Surgery Flashcards
(277 cards)
1
Q
What is involved in a pre-op assessment?
A
Basically look for likely complications of surgery.
History:
- History of Presenting Complaint.
- PMHx (CV, Renal, Respiratory disease all influence management, as do Endocrine diseases such as DM, Thyroid or Addison’s)
- Surgical Hx
- Anaesthetic Hx (any issues)
- Drug Hx, look out for drugs that must be stopped pre-operatively.
- Family Hx, mainly asking about intra-operative complications (e.g. Malignant Hyperthermia)
- Social Hx (smoking, exercise tolerance, alcohol use)
Examination:
- CVS + Resp + Abdo
- Airway Exam (assertain MALLAMPATI GRADE, look at face/neck/jaw/airway for any abnormalities that could complicate intubation)
- ASA grade
2
Q
Describe the ASA Grades (I to VI)
A
I = Normal II = Patient with mild systemic disease, some functional limitation. (SMOKERS and SOCIAL DRINKERS) III = Patient with severe systemic disease, significant functional limitation. (ALCOHOLICS) IV = Patient with severe systemic disease that is also a constant threat to life. V = Moribund patient who is not expected to survive without the operation. VI = Brain dead patient whos organs are being harvested.
3
Q
What investigations does a patient need before or around surgery?
A
- Bloods: FBC, Us and Es, LFTs, Clotting Screen, G&S (if blood loss isnt expected), X-Match (if it is)
- Imaging: ECG (as standard to look for cardiac disease), CXR (if indicated).
- 3 Rogue tests to remember: Pregnancy test, Sickle cell, MRSA swab.
4
Q
What is likely to happen to malnourished surgical patients?
A
Slow wound healing or wound breakdown, possibly leading to an infection.
Screen with Malnutrition Universal Screening Tool.
Treat with nutritional support. Depending on how functional the patient’s GI tract is, could be oral supplementation, NG or NJ tubes, Gastrotomy, Jejunostomy, Parenteral nutrition. Timed to make them ready for the operation.
5
Q
What is the ERAS?
A
Enhanced Recovery After Surgery.
Management suggestions aimed at helping patients recover faster, involves:
- Reducing NBM times (6 and 2)
- Pre-op carb loading
- Minimally invasive surgery
- Minimising drain NG tube usage
- Rapid re-introduction of food post-op (ideally within first 24 hours)
- Rapid mobilisation post-op
6
Q
How do you define and manage a high output stoma?
A
Any stoma producing more than 1.5L of clear fluid per day. Puts patient at signficantly increased risk of dehydration so important to manage quickly.
1) Look for any signs of systemic infection or persistent disease, both can drive up output. If not move onto regular management.
2) Nutritional support.
3) Reduce hypotonic fluids to 500mL a day.
4) Reduce gut motility with high doeses of Codeine Phosphate and Loperamide.
5) Reduce GI secretions with PPIs.
6) Low fibre diet to reduce intra luminal water.
7
Q
NSAIDs Side Effects?
A
I GRAB
Interactions with other drugs (e.g. Warfarin) Gastric ulceration Renal impairment Asthma sensitivity Bleeding risk
8
Q
Opioids side effects?
A
Constipation and Nausea are very common, can co-prescribe drugs to manage.
Sedation (resp and CNS), Confusion can be unfortunate side effects that are harder to manage.
Tolerance and Dependence with chronic use.
9
Q
What are the Indications and Contraindications for Mechanical VTEP?
A
Indications: Any surgery at all.
Contraindications: PAD, Peripheral Oedema, Skin Conditions affecting the lower legs.
Alternatives include LMWH or Unfractionated Heparin (if eGFR <30)
10
Q
What are the indications for blood transfusion?
A
Hb below 70, aim for 90 afterwards.
11
Q
What tests must be performed before transfusion? What monitoring must you do?
A
G&S and X-Match
Monitor obs @
- Start
- 15 Minutes in
- 1 Hour in
- End
12
Q
What are the 3 main blood products and when are they given?
A
Packed Red Cells:
- Mainly RBCs
- Given in either Acute Blood Loss or Chronic/Symptomatic Anaemia.
Platelets:
- Mainly Platelets
- Given in Haemorrhagic shock, Thrombocytopenia
Fresh Frozen Plasma:
- Mainly Clotting Factors
- Given in Haemorrhage patients with a background of LIVER DISEASE, DIC.
Major Haemorrhages you give Packed Red Cells and Fresh Frozen Plasma.
13
Q
How do you manage a tablet controlled diabetic pre-surgery?
A
- If poor control, treat as insulin dependent.
- If Sulphonylurea, switch to something else 2-3 days before surgery as MASSIVE hypo risk.
- Otherwise treat similary to insulin. If on AM list omit morning medication take afternoon. If on PM list omit afternoon medication take evening medication.
14
Q
What do you do if a diabetic isnt going to be able to eat for a while post-op?
A
Variable rate insulin infusion.
15
Q
How do you treat a diet controlled diabetic peri-op?
A
Same as a non-diabetic, but monitor blood gluose quite regularly in and around the procedure.
16
Q
How do you manage a patient on Warfarin before and after surgery?
A
Before:
- MINOR surgery, no change needed if INR is below 3.5
- MAJOR surgery, switch to Heparin 3-5 dayd before procedure, stop Heparin 6 hours before procedure,
- If INR is greater than 1.5 on day of surgery, give Vitamin K.
- In emergencies also give Vitamin K to correct INR.
After:
- Initially put them on Heparin until INR is within limits as Warfarin is weirdly pro-thrombotic,
17
Q
How do you manage a patient on DOACs (such as Apixaban, Rivaroxaban, Dabigatran)?
A
Entirely dependent on bleeding risk with the procedure, so harder to manage:
- No risk; Perform surgery immediately before patient is due next dose, restart it 6 hours afterwards.
- Moderate risk; Omit DOAC 24 hours before procedure
- High risk; Omit DOAC 48 hours before procedure
18
Q
How do you manage patients on antiplatelets around surgery?
A
Decision made by experts as takes 5 days to reverse effects and patient is at high risk of stents thrombosis and other complications in that time.
19
Q
Which patients require Cortisteroid Cover Therapy in surgery?
A
Anyone on more than 5mg of Prednisolone a day
20
Q
How much Corticosteroid Cover Therapy should patients be given?
A
- Minor surgery = No supplementation
- Moderate surgery = 50mg of HCS before induction, 25mg of HCS every 8 hours for 24 hours, then switch to regular dose.
- Major surgery = 100mg of HCS before induction, 50mg of HCS every 8 hours for 24 hours, half doses every day after that until normal dose reached, switch to oral.
21
Q
What is the purpose of Propofol in anaesthetics?
A
Induction, and then Total IV Anaesthesia Maintenance throughout surgery.
If IV access cant be achieved a Volatile Agent + Nitrous Oxide + Oxygen can be used.
22
Q
What are the side effects of Propofol?
A
Respiratory and Cardiac depression, as well as pain on injection.
23
Q
Generally speaking, what are the complications of surgery?
A
Complications to do with anaesthesia:
Nausea, Vomiting, Respiratory depression.
Complicatioms to domwith surgery generally:
Infection, haemorrhage, NV damage, DVT/PE
Complications specific to that procedure itself:
Damage to surrounding structures or to the system itself.
24
Q
What are the causes of post-op pyrexia?
A
5 Ws: Wind (atelectasis) Water (UTI) Wound (Infection at wound site) Walking (DVT or PE) Wonder drug (Drug fever)
Also blood transfusion or physiological response to surgery.
Low threshold for investigation for infection, and bear in mind rogue infections such as at cannula sites, meningitis, endocarditis, peritonitis.
25
Which drugs need to be witheld before surgery?
Anticoagulants and Hypoglycaemics.
COCP: 4 weeks before.
HRT: 4-6 weeks before.
ACE inhibitors and ARBs: 24 hours before.
Pottasium sparing diuretics (such as Spironolactone and Amiloride): Omited morning of procedure.
Lithium: 24 hours before.
26
What antibiotics are used prophylactically in General Surgery?
Pancreatic and Upper GI Surgery = Co-Amoxiclav 1.2g
HPB, Lower GI and Colorectal Surgery = Metronidazole 500 mg + Gentamicin 120mg
Appendectomy = Metronidazole 500 mg
26
What antibiotic is used prophylactically in Breast surgery?
Co-Amoxiclav 1.2g
27
What antibiotic is used prophylactically in Orthopaedic or Vascular surgery?
Co-Amoviclav.
1.2g Initially at induction, then 600mg 8 hours post op and 16 hours post op.
28
What antibiotics are used prophylactically in Urology?
Generally = Gentamicin 120mg +/- Metronidazole 500mg
No need for prophylaxis in TURBT
29
What are the 7 Ds of nipple changes suggestive of cancer?
- Discharge
- Deviation
- Dimpling
- Destruction
- (pagets) Disease
- Depression
- Displacement
30
What is a Phylodes tumour?
A cystic tumour of the breast, can be malignant can be benign, worth investigating cysts because of this risk.
Fast growing.
31
What is the screening programme like for breast cancer?
- Women aged 50-70
- Every 3 years
- Mammogram
- Can get one earlier if they feel a change
32
Elements to the triple assessment?
- Clinical examination
- Imaging (Mammogram + USS)
- Diagnostic (FNA or Core Biopsy of any breast lump for hystology)
(N.B, MRI is better for Lobular cancers, multifocal cancers, creening younger women with denser breast tissue)
33
What are the differences between core biopsy and FNA?
- Core biopsy is prefered now, gives more information.
- Can determine grade and receptor status of tumour
- FNA is less painful and has fewer concentrations, but gives less info.
34
How does breast cancer spread?
Lymphatics
Vascular extension
Direct invasion
Metastasis (Brain, Bone, Liver, Lung, Adrenal, Ovaries)
35
How do you treat breast cancer?
- Surgery (WLE for marginal or small lesions, patient choice or if unifocal. If greater than 4 cm or multifocal, need mastectomy)
- Sentinel lymph node biopsy/ Sample/ LN clearance
- Chemo
- Radio
- Hormonal therapy
- Biological
36
What does triple negative cancer mean?
Prog, Oest and HER 2 negative
37
What is the most common chemo regime for breast cancer?
FEC
5-Fluorouacil, Epirubicin and Ciclophosphamide
38
How do you decide what hormonal treatment to give breast cancer patients?
Done by age
Pre-menopausal- Tamoxifen
Post-menopausal- Aromatase inhibitors (reduce DVT risk, increase osteoperosis risk)
39
Presentations involving gallstones?
- Asymptomatic
- Colic (nothing on exam, rarely anything in the blood)
- Acute Cholecystitis (spectrum, mild pain to septic. May see fever, inflammation or mildy raised LFTs)
- Ascending Cholangitis (very sick, high mortality rate)
- Perforation
- Pancreatitis
- Gallstone Ileus (massive stone forms a fistula with the ileum and causes mechanical onstruction)
- Empyema of the Gallbladder (fills with pus)
- Mucusele (fills with mucus, no infection)
40
How high must Amylase be to diagnosis Pancreatitis
3x the upper limit
41
How do you manage Ascending Cholangitis?
- First treat Sepsis
- Percutaneous drainage of system
- Possibly lap choly
Think of fluids, Vitamin K. Patient wont be able to absorb Vit K and therefore at risk of clotting derangement.
42
What would an USS of the gallbladder show in Acute Cholecystitis?
- Thickened gallbladder wall. Any inflammation causing oedema will show up like this.
- Possibly stones.
- Possibly dilatation of the bile ducts.
43
What is the gold standard investigation for gallstones?
USS.
HOWEVER may not show them if theyre in duct due go overlying bowel. Will need MRCP.
If we know for sure stones are the cause of the symptoms, and its still there and isnt going to pass, send to ERCP.
Most patients end up with USS, then MRCP, then either or both of ERCP and Lap Choly
44
Treatments for gallstones?
If in:
- Gallbladder: Lap Choly
- Bile duct: ERCP +/- Lap Choly
45
How do you investigate the pancreas?
Triple contrast CT.
46
How do you investigate a upper/mid/lower bowel bleed?
```
Upper = OGD
Mid = Capsule endoscopy
Lower = Colonoscopy
```
47
How can alcohol cause anaemia?
B12 Deficiency
Causes severe gastritis, bleeds, Iron Deficiency
48
Common causes of lower GI bleed?
- Polyps
- Haemorrhoids
- Cancer
- Diverticular bleed
49
How do you choose Laproscopic vs Open hernia repair?
Most patients are eligible for both, their choice.
If bilateral go laproscopic.
If skin changes or damage around the hernia itself go laproscopic, as insitions are awar from site.
If recurrent go for whatever they didnt have last time, more liekly to resolve it.
Cardioresp compromise is a CI for laproscopic surgery as may not be handle the pneumoperitineum necesarry for laproscopic surgery.
If they’ve had abdominal surgery before laproscopic surgery is going ti be difficult therefore open is more appropriate.
50
How does ischaemia present?
Overwhelming pain and discomfort, very far out of proportion with their clinical picture.
Few signs, apart from quite severe Ischaemia.
51
How do you manage bowel ischaemia?
Temporary ischaemia: Supportive, fluids and antibiotics
| Severe ischaemia: Surgery, resection of the bowel.
52
Definition of a fistula?
Abnormal connection between two epithelialium lined spaces.
53
What are rhe key history points to ask for in a pre-op assessment?
- HPC + Whats been done so far.
- Surgical history
- Anaesthetic history (any allergies, any reactions, any nausea)
- Past medical history (CARDIO, RESP, RENAL AND ENDOCRINE conditions all affect surgery)
- Drug history (anything need to be stopped?)
- Family history (Malignant Hyperthermia)
- Social history (smoking, alcohol, exercise tolerance)
54
What must be assessed in a pre-op assessment?
- Abdomen, Heart, Lungs
- Airway exam (MALLAMPATI CLASSIFICATION)
- ASA Grade
55
What are the ASA grades?
```
I = Totally healthy patient
II = Mild systemic disease, smoker, social drinker, pregnant, obese
III = Severe systemic disease, alcoholic
IV = Systemic disease that is a constant threat to patients life
V = Moribund. Not expected to live without the operation
```
56
What blood tests (6) and imaging (2) would you consider in a pre-op assessment?
Bloods:
- FBC, Us and Es, LFTs
- X-Match, Clotting screen, Group and Save
Imaging:
- ECG. All patients.
- CXR. Done in smokers, those with a new cardioresp symptom, those with lung disease without a recent XR, and those whove recently been to a TB area.
57
What are the 3 roguer tests to order in a pre-op?
- MRSA swab
- Sickle cell
- Pregnancy
58
How do you assess a patient’s airways before surgery?
- FACE: Look for any abnormalities, especially involving the mandible.
- NECK: Assess range of motion in all directions.
- MOUTH: Ask them to open their mouth and judge oropharynx (Mallampati) and teeth/dentures.
59
What does a typical fluid maintenance regime look like?
1st: 500mL 0.9% Saline with 20 mmol/L of K over 8 hours
2nd: 1L of 5% Dextrose with 20mmol/L of K over 8 hours
3rd: 500mL 5% Dextrose with 20 mmol/L of K over 8 hours
N.B. Ommit K in first bag if post op
60
What systems of assessment do nutritionists use in Malnourished patients?
- MUST
- Grip Strength
- Tricep Skin Fold Thickness
- Mid Arm Circumference
61
What steps can be taken to accelerate post-op recovery?
Enhanced Recovery After Surgery measures (ERAS).
- Reduction in NBM times (6 and 2)
- Pre-Op carb loading
- Minimally invasive surgery
- Minimising use of drains and NG tubes
- Rapid reintroduction of feeding post-op (immediately if not GI surgery, within 24 hours if GI)
- Rapid mobilisation
62
How would you manage a high output stoma?
Start by assessing wether or not there is an underlying systemic disease or infection here.
If not, simoly try to drive dowm stoma output:
- Reducing fluids to 500 mL
- Reducing gut motility with Codeine and Loperamide
- Reducing secretions with high doses of PPIs
- Using WHO solution tomreduce sodium loss
- Low fibre diet to reduce water in the lumen
63
What problems can arise from poorly comtrolled pain post-op?
- Issues associated with reduced mobility. DVT/PE, slower healing, slower restoration of function.
- Issues associated with reduced lung oxygenation. Pneumonia and basal atelectasis.
64
What options for VTE Prophylaxis exist?
- Mechanical (anti-embolic stockings)
| - Pharmacological (LMWH as standard, UH if eGFR below 30)
65
How would you manage a diabetic patient who wont be able to eat for a while post-op?
Put them on VRII 2 hours before going into surgery. Aim for BMs between 6 and 10. When they are ready to eat, give them a dose of rapid acting insulin immediately before the meal.
66
How do you manage a diabetic patient for surgery if they are on Sulphonylureas?
Must be switched to a different OHG tablet 3 days before, risk of hypo in surgery is too great.
67
How do you manage a diet controlled diabetic surgically?
As a normal patient, just with more regular BM monitoring in and around surgery.
68
How would you manage someone on Metformin who also needs IV contrast during surgery?
eGFR>60 and Normal creatinine: No action taken.
Either eGFR<60 or Raised creatinine: Stop metformin after contrast is given, wait 2 days, check renal function. If all clear you can restart Metformin.
69
How do you manage a patient on Warfarin around surgery?
- Safe for minor surgery so long as INR is below 3.5
- If major surgery, will need to stop Warfarin 3-5 days before, switch to Heparin, which can then be stopped 6 hours before surgery.
- In emergencies, Warfarin can be reversed with Vit K and FFP.
Remeber to have patients on Heparin immediately post op, as Warfarin is pro-thrombotic initiall.
70
How do you manage a patient on DOACs going for surgery?
Decision made based around bleeding risk:
- Minor = Perform surgery at time of next DOAC dose, restart 6 hours later.
- Moderate = Omit DOAC 24 hours before
- Likely = Omit DOAC 48 hours before
71
Which patients should be considered for Corticosteroid cover therapy around surgery?
Anyone on more than 5mg of Prednisolone.
Minor surgery, local anaesthetic = None needed.
Moderate surgery (e.g. hip replacement) =
- 50mg @ Induction
- 25mg every 8 hours for the next 24 hours
- Then back on normal dosage
Major surgery =
- 100mg @ Induction
- 50mg every 8 hours for the next 24 hours
- Half dose each day until normal dose reached
- Continue normal dose
72
What are the risks to the patient if adequate cover isnt given?
HYPOTENSION and ADDISONS
73
How do you bring a patient out of anaesthesia?
- Change inspired gas to 100% O2
- Discontinue any anaesthetic infusion
- Reverse muscle paralysis
- Once spontaneously breathing, extubate
- Put in recovery position
- Give oxygen by face mask
74
What are the 3 types of post-op complications to bear in mind?
- ANAESTHESIA related: Nausea and Vomiting, Respiratory depression
- SURGERY related: Infection, Haemorrhage, NV damage, DVT/PE)
- PROCEDURE related: Damage to surounding structures, to the system involved
75
What do you consider in a post-op patient with pyrexia?
- First could it be due to blood transfusion, or tissue damage, or atelectasis.
- Them consider the other Ws: wound infection, water infection, drug related or PE/DVT
76
Causes of hypertension post-op?
- Pain
- Urinary retention
- Drugs
77
How do you manage a patient with reduced urine output post-op?
- Check catheter, attempt to flush through.
- If fine cause is likely AKI or hypovolaemia
- Fluid challenge
- Stop nephrotixic drugs
- USS bladder to look for retention
78
What diabetes numbers do we need to know?
For diagnosis:
- Random of 11.1
- Fasting of 7 or HbA1c of 6.5/48
For escalation of treatment:
- HbA1c of 7.5/58
79
Generally, what causes LUTS in men and women?
Men: BPH
Womem: UTIs and the Menopause
80
What medications would you give someone with BPH?
Tamsulosin. 5-Alpha-Reductase Inhibitor. Causes very quick shrinkage of the prostate. Relief in a few days
Finasteride. Also an inhibitor but works much more slowly and causes more long term shrinkage. Relief takes 6 months
81
What can cause acute urinary retention?
- BPH and Prostate Cancer
- UTI
- Constipation
- Pain
- Strictures
- Drugs e.g. Epidurals and Anti-Muscarinics
- Nerve Issues e.g. Surgery, MS and Parkinsons.
82
How do you investigate and manage Acute Urinary Retention?
- Diagnosis is achieved with a Post-Void Bladder Scan.
- But usually do a USS as well to look for hydronephrosis.
- Consider Catheterised Specimen Urine Culture
Management = Catheterise, Treat cause.
Watch out for POST-OBSTRUCTIVE DIURESIS. Diuresis causes a sudden loss in concentration gradient in the kidney, causing over diuresis and AKI. Manage by
- Monitoring fluids. If losing more than 200ml an hour..
- Replace fluids. 50% of loss
83
How do you distinguish Chronic and Acute urinary retention?
- Chronic is by definition painless
| - Chronic leads to a much larger residual volume than Acute.
84
What can cause chronic urinary retention in men and in women?
Men: Still mostly BPH
Women: Commonly either Prolapses or Fibroid masses
Both: Neuro causes are quite common (Stroke, MS, Parkinsons)
85
Older person comes in with Painless LUTS, Nocturnal Enuresis, Overflow Incontinence, what are you thinking?
Chronic Urinary Retention.
86
What are the 6 common causes of haematuria?
- Infection
- Malignancy
- Stone
- Radiation
- Trauma (e.g. Catheterisation)
- Schistosomiasis
87
What does a raised Albumin:Creatinine ratio indicate?
- Early stages of CKD
| - Particularly cases associated with Diabetes
88
What are the different forms of incontience and what causes them?
- Stress = Surgery, Obesity, Pregnancy and Post-partum
- Urge = Often Idiopathic, Caffeine use, Anti-Cholinergic medication, Infection, Malignancy, Neuro conditions.
- Mixed
- Overflow = Retention
- Constant = Anatomical abnormalities like Fistulae
89
How would you investigate an incontinence patient?
Initially: MSU Dip and PVBS
Later: Flex Cystoscopy, Urodynamics, Maybe CT Urogram or US KUB.
Consider keeping a bladder diary.
90
What are the treatment options for Stress Incontinence?
1st Line = Weight loss, Reduce fluids, Reduce caffeine, Stop smoking.
2nd Line = Duloxetine and PFMT.
3rd Line = Tension free vaginal tape, Intra-mural bulking agent, Artificial sphincter
91
What are the different management options for Urge incontinence?
1st Line = Weight loss, Reduce fluids, Reduce caffeine, Stop smoking.
2nd Line = Oxybutinin and Bladder training
3rd Line = Botox injections, PC Sacral nerve stimulation
92
What are the common types of kidney stones?
- Calcium Oxalate and Calcium Phosphate form the bulk of them.
- Mixed stones are also seen.
- In patients with high levels of Urate (e.g. Gout) you see Urate stones
- Infection related stones such as Struvite
- Sometimes stones are related to metabolic disorders, such as Cysteine stones.
93
What is the gold standard investigation for renal stones?
Non-Conrrast CT KUB
94
How do you manage a patient with a kidney stone?
- Fluids
- Pain relief (IM or PR Diclofenac) and Anti-emetics
- Consider Tamsulosin
- Give antibiotics if patient looks septic
If complicated (AKI, Infection, Signficant pain, >5mm), best to maintain ureter patency with either:
- Nephrostomy tube
- JJ Stent
Then wait for it to pass. If not then need to get rid of it, method used relates to size of stone:
- Smaller than 2mm Extra-Corporeal Shock Wave Lithotripsy
- Larger than 2mm Percutaneous Nephrolithotomy
Admit and Monitor.
95
How and why do you manage Bladder stones?
Often asymptomatic, but treat because can cause LUTS and are a risk factor for TCC Bladder Cancer.
Management is therapeutic Cystoscopy
96
Where do RCCs spread to?
Direct spread to the Adrenal glands, IVC, Renal vein, Lymph nodes.
Mets to BBLL (brain, bones, lungs, liver)
97
What are the main risk factors for RCC?
- Smoking is most common
- But Dyalisis is strongest (30x increases)
- High BP, Obesity
- PCKD, Horseshoe kidney, Other genetic malformations
- Industrial exposure
98
How can an RCC present?
Normally Haematuria.
Look out for flank pain/mass, non specific symptoms like weight loss/fever/tiredness and LEFT VARICOCELE.
Look out for METS (haemoptysis or fractures)
Look out for PNS (polycythaemia, Hypercalcaemia, Hypertension, Fever)
99
What is the gold standard for RCC diagnosis?
CT AP, Pre and Post IV Contrast.
100
Treatment options for RCC?
- Partial and Radical Nephrectomy
- PC Radio Frequency Ablation if not fit for surgery
- IFN Alpha or IL2 Agents or Metastasis removal if spread
Chemo not effective
101
How would you investigate and manage Bladder cancer?
1) Flexible Cystoscopy
2) Rigid Cystoscopy if something is found
3) Biopsy and TURBT then and there
Patients will likely then go for a staging CT scan:
- If Muscle invasive, Radical cystectomy + Ileal Conduit
- If Mets, Cisplatin chemotherapy
102
If patient has an enlarged prostate and raised PSA, how xan you distinguish between BPH and cancer?
- Free:Total PSA, more specific for cancer
- Biopsy (either transperineal or transrectal)
- CT AP or MRI for staging
103
What is the surgical option for BPH and what is the issue with it?
TURP
TURP syndrome. Process causes fluid overload and loss of Na which causes confusion, nausea, agitation and visual disturbances.
104
How do you treat Prostatitis?
- Prolongued course of Ciprofloxacin
- NSAIDs and Paracetemol for pain relief
- Finasteride or Tamsulosin or Stool softeners to try and reduce pain
105
What signs are present in Epididimo-Orchitis?
- Fever
- Tender, red hydrocele
- Present cremasteric reflex
- Prehn’s Sign positive
106
What are the risk factors for testicular torsion?
- Anatomical abnormalities (e.g. undescended, bell-clapper)
- Prior torsion
- Neonates
- Aged 12-25
- Family history
107
How does torsion of Hydratid of Morgani present?
Torsion with a positive blue dot sign
108
What surgical options are available for testicular torsion?
Viable Testes = Bilateral Orchidopexy
| Not Viable Testes = Orchidectomy
109
What investigations would you order for suspected testicular cancer?
Tumour markers: Beta-HCG, AFP, LDH
Imaging: USS and Staging CT
Management is usually orchidectomy and cisplatin chemo.
110
What is Fibromuscular Dysplasia?
A condition marked by vessel wall hypertrophy which affects the carotid and renal arteries, causing reduced blood flow.
Patients present YOUNG with either TIA symptoms or secondary hyperension.
Diagnosis requires Duplex US, MRA or CTA.
Treatment is management of cardiac risk factors and balloon angioplasty.
111
What is the gold standard investigation for a stroke?
Urgent non-contrast CT head.
| +/- Duplex USS of Carotid arteries, ECG...
112
How do you treat Carotid artery stenosis?
Management of risk factors (Aspirin, Statin, BP and BM control, Stop smoking)
Carotid Endarterectomy (if stenosis greater than 50%)
113
How do you investigate and classify a AAA?
Most are picked up on screening (men aged 65) or if symptomatic. Receive an abdo USS which confirms diagnosis, them a CT which gives size.
<3cm = Fine
3cm - 4.4cm = Yearly USS
4.5cm - 5.4cm = 3 Monthly USS
>5.5cm = Open repair or Endovascular repair
(Also operate if growing more than 1 cm a year)
114
Which direction of AAA is safer?
Posterior
115
How do you manage a ruptured AAA?
- High flow oxygen
- 2x large bore canula
- Bloods
- Until they can be transfered focus is on managin Blood Pressure. PERMISSIVE HYPOTENSION, pushing it too high could dislodge a clot an lead to further bleeding. Want to keep systolic at about 100. If theyre conscious, BP is fine,
- Transfer to local Vascular Unit for Open repair.
116
What is an aortic dissection?
A tear in the tunica intima of the aorta causing the intima and media to split apart.
Two kinds:
- Those progressing anterogradly (towards the iliac arteries)
- Those progressing retrogradly (towards the Aortic valve and potentially causing prolapse and tamponade)
117
How will an aortic dissection present?
- Tearing chest pain
- High HR, Low BP, Aortic rugurg murmur
- Signs of reduced end organ perfusion, such as limb ischaemia, abdo pain, drop in urine output.
118
How are Aortic Dissections managed?
Depends on Location:
Stanford Type A = Involve the Ascending Aorta and must be managed surgically. AA Removal and graft.
Stanford Type = Not Involving Ascending Aorta and have much greater prognosis. Uncomplicated can be managed with beta blockers and surveillance. Complicated still go for surgical repair.
Both cases will require long term management of cardiac risk factors.
119
What are some important complications of aortic regurgitation?
Rupture, Aortic regurgitation, MI, Tamponade, Stroke
120
What is a standard set of investigations for someone with a vascular issue?
ECG, Cardiac bloods, Doppler, CT Angiogram (maybe MR angiogram)
121
How do you manage acute limb ischaemia?
Immediate = HFO2, LMW Heparin
Assess limb for viability: TI, TIIA, TIIB, TIII
If TI or TIIA; Conservative management. Continue heparin and monitor.
If TIIB; Bypass, Embolectomy or Local Thrombolysis
If TIII; Amputation.
122
What is Chronic Limb Ischaemia and what causes it?
It is Peripheral Artery Disease that causes a SYMPTOMATIC drop in blood supply.
RFs = Smoking, DM, BP, Lipids, Age, Family history, Obesity
123
What are the stages of Chronic Limb Ischaemia?
Seem to be two classification systems, by symptoms:
- I is Asymptomatic
- II causes Intermitent Claudication
- III causes Rest Pain
- IV causes Ulceration and Gangrene
```
Or by ABPI:
Above 0.9 = Normal
0.8-0.9 = Mild
0.5-0.8 = Moderate
Below 0.5 = Severe
```
Can also diagnose Severe with a Bergers test that elicites pain at an angle below 20 degrees.
124
What is Critical Limb Ischaemia and how is it defined?
Severe Chronic Limb Ischaemia.
Either with:
- ABPI less than 0.5
- Ulcers/Gangrene/Skin changes
- Rest Pain present for more than 2 weeks.
125
How do you manage chronic limb ischaemia?
1) Lifestyle (weight loss, stop smoking, exercise)
2) Statins, Clopidogrel, DM control
If fails
3) Surgery for:
- Angioplasty
- Bypass grrafting
- Amputation
126
Patient comes in with abdo pain, normal exam and no abnormalities apart from acidosis amd high lactate, what are you thinking of?
Acute Mesenteric Ischaemia.
Resus/Antibiotics/Surgery (bowel excision and revascularisation)
127
What can cause a raised Amylase?
BAPED
```
Bowel perforation
Acute Mesenteric Ischaemia
Pancreatitis
Ectopic
DKA
```
128
How do Varicose veins present?
- Initially, cosmetic issue.
- Leading to pain, itching, aching, swelling
- Later complications include skin changes, ulceration, bleeding, thromboplebitis
Look out for the features of venous insuficiency:
Oedema, Eczema, Ulcers, Skin Staining, Lipodermatosclerosis
129
How do you manage Varicose Veins?
Non-Invasive:
- Avoid standing for prolongued periods of time
- Lose weight
- Exercise
- Compression stockings
Invasive:
- Ligation, Stripping, Avulsion
- Thermal ablation
Manage any ulcers with 4 layer bandaging
130
What is Thoracic Outlet Syndrome?
Hyper-extension injury OR RSI OR anatomical abnormalities cause swelling or haemorrhage cause narrowing of the thoracic outlet leading to compression of the neurovascular bundle as it leaves the thorax. This causes
- Neuro symptoms; Weakness and paraesthesia
- Arterial symptoms; Claudication
- Venous symptoms; Oedema and DVT
131
How is Thoracic Outlet Syndrome managed?
Non-Surgically through weight loss, PT or even Botox injections
Surgically though Decompression procedures.
132
How does Subclavian Steal Syndrome occur?
Atherosclerosis in the arteries of an arm (usually the left) causes a drop in blood flow to the brain to compensate for increased blood flow into the arm during exercise.
Symptoms are mainly Claudication and Neurological (vertigo, diploplia, syncope, visual loss)
133
How do you manage subclavian steal syndrome?
Conservatively: Statins and other risk factor management.
Surgical: Endovascular repair or bypass.
134
What happens at a triple assessment clinic?
1) History and Exam
2) Mammogram and Ultrasound
3) Core Biopsy of any Suspicious Lesions (chosen over FNA as can distinguish invasive and in situ carcinomas), FNA can be used to drain any confirmed cyst.
All women with a breast lump should be seen in clinic.
135
What causes Galactorrhoea?
Hyperprolactinaemia.
Pituitary Adenoma, Prolactinoma, SSRIs, Antipsychotics, VZ, Hypothyroidism, Renal Failure, Liver Failure
136
How can you manage Galactorrhoea?
Remove cause, e.g. change meds, treat hypothyroidism, remove rumour surgically.
Until them can use Dopamine to suppress Prolactin production
137
What are the causes of Mastalgia?
- Cyclical. Caused by hormonal changes ad therefore present at a predictable time of the month. Bilateral.
- Non-cyclical. Caused by medication. OCP, Sertraline, Haloperidol.
- Extra-mammary. Chest pain and shoulder pain can radiate to the breasts.
138
How do you manage Mastalgia?
In most cases, reasure them its not cancer (very rarely presents as pain) and focus on analgesia.
Paracetemol, Ibuprofen, Topical NSAIDs. If medication related, switch meds.
BRAS: Soft at night, better fitting during the day can help tremendously.
139
How do you treat Mastitis?
Lactational: Teach better technique and give 14 days of Fluclox. Try to avoid stopping feeding.
Non-Lactational: 14 days of Co-Amoxiclav
Analgesia
140
What causes Mastitis?
Staph Aureus.
Either poor breastfeeding technique OR existing risk factors such as duct ectasia.
141
How do you distinguish cancer and cysts on examination?
Cysts are: Smooth, Soft, Tender often Multiple. Have a halo shape on mammography.
Tumours are: Hard, Craggy, Non-Tender and usually single.
However will still need a core biopsy to diagnose.
142
How do you manage breast cysts?
Generally self resolve, no further management needed.
If persisting/symptomatic/potentially cancerous do an FNA.
If bloody, cytology.
Monitor for complications. Increases risk of cancer and can lead to Fibroadenosis.
143
How does Mammary Duct Ectasia present?
- Creamy/yellow/green Discharge
- Palpable Mass
- Nipple Retraction
Mammagram shows dilated, calcified ducts. Histology shows PLASMA CELLS.
144
How does fat necrosis of the breasts occur?
Trauma causes inflammation causes ischaemic necrosis of fat lobules
Requires core biopsy to distinguish from breast cancer.
Self limiting, reassure and give analgesia.
145
How does fibroadenoma present?
Highly mobile, rubbery, well defined masses. Often bilateral.
146
When do you excise a bening breast lump?
Symptomatic or atypical cells seen on histology.
147
How do you manage the 4 main breast cancers?
DCIS:
- Complete Wide Lobe Excision
LCIS:
- If low grade, monitoring
- If high grade, excision
- If BRCA +ve, B/L Mastectomy
IDC and ILC:
- Breast conserving options such as WLE.
- Mastectomy. Multifocal disease, recurrence.
- Axillary surgery. Either SN biopsy or AN clearance. AN safer but leads to complications such as paraesthesia and lymphoedema.
Hormonal options: Tamoxifen (younger women) Aromatase Inihibitors (PM women) if Oestrogen +ve.
Other options exist if HER2 or PR +ve
148
What are the 3 receptors tested for in breast surgery?
ER
PR
HER2
149
How do you distinguish Eczema of the nipple and Paget’s?
Pagets starts at the nipple, spreads to the areola
Eczema starts at the areola, spreads to the nipple
150
When should breast cancer patients be offered Radiotherapy?
ALL cases of breast concerving surgery require Radiotherapy
151
What is the most recent screening programme for breast cancer in the UK.
Mammogram every 3 years, women aged 47-73
152
Hos is breast cancer scored?
Nottingham Prognostic Index
Size, lymph nodes, Grade all considered
153
What is raised Lactate actually a sign of?
Tissue hypoperfusion, somewhere.
154
How do you interpret a raised Amylase?
3x Normal upper limit = Pancreatitis
Raised but not that much = Bowel perforation, DKA, Ectopic
155
Broadly how do you manage an acute abdomen?
- IV Acsess
- NBM
- Analgesia and Anti-Emetics
- Order suitable imaging
- VTE prophylaxis
- Urine dip
- Bloods
- Consider catheter or NG tube
- Fluid resus and monitor fluid output
156
What abdominal incisions are used and when?
- Lanz incision: Appendectomies
- Midline incision: Emergency procedures, can access the majority of the abdomen
- Kocher incision: Anything involving the biliary tree
157
What are the 4 common causes of haematemesis?
- Bleeding varix
- Bleeding ulcer
- Oesophagitis
- MW tear
158
What are the 3 common causes of oesophagitis?
- Candida
- GORD
- Bisphosphonates
159
What two scoring systems are used in haematemesis?
- Blatchford (uses biochemical markers to assess risk pre-endoscopy)
- Rockall (uses both biochemistry and findings on OGD to assess severity of bleed)
160
When do you do a group and save or X-match.
All bleeds should have a group and save, severe bleeds should have X-match with some units of blood set aside.
161
How do you manage a bleeding peptic ulcer?
- OGD
- Injection of adrenaline
- Cauterisation
- High dose IV PPI
- H Pylori eradication
162
How do you manage a bleeding oesophageal varix?
- OGD
- Prophylactic antibiotics
- Endoscopic banding
- Terlipressin should be given to reduce blood flow to the varix
- Sengstaken-Blakemore tubes can be inserted in severe cases
- Any bleed can be treated with Angio-Embolisation
- Long term, beta blockers.
163
What are the two broad types of Dysphagia?
Mechanical:
- CANCER (most common)
- Bening stricture
- Compression
- Pharyngeal pouch
Neuromuscular:
- Post stroke
- Achalasia
- Diffuse oesophageal spasm
- Myasthenia gravis
164
What questions should you ask someone with dysphagia?
- Is there difficulty in INITIATING swallowing
- Do you cough after swallowing
- Do you have to swallow a few times to get food down
- Is there pain
- Have you lost weight
- Hoarse voice
- Regurgitation
165
How do you investigate dysphagia?
- First endoscopy (biopsy of any lesion)
- Bloods
- Motility testing through MANOMETRY
- 24hr pH studies
166
Who gets 2 week wait referals for endoscopy?
- Anyone at all with dysphagia
| - Anyone over 55 with upper abdo pain, reflux or dyspepsia
167
What causes bowel obstruction?
```
Small = Adhesions and hernias
Large = Malignancy, diverticular disease, volvulus. Cancer until proven otherwise.
```
Can also think of it as intraluminal (gallstone, faeces), luminal (cancer, strictures, intussusception, lymohoma) and extramural (hernias, adhesions, volvulus).
168
How do you manage a bowel obstruction?
Conservative: NBM, Analegesia, Anti-emetics, NG tube to decompress the bowel (Suck), Fluids and electrolyte replacement (Drip), urinary catheter and fluid balance.
If not resolving within 24 hours, do a WATER SOLUBLE CONTRAST STUDY. If contrast does not reach the colon within 6 hours, obstruction probably wont resolve and therefore will need surgery.
(N.B. LBO and Virgin bowel SBO rarely settles without surgery)
(Obviously if ischaemic immediately send for surgery)
169
What is Boerhaave Syndrome?
Excessive vomiting leading to oesophageal perforation, either into the thorax or the abdomen. Look for palpable crepitus.
170
What signs on an AXR are indicative of bowel perforation?
- Rigler’s: Can see both sides of the bowel
| - Psoas: Loss of sharp delienation of psoas muscle border
171
What are the surgical procedures used to treat a GI perforation?
- Repairing a perforated ulcer (with an omental patch)
- Resecting a perforated diverticulum (e.g. via Hartmann’s)
- Thorough washout of the peritoneum
Beyond that options are highly individualised to the patient and the location of perforation
172
What are the 3 biggest causes of Melaena?
- Peptic ulcer disease
- Liver disease
- Gastric cancer
173
What artery is at risk of damage in a gastric ulcer?
Gastroduodenal artery. Common cause of melaena.
174
What will blood tests look like in a patient with an upper GI bleed?
- Possibly anaemic. Acute bleeds may not initially show up as anaemia.
- Raised Urea:Creatinine ratio (>30:1, will not be this high in lower GI bleed)
- LFTs may be deranged if varices are the cause
175
What are the differential diagnoses for fresh rectal bleeding?
- Diverticulosis
- Ischaemic colitis
- Infective colitis
- Haemorrhoids
- Malignancy
- Angiodysplasia
- UC
- Radiation proctitis
176
How do you distinguish a diverticular disease bleed from diverticulitis?
DD bleed just presents as GI bleeding
Diverticulitis will be painful and may have systemic features
177
How do haemorrhoids present?
- Mass felt at rectum
- Itchyness
- Bleeding. Normally in the pan, on the surface of the stool or on the paper.
- If they thrombose, intensely painful.
178
How would you investigate someone with a suspected lower GI bleed?
- If stable, Flex Sig. Often done as an outpatient.
- In inconclusive, full Colonoscopy.
- If unstable or large bleed, also consider Upper GI Endoscopy
- If Colonoscopy non-diagnostic, or if active bleeding, or if severely unstable, consider a CT ANGIOGRAM. Can identify specific vessel, an permits for therapeutic ARTERIAL EMBOLISATION.
179
How do you manage an acute rectal bleed?
Initially, attempt conservative therapy as 95% are self limiting. Monitor obs, give fluid and blood products and keep patient comfortable.
If not resolving or unstable, go for:
- Adrenaline injection endoscopically
- Bipolar electrocoagulation
- Argon plasma coagulation
- Endoscopic cliping or band ligation
- If undergoing angiography, consider arterial embolisation
May require surgery.
180
When should a GORD patient go for endoscopy?
- To rule out malignancy
- If not resolving under normal PPI treatment
- If worried about complications e.g. stricture or Barret’s
181
When should a GORD patient be considered for surgery and what does this surgery involve?
- Not responding to any sort of medical therapy
- Patient preference to avoid long term medication
- Patients with recurrent complications such as pneumonia amd bronchiectasis.
Surgery involves fundoplication of the fundus around the LOS (Niessens method). Main side effects are dysphagia, bloating, inability to vomit, however these tend to dissapear in the weeks following surgery as swelling and inflammation heals.
182
What are the complications of GORD.
- Barrett’s
- Oesophagitis
- Strictures
- Cancer
- Pneumonia!! (aspiration)
183
What is Barrett’s oesophagus and how is it diagnosed?
Metaplasia of the stratified squamous layer of the oesophagus into simple columnar gastric epithelium.
Diagnosis relies on biopsy.
184
How do you manage Barrett’s?
- High dose PPI BD
- Lifestyle advise
- Immediately stop any steroids or NSAIDs
- Regular endoscopic monitoring for progression to adenocarcinoma.
Regularity depends on stage:
- No dysplasia; Every 2-5 years
- Low grade; Every 6 months
- High grade; Every 3 months
185
How do you investigate oesophogeal cancer?
OGD first. Biopsy of any lesion.
If positive consider:
- CT CAP to look for distant mets
- Endoscopic USS can measure penetration and therefore give a T score
- Laparoscopy to look for peritoneal mets
- FNA of any nearby and swollen lymoh nodes
186
How do you manage oesophageal cancer?
Majority get managed palliatively:
- Oesophageal stent
- Chemo or radio
- Nutritional supoort
Curative:
- Major get some sort of neo-adjuvant chemo or radio-chemo.
- Oesophageal resection surgery. Major undertaking that carries a high risk of complications such as pmeumonia, anastomic leak, malnutrition. Will require nutritional support usually through a feeding jejunostomy.
187
What causes oesophageal rupture and how does it present?
Either iatrogenic due to endoscopy or forceful vomiting.
```
Mackler’s Triad:
- Abdominal pain
- Vomiting
-Subcutaneous emphysema
(However, SCE is actually weirdly rare to pick up and respiratory distress is much more common)
```
188
How do you investigate an oesophageal rupture and what would you see?
- CXR: Pneumomediastinum
| - CT CAP + IV and oral contrast: Air or fluid in the mediastinum or pleural cavity.
189
What are the principles of managing an oesophageal leak?
- Control the leak (normally surgically, using part of the diaphragm to buttress it while a trans-gastric drain can be put in). If small leak may not be necesarry.
- Eradication of contamination (washout, antibiotics, antifungals)
- Decompress the oesohagus (NG tube, probably need endoscopic placement. Can also be theough TG drain)
- Nutritional support
190
How do you manage a MW tear?
Small oesophageal rupture, therefore manage conservatively.
Fluid resus, take bloods, monitor.
191
What are oesophageal motility disorders?
Group of conditions characterised by abnormal swallowing to liquids and solids due to abnormal peristalsis.
Two main ones:
- Achalasia. Sphincter fails to relax, SM fails to contract. PROGRESSIVE.
- Diffuse Oesophageal Spasm. Multi-focal high amplitude contractions. Can progress to Achalasia
192
What is oesophageal manometry and what can it show?
Probe is inserted into the oesophagus. Records the behaviour of the muscle and sphincter.
3 Features of Achalasia on Manometry are:
- Absence of peristalsis
- Failure of relaxation if the LOS
- High resting sphincter tone
Features if DOS are:
- Repititive, simultaneous, ineffective spasms
- +/- Dysfunction if the LOS
193
How do you manage achalasia?
Conservative:
- Sleep with many pillows
- Eat smart, plenty of fluids
Medical:
- CCBs
- Nitrates
- Botox injections
Surgical:
- Endoscopic balloon dilation
- Laparoscopic Heller myotomy
194
How do you manage DOS?
- CCBs and Nitrates have some effect.
| - Myotomy or Pneumatic Dilation can be beneficial in severe cases.
195
What are the different causes of oesophageal dysmobility?
- Achalasia
- DOS
- CREST
- Myositis
- Polymyositis
196
How do you investigate a suspected hiatus hernia?
OGD is the gold standard investigation, showing upwards displacement of the Z line.
197
How do you manage a hiatus hernia?
Conservative:
- PPIs (must be taken in the morning before food)
- Weight loss, Diet alteration, Sleeping with pillows
- Cut down smoking and drinking
Surgical:
- Indicated if symptomatic inspite of treatment, nutritional issues, risk of strangulation or volvulus
- Fundoplication is an option
- Cruroplasty
198
What is Borchardt’s Triad and what does it mean?
Severe epigastric pain, Retching without vomiting, Inability to pass an NG tube
199
When do you refer someone for urgent endoscopy when suspecting malignancy?
ALARMS
Anaemia, Lost weight, Anorexia, Rapid onset, Melaena, Swallowing difficulties.
200
What is Zollinger-Ellison Syndrome?
Triad of:
- Severe peptic ulcer disease
- Gastric acid hypersecretion
- Gastrinoma
Usually caused by a pancreatic tumour secreting gastrin. Normally MEN 1
201
What are the MEN syndromes?
Multiple Endocrine Neoplasia.
```
1 = Parathyroid, Pancreatic, Pituitary (adrenal and thyroid)
2A = Parathyroid and Phaeochromocytoma (+medullary thyroid cancer)
2B = Phaeochromocytoma (+medullary thyroid cancer)
```
Genetic predispositions to cancers of the endocrine system.
202
How can you test for H Pylori?
- Biopsy, rapid urease test
- Urease breath test
- Stool antigen test
- Serum antibodies for H Pylori
203
What are the borders of the Inguinal canal?
AMFL
Aponeurosis, Muscle, Fascia, Ligament
- Aponeurosis of external oblique
- IO and TA muscles
- Transversalis fascia
- Inguinal ligament
AMFL is also risk factors (Age, Male, Fat, Lots of pressure)
(Femoral is the same except Females)
204
When do you do open/laprascopic hernia repairs?
Open: If first hernia, male and at low risk of chronic pain
Laparoscopic: Any other time
205
How do you diagnose a hernia (femoral or inguinal)?
Clinical diagnosis, just crack on.
If in real doubt can do an USS.
206
What are the two approaches to a femoral hernia?
High: Easier access, used in emergencies.
Low: Less disruption to surounding structures, used electively.
207
What questions are important to ask for in Gastroenteritis?
- Are friends similarly affected
- Recent travel
- Recent antibiotics use
208
What are some severe complications of gastroenteritis?
- Guillan Barre syndrome (immune system attacks peripheral nerve cells, cause is often a Campylobacter infection)
- Reactive Arthritis
- Haemolytic Uraemic syndrome (combo of haemolytic anaemia and AKI, cause is often an E Coli or Campylobacter Gastro infection)
209
What causes Gastroenteritis?
- Viruses (only last 1-3 days, mostly diarrhoea): Rotavirus, Norovirus, Adenovirus
- Bacteria (longer lasting): Campylobacter, Salmonella, E.Coli, Shigella
- Bacterial TOXINS (very acute illness, matter of hours): Staph aureus, Bacillus Cerues
- Parasites (most common in travellers): Cryptosporidium, Entamoeba, Giardia, Schistosoma
- HA Infections: C. Diff most common by far.
- Non-Infectious: Radiation, Microscopic, IBD, Chronic ischaemic colitis
210
When must you notify PHE about a diarrhoea case? What other measures must ne taken?
- If bloody/mucousy
- If food poisoning is cause
- If Campylobacter or Salmonella
- Exclude from work for 48 hours
- If C.Diff isolate, consider closing the ward
211
How would you treat Giardiasis, Amoebiasis and Schistosomiasis?
Giardiasis = Metronidazole
Amoebiasis = Metronidazole (WATCH OUT FOR AMOEBIC LIVER ABCESS)
Schistosomiasis = Praziquantel
212
What are the management options for Angiodysplasia?
Small bleeds make up the majority of cases and can be managed through:
- Fluids
- Bed rest
- +/- Tranexamic acid to reduce the bleeding down
Larger bleeds can be managed surgically:
- Argon Plasma Coagulation. Exposure to argon and electricity rapidly stops bessel bleeding.
- Sclerotherapy
- Band ligation
- Mesenteric angiography (mostly used if endoscopic options above are not available)
Bowel resection is also available if bleeding is continuous/severe/multi-focal
213
What are neuroendocrine tumours?
Tunours of the neuroendocrine cells of the GI tract, associated with genetic conditions like MEN 1.
Presentation = Abdo pain, N, V, WL, Distention and Obstruction. OR
Carcinoid syndrome:
- NE tumours that secrete functional hormones e.g. somatostatin, gastrin and prostaglandins.
- Causes flushing, pain, diarrhoea, wheezing and palpitations. Often triggered by coffee/alcohol.
214
What are the tumour markers for NE tumours? What else is useful in diagnosis?
5-HIAA and Chromogranin A
Genetic testing is also useful, as are Endoscopy and CT enteroclysis to find the mass.
WHOLE BODY SOMATOSTATIN RECEPTOR SCINTIGRAPHY is good to look for mets.
215
How do you treat NE tumours?
- Surgical resection +/- LN clearance is the only curative option.
- BEWARE CARCINOID SYNDROME. Caused by massive release of hormomes im surgery, mediate with Somatostatin analogues.
SI: Resection + LN clearance
LI: Resection + LN clearance (worse prognosis)
Appendix: Appendectomy, if larger than 2cm also take out right hemicolom
Rectal: Endoscopic resection or AP resection
- However many present too late so palliative is most common option.
216
How do you diagnose appendicitis?
Clinical diagnosis, US scan if unsure.
217
How do you manage appendicitis?
Laparascopic appendectomy. As with any laparascopic procedure, entire peritoneum should be investigated for other abnormalities. Meckel’s is a common co-occurence.
+/- Histopathology to look for malignancy as cause.
218
How do you actually diagnose UC and Crohn’s?
Colonoscopy with biopsy (faecal calprotectin has good sensitivity but not gold standard).
CT or MRI used for complications
219
Patient comes in with IBD related diarrhoea, why shouddnt you give Loperamide?
Can perpetuate Toxic Megacolon.
220
What are the important complications of Crohns?
GI:
- Fistula
- Stricture
- Perianal abscess
- Malignancy
Non-GI:
- Malabsoprtion (and delayed growth in kids)
- Osteoperosis
- Increased risk of gallstones (due to reduced resorbtion of bile salts)
- AND kidney stones (causes hyperoxaluria, oxalate stones)
221
Histological changes of Crohns?
- Inflammation contained within the mucosa and submucosa
- Crypt abscesses
- Goblet cell hypoplasia
- Pseudopolyps
222
What are the indications for surgery in UC?
- Not responding to medical treatment
- Toxic megacolon
- Bowel perforation
- Dysplastic cells picked up during routine monitoring (reduces the risk of colonic carcinoma)
223
How is colon cancer screened for in the UK?
Every 2 years if between 60 and 75, FOB testing.
If positive, colonoscopy with biopsy (gold standard)
Blood test for CEA.
224
When are chemo and radio therapy used in colon cancer?
Chemo: If metastatic. Regime = FOLFOX (Folinic acid, 5-Fluorouacil and Oxaliplatin)
Radio: Is useful for rectal cancer only
225
What is Pseudoobstruction?
A condition that presents identically to obstruction but without any mechanical obstruction. Differ in that bowel sounds are normal in PO.
Caused by High Ca/Low Mg/Low thyroid, Opioids/CCBs/anti-depressants, recent surgery and recent cardiac event.
CT scan with IV contrast can be used to rule out Mechanical obstruction and show dilation of the bowel.
Manage conservatively, treat cause and fluids.
226
How do you stage Acute Diverticulitis?
Hinchey classification, guides mamagement and predicts morbidity and mortality.
S1: Phlegmon, Pericolic/Mesenteric abscess
S2: Pelvic abscess
S3: Purulenr peritonitis
S4: Faecal peritonitis
227
How do you manage acute diverticulitis?
Conservatively: IV Antibiotics, Fluids, Analgesia and Bowel rest.
Surgically if perforation or not imrpoving. Hartmann’s
228
Risk factors for developing a volvulus?
- Old Man
- Neuropsych disorders
- Nursing home resident
- Chronic constipation
- History of abdo operations
229
How do you investigate a suspected bowel obstruction?
- Ca, TFTs and Mg (rule out a pseud)
- AXR
- CT AP with contrast
230
How do you manage a bowel volvulus?
Conservative:
- Sigmoidoscope decompression
- Insertion of a flatus tube
Surgical:
- Ischaemia/perforation/repeated failed decompressions/necrotic bowel on endoscopy
231
How do you manage an anal fisure?
- INCREASE FIBRE AND FLUIDS. By far the most effective option, allows it to heal.
- Obviously analgesia
- Stool softeners like Lactulose are the next step.
- Finally, creams like GTN or Diltiazem can be used
232
What is an anal fistula, how does it present and how do you treat it?
Abnormal connection between the skin around anus and anal canal. Usually secondary to chronic inflammatory processes (IBD or infection), abscesses or trauma to the region.
Will present with dischrage onto the perineum, pain, swelling, change in bowel habits, possibly systemic features of infection.
Small cases can be managed conservatively. Larger ones will need a Fistulotomy to open up the fistula and let it heal by secondary intention.
233
How do you manage an Anorectal abscess?
- No room for conservative management due to risk of recurence, fistual formation, cellulitis and sepsis
- Antibiotics
- Surgical incision and drainage, then allow to heal by secondary intention.
234
What is the distinction between a pilonidal sinus and a fistula-in-ano?
PNS opens up onti the skin but does not continue into the anal canal.
Distinction made in Flex Sig
235
How do you manage a Pilonidal Sinus?
- Conservatively: Shave area, wash it, try and pluck out hair.
- Medically: Can give ABs if look unwell
- Surgically: Can drain if recurrent disease or abscesses.
236
What is Anal Intraepithelial Neoplasia?
Neoplasia affecting the anal canal caused by HPV.
Risk factor for SCC of the ass and Adenocarcinoma
237
What are the risk factoes for anal cancer?
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HPV infection
HIV infection
Increasing age
Smoking
Immunosuppresant medication
Crohns disease
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238
How do you manage anal cancer?
Chemoradiotherapy with 5-Fluorouracil is now prefered over surgical resection.
239
What are the treatment options for haemorrhoids?
Conservative: Eat better, more fibre, more fluids, Lignocaine gel
Medical: Rubber band ligation, infrared coagulation, diathermy
Surgical: Haemorrhoidectomy
240
What does dark “coca-cola” urine mean in the context of jaundice?
High levels of CONJUGATED bilirubin.
Therefore likely pre or intra-hepatic cause of jaundice (post would have normal urine as unconjugated bilirubin cant enter the urine)
241
What do the various LFTs mean?
Bilirubin = Jaundice
Albumin = Indicator of Synthetic function of the Liver
AST and ALT = Hepatocelular injury
Alkaline Phosphatase = Biliary obstruction (or bone injury)
Gamma-GT = Alcoholism
242
What is a “Liver screen”?
Battery of tests ordered on top of LFTs in liver damage patients. Acute screen vs Chronic screen
Acute tests for:
- Hep A/B/C/E
- CMV and EBV
- Paracetemol
- Ceruloplasmin
- Antinuclear antibodies and IgG
Chronic tests for:
- Hep B and C
- Caeruloplasmin
- Ferritin and Transferin
- TTG
- Alpha 1 Antitrypsin
- Autoantibodies
243
What could a raised CA 19-9 and CEA mean?
Pancreatic or Bowel cancer respectively.
Both together and mildly raised possibly a cyst.
244
How do you manage Liver cysts?
Normally you dont, patients are rarely symptomatic. Monitor at 3/6/12 months after detection to look for growth.
If patient becomes symptomatic (pain, early satiety, nausea) or if diagnosis uncertain, can remove them. US guided aspiration or Laparoscopic deroofing are commonly performed. Later more effective, less recurrence.
245
When and how do you treat Polycystic Liver disease?
When they become symptomatic (abdo pain), when signs of cirrhosis or portal hypertension arise, if potentially malignant, if worried about malignant potential.
Surgical options:
- US Guided FNA (offers relief but cysts will fill back up)
- Laparascopic de-roofing (gets rid of the cyst totally)
- Lobe resection if too many in one space
- Transplants in very severe cases
246
Why cant you FNA Hydatid cysts or Cystic neoplasms?
- Hydatid, leads to anaphylaxis. De-roof instead (+/- Praziquantel)
- Cycstic neoplasms, leads to seeding. Lobe resection instead.
247
What causes a liver abscess?
Polymicrobial infection (E.coli + Klebsiella...)
Route cause is usually Cholecystitis, Cholangitis, Diverticulitis, Appendicitis, Sepsis.
Give antibiotics based on sensitivity and aspirate abscess.
248
What is Alpha fetoprotein?
Tumour marker for HCC.
249
What is the significance of the AST:ALT ratio?
Greater than 2 is highly suggestive of alcoholic liver disease
Around 1 is much more likely to be viral hepatitis.
250
What scoring systems are used in liver cancer?
Barcelona Clinic Liver Cancer system is used fir STAGING
Child-Pugh scores are used to assess the risk of mortality from cirrhosis.
251
What treatment options are available for HCC?
Surgical resection and transplant are the only two curative options, but obviously this is limited by issues with tumour size.
Non-Surgical options:
- Image guided ablation using US probes for SMALL TUMOURS
- Alcohol ablation
- TACE (trans arterial chemo emboisation) for LARGE TUMOURS
252
What drugs can trigger pancreatitis?
NSAIDs
Diuretics
Azathioprine
253
What are the most common presenting symptoms in Acute Pancreatitis, aside from EG pain?
- Bruising (GT and Cullen’s signs)
- Tetany from the Hypocalcaemia
- Jaundice
- Nausea and Vomiting
(Abdomen often SNT)
254
What makes up the modified Glasgow criteria and how do you interpret it?
Used to interpret the severity of pancreatitis. Anyone with 3 or more features should be considered severe and managed in HDU.
PO2, Age, Neutrophils, Calcium, Renal function, Enzymes (AST and LDH), Albumin, Sugar.
255
What is the role of imaging in Pancreatitis?
Not that important.
Diagnosis made on Lipase/Amylase. Severity calculated using modified Glasgow score.
Can do a USS if gallstones are suspected diagnosis.
Contrast enhanced CT scan is useful for visualising necrosis and therefore later surgical decision making, however this should be left until 6-10 days after admission when in recovery.
256
How do you manage a pancreatitis patient.
No curative option. Supportive care and hope they get better.
- High flow O2
- IV fluid resus
- NG tube (if vomiting)
- Catheterise and monitor fluid output
- Opioid analgesia
- Broad spec antibiotic if necrosis suspected
- HDU if severe
- Treat cause
257
What are the Local and Systemic complications of Pancreatitis to look out for?
Local:
- Pancreatic Necrosis. Happens about a week after due to prolongued inflammation, very prone to infection so treat with ABs (imipenem) and Necrosecromy.
- Pseudocyst. Collection of blood, fluid, enzymes and tissue in the epithelium of the pancreas. Can cause mass effect, can haemorrhage or rupture so should be monitored. Half self resolve, half require surgical debridement.
Systemic:
- DIC
- ARDS
- Hypocalcaemia
- Hyperglycaemia
- Shock and Organ Failure
258
What are the features of chronic pancreatitis?
- Chronic pain
- Malabsorption due to exocrine dysfunction
- DM due to endocrine dysfunction
259
How do you diagnose Chronic Pancreatitis?
Usually clinical, Amylase and Lipase wont really be raised.
Faecal Elastase levels are quite sensitive.
CTPA and Abdo USS are both good for visualising.
260
How do you manage Chronic Pancreatitis?
- Stop drinking
- Analgesia. Ideally simple analgesia and a weak opioid. (TCAs prefered over stromg opioids in severe cases to avoid dependency)
- PANCREATIC ENZYME SUPPLEMENTATION
- DM management
- Steroids only if AI cause
- Monitoring for risk of cancer
261
What is Thrombophlebitis Migrans?
Recurrent, migrating, superficial thrombophlebitis caused by a hypercoagulable state due to malignancy.
Associated with gastric, pancreatic and lung cancer.
262
What is Courvoisier’s Law?
Jaundice +
- Palpable gallbladder = Cancer
- Non-palpable gallbladder = Gallstones
263
What can cause obstructive jaundice?
Gallstones
Cholangiocarcinoma
Benign gallbladder stricture
Pancreatic cancer
264
How would you investigate pancreatic cancer?
- LFTs (raised bilirubbin and alp phos showing an obstructive picture)
- CA 19-9
- Abdo USS is usually the first test ordered
- Pancreatic Protocol CT Scan is the best for DIAGNOSIS as well as PROGNOSIS
- US guided FNA of the lesion may be useful if diagnosis is unclear
265
How would you manage pancreatic cancer?
Only curative options are surgical:
- Whipples if head
- Disral pancreatectimy if body or tail
Chemo:
- 5-Flouruoacil is used as adjuvant
- FOLFIRINOX regime in metastatic disease
However most patients are managed paliatively with pain relief and management of the endo and exocrine functions of the pancreas.
266
How do you manage biliary colic or acute cholecystitis?
- Fluids
- Analgesia
- NSAIDs and Opioids
- Antiemetics
- IV Co-Amoxiclav if cholecystitis
- Lifestyle factors going forward
Lap Cholies @
- Within 6 weeks if colic
- Within 1 week (ideally first 3 days) if Cholecystitis
267
What are the common causes of Ascending Cholangitis?
- Gallstones
- Recent ERCP
- Cholangiocarcinoma
(Should be easy to distinguish from history)
268
How do you manage ascending cholangitis?
FIRST: Treat the infection; Fluids, Cultures, Co-Amox and Metro
SECOMD: Definitive management; ERCP to drain system. Consider sphincterotomy and leaving in a stent so ir can drain.
From there treat cause (lap cholie or tumour resection)
269
What are some risk factors for cholangiocarcinoma?
- PSC
- UC
- Alcohol
- DM
- Toxins
- HIV or HEP
Presents as obstructive jaundice or ascending cholangitis.
270
How do you investigate and manage a cholangiocarcinoma?
Investigate:
- Tumour markers (both CEA and CA 19-9)
- US to prove obstructive jaundice
- MRCP for diagnosis
- CT or ERCP are best for staging
Management:
- Most have to have paleative options such as stenting, surgery or palliative radiotherapy
- Complete surgical resection and Radiotherapy can be curative in early disease.
271
What is the tumour marker and chemo option for colon cancer?
CEA and FOLFOX
272
What are the most important things to remember when managing a patient with a spleen injury?
Vaccines against capsulated organisms
Maintain haemodynamic stability
Early removal of dead tissue due to infection risk
273
How do you treat PSC and PBC?
- UDCA
- ADEK
- Chlestryamine
274
What drugs can cause agranulocytosis?
- NSAIDs
- Carbimazole
- Sulfasalazine
- Antipsychotics (e.g. Clozapine)
275
Outline RA management?
- Meth + Sulf + Hydroxy
- IA and IM steds for remission
- NSAIDs for pain
- Manage CVD risk factors
- PT and OT
276
What tests are diagnostic (or nearly) for SLE?
- ANA
- Decreased C3 and C4
- ESR high, CRP near normal
- Skin/Lung/Kidney biopsies
Dont forget complete drug history!!!
