Surgical Radiology Mushkies Flashcards
1
Q
Achalasia defn?
A
Focal motility disorder of the oesophagus caused by degeneration of the myenteric plexus of Auerbach
2
Q
Causes of achalasia?
A
- Usually idiopathic
2. Can be secondary to Chagas disease
3
Q
Achalasia presentation?
A
- Dysphagia to solids then liquids
- Retrosternal cramps
- Regurgitation esp. at night +/- aspiration pneumonia
- Weight loss
4
Q
Ix of achalasia?
A
- Ba swallow
- CXR = wide mediastinum + double RH border
- Manometry = failure of relaxation and reduced peristalsis
- OGD = exclude oesophageal SCC
5
Q
Mx of achalasia?
A
- Med = CCB, nitrates
- Interventional = botox injection, endoscopic balloon dilatation
- Surgical = Heller’s cardiomyotomy (open or lap)
6
Q
Achalasia on barium swallow?
A
- 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)
7
Q
Oesophageal carcinoma epidemiology?
A
5M:1F, Transkei and China
8
Q
Pathophysiology of oesophageal carcinoma?
A
- Adenocarcinoma (65%) = lower 1/3rd, GORD –> Barrett’s –> dysplasia –> Ca
- SCC (35%) = upper 2/3rds, association with EtOH and smoking, commonest type worldwide
9
Q
Oesophageal carcinoma spread?
A
Local –> LNs –> blood
10
Q
Major RFs for oesophageal carcinoma?
A
- GORD –> Barrett’s
- EtOH and smoking
- Achalasia
- Plummer-Vinson (20% risk of SCC)
11
Q
Presentation of oesophageal carcinoma?
A
- Progressive dysphagia
- Weight loss
- Upper 3rd = hoarseness and bovine cough
12
Q
Oesophageal carcinoma Ix?
A
- Dx = OGD + biopsy
2. Staging = CT, EUS, laparoscopy, mediastinoscopy
13
Q
Oesophageal carcinoma Mx?
A
- MDT
- Oesophagectomy = 25% have resectable tumours
- Palliation = 75%
14
Q
Oesophagectomy types?
A
- Ivor-Lewis (2 stage)
- McKeown (3 stage)
- 15% 5 year survival
15
Q
Oesophagectomy palliation?
A
- Analgesia
- Laser coagulation
- Stenting
- 5% 5 year surivival
16
Q
Oesophageal cancer on imaging?
A
Irregular, shouldered stricture of the oesophagus (‘apple core’ lesion)
17
Q
Pharyngeal pouch aka?
A
Zenker’s diverticulum
18
Q
Pharyngeal pouch on imaging?
A
Contrast filling of blind-ended pouch adjacent to and in continuity with the oesophagus
19
Q
Hiatus hernia classification?
A
- Sliding = 80%
- Rolling = 15%
- Mixed = 5%
20
Q
Sliding hiatus hernia fx?
A
- GOJ slides up into chest
2. Often associated with GORD
21
Q
Rolling hiatus hernia fx?
A
- GOJ remains in abdomen but a bulge of stomach rolls into chest alongside the oesophagus
- LOS remains intact so GORD uncommon
- Can –> strangulation
22
Q
Presentation of hiatus hernia?
A
- Often symptomatic
- Sliding = GORD (dyspepsia)
- Rolling = strangulation
23
Q
Hiatus hernia Ix?
A
- CXR = gas bubble and fluid level in chest
- Ba swallow = diagnostic
- OGD = for oesophagitis
- 24hr pH + manometry = exclude dysmotility or achalasia, confirm reflux
24
Q
Hiatus hernia Mx?
A
- 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)
25
Imaging of small bowel obstruction?
1. AXR
2. Erect CXR
3. CT with oral contrast = transition point
4. Gastrograffin follow through = may be therapeutic if adhesional obstruction
26
Mx of small bowel mechanical obstruction?
1. Regular clinical examination for signs of strangulation
2. Consider need for parenteral nutrition
3. 80% resolve without surgery
4. Laporotomy +/- adhesioloysis +/- resection +/- stoma
27
Indication for surgical mx of small bowel mechanical obstruction?
1. Failure of conservative Mx = up to 72 hours
2. Development of sepsis
3. Peritonitis
4. Evidence of strangulation
28
Mx of small bowel ileus?
1. Correct any underlying abnormalities = electrolytes, drugs
2. Consider need for parenteral nutrition
29
Fx of small bowel obstruction on imaging?
1. Dilated loops of bowel >=3cm in width
2. Centrally located, many loops, many fluid levels
3. Valvulae conniventes = lines go completely across
4. No gas in large bowel
30
Fx of large bowel obstruction on imaging?
1. Dilated loops of bowel >=6cm in width
2. Peripherally located, fewer loops
3. Haustra = lines go partially across
4. No gas in rectum
31
Mx of large bowel obstruction?
1. Regular clinical examination for signs of strangulation
2. Consider need for parenteral nutrition
3. Non-surgical = endoscopic stenting, may offer a bridge to surgery
4. Surgical = Hartmann's, colectomy w/ primary anastomosis, palliative bypass procedure
32
Indications for surgical mx of large bowel obstruction?
1. Closed loop obstruction
2. Obstructing neoplasm
3. Strangulation or perforation
4. Failure of conservative mx
33
2 types of large bowel volvulus on imaging?
1. Emerging from LIF = sigmoid (commoner)
| 2. Emerging from RIF = caecal
34
Pathophysiology of volvulus?
1. Long mesentery with short base predisposes to torsion
2. Vascular supply may be compromised --> strangulation
3. Increased risk in psychogeriatric pts (disease and Rx)
4. Typically a long hx of constipation
35
Presentation of volvulus?
1. Often in elderly pts with comorbidities
| 2. Grossly distended, tympanic abdomen
36
Mx of sigmoid volvulus?
1. Resus = drip and suck
2. Detorse with flatus tube
3. May need sigmoid colectomy
4. Often recurs
37
Mx of caecal volvulus?
1. Resus = drip and suck
2. 10% can be detorsed with colonoscopy
3. Often needs surgery = caecostomy/right hemi with primary ileocolic anastomosis
38
Gastric volvulus film?
1. Gastric dilatation
| 2. Double bubble on erect films
39
Presentation of gastric volvulus?
1. Vomiting
2. Pain
3. Failed attempts to pass NGT
40
RFs for gastric volvulus?
1. Roling hiatus hernia
| 2. Gastric/oesophageal surgery
41
Mx of gastric volvulus?
1. Endoscopic manipulation
| 2. Emergency laparotomy
42
Chronic pancreatitis on AXR?
Horizontal speckled calcification at L1/L2
43
AAA on AXR?
Fusiform calcification in the midline
44
Fusiform definition?
Tapered at both ends
45
Gallstones on AXR?
Cluster of circular calcifications at L1
46
Rigler's triad?
1. SBO
2. Pneumobilia
3. Gallstone in RIF
47
Rigler's sign?
Air on both sides of bowel wall
48
Mx of foreign body on AXR?
1. Unstable = theatre
2. Stable = endoscopic removal/watch and wait with serial radiographs
3. Batteries = oesophagus (remove), stomach (sage)
4. Large sharp objects = may consider laparotomy
49
Perforated viscus on AXR?
1. Air under the diaphragm
| 2. Rigler's sign
50
Ddx of air under diaphragm/Rigler's sign?
1. Spontaneous = perforated DU
2. Iatrogenic = laparotomy/laparoscopy
3. Traumatic
4. Misc = via female genital tract
51
Presentation of perforated viscus?
1. Sudden onset severe epigastric pain
2. Vomiting
3. Peritonitic abdomen
52
Perforated viscus on CXR and AXR?
1. CXR = upright for 15 mins first, 70% show free air
| 2. AXR = Rigler's sign
53
Duodenal perforation Mx?
Abdominal washout and omental patch repair
54
Gastric perforation Mx?
Excise ulcer and repair defect, and send specimen for histology to ecxlude Ca
55
What is 90% positive in perforated Duodenal ulcers?
H. pylori
56
Clinical signs of tension pneumothorax?
1. Resp distress
2. Raised JVP, reduced BP
3. Tracheal shift and displaced apex
4. Hyper-resonance to percussion
5. Reduced breath sounds
6. Reduced vocal resonance
57
Pathophysiology of tension pneumothorax?
1. One way flap valve allows air to be drawn into pleural cavity on each inspiration without escape
2. Mediastinal shift compresses the great vessels, preventing filling of the heart --> shock
58
Diverticulum definition?
Outpouching of a tubular structure
59
Pathophysiology of diverticulosis?
1. 30% of Westerners by 60 y/o
2. F>M
3. High intraluminal pressures --> herniation of mucosa throughout muscularis propria at points of weakness where perforating arteries enter
60
Saint's triad?
1. DIverticular disease
2. Hiatus hernia
3. Cholelithiasis
61
Mx of diverticular disease?
1. High fibre diet, mebeverine may help
| 2. Elective laparoscopic sigmoid colectomy
62
Mebevirine?
Anti-spasmodic
63
Ix of choice for diverticulitis?
CT has very high sensitivity and specificity
64
Hinchey grading?
1. Small confined pericolic abscess (<5% mortality)
2. Large abscesses extending into pelvis (<5%)
3. Purulent peritonitis (15%)
4. Faecal peritonitis (45%)
65
Mx of perforated diverticulum?
1. Resus = admit, NBM, fluids, Abx
2. 1-2 = surgery rarely needed
3. On table washout may suffice
4. Hartmanss
66
Complications of diverticular disease?
1. Obstruction (strictures)
2. Perforation
3. Haemorrhage
4. Fistulae
5. Abscess
67
Colorectal cancer on imaging?
1. Typically a double-contrast enema
| 2. Apple-core stricture with shouldered margins
68
Diverticulosis imaging?
Double-contrast enema
69
RFs for colorectal cancer?
1. Diet
2. IBD
3. Familial = FAP, HNPCC, Peutz Jeghers
4. Smoking
5. Genetics
70
Dukes staging for colorectal Ca?
A. Confined to bowel wall
B. Through bowel wall but no LNs
C. Regional LNs
D. Distant mets
71
UC imaging?
Double-contrast enema
72
UC features on double-contrast enema?
1. Lead piping
2. Mucosal thickening +/- thumbprinting
3. Pseudopolyps
73
CD features on imaging?
1. Rose thorn ulcers
2. String sign of Kantor
3. Cobblestoning
4. Skip lesions
74
Gallstones on imaging?
1. Stones --> acoustic shadow
2. Dilated ducts >6mm +/- stones in ducts
3. Inflamed gallbladder = wall oedema
75
ERCP therapeutics?
1. Sphincterotomy + trawling of ducts allow stone removal
| 2. Strictures may be stented or dilated
76
Complications of ERCP?
1. Pancreatitis
2. Bleeding
3. Bowel perforation
4. Contrast allergy
77
Advantages of MRCP?
Non-invasive and no contrast necessary
78
What can ERCP and MRCP show on film?
1. Filling defects
2. Strictures
3. Duct dilatation
79
Mx of acute cholecystitis?
1. Conservative = 80-90% settle over 24-48 hrs
2. Medical = Abx --> cefuroxime and metronidazole
3. Surgical = If <72hrs may perform hot gallbladder, otherwise elective lap chole @ 6-12 weeks
80
Nephrolithiasis stone types?
1. Calcium oxalate = 75%
2. Magnesium ammonium phosphate = 15%
3. Urate = 5%
4. Cystine = 1%
81
Condition associated with cystine stones?
Fanconi syndrome
82
Pathophysiology of nephrolithiasis?
1. Increased conc of urinary solute
2. Decreased urine volume
3. Urinary stasis
83
Common anatomical sites of nephrolithiasis?
1. Pelvi-ureteric junction
2. Pelvic brim
3. Vesico-ureteric junction
84
Nephrolithiasis Mx?
1. Initial = analgesia, IV fluids
2. Conservative = <5mm, 90-95% pass spontaneously
3. Medical = 5-10mm, nifedipine/tamsulosin, most pass w/in 48h
4. Active stone removal
85
Active stone removal indications?
1. Stones >10mm
2. Persistent obstruction
3. Renal insufficiency
4. Infection
86
Active stone removal procedures?
1. ESWL
2. Uretero-renoscopy + Dormier basket
3. Percutaneous nephrolithotomy
4. Lap/open stone removal
87
Febrile with renal obstruction?
1. Surgical emergency
2. Percutaneous nephrostomy or ureteric stent
3. IV Abx = e.g. cefuroxime 1.5g IV TDS
88
Extradural haematoma shape?
Lentiform opacification
89
Subdural haematoma shape?
Sickle-shaped
90
Types of brain injury?
1. Primary = time of injury as a direct result of injury
| 2. Secondary = after primary injury
91
Primary brain injury types?
1. Diffuse = concussion (temporary reduction in brain function), diffuse axonal injury
2. Focal = contusion, intracranial haemorrhage
92
Secondary brain injury causes?
1. Raised ICP
2. Infection
3. Hypoxia/hypercapnia
4. Hypotension
93
Monroe-Kelly Doctrine?
1. Cranium is a rigid box --> total volume of intracranial contents must remain constant if ICP is not to change
2. Increase in volume of one constituent --> compensatory reduction in another
3. Blood, CSF, Brain
4. These mechanisms can compensate for a volume change of 100ml before ICP increases
5. As autoregulation fails, ICP rapidly increases --> herniation
94
Cushing reflex is indicative of?
Imminent herniation due to raised ICP
95
Cushing reflex?
1. Hypertension
2. Bradycardia
3. Irregular breathing
96
NICE indications for Head CT?
1. Basal/depressed skull fracture
2. Amnesia >30m retrograde
3. Neurology = seizures, focal weakness, blown pupil
4. GCS<13 at scene or <15 2hr after trauma
5. Persistent vomiting
97
Digital Subtraction Angiography?
A fluoroscopy technique used in interventional radiology to clearly visualize blood vessels in a bony or dense soft tissue environment
98
Mx of acute limb ischaemia?
1. Resus = NBM, hydration, analgesia
2. Unfractionated heparin IVI = prevent thrombus expansion
3. Angiography = only if incomplete occlusion
4. Surgery = embolectomy with fogarty catheter, emergency reconstruction
99
Complications of mx of acute ischaemia?
1. Reperfusion injury --> compartment syndrome
| 2. Chronic pain syndromes
100
Fogarty arterial embolectomy catheter?
Remove fresh emboli in the arterial system
101
Mx of chronic limb ischaemia?
1. Non-surgical = RF control, analgesia, graded exercise programmes (walk through pain)
2. Interventional = angioplasty +/- stenting
3. Surgical = reconstruction, endarterectomy, amputation
102
Hip fracture imaging?
1. Orthogonal views = AP and lateral
2. Follow Shenton's lines
3. Intra-or extracapsular
4. Displaced or non-displaced (Garden classification)
103
Classification of hip fracture?
1. Intracapsular = subcapital, transcervical, basicervical
| 2. Extracapsular = intertrochanteric, subtrochanteric
104
Garden classification of intracapsular fractures?
1. Incomplete, undisplaced
2. Complete, undisplaced
3. Complete, partially displaced
4. Complete, completely displaced
105
Mx of intracapsular fractures?
1. Garden 1/2 = ORIF with cancellous screws
| 2. Garden 3/4 = <55 (ORIF with screws), >55 (THR or hemiarthroplasty)
106
Mx of extracapsular fractures?
ORIF with DHS
107
Specific complications of hip fracture?
1. AVN of femoral hear in displaced fractures
2. Non/mal-union
3. Infection
4. Osteoarthritis
108
Typical shoulder dislocation?
Typically anterior dislocation with humeral head located antero-inferiorly
109
2 types of special shoulder lesion?
1. Bankhart lesion
| 2. Hill-Sachs lesion
110
Bankhart lesion?
Damage to glenoid labrum
111
Hill-Sachs lesion?
Cortical depression in posterolateral part of humeral head
112
Presentation of shoulder dislocation?
1. Severe pain
2. Loss of shoulder contour
3. Humeral head palpable in infraclavicular fossa
113
Complications of shoulder dislocation?
1. Axillary nerve injury
| 2. Recurrent dislocation = 90% pts <20 y/o with traumatic dislocation
114
Mx of shoulder dislocation?
1. Resuscitate
2. Analgesia
3. Assess NV deficit
4. Reduction under sedation e.g. propofol
5. Sling for 3-4 weeks
6. Physio
115
Types of shoulder dislocation reduction?
1. Hippocratic
| 2. Kocher's
116
Hippocratic reduction?
Longitudinal traction with arm in 30 degrees and counter traction at the axilla
117
Kocher's reduction?
External rotation of adducted arm, anterior movement, internal rotation
118
Femoral and tibial fractures imaging?
Request AP and lateral films
119
Gustillo classification of open fractures?
1. Wound <1cm in length
2. Wound >1cm in length with minimal soft tissue damage
3. Extensive soft tissue damage
120
Most dangerous complication of open fracture?
C. perfringens
121
Complication of femoral fractures?
1. Hypovolaemic shock
2. NV = SFA and sciatic nerve
3. Fat embolism
122
Complication of tibial fractures?
1. Compartment syndrome
2. NV injury
3. Fat embolism
123
Mx of femoral and tibial fractures?
1. Resus and Mx life threatening injuries first
2. Assess neurovascular status of limb = urgent angio if distal pulses compromised
3. Cross match
4. Open specific management
5. Debridement and fixation in theatre = ORIF/Ex-fix
124
Cross match amount for femoral fractures?
4 units
125
Cross match amount for tibial fractures?
2 units
126
Specific Mx of open femoral and tibial fractures?
6 As
1. Analgesia = morphine and metoclopramide
2. Assess = NV status + photo
3. Asepsis = wash, cover with sterile soaked gauze
4. Alignment = reduce and splint
5. Abx = augmentin 1.2g IV
6. Anti-tetanus
127
Colles' fracture?
1. Extra-articular fracture of the distal radius
2. Dorsal displacement of the distal fragment
3. Dorsal angulation of the distal fragment
4. +/- avulsion of ulna styloid
5. Extras = reduced radial height and inclination, loss of volar tilt
128
Mx of Colles' fracture?
1. Resuscitate + Mx life threatening injuries
2. Assess NV injury = median nerve and radial artery
3. Reduction and fixation
4. Fracture clinical appointment for ortho assessment
129
Reduction and fixation of Colles' fracture?
1. Haematoma block or Bier's block (with prilocaine)
| 2. Dorsal backslab with 3 point pressure
130
Specific complications of Colles' fracture?
1. Median nerve injury
2. Tendon rupture esp. EPL
3. Carpal tunnel syndrome
4. Mal/non-union
5. Frozen shoulder/adhesive capsulitis
131
Monteggia fracture?
1. Fracture of proximal third of ulnar shaft
2. Anterior dislocation of radial head at capitellum
3. May --> palsy of deep branch of radial nerve --> weak finger extension but no sensory loss
132
Galleazz fracture?
1. Fracture of radial shaft between middle and distal 2rd
| 2. Dislocation of distal radio-ulnar joint
133
Classification of supracondylar humeral fracture?
1. Extension = distal fragment displaces posteriorly
| 2. Flexion = distal fragment displaced anteriorly
134
Complications of supracondylar humeral fracture?
1. NV = brachial artery and median nerve mainly
2. Compartment syndrome
3. Mal-union = gunstock deformity (cubitus varus)
135
Proximal humerus fracture complications?
1. Surgical neck = axillary nerve damage
| 2. Shaft = radial nerve damage
136
Mx of proximal humerus fracture?
Collar and cuff or ORIF
137
Weber classification?
Distal fibula fracture, relation of fracture to joint line
A. Below joint line
B. at joint line
C. above joint line
138
Significance of Weber B and C fracture?
Possible injury to the syndesmotic ligaments between tibia and fibula --> Instability
139
Most common Salter-Harris fracture?
SH2
140
Salter-Harris fracture with greatest risk to physis?
SH5
141
Young and Burgess classification?
Pelvic fracture
1. Lateral compression = ipsilateral pubic rami fractures
2. AP compression = open book fracture
3. Vertical shear = inherently unstable
142
Complications of pelvic fracture?
1. Haemorrhage
2. Urethral injury
3. Bladder injury
143
Complications of fractures?
1. General complications
| 2. Specific complications
144
General complications of fracture?
1. Tissue damage = haemorrhage and shock, infection, rhabdo
2. Anaesthesia = anaphylaxis, teeth damage, aspiration
3. Prolonged bed rest = Infection, pressure sores, muscle wasting, VTE, reduced BMD
145
Specific complications of fracture?
1. Immediate
2. Early
3. Late
146
Specific immediate complications of fractures?
1. Neurovascular
| 2. Visceral
147
Specific early complications of fractures?
1. Infection
2. Compartment syndrome
3. Fat embolism --> ARDS
148
Specific late complications of fractures?
1. AVN
2. Union problems
3. Growth disturbance
4. Post-traumatic osteoarthritis
5. CRPS
6. Myositis ossificans
149
Nerve injury classification?
Seddon classification
150
Seddon classification of nerve injury?
1. Neuropraxia = temporary interruption of conduction
2. Axonotmesis = disruption of axon with preservation of connective tissue framework, recovery possible
3. Neurotmesis = disruption of entire nerve fibre, recovery incomplete
151
Problems with union?
1. Delayed union = longer than expected
2. Non-union = fails to unite
3. Mal-union = unites in imperfect position
152
Causes of problems with union?
5 Is
1. Infection
2. Ischaemia
3. Interfragmentary movement
4. Interposition of soft tissue
5. Intercurrent illness
153
Mx of problems with union?
1. Optimise biology = infection, bone graft, blood supply, BMPs
2. Optimise mechanics = ORIF
154
Myositis ossificans?
1. Heterotopic ossification of muscle at sites of haematoma formation
2. Leads to restricted, painful movement
3. Commonly affects the elbow and quadriceps
155
Myositis ossificans Mx?
Excise
