- Clinical suspicion of obstruction (if perforation -> CXR)
- Acute exacerbation of inflammatory bowel disease
- Sharp/poisonous foreign body
In specific circumstances: • Palpable mass • Constipation • Acute and chronic pancreatitis • Smooth and small foreign body, e.g., coin, battery • Blunt or stab abdominal injury
How to differentiate between sigmoid and caecal volvulus?
Sigmoid volvulus - coffee bean shape
arises in the pelvis (left lower quadrant)
extends towards the RUQ
ahaustral in appearance
sigmoid volvulus causes obstruction of the proximal large bowel, therefore the ascending, transverse and descending colon may be dilated
few air-fluid levels may be seen
Caecal volvulus - embryonic shape arises in the right lower quadrant extends towards the epigastrium or LUQ colonic haustral pattern is maintained distal colon is usually collapsed and the small bowel is distended one air-fluid level may be seen
Definition: Ischemic colitis refers to inflammation of the colon secondary to vascular insufficiency and ischemia
Epi: disease of the elderly (age >60 years) where atherosclerotic disease or low flow states
PC: abdominal pain and bloody stools
Location of ischemia relates to anatomy of vessels SMA (Caecum to splenic flexture) IMA (beyond splenic flexure).
Path: Diminished or absent blood flow leads to bowel wall ischemia and secondary inflammation. Bacterial contamination may produce superimposed pseudomembranous inflammation. If necrosis develops then ulcerations or perforation can occur. Following the acute event, fibrosis may lead to stricture of the bowel lumen.
Ix, AXR can be normal or can show ‘thumbprinting’ due to mucosal edema/hemorrhage, dilatation
CT is investigation of choice and commonly shows bowel wall thickening, fat strands, vascular occlusion.
Mx: anticoagulation or thrombolysis, either systemically or locally
Layers of the scrotum and contents
Contents of the spermatic cord
Rule of Threes: Three layers (external spermatic from EO, cremasteric from IO and internal spermatic from transveralis fascia) Three arteries (Artery to vas, cremasteric artery, testicular artery) Three veins (Pampniform plexus, cremastric vein and vein of the vas) TWO nerves: Genital branch of genital femoral nerve, Sympathetic & Parasympthaetic nerve from T10-T11 Three extra things: obliterated processus vaginalis, Vas deferens, Lymphatics
Layers: Some Damned Englishmen called it The Testes
SCS, Dartos fascia, External spermatic fascia, Cremasteric fascia, Internal Spermatic Fascia, Tunica vaginalis, Tunica albuginea
Horizontal incision of appendicitis, closer to the ASIS than Gridiron
Provides better cosmetic result but increases risk of inguinal hernia due to dividing nerves that can cause denervation of the muscles of the inguinal canal
One third along the way of the line between the ASIS and umbilicus, transverse incision perpendicular to this line
Aka Mcburney’s incision as it is over mcburney’s point
Transverse incision 5cm above pubic symphsis 10-12 cm across midline Mostly used by gynae for cs and ovariation operations or urologists for access to bladder and prostate Offers excellent cosmetic results
3cm below and parallel to the subcostal margin from midline to border of the rectus abdominis
R-sided kocher for open chole
L-sided for splenectomy
Can’t be extended medially, if extended too far laterally intercostal nerves can be dmaged
Double kocker linked into the middle
Access to liver and spleen and bilateral adrenalectomy, radical pancreatic and gastric surgery, whipples
Liver transplant /resection
Vertical incision medial to the lateral border of the abdominal rectus
Has high risk of incisional hernia and damaged nerves in rectus sheath- on longer recommended
Extended gridiron (One third along the way of the line between the ASIS and umbilicus, transverse incision perpendicular to this line) that allow views of caecum and right colon
Acute diverticulitis classification
Stage I: small or confined pericolic or mesenteric abscess.
Stage II: large paracolic abscess often extending into pelvis.
Stage III: perforated diverticulitis where a peri-diverticular abscess has perforated resulting in purulent peritonitis.
Stage IV: perforated diverticulitis where there is free perforation and is associated with faecal peritonitis.
Pre-op what drugs should you stop?
1. Metformin if pt at risk of AKI OR pt is missing >1 meal. Stop it from when the pre-op fast begins. If pt has metform > OD, then replace with variable rate insulin infusion.
3. ACEi - stop for 24hrs, risk of hypotension
4. Spiro - don’t take morning of operation due to risk of hyperkalaemia
5. MAOi e.g. pethidine hydrochloride
6. Lithium - for 24hrs if its a major op
7- Warfarin - stop 5 days unless on metallic valve in which case admit and manage on heparin infusion pump
HIV - get specialist advice
Pre-op - what drugs shouldn’t you stop?
Anti-parkinsonian Anti-epileptics Thyroid or Antithyroid Drugs of dependence Antipsychotics Anxiolytics Bronchodilators Glaucoma Meds Immunosuppressants
What would need a midline laparotomy?
Emergency: Perforation (bowel) Trauma AAA rupture Hartmann’s
Layers of the abdominal wall when you make a midline incision
Skin Camper’s fascia Scarper’s Fascia Linea Alba (Midline) Transveralis fascia Pre-peritoneal fat Peritoneum
Anterior SCS External oblique, Internal oblique, Transversus abdominis, Transveralis fascia , Preperitoneal fat, Peritoneum.
Whats the significance of the arcuate line?
Arcuate line - marks when the IO and TA pass anteriorly to the rectus muscles. (Really important learn this)
The arcuate line or semicircular line of Douglas is located at roughly one-third of the distance from the pubic crest to the umbilicus. It is the demarcation where the internal oblique and transversus abdominis aponeuroses of the rectus sheath start to pass anteriorly to the rectus abdominis muscle, leaving only the transversalis fascia posteriorly.
Post op complications
Immediate: Anaesthetic complications, bleeding (primary or reactionary), damage to near by structures
Early complications: Bleeding (secondary often due to inflammation), infection & abscess, dehiscence*, pain, VTE, atelectasis**, CAP (can be secondary to atelectais), Post op urinary retention and hypovolaemic shock; Paralytic Ileus (pts vomit, monitor electrolytes), abx associated colitis.
Specific: anastamotic leak, eneterocutenaous fistulae
Late: failure/recurrence, scarring (hypertrophic or keloid)
- rupture along the surgical suture- if superficial rupture just wash and wound care, if full thickness > resus and return to theatre RTT)
- *(people in bed, pain, etc - chest physio)
Protrusion of a viscous (or part of a viscus) through a defect in its wall into an abnormal position.
TCC vs SCC of the bladder
Other: voiding irritability: dysuria, frequency, urgency; Recurrent UTIs and retention and obstructive renal failure
Most common bladder cancer is transitional cell carcinoma (SCC is developing countries due to schistosomiasis, schistoma cause chronic bladder inflammation),
Things to ask in the history:
- Exposure to dye or rubber industries due to beta-napthlamine
- Other causes is staghorn calculi, or long term catheter or any bladder inflammation
Patients present with Painless frank haematuria or with multiple UTIs
Ix to order:
Urine dip (sterile pyuria), cytology, FBC (anaemia), U&Es,
IV Urography would show filling defects
Cystoscopy + Biopsy for diagnosis
Bimanual EUA to help assess spread (rubberythickness = T2, mobile mass T3, fixed mass T4)
MRI/CT for staging
Depends on the staging: Tis = carcinoma in situ Ta = confined to epithelium T1 = Tumour in lamina propria Felt at EUA: T2 = Superficial muscle involved T3= Deep muscle involves T4 = Invasion of prostate, uterus or vagina
SUPERFICIAL (Tis, Ta and T1 = 80% of patients)
- Transurethral Resection of Bladder Tumour (TURBT) can be done via resection or diathermy
- Intravesciular Chemo: Mitomycin C
- Intravesicular immunotherapy: BCG
INVASIVE (T2, T3):
1. Radical cystectomy, LN dissection + ileal conduit is gold standard
± Adjuvant chemo -MVAC (Methotrexate, vinblastine, doxorubicin and cisplatin)
2nd line Immunotherapy e.g. nivolumab
C- Long term catheter
M- pallaitve chemo MVAC and radiotherapy
+ EXTENSIVE FOLLOW UP as 70% Of bladder tumours recur
Low risk @ 9 month then yearly
High risk every 3 months for 2 years then every 6 months
What is a radical cystecomy and what happens after a radical cystectomy? + incl complications
Cystectomy - removal of bladder
Radical cystectomy M: prostate and seminal vesicles. F: removal of the uterus, ovaries and part of the vagina
Upper tract diversion (end urostomy) or neo bladder (60cm small bowel joined to ureter and urethras, still have external sphincter, continent, need to be able to self catheterise, initially when they have it they can only hold 200ml but as time goes on you can hold 600ml)
Early - urinary leak from stents, infection, DVT
Late - infection, uteroileal strictures and reflux of infected urine can both lead to hydronephrosis / renal function decline, poor bladder emptying can lead to urinary calculi, metabolic acidosis (worse with more proximal bowel conduits) due to the absorption of ammonia from urine (NH4 > NH3 + H+) in the intestinal luminal cells, causing excess hydrogen ions and metabolic acidosis
Common sites of impaction of renal calculi
- Ureteropelvic junction (pelvis meets ureters)
- Where the iliac artery crosses the ureter
- Vas deferens/broad ligament
- Ureterovesical junction (Ureter meets the bladder wall)
- Ureteric office
Bladder calculi vs renal calculi presentation vs UTI
Renal: Loin to groin pain associated with microscopic heamaturia, visible haematuria is rare but can occur (Rf: UTI, stasis 2ndary to obstruction, hypercalcaemia(
Bladder: Dysuria, haematuria and frequency ±intermittent stream. Suprapubic pain that radiates to perineum or penis tip. Pain worse at the end of micturition
UTI: Dysuria, frequency, cloudy/smelly urine
Renal Cell Carcinoma Presentation + Extra features
Over 50% of RCC patients are asymptomatic on presentation, and renal masses are often found incidentally on imaging done for other indications
Most common renal tumour, often M >40yo
Classic triad - haematuria (±clot), flank pain (40%), abdominal mass (20%), is uncommon <10% of pts
If any, it presents with Abdo pain, haematuria and oedema
Rarely: new L varicocele (tumour obstructing left testicular vein, which drains into renal vein, R drains into IVC - > can present with bilateral oedema)
PUO + FLAWS
- EPO - polycytheamia
- Renin -HTN
- Vit D OH ylation / PTH like hormone hypercalcaemia
- ACTH - cushing’s
Symptoms of mets e.g. cough or bone pain
GOLDEN YELLOW IN COLOUR
Conditions RCC can be associated with
- Von Hippel Lindau
RCC + Phaeo + CNS haemangiomas
- Tuberous Sclerosis
Multisystem tumours + developemental delay + seizures + skin lesions e.g. shagreen patch, ash leaf etc
Ix & Management of RCC
Ix: Hx, exam, urine dip, obs, bloods, flex cystoscopy (quick, painless), CXR, USS, then CT, biopsy not needed prior to nephrectomy (TCC - biopsy IS needed)
Mx: Robson staging
C: Well controlled HTN, stop smoking, thromboprophylaxis
Stage 1 or 2 - Nephrectomy
Stage 3- Radical nephrectomy + Sunitinib for 1 year (kidney, mesentery and part of ureter)
Stage 4 - Combination therapy of TKI and check point inhibitor (Pembrolizimab and Axitinib), Palliative radiation and bisphophonates for mets
M- TKI inhibitors e.g. pazopanib; MTORi e.g. Temsirolimus
S - T1 - radical nephrectomy , if they have 1 you can do partial nephrectomy,
T1RF vs T2RF and RF
Resp failure = pO2 < 8.0
T1 = CO2 is low or normal
T2 = CO2 is high
pH will be in normal range BUT body never over compensates so if <7.4 - compenating an acidosis >7.4 compensating an alkalosis
Lateral femoral cutaneous nerve becomes trapped under inguinal ligament where it attaches to ASIS
Burning or pain or numbness in lateral thigh with no abnormality
Exacerbated by periods of standing
Foot drop causes
Foot drop is caused by weakness of the muscles of ankle dorsiflexion (tibialis anterior) supplied by the common peroneal nerve (L4, L5 and S1 nerve root).
Foot drop may therefore be caused by:
Isolated common peroneal nerve palsy (e.g. secondary to fibular # or compression of nerve near the fibula e.g. plaster cast)
L5 radiculopathy (e.g. disc prolapse)
Generalized polyneuropathy involving multiple nerves (e.g. diabetic neuropathy, motor neurone disease, Charcot-Marie Tooth disease)
Sciatic nerve palsy
Presents with loss of movement and sensation in the leg/foot.
Sensation: loss of leg - everywhere apart from:
- medial aspect of leg- supplied by the saphenous n which is a branch of the femoral n
- upper calf supplied by posterior femoral cutaneous nerve
Motor: all muscles of foot and leg (can’t dorsiflex or plantar flex the foot)
Spinal: Spinal stenosis, spondylolithesis, anything in spinal canal e.g. mets, infection
Non-spinal causes: Pregnancy, Piriformis syndrome, trauma and tumours
Iatrogenic (IM injections in the Lower inner quadrant of buttock instead of upper outer or due to posterolateral approach in hip surgery)
Sciatic nerve divides into common peroneal and tibial nerve ~ mid thigh
Unable to flex the knee
Absence of ankle jerk
What sensation loss would you expect?
How is this damaged?
How does the palsy present?
- vulnerable to damage in posterior knee dislocations
or compressed behind medial malleolus
- branch of sciatic nerve
- Loss of sensation over the sole of the foot
- supplies calf flexors and gives rise to medial and laterla plantar nerves -> intrinsic muscles of foot, ankle inversion and ankle jerk + sensation over plantar foot surface
Injury presents as:
-Shuffling gait as can’t lift foot properly
- Loss of ankle inversion and ankle jerk
- Eventually -> claw foot, atrophy of foot musclees and loss of arch of foot
Differences between tibial nerve and peroneal nerve injuries: TIPPED
• Tibial → impaired foot Inversion and Plantarflexion
• Peroneal → impaired foot Eversion and Dorsiflexion
Can’t extend knee
Loss of knee jerk
What sensation loss would you expect?
How is this damaged?
Would expect loss of sensation over the anterior thigh and medial aspect of leg
Femoral n is vulnerable to trauma as it sits most lateral in the femoral triangle. Vulnerable to trauma, hip dislocations or thigh haematoma
It supples motor branch of quads (knee extension and knee jerk) and sensory branch to anteromedial thigh and medial calf and medial edge of foot via saphenous nerve
Obtruator nerve palsy
Often damaged in obstetric surgerys and pelvic disease
Loss of hip adduction and loss of sesnation to upper inner thigh
(irrelevant but Hip pain is often referred to knee to obtruator nerve)
What anaesthetic do you give before manipulation of colles fracture?
You do a Bier Block (squeeze blood out of limb, tourniquet around upper arm, IV Prilocaine distal to tourniquet
Best choice of LA is prilocaine as is least cardiotoxic
What LA do you use for spinal or epiduaral anaesthesia
Bupivicaine as its longer acting
CI as IV LA as its cardiotoxic
What gel can we use for catheterisation and what topical do we use for cannulating kids
Lidocaine gel for catheters
Lidocaine /prilocaine topical emulsion (Emla is brand name)
Which cancers are associated with FAP?
- Hepatoblastoma as kids
- Colorectal cancer (100% of patients with FAP develop it by 40 years of age if prophylactic colectomy is not performed)
- Duodenal Cancer - 2nd leading cause of cancer death, they commonly get polyps around sphincter of oddi (abdominal pain and obstructive jaundice)
- Thyroid cancer
How do we manage a bleeding ulcer?
C: Blood transfusion
M: IV PPI
3 main techniques: Glue - Non-variceal, Sclerosants - Variceal
- Injection therapy (inject with adrenaline - most common, adhessives (fibrin glue) and sclerosants (pure ethanol))
- Thermal methods (argon coag or heater coag) (superior to other 2 in terms of reducing further bleeding and surgery)
- Mechanical therapy (clips)
Haemorrhoids Ix and Mx
Haemorrhoid - dilatation of superior rectal arteries within anal canal
Anal exam: DRE + Anoscope (just a source of light)
Colonoscopy /Flexi sigmoidoscopy performed to exclude sinister cause if you were suspicious due to presentation
A/S -> C- dietary and life style modification
Grade 1 (confined to canal) - topical steroids
Grade 2/3 (reduce spontaneously, 3 don’t) - Rubber band ligation
grade 4 - haemorhoiddectomy
Core biopsy stages of breast
B1 - normal B2 - benign breast tissue (e.g. when fat necrosis lump is aspirated this will be the stage) B3 - equivocal, probably bengin B4 - suspicious, probably malignant B5 - malignant breast tissue
Painful subcutaneous cord like lump in breast, what is the diagnosis?
Mondor disease - thrombophlebitis of superficial veins of breast and anterior chest wall
44 Year old woman presents with 1 month history of jaundice associated with fatigue itching and dark urine She has pmhx of early onset rheum arthritis. O/E jaundiced, xanthelasma, abdo exam NAD.
What features in this history point to the diagnosis?
What investigations would you do?
Primary biliary cirrhosis
- Middle aged women are most commonly affected
- Autoimmune condition and she has AI hx with RA
- Pruritus is most common symptom
- ob j and xanthelasma are other symptoms
- some can present with symptoms of portal hypertension
Mx: Ursodeoxycholic acid for itching, transplant needed
Thyroid cancers types and mx
70% are papillary adenocarcinomas
20% are follicular carcinomas
1. Papillary ac - common in adolescent and young adults, thyroid nodule, ±LNs. Can be mulitfocal Histology for papillary -> orphan annie (spread via lymph). Thyroidectomy ± LN excision ±radioiodine
2. Follicular - discrete single encapsulated lesion, spread via blood to lungs and bone. Mx is total thyroidectomy (if <1cm can do lobectomy)
Both can be TSH dependent so post op, both must take Thyroxine life long to suppress endogenous TSH secretion and reduce risk of recurrence
3. Medullary - MEN2 if young, spontaneous if older, parafollicular C cells origin, CEA and calcitonin markers, do phaeo screen pre thryoidectomy op
4. Anaplastic - rare, >60, undifferentiated cell origin, rapid growth, usually palliative (Presents elderly patient with rapid growth of lump)
50 year old presents with midline neck mass that has been increasing in size over a few months. Enlarged firm irregular thyroid that isn’t painful. No LNs. Biopsy denies malignancy.
Riedel’s Thyroiditis - autoimmune fibrosis of the thyroid
difficult to distinguish from cancer
30% will go on to develop hypothyroidism
Multinodular goiter vs Plummer’s (what is it and mx)
Multinodular goiter: Typically middle aged women typically presenting with large goiter or dysphagia. Can be euthyroid or subclinical hyperthyroid
Mx: can manage with thyroxine or if pressure effects thyroidectomy.
One nodule can become autonomous in its thyroxine production and be a thyroxine secreting adenoma -> Toxic multinodular goiter or plummer disease and present with cardiac features e.g. AF and palpitations. Treat with radioiodine or subtotal thyroidectomy as carbimazole will not have much affect
Reducible = contents of hernia can be returned to the abdomen by lying down or by manual reduction. Exhibit an expansile cough impulse
Irrededucible - cannot be returned to abdomen and no cough impulse
Incarcerated - patient has symptoms and predisosed to strangulation (this occurs when adhesions develop between hernial sac and contents)
Strangulated - Obstruction sx. Occurs when hernia twists upon itself and interferes with blood supply. Initially venous return is obstructed -> oedema -> cuts off arterial. Ischaemia and necrosis within 6 hrs
Richter - only one side of the bowel wall is strangulated with the hernial sac. Pain, erythema, perforation potential but no obstructive signs
Perforated - peritonitis, rigid abdomen, urgent laparotomy
Acute Otitis externs vs media management
1st line - Topical cipro/antifungal drops ± steroids; microsuction if there is debris
2nd line - Oral fluclox if its spreading, oral antifungal, refer to ENT if diabetic
AOM: Mostly conservative (will discharge and heal within 6 weeks), can be given antibiotics in certain situations
If diabetic / young boy -> high suspicion of headache
If glue ear develops and dosn’t go away in 12 wks -> grommet (NB If adult - suspect nasopharyngeal cancer if unilateral grommet)
When do you give abx in AOM
Antibiotics should be prescribed immediately if:
Otitis media with perforation and/or discharge in the canal
Symptoms lasting more than 4 days or not improving
Systemically unwell but not requiring admission
Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
Younger than 2 years with bilateral otitis media
Amoicillin 5-7 day , penicillin allergy > erythromycin or clarithromycin should be given.
Head and neck cancer 2 WW criteria
45 and over with:
- persistent unexplained hoarseness or
- an unexplained lump in the neck
unexplained ulceration in the oral cavity lasting for more than 3 weeks or
a persistent and unexplained lump in the neck.
- Urgent referral to dentist:
a lump on the lip or in the oral cavity or
a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.
people with an unexplained thyroid lump.
AUTOSOMAL DOMINANT CONDITION
Otosclerosis describes the replacement of normal bone by vascular spongy bone. It causes a progressive conductive deafness due to fixation of the stapes at the oval window. Otosclerosis is autosomal dominant and typically affects young adults
Onset is usually at 20-40 years - features include: conductive deafness tinnitus normal tympanic membrane* positive family history
*10% have flamingo tinge due to hyperaemia
IBD Surgical operation complications
• Anastomotic stricture
• Pelvic abscess
retraction, stenosis, prolapse, dermatitis
• Pouchitis (50%): metronidazole + cipro
• ↓ female fertility
• Faecal leakage
1) AP supine or erect
Visibility - Assess the X-ray to ensure the whole abdomen is visible from the level of the diaphragm to the pelvis.
Ensure the exposure is adequate to allow radiological assessment of both the small and large bowel.
- Bowel and other organs: small bowel, large bowel, lungs, liver, gallbladder, stomach, psoas muscles, kidneys, spleen and bladder.
- Bones: ribs, lumbar vertebrae, sacrum, coccyx, pelvis and proximal femurs.
- Calcification and artefact (e.g. renal stones)
Arterial vs Venous vs Neuropathic ulcer pc ix and management
- Deep, painful and sharply defined, shins/foot
- O/E Reduced peripheral pulses
- Intermittent Claudication Symptoms (Cold feet, hair loss, toe nail dystrophy, cyanosis)
- Ix: Contrast angiography
- Mx: Angioplasty or vascular reconstruction
- Painless, sloping, shallow ulcers
- Medial Malleolus is usual site
- Rf: Venous insufficiency, varicosities, DVT, obesity
- Associated with hemosiderin deposition (opaque brown large patches) and lipodermatosclerosis (waxy thickened)
- Mx: Ulcer community clinic, focus on prevention (compression stockings, venous surgery), optmise risk factors (nutrition, smoking)
- Painless, insensate surrounding skin (‘glove and stocking distribution’. Can’t feel so cause severe damage to feet without realising)
- WARM foot, GOOD pulses
- Occur on pressure points i.e. heal, tips and between toes, metartarsal heads
- Mx: Regular check ups assessing sensation, keep toe nails short and avoid walking barefoot
Locally -> pelvic structures
Lymph -> iliac and para-aortic nodes
Haem -> bones, liver and lungs
Robson staging • Confined to kidney • Involves perinephric fat, but not Gerota’s fascia • Spread into renal vein • Spread to adjacent / distant organs
Usually spread directly via renal vein or lymph or via blood to bone liver and lung
quantify haematuria: thick blood or discoloured urine, presence of clots? Anaemia sx
- painless haematuria, frequency - bladder cancer
- dysuria - infective
- voiding symptoms - prostatic ca or BPH
- storage sx /flaws - TCC
C- avoid caffeine and alcohol, bladder training, double voiding to ensure bladder is completely empty
M - if symptomatic and bothersome:
1st line Tamsulosin (alpha blocker) S/E: drowsiness, hypotension, depression, EPSE, increased wt
2nd line Finasteride (5alpha reductase inhibitor)
S/E: excreted in semen, use condoms, ED
If affect QoL or complications of BPH
TUIP (transurethral incision of prostate) is first line as is less invasive
TURP (cystoscopic resection of lateral and middle lobes of prostate) is more invasive and higher risks but can produce better outcomes
Laser prostatectomy - can be considered in patients on anticoagulation
Open prostatecomy - used for v large prostates >100g
Prostate cancer mx
C- Active Surveillance w/ DRE and PSA ± core biopsy
(If T1/T2 and <10 year life expectancy (a large % of pts) just manage with @ surveillance as unlikely to affect their morbidity.
- Radical prostatectomy (and goserelin if node +ve)
- Only improves survival vs. active monitor if <75yrs
- 70% risk of ED, 50% incontinence (
- Brachytherapy: implantation of palladium seeds
- Better option for those who want to remain fertile, S/E prostatitis
• Used for metastatic or node +ve disease
• LHRH analogues inhibit pituitary gonadotrophins → ↓ testosterone E.g. goserelin
• Anti-androgens E.g. cyproterone acetate, flutamide
Immediate • TURP syndrome- fluid overload hypervolaemic and dilutional hyponatraemia ↓Na, bradycardia/arrthymia. hypertension -> hypotension dyspnoea and visual disturbance (absorption of large volumes of irrigation through prostatic plexus) • Haemorrhage Early • Haemorrhage • Infection • Clot retention: requires bladder irrigation Late • Retrograde ejaculation: common • ED: ~10% • Incontinence: ≤10% • Urethral stricture • Recurrence
Should we screen using PSA?
• Population based screening not recommended in UK
• PSA not an accurate tumour marker
• ERSPC trial showed small mortality benefit, PLCO trial
showed no benefit.
• Must balance mortality benefit ̄c harm caused by over
diagnosis and over treatment of indolent cancers.
Indications for PSA and DRE
Any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or retention, or
Erectile dysfunction, or
RCC 1• Confined to kidney 2• Involves perinephric fat, but not Gerota’s fascia 3• Spread into renal vein 4• Spread to adjacent / distant organs
Pancreatic cancer pc, histopath, ix, mx
PC: Painless obstructive jaundice, epigastric pain that radiates backwards, acute onset DM in elderly
Epigastric mass, palpable gallbladder (courvoisier’s), Thrombophlebitis migrans (Trousseau sign)
Adenocarcinoma (90% cases)
Bloods: Cholestatic LFTs, Ca19-9 (90% sensitive), CALCIUM
Imaging: USS (dilated ducts) guided biopsy,
Pancreatic protocol CT (Triphasic CT AP)
If further imaging needed -> MRI, EUS and laparoscopy.
pancreatic cancer management
- Pancreatic Protocol CT (triphasic CT, CAP)
- IF more info needed for staging can do EUS, Laparoscopy or MRI for liver mets
Specialistic Pancreatic MDT
1) Psychological support (Fatigue, px, GI sx -> anxiety/depression)
2) Analgesia pain ladder who, severe, you can consider a percutaneous coeliax plexus nerve block EUS guided
3) N - Nutrition: enteric-coated pancreatin (for those with unresectable pancreatic ca)
M & S:
4)Chemo to non resectable (Gemcap) + stents
5) Resectable- Surgery (preferably pylorus preserving surgery)
6) Embolism prophylaxis
7) Adjuvant therapy given post op (gemcitabine plus capecitabine)
8) Spread -> If metastatic you give FOLFIRINOX
Pancreatic endocrine neoplasms
Insulinoma - most common PEN, features of hypoglycaemia , whipples triad of features (attacks induced by starvation, hypolycaemia during attacks and symptoms relieved by eating), raised Cpeptide (unlike inappropriate insulin administration), 20% malignant so they are resected
VIPoma (vasoactive intestin polypeptide) - VIP stimulates secretio of water and electrolytes in intestines -> severe diarrhoea, dehydration and hypokalaemia.
Glucagonoma - very rare, associated with Men 1, blistering rash over bum/legs,
Gsatrinoma - tumour of G cells of pancreas
Man presents with bright red nodule on end of index finger that bleeds easily it has grown rapidly in last week and is now 1cm
It is an acquired haemangioma (localised excess of proliferating capillaries) Tend to blled heavily on minimal trauma
Partial prolapse - mucosa only -
Complete prolapse - mucosa and muscle - results in incontinence and mucus discharge - Surgical lifting of the prolapse, redudnant mucosa excised and muscle is folded using sutures (DeLorme procedure)
NB children - digital reduction or submuc injections
Fistula definition and management
Fistula - abnormal connection between to epithelial surfaces (exception to this is AV fistula which is between two endothelial surfaces)
Management depends on whether its above or below the puborectalis muscle sling (slings around the rectum to the pubic bone)
Below (intersphincteric)- ‘Laying open the fistula tract’
Above (higher trans sphincteric fistulae) - Seton insterion
NB you can work out the location of the other end of the fistula using Goodsall’s rule. If it is anterior to 3-9 oc lock ->straight. If its posterior to this line, its curved.
Don’t treat with abx, treat with incision & drainage as if it ruptures it can cause fistula formation
Curretttage and drain out
Packed loosely and left to heal via granulation
- Conservative measures: high-fibre diet, adequate fluid intake, sitz baths, and topical analgesia. Stool softeners can be useful to make defecation less uncomfortable
- M: Diltiazem cream and glycerin trinitrate creams relax anal tone
- S: Refractory to medical mx you can give botulinum toxin or sphincterotomy
72 year old lady has a fall in the snow. XR shows intertrochanteric fracture, how would you manage this?
Intertrochanteric is extracapsular
How would Takayasu’s present? ix and mx
HTN, arm claudication, absent pulses, bruit and visual disturbances + systemic flaws
Angiography will show narrowing of aorta and aortic branches
Mx: Steroids but condition is progressive and prognosis is poor (death within a few years)
Critical limb ischaemia diagnostic criteria
Greater than 2 weeks duration
Ankle pressure of less than 40mmHg
Rest pain (worse on raising feet) or tissue loss
Indications for amputations
dead limb - gangrene
deadly limb - wet gangrene, spreading cellulitis, AV fistula
dead useless limb - paralysis and providing mobility issues, severe rest pain with unreconstructable crtiical leg iscahemia
Hallux/toe Transmetatarsal Below Knee Through Knee Above Knee Choosing the level depends on the disease process being treated, desired functional outcome and comorbidities of patient
True AAA definition
True aneurysm = Dilatation of blood vessel involving all layers of wall, >50% normal diameter, fusiform (in line, entirety of vessel wall, most AAA are fusiform) or saccular (ballooning to one part of the wall, balloons adjacent to direction of flow, most berry aneurysms are saccular) (hold a sack of potatoes over your back)
5.5 or larger, >1cm per year or syptomatic-> 2WW or ‘urgent elective repair’
Small 3-4.4cm - annual surveillance USS,
Medium 4.5-5.4cm - 3 monthly surveillance
Indications for different type of knee joint imaging
XR - for fracture
MRI - meniscal or cruciate injury
Arthroscopy - inside the joint, EUA (decreased tone)
A patient with a previous nephrectomy presents to ED with loin pain. CT-KUB reveals they have a stone in the PUJ of their remaining kidney, with mild hydronephrosis. Bloods reveal creatinine of 200 (baseline 80), urea 16 (5) with normal inflammatory markers. What is the best therapeutic intervention?
Not obstructed -> priority is removing the stone
Remove stone based on size:
- Small (tamsulosin + pain relief) <5mm
- Medium (>10mm) ECSWL, if that fails or pregnant/have a AAA Dormier Basket (can do distal ureter as well as pelvis)
- Large or complex >20mm - Percutaneous lithotomy (can try dormier basket too but percutaneous lithotomy is better for renal pelvis or complex stones e.g. stahorn calculi)
NB staghorn - can either percut. neph. OR if there is reduced function of that kidney (contributes less than <15% to the function of the kidneys, as evidence by DMSA) then consider nephrectomy
If it is obstructed > priority is resolving the infection
C - A-E, fluids
M - IV Abx (Ceff) + pain relief
1st line Nephrostomy (stoma to drain the pus)
or JJ Stent (bypasses the stone)
L2 - anteromedial thigh L3 - medial thigh, above the knee L4 - Medial malleolus L5 - Dorsum of foot, 1st dorsal websapce S1 - Lateral maleolus, lateral foot, heel + sole of foot
L1 - inguinal ligament
T10 - navel
1, 2, 3, 4, 5, 6,7,8 C5 - regimental patch C6, 7, 8 tips of thumb, middle littlle finger T1 - medial forearm T2 - medial arm T3 - armpit C4 - shoulder tip
Myotomes (lower limb)
L3 - thigh adduction L4 - knee extension L5 - ankle dorsiflexion S1 - ankle plantarflexion (S2-S4 erection) L2 for a number two - hip flexion to do a poo
Myotomes upper limb
C5 Shoulder abduction C6 - elbow flex C7 - elbox ext C8 - wrist flex T 1 - thumb opposition
Viruses associated with nasopharyngeal or oral cancers
EBV and HPV are associated with naso-oropharyngeal cancers
Non-invasive, Pre-malignant condition, shows calcification on mammography
As pre-malignant needs surgical excision:
WLE + Radiotherapy
Only time you would offer mastectomy: Bilateral Palpable lump >4cm Declines radiotherapy
Breast cancer stages
• Stage 1: confined to breast, mobile, no LNs
• Stage 2: Stage 1 + nodes in ipsilateral axilla
• Stage 3: Stage 2 + fixation to muscle (not chest wall)
LNs matted and fixed, large skin involvement
• Stage 4: Complete fixation to chest wall + mets
Breast cancer management
• Bone pain: DXT, bisphosphonates, analgesia
• Brain: occasional surgery, DXT, steroids, AEDs • • Lymphoedema bras: decongestion, compression
- Radiotherapy if post WLE, post mastectomy + high risk. axillary node positive or palliative bone pain
- Chemo if pre-menopausal, node +ve, high grade or recurrent tumours. 6 cycles of FEC: 5-FU, Epirubicin, Cyclophosphamide + Trastuzumab (anti-Her2) is used if Her2+ve
- Endocrine therapy if ER +ve or PR +ver. Tamoxifen and Anastrozole.
- Mastectomy if bilateral, nipple involvement >4cm, radiotx declined, pt choice
- All pts with invasive breast carcinoma should have axillary node clearance i.e. sentinel node resection and histology
- Reconstructive surgery at primary surgery or later stage either implants or flaps (lat dorsi or rectus abdominis)
An 80 year old male presents to his GP with a 6 week history of fresh blood mixed in with his stool and is now experiencing occasional incontinence. On examination you notice some external skin tags around the anus but identify no abnormality on internal examination. What is the most likely diagnosis and management?
Anal cancer Very few diseases cause incontinence Normall presents with: • Perianal pain and bleeding • Pruritis ani • Faecal incontinence- 70% have sphincter involvement @ presentation O/E only 25% have palpable lesion Management: Chemoradiotherapy: most pts 5YS of 50% Surgery: reserved for § Tumours that fail to respond to radiotherapy § GI obstruction § Small anal margin tumours w/o sphincter involvement
Skin cancer management
Excision + 2O margin excision depending on Bres depth
• ± lymphadenectomy
• ± adjuvant chemo (may use isolated limb perfusion)
SCC - Excision + radiotherapy to affected nodes
BCC (rolled pearly edge s ±telangiectasia, can ulcerate)
• Excision- Mohs: complete circumferential margin assessment using frozen section histology (stays local)
• Cryo/radio may be used.
Acitinic Keratosis - Cautery, Cryo, 5-FU, Imiquimod, Photodynamic phototherapy
Squamous Cell Carcinoma
• Ulcerated lesion ̄c hard, raised everted edges
• Sun exposed areas
• Sun exposure: scalp, face, ears, lower leg • May arise in chronic ulcers: Marjolin’s Ulcer • Xeroderma pigmentosa
• Solar/actinic keratosis → Bowen’s → SCC
• Lymph node spread is rare
Breslow Depth is biggest prognostic factor
Metastasize to liver and eye often via lymphatics
Types 1. Superficial Spreading: 80% § Irregular boarders, colour variation § Commonest in Caucasians § Grow slowly, metastasise late = better prognosis 2. Lentigo Maligna Melanoma § Often elderly pts. § Face or scalp 3. Acral Lentiginous - Asian's, blacks, palms soles, subungal 4. Nodular Melanoma § All sites § Younger age, new lesion § Invade deeply, metastasis early = poor prog 5. Amelanotic § Atypical appearance → delayed Dx
Different types of hip dislocation
Posterior dislocation > shortened right hip, which is flexed, adducted and internally rotated
Superior = Extended and external rotated ( a see)
Inferior = Flexed and externally rotated (ai-o-fe)
NOF - Shortened and externally rotated
Pelvic fractures - Trauma, shock, haematuria
A 55 year old female presents with acute left leg pain. Her leg is pale and cold, with no palpable pulses. She has a past medical history of AF. On examination you note from the knee down she has complete sensory loss and profound paralysis. What is the most appropriate management?
Rutherford classification for acute limb ischaemia
I = viable limb, II = threatened, salvageable, III = non-salvageable
II a - treat promptly, minimal sensory loss, often inaudible arterial DUS
IIb - treat immediately - sensory loss of more than just toes, usually inaudible arterial DUS, Mild-moderate muscle weakness
III - profound sensory loss, paralysis, inaudible arterial and venous DUS
What are the different causes and management of acute limb ischaemia?
Embolic and Thrombotic are different causes.
• Rehydration: IV fluids
• Analgesia: morphine + metoclopramide
• Abx: e.g. co-amoxiclav if signs of infection
• Unfractionated heparin IVI: prevent extension (5000 IU bolus then 1000u/hr use APTTR* to monitor @ 4-6hrs)
Yes: urgent surgery: embolectomy or bypass
No: angiogram + observe for deterioration
Amputation if - Irreversible limb ischaemia (mottled non-blanching appearance with hard woody muscles)
- Sudden onset absent claudication history, AF in the history, contralateral pulses are present
- results in profound ischaemia
- typically lodged at femoral bifurcation
- Mx: Embolectomy under LA/GA with fogarty catheter
Thrombotic (60%): plaque in situ -> ruptured
- onset over hours- days, claudication history present and contralateral pulses absent
- results in incomplete ischaemia due to collaterals
- Mx: Thrombolysis + angiography/ angioplasty
*APPT ratio is used exclusively for UFH monitoring
Types of otitis media and how to differentiate them
AOM - Pain first then discharge, can have Hearing loss, . History of recent viral illness/ear infection.
OME - glue ear, hearing loss is usually PC, conductive
Chronic OM - Persistent otorrhoea >6 weeks. May have hearing loss.
Cholesteatoma (destructive cysts made of sq keratinised epithelium in the middle ear)-PC: recurrent ear infections, fouls smelling discharge, conductive hearing loss
As it advances it errodes into facial n (paralysis) or chorda tympani n (causing metallic taste in tongue) or cause veritgo. Surgical management.
Managing intermittent claudication
Ix: 1st line Duplex, 2nd line MRA, 3rd line CTA
C- Supervised exercise programme
2hour a week, per 3 month period encouraging people to maximal pain
M - Naftidrofuryl oxalate if exercise hasn’t improved or they refuse bypass surgery
S- If exercise hasn’t helped and they have suitable vasculature (check flow with Duplex + CTA), you can do angioplasty and stenting usually first line
Short segment and easy to get to > Angioplasty & stenting
If long segment > Bypass using ispilateral long saphenous vein or PTFE graft if you can’t get leg vein
<35 usually sex:
Mx = IM ceftriaxone and doxy
> 35 often not STI, usually enteric bugs:
E Coli, Klebsiella
A 43 year old woman presents with intermittent painless dysphagia. She reports no weight loss. She is normally fit and well, with no significant PMHx. Routine blood tests reveal a Hb of 97, Iron 40, Ferritin 2, Plts 400, WCC 4, Na 134, K 3.5. What is the most likely diagnosis.
Plummer–Vinson syndrome is a rare disease characterized by difficulty swallowing, iron-deficiency anemia, glossitis, cheilosis and esophageal webs. Treatment with iron supplementation and mechanical widening of the esophagus generally provides an excellent outcome.
A patient presents with a 2/7 history of sore throat. The patient reports no difficulty breathing but is unable to swallow and is spitting out their saliva. On assessment you notice a large right sided tonsillar swelling with deviation of uvula. What should your initial management be?
Diagnosis of Quinsy or Peritonsillar abscess
Red flags: Stridor Breathing difficulty Trismus Spitting out saliva / drooling
Initial: IVF, Abx, Dex.
Next: Refer to ENT > Same day Mx or clinic next day.
An unwell patient underwent operative management for acute cholecystitis. Intra-operatively the anatomy distorted, and the cholecystectomy was abandoned due to difficulty. What should be the next step in management?
Barium Swallow shows corkscrew oesophagus
This is DES diffuse oesophageal spasm aka ‘nutcracker oesophagus’
Idiopathic, intermittent spasm of distal of oesophagus causing intermittent chest pains after eating accompanised with dysphagia
Ba Swallow can show corkscrew in active disease bt cna also be normal
Manometry will show prolonged powerful oesophageal cotractons
Oesophageal carcinoma histopath and Mx
adenocarcinoma (65%), Lower 3rd GORD → Barrett’s → dysplasia → Ca
SCC (35%) Upper and middle 3rd, EtOH and smoking § Commonest type worldwide (Hoarseness: recurrent laryngeal N. invasion in upper third only)
UGI allows biopsy, ba swallow often not used apple core stricture
Only 25-30% have resectable tumours
Neo-adjuvant chemo before surgery to downstage tumour: e.g. cisplatin + 5FU
1 Ivor-Lewis (2 stage): abdominal + R
2 McKeown (3 stage): abdominal + R
thoracotomy + left neck incision
3 Trans-hiatal: abdominal incision
Palliative care in oesophageal cancer
• Majority of pts.
• Laser coagulation
• Alcohol injection + ↓ Ascites (spiro)
• Stenting and Secretion reduction (e.g. hyoscine patch) • Analgesia: e.g. fentanyl patches
• Radiotherapy: external or brachytherapy
• Referral to Palliative care team and Macmillan nurses
• Prognosis, 5ys <5%, Median: 4mo
Achalasia path, pc, ix, and mx
Pathophysiology- Degeneration of myenteric plexus (Auerbach’s) > ↓ peristalsis & LOS fails to relax
• Cause 1o / idiopathic: commonest; 2o: Chagas’ disease (S. America, T. cruzii)
§ Dysphagia: liquids then solids
§ Regurgitation (esp. at night)
§ Substernal cramps
§ Wt. loss
• Comps: Chronic → oesophageal SCC in 3-5%
§ Ba swallow: dilated tapering oesophagus - Bird’s beak
§ Manometry: failure of relaxation + ↓ peristalsis
§ CXR: widened mediastinum, double RH border
§ OGD: exclude malignancy
§ Med: CCBs, nitrates
§ Int: botox injection, endoscopic balloon dilatation
§ Surg: Heller’s cardiomyotomy (typically lap)
NICE guidelines only recommend treatment with intra-nasal corticosteroids if the symptoms of sinusitis are severe or have lasted for a period of 10 days or more.
Antibiotics are only advised if individuals are systemically unwell or have significant co-morbidities that pre-dispose them complications (for example chronic severe COPD).
Do not prescribe antihistamines, steam inhalation or oral corticosteroids
This is acute otitis media with effusion
Peaks at 2 years PC: Conductive hearling loss
O/E: Tympanic is stretched inwards (instead of bulging outwards) especially around the bone / pars flacida. Loss of light reflex. Yellow fluid behind tympanic membrane
Eustachain tube is shorter and straighter in children and so is vulnerable to debris/organisms getting stuck and infected. Once it gets inflammed it closes and can’t do its job,
Mx: Can be self limiting, if after 12 weeks it hasn’t resolved can insert a grommet (10% of pts) (a small ventilation tube that sits in eustachian tube, it is a stout cylinder that allows air pressure to equalize through the tympanic membrane )
Cx: 2ndary speech and language delay, behavioural or balance problems may also be seen
! Unilateral Glue ear in adult = ?nasopharyngeal carcinoma
Branchial Cyst vs Cystic Hygroma
Embryological remnant of branchial arch development, 3rd decade
Smooth firm fluctuant swelling , classically ⅓ down anterior border of sternocleidomastoid
Do NOT transilluminate
Can become large and tender in URTIs
Ix: USS + FNA, contains cholesterol crystals
Mx: Complete excision of cyst and tract
Complications: Branchial sinus and fistula
Congenital Proliferation of lymph vessels in the posterior triangle of the neck
Multicystic, fleshy, compressible and contains clear fluid
O/E: Transilluminates brightly
IX: CT/MRI for diagnosis
Mx: Excision of mass
A 80-year-old lady presents with a 5 day history painful left sided neck swelling below the angle of the jaw. She also complains of a foul taste in her mouth. On examination, she has a temperature of 37.8ºC and a 4x5cm submandibular mass which is tender to palpation. There is associated tender lymphadenopathy. What is the most likely diagnosis?
This lady has sialadenitis - inflammation of the salivary gland likely secondary to obstruction by a stone impacted in the duct. The duct from the submandibular gland drain into the floor of the mouth and purulent discharge from this duct causes a foul taste in the mouth.
There are 3 main salivary glands:
the parotid glands are anterior and inferior to each ear
the submandibular glands lies below the angle of the jaw the sublingual glands lie beneath the tongue
Disorders of these glands occur due to infection, inflammation, obstruction or malignancy.
Submandibular gland swelling:
Tumour: benign or malignant
A 64-year-old woman presents to her GP with a five-day history of feeling right earache and feeling generally unwell. In the last day she has developed painful blistering around the ear and her husband has told her that her facial movements appear different. Her past medical history includes hypertension, for which she takes amlodipine.
On examination, a vesicular rash is noted around the right ear and the patient has a visible right-sided facial palsy. Her observations are normal and she is apyrexial.
Given the likely diagnosis, which of the following is the most appropriate treatment plan?
The diagnosis here is that of Ramsay Hunt syndrome, given the palsy and characteristic auricular pain and rash.
Management includes both antivirals and corticosteroids; given that the patient is systemically well on examination and observations are normal, these can be given orally rather than intravenously.
Ear pain is usually first feature, then facial nerve palsy and rash ± tinnitus/vertigo
Resus: ATLS guidelines 1º and 2º survey CT Traumagram Open fractures: Gustilo-Anderson, NV status, Abx, Saline gauze, Analgesia, Anti tetanus, Photograph
Area, blood flow, communition, dirt, soft tissue defect
Early: NV damage, visceral damage
Medium: Compartment syndrome, infection, fat embolism
Late: Union, AVN, growth distrubance, post traumatic OA, complex regional pain synd,
classifying physeal fractures Type I - straight across Type II - straight and then goes above Type III - Straight the below Type IV - going Through the growth plate Type V - Crush injury
Extracapsular - DHS
Garden I or II - DHS / cannulated
Garden III or IV - If <55, DHS / cannulated (don’t do arthroplasty as they have a 10% failure rate per decade)
If not do hemiarthroplasty as you are less worried about the risk of the prosthesis perforating through the acetabulum and therefore they only last about a decade.
Unless they’re cognitively intact and can walk a mile unaided/just a stick and are fit for a longer surgery, in which case you can do THR. This is a better option for OA patients as well as they are less likely to dislocate it cos of their stiffness.
Boris, a 65 year old man who presents to A&E following sudden onset chest pain which began whilst he was on his weekly pheasant hunt. The pain is tearing in nature, radiates through the back. On examination he is profoundly pale (even for him), hypotensive and still reports the pain is ongoing. You send off some bloods, gain IV access have arranged for a portable CXR. What is it? What is the most likely abnormality on the CXR? Widened mediastinum Abnormal aortic contour Pleural effusion Tracheal deviation CXR will be normal
Aortic dissection: injury to the innermost layer of the aorta (intima) allows for blood to flow between the aortic walls, forcing them apart.
Widened mediastinum (56-63%),
abnormal aortic contour (48%),
aortic knuckle double calcium sign >5mm (14%), pleural effusion (L>R), tracheal shift, left apical cap, deviated NGT. ‘Normal’ in 11-16%.
TTE - 75% diagnostic for type A, 40% diagnostic typeB
TOE -more sensitive, needs ICU Sedation
CT -widened mediastinum
Type A vs Type B Aortic Dissection
- Stanford Type A: 70% of dissections, involves the ascending aorta (pre L-subclavian branch) (two types)
It has a worse prognosis than type B and needs to be managed surgically in the first instance with an aortic root repair (stent/graft)
- Stanford Type B: Does not involve ascending aorta – descending aorta, after the L subclavian branch. Uncomplicated type B can be managed medically with antihypertensives. If rupture, refractory HTN, limb ischaemia -> surgery
Tell me everything you know about carotid artery disease…
Carotid artery disease: narrowing or constriction of the lumen of the carotid artery, usually secondary to atherosclerosis
Previous TIA/stroke; Amarousis fugax; carotid bruit
Ix: Carotid Duplex, MRA, Echo then CT MRI ifn eeded
Mx: CMS (Endarectomy if >70 or >50 and symptomatic)
If with wells score dvt is likely do an Leg USS
If scan >4h start on Tx dose Enoxaparin (1.5mg/kg) or Rivaroxaban 15mg BD 3 weeks, then 20mg BD 3/6 months
Painless lump, can’t feel it separate to the testicle. Can also present with hydrocele, pain and gynaecomastia.
Germ cell (most common 95%): Pure seminoma (40%) (30-40s), which are radiosensitive, respond well to chemo; Non-seminoma (60%) (of which Teratoma is the main type or choriocarcinomas), don’t respond well to chemo, poor prognosis.
Sergeants (seminoma 30-45) and troops (teratomas 20-35)
Non- Germ cell (Sex cord stromal tumours e.g. sertoli, leydig)
Ix: AFP, LDH hCG marker. Never do biopsy, USS is first line
Staging - Royal Marsden classification
Mx- all get radical orchidectomy.
Seminoma Stage 1+2 - radiotherapy
Stage 3-4 - radiotherapy & chemotherapy
Stage 1 just surveillance + orchidectomy; Stage 2 orchidectomy + chemo + paraortic LN dissection
Stage 3 - orchidectomy + chemo
What is the purpose of anaesthesia and what are the different types?
Aims hypnosis: loss of consciousness amnesia: loss of memory analgesia: loss of pain sensation areflexia: loss of reflex muscle relaxation: paralysis
intravenous: propofol, thiopentone, etomidate
inhalational: sevoflurane, nitrous oxide
inhalational agents most suitable
propofol is only IV agent that can do both induction & maintenance
A fat embolism (FE) is a piece of intravascular fat that lodges within a blood vessel and causes a blockage of blood flow. Fat emboli commonly occur after fractures to the long bones of the lower body, particularly the femur (thighbone), tibia (shinbone), and pelvis.
Present with hypoxia and ARDS.
Treatment is mostly supportive care. This may involve oxygen therapy, intravenous fluids, albumin, and mechanical ventilation.
40 yo patient complains of lump in R breast that has been present of rsome time. USS shows breast cyst which is aspirated under USS guidance. Aspirate is found to be blood stained. What are the next steps?
Breast cyst management - aspiratio alone
Small percentage of breast cysts may contain malingant focus within their walls. Blood stained aspirate calls for aspirate cytology as next step to look for signs of malignancy. If present, a core biopsy would be required as we need to differentiate between DCIS or ICS.
Urethritis + arthritis + iritis traditionally these three
1-4 weeks after underlying gastroenteritis (campylo, shigella. yersinia) or STI (chlamydia, ureaplasma)
Two other features that can occur are circinate balanitis and keratoma blennorrhagicum.
30% of them have circinate balanitis - annular red rash on glans penis
Keratoderma blennorrhagicum - pustular, crusty, yellow-brown papular lesions on soles of feet
Mx: NSAIDs and local steroids, Relapse may need sulfasalazine or methotrexate
What are reperfusion injuries that can occur post ALI revascularisation
- May perform prophylactic fasciotomy at time of revascularisation to prevent this
Rhabdomyolysis: Myoglobinuria, Acute kidney injury, Hyperkalaemia, metabolic acidosis
Non-cardiogenic pulmonary oedema, ARDS
Conservative • Lose wt. • Raise head of bed • Small regular meals ≥ 3h before bed • Stop smoking and ↓ EtOH • Avoid hot drinks and spicy food • Stop drugs: NSAIDs, anti-AChM, nitrates, CCB, TCAs Medical • OTC antacids: Gaviscon, Mg trisilicate • 1: Full-dose PPI for 1-2mo- Lansoprazole 30mg OD • 2: No response → double dose PPI BD • 3: No response: add an H2RA- Ranitidine 300mg nocte • Control: low-dose acid suppression PRN Surgical: Nissen Fundoplication • Indications: all 3 of: § Severe symptoms § Refractory to medical therapy § Confirmed reflux (pH monitoring)
14 year old girl attends paeds outpt following meningococcal septicaemia a few weeks previously. She complains of feeling tired, weak and having a poor appettie. She feels dizzy when standing up from sitting. Her blood test show Na 127 and K 5.4. Tx?
These features are typical of adrenal insufficiency.
This and the recent men septicaemia points to an underlying diagnosis of Waterhouse Friderichsen syndrome (bilateral haemorrhage into adrenal glands cause dby meningococcal septicaemia.
Management is by replacement of glucocorticoids and mineralocorticoids: hydrocortisone and fludrocortisone
What is adrenal insufficiency and how do we test for it?
Addison’s disease, also called adrenal insufficiency, is an uncommon disorder that occurs when your body doesn’t produce enough of certain hormones. In Addison’s disease, your adrenal glands, do not produce glucocorticods, mineralocorticoids and adrenal androgens. As a result, low:
MR -> high K, low Na, postural hypotension
GC -> hypoglycaemia and wt loss
Androgens -> decreased libido and body hair
and.. excess ACTH -> increased pigmentation in sun exposed areas, pressure areas, buccal mucosa and recent scars
Ix: SHORT SYNACTHEN TEST (adminster acth and expect a rise in cortisol, if adrenals can’t produce cortisol -> insufficiency)
Mx: Hydrocortison and fludrocoritsone in addisons
Transient sudden vision loss in one eye due to passage of an embolus through the retinal artery
R sided Amaurosis fugax requires Right carotid endarterectomy unlike
R sided facial weakness = L sided endarterectomy as its due to L carotid artery
(of course threshold of endarectomy has to be met in both cases)
Pyogenic Liver abscess
Single or multiple abscess that arise from infection in portal system (appendicitis diverticulitis or pelvic infection) OR biliary tree
PC insidous fever rigor and swinging pyrexia tender palpable liver ad jaundice
ABx + percutaneous drainage
Budd Chiari Syndrome
Triad of abdominal pain ascites and hepatomegaly
Rf Thrombophilias COCP Polycytheamia and malignancy
Diagnosis by doppler will swho obliteration of hepatic vein and reversal of flow in portal vein
Tx with thrombolyisis or anticoag
70% die within a year
1 month old baby brought to GP with swelling of both lower limbs. OE edema that is non pitting and firm to touch
46 yo presents with worsening swelling of legs OE very oedematous and firm, skin is thickened hard and grey
If presents congenitally > Milroy disease
If presents <35 - lymphoedema praecox
>35 - lymphoedema tarda
Mx: comrpession elevation abx if infected and if refractory -> debulking surgery
2nd pc-> secondary lymphoedema (Elephantiasis or lymphatic filiaris), Skin thickening of legs and gentials due to infection by parasite causing obstruction
84 yo women comes to A&E with 6hr history of severe colicky cnetral abdo pain
Pale and sweaty with irreg irreg pulse of 125/min BP is 105/68. Diffus etenderness on abdo exam and DRE revelas fresh blood. What ix?
Chronic pancreatitis ix?
No consensus on an optimal diagnostic test or universally accepted diagnostic criteria for chronic pancreatitis. Initial tests include laboratory testing and an abdominal x-ray. If pancreatic calcifications are absent, a dedicated pancreas protocol CT. If uncertain refer to gastro for MRCP and EUS and ERCP
Lab testing: non specific but high glucose or low faecal elastase (only in severe disease)
46 yo women presents with multiple painful lesions over her body OE each of these is soft and mobile and 2cm in size she has no other symptoms
Multiple painful lipomas = Dercum disease
Commonly in obese middle aged women and accompanied by headaches amenorrhoea and reduced sweating
32 yo presents with long history of pruritus ani
OE large pink confluent lesions around theanus
Aka anal warts caused by HPV 6 and 11
OE can be pink and grey around anus and perineum if large and coalesce they’re known as Condylomata Acuminata
Condylomata Lata - Large white lesions in genital region secondary to syphillis
Baby with CF and bile stained vomiting. what mx?
Meconium ileus (thick meconium plug causes obstruction) If uncomplicated gastrogaffin enema will help dislodge if this fails laparotomy required
48 yo man presents with 3 month history of foul smelling flaky discharge from R ear. He admits to gradually losing hearing in R ear
OE perforation seen at superior border of attic
Mx is microsuction
Classic presentation of a cholesteatoma
Chronic destructive infection, white flakey discharge that is composed of squamous keratinised epithelium
Can also get deafness and vertigo
Cholesteatoma gradually eats into surrounding tissue (dura mata and facial nerve and bone causing further complications
Buerger disease is associated with what antigen?
it is medium vessel vasculitis
Young man with claudication despite having few risk factors for atherosclerosis. Typically <45 yo who smoke heavily
Common in asians and ashkenazi jews
HLA B5 association
Arteriography will show mutliple corkscrew collaterals
Mx is analgesia and stop smoking
NB Takayasu’s is younger women with large vessel vasculitis e.g. HTN, arm claudication, visual changes, mx is steroids and death within a fwe years
72 yo presets with sudden onset pain in right calf
PMHx severe pain in both knees for which she takes regular diclofenac
OE calf is warm and swollen and tender compared to other side
Doppler US shows no clot
Ruptured Baker’s cyst
Underlying OA can cause synovium of the knee to bulge posteriorly
Catheter containing pressure sensors which is passed via nose into lower oesophagus and pt is asked to perform a series of swallows
Pts with achalasia exhibit and increased lower oesophageal pressure at rest
CREST syndrome Ix
Renal impairment might also be present
Posterior interosseus nerve is branch of radial nerve that runs deep in forearm to supply wrist and finger extensors (except from extensor carpi radialis longus)
It is damagd in ofrearm fractures and results in wrist drop and inability to extend fingers(wrist drop is slighy as ECRL works)
No sensory nerve loss with these lesions
Modified vs Unmodified radical mastectomy
Modified - breast, overlying skin incl nipple, axillary contents
Unmodified - breast, overlying skin incl nipple, axillary contents, pec muscles
Dexamethasone suppression test
This is done in pts with cushing syndrom symptoms e.g. striae acne hirsuitism easy bruising hyperglycaemia proximal myopathy
Cushings disease, ectopic ACTH from malignancy
Either collect 24 hr free urinary cortisol or give dexamethasone and see if that suppresses the serum cortisol
Flushing diarrhoea bronchospams abdo pain percipitated by stress alcohol and caffeine.
Path: enterochromaffin cells fo GI tract, produce serotonin
Ix: 5-HIAA (breakdown product of serotonin) hydroxyindole acetic acid
Mx: resection or if widespread give octreotide a SS analogue that inhibits 5ht release
Oesopahgeal web pathophysiology
Chronic IDA can cause hyperkeratinisation of upper oesophagus and the formation of a membrane web hat extends partially across the lumen
Mx: Iron supplements +- endoscopic dilatation
! Predisposes to SCC oesophageal
To or not to CT a AAA?
If they’re hypotensive and tachy -> emergency surgery no time to CT
Male Patient presents with ED wanting viagra- how do you proceed?
NICE: Full history from the patient and examining them for any genitourinary causes, initial investigations such as total testosterone, glucose profile, and lipid profile are performed to identify any reversible or modifiable risk factors.
If testosterone low -> repeat and test FSH and LH
A 28-year-old man presents with a 1-day history of severe anal pain, in particular on defecation. On further questioning, he has been more constipated recently and has previously had 1 episode of a small amount of fresh red blood on the toilet paper 1 week ago.
On examination, you notice a palpable, bulging nodule just external to the anal opening. It is tender to touch.
What is the most likely diagnosis?
Thrombosed haemorrhoid is the most likely due to the recent history of constipation and likely formation of a haemorrhoid which has become acutely painful (due to thrombosis) with a visible bulging mass outside of the anal opening. If presenting within 72 hours -> surgical management
An external haemorrhoid is the next most likely - however, they would not tend to be as acutely painful.
Sepsis is defined as an infection that triggers a particular Systemic Inflammatory Response Syndrome (SIRS). This is characterised by body temperature outside 36 oC - 38 o C, HR >90 beats/min, respiratory rate >20/min, WBC count >12,000/mm3 or < 4,000/mm3.
Haemorrhagic shock classes
Class I shock would be completely compensated for.
Class II shock would cause tachycardia.
Class III shock causes tachycardia and hypotension as well as confusion.
Class IV shock causes loss of consciousness as well as severe hypotension.
one off abdo uSS at 65 yo
Which side is varicocele likely to be on?
80% are on L side
Whilst performing a pre-anaesthetic assessment, a young patient mentions that her mother ‘had a bad reaction to some of the drugs’ during an appendicectomy procedure many years ago and had to stay in intensive care on a ventilator for a short time after the operation. There were no long term complication. What condition should you be most worried about?
Pseudocholinesterase deficiency (also known as suxamethonium apnoea) is a rare abnormality in the production of plasma cholinesterases. This leads to an increased duration of action of muscle relaxants used in anaesthesia, such as suxamethonium. Respiratory arrest is inevitable unless the patient can be mechanically ventilated safely while waiting for the circulating muscle relaxants to degrade.
Pre-anaesthetic assessments are important to recognise a family history or previous episodes of complications such as this before they occur.
Stop 5 days pre-op
Stratify into high thromboembolic risk or low thromboembolic risk (e.g. high chadvasc score, previous recent VTE, valve, recurrent DVT/PE)
If high risk -> varies between centres (check INR 2 days pre op and give therapeutic dose of LMWH. 1 day pr eop give 50% dose of LMWH. Withold LMWH for 24 hours pre op.)
If low risk, admit and check INR on day of surgery aiming for INR <1.5
Complications of line insertion
Despite line type: most common immediate complication is haemorrhage
Most common complication overall is infection
- Femoral - more assoc with thrombus and infection
- Subclavian - haemorrhage
- Internal jugular lines - pneumothorax
How to treat hypophosphataemia?
Oral phosphate replacement
IV phophsate binds to calcium and causes it to precipitate in tissues (metastatic calcification) causing severe hypocalcaemia
If hyphosphataemia is severe pt is at risk of arrhytmia, cardiogenic shock and seizures therefore faster adminstration is needed. In these situ you can give via central line no faster than 30mmol over 6 hours
Alcoholic pt on day 5 has a drop in electrolytes - cause?
High suspicion of refeeding syndrome
Measure levels of potassium phosphate and MAGNESIUM
Chronic pancreatitis causes
Metabolic abnormalities: hyperlipidaemia and hypercalcaemia
Congenital: CF, cholechondral cysts
H pylori (80% of all peptic ulcers, 95% of duodenal and 80% of gastric) NSAIDs 20% of gastric ulcers and 5% duodenal ulcers
Toxic megacolon treatment
Supportive + resus consider broad spex abx prophylactically IV steroids NG tube After 72 hours if no improvement -> subtotal colectomy (has less mortality than panproctocolectomy, can later have completion protectomy)
When do we admit people with haemorrhoids?
Extremely painful, acutely thrombosed external haemorrhoids who present within 72 hours of onset (reduction or excision may be needed). Internal haemorrhoids that have prolapsed and become swollen, incarcerated, and thrombosed (haemorrhoidectomy may be needed). Perianal sepsis (a rare but life-threatening complication).
Crohn’s flare mimics
alternative explanations for symptoms in patients who initially appear to be having a relapse or recurrence of CD. These may include:
Bile salt malabsorption* (2ndary to resection of terminal ileal disease)
*Increased delivery of bile salts into colon irritates bowel -> intractable diarrhoea. Prescribe bile acid sequester such as cholestyramine can reduce symptoms
Bowel obstruction causes in order
Adhesions Hernia Malignancy (CRC most common cause of LBO only) IBD Diverticulitis
Breast cancer spread
- Direct extension into muscle/skin -> dimpling
- Lymph - > peau d’orange, arm oedema
- Blood -> liver, lung, brain and bone
- Transcoelomic spread > pleural effusion (invasion of the serosal lining of an organ by malignant cells)
Nerve to vastus medialis
Extracapsula fracture management
o Subtrochanteric = Intramedullary nail
• DHS over IM nail
A 54-year-old woman attends the GP with a one-day history of hearing loss in her right ear. There is no discharge or pain. She has no history of dizziness or tinnitus.
Assessment by otoscopy shows a small amount of wax in the right ear with no other obvious changes to the external auditory meatus or tympanic membranes bilaterally. Weber test lateralises to the left side. Rinne test shows air conduction louder than bone conduction bilaterally.
What is the most appropriate next step?
Acute sensorineural hearing loss is an emergency and requires urgent referral to ENT for audiology assessment and brain MRI
“if on one side they need the volume high, don’t forget to get an MRI”
To rule out vestibular schawnoma
High-dose oral corticosteroids are used by ENT for all cases of SSNHL
Majority of SSNHL is idiopathic
autoimmune conditions (e.g. Behcet’s or SLE),
Infectious causes (e.g. meningitis, mumps, Lyme d),
metabolic causes (e.g. diabetes, hypothyroidism), or neoplasm
Ear wax management
No infective signs, conductive hear loss (i.e. not a schwannoma in disguise) ->
1st olive oil / topical tx to soften
Then can consider ear syringing etc
Drugs that cause tinnitus
may be precipitated by relatively minor trauma
on examination, classically a bilateral, red swelling arising from the nasal septum
this may be differentiated from a deviated septum by gently probing the swelling. Nasal septal haematomas are typically boggy whereas septums will be firm
REFER URGENTLY TO ENT for surgical drainage + IV abx
as nasal septal necrosis develops 3-4d, causing ‘saddle nose deformity’
ENT red flags
Unilateral sensorineuronal hearing loss
Unilateral nasal polyp
Recurrent epistaxis (one off episode is fine)
Blood stained nasal discharge
Unilateral Glue ear in adult = ?nasopharyngeal carcinoma
hernia repair complications
ilioinguinal nerve palsy - ipsilateral numbness and pain of hemi-scrotum / mons pubis & labium major. it can get trapped in hernia repair.
Other: wound infection, haematoma, mesh infection and ischaemic orchitis
How do we manage axillary disease in breast cancer?
+ve Axillary clearance
Following operation radiotherapy offered if:
Declined axillary clearance
Multiple axillary LN’s
67 yo 24hrs post op following uncomplicated lap chole. Pt is HIV positive and has thrombocytopenia at pre op assessnent (60plt). He is complaining of chest pain and SOB and abdomen is more distended with sig peri umbilical tenderness. Post op ECG shows lateral ischaemia and Hb is 7.5. He is tachy and BP is 115/75. Next step?
Likely having a umbilical port site haematoma and the blood loss is precipitating chest pain and dyspnoea.
Perioperative steroid control for pts who are on steroids?
Any pt who takes 5 or more mg of steroids daily should have 100mg IV/IM hydrocortistone at the induction of anaesthesia until the patient can take double their usual oral glucocorticoid dose by mouth.
This should then be tapered back to the appropriate maintenance dose, in most cases within 48 h, although for up to a week if surgery is more major/complicated‐clinical judgement should be used to guide this.
Wound dehiscence with bowel poking through
Cover the small bowel with sterile saline soaked gauze
Give IV abx
Return pt to theatre for immediae closure of abdomen with tension sutures
Insulin depdent diabetics, how to manage their diabetes in major surgery?
on the day of surgery:
- start an IV substrate infusion of KCl with glucose and sodium chloride
- VRII of soluble human insulin in sodium chloride 0.9 % should be given via a syringe pump at an initial infusion rate determined by bedside CABG. Hourly blood-glucose measurement should be taken to ensure that the intravenous insulin infusion rate is correct for at least the first 12 hours
on the day before surgery, once daily long-acting insulin analogues should be given at 80 % of the usual dose; otherwise the patient’s usual insulin should be given as normal;
on the day of surgery and throughout the intra-operative period, once daily long-acting insulin analogues should be continued at 80 % of the usual dose; all other insulin should be stopped until the patient is eating and drinking again after surgery;
Post op cellulitis
Immunocompetent: Strep pyogenes or Staph aureus
Immunocompromised: Staph Epidermidis
Foramen of Winslow
Important anatomical landmark
Only communication between greater and lesser sac
First part of duodenum
Hepatoduodenal ligament (containing portal triad)
Caudate liver lobe
Gastric cancer risk factors
- Pernicious anaemia
- H Pylori
- Partial gastrectomy
- Dried fish /cured meats - high quantity of nitrosamines
- Blood group A
- Atrophic gastritis
Japan, M>F 2:1,
Arteries that supply the oesophagus
Inferior thyroid artery
L gastric artery
what makes up the gastro oeosphageal sphincter?
1) Intrinsic - LOS is a 4cm section of hypertrophied smooth muscle which is continuous with the smooth muscle wall of the oesophagus. It maintains contraction above the resting intragastric pressure
2) Extrinsic sphincter - skeletal muscle fibres of the right crus of the diaphragm that sling around the oesophagus (supports the LOW at rest but also contracts with diaphragm during inspiration to prevent further reflux)
3) Physiological sphincter - oesophagus projects 2-3cm into abdo cavity therefore a rise in IAP leads to compression of the abdominal portion of the oesophagus to preent reflux. + angle of His provides a flap valve
Hiatus hernia management
- 50% have GORD sx
- 80% Of HH are sliding and don’t require surgery usually and 20% are rolling and do necessitate surgery to prevent strangulation
- Los Angeles score classification
- Complications: Bleeding, stricture, barrets and malignancy
- Trial of acid suppression therapy e.g. PPI or H2 antag
- Surgery unless severe and refractory to optimum medical mx and 24 hour ph confirms severe reflux
40% peptic ulceration
20% oesophagitis/ gastritis
15% MW tears
7% oesophageal varices
Once bleeding has occured from varices 80% will re bleed within 2 years
Acute: h/d stabilisation and sclerotherapy/banding + IV PPI and Terlipressin
If this fails to control bleeding, Sengstaken Blakenmore tube is next line
Only repeat endoscopy if pt is stable if pt isn’t it is unlikely to help
NB if pt has meleana after varices but is stable this can be normal as pts can have meleans 3/4 days after endoscopic management. Get FBC to rule out occult haemorrhage and reassure.
In the long run consider TIPSS to prevent further re bleeding but it carries a lot of conseuqences e.g. sepsis, precipitation of encephalopathy and risk of re-occlusion so is done when pt is stable.
Other: Propanolol and repeat endoscopy monitoring and banding.
Causes of gastric outlet obstruction
Fibrotic strictures secondary to duodenal ulceration
Fibrotic strictures secondary to cancer of pylorus
Rare causes: other cancers eg mets, GIST, gastric volvulus,
Which hormones secreted by pancreas?
An 88-year-old lady presents with a large mass in the upper inner quadrant of her right breast. Investigations confirm an oestrogen receptor positive, invasive ductal carcinoma. She has declined operative treatment. How would you manage her?
Elderly patients may be managed using endocrine therapy alone. Eventually most will escape hormonal control. Letrozole
A 27-year-old man is rushed into the emergency department after a frontal crash with his motorbike. He is awake and alert but he complains of excruciating pain in his left leg. On examination, there is an open fracture of the left tibia with extensive soft tissue damage and contamination. Intravenous antibiotics have been prescribed.
Which one of the following is the first-line management for his fracture?
Drugs - IV abx
Debridement - in theatres (immediately for highly contaminated wounds and within 12 or 24 hours otherwise, depending on the injury.)
Delay - # fixation until soft tissues have recovered
Functional incontinence vs urethral stricutre vs mixed urinary inconteinence
In functional incontinence, there is a normal urinary system however other barriers cause the patients to become incontinent, such as poor mobility or pain.
Urethral stricture can cause dribbling and incontinence:
iatrogenic e.g. traumatic placement of indwelling urinary catheters
sexually transmitted infections
Mixed - features or urge and stress