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Phase 4 > Surgery > Flashcards

Surgery Flashcards

1
Q

List the types of oesophageal cancer and associated risk factors

A
  • Squamous cell carcinoma
  • Adenocarcinoma

Risk factors: smoking, alcohol, hot beverages, GORD, Barrett’s, obesity, achalasia

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2
Q

Describe the signs and symptoms associated with oesophageal cancer

A
  • Progressive dysphagia (solids then liquids)
  • Weight loss
  • Anaemia
  • Less common – odynophagia, cough, hoarseness, haematemesis, melaena
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3
Q

List differential diagnoses for dysphagia

A

Within lumen
> Food bolus
> Foreign body
> Oesophageal candidiasis

Within wall
> Peptic/caustic stricture
> Schatzki ring
> Pharyngeal pouch
> Achalasia / oesophageal dysmotility
> Oesophageal web
> Oesophageal cancer

Outside oesophagus
> Mediastinal mass
> Lymphoma
> Thoracic aortic aneurysm
> Globus hystericus

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4
Q

Describe the treatment of oesophageal cancer

A

Curative intent – early cancers
> endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD)

> Endoscopic mucosal therapy – Barrett’s oesophagus with dysplasia

Tumours beyond mucosa +/- LN
> Neoadjuvant chemoradiation

> Surgery
> Ivor-Lewis oesophagectomy OR three stage (McKeown) operation

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5
Q

Describe the anatomy, blood supply, nerve supply and lymphatic drainage of the stomach

A

4 sections: cardia, fundus, body, pylorus

Blood supply
> Lesser curvature: left gastric artery (coeliac trunk branch)
> Greater curvature: left & right gastroepiploic arteries
> Fundus: short fastric artery (splenic branch)
> Pylorus: right gastric artery (common hepatic branch)

Venous drainage matches arterial supply

Nerve supply
> Parasympathetic: vagus nerve
> Sympathetic nerve: T6-T9 spinal cord segments

Lymphatics
> Lymph fluid drains into gastric and gastroomental lymph nodes found at curvatures

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6
Q

List risk factors for gastric cancer

A

Diet
> Processed meat
> Low fruit/veg intake
> High salt intake
> Nitrates / nitrites

Obesity

Smoking

H. pylori

Age > 50

Ethnicity – Asian and Pacific Islanders

Male gender

Heavy alcohol use

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7
Q

Describe the signs and symptoms of gastric cancer

A

Weight loss

Abdo pain

Nausea

Dysphagia

Melaena

Early satiety

Ulcer type pain

Occult GI bleeding more common than overt bleeding

Signs

  • Palpable abdominal mass
  • Palpable lymph node
    > Left supraclavicular node (Virchow’s)
    > Periumbilical (Sister Mary Joseph)
  • Ascites
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8
Q

Describe the different types of gastric cancer and their routes of spread

A

Primary

> Adenocarcinoma (94%)
> Tubular
> Papillary
> Mucinous
> Signet ring

> Lymphoma (4%)

> GI stromal tumour (GIST)
> Type of sarcoma, develops in the connective tissue

> Secondary
> Direct invasion from nearby organs

Routes of spread

> Haematogenous

> Peritoneal seeding
> Krukenberg tumours – ovarian metastasis
> Blumer’s shelf – metastasis in pouch of Douglas

> Lymphatic spread

> Direct – to adjacent organs

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9
Q

Describe the pathological classification of gastric cancer

A

Lauren classification

> Intestinal type
> Due to H. pylori
> Distal stomach
> Ulcerated growth
> Declining due to treatment of H. pylori

> Diffuse type
> Mainly affects cardia
> Younger age, worse prognosis
> No pre-cancerous lesions

> > Linitis plastica
> Diffuse type gastric cancer
> Tumour often infiltrates the submucosa and muscularis propria
> Superficial biopsies may be falsely negative
> “Leather bottle stomach”

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10
Q

Describe the investigations used in gastric cancer

A

Bloods

FBC – microcytic anaemia

LFTS – if deranged, possible mets

No reliable tumour markers but CEA, Ca125 and CA19-9 may be raised

Upper GI endoscopy

CT thorax, abdomen and pelvis – assess for metastatic disease

Staging laparoscopy to look for peritoneal metastases if considering resection

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11
Q

Describe the treatment of gastric cancer

A

> Peri-operative chemotherapy

> Proximal cancers – total gastrectomy

> Distal cancers (antrum or pylorus) - subtotal gastrectomy

> Very early T1 gastric cancers – endoscopic mucosal resection (EMR)

Advanced disease – palliative therapy
> Nutrition – enteral feed, build up drinks
> Treatment of infection
> Maintain lumen patency (stenting or endoscopic laser treatment)
> Palliative surgery (gastro-jejunostomy) to by-pass obstruction

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12
Q

List complications of total gastrectomy

A

Anastomotic leak

Dumping syndrome
> Sudden and large passage of hypertonic gastric contents into small intestine
> Results in an intraluminal fluid shift and subsequent intestinal distention
> Symptoms of nausea, vomiting, diarrhoea, hypovolaemia

Vitamin B12 deficiency – loss of secretion of intrinsic factor

MI / stroke / respiratory failure / DVT / PE

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13
Q

Describe the characteristics of Helicobacter pylori and its treatment

A

Gram negative helical bacterium produces urease enzyme

Breaks down urea into CO2 and ammonia

Ammonia neutralises stomach acid creating alkaline microenvironment

Sets off cycle of repeated damage to epithelial cells, leading to inflammation, ulceration and ultimately gastric neoplasia

Eradication – triple therapy, 1 PPI + 2 antibiotics
> Omeprazole 20mg BD (PPI)
> Clarithromycin 500mg BD
> Amoxicillin 1g BD

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14
Q

Describe the anatomy of the pancreas, including blood supply

A
  • Head
  • Neck
  • Body
  • Uncinate process
  • Tail

Blood supply
- Gastroduodenal artery
- Superior & inferior pancreaticoduodenal artery
- Splenic artery - greater pancreatic artery

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14
Q

Describe the functions of the pancreas

A

Endocrine - islets of Langerhans
> Alpha cells: glucagon
> Beta cells: insulin + amylin (slows gastric emptying)
> Delta cells - somatostatin (regulates alpha & beta)
> Gamma cells: pancreatic polypeptide
> Epsilon cells: ghrelin (appetite)

Exocrine - acinar & duct tissue
- Proteases - trypsinogen and chymotrypsinogen
- Amylase: starch & maltose
- Lipase
- Others: elastase, ribonuclease…

Regulated by vagal innervation

> Acidic chime entering duodenum encourages S cells to release secretin which release alkaline pancreatic juices

> Fatty acids in duodenum release cholecystokinin, leads to secretion of digestive enzymes and bile from gallbladder

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15
Q

List risk factors for pancreatic cancer

A

Smoking, diabetes, high BMI, alcohol excess

Chronic and hereditary pancreatitis

Genetic familial syndromes e.g. Von-Hippel Lindau, MEN1

Medical conditions: peptic ulcer disease, IBD

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16
Q

Describe the signs and symptoms of pancreatic cancer

A

Obstructive jaundice (often painless) or pain radiating through to back

Cachexia, anorexia and unexplained weight loss

Pale stools and dark urine

loss of endocrine function - type 3c diabetes

Nausea / vomiting

Palpable gallbladder (Courvoisier’s sign)

Acute pancreatitis

Haematemesis, melaena, IDA

investigations
- high resolution CT scan
- ultrasound
- imaging may demonstrate double duct sign
> simultaneous dilatation of the common bile and pancreatic ducts

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17
Q

List types of pancreatic cancer

A

Solid non-endocrine
> Pancreatic ductal adenocarcinoma (PDAC)
> Adenosquamous
> Acinar cell
> Giant cell
> Pancreatoblastoma

Cystic non-endocrine
> Serous cystic
> Mucinous cystic
> Solid and cystic papillary
> Acinar cell cystadenocarcinoma
> IPMN – intraductal papillary mucinous neoplasm – malignant transformation possible

Neuroendocrine – functional v non-functional

> Gastrinoma - Zollinger-Ellison syndrome
> Increased levels of gastrin and stomach acid leading to ulcers and diarrhoea

> Insulinoma
> Slow growing, can present with hypoglycaemic coma

> Glucagonoma - High BMs

> VIPoma - Vener-Morrison syndrome

> Somatostatinoma

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18
Q

Describe the treatment for pancreatic cancers

A

Head of pancreas cancer
> Whipple’s procedure (pancreaticoduodenectomy) +/- pylorus sparing

Body / tail - distal pancreatectomy / total pancreatectomy

Neoadjuvant / adjuvant chemotherapy

Not for resection
> Palliative intent
> Relieve obstruction via biliary stent or duodenal stent if GOO
> Palliative chemotherapy

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18
Q

Describe Familial Adenomatous Polyposis (FAP)

A

APC gene (chromosome 5), AD inheritance

Gardner’s syndrome (subtype of FAP)

Numerous (>100) polyps

Almost 100% risk by age 40

Total colectomy performed in mid 20s

Still require endoscopic surveillance

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18
Q

List risk factors for CRC

A

Dietary – low fibre, high animal fat & red meat

Excess bile salts

Increasing age: majority >50 years age

Previous colon cancers or previous colorectal adenomas

Family history

IBD (UC > Crohn’s)

Familial conditions: FAP, HNPCC, juvenile polyps

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19
Q

Describe Lynch syndrome

A

Predominantly right-sided lesions

AD inheritance

Also increases risk of endometrial, breast, prostate and gastric cancer

most common inherited condition for CRC

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20
Q

Describe the adenoma-carcinoma sequence

A

Adenoma – benign neoplasm of large bowel glandular epithelium

Adenomas undergo dysplastic change to become carcinomas

Majority left-sided lesions

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21
Q

Describe the presentation of CRC

A

Change in bowel habit
> Bloods / mucus PR
> Lower abdo pain
> LBO / perforation
> Rectal pain / tenesmus
> Fistulate to adjacent structures
> Iron deficiency anaemia
> Weight loss
> Mass in RIF
> SBO or appendicitis in caecal lesions

30% present as an emergency
> Obstruction
> Perforation

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22
Q

How is the severity of UC classified?

A

Truelove and Witts Criteria

Moderate: 4-8 stool a day

Severe: 8 stools a day, may have fever or night sweats

Fulminant
>10 stools a day
Abdo pain, fever
Hypotension, tachycardia
Low Hb
Increased WCC &CRP, lowered albumin

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23
Q

Describe Duke’s classification for CRC

A

A – limited to bowel mucosa

B – infiltrating through muscle wall

C – local lymph node involvement

D – distant spread (lung, liver, bone)

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24
Q

Describe the treatment of UC

A

inducing remission

  • Mild acute UC
    > topical (rectal) mesalazine (aminosalicylate)
  • moderate acute UC
    > topical (rectal) + oral mesalazine
    > Prednisolone
  • Severe acute UC
    > IV steroids e.g. hydrocortisone
    > IV ciclosporin if steroids contraindicated
    > if no improvement after 72h
    » Infliximab
    » Surgery

maintaining remission
- after mild/moderate flare: topical mesalazine OR topical + oral mesalazine

  • following a severe relapse or if >=2 exacerbations in the past year: oral azathioprine or oral mercaptopurine
  • Maintaining remission
    > Aminosalicylate, azathioprine or mercaptopurine
  • Predfoam enemas for toxic megacolon
  • Total panproctocolectomy is curative - patient will have a permanent ileostomy or an ileo-anal anastomosis (J-pouch)
    > sub-total colectomy in acute flare due to risk of infection
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25
Q

List investigations for CRC

A
  • Colonoscopy and biopsy
  • Staging CT CAP
  • Bloods, stool qFIT
  • ECG - exclude ischaemic bowel from AF
  • CEA marker - carcinoembryonic antigen
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26
Q

Describe the management of CRC

A
  • Surgical resection
  • Adjuvant chemoradiotherapy
  • Palliative stenting for inoperable lesions; perform bypass surgery or colostomy to avoid obstruction
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27
Q

Which patients should be investigated for CRC?

A

Patients >50 with >6 week history of
- Change in bowel habit
- Rectal bleeding
- IDA

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28
Q

Describe the symptoms of anal cancer

A

Can be painful – constant pain suggests invasion into sphincter / sidewall

Blood and mucus on wiping

Tenesmus

Red flags – weight loss, anorexia, groin nodes

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29
Q

Name the most common type of anal cancer and its risk factors

A

Most commonly SSC, less commonly adenocarcinoma

Risk factors – HPV / anogenital warts or dysplasia / immunosuppression

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30
Q

List risks of blood transfusions

A

Transfusion reactions
> ABO & rhesus incompatible blood
> Unanticipated immunological reactions to correctly crossmatched blood

Transfusion transmitted infections

Poorer outcomes in surgical patients who are transfused

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31
Q

List complications of massive transfusion

A

Impaired oxygen delivery to tissues

Metabolic acidosis / hypocalcaemia

Coagulopathy – dilutional / consumptive

Hypothermia

Hyperkalaemia

Fluid overload

Transfusion related acute lung injury (TRALI)

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32
Q

List causes of perforated viscus

A

Upper GI (most common)
> DU/GU, gastric cancer, gallbladder, iatrogenic

Colonic (less common)
> CRC, diverticulum, stercoral, appendicitis, colitis

Small bowel (least common)
> Meckel’s diverticulum, ischaemia, Crohn’s, lymphoma

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33
Q

List risk factors for peptic ulcer disease

A

Infection – H. pylori

Neoplasia – gastric carcinoma

Vascular – inflammatory / autoimmune

Trauma – stab wounds

Iatrogenic – ERCP or OGD

Endocrine – Zollinger-Ellison syndrome: excessive gastrin

Drugs – NSAID use

Chemical – caustic substances/batteries

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34
Q

Define stercoral colitis

A

Stercoral colitis is an inflammatory colitis related to increased intraluminal pressure from impacted faecal material in the colon

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35
Q

Describe the management of a perforated ulcer

A

IV antibiotics + IV PPI

Perforated duodenal ulcer - oversew and omental patch

Gatric ulcer perforation - same or partial gastrectomy

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36
Q

Describe the clinical presentation of a small bowel obstruction

A

Faeculent vomiting

Absolute constipation

Colicky abdominal pain

Distended abdo with tinkling bowel sounds (BS)

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37
Q

List causes of small bowel obstruction

A

Intraluminal
> Foreign bodies
> Gallstones
> Meconium

Intramural
> Tumours
> Crohn’s – inflammatory strictures

Extrinsic
> Adhesions
> Hernias
> Cancer

Less common: gallstone ileus, intussusception, volvulus

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38
Q

Describe the pathophysiology of small bowel obstruction

A

Gas and fluid accumulate proximal to the site of the obstruction

Intestinal activity increases to overcome the obstruction > colicky pain

Ongoing gas and fluid accumulation > bowel distends > intraluminal pressure rises

Intestinal motility is reduced with fewer contractions

Intramural pressure becomes high, intestinal microvascular perfusion is impaired leading to intestinal ischaemia > necrosis

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39
Q

List investigations used in SBO

A

History and examination

Bloods

AXR +/- CT A/P
> AXR supine will show dilated small bowel loops >3cm, erect AXR will show air-fluid level

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40
Q

Describe the management of SBO

A

Drip and suck
> Pass NG tube, give IV fluids

> NG tube decompresses small bowel by draining content upwards

> IV fluids used to catch up with losses

Monitor UO – intake/output chart

Theatre after 48h

Trial of gastrografin if unsuccessful

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41
Q

Describe a sigmoid volvulus and AXR findings

A

Bowel twists on its mesentery and obstructs

Causes massive blockage at location and upstream

AXR:
> Coffee bean sign
> Points to LUQ
> Loop arising from LIF twists
> Dilated proximal large bowel + small bowel

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42
Q

List risk factors for volvulus

A

Common in patients with

Reduced mobility

Psychotropic medications, opiates, antidepressants

Chronic laxatives

Parkinson’s

Schizophrenia

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43
Q

Describe the management of sigmoid volvulus

A

Fluid and electrolyte replacement

Decompression using flexible sigmoidoscopy

Surgery if ischaemia or elective sigmoid colectomy for recurrent sigmoid volvulus.

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44
Q

Describe a caecal volvulus

A

Location is variable

Distended caecum, remainder of colon collapses

Obstruction is where volvulus is

Small bowel can be dilated depending on ileocaecal valve

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45
Q

Describe the presentation of LBO and list causes

A

Clinical presentation
> Absolute constipation and distension
+/- vomiting (depending on whether ileocaecal valve is open or closed)

Causes
> Stricture
> Malignant (CRC)
> Benign (diverticula, ischaemia, IBD)
> External compression; gynaecological malignancy
> Volvulus
> Adhesions

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46
Q

Describe the management of LBO

A
  • IV fluids + NG tube
  • Surgery
    > If volvulus: flexible sigmoidoscopy decompression +/- flatus tube
    > Laparotomy (caecal volvulus)
    > Defunctioning colostomy / ileostomy
    > Colonic stent

Closed-loop obstruction (competent ileocaecal valve not relieving pressure) - SURGICAL EMERGENCY

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47
Q

Describe the risk factors and presentation of ischaemic gut

A

Risk factors - Elderly / vasculopath / AF

  • Small bowel
    > Central abdominal pain, colicky then constant, pain out of keeping with abdominal findings
    > Vomiting (possible altered blood)
  • Colon - ischaemic colitis
    Colitis
    > LIF pain
    > Diarrhoea (may be bloody)
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48
Q

Describe investigations and management of ischaemic colitis

A

Initial investigations
> Very high WCC and CRP
> May have lactic acidosis on ABG
> AXR may look abnormal/obstructed

Management
> Initial resus and IV antibiotics
> Small bowel - laparotomy

> > Pan-ischaemia is fatal and non-resectable

> > Segmental ischaemic – resect

Colon
> Conservative treatment
> If perforates or deteriorating patient may need Hartmanns/colectomy

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49
Q

Describe the clinical presentation of appendicitis

A

Periumbilical pain migrates to RIF with guarding, rigidity, rebound tenderness - Max tender over McBurney’s point, 2/3 of the way along line between umbilicus and ASIS

Nausea and vomiting

Anorexia (common feature especially children)

Flatulence, bowel irregularity, diarrhoea

Pain on walking / speed bumps / potholes

Rovsing’s sign – pain in RIF when LIF is palpated

Psoas stretch sign

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50
Q

What is Valentino’s syndrome?

A

Perforated peptic ulcer

Chemical fluid from ulcer streams along right paracolic gutter to RIF

Causes peritoneal irritation and consequent chemical appendicitis

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51
Q

Describe the management of appendicitis

A

Young man – convincing clinically, proceed to lap/open appendicectomy

Young woman – HCG to exclude ectopic, pelvis USS to exclude ovarian pathology, proceed to diagnostic lap +/- appendicectomy

Older man/woman - CT A/P to exclude malignancy and confirm appendicitis

IV Abx in complicated presentations only

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52
Q

Define diverticula

A

Diverticula are acquired outpouchings of mucosa and submucosa, predominantly sigmoid colon

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53
Q

Describe the clinical presentation of diverticulitis

A

diverticula are outpouchings of the colonic mucosa through the muscular wall of the colon

the usual site is between the taenia coli where vessels pierce the muscle to supply the mucosa

  • LIF pain (except Asian, more likely RIF pain)
  • Fever
  • Change in bowel habit
  • Nausea, vomiting
  • Urinary symptoms
  • PR bleeding
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54
Q

List risk factors for diverticular disease

A

Low fibre

High fat

Red meat

Physical inactivity

Current smokers

Drugs – NSAIDs, steroids, opiates

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55
Q

List acute and chronic complications of diverticular disease

A

Acute
> Abscess, perforation, haemorrhage
> Perforation leads to generalised peritonitis, distended abdomen, diffuse tenderness/guarding

Chronic
> Stricture

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56
Q

Describe the management of diverticulitis

A

Initial management – IV antibiotics, fluids, analgesia

Non-improving patients or those with complications require intervention e.g. drainage of abscess, colonic resection if perforation or obstruction

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57
Q

Describe the composition of bile

A

Bilirubin - pigment - breakdown of haem products

Cholesterol - excreted in bile, requires lecithin and bile salts to solubilise

Bile salts - cholic & chenodeoxycholic acid conjugated to taurine and glycine; fat emulsifiers

Lecithin - fat emulsifier

Inorganic salts - NaCl, NaHCO3 - neutralisation of gastric acid

Water

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58
Q

Describe the pathophysiology of gallstones

A

Mixed stones
> Cholesterol supersaturation
> Gallbladder function (emptying/absorption)
> Reduced bile acid concentration (gut bugs, ileal resection/disease)

Pigment stones
> Accumulation of bilirubin e.g. due to haemolytic anaemia
> Bile stasis
> Biliary tract colonisation (deconjugation of bilirubin diglucuronide)
> Foreign body (stents, parasites)

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59
Q

List risk factors for gallstones

A

4 Fs - Female (oestrogen drives stone formation), fair, fertile, forties

Genetics

Low calorie diet, rapid weight loss

PPI use

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60
Q

Describe the clinical features and management of biliary colic

A

Clinical features
> Colicky RUQ / epigastric pain
> Acute onset, initiated by eating & drinking fatty foods
> Radiating to back
> Nausea and vomiting
> Dyspepsia, flatulence, food intolerance

Duration
> Lasts minutes to hours
> Settles spontaneously
> Well in between episodes

Blood results
> WCC, CRP – normal
> LFTs – normal

Management – analgesia and elective lap chole if severe
> If CBD is cut, hepatojejunostomy is performed; however, lifetime of recurrent biliary sepsis, gallstones

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61
Q

Describe the clinical features and management of acute cholecystitis

A

Obstruction of the cystic duct / Hartmann’s pouch

Pressure on/within GB increases

Leads to hypertrophy, relative ischaemia, peri-cholecystic oedema

Superadded infection

features
- Murphy’s sign +ve
- Boas siwn: hyperaesthesia beneath right scapula

Blood results
> WCC, CRP – raised
> LFTs – normal / mildly deranged

Management
> Standard initial Rx
» NBM – low fat diet
» Analgesia
> IV Antibiotics
> early laparoscopic cholecystectomy within 1 week of diagnosis
> Percutaneous cholecystostomy if gangrenous

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62
Q

List complications of cholecystitis

A

Gangrene

Chronic cholecystitis

Emphysema of GB

Mucocoele

Empyema of GB

Perforation

Mirizzi syndrome: GB stone impacted in Hartmann’s pouch leads to pressure and erosion of common hepatic duct

Gallstone ileus
> seen as small bowel obstruction + air in biliary tree on AXR

Carcinoma

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63
Q

Describe the causes, clinical presentation and management of ascending cholangitis

A

Clinical presentation
> Charcot’s triad
» Fevers / rigors
» Jaundice
» Pain

> Raynaud’s pentad
> Charcot’s
> CNS depression
> Shock

Causes: CBD stones, stricture, anastomotic stricture, post-ERCP

commonly caused by E. coli

Management
- Aggressive resus
- IV Abx - triple therapy - gent, amox, metro OR tazocin
- Urgent ERCP, sphincterotomy +/ stent
- Percutaneous transhepatic cholangiography

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64
Q

Describe gallstone ileus

A

In older individuals, long-term low-grade inflammation causes a fistula connecting duodenum & GB (sometimes stomach)

Presentation
> Presents as SBO
» Vomiting, distended abdomen, absolute constipation
» AXR may show stones & air in biliary tree
» Often impact at IC valve

Management
> Laparotomy
> Enterotomy and removal
> Leave GB alone

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65
Q

Describe the pathophysiology of acute pancreatitis

A

Pancreatic enzymes are prematurely activated leading to autodigestion

Triggered by injury to acinar cells or impairment of zymogen granules which store and package enzymes, or anything damaging duct epithelium

Important: conversion of trypsinogen to trypsin

Once cellular injury has been initiated, inflammatory process can lead to local oedema, haemorrhage and necrosis

Inflammatory mediators released into bloodstream lead to severe systemic complications including organ failure or death

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66
Q

List causes of acute pancreatitis

A

I GET SMASHED

Iatrogenic
Gallstones
Ethanol
Trauma
Steroids
Mumps / malignancy
Autoimmune (IgG4)
Scorpion stings
Hypercalcaemia / hypertrygliceridaemia
ERCP

Drugs
> azathioprine
> thiazides
> oestrogen
> mesalazine

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67
Q

Describe the investigations carried out in acute pancreatitis

A

Investigations

  • Bloods including AMYLASE or lipase

Imaging

> Erect CXR to exclude pneumoperitoneum or LRTI

> USS abdo to exclude gallstones & determine CBD diameter

> > also demonstrates pancreatic head masses and pancreatic oedema

> MRCP - exclude biliary or pancreatic stones

> ERCP: especially with coexisting cholangitis in gallstone pancreatitis

> EUS: idiopathic pancreatitis

> CT with contrast

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68
Q

Describe CT findings in acute pancreatitis

A

Rule out peripancreatic collections, necrosis, abscesses and vascular complications of pancreatitis e.g. portal venous thrombus, pseudoaneurysms or haemorrhage

Areas of reduced parenchymal enhancement indicate necrosis

Interstitial oedematous pancreatitis
> Pancreas enlargement due to oedema
> Milder form
> Symptoms usually resolve within first week

> Acute interstitial pancreatitis
> Peripancreatic fat stranding centred on the head and body of the pancreas

> Pancreatic pseudocyst
> Well-defined fluid density cystic lesion

Necrotising pancreatitis
> Acute necrotic collection
» Ill-defined peripancreatic fat stranding with free fluid
> Early walled off necrosis
» Ill-defined peripancreatic collections that cross between anatomical compartments
» Become more organised with thick enhancing walls and heterogeneous internal debris

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69
Q

Describe severity scores for acute pancreatitis

A

Glasgow (Imrie) score >=3 within 48h of admission indicates severe, likely to develop complications
> Age, oxygen, WCC, urea, calcium, glucose, albumin, LDH, AST/ALT

Modified Glasgow / PANCREAS score

Revised Atlantic Classification
> Mild – no organ failure, no local/systemic complications
> Moderate – transient organ failure (<48h), local/systemic complications
> Severe – persistent organ failure (>48h)

CRP of >300mg/L 72h after onset of symptoms – necrosis likely

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70
Q

List complications of acute pancreatitis

A

Acute

> Local

> > Acute peripancreatic fluid collection (<4wk) developing into a pseudocyst (>4wk)

> > Acute necrotic collection (<4wk) developing into walled-off necrosis (>4wk)

> > Gastric outlet obstruction

> > Haemorrhage (splenic or GDA pseudoaneurysm)

> > Portal vein thrombosis

> Distant / systemic
> Hypotension / shock / arrhythmias
> Infection
> Respiratory failure: ARDS, atelectasis, pleural effusions, pulmonary oedema
AKI / renal failure
Ileus
Liver failure / ascites
DIC

Chronic
> Chronic pancreatitis (CP) - calcifications, ducts, strictures, stones
> Exocrine failure – malnutrition
> Endocrine failure – type 3c diabetes
> PD stones/strictures

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71
Q

Describe the management of acute pancreatitis

A

Respiratory support

IVF resuscitation and fluid balance

Analgesia

No role for antibiotics in initial setting, consider if infected collection

Late – ERCP if required, nutritional support

Collections
> Sterile pseudocyst – no management needed except monitoring
> Walled off necrosis: drainage – cyst gastroscopy or percutaneous cyst drainage

72
Q

Describe the clinical presentation, pathophysiology and causes of chronic pancreatitis

A

Pathophysiology
> Long standing chronic inflammation of pancreatic parenchyma to fibrous tissue
> Fibrosis results in exocrine insufficiency and malabsorption
> In advanced stages it leads to endocrine insufficiency and diabetes

Symptoms
> Upper abdo pain
> Nausea and vomiting
> Steatorrhoea
> Weight loss
> Diabetes

Causes
> Alcohol
> Idiopathic
> Autoimmune
> Hereditary

73
Q

Describe the clinical presentation of acute pancreatitis

A
  • Epigastric pain radiating to back
  • Nausea / vomiting
  • Fever
  • Periumbilical discolouration (Cullen’s sign)
  • Flank discolouration (Grey-Turner sign)
  • Ischaemic (Purtscher) retinopathy - temporary/permanent blindness
74
Q

Describe the diagnosis and treatment of chronic pancreatitis

A

Diagnosis:
- Calcified / fibrotic pancreas on imaging
- Serum amylase is normal
- Faecal elastase is high
- Autoimmune screen

Treatment
> Medical
» Insulin
» Analgesia
» Diet modification
» Pancreatic enzymes (CREON)

> Surgery
> Resection and drainage procedures

75
Q

Describe the causes and presentation of oesophageal perforation

A

Causes: caustic substances, OGD, Boerhaaves syndrome, trauma

  • Depending on site can present as neck, chest or abdominal pain

High mortality - sepsis leading to shock, multiorgan failure, death

76
Q

Describe the investigations and management of oesophageal perforation

A

Imaging
- Plain CXR - pneumomediastinum, hydropneumothorax
- CT with oral contrast - extraluminal contrast

Management
- Conservative
> Resuscitation, IV antibiotics, NBM

  • Surgical
    > Thoracotomy + surgical repair: thoracic oesophageal perf
    > Laparotomy: intra-abdominal perf + peritonitis
    > Stents - palliative, contained perfs
    > Percutaneous drainage
77
Q

List signs of perforation on AXR (pneumoperitoneum)

A
  • Continuous hemidiaphragm with crisp delineation
  • Rigler’s sign - increased delineation of wall of bowel due to free gas
  • Football sign: gas bubble rises to top of abdomen forming a ball, most commonly seen in NEC in babies
  • Air surrounding falciform ligament - visible line on AXR
78
Q

Describe the anatomy of the breast

A

The breast consists of 15-20 lobes separated by ligaments of Cooper

Lobes contain alveoli, which contain lactocytes

Alveoli are surrounded by myoepithelial cells (contractile)

Lobes are connected by ductal system

Oxytocin stimulates myoepithelial cells to contract, pushing milk into lactiferous ducts and towards the nipple

Ducts converge at lactiferous sinus (below nipple)

Variably fibrous / fatty interlobular stroma, blood vessels, nerves

The nipple has an average of nine openings which are surrounded by the areola

Montgomery tubercles are glands which secrete a sebaceous fluid that lubricates the nipple and protects the skin

79
Q

Describe the blood supply and lymphatic drainage of breast

A

Internal thoracic (medially)

Axillary (laterally)
> Lateral thoracic artery
> Pectoral branch of acromioclavicular artery
> Subscapular artery

Intercostal arteries
> Lateral perforating branches

Venous drainage - corresponding veins

Lymphatic drainage
> Axillary nodes
> Internal thoracic

80
Q

Describe the presentation of breast cancer

A

Nipple/areola
> Retraction
> Eczema
> Discharge
> Lump

Skin
> Retraction
> Focal nodularity / texture change
> Rash / erosion / ulceration
> Fixation
> Dimpling
> Tethering

Oedema

Discolouration

Peau d’orange
> Aggressive inflammatory breast cancer or mastitis

Asymmetry

Pain only in 6% of breast cancers

81
Q

List risk factors for breast cancer

A

Modifiable
> Smoking
> Alcohol
> Obesity
> Sedentary lifestyle
> COCP, HRT

Non-modifiable
> Age
> Family history – BRCA1/2
> Parity
> Radiation
> High risk lesion
> Early menarche / late menopause
> Nulliparity or children after 32

82
Q

Describe the assessment of breast cancer

A

Triple assessment - examination/history, imaging, tissue diagnosis

Imaging
> Mammogram: >40 years
> USS <40 years
> MRI

Biopsy
> FNAC - fine needle aspiration cytology
- Core needle biopsy

83
Q

Which index is used to determine prognosis of breast cancer following surgery?

A

Nottingham Prognostic Index - uses size, grade and nodal status

84
Q

Explain the management of breast cancer

A

Surgery (+ sentinel node biopsy)
> Wide local excision + radiotherapy
> Mastectomy (simple / skin sparing / nipple sparing)

> Reconstruction: DIEP flap, TRAM flap, TUG flap, lat dorsi flap, implants

For axilla: clearance if SNLB shows >= 3 nodes involved

+/- chemoradiotherapy

Endocrine therapy
- Tamoxifen: selective oestrogen receptor modulator used in pre-menopausal women & men
- Aromatase inhibitors e.g. letrozole, anastrozole in post-menopausal women
- Trastuzumab (Herceptin) for HER2 +ve cancers

85
Q

List benign breast conditions

A

Inflammatory
> Fat necrosis (trauma)
> Periductal mastitis
> Abscess (lactational and non-lactational)

Proliferative conditions
> Fibroadenoma
> Cysts
> Fibrocystic disease
> Sclerosing adenosis
> Papilloma

86
Q

Describe common breast cancers

A

Pre-invasive: high grade dysplasia
> Lobular carcinoma in situ (LCIS)
> Ductal carcinoma in situ (DCIS)

Invasive:
> Invasive ductal carcinoma (IDC)
> Invasive lobular carcinoma (LDC)
> Others
» Malignant Phyllodes tumour
» Tubular carcinoma
» Mucinous carcinoma
etc

87
Q

Describe the breast screening programme in Scotland

A

Mammogram for 50-70 year old women every 3 years

88
Q

Describe the anatomy of the thyroid gland

A

2 lobes connected by isthmus

Blood supply
> Superior thyroid artery – branch of external carotid

> Inferior thyroid artery – branch of thyrocervical trunk (branch of subclavian)

Venous drainage
> Internal jugular vein
> Brachiocephalic veins

Lymph nodes: anterior cervical chain

89
Q

List the types of thyroid cancer

A
  • Papillary: most common
  • Follicular
  • Medullary: C cells
  • Anaplastic: rare, aggressive
  • Lymphoma
90
Q

List clinical features of thyroid cancer

A

Palpable single or multiple lumps

Rapid growth

Pain

Cough, hoarse voice, stridor

Multiple enlarged cervical lymph nodes

Tethering of the lump to surrounding structures

91
Q

List differential diagnoses for thyroid cancer

A

Benign thyroid adenoma or thyroid cyst

Goitre
> Simple – iodine deficiency

> Toxic – Grave’s / solitary nodule / multinodular

> Thyroiditis – Hashimoto’s, Riedel’s, De Quervain’s

> Amyloid / Bacterial infection (TB, syphilis)

Thyroglossal duct cyst

Thyroglossal fistula

Ectopic/lingual thyroid

92
Q

Describe the management of thyroid cancer

A

Surgery
> Hemi-thyroidectomy
> Total thyroidectomy

Non-surgical treatment
> Radioiodine therapy
> External beam radiotherapy
> Chemotherapy

93
Q

Describe the features of hyperthyroidism

A

Stimulating metabolism, heat production and oxygen consumption

Cardiac features caused by B adrenergic sympathetic activity

TFTs – low TSH, high T4

Features
- Palpitations
- Tachycardia
- Cardiac arrhythmias
- Sweating
- Tremor
- Lethargy
- Heat intolerance
- Diarrhoea

94
Q

Describe the treatment of hyperthyroidism

A

Antithyroid drugs – carbimazole, prophylthiouracil

Propranolol

Radioactive iodine

Surgery

95
Q

Describe the features of hyperparathyroidism and the different types

A

Primary – disorder of parathyroid gland
> High PTH, high calcium
> Causes: adenoma, hyperplasia, cancer

clinical features - fatigue, aches, low mood. PTH may be normal.

Secondary - secondary to uraemia (long-term dialysis)

Tertiary - post-renal transplant

96
Q

List the symptoms of hypercalcaemia

A

GI
> Nausea and vomiting
> Abdominal pain
> Pancreatitis
> Ulcer
> Constipation

CV
> High BP
> Bradycardia
> Heart block
> Arrhythmias

Renal
> Colic
> Polyuria
> Oliguria
> Thirst
> Renal failure

Neuro
> Anxiety
> Depression
> Headaches
> Confusion

97
Q

List causes of hypercalcaemia

A

Malignancy
> Solid tumour
> Metastasis

Haematological
> Myeloma, lymphoma, leukaemia

Hyperparathyroidism
> Lithium, familial (MEN), FHH

High bone turnover
> Paget’s, thiazides, hyperthyroid

Excess vitamin D

Renal failure – secondary HPT

Addisonian crisis

Lab error - haemoconcentration

98
Q

Describe the anatomy of the adrenal gland

A

Blood supply
> Inferior phrenic, renal and aortic branches

Venous drainage
> IVC on right
> Left renal vein on left

Cortex
> Zona glomerulosa – mineralocorticoids
> Zona fasciculata – glucocorticoids
> Zona reticularis – androgens (DHEA)

Medullary
> Noradrenaline, adrenaline

99
Q

Describe the causes and features of Cushing’s disease

A

Increased levels of glucocorticoids

Causes:
> ACTH-dependent: pituitary or ectopic (small cell lung cancer)
> ACTH-independent: adrenal origin
» Adenoma
» Carcinoma
» Bilateral hyperplasia (Carney’s syndrome)
>Most common – iatrogenic administration of steroids

Features
> Obesity
> Hirsutism
> Muscle weakness
> Striae
> Acne
> Diabetes
> Bruising
> Fractures
> Buffalo hump
> High BP

100
Q

Describe investigations and management of Cushing’s disease

A

Investigations
> Dexamethasone suppression testing: cortisol is not suppressed

> ACTH level
> ACTH-Dependent: high
> ACTH-independent: low

> CT scan or MRI

Management

> Surgery
> Transsphenoidal pituitary surgery
> Laparoscopic adrenalectomy

101
Q

Describe adrenocortical carcinoma and its management

A

Suspected when mass size is >6cm

Associated with
> MEN1
> Li Fraumeni syndrome (breast, brain, osteosarcoma)

Management
> Medical: mitotane – causes adrenal necrosis
> Surgery: laparoscopic or transabdominal approach

102
Q

Describe the features of phaeochromocytoma, investigations and management

A

Functioning tumour of medulla – secretes catecholamines

Features
> High BP
> Headache
> Palpitations
> Arrhythmias (intermittent)

Investigations
- CT, MRI or MIBG (radioisotope localisation)
- Urinary catecholamines

Management
- Alpha and beta blockade
- Laparoscopic excision

103
Q

Describe Conn’s syndrome

A

Primary aldosteronism

Features
- High BP
- Low potassium
- Low renin
- Water retention

Cause – benign adrenal adenoma

Investigations – selective venous sampling

Management
- Spironolactone
- Laparoscopic adrenalectomy

104
Q

List daily requirements of water, sodium, potassium and glucose for IV fluid replacement

A

Water: 25 mL/kg/day

Na+: 1.0 mmol/kg/day

K+: 1.0 mmol/kg/day

Glucose: 50g/day

105
Q

List drugs which must be stopped or altered prior to surgery

A

Drugs to stop prior to surgery – CHOW

Clopidogrel
> Stop 7 days prior due to bleeding risk
> Aspirin and other anti-platelets can be continued

Hypoglycaemics

Oral contraceptive pill or HRT
> Stop 4 weeks before surgery due to DVT risk

Warfarin
> Stop 5 days prior due to bleeding risk
> Commence on therapeutic dose LMWH
> If INR >1.5, give PO vitamin K

DOACs will also need to be stopped but duration depends on each one

Drugs to alter

> Subcutaneous insulin
> Switch to variable-rate insulin infusion (VRIII)

> Long-term steroids
> Must be continued due to risk of Addisonian crisis if stopped
> If patient cannot take orally, switch to IV

106
Q

List correction agents for overdoses

A

Flumazenil is the reversal agent for midazolam OD

N-acetyl cysteine is the rescue agent for paracetamol OD

Naloxone is the reversal agent for opiate OD

107
Q

Describe colonic polyps

A

Any growth from lining of large bowel

Can be pedunculated or sessile

Types
> Tubular – smaller, less potential
> Villous – larger, frond-like lesions, greater malignant potential
> Tubulovillous - both

Presentation
> PR bleeding
> Mucous discharge or prolapse if low in rectum

Can be precancerous

108
Q

List causes of PR bleeding

A

Anticoagulants

Bleeding diathesis / coagulopathy

Haemorrhoids

Diverticulosis

CRC

Colitis (Crohn’s / UC / infective / C. diff / ischaemic)

Angiodysplasia

Meckel’s with ectopic gastric mucosa

109
Q

Describe perianal abscesses

A

Acute perianal pain, purulent discharge, erythema and swelling +/- systemic upset

Cryptoglandular origin: an anal crypt gland becomes obstructed with inspissated debris and leads to infection

Mangement - EUA (examination under anaesthesia), incision and drainage (+/- fistulotomy)

Beware the obese diabetic who is unwell – necrotising perianal sepsis

110
Q

Describe fistula in ano

A

Causes
- Cryptoglandular
- Crohn’s
- Drugs
- Radiation
- Tumour

Symptoms: discharge, pain, soiling

Imaging: MRI pelvis

Management

> Crohn’s
- induce remission with glucocorticoids
- enteral feeding can be used
- second-line: mesalazine
- azathioprine and mercaptopurine may be added
- infliximab may be used for refractory / fistulating disease
- Metronidazole if isolated perianal fistula

  • Lay open and remove internal opening - heal by secondary intention
  • Repeated seton until laying open is possible
  • Complex procedures –
    > LIFT procedure - ligation of intersphincteric fistula tract
    > Endoanal advancement flap
111
Q

Describe anal fissures

A

Symptoms
> Sharp anal pain – cut glass – during and after defecation
> A little blood on wiping

Posterior, high pressure most common – sphincteric spasm due to pain limits local blood flow and prevents healing

Management
> Prevent constipation
> Topical Rx – diltiazem ointment, rectogesic (GTN)
> If persists at 6/52 consider EUA – exclude sinister pathology
> Intersphincteric botox injection
> Lateral internal sphincterotomy
> Defunctioning stoma

112
Q

Describe thrombosed external haemorrhoid

A

Aka perianal haematoma

Symptoms
> Acute severe perianal pain
> Blood on wiping and in pan
> Perianal lump

Either conservative management or incision and evacuation

Symptoms usually last 2/52 regardless

Little evidence that surgery improves pain over this period, although initial relief is usually marked

Conservative Rx
> stool softeners
> Topical local anaesthetic gel
> Cool pack
> refer for excision if <72h

113
Q

Describe rectal prolapse

A

Protrusion of all layers of the rectal wall through anal canal

Symptoms
- A lump coming down on defecation or standing
- Blood and mucus on wiping
- Incontinence
- Usually not painful
- Patient may confuse for prolapsing haemorrhoids

Usually elderly women – pelvic floor / sphincter complex weakness after obstetric injury followed by age and menopause-related muscle weakening

Management
- Initially – push it back in
- Conservative if very unfit
- Perineal repair (Delorme’s / Altmeier’s)
- Abdominal rectopexy

114
Q

Compare colostomy and ilostomy

A

Ileostomy
- usually RIF
- Spouted
- effluent is liquid to semi-liquid
- higher output

Colostomy
- usually LIF
- Flat / flush with skin
- semi-solid to solid effluent
- lower output

115
Q

List the clinical features of hypothyroidism

A

Symptoms
> Tiredness
> Weight gain
> Anorexia
> Cold intolerance
> Depression
> Poor libido
> Dry brittle hair and dry coarse skin
> Constipation
> Menorrhagia

Signs
> Ataxia
> Deafness
> Hypertension
> Bradycardia
> Cold peripheries
> Anaemia

116
Q

List causes of hyperthyroidism

A

Grave’s disease – diffuse enlargement

Toxic multinodular goitre

Toxic adenoma

117
Q

Describe Grave’s disease

A

Autoimmune disease

> autoantibodies
> TSH receptor stimulating antibodies
> anti-thyroid peroxidase antibodies

Thyroid enlarged and increased vascularity (may be audible bruit)

Usually young females

Symptoms of hyperthyroidism and thyroid eye disease
> Proptosis
> Lid retraction and lid lag
> Oedema
> pretibial myxoedema
> thyroid acropachy

thyroid scintigraphy
> diffuse, homogeneous, increased uptake of radioactive iodine

118
Q

List symptoms of GORD

A

Dyspepsia

Heartburn

Nausea

Epigastric / retrosternal pain

Bloating

Anorexia

Early satiety

Unintentional weight loss

Dysphagia

GI bleeding

Persistent continuous vomiting

Red flags
> Iron deficiency anaemia
> Epigastric mass

119
Q

List investigations used in oesophageal pathology

A

Upper GI endoscopy

Barium swallow

24h pH monitoring if endoscopy is normal

Oesophageal manometry – if endoscopy is normal
> Need to see transmitted peristalsis of oesophageal muscle and relaxation of lower oesophageal sphincter

120
Q

List complications of GORD and management options

A

Complications
> Oesophagitis
> Ulcers
> Benign stricture
> Barrett’s oesophagus
> Oesophageal adenocarcinoma
> Iron deficiency anaemia

Drug management
> H2 receptor blocker (ECL cells) – cimetidine, ranitidine
> PPI (parietal cells) – omeprazole, esomeprazole

121
Q

Describe hiatus hernias

A

Sliding hiatus hernia
> Gastric fundus protrudes into thoracic cavity
> Lower oesophageal sphincter is no longer in contact with diaphragm

Paraoesophageal “rolling” hiatus hernia
> More dangerous, less symptomatic as lower oesophageal sphincter is potentially still functioning
> Rolling hernia means risk of strangulation of gastric fundus

Management
> Weight loss
> Symptomatic relief : PPI, H2 receptor antagonist

Surgery - Nissen fundoplication, Linx procedure

122
Q

Describe achalasia and its management

A

Caused by loss of acetylcholine receptors in lower oesphageal muscles

Dysphagia, regurgitation, pain (type II/III)

Management
> Botox injection into lower oesophageal sphincter to cause muscle relaxation
> Balloon dilatation across OG junction
> Hellers Myotomy for achalasia
> POEM (per oral endoscopic myotomy)

123
Q

Describe the features and management of abscesses

A

Collection of pus surrounded by a pyogenic membrane

Pus – dead leukocytes, bacteria and tissue debris

Features
> Red, hot, tender swelling
> Fluctuant +++

Outcomes
> Rupture
> Discharge into another organ – fistula
> Discharge into an epithelial surface – sinus

Management – drainage
> Skin and soft tissue – I&D under LA/GA
> Intra-abdominal abscess – Abx + IR drainage or laparoscopic washout

124
Q

Describe erysipelas and its management

A

Spreading cuticular lymphangitis

Common organisms – streptococcus pyogenes

> Rose-pink rash that extends to adjacent skin
Raised
Sharply defined margins
Vesicles contain serum, not pus

Milian’s ear sign

Management
> Wound swab
> Antibiotics – want to cover gram +ve flucloxacillin

125
Q

Describe cellulitis and its management

A

Spreading inflammation of subcutaneous and fascial layers – suppuration, sloughing or gangrene

Common in diabetic, malnourished patients

Features
> Swollen
> Tender
> Hot
> No definite edge
> Vesicles may contain pus

PO/IV Abx depending on patient and severity

126
Q

Describe necrotising fasciitis and its management

A

A polymicrobial bacterial infection - destruction of the soft tissues and fascia

Surgical emergency

Risk factors
> Diabetes
> Smoking
> Penetrating trauma
> Pressure sores

Clinical features
> Rapidly progressing
> Generally unwell, tachycardic, fever +/- hypotensive
> Oedema stretching beyond visible skin erythema
> Pain out of proportion to affected area
> Crepitus
> Fournier gangrene – nec fasc affecting external genitalia and perineum

Management
> Fluid resuscitation
> IV Abx – covering gram +ve, gram –ve and anaerobes
> Surgical debridement
+/- plastic surgery review for skin graft

127
Q

Describe peritonitis

A

Inflammation of the peritoneum

Causes
> bacterial inflammation
> Gastrointestinal perforation – perforated ulcer, appendix, diverticulum
> Transmural translocation (no perforation) e.g. pancreatitis, ischaemic bowel
> Exogenous contamination e.g. drains, open surgery, trauma
> Female genital tract infection e.g. pelvic inflammatory disease
> Haematogenous spread (rare) e.g. septicaemia
> Chemical – bile, barium
> Ischaemia – strangulated bowel, vascular occlusion

Management
> Resuscitate – IVF / Urinary catheter
> IV Abx
> CXR +/- CTAP
> Theatre

128
Q

Describe UC and its symptoms

A

> Involves rectum and extends proximally to involve all or part of colon (left side)

> Continuous spread (no skip lesions)

> Ulcers, pseudopolyps

> Diffuse mucosal inflammation – no transmural ulceration

> Limited to colon

Symptoms
> Bloody diarrhoea
> Mucus
> Abdominal pain
> Tenesmus and urgency

> Extraintestinal
> Erythema nodosum, pyoderma gangrenosum
> Uveitis
> Arthritis
> Aphthous ulcers
> Primary sclerosing cholangitis (PSC)

129
Q

Describe Crohn’s disease

A

Patchy transmural inflammation in any part of GI tract
> skip lesions mouth-anus
> transmural inflammation
> goblet cells
> granulomas
> strictures: Kantor’s string sign
> rose-thorn ulcers

Defined by
> Location – terminal ileum, ileocolic, upper GI
» terminal ileitis increases gallstone risk

> Disease – inflammatory, stricturing, fistulating
Cobblestone appearance
Creeping fat – adhesions and fistula

Risk factors – smoking, prior appendicectomy, family history

Diagnosis
> Colonoscopy – cobblestoning
> Histology – discontinuous, granulomatous inflammation
> CT/USS/MRI - abscess/fistulae
> Capsule enteroscopy

130
Q

Describe the management of Crohn’s

A

Inducing remission: glucocorticoids

> Aminosalicylates e.g. mesalazine (second-line to glucocorticoids)

> Immunosuppressants e.g. azathioprine, 6-mercaptopurine, cyclosporin (add-on)

> Biological therapy: infliximab, adalimumab

Maintaining remission - azathioprine or mercaptopurine first-line (methotrexate second-line)

Most patients eventually have surgery
> stricturing terminal ileal disease - ileocaecal resection
> segmental small bowel resections
> stricturoplasty

131
Q

Define haemorrhoids and the causes of haemorrhoids

A

Cushions of highly vascular tissue found within the submucosal space and are considered part of the anatomy of the anal canal

Causes
> Constipation, prolonged straining
> Exercise, gravity
> Nutrition (low fibre diet)
> Pregnancy, increased intra-abdominal pressure
> Irregular bowel habits (constipation / diarrhoea)
> Genetics, absence of valves within the haemorrhoidal veins
> Aging

132
Q

Describe the presentation, grading and treatment of haemorrhoids

A

Acute – thrombosed piles

Chronic
> Internal
» Painless bleeding
» Itch

> External
> Bleeding
> Swelling and discomfort
> Mucous discharge

investigation - PR exam, proctoscopy

Grading
> grade I: do not prolapse out of anal canal
> grade II: prolapse on defecation but reduce spontaneously
> grade III: can be manually reduced
> grade IV: cannot be reduced

Treatment

> Medical
> Dietary / lifestyle: avoid constipation
> Creams
> anusol: astringent to shrink haemorrhoids (short-term)
> topical lidocaine

Non-surgical
> Injection sclerotherapy
> Rubber band ligation (RBL)
> Transanal haemorrhoidal dearterialization (THD)

Surgery
> Open/closed haemorrhoidectomy
> Procedure for prolapse and haemorrhoids (PPH)
> Infrared photocoagulation
> Haemorrhoidal artery ligation operation (HALO)

133
Q

Define anal fissures and their symptoms

A

Tear in the epithelial lining of the anal canal

Symptoms

  • Acute
    > Pain
    > Bleeding
  • Chronic
    > Symptoms beyond 6-8/52
    > Sentinel tag at the external apex
    > Exposed internal sphincter muscle
    > Hypertrophied anal papilla at the internal apex
134
Q

List treatments for anal fissure

A

Conservative measures
> High fibre intake
> Stool softeners
> Sitz baths

Medical
> GTN ointment
> Diltiazem ointment
> Botox

Surgical
> Lateral internal sphincterotomy
> Anal advancement flap
> Fissurectomy

135
Q

Describe pilonidal sinus & its treatment

A

Acquired condition related to the presence of hair in the natal cleft

Loose hair causes a foreign body reaction leading to midline pit formation

Presentation
> Simple cyst
> Acute abscess with/without cellulitis
> A chronic draining sinus
> May have a tracking sinus or multiple sinuses

Treatment
> Non-operative
» Local hair control – shaving or laser epilation
» Improved hygiene

> Operative
> PNS abscess – incision & drainage
> Karydakis & Bascom’s procedure

136
Q

Describe the pathophysiology, presentation and management of a tension pneumothorax

A

Pathophysiology
- Blunt or penetrating injury
> Results from a one-way air leak which results in trapped air within the thoracic cavity – collapsing the affected lung
> Mediastinal shift results in decreased venous return and compression of the opposite lung
> Decreased venous return reduces cardiac output
> Obstructive shock

Clinical signs
- Respiratory distress
- Deviated trachea
- Distended neck veins
- Absent breath sounds / markedly decreased on the affected side
- Hyperresonant to percuss
- Minimal chest movement

Management
- Oxygen – 15L trauma mask (non-rebreather)
- Grey venflon – second intercostal space mid clavicular line to buy some time
- Chest drain

137
Q

Describe the pathophysiology, clinical signs and management of cardiac tamponade

A

Pathophysiology
> penetrating or blunt
> Cardiac tamponade is the accumulation of pericardial fluid, blood, pus or air within the pericardial space
> Results in an increase in intra-pericardial pressure, restricting cardiac filling and decreasing cardiac output
> Obstructive shock

Clinical signs
> Tachycardia, hypotension
> Distant heart sounds
> Distended neck veins
> Pulsus paradoxus >10 mmHg
> Abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration

Management
> Drainage of the pericardial fluid either by pericardiocentesis or surgical drainage – usually with a thoracotomy in trauma and creation of a pericardial window

138
Q

Describe acute limb ischaemia and its clinical presentation

A

Sudden decrease in limb arterial perfusion with potential threat to limb survival ; onset <2 weeks

Presentation: 6 Ps
- Pain
- Pulseless
- Pallor
- Poikilothermia (perishingly cold)
- Paraesthesia – indicative of neuronal ischaemia
- Paralysis – indicative of neuronal ischaemia

139
Q

List investigations and management for acute limb ischaemia

A

Rutherford classification for staging of severity

Investigations
> ECG, echo
> CT angiography
> Arterial Doppler ultrasound (initial investigation)
> ABPI

Management: surgical emergency

> Resuscitation and analgesia (IV opioids)
IV unfractionated heparin to prevent clot propagation

> Revascularisation options
> Surgical embolectomy +/- fasciotomy
> Endovascular: targeted thrombolysis
Late diagnosis: amputation

140
Q

Describe causes of acute limb ischaemia

A
  • Thrombo-embolus
    > E.g. AF, infective endocarditis, antiphospholipid syndrome
    > Managed via open arteriotomy or catheter-directed thrombectomy
  • Aneurysm
    > Higher amputation rates as no collateral circulation
  • Trauma & iatrogenic injury
  • Dissection
141
Q

Describe the pathophysiology and clinical presentation of chronic limb ischaemia

A

History
- Walking distance aka claudication distance
- Rest pain
> Pain at rest, numbness, paraesthesia – critical limb ischaemia

Examination
- absent / diminished pedal pulses
- cold / shiny / scaly skin
- peripheral hair loss
- ulceration / gangrene
- thickened toenails

critical limb ischaemia
> buerger’s angle <20
> capillary refill time >15s
> diminished/absent pulses
> evidence of gangrene or ulceration

142
Q

Describe findings on inspection in chronic venous insufficiency

A

Haemosiderin deposition
> Erythrocyte leakage & breakdown
> Release of iron

Lipodermatosclerosis
> Inflammation and fibrosis

Venous eczema

> Venous ulceration
> Sloping edges
> Shallow
> Large
> management: compression bandaging, oral pentoxifylline

143
Q

Describe chronic limb threatening ischaemia and its features on examination

A

Peripheral arterial disease combined with
> Rest pain + night pain
> Gangrene
> Limb ulceration / tissue loss >2 weeks

Examination
> Absent peripheral pulses
> Buerger’s test
» Foot blanches on elevation + dependent hyperaemia
» Hyperaemic foot “sunset”
> Arterial ulcers / tissue loss / necrosis
» Classically “punched out”, distal, painful

144
Q

Describe investigations for chronic limb threatening ischaemia

A

Resting + exercise ankle-brachial pressure indices (ABPI)

Arterial duplex ultrasound

Non-invasive angiography – CT / MRI

Conventional needle angiography / DSA (digital subtraction angiography) - best imaging

145
Q

Describe the management of peripheral arterial disease and chronic limb threatening ischaemia

A

PAD:
Conservative: risk modification, patient education, smoking cessation

Secondary prevention - clopidogrel and atorvastatin 80mg

If claudication: cilostazol – phosphodiesterase 3 inhibitor – vasodilator -

Chronic limb threatening ischaemia

> Revascularise

> > Open surgery: endarterectomy, bypass grafting
> used for long segment stenosis, multifocal lesions, lesions of common femoral artery and purely infrapopliteal disease, low-risk patients

> > Endovascular surgery: balloon angioplasty+/- stent
> used for short segment stenosis, aortic iliac disease, high-risk disease

> If necrosis / gangrene – below or above knee amputation

146
Q

Define abdominal aortic aneurysms and describe their classification

A

True aneurysms involve all layers of the arterial wall, > 50% dilatation of the artery

> False / pseudo aneurysm – bleeding tamponade by surrounding tissue
> Causes – IVDU and cardio procedures due to puncturing vessels

2 types of aneurysm
> Saccular (outpouching), usually subarachnoid
> Fusiform (majority) of AAA
» Related to position of renal arteries: infrarenal, suprarenal…

147
Q

List risk factors for AAA

A

Age >65

Male gender

Smoking

Family history of AAA

Atherosclerosis

History of other vascular aneurysms, especially popliteal aneurysm

Arterial hypertension

Greater height

Obesity

COPD

Congenital disorders e.g. Marfan’s, Ehlers-Danlos

148
Q

Describe treatment options for AAA

A

Open repair (consider repair >5.5cm): good long-term outcomes

EVAR (endovascular aneurysm repair): may need reintervention in future

149
Q

Describe the presentation, investigations and treatment of an AAA rupture

A

Presentation
> Sudden onset severe back/lower abdo pain
> Expansile abdominal mass +/- tenderness
> Cardiovascular instability e.g. hypotension / collapse
> Assess peripheral pulses
> Beware “renal colic” in men <50, retroperitoneal fluid can cause flank pain

Surgical emergency, high mortality

Investigations: abdo exam, CT

Management
> Resuscitation
> Permissive hypotension: less chance of disrupting haematoma with lower BP
> Repair – open or EVAR

150
Q

List antiemetics for post-op nausea

A

Serotonin antagonists (5HT) - ondansetron 4mg

Corticosteroid – dexamethasone 4-8mg

Dopamine antagonists (D2) - droperidol 0.625-1.25mg

Metoclopramide – 25-50mg

151
Q

List complications associated with massive transfusion

A

Metabolic acidosis / hypocalcaemia

Coagulopathy – dilutional / consumptive

Hypothermia

Hyperkalaemia

TACO – Transfusion-associated circulatory overload

Transfusion related acute lung injury (TRALI)

152
Q

Describe the classification of severity of UC and its management

A

Truelove & Witts Criteria

Severity
- Mild: <4 stools/day, small amount of blood
- Moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
- Severe: >6 stools/day, features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)

Management

  • Mild to moderate UC
    > topical (rectal) aminosalicylate e.g. mesalazine
    » if remission not achieved within 4 weeks add oral aminosalicylate, if still not achieved, topical/oral steroid
  • severe colitis
    > IV methylprednisolone
    > intravenous ciclosporin if steroids not tolerated

IF toxic megacolon - surgical referral, may need emergent colitis (consider rescue infliximab)

following a severe relapse or >=2 exacerbations in the past year: oral azathioprine or oral mercaptopurine

153
Q

What is the diameter for megacolon?

A

369

3cm - small bowel

6cm - large bowel

9cm - caecum

154
Q

Describe milk-alkali syndrome

A

Triad of hypercalcaemia, metabolic alkalosis and renal insufficiency (AKI).

Associated with excess calcium supplementation e.g. calcium carbonate

lab features: high calcium, low PTH

155
Q

Describe anaphylaxis and its management

A

Features
- airway compromise: swelling of the throat and tongue →hoarse voice and stridor
- Breathing problems: respiratory wheeze, dyspnoea
- Circulation problems: hypotension, tachycardia
- generalised rash, urticaria

serum tryptase levels can confirm anaphylaxis

Management
- adults: 500mcg or 0.5ml 1 in 1000 adrenaline (IM)
- 6-12 years: 300mcg or 0.3ml 1 in 1000 adrenaline (IM)
- 6 months - 6 years: 150 mcg or 0.15ml 1 in 1000 adrenaline (IM)
- <6 months: 100-150 mcg or 0.15ml 1 in 1000 adrenaline (IM)

adrenaline can be repeated every 5 mins.

best site for injection - anterolateral aspect of middle third of thigh

if refractory anaphylaxis: respiratory or cardiovascular compromise despite 2 doses

management following stabilisation
> non-sedating oral antihistamine

156
Q

Describe Paget’s disease of the bone and its management

A

Increased bone turnover

Association with age >55, smoking, genetics, paramyxoviruses e.g. measles, RSV, canine distemper virus

Clinical features
> bone pain (Deep, dull, nighttime)
> Skeletal deformities
» increased hat size (skull involvement), hearing loss
» bowed tibias
» kyphosis
» fractures

Lab features
> increased serum ALP
> normal calcium and phosphate

X-ray: localised bone enlargement and deformity, patchy cortical thickening with sclerosis

Bone biopsy is the most sensitive test

Complications
- Neurological: nerve root compression,, spinal stenosis
- Orthopaedic: OA, pathological fractures, enlargement/deformity
- Oncological: osteosarcoma
- Other: HF, secondary hyperparathyroidism
- malignancy: osteosarcoma

management:
> analgesia
> bisphosphonates
> PT/OT
> Corrective surgery, joint replacement

157
Q

Describe multiple myeloma

A

malignant proliferation of plasma cells that secrete monoclonal antibodies and light immunoglobulin chains.

clinical fratures
> lethargy
> bone pain
> pathological fracture
> amyloidosis
> pancytopenia (marrow infiltration)

Diagnosis requires two of the following 3 criteria:
1. Marrow plasmacytosis
2. Serum/urinary immunoglobulin light chains (Bence Jones protein)
3. Skeletal lesions (osteolytic lesions, pepperpot skull and pathological fractures)

If serum / urine monoclonal antibodies but do not fulfil the criteria for multiple myeloma: monoclonal gammopathy of uncertain significance

Management
> analgesia
> bisphosphonates
> orthopaedic interventions
> <55yy: allogeneic stem cell transplantation
> palliative chemo

Complications

> Renal failure (caused by the deposition of light chains within the kidney)
> managed by promoting fluid intake although renal replacement therapy may be required

158
Q

Describe the adverse effects of the following cytotoxic agents

  • cyclophosphamide (alkylating agent)
  • bleomycin (cytotoxic)
  • doxorubicin (anthracycline)
  • methotrexate
  • 5-FU
  • 6-mercaptopurine
  • cytarabine
  • vincristine, vinblastine
  • docetaxel
  • cisplatin
  • hydroxyurea
A

cyclophosphamide
> haemorrhagic cystitis
> myelosuppression
> transitional cell carcinoma

bleomycin
- lung fibrosis

doxorubicin
- cardiomyopathy

methotrexate
- myelosuppression
- mucositis
- liver fibrosis
- lung fibrosis

5-FU
- myelosuppression
- mucositis
- dermatitis

6-mercaptopurine
- myelosuppression

cytarabine
- myelosuppression
- ataxia

vincristine: peripheral neuropathy, paralytic ileus

docetaxel: neutropaenia

cisplatin: ototoxicity, peripheral neuropathy

159
Q

Describe cryptorchidism and its management

A
  • congenital undescended testis by 3 months of age
  • increased risk of testicular cancer

treatment
- orchidopexy at 6-18 months of age

retractile testis: appears in warm conditions or can be brought down on clinical examination and does not immediately retract

160
Q

Describe the investigations and management of renal stones

A

Investigations
- urine dipstick
- Non-contrast CT KUB
- ultrasound for pregnant women and children

Managemenet
Analgesia - NSAIDs, usually diclofenac

Alpha blockers e.g. tamsulosin to facilitate passage for distal ureteric stones <10mm

Renal stones
> watchful waiting if <5mm and asymptomatic
> 5-10mm: shockwave lithotripsy
> 10-20mm: shockwave lithotripsy OR ureteroscopy
> >20mm: percutaneous nephrolithotomy

Ureteric stones
> extracorporeal shockwave lithotripsy +/- alpha blockers <20mm
> >20mm ureteroscopy

Infected Obstructed Urinary System - surgical emergency
> decompression via percutaneous nephrostomy

161
Q

Describe cholangiocarcinoma and its management

A

bile duct cancer, risk factor is primary sclerosing cholangitis

features
- persistent biliary colic symptoms
- anorexia, jaundice, weight loss
- palpable mass in RUQ: Courvoisier sign
- periumbilical lymphadenopathy (Sister Mary Joseph nodes), Virchow node
- raised CA 19-9 levels

162
Q

Describe local anaesthetic agents

A
  • lidocaine
    > affects Na channels in the axon
    > toxicity: due to IV or excess administration
  • cocaine
    > applied topically to nasal mucosa in ENT surgery
  • bupivacaine
    > binds to intracellular portion of sodium channels and blocks sodium influx into cells
    > longer duration than lignocaine
    > cardiotoxic; levobupivacaine is less cardiotoxic
  • prilocaine
    > used for intravenous regional anaesthesia
  • prilocaine
  • lignocaine

Adrenaline may be added to local anaesthetic drugs to prolong duration of action and permit usage of higher doses

163
Q

describe pilonidal disease and its management

A

condition where sinuses and cysts form near the upper part of the natal cleft of the buttocks

clinical features
- abscess
> pain (may be severe)
> purulent discharge
> fluctuant swelling at site

management
- asymptomatic: managed conservatively with local hygiene
- symptomatic
> acute: incision and drainage
> chronic/recurrent: excision of the pits and obliteration of underlying cavity

164
Q

describe TURP syndrome

A

rare and life-threatening complication of transurethral resection of the prostate surgery

pathophysiology - venous destruction and absorption of irrigation fluid

risk factors
- surgical time >1h
- height of bag >70cm
- resected >60g
- large blood loss
- perforation
- large amount of fluid used
- poorly controlled CHF

other complications
- retrograde ejaculation

165
Q

what investigation can be performed to ensure that a colonic anastomosis is intact

A

gastrografin enema

166
Q

describe prostate cancer

A

adenocarcinoma most common

most cancers lie in the peripheral zone

investigations
PSA >4
multiparametric MRI

Gleason grading system used

treatment
- watch and wait (low Gleason score)

  • radiotherapy / brachytherapy
  • surgery - radical prostatectomy
    > complications: incontinence, erectile dysfunction, urethral stenosis
  • hormonal therapy
    > LHRH analogues
167
Q

list blood film features in hyposplenism and 2 causes of hyposplenism

A

causes: post-splenectomy, coeliac disease

features
- target cells
- Howell-Jolly bodies
- Pappenheimer bodies
- Siderotic granules
- Acanthocytes

168
Q

describe blood film features of the following conditions
- IDA
- myelofibrosis
- intravascular haemolysis
- megaloblastic anaemia

A

IDA
- target cells
- pencil poikilocytes
- if combined B12/folate deficiency: dimorphic film with mixed microcytic and macrocytic cells

Myelofibrosis
- tear drop poikilocytes

Intravascular haemolysis
- schistocytes

megaloblastic anaemia
- hypersegmented neutrophils

169
Q

describe a gastric volvulus

A

Borchardt’s triad of vomiting, severe epigastric pain and failure to pass NG tube

170
Q

describe the management of transplant rejection

A

hyperacute rejection (minute to hours)
- due to pre-existing antibodies against ABO or HLA antigens
- no treatment is possible - graft must be removed

acute graft failure (<6 months)
- mismatched HLA. Cell-mediated (cytotoxic T cells)
- also caused by CMV
- may be reversible with immunosuppression and steroids

chronic graft failure (>6 months)
- antibody and cell-mediated mechanisms cause fibrosis

171
Q

describe a venous ulcer

A

occur due to the pooling of blood and waste products in the skin secondary to venous insufficiency.

occur in the gaiter area (between the top of the foot and bottom of the calf muscle)

associated with chronic venous changes
- haemosiderin deposits
- venous eczema
- lipodermatosclerosis

Occur after a minor injury to the leg

features
- large and shallow
- irregular, gently sloping border
- more likely to bleed
- less painful than arterial ulcers
- pain relieved by elevation and worse on lowering the leg

management
- compression therapy
- cleaning, debridement and dressing of wound
- pentoxifylline
- analgesia (but avoid NSAIDs)
- Tissue viability / specialist leg ulcer clinics in complex or non-healing ulcers

172
Q

describe an arterial ulcer

A

Occur distally, affecting the toes or dorsum of the foot

associated with peripheral arterial disease
> absent pulses, pallor and intermittent claudication

features
- small and deep
- well defined borders
- “punched-out” appearance
- pale colour due to poor blood supply
- less likely to bleed
- painful
- pain worse at night (when lying horizontally)
- pain worse on elevating and improved by lowering the leg (gravity helps the circulation)

management
- urgent referral to vascular to consider surgical revascularisation

173
Q

describe the areas and muscle movements supplied by the following nerves

  • deep peroneal
  • superficial peroneal
  • tibial
A

deep peroneal
- anterior compartment: tibialis anterior, extensor digitorum longus, peroneus tertius, extensor hallucis longus
> actions: dorsiflexion, inversion, eversion, toe extension,

superficial peroneal
- peroneal compartment: peroneus longus, peroneus brevis
> actions: eversion, plantarflexion

tibial
- posterior compartment: gastrocnemius, soleus, flexor digitorum longus, flexor hallucis longus, tibialis posterior
> actions: plantarflexion, toe flexion, inversion

174
Q

describe inguinal and femoral hernias

A

inguinal hernias
- superior and medial to pubic tubercle
- direct:
> cannot be reduced by pressing on deep inguinal ring
- indirect: exit point is the deep inguinal ring
> can be reduced by pressing on deep inguinal ring

femoral hernia
- inferior and lateral to pubic tubercle
- more common in multiparous women
- higher risk of strangulation

175
Q

describe total parenteral nutrition (TPN)

A

indications
- flare of inflammatory bowel disease
- short bowel syndrome
- bowel obstruction

TPN is very irritant to veins and can cause thrombophlebitis
> normally given through a central line

complications
- sepsis
- hyperglycaemia / hypoglycaemia
- dehydration and electrolyte imbalances

176
Q

describe testicular cancer and its treatment

A

2 types
> non-seminomas (mostly teratomas - terrible twenties)

> seminomas: sucky sirties

in older men
- interstitial tumour
- lymphoma

investigations
- scrotal USS
- bloods: AFP, bHCG, LDH
- staging CT CAP

common sites of metastasis: lymphatics, lungs, liver, brain

treatment
- radical orchidectomy
- chemotherapy / radiotherapy
- sperm banking for future use

177
Q

describe entonox and its use

A

Entonox is 50% O2 and 50% NO anaesthetic gas
> analgesic equivalent of 15mg morphine SC

often used in sports injuries

Contraindications
- impaired consciousness
- confirmed/presumed pneumothorax

178
Q

describe the ERAS protocol

A

key components

  • pre-operative
    > pre-admission education
    > reduced fasting duration
    > VTE prophylaxis
  • operative
    > active warming
    > opioid sparing
    > avoidance of prophylactic NG tubes and drains
  • post-operative
    > early oral nutrition
    > early ambulation
    > early catheter removal
    > pain and nausea management
179
Q

describe a Hartmanns procedure

A

aka proctosigmoidectomy

emergency procedure involving resection of rectosigmoid colon with closure of anorectal stump and formation of colostomy

> colostomy may be permanent or reversed at a later date

> performed in bowel obstruction due to tumour or significant diverticular disease

179
Q

Describe the WHO surgical safety checklist

A

aim is to reduce the risk of human error

checklist is completed at 3 stages:
> Before induction of anaesthesia
> Before first skin incision
> Before patient leaves theatre

involves multiple members of the team checking essential factors, such as:

  • Patient identity
  • Allergies
  • Operation
  • Risk of bleeding
  • Introductions of all team members
  • Anticipated critical events
  • Counting the number of sponges and needles to ensure nothing is left inside the patient
180
Q
A

Phase 4 (14 decks)

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