Surgery A Flashcards
When is nipple discharge concerning for breast cancer?
Unilateral blood filled discharge
What breast conditions is milky discharge seen in?
Pregnancy and pituitary adenomas
What breast conditions are associated with brown/green discharge?
Mammary duct ectasia and intraductal papilloma if there is some blood
Describe the features of breast abscesses?
These may be lactational/non-lactational, periareolar/peripheral and are often associated with smoking. Clinically they present as erythematous, tender, fluctuant and systemically unwell. Management is with aspiration and excision of any necrotic skin.
Describe the features of mastitis?
These are associated with lactation where the skin becomes dry and cracked allowing an infection to enter. It is usually a staphylococcus infection and presents clinically with erythema, tender, hot and the patient is unwell. Management is with oral/IV antibiotics.
It is important that inflammatory breast cancer is ruled out.
How should gynaecomastia be investigated?
Hyperplasia of stromal and ductal tissue in the male breast. It may be unilateral, concentric and tender. Exclude cancer and see if the cause is physiological, pathological, drug induced or idiopathic.
Describe the features of fibroadenoma
A Benign condition which is the most common lesion of the breast, occurring in 25% of women between 15-35. They are hormone dependent and composed of connective tissue and proliferating epithelium. They are firm, non tender, highly mobile, single or multiple. Triple assessment should be done.
Describe the features of breast cysts
These are common in the over 35s who are perimenopausal. The cyst may fluctuate with menstrual cycle. They will be well demarcated from the surrounding tissue. They are firm, mobile and either tender or non-tender. Treat by aspiration, if bloody fluid is aspirated they will need a biopsy or of complete resolution not achieved they may need an excision.
Describe the features of fibrocystic change in the breast
These are most common in 30s-50s and have an association with cysts, stromal proliferation and epithelial hyperplasia. They are heavily associated with an imbalance of progesterone and oestrogen. 50% are asymptomatic and any report should be investigated with triple assessment.
Describe the features of phyllodes tumour and sarcoma
Leaf-like tumour which occur in late 30s-50s, rapid growth. They are usually benign but occasionally malignant. They have a brown cut surface.
What are the risk factors for breast cancer?
Risk factors include being over 50, family history, 1st pregnancy after 30 years old, HRT, alcohol, perimenopausal obesity, genetic (BRCA/Li-Fraumeni), cold countries and smoking.
How does breast cancer present?
They present with a hard, irregular, tethered lump. They may change in shape, show ulceration, skin changes (Peau d’orange), inflammatory breast cancer, nipple changes (paget’s disease, discharge and inversion). Metastatic changes may have axillary lumps.
What are the types of breast cancer?
Types of breast cancer include: DCIS (ductal carcinoma in situ), ductal, lobular, mixed, LCIS (Lobular carcinoma in situ), tubular, mucinous, intracystic papillary, medullary, sarcoma and lymphoma.
DCIS is a pre-invasive cancer picked up due to abnormal calcification in the breast. There are malignant cells within the ducts and a proportion progress to invasive.
How is breast cancer managed surgically?
Removal of a lump is called a wide local excision which has a very high chance of success and is more psychologically beneficial than mastectomy. Mammoplasty can be used to reduce the size of these lesions. Post surgery radiology should be done to confirm success.
Mastectomy is a partial or complete removal of the beast tissue which is very successful but will need an implant to make psychologically better. Should only be done if disease is wide spread, multifocal and the tumour is relatively large. Also done if WLE is unsuccessful.
Axillary surgery: This is done to determine if the nodes are involved in metastatic disease and see whether chemotherapy is needed. This is done through sentinel node biopsy or axillary node clearance. The sentinel node biopsy involves using a blue dye and a radioactive tracer. After one or two weeks the tumour will be visible.
How should mastitis with breastfeeding be treated?
Encourage to continue breast feeding and topical NSAIDs
Should breast feeding continue with an abscess?
No
How should oestrogen receptor positive breast cancers be treated?
Tamoxifen - pre menopausal
Tamoxifen stops oestrogen from binding to oestrogen-receptor-positive cancer cells. It’s taken every day as a tablet or liquid.
Post-menopause, you may be offered an aromatase inhibitor.
3 aromatase inhibitors may be offered. These are anastrozole, exemestane and letrozole. These are taken as a tablet once a day.
How should HER2 receptor positive breast cancer be treated?
After surgery, chemotherapy and radiotherapy; Herceptin (trastuzumab) should be offered
How should triple negative breast cancer be treated?
Surgery, radiotherapy and continued chemotherapy
Describe the anatomical and functional features of the large intestine
The function of the large intestine is to absorb water and the residues of liquid chyme. It can be differentiated from the small intestine because it has a greater diameter, teniae coli (longitudinal ribbons on the outside of the colon), haustra (Sacculations of the wall of the colon which can be seen on CXR) and epiploic appendices (small fatty omentum like projections from the colon).
The large intestine is supplied by the superior mesenteric artery (Caecum to transverse colon) and inferior mesenteric artery (descending colon to proximal rectum). The mid and distal rectum is supplied by the middle and inferior rectal arteries which are branches of the internal iliac artery. The venous supply reflects the arterial supply.
What is the physiology of defecation?
- Rectum becomes distended - initiates the rectosphinteric reflex
- Internal anal sphincter then relaxes involuntary through parasympathetic fibres
- The external anal sphincter then relaxes voluntarily via the pudendal nerve’s actions of skeletal muscle. This can be used to delay defecation.
- Contraction of the abdominal wall muscles and relaxation of the pelvic wall muscles
What is diverticular disease?
Diverticular disease is when out pouching of the mucous membrane through the muscle wall of the bowel. These lie alongside the taenia coli and are overlapped by epiploic appendices. This is most common in the sigmoid colon and western countries because of the low fibre diet.
Hypertrophy of the muscle of the colon produces high intra-luminal pressures which cause herniation of the bowel mucosa at the sites of the potential weakness in the bowel wall (vessel entry points).
Diverticular disease presents with abdominal discomfort (associated with constipation). Acute diverticulitis, inflamed diverticulum, abdominal pain which is most commonly found in the lower abdomen. In some cases there may be bowel obstruction due to muscle thickening and fibrosis.
One of the most common causes of PR bleeding is due to erosion through to a vessel.
Describe the features of diverticulitis
Diverticulitis should be investigated with an OP colonoscopy or CT colonoscopy for diverticular disease.
Acute diverticulitis should be investigated with bloods (FBC, CRP, U&Es, LFTs, clotting, lactate and ABGs), urine dipstick, CXR to check for pneumoperitonitis and CT abdo/pelvis.
In chronic diverticular disease the patient should be given dietary advice (high fibre diet) and bulking agents such as fybogel.
Acute diverticulitis should be assessed for sepsis, percutaneous drainage of any abscess and surgery may be required to resect the disease bowel (+/- stoma) which is known as the Hartmann’s procedure.
What are the risk factors for colorectal cancer?
Age above 50, family history, history of colonic polyps, inflammatory bowel disease, type 2 diabetes, red meat, minimal exercise, alcohol and smoking
What are the symptoms of colorectal cancer?
PR bleeding (Bright red if rectal or dark red in right sided tumours)
Change in bowel habit (particular if they have become loose)
Tenesmus (sensation of incomplete evacuation after passing stool which may suggest rectal tumour)
Abdominal Pain (Late presentation)
Tiredness (seen when anaemic due to blood loss) Weight loss (uncommon in colorectal cancer)
Emergency presentation where the tumour perforated the bowel causing pain and bowel obstruction from the tumour blocking the lumen.
What are the investigations for colorectal cancer?
Bloods: Hb, U&Es and LFTs
Colonoscopy: This is the gold standard investigation as it can identify the majority of the differentials as well as tumours. Biopsies can also be taken.
CT colonoscopy: This is useful for colonic lesions and polyps under 6 mm and those unfit for colonoscopy.
CT chest and abdo can be used for staging lymph node involvement.
What is the treatment for colorectal cancer?
Resection of the primary tumour:
- Right hemicolectomy for right sided and transverse colon tumours
- Left hemicolectomy for left sided tumours
- Anterior resection or Hartmann’s procedure for rectal and sigmoid tumours
The secondary metastases may also need resection such as in the liver or lung.
Chemotherapy: This may be used for palliation, prior to surgery if metastatic spread or post surgery for lymph node involvement.
Neo-adjuvant radiotherapy/chemo-radiotherapy:
Attempt to shrink the primary tumour pre-operatively in rectal cancers or used in palliative therapy setting if rectal tumour symptoms are troubling.
Colonic Stents: Can be used in obstructive colonic tumours - particularly left sided/recto-sigmoid tumours but these often become displaced.
