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PM Finals > Surgery (multiple) > Flashcards

Surgery (multiple) Flashcards

1
Q

‘halo appearance’ on mammography?

A

breast cyst

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2
Q

Tamoxifen MoA

A

Selective oEstrogen Receptor Modulators (SERM)

oestrogen receptor antagonist and partial agonist.

mx of oestrogen receptor-positive breast cancer in premenopausal women

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3
Q

Tamoxifen adverse effects

A

menstrual disturbance:vaginal bleeding, amenorrhoea

hot flushes

venous thromboembolism

endometrial cancer

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4
Q

Adverse effects of aromatase inhibitors

A

(Anastrozole and letrozole)

osteoporosis (!!)
NICE recommends a DEXA scan when initiating

hot flushes

arthralgia, myalgia

insomnia

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5
Q

Fibroadenoma mx

A

nothing
if >3cm , surgically excise

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6
Q

Breast cyst

A

aspirated

if blood stained or persistently refill should be biopsied or excised

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7
Q

Main breast reconstruction options after cancer removal

A

latissimus dorsi myocutaneous flap and sub pectoral implants

Women wishing to avoid a prosthesis may be offered TRAM or DIEP flaps

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8
Q

Factors determining Mastectomy or wide local excision

A

M v WLE:

multifocal / solitary lesion
central / peripheral location
large lesion small breast / small lesion large breast
DCIS >4cm / DCIS <4cm
Patient choice

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9
Q

What determines prognosis following breast cancer surgery?

A

Nottingham Prognostic Index

Tumour Size x 0.2 + Lymph node score+Grade score

also vascular invasion and receptor status

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10
Q

How does axillary lymphadenopathy affect mx of breast cancer?

A

clinically palpable lymphadenopathy -> axillary node clearance at primary surgery

not clinically palpable –> pre-operative USS

USS negative -> sentinel node biopsy

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11
Q

Radiotherapy indication for breast ca

A

After wide local excision –> whole breast radiotherapy
(reduces recurrence risk by 2/3)

After mastectomy -> radiotherapy for T3-T4 tumours & those w 4 or more +ve axillary nodes

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12
Q

Hormonal/ biological therapy indications for breast ca

A

ER+ve (hormonal)
Tamoxifen - premenopausal
Aromatase inhb (anastrozole) - post-m

HER2 +ve (biological)
Trastuzumab (Herceptin)
[^^^ cannot be used in pts w heart disorders]

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13
Q

Chemotherapy indications for breast ca

A
  • neo-adjuvent (before surgery) to downstage a primary lesion allowing breast conserving operation rather than mastectomy
  • post adjacent depending on stage
  • if axillary node disease - FEC-D is used
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14
Q

2ww breast ca referral criteria

A

REFER:
- >=30yrs & unexplained breast lump
- >=50yrs with unilateral nipple: discharge/ retraction/ other concerning changes

Consider:
- skin changes suggesting breast ca
- >=30yrs w unexplained lump in axilla

non-urgent referral if under 30 w/ unexplained breast lump

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15
Q

Breast cs RFs

A

-BRACA1/2 genes
-nulliparity (or 1st preg >30)
-early menarche, late menopause
-combined HRT
- COCP use
- P53 gene mutations
- obesity
-fhx of 1stdeg relative w breast ca when pre-menopause
- ionising radiation
- not breastfeeding
- past breast ca
- previous breast surgery

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16
Q

breast ca screening for who? how frequent?

A

women between 50-70 years

every 3 years

(after 70 still allowed, but make own appointments)

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17
Q

Types of breast ca & mist common?

A

Invasive ductal carcinoma.
(most common) (renamed ‘No Special Type (NST))

Invasive lobular carcinoma
Ductal carcinoma-in-situ (DCIS)
Lobular carcinoma-in-situ (LCIS)
Other rare types

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18
Q

Fat necrosis mx

A

Rare and may mimic breast cancer so further investigation is always warranted (imaging & core biopsy)

if fat necrosis - nothing

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19
Q

Cyclical mastalgia mx

A

supportive bra - firstline
conservative: simple oral/ topical analgesia

(flaxseed oil and evening primrose oil sometimes used but not recommended by NICE CKS)

if pain not responding to above in 3mos-> referral -> bromocriptine and danazol (hormonal agents)

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20
Q

Duct ectasia tx

A

troublesome nipple discharge may be treated by microdochectomy (if young) or total duct excision (if older)

Otherwise nothing as this is normal varient of breast involution

(don’t confuse w periductal mastitis - younger smokers -inflammation - tx w Abx)
Smoking is a RF for this too

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21
Q

Mastitis mx

A

typically associated with breastfeeding

1st line - continue breastfeeding.
Simple mx: analgesia, warm compresses

Treat if:
- systemically unwel
- nipple fissure present
- no improvement after 12-24 hours of effective milk removal
- culture indicates infection

1st line abx: oral flucloxacillin, 10-14 day
(most common cx = Staph aureus)

if develops into breast access -> I&D

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22
Q

Reporting of breast c investigations grade 1-5

A

1 - No abnormality
2 - Abnormality with benign features
3 - Indeterminate probably benign
4 - Indeterminate probably malignant
5 -Malignant

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23
Q

Paget’s dx v eczema of nipple

A

Paget - nipple primarily and only latterly spreads to the areolar (the opposite occurs in eczema)

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24
Q

Brain death testing involves

A

criteria to test
- deep coma, unknown aetiology
- reversible causes excluded
- no sedation
- normal electrolytes

Testing involves
- fixed pupils
- no corneal reflex
- no oculo-vestibular reflex (caloric test)
- no response to supraorbital pressure
- no cough to bronchial stimulation/ gagging to pharyngeal stimulation
- No rest effort observed when ventilator disconnected (for 5 mins to allow CO2 to build up)

2 experienced doctors on two separate occasions !!
(experienced in brain stem testing, 5 yrs post grad, one is consultant, not part of transplant team)

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25
Q

Brainstem compression (coning) / life threatening ICP mx

A

osmotherapy with hypertonic saline or manitol,

neurosurgical decompression -> decompressive craniotomy

ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT scan.

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26
Q

Cushing reflex

A

physiological nervous system response to raised ICP

Cushing triad of widened pulse pressure (increasing systolic, decreasing diastolic), bradycardia, and irregular respirations

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27
Q

constricted pupil causes

A

Bilaterally:
Opiates
Pontine lesions
Metabolic encephalopathy

Unilateral:
Sympathetic pathway disruption

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28
Q

dilated pupil causes

A

fixed pupil w sluggish/no response to light
- CN3 compression (uni-/bi-lateral)
- poor CNS perfusion (if bilateral)

cross reactive (RAPD)
- optic nerve injury

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29
Q

CT head within 1 hour of head injury

A

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

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30
Q

CT head within 8 hours of head injury

A

loss of consciousness or amnesia since the injury with:
>= 65 years
hx of bleeding or clotting disorders including anticogulants
dangerous mechanism of injury
more than 30 minutes’ retrograde amnesia of events immediately before the head injury

If a patient is on warfarin & no other indications

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31
Q

conditions associated with berry aneurysms

A

hypertension,adult polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta

berry aneurysms -> spontaneous SAH

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32
Q

SAH ix

A

non-contrast CT head
- acute blood = hyperdense/bright
- If w/in 6hrs & normal -> NO lumbar puncture
- If >6hrs & normal -> LP 12hrs post symptom onset

LP findings: xanthochromia, normal/ raised opening pressure

Once confirmed, find cause
- CT intracranial angiogram
+/- digital subtraction angiogram

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33
Q

subarachnoid haemorrhage mx

A

supportive
VTE prophylaxis
stop antithrombotics - reversal if needed

vasospasm prevented w oral nimodipine

prompt intervention needed due to risk of rebleeding of aneurysm
- w/in 24hrs: coil by interventional neuroradiologists / craniotomy & clipping

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34
Q

most common type of anal cancer?

A

SCC

(other: melanomas, lymphomas, and adenocarcinomas)

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35
Q

lymphatic spread of anal cancer?

A

anal margin tumours ->inguinal lymph nodes
more proximal -> pelvic lymph nodes.

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36
Q

anal ca RFs

A

HPV infection!! - esp for SCC ( HPV16 or HPV18 subtypes)
Anal intercourse
High sexual partners
Men sex men
Immunosuppressants
Woman w cervical ca or CIN
smoking

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37
Q

T stage system for anal cancer

A

(examination, including a digital rectal examination, anoscopic examination with biopsy, and palpation of the inguinal nodes)

TX - cannot be assessed
T0 - no evidence
Tis - carcinoma in situ
T1 - tumor 2cm or less
T2 - 2cm-5cm
T3 - more than 5cm
T4 - any size, invading adjacent organ (not incuding rectum/ sphincter muscle)

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38
Q

where are anal fissure usually found?

A

90% - posterior midline

if elsewhere, likely underlying cause, e.g. Chron’s

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39
Q

Anal fissure mx

A

<1wk
- soften stool (high fibre & fluid diet), bulk-forming laxatives 1st line –> 2nd: lactulose
- lubricants before defecation (petroleum jelly)
- topical anaesthetics
- analgesia

chronic (>6wks)
- continue above
- 1st line: topical GTN
- 2nd: if GTN not effective after 8wks -> surgery (shincerotomy) or botulinum toxin

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40
Q

colorectal cancer staging involves:

A

(all pts diagnosed w CRC should have:)

  • carcinoembryonic antigen (CEA)
  • CT of the chest, abdomen and pelvis
  • colonoscopy or CT colonography
  • tumours below the peritoneal reflection should have their mesorectum evaluated with MRI.

TNM (Tumour, Node, Metastasis) staging system to stage CRC from prognosis & tx

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41
Q

Indication for a FIT test

A

( Faecal Immunochemical Test (FIT) )
NHS bowel cancer screening programme (every 2yrs, 60-74)

& to guide referral for CRC:
-abdominal mass

-change in bowel habit

  • iron-deficiency anaemia
  • aged 40 and over with unexplained weight loss and abdominal pain
  • aged under 50 with rectal bleeding and abdominal pain or weight loss,
  • aged 50 and over with any of the following unexplained symptoms:
    rectal bleeding
    abdominal pain
    weight loss,
  • aged 60 and over with anaemia even in the absence of iron deficiency

(abnormal results are offered a colonoscopy)

42
Q

Diverticular disease tx

A
  • increased fibre
  • mild diverticulitis: Abx
  • Peri colonic abscesses: surgical/ radiological drainage
  • Recurrent episodes of acute diverticulitis requiring hospitalisation - surgical resection
  • Hinchey stage IV perforations (generalised faecal peritonitis) - resection and usually a stoma, laparoscopic washout and drain insertion, potential HDU admission due to high risk post op complications
43
Q

Dukes classification

A

extent of spread of colorectal cancer

a - confined to mucosal wall
b - invading bowel wall
c - lymph node met
d - distant met

44
Q

Grading of internal haemorrhoids

A

(internal - above dentate line, usually painless)
1 - do not prolapse out of anal canal
2- prolapse on defection, reduce spontaneously
3 - manually reduced
5 - cannot be reduced

45
Q

haemorrhoids mx

A
  • soften stools: increase dietary fibre and fluid intake
  • topical local anaesthetics and steroids
  • outpatient treatments: rubber band ligation is superior to injection sclerotherapy
  • surgery - large symptomatic haemorrhoids which do not respond to outpatient treatments

newer treatments: Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy

Acutely thrombosed external haemorrhoids
<72hrs - referral considered for excision
- otherwise conservative: stool softeners, ice packs, analgesia

46
Q

Ischaemic colitis on x ray?

A

‘thumbprinting’ may be seen on abdominal x-ray due to mucosal oedema/haemorrhage

likely in in ‘watershed’ areas such as the splenic flexure

47
Q

Volulus ix & mx

A

Abdo x ray
sigmoid volvulus: large bowel obstruction (large, dilated loop of colon, often with air-fluid levels) + coffee bean sign
caecal volvulus: small bowel obstruction may be seen

Management
sigmoid volvulus: rigid sigmoidoscopy with rectal tube insertion
caecal volvulus: management is usually operative. Right hemicolectomy is often needed

48
Q

duodenal atresia age at px, ix and mx

A

Few hours after birth, RF- downs synd.

AXR shows double bubble sign, contrast study may confirm

Duodenoduodenostomy

49
Q

Malrotation with volvulus age at px, ix and mx

A

3-7 days after birth

Upper GI contrast study- DJ flexure is more medially placed,
USS - abnormal orientation of SMA and SMV

Ladd’s procedure

50
Q

Meconium ileus age at px, ix and mx

A

24-48 hours of life , RF- cystic fibrosis,

Air - fluid levels on AXR, sweat test to confirm cystic fibrosis

Surgical decompression, serosal damage may require segmental resection

51
Q

Necrotising enterocolitis age at px, ix and mx

A

Usually second week of life

Dilated bowel loops on AXR, pneumatosis and portal venous air

Conservative and supportive for non perforated cases, laparotomy and resection in cases of perforation of ongoing clinical deterioration

52
Q

Rovsing’s sign:

A

more pain in RIF than LIF when palpating LIF

53
Q

Boas sign?

A

cholecystitis- hyperaesthesia felt by the patient to light touch in the right lower scapular region or the right upper quadrant of the abdomen

54
Q

what is a Richter hernia and complication

A

only the antimesenteric border of the bowel herniates through the fascial defect

can present with strangulation without symptoms of obstruction

55
Q

Congenital inguinal hernia tx

A

Should be surgically repaired soon after diagnosis as at risk of incarceration

56
Q

Infantile umbilical hernia tx

A

Symmetrical bulge under the umbilicus, rf: premature and Afro-Caribbean babies

The vast majority resolve without intervention before the age of 4-5 years

57
Q

sudden full wound dehiscence mx

A

Coverage of the wound with saline impregnated gauze (on the ward)

IV broad-spectrum antibiotics

Analgesia

IV fluids

Arrangements made for a return to theatre

58
Q

Ix appendicitis

A

thin, male patients - clinical

females - USS (free fluid)

In UK, don’t use CT scans

59
Q

Appendicits mx

A

laparoscopic appendicectomy (can be open)

prophylactic intravenous antibiotics

60
Q

hyperechoic mass on liver USS?

A

liver haemangioma- benign

61
Q

Liver cell adenoma features

A

linked to COCP use

USS: mixed echocity & heterogeneous texture

leave it, if haemorrhage or symptoms -> removal

beware of cytadenoma (rare w malignant potential, solitary multiloculated lesions, surgical resection always)

62
Q

most common extra intestinal manifestation of amoebiasis?

features & tx

A

Amoebic liver abscess (fever RUQ)

USS: fluid filled structure with poorly defined boundaries

Aspiration: odourless fluid which has an anchovy paste consistency

Tx: metronidazole

63
Q

Hyatid cysts features & mx ?

A

Seen in echinococcosis infection -> parasitic infection caused by tapeworm

Px: abnormal LFTs & eosinophilia

USS: septa & hydatid sand / daughter cysts

Tx: sterilisation w mebedazole then surgical resection.

64
Q

Fistula in ano tx

A

Lay open if low, no sphincter involvement or IBD

if complex, high or IBD insert seton

65
Q

Adalimumab
Infliximab
Etanercept

Target & use?

A

TNF alpha inhibitor

Crohns disease
Rheumatoid disease

66
Q

Bevacizumab

A

Anti VEGF (anti angiogenic)

Colorectal cancer
Renal
Glioblastoma

67
Q

Trastuzumab

A

HER receptor

Breast cancer

68
Q

Imatinib

A

Tyrosine kinase inhibitor

Gastrointestinal stromal tumours
Chronic myeloid leukaemia

69
Q

Basiliximab

A

IL2 binding site

Renal transplants

70
Q

Cetuximab

A

Epidermal growth factor inhibitor

EGF positive colorectal cancers

71
Q

what is Cryptorchidism?

A

congenital undescended testis failed to reach the bottom of the scrotum by 3 months of age

surgical correction! -> 40x more likely to get testicular cancer (seminoma)

72
Q

Cryptorchidism tx

A

Orchidopexy at 6- 18 mo

Intra-abdominal testis -evaluated laparoscopically and mobilised

After the age of 2 years - better to do orchidectomy due to degradation

73
Q

Critera for malnourishment and at risk?

A

Patients identified as being malnourished
- BMI < 18.5 kg/m2
- unintentional weight loss of > 10% over 3-6months
- BMI < 20 kg/m2 and unintentional weight loss of > 5% over 3-6/12

AT RISK of malnutrition
- Eaten nothing or little > 5 days, who are likely to eat little for a further 5 days
- Poor absorptive capacity
- High nutrient losses
- High metabolism

74
Q

complications of enteral feeding

A

diarrhoea
aspiration
metabolic: hyperglycaemia & refeeding syndrome

75
Q

Borders & contents of the femoral canal

A

fem canal is at the medial aspect of femoral sheath

laterally - femoral vein
Medically - Lacunar ligament
Anteriorly - inguinal ligament
Posteriorly - pectineal ligament

Contents
Lymphatic vessels
Cloquet’s lymph node

significance- allows expansion of fem vein to allow for increased venous return. Potential space & site of fem hernias

76
Q

Complications of a femoral hernia

A

Incarcination - herniated tissues cannot be reduced

Strangulation - Surgical emergency, ischemia due to comprised blood supply, tender & likely non-reducible & systemically unwell

Bowel obstruction - also emergency

Bowel ischemia

77
Q

femoral hernia mx

A

Surgical repair is a necessity, given the risk of strangulation, laparoscopically or via a laparotomy (usually for emergencies)

78
Q

Fluid resuscitation indication

A

> 15% total body area burns in adults (>10% children)

79
Q

Parkland formula

A

For Fluid resuscitation in burns in the first 24hrs- Crystalloid only

Total fluid requirement in 24 hours =
4 ml x (total burn surface area (%)) x (body weight (kg))

50% given in first 8 hours
50% given in next 16 hours

80
Q

burns fluid mx after first 24hrs

A

Colloid infusion is begun at a rate of 0.5 ml x(total burn surface area (%))x(body weight (kg))
–> albumin & FFP

Maintenance crystalloid (dextrose-saline) - rate of 1.5 ml x(burn area)x(body weight)

81
Q

hiatus hernia ix & mx

A

(rolling or sliding)

ix - barium swallow (usually found incidentally on endoscopy -occurs first due to nature of symptoms.

Mx
- conservative mx: weight loss
- medical: PPI
surgical: most do not need surgery. Only in symptomating rolling(paraoesophagheal) hernias

82
Q

normal diameter of small & large bowel

A

small = 35mm

large = 55mm

83
Q

Inguinal hernia tx

A

treat medically fit patients even if they are asymptomatic
- mesh repair has lowest recurrence
- unilateral - open approach
- bilateral & recurrent - laparoscopic

hernia truss if not fit for surgery (cannot use this in femoral hernias due to high risk of strangulation)

if stagnated do not manually reduce!

84
Q
A
85
Q

lidocaine maximum safe dose?

A

3mg/kg

200mg (or 500mg if given in solutions containing adrenaline), which equates to 3mg/kg for a 66kg patient.

equivalent of 20ml of 1% solution or 10ml of 2% solution

86
Q

Carotid endarterectomy can damage

A

hypoglossal nerve

87
Q

Types of organ rejection

A

Hyperacute. This occurs immediately through presence of pre formed antigens (such as ABO incompatibility).

Acute. Occurs during the first 6 months and is usually T cell mediated. Usually tissue infiltrates and vascular lesions.

Chronic. Occurs after the first 6 months. Vascular changes predominate.

88
Q

Familial adenomatous polyposis characteristics

A

APC gene, dominant

over 100 colonic adenomas
Cancer risk of 100%

mx: if at known risk do genetic testing as teen. Annual flexi sigmoidoscopy from 15yrs. If no polyps = 5 yearly colonoscopy from 20. Polyps found = resectional surgery

89
Q

Peutz -Jeghers syndrome

A

Multiple benign intestinal hamartomas. Episodic obstruction and intussusception

Increased risk of colorectal, gastric, breast, ovarian, cervical, pancreatic & testicular ca.

Annual examination
Pan intestinal endoscopy every 2-3 years

90
Q

HNPCC (Lynch syndrome)

A

Germline mutations of DNA mismatch repair genes

increased risk of colorectal. endometrial & gastric ca

Scanty colonic polyps may be present
Colonic tumours likely to be right sided and mucinous

colonoscopy every yr from age 25.

91
Q

Small bowel obstructions

A

intial steps:
- NBM
- IV fluids
- nasogastric tube with free drainage

some patients settle with conservative management but otherwise will require surgery

92
Q

Acute cholecystitis ix

A

ultrasound is the first-line investigation of choice

if the diagnosis remains unclear then cholescintigraphy (HIDA scan) may be used

93
Q

Acute cholecystitis mx

A

intravenous antibiotics

early laparoscopic cholecystectomy, within 1 week of diagnosis

94
Q

acute pancreatitis ix

A

serum lipase - more sensitive and specific, & longer half life

serum amylase

dx can be made without imaging if characteristic pain + amylase/lipase > 3 times normal level

early ultrasound imaging important for aetiology to determine mx

95
Q

severe pancreatitis scoring?

A

Ranson score, Glasgow score and APACHE II.

P - PaO2 (< 7.9 kPa).
A - age (>55).
N - neutrophils (white cell count > 15x 109/L).
C - calcium (calcium < 2 mmol/L).
R - renal function (urea > 16 mmol/L).
E - enzymes (lactate dehydrogenase > 600 IU/L).
A - albumin (albumin < 32 g/L).
S - sugar (blood glucose > 10 mmol/L).

actual amylase level is not of prognostic value

96
Q

Acute pancreatitis: causes

A

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)

97
Q

Acute pancreatitis mx

A

fluid resuscitation - aggressive & early hydration w crystalloids

aim urine output >0.5mls/kg/hr

nutrition - NOT routinely nil by mouth unless vomitting lots, enteral nutrition should be offered w/in 72hrs

NO routine Abx

98
Q

Boerhaave’s syndrome
dx

A

Diagnosis is CT contrast swallow.

99
Q

Cholangiocarcinoma association

A

Primary sclerosing cholangitis & raised CA 19-9 levels

100
Q

Chronic pancreatitis
causes

A

alcohol excess most common !!

idiopathic

genetic: cystic fibrosis, haemochromatosis

ductal obstruction: tumours, stones, structural abnormalities including pancreas divisum and annular pancreas

101
Q
A

PM Finals (21 decks)

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