Surgical questions 3 Flashcards
What radiographical findings would you look for in a patient with suspected kidney stones? What are the soft tissue rim and tail signs?
The stones themselves
Hydronephrosis or hydroureter
Perinephric fluid
In the soft tissue rim sign, stones may be surrounded by a rim of soft tissue, which can help differentiate between phleboliths.
The tail sign is where a soft tissue opacity extends away from the stone like a tail and is consistent with a pelvic phlebolith.
What are the complications of kidney stones?
Ureteric stricture from passage of the stone
Acute or chronic pyelonephritis
Renal failure due to obstruction
Intrarenal or perinephric abscess
Xanthogranulomatous pyelonephritis - a type of chronic bacterial pyelonephritis characterised by destruction of renal parenchyma and presence of granulomas and abscesses. Nephrectomy is the standard treatment.
Urince extravasation into the pelvic cavity.
What are the investigations for acute lower GI haemorrhage that may be considered to localise the site of bleeding?
Colonoscopy
Mesenteric angiography - particularly useful for detecting angiodysplasia and can be accompanied by embolisation
CT angiography - but lack of therapeutic capability
Technetium-99m-labelled red blood cell scintigraphy - can detect small amounts of bleeding.
Upper GI endoscopy (80% of GI haemorrhage is upper)
Gastric lavage - to rule out UGI bleed
Small bowel visualisation by enteroscopy or video capsule endoscopy.
What is the treatment for Boerhaave’s oesophagus?
Resuscitation, PPI antibiotics, antifungals and surgery (debridement of mediastinum and placement of T-tube for drainage and formation of a controlled oesophagocutaneous fistula)
What are the causes of vertigo?
Peripheral: Meniere’s disease, BPPV, vestibular failure, labyrinthitis, cholesteatoma
Central: acoustic neuroma, MS, head injury, inner ear syphilis, vertebrobasilar insufficiency
Drugs: gentamicin, diuretics, co-trimoxazole and metronidazole
What is Meniere’s disease?
Dilatation of the endolymphatic spaces of the membranous labyrinth causes vertigo for around 12 hours with prostration, nausea/vomiting and a feeling of fullness in the ears. Can have uni- or bilateral tinnitus and sensorineural deafness. Attacks occur in clusters
How is Meniere’s disease diagnosed?
Electrocochleography
Endolymphatic space MRI
How do you treat Meniere’s disease?
Prochlorperazine as Buccastem if vomiting
Surgical approaches e.g. endolymphatic shunts
Labyrinthectomy may stop vertigo but causes ipsilateral deafness. Vestibular neurectomy spares hearing
Day case instillation of ototoxic drugs
What is BPPV?
Attacks of sudden rotational vertigo lasting approx 30s which are provoked by head turning. this is due to displacement of otoconia in the semicircular canals.
What are the causes of BPPV?
Idiopathic Middle ear disease Head injury Otosclerosis Spontaneous labyrinthine degeneration Post-viral illness Stapes surgery (perilypmh leak)
How should BPPV be treated?
Usually self-limiting --> reassurance Try vestibular rehabilitation exercises Reduce alcohol Betahistine/prochlorperazine Epley manoeuvres Last resort - posterior semicircular canal denervation
What is acute vestibular failure?
It follows a febrile illness e.g. in winter/ HSV-1 and causes sudden vertigo, vomiting and prostration which are exacerbated by head movement.
How do you treat acute vestibular failure?
Cyclizine
Improvement occurs within days although recover occurs within 2-3 weeks/longer if elderly.
Methylprednisolone may also help.
What is the anatomical definition of lower GI haemorrhage?
LGI haemorrhage refers to bleeding that arises distal to the ligament of Treitz at the duodeno-jejunal junction.
What is the anatomical significance of the dentate line?
The dentate or pectinate line represents an anatomical watershed that separates different epithelial cell types, arterial supply, venous drainage, lymphatic drainage and nervous supply.
Above: columnar epithelium, supplied by the superior rectal artery (inferior mesenteric) and drained via portal circulation. It drains into the mesenteric nodes and is innervated by autonomic fibres.
Below: lined by stratified squamous epithelium and supplied by the inferior rectal artery (branches of the internal iliac) and drained into the systemic circulation via internal iliac veins. Lymphatic drainage is inguinal nodes. Supplied by somatic fibres.
What are the known risk factors for colorectal cancer?
Increasing age
Male sex (rectal carcinoma)
Central oebesity
Colorectal disease: IBD, previous history of colorectal cancer, colorectal polyps, previous irradiation
Familial conditions including: FAP, HNPCC, Peutz-Jegher’s, Juvenile polyposis, Cowden’s disease, MYH-related polyposis
Sedentary lifestyle
What are the main complications of urethral bladder catheterisation?
Urethral trauma
Urethral scarring and stricture
Creation of a false passage in the urethera
Urinary tract infection, especially with Proteus
Bladder perforation
What are the complications of chronic urinary retention?
Urinary incontinence due to overflow Urinary tract infection Bladder stones Hydronephrosis Renal failure secondary to hydronephrosis Acute-on-chronic urinary retention Bladder wall hypertrophy
Which drugs commonly cause urinary retention?
Any drug with anti-muscarinic effects, especially:
- antihistamines (e.g. chlorpheniramine, cetirizine)
- tricyclic antidepressants
- drugs used to treat urinary incontinence e.g. tolterodine, oxybutynin
Is the PSA useful for detecting prostate cancer?
Yes if the patient has possibly symptoms.
Yes if the PSA >10ng/ml as it is likely to be prostate cancer.
N, if the PSA turns out to be between 3-10ng/ml as the patient will then then anxious, may have to undergo a significant procedure and then be diagnosed with a prostate cancer that would never have caused any problems.
Define stoma
An artificial opening of an internal tube that has been brought to the surface.
What are the top three causes for renal transplantation?
Glomerulonephritis
Diabetic nephropathy
PKD
What are the top three reasons for liver transplantation?
Cirrhosis
Acute hepatic failure (hep A and B, paracetamol overdose)
Hepatic malignancy
What problems may occur following transplantation?
Rejection - acute or chronic
Infection secondary to immunosuppression
Increased risk of other pathologies, including skin malignancy, post-transplant lymphoproliferative disease, and hypertension and hyperlipidaemia causing cardiovascular disease
Disease recurrence
Chronic graft dysfunction
Psychological
