A Grade Surgical Conditions Flashcards
(345 cards)
1
Q
What is the acute abdomen?
A
A description of pain in the abdomen that has started in the past 5 days. There are a wide range of differentials
2
Q
What are the differentials when abdo pain is generalised?
A
Intra-abdo haemorrhage
Viscous organ peforation
Mesenteric Ischaemia
Bowel Obstruction
3
Q
What is the most serious cause of an intra-abdominal haemorrhage?
A
Ruptured AAA
4
Q
What are the signs and symptoms of AAA?
A
- Back/loin pain
- Collapse
- Hypotension
- Pulsatile abdo mass
- Lower limb ischaemia
5
Q
What investigations should be performed if AAA is suspected?
A
CT Abdo of pelvis and abdo w/ contrast of arteries
6
Q
How is a AAA treated?
A
Surgery `
7
Q
What can viscous organ perforation cause?
A
peritonitis
8
Q
What are the most common causes of rupture?
A
Gastroduodenal Ulcer
Colonic Diverticulitis
9
Q
What are the signs of viscus organ perforation?
A
RIGID ABDOMEN
Involuntary guarding
Patient lying completely still
Deranged observations, lactate and inflammatory markers
10
Q
What investigations should be done if organ perforation suspected?
A
ERECT CXR
CT abdo/pelvis
11
Q
What is the management for viscus organ perforation?
A
Prompt surgical repair and washout to prevent bowel contents from spilling out into abdo
12
Q
What are the signs of mesenteric ischaemia?
A
Pain out of proportion to examination
High lactate
13
Q
What are the risk factors for mesenteric ischaemia?
A
Artertiopaths (angina, previous MI)
AAA, AF, DVT, PE
14
Q
What can mesenteric ischaemia lead to?
A
necrosis and perforation
15
Q
What are the causes of mesenteric ischaemia?
A
Mesenteric artery thromboembolism (embolus thrown off from the heart plus chronic atherosclerotic thrombosis)
Non occulusive ischaemia related to hypotension
Mesenteric venous thrombosis
16
Q
What are the investigations for mesenteric ischaemia?
A
Lactate
CT abdo and pelvis
17
Q
What is bowel obstruction?
A
A mechanical blockage of bowel = proximal bowel dilates and becomes ischaemic, then necrotic and then it perforates
18
Q
What are the signs and symptoms of bowel obstruction?
A
Colicky pain Nausea and vomiting ABSOLUTE CONSTIPATION Distended abdo Tinkling bowel sounds Deranged observations and inflammatory markers
19
Q
What investigations should be requested?
A
CT(differentiates between small bowel and large bowel obstruction)
FBC, UsEs, Renal Function, Coag Panel, Serum amylase/lipase (large bowel suspected)
ABG, FBC, CRP, electrolytes, glucose, u&es, amylase, group and save
20
Q
What are the causes of small bowel obstruction?
A
Adhesions
Hernia
21
Q
What are the causes of large bowel obstruction?
A
Tumour
Volvulus
22
Q
What is the treatment for bowel obstruction?
A
IV fluids, rebalance electrolytes, group and save
Primary resection/laparatomy
23
Q
What conditions might present with right upper quadrant pain?
A
Cholecystitis and renal colic
24
Q
What are the signs of cholecystitis ?
A
Sudden onset RUQ pain radiating to back
Charcots Triad (indicates ascending cholangitis)
- FEVER
- RUQ pain
- Jaundice
Reynauds Pentad (suggests obstruction) - Charcots Triad + shock and altered mental status
25
What imaging is performed for cholecystitis?
US is performed first to rule other things out and to evaluate any cholecystitis
26
How is cholecystitis treated?
Mild/Moderate
- Paracetamol/ diclofenac/morphine
- Plasma-lyte IV infusion
- Antibiotics if sepsis or infection suspected
- Cholecystostomy
Severe
- ITU admission
- Paracetamol/ diclofenac/morphine
- Plasma-lyte IV infusion
- Antibiotics if sepsis or infection suspected
- Cholecystostomy
27
What investigations are performed if cholecystitis is suspected?
FBC, CRP, bilirubin, LFTs, serum lipase or amylase, blood/bile cultures
28
What is cholecystitis?
Inflammation of the gallbladder
29
What are the causes of cholecystitis?
complete cystic duct obstruction due to an impacted gallstone in the gallbladder neck or cystic duct
30
What is Renal Colic?
- Colicky loin to gain pain caused by obstruction of flow in ureter leading to increased wall tension in urinary tract
- Increased prostaglandins synthesis resulting in vasodilatation causing diuresis which further increases pressure
31
What investigations should be performed if renal colic is suspected?
Urinalysis (microscopic haematuria)
24 hr urine collection for recurrent stone formers
FBC, serum electrolytes, urea and creatinine
CT-KUB (kidney,ureter,bladder)
Ultrasound
32
What is the management for renal colic?
Acute renal colic
- conservative management (hydration, pain control, anti-emetics)
Confirmed stone
- conservative management, surgical decompression, medical expulsive therapy (tamsulosin), surgical removal
antibiotic therapy (gentamicin) if infection indicated
33
What is pancreatitis?
Inflammation of the pancreas
34
What is the diagnostic criteria for pancreatitis?
2/3 of:
- acute onset of severe epigastric pain relieved by bending forward
- elevated amylase/lipase
- imaging features consistent on CT/MRI/US
35
What is the most common subtype of pancreatitis?
Interstitial oedematous pancreatitis
36
What form of imaging should be done if pancreatitis suspected?
US (identifies gallstones, vascular complications and necrosis)
CT (focal or diffuse enlargement, oedema, necrosis, abscess, haemorrhage, calcification)
37
How does a patient with pancreatitis present?
sudden-onset mid-epigastric or left upper quadrant abdominal pain, which often radiates to the back
Nausea and vomiting
Signs of hypovolaemia (hypotension, tachycardia, dry mucous membranes, sweating)
38
What investigations should be done for acute pancreatitis?
Serum lipase/amylase, FBC, CRP, LFTs, CXR, pulse oximetry, urea, serum calcium
39
What is the treatment for pancreatitis?
```
IV fluids
Ibuprofen/codeine/morphine
O2
Ondansetron
Empiric IV antibiotics if infection suspected
```
40
What is gastric ulcer disease?
Gastric ulceration due to gastric acid excess
41
How does an ulcer present?
Epigastric pain relieved by eating or antacid
42
What are the complications of a gastric ulcer?
Upper GI haemorrhage --> malaena/haematemesis
Perforation --> generalised acute abdo pain, peritonism, shock
43
What imaging should be performed if gastric ulcer suspected?
CT
| Erect CXR
44
What should be suspected if a patient presents with right lower quadrant pain?
```
Appendicitis
Urinary Tract Complications
- Pyelonephritis, nephrolithiasis
Ectopic Pregnancy
Crohns/UC
IBD
```
45
What should be suspected if a patient presents with left lower quadrant pain?
```
Urinary Tract Complications
- pyelonephritis, nephrolithisis
Ectopic Pregnancy
Diverticulitis
IBS
Crohns/ UC
Hernia
Ovarian cyst/torsion
```
46
What should be suspected if a patient presents with left upper quadrant pain?
Splenic Rupture
Peptic Ulcer
Nephrolithiasis
Gastritis
47
What should be suspected if a patient presents with suprapubic pain?
```
Cystitis
Acute urinary retention
Appendicitis
IBD
Ovarian Cyst
```
48
What does umbilical pain indicate?
```
Appendicitis
SB/LB obstruction
IBS
IBD
Gastroenteritis
Ischaemic Colitis
AAA
```
49
What does left and right lumbar region pain indicate?
Nephrolithiasis
Pyelonephritis
Infectious or ischaemic colitis
50
What are the signs of appendicitis?
Central pain that radiates to the right
| Nausea,vomiting, anorexia, tachycardia, pyrexia, RLQ tenderness, guarding
51
What is necrotising fascitis?
A rapidly progressive infection of the deep fascia causing necrosis of subcutaneous tissue
52
What is Type 1 necrotising fascitis?
A polymicrobial infection
53
What is type 2 necrotising fascitis?
Nec fasc caused by group a haemolytic strep
54
What is type 3 necrotising fascitis?
NF caused by clostridium (gas gangrene)
55
What is type 4 necrotising fascitis ?
NF caused by MRSA
56
What are the signs and symptoms of NF?
```
Anaesthesia or severe pain that is out of proportion to cellulitis
Fever
Skin discolouration
Sloughing of fascia
Swelling
Palpitations
Tachycardia
Tachypnoea
Hypotension
Lightheadedness
Nausea and vomiting
```
57
What investigations do you want to do in a suspected NF?
```
FBC
Serum electrolytes (hyponatremia)
U&Es (Raised)
CRP(Raised)
CK (Raised)
Lactate (Raised)
Tissue and Blood cultures
ABG
```
58
What scoring system is used to determine NF?
LRINEC
59
What is the management of NF?
Surgical debridement plus haemodynamic support
- Excisions should extend beyond the area of visible
necrosis
Empirical Antibiotics
- Flucloxacillin, Benzylpenicillin, Gentamycin, Clindamycin
60
What are cutaneous burns?
A common injury to the skin and superficial tissues caused by heat from hot liquids, flame, or contact with heated objects/electrical current or chemicals
61
What are thermal burns?
Burns from
| - heat, hot liquids, flame or contact with heated objects
62
What are electrical burns?
Low, intermediate or high voltage exposure
63
What are chemical burns?
Burns caused by industrial/household chemical products
64
What are non-accidental burns?
Burns from neglect or abuse (20% of paediatric cases)
65
What are the presentations of burns?
```
Erythema
Dry and painful/insenate burns
Wet and painful burns
Cellulitis
Blistering
```
66
What investigations can be done when a burns patient presents?
FBC
Metabolic panel (increased urea, creatinine, glucose, decreased Na and K)
ABG
Wound biopsy culture, wound histology
67
What is the management of burns?
Outpatients (smaller burns)
- lukewarm water and plain soap. Topical silver sulfadiazine
Inpatient
- ABCDE
- Assess % of burns
- Initial excision and debridement
- Graft or flap
- Rehab and reconstruction
68
What formula is used to assess fluid requirements in a patient with burns >15% BSA?
Parkland formula
4 ml of Lactated Ringer's per kilogram per % BSA over first 24 hours
first half given over first 8 hours
second half given over next 16 hours
69
How do you assess %BSA?
Rule of nine
| Hand width = 1%
70
What is a Erythema/Superficial burn?
Burn that only effects epidermis
Pain
Blanchable
71
What is a Superficial-partial thickness burn?
Burn that penetrates the superficial dermis
Pain
Blisters
Blanchable
72
What is a deep-partial thickness burn?
Burn that penetrates the deep dermis
Pain
NOT BLANCHABLE
Soft
73
What is a full thickness burn?
Burn that penetrates muscle, bone
Pain
NOT BLANCHABLE
Hard
74
When is an escharotomy indicated?
When burns are circumferential and deep-partial thickness
75
What is compartment syndrome?
When tissue pressure exceeds perfusion pressure in a limb comparment.
Increased perfusion = swelling and oedema = increased pressure = micro and macrovascular occlusion = myoneural ischaemia
76
What is the most common site of ACS?
Lower leg
followed by forearm and then thigh
77
What is the most common injury that leads to ACS?
Tibial shift fracture
78
What is the aetiology behind ACS?
Fractures, crush injuries, burns, tight dressing, reperfusion injury, extravasation of IV fluids
79
How does ACS present?
Pain (most sensitive sign. Pain out of proportion to injury)
Pulselessness (advanced sign. Indicates amputation)
Pallor
Paraesthesia
Swelling, pink discolouration, tense woody compartment on palpitations
80
How is ACS diagnosed?
Clinical evaluation
X-Ray
Compartment Pressure Monitoring
81
When is compartment pressure monitoring indicated?
If GCS is decreased, in polytrauma or if clinical evaluation is inconclusive
82
What is the management of compartment syndrome?
Morphine
Removal of all casts/occlusive or circumfurential dressings
Fasciotomy
83
What is osteoarthritis?
The loss of cartilage at a joint, resulting in bone remodelling and associated inflammation
84
What are the risk factors of osteoarthritis?
Obesity, repetitive use, trauma, female sex, age, family history
85
How does osteoarthritis present?
Pain on use, easing of pain at rest, decreased function, decreased range of motion, swelling, erythema, joint nodules, crepitus, bony swellings
86
What investigations are done when osteoarthritis is suspected?
```
Joint examination
X-Ray
Joint aspiration
FBC (normal)
CRP and ESR (normal)
LFTs and Creatinine (check to see if suitable for NSAID therapy)
```
87
How is osteoarthritis managed?
Exercise and weight loss
Cold/Heat therapy
```
NSAID use (naproxen, ibuprofen, diclofenac) - topical or oral
PRESCRIBE OMEPRAZOLE IF >60
```
Paracetamol
Topical capsacin
Intra-articular injections (steroids)
Joint replacement therapy
88
What is septic arthritis ?
Infection of one or more joint caused by pathogenic innoculation of microbes
89
What organisms cause septic arthritis?
staphylococcus
streptococcus
MRSA
Gonorrhoea
90
How does septic arthritis spread?
Haematogenous spread to joint
| Direct spread to joint
91
How does septic arthritis present?
Hot, swollen, painful restricted joint
An acute onset
Fever
92
What are the risk factors for septic arthritis?
```
Underlying joint disease
Prosthetic joint
Age
Immunosuppresion
Tick Exposure
Recent joint surgery
```
93
What investigations should be done if septic arthritis is suspected?
```
Synovial fluid microscopy, culture and WCC
Blood culture
WCC, ESR, CRP
U&Es
LFTs
Plain X-Ray
US
```
94
What is the treatment for septic arthritis is there is systemic involvement?
Sepsis treatment
- Take blood cultures, lactate and urine output
- Give O2, IV fluids and empirical antibiotics
amoxicillin, metrondiazole and gentamycin
95
What is the treatment for septic arthritis in a prosthetic joint?
surgery (atherocentesis)
96
What is the treatment for septic arthritis in an inaccessible native joint?
Ultrasound guided joint aspiration
Antibiotics
Paracetamol, ibuprofen and diclofenac
97
What is the treatment for septic arthritis in an accessible native joint?
Empirical antibiotics
Paracetamol, ibuprofen and diclofenac
98
What complications can arise from septic arthritis?
Osteomyelitis
99
What is a femoral shaft fracture?
A fracture of the femoral shaft
100
How does a femoral shaft fracture occur?
High energy injuries such as RTAs (often in younger people)
Low impact injuries such as falling from standing or a gunshot (more common in elderly)
101
What conditions are associated with femoral shaft fracture?
Ipsilateral femoral nexk fractures, tibial shaft fractures, cerebral haemorrhage or thoracic injuries
102
What is the incidence of femoral shaft fracture?
37/100,000
103
What are the fracture patterns of a femoral shaft patterns ?
Transverse (pure bending)
Spiral (rotational)
Oblique (uneven bending)
Comminuted (high speed crash)
104
What is the presentation of a femoral shaft patterns?
Pain in thigh
Tense and swollen thigh
Shortened thigh
105
How do you initially manage a femoral shaft fracture ?
ABCDE
| Advanced Trauma Life Support
106
How much blood loss can occur in a femoral shaft fracture?
1000-1500ml
107
What imaging should be done in a femoral shaft fracture?
Radiographs
| CT
108
What investigations should be done in a femoral shaft fracture?
```
ESR
CRP
Lactate
FBC
Urine output
```
109
How should a femoral shaft fracture be managed?
Anterograde/retrograde intramedullary nails
External fixation
Long limb cast
Abx if wound was open
110
What are the complications of a femoral shaft fracture
| ?
```
Pudendal nerve injury
Femoral artery/nerve injury
Malunion
Rotational malalignment
Infection
```
111
Name some causes of raised ICP?
```
Localised mass lesions
Neoplasm
Abscess
Focal Oedema secondary to trauma
Diffuse Oedema
Obstructive hydrocephalus
```
112
How does raised ICP present?
Headache
- can be nocturnal, when waking, worse on coughing
Papilloedema
Vomiting
Changes in mental state
Syncope
113
What investigations can be done if raised ICP is suspected?
CT
MRI
Blood glucose, renal function, electrolytes, ICP monitoring
114
How should raised ICP be managed?
CSF drainage
Head of bed elevation
Analgesia and sedation
Mannitol or hypertonic saline
115
What is a subarachnoid haemorrhage?
Bleeding into the subarachnoid space
116
What is the aetiology behind a SAH?
Rupture of intracranial saccular aneurysm
| AV malformations, arterial dissections, anti-coag use
117
What is the incidence of SAH?
6-8 in 100,000 people experience a SAH
118
What are the risk factors of SAH?
Hypertension, smoking, family history, ADPKD
119
What is the presentation of SAH?
```
Thunderclap headache
Decrease in consciousness
Neck stiffness and muscle aches
Photophobia
Nausea and vomiting
```
120
What investigations should be performed if SAH is suspected?
CT Head
| FBC, U&Es, Clotting Profile, Troponin, Serum Glucose, ECG
121
What is the management for SAH?
ABCDE (including GCS)
If GCS <8 and Falling
- IV Fluids, nimodipine, surgery and continuous ECG
If GCS >8
- IV fluids, nimodipine, analgesia, surgery
122
What surgery is performed for a SAH?
Endovascular coiling or clipping
123
What are the complications involved with SAH?
Death
Cognitive Impairment
Reoccurrence
Chronic hydrocephalus
124
What is a subdural haematoma?
Collection of blood between dura and arachnoid mater
125
How does herniation occur in subdural haematoma?
Increasing volumes of blood = compression of brain parenchyma = herniation
126
What is the incidence of Subdural Haematoma?
50-60% of all intracranial haematomas
127
What is the aetiology behind Subdural Haematoma?
Trauma (torsional or shearing forces) = disruption of cortical veins = bleeding = haematoma
128
What is the presentation of a Subdural Haematoma?
```
Evidence of trauma
Headache, nausea, vomiting
Decrease GCS and consciouness
Confusion
Seizure
Incontinence
Weakness
Speech and vision change
```
129
What investigations should be done for a Subdural Haematoma?
CT head
FBC, clotting profile
130
What is the management for a Subdural Haematoma?
ABCDE including GCS
Trauma craniotomy
Prophylactic anti-epileptics (phenytoin)
Monitoring
131
What are the indications for a trauma craniotomy?
Haematoma >10mm
Midline shift >5mm
GCS >9
ICP >20mmHg
132
What are the complications of a Subdural Haematoma?
```
Neurological deficit
Coma
Death
Stroke
Epilepsy
Infection at surgical site
```
133
What is a AAA?
An abdominal aortic aneurysm is a permanent pathological dilation of the aorta with a diameter of
>3cm
134
What is the epidemiology behind a AAA?
Incidence is higher M>F
Rupture is higher F>M
Most arise below renal artery level
135
What are the risk factors for a AAA?
Smoking, FH, age, congenital connective tissue disorders
136
How does AAA present?
Usually asymptomatic
| Can present with abdo/back pain and a palpable abdo mass
137
How does a ruptured AAA present?
Severe and sudden Abdo and back pain
| Syncope/shock and collapse
138
What investigations should be done if a AAA is suspected?
Abdominal US
CT
MRI
139
Who is screened for AAA's?
Men >65
140
What is the management for AAA?
Rupture
- Standard resus (IV fluids, airway, bloods) and ABCDE
- EVAR
Large AAA
- EVAR or Open Elective Surgery
Small AAA
- observation
141
What complications are associated with AAA?
```
Death
Abdo compartment syndrome
AKI
Ileus, obstruction, Ischaemic colitis
Graft infection
Aortic neck dilation
```
142
Define breast cancer
A malignancy originating in the breasts and nodal basins
143
What is the aetiology behind breast cancer?
Genetic Factors (BRCA1, BRCA2, HER2), Hormonal Factors
144
What is the epidemiology behind breast cancer?
Most common female malignancy
25% of diagnosis occur before age 50
15% of all new cancer cases
145
What are the risk factors for breast cancer?
```
Previous Hx of Breast Cancer
Age
FH of breast cancer
BRCA 1
BRCA2
HER2
Nulliparity
First child after 30
Early menarche, late menopause
HRT
COCP
```
146
How does breast cancer present?
```
Breast mass
Nipple discharge
Axillary lymphadenopathy
Skin thickening or contour changes
Nipple changes
```
147
What are the diagnostic investigations for breast cancer?
Triple Assessment
1. History and breast examination
2. Imaging - mammography and ultrasound. US typically used for men and women under 35
3. Histology - core biopsy or FNA
148
In the triple assessment, how is the examination score measured?
```
P1 = Normal
P2 = Benign
p3= uncertain/likely benign
P4 = Malignancy suspicion
P5 = Malignant
```
149
In the triple assessment, how is the Imaging Score Generated?
```
M1/U1 = Normal
M2/U2 = Benign
M3/U3= uncertain/likely benign
M4/U4 = Malignancy suspicion
M5/U4 = Malignant
```
150
In the triple assessment, how is the Histology score generated?
```
B1 = Normal
B2 = Benign
B3= uncertain/likely benign
B4 = Malignancy suspicion
B5 = Malignant
```
151
What are the staging diagnostics for breast cancer?
```
ER and PR receptor status
HER2 status
CXR
LFTs
CT
Bone scintagraphy
```
152
What treatment is available for breast cancer?
Lumpectomy or total mastectomy with SLNB
Chemotherapy
Radiotherapy
Tamoxifen (premenopausal women with hormone receptor postitive disease) Aromatase Inhibitor (Post-menopausal women with hormone receptor positive disease)
Bone Health Support (vitamin D and calcium)
153
What are the complications of breast cancer?
Chemo related nausea/neutropenic fever/ovarian failure
Lymphoedema
Treatment related osteopenia
Metastasis
Death
154
What is the prognosis for breast cancer?
85% 5 year survival rate
| 75% 10 year survival rate
155
Define prostate cancer?
A malignant tumour of glandular origin situated in the prostate. They are adenocarcinoma
156
What is the cause of prostate cancer?
It is unknown but a high fat diet and genetics play a part in its development
157
What is the epidemiology behind prostate cancer?
makes up 26% of all male cancer diagnosis in UK
173/100,000 diagnosed
158
What risk factors can predispose you to prostate cancer?
Increasing age
Black Men > White Men
First degree relative w/ Hx of prostate cancer
159
What is the presentation of prostate cancer?
LUTS
- weak stream, hesitancy, retention, frequency, urge incontinence
Haematuria, dysuria
Impotence
Tenesmus
Bone
Asymmetrical, nodular prostate gland on DRE
160
What investigations should be done if prostate cancer is suspected?
```
PSA
PCA3 urine test
Urinalysis to exclude renal bladder pathology
Renal function test
Prostate biopsy
Uroflow measurement
```
161
What grading system is used in prostate cancer?
Gleason Grading System
Grade 1: small, uniform glands with minimal nuclear changes.
Grade 2: medium-sized acinii, separated by stromal tissue but more closely arranged.
Grade 3: marked variation in glandular size and organisation and infiltration of stromal and neighbouring tissues.
Grade 4: marked atypical cytology with extensive infiltration.
Grade 5: sheets of undifferentiated cells.
162
How is prostate cancer managed?
```
MDT lead treatment
Active surveillance
Radical Prostatectomy
Radical Radiotherapy
Androgen deprivation therapy (enzalutamide - to be used in those with metastatic prostate cancer)
Chemotherapy
```
163
What are the complications of prostate cancer?
Urinary tract obstruction
Sexual dysfunction
Metastasis
Death
164
What is acute urinary retention?
The sudden inability to pass urine. It is usually painful.
165
What is the structural causes of acute urinary retention?
Men = BPH, Meatal Stenosis, Paraphimosis, Penile Contricting Bands, Phimosis, Prostate Cancer
Woman - Prolapse, Pelvic Mass, Retroverted Gravid Uterus
Both = Bladder calculi, bladder cancer, faecal impaction, GI or retroperitoneal malignancy, urethral strictures, foreign bodies, stones
166
What are the infectious and inflammatory causes of acute urinary retention?
Men = balanitis, prostatitis, prostatic abscess
Women = acute vulvovaginitis, vaginal lichen planus, llichen sclerosis, vaginal pemphigus
Both = schistomiasis, cystitis, HSV, VZV, peri-urethral abscess
167
What are the drug-related causes of acute urinary retention?
```
Anticholinergics
Opioid and Anaesthetics
Alpha-adrenoreceptor agonists
Benzodiazepines
NSAIDs
Detrusor Relaxants
CCBs
Antihistamines
Alcohol
```
168
When is AUR most commonly encountered?
Post-operatively due to
- pain, traumatic instrumentation, bladder overdistention, drugs, iatrogenic error, decreased mobility and increased bed rest
169
What is the epidemiology behind AUR?
3 in 1000
| M>F
170
How does AUR present?
Patient uncomfortable and unable to pass urine. Tender and distended bladder.
171
What should you look for in a history and examination when investigating AUR?
History
- Associated symptoms (fever, weakness, sensory loss), previous LUTS, PMH, check medication
Examination
- Abdo = tender, enlarged bladder that is dull to percuss above level of pubis symphysis
- Genitourinary = phimosis, meatal stenosis, discharge, vaginal inflammation, prolapse
- Neuro = Look for evidence of disc prolapse or cord compression via testing lower limb power
172
What are the differentials for AUR?
Chronic Urinary Retention
| Prostatic hyperplasia
173
What investigations should be performed when AUR is suspected?
```
Urinalysis
MSU
Blood Tests (FBC, U&Es, eGFR, Blood Glucose, PSA)
Ultrasound
CT
```
174
How is AUR managed?
Catheterisation
| Investigate cause and treat as per local guidelines
175
What are the complications associated with AUR?
UTIs
AKI
Post-retention haematuria
176
What is stress incontinence ?
involuntary leakage of urine on effort or exertion, or on sneezing or coughing. This is due to an incompetent sphincter. Stress incontinence may be associated with genitourinary prolapse.
177
What are the risk factors for stress incontinence?
Pregnancy, vaginal delivery, diabetes mellitus, oral oestrogen therapy, high BMI, hysterectomy
178
What investigations should be done?
Bimanual examination
DRE (men) to assess prostate
Urine dipstick, assess residual urine, urinary flow rate, urodynamic studies,
179
How is stress incontinence managed?
Pads or collecting devices
Pelvic floor exercises
Duloxetine
Surgical treatment (open colposuspension, autologous rectus fascial sling)
180
What is an uncomplicated UTI?
infection of the urinary tract by a usual pathogen in a person with a normal urinary tract and with normal kidney function.
181
What is a complicated UTI?
anatomical, functional, or pharmacological factors predispose the person to persistent infection, recurrent infection or treatment failure - eg, abnormal urinary tract.
182
What pathogens cause UTIs?
```
E. Coli
Staph saprophyticus
Enterococci
Klebsiella
Proteus Vulgaris
Candida Albicans
Pseudomonas
```
183
What are the risk factors for UTI?
```
Recent instrumentation of renal tract
Stasis of urine
Abnormal renal tract
Not voiding after sex
Catheterisation
Diabetes
Pregnancy
```
184
How does a UTI present?
```
Urinary frequency
Dysuria
Haematuria
Foul smelling, cloudy urine
Burning sensation on urination
Urgency
Pyrexia, rigors
Nausea +/- vomiting
Delirium (Elderly)
```
185
What investigations should be done for a UTI?
History
Urinalysis
Urine culture
US of upper urinary tract
186
What is the treatment for UTI?
Trimethorprim or nitrofurantoin
| Ciproflox if complicated UTI
187
What are the complications of UTI?
Ascending infection - pyelonephritis, hydronephrosis, AKI, sepsis
188
What is testicular torsion?
Twisting of the testis around the spermatic cord resulting in occlusion of testicular blood vessels and can lead to ischaemia
189
Epidemiology of testicular torsion?
Typically effects neonates or post-pubertal bous
L side > R side
Often unilateral
190
What is intravaginal torsion?
Occurs when the posterior lateral aspect of the testes is not properly fixated to the tunica vaginalis.
Occurs in 12% of males
191
What is extravaginal torsion?
Occurs more often in neonates
Spermatic cord and tunica vaginalis undergo torsion in or below the inguinal canal
192
How does testicular torsion present?
```
Acute swelling in testis
Sudden and severe pain in one testis
Lower abdo pain
Nausea and vomiting
Erythema of scrotal skin
Swollen and tender testis retracted upwards
```
193
Differentials for testicular torsion?
Epididymitis
Orchitis
Hydrocele
Hernia
194
What investigations should be done for testicular torsion?
Ultrasound
Doppler
MRI
Urinalysis
195
How is testicular torsion managed?
Prompt clinical examination
Emergency urology referral
Orchidopexy or orchiectomy
196
What are the complications of testicular torision?
Subfertility
| Infertillity
197
What is acute limb ischaemia?
A sudden decrease in limb perfusion causing a potential threat to limb viability
198
What is the most common cause of acute limb ischaemia ?
acute thrombotic occlusion of a previously partially occluded, thrombosed arterial segment
embolus from a distant site
trauma
Compartment Syndrome
199
What are less common causes of acute limb ischaemia?
```
Vasculitis
Popliteal entrapment syndrome
Compartment Syndrome
Iatrogenic
Aortic Dissection
Graft Occlusion
```
200
What are the risk factors for acute limb ischaemia ?
```
AF
Hypertension
Smoking
Diabetes
Recent MI
```
201
What are the 6 Ps of acute limb ischaemia ?
Pain (worse distally)
Pallor (white rather than blue)
Pulselessness (doppler)
Paraesthesia
Perishingly Cold (compare to contralateral limb)
Paralysis (poor prognosis of irreversible ischaemia)
202
What examinations should be performed in acute limb ischaemia?
CV exam
Abdomen (check for AAA)
The affected limb
- Inspection (colour, scars)
- Palpation (temperature, pulses, tenderness, neurological function)
- Auscultation (Arterial doppler - compare to contralateral limb)
- Move leg passively and ask patient if they can move affected limb
203
What investigations should be performed if acute limb ischaemia is suspected?
```
FBC
UsEs
Serum Glucose and Lactate
Clotting Panel
ESR
Group and Save
Cross Match
```
ECG
Doppler
204
What is the immediate management for acute limb ischaemia?
```
IV heparin
Analgesia - morphine
Oxygen
CT angiogram if feasible
Call vascular surgeon for review
```
205
What are the complications of acute limb ischaemia?
Myoglobinaemia
Rhabdomyolysis
Acute tubular necrosis
Hyperkalaemia
206
What is infective endocarditis?
An infection involving the endocardial surface of the heart and the chordae tendineae
207
What organisms cause endocarditis?
Viridans group streptococci
Staph aureus
Enterococci
208
Endocarditis statistics
M>F
| >60 yrs old = most prevalent
209
What are the risk factors for developing infective endocarditis?
Artificial prosthetic heart valves
Congenital Heart Disease
IVDU
210
How does infective endocarditis present?
```
Fever/chills
Night sweats, fatigue, malaise, weakness
Arthralgia
Headache
SOB
Janeway lesions
Oslers nodes
Roth Spots (fundoscopy)
Splinter haemorrhages
Heart Murmur
Arthritis
Meningism
```
211
What investigations should be done if infective endocarditis is suspected?
```
FBC
Serum chemistry
Urinalysis
Blood cultures
ECG
Echo
CXR
```
212
What is the initial management for infective endocarditis?
Supportive measures
Amoxicillin (+/- gentamycin)
Surgery
213
What are the complications of infective endocarditis?
CHF
Systemic Embolisation
Mitral valve vegetation
214
What is the diagnostic criteria for endocarditis?
Duke's criteria
| - 2 major/ 1 major + 3 minor/ 5 minor for diagnosis
215
What are the major criteria of Dukes crtiteria?
Positive blood culture for IE
| Evidence of endocardial involvement (abscess, valvular regurg, oscillating intracardiac mass on valve, abscess)
216
What are the minor Duke's criteria
predisposing heart condition or intravenous drug use.
Fever
Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial haemorrhage, conjunctival haemorrhages and Janeway's lesions.
Immunological phenomena: glomerulonephritis, Osler's nodes, Roth's spots and rheumatoid factor.
Microbiological phenomena: positive blood culture
PCR: broad-range PCR of 16S
Echocardiographic findings consistent with IE
217
Define ischaemic heart disease?
An inability to provide adequate blood supply to the myocardium, is primarily caused by atherosclerosis of the epicardial coronary arteries
218
What is the aetiology behind stable ischaemic heart disease?
Atherosclerosis, vasospasm, endothelial dysfunction, embolism, coronary artery dissection, vasculitis/arteritis
219
Statistics behind ischaemic heart disease
M>F
1/5 men die every year
1/7 women die every year
Poor > Rich
220
What are the risk factors for ischaemic heart disease?
```
Increasing Age
Social deprivation
Smoking
Poor nutrition
Stress
Alcohol
HTN
Hypercholesterolaemia
Obesity
Diabetes
Family History
```
221
How does ischaemic heart disease present?
Chest pressure lasting several minutes provoked by emotional stress or exercise (relieved by GTN)
222
What investigations should be done if ischaemic heart disease is suspected?
```
Resting ECG
Haemoglobin
Lipid profile
Fasting blood glucose
HbA1c
```
223
How should ischaemic heart disease be managed?
Lifestyle education
Antiplatelet therapy (Aspirin, clopidogrel)
Lipid lowering therapy (atorvastatin, simvastatin, rosuvastatin)
Antihyertensive therapy
- B Blocker (metoprolol, bisoprolol)
- ACEi (lisinopril, ramipril, losartan)
Blood Sugar Control
- Metformin, Glimepiride,
CABG or PCI
GTN spray
224
What are the complications of ischaemic heart disease?
```
Myocardial infarction
Sudden cardiac death
Stroke
Peripheral arterial disease
Ischaemic cardiomyopathy
```
225
What is unstable angina?
An acute coronary syndrome defined by the absence of biochemical evidence of myocardial damage.
226
What is the aetiology behind unstable angina?
Coronary artery disease
| Vasospasm
227
How does unstable angina present?
Increasing frequency and severity of chest pain, retrosternal pain radiating to jaw, arm or neck, dyspnoea
228
What investigations should be done for unstable angina ?
```
ECG
Cardiac biomarkers (troponin)
FBC
Electrolytes
Renal function
Blood sugar
Lipid profile
Coag profile
CXR
Echo
Myocardial perfusion studdy
CT Chest
Coronary angiography
```
229
What is the management for cardiac chest pain?
Oxygen, nitrates, morphine
| Betablockers (metoprolol, lisoprolol, labetalol, atenalol. propranalol, bisoprolol)
230
Define a STEMI?
STEMI is an acute myocardial infarction with new and persistent ST segment elevation in two contiguous leads
231
What is an acute myocardial infarction?
Cell death that occurs because of a prolonged tissue perfusion/tissue demand mismatch
232
What are the risk factors for developing a STEMI?
```
Increasing age
Male
FH
Smoking
Diabetes
Hypertension
Dyslipidaemia
Obesity
```
233
What is the incidence of STEMI?
500/1,000,000
M>F
Younger > Older
Incidence in women increases after menopause
234
How does STEMI present?
- Chest pain (retrosternal, crushing, heavy and diffuse. Can radiate to left arm, neck or jaw)
- Dyspnoea
- Pallor
- Diaphoresis
- Nausea/vomiting
- Dizziness or light-headedness
- Palpitations
- Distress and anxiety
235
What investigations should be done if STEMI is suspected?
```
ECG
Cardiac Troponin
Glucose
FBC
Electrolytes, urea, creatinine, eGFR
CRP
Serum Lipids
```
236
Differentials for STEMI
```
Unstable Angina
NSTEMI
Aortic Dissection
PE
Pneumothorax
```
237
How should STEMI be managed?
```
Aspirin + clopidogrel
Morphine
Ondansentron
Oxygen
IV GTN
```
PCI if symptoms presented <12 hours ago
238
What are the complications of a STEMI?
Sinus bradycardia, first degree heart block, second degree heart block
Recurrence
Congestive Heart Failure
Death
239
What is an NSTEMI ?
Chest pain without ST-segment elevation
| but troponin levels are raised
240
How is an NSTEMI assessed?
ECG (diagnostic)
| Troponin
241
What should be offered if NSTEMI is diagnosis is made?
Aspirin
Ticagrelor
Clopidogrel
LMW Heparin
242
What system is used to assess risk of cardiovascular event of NSTEMI patients?
GRACE scoring system
243
What is a pneumothorax?
Collection of air in the pleural cavity resulting in the affected lung collapsing
244
What are the types of pneumothorax?
Primary spontaneous pneumothorax
Secondary Pneumothorax (associated with underlying lung disease)
Traumatic Pneumothorax
Iatrogenic Pneumothorax
245
What is a tension pneumothorax?
Life threatening variant of pneumothorax resulting in impaired respiration and haemodynamic instability
246
What are common findings in a tension pneumothorax?
```
Chest pain
Tachycardia
Tachypnoea
Lowering O2 sats and BP
Tracheal displacement away from affected side
```
247
How do you manage a tension pneumothorax?
Oxygen
| Emergency needle decompression (large bore needle through second or third anterior intercostal space)
248
When does a tension pneumothorax tend to arise?
In ventilated patient
Trauma
Resucitation patients
In COPD, Asthma
Patients revieving non-invasive ventilation
Patients undergoing hyperbaric oxygen treatment
249
What are the risk factors for developing pneumothorax?
```
Smoking
Marfans syndrome
Endometriosis
COPD
CF
Malignanxy
Pulmonary Fibrosis
TB
```
250
How does a pneumothorax present?
Sudden chest pain with shortness of breath
Distressed and sweating patient
Tachycardia
Hypotension
Decreased air entry and chest movements on affected side
Tracheal deviation
Hyperresonance and reduced breath sounds over effected area
251
What investigations should be performed for pneumothorax?
Erect CXR
ABG (hypoxia)
O2 sats
252
How is a pneumothorax managed?
Supplemental O2
Chest drain / Needle aspiration
Persistent air leak = thoracic surgery referral
Pleurodesis (minocylcline)
253
What is otitis media?
Infection of the middle ear
254
What organisms can cause otitis media?
Haemophilus Influenzae
Streptococcus pneumoniae
Moraxella catarrhalis
255
What is the pathophysiology behind otitis media?
Upper respiratory infecitons can effect the nasal passages and consequently, the effect of the eustachian tube (draining the middle ear). This allows for effusion to develop and nasopharyngeal bacteria will contaminate the effusion.
256
How does otitis media present?
```
Otalgia
Recent Hx of Upper Resp symptoms
Bulging typanic mebrane
Myringitis
Fever
Irritability
Sleep Disturbance
```
257
What investigations are performed for otitis media?
None - diagnosis is clinical
258
How is otitis media managed?
Paracetamol
Ibuprofen
Amoxicillin (delayed)/ erythromycin (penicillin allergic)
259
What are the complications of acute otitis media?
```
Otitis media with effusion
Mastoiditis
Acutely perforated tympanic membrane
Facial Nerve Palsy
Meningitis
Encephalitis
```
260
What is otitis externa?
Inflammation of the outer ear
261
What are the risk factors for otitis externa?
```
Hot and humid climates
Swimming
Older Age
Immunocompromise
DM
Wax build up
Eczema
```
262
What is the pathophysiology behind otitis externa?
Disturbance of lipid/acid balance of the ear canal
263
What organisms can cause otitis externa?
Staph aureus
P. aeruginosa
Candida
264
What irritants can cause otitis externa?
```
Topical medications
Hearing aids
Earplugs
Foreign bodies
Water in ear
Chemicals
```
265
How does otitis externa present?
```
Ear canal erythema, oedema and exudate
Mobile tympanic membrane
Pain with movement of tragus or auricle
Pre-auricular lymphadenopathy
Hearing Loss
Cellulitis spreading beyond ear
Ottorhoea
Aural Fullness
Itching
```
266
What investigations should be performed if otitis externa is suspected?
Otoscopy
| Tympanometry
267
How should otitis externa be managed?
Ciprofloxacin/dexamethasone drops
OR
Ofloxaxin drops
Paracetamol and ibuprofen
268
What is a Hiatus Hernia?
The herniation of a part of the abdominal viscera through the oesophageal aperture of the diaphragm
269
What are the risk factors for a hiatus hernia?
```
Obesity
Pregnancy
Ascites
Advancing Age
Genetics
Previous gastro-oesophageal surgery
```
270
What is the cause of hiatus hernia?
Widening of the diaphragmatic hiatus
Oesophageal Shortening
Increased intra-abdominal pressure pushing up the stomach
271
What are the two types of hiatus hernia?
Sliding (gastro-oesophageal junction slides into the thoracic cavity - 85-95% of cases)
Para-oesophageal hiatus hernia - the gastro-oesophageal junction remains in place but a part of the stomach herniates into the chest next to the oesophagus
272
What is concerning about para-oesophageal hernias?
Risk of obstruction, volvulus or ischaemia
273
How does a hiatus hernia present?
Asymptomatic (often with sliding hernias) OR:
- Retrosternal burning sensation
- Heartburn when lying or sitting
- Gastro-oesophageal reflux
- Difficulty Swallowing
Para-oesophageal hernia
- chest pain
- epigastric pain
- fullness
- nausea
274
What investigations should be done for hiatus hernias?
CXR
Barium swallow
Endoscopy
275
What diseases are associated with hiatus hernia?
Reflux oesophagitis
Barrett's oesophagus
Oesophageal adenocarcinoma
Reflux laryngitis
276
How is a hiatus hernia treated?
In absence of symptoms, sliding hernias do not require treatment
LIFESTYLE:
Avoid tight clothing, weight loss, remaining elevated when sleeping, smaller meals
PHARMACOLOGICAL:
- Omeprazole
- Lansoprazole
SURGICAL:
Fundoplication
277
What are the indications for surgery?
People who are intolerant to/do not comply with therapeutic regimes
People with respiratory complications of reflux
People with symptomatic para-oesophageal hernia
People who require high doses of medication or in whom high doses are not working
278
What is GORD?
Gastro-oesophageal Reflux Disease - prolonged exposure to gastric acid in the oesophagus
279
What factors predispose people to GORD?
```
Increased intra-abdominal pressure
Inadequate cardiac sphincter
Smoking
Alcohol
Pregnancy
Obesity
Systemic sclerosis
Hiatus hernia
Drugs (TCA's, ANTI CHOLINERGICS, NITRATES, CCB's)
```
280
How does GORD present?
```
Dyspepsia
Retrosternal discomfort
Acid or water brash
Odynophagia
Chest Pain
Epigastric Pain
```
281
How is GORD investigated?
Endoscopy
FBC
Barium Swallow
Oesophageal pH monitoring
282
How is GORD managed?
LIFESTYLE:
- weight loss
- smoking cessation
- reduce alcohol
- small, regular meals
PHARMACOLOGICAL:
- Omeprazole
Endoscopy
Laproscopic fundoplication
283
What are the complications of GORD?
Oesophagitis
Anaemia
Stricture
Barret's oesophagus
284
When should someone with GORD be referred for investigations into upper GI cancer?
Dysphagia - food sticking
Dyspepsia with weight loss/anaemia/vomiting
Dyspepsia with FH of upper GI cancer, Barrett's oesophagitis, Pernicious Anaemia, Jaundice, Upper Abdo Mass
285
What is Crohn's disease?
A chronic relapsing IBD characterised by transmural granulomatous inflammation that can affect any part of the GI tract
286
What is the most common site of crohn's?
Terminal ileum
287
What are the extra-intestinal manifestations of Crohn's?
```
Iritis
Arthritis
Erythema Nodosum
Pyoderma Gangrenosum
Fatty liver
Renal Stones
Osteomalacia
```
288
Epidemiology of crohn's?
M=F
2 age peaks
- 15-30 years
- 50-70 years
Strong genetic link
289
What are the risk factors for Crohn's?
Genetics
| Smoking
290
How does Crohn's present?
```
Diarrhoea (often not bloody or mucusy)
Abdo pain
Weight loss
Aphthous Ulcers
Perianal abscess
Anal fissure
```
Pain etc is intermittent
May have skin, eye or joint problems too.
291
What blood tests are done if Crohn's is suspected?
```
FBC
CRP
U&Es
LFTs
Faecal calprotectin
```
292
What other forms of investigations are done for Crohn's?
Endoscopy
Colonoscopy
+ Biopsy
293
How is Crohn's managed?
Correction of any vitamin/mineral deficiencies
Flare Up:
- Oral Prednisolone, IV hydrocortisone
- Azathioprine
- Infliximab (severe active crohn's)
Maintaining Remission:
- Smoking Cessation
- Azathioprine/ Mercaptopurine
- Methotrexate (if pt does not tolerate azathioprine etc.)
Surgery
294
What are the indications for surgery in Crohn's?
Stricture formation
Fistula formation
Localised to distal ileum
295
Why are anti-diarrhoeals not given in an active flare?
Can cause toxic megacolon
296
What are the complications of Crohns?
```
Stricutres
Fistulas
Perforation of bowel
Cancer
Osteoporosis (steroid therapy)
Iron, folate and vit b12 deficiency
Gallstones and oxalate renal stones
```
297
What is Ulcerative Colitis?
Inflammation of the colon with periods of relapse and remission. Limited to colon and rectum. Superficial mucosa only affected.
298
Epidemiology of UC?
Most common type of IBD
M=F
Peak incidence = late adolescence, early adulthood
299
What is the cause of UC?
Probably autoimmune
300
What are the risk factors for UC?
Family History
301
What is protective against UC?
Smoking
302
What are the symptoms of
```
Bloody diarrhoea
Colicky abdo pain
Urgency
Tenesmus
Rectal bleeding
Malaise
Fever
Weight Loss
Tender abdo on examination
```
303
What extra-intestinal diseases are associated with UC?
```
Erythema nodosum
Episcleritis
Anterior uveitis
Ankylosing spondylitis
Primary sclerosing cholangitis
```
304
What blood tests should be performed if UC is suspected?
```
FBC
Renal function
CRP
U&Es
LFTs
ESR
Iron studies, Vit B12 and folate
Faecal calprotectin
p-ANCA testing
```
305
What other investigations should be done for UC?
Sigmoidoscopy and rectal biopsy
Colonoscopy and biopsy
Abdo XRay
306
Truelove and Witt categories for UC?
Mild - <4 stools a day, only small amount of blood in stool, no anaemia, no tachycardia, normal ESR and CRP
Moderate - 4-6 stools daily, more blood than mild disease, no anaemia, no tachycardia, no fever, normal esr and crp
Severe - >6 stools daily with visible blood, one or more feature of systemic upset (fever, tachy, anaemia, raised ESR, CRP)
307
When is urgent hospital referral considered for UC patients?
Abdo pain with distended abdomen
| Failed response to steroids after two weeks
308
How is UC managed?
Mesalazine (oral or topical)
Corticosteroids (flare up)
Azathiopurine (pt intolerant to corticosteroids, relapse within 6 weeks of stopping steroids, relapse with small doses of steroids regularly)
Infliximab for moderate to severe disase
Surgery
- total colectomy (ileal pouch-anal anastamosis)
309
When is surgery indicated in UC?
Stools >8 daily
Pyrexia
Tachycardia
Colonic dilation on abdo X-RAY
310
What complications are associated with UC?
Colorectal cancer
Toxic megacolon
Osteoporosis (due to drug treatment)
311
Colorectal cancer epidemiology
2/3 occurs in colon
1/3 occurs on rectum
4th most common cancer overall
Highest incidence in people aged 85-89
312
What are risk factors for developing colorectal cancers?
```
FH of colorectal neoplasia
PH of colorectal neoplasm
IBD
Polyposis syndromes (Gardner's syndrome, Peutz-Jeghers Syndrome etc)
HNPCC
DM
History of small bowel, endometrial, breast or ovarian cancer
Sedentary Lifestyle
```
313
How does colorectal cancer present?
Right Sided
- weight loss, anaemia, occult bleeding, mass in right iliac fossa
Left Sided
- colicky pain, rectal bleeding, bowel obstruction, tenesmus, mass in left iliac fossa, early change in bowel habit, less advanced disease at presentation
Rectal bleeding
314
What investigations should be performed for suspected colorectal cancer?
```
Full blood count
Us Es
Liver Function Tests
Iron studies, ferritin, B12, folate
Faecal Occult Blood Test
```
Colonoscopy
315
What is the referral criteria for colorectal cancer?
- aged 40 and over w/ unexplained weight lorr and abdo pain
- Aged 50 and over with unexplained rectal bleeding
- Aged 60 and over with:
- Iron deficiency anaemia
OR
- Changes in bowel habit OR
- Tests show occult blood
in faeces
- Abdo or rectal mass
316
What staging system is used to grade colorectal cancer?
Dukes Staging System
317
Dukes Staging System
Dukes A - cancer in the innermost lining of bowel/ slight growth into muscle layer
Dukes B - cancer grown through the muscle layer of the bowel
Dukes C - cancer has spread to at least one lymph node close to the bowel
Dukes D - cancer has metastasised to other area
318
What is the management for colorectal cancer?
Surgery
Radiotherapy
Chemotherapy
319
Where are the common sites for metastasis in colorectal cancer?
```
Liver
Lung
Peritoneum
Ovaries
Brain
```
320
What is the 5 year survival rate for colorectal cancer?
50%
321
What is an inguinal hernia?
the protrusion of abdo contents through the fascia of the abdo wall
322
Epidemiology of inguinal hernias
M>F
Most common in infants or people aged 75 or above
Indirect more common in children
Direct more common in elderly
323
What is the presentation of an inguinal hernia?
Swelling in the groin that may appear with lifting and be accompanied by sudden pain
Pain in scrotum (INDIRECT)
Increased swelling on coughing
Lump that may reduce when lying down
324
What is an indirect hernia?
Protrusion through the internal inguinal ring, along the inguinal canal through abdo wall, running laterally to inf epigastric vessels
325
What is a direct hernia?
Produces directly through a weakness in posterior wall of inguinal canal, running medially to inf epigastric vessels
326
What investigations are done to diagnose a hernia?
Ultrasound
| MRI if US unclear
327
How is a hernia managed?
In adults, if small - conservative management unless painful, then surgery
Surgery if large, painful or in paediatric cases
328
What complications are associated with hernias?
```
Recurrence
Infarcted testes (or ovary)
Wound infection
Hydrocele
Bladder or intestinal injury
```
329
What are the most common causes of upper GI bleeding?
Oesophageal varices
Mallory-weiss tear
Duodenal or gastric ulcers
Gastric or duodenal cancer
330
What is the glasgow-blatchford score?
a scoring system used in suspected upper GI bleed on initial presentation. A score >0 indicates a GI bleed
331
What biochemical result would suggest an upper GI bleed?
A raised urea level
332
What is the Rockall score?
Used for patients that have had endoscopy. Provides percentage risk for mortality.
333
How is an upper GI bleed managed?
```
ABCDE
Bloods
Access (2 large bore cannula)
Transfuse
Endoscopy
Drugs (stop anticoags and NSAIDs)
```
334
What blood tests should be done in an upper GI bleed?
```
FBC
UsEs
Coag panel
LFTs
Crossmatch
```
335
What are gallstones?
A stone formed within gallbladder made of bile components
336
Epidemiology behind gallstones
10-15% of adults develop gallstones
Most common presentations = biliary colic and acute cholecystitis
70% of patients with gallstones are asymptomatic at time of diagnosis
337
What are the risk factors for developing gallstones?
```
Fair
Fat
Female
Fertile
Forty
Increasing age
Sudden weight loss
Diabetes
```
338
What are the most common types of gallstone?
Cholesterol stone (Radiolucent)
Black pigment stones (Radiolucent)
Mixed stones - calcium salts, bile pigment and cholesterol (radiopaque)
Brown stones (result of stasis and infection within the biliary system)
339
What is the pathophysiology behind biliary colic?
gallstone impacting in cystic duct or ampulla of vater
340
Pathophysiology behind acute cholecystitis?
Distension of the gallbladder = necrosis and ischaemia of mucosal wall
341
What are the symptoms of biliary colic?
Pain in epigastrium or RUQ and might radiate to back (interscapular region)
Nausea or vomiting
Doesn't fluctuate
342
What investigations should be done for suspected biliary colic?
Ultrasound
Urinalysis, ECG and CXR (exclude other things)
LFTs
ERCP
343
How does acute cholecystitis present?
```
RUQ pain
Vomiting
Fever
Local peritonism
GB mass
Jaundice (stone moved to common bile duct)
```
344
What investigations should be done for acute cholecystitis ?
FBCs
LFTs
US
345
How is gallstones, colic and cholecystitis managed?
Opioids +/- diclofenac
IV antibiotics
Cholecystectomy
