Surgery

Question 1

Define mastitis:

Answer 1

Mastitis is the inflammation of the breast tissue, which can be with or without an infection. When associated with lactation in postpartum women, the condition is specified as puerperal mastitis. Alternatively, mastitis can be seen in women who are not breastfeeding.

Question 2

What is the cause of non-infectious mastitis:

Answer 2

Mastitis unrelated to pregnancy and breastfeeding is typically due to obstruction of the ducts from cellular debris. This can result in a local inflammatory response in non-infectious mastitis.

Question 3

What is the cause of infectious mastitis:

Answer 3

In infectious mastitis, bacteria from the skin can then enter the ducts, causing inflammation and may progress to peri-areolar abscesses. The most common causative pathogen is Staphylococcus aureus.

Question 4

Name some risk factors for non-lactational mastitis:

Answer 4

Cigarette smoking
Nipple rings
Diabetes mellitus
Immunocompromise

Question 5

Signs and symptoms of non-lactational mastitis

Answer 5

Localised symptoms: Painful, tender, red, and hot breast.
Systemic symptoms: Fever, rigours, myalgia, fatigue, nausea, and headache.
Additional information: The condition is usually unilateral and tends to present within the first week postpartum.
In some cases, mastitis may develop into a breast abscess, manifesting as a fluctuant, tender mass with overlying erythema.

Question 6

What is the investigation for non-lactational mastitis

Answer 6

Ultrasound: Utilised to identify a potential abscess, appearing as a collection of pus.
Additional information: Early referral to secondary care is vital if an abscess is suspected.

Question 7

What is the management for non-lactational mastitis:

Answer 7

Provide analgesia to manage symptoms (i.e. paracetamol, ibuprofen)
Warm and cold compresses may also help.
Antibiotics may be considered if acute pain, severe symptoms or symptoms lasting more than 12-24 hours, fever or positive cultures
Flucloxacillin or clindamycin for those with penicillin allergy
Treatment is indicated for 10-14 days.
In cases where the condition does not improve, consider intravenous antibiotics (i.e. vancomycin) or ultrasound to evaluate for the presence of a breast abscess.
Patients may also benefit from antifungal therapy (i.e. nystatin) for concomitant nipple candidiasis

Question 8

Name some complications of mastitis:

Answer 8

Breast abscess
Recurrence:
More common if treatment is delayed or too short in duration

Question 9

What is pueperal mastitis?

Answer 9

Puerperal mastitis is a condition characterised by inflammation and potential infection of the breast tissue, typically associated with lactation in postpartum women.

Question 10

What causes pueperal mastitis?

Answer 10

Puerperal mastitis is often caused by milk stasis or blocked milk ducts. Milk stasis may occur due to inadequate milk removal, either from poor breastfeeding techniques or infrequent feeding. This can result in an inflammatory response and a potential secondary bacterial infection. The bacteria enter the breast tissue, often through a cracked or sore nipple. Staphylococcus aureus is the most common bacterial pathogen implicated in infectious cases.

Question 11

Name some risk factors for pueperal mastitis?

Answer 11

Difficulties feeding
Reduced milk clearance from the breast
This may be related to weaning, bottle feeding, mastalgia, or infant preference for one breast or another.
Occlusion of milk ducts
Damage to the nipple (i.e. fissures, cracks or sores)
Injuries to the breast (i.e. tight clothing, seat belts)
Maternal stress
Previous history of mastitis
Cigarette smoking
Presence of breast implants
Shaving or plucking of hairs around the nipples

Question 12

Signs and symptoms of pueperal mastitis?

Answer 12

Puerperal mastitis typically presents within one week of birth with the following symptoms:
Painful, tender, red, and hot breast. It is typically unilateral.
Systemic symptoms: Fever, rigours, myalgia, fatigue, nausea, and headache.
Potential complications: In some cases, a breast abscess may develop, which presents as a fluctuant, tender mass with overlying erythema.
Some patients may have associated axillary lymphadenopathy.
There is a severe deep burning breast pain

Question 13

What are the investigations for pueperal mastitis?

Answer 13

Clinical evaluation: Puerperal mastitis is primarily diagnosed based on clinical symptoms and breast examination.
Ultrasonography: This may be used in cases where an abscess is suspected.
Cultures:
Not routinely indicated
Used if severe, recurrent or the presentation is abnorm

Question 14

What is the conservative management for pueperal mastitis?

Answer 14

Most women improve with conservative management:
Analgesia: Over-the-counter pain relievers and anti-inflammatories can help manage pain and inflammation.
Avoid wearing a bra at night
Continued breastfeeding or pumping: To promote milk flow and prevent stasis. The mother should be reassured that this poses no risk to the baby.
Consider an assessment of breastfeeding by a specialist to determine if feeding pattern or positioning could be improved to reduce the risk of recurrence.
It is recommended to breastfeed 8-12 times per day to aid clearance.
Advise on methods to facilitate milk removal, e.g. manual expression.

Question 15

What is the further management for puerperal mastitis?

Answer 15

Antibiotic therapy may be used for women who do not improve after 24 hours of conservative management if they have signs of systemic upset or if there are breaks in the skin around the nipple.
Flucloxacillin or clarithromycin are typically the first line.
Treatment is often used for 10-14 days.
The choice of antibiotic may be guided by culture results if available.
Surgical management (incision and drainage or needle aspiration):
This may be required in severe cases where a breast abscess has developed.
A sample of the fluid should be sent off for culture to enable sensitivities of the bacteria to be determined to tailor antibiotic treatment.

Question 16

What are the complications of pueperal mastitis?

Answer 16

Abscesses are seen in approximately 1 in 20 women with puerperal mastitis.
Sepsis
Candida of the nipple:
This can occur after puerperal mastitis is treated with antibiotics.
It presents with painful and itchy nipples, with flaky and cracked skin around the areola.
The baby may, in turn, develop candida of the mouth or tongue following continued feeding.
If this develops, both mother and baby require oral antifungal treatment (e.g. miconazole).

Question 17

Define breast cysts:

Answer 17

Breast cysts are fluid-filled sacs within the breast tissue that can be palpated as a lump

Question 18

Signs and symptoms of breast cysts:

Answer 18

The aetiology of breast cysts is not fully understood but hormonal fluctuations are believed to play a significant role. Clinically, they may be asymptomatic or present with pain and tenderness, particularly in the premenstrual phase. On physical examination, they typically feel round or oval and smooth with distinct edges.

Question 19

What are the investigations for breast cysts:

Answer 19

Diagnosis usually involves ultrasound imaging which distinguishes cysts from solid masses. Fine needle aspiration (FNA) may also be performed for therapeutic and diagnostic purposes; clear fluid aspiration without residual mass generally confirms the diagnosis of a simple cyst.

Question 20

What is the management for breast cysts:

Answer 20

If symptomatic, treatment options include watchful waiting, oral contraceptives to regulate hormonal imbalances, or surgical excision in case of persistent or recurrent cysts. It’s important to note that breast cysts do not increase the risk of breast cancer.

Question 21

Define fibroadenomas:

Answer 21

Fibroadenomas are benign tumours that consist of a mixture of fibrous and epithelial tissue. They originate from the lobules, the milk-producing glands in the breast. They are a common cause of breast lumps, particularly in women under the age of 40 years.

Question 22

Causes of fibroadenomas:

Answer 22

The exact cause of fibroadenomas is unclear. However, they seem to be influenced by reproductive hormones, as they often enlarge during pregnancy or in times of hormone replacement therapy (HRT) use and shrink after menopause. They are also associated with Cowden’s syndrome.
They consist of fibrous and epithelial tissue.

Question 23

What are simple fibroadenomas:

Answer 23

These are 1-3 cm in diameter and consist of uniform-appearing cells.
These are not associated with an increased risk of breast cancer.
The majority of fibroadenomas are considered to be simple.

Question 24

What are complex fibroadenomas?

Answer 24

These are typically larger in size and are not as homogenous under the microscope. They may contain popcorn calcifications or cysts.
These are associated with a small increased risk of breast cancer.

Question 25

What are giant fibroadenomas?

Answer 25

A fibroadenoma is considered to be giant when it is greater than 5 cm in diameter.

Question 26

What are the signs and symptoms of fibroadenomas:

Answer 26

A firm, non-tender breast mass
The mass is rounded and has smooth edges
The mass is highly mobile upon palpation, often referred to as having a “rubbery” consistency and may be referred to as a “breast mouse.”
The mass typically does not grow beyond 3cm in diameter
The overlying skin is normal
They are most commonly located in the upper outer quadrant.

Question 27

While fibroadenomas are benign, patients usually undergo a triple assessment to exclude more serious pathology. NICE Guidelines recommend referral under two-week wait protocols for

Answer 27

Women over 30 years with an unexplained breast lump
Women over 50 with changes to the nipple (i.e. discharge, retraction, skin changes)
A referral should also be considered in women with skin changes suggestive of breast cancer or for women aged over 30 years with an unexplained lump in the axilla.

Question 28

What are the investigations for women under 30 with an unexplained breast mass:

Answer 28

Clinical examination and history of the breast lump
Imaging
Ultrasound is used for women under the age of 40 due to higher breast density. Fibroadenomas appear as oval or round, well-circumscribed and solid. They typically are wider than tall.
A mammogram is used for women over the age of 40. Fibroadenomas appear as oval or round, with popcorn calcifications occasionally seen.
Needle biopsy (fine needle aspiration or core biopsy):
This may be done if there is diagnostic uncertainty on imaging, the lesion is enlarging, or if the lesion is above a certain size.

Question 29

What is the management for fibroadenoma:

Answer 29

Conservative management: Many fibroadenomas do not require treatment and will regress naturally after menopause.
Removal of the fibroadenoma: This may be required if the fibroadenoma is large, growing, causing significant symptoms, or if there is diagnostic uncertainty after triple assessment. Removal may be achieved by:
Vacuum-assisted excision biopsy: For small fibroadenomas, local anaesthetic may be used. A small incision is made into the skin, and a needle with an associated vacuum can be inserted. This is used to aspirate the fibroadenoma under ultrasound guidance.
Surgical excision biopsy: This is done under general anaesthesia.

Question 30

What is the prognosis of fibroadenomas:

Answer 30

Fibroadenomas are benign lesions of the breast, typically reaching a maximum size of 2-3 cm before reducing in size at menopause.
There may be a small increased risk of breast cancer associated with complex or multiple fibroadenomas.

Question 31

Define large bowel obstruction:

Answer 31

Large bowel obstruction refers to a medical emergency where the intestines’ normal passage of food, fluids, and gas is impeded, requiring immediate medical intervention.

Question 32

What is the most common cause of large bowel obstruction?

Answer 32

While colorectal cancer is the most common cause globally, diverticular disease is a leading cause in Western countries

Question 33

What are the causes of large bowel obstruction:

Answer 33

Colonic tumours - overall most common cause
Strictures, often secondary to diverticular disease, inflammatory bowel disease, or post-surgical anastomosis
Volvulus, either sigmoid or caecal - most common benign cause
Hernias
Adhesions

Question 34

What are the signs and symptoms of large bowel obstruction:

Answer 34

Cramping abdominal pain
Bloating
Absolute constipation, characterized by an inability to pass wind or faeces
Potential nausea and vomiting, though these are more common in small bowel obstruction and are considered late signs in large bowel obstruction. Faeculent vomiting suggests lower level of obstruction.

Question 35

What are the investigations for large bowel obstruction:

Answer 35

Blood tests: FBC (anaemia could suggest malignancy, especially if microcytic i.e. iron-deficiency), electrolyte imbalances and suggest fluid shifts, raised lactate on VBG can suggest ischaemia.
CEA may be done later on when suspecting colorectal cancer.
Abdominal X-ray: A primary tool for diagnosing large bowel obstruction
CT Abdomen: Essential in identifying the cause (e.g. malignancy), as well as providing more details such as the transition point and distinguishing between caecal and sigmoid volvulus.

CT abdomen with contrast is the preferred investigation for diagnosing large bowel obstruction, revealing distended loops and potential transition points (sites of narrowing/blockage).

Question 36

Compare small and large bowel obstruction:

Answer 36

Question 37

What is the management for large bowel obstruction:

Answer 37

Supportive care: ‘Drip and suck’ approach - IV fluids, nasogastric tube insertion to help decompress bowel, anti-emetic medication

Decompression of sigmoid volvulus: Typically achieved using a flexible sigmoidoscope

Surgical intervention: Approximately 70% of large bowel obstruction patients require surgical intervention, either laparoscopic or open colonic resection, which may involve primary anastomosis or stoma formation.

Palliative care: For patients with malignant large bowel obstruction unfit for surgery, palliative stenting can be performed to alleviate symptoms.

Question 38

Define small bowel obstruction?

Answer 38

Small bowel obstruction (SBO) is a mechanical disruption in the small bowel, leading to significant clinical symptoms such as bilious or faeculent vomiting, abdominal pain and distension, and complete constipation.

Question 39

Causes of small bowel obstruction:

Answer 39

Factors outside the bowel
Adhesions
Most common cause in the Western world
Prior intra-abdominal surgeries increase the risk of adhesion development. The larger the operation, the higher the likelihood of adhesion formation.
Intra-abdominal hernia
Incarcerated hernias can precipitate acute obstruction

Factors relating to the bowel wall
Crohn’s disease - stricturing (rather than fistulating) disease is what specifically causes SBO
Appendicitis

Factors relating to inside the bowel
Malignancy
Foreign body ingestion
Gallstone ileus
Peutz-Jegher’s syndrome, due to hamartomas throughout the gastrointestinal tract. Pigmented lesions in the oral mucosa, palms, and plantar surfaces should raise suspicions for Peutz-Jegher’s syndrome

Diseases causing small bowel obstruction in children
Intussusception
Volvulus
Intestinal atresia
Appendicitis

Question 40

Signs and symptoms of small bowel obstruction:

Answer 40

Abdominal pain with distension (Initially colicky pain that becomes continuous)
Bloating and vomiting (often bilious)
Failure to pass flatus or stool
History of abdominal/gynaecological surgery or hernia
Tympanic, high-pitched bowel sounds on examination
An empty rectum on examination in complete bowel obstruction

Patients may also present with fever and significant fluid depletion. Peritonitis indicates severe bowel obstruction with developing complications (e.g. perforation, especially in closed-loop obstructions), necessitating urgent surgical intervention.
Simple or partial SBO may still result in passing some flatus/stool and present with a mild temperature.
If untreated, SBO can progress to ischaemic or necrotic bowel, leading to perforation.

Question 41

What are the investigations for small bowel obstruction?

Answer 41

Basic blood tests including FBC, U+Es, and lactate
FBC (To identify leukocytosis or anaemia)
U+Es (To detect organ dysfunction or signs of hypovolaemia)
Lactate (To establish if there is bowel ischaemia or necrosis, though it can be falsely low due to liver metabolism)
Amylase (To rule out acute abdomen conditions)

Abdominal and chest X-ray
Performed in an upright position to detect pneumoperitoneum
Absence of air in the rectum can indicate complete obstruction

Question 42

Management for small bowel obstruction:

Answer 42

Begin with resuscitation protocols (ABCDE)
Correct fluid and electrolyte imbalances to reduce operative risk before surgery for obstruction
Fluid resuscitation and NG tube to aspirate content for decompression (‘Drip and suck’)
Gastrografin can be administered as both a diagnostic and therapeutic measure in cases of partial obstruction. The presence of gastrografin in the rectum 24 hours post-administration indicates a resolving partial SBO, reducing the need for surgical intervention.

If conservative measures fail, consider surgery. The type of surgery depends on the cause and may include:
Adhesionolysis
Bowel resection
Closure of hernias
Tumour resection

Question 43

Compare the specific symptoms between small bowel obstruction and large bowel obstruction?

Answer 43

• What are the signs specific to SBO?
  
  • Early onset bilious vomiting
  • Tinkling bowel sounds (more common in early bowel obstruction)
• What are the signs specific to LBO?
  
  • Late onset vomiting- may progress to faecal vomiting
  • Absolute constipation (not passing wind or faeces)
  • What may there be a history of?Possible malignant symptoms like change in bowel habit, weight loss, rectal bleeding

Question 44

What is the main difference in signs between paralytic ileus and mechanical bowel obstruction?

Answer 44

• Paralytic ileus → complete absence of bowel sounds
• Mechanical bowel obstruction → tinkling bowel sounds

Question 45

Complications of bowel obstructions:

Answer 45

• bowel ischaemia
• bowel perforation
• peritonitis

Question 46

What is post operative ileus?

Answer 46

Post-operative ileus is a common complication following surgery. It is characterized by abdominal distension, absent bowel sounds and obstructive symptoms such as nausea and vomiting.

Question 47

In cases of nausea with bowel obstruction, which antiemetic acts as an antihistamine and anticholinergic, reducing nausea and vomiting.

Answer 47

IM cyclizine

Question 48

What are the risk factors for paralytic ileus

Answer 48

he is obese, he is on anticholinergic and opiate medications, he had an operation with bowel handling and complicated by peritonitis, and he has not mobilised properly post-operatively.

Question 49

Treatment for right sided and left sided colonic cancers?

Answer 49

Right sided colonic cancers can be treated with a laparotomy, right hemicolectomy and (usually) a primary anastomosis if they cause obstruction.

left sided cancers include left hemicolectomy with either an end colostomy or primary anastomosis, or a sub-total colectomy and anastomosis or a colonic stent insertion

Question 50

What is a Hartmann’s procedure?

Answer 50

a type of colectomy that removes part of the colon and sometimes rectum (proctosigmoidectomy). The remaining rectum is sealed, creating what is known as Hartmann’s pouch. The remaining colon is redirected to a colostomy. It can be reversed later.

Question 51

What is a sign of peritonitis:

Answer 51

A rigid abdomen with percussion tenderness is a sign of peritonitis. Evidence of peritonitis is a major indication for the urgent surgical intervention. Not only can it represent complete bowel obstruction, but can also indicate perforation or ischemia of the bowel. In this case, there is also thumb printing of the small bowel wall indicating ischaemia of the bowel, meaning urgent laparotomy may be needed. In most cases, an urgent CT scan is performed to localize the site of obstruction, but this should not delay surgical intervention

Question 52

In patients with small bowel obstruction and signs of strangulation caused by an incarcerated femoral hernia, prompt surgical intervention through emergency laparotomy is essential to prevent faecal peritonitis, gangrene and poor outcomes.

Answer 52

Femoral hernia account for <10% of groin hernias and are more common in women. However, they present a higher risk for incarceration and strangulation. This patient has features of obstruction and should be taken to theatre overnight. It is most likely to be small bowel in the hernia and may lead to perforation, either from over-distension proximal to this or from infarct around the strangulated segment, resulting in faecal peritonitis. Delaying theatre increases the risk of gangrene and perforation worsening outcomes for the patient

Question 53

sigmoid vs caecal volvulus

Answer 53

There is a distended loop of large bowel which looks like an upside down human embryo in the abdomen. This is a classical findings in caecal volvulus. Sometimes to “embryo” can appear upright depending on how much the caecum has rotated. The differential diagnosis is sigmoid volvulus but the features that favour caecal volvulus are the fact that it arises from the right lower quadrant and that there are occasional small haustral folds visible

Question 54

Treatment for volvulus:

Answer 54

In cases of large bowel obstruction caused by volvulus, initial management typically involves sigmoidoscopic decompression and flatus tube insertion before consideration of surgical intervention.

Question 55

What does a radiograph show when there is a “double wall sign”

Answer 55

otherwise known as Rigler’s sign where there is crisp definition of both sides of the bowel wall. This is significant as it means there is air on both sides of the bowel wall which when there has not been recent surgery is most likely to mean perforation.

Question 56

Define a surgical site infection::

Answer 56

A surgical site infection refers to local signs of infection around the surgical wound, with or without systemic features.

Question 57

What is the aetiology of surgical site infections?

Answer 57

During surgery, skin and/or non-sterile organs are breached, potentially introducing microorganisms into previously sterile spaces. Depending on the number of organisms introduced, the virulance of the pathogen and the host’s immune response, this can cause infection in the post-operative period. Wound infections can be classified by depth: from superficial to deep incisional, and organ/space infection.
Causative organisms vary by site. Commonly isolated organisms include:
Staphylococcus aureus - particularly orthopaedic surgeries
Escherichia coli - particularly abdominal surgeries
Pseudomonas aeruginosa
Some people are at increased risk of surgical site infections. These include:
Advanced age
Frailty
Comorbidities
Complexity of surgery
Immunosuppression
Smoking status

Question 58

What are the clinical features of surgical site infections?

Answer 58

Fever
Localised pain
Erythema ± signs of spread from the wound
Discharge from wound
Abscess ± sinus formation

Question 59

What are the investigations for surgical site infections?

Answer 59

Bedside:
Basic observations & NEWS scoring
Wound swab
Bloods:
FBC, U&E, CRP + others relevant
± Sepsis six: blood cultures, urine output, lactate

Question 60

What is the management for preventing surgical site infections?

Answer 60

Pre-operative
Optimising comorbidities
Showering with soap prior to surgery ± MRSA decolonisation with nasal mupirocin + chlorhexidine body wash if higher risk for S. aureus infection
Avoiding hair removal and using electronic clippers if indicated
Patient and staff wear appropriate clothing to minimise risk
Reducing traffic through the operating theatre
Laminar flow air
Antibiotic prophylaxis for surgeries involving prostheses/implants, clean-contaminated surgery, contaminated surgery. This is timed to provide optimal concentrations at the time of incision.

Intra-operative
Hand decontamination
Sterile gowns & gloves, with a prepared sterile field
Antiseptic skin preparation
Maintaining homeostasis: temperature, clotting, oxygen saturations, blood pressure
Wound closure in layers with appropriate sutures
Appropriate dressings

Post-operative
Aseptic techniques for dressing changes
Wound cleansing with sterile saline up to 48 hours, after which tap water can be used
Monitoring and safety netting for signs of infection

Question 61

What is the treatment for surgical site infections?

Answer 61

If a wound infection occurs after surgery, this is treated with antibiotics to cover the likely organisms. Once cultures and sensitivities come back, more targeted antibiotics can be used. Further procedures such as abscess drainage or debridement may be necessary. If it is a simple infection such as cellulitis (indicated by erythema around the wound, lack of pus, systemic signs), management is typically with flucloxacillin (or clarithyromycin if penicillin allergy).

Question 62

Define testicular torsion:

Answer 62

Testicular torsion is a urological emergency that occurs when a testicle twists around the spermatic cord. This leads to the obstruction of blood flow to the affected testicle which eventually results in testicular necrosis and atrophy.

Question 63

What is the epidemiology of testicular torsion?

Answer 63

Testicular torsion has two peaks in incidence: in the neonatal period and at age 13-16 years
It can occur in men of any age
Approximately 3300 cases occur per year in England

Question 64

Name some risk factors for testicular torsion:

Answer 64

Previous testicular torsion (suspect if history of episodes of testicular pain that self-resolved)
Family history of testicular torsion
Undescended testes
Testicular tumours
May be precipitated by trauma or exercise

Question 65

What are the main symptoms of testicular torsion:

Answer 65

Sudden onset severe pain in one testicle
Nausea and vomiting due to pain
Abdominal or groin pain

Question 66

On examination what do you get in testicular torsion?

Answer 66

Unilateral tender testicle
Testicle may appear swollen
The testicle may be high riding in the scrotum or lying in the transverse plan
Unilateral loss of cremasteric reflex (stroking the inner thigh should cause the ipsilateral testicle to elevate)
Persistent pain despite elevation of the testicle (negative Prehn’s sign)

Question 67

What are the investigations for testicular torsion?

Answer 67

The diagnosis of testicular torsion is clinical and all suspected cases require urgent surgical management with scrotal exploration.
Investigations may be required in preparation for surgery, e.g. baseline blood tests including group and saves and clotting screen, ECG.
In cases where there is significant uncertainty regarding the diagnosis, Doppler ultrasound may be used to demonstrate reduced or absent blood flow to the affected testicle. However this may be falsely reassuring in early or intermittent torsion and so should usually not be done.
Urinalysis may also be done to investigate for a urinary tract infection (that may precipitate epididymo-orchitis) if this is suspected.

Question 68

What is the management for testicular torsion?

Answer 68

Conservative:
Immediate referral to urology for emergency surgery
Keep patients nil by mouth
Manual reduction of the torsion may be attempted (immediate surgery is still required for orchidopexy if this is successful)
Medical:
Ensure adequate analgesia is given for pain
Antiemetics may be required for nausea and vomiting
Surgical:
Urgent surgical exploration is crucial to confirm the diagnosis and to attempt to salvage the testicle
If the testicle is viable, bilateral orchidopexy should be carried out
If it is not viable, it should be removed (an orchidectomy) - a prosthesis may be implanted at a later date for cosmetic reasons
Orchidopexy of the contralateral testicle should always be carried out to reduce the risk of recurrence on the other side

Question 69

What are the complications of testicular torsion?

Answer 69

Testicular atrophy, ischaemia and necrosis
Impaired fertility (affecting 36-39% of patients after torsion)
Chronic intermittent torsion may cause segmental ischaemia of the testicle
Without orchidopexy of the contralateral testicle, there is a 40% risk of torsion on the other side

Question 70

What is the prognosis of testicular torsion?

Answer 70

Testicular atrophy, ischaemia and necrosis
Impaired fertility (affecting 36-39% of patients after torsion)
Chronic intermittent torsion may cause segmental ischaemia of the testicle
Without orchidopexy of the contralateral testicle, there is a 40% risk of torsion on the other side

Question 71

Define varicose veins:

Answer 71

Varicose veins are dilated and tortuous superficial veins commonly seen in the lower limbs. They develop due to the incompetence of the valves between the deep and superficial venous systems, which results in retrograde flow and pooling of blood in the superficial venous system.

Question 72

Risk factors for varicose veins:

Answer 72

Risk factors include:
Age
Female sex
Family history of varicose veins
Obesity
Immobility, lack of movement and prolonged standing
Deep vein thrombosis
Trauma to the veins of the lower limbs
Pregnancy
Hormonal changes alter the valve’s activities and the pliability of the walls of the veins
Later in pregnancy, the large uterus can compress the inferior vena cava impairing venous return and increasing venous hypertension.

Question 73

What causes varicose veins?

Answer 73

Blood in the lower limb normally drains from superficial veins to deep veins, which are buried beneath the fascia. In varicose veins, incompetent valves enable the backflow of blood from the deep veins to the superficial veins, increasing venous pressure and causing dilatation of the superficial vein.
The development of varicose veins, therefore, involves a complex interplay of factors that ultimately lead to venous insufficiency and valve incompetence.

Question 74

How are varicose veins classified?

Answer 74

Varicose veins can be categorised based on their CEAP classification:
Clinical picture
(a)Etiology
Anatomical distribution
Pathophysiology

Question 75

What are the signs and symptoms of varicose veins?

Answer 75

Varicose veins may present with the following clinical features:
Visible superficial veins
Pain, often presenting as a feeling of heaviness or cramping
Oedema
Venous ulcers in advanced cases
Skin discolouration due to increased haemosiderin deposits
Risk of haemorrhage

Question 76

What are the distinctive tests done for varicose veins?

Answer 76

Trendelenburg’s test:
With the patient lying supine, their leg is elevated and the venous system is emptied. A tourniquet can then be placed at the saphenofemoral junction.
If the veins refill from below, then this indicates the incompetent valve is below the level of the tourniquet.
If the veins do refill then the incompetent valve

Question 77

What are the investigations for varicose veins?

Answer 77

Doppler ultrasound: The key diagnostic method for varicose veins. It provides information on the anatomy of the veins and the competence of the valves.
Duplex ultrasound: Used to measure blood flow and detect blockages or abnormalities of the veins.
Venography: This may be considered in complex cases where other investigations are inconclusive.
MR venography: May be used when non-invasive tests are inconclusive and surgery is being considered.

Duplex ultrasound is the gold standard imaging modality for assessing the competence of venous valves, evidence of any deep venous thrombosis or stenosis.

Question 78

When are patients with varicose veins referred to vascular surgery:

Answer 78

Patients with symptomatic varicose veins (i.e. other than cosmetic), require referral to vascular surgery.
Emergency referral is used for active bleeding of varicose veins
Urgent referrals are used when patients have experienced active bleeding
Routine referral should be done for patients with:
Pain, itching, aching, discomfort or swelling due to their varicose veins
Venous ulcers (active or healed)
Skin changes associated with chronic venous insufficiency (i.e. pigmentation, eczema, lipodermatosclerosis)

Question 79

What is the management for varicose veins?

Answer 79

Lifestyle modifications are recommended for all individuals:
Reduction of long periods of standing
Elevation of lower limbs when possible
Weight loss
Regular walking to promote venous return

Invasive interventions:
Endothermal (radiofrequency) ablation: Destruction of the vein endothelium via a high-temperature catheter
Endovenous laser ablation: Destruction of the vein using a laser
Injection sclerotherapy: Injection of a sclerosant substance at several points in the vein, leading to occlusion

Surgery:
Avulsion therapy: Individual veins are excised by making small incisions into the skin and removal of the veins using forceps
Vein stripping: A wire is inserted into the saphenous vein and is used to pull the varicose veins out of the leg.
If intervention is not indicated, then compression stockings may be used
Ankle brachial pressure index must be done prior to prescribing compression stockings to rule out arterial insufficiency - Compression bandaging is contraindicated in patients with an ABPI less than 0.8 due to the risk of precipitating limb ischaemia

Question 80

What are the complications for varicose veins?

Answer 80

Haemorrhage of varicose veins
Thrombophlebitis
Venous ulcers
Deep venous thrombosis
Psychological impact and reduced quality of life

Question 81

What is the prognosis for varicose veins?

Answer 81

Without intervention, varicose veins will increase in size and develop complications. However, varicose veins can commonly recur after endovascular or surgical intervention.

Question 82

Define volvulus

Answer 82

Volvulus is a pathological condition in which a portion of the gastrointestinal tract undergoes abnormal twisting or rotation around its mesenteric axis, leading to bowel obstruction and potential vascular compromise.

Question 83

Risk factors for volvulus:

Answer 83

Age: Older adults are more susceptible.
Anatomical Abnormalities: Congenital or acquired conditions that result in a redundant or elongated bowel, such as congenital malrotation or prior abdominal surgery.
Diet: High-fiber diets can reduce the risk, while low-fiber diets may increase it.
Chronic Constipation: Conditions leading to chronic constipation can predispose individuals to volvulus.
Neurological Disorders: Conditions affecting bowel motility, such as Parkinson’s disease or spinal cord injuries.
Previous Volvulus: A history of volvulus increases the risk of recurrence.

Question 84

What are the two most common volvulus?

Answer 84

Sigmoid Volvulus
Sigmoid volvulus occurs when the sigmoid colon twists around its mesenteric axis. This often happens in the presence of a redundant sigmoid colon. The twisted sigmoid segment can result in partial or complete bowel obstruction. Without prompt intervention, it can lead to ischemia and gangrene of the affected bowel.

Caecal Volvulus
Caecal volvulus involves the caecum and ascending colon twisting around its mesenteric axis. This condition may be associated with a mobile cecum. Similar to sigmoid volvulus, cecal volvulus can lead to bowel obstruction and compromised blood supply if left untreated.

Question 85

What are the signs and symptoms of volvulus:

Answer 85

Acute Abdominal Pain: Sudden and severe abdominal pain, often with a colicky or cramping quality.
Abdominal Distension: Swelling and distension of the abdomen due to bowel obstruction.
Constipation: Inability to pass stool, which may progress to obstipation (complete constipation).
Nausea and Vomiting: Nausea, with or without vomiting, may occur as a result of bowel obstruction.
Tenderness on Abdominal Examination: The abdomen may be tender to palpation, especially over the site of volvulus.
Absent Bowel Sounds: Bowel sounds may be decreased or absent due to the obstruction.

Question 86

What are the investigations for volvulus?

Answer 86

Blood tests - FBC may show leucocytosis, suggesting an inflammatory response. U+Es may reveal electrolyte imbalances and dehydration. VBG may show raised lactate if concerns over bowel ischaemia.
Abdominal X-ray: Often shows a characteristic “coffee bean sign” or “bird’s beak sign” indicative of twisted bowel loops (see below).
CT Scan: Provides detailed images of the abdomen, helping to confirm the diagnosis and assess bowel viability.

Question 87

What is the management for volvulus?

Answer 87

Endoscopic Detorsion: For sigmoid volvulus, rigid sigmoidoscopy with rectal tube insertion can be used to untwist the bowel, relieving the obstruction.
Surgical Intervention: In cases of unsuccessful endoscopic detorsion or caecal volvulus, surgery is necessary. Surgical options may include resection of non-viable bowel segments or fixation of mobile caecum - right hemicolectomy is often needed.
Fluid Resuscitation: Patients often require intravenous fluids to correct dehydration and electrolyte imbalances.
Pain Management: Analgesics may be administered to alleviate abdominal pain.
Antibiotics: Prophylactic antibiotics are sometimes prescribed, especially in cases where bowel ischaemia is suspected.

Question 88

What are the complications of volvulus?

Answer 88

Bowel Ischaemia: Reduced blood supply to the twisted bowel segment can result in tissue ischemia and necrosis.
Bowel Perforation: Prolonged obstruction can cause bowel wall perforation, leading to peritonitis.
Sepsis: Infection can spread systemically, leading to sepsis, which is life-threatening.
Abscess Formation: Infected or necrotic bowel tissue can result in abscess formation within the abdomen.
Recurrence: Some individuals may be at increased risk of recurrent volvulus, requiring ongoing management.