Surgery: General Flashcards
Ddx for Young Female RIF Pain
GI: appendicitis, mesenteric adenitis, terminal ileitis, constipation, IBS
GU: ureteric calculus + UTI
Gyn: ectopic preg, tubo-ovarian pathology abscess/cyst/torsion, endometriosis, PID, mittelschmerz
Ddx of Appendicitis
GI: mesenteric adenitis, terminal ileitis, caecal diverticulitis, Meckel’s diverticulum
GU: testicular torsion, ureteric calculus, UTI
Gyn: ectopic preg, tubo-ovarian pathology abscess/cyst/torsion, endometriosis, PID, mittelschmerz
Ddx of Terminal Ileitis
Inflammation: CD + backwash ileitis
Infection: yersinia, salmonella, c difficile, mycobacterium
Malignancy: adenocarcinoma, metastatic, lymphoma, carcinoid
Plus spondyloarthropathies + vasculitides
RFs for PONV
Patient: female, younger, non-smoker, prev ep, motion sickness
Surgical: prolonged, abdo lap, intracranial, middle ear, squint, gynae, poor pain control after
Anaesthetic: prolonged, intraop bleed, inhalational agents, overuse of bag and mask ventilation, spinal, opioids
Alternative causes of PONV
Infection, GI (ileus or obstrc), metabolic (hyperCa, uraemia, DKA), meds, raised ICP, anxiety
Mx of PONV
Prophylactic - antiemetics, dex at induction, anaesthetic measures
Conservative - adequate fluids, adequate analgesia, ensure no obstrc
Pharmaceutical - multimodal therapy
The red flag condition for N+V?
Incarcerated Hernia
The red flag conditions for epigastric pain? (2)
MI + Leaking AAA (also flank pain)
The red flag condition for RUQ pain?
RLL Pneumonia
The red flag condition for groin pain?
Torted Testes
The red flag conditions for RIF pain? (2)
Large bowel obstrc + ruptured ectopic preg (also LIF pain)
What would pain out of proportion to clinical findings suggest?
Ischaemic Bowel
What is the most common acute abdo dx worldwide?
Appendicitis
Antiemetics if impaired gastric emptying
Metoclopramide or Domperidone
Antiemetic if suspected obstrc
Hyoscine
Antiemetic if metabolic
Metoclopramide
Antiemetics if opioid induced
Ondansetron or Cyclizine
What is involved in the pre-op examination?
General - identify any underlying undx pathology
Airway - predict difficulty of intubation
Outline the ASA classification
I - normal healthy pt
II - mild systemic disease: current smoker, preg, BMI 30-40
III - severe systemic disease: BMI >40
IV - above + constant threat to life
V - moribund + won’t survive w/o op
What does the ASA grade correlate with?
Risk of post op comps and absolute mortality
What is included in the airway examination?
Any obv facial abnormalities e.g. retrognathia
Degree of mouth opening, dentition and loose teeth, Mallampati classification
Neck ROM and distance b/w thyroid cartilage and chin <6.5cm difficult intubation
The pre-op drug regime
To stop - OCP/HRT, hypoglycaemics, clopidogrel, warfarin
To alter - S/C insulin + long term steroids
To start - LMWH, TED stockings, abx
CIs for NG Tube
Absolute - mid face trauma + recent nasal surgery
Relative - coag abnormalities, recent alkaline ingestion, oesophageal varices/strictures
How do you measure the length of a NG tube?
Tip of nose, to earlobe, to bottom of xiphoid process
NG Tube Insertion Tips
Agree signal to stop procedure
Inspect for deviated septum and visible polyps
Aim the tube horizontally along the nasal cavity floor
Advance with each swallow and ask pt to tuck chin
What pH indicates gastric acid?
<5.5
Which veins can you insert a central venous catheter? (3)
Internal jugular, subclavian, femoral
Why might a pt need a CVC? (3)
Meds that require administration centrally: vasopressors, inotropes, TPN, chemo
Access to extracorporeal circuit for haemodialysis
To monitor central venous pressure
How long does central venous access give you?
CVC - days to wks
PICC - wks to mnths
Tunnelled - mnths to yrs
What are the comps of central venous access?
Immediate: haemorrhage, pneumothorax, arterial puncture, arrhythmias, cardiac tamponade, air embolism
Delayed: venous stenosis, thrombosis, erosion of vessel, line fracture, catheter colonisation, line related sepsis
What is a common indication for a PICC line?
Following an oesophagectomy or Whipple’s procedure for chemo
They’re sited by specialist nurses, checked in place by CXR, only the radiologist or ICU consultant can approve placing
What are the borders of the triangle of safety for chest drain insertion?
Lateral edges of pectoralis major and latissimus dorsi, apex of axilla, fifth intercostal space
Absorbable Sutures
Vicryl, monocryl, PDS
Non-Absorbable Sutures
Nylon, prolene, silk
The different ways of giving oxygen therapy
Nasal Cannula - max 4L/min and can deliver 25-35% FiO2
Face Mask - max 10L/min and can deliver 25-60% FiO2
Non Rebreathe - max 15L/min and can deliver 80-85% FiO2
Level 2 Care - high flow nasal cannula and NIV
Level 3 Care - mechanical ventilation
What is the dual blood supply of the liver?
70% Portal Vein + 30% Hepatic Artery
What joins to form the portal vein?
NB: the PV has NO valves
Splenic + Superior Mesenteric
What’s the most common site of rupture in Boerhaave syndrome?
Lower 1/3 in the left posterolateral distal oesophagus
What are the main causes of Boerhaave syndrome? (3)
Alcoholics, GORD, iatrogenic
Mackler Triad
Vomiting, lower chest pain, surgical emphysema
Hamman Sign
O/e mediastinal crunch synchronous w the heartbeat
Ix for Boerhaaves
CXR - pneumomediastinum, pneumothorax, pleural effusion
Oesophagram - extraversion of contrast material
CT w Gastrografin - identify the site of perforation
Which is the rough estimate b/w litres per minute and approximate FiO2?
It inc in increments of 4% for every LPM given:
1 - 24% 2 - 28% 3 - 32% 4 - 36% 5 - 40% 6 - 44% 7 - 48% 8 - 52% 9 - 56% 10 - 60%
Definition of definitive airway
A tube in the trachea w a cuff e.g. ET tube or a tracheostomy
What common cancers met to bone?
Men - prostate - sclerotic bone mets
Women - breast - lytic bone mets
Which hernia is most likely to strangulate?
Femoral > Inguinal
How do you know the bag + valve mask is working? (3)
The chest is rising, the mask is misting, end tidal CO2
Why is CO2 used during laparoscopy? (3)
Inert
Soluble
Inflammable
How does gastric ca typically present?
Dyspepsia + Anaemia
What are the causes of a post op fever?
The 5W’s: wind, water, wound, walking, wonder drugs ie pneumonia, UTI, infection at incision organ blood, PE/DVT, drugs/transfusion
How do you prep someone for surgery as an F1?
- NBM + Fluids
- Drugs: Allergies, Bleeding Risk, VTE, Abx
- Airway Difficulty
What is the surg safety checklist before induction of anaesthesia? (3)
Pt confirmed identity, site, procedure + given consent
The site is marked, anaesth machine + meds checked, pt has pulse ox on
Any allergies recorded, risk of blood loss, assessed difficulty of airway
What is the surg safety checklist before skin incision? (5)
Staff introductions, confirm pt name site procedure, abx prophylaxis, anticipated critical events, essential imaging displayed
Which xray view shows the occiput?
Towne’s
What is done during the primary survey?
Intubation and ventilation, two large bore cannulas (14G), bloods (FBC, U&Es, clotting, glucose, crossmatch), IV fluid, monitoring (pulse, BP, oximetry, RR), ECG, arrange plain films
What is done during the secondary survey?
Full examination, medical history, NGT and urinary catheter (unless contraindicated), further imaging
The eye component of GCS
Spontaneous opening – 4
To speech – 3
To pain – 2
No response – 1
The verbal component of GCS
Orientated response – 5
Confused conversation – 4
Inappropriate words – 3
Incomprehensible sounds – 2
No response to pain – 1
The motor component of GCS
Obeys commands – 6
Localises pain – 5
Normal flexion to pain (withdrawal) – 4
Abnormal flexion to pain (decorticate i.e. flexes upper extends lower) – 3
Extends all to pain – 2
No response to pain – 1
What is the presence of a fixed dilated pupil highly suggestive of?
Raised ICP requiring urgent neurosurgical intervention
How do chronic SDH often px?
A vague history of sx such as fluctuating conciousness, headache, personality change & confusion
RFs for SDH
Elderly, susceptible to falls (alcoholics and epileptics), on long term anticoag
SDH shape on CT
Crescent
EDH shape on CT
Biconvex
Where does the blood tend to extend along in SDH?
Falciform ligament & tentorium cerebelli
What are the clinical signs of hydrocephalus? (5)
Inc head circumference, open ant fontanelle will bulge and become tense, failure of upward gaze, dilated scalp veins, bradycardia
Why do pts w hydrocephalus px w failure of upward gaze?
Compression of the superior colliculus of the midbrain
Aetiology of obstrc and non-obstrc hydrocephalus
Obstrc: tumour, intraventricular/subarachnoid haemorrhage, aqueduct stenosis
Non-Obstrc: meningitis, post-haemorrhagic, choroid plexus tumour
What is the triad of sx for normal pressure non-obstrc hydrocephalus?
Dementia, incontinence, disturbed gait
Typical subdural haematoma pt
Elderly alcoholic on anticoag w hx of head injury and insidious onset of fluctuating confusion and dec consciousness
When does diffuse axonal injury occur?
When the head is rapidly ac/decelerated
Imaging: Extradural vs Subdural
convEX=EXtradural
Cushings triad of raised ICP
HTN, bradycardia, irregular respirations
When should you CT head immediately following head injury?
GCS <13 on initial ass or <15 at 2hrs
Suspected open/depressed skull # or any sign of basal skull #
Post-traumatic seizure or focal neuro deficit
> 1 episode of vomiting
What are the signs of basal skull #? (4)
Panda eyes, CSF leakage from nose/ear, Battle’s sign, haemotympanum
When should you CT head within 8hrs following head injury?
If they’re on warfarin OR amnesia/LOC since injury who are 65+yrs, hx of clotting disorders, dangerous mech of injury, >30mins retrograde amnesia
What is the minimum cerebral perfusion pressure in adults + children?
Adults: 70mmHg | Children: 40-70mmHg
Oculomotor nerve lesion (3)
Down and out eye, loss of accommodation, pupillary dilation
Ddx of bilaterally constricted eyes (3)
Opiates, pontine lesions, metabolic encephalopathy
What findings in the CSF would prove SAH?
Xanthochromia w N/raised opening pressure
What are causes of spontaneous SAH? (3)
Intracranial aneurysm, AV malformation, pituitary apoplexy
What conditions are a/w berry aneurysms? (3)
PCKD, Ehlers-Danlos, Coarctation of the Aorta
What should you do as soon as SAH is confirmed?
Refer to neurosurgery, identify cause w CT intracranial angiogram +/- catheter angiogram, keep on bed rest w well controlled BP
Tx for spontaneous SAH caused by intracranial aneurysm
Ideally within 24hrs
Majority: coil by interventional neuroradiologist
Minority: craniotomy and clipping by neurosurgeon
Comps of aneurysmal SAH (5)
Rebleeding, vasospasm, hypoNa, seizures, hydrocephalus
How do you prevent vasospasm?
21d course of nimodipine
How do you confirm SAH?
CT -> if neg perform LP @ 12hrs to distinguish b/w a traumatic tap
Which views are taken during mammograms?
Oblique + Craniocaudal
At which age do you perform a mammogram
> 40y
What are the mammographic features of breast ca
Ill-defined or spiculated mass Parenchymal distortion Overlying skin thickening Malignant calcifications Enlarged axillary lymph nodes
What are the US features of breast ca
Ill-defined usually hypoechoic mass
Distal acoustic shadowing
Surrounding halo
Abnormal axillary nodes
What are US useful for distinguishing b/w?
Solid vs cystic lump
If breast US confirms a ca where else should you US?
The axilla to help plan tx
If the mammogram and US are equivocal what method of imaging should you perform next?
MRI
Outline the components of triple assessment
Hx and exam, imaging (US/mammography), histology (core biopsy/FNA/VAM)
Why are core biopsies often preferred to FNA?
They provide more detail inc ER, PR and HER2 status
How would you stage breast ca?
If pt has sx perform FBC, U&Es, LFTs, bone profile & if any are abnormal CXR, liver US, bone scan
Breast ca tx
If fit surgery, if not primary endo therapy, if >3cm neo-adjuvant chemo
Factors to consider when planning surgery
Pts choice, mass size relative to breast size, position
What is the most likely outcome if the tumour is behind the nipple?
Mastectomy
The most common histological subtype
Invasive ductal carcinoma
Ratio of invasive ductal:invasive lobular prevalence
17:3
Outline the NHS breast screening programme
Mammogram every 3yrs b/w 50-70y
Typically 4/100 will need further testing with 1/100 being diagnosed w cancer
When would you consider radiotherapy following mastectomy?
High risk of local recurrence e.g. involved margins, vascular/dermal invasion, heavily node positive
RFs for Breast Cancer
Age, FHx, BRCA, Prev, Oestrogen: nulliparity, first preg >30yrs, early menarche, late menopause, HRT, obesity
Mx of Mastitis
Encourage to continue breastfeeding; if sys unwell, nipple fissure, not improving after 12-24hrs start 2w flucloxacillin and continue feeding; if abscess incise and drain
What conditions does ANDI encompass?
Fibroadenosis
Cyst Formation
Epitheliosis
Papillomatosis
When do you perform a mastectomy > wide local excision for DCIS?
> 4cm
What is the Nottingham Prognostic Index?
(Tumour Size x 0.2) + LN Score + Grade Score = NPI
What is the most common type of breast cancer?
Invasive Ductal Carcinoma
Why do we not routinely screen pts under 40?
Mammography has a red sensitivity in denser breast tissue
When is MRI the ix of choice?
Pts w implants
Plus: in younger pts who might have a strong fhx and as second line imaging for breast masses
Ddx for Solid Breast Mass
Localised benign area, carcinoma, cyst, fibroadenoma, periductal mastitis, duct ectasia, abscess
Which subtype of fibroadenomas can recur and must be excised?
Phyllodes
Which age group are breast cysts most common?
Perimenopausal
Ddx of Spiculated Mass
Cancer + Radial Scar
What age group can aromatase inhibitors be used for?
Post-Menopausal
At what size should you core biopsy a fibroadenoma?
> 4cm
What scan should be performed before starting a pt on an aromatase inhibitor?
DEXA
Who should undergo a 2wk referral?
Aged >=30 who have an unexplained breast lump with or w/o pain and consider in those w an unexplained lump in the axilla
Aged >=50 who have unilateral nipple sx
Ddx of Bloody Discharge
Carcinoma + Intraductal Papilloma
Ddx of Duct Ectasia
Carcinoma + Periductal Mastitis
Mx of Mastitis
The first line is to continue breastfeeding but if sys unwell, nipple fissure, sx not improving after 12-24hrs add flucloxacillin 10-14d
Tx of Breast Abscess
Incision + Drainage
How does Paget’s disease of the breast present?
An eczematoid change ie reddening and thickening of the nipple a/w underlying breast cancer
What are the three branches of the coeliac axis?
Left Gastric, Hepatic, Splenic
Where does the right gastric artery come from?
Hepatic
What are the three branches of the superior mesenteric artery?
Right Colic, Ileocolic, Middle Colic
What does the ileocolic artery supply?
Terminal Ileum, Caecum, Appendix
What are the three branches of the inferior mesenteric artery?
Left Colic, Sigmoid, Superior Rectal
Where are the watershed areas?
The second part of the duodenum: junction of the coeliac + SMA
The splenic flexure: junction of the superior + inferior mesenteric arteries
You either leave/take it you don’t anastomose around it
How many pple have a right colic artery?
5-10%
What is the indication for a right hemicolectomy?
Cancer in caecum, ascending colon, hepatic flexure
Why is knowledge of the arterial supply so important?
You require healthy ends to form an anastomosis + aids lymphadenectomy
Stage histologically, prognostic, chemo requirements
Why do you remove the blood vessels during GI surgery?
Lymphadenectomy
Sigmoid Colectomy vs Hartmann’s
Sigmoid Colectomy: only treats benign disease eg diverticular disease or strictures
Ant Resection: tx cancer in the sigmoid and forming a colorectal anastomosis
Hartmann’s: emergency Bowel obstrc pathology has to be removed and close off the distal sigmoid/rectum and bring out an end stoma Can be done anywhere along the colon \+/- reversible in the future
Why is a sigmoid colectomy NOT a cancer operation?
It doesn’t harvest every lymph node from the originating vessel but only the sigmoid artery
Anterior Resection vs APER
AR: leaves a variable length of rectum and the anus which you can anastomose
APER: removes rectum + anus for when the tumour is on or invading the anal sphincter
What are the requirements for an anterior resection?
You have to have a 1cm clearance of healthy bowel b/w tumour and anal sphincter so you can anastomose
What sx do pts complain of if the tumour is low lying?
Incontinence, urgency, bleed + the feeling of sitting on something if it’s that low
How does the lower part of rectum and anus survive following an AR?
It has a dual blood supply: despite the superior rectal artery being removed it still has the inferior rectal artery coming from the pudendal artery
Where are the majority of colorectal cancers?
- Rectum
- Sigmoid
- Caecum
If you have a splenic flexure tumour you can not make an anastomsis here after
T
What blood supply is removed during a left hemicolectomy?
Left Colic
Left branch of middle colic
Extended R Hemi > L Hemi
Ileocolic, right colic, whole middle colic, left colic
Anastomose ileum to sigmoid colon
Better oncologically
Blood supply to small-large bowel anastomosis is better than large-large
What blood supply is removed during a right hemicolectomy?
Right Colic
Ileocolic
Right branch of middle colic
What anastomosis do we do following a right hemicolectomy?
Side to side stapled small bowel to transverse colon
What artery do you take during an AR or an APER?
Inf Mesenteric Artery
Why is a left hemi such a rare operation?
The Watershed Area + the difficulty of anastomosing the transverse colon
What operation would you op for to tx a transverse colon tumour?
Either right hemi or extended right hemi depending where the tumour was along the transverse colon
Defunction vs Hartmann’s
Both used in the emergency setting likely following bowel obstrc
If the pathology is left in it is NOT a Hartmann’s procedure
The defunctioning stoma is looped small/large bowel to rest the distal bowel before reversing
How can you tell which stoma it is?
Spouted R - Ileostomy
Flattened L - Colostomy
If it’s on the right side of the abdomen it’ll be small bowel EXCEPT if it’s transverse colon
If it’s on the left side of the abdomen it’ll be large bowel
If still in doubt check the contents of the bag
When else would you see a loop
Emerg op
After a low anterior resection and you want the anastomosis to heal
Ix
CT - free air, points of obstrc, thickened bowel
US - hollow viscus w stones
OGD/Colonoscopy
Endoscopy - diagnostic + therapeutic (polypectomy, clip bleeding ulcer, colonic stent as a bridge to surgery)
CTC - order in clinic not acute, less severe bowel prep as colonscopy, leas invasive, virtual colonscopy, can’t take biopsy or polypectomy)
MRI - rectal cancers, solid viscus, high resolution defined tissue planes to determine who requires preop radiotherapy + what requires resection
Laparoscopy - diagnostic, drain cysts, appendectomy
What is the telltale sign of a stone on US?
It casts an acoustic shadow
What do you want to know if a pt has postop pyrexia?
The Time of Onset
Day 0-2: tissue damage and necrosis, haematoma formation, pulmonary collapse, infection at site of surgery
Day 3-5: sepsis + pneumonia
Day 5-7: anastamotic leak, fistula formation, DVT/PE
How should you ix
Hx: cough, sputum, dysuria, freq, calf pain
O/e: wounds, drain sites, chest, abdomen, calves
Ix: cultures + CXR
Postop Pain
Wound pain vs chest pain
Erythematous, hot, pus
Wound: maximal in first 72hrs but if worsening check for infection
Chest: cardiac retrosternal +/- arm radiation vs pleuritic sharp, localised, worse on inspiration
Abdo: sepsis, leak, urinary retention
Urine Output
Physiological response to surgery/stress or
prerenal failure, acute renal failure, urinary retention
Why TNM
Prognostic
Guide whether need adjuvant therapy after surgery
How does the TNM and Dukes staging map up together?
Duke A = T1-2
Duke B = T3-4
Duke C = N1+
Duke D = M1+
How do you examine a stoma?
Tbc
When is a Whipple’s procedure appropriate for treating carcinoma of the head of pancreas?
Only in <20% of pts where no distant metastases and vascular invasion is still at a minimum otherwise perform ERCP and biliary stenting
Which part of the colon is retroperitoneal?
Ascending, Descending, Rectum
What lies on the transpyloric plane?
MSK: vertebra L1 and 9th costal cartilage
Vasc: origin of SMA and formation of portal vein
Visceral: pylorus, GB fundus, DJ junction, neck of pancreas and hila of kidneys
Which drugs can cause acute pancreatitis?
Azathioprine Mesalazine Didanosine Bendroflumethiazide Furosemide Pentamidine Steroids Sodium Valproate
What can pts commonly get following a cholecystectomy?
Common bile duct stone or injury: wks vs days
Ix for chronic pancreatitis
Faecal elastase and CT pancreas w IV contrast
Ddx of hyperamylasaemia
Acute Pancreatitis Pancreatic Pseudocyst Mesenteric Infarct Perforated Viscus Acute Cholecystitis DKA
Typical hx of chronic pancreatitis
Abdo pain following meals, takes pancreatic enzymes, steatorrhoea, diabetes, chronic alcohol abuse
Biliary Colic vs Cholecystitis vs Cholangitis
Not sys unwell just colicky pain
Sys unwell and murphy’s pos
Charcot’s triad (fever, jaundice, RUQ pain) - Reynolds pentad (w altered mental status and shock)
What disease does chronic pancreatitis put you at risk of? Annual ix?
Type 3c diabetes ie pancreatogenic therefore annual HbA1c measurements
Most common causative organism of ascending cholangitis
E coli then klebsiella and enterobacter
Which test is useful when considering Wilson’s disease?
Ceruloplasmin
What are a/w pigmented gallstones?
Sickle cell anaemia
What ultrasound finding is a strong RF for cholangiocarcinoma?
A Porcelain GB ie intramural wall calcification
The Modified Glasgow Score
PaO2 Age Neutrophilia Calcium Renal Function Enzymes Albumin Sugar
> =3 ?ITU
What is the radiological sign of surgical emphysema?
The air outlines the pec major resulting in the ginkgo leaf sign
Tx of acute cholecystitis
Analgesia, IV fluids and abx, early lap cholecystectomy within wk of dx
What typically has pain that radiates to the interscapular region?
Biliary colic NOT peptic ulcers
What is Beck’s triad?
Cardiac tamponade pts: hypotension, raised JVP, muffled heart sounds
Whats is Cushing’s triad?
Raised ICP: hypertension, bradycardia, irr/dec RR
What are the comps of a gastrectomy?
Dumping syndrome, early satiety, wt loss, osteoporosis, IDA, vit B12 def, subacute combined degen of spinal cord, inc risk of gastric ca and GS
What does the H in GET SMASHED include?
Hypertriglyceridaemia
Hyperchylomicronaemia
Hypercalcaemia
Hypothermia
Ddx of rectal bleeding
Fissure
Haemorroids
IBD
Cancer
What do all pts presenting w rectal bleeding require?
DRE and procto-sigmoidoscopy, if clear view cannot be obtained bowel prep w enema and flexible sigmoidoscopy, altered bowel habit colonoscopy and XS pain EUA
What type is anal ca on biopsy?
Squamous Cell Carcinoma
What typically causes anal ca?
HPV infection therefore those immunocompromised are most at risk
Tx of Anal Cancer
Chemoradiotherapy
What does a biopsy report showing fibromuscular obliteration suggest?
Solitary rectal ulcer syndrome where extensive collagenous deposits are often seen
Mx of Haemorrhoids
Consrv: dietary advice +/- topical analgesics and bulk forming laxatives
Non-Op: rubber band ligation or injection sclerotherapy
Surgical: excisional haemorrhoidectomy or stapled haemorrhoidopexy
What is nocturnal diarrhoea and incontinence typical of?
IBD
Which part of the bowel is often spared from diverticular disease?
The rectum as it lacks taenia coli
What is the Hinchey classification of complicated diverticulitis?
I - paracolonic abscess
II - pelvic abscess
III - purulent peritonitis
IV - faecal peritonitis
Why is a loop ileostomy better than a loop colostomy following a colonic anastomosis?
Small bowel heals well vs the reversal of a loop colostomy carries the same risk of anastomotic leak as the original surgery
Anterior vs Abdominal Perineal Resection
If the malignancy is >5cm from the anal verge, anterior, temporary loop ileostomy
If the malignancy is <5cm from the anal verge, AP, permanent end colostomy
What is Hartmann’s procedure?
Similar to a high anterior resection in that the rectal stump is retained but usually in emerg setting when high risk of anastomotic breakdown and a temporary end colostomy is formed instead
Comps of bowel resection
I: haemorrhage, injury to spleen and ureter, anaesthetic risks
E: haemorrhage, infection, pain, anastomotic leak, blood clots
L: hernia + adhesions
Urostomy vs Ileostomy vs Colostomy
Urostomy: RIF, sprouted, urine drains via an ileal conduit
Ileostomy: RIF, sprouted, liquid faecal effluent
Colostomy: LIF, flushed, semisolid faecal effluent
Temporary loop vs end ileostomy
A temp end ileostomy is formed when it is considered unsafe to form an anastomosis at that time
Comps of a stoma
Itself: early (haemorrhage, ischaemia, retraction) + late (fistulae and prolapse)
Around: early (abscess) + late (parastomal hernia and dermatitis)
Systemic: early (obstruction, dehydration, hypoK) + late (sepsis and psych)
What is toxic megacolon seen in?
UC
Ddx of acute pancreatitis
Perf peptic ulcer, gastritis, atypical MI
What are the general mx principles of pancreatitis? (3)
NBM, fluid resus, analgesia
Which volvulus is more common?
Sigmoid 8:2 Caecal
Mx of Sigmoid Volvulus
Use a rigid sigmoidoscopy and insert a rectal tube unless there’s bowel obstruction and peritonitis go straight to an urgent midline laparotomy
Mx of Caecal Volvulus
A right hemicolectomy is often required
Outline Dukes Classification
A: confined to bowel
B: invading bowel wall
C: lymph node mets
D: distant mets
Which enema is used to ix anastomosis healing as it’s less toxic if there is a leak?
Gastrografin > Barium
Ix for >60yo pt w tiredness and IDA
Colonoscopy (diagnostic) > faecal occult blood (screening)
How do thrombosed haemorrhoids px?
Sx: sig pain preceded by straining
Signs: purplish, oedematous, tender s/c perianal mass
Tx for Thrombosed Haemorrhoids
Within 72hrs consider excision otherwise analgesia, ice pack and stool softeners
What analgesia should be avoided postoperatively following major abdo surgery in pts w resp disease?
Opioid
Anaesthesia: Epidural > Spinal
It can be topped up and titrated
When should you give blood following an upper GI bleed?
If there’s signs of grade III/IV shock OR Hb <70
Mx of Anal Fissure
Consrv: dietary advice, bulk forming laxative, lubricants before defecation, 5% lidocaine ointment, analgesia
Medical: if presenting >1wk sx then add 0.2-0.4% GTN ointment or topical diltiazem
Surgical: if above ineffective after 8wks then refer for botulinum toxin injection or lateral partial internal sphincterotomy
Where are 90% of anal fissures found?
On the posterior midline therefore consider an underlying cause if they’re found elsewhere
What are the RFs and mx for urinary incontinence?
Types: stress, urge, mixed, overflow, functional
Both: exclude DM/UTI, bladder diaries, urodynamic testing, encourage reduction of caffeine/fizzy drinks, optimise wt
Stress RFs: age, obesity, children, traumatic delivery, pelvic surgery
Stress Mx: 1. 3m pelvic floor exercises 2. SNRI eg duloxetine OR surgical eg burch colposuspension
Urge RFs: age, obesity, smoking, DM, FHx
Urge Mx: 1. 6w bladder training 2. antimuscarinic eg oxybutynin 3. beta-3 agonist eg mirabegron 4. surgical eg botox injection
What imaging should pts whose tumours lie below the peritoneal reflection have to evaluate their mesorectum?
MRI
What does an anastomosis require to heal?
- Adequate blood supply 2. Mucosal apposition 3. No tissue tension
What are the causes of chronic pancreatitis?
Common: Alcohol; Smoking; AI
Rarely: Cystic Fibrosis; Haemochromatosis; Duct Obstruction; Pancreas Divisum
What are the ddx for pain following a meal?
- Gastric Ulcer 2. Biliary Colic 3. Pancreatitis
Ix for Chronic Pancreatitis
US +/- CT
Cholecystitis vs Cholangitis
Jaundice
Tx of Cholangitis
IV Abx + ERCP
How are haemorrhoids graded?
I: remain in the rectum
II: prolapse on defecation but spontaneously reduce
III: prolapse on defecation but require digital reduction
IV: remain persistently prolapsed
What are solitary rectal ulcer a/w?
Chronic straining and constipation
Ix for Solitary Rectal Ulcer
Once biopsied to exclude malignancy workup includes endoscopy, defecating proctogram, ano-rectal manometry studies
Who are the typical pts who get a sigmoid volvulus?
Older pts w chronic constipation, Chagas disease, Parkinson’s disease, Duchenne muscular dystrophy, schizophrenia
Who are the typical pts who get a caecal volvulus?
Any Age
Adhesions
Pregnancy
What stoma is required for an emergency Hartmann’s procedure?
End Colostomy
Ix for Rectal Intussusception
Defecating Procotogram
Where are the three anal cushions located?
At 3, 7 and 11 o’clock
What is Goodsall’s rule?
It determines the path of an anal fistula: if anterior the track is in a straight line vs if posterior the internal opening is always at 6 o’clock
Most common stone composition
CaOx
Which rare inherited condition can predispose to stones?
Cystinuria
What may be underlying recurrent stones?
Metabolic problems - hyperPTH, gout, cystinuria
Anatomical problems - PUJ obstrc, horseshoe kidney, ureteric stricture
What is the gold standard imaging for stones?
Non-contrast CT KUB
Renal colic ddx
AAA, biliary colic, constipation, bowel obstrc, ectopic pregnancy
When would you admit a pt w renal colic?
Single kidney, renal impairment, pyrexia, continuing pain, large stone, severe obstrc on CT, pregnant
NB: otherwise can be discharged w stone clinic OPA
Tx of stones
Conservative Tamsulosin ESWL Ureteroscopy PCNL
What is the conservative advice?
Ensure high fluid intake 2.5-3L/day, red salt and animal proteins esp red meat, don’t cut back on dairy just ca sups
NB: attend A&E if pyrexia or pain not controlled by analgesia
Haematuria ddx
Underlying malignancy UNTIL proven otherwise along the length of the urinary tract, infection, trauma, drugs, urological hx e.g. 2° haemorrhage
When would you admit a pt w haematuria?
Clots/retention Anaemic/renal impairment Tachycardic/hypotensive Prolonged bleeding Elderly/frail
NB: otherwise encourage fluids, ix cause, next available haematuria clinic app
Describe the three way catheter used for haematuria
Attachments: inflates balloon, urine bag, wash inflow for bladder irrigation
What are the two important ix to do for haematuria?
CT Urogram and Cystoscopy
Most common bladder ca
Transitional cell carcinoma
Which type of bladder ca does schistosomiasis cause?
Squamous cell carcinoma
Bladder ca RFs
Smoking, aniline dyes, rubber, textiles, printing
Mx of bladder ca
TURBT
Flexible cystoscopy surveillance
Intravesical chemo (mitomycin C) or immuno (BCG)
Radical cystectomy or radio
What does TURBT stand for?
Transurethral Resection of Bladder Tumour
Bladder ca classification
Carcinoma in situ
Ta - affects the epithelium
T1 - invades subepithelial connective tissue
T2a - invades superficial muscle
T2b - invades deep muscle
T3a - invades perivesical tissue microscopically
T3b - invades perivesical tissue macroscopically
T4 - invades contiguous organs
LUTS FUNDD HIPSS
Storage Sx:
Freq
Urgency
Nocturia
Post-Micturition Sx:
Dribbling
Dysuria
Voiding Sx: Hesitancy Intermittency Poor Flow Straining Sensation of Incomplete Emptying
BPE vs BPH
Benign Prostate Enlargement (clinical dx) vs Hyperplasia (histo dx)
What are the three components of the hald diagram?
LUTS, BPE, Bladder Outflow Obstrc
BPH RFs
Age, hormonal, obesity, diabetes, dyslipidaemia, genetic
Epi of BPH
Afro-Caribbean
Epi of stones
Caucasian
Medical mx of BPH
Tamsulosin - alpha blocker
Finasteride - 5 alpha reductase inhibitor
Solifinacen - anticholinergic
Mirabegron - beta 3 agonist
Sildenafil - PDE5 inhibitor
Surgical mx of BPH
TURP
HoLEP
Urolift
Rezum
How do you assess urinary retention?
Palpate suprapubic swelling, dull to percuss, bladder scan, consider CISC if post pelvic surgery, urethral catheterisation
What do you do if urethral catheterisation fails?
Use a catheter introducer, flexi guided, go suprapubic
Mx of acute retention
Painful and <1-1.5L
Catheter and alpha blockers, record residual urinalysis u&e, consider TWOC
Mx of chronic retention
Painless and >1-1.5L
Leave the catheter in, ultrasound, monitor residuals, F/U, consider surgery if enlarged prostate
What does TWOC stand for?
Trial WithOut Catheter
List the different types of Foleys
Short Term:
Simplastic
PTFE Coated
Long Term:
Hydrogel Coated & Silicone
What are the most common px of urinary sepsis?
UTI, pyelonephritis, pyonephrosis, shock, multi organ failure, ARDS
Who should you involve if the pt has urinary sepsis?
Urologist, microbiology, HDU/ITU
What is a medical emerg in urology?
Pyonephrosis - obstrc w infection - requires nephrostomy (local anaes) or stent (general anaes)
What can cause a raised PSA?
BPH UTI Urinary Retention Catheterisation Prostate Cancer
What is the most sensitive test for testicular ca?
Urgent same day ultrasound showing hypoechoic area
What is Fournier’s gangrene?
Fulminant infective nec fas of perineum +/- suprapubic and thighs, rapidly spreads, offensive odour, crepitus under the skin, severe pain
Tx of Fournier’s gangrene
Urgent broad spec abx + radical debridement -> referral to plastics for graft
Which pts are most at risk of Fournier’s gangrene?
Diabetics + Immunosuppressed
What must you always do after placing a catheter?
Pull the foreskin forward to prevent paraphimosis and document that you have
What should you be considering in a pt w haematuria?
The anatomical area (ultrasound lower vs cystoscopy upper) and cause (infection, calculi, malignancy)
What do you want to perform for suspected malignancy?
Tissue biopsy to confirm dx (ureteroscopy + biopsy) and consider both local and regional staging (CT urogram + CT chest)
What should be noted if you suspect a staghorn calculus on plain AXR?
Establish if the pt has had contrast in the last few hrs as it may not have been excreted due to a distal obstruction
Ddx for Acute Scrotal Pain
Torsion
Trauma
Infection
Malignancy
When is Prehn’s sign pos?
Scrotal elevation relieves pain in epididymitis but not torsion
When do you refer pts for suspected bladder/renal cancer?
Aged 45 and over with: unexplained visible haematuria w/o urinary tract infection or visible haematuria that persists or recurs after successful tx of UTI
Aged 60 and over with: unexplained non-visible haematuria and either dysuria or a raised WCC
What is nutcracker syndrome?
Left varicocele due to compression of the testicular vein by RCC as it joins left renal vein
RFs for RCC
Smoking Industry Dialysis HTN Obesity PCKD
Where do most prostate adenocarcinomas arise?
Posterior Peripheral Zone
What can germ cell tumours be divided up into?
Seminomas
Non-Seminomas: embryonal, yolk sac, teratoma, choriocarcinoma
What can non-germ cell tumours be divided up into?
Leydig + Sarcomas
Late comps of radical prostatectomy
Incontinence, ED, urethral stenosis
What is retrograde ejaculation a common comp of?
Alpha blockers and TURP
What post void volumes are considered physiological in pts aged above/below 65yrs?
<50ml if <65y
<100ml if >65y
What is chronic urinary retention defined as?
Presence of >500ml within the bladder after voiding
What does a post catheterisation urine volume of >800ml suggest?
Acute on chronic urinary retention
What meds can cause acute urinary retention?
Anticholinergics Benzodiazepines Antihistamines Opioids TCAs
Ddx for urinary retention
Urethral obstrc: BPH, stricture, calculi, cystocele, constipation
Plus meds, neuro, UTI, postop, postpartum
Why do adult pts w a hydrocele require an urgent ultrasound?
To exclude any underlying causes such as a tumour
Aside from tumours what else can hydroceles develop secondary to?
Epididymo-orchitis and testicular torsion
How does epididymo-orchitis present?
Acute pain and swelling following urological intervention, pyrexia, pos urine dip
What is a/w mumps?
Orchitis
Which side are varicoceles typically?
The left because the testicular vein drains into the renal vein as opposed to directly into the IVC
Screen for LUTS
Storage: FUND + Voiding: HIPS
Frequency
Urgency
Nocturia
Dysuria
Hesitancy
Incomplete
Poor Stream
Straining
Mx of nocturia
Advise moderating fluid intake at night, furosemide 40mg late afternoon, consider desmopressin
Mx of predominantly overactive bladder
Conservative: moderating fluid intake + bladder retraining
Pharmaco: antimuscarinic -> mirabegron
Mx of predominantly voiding sx
Conservative: prudent fluid intake + pelvic floor training
Pharmaco: alpha blocker, use 5α reductase inhibitor if prostate, use antimuscarinic if mixed sx
Give examples of antimuscarinic drugs
Oxybutynin
Tolterodine
Darifenacin
What can be used as immediate pain relief for renal colic?
IM Diclofenac
Mx of stones
<5mm: watch + wait
<10mm: alpha blocker, oral nifedipine, SWL
10-20mm: URS
> 20mm: PCNL
SWL = Shockwave Lithotripsy URS = Ureteroscopy PCNL = Percutaneous Nephrolithotomy
Aetiology of hydronephrosis
Unilateral: PACT + Bilateral: SUPER
Pelvic-Ureteric Obstrc
Aberrant Renal Vessels
Calculi
Tumours of Renal Pelvis
Stenosis of Urethra Urethral Valve Prostatic Enlargement Extensive Bladder Tumour Retro-Peritoneal Fibrosis
What should be performed on all pts w renal colic within 14hrs of admission?
Non contrast CT KUB
NB: if pyrexic, solitary kidney, uncertain dx perform immediately
What are the medical indications for circumcision?
Phimosis
Paraphimosis
Recurrent Balanitis
Balanitis Xerotica Obliterans
What is important to exclude prior to circumcision?
Hypospadias
Tx of acute balanitis
Dependent on underlying cause: STI - abx, candida - antifungal, dermatitis - topical hydrocortisone
What should men presenting w ED be screened for?
Underlying diabetes, CVD and hypogonadism therefore test glucose, lipid profile, testosterone
What is generally considered to be a normal age-adjusted serum PSA?
50-59yrs: <3ng/ml
60-69yrs: <4ng/ml
>70yrs: <5ng/ml
Urethral injury: bulbar vs membranous rupture
Bulbar: most common, straddle type injury, triad of 1) urinary retention 2) perineal haematoma 3) blood at the meatus
Membranous: either extra or intra peritoneal, pelvic #, penile/perineal oedema/haematoma and upwards displacing prostate on PR
Ix + Mx of urethral injury
Ascending urethrogram + surgically placed suprapubic catheter
Ix + Mx of bladder injury
IVU/Cystogram + extra: conservative or intra: laparotomy
SEs of alpha blockers e.g. tamsulosin and alfuzosin
Dizziness, postural hypotension, dry mouth
Tamsulosin doesn’t help w posture, no wonder dizziness can foster!
SEs of 5 α reductase inhibitor e.g. finasteride
Sexual dysfunction, ED, reduced libido, ejaculation problems, gynaecomastia
What is a TURP syndrome?
Presents w CNS, resp and systemic sx caused by irrigation w glycine resulting in hypoNa and hyperammonia
How is bladder voiding measured?
By urodynamic studies
RFs for testicular ca
FHx Infertility Klinefelter’s Cryptorchidism Mumps Orchitis
When should PSA testing not be done within?
At least: 48hrs of ejaculation or vigorous exercise, 1w DRE, 4w proven urinary infection, 6w prostate biopsy
Which drug is a recognised non infective cause of epididymitis?
Amiodarone
Which reflex is lost following testicular torsion?
Cremasteric
What is a common cause of a hydrocele in children?
A patent processus vaginalis
Tx of hydrocele
Children - trans inguinal ligation of PPV
Adults - Lords or Jabouley procedure
Raised AFP and HCG: seminoma or non-seminoma?
Non-Seminoma
Classical triad of RCC
Loin Pain
Haematuria
Abdo Mass
Most effective mx option in RCC
Partial/total radical nephrectomy
RFs for prostate ca
Age
FHx
Obesity
Afro-Caribbean
RFs for bladder ca
Transitional cell carcinoma: smoking, aniline dyes, rubber manufacture, cyclophosphamide
Squamous cell carcinoma: smoking + schistosomiasis
What medical benefits does circumcision reduce the risk of?
UTI, HIV, penile cancer
How can hydroceles be divided?
Communicating: PPV
Non-Communicating: XS fluid production within tunica vaginalis
Which ca classically results in cannonball mets in the lungs?
RCC + Choriocarcinoma
What should your work up inc for a left varicocele?
Must exclude RCC
Tx of Infantile Hydrocele
Reassurance and surgical repair ie Lord’s or Jaboulay’s if it does not resolve within 1-2yrs
Urethral Injury: Bulbar vs Membranous
Bulbar: more common; straddle type injury; triad of urinary retention, perineal haematoma and blood at the meatus
Membranous: extra or intraperitoneal; usually due to pelvic fracture; penile/perineal oedema/haematoma and high riding prostate
Ix for Urethral Injury
Ascending Urethrogram
Mx of Urethral Injury
Suprapubic Catheter
How does rhabdomyolysis cause AKI?
ATN
What causes acute interstitial nephritis?
Drugs, Autoimmune, Infection
Comps of TURP
Turp Syndrome
Urethral Stricture/UTI
Retrograde Ejaculation
Perforation of Prostate
Why does TURP syndrome occur?
When irrigation fluid enters the systemic circulation leading to: dilutional hyponatraemia, fluid overload, glycine toxicity
ED: Organic vs Psychogenic
Organic: gradual onset, normal libido, lack of tumescence, recent op/trauma, DHx, SHx
Psychogenic: sudden onset, dec libido, good quality spontaneous or self stimulated erections, major life event, problems or changes in a relationship, prev psychological problems, hx of premature ejaculation
Ix for ED
Calculate CVD risk by measuring lipid and fasting glucose
Measure free testosterone b/w 9-11am and if low repeat along with FSH, LH and prolactin
Mx of ED
- PDE-5 Inhibitor 2. Vacuum Device
Any hormone abnormalities refer to endo and if a young male who has always had difficulty refer to urology
Which type of renal stones are radiolucent?
Urate + Xanthine
What are stag horn calculi composed of?
Struvite: Magnesium Ammonium Phosphate or Triple Phosphate
What pH of urine do struvite stones form in?
Alkaline
Which renal stones are inherited?
Cystine
How long after ejaculation, vigorous exercise and prostatitis/UTI should you wait before measuring PSA?
Ejaculation/Exercise: 48hrs
Prostatitis/UTI: 1mnth
How does torsion of the testicular appendage present?
Hx: sudden onset pain in one hemiscrotum w no other urinary sx
O/e: the superior pole will be tender with a blue discolouration and the cremasteric reflex is usually preserved
Which pathogen most commonly causes acute bacterial prostatis?
E Coli
Mx of Acute Bacterial Prostatitis
14d Quinolone + STI Screen
Acute Bacterial Prostatitis RFs
Recent UTI; urogenital instrumentation; intermittent bladder catheterisation; recent prostate biopsy
How does your age group match with the most likely organism responsible for epididymo-orchitis?
<35: Chlamydia
>35: E. Coli
Does a vasectomy work immediately?
No
When can UPSI begin following a vasectomy?
After semen analysis x2 usually done at 16 and 20wks
What is important to ask about alongside past surgical hx?
Anaesthetic hx
?issues, ?well intra and post op, ?PONV
IV Induction Agents
Sodium Thiopentone - rapid sequence of induction
Etomidate - short acting agent w no analgesic properties
Propofol - GABA receptor agonist used for inducing and maintaining
Ketamine - NMDA receptor antagonist used if haemodynamically unstable
What ops require G+S beforehand?
Thyroidectomy, lap chole, appendicectomy, elective c/s, hysterectomy
What ops require XM 2 units beforehand?
Salpingectomy + THR
What ops require XM 4-6 units beforehand?
Elective AAA repair, upper GI surg, hepatectomy, cystectomy, oophorectomy
Where is IO access typically undertaken?
Anteromedial aspect of proximal tibia
How is local anaesthetic toxicity treated?
IV 20% Lipid Emulsion
What are CIs to adding adrenaline to locals?
Pt on TCA or MAOI
What are the causative agents for malignant hyperthermia?
Halothane
Suxamethonium
Antipsychotics
Tx for Malignant Hyperthermia
IV Dantrolene
Muscle Relaxants
Suxamethonium - depolarising
Rocuronium - non depolarising
Which drugs are classically used as an antiemetic at the start/end of an op?
At the start dexamethasone then ondansetron at the end
What drugs will you find in the emergency tray?
Epinephrine: cardiac arrest, anaphylaxis, bronchospasm
Amiodarone: arrhythmia
Atropine: bradycardia
Ephedrine: hypotension
Hydralazine: hypertension
What is used to reverse muscle relaxants?
Neostigmine 2.5mg + Glycopyrronium 500mcg
The first is an anticholinesterase inhibitor whilst the latter inhibits ACh to reduce SEs
What are the two benefits of fentanyl?
Pain control AND it reduces the amount of gas required for induction
What is the CI to suxamethonium?
Any penetrating eye injuries or acute narrow angle glaucoma as it inc IOP
