Week 6 - Biliary Tract, Breast, & Genitourinary System Flashcards
What are the symptoms of prostatic enlargement?
Features of uncomplicated lower urinary tract symptoms (LUTS), which is a nonspecific term that encompasses symptoms of bladder outlet obstruction (BOO) and bladder irritation (overactive bladder or OAB).
Discuss the anatomy of the Intrahepatic bile ducts?
Discuss the anatomy of the biliary tree?
Bile is initially secreted from hepatocytes and drains from both lobes of the liver via canaliculi, intralobular ducts and collecting ducts into the left and right hepatic ducts. These ducts amalgamate to form the common hepatic duct, which runs alongside the hepatic vein.
As the common hepatic duct descends, it is joined by the cystic duct – which allows bile to flow in and out of the gallbladder for storage and release. At this point, the common hepatic duct and cystic duct combine to form the common bile duct.
The common bile duct descends and passes posteriorly to the first part of the duodenum and head of the pancreas. Here, it is joined by the main pancreatic duct, forming the hepatopancreatic ampulla (commonly known as the ampulla of Vater) – which then empties into the duodenum via the major duodenal papilla. This papilla is regulated by a muscular valve, the sphincter of Oddi.
Discuss the anatomy of the biliary tree with regards to a gallstone lodging at varying levels and the symptoms/ 5 conditions that may result.
If a gallstone becomes lodged or impacted at various levels within the biliary tree, it can lead to several symptoms and conditions:
Discuss your management of a 70-year-old man presenting with painless obstructive jaundice and a palpable gallbladder.
- 5 possible causes of obstructive jaundice?
- Qs on history taking?
- Physical exam findings?
- 5 Blood tests?
- 4 imaging ixs?
Obstructive jaundice refers to the blockage of bile flow, leading to the accumulation of bilirubin in the bloodstream, which results in yellowing of the skin and eyes. The presence of a palpable gallbladder suggests a potential pathology involving the gallbladder or the biliary tree. Here’s an outline of the management approach for this patient:
Approach to Gallstones:
- History?
- Examination?
- 10 differentials?
Approach to Gallstones:
- Investigations?
- Management?
- When to request acute general surgery assessment?
- When to request non-acute general surgery assessment?
How would you differentiate between biliary colic and acute cholecystitis in a patient presenting to the emergency department with upper right sided abdominal pain?
- Pain characteristics?
- Associated symptoms?
- Physical examination findings?
Biliary colic is the most common complication of gallstones and acute cholecystitis is the second most common presentation.
Biliary colic pain:
- is in the right upper quadrant and is a moderately severe, often crescendo pain which may radiate around or through to the back.
- may be brought on after ingestion of fatty foods.
- may persist for several hours, may be colicky and accompanied by nausea.
Acute cholecystitis pain:
- is steady and severe.
- may radiate to right shoulder or back.
- may have associated symptoms such as fever, nausea, vomiting, and anorexia.
How does the management of biliary colic differ from acute cholecystitis?
A patient comes to see you with asymptomatic gallstones. She wants to know the potential complications. Describe these to her (6).
Complications due to gallstone impaction at the gallbladder neck or infundibulum
- Mirizzi syndrome = extrinsic compression of the common bile duct (or any extrahepatic bile duct) by gallstone(s) impacted in the cystic duct or the infundibulum of the gallbladder.
- Gallbladder mucocele (gallbladder hydrops) = marked distention of the gallbladder with sterile mucinous content due to chronic biliary outflow obstruction
Outline the aetiology of gallstones.
What are the risk factors and pathophysiology of Cholesterol stones?
General
- Imbalance in bile salts, lecithin (stabilizer), cholesterol, calcium carbonate, and bilirubin
- Biliary stasis is a key component in gallstone formation.
- Impaired gallbladder emptying (e.g., due to bowel rest, prolonged total parenteral nutrition, pregnancy ) → biliary sludge → bile stasis (cholestasis)
What are the risk factors and pathophysiology of Black pigment gallstones?
What are the risk factors and pathophysiology of Mixed/brown pigment gallstones?
Describe the pathophysiology of different gallstones?
Pathophysiology for different types of gallstones
- Cholesterol stones arise only in the gallbladder but can be transported into the cystic duct as well as the common bile duct and cause obstruction and stasis.
- Pigmented gallstones contain varying amounts of calcium bilirubinate and can arise anywhere in the biliary tree. Black pigment stones arise mostly in the gallbladder (due to increased hemolysis; e.g., in sickle cell disease), whereas brown pigment stones typically arise in inflamed portions of the biliary duct (e.g., due to bacterial or parasitic infections).
List & Describe 4 Complications of Gallstones?
Discuss the constituents and formation of bile.
The main steps in the formation of bile are the uptake of bile acids and ions from plasma across the basolateral (sinusoidal) membrane, transport through the hepatocyte, and excretion via the canalicular membrane.
What are the clinical features of Cholelithiasis?
Cholelithiasis refers to the presence of abnormal concretions (gallstones) in the gallbladder.
Clinical features of Acute cholecystitis?
Acute cholecystitis refers to the acute inflammation of the gallbladder, which is typically due to cystic duct obstruction by a gallstone (acute calculous cholecystitis).
Acute cholecystitis should always be suspected in a patient with a history of gallstones who presents with RUQ pain, fever, and leukocytosis
Clinical features of Acute Cholangitis?
Acute cholangitis (ascending cholangitis) refers to a bacterial infection of the biliary tract, typically secondary to biliary obstruction and stasis (e.g., due to choledocholithiasis, biliary stricture).
Clinical features of Choledocholithiasis?
Choledocholithiasis refers to the presence of gallstones in the common bile duct (CBD).
How would you investigate a 56-year-old woman presenting with a mass in the right breast which is suspicious of cancer?
List 7 differentials of nipple discharge? When is it abnormal?
Algorithm?
Spontaneous nipple discharge unrelated to pregnancy or breastfeeding is considered abnormal. In most cases it has a benign (ie. noncancerous) cause, and is more likely to be unilateral, confined to one duct, and clear or bloodstained in appearance. Nipple discharge associated with other breast symptoms such as a lump, ulceration, or inversion of the nipple require prompt investigation.
What is the Triple Test for investigating breast symptoms?
Triple test: Evaluate new breast symptoms using the triple test of:
1. history and examination
2. imaging – mammography and/or ultrasound
3. non-excisional biopsy – fine needle aspiration (FNA) or core biopsy
The triple test is positive if any of the components show an indeterminate, suspicious, or malignant finding. If positive, arrange further specialist assessment. If all components of the triple test are negative, and there are no other high-risk factors, this provides good evidence that cancer is unlikely (< 1%), and further investigation can be avoided for most of these patients.
How do you manage a 45-year-old woman who presents to you with nipple discharge?
Evaluation and treatment of a woman presenting with breast pain?
What is Mastalgia? How is it classified?
Aetiology of Mastalgia:
- Cyclical? (3)
- Non-cyclical? (9)
- Extramammary? (4)
List 8 Causes of Cyclical Mastalgia?
**Noncyclical breast pain **— Noncyclical pain affects up to one-third of women with true mastalgia. The pain does not follow the usual menstrual pattern, may be constant or intermittent, and is more likely to be unilateral and variable in its location in the breast. Noncyclical breast pain is more likely to be related to a breast or chest wall lesion.
Diagnostic algorithm for palpable breast abnormalities in women less than 30 years of age?
Diagnostic algorithm for palpable breast abnormalities in patients aged 40 years and over?
List the investigations you might use for a patient presenting with mastalgia and why.
- Be aware that imaging is not indicated for most patients presenting with mastalgia.
- Breast pain is rarely the only presenting symptom for breast cancer.
- Imaging can identify non‑cancer causes such as fibrocystic disease, breast cysts, and fat necrosis secondary to trauma.
- Consider the benefits of reassurance versus the risks of over‑diagnosis.
- If patient anxiety, consider private breast imaging.
- Arrange diagnostic breast imaging if breast pain is associated with a lump or other signs for suspicion of breast cancer or if there is a focal symptom in women and men aged 50 years or older.
What is Mastitis?
Broadly, inflammatory disorders of the breast can be divided into three categories: infectious mastitis, non-infectious mastitis and mastitis related to underlying malignancy.
Pathophysiology and Aetiology of Mastitis?
Pathophysiology of Mastitis
- Nipple fissures facilitate the entry of bacteria located in the nostril and throat of the infant or on the skin of the mother into the milk ducts during breastfeeding.
- Prolonged breast engorgement (due to overproduction of milk ) or insufficient drainage of milk (e.g., due to infrequent feeding, quick weaning, illness in either the baby or mother) result in milk stasis, which creates favorable conditions for bacterial growth within the lactiferous ducts.
List & Describe 8 Inflammatory Breast conditions?
List 4 Investigations to consider for investigations for inflammatory breast conditions?
List and explain 7 differentials for a scrotal lump?
List 7 Painful causes of scrotal swelling?
List 6 Non-painful causes of scrotal swelling?
A 40-year-old man notices a lump in his scrotum and presents to your surgery. Discuss your consultation and management.
- 3 red flags?
- History?
- Examination?
- Investigations?
Red Flags
- Testicular torsion
- Testicular cancer
- Strangulated inguinal hernia
Arrange investigations:
1. MSU
2. If epididymo-orchitis – a sexually transmitted infection (STI) check (especially if patient aged < 35 years)
3. If specifically indicated – ultrasound scrotum with or without lower abdomen
4. If testicular cancer suspected – arrange:
o tumour markers (serum beta-HCG, LDH and alpha-fetoprotein).
o CT abdomen, pelvis, and chest if indicated.
Describe the management of a male adult presenting with a scrotal swelling.
How would you investigate and manage a man found to have a suspected testicular neoplasm? (7)
How are testicular tumours classified?
Germ cell tumors of the testis (95%)
1. Seminoma
2. Non-seminoma
- Embryonal carcinoma
- Teratoma
- Testicular choriocarcinoma
- Yolk sac tumour
- Mixed germ cell tumour
Non-germ cell tumors of the testis (5%)
1. Leydig cell tumors
2. Sertoli cell tumors
3. Secondary - Lymphoma
List the clinical features of testicular tumours?
Staging of testicular tumours?
Which investigations should be performed in a patient with suspected testicular tumour?
- 3 Lab tests?
- 2 Imaging techniques?
- How is histopathology confirmed?
- Suspicion of a testicular tumor is usually established based on the clinical findings and ultrasound (to localize the tumor).
- Tumor markers and abdominopelvic CT scan may further support the diagnosis, while histology following radical inguinal orchiectomy provides diagnostic confirmation.
- If a testicular tumor is suspected, the testis should be removed and sent to pathology. Transscrotal biopsy should not be conducted because of the risk of tumor seeding!
List 5 Differential diagnoses of painless testicular swelling?
What is the treatment for testicular tumour?
Surgery
- Prior to surgery: sperm cryopreservation
- Radical inguinal orchiectomy
Causes of Urinary Incontinence:
- 5 Neurological causes?
- 7 Genitourinary causes?
- 7 Transient causes?
- 4 General risk factors?
DIAPPERS: Delirium/confusion, Infection, Atrophic urethritis/vaginitis, Pharmaceutical, Psychiatric causes (especially depression), Excessive urinary output (hyperglycemia, hypercalcemia, CHF), Restricted mobility, Stool impaction.
What are 7 types of urinary incontinence?
- Stress incontinence
- Urge incontinence
- Mixed incontinence
- Total incontinence
- Overflow incontinence (overflow bladder)
- Neurogenic bladder dysfunction
- Enuresis risoria
What are 4 groups of medications used for urinary incontinence?
- Examples?
- MOA?
- Muscarinic antagonists
- Sympathomimetics
- Muscarinic agonists
- Alpha-1 antagonists
Outline a general approach for the workup of incontinence of unknown mechanism:
- History?
- Physical Examination?
Outline a general approach for the workup of incontinence of unknown mechanism:
- Initial diagnostics? (2)
- Upper urinary tract studies? (2)
- Advanced Studies? (4)
Advanced Studies:
1. Micturating cystourethrogram: to detect vesicoureteral reflux and/or morphological abnormalities (e.g., diverticula, obstruction)
2. Urodynamic studies: to determine detrusor and sphincter function
3. Cystoscopy: to evaluate for tumors and vesicorectal and vesicovaginal fistulae
4. MRI : to assess for pelvic floor defects, urinary tract anomalies, and masses
Describe an approach to the management of urinary incontinence?
- Conservative management? (4)
- Identify and manage: Transient causes of UI, e.g., urinary tract infection, constipation & Barriers to voiding
- Initiate conservative management of UI for all patients.
- Start specific management based on the subtype.
- Continence products (e.g., pads, external catheters) may be helpful as a temporary or permanent adjunct.
Define sensory and motor urge incontinence?
- Aetiology? (3)
- Risk factors? (3)
- Sensory urge incontinence: pathologically increased bladder sensitivity, which results in the reflex action of bladder emptying
- Motor urge incontinence: autonomous detrusor overactivity
2 Clinical features of Urge Incontinence?
2 Diagnostics for Urge Incontinence?
- Urinary urgency: sudden urge to urinate
- Loss of urine without exertion, with urinary tenesmus → frequent episodes, with variable volumes of urine voided each time
Treatment for Urge Incontinence:
- Nonpharmacological treatment? (3)
- First line medical treatment?
- 3 second line treatments?
Second-line treatment of Urge Incontinence
1. Endoscopic injection of botulinum toxin at different points in the bladder wall
2. Sacral nerve stimulation
3. Augmentation cystoplasty
What is Stress Incontinence?
- Pathomechanism?
- 8 Risk Factors?
Stress incontinence is the involuntary leakage of urine following any activity associated with raised intra-abdominal pressure (e.g., coughing, sneezing).
Clinical features/Triggers of Stress Incontinence?
- Diagnostics?
- Physical activity that causes increased intra-abdominal pressure (e.g., laughing, sneezing, coughing, exercising) leads to loss of urine
- Frequent, predictable, small-volume urine losses with no urge to urinate prior to the leakage
4 Conservative Treatments for Stress Incontinence?
- Surgical treatments?
Stress Incontinence - Conservative Treatment
1. Kegel exercises
2. Lifestyle changes (e.g., weight loss, avoiding alcohol and caffeine, smoking cessation)
3. Vaginal pessary
4. Possible pharmacotherapy
- Duloxetine: to enhance sphincter contraction
- Anticholinergic drugs can be used, but they tend to only be effective in mild cases of stress incontinence.
Describe the neural circuits controlling continence and micturition.
(A) Urine storage reflexes. During the storage of urine, distention of the bladder produces low level vesical afferent firing, which in turn stimulates (1) the sympathetic outflow to the bladder outlet (base and urethra) and (2) pudendal outflow to the external urethral sphincter. These responses occur by spinal reflex pathways and represent “guarding reflexes,” which promote continence. Sympathetic firing also inhibits detrusor muscle and modulates transmission in bladder ganglia. A region in the rostral pons (the pontine storage center, or “L” region) increases external urethral sphincter activity. (B) Voiding reflexes. During elimination of urine, intense bladder afferent firing activates spinobulbospinal reflex pathways passing through the pontine micturition center, which stimulate the parasympathetic outflow to the bladder and internal sphincter smooth muscle and inhibit the sympathetic and pudendal outflow to the urethral outlet. Ascending afferent input from the spinal cord may pass through relay neurons in the periaqueductal gray (PAG) before reaching the pontine micturition center.
Describe an approach to a female presenting with urinary incontinence.
- History?
- Questionnaire?
- Grade?
- Examination?
- Investigations?
What are the Causes of Haematuria?
- Renal?
- Ureter?
- Bladder?
- Urethra?
Outline the physiology of micturition.
- 8 Steps?
How is urinary continence maintained in the male vs. the female?
Discuss your investigation of a 56-year-old man presenting with a history of macroscopic haematuria.
Diagnostic imaging pathway for painless macroscopic haematuria?
Outline the evaluation of the adult with asymptomatic hematuria?
What are 5 risk factors for prostate cancer?
- Advanced age (> 50 years)
- Family history
- African-American descent
- Genetic disposition (e.g., BRCA2, Lynch syndrome)
- Dietary factors: high intake of saturated fat, well-done meats, and calcium
Advanced age is the main risk factor for prostate cancer. Sexual activity and benign prostatic hyperplasia (BPH) are not associated with prostate cancer.
Symptoms of Prostate cancer?
3 features on DRE?
Features suggestive of prostate cancer on DRE include:
1. Localized indurated nodules on an otherwise smooth surface
2. Prostatomegaly, lobar asymmetry, obliteration of the sulcus
3. Hard nontender nodules
How is Prostate cancer diagnosed?
- Approach?
- PSA?
Approach
- Suspect prostate cancer in patients with elevated PSA levels detected on routine screening and/or abnormal findings on DRE.
- Consider adjunctive PSA testing (e.g., free PSA:total PSA ratio, PSA density, urinary prostate cancer antigen 3 levels) before performing a biopsy.
- Confirm the diagnosis on image-guided prostate biopsy.
- Stage prostate cancer to determine the appropriate management and prognosis.
Diagnostic Imaging pathway for suspected prostate cancer?
What are the 2 initial imaging modalities for diagnosing prostate cancer?
Which imaging modalities are best for evaluating tumour extent?
Initial imaging
1. mpMRI of the prostate: Becoming the preferred imaging modality for suspected prostate cancer.
2. Transrectal ultrasound of the prostate: predominantly used to guide prostate biopsy if there is clinical suspicion of prostate cancer.
mpMRI is the preferred method for detecting local tumor extent (including recurrent prostate cancer) and PET-CT is preferred to evaluate for metastatic disease.
Describe the Staging for Prostate Cancer?
T2 = Organ confined
T3 = Extraprostatic extension
T3a = Extraprostatic extension (unilateral or bilateral) or microscopic invasion of bladder neck
T3b = Tumor invades seminal vesicle(s)
T4 = Tumor is fixed or invades adjacent structures other than seminal vesicles such as external sphincter, rectum, bladder, levator muscles, and/or pelvic wall
How are Prostate biopsies performed?
How are prostate cancers graded?
Gleason score and grade groups are used to grade the metastatic potential of prostate adenocarcinoma based on gland-forming differentiation.
Discuss the management of a 68-year-old man found to have prostate cancer.
- 5 Management options?
- Watchful waiting
- Active surveillance
- Androgen deprivation therapy (ADT)
- Radiation therapy
- Surgery - Radical prostatectomy
- Chemotherapy
Also - Management of bone health
What is the significance and management of an ‘elevated PSA’?
What is the difference between Watchful Waiting and Active Surveillance for Prostate Cancer?
What is Androgen Deprivation Therapy for Prostate Cancer?
- Definition?
- Indications? (1)
- Options? (4)
- Adverse Effects? (6)
Describe the role of Androgen synthesis inhibitors and androgen receptor antagonists in the treatment of prostate cancer?
- Initiate prophylaxis against treatment-induced osteoporosis and fractures in all patients on androgen deprivation and/or glucocorticoids.
- First-generation antiandrogens (flutamide and bicalutamide) are used only for the short-term management of a testosterone flare.
Radiotherapy for Prostate Cancer:
- 3 Indications?
- 2 Options?
- 4 Complications?
Radical prostatectomy for Prostate Cancer:
- 2 Indications?
- Technique?
- 3 Complications?
6 Complications of BPH?
Complications of BPH
1. Recurrent UTI
2. Urinary retention with bladder distension and bladder wall thickening (hypertrophy)
3. Bladder calculi
4. Hydronephrosis
5. Chronic kidney disease
6. Gross hematuria
4 Risk factors for urinary calculi?
- Clinical features?
Risk factors:
1. Low fluid intake, dehydration
2. Male sex
2. Personal or family history
3. Loop diuretics
4. Postcolectomy and/or postileostomy
Which antibiotics are first line for Perioperative antibiotic prophylaxis?
