Surgery Flashcards
(79 cards)
1
Q
3 vessels typically used for CABG
A
- Internal mammary artery
- Radial artery
- Great saphenous vein
2
Q
Reasons for CABG over PCI?
A
Both are for coronary artery disease, to improve blood flow to heart.
CABG used if:
1. Multiple vessel disease
2. Diabetes
3. Significant blockage in left arteries (LAD/LCX over 50 and 70%)
4. LV dysfunction or mitral valve disease
3
Q
How is a CABG performed?
A
- Midline sternotomy
- Cardioplegia (controlled cardiac arrest)
- Proximal ends of radial artery/GSV are anastomosed onto ascending aorta. (The LIMA is supplied directly by left subclavian)
- Distal ends are anastomosed directly to target region of heart
- +/- pacing wire (post op AF in 1/3)
- chest drain insertion
4
Q
Gold standard investigation for suspected coronary artery disease
A
CT Angiography
5
Q
Surgical management for valvular disease
Catheter-based
Open heart surgery - main surgical approach?
What ix is used to assess valve function prior to closure?
A
- TAVI: Transcatheter aortic valve implantation: minimally invasive, LA. under X-ray guidance + fluoroscopy, access to aortic valve via guidewire in femoral artery. TV placed over diseases vavlue.
- Open heart surgery: valve repair/replacement with mechanical/tissue valves.
Midline sternotomy + cardiopulmonary bypass
Transesophageal ECHO
6
Q
Describe the branches off the aorta
A
- Brachiocephalic–>Right subclavian and right common carotid
- Left common carotid
- Left subclavian
7
Q
What information is received from an ECHO prior to valve replacement?
A
- Pre-valve and post-valve velocity
- Used in an equation to generate valve gradient
- in aortic stenosis (think hose pipe) the pressure is greater past the valve than before = higher gradient
- determines what type of prosthetic valve will be needed and the severity of disease
- aortic radius
8
Q
Role of cardiopulmonary bypass machine?
What medications are given during process?
A
- Bypasses the heart and the lungs during open heart surgery
- cannula inserted into right atrium and into aorta
- blood from right atrium is connected into machine which is pumped at a rate (based on patient’s weight) and oxygenated through fibres before being returned to aorta
- heparin as a blood thinner (reduce clot formation in the bypass machine) and protamine as a reversal agent
9
Q
IV Fluids
Intracellular: 2/3
Extracellular: 1/3
What compartments does the extracellular space split into?
Fluid moving into the non-functional space comes at expense of the intravascular space - resulting in…?
A
- Intravascular (20%)
- Interstitial (80%)
- The “third space” - areas that do not normally contain fluid - peritoneal/pleural/pericardial cavities, joints, excessive fluid within interstitial space (development of oedema)
- causing hypotension and reduced tissue perfusion
10
Q
4 sources of fluid intake
6 sources of fluid output
Define “insensible fluid loss”
A
Oral fluids, NG/PEG feed, IV fluids, TPN
Bowel/stoma output, vomiting, urine, sweating, drain output, bleeding
Insensible: fluid loss difficult to measure so only estimated (respiration, burns, sweat, stools) - in fever can be»_space;»>
11
Q
Fluid balance chart
- the fluid input should match the output
- determine if patient is fluid +ve or -ve
- if they are fluid -ve (more lost than gained)?
- if they are fluid +ve
A
- May req additional IV fluids
- Less
12
Q
Assessing fluid status
1. Signs of hypovolaemia
2. Signs of fluid overload
A
- HYPOVOLAEMIA
* Delayed CRT (>2 sec)
* Cold peripheries
* Reduced skin turgour
* Dry mouth, thirsty
* Hypotension (<100 systolic)1.1
* Tachycardia, tachypnoea
* Reduced urine output
* Increased bodyweight from baseline - FLUID OVERLOAD
* Peripheral oedema - ankles/sacrum
* Pulmonary oedema - SoB, low O2 sats, raised rep rate, bibasal crackles
* Raised JVP
* Increased body weight from baseline
13
Q
ACUTE ABDOMEN:
Generalised abdominal pain (4)
A
Peritonitis - general: perforation of organ; local - organ inflammation; SBP
Ruptured AAA
Ischemic colitis
Bowel obstruction
14
Q
ACUTE ABDOMEN:
RUQ PAIN (5)
A
Gallstones/bilary colic
Cholecystitis
Cholangitis
Hepatitis/liver abcess
15
Q
ACUTE ABDOMEN:
EPIGASTRIC PAIN (5)
A
Oesophagitis
Acute Gastritis
Pancreatitis
Ruptured AAA
Peptic ulcer disease - rupture
16
Q
ACUTE ABDOMEN:
LUQ pain (3)
A
Splenic - abscess, rupture, omegaly
17
Q
ACUTE ABDOMEN:
LEFT/RIGHT HYPOCHONDRIAL (FLANKS)
A
- Pyelonephritis
- Kidney stones/ureteric colic
- Ruptured AAA
- (all loin to groin pain)
18
Q
ACUTE ABDOMEN:
CENTRAL ABDOMINAL PAIN
A
Appendicitis (early stages)
Ruptured AAA
Ischemic colitis
Bowel obstruction
19
Q
ACUTE ABDOMEN:
RIF PAIN (5 inc. 3 gynae)
A
Appendicitis (later)
Bowel obstruction
Meckel’s diverticultiis
Gynae: Ovarian torsion, Ruptured ovarian cyst. ectopic pregnancy
Acute flare-up IBD (Crohn’s)
20
Q
ACUTE ABDOMEN
SUPRAPUBIC PAIN (5)
A
UTI
Acute urinary retention
Prostatitis
Gynae: PID, placental abruption
21
Q
ACUTE ABDOMEN:
LIF PAIN (5 inc. 3 gynae)
A
Diverticular disease - diverticulitis
Gynae: ruptured ovarian cyst, ectopic pregnancy, ovarian torsion
Acute flare-up IBD (UC)
22
Q
Management: Acute Abdomen
1. Emergency management
2. Investigations
3. Initial management options
A
1. Assess with A-E Approach; escalate to seniors
2. Investigations:
Bedside:
* Bloods - FBC (Hb, WCC), U&E (kidney function, e-), LFT (bilary/hepatic system), Group&Save (prior to theatre for blood transfusion), CRP, amylase (panc), INR (liver function), calcium (panc scoring)
* ABG/VBG - lactate (indication of tissue ischemia, O2 in ABG for acute pancreatitis)
* Cultures - infection suspected
* Urine - serum hCG (ectopic pregnancy)
Imaging:
* Generally Abdo CT
* Abdominal U/S: gallstones/bilary ducts, gynae
* Abdominal XR: bowel obstruction
3. Initial management
1. NBM (if surgery req/bowel obstruction)
2. NG tube (if BO)
3. IV Fluids (resus/maintenance)
4. IV Abx (if infection suspected)
5. Analgesia and prescribe regular meds
6. VTE risk assessment
23
Q
Appendicitis
Presentation
RFs
Abdo Examination findings
DRE findings
Dx/Ix
Management
Complications
A
- central –> RIF pain, anorexia, vomiting, fever
- young, male
- tenderness @McBurney’s point (1/3 from ASIS to umbilicus), Rovsing’s sign (LIF palpation causes pain in RIF), guarding, rebound tenderness RIF, percussion tenderness
- Right sided tenderness (during early stages)
- clinical diagnosis
- ix = +/- CT scan to confirm; US in females; diagnostic laporoscopy
- mx = emegrency admission for appendicectomy
- complications:
1. Rupture = peritonitis
2. Appendix mass (omentum) - abx and conserv. mx prior to surgery
24
Q
Bowel obstruction
* The higher up the bowel obstruction…
* Big 3 causes
* Other causes (3 + paeds)
* Classification
* Identification of closed-loop bowel obstruction - in large or small bowel
* Presentation
* Initial Mx
* Investigation
* Surgical intervention examples (4) - laporoscopic or laparotomy
A
- The greater the fluid losses that can’t be reabosrbed (third-spacing) –> hypovolaemia and shock
- Adhesions (SB), cancer (LB), hernias (SB)
- Strictures (Crohn’s), volvulus, diverticular disease, intussusception (<2yrs)
- Small bowel or large bowel obstruction; open or closed-loop obstruction
- Large bowel + competent ileocaecal valve: bowel expansion, ischemia & perforation. Or small bowel (adhesions/hernias/volvulus)
Presentation
1. Vomiting - green bilious
2. X Stool X or reduced flatus
3. Generalised abdominal pain & distension
4. Tinkling/reduced bowel sounds (sometimes)
Mx: - A-E.
- Drip and suck: IV Fluids, NBM & NG tube with free drainage
- Bloods - FBC, U&E, VBG (met. alkalosis; raised lactate), LFT, Coag, Group & Save
Ix - Abdo X-ray: distended bowel loops (valvulae:SB, hasutra:LB)
- Abdo CT (can go straight without XR to confirm dx)
- Chest XR (air under diaphragm)
Surgery
Exploratory - Adhesiolysis
- Hernia repair
- Emergency resection (obstructing tumour)
25
**Paralytic Ileus - pseudoobstruction**\\
Causes (4)
Most common cause
Presentation
Key differentiating sign from bowel obstruction
Mx
| peristalsis of small bowel stops; differential for small bowel obstructi
* Surgery, inflammation (peritonitis, appendicitis etc), electrolyte imbalance (low K+, low Na+), trauma
* Post abdo surgery (extensive bowel handling)
* Vomiting (green bilious), x stool/reduced flatus, generalised abdominal pain and distension
* Absent bowel sounds rather than tinkling
* Mx - supportive care: NBM, NG tube (if vomiting), IV fluids, mobilisation, +/- TPN
in a post op patient with reduced bowel sounds and distension post op ileus is most likely
26
**Volvulus**
Types
Causes
Presentation
Ix
What is the **coffee-bean**sign?
Initial Mx
Mx - surgical/conservative
| twisting of the bowel around itself and the mesentry --> Closed loop obs
* sigmoid (80%) or caecal
* sigmoid - chronic constipation, excessive laxative use, high fibre diet, old age, Parkinson's/neuro/psych, caecal - old age, adhesions & pregnancy
* BO
* Abdo XR + Abdo CT (confirms diagnosis)
* Sign of sigmoid volvulus on abdo XR
* drip & suck
* endoscopic decompression (if w/o peritonitis)
* OR surgical management (laparotomy + Hartmann's procedure for *sigmoid* or ileocaeccal resection/right hemicolectomy for *caecal*)
## Footnote
chronic constipation --> sinking of bowel loops into mesentry, twisting
27
**Hernias**
Presentation
Types (8)
Complications (3)
What is *Richter's hernia*?
What is *Madyl's hernia*?
General management (3)
* Palpable lump, protrudes when standing/coughing, aching/dragging sensation, reducible/irreducible
* Inguinal, femoral, incisional, umbilical, eipgastric, spigelian, obturator, hiatus
1. incarceration (irreducible, no pain as such)
2. obstruction (pain, distension, vomiting, constipation)
3. strangulated (irreducible, pain & erythema) + symptoms obstruction
* Abdominal wall hernia (rare) - only part of bowel wall herniates, causing strangulation but NOT obstruction
* 2 different bowel loops within one hernia
* Conservative (if wide neck), tension-free repair (mesh) or tension (suture muscles/tissues)
28
**Inguinal hernias**
* Location
* Distinguish indirect from direct
* Superior and medial to pubic tubercle
* **Indirect -** bowel goes through deep and superficial inguinal ring, through canal to scrotum; pressure applied to DIR hernia will remain reduced
* **Direct**: bowel herniates directly into canal, due to weakness in Hesselbach's triangle,pressure applied to DIR does not reduce hernia
29
**Femoral hernias**:
Location
Contents
Location - herniation through the femoral cancal, inferior/lateral to pubic tubercle
Contents - femoral Nerve, Artery, Vein, Canal (lymph vessels/nodes)
30
**Spigelian hernias** - location, presentation
**Diastasis recti** - location, why not typically a hernia, causes (3)
**obturator hernias** - location, causes, presentation
What is Howship-Romberg sign?
* Through spigelian fascia (aponeurosis of rectus abdominis and semilunar line); non-specific abdo pain +/- noticable lump
* widening of linea alba (connective tissue seperating the rectusabdominus), gap of muscles rather than bowel protrusion, congenital/obese/pregnancy
* protrusion of abdo/pelvic contents into pelvic obturator foramen, multiple pregnancies/old age, asymptomatic or pain in groin/thigh (obturator nerve irritation)
* pain in thigh during internal rotation of hip
31
**Hiatus hernias**
Defintion
Classes 1-4
Risk factors (3)
Ix
Stomach contents through hole in diaphragm
1. Sliding (stomach slides up, GOJ enters diaphragm)
2. Rolling (seperate portion of stomach enters alongside oesophagus)
3. Combination
4. Large (abdo contents in thorax)
Age, obesity, pregnancy
Ix - chest XR, abdo CT, endoscopy, barium swallow testing
Mx - conservative (treat reflux), surgical repair (lap fundoplication)
32
**Haemorrhoids**
Examination
Mx
Prevention
Non-surgical treatments
Surgical treatments
What is a *thrombosed haemorrhoid?*
* Ex - bear down (prolapse), proctoscopy
* Mx - topical treatments (*Anusol*astringent containing to shrink haemorrhoids; *Ansuol HC* steroid containing, germoloids cream - contains LA, procosedyl ointment)
* Prevention - high fibre diet, fluids, avoid strain
* Non-surgical - rubber band ligation, injection sclerotherapy, infra-red coagulation, bipolar diathermy
* Surgical- haemorrhoidal artery ligation, (stapled) haemorrhoidectomy
* Thrombosed- strangulation at base of haemorrhoid, causing clot formation and severe pain. Resolve with time but consider admission if in severe pain
*
*
33
**Diverticular disease**
* diverticulosis: RFs, presentation, ix, mx:
* Diverticulitis: presentation, mx for uncomplicated/complicated
* Investigation for perforated diverticulum?
* What complications would require surgery?
**Diverticulosis**
* Old age, low fibre diet, obesity, NSAID use
* LIF pain, constipation, rectal bleeding
* Abdo CT/colonoscopy
* Increase fibre intake, bulk-forming laxatives (*isphagula husk*)
**Acute diverticulitis**
* LIF pain, fever, diarrhoea, N&V, rectal bleeding
* *Uncomplicated*: in primary care:
1. Co-amoxiclav (5day)
2. Analgesia (pct)
3. Avoid solid food until symptoms improve
4. Follow-up in 2days
* *Complicated*: admit
1. NBM or clear fluids only
2. IV Abx
3. IV Fluids
4. Analgesia
*Complications*
* Diverticular abscess
* Perforation
* Peritonitis
* Large haemorrhage
* Fistula
* Ileus/obstruction
**Bowel perforation**
- Erect Chest X-ray
- pneumoperitoneum: suggestive of perforated abdominal structure (e.g. diverticula or ulcer)
34
**Mesenteric ischemia**
* Lack of blood flow through which vessels (from abdo aorta)?
* Classical triad of chronic mesenteric ischemia (*intestinal angina*) and diagnosis- same RFs as for CVD
* Managment CMI
* Presentation: acute mesenteric ischemia
* Ix and Mx
* Mortality rate
## Footnote
Ischemia in the small bowel - mesenteric
In large bowel - ischemic colitis
* Coeliac, superior and inferior mesenteric
**Chronic mesenteric ischemia**
1. Central colicky abdo pain (post-prandial 1-2hr)
2. Weight loss (due to food avoidance)
3. Abdominal bruit
- Ix: CT angiography
- Mx: reduce RFs, secondary prevention (statin, antiplatelet), revascularisation (stenting/open surgery)
**Acute mesenteric ischemia**
* Thrombus (CVD) or embolus (from AF)
* *generalised abdominal pain disproportionate to examination findings*
* Contrast CT Abdo
* Surgery: remove nectrotic bowel, remove/bypass thrombus (open surgery/endovascular)
* 50%
35
**Gallstones**
* Presentation
* What complications can patients present with (often gallstones themselves are asymptomatic)
* Initial ix (2)
* Further ix options (2)
* Mx
* Complications of surgical management
* Presentation of PCS
* *When would stones within the common bile duct be suspected?*
* RUQ colicky pain, after (fatty) meals 1-8hr, N&V
* Or present with acute cholecystitis, acute cholangitis, obstructive jaundice or pancreatitis
* Ix: Abdo U/S and Bloods (LFTs)
* Further ix if stones suspected in bile ducts: MRCP/ERCP
* Lap chole - if symptomatic or complications occur
* Bleeding, infection, adhesions/strictures, damage to BDowel, VTE, post-cholecystectomy syndrome
* Due to changes in bile flow --> diarrhoea, indigestion, abdo pain, intolerance of fatty foods
* *Ultrasound scan shows bile duct dilatation, jaundice, or raised bilirubin on LFTs - requires MRCP*
36
**Acute cholecystitis**
Presentation
Examination findings
Initial Ix
If diagnosis unclear -
Mx
## Footnote
caused by blocked cystic duct
* RUQ pain --> shoulder, fever, N&V, tachycardia, tachypnoea
* Murphy's sign: arrested inspiration on RUQ palpation
* Abdo US (thickened GB wall, stones/sludge, fluid around GB), Bloods (deranged LFTs)
* HIDA scan cholescintigraphy
* Emergency admission
* Conservative: NBM, IV Fluids, NG tube if vomiting
* Medical: IV Abx as per trust guidelines
* Surgical: cholecystectomy within 1 week of diagnosis
37
**Acute cholangitis**
* Charcot's triad
* Additional 2 factors
* Ix (imaginefrom least to most sensitive)
* Emergency admission - ix
* Management
* Example of proceudres during the ERCP
## Footnote
infection in the bile ducts; obstruction from gallstones or infection via ERCP
* RUQ pain, jaundice (raised bilirubin), fever
* Confusion and hypotension
* Abdo US --> CT --> MRCP --> ERCP
* Sepsis 6
* Conservative: NBM, IV Fluids, NG tube if vomiting
* Medical: IV Abx
* Surgical: ERCP after 24-48hrs to relieve obstruction
* stenting, balloon dilatation, sphincterectomy, stone removal
38
**Pancreatitis**
Causes (main 3)
Others (less common)
Which class of drugs increase the risk (2)
Presentation
Investigations
When would you do a CT Abdo
Glasgow Score: *0-1=mild, 2=moderate, 3+=severe* : what criteria is it based on?
Complications
* Gallstones, alcohol, post-ERCP
* Iatrogenic, trauma, steroids, mumps, autoimmune, scorpion sting, hyperlipidemia, drugs
* Diuretics - *Furosemide* and *Thiazides* and immunosuppressants (*Azathioprine*)
* Epigastric pain to back, N&V, fever, tachycardia
* FBC (WCC), U&E (urea), LFT (albumin. transaminase), Ca, Amylase (x3 upperlimit) or lipase, glucose
* ABG (PaO2, glucose) - need to determine severity using glasgow criteria: based on age and clinical findings such as calcium, urea and glucose
* CT Abdo if complications suspected
* **PANCREAS**
* Pa02 <8
* Age >55
* Neutrophils (WBC >15)
* Calcium <2 - LOW CALCIUM FOR SOME REASON
* uRea >16
* Enzymes (LDH >600 and AST/ALT >200)
* Albumin <32
* Blood glucose >10
* **Mx**
Initial resus: A-E approach
* Conservative: Admission - IV Fluids, NBM, analgesia
* Abx only if abscess or necrotising
* Abscess, Necrosis, pseudocysts, pancreatic fluid colection chronic pancreatitis,
39
**Chronic pancreatitis**
Key complications
1. Chronic epigastric pain
2. Loss of exocrine function - reduced pancreatic enzymes
3. Loss of endocrine function: reduced insulin release (diabetes)
4. Damage/strictures in biliary duct system - obstruction of bile and pancreatic juice
5. Formation of pseudocysts and abscess
40
**Chronic pancreatitis**
Management
* Conservative - avoid alcohol/smoking; analgesia
* Medical - replacement enzymes (Creon) for absorption of fat (reduce steatorrhoea and fat-soluble vitamin deficinecy); S/C insulin if diabetic
* Operative - ERCP with stenting
* Surgical - specialist centres for complications
41
**Peripheral vascular disease**
- Main 2 ways of classifying
- Definitions
| = PAD: narrowing/occlusion of peripheral arteries, causing reduction in
1. **Acute Limb Ischemia** - sudden onset rapid ischemia, 6 Ps, embolus/thrombus
2. **Chronic Limb Ischemia** (2)= intermittent claudication (crampy pain on exertion, relieved by rest, calf/thighs typically) aor critical limb ischemia (end-stage PAD, pain at rest)
(Acute on chronic also)
42
**Acute limb ischemia**
- 6 Ps
- Classify into (3)
- Initial Ix
- Factors suggestive of thrombus
- FActors suggestive of embolus
- Management: initial (4) and definitive (examples)
## Footnote
can be due to thrombus or embolus depending on pmhx and presenting complaint
- Pain @ rest, pallor, paraesthesia, pulseless, perishingly cold, paralysis (at 4hrs; irreversible if left for 6)
- Viable (motor and sensation intact, reviewd in AM), threatened (requries OOH) or irreversible (non-salvageable)
- Bloods = VBG (lactate), Group & Save
- Hand-held Doppler; if signals present --> ABPI
-**Thrombus**= existing PAD, intermittent claudication with sudden deterioration, reduced/absent pulses in C/L limb, evidence of vascular disease - MI, stroke, TIA etc
- **Embolus** = sudden onset painful leg <24hr, evidence of site of embolus (AF, recent MI), no PAD, evidence of proximal aneurysm (adbo/popliteal)
- **Initial mx**
- A-E
- Analgesia (IV Morphine)
- IV Heparin infusion
- Vasc review
- **Definitive mx options**
- Intra-arterial thrombolysis = via catheter to artery
- Surgical embolectomy/thrombectomy = removal of blockage
- Endarterectomy
- Bypasssurgery
- Amputation
43
**Peripheral vascular disease**
Describe Buerger's test (part 1)
Buerger's angle
Part 2: what colours do the legs go when hanging off the bed?
* If pallor develops in legs after 1-2 mins of lifting at 45degrees = likely PAD
* The angle at which the legs go pale
* +ve test for PAD if they go blue --> dark-red (ischemia --> vasodilation response)
44
**PVD**
Examination
Ix (3)
ABPI >1.3, >0.9, 0.6-0.9, 0.3-0.6, <0.3
Mx: conservative (2), medical (3), interventional options (3)
* Peripheral pulses (femoral, popliteal, dorsalis pedis, posterior tibialis)
* **IX**
* *1st line* = Duplex Ultrasound
* ABPI
* MRA prior to any intervention
* Calicification of arteries (e.g. diabetic)
* **ABPI interpretation**
* Normal
* Claudication (mild PAD)
* Rest pain (mod-severe)
* Impending (severe- critical)
**Management**
* Conservative = lifestyle changes, manage modifiable RFs; *Structured exercise program* (first-line)
* Medical =
1. Atorvastatin 80mg
2. Clopidogrel 75mg OD
3. Naftidofuryl oxalate (peripheral vasodilator)
* Surgical
* Endovascular revascularisation = percutaneous angioplast +/- stent
* Surgical revascularisation = endarterectomy, bypass, open surgery
45
**DVT**
* Presentation
* If measuring the difference in circumference between both calves, how many cm is considered significant?
* What is the **WELLS SCORE**?
* D-Dimer is sensitive but not specific for VTE - what else can raise D-Dimer?
* Investigations
* Initial mx
* Long term mx
* Duration of long term (3 months, -6 months, 3-6 mo)
* What if the first line investigation can't be carried out in 4 hours?
* What if this comes back negative but there is still high suspicion for DVT?
* When patients have an unprovoked VTE after 3-6months treatment what should they be tested for (2)?
* Unilateral calf swelling, redness, pain, dilated superficial veins
* >3cm
* Predicts chance of symptomatic patient having a DVT or PE (recent surgery, clinical findings, pmhx e.g. cancer and calf swelling). For DVT = **2 level Wells Score**
* Surgery, cancer, pneumonia, heart failure, pregnancy
**Ix**
* DVT= Doppler ultrasound
* PE = CTPA
**Mx**
* Initial - Anticoagulation = *DOAC* - *Apixaban*
* Long term - Anticoagulation *DOAC, Warfarin, LMWH*
* 3 months = if reversible cause
* 6 months = irreversible underlying cause, unclear, recurrent
* 3-6months = active cancer
* If ultrasound not carried out within 4 hrs, start interim anticoagulation. If comes back negative, stop interim anticoagulation (if likely DVT with Wells >2 and +ve D-Dimer repeat in 6-8 days later)
**Unprovoked VTE**
- Antiphospholipid syndrome (abs)
- Hereditary thrombophilias if have 1st degree relative also affected by DVT/PE
46
**Varicose veins**
* How do they develop?
* Risk factor populations
* Presentation: engorged/dilated superficial leg veins >3mm diameter +/- what other symptoms?
* Ix
* Special tests - name 4
* Mx - conservative and surgical
* When valves become incompetent, blood drawn downwards by gravity, pooling in veins and feet
* **incompetent valves in the perforating veins** (between deep and superficial) causes overflow of blood in superficial veins --> dilatation and engorgement
* Pregnancy, obesity, prolonged standing age,
* aching/dragging/cramping, burning/itching, restless legs, sx of CVI
* **Duplex ultrasound** - measures speed & volume of blood flow - demonstrates *retrograde venous flow*
* Tap (incompetent valve between varicose vein & SFJ)
* Cough (incompetent valve at SFJ)
* Trendelenburg (tourniquet prevents distal varicose veins from reappearing)
* Perthes (increased dilation of superficial veins during calf muscle pumping)
* **Mx**
* Conservative = leg elevation to help drainage, exercise, compression stockings, W/L
* Surgical = endothermal ablation, sclerotherapy, stripping
47
Distinguish:
**varicose**
**reticular**
**telangectasia** = thread/spider veins
Varicose = >3mm diameter
Reticular = 1-3mm
Telangectasia = <1mm
48
**Chronic venous insufficiency**: define the following skin changes:
- haemosiderin deposition
- venous eczema
- lipodermatosclerosis
- panniculitis
- atrophie blanche
## Footnote
impaired blood flow from veins to the heart; often associated with varicose veins; incompetent valves --> pumping less effective --> blood pools in veins of legs (causing venous hypertension)
- brown discolouration due to leakage of hb
- chronic inflammatory response causing dry/itchy/flaky/red skin
- hardening of skin and subcut tissue, causing constriction - "inverted champagne bottle" appearance
- inflammation of subcut fat
- patches of white scar tissue surrounded by hyperpigmentation
49
CVI
Conservative mx
Weight loss
Exercise
Keep legs elevated
Compression stockings
Skin care- emollients, steroids for eczema flare-ups/lipodermatosclerosis
50
**Ulcers**
Arterial
* associated with PAD, absent pulses, intermittent claudication
* punched out appearance
* toes or dorsum; heel
* deeper and smaller than venous
* painful, worse at night and by elevating
51
**Ulcers**
Venous
* associate with CVI, varicose veins
* Skin changes of CVI - haemosiderin deposition, lipodermatosclerosis, venous eczema, atrophie blanche
* affect gaiter area
* more widespread, and sueprficial than arterial, more likely to bleed
* irregular, gently sloping border
* less painful than arterial, pain relieved byelevation (helps venous blood return to heart)
52
Ulcers
**Marjolin**
* SCC, lower limbs
* occur at sites of chronic inflammation
53
**Ulcers**
Neuropathic
* diabetes, underlying peripheral neuropathy
* plantar surface of metatarsal head/hallux
* pressure points
54
**Ulcers**
pyoderma gangrenosum
* IBD/RA
* Stoma sites
* nodules/pustules that ulcerate
55
**Ulcers**
Investigation (both A & V)
Other ix
Mx arterial
Mx venous
Mx mixed
Mx diabetic
* ABPI
* Bloods - FBC/CRP (infection, anaemia), Hba1c (diabetes)
* Swabs - ?infection
* Skin biopsy ?skin cancer
* **Arterial**: urgent vascular referral ?surgical revasculariation
* **Venous**: compression therapy +/- referral to clinics for specialist treatment (complex/non-healing/diabetic)
* **Mixed**: referral to vascular surgery
* **Neuropathic**: cushioned shoes to reduce callous formation, referral to diabetic foot services
56
**AAA** - dilation >3cm
* screening age
* screening results: 3, 3-4.4, 4.4-5.4, >5.5
* presentation
* ix (2)
* Elective repair is recommended for patients with (3)
* Mx options
* Men 65+ U/S
* Less than 3: Normal
* 3-4.4: Low-risk rupture, small aneurysm, 12 mo U/S
* 4.4-5.4; Low risk, 3 mo U/S, medium aneurysm
* >5.5: High risk rupture- 5%, large (1/1000 detected at screening) - urgent referral vasc surg
* abdo pain, pulsatile mass
* U/S; CTA
**Elective repair**:
>5.5cm diameter, >1cm growth per year, symptomatic
**Mx**
- Endovascular aneurysm repair (EVAR) - stent via femoral artery
- Open repair (laparotomy)
57
Ruptured AAA
* Presentation (3)
* Ix
* Mx
1. Severe abdo pain radiating to back/groin
2. Haemodynamic instability, LoC
3. Pulsatile mass in abdomen
**Ix**
- Clinical diagnosis alone
- or CTA to diagnose/exclude if haemodynamically stable
**Mx**
- A-E: Bloods (6 x u crossmatch), Iv Access
* Permissive hypotension - *cautious fluid resus aiming for lower than normal BP*
* Unstable --> urgent surgical repair
58
**Aortic dissection**
* Stanford:Type A vs Type B
* DeBakey: Type I/II, Type III
* Risk factors
* Presentation
* Ix - if stable (and typical finding?)
* OTHER IX
* Mx - initial
## Footnote
tear in the inner layer of the arota: blood flow within the intima and media layers of the aorta
* A: Ascending, before brachiocephalic artery; most common
* B: Descending, after left subclavian
* I: Ascending --> arch --> distal
* II: Confined to ascending aorta
* III: Descending aorta
* RFs: hypertension, CTDs (Marfan's, E/D), congenital heart defects (bicuspid valve, coarctation of the aorta), heart surgery (AVR, CABG)
* Sudden onset severe chest pain (+/- radiating to back); hypertension, >20mm Hg BP difference between arms, radial pulse deficit, diastolic murmur, abdo pain, hypotension (as progresses)
**Ix**
* CTthorax
* **false lumen** - "double lumen" in both ascending and descending aorta +/- intimal flap
* CXR, ECG (note MI in combination)
**Mx**
A-E
Analgesia (IV Morphine)
Control BP to systolic 100-120 (beta-blockers)
Urgent referral vasc surgeons
59
**Carotid artery stenosis**
* Classification (mild, moderate, severe)
* Presentation
* Ix (2)
* Mx - conservative & surgical
* Complication of endarterectomy
## Footnote
narrowing of the carotid arteries in the neck ; by atherosclerosis
* Mild: less than 50%
* Severe: greater than 70%
* Asymptomatic; diagnosed post stroke/TIA
* *or* carotid bruit (turbulent flow)
* Carotid U/S
* CT/MR Angiogram prior to intervention
* Cons mx: address RFs
* Medical mx: Atorvastatin and Antiplatelet (Clopidogrel, aspirin, ticagrelor)
* Surgical: **carotid endarterectomy**, angioplasty + stenting
* Nerve injury; stroke
60
**Buerger disease/ thrombophlebitis obliterans**
* Presentation
* angiogram finding
* mx (2)
## Footnote
thrombus formation in small/medium blood vessels of the arterial system, affects hands and feet
* painful blue fingertips/toes --> ulcers/gangrene
* **corkscrew collaterals** (new formation to bypass affected arteries)
* smoking cessation
* IV iloprost
61
**Breast cancer**
Triple assessment
Referral guideliines:
- breast lump or axillary lump 30+ yrs
- unilateral nipple changes 50+
- skin changes suggestive of breast ca
- unexplained breast lumps under 30 yrs
1) Assessment (hx and examination)
2) Imaging (US or Mammography)
3) Histology (FNA or core biopsy)
**2WW referral** for over 30 with unexplained breast/axillary lump, over 50 with unilateral nipple change, any age with skin changes suggestive of breast ca
**Non-urgent referral** for u/e breast lumps under 30 yrs
62
Fibroadenoma
*"breast mouse"*
- examination findings
- age group
- hormone responsive?
- Mx
- if>3cm
* smooth, mobile, round, untethered, well-circumscribed, under 3cm, painless
* 20-40yrs
* yes; hence regress post menopause
* refer to exclude breast ca (if applicable), education
* surgical excision if over 3cm adn casing moderate discomfort
63
Fibrocystic breast changes = **fibroadenosis**
* Hormone responsive?
* Presenting sx (3)
* Mx
* Variation of normal - hardening of the ducts and lobules (stroma) in response to female sex hormones
* Yes; regress post menopause; can be worse prior to menstruation
* Lumpiness, mastalgia, fluctation in breast size
* refer to exclude breast ca; supportive care (specific bra; NSAIDs, hormonal treatments under guidance)
64
**Breast cyst**
* Examination findings
* Typical age group
* Most common time to have them
* mx
* incrased risk of breast ca?
* smooth, well circumscribed, possibly fluctant, mobile
* 30-50
* more in post menopausal period
* change in size with menstrual cycle
* exclude breast ca --> possible **FNA or excision**
* slightly
65
**Fat necrosis**
- formed by
- common triggers (3)
- examination findings
- mx
* localised scarring of fat tissue and necrosis
* associated with an **oil cyst** of liquid fat
* trauma, radiotherapy, surgery
* painless, firm, irregular shape, fixed, + skin dimpling/nipple inversion
* rule out brast ca - conservatvge management or surgery
66
**Lipoma**
* Examination findings
* mx
* soft, painless, mobile
* no skin changes
* conservative with reassurance or surgical removal
67
**Galactocele**
breast-milk filled cyst due to blocked lactiferous duct
* examination findings
* management
* smooth, firm, mobile, painless lump **beneath areola**
* spontaneously resolve or drain with needle
68
**Phyllodes tumour**
* What is it?
* Presentation
* most common age
* Benign/borderline/malignant?
* mx
* tumours of stroma (ducts and lobules)
* rapidly growing lump
* 40-50
* 50%, 25%, 25%
* wide excision
* chemo for malignant/metastatic
69
**Breast pain**
- typical cause if cyclical - e.g. luteal phase (2 weeks before menstruation)
- if non-cyclical (3)
- what can help diagnosis
- supportive mx (4)
- hormonal treatment
**Cyclical**
* Premenstrual syndrome
**Non-cyclical**
* costochondritis
* medications (OCP)
* infection
* pregnancy
* skin - shingles
**Diagnosis**
* breast diary
**Mx**
* supportive bra
* NSAIDs
* avoiding caffeine
* apply heat to area
**hormonal treatment**
- *Danazol*
- *Tamoxifen*
70
**Gynaecomastia**
*excess growth of breast tissue in males due to imbalance between oestrogen and testosterone, or increased prolactin ; generally idiopathic/benign*
**Excess oestrogen**
* What 2 cancers could be related
* what could also be an underlying cause (2)
* medications
**Reduced testosterone**
* causes (5)
* medications
**Increased prolactin levels**
* medications
**Dx**
**Mx**
**Increased oestrogen**
small cell lung cancer secreting hCG testicular ca - Leydig cell (in 2%) - note testicular exam (and US)
*steroids, digoxin*
**Reduced testosterone**
liver failure and hyperthyroidism
testicular damage
testosterone deficiency (old age)
reduced LH/FSH (hypothalamus/pituitary related)
Klinefelter syndrome (XXY)
orchitis
*Spironalactone*
**Increased prolactin**
*Antipsychotics* - dopamine antagonists
*GnRH agonists*
**Other**
drugs, alcohol
**Dx**
Pseudogynaecomastia (obesity) - distinguish gynaecoamastia by presence of firm tissue behind areola
**Mx**
depends on underlying cause - watchful waiting or indepth if rapid onset (bloods, imaging)
treat if problematic- *Tamoxifen* or surgery
71
**Hyperprolactinaemia**
Causes -
* hormone-secreting pituitary tumour
* endocrine disorders (2)
* medications -
Patho- suppressed GNRH -->
* reduced LH and FSH release --> what can this cause?
* Ix
prolactinoma
PCOS or hypothyroid
dopamine antagonists
menstrual irregularities (amenorrhoea), gynaecomastia (men), reduced libido and ED
Ix - bloods (prolactin, renal profile, TFTs, LFTs)
dopamine agonists - *Bromocriptine or Cabergoline*
surgery if pituitary tumour
72
**Duct ectasia**
* Presentation
* age group
* risk factor
* ix
* mx
* nipple discharge - white,grey,green , **slit like retraction/**inversion, tenderness/pain, breast lump
* multiple duct discharge
* perimenopausal (50+)
* smoking
* triple assessment + ductography/ductoscopy/cytology
* self-resolve (benign); sx management, surgical excision if problematic, abx if infection suspected
73
**Intraductal papilloma**
*proliferation of epithelial cells; benign *
* Presentation
* age range
* ix
* what is seen on ductography
* mx
* tissue is examined for ?
* clear or blood stained discharge from a single duct - *most common cause of blood stained nipple discharge in younger women*
* 35-50
* triple assessment + ductography - filling defect is seen
* surgical excision
* atypical hyperplasia
74
**Candida of the nipple**
* can be caused by
* and can result in
* treatment for mother
* and baby
* post antibiotics
* recurrent mastitis
* topical micanazole 2%
* oral micanazole or nystatin
75
**Lactational mastitis**
Painful, tender, erythmatous breast +/- fever
Mx -
1st line?
If symptoms do not improve within 12-24hrs/or if culture indicates infection?
If develops into abscess?
* Continue breast-feeding, analgesia, warm compress
* Oral Fluclox 10-14day; continue breast-feeding
* Incision and drainage
76
Distinguish Paget's disease of the nipple from eczema
Paget's disease: nipple --> areola; unilateral
Eczema: starts on breast --> areola, rarely affects nipple; both breasts
77
**Breast cancer**
* Types- insitu
* Types - invasive
* Other
* Rarer types
* Paget's disease of the nipple implies..
* DCIS
* LCIS
* IDC
* ILC
* Inflammatory
* Medullary, mucinous etc
* Invasive cancer
78
**Triple assessment**
1. Hx and Ex
2. Imaging - US or mammogram? What else is assessed?
3. Biopsy - 2 types? When would **sentinel lymph node biopsy** be used? Which receptors are the sample tested for?(3) What is triple negative?
2. US for under 30, mammogram for over 30. Imaging includes **axillary US** to assess axillary LNs.
3. FNA or core biopsy (inc. US guided biopsy of abnormal nodes)
SLNB used during breast ca surgery when initial ultrasound doesn't show abnormal nodes.
SAmples are tested for:
1. Oestrogen receptors
2. Progrestergone receptors
3. HER2
Triple neg if -ve to all above
79
**Breast cancer management**
* Which patients require axillary LN clearance during surgery, without pre-op axillary U/S or sentinel node biopsy first?
* Main 2 options for surgery
* Indications for both
**Other management includes hormonal, biological and chemotherapy**
- Options for hormonal (2)
- Options for biological - mabs (3)
- Chemo regimen and reason
* If patient presents with clinically palpable lymphadenopathy
**Surgical options**
1. Wide local excision + radio-x (*small, peripheral, solitary, less than4cm DCIS*)
2. Mastectomy + initial/delayed reconstruction (*larger, central, multifocalm, DCIS greater than 4*)
**Hormonal**
- Tamoxifen (SERM)
- Anastrozle/Letrozole (Aromatase inhibitor)
**Biologic**
For HER2+ve
- Trastazumab (Herceptin)
- Pertuzumab (Perjeta)
- Neratinib (Nerlynx)
**Chemo**
FEC-D
Neoadjuvant or after surgery e.g. in axillary node disease
