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Medicine and Surgery Mushkies > Surgical Radiology Mushkies > Flashcards

Surgical Radiology Mushkies Flashcards

1
Q

Achalasia defn?

A

Focal motility disorder of the oesophagus caused by degeneration of the myenteric plexus of Auerbach

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2
Q

Causes of achalasia?

A
  1. Usually idiopathic

2. Can be secondary to Chagas disease

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3
Q

Achalasia presentation?

A
  1. Dysphagia to solids then liquids
  2. Retrosternal cramps
  3. Regurgitation esp. at night +/- aspiration pneumonia
  4. Weight loss
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4
Q

Ix of achalasia?

A
  1. Ba swallow
  2. CXR = wide mediastinum + double RH border
  3. Manometry = failure of relaxation and reduced peristalsis
  4. OGD = exclude oesophageal SCC
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5
Q

Mx of achalasia?

A
  1. Med = CCB, nitrates
  2. Interventional = botox injection, endoscopic balloon dilatation
  3. Surgical = Heller’s cardiomyotomy (open or lap)
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6
Q

Achalasia on barium swallow?

A
  1. Proximal dilatation of the oesophagus with smooth distal tapering (bird’s beak appearance)
  2. May be food particles visible
  3. Significant negative = apple core stricture suggestive of oesophageal SCC (occurs in 3% pts with achalasia)
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7
Q

Oesophageal carcinoma epidemiology?

A

5M:1F, Transkei and China

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8
Q

Pathophysiology of oesophageal carcinoma?

A
  1. Adenocarcinoma (65%) = lower 1/3rd, GORD –> Barrett’s –> dysplasia –> Ca
  2. SCC (35%) = upper 2/3rds, association with EtOH and smoking, commonest type worldwide
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9
Q

Oesophageal carcinoma spread?

A

Local –> LNs –> blood

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10
Q

Major RFs for oesophageal carcinoma?

A
  1. GORD –> Barrett’s
  2. EtOH and smoking
  3. Achalasia
  4. Plummer-Vinson (20% risk of SCC)
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11
Q

Presentation of oesophageal carcinoma?

A
  1. Progressive dysphagia
  2. Weight loss
  3. Upper 3rd = hoarseness and bovine cough
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12
Q

Oesophageal carcinoma Ix?

A
  1. Dx = OGD + biopsy

2. Staging = CT, EUS, laparoscopy, mediastinoscopy

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13
Q

Oesophageal carcinoma Mx?

A
  1. MDT
  2. Oesophagectomy = 25% have resectable tumours
  3. Palliation = 75%
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14
Q

Oesophagectomy types?

A
  1. Ivor-Lewis (2 stage)
  2. McKeown (3 stage)
  3. 15% 5 year survival
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15
Q

Oesophagectomy palliation?

A
  1. Analgesia
  2. Laser coagulation
  3. Stenting
  4. 5% 5 year surivival
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16
Q

Oesophageal cancer on imaging?

A

Irregular, shouldered stricture of the oesophagus (‘apple core’ lesion)

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17
Q

Pharyngeal pouch aka?

A

Zenker’s diverticulum

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18
Q

Pharyngeal pouch on imaging?

A

Contrast filling of blind-ended pouch adjacent to and in continuity with the oesophagus

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19
Q

Hiatus hernia classification?

A
  1. Sliding = 80%
  2. Rolling = 15%
  3. Mixed = 5%
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20
Q

Sliding hiatus hernia fx?

A
  1. GOJ slides up into chest

2. Often associated with GORD

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21
Q

Rolling hiatus hernia fx?

A
  1. GOJ remains in abdomen but a bulge of stomach rolls into chest alongside the oesophagus
  2. LOS remains intact so GORD uncommon
  3. Can –> strangulation
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22
Q

Presentation of hiatus hernia?

A
  1. Often symptomatic
  2. Sliding = GORD (dyspepsia)
  3. Rolling = strangulation
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23
Q

Hiatus hernia Ix?

A
  1. CXR = gas bubble and fluid level in chest
  2. Ba swallow = diagnostic
  3. OGD = for oesophagitis
  4. 24hr pH + manometry = exclude dysmotility or achalasia, confirm reflux
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24
Q

Hiatus hernia Mx?

A
  1. Conservative = weight loss, raise head of bed, stop smoking
  2. Medical = PPis, H2RAs
  3. Surgical = if intractable symptoms despite medical treatment, should repair rolling hernia (even if asymptomatic, as it may strangulate)
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25
Q

Imaging of small bowel obstruction?

A
  1. AXR
  2. Erect CXR
  3. CT with oral contrast = transition point
  4. Gastrograffin follow through = may be therapeutic if adhesional obstruction
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26
Q

Mx of small bowel mechanical obstruction?

A
  1. Regular clinical examination for signs of strangulation
  2. Consider need for parenteral nutrition
  3. 80% resolve without surgery
  4. Laporotomy +/- adhesioloysis +/- resection +/- stoma
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27
Q

Indication for surgical mx of small bowel mechanical obstruction?

A
  1. Failure of conservative Mx = up to 72 hours
  2. Development of sepsis
  3. Peritonitis
  4. Evidence of strangulation
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28
Q

Mx of small bowel ileus?

A
  1. Correct any underlying abnormalities = electrolytes, drugs
  2. Consider need for parenteral nutrition
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29
Q

Fx of small bowel obstruction on imaging?

A
  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
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30
Q

Fx of large bowel obstruction on imaging?

A
  1. Dilated loops of bowel >=6cm in width
  2. Peripherally located, fewer loops
  3. Haustra = lines go partially across
  4. No gas in rectum
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31
Q

Mx of large bowel obstruction?

A
  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
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32
Q

Indications for surgical mx of large bowel obstruction?

A
  1. Closed loop obstruction
  2. Obstructing neoplasm
  3. Strangulation or perforation
  4. Failure of conservative mx
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33
Q

2 types of large bowel volvulus on imaging?

A
  1. Emerging from LIF = sigmoid (commoner)

2. Emerging from RIF = caecal

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34
Q

Pathophysiology of volvulus?

A
  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
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35
Q

Presentation of volvulus?

A
  1. Often in elderly pts with comorbidities

2. Grossly distended, tympanic abdomen

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36
Q

Mx of sigmoid volvulus?

A
  1. Resus = drip and suck
  2. Detorse with flatus tube
  3. May need sigmoid colectomy
  4. Often recurs
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37
Q

Mx of caecal volvulus?

A
  1. Resus = drip and suck
  2. 10% can be detorsed with colonoscopy
  3. Often needs surgery = caecostomy/right hemi with primary ileocolic anastomosis
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38
Q

Gastric volvulus film?

A
  1. Gastric dilatation

2. Double bubble on erect films

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39
Q

Presentation of gastric volvulus?

A
  1. Vomiting
  2. Pain
  3. Failed attempts to pass NGT
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40
Q

RFs for gastric volvulus?

A
  1. Roling hiatus hernia

2. Gastric/oesophageal surgery

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41
Q

Mx of gastric volvulus?

A
  1. Endoscopic manipulation

2. Emergency laparotomy

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42
Q

Chronic pancreatitis on AXR?

A

Horizontal speckled calcification at L1/L2

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43
Q

AAA on AXR?

A

Fusiform calcification in the midline

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44
Q

Fusiform definition?

A

Tapered at both ends

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45
Q

Gallstones on AXR?

A

Cluster of circular calcifications at L1

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46
Q

Rigler’s triad?

A
  1. SBO
  2. Pneumobilia
  3. Gallstone in RIF
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47
Q

Rigler’s sign?

A

Air on both sides of bowel wall

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48
Q

Mx of foreign body on AXR?

A
  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
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49
Q

Perforated viscus on AXR?

A
  1. Air under the diaphragm

2. Rigler’s sign

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50
Q

Ddx of air under diaphragm/Rigler’s sign?

A
  1. Spontaneous = perforated DU
  2. Iatrogenic = laparotomy/laparoscopy
  3. Traumatic
  4. Misc = via female genital tract
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51
Q

Presentation of perforated viscus?

A
  1. Sudden onset severe epigastric pain
  2. Vomiting
  3. Peritonitic abdomen
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52
Q

Perforated viscus on CXR and AXR?

A
  1. CXR = upright for 15 mins first, 70% show free air

2. AXR = Rigler’s sign

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53
Q

Duodenal perforation Mx?

A

Abdominal washout and omental patch repair

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54
Q

Gastric perforation Mx?

A

Excise ulcer and repair defect, and send specimen for histology to ecxlude Ca

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55
Q

What is 90% positive in perforated Duodenal ulcers?

A

H. pylori

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56
Q

Clinical signs of tension pneumothorax?

A
  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
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57
Q

Pathophysiology of tension pneumothorax?

A
  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
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58
Q

Diverticulum definition?

A

Outpouching of a tubular structure

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59
Q

Pathophysiology of diverticulosis?

A
  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
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60
Q

Saint’s triad?

A
  1. DIverticular disease
  2. Hiatus hernia
  3. Cholelithiasis
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61
Q

Mx of diverticular disease?

A
  1. High fibre diet, mebeverine may help

2. Elective laparoscopic sigmoid colectomy

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62
Q

Mebevirine?

A

Anti-spasmodic

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63
Q

Ix of choice for diverticulitis?

A

CT has very high sensitivity and specificity

64
Q

Hinchey grading?

A
  1. Small confined pericolic abscess (<5% mortality)
  2. Large abscesses extending into pelvis (<5%)
  3. Purulent peritonitis (15%)
  4. Faecal peritonitis (45%)
65
Q

Mx of perforated diverticulum?

A
  1. Resus = admit, NBM, fluids, Abx
  2. 1-2 = surgery rarely needed
  3. On table washout may suffice
  4. Hartmanss
66
Q

Complications of diverticular disease?

A
  1. Obstruction (strictures)
  2. Perforation
  3. Haemorrhage
  4. Fistulae
  5. Abscess
67
Q

Colorectal cancer on imaging?

A
  1. Typically a double-contrast enema

2. Apple-core stricture with shouldered margins

68
Q

Diverticulosis imaging?

A

Double-contrast enema

69
Q

RFs for colorectal cancer?

A
  1. Diet
  2. IBD
  3. Familial = FAP, HNPCC, Peutz Jeghers
  4. Smoking
  5. Genetics
70
Q

Dukes staging for colorectal Ca?

A

A. Confined to bowel wall
B. Through bowel wall but no LNs
C. Regional LNs
D. Distant mets

71
Q

UC imaging?

A

Double-contrast enema

72
Q

UC features on double-contrast enema?

A
  1. Lead piping
  2. Mucosal thickening +/- thumbprinting
  3. Pseudopolyps
73
Q

CD features on imaging?

A
  1. Rose thorn ulcers
  2. String sign of Kantor
  3. Cobblestoning
  4. Skip lesions
74
Q

Gallstones on imaging?

A
  1. Stones –> acoustic shadow
  2. Dilated ducts >6mm +/- stones in ducts
  3. Inflamed gallbladder = wall oedema
75
Q

ERCP therapeutics?

A
  1. Sphincterotomy + trawling of ducts allow stone removal

2. Strictures may be stented or dilated

76
Q

Complications of ERCP?

A
  1. Pancreatitis
  2. Bleeding
  3. Bowel perforation
  4. Contrast allergy
77
Q

Advantages of MRCP?

A

Non-invasive and no contrast necessary

78
Q

What can ERCP and MRCP show on film?

A
  1. Filling defects
  2. Strictures
  3. Duct dilatation
79
Q

Mx of acute cholecystitis?

A
  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
Q

Nephrolithiasis stone types?

A
  1. Calcium oxalate = 75%
  2. Magnesium ammonium phosphate = 15%
  3. Urate = 5%
  4. Cystine = 1%
81
Q

Condition associated with cystine stones?

A

Fanconi syndrome

82
Q

Pathophysiology of nephrolithiasis?

A
  1. Increased conc of urinary solute
  2. Decreased urine volume
  3. Urinary stasis
83
Q

Common anatomical sites of nephrolithiasis?

A
  1. Pelvi-ureteric junction
  2. Pelvic brim
  3. Vesico-ureteric junction
84
Q

Nephrolithiasis Mx?

A
  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
Q

Active stone removal indications?

A
  1. Stones >10mm
  2. Persistent obstruction
  3. Renal insufficiency
  4. Infection
86
Q

Active stone removal procedures?

A
  1. ESWL
  2. Uretero-renoscopy + Dormier basket
  3. Percutaneous nephrolithotomy
  4. Lap/open stone removal
87
Q

Febrile with renal obstruction?

A
  1. Surgical emergency
  2. Percutaneous nephrostomy or ureteric stent
  3. IV Abx = e.g. cefuroxime 1.5g IV TDS
88
Q

Extradural haematoma shape?

A

Lentiform opacification

89
Q

Subdural haematoma shape?

A

Sickle-shaped

90
Q

Types of brain injury?

A
  1. Primary = time of injury as a direct result of injury

2. Secondary = after primary injury

91
Q

Primary brain injury types?

A
  1. Diffuse = concussion (temporary reduction in brain function), diffuse axonal injury
  2. Focal = contusion, intracranial haemorrhage
92
Q

Secondary brain injury causes?

A
  1. Raised ICP
  2. Infection
  3. Hypoxia/hypercapnia
  4. Hypotension
93
Q

Monroe-Kelly Doctrine?

A
  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
Q

Cushing reflex is indicative of?

A

Imminent herniation due to raised ICP

95
Q

Cushing reflex?

A
  1. Hypertension
  2. Bradycardia
  3. Irregular breathing
96
Q

NICE indications for Head CT?

A
  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
Q

Digital Subtraction Angiography?

A

A fluoroscopy technique used in interventional radiology to clearly visualize blood vessels in a bony or dense soft tissue environment

98
Q

Mx of acute limb ischaemia?

A
  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
Q

Complications of mx of acute ischaemia?

A
  1. Reperfusion injury –> compartment syndrome

2. Chronic pain syndromes

100
Q

Fogarty arterial embolectomy catheter?

A

Remove fresh emboli in the arterial system

101
Q

Mx of chronic limb ischaemia?

A
  1. Non-surgical = RF control, analgesia, graded exercise programmes (walk through pain)
  2. Interventional = angioplasty +/- stenting
  3. Surgical = reconstruction, endarterectomy, amputation
102
Q

Hip fracture imaging?

A
  1. Orthogonal views = AP and lateral
  2. Follow Shenton’s lines
  3. Intra-or extracapsular
  4. Displaced or non-displaced (Garden classification)
103
Q

Classification of hip fracture?

A
  1. Intracapsular = subcapital, transcervical, basicervical

2. Extracapsular = intertrochanteric, subtrochanteric

104
Q

Garden classification of intracapsular fractures?

A
  1. Incomplete, undisplaced
  2. Complete, undisplaced
  3. Complete, partially displaced
  4. Complete, completely displaced
105
Q

Mx of intracapsular fractures?

A
  1. Garden 1/2 = ORIF with cancellous screws

2. Garden 3/4 = <55 (ORIF with screws), >55 (THR or hemiarthroplasty)

106
Q

Mx of extracapsular fractures?

A

ORIF with DHS

107
Q

Specific complications of hip fracture?

A
  1. AVN of femoral hear in displaced fractures
  2. Non/mal-union
  3. Infection
  4. Osteoarthritis
108
Q

Typical shoulder dislocation?

A

Typically anterior dislocation with humeral head located antero-inferiorly

109
Q

2 types of special shoulder lesion?

A
  1. Bankhart lesion

2. Hill-Sachs lesion

110
Q

Bankhart lesion?

A

Damage to glenoid labrum

111
Q

Hill-Sachs lesion?

A

Cortical depression in posterolateral part of humeral head

112
Q

Presentation of shoulder dislocation?

A
  1. Severe pain
  2. Loss of shoulder contour
  3. Humeral head palpable in infraclavicular fossa
113
Q

Complications of shoulder dislocation?

A
  1. Axillary nerve injury

2. Recurrent dislocation = 90% pts <20 y/o with traumatic dislocation

114
Q

Mx of shoulder dislocation?

A
  1. Resuscitate
  2. Analgesia
  3. Assess NV deficit
  4. Reduction under sedation e.g. propofol
  5. Sling for 3-4 weeks
  6. Physio
115
Q

Types of shoulder dislocation reduction?

A
  1. Hippocratic

2. Kocher’s

116
Q

Hippocratic reduction?

A

Longitudinal traction with arm in 30 degrees and counter traction at the axilla

117
Q

Kocher’s reduction?

A

External rotation of adducted arm, anterior movement, internal rotation

118
Q

Femoral and tibial fractures imaging?

A

Request AP and lateral films

119
Q

Gustillo classification of open fractures?

A
  1. Wound <1cm in length
  2. Wound >1cm in length with minimal soft tissue damage
  3. Extensive soft tissue damage
120
Q

Most dangerous complication of open fracture?

A

C. perfringens

121
Q

Complication of femoral fractures?

A
  1. Hypovolaemic shock
  2. NV = SFA and sciatic nerve
  3. Fat embolism
122
Q

Complication of tibial fractures?

A
  1. Compartment syndrome
  2. NV injury
  3. Fat embolism
123
Q

Mx of femoral and tibial fractures?

A
  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
Q

Cross match amount for femoral fractures?

125
Q

Cross match amount for tibial fractures?

126
Q

Specific Mx of open femoral and tibial fractures?

A

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
Q

Colles’ fracture?

A
  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
Q

Mx of Colles’ fracture?

A
  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
Q

Reduction and fixation of Colles’ fracture?

A
  1. Haematoma block or Bier’s block (with prilocaine)

2. Dorsal backslab with 3 point pressure

130
Q

Specific complications of Colles’ fracture?

A
  1. Median nerve injury
  2. Tendon rupture esp. EPL
  3. Carpal tunnel syndrome
  4. Mal/non-union
  5. Frozen shoulder/adhesive capsulitis
131
Q

Monteggia fracture?

A
  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
Q

Galleazz fracture?

A
  1. Fracture of radial shaft between middle and distal 2rd

2. Dislocation of distal radio-ulnar joint

133
Q

Classification of supracondylar humeral fracture?

A
  1. Extension = distal fragment displaces posteriorly

2. Flexion = distal fragment displaced anteriorly

134
Q

Complications of supracondylar humeral fracture?

A
  1. NV = brachial artery and median nerve mainly
  2. Compartment syndrome
  3. Mal-union = gunstock deformity (cubitus varus)
135
Q

Proximal humerus fracture complications?

A
  1. Surgical neck = axillary nerve damage

2. Shaft = radial nerve damage

136
Q

Mx of proximal humerus fracture?

A

Collar and cuff or ORIF

137
Q

Weber classification?

A

Distal fibula fracture, relation of fracture to joint line
A. Below joint line
B. at joint line
C. above joint line

138
Q

Significance of Weber B and C fracture?

A

Possible injury to the syndesmotic ligaments between tibia and fibula –> Instability

139
Q

Most common Salter-Harris fracture?

140
Q

Salter-Harris fracture with greatest risk to physis?

141
Q

Young and Burgess classification?

A

Pelvic fracture

  1. Lateral compression = ipsilateral pubic rami fractures
  2. AP compression = open book fracture
  3. Vertical shear = inherently unstable
142
Q

Complications of pelvic fracture?

A
  1. Haemorrhage
  2. Urethral injury
  3. Bladder injury
143
Q

Complications of fractures?

A
  1. General complications

2. Specific complications

144
Q

General complications of fracture?

A
  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
Q

Specific complications of fracture?

A
  1. Immediate
  2. Early
  3. Late
146
Q

Specific immediate complications of fractures?

A
  1. Neurovascular

2. Visceral

147
Q

Specific early complications of fractures?

A
  1. Infection
  2. Compartment syndrome
  3. Fat embolism –> ARDS
148
Q

Specific late complications of fractures?

A
  1. AVN
  2. Union problems
  3. Growth disturbance
  4. Post-traumatic osteoarthritis
  5. CRPS
  6. Myositis ossificans
149
Q

Nerve injury classification?

A

Seddon classification

150
Q

Seddon classification of nerve injury?

A
  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
Q

Problems with union?

A
  1. Delayed union = longer than expected
  2. Non-union = fails to unite
  3. Mal-union = unites in imperfect position
152
Q

Causes of problems with union?

A

5 Is

  1. Infection
  2. Ischaemia
  3. Interfragmentary movement
  4. Interposition of soft tissue
  5. Intercurrent illness
153
Q

Mx of problems with union?

A
  1. Optimise biology = infection, bone graft, blood supply, BMPs
  2. Optimise mechanics = ORIF
154
Q

Myositis ossificans?

A
  1. Heterotopic ossification of muscle at sites of haematoma formation
  2. Leads to restricted, painful movement
  3. Commonly affects the elbow and quadriceps
155
Q

Myositis ossificans Mx?

Medicine and Surgery Mushkies (52 decks)

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