Treatment options Crohn Stricture
Medical
- escalate if inflammatory component
Endoscopic
- balloon dilation
Surgical
- resection
- stricture-plasty
–Heineke-Mikulicz
– Finney U
Crohns pathology
Micro
- noncaseating granulomas (epithelioid Langerhan’s giant cells= macrophages)
-transmural inflammation
Macro
- Throughout GI tract
- discontinuous/skip lesions
-cobblestoned mucosa
- fat wrapping
-fistulas
-strictures
WHO conditions of screening test
- the condition should be an important health problem
- there should be a recognisable latent or early symptomatic stage
- the natural history of the condition, including development from latent to declared disease, should be adequately understood
- there should be an accepted treatment for patients with recognised disease
- there should be a suitable test or examination that has a high level of accuracy
- the test should be acceptable to the population
- there should be an agreed policy on whom to treat as patients
- facilities for diagnosis and treatment should be available
- the cost of screening (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole, and
- screening should be a continuing process and not a ‘once and for all’ project.
Sensitivity
- Ability of the test to detect all those that have the disease
- TPs/ all the positives ( TP + FN)
- Low sensitivity leads to high numbers of false negatives ( patients incorrectly told they don’t have the disease)
- Positive result is useful rule in
Specificity
- Ability of the test to detect those who do not have the disease
-TNs / all the negatives (TN + FP)
-Low specificity leads to high numbers of false positives ( patients who don’t have the disease being told they do)
-Negative result is useful rule out
Pro/Con Screening
Benefits of screening
- Lower morbidity and mortality
- Reduce anxiety around condition
- Save health care costs
Downsides
- False reassurance
- Physical and psychological harm of test
- Cost of screening and of further tests to individual/health system
- Unnecessary treatment
- Opportunity cost
Audit cycle
The Surgical Audit Cycle Surgical audit activities are based on a five-step cycle:
* Step 1: Determine scope
○ : A thoughtful decision about which area(s) of surgical practice to review.
* Step 2: Select standards
○ : A clear description of what is good practice in this area against which the results of the audit will be compared.
* Step 3: Collect data
○ : The collection of relevant data.
* Step 4: Present and interpret results including peer review:
○ Comparison of results to standards and/or those of peers, discussion with peers
○ decision about what changes may lead to improvement e.g. learning new skills, changes in practice, systems etc.
* Step 5: Make changes and monitor progress
○ Alteration or confirmation of practice in accord with the results of analysis and consultation with peers, then checking that improvement has occurred.
What is audit
Surgical audit is a systematic, critical analysis of the quality of surgical care that is reviewed by peers against explicit criteria or recognised standards, and then used to further inform and improve surgical practice with the ultimate goal of improving the quality of care for patients.
Virchows triad
- Hypercoagulability
○ Changes in blood composition ( platelets or clotting factors)
○ Can be congenital or acquired- Stasis
○ Impaired blood flow
eg Immobility - Endothelial dysfunction
- Stasis
Septic shock
Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.
* Septic shock clinical criteria: Sepsis and (despite adequate volume resuscitation) both of: ○ Persistent hypotension requiring vasopressors to maintain MAP greater than or equal to 65 mm Hg, and ○ Lactate greater than or equal to 2 mmol/L * With these criteria, hospital mortality is in excess of 40%
Sepsis(III)
Sepsis is life-threatening organ dysfunction due to a dysregulated host response to infection
- Sepsis clinical criteria:
- organ dysfunction is defined as an increase of 2 points or more in the Sequential Organ Failure Assessment (SOFA) score
qSOFA
HAT:
Hypotension <100
Altered mental state
Tachypnoea >22
Pathophys Sepsis
- Sepsis is life-threatening organ dysfunction due to a dysregulated host response to infection
- Complex interaction between inciting microbe, host immune response proinflammatory cytokines and coagulation system
○ Pathogen or endotoxin/exotoxin produced by pathogen (PAMP) activates cellular response
○ Subsequent host response involves activation and release of cytokines (Il-1, TNFa, IFNgamma ), leukotriene pathway, complement activation, coagulation cascade, stress hormone release and
○ Progressive microcirculatory disturbance endothelial dysfunction, micro vessel thrombosis.
○ It results in end-organ micro thrombosis, and a progressive increase in capillary permeability, eventually resulting in loss of circulatory integrity and vasoplegia. - End result is shock causing global tissue hypoxia and dysfunction
- Complex interaction between inciting microbe, host immune response proinflammatory cytokines and coagulation system
Merkel Cell Pathophys
Pathophysiology
- Aggressive neuroendocrine malignant tumour of skin
- Thought to develop from epidermal pluripotent stem cell and aquire neuroendocrine features (rather than develop from Merkel cell)
- Many associated with Merkel polyomavirus
Propensity for regional and distant spread
NSTI pathophys
- Aggressive synergistic microbial soft tissue infection characterized by widespread necrosis of subcutaneous tissue and fascia
- Microbial invasion of subcutaneous soft tissue
○ Traumatic injury/ procedure related - Bacterial infiltrate through release of endo toxins and exotoxins causing tissue necrosis
○ Obliterative endarteritis, thrombosis and necrosis of small vessels leading to soft tissue necrosis - Further spread along fascial planes where perfusion is less ( muscles usually spared due to good blood supply)
- Tissue injury and oedema causes compartment swelling and may compromise tissue perfusion further
- Hematogenous spread of infection/bacteriaemia with remote toxin/cytokine release
- Activation of systemic inflammatory response through PAMP and host immune response including IL-1, TNFa, INFg which can lead to septic shock/MODS.
- Microbial invasion of subcutaneous soft tissue
Stages of healing
- Linear process of formation of skin integrity
Haemostasis
Inflammation
Epithelialization
Fibroplasia
Maturation
Classification of surgical wounds
Clean Elective, not emergency, non-traumatic, primarily closed; no acute inflammation; no break in technique; respiratory, gastrointestinal, biliary and genitourinary tracts not entered
< 2
Clean – contaminated Urgent or emergency case that is otherwise clean; elective opening of respiratory, gastrointestinal, biliary or genitourinary tract with minimal spillage (eg., appendectomy) not encountering infected urine or bile; minor technique break
<10
Contaminated Nonpurulent inflammation; gross spillage from gastrointestinal tract; entry into biliary or genitourinary tract in the presence of infected bile or urine; major break in technique; penetrating trauma <4 hours old; chronic open wounds to be grafted or covered
10-20
Dirty Purulent inflammation (e.g., abscess); preoperative perforation of respiratory, gastrointestinal, biliary or genitourinary tract; penetrating trauma >4 hours old
20-40
