Surgery (non-ortho) Flashcards
A 29 year old man has had a sore throat for the past 5 days. Over the past 24 hours he has notices increasing and severe throbbing pain in the region of his right tonsil. He is pyrexial and on examination he is noted to have a swelling of this area. What is the most likely cause?
Tonsillar cancer Lymphoma Quinsy Glandular fever Common cold
Unilateral swelling and fever is usually indicative of quinsy. Surgical drainage usually produces prompt resolution of symptoms.
Acute tonsillitis
Characterised by pharyngitis, fever, malaise and lymphadenopathy.
Over half of all cases are bacterial with Streptococcus pyogenes the most common organism
The tonsils are typically oedematous and yellow or white pustules may be present
Infectious mononucleosis may mimic the condition.
Treatment with penicillin type antibiotics is indicated for bacterial tonsillitis.
Bacterial tonsillitis may result in local abscess formation (quinsy)
A 76 year old man presents with a painful right arm (he is right handed). On examination, he has a cool right forearm and absent radial and brachial pulses. A duplex scan shows thrombus occluding the brachial artery. What is the most appropriate course of action?
Administration of therapeutic low molecular weight heparin Brachial embolectomy without fasciotomy Intra arterial thrombolysis Systemic thrombolysis Brachial embolectomy with fasciotomy
Brachial embolectomy without fasciotomy
Options to treat upper limb embolic events include either anticoagulation or surgery. Background arterial lesions are very rarely present in the upper limb so embolectomy is usually successful. Anticoagulation with intravenous unfractionated heparin is a reasonable alternative. However, note that low molecular weight heparin is not used in this setting as its difficult to control perioperatively.
Acute limb ischaemia
Thrombosis of a pre-existing site of atherosclerosis if the commonest cause of acute limb ischaemia
Acute thrombosis of popliteal aneurysms poses the greatest threat to the limb
Sudden occlusion of a large proximal vessel results in the typical appearances of acute limb ischaemia
Clinical appearances
Less than 6 hours = White leg
At 6 -12 hours = Mottled limb with blanching on pressure
More than 12-24 hours = Fixed mottling
Management of acutely ischaemic leg
- White leg with sensorimotor deficit Surgery and embolectomy
- Dusky leg, mild anaesthesia Angiography
- Fixed mottling Primary amputation
Role of thrombolysis
Intra arterial thrombolysis is better than peripheral thrombolysis
Mainly indicated in acute on chronic thrombosis
Avoid if within 2 months of CVA or 2 weeks of surgery
Aspiration of clot may improve success rate if the thrombosis is large
Surgery
Both groins should be prepared
Transverse arteriotomy is easier to close
Poor inflow should be managed with iliac trawl- if this fails to improve then consider a femoro-femoral cross over or axillo-femoral cross over.
A check angiogram should be performed on table and prior to closure
Systemic heparinisation should follow surgery
Fasciotomy should be considered if the time between onset and surgery exceeds 6 hours
A 14 year old boy presents with enlarged tonsils that meet in the midline. Oropharyngeal examination confirms this finding and you also notice peticheal haemorrhages affecting the oropharynx. On systemic examination he is noted to have splenomegaly. What is the most likely cause?
Oral candidiasis Infection with Streptococcus pyogenes Infection with Rickettsia rickettsii Infection with Epstein Barr virus Infection with Staphylococcus aureus
EBV - A combination of pharyngitis and tonsillitis is often seen in glandular fever. Antibiotics containing penicillin may produce a rash when given in this situation, leading to a mistaken label of allergy. Infection with candidiasis can occur in individuals with systemic illness of which splenomegaly may be a feature. However, its unlikely to only affect the tonsils.
Acute tonsillitis
Characterised by pharyngitis, fever, malaise and lymphadenopathy.
Over half of all cases are bacterial with Streptococcus pyogenes the most common organism
The tonsils are typically oedematous and yellow or white pustules may be present
Infectious mononucleosis may mimic the condition.
Treatment with penicillin type antibiotics is indicated for bacterial tonsillitis.
Bacterial tonsillitis may result in local abscess formation (quinsy)
An 8 year old boy presents with abdominal pain,a twelve hour history of vomiting, a fever of 38.3 0C and four day history of diarrhoea. His abdominal pain has been present for the past week. What is the most likely cause?
Coeliac disease Appendix abscess Irritable bowel syndrome Mesenteric adenitis Diverticulitis
Appendix Abscess
The high fever and diarrhoea together with vomiting all point to a pelvic abscess. The presence of pelvic pus is highly irritant to the rectum, and many patients in this situation will complain of diarrhoea. Mesenteric adenitis is less likely to run such a protracted course. IBS does not typically produce such marked systemic symptoms. Diverticulitis is almost unheard of in children.
Appendicitis Pain radiating to right iliac fossa Anorexia (very common) Short history Diarrhoea and profuse vomiting rare
Crohn’s disease
Often long history
Signs of malnutrition
Change in bowel habit, especially diarrhoea
Mesenteric adenitis
Mainly affects children
Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp.
Patients have a higher temperature than those with appendicitis
If laparotomy is performed, enlarged mesenteric lymph nodes will be present
Diverticulitis
Both left and right sided disease may present with right iliac fossa pain
Clinical history may be similar, although some change in bowel habit is usual
When suspected, a CT scan may help in refining the diagnosis
Meckel’s diverticulitis
A Meckel’s diverticulum is a congenital abnormality that is present in about 2% of the population
Typically 2 feet proximal to the ileocaecal valve
May be lined by ectopic gastric mucosal tissue and produce bleeding
Perforated peptic ulcer
This usually produces upper quadrant pain but pain may be lower
Perforations typically have a sharp sudden onset of pain in the history
Incarcerated right inguinal or femoral hernia
Usually only right iliac fossa pain if right sided or bowel obstruction.
Bowel perforation secondary to caecal or colon carcinoma
Seldom localised to right iliac fossa, although complete large bowel obstruction with caecal distension may cause pain prior to perforation.
Gynaecological causes
Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian torsion/Threatened or complete abortion/Mittelschmerz
Urological causes
Ureteric colic/UTI/Testicular torsion
Other causes
TB/Typhoid/Herpes Zoster/AAA/Situs inversus
A 74 year old man presents with a painful right leg. The pain developed suddenly the preceeding evening. However, he wondered if it might resolve overnight, instead, it has got worse. On examination, his right leg is cold and white with diminished distal sensation. A CT angiogram shows a thrombus occluding the external iliac artery with no atheromatous disease. What is the most appropriate course of action?
Femoral embolectomy and below knee fasciotomy Femoral embolectomy alone Femoral popliteal bypass graft without fasciotomy Femoral embolectomy with above and below knee fasciotomy Femoro-femoro cross over graft with above and below knee fasciotomy
Femoral embolectomy and below knee fasciotomy
Delayed limb re-perfusion = Risk of compartment syndrome
Delayed surgery for limb ischaemic carries a risk of re-perfusion injury and compartment syndrome. Where surgery is delayed beyond 6 hours, most surgeons would perform a fasciotomy at the same time as the embolectomy. However, whilst the compartments below the knee are vulnerable, its very rare for this to occur in the thigh and so, as a rule, the thigh is not treated in this manner.
Acute limb ischaemia
Thrombosis of a pre-existing site of atherosclerosis if the commonest cause of acute limb ischaemia
Acute thrombosis of popliteal aneurysms poses the greatest threat to the limb
Sudden occlusion of a large proximal vessel results in the typical appearances of acute limb ischaemia
Clinical appearances
Less than 6 hours = White leg
At 6 -12 hours = Mottled limb with blanching on pressure
More than 12-24 hours = Fixed mottling
Management of acutely ischaemic leg
- White leg with sensorimotor deficit Surgery and embolectomy
- Dusky leg, mild anaesthesia Angiography
- Fixed mottling Primary amputation
Role of thrombolysis
Intra arterial thrombolysis is better than peripheral thrombolysis
Mainly indicated in acute on chronic thrombosis
Avoid if within 2 months of CVA or 2 weeks of surgery
Aspiration of clot may improve success rate if the thrombosis is large
Surgery
Both groins should be prepared
Transverse arteriotomy is easier to close
Poor inflow should be managed with iliac trawl- if this fails to improve then consider a femoro-femoral cross over or axillo-femoral cross over.
A check angiogram should be performed on table and prior to closure
Systemic heparinisation should follow surgery
Fasciotomy should be considered if the time between onset and surgery exceeds 6 hours
A 22 year old man is investigated for weight loss. A duodenal biopsy taken as part of his investigations shows total villous atrophy and lymphocytic infiltrate. He has a skin lesion that has small itchy papules.
A. Pyoderma gangrenosum B. Erythroderma C. Dermatitis herpetiformis D. Acanthosis nigricans E. Multiple lipomata F. Multiple neurofibromata G. Multiple telangectasia H. None of the above
Dermatitis herpetiformis
The patient has coeliac disease and this is associated with dermatitis herpetiformis.
Skin lesions may be referred for surgical assessment, but more commonly will come via a dermatologist for definitive surgical management.
Basal Cell Carcinoma
Most common form of skin cancer.
Commonly occur on sun exposed sites apart from the ear.
Sub types include nodular, morphoeic, superficial and pigmented.
Typically slow growing with low metastatic potential.
Standard surgical excision, topical chemotherapy and radiotherapy are all successful.
As a minimum a diagnostic punch biopsy should be taken if treatment other than standard surgical excision is planned.
Squamous Cell Carcinoma
Again related to sun exposure.
May arise in pre - existing solar keratoses.
May metastasize if left.
Immunosupression (e.g. following transplant), increases risk.
Wide local excision is the treatment of choice and where a diagnostic excision biopsy has demonstrated SCC, repeat surgery to gain adequate margins may be required.
Malignant Melanoma The main diagnostic features (major criteria): Change in size Change in shape Change in colour Secondary features (minor criteria) Diameter >6mm Inflammation Oozing or bleeding Altered sensation
Treatment
Suspicious lesions should undergo excision biopsy. The lesion should be removed in completely as incision biopsy can make subsequent histopathological assessment difficult.
Once the diagnosis is confirmed the pathology report should be reviewed to determine whether further re-excision of margins is required (see below):
Margins of excision-Related to Breslow thickness
Lesions 0-1mm thick 1cm
Lesions 1-2mm thick 1- 2cm (Depending upon site and pathological features)
Lesions 2-4mm thick 2-3 cm (Depending upon site and pathological features)
Lesions >4 mm thick 3cm
Further treatments such as sentinel lymph node mapping, isolated limb perfusion and block dissection of regional lymph node groups should be selectively applied.
Kaposi Sarcoma
Tumour of vascular and lymphatic endothelium.
Purple cutaneous nodules.
Associated with immuno supression.
Classical form affects elderly males and is slow growing.
Immunosupression form is much more aggressive and tends to affect those with HIV related disease.
Non malignant skin disease:
Dermatitis Herpetiformis
Chronic itchy clusters of blisters.
Linked to underlying gluten enteropathy (coeliac disease).
Dermatofibroma Benign lesion. Firm elevated nodules. Usually history of trauma. Lesion consists of histiocytes, blood vessels and fibrotic changes.
Pyogenic granuloma Overgrowth of blood vessels. Red nodules. Usually follow trauma. May mimic amelanotic melanoma.
Acanthosis nigricans
Brown to black, poorly defined, velvety hyperpigmentation of the skin.
Usually found in body folds such as the posterior and lateral folds of the neck, the axilla, groin, umbilicus, forehead, and other areas.
The most common cause of acanthosis nigricans is insulin resistance, which leads to increased circulating insulin levels. Insulin spillover into the skin results in its abnormal increase in growth (hyperplasia of the skin).
In the context of a malignant disease, acanthosis nigricans is a paraneoplastic syndrome and is then commonly referred to as acanthosis nigricans maligna. Involvement of mucous membranes is rare and suggests a coexisting malignant condition.
A 72 year old man is investigated for weight loss. On examination he is deeply jaundiced and cachectic. He also has a dark velvety lesion coating his tongue.
A. Pyoderma gangrenosum B. Erythroderma C. Dermatitis herpetiformis D. Acanthosis nigricans E. Multiple lipomata F. Multiple neurofibromata G. Multiple telangectasia H. None of the above
Acanthosis nigricans
Acanthosis nigricans may be associated with GI malignancies such as gastric and pancreatic cancer.
Skin lesions may be referred for surgical assessment, but more commonly will come via a dermatologist for definitive surgical management.
Basal Cell Carcinoma
Most common form of skin cancer.
Commonly occur on sun exposed sites apart from the ear.
Sub types include nodular, morphoeic, superficial and pigmented.
Typically slow growing with low metastatic potential.
Standard surgical excision, topical chemotherapy and radiotherapy are all successful.
As a minimum a diagnostic punch biopsy should be taken if treatment other than standard surgical excision is planned.
Squamous Cell Carcinoma
Again related to sun exposure.
May arise in pre - existing solar keratoses.
May metastasize if left.
Immunosupression (e.g. following transplant), increases risk.
Wide local excision is the treatment of choice and where a diagnostic excision biopsy has demonstrated SCC, repeat surgery to gain adequate margins may be required.
Malignant Melanoma The main diagnostic features (major criteria): Change in size Change in shape Change in colour Secondary features (minor criteria) Diameter >6mm Inflammation Oozing or bleeding Altered sensation
Treatment
Suspicious lesions should undergo excision biopsy. The lesion should be removed in completely as incision biopsy can make subsequent histopathological assessment difficult.
Once the diagnosis is confirmed the pathology report should be reviewed to determine whether further re-excision of margins is required (see below):
Margins of excision-Related to Breslow thickness
Lesions 0-1mm thick 1cm
Lesions 1-2mm thick 1- 2cm (Depending upon site and pathological features)
Lesions 2-4mm thick 2-3 cm (Depending upon site and pathological features)
Lesions >4 mm thick 3cm
Further treatments such as sentinel lymph node mapping, isolated limb perfusion and block dissection of regional lymph node groups should be selectively applied.
Kaposi Sarcoma
Tumour of vascular and lymphatic endothelium.
Purple cutaneous nodules.
Associated with immuno supression.
Classical form affects elderly males and is slow growing.
Immunosupression form is much more aggressive and tends to affect those with HIV related disease.
Non malignant skin disease:
Dermatitis Herpetiformis
Chronic itchy clusters of blisters.
Linked to underlying gluten enteropathy (coeliac disease).
Dermatofibroma Benign lesion. Firm elevated nodules. Usually history of trauma. Lesion consists of histiocytes, blood vessels and fibrotic changes.
Pyogenic granuloma Overgrowth of blood vessels. Red nodules. Usually follow trauma. May mimic amelanotic melanoma.
Acanthosis nigricans
Brown to black, poorly defined, velvety hyperpigmentation of the skin.
Usually found in body folds such as the posterior and lateral folds of the neck, the axilla, groin, umbilicus, forehead, and other areas.
The most common cause of acanthosis nigricans is insulin resistance, which leads to increased circulating insulin levels. Insulin spillover into the skin results in its abnormal increase in growth (hyperplasia of the skin).
In the context of a malignant disease, acanthosis nigricans is a paraneoplastic syndrome and is then commonly referred to as acanthosis nigricans maligna. Involvement of mucous membranes is rare and suggests a coexisting malignant condition.
A lesion that may occur in a 32 year old man with long standing Crohns disease.
A. Pyoderma gangrenosum B. Erythroderma C. Dermatitis herpetiformis D. Acanthosis nigricans E. Multiple lipomata F. Multiple neurofibromata G. Multiple telangectasia H. None of the above
Pyoderma gangrenosum
Pyoderma gangrenosum may occur in Crohns disease.
Skin lesions may be referred for surgical assessment, but more commonly will come via a dermatologist for definitive surgical management.
Basal Cell Carcinoma
Most common form of skin cancer.
Commonly occur on sun exposed sites apart from the ear.
Sub types include nodular, morphoeic, superficial and pigmented.
Typically slow growing with low metastatic potential.
Standard surgical excision, topical chemotherapy and radiotherapy are all successful.
As a minimum a diagnostic punch biopsy should be taken if treatment other than standard surgical excision is planned.
Squamous Cell Carcinoma
Again related to sun exposure.
May arise in pre - existing solar keratoses.
May metastasize if left.
Immunosupression (e.g. following transplant), increases risk.
Wide local excision is the treatment of choice and where a diagnostic excision biopsy has demonstrated SCC, repeat surgery to gain adequate margins may be required.
Malignant Melanoma The main diagnostic features (major criteria): Change in size Change in shape Change in colour Secondary features (minor criteria) Diameter >6mm Inflammation Oozing or bleeding Altered sensation
Treatment
Suspicious lesions should undergo excision biopsy. The lesion should be removed in completely as incision biopsy can make subsequent histopathological assessment difficult.
Once the diagnosis is confirmed the pathology report should be reviewed to determine whether further re-excision of margins is required (see below):
Margins of excision-Related to Breslow thickness
Lesions 0-1mm thick 1cm
Lesions 1-2mm thick 1- 2cm (Depending upon site and pathological features)
Lesions 2-4mm thick 2-3 cm (Depending upon site and pathological features)
Lesions >4 mm thick 3cm
Further treatments such as sentinel lymph node mapping, isolated limb perfusion and block dissection of regional lymph node groups should be selectively applied.
Kaposi Sarcoma
Tumour of vascular and lymphatic endothelium.
Purple cutaneous nodules.
Associated with immuno supression.
Classical form affects elderly males and is slow growing.
Immunosupression form is much more aggressive and tends to affect those with HIV related disease.
Non malignant skin disease:
Dermatitis Herpetiformis
Chronic itchy clusters of blisters.
Linked to underlying gluten enteropathy (coeliac disease).
Dermatofibroma Benign lesion. Firm elevated nodules. Usually history of trauma. Lesion consists of histiocytes, blood vessels and fibrotic changes.
Pyogenic granuloma Overgrowth of blood vessels. Red nodules. Usually follow trauma. May mimic amelanotic melanoma.
Acanthosis nigricans
Brown to black, poorly defined, velvety hyperpigmentation of the skin.
Usually found in body folds such as the posterior and lateral folds of the neck, the axilla, groin, umbilicus, forehead, and other areas.
The most common cause of acanthosis nigricans is insulin resistance, which leads to increased circulating insulin levels. Insulin spillover into the skin results in its abnormal increase in growth (hyperplasia of the skin).
In the context of a malignant disease, acanthosis nigricans is a paraneoplastic syndrome and is then commonly referred to as acanthosis nigricans maligna. Involvement of mucous membranes is rare and suggests a coexisting malignant condition.
A 67 year old male is diagnosed as having a 7cm infra renal abdominal aortic aneurysm. What is the likely risk of rupture over the next 5 years?
<10% 20% 25% 75% 35%
Risks of abdominal aortic aneurysm rupture (over 5 years):
5-5.9cm = 25%
6-6.9cm= 35%
7cm and over = 75%
Aneuryms greater than 5cm in diameter on USS should be formally assessed using CT scanning with arterial phases to delineate anatomy and facilitate surgical planning.
Abdominal aortic aneurysms are a common problem in vascular surgery.
They may occur as either true or false aneurysm. With the former all 3 layers of the arterial wall are involved, in the latter only a single layer of fibrous tissue forms the aneurysm wall.
True abdominal aortic aneurysms have an approximate incidence of 0.06 per 1000 people. They are commonest in elderly men and for this reason the UK is now introducing the aneurysm screening program with the aim of performing an abdominal aortic ultrasound measurement in all men aged 65 years.
Causes
Several different groups of patients suffer from aneurysmal disease.
The commonest group is those who suffer from standard arterial disease, i.e. Those who are hypertensive and have been or are smokers.
Other patients such as those suffering from connective tissue diseases such as Marfan’s may also develop aneurysms. In patients with abdominal aortic aneurysms the extracellular matrix becomes disrupted with a change in the balance of collagen and elastic fibres.
Management
Most abdominal aortic aneurysms are an incidental finding.
Symptoms most often relate to rupture or impending rupture.
20% rupture anteriorly into the peritoneal cavity. Very poor prognosis.
80% rupture posteriorly into the retroperitoneal space
The risk of rupture is related to aneurysm size, only 2% of aneurysms measuring less than 4cm in diameter will rupture over a 5 year period. This contrasts with 75% of aneurysms measuring over 7cm in diameter.
This is well explained by Laplaces’ law which relates size to transmural pressure.
For this reason most vascular surgeons will subject patients with an aneurysm size of 5cm or greater to CT scanning of the chest, abdomen and pelvis with the aim of delineating anatomy and planning treatment. Depending upon co-morbidities, surgery is generally offered once the aneurysm is between 5.5cm and 6cm.
Indications for surgery
Symptomatic aneurysms (80% annual mortality if untreated)
Increasing size above 5.5cm if asymptomatic
Rupture (100% mortality without surgery)
Surgical procedures
Abdominal aortic aneurysm repair
Procedure:
GA
Invasive monitoring (A-line, CVP, catheter)
Incision: Midline or transverse
Bowel and distal duodenum mobilised to access aorta.
Aneurysm neck and base dissected out and prepared for cross clamp
Systemic heparinisation
Cross clamp (proximal first)
Longitudinal aortotomy
Atherectomy
Deal with back bleeding from lumbar vessels and inferior mesenteric artery
Insert graft either tube or bifurcated depending upon anatomy
Suture using Prolene (3/0 for proximal , distal anastomosis suture varies according to site)
Clamps off: End tidal CO2 will rise owing to effects of reperfusion, at this point major risk of myocardial events.
Haemostasis
Closure of aneurysm sac to minimise risk of aorto-enteric fistula
Closure: Loop 1 PDS or Prolene to abdominal wall
Skin- surgeons preference
Post operatively:
ITU (Almost all)
Greatest risk of complications following emergency repair
Complications: Embolic- gut and foot infarcts
Cardiac - owing to premorbid states, re-perfusion injury and effects of cross clamp
Wound problems
Later risks related to graft- infection and aorto-enteric fistula
Special groups
Supra renal AAA
These patients will require a supra renal clamp and this carries a far higher risk of complications and risk of renal failure.
Ruptured AAA
Pre-operatively the management depends upon haemodynamic instability. In patients with symptoms of rupture (typical pain, haemodynamic compromise and risk factors) then ideally prompt laparotomy. In those with vague symptoms and haemodynamic stability the ideal test is CT scan to determine whether rupture has occurred or not. Most common rupture site is retroperitoneal 80%. These patients will tend to develop retroperitoneal haematoma. This can be disrupted if Bp is allowed to rise too high so aim for Bp 100mmHg.
Operative details are similar to elective repair although surgery should be swift, blind rushing often makes the situation worse. Plunging vascular clamps blindly into a pool of blood at the aneurysm neck carries the risk of injury the vena cava that these patients do not withstand. Occasionally a supracoeliac clamp is needed to effect temporary control, although leaving this applied for more than 20 minutes tends to carry a dismal outcome.
EVAR Increasingly patients are now being offered endovascular aortic aneurysm repair. This is undertaken by surgeons and radiologists working jointly. The morphology of the aneurysm is important and not all are suitable. Here is a typical list of those features favoring a suitable aneurysm: Long neck Straight iliac vessels Healthy groin vessels
Clearly few AAA patients possess the above and compromise has to be made. The use of fenestrated grafts can allow supra renal AAA to be treated.
Procedure:
GA Radiology or theatre Bilateral groin incisions Common femoral artery dissected out Heparinisation Arteriotomy and insertion of guide wire Dilation of arteriotomy Insertion of EVAR Device Once in satisfactory position it is released Arteriotomy closed once check angiogram shows good position and no endoleak
Complications:
Endoleaks depending upon site are either Type I or 2. These may necessitate re-intervention and all EVAR patients require follow up . Details are not needed for MRCS.
A 48 hour old neonate develops increasing abdominal distension. He had a normal delivery but has yet to pass any meconium. Following digital rectal examination liquid stool is released.
A. Meckel diverticulum B. Pyloric stenosis C. Acute appendicitis D. Mesenteric adenitis E. Intussusception F. Malrotation G. Hirschsprung disease
Hirschsprung disease
Hirschsprungs may present either with features of bowel obstruction in the neonatal period or more insidiously during childhood. After the PR there may be an improvement in symptoms. Diagnosis is by full thickness rectal biopsy.
Paediatric Gastrointestinal disorders
Pyloric stenosis
M>F
5-10% Family history in parents
Projectile non bile stained vomiting at 4-6 weeks of life
Diagnosis is made by test feed or USS
Treatment: Ramstedt pyloromyotomy (open or laparoscopic)
Acute appendicitis
Uncommon under 3 years
When occurs may present atypically
Mesenteric adenitis
Central abdominal pain and URTI
Conservative management
Intussusception
Telescoping bowel
Proximal to or at the level of, ileocaecal valve
6-9 months age
Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool.
Treatment: reduction with air insufflation
Malrotation
High caecum at the midline
Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia
May be complicated by development of volvulus, infant with volvulus may have bile stained vomiting
Diagnosis is made by upper GI contrast study and USS
Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a ladds procedure is performed
Hirschsprung’s disease
Absence of ganglion cells from myenteric and submucosal plexuses
Occurs in 1/5000 births
Full thickness rectal biopsy for diagnosis
Delayed passage of meconium and abdominal distension
Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure
Oesophageal atresia
Associated with tracheo-oesophageal fistula and polyhydramnios
May present with choking and cyanotic spells following aspiration
VACTERL associations
Meconium ileus
Usually delayed passage of meconium and abdominal distension
Majority have cystic fibrosis
X-Rays may not show a fluid level as the meconium is viscid (depends upon feeding), PR contrast studies may dislodge meconium plugs and be therapeutic
Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs
Biliary atresia
Jaundice > 14 days
Increased conjugated bilirubin
Urgent Kasai procedure
Necrotising enterocolitis
Prematurity is the main risk factor
Early features include abdominal distension and passage of bloody stools
X-Rays may show pneumatosis intestinalis and evidence of free air
Increased risk when empirical antibiotics are given to infants beyond 5 days
Treatment is with total gut rest and TPN, babies with perforations will require laparotomy
A 7 month old girl presents with vomiting and diarrhoea. She is crying and drawing her legs up. There is a a sausage shaped mass in the abdomen.
A. Meckel diverticulum B. Pyloric stenosis C. Acute appendicitis D. Mesenteric adenitis E. Intussusception F. Malrotation G. Hirschsprung disease
Intussusception
Sausage shaped mass (colon shaped) is common in intussusception. The other common sign is red jelly stool.
Paediatric Gastrointestinal disorders
Pyloric stenosis
M>F
5-10% Family history in parents
Projectile non bile stained vomiting at 4-6 weeks of life
Diagnosis is made by test feed or USS
Treatment: Ramstedt pyloromyotomy (open or laparoscopic)
Acute appendicitis
Uncommon under 3 years
When occurs may present atypically
Mesenteric adenitis
Central abdominal pain and URTI
Conservative management
Intussusception
Telescoping bowel
Proximal to or at the level of, ileocaecal valve
6-9 months age
Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool.
Treatment: reduction with air insufflation
Malrotation
High caecum at the midline
Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia
May be complicated by development of volvulus, infant with volvulus may have bile stained vomiting
Diagnosis is made by upper GI contrast study and USS
Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a ladds procedure is performed
Hirschsprung’s disease
Absence of ganglion cells from myenteric and submucosal plexuses
Occurs in 1/5000 births
Full thickness rectal biopsy for diagnosis
Delayed passage of meconium and abdominal distension
Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure
Oesophageal atresia
Associated with tracheo-oesophageal fistula and polyhydramnios
May present with choking and cyanotic spells following aspiration
VACTERL associations
Meconium ileus
Usually delayed passage of meconium and abdominal distension
Majority have cystic fibrosis
X-Rays may not show a fluid level as the meconium is viscid (depends upon feeding), PR contrast studies may dislodge meconium plugs and be therapeutic
Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs
Biliary atresia
Jaundice > 14 days
Increased conjugated bilirubin
Urgent Kasai procedure
Necrotising enterocolitis
Prematurity is the main risk factor
Early features include abdominal distension and passage of bloody stools
X-Rays may show pneumatosis intestinalis and evidence of free air
Increased risk when empirical antibiotics are given to infants beyond 5 days
Treatment is with total gut rest and TPN, babies with perforations will require laparotomy
A 1 month old baby girl presents with bile stained vomiting. She has an exomphalos and a congenital diaphragmatic hernia.
A. Meckel diverticulum B. Pyloric stenosis C. Acute appendicitis D. Mesenteric adenitis E. Intussusception F. Malrotation G. Hirschsprung disease
Malrotation
Exomphalos and diaphragmatic herniae are commonly associated with malrotation.
Paediatric Gastrointestinal disorders
Pyloric stenosis
M>F
5-10% Family history in parents
Projectile non bile stained vomiting at 4-6 weeks of life
Diagnosis is made by test feed or USS
Treatment: Ramstedt pyloromyotomy (open or laparoscopic)
Acute appendicitis Uncommon under 3 years When occurs may present atypically Mesenteric adenitis Central abdominal pain and URTI Conservative management
Intussusception
Telescoping bowel
Proximal to or at the level of, ileocaecal valve
6-9 months age
Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool.
Treatment: reduction with air insufflation
Malrotation
High caecum at the midline
Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia
May be complicated by development of volvulus, infant with volvulus may have bile stained vomiting
Diagnosis is made by upper GI contrast study and USS
Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a ladds procedure is performed
Hirschsprung’s disease
Absence of ganglion cells from myenteric and submucosal plexuses
Occurs in 1/5000 births
Full thickness rectal biopsy for diagnosis
Delayed passage of meconium and abdominal distension
Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure
Oesophageal atresia
Associated with tracheo-oesophageal fistula and polyhydramnios
May present with choking and cyanotic spells following aspiration
VACTERL associations
Meconium ileus
Usually delayed passage of meconium and abdominal distension
Majority have cystic fibrosis
X-Rays may not show a fluid level as the meconium is viscid (depends upon feeding), PR contrast studies may dislodge meconium plugs and be therapeutic
Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs
Biliary atresia
Jaundice > 14 days
Increased conjugated bilirubin
Urgent Kasai procedure
Necrotising enterocolitis
Prematurity is the main risk factor
Early features include abdominal distension and passage of bloody stools
X-Rays may show pneumatosis intestinalis and evidence of free air
Increased risk when empirical antibiotics are given to infants beyond 5 days
Treatment is with total gut rest and TPN, babies with perforations will require laparotomy
A 6 year old child develops ballooning of the foreskin on micturition and is brought to the clinic by his anxious mother. One examination the foreskin is non retractile but otherwise normal. By which age are 95% of all foreskins retractile
2 years 16 years 8 years 5 years 10 years
By 16 years of age almost all foreskins should be retractile and if they are not circumcision should be considered at around this time.
Paediatric urology- foreskin disorders
Disorders of the foreskin
At birth and in the neonatal period the normal foreskin is non retractile due to the presence of adhesions between the foreskin and glans. In most cases these will separate spontaneously. By the end of puberty 95% of foreskins can be retracted. In some children the non-retractile foreskin may balloon during micturition. This is a normal variant and requires no specific treatment.
Balanitis This is inflammation of the glans penis. It may occur in both circumcised and non-circumcised individuals.
Posthitis This is inflammation of the foreskin. It may occur as a result of infections such as gonorrhoea and other STD’s. It may also complicate diabetes. Posthitis may progress to phimosis and as this may make cleaning of the glans difficult and allow progression to balanoposthitis.
Paraphimosis Prolonged retraction of the foreskin proximal to the glans may allow oedema to occur. This may then make foreskin manipulation difficult. It can usually be managed by compression to reduce the oedema and replacement of the foreskin. Where this fails a dorsal slit may be required and this followed by delayed circumcision.
Phimosis This is inability to retract the foreskin and may be partial or complete. It may occur secondary to balanoposthitis or balanitis xerotica obliterans. Depending upon the severity and symptoms treatment with circumcision may be required.
Balanitis xerotica obliterans This is a dermatological condition in which scarring of the foreskin occurs leading to phimosis. It is rare below the age of 5 years. Treatment is usually with circumcision.
A neonate is noted to have colonic obstruction, what is the most likely cause?
Imperforate anus Meconium plugs Colonic atresia Anal atresia Sigmoid volvulus
Cystic fibrosis is the most common cause of meconium plugs and such cases can be treated with intestinal lavage, this should be followed by formal testing for CF.
Paediatric Gastrointestinal disorders
Pyloric stenosis
M>F
5-10% Family history in parents
Projectile non bile stained vomiting at 4-6 weeks of life
Diagnosis is made by test feed or USS
Treatment: Ramstedt pyloromyotomy (open or laparoscopic)
Acute appendicitis
Uncommon under 3 years
When occurs may present atypically
Mesenteric adenitis
Central abdominal pain and URTI
Conservative management
Intussusception
Telescoping bowel
Proximal to or at the level of, ileocaecal valve
6-9 months age
Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool.
Treatment: reduction with air insufflation
Malrotation
High caecum at the midline
Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia
May be complicated by development of volvulus, infant with volvulus may have bile stained vomiting
Diagnosis is made by upper GI contrast study and USS
Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a ladds procedure is performed
Hirschsprung’s disease
Absence of ganglion cells from myenteric and submucosal plexuses
Occurs in 1/5000 births
Full thickness rectal biopsy for diagnosis
Delayed passage of meconium and abdominal distension
Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure
Oesophageal atresia
Associated with tracheo-oesophageal fistula and polyhydramnios
May present with choking and cyanotic spells following aspiration
VACTERL associations
Meconium ileus
Usually delayed passage of meconium and abdominal distension
Majority have cystic fibrosis
X-Rays may not show a fluid level as the meconium is viscid (depends upon feeding), PR contrast studies may dislodge meconium plugs and be therapeutic
Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs
Biliary atresia
Jaundice > 14 days
Increased conjugated bilirubin
Urgent Kasai procedure
Necrotising enterocolitis
Prematurity is the main risk factor
Early features include abdominal distension and passage of bloody stools
X-Rays may show pneumatosis intestinalis and evidence of free air
Increased risk when empirical antibiotics are given to infants beyond 5 days
Treatment is with total gut rest and TPN, babies with perforations will require laparotomy
A 42 year old teacher presents with an ulcer associated with varicose veins in the long saphenous vein territory. Apart from a DVT 1 year ago, she has no other past medical history.
A. No further management needed
B. Injection sclerotherapy using 0.5% Sodium tetradecyl sulphate
C. Injection sclerotherapy using 5% phenol
D. Long saphenous vein ligation
E. Long saphenous vein stripped to the ankle
F. Long saphenous vein stripped to the knee
G. Doppler scan
H. Duplex scan
I. Endothermal ablation
Duplex scan
This patient needs a duplex scan to assess the patency of her deep venous system before surgery can be undertaken. Other indications for duplex scan include recurrent varicose veins or complications.
Chronic venous insufficiency and varicose veins
Wide spectrum of disease ranging from minor cosmetic problem through to ulceration and disability. It is commoner in women than men and is worse during pregnancy. Varicose veins are best considered as being a saccular dilation of veins (WHO). Chronic venous insufficiency is a series of tissue changes which occur in relation to pooling of blood in the extremities with associated venous hypertension occurring as a result of incompetent deep vein valves.
The veins of the lower limb consist of an interconnected network of superficial and deep venous systems. Varices occur because of localised weakness in the vein wall resulting in dilatation and reflux of blood due to non union of valve cusps. Histologically the typical changes include fibrous scar tissue dividing smooth muscle within media in the vessel wall.
Tissue damage in chronic venous insufficiency occurs because of perivascular cytokine leakage resulting in localised tissue damage coupled with impaired lymphatic flow.
Diagnosis Typical symptoms of varicose veins include: Cosmetic appearance Aching Ankle swelling that worsens as the day progresses Episodic thrombophlebitis Bleeding Itching
Symptoms of chronic venous insufficiency include: Dependant leg pain Prominent leg swelling Oedema extending beyond the ankle Venous stasis ulcers
The typical venous stasis ulcer is:
Located above the medial malleolus
Indolent appearance with basal granulation tissue
Variable degree of scarring
Non ischaemic edges
Haemosiderin deposition in the gaiter area (and also lipodermatosclerosis).
Differential diagnosis Lower limb arterial disease Marjolins ulcer Claudication Spinal stenosis Swelling due to medical causes e.g. CCF.
Exclusion of these differentials is by means of physical examination and ankle brachial pressure index measurement.
Examination
Assess for dilated short saphenous vein (popliteal fossa) and palpate for saphena varix medial to the femoral artery
Brodie-Trendelenburg test: to assess level of incompetence
Perthes’ walking test: assess if deep venous system competent
Investigation
Doppler exam: if incompetent a biphasic signal due to retrograde flow is detected
Duplex scanning: to ensure patent deep venous system (do if DVT or trauma)
All patients should have a Doppler assessment to assess for venous reflux and should be classified as having uncomplicated varicose veins or varicose veins with associated chronic venous insufficiency. In the history establishing a previous thrombotic event (DVT/ lower limb fracture) is important and patients with such a history and all who have evidence of chronic venous insufficiency should have a duplex scan performed.
Owing to litigation patients with saphenopopliteal incompetence should have a duplex scan performed and the site marked by scan on the day of surgery.
Treatment Indications for surgery: Cosmetic: majority Lipodermatosclerosis causing venous ulceration Recurrent superficial thrombophlebitis Bleeding from ruptured varix
Condition Therapy
Minor varicose veins - no complications Reassure/ cosmetic therapy
Symptomatic uncomplicated varicose veins In those without deep venous insufficiency options include; endothermal ablation, foam sclerotherapy, saphenofemoral / popliteal disconnection, stripping and avulsions, compression stockings
Varicose veins with skin changes Therapy as above (if compression minimum is formal class I stockings)
Chronic venous insufficiency or ulcers Class 2-3 compression stockings (ensure no arterial disease).
Application of formal compression stockings (usually class II/III). In patients who have suffered ulceration, compression stockings should be worn long term. Where ulceration is present and established saphenofemoral reflux exists this should be addressed surgically for durable relief of symptoms, either at the outset or following ulcer healing. Injection sclerotherapy (5% Ethanolamine oleate), foam is increasingly popular, though transient blindness has been reported. Endo venous laser therapy is another minimally invasive option Sapheno-femoral or sapheno-popliteal ligation, in the case of the LSV; stripping and multiple phlebectomies
Current best practice guidance
In the United Kingdom the National Institute of Clinical Excellence guidance on varicose veins suggests that for patients with symptomatic varicose veins the first line procedure of choice should be endothermal ablation (see reference for more information). Where this is unavailable or unsuitable then foam sclerotherapy should be the second line option. Surgery is currently the third line treatment option.
Trendelenburg procedure (sapheno-femoral junction ligation)
Head tilt 15 degrees and legs abducted
Oblique incision 1cm medial from artery
Tributaries ligated (Superficial circumflex iliac vein, Superficial inferior epigastric vein, Superficial and deep external pudendal vein)
SF junction double ligated
Saphenous vein stripped to level of knee/upper calf. NB increased risk of saphenous neuralgia if stripped more distally
A 42 year old accountant presents with thrombophlebitis of a long standing varicosity of the inner thigh. His past medical history is unremarkable apart from a conservatively managed tibial fracture of the ipsilateral limb 10 years ago. Doppler and clinical assessment demonstrate saphenofemoral junction incompetence.
A. No further management needed
B. Injection sclerotherapy using 0.5% Sodium tetradecyl sulphate
C. Injection sclerotherapy using 5% phenol
D. Long saphenous vein ligation
E. Long saphenous vein stripped to the ankle
F. Long saphenous vein stripped to the knee
G. Doppler scan
H. Duplex scan
I. Endothermal ablation
Duplex scan
Tibial fractures are a well recognised risk factor for occult lower limb deep venous thrombosis and most surgeons would perform a duplex scan to exclude deep venous insufficiency prior to surgery.
Chronic venous insufficiency and varicose veins
Wide spectrum of disease ranging from minor cosmetic problem through to ulceration and disability. It is commoner in women than men and is worse during pregnancy. Varicose veins are best considered as being a saccular dilation of veins (WHO). Chronic venous insufficiency is a series of tissue changes which occur in relation to pooling of blood in the extremities with associated venous hypertension occurring as a result of incompetent deep vein valves.
The veins of the lower limb consist of an interconnected network of superficial and deep venous systems. Varices occur because of localised weakness in the vein wall resulting in dilatation and reflux of blood due to non union of valve cusps. Histologically the typical changes include fibrous scar tissue dividing smooth muscle within media in the vessel wall.
Tissue damage in chronic venous insufficiency occurs because of perivascular cytokine leakage resulting in localised tissue damage coupled with impaired lymphatic flow.
Diagnosis Typical symptoms of varicose veins include: Cosmetic appearance Aching Ankle swelling that worsens as the day progresses Episodic thrombophlebitis Bleeding Itching
Symptoms of chronic venous insufficiency include: Dependant leg pain Prominent leg swelling Oedema extending beyond the ankle Venous stasis ulcers
The typical venous stasis ulcer is:
Located above the medial malleolus
Indolent appearance with basal granulation tissue
Variable degree of scarring
Non ischaemic edges
Haemosiderin deposition in the gaiter area (and also lipodermatosclerosis).
Differential diagnosis Lower limb arterial disease Marjolins ulcer Claudication Spinal stenosis Swelling due to medical causes e.g. CCF.
Exclusion of these differentials is by means of physical examination and ankle brachial pressure index measurement.
Examination
Assess for dilated short saphenous vein (popliteal fossa) and palpate for saphena varix medial to the femoral artery
Brodie-Trendelenburg test: to assess level of incompetence
Perthes’ walking test: assess if deep venous system competent
Investigation
Doppler exam: if incompetent a biphasic signal due to retrograde flow is detected
Duplex scanning: to ensure patent deep venous system (do if DVT or trauma)
All patients should have a Doppler assessment to assess for venous reflux and should be classified as having uncomplicated varicose veins or varicose veins with associated chronic venous insufficiency. In the history establishing a previous thrombotic event (DVT/ lower limb fracture) is important and patients with such a history and all who have evidence of chronic venous insufficiency should have a duplex scan performed.
Owing to litigation patients with saphenopopliteal incompetence should have a duplex scan performed and the site marked by scan on the day of surgery.
Treatment Indications for surgery: Cosmetic: majority Lipodermatosclerosis causing venous ulceration Recurrent superficial thrombophlebitis Bleeding from ruptured varix
Condition Therapy
Minor varicose veins - no complications Reassure/ cosmetic therapy
Symptomatic uncomplicated varicose veins In those without deep venous insufficiency options include; endothermal ablation, foam sclerotherapy, saphenofemoral / popliteal disconnection, stripping and avulsions, compression stockings
Varicose veins with skin changes Therapy as above (if compression minimum is formal class I stockings)
Chronic venous insufficiency or ulcers Class 2-3 compression stockings (ensure no arterial disease).
Application of formal compression stockings (usually class II/III). In patients who have suffered ulceration, compression stockings should be worn long term. Where ulceration is present and established saphenofemoral reflux exists this should be addressed surgically for durable relief of symptoms, either at the outset or following ulcer healing. Injection sclerotherapy (5% Ethanolamine oleate), foam is increasingly popular, though transient blindness has been reported. Endo venous laser therapy is another minimally invasive option Sapheno-femoral or sapheno-popliteal ligation, in the case of the LSV; stripping and multiple phlebectomies
Current best practice guidance
In the United Kingdom the National Institute of Clinical Excellence guidance on varicose veins suggests that for patients with symptomatic varicose veins the first line procedure of choice should be endothermal ablation (see reference for more information). Where this is unavailable or unsuitable then foam sclerotherapy should be the second line option. Surgery is currently the third line treatment option.
Trendelenburg procedure (sapheno-femoral junction ligation)
Head tilt 15 degrees and legs abducted
Oblique incision 1cm medial from artery
Tributaries ligated (Superficial circumflex iliac vein, Superficial inferior epigastric vein, Superficial and deep external pudendal vein)
SF junction double ligated
Saphenous vein stripped to level of knee/upper calf. NB increased risk of saphenous neuralgia if stripped more distally
A 43 year old lady presents with a thigh varicosity in the territory of the long saphenous vein. She underwent endovenous laser therapy 5 years previously. On duplex assessment she has a patent deep venous system and sapheno-femoral junction incompetence.
A. No further management needed
B. Injection sclerotherapy using 0.5% Sodium tetradecyl sulphate
C. Injection sclerotherapy using 5% phenol
D. Long saphenous vein ligation
E. Long saphenous vein stripped to the ankle
F. Long saphenous vein stripped to the knee
G. Doppler scan
H. Duplex scan
I. Endothermal ablation
Long saphenous vein stripped to the knee
In the UK, NICE, suggest the use non operative measures such as endothermal ablation for first time varicose veins. Recurrences respond far less favourably and are best managed with surgery.
Chronic venous insufficiency and varicose veins
Wide spectrum of disease ranging from minor cosmetic problem through to ulceration and disability. It is commoner in women than men and is worse during pregnancy. Varicose veins are best considered as being a saccular dilation of veins (WHO). Chronic venous insufficiency is a series of tissue changes which occur in relation to pooling of blood in the extremities with associated venous hypertension occurring as a result of incompetent deep vein valves.
The veins of the lower limb consist of an interconnected network of superficial and deep venous systems. Varices occur because of localised weakness in the vein wall resulting in dilatation and reflux of blood due to non union of valve cusps. Histologically the typical changes include fibrous scar tissue dividing smooth muscle within media in the vessel wall.
Tissue damage in chronic venous insufficiency occurs because of perivascular cytokine leakage resulting in localised tissue damage coupled with impaired lymphatic flow.
Diagnosis Typical symptoms of varicose veins include: Cosmetic appearance Aching Ankle swelling that worsens as the day progresses Episodic thrombophlebitis Bleeding Itching
Symptoms of chronic venous insufficiency include: Dependant leg pain Prominent leg swelling Oedema extending beyond the ankle Venous stasis ulcers
The typical venous stasis ulcer is:
Located above the medial malleolus
Indolent appearance with basal granulation tissue
Variable degree of scarring
Non ischaemic edges
Haemosiderin deposition in the gaiter area (and also lipodermatosclerosis).
Differential diagnosis Lower limb arterial disease Marjolins ulcer Claudication Spinal stenosis Swelling due to medical causes e.g. CCF.
Exclusion of these differentials is by means of physical examination and ankle brachial pressure index measurement.
Examination
Assess for dilated short saphenous vein (popliteal fossa) and palpate for saphena varix medial to the femoral artery
Brodie-Trendelenburg test: to assess level of incompetence
Perthes’ walking test: assess if deep venous system competent
Investigation
Doppler exam: if incompetent a biphasic signal due to retrograde flow is detected
Duplex scanning: to ensure patent deep venous system (do if DVT or trauma)
All patients should have a Doppler assessment to assess for venous reflux and should be classified as having uncomplicated varicose veins or varicose veins with associated chronic venous insufficiency. In the history establishing a previous thrombotic event (DVT/ lower limb fracture) is important and patients with such a history and all who have evidence of chronic venous insufficiency should have a duplex scan performed.
Owing to litigation patients with saphenopopliteal incompetence should have a duplex scan performed and the site marked by scan on the day of surgery.
Treatment Indications for surgery: Cosmetic: majority Lipodermatosclerosis causing venous ulceration Recurrent superficial thrombophlebitis Bleeding from ruptured varix
Condition Therapy
Minor varicose veins - no complications Reassure/ cosmetic therapy
Symptomatic uncomplicated varicose veins In those without deep venous insufficiency options include; endothermal ablation, foam sclerotherapy, saphenofemoral / popliteal disconnection, stripping and avulsions, compression stockings
Varicose veins with skin changes Therapy as above (if compression minimum is formal class I stockings)
Chronic venous insufficiency or ulcers Class 2-3 compression stockings (ensure no arterial disease).
Application of formal compression stockings (usually class II/III). In patients who have suffered ulceration, compression stockings should be worn long term. Where ulceration is present and established saphenofemoral reflux exists this should be addressed surgically for durable relief of symptoms, either at the outset or following ulcer healing. Injection sclerotherapy (5% Ethanolamine oleate), foam is increasingly popular, though transient blindness has been reported. Endo venous laser therapy is another minimally invasive option Sapheno-femoral or sapheno-popliteal ligation, in the case of the LSV; stripping and multiple phlebectomies
Current best practice guidance
In the United Kingdom the National Institute of Clinical Excellence guidance on varicose veins suggests that for patients with symptomatic varicose veins the first line procedure of choice should be endothermal ablation (see reference for more information). Where this is unavailable or unsuitable then foam sclerotherapy should be the second line option. Surgery is currently the third line treatment option.
Trendelenburg procedure (sapheno-femoral junction ligation)
Head tilt 15 degrees and legs abducted
Oblique incision 1cm medial from artery
Tributaries ligated (Superficial circumflex iliac vein, Superficial inferior epigastric vein, Superficial and deep external pudendal vein)
SF junction double ligated
Saphenous vein stripped to level of knee/upper calf. NB increased risk of saphenous neuralgia if stripped more distally
An elderly diabetic male presents with a severe deep seated otalgia and a facial nerve palsy, he has completed a course of amoxycillin with no benefit. What is the most likely diagnosis?
Malignant otitis externa Otosclerosis Acoustic neuroma Meniers disease Viral illness
A combination of severe otalgia and facial nerve palsy in a diabetic should raise suspicion of malignant otitis externa. This is a condition caused by pseudomonas. It commences as otitis externa and then progresses to involve the temporal bone. Spread of the disease outside the external auditory canal occurs through the fissures of Santorini and the osseocartilaginous junction.
Acute otitis externa Boil in external auditory meatus Acute pain on moving the pinna
Conductive hearing loss if lesion is large
When rupture occurs pus will flow from ear Ear packs may be used
Topical antibiotics
Operative debridement may be needed in severe cases
Chronic otitis externa Chronic combined infection in the external auditory meatus usually combined staphylococcal and fungal infection Chronic discharge from affected ear, hearing loss and severe pain rare Cleansing of the external ear and treatment with antifungal and antibacterial ear drops
Acute suppurative otitis media Viral induced middle ear effusions secondary to eustacian tube dysfunction Most common in children and rare in adults
May present with symptoms elsewhere (e.g. vomiting) in children
Severe pain and sometimes fever
May present with discharge is tympanic rupture occurs Antibiotics (usually amoxycillin)
Chronic suppurative otitis media May occur with or without cholesteatoma
Those without cholesteatoma have a perforation of the pars tensa
Those with cholesteatoma have a perforation of the pars flaccida Those without cholesteatoma may complain of intermittent discharge (non offensive)
Those with cholesteatoma have impaired hearing and foul smelling discharge Simple pars tensa perforations may be managed non operatively or a myringoplasty considered if symptoms troublesome.
Pars flaccida perforations will usually require a radical mastoidectomy
Otosclerosis
Progressive conductive deafness
Secondary to fixation of the stapes in the oval window
Treatment is with stapedectomy and insertion of a prosthesis
Acoustic neuroma
Symptoms of gradually progressive unilateral perceptive deafness and tinnitus
Involvement of the vestibular nerve may cause vertigo
Extension to involve the facial nerve may cause weakness and then paralysis.
Pre auricular sinus
Common congenital condition in which an epithelial defect forms around the external ear
Small sinuses require no treatment
Deeper sinuses may become blocked and develop episodes of infection, they may be closely related to the facial nerve and are challenging to excise
An 18 month old boy is brought to the emergency room by his parents. He was found in bed with a nappy filled with dark red blood. He is haemodynamically unstable and requires a blood transfusion. Prior to this episode he was well with no prior medical history. What is the most likely cause?
Necrotising enterocolitis Anal fissure Oesophageal varices Meckels diverticulum Crohns disease
Meckels diverticulum is the number one cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years.
Meckel’s diverticulum
Congenital abnormality resulting in incomplete obliteration of the vitello-intestinal duct
Normally, in the foetus, there is an attachment between the vitello-intestinal duct and the yolk sac.This disappears at 6 weeks gestation.
The tip is free in majority of cases.
Associated with enterocystomas, umbilical sinuses, and omphaloileal fistulas.
Arterial supply: omphalomesenteric artery.
2% of population, 2 inches long, 2 feet from the ileocaecal valve.
Typically lined by ileal mucosa but ectopic gastric mucosa can occur, with the risk of peptic ulceration. Pancreatic and jejunal mucosa can also occur.
Clinical
Normally asymptomatic and an incidental finding.
Complications are the result of obstruction, ectopic tissue, or inflammation.
Removal if narrow neck or symptomatic. Options are between wedge excision or formal small bowel resection and anastomosis.
Which of the following statements relating to sebaceous cysts is false?
When infected are also known as Cocks peculiar tumour Typically contain pus Are usually associated with a central punctum Most commonly occur on the scalp They will typically have a cyst wall
Sebaceous cysts usually contain sebum, pus is only present in infected sebaceous cysts which should then be treated by surgical incision and drainage.
Sebaceous cysts
Originate from sebaceous glands and contain sebum.
Location: anywhere but most common scalp, ears, back, face, and upper arm (not palms of the hands and soles of the feet).
They will typically contain a punctum.
Excision of the cyst wall needs to be complete to prevent recurrence.
A Cock’s ‘Peculiar’ Tumour is a suppurating and ulcerated sebaceous cyst. It may resemble a squamous cell carcinoma- hence its name.
A 42 year old lady who has systemic lupus erythematosus presents to the clinic with a 5 day history of a painful purple lesion on her index finger. On examination she has a tender red lesion on the index finger.
A. Malignant fibrous histiocytoma B. Oslers nodes C. Heberdens nodes D. Bouchards nodes E. Carpal tunnel syndrome F. Complex regional pain syndrome G. Osteoclastoma H. Osteosarcoma I. Ganglion
Oslers nodes
Osler nodes are normally described as tender, purple/red raised lesions with a pale centre. These lesions occur as a result of immune complex deposition. These occur most often in association with endocarditis. However, other causes include SLE, gonorrhoea, typhoid and haemolytic anaemia.
Dupuytrens contracture
Fixed flexion contracture of the hand where the fingers bend towards the palm and cannot be fully extended.
Caused by underlying contractures of the palmar aponeurosis . The ring finger and little finger are the fingers most commonly affected. The middle finger may be affected in advanced cases, but the index finger and the thumb are nearly always spared.
Progresses slowly and is usually painless. In patients with this condition, the tissues under the skin on the palm of the hand thicken and shorten so that the tendons connected to the fingers cannot move freely. The palmar aponeurosis becomes hyperplastic and undergoes contracture.
Commonest in males over 40 years of age.
Association with liver cirrhosis and alcoholism. However, many cases are idiopathic.
Treatment is surgical and involves fasciectomy. However, the condition may recur and many surgical therapies are associated with risk of neurovascular damage to the digital nerves and arteries.
Carpel tunnel syndrome
Idiopathic median neuropathy at the carpal tunnel.
Characterised by altered sensation of the lateral 3 fingers.
The condition is commoner in females and is associated with other connective tissue disorders such as rheumatoid disease. It may also occur following trauma to the distal radius.
Symptoms occur mainly at night in early stages of the condition.
Examination may demonstrate wasting of the muscles of the thenar eminence and symptoms may be reproduced by Tinels test (compression of the contents of the carpal tunnel).
Formal diagnosis is usually made by electrophysiological studies.
Treatment is by surgical decompression of the carpal tunnel, a procedure achieved by division of the flexor retinaculum. Non - surgical options include splinting and bracing.
Osler’s nodes Osler’s nodes are painful, red, raised lesions found on the hands and feet. They are the result of the deposition of immune complexes.
Bouchards nodes Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the articular cartilage.
Heberdens nodes Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the fingertip sideways. It typically affects the DIP joint.
Ganglion Swelling in association with a tendon sheath commonly near a joint. They are common lesions in the wrist and hand. Usually they are asymptomatic and cause little in the way of functional compromise. They are fluid filled although the fluid is similar to synovial fluid it is slightly more viscous. When the cysts are troublesome they may be excised.
A 62 year old lady presents with an non tender lump overlying the distal interphalangeal joint of the index finger. On examination she has a hard, non tender lump overlying the joint and deviation of the tip of the finger.
A. Malignant fibrous histiocytoma B. Oslers nodes C. Heberdens nodes D. Bouchards nodes E. Carpal tunnel syndrome F. Complex regional pain syndrome G. Osteoclastoma H. Osteosarcoma I. Ganglion
Heberdens nodes
Heberdens nodes may produce swelling of the distal interphalangeal joint with deviation of the finger tip.
Dupuytrens contracture
Fixed flexion contracture of the hand where the fingers bend towards the palm and cannot be fully extended.
Caused by underlying contractures of the palmar aponeurosis . The ring finger and little finger are the fingers most commonly affected. The middle finger may be affected in advanced cases, but the index finger and the thumb are nearly always spared.
Progresses slowly and is usually painless. In patients with this condition, the tissues under the skin on the palm of the hand thicken and shorten so that the tendons connected to the fingers cannot move freely. The palmar aponeurosis becomes hyperplastic and undergoes contracture.
Commonest in males over 40 years of age.
Association with liver cirrhosis and alcoholism. However, many cases are idiopathic.
Treatment is surgical and involves fasciectomy. However, the condition may recur and many surgical therapies are associated with risk of neurovascular damage to the digital nerves and arteries.
Carpel tunnel syndrome
Idiopathic median neuropathy at the carpal tunnel.
Characterised by altered sensation of the lateral 3 fingers.
The condition is commoner in females and is associated with other connective tissue disorders such as rheumatoid disease. It may also occur following trauma to the distal radius.
Symptoms occur mainly at night in early stages of the condition.
Examination may demonstrate wasting of the muscles of the thenar eminence and symptoms may be reproduced by Tinels test (compression of the contents of the carpal tunnel).
Formal diagnosis is usually made by electrophysiological studies.
Treatment is by surgical decompression of the carpal tunnel, a procedure achieved by division of the flexor retinaculum. Non - surgical options include splinting and bracing.
Osler’s nodes Osler’s nodes are painful, red, raised lesions found on the hands and feet. They are the result of the deposition of immune complexes.
Bouchards nodes Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the articular cartilage.
Heberdens nodes Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the fingertip sideways. It typically affects the DIP joint.
Ganglion Swelling in association with a tendon sheath commonly near a joint. They are common lesions in the wrist and hand. Usually they are asymptomatic and cause little in the way of functional compromise. They are fluid filled although the fluid is similar to synovial fluid it is slightly more viscous. When the cysts are troublesome they may be excised.
A 17 year old boy is brought to the clinic by his mother who is concerned about a lesion that has developed on the dorsal surface of his left hand. On examination he has a soft fluctuant swelling on the dorsal aspect of the hand, it is most obvious on making a fist.
A. Malignant fibrous histiocytoma B. Oslers nodes C. Heberdens nodes D. Bouchards nodes E. Carpal tunnel syndrome F. Complex regional pain syndrome G. Osteoclastoma H. Osteosarcoma I. Ganglion
Ganglion
Ganglions commonly occur in the hand and are usually associated with tendons. They are typically soft and fluctuant. They do not require removal unless they are atypical or causing symptoms.
Dupuytrens contracture
Fixed flexion contracture of the hand where the fingers bend towards the palm and cannot be fully extended.
Caused by underlying contractures of the palmar aponeurosis . The ring finger and little finger are the fingers most commonly affected. The middle finger may be affected in advanced cases, but the index finger and the thumb are nearly always spared.
Progresses slowly and is usually painless. In patients with this condition, the tissues under the skin on the palm of the hand thicken and shorten so that the tendons connected to the fingers cannot move freely. The palmar aponeurosis becomes hyperplastic and undergoes contracture.
Commonest in males over 40 years of age.
Association with liver cirrhosis and alcoholism. However, many cases are idiopathic.
Treatment is surgical and involves fasciectomy. However, the condition may recur and many surgical therapies are associated with risk of neurovascular damage to the digital nerves and arteries.
Carpel tunnel syndrome
Idiopathic median neuropathy at the carpal tunnel.
Characterised by altered sensation of the lateral 3 fingers.
The condition is commoner in females and is associated with other connective tissue disorders such as rheumatoid disease. It may also occur following trauma to the distal radius.
Symptoms occur mainly at night in early stages of the condition.
Examination may demonstrate wasting of the muscles of the thenar eminence and symptoms may be reproduced by Tinels test (compression of the contents of the carpal tunnel).
Formal diagnosis is usually made by electrophysiological studies.
Treatment is by surgical decompression of the carpal tunnel, a procedure achieved by division of the flexor retinaculum. Non - surgical options include splinting and bracing.
Osler’s nodes Osler’s nodes are painful, red, raised lesions found on the hands and feet. They are the result of the deposition of immune complexes.
Bouchards nodes Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the articular cartilage.
Heberdens nodes Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the fingertip sideways. It typically affects the DIP joint.
Ganglion Swelling in association with a tendon sheath commonly near a joint. They are common lesions in the wrist and hand. Usually they are asymptomatic and cause little in the way of functional compromise. They are fluid filled although the fluid is similar to synovial fluid it is slightly more viscous. When the cysts are troublesome they may be excised.
Which of the following statements relating to Keloid scars is untrue?
They have a predilection for sternal , mandibular and deltiod area wounds They are confined to the margins of the original injury They often recur following excision May occur even after superficial injury They may be treated by injection of triamcinolone
Hypertrophic scars remain confined to the wound edges.
Keloids (by definition) will tend to extend beyond the margins of the wound and in wounds of any depth.
Wound healing
Surgical wounds are either incisional or excisional and either clean, clean contaminated or dirty. Although the stages of wound healing are broadly similar their contributions will vary according to the wound type.
The main stages of wound healing include:
Haemostasis
Minutes to hours following injury
Vasospasm in adjacent vessels, platelet plug formation and generation of fibrin rich clot.
Inflammation
Typically days 1-5
Neutrophils migrate into wound (function impaired in diabetes).
Growth factors released, including basic fibroblast growth factor and vascular endothelial growth factor.
Fibroblasts replicate within the adjacent matrix and migrate into wound.
Macrophages and fibroblasts couple matrix regeneration and clot substitution.
Regeneration
Typically days 7 to 56
Platelet derived growth factor and transformation growth factors stimulate fibroblasts and epithelial cells.
Fibroblasts produce a collagen network.
Angiogenesis occurs and wound resembles granulation tissue.
Remodeling
From 6 weeks to 1 year
Longest phase of the healing process and may last up to one year (or longer).
During this phase fibroblasts become differentiated (myofibroblasts) and these facilitate wound contraction.
Collagen fibres are remodeled.
Microvessels regress leaving a pale scar.
The above description represents an idealised scenario. A number of diseases may distort this process. Neovascularisation is an important early process. Endothelial cells may proliferate in the wound bed and recanalise to form a vessel. Vascular disease, shock and sepsis can all compromise microvascular flow and impair healing.
Conditions such as jaundice will impair fibroblast synthetic function and immunity with a detrimental effect in most parts of the healing process.
Problems with scars:
Hypertrophic scars
Excessive amounts of collagen within a scar. Nodules may be present histologically containing randomly arranged fibrils within and parallel fibres on the surface. The tissue itself is confined to the extent of the wound itself and is usually the result of a full thickness dermal injury. They may go on to develop contractures.
Keloid scars
Excessive amounts of collagen within a scar. Typically a keloid scar will pass beyond the boundaries of the original injury. They do not contain nodules and may occur following even trivial injury. They do not regress over time and may recur following removal.
Drugs which impair wound healing: Non steroidal anti inflammatory drugs Steroids Immunosupressive agents Anti neoplastic drugs
Closure
Delayed primary closure is the anatomically precise closure that is delayed for a few days but before granulation tissue becomes macroscopically evident.
Secondary closure refers to either spontaneous closure or to surgical closure after granulation tissue has formed.
What is the investigation of choice to look for renal scarring in a child with vesicoureteric reflux?
Abdominal x-ray Ultrasound DMSA CT KUB Micturating cystourethrogram
DMSA
Vesicoureteric reflux (VUR) is the abnormal backflow of urine from the bladder into the ureter and kidney. It is relatively common abnormality of the urinary tract in children and predisposes to urinary tract infection (UTI), being found in around 30% of children who present with a UTI. As around 35% of children develop renal scarring it is important to investigate for VUR in children following a UTI
Pathophysiology of VUR
ureters are displaced laterally, entering the bladder in a more perpendicular fashion than at an angle
therefore shortened intramural course of ureter
vesicoureteric junction cannot therefore function adequately
The table below summarises the grading of VUR
{Grade}
I Reflux into the ureter only, no dilatation
II Reflux into the renal pelvis on micturition, no dilatation
III Mild/moderate dilatation of the ureter, renal pelvis and calyces
IV Dilation of the renal pelvis and calyces with moderate ureteral tortuosity
V Gross dilatation of the ureter, pelvis and calyces with ureteral tortuosity
Investigation
VUR is normally diagnosed following a micturating cystourethrogram
a DMSA scan may also be performed to look for renal scarring
A 24-year-old female is referred to the acute surgical team as she is noted to have an absent left radial pulse. Apart from some dizziness and lethargy, the patient does not have any features suggestive of an acute ischaemic limb. Blood tests are as follows:
Na+ 136 mmol/l
K+ 4.1 mmol/l
Urea 2.3 mmol/l
Creatinine 77 µmol/l
ESR 66 mm/hr
What is the most likely diagnosis?
Turner's syndrome Takayasu's arteritis Kawasaki disease Coarctation of the aorta Breast carcinoma with local spread
Takayasu’s arteritis
Inflammatory, obliterative arteritis affecting aorta and branches
Females> Males
Symptoms may include upper limb claudication
Clinical findings include diminished or absent pulses
ESR often affected during the acute phase
Takayasu’s arteritis is a large vessel vasculitis. It typically causes occlusion of the aorta and questions commonly refer to an absent limb pulse. It is more common in females and Asian people
Associations
renal artery stenosis
Management
steroids
A 28 year old man is playing tennis when he suddenly collapses and has a GCS of 4 when examined.
A. Acute sub dural haematoma B. Chronic sub dural haematoma C. Acute extradural haematoma D. Chronic extradural haematoma E. Intraventricular haemorrhage F. Sub arachnoid haemorrhage
Sub arachnoid haemorrhage
A sudden collapse and loss of consciousness is most likely to be due to a sub arachnoid haemorrhage. The other potential causes in the list usually occur as a sequel to a traumatic event, which has not occurred here.
Extradural haematoma Bleeding into the space between the dura mater and the skull. Often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery.
Features
Raised intracranial pressure
Some patients may exhibit a lucid interval
Subdural haematoma Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes. May be either acute or chronic.
Risk factors include old age and alcoholism.
Slower onset of symptoms than a extradural haematoma.
Intracerebral haematoma Usually hyperdense lesions on CT scanning. Arise in areas of traumatic contusion with fuse to become a haematoma. Areas of clot and fresh blood may co-exist on the same CT scan (Swirl sign). Large haematomas and those associated with mass effect should be evacuated.
Subarachnoid haemorrhage Usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury
Intraventricular haemorrhage Haemorrhage that occurs into the ventricular system of the brain. It is relatively rare in adult surgical practice and when it does occur, it is typically associated with severe head injuries. In premature neonates it may occur spontaneously. The blood may clot and occlude CSF flow, hydrocephalus may result.
In neonatal practice the vast majority of IVH occur in the first 72 hours after birth, the aetiology is not well understood and it is suggested to occur as a result of birth trauma combined with cellular hypoxia, together with the delicate neonatal CNS.
A 2 day old premature neonate is born by emergency cesarean section for maternal illness. The baby is noted to become floppy and unresponsive.
A. Acute sub dural haematoma B. Chronic sub dural haematoma C. Acute extradural haematoma D. Chronic extradural haematoma E. Intraventricular haemorrhage F. Sub arachnoid haemorrhage
Intraventricular haemorrhage
Neonatal deterioration in premature babies is not infrequently due to intra ventricular haemorrhage. In extreme prematurity the prognosis can be very poor.
Extradural haematoma Bleeding into the space between the dura mater and the skull. Often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery.
Features
Raised intracranial pressure
Some patients may exhibit a lucid interval
Subdural haematoma Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes. May be either acute or chronic.
Risk factors include old age and alcoholism.
Slower onset of symptoms than a extradural haematoma.
Intracerebral haematoma Usually hyperdense lesions on CT scanning. Arise in areas of traumatic contusion with fuse to become a haematoma. Areas of clot and fresh blood may co-exist on the same CT scan (Swirl sign). Large haematomas and those associated with mass effect should be evacuated.
Subarachnoid haemorrhage Usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury
Intraventricular haemorrhage Haemorrhage that occurs into the ventricular system of the brain. It is relatively rare in adult surgical practice and when it does occur, it is typically associated with severe head injuries. In premature neonates it may occur spontaneously. The blood may clot and occlude CSF flow, hydrocephalus may result.
In neonatal practice the vast majority of IVH occur in the first 72 hours after birth, the aetiology is not well understood and it is suggested to occur as a result of birth trauma combined with cellular hypoxia, together with the delicate neonatal CNS.
A 78 year old man is brought to the emergency department by the police. He is found wandering around the town centre and is confused. His family report that he is usually well apart from a simple mechanical fall 3 weeks previously from which he sustained no obvious injuries.
A. Acute sub dural haematoma B. Chronic sub dural haematoma C. Acute extradural haematoma D. Chronic extradural haematoma E. Intraventricular haemorrhage F. Sub arachnoid haemorrhage
Chronic sub dural haematoma
The injuries that are responsible for chronic sub dural haematomas are usually fairly trivial and forgotten by the patient and their families. The onset of symptoms can be insidious with vague symptomatology and confusion predominating.
Extradural haematoma Bleeding into the space between the dura mater and the skull. Often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery.
Features
Raised intracranial pressure
Some patients may exhibit a lucid interval
Subdural haematoma Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes. May be either acute or chronic.
Risk factors include old age and alcoholism.
Slower onset of symptoms than a extradural haematoma.
Intracerebral haematoma Usually hyperdense lesions on CT scanning. Arise in areas of traumatic contusion with fuse to become a haematoma. Areas of clot and fresh blood may co-exist on the same CT scan (Swirl sign). Large haematomas and those associated with mass effect should be evacuated.
Subarachnoid haemorrhage Usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury
Intraventricular haemorrhage Haemorrhage that occurs into the ventricular system of the brain. It is relatively rare in adult surgical practice and when it does occur, it is typically associated with severe head injuries. In premature neonates it may occur spontaneously. The blood may clot and occlude CSF flow, hydrocephalus may result.
In neonatal practice the vast majority of IVH occur in the first 72 hours after birth, the aetiology is not well understood and it is suggested to occur as a result of birth trauma combined with cellular hypoxia, together with the delicate neonatal CNS.
Which of the following statements relating to necrotising enterocolitis is false?
It has a mortality of 30% Most frequently presents in premature neonates less than 32 weeks gestation. Should be managed by early laparotomy and segmental resections in most cases. Pneumostosis intestinalis may be visible on plain abdominal x-ray. May be minimised by use of breast milk over formula feeds.
Most cases will settle with conservative management with NG decompression and appropriate support. Laparotomy should be undertaken in patients who progress despite conservative management or in whom compelling indications for surgery exist (eg free air).
Pyloric stenosis
M>F
5-10% Family history in parents
Projectile non bile stained vomiting at 4-6 weeks of life
Diagnosis is made by test feed or USS
Treatment: Ramstedt pyloromyotomy (open or laparoscopic)
Acute appendicitis
Uncommon under 3 years
When occurs may present atypically
Mesenteric adenitis
Central abdominal pain and URTI
Conservative management
Intussusception
Telescoping bowel
Proximal to or at the level of, ileocaecal valve
6-9 months age
Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool.
Treatment: reduction with air insufflation
Malrotation
High caecum at the midline
Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia
May be complicated by development of volvulus, infant with volvulus may have bile stained vomiting
Diagnosis is made by upper GI contrast study and USS
Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a ladds procedure is performed
Hirschsprung’s disease
Absence of ganglion cells from myenteric and submucosal plexuses
Occurs in 1/5000 births
Full thickness rectal biopsy for diagnosis
Delayed passage of meconium and abdominal distension
Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure
Oesophageal atresia
Associated with tracheo-oesophageal fistula and polyhydramnios
May present with choking and cyanotic spells following aspiration
VACTERL associations
Meconium ileus
Usually delayed passage of meconium and abdominal distension
Majority have cystic fibrosis
X-Rays may not show a fluid level as the meconium is viscid (depends upon feeding), PR contrast studies may dislodge meconium plugs and be therapeutic
Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs
Biliary atresia
Jaundice > 14 days
Increased conjugated bilirubin
Urgent Kasai procedure
Necrotising enterocolitis
Prematurity is the main risk factor
Early features include abdominal distension and passage of bloody stools
X-Rays may show pneumatosis intestinalis and evidence of free air
Increased risk when empirical antibiotics are given to infants beyond 5 days
Treatment is with total gut rest and TPN, babies with perforations will require laparotomy
A 4 year old child presents with a 4-5 day history of feeling generally unwell and also of having a sore throat. On examination, there is marked cervical lymphadenopathy, the oropharynx is covered with a thick grey membrane which bleeds following attempted removal. What is the most likely diagnosis?
Acute streptococcal pharyngitis Infection with Epstein Barr virus Diptheria Ludwigs angina Ingestion of caustic soda
Infection with diphtheria classically causes a systemic illness that lasts several days. The tonsils or pharynx can be covered in a thick grey membrane which bleeds on attempted removal. There is often quite marked cervical adenopathy and some individuals can have a bulls neck appearance. Death can occur through airway compromise, which is why the often described attempted removal of the pseudomembrane so beloved of examiners, is, in practice rather a foolish thing to attempt in a young child!
Acute tonsillitis
Characterised by pharyngitis, fever, malaise and lymphadenopathy.
Over half of all cases are bacterial with Streptococcus pyogenes the most common organism
The tonsils are typically oedematous and yellow or white pustules may be present
Infectious mononucleosis may mimic the condition.
Treatment with penicillin type antibiotics is indicated for bacterial tonsillitis.
Bacterial tonsillitis may result in local abscess formation (quinsy)
A 25 year old cyclist is hit by a bus traveling at 30mph. He is not wearing a helmet. He arrives with a GCS of 3/15 and is intubated. A CT scan shows evidence of cerebral contusion but no localising clinical signs are present
A. Intravenous mannitol B. Parietotemporal craniotomy C. Burr Hole decompression D. Posterior fossa craniotomy E. Insertion of intracranial bolt monitor F. Discharge G. Intravenous frusemide
Insertion of intracranial bolt monitor
This patient may well develop raised ICP over the next few days and Intracranial pressure monitoring will help with management.
Head injury management- NICE Guidelines
Summary of guidelines
All patients should be assessed within 15 minutes on arrival to A&E
Document all 3 components of the GCS
If GCS <8 or = to 8, consider stabilising the airway
Treat pain with low dose IV opiates (if safe)
Full spine immobilisation until assessment if:
- GCS < 15
- neck pain/tenderness
- paraesthesia extremities
- focal neurological deficit
- suspected c-spine injury
If a c-spine injury is suspected a 3 view c-spine x-ray is indicated. CT c-spine is preferred if:
- Intubated
- GCS <13
- Normal x-ray but continued concerns regarding c-spine injury
- Any focal neurology
- A CT head scan is being performed
- Initial plain films are abnormal
Immediate CT head (within 1 hour) if: GCS < 13 on admission GCS < 15 2 hours after admission Suspected open or depressed skull fracture Suspected skull base fracture (panda eyes, Battle's sign, CSF from nose/ear, bleeding ear) Focal neurology Vomiting > 1 episode Post traumatic seizure Coagulopathy
Contact neurosurgeon if: Persistent GCS < 8 or = 8 Unexplained confusion > 4h Reduced GCS after admission Progressive neurological signs Incomplete recovery post seizure Penetrating injury Cerebrospinal fluid leak
Observations
1/2 hourly GCS until 15
A 32 year old rugby player is crushed in a scrum. He is briefly concussed but then regains consciousness. He then collapses and is brought to A+E. His GCS on arrival is 6/15 and his left pupil is dilated.
A. Intravenous mannitol B. Parietotemporal craniotomy C. Burr Hole decompression D. Posterior fossa craniotomy E. Insertion of intracranial bolt monitor F. Discharge G. Intravenous frusemide
Parietotemporal craniotomy
This man needs urgent decompression and extradural haematoma is the most likely event, from a lacerated middle meningeal artery. The debate as to whether Burr Holes or craniotomy is the best option continues. Most neurosurgeons would perform a craniotomy. However, rural units and those units without neurosurgical kit facing this emergency may resort to Burr Holes.
Head injury management- NICE Guidelines
Summary of guidelines
All patients should be assessed within 15 minutes on arrival to A&E
Document all 3 components of the GCS
If GCS <8 or = to 8, consider stabilising the airway
Treat pain with low dose IV opiates (if safe)
Full spine immobilisation until assessment if:
- GCS < 15
- neck pain/tenderness
- paraesthesia extremities
- focal neurological deficit
- suspected c-spine injury
If a c-spine injury is suspected a 3 view c-spine x-ray is indicated. CT c-spine is preferred if:
- Intubated
- GCS <13
- Normal x-ray but continued concerns regarding c-spine injury
- Any focal neurology
- A CT head scan is being performed
- Initial plain films are abnormal
Immediate CT head (within 1 hour) if: GCS < 13 on admission GCS < 15 2 hours after admission Suspected open or depressed skull fracture Suspected skull base fracture (panda eyes, Battle's sign, CSF from nose/ear, bleeding ear) Focal neurology Vomiting > 1 episode Post traumatic seizure Coagulopathy
Contact neurosurgeon if: Persistent GCS < 8 or = 8 Unexplained confusion > 4h Reduced GCS after admission Progressive neurological signs Incomplete recovery post seizure Penetrating injury Cerebrospinal fluid leak
Observations
1/2 hourly GCS until 15
A 30 year old women is injured in a skiing accident. She suffers a blow to the occiput and is concussed for 5 minutes. On arrival in A+E she is confused with GCS 10/15. A CT scan shows no evidence of acute bleed or fracture but some evidence of oedema with the beginnings of mass effect
A. Intravenous mannitol B. Parietotemporal craniotomy C. Burr Hole decompression D. Posterior fossa craniotomy E. Insertion of intracranial bolt monitor F. Discharge G. Intravenous frusemide
Intravenous mannitol
This women has raised ICP and mannitol will help reduce this in the acute phase.
Head injury management- NICE Guidelines
Summary of guidelines
All patients should be assessed within 15 minutes on arrival to A&E
Document all 3 components of the GCS
If GCS <8 or = to 8, consider stabilising the airway
Treat pain with low dose IV opiates (if safe)
Full spine immobilisation until assessment if:
- GCS < 15
- neck pain/tenderness
- paraesthesia extremities
- focal neurological deficit
- suspected c-spine injury
If a c-spine injury is suspected a 3 view c-spine x-ray is indicated. CT c-spine is preferred if:
- Intubated
- GCS <13
- Normal x-ray but continued concerns regarding c-spine injury
- Any focal neurology
- A CT head scan is being performed
- Initial plain films are abnormal
Immediate CT head (within 1 hour) if: GCS < 13 on admission GCS < 15 2 hours after admission Suspected open or depressed skull fracture Suspected skull base fracture (panda eyes, Battle's sign, CSF from nose/ear, bleeding ear) Focal neurology Vomiting > 1 episode Post traumatic seizure Coagulopathy
Contact neurosurgeon if: Persistent GCS < 8 or = 8 Unexplained confusion > 4h Reduced GCS after admission Progressive neurological signs Incomplete recovery post seizure Penetrating injury Cerebrospinal fluid leak
Observations
1/2 hourly GCS until 15
A 25-year-old female with a history of bilateral vitreous haemorrhage is referred with bilateral lesions in the cerebellar region. What is the likely diagnosis?
Neurofibromatosis type I Neurofibromatosis type II Tuberous sclerosis Von Hippel-Lindau syndrome Sarcoidosis
Retinal and cerebellar haemangiomas are key features of Von Hippel-Lindau syndrome. Retinal haemangiomas are bilateral in 25% of patients and may lead to vitreous haemorrhage
on Hippel-Lindau (VHL) syndrome is an autosomal dominant condition predisposing to neoplasia. It is due to an abnormality in the VHL gene located on short arm of chromosome 3
Features
cerebellar haemangiomas
retinal haemangiomas: vitreous haemorrhage
renal cysts (premalignant)
phaeochromocytoma
extra-renal cysts: epididymal, pancreatic, hepatic
endolymphatic sac tumours
The medical team refer a 72 year old lady with a bilateral swollen legs. Deep vein thrombosis has been excluded and there is no response to diuretics. On further questioning, the patient reveals that she was born with the swelling in both of her legs.
A. Milroy's disease B. Meige's disease C. Lymphoedema tarda D. Filariasis E. Tuberculosis F. Locally advanced bladder carcinoma G. Malaria
Milroy’s disease
Milroy’s disease is present from birth and is due to failure of the lymphatic vessels to develop. Note that Meige’s disease develops AFTER birth.
Lymphoedema
Due to impaired lymphatic drainage in the presence of normal capillary function.
Lymphoedema causes the accumulation of protein rich fluid, subdermal fibrosis and dermal thickening.
Characteristically fluid is confined to the epifascial space (skin and subcutaneous tissues); muscle compartments are free of oedema. It involves the foot, unlike other forms of oedema. There may be a ‘buffalo hump’ on the dorsum of the foot and the skin cannot be pinched due to subcutaneous fibrosis.
Causes of lymphoedema
Primary
Congenital < 1 year: sporadic, Milroy’s disease
Onset 1-35 years: sporadic, Meige’s disease
> 35 years: Tarda
Secondary
Bacterial/fungal/parasitic infection (filariasis)
Lymphatic malignancy
Radiotherapy to lymph nodes
Surgical resection of lymph nodes
DVT
Thrombophlebitis
Indications for surgery
Marked disability or deformity from limb swelling
Lymphoedema caused by proximal lymphatic obstruction with patent distal lymphatics suitable for a lymphatic drainage procedure
Lymphocutaneous fistulae and megalymphatics
Procedures
Homans operation Reduction procedure with preservation of overlying skin (which must be in good condition). Skin flaps are raised and the underlying tissue excised. Limb circumference typically reduced by a third.
Charles operation All skin and subcutaneous tissue around the calf are excised down to the deep fascia. Split skin grafts are placed over the site. May be performed if overlying skin is not in good condition. Larger reduction in size than with Homans procedure.
Lymphovenous anastamosis Identifiable lymphatics are anastomosed to sub dermal venules. Usually indicated in 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.
A 52 year old woman presents with rapid swelling of the left leg. The swelling is greater in the thigh compared to the calf.
A. Milroy's disease B. Meige's disease C. Lymphoedema tarda D. Filariasis E. Tuberculosis F. Locally advanced bladder carcinoma G. Malaria
Locally advanced bladder carcinoma
Always consider a malignancy in an older adult with new lymphoedema in a limb, especially if the swelling is greater proximally than distally. If malignancy is excluded consider the diagnosis of lymphoedema tarda.
Lymphoedema
Due to impaired lymphatic drainage in the presence of normal capillary function.
Lymphoedema causes the accumulation of protein rich fluid, subdermal fibrosis and dermal thickening.
Characteristically fluid is confined to the epifascial space (skin and subcutaneous tissues); muscle compartments are free of oedema. It involves the foot, unlike other forms of oedema. There may be a ‘buffalo hump’ on the dorsum of the foot and the skin cannot be pinched due to subcutaneous fibrosis.
Causes of lymphoedema
Primary
Congenital < 1 year: sporadic, Milroy’s disease
Onset 1-35 years: sporadic, Meige’s disease
> 35 years: Tarda
Secondary
Bacterial/fungal/parasitic infection (filariasis)
Lymphatic malignancy
Radiotherapy to lymph nodes
Surgical resection of lymph nodes
DVT
Thrombophlebitis
Indications for surgery
Marked disability or deformity from limb swelling
Lymphoedema caused by proximal lymphatic obstruction with patent distal lymphatics suitable for a lymphatic drainage procedure
Lymphocutaneous fistulae and megalymphatics
Procedures
Homans operation Reduction procedure with preservation of overlying skin (which must be in good condition). Skin flaps are raised and the underlying tissue excised. Limb circumference typically reduced by a third.
Charles operation All skin and subcutaneous tissue around the calf are excised down to the deep fascia. Split skin grafts are placed over the site. May be performed if overlying skin is not in good condition. Larger reduction in size than with Homans procedure.
Lymphovenous anastamosis Identifiable lymphatics are anastomosed to sub dermal venules. Usually indicated in 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.
A 34 year old African teacher attends A&E with a swollen leg. She has been in England for 2 weeks. She lives in an area prevalent with mosquitoes and where there is poor sanitation.
A. Milroy's disease B. Meige's disease C. Lymphoedema tarda D. Filariasis E. Tuberculosis F. Locally advanced bladder carcinoma G. Malaria
Filariasis
Filariasis is caused by the nematode Wuchereria bancrofti, which is mainly spread by mosquito. The oedema can be gross leading to elephantitis. Treatment is with diethylcarbamazine.
Lymphoedema
Due to impaired lymphatic drainage in the presence of normal capillary function.
Lymphoedema causes the accumulation of protein rich fluid, subdermal fibrosis and dermal thickening.
Characteristically fluid is confined to the epifascial space (skin and subcutaneous tissues); muscle compartments are free of oedema. It involves the foot, unlike other forms of oedema. There may be a ‘buffalo hump’ on the dorsum of the foot and the skin cannot be pinched due to subcutaneous fibrosis.
Causes of lymphoedema
Primary
Congenital < 1 year: sporadic, Milroy’s disease
Onset 1-35 years: sporadic, Meige’s disease
> 35 years: Tarda
Secondary
Bacterial/fungal/parasitic infection (filariasis)
Lymphatic malignancy
Radiotherapy to lymph nodes
Surgical resection of lymph nodes
DVT
Thrombophlebitis
Indications for surgery
Marked disability or deformity from limb swelling
Lymphoedema caused by proximal lymphatic obstruction with patent distal lymphatics suitable for a lymphatic drainage procedure
Lymphocutaneous fistulae and megalymphatics
Procedures
Homans operation Reduction procedure with preservation of overlying skin (which must be in good condition). Skin flaps are raised and the underlying tissue excised. Limb circumference typically reduced by a third.
Charles operation All skin and subcutaneous tissue around the calf are excised down to the deep fascia. Split skin grafts are placed over the site. May be performed if overlying skin is not in good condition. Larger reduction in size than with Homans procedure.
Lymphovenous anastamosis Identifiable lymphatics are anastomosed to sub dermal venules. Usually indicated in 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.
A 21 year old post man notices leg pain after 5 minutes walking during his round. It improves 3 minutes after stopping. Clinically he is noted to have reduced hair of the lower limbs and his calf muscles appear atrophied. There is a weak popliteal pulse, but it is still present when the knee is fully extended. What is the most likely diagnosis?
Occlusive arterial disease caused by atherosclerosis Popliteal fossa entrapment Cerebral vascular accident Diabetes mellitus Adductor canal compression syndrome
Adductor canal compression syndrome most commonly presents in young males and is an important differential diagnosis in men presenting with symptoms of acute limb ischaemia on exertion. It is caused by compression of the femoral artery by the musculotendinous band from adductor magnus muscle.
The treatment consists of the division of the abnormal band and restoration of the arterial circulation. Popliteal fossa entrapment is the main differential diagnosis, however the pulse disappears when the knee is fully extended.
Adductor canal
Also called Hunter’s or subsartorial canal
Immediately distal to the apex of the femoral triangle, lying in the middle third of the thigh. Canal terminates at the adductor hiatus.
Borders Contents
Laterally Vastus medialis muscle Saphenous nerve
Posteriorly Adductor longus, adductor magnus Superficial femoral artery
Roof Sartorius Superficial femoral vein
A 18 year old boy is involved in a fall from a balcony whilst intoxicated. He has bruising over the mastoid area and is unconscious.
A. Acute sub dural haematoma B. Intra cerebral haematoma C. Extra dural haematoma D. Chronic sub dural haematoma E. Basal skull fracture F. Subarachnoid haemorrhage G. Diffuse axonal injury
Basal skull fracture
Bruising over the mastoid process of the temporal bone is battle’s sign caused by a basal skull fracture
Head injury
Patients who suffer head injuries should be managed according to ATLS principles and extra cranial injuries should be managed alongside cranial trauma. Inadequate cardiac output will compromise CNS perfusion irrespective of the nature of the cranial injury.
Types of traumatic brain injury
Extradural haematoma Bleeding into the space between the dura mater and the skull. Often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery.
Features
Raised intracranial pressure
Some patients may exhibit a lucid interval
Subdural haematoma Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes. May be either acute or chronic.
Risk factors include old age and alcoholism.
Slower onset of symptoms than a extradural haematoma.
Subarachnoid haemorrhage Usually occurs spontaneously in the context of a ruptured cerebral aneurysm, but may be seen in association with other injuries when a patient has sustained a traumatic brain injury.
Pathophysiology
Primary brain injury may be focal (contusion/ haematoma) or diffuse (diffuse axonal injury)
Diffuse axonal injury occurs as a result of mechanical shearing following deceleration, causing disruption and tearing of axons
Intra-cranial haematomas can be extradural, subdural or intracerebral, while contusions may occur adjacent to (coup) or contralateral (contre-coup) to the side of impact
Secondary brain injury occurs when cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury. The normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia
The Cushings reflex (hypertension and bradycardia) often occurs late and is usually a pre terminal event
Management
Where there is life threatening rising ICP such as in extra dural haematoma and whilst theatre is prepared or transfer arranged use of IV mannitol/ frusemide may be required.
Diffuse cerebral oedema may require decompressive craniotomy
Exploratory Burr Holes have little management in modern practice except where scanning may be unavailable and to thus facilitate creation of formal craniotomy flap
Depressed skull fractures that are open require formal surgical reduction and debridement, closed injuries may be managed non operatively if there is minimal displacement.
ICP monitoring is appropriate in those who have GCS 3-8 and normal CT scan.
ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT scan.
Hyponatraemia is most likely to be due to syndrome of inappropriate ADH secretion.
Minimum of cerebral perfusion pressure of 70mmHg in adults.
Minimum cerebral perfusion pressure of between 40 and 70 mmHg in children.
A 18 year old boy falls off a balcony and hits the right side of the head. He is admitted to the emergency department and has a GCS of 8. He is admitted for observation, and over the following twelve hours develops an increasing headache and confusion. A CT scan shows a crescent shaped collection of fluid between the brain and the dura with associated midline shift.
A. Acute sub dural haematoma B. Intra cerebral haematoma C. Extra dural haematoma D. Chronic sub dural haematoma E. Basal skull fracture F. Subarachnoid haemorrhage G. Diffuse axonal injury
Acute sub dural haematoma
Sub dural haematomas are the commonest intracranial mass lesions resulting from trauma. They are classified as acute, sub acute or chronic according to tempo of onset. Acute sub dural haematomas will present within 72 hours of the original injury and have hyperdense, crescent shaped appearances on CT scanning.
Head injury
Patients who suffer head injuries should be managed according to ATLS principles and extra cranial injuries should be managed alongside cranial trauma. Inadequate cardiac output will compromise CNS perfusion irrespective of the nature of the cranial injury.
Types of traumatic brain injury
Extradural haematoma Bleeding into the space between the dura mater and the skull. Often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery.
Features
Raised intracranial pressure
Some patients may exhibit a lucid interval
Subdural haematoma Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes. May be either acute or chronic.
Risk factors include old age and alcoholism.
Slower onset of symptoms than a extradural haematoma.
Subarachnoid haemorrhage Usually occurs spontaneously in the context of a ruptured cerebral aneurysm, but may be seen in association with other injuries when a patient has sustained a traumatic brain injury.
Pathophysiology
Primary brain injury may be focal (contusion/ haematoma) or diffuse (diffuse axonal injury)
Diffuse axonal injury occurs as a result of mechanical shearing following deceleration, causing disruption and tearing of axons
Intra-cranial haematomas can be extradural, subdural or intracerebral, while contusions may occur adjacent to (coup) or contralateral (contre-coup) to the side of impact
Secondary brain injury occurs when cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury. The normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia
The Cushings reflex (hypertension and bradycardia) often occurs late and is usually a pre terminal event
Management
Where there is life threatening rising ICP such as in extra dural haematoma and whilst theatre is prepared or transfer arranged use of IV mannitol/ frusemide may be required.
Diffuse cerebral oedema may require decompressive craniotomy
Exploratory Burr Holes have little management in modern practice except where scanning may be unavailable and to thus facilitate creation of formal craniotomy flap
Depressed skull fractures that are open require formal surgical reduction and debridement, closed injuries may be managed non operatively if there is minimal displacement.
ICP monitoring is appropriate in those who have GCS 3-8 and normal CT scan.
ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT scan.
Hyponatraemia is most likely to be due to syndrome of inappropriate ADH secretion.
Minimum of cerebral perfusion pressure of 70mmHg in adults.
Minimum cerebral perfusion pressure of between 40 and 70 mmHg in children.
A baby is brought to casualty unconscious and in a vegetative state. She has cigarette burns on her legs.
A. Acute sub dural haematoma B. Intra cerebral haematoma C. Extra dural haematoma D. Chronic sub dural haematoma E. Basal skull fracture F. Subarachnoid haemorrhage G. Diffuse axonal injury
Diffuse axonal injury
The baby is likely to be a victim of shaken baby syndrome. This may result in diffuse axonal injury causing extensive lesions in the white matter.
Head injury
Patients who suffer head injuries should be managed according to ATLS principles and extra cranial injuries should be managed alongside cranial trauma. Inadequate cardiac output will compromise CNS perfusion irrespective of the nature of the cranial injury.
Types of traumatic brain injury
Extradural haematoma Bleeding into the space between the dura mater and the skull. Often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery.
Features
Raised intracranial pressure
Some patients may exhibit a lucid interval
Subdural haematoma Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes. May be either acute or chronic.
Risk factors include old age and alcoholism.
Slower onset of symptoms than a extradural haematoma.
Subarachnoid haemorrhage Usually occurs spontaneously in the context of a ruptured cerebral aneurysm, but may be seen in association with other injuries when a patient has sustained a traumatic brain injury.
Pathophysiology
Primary brain injury may be focal (contusion/ haematoma) or diffuse (diffuse axonal injury)
Diffuse axonal injury occurs as a result of mechanical shearing following deceleration, causing disruption and tearing of axons
Intra-cranial haematomas can be extradural, subdural or intracerebral, while contusions may occur adjacent to (coup) or contralateral (contre-coup) to the side of impact
Secondary brain injury occurs when cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury. The normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia
The Cushings reflex (hypertension and bradycardia) often occurs late and is usually a pre terminal event
Management
Where there is life threatening rising ICP such as in extra dural haematoma and whilst theatre is prepared or transfer arranged use of IV mannitol/ frusemide may be required.
Diffuse cerebral oedema may require decompressive craniotomy
Exploratory Burr Holes have little management in modern practice except where scanning may be unavailable and to thus facilitate creation of formal craniotomy flap
Depressed skull fractures that are open require formal surgical reduction and debridement, closed injuries may be managed non operatively if there is minimal displacement.
ICP monitoring is appropriate in those who have GCS 3-8 and normal CT scan.
ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT scan.
Hyponatraemia is most likely to be due to syndrome of inappropriate ADH secretion.
Minimum of cerebral perfusion pressure of 70mmHg in adults.
Minimum cerebral perfusion pressure of between 40 and 70 mmHg in children.
A 63 year old man presents with a non healing ulcer on his foot. His ABPI measurements are 0.35. A duplex scan shows a 4 cm 90% stenotic lesion of the superficial femoral artery with no distal disease.
A. Femoro-above knee popliteal bypass graft using PTFE
B. Femoro-above knee popliteal bypass graft using long saphenous vein
C. Femoro-distal bypass graft using PTFE
D. Femoro-distal bypass graft using PTFE with Miller Cuff
E. Femoro-distal bypass graft using long saphenous vein
F. Above knee amputation
G. Below knee amputation
H. Angioplasty
Angioplasty
Short occlusions are generally reasonable candidates for primary attempts at angioplasty.
Indications for surgery to revascularise the lower limb Intermittent claudication Critical ischaemia Ulceration Gangrene
Intermittent claudication that is not disabling may provide a relative indication, whilst the other complaints are often absolute indications depending upon the frailty of the patient.
Assessment
Clinical examination
Ankle brachial pressure index measurement
Duplex arterial ultrasound
Angiography (standard, CT or MRI): usually performed only if intervention being considered.
Angioplasty
In order for angioplasty to be undertaken successfully the artery has to be accessible. The lesion relatively short and reasonable distal vessel runoff. Longer lesions may be amenable to sub-intimal angioplasty.
Surgery
Surgery will be undertaken where attempts at angioplasty have either failed or are unsuitable. Bypass essentially involves bypassing the affected arterial segment by utilising a graft to run from above the disease to below the disease. As with angioplasty good runoff improves the outcome.
Some key concepts with bypass surgery
Superficial femoral artery occlusion to the above knee popliteal
In the ideal scenario, vein (either in situ or reversed LSV) would the used as a conduit. However, prosthetic material has reasonable 5 year patency rates and some would advocate using this in preference to vein so that vein can be used for other procedures in the future. In general terms either technique is usually associated with an excellent outcome (if run off satisfactory).
Procedure
Artery dissected out, IV heparin 3,000 units given and then the vessels are cross clamped
Longitudinal arteriotomy
Graft cut to size and tunneled to arteriotomy sites
Anastomosis to femoral artery usually with 5/0 ‘double ended’ Prolene suture
Distal anastomosis usually using 6/0 ‘double ended’ Prolene
Distal disease
Femoro-distal bypass surgery takes longer to perform, is more technically challenging and has higher failure rates.
In elderly diabetic patients with poor runoff a primary amputation may well be a safer and more effective option. There is no point in embarking on this type of surgery in patients who are wheelchair bound.
In femorodistal bypasses vein gives superior outcomes to PTFE.
Rules
Vein mapping 1st to see whether there is suitable vein (the preferred conduit). Sub intimal hyperplasia occurs early when PTFE is used for the distal anastomosis and will lead to early graft occlusion and failure.
Essential operative procedure as for above knee fem-pop.
If there is insufficient vein for the entire conduit then vein can be attached to the end of the PTFE graft and then used for the distal anastomosis. This type of ‘vein boot’ is technically referred to as a Miller Cuff and is associated with better patency rates than PTFE alone.
Remember the more distal the arterial anastomosis the lower the success rate.
A 63 year old man who previously smoked 20 cigarettes a day and has newly diagnosed type II diabetes. He presents with rest pain. A diagnostic angiogram demonstrates occlusion of the distal superficial femoral artery continuing below the knee. He has reasonable posterior tibial artery below this level which branches to give good runoff to the foot. He has varicose veins.
A. Femoro-above knee popliteal bypass graft using PTFE
B. Femoro-above knee popliteal bypass graft using long saphenous vein
C. Femoro-distal bypass graft using PTFE
D. Femoro-distal bypass graft using PTFE with Miller Cuff
E. Femoro-distal bypass graft using long saphenous vein
F. Above knee amputation
G. Below knee amputation
H. Angioplasty
Femoro-distal bypass graft using PTFE with Miller Cuff
This man needs a bypass operation. Using PTFE alone will not give a good result as sub intimal hyperplasia will give poor outcome early. Using a vein cuff (Miller cuff) at the end of a PTFE graft will improve the situation.
Indications for surgery to revascularise the lower limb Intermittent claudication Critical ischaemia Ulceration Gangrene
Intermittent claudication that is not disabling may provide a relative indication, whilst the other complaints are often absolute indications depending upon the frailty of the patient.
Assessment
Clinical examination
Ankle brachial pressure index measurement
Duplex arterial ultrasound
Angiography (standard, CT or MRI): usually performed only if intervention being considered.
Angioplasty
In order for angioplasty to be undertaken successfully the artery has to be accessible. The lesion relatively short and reasonable distal vessel runoff. Longer lesions may be amenable to sub-intimal angioplasty.
Surgery
Surgery will be undertaken where attempts at angioplasty have either failed or are unsuitable. Bypass essentially involves bypassing the affected arterial segment by utilising a graft to run from above the disease to below the disease. As with angioplasty good runoff improves the outcome.
Some key concepts with bypass surgery
Superficial femoral artery occlusion to the above knee popliteal
In the ideal scenario, vein (either in situ or reversed LSV) would the used as a conduit. However, prosthetic material has reasonable 5 year patency rates and some would advocate using this in preference to vein so that vein can be used for other procedures in the future. In general terms either technique is usually associated with an excellent outcome (if run off satisfactory).
Procedure
Artery dissected out, IV heparin 3,000 units given and then the vessels are cross clamped
Longitudinal arteriotomy
Graft cut to size and tunneled to arteriotomy sites
Anastomosis to femoral artery usually with 5/0 ‘double ended’ Prolene suture
Distal anastomosis usually using 6/0 ‘double ended’ Prolene
Distal disease
Femoro-distal bypass surgery takes longer to perform, is more technically challenging and has higher failure rates.
In elderly diabetic patients with poor runoff a primary amputation may well be a safer and more effective option. There is no point in embarking on this type of surgery in patients who are wheelchair bound.
In femorodistal bypasses vein gives superior outcomes to PTFE.
Rules
Vein mapping 1st to see whether there is suitable vein (the preferred conduit). Sub intimal hyperplasia occurs early when PTFE is used for the distal anastomosis and will lead to early graft occlusion and failure.
Essential operative procedure as for above knee fem-pop.
If there is insufficient vein for the entire conduit then vein can be attached to the end of the PTFE graft and then used for the distal anastomosis. This type of ‘vein boot’ is technically referred to as a Miller Cuff and is associated with better patency rates than PTFE alone.
Remember the more distal the arterial anastomosis the lower the success rate.
A wheelchair bound 78 year old women with ischaemic heart disease secondary to long smoking history and longstanding type II diabetes presents with rest pain and a non healing ulcer on the dorsum of her foot. Angiogram shows reasonable superficial femoral artery and iliacs. At the level of the popliteal there is an occlusion. Below this there is a short area of patent posterior tibial and this reconstitutes lower down the leg to flow to the foot.
A. Femoro-above knee popliteal bypass graft using PTFE
B. Femoro-above knee popliteal bypass graft using long saphenous vein
C. Femoro-distal bypass graft using PTFE
D. Femoro-distal bypass graft using PTFE with Miller Cuff
E. Femoro-distal bypass graft using long saphenous vein
F. Above knee amputation
G. Below knee amputation
H. Angioplasty
Above knee amputation
A femoro-distal bypass graft would carry a high risk of failure and risk of peri-operative myocardial infarct. This lady would be well suited to primary amputation.
Indications for surgery to revascularise the lower limb Intermittent claudication Critical ischaemia Ulceration Gangrene
Intermittent claudication that is not disabling may provide a relative indication, whilst the other complaints are often absolute indications depending upon the frailty of the patient.
Assessment
Clinical examination
Ankle brachial pressure index measurement
Duplex arterial ultrasound
Angiography (standard, CT or MRI): usually performed only if intervention being considered.
Angioplasty
In order for angioplasty to be undertaken successfully the artery has to be accessible. The lesion relatively short and reasonable distal vessel runoff. Longer lesions may be amenable to sub-intimal angioplasty.
Surgery
Surgery will be undertaken where attempts at angioplasty have either failed or are unsuitable. Bypass essentially involves bypassing the affected arterial segment by utilising a graft to run from above the disease to below the disease. As with angioplasty good runoff improves the outcome.
Some key concepts with bypass surgery
Superficial femoral artery occlusion to the above knee popliteal
In the ideal scenario, vein (either in situ or reversed LSV) would the used as a conduit. However, prosthetic material has reasonable 5 year patency rates and some would advocate using this in preference to vein so that vein can be used for other procedures in the future. In general terms either technique is usually associated with an excellent outcome (if run off satisfactory).
Procedure
Artery dissected out, IV heparin 3,000 units given and then the vessels are cross clamped
Longitudinal arteriotomy
Graft cut to size and tunneled to arteriotomy sites
Anastomosis to femoral artery usually with 5/0 ‘double ended’ Prolene suture
Distal anastomosis usually using 6/0 ‘double ended’ Prolene
Distal disease
Femoro-distal bypass surgery takes longer to perform, is more technically challenging and has higher failure rates.
In elderly diabetic patients with poor runoff a primary amputation may well be a safer and more effective option. There is no point in embarking on this type of surgery in patients who are wheelchair bound.
In femorodistal bypasses vein gives superior outcomes to PTFE.
Rules
Vein mapping 1st to see whether there is suitable vein (the preferred conduit). Sub intimal hyperplasia occurs early when PTFE is used for the distal anastomosis and will lead to early graft occlusion and failure.
Essential operative procedure as for above knee fem-pop.
If there is insufficient vein for the entire conduit then vein can be attached to the end of the PTFE graft and then used for the distal anastomosis. This type of ‘vein boot’ is technically referred to as a Miller Cuff and is associated with better patency rates than PTFE alone.
Remember the more distal the arterial anastomosis the lower the success rate.
Which of the following does not cause parotid enlargement?
Liver cirrhosis Myxoedema Amiodarone Tuberculosis Sjogrens syndrome
Drugs commonly implicated in parotid gland enlargement include:
Thiouracil, isoprenaline, phenylbutazone, high oestrogen dose contraceptive pills.
Parotid gland clinical
Benign neoplasms
Up to 80% of all salivary gland tumours occur in the parotid gland and up to 80% of these are benign. There is no consistent correlation between the rate of growth and the malignant potential of the lesion. However, benign tumours should not invade structures such as the facial nerve.
With the exception of Warthins tumours, they are commoner in women than men. The median age of developing a lesion is in the 5th decade of life.
Benign tumour types
Benign pleomorphic adenoma or benign mixed tumor Most common parotid neoplasm (80%)
Proliferation of epithelial and myoepithelial cells of the ducts and an increase in stromal components
Slow growing, lobular, and not well encapsulated
Recurrence rate of 1-5% with appropriate excision (parotidectomy)
Recurrence possibly secondary to capsular disruption during surgery
Malignant degeneration occurring in 2-10% of adenomas observed for long periods, with carcinoma ex-pleomorphic adenoma occurring most frequently as adenocarcinoma
Warthin tumor (papillary cystadenoma lymphoma or adenolymphoma) Second most common benign parotid tumor (5%)
Most common bilateral benign neoplasm of the parotid
Marked male as compared to female predominance
Occurs later in life (sixth and seventh decades)
Presents as a lymphocytic infiltrate and cystic epithelial proliferation
May represent heterotopic salivary gland epithelial tissue trapped within intraparotid lymph nodes
Incidence of bilaterality and multicentricity of 10%
Malignant transformation rare (almost unheard of)
Monomorphic adenoma Account for less than 5% of tumours
Slow growing
Consist of only one morphological cell type (hence term mono)
Include; basal cell adenoma, canalicular adenoma, oncocytoma, myoepitheliomas
Haemangioma Should be considered in the differential of a parotid mass in a child
Accounts for 90% of parotid tumours in children less than 1 year of age
Hypervascular on imaging
Spontaneous regression may occur and malignant transformation is almost unheard of
Malignant salivary gland tumours
Mucoepidermoid carcinoma 30% of all parotid malignancies
Usually low potential for local invasiveness and metastasis (depends mainly on grade)
Adenoid cystic carcinoma Unpredictable growth pattern
Tendency for perineural spread
Nerve growth may display skip lesions resulting in incomplete excision
Distant metastasis more common (visceral rather than nodal spread)
5 year survival 35%
Mixed tumours Often a malignancy occurring in a previously benign parotid lesion
Acinic cell carcinoma Intermediate grade malignancy
May show perineural invasion
Low potential for distant metastasis
5 year survival 80%
Adenocarcinoma Develops from secretory portion of gland
Risk of regional nodal and distant metastasis
5 year survival depends upon stage at presentation, may be up to 75% with small lesions with no nodal involvement
Lymphoma Large rubbery lesion, may occur in association with Warthins tumours
Diagnosis should be based on regional nodal biopsy rather than parotid resection
Treatment is with chemotherapy (and radiotherapy)
Diagnostic evaluation
Plain x-rays may be used to exclude calculi
Sialography may be used to delineate ductal anatomy
FNAC is used in most cases
Superficial parotidectomy may be either diagnostic of therapeutic depending upon the nature of the lesion
Where malignancy is suspected the primary approach should be definitive resection rather than excisional biopsy
CT/ MRI may be used in cases of malignancy for staging primary disease
Treatment
For nearly all lesions this consists of surgical resection, for benign disease this will usually consist of a superficial parotidectomy. For malignant disease a radical or extended radical parotidectomy is performed. The facial nerve is included in the resection if involved. The need for neck dissection is determined by the potential for nodal involvement.
Other parotid disorders
HIV infection
Lymphoepithelial cysts associated with HIV occur almost exclusively in the parotid
Typically presents as bilateral, multicystic, symmetrical swelling
Risk of malignant transformation is low and management usually conservative
Sjogren syndrome
Autoimmune disorder characterised by parotid enlargement, xerostomia and keratoconjunctivitis sicca
90% of cases occur in females
Second most common connective tissue disorder
Bilateral, non tender enlargement of the gland is usual
Histologically, the usual findings are of a lymphocytic infiltrate in acinar units and epimyoepithelial islands surrounded by lymphoid stroma
Treatment is supportive
There is an increased risk of subsequent lymphoma
Sarcoid
Parotid involvement occurs in 6% of patients with sarcoid
Bilateral in most cases
Gland is not tender
Xerostomia may occur
Management of isolated parotid disease is usually conservative
At which of the following time frames is secondary haemorrhage most likely to occur following tonsillectomy?
Between 5 and 10 days after surgery During the first 6 hours after surgery Between 6 and 12 hours after surgery Upon resumption of normal feeding Between 2 and 3 days post operatively
Between 5 and 10 days after surgery
Haemorrhage in the first 6 hours after surgery is termed reactionary haemorrhage. Feeding does not increase the risk and may actually lower the risks of infection developing.
Secondary haemorrhage after tonsillectomy
Haemorrhage is a feared complication following tonsillectomy. Primary, or reactionary haemorrhage most commonly occurs in the first 6-8 hours following surgery. It is managed by immediate return to theatre.
Secondary haemorrhage occurs between 5 and 10 days after surgery, it is often associated with a wound infection. Treatment is usually with admission and antibiotics. Severe bleeding may require surgery. Secondary haemorrhage occurs in 3% of all tonsillectomies.
A 6 week old baby boy is brought to the clinic by his mother. She is concerned because although the left testis is present in the scrotum the right testis is absent. She reports that it is sometimes palpable when she bathes the child. on examination the right testis is palpable at the level of the superficial inguinal ring. What is the most appropriate management?
Discharge Re-assess in 5 years Laparoscopy Re-assess in 6 months Orchidopexy
Re-assess in 6 months
Undescended testes are not uncommon in young children. They may be present in 4% of term infants, but only in 1.3% children at 3 months of age. In this scenario the testis is retractile and can be managed expectantly.
Cryptorchidism
A congenital undescended testis is one that has failed to reach the bottom of the scrotum by 3 months of age. At birth up to 5% of boys will have an undescended testis, post natal descent occurs in most and by 3 months the incidence of cryptorchidism falls to 1-2%. In the vast majority of cases the cause of the maldescent is unknown. A proportion may be associated with other congenital defects including:
Patent processus vaginalis Abnormal epididymis Cerebral palsy Mental retardation Wilms tumour Abdominal wall defects (e.g. gastroschisis, prune belly syndrome)
Differential diagnosis
These include retractile testes and, in the case of absent bilateral testes the possibility of intersex conditions. A retractile testis can be brought into the scrotum by the clinician and when released remains in the scrotum. If the examining clinician notes the testis to return rapidly into the inguinal canal when released then surgery is probably indicated.
Reasons for correction of cryptorchidism
Reduce risk of infertility
Allows the testes to be examined for testicular cancer
Avoid testicular torsion
Cosmetic appearance
Males with undescended testis are 40 times as likely to develop testicular cancer (seminoma) as males without undescended testis
The location of the undescended testis affects the relative risk of testicular cancer (50% intra-abdominal testes)
Treatment
Orchidopexy at 6- 18 months of age. The operation usually consists of inguinal exploration, mobilisation of the testis and implantation into a dartos pouch.
Intra-abdominal testis should be evaluated laparoscopically and mobilised. Whether this is a single stage or two stage procedure depends upon the exact location.
After the age of 2 years in untreated individuals the Sertoli cells will degrade and those presenting late in teenage years may be better served by orchidectomy than to try and salvage a non functioning testis with an increased risk of malignancy.
A 28 year old man falls and hits his head against a wall. There is a brief loss of consciousness. When assessed in accident and emergency he is alert and orientated with a GCS of 15, imaging shows no fracture of the skull. What is his risk of having an intracranial haematoma requiring removal?
1 in 6000 1 in 40 1 in 4 1 in 50,000 1 in 120
1 in 6000
Risk of haematoma (requiring removal) in adults attending accident and emergency units following head injury.
- Concussion, no skull fracture Orientated 1 in 6000
- Concussion, no skull fracture Not orientated 1 in 120
- Skull fracture Orientated 1 in 32
- Skull fracture Not orientated 1 in 4
With which of the conditions listed below is Boas’ sign classically associated?
Perforation of the thoracic oesophagus Acute cholecystitis Hepatocellular carcinoma Closed loop small bowel obstruction Acute diverticulitis
Boas’ sign refers to hyperaesthesia of the tip of the right scapula and is seen classically in association with acute cholecystitis.
A number of eponymous abdominal signs are noted. These include:
Rovsings sign- appendicitis
Boas sign -cholecystitis
Murphys sign- cholecystitis
Cullens sign- pancreatitis (other intraabdominal haemorrhage)
Grey-Turners sign- pancreatitis (or other retroperitoneal haemorrhage)
A 56 year old man presents with episodes of pruritus ani and bright red rectal bleeding. On examination there is a mass in the ano rectal region and biopsies confirm squamous cell cancer. What is the most likely cause?
Anal cancer Rectal cancer Soft tissue sarcoma Retro-rectal cyst Pilonidal sinus disease
These are features of anal cancer. Anal cancers arise from the cutaneous epithelium and are therefore typically squamous cell. They are usually sensitive to chemoradiotherapy.
Rectal bleeding is a common cause for patients to be referred to the surgical clinic. In the clinical history it is useful to try and localise the anatomical source of the blood. Bright red blood is usually of rectal anal canal origin, whilst dark red blood is more suggestive of a proximally sited bleeding source. Blood which has entered the GI tract from a gastro-duodenal source will typically resemble malaena due to the effects of the digestive enzymes on the blood itself.
In the table below we give some typical bleeding scenarios together with physical examination findings and causation.
- Fissure in ano Bright red rectal bleeding Painful bleeding that occurs post defecation in small volumes. Usually antecedent features of constipation Muco-epithelial defect usually in the midline posteriorly (anterior fissures more likely to be due to underlying disease)
- Haemorroids Bright red rectal bleeding Post defecation bleeding noted both on toilet paper and drips into pan. May be alteration of bowel habit and history of straining. No blood mixed with stool. No local pain. Normal colon and rectum. Proctoscopy may show internal haemorrhoids. Internal haemorrhoids are usually impalpable.
- Crohns disease Bright red or mixed blood Bleeding that is accompanied by other symptoms such as altered bowel habit, malaise, history of fissures (especially anterior) and abscesses. Perineal inspection may show fissures or fistulae. Proctoscopy may demonstrate indurated mucosa and possibly strictures. Skip lesions may be noted at colonoscopy.
- Ulcerative colitis Bright red bleeding often mixed with stool Diarrhoea, weight loss, nocturnal incontinence, passage of mucous PR. Proctitis is the most marked finding. Peri anal disease is usually absent. Colonoscopy will show continuous mucosal lesion.
- Rectal cancer Bright red blood mixed volumes Alteration of bowel habit. Tenesmus may be present. Symptoms of metastatic disease. Usually obvious mucosal abnormality. Lesion may be fixed or mobile depending upon disease extent. Surrounding mucosa often normal, although polyps may be present.
Investigation
All patients presenting with rectal bleeding require digital rectal examination and procto-sigmoidoscopy as a minimal baseline.
Remember that haemorrhoids are typically impalpable and to attribute bleeding to these in the absence of accurate internal inspection is unsatisfactory.
In young patients with no other concerning features in the history a carefully performed sigmoidoscopy that demonstrates clear haemorrhoidal disease may be sufficient. If clear views cannot be obtained then patients require bowel preparation with an enema and a flexible sigmoidscopy performed.
In those presenting with features of altered bowel habit or suspicion of inflammatory bowel disease a colonoscopy is the best test.
Patients with excessive pain who are suspected of having a fissure may require an examination under general or local anaesthesia.
In young patients with external stigmata of fissure and a compatible history it is acceptable to treat medically and defer internal examination until the fissure is healed. If the fissure fails to heal then internal examination becomes necessary along the lines suggested above to exclude internal disease.
Special tests
In patients with a malignancy of the rectum the staging investigations comprise an MRI of the rectum to identify circumferential resection margin compromise and to identify mesorectal nodal disease. In addition to this CT scanning of the chest abdomen and pelvis is necessary to stage for more distant disease. Some centres will still stage the mesorectum with endo rectal ultrasound but this is becoming far less common.
Patients with fissure in ano who are being considered for surgical sphincterotomy and are females who have an obstetric history should probably have ano rectal manometry testing performed together with endo anal ultrasound. As this service is not universally available it is not mandatory but in the absence of such information there are continence issues that may arise following sphincterotomy.
Management
- Fissure in ano GTN ointment 0.2% or diltiazem cream applied topically is the usual first line treatment. Botulinum toxin for those who fail to respond. Internal sphincterotomy for those who fail with botox, can be considered earlier in males.
- Haemorroids Lifestyle advice, for small internal haemorrhoids can consider injection sclerotherapy or rubber band ligation. For external haemorrhoids consider haemorrhoidectomy. Modern options include HALO procedure and stapled haemorrhoidectomy.
Inflammatory bowel disease Medical management- although surgery may be needed for fistulating Crohns (setons). - Rectal cancer Anterior resection or abdomino-perineal excision of the colon and rectum. Total mesorectal excision is now standard of care. Most resections below the peritoneal reflection will require defunctioning ileostomy. Most patients will require preoperative radiotherapy.
A 52 year old man falls off his bike. He is found to have a pelvic fracture. On examination, he is found to have perineal oedema and on PR the prostate is not palpable. A urine dipstick shows blood. What is the most likely underlying problem?
Bulbar urethral rupture Bladder outflow obstruction Bladder rupture Bladder contusion Membranous urethral rupture
A pelvic fracture and highly displaced prostate should indicate a diagnosis of membranous urethral rupture.
Lower genitourinary tract trauma
Most bladder injuries occur due to blunt trauma
85% associated with pelvic fractures
Easily overlooked during assessment in trauma
Up to 10% of male pelvic fractures are associated with urethral or bladder injuries
Urethral injury Mainly in males Blood at the meatus (50% cases) There are 2 types: i.Bulbar rupture - most common - straddle type injury e.g. bicycles - triad signs: urinary retention, perineal haematoma, blood at the meatus ii. Membranous rupture - can be extra or intraperitoneal - commonly due to pelvic fracture - Penile or perineal oedema/ hematoma - PR: prostate displaced upwards (beware co-existing retroperitoneal haematomas as they may make examination difficult)
- Investigation: ascending urethrogram
- Management: suprapubic catheter (surgical placement, not percutaneously)
External genitalia injuries (i.e., the penis and the scrotum)
Secondary to injuries caused by penetration, blunt trauma, continence- or sexual pleasure-enhancing devices, and mutilation
Bladder injury
rupture is intra or extraperitoneal
presents with haematuria or suprapubic pain
history of pelvic fracture and inability to void: always suspect bladder or urethral injury
inability to retrieve all fluid used to irrigate the bladder through a Foley catheter indicates bladder injury
investigation- IVU or cystogram
management: laparotomy if intraperitoneal, conservative if extraperitoneal
A 43 year old lady presents with 24 hour history of generalised right upper quadrant pain. On admission, she is septic and jaundiced and there is tenderness in the right upper quadrant. What is the most likely diagnosis?
Cholecystitis Cholangitis Gallbladder empyema Gallbladder abscess Liver abscess
A combination of sepsis and jaundice generally favors a diagnosis of cholangitis. Conditions such as empyema may cause sepsis but not marked jaundice, the same is also true of the other differentials listed.
Gallstones
Up to 24% of women and 12% of men may have gallstones. Of these up to 30% may develop local infection and cholecystitis. In patients subjected to surgery 12% will have stones contained within the common bile duct. The majority of gallstones are of a mixed composition (50%) with pure cholesterol stones accounting for 20% of cases.
The aetiology of CBD stones differs in the world, in the West most CBD stones are the result of migration. In the East a far higher proportion arise in the CBD de novo.
The classical symptoms are of colicky right upper quadrant pain that occurs post prandially. The symptoms are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal.
Investigation
In almost all suspected cases the standard diagnostic work up consists of abdominal ultrasound and liver function tests. Of patients who have stones within the bile duct, 60% will have at least one abnormal result on LFT’s. Ultrasound is an important test, but is operator dependent and therefore may occasionally need to be repeated if a negative result is at odds with the clinical picture. Where stones are suspected in the bile duct, the options lie between magnetic resonance cholangiography and intraoperative imaging. The choice between these two options is determined by the skills and experience of the surgeon. The advantages of intra operative imaging are less useful in making therapeutic decisions if the operator is unhappy about proceeding the bile duct exploration, and in such circumstances pre operative MRCP is probably a better option.
Biliary colic Colicky abdominal pain, worse post prandially, worse after fatty foods If imaging shows gallstones and history compatible then laparoscopic cholecystectomy
Acute cholecystitis
Right upper quadrant pain
Fever
Murphys sign on examination
Occasionally mildly deranged LFT’s (especially if Mirizzi syndrome)
Imaging (USS) and cholecystectomy (ideally within 48 hours of presentation) (2)
Gallbladder abscess
Usually prodromal illness and right upper quadrant pain
Swinging pyrexia
Patient may be systemically unwell
Generalised peritonism not present
Imaging with USS +/- CT Scanning
Ideally surgery, sub total cholecystectomy may be needed if Calots triangle is hostile
In unfit patients percutaneous drainage may be considered
Cholangitis Patient severely septic and unwell Jaundice Right upper quadrant pain Fluid resuscitation Broad spectrum intravenous antibiotics Correct any coagulopathy Early ERCP
Gallstone ileus
Patients may have a history of previous cholecystitis and known gallstones
Small bowel obstruction (may be intermittent)
Laparotomy and removal of gallstone from small bowel, the enterotomy must be made proximal to the site of obstruction and not at the site of obstruction. The fistula between the gallbladder and duodenum should not be interfered with.
Acalculous cholecystitis
Patients with inter current illness (e.g. diabetes, organ failure)
Patient of systemically unwell
Gallbladder inflammation in absence of stones
High fever
If patient fit then cholecystectomy, if unfit then percutaneous cholecystostomy
Treatment
Patients with asymptomatic gallstones rarely develop symptoms related to them (less than 2% per year) and may therefore be managed expectantly. In almost all cases of symptomatic gallstones the treatment of choice is cholecystectomy performed via the laparoscopic route. In the very frail patient there is sometimes a role for selective use of ultrasound guided cholecystostomy.
During the course of the procedure some surgeons will routinely perform either intra operative cholangiography or laparoscopic USS to either confirm anatomy or to exclude CBD stones. The latter may be more easily achieved by use of laparoscopic ultrasound. If stones are found then the options lie between early ERCP in the day or so following surgery or immediate surgical exploration of the bile duct. When performed via the trans cystic route this adds little in the way of morbidity and certainly results in faster recovery. Where transcystic exploration fails the alternative strategy is that of formal choledochotomy. The exploration of a small duct is challenging and ducts of less than 8mm should not be explored. Small stones that measure less than 5mm may be safely left and most will pass spontaneously.
Risks of ERCP Bleeding 0.9% (rises to 1.5% if sphincterotomy performed) Duodenal perforation 0.4% Cholangitis 1.1% Pancreatitis 1.5%
A 23 year old lady is admitted with right upper quadrant pain. On examination, she is tender in the right upper quadrant. Imaging shows signs of acute cholecystitis due to gallstones. The CBD appears normal. Liver function tests are normal. What is the most appropriate course of action?
Laparoscopic cholecystectomy during the next 24-48 hours Open cholecystectomy during the next 24-48 hours Laparoscopic cholecystectomy 3 months following resolution of the attack Open cholecystectomy 3 months following the attack Laparoscopic cholecystectomy after 5 days of intravenous antibiotics
In most cases the treatment of choice for acute cholecystitis is an acute cholecystectomy performed early in the illness. Delayed surgery particularly around 5- 7 days after presentation is much more technically challenging and is often best deferred. In most cases the procedure can be performed laparoscopically, even when acute inflammation is present.
Up to 24% of women and 12% of men may have gallstones. Of these up to 30% may develop local infection and cholecystitis. In patients subjected to surgery 12% will have stones contained within the common bile duct. The majority of gallstones are of a mixed composition (50%) with pure cholesterol stones accounting for 20% of cases.
The aetiology of CBD stones differs in the world, in the West most CBD stones are the result of migration. In the East a far higher proportion arise in the CBD de novo.
The classical symptoms are of colicky right upper quadrant pain that occurs post prandially. The symptoms are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal.
Investigation
In almost all suspected cases the standard diagnostic work up consists of abdominal ultrasound and liver function tests. Of patients who have stones within the bile duct, 60% will have at least one abnormal result on LFT’s. Ultrasound is an important test, but is operator dependent and therefore may occasionally need to be repeated if a negative result is at odds with the clinical picture. Where stones are suspected in the bile duct, the options lie between magnetic resonance cholangiography and intraoperative imaging. The choice between these two options is determined by the skills and experience of the surgeon. The advantages of intra operative imaging are less useful in making therapeutic decisions if the operator is unhappy about proceeding the bile duct exploration, and in such circumstances pre operative MRCP is probably a better option.
Specific gallstone and gallbladder related disease
Disease Features Management
Biliary colic Colicky abdominal pain, worse post prandially, worse after fatty foods If imaging shows gallstones and history compatible then laparoscopic cholecystectomy
Acute cholecystitis
Right upper quadrant pain
Fever
Murphys sign on examination
Occasionally mildly deranged LFT’s (especially if Mirizzi syndrome)
Imaging (USS) and cholecystectomy (ideally within 48 hours of presentation) (2)
Gallbladder abscess
Usually prodromal illness and right upper quadrant pain
Swinging pyrexia
Patient may be systemically unwell
Generalised peritonism not present
Imaging with USS +/- CT Scanning
Ideally surgery, sub total cholecystectomy may be needed if Calots triangle is hostile
In unfit patients percutaneous drainage may be considered
Cholangitis
Patient severely septic and unwell
Jaundice
Right upper quadrant pain
Fluid resuscitation
Broad spectrum intravenous antibiotics
Correct any coagulopathy
Early ERCP
Gallstone ileus
Patients may have a history of previous cholecystitis and known gallstones
Small bowel obstruction (may be intermittent)
Laparotomy and removal of gallstone from small bowel, the enterotomy must be made proximal to the site of obstruction and not at the site of obstruction. The fistula between the gallbladder and duodenum should not be interfered with.
Acalculous cholecystitis
Patients with inter current illness (e.g. diabetes, organ failure)
Patient of systemically unwell
Gallbladder inflammation in absence of stones
High fever
If patient fit then cholecystectomy, if unfit then percutaneous cholecystostomy
Treatment
Patients with asymptomatic gallstones rarely develop symptoms related to them (less than 2% per year) and may therefore be managed expectantly. In almost all cases of symptomatic gallstones the treatment of choice is cholecystectomy performed via the laparoscopic route. In the very frail patient there is sometimes a role for selective use of ultrasound guided cholecystostomy.
During the course of the procedure some surgeons will routinely perform either intra operative cholangiography or laparoscopic USS to either confirm anatomy or to exclude CBD stones. The latter may be more easily achieved by use of laparoscopic ultrasound. If stones are found then the options lie between early ERCP in the day or so following surgery or immediate surgical exploration of the bile duct. When performed via the trans cystic route this adds little in the way of morbidity and certainly results in faster recovery. Where transcystic exploration fails the alternative strategy is that of formal choledochotomy. The exploration of a small duct is challenging and ducts of less than 8mm should not be explored. Small stones that measure less than 5mm may be safely left and most will pass spontaneously.
Risks of ERCP(1) Bleeding 0.9% (rises to 1.5% if sphincterotomy performed) Duodenal perforation 0.4% Cholangitis 1.1% Pancreatitis 1.5%
A 52 year old woman with known Hashimotos thyroiditis presents with a neck swelling. She describes it as rapidly increasing in size over 3 months and she complains of dysphagia to solids. On examination, there is an asymmetrical swelling of the thyroid gland. What is the most likely diagnosis?
Anaplastic thyroid cancer Follicular thyroid cancer Papillary thyroid cancer Lymphoma Toxic adenoma
Thyroid lymphoma (Non Hodgkin’s B cell lymphoma) is rare. It should be considered in patients with a background of Hashimoto’s thyroiditis and a rapid growth in size of the thyroid gland. Diagnosis can be made with core needle biopsy; however an incisional biopsy may be needed. Radiotherapy is the main treatment option.
Thyroiditis
Sub acute thyroiditis
Subacute thyroiditis (also known as De Quervain’s thyroiditis) is thought to occur following viral infection and typically presents with hyperthyroidism
Features Hyperthyroidism Painful goitre Raised ESR Globally reduced uptake on iodine-131 scan
Management
Usually self-limiting - most patients do not require treatment
Thyroid pain may respond to aspirin or other NSAIDs
In more severe cases steroids are used, particularly if hypothyroidism develops
Hashimotos thyroiditis
Hashimotos thyroiditis is an immunological disorder in which lymphocytes become sensitised to thyroidal antigens. The three most important antibodies include; thyroglobulin, TPO and TSH-R. During the early phase of Hashimotos the the thyroglobulin antibody is markedly elevated and then declines.
Features
Goitre and either euthyroid or mild hypothyroidism
Progressive hypothyroidism (and associated symptoms)
Management
During the hyperthyroid phase of illness beta blockers may manage symptoms
As hypothyroidism develops patients may require thyroxine
A 34 year old female presents with a thyroid nodule. She has a family history of thyroid disease and both her sisters have undergone total thyroidectomies. Her past medical history includes hypertension which has been difficult to manage. What is the most likely underlying thyroid lesion?
Papillary thyroid cancer Follicular adenoma Medullary thyroid cancer Anaplastic thyroid cancer Lymphoma of the thyroid
This is a typical scenario for medullary carcinoma in which a phaeochromocytoma may also be present. It may be inherited in an autosomal dominant fashion and affected family members may be offered prophylactic thyroidectomy.
Thyroid disease
Patients may present with a number of different manifestations of thyroid disease. They can be broadly sub classified according to whether they are euthyroid or have clinical signs of thyroid dysfunction. In addition it needs to be established whether they have a mass or not.
Assessment
History
Examination including USS
If a nodule is identified then it should be sampled ideally via an image guided fine needle aspiration
Radionucleotide scanning is of limited use
Thyroid Tumours Papillary carcinoma Follicular carcinoma Anaplastic carcinoma Medullary carcinoma Lymphoma's
Multinodular goitre
One of the most common reasons for presentation
Provided the patient is euthyroid and asymptomatic and no discrete nodules are seen, they can be reassured.
In those with compressive symptoms surgery is required and the best operation is a total thyroidectomy.
Sub total resections were practised in the past and simply result in recurrent disease that requires a difficult revisional resection.
Endocrine dysfunction
In general these patients are managed by physicians initially.
Surgery may be offered alongside radio iodine for patients with Graves disease that fails with medical management or in patients who would prefer not to be irradiated (e.g. pregnant women).
Patients with hypothyroidism do not generally get offered a thyroidectomy. Sometimes people inadvertently get offered resections during the early phase of Hashimotos thyroiditis, however, with time the toxic phase passes and patients can simply be managed with thyroxine.
Complications following surgery
Anatomical such as recurrent laryngeal nerve damage.
Bleeding. Owing to the confined space haematoma’s may rapidly lead to respiratory compromise owing to laryngeal oedema.
Damage to the parathyroid glands resulting in hypocalcaemia.
A 29 year old man presents to the clinic with a recurrent thyroid cyst. It has been drained now on three occasions. Each time the cyst is aspirated and cytology is reassuring. What is the most appropriate course of action?
Reassure and discharge Resection of the ipsilateral thyroid lobe Enucleation of the cyst Total thyroidectomy Radio-isotope scan
Persist refilling cysts may be associated with a well differentiated tumour and should be removed by lobectomy.
Large multinodular goitre Surgery for pressure symptoms. Total thyroidectomy is treatment of choice
Toxic nodule Hemithyroidectomy
Follicular lesion (THY 3f) Hemithyroidectomy to establish diagnosis
Papillary thyroid cancer Total thyroidectomy and central compartment nodal dissection (extended lymphadenectomy as required)
Follicular thyroid cancer Total thyroidectomy (usually completion as already had hemithyroidectomy)
Anaplastic thyroid cancer Palliative radiotherapy
Medullary thyroid cancer Total thyroidectomy (screen for other MEN tumours)
Lymphoma of the thyroid Consider core biopsy
Persistent refilling cysts Hemithyroidectomy
Graves disease with significant eye signs Total thyroidectomy
Graves disease without significant eye signs Patient choice radioiodine Vs surgery
A 22 year old man presents with a 6 day history of passage of bloody diarrhoea with passage of mucous and slime. He is passing an average of 8 to 9 bowel movements per day. On digital rectal examination there is no discrete abnormality to feel, but there is some blood stained mucous on the glove. What is the most likely diagnosis?
Solitary rectal ulcer syndrome Ulcerative colitis Irritable bowel syndrome Rectal cancer Diverticulitis
The passage of bloody diarrhoea together with mucus and a short history makes this a likely first presentation of inflammatory bowel disease. A rectal malignancy in a 22 year old would be a very unlikely event. The history is too short to be consistent with solitary rectal ulcer.
Rectal bleeding is a common cause for patients to be referred to the surgical clinic. In the clinical history it is useful to try and localise the anatomical source of the blood. Bright red blood is usually of rectal anal canal origin, whilst dark red blood is more suggestive of a proximally sited bleeding source. Blood which has entered the GI tract from a gastro-duodenal source will typically resemble malaena due to the effects of the digestive enzymes on the blood itself.
Fissure in ano Bright red rectal bleeding Painful bleeding that occurs post defecation in small volumes. Usually antecedent features of constipation Muco-epithelial defect usually in the midline posteriorly (anterior fissures more likely to be due to underlying disease)
Haemorroids Bright red rectal bleeding Post defecation bleeding noted both on toilet paper and drips into pan. May be alteration of bowel habit and history of straining. No blood mixed with stool. No local pain. Normal colon and rectum. Proctoscopy may show internal haemorrhoids. Internal haemorrhoids are usually impalpable.
Crohns disease Bright red or mixed blood Bleeding that is accompanied by other symptoms such as altered bowel habit, malaise, history of fissures (especially anterior) and abscesses. Perineal inspection may show fissures or fistulae. Proctoscopy may demonstrate indurated mucosa and possibly strictures. Skip lesions may be noted at colonoscopy.
Ulcerative colitis Bright red bleeding often mixed with stool Diarrhoea, weight loss, nocturnal incontinence, passage of mucous PR. Proctitis is the most marked finding. Peri anal disease is usually absent. Colonoscopy will show continuous mucosal lesion.
Rectal cancer Bright red blood mixed volumes Alteration of bowel habit. Tenesmus may be present. Symptoms of metastatic disease. Usually obvious mucosal abnormality. Lesion may be fixed or mobile depending upon disease extent. Surrounding mucosa often normal, although polyps may be present.
Investigation
All patients presenting with rectal bleeding require digital rectal examination and procto-sigmoidoscopy as a minimal baseline.
Remember that haemorrhoids are typically impalpable and to attribute bleeding to these in the absence of accurate internal inspection is unsatisfactory.
In young patients with no other concerning features in the history a carefully performed sigmoidoscopy that demonstrates clear haemorrhoidal disease may be sufficient. If clear views cannot be obtained then patients require bowel preparation with an enema and a flexible sigmoidscopy performed.
In those presenting with features of altered bowel habit or suspicion of inflammatory bowel disease a colonoscopy is the best test.
Patients with excessive pain who are suspected of having a fissure may require an examination under general or local anaesthesia.
In young patients with external stigmata of fissure and a compatible history it is acceptable to treat medically and defer internal examination until the fissure is healed. If the fissure fails to heal then internal examination becomes necessary along the lines suggested above to exclude internal disease.
Special tests
In patients with a malignancy of the rectum the staging investigations comprise an MRI of the rectum to identify circumferential resection margin compromise and to identify mesorectal nodal disease. In addition to this CT scanning of the chest abdomen and pelvis is necessary to stage for more distant disease. Some centres will still stage the mesorectum with endo rectal ultrasound but this is becoming far less common.
Patients with fissure in ano who are being considered for surgical sphincterotomy and are females who have an obstetric history should probably have ano rectal manometry testing performed together with endo anal ultrasound. As this service is not universally available it is not mandatory but in the absence of such information there are continence issues that may arise following sphincterotomy.
Management
Fissure in ano GTN ointment 0.2% or diltiazem cream applied topically is the usual first line treatment. Botulinum toxin for those who fail to respond. Internal sphincterotomy for those who fail with botox, can be considered earlier in males.
Haemorroids Lifestyle advice, for small internal haemorrhoids can consider injection sclerotherapy or rubber band ligation. For external haemorrhoids consider haemorrhoidectomy. Modern options include HALO procedure and stapled haemorrhoidectomy.
Inflammatory bowel disease Medical management- although surgery may be needed for fistulating Crohns (setons).
Rectal cancer Anterior resection or abdomino-perineal excision of the colon and rectum. Total mesorectal excision is now standard of care. Most resections below the peritoneal reflection will require defunctioning ileostomy. Most patients will require preoperative radiotherapy.
In which of the conditions described below is Rovsing’s sign most likely to be absent?
Locally advanced caecal cancer Para ileal appendicitis Right sided colonic diverticulitis Retrocaecal appendicitis Severe terminal ileal Crohns disease
Any advanced right iliac fossa pathology can result in a positive Rovsings sign. However, in retrocaecal appendicitis, it may be absent and this fact can contribute to a delayed diagnosis if undue weight is placed on the presence of the sign in making the diagnosis.
Rovsings sign- appendicitis
Boas sign -cholecystitis
Murphys sign- cholecystitis
Cullens sign- pancreatitis (other intraabdominal haemorrhage)
Grey-Turners sign- pancreatitis (or other retroperitoneal haemorrhage)
An 8 year old boy presents with a 4 hour history of right iliac fossa pain with nausea and vomiting. He has been back at school for two days after being kept home with a flu like illness. On examination, he is tender in the right iliac fossa, although his abdomen is soft. Temperature is 39.3oC. Blood tests show a CRP of 40 and a WCC of 8.1. What is the most appropriate course of action?
Abdominal MRI scan Abdominal CT scan Diagnostic laparoscopy Active observation Colonoscopy
The key point in the history is the preceding flu like illness and absence of abdominal signs. These make mesenteric adenitis the most likely diagnosis. The patient should have a period of active observation, if this were to represent early appendicitis, then the clinical picture may change and this would be detected with serial examination.
Appendicitis Pain radiating to right iliac fossa Anorexia (very common) Short history Diarrhoea and profuse vomiting rare Crohn's disease Often long history Signs of malnutrition Change in bowel habit, especially diarrhoea
Mesenteric adenitis
Mainly affects children
Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp.
Patients have a higher temperature than those with appendicitis
If laparotomy is performed, enlarged mesenteric lymph nodes will be present
Diverticulitis
Both left and right sided disease may present with right iliac fossa pain
Clinical history may be similar, although some change in bowel habit is usual
When suspected, a CT scan may help in refining the diagnosis
Meckel’s diverticulitis
A Meckel’s diverticulum is a congenital abnormality that is present in about 2% of the population
Typically 2 feet proximal to the ileocaecal valve
May be lined by ectopic gastric mucosal tissue and produce bleeding
Perforated peptic ulcer
This usually produces upper quadrant pain but pain may be lower
Perforations typically have a sharp sudden onset of pain in the history
Incarcerated right inguinal or femoral hernia
Usually only right iliac fossa pain if right sided or bowel obstruction.
Bowel perforation secondary to caecal or colon carcinoma
Seldom localised to right iliac fossa, although complete large bowel obstruction with caecal distension may cause pain prior to perforation.
Gynaecological causes
Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian torsion/Threatened or complete abortion/Mittelschmerz
Urological causes
Ureteric colic/UTI/Testicular torsion
Other causes
TB/Typhoid/Herpes Zoster/AAA/Situs inversus
A 6 day old child is suspected of having a malrotation and requires urgent abdominal exploration. What is the most appropriate surgical approach?
Midline abdominal incision Paramedian incision Transverse supra umbilical abdominal incision Transverse infra umbilical abdominal incision Battle incision
In young children, laparotomy is performed via transverse supra umbilical incision. Access via midline incisions is very poor and they should not be used.
Midline incision
Commonest approach to the abdomen
Structures divided: linea alba, transversalis fascia, extraperitoneal fat, peritoneum (avoid falciform ligament above the umbilicus)
Bladder can be accessed via an extraperitoneal approach through the space of Retzius
Paramedian incision
Parallel to the midline (about 3-4cm)
Structures divided/retracted: anterior rectus sheath, rectus (retracted), posterior rectus sheath, transversalis fascia, extraperitoneal fat, peritoneum
Incision is closed in layers
Battle
Similar location to paramedian but rectus displaced medially (and thus denervated)
Now seldom used
Kocher’s Incision under right subcostal margin e.g. Cholecystectomy (open)
Lanz Incision in right iliac fossa e.g. Appendicectomy
Gridiron Oblique incision centered over McBurneys point- usually appendicectomy (less cosmetically acceptable than Lanz
Gable Rooftop incision
Pfannenstiel’s Transverse supra pubic, primarily used to access pelvic organs
McEvedy’s Groin incision e.g. Emergency repair strangulated femoral hernia
Rutherford Morrison Extraperitoneal approach to left or right lower quadrants. Gives excellent access to iliac vessels and is the approach of choice for first time renal transplantation.
A 14 year old female is admitted with sudden onset right iliac fossa pain. She is otherwise well and on examination has some right iliac fossa tenderness but no guarding. She is afebrile. Urinary dipstick is normal. Her previous menstrual period two weeks ago was normal and pregnancy test is negative. What is the most likely underlying diagnosis?
Mittelschmerz Endometriosis Appendicitis Crohns disease Pelvic abscess
The timing of the pain and the fact that it is mid cycle makes Mittelschmerz the most likely cause. When follicular cysts rupture, there is sometimes associated bleeding of small volume. The cyst contents and blood if present can be very irritant and pain can sometimes mimic appendicitis or pelvic inflammatory disease. However, normal inflammatory markers makes the former less likely and unless the 14 year old was sexually active, PID is also relatively rare in this group. Crohns disease and pelvic abscesses would typically present with a more protracted history and raised inflammatory markers and fever.
Appendicitis Pain radiating to right iliac fossa Anorexia (very common) Short history Diarrhoea and profuse vomiting rare
Crohn’s disease
Often long history
Signs of malnutrition
Change in bowel habit, especially diarrhoea
Mesenteric adenitis
Mainly affects children
Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp.
Patients have a higher temperature than those with appendicitis
If laparotomy is performed, enlarged mesenteric lymph nodes will be present
Diverticulitis
Both left and right sided disease may present with right iliac fossa pain
Clinical history may be similar, although some change in bowel habit is usual
When suspected, a CT scan may help in refining the diagnosis
Meckel’s diverticulitis
A Meckel’s diverticulum is a congenital abnormality that is present in about 2% of the population
Typically 2 feet proximal to the ileocaecal valve
May be lined by ectopic gastric mucosal tissue and produce bleeding
Perforated peptic ulcer
This usually produces upper quadrant pain but pain may be lower
Perforations typically have a sharp sudden onset of pain in the history
Incarcerated right inguinal or femoral hernia
Usually only right iliac fossa pain if right sided or bowel obstruction.
Bowel perforation secondary to caecal or colon carcinoma
Seldom localised to right iliac fossa, although complete large bowel obstruction with caecal distension may cause pain prior to perforation.
Gynaecological causes
Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian torsion/Threatened or complete abortion/Mittelschmerz
Urological causes
Ureteric colic/UTI/Testicular torsion
Other causes
TB/Typhoid/Herpes Zoster/AAA/Situs inversus
A 56 year old man is involved in a road traffic accident. He is found to have a pelvic fracture. He reports that he has some lower abdominal pain. He has peritonism in the lower abdomen. The nursing staff report that he has not passed any urine. A CT scan shows evidence of free fluid. What is the most likely diagnosis?
Membranous urethral injury Bladder rupture Bladder contusion Bulbar urethral injury Urinary tract infection
A pelvic fracture and lower abdominal peritonism should raise suspicions of bladder rupture (especially as this man cannot pass urine).
Lower genitourinary tract trauma
Most bladder injuries occur due to blunt trauma
85% associated with pelvic fractures
Easily overlooked during assessment in trauma
Up to 10% of male pelvic fractures are associated with urethral or bladder injuries
Urethral injury Mainly in males Blood at the meatus (50% cases) There are 2 types: i.Bulbar rupture - most common - straddle type injury e.g. bicycles - triad signs: urinary retention, perineal haematoma, blood at the meatus ii. Membranous rupture - can be extra or intraperitoneal - commonly due to pelvic fracture - Penile or perineal oedema/ hematoma - PR: prostate displaced upwards (beware co-existing retroperitoneal haematomas as they may make examination difficult)
- Investigation: ascending urethrogram
- Management: suprapubic catheter (surgical placement, not percutaneously)
External genitalia injuries (i.e., the penis and the scrotum)
Secondary to injuries caused by penetration, blunt trauma, continence- or sexual pleasure-enhancing devices, and mutilation
Bladder injury
rupture is intra or extraperitoneal
presents with haematuria or suprapubic pain
history of pelvic fracture and inability to void: always suspect bladder or urethral injury
inability to retrieve all fluid used to irrigate the bladder through a Foley catheter indicates bladder injury
investigation- IVU or cystogram
management: laparotomy if intraperitoneal, conservative if extraperitoneal
What is the most likely explanation for a 63 year old male to complain of a painless blood stained mucous rectal discharge 6 months following a Hartmann’s procedure?
Pelvic abscess Crohns disease Dysplasia of the rectal stump Diversion proctitis Fissure in ano
Once the bowel has been disconnected, a degree of inflammation is commonly seen in the quiescent bowel. This is typically referred to as diversion colitis. Dysplasia is not usually seen in this context as a Hartmanns procedure is not usually a treatment modality used for IBD (which is the main risk factor for dysplasia).
Rectal bleeding is a common cause for patients to be referred to the surgical clinic. In the clinical history it is useful to try and localise the anatomical source of the blood. Bright red blood is usually of rectal anal canal origin, whilst dark red blood is more suggestive of a proximally sited bleeding source. Blood which has entered the GI tract from a gastro-duodenal source will typically resemble malaena due to the effects of the digestive enzymes on the blood itself.
- Fissure in ano Bright red rectal bleeding Painful bleeding that occurs post defecation in small volumes. Usually antecedent features of constipation Muco-epithelial defect usually in the midline posteriorly (anterior fissures more likely to be due to underlying disease)
- Haemorroids Bright red rectal bleeding Post defecation bleeding noted both on toilet paper and drips into pan. May be alteration of bowel habit and history of straining. No blood mixed with stool. No local pain. Normal colon and rectum. Proctoscopy may show internal haemorrhoids. Internal haemorrhoids are usually impalpable.
- Crohns disease Bright red or mixed blood Bleeding that is accompanied by other symptoms such as altered bowel habit, malaise, history of fissures (especially anterior) and abscesses. Perineal inspection may show fissures or fistulae. Proctoscopy may demonstrate indurated mucosa and possibly strictures. Skip lesions may be noted at colonoscopy.
- Ulcerative colitis Bright red bleeding often mixed with stool Diarrhoea, weight loss, nocturnal incontinence, passage of mucous PR. Proctitis is the most marked finding. Peri anal disease is usually absent. Colonoscopy will show continuous mucosal lesion.
- Rectal cancer Bright red blood mixed volumes Alteration of bowel habit. Tenesmus may be present. Symptoms of metastatic disease. Usually obvious mucosal abnormality. Lesion may be fixed or mobile depending upon disease extent. Surrounding mucosa often normal, although polyps may be present.
Investigation
All patients presenting with rectal bleeding require digital rectal examination and procto-sigmoidoscopy as a minimal baseline.
Remember that haemorrhoids are typically impalpable and to attribute bleeding to these in the absence of accurate internal inspection is unsatisfactory.
In young patients with no other concerning features in the history a carefully performed sigmoidoscopy that demonstrates clear haemorrhoidal disease may be sufficient. If clear views cannot be obtained then patients require bowel preparation with an enema and a flexible sigmoidscopy performed.
In those presenting with features of altered bowel habit or suspicion of inflammatory bowel disease a colonoscopy is the best test.
Patients with excessive pain who are suspected of having a fissure may require an examination under general or local anaesthesia.
In young patients with external stigmata of fissure and a compatible history it is acceptable to treat medically and defer internal examination until the fissure is healed. If the fissure fails to heal then internal examination becomes necessary along the lines suggested above to exclude internal disease.
Special tests
In patients with a malignancy of the rectum the staging investigations comprise an MRI of the rectum to identify circumferential resection margin compromise and to identify mesorectal nodal disease. In addition to this CT scanning of the chest abdomen and pelvis is necessary to stage for more distant disease. Some centres will still stage the mesorectum with endo rectal ultrasound but this is becoming far less common.
Patients with fissure in ano who are being considered for surgical sphincterotomy and are females who have an obstetric history should probably have ano rectal manometry testing performed together with endo anal ultrasound. As this service is not universally available it is not mandatory but in the absence of such information there are continence issues that may arise following sphincterotomy.
Management
Fissure in ano GTN ointment 0.2% or diltiazem cream applied topically is the usual first line treatment. Botulinum toxin for those who fail to respond. Internal sphincterotomy for those who fail with botox, can be considered earlier in males.
Haemorroids Lifestyle advice, for small internal haemorrhoids can consider injection sclerotherapy or rubber band ligation. For external haemorrhoids consider haemorrhoidectomy. Modern options include HALO procedure and stapled haemorrhoidectomy.
Inflammatory bowel disease Medical management- although surgery may be needed for fistulating Crohns (setons).
Rectal cancer Anterior resection or abdomino-perineal excision of the colon and rectum. Total mesorectal excision is now standard of care. Most resections below the peritoneal reflection will require defunctioning ileostomy. Most patients will require preoperative radiotherapy.
Which abdominal sign is described as being present when a patient with cholecystitis experiences pain on palpation of the right upper quadrant most marked on inspiration?
Murphy's sign Boas' sign Rovsing's sign Cullens sign Grey Turners sign
Murphy’s sign
Rovsings sign- appendicitis
Boas sign -cholecystitis
Murphys sign- cholecystitis
Cullens sign- pancreatitis (other intraabdominal haemorrhage)
Grey-Turners sign- pancreatitis (or other retroperitoneal haemorrhage)
A 19 year old man presents with diarrhea and rectal bleeding that has been present for the past two weeks. In addition, he has noticed that he has had incontinence at night. What is the most likely cause?
Viral gastroenteritis Inflammatory bowel disease Intersphincteric abscess Irritable bowel syndrome and haemorrhoids Irritable bowel syndrome and a fissure in ano
Nocturnal diarrhea and incontinence is a key feature in the history and is strongly suggestive of a diagnosis of IBD. More benign IBS presentations seldom have nocturnal events or a short history.
Rectal bleeding is a common cause for patients to be referred to the surgical clinic. In the clinical history it is useful to try and localise the anatomical source of the blood. Bright red blood is usually of rectal anal canal origin, whilst dark red blood is more suggestive of a proximally sited bleeding source. Blood which has entered the GI tract from a gastro-duodenal source will typically resemble malaena due to the effects of the digestive enzymes on the blood itself.
- Fissure in ano Bright red rectal bleeding Painful bleeding that occurs post defecation in small volumes. Usually antecedent features of constipation Muco-epithelial defect usually in the midline posteriorly (anterior fissures more likely to be due to underlying disease)
- Haemorroids Bright red rectal bleeding Post defecation bleeding noted both on toilet paper and drips into pan. May be alteration of bowel habit and history of straining. No blood mixed with stool. No local pain. Normal colon and rectum. Proctoscopy may show internal haemorrhoids. Internal haemorrhoids are usually impalpable.
- Crohns disease Bright red or mixed blood Bleeding that is accompanied by other symptoms such as altered bowel habit, malaise, history of fissures (especially anterior) and abscesses. Perineal inspection may show fissures or fistulae. Proctoscopy may demonstrate indurated mucosa and possibly strictures. Skip lesions may be noted at colonoscopy.
- Ulcerative colitis Bright red bleeding often mixed with stool Diarrhoea, weight loss, nocturnal incontinence, passage of mucous PR. Proctitis is the most marked finding. Peri anal disease is usually absent. Colonoscopy will show continuous mucosal lesion.
- Rectal cancer Bright red blood mixed volumes Alteration of bowel habit. Tenesmus may be present. Symptoms of metastatic disease. Usually obvious mucosal abnormality. Lesion may be fixed or mobile depending upon disease extent. Surrounding mucosa often normal, although polyps may be present.
Investigation
All patients presenting with rectal bleeding require digital rectal examination and procto-sigmoidoscopy as a minimal baseline.
Remember that haemorrhoids are typically impalpable and to attribute bleeding to these in the absence of accurate internal inspection is unsatisfactory.
In young patients with no other concerning features in the history a carefully performed sigmoidoscopy that demonstrates clear haemorrhoidal disease may be sufficient. If clear views cannot be obtained then patients require bowel preparation with an enema and a flexible sigmoidscopy performed.
In those presenting with features of altered bowel habit or suspicion of inflammatory bowel disease a colonoscopy is the best test.
Patients with excessive pain who are suspected of having a fissure may require an examination under general or local anaesthesia.
In young patients with external stigmata of fissure and a compatible history it is acceptable to treat medically and defer internal examination until the fissure is healed. If the fissure fails to heal then internal examination becomes necessary along the lines suggested above to exclude internal disease.
Special tests
In patients with a malignancy of the rectum the staging investigations comprise an MRI of the rectum to identify circumferential resection margin compromise and to identify mesorectal nodal disease. In addition to this CT scanning of the chest abdomen and pelvis is necessary to stage for more distant disease. Some centres will still stage the mesorectum with endo rectal ultrasound but this is becoming far less common.
Patients with fissure in ano who are being considered for surgical sphincterotomy and are females who have an obstetric history should probably have ano rectal manometry testing performed together with endo anal ultrasound. As this service is not universally available it is not mandatory but in the absence of such information there are continence issues that may arise following sphincterotomy.
Management
Fissure in ano GTN ointment 0.2% or diltiazem cream applied topically is the usual first line treatment. Botulinum toxin for those who fail to respond. Internal sphincterotomy for those who fail with botox, can be considered earlier in males.
Haemorroids Lifestyle advice, for small internal haemorrhoids can consider injection sclerotherapy or rubber band ligation. For external haemorrhoids consider haemorrhoidectomy. Modern options include HALO procedure and stapled haemorrhoidectomy.
Inflammatory bowel disease Medical management- although surgery may be needed for fistulating Crohns (setons).
Rectal cancer Anterior resection or abdomino-perineal excision of the colon and rectum. Total mesorectal excision is now standard of care. Most resections below the peritoneal reflection will require defunctioning ileostomy. Most patients will require preoperative radiotherapy.
Of the surgical incisions listed below, which is most suitable for a 45 year old female undergoing a first time renal transplant?
Abdominal midline Paramedian Battle Rutherford Morrison Pfannenstiel
A Rutherford Morrison incision is the traditional approach for a renal transplant and provides extra peritoneal access to the iliac vessels.
Midline incision
Commonest approach to the abdomen
Structures divided: linea alba, transversalis fascia, extraperitoneal fat, peritoneum (avoid falciform ligament above the umbilicus)
Bladder can be accessed via an extraperitoneal approach through the space of Retzius
Paramedian incision
Parallel to the midline (about 3-4cm)
Structures divided/retracted: anterior rectus sheath, rectus (retracted), posterior rectus sheath, transversalis fascia, extraperitoneal fat, peritoneum
Incision is closed in layers
Battle
Similar location to paramedian but rectus displaced medially (and thus denervated)
Now seldom used
Kocher’s Incision under right subcostal margin e.g.
Cholecystectomy (open)
Lanz Incision in right iliac fossa e.g. Appendicectomy
Gridiron Oblique incision centered over McBurneys point- usually appendicectomy (less cosmetically acceptable than Lanz
Gable Rooftop incision
Pfannenstiel’s Transverse supra pubic, primarily used to access pelvic organs
McEvedy’s Groin incision e.g. Emergency repair strangulated femoral hernia
Rutherford Morrison Extraperitoneal approach to left or right lower quadrants. Gives excellent access to iliac vessels and is the approach of choice for first time renal transplantation.
A 56 year old man is investigated with an abdominal CT scan for a change of bowel habit towards constipation. It shows no colonic lesions. However, a right sided adrenal lesion is noted and measures 2.5cm in diameter. What is the most appropriate course of action?
Arrange an MRI of the adrenal gland Arrange an adrenal USS Arrange an image guided core biopsy Undertake an adrenalectomy Arrange a hormonal assay
The vast majority of small adrenal lesions are incidental, benign and non functioning adenomas. Apart from minimal workup, no further investigation is needed. Of note, if there are concerns about malignancy, the only surgical option is adrenalectomy.
Adrenal lesions- Incidental
Incidentaloma of the adrenal glands have become increasingly common as CT scanning of the abdomen is widely undertaken. Prevalences range from 1.5-9% in autopsy studies. Overall, 75% will be non functioning adenomas. However, a thorough diagnostic work up is required to exclude a more significant lesion.
Investigation
Morning and midnight plasma cortisol measurements
Dexamethasone suppression test
24 hour urinary cortisol excretion
24 hour urinary excretion of catecholamines
Serum potassium, aldosterone and renin levels
Management
The risk of malignancy is related to the size of the lesion and 25% of all masses greater than 4cm will be malignant. Such lesions should usually be excised. Where a lesion is a suspected metastatic deposit a biopsy may be considered.
An 8 year old boy is examined by his doctor as part of a routine clinical examination. The doctor notices a smooth swelling in the right iliac fossa. It is mobile and he is otherwise well. What is the most likely underlying cause?
Meckels diverticulum Spigelian hernia Mesenteric cyst Appendix mass Liposarcoma
Mesenteric cysts are often smooth. Imaging with ultrasound and CT is usually sufficient. Although rare, they most often occur in young children (up to 30% present before the age of 15). Many are asymptomatic and discovered incidentally. Acute presentations are recognised and may occur following cyst torsion, infarction or rupture. Most cysts will be surgically resected.
Spigelian hernias are very rare in children, liposarcomas are not smooth swellings. An appendix mass will usually produce systemic illness.
Appendicitis Pain radiating to right iliac fossa Anorexia (very common) Short history Diarrhoea and profuse vomiting rare Crohn's disease Often long history Signs of malnutrition Change in bowel habit, especially diarrhoea
Mesenteric adenitis
Mainly affects children
Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp.
Patients have a higher temperature than those with appendicitis
If laparotomy is performed, enlarged mesenteric lymph nodes will be present
Diverticulitis
Both left and right sided disease may present with right iliac fossa pain
Clinical history may be similar, although some change in bowel habit is usual
When suspected, a CT scan may help in refining the diagnosis
Meckel’s diverticulitis
A Meckel’s diverticulum is a congenital abnormality that is present in about 2% of the population
Typically 2 feet proximal to the ileocaecal valve
May be lined by ectopic gastric mucosal tissue and produce bleeding
Perforated peptic ulcer
This usually produces upper quadrant pain but pain may be lower
Perforations typically have a sharp sudden onset of pain in the history
Incarcerated right inguinal or femoral hernia
Usually only right iliac fossa pain if right sided or bowel obstruction.
Bowel perforation secondary to caecal or colon carcinoma
Seldom localised to right iliac fossa, although complete large bowel obstruction with caecal distension may cause pain prior to perforation.
Gynaecological causes
Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian torsion/Threatened or complete abortion/Mittelschmerz
Urological causes
Ureteric colic/UTI/Testicular torsion
Other causes
TB/Typhoid/Herpes Zoster/AAA/Situs inversus
An 84 year old lady presents with a tender painful lump in the right groin and signs of small bowel obstruction. What is the most appropriate surgical incision to address this problem?
Lothessien McEvedy Midline abdominal Paramedian Kockers
A McEvedy incision is traditionally used to approach incarcerated femoral hernias. The disadvantage of the Lothessien approach is that it weakens the inguinal canal and predisposes to inguinal hernia formation. The other incisions would not usually address femoral hernias. Given the features of bowel obstruction, a low approach would be inappropriate.
Midline incision
Commonest approach to the abdomen
Structures divided: linea alba, transversalis fascia, extraperitoneal fat, peritoneum (avoid falciform ligament above the umbilicus)
Bladder can be accessed via an extraperitoneal approach through the space of Retzius
Paramedian incision
Parallel to the midline (about 3-4cm)
Structures divided/retracted: anterior rectus sheath, rectus (retracted), posterior rectus sheath, transversalis fascia, extraperitoneal fat, peritoneum
Incision is closed in layers
Battle
Similar location to paramedian but rectus displaced medially (and thus denervated)
Now seldom used
Kocher’s Incision under right subcostal margin e.g. Cholecystectomy (open)
Lanz Incision in right iliac fossa e.g. Appendicectomy
Gridiron Oblique incision centered over McBurneys point- usually appendicectomy (less cosmetically acceptable than Lanz
Gable Rooftop incision
Pfannenstiel’s Transverse supra pubic, primarily used to access pelvic organs
McEvedy’s Groin incision e.g. Emergency repair strangulated femoral hernia
Rutherford Morrison Extraperitoneal approach to left or right lower quadrants. Gives excellent access to iliac vessels and is the approach of choice for first time renal transplantation.
A 59 year old man is referred with symptoms of dysphagia. On examination, he has a large goitre and on imaging there is significant retrosternal extension and features of a multinodular goitre. What is the most appropriate course of action?
Total thyroidectomy Sub total thyroidectomy Thyroid lobectomy Radio-iodine Conservative management
Total thyroidectomy
Sub total thyroidectomy is no longer routinely undertaken in this group.
Large multinodular goitre Surgery for pressure symptoms. Total thyroidectomy is treatment of choice
Toxic nodule Hemithyroidectomy
Follicular lesion (THY 3f) Hemithyroidectomy to establish diagnosis
Papillary thyroid cancer Total thyroidectomy and central compartment nodal dissection (extended lymphadenectomy as required)
Follicular thyroid cancer Total thyroidectomy (usually completion as already had hemithyroidectomy)
Anaplastic thyroid cancer Palliative radiotherapy
Medullary thyroid cancer Total thyroidectomy (screen for other MEN tumours)
Lymphoma of the thyroid Consider core biopsy
Persistent refilling cysts Hemithyroidectomy
Graves disease with significant eye signs Total thyroidectomy
Graves disease without significant eye signs Patient choice radioiodine Vs surgery
A 21 year old women is admitted with a 48 hour history of worsening right iliac fossa pain. She has been nauseated and vomited twice. On examination, she is markedly tender in the right iliac fossa with localised guarding. Vaginal examination is unremarkable. Urine dipstick (including beta HCG) is negative. Blood tests show a WCC of 13.5 and CRP 70. What is the most appropriate course of action?
Open appendicectomy Laparotomy Abdominal ultrasound Laparoscopic appendicectomy Abdominal CT scan
Laparoscopic appendicectomy
The most likely diagnosis is appendicitis. The negative vaginal examination (and therefore by definition the absence of cervical excitation) makes pelvic inflammatory disease unlikely. Given the raised inflammatory markers, the correct course of action is to proceed with surgery. In females, there are considerable advantages of undertaking this laparoscopically as it allows evaluation of the pelvic viscera. Imaging with USS is unlikely to alter management as it has a false negative rate and given the context of the clinical findings, surgery is likely to occur in any case. Whilst a CT scan would allow for an accurate pre-operative diagnosis, it carries a significant radiation dose, and again, is unlikely to alter management.
Appendicitis Pain radiating to right iliac fossa Anorexia (very common) Short history Diarrhoea and profuse vomiting rare
Crohn’s disease
Often long history
Signs of malnutrition
Change in bowel habit, especially diarrhoea
Mesenteric adenitis
Mainly affects children
Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp.
Patients have a higher temperature than those with appendicitis
If laparotomy is performed, enlarged mesenteric lymph nodes will be present
Diverticulitis
Both left and right sided disease may present with right iliac fossa pain
Clinical history may be similar, although some change in bowel habit is usual
When suspected, a CT scan may help in refining the diagnosis
Meckel’s diverticulitis
A Meckel’s diverticulum is a congenital abnormality that is present in about 2% of the population
Typically 2 feet proximal to the ileocaecal valve
May be lined by ectopic gastric mucosal tissue and produce bleeding
Perforated peptic ulcer
This usually produces upper quadrant pain but pain may be lower
Perforations typically have a sharp sudden onset of pain in the history
Incarcerated right inguinal or femoral hernia
Usually only right iliac fossa pain if right sided or bowel obstruction.
Bowel perforation secondary to caecal or colon carcinoma
Seldom localised to right iliac fossa, although complete large bowel obstruction with caecal distension may cause pain prior to perforation.
Gynaecological causes
Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian torsion/Threatened or complete abortion/Mittelschmerz
Urological causes
Ureteric colic/UTI/Testicular torsion
Other causes
TB/Typhoid/Herpes Zoster/AAA/Situs inversus
Which of the following signs is seen in patients who have a significant retroperitoneal haemorrhage?
Boas' sign Pembertons sign Grey Turners sign Cullens sign Rovsing's sign
Grey Turner:
Rovsings sign- appendicitis
Boas sign -cholecystitis
Murphys sign- cholecystitis
Cullens sign- pancreatitis (other intraabdominal haemorrhage)
Grey-Turners sign- pancreatitis (or other retroperitoneal haemorrhage)
What is the most likely diagnosis in a 17 year old man who presents with painful bright red rectal bleeding that has been noticed to occur in past 2 weeks?
Fistula in ano Fissure in ano External haemorrhoids Internal haemorrhoids Ulcerative colitis
Painful rectal bleeding is typically seen with fissure in ano (most will be posterior). The initial history is often short (as in this case). A fistula is more likely to present with discharge than just blood. Haemorrhoidal disease bleeding is usually painless. Although thrombosed haemorrhoids may be painful, they typically occur in patients with a longer history.
Rectal bleeding is a common cause for patients to be referred to the surgical clinic. In the clinical history it is useful to try and localise the anatomical source of the blood. Bright red blood is usually of rectal anal canal origin, whilst dark red blood is more suggestive of a proximally sited bleeding source. Blood which has entered the GI tract from a gastro-duodenal source will typically resemble malaena due to the effects of the digestive enzymes on the blood itself.
In the table below we give some typical bleeding scenarios together with physical examination findings and causation.
Fissure in ano Bright red rectal bleeding Painful bleeding that occurs post defecation in small volumes. Usually antecedent features of constipation Muco-epithelial defect usually in the midline posteriorly (anterior fissures more likely to be due to underlying disease)
Haemorroids Bright red rectal bleeding Post defecation bleeding noted both on toilet paper and drips into pan. May be alteration of bowel habit and history of straining. No blood mixed with stool. No local pain. Normal colon and rectum. Proctoscopy may show internal haemorrhoids. Internal haemorrhoids are usually impalpable.
Crohns disease Bright red or mixed blood Bleeding that is accompanied by other symptoms such as altered bowel habit, malaise, history of fissures (especially anterior) and abscesses. Perineal inspection may show fissures or fistulae. Proctoscopy may demonstrate indurated mucosa and possibly strictures. Skip lesions may be noted at colonoscopy.
Ulcerative colitis Bright red bleeding often mixed with stool Diarrhoea, weight loss, nocturnal incontinence, passage of mucous PR. Proctitis is the most marked finding. Peri anal disease is usually absent. Colonoscopy will show continuous mucosal lesion.
Rectal cancer Bright red blood mixed volumes Alteration of bowel habit. Tenesmus may be present. Symptoms of metastatic disease. Usually obvious mucosal abnormality. Lesion may be fixed or mobile depending upon disease extent. Surrounding mucosa often normal, although polyps may be present.
Fissure in ano GTN ointment 0.2% or diltiazem cream applied topically is the usual first line treatment. Botulinum toxin for those who fail to respond. Internal sphincterotomy for those who fail with botox, can be considered earlier in males.
Haemorroids Lifestyle advice, for small internal haemorrhoids can consider injection sclerotherapy or rubber band ligation. For external haemorrhoids consider haemorrhoidectomy. Modern options include HALO procedure and stapled haemorrhoidectomy.
Inflammatory bowel disease Medical management- although surgery may be needed for fistulating Crohns (setons).
Rectal cancer Anterior resection or abdomino-perineal excision of the colon and rectum. Total mesorectal excision is now standard of care. Most resections below the peritoneal reflection will require defunctioning ileostomy. Most patients will require preoperative radiotherapy.
A 34 year old lady is undergoing a laparoscopic cholecystectomy for cholecystitis. She has been unwell for the past 10 days. On attempting to dissect the gallbladder (which is distended), all that can be seen are the gallbladder fundus and dense adhesions make it difficult to dissect Calots triangle. What is the best course of action?
Perform an operative cholecystostomy Dissect the adhesions off Calots triangle and continue with the cholecystectomy Dissect out the bile duct and perform a cholangiogram Arrange an ERCP Arrange a PTC
Perform operative cholecystectomy
The timeframe of 10 days makes attempts at proceeding with surgery hazardous even in experienced hands. However, the patient is unwell and this will not settle without some form of intervention. If only the fundus can be seen, then it may be difficult to even proceed with a sub total cholecystectomy. Therefore, a cholecystostomy can be performed and this will usually allow the situation to settle. Definitive surgery can then be undertaken in more favourable circumstances.
Gallstones Typically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results. Usually small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundice
Cholangitis Usually obstructive and will have Charcot’s triad of symptoms (pain, fever, jaundice) Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile.
Pancreatic cancer Typically painless jaundice with palpable gallbladder (Courvoisier’s Law) Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatis may be the culprit in which case the bile duct may be of normal calibre.
TPN (total parenteral nutrition) associated jaundice Usually follows long term use and is usually painless with non obstructive features Often due to hepatic dysfunction and fatty liver which may occur with long term TPN usage.
Bile duct injury Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive type Often due to a difficult laparoscopic cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice develops rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury.
Cholangiocarcinoma Gradual onset obstructive pattern Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis.
Septic surgical patient Usually hepatic features Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis.
Metastatic disease Mixed hepatic and post hepatic Combination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier)
A 17 year old male is admitted with lower abdominal discomfort. He has been suffering from intermittent right iliac fossa pain for the past few months. His past medical history includes a negative colonoscopy and gastroscopy for iron deficiency anaemia. The pain is worse after meals. Inflammatory markers are normal. What is the most likely cause?
Appendicitis Crohns disease Peptic ulcer disease Meckels diverticulum Irritable bowel syndrome
This scenario should raise suspicion for Meckels as these may contain ectopic gastric mucosa which may secrete acid with subsequent bleeding and ulceration. The iron deficiency anaemia is makes a Meckels more likely than IBD.
Appendicitis Pain radiating to right iliac fossa Anorexia (very common) Short history Diarrhoea and profuse vomiting rare
Crohn’s disease
Often long history
Signs of malnutrition
Change in bowel habit, especially diarrhoea
Mesenteric adenitis
Mainly affects children
Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp.
Patients have a higher temperature than those with appendicitis
If laparotomy is performed, enlarged mesenteric lymph nodes will be present
Diverticulitis
Both left and right sided disease may present with right iliac fossa pain
Clinical history may be similar, although some change in bowel habit is usual
When suspected, a CT scan may help in refining the diagnosis
Meckel’s diverticulitis
A Meckel’s diverticulum is a congenital abnormality that is present in about 2% of the population
Typically 2 feet proximal to the ileocaecal valve
May be lined by ectopic gastric mucosal tissue and produce bleeding
Perforated peptic ulcer
This usually produces upper quadrant pain but pain may be lower
Perforations typically have a sharp sudden onset of pain in the history
Incarcerated right inguinal or femoral hernia
Usually only right iliac fossa pain if right sided or bowel obstruction.
Bowel perforation secondary to caecal or colon carcinoma
Seldom localised to right iliac fossa, although complete large bowel obstruction with caecal distension may cause pain prior to perforation.
Gynaecological causes
Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian torsion/Threatened or complete abortion/Mittelschmerz
Urological causes
Ureteric colic/UTI/Testicular torsion
Other causes
TB/Typhoid/Herpes Zoster/AAA/Situs inversus
A 68 year old man with type 2 diabetes is admitted to hospital unwell. On examination, he has features of septic shock and right upper quadrant tenderness. He is not jaundiced. Imaging shows a normal calibre bile duct and no stones in the gallbladder. What is the most likely diagnosis?
Acute calculous cholecystitis Acute acalculous cholecystitis Cholangitis Mirizzi syndrome Sphincter of oddi dysfunction
This is the classic description of acalculous cholecystitis and its commonest in patients with type 2 diabetes. If you answered it incorrectly, ensure that you were not caught out by the acute calculous cholecystitis as this is a common exam mistake if options are mis read in a rush.
Up to 24% of women and 12% of men may have gallstones. Of these up to 30% may develop local infection and cholecystitis. In patients subjected to surgery 12% will have stones contained within the common bile duct. The majority of gallstones are of a mixed composition (50%) with pure cholesterol stones accounting for 20% of cases.
The aetiology of CBD stones differs in the world, in the West most CBD stones are the result of migration. In the East a far higher proportion arise in the CBD de novo.
The classical symptoms are of colicky right upper quadrant pain that occurs post prandially. The symptoms are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal.
Investigation
In almost all suspected cases the standard diagnostic work up consists of abdominal ultrasound and liver function tests. Of patients who have stones within the bile duct, 60% will have at least one abnormal result on LFT’s. Ultrasound is an important test, but is operator dependent and therefore may occasionally need to be repeated if a negative result is at odds with the clinical picture. Where stones are suspected in the bile duct, the options lie between magnetic resonance cholangiography and intraoperative imaging. The choice between these two options is determined by the skills and experience of the surgeon. The advantages of intra operative imaging are less useful in making therapeutic decisions if the operator is unhappy about proceeding the bile duct exploration, and in such circumstances pre operative MRCP is probably a better option.
Biliary colic Colicky abdominal pain, worse post prandially, worse after fatty foods If imaging shows gallstones and history compatible then laparoscopic cholecystectomy
Acute cholecystitis
Right upper quadrant pain
Fever
Murphys sign on examination
Occasionally mildly deranged LFT’s (especially if Mirizzi syndrome)
Imaging (USS) and cholecystectomy (ideally within 48 hours of presentation) (2)
Gallbladder abscess
Usually prodromal illness and right upper quadrant pain
Swinging pyrexia
Patient may be systemically unwell
Generalised peritonism not present
Imaging with USS +/- CT Scanning
Ideally surgery, sub total cholecystectomy may be needed if Calots triangle is hostile
In unfit patients percutaneous drainage may be considered
Cholangitis Patient severely septic and unwell Jaundice Right upper quadrant pain Fluid resuscitation Broad spectrum intravenous antibiotics Correct any coagulopathy Early ERCP
Gallstone ileus
Patients may have a history of previous cholecystitis and known gallstones
Small bowel obstruction (may be intermittent)
Laparotomy and removal of gallstone from small bowel, the enterotomy must be made proximal to the site of obstruction and not at the site of obstruction. The fistula between the gallbladder and duodenum should not be interfered with.
Acalculous cholecystitis
Patients with inter current illness (e.g. diabetes, organ failure)
Patient of systemically unwell
Gallbladder inflammation in absence of stones
High fever
If patient fit then cholecystectomy, if unfit then percutaneous cholecystostomy
Treatment
Patients with asymptomatic gallstones rarely develop symptoms related to them (less than 2% per year) and may therefore be managed expectantly. In almost all cases of symptomatic gallstones the treatment of choice is cholecystectomy performed via the laparoscopic route. In the very frail patient there is sometimes a role for selective use of ultrasound guided cholecystostomy.
During the course of the procedure some surgeons will routinely perform either intra operative cholangiography or laparoscopic USS to either confirm anatomy or to exclude CBD stones. The latter may be more easily achieved by use of laparoscopic ultrasound. If stones are found then the options lie between early ERCP in the day or so following surgery or immediate surgical exploration of the bile duct. When performed via the trans cystic route this adds little in the way of morbidity and certainly results in faster recovery. Where transcystic exploration fails the alternative strategy is that of formal choledochotomy. The exploration of a small duct is challenging and ducts of less than 8mm should not be explored. Small stones that measure less than 5mm may be safely left and most will pass spontaneously.
Risks of ERCP(1) Bleeding 0.9% (rises to 1.5% if sphincterotomy performed) Duodenal perforation 0.4% Cholangitis 1.1% Pancreatitis 1.5%
A 24 year old woman presents with a long history of obstructed defecation and chronic constipation. She often strains to open her bowels for long periods and occasionally notices that she has passed a small amount of blood. On examination, she has an indurated area located anteriorly approximately 3cm proximal to the anal verge. What is the most likely diagnosis?
Haemorrhoids Rectal cancer Ulcerative colitis Solitary rectal ulcer syndrome Fissure in ano
Solitary rectal ulcers are associated with chronic constipation and straining. It will need to be biopsied to exclude malignancy (the histological appearances are characteristic). Diagnostic work up should include endoscopy and probably defecating proctogram and ano-rectal manometry studies.
Rectal bleeding is a common cause for patients to be referred to the surgical clinic. In the clinical history it is useful to try and localise the anatomical source of the blood. Bright red blood is usually of rectal anal canal origin, whilst dark red blood is more suggestive of a proximally sited bleeding source. Blood which has entered the GI tract from a gastro-duodenal source will typically resemble malaena due to the effects of the digestive enzymes on the blood itself.
Fissure in ano Bright red rectal bleeding Painful bleeding that occurs post defecation in small volumes. Usually antecedent features of constipation Muco-epithelial defect usually in the midline posteriorly (anterior fissures more likely to be due to underlying disease)
Haemorroids Bright red rectal bleeding Post defecation bleeding noted both on toilet paper and drips into pan. May be alteration of bowel habit and history of straining. No blood mixed with stool. No local pain. Normal colon and rectum. Proctoscopy may show internal haemorrhoids. Internal haemorrhoids are usually impalpable.
Crohns disease Bright red or mixed blood Bleeding that is accompanied by other symptoms such as altered bowel habit, malaise, history of fissures (especially anterior) and abscesses. Perineal inspection may show fissures or fistulae. Proctoscopy may demonstrate indurated mucosa and possibly strictures. Skip lesions may be noted at colonoscopy.
Ulcerative colitis Bright red bleeding often mixed with stool Diarrhoea, weight loss, nocturnal incontinence, passage of mucous PR. Proctitis is the most marked finding. Peri anal disease is usually absent. Colonoscopy will show continuous mucosal lesion.
Rectal cancer Bright red blood mixed volumes Alteration of bowel habit. Tenesmus may be present. Symptoms of metastatic disease. Usually obvious mucosal abnormality. Lesion may be fixed or mobile depending upon disease extent. Surrounding mucosa often normal, although polyps may be present.
Investigation
All patients presenting with rectal bleeding require digital rectal examination and procto-sigmoidoscopy as a minimal baseline.
Remember that haemorrhoids are typically impalpable and to attribute bleeding to these in the absence of accurate internal inspection is unsatisfactory.
In young patients with no other concerning features in the history a carefully performed sigmoidoscopy that demonstrates clear haemorrhoidal disease may be sufficient. If clear views cannot be obtained then patients require bowel preparation with an enema and a flexible sigmoidscopy performed.
In those presenting with features of altered bowel habit or suspicion of inflammatory bowel disease a colonoscopy is the best test.
Patients with excessive pain who are suspected of having a fissure may require an examination under general or local anaesthesia.
In young patients with external stigmata of fissure and a compatible history it is acceptable to treat medically and defer internal examination until the fissure is healed. If the fissure fails to heal then internal examination becomes necessary along the lines suggested above to exclude internal disease.
Special tests
In patients with a malignancy of the rectum the staging investigations comprise an MRI of the rectum to identify circumferential resection margin compromise and to identify mesorectal nodal disease. In addition to this CT scanning of the chest abdomen and pelvis is necessary to stage for more distant disease. Some centres will still stage the mesorectum with endo rectal ultrasound but this is becoming far less common.
Patients with fissure in ano who are being considered for surgical sphincterotomy and are females who have an obstetric history should probably have ano rectal manometry testing performed together with endo anal ultrasound. As this service is not universally available it is not mandatory but in the absence of such information there are continence issues that may arise following sphincterotomy.
Management
Fissure in ano GTN ointment 0.2% or diltiazem cream applied topically is the usual first line treatment. Botulinum toxin for those who fail to respond. Internal sphincterotomy for those who fail with botox, can be considered earlier in males.
Haemorroids Lifestyle advice, for small internal haemorrhoids can consider injection sclerotherapy or rubber band ligation. For external haemorrhoids consider haemorrhoidectomy. Modern options include HALO procedure and stapled haemorrhoidectomy.
Inflammatory bowel disease Medical management- although surgery may be needed for fistulating Crohns (setons).
Rectal cancer Anterior resection or abdomino-perineal excision of the colon and rectum. Total mesorectal excision is now standard of care. Most resections below the peritoneal reflection will require defunctioning ileostomy. Most patients will require preoperative radiotherapy.
A 46 year old man is admitted to hospital with a femoral shaft fracture that occurred suddenly whilst he was out walking his dog. On examination, there is no neurovascular deficit distal to the fracture site. He has a large firm nodule in the left lobe of the thyroid, there is no associated lymphadenopathy. What is the most likely underlying cause?
Papillary thyroid cancer Follicular thyroid cancer Thyroid gland lymphoma Anaplastic thyroid cancer Medullary thyroid cancer
Follicular carcinomas may metastasise haematogenously (often to bone) where they may give rise to pathological fractures as in this case.
Multinodular goitre
One of the most common reasons for presentation
Provided the patient is euthyroid and asymptomatic and no discrete nodules are seen, they can be reassured.
In those with compressive symptoms surgery is required and the best operation is a total thyroidectomy.
Sub total resections were practised in the past and simply result in recurrent disease that requires a difficult revisional resection.
Endocrine dysfunction
In general these patients are managed by physicians initially.
Surgery may be offered alongside radio iodine for patients with Graves disease that fails with medical management or in patients who would prefer not to be irradiated (e.g. pregnant women).
Patients with hypothyroidism do not generally get offered a thyroidectomy. Sometimes people inadvertently get offered resections during the early phase of Hashimotos thyroiditis, however, with time the toxic phase passes and patients can simply be managed with thyroxine.
Complications following surgery
Anatomical such as recurrent laryngeal nerve damage.
Bleeding. Owing to the confined space haematoma’s may rapidly lead to respiratory compromise owing to laryngeal oedema.
Damage to the parathyroid glands resulting in hypocalcaemia.
A 21 year old women presents with right iliac fossa pain. She reports some bloodstained vaginal discharge. On examination, she is afebrile and has a pulse rate of 97 bpm, normal blood pressure. She has diffuse lower abdominal tenderness. What is the most appropriate course of action?
Laparotomy Laparoscopy Abdominal and pelvic MRI scan Abdominal and pelvic CT scan Abdominal and pelvic USS
Abdominal and pelvic USS
The history of blood stained discharge and tenderness makes an ectopic pregnancy a strong possibility, a USS should be performed and a pregnancy test undertaken. If the beta HCG is high then an intra uterine pregnancy should be found. If it is not, then an ectopic pregnancy is likely and surgery should be considered.
Appendicitis Pain radiating to right iliac fossa Anorexia (very common) Short history Diarrhoea and profuse vomiting rare
Crohn’s disease
Often long history
Signs of malnutrition
Change in bowel habit, especially diarrhoea
Mesenteric adenitis
Mainly affects children
Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp.
Patients have a higher temperature than those with appendicitis
If laparotomy is performed, enlarged mesenteric lymph nodes will be present
Diverticulitis
Both left and right sided disease may present with right iliac fossa pain
Clinical history may be similar, although some change in bowel habit is usual
When suspected, a CT scan may help in refining the diagnosis
Meckel’s diverticulitis
A Meckel’s diverticulum is a congenital abnormality that is present in about 2% of the population
Typically 2 feet proximal to the ileocaecal valve
May be lined by ectopic gastric mucosal tissue and produce bleeding
Perforated peptic ulcer
This usually produces upper quadrant pain but pain may be lower
Perforations typically have a sharp sudden onset of pain in the history
Incarcerated right inguinal or femoral hernia
Usually only right iliac fossa pain if right sided or bowel obstruction.
Bowel perforation secondary to caecal or colon carcinoma
Seldom localised to right iliac fossa, although complete large bowel obstruction with caecal distension may cause pain prior to perforation.
Gynaecological causes
Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian torsion/Threatened or complete abortion/Mittelschmerz
Urological causes
Ureteric colic/UTI/Testicular torsion
Other causes
TB/Typhoid/Herpes Zoster/AAA/Situs inversus
A 43 year old lady presents with an attack of acute pancreatitis. It is classified as a mild attack on severity scoring. Imaging identifies gallstones but a normal calibre bile duct, and a peripancreatic fluid collection. Which of the following management options is most appropriate?
Intravenous octreotide Cholecystectomy within 4 weeks Nasogastric tube drainage of the stomach Insertion of a radiological drain Avoidance of enteral feeding
Patients with gallstone pancreatitis should undergo early cholecystectomy.
Enteral feeding helps minimise gut bacterial translocation and should be given to most patients with pancreatitis. Many studies have evaluated the role of octreotide in reducing pancreatic secretions and shown no benefit
The use of antibiotics in pancreatitis is controversial. However, a recent Cochrane review has presented reasonable evidence in favor of administration of imipenem to prevent infection in established necrosis.
Management of Acute Pancreatitis in the UK
Diagnosis
Traditionally hyperamylasaemia has been utilised with amylase being elevated three times the normal range.
However, amylase may give both false positive and negative results.
Serum lipase is both more sensitive and specific than serum amylase. It also has a longer half life.
Serum amylase levels do not correlate with disease severity.
Differential causes of hyperamylasaemia Acute pancreatitis Pancreatic pseudocyst Mesenteric infarct Perforated viscus Acute cholecystitis Diabetic ketoacidosis
Assessment of severity
Glasgow, Ranson scoring systems and APACHE II
Biochemical scoring e.g. using CRP
Features that may predict a severe attack within 48 hours of admission to hospital
Initial assessment Clinical impression of severity Body mass index >30 Pleural effusion APACHE score >8
24 hours after admission Clinical impression of severity APACHE II >8 Glasgow score of 3 or more Persisting multiple organ failure CRP>150
48 hours after admission Glasgow Score of >3 CRP >150 Persisting or progressive organ failure Table adapted from UK guidelines for management of acute pancreatitis. GUT 2005, 54 suppl III
Management
Nutrition
There is reasonable evidence to suggest that the use of enteral nutrition does not worsen the outcome in pancreatitis
Most trials to date were underpowered to demonstrate a conclusive benefit.
The rationale behind feeding is that it helps to prevent bacterial translocation from the gut, thereby contributing to the development of infected pancreatic necrosis.
Use of antibiotic therapy
Many UK surgeons administer antibiotics to patients with acute pancreatitis. However, there is very little evidence to support this practice.
A recent Cochrane review highlights the potential benefits of administering Imipenem to patients with established pancreatic necrosis in the hope of averting the progression to infection.
There are concerns that the administration of antibiotics in mild attacks of pancreatitis will not affect outcome and may contribute to antibiotic resistance and increase the risks of antibiotic associated diarrhoea.
Surgery
Patients with acute pancreatitis due to gallstones should undergo early cholecystectomy.
Patients with obstructed biliary system due to stones should undergo early ERCP.
Patients with extensive necrosis where infection is suspected should usually undergo FNA for culture.
Patients with infected necrosis should undergo either radiological drainage or surgical necrosectomy. The choice of procedure depends upon local expertise.
A 21 year old male is admitted with a 3 month history of intermittent right iliac fossa pain. He suffers from episodic diarrhoea and has lost 2 kilos in weight. On examination, he has some right iliac fossa tenderness and is febrile. What is the most likely cause?
Appendicitis Irritable bowel syndrome Inflammatory bowel disease Infective gastroenteritis Meckels diverticulum
The history of weight loss and intermittent diarrhea makes inflammatory bowel disease the most likely diagnosis. Conditions such as appendicitis and infections have a much shorter history. Although Meckels can bleed and cause inflammation, they seldom cause marked weight loss.
Appendicitis Pain radiating to right iliac fossa Anorexia (very common) Short history Diarrhoea and profuse vomiting rare
Crohn’s disease
Often long history
Signs of malnutrition
Change in bowel habit, especially diarrhoea
Mesenteric adenitis
Mainly affects children
Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp.
Patients have a higher temperature than those with appendicitis
If laparotomy is performed, enlarged mesenteric lymph nodes will be present
Diverticulitis
Both left and right sided disease may present with right iliac fossa pain
Clinical history may be similar, although some change in bowel habit is usual
When suspected, a CT scan may help in refining the diagnosis
Meckel’s diverticulitis
A Meckel’s diverticulum is a congenital abnormality that is present in about 2% of the population
Typically 2 feet proximal to the ileocaecal valve
May be lined by ectopic gastric mucosal tissue and produce bleeding
Perforated peptic ulcer
This usually produces upper quadrant pain but pain may be lower
Perforations typically have a sharp sudden onset of pain in the history
Incarcerated right inguinal or femoral hernia
Usually only right iliac fossa pain if right sided or bowel obstruction.
Bowel perforation secondary to caecal or colon carcinoma
Seldom localised to right iliac fossa, although complete large bowel obstruction with caecal distension may cause pain prior to perforation.
Gynaecological causes
Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian torsion/Threatened or complete abortion/Mittelschmerz
Urological causes
Ureteric colic/UTI/Testicular torsion
Other causes
TB/Typhoid/Herpes Zoster/AAA/Situs inversus
A 48 year old woman with end stage renal failure is undergoing a live donor renal transplant. The surgeon decides to implant the kidney in the left iliac fossa via a Rutherford Morrison incision. To which of the following vessels should the transplanted kidney be anastomosed?
Aorta and inferior vena cava Internal iliac artery and vein Common iliac artery and vein External iliac artery and vein Inferior epigastric artery and vein
First time renal tranplants and typically implanted in the left or right iliac fossae. The vessels are usually joined to the external iliac artery and vein as these are the most easily accessible. The Rutherford Morrison incision provides access to the external iliac vessels.
A number of different organ and tissue transplants are now available. In many cases an allograft is performed, where an organ is transplanted from one individual to another. Allografts will elicit an immune response and this is one of the main reasons for organ rejection.
Graft rejection occurs because allografts have allelic differences at genes that code immunohistocompatability complex genes. The main antigens that give rise to rejection are:
ABO blood group
Human leucocyte antigens (HLA)
Minor histocompatability antigens
ABO Matching
ABO incompatibility will result in early organ rejection (hyperacute) because of pre existing antibodies to other groups. Group O donors can give organs to any type of ABO recipient whereas group AB donor can only donate to AB recipient.
HLA System
The four most important HLA alleles are:
HLA A
HLA B
HLA C
HLA DR
An ideal organ match would be one in which all 8 alleles are matched (remember 2 from each parent, four each = 8 alleles). Modern immunosuppressive regimes help to manage the potential rejection due to HLA mismatching. However, the greater the number of mismatches the worse the long term outcome will be. T lymphocytes will recognise antigens bound to HLA molecules and will then become activated. Clonal expansion then occurs with a response directed against that antigen.
Types of organ rejection
Hyperacute. This occurs immediately through presence of pre formed antibodies (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.
Hyperacute
Renal transplants at greatest risk and liver transplants at least risk. Although ABO incompatibility and HLA Class I incompatible transplants will all fare worse in long term.
Acute
All organs may undergo acute rejection. Mononuclear cell infiltrates predominate. All types of transplanted organ are susceptible and it may occur in up to 50% cases.
Chronic
Again all transplants with HLA mismatch may suffer this fate. Previous acute rejections and other immunosensitising events all increase the risk. Vascular changes are most prominent with myointimal proliferation leading to organ ischaemia. Organ specific changes are also seen such as loss of acinar cells in pancreas transplants and rapidly progressive coronary artery disease in cardiac transplants.
Surgical overview-Renal transplantation
A brief overview of the steps involved in renal transplantation is given.
Patients with end stage renal failure who are dialysis dependent or likely to become so in the immediate future are considered for transplant. Exclusion criteria include; active malignancy, old age (due to limited organ availability). Patients are medically optimised.
Donor kidneys, these may be taken from live related donors and close family, members may have less HLA mismatch than members of the general population. Laparoscopic donor nephrectomy further minimises the operative morbidity for the donor. Other organs are typically taken from brain dead or dying patients who have a cardiac arrest and in whom resuscitation is futile. The key event is to minimise the warm ischaemic time in the donor phase.
The kidney once removed is usually prepared on the bench in theatre by the transplant surgeon immediately prior to implantation and factors such as accessory renal arteries and vessel length are assessed and managed.
For first time recipients the operation is performed under general anaesthesia. A Rutherford-Morrison incision is made on the preferred side. This provides excellent extraperitoneal access to the iliac vessels. The external iliac artery and vein are dissected out and following systemic heparinisation are cross clamped. The vein and artery are anastamosed to the iliacs and the clamps removed. The ureter is then implanted into the bladder and a stent is usually placed to maintain patency. The wounds are then closed and the patient recovered from surgery.
In the immediate phase a common problem encountered in cadaveric kidneys is acute tubular necrosis and this tends to resolve.
Graft survival times from cadaveric donors are typically of the order of 9 years and monozygotic twin transplant (live donor) may survive as long as 25 years.
A 65 year old man presents with significant lower urinary tract symptoms and is diagnosed as having benign prostatic hyperplasia. Which of the following drug treatments will produce the slowest clinical response?
Tamsulosin Alfuzosin Doxazosin Finasteride Terazosin
5 alpha reductase inhibitors have a more favorable side effect profile than α blockers.
Alpha blockers have a faster onset of action (but lower reduction of complications from BPH) than 5 α reductase inhibitors.
Benign prostatic hyperplasia occurs via an increase in the epithelial and stromal cell numbers in the peri-urethral zone of the prostate. BPH is very common and 90% of men aged over 80 will have at least microscopic evidence of benign prostatic hyperplasia. The causes of BPH are still not well understood, but the importance of androgens remains appreciated even if the exact role by which they induce BPH is elusive.
Presentation
The vast majority of men will present with lower urinary tract symptoms. These will typically be:
Poor flow Nocturia Hesitancy Incomplete and double voiding Terminal dribbling Urgency Incontinence
Investigation
Digital rectal examination to assess prostatic size and morphology.
Urine dipstick for infections and haematuria.
Uroflowmetry (a flow rate of >15ml/second helps to exclude BOO)
Bladder pressure studies may help identify detrusor failure and whilst may not form part of first line investigations should be included in those with atypical symptoms and prior to redo surgery.
Bladder scanning to demonstrate residual volumes. USS if high pressure chronic retention.
Management
Lifestyle changes such as stopping smoking and altering fluid intake may help those with mild symptoms.
Medical therapy includes alpha blockers and 5 α reductase inhibitors. The former work quickly on receptor zones located at the bladder neck. Cardiovascular side effects are well documented. The latter work on testosterone metabolising enzymes. Although they have a slower onset of action, the 5 α reductase inhibitors may prevent acute urinary retention.
Surgical therapy includes transurethral resection of the prostate and is the treatment of choice in those with severe symptoms and those who fail to respond to medical therapy. More tailored bladder neck incision procedures may be considered in those with small prostates. Retrograde ejaculation may occur following surgery. The change in the type of irrigation solutions used has helped to minimise the TURP syndrome of electrolyte disturbances.
A 45 year old man develops a colocutaneous fistulae following reversal of a loop colostomy fashioned for the defunctioning of an anterior resection. Pre-operative gastrograffin enema showed no distal obstruction or anastamotic stricture.
A. No further action needed B. Intravenous fluids C. Intravenous fluids and nasogastric tube D. Total parenteral nutrition and octreotide E. Defunctioning stoma F. Insertion of seton G. Intravenous octreotide H. Lay open fistula
No further action needed
Colocutaneous fistulae may occur as a result of anastomotic leakage following loop colostomy reversal. In the absence of abdominal signs a laparotomy is not necessarily required. Signs of wound sepsis may require antibiotics. Because there is not any distal obstruction (note normal pre-operative gastrograffin enema) these fistulae will usually close spontaneously.
A fistula is defined as an abnormal connection between two epithelial surfaces.
There are many types ranging from Branchial fistulae in the neck to entero-cutaneous fistulae abdominally.
In general surgical practice the abdominal cavity generates the majority and most of these arise from diverticular disease and Crohn’s.
As a general rule all fistulae will resolve spontaneously as long as there is no distal obstruction. This is particularly true of intestinal fistulae.
The four types of fistulae are:
Enterocutaneous
These link the intestine to the skin. They may be high (>500ml) or low output (<250ml) depending upon source. Duodenal /jejunal fistulae will tend to produce high volume, electrolyte rich secretions which can lead to severe excoriation of the skin. Colo-cutaneous fistulae will tend to leak faeculent material. Both fistulae may result from the spontaneous rupture of an abscess cavity onto the skin (such as following perianal abscess drainage) or may occur as a result of iatrogenic input. In some cases it may even be surgically desirable e.g. mucous fistula following sub total colectomy for colitis.
Suspect if there is excess fluid in the drain.
Enteroenteric or Enterocolic
This is a fistula that involves the large or small intestine. They may originate in a similar manner to enterocutaneous fistulae. A particular problem with this fistula type is that bacterial overgrowth may precipitate malabsorption syndromes. This may be particularly serious in inflammatory bowel disease.
Enterovaginal
Aetiology as above.
Enterovesicular
This type of fistula goes to the bladder. These fistulas may result in frequent urinary tract infections, or the passage of gas from the urethra during urination.
Management
Some rules relating to fistula management:
They will heal provided there is no underlying inflammatory bowel disease and no distal obstruction, so conservative measures may be the best option
Where there is skin involvement, protect the overlying skin, often using a well fitted stoma bag- skin damage is difficult to treat
A high output fistula may be rendered more easily managed by the use of octreotide, this will tend to reduce the volume of pancreatic secretions.
Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal) these may necessitate the use of TPN to provide nutritional support together with the concomitant use of octreotide to reduce volume and protect skin.
When managing perianal fistulae surgeons should avoid probing the fistula where acute inflammation is present, this almost always worsens outcomes.
When perianal fistulae occur secondary to Crohn’s disease the best management option is often to drain acute sepsis and maintain that drainage through the judicious use of setons whilst medical management is implemented.
Always attempt to delineate the fistula anatomy, for abscesses and fistulae that have an intra abdominal source the use of barium and CT studies should show a track. For perianal fistulae surgeons should recall Goodsall’s rule in relation to internal and external openings.
A 43 year old man has suffered from small bowel Crohns disease for 15 years. Following a recent stricturoplasty he develops an enterocutaneous fistula which is high output. Small bowel follow through shows it to be 15 cm from the DJ flexure. His overlying skin is becoming excoriated.
A. No further action needed B. Intravenous fluids C. Intravenous fluids and nasogastric tube D. Total parenteral nutrition and octreotide E. Defunctioning stoma F. Insertion of seton G. Intravenous octreotide H. Lay open fistula
Total parenteral nutrition and octreotide
This man has a high output and anatomically high fistula. Drying up the fistula with octreotide will not suffice, his nutrition is compromised and TPN will help.
A fistula is defined as an abnormal connection between two epithelial surfaces.
There are many types ranging from Branchial fistulae in the neck to entero-cutaneous fistulae abdominally.
In general surgical practice the abdominal cavity generates the majority and most of these arise from diverticular disease and Crohn’s.
As a general rule all fistulae will resolve spontaneously as long as there is no distal obstruction. This is particularly true of intestinal fistulae.
The four types of fistulae are:
Enterocutaneous
These link the intestine to the skin. They may be high (>500ml) or low output (<250ml) depending upon source. Duodenal /jejunal fistulae will tend to produce high volume, electrolyte rich secretions which can lead to severe excoriation of the skin. Colo-cutaneous fistulae will tend to leak faeculent material. Both fistulae may result from the spontaneous rupture of an abscess cavity onto the skin (such as following perianal abscess drainage) or may occur as a result of iatrogenic input. In some cases it may even be surgically desirable e.g. mucous fistula following sub total colectomy for colitis.
Suspect if there is excess fluid in the drain.
Enteroenteric or Enterocolic
This is a fistula that involves the large or small intestine. They may originate in a similar manner to enterocutaneous fistulae. A particular problem with this fistula type is that bacterial overgrowth may precipitate malabsorption syndromes. This may be particularly serious in inflammatory bowel disease.
Enterovaginal
Aetiology as above.
Enterovesicular
This type of fistula goes to the bladder. These fistulas may result in frequent urinary tract infections, or the passage of gas from the urethra during urination.
Management
Some rules relating to fistula management:
They will heal provided there is no underlying inflammatory bowel disease and no distal obstruction, so conservative measures may be the best option
Where there is skin involvement, protect the overlying skin, often using a well fitted stoma bag- skin damage is difficult to treat
A high output fistula may be rendered more easily managed by the use of octreotide, this will tend to reduce the volume of pancreatic secretions.
Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal) these may necessitate the use of TPN to provide nutritional support together with the concomitant use of octreotide to reduce volume and protect skin.
When managing perianal fistulae surgeons should avoid probing the fistula where acute inflammation is present, this almost always worsens outcomes.
When perianal fistulae occur secondary to Crohn’s disease the best management option is often to drain acute sepsis and maintain that drainage through the judicious use of setons whilst medical management is implemented.
Always attempt to delineate the fistula anatomy, for abscesses and fistulae that have an intra abdominal source the use of barium and CT studies should show a track. For perianal fistulae surgeons should recall Goodsall’s rule in relation to internal and external openings.
A 33 year old lady presented with jaundice secondary to common bile duct stones. A cholecystectomy and common bile duct exploration is performed and the bile duct closed over a T tube. Six weeks post operatively a T tube cholangiogram is performed and shows no residual stones. The T tube is removed and five hours after removal a small amount of bile is noted to be draining from the T tube site.
A. No further action needed B. Intravenous fluids C. Intravenous fluids and nasogastric tube D. Total parenteral nutrition and octreotide E. Defunctioning stoma F. Insertion of seton G. Intravenous octreotide H. Lay open fistula
No further action needed
When the bile duct is closed over a T Tube the latex in the T tube encourages tract fibrosis. This actually encourages a fistula to develop. The result is that when the tube is removed any bile which leaks will usually drain through the tract. Provided that there are no residual stones in the duct the fistula will slowly close. Persistent high volume drainage may be managed with ERCP and sphincterotomy.
A fistula is defined as an abnormal connection between two epithelial surfaces.
There are many types ranging from Branchial fistulae in the neck to entero-cutaneous fistulae abdominally.
In general surgical practice the abdominal cavity generates the majority and most of these arise from diverticular disease and Crohn’s.
As a general rule all fistulae will resolve spontaneously as long as there is no distal obstruction. This is particularly true of intestinal fistulae.
The four types of fistulae are:
Enterocutaneous
These link the intestine to the skin. They may be high (>500ml) or low output (<250ml) depending upon source. Duodenal /jejunal fistulae will tend to produce high volume, electrolyte rich secretions which can lead to severe excoriation of the skin. Colo-cutaneous fistulae will tend to leak faeculent material. Both fistulae may result from the spontaneous rupture of an abscess cavity onto the skin (such as following perianal abscess drainage) or may occur as a result of iatrogenic input. In some cases it may even be surgically desirable e.g. mucous fistula following sub total colectomy for colitis.
Suspect if there is excess fluid in the drain.
Enteroenteric or Enterocolic
This is a fistula that involves the large or small intestine. They may originate in a similar manner to enterocutaneous fistulae. A particular problem with this fistula type is that bacterial overgrowth may precipitate malabsorption syndromes. This may be particularly serious in inflammatory bowel disease.
Enterovaginal
Aetiology as above.
Enterovesicular
This type of fistula goes to the bladder. These fistulas may result in frequent urinary tract infections, or the passage of gas from the urethra during urination.
Management
Some rules relating to fistula management:
They will heal provided there is no underlying inflammatory bowel disease and no distal obstruction, so conservative measures may be the best option
Where there is skin involvement, protect the overlying skin, often using a well fitted stoma bag- skin damage is difficult to treat
A high output fistula may be rendered more easily managed by the use of octreotide, this will tend to reduce the volume of pancreatic secretions.
Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal) these may necessitate the use of TPN to provide nutritional support together with the concomitant use of octreotide to reduce volume and protect skin.
When managing perianal fistulae surgeons should avoid probing the fistula where acute inflammation is present, this almost always worsens outcomes.
When perianal fistulae occur secondary to Crohn’s disease the best management option is often to drain acute sepsis and maintain that drainage through the judicious use of setons whilst medical management is implemented.
Always attempt to delineate the fistula anatomy, for abscesses and fistulae that have an intra abdominal source the use of barium and CT studies should show a track. For perianal fistulae surgeons should recall Goodsall’s rule in relation to internal and external openings.
A 52 year old woman presents with a neck swelling. Her GP reports that her TSH value is low at 0.01. A scintigraphy demonstrates a hot nodule. What is the most likely diagnosis?
Graves disease Toxic adenoma Papillary thyroid cancer Hashimotos thyroiditis De Quervains thyroiditis
This lady has thyrotoxicosis (low TSH) and a hot solitary nodule indicating a toxic adenoma. Thyroid cancer rarely causes thyrotoxicosis or hot nodules.
Causes of hyperthyroidism include: Diffuse toxic goitre (Graves Disease) Toxic nodular goitre Toxic nodule Rare causes
Graves disease
Graves disease is characterised by a diffuse vascular goitre that appears at the same time as the clinical manifestations of hyperthyroidism. It is commonest in younger females and may be associated with eye signs. Thyrotoxic symptoms will predominate. Up to 50% of patients will have a familial history of autoimmune disorders. The glandular hypertrophy and hyperplasia occur as a result of the thyroid stimulating effects of the TSH receptor antibodies.
Toxic nodular goitre
In this disorder the goitre is present for a long period of time prior to the development of clinical symptoms. In most goitres the nodules are inactive and in some cases it is the internodular tissue that is responsible for the hyperthyroidism.
Toxic nodule
Overactive, autonomously functioning nodule. It may occur as part of generalised nodularity or be a true toxic adenoma. The TSH levels are usually low as the autonomously functioning thyroid tissue will exert a negative feedback effect.
Lethargy Tachycardia Emotionally labile Agitation Heat intolerance Hot, moist palms Weight loss Exopthalmos Excessive appetite Thyroid goitre and bruit Palpitations Lid lag/retraction
Diagnosis
The most sensitive test for diagnosing hyperthyroidism is plasma T3 (which is raised). Note in hypothyroidism the plasma T4 and TSH are the most sensitive tests. A TSH level of <0.5U/L suggests hyperthyroidism. TSH receptor antibodies may be tested for in the diagnosis of Graves.
Treatment
First line treatment for Graves disease is usually medical and the block and replace regime is the favored option. Carbimazole is administered at higher doses and thyroxine is administered orally. Patient are maintained on this regime for between 6 and 12 months. Attempts are then made to wean off medication. Where relapse then occurs the options are between ongoing medical therapy, radioiodine or surgery.
A 20 year old complains of severe pain and swelling of the scrotum after a cystoscopy. He had mumps as a child. The testis is tender. The urine dipstick is positive for leucocytes.
A. Haematocele B. Epididymal cyst C. Hydrocele D. Testicular torsion E. Orchitis F. Epididymo-orchitis
Epididymo-orchitis
Epididymo-orchitis: acute pain and swelling after urological intervention. To differentiate from testicular torsion there is usually pyrexia and positive urine dipstick.
Inguinal hernia If inguinoscrotal swelling; cannot “get above it” on examination
Cough impulse may be present
May be reducible
Testicular tumours Often discrete testicular nodule (may have associated hydrocele)
Symptoms of metastatic disease may be present
USS scrotum and serum AFP and β HCG required
Acute epididymo-orchitis Often history of dysuria and urethral discharge
Swelling may be tender and eased by elevating testis
Most cases due to Chlamydia
Infections with other gram negative organisms may be associated with underlying structural abnormality
Epididymal cysts Single or multiple cysts
May contain clear or opalescent fluid (spermatoceles)
Usually occur over 40 years of age
Painless
Lie above and behind testis
It is usually possible to “get above the lump” on examination
Hydrocele Non painful, soft fluctuant swelling
Often possible to “get above it” on examination
Usually contain clear fluid
Will often transilluminate
May be presenting feature of testicular cancer in young men
Testicular torsion Severe, sudden onset testicular pain
Risk factors include abnormal testicular lie
Typically affects adolescents and young males
On examination testis is tender and pain not eased by elevation
Urgent surgery is indicated, the contra lateral testis should also be fixed
Varicocele Varicosities of the pampiniform plexus
Typically occur on left (because testicular vein drains into renal vein)
May be presenting feature of renal cell carcinoma
Affected testis may be smaller and bilateral varicoceles may affect fertility
Management
Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour.
Torsion is commonest in young teenagers and the history in older children can be difficult to elicit. Intermittent torsion is a recognised problem. The treatment is prompt surgical exploration and testicular fixation. This can be achieved using sutures or by placement of the testis in a Dartos pouch.
Varicoceles are usually managed conservatively. If there are concerns about testicular function of infertility then surgery or radiological management can be considered.
Epididymal cysts can be excised using a scrotal approach
Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated.
A 20 year old complains of severe pain in the right scrotal area after jumping onto his moped. He has also noticed discomfort in this area over the past few months. On examination there is a swollen, painful testis that is drawn up into the groin.
A. Haematocele B. Epididymal cyst C. Hydrocele D. Testicular torsion E. Orchitis F. Epididymo-orchitis
Testicular torsion
Testicular torsion: Severe pain which can be spontaneous or precipitated by minor trauma. There is usually severe pain and the patient will often not tolerate the testis being touched. Urgent scrotal exploration is indicated. It is associated with a high investment of the the tunica vaginalis with horizontal testicular lie, or when the epididymis and testis are separated by a mesorchium, in which case the twist occurs at that point.
Inguinal hernia If inguinoscrotal swelling; cannot “get above it” on examination
Cough impulse may be present
May be reducible
Testicular tumours Often discrete testicular nodule (may have associated hydrocele)
Symptoms of metastatic disease may be present
USS scrotum and serum AFP and β HCG required
Acute epididymo-orchitis Often history of dysuria and urethral discharge
Swelling may be tender and eased by elevating testis
Most cases due to Chlamydia
Infections with other gram negative organisms may be associated with underlying structural abnormality
Epididymal cysts Single or multiple cysts
May contain clear or opalescent fluid (spermatoceles)
Usually occur over 40 years of age
Painless
Lie above and behind testis
It is usually possible to “get above the lump” on examination
Hydrocele Non painful, soft fluctuant swelling
Often possible to “get above it” on examination
Usually contain clear fluid
Will often transilluminate
May be presenting feature of testicular cancer in young men
Testicular torsion Severe, sudden onset testicular pain
Risk factors include abnormal testicular lie
Typically affects adolescents and young males
On examination testis is tender and pain not eased by elevation
Urgent surgery is indicated, the contra lateral testis should also be fixed
Varicocele Varicosities of the pampiniform plexus
Typically occur on left (because testicular vein drains into renal vein)
May be presenting feature of renal cell carcinoma
Affected testis may be smaller and bilateral varicoceles may affect fertility
Management
Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour.
Torsion is commonest in young teenagers and the history in older children can be difficult to elicit. Intermittent torsion is a recognised problem. The treatment is prompt surgical exploration and testicular fixation. This can be achieved using sutures or by placement of the testis in a Dartos pouch.
Varicoceles are usually managed conservatively. If there are concerns about testicular function of infertility then surgery or radiological management can be considered.
Epididymal cysts can be excised using a scrotal approach
Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated.
An 8 year old presents with scrotal swelling. He has just recovered from an acute viral illness with swelling of the parotid glands. On examination both testes are tender and slightly swollen.
A. Haematocele B. Epididymal cyst C. Hydrocele D. Testicular torsion E. Orchitis F. Epididymo-orchitis
Orchitis
Orchitis may be associated with mumps viral infections.
Inguinal hernia If inguinoscrotal swelling; cannot “get above it” on examination
Cough impulse may be present
May be reducible
Testicular tumours Often discrete testicular nodule (may have associated hydrocele)
Symptoms of metastatic disease may be present
USS scrotum and serum AFP and β HCG required
Acute epididymo-orchitis Often history of dysuria and urethral discharge
Swelling may be tender and eased by elevating testis
Most cases due to Chlamydia
Infections with other gram negative organisms may be associated with underlying structural abnormality
Epididymal cysts Single or multiple cysts
May contain clear or opalescent fluid (spermatoceles)
Usually occur over 40 years of age
Painless
Lie above and behind testis
It is usually possible to “get above the lump” on examination
Hydrocele Non painful, soft fluctuant swelling
Often possible to “get above it” on examination
Usually contain clear fluid
Will often transilluminate
May be presenting feature of testicular cancer in young men
Testicular torsion Severe, sudden onset testicular pain
Risk factors include abnormal testicular lie
Typically affects adolescents and young males
On examination testis is tender and pain not eased by elevation
Urgent surgery is indicated, the contra lateral testis should also be fixed
Varicocele Varicosities of the pampiniform plexus
Typically occur on left (because testicular vein drains into renal vein)
May be presenting feature of renal cell carcinoma
Affected testis may be smaller and bilateral varicoceles may affect fertility
Management
Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour.
Torsion is commonest in young teenagers and the history in older children can be difficult to elicit. Intermittent torsion is a recognised problem. The treatment is prompt surgical exploration and testicular fixation. This can be achieved using sutures or by placement of the testis in a Dartos pouch.
Varicoceles are usually managed conservatively. If there are concerns about testicular function of infertility then surgery or radiological management can be considered.
Epididymal cysts can be excised using a scrotal approach
Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated.
Which of these factors does not increase the risk of abdominal wound dehiscence following laparotomy?
Jaundice Abdominal compartment syndrome Poorly controlled diabetes mellitus Administration of intravenous steroids Use of Ketamine as an anaesthetic agent
Ketamine does not affect healing. All the other situations in the list carry a strong association with poor healing and risk of dehisence
Abdominal wound dehiscence
This is a significant problem facing all surgeons who undertake abdominal surgery on a regular basis. Traditionally, it is said to occur when all layers of an abdominal mass closure fail and the viscera protrude externally (associated with 30% mortality).
It can be subdivided into superficial, in which the skin wound alone fails and complete, implying failure of all layers.
Factors which increase the risk are:
- Malnutrition
- Vitamin deficiencies
- Jaundice
- Steroid use
- Major wound contamination (e.g. faecal peritonitis)
- Poor surgical technique (Mass closure technique is the preferred method-Jenkins Rule)
When sudden full dehiscence occurs the management is as follows:
- Analgesia
- Intravenous fluids
- Intravenous broad spectrum antibiotics
- Coverage of the wound with saline impregnated gauze (on the ward)
- Arrangements made for a return to theatre
Surgical strategy
Correct the underlying cause (e.g. TPN or NG feed if malnourished)
Determine the most appropriate strategy for managing the wound
Options
Resuturing of the wound This may be an option if the wound edges are healthy and there is enough tissue for sufficient coverage. Deep tension sutures are traditionally used for this purpose.
Application of a wound manager This is a clear dressing with removable front. Particularly suitable when some granulation tissue is present over the viscera or where there is a high output bowel fistula present in the dehisced wound.
Application of a ‘Bogota bag’ This is a clear plastic bag that is cut and sutured to the wound edges and is only a temporary measure to be adopted when the wound cannot be closed and will necessitate a return to theatre for definitive management.
Application of a VAC dressing system These can be safely used BUT ONLY if the correct layer is interposed between the suction device and the bowel. Failure to adhere to this absolute rule will almost invariably result in the development of multiple bowel fistulae and create an extremely difficult management problem.
A 23 year old lady has suffered from diarrhoea for 8 months, she has also lost 2 Kg in weight. At colonoscopy appearances of melanosis coli are identified and confirmed on biopsy
A. Campylobacter jejuni infection B. Salmonella gastroenteritis infection C. Crohns disease D. Ulcerative colitis E. Irritable bowel syndrome F. Ischaemic colitis G. Laxative abuse H. Clostridium difficile infection
Laxative abuse
This may occur as a result of laxative abuse and consists of lipofuschin laden marcophages that appear brown.
World Health Organisation definitions
Diarrhoea: > 3 loose or watery stool per day
Acute diarrhoea < 14 days
Chronic diarrhoea > 14 days
Acute Diarrhoea
Gastroenteritis May be accompanied by abdominal pain or nausea/vomiting
Diverticulitis Classically causes left lower quadrant pain, diarrhoea and fever
Antibiotic therapy More common with broad spectrum antibiotics
Clostridium difficile is also seen with antibiotic use
Constipation causing overflow A history of alternating diarrhoea and constipation may be given
May lead to faecal incontinence in the elderly
Chronic Diarrhoea
Irritable bowel syndrome Extremely common. The most consistent features are abdominal pain, bloating and change in bowel habit. Patients may be divided into those with diarrhoea predominant IBS and those with constipation predominant IBS.
Features such as lethargy, nausea, backache and bladder symptoms may also be present
Ulcerative colitis Bloody diarrhoea may be seen. Crampy abdominal pain and weight loss are also common. Faecal urgency and tenesmus may occur
Crohn’s disease Crampy abdominal pains and diarrhoea. Bloody diarrhoea less common than in ulcerative colitis. Other features include malabsorption, mouth ulcers perianal disease and intestinal obstruction
Colorectal cancer Symptoms depend on the site of the lesion but include diarrhoea, rectal bleeding, anaemia and constitutional symptoms e.g. Weight loss and anorexia
Coeliac disease
In children may present with failure to thrive, diarrhoea and abdominal distension
In adults lethargy, anaemia, diarrhoea and weight loss are seen. Other autoimmune conditions may coexist
Other conditions associated with diarrhoea include:
Thyrotoxicosis
Laxative abuse
Appendicitis with pelvic abscess or pelvic appendix
Radiation enteritis
Diagnosis
Stool culture
Abdominal and digital rectal examination
Consider colonoscopy (radiological studies unhelpful)
Thyroid function tests, serum calcium, anti endomysial antibodies, glucose
A 68 year old lady has recently undergone an abdominal aortic aneurysm repair. The operation was performed electively and was uncomplicated. Since surgery she has had repeated episodes of diarrhoea.
A. Campylobacter jejuni infection B. Salmonella gastroenteritis infection C. Crohns disease D. Ulcerative colitis E. Irritable bowel syndrome F. Ischaemic colitis G. Laxative abuse H. Clostridium difficile infection
Ischaemic colitis
The IMA is commonly ligated during an AAA repair and this may then render the left colon relatively ischaemic, thereby causing mesenteric colitis. Treatment is supportive and most cases will settle with conservative management.
World Health Organisation definitions
Diarrhoea: > 3 loose or watery stool per day
Acute diarrhoea < 14 days
Chronic diarrhoea > 14 days
Acute Diarrhoea
Gastroenteritis May be accompanied by abdominal pain or nausea/vomiting
Diverticulitis Classically causes left lower quadrant pain, diarrhoea and fever
Antibiotic therapy More common with broad spectrum antibiotics
Clostridium difficile is also seen with antibiotic use
Constipation causing overflow A history of alternating diarrhoea and constipation may be given
May lead to faecal incontinence in the elderly
Chronic Diarrhoea
Irritable bowel syndrome Extremely common. The most consistent features are abdominal pain, bloating and change in bowel habit. Patients may be divided into those with diarrhoea predominant IBS and those with constipation predominant IBS.
Features such as lethargy, nausea, backache and bladder symptoms may also be present
Ulcerative colitis Bloody diarrhoea may be seen. Crampy abdominal pain and weight loss are also common. Faecal urgency and tenesmus may occur
Crohn’s disease Crampy abdominal pains and diarrhoea. Bloody diarrhoea less common than in ulcerative colitis. Other features include malabsorption, mouth ulcers perianal disease and intestinal obstruction
Colorectal cancer Symptoms depend on the site of the lesion but include diarrhoea, rectal bleeding, anaemia and constitutional symptoms e.g. Weight loss and anorexia
Coeliac disease
In children may present with failure to thrive, diarrhoea and abdominal distension
In adults lethargy, anaemia, diarrhoea and weight loss are seen. Other autoimmune conditions may coexist
Other conditions associated with diarrhoea include:
Thyrotoxicosis
Laxative abuse
Appendicitis with pelvic abscess or pelvic appendix
Radiation enteritis
Diagnosis
Stool culture
Abdominal and digital rectal examination
Consider colonoscopy (radiological studies unhelpful)
Thyroid function tests, serum calcium, anti endomysial antibodies, glucose
A 23 year old man is admitted to hospital with diarrhoea and severe abdominal pain. He was previously well and his illness has lasted 18 hours.
A. Campylobacter jejuni infection B. Salmonella gastroenteritis infection C. Crohns disease D. Ulcerative colitis E. Irritable bowel syndrome F. Ischaemic colitis G. Laxative abuse H. Clostridium difficile infection
Campylobacter jejuni infection
Severe abdominal pain tends to favour Campylobacter infection.
World Health Organisation definitions
Diarrhoea: > 3 loose or watery stool per day
Acute diarrhoea < 14 days
Chronic diarrhoea > 14 days
Acute Diarrhoea
Gastroenteritis May be accompanied by abdominal pain or nausea/vomiting
Diverticulitis Classically causes left lower quadrant pain, diarrhoea and fever
Antibiotic therapy More common with broad spectrum antibiotics
Clostridium difficile is also seen with antibiotic use
Constipation causing overflow A history of alternating diarrhoea and constipation may be given
May lead to faecal incontinence in the elderly
Chronic Diarrhoea
Irritable bowel syndrome Extremely common. The most consistent features are abdominal pain, bloating and change in bowel habit. Patients may be divided into those with diarrhoea predominant IBS and those with constipation predominant IBS.
Features such as lethargy, nausea, backache and bladder symptoms may also be present
Ulcerative colitis Bloody diarrhoea may be seen. Crampy abdominal pain and weight loss are also common. Faecal urgency and tenesmus may occur
Crohn’s disease Crampy abdominal pains and diarrhoea. Bloody diarrhoea less common than in ulcerative colitis. Other features include malabsorption, mouth ulcers perianal disease and intestinal obstruction
Colorectal cancer Symptoms depend on the site of the lesion but include diarrhoea, rectal bleeding, anaemia and constitutional symptoms e.g. Weight loss and anorexia
Coeliac disease
In children may present with failure to thrive, diarrhoea and abdominal distension
In adults lethargy, anaemia, diarrhoea and weight loss are seen. Other autoimmune conditions may coexist
Other conditions associated with diarrhoea include:
Thyrotoxicosis
Laxative abuse
Appendicitis with pelvic abscess or pelvic appendix
Radiation enteritis
Diagnosis
Stool culture
Abdominal and digital rectal examination
Consider colonoscopy (radiological studies unhelpful)
Thyroid function tests, serum calcium, anti endomysial antibodies, glucose
A 6 year old child presents with colicky abdominal pain, vomiting and the passage of red current jelly stool per rectum. On examination the child has a tender abdomen and a palpable mass in the right upper quadrant. Imaging shows an intussusception. Which of the conditions below is least recognised as a precipitant?
Inflammation of Peyers patches Cystic fibrosis Meckels diverticulum Mesenteric cyst Mucosal polyps
Mesenteric cysts may be associated with intra abdominal catastrophes where these occur they are typically either intestinal volvulus or intestinal infarction. They seldom cause intussusception. Cystic fibrosis may lead to the formation of meconium ileus equivalent and plugs may occasionally serve as the lead points for an intussusception.
Intussusception typically presents with colicky abdominal pain and vomiting. The telescoping of the bowel produces mucosal ischaemia and bleeding may occur resulting in the passage of “red current jelly” stools. Recognised causes include lumenal pathologies such as polyps, lymphadenopathy and diseases such as cystic fibrosis. Idiopathic intussceception of the ileocaecal valve and terminal ileum is the most common variant and typically affects young children and toddlers.
The diagnosis is usually made by abdominal ultrasound investigation. The decision as to the optimal treatment is dictated by the patients physiological status and abdominal signs. In general, children who are unstable with localising peritoneal signs should undergo laparotomy, as should those in whom attempted radiological reduction has failed.
In relatively well children without localising signs attempted pneumatic reduction under fluroscopic guidance is the usual treatment.
A 43 year old female has undergone a renal transplant 12 months previously. Over the past few weeks there have been concerns about deteriorating renal function.
A. Non contrast abdominal CT scan B. DMSA scan C. PET/CT scan D. MAG 3 Renogram E. Renal ultrasound scan F. DTPA Scan G. Micturating cystourethrogram H. Intra venous urography
MAG 3 Renogram
Because it is excreted by renal tubular cells a MAG 3 renogram provides excellent imaging of renal function and is often used in investigating failing transplants.
DMSA scan Dimercaptosuccinic acid (DMSA) scintigraphy DMSA localises to the renal cortex with little accumulation in the renal papilla and medulla. It is useful for the identification of cortical defects and ectopic or aberrant kidneys. It does not provide useful information on the ureter of collecting system.
Diethylene-triamine-penta-acetic acid (DTPA)
This is primarily a glomerular filtration agent. It is most useful for the assessment of renal function. Because it is filtered at the level of the glomerulus it provides useful information about the GFR. Image quality may be degraded in patients with chronic renal impairment and derangement of GFR.
MAG 3 renogram
Mercaptoacetyle triglycine is an is extensively protein bound and is primarily secreted by tubular cells rather than filtered at the glomerulus. This makes it the agent of choice for imaging the kidneys of patients with existing renal impairment (where GFR is impaired).
Micturating cystourethrogram (MCUG scan) This scan provides information relating to bladder reflux and is obtained by filling the bladder with contrast media (via a catheter) and asking the child to void. Images are taken during this phase and the degree of reflux can be calculated
Intra venous urography
This examination is conducted by the administration of intravenous iodinated contrast media. The agent is filtered by the kidneys and excreted and may provide evidence of renal stones or other structural lesions. A rough approximation of renal function may be obtained using the technique. But it is not primarily a technique to be used for this purpose. With the advent of widespread non contrast CT scan protocols for the detection of urinary tract calculi it is now rarely used.
PET/CT
This may be used to evaluate structurally indeterminate lesions in the staging of malignancy.
A 5 year old boy presents with recurrent urinary tract infections and left sided loin pain. On investigation he is found to have a left sided PUJ obstruction, there are concerns that he may have developed renal scarring.
A. Non contrast abdominal CT scan B. DMSA scan C. PET/CT scan D. MAG 3 Renogram E. Renal ultrasound scan F. DTPA Scan G. Micturating cystourethrogram H. Intra venous urography
DMSA scan
Although MAG 3 renograms may provide some information relating to the structural integrity of the kidney, many still consider a DMSA scan to be the gold standard for the detection of renal scarring (which is the main concern in PUJ obstruction and infections).
DMSA scan Dimercaptosuccinic acid (DMSA) scintigraphy DMSA localises to the renal cortex with little accumulation in the renal papilla and medulla. It is useful for the identification of cortical defects and ectopic or aberrant kidneys. It does not provide useful information on the ureter of collecting system.
Diethylene-triamine-penta-acetic acid (DTPA)
This is primarily a glomerular filtration agent. It is most useful for the assessment of renal function. Because it is filtered at the level of the glomerulus it provides useful information about the GFR. Image quality may be degraded in patients with chronic renal impairment and derangement of GFR.
MAG 3 renogram
Mercaptoacetyle triglycine is an is extensively protein bound and is primarily secreted by tubular cells rather than filtered at the glomerulus. This makes it the agent of choice for imaging the kidneys of patients with existing renal impairment (where GFR is impaired).
Micturating cystourethrogram (MCUG scan) This scan provides information relating to bladder reflux and is obtained by filling the bladder with contrast media (via a catheter) and asking the child to void. Images are taken during this phase and the degree of reflux can be calculated
Intra venous urography
This examination is conducted by the administration of intravenous iodinated contrast media. The agent is filtered by the kidneys and excreted and may provide evidence of renal stones or other structural lesions. A rough approximation of renal function may be obtained using the technique. But it is not primarily a technique to be used for this purpose. With the advent of widespread non contrast CT scan protocols for the detection of urinary tract calculi it is now rarely used.
PET/CT
This may be used to evaluate structurally indeterminate lesions in the staging of malignancy.
A 17 year old man is referred to the urology clinic. As a child he was diagnosed as having a right sided PUJ obstruction. However, he was lost to follow up. Over the past 7 months he has been complaining of recurrent episodes of right loin pain. A CT scan shows considerable renal scarring.
A. Non contrast abdominal CT scan B. DMSA scan C. PET/CT scan D. MAG 3 Renogram E. Renal ultrasound scan F. DTPA Scan G. Micturating cystourethrogram H. Intra venous urography
MAG 3 Renogram
In patients with long standing PUJ obstruction and renal scarring the main diagnostic question is whether the individual has sufficient renal function to consider a pyeloplasty or whether a primary nephrectomy is preferable. Since the CT has demonstrated scarring there is no use in obtaining a DMSA scan. Of the investigations listed both a DTPA and MAG 3 renogram will allow assessment of renal function. However, MAG 3 is superior in the assessment of renal function in damaged kidneys (as it is subjected to tubular secretion).
DMSA scan Dimercaptosuccinic acid (DMSA) scintigraphy DMSA localises to the renal cortex with little accumulation in the renal papilla and medulla. It is useful for the identification of cortical defects and ectopic or aberrant kidneys. It does not provide useful information on the ureter of collecting system.
Diethylene-triamine-penta-acetic acid (DTPA)
This is primarily a glomerular filtration agent. It is most useful for the assessment of renal function. Because it is filtered at the level of the glomerulus it provides useful information about the GFR. Image quality may be degraded in patients with chronic renal impairment and derangement of GFR.
MAG 3 renogram
Mercaptoacetyle triglycine is an is extensively protein bound and is primarily secreted by tubular cells rather than filtered at the glomerulus. This makes it the agent of choice for imaging the kidneys of patients with existing renal impairment (where GFR is impaired).
Micturating cystourethrogram (MCUG scan) This scan provides information relating to bladder reflux and is obtained by filling the bladder with contrast media (via a catheter) and asking the child to void. Images are taken during this phase and the degree of reflux can be calculated
Intra venous urography
This examination is conducted by the administration of intravenous iodinated contrast media. The agent is filtered by the kidneys and excreted and may provide evidence of renal stones or other structural lesions. A rough approximation of renal function may be obtained using the technique. But it is not primarily a technique to be used for this purpose. With the advent of widespread non contrast CT scan protocols for the detection of urinary tract calculi it is now rarely used.
PET/CT
This may be used to evaluate structurally indeterminate lesions in the staging of malignancy.
A 35-year-old female is admitted to hospital with hypovolaemic shock. CT abdomen reveals a haemorrhagic lesion in the right kidney. Following surgery and biopsy this is shown to be an angiomyolipomata. What is the most likely underlying diagnosis?
Neurofibromatosis Budd-Chiari syndrome Hereditary haemorrhagic telangiectasia Von Hippel-Lindau syndrome Tuberous sclerosis
Tuberous sclerosis Tuberous sclerosis (TS) is a genetic condition of autosomal dominant inheritance. Like neurofibromatosis, the majority of features seen in TS are neuro-cutaneous
Cutaneous features
depigmented ‘ash-leaf’ spots which fluoresce under UV light
roughened patches of skin over lumbar spine (Shagreen patches)
adenoma sebaceum: butterfly distribution over nose
fibromata beneath nails (subungual fibromata)
café-au-lait spots* may be seen
Neurological features
developmental delay
epilepsy (infantile spasms or partial)
intellectual impairment
Also
retinal hamartomas: dense white areas on retina (phakomata)
rhabdomyomas of the heart
gliomatous changes can occur in the brain lesions
polycystic kidneys, renal angiomyolipomata
*these of course are more commonly associated with neurofibromatosis. However a 1998 study of 106 children with TS found café-au-lait spots in 28% of patients
A 22 year old man is participating in vigorous intercourse and suddenly feels a snap and his penis becomes swollen and painful. The admitting surgeon suspects a penile fracture. Which of the following is the most appropriate initial management?
MRI scan of the penis Immediate surgical exploration CT scan of the penis USS of the penis Cystogram
Suspected penile fractures should be surgically explored and the injury repaired.
Penile fractures are a rare type of urological trauma that may be encountered. The injury is usually in the proximal part of the penile shaft and may involve the urethra. A classically history of a snapping sensation followed by immediate pain is usually given by the patient (usually during vigorous intercourse). On examination there is usually a tense haematoma and blood may be seen at the meatus if the urethra is injured.
When there is a a strong suspicion of the diagnosis the correct management is surgical and a circumferential incision made immediately inferior to the glans. The skin and superficial tissues are stripped back and the penile shaft inspected. Injuries are usually sutured and the urethra repaired over a catheter.
Which of the following does not cause red urine?
Rifampicin Phosphaturia Beetroot Rhubarb Blackberries
Phosphaturia causes cloudy urine not red urine
Causes of haematuria
Trauma
Injury to renal tract
Renal trauma commonly due to blunt injury (others penetrating injuries)
Ureter trauma rare: iatrogenic
Bladder trauma: due to RTA or pelvic fractures
Infection
Remember TB
Malignancy
Renal cell carcinoma (remember paraneoplastic syndromes): painful or painless
Urothelial malignancies: 90% are transitional cell carcinoma, can occur anywhere along the urinary tract. Painless haematuria.
Squamous cell carcinoma and adenocarcinoma: rare bladder tumours
Prostate cancer
Penile cancers: SCC
Renal disease
Glomerulonephritis
Stones
Microscopic haematuria common
Structural abnormalities
Benign prostatic hyperplasia (BPH) causes haematuria due to hypervascularity of the prostate gland
Cystic renal lesions e.g. polycystic kidney disease
Vascular malformations
Renal vein thrombosis due to renal cell carcinoma
Coagulopathy
Causes bleeding of underlying lesions
Drugs
Cause tubular necrosis or interstitial nephritis: aminoglycosides, chemotherapy
Interstitial nephritis: penicillin, sulphonamides, and NSAIDs
Anticoagulants
Benign
Exercise
Gynaecological
Endometriosis: flank pain, dysuria, and haematuria that is cyclical
Iatrogenic
Catheterisation
Radiotherapy; cystitis, severe haemorrhage, bladder necrosis
Pseudohaematuria For example following consumption of beetroot
From the list below, which drug is known to cause haemorrhagic cystitis?
Rifampicin Methotrexate Dexamethasone Leflunomide Cyclophosphamide
Cyclophosphamide is metabolised into a toxic metabolite acrolein. The effects may be attenuated by administration of large volumes of intravenous fluids and mesna (which neutralises the metabolite). The condition may be managed initially by bladder catheterisation and irrigation.
Causes of haematuria
Trauma
Injury to renal tract
Renal trauma commonly due to blunt injury (others penetrating injuries)
Ureter trauma rare: iatrogenic
Bladder trauma: due to RTA or pelvic fractures
Infection
Remember TB
Malignancy
Renal cell carcinoma (remember paraneoplastic syndromes): painful or painless
Urothelial malignancies: 90% are transitional cell carcinoma, can occur anywhere along the urinary tract. Painless haematuria.
Squamous cell carcinoma and adenocarcinoma: rare bladder tumours
Prostate cancer
Penile cancers: SCC
Renal disease
Glomerulonephritis
Stones
Microscopic haematuria common
Structural abnormalities
Benign prostatic hyperplasia (BPH) causes haematuria due to hypervascularity of the prostate gland
Cystic renal lesions e.g. polycystic kidney disease
Vascular malformations
Renal vein thrombosis due to renal cell carcinoma
Coagulopathy
Causes bleeding of underlying lesions
Drugs
Cause tubular necrosis or interstitial nephritis: aminoglycosides, chemotherapy
Interstitial nephritis: penicillin, sulphonamides, and NSAIDs
Anticoagulants
Benign
Exercise
Gynaecological
Endometriosis: flank pain, dysuria, and haematuria that is cyclical
Iatrogenic
Catheterisation
Radiotherapy; cystitis, severe haemorrhage, bladder necrosis
Pseudohaematuria For example following consumption of beetroot
Which one of the following is least likely to cause malabsorption?
Primary biliary cirrhosis Ileo-colic bypass Chronic pancreatitis Whipples disease Hartmans procedure
In a Hartmans procedure the sigmoid colon is removed and an end colostomy is fashioned. The bowel remains in continuity and no absorptive ability is lost.
An ileo-colic bypass leaves a redundant loop of small bowel in continuity, where the contents will stagnate and bacterial overgrowth will occur. Therefore this is recognised cause of malabsorption
Malabsorption is characterised by diarrhoea, steatorrhoea and weight loss. Causes may be broadly divided into intestinal (e.g. villous atrophy), pancreatic (deficiency of pancreatic enzyme production or secretion) and biliary (deficiency of bile-salts needed for emulsification of fats)
Intestinal causes of malabsorption coeliac disease Crohn's disease tropical sprue Whipple's disease Giardiasis brush border enzyme deficiencies (e.g. lactase insufficiency)
Pancreatic causes of malabsorption
chronic pancreatitis
cystic fibrosis
pancreatic cancer
Biliary causes of malabsorption
biliary obstruction
primary biliary cirrhosis
Other causes
bacterial overgrowth (e.g. systemic sclerosis, diverticulae, blind loop)
short bowel syndrome
lymphoma
A 22 year old man presents with his first presentation of ulcerative colitis. Despite aggressive medical management with steroids, azathioprine and infliximab his symptoms remain unchanged and he has developed a megacolon.
A. Proctectomy B. Anterior resection C. Panproctocolectomy D. Panproctocolectomy and ileoanal pouch E. Sub total colectomy F. Right hemicolectomy
Sub total colectomy
In patients with fulminant UC a sub total colectomy is the safest treatment option. The rectum will be left in situ as resection of the rectum in these acutely unwell patients carries an extremely high risk of complications.
Surgery for inflammatory bowel disease
Patients with inflammatory bowel disease (UC and Crohns) frequently present in surgical practice. Ulcerative colitis may be cured by surgical resection (Proctocolectomy), this is not the case in Crohns disease which may recur and affect other areas of the gastrointestinal tract.
Ulcerative colitis
Elective indications for surgery include disease that is requiring maximal therapy, or prolonged courses of steroids.
Longstanding UC is associated with a risk of malignant transformation. Dysplastic transformation of the colonic epithelium with associated mass lesions is an absolute indication for a proctocolectomy.
Emergency presentations of poorly controlled colitis that fails to respond to medical therapy should usually be managed with a sub total colectomy. Excision of the rectum is a procedure with a higher morbidity and is not generally performed in the emergency setting. An end ileostomy is usually created and the rectum either stapled off and left in situ, or, if the bowel is very oedematous, may be brought to the surface as a mucous fistula.
Patients with IBD have a high incidence of DVT and appropriate thromboprophylaxis is mandatory.
Restorative options in UC include an ileoanal pouch. This procedure can only be performed whilst the rectum is in situ and cannot usually be undertaken as a delayed procedure following proctectomy.
Ileoanal pouch complications include, anastomotic dehiscence, pouchitis and poor physiological function with seepage and soiling.
Crohns disease
Surgical resection of Crohns disease does not equate with cure, but may produce substantial symptomatic improvement.
Indications for surgery include complications such as fistulae, abscess formation and strictures.
Extensive small bowel resections may result in short bowel syndrome and localised stricturoplasty may allow preservation of intestinal length.
Staging of Crohns will usually involve colonoscopy and a small bowel study (e.g. MRI enteroclysis).
Complex perianal fistulae are best managed with long term draining seton sutures, complex attempts at fistula closure e.g. advancement flaps, may be complicated by non healing and fistula recurrence.
Severe perianal and / or rectal Crohns may require proctectomy. Ileoanal pouch reconstruction in Crohns carries a high risk of fistula formation and pouch failure and is not recommended.
Terminal ileal Crohns remains the commonest disease site and these patients may be treated with limited ileocaecal resections.
Terminal ileal Crohns may affect enterohepatic bile salt recycling and increase the risk of gallstones.
A 22 year old lady has a long history of severe perianal Crohns disease with multiple fistulae. She is keen to avoid a stoma. However, she has progressive disease and multiple episodes of rectal bleeding. A colonoscopy shows rectal disease only and a small bowel study shows no involvement with Crohns.
A. Proctectomy B. Anterior resection C. Panproctocolectomy D. Panproctocolectomy and ileoanal pouch E. Sub total colectomy F. Right hemicolectomy
Proctectomy
Severe rectal Crohns that has developed complications such as haemorrhage and multiple fistulae is usually best managed with proctectomy. Although a diverting stoma may reduce the risk of local sepsis it is unlikely to reduce the bleeding. She is keen to conserve a rectum, however, an ileoanal pouch in this setting is unwise.
Surgery for inflammatory bowel disease
Patients with inflammatory bowel disease (UC and Crohns) frequently present in surgical practice. Ulcerative colitis may be cured by surgical resection (Proctocolectomy), this is not the case in Crohns disease which may recur and affect other areas of the gastrointestinal tract.
Ulcerative colitis
Elective indications for surgery include disease that is requiring maximal therapy, or prolonged courses of steroids.
Longstanding UC is associated with a risk of malignant transformation. Dysplastic transformation of the colonic epithelium with associated mass lesions is an absolute indication for a proctocolectomy.
Emergency presentations of poorly controlled colitis that fails to respond to medical therapy should usually be managed with a sub total colectomy. Excision of the rectum is a procedure with a higher morbidity and is not generally performed in the emergency setting. An end ileostomy is usually created and the rectum either stapled off and left in situ, or, if the bowel is very oedematous, may be brought to the surface as a mucous fistula.
Patients with IBD have a high incidence of DVT and appropriate thromboprophylaxis is mandatory.
Restorative options in UC include an ileoanal pouch. This procedure can only be performed whilst the rectum is in situ and cannot usually be undertaken as a delayed procedure following proctectomy.
Ileoanal pouch complications include, anastomotic dehiscence, pouchitis and poor physiological function with seepage and soiling.
Crohns disease
Surgical resection of Crohns disease does not equate with cure, but may produce substantial symptomatic improvement.
Indications for surgery include complications such as fistulae, abscess formation and strictures.
Extensive small bowel resections may result in short bowel syndrome and localised stricturoplasty may allow preservation of intestinal length.
Staging of Crohns will usually involve colonoscopy and a small bowel study (e.g. MRI enteroclysis).
Complex perianal fistulae are best managed with long term draining seton sutures, complex attempts at fistula closure e.g. advancement flaps, may be complicated by non healing and fistula recurrence.
Severe perianal and / or rectal Crohns may require proctectomy. Ileoanal pouch reconstruction in Crohns carries a high risk of fistula formation and pouch failure and is not recommended.
Terminal ileal Crohns remains the commonest disease site and these patients may be treated with limited ileocaecal resections.
Terminal ileal Crohns may affect enterohepatic bile salt recycling and increase the risk of gallstones.
A 22 year old man has a long history of ulcerative colitis. His symptoms are well controlled with steroids. However, attempts at steroid weaning and use of steroid sparing drugs have repeatedly failed. He wishes to avoid a permanent stoma.
A. Proctectomy B. Anterior resection C. Panproctocolectomy D. Panproctocolectomy and ileoanal pouch E. Sub total colectomy F. Right hemicolectomy
Panproctocolectomy and ileoanal pouch
In patients with UC where medical management is not successful, surgical resection may offer a chance of cure. Those patients wishing to avoid a permanent stoma may be considered for an ileoanal pouch. However, this procedure is only offered in the elective setting.
Surgery for inflammatory bowel disease
Patients with inflammatory bowel disease (UC and Crohns) frequently present in surgical practice. Ulcerative colitis may be cured by surgical resection (Proctocolectomy), this is not the case in Crohns disease which may recur and affect other areas of the gastrointestinal tract.
Ulcerative colitis
Elective indications for surgery include disease that is requiring maximal therapy, or prolonged courses of steroids.
Longstanding UC is associated with a risk of malignant transformation. Dysplastic transformation of the colonic epithelium with associated mass lesions is an absolute indication for a proctocolectomy.
Emergency presentations of poorly controlled colitis that fails to respond to medical therapy should usually be managed with a sub total colectomy. Excision of the rectum is a procedure with a higher morbidity and is not generally performed in the emergency setting. An end ileostomy is usually created and the rectum either stapled off and left in situ, or, if the bowel is very oedematous, may be brought to the surface as a mucous fistula.
Patients with IBD have a high incidence of DVT and appropriate thromboprophylaxis is mandatory.
Restorative options in UC include an ileoanal pouch. This procedure can only be performed whilst the rectum is in situ and cannot usually be undertaken as a delayed procedure following proctectomy.
Ileoanal pouch complications include, anastomotic dehiscence, pouchitis and poor physiological function with seepage and soiling.
Crohns disease
Surgical resection of Crohns disease does not equate with cure, but may produce substantial symptomatic improvement.
Indications for surgery include complications such as fistulae, abscess formation and strictures.
Extensive small bowel resections may result in short bowel syndrome and localised stricturoplasty may allow preservation of intestinal length.
Staging of Crohns will usually involve colonoscopy and a small bowel study (e.g. MRI enteroclysis).
Complex perianal fistulae are best managed with long term draining seton sutures, complex attempts at fistula closure e.g. advancement flaps, may be complicated by non healing and fistula recurrence.
Severe perianal and / or rectal Crohns may require proctectomy. Ileoanal pouch reconstruction in Crohns carries a high risk of fistula formation and pouch failure and is not recommended.
Terminal ileal Crohns remains the commonest disease site and these patients may be treated with limited ileocaecal resections.
Terminal ileal Crohns may affect enterohepatic bile salt recycling and increase the risk of gallstones.
A 32 year old man is admitted with a distended tense abdomen. He previously underwent a difficult appendicectomy 1 year previously and was discharged. At laparotomy the abdomen is filled with a gelatinous substance.
A. Metastatic adenocarcinoma of the pancreas B. Metastatic appendiceal carcinoid C. Metastatic colonic cancer D. Pseudomyxoma peritonei E. MALT lymphoma F. Retroperitoneal liposarcoma G. Retroperitoneal fibrosis
Pseudomyxoma peritonei
Pseudomyxoma is classically associated with mucin production and the appendix is the commonest source.
Pseudomyxoma peritoneii- Curative treatment is peritonectomy (Sugarbaker procedure) and heated intra peritoneal chemotherapy.
Pseudomyxoma Peritonei
Rare mucinous tumour
Most commonly arising from the appendix (other abdominal viscera are also recognised as primary sites)
Incidence of 1-2/1,000,000 per year
The disease is characterised by the accumulation of large amounts of mucinous material in the abdominal cavity
Treatment
Is usually surgical and consists of cytoreductive surgery (and often peritonectomy c.f Sugarbaker procedure) combined with intra peritoneal chemotherapy with mitomycin C.
Survival is related to the quality of primary treatment and in Sugarbakers own centre 5 year survival rates of 75% have been quoted. Patients with disseminated intraperitoneal malignancy from another source fare far worse.
In selected patients a second look laparotomy is advocated and some practice this routinely.
