Surgery Flashcards

Question

Portacath

Answer 1

Port installed beneath the skin, and connected to a vein by a catheter

Answer 2

Report any signs of infection/bleeding Do not get the site wet Avoid contact sports

Answer 3

A balloon catheter, passed from the femoral vein, through the right side of the heart into the pulmonary artery. Used to measure pulmonary artery pressures.

Answer 4

Arrythmias Valve trauma Pulmonary infarction / pulmonary artery rupture

Answer 5

Indications: - Frequent blood sampling / ABG analysis - Continuous invasive BP monitoring Usually inserted into radial artery in the critically ill, after performing Allen’s test

Answer 6

The location of the carina on a CXR

Answer 7

- Spouted, with prominent mucosal folds - Tend to be on the RHS - Bag will have bilious contents

Answer 8

One lumen Generally permanent Indications = definitive surgery to remove colon

Answer 9

Two lumens Often temporary and reversed at a later date; Indications = to rest distal bowel, to protect distal anastomoses, to provide functional relief from severe incontinence

Answer 10

Usually flush to the skin, with flat mucosal folds. Tend to be on the LHS Contents tend to be more faeculant. Can be loop or end (but end colostomies are far more common)

Answer 11

Formed from a short section of disconnected ileum, into which one or both ureters are directed after a radical urinary tract surgery. They are indistinguishable from an end ileostomy unless output can be seen.

Answer 12

A connection from the anterior stomach to the anterior abdominal wall. Features: - Narrow in calibre - Flush to the skin - Usually in LUQ - Fitted with indwelling access device. Indications: for stomach drainage or direct feeding.

Answer 13

A connection from the jejunum to the abdominal wall, for direct feeding. Appearances are the same as a gastrostomy.

Answer 14

Infarction / necrosis Infection High output from the stoma leading to severe dehydration

Answer 15

Parastomal hernia (incisional hernia at the stoma site) Stoma prolapse (underlying bowel protrudes through the orifice) Stoma retraction (pulled/drawn below skin level) Stenosis (narrowing of stomal opening)

Answer 16

1. Ask the patient if they have had any pain or issues with their stoma. 2. Gently palpate the abdomen for distension / tenderness. 3. Ask the patient to cough – observe for parastomal hernia. 4. Observe the surrounding skin quality for any signs of infection. 5. Determine the type of stoma (define the siting, spouting and contents) 6. Observe specifically for any signs of infarction, prolapse, or retraction. 7. Listen for bowel sounds 8. State that you would like to view the patient’s fluid balance chart.

Answer 17

1. Haemostasis (immediate) 2. Inflammation (0 – 3 days) 3. Proliferation (3 days – 3 weeks) 4. Remodelling (3 weeks – 1 year)

Answer 18

Platelets aggregate at the site in response to exposed collagen, releasing inflammatory markers and activate clotting and coagulation cascades Haemostasis is then achieved by vasospasm and thrombus formation.

Answer 19

Days 0-3 Vasodilatation and increased capillary permeability allow inflammatory cells to enter the wound, leading to oedema. Neutrophils enter the tissues to debride and kill bacteria, followed by macrophages to phagocytose debris and orchestrate fibroblast migration.

Answer 20

Day 3 - 21 Fibroblasts migrate in to synthesise collagen, with myofibroblasts secreting actin-containing products to cause wound contraction. Angiogenesis is stimulated by hypoxia and cytokines => creates granulation tissue.

Answer 21

3 weeks - 1 year Re-orientation and maturation of collagen fibres to increase wound strength.

Answer 22

The combination of capillary loops and myofibroblasts, giving the appearance of small, red foci that bleed easily (commonly seen when a scab is picked). It is these capillary loops that allow the inflammatory cells to enter the damaged tissue to promote defence and healing. Infected granulation tissue will be painful; discharging; erythematous & swollen; and the patient may have systemic features.

Answer 23

The covering of a surface with the skin layers removed with epithelial tissue, occurring from the outer edges of the wound after granulation.

Answer 24

Takes place when there is a close apposition of clean wound edges. => Fibrin is able to form a weak framework between the edges, over which the capillaries proliferate and secrete collagen into the fibrin network. => The elastic network of the dermis cannot be replaced.

Answer 25

Takes place in wounds where skin edges cannot be clearly opposed. 1. Phagocytosis removes debris 2. Granulation tissue forms to fill the defect. 3. Epithelial regeneration then covers the surface

Answer 26

Occur in a wound or around a suture: 1. Heat 2. Erythema 3. Swelling 4. Pain 5. Loss of function

Answer 27

Depending on the severity, the patient may need: 1. No treatment 2. Oral/IV ABX 3. Re-intervention on the ward / in theatre to open, drain, debride, rinse and pack the wound Cultures are always recommended.

Answer 28

• Valve incompetence and reflux • Calf muscle dysfunction • Toxins accumulate => inflammation and necrosis of tissue.

Answer 29

Generally located below the knee and above the ankle (gaiter area). • Large and irregular • Shallow with sloping edges • Granulation tissue

Answer 30

• Lipodermatosclerosis • Venous eczema • Haemosiderin (red/brown colour) • Atrophie Blanche (smooth, white sclerotic plaques) • Heavy, aching, pruritis, oedema

Answer 31

• Dressings +/- antibiotics +/- emollients • Debridement – surgery/dressings/larvae • Elevation and compression (EXCLUDE ARTERIAL INSUFFICIENCY FIRST) => 1st line = 4-layer bandaging => Other = stockings • Skin graft / superficial venous surgery

Answer 32

• Atheromatous changes cause compromised blood flow • Results in hypoxia and accumulation of toxins => inflammation and necrosis of tissue.

Answer 33

Diabetes, HTN, smoking, arterial disease, cholesterol emboli, Raynaud’s disease, Trauma

Answer 34

Located on bony prominences (usually lateral malleolus and toes) • Smaller and round • “Punched out” borders • Little granulation tissue and dry • Very painful

Answer 35

• 6Ps – pain, pulseless, pale, paraesthesia, paralysis, perishingly cold • Claudication/ischaemic rest pain symptoms • Cool, hairless, dry, shiny skin

Answer 36

Dressings +/- antibiotics +/- emollients Debridement – surgery/dressings/larvae ABPI to identify severity Manage vascular risk factors – e.g. antiplatelets, stop smoking Surgical revascularisation

Answer 37

Peripheral neuropathy => loss of protective sensation and trauma goes unnoticed Vascular disease => reduced wound healing

Answer 38

• Small, round, deep • “Punched out” borders • Thick rim • PAINLESS

Answer 39

• Surrounding callous • Loss of sensation • Dry, cracked skin

Answer 40

• Dressings +/- antibiotics +/- emollients • Debridement – surgery/dressings/larvae • Optimise glycaemic control • Treat co-existing arterial disease • Good foot care • Offload pressure (therapeutic footwear)

Answer 41

an anatomically variable blood vessel that forms a major anastomotic network between the superior and inferior mesenteric arteries

Answer 42

Most common variant is Adenocarcinoma Squamous and adeno-squamous variants can be found in the distal rectum.

Answer 43

Family History (+ FAP / HNPCC) Age Western Diet (low in dietary fibre, high in fats) UC Smoking Heavy alcohol consumption

Answer 44

Fruit and veg / fibre consumption Exercise HRT Aspirin/NSAIDs

Answer 45

Autosomal dominant defect in tumour-suppressor APC gene. Develop hundreds of adenomas throughout colon, CRC in 100% if untreated (~36y).

Answer 46

Responsible for <5% of all cancers Arises from autosomal dominant mutations affecting various mismatch repair genes Predisposes to cancers of colon, ovaries, endometrium, stomach, bladder, brain and skin Young onset and aggressive

Answer 47

Initially by direct infiltration through the bowel wall. It then involves lymphatics and blood vessels with subsequent spread – primarily to the liver (also lung, bone). Transcoelomic spread can occur

Answer 48

Usually as a polypoid mass with ulceration Characteristic “signet ring cells” on histology.

Answer 49

Recto-sigmoid region Rectum ~45% Sigmoid colon ~25% Descending colon ~5% Transverse colon ~10% Caecum & ascending colon ~15%

Answer 50

Right-sided tumours: => Often asymptomatic; may present with weight loss/iron-deficiency anaemia; can present with abdominal discomfort and change in bowel habit. Left-sided tumours: => PR bleeding/mucous, altered bowel habit, tenesmus, obstruction, mass on PR examination. Rectal tumours: => PR bleeding, pain, changes in bowel habit, masses/stricture

Answer 51

In patients >40 years - Rectal bleeding or change in bowel habit >6 weeks - Persistent rectal bleeding in those >45, with no obvious cause of benign anal disease - Iron deficiency anaemia, without an obvious cause - Palpable abdo/PR mass

Answer 52

HIGH RISK GROUPS Routine regular colonoscopy – in high-risk groups with positive family history (FAP, HNPCC, MUTYH-associated polyposis). AVERAGE-RISK POPULATION – faecal occult blood (FOB) testing - FOB test is done every 2 years between the ages of 50 and 74, and a single flexible sigmoidoscopy is performed at age 55. - A colonoscopy is performed if there is a positive FOB test.

Answer 53

History, Abdo Exam + DRE Blood tests => FBC, U&E, LFT, Magnesium, Calcium => Carcinoembryonic antigen (CEA) – tumour marker, can be used to monitor disease. => Coagulation => G&S/XM Colonoscopy +/- biopsy = gold-standard Imaging for staging - CT colon – “virtual colonoscopy” - CT CAP

Answer 54

Carcinoembryonic antigen (CEA)

Answer 55

Tumour invades submucosa +/- muscularis propria

Answer 56

Tumour invades past the muscularis propria (into subserosa / directly into other organs, but no LN involvement)

Answer 57

Regional LN involvement

Answer 58

Distant metastases (= advanced bowel cancer)

Answer 59

Involves a wide resection of the mass and regional lymphatics and blood supply Surgical procedure depends on location of tumour

Answer 60

Removal of the rectum and sigmoid colon Almost always performed due to a sigmoid or rectal cancer Can be high vs. low - depending on how much of the rectum is removed

Answer 61

Removal of sigmoid colon

Answer 62

Removal of the splenic flexure, descending colon, and a portion of the sigmoid colon. - bowel malignancy (most common) - diverticular disease, - bowel ischaemia - bowel perforation.

Answer 63

Removal of the terminal ileum, caecum (including the appendix), ascending colon, and hepatic flexure. An EXTENDED right hemicolectomy further involves the removal of the transverse colon as well. - bowel malignancy (most common) - diverticular disease, - bowel ischaemia - bowel perforation.

Answer 64

Removal of perineal skin, anal sphincters, rectum, and sigmoid colon. - very low rectal cancers - anal cancers refractory to chemoradiotherapy - severe perianal Crohn’s disease

Answer 65

Removal of entire colon and rectum Used in ulcerative colitis

Answer 66

Removal of the large bowl, but leaving the sigmoid colon and rectum

Answer 67

Used pre-operatively in rectal cancer to reduce recurrence and increase survival. Higher risks of post-operative complications (DVT, pathological fractures, fistula formation). Post-operative radiotherapy is used only if high risk of local recurrence.

Answer 68

Adjuvant chemotherapy – usually oxaplatin or 5-FU based. May be used in palliation of metastatic disease.

Answer 69

1. ABCDE Approach 2. Analgesia & NG tube decompression 3. AXR & erect CXR – confirm Dx and check for perforation 4. CT to determine level of obstruction 5. Surgery once the patient is adequately hydrated (or endoscopic stenting for palliation).

Answer 70

Squamous cell carcinoma (80%)

Answer 71

- Ano-receptive sex - Syphilis infection - Anal warts/cervical cancer (HPV) - Immunosuppression

Answer 72

= an embryological division between the upper 2/3rds and the lower 1/3rd of the anal canal

Answer 73

Columnar epithelium Lymph draining to internal iliac nodes Portal venous drainage (thus hepatic metastases). More common in women, worse prognosis.

Answer 74

Squamous epithelium Lymph drainage to superficial inguinal nodes. Caval venous drainage (thus pulmonary metastases) More common in men, better prognosis.

Answer 75

Bleeding, discharge Pain, fistula Changes in bowel habits Pruritis ani Masses or stricture, ulcer

Answer 76

Unexplained anal mass Anal ulceration.

Answer 77

1. Spreads locally (rectum, sphincter, scrotum, vagina). 2. Inguinal LNs involved in 10-20% at presentation. 3. Metastases to liver, lung, bone.

Answer 78

Radiotherapy plus chemotherapy = mainstay of treatment Small tumours at anal margin = local excision alone

Answer 79

Examination under general anaesthetic (PR + proctoscopy) Imaging Biopsy

Answer 80

The mechanical or functional blockage of the bowel, resulting in absolute constipation. - Mechanical – physical blockage of the passage of intestinal contents. - Functional – decreased bowel motility.

Answer 81

Vomiting (Bilious vomiting = upper small bowel obstruction; Faeculent vomiting = more distal small bowel obstruction) Pain (initially colicky, then constant; NO pain in functional obstruction) Constipation

Answer 82

= when the patient is not passing flatus or faeces rectally. Suggests complete obstruction of the bowel

Answer 83

Abdo Distension => Due to fluid and air accumulation in the bowel. Tinkling Bowel Sounds (or NO bowel sounds if paralytic ileus) Dehydration => Caused by: 1. Vomiting, 2. Lack of fluid intake 3. “Third spacing” Central resonance to percussion, dull flanks Scars (previous surgery => Adhesions) Palpable mass (causing the obstruction) NO abdominal tenderness (unless strangulation)

Answer 84

Absolute constipation and pain are more prominent early, vomiting often late. Symptoms are generally more gradual due to the large volume of colon. Pain tends to be lower (suprapubic)

Answer 85

Vomiting is the predominant early feature, constipation often late. Pain tends to be peri-umbilical.

Answer 86

There will be dilatation of proximal bowel with sequestration of fluid into the intestinal lumen. The fluid sequestered into the bowel tends to be very electrolyte rich – patients will typically have an AKI and hypokalaemia.

Answer 87

Adhesions (80%) Hernias Crohn’s Disease Intussusception

Answer 88

Carcinoma of the colon UNTIL PROVEN OTHERWISE Diverticular disease Sigmoid volvulus Constipation

Answer 89

1. The bowel wall becomes oedematous and distends. 2. Bacteria proliferate in the obstructed bowel. 3. As the bowel distends, vessels become stretched and the blood supply is compromised, leading to strangulation (=> ischaemia and necrosis). 4. Eventually the bowel will perforate (=> peritonitis).

Answer 90

Most common with volvulus or hernia, however can occur in any obstruction. Increasing pain/tenderness, with leucocytosis and systemic upset. May progress to perforation and peritonism, with absent bowel sounds.

Answer 91

= a twisting of a loop of bowel around its mesenteric axis, resulting in obstruction together with venous occlusion at the base of the mesentery. The bowel stretches, becomes ischaemic and is more likely to perforate.

Answer 92

Most common in elderly, constipated patients. Classic “coffee bean” appearance on X-ray. Tx = insertion of a long flatus tube advanced into the sigmoid, which often untwists the volvulus (releases large amounts of faeces/gas). If this is unsuccessful, there will be an emergency laparotomy.

Answer 93

Due to congenital malrotation Gives the classic “embryo” appearance of an ectopically placed caecum on AXR. Treatment is untwisting during laparotomy.

Answer 94

= temporary disruption of normal peristaltic activity, without mechanical blockage.

Answer 95

There will be NO BOWEL SOUNDS, and an identifiable cause: 1. Post-surgery (normally up to 4 days) 2. Due to anastomotic leak / intra-abdominal sepsis 3. Electrolyte disturbances 4. Critically unwell patients on ITU with multiple injuries

Answer 96

LBO when no identifiable cause can be found (a form of paralytic ileus).

Answer 97

Air in the colon in paralytic ileus, none in SBO Bowel sounds present in SBO, absent in ileus.

Answer 98

BEDSIDE Basic observations Abdominal Exam, PR, hernial orifices BLOODS FBC, U&E, LFT, Amylase CRP, ABG/VBG IMAGING Supine AXR Erect CXR (if perforation suspected) CT CAP Contrast enema (differentiates obstruction and pseudo-obstruction)

Answer 99

Used for contrast in a contrast enema, but may also have a therapeutic effect in bowel obstruction!

Answer 100

Dilated loops of bowel are >3cm in diameter. Dilated loops of bowel are more central in the abdomen. Valvulae conniventes/plicae circulares present (full crossings).

Answer 101

Dilated loops of bowel are >6cm in diameter (>9cm at caecum). Dilated loops are more peripheral. Haustra present (incomplete crossings). May be small bowel dilatation, depending on duration of obstruction and incompetence of the ileocaecal valve

Answer 102

ABCDE resuscitation (IV fluids to replace losses, catheter for fluid balance, bloods) NBM + NG decompression of the stomach (Ryle’s tube) If no signs of strangulation, delay operative Mx by 48 hours If signs of strangulation or severe obstruction, then surgical management of the cause of obstruction. => ABX therapy will be commenced if there are signs of strangulation.

Answer 103

Generally requires operative management (Hartmann’s) If due to faecal impaction, enemas or manual evacuation will be tried.

Answer 104

Intussusception Incarcerated hernia Malrotation of the bowel Hirschsprung's disease Meconium ileus

Answer 105

General Factors: Poor diet, dehydration, lack of exercise, IBS, old age, pain Anorectal Disease: Fissure, stricture, rectal prolapse Metabolic/endocrine: Hypercalcaemia, hypothyroidism, hypokalaemia Drugs: Opiates, anticholinergics, iron, aluminium-based antacids, diuretics Neuromuscular: Spinal/pelvic nerve injury, diabetic neuropathy, Hirschsprung’s disease

Answer 106

Bloods (FBC, ESR, U&Es, Calcium, TFTs). Not required in mildly affected individuals.

Answer 107

The internal anal sphincter is an involuntary sphincter, surrounding the upper 2/3rds of the anal canal Tonic contraction is stimulated by sympathetic fibres from the superior rectal/hypogastric plexus. Parasympathetic fibres inhibit this tonic contraction, thus requiring contraction of the puborectalis/the external anal sphincter to maintain continence.

Answer 108

Tends to be clear/yellow/milky and bilateral. Milky - due to pregnancy/hyperprolactinaemia

Answer 109

Can be physiological around the menopause, due to duct ectasia. Can be due to fibrocystic disease

Answer 110

Blood-stained discharge Unilateral discharge ANY colour discharge with symptom suspicion of underlying disease

Answer 111

Treatment will be based on the cause of discharge.

Answer 112

An infection of the ducts beneath the nipple More common in smokers and those with nipple piercings. Symptoms: - Tender, hot/red breast - Nipple discharge – can be bloody/non-bloody Tx = analgesia +/- ABX

Answer 113

The extension of the breast towards the axilla

Answer 114

Mammary glands = modified sweat glands; ~15-20 secretory lobules Connective tissue – condenses to form suspensory ligaments (of Cooper). Fatty tissue

Answer 115

Internal thoracic artery (a branch of the subclavian artery) => medial part of breast Lateral thoracic and lateral mammary arteries => lateral part of breast

Answer 116

via the corresponding veins to the arteries, into the axillary and internal thoracic veins.

Answer 117

75% of the lymph drains into the ipsilateral axilla 25% goes via the internal mammary lymph nodes, draining to the contralateral axilla. Some drainage to inferior deep cervical and infraclavicular nodes

Answer 118

Fibroadenoma Fibrocystic disease Breast cysts Breast abscess Fat necrosis Phylloides Tumour

Answer 119

Tend to be smooth and mobile structures

Answer 120

Tend to be irregular, craggy and fixed.

Answer 121

Mostly seen in young females of reproductive age. Tend to shrink after menopause

Answer 122

Painless (or very localised pain) Rubbery, well-demarcated lump. Highly mobile (sometimes called a “breast mouse”) and not tethered to the skin. Can be multiple and bilateral. Not associated with any lymphadenopathy

Answer 123

1/3 regress, 1/3 remain the same, 1/3 get bigger Tx: - Mostly need no treatment, as they have very low malignant potential. - Can be excised if large (>4cm)

Answer 124

Due to a combination of localised fibrosis, inflammation, cyst formation and hormone-driven (cyclical) breast pain. Presents exclusively between menarche and the menopause.

Answer 125

Lumpy, rope-like texture in the breast. Cyclical swelling and tenderness Pain in the armpit Greenish/dark brown nipple discharge, that’s free of blood.

Answer 126

Supportive bra Combined OCP Evening primrose oil

Answer 127

A benign, fluid-filled cyst of the breast. Typically seen in perimenopausal women. Can be associated with fibrocystic change, or occur alone.

Answer 128

Sudden onset swelling. Symmetrical smooth round lump Usually painless and solitary Not associated with lymphadenopathy

Answer 129

Drainage under USS guidance – usually straw-coloured liquid (if suspicious – e.g. blood-stained – then should be sent for cytology) Then the breast is re-examined, as it can co-exist with cancer.

Answer 130

Usually seen in females of BMI >30 Generally occurs following a history of trauma to the breast.

Answer 131

Presents as a firm, painless lump Can be tender around it Irregular outline May be associated with skin thickening/retraction Can be red or bruised

Answer 132

Must undergo triple assessment

Answer 133

Will resorb naturally, give simple analgesia.

Answer 134

1. Lactational – caused by staph. aureus in breast feeding women. 2. Non-lactational – caused by gram-negative bacteria in diabetics and smokers.

Answer 135

Hot, red, swollen lump. Can lead to systemic upset – pyrexia, sepsis.

Answer 136

USS-guided aspiration Antibiotics Rest the breast from breastfeeding – use breast pump and dump contents.

Answer 137

= a rapidly growing tumour of the stroma => 75% benign, 25% malignant Presentation: - Smooth, firm lump - Usually painless Investigations: - Triple assessment with core needle biopsy - Sometimes excisional biopsy needed to fully rule out malignancy

Answer 138

1. Clinical assessment – Hx and Examination 2. Radiological imaging 3. Tissue biopsy

Answer 139

Mammogram – not typically used for younger patients due to dense breast tissue. USS Breast (all women will also have an ultrasound of the axilla)

Answer 140

1. Fine needle aspiration – collects a sample of cells 2. Core needle biopsy – collects a core of tissue, USS or MRI guides process 3. Open (surgical) biopsy – removes all/part of an abnormality.

Answer 141

Carries a lifetime risk of 1 in 8 for a woman in the UK. Incidence increases with age 1% of cases are in males 5-10% are associated with gene errors.

Answer 142

Most tumours are invasive adenocarcinomas, of which: - Invasive Ductal Carcinoma (90%) - Invasive Lobular Carcinoma (5%) - Other (5%) Can be either oestrogen-receptor/progesterone-receptor/HER-2 positive or negative

Answer 143

better prognosis

Answer 144

worse prognosis

Answer 145

25% genetic factors (PMHx, FHx, BRCA positive) 75% environmental factors (mostly to do with increased oestrogen exposure) • Early menarche/late menopause • Nulliparity • Not breastfeeding • HRT / COCP • Obesity • Smoking

Answer 146

Autosomal dominantly inherited gene, chromosome 17 Lifetime risk of breast cancer – 60-90% Lifetime risk of ovarian cancer – 40-60% Also associated with prostate and colon cancer

Answer 147

Autosomal dominantly inherited gene, chromosome 13 Lifetime risk of breast cancer – 45-85% Lifetime risk of ovarian cancer – 10-30% Lifetime risk of MALE breast cancer – 5-10%

Answer 148

Feeling a thick area/bump/hard lump Skin changes – sores, dimple, peau d’orange, Paget’s disease of the nipple, Engorged veins Nipple changes – crust, sunken, discharge. New shape/size/asymmetry between breast. Palpable lump in axilla

Answer 149

= Rare but highly associated with underlying neoplasm. Often mistaken for eczema of the nipple Clinical features are reddening, rough/flaking skin, itching and ulceration of the nipple. MUST do skin biopsy to confirm diagnosis

Answer 150

LOCAL = into overlying skin (causes tethering/nipple retraction), into pectoral muscles (causes deep fixation of tumour). LYMPHATICS = nodal involvement common in axilla as well as clavicular nodes; can block lymphatics and prevent lymphatic drainage (causing Peau d’orange) DISTAL DISSEMINATION = commonly to the bone, lung, liver and brain.

Answer 151

= a pre-cancerous lesion: Normally ductal (DCIS) but can be lobular (LCIS) Abnormal cells that haven’t yet developed the ability to breach the basement membrane. If left, it will become cancerous, therefore offered similar treatments as breast cancer

Answer 152

T1 <2cm T3 >5cm T4 = fixed to chest or peau d’orange N0 = no nodes N1 = mobile ipsilateral nodes N2 = fixed nodes M0 = no distant metastases M1 = distant metastases If metastases are suspected, the patient will have a liver USS, CXR & bone scan

Answer 153

All patients are treated surgically, if they are fit for surgery. => Wide local excision or Mastectomy Regional lymph nodes must also be managed – sentinel node biopsy is performed Most breast surgery is combined with adjuvant RADIOTHERAPY for invasive disease If there is nodal disease, or high-grade tumours, CHEMOTHERAPY is considered If the tumour is ER/HER2 positive, adjuvant hormonal/biologic treatment is given for 5 years.

Answer 154

Wide Local Excision = Breast-conserving surgery => can be used providing the breast if of adequate size and the tumour location is not central/retro-areolar. => Margins are checked to ensure they are clear of disease Simple Mastectomy => Preferred for large tumours (or small breasts), central location of the tumour or late presentation with complications.

Answer 155

1. Inject dye into/around the tumour bulk to identify the first 1-2 nodes that drain the tumour, which are removed and analysed histologically. 2. If negative, it can be assumed that there is no nodal involvement. 3. If positive, full axillary clearance is required (20% risk of lymphoedema)

Answer 156

Tamoxifen if pre-/perimenopausal (breast-selective ER-antagonist Aromatase inhibitors (e.g. letrazole, aromisin, exemestone) if post-menopausal, to stop peripheral oestrogen production. Herceptin (traztuzumab) if HER2 positive (this is always combined with chemotherapy).

Answer 157

NPI = (tumour size x 0.2) + histological grade + nodal status If treated with surgery alone, 10-year survival rates are: - NPI <2.4 = 95% - NPI 2-4 – 3.4 = 85% - NPI 3.4 – 4.4 = 70% - NPI 4.4 – 5.4 = 50% - NPI >5.4 = 20%

Answer 158

Formed of smooth muscle with subepithelial anastomoses of the rectal arteries/veins (i.e. highly vascular areas) They act to assist the anal sphincter in maintaining continence. There are three, positioned at the 3-, 7- and 11 o’clock positions when viewed from the lithotomy position.

Answer 159

= disrupted/dilated anal vascular cushions

Answer 160

According to their size: 1st Degree - Remain in the rectum 2nd Degree - Prolapse through the anus on defecation but spontaneously reduce 3rd Degree - Prolapse through the anus on defecation but require digital reduction 4th Degree - Remain persistently prolapsed

Answer 161

Idiopathic Excessive straining/increased anal tone – chronic constipation, low-fibre diet. Increasing age Factors that cause congestion of superior rectal veins – cardiac failure, rectal carcinoma, portal hypertension, any raised IAP

Answer 162

superior rectal veins = into the inferior mesenteric vein (portal drainage), middle/inferior rectal veins = into the IVC.

Answer 163

Often asymptomatic Painless rectal bleeding - Usually bright red blood on the paper - Only seen on the surface of the stool (not mixed in). Prolapse Mucous discharge Pruritis ani Impaired continence Rectal fullness/anal lump Pain if the haemorrhoids are thrombosed.

Answer 164

Anaemia – if severe/continuous bleed. Thrombosis Ulceration/gangrene (secondary to thrombosis). Perianal sepsis.

Answer 165

Occurs when prolapsing haemorrhoids are gripped by the anal sphincter (“strangulated”). Venous return is occluded, leading to thrombosis. Haemorrhoids swell, become purple/blue and tense, cause significant pain/distress. Often fibrose within 2-3 weeks, giving spontaneous cure. Management is conservative – cold compresses, opioids and rest.

Answer 166

It is important to exclude other causes of rectal bleeding – malignancy, IBD, diverticular disease. Investigations: - PR exam – prolapsing haemorrhoids are obvious. - Proctoscopy – can visualise the haemorrhoids and assess for any lesion higher in the rectum. - Abdominal exam – palpable mass, enlarged liver. - Colonoscopy/flexi-sigmoidoscopy – if symptoms suggest a different pathology (e.g. malignancy). If significant/prolonged bleeding – FBC and coagulation screen.

Answer 167

Conservative/medical management Sclerotherapy (1st and 2nd degree) Banding (1st to 3rd degree) Surgical (reserved for 3rd and 4th degree)

Answer 168

Advice to patient – plenty of fluids, lots of fibre, try not to strain. Ice packs Topical analgesia (e.g. instillagel) Bulk forming laxative

Answer 169

- 5% phenol in almond oil is injected above each haemorrhoid as a sclerosing injection. - Suitable for 1st and 2nd degree haemorrhoids - Painless, as placed high in anal canal above the dentate line.

Answer 170

= applicaton of small rubber band to the protruding mucosa to cause strangulation. Can be done to 1st to 3rd degree haemorrhoids Band must be above dentate line

Answer 171

Reserved for 3rd and 4th degree haemorrhoids Stapled haemorrhoidopexy Haemorrhoid artery ligation operation (HALO) Surgical haemorrhoidectomy (now less commonly used)

Answer 172

Levator Ani Internal anal sphincter = Thickening of the involuntary smooth muscle of bowel External anal sphincter = voluntary muscle

Answer 173

the mucosa gathers into longitudinal folds containing the anal glands. Anal glands secrete mucous to help with propulsion of faeces.

Answer 174

from embryological hindgut. Columnar epithelium. Blood supply from superior rectal artery (from inferior mesenteric artery). Venous drainage by superior rectal vein (branch of inferior mesenteric vein). Internal iliac lymph nodes Innervated by inferior hypogastric plexus – sensitive to stretch only.

Answer 175

from ectoderm. Non-keratinising stratified squamous epithelium. Blood supply from the inferior rectal artery (from pudendal a., a branch of internal iliac a.) Venous drainage by inferior rectal vein (branch of internal pudendal vein). Superficial inguinal lymph nodes. Innervated by pudendal nerve – sensitive to pain, temperature, touch and pressure.

Answer 176

anyone with palpable inguinal lymph nodes should also have a PR exam (?anal cancer)

Answer 177

the epithelial cells become keratinised squamous (“true skin”)

Answer 178

= "thrombosed external haemorrhoid" however, unlike internal haemorrhoids it is covered by squamous epithelium supplied by somatic nerves, and thus is painful Onset is acute, with sudden pain and a lump at the anal verge.

Answer 179

Left untreated, they will either subside over a few days to leave a fibrous tag, or rupture to discharge clotted blood. In the acute phase they can be incised and drained under LA. If they are already discharging/being resorbed, hot baths and reassurance is all that is necessary.

Answer 180

Anal sinuses/crypts are most common site of infection

Answer 181

Usually caused by gut organisms Associated with Crohn’s, DM and malignancy Tx = incision and drainage under GA, to prevent rupture/formation of a fistula.

Answer 182

Obstruction of natal cleft hair follicles around 6cm above the anus, with ingrowing of hair leading to a foreign body reaction. This can lead to abscess formation or tracks to the skin as a pilonidal sinus with foul discharge.

Answer 183

= excision of the sinus tract and primary closure, with pre-op ABX. => Hygiene and hair removal advise should be given.

Answer 184

= an abnormal connection between the anal canal and the skin. Presents as intermittent or continuous discharge of pus/blood/mucous from the perineum.

Answer 185

Usually the result of an abscess (1 in 3 abscess patients have a fistula). - IBD - Diverticular disease - Rectal Carcinoma - TB - Immunocompromised individuals

Answer 186

Examination of the tract (VERY painful, only done under anaesthetic) MRI Endoanal USS

Answer 187

the position of the external opening can give you clues as to the tract of the fistula. Anterior to transverse line – short, direct radicular tract to the interior opening. Posterior to transverse line – curved/horseshoe tract to the interior opening. The exception to this rule is anterior fistulas that lie >3cm from the anus, which may drain like posterior fistulas with a curved track to the posterior midline

Answer 188

Superficial and low-level fistulae => laid open to heal by secondary intention (fistulotomy). High fistulae (involving the continence muscles of the anus) may be injected with fibrin glue or a “fistula plug”. If these methods fail, a “seton suture” gradually tightened over time can be used to maintain continence (ensures the sphincter is fixed by scar tissue before the tract is divided by tightening the suture). Recurrent fistulae associated with Crohn’s may respond to metronidazole.

Answer 189

An anal fissure is a longitudinal tear in the sensitive anal canal mucosa, distal to the dentate line. Usually at 6 o’clock (90%) or 12 o’clock (10%, due to parturition). Can be acute (present <6 weeks) or chronic (present >6 weeks).

Answer 190

Mainly constipation. Parturition – causing anterior/12 o’clock tears. Rarer causes: - Infections (syphilis/herpes) - Trauma - Crohn’s - Anal cancer - Psoriasis

Answer 191

SYMPTOMS Pain, worse on defecation, lasting for hours afterwards Associated constipation Pruritis Ani PR bleeding on defecation (fresh red) O/E: Midline longitudinal tear in the rectal mucosa PR may not be possible due to pain/sphincter spasm

Answer 192

Proctoscopy and sigmoidoscopy should be performed under anaesthesia to exclude other anorectal diseases. Enlarged nodes in the groin suggest a complicating factor.

Answer 193

Early small fissures may heal spontaneously, with symptomatic relief and a high fibre diet. => Local anaesthetic ointments and a lubricant laxative If chronic, 0.4% GTN cream is used to relax the anal sphincter and allow the torn epithelium to heal. => SEs of GTN = headaches Botox injection has the same effect and can last up to 8 weeks (but small risk of incontinence afterwards). Intractable fissures/recurrent cases may require a sphincterotomy (submucosal division of the external sphincter under GA).

Answer 194

= outpouchings of bowel wall can occur anywhere in the GI tract but are more common in the sigmoid (95% of cases) and descending colon.

Answer 195

Sigmoid has smallest lumen and highest pressures, therefore more prone to diverticulum formation

Answer 196

Weakened bowel => stool movement increases intraluminal pressure => outpouching of the bowel wall.

Answer 197

True (involving all layers of the intestine – serosa, muscle, submucosa, mucosa). False (does not contain all layers – often mucosa pushed through muscle defect).

Answer 198

• Western/low fibre diet • Age >50 years • Male • Obesity • Connective tissue disorders – e.g Marfans, Ehler-danlos; predisposition to weakened GI wall. • Smoking • Family history • NSAID use

Answer 199

= the presence of diverticula

Answer 200

= the presence of diverticula + symptomatic

Answer 201

= bacterial overgrowth within the gut causes inflammation of the diverticula.

Answer 202

Highest prevalence = Europe and the USA (rare in Africa and Asia). Age: => 50% of over 50s => 80% of over 80s in the UK.

Answer 203

most commonly (95% of cases) asymptomatic and discovered incidentally If symptomatic, they exactly mimic Sx of carcinoma of the colon: - Left-sided colic, relieved by defecation - Altered bowel habit (including PR blood/mucous) - Nausea - Flatulence - Severe pain and constipation if severe (causing luminal narrowing)

Answer 204

PR (to r/o DDx of abscess/cancer) Sigmoidoscopy/colonoscopy Barium enema CT

Answer 205

Mebeverine is 1st line Surgery may be considered if recurrent/very severe (rarely resorted to due to compications)

Answer 206

Dietary Advice only for asymptomatic diverticulae (increase dietary fibre and balanced diet).

Answer 207

SYMPTOMS Severe left-sided colic Constipation (or overflow diarrhoea) Symptoms mimicking appendicitis, but on the left. Systemically unwell If there is extensive inflammation, the diverticula can perforate, and the patient can present with localised/generalised peritonitis. SIGNS Fever & tachycardia Tenderness, guarding & rigidity on LHS Can be a palpable mass in LIF Raised WCC & inflammatory markers

Answer 208

If a patient is taking corticosteroids or immunosuppressants, this can mask symptoms of diverticulitis.

Answer 209

Complicated – presence of abscess, formation of fistula, stricture, free perforation. Simple – inflammation without any of these features.

Answer 210

Diverticulitis is NOT typically associated with bleeding, as blood vessels become scarred from the inflammation. However, diverticular bleeds occur when the diverticulum erodes into a submucosal blood vessel. This causes haematochezia (the passage of bright red blood in the stool). This is generally large-scale and painless.

Answer 211

Mild Attacks (uncomplicated, low-grade fever): - Bowel rest (fluids only) at home - Oral co-amoxiclav +/- metronidazole Severe Attacks (complicated, high-grade fever): - Admit if pain cannot be controlled, or oral fluids cannot be tolerated - Give analgesia, IV fluids, IV cefuroxime & metronidazole & keep NBM - Order erect CXR, AXR and contrast CT to assess for complications - DO NOT SCOPE in acute attack - Further management depends on degree of complications.

Answer 212

Perforation Abscess Formation Bleeding Fistula Formation Intestinal Obstruction

Answer 213

Usually acute diverticulitis Can lead to formation of a paracolic/pelvic abscess, fistulae or generalised peritonitis Presents with ileus & peritonitis +/- shock Mortality is up to 40% Mx = Laparotomy +/- Hartmann’s procedure

Answer 214

Presents with swinging fever, leucocytosis and localising signs (e.g. boggy rectal mass) Mx = drainage under CT guidance

Answer 215

Colovesical (=> UTI and pneumaturia) Colovaginal (=> foul discharge)

Answer 216

Most commonly sigmoid after repeated episodes of diverticulitis. Chronic inflammation leads to scarring and the formation of a diverticular mass, which causes obstruction and may mimic colonic carcinoma.

Answer 217

= An outpouching in the lower part of the small intestine. A congenital abnormality - a remnant of the vitello-intestinal duct. Approx. 2% of population have them, most are asymptomatic.

Answer 218

= Meckel's Diverticulum

Answer 219

Affects 2% of population 2 years old 2:1 M:F ratio 2 inches long 2 feet proximal to ileocaecal valve 2 types of ectopic tissue (gastric/pancreatic)

Answer 220

Most commonly presents in young (<2 years old) children with painless melaena, then followed by obstruction / intussusception. HOWEVER: can mimic appendicitis and present very similarly.

Answer 221

= sudden onset, severe abdominal pain which may indicate potentially life-threatening intra-abdominal pathology that requires urgent surgical intervention.

Answer 222

occurs particularly in older people, in children, in the immunocompromised, and in the last trimester of pregnancy.

Answer 223

Gallstones Cholangitis Hepatitis Liver abscess Cardiac causes Lower lobe pneumonia

Answer 224

Spleen Abscess Acute splenomegaly Spleen rupture Lower lobe pneumonia Cardiac causes

Answer 225

Oesophagitis Peptic Ulcer Perforated Ulcer Pancreatitis MI

Answer 226

Renal stones Pyelonephritis

Answer 227

Renal stones Pyelonephritis

Answer 228

AAA rupture Appendicitis (early) Meckel’s diverticulitis Small bowel obstruction Ischaemic bowel Peritonitis DKA

Answer 229

Diverticulitis IBD Constipation Ovarian Cyst Ectopic pregnancy Hernias

Answer 230

Appendicitis IBD Caecum obstruction Ovarian cyst/torsion Ectopic pregnancy Hernias

Answer 231

Testicular Torsion Urinary retention Cystitis Placental Abruption Large bowel obstruction PID Endometriosis

Answer 232

AAA rupture – most serious cause, requires immediate surgical intervention. Ruptured ectopic pregnancy Bleeding from organ Gastric ulcer Trauma

Answer 233

= Inflammation of the peritoneum. Localised – when the inflammation is in a limited area (e.g. adjacent to inflamed appendix/diverticulum prior to rupture). Generalised – when the inflammation is widespread (e.g. after the rupture of an abdominal organ).

Answer 234

Patients lay completely still, with shallow breathing. => Pain is made worse by movement/ coughing/ inspiration Tachycardia and potentially hypotension/pyrexia. Percussion/rebound tenderness Involuntary guarding (reflex contraction of abdominal muscles on examination of the inflamed area) and rigidty (increased tone at rest). Reduced or absent bowel sounds.

Answer 235

Any patient who has severe pain out of proportion to the clinical signs has ischaemic bowel until proven otherwise. - Diffuse and constant abdominal pain reported. - Examination may be unremarkable. - Acidaemia with raised lactate on blood gases (due to impaired blood supply resulting in anaerobic respiration of the tissues)

Answer 236

Definitive diagnosis of ischaemic bowel is via a CT scan with IV contrast. These patients require early surgical involvement to prevent perforation of the bowel and subsequent peritonitis and potential sepsis.

Answer 237

Constant pain, supported by a raised temperature, pulse and leucocytosis. Includes peritonitis

Answer 238

Colicky pain => Crescendos to become very severe and then completely goes away (except biliary colic) Patients often agitated. Pain may become constant with superimposed inflammation.

Answer 239

Foregut (oesophagus to D2) pain is referred to the upper abdomen. Midgut (D2 to transverse colon) pain is referred to the middle abdomen Hindgut pain is referred to the lower abdomen.

Answer 240

A to E assessment (Pregnancy test if female) Certain presentations require an urgent laparotomy: 1. Rupture of an organ (spleen, aorta, ectopic) 2. Peritonitis Keep NBM if for theatre

Answer 241

Basic observations ECG (exclude MI) Urine dip Pregnancy test BM (?DKA) Bloods - FBC, U&E, LFTs, Amylase/lipase, ABG/VBG, CRP, Coagulation, Group and save/ XM, ?Blood cultures Imaging - depending on DDx

Answer 242

Amylase 3x higher than upper limit to be diagnostic of pancreatitis Values lower than this suggests other pathology – e.g. perforated bowel, ectopic pregnancy, DKA.

Answer 243

Erect CXR – evidence of bowel perforation Abdominal X-Ray => Bowel obstruction, Toxic megacolon, Foreign body ingestion (if radio-opaque) Abdominal Ultrasound => Biliary pathologies, KUB, Gynae pathologies, Appendix In a patient who is very unwell, a CT is a good option

Answer 244

Appendicitis (occurs in ~6-10% of population)

Answer 245

= inflammation of the appendix, usually caused by blockage within the lumen. This can be due to: - Faecolith (a stone made of faeces) – most common. - Swollen lymphoid tissue in the wall – common in adolescence - Parasites - Tumours Bacteria can proliferate in the closed loop of bowel, eventually leading to ischaemia & necrosis. The appendix can eventually perforate due to the raised intraluminal pressure, releasing bacteria into the abdominal cavity.

Answer 246

Abdominal pain - Starts dull and central - Then becomes localised and sharp in the RIF at McBurney’s point - Pain may not be severe until the appendix has ruptured! Constipation (or sometimes diarrhoea). Anorexia Nausea and vomiting (after the pain starts).

Answer 247

1/3 of the way between the ASIS and the umbilicus

Answer 248

Rebound and percussion tenderness in RIF (maximum at McBurney’s point) Guarding (especially if perforated) Rovsing’s Sign Tachycardia, tachypnoea Mild pyrexia Psoas sign – pain on R hip extension: retroperitoneal retrocaecal appendix. Obturator sign – pain on internal rotation of R hip: pelvic appendix.

Answer 249

more painful in RIF than LIF when LIF pressed

Answer 250

Abdominal exam and PR Pelvic examination in females Pregnancy test Bloods – FBC, U&E, CRP/ESR Urinalysis USS/CT – if diagnostic uncertainty AXR/erect CXR – if questioning perforation.

Answer 251

If confirmed - NBM ready for appendectomy. - Resuscitation – IV fluids and IV metronidazole/cephalosporin pre-op - Appendectomy (laparoscopic is gold standard) - If ruptured appendix – remove the appendix and do a wash out (using large volumes of sterile fluid).

Answer 252

Haematoma; surgical site infections

Answer 253

SBO (adhesions); incisional hernia.

Answer 254

Perforation Surgical site infection Appendix mass Pelvic abscess Surgical damage to other organs Universal post-op complications – DVT/PE, bleeding, ileus, etc. Adhesions – small bowel obstruction due to scarring.

Answer 255

when an inflamed appendix becomes covered with omentum and forms a mass

Answer 256

More common in Caucasians, and Ashkenazi Jews.

Answer 257

1. Ulcerative colitis 2. Crohn’s disease 3. Indeterminate colitis – when it is not possible to distinguish between UC and Crohn’s.

Answer 258

poor diet, FHx, smoking, altered immune states

Answer 259

deep penetrating linear ulcers or fissuring typically seen within stenosed terminal ileum with a thickened wall. They appear as thorn-like extraluminal projections on barium studies One of the typical signs of Crohn's disease

Answer 260

due to a combination of extensive, broad, linear transverse and longitudinal ulcerations/fissures within an inflamed mucosal surface => gives an appearance reminiscent of cobblestones. Often seen in Crohn's disease

Answer 261

Inflammation affects any part of the GI tract (mouth to anus). => Most commonly terminal ileum and proximal ascending colon Can affect just one area, or multiple areas leaving normal bowel in between (“skip lesions”). Involved bowel is narrowed due to thickened wall, with deep ulcers Due to inflammation, a lot of fat wrapping/stranding is seen around the intestine. Inflammation extends through ALL layers of the bowel, so fistulas and strictures are common.

Answer 262

Abdominal pain (varying in character) Diarrhoea - Steatorrhoea in ileal disease - Bloody in colonic disease Weight loss (or FTT) – due to malnutrition Severe aphthous ulceration of the mouth (early sign) Anal complications – fissure, fistula, haemorrhoids, skin tags, abscesses Extra-GI manifestations of IBD Can present with RIF pain/mass

Answer 263

thought to be autoimmune in nature. The inflammation only affects the mucosa (i.e. superficial ulceration). Ulceration is extensive and continuous. Mucosa is reddened, inflamed and bleeds easily. Only very small portions of normal mucosa. Inflammation leads to loss of the colonic haustra. Gives the adjacent mucosa the appearance of inflammatory polyps.

Answer 264

Inflammation that starts at the rectum, extending proximally along the colon Proctitis – affects the rectum alone Proctosigmoiditis Distal colitis Extensive colitis Pancolitis – whole colon is affected

Answer 265

Common in Crohn's as all layers of the bowel are affected Uncommon in UC, as inflammation is mostly superficial

Answer 266

inflammation of the distal terminal ileum in ulcerative colitis patients

Answer 267

Crampy lower abdominal discomfort Gradual onset diarrhoea (often bloody) Urgency and tenesmus if disease confined to rectum Extra-GI manifestations. AXR – may show dilated colon, with thumb-printing of the bowel wall.

Answer 268

Indicates inflammation and thickening.

Answer 269

During Active phase of IBD: • Skin disorders – erythema nodosum, pyoderma gangrenosum • Joints – arthralgia of large joints • Eye manifestations – conjunctivitis/episcleritis/iritis • Venous thrombosis • Fatty liver Unrelated to disease activity: • Autoimmune hepatitis • Gallstones • Renal calculi • Primary sclerosing cholangitis • Cholangiocarcinoma • Ankylosing spondylitis

Answer 270

Crohn’s – transmural inflammation, lymphoid hyperplasia, granulomas. UC – mucosal inflammation, crypt abscesses, goblet cell depletion. HOWEVER it may not be possible to distinguish between IBDs if the biopsy is taken in the acute phase – “indeterminate inflammatory colitis”.

Answer 271

Bloods => FBC, U&E, LFT, CRP/ESR, Serum iron, B12, folate Stool Studies => Stool chart; MCS x3 to exclude infective causes; Calprotectin Radiology => AXR/CXR in acute disease => CT in Crohn’s Endoscopy => Rigid/flexi-sigmoidoscopy => Colonoscopy => Endoscopic rectal biopsy => Biopsies

Answer 272

to prolong the remission phase and prevent relapses with maintenance therapy

Answer 273

Mild attack (= symptomatic but systemically well): - Oral prednisolone - Tapered steroids and review in clinic

Answer 274

Severe attack (= symptomatic + systemic upset) - Raised temp, HR, CRP/ESR and low albumin warrant admission - Start IV steroids (hydrocortisone 100mg/6h) - NBM, parenteral nutrition - High level monitoring - Thiopurines (e.g. Azathioprine or 6-mercaptopurine) are 2nd line - Biological agents (infliximab) used in refractory disease not responding to medical treatment - Once improving, transfer to oral prednisolone as per mild attack If unable to control, surgical advice should be sought.

Answer 275

Proctitis/proctosigmoiditis – topical aminosalicylate (e.g. mesalazine suppository/enema) +/- oral mesalazine More extensive disease – loading dose oral mesalazine +/- oral beclomethasone and topical mesalazine 2nd line (after 4 weeks of unsuccessful 1st line Tx) – add oral prednisolone 3rd line – tacrolimus after a further 2-4 weeks 4th line – biological agents, considered by a specialist

Answer 276

MDT management 1st line = Start IV corticosteroids Assess the patient with regard to surgical intervention SC LMWH Avoid any anti-motility drugs 2nd line – IV ciclosporin if symptoms worsen or no improvement within 72h of steroids 3rd line – biological agents, considered by a specialist

Answer 277

Likelihood of surgery is suggested by: >8 motions/day, pyrexia, tachycardia, colonic dilatation, low albumin, low Hb, CRP <45

Answer 278

5-ASA derivatives are 1st line (topical if proctosigmoiditis, oral if left-sided) => Sulfasalazine, mesalazine Oral thiopurines are 2nd line => Azathioprine, mercaptopurine

Answer 279

UC – colectomy provides cure. Crohn’s - surgery is never curative and patients still tend to develop recurrent disease. => Temporary ileostomies can be used to rest the distal diseased bowel => Can perform limited resection of the small bowel (but must keep it above 1m long to prevent malabsorption)

Answer 280

EMERGENCY PROCEDURES: • Subtotal colectomy & end ileostomy (leaves rectal stump, so still a proctitis/cancer risk) • Proctocolectomy & end ileostomy (rectal stump also removed) ELECTIVE PROCEDURES: • Completion proctocolectomy & ileoanal pouch reconstruction (faecal continence maintained) • Colectomy and ileorectal anastomosis

Answer 281

Bowel perforation Lower GI haemorrhage Toxic dilatation (more common in UC) Colonic carcinoma => Higher risk in Crohn’s than UC

Answer 282

UC patients with pancolitis for 20 years have 15% risk (surveillance required)

Answer 283

Features – persistent fever, tachycardia, loose blood-stained stools. Investigations: Falling albumin/potassium. AXR – dilated (>6cm) colon with mucosal islands. Perforation is imminent – surgery often required

Answer 284

SBO Fistulae Abscess formation B12/folate/iron deficiencies

Answer 285

= the protrusion of viscus through a defect in the walls of its containing cavity into an abnormal position.

Answer 286

1. Reducible – contents can be manipulated back to its original position through the defect. 2. Irreducible – cannot be reduced without surgery.

Answer 287

= an irreducible hernia, with the contents trapped due to adhesions.

Answer 288

= Compression of bowel => obstructed venous return => ischaemia Can lead to necrosis, gangrene and perforation if left untreated

Answer 289

= Bowel contents cannot pass through the herniated bowel Presents as abdominal pain and distension; absolute constipation; N&V.

Answer 290

Male (increased risk of central obesity) Increasing age, protein deficiencies (less collagen for tensile strength) Heavy lifting, chronic cough, chronic constipation, obesity (Increased intra-abdominal pressure)

Answer 291

Due to natural weakness in semilunar space between two muscle groups.

Answer 292

= most common type of hernia Occurs through the inguinal canal => Can be direct/indirect

Answer 293

when abdominal viscera or omentum pass through the femoral ring into the potential space of the femoral canal.

Answer 294

Try to reduce the hernia to prevent obstruction/strangulation If the hernia is irreducible, elective surgery is considered. => Open or laparoscopic => Generally done as a day case If obstructed/strangulated, an emergency Hartmann’s procedure is performed.

Answer 295

Treated with herniotomy and ligation of the processus vaginalis at about the age of one year.

Answer 296

Extends inferiorly and medially through the inferior part of the abdominal wall. Is about 4cm long Embryologically, was used to allow the descent of the testes into the scrotum Contains: - Spermatic cord (if male) / round ligament (if female) - Nerves - Arteries Has a deep and superficial inguinal ring

Answer 297

found ~1cm above the midpoint of the inguinal ligament (lateral to the epigastric vessels).

Answer 298

= halfway from ASIS to pubic tubercle

Answer 299

found just superior to the pubic tubercle.

Answer 300

ROOF = transversalis fascia; internal oblique; transversus abdominis ANTERIOR = aponeurosis of external oblique; internal oblique POSTERIOR = Transversalis fascia FLOOR = Inguinal ligament

Answer 301

Indirect Inguinal Hernia (~80%)

Answer 302

The hernia goes through in the deep ring, through the inguinal canal and out through the superficial ring. Accounts for ~80% of inguinal hernias More likely to strangulate

Answer 303

Hernia goes through a defect in the posterior wall. It exits through the superficial ring. Accounts for ~20% of inguinal hernias Reduce easily, rarely strangulate.

Answer 304

= a triangular region in the anterior abdominal wall, which is a particular area of potential weakness. Inferior border = the inguinal ligament Lateral border = inferior epigastric vessels Medial border = rectus abdominis muscle.

Answer 305

Painless swelling in the groin Often asymptomatic May come and go, or emerge suddenly – e.g. after heavy lifting They can become symptomatic and the common features of this are: - Pain – particularly when coughing or stooping - Change in bowel habit - Burning sensation in the groin - Scrotal swelling (in males)

Answer 306

To differentiate between indirect/direct on examination: - Reduce the hernia - Press over the deep ring (just above the midpoint of the inguinal ligament. - Ask the patient to cough. - If the hernia reappears – it is a DIRECT hernia. Absolute differentiation can ONLY be achieved via surgical exploration – the inferior epigastric vessels are used as the landmark. => Indirect inguinal hernias are lateral to the inferior epigastric vessels. => Direct inguinal hernias are medial to the inferior epigastric vessels.

Answer 307

= an anatomical compartment, in the anterior thigh. Normally lies medial to the femoral vein ( N A V [Y] ) Its purpose is allow space for the vein to expand. Normally contains a small amount of fatty tissue and lymph nodes.

Answer 308

• Female (due to wider anatomy of pelvis) • Pregnancy • Raised intra-abdominal pressure • Increasing age

Answer 309

There is a HIGH risk of strangulation due to the narrow neck of the femoral canal and strong borders. => 50% present as a surgical emergency with an obstructed or strangulated hernia

Answer 310

50% present as a surgical emergency with an obstructed or strangulated hernia Otherwise present as painless groin lump

Answer 311

Inguinal hernias are SUPERIOMEDIAL to the pubic tubercle Femoral hernias are INFEROLATERAL to the pubic tubercle

Answer 312

= a hernia involving only one side wall of the bowel, and not the bowel lumen, which can result in bowel strangulation and perforation without causing obstruction or any of its warning signs. They are particularly likely in the femoral sac.

Answer 313

Due to a defect in transversalis fascia = umbilical ring, where the umbilical vessels passed in-utero Occur in babies More common in black, male, premature babies

Answer 314

Occur adjacent to the umbilicus due to a weakness in the linea alba More common in 35-50 year old women Usually caused by raised IAP.

Answer 315

Generally asymptomatic, more prominent on coughing/laughing. Low strangulation risk, very rarely become obstructed.

Answer 316

Localised dragging pain and enlarging hernia over time. High risk of strangulation as the weakness is not a natural occurrence.

Answer 317

90% retract by the age of 2 (consider surgical repair in a child >2)

Answer 318

Early operative management advised => excision of the sac and stitching of the rectus sheath; with mesh repairs for larger defects

Answer 319

= a hernia that occurs through a previously made incision in the abdominal wall, i.e. the scar left from a previous surgical operation. An incisional hernia should form part of the consent process along with a scar in abdominal surgery.

Answer 320

• Emergency surgery – 2x risk of hernia • Type of incision used – e.g. midline. • Poor surgical technique • Absorbable stitches • Anything that may affect the ability of the wound to heal: - Immunosuppression - Wound infection - Smoking - Diabetes - Vascular disease - Pre-op chemo

Answer 321

Bulge in the scar and local discomfort Subacute bowel obstruction is common as the hernia enlarges Usually a wide neck, so strangulation uncommon (but becomes more likely the longer it’s there, as adhesions begins to make it irreducible)

Answer 322

Usually repaired with mesh, but often reoccur after repair as the risk factors are still there. => Weight loss and smoking cessation will increase likelihood of successful repair. => Recurrence risk of 2-5% for small incisions, and 10-20% for large ones.

Answer 323

= Herniation of FAT which overlies the bowel through the linea alba, above the umbilicus. Usually small – 1cm diameter

Answer 324

Over 75% asymptomatic, but can cause pain/discomfort Varies from mild epigastric pain to a deep burning pain, radiating to the back or lower abdomen. => Aggravated be exercise/eating => Relieved by reclining Can also have symptoms of abdominal bloating, N&V.

Answer 325

If there are symptoms of pain, then the defect is often surgically repaired

Answer 326

= separation of rectus abdominus due to linea alba laxity Appears as a bulge in the upper abdomen, worse when sitting up and retracts when lying down.

Answer 327

- Men – weight gain (truncal obesity) - Women – pregnancy - Repeated midline operations - Chronically raised intra-abdominal pressure

Answer 328

Diagnosis through USS.

Answer 329

Physiotherapy to strengthen the rectus abdominus (no indication for surgical management)

Answer 330

Peptic ulceration ~40% Gastroduodenal erosions ~15% Oesophagitis ~15% Mallory-Weiss syndrome ~15% Varices ~10% Upper GI malignancy ~1%

Answer 331

partial-thickness tear of the oesophagus after repeated vomiting, causing haemorrhage

Answer 332

Symptoms: - Haematemesis - Melaena (blood altered by bacteria) - Haematochezia (unaltered PR blood, can occur in massive upper GI bleeds) - Abdo pain Signs will be of any underlying cause, and of shock. Iron-deficiency anaemia (if chronic blood loss)

Answer 333

Managed as per haemorrhagic shock 1. Assess using Glasgow-Blatchford score 2. Endoscopy should occur within 4 hours if indicated, generally as soon as stabilised => Can identify the site of bleeding and administer treatment (adrenaline injection/ diathermy/ banding of varices) 3. IV Omeprazole to reduce the risk of rebleed (high mortality) 4. High level monitoring to assess for signs of a rebleed 5. Definitive surgery (laparotomy) or angiographic embolisation may be needed

Answer 334

If bleeding recurs after endoscopy If it is persistent despite endoscopic treatment If bleeding is torrential and obscuring adequate visualisation

Answer 335

= a scoring system for UGIB Includes: - SBP, - pulse, - Hb, - blood urea level, - evidence of melaena - recent syncope - hepatic disease - cardiac failure Scores >6 indicate mortality >50%, thus urgent intervention is required

Answer 336

= a score for prediction of mortality in UGIB includes age, shock, co-morbidity AND endoscopy findings

Answer 337

= extremely dilated sub-mucosal veins in the lower third of the oesophagus. most often a consequence of portal hypertension, following cirrhosis of the liver.

Answer 338

ABCDE Resuscitation Vitamin K & FFP (if needed) to correct clotting IV Terlipressin (or somatostatin analogues) IV antibiotic prophylaxis => Significantly reduces mortality If still bleeding, attempt endoscopic banding and adrenaline injection under GA => As a last line, balloon tamponade devices can be used to temporarily compress varices. Transjugular Intrahepatic Portosystemic Shunting (TIPSS) = the definitive procedure for varices resistant to banding, carried out by interventional radiology.

Answer 339

Treatment should be stopped after definitive haemostasis has been achieved, or after five days, unless there is another indication for its use.

Answer 340

= a shunt between portal and hepatic veins the definitive procedure for varices resistant to banding, carried out by interventional radiology.

Answer 341

Following an initial bleed, endoscopy is indicated as soon as haemodynamically stable => to identify the site of bleeding, estimate the risk of rebleeding and administer ADRENALINE AND BAND THERAPY. (Sclerotherapy is 2nd line) Following endoscopy, non-selective beta-blockers (e.g. propranolol) are used.

Answer 342

80% of varices rebleed within 2 years.

Answer 343

Primary prophylaxis should be implemented (beta-blockers and endoscopic banding) if asymptomatic varices are found.

Answer 344

Diseases of the mouth/tongue – e.g. tonsilitis Neuromuscular disorders – MG, MND, bulbar palsy Oesophageal motility disorders – achalasia, scleroderma, diabetes Extrinsic pressure – goitre, lymph nodes, enlarged left atrium Intrinsic lesion – foreign body, benign/malignant stricture, pharyngeal pouch, oesophageal web (Plummer-Vinson Syndrome)

Answer 345

Oropharyngeal Dysphagia => Difficulty initiating swallow +/- choking/aspiration Oesophageal Dysphagia => Food “sticks” after swallowing +/- regurgitation

Answer 346

Caused by neurological disease Investigations: • Neuro exam • Videofluoroscopic swallowing assessment

Answer 347

Caused by: • Dysmotility, • Stricture (e.g. intrinsic oesophageal malignancy or extrinsic bronchial ca.) • Oesophagitis (reflux, candidiasis) • Pharyngeal pouch Investigations: • Barium swallow • Endoscopy (OGD) • Biopsy

Answer 348

Malignant strictures have a SHORT history of progressive dysphagia, associated with severe weight loss in elderly patients. If the history strongly suggests malignancy, endoscopy & biopsy is 1st line.

Answer 349

A triad of dysphagia, as well as koilonychia and glossitis (both signs of IDA) It is a pre-malignant condition due to hyperkeratinisation of the oesophagus causing an oesophageal web. Tx = iron supplementation and dilation of the web via OGD

Answer 350

Due to a lack of coordinated muscle contraction and relaxation at the lower end of the oesophagus, leading to retention of the food bolus. Over time, the oesophagus becomes markedly dilated (megaoesophagus), with a classic “rat tail” appearance below the megaoesophagus seen on barium studies.

Answer 351

typically in younger/middle-aged patients (30s) - Dysphagia - Regurgitation - Substernal cramps - Nocturnal cough

Answer 352

Barium swallows OGD – dilated oesophagus with a pond of stagnant food/fluid Oesophageal manometry – increased lower oesophageal sphincter pressure

Answer 353

Conservative/lifestyle measures – chew food well, always eat upright, drink lots with meals, etc. Botulinum toxin injection (provides temporary relief; done if unsuitable for invasive procedures) Endoscopic balloon dilation (risk of oesophageal rupture) Heller’s cardiomyotomy

Answer 354

the muscles of the cardia are divided, and the upper wall of the stomach is sutured onto the lower oesophagus

Answer 355

Risk of oesophageal rupture

Answer 356

= an outpouching of posterior pharyngeal wall Typically seen around C5-6 level. Seen mostly in 60-80 year olds, and more common in males (5:1)

Answer 357

• Dysphagia => Solids AND liquids • Regurgitation • Chronic cough • Gurgling on drinking • Halitosis • Globus

Answer 358

Initial investigation is with barium swallow.

Answer 359

It may not require treatment, but if symptomatic then consider endoscopic repair/open surgery.

Answer 360

Generally occurs in those aged >60 Although becoming more common in younger age groups!!!

Answer 361

!!!! Initially asymptomatic Progressive dysphagia – starting with solids, progressing to liquids and eventually difficulty swallowing saliva Weight loss and anorexia Retrosternal chest pain Coughing/aspiration Occasional lymphadenopathy

Answer 362

Most are now in the lower 1/3rd of oesophagus, mainly adenocarcinomas The remainder are mainly SCCs

Answer 363

More common in UK and western Europe Typically lower 1/3 of oesophagus Risk factors: • GORD – obesity/alcohol/medications • Barrett’s Oesophagus • Smoking Metastasise earlier via lymphatics

Answer 364

More common worldwide Typically middle and upper 1/3 oesophagus Risk factors: • Alcohol and Smoking • Diet – high nitrates/nitrosamines • Chronic inflammation (e.g. Achalasia) Regional lymph node spread.

Answer 365

Prognosis is poor – <10% 5-year survival (SCC has a slightly better prognosis as it is more responsive to radiotherapy)

Answer 366

Metastases (to liver/lungs/bone) are common at diagnosis (25%) as presents late

Answer 367

If suspected oesophageal malignancy – urgent OGD and biopsy. Staging: - CT CAP - PET-CT scan - Laparoscopy to exclude peritoneal mets

Answer 368

Radical curative oesophagectomy for T1/T2 localised disease => Pre-op chemotherapy improves survival, but causes morbidity Chemoradiotherapy combinations can be used if surgery is not indicated Palliation can involve oesophageal stenting to restore swallowing (many cases treated as palliative as advanced disease at presentation)

Answer 369

Most commonly affects people age 50-70 Especially in Japanese populations.

Answer 370

Most are adenocarcinomas and most occur in the antrum. More rarely stromal tumours (more slow growing/benign)

Answer 371

Tend to appear as polypoids or ulcerating lesions with rolled edges “Leather bottle stomach” occurs when there is submucosal infiltration of tumour with marked fibrous reaction, producing a small but thickened & contracted stomach

Answer 372

- H. pylori infection leading to metaplasia - High salt/nitrate diet - Smoking - Genetic factors – blood group A / HNPCC, Japanese - Pernicious anaemia - Adenomatous polyps - Low socio-economic status

Answer 373

Direct invasion of abdominal viscera Lymphatic spread (Virchow’s node) Portal dissemination to the liver Transcoelomic spread can cause peritoneal metastases (including bilateral ovarian tumours)

Answer 374

Often non-specific! Epigastric pain, as with gastric ulcer Nausea & vomiting (vomiting more frequent if tumour is near the fundus) Dysphagia (if tumour is near the fundus) Anorexia / weight loss

Answer 375

Usually completely absent until late disease Palpable epigastric mass (50%) Large left supraclavicular node (Virchow’s) Hepatomegaly, jaundice & ascites Acanthosis nigricans Anaemia

Answer 376

History & Examination Bloods – FBC, U&E, LFT OGD and multiple ulcer edge biopsy STAGING: - Endoscopic USS and CT - Staging laparoscopy

Answer 377

Gastrectomy: => Partial gastrectomy for tumours in the distal 2/3rds of the stomach, otherwise total gastrectomy. => Associated with many complications Combination chemotherapy can increase survival in advanced disease Endoscopic mucosal resection for tumours confined to the mucosa. Wide local excision for stromal tumours Stenting of the pylorus can be palliative to relieve gastric outlet obstruction in patients with pyloric tumours.

Answer 378

Only ~1/3 have curable disease at presentation, the remainder are treated palliatively. <10% 5-year survival <20% for those undergoing radical surgery

Answer 379

MANY COMPLICATIONS Chronic diarrhoea/vomiting, Dumping syndrome, Bacterial overgrowth Malabsorption, Anaemia, Osteomalacia

Answer 380

= an uncommon adenocarcinoma Occurs in the elderly, associated with long-standing gallstones

Answer 381

Direct invasion of the liver Lymphatic spread

Answer 382

(resembles chronic cholecystitis) - RUQ pain - N&V - Weight loss - Obstructive jaundice - Palpable mass

Answer 383

Staging CT CAP, staging laparoscopy for peritoneal mets Treatment = surgical: => Radical cholecystectomy +/- liver resection if caught incidentally Most tumours present too late for surgical therapy (survival is short)

Answer 384

Adenocarcinoma arising from the epithelium of the bile duct/ampulla Common sites = at the confluence of the ducts in the biliary tree Slow growing and metastasise late, but are often advanced at presentation with low long-term survival.

Answer 385

More likely to occur in patients with primary sclerosing cholangitis or IBD

Answer 386

Painless progressive jaundice (as with cancer of the head of the pancreas) Can present like HCC (if arising from the cells of the intrahepatic ducts)

Answer 387

Extra-hepatic or periampullary tumours may be treated by curative resection (Whipple’s procedure) Palliative stenting (ERCP) may be used in advanced disease

Answer 388

= formed by the joining of the pancreatic duct and common bile duct.

Answer 389

Prevents the reflux of duodenal contents into the biliary tree Located between the ampulla of Vater and the wall of the 2nd part of the duodenum.

Answer 390

water, cholesterol, bile salts, conjugated bilirubin, phospholipids.

Answer 391

1. Produced by the liver 2. Stored and concentrated in the gallbladder 3. Lipid-rich food in the duodenum stimulates CCK release 4. CCK causes the gallbladder to contract and the sphincter of Oddi to relax. 5. Bile passes from the GB into the duodenum.

Answer 392

= formation of stones in the gallbladder

Answer 393

= stone impaction in the common bile duct.

Answer 394

= reduction/stoppage of bile flow.

Answer 395

1. Cholesterol Supersaturation 2. Stasis of Bile 3. Increased Hb breakdown

Answer 396

Caused by: 1) increased plasma oestrogen (obesity, pregnancy, OCP, female) 2) depletion of the bile acid pool (terminal ileal resection/disease) Blood cholesterol levels have very little influence on bile cholesterol

Answer 397

Lack of stimulus to GB emptying – fasting, TPN

Answer 398

Haemolytic disorders – e.g. spherocytosis, sickle cell disease, malaria

Answer 399

20% are cholesterol 75% are mixed (predominantly cholesterol) 5% are bile pigments

Answer 400

Generally caused by cholesterol supersaturation and bile stasis. Often solitary, Large (>2.5cm), Smooth RFs: • Increasing age • Obesity, high fat diet, rapid weight loss • Female sex, multiparity, pregnancy, OCP • DM • Ileal disease (e.g. Crohn’s) / resection • Liver cirrhosis

Answer 401

Multiple stones “Generations” – a range of colours and shapes

Answer 402

Multiple, Small Black (associated with haemolytic conditions) or brown (due to bile stasis/infection)

Answer 403

MAJORITY ARE ASYMPTOMATIC If they are symptomatic, the symptoms depend on the location of the stone: => Biliary Colic/Acute cholecystitis => Choledocholithiasis => Mirizzi’s Syndrome => Gallstone Ileus

Answer 404

stone impaction in the common bile duct, which can cause biliary colic if temporary, or painful obstructive jaundice if more prolonged. This can predispose to ascending cholangitis or acute pancreatitis

Answer 405

gallstone impacted in the cystic duct / Hartmann’s pouch (at the neck of the gallbladder); causes extrinsic compression of the common hepatic duct. This leads to obstructive jaundice, without dilation of the cystic/common bile duct

Answer 406

(UNCOMMON) a large gallstone erodes through to the gallbladder lumen to create a fistula into the adjacent duodenum. This can then produce an obstruction if it impacts in a narrow segment of bowel.

Answer 407

Severe, constant epigastric/RUQ pain Crescendo characteristic (peaks around 2 hours after eating, due to CCK peak at this time). May radiate to the back or right shoulder/subscapular region Worse upon food consumption (especially fatty foods) Worst mid-evening, lasting until the early hours (often wakes the patient) Can be associated with N&V Pain often resolves after analgesia, or spontaneously if the stone becomes unblocked and passes down the bile duct. The patient will be systemically well

Answer 408

An obstruction of gallbladder emptying, leading to gallbladder distension. There is ongoing water reabsorption from the retained bile, which becomes highly concentrated, leading to a secondary inflammatory response in the wall of the gallbladder.

Answer 409

Initial features are similar to biliary colic, until the inflammatory component develops, leading to: - Severe localised RUQ pain (as inflamed GB touches the peritoneum), with guarding and rigidity - Vomiting & systemic upset (fever & leucocytosis) - Palpable gallbladder (Murphy’s sign positive) - Rarely the gallbladder can become gangrenous and perforate, leading to generalised peritonitis.

Answer 410

Whilst applying pressure in the RUQ, ask the patient to inspire deeply. Murphy’s sign is POSITIVE when there is a halt in inspiration due to pain. A similar manoeuvre in the LUQ should not elicit discomfort Murphy’s sign is specific (if found, it is likely that the diagnosis is cholecystitis), but it is not sensitive (not everyone with cholecystitis will have a positive Murphy’s sign).

Answer 411

= Repeated episodes of inflammation due to gallstones lead to fibrosis and thickening of the gallbladder wall. Features: - Recurrent bouts of abdominal pain due to mild cholecystitis - Discomfort and flatulence after fatty meals

Answer 412

Obstructive jaundice and biliary colic Attacks last for hours to days, ceasing when the stone passes through the Sphincter of Oddi or disimpacts and falls back into the dilated common bile duct. If the obstruction is not relieved, the chronic back pressure can lead to secondary biliary cirrhosis and liver failure.

Answer 413

In a patient with painless jaundice and an enlarged gallbladder the cause is unlikely to be gallstones and therefore presumes the cause to be an obstructing MALIGNANCY until proved otherwise.

Answer 414

= an infection of the common bile duct, usually caused by bacteria ascending from the duodenum. Usually occurs following obstruction due to choledocholithiasis

Answer 415

Classic symptoms = Charcot’s Triad: 1. Fever (+/- rigors) 2. Jaundice 3. RUQ Pain

Answer 416

Charcot’s Triad: 1. Fever (+/- rigors) 2. Jaundice 3. RUQ Pain => Suggestive of ascending cholangitis

Answer 417

Observations Abdo exam BLOODS - WBC, LFTs, Amylase/lipase, prothrombin time Abdo USS MRCP/ERCP

Answer 418

Abdo USS Can show sludge/stones Shows thickened gallbladder wall in acute/chronic inflammation Shows increased diameter of common bile duct in obstruction

Answer 419

(Magnetic Resonance Cholangiopancreatography) Any patients with an inconclusive USS/CT scan and symptoms of gallstones should undergo an MRCP Gives detailed information about the biliary tract anatomy of the patient and can detect stones.

Answer 420

= endoscopic retrograde cholangiopancreatography Gold standard for cholangitis – both diagnostic and therapeutic. Endoscope is passed via oesophagus into duodenum, fine catheter is passed into the common bile duct.

Answer 421

ERCP - it is both diagnostic and therapeutic

Answer 422

Cholecystectomy only indicated if the patient is at significant risk of complications due to co-morbidities (e.g. diabetes or chronic renal failure)

Answer 423

Admit for bed rest, with fluids and analgesia (keep NBM) Elective laparoscopic cholecystectomy => Preferably during the first 72 hours (“hot cholecystectomy”) => Otherwise scheduled for 6 weeks later (“cold cholecystectomy”) Medical Tx involve oral bile salts (chenodeoxycholic acid) for small, non-calcified stones in a minority of patients unfit for surgery

Answer 424

Hot = within 72 hours Cold = 6 weeks later

Answer 425

Bile leakage; Jaundice due to ductal injury Missed stones in the CBD. Patients may complain of intolerance to fatty meals post-surgery

Answer 426

As per biliary colic, but also IV co-amoxiclav

Answer 427

Laparoscopic cholecystectomy, with cholangiogram to ensure no stones remain in the common bile duct (if so, removed at ERCP)

Answer 428

ERCP for sphincterotomy and to remove the stones, as an emergency if there is a high fever Any intervention is preceded with vitamin K, as a lack of bile salts mean this may not have been absorbed well Elective laparoscopic cholecystectomy

Answer 429

A jaundiced patient is at higher risk of infection, venous thrombosis, bleeding and hepatic/renal failure.

Answer 430

Sepsis six bundle, with IV antibiotics Emergency ERCP

Answer 431

Diarrhoea/ steatorrhoea Weight loss / FTT Lethargy

Answer 432

- Anaemia (Fe / B12 / Folate) - Bleeding disorders (vitamin K) - Oedema (protein) - Osteomalacia (vitamin D) - Neuropathy

Answer 433

Bloods: => FBC, iron studies, B12 & folate, calcium, magnesium, phosphate, lipid profile, LFTs, TFTs, inflammatory markers, clotting & coeliac serology Stool studies => MCS (plus ova, cysts & parasites if recent travel and C. diff toxin if recent ABX) => Faecal elastase (if ?chronic pancreatitis) => Calprotectin (r/o IBD) Further studies are guided by clinical suspicion: Endoscopy: - OGD + duodenal biopsy – coeliac disease - Colonoscopy + biopsy – Crohn’s disease - ERCP – biliary obstruction/chronic pancreatitis Breath hydrogen analysis => ?bacterial overgrowth

Answer 434

= Inflammation of jejunal mucosa in response to gluten Alpha-glandin is modified by tissue transglutaminase enzymes (TTG) It then activates an autoimmune reaction against the mucosa Biopsy of the duodenal mucosa will show flattened mucosa due to loss of villi => Hyperplasia of crypts to compensate => Also increased intraepithelial lymphocytes

Answer 435

1/3rd are asymptomatic Non-specific features = IDA, weight loss/ fatigue or apthous ulcers Dermatitis herpetiformis is a recognised skin manifestation

Answer 436

FBC (anaemia), clotting (can be prolonged), bone profile (suggestive of osteomalacea) Endomysial antibodies (EMA) and TTG antibodies present Duodenal biopsy = gold-standard for diagnosis Bone densitometry should be performed due to osteoporosis risk

Answer 437

Duodenal biopsy

Answer 438

Lifelong gluten free diet => Verify that gluten-free diet is working with EMA tests Be aware there is a small increased risk of small bowel lymphoma/adenocarcinoma

Answer 439

Most commonly due to high alcohol intake, leading to inappropriate enzyme activity within the pancreas. Leads to precipitation of proteins that plug the pancreatic ducts, providing a nidus for infection/calcification, and cause of ductal hypertension The end result of the process is fibrosis of the parenchyma, and disturbed exocrine function (trypsins, amylases, and lipases).

Answer 440

Epigastric pain, radiating to the back => Relieved by sitting forwards or hot water bottles on epigastrium/back Weight loss, bloating & steatorrhoea Brittle diabetes Obstructive jaundice Symptoms are relapsing, and progressively worsen

Answer 441

= insulin dependent DM, characterised by sudden swings in glucose level for no apparent reason

Answer 442

Serum amylase/lipase are rarely elevated, butFAECAL ELASTASE is elevated. Trypsinogen levels >10 in steatorrhoea is diagnostic There may be signs of alcohol abuse (macrocytic anaemia, GGT) Transabdominal USS may show pseudocyst Contrast CT/MRCP can confirm diagnosis with pancreatic calcifications

Answer 443

Analgesia (pain management is a vital part of Mx) Creon (lipase) and Multivite (fat soluble vitamins) Monitoring of blood sugars Treatment of alcohol abuse (complete abstinence) Low fat diet Partial pancreatectomy/pancreatojejunostomy may be required if there is unremitting pain, narcotic abuse or weight loss

Answer 444

Typically presents in patients >60 years Associated with smoking, alcohol, diabetes and chronic pancreatitis (also a genetic component) - 60% in the head of pancreas - 25% in the body - 15% in the tail

Answer 445

Presentation depends on the location of the tumour HEAD - Presents earlier - Painless jaundice (obstructive); but pain may develop as disease progresses - OE => signs related to obstructive jaundice, Courvoisier’s sign in some cases or palpable abdominal mass BODY/TAIL - More likely to present late - Dull abdominal pain, radiating through to the back Partially relieved on sitting forwards - Non-specific B symptoms common - Often no physical signs on examination Either can also present as acute pancreatitis or diabetes

Answer 446

The majority of pancreatic malignancies are ductal adenocarcinomas. Islet cell tumours make up <2% of pancreatic neoplasms

Answer 447

= thrombosis of the superficial/deep leg veins (thrombophlebitis migrans) related to pancreatic carcinoma

Answer 448

Symptomatic hypoglycaemia events (often in mornings/on exertion) as well as gross weight gain 90% are benign

Answer 449

Often asymptomatic; Secondary diabetes may develop

Answer 450

Zollinger-Ellison syndrome, with oesophagitis, GI ulcers and diarrhoea

Answer 451

Presents with: diabetes (insulin release inhibited), achlorrhydia (gastrin release inhibited) gallstones (CCK release inhibited)

Answer 452

Bloods: - FBC, U&Es, LFTs (obstructive jaundice) - CA 19.9 or CEA (non-specific) are useful as a baseline - Amylase is rarely elevated USS: => Confirms obstruction & duct dilation CT: => Pancreatic mass +/- dilated biliary tree +/- hepatic metastases Endoscopic USS +/- biopsy => Detailed information about the location of the tumour, its local spread and involvement of local lymph nodes & allows biopsy Staging laparoscopy may be required

Answer 453

Patients will be discussed at MDT Only 10-15% of tumours are suitable for radical surgery (= Whipple's procedure) => Tumour must be <3cm with no metastases in a fit patient Non-curative surgery provides no survival benefit, if the tumour is non-operable, ERCP/PTC stent insertion may help jaundice/anorexia.

Answer 454

A portion of the pancreas is removed, along with a portion of the duodenum, the ball bladder and part of the bile duct The remaining organs are reattached to restore digestive function - Post-op mortality = ~5%; morbidity is high - Post-op chemotherapy has been shown to improve survival

Answer 455

Mean survival <6 months 5-year survival <2%; rising to 5-15% following Whipple’s procedure Ampullary and islet cell tumours carry a better prognosis, as they often present relatively early.

Answer 456

T10 Oesophagus, vagal nerve trunks, oesophageal branches of the left gastric vessels and lymphatics pass through the diaphragm here

Answer 457

= the protrusion of an organ (typically the stomach) through the oesophageal opening in the diaphragm, into the thoracic cavity.

Answer 458

80% of cases G-O junction slides upwards through the hiatus to lie above the diaphragm. Usually of no significance, but symptoms may occur due to associated reflux.

Answer 459

20% of cases A small part of the fundus rolls up through the hernia alongside the oesophagus, but the sphincter remains competent below the diaphragm. The proportion of the stomach that herniates is variable and may increase with time, eventually may evolve to have almost the entire stomach sitting in the thorax. Very occasionally can present with severe pain, requiring surgical intervention for gastric volvulus/ strangulation.

Answer 460

Sliding Rolling Mixed

Answer 461

Age = biggest risk factor Increased intra-abdominal pressure: - Pregnancy - Obesity - Ascites

Answer 462

vast majority = completely asymptomatic GORD Symptoms Vomiting Weight loss (a rare, but serious presentation) Bleeding and / or anaemia (secondary to oesophageal ulceration), Hiccups Palpitations Swallowing difficulties (either oesophageal stricture formation or rarely incarceration of the hernia).

Answer 463

OGD = gold-standard They can also be diagnosed incidentally, either on a CT or MRI scan. If there are symptoms of gastric outflow obstruction or weight loss, whereby an upper GI malignancy may be suspected, an urgent CT thorax and abdomen is mandatory.

Answer 464

INITIAL Mx = CONSERVATIVE 1st line = PPI => Acting to reduce gastric acid secretion and aiding in symptom control. Lifestyle modification: => Including weight loss, alteration of diet (earlier meals, smaller portions), and sleeping with the head of the bed raised. => Smoking cessation and reduction in alcohol intake should be advised

Answer 465

1. Remaining symptomatic, despite maximal medical therapy 2. Increased risk of strangulation/volvulus* => rolling type or mixed type hernia, or containing other abdominal viscera) 3. Nutritional failure (due to gastric outlet obstruction)

Answer 466

immediate stomach decompression via a NG tube prior to surgical intervention.

Answer 467

the stomach twists on itself by 180 degrees, leading to obstruction of the gastric passage and tissue necrosis Requires prompt surgical intervention. Typically presents with Borchardt's triad: 1. Severe epigastric pain 2. Retching without vomiting 3. Inability to pass an NG tube

Answer 468

1. Severe epigastric pain 2. Retching without vomiting 3. Inability to pass an NG tube Indicates likely stomach volvulus

Answer 469

The hernia is reduced from the thorax into the abdomen and the hiatus reapproximated to the appropriate size. Any large defects usually require mesh to strengthen the repair. The gastric fundus is wrapped around the lower oesophagus and stitched in place (to strengthen LOS and keep GOJ in place)

Answer 470

Recurrence Inability to belch (due to reinforcement of LOS) => bloating Dysphagia (if fundoplication is too tight) Fundal necrosis (if blood supply disrupted)

Answer 471

1. ENDOCRINE - Alpha and beta cells - Secretes hormones like insulin and glucagon into the bloodstream for glucose homeostasis. 2. EXOCRINE - Acinar cells - Secrete amylases, lipases and proteases into the duodenum to aid digestion.

Answer 472

Keeping the enzymes away from sensitive tissues in vesicles (zymogen granules). Storing the enzymes as proenzymes (Zymogens) which first need to be activated by the protease trypsin.

Answer 473

I GET SMASHED: Idiopathic (20%) Gallstones (40%) Ethanol (35%) Trauma (15%) Steroids Mumps (+ CMV, EBV) Autoimmune Scorpion venom Hyper/hypo (hyperlipidaemia, hypercalcaemia, hypothermia) ERCP Drugs (thiazides, sulphonamides, ACEIs, NSAIDs)

Answer 474

Gallstones Ethanol

Answer 475

An initial insult to the pancreas leads to leakage of activated pancreatic enzymes into the pancreatic and peripancreatic tissue, causing an acute inflammatory reaction. The liberation of digestive enzymes results in extensive local tissue necrosis, particular fat necrosis. Litres of extracellular fluid collect in the gut, peritoneum and retroperitoneum.

Answer 476

Causes increased zymogen release from acinar cells; and also causes a decrease in fluids and bicarbonates in ducts. This means pancreatic juices are thick and sludge-like (with many enzymes, but not much fluid) which can form a plug and block ducts. Increase in pressure can cause distension of the ducts. Distension can bring zymogen granules in contact with lysosomes which may contain digestive enzymes – can cause a cascade of pancreatic autodigestion. In response to this, there is a release of cytokines, leading to an immune response.

Answer 477

gallstones => block Sphincter of Oddi This then becomes a similar situation to alcohol-induced acute pancreatitis where there is backing up to pancreatic juices.

Answer 478

Gradual/sudden onset severe epigastric pain Classically radiates to the back May be relieved by sitting forward N&V is prominent

Answer 479

Tachycardia (shock in severe disease) Fever Ileus Jaundice Rigid abdomen Cullen’s sign Grey-Turner’s sign (In general, bruising signs occur after 48 hours and are an indicator of grave prognosis)

Answer 480

= peri-umbilical bruising, due to peritoneal haemorrhage

Answer 481

= bruising of the flanks

Answer 482

Used to assess severity and prognosis P – PaO2 <8 kPa A – Age >55 N – Neutrophils, WCC > 15x109/L C – Calcium <2mmol/L R – Renal, urea >16 mmol/L E – Enzymes, LDH >600 IU/L or AST >200 IU/L A – Albumin <32 g/L S – Sugar, glucose >10 mmol/L A score of 3 or more is severe disease.

Answer 483

allocates points for assessment of clinical parameters (A), age (B) and co-morbid disease (C). Scores >9 indicate severe pancreatitis Mortality is high if this score increases after admission

Answer 484

includes age and lab scores on admission, then clinical findings at 48 hours to give a mortality risk figure.

Answer 485

Baseline FBC, CRP, U&E, LFT, glucose and calcium to assess progression Raised serum amylase (>1000 U/mL) => Very sensitive if measured within 24h of onset and >3x normal Raised serum lipase = more sensitive and specific ABG to monitor oxidation and acid-base status

Answer 486

Acute pancreatitis Cholecystitis, GI perforations Mesenteric infarctions

Answer 487

AXR Erect CXR - to assess for perforations CT: => Can show enlarged pancreas with stranding, abscess, collections, necrosis, or pseudocyst MRCP: => Better visualisation of collections and also the ductal system Endoscopic USS: => Newest method of visualising the pancreas, but more rarely used.

Answer 488

ACBDE approach, then supportive treatment Aggressive IV fluid resuscitation, catheterise and consider CVP monitoring Regular Obs Daily bloods (FBC, U&E, Calcium, glucose, ABG) Analgesia NBM until pain free – “rests” the pancreas NG tube suction if ileus/emesis PPI to prevent stress ulcer Anticoagulation Consider HDU/ITU

Answer 489

ABX in severe cases /infection/necrosis Laparotomy and debridement if abscess/pancreatic necrosis on CT Urgent ERCP (if due to gallstones) Find & treat the causative agent

Answer 490

Hypovolaemic Shock ARDS Renal failure DIC Hypocalcaemia Hyperglycaemia

Answer 491

Pancreatic pseudocyst Abscesses Bleeding from elastase eroding a minor vessel Thrombosis of splenic/gastroduodenal aa. (causing bowel necrosis) Fistulae

Answer 492

• The inflammatory process causes blood vessels to become leaky and then rupture, leading to pancreatic tissue swelling. • This causes premature activation of lipases which then starts to destroy peripancreatic fat. • The fat and tissues liquefy and can start necrosing (process called Liquefactive Haemorrhagic Necrosis)

Answer 493

= a localised fluid collection, rich in pancreatic enzymes, with a non-epithelialised wall containing fibrous/granulation tissue. Commonly occur in pancreatitis, from day 10 onwards Form due to disruptions of the pancreatic duct, leading to extravasation of enzymes.

Answer 494

Most resolve without intervention - only require supportive care and regular monitoring. Indications for drainage include: - Complications (bleeding / infection) - Relief of symptoms - Concern about malignancy (cytology and cystic fluid analysis)

Answer 495

Deep, persistent abdominal pain Abdominal mass Anorexia (due to pressure on adjacent bowel) Jaundice Sepsis (if infected) Pleural effusion

Answer 496

Abdominal CT = gold-standard if pseudocyst is suspected MRI may be better to differentiate pseudocyst from necrosis ERCP/endoscopic USS can be useful to plan therapy if endoscopic drainage is being considered.

Answer 497

benign prostatic hyperplasia Benign nodular/ diffuse proliferation of glandular layers of the prostate, leading to enlargement of the inner transitional zone. Affects 70% of those >70.

Answer 498

FILLING Sx - Due to bladder overactivity => Frequency, nocturia, Urgency VOIDING Sx - Due to bladder outlet obstruction => Hesitancy/ dribbling, Poor/ intermittent stream, Strangury, Retention with overflow incontinence/ acute retention Sx DUE TO COMPLICATIONS => Occasionally haematuria (due to rupture of veins into the cyst but this is a red flag), Symptoms of associated UTI, Bladder stones, Chronic renal failure

Answer 499

UTI, overflow incontinence, bladder calculi, bladder diverticulae, bilateral hydronephrosis and renal failure.

Answer 500

Hx: - Clarify symptoms and concerns - QoL, international prostate symptom score (IPSS) Abdo exam and DRE: - ?signs of a distended bladder - DRE - typically sulcus is still palpable, smooth & round (not craggy) Urine dipstick, urinalysis and MCS Bloods – FBC, U&Es, PSA* (<4ng/ml normal, can be adjusted for age and prostatic size) Frequency/volume chart.

Answer 501

15ml/sec usually normal. <12ml/sec usually indicates obstruction or weak bladder contractility Need to remember that it requires >150mL to be voided (not possible for some patients)!!!

Answer 502

= a glycoprotein produced by normal and cancerous prostate cells. Secreted by prostate epithelial cells into prostatic fluid, where its function is to liquefy semen and thus allow spermatozoa to move more freely. Although PSA is secreted into prostatic fluid and semen, small amounts of PSA are present in blood. Interpreting PSA results can be difficult because various things can increase/decrease serum PSA levels.

Answer 503

Prostate enlargement. Older age Infection (e.g. prostatitis and urinary tract infection). Physical causes, (including following vigorous exercise, digital rectal examination, catheterization, and prostate biopsy) Prostate cancer A normal prostate

Answer 504

Certain drugs (including 5-alpha reductase inhibitors, aspirin, statins, and thiazide diuretics) Obesity.

Answer 505

Prostate enlargement. Prostate cancer. Infection. A normal prostate

Answer 506

Mild: - Reassure not cancer, watchful waiting and follow-up. - Lifestyle modification – avoid alcohol/caffeine, relax when voiding, void twice in a row to help emptying, bladder retraining therapy. Moderate - Severe: - Alpha blockers (e.g. doxazosin, tamsulosin) - 5-alpha reductase inhibitors (e.g. finasteride, dutasteride) Severe = Surgery - Transurethral resection of the prostate (TURP) or open prostatectomy - Laser, prostatic urethral lift, steam treatment - Vascular: prostatic artery embolization

Answer 507

If acute retention – attempt urethral catheter drainage (suprapubic if urethral not possible).

Answer 508

Adrenoceptor antagonists, blocks receptors on prostatic SmM (stromal) SEs: postural hypotension, drowsiness.

Answer 509

5-AR enzyme converts testosterone into dihydrotestosterone, reduces prostate volume SEs – impotence, reduced libido, excreted in semen (condom use needed)

Answer 510

Complications: - TURP syndrome (dilutional hyponatraemia), - UTI/Urethral stricture, - Retrograde ejaculation, - Prostate can regrow/perforate bleeding, - incontinence, - impotence, - bladder neck stenosis. Tend to require catheter for few days post-op.

Answer 511

Most are adenocarcinomas: generally, occurs in the posterior, outer, glandular portion of tissue (so biopsy must be transrectal).

Answer 512

Age FHx Raised testosterone levels.

Answer 513

Can spread: - locally (seminal vesicles, bladder, rectum); - by lymphatics (iliac/ para-aortic nodes); - by haematogenous spread (classically to the bone).

Answer 514

Often asymptomatic (found on PR/ histology of BPH or suspected by raised PSA) Symptoms can depend on extent of spread: => LOCAL disease = Weak stream, hesitancy, sensation of incomplete emptying, urinary frequency, urgency, urge incontinence. => LOCALLY INVASIVE Disease = Haematuria, dysuria, incontinence, haematospermia, Perineal and suprapubic pain, Obstruction of ureters, Impotence, Rectal symptoms (tenesmus) => METASTATIC DISEASE

Answer 515

PR Exam => hard, craggy, irregular prostate, possible nodule, immobile and palpable seminal vesicles

Answer 516

Most cancers cause lytic lesions, but prostate cancer causes sclerotic bony mets

Answer 517

DRE PSA – >10ng/ml suggestive of tumour (better for monitoring than for diagnosis) Multiparametric MRI => Vital for Gleason score which helps to decide management Biopsy: => most common approach is transrectal ultrasound-guided (TRUS) biopsy Bone XR/scan and CT for staging

Answer 518

two areas of prostate tissue are graded out of 5 and added together to give a combined score out of 10. 6 or less, considered low risk 8 or more, considered high risk

Answer 519

Localised Prostate Cancer (T1/2): - Active surveillance (regular PSA, DRE, re-biopsy monitoring) - Radiotherapy or brachytherapy: lower risks of impotence and incontinence - Radical prostatectomy (higher risk) Advanced Prostate Cancer (T3/4): - Active surveillance not recommended => choice of radiotherapy or surgery offered Metastatic Disease: - Hormonal therapy, GnRH agonists, e.g. Goserelin/ buserelin (reduce testosterone production) - Used palliatively or as an adjunct to a curative therapy in high-risk disease - An anti-androgen (e.g. cyproterone acetate) is co-prescribed initially to prevent the early rise in testosterone.

Answer 520

LUMINAL Bladder Tumour MURAL Urethral stricture Congenital abnormalities Neuropathic bladder EXTRAMURAL BPH / prostate cancer Phimosis / paraphimosis

Answer 521

SYMPTOMS - Suprapubic pain - Hesitancy and diminished force of the stream - Terminal dribbling - Overflow incontinence - Signs of infection (due to stasis of urine) SIGNS - Palpable, full bladder - Loin tenderness / palpable hypernephrotic kidney - Enlarged prostate on PR (poor sensitivity for prostatic obstruction)

Answer 522

- Bloods – FBC, U&Es - Urine – dip, MC&S - USS – hydronephrosis - CT/MRI

Answer 523

Catheterisation (suprapubic/urethral) – beware of large diuresis following relief of obstruction Find and treat underlying cause

Answer 524

= narrowing of the preputial orifice, resulting in the inability to retract the foreskin.

Answer 525

Causes: - Most often idiopathic - Congenital - Chronic balanitis - Traumatic forcible retraction of the foreskin Normal in children <2 years old.

Answer 526

In children, it may present as ballooning of the foreskin and poor stream during urination. In adults, it presents as pain during intercourse and inability to retract the foreskin.

Answer 527

Good hygiene Steroid cream (to help soften the foreskin) Circumcision if troublesome symptoms.

Answer 528

Results from pulling a tight foreskin over the glans, obstructing venous return and leading to a swollen, painful glans. As the gland swells, it becomes increasingly difficult to replace the foreskin.

Answer 529

- After an erection/ vigorous sex, - Chronic balanitis - Following urethral catheterisation (remember to replace the foreskin).

Answer 530

Emergency Tx involves local anaesthesia and then applying pressure to the glans, or slitting the foreskin dorsally. Circumcision is offered after paraphimosis to prevent recurrence.

Answer 531

50% of cases associated with HPV 16/18 More common in smokers, and immunosuppression

Answer 532

Presents as persistent itchy red patch on the penis, progressing to an infiltrating ulcer. There is never any urethral involvement/symptoms

Answer 533

Diagnosis is with punch biopsy => squamous cell carcinoma

Answer 534

Early cancers – cured with radiotherapy or penis-preserving excision Inguinal LN involvement – more radical Tx required (success rates lower)

Answer 535

Persistent (hours to days) erection of the corpora cavernosa of the penis Reduction in blood flow can lead to ischaemia.

Answer 536

Usually idiopathic Trauma Sickle-cell disease Intra-cavernosal injections for impotence

Answer 537

- Ice packs - Alpha-agonists - Selective embolisation - Aspiration of corpus cavernosum - Surgical intervention

Answer 538

Upwards curvature of the penis when erect Cause = unknown => Fibrous scarring following trauma is a possibility.

Answer 539

Managing psychological effects Surgical intervention may help penetration.

Answer 540

Erection requires increased arterial inflow, and occlusion of venous outflow. This is mediated by parasympathetic fibres from S2-4.

Answer 541

Ageing (70% of 70 year olds have difficulty obtaining an erection) Neurogenic – e.g. spinal cord lesion/stroke/nerve-damage Vascular – HTN/arterial disease Hormonal – DM/pituitary failure Pharmacological – alcohol, anti-hypertensives, oestrogens, tranquilisers Psychogenic

Answer 542

Cause is usually determined using history and examination + Urine dipstick + Hormone screen

Answer 543

Treat reversible medical cause / correcting hormonal disturbances Smoking cessation, reduce alcohol Sildenafil (Viagra) – causes vasodilation of corpus cavernosum => (CI in patients with hypotension) Intracavernosal alprostadil (PGE-1) injection Vacuum condoms or inflatable intrapenile prostheses if these treatments fail

Answer 544

An uncommon form of undescended testes The testicle has strayed from the normal line of descent Most common site is superior inguinal pouch

Answer 545

Common The testis has followed the normal route of descent but stopped short of the scrotum Most commonly due to a local defect in development, and the affected testis is small and accompanied by a persistent processus vaginalis.

Answer 546

Normal testes, with an excessive cremasteric reflex. They are often confused with maldescended testes, but on examination they can be found at the external inguinal ring, and can be coaxed down.

Answer 547

Retractile testes are normal and require no treatment Ectopic/undescended testes must be surgically placed into the scrotum (orchidopexy) if they are to function as a reproductive organ (recommended age = 6 months).

Answer 548

Defective spermatogenesis Increased risk of torsion, malignancy and indirect inguinal hernia.

Answer 549

1. Can I get above it? Yes => primary scrotal swelling No => ?inguinal hernia If primary: 2. is it cystic or solid? 3. Is it separate to the testes? ALWAYS suspect torsion and order doppler USS to exclude if any suspicion. => Cremasteric reflex – absent ipsilaterally in torsion

Answer 550

A common cause of scrotal lump Occurs due to cystic degeneration of epididymal structures. Previously known as spermatocoele

Answer 551

- Lump should be cystic (transilluminates) and separate from the testes (almost always at the upper pole) - Contained fluid can be clear/contain sperm/be milky (previously termed spermatocoele) - Can sometimes be painful or the bulkiness can be troublesome

Answer 552

If they cause significant symptoms they may be excised (rather than just aspirated, as this can lead to recurrence).

Answer 553

Most common cause of scrotal enlargement Due to an excessive collection of serous fluid in the processus vaginalis

Answer 554

A fluctuant swelling that transilluminates PRIMARY (idiopathic): also “vaginal hydrocoele”, separate from the peritoneal cavity SECONDARY: fluid collects due to underlying inflammation in the epididymis/testes or an underlying cancer.

Answer 555

O/E - soft, fluctuant lump; will transilluminate May need USS to r/o more severe underlying pathology

Answer 556

Most often, reassurance of benign nature is suitable treatment If swelling is causing problems, then excision of sac is possible (aspiration can lead to recurrence).

Answer 557

= varicosities of the pampiniform plexus

Answer 558

Most commonly on the left (90%) Patients complain of a dragging sensation and ache Feels like a “bag of worms” on palpation, and may only be palpable in a standing position Associated with reduced spermatogenesis and subfertility

Answer 559

The left testicular vein drains into the left renal vein at a right angle, rather than the right testicular vein that drains into the IVC obliquely. Valvular incompetence at the junction of the left renal vein is the pathological process that leads to varicocoele. Rarely, it can be caused by a left renal tumour or other pathology compressing the left renal vein.

Answer 560

Usually, reassurance of benign nature is enough. Treatment options are radical embolisation of the left renal vein, or surgical ligation and division of the testicular veins.

Answer 561

= a urological/ surgical emergency. The testicle twists on itself, obstructing venous return => ischaemia

Answer 562

Usually due to a congenital abnormality – e.g. maldescent/ bell-clapper testes.

Answer 563

In adolescents, often with a history of mild trauma or previous attacks of pain due to partial torsion and spontaneous resolution. Sudden onset severe pain in the groin/ lower abdomen (T10) Often accompanied by N&V. Can be intermittent and brought on by physical activity.

Answer 564

Unilateral hot, swollen, tender testis, sometimes lying high and transverse within the scrotum Absent cremasteric reflex. Raising testis worsens pain.

Answer 565

Torsion is a CLINICAL DIAGNOSIS so this wouldn’t be done, but: doppler USS shows a lack of blood supply to the testes. Urine dip to exclude infective cause. If in doubt, surgical exploration

Answer 566

URGENT SURGERY – manual distortion can be attempted under analgesia for temporary relief of pain => Viable testis = surgically untwisted and sutured to the tunica vaginalis with fixation of the contralateral testicle also. => Non-viable testis = orchidectomy an fixation of the contralateral testicle also.

Answer 567

Salvage rate of 80% for patients operated on within 6 hours of initial torsion.

Answer 568

Similar to testicular torsion, but it is an embryological remnant that twists Less painful, causes a small blue nodule to be visible under the scrotum. Classically occurs at the start of puberty

Answer 569

Undescended/ectopic testes (greater risk if not in the anatomical position by 13 years) Infertility Hypospadia FHx / PMHx

Answer 570

Seminomas Non-seminomatous germ cell tumours (NSGCTs) – include teratomas, yolk sac tumours and choriocarcinomas

Answer 571

Arises from the cells of the seminiferous tubules, in 30-40 year olds It has a solid appearance macroscopically Microscopically, can range from well-differentiated spermatocyte cells to undifferentiated round cells.

Answer 572

Arises from totipotent germ cells, in 20-30 year olds Cystic appearance macroscopically, and variable cell types microscopically

Answer 573

Local spread of testicular tumours through the capsule is rare Lymph node spread is to the para-aortic nodes Bloodborne spread is early to the lungs and liver

Answer 574

PAINLESS LUMP in the testes Hydrocoele Haematospermia Symptoms of metastases (e.g. abdominal swelling, breathing difficulties) Drain to para-aortic nodes, so first palpable node is likely to be supraclavicular Rarely – as a painful, rapidly enlarging swelling; or gynaecomastia due to paraneoplastic syndrome

Answer 575

Scrotal USS Tumour markers => NSGCTs – usually produce AFP, some produce bHCG => Seminomas – never produce AFP, 10% produce bHCG (^^Useful for diagnosis and also follow-up) CT CAP – for staging

Answer 576

If suspected, early surgical exploration through an inguinal incision is indicated. Orchidectomy for obvious/previously diagnosed tumours Biopsy and frozen section if diagnosis unclear (then orchidectomy if confirmed) Retroperitoneal LN dissection may also be undertaken Post-surgical radiotherapy (for seminomas) or combination chemotherapy (NSCGTs) Sperm banking is used due to the risk of infertility.

Answer 577

Acute infections usually arise due to an ascending infection via the vas deferens. => After gonococcal/non-gonoccocal urethritis => After UTI due to E. coli Can spread haematogenously – e.g. TB, mumps

Answer 578

Painful swelling of the epididymis Often with secondary hydrocoele History of discharge (STI) /dysuria (UTI) Examination of the prostate may reveal co-existent prostatitis Positive Phren’s test

Answer 579

First catch urine MCS + STI screen USS

Answer 580

6 weeks ciprofloxacin (add doxycycline if suspecting chlamydia) Analgesia and scrotal support may provide pain relief

Answer 581

Fever/rigors, Perineal pain, Difficulty voiding, UTI symptoms Pain on ejaculation / haematospermia PR – prostate exquisitely tender and enlarged Often presents alongside epididymo-orchitis

Answer 582

Mx = 6 weeks ciprofloxacin

Answer 583

= discharge and discomfort within the penis in men. Generally split into gonococcal urethritis and non-gonococcal urethritis (of which the most common cause is chlamydia).

Answer 584

Gonorrhoea = gram -ve intracellular diplococcus spread by sexual contact. SYMPTOMS: • 50% of women and 10% of men are asymptomatic • Men present with dysuria and urethral discharge, and can ascend to cause epididymitis or prostatitis • Women present with vaginal discharge, pelvic pain, dysuria, and IMB

Answer 585

• Gram stain (for gram negative diplococci) and culture of the discharge • NAAT from urine as an alternative • Blood culture if suspecting disseminated gonococcus • Test for co-existing pathogens (chlamydia/syphilis)

Answer 586

Stat IM ceftriaxone Follow-up and repeat cultures 72 hours after treatment. Trace and treat all sexual contacts

Answer 587

Asymptomatic in 50% of men, and 80% of women Men – dysuria, discharge, can ascend (epididymitis) Women – discharge, bleeding, and lower abdo pain

Answer 588

First void urine in men, endocervical swab in women Cell culture is gold standard but takes time, so immunofluorescence/PCR are used. Assess for co-existing gonnorhoea.

Answer 589

1g azithromycin as a single dose, OR 7 day course of doxycycline/ erythromycin

Answer 590

= frequency/dysuria without infection (abacteriuric) Can be caused by post-coital bladder trauma, atrophic vaginitis, interstitial nephritis.

Answer 591

Urethral tears require special urological action. => Need contrast urethrography to determine if partially or fully torn If partially intact, it can be treated conservatively by prolonged catheterisation. Complete tears require suprapubic catheterisation and then formal repair.

Answer 592

= a scar of the urethral epithelium, which commonly extends into the underlying corpus spongiosum. The fibroblastic activity leads to a shortening of urethral length, and narrowing of luminal size.

Answer 593

- Blunt perineal trauma (straddle injury, pelvic fracture) - Iatrogenic – catheter insertion/long-term catheterisation - Gonoccocal/non-gonococcal urethritis - Balanitis xerotica obliterans (white atrophic plaques leading to phimosis)

Answer 594

Obstructive voiding symptoms that worsen gradually Initial frequency/dysuria Hesitancy/straining Urinary retention Splayed stream (if meatal stricture present) O/E: - firm areas consistent with periurethral scarring - The patient is often <50, and there will be no prostate abnormalities

Answer 595

Uroflowmetry Urethrogram – determine stricture length, location, calibre, significance. Urethroscopy may also be of use

Answer 596

1st line – optical urethrotomy Urethroplasty for those that recur (50%)

Answer 597

= a tumour of the transitional cell epithelium (lines the calyces, renal pelvis, ureter, bladder and urethra) => Bladder tumours are 50x more common than tumours of the ureter/renal pelvis.

Answer 598

Smoking Aromatic amines – rubber/plastic/dye industry workers Chronic cystitis Pelvic irradiation

Answer 599

Painless haematuria +/- clots (= most common presentation) Recurrent UTI Voiding symptoms Pain from invasion of local structures

Answer 600

Urine MCS / cytology (cancers can cause sterile pyuria) Cystoscopy and biopsy (gold standard) CT/MRI or lymphangiography to assess spread

Answer 601

Carcinoma in situ / T1 bladder carcinomas => Transurethral resection on bladder tumour (TURBT) at cystoscopy with intravesical chemotherapy T2-T3 tumours, or high grade tumours: => Radical cystectomy is gold-standard, with pre-operative chemo => An ileal conduit is used to leave a urostomy T4 (invasion beyond the bladder) => Treated palliatively Long-term follow-up with cystoscopy is required

Answer 602

Rarer than TCC Presents similarly to TCC RFs = anything that irritates the lining of the bladder, leading to squamous metaplasia => E.g. schistosomiasis or bladder calculi

Answer 603

Intraperitoneal bladder rupture => Treated with laparotomy and suturing of the bladder Extraperitoneal bladder rupture => Treated conservatively with prolonged urethral/suprapubic catheterisation.

Answer 604

vascular tumours, arising from the proximal tubular epithelium Account for 90% of renal tumours Main risk factor is prolonged haemodialysis (15% develop this)

Answer 605

50% are incidental findings 10% present as classic triad – haematuria, loin pain & abdominal mass – plus vague B symptoms Rarely, invasion of left renal vein leads to varicocoele There may be signs of polycythaemia / HTN (if renin/EPO secretion)

Answer 606

Urine cytology USS to differentiate solid from cystic mass CT/MRI to assess tumour CXR (“cannonball” mets) Renal angiography (if considering partial nephrectomy)

Answer 607

Radical nephrectomy Partial nephrectomy • If peripheral tumour smaller than 5cm • If bilateral tumours or poor kidney function Post-op chemotherapy

Answer 608

An undifferentiated mesodermal tumour (nephroblastoma) Generally presents at 3.5 years with: - Flank pain - Abdominal mass Should NOT be biopsied (risk of spread due to tumour fragility!) Treatment: - Pre-operative chemotherapy - Nephrectomy

Answer 609

Solitary/multiple cysts Commonly occur in the elderly (50% will have a renal cyst by age 50%) Presentation: - Often asymptomatic - Can cause haematuria/pain Polycystic kidney disease is a common cause, with other causes being medullary cystic disease, or medullary sponge kidney

Answer 610

= blockage of ureter, leads to enlargement of the urinary tract superior to the obstruction Causes can be luminal, mural, or extra-mural

Answer 611

Dilation of the renal pelvis

Answer 612

Calculus Sloughed renal papilla Blood clot TCC of renal pelvis/ureter Bladder tumour

Answer 613

Ureteric stricture (TB, post-calculus, post-surgery) Congenital pelviureteric neuromuscular dysfunction Congenital megaureter

Answer 614

Pelviureteric compression (due to external tumours, diverticulitis, AAA, retroperitoneal fibrosis)

Answer 615

Varying loin pain, greater when urine volume increases Anuria (if complete bilateral obstruction) or polyuria (if partial blockage causes renal impairment) Loin tenderness Palpable hydronephrotic kidney

Answer 616

ALWAYS exclude acute scrotum and AAA in men and pregnancy in women. - Urine dip (positive blood) + MCS - USS to confirm upper tract dilation - Abdominal plain film - CT to outline detailed cause of obstruction - Retrograde pyelogram may be used at cystoscopy to further outline ureteric abnormalities (e.g. TCC)

Answer 617

Nephrostomy may be required to decompress the pelvicalyceal system, => preserving kidney function => preventing infection from developing Surgical management (e.g. stenting) may be required depending on the cause

Answer 618

Calculi can form in the collecting ducts and may be deposited anywhere from the renal pelvis to the urethra. Classic sites are the: 1. Pelviureteric junction, 2. Pelvic brim 3. Vesicoureteric junction

Answer 619

Calcium oxalate (75%) Magnesium ammonium phosphate Urate-based

Answer 620

- Obesity - Dehydration - FHx/PMHx of stone disease - Anatomical abnormalities

Answer 621

can present in many ways: - Renal colic – excruciating “loin to groin” spasms, with N&V ; occurs if stone is impacted in the ureter. - Dull loin pain – if the stone is in the major/minor calyx - UTI – secondary to partial/complete obstruction O/E => There are few clinical signs on examination

Answer 622

Bloods – include calcium, phosphate, glucose, bicarbonate, and urate levels Urine dip – 95% positive for blood; r/o infection; beta-HCG is vital Urine MCS Imaging: • AXR (80% visible) • Non-contrast CT KUB (99% visible, can also also exclude abdominal DDx)

Answer 623

A-E Assessment (IV fluids if no oral intake) 75mg diclofenac IM unless contraindicated => Beware of post-renal AKI IM metoclopramide if severe nausea/vomiting IV ABX according to guidelines if signs of infection Assess whether admission is required, if there is… - Still severe pain at 1 hour - A risk of AKI - Signs of shock/infection - Uncertainty over diagnosis Consider Active (surgical) Treatment Conservative (medical) Treatment

Answer 624

- Low chance of spontaneous passage (>10mm) - Persistent pain - Ongoing obstruction - Signs of infection - Renal insufficiency

Answer 625

Extracorporeal shockwave lithotripsy (ESWL) If hydronephrosis present, may need a percutaneous nephrostomy to decompress the pelvicalyceal system prior to outpatient ESWL Uretoscopy => Various energy sources (e.g. laser) can be used to break up the stone Percutaneous nephrolithotomy => Used for renal (not ureteric) calculi that do not respond to ESWL

Answer 626

Outpatient procedure for ureteric calculus Shockwave is focused on the stone to break it up, so it can be passed spontaneously If hydronephrosis present, may need a percutaneous nephrostomy to decompress the pelvicalyceal system prior to outpatient ESWL

Answer 627

Tamsulosin (1st line; alpha-blocker) or nifedipine – increase the rate of spontaneous expulsion Patient Education, if sending them home Refer the patient to urology within one week for r/v

Answer 628

Many stones (80%) will pass naturally Advise to maintain a high fluid intake Advise to return if there is any increase in pain or signs of infection First-time stone formers should also be advised to pass urine through a sieve to collect the stone for analysis

Answer 629

Bladder outflow obstruction Presence of a foreign body (prolonged catheterisation) Upper urinary tract stone passing down

Answer 630

Symptoms of UTI (there is often significant bacteriuria) Can be distinguished from UTI as haematuria and pain generally occur at the end of micturition as the bladder contracts In males, the pain can be felt at the tip of the penis rather than a general burning May be perineal pain if there is trigonitis Anuria/bladder distension if the stone is obstructing

Answer 631

Same as for upper tract stone

Answer 632

Medical expulsive therapy ESWL if the stone is large

Answer 633

Can predispose to SCC

Answer 634

= a focal dilation of an artery >150% of its normal diameter

Answer 635

Asymptomatic (found incidentally) Mass effects – pressure on adjacent structures Embolic events – due to development of mural thrombi Haemorrhage – due to rupture

Answer 636

= dilations of the abdominal aorta to >3cm

Answer 637

Male gender (5x more common in males) Increasing age Smoking HTN FHx Hyperlipidaemia

Answer 638

Main complication = AAA rupture Retroperitoneal leak Embolisation Aortoduodenal fistula

Answer 639

NORMALLY ASYMPTOMATIC => mostly detected as an incidental finding or during screening. PRESENTATION OF AAA RUPTURE: - Severe continuous/intermittent epigastric pain, radiating to the back/groin - Pulsatile, expansile abdominal mass - Signs of shock / haemodynamic compromise "Classic" Triad = flank or back pain, hypotension, and a pulsatile abdominal mass

Answer 640

consider and r/o AAA

Answer 641

1. flank or back pain, 2. hypotension 3. pulsatile abdominal mass

Answer 642

~20% of AAA ruptures will rupture anteriorly into the peritoneal cavity (which are associated with a very poor prognosis) ~80% rupture posteriorly into the retroperitoneal space

Answer 643

In the routine outpatient setting, any suspected AAA should be initially investigated by USS. (AXR is not indicated!!) a follow-up CT scan with contrast is warranted when at threshold diameter of 5.5cm. => This provides more anatomical details in order to determine suitability for endovascular procedures.

Answer 644

Emergency A-E resuscitation => Including 2 large bore cannulae, urgeny bloods (incl. XM) => Any shock should be treated very carefully – “permissive hypotension” Transfer to local vascular unit Patient taken to theatre => Open repair if unstable => If stable, CT angiogram to consider EVAR

Answer 645

Only 50% of ruptured AAAs make it to hospital, and of these patients only 50% will survive the operation.

Answer 646

Raising the BP will dislodge any clot and may precipitate further bleeding, therefore aim to keep the BP ≤100mmHg

Answer 647

AAAs that measure <5.5cm: - Monitored by regular USS/CT - Modification of risk factors – e.g. control of HTN - 75% will eventually require surgery

Answer 648

In a patient who is otherwise fit: - AAAs >5.5 cm - AAAs expanding >1cm/year - Symptomatic In a patient who is unfit: - AAA may be left until 6cm or more prior to repair, due to the significant risk of mortality from an elective repair compared to the risk of mortality if not repaired.

Answer 649

HTN, FHx of rupture, Smokers Females => these patients may have surgery performed at an earlier stage.

Answer 650

Endovascular Aneurysm Repair (EVAR): = Most common surgery, uses femoral arteries to access and stent the aorta under fluoroscopic guidance => Lower mortality rate, Lower post-op morbidity and shorter hospital stay, ITU not required. => Lifelong monitoring is required and re-intervention is not uncommon Open Surgery: - Involves a midline laparotomy or long transverse incision, exposing the aorta, and clamping the aorta proximally and the iliac arteries distally - The aneurysm segment is then removed and replaced with a prosthetic graft These have similar long-term outcomes, but EVAR has better short-term outcomes

Answer 651

ENDOVASCULAR LEAK => an incomplete seal forms around the aneurysm resulting in blood leaking around the graft. often asymptomatic hence regular surveillance (usually USS) is needed. If left untreated, the aneurysm can expand and subsequently rupture. As such, any aneurysm expansion following EVAR warrants investigation for endoleak.

Answer 652

Frequently associated with other aneurysms elsewhere in the body

Answer 653

Usually asymptomatic may present with complications: - Acute limb ischaemia – due to rupture/thrombosis of the aneurysm or due to distal emboli - Chronic limb ischaemia – gradual occlusion of the aneurysm - DVT – if occluding popliteal veins

Answer 654

- USS – to determine the size of the aneurysm - Angiography – prior to surgery to assess distal arterial tree

Answer 655

- Femoral to distal popliteal bypass grafts - Intra-vascular thrombolysis or embolectomy may occur at time of surgery for distal emboli.

Answer 656

= all layers of the arterial wall are involved. Can be Symmetrical/fusiform vs. asymmetrical/saccular

Answer 657

= all layers of the arterial wall are involved. Can be Symmetrical/fusiform vs. asymmetrical/saccular

Answer 658

= the surrounding soft tissues lined by thrombus form the wall of the aneurysm, mainly following trauma. => E.g. femoral artery puncture with inadequate compression.

Answer 659

tunica intima (innermost layer), tunica media (middle layer) tunica adventitia (outermost layer).

Answer 660

= A tear in the intima leads to blood tracking into the arterial media. The arterial media splits, forming a false channel. Most commonly occurs in the aorta

Answer 661

propagates towards the iliac arteries

Answer 662

propagate towards the aortic valve (at the root of the aorta) => Can result in prolapse of the aortic valve, bleeding into the pericardium, and cardiac tamponade

Answer 663

HTN Atherosclerotic disease Connective tissue disorders (Marfan’s / Ehler’s-Danlos) Male gender

Answer 664

External rupture – massive fatal haemorrhage Internal rupture – (rare) blood tracks back into the lumen to produce a double channelled aorta. Blockage of distal main artery branches: - Coronary arteries => MI - Brachiocephalic trunk => unequal arm pulses + central neurological Sx - Renal arteries => anuria/AKI - SMA/IMA => acute mesenteric ischaemia - Iliac arteries => acute lower limb ischaemia Cardiac tamponade

Answer 665

A. TYPE A – involves the ascending aorta and can propagate to the aortic arch and descending aorta; the tear can originate anywhere along this path - i.e. DeBakey Types I and II - ~70% of cases B. TYPE B - does not involve the ascending aorta, occurring in any other part of the aortic arch and descending aorta - i.e. DeBakey Type III - ~30% of cases

Answer 666

I. Type I – originates in the ascending aorta and propagates at least to the aortic arch => Carry the highest mortality II. Type II – confined to the ascending aorta III. Type III – originates distal to the subclavian artery in the descending aorta - IIIa = extends distally to the diaphragm - IIIb = extends beyond the diaphragm into the abdominal aorta

Answer 667

Severe, very sudden onset central chest pain, described as “tearing” => It may radiate down the arm/to the back (mimicking MI) Shock (hypovolaemic / cardiogenic) => Tachycardia, Hypotension Signs of end-organ hypoperfusion => such as reduced urine output, paraplegia, lower limb ischaemia, abdominal pain secondary to ischaemia, or deteriorating conscious level

Answer 668

Bloods: - FBC, U&Es, LFTs, troponin, coagulation; - XM of at least 4 units, - ABG to aid initial assessment. ECG – to exclude any cardiac pathology. CT angiogram confirms diagnosis (Transoesophageal ECHO)

Answer 669

Bloods: - FBC, U&Es, LFTs, troponin, coagulation; - XM of at least 4 units, - ABG to aid initial assessment. ECG – to exclude any cardiac pathology. CT angiogram confirms diagnosis (double lumen seen) (Transoesophageal ECHO)

Answer 670

A-E resuscitation with urgent cardiothoracic advice => Cautious fluid resuscitation – target pressure should be sufficient for cerebral perfusion only Patients managed on ITU Type A: - Patients are considered for surgery if fit enough, due to the risk of tamponade - Surgery is removal of ascending aorta (with or without the arch) and replacement with synthetic graft. - Carries high operative mortality.

Answer 671

A-E resuscitation with urgent cardiothoracic advice => Cautious fluid resuscitation – target pressure should be sufficient for cerebral perfusion only Patients managed on ITU Patients are managed medically unless there are certain complications (rupture, renal, visceral or limb ischaemia, refectory pain, or uncontrollable hypertension) First line Tx = management of HTN with intravenous beta blockers (labetalol) (or calcium channel blockers as second line therapy).

Answer 672

Following initial management, all patients need: - lifelong antihypertensive therapy - surveillance imaging

Answer 673

= the space between the first rib and clavicle, through which the subclavian artery, subclavian vein and brachial plexus pass.

Answer 674

= narrowing of the thoracic outlet causing compression of the neurovascular bundle. Symptoms can be neurological (most common), venous, or arterial.

Answer 675

- Cervical rib - Healed clavicular fracture - Excess scalene muscle development - Hyperextension/repetitive stress injuries

Answer 676

The specific clinical features present will be dependent on neurological, arterial, or venous involvement. Symptoms may also worsen with certain movements – e.g. shoulder abduction or extension. BRACHIAL PLEXUS Sx: - Paraesthesia and/or motor weakness (most often in the C8-T1 distribution) - Wasting of the small muscles of the hand ARTERIAL Sx: - Upper limb claudication if working their hands above their head - Acute limb ischaemia – due to occlusion, distal embolisation or aneurysm. VENOUS Sx: - Swelling of extremities - Can lead to DVT - Can be prominent veins over the shoulder due to collateralisation

Answer 677

Blood Pressure: - Arm BP will be lower in the affected arm, and will vary with posture. Bloods - including FBC and clotting screen Plain CXR for potential bony abnormalities - can show cervical rib or healed clavicular fracture For suspected venous/arterial TOS - Venous/arterial duplex USS - Arteriography can confirm obstruction - Any patient presenting with acute limb ischaemia needs CT angiogram For suspected neurogenic TOS: - Nerve conduction studies

Answer 678

The treatment approach depends upon the cause of TOS and what is being compressed. For nTOS: - Physiotherapy for 6 months => Aiming to improve mobility in the neck and shoulder, strengthen the surrounding muscles, and relax the scalene muscles. - Botox injections can be used to relax the scalene muscles For vTOS: - May need thrombolysis and anti-coagulation, under guidance form the haematology teams - Most cases will need surgical management For aTOS: - Acute limb ischaemia – urgent vascular input - Otherwise, most cases are caused by anatomical abnormalities that can be managed in the elective surgical setting.

Answer 679

= vascular compromise of the bowel. most commonly occurs due to arterial occlusion of the SMA, supplying the small bowel and some of the colon.

Answer 680

Acute = most commonly caused by a blood clot in the main mesenteric artery. Chronic = most commonly caused by thrombosis superimposed on atherosclerosis.

Answer 681

Acute = most commonly caused by a blood clot in the main mesenteric artery. Chronic = most commonly caused by thrombosis superimposed on atherosclerosis.

Answer 682

- Severe post-prandial colic (“gut claudication”) – about 30 min after eating - PR bleeding - Weight loss (eating is painful) - Malabsorption

Answer 683

It is difficult to diagnose, but can be visualised on angiography and treated with angioplasty.

Answer 684

Typically a disease of the elderly (age >60 years). Diminished / absent blood flow leads to bowel wall ischaemia and secondary inflammation. Bacterial contamination may produce superimposed pseudomembranous inflammation. If necrosis develops then ulcerations or perforation can occur

Answer 685

“Ischaemic colitis” - Left sided abdominal pain - Bloody diarrhoea Pyrexia, tachycardia, leucocytosis Can progress to gangrenous colitis, with peritonitis and shock.

Answer 686

Barium enema / AXR => “thumb printing” due to mucosal oedema/haemorrhage Contrast enhanced CT MR angiography = diagnostic

Answer 687

Conservative – most recover with fluids and ABX Percutaneous transluminal angioplasty and stenting for severe cases.

Answer 688

= the narrowing of one or more renal arteries. Causes: - ~90% due to atherosclerosis - 10% due to fibromuscular dysplasia

Answer 689

Resistant HTN Worsening renal function after ACEIs (if bilateral) Oedema (usually legs/feet/ankles; sometimes hands/face) Other signs of reduced renal function Renal bruits on examination

Answer 690

- Renal USS – small affected kidney, doppler showing disturbance in renal flow. - CT/MR angiography can then confirm diagnosis - Renal angiography = gold-standard

Answer 691

Lifestyle changes if due to atherosclerosis: - Exercise, weight loss if necessary, healthy diet. - Smoking cessation Medical regimens: - ACEis with statins & antiplatelets (contraindicated in bilateral disease) Surgical management: - Angioplasty and stenting (thought to be equally as effective as medical Mx) - Endarterectomy – cleaning out plaque from the vessel - Bypass surgery – vein or plastic tube used to connect the kidney to the aorta

Answer 692

A blunt injury = when a blood vessel is crushed or stretched.   A penetrating injury = when a blood vessel is punctured, torn or severed.   Either type of vascular trauma can cause the blood vessel to clot (=> ischaemia), or cause bleeding which can lead to life-threatening haemorrhage

Answer 693

If there is pulsatile external haemorrhage => diagnosis of arterial injury is obvious When blood accumulates in deep tissues the only manifestation may be shock Presence of pulses distal to injury DOES NOT EXCLUDE ARTERIAL INJURY

Answer 694

Must be suspected when patient has 1 or more of the "6 Ps": => Pain, pallor, paralysis, perishingly cold, paraesthesia, pulselessness

Answer 695

A cleanly transected artery will often constrict and retract, limiting blood loss. A longitudinal / badly lacerated vessel cannot limit blood loss and may produce greater blood loss. Mx: - Haemorrhage can normally be arrested by applying pressure to gauze swabs. - If there is significant ischaemia, vascular grafting/repair may be needed. - If the main artery and vein have been severed, the vein will always be repaired first to allow venous drainage before repairing the artery.

Answer 696

- Penetrating trauma = most common - Erosion of aneurysm into a neighbouring vein - Iatrogenic – patients on haemodialysis

Answer 697

= an acquired communication between an artery and vein. There is shunting from the high-pressure arterial side to the low-pressure venous side. => Peripheral venous pressures are increased => Peripheral arterial resistance decreases

Answer 698

Patient’s with non-iatrogenic AVFs may complain of limb heaviness, aggravated with dependency and relieved by elevation. Pain OE – oedema, prominent veins, audible murmur/palpable thrill (can be pulsatile) => Rarely, can be signs of CCF if the communication is very large.

Answer 699

VBG will show higher O2 sats distal to the AVF. Can be consumptive coagulopathies due to changes in blood flow activating the clotting cascade Duplex USS or contrast CT can confirm diagnosis

Answer 700

Most symptomatic AVFs are amenable to surgical or interventional treatment. - Surgical Repair (often surgical bypass) - Endovascular Treatment (balloon +/- stenting)

Answer 701

Medial long (great) saphenous vein – drains to the saphenofemoral junction Lateral short saphenous vein – drains into the popliteal vein => Drains the skin and superficial tissues

Answer 702

- Veins accompanying the major arteries of the lower limb - Drain the muscular compartment

Answer 703

= abnormally dilated and lengthened superficial veins. They can be primary (most common) or secondary. 1. Primary: - Likely to be due to a primary superficial valve defect, with familial elements - There is NO deep venous incompetence. 2. Secondary: - Occur secondary to deep venous incompetence => Previous DVT (although veins recanalize, their valves remain incompetent) => Raised systemic venous pressure (due to compression, A-V fistula, or severe tricuspid valve incompetence

Answer 704

prolonged standing, obesity, pregnancy, FHx

Answer 705

- Most patients are most affected by the unsightly appearance - Can cause tiredness, aching or throbbing of the legs. - Oedema of the ankles (particularly on standing for long periods) - Itching and nocturnal cramps - Signs of deep venous insufficiency (haemosiderosis, venous eczema, lipodermatosclerosis)

Answer 706

= a dilatation of the saphenous vein at the saphenofemoral junction in the groin. As it displays a cough impulse, it is commonly mistaken for a femoral hernia; => Suspicion should be raised in any suspected femoral hernia if the patient has concurrent varicosities present in the rest of the limb. [Ix] These can be best identified via duplex ultrasound [Mx] is via high saphenous ligation.

Answer 707

Occurs when the valves of the deep venous system are incompetent. =>The calf pump can no longer efficiently return blood to the thoracic cavity. Primary cause = congenital absence of valves Secondary cause = DVT causing vascular damage or AVF raising venous pressure

Answer 708

Lower limb aching pain / discomfort Oedema of lower leg Superficial varicose veins (raised central pressure causes perforator vein incompetence) Haemosiderin deposition in gaiter area Venous eczema (particularly over pigmented area), causing pruritis Atrophie blanche Lipodermatosclerosis (s.c. tissue replaced by thick fibrous tissue, giving an inverted champagne bottle appearance) Ulceration

Answer 709

Hand-held Doppler: - Can identify reflux at saphenofemoral/ saphenopopliteal junctions. Duplex USS = gold-standard - Can diagnose valve at the great/short saphenous veins and any perforators, as well as large vein occlusion. Venography: - Can detect deep vein occlusion and perforating vein reflux

Answer 710

- Tourniquet placed around the ankle to occlude superficial veins, and contrast is injected into the foot. - Fluoroscopy then used to see the progress through the deep system

Answer 711

1. Symptomatic primary or recurrent varicose veins 2. Lower‑limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufficiency 3. Superficial vein thrombosis (characterised by the appearance of hard, painful veins) with suspected venous incompetence 4. A venous leg ulcer (a break in the skin below the knee that has not healed within 2 weeks)

Answer 712

Lifestyle advice: - Avoid prolonged standing - Exercise regularly (promotes calf muscle function) - Weight loss Graded compression stockings: - For minor varicosities, the elderly/unfit and for pregnancy - Check ABPI before use - Any venous ulceration from deep venous incompetence generally requires four-layer bandaging

Answer 713

Endothermal Ablation: - Involves heating the vein from inside (via radiofrequency or laser catheters), causing irreversible damage to the vein which closes it off. Sclerotherapy: - For cosmetically undesirable superficial varicosities - Chemical sclerosing agent (foam) is injected into the varicose vein, causing an inflammatory response that closes off the vein. and the vein is kept compressed with bandaging for two weeks to allow fibrosis to take place. Surgical Ligation - Remains the gold-standard treatment - Making an incision in the groin (or popliteal fossa) and identifying the responsible, refluxing vein, before tying it off and stripping it away.

Answer 714

Worsen over time: - Even many patients who have treated varicose veins often require re-intervention surgery. Haemorrhage – caused by minor trauma to a dilated vein Phlebitis – can occur spontaneously, or following foam sclerotherapy => Veins become hard (thrombosis) and tender, with overlying erythema

Answer 715

Progressive occlusion of the arteries Causes: 1. Atherosclerosis (= most common) 2. Fibromuscular dysplasia (non-inflammatory artery wall thickening) 3. Vasculitis (inflammation) 4. Buerger’s Disease (acute inflammation and thrombosis of lower limb veins, common in young heavy smoker)

Answer 716

0.9 – 1.0

Answer 717

0.6 – 0.9

Answer 718

0.3 – 0.6

Answer 719

indicates calcified blood vessels or an incorrect calculation

Answer 720

= leg pain (aching/ cramping/ tired feeling) upon exertion due to narrowing of the arteries not allowing enough blood flow to support the oxygen demand of the tissues (“angina of the legs”). At rest, the collateral system is able to meet the oxygen requirement of the muscles.

Answer 721

Spinal stenosis – symptoms are similar, but pain is relieved by sitting down or flexing spine rather than standing still. Venous claudication – pain comes on gradually from the moment walking starts, relieved by leg elevation. Arthritis Peripheral neuropathy Popliteal artery entrapment

Answer 722

Absent pulses Cold, pale legs Atrophic, hairless & shiny skin Buerger’s angle <20 degrees Arterial ulcers

Answer 723

Ischaemic “cramping” pain on walking, relieved by rest Pain reproducible at a similar level – claudication distance Most commonly in the calf (femoral disease) Pain in thigh/buttock suggests ileal disease, which is often bilateral. => Ask about penile function (Leriche Syndrome)

Answer 724

Indicative of critical lower limb ischaemia. Classically occurs at night, in the forefoot => Due to decreased effects of gravity and decreased BP Pain wakes patient from sleep Often gain relief by swinging leg over the side of the bed, or walking on a cold floor. There will be a history of intermittent claudication and signs of arterial insufficiency in the leg. At this stage, ulcers are likely to form from minor injuries (as healing is impaired).

Answer 725

Bloods – FBC (r/o anaemia), HbA1c, lipids Vascular examination BP ABPI = most important initial investigation CT/MR angiography

Answer 726

depends on ABPI results and level of symptoms

Answer 727

Progression from intermittent claudication to critical ischaemia is unlikely => conservative measures are used (progression more likely in diabetics and those with claudication distance <50m, so more aggressive treatment may be considered in these patients). Conservative measures: 1. Lifestyle measures – stop smoking, exercise to the point of claudication to improve collaterals, weight loss 2. Raising the heel of shoes (decrease calf work) 3. Foot care to prevent minor trauma and ulceration 4. Optimisation of BP (but avoid beta-blockers) and diabetes 5. Start on antiplatelet and statin

Answer 728

Referral to vascular surgery Revascularisation: 1. Percutaneous Transluminal Angioplasty +/- stenting 2. Surgical reconstruction Amputation - Relieve pain and prevent death from sepsis - Level of amputation must be high enough to ensure healing (but above knee amputation has worse outcome than below knee)

Answer 729

Unlike arterial disease, the pain is unlikely to be relieved by swinging the foot over the bed the foot will be red and warm, with strong pulses.

Answer 730

can lead to the foot being severely ischaemic but PAINLESS. Diabetics more likely to present with ulceration of critically ischaemic limb, which can rapidly progress to gangrene.

Answer 731

DRY – just dead tissue, no infection (no ABX required), can self-amputate WET – dead tissue infected with bacteria (ABX required), gangrenous part needs to be removed. It presents in the toes first, progressing proximally to line where there is adequate oxygenation. Characteristically, it is initially blue-purple in colour, with progressive blacking of tissues and numbness.

Answer 732

Embolus Thrombus Trauma (including during angioplasty)

Answer 733

1. Endothelial Dysfunction – trauma, inflammation, atheroma 2. Changes in blood flow – stasis or slow flow 3. Changes in blood coagulability

Answer 734

EMBOLUS Sudden onset Very severe Sx due to lack of collaterals Normally identifiable cause (e.g. AF, AAA) Previously normal pulses No history of arterial disease THROMBUS Insidious onset Less severe Sx as advanced collaterals No obvious source Long-standing decreased pulses bilaterally Previous history of intermittent claudication, stroke, MI, etc.

Answer 735

1. Pain 2. Pallor 3. Pulselessness 4. Perishingly cold 5. Paraesthesia 6. Paralysis 5&6 in late-stage disease only, indicate a threatened limb

Answer 736

6 Ps (particularly paraesthesia and paralysis) Pain on passive movement or squeezing the calf are also signs of a threatened limb

Answer 737

Fixed staining (colour changes that are non-blanching) of the leg Rigid muscles

Answer 738

maximum of 6 hours

Answer 739

1. A-E Resuscitation 2. IV heparin as soon as the diagnosis is made. - Prevent propagation of the clot 3. Assessment of the limb - ?thrombolysis if blockage appears to be resolving - ?urgent surgery if no apparent blood supply - Amputation if leg not thought to be viable 4. Urgent CT angiogram - Can help differentiate between thrombotic/embolic causes and direct management 5. Mx of embolus: - Open embolectomy or intra-arterial thrombolysis; investigate underlying cause. 6. Mx of thrombus: - thrombolysis and angioplasty or bypass surgery or intra-arterial thrombolysis to treat underlying cause

Answer 740

= inflammation and oxidative damage when blood flow is restored after long period of anoxia, can lead to oedema and compartment syndrome.

Answer 741

To relieve ischaemic rest pain, consider for end of life care Dangerous leg => e.g. full of pus, full of dead muscle Oncological => e.g. sarcoma Useless => e.g. severely mangled following trauma, congenital defects

Answer 742

Alongside the organ of origin – e.g. paracolic, parapancreatic Pelvic – e.g. post-pelvic sepsis (appendicitis) Subphrenic – e.g. post-GI perforation

Answer 743

malaise, anorexia, SWINGING PYREXIA, tachycardia, possibly a mass.

Answer 744

Diagnosis is generally with CT abdo/pelvis

Answer 745

IV empirical ABX Radiologically-guided (CT/USS) drainage where possible. Surgical drainage is a last-line measure.

Answer 746

Drainage: - Often performed under GA, and strong analgesia is required. - The point of maximum fluctuance is incised, and then blunt probing ensures that all loculi are drained. Small abscesses need only a dry dressing. Deeper abscesses required frequent packing with antiseptic gauze/use of a corrugated drain to keep them open until they have filled with granulation tissue.

Answer 747

GENERAL Age, malnutrition, immunosuppression, malignancy, obesity, hypoxia, anaemia LOCAL FACTORS Type of surgery (clean vs. contaminated), length of procedure, residual local malignancy, foreign body insertion, ischaemia MICROBIOLOGICAL FACTORS Lack of ABX prophylaxis, virulence of organism

Answer 748

Used for: - Contaminated/dirty surgeries, - Placement of foreign materials - Immunosuppression, - Previous foreign body implants, - Heart valve disease, - peripheral vascular disease Dose and timing factors are important, with the highest tissue concentration required at the moment of tissue contamination. => This normally means IV administration at the moment of incision. Often 2 further doses are given at appropriate times to complete a 24-hour course.

Answer 749

Caused by clostridium perfringens found in soil/faeces Can arise from trivial injury, often in immunosuppressed patients There is initially gas in the tissues and skeletal muscles (crepitus), with oedema and spreading gangrene plus systemic upset. Patients may need resuscitation Tx = aggressive debridement and IV penicillin + metronidazole.

Answer 750

(necrotising fasciitis): Aerobes and synergistic anaerobes infect an initial wound/surgical site. Leads to severe wound pain and gas in the tissues. There may be excessive subdermal gangrene Tx = debridement, ABX and systemic support.

Answer 751

MILD pyrexia is common post-operatively as a response to tissue injury and stress. When called to review the patient for infection vs. post-op fever: 1. Cut – inspect wound for superficial infection/haematoma 2. Collection 3. Cannula – any thrombophlebitis/infection 4. Chest – exclude infection, infarction, acute heart failure. 5. Central line - ?infection 6. Catheter – urine output, ?infection 7. Calves - ?DVT

Answer 752

1. Signs of reduced perfusion • Prolonged capillary refill time • Reduced urine output • Altered mental state. 2. Low BP • Usually by at least 40mmHg 3. Raised lactate • Anaerobic respiration produces lactate, which accumulates in the blood, causing a hyperlactataemia.

Answer 753

Papillary Carcinoma Follicular Carcinoma Medullary Carcinoma Anaplastic Carcinoma

Answer 754

~70% of malignant carcinomas Presents most commonly age 40-50 RFs – previous neck radiation Spreads locally and metastasises to local nodes => Can go to bone/lung, but this is rare Tx: - Cured by surgical resection, including metastases - +/- Neck LN dissection if nodal involvement - +/- Radio-iodine therapy as an adjunct Prognosis is good

Answer 755

20% of cases of malignant carcinoma Metastasises via the bloodstream, classically to the bone Tx: - As per papillary ca. Prognosis is good

Answer 756

5% of cases of malignant carcinoma Generally affects older adults Can affect children/young adults as part of MEN syndromes (MEN IIa/IIb) Arise from parafollicular / “C” cells => Secrete calcitonin, so plasma calcitonin levels are raised. => Calcitonin levels can be measured following treatment for monitoring Tx: - Total thyroidectomy +/- lymph nodes if involved +/- radiotherapy if haven't been able to get it out. Prognosis is poor

Answer 757

<5% of cases of malignant carcinoma Occurs in elderly populations Extremely locally aggressive , with rapid and extensive local invasion Complications of tracheal/ SVC obstruction Total thyroidectomy often not possible External radiotherapy may give palliation Prognosis is poor

Answer 758

Most present as asymptomatic thyroid nodules or lymph nodes There may be hoarseness/ dysphagia / weight loss Thyroid dysfunction is rare

Answer 759

History & examination USS Technetium scans: - “Hot” suggests adenoma - “Cold” may suggest malignancy Fine needle aspiration and cytology

Answer 760

Median Sternotomy – most common approach for heart / aortic arch operations Anterolateral Thoracotomy – access to the right side of the heart. Posterolateral Thoracotomy – access to distal aortic arch and descending thoracic aorta. Bilateral transverse thoracotomy (clam shell) – popular for double lung transplants or heart-lung transplants

Answer 761

Open heart surgery – any surgery requiring cardio-pulmonary bypass Closed heart surgery – does not require a bypass

Answer 762

Takes over the function of the heart and lungs, allowing a motionless blood-free field for operation. The ascending aorta is clamped and cannulated, and a venous line inserted into the right atrium to drain venous blood. The system involves a heat exchanger to regulate temperature, an oxygenator, an arterial pump and a filter. There is no coronary blood supply, so the potential for ischaemic damage is minimised by arresting the heart in a high potassium (cardioplegic) solution, and also cooling the myocardium to between 4 and 12 degrees.

Answer 763

Main complications are due to activation of the clotting cascade within the bypass machine, which consumes clotting factors and platelets. This is prevented with high-dose systemic heparin before cannulation, This is reversed after the operation with protamine sulfate (blood products may also be needed to reverse this).

Answer 764

Performed through median sternotomy incision and cardio-pulmonary bypass. The left internal mammary artery is most commonly used as a conduit, harvested from the chest wall. => Enlarges in response to demand, resistant to atheroma formation. Saphenous vein harvest was previously used and continues to be used for secondary targets, however results are less good than IMA grafts.

Answer 765

CABG provides better symptomatic relief and requires fewer late re-interventions than PCI in managing coronary artery disease

Answer 766

• MI • Bleeding • Stroke • Arrythmias • Tamponade • Aortic dissection • Respiratory / systemic complications

Answer 767

e.g. ball-in-cage or bileaflet valves Durable, but thrombogenic (this require anticoagulation with warfarin) Will be able to hear the valve “click” from the end of the bed

Answer 768

Homographs (human) or Xenographs (generally from pigs Anticoagulation is not required, but more prone to degenerative failure. Homographs are more resistant to degeneration, so are preferred in younger patients to avoid long-term anticoagulation.

Answer 769

Infection of a prosthetic valve is rare but devastating risk is lowest with homograft valves.

Answer 770

Splenic trauma Hypersplenism Autoimmune haemolysis (ITP, congenital haemolytic anaemias).

Answer 771

Main issue = increased risk of infection mainly by encapsulated organisms (e.g. strep pneumoniae), as the spleen usually contains a large number of macrophages.

Answer 772

Mobilise soon after operation due to transient increase in platelets. => LMWH whilst in hospital => Aspirin advised in the short-term Immunise according to local regimens => Pneumococcal 2 weeks prior to surgery, or ASAP following emergency surgery => Hib, Men C and annual flu vaccinations Lifelong penicillin V (erythromycin if allergic) => Penicillin V does not protect against haemophilus infections, however. Advice to carry alert card and seek immediate medical advice if signs of infection. If travelling abroad, warn of severe malaria risks. ((This advice also applies to hyposplenic patients – e.g. sickle cell ))

Answer 773

= Spontaneous rupture of the oesophagus that occurs as a result of repeated episodes of vomiting. PRESENTATION: - sudden onset of severe chest pain that may complicate severe vomiting. - Subcutaneous emphysema may be observed on the chest wall.

Answer 774

Diagnosis is CT contrast swallow. Treatment is with thoracotomy and lavage If less than 12 hours after onset then primary repair is usually feasible

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