Surgery

Question 1

Abdominal aortic aneurysm

Answer 1

Abdominal aortic aneurysms occur primarily as a result of the failure of elastic proteins within the extracellular matrix. Aneurysms typically represent dilation of all layers of the arterial wall. Most aneurysms are caused by degenerative disease. After the age of 50 years the normal diameter of the infrarenal aorta is 1.5cm in females and 1.7cm in males. Diameters of 3cm and greater, are considered aneurysmal. The pathophysiology involved in the development of aneurysms is complex and the primary event is loss of the intima with loss of elastic fibres from the media. This process is associated with, and potentiated by, increased proteolytic activity and lymphocytic infiltration.

Major risk factors for the development of aneurysms include smoking and hypertension. Rare but important causes include syphilis and connective tissues diseases such as Ehlers Danlos type 1 and Marfans syndrome.

Question 2

Abdominal pain

Answer 2

The table below gives characteristic exam question features for conditions causing abdominal pain. Unusual and ‘medical’ causes of abdominal pain should also be remembered:

myocardial infarction

diabetic ketoacidosis

pneumonia

acute intermittent porphyria

lead poisoning

Condition

Characteristic exam feature

Peptic ulcer disease

Duodenal ulcers: more common than gastric ulcers, epigastric pain relieved by eating
Gastric ulcers: epigastric pain worsened by eating
Features of upper gastrointestinal haemorrhage may be seen (haematemesis, melena etc)

Appendicitis

Pain initial in the central abdomen before localising to the right iliac fossa
Anorexia is common
Tachycardia, low-grade pyrexia, tenderness in RIF
Rovsing’s sign: more pain in RIF than LIF when palpating LIF

Acute pancreatitis

Usually due to alcohol or gallstones
Severe epigastric pain
Vomiting is common
Examination may reveal tenderness, ileus and low-grade fever
Periumbilical discolouration (Cullen’s sign) and flank discolouration (Grey-Turner’s sign) is described but rare

Biliary colic

Pain in the RUQ radiating to the back and interscapular region, may be following a fatty meal. Slight misnomer as the pain may persist for hours
Obstructive jaundice may cause pale stools and dark urine
It is sometimes taught that patients are female, forties, fat and fair although this is obviously a generalisation

Acute cholecystitis

History of gallstones symptoms (see above)
Continuous RUQ pain
Fever, raised inflammatory markers and white cells
Murphy’s sign positive (arrest of inspiration on palpation of the RUQ)

Diverticulitis

Colicky pain typically in the LLQ
Fever, raised inflammatory markers and white cells

Abdominal aortic aneurysm

Severe central abdominal pain radiating to the back
Presentation may be catastrophic (e.g. Sudden collapse) or sub-acute (persistent severe central abdominal pain with developing shock)
Patients may have a history of cardiovascular disease

Intestinal obstruction

History of malignancy/previous operations
Vomiting
Not opened bowels recently
‘Tinkling’ bowel sounds

Question 3

Abdominal swelling

Answer 3

The table below gives characteristic exam question features for conditions causing abdominal swelling

Condition

Characteristic exam feature

Pregnancy

Young female
Amenorrhoea

Intestinal obstruction

History of malignancy/previous operations
Vomiting
Not opened bowels recently
‘Tinkling’ bowel sounds

Ascites

History of alcohol excess, cardiac failure

Urinary retention

History of prostate problems
Dullness to percussion around suprapubic area

Ovarian cancer

Older female
Pelvic pain
Urinary symptoms e.g. urgency
Raised CA125
Early satiety, bloating

Question 4

Abdominal wall hernias

Answer 4

The classical surgical definition of a hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it.

Risk factors for abdominal wall hernias include:

obesity

ascites

increasing age

surgical wounds

Features

palpable lump

cough impulse

pain

obstruction: more common in femoral hernias
strangulation: may compromise the bowel blood supply leading to infarction

Types of abdominal wall hernias:

Type of hernia

Details

Inguinal hernia

Inguinal hernias account for 75% of abdominal wall hernias. Around 95% of patients are male; men have around a 25% lifetime risk of developing an inguinal hernia.
Above and medial to pubic tubercle
Strangulation is rare

Femoral hernia

Below and lateral to the pubic tubercle
More common in women, particularly multiparous ones
High risk of obstruction and strangulation
Surgical repair is required

Umbilical hernia

Symmetrical bulge under the umbilicus

Paraumbilical hernia

Asymmetrical bulge - half the sac is covered by skin of the abdomen directly above or below the umbilicus

Epigastric hernia

Lump in the midline between umbilicus and the xiphisternum
Most common in men aged 20-30 years

Incisional hernia

May occur in up to 10% of abdominal operations

Spigelian hernia

Also known as lateral ventral hernia
Rare and seen in older patients
A hernia through the spigelian fascia (the aponeurotic layer between the rectus abdominis muscle medially and the semilunar line laterally)

Obturator hernia

A hernia which passes through the obturator foramen. More common in females and typical presents with bowel obstruction

Richter hernia

A rare type of hernia where only the antimesenteric border of the bowel herniates through the fascial defect

Richter’s hernia can present with strangulation without symptoms of obstruction

Abdominal wall hernias in children:

Type of hernia

Details

Congenital inguinal hernia

Indirect hernias resulting from a patent processus vaginalis
Occur in around 1% of term babies. More common in premature babies and boys
60% are right sided, 10% are bilaterally
Should be surgically repaired soon after diagnosis as at risk of incarceration

Infantile umbilical hernia

Symmetrical bulge under the umbilicus
More common in premature and Afro-Caribbean babies
The vast majority resolve without intervention before the age of 4-5 years
Complications are rare

Question 5

Acute pancreatitis: causes

Answer 5

The vast majority of acute pancreatitis in the UK are caused by gallstones and alcohol

Popular mnemonic is GET SMASHED

Gallstones

Ethanol

Trauma

Steroids

Mumps (other viruses include Coxsackie B)

Autoimmune (e.g. polyarteritis nodosa), Ascaris infection

Scorpion venom

Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia

ERCP

Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)

Question 6

Anal fissure

Answer 6

Anal fissures are longitudinal or elliptical tears of the squamous lining of the distal anal canal. If present for less than 6 weeks they are defined as acute, and chronic if present for more than 6 weeks.
Risk factors

constipation

inflammatory bowel disease

sexually transmitted infections e.g. HIV, syphilis, herpes

Features

painful, bright red, rectal bleeding

around 90% of anal fissures occur on the posterior midline.

if the fissures are found in alternative locations then other underlying causes should be considered e.g. Crohn’s disease

Management of an acute anal fissure (< 6 weeks)

dietary advice: high-fibre diet with high fluid intake

bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried

lubricants such as petroleum jelly may be tried before defecation

topical anaesthetics

analgesia

topical steroids do not provide significant relief

Management of a chronic anal fissure (> 6 weeks)

the above techniques should be continued

topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure

if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin

The combination of pain and bleeding is very characteristic of anal fissures. Pain is a feature of thrombosed external haemorrhoids but is unusual with internal haemorrhoids. Superficial anal fissures may be difficult to see on examination.

Question 7

Anal fissure

Answer 7

Anal fissures are longitudinal or elliptical tears of the squamous lining of the distal anal canal. If present for less than 6 weeks they are defined as acute, and chronic if present for more than 6 weeks.
Risk factors

constipation

inflammatory bowel disease

sexually transmitted infections e.g. HIV, syphilis, herpes

Features

painful, bright red, rectal bleeding

around 90% of anal fissures occur on the posterior midline.

if the fissures are found in alternative locations then other underlying causes should be considered e.g. Crohn’s disease

Management of an acute anal fissure (< 6 weeks)

dietary advice: high-fibre diet with high fluid intake

bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried

lubricants such as petroleum jelly may be tried before defecation

topical anaesthetics

analgesia

topical steroids do not provide significant relief

Management of a chronic anal fissure (> 6 weeks)

the above techniques should be continued

topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure

if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin

Answer 8

Anti-oestrogen drugs

Selective oEstrogen Receptor Modulators (SERM)

Tamoxifen is a SERM which acts as an oestrogen receptor antagonist and partial agonist. It is used in the management of oestrogen receptor-positive breast cancer.

Adverse effects

menstrual disturbance: vaginal bleeding, amenorrhoea

hot flushes - 3% of patients stop taking tamoxifen due to climateric side-effects

venous thromboembolism

endometrial cancer

osteoporosis

Aromatase inhibitors

Anastrozole and letrozole are aromatase inhibitors that reduces peripheral oestrogen synthesis. This is important as aromatisation accounts for the majority of oestrogen production in postmenopausal women and therefore anastrozole is used for ER +ve breast cancer in this group.

Adverse effects

osteoporosis

hot flushes

arthralgia, myalgia

insomnia

Question 9

Ascending cholangitis

Answer 9

Ascending cholangitis is a bacterial infection (typically E. coli) of the biliary tree. The most common predisposing factor is gallstones.

Charcot’s triad of right upper quadrant (RUQ) pain, fever and jaundice occurs in about 20-50% of patients

fever is the most common feature, seen in 90% of patients

RUQ pain 70%

jaundice 60%

hypotension and confusion are also common (the additional 2 factors in addition to the 3 above make Reynolds’ pentad)

Other features

raised inflammatory markers

Management

intravenous antibiotics

endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction

Question 10

Benign prostatic hyperplasia

Answer 10

Benign prostatic hyperplasia (BPH) is a common condition seen in older men.

Risk factors

age: around 50% of 50-year-old men will have evidence of BPH and 30% will have symptoms. Around 80% of 80-year-old men have evidence of BPH
ethnicity: black > white > Asian

BPH typically presents with lower urinary tract symptoms (LUTS), which may be categorised into:

voiding symptoms (obstructive): weak or intermittent urinary flow, straining, hesitancy, terminal dribbling and incomplete emptying

storage symptoms (irritative) urgency, frequency, urgency incontinence and nocturia

post-micturition: dribbling

complications: urinary tract infection, retention, obstructive uropathy

Management options

watchful waiting

medication: alpha-1 antagonists, 5 alpha-reductase inhibitors. The use of combination therapy was supported by the Medical Therapy Of Prostatic Symptoms (MTOPS) trial
surgery: transurethral resection of prostate (TURP)

Alpha-1 antagonists e.g. tamsulosin, alfuzosin

decrease smooth muscle tone (prostate and bladder)

considered first-line, improve symptoms in around 70% of men

adverse effects: dizziness, postural hypotension, dry mouth, depression

5 alpha-reductase inhibitors e.g. finasteride

block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH

unlike alpha-1 antagonists causes a reduction in prostate volume and hence may slow disease progression. This however takes time and symptoms may not improve for 6 months. They may also decrease PSA concentrations by up to 50%

adverse effects: erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia

Question 11

Blood Products

Answer 11

This patient is actively bleeding. The consultant appreciates the need to replace this individual with blood products. Over resuscitation using 0.9% saline can result in dilutional anaemia. This does not improve oxygen transport/ delivery or coagulopathy.

In patients for whom we do not know their blood group, O rhesus negative blood may be prescribed. O rhesus negative is considered the universal donor. O rhesus negative can give blood to any other blood group.

It is imperative to prescribe 1. The correct blood product. 2. The right product for the right patient. Transfusion reactions are serious and deadly.

Excellent resource for blood groups - https://www.pathology.med.umich.edu/bloodbank/manual/bbchart/

Blood products - cross matching

Whole blood fractions

Fraction

Key points

Packed red cells

Used for transfusion in chronic anaemia and cases where infusion of large volumes of fluid may result in cardiovascular compromise. Product obtained by centrifugation of whole blood.

Platelet rich plasma

Usually administered to patients who are thrombocytopaenic and are bleeding or require surgery. It is obtained by low speed centrifugation.

Platelet concentrate

Prepared by high speed centrifugation and administered to patients with thrombocytopaenia.

Fresh frozen plasma

Prepared from single units of blood.

Contains clotting factors, albumin and immunoglobulin.

Unit is usually 200 to 250ml.

Usually used in correcting clotting deficiencies in patients with hepatic synthetic failure who are due to undergo surgery.

Usual dose is 12-15ml/Kg-1.

It should not be used as first line therapy for hypovolaemia.

Cryoprecipitate

Formed from supernatant of FFP.

Rich source of Factor VIII and fibrinogen.

Allows large concentration of factor VIII to be administered in small volume.

SAG-Mannitol Blood

Removal of all plasma from a blood unit and substitution with:

Sodium chloride

Adenine

Anhydrous glucose

Mannitol

Up to 4 units of SAG M Blood may be administered. Thereafter whole blood is preferred. After 8 units, clotting factors and platelets should be considered.

Cross matching

Must be cross matched

Can be ABO incompatible in adults

Packed red cells

Platelets

Fresh frozen plasma

Cryoprecipitate

Whole blood

Question 12

Brain death

Answer 12

Criteria for brain stem death testing

Deep coma of known aetiology.

Reversible causes excluded

No sedation

Normal electrolytes

Testing for brain death

Fixed pupils which do not respond to sharp changes in the intensity of incident light

No corneal reflex

Absent oculo-vestibular reflexes - no eye movements following the slow injection of at least 50ml of ice-cold water into each ear in turn (the caloric test)

No response to supraorbital pressure

No cough reflex to bronchial stimulation or gagging response to pharyngeal stimulation

No observed respiratory effort in response to disconnection of the ventilator for long enough (typically 5 minutes) to ensure elevation of the arterial partial pressure of carbon dioxide to at least 6.0 kPa (6.5 kPa in patients with chronic carbon dioxide retention). Adequate oxygenation is ensured by pre-oxygenation and diffusion oxygenation during the disconnection (so the brain stem respiratory centre is not challenged by the ultimate, anoxic, drive stimulus)

The test should be undertaken by two appropriately experienced doctors on two separate occasions. Both should be experienced in performing brain stem death testing and have at least 5 years post graduate experience. One of them must be a consultant. Neither can be a member of the transplant team (if organ donation contemplated).

Question 13

Breast cancer screening

Answer 13

The NHS Breast Screening Programme is being expanded to include women aged 47-73 years from the previous parameter of 50-70 years. Women are offered a mammogram every 3 years. After the age of 70 years women may still have mammograms but are ‘encouraged to make their own appointments’.

The effectiveness of breast screening is regularly debated although it is currently thought that the NHS Breast Screening Programme may save around 1,400 lives per year.

Familial breast cancer

NICE published guidelines on the management of familial breast cancer in 2013, giving guidelines on who needs referral.

If the person concerned only has one first-degree or second-degree relative diagnosed with breast cancer they do NOT need to be referred unless any of the following are present in the family history:

age of diagnosis < 40 years

bilateral breast cancer

male breast cancer

ovarian cancer

Jewish ancestry

sarcoma in a relative younger than age 45 years

glioma or childhood adrenal cortical carcinomas

complicated patterns of multiple cancers at a young age

paternal history of breast cancer (two or more relatives on the father’s side of the family)

Women who are at an increased risk of breast cancer due to their family history may be offered screening from a younger age. The following patients should be referred to the breast clinic for further assessment:

one first-degree female relative diagnosed with breast cancer at younger than age 40 years, or

one first-degree male relative diagnosed with breast cancer at any age, or

one first-degree relative with bilateral breast cancer where the first primary was diagnosed at younger than age 50 years, or

two first-degree relatives, or one first-degree and one second-degree relative, diagnosed with breast cancer at any age, or

one first-degree or second-degree relative diagnosed with breast cancer at any age and one first-degree or second-degree relative diagnosed with ovarian cancer at any age (one of these should be a first-degree relative), or

three first-degree or second-degree relatives diagnosed with breast cancer at any age

NICE guidelines suggest a cut-off age of 30 years when a woman has an unexplained breast lump with or without pain. As this 28-year-old is below this cut-off she should be referred non-urgently to the local breast services.

Question 14

Breast cancer: referral

Answer 14

NICE published referral guidelines for suspected breast cancer in 2015 (our emphasis):

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:

aged 30 and over and have an unexplained breast lump with or without pain or

aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people:

with skin changes that suggest breast cancer or

aged 30 and over with an unexplained lump in the axilla

Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain.

Paternal family history of breast cancer - secondary care referral

Importance: 43

Paternal family history of breast cancer warrants a secondary care referral.

Breast cancer might not be evident in breast examination hence option 1 and 5 are incorrect.

Waiting for the routine screen may delay the diagnosis as she is at high risk for familial breast cancer.

Review in one year may delay the diagnosis.

Question 15

Basic breast anatomy

Answer 15

Most breast cancers arise from duct tissue followed by lobular tissue, described as ductal or lobular carcinoma respectively. These can be further subdivided as to whether the cancer hasn’t spread beyond the local tissue (described as carcinoma-in-situ) or has spread (described as invasive). Therefore, common breast cancer types include:

Invasive ductal carcinoma. This is the most common type of breast cancer. To complicate matters further this has recently been renamed ‘No Special Type (NST)’. In contrast, lobular carcinoma and other rarer types of breast cancer are classified as ‘Special Type’

Invasive lobular carcinoma

Ductal carcinoma-in-situ (DCIS)

Lobular carcinoma-in-situ (LCIS)

Rarer types of breast cancer are shown in the following list. These are classed as ‘Special Type’ but as noted previously remember that a relatively common type of breast cancer (lobular) is also Special Type:

Medullary breast cancer

Mucinous (mucoid or colloid) breast cancer

Tubular breast cancer

Adenoid cystic carcinoma of the breast

Metaplastic breast cancer

Lymphoma of the breast

Basal type breast cancer

Phyllodes or cystosarcoma phyllodes

Papillary breast cancer

Other types of breast cancer include the following (although please note they may be associated with the underlying lesions seen above, rather than completely separate subtypes):

Paget’s disease of the nipple is an eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer. In half of these patients, it is associated with an underlying mass lesion and 90% of such patients will have an invasive carcinoma. 30% of patients without a mass lesion will still be found to have an underlying carcinoma. The remainder will have carcinoma in situ.

Inflammatory breast cancer where cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast. This accounts for around 1 in 10,000 cases of breast cancer.

Tamoxifen is used as the women is pre-menopausal. There is ongoing debate about whether therapy should be for 5 years or longer.

Question 16

management of breast cancer

Answer 16

Breast cancer: management

The management of breast cancer depends on the staging, tumour type and patient background. It may involve any of the following:

surgery

radiotherapy

hormone therapy

biological therapy

chemotherapy

Surgery

The vast majority of patients who have breast cancer diagnosed will be offered surgery. An exception may be a very frail, elderly lady with metastatic disease who may be better managed with hormonal therapy.

Prior to surgery, the presence/absence of axillary lymphadenopathy determines management:

women with no palpable axillary lymphadenopathy at presentation should have a pre-operative axillary ultrasound before their primary surgery

if positive then they should have a sentinel node biopsy to assess the nodal burden

in patients with breast cancer who present with clinically palpable lymphadenopathy, axillary node clearance is indicated at primary surgery

this may lead to arm lymphedema and functional arm impairment

Depending on the characteristics of the tumour women either have a wide-local excision or a mastectomy. Around two-thirds of tumours can be removed with a wide-local excision. The table below lists some of the factors determining which operation is offered:

Mastectomy
Women should be offered breast reconstruction to achieve a cosmetically suitable result regardless of the type of operation they have. For women who’ve had a mastectomy this may be done at the initial operation or at a later date.

Radiotherapy

Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds. For women who’ve had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes

Hormonal therapy

Adjuvant hormonal therapy is offered if tumours are positive for hormone receptors. For many years this was done using tamoxifen for 5 years after diagnosis. Tamoxifen is still used in pre- and peri-menopausal women. In post-menopausal women, aromatase inhibitors such as anastrozole are used for this purpose*. This is important as aromatisation accounts for the majority of oestrogen production in post-menopausal women and therefore anastrozole is used for ER +ve breast cancer in this group.

Important side-effects of tamoxifen include an increased risk of endometrial cancer, venous thromboembolism and menopausal symptoms.

Biological therapy

The most common type of biological therapy used for breast cancer is trastuzumab (Herceptin). It is only useful in the 20-25% of tumours that are HER2 positive.

Trastuzumab cannot be used in patients with a history of heart disorders.

Chemotherapy

Cytotoxic therapy may be used either prior to surgery (‘neoadjuvanant’ chemotherapy) to downstage a primary lesion or after surgery depending on the stage of the tumour, for example, if there is axillary node disease - FEC-D is used in this situation.

HRT, early menarche, late menopause and COCP all increase the risk of breast cancer whereas multiple pregnancy and breastfeeding reduce the risk

Important for meLess important

The correct answer here is early menarche which is a risk factor for breast cancer along with late menopause, combined oral contraceptive use and hormone replacement therapy.

Multiple pregnancy and breastfeeding are protective and reduce the risk of breast cancer.

Question 17

Breast disorders

Answer 17

The table below describes some of the features seen in the most common breast disorders:

Disorder

Features

Fibroadenoma

Common in women under the age of 30 years
Often described as ‘breast mice’ due as they are discrete, non-tender, highly mobile lumps

Fibroadenosis (fibrocystic disease, benign mammary dysplasia)

Most common in middle-aged women
‘Lumpy’ breasts which may be painful. Symptoms may worsen prior to menstruation

Breast cancer

Characteristically a hard, irregular lump. There may be associated nipple inversion or skin tethering

Paget’s disease of the breast - intraductal carcinoma associated with a reddening and thickening (may resemble eczematous changes) of the nipple/areola

Mammary duct ectasia

Dilatation of the large breast ducts
Most common around the menopause
May present with a tender lump around the areola +/- a green nipple discharge
If ruptures may cause local inflammation, sometimes referred to as ‘plasma cell mastitis’

Duct papilloma

Local areas of epithelial proliferation in large mammary ducts
Hyperplastic lesions rather than malignant or premalignant
May present with blood stained discharge

Fat necrosis

More common in obese women with large breasts
May follow trivial or unnoticed trauma
Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
Rare and may mimic breast cancer so further investigation is always warranted

Breast abscess

More common in lactating women
Red, hot tender swelling

Lipomas and sebaceous cysts may also develop around the breast tissue.

Question 18

Fat necrosis of the breast

Answer 18

Fat necrosis

Up to 40% cases usually have a traumatic aetiology

Physical features usually mimic carcinoma

Mass may increase in size initially

Consider non-urgent referral in people aged < 30 years with an unexplained breast lump with or without pain

Importance: 49

Consider non-urgent referral in people aged < 30 years with an unexplained breast lump with or without pain.

Two-week rule referral is not necessary at this stage.

She needs to be referred. Review by GP in 6 months or one year might delay the diagnosis.

Having no follow-up is not appropriate as this patient needs to have the appropriate investigations.

Question 19

Breast cancer: referral

Answer 19

NICE published referral guidelines for suspected breast cancer in 2015 (our emphasis):

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:

aged 30 and over and have an unexplained breast lump with or without pain or

aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people:

with skin changes that suggest breast cancer or

aged 30 and over with an unexplained lump in the axilla

Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain.

Breast abscess in lactational women: Staphylococcus aureus is the most common cause

Importance: 62

Staphylococcus aureus is the most common cause of breast abscess in lactational women.

Candida species is not a common cause of breast abscess in lactating women.

Group B streptococcus and klebsiella pneumoniae are causes of breast abscess in non-lactating women.

Staphylococcus epidermidis is not a common cause of breast abscess in lactating women.

Question 20

Breast abscess

Answer 20

In lactational women Staphylococcus aureus is the most common cause

Typical presentation is with a tender, fluctuant mass in a lactating women

Diagnosis and treatment is performed using USS and associated drainage of the abscess cavity. Antibiotics should also be administered

Where there is necrotic skin overlying the abscess, the patient should undergo surgery

Young female with small fibroadenomas (less than 3cm on imaging): first-line management is watchful waiting without biopsy

Importance: 76

Young female with small fibroadenomas (less than 3cm on imaging): first-line management is watchful waiting without the biopsy.

Fine needle biopsy an core biopsy is not necessary given the size of the lesion.

Excision and mastectomy are not appropriate at this stage.

Breast fibroadenoma

Basics

Develop from a whole lobule

Mobile, firm breast lumps

12% of all breast masses

Over a 2 year period up to 30% will get smaller

No increase in risk of malignancy

Question 21

Circumcision

Answer 21

Circumcision has been performed in a variety of cultures for thousands of years. Today it is mainly people of the Jewish and Islamic faith who undergo circumcision for religious/cultural reasons. Circumcision for religious or cultural reasons is not available on the NHS.

The medical benefits of routine circumcision remain controversial although some evidence has emerged that it:

reduces the risk of penile cancer

reduces the risk of UTI

reduces the risk of acquiring sexually transmitted infections including HIV

Medical indications for circumcision

phimosis

recurrent balanitis

balanitis xerotica obliterans

paraphimosis

It is important to exclude hypospadias prior to circumcision as the foreskin may be used in surgical repair. Circumcision may be performed under a local or general anaesthetic.

Question 22

Colorectal cancer screening

Answer 22

Overview

most cancers develop from adenomatous polyps. Screening for colorectal cancer has been shown to reduce mortality by 16%

the NHS offers home-based, Faecal Immunochemical Test (FIT) screening to older adults

another type of screening is also being rolled out - a one-off flexible sigmoidoscopy

Faecal Immunochemical Test (FIT) screening

Key points

the NHS now has a national screening programme offering screening every 2 years to all men and women aged 60 to 74 years in England, 50 to 74 years in Scotland. Patients aged over 74 years may request screening

eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post

a type of faecal occult blood (FOB) test which uses antibodies that specifically recognise human haemoglobin (Hb)

used to detect, and can quantify, the amount of human blood in a single stool sample

advantages over conventional FOB tests is that it only detects human haemoglobin, as opposed to animal haemoglobin ingested through diet

only one faecal sample is needed compared to the 2-3 for conventional FOB tests

whilst a numerical value is generated, this is not reported to the patient or GP, who will instead be informed if the test is normal or abnormal

patients with abnormal results are offered a colonoscopy

At colonoscopy, approximately:

5 out of 10 patients will have a normal exam

4 out of 10 patients will be found to have polyps which may be removed due to their premalignant potential

1 out of 10 patients will be found to have cancer

Question 23

Flexible sigmoidoscopy screening

Colorectal cancer: referral guidelines

Answer 23

Key points

screening for bowel cancer using sigmoidoscopy is being rolled out as part of the NHS screening program

the aim (other than to detect asymptomatic cancers) is to allow the detection and treatment of polyps, reducing the future risk of colorectal cancer

this is being offered to people who are 55-years-old

NHS patient information leaflets refer to this as ‘bowel scope screening’

patients can self-refer for bowel screening with sigmoidoscopy up to the age of 60, if the offer of routine one-off screening at age 55 had not been taken up

Colorectal cancer: referral guidelines

NICE updated their referral guidelines in 2015. The following patients should be referred urgently (i.e. within 2 weeks) to colorectal services for investigation:

patients >= 40 years with unexplained weight loss AND abdominal pain

patients >= 50 years with unexplained rectal bleeding

patients >= 60 years with iron deficiency anaemia OR change in bowel habit

tests show occult blood in their faeces (see below)

An urgent referral (within 2 weeks) should be ‘considered’ if:

there is a rectal or abdominal mass

there is an unexplained anal mass or anal ulceration

patients < 50 years with rectal bleeding AND any of the following unexplained symptoms/findings:

• → abdominal pain
• → change in bowel habit
• → weight loss
• → iron deficiency anaemia

Faecal Occult Blood Testing (FOBT)

This was one of the main changes in 2015. Remember that the NHS now has a national screening programme offering screening every 2 years to all men and women aged 60 to 74 years. Patients aged over 74 years may request screening.

In addition FOBT should be offered to:

patients >= 50 years with unexplained abdominal pain OR weight loss

patients < 60 years with changes in their bowel habit OR iron deficiency anaemia

patients >= 60 years who have anaemia even in the absence of iron deficiency

Colorectal cancer screening - PPV of FOB = 5 - 15%

Importance: 47

There is also a 30-45% chance of having an adenoma with a positive faecal occult blood test

Screening for colorectal cancer via faecal occult blood testing is not appropriate under the age of 60

Importance: 75

This woman has the symptoms of irritable bowel syndrome. She does not describe any red flag symptoms and has unremarkable blood results.

Repeating the full blood count is unlikely to add more to the clinical picture.

Screening for colorectal cancer via faecal occult blood testing is not appropriate under the age of 60 or in symptomatic patients.

Steroids and azathioprine are not used to treat irritable bowel symptoms, they are treatments for ulcerative colitis which is unlikely given this lady’s symptoms and normal bloods.

Patient >= 60 years old with new iron-deficiency anaemia → urgent colorectal cancer pathway referral

Question 24

Epididymo-orchitis

Answer 24

Epididymo-orchitis describes an infection of the epididymis +/- testes resulting in pain and swelling. It is most commonly caused by local spread of infections from the genital tract (such as Chlamydia trachomatis and Neisseria gonorrhoeae) or the bladder.

The most important differential diagnosis is testicular torsion. This needs to be excluded urgently to prevent ischaemia of the testicle.

Features

unilateral testicular pain and swelling

urethral discharge may be present, but urethritis is often asymptomatic

factors suggesting testicular torsion include patients < 20 years, severe pain and an acute onset

Management

the British Association for Sexual Health and HIV (BASHH) produced guidelines in 2010

if the organism is unknown BASHH recommend: ceftriaxone 500mg intramuscularly single dose, plus doxycycline 100mg by mouth twice daily for 10-14 days

further investigations following treatment are recommended to exclude any underlying structural abnormalities

An epididymal cyst is a cause of scrotal swelling which can be palpated as separate from the body of the testicle

Question 25

Haemorrhoids

Answer 25

Haemorrhoidal tissue is part of the normal anatomy which contributes to anal continence. These mucosal vascular cushions are found in the left lateral, right posterior and right anterior portions of the anal canal (3 o’clock, 7’o’clock and 11 o’clock respectively). Haemorrhoids are said to exist when they become enlarged, congested and symptomatic

Clinical features

painless rectal bleeding is the most common symptom

pruritus

pain: usually not significant unless piles are thrombosed

soiling may occur with third or forth degree piles

Types of haemorrhoids

External

originate below the dentate line

prone to thrombosis, may be painful

Internal

originate above the dentate line

do not generally cause pain

Grading of internal haemorrhoids

Grade I

Do not prolapse out of the anal canal

Grade II

Prolapse on defecation but reduce spontaneously

Grade III

Can be manually reduced

Grade IV

Cannot be reduced

Management

soften stools: increase dietary fibre and fluid intake

topical local anaesthetics and steroids may be used to help symptoms

outpatient treatments: rubber band ligation is superior to injection sclerotherapy

surgery is reserved for large symptomatic haemorrhoids which do not respond to outpatient treatments

newer treatments: Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy

Acutely thrombosed external haemorrhoids

typically present with significant pain

examination reveals a purplish, oedematous, tender subcutaneous perianal mass

if patient presents within 72 hours then referral should be considered for excision. Otherwise patients can usually be managed with stool softeners, ice packs and analgesia. Symptoms usually settle within 10 days

Question 26

Anorectal disorders

Answer 26

Haemorrhoids

Location: 3, 7, 11 o’clock position
Internal or external
Treatment: Conservative, Rubber band ligation, Haemorrhoidectomy

Fissure in ano

Location: midline 6 (posterior midline 90%) and 12 o’clock position. Distal to the dentate line
Chronic fissure > 6/52: triad: Ulcer, sentinel pile, enlarged anal papillae

Proctitis

Causes: Crohn’s, ulcerative colitis, Clostridium difficile

Ano rectal abscess

E.coli, staph aureus
Positions: Perianal, Ischiorectal, Pelvirectal, Intersphincteric

Anal fistula

Usually due to previous ano-rectal abscess
Intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric. Goodsalls rule determines location

Rectal prolapse

Associated with childbirth and rectal intussceception. May be internal or external

Pruritus ani

Systemic and local causes

Anal neoplasm

Squamous cell carcinoma commonest unlike adenocarcinoma in rectum

Solitary rectal ulcer

Associated with chronic straining and constipation. Histology shows mucosal thickening, lamina propria replaced with collagen and smooth muscle (fibromuscular obliteration)

Question 27

Head injury - types of traumatic brain injury

Answer 27

TBI

Basics

primary brain injury may be focal (contusion/haematoma) or diffuse (diffuse axonal injury)

diffuse axonal injury occurs as a result of mechanical shearing following deceleration, causing disruption and tearing of axons

intra-cranial haematomas can be extradural, subdural or intracerebral, while contusions may occur adjacent to (coup) or contralateral (contre-coup) to the side of impact

secondary brain injury occurs when cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury. The normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia

the Cushings reflex (hypertension and bradycardia) often occurs late and is usually a pre terminal event

Type of injury

Notes

Extradural (epidural) haematoma

Bleeding into the space between the dura mater and the skull. Often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of epidural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery.

Features

features of raised intracranial pressure

some patients may exhibit a lucid interval

Subdural haematoma

Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes.

Risk factors include old age, alcoholism and anticoagulation.

Slower onset of symptoms than a epidural haematoma. There may be fluctuating confusion/consciousness

Subarachnoid haemorrhage

Classically causes a sudden occipital headache. Usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury

Question 28

Head injury: NICE guidance on investigation

Answer 28

Head injury: NICE guidance on investigation

NICE has strict and clear guidance regarding which adult patients are safe to discharge and which need further CT head imaging. The latter group are also divided into two further cohorts, those who require an immediate CT head and those requiring CT head within 8 hours of injury:

CT head immediately

GCS < 13 on initial assessment

GCS < 15 at 2 hours post-injury

suspected open or depressed skull fracture.

any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).

post-traumatic seizure.

focal neurological deficit.

more than 1 episode of vomiting

CT head scan within 8 hours of the head injury - for adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury:

age 65 years or older

any history of bleeding or clotting disorders

dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)

more than 30 minutes’ retrograde amnesia of events immediately before the head injury

If a patient is on warfarin who have sustained a head injury with no other indications for a CT head scan, perform a CT head scan within 8 hours of the injury.

Question 29

Hearing Loss

Answer 29

Hearing Loss

Hearing loss may be conductive or sensorineural. To determine which is present patients will often require a formal assessment with pure tone audiometry. In the clinical setting Webers and Rinnes tests may be helpful in categorising various types of hearing loss.

Webers and Rinnes Tests
In a normal patient, the Weber tuning fork sound is heard equally loud in both ears with no one ear hearing the sound louder than the other. A patient with symmetrical hearing loss will hear the Weber tuning fork sound equally well with diagnostic utility only in asymmetric (one-sided) hearing losses. In a patient with asymmetrical hearing loss, the Weber tuning fork sound is heard louder in one ear versus the other. This clinical finding should be confirmed by repeating the procedure and having the patient occlude one ear with a finger; the sound should be heard best in the occluded ear.

Rinne Test

Weber without lateralisation

Weber lateralises to left

Weber lateralises to right

Both ears Air>Bone

Normal

Sensorineural loss on right

Sensorineural loss on left

Left Bone > Air

Conductive loss on left

Combined loss on left

Right Bone> Air

Combined loss on right

Conductive loss on right

Both Bone > Air

Combined loss on right and conductive on left

Combined loss on left and conductive on right

Question 30

Inguinal hernia

Answer 30

Inguinal hernia

Inguinal hernias account for 75% of abdominal wall hernias. Around 95% of patients are male; men have around a 25% lifetime risk of developing an inguinal hernia.

Features

groin lump: disappears on pressure or when the patient lies down

discomfort and ache: often worse with activity, severe pain is uncommon

strangulation is rare

Whilst traditional textbooks describe the anatomical differences between indirect (hernia through the inguinal canal) and direct hernias (through the posterior wall of the inguinal canal) this is of no relevance to the clinical management.

Management

the clinical consensus is currently to treat medically fit patients even if they are asymptomatic

a hernia truss may be an option for patients not fit for surgery but probably has little role in other patients

mesh repair is associated with the lowest recurrence rate

The Department for Work and Pensions recommend that following an open repair patients return to non-manual work after 2-3 weeks and following laparoscopic repair after 1-2 weeks

Complications

early: bruising, wound infection
late: chronic pain, recurrence

Question 31

Lower urinary tract symptoms in men

Answer 31

Lower urinary tract symptoms in men

Lower urinary tract symptoms (LUTS) in men are very common and are present in the majority of men aged > 50 years. They are most commonly secondary to benign prostatic hyperplasia but other causes should be considered including prostate cancer.

It is useful to classify the symptoms into 3 broad groups.

Voiding

Storage

Post-micturition

Hesitancy
Poor or intermittent stream
Straining
Incomplete emptying
Terminal dribbling

Urgency
Frequency
Nocturia
Urinary incontinence

Post-micturition dribbling
Sensation of incomplete emptying

Examination

urinalysis: exclude infection, check for haematuria

digital rectal examination: size and consistency of prostate

a PSA test may be indicated, but the patient should be properly counselled first

It is useful to get the patient to complete the following to guide management:

urinary frequency-volume chart: distinguish between urinary frequency, polyuria, nocturia, and nocturnal polyuria.

International Prostate Symptom Score (IPSS): assess the impact on the patient’s life. This classifies the symptoms as mild, moderate or severe

Management
Predominately voiding symptoms

conservative measures include: pelvic floor muscle training, bladder training, prudent fluid intake and containment products

if ‘moderate’ or ‘severe’ symptoms offer an alpha-blocker

if the prostate is enlarged and the patient is ‘considered at high risk of progression’ then a 5-alpha reductase inhibitor should be offered

if the patient has an enlarged prostate and ‘moderate’ or ‘severe’ symptoms offer both an alpha-blocker and 5-alpha reductase inhibitor

if there are mixed symptoms of voiding and storage not responding to an alpha blocker then a antimuscarinic (anticholinergic) drug may be added

Predominately overactive bladder

conservative measures include moderating fluid intake

bladder retraining should be offered

antimuscarinic drugs should be offered if symptoms persist. NICE recommend oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily preparation)

mirabegron may be considered if first-line drugs fail

Nocturia

advise about moderating fluid intake at night

furosemide 40mg in late afternoon may be considered

desmopressin may also be helpful

Question 32

Minor surgery

Answer 32

Minor surgery

Local anaesthetic (LA)

Lidocaine is the most widely used LA. It has a rapid onset of action and anaesthesia lasts for around 1 hour.

the maximum safe dose is 3mg/kg. The BNF states 200mg (or 500mg if given in solutions containing adrenaline), which equates to 3mg/kg for a 66kg patient. This is the equivalent of 20ml of 1% solution or 10ml of 2% solution

lidocaine is available pre-mixed with adrenaline. This increases the duration of action of lidocaine and reduces blood loss secondary to vasoconstriction. It must never be used near extremities due to the risk of ischaemia

Suture material

Non-absorbable

Absorbable

Silk
Novafil
Prolene
Ethilon

Vicryl
Dexon
PDS

Non-absorbable sutures are normally removed after 7-14 days, depending on the location. Absorbable sutures normally disappear after 7-10 days. Removal times for non-absorbable sutures are shown below:

Area

Removal time (days)

Face

3 - 5

Scalp, limbs, chest

7 - 10

Hand, foot, back

10 - 14

Question 33

Penile cancer

Answer 33

Penile cancer

Penile cancer is a rare form of cancer that is usually a squamous cell carcinoma.

Features

penile lump

penile ulceration

Risk factors:

Human immunodeficiency virus infection

Human papillomavirus virus infection

Genital warts

Poor hygiene

Phimosis

Paraphimosis

Balanitis

Age >50

Treatment:

Radiotherapy

Chemotherapy

Surgery

Prognosis:

Approximately 50% at 5 years

Question 34

Peripheral arterial disease management

Answer 34

Peripheral arterial disease management

Peripheral arterial disease (PAD) is strongly linked to smoking. Patients who still smoke should be given help to quit smoking.

Comorbidities should be treated, including

hypertension

diabetes mellitus

obesity

As with any patient who has established cardiovascular disease, all patients should be taking a statin. Atorvastatin 80 mg is currently recommended. In 2010 NICE published guidance suggesting that clopidogrel should be used first-line in patients with peripheral arterial disease in preference to aspirin.

Exercise training has been shown to have significant benefits. NICE recommend a supervised exercise programme for all patients with peripheral arterial disease prior to other interventions.

Severe PAD or critical limb ischaemia may be treated by:

angioplasty

stenting

bypass surgery

Amputation should be reserved for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty of bypass surgery.

Drugs licensed for use in peripheral arterial disease (PAD) include:

naftidrofuryl oxalate: vasodilator, sometimes used for patients with a poor quality of life

cilostazol: phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects - not recommended by NICE

Question 35

Prostate cancer PSA testing

Answer 35

Prostate cancer PSA testing

Prostate specific antigen (PSA) is a serine protease enzyme produced by normal and malignant prostate epithelial cells. It has become an important tumour marker but much controversy still exists regarding its usefulness as a screening tool.

The NHS Prostate Cancer Risk Management Programme (PCRMP) has published updated guidelines in 2009 on how to handle requests for PSA testing in asymptomatic men. A recent European trial (ERSPC) showed a statistically significant reduction in the rate of death prostate cancer by 20% in men aged 55 to 69 years but this was associated with a high risk of over-diagnosis and over-treatment. Having reviewed this and other data the National Screening Committee have decided not to introduce a prostate cancer screening programme yet but rather allow men to make an informed choice.

Age-adjusted upper limits for PSA were recommended by the PCRMP:

Age

PSA level (ng/ml)

50-59 years

3.0

60-69 years

4.0

> 70 years

5.0

However, NICE Clinical Knowledge Summaries currently suggest a different cut-off:

men aged 50-69 years should be referred if the PSA is >= 3.0 ng/ml OR there is an abnormal DRE

note this is a lower threshold than the PCRMP 60-69 years limits recommended above

PSA levels may also be raised by*:

benign prostatic hyperplasia (BPH)

prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after treatment)

ejaculation (ideally not in the previous 48 hours)

vigorous exercise (ideally not in the previous 48 hours)

urinary retention

instrumentation of the urinary tract

Poor specificity and sensitivity

around 33% of men with a PSA of 4-10 ng/ml will be found to have prostate cancer. With a PSA of 10-20 ng/ml this rises to 60% of men

around 20% with prostate cancer have a normal PSA

various methods are used to try and add greater meaning to a PSA level including age-adjusted upper limits and monitoring change in PSA level with time (PSA velocity or PSA doubling time)

*whether digital rectal examination actually causes a rise in PSA levels is a matter of debate

Avoid performing a prostate specific antigen test within one month of prostatitis

Question 36

Prostate cancer: investigation

Answer 36

Prostate cancer: investigation

The traditional investigation for suspected prostate cancer was a transrectal ultrasound-guided (TRUS) biopsy. However, recent guidelines from NICE have now advocated the increasing use of multiparametric MRI as a first-line investigation.

Complications of TRUS biopsy:

sepsis: 1% of cases
pain: lasting >= 2 weeks in 15% and severe in 7%
fever: 5%

haematuria and rectal bleeding

Multiparametric MRI is now the first-line investigation for people with suspected clinically localised prostate cancer.

the results are reported using a 5‑point Likert scale

If the Likert scale is >=3 a multiparametric MRI-influenced prostate biopsy is offered

If the Likert scale is 1-2 then NICE recommend discussing with the patient the pros and cons of having a biopsy.

Prostate cancer - more common in the Afro-Caribbean population

Prostate cancer: features

Prostate cancer is now the most common cancer in adult males in the UK and is the second most common cause of death due to cancer in men after lung cancer.

Risk factors

increasing age

obesity

Afro-Caribbean ethnicity

family history: around 5-10% of cases have a strong family history

Localised prostate cancer is often asymptomatic. This is partly because cancers tend to develop in the periphery of the prostate and hence don’t cause obstructive symptoms early on. Possible features include:

bladder outlet obstruction: hesitancy, urinary retention

haematuria, haematospermia

pain: back, perineal or testicular

digital rectal examination: asymmetrical, hard, nodular enlargement with loss of median sulcus

NICE advise that, as PSA levels may be increased, testing should not be done within at least:

6 weeks of a prostate biopsy

4 weeks following a proven urinary infection

1 week of digital rectal examination

48 hours of vigorous exercise

48 hours of ejaculation

Question 37

Renal Stones

Answer 37

The British Association of Urological Surgeons (BAUS) published guidelines in 2018 on the management of acute ureteric/renal colic.

Initial management of renal colic

Medication

the BAUS recommend an NSAID as the analgesia of choice for renal colic

whilst diclofenac has been traditionally used the increased risk of cardiovascular events with certain NSAIDs (e.g. diclofenac, ibuprofen) should be considered when prescribing

the CKS guidelines suggest for patients who require admission: ‘Administer a parenteral analgesic (such as intramuscular diclofenac) for rapid relief of severe pain’

BAUS no longer endorse the use of alpha-adrenergic blockers to aid ureteric stone passage routinely. They do however acknowledge a recently published meta-analysis advocates the use of α-blockers for patients amenable to conservative management, with greatest benefit amongst those with larger stones

Initial investigations

urine dipstick and culture

serum creatinine and electrolytes: check renal function

FBC / CRP: look for associated infection

calcium/urate: look for underlying causes

also: clotting if percutaneous intervention planned and blood cultures if pyrexial or other signs of sepsis

Imaging

BAUS now recommend that non-contrast CT KUB should be performed on all patients, within 14 hours of admission

if a patient has a fever, a solitary kidney or when the diagnosis is uncertain an immediate CT KUB should be performed. In the case of an uncertain diagnosis, this is to exclude other diagnoses such as ruptured abdominal aortic aneurysm

CT KUB has a sensitivity of 97% for ureteric stones and a specificity of 95%

ultrasound still has a role but given the wider availability of CT now and greater accurary it is no longer recommend first-line. The sensitivity of ultrasound for stones is around 45% and specificity is around 90%

Management of renal stones

Stones < 5 mm will usually pass spontaneously. Lithotripsy and nephrolithotomy may be for severe cases.

Most renal stones measuring less than 5mm in maximum diameter will typically pass within 4 weeks of symptom onset. More intensive and urgent treatment is indicated in the presence of ureteric obstruction, renal developmental abnormality such as horseshoe kidney and previous renal transplant. Ureteric obstruction due to stones together with infection is a surgical emergency and the system must be decompressed. Options include nephrostomy tube placement, insertion of ureteric catheters and ureteric stent placement.

In the non-emergency setting, the preferred options for treatment of stone disease include extra corporeal shock wave lithotripsy, percutaneous nephrolithotomy, ureteroscopy, open surgery remains an option for selected cases. However, minimally invasive options are the most popular first-line treatment.

Shockwave lithotripsy

A shock wave is generated external to the patient, internally cavitation bubbles and mechanical stress lead to stone fragmentation. The passage of shock waves can result in the development of solid organ injury. Fragmentation of larger stones may result in the development of ureteric obstruction. The procedure is uncomfortable for patients and analgesia is required during the procedure and afterwards.

Ureteroscopy

A ureteroscope is passed retrograde through the ureter and into the renal pelvis. It is indicated in individuals (e.g. pregnant females) where lithotripsy is contraindicated and in complex stone disease. In most cases a stent is left in situ for 4 weeks after the procedure.

Percutaneous nephrolithotomy

In this procedure, access is gained to the renal collecting system. Once access is achieved, intra corporeal lithotripsy or stone fragmentation is performed and stone fragments removed.

Therapeutic selection

Disease

Option

Stone burden of less than 2cm in aggregate

Lithotripsy

Stone burden of less than 2cm in pregnant females

Ureteroscopy

Complex renal calculi and staghorn calculi

Percutaneous nephrolithotomy

Ureteric calculi less than 5mm

Manage expectantly

Question 38

Prevention of renal stones

Answer 38

Prevention of renal stones
Calcium stones may be due to hypercalciuria, which is found in up to 5-10% of the general population.

high fluid intake

low animal protein, low salt diet (a low calcium diet has not been shown to be superior to a normocalcaemic diet)

thiazides diuretics (increase distal tubular calcium resorption)

Oxalate stones

cholestyramine reduces urinary oxalate secretion

pyridoxine reduces urinary oxalate secretion

Uric acid stones

allopurinol

urinary alkalinization e.g. oral bicarbonate

Question 39

Scrotal problems

Answer 39

Scrotal problems

Epididymal cysts

Epididymal cysts are the most common cause of scrotal swellings seen in primary care.

Features

separate from the body of the testicle

found posterior to the testicle

Associated conditions

polycystic kidney disease

cystic fibrosis

von Hippel-Lindau syndrome

Diagnosis may be confirmed by ultrasound.

Management is usually supportive but surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts.

Hydrocele

A hydrocele describes the accumulation of fluid within the tunica vaginalis. They can be divided into communicating and non-communicating:

communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life

non-communicating: caused by excessive fluid production within the tunica vaginalis

Hydroceles may develop secondary to:

epididymo-orchitis

testicular torsion

testicular tumours

Features

soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle

the swelling is confined to the scrotum, you can get ‘above’ the mass on examination

transilluminates with a pen torch

the testis may be difficult to palpate if the hydrocele is large

Diagnosis may be clinical but ultrasound is required if there is any doubt about the diagnosis or if the underlying testis cannot be palpated.

Management

infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years

in adults a conservative approach may be taken depending on the severity of the presentation. Further investigation (e.g. ultrasound) is usually warranted however to exclude any underlying cause such as a tumour

Varicocele

A varicocele is an abnormal enlargement of the testicular veins. They are usually asymptomatic but may be important as they are associated with infertility.

Varicoceles are much more common on the left side (> 80%). Features:

classically described as a ‘bag of worms’

subfertility

Diagnosis

ultrasound with Doppler studies

Management

usually conservative

occasionally surgery is required if the patient is troubled by pain. There is ongoing debate regarding the effectiveness of surgery to treat infertility

For each of the following scenarios please select the most likely diagnosis

Question 40

Subarachnoid haemorrhage

Answer 40

A subarachnoid haemorrhage (SAH) is an intracranial haemorrhage that is defined as the presence of blood within the subarachnoid space, i.e. deep to the subarachnoid layer of the meninges.

The most common cause of SAH is head injury and this is called traumatic SAH . In the absence of trauma, SAH is termed spontaneous SAH . The rest of this note focuses on spontaneous SAH.

Causes of spontaneous SAH include:

Intracranial aneurysm* (saccular ‘berry’ aneurysms): this accounts for around 85% of cases. Conditions associated with berry aneurysms include adult polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta

Arteriovenous malformation

Pituitary apoplexy

Arterial dissection

Mycotic (infective) aneurysms

Perimesencephalic (an idiopathic venous bleed)

Classical presenting features include:

Headache: typically sudden-onset (‘thunderclap’ or ‘baseball bat’), severe (‘worst of my life’) and occipital

Nausea and vomiting

Meningism (photophobia, neck stiffness)

Coma

Seizures

Sudden death

ECG changes including ST elevation may be seen

Confirmation of SAH:

Computed tomography (CT) head

Acute blood (hyperdense/bright on CT) is typically distributed in the basal cisterns, sulci and in severe cases the ventricular system.

CT is negative for SAH (no blood seen) in 7% of cases.

Lumbar puncture (LP)

Used to confirm SAH if CT is negative.

LP is performed at least 12 hours following the onset of symptoms to allow the development of xanthochromia (the result of red blood cell breakdown).

Xanthochromia helps to distinguish true SAH from a ‘traumatic tap’ (blood introduced by the LP procedure).

As well as xanthochromia, CSF findings consistent with subarachnoid haemorrhage include a normal or raised opening pressure

Referral to neurosurgery to be made as soon as SAH is confirmed

After spontaneous SAH is confirmed, the aim of investigation is to identify a causative pathology that needs urgent treatment:

CT intracranial angiogram (to identify a vascular lesion e.g. aneurysm or AVM)

+/- digital subtraction angiogram (catheter angiogram)

Treatment

The treatment in spontaneous SAH is in accordance with the causative pathology

Intracranial aneurysms are at risk of rebleeding and therefore require prompt intervention, preferably within 24 hours

Most intracranial aneurysms are now treated with a coil by interventional neuroradiologists, but a minority require a craniotomy and clipping by a neurosurgeon

Until the aneurysm is treated, the patient should be kept on strict bed rest, well-controlled blood pressure and should avoid straining in order to prevent a re-bleed of the aneurysm

Vasospasm is prevented using a 21-day course of nimodipine (a calcium channel inhibitor targeting the brain vasculature) and treated with hypervolaemia, induced-hypertension and haemodilution**

Hydrocephalus is temporarily treated with an external ventricular drain (CSF diverted into a bag at the bedside) or, if required, a long-term ventriculo-peritoneal shunt

Complications of aneurysmal SAH:

Re-bleeding (in around 30%)

Vasospasm (also termed delayed cerebral ischaemia), typically 7-14 days after onset

Hyponatraemia (most typically due to syndrome inappropriate anti-diuretic hormone (SIADH))

Seizures

Hydrocephalus

Death

Important predictive factors in SAH:

conscious level on admission

age

amount of blood visible on CT head

Coiling of the aneurysm by an interventional radiologist is the most likely management option from the list. This is based on the patient’s relatively stable state at this point.

Craniotomy and clipping of the aneurysm might be appropriate if the patient was showing more evidence of raised intracranial pressure, such as haemodynamic instability or change in GCS.

Whether or not the aneurysm is coiled or clipped, the priority is to prevent further bleeding, so mechanically occluding the aneurysm is important, preferably within the first 24 hours. Therefore, the other options are not likely to be the correct, definitive, management of the patient’s condition.

Tranexamic acid has been used in some studies to aim to prevent early rebleeds in patients with subarachnoid haemorrhage (SAH), but this is not standard practice and is not definitive management of the situation.

Studies into therapeutic cooling of patients after SAH are limited, and it is not recognised as a standard part of management.

Supportive therapies may be important to manage the patient’s condition, but outright conservative management would not be appropriate for this patient due to the risk of rebleeding, and the very poor prognosis this would carry.

If subarachnoid haemorrhage is suspected but the CT head is normal, a lumbar puncture is required to confirm or exclude this diagnosis

Importance: 76

Question 41

Testicular torsion

Answer 41

Basics

twist of the spermatic cord resulting in testicular ischaemia and necrosis.

most common in males aged between 10 and 30 (peak incidence 13-15 years)

Features

pain is usually severe and of sudden onset

the pain may be referred to the lower abdomen

nausea and vomiting may be present

on examination, there is usually a swollen, tender testis retracted upwards. The skin may be reddened

cremasteric reflex is lost

elevation of the testis does not ease the pain (Prehn’s sign)

Management

treatment is with urgent surgical exploration

if a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral.

Question 42

Colorectal cancer treatment

Answer 42

A low anterior resection would be the most preferable surgery for the patient in this scenario. The important information to consider when answering this question is the position of the tumour, the grading and whether it is operable. The fact that this patients tumour is rectal means that there are only two surgical procedures in the list of possible answers that could be right; abdominoperineal resection and low anterior resection. Left hemicolectomy and total colectomy are used to surgically treat colonic diseases, including malignancies. Furthermore, Hartmann’s procedure is no longer used as frequently as in the past, and is now largely reserved for emergency colorectal surgery and terminally ill patients. Due to this, these options are inappropriate responses to this question.

Both abdominoperineal resections and low anterior resections are used to treat rectal malignancy. However, abdominoperineal resections, which involve the removal of the anus, rectum and section of sigmoid colon, are used for tumours located in the distal one third of the rectum. Given that the patient in this question has a mid-rectal tumour, this surgical procedure would be inappropriate. Low anterior resection is the operation of choice for this patient and patients whose malignancy lies in the upper two thirds of their rectum. This surgery involves resection of the area of malignancy, followed by anastomosis. To attempt to reduce complication rates, a defunctioning ileostomy can be created, which results in the majority of bowel matter bypassing the newly formed anastomosis.

Colorectal cancer treatment

Patients diagnosed as having colorectal cancer should be completely staged using CT of the chest/ abdomen and pelvis. Their entire colon should have been evaluated with colonoscopy or CT colonography. Patients whose tumours lie below the peritoneal reflection should have their mesorectum evaluated with MRI.

Once their staging is complete patients should be discussed within a dedicated colorectal MDT meeting and a treatment plan formulated.

Treatment of colonic cancer

Cancer of the colon is nearly always treated with surgery. Stents, surgical bypass and diversion stomas may all be used as palliative adjuncts. Resectional surgery is the only option for cure in patients with colon cancer. The procedure is tailored to the patient and the tumour location. The lymphatic drainage of the colon follows the arterial supply and therefore most resections are tailored around the resection of particular lymphatic chains (e.g. ileo-colic pedicle for right sided tumours). Some patients may have confounding factors that will govern the choice of procedure, for example a tumour in a patient from a HNPCC family may be better served with a panproctocolectomy rather than segmental resection.

Following resection the decision has to be made regarding restoration of continuity. For an anastomosis to heal the key technical factors include; adequate blood supply, mucosal apposition and no tissue tension. Surrounding sepsis, unstable patients and inexperienced surgeons may compromise these key principles and in such circumstances it may be safer to construct an end stoma rather than attempting an anastomosis.

When a colonic cancer presents with an obstructing lesion; the options are to either stent it or resect. In modern practice it is unusual to simply defunction a colonic tumour with a proximal loop stoma. This differs from the situation in the rectum (see below).
Following resection patients with risk factors for disease recurrence are usually offered chemotherapy, a combination of 5FU and oxaliplatin is common.

Treatment of rectal cancer

The management of rectal cancer is slightly different to that of colonic cancer. This reflects the rectum’s anatomical location and the challenges posed as a result. Tumours located in the rectum can be surgically resected with either an anterior resection or an abdomino-perineal excision of rectum (APER). The technical aspects governing the choice between these two procedures can be complex to appreciate and the main point to appreciate for the exam is that involvement of the sphincter complex or very low tumours require APER. In the rectum a 2cm distal clearance margin is required and this may also impact on the procedure chosen. In addition to excision of the rectal tube an integral part of the procedure is a meticulous dissection of the mesorectal fat and lymph nodes (total mesorectal excision/ TME).

In rectal cancer surgery involvement of the cirumferential resection margin carries a high risk of disease recurrence. Because the rectum is an extraperitoneal structure (until you remove it that is!) it is possible to irradiate it, something which cannot be offered for colonic tumours. This has a major impact in rectal cancer treatment and many patients will be offered neoadjuvent radiotherapy (both long and short course) prior to resectional surgery. Patients with T1 and 2 /N0 disease on imaging do not require irradiation and should proceed straight to surgery. Patients with T4 disease will typically have long course chemo radiotherapy. Those with T3 , N0 tumours may be offered short course radiotherapy prior to surgery. Patients presenting with large bowel obstruction from rectal cancer should not undergo resectional surgery without staging as primary treatment (very different from colonic cancer). This is because rectal surgery is more technically demanding, the anastomotic leak rate is higher and the danger of a positive resection margin in an unstaged patient is high. Therefore patients with obstructing rectal cancer should have a defunctioning loop colostomy.

Question 43

Colorectal Interventions

Answer 43

Summary of procedures

The operations for cancer are segmental resections based on blood supply and lymphatic drainage.

Site of cancer

Type of resection

Anastomosis

Caecal, ascending or proximal transverse colon

Right hemicolectomy

Ileo-colic

Distal transverse, descending colon

Left hemicolectomy

Colo-colon

Sigmoid colon

High anterior resection

Colo-rectal

Upper rectum

Anterior resection (TME)

Colo-rectal

Low rectum

Anterior resection (Low TME)

Colo-rectal
(+/- Defunctioning stoma)

Anal verge

Abdomino-perineal excision of rectum

None

In the emergency setting where the bowel has perforated the risk of an anastomosis is much greater, particularly when the anastomosis is colon-colon. In this situation an end colostomy is often safer and can be reversed later. When resection of the sigmoid colon is performed and an end colostomy is fashioned the operation is referred to as a Hartmans procedure. Whilst left sided resections are more risky, ileo-colic anastomoses are relatively safe even in the emergency setting and do not need to be defunctioned.

References

A review of the diagnosis and management of colorectal cancer and a summary of the UK National Institute of Clinical Excellence guidelines is provided in:
Poston G, et al . Diagnosis and management of colorectal cancer:summary of NICE guidance. BMJ 2011: 343: d 6751.

A Hartmann’s procedure would be the most preferable surgery for the patient in this scenario. The important pieces of information to consider when answering this question are the urgency of the operation and the location of the malignancy. This patient has presented to hospital as an emergency perforation, resulting from his malignancy. Therefore, the surgery for this patient needs to be appropriate for an emergency situation. Under routine circumstances, this patient would receive surgery that would consist of resection of the relevant section of bowel and then anastomosis of the two ends. However, in emergency situations anastomosis is not a preferable surgical option.

Hartmann’s procedure involves resection of the relevant portion of bowel and formation of an end colostomy/ileostomy. In the future patients can undergo a reversal of Hartmann’s procedure, whereby the end colostomy is closed following the formation of a colorectal anastomosis, restoring continuity of the bowels. This makes it the ideal surgical procedure for emergency situations. Furthermore, this operation involves resection of the sigmoid colon, where this patients tumour is located.

Abdominoperineal resections and low anterior resections are used to treat rectal malignancies, and are therefore inappropriate responses to this question. A total colectomy is not required in this patient, as it is only the sigmoid colon that is affected, meaning removal of the entire colon is an out of proportion response to the problem. A left hemicolectomy, could at first glance, appear a correct answer. However, the emergency of the patients situation dictates that anastomosis formation is not advisable, meaning a Hartmann’s procedure is more appropriate, and the correct answer for this scenario.

Question 44

Vasectomy

Answer 44

Male sterilisation - vasectomy

failure rate: 1 per 2,000 - male sterilisation is a more effective method of contraception than female sterilisation

simple operation, can be done under LA (some GA), go home after a couple of hours

doesn’t work immediately

semen analysis needs to be performed twice following a vasectomy before a man can have unprotected sex (usually at 16 and 20 weeks)

complications: bruising, haematoma, infection, sperm granuloma, chronic testicular pain (affects between 5-30% men)

the success rate of vasectomy reversal is up to 55%, if done within 10 years, and approximately 25% after more than 10 years

Question 45

Venous thromboembolism: prophylaxis in patients admitted to hospital

Answer 45

VTEs can cause severe morbidity and mortality, but they are preventable. Current NICE guidelines (updated for 2018) outline recommendations for assessment and management of patients at risk of VTE in hospital.

Risk factors

All patients admitted to hospital should be individually assessed to identify risk factors for VTE development and bleeding risk. For medical and surgical patients the recommended risk proforma is the department of healths VTE risk assessment tool.

The following inpatients would be deemed at increased risk of developing a VTE:

Medical patients:

significant reduction in mobility for 3 days or more (or anticipated to have significantly reduced mobility)
Surgical/trauma patients:

hip/knee replacement

hip fracture

general anaesthetic and a surgical duration of over 90 minutes

surgery of the pelvis or lower limb with a general anaesthetic and a surgical duration of over 60 minutes

acute surgical admission with an inflammatory/intra-abdominal condition

surgery with a significant reduction in mobility

General risk factors:

active cancer/chemotherapy

aged over 60

known blood clotting disorder (e.g. thrombophilia)

BMI over 35

dehydration

one or more significant medical comorbidities (e.g. heart disease; metabolic/endocrine pathologies; respiratory disease; acute infectious disease and inflammatory conditions)

critical care admission

use of hormone replacement therapy (HRT)

use of the combined oral contraceptive pill

varicose veins

pregnant or less than 6 weeks post-partum

After a patients VTE risk has been assessed, this should be compared to their risk of bleeding to decide whether VTE prophylaxis should be offered. If indicated VTE prophylaxis should be started as soon as possible.

Types of VTE prophylaxis

Mechanical:

Correctly fitted anti-embolism (aka compression) stockings (thigh or knee height)

An Intermittent pneumatic compression device

Pharmacological:

Fondaparinux sodium (SC injection)

Low molecular weight heparin (LMWH) - e.g. enoxaparin (brand name = Clexane)

Unfractionated heparin (UFH) - used in patients with chronic kidney disease

Management

In general, all medical patients deemed at risk of VTE after individual assessment are started on pharmacological VTE prophylaxis. This is providing the risk of VTE outweighs the risk of bleeding (this is often a clinical judgement) and there are no contraindications. Those at very high risk may be offered anti-embolic stockings alongside the pharmacological methods.

For surgical patients at low risk of VTE first-line treatment is anti-embolism stockings. If a patient is at high risk these stockings are used in conjunction with pharmacological prophylaxis.

Advice for patients

Pre-surgical interventions:

Advise women to stop taking their combined oral contraceptive pill/hormone replacement therapy 4 weeks before surgery.
Post-surgical interventions:

Try to mobilise patients as soon as possible after surgery

Ensure the patient is hydrated

Post procedure prophylaxis

For certain surgical procedures (hip and knee replacements) pharmacological VTE prophylaxis is recommended for all patients to reduce the risk of a VTE developing post-surgery. NICE make the following recommendations:

Procedure

Prophylaxis

Elective hip

LMWH for 10 days followed by aspirin (75 or 150 mg) for a further 28 days

or

LMWH for 28 days combined with anti-embolism stockings until discharge

or

Rivaroxaban

Elective knee

Aspirin (75 or 150 mg) for 14 days

or

LMWH for 14 days combined with anti-embolism stockings until discharge

or

Rivaroxaban

Fragility fractures of the pelvis, hip and proximal femur

LMWH or fondaparinux

‘Continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility’