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1

Pathophysiology of acute pancreatitis

Pancreatic enzymes released and activated-> multi stage process

 

Oedema + fluid shift + vomiting ---> hypovolaemic shock

Enzymes----> autodigestion

Vessel autodigestion---> retroperitoneal haemorrhage

Inflammation-----> pancreatic necrosis

2

Implications of pancreatic necrosis

Super-added infection in 50% of patients with necrosis

3

Epidemiology of acute pancreatitis

1% of surgical admissions

4th and 5th decades

10% mortality

4

Aetiology of pancreatitis

 

Idiopathic (?microstones)

Gallstones

Ethanol

Trauma

Steroids

Mumps (+ other infections e.g. Coxsackie B)

Autoimmune: PAN

Scorpion (Trinidadian)

Hyperlipidaemia, Hypercalcaemia, Hypothermia

ERCP

Drugs: thiazides, azathioprine

5

Severe epigastric pain radiating to the back

May be relieved by sitting forward

Vomiting

?Acute pancreatitis

6

Raised HR, Raised RR

Fever

Hypovolaemia---> shock

Epigastric tenderness

Jaundice

Ileus (absent bowel sounds)

Ecchymoses

?Acute pancreatitis

7

Grey turner's

Flank ecchymoses

8

Cullen's

Periumbilical ecchymosis (tracks up falciform)

9

Grey Turner's sign

Flank ecchymosis

Acute pancreatitis

10

Cullens sign

Peri-umbilical ecchymosis

Acute pancreatitis

11

Ddx for acute pancreatitis

Perforated duodenal ulcer

Mesenteric infarction

MI

12

Difference between Glasgow and Ranson criteria

Glasgow criteria valid for EtOH and gallstones
 whereas Ranson only applicable to Etoh and can only be fully applied after 48 hours

13

Components of modified glasgow score

PANCREAS

PaO2 <8kPA

Age >55

Neutrophils >15 x 10^9

Ca <2mM

Renal function, U >16mM

Enzymes: LDH >600iu/L, AST >200 iu/L

Albumin <32 g/L

Sugar >10mM

14

Modified Glasgow criteria cut offs

1= mild

2= moderate

3= severe

15

Ix in acute pancreatitis and what would be seen

 

 

Bloods

Bloods:

FBC- raised WCC

Raised amylase (>1000/3x ULN) and raised lipase

U+Es: dehydration and renal failure

LFTs: cholestatic picture, raised AST, raised LDH

Ca: reduced

Glucose: raised

CRP: monitor progress, >150 after 48 hours= severe

ABG: reduecd O2 suggests ARDS

 

 

16

Ix in acute pancreatitis and what would be seen

 

 

Urine

Glucose

Raised conjugated bilirubin

Reduced urobiliongen

17

Ix in acute pancreatitis and what would be seen

 

 

Imaging

CXR: ARDS, exclude perforated DU

AXR: sentinel loop, pancreatic calcification

 

USS: gallstones and dilated ducts, inflammation

Contrast CT: Balthazar severity score

18

Cut offs for amylase in acute pancreatitis

>1000/ 3xULN

19

Difference between lipase and amylase

Lipase is more sensitive and speciic

20

CRP >150 after 48hrs in acute pancreatitis

Severe

21

What is used to grade severity of pancreatitis on CT?

Balthazar severity score

22

Complications of acute pancreatitis

Early: systemic

Respiratory: ARDS, pleural effusion

Shock: hypovolaemic or septic

Renal failure

DIC

Metabolic: hypocalcaemia, raised glucose, metabolic acidosis

23

Complications of acute pancreatitis

Late (>1w)

Pancreatic necrosis

Pancreatic infection

Pancreatic abscess: may form in pseudocyst or in pancreas, may require open or percutaenous drainage

Bleeding: e.g. from splenic artery, may require embolisation

Thrombosis: splenic artery, GDA or colic branches of SMA, may subsequently lead to bowel necrosis. Portal vein, may subsequently lead to portal HTN

Fistula formation: pancreato-cutaneous due to skin breakdown

24

Def: pancreatic pseudocyst

Collection of pancreatic fluid in the lesser sac, surrounded by granulation tissue

Occurs in 20% especially in EtOHic pancreatitis

25

4-w after acute attack

Persisting abdominal pain

Epigastric mass-> early satiety

?Pancreatic pseudocyst

26

Complications of pancreatic pseudocyst

Infection-> abscess

Obstruction of duodenum or common bile duct

27

Ix in pancreatic pseudocyst

Persistently raised amylase +/- deranged LFTs

USS/CT

28

Management of pancreatic pseudocyst

<6cm: spontaneous resolution

>6cm:

Endoscopic cyst-gastrostomy

Percutaenous drainage under US/CT

29

Causes of chronic pancreatitis

 

AGITS

Alcohol: 70%

Genetic: CF, HH

Immune: lymphoplasmacytic sclerosing pancreatitis (raised IgG4)

TGs raised

Structural: obstruction by tumour, pancreas divisum

30

Sentinal loop

Focal dilated proximal jejunal loop in the LUQ

Acute pancreatitis

31

Pancreatic calcification

32

Epigastric pain: bores through to back

Relieved by sitting back or hot water bottle: erythema ab igne

Exacerbated by fatty food or EtOH

Steatorrhoea and weight loss

(Polyuria and polydipsia)

(Epigastric mass)

Chronic pancreatitis

 

(DM)

(pancreatic pseudocyst)

33

Complications of chronic pancreatitis

Pseudocyst

DM

Pancreatic cancer

Pancreatic swelling-> biliary obstruction

Splenic vein thrombosis

34

Ix in chronic pancreatitis

Raised glucose

Reduced faecal elastase= indicative of reduced exocrine function

LFTs

 

USS: pseudocyst

AXR: speckled pancreatic clacifications

CT: pancreatic calcifications

35

Serum amylase in chronic pancreatitis

serum amylase level is not routinely raised, is not diagnostic in chronic pancreatitis, and testing should therefore not be performed.

36

Px of chronic pancreatitis

1/3rd die within 10y

37

Conservative management of chronic pancreatitis

No EToH or smoking

Reduced fat and increased carb diet

38

Medical management of chronic pancreatitis

Analgesia: NSAIDS/paracetamol first line. ?weak opiate (codeine phospohate) if not effective. May need additional pain relief in primary care e.g. coeliac plexus block.

Enzyme supplementation e.g. Creon

Cobalamin/thiamine supplementation

ADEK vitamins

DM Rx

 

(Octreotide: somatostatin analgoe that inhibits pancreatic enzyme secretions)

39

Screening in chronic pancreatitis

DM

Osteoporosis

40

Indications for Surgical Mx of chronic pancreatitis

Unremitting pain

Weight loss

Duct blockage

41

Surgical options of management of chronic pancreatitis

Distal pancreatectomy: Whipple's

Pancreaticojejunostomy: drainage

Endoscopic stenting

42

Monitoring in management of acute pancreatitis

Manage at appropriate level e.g. ITU if severe

Constant reassessment:

Hourly TPR, UO

Daily FBC, U+Es, Ca, glucose, amylase

43

Medical management of acute pancreatitis

ABC approach

Aggressive fluid resus: keep UO >30ml/h

Catheter+/- CVP

 

Pancreatic rest:

NBM

NGT if vomiting

TPN may be required

 

Analagesia:

pethidine or buprenorphine ± intravenous (IV) benzodiazepines. Morphine is relatively contra-indicated because of possible spastic effect on the sphincter of Oddi.

 

Antibiotics:

Not routinely given, use if suspected infection or before ERCP

Penems often used, but use to treat specific infections

 

Mx complications

 

 

44

Mx of the complications of acute pancreatitis

ARDS: O2 therapy or ventilation

Raied glucose: insulin sliding scale

Ca

EToH withdrawal: chlordiazepoxide

45

ERCP use in acute pancreatitis

Diagnostic

Can be used if pancreatitis with dilated ducts secondary to gallstones. ERCP and sphincterectomy -> reduces complications

46

Indications for surgical management of acute pancreatitis

Infected pancreatic necrosis

Pseudocyst or abscess

Unsure re dx

47

Operations used in treatment of acute pancreatitis

Laparotomy + necrosectomy (pancreatic debridement)

Laparotomy + peritoneal lavage

Laparostomy: abdomen left open with sterile packs in ITU

48

Epidemiology of gallstones

~8% of the population >40 years

Incidence increasing

Slight increased incidence in females

90% of gallstones remain asymptomatic

49

5Fs of gallstones

Fair

Fat

Female

Forty

Fertile

50

What is the general composition of gallstones

Phopsholipids: lecithin

Bile pigments (broken down Hb)

Cholesterol

51

What are the relative proportions of the different types of gall stones?

Mixed stones: 75%

Cholesterol stones: 20%

Pigment stones: 5%

52

What is the aetiology of gallstones

Lithogenic bile: Admirand's triangle

Biliary sepsis

GB hypomotility-> stasis: pregnancy, OCP, TPN, fasting

53

What is admirand's triangle

A delicate balacnce exists between the levels of bile acids, phospholipids and cholesterol

When this balance is disrupted, especially when there is supersaturation with cholesterol, there is predisoposition to the formation of lithogenic bile and the conseuqent development of cholesterol-type gallstones.

This is because when cholesterol supersaturates it tends to crystallise and in the presence of enucleating factors can be a nidus for stone formation

54

Large often solitary gallbladder stone

Cholsterol

55

Formation of cholesterol gallstones

According to Admirand's triangle:

decreased bile salts

decreased lecithin

increased cholesterol

56

What are the risk factors for the development of cholesterol stones?

Female

OCP/pregnancy

Increasing age

High fat diet + obesity

Racial e.g. American Indian tribes

Loss of terminal ileum (reduction in bile salt reabsorption)

57

What is the composition of pigment stones in the gall bladder

Calcium bilirubinate

 

58

With what are pigment GB stones associated?

Haemolysis

59

Small, black gritty, fragile GB stones

Pigment stones

60

Often multiple GB stones with cholesterol as the major component

Mixed stones

61

What are the complications of gallstones

In the gallbladder:

Biliary colic

Acute cholecystitis +/- empyema

Chronic cholecystitis

Mucocele

Carcinoma

Mirizzi's syndrome

 

In the CBD:

Obstructive jaundice

Pancreatitis

Cholangitis

 

In the gut:

Gallstone ileus

62

Mirizzi's syndrome

Mirizzi's syndrome is a rare complication in which a gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the common bile duct (CBD) or common hepatic duct, resulting in obstruction and jaundice. The obstructive jaundice can be caused by direct extrinsic compression by the stone or from fibrosis caused by chronic cholecystitis (inflammation). A cholecystocholedochal fistula can occur

63

Pathogenesis of biliary colic

Gallbladder spasm against a stone impacted in the neck of the gallbladder: Hartmann's pouch

Less commonly, the stone may be in the CBD

64

What is Hartmann's pouch?

a spheroid or conical pouch at the junction of the neck of the gallbladder and the cystic duct.

65

RUQ pain radiating to back (scapular region)

Associated with sweating, pallor, N+V

Attacks may be precipitated by fatty food and last <6h

O/E tenderness in right hypochondrium

(jaundice)

?Biliary colic

(if stone is in the CBD)

66

DDx for biliary colic

Cholecystitis/other gallstone disease

Pancreatitis

Bowel perforation

67

Ix in biliary colic

 

Urine

Same work up as cholecystitis

Urine:

Bilirubin, urobilinogen, Hb

 

 

68

Ix in biliary colic

 

Bloods

Bloods: FBC, U+E, amylase, LFTs, G+S, clotting CRP

69

Ix in biliary colic

 

Imaging

AXR: 10% of gallstones are radio-opaque

Erect CXR: ?perforation

 

USS:

stones: acoustic shadow

dilated ducts >6mm

Inflamed GB: wall oedema

70

Indications for MRCP in biliary colic

bile duct dilated and or liver function tests abnormal and USS has not detected CBD stones

71

What is the indication for endoscopic USS in biliary colic

If MRCP does not allow diagnosis to be made

72

Mx of biliary colic

Conservative:

Rehydrate and NBM

Opioid analgesia: morphine 5-10mg/2h max

High recurrence rate therefore surgical management is favoured

NB asymptomatic gallbladder stones do not need treatment

 

Surgical:

Laparoscopic cholecystectomy:

Urgent (within 1w of diagnosis in those with acute cholecystitis)

Elective at 6-12w

Percutaenous choleystotomy

73

Indications for percutaenous cholecystotomy

Management of gallbladder empyema when:

surgery is contraindicated at presentation and conservative management is unsuccessful.

 

Reconsider lap chole for people whho have had percutaenous cholecystotomy once they are well enough for surgery

74

Mx of CBD stones

Offer bile duct clearance and lap chole to people with symptomatic or asymptomatic CBD stones

 

Clear the bile duct:

surgically at the time of lap chole

or with ERCP before or at time of surgery

 

If the bile duct cannot be cleared with ERCP, use bilirary stenting to achieve drainage as a definitive measure until definitive clearance

75

Pathogenesis of acute cholecystitis

Stone or sludge impaction in Hartmann's pouch leading to chemical and or bacterial inflammation

5% are acalculous: sepsis, burns, DM

76

Sequelae of acute cholecystitis

Resolution +/- recurrence

Gangrene and rarely perf

Chronic cholecystitis

Empyema

77

Servere RUQ pain

Continuous radiating to right scapula and epigastrium

Fever

Vomiting

?Acute cholecystitis

78

Local peritonism in RUQ, tachycardia with shallow breathing

+/- jaundice

Murphy's sign

Phlegmon

Boas's sign

?Acute cholecystitis

79

What is Murphy's sign

2 fingers over the GB and ask patient to breath in

Pain and breath catch, must be -ve on the left

80

What is phlegmon

May be palpable in acute cholecystitis

Mass of adherent omentum and bowel

81

What is Boas' sign

Hyperaesthesia below the right scapula

82

Ix in acute cholecystitis

 

Urine

Bilirubin, urobilinogen

83

Ix in acute cholecystitis

 

Bloods

FBC: raised WCC

U+E: dehydration from vomiting

Amylase, LFTs, G+S, clotting, CRP

84

Ix in acute cholecystitis

 

Imaging

AXR: gallstone, porcelain GB

Erect CXR: perforation

 

USS:

stones, acoustic shadow

Dilated ducts >6mm

Inflamed GB: wall oedema

 

MRCP if dilated ducts seen on USS

85

Porcelain gallbladder is an uncommon manifestation of chronic cholecystitis, characterized by intramural calcification of the gallbladder wall [1]. The term "porcelain gallbladder" is used to describe the bluish discoloration and brittle consistency of the gallbladder wall seen in this condition [

86

Mx of acute cholecystitis

Admit

 

Conservative:

NBM

Fluid resuscitation

Analgesia: paracetamol, diclofenac, codeine, naproxen, IM pethidine

Abx:

cef and met

80-90% settle over 24-48h

Deterioration may be suggestive of perforation/empyema

 

Surgical:

May be elective surgery at 6-12w (once inflammation has reduced)

Or if <72h can perform lap chole in acute phase

 

87

High fever

RUQ mass

Think ?GB empyema

 

Percutaenous drainage via cholecystotomy may be indicated

88

Vague upper abdominal discomfort

Distension, bloating

Nausea

Flatulence, burping

Symptoms exacerbated by fatty foods

Flatulent dyspepsia

?Chronic cholecystitis

89

Ddx in chronic cholecystitis

PUD

IBS

Hiatus hernia

Chronic pancreatitis

90

Ix in chronic cholecystitis

AXR: porcelain GB

US: stones, fibrotic, shrunken GB

MRCP

91

Mx of chronic cholecystitis

Medical: bile salts (not very effective)

 

Surgical:

Elective cholecystectomy

ERCP first if USS shows dilated ducts and stones

92

What are the features of gallstone mucocele

Neck of the GB blocked by stone but contents remain sterile

Can be very large-> palpable mass

May become infected--> empyema

93

Features of GB carcinoma

Rare

Associated with gallstones and gallbladder polyps

May see porcelain GB

Incidental Ca found in 0.5-1% of lap choles

94

Features of Gallstone ileus

Large stone >2.5cm erodes from GB into duodenum through a cholecysto-duodenal fistula 2o to inflammation

May impact in the distal ileum leading to obstruction

Rigler's triad

95

What is Rigler's triad

Pneumobilia

SBO

Gallstone in RLQ

96

Rigler triad consists of three findings seen in gallstone ileus:

pneumobilia

small bowel obstruction

gallstone, usually in the right iliac fossa

Rigler triad should not be confused with Rigler sign or the Hoffman-Rigler sign.

 

97

What is Bouveret's syndrome?

Gastric outlet obstruction due to gallstone

98

Causes of obstructive jaundice

 

Rule of 30%s...

30% stones

30% Ca head of the pancreas

30% other

99

What are other causes of obstructive jaundice

LNs @ porta hepatis: TB, Ca

Inflammatory: PBC, PSC

Drugs: OCP, sulfonylureas, fluclox

Neoplastic: cholangiocarcinoma

Mirizzi's syndrome

100

Jaundice

Dark urine, pale stools

Itch

Obstructive jaundice

 

Itch due to bile salts

101

At what [serum] is obstructive jaundice noticeable and where is it seen first

Noticable at ~50mM

Seen at tongue frenulum first

102

Ix in obstructive jaundice

 

Urine

Dark

Raised bilirubin

Reduced urobilinogen

103

Ix in obstructive jaundice

 

Bloods

FBC: raised WCC in cholangitis

U+Es: hepatorenal syndrome

LFTs: raised conjugated bilirubin, ++ ALP, +AST/ALT

Clotting: reduced VitK--> Raised INR

G+S: may need ERCP

Immune: AMA, ANCA, ANA

 

104

Ix in obstructive jaundice

Imaging

AXR: may visualise stone

Pneumobilia suggests gas forming infection

 

USS:

DIlated ducts >6mm

Stones (95% accurtate)

Tumour

 

MRCP or ERCP

 

PTC: percutaneous transhepatic colangiography

105

What is PCT

Percutaneous transhepatic cholangiography (PTHC or PTC) or percutaneous hepatic cholangiogram is a radiologic technique used to visualize the anatomy of the biliary tract. A contrast medium is injected into a bile duct in the liver, after which X-rays are taken.

106

Pneumobilia

May be suggestive of a gas forming infection

107

Mx of stone causing obstructive jaundice

Conservative:

Monitor LFTs, stone passage may lead to resolution

Vits ADEK

Analgesia

Cholestyramine

 

Interventional:

If no resolution, worsening LFTs or cholangitis

ERCP with sphincterectomy and stone extraction

 

Surgical:

Open/lap stone removal with T tube placement

T tube cholangiogram 8d later to confirm stone removal

Delayed cholecystectomy to prevent recurrence

108

MOA cholestyramine

Cholestyramine is a bile acid sequestrant. It works by helping the body remove bile acids, which can lower cholesterol levels in the blood. The medicine is also used to relieve itching that's caused by a bile duct blockage

109

Features of ascending cholangitis

Charcot's triad

Reynolds pentad

110

What is Charcot's triad

Fever/rigors

RUQ pain

Jaundice

111

What is Reynolds pentad

Charcot's tirad

Shock

Confusion

112

Mx of ascending cholangitis

Cef and met

1st ERCP

2nd: open or lap stone removal with T tube drain

113

Risk factors for pancreatic carcinoma

SINED

Smoking

Inflammation: chronic pancreatitis

Nutrition: high fat diet

EtOH

DM

114

Pathology of pancreatic carcinoma

90% are ductal adenocarcinomas

Present late, metastasise early

Direct extension to local structures, lymphatics, haematogenously to liver and lungs

115

Location of pancreatic adenocarcinoma

60% in head

25% in body

15% in tail

116

(Male) >60y

Painless obstructive jaundice picture

or epigastric pain radiating to back and relieved by sitting forward

Anorexia, weight loss and malabsorption

Acute pancreatitis

Sudden onset DM

?Pancreatic carcinoma

117

Palpable gallbladder

Jaundice

Epigastric mass

(Trousseau's sign)

Splenomegaly

Ascites

Pancreatic adenocarcinoma

 

(Thrombophlebitis migrans)

 

Splenomegaly due to PV thrombosis leading to portal HTN

118

What is Courvossier's law

In the presence of painless obstructive jaundice, a palpable gall bladder is unlikely to be due to stones

119

Why does Coruvossier's sign occur

Cause unlikely to be gallstones, gallstones form over an extended period of time resulting in a shrunken, fibrotic gall bladder that does not easily distend, this is less likely to be palpable on examination

In contrast, the gallbladder is more enlarged in pathologies that cause obstruction of the biliary tree over longer periods of time e.g. pancreatic malgiancny leading to passive distension from back pressure

120

Ix in pancreatic carcinoma

Bloods

Cholestatic LFTs

Ca 19-9

Raised Ca

121

Ix in pancreatic carcinoma

 

Imaging

USS: pancreatic mass, dilated ducts, hepatic mets, guide biopsy

 

EUS: better than CT/MRI for staging

 

CXR: mets

 

Laparoscopy: mets, staging

122

ERCP in pancreatic caricnoma

Shows anatomy

Allows stenting

Biopsy of peri-ampullary lesions

123

5y survival of pancreatic carcinoma

<2%

 

Mean survival <6m

124

Mx of pancreatic carcinoma

Sx:

fit, nomets, tumour <3cm (<10% patients)

Whipple's pancreaticoduodenectomy

Distal pancreatectomy

Post-op chemo delays progression

 

 

Palliation:

Endoscopic/percutaneous stenting of CBD

Paliative bypass surgery: cholecystojejunosostomy, gastrojejunostomy

Pain relief: may need coeliac plexus block

125

Epidemiology of pancreatic endocrine neoplasia

30-60 y/o

15% associated with MEN1

126

With which MEN are pancreatic endocrine neoplasias associated?

MEN1

127

Fasting/exercise induced hypoglycaemia

Confusion, stuipor< LOC

Raised insulin, raised c-peptide, reduced glucose

Insulinoma

128

Hypergastrinaaemia--> hyperchlorhydia---> PUD and chronic diarrhoea due to inactivation of pancreatic enzymes

Gastrinoma (Zollinger-Ellison)

129

Raised glucagon

Necrolytic migratory erythema

Glucagonoma

130

Necrolytic migratory erythema

Characteristic rash of glucagonoma

131

Watery diarrhoea

Hypokalaemia

Achlorrhydia

Acidosis

VIPoma/ Verner-Morrison/ WDHA syndrome

132

MOA somatostatin

Inhibits glucagon and insulin release

Inhibits pancreatic enzyme secretion

133

DM

Steatorrhoea

Gallstones

 

Usually very malignant tumour with poor prognosis

Somatostatinoma

134

Favoured sites are stomach and duodenum followed by jejunum and ileum

Usually located in submucosa

Maybe visualised as a sessile mass

May cause pain from localised inflammation or more rarely, mucosal bleeding

2% of tumours arise in this tissue

Ectopic pancreas

135

Failuire of fusion of dorsal and ventral buds---> bulk of pancreas drains through smaller accessory duct.

Usually asymptomatic

May present with chronic pancreatitis

Pancreas divisum

136

Fusion of dorsal and ventral buds around duodenum

May present with infantile duodenal obstruction

Annular pancreas

137

Pancreas divisum

138

Annular pancreas

139

What is a Klatskin tumour

Typically occuring cholangiocarcinoma at confluence of right and left hepatic ducts

140

Features of cholangiocarcinoma

Rare bile duct tumour

Adenocarcinoma

[Klatskin tumour[

141

Klatskin tumour

142

Risk factors for cholangiocarcinoma

PSC

UC

Choledocholithiasis

Hep B/C

Choledochal cysts

Lynch 2

Flukes

143

Progressive painless obstructive jaundice

GB not palpable

Steatorrhoea

Weight loss

?Cholangiocarcinoma

144

Ix in cholangiocarcinoma

Cholestatic LFTs

CA19-9

145

Mx of cholangiocarcinoma

Poor Px

Palliative stenting

146

Pathophysiology of Hydatid cyst

Zoonotic infection by Echinococcus granulosus

Occurs in sheep-rearing communities

Parasite penetrates the portal system and infects the liver---> calcified cyst

147

Mostly asymptomatic

Pressure effects: non-specific pain, abdominal fullness, obstructive jaundice

 

Rupture: biliary colic, jaundice, urticaria, anaphylaxis, 2o infection

?Hydatid cyst

148

Ix in hydatid cyst

Eosinophilia

CT

149

Rx in hydatid cyst

Rx: albendazole

Sx: cystectomy for large cysts

150

What are the aims of pre-operative assessment and planning

Informed consent

Assess risk vs benefits

Optimise fitness of patient

Check anaesthesia/analgesia type with anaesthetist

151

OP CHECS

Operative fitness: cardiorespiratory comorbidities

Pills

Consent

History: MI, asthma, HTN, jaundice, complications of anaesthesia, DVT

Ease of intubation: neck arthritis, dentures, loose teeth

Clexane: DVT prophylaxis

Site: correct and marked

152

Anticoagulants pre-op

Balance risk of haemorrhage with risk of thrombosis

Avoid epidural, spinal and regional blocks

153

AED pre-op

Continue as usual

Post-op give IV or via NGT if unable to tolerate orally

154

OCP/HRT pre-op

Stop 4w before major/leg sx

Restart 2w post-op if mobile

155

Beta-blockers pre-op

Continue as normal

156

What are the routine pre-op bloods?

FBC

U+Es

G+S

Clotting

Glucose

157

What specific bloods are used pre-op

LFTs: liver disease, EtOH, jaundice

TFT: thyroid disease

Electrophoresis if from risk background

158

Cross-match for gastrectomy

4u

159

X-match for AAA

6u

160

How is cardiorespiratory function assessed pre-operatively

CXR: cardiorespiratory disease/symptoms, >65 y/o

Echo: poor LV function,?murmurs

ECG: HTN, Hx of cardiac disease, >55y

Cardiopulmonary exercise testing

PFT: known pulmonary disease or obesity

 

 

161

Why may you do an C spine XR pre-operatively

Flexion and extension views, in RA/AS

162

What are the different ASA grades

1: Normally healthy

2: Mild systemic disease

3: Severe systemic disease that limits activity

4: Systemic disease which is a constant threat to life

5: Moribund, not expected to survive 24h even with operation

163

NBM pre-op

>2h for clear fluids

>6h for solids

164

Bowel prep indications

May be needed in left-sided operations

Not usually needed in right-sided procedures

Necessity is controversial

165

What are the risks of bowel prep

Liquid bowel contents spilling during Sx

Electrolyte disturbance

Dehydration

Increased rate of post-op anastamotic leak

166

Indications for prophylactic Abx

Gi Sx

Joint replacement

167

Elective GI Sx post-op infection rate

20%

168

When are prophylactic Abx given preoperatively

15-60 mins before Sx

169

What are some bowel prep options

Picloax: picosulfate and Mg citrate

Klean-prep: macrogol

170

Abx prophlyaxis for

 

Biliary sx

Cef 1.5g and met 500mg IV

171

Abx prophlyaxis for

 

CR or appendicetomy

Cef and Met TDS

172

Abx prophlyaxis for

 

Vascular Sx

Co-amoxiclav 1.2g IV TDS

173

DVT prophylaxis in surgery

Low risk: early mobilisation

Medium risk: early mobilisation + TEDs + 20mg enoxaparin

High: early mobilisation + TEDS + 40mg enoxaparin and intermittent compression boots perioperatievely

174

Risk of DM in surgery

Increased risk of post-operative complications

 

175

How does DM increase the risk of post-operative complications?

Sx leads to the release of stress hormones which antagonise insulin

Patients are NBM

Increased risk of infection

Coexistant IHD and PVD

176

What should be done in DM patients pre-operatively?

Urine dipstick: proteinuria

Venous glucose

U+Es: K

177

What is the practical management of patients with IDDM when having surgery

Put patient first on list and inform surgeon and anaesthetist

Some centres prefer to use GKI infusions (mixture of glucose, insulin and potassium)

Sliding scale is not always necessary for minor ops, if in doubt, liase with diabetes specialist nurse

178

Management of insuilin pre and peri-operatively

Stop long acting insulin the night before

Omit AM insulin if sx if in the morning

Start sliding scale

179

Outline sliding scale

5% Dextroes with 20mmol KCl 125ml/hr

Infusion pump with c50u actrapid

Check CPG hourly and adjust insulin rate

180

What is target glucose when on a sliding scale

7-11mM

181

Post-op Mx of sliding scale

Continue sliding scale until tolerating food

Switch to SC regimen around meal

182

Mx of NIDDM and surgery

If glucose control poor (fasting glucose >10mM) treat as IDDM

Omit oral hypoglycaemics on the AM of Sx

Eating post-op: resume oral hypoglycaemics with meal

Not eating post-op: check fasting glucose on AM of surgery, start insulin sliding scale. Consult specialist team about restrting PO Rx

183

Mx of diet controlled DM in surgery

Usually no problem

Patient may be briefly insulin-dependant post-op

Monitor CPGs

184

Risks of steroids and surgery

Poor wound healing

Infection

Adrenal crisis

185

Mx of LT steroids and surgery

Need to increase steroids to cope with stress

Consider cover if high-dose steroids have been received within the past year

186

Steroid Rx in major surgery

Hydrocortisone 50-100mg IV with pre-med then 6-8 hourly for 3d

 

Usual pre-operative steroids +25 mg hydrocortisone @ induction +100 mg day-1 for 48 – 72h

187

Steroid Rx in minor surgery

As for major but only for 24h

188

Jaundice and surgery

Best to avoid operating

Use ERCP instead

189

Risks of jaundice and surgery

Patients with obstructive jaundice have increased risk of post-op renal failure, need to maintain a good UO

Coagulopathy

Increased infection risk---> cholangitis

190

Pre-Op Mx of jaundice

Avoid morphine in pre-med due to possible spastic effect on the sphincter of Oddi

Check clotting and consider pre-op vit K

Give 1L NS pre-op unless CCF-> moderate diuresis

Catheterise to monitor UO

Abx prophlyaxis

191

Intra-op Mx of jaundice

Hourly UO monitoring

NS titrated to output

192

Post-op mx of jaundice

Intensive monitoring of fluid status

Consider CVP and frusemide if poor output despite NS

193

Anticoagulated patients and surgery

Risk of haemorrhage vs risk of thrombosis

Consultant surgeon, anaesthetist and haemotologist

Very minor surgery can be undertaken without stopping warfarin if INR <3.5

Avoid spinal, epidural and regional blocks

In general continue aspirin/clopidogrel unless risk of bleeding is high, in which case stop 7d before surgery

194

Mx of anticoagulated with low-thromboembolic risk e.g. AF

Stop warfarin 5d pre-op, need INR <1.5

Restart next day

195

Mx of anticoagulated with high thromboembolic risk e.g. valves, recurrent VTE

Need bridging with LMWH

Stop warfaring 5d pre-op and start LMWH

Stop LMWH 12-18h pre-op

Restart LMWH 6h post-op

Restart warfarin next day

Stop LMWH when INR >2

196

Mx of anticoagulated patients requiring emergency surgery

Discontinue warfarin

Vit K 5mg slow IV

Request FFP or PCC (prothrombin complext concentrate) to cover surgery

197

Risks of COPD and surgery

Basal atelectasis

Aspiration

Chest infection

198

Pre-op Mx of smoking/COPD

CXR

PFTs

Physio

Quit smoking at least 4w prior to surgery

199

What are the aims of anaesthesia

Hypnosis, analgesia, muscle relaxation

200

Principles of anaesthesia

Induction

Muscle relaxation

Airway control

Maintenance

End of anaesthesia

201

Induction agent for anaesthesia

IV propofol

202

Muscle relaxation for anaesthesia

Depolarising: suxamethonium

Non-depolarising: vecuronium , atracurium

203

Airway control for anaesthesia

ET tube

LMA

204

Maintenance for anaesthesia

Usually volatile agent added to NO2/O2 mix e.g. halothan, enflurane

205

End of anaesthesia

Change inspired gas to 100% O2

Reverse paralysis: neostigmine and atropine (prevents muscarinic side effects)

206

Pre-medications for anaesthesia

7As

Anxiolytics and Amnesia: temazepam

Analgesics: opioids, NSAIDs, paracetamol

Anti-emetics: ondansteron 4mg/ metoclopramide 10mg

Antacids: lansoprazole

Anti-sialogue: glycopyrolate (reduces secretion)

Antibiotics

207

Features of regional anaesthesia

May be used for minor procedures or if unsuitable for GA

Nerve or spinal blocks

Use long-acting agents e.g. bupivacaine

208

What are the contraindications to nerve/spinal blocks

Local infection

Clotting abnormality

209

Complications of

 

Propofol induction

Cardiorespiratory depression

210

Complications of

 

Intubation

Oro-pharyngeal injury with laryngoscope

Oesophageal intubation

211

Complications of

 

Loss of pain sensation

Urinary retention

Pressure necrosis

Nerve palsies

212

Complications of

 

Loss of muscle power in anaesthesia

Corneal abrasion

No cough---> atelectasis + pneumonia

213

Complications of

 

Malignant hyperpyrexia

Rare complication precipitated by halothane or suxamethonium

AD inheritance

Rapid rise in temperature and masseter spasm

Rx: dantrolene and cooling

214

Complications of

Anaphylaxis in anaesthetics

Rare

Possible triggers:

antibiotics

colloid

NM blockers

215

What is the necessity of analgesia in surgery

Pain-> autonomic acitvation--> arteriolar constriction-> reduced wound perfusion--> impaired wound healing

Pain-> decreased mobilisation-> increased VTE and decreased function

Pain-> decreased respiratory excursion and decreased cough--> atelectasis and pneumonia

 

Humanitarian considerations

216

General guidance for anaesthesia

Give regular doses at fixed intervals

Consider best route: PO if possible

PCA (patient-controlled) should be considered: morphine, fentanyl

Follow stepwise approach

Liaise with acute pain service

217

Pre-op analgesia

Epidural e.g. bupivacaine

218

End-op analgesia

Infiltrate wound edge with LA

Infiltrate major regional nerves with LA

219

Features of spinal/epidural anaesthesia

Decreased SE as drugs more localised

First line for major bowel resection

Caution: respiratory depression, neurogenic shock (reduced BP)

220

What is the WHO pain ladder

Non-opiod +/- adjuvants

Weak opiod + non-opioid +/- adjuvants

Strong opiod + non-opioid +/- adjuvants

221

Non-opioid pain medications

Paracetamol

NSAIDs: ibuprofen, diclofenac

222

Weak opioid pain medications

Codeine

Dihydrocodeine

Tramadol

223

Strong opioid analgesia

Morphine

Oxycodone

Fentanyl

224

What is ERAS

Enhanced recovery after surgery

Commonly employed in colorectal and orthopaedic surgery

225

Aims of EPAR

Optimisie pre-op preparation for surgery

Avoid iatrogenic problems e.g. ileus

Minimise adverse physiological/immunological responses to surgery: (raised cortisol, reduced insulin) (hypercoagulbility) (immunosuppression)

Increase speed of recover and return to function

Recognise abnormal recovery and allow early intervention

226

Pre-op approach EPAR

Optimisation:

Aggressive physiological optimisation e.g. Hydration, BP, anaemia, DM, co-morbidities

Smoking cessation >4w before surgery

Admission on day of surgery, avoidance of prolonged fast

Carb loading prior to surgery

Fully informed patient encouraged to participate in recovery

227

Intra-op approach EPAR

Short-acting anaesthetic agents

Epidural use

Minimally invasive technqiues

Avoid drains and NGTs where possible

228

Post-op approach to EPAR

 

Aggressive Rx of pain and nausea

Early mobilisation and PT

Early resumption of oral intake

Early discontinuation of IV fluids

Remove drains and urinary catheters ASAP

229

How can surgical complications be characterised

Immediate (<24h)

Early (1d-1m)

Late (>1m)

230

What are the immediate surgical complications

<24h

Intubation leading to oropharyngeal trauma

Surgical trauma to local structures

Primary or reactive haemorrhage

231

What are the early surgical complications

1d-1m

Secondary haemorrhage

VTE

Urinary retention

Atelectasis and pneumonia

Wound infection and dehiscence

Antibitoic associated colitis

232

What are the late surgical complications

>1m

Scarring

Neuropathy

Failure or recurrence

233

How can post-op haemorrhage be classified?

Primary

Reactive

Secondary

234

What is primary haemorrhage

Continuous bleeding starting during surgery

235

What is reactive bleeding

Bleeding at the end of surgery or early post-op

2o to increased CO and BP

236

What is secondary bleeding

Bleeding >24h post op

Usually due to infection

237

What are the causes of post-op urinary retention?

Drugs: opioids, epidural/spinal, anti-AChM

Pain: sympathetic activation leading to sphincter contraction

Psychogenic: hospital environment

238

What are the risk factors for post-op urinary retention?

Male

Increasing age

Neuropathy e.g. DM, EtOH

BPH

Surgery type: hernia and anorectal

239

Mx of post-op urinary retention

Conservative:

Privacy, ambulation, void to running taps or in hot bath, analgesia

 

Catheterise +/- gent 2.5mg/kg IV stat

 

TWOC: if failed may be sent home with silicone catheter and urology output f/up

240

Features of pulmonary atelectasis

Occurs after nearly every GA

Mucus plugging + absorption of distal air---> collapse

241

What are the causes of pulmonary atelectasis

Pre-op smoking

Anaesthetic: increases mucus production, reduced mucociliary clearance

Pain inhibitng respiratory excursion and cough

242

First 48 hours post-sx

Mild pyrexia

Dyspnoea

Dull bases with reduced air entry

?Pulmonary atelectasis

243

Mx of pulmonary atelectasis

Analgesia to aid coughing

Chest PT

244

Features of wound infection

5-7d post-op

S. aureus and coliforms

245

How can operations be classified

Clean

Clean/cont

Contaminated

Dirty

246

What is a clean operation

Incision of uninfected skin without opening viscus

247

What is a clean/cont operation

Intraoperative beach of viscus (not colon)

248

What is a contaminated operation?

Breach of viscus and spillage or opening of colon

249

What is a dirty operation

Site already contaminated- faeces, urine, trauma

250

How can the risk factors for post-op wound infection be classified?

Pre-operative

Operative

Post-operative

251

What are the pre-op risk factors for wound infection

Increasing age

Comorbidities e.g. DM

Pre-existing infection e.g. appendix perf

Patient colonisation e.g. MRSA

252

What are the operative risk factors for wound infection?

Op classification and wound infection risk

Duration

Technical: pre-op Abx, asepsis

253

What are the post-operative risk factors for wound infection

Contamination to wound from staff

254

Mx of wound infection

Regular wound dressing

Abx

Abscess drainage

255

Occurs 10d post-op

Preceded by serosanguinous discharge from wound

Wound dehiscence

256

How can the risk factors for wound dehiscence be classified?

Pre-op

Op

Post-op

257

What are the pre-op risk factors for wound dehiscence?

Increasing age

Smoking

Obesity, malnutrition, cachexia

Comorbidities e.g. DM, uraemia, chronic cough, Cancer

Drugs: steroids, chemo, RTx

258

What are the operative risk factors for wound dehiscence?

Length and orientation of incision

Closure technique: follow Jenkin's rule

Suture material

259

What is Jenkin's rule?

It is a rule for closure of the abdominal wound. It states that for a continuous suture, the length of suture used should be at least four times the length of the wound with sutures 1cm apart and with 1cm bites of the wound edge

(More recent research has shown that the optimal ratio may in fact be 6:1)

260

What are the post-operative risk factors for wound dehiscence?

Increased IAP e.g. prolonged ileus leading to distension

Infection

Haematoma/seroma formation

261

Mx of wound dehiscence

Replace abdo contents and cover with sterile soaked gauze

IV Abx: cef and met

Opioid analgesia

Call senior and arrange theatre

Repair:

wash bowel, debride wound edge, close with deep non-absorbable sutures e.g. nylon

May require VAC dressing or grafting

262

What are the Cxs of cholecystectomy

Conversion to open: 5%

CBD injury: 0.3%

Bile leak

Retained stones needing ERCP

Fat intolerance/ loose stools

263

What are the early complications of inguinal hernia repair?

Haematoma/seroma formation: 10%

Intra-abdominal injury (laparoscopic)

Infection

Urinary retention

264

What are the late complications of inguinal hernia repair?

Recurrence (<2%)

Ischaemic orchitis (0.5%)

Chronic groin pain/paraesthesia (5%)

265

What are the complications of appendicectomy

Abscess formation

Fallopian tube trauma

Right hemicolectomy e.g. for carcinoid, caecal necrosis

266

What are the early complications of colonic surgery?

Ileus

AAC (acute acalculous cholecystitis)

Anastomotic leak

Enterocutaneous fistulae

Abdominal or pelvic abscess

267

What are the late complications of colonic surgery?

Adhesions leading to obstruction

Incisional hernia

268

What are the causes of post-op ileus?

Bowel handling

Anaesthesia

Electrolyte imbalance

269

Post surgery:

Distension

Constipation +/- vomiting

Absent bowel sounds

?post-op ileus

270

Mx of post-op ileus

IV fluids and NGT

TPN if prolonged

271

What are the complications of anorectal surgery?

Anal incontinence

Stenosis

Anal fissure

272

What are the complications of small bowel surgery?

Short gut syndrome (<250cm)

273

Def: short gut syndrome

Malabsorption disorder caused by the surgical removal of a large portion of the small intestine

274

Abdominal pain

Diarrhea and steatorrhea (oily or sticky stool, which can be malodorous)

Fluid depletion

Weight loss and malnutrition

Fatigue

?Small gut syndrome

May also have complications caused by malabsorption in vitamin absoprtion e.g. anaemia, hyperkeratosis, easy brusing, muscle spasms, poor blood clotting and bone pain

275

What are the complications of splenectomy

Gastric dilatation 2o to gastric ileus: prevent with NGT

Thrombocytosis-> VTE

Infection: encapsulated organisms

276

What are the complications of arterial surgery

Thrombosis and embolisation

Anastomotic leak

Graft infection

277

What are the complications of aortic surgery?

Gut ischaemia

Renal failure

Aorto-enteric fistula

Anterior spinal syndrome

Emboli: distal ischaemia--> trash foot

278

Complications of breast surgery

Arm lymphoedema

Skin necrosis

Seroma

279

What are the complications of urological surgery?

Sepsis

Uroma: extravasation or urine

280

What are the complications of prostatectomy?

Urinary incontinence

Erectile dysfunction

Retrograde ejaculation

Prostatitis

281

What are the complications of thyroidectomy?

Wound haematoma--> tracheal obstruction

Recurrent laryngeal nerve trauma-> hoarse voice

- transient in 1.5%

- permanent in 0.5%

Damage to R nerve more common due to it being more medial

Hypoparathyroidism---> hypocalcaemia

Thyroid storm

Hypothyroidism

282

What are the complications of tracheostomy?

Stenosis

Mediastinitis

Surgical emphysema

283

What are the complications of # repair?

Mal/non-union

Osteomyelitis

AVN

Compartment syndrome

284

What are the complications of hip replacement?

Deep infection

VTE

Dislocation

Nerve injury: sciatic, SGN

Leg length discrepancy

285

What are the complications of cardiothoracic surgery

Pneumo/haemothorax

Infection: mediastinitis, empyema

286

How can post-op pyrexia be classified?

Early 0-5d

Delayed >5d

287

What are the early causes of post-op pyrexia

0-5d post-op

Blood transfusion

Physiological: SIRS from trauma, 0-1d

Pulmonary atelectasis: 24-48hr

Infection: UTI, superficial thrombophlebitis, cellulitis

Drug reaction

288

What are the delayed causes of post-op pyreixa

>5d post-op

Pneumonia

VTE: 5-10d

Wound infection: 5-7d

Anastomotic leak: 7d

Collection: 5-20d

289

Examination work up in post-op pyrexia

Obs, notes and drug chart

Wound

Abdo + DRE

Legs

Chest

Lines

Urine

Stool

290

What are the Ix in post-op pyrexia?

Urine: dip, MC+S

Bloods: FBC, CRP, cultures +/- LFTs

Cultures: wound swabs, CVP tip for culture

CXR

291

Cause of post-op pneumonia

Anaesthesia-> atelectasis

Pain-> reduced cough

Sx-> immunosuppression

292

Rx of post-op pneumonia

Chest physio: encourage coughing

Good analgesia

Abx

293

Malaise

Swinging fever, rigors

Localised peritonitis

Shoulder tip pain (if subphrenic)

Post-op

?Collection

294

What are the locations of collections?

Pelvic: 4-10d post-op

Subphrenic: present 7-21d post-op

Paracolic gutters

Lesser sac

Hepatorenal recess (Morrison's space)

Small bowel (interloop spaces)

295

What is Morrison's space

Hepatorenal recess

296

Ix in collection

FBC, CRP, cultures

USS, CT

Diagnostic lap

297

Rx of post-op collection

Abx

Drainage/washout

298

Def: cellulitis

Acute infection of subcutaneous connective tissue

299

Cause of cellulitis:

Beta haemolytic strep and staph aureus

300

Pain, swelling, erythema and warmth

Systemic upset

+/- lymphadenopathy

Cellulitis

301

Rx of cellulitis

Benpen IV

Pen V and fluclox PO

302

Def: diverticulum

Out-pouching of tubular structure

303

True diverticulum

Composed of complete wall e.g. Meckel's

304

Def: false diverticulum

Composed of mucosa only (pharyngeal, colonic)

305

Diverticular disease

Symptomatic diverticulosis

306

Def: diverticulitis

Inflammation of diverticula

307

Epidemiology of diverticular disease

30% have diverticulosis by 60 years

F>M

308

Pathophysiology of diverticular disease

Associated with increased intraluminal pressure: low fibre diet has no osmotic effect to keep stool wet

Mucosa herniates through muscularis propria at points of weakness i.e. where perforating arteries enter

Most commonly located in the sigmoid colon

 

309

What is Saint's triad

 

Unifying factor?

Hiatus hernia

Cholelithiasis

Diverticular disease

 

?Obesity

310

Symptoms of diverticular disease

Altered bowel habit +/- left sided colic, relieved by defecation

Nausea

Flatulance

311

Altered bowel habit +/- left sided colic, relieved by defecation

Nausea

Flatulance

?Diverticular disease

312

Rx for diverticular disease

High fibre diet

Mebeverine may help

Elective resection for chronic pain

313

Pathophysiology of diverticulitis

Inspissated faeces-> obstruction of diverticulum

Think in elderly patient with previous history of constipation

314

Presentation of diverticulitis

Abdominal pain and tenderness

Typically LIF

Localised peritonitis

Pyrexia

315

Abdominal pain and tenderness

Typically LIF

Localised peritonitis

Pyrexia

Diverticulitis

316

Ix in diverticulitis: bloods

FBC

Raised WCC

Raised CRP/ESR

Amylase

G+S/x-match

317

Ix in diverticulitis: imaging

Erect CXR: ?perforation

AXR: fluid level/air in bowel wall

Contrast CT

Gastrograffin enema

318

Ix in diverticulitis: endoscopy

Flexi sig

Colonscopy (not used in acute attack)

319

What can be used to grade diverticulitis perforation

Hinchey grading

320

Hinchey 1

Localised para-colonic abscess- surgery rarely needed

321

Hinchey 2

Large abscess extending into pelvis

May resolve without surgery

322

Hinchey 3

Generalised purulent peritonitis

Surgery needed

323

Hinchey 4

Generalised faecal peritonitis

Surgery needed

324

Mx of mild acute diverticulitis

Can be treated at home with bowel rest (fluids only)

and abx- some conflicting evidence about use of abx in uncomplicated diverticular disease.. (augmentin +/- met)

325

Indications for admission acute diverticulitis

Unwell

Fluids can't be tolerated

Pain can't be controlled

326

Medical Mx of acute diverticulitis

NBM

IV fluids

Analgesia: paracetamol

Antibiotics: cef and met

Most cases settle

327

NSAIDs and opioid analgesics in diverticulitis

Have been identified as risk factors for perforation

328

Indications for surgical management of diverticulitis

Perforation

Large haemorrhage

Stricture leading to obstruction

329

Surgical procedure used in diverticulitis

Harmann's to resect diseased bowel

330

Complications of diverticulitis

Perforation

Haemorrhage

Abscess

Fistulae

Strictures

331

Sudden onset pain

Generalised peritonitis and shock

+/- preceding diverticulitis

?Perforation

332

Mx of perforation in diverticulitis

CXR: free air under the diaphragm

Rx: Hartmann's

333

Suddeen painless, bright red PR bleed

Following diverticulitis

?Haemorrhage

334

Ix in ?haemorrhage in diverticulitis

Mesenteric angiography or colonoscopy

335

Mx of haemorrhage in diverticulitis

Usually stops spontaneously

May need transfusion

Colonoscopy +/- diathermy/adrenaline

Embolisation

Resection

336

Walled off perforation

Swinging fever

Localising signs e.g. boggy rectal mass

Leukocytosis

Hx of diverticulitis

?Abscess

337

Mx of diverticulitis abscess

Abx + CT/US guided drainage

338

Types of of fistulae following diverticulitis

Enterocolic

Colovaginal

Colovesicular

339

Pneumaturia + intractable UTIs

?Colovesciular fistula

340

What may occur after diverticulitis

Colon may heal with fibrous strictures

341

Mx of strictures post diverticulitis

Resection (usually with primary anastomosis)

Stenting

342

How can bowel obstruction be classified

Simple

Closed loop

Strangulated

343

Simple bowel obstruction

1 obstructing point + no vascular compromise

May be partial or complete

344

Closed-loop bowel obstruction

Bowel obstructed at two points

Left CRC with competent ileocaecal valve. Volvulus

Gross distension can lead to perforation

345

Strangulated bowel obstruction

Compromised blood supply

Localised, constant pain + peritonism

Fever and raised WCC

346

What are the commonest causes of SBO

Adhesions: 60%

Hernia

347

What are the commonest causes of LBO

Colorectal neoplasia (60%)

Diverticular stricture (20%)

Volvulus 5%

348

How can bowel obstruction be classified

Non-mechanical

Mechanical

349

What is non-mechanical bowel obstruction?

Paralytic ileus

350

Causes of paralytic ileus

Post-op

Peritonitis

Pancreatitis or any localised inflammation

Posions/drugs: anti-AChM

Pseudo-obstruction

Metabolic: hypokalaemia, hyponatraemia, hypomagnesia, uraemia

Mesenteric ischaemia

351

Intestinal pseudo-obstruction

Intestinal pseudo-obstruction is a clinical syndrome caused by severe impairment in the ability of the intestines to push food through. It is characterized by the signs and symptoms of intestinal obstruction without any lesion in the intestinal lumen.[1] Clinical features can include abdominal pain, nausea, severe distension, vomiting, dysphagia, diarrhea and constipation, depending upon the part of the gastrointestinal tract involved.[2] The condition can begin at any age and it can be a primary condition (idiopathic or inherited) or caused by another disease (secondary).[3]

It can be chronic[4] or acute.[5]

352

How can mechanical bowel obstruction be classified?

Intraluminal

Intramural

Extramural

353

What are the intraluminal causes of bowel obstruction

Impacted matter: faeces, worms, bezoars

Intussuception

Gallstones

354

What are the intramural causes of mechanical obstruction?

Benign stricutre: IBD, Sx, ischaemic colitis, diverticulitis, RTx

Neoplasia

Congenital atresia

355

What are the extramural causes of bowel obstruction

Hernia

Adhesions

Volvulus (sigmoid, caecal, gastric)

Extrinsic compression: pseudocyst, abscess, haematoma, tumour e.g. ovarian, congenital bands e.g. Ladds

356

Ladd's bands

Ladd's bands, sometimes called bands of Ladd, are fibrous stalks of peritoneal tissue that attach the cecum to the abdominal wall and create an obstruction of the duodenum. This condition is found in malrotation of the intestine.

357

Presentation of bowel obstruction

Abdominal pain:

Colicky, central but level depends on gut region, constant/localised pain suggest strangulation or impending perforation

Distension:

with lower bowel involvement

Vomiting:

early in high, late or absent in low

Absolute constipation

358

Abdominal pain:

Colicky, central but level depends on gut region, constant/localised pain suggest strangulation or impending perforation

Distension:

with lower bowel involvement

Vomiting:

early in high, late or absent in low

Absolute constipation

?Bowel obstruction

359

Absolute constipation

Of flatus and faeces

360

Examination findings in bowel obstruction

Tachycardia: hypovolaemia, strangulation
Dehydration, hypovolaemia

Fever: suggests inflammatory disease or strangulation

Surgical scars

Hernias

Mass: neoplastic or inflammatory

Bowel sounds: increased in mechanical obstruction, reduced in ileus

PR: empty rectum, rectal mass, hard impacted stool, blood from higher pathology

361

Bowel obstruction, increased bowel sounds

Mechanical obstruction

362

Bowel obstruction, reduced bowel sounds

Ileus

363

Ix in bowel obstruction: bloods

FBC: raised WCC

U+Es: dehydration, electrolyte abnormalities

Amylase: ++ in strangulation/perforation

VBG: raised lactate in strangulation

G+S, clotting: may need Sx

364

Ix in bowel obstruction: imaging

Erect CXR

AXR +/- erect film for fluid levels

CT: can show transition point

365

Ix in bowel obstruction: gastrograffin studies

Look for mechanical obstruction: no free flow

Follow through or enema

Follow through may relive mild mechanical obstruction, usually adhesional

366

Ix in bowel obstruction: colonoscopy

Can be used in some cases

Risk of perforation

May be used to therapeutically stent

367

AXR findings in ileus

Both small and large bowel may be visible

No clear transition point

368

SBO AXR findings

Diameter >3

Central

Valvulae coniventes: completely across

LB gas absent

Many loops

Many, short fluid levels

369

370

LBO AXR findings

>6cm (caecum >9cm)

Peripheral loccation

Haustra- partially across

LB gas present in rectum

Few loops

Few, long fluid levels

371

372

373

Def: Meckel's diverticulum

Ileal remnant of vitellointestinal duct

Joins yoke sac to midgut lumen

374

Features of Meckel's diverticulum

A true diverticulum

2 inches long

2ft from ileocaecal vavle on antimesenteric border

2% of population

2% symptomatic

Contain ectopic gastric or pancreatic tissue

375

Symptomatic Meckel's presentation

Rectal bleeding from gastric mucosa

Diverticulitis mimicking appendicitis

Intussuception

Volvulus

Malignant change: adenocarcinoma

Raspberry tumour: musoca protruding at umbilicius: vitello-intestinal fistula

Littre's hernia

376

Rectal bleeding from gastric mucosa

Diverticulitis mimicking appendicitis

Intussuception

Volvulus

Malignant change: adenocarcinoma

Raspberry tumour: musoca protruding at umbilicius: vitello-intestinal fistula

Littre's hernia

Meckels diverticulum

377

Littre hernia

Littre hernia is a hernia containing a Meckel's diverticulum. Also known as a persistent omphalomesenteric duct hernia. It is most frequently encountered in the inguinal region.

 

378

Dx of Meckel's

Tc pertechnecate scan +ve in 70% (detects gastric mucosa)

379

Rx Meckels

Surgical resection

380

Def: intussuception

Portion of the intestine (the intussuception) is invaginated into its own lumen (the intussuscipiens)

381

Causes of intussuception

Hypertrophied Peyer's patch

Meckel's

HSP

Petuz-Jeghers

Lymphoma

382

Presentation of intussuception

6-12mo

Colicky abdo pain: episodic incosolable crying, drawing up legs +/- bilious vomiting

Redcurrent jelly stools

Sausage shaped abdominal mass

383

6-12mo

Colicky abdo pain: episodic incosolable crying, drawing up legs +/- bilious vomiting

Redcurrent jelly stools

Sausage shaped abdominal mass

Intussuception

384

NB intussuception in adults

Rarely occurs

If it does, consider neoplasm as a lead point

385

Mx of intussusception

Resuscitate and X-match, NGT

US + reduction by air enema

Sx if irreducible

386

Def: mesenteric adenitits

URTI/viral infeciotn-> enlargement of mesenteric LNs= pain tenderness and fever

387

Differentiating features of mesenteric adenitis

Post URTI

Headache + photophobia

Higher temperature

Tenderness is more generalised

Lymphocytosis

388

Gross anatomy: External ear

Auricle

External auditory meatus

389

Gross antomy: middle ear

Tympanic:

malleus, incus and stapes

390

Gross anatomy: inner ear

Semicircular canals, vestibule, cochlea

391

392

Purpose of audiometry

Quantify loss and determine its nature

393

Features of pure tone audiometry

Headphones deliver tones at different frequencies and strengths

Patient indicates when sound appears and disappears

Mastoid vibrator- bone conduction threshold

Threshold at different frequences are plotted to give an audiogram

394

Purpose of tympanometry

Measures stiffness of the ear drum

Evaluates middle ear function

395

Flat tympanogram=

Mid ear fluid or perforation

396

Shifted tympanogram=

+/- mid ear pressure

397

Features of evoked response audiometry

Auditory stimulus with measurement of elicited brain response by surface electrode

Used for neonatal screening if otoacoustic emission test negative

398

Presentation of otitis externa

Watery discharge

Itch

Pain and tragal tenderness

399

Watery discharge

Itch

Pain and tragal tenderness

?Otitis externa

400

Causes of otitis externa

Moisture e.g. swimming

Trauma e.g. fingernails

Absence of wax

Hearing aid

401

Organisms causing otitis externa

Pseudomonas

Staph aureus

402

OE

403

OE

404

Mx of otitis externa

Conservative: remove precipitating factors

 

Medical:

Analgesia e.g. paracetamol or ibuprofen

Treat inflammation:

Topical acetic acid

For more severe cases consider topical antibitoic +/- corticosteroid

 

Surgical:

?Cleaning of ear if required

405

Rx in non-infected eczematous OE

Betamethasone

406

Combination therapies for OE

Betamethasone with neomycin

Hydrocortisone with gentamicin

407

Rx for fungal OE

Consider clotrimazole

408

Consideration for amingoglycoside treatment of OE

If perf can lead to ototoxicity

409

Severe otalgia which is worse at night

Copious otorrhoea

Granulation tissue in the canal

(90% in DM)

Malignant otitis externa

410

Implications of malignant OE

Life-threatening infection which can lead to skull osteomyletitis

Look for tenderness of mastoid process

411

Rx of malignant OE

Admit for IV abx

+/- surgical debridement

412

Malignant OE

413

Def: bullous myringitis

Painful haemorrhagic blisters on deep meatal skin and tympanic membrane

Associated with influenza infection

414

With what is bullous myringitis associated

Influenza infection

415

Bullous myringitis

416

What are the symptoms of TMJ dysfunction

Earache (referred pain from auriculo temporal nerve)

Facial pain

Joint-clicking/popping

Teeth-grinding (bruxism)

Stress (associated with depression)

417

Joint tenderness exacerbated by lateral movements of open jaw

?TMJ dysfunction

418

Ix of TMJ dysfunction

MRI

419

Mx of TMJ dysfunction

NSAIDs

stabilising orthodontic occlusal prostheses

420

How can OM be classified?

Acute

OME

Chronic

Chronic suppurative OM

421

Acute OM=

Acute phase OM

422

OME=

Effusion after symptom regression

423

Chronic OM=

Effusion >3mo if bilateral or >6mo if unilateral

424

Def: chronic suppurative OM

Ear discharge with hearing loss and evidence of central drum perforation

425

Presentation of acute OM

Usually children post viral UTI

Rapid onset ear pain, tugging

Irrritability, anorexia, vomiting

Purulent discharge if perforation

426

Usually children post viral UTI

Rapid onset ear pain, tugging

Irrritability, anorexia, vomiting

Purulent discharge if perforation

Acute OM

427

Bulging red TM

Fever

Acute OM

428

Rx in acute OM

Paracetamol

Amoxicillin: may used delayed presecription

429

How can the cx of OM be classified

Intratemporal

Intracranial

Systemic

430

Intratemporal complications of OM

OME

Perforation of TM

Mastoidis

Facial N. palsy

431

Intracranial Cxs of OM

Meningitis/encephalitis

Brain abscess

Sub/epidural abscess

432

Systemic cxs of OM

Bacteraemia

Septic arthritis

IE

433

Acute OM

434

Features of delayed antibiotic prescribing strategies

Should be started if symptoms not improving within 4d of onset of symptoms or signficiant worsening of symptoms

Safety net

435

Inattention at school

Poor speech development

Hearing impairment

?OME

436

OME

Retracted, dull TM

Fluid level

437

Audiometry in OME

Flat tympanogram

438

Mx of OME

Usually resolves spontaenously

Consider grommets if persistent hearing loss

SE: infections and tympanosclerosis

439

Painless discharge with hearing loss

Chronic suppurative OM

440

Chronic suppurative OM

441

Rx chronic suppurative OM

Aural toilet

Abx/steroid ear drops

442

Complications of chronic suppurative OM

Cholesteatoma

443

Def: mastoiditis

Middle-ear inflammation-> destruction of mastoid air cells and abscess formation

 

444

Fever

Mastoid tenderness

Protruding auricle

?Mastoiditis

445

Ix in mastoiditis

CT

446

Mx in mastoiditis

IV Abx

Myringotomy and mastoidectomy

447

Def: cholesteatoma

Locally destructive expansion of stratified squamous epithelium within the middle ear

448

How can cholesteatoma be classified?

Congenital

Acquired: secondary to attic perforation in chronic suppurative OM

449

Foul smelling white discharge

Headache/pain

CN involvement: vertigo, deafness, facial paralysis

?Cholesteatoma

450

Cholesteatoma

Pearly white with surrounding inflammation

451

Cx of cholesteatoma

Deafness (ossicle destruction)

Meningitis

Cerebral abscess

452

Mx of cholesteatoma

Sx

453

Def: tinnitus

Sensation of sound without external sound stimulation

454

How can causes of tinnitus be classified?

Specific

General

Drugs

455

Specific causes of tinnitus

Meniere's

Acoustic neuroma

Otosclerosis

Noise-induced

Head injury

Hearing loss e.g. presbyacusis

456

Presbyacusis

Loss of hearing that gradually occurs in most individuals as they grow older

457

General causes of tinnitus

Raised BP

Anaemia

458

Drugs causing tinnitus

Aspirin

Aminoglycosides

Loop diuretics

ETOH

459

Components of tinnitus history

Character: constant or pulsatile

Unilateral (acoustic neuroma)

FHx: otoscleoris

Alleviating/exacerbating factors e.g. worse at night

Associations:

Vertigo: Meniere's, acoustic neuroma

Deafness: Meniere's, acoustic neuroma

 

Causes e.g. head injury, noise, drugs, Fhx

460

Def: otosclerosis

Hereditary disorder causing progressive deagness due to bone overgrowth in the inner ear

461

Examination in tinnitus

Otoscopy

Tuning fork tests

Pulse and BP

462

Ix in tinnitus

Audiometry and tympanogram

MRI if unilateral to exclude acoustic neuroma

463

Mx of tinnitus

Treat underlying causes

Psych support: tinnitus retraining therapy

Hypnotics at night may help

464

Def: vertigo

The illusion of movement

465

How can the causes of vertigo be classified

Peripheral/vestibular

Central

Drugs

466

Peripheral causes of vertigo

Meniere's

BPPV

Labyrinthitis

467

Central causes of vertigo

Acoustic neuroma

MS

Vertebrobasilar insufficiency

Stroke

Head injury

Inner ear syphillis

468

Drugs causing vertigo

Gentamicin

Loop diuretics

Metronidazole

Co-trimoxazole

469

Components of vertigo history

Is it true vertigo or light-headedness: which way are things moving: spinning/whirling when not moving (vertigo), sense of imbalance or staggering when walking (disequilibirium), light headedness (presyncope), dizziness caused by hyperventilation

Timespan

Associated symptoms: n/v, hearing loss, tinnitus, nystagmus

470

Nystagmus

Condition of involuntary eye movement

can be physiological or pathological

471

Examinations and tests in vertigo

Hearing

Cranial nerve

Cerebellar and gait

Rombergs +ve= vestibular or proprioception

Hallpike manouvre

Audiometry, calorimetry, LP, MRI

472

Meniere's triad

Vertigo

Tinnitus

Hearing loss

473

Pathology of Meniere's disease

Dilatation of endolymph spaces of membranous labyrinth (endolymphatic oedema)

474

Attacks occuring in clusters lasting up to 12h

Progressive SNHL

Vertigo and n+v

Tinnitus

Aural fullness (pressure in the ears)

?Meniere's

475

Audiometry showing low frequency SNHL which fluctuates

Meniere's

476

Mx: Meniere's disease

Medical:

Symptomatic reliefe: prochlorperazine (if severe) or betahistine or cyclizine

 

Surgical:

Gentamicin instillation via grommets

Saccus decompression

477

Follows febrile illness (e.g. URTI)

Sudden vomiting

Severe vertigo exacerbated by head movemenet

Vestibular neuronitis/viral labyrinthistis

478

Mx of viral labyrinthitis

Cyclizine

Improvement in days

479

Pathology of BPV

Displacement of otoliths in semicircular canals

Common after head injury

480

Sudden rotational vertigo for <30s
 Provoked by head turning

Nystagmus

BPV

481

Features of classic BPPV

Geotropic nystagmus with the problem ear down

Predominantly rotatory fast phase toward undermost ear

Latency (a few seconds)

Limited duration (< 20 s)

Reversal upon return to upright position

Response decline upon repetitive provocation

482

How can nystagmus be classified

Begins as a slow pursuit movement followed by a fast rapid, resetting phase

Named by direction of the fast phase

Right or left beating (horizontal nystagmus)

Up-beating or down-beating (vertical)
Or direction changing

If the movements are not horizontal or vertical then the nystagmus is rotational (clockwise or counter-clockwsie)

Can also have visual evoked nystagamus (VER)- implies central lesion

483

Causes of BPV

Idiopathic

Head injury

Otosclerosis

Post-viral

484

Dx of BPV

Hallpike manoeuvre-> upbeat torsional nystagmus

485

Rx of BPV

Self-limiting

Epley manoeuvre

Betahistine

486

Difference between primary and secondary otalgia

Primary there is usually abnormality on examination

Secondary is normal looking ear

487

Causes of primary otalgia

OE/OM

FB

Barotrauma

 

 

Rarely:

OME

Ramsay hunt

Perichorditis

Cellulitis

Relapsing polychondritis etc.

488

Causes of secondary otalgia

Can be classified on basis of nerve territory

e.g.

Trrigeminal TMJ problems

Facial: CPA lesions etc

Glossopharyngeal: tumours in PNS/pharynx

Vagus: tumours in pharynx/larynx, GORD

Spinal nerves: arthritis/tumours

489

Borders of the anterior triangle of the neck

Mandible

Midline

Sternocleidomastoid

490

Borders of the posterior triangle of the neck

Sternocleidomastoid

Trapezius

Clavicle

491

Quinsy=

Peritonsillar abscess

492

Definition of a definitive airway

In the trachea

Cuffed below the vocal cords

Attached to oxygen

Secured

493

What are the indications for intubation

A: protection and patency

B: respiratory failure, increase FRC, decreased WOB, secretion management, to facilitate bronchoscopy

C: minimise oxygen consumption and optimise O2 delivery

D: unresponsive to pain, prevent brain injury

E: temperature control

 

494

Causes of stridor

Children: croup, inhaled FB, tracheitis, abscess (retropharyngeal, peritonsillar), anaphylaxis, epiglottits, laryngomalacia, VC dysfunction, subglottic stenosis, laryngeal web, laryngeal tumours, tracheomalacia, choanal atresia, tracheal stenosis

 

Adults: anaphylaxis, laryngitis, epiglottits/supraglottitis, FB, abscess, laryngospasm, tumour

495

Sound of stridor

Insipiratory

NB: stridor can be biphasic if obstruction is at the level of the glottis

496

Causative organisms in epiglottits

Strep

Staph

HiB

Pseudomonas

Moraxella catarrhalis

TB

497

Rapid onset

Unwell

Odynophagia

Drooling

Fever

Anterior tenderness over hyoid bone

Lymphadenopathy

Tripod sign

Progressing rapibldy to SOB, resp distress, airway obstruction, stridor

?Epiglottis/supraglottits

498

Ix in epiglottits

Airway prep

Lateral neck XR

Bloods +/- cultures

499

Mx of epiglottits

IV antibiotics: usually 3rd gen cephalosporin

Steroids

Intubation +/- cricothyroidotomy c trachy if airway obstructed

500

Mx of stridor

ABCDE

Appropriate area e.g. A&E resus

Adrenaline (1:1000) nebulised

Steroids: budenoside nebs + IV dex

O2

Intubation if needed

Cricothyroidotomy either needle or surgical

501

Site of location of cricothyroidotomy?

Through cricothyroid membrane inbetween thyroid cartilage and cricoid

Can be done with large bore cannulae or surgically

502

Mx of epistaxis

1. External compresion:  90% anterior, 10% posterior, lean forward and distal part of nose, spit anything that enters mouth

2. Packing:

Anterior: merocel (nasal tampon)/ Rapid rhino

48hrs

After removal cauterise and give naseptin cream (NB contain peanut oil)

Posterior packing: urinary catheter, insert until tip seen at back of mouth, inflate balloon slowly, don't let go of catheter

3. Cautery using silver nitrate

4. Theatre

Surgical ligation of the sphenopalantine artery

 

 

503

What is Little's area?

AKA Kiesselbach's plexus

Kiesselbach's plexus, which lies in Kiesselbach's area, Kiesselbach's triangle, or Little's area, is a region in the anteroinferior part of the nasal septum where four arteries anastomose to form a vascular plexus. The arteries are:[1]

Anterior ethmoidal artery and posterior ethmoidal artery (both from the ophthalmic artery)

Sphenopalatine artery (terminal branch of the maxillary artery)

Greater palatine artery (from the maxillary artery)

Septal branch of the superior labial artery (from the facial artery)

90% of nosebleeds occur here due to the drying effect of air

504

What are the red flags in epistaxis?

Age >50y

Nasal obstruction

Facial pain

Hearing loss

Proptosis/double vision

Lymphadenopathy, weight loss

 

505

Middle-aged Chinese people with epistaxis think

?Nasopharyngeal carcinoma as high incidence

506

Occupational exposure to dust/chemicals with epistaxis

Think nasopharyngeal carcinoma as RF

507

Epistaxis in child <2

 

Shouldn't happen

?NAI

508

Risk factors for mastoiditis

Young children

Immunocompromised

Cholesteatoma

509

Organisms causing mastoiditis

Strep pneumonia, pyogenes, staph, pseudomonas, HiB

510

Unwell

Fever

Painful over mastoid process

Swollen and boggy

Young children: irritable, pinna protrusion +/- discharge

TM perforation

Hx of otitis media

Chronic: recurrent otalgia, headache, fever, OME/suppurative OM

?Mastoiditis

511

Mastoiditis

512

O/E

6th or 7th nerve palsy

Conductive deafness

Boggy swelling behind ear

?Mastoiditis

513

Ix in mastoiditis

FBC, CRP, blood cultures

Ear swab

CT/MRI

Audiogram

514

Mx of mastoiditis

High dose broad specrutm IV Abx

Analgesia

Emergency mastoidectomy for cholesteatoma and mastoid oteitits or intracranial spread or not improving

 

515

Dizziness what other questions should you ask?

N+V

Tinnitus

Hearing loss

Feeling of aural fullness

Headaches

Visual changes

Weakness

Numbness

516

Usually preceded by paranasal sinusitits

Medical emergency

Also caused by local trauma, insect or animal bites, FB, URTI

Periorbital cellulitis

 

517

Ocular pain

Eyelid swelling

Erythema

?Periorbital cellulitis

518

What differentiates between periorbital cellulitis and orbital cellulitis

Orbital also presents with painful eye movements, proptosis, opthalmoplegia, visual impairment, chemosis

519

Aetiology of SNHL

Usually idiopathic

520

Mx of idiopathic SNHL

Short-course high dose steroids (+/- PPI cover)

With repeat audiogram F/U

521

Def: acoustic neuroma

Benign slow-growing tumour of the vestibular nerve (vestibular schwanomma)

522

Sudden onset or progressive SNHL, tinnitus, balance issues, vertigo

?Acoustic neuroma

523

Local effects of acoustic neuroma

5th trigeminal causing facial numbness and tingling

Facial nerve can also be affected

If very large can compress the brainstem or cuse raised ICP

524

Most common site of acoustic neuroma growth

Cerebellopontine angle

525

Mx of acoustic neuroma

Watchful waiting with MRI/audiogram

Stereotactic radiotherapy

526

Cx of acoustic neuroma sx?

Loss of hearing

Damage to other cranial nerves esepcially the 7th

527

Bell's palsy

528

Sudden onset unilateral facial droop

+/- hyperacusis

Loss of sensation in anterior 2/3rds of tongue

Bell's palsy

529

What differentiates between LMN and UMN Bell's palsy

UMN lesions have forehead sparing as frontalis receives innervation from both hemispheres)
For it to be true Bell's it must not have forehead sparing

530

Why should Lyme disease serology be done in Bell's palsy in endemic areas

As LD can lead to facial nerve palsy

531

Mx of Bell's palsy

Short term high dose (60-80mg) steroids + eye care (drops with taping at night)

532

Bell's palsy px

Incomplete lesions have better prognosis

533

What is Ludwig's angina

Submandibular space infection

Aggressive and rapidly spreading cellulits from which patients can become quickly septic with compromised airway

534

Unwell

Fever

Mouth pain

Drooling

Dysphagia

 

Ludwig's angina

535

Mx of Ludwig's angina

IV Abx with anaerobe cover

Close monitoring

Airway +++

536

Def: conductive hearing loss

Impaired conduciton anywhere between auricle and round window

537

How can the causes of conductive hearing loss be classified?

External canal obstruciton

TM perforation

Ossicle defects

Inadequate eustachian tube ventilation of midddle air

 

538

Causes of external canal obstruction Leading to conductive hearing loss

Wax

Pus

FB

539

Causes of TM perforation Leading to conductive hearing loss

Trauma

Infection

540

Causes of ossicle defects leading to conductive hearing loss?

Otosclerosis

Infection

Trauma

541

Def: sensorineural hearing loss

Defects of cochlea, cochlear nerve or brain

542

Which drugs can cause sensorineural hearing loss?

Aminoglycosides

Vancomycin

543

Which post-infective syndromes are associated with sensorineural hearing loss?

Meningitis

Measles

Mumps

Herpes

544

What are some miscellaneous causes of sensorineural hearing loss?

Meniere's

Trauma

MS

CPA lesions e.g. acoustic neuroma

Low B12

545

Acoustic neuroma=

Benign slow-growing tumour of superior vestibular nerve

546

􀁸 Slow onset, unilat SNHL, tinnitus ± vertigo
􀁸 Headache (↑ICP)
􀁸 CN palsies: 5,7 and 8
􀁸 Cerebellar signs

?Acoustic neuroma

547

All patients with unilateral tinnitus/deafness should receive
an?

MRI

548

What syndrome associated with acoustic neuromas?

NF2

549

What accounts for 80% of CPA tumours?

Acoustic neuromas

550

Common cause of CPA syndrome?

Acoustic neuromas

551

Bruns nystagmus

Dancing eyes

Seen in large tumours due to compression of the flocculi in CPA syndrome

552

Features of CPA syndrome

Tumours within nerve cannaliculi: unilateral SNHL, tinnitus or disequilibirium
 (speech discrimination out of proportion to hearing loss and difficulty talking on the telephone are frequent accompaniements)

Tumours extending into the CPA may present with disequilibrium and ataxia

With brainstem extension, midfacial and corneal hypesthesia, hydrocephalies and other CN palsies become more prevalent

553

DDx slow onset unilateral SNHL

Meningioma

Cerebellar astrocytoma

Mets

554

Otosclerosis

AD condition characterised by fixation of the stapes at the oval window

F>M 2:1

555

Begins early in adult life

Bilateral conductive deafness + tinnitus

HL improved in noisy places (Willis' paracousis)

Worsened by pregnancy/menstruation

Otosclerosis

556

>65y

Bilateral slow onset hearing loss

+/- tinnitus

Age-related hearing loss i.e. presbyacussis

557

Congenital causes of conductive hearing loss in children

Anomalies of pinna, external auditory canal, TM or ossicles

Congenital cholesteatoma

Pierre-Robin

558

Congenital causes of SNHL in children

AD: Waardenburgs: SNHL, heterochromia + telecanthus

AR: Alports (SNHL + haematuria), Jewell-Lange-Nielson

X-Linked: Alports

Infections: CMV, rubella, HSV, toxo, GBS

Ototoxic drugs

559

Perinatal causes of paediatric hearing loss

Anoxia

CP

Kernicterus

Infeciton: meningitis

560

Acquired causes of paediatric hearing loss

OM/OME

Infection: meningitis, measles

Head injury

561

What are some congenital anomalies seen in the ear

1st and 2nd branchial arches form auricle while 1st branchial groove forms external auditory canal

Malfusion leads to accessory tags/auricles and preauricular pits, fistulae or sinuses

Sinuses may get infected

562

Features of pinna heamatoma

Blunt trauma leading to subperichondrial haematoma

Can lead to ischaemic necrosis of cartilage and subsequent fibrosis to cauliflower ears

563

Mx of pinna haematoma

Aspiration and firm packing to auricle contour

564

Def: exostoses

Smooth, symmetrical bony narrowing of external canals

565

Pathology of exostoses

Bony hypertrophy due to cold exposure e.g. from swimming/surfing

Asymptomatic unless narrowing occludes the canal leading to conductive deafness

566

Causes of TM perforation

OM

Trauma

Barotrauma

FB

567

What are the classifications of allergic rhinosinusitis?

Seasonal

Perennial

568

Pathology of allergic rhunosinusitis?

T1HS Ig-E mediated inflammation from allergen exposure leading to mediator relesase from mast cells

Allergens include pollen, house dust mites

569

Sneezing

Pruritus

Rinorrhoea

?Allergic rhinosinusitis

570

Swollen, pale and boggy nasal turbinates

Nasal polyps

?Allergic rhinosinusitis

571

External nose parameters

Extends from the nasal bones and surrounding parts of the maxilla and frontal bone

Supported by the central septal cartilage and its lateral processes

At the apex there are two major alar cartilages

Near the maxilla there are smaller minor alar cartilages

572

573

Internal nose parameters

Comprises two paired nasal cavities which extend and expand supero-posteriorly from the anterior nares

Nasal septum separates left and right

Hard palate makes up the floor of the cavities and separates them from the oral cavity

Posterior nares open posteriorly into the nasopharynx

574

What are the three regions of the internal nose?

Vestibular: just inside nostrils

Respiratory: ciliated epithelium making up the bulk of the cavity walls

Olfactory: specialised olfactory epithelium on the roofs of the cavities

575

What are found on the lateral walls of each nasal cavities?

Superior middle and inferior conchae

576

Which bone do the superior and middle conchae arise from?

Ethmoid

577

Which bone do the inferior conchae extend from?

The maxilla

578

What do the conchae form?

Narrow air passages known as the superior, middle and inferior meatus

579

What is the major route for nerve entry into the nasal cavity?

Sphenopalatine formaen and is found on the postero-lateral wall of the superior meatus

580

What is the space above the superior concha called?

The spheno-ethmoidal recess

581

What are the 4 paranasal sinuses?

Ethmoidal

Sphenoidal

Maxillary

Frontal

582

583

584

Features of the ethmoidal sinus

Collection of specialised ethmoidal air cells in the respiratory region of the nose

Openings in the bulla ethmoidalis on the lateral wall of the middle meatus

Cells between medial and lateral plates of the ethmoid labyrinths

585

Features of the sphenoidal sinuses?

Posterior to the nasal cavity within the sphenoid bone

Openings in the posterior wall of the spheno-ethmoidal recess

Immediately antero-inferior to the pituitary fossa

586

What is the largest of the nasal sinuses?

Maxillary

587

Features of the maxillary sinus

Beyond the lateral walls of the nasal cavity within the maxillae

Openings in the hiatus semilunaris floor on the lateral wall of the middle meatus

Drain at the apex- prone to filling with fluids that are hard to drain

588

Features of the frontal sinus

Superior to the nasal cavities within the frontal bone

Openings in the hiatus semilunaris roof on the lateral wall of the middle meatus

Drains through the frontonasal duct to the ethmoidal infundibulum

589

What is the course of the nasolacrimal duct?

Carries tears from the corner of the eye opening in the inferior meatus, inerfo-anterior to the hiatus semilunaris

590

Whence does the blood supply of the nose come?

Internal and external carotid arteries

591

What are the significant arteries supplying the nose?

Sphenopalantine artery

Greater palantine artery

Anterior and posterior ethmoidal arteries

592

593

Features of the sphenopalatine artery?

Terminal branch of the maxillary artery- branch of external carotid

Enters the cavity through the sphenopalatine formaen

Gives lateral branches supplying most of the lateral wall and medial branches to medial wall

594

Features of the greater palatine artery

Branch of maxillary artery: branch of external carotid

Enters the anterior floor of the nasal cavity through the incisive canal and supplies the anterior septum and floor

Anastomoses with septal branches of the sphenopalatine artery

595

From which artery do the ethmoidal arteries branch and what carotid does it originate from?

Ophthalmic artery

Internal carotid

596

How do the ethmoidal arteries enter the nasal cavity?

Through the cribiform plate

597

Course of the anterior and posterior ethmoidal arteries

Anterior: anastomoses with branches of the sphenopalatine artery and terminates as the external nasal artery

Posterior division supplies the upper lateral and medial walls

598

Whence comes the general sensory innervation of the nose?

Ophthalmic and maxillary division of V

599

What innervates the mucous glands in the nose?

Parasympathetic fibres of the facial nerve: arise form the pterygopalatine ganglion and run with V2 fibres

600

Branches of the facial nerve

To Zanzibar By Motor Car

Temporal

Zygomatic

Buccal

Mandibular

Cervical

601

Branches of the trigeminal nerve

Ophthalmic

Maxillary

Mandibular

602

Cranial exits of trigeminal nerve branches

Standing

Room

Only

Superior orbital fissure

Foramen rotundum

Foramen ovale

603

Features of ophthalmic nervous supply of the nose

Two key branches: ethmoidal nerves

Anterior branch: travels with anterior ethmoidal artery and supplies the anterior medial and lateral walls before terminating as the external nasal nerve

Posterior branch supplies the ethmoidal air cells and does not enter the nasal cavity

604

Features of maxillary nerve supply of nasal cavity

Lateral branches supply the lateral wall

Nasopalantine nerve supplies the medial wall before terminating in the oral muscoa

605

606

Ix in allergic rhinosinusitis

Skin-prick testing to find allergnes

RAST

607

Mx of allergic rhinitis

Allergen avoidance: regulalry washing bedding, avoid pollen

 

Rx:

1st Line:

PRN: Oral antihistamine e.g. cetirazine, desloratidine or intranasal e.g. azelastine

Preventative: intranasal corticosteroid e.g. beclometasone (if nasal blockage or polyps) or oral antihistamine

 

2nd line:

Intranasal steroid + antihistamine (oral)

 

3rd line:

Zafirlukast (leukotriene antag)

 

4th line:

Immunotherapy: to induce desensitisation to allergen

 

Oral corticosteroids can be considered for severe symptoms

 

608

What are some adjuvant nasal decongestants?

Pseudoephedrine, otrivine

609

Pathophysiology of sinusitis

Viruses-> mucosal oedema and decreased mucosal ciliary actions leading to mucus retention and secondary bacterial infection

610

Causative organisms acute bacterial sinusitis?

Pneumococcus, Haemophilus, Moraxella

611

Causative organisms chronic bacterial sinusitis

S. aureus, anaerobes

612

Causes of sinusitis

Majority are bacterial infection 2o to viral

5% due to dental root infections

Diving/swimming in infected water

Anatomical variation may leave individuals susceptile e.g. deviated septum, nasal polyps

Systmic disease e.g. PCD/Kartagener's

613

Pain increasing on bending/straining

Discharge from nose-> foul taste

Nasal obstruciton/congestion

Anosmia or cacosmia (bad smell without external source)

Systemic symptoms

?Bacterial sinusitis

614

Which sinus liklely to be invovled if cheek/teeth pain in sinusitis

Maxillary

615

Which sinus liklely to be invovled if pain between eyes in sinusitis

Ethomidal

616

Ix in sinusitis

Nasendoscopy +/- CT

617

Mx of acute single episode of sinusitis

Bed-rest, decongestants, analgesia

Nasal douching and topical steroids

Abx of uncertain benefit

618

Mx of chronic/recurrent sinusitis?

Usually a structural or drainage problem

Stop smoking and fluticasone nasal spray

Functional endoscopic sinus sx if medical therapy fails

619

Complications of sinusits (rare)

Mucoceles-> pyoceles

Orbital cellulitis/abscess

Ostemoyelitis e.g. staph in frontal bone

Intracranial infection e.g. meningitis, encephalitis, abscess, CVST

620

What are the sites of nasal polyps

Middle turbinates

Middle meatus

Ethmoids

621

Water, anterior rhinorrhoea

Purulent post-nasal drip

Nasal obstruciton

Sinusitis

Headaches

Snoring

?Nasal polyps

622

Mobile pale insensitive growths in nasal cavity

?Nasal polyps

623

What are the associations of nasal polyps?

Allergic/non-allergic rhinitis

CF

Aspirin hypersensitvity

Asthma

624

Single unilateral nasal polyp

May be a sign of rare but sinister pathology e.g.

Nasopharyngela Ca

Glioma

Lymphoma

Neuroblastoma

Sarcoma

 

CT + histology

625

Nasal polyps in children

Rare in <10, must consider neoplastic disease or CF

626

Mx of nasal polyps

Drugs:

Betamethasone for 2/7

Short course of oral steroids

Endoscopic polypectomy

627

No direct response but intact conseunsual response to light

Cannot initiate consensual response in contralteral eye

Dilatation on moving light from normal to abnormal eye

 

What is the defect?

Afferent defect

628

Cause of afferent pupillary defect?

Total CNII lesion

629

Marcus-Gunn pupil=

RAPD

630

Minor constriction to direct light

Dilatation on moving light from normal to abnormal eye

RAPD- Marcus Gunn pupil

631

Causes of RAPD

Optic neuritis

Optic atrophy

Retinal disease

632

Dilated pupil does not react to light

Initiates consensual response in contralateral pupil

Ophthalmoplegia and ptosis

Efferent defect

633

Cause of efferent pupillary defect

3rd nerve palsy

 

634

Medical 3rd nerve palsy

Pupil sparing as the visceral constrictive fibres run on the outisde of the nerve so are spared in vascular aetiologies

635

Complete 3rd nerve palsy=

"surgical third"

636

Ptosis

Down and out pupil

Dilated pupil

?3rd nerve palsy

637

Causes of third nerve palsy

DM (75% pupil sparing)

Temporal arteritis

SLE

MS

Cavernous sinus thrombosis

Amyloid

PCA aneurysm

Tumour

638

Ipsilateral third nerve palsy with contralateral hemiplegia

Weber syndrome= midbrain stroke

639

Whence does the CNIII arise?

Rostral midbrain

640

What are the nuclei of CNIII?

Oculomotor nucleus (somatic fibres)- eye movements

Edinger-Westphal nucleus (visceral fibres)- pupillary constriciton

 

 

641

Course of the oculomotor nerve?

Passes between the posterior cerebral and superior cerebellar arteries and then through the cavernous sinus and out through the superior orbital fissure

642

Branches of CNIII

Superior branch- levator palpebrae

Inferior branch- MR, IR and IO muscles and carries the visceral fibres

 

643

3rd nerve palsy

 

ptosis

'down and out' pupil

dilated pupil

644

DDx of a fixed, dilated pupil

Mydriatics e.g. tropicamide

Iris trauma

Acute glaucoma

CN3 compression: tumour, coning

645

646

RAPD

647

Young woman with sudden blurring of near vision

Initially unilateral and then bilateral pupil dilatation

Dilated pupil has no response to light and sluggish response to accomodation

= a tonic pupil

Holmes-Adie pupil

648

Iris shows spontaneous wormy movmenets on slit-lamp examination

Iris streaming

Holmes-Adie pupil

649

Aetiology of Holmes-Adie pupil

Damage to postganglionic parasympathetic fibres

Idiopathic: may have viral aetiology

650

Homes-Adie pupil

651

Tonic pupil + absent knee/ankle jerks + reduced BP=

Holmes-Adie syndrome

652

Johann Horner

Swiss opthalmologist

653

Features of Horner's syndrome

 

PEAS

 

Ptosis: partial (superior tarsal muscle)

Enophthalmos

Anhydrosis

Small pupil

654

Horner's syndrome

655

How can the causes of Horner's syndrome be classified?

Central

Pre-ganglionic

Post-ganglionic

656

What are the central causes of Horner's

MS

Wallenberg's Lateral Medullary Syndrome

657

Small, irregular pupils

Accomodate but don't react to light

Atrophied and depigmented Iris

Argyll-Robertson

658

Argyll-Robertson pupil

"prostitutes pupil"

Accomodates but doens't react

659

Causes of Argyll Robertson

DM

Quaternary syphillis

660

Reduced acuity

Reduced colour vision (especially red)

Central scotoma

Pale optic disc

RAPD

?Optic atrophy/opticneuropathy

661

What are the most common causes of optic atrophy?

 

MS and glaucoma

662

How can the causes of optic neuropathy be classified?

CAC VISION

Congenital

Alcohol and other toxins

Compression

 

Vascular

Inflammatory

Sarcoid

Infection

Oedema

Neoplastic infiltration

663

What are the congenital causes of optic atrophy?

Leber's hereditary optic neuropathy

Hereditary motor and sensory neuropathy/ Charcot Marie Tooth

Friedrich's ataxia

Wolfram (DIDMOAD)

Retinitis pigmentosa

664

Attacks of acute visual loss, sequential in each eye

+/- ataxia and cardiac defects

FHx

Onset in 20-30s

Leber's hereditary optic neuropathy

Mitochondrial disease

665

What are the toxins causing optic neuropathy?

Ethambutol

Pb

B12 deficiency

666

What are the compressive causes of optic neuropathy

Neoplasia: optic glioma, pituitary adenoma

Glaucoma

Paget's

667

What are the vascular causes of optic atrophy

DM, GCA, thromboembolic

 

668

What are the inflammatory causes of optic atrophy

MS, Devic's, DM

669

Devic's disease

Neuromyelitis optica (NMO), also known as Devic's disease or Devic's syndrome, is a heterogeneous condition consisting of the simultaneous inflammation and demyelination of the optic nerve (optic neuritis) and the spinal cord (myelitis). It can be monophasic or recurrent.

670

What are the infective causes of optic atrophy?

Herpes zoster, TB, syphillis

671

oedematous causes of optic atrophy

Papilloedema

672

Anteroposterior anatomy of the eyeball

Cornea

Anterior chamber (aqueous humours)

Uvea (Iris, ciliary body, choroid plexus)

Posterior chamber

Lens

Vitreous humour

673

What are the two muscles responsible for eyelid movement

 

Obicularis oculi- closes the eyelids, innervated by CN7 (Bell's palsy)

 

Levator palpebrae- opens the eyelid, innervated by CN3 (Horner's)

674

What is the conjunctiva

Mucus membrane covering the eyeball

Semi-transparent hence the white colouring

Starts at the edge of the cornea (imbus) and loops forward to form the inner surface of the eyelid. 

675

Where are the majority of tears produced?

Accessory tear glands located within the eyelid and the conjunctiva

Lacrimal gland itself is primarily responsible for reflexive tearing. 

676

What is a consideration for lid laceration in the nasal quadrant of the lid?

Compromising the canalicular tear-drainage pathway. 

 

677

What is a consideration re drug administration and nasolacrimal duct

Nasal absorption of drugs can have profound effects. 

hence why squeezing the medial canthus during administration of eye drops can help mitigate htis

678

Features of the sclera

White fibrous outer layer of the eyeball, continuous with the cornea anteriorly and the optic nerve sheath posteriorly 

679

Anterior chamber of the eye=

Between cornea and the iris

680

Posterior chamber of the eye

Between the iris and the lens

681

Viterous chamber of the eye

Extends from the lens to the retina

 

682

What is PVD in the context of ophthalmology?

Posterior viterous detachment

usually benign but can cause retinal tears

683

Where in the eye is the aqueous humor produced?

Posterior chamber, flowing through the pupil into the anterior chamber where it drains into the venous circulation via the Canal of schlemm

684

Features of the cornea

Avascular receiving its nutrition from tears on the outside and aqueous fluid internally with peripheral blood vessels

685

What are the layers of the cornea

Epithelium

Bowman's layer (belfry)

Stroma

Descemet's membrane (deep)

Endothelium

686

Damage to which layer of the cornea can lead to scar formation?

Corneal stroma

687

What forms the anterior chamber angle

Angle formed by the inner cornea and the root of the iris

Location of the Schlemms canal

688

Def: uvea

Iris

Ciliary body (secretes aqueous fluid and controls the shape of the lens)

Choroid plexus

689

Components of the lens

Capsule

Nucleus

Cortex

690

How are cataracts described?

 

Described by where they occur

I.e. nucleur, cortical, subcapsular

 

691

What does contraction of the ciliary muscle lead to?

Causes the zonule ligaments holding the lens in place to relax

Allowing the lens to become rounder

692

Presbyopia

Difficulty focusing on nearby objects

693

What is the macula

Pigmented area of the retina responsible for central vision

Within the macula lies the fovea (susceptible to injury during retinal detachments)

694

What are the bones making up the orbital walls?

Frontal

Sphenoid (greater wing)

Ethmoid

Lacrimal

Palatine

Maxillary

Zygomatic

695

What is the entry point for the nerves and vessels supplying the orbit

Orbital apex

696

Nerves passing through the orbital fissure

Live Frankly To See Absolutley No Insult 

Lacrimal and Frontal divisions of V1

Trochlear nerve

Superior division fo the oculomotor nerve

Abducens

Nasociliary branch of V1

Inferior division of III

697

What is the thinnest bone in the orbit?

Ethmoid

Mose likely to perforate from an eroiding sinus infection in children

698

699

Funciton of LR

Abduction

700

Function of MR

Adduction

701

Extraocular muscle lesion, patients report

Diplopia when looking in the affected direction

702

Featuers of Horner's syndrome

PAMEL

Ptosis

Anhydrosis

Miosis

Enophthalmos

Loss of ciliospinal reflex

703

Ciliospinal reflex

The ciliospinal reflex (pupillary-skin reflex) consists of dilation of the ipsilateral pupil in response to pain applied to the neck, face, and upper trunk. If the right side of the neck is subjected to a painful stimulus, the right pupil dilates (increases in size 1-2mm from baseline). This reflex is absent in Horner's syndrome and lesions involving the cervical sympathetic fibers. The enhanced ciliospinal reflex in asymptomatic patients with cluster headache is due to preganglionic sympathetic mechanisms.

 

704

Mydriasis

Excessive dilataion of the pupil

705

Crossed eye

Nerve palsy

6th nerve palsy

706

Causes of 6th nerve palsy

Vasculopathic

Tumour

False localising sign i.e. raised ICP

707

Action of Trochlear nerve

SO

Causes eye depression and intorsion

Looking towards nose: more up down

Looking laterally: more rotational

708

4th nerve palsy

Nasal upshoot

709

Nasal upshoot nerve palsy causing?

4th nerve palsy

710

Causes of 4th nerve palsy

Vasculopathic

Tumour

Congenital

Trauma

711

Why do pupils blow first in 3rd nerve compression

As the fibres controlling pupillary constriction run on the external surface of the nerve

712

Pseudotumour cerebri

=Idiopathic intracranial HTN

713

What are the components of visual history?

Vision

Sensation

Appearance

Discharge

714

What are some significant symptoms in a red eye history

 

Vision

Blurred

Distorted

Diplopia

Field defect/scotoma

Floaters/flashes

715

What are some significant symptoms in a red eye history:

Sensation

Irritation

Pain

Itching

Photophobia

FB

716

What are some significant symptoms in a red eye history

Appearance

Red: ?distribution

Lump

Puffy lids

717

What are some significant symptoms in a red eye history

 

Discharge

Watering

Sticking 

Stringy

718

What are the key questions in the examination of a red eye?

Inspect A-P

Is acuity affected

Is the globe painful

Pupils equal and reactive?

Corena: intact, cloudy? Use fluorescein

719

What are the signs of serious disease in a red eye history?

Photophobia

Poor vision

Corneal fluorescein staining

Abnromal pupil

720

Red eye

++++ pain

No photoboia

Reduced acuity

Hazy/cloudy cornea

Large pupil

Raised IOP

?Acute glaucoma

721

?Acute glaucoma

722

Eclipse sign

The eclipse sign using an oblique flashlight has been well described as a tool to detect shallow anterior chamber. A beam of light shone from the temporal aspect of the cornea towards the root of nose produces a semicircular shadow of the iris in the nasal area. The width of the semicircular shadow gives an indication of the depth of the anterior chamber. A shallow anterior chamber produces a broader shadow compared to an anterior chamber of normal depth as it is the eclipse of the light.

723

Red eye

++ pain

++ photophobia

Reduced acuity

Pain on accomodation

Normal cornea

Small pupil

Normal IOP

?Anterior uveitis 

724

Red eye

Abdominal pain

?Acute closed angle glauocma

725

Red eye

+/- pain

+ photobia

Normal acuity

Normal cornea

Normal pupil

Normal IOP

?Conjunctivitis

726

How can the ddx of red eye be classified?

Site: 

Lids

Conjunctiva

Sclera

Cornea

Anterior chamber

727

What are the mechanical causes of red eye

Lids:

Ectropion, entropion, FB, trichiasis

 

Conjunctiva:

Sub cojunctival haemorrhage

 

Sclera:

Perforation

 

Cornea: 

Foreign body

Abrasion

 

Anterior chamber;

Acute glaucoma

728

What are the inflammatory causes of red eye?

Lids:

Blepharitis, Chalazion

 

Conjunctiva:

Allergic conjunct

 

Sclera:

Chemical burn, episcleritis, scleritis

 

Anterior chamber:

Iritis/uveitis

729

What are the infective causes of red eye?

 

Lids:

Perioribital cellulitis, orbital cellulitis 

 

Conjunctiva:

Conjunctivitis

 

Cornea:

Keratitis

 

Ant chamber:

Endophthalmitis

730

Anterior uveitis

731

Scleritis

732

Aetiology of acute closed angle glaucoma?

Blocked drainage of aqueous from anterior chamber vis the canal of Schlemm

Pupilar dilatation worsens the blockage

IOP rises from 15-20--> 60mmHg

733

RFs for acute closed angle glaucoma

Hypermetropia

Shallow anterior chamber

Female

FHx

Increased age

Drugs:

anticholinergics

sympathomimetics

TCAs

Anti-histmaines

734

Prodrome: rainbow haloes around lights at night time

Severe pain with n+v

Reduced acuity and blurred vision

Acute closed angle glaucoma

735

Cloudy cornea with circumcorneal injection

Fixed dilated, irregular pupil

Raised IOP makes eye feel hard

Acute cloesd angle glaucoma

736

Ix in acute closed angle glaucoma

Tonometry: raised IOP, usually >40mmHg

737

Mx of acute closed angle glaucoma

Refer to ophthalmology

Lie the person flat

Pilocarpine eye drops (2% blue, 4% brown) (miosis opens blockage)

Acetazolamide 500mg IV stat: reduces aqueous formation

Analgesia

+/- antiemetic

738

What are the aims of the treatment of angle closure glauocma

Reduce intraocular pressure

Ease symptoms

Prevent development/further progression of glaucoma

739

Definitive treatment for angle closure glaucoma

Laser iridotomy to allow aqueous humour to freely flow into posterior chamber. 

740

Pathophysiology of uveitis

Inflammation of uvea (iris, ciliary body and choroid)

If just iris and ciliary body= anterior uveitis

741

Acute pain and photophobia

Pain on accomodation

Blurred vision

?Acute uveitis

742

Small pupil initially, irregular later

Circumcorneal injection

Hypopyon (pus in anterior chamber)

Keratic precipitates on back of cornea

Talbots test: pain on convergence

Anterior uveitis

743

What are the systemic associations of anterior uveitis

Seronegative arthritits: AS, psoriatic, Reiter's

Stills'/JIA

IBD

Sarcoidosis

Behcet's

 

Infections: TB, leprosy, syphilis, HSV, CMV, toxo

744

Mx of anterior uveitis

Refer to ophthalmology

Prednisolone

Cyclopentolate drops: dilates pupil and prevents adhesions between the iris and lens

745

Def: episcleritis

Inflammation below conjunctiva in the episclera

746

Localised reddening that can be moved over sclera

Painless/mild discomfort

Acuity preserved

Episcleritis

747

Causes of episcleritis

Usually idiopathic

May complicate RA or SLE

748

Rx in episcleritis

Topical or systemic NSAIDs

749

What is the most common cause of red eye?

Conjunctivitis

750

Def: scleritis

Vasculitis of the sclera

751

Severe pain worse on eye movement

Vessels won't move over sclera

Conjunctival oedema (chemosis)

Scleritis

752

Causes of scleritis

Wegener's

RA

SLE

Vasculitis

753

Scleritis, what should you do?

RFTs as may be first presentation of Wegner's

754

Cx of scleritis

Scleromalacia leading to globe perforation

755

Mx of scleritis?

Refer to specialist

Most need corticosteroids or immunosuppressants

756

Often bilateral with purulent discharge

Bacterial: sticky (staph, strep, haemophilus)

viral: watery

Discomfort

Vessels may be moved over slcera

Acuity unaffected

Conjunctivitis

757

What are the classes of conjunctivitis?

Viral

Bacterial

Allergic

758

Rx bacterial conjunctivitis

Chloramphenicol 0.5% ointment

759

Rx allergic conjunctivitis

Anti-histamine drops e.g. emedastine

760

What are the divisions of the pharynx

Nasopharynx

Oropharynx

Laryngopharynx

761

Extent of the nasopharynx

From the posterior nares to the soft palate

762

Extent of the oropharynx

From the soft palate to the superior margin of the epiglottis

763

Extent of the laryngopharynx

From the superior margin of the epiglottis to the oesophagus

764

765

How are the layers of the neck arranged

In various fascial layers: superficial fascia which surrounds the anterior neck and is innervated by CNVII

Deep fascia: surrounds rest of the neck, several different layers

766

What are the layers of the deep fascia in the neck?

Investing layer: surrounds all structures within the neck

Carotid sheaths: laterally surrounds the neurovascular components

Pre-treacheal layer: ventrally, surrounds the viscera

Pre-vertebral layer: dorsally: surrounds the vertebrae and associated muscles

767

768

What are the four longitudinal compartments in the neck

2 vascular compartments: bilaterally, covered by the carotid sheath

Visceral compartment: ventrally: covered by the pre-tracheal fascia

Vertebral compartment: dorsally: covered by the pre-vertebral fascia

769

What are the contents of the vascular compartment of the neck?

Internal jugular vein

Common carotid

Vagus nerve

770

What are the contents of the visceral compartment of the neck?

Contains the pharynx, larynx, trachea, oesophagus and thyroid gland

771

What are the contents of the vertebral compartment of the neck?

Contains the vertebral column and associated deep muscles

772

What are the branches of the external carotid artery?

Some Anatomists Like Fucking, Others prefer S and M

Superior thyroid: supplies thyroid gland

Ascending pharygneal: small posterior branch supplying around the pharynx

Lingual: anterior branch to the tongue

Facial: supplies the front of the face, soft palate and submandibular glands

Occipital: supplies the posterior scalp

Posterior auricular: ssupplies the ear

 

Terminates at the parotid gland, bifurcating into two terminal branches:

Superficial temporal: supplies the parotid gland, lateral face and temple region

Maxillary: supplies numerous structures around the maxilla and mandible

 

773

Where does the common carotid bifurcate?

At the superior margin of the thyroid cartilage

774

How can the muscles of the neck be divided?

Supra and infrahyoid (strap)

775

What are the suprahyoid muscles?

Digastric: both insert on the medial hyoid: anterior belly (innervated by nerve to mylohyoid (of V3), posterior belly (arises from mastoid process and innervated by CNVII

Stylohyoid: arses from the base of the sytloid process and inserts on the lateral hyoid (CNVII)

776

What is the innervation of the infra-hyoid strap muscles?

C1-C3

777

What are the infra-hyoid muscles?

Omohyoid

Sternohyoid

Thyrohyoid

Sternothyroid

778

Action of the suprahyoid muscles

Depress the mandible or raise the hyoid

779

Actions of the infrahyoid

Depress the hyoid or fix the hyoid so that the suprahyoid muscles can act

780

What are the constricter muscles of the pharynx?

Superior: from the pterygomandibular raphe to the pharyngeal tubercle

Middle: from the hyoid bone

Inferior: from the thyroid cartilage

 

All overlap to make up the pharyngeal walls

781

What innervates the constrictor muscles of the pharynxx?

Vagus nerve

782

What are the three longitudinal muscles of the pharynx?

Stylopharyngeus

Salpingopharyngeus

Palatopharyngeus

 

All innervated by vagus except stylopharyngeus which is innervated by the glossopharyngeal

783

Which muscle of the pharynx is innervated by glossopharyngeal nerve rather than vagus?

Stylopharyngeus

784

785

def: corneal abrasion

Epithelial breach w/o keratitis

Cause: trauma

786

Pain

Photophobia

Blurred vision

Following trauma

?Corneal abrasion

787

Ix in corneal abrasion

Slit lamp: fluorescein stains defect green

788

Rx in corneal abrasion

Chloramphenicol ointment for infection prohpylaxis

789

Causes of corneal ulcer + keratitis

Bacterial, herpetic, fungal, protozoa, vasculitic (RA)

790

Corneal ulcer

791

Dendritic ulcer=

Herpes simplex keratitis

792

Dendritic ulcer

Herpes simplex keratitis

793

Acanthomoeba

Protozoal infection affecting contact lens wearers in swimming pools

794

Acanthomoeba

795

Pain, photophobia

Conjuncitval hyperaemia

Reduced acuity

White corneal opacity

?Corneal ulcer

796

RF for corneal ulcer?

Contact lens wearers

797

Ix in corneal ulcer

Fluorescein on slit lamp

798

Rx in corneal ulcer

Refer to specialist who will

Take smears and cultures

Abx drops, oral/topical aciclovir

Cyclopegics/mydriatics to ease photophobia

NB steroids may worsen symptoms

799

Complications of corneal ulcer

Scarring and visual loss

800

Def: ophthalmic shingles

VZV of CNV1

20% of all shingles

801

Pain in CNV1 dermatome preceding blistering rash

keratitis, iritis

Hutchinson's sign

Ophthalmic involvement: keratitis + corneal  ulceration

?Opthalmic shingles

802

Hutchinson's sign

Nose-tip zoster due to involvement of nasociliary branch

Increased risk of globe involvement as nasociliary involvement also supplies globe

803

Ophthalmic shingles

804

Hutchinson's sign

Nose tip zoster due to involvement of nasociliary branch

Increased risk of globe involvement as nasociliary branch also supplies globe

805

Key questions in sudden loss of vision

 

HELLP

Headache associated? GCA

Eye movements hurt? Optic neuritis

Lights/flashes preceding visual loss? Retinal detachment

Like curtain descending? TIA/GCA

Poorly controlled DM? Vitreous bleed from new vessels

806

Anterior ischaemic optic neuropathy

Optic nerve damage due to occlusion of posterior ciliary arteries, etiher by inflammation or atheroma

Pale/swollen optic disc

807

Causes of anterior ischaemic optic neuropathy?

Arteritic: GCA

Non-arteritic: HTN, DM, raised lipids, smoking

808

809

Unilateral loss of acuity over hours-days

Reduced colour discrimination (dyschromatopsia)

Eye movements may hurt

 

Reduced acuity

Reduced colour vision

Enlarged scotoma

Optic disc may be: swollen, normal, blurred

Afferent defect

?Optic neuritis

810

Causes of optic neuritis?

MS (45-80% >15y)

DM

Drugs: ethambutol, chloramphenicol

Vitamin deficiency

Infection: Zoster, Lyme disease

811

Rx Optic neuritis

High dose IV methyl predniosolone for 72h

Then oral pred for 11/7

812

What are the sources of vitreous haemorrhage

New vessles: DM

Retinal tears/detachment/trauma

813

Optic neuritis

814

Small black dots/ring floaters

Obscured vision

?Viterous haemrorrhage

815

Viterous haemorrhage

816

What can happen in large vitreous bleeds

Can obscure vision-> no red reflex

Difficulty visualising retina

817

Mx of vitreous haemorrhage

Vitrectomy may be performed in dense VH

Usually undergoes spontaneous absorption

818

Dramatic unilateral visual loss in seconds

Afferent pupil defect may precede retinal changes

Pale retina with cherry-red macula

Central retinal artery occlusion

 

819

Causes of central retinal artery occlusion

GCA

Thromboembolism: clot, infective, tumour

820

Rx in retinal artery occlusion

If seen <6h aim is to increas retinal blood flow by reducing IOP:

Ocular massage, surgical removal of aqueous, local and systemic antihypertensives

821

What is more common retinal vein or artery occlusion