Dopamine antagonists
What other symptoms can be caused by a raised prolactin level and why?
Prolactin suppresses the production of GnRH from the hypothalamus which in turn causes:
- menstrual irregularities
- erectile dysfunction
- reduced libido
- gynaecomastia
How are prolactinomas classified?
Macro = >10mm
Micro = <10mm
What other symptoms can be caused when a patient has a macroadenoma in the pituitary gland?
Headaches
Bitemporal hemianopia (compression of the optic chiasm)
What other conditions can cause discharge from the nipple (that is non milk-based)?
Mammary duct ectasia
Intraductal papilloma
Pus from breast abscesses
What investigations are carried out for a patient presenting with galactorrhoea?
- Pregnancy test
- LFTs
- U+Es
- TFTs
- Serum prolactin levels
- MRI to assess for pituitary tumours
How are patients with galactorrhoea managed?
Treatment for underlying cause
Dopamine agonists (bromocriptine and cabergoline)
Trans-sphenoidal surgery to remove pituitary gland tumours.
What are the main things that need to be excluded when a patient presents with breast pain?
- Cancer
- Infection
- Pregnancy
At what age do intraductal papillomas most commonly occur?
35-55 years
What does ductography involve?
What would be seen if a patient had an intraductal papilloma?
Injection of contrast into the ducts of the breast prior to mammogram.
There would be a filling defect in the duct that had the papilloma.
What is the firstline abx treatment for women with infective or non-resolving mastitis?
Flucloxacillin for 10 days
Erythromycin (penicillin allergic)
What is the treatment if mastitis is caused by candida? How is Candida of the nipple treated?
Fluconazole
Topical Miconazole
When do NICE recommend a 2WW referral for suspected breast cancer?
Unexplained breast lump in a patient 30 and above.
Unilateral nipple changes (retraction, discharge) in patients 50 and above.
When do NICE recommend to consider a 2WW referral for suspected breast cancer?
Unexplained lump in the axilla in a patient 30 or above.
Skin changes suggestive of cancer.
When do NICE recommend a non-urgent referral to breast clinic for patients?
Unexplained lump in patients under 30.
What are the symptoms of fibrocystic breast changes?
- Lumpiness
- Mastalgia
- Fluctuation in breast size
How would fat necrosis appear on examination of the breast? What investigations are needed and why?
- Painless
- Firm
- Fixed
- Irregular
- Skin dimpling may be present
(History of trauma)
Fat necrosis may appear similarly to breast cancer on mammogram and USS - histology is normally needed in order to exclude breast cancer.
What is a Phyllodes tumour? When does this more often occur?
Tumour of the connective tissue of the breast that can be benign or malignant. In women aged between 40-50.
What drugs can cause gynaecomastia?
- Anabolic steroids
- Digoxin
- Antipsychotics
- Spironolactone
What blood tests can be carried out for a patient with gynaecomastia?
U+Es
LFTs
TFTs
Testosterone
Sex Hormone-binding globulin
Oestrogen
Prolactin
LH + FSH
Genetic karyotyping
AFP + Beta hCG (testicular cancer markers)
What imaging can be done for a patient presenting with gynaecomastia?
CXR - certain paraneoplastic syndromes
Breast USS
Mammography
Testicular USS
Being obese can increase the amount of oestrogen that is produced and secreted: Name 4 more things that can increase the amount of oestrogen in the body.
Hyperthyroidism
Testicular cancer
Liver cirrhosis and failure
Beta hCG secreting tumours
Testosterone deficiency in older men is a reason for reduction in the amount of testosterone in the body: Name 4 more.
Klinefelter’s syndrome
Hypothalamus or pituitary tumours
Orchitis
Testicular damage
Increased exposure to oestrogen is a risk factor for breast cancer: Name 5 more.
- Female
- More dense breast tissue
- Obesity
- Smoking
- Family history/genetics
Other than breast cancer which cancers do the BRCA genes increase the risk of developing?
Ovarian
Prostate
Bowel
What is the difference between localised and generalised peritonitis?
Localised - organ inflammation
Generalised - organ rupture with release of the contents into the peritoneal cavity
What medications can be used as chemoprevention in women with high risk of breast cancer development?
Tamoxifen - pre-menopausal
Anastrozole - post-menopausal
When would it be appropriate to use an MRI for a patient with suspected breast cancer?
For screening in women at higher risk of developing breast cancer -> to assess the size and features of a tumour.
When is a sentinel lymph node biopsy used for breast cancer?
If the initial USS does not show any lymph nodal involvement.
Where does breast cancer most common metastasise to?
Bone
Brain
Lung
Liver
What investigations may be required in order to stage the breast cancer?
- Lymph node assessment and biopsy
- MRI of the breast and axilla
- Liver USS
- CT of the thorax, abdomen and pelvis for lung, abdominal or pelvic metastasis.
- Isotope bone scan for boney mets
What are the options for tumour removal in a patient with breast cancer?
Wide local excision - with adjuvant radiotherapy
Mastectomy
What are the common side effects associated with radiotherapy used for breast cancer?
- General fatigue
- Local skin and tissue irritation
- Fibrosis of breast tissue
- Shrinking of the breast tissue
- Long term skin colour changes
Why does Tamoxifen increase the risk of endometrial cancer?
Why does Tamoxifen increase the risk of VTE?
As it is a selective oestrogen receptor modulator - this means it blocks the oestrogen receptors in the breast tissue but it stimulates oestrogen receptors in the uterus.
Impact on oestrogen receptors in the liver make the blood hypercoaguable.
Why are aromatase inhibitors given to post-menopausal women for treatment of breast cancer?
What do they increase the risk of?
In post-menopausal women the primary source of oestrogen is in the conversion of androgens to oestrogen in the fat (adipose) tissue which is catalysed by the enzyme aromatase.
Aromatase inhibitors stop the production of oestrogen from the androgens in adipose tissue.
Therefore, they increase the risk of osteoporosis.
Other than Tamoxifen and Aromatase inhibtors, what other options are available for the treatment of oestrogen receptor positive breast cancer?
Fulvestrant - selective oestrogen receptor downregulator
GnRH agonists
Ovarian surgey -> oopherectomy
What needs to be montitored closely for patients on Herceptin?
Heart function - ECG, ECHO
Other than Herceptin what other medications can be used in combination with or instead for the treatment of HER-2 positive breast cancer?
Pertuzumab
Neratinib
How long should patients who have had breast cancer have surveillance mammograms for?
5 years
What are the options for reconstruction after breast-conserving surgery?
Partial reconstruction - flap or fat tissue
Reduction and reshaping - removing tissue and reshaping both breasts to match
What are the options for reconstruction after a mastectomy?
Breast implants
Flap reconstruction - using tissue from another part of the body to reconstruct the breasts.
At what size is a fibroadenoma eligible for removal?
above 3cm
When is FEC-D chemotherapy indicated for breast cancer?
When there is nodal involvement.
What is the difference between paget’s disease of the nipple and eczema of the nipple?
Paget’s starts with the nipple and spreads to the surrounding areolar tissue.
Eczema of the nipple is normally confined to the areolar tissue and does not affect the nipple itself.
What does a ‘snowstorm sign’ on USS of the breast indicate?
Breast implant rupture
Why is it important to ensure that analgesia post-op is adequate?
To ensure:
- mobility
- full ventilation of lungs (to avoid infection and atelectasis)
- adequate oral intake
Having a history of motion sickness is a risk factor for post-op nausea and vomiting: Name 5 more.
- Use of opiates for post-op analgesia
- Younger age
- Non-smoker
- Use of volatile anaesthetics
- Female
Which anti-emetic agents are used as prophylactic prevention of post-op N+V? Which one is not used for patients experiencing post-op N+V and what can be used instead?
Cyclizine
Ondansetron
Dexamethasone
Dexamethasone and instead you can use Prochlorperazine.
Why is TPN administered through a central line?
As it is irritant to veins and can cause thrombophelbitis.
What are the post-op complications that need to be closely monitored for?
- Anaemia
- Atelectasis
- Infection
- Wound dehiscence
- Haemorrhage
- Ileus
- Delirium
- Urinary retention
- AKI
- Acute coronary syndromes
- Arrhythmias
- Shock (hypovolaemia)
- DVT
- PE
At what level of Hb should post-op anaemia be treated and what should it be treated with?
<100 = oral iron
<70-80 = blood transfusion
What are the different compartments in which fluid is stored in the body?
Intracellular (2/3)
Extracellular (1/3)
- Intravascular (20%)
- Interstitial (80%)
- Third space (non-functional)
What are examples of areas in the body in which third spacing can occur?
Peritoneal cavity
Pleural cavity
Pericardial cavity
Joints
What are the main reasons for giving a patient IV fluids?
Resuscitation
Maintenance
Replacement
What are crystalloid fluids?
Water + sugar and salt
What are colloid fluids?
Fluid that contains larger molecules and stays in the intravascular space for longer.
What is an example of when a colloid fluid may be used?
Human albumin solution used for patients with decompensated liver disease.
What is the normal fluid osmolality?
275-295mOsmol/kg
What type of fluids are given for resuscitation? What type of fluids are definitelty avoided for resuscitation?
Isotonic fluids
Hypotonic solutions (cause water to move out of the blood = decrease in blood volume).
What needs to be monitored daily for patients on maintenance fluids?
Fluid status
Fluid balance
U+Es
How many ASA grades are there?
6
What are the grades of ASA?
I = normal healthy individual
II = mild systemic disease
III = severe systemic disease
IV = severe systemic disease that constantly threatens life
V = ‘moribund’ and expected to die without surgery
VI = brain dead and undergoing organ donation
When should warfarin be stopped before an operation?
5 days before and bridged with LMWH
When should DOACs be stopped before an operation?
24-72 hours
What is the management during and after surgery for a patient on long term corticosteroids?
Additional IV hydrocortisone at induction and during the post-op period.
Doubling of their normal dose once they are eating and drinking again.
Which diabetic drugs are omitted during surgery?
Sulfonylureas stopped whilst the patient is not eating and drinking.
SGLT2 stopped 3 days before.
What is a volvulus?
When a loop of bowel twists on itself and the mesentry attached to it.
What are the two main types of volvulus?
Sigmoid
Caecal
What is the most common cause of sigmoid volvulus?
Chronic constipation
What are some of the risk factors for developing a volvulus?
Neuropsychiatric disorders
Nursing home residents
Pregnancy
Chronic constipation
High fibre diet (bigger stools)
Adhesions
What are the signs seen on Xray for someone presenting with a volvulus?
Sigmoid - coffee bean
Caecal - embryo
What investigation is used for diagnosis of a volvulus?
Contrast CT - abdo
What are the conservative and surgical treatments for a volvulus?
Conservative - endoscopic decompression of the sigmoid.
Surgical - laparatomy, hartmann’s procedure for sigmoid and ileocaecal resection or right hemicolectomy for caecal volvulus.
What are the common causes of ileus?
- Infection or inflammation
- Handling of the bowel during surgery
- Electrolyte imbalance
- Injury to the bowel
What is the supportive treatment for a patient with ileus?
- NBM
- NG (if vomiting)
- IV fluids
- Mobilising
- TPN may be required if nutrition is needed whilst waiting for bowel to mobilise again.
What are the two main causes of acute cholangitis?
Obstruction of the bile duct
Infection introduced during ERCP
What are the most common causative organisms for acute cholangitis?
E.coli
Klebsiella species
Enterococcus species
What is charcot’s triad?
RUQ pain
Jaundice
Fever
What are the steps for managing a patient with acute cholangitis?
Initial managment involves treating for sepsis and an acute abdomen:
- NBM
- IV fluids
- Blood cultures
- IV antibiotics
- Consider admission to HDU or ITU
Then an ERCP is required to remove any stones blocking the bile duct - during this a number of procedures can be performed:
- Cholangio-pancreatography
- Sphincterectomy
- Stone removal
- Balloon dilatation
- Biliary stenting
- Biopsy
If a patient is unsuitable for ERCP or this has already been tried then Percutaneous Transhepatic Cholangiogram can be used to remove the obstruction.
What does ERCP stand for?
Endoscopic Retrograde Cholangio-pancreatography
What is the difference between diverticulosis, diverticular disease and diverticulitis?
Diverticulosis - outpouchings present in the colon
Diverticular disease - when the outpouchings cause sx
Diverticulitis - when the outpouchings become inflamed or infected.
Where are diverticula most commonly found?
In the sigmoid colon
What are some of the risk factors for developing diverticulosis?
- increasing age
- low fibre diet
- obesity
- use of NSAIDs
How is uncomplicated diverticulitis managed?
Managed in primary care
- Oral co-amoxiclav (5 days)
- Analgesia (NSAIDs and Opiates avoided)
- Clear fluids
- Follow-up in 2 days
How is complicated diverticulitis managed?
Hospital admission.
- NBM
- IV fluids
- IV antibiotics
- Analgesia
- Urgent CT scan
- Possible surgery depending on cause or complications
What are some of the complications that can occur due to diverticulitis?
Perforation
Peritonitis
Haemorrhage
Ileus/obstruction
Fistula formation
How might a patient with diverticulitis present?
Pain and tenderness in the left iliac fossa
Fever
Diarrhoea
Nausea and vomiting
Rectal bleeding
Palpable abdominal mass
(Raised inflammatory markers and WBC)
What is the blood supply to the gut?
Coeliac artery (foregut)
Superior mesenteric artery (midgut)
Inferior mesenteric artery (hindgut)
What is the classic triad of chronic mesenteric ischaemia?
Central colicky abdominal pain after eating
Weight loss (food avoidance)
Abdominal bruits
What is the management of chronic mesenteric ischaemia?
- Reducing modifiable risk factors
- Secondary prevention (statin + antiplatelet)
- Revascularisation (endovascular or open)
Which artery is the most common location for a thrombus causing acute mesenteric ischaemia?
Superior mesenteric artery
What is the diagnostic investigation of choice for chronic mesenteric ischaemia?
CT angiography
What is the investigation of choice for a patient with acute mesenteric ischaemia?
Contrast CT of abdomen
What is the management of a patient with acute mesenteric ischaemia?
Surgery to remove the necrotic bowel and to either remove or bypass the thrombus.
What are the three main complications of hernias?
Incarceration
Obstruction
Strangulation
What is a Richter’s hernia?
Any abdominal hernia can be a richter’s hernia - this is when only some of the bowel wall and lumen of the bowel herniates through the opening and the other section stays in the peritoneal cavity.
What is a Madyl’s hernia?
When two separate loops of bowel herniate through the same opening so are contained within the same hernia.
What are the 3 managment options for hernias and what do they involve?
Conservative - leaving the hernia alone; this can be done when the hernia has a wide neck (low risk of complications) and the patient is not a suitable candidate for surgery.
Tension-free repair - mesh is placed over the weakness and sutured into the muscle and tissue to prevent herniation. low risk of recurrence but sometimes the mesh can result in some chronic pain.
Tension repair - this is when the weakness is sutured closed (like a wound) this has high rates of recurrence and is associated commonly with post-op pain so is now not routinely performed.
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What is the difference between an indirect and direct inguinal hernia?
Indirect - bowel herniates through the inguinal canal.
Direct - bowel herniates through a weakness in Hesselbach’s triangle.
Clinically, how can an indirect inguinal hernia be distinguished from a direct hernia?
Reduce the hernia
Cover the deep inguinal ring (mid-way point from ASIS to pubic tubercle)
Get the patient to cough - if the hernia remains reduced then it is an indirect hernia.
What are the borders of Hesselbach’s triangle?
Medial border - Rectus abdominis
Superior/lateral border - Inferior epigastric vessels
Inferior border - inguinal ligament
Where do femoral hernias herniate through?
Why are femoral hernias at a higher risk for strangulation?
The femoral canal and out of the femoral ring.
The femoral ring is a very narrow opening.
What are the borders of the femoral canal?
anterior border - inguinal ligament
medial border - lacunar ligament
lateral border - femoral vein
posterior border - pectineus
In what group of patients is diastasis recti common?
Post-partum women
What are the 4 types of hiatus hernia?
- Sliding
- Rolling
- Sliding and rolling
- Large opening with additional abdominal organs entering the thorax
What is the difference btween a sliding and a rolling hiatus hernia?
Sliding is when the stomach slides up into the thorax throught the diaphragm with the gastro-oesophageal junction passing up into the thorax.
Rolling is when a separate part of the stomach folds arounnd and enters through the diaphragm opening alongside the oesophagus.
What are 3 key risk factors for the development of a hiatus hernia?
Increasing age
Obesity
Pregnancy
What symptoms may a patient present with if they have a hiatus hernia?
- Heartburn
- Acid reflux
- Reflux of food
- Burping
- Bloating
- Halitosis
On which imaging modalities can a hiatus hernia be seen?
CXR
CT scans
Endoscopy
Barium swallow
What is the surgical treatment for a hiatus hernia?
Laparascopic fundoplication
What score can be used to assess the probability of appendicitis?
Alvarado score
What are important differentials to consider when assessing a patient for suspected appendicitis?
Ovarian cyst
Ectopic pregnancy
Meckel’s diverticulum
Mesenteric adenitis (younger children)
What are the three main causes for bowel obstruction?
Adhesions (SB)
Hernias (SB)
Tumours (LB)
Other than the three main causes what are some other causes of bowel obstruction?
Strictures
Diverticular disease
Volvulus
Intussusception
What can cause a closed-loop bowel obstruction?
Adhesions
Hernias
Volvulus
A single obstruction in the large bowel if the patient has a normally functioning ileocaecal valve.
What are the normal upper limits for the different sections of the bowel?
3cm - small bowel
6cm - colon
9cm - caecum
What are the different surgical interventions that can be performed for a bowel obstruction?
Exploratory surgery - uknown cause
Adhesiolysis
Hernia repair
Emergency resection - tumour
Stenting - pushing the tumour out of the way.
Colostomy vs ileostomy?
Colostomy - LIF, solid, flush
Ileostomy - RIF, liquid, spouted
What is a loop colostomy? What is the purpose?
When a loop of bowel is pulled through the abdominal wall and split into to make two openings but still attached at the middle.
It can allow for a diverision of stool whilst a more distal part of the bowel heals, can be temporary measure.
What are the risk factors for developing TURP syndrome?
Surgical time more than one hour
Height of the bag more than 70cm
Resection of more than 60g
Large blood loss
Perforation
Large amount of fluid used
Poorly controlled CHF
What are the causes of pancreatitis?
I GET SMASHED:
I = idiopathic
G = gallstones
E = ethanol
T = trauma
S = steroids
M = mumps/malignancy
A = autoimmune
S = scorpion
H = hypercalcaemia
E = ERCP
D = drugs
What are the poor prognostic factors for a patient with pancreatitis?
PANCREAS
P = Pa02 (<8)
A = Age (over 55)
N = Neutrophils (>15)
C = Calcium (<2)
R = raised urea (>16)
E = Enzyme LDH (>600 units)
A = albumin (<32)
S = sugar (>10)
What are the initial management steps for a patient with pancreatitis?
Iv fluid resus
O2
Analgesia
IV abx - acute cholangitis or pancreatic necrosis.
Nutrition (TPN)
What bloods are important for investigating acute pancreatitis?
Lipase and Amylase - markers and prognosis
LFTs - hepatic obstruction/involvement
U+Es - albumin (prognosis)
CRP
Glucose
Blood gas
Bone profile
What are the differences between sigmoid and caecal volvuli?
Sigmoid volvulus:
- arises in the pelvis (left lower quadrant)
- extends towards the right upper quadrant
- ahaustral in appearance
- sigmoid volvulus causes obstruction of the distal large bowel, therefore the ascending, transverse and descending colon may be dilated
- few air-fluid levels may be seen
- coffee-bean sign
Caecal volvulus:
- arises in the right lower quadrant
- extends towards the epigastrium or left upper quadrant
- colonic haustral pattern is maintained
- distal colon is usually collapsed and the small bowel is distended
- one air-fluid level may be seen
- embryo sign
