Surgery Flashcards
AXR indications
- Clinical suspicion of obstruction (if perforation -> CXR)
- Acute exacerbation of inflammatory bowel disease
- Sharp/poisonous foreign body
In specific circumstances: • Palpable mass • Constipation • Acute and chronic pancreatitis • Smooth and small foreign body, e.g., coin, battery • Blunt or stab abdominal injury
How to differentiate between sigmoid and caecal volvulus?
Sigmoid volvulus - coffee bean shape
arises in the pelvis (left lower quadrant)
extends towards the RUQ
ahaustral in appearance
sigmoid volvulus causes obstruction of the proximal large bowel, therefore the ascending, transverse and descending colon may be dilated
few air-fluid levels may be seen
Caecal volvulus - embryonic shape arises in the right lower quadrant extends towards the epigastrium or LUQ colonic haustral pattern is maintained distal colon is usually collapsed and the small bowel is distended one air-fluid level may be seen
Ischaemic colitis
Definition: Ischemic colitis refers to inflammation of the colon secondary to vascular insufficiency and ischemia
Epi: disease of the elderly (age >60 years) where atherosclerotic disease or low flow states
PC: abdominal pain and bloody stools
Location of ischemia relates to anatomy of vessels SMA (Caecum to splenic flexture) IMA (beyond splenic flexure).
Path: Diminished or absent blood flow leads to bowel wall ischemia and secondary inflammation. Bacterial contamination may produce superimposed pseudomembranous inflammation. If necrosis develops then ulcerations or perforation can occur. Following the acute event, fibrosis may lead to stricture of the bowel lumen.
Ix, AXR can be normal or can show ‘thumbprinting’ due to mucosal edema/hemorrhage, dilatation
CT is investigation of choice and commonly shows bowel wall thickening, fat strands, vascular occlusion.
Mx: anticoagulation or thrombolysis, either systemically or locally
Layers of the scrotum and contents
Contents of the spermatic cord
Rule of Threes: Three layers (external spermatic from EO, cremasteric from IO and internal spermatic from transveralis fascia) Three arteries (Artery to vas, cremasteric artery, testicular artery) Three veins (Pampniform plexus, cremastric vein and vein of the vas) TWO nerves: Genital branch of genital femoral nerve, Sympathetic & Parasympthaetic nerve from T10-T11 Three extra things: obliterated processus vaginalis, Vas deferens, Lymphatics
Layers: Some Damned Englishmen called it The Testes
SCS, Dartos fascia, External spermatic fascia, Cremasteric fascia, Internal Spermatic Fascia, Tunica vaginalis, Tunica albuginea
Lanz incision
Horizontal incision of appendicitis, closer to the ASIS than Gridiron
Provides better cosmetic result but increases risk of inguinal hernia due to dividing nerves that can cause denervation of the muscles of the inguinal canal
Gridiron
One third along the way of the line between the ASIS and umbilicus, transverse incision perpendicular to this line
Aka Mcburney’s incision as it is over mcburney’s point
Pfannestiel
Transverse incision 5cm above pubic symphsis 10-12 cm across midline Mostly used by gynae for cs and ovariation operations or urologists for access to bladder and prostate Offers excellent cosmetic results
Kocher
3cm below and parallel to the subcostal margin from midline to border of the rectus abdominis
R-sided kocher for open chole
L-sided for splenectomy
Can’t be extended medially, if extended too far laterally intercostal nerves can be dmaged
Rooftop incision
Double kocker linked into the middle
Access to liver and spleen and bilateral adrenalectomy, radical pancreatic and gastric surgery, whipples
Liver transplant /resection
Battle’s
Vertical incision medial to the lateral border of the abdominal rectus
Has high risk of incisional hernia and damaged nerves in rectus sheath- on longer recommended
Rutherford Morris
Extended gridiron (One third along the way of the line between the ASIS and umbilicus, transverse incision perpendicular to this line) that allow views of caecum and right colon
Acute diverticulitis classification
Hinchey’s classification:
Stage I: small or confined pericolic or mesenteric abscess.
Stage II: large paracolic abscess often extending into pelvis.
Stage III: perforated diverticulitis where a peri-diverticular abscess has perforated resulting in purulent peritonitis.
Stage IV: perforated diverticulitis where there is free perforation and is associated with faecal peritonitis.
Pre-op what drugs should you stop?
Stop:
1. Metformin if pt at risk of AKI OR pt is missing >1 meal. Stop it from when the pre-op fast begins. If pt has metform > OD, then replace with variable rate insulin infusion.
2. COCP
3. ACEi - stop for 24hrs, risk of hypotension
4. Spiro - don’t take morning of operation due to risk of hyperkalaemia
5. MAOi e.g. pethidine hydrochloride
6. Lithium - for 24hrs if its a major op
7- Warfarin - stop 5 days unless on metallic valve in which case admit and manage on heparin infusion pump
HIV - get specialist advice
Pre-op - what drugs shouldn’t you stop?
Anti-parkinsonian Anti-epileptics Thyroid or Antithyroid Drugs of dependence Antipsychotics Anxiolytics Bronchodilators Glaucoma Meds Immunosuppressants
What would need a midline laparotomy?
Emergency: Perforation (bowel) Trauma AAA rupture Hartmann’s
Elective:
Colectomy
AAA
Vascular bypass
Layers of the abdominal wall when you make a midline incision
Skin Camper’s fascia Scarper’s Fascia Linea Alba (Midline) Transveralis fascia Pre-peritoneal fat Peritoneum
Abdominal muscles
Anterior SCS External oblique, Internal oblique, Transversus abdominis, Transveralis fascia , Preperitoneal fat, Peritoneum.
Whats the significance of the arcuate line?
Arcuate line - marks when the IO and TA pass anteriorly to the rectus muscles. (Really important learn this)
The arcuate line or semicircular line of Douglas is located at roughly one-third of the distance from the pubic crest to the umbilicus. It is the demarcation where the internal oblique and transversus abdominis aponeuroses of the rectus sheath start to pass anteriorly to the rectus abdominis muscle, leaving only the transversalis fascia posteriorly.
Post op complications
Immediate: Anaesthetic complications, bleeding (primary or reactionary), damage to near by structures
Early complications: Bleeding (secondary often due to inflammation), infection & abscess, dehiscence*, pain, VTE, atelectasis**, CAP (can be secondary to atelectais), Post op urinary retention and hypovolaemic shock; Paralytic Ileus (pts vomit, monitor electrolytes), abx associated colitis.
Specific: anastamotic leak, eneterocutenaous fistulae
Late: failure/recurrence, scarring (hypertrophic or keloid)
- rupture along the surgical suture- if superficial rupture just wash and wound care, if full thickness > resus and return to theatre RTT)
- *(people in bed, pain, etc - chest physio)
Hernia
Protrusion of a viscous (or part of a viscus) through a defect in its wall into an abnormal position.
TCC vs SCC of the bladder
PAINLESS HAEMATURIA
Other: voiding irritability: dysuria, frequency, urgency; Recurrent UTIs and retention and obstructive renal failure
Most common bladder cancer is transitional cell carcinoma (SCC is developing countries due to schistosomiasis, schistoma cause chronic bladder inflammation),
Things to ask in the history:
- Exposure to dye or rubber industries due to beta-napthlamine
- Other causes is staghorn calculi, or long term catheter or any bladder inflammation
Patients present with Painless frank haematuria or with multiple UTIs
Ix to order:
Urine dip (sterile pyuria), cytology, FBC (anaemia), U&Es,
IV Urography would show filling defects
Cystoscopy + Biopsy for diagnosis
Bimanual EUA to help assess spread (rubberythickness = T2, mobile mass T3, fixed mass T4)
MRI/CT for staging
TCC management
Depends on the staging: Tis = carcinoma in situ Ta = confined to epithelium T1 = Tumour in lamina propria Felt at EUA: T2 = Superficial muscle involved T3= Deep muscle involves T4 = Invasion of prostate, uterus or vagina
SUPERFICIAL (Tis, Ta and T1 = 80% of patients)
- Transurethral Resection of Bladder Tumour (TURBT) can be done via resection or diathermy
- Intravesciular Chemo: Mitomycin C
- Intravesicular immunotherapy: BCG
INVASIVE (T2, T3):
1. Radical cystectomy, LN dissection + ileal conduit is gold standard
± Radiotherapy
± Adjuvant chemo -MVAC (Methotrexate, vinblastine, doxorubicin and cisplatin)
2nd line Immunotherapy e.g. nivolumab
T4 PALLIATIVE:
C- Long term catheter
M- pallaitve chemo MVAC and radiotherapy
+ EXTENSIVE FOLLOW UP as 70% Of bladder tumours recur
Low risk @ 9 month then yearly
High risk every 3 months for 2 years then every 6 months
What is a radical cystecomy and what happens after a radical cystectomy? + incl complications
Cystectomy - removal of bladder
Radical cystectomy M: prostate and seminal vesicles. F: removal of the uterus, ovaries and part of the vagina
After:
Upper tract diversion (end urostomy) or neo bladder (60cm small bowel joined to ureter and urethras, still have external sphincter, continent, need to be able to self catheterise, initially when they have it they can only hold 200ml but as time goes on you can hold 600ml)
Complications:
Early - urinary leak from stents, infection, DVT
Late - infection, uteroileal strictures and reflux of infected urine can both lead to hydronephrosis / renal function decline, poor bladder emptying can lead to urinary calculi, metabolic acidosis (worse with more proximal bowel conduits) due to the absorption of ammonia from urine (NH4 > NH3 + H+) in the intestinal luminal cells, causing excess hydrogen ions and metabolic acidosis
Common sites of impaction of renal calculi
- Ureteropelvic junction (pelvis meets ureters)
- Where the iliac artery crosses the ureter
- Vas deferens/broad ligament
- Ureterovesical junction (Ureter meets the bladder wall)
- Ureteric office
Bladder calculi vs renal calculi presentation vs UTI
Renal: Loin to groin pain associated with microscopic heamaturia, visible haematuria is rare but can occur (Rf: UTI, stasis 2ndary to obstruction, hypercalcaemia(
Bladder: Dysuria, haematuria and frequency ±intermittent stream. Suprapubic pain that radiates to perineum or penis tip. Pain worse at the end of micturition
UTI: Dysuria, frequency, cloudy/smelly urine
Renal Cell Carcinoma Presentation + Extra features
Over 50% of RCC patients are asymptomatic on presentation, and renal masses are often found incidentally on imaging done for other indications
Most common renal tumour, often M >40yo
Classic triad - haematuria (±clot), flank pain (40%), abdominal mass (20%), is uncommon <10% of pts
If any, it presents with Abdo pain, haematuria and oedema
Rarely: new L varicocele (tumour obstructing left testicular vein, which drains into renal vein, R drains into IVC - > can present with bilateral oedema)
PUO + FLAWS
Endocrine features:
- EPO - polycytheamia
- Renin -HTN
- Vit D OH ylation / PTH like hormone hypercalcaemia
- ACTH - cushing’s
Symptoms of mets e.g. cough or bone pain
GOLDEN YELLOW IN COLOUR
Conditions RCC can be associated with
- Von Hippel Lindau
RCC + Phaeo + CNS haemangiomas - Tuberous Sclerosis
Multisystem tumours + developemental delay + seizures + skin lesions e.g. shagreen patch, ash leaf etc
Ix & Management of RCC
Ix: Hx, exam, urine dip, obs, bloods, flex cystoscopy (quick, painless), CXR, USS, then CT, biopsy not needed prior to nephrectomy (TCC - biopsy IS needed)
Mx: Robson staging
C: Well controlled HTN, stop smoking, thromboprophylaxis
Stage 1 or 2 - Nephrectomy
Stage 3- Radical nephrectomy + Sunitinib for 1 year (kidney, mesentery and part of ureter)
Stage 4 - Combination therapy of TKI and check point inhibitor (Pembrolizimab and Axitinib), Palliative radiation and bisphophonates for mets
M- TKI inhibitors e.g. pazopanib; MTORi e.g. Temsirolimus
S - T1 - radical nephrectomy , if they have 1 you can do partial nephrectomy,
T1RF vs T2RF and RF
Resp failure = pO2 < 8.0
T1 = CO2 is low or normal
T2 = CO2 is high
Compensated ABG
pH will be in normal range BUT body never over compensates so if <7.4 - compenating an acidosis >7.4 compensating an alkalosis
Meralgia paraesthetica
Lateral femoral cutaneous nerve becomes trapped under inguinal ligament where it attaches to ASIS
Burning or pain or numbness in lateral thigh with no abnormality
Exacerbated by periods of standing
Foot drop causes
Foot drop is caused by weakness of the muscles of ankle dorsiflexion (tibialis anterior) supplied by the common peroneal nerve (L4, L5 and S1 nerve root).
Foot drop may therefore be caused by:
Isolated common peroneal nerve palsy (e.g. secondary to fibular # or compression of nerve near the fibula e.g. plaster cast)
L5 radiculopathy (e.g. disc prolapse)
Generalized polyneuropathy involving multiple nerves (e.g. diabetic neuropathy, motor neurone disease, Charcot-Marie Tooth disease)
Sciatic nerve palsy
Presents with loss of movement and sensation in the leg/foot.
Sensation: loss of leg - everywhere apart from:
- medial aspect of leg- supplied by the saphenous n which is a branch of the femoral n
- upper calf supplied by posterior femoral cutaneous nerve
Motor: all muscles of foot and leg (can’t dorsiflex or plantar flex the foot)
Causes:
Spinal: Spinal stenosis, spondylolithesis, anything in spinal canal e.g. mets, infection
Non-spinal causes: Pregnancy, Piriformis syndrome, trauma and tumours
Iatrogenic (IM injections in the Lower inner quadrant of buttock instead of upper outer or due to posterolateral approach in hip surgery)
Sciatic nerve divides into common peroneal and tibial nerve ~ mid thigh
Unable to flex the knee
Absence of ankle jerk
What sensation loss would you expect?
How is this damaged?
How does the palsy present?
Tibial nerve
- vulnerable to damage in posterior knee dislocations
or compressed behind medial malleolus
- branch of sciatic nerve
- Loss of sensation over the sole of the foot
- supplies calf flexors and gives rise to medial and laterla plantar nerves -> intrinsic muscles of foot, ankle inversion and ankle jerk + sensation over plantar foot surface
Injury presents as:
-Shuffling gait as can’t lift foot properly
- Loss of ankle inversion and ankle jerk
- Eventually -> claw foot, atrophy of foot musclees and loss of arch of foot
Differences between tibial nerve and peroneal nerve injuries: TIPPED
• Tibial → impaired foot Inversion and Plantarflexion
• Peroneal → impaired foot Eversion and Dorsiflexion
Can’t extend knee
Loss of knee jerk
What sensation loss would you expect?
How is this damaged?
Femoral palsy
Would expect loss of sensation over the anterior thigh and medial aspect of leg
Femoral n is vulnerable to trauma as it sits most lateral in the femoral triangle. Vulnerable to trauma, hip dislocations or thigh haematoma
It supples motor branch of quads (knee extension and knee jerk) and sensory branch to anteromedial thigh and medial calf and medial edge of foot via saphenous nerve
Obtruator nerve palsy
Often damaged in obstetric surgerys and pelvic disease
Loss of hip adduction and loss of sesnation to upper inner thigh
(irrelevant but Hip pain is often referred to knee to obtruator nerve)
What anaesthetic do you give before manipulation of colles fracture?
You do a Bier Block (squeeze blood out of limb, tourniquet around upper arm, IV Prilocaine distal to tourniquet
Best choice of LA is prilocaine as is least cardiotoxic
What LA do you use for spinal or epiduaral anaesthesia
Bupivicaine as its longer acting
CI as IV LA as its cardiotoxic
What gel can we use for catheterisation and what topical do we use for cannulating kids
Lidocaine gel for catheters
Lidocaine /prilocaine topical emulsion (Emla is brand name)
Which cancers are associated with FAP?
- Hepatoblastoma as kids
- Colorectal cancer (100% of patients with FAP develop it by 40 years of age if prophylactic colectomy is not performed)
- Duodenal Cancer - 2nd leading cause of cancer death, they commonly get polyps around sphincter of oddi (abdominal pain and obstructive jaundice)
- Thyroid cancer
How do we manage a bleeding ulcer?
C: Blood transfusion
M: IV PPI
S: Endoscopy
3 main techniques: Glue - Non-variceal, Sclerosants - Variceal
- Injection therapy (inject with adrenaline - most common, adhessives (fibrin glue) and sclerosants (pure ethanol))
- Thermal methods (argon coag or heater coag) (superior to other 2 in terms of reducing further bleeding and surgery)
- Mechanical therapy (clips)
Haemorrhoids Ix and Mx
Haemorrhoid - dilatation of superior rectal arteries within anal canal
Ix:
Anal exam: DRE + Anoscope (just a source of light)
Colonoscopy /Flexi sigmoidoscopy performed to exclude sinister cause if you were suspicious due to presentation
Mx:
A/S -> C- dietary and life style modification
M-
Grade 1 (confined to canal) - topical steroids
Grade 2/3 (reduce spontaneously, 3 don’t) - Rubber band ligation
S-
grade 4 - haemorhoiddectomy
Core biopsy stages of breast
B1 - normal B2 - benign breast tissue (e.g. when fat necrosis lump is aspirated this will be the stage) B3 - equivocal, probably bengin B4 - suspicious, probably malignant B5 - malignant breast tissue
Painful subcutaneous cord like lump in breast, what is the diagnosis?
Mondor disease - thrombophlebitis of superficial veins of breast and anterior chest wall
44 Year old woman presents with 1 month history of jaundice associated with fatigue itching and dark urine She has pmhx of early onset rheum arthritis. O/E jaundiced, xanthelasma, abdo exam NAD.
What features in this history point to the diagnosis?
What investigations would you do?
Primary biliary cirrhosis
- Middle aged women are most commonly affected
- Autoimmune condition and she has AI hx with RA
- Pruritus is most common symptom
- ob j and xanthelasma are other symptoms
- some can present with symptoms of portal hypertension
ANA postiive
Liver biopsy
Mx: Ursodeoxycholic acid for itching, transplant needed
Thyroid cancers types and mx
70% are papillary adenocarcinomas
20% are follicular carcinomas
5% medullary
1% anaplastic
1. Papillary ac - common in adolescent and young adults, thyroid nodule, ±LNs. Can be mulitfocal Histology for papillary -> orphan annie (spread via lymph). Thyroidectomy ± LN excision ±radioiodine
2. Follicular - discrete single encapsulated lesion, spread via blood to lungs and bone. Mx is total thyroidectomy (if <1cm can do lobectomy)
Both can be TSH dependent so post op, both must take Thyroxine life long to suppress endogenous TSH secretion and reduce risk of recurrence
3. Medullary - MEN2 if young, spontaneous if older, parafollicular C cells origin, CEA and calcitonin markers, do phaeo screen pre thryoidectomy op
4. Anaplastic - rare, >60, undifferentiated cell origin, rapid growth, usually palliative (Presents elderly patient with rapid growth of lump)
50 year old presents with midline neck mass that has been increasing in size over a few months. Enlarged firm irregular thyroid that isn’t painful. No LNs. Biopsy denies malignancy.
Riedel’s Thyroiditis - autoimmune fibrosis of the thyroid
difficult to distinguish from cancer
30% will go on to develop hypothyroidism
Multinodular goiter vs Plummer’s (what is it and mx)
Multinodular goiter: Typically middle aged women typically presenting with large goiter or dysphagia. Can be euthyroid or subclinical hyperthyroid
Mx: can manage with thyroxine or if pressure effects thyroidectomy.
Complications:
One nodule can become autonomous in its thyroxine production and be a thyroxine secreting adenoma -> Toxic multinodular goiter or plummer disease and present with cardiac features e.g. AF and palpitations. Treat with radioiodine or subtotal thyroidectomy as carbimazole will not have much affect
Hernia Descriptors:
- Reducible
- IrReducible
- Strangulated
- Incarcerated
- Richter
- Perforated
Reducible = contents of hernia can be returned to the abdomen by lying down or by manual reduction. Exhibit an expansile cough impulse
Irrededucible - cannot be returned to abdomen and no cough impulse
Incarcerated - patient has symptoms and predisosed to strangulation (this occurs when adhesions develop between hernial sac and contents)
Strangulated - Obstruction sx. Occurs when hernia twists upon itself and interferes with blood supply. Initially venous return is obstructed -> oedema -> cuts off arterial. Ischaemia and necrosis within 6 hrs
Richter - only one side of the bowel wall is strangulated with the hernial sac. Pain, erythema, perforation potential but no obstructive signs
Perforated - peritonitis, rigid abdomen, urgent laparotomy
Acute Otitis externs vs media management
AOE:
1st line - Topical cipro/antifungal drops ± steroids; microsuction if there is debris
2nd line - Oral fluclox if its spreading, oral antifungal, refer to ENT if diabetic
AOM: Mostly conservative (will discharge and heal within 6 weeks), can be given antibiotics in certain situations
If diabetic / young boy -> high suspicion of headache
If glue ear develops and dosn’t go away in 12 wks -> grommet (NB If adult - suspect nasopharyngeal cancer if unilateral grommet)
When do you give abx in AOM
Antibiotics should be prescribed immediately if:
Otitis media with perforation and/or discharge in the canal
Symptoms lasting more than 4 days or not improving
Systemically unwell but not requiring admission
Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
Younger than 2 years with bilateral otitis media
Amoicillin 5-7 day , penicillin allergy > erythromycin or clarithromycin should be given.
Head and neck cancer 2 WW criteria
Laryngeal cancer
45 and over with:
- persistent unexplained hoarseness or
- an unexplained lump in the neck
Oral cancer
- Suspected:
unexplained ulceration in the oral cavity lasting for more than 3 weeks or
a persistent and unexplained lump in the neck.
- Urgent referral to dentist:
a lump on the lip or in the oral cavity or
a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.
Thyroid cancer
people with an unexplained thyroid lump.
Otosclerosis
AUTOSOMAL DOMINANT CONDITION
Otosclerosis describes the replacement of normal bone by vascular spongy bone. It causes a progressive conductive deafness due to fixation of the stapes at the oval window. Otosclerosis is autosomal dominant and typically affects young adults
Onset is usually at 20-40 years - features include: conductive deafness tinnitus normal tympanic membrane* positive family history
Management
hearing aid
stapedectomy
*10% have flamingo tinge due to hyperaemia
IBD Surgical operation complications
Abdominal
• SBO
• Anastomotic stricture
• Pelvic abscess
Stoma:
retraction, stenosis, prolapse, dermatitis
Pouch
• Pouchitis (50%): metronidazole + cipro
• ↓ female fertility
• Faecal leakage
AXR presenting
1) AP supine or erect
2) Exposure
Visibility - Assess the X-ray to ensure the whole abdomen is visible from the level of the diaphragm to the pelvis.
Ensure the exposure is adequate to allow radiological assessment of both the small and large bowel.
BBC approach:
- Bowel and other organs: small bowel, large bowel, lungs, liver, gallbladder, stomach, psoas muscles, kidneys, spleen and bladder.
- Bones: ribs, lumbar vertebrae, sacrum, coccyx, pelvis and proximal femurs.
- Calcification and artefact (e.g. renal stones)
Arterial vs Venous vs Neuropathic ulcer pc ix and management
Arterial ulcer
- Deep, painful and sharply defined, shins/foot
- O/E Reduced peripheral pulses
- Intermittent Claudication Symptoms (Cold feet, hair loss, toe nail dystrophy, cyanosis)
- Ix: Contrast angiography
- Mx: Angioplasty or vascular reconstruction
Venous Ulcer
- Painless, sloping, shallow ulcers
- Medial Malleolus is usual site
- Rf: Venous insufficiency, varicosities, DVT, obesity
- Associated with hemosiderin deposition (opaque brown large patches) and lipodermatosclerosis (waxy thickened)
- Mx: Ulcer community clinic, focus on prevention (compression stockings, venous surgery), optmise risk factors (nutrition, smoking)
Neuropathic Ulcer
- Painless, insensate surrounding skin (‘glove and stocking distribution’. Can’t feel so cause severe damage to feet without realising)
- WARM foot, GOOD pulses
- Occur on pressure points i.e. heal, tips and between toes, metartarsal heads
- Mx: Regular check ups assessing sensation, keep toe nails short and avoid walking barefoot
TCC spread
Locally -> pelvic structures
Lymph -> iliac and para-aortic nodes
Haem -> bones, liver and lungs
RCC staging
Robson staging • Confined to kidney • Involves perinephric fat, but not Gerota’s fascia • Spread into renal vein • Spread to adjacent / distant organs
Usually spread directly via renal vein or lymph or via blood to bone liver and lung
Haematuria assessment
quantify haematuria: thick blood or discoloured urine, presence of clots? Anaemia sx
- painless haematuria, frequency - bladder cancer
- dysuria - infective
- voiding symptoms - prostatic ca or BPH
- storage sx /flaws - TCC
BPH m
C- avoid caffeine and alcohol, bladder training, double voiding to ensure bladder is completely empty
M - if symptomatic and bothersome:
1st line Tamsulosin (alpha blocker) S/E: drowsiness, hypotension, depression, EPSE, increased wt
2nd line Finasteride (5alpha reductase inhibitor)
S/E: excreted in semen, use condoms, ED
S
If affect QoL or complications of BPH
TUIP (transurethral incision of prostate) is first line as is less invasive
TURP (cystoscopic resection of lateral and middle lobes of prostate) is more invasive and higher risks but can produce better outcomes
Laser prostatectomy - can be considered in patients on anticoagulation
Open prostatecomy - used for v large prostates >100g
Prostate cancer mx
Gleason Grade
C- Active Surveillance w/ DRE and PSA ± core biopsy
(If T1/T2 and <10 year life expectancy (a large % of pts) just manage with @ surveillance as unlikely to affect their morbidity.
S
- Radical prostatectomy (and goserelin if node +ve)
- Only improves survival vs. active monitor if <75yrs
- 70% risk of ED, 50% incontinence (
- Brachytherapy: implantation of palladium seeds
- Better option for those who want to remain fertile, S/E prostatitis
M
• Used for metastatic or node +ve disease
• LHRH analogues inhibit pituitary gonadotrophins → ↓ testosterone E.g. goserelin
• Anti-androgens E.g. cyproterone acetate, flutamide
TURP complications
Immediate • TURP syndrome- fluid overload hypervolaemic and dilutional hyponatraemia ↓Na, bradycardia/arrthymia. hypertension -> hypotension dyspnoea and visual disturbance (absorption of large volumes of irrigation through prostatic plexus) • Haemorrhage Early • Haemorrhage • Infection • Clot retention: requires bladder irrigation Late • Retrograde ejaculation: common • ED: ~10% • Incontinence: ≤10% • Urethral stricture • Recurrence
Should we screen using PSA?
• Population based screening not recommended in UK
• PSA not an accurate tumour marker
• ERSPC trial showed small mortality benefit, PLCO trial
showed no benefit.
• Must balance mortality benefit ̄c harm caused by over
diagnosis and over treatment of indolent cancers.
Indications for PSA and DRE
Any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or retention, or
Erectile dysfunction, or
Visible haematuria.
Robson staging
RCC 1• Confined to kidney 2• Involves perinephric fat, but not Gerota’s fascia 3• Spread into renal vein 4• Spread to adjacent / distant organs
Pancreatic cancer pc, histopath, ix, mx
PC: Painless obstructive jaundice, epigastric pain that radiates backwards, acute onset DM in elderly
Epigastric mass, palpable gallbladder (courvoisier’s), Thrombophlebitis migrans (Trousseau sign)
Men>60
Adenocarcinoma (90% cases)
Ix:
Bloods: Cholestatic LFTs, Ca19-9 (90% sensitive), CALCIUM
Imaging: USS (dilated ducts) guided biopsy,
Pancreatic protocol CT (Triphasic CT AP)
If further imaging needed -> MRI, EUS and laparoscopy.
pancreatic cancer management
NICE Guidelines:
Staging:
- Pancreatic Protocol CT (triphasic CT, CAP)
- IF more info needed for staging can do EUS, Laparoscopy or MRI for liver mets
C
Specialistic Pancreatic MDT
1) Psychological support (Fatigue, px, GI sx -> anxiety/depression)
2) Analgesia pain ladder who, severe, you can consider a percutaneous coeliax plexus nerve block EUS guided
3) N - Nutrition: enteric-coated pancreatin (for those with unresectable pancreatic ca)
M & S:
4)Chemo to non resectable (Gemcap) + stents
5) Resectable- Surgery (preferably pylorus preserving surgery)
6) Embolism prophylaxis
7) Adjuvant therapy given post op (gemcitabine plus capecitabine)
8) Spread -> If metastatic you give FOLFIRINOX
Pancreatic endocrine neoplasms
Insulinoma - most common PEN, features of hypoglycaemia , whipples triad of features (attacks induced by starvation, hypolycaemia during attacks and symptoms relieved by eating), raised Cpeptide (unlike inappropriate insulin administration), 20% malignant so they are resected
VIPoma (vasoactive intestin polypeptide) - VIP stimulates secretio of water and electrolytes in intestines -> severe diarrhoea, dehydration and hypokalaemia.
Glucagonoma - very rare, associated with Men 1, blistering rash over bum/legs,
Gsatrinoma - tumour of G cells of pancreas
Man presents with bright red nodule on end of index finger that bleeds easily it has grown rapidly in last week and is now 1cm
Pyogenic Granuloma
It is an acquired haemangioma (localised excess of proliferating capillaries) Tend to blled heavily on minimal trauma
Prolapsed Rectum
Partial prolapse - mucosa only -
Complete prolapse - mucosa and muscle - results in incontinence and mucus discharge - Surgical lifting of the prolapse, redudnant mucosa excised and muscle is folded using sutures (DeLorme procedure)
NB children - digital reduction or submuc injections
Fistula definition and management
Fistula - abnormal connection between to epithelial surfaces (exception to this is AV fistula which is between two endothelial surfaces)
Management depends on whether its above or below the puborectalis muscle sling (slings around the rectum to the pubic bone)
Below (intersphincteric)- ‘Laying open the fistula tract’
Above (higher trans sphincteric fistulae) - Seton insterion
NB you can work out the location of the other end of the fistula using Goodsall’s rule. If it is anterior to 3-9 oc lock ->straight. If its posterior to this line, its curved.
Anal abscess
Don’t treat with abx, treat with incision & drainage as if it ruptures it can cause fistula formation
Curretttage and drain out
Packed loosely and left to heal via granulation
Anal fissure
- Conservative measures: high-fibre diet, adequate fluid intake, sitz baths, and topical analgesia. Stool softeners can be useful to make defecation less uncomfortable
- M: Diltiazem cream and glycerin trinitrate creams relax anal tone
- S: Refractory to medical mx you can give botulinum toxin or sphincterotomy
72 year old lady has a fall in the snow. XR shows intertrochanteric fracture, how would you manage this?
DHS
Intertrochanteric is extracapsular
How would Takayasu’s present? ix and mx
HTN, arm claudication, absent pulses, bruit and visual disturbances + systemic flaws
Angiography will show narrowing of aorta and aortic branches
Mx: Steroids but condition is progressive and prognosis is poor (death within a few years)
Critical limb ischaemia diagnostic criteria
Greater than 2 weeks duration
Ankle pressure of less than 40mmHg
Rest pain (worse on raising feet) or tissue loss
Indications for amputations
dead limb - gangrene
deadly limb - wet gangrene, spreading cellulitis, AV fistula
dead useless limb - paralysis and providing mobility issues, severe rest pain with unreconstructable crtiical leg iscahemia
