Surgery/Urology Flashcards
Most common causes of acute abdominal pain
Nonspecific - 43%
Acute appendicitis - 4-20%
Acute cholecystitis - 3-9%
SBO - 4%
Uterolithiasis - 4%
Most common, non-obstetric cause of surgical emergency in pregnancy
Appendicitis
2 causes of appendicitis
Obstructing faecolith (adults)
Enlarged mesenteric lymph node (children)
Best signs of appendicitis in adults vs children
Adults:
RLQ pain
Periumbilical pain localising to RIF
Abdominal rigidity
Children:
Decreased bowel sounds
Positive psoas sign - extension hip
Positive obturator sign - internal rotation thigh
Positive Rovsing’s sign
Complications of appendicitis
Perforation 17-32%
Peritonitis
Intraabdominal abscess
Bowel obstruction
Sepsis
Causes of pancreatitis
Idiopathic
Gallstones
ETOH
Trauma
Steroids
Mumps, malignancy
Autoimmune
Scorpion sting
Hypercalcaemia, hyperlipidaemia
ERCP
Drugs
Pathognomonic signs of pancreatitis
Cullen’s sign - periumbilical subcutaeneous ecchymosis and oedema
Grey Turner sign - flank bruising
Atlanta criteria for diagnosis of pancreatitis
- Abdominal pain suggestive of pancreatitis
- Raised serum lipase/amylase x3 normal limit
- Characteristic findings on radiological imaging
Risk factors for AAA
Screening criteria:
Male
>65
Smoker
HTN
Atherosclerosis
Connective tissue disorder
Hyperlipidaemia
70 male with acute severe abdominal pain and haematuria.
Diagnosis not to miss:
AAA rupture involving renal arteries
Lifetime risk of AAA rupture of diameters:
5cm
6cm
7cm
5cm - 20%
6cm - 40%
7cm - 50%
4 types of bowel obstruction
Small bowel obstruction
Large bowel obstruction
Ileus
Psuedoobstruction (Parkinson’s, MS, hypothyroidism, Hirschsprung, diabetic neuropathy)
Diverticular disease
- location by ethnicity
- Age group prevalence
Caucasian - sigmoid colon
Asian - ascending colon
Age 40+, 65% prevalence by age 85
Management of diverticulitis in community
Mild uncomplicated - analgesia, liquid diet 2-3 days
Consider abx in patients with comorbidities, systemically unwell (but not for hospital), no improvement in 48 hours:
Metronidazole 400mg tds 5-7 days
PLUS
Cotrimoxazole 960mg BD 5 days
OR
Amoxicillin 500mg tds 7 days
OR
Cefalexin 500mg 2-3 times/day 5 days
OR
Augmentin 625mg tds 5 days
Risk factors for renal stones
Family hx renal stone
Prev renal stone
Chronic dehydration
Abnormality of renal tract
Obesity
Hyperparathyroidism
Gout
Idiopathic hypercalciuria
Referrral criteria for ureteric stones
Fever >38 deg
Pain uncontrolled
Bilateral stones
Stone >7mm
Known renal disease
Solitary kidney
Creatinine >160
Peritonitis
Obstructive causes of urinary retention
Neoplasm
Calculus
Blood clot
Faecal impaction
Strictures
FB
Men: BPH, phimosis, paraphimosis
Women: pelvic organ prolapse, pregnancy
Infection/inflammatory causes of urinary retention
Varicella
Lyme disease
Cystitis
Urethritis
HSV
Men: balanitis, prostatitis, prostatic abscess
Women: vulvovagnitis, Behcet disease, vaginal skin disease
Medication causes of urinary retention
Anticholinergics
Antihistamines
Antihypertensives
Antidepressants
Anti-Parkinson’s
Antipsychotics
Muscle relaxants
Sympathomimetics
Beta adrenergic
Neurological causes of urinary retention
Diabetic cystopathy
Spinal cord injury
Cauda equina
Spinal abscess
Guillain Barre
CVA
MS
AUA scoring for BPH severity
In the past month:
1. Frequency of sensation of not complete emptying
2. Frequency of repeat urination within 2 hours
3. Frequency of stopping and starting multiple times during void
4. Difficult to postpone urination
5. Weak stream
6. Push or strain to urinate
7. Number of time urinating overnight
Scoring 0-5 - none, less than 20%, less than half, half, more than half, always
Mild 0-7, moderate 8-19, severe 20-35
Criteria for post obstructive diuresis
Risk >1.5L draining post IDC
Creatinine >200
> 200mL/hour for 2 hours
3L over 24 hours
Replace with IVF 50% previous hour’s urine output
Risk for gallstones
Fat, female, fair (European), fertile (pre-menopausal), forty
Family hx
Sudden weight loss
Diabetes
Oral contraceptive
Pregnancy
Haemolytic disorder
Charcot’s triad for ascending cholangitis
RUQ pain
Jaundice
Fever
Complications of gallstones
Mirizzi syndrome
Gallstone ileus
Gallbladder cancer
Differentiating internal haemorrhoids vs external haemorrhoids
Internal:
- Above dentate line
- No sensation (visceral innervation)
- Rectal mucosal lining
- Grade 1 - bulge into lumen
- Grade 2 - Prolapse with straining, spontaneous reduction
- Grade 3 - Prolapse with straining, manual reduction
- Grade 4 - Prolapsed and non-reducible, risk of strangulation
External:
- Below dentate line
- Painful (somatic innervation)
- Squamous epithelium
High risk features for colorectal cancer
Family history
Personal hx ca or polyps
Persistent change in bowel habit
Blood mixed in stools
Tenesmus
Unexplained weight loss
Iron deficiency anaemia
Risks for haemorrhoids
Constipation
Frequent defecation
Pregnancy
Prolonged sitting
Causes of mesenteric ischaemia
Arterial thromboembolism
- Age >60
- AF
- Vasculopath
- Smoker
- Recent MI
- Valvular heart disease
- Aortic atherosclerosis/aneurysm
Venous thrombosis
- Younger patients
- Hypercoagulable
- Dehydration
- Portal HTN
- Abdominal infection
- Blunt trauma
- Pancreatitis
- Splenectomy
- Portal malignancy
Mesenteric ischaemia vs colonic ischaemia presentation
Mesenteric:
Age >50
Usually has precipitating medical cause
Pain more severe
Patient seriously ill
Colonic:
>90
Can have predisposing lesion - ca, stricture, diverticulitis, faecal impaction
Moderate rectal bleeding/bloody diarrhoea
Xray findings of ischaemic bowel
Thumb printing/thickened bowel loops
Air in portal vein (late finding)
Risk factors for anal fissure
Constipation
IBD
Trauma
Anal cancer
STI, HIV
Childbirth and pregnancy
Locations for anal fissures
Posterior midline - most common
Anterior midline - 8-25%
Lateral regions - consider Crohn’s, malignancy, HIV, TB
Management of anal fissures
Topical anaesthetic gel
Topical GTN/diltiazem
Stool softeners
Frequent warm baths
Chronic (>6 weeks) - consider botox, internal sphinterotomy
Acute referral
- Large bleeding
- Concurrent infection/abscess
Areas of abscess and fistula extension for complex perianal abscess
Ischiorectal abscess - in ischiorectal fossa
Intersphincteric abscess - Between internal and external anal sphincters
Fistulae:
- Intersphincteric
- Transphincteric
- Suprasphinteric
- Extrasphincteric
Risk factors for perianal abscess
Male
Mean age 40
Diabetes, immunocompromised
STI
Anal fissures
Crohn’s disease
Receptive anal intercourse
2 types of mastitis/breast abscess and microbial causes
Lactational
- Milk stasis, nipple damaged, latch problems, missed feeds/pump
- Usually peripheral breast
- Staph aureus,
Staph epidermidis, Strep
- Fluclox 1g tds 5-7 days
Non-lactational
- Squamous metaplasia of lactiferous ducts causing blockage
- Usually periareolar/subareolar
- Cracked, damaged nipples
- Aerobic and anaerobic bacteria
- Augmentin 625mg tds 7 days
Signs and symptoms of ischaemic limb
Pain
Pallor
Paraesthesia
Pulselessness
Poikylothermia
Paralysis
Palpable lump in testis, no pain or mild ache, possible concurrent hydrocoele
Dx? Management?
Testicular ca - 97% germinal seminoma
Average age 32
> urgent USS
Gradual increasing unilateral testicular pain. Fever, discharge.
Tender swollen epididymis, normal cremasteric reflex.
Dx? Mangement?
Epididymitis
Most common cause of painful testicular swelling in post-pubertal males
- STI in sexually active to age 35
- UTI pathogen in others
STI swabs, MSU, contact trace and treat partners last 3 months, no intercourse for 2 weeks and 7 days after contacts treated
Ceftriaxone 500mg IM stat + doxycycline 100mg BD 14 days
If UTI - augmentin 625mg tds 10 days
OR cotrimoxazole 960mg BD 10 days OR ciprofloxacin 500mg BD 10 days
Dull ache/throbbing in scrotum, worse on prolonged standing, “bag of worms” scrotal swelling
Dx? Management?
Varicocoele
Cause of reversible infertility
NSAIDs
Supportive underwear
Varicocoelectomy
Painless scrotal swelling, not reducible, transilluminable
Hydrocoele
Presents in infancy or adulthood
Self-limiting in children (patent processus vaginalis)
Adults - aspirate and USS to r/o malignancy, infection
Sudden onset testicular pain and high fever, nausea and vomiting. Testicle enlarged, indurated, tender.
Orchitis
Check parotid glands to rule out mumps
Scrotal support
Ice
Bed rest
Abx if indicated
Mumps orchitis risk of infertility
Painful, red, firm scrotal mass. Vomiting. Irreducible. Non transilluminating.
Incarcerated inguinal hernia
Acute general surgery referral
Acute severe testicular pain, swelling, ecchymosis, vomiting. Hx trauma.
Testicular rupture/haematoma
Acute urology referral
Risk groups for testicular torsion
Neonates - undescended testes
Age 12-25
FHx or PHx testicular torsion
Bell clapper deformity
Acute severe testicular pain, no fever, blue dot sign on scrotum
Torsion of testicular appendage
Need to rule out torsion
Acute severe testicular pain, no fever, nausea and vomiting, abnormal gait.
May have hx preceding intermittent episodes.
High riding testicle, suprapubic tenderness, abnormal ipsilateral cremasteric reflex
Urgent paeds surg/urology referral
Surgical exploration within 6 hours of onset
Causes of priapism
- Idiopathic - most common
- Blunt trauma
- Intracavernosal injection of medication
- Medications - anticoagulants, antipsychotics, sildenafil
- Drugs - alcohol, cannabis, cocaine
- Sickle cell disease - ischaemic priapism
Priapism:
Presentation
Examination
Management
Persistent erection >2 hours in absence of sexual excitation
Engorged corpora cavernosa, flaccid corpus spongiosum and glans
Analgesia
Ice
Walk up stairs (arterial steal)
Refer to urology if not resolving
Complications of paraphimosis
Ischaemia
Skin necrosis
Penile necrosis
Glans infarct
Gangrene
Urinary obstruction
Bladder distension
Post reduction scarring, phimosis
Management of paraphimosis
Analgesia, lignocaine gel/EMLA
Ice method - wrap penis in glove, ice over swollen foreskin
Osmotic agent - do not use if penile necrosis.
- Sugar - apply to glans, cover, 2 hours
- 50% dextrose - soak in gauze, apply to glans, cover, 1 hour
- 20% mannitol - soak in gauze, apply to glans, cover, 45 mins
Compression - wrap compressive bandage distal > proximal. Leave for 20 mins
Manual reduction - lubricant, draw swollen foreskin forward, push glans backwards
Advice:
- No retraction 1/52
- No sexual intercourse
- Avoid irritants
- Observe for infection
Bacterial causes of acute prostatitis
Gram-negative organisms (E. coli, Klebsiella, Proteus, Enterococcus)
Pseudomonas in IDUC
STI
Trimethoprim 300mg OD 2-4 weeks
Ciprofloxacin 500mg BD 4 weeks
Complicated, risk of resistance (recent travel Middle East, Asia, Africa) - Cefalexin 500mg BD/augmentin 625mg BD 2-4 weeks
4-6 weeks if chronic
Complications of prostatitis
Chronic prostatitis
Chronic pelvic pain
Prostatic abscess
Bacteraemia
Epididymitis
Spinal/sacroiliac infection
Endocarditis (valvular disease)
Symptoms and signs of prostatitis
Fever, malaise
Perineal pain
dysuria, frequency, slow flow, urgency
Prostate on DRE: firm, oedematous, tender +++
Definition of microscopic haematuria
> 20x10^6/L RBC in 2 of 3 properly collected midstream urine specs, 7 days apart
No evidence of infection
Causes of haematuria
Renal trauma
Renal disease
Acute glomerulonephritis (acute HTN, oliguria, oedema, ACR >30, red cell casts, rise eGFR)
Cystitis, pyelonephritis
Renal calculus
Prostatitis
BPH
Prostate ca
Menses
Vigorous exercise
Recent urological instrumentation
Bladder ca
Rupture AAA
