What is Pseudomembranous Colitis?
- Acute inflammatory condition which occurs secondary to antibiotic use
- Clostridium Difficile (gram positive anaerobe)
- Presentation is usually within 3 - 9 days, although symptoms may develop up to 6 weeks after antibiotic use
- Presentation = proximal colon and caecum and present with a RLQ pain which may mimic appendicitis
- Diagnosis = stool testing for Clostridium Difficile toxins
- Complications = hypovolaemic shock, electrolyte imbalance, hypoalbuminaemia, perforation of the bowel and toxic megacolon
What is the management of Pseudomembranous Colitis?
- Fluid Resuscitation (mild cases do not require admission)
- Oral Metronidazole for 10 days
- Resistant and recurrent cases are treated with Oral Vancomycin
- intravenous preparations are avoided as the drug does not reach the intestinal mucosa
- Anti-Diarrhoeal Agents must be avoided as this would lead to retention of the C. difficile toxin
What is Neurogenic Shock?
- Sudden disruption or injury to the sympathetic nervous pathways
- Results in loss of vasomotor tone and pooling of blood in the peripheries
- Severe Hypotension
- Causes of neurogenic shock include injury to the brain and spinal cord, and acute emotional stress
What is Spinal Shock?
- Transient state occurring after injury to the spinal cord
- Loss of all voluntary and reflex activity below the level of the injury
- Hypotonic Flaccid Paralysis which also affects the bladder and bowel
- This loss can be complete initially but may resolve over a period of days and weeks following the injury
What are the key features of an Arterial Ulcer?
- Well Demarcated
- Heels, Toes and over Bony Prominences
- Due to Arterial Insufficiency and Ischaemia = Atherosclerosis
- Dusky Discolouration
- Shiny, Hairless Skin
- Thickening of the Toenails
- Intermittent Claudication
- Poor Pulses
- Coronary Angiography =define arterial lesions which may be improved by angioplasty or vascular reconstruction
What are the key features of an Venous Ulcer?
- Middle Aged Women
- Cause = Venous Hypertension and assoc w Varicose Veins
- Medial Gaiter Area (from the ankle to the proximal calf)
- Surrounding skin = Oedematous, Dark (caused by haemosiderin deposition), Eczematous and Thickened (lipodermatosclerosis)
What history questions should you ask in a Vascular Patient station?
- Vascular Risk Factors:
- personal or family history of diabetes
- smoking habits
- exertional capacity before onset of claudication (e.g. walking distance, number of stairs they can climb)
What are the associations of Primary Biliary Cirrhosis?
- Rheumatoid Arthritis
- Sjogren’s Syndrome
ERCP - ‘beading’ of the biliary tree
Primary Sclerosing Cholangitis
What is Buerger Disease?
- Vasculitis of medium-sized vessels
- Results in progressive obliteration of distal arteries
- Young Men (< 45 years)
- Smoke heavily
- Asians and Ashkenazi Jews
- Pain = main symptom
- Chronic Inflammation and Thrombosis can result in Ulceration and Gangrene (often requiring amputations)
- Arteriography = normal proximal vessels and distal occlusions with multiple ‘corkscrew’ collaterals
- Management = analgesia and stop smoking - if tobacco use is not ceased, multiple amputations will be unavoidable
What is Takayasu Arteritis?
- Pulseless Disease or Aortic-Arch Syndrome
- Granulomatous Inflammation of the aorta and its major branches.
- Arm Claudication
- Absent Pulses
- Visual Disturbance (transient amblyopia and blindness)
- Systemic Illness (malaise, fever, night sweats and weight loss)
- Younger Asian Women
- Diagnosis = Angiography which shows aorta narrowing and its major branches
- Management = steroids but the condition is progressive and death occurs within a few years
What are the markers of poor prognosis in Pancreatitis?
What are the investigation findings in Pancreatitis?
- Raised Amylase (above 4 times the normal upper limit)
- 40 - 140 U/L
- Elevated Serum Lipase (2 times upper normal limit)
- 0 - 160 U/L
What are the potential complications of a Supracondylar Fracture?
- Volkmann Ischaemic Contracture
- brachial artery injury = circulatory compromise and ischaemia = fibrosis of the forearm compartment
- secondary to untreated compartment syndrome
- forearm appears to be shortened and held in flexion at the wrist and the fingers
- Treatment = surgery
- Carpal Tunnel Syndrome = median nerve injury
- Ulnar Nerve Palsy = stretching of the ulnar nerve over an increasing valgus deformity
- Cubitus Varus Deformity (‘gunstock deformity’) = malunion of supracondylar fractures
What are the features of Chagas Disease?
- Central and South America
- Trypanosoma Cruzi = protozoa
- Primary Disease
- skin nodule – a chagoma
- fever, malaise, lymphadenopathy etc
- Secondary Disease
- 30% after years
- dysphagia (similar to achalasia)
- destruction of the oesophageal myenteric plexus
- retained food eventually results in oesophageal dilatation
- ‘megaoesophagus’ can be seen on barium swallow
What is the treatment of Anaphylaxis?
- Adrenaline i
- IM (10 mL of 1:1000 solution)
- IV antihistamines (e.g. chlorphenamine) and IV hydrocortisone are used to assist in dampening the inflammatory response
- Fluids are used for hypotension
- Salbutamol can be administered simultaneously to aid the relief of bronchospasm
What is the cause of Appendicitis?
- Inflammation of the appendix
- Secondary to obstruction of the appendiceal opening into the caecum.
- Causes of obstruction include faecoliths and lymphoid hyperplasia secondary to viral infections
What are the signs of Appendicitis?
- Localized peritonitis over McBurney point (found 1/3 of the way between the ASIS and umbilicus)
- Palpation over the LIF may cause pain in the rRIF (Rovsing Sign)
- Location (of inflamed appendix)
- bladder = urinary frequency
- rectum = diarrhoea
- psoas muscle = patient will feel most comfortable lying with the hip flexed
What are the key features of Acromegaly?
- GH secreting tumour
- GH = anabolic
- SoL = early morning headache that is worse on coughing and straining
- Risks = colon cancer and atheromatous disease
- Diagnosis = glucose tolerance test (75 g glucose - GH not suppressed)
- surgery = transphenoidal
- medical = octreotide (somatostatin analogues)
- N.B. Tumour before bone epiphysis fusion = gigantism
Cholangiocarcinoma vs Pancreatic Cancer?
- Adenocarcinoma of the Biliary Tree
- Assoc w UC, PSC and Crohn’s
- Poor Prognosis = 6 months (not amenable to surgery at time of presentation
- 50-70 years old
- F = M
What is Brown-Séquard Syndrome?
- Ipsilateral = loss of motor and dorsal columns (decussates at the level of entry into the spinal cord)
- Contralateral = loss of spinothalamic (decussates at medulla)
- Best prognosis of all spinal cord lesions
What is the treatment of Wilson’s Disease?
Penicillamine = chelates copper and encourages its excretion
Ampicillin and Amoxicillin precipitates a widespread rash in which condition?
Infectious Mononucleosis = don’t give it!
What are the features of Anal Carcinoma?
- SCC (80%)
- Elderly population
- Associated w Human Papilloma Virus (types 16, 18, 31 and 33) and Anal Warts
- Non-Specific Symptoms:
- intermittent bleeding
- inguinal lymphadenopathy
What is the diagnosis and treatment of Anal Carcinoma?
- Rectal Examination under anaesthesia
- CT/MRI can be used to assess the extent of pelvic spread
- Localized = radiotherapy with or without excision
- Larger = abdominoperineal (AP) resection with colostomy
- sigmoid colon, rectum and anus are removed
- defect in the perineum is closed with a mesh or muscle flap
What are the key features of a Para-Umbilical Hernia?
- Multiparous Women
- Above/Below Umbilicus in the Linea Alba
- Narrow Neck = Strangulation
What is a Pseudo-Polyp?
- Inflammatory Bowel Disease
- In an area of oedematous, swollen bowel surrounded by ulcerations, it looks as if the oedema is protruding from the walls of the bowel wall as a polyp
- In reality, these ‘polyps’ are merely areas of swollen bowel mucosa
What is Morton Neuroma?
- Between 3rd & 4th Metatarsal of the Foot
- Middle-Aged Women
- Pain (shooting) when wearing shoes (relieved when removed)
- Diagnosis = clinical (but confirm w MRI or US)
- Foot X-rays = Normal
- Treatment = surgical excision (= cure)
What is Plantar Fasciitis?
- Pain in the heels when walking
- Inflammation of the fascia as it inserts into the calcaneum
What are some potential complications of Angiography?
- False Aneurysm (commonly after trauma or iatrogenic = pulsatile, minimally tender)
- ultrasound-guided compression
- Groin Abscess = tender and fluctuant but not pulsatile
What are the key features of Duct Ectasia?
- Skin/Nipple Retraction
- Greenish/Brown Nipple Discharge
What is Intraductal Papilloma?
- Benign Tumours of Lactiferous Glands
- Pre-Menopausal Women
- Pain within the Nipple or Areola
- Associated w Discharge which may be Blood-Stained
- In most cases there is no associated breast lump
- Investigations =
- cytology (no malignant cells)
- ultrasound (more sensitive than mammography for intraductal papillomas)
- lump present = biopsy
- Treatment =
- significant symptoms or a risk of malignancy = surgical excision of the affected duct can be undertaken (microdochectomy)