Surgical Radiology Mushkies Flashcards
Achalasia defn?
Focal motility disorder of the oesophagus caused by degeneration of the myenteric plexus of Auerbach
Causes of achalasia?
- Usually idiopathic
2. Can be secondary to Chagas disease
Achalasia presentation?
- Dysphagia to solids then liquids
- Retrosternal cramps
- Regurgitation esp. at night +/- aspiration pneumonia
- Weight loss
Ix of achalasia?
- Ba swallow
- CXR = wide mediastinum + double RH border
- Manometry = failure of relaxation and reduced peristalsis
- OGD = exclude oesophageal SCC
Mx of achalasia?
- Med = CCB, nitrates
- Interventional = botox injection, endoscopic balloon dilatation
- Surgical = Heller’s cardiomyotomy (open or lap)
Achalasia on barium swallow?
- Proximal dilatation of the oesophagus with smooth distal tapering (bird’s beak appearance)
- May be food particles visible
- Significant negative = apple core stricture suggestive of oesophageal SCC (occurs in 3% pts with achalasia)
Oesophageal carcinoma epidemiology?
5M:1F, Transkei and China
Pathophysiology of oesophageal carcinoma?
- Adenocarcinoma (65%) = lower 1/3rd, GORD –> Barrett’s –> dysplasia –> Ca
- SCC (35%) = upper 2/3rds, association with EtOH and smoking, commonest type worldwide
Oesophageal carcinoma spread?
Local –> LNs –> blood
Major RFs for oesophageal carcinoma?
- GORD –> Barrett’s
- EtOH and smoking
- Achalasia
- Plummer-Vinson (20% risk of SCC)
Presentation of oesophageal carcinoma?
- Progressive dysphagia
- Weight loss
- Upper 3rd = hoarseness and bovine cough
Oesophageal carcinoma Ix?
- Dx = OGD + biopsy
2. Staging = CT, EUS, laparoscopy, mediastinoscopy
Oesophageal carcinoma Mx?
- MDT
- Oesophagectomy = 25% have resectable tumours
- Palliation = 75%
Oesophagectomy types?
- Ivor-Lewis (2 stage)
- McKeown (3 stage)
- 15% 5 year survival
Oesophagectomy palliation?
- Analgesia
- Laser coagulation
- Stenting
- 5% 5 year surivival
Oesophageal cancer on imaging?
Irregular, shouldered stricture of the oesophagus (‘apple core’ lesion)
Pharyngeal pouch aka?
Zenker’s diverticulum
Pharyngeal pouch on imaging?
Contrast filling of blind-ended pouch adjacent to and in continuity with the oesophagus
Hiatus hernia classification?
- Sliding = 80%
- Rolling = 15%
- Mixed = 5%
Sliding hiatus hernia fx?
- GOJ slides up into chest
2. Often associated with GORD
Rolling hiatus hernia fx?
- GOJ remains in abdomen but a bulge of stomach rolls into chest alongside the oesophagus
- LOS remains intact so GORD uncommon
- Can –> strangulation
Presentation of hiatus hernia?
- Often symptomatic
- Sliding = GORD (dyspepsia)
- Rolling = strangulation
Hiatus hernia Ix?
- CXR = gas bubble and fluid level in chest
- Ba swallow = diagnostic
- OGD = for oesophagitis
- 24hr pH + manometry = exclude dysmotility or achalasia, confirm reflux
Hiatus hernia Mx?
- Conservative = weight loss, raise head of bed, stop smoking
- Medical = PPis, H2RAs
- Surgical = if intractable symptoms despite medical treatment, should repair rolling hernia (even if asymptomatic, as it may strangulate)
Imaging of small bowel obstruction?
- AXR
- Erect CXR
- CT with oral contrast = transition point
- Gastrograffin follow through = may be therapeutic if adhesional obstruction
Mx of small bowel mechanical obstruction?
- Regular clinical examination for signs of strangulation
- Consider need for parenteral nutrition
- 80% resolve without surgery
- Laporotomy +/- adhesioloysis +/- resection +/- stoma
Indication for surgical mx of small bowel mechanical obstruction?
- Failure of conservative Mx = up to 72 hours
- Development of sepsis
- Peritonitis
- Evidence of strangulation
Mx of small bowel ileus?
- Correct any underlying abnormalities = electrolytes, drugs
- Consider need for parenteral nutrition
Fx of small bowel obstruction on imaging?
- Dilated loops of bowel >=3cm in width
- Centrally located, many loops, many fluid levels
- Valvulae conniventes = lines go completely across
- No gas in large bowel
Fx of large bowel obstruction on imaging?
- Dilated loops of bowel >=6cm in width
- Peripherally located, fewer loops
- Haustra = lines go partially across
- No gas in rectum
Mx of large bowel obstruction?
- Regular clinical examination for signs of strangulation
- Consider need for parenteral nutrition
- Non-surgical = endoscopic stenting, may offer a bridge to surgery
- Surgical = Hartmann’s, colectomy w/ primary anastomosis, palliative bypass procedure
Indications for surgical mx of large bowel obstruction?
- Closed loop obstruction
- Obstructing neoplasm
- Strangulation or perforation
- Failure of conservative mx
2 types of large bowel volvulus on imaging?
- Emerging from LIF = sigmoid (commoner)
2. Emerging from RIF = caecal
Pathophysiology of volvulus?
- Long mesentery with short base predisposes to torsion
- Vascular supply may be compromised –> strangulation
- Increased risk in psychogeriatric pts (disease and Rx)
- Typically a long hx of constipation
Presentation of volvulus?
- Often in elderly pts with comorbidities
2. Grossly distended, tympanic abdomen
Mx of sigmoid volvulus?
- Resus = drip and suck
- Detorse with flatus tube
- May need sigmoid colectomy
- Often recurs
Mx of caecal volvulus?
- Resus = drip and suck
- 10% can be detorsed with colonoscopy
- Often needs surgery = caecostomy/right hemi with primary ileocolic anastomosis
Gastric volvulus film?
- Gastric dilatation
2. Double bubble on erect films
Presentation of gastric volvulus?
- Vomiting
- Pain
- Failed attempts to pass NGT
RFs for gastric volvulus?
- Roling hiatus hernia
2. Gastric/oesophageal surgery
Mx of gastric volvulus?
- Endoscopic manipulation
2. Emergency laparotomy
Chronic pancreatitis on AXR?
Horizontal speckled calcification at L1/L2
AAA on AXR?
Fusiform calcification in the midline
Fusiform definition?
Tapered at both ends
Gallstones on AXR?
Cluster of circular calcifications at L1
Rigler’s triad?
- SBO
- Pneumobilia
- Gallstone in RIF
Rigler’s sign?
Air on both sides of bowel wall
Mx of foreign body on AXR?
- Unstable = theatre
- Stable = endoscopic removal/watch and wait with serial radiographs
- Batteries = oesophagus (remove), stomach (sage)
- Large sharp objects = may consider laparotomy
Perforated viscus on AXR?
- Air under the diaphragm
2. Rigler’s sign
Ddx of air under diaphragm/Rigler’s sign?
- Spontaneous = perforated DU
- Iatrogenic = laparotomy/laparoscopy
- Traumatic
- Misc = via female genital tract
Presentation of perforated viscus?
- Sudden onset severe epigastric pain
- Vomiting
- Peritonitic abdomen
Perforated viscus on CXR and AXR?
- CXR = upright for 15 mins first, 70% show free air
2. AXR = Rigler’s sign
Duodenal perforation Mx?
Abdominal washout and omental patch repair
Gastric perforation Mx?
Excise ulcer and repair defect, and send specimen for histology to ecxlude Ca
What is 90% positive in perforated Duodenal ulcers?
H. pylori
Clinical signs of tension pneumothorax?
- Resp distress
- Raised JVP, reduced BP
- Tracheal shift and displaced apex
- Hyper-resonance to percussion
- Reduced breath sounds
- Reduced vocal resonance
Pathophysiology of tension pneumothorax?
- One way flap valve allows air to be drawn into pleural cavity on each inspiration without escape
- Mediastinal shift compresses the great vessels, preventing filling of the heart –> shock
Diverticulum definition?
Outpouching of a tubular structure
Pathophysiology of diverticulosis?
- 30% of Westerners by 60 y/o
- F>M
- High intraluminal pressures –> herniation of mucosa throughout muscularis propria at points of weakness where perforating arteries enter
Saint’s triad?
- DIverticular disease
- Hiatus hernia
- Cholelithiasis
Mx of diverticular disease?
- High fibre diet, mebeverine may help
2. Elective laparoscopic sigmoid colectomy
Mebevirine?
Anti-spasmodic
Ix of choice for diverticulitis?
CT has very high sensitivity and specificity
Hinchey grading?
- Small confined pericolic abscess (<5% mortality)
- Large abscesses extending into pelvis (<5%)
- Purulent peritonitis (15%)
- Faecal peritonitis (45%)
Mx of perforated diverticulum?
- Resus = admit, NBM, fluids, Abx
- 1-2 = surgery rarely needed
- On table washout may suffice
- Hartmanss
Complications of diverticular disease?
- Obstruction (strictures)
- Perforation
- Haemorrhage
- Fistulae
- Abscess
Colorectal cancer on imaging?
- Typically a double-contrast enema
2. Apple-core stricture with shouldered margins
Diverticulosis imaging?
Double-contrast enema
RFs for colorectal cancer?
- Diet
- IBD
- Familial = FAP, HNPCC, Peutz Jeghers
- Smoking
- Genetics
Dukes staging for colorectal Ca?
A. Confined to bowel wall
B. Through bowel wall but no LNs
C. Regional LNs
D. Distant mets
UC imaging?
Double-contrast enema
UC features on double-contrast enema?
- Lead piping
- Mucosal thickening +/- thumbprinting
- Pseudopolyps
CD features on imaging?
- Rose thorn ulcers
- String sign of Kantor
- Cobblestoning
- Skip lesions
Gallstones on imaging?
- Stones –> acoustic shadow
- Dilated ducts >6mm +/- stones in ducts
- Inflamed gallbladder = wall oedema
ERCP therapeutics?
- Sphincterotomy + trawling of ducts allow stone removal
2. Strictures may be stented or dilated
Complications of ERCP?
- Pancreatitis
- Bleeding
- Bowel perforation
- Contrast allergy
Advantages of MRCP?
Non-invasive and no contrast necessary
What can ERCP and MRCP show on film?
- Filling defects
- Strictures
- Duct dilatation
Mx of acute cholecystitis?
- Conservative = 80-90% settle over 24-48 hrs
- Medical = Abx –> cefuroxime and metronidazole
- Surgical = If <72hrs may perform hot gallbladder, otherwise elective lap chole @ 6-12 weeks
Nephrolithiasis stone types?
- Calcium oxalate = 75%
- Magnesium ammonium phosphate = 15%
- Urate = 5%
- Cystine = 1%
Condition associated with cystine stones?
Fanconi syndrome
Pathophysiology of nephrolithiasis?
- Increased conc of urinary solute
- Decreased urine volume
- Urinary stasis
Common anatomical sites of nephrolithiasis?
- Pelvi-ureteric junction
- Pelvic brim
- Vesico-ureteric junction
Nephrolithiasis Mx?
- Initial = analgesia, IV fluids
- Conservative = <5mm, 90-95% pass spontaneously
- Medical = 5-10mm, nifedipine/tamsulosin, most pass w/in 48h
- Active stone removal
Active stone removal indications?
- Stones >10mm
- Persistent obstruction
- Renal insufficiency
- Infection
Active stone removal procedures?
- ESWL
- Uretero-renoscopy + Dormier basket
- Percutaneous nephrolithotomy
- Lap/open stone removal
Febrile with renal obstruction?
- Surgical emergency
- Percutaneous nephrostomy or ureteric stent
- IV Abx = e.g. cefuroxime 1.5g IV TDS
Extradural haematoma shape?
Lentiform opacification
Subdural haematoma shape?
Sickle-shaped
Types of brain injury?
- Primary = time of injury as a direct result of injury
2. Secondary = after primary injury
Primary brain injury types?
- Diffuse = concussion (temporary reduction in brain function), diffuse axonal injury
- Focal = contusion, intracranial haemorrhage
Secondary brain injury causes?
- Raised ICP
- Infection
- Hypoxia/hypercapnia
- Hypotension
Monroe-Kelly Doctrine?
- Cranium is a rigid box –> total volume of intracranial contents must remain constant if ICP is not to change
- Increase in volume of one constituent –> compensatory reduction in another
- Blood, CSF, Brain
- These mechanisms can compensate for a volume change of 100ml before ICP increases
- As autoregulation fails, ICP rapidly increases –> herniation
Cushing reflex is indicative of?
Imminent herniation due to raised ICP
Cushing reflex?
- Hypertension
- Bradycardia
- Irregular breathing
NICE indications for Head CT?
- Basal/depressed skull fracture
- Amnesia >30m retrograde
- Neurology = seizures, focal weakness, blown pupil
- GCS<13 at scene or <15 2hr after trauma
- Persistent vomiting
Digital Subtraction Angiography?
A fluoroscopy technique used in interventional radiology to clearly visualize blood vessels in a bony or dense soft tissue environment
Mx of acute limb ischaemia?
- Resus = NBM, hydration, analgesia
- Unfractionated heparin IVI = prevent thrombus expansion
- Angiography = only if incomplete occlusion
- Surgery = embolectomy with fogarty catheter, emergency reconstruction
Complications of mx of acute ischaemia?
- Reperfusion injury –> compartment syndrome
2. Chronic pain syndromes
Fogarty arterial embolectomy catheter?
Remove fresh emboli in the arterial system
Mx of chronic limb ischaemia?
- Non-surgical = RF control, analgesia, graded exercise programmes (walk through pain)
- Interventional = angioplasty +/- stenting
- Surgical = reconstruction, endarterectomy, amputation
Hip fracture imaging?
- Orthogonal views = AP and lateral
- Follow Shenton’s lines
- Intra-or extracapsular
- Displaced or non-displaced (Garden classification)
Classification of hip fracture?
- Intracapsular = subcapital, transcervical, basicervical
2. Extracapsular = intertrochanteric, subtrochanteric
Garden classification of intracapsular fractures?
- Incomplete, undisplaced
- Complete, undisplaced
- Complete, partially displaced
- Complete, completely displaced
Mx of intracapsular fractures?
- Garden 1/2 = ORIF with cancellous screws
2. Garden 3/4 = <55 (ORIF with screws), >55 (THR or hemiarthroplasty)
Mx of extracapsular fractures?
ORIF with DHS
Specific complications of hip fracture?
- AVN of femoral hear in displaced fractures
- Non/mal-union
- Infection
- Osteoarthritis
Typical shoulder dislocation?
Typically anterior dislocation with humeral head located antero-inferiorly
2 types of special shoulder lesion?
- Bankhart lesion
2. Hill-Sachs lesion
Bankhart lesion?
Damage to glenoid labrum
Hill-Sachs lesion?
Cortical depression in posterolateral part of humeral head
Presentation of shoulder dislocation?
- Severe pain
- Loss of shoulder contour
- Humeral head palpable in infraclavicular fossa
Complications of shoulder dislocation?
- Axillary nerve injury
2. Recurrent dislocation = 90% pts <20 y/o with traumatic dislocation
Mx of shoulder dislocation?
- Resuscitate
- Analgesia
- Assess NV deficit
- Reduction under sedation e.g. propofol
- Sling for 3-4 weeks
- Physio
Types of shoulder dislocation reduction?
- Hippocratic
2. Kocher’s
Hippocratic reduction?
Longitudinal traction with arm in 30 degrees and counter traction at the axilla
Kocher’s reduction?
External rotation of adducted arm, anterior movement, internal rotation
Femoral and tibial fractures imaging?
Request AP and lateral films
Gustillo classification of open fractures?
- Wound <1cm in length
- Wound >1cm in length with minimal soft tissue damage
- Extensive soft tissue damage
Most dangerous complication of open fracture?
C. perfringens
Complication of femoral fractures?
- Hypovolaemic shock
- NV = SFA and sciatic nerve
- Fat embolism
Complication of tibial fractures?
- Compartment syndrome
- NV injury
- Fat embolism
Mx of femoral and tibial fractures?
- Resus and Mx life threatening injuries first
- Assess neurovascular status of limb = urgent angio if distal pulses compromised
- Cross match
- Open specific management
- Debridement and fixation in theatre = ORIF/Ex-fix
Cross match amount for femoral fractures?
4 units
Cross match amount for tibial fractures?
2 units
Specific Mx of open femoral and tibial fractures?
6 As
- Analgesia = morphine and metoclopramide
- Assess = NV status + photo
- Asepsis = wash, cover with sterile soaked gauze
- Alignment = reduce and splint
- Abx = augmentin 1.2g IV
- Anti-tetanus
Colles’ fracture?
- Extra-articular fracture of the distal radius
- Dorsal displacement of the distal fragment
- Dorsal angulation of the distal fragment
- +/- avulsion of ulna styloid
- Extras = reduced radial height and inclination, loss of volar tilt
Mx of Colles’ fracture?
- Resuscitate + Mx life threatening injuries
- Assess NV injury = median nerve and radial artery
- Reduction and fixation
- Fracture clinical appointment for ortho assessment
Reduction and fixation of Colles’ fracture?
- Haematoma block or Bier’s block (with prilocaine)
2. Dorsal backslab with 3 point pressure
Specific complications of Colles’ fracture?
- Median nerve injury
- Tendon rupture esp. EPL
- Carpal tunnel syndrome
- Mal/non-union
- Frozen shoulder/adhesive capsulitis
Monteggia fracture?
- Fracture of proximal third of ulnar shaft
- Anterior dislocation of radial head at capitellum
- May –> palsy of deep branch of radial nerve –> weak finger extension but no sensory loss
Galleazz fracture?
- Fracture of radial shaft between middle and distal 2rd
2. Dislocation of distal radio-ulnar joint
Classification of supracondylar humeral fracture?
- Extension = distal fragment displaces posteriorly
2. Flexion = distal fragment displaced anteriorly
Complications of supracondylar humeral fracture?
- NV = brachial artery and median nerve mainly
- Compartment syndrome
- Mal-union = gunstock deformity (cubitus varus)
Proximal humerus fracture complications?
- Surgical neck = axillary nerve damage
2. Shaft = radial nerve damage
Mx of proximal humerus fracture?
Collar and cuff or ORIF
Weber classification?
Distal fibula fracture, relation of fracture to joint line
A. Below joint line
B. at joint line
C. above joint line
Significance of Weber B and C fracture?
Possible injury to the syndesmotic ligaments between tibia and fibula –> Instability
Most common Salter-Harris fracture?
SH2
Salter-Harris fracture with greatest risk to physis?
SH5
Young and Burgess classification?
Pelvic fracture
- Lateral compression = ipsilateral pubic rami fractures
- AP compression = open book fracture
- Vertical shear = inherently unstable
Complications of pelvic fracture?
- Haemorrhage
- Urethral injury
- Bladder injury
Complications of fractures?
- General complications
2. Specific complications
General complications of fracture?
- Tissue damage = haemorrhage and shock, infection, rhabdo
- Anaesthesia = anaphylaxis, teeth damage, aspiration
- Prolonged bed rest = Infection, pressure sores, muscle wasting, VTE, reduced BMD
Specific complications of fracture?
- Immediate
- Early
- Late
Specific immediate complications of fractures?
- Neurovascular
2. Visceral
Specific early complications of fractures?
- Infection
- Compartment syndrome
- Fat embolism –> ARDS
Specific late complications of fractures?
- AVN
- Union problems
- Growth disturbance
- Post-traumatic osteoarthritis
- CRPS
- Myositis ossificans
Nerve injury classification?
Seddon classification
Seddon classification of nerve injury?
- Neuropraxia = temporary interruption of conduction
- Axonotmesis = disruption of axon with preservation of connective tissue framework, recovery possible
- Neurotmesis = disruption of entire nerve fibre, recovery incomplete
Problems with union?
- Delayed union = longer than expected
- Non-union = fails to unite
- Mal-union = unites in imperfect position
Causes of problems with union?
5 Is
- Infection
- Ischaemia
- Interfragmentary movement
- Interposition of soft tissue
- Intercurrent illness
Mx of problems with union?
- Optimise biology = infection, bone graft, blood supply, BMPs
- Optimise mechanics = ORIF
Myositis ossificans?
- Heterotopic ossification of muscle at sites of haematoma formation
- Leads to restricted, painful movement
- Commonly affects the elbow and quadriceps
Myositis ossificans Mx?
Excise