Surgery Flashcards
Abdominal aortic aneurysm
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.
Abdominal pain
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
Abdominal swelling
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
Abdominal wall hernias
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
Acute pancreatitis: causes
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)
Anal fissure
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.
Anal fissure
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
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
Ascending cholangitis
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
Benign prostatic hyperplasia
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
Blood Products
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
Brain death
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).
Breast cancer screening
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.
Breast cancer: referral
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.
Basic breast anatomy
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.
management of breast cancer
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.
Breast disorders
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.
Fat necrosis of the breast
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.
Breast cancer: referral
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.
Breast abscess
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
Circumcision
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.
Colorectal cancer screening
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
Flexible sigmoidoscopy screening
Colorectal cancer: referral guidelines
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
Epididymo-orchitis
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
Haemorrhoids
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
Anorectal disorders
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)
Head injury - types of traumatic brain injury
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
Head injury: NICE guidance on investigation
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.
Hearing Loss
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
Inguinal hernia
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
Lower urinary tract symptoms in men
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
Minor surgery
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
Penile cancer
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
Peripheral arterial disease management
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
Prostate cancer PSA testing
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
Prostate cancer: investigation
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
Renal Stones
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
Prevention of renal stones
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
Scrotal problems
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
Subarachnoid haemorrhage
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
Testicular torsion
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.
Colorectal cancer treatment
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.
Colorectal Interventions
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.
Vasectomy
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
Venous thromboembolism: prophylaxis in patients admitted to hospital
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’
