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The Podmedics’
Surgery Revision Notes
© Podmedics 2010
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Introduction Welcome to these notes on the basics of surgery for undergraduates. Learning in an age where information, both in the clinic and the library, is so accessible, the authors have often felt a little overwhelmed. While many texts are excellent, we feel that none currently provide a good summary to get students started. Often the hardest toil in studying medicine is figuring out how precisely to get started. In these notes we outline some of the common processes that are used to break down both presentation of the disease and the processes that drive it. Having done this, we then use these techniques as a schema for our notes. The notes are based upon a series of podcasts written by Jonny and Ed during early 2008 (the podcasts are available at the site). While they are clearly aimed at the level required for UK final MBBS, they should be useful to students at any stage of their training. It is our belief that these notes, together with the supporting podcasts, make up a definitive and useful revision tool for students. A considerable amount of work has gone into preparing these notes. Please support us by telling you friends and pointing them in our general direction.
Thank you and good luck.
The Podmedics Team
Contact us The Podmedics constantly aim to improve the quality, accuracy and consistency of their content - please do get in touch if you have any questions or comments.
Ed Wallitt:
[email protected] Jonny Manley:
[email protected]
Please do not reproduce these notes without prior permission. All images remain the property of their original authors.
DISCLAIMER: No responsibility is taken for errors/omissions from these notes. They are written by students for students. © Podmedics 2010
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Podmedics’ Recommended Texts/Links/Courses
Websites www.podmedics.com Please forgive us the indulgence of being placed first.
www.onexamination.com You must answer questions from this site!
Google images Fantastic for practising presentations of just about anything you can think of.
Texts Surgical Talk Probably the only medical book ever written that is possible to read in bed.
Lecture Notes on Surgery Harold Ellis was one of the finest surgeons and medical educators of his time. His book is great (...if you want to be a surgeon)!
Courses The 10-week Surgery Revision Course Hosted by the MDU and the mighty Mr Barry Paraskevas
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Table of Contents Key Principles ! Surgical Fluids and Nutrition!
8 12
Fluids!
12
Nutrition!
15
Trauma Surgery! Advanced Trauma Life Support (ATLS)!
18 18
Chest Trauma!
24
Head Trauma!
28
Burns!
32
Peri-operative Care !
35
Pre-operative!
35
Post-operative!
38
Skin Disorders!
42
The Oesophagus !
47
Clinical Anatomy!
47
Dysphagia!
48
Oesophageal Tumours!
50
Gastro-oesphageal reflux disease!
52
Hiatus Hernia and other conditions!
53
The Stomach!
57
Clinical Anatomy!
57
Acute Upper GI Bleed!
59
Peptic ulcer!
61
Perforated Peptic Ulcer!
63
Gastric Cancer!
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Gallstone and Biliary Disease!
68
Clinical Anatomy!
68
Introduction to Gallstones!
69
Gallbladder Complications!
70
Biliary Tree Complications!
73
Intestinal Complications!
75
The Spleen!
77
Clinical Anatomy!
77
Hypersplenism & Hyposplenism!
78
Splenectomy!
79
Splenic Trauma!
80
The Pancreas!
83
Clinical Anatomy!
83
Pancreatitis!
85
Pancreatic Tumours!
90
Basic Principles of the Lower Gastrointestinal Surgery !
92
Important Clinical Anatomy!
92
Intestinal Obstruction!
95
Colon Cancer and Stomas!
100
Colorectal carcinoma!
100
Emergency bowel operations!
103
Stomas!
104
Inflammatory Conditions!
105
Appendicitis!
105
Diverticular Disease!
107
Surgical Ulcerative Colitis!
109
Crohn’s Disease!
Peri-Anal Disease! Clinical Anatomy!
111
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Haemmorrhoids!
114
Anal Fissures!
116
Anal abscess/Anal sepsis!
117
Anal Fistula!
118
Rectal Prolapse!
119
Anal Carcinoma!
120
Breast Disease !
123
Clinical Anatomy!
123
Diagnostic Principles in Breast Disease!
124
Benign Breast Disease!
125
Malignant Breast Disease!
127
Neck Lumps!
131
Clinical Anatomy!
131
Lymphadenopathy!
134
Solitary Lumps in the Neck!
135
Thyroid Surgery!
139
Hernias !
143
Vascular Surgery !
149
Clinical Anatomy!
149
Venous Disorders!
151
Arterial Disorders!
154
Orthopaedics!
167
Basic Fractures!
167
The Hip!
170
Important other fractures for finals!
175
The Knee!
179
Neurosurgery!
183
Clinical Anatomy!
183
Spinal Cord Compression!
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Neurological Tumours!
186
Hydrocephalus!
187
Urology!
189
Clinical Anatomy!
189
Common presentations!
190
Kidney and Bladder!
197
Prostate Disease!
202
The Scrotum!
206
Testicular Cancer!
Appendix!
210
212
Common abdominal scars!
212
Common drugs!
213
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Key Principles Here we outline some of the different common techniques that can be applied throughout the field of surgery.
General approach to defining a disease 1. 2. 3. 4.
Definition (and classification) Epidemiology (and risk factors) Aetiology Clinical features a. Symptoms/Signs (further split each into general and specific) 5. Investigations 6. Management 7. Complications
Common techniques Aetiology When thinking about aetiology try to think in terms of... 1.
2. !
Anatomy - i.e. what are the surrounding structures/associated pathologies that could be causing the given problem. Surgical sieve - what pathological processes could be occurring?
THE “VINTA MEDIC” SURGICAL SIEVE
Process
Sub-split
Process
Vascular
Heart Blood vessels
Metabolic/Nutritional
Infection
Bacterial Viral Fungal Protozoal
Electrolytic
Neoplastic
Primary Secondary
Degenerative
Trauma
Penetrating Non-penetrating
Iatrogenic
Autoimmune
Gel and Coombs classification
Congenital
Sub-split
Anions Cations Non-charged
Drugs Interventional procedures
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Clinical features
This should be split into symptoms and signs and each of these should be sub-divided into general and specific. Have this table memorised in your head and go through it logically when you are thinking of investigations to do. Investigations
Modalities Cultures
Bloods - ABG Bloods - Venous Imaging
Scopic/Biopsy Functional
Tests + Findings Blood Urine MC & S, dipstick / pregnancy test CSF Joint aspirate Pleural/peritoneal fluid NB: usually justified if the patient is ill For each test you must be able to justify why you are performing it Plain X-ray e.g. chest, abdomen, bones Plain X-ray series + contrast USS CT/MRI PET/radio-isotope Specific tests for a given system that do not fit into the above. e.g. ECG, lung function test, pH manometry
Treatment
If an emergency you must first talk about RESUSCITATION e.g. Airway, Breathing, Circulation etc.
Modalities
Specifics
CONSERVATIVE
Always think about: 1. Basic things e.g. analgesia, fluids, 2. Risk factor management
MEDICAL
This is surgery..but we still use drugs
SURGICAL
What techniques can be used, what do they involve and when are they indicated
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Complications These are split into general (applicable to any surgery) and specific (applicable to the described surgery). GENERAL
Think in terms of: Airway e.g. difficulties with management Breathing e.g. hypoxia Circulation Drugs e.g. allergies, anaesthetic reactions Exposure to the theatre environment e.g. hypothermia, accidental injury
Specific - Immediate
At time of surgery e.g. primary haemorrhage, visceral damage
Specific - Early
1-3 days post-surgery e.g. pyrexia, SOB, reactionary haemorrhage, urinary retention, oliguria
Specific - Late
3-10 days post-surgery e.g. infection, DVT/PE, C. diff colitis
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Surgical Fluids and Nutrition Fluids Fluid and Electrolyte Distribution Average 70kg man - 42L (60-70%) - ⅔ INTRACELLULAR - ⅓ EXTRACELLULAR (plasma, interstitial, transcellular e.g. ocular, fluid, pleural)
! !
Osmolality (280-295 mosmol/l) - should be equal between IC and EC CHARGED + UNCHARGED
∴ (Na++K++Cl-+HCO-) + (urea+glucose) = 2(Na++K+) + urea + glucose
INPUT
OUTPUT
Oral
1.5L
Urine
1.5L
Food
1L
Stool
0.5L
Oxidative water
0.5L
Skin
0.5L
Lungs
0.5L
TOTAL
3L
3L
Total insensible = skin loss + lung loss.
Daily Requirements Water • 40ml/kg/day ~ 3 L per day Electrolytes • Na+ = 100 mmol/day • K+ = 60 mmol/day
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Indications for Intravenous Fluids 1. 2. 3. 4. 5.
Pre-operative resuscitation Replacement of normal loss Replacement of additional loss Postoperative resuscitation Electrolyte disorders
Types of Fluids
Types CRYSTALLOIDS
Normal saline
154 mmol Na+ in 1L
Dextrose saline
30 mmol/l Na+ + 40g dextrose
5% dextrose
50g dextrose in IL
Hartmannʼs (lactated Ringerʼs solution)
Anions + Cations + Ca + lactate
- “Electrolytes in water that form a true solution and pass through semi-permeable membrane.”
COLLOIDS - “Fluid with high molecular weight molecules that does not form a true solution and does not pass through a semi-permeable membrane.”
Contents
Natural e.g. blood, albumin
Synthetic e.g. Gelofusin, Haemaccel
Dextran compounds
Fluid Regimes 1L normal saline + 2L 5% dextrose OR
3L dextrose saline
+ 20mmol/l of K+ per bag
Important caveats: • Always replace ADDITIONAL LOSSES e.g. vomiting, diarrhoea, ileostomies, 3rd space • If fever (20% extra/day or 500ml/degree above 37) • No potassium 24-48 hours post surgery (non-cardiac) Hartmannʼs is also known as LACTATED RINGERʼS SOLUTION and should be avoided in liver and renal failure.
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Assessment of volume status • Check fluid charts and other bedside charts, quick history. • Observation: awake/orientated or confused, shortness of breath. • Inspect for: • Cap. refill (> 3 secs) • Temperature of the hands • Increased skin turgor • Tachycardia/tachypnoea • Blood pressure (late sign) • Low JVP • Sunken eyes • Dry mucous membranes
Features of JVP: • • • • •
Falls on inspiration Falls on standing Non-pulsatile Lies between the 2 heads of the SCM Has a double waveform
• Examine chest and peripheries for oedema
URINE OUTPUT: Should be 0.5 ml/kg/hr (= 30ml/hr for 70kg man) If no output/anuria: 1. SIMPLE STUFF e.g. check catheter & bag, flush the catheter with 50 mL saline using a bladder syringe 2. Fluid challange (250ml colloid - repeat a couple of times) 3. Senior review and consider CVP monitoring
A central venous pressure line is often used in order to gauge the response to a fluid challange. • If the patient is UNDERFILLED the CVP will not increase with the challange or will increase the fall again • If the patient FILLED then the CVP will rise (> 10mmHg) and stay elevated
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Nutrition Nutrition is important as it affects outcome 1. Impaired immune system 2. Delayed/poor wound healing 3. Longer rehabilitation (so increased cost, nosocomial infections, DVTs)
Assessment
HISTORY EXAMINATION
ANTHROPOMETRIC
BLOOD TESTS
Eating habit, diet, recent changes in weight/appetite Regular weights BMI Waist circumference (>102 cm in men, > 88 cm in women) Upper arm circumference Ulnar length Grip strength Skin fold thickness Albumin Pre-albumin Phosphate Transferrin Lymphocyte count
BMI = weight (kg) / height (m)2
Normal
18.5 - 25
Overweight
25 - 30
Obese
30 - 40
Morbidly obese
> 40
Waist circumference is a better representation of omental fat + better predicts development of metabolic syndrome.
Daily Requirements Calories:! Protein:!! Nitrogen:!
25-35 kcal/kg/2 hrs (usually ~ 2500 per day for men and ~ 2000 per day for women) 1.5 kg/24 12g per day
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Nutritional Therapy
Basic definitions:
• ENTERAL - “Nutrition that is delivered via the normal enteral route” • PARENTERAL - “Nutrition that is delivered directly through the venous system.”
1. Enteral Nutrition
To use this form of nutrition it is necessary for patients to have some degree of functioning bowel. There are 3 types of feed: 1. POLYMERIC • Near to normal e.g. food-supplements (Nsure, Fortisip), OSMOLITE 2. DISEASE SPECIFIC • Gluten-free diets in coeliac disease, liver disease feeds 3. ELEMENTAL • Basic AA and saccharides e.g. chronic multiple fistulae in Crohns This may be administered: 1. ORAL 2. Fine-bore NG tube (check for aspirate, CXR) [< 6 weeks] 3. Gastrostomy (surgical/PEG) 4. Jejunostomy
Complications of enteral nutrition:
Feed itself
Method of delivery
Too much feed/too little feed Intolerance (nausea/vomiting and diarrhoea) Electrolyte + glucose imbalance Malposition of NG tube Tube obstruction Infection around gastrostomy/jejunostomy
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2. Total Parenteral Nutrition
This should be avoided if at all possible. The main indication is NON-FUNCTIONING BOWEL • e.g. short bowel syndrome, prolonged ileus, severe Crohnʼs disease May be administered through: 1. Large peripheral line 2. Central line (tunnelled = Hickmann line)
Complications of parenteral nutrition:
Feed itself
Method of delivery
Reactive hypoglycaemia Fatty liver Vitamin deficiencies Complications of inserting a central line e.g. pneumothorax, bleeding Infection around site Sepsis Malposition
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Trauma Surgery
Advanced Trauma Life Support (ATLS) Trauma is the leading cause of death due to injury worldwide, and may be defined as: “A body wound or shock caused by a serious and life-threatening injury.”
The trimodal death distribution describes death due to injury in three peaks or periods. The first occurs within seconds to minutes of injury and is due to severe injuries where only prevention can reduce deaths. The second occurs within minutes to hours, where the golden hour of care with rapid assessment and resuscitation can save lives. The third peak occurs after several days to weeks and is often due to sepsis and multiple organ dysfunction. When treating traumatised patients we use ATLS Principles:
1. Primary Survey/Resuscitation • ABCDE 2. Secondary Survey • AMPLE • Top-to-toe examination 3. Definitive treatment
TRIAGE is the process of prioritising care based upon available resources and the extent of injuries sustained.
The Primary Survey This basically is RESUSCITATION and may be remembered using the familiar mneumonic ABCDE.
1. Airway and C-spine
The C-spine must be secured with in-line immobilisation. Unknown trauma to this area could lead to severe spinal injury and breathing compromise. Initially this may require manual immobilisation, but eventually inline support of the C-spine needs triple immobilisation with: 1. Hard collar 2. Blocks or sandbags 3. Tape over chin and forehead
Airway and C-spine
Breathing
Circulation
Disability
Exposure
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The airway must be assessed and treated.
ASSESSMENT
TREATMENT
1. If orientated and speaking...AIRWAY IS SECURE. 2. If obtunded or gurgling/stridor...AIRWAY NEEDS SECURING. 3. If complete obstruction...OPEN and SECURE. Chin lift or jaw thrust Remove foreign bodies with fingers Suction with a Yanker tube e.g. vomit, blood Secure the airway e.g. nasopharyngeal, oropharyngeal - Guedel, ET tube, surgical
Types of Airway
The best person to manage the compromised airway is an anaesthetist. Airways may be divided into: NON-SURGICAL and SURGICAL and NON-DEFINITIVE and DEFINITIVE A definitive airway is an adequately secured, cuffed tube in the trachea. An ETT and tracheostomy are definitive airways. Note that an LMA is not a definite airway, as patients are still at risk of aspiration. The indications for a definitive airway are: • • • • •
Apnoea Inability to maintain a patent airway Risk of aspiration or obstruction GCS < 8 Inadequate oxygenation via face mask oxygenation
NON-SURGICAL AIRWAYS Nasopharyngeal
Sizing - patientʼs little finger For the conscious patient with an intact gag reflex Contraindicated in basal skull fractures
Oropharyngeal (Guedel)
Sizing - from the angle of the mouth to the tragus For the unconscious patient with an absent gag reflex
Endotracheal tube (ETT)
Sizing - 6-8 mm diameter, a general rule of thumb 7 mm for an adult female and 8 mm for an adult male This is a definitive airway The correct positioning of an ETT can be confirmed with: 1. Bilateral air entry on auscultation 2. No borborygmi 3. C02 detector 4. CXR
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NON-SURGICAL AIRWAYS SURGICAL AIRWAYS Needle cricothyroidotomy Surgical cricothyroidotomy
These are required where attempted ETT has failed. A needle cricothyroidotomy is a short-term measure. It can only oxygenate the patient for 30-45 minutes, as ventilation is limited with a wide-bore cannulae. A surgical cricothyroidotomy is preferable to a tracheostomy in an emergency situation.
Tracheostomy
A tracheostomy is a definitive airway.
2.
Breathing
Attach patients to a monitor for BP, HR, ECG tracing and oxygen saturations and do an ABG to assess oxygenation. All patients should have high flow oxygen through a non-rebreathing mask.
Assessment: INSPECTION Signs
Agitiation (hypoxia) Obtundation (hypercarbia) Cyanosis (peripheral/ central)
PALPATION Trachea for deviation Paradoxical breathing flail chest segments
PERCUSSION Hyper-resonance (PNEUMOTHORAX)
AUSCULTATION Air entry (absent, unilateral, bilateral)
Hypo-resonance (HAEMOTHORAX)
Respiratory rate and oxygen saturations Breathing pattern (in cervical cord transection involving C3-5 supplying the diaphragm there will be abdominal breathing) Snoring, gurgling, stridor, hoarseness
Treat any life-threatening problems such as tension pneumothorax, massive haemothorax or flail chest. It is important to maintain adequate oxygenation to prevent cerebral hypoxaemia and ischaemia.
3. Circulation
Secure IV access (2 large bore cannulae into ante-cubital fossae) and take trauma bloods (FBC, U&Es, clotting) & CROSS-MATCH 6 units. Consider urinary catheterisation after PR to exclude a high-riding prostate, which indicates urethral injury.
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Shock can be classified into: 1. HAEMORRHAGIC 2. NON-HAEMORRHAGIC a. Cardiogenic b. Neurogenic c. Septic The most common form of shock in the context of trauma is HAEMORRHAGIC shock. Assess for hypovolaemia and SHOCK: Observation: alert and orientated, confused, or unconscious. Inspect for: • • • • • • •
Cap. refill (> 3 secs) Cold hands Tachycardia Tachypnoea Hypotension (late sign) Low JVP Low urine output
Haemorrhagic shock can be divided into four classes. The percentage blood loss parameters are easily remembered using the tennis scoring system and blood loss volume is based on a 70 kg male, where total blood volume is approximately 5 L (7 % of the circulating blood volume). Class I
Class II
Class III
Class IV
Blood loss (%)
< 15 %
15 - 30 %
30 - 40 %
> 40 %
Blood loss (mL)
< 750 mL
750 - 1500 mL
1500 - 2000 mL
> 2000 mL
HR
< 100
100 - 120
120 - 140
> 140
BP
Normal
Normal
Decreased
Decreased
PP
Normal
Decreased
Decreased
Decreased
RR
14 - 20
20 - 30
30 - 40
> 35
UO (mL/hr)
> 30
20 - 30
5 - 15
Anuric
CNS status
Anxious
Anxious
Confused
Lethargic
Simply put, patients with Class I shock have normal parameters but maybe anxious. Class II patients are tachycardic and tachypnoeic but BP remains normal with a decreased PP. Class III patients have tachycardia, tachypnoea, hypotension and confusion, and Class IV patients have all signs of shock with a reduced GCS. All patients with signs of shock are presumed to have haemorrhagic shock, as this is the most common cause of shock in the context of trauma. 1-2 litres warm crystalloid (Hartmanns/normal saline) should be administered STAT. Blood (type-specific, crossmatched or O. negative emergency blood) may be required if the patient continues to haemorrhage. There are four main sources of HAEMORRHAGIC SHOCK which can be remembered using the mneumonic “Blood on the floor x four more” © Podmedics 2010
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CHEST, RETROPERITONEUM, PELVIS, THIGH AND ON THE FLOOR
Response to initial fluid resuscitation (2 L crystalloid) determines subsequent therapy, and response can be divided into rapid, transient and no response: Rapid Response Minimal blood loss
Transient Response Ongoing blood loss or inadequate resuscitation
No Response Exanguinating haemorrhage
Vital signs
Normal
Transient improvement but recurrence of tachycardia and hypotension
Remains shocked
% Blood loss
10 - 20 %
20 - 40 %
> 40 %
Need for more crystalloid
Low
High
High
Need for blood
Low
Moderate
High
Blood preparation
Type and crossmatch
Type-specific
O-negative
Need for operative intervention
Low
Moderate
High
4.Disability Assess: 1. Coma scale (see head trauma) • AVPU • GCS 2. Limb Posture 3. Pupils! !
The Pupils Assess for size, equality and responsiveness: Appearance
Cause
Bilateral fixed and dilated
Death, hypovolaemia, drugs (ecstasy, adrenaline)
Unilateral fixed and dilated
Orbital injury, oculomotor nerve compression, stroke
Bilateral pinpoint
Opioid drugs
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Bilateral constriction
Brainstem injury
Irregular
Trauma, post eye operation
5.Exposure Remove all clothes & prevent hypothermia (warmed IV fluids, warm resuscitation room, hot air). Look for evidence of trauma: • Front • Back (log-roll to protect C-spine) • PR for high-riding prostate
Imaging in Trauma There are 3 important mobile tests: 1. 2. 3.
C-spine XR (must include C7-T1) Pelvis XR Chest XR
[+ ultrasound abdomen] also known as a FAST scan. Other tests may be performed but the patient should be stable first. Beware of the donut of death!
The Secondary Survey This has 2 important components: 1.
HISTORY - “AMPLE” Age Medication Past medical history/pregnant Last meal Events
2. !
Top-to-toe examination
Note: if the patientʼs state changes at any time then you must return to the beginning of the primary survey.
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Chest Trauma There a huge number of possible chest injuries that result from trauma. Here we consider the most important: 1. 2. 3. 4. 5.
Rib fractures, pulmonary contusion and flail segments Pneumothorax Haemothorax Cardiac tamponade Others: tracheobronchial tree injury, blunt cardiac injury, aortic disruption, diaphragmatic injury, oesophageal rupture
Remember the mneumonic ATOM FC memorise life threatening chest injuries: Airway obstruction Tension pneumothorax Open pneumothorax Massive haemothorax Flail chest Cardiac tamponade
1. Rib Fractures
• Fractures of ribs 1 - 3 imply severe injury to the head, neck and great vessels • Fractures of ribs 4 - 9 are most common and can damage adjacent viscera leading to haemopneumothorax and lung contusion • Fractures of ribs 10 - 12 can damage the liver and spleen Multiple fractures can lead to Flail segment “ ≥ 2 consecutive ribs fractures in ≥ 2 places”
This causes HYPOXIA from 1. PARADOXICAL MOVEMENT ON INSPIRATION 2. Restricted chest wall movement due to pain 3. Underlying lung contusion Treatment is with • Analgesia • Strapping of the segments • Invasive positive pressure ventilation (if resistant hypoxia)
2. Pneumothorax “Air in the pleural space.”
This is due to either blunt or penetrating trauma and there are 3 types:
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a. SIMPLE - “accumulation of air with no mediastinal displacement.” b. TENSION - accumulation of air through a one-way valve leading to accumulation and mediastinal displacement.” c. OPEN - “opening in the chest wall (2/3 diameter of the trachea) resulting in a sucking chest wound.”
A tension pneumothorax is a MEDICAL EMERGENCY!
INSPECTION Important signs
PALPATION
- Sudden cardiorespiratory compromise - SOB
- Reduced movement on affected side - Tracheal displacement away from affected side
PERCUSSION Hyper-resonant
AUSCULTATION Absent breath sounds on affected side
IMMEDIATE RX - “...large bore needle into 2nd intercostal space in mid-clavicular line.” (needle thoracotomy) Initial management of an open pneumothorax is placing a sterile dressing secured on three sides in order to provide a flutter-type valve effect. Definitive treatment for all pneumothoraces is the insertion of a chest drain on the affected side (draining the apex) in the 5th intercostal space, just anterior to the mid-axillary line.
3. Haemothorax “Blood in the pleural space”
These are due to penetration or decelerating injuries
Important signs
INSPECTION
PALPATION
- Distress - Hypoxia - Distended neck veins
- Decreased movement on affected side - Tracheal deviation away from the affected side
PERCUSSION Stony dull
AUSCULTATION Decreased breath sounds on affected side
Treatment depends on the size • Small (< 1.5L) • Fluid resuscitiation • Chest drain • Massive (> 1.5L or draining > 200ml/hr for 2 - 4 hrs) from damage to the great vessels, hilar and heart • Fluid resuscitation (including blood) • Chest drain • Thoracotomy
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4. Cardiac Tamponade
“Blood from the great vessels/heart within the pericardial sac leading to restricted filling and contraction.”
Clinical features described in BECKʼS TRIAD 1. 2. 3.
Elevated JVP (restricted filling) Hypotension (restricted filling and contractility) Muffled heart sounds (blood in pericardial sac)
Donʼt forget Kussmaulsʼ sign, a rising JVP with inspiration. Investigation: • Echocardiography Management: • Peri-cardiocentesis with ECG monitoring (to detect myocardium) • Thoracotomy
5. Others
Tracheobronchial tree injury (high mortality) Clinical features • Haemoptysis • Subcutaneous emphysema • Tension pneumothorax with persistent air leak after tube thoracostomy Investigation • Bronchoscopy Management • Surgery Blunt myocardial contusion Clinical features • Hypotension • Dysrhythmias • Wall motion abnormality on echocardiography Management • Monitor for dysrrhymias
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Aortic Disruption Most common cause of death following rapid deceleration in an automobile collision or fall from a great height. Usually , there is an incomplete laceration near the ligamentum arteriosum of the aorta and a contained haematoma. Diagnosis requires a high index of suspicion. Investigation • CXR - widened mediastinum • CT chest Management ! • Cardiothoracic surgery Diaphragmatic injury These are more common on the left side and maybe caused by blunt or penetrating trauma. Early diagnosis requires a high index of suspicion. Investigations • CXR - elevation of the diaphragm Management • Surgery Oesophageal rupture This maybe due to blunt or penetrating trauma. Blunt oesophageal rupture is due to the forceful expulsion of gastric contents into the oesophagus, after a severe trauma to the upper abdomen. Clinical features • Pain out of proportion to the injury • Left pleural effusion or pneumomediastium • Particulate matter in the chest drain Investigations • Oesophagosocpy • Contrast studies Management • Chest drain • Surgery
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Head Trauma Basic anatomy The scalp is made up of 5 layers of tissue which can be remembered using the mneumonic “SCALP”: ! ! ! ! !
Skin Connective tissue Aponeurosis Loose areolar tissue Pericranium
The skull is composed of: 1. Cranial vault - divided into three regions: anterior, middle and posterior cranial fossa and is thinnest in the temporal regions (but protected by the temporalis muscle - note this is the area affected with rupture of the middle meningeal artery and development of an extradural haematoma) 2. Base - irregular in nature and prone to injury from forceful movement The meninges consists of three layers that cover the brain: 1. Dura 2. Arachnoid 3. Pia
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Classification This is the commonest cause of trauma death. Classification of brain injury Mechanism Blunt Penetrating
High or low velocity Gunshot or other penetrating injuries
Severity Mild Moderate Severe
GCS 13 -15 GCS 9 - 12 GCS < 8
Morphology Vault Basilar
Intracranial lesions Focal Diffuse
Linear or stellate, depressed or non-depressed, open or closed CSF leak or cranial nerve palsies e.g. basal skull fracture - panda eyes, rhinorrhea, Battleʼs sign and otorrhoea Epidural, subdural, subarachnoid, intracerebral Concussion, contusion (coup and contracoup), hypoxic injury
Severity of injury should be assessed using: 1. AVPU - a simplified version of the glasgow coma scale ! Alert ! Voice ! Pain (indicates GCS < 8) ! Unresponsive 2. GCS (see table and assess using the best motor response) ! Mild - GCS 13 -15 ! Moderate - GCS 9 - 12 ! Severe - GCS < 8
Observation
Score
Eye opening - Spontaneous
4
- To speech
3
- To pain
2
- None
1
Best verbal response
The real problem with head injury is explained using the Monroe-Kelly doctrine. It states that the total volume within the cranium must remain constant, as the cranium is a rigid, non-expansile structure. A small increase in volume can be compensated for but once the compensatory mechanism is exhausted, there is an exponential increased in the ICP. If this occurs then the pressure will rise leading eventually to BRAIN HERNIATION, also known as coning. Features of raised intracranial pressure: • Headache • Vomiting • Seizures • Drowsiness • Papilloedema • Features of coning: • Ipsilateral pupil vasodilatation (CN III palsy) • Contralateral hemiparesis • Cushingʼs response (rising BP and falling HR)
- Orientated
5
- Confused
4
- Inappropriate words
3
- Incomprehensible
2
- None
1
Best motor response - Obeys commands
6
- Localizes to pain
5
- Withdraws from pain
4
- Abnormal flexion
3
- Extension
2
- None
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• Coma
Investigations • Skull XR (lateral is the most useful) • C-spine XR • Head CT (see NICE guidelines for head CT) Main indications for head CT: • GCS < 13 • Change in GCS 2 hours following injury • Focal neurological deficit • Open or depressed skull fracture • Post-traumatic seizure • Vomiting > 1 • LOC and > 65 years/coagulopathy/dangerous mechanism of injury/antegrade amnesia > 30 mins
Treatment of head injury This depends on the severity: MILD - discharge with written information and a responsible companion MODERATE - admit for neurological observations SEVERE - neurosurgical referral Modalities CONSERVATIVE
MEDICAL SURGICAL
Specifics Airway - secure airway Breathing - oxygen Circulation - IV access, fluid resuscitation Ventilation Antiepileptics for seizures Neurosurgical input
It is important to maintain good oxygenation to avoid cerebral hypoxia and ischaemic damage, and normocapnia. Hypercapnia will cause cerebral vasoconstriction and lead to cerebral hypoxia and also increased intracranial pressure. Raised intra-cranial pressure is COMPLEX to treat.
Modalities CONSERVATIVE MEDICAL
SURGICAL
Specifics Try to correct complications e.g. hypoxia, hypercapnia, hypovolaemia Ventilation Steroids Mannitol and fluid restriction Neurosurgical input is very important
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Types of Cranial Bleeding A quick revision of the different meningeal layers and blood supply in this region:
Pics from left to right
Location
Injury
Clinical Features
Management
Extra-dural Pic: right grey lens shaped haematoma + midline shift
Outside the dura mater
Disruption of arteries from the middle meningeal artery
LOC Lucid period Deterioration (coning) Death
CT Lens shaped haematoma
Sub-dural Pic: left cresenteric haematoma + midline shift
Between arachnoid Rupture of bridging vein and dura
Subarachnoid Pic: blood in the subarachnoid basal cisterns
Under arachnoid
Intra-cerebral Pic: Intracerebral and intraventricular haemorrhage
Within brain tissue
Trauma or ruptured Berry aneurysm
Damage to brain substance
Insidious onset (alcoholics/elderly/ epileptics/those on anticoagulants)
Rx: Neurosurgical drainage CT Cresenteric shaped haematoma
Headache, sensory/ motor S/S
Rx: Surgical evacuation of haematoma
Sudden onset occipital headache
CT, cerebral angiography
Meningism
Rx: Conservative (nimodipine)/Surgery (clipping/embolisation)
Compressive and localising signs
Surgical drainage
Remember on CT acute bleeding is high attenuation = white and older bleeding is low attenuation = black/ grey. Always comment on ANY MIDLINE SHIFT!
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Burns Burns tend to affect particular groups of people • Age: Toddlers and elderly • Disease states: epileptics, post-stroke, alcoholism • Occupations: welders/chefs There are 4 types of burn: 1. Thermal 2. Chemical 3. Electrical 4. Friction
The severity and management of a burn depends on its thickness:
Nomenclature
Depth
Clinical features
Superficial
First degree burn
Epidermis
Erythema Painful
Partial: 1. Superficial 2. Deep
Second degree burn Third degree burn
Papillary dermis Reticular dermis
Blistering Painful
Deep
Third degree burn
Epidermis, dermis and subcutaneous fat
Leathery White to charred Painless
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Assessment of a burn This is done using a special assessment tool: “WALLACE RULE OF NINES”
Management Should be managed in a specialist burns unit (second/third degree burns > 10 % in children or > 20 % in adults) Requires a normal ATLS approach but with special considerations AIRWAY • Laryngeal oedema following inhalation injury may complicate intubation: low threshold for intubation, surgical airways BREATHING • CO poisoning (carboxyhaemoglobin) and inhalational pneumonitis - oxygen and low threshold for intubation and mechanical ventilation • Escharotomy of chest wall CIRCULATION • Fluid losses can be huge and must assessed and replaced, best guide to adequate fluid replacement is urine output • Burns calculator 4 x weight (kg) x % burn = mL crystalloid in 24h, half given in 1st 8h then 2nd half given in the following 16h or [weight (kg) x % burn]/2 = mL colloid per 4h, 4h, 4h, 6h, 6h and 12h Aim for urine output of 0.5 ml/kg/h
Additional adjuncts • • • • •
Partial thickness - flamazine cream/clingfilm/plastic bags/analgesia Escharotomy and fasciotomy Antibiotics Surgical skin grafting PPI (Curlingʼs ulcer - stress ulcer)
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Complications
Specific - Early
Specific - Intermediate Specific - Late
Multiorgan failure Pulmonary complications e.g. atelectasis, ARDS Infection Constricting eschars Contractures Scarring Curlingʼs ulcer Psychological e.g. PTSD
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Peri-operative Care May be split into: - PRE-OPERATIVE - OPERATIVE - POST-OPERATIVE
Pre-operative The main purpose is to identify RISK. Patients may be classified using the American Society of Anaesthesiologists (ASA):
ASA Grade
Definition
Mortality
I
Normal
0.05%
II
Mild systemic disease No limit in activity
0.40%
III
Severe systemic disease Limits activity Not incapacitating
4.50%
IV
Incapacitating systemic disease
25%
V
Moribund Not survive with or without surgery for > 24h
> 50%
Pre-Assessment of the Surgical Patient “A SCREENING PROCEDURE for disease that may compromise the conduct or complications of surgery.” Can follow a basic history structure: PRESENTING COMPLAINT • Review reasons for surgery and history surrounding problem. PAST HISTORY AND SYSTEMATIC ENQUIRY • Medical history • Surgical history (previous operation and any adverse outcomes) • Modified systematic enquiry looking for:
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1) CARDIOVASCULAR DISEASE (e.g. ischaemia, hypertension, arrhythmia) 2) RESPIRATORY DISEASE (e.g. COPD, asthma, lung fibrosis) 3) ENDOCRINE (e.g. DM, corticosteroids, thyroids) DRUGS • Allergy • Current medication (steroids, anti-coagulant, contraception, immunosuppressants etc.) • Anaesthetics FAMILY HISTORY • History of anaesthetic problems e.g. malignant hyperthermia, sickle cell SOCIAL • Habits and rehabilitation etc. Then...move onto INVESTIGATIONS for specific problems.
Preparation for Surgery This may be split into: 1) GENERAL • • • • • •
Consent Book theatre/anaesthetist Fasting or NBM Mark site of operation I.V. cannulation Urinary catheter
FASTING/NBM Guidelines
Fluids: none 2 hours before procedure Food: none 6 hours before procedure (usually patients are fasted from night before)
2) INVESTIGATIONS • • • •
Bloods (FBC, U&Es, LFTs, clotting, G&S/CM, Hb electrophoresis) Imaging: CXR ECG MRSA swab
3) MEDICATIONS • DVT prophylaxis (TEDS, LMWH) • Prophylactic antibiotics e.g. abdominal surgery - cefuroxime and metronidazole, vascular surgery - coamoxiclav • Bowel preparation
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Considerations for for specific conditions
CONDITIONS
Consideration
Type I DM
Co-existing disease e.g. renal/cardiovascular
- “First on list” - Convert to sliding scale - Omit long-acting insulin
- Sliding scale until eating
Type II DM
Co-existing disease e.g. renal/cardiovascular
- Omit oral hypoglycaemics on day of surgery
- Sliding scale post-op - Restart oral when eating
Steroid use
Addisonian crisis
- Continue steroid up until surgery
- IV hydrocortisone until normal oral intake
Increased mortality: - Coagulopathy - Infections - Hepato-renal syndrome
- Normalise clotting - Prophylactic antibiotics
- Good hydration
Bleeding potential
- Stop/convert to heparin - FFP lower INR in an emergency
- Re-warfarinise once oral intake
Hyperkalaemia/Fluids Drug clearance
- Dialyses - Desmopressin for impaired bleeding function
- IV naloxone
Obstructive jaundice
Anti-coagulants
Chronic renal failure
Pre-op
Post-op
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Post-operative There are always many things to think about in the patient who has just returned from theatre:
1. Fluids (covered above in surgical fluids) 2. Pain relief 3. Complications (common ones include pyrexia)
Analgesia The management of post-operative pain has 2 stages
a. Pre-operative: effective counselling about possibility of pain and patient choice b. Post-operative: preventing and treating breakthrough pain
It is also important that pain and itʼs perception can have effects over and above psychological distress:
Organ system
Effect
Psychological
Anxiety Fatigue
Cardiovascular
Increased myocardial O2 consumption
Respiratory
Reduced coughing ∴ sputum retention Atelectasis
Gastrointestinal Genito-urinary Musculoskeletal Endocrine
Decreased gastric emptying Reduced gut motility Urinary retention Reduced mobility (→ pressure sores and DVTs) Hyperglycaemia Protein catabolism Sodium retention
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Assessment Pain is subjective! Observer assessment is unreliable
Can be assessed by 1. Talking to patient 2. Looking at vital functions 3. Various scales • Visual analogue scales • Verbal numerical reporting scale • Categorical rating scale
The Relief of Pain
This may be divided into: 1. NON-PHARMACOLOGICAL • Basic things e.g. pre-op preparation, relaxation therapy, hypnosis, cold/heat, splinting, TENS • Interventional e.g. local anaesthetic infiltration of wounds, nerve blocks. 2. PHARMACOLOGICAL • This uses the WHO analgesic ladder
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Consider the following • Regular administration • Patient-controlled analgesia
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Post-operative Pyrexia This is exceedingly common after surgery and is associated with different complications depending on when it occurs. All these complications are more serious in
Timeframe < 24 h
24 - 72 hours
3 to 10 days
Complication
Look for
Systemic response to trauma
Exclusion of others
Pre-operative infection
-
Pulmonary atelectasis
Tachycardia + tachypnoea Reduced air entry to bases CXR - consolidation and collapse
Chest infection
As above + more severe
Chest infection
As above + more severe
Wound infection
Local erythema, discharge and dehiscence
Urinary tract infection
Symptoms +ve. urine dipstick
Anastomotic leak DVT/PE
Calf pain and tenderness
Intraperitoneal sepsis
Abdominal pain, distension and ileus
Assessment • Perform a good history and examination then do basic investigations and look bedside charts. SEPTIC SCREEN Modalities Cultures Bloods - ABG Bloods - Venous Imaging
Tests + Findings Blood Urine MC & S Yes Routine bloods (infectious markers) CXR Abdominal ultrasound/CT
Scopic/Biopsy Functional/Special
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Skin Disorders This section is basically about lumps and bumps. We have chosen to put them at the start of these notes as the principles outlined here are important for the rest of the course.
Basic Principles Always think about lumps in terms of: ! ! ! ! ! !
SITE SIZE SHAPE (edge, surface)
! !
TENDERNESS TEMPERATURE
CONSISTENCY (transillumination, pulsation) COLOUR
[+ always look for local lymph nodes]
The best way to approach lumps in an exam is to recognise what it is then real-off a ʻmodified definitionʼ. In the rest of this section we shall consider these basic definitions.
Cystic swellings
“A fluid filled cavity lined by epithelium.”
1. Sebaceous cysts • • • • •
Mobile, firm swelling with a visible punctum. Fixed to skin + has a foul-smelling toothpaste-like discharge. Found in hair-bearing regions. If infected it is called an ABSCESS. Rx - excision
2. Dermoid cysts There are 2 types !
1. Inclusion dermoids • Firm cystic swelling not attached to the overlying skin that occur at sites of embryological fusion e.g. neck midline and outer angle of the orbit. © Podmedics 2010
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• Rx - excision 2. Implantation dermoids • Firm cystic swelling not attached to the overlying skin occurring most commonly in the hands of gardeners due to penetration injury • Rx - excision Ganglions • Tense cystic swellings on dorsum of hand, wrist not attached to overlying skin. • Lined by fibrous tissue originating from the synovial lining of joint/tendon sheath. • Rx - excision, traditionally hit with a bible
Lipomas • Soft, non-tender, fluctuant lumps that have a definable edge and are not attached to the overlying skin (particularly on trunk and limbs) • If multiple and painful → Dercumʼs disease • Rarely calcify or undergo sarcomatous change
Keloid scarring • • • •
Irregular hypertrophy of collagen forming a raised edge that extends outside the scar [cf. hypertrophic scar - does not extend outside] More common in blacks Rx - corticosteroid injections/excision
Benign and Malignant skin tumours 1. Benign Seborrhoeic keratoses • • • •
“Brown/yellow oval lesion with a greasy and well demarcated border” Stuck-on appearance Very common in elderly patients Rx - nil
Keratoacanthoma (molloscum sebaceum) • • • •
“Rounded swelling with rolled edges and a central keratin plug” Occurs on light-exposed skin Important differentials include BCC and SCC, however a keratoacanthoma will spontaneously regress Rx - watch and wait, or excision
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2. Malignant
Malignant cutaneous tumours are increasingly common in ageing skin exposed to prolonged UV radiation. Those of fairer skin types are at higher risk.
Basal cell carcinoma (BCC) • • • •
Lesion with a pearly rolled edge, telangiectasia and central depression Known as the “rodent ulcer” as the tumour rarely metastasises, but local invasion can be destructive Occurs on sun exposed areas Rx - excision
Actinic or solar keratoses • • • •
Flat lesions with a red/scaly surface Sun-exposed areas (face, bald scalp, forearms, dorsum of hands) that progresses to become multiple Maybe pre-malignant to SCC Cryotherapy or topical 5-FU
Bowenʼs disease (squamous cell carcinoma in situ) • Solitary patch of red, scaly skin often below the knees • This is also known as Queyratʼs erythroplasia in the penis, or a Marjolinʼs ulcer when a SCC develops in a chronic ulcer • Maybe pre-malignant to SCC • Rx - excision Squamous cell carcinoma! • A keratotic lump, polypoid mass or cutaneous ulcer in a sun-exposed area • Rx - excision Lentigo Maligna (Hutchinsonʼs freckle) • Flat, brown are with irregular pigmentation usually on the face • Rx - biopsy Malignant melanomas These are the most dangerous of the malignant skin tumours and may occur in pre-existing moles. With the exception of lentigo maligna melanoma, they occur in a relatively younger age group than other skin cancers and incidence is rising as a result of increased sun exposure. Simplified diagnostic criteria: Asymmetry Border (iregular) Colour (non-uniform) Diameter > 7mm Elevation Look for neighbouring satellite lesions and localised lymphadenopathy.
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There are 4 types 1. Lentigo maligna melanoma - invasive nodular melanoma within a lentigo maligna 2. Superficial spreading melanoma - most common; irregularly pigmented patch with an irregular edge usually on the leg or trunk 3. Nodular melanoma - rapidly growing lump 4. Acral melanoma - rare but more common in Asian or Afro-Carribean patients; pigmented patch on the sole or palm, or subungual pigmentation Prognosis is based on Breslowʼs thickness or Clarkeʼs level. Rx - excision
Ulcers “Interruption in the continuity of an epithelial surface.”
Necrotic material tends to accumulate as SLOUGH in the base of the ulcer.
Cause VENOUS 70 %
Venous hypertension Extravasation of blood → lipodermatoscleros is and poor blood supply
ARTERIAL 2%
NEUROPATHIC
1. Large vessel disease (e.g. PVD) 2. Small vessel disease (e.g. Buergerʼs disease) Repetitive mechanical forces of gait
Sites Medial side of the leg, above the medial malleolus (gaiterʼs region)
Features Sloping edge
Treatment Conservative - 4 layered bandage technique (ABPI > 0.8) Surgical - Skin grafting - Treat varicosities
Pressure points
Punched out edge
1. Ball of the heel 2. Malleoli 3. Between the toes
Erythematous halo
Plantar aspect of foot under metatarsal heads/ toes
Pale granulation tissue
Treat underlying cause e.g. poor perfusion
Cold skin
Minimise risk factors for arteriopathy e.g. smoking, HTN
Punched out edge
Remove any callus
Sensory loss
Proper shoes Metabolic control Antibiotics (pseudomonas in diabetics)
• Neoplastic • Malignant change in a pre-exisiting ulcer, with an everted/rolled edge = Marjolinʼs ulcer © Podmedics 2010
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The Oesophagus Clinical Anatomy The oesophagus is a muscular tube about 25 cm in length (40 cm from mouth to stomach) Important landmarks: • • • • •
Starts at C6 (cricoid) Passes behind thyroid and trachea. Important anterior relations: left bronchus, aortic arch, left atrium Pierces diaphragm at T8 Forms gastro-oesophageal junction at T10.
May be divided into 3 parts: 1. UPPER THIRD (striated) 2. MIDDLE THIRD (mixed) 3. LOWER THIRD (smooth)
The oesophagus is lined by squamous non-keratinising epithelium.
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Dysphagia The 3 important swallowing symptoms: DYSPHAGIA - “conscious difficulty in swallowing” APHAGIA - “inability to swallow” ODYNOPHAGIA - “painful swallowing”
Divide these as follows:
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ORAL
NEUROLOGICAL
MECHANICAL
Painful
Tonsillitis Pharyngitis Ulcers
Obstructive
Quinsy Pharyngeal pouch Epiglottitis
Bulbar
MND GB-syndrome
Pseudobulbar
CVA MS MND
Local
CREST Achalasia
In the lumen
Foreign body Food
In the wall
Carcinoma Stricture
Outside the wall
Retrosternal goitre Lymphadenopathy Bronchial carcinoma (left) Thoracic aortic aneurysm
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Oesophageal Tumours Divided into: !
PRIMARY • Benign e.g. polyp, lipomas, haemangiomas, leiomyomas • Malignant
!
SECONDARY (rare)
There are 2 types of: • 50% squamous cell carcinoma (upper half) • 50% adenocarcinoma (lower half) Adenocarcinomas are becoming more common as the incidence of GORD and Barrettʼs oesophagus increases.
Note: Epidemiology • Men (5:1) • > 50y • Iran/South Africa, China
10 % GORD
Barrettʼs oesophagus
1 % Barrettʼs
Adenocarcinoma
Risk factors • LIFESTYLE e.g. smoking, alcohol, diets rich in nitrosamines or vitamin C deficient ! • OTHER DISEASE e.g. Barrettʼs (adenocarcinoma), achalasia (squamous), Plummer-Vinson (squamous)
Clinical features
GENERAL • Weight loss, anorexia, malaise SPECIFIC • Dysphagia (progressive, solids then liquids then saliva) • Others e.g. haematemesis (bleeding), hoarseness (L. recurrent laryngeal nerve), aspiration pneumonias, perforation (rare)
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Investigations
Modalities
Tests + Findings
Cultures
-
Bloods - ABG
-
Bloods - Venous
Imaging
Scopic/Biopsy Functional
FBC (anaemia) LFTS (mets) U&Es (nutrition/dehydration) Ca2+ (mets) G&S + CXM CXR Barium swallow (apple-core appearance) CT (staging) Endoscopic ultrasound or mediastinoscopy (local staging) Endoscopy & biopsy -
Metastases • Local • Mediastinum (trachea, aorta, pleura and lung) • Lymphatic • Paraoesophageal • Blood • Liver and lung Prognosis 5 year survival < 5%
Management
Modalities CONSERVATIVE
MEDICAL SURGICAL Only 1/3 are operable
Specifics Analgesia Reduce size of tumour (alcohol / lasers) Relieve obstruction (stent, dilatation) Chemoradiotherapy to shrink tumour (neo-adjuvant) Oesophagectomy + lymph node removal (approaches - thorax, abdomen or both)
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Gastro-oesphageal reflux disease “Reflux of acidic contents into the oesophagus” Problems due to: ! ! 1. Oesophagitis ! 2. Barrettʼs (pre-malignant transformation)
Risk factors !
LIFESTYLE e.g. alcohol, large meals, smoking (relaxes the LOS)
!
RAISED IAP e.g. obesity, pregnancy
!
STRUCTURAL PROBLEMS e.g. hernias
Clinical features The main feature is retrosternal, burning chest pain that is worse when bending / lying down and is made worse by meals (particularly spicy ones) and hot fluids. Other features include acid and water brash, and aspiration pneumonia.
Investigations As above - most important is ENDOSCOPY + / - barium swallow. Manometry or 24h PH monitoring if endoscopy is normal.
Complications Approximately 10% develop Barrettʼs oesophagus, which is metaplasia of squamous to columnar epithelium in the lower oesophagus. This requires regular surveillance as it is pre-malignant for adenocarcinoma.
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Hiatus Hernia and other conditions Hernia may be defined as: “Abnormal protrusion of a viscera and its coverings through a defect into a place where it should not be.” (see later for more hernias)
3 types: 1. SLIDING (80%) 2. PARAOESOPHAGEAL or ROLLING (5%) 3. MIXED (15%)
Investigation • Endoscopy • Barium swallow Management of hiatus hernia Note: para-oesophageal hernias always require an operation due to risk of strangulation.
Modalities CONSERVATIVE MEDICAL
SURGICAL
Specifics Modify risk factors e.g. stop smoking, reduced alcohol, smaller meals, eat > 3h before bed, avoid tight clothing Antacids Alginates e.g. Gaviscon H2 antagonists e.g. ranitidine, cimetidine PPI e.g. omeprazole, lansoprazole Nissen fundoplication
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Other Oesophageal Conditions
Oesophageal rupture This is rare and has a poor prognosis. Aetiology • TRAUMA (external or internal) • INs/OUTs e.g. corrosives & violent emesis (Boerhaveʼs syndrome) Clinical presentation Severe, acute chest pain and collapse, with hydropneumothorax on chest radiograph.
Treatment • Fluid resuscitiation • Antibiotics to prevent medastinitis • Surgery
Pharyngeal pouch This is a pulsion diverticulae that occurs due to peristalsis against resistance resulting from un-coordinated muscle spasm. The diverticulae occurs in area of weakness between the thyro-pharyngeus and crico-pharyngeus inferior constrictor muscles. This point of weakness is known as Killianʼs dehiscence. It is more common on the left side.
Clinical features Patients present with dysphagia, regurgitation and a palpable swelling in the neck which gurgles. The patient may also complain of halitosis or present with an aspiration pneumonia.
Treatment Excise the pouch or staple it endoscopically.
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Plummer-Vinson syndrome This is the development of a oesophageal web due to hyperkeratinisation in the upper oesophagus. This causes dysphagia and is associated with chronic iron deficiency anaemia. Aetiology • Middle-aged • Men It is a pre-malignant condition for SCC of the oesophagus in the cricopharyngeus. Other pre-malignant conditions of the oesophagus include achalasia and Barrettʼs oesophagus. Treatment includes ferrous sulphate tablets for iron deficiency anaemia and oesophageal dilatation.
Achalasia “Degenerative of Auerbach plexus leading to loss of relaxation (lower 1/3rd)” This can also occur with Chagaʼs disease (Trypanosome cruzii). Like Barrettʼs oesophagus and PlummerVinson syndrome, this is a pre-malignant condition for squamous cell carcinoma.
Clinical features Patients present with “intermittent” dysphagia.
Diagnosis is with barium swallow which shows the typical appearance of tapering birds beak or rats tail.
3 main treatments are available: 1. Endoscopic dilatation 2. Hellerʼs cardiomyotomy 3. Botulinum injection
Note features of barium swallow: Feature
Pathology
Birdʼs beak/ratʼs tail
Achalasia
Apple core
Oesophageal carcinoma
Corkscrew/nutcracker
Oesophageal spasm
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The Stomach
Clinical Anatomy The stomach is a J-shaped organ with 2 curvatures (GREATER and LESSER) It has 4 parts: • • • •
CARDIA (6) FUNDUS (2) BODY (1) PYLORIC ANTRUM (10)
Important glands of the stomach • Parietal cells - secrete gastric acid and intrinsic factor; stimulated by gastrin; inhibited by somatostatin of high PH • Chief cells - secrete pepsinogen and renin • APUD or enteroendocrine cells - secrete gastrin, histamine, serotonin, cholecystokinin and somatostatin
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Blood supply • Arterial • Lesser curvature • L. gastric (coeliac branch) • R. gastric (R. hepatic branch) Greater curvature • R. gastro-epiploic (gastroduodenal branch) • L. gastro-epiploic (splenic branch) • • Venous • Enters portal system of liver • Lymphatics • Perigastric • Coeliac nodes • Nervous supply • Vagus nerve has a posterior and anterior branch. It has motor (emptying) and secretory (acid production) functions.
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Acute Upper GI Bleed This is a MEDICAL EMERGENCY
Aetiology • ULCERATION (duodenal 40%, gastric)! • INFLAMMATION (gastritis, oesophagitis) • OTHERS e.g. Mallory-Weiss, carcinoma, varices, angiodysplasia, HHT, Peutz-Jegherʼs, aortoenteric fistula
Clinical features These are due to: 1. DISPLACED BLOOD leading to malaena (black/tarry) or haematemsis (coffee-ground vomit) 2. LOSS OF BLOOD leading to hypovolaemia
Management “I would make sure the patient was in a safe place, attached to monitoring equipment and inform a senior colleague... ...I would then resuscitate with respect to Airway • Secure Breathing • High flow oxygen Circulation • • • •
2 x large bore IV cannulae Take bloods (Normal bloods + amylase + group and save and crossmatch 4 units) Assess volume status, catheterise Give fluids • 2L normal saline STAT • Then... colloid or blood
Direct patient towards OGD with therapeutic adjuncts 1. Omeprazole 2. Antibiotics e.g. cephalosporin 3. Terlipressin (if varices are likely)
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ROCKALL SCORING SYSTEM - a prognostic indicator. It has 2 components 1. Pre-OGD (age, co-morbidity and shock) 2. At OGD (diagnosis and risk of re-bleed) [< 3 = good, > 8 = bad]
Purpose of OGD: • DIAGNOSTIC • THERAPEUTIC • Banding • Sclerotherapy • Adrenaline injection
After the OGD...classify as STABLE or UNSTABLE
STABLE
UNSTABLE = uncontrollable haemorrage/ significant risk of re-bleed
CONSERVATIVE
Treat cause
Stabilise
MEDICAL
PPI H.pylori eradication
-
SURGICAL
DU - Underunning GU - Excision of gastrectomy
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Peptic ulcer Epidemiology • M > F, elderly Sites • • • • •
Duodenum - often in the 1st part of the duodenum, 2cm from the pylorus Stomach Oesophagus Jejunum (Zollinger-Ellison syndrome) Meckelʼs diverticulum (in the presence of gastric mucosa)
Risk factors 1. Lifestyle: smoking, alcohol 2. Other disease: H.pylori & drugs (NSAIDS, steroids), burns (Curling ulcer), head injury (Cushingʼs ulcer), Zollinger-Ellison Syndrome
Clinical features Patients maybe assymptomatic or present with symptoms of dyspepsia, indigestion, retrosternal pain. In a DU pain is relieved by eating (or drinking milk) and is worst at night or before meals. In PU pain is worst when eating. There are two important complications of a PU ! 1. Perforation 2. Bleeding - this usually occurs in a posterior duodenal ulcer that erodes into the gastroduodenal artery (see acute GI bleed) A PU can also lead to gastric outlet obstruction and malignancy. We will discuss a perforated PU in further detail later on.
Investigation Endoscopy and CLO test, urease test, urea breath test or serology for H.pylori.
Treatment Modalities Conservative Medical
Treatment Avoid NSAIDS, steroids, alcohol and stop smoking H.pylori eradication PPI
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Modalities Surgical This is rarely required now since the success of PPIs in PU disease
Treatment Vagotomy - CN X normally stimulates gastric acid secretion and relaxation of the pyloric sphincter, therefore a highly selective vagotomy to the nerves of Latarjet can be performed. However a pyloroplasty or gastroenterostomy is required as this causes pyloric sphincter contraction and bilious vomiting. Antrectomy and vagotomy • Billroth I (gastroduodenostomy) • Billroth II (gastrojejunostomy) Subtotal gastrectomy and roux-en-Y formation for refractory disease or Zollinger-Ellison syndrome
Zollinger-Ellison syndrome
This is a gastrinoma of the pancreas which causes hypersecretion of gastrin, and therefore HCl from the parietal cells of the stomach. These may be sporadic or inherited (MEN) and 60 % are malignant.
Clinical features • • • •
Abdominal pain Dyspepsia Diarrhoea and steatorrhoea Haematemesis
Treatment • High dose PPI • Excision • Chemotherapy
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Perforated Peptic Ulcer This is a MEDICAL EMERGENCY
1. Symptoms • Sudden onset abdominal pain (epigastric then generalised) 2. Signs INSPECTION General
Unwell patient
PALPATION
PERCUSSION
Rigid abdomen
Tender
AUSCULTATION Absent (paralytic)
Generalised tenderness with guarding + rebound i.e. peritonitic
Investigations Modalities Cultures Bloods - ABG Bloods - Venous Imaging
Tests + Findings Yes As above Erect CXR (will show 70%) - “free air under the diaphragm” CT for location of perforation
Scopic/Biopsy
-
Functional
-
Management First… RESUSCITATION If patient is very unwell and ∴ unsuitable for surgery, manage conservatively as perforation may self-seal Modalities CONSERVATIVE
MEDICAL
Specifics Analgesia IV Fluids and catheterisation NBM + NG tube Antibiotics
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MOST COMMON PERFORATIONS 1. Duodenal (1st part anterior) 2. Gastric 3. Ulcerative gastric cancer
Modalities SURGICAL
Specifics DU - Laparotomy + washout + omental repair GU/cancer - excision or gastrectomy
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Gastric Cancer Epidemiology • M>F • Common in Japan, China Risk factors !
Lifestyle: smoking, alcohol, diet
!
Other diseases: Blood group A, atrophic gastritis, pernicious anaemia, previous partial gastrectomy
Pathology Most are ADENOCARCINOMAS (others - MALT, lymphoma) 2 classification systems: 1. MACROSCOPIC - Bormann Classification • Fungating • Excavating • Ulcerating and raised • Linitis plastica 2. MICROSCOPIC • INTESTINAL (53%) • DIFFUSE (30%) Clinical features Patients may present with general features of malignancy (weight loss, anorexia, fatigue) or specific to the stomach e.g. upper abdominal mass, haemorrhage or rarely, gastric outflow obstruction
Investigations
Modalities
Tests + Findings
Cultures
-
Bloods - ABG
-
Bloods - Venous
Imaging Scopic/Biopsy Functional
FBC (anaemia due to chronic disease/blood loss) LFTs (mets) Clotting (pre-surgical & as an LFT) Barium meal CT for staging Gastroscopy + biopsy -
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Management
Modalities CONSERVATIVE
MEDICAL SURGICAL
Specifics Analgesia Antiemetics Anti-secretion e.g. hyoscine Palliative therapy Chemotherapy Only possible in early disease Total (proximal lesion) or partial (distal lesion) gastrectomy 2 types of partial gastrectomy 1. Billrothʼs I - gastroduodenostomy; direct anastomosis of stomach to duodenum 2. Billrothʼs II - gastrojejunosotmy; anastomosis of stomach to jejunum leaving a duodenal stump Lymph clearance D1 = + perigastric nodes D2 = + coeliac nodes Or palliative interventions for gastric outlet obstruction e.g bypass, resection or stenting
Complications of gastrectomy
Complication Early
Haemorrhage Infection Duodenal stump leak Failure of gastric emptying and bilious vomiting
Intermediate
D - Dumping syndrome presents with abdominal distension, flushing and sweating • Early dumping syndrome: immediately after a mearl, food has an osmotic effect casuing nausea, fluid shift and hypotension • Late dumping syndrome: ~ 2 hours after a meal, reactive hypoglycaemia occurs due to fast transit of food through the small bowel and insulin production D - Diarrhoea
Late
D - Deficiency of B12 (IF is produced by the stomach), Fe (HCl is required for the absorption of iron), vitamin D (osteomalacia) Alkaline gastritis Blind-loop syndrome - bacterial proliferation in the duodenal stump of Billroth II Recurrent ulceration Malignancy
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Complications of Gastrectomy can be remembered using the 3 Ds.
D - Dumping syndrome D - Diarrhoea D - Deficiency of vitamin B12
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Gallstone and Biliary Disease Clinical Anatomy Gallbladder lies between R and quadrate lobes of the liver. MCL at R. costal margin.
There are 3 parts: 1. Fundus 2. Body 3. Neck (Hartmannʼs pouch)
It open into CYSTIC duct (joins common hepatic to form the common bile duct) and holds around 50 ml of bile.
The blood supply is: • ARTERIAL - cystic artery from R. hepatic artery • VENOUS - direct to liver sinusoids The epithelium is composed of COLUMNAR CELLS + mucus glands
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Introduction to Gallstones
“Stones that form within the biliary system.”
There are 3 types: 1. MIXED (80%) 2. CHOLESTEROL (15%) - large stones - known as SOLITAIRES (fasceted when you cut through them) 3. PIGMENT (5%) - haemolytic states such as HS and SS
Epidemiology
5 Fʼs: • • • •
Incidence increasing F>M Most asymptomatic (15% over 60y) More common in blacks and Asians
Aetiology
Fatty Fertile Forty Female Fair
Largely unknown but common theories include 1. 2. 3. 4.
BILE SUPERSATURATED WITH CHOLESTEROL (Amirandʼs triangle) Biliary tree sepsis Lithogenic bile secretion Anatomical abnormalities
Risk factors Traditional classification is 5 Fs - Fat, Forty, Female, Fertile, Fair.
New classification • Lifestyle: e.g. high fat/cholesterol ! • Other conditions e.g. haemolytic states (pigment states), loss of terminal ileum (Crohnʼs) • Drugs e.g. COC Complications depend on the site of impaction: 1. GALLBLADDER e.g. biliary colic, acute and chronic cholecystitis, mucocoele, empyema, perforation, carcinoma of the gallbladder 2. IN BILIARY TRACT e.g. obstructive jaundice, ascending cholangitis, pancreatitis 3. OUTSIDE BILIARY TRACT e.g. gallstone ileus and small bowel obstruction © Podmedics 2010
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Gallbladder Complications
1. Biliary Colic “Blockage in the cystic duct”
Clinical features Symptoms: • RUQ pain after fatty meal (radiates to epigatrium and tip of R scapula) • Associated with sweating/nausea/flatulent dyspepsia Signs: • Mild RUQ tenderness Note: classically biliary colic IS NOT A COLIC. Pain rises to plateau and remains there for many hours!
Management FBC, LFTs, CRP are normal, however USS reveals gallstones. RESUSCITATION and exclude emergency (e.g. perforation, pancreatitis).
Modalities CONSERVATIVE
Specifics Fluids Analgesia (pethidine 50mg/4h IM/PO) NBM
MEDICAL SURGICAL
Urgent cholecystectomy Elective cholecystectomy (6-12 weeks later)
2. Acute Cholecystitis
“Obstructed gallbladder + infection.” This can be divided into acalculous (10%) and calculous (90%).
Clinical features - “patient is more unwell” Symptoms: • Systemically unwell • Severe, constant RUQ pain, greater radiation © Podmedics 2010
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Signs: • More severe RUQ tenderness • Positive Murphyʼs sign (cessation of inspiration with pressure on gallbladder - must be negative on the left) [present in 75%] • Low-grade temperature
Investigations
Modalities Cultures Bloods - ABG Bloods - Venous
Imaging
Tests + Findings Blood, urine dipstick (bilirubin) Lactate FBC (infection) CRP (infection) U&Es (dehydration) Amylase (exclude pancreatitis) LFTs (obstruction) Clotting (pre-surgical & as an LFT) AXR (10-15% radio-opaque) CXR (exclude perforation) USS (distended thickened gallbladder, gallstones, pericholecystic fluid)
Scopic/Biopsy
-
Functional
-
Management
Modalities CONSERVATIVE
MEDICAL SURGICAL
Specifics Fluids Analgesia (pethidine 50mg/4h IM/PO) NBM Cefuroxime and metronidazole Urgent cholecystectomy (< 72h and severe) Elective cholecystectomy (6-12 weeks later)
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Complications of acute cholecystits • • • • •
Recurrence Gangrene leading to perforation Mucocoele Empyema (drained with cholecystostomy) Mirriziʼs syndrome - large gallstone compressing the bile duct causing obstructive jaundice
A cholecystectomy maybe performed open or laparoscopically. An open incision is known as a Kocherʼs incision.
Specific complications of laparoscopic cholecystectomy
Specific Immediate
Complication Trocar related vessel or visceral damage CBD injury and bile leak Conversion to open cholecystectomy/laparotomy Stone spillage
Early
Acute pancreatitis
Late
Incisional hernia
Laparoscopic vs. open cholecystectomy
Advantages
Disadvantages
Small incisions have better cosmesis
Special equipment and training required
Less post-op pain
More difficult to control complications
Earlier mobilisation
Loss of tactile feedback
Reduced risk of DVT and hospital acquired infection
CI in bleeding disorders, shock and adhesions
Earlier return to work
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Biliary Tree Complications There are 3 important sequelae to impaction of gallstones within the biliary tree:
1. Obstructive jaundice 2. Ascending cholangitis 3.
Pancreatitis (considered later)
1. Obstructive jaundice
“Small stone blocks distal biliary ductsʼ Patient will therefore have features of an elevated conjugated bilirubin • Jaundice (late) • Pale stools (like houmous) • Dark urine (like coca-cola) It is always important to investigate these patients for cancer e.g. pancreatic, cholangiocarcinoma. First line investigation is an ultrasound to assess for the presence of gallstones, pancreatic mass, level of obstruction, degree of dilatation of the CBD +- intrahepatic biliary tree.
2. Ascending Cholangitis
“Infection upon a background of obstruction of distal biliary ducts” CHARCOT’s TRIAD is classical Symptoms I. FEVER (+rigors) II. PAIN III. JAUNDICE
Signs Remember Courvoisierʼs law: “In the presence of obstructive jaundice if there is a palpable gallbladder it is unlikely to be stone.”
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Investigations
As above Consider 3 SCOPIC INVESTIGATIONS:
1) Endoscopic retrograde cholangio-pancreatography (ERCP) • Endoscope passed into 2nd part of duodenum and papilla is cannulated. Dye is injected an image taken of the biliary tree. • Biopsies can be performed • Can also be therapeutic (stone removal, stent insertion) 2) Percuaneous transhepatic cholangiography • This performed 2nd line (after ERCP failure or if not possible) • Percutaneous cannulation of intrahepatic bile duct and injection of dye. 3) Magnetic resonance cholangiopancreatography • Non-invasive technique that does not require the use of contrast • Produces images similar to ERCP
Management
Modalities CONSERVATIVE
MEDICAL SURGICAL
Specifics Fluids Analgesia (pethidine 50mg/4h IM/PO) NBM Cefuroxime and gentamicin (for pseudomonas cover) 1. EMERGENCY - remove stone and insert a T-tube (open or ERCP) 2. ELECTIVE - cholecystectomy
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Intestinal Complications There is only 1 important complication here and it is rare.
GALLSTONE ILEUS Occurs as large gallstone (e.g. solitaire) fistulates into first part of the duodenum then becomes stuck in the small intestine.
See later for notes on small bowel obstruction.
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The Spleen Clinical Anatomy • Largest organ of the lymphoreticular system • Situated in LUQ (9,10,11th ribs) note: spleen is not palpable in health
Important relations: • • • •
Anterior: stomach Posterior: ribs, diaphragm Medial: L. kidney Lateral: splenic colonic flexure
Blood supply via SPLENIC ARTERY (coeliac axis) and SPLENIC VEIN
Functions (reflects pathology nicely) 1. Immunological e.g. a large lymph node 2. Haematology e.g. sequestration and removal of old cells
Clinical characteristics of the spleen • • • • •
Enlarges INFERO-MEDIALLY (start RIF and move toward LUQ) Dull to percussion Cannot get above it Notched Cannot ballot (cf. kidney)
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Hypersplenism & Hyposplenism
1. Splenomegaly There are 3 types: 1. MASSIVE (> 8cm) 2. MODERATE (4-8cm) 3. TIP (<4cm)
Types
Causes
MASSIVE
1. Myeloproliferative disorders e.g. CML 2. Myelofibrosis 3. Tropical disease e.g. malaria, leishmaniasis, kala-azar
MODERATE
1. Myeloproliferative disorders 2. Infiltration (Gaucherʼs/amyloid)
TIP
1. 2. 3. 4.
Myeloproliferative Congestion Excessive usage e.g. haemolytic states Infection (EBV, IE)
MYELOPROLIFERATIVE/LYMPHOPROLIFERATIVE disorders are a cause of all of them
HYPOSPLENISM May be either: 1. IATROGENIC (asplenism) • e.g. post-trauma or surgery 1. AUTOSPLENECTOMY (hypospenism) • Haemolytic e.g. sickle-cell • Inflammatory process e.g. SLE, coeliac, UC
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Investigations
Modalities Cultures Bloods - ABG Bloods - Venous
Imaging
Scopic/Biopsy Functional
Tests + Findings Blood cultures (infection) FBC (leukocytosis) U&Es (dehydration, electrolyte disturbance) LFTS (liver disease) CLOTTING (liver disease) G&S + CXM (for surgery) AXR Ultrasound Abdominal CT Bone marrow biopsy (haematological disorder) Cr51 red cell scan to show ectopic splenic tissue
Splenectomy Indications
There are 2 important indications for splenectomy: 1) TRAUMA (see later) 2) HAEMATOLOGICAL COMPLICATIONS • e.g. ITP, hereditary spherocytosis Others: part of another procedure (e.g. radical gastrectomy), primary splenic lesion (tumours, abscess, cysts, aneursyms)
Surgical Approaches Surgery may be either: 1. OPEN (emergency - laparotomy, elective - upper middle and L. subcostal incision) 2. LAPARASCOPIC
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Complications
GENERAL
Think in terms of ABCDE
Specific - Early
L. lower lobe atelectasis Sepsis
Specific - Intermediate Specific - Late
Pancreatitis Sub-phrenic abscess Encapsulated infections
ALL PATIENTS REQUIRE INFECTION PROPHYLAXIS 1. Pneumococcus (Pneumovax) 2. Meningococcus (Men C) 3. Haemophilus (Hib) + Prophylactic penicillin
Splenic Trauma This is relatively common and an important cause of spleen removal. The key problem is vascularity of the organ that leads to large internal blood losses.
Mechanism of injury • Penetration/non-penetrating trauma • Iatrogenic trauma (e.g. surgery to colon/stomach) • Spontaneous rupture e.g. EBV infection
Remember: small degrees of trauma may lead to SUB-CAPSULAR HAEMATOMA
Classification - based on CT scan I - Capsular Tear II - Capsular Tear + Parenchymal injury III - Tear up to the hilum IV - Complete fracture © Podmedics 2010
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Clinical features There will be a history together with LUQ pain and tenderness or generalised peritonitis. Features of shock will also be present. 2 important eponymous signs: 1. Kehrʼs sign: L. shoulder tip pain 2. Ballanceʼs sign: new onset shifting dullness in R. flank
Management CONSERVATIVE: for Type I & II! • Analgesia and fluid resuscitiaion: IV fluids (blood), monitoring! SURGICAL: For Type III & IV • Laparotomy (suture, salvage, splenectomy - partial or total)!
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The Pancreas
Clinical Anatomy The pancreas is a retro-peritoneal organ (level of L1 in transpyloric plane) It is contained within the C-curve of the duodenum It has 3 parts: 1. Head (+/- uncinate process) 2. Body 3. Tail
Relations • POSTERIOR: IVC, aorta, mesenteric vessels, diaphragm crura • ANTERIOR: stomach • TAIL: splenic hilum Blood supply • ARTERIAL: superior and inferior pancreatico-duodenal, splenic • Corresponding VEINS (to portal system) © Podmedics 2010
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Lymphatics • Upper border nodes • Superior mesenteric nodes
Structure/Function Pancreas has 2 broad functions 1) ENDOCRINE - insulin, glucagon, stomatostatin 2) EXOCRINE - trypsinogen (protease) and chymotrypsinogen (lipase) Microstructure is composed of alveoli of secretory cells. Formed into ductules. These then join into 2 main ductal systems: 1) Main duct (Wirsung) - joined by the common bile duct to form Ampulla of Vater. 2) Accessory duct (Santorini) - drain superior to main duct directly into D2. ISLETS OF LANGERHANS - found between alveoli (most are in the tail)
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Pancreatitis There are 2 types of pancreatitis: 1) Acute 2) Chronic (+ acute-on-chronic)
Acute Pancreatitis “Inflammatory condition of the pancreas”
This should be regarded as both a local and systemic disorder.
Epidemiology • • • •
Common - 1:100 general surgical admissions Middle age M=F Mortality is ~ 12%
Aetiology Gallstones (45%) Ethanol (25%) Trauma Steroids Mumps + other infections e.g. Coxsackie B Autoimmune e.g. PAN Scorpion venom Hyperlipidaemia (+ hypercalcaemia, hypotension, hypothermia) ERCP Drugs e.g. thiazides, HIV drugs IDIOPATHIC (20%)
Clinical Features Symptoms: • Epigastric/perigastric pain radiating to the back • Relieved by sitting forwards/Associated with vomiting Signs: • General: unwell patients with fever, tachycardia, jaundice • Specific: Localised/Generalised peritonitis +/- shock/ileus • Cullenʼs sign - peri-umbilical echymosses! • Grey-Turners - flank echymosses
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Investigations
Modalities Cultures Bloods - ABG Bloods - Venous
Imaging
Scopic/Biopsy Functional
Tests + Findings urine dipstick (bilirubin, glucose) Yes FBC (leukocytosis and low haematocrit) U&Es (dehydration, renal function) LFTs (obstructive) Amylase Lipids (hyperlipidaemia) Serum lipase Calcium (hypo- and hypercalcaemia) Glucose Albumin Erect CXR (exclude perforation) AXR (paralytic ileus) Ultrasound (inflammation around pancreas, gallstones) CT abdomen (define anatomy + Balthazar score) ERCP -
Notes on amylase • 80% raised in acute pancreatitis within 2-12 hours (return normal within week) • NON-SPECIFIC • If > 1000 pancreatitis over other causes RANSON/GLASGOW (UK) CRITERIA (PANCREAS mneumonic) • Predictive of severity and mortality • RANSON is better for alcohol-induced and only applied after 48 hours
PaO2 < 8 kPa Age > 55 Neutrophilia > 15x109 Calcium < 2.0 mmol/l Renal function impaired Enzymes e.g. LDH > 600 IU, AST > 200 IU Albumin < 32 g/dl Sugar > 10 mmol
1 = MILD 2 = MODERATE > 3 within 48 hours = SEVERE
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Management Modalities CONSERVATIVE
Specifics Fluids Analgesia (pethidine and morphine) NBM + NG tube Oxygen (keep Pa02 > 8 KPa Correct abnormal metabolities e.g. calcium Insulin sliding scale if elevated glucose ? Alcohol withdrawal - chlordiazepoxide and vitamins
MEDICAL SURGICAL
Moderate/severe - Antibiotics (meripenem, imipenem) Indicated for severe complications e.g. necrosis, pseudocyst, abscess, failure of resolution 1. Laporotomy and debridement/lavage 2. Laparostomy (pack and leave open in ITU)
Complications
GENERAL Specific - Early
Think in terms of ABCDE ARDS Atelectasis Pleural effusion (transudate) Organ failure (cardiac, renal) DIC
Specific - Intermediate
Infection Necrosis Pseudocyst formation
Specific - Late
Chronic pancreatities Pancreatic tumour
Pancreatic Pseudocyst “Collection of fluid in lesser sac that occurs in around 20% cases. “
• Suspect with persistently raised amylase. • If < 6cm it may resolve spontaneously • If > 6cm it requires surgery e.g. percutaneous drainage, laparoscopic, laparotomy
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Chronic Pancreatitis
“Repeated episodes of pancreatic inflammation leading to structural damage and fibrosis.”
Leading to complications of: 1. Exocrine dysfunction e.g. malabsorption 2. Endocrine dysfunction e.g. diabetes mellitus
Epidemiology • Uncommon ~ 30/100,000 • Most due to ALCOHOL • Other causes are cystic fibrosis, congenital causes e.g. pancreas divisum, hyperlipaemia and idiopathic)
Clinical Features
Symptoms: • General: weight loss, poor appetite • Specific: • Pain • Exocrine deficiency e.g. steatorrhoea • Endocrine deficiency e.g. polyuria, poldipsia etc. Signs: • General: thin patient • Specific: erythema ab igne (from hot water bottles), epigastric tenderness Investigations
Modalities
Tests + Findings
Cultures
-
Bloods - ABG
-
Bloods - Venous
FBC (leukocytosis and low haematocrit) U&Es (dehydration, renal function) LFTs (obstructive) Amylase Lipids (hyperlipidaemia) Serum lipase Calcium (hypo- and hypercalcaemia) Glucose Albumin
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Modalities Imaging
Scopic/Biopsy Functional
Tests + Findings AXR (speckled pancreatic calcification) CT scan (structural changes and inflammation) MRCP (gallstones) MRI (structural changes) ERCP (gallstones) Pancreolauryl test (for endocrine function)
Management
Modalities CONSERVATIVE
MEDICAL SURGICAL
Specifics Analgesia (can be problematic and require strong opiods/coeliac plexus block) Treat exocrine dysfunction (Pancreatin, Creon) Treat endocrine dysfunction (insulin) Moderate/severe - Antibiotics (meripenem, imipenem) Indicated for complications e.g. uncontrolled pain 1. REMOVE OBSTRUCTION e.g. stenting, cholecystectomy 2. DRAIN DUCTS/CYSTS e.g. pancreaticojejunostomy 3. RESECT - Distal (distal pancreatectomy), Proximal (Whippleʼs procedure = pancreatoduodenectomy)
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Pancreatic Tumours May be either: 1) BENIGN - uncommon. Occur as part of the MEN syndromes. 2) MALIGNANT
Pancreatic Carcinoma Most pancreatic carcinomas are DUCTAL ADENOCARCINOMAS and occur in the HEAD. Others: ampullary tumour, insulinomas, gastrinomas, glucagonomas, VIPomas
Epidemiology • • • •
Increasing incidence M>F Elderly Western Countries
Risk factors 1. 2. 3. 4.
LIFESTYLE: smoking and alcohol DYE EXPOSURE: naphthylamine, benzidine DISEASE STATES: chronic pancreatities, diabetes CONGENITAL: pancreas divisum
Clinical Features Symptoms: • General: anorexia, malaise, weight loss • Specific: Chronic epigastric pain radiating to the back (relieved by sitting forwards), steatorrhoea i.e. disturbed exocrine function, symptoms of diabetes i.e. disturbed endocrine function. Signs: • General: cachexia, lymphadenopathy, signs of chronic EtOH use, jaundice • Specific: palpable gallbladder (courvoisierʼs law), hepatosplenomegaly, ascites Rare features are thrombophlebitis migrans and marantic endocarditis
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Investigations
Modalities Cultures Bloods - ABG Bloods - Venous
Imaging
Scopic/Biopsy
Functional
Tests + Findings Urine dipstick (glucose, bilirubin) FBC (anaemia of chronic disease) U&E (illness and dehydration) LFTs (obstructive jaundice, mets) Glucose (endocrine dysfunction) CA 19.9 [sensitivity of 90%] USS abdomen (mass, dilatation and gallstones) Triple phase CT (mass and staging) MRCP ERCP + biopsy Ultrsound-guided biopsy Laparoscopy Pancreolauryl test (for endocrine function)
Management
Modalities CONSERVATIVE
MEDICAL SURGICAL
Specifics Analgesia (strong opiod or coeliac plexus block) Relieve obstruction Palliative radiotherapy 20% of tumour are resectable 1. Whippleʼs procedure 2. Chemotherapy post-op
The prognosis is dismal with a mean survival of around 6 months
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Basic Principles of the Lower Gastrointestinal Surgery
Important Clinical Anatomy The Duodenum • C-shaped (~ 25cm in length) • 4 sections: D1-D4 Important relations: D1 - Gastroduodenal and CBD posterior D2 - Duodenal papilla receives CBD and pancreatic duct at sphincter of Oddi and accessory pancreatic duct D3 - Mesenteric vessel anteriorly 9SMA and SMV) D4 - Suspensory ligament of Treitz distinguishes this part from ileocaecal junction
Blood supply • D1-D2: superior pancreaticoduodenal artery (gastroduodenal a. from coeliac axis) • D3-D4: inferior pancreaticoduodenal artery (sup. mesenteric a.)
Small Intestine • ~ 6.5m in length • Split into • 50% JEJUNUM • 50% ILEUM
JEJUNUM
ILEUM
Location
Umbilical
Hypogastric/pelvic
Diameter
Wide
Narrow
Wall
Thick
Thin
Arcades
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Large Intestine • ~ 1.5m in length • Distinguished from the small bowel as it is 1. Wider 2. Taenia coli which end at the appendix 3. Haustra 4. Appendiced epiploicae Divided into: 1. Caecum 2. Vermiform appendix 3. Ascending colon 4. Hepatic flexure 5. Transverse colon 6. Splenic flexure 7. Descending colon 8. Sigmoid colon 9. Rectum 10. Anus Peritoneal attachments • PERITONEUM: transverse and sigmoid • NO PERITONEUM: ascending and descending • VARIABLE: caecum, rectum Arterial Blood Supply Divide structures into: A. FOREGUT (mouth to D2) • Coeliac axis (T12) B. MIDGUT (D2 to distal transverse colon) • Superior mesenteric artery (L1) C. HINDGUT (distal transverse colon to anus) • Inferior mesenteric artery (L3) Venous supply A. SUPERIOR MESENTERIC VEIN (→ portal vein) B. INFERIOR MESENTERIC VEIN (→ splenic vein)
Lymphatic drainage • Corresponds with the blood supply • Small nodes on bowel drain to large mesenteric nodes… then to mesenteric vessel nodes then to cisterna chyli.
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Peritoneal cavity 2 layers: ! Parietal - outer ! Visceral - inner Between these layers are serous fluid. The peritoneum has two main regions which is connected by the epiploic foramen (foramen of Winslow) • Greater sac • Lesser sac - which is further subdivided into the lesser and greater omentum The peritoneum acts to protect the organs and hold them in place. There are areas in which there are double folds of peritoneum, which are known as: 1. Mesentery contains nerves and blood vessels to supply organs. The mesentery connects organs to the posterior abdominal wall, for example mesoappendix, transverse and sigmoid mesocolon. 2. Ligaments which connect one organ with another or another part of the body. 3. Omentum which is divided into the lesser and greater omentum. The lesser omentum extends from the liver to the lesser curvature of the stomach. The greater omentum extends from the the greater curve of the stomach, descends infront of the small intestine and turns up towards the transverse colon, forming an apron. The greater omentum has a cribiform appearance, which contains adipose tissue. Sometimes a loop of intestine can become strangulated in the foramen of Winslow. Also the hepatic artery can be compressed in the foramen of Winslow if the cystic artery is damaged during cholecystectomy.
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Intestinal Obstruction There are 3 important types of intestinal obstruction 1. SIMPLE - 1 obstructing point & no vascular compromise 2. STRANGULATED - vascular compromise 3. CLOSED LOOP - 2 obstructing points and danger of perforation • LBO in the presence of a competent ileocaecal valve • Caecal volvulus • Sigmoid volvulous The most useful classification is based upon AETIOLOGY
1. MECHANICAL
In the lumen MECHANICAL
Faeces Foreign bodies Gallstones Intussusception
In the wall CONGENITAL e.g. atresia, imperforate anus, stenosis
Outside the wall ADHESIONS Hernia Volvulus
ACQUIRED • Neoplasia • Inflammation e.g. IBD, diverticulitis
2. NON-MECHANICAL - the bowel is “shock” • SURGICAL SHOCK e.g. post-operative, peritonitis, ischaemia • MEDICAL SHOCK e.g. electrolyte aberrations, drugs e.g. anticholinergics Ogilivieʼs syndrome: features of obstruction on AXR but no obvious obstructing point
In practice remember: Small bowel - ADHESIONS and HERNIAS Large bowel - NEOPLASIA, DIVERTICULITIS and VOLVULUS
Clinical features There are 4 cardinal symptoms: 1. PAIN (usually central - SBO, lower - LBO and colicky, if constant think of strangulation/impending perforation) 2. CONSTIPATION (absolute - no faeces or flatus) 3. VOMITING (early in SBO) 4. DISTENSION (prominent in low obstruction) © Podmedics 2010
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Signs
INSPECTION General
Unwell patient Distended abdomen
Specific
Surgical scars Hernia (inguinal/ femoral)
PALPATION Tender + rebound/ guarding in strangulation/ perforation Masses
PERCUSSION Percussion tenderness if strangulation/ perforation
AUSCULTATION Small bowel • Tinkling Paralytic • None
Investigations
Modalities
Tests + Findings
Cultures
Bloods (if septic), Urine dipstick
Bloods - ABG
Metabolic acidosis in ischaemia
Bloods - Venous
Imaging
FBC (leukocytosis) U&Es (dehydration, electrolyte disturbance) Amylase (any acute abdomen) G&S + CXM Erect CXR (exclude perforation) & AXR (look for obstruction) Gastrograffin enema CT
Scopic/Biopsy
-
Functional
-
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Basic Interpretation of the Related Chest and Abdominal Radiograph Erect chest radiograph
Causes of air under the diaphragm: Perforated viscus e.g. bowel/PU Iatrogenic e.g. laparotomy/scopy Gas forming bacteria Water-skiers
Abdominal radiograph The 3,6,9 rule: if SB > 3cm, LB > 6cm and caecum > 9cm, the bowel is dilated Look at the rectal area for gas - if there is no gas this is an indication for bowel obstruction
Comparison of large and small bowel obstruction features
Feature
SBO (left)
LBO (right)
Bowel diameter (cm)
3-5
>5
Position of loops
Central
Peripheral
Fluid levels (erect)
Many
Few
Bowel markings
Valvulae conniventes (all the way across)
Haustra (partially across)
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Management 1. Mechanical These are mostly managed if a conservative fashion (unless there are signs of strangulation) Look for signs of resolution for around 24 hours: • Reduced pain • Reduced NGT aspirate • Passage of flatus • Resolution of AXR findings
Modalities CONSERVATIVE
MEDICAL SURGICAL
Specifics NBM & NG tube (“drip and suck”) Analgesia Gastrograffin (oral/NG tube) Flatus tube for sigmoid volvulus There are 3 important indications: 1. Simple obstruction (neoplasms or failure of conservative approach) 2. Closed loop obstructions 3. STRANGULATION/PERFORATION
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2. Non-Mechanical
Modalities CONSERVATIVE
MEDICAL SURGICAL
Specifics Prevention e.g reduced bowel handling, peritoneal lavage Analgesia NBM & NG tube (“drip and suck”) Treat cause (e.g. electrolytes) -
As a general rule: Virgin abdomens will probably end up requiring an operation to relieve the obstruction Non-virgin abdomens will probably only require conservative management
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Colon Cancer and Stomas Colorectal carcinoma “A malignant neoplasm of the colon or rectum.”
Epidemiology • • • •
3rd commonest cancer M=F Elderly Western
Aetiology • Lifestyle: Western diet (red meat, low fibre), smoking • Familial 1. 2. 3. 4. 5.
Familial adenomatous polyposis (AD) Gardinerʼs syndrome (AD) Hereditary non-polyposis coli Peutz-Jeghers syndrome Family history
• Previous disease states: IBD - 10 % risk/10 years in those with UC • Previous therapies: radiation, gastrectomy
Pathology May be classified with 2 classification systems: !
1. MACROSCOPIC • 30% recto-sigmoid junction • 25% sigmoid colon • L. sided tumours → annular stenosing • R. sided tumours → sessile/polypoid 2. MICROSCOPIC (Dukeʼs criteria)
! !
! !
A. Confined to bowel wall B. Through bowel node but no nodal involvement C. In lymph nodes ! C1 ! C2 involved apical node D. Distant mets
Note that Dukeʼs B with perforation requires adjuvant chemotherapy.
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Clinical features
Symptoms: • General: weight loss, anorexia, malaise • Specific • R. sided tumours → present late with diarrhoea and anaemia • L. sided tumours → commonly cause obstruction • Rectal tumours → obstruction/rectal symptoms (tenesmus)
Signs: • General: anaemia & cachexia • Specific • Mass • Signs of obstruction • Hepatomegaly • PR - mass or fistulae Investigations
Modalities Cultures Bloods - ABG Bloods - Venous
Imaging
Scopic/Biopsy
Functional
Tests + Findings FAECAL OCCULT BLOOD suggested as screening programme FBC (anaemia of chronic disease, iron deficiency anaemia) U&Es (diarrhoea) LFTs (mets) CEA (better at monitoring course) Clotting G&S/CXM (pre-surgical) CXR (mets) Barium/gastrograffin enema - apple core lesion CT/MRI (staging) - liver, lung and bone metastases CT for virtual colonoscopy Sigmoidoscopy + biopsy (flexible sigmoidoscopy can reach the splenic flexure) Colonoscopy + biopsy (colonoscopy can reach the ileocaecal valve) -
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Management
Modalities CONSERVATIVE/PALLIATIVE MEDICAL SURGICAL
Specifics By-pass, diversion or decompression Adjuvant chemotherapy in Dukeʼs C or B (perforated) or for colon tumours and neoadjuvant radiotherapy for rectal tumours RESECTION (see below)
R hemicolectomy for R sided tumours Extended R hemicolectomy for distal R sided tumour/ transverse colon tumour L hemicolectomy for left sided tumours Sigmoid colectomy for sigmoid tumours
Anterior resection for tumours > 4cm from the anal verge. The colon is anastomosed to the remaining rectal stump, and a defunctioning loop ileostomy may be performed. Abdomino-perineal resection for tumours < 4cm from the anal verge. There is complete removal of the anus and a permanent end colostomy is formed. Neoadjuvant radiotherapy maybe used to shrink the rectal tumour prior to resection. Adjuvant chemotherapy is used for types B and C colorectal carcinomas.
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Emergency bowel operations In large bowel obstruction due to colorectal carcinoma or stricture, for example diverticulitis, a Hartmannʼs procedure is performed. The obstruction is removed, the rectal stump is closed and left in the pelvis whilst a temporary colostomy is formed. Often, a direct anastomosis is not undertaken as this affects healing in the presence of inflammation.
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Stomas “A stoma (mouth) is a surgical created communication between the bowel and the skin.”
They may either temporary or permanent
Types: 1. Colostomy 2. Ileostomy 3. Urostomy (ileal conduit)
When inspecting a stoma ask yourself: • Where is it? • What is in it? • How is the communication created? + look for scars and ALWAYS CHECK THE PERINEUM.
Colostomy Site Bag Contents Opening
Ileostomy
Urostomy
L. iliac fossa (usually)
R. iliac fossa (usually)
R. iliac fossa (usually)
Solid
Liquid
Urine
Flush with skin
Spouted
Flush with skin
Complications of stoma formation
Specific Immediate
Complication Haemorrhage
Early
High output stoma Hypokalaemia Retraction Ischaemia
Late
Prolapse SBO Parastomal hernia Fistulae Dermatitis
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Inflammatory Conditions In this section we talk about A. B. C. D.
Appendicitis Diverticular disease Crohnʼs disease Ulcerative colitis
Appendicitis “Inflammation of the vermiform appendix”
Epidemiology
• Very common (up to 12% of population) • Can occur at any age • Rare < 2 • Peaks in childhood years Pathology The main processes occuring are 1. Obstruction - usually due to a feacolith 2. Lymphoid hyperplasia
The main worry is PERFORATION • Localised → appendix mass • Systemic → peritonitis
Clinical features
Symptoms: • General: Pyrexia, malaise and anorexia • Specific • Central colicky abdominal pain (hindgut colic) • Vomiting • Pain localized to R. iliac fossa © Podmedics 2010
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Signs: • General: patient still with flexed hips and knees. Pyrexia, fetor oris + coated tongue • Specific • Localised - garding and rebound over McBurneyʼs point (⅔ distance between umbilicus and ASIS) • Generalised - rigid and tender over all abdomen + an ileus
Investigations
Modalities Cultures Bloods - ABG Bloods - Venous
Imaging
Scopic/Biopsy Functional
Tests + Findings Urine MC & S + dipstick + βHCG FBC (neutrophil leucocytosis) CRP (infectious marker) amylase Ultrasound (exclude gynae cause, appendix inflammation indicated by free fluid and diameter > 6mm) CT for atypical cases Laparoscopy -
Management
Modalities CONSERVATIVE
MEDICAL SURGICAL
Specifics Analgesia Fluids NBM Cefuroxime and metronidazole OPEN LAPAROSCOPIC - particularly good for girls
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3 important complications to be aware of:
1. PERFORATION (young and the old) 2. MASS (may resolve with antibiotics) 3. ABSCESS (may require antibiotics and drainage)
Diverticular Disease “An acquired condition of mucosal lined out-pouchings through the wall of the colon.”
Epidemiology • Very common • F>M
DIVERTICULUM
Single out-pouching
DIVERTICULOSIS
Many out-pouchings
DIVERTICULAR DISEASE
Symptomatic outpouchings
Risk factors • Lifestyle: low fibre diet and obesity • Other conditions: hiatus hernia & cholelithiasis (SAINTʼS triad)
Complication
Clinical features Most patients and asymptomatic (∴ do not have diverticular disease)
Diverticulitis
L. sided appendicitis
Haemorrhage
Sudden painless, large PR bleed
Perforation
Symptomatic patients may have
Abscess formation
• Mild alteration in bowel habit with L. sided colic relieved on defecation • A complication
Fistulae
Investigations
Features
Strictures
Peritonitis Swinging fever and boggy rectal mass Enterocolic Colovaginal Colovesical Large bowel obstruction
Will depend on the situation. For acute diverticulitis…
Modalities Cultures Bloods - ABG Bloods - Venous
Tests + Findings If unwell FBC (neutrophil leucocytosis) CRP (infectious marker) U&E (dehydration) © Podmedics 2010
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Modalities Imaging
Scopic/Biopsy Functional
Tests + Findings Erect CXR (perforation) AXR (fluid level, air in the wall) Gastrograffin enema Ultrasound Angiography CT scan Sigmoidoscopy/colonoscopy -
Treatment This will depend on the severity and the specific complication. If mild symptomatic disease: • Treat conservatively with! risk factor modification e.g. increase fibre/fluids and lose weight • Antisposmodic may help e.g. mebeverine For acute diverticulitis:
Modalities CONSERVATIVE
MEDICAL SURGICAL
Specifics Analgesia Fluids NBM Cefuroxime and metronidazole This is indicated for PERFORATION, HAEMORRHAGE and OBSTRUCTION 1. Harmannʼs procedure 2. Elective sigmoid colectomy and anastomosis For less severe PR bleeding an angiography and embolisation can be performed
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Surgical Ulcerative Colitis “A chronic relapsing inflammatory condition of the colonic mucosa”
It ALWAYS starts at the rectum and spreads proximally (20% develop a PAN-COLITIS)
Epidemiology
• Most common between 20 - 35 years • F>M • Non-smokers Clinical features
Symptoms: • General: weight loss, fever, anorexia and malaise • Specific • Crampy abdominal pains • Diarrhoea (blood/mucus) • Rectal symptoms (urgency or tenesmus) Extra-intestinal manifestations e.g. uveitis, ank. spondylitis, erythema nodosum • Signs: • General: clubbing. Systemically unwell in acute disease • Specific (if acute disease) • Tender abdomen • PR bleeding on glove Complications include • • • • •
Toxic megacolon Perforation Strictures Perianal disease Colorectal carcinoma
Investigations:
Modalities Cultures Bloods - ABG
Tests + Findings Stool (exclude infection), blood In unwell
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Modalities Bloods - Venous
Imaging
Scopic/Biopsy Functional
Tests + Findings FBC (neutrophil leucocytosis) CRP and ESR (infectious marker) U&E (dehydration) LFT (albumin) G&S/CXM if for surgery Erect CXR (perforation) AXR (toxic megacolon, thickened walls, thumb printing, strictures) Gastrograffin enema (lead-piping, loss of haustra, granular mucosa) CT scan Sigmoidoscopy/colonoscopy (no serosal involvement and crypt abscess) -
Severity may be graded using the Truelove and Witts Criteria
Management If chronic/intermittent the MEDICAL MANAGEMENT • Surgery may be reserved for chronic symptoms or high grade dysplasia. If acute… SURGICAL MANAGEMENT • • • •
Toxic megacolon Perforation Massive PR haemorrhage Colitis not responding to medical management
Modalities CONSERVATIVE
MEDICAL
Specifics Analgesia Fluids NBM IV hydrocortisone Rectal steroids e.g. prednisolone foam enemas Blood transfusion if Hb low If improves...prednisolone + sulphasalazine
SURGICAL
If no improvement.. Panproctocolectomy, total or subtotal colectomy with ileostomy
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Crohn’s Disease “An inflammatory condition of unknown aetiology that can affects the entire length of the GI tract.”
It is characterised by: • Patchy transmural inflammation • Non-caseating granulomas
Epidemiology • Most common between 20-35 years • Smokers • M=F Clinical features
Symptoms: • General: weight loss, fever, malaise and anorexia • Specific • Diarrhoea (blood/mucus) • Crampy abdominal pain • Bowel obstruction Extraintestinal: anl. spond, erythema nodosum • Signs: • General: thin, clubbing, aphthous ulcers • Specific • Tender abdomen • Look for RIF mass • PR - perianal disease e.g. fistulas, fissures, perianal abscess Investigations
Modalities Cultures Bloods - ABG Bloods - Venous
Tests + Findings Stool (exclude infection), blood In unwell FBC (neutrophil leucocytosis) CRP, ESR (infectious marker) U&E (dehydration) LFT (albumin) G&S/CXM if for surgery © Podmedics 2010
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Modalities Imaging
Scopic/Biopsy Functional
Tests + Findings Erect CXR (perforation) AXR (toxic megacolon, strictures) Gastrograffin enema + FOLLOW -THROUGH (cobblestone mucosa, rosethorn ulcer, string sign) CT scan MRI (perianal disease) Colonoscopy (cobblestones appearance, fissuring, serosal involvement) -
Management
Usually this is managed medically with steroids + immunosuppressants Surgery is reserved for 2 setting: 1. 2.
Emergency (complications) Elective (chronic problems)
Surgical options include • Stricturoplasty • Limited resections • Ileo-caecal resection
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Peri-Anal Disease
Clinical Anatomy Rectal Anatomy
The rectum is ~ 15cm and curved It starts at 3rd segment of sacrum and ends at prostate/lower ¼ of the vagina
Important relations • POSTERIOR: Sacrum, midle sacral artery and coccyx • ANTERIOR: Prostate, bladder, vagina Note: the muscle layer are completely fused ∴ no haustrae.
Anal Canal
The anal canal is ~ 5cm and straight It is divided into two ½s by the DENTATE LINE
! ! !
LOWER HALF - squamous epithelium and inferior rectal artery UPPER HALF - columnar epithelium and superior rectal artery (branch of inferior mesenteric)
Continence is maintained by two sphincters INTERNAL SPHINCTER • Involuntary circular muscle of rectum EXTERNAL SPHINCTER • Made up 3 striated rings (external, superficial and subcutaneous) • Supplies by pudendal nerve (S 2,3,4)
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Haemmorrhoids “Dilated and disrupted vascular anal cushions”
These are most commonly found at the 3,7 and 11 oʼclock positions
May be classified according to anatomical severity:
• 1st degree - never prolapse • 2nd degree - prolapse on straining • 3rd degree - constantly prolapsed A “strangulated haemorrhoid” occurs when the sphincter cuts off the blood supply
Epidemiology • 50% of Western population affected Risk factors • Lifestyle: low fibre diet • Impaired venous return e.g. pregnancy, portal hypertension and pelvic malignancy • Rectal carcinoma Clinical Features
Symptoms: • • • •
Fresh PR bleeding A lump Pain Itching
Signs: • May be seen, ellicited or felt on PR • Abdominal exam may reveal abnormality
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Management
Modalities CONSERVATIVE MEDICAL SURGICAL
Specifics Increase fibre and fluid intake Toilet habit (limit time) Topical steroid/anaesthetic e.g. Anusol Laxative e.g. lactulose 1. 5% phenol in almond oil 2. Endoscopic banding/cryotherapy 3. Haemorrhoidectomy (final resort)
Note: Peri-anal haematomas These are haematomas that are caused by burst peri-anal venules. Usually due to straining Compared to haemorrhoids they appear blue. Most will resolve spontaneously but may need surgical drainage
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Anal Fissures “A tear in the anal mucocutaneous epithelium.”
These are most common at the 6 and 12 oʼclock positions.
Aetiology is usually either hard stool or trauma. However may be associated with Crohnʼs, syphilis and anal carcinoma.
Clinical features Symptoms: • Pain on defaecation • Fresh PR bleeding Signs: • Pain on cheek spreading • PR usually impossible • May be a “sentinal pile.”
Treatment
Modalities CONSERVATIVE MEDICAL
SURGICAL
Specifics Increase fibre and fluid intake Toilet habit (limit time) Stool softeners Reduce anal spasm e.g. 0.2% GTN cream, diltiazen cream, botulinum injection Lateral spincterotomy at 3 o'clock
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Anal abscess/Anal sepsis Anal sepsis either originated from ABOVE (e.g. pelvic abscess) or is due to a LOCAL problem (e.g. infection of the anal glands)
Common organisms include • Staph. • Strep. • E. coli The most important compliation is the formation of a FISTULA.
Types: a. b. c. d.
Perianal Ischiorectal Pelvirectal Inter-sphincteric
Clinical features Symptoms: • General: Swing fevers and malaise • Local • Mass • Throbbing pain + surround tenderness • Purulent discharge Signs • • • • •
General: systemic infection Perianal erythema Discharge Bulging mass PR - a boggy and fluctuant painful mass
Treatment
Modalities CONSERVATIVE MEDICAL SURGICAL
Specifics Analgesia Flucloxacillin + penicillin If above fails… Incision, drainage and packing ...leave to heal. © Podmedics 2010
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Anal Fistula “An abnormal connection between the ano-rectal passage and the skin.”
There are many types:
• • • •
INTER-SPINCTERIC TRANS-SPINCTERIC SUPRA-SPHINCTERIC EXTRA-SPHINCTERIC
Clinical features Symptoms • Pain and discharge of purulent fluid/faeces • Perianal irritation Signs • “Dot” and associated discharge and skin changes • PR - indurated area around the fistula
Treatment
Modalities CONSERVATIVE MEDICAL SURGICAL
Specifics Analgesia Antibiotics if associated infection 1. EUA to determine extent 2. Lay open tract and heal by secondary intent
If low… division of spincters Ih high...Seton suture to stimulate fibrosis of tract
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Rectal Prolapse “Protrusion of rectal tissue through the anal canal.”
There are 2 types: a. PARTIAL - mucosa only (common in children) b. COMPLETE - full thickness of rectum
Clinical features Symptoms: • Mass • Associated bleeding and ulceration • Incontinence of urine or faeces Signs: • View the prolapse on straining • PR - tone Investigations These must be investigated as there may be an underlying lesion e.g. carcinoma • Imaging - endoanal ultrasound/MRI • Scopic - Sigmoidoscopy • Functional - anorectal manometry
Treatment
Modalities CONSERVATIVE MEDICAL SURGICAL
Specifics Pelvic floor exercise Stool softeners 2 approaches 1. Delormʼs procedure: perineal approach to resection of excess rectal mucosa 2. Rectopexy: the rectum is fixed to the sacrum
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Anal Carcinoma Epidemiology • Uncommon • Most occur in male homosexuals due to associated with High Grade HPV (16, 18, 31, 33) Pathology
Can be broken down by histology • 80% squamous • 20% others e.g. adenocarcinoma, lymphoma, melanoma ..or location • Anal margin: below the dentate line (men with a good prognosis) - spreads to pelvic nodes • Anal canal: above the dentate line (women with a poor prognosis) - spread to inguinal nodes Clinical features
Symptoms: • General: malaise, weight loss, anorexia • Specific • Rectal bleeding • Pain • Incontinence Signs: • Mass + lymph nodes +/- fistula
Investigations
Modalities
Tests + Findings
Cultures
-
Bloods - ABG
-
Bloods - Venous
Imaging Scopic/Biopsy Functional/Special
FBC (anaemia of chronic disease/blood loss) LFTs (mets) Ca (mets) CT (spread) Rectal EUA + biopsy © Podmedics 2010
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Treatment
Modalities CONSERVATIVE MEDICAL SURGICAL
Specifics Analgsia Palliative radiotherapy Chemo + radiotherapy (if inguinal nodes involves) Resection
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Breast Disease Clinical Anatomy The breast are modified sweat-glands that are located between 2-6th ribs on the anterior chest wall Underlying muscles are: • ⅔ PECTORALIS MAJOR • ⅓ SERRATUR ANTERIOR
The basic structure is composed of 1. ADIPOSE TISSUE 2.15-20 LOBULES arranged in a hierarchical duct system (TLDU, extra-lobular duct, major duct)!
Arterial Blood Supply •Axillary artery •Internal thoracic arteries •Intercostal arteries
Lymphatic Drainage There are 3 basic lymphatic channel draining the breast and these are very important: 1. AXILLARY 2. INTERNAL MAMMARY 3. SUPRACLAICULAR The axillary nodes are split into 5 distinct groups • • • • •
Anterior Posterior Lateral Central Apical
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Diagnostic Principles in Breast Disease “Triple Assessment” are the key words here:
Modality 1. Clinical Assessment
Specific History • Particularly lumps, pain, nipple discharge • PMH/FH/DH Examination • Breast • Nodes/back
2. Radiology
Ultrasound (if < 35 years) Mammography • Oblique and cranio-caudal views • 10% false negative rate
3. Biopsy
Fine needle aspiration cytology • Easy to do • 95% sensitivity Core biopsy/Tru-cut • Histology • Oestrogen receptor status
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Benign Breast Disease These should be divided into:
a. Congenital
These are rare conditions such as amastia (absence of breast), hypoplasia and accessory nipples. Accessory nipples represent failure of the milk line to regress and can be excised if problematic.
b. Acquired You can divide these further into: 1. Hormonal/cyclical • ANDI, cystic breast disease, fibroadenomas 2. Infective 3. Inflammatory • Fat necrosis, duct ectasia 4. Neoplastic • Duct papilloma, lipomas, cysts
1. Hormonal/cyclical ANDI = Abnormalities of Normal Development and Involution
Benign Mammary Dysplasia/ANDI
Abnormality of cycles - Fibrocystic disease • Common in pre-menopausal women (25-45) with painful and nodular lump in second half of cycle • Investigation - triple assesment if lump • Treatment • 1st line - Analgesia/evening primrose oil • 2nd line - Tamoxifen/bromocriptine • 3rd line - excision Abnormality of Development - Fibroadenoma • • • •
Overgrowth of single breast lobule Young women with smooth, firm, mobile mass (“breast mouse”) Investigate with TRIPLE ASSESSMENT If < 30 - observe, if > 30 excise
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2. Infective breast disease
They are all treated with analgesia and antibiotics (e.g. flucloxacillin)
There are 2 important types: 1. Lactational • Cracked nipple from breast ffeding allows stap. entry • Most important compication is breast abscess formation • No need to stop breast feeding 2. Non-lactational • Staph. aureus • Most important complication is periductal mastitis (suggested by chronicity e.g. mastalgia, discharge and fibrosis that lead to nipple retraction)
3. Inflammatory breast disease
1. Duct ectasia • Dilated sub-areolar ducts that become filled with cellular debris → periductal inflamatory response • Present with subareolar lump and green discharge 2. Fat necrosis • Trauma (postive history in 50%) followed by fibrosis and calcification • Increased incidence of cancer
4. Benign Neoplasms
• Can be from the skin • e.g. lipoma, cysts • From the breast itself • Duct papilloma (present with blood stained discharge and treated with microdochectomy)
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Malignant Breast Disease Epidemiology • Very common (1:11) in the Western world. • Risk increased with age Risk factors • • • • •
1% occur in men Lifestyle: alcohol intake, high saturated fat diet Prolonged exposure to oestrogens: early menarche, late menopause, exogenous hormones Family history: Ca in first degree relative. BRCA 1 & 2 1st child over 30 years
Pathology The most important types of tumour are: 1. DUCTAL 2. LOCULAR
Both of these tumours go through an IN SITU phase (ductal is much more common). • Carcinoma that has not penetrated the basement membrane • Low- to high- grade Other include: • Medullary - younger patients • Colloid/mucinous - older patients and tend to look benign on the mammogram • Papillary
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Investigation 1. Triple assessment (histological grading and oestrogen receptor status) 2. Staging • CLINICAL • TNM Clinical staging system
Stage 1
Early disease Tumour confined to breast
Stage 2
Early disease Tumour spread to movable ipsilateral axillary nodes
Stage 3
Local advanced disease Tumour spread to superficial chest wall + involvement of ipsilateral internal mammary
Stage 4
Advanced Metastases present at distant sites e.g. liver, lungs, brain
TNM Staging System
0
1
2
3
Tumour
CIS/Pagetʼs
< 2cm No skin fixation
2-5cm Skin distortion
5-10cm Ulceration Fixed to pectoral muscle
Nodes
No nodes
Ipsilateral Mobile
Ipsilateral Fixed
Internal Mammary
Mets
No mets
Liver, bone, lung
4 > 10cm Chest wall extension
Management This should be in a specialist breast centre and is multi-modality e.g. surgery, radiotherapy and chemotherapy. Divide treatments into: 1. Early disease 2. Advanced disease
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1. Early disease
There are 4 aims: 1.
Local treatment of the tumour • Wide local excision + radiotherapy • Mastectomy (large tumours or patient choice)
2.
Axillary clearance • Assessment with axillary sampling/Sentinal mode mapping • Treatment with axillary clearance
3.
Prevention of recurrence • Radiotherapy after WLE • Chemotherapy if young, large tumour or high risk of recurrence • Hormonal e.g. Tamoxifen/Arimidex
4.
Reconstruction • TRAM flap • Latissimus dorsi flap
Sentinal Node Mapping Involves identification of the first node draining the tumour through injecting radioactive isotope and a dye. Sampling of this node then determines whether axillary clearance is necessary
2. Advanced disease
The first line is usually TAMOXIFEN
Other important adjuncts include • Local recurrence - re-excision, radiotherapy • Metastatic disease - bisphosphonates and steroids • Palliation - package of care, analgesia
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Complications of breast surgery
GENERAL Specific - Early Specific - Intermediate
Specific - Late
Think in terms of ABCDE Pneumothorax Infection Haematoma Seroma Frozen shoulder Lymphoedema Nerve damage e.g. brachial numbness
Breast Screening This is a programme introduced after publication of the Forest Report (1988) Involves: 1. 2.
Self-examination 2-view mammography every 3 years between 50-64 year old (> 64y can self-refer)
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Neck Lumps
Clinical Anatomy
The neck may be subdivided into: • ANTERIOR TRIANGLE • • • •
Submandibular (under chin) Submental (under chin in midline) Carotid (pulsatile) Muscular (midline)
• POSTERIOR TRIANGLE
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It is important to be aware of the different lymphatic drainage areas of the neck:
1
Submental/ submandibular
II
Jugulo-digastric
III
Middle jugular nodes
IV
Inferior jugular nodes
V
Posterior triangle
VI
Ant. compartment group
The Thyroid • Endocrine organ that lies in the pre-tracheal fascia over the 2-4th tracheal rings • Relations: ANTERIOR: strap. muscles POSTERIOR: parathyroid glands, larynx, trachea, superior and recurrent laryngeal nerves
There are 3 parts to the gland 1. Isthmus 2. Lateral lobes 3. Pyramidal lobes (inconsistent)
Blood supply • Arterial • SUPERIOR THYROID A. (branch of external carotid) • INFERIOR THYROID A. (branch of subclavian) • Venous • SUPERIOR THYROID V. (internal jugular) • MIDDLE THYROID V. (internal jugular) • INFERIOR THYROID V. (brachiocephalic) • Lymphatic • Mostly towards the middle jugular nodes © Podmedics 2010
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The Salivary Glands
There are 3 sets 1. Sublingual 2. Submaxillary 3. Parotid (largest)
The Parotid Gland
This is the largest of the 3 glands Shape/Location • It resembles a three-sided pyramid with the apex directed downwards. • Lies over the MANDIBULAR RAMUS (anterior and inferior to the ear) Important relations ! !
FACIAL NERVE EXTERNAL CAROTID ARTERY (bifurcated beneath to form the maxillary and superficial temporal a.
Drains into Stensonʼs duct → upper 2nd molar at the parotid papilla.
The Submandibular duct
Lies above the digastric muscle Separated into SUPERFICIAL and DEEP portions by mylohyoid. Drains into Whartonʼs duct → sublingual caruncles (either side of sublingual frenulum)
The Sublingual Gland This is the smallest of the 3 glands and lies ANTERIOR to the submandibular gland. Drains via Bartholinʼs duct to join the submandibular duct → sublingual caruncles.
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Lymphadenopathy “Enlarged lymph nodes”
This is the COMMONEST CAUSE of a lump in the neck.
Divide them into: • LOCALISED • GENERALISED
Infection LOCALISED
Primary e.g. lymphadenitis
Neoplasia
Autoimmune
Primary e.g. lymphoma Secondary
GENERALISED
Infections
Lymphoma
1. Acute e.g. EBV 2. Chronic e.g. HIV
CLL
Sarcoid
The history/examination should be fairly definitive and is the most important diagnostic tool.
Investigations
Modalities
Tests + Findings
Cultures
-
Bloods - ABG
-
Bloods - Venous Imaging Scopic/Biopsy Functional/Special
FBC, CRP, TFTs, LFTs, blood film, serological test CXR FNAC, core biopsy -
Treatment • Obviously directed at cause
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Solitary Lumps in the Neck [Note: these will still usually be lymph nodes]
Divide up as follows
• ANTERIOR TRIANGLE • POSTERIOR TRIANGLE
Anterior Triangle lumps This may be subdivided into 1. Pulsatile 2. Non-pulsatile 3. Submandibular
Pulsatile lumps
These occur in 3 settings: • Tortuos carotid artery (normal) • Carotid artery aneurysm • Carotid body tumour (chemodactoma)
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Non-pulsatile lumps
Classify these according to whether they are in the midline or not
MIDLINE • Thyroglossal cyst • Dermoid cyst • Ectopic thyroid tissue NON-MIDLINE • Branchial cyst • Pharyngeal pouch • Laryngocele (wind instrument players) 2 important ones are:
Branchial cysts
• These are “embryological remnants of the 2nd pharyngeal cleft.” ! • Present in early adulthood with SOFT-SWELLING and transilluminated (often post-URTI) • Occur at upper ⅔ of anterior sternomastoid. • Need aspiration shows cholesterol crystals • Treatment is excision Pharyngeal pouch
• This is a “mucosal protrusion between the 2 parts of the inferior laryngeal constrictor” • Present on the left in elderly patients • It is a lump that INCREASES IN SIZE ON SWALLOWING • Treatment is excision + cricopharygeal myotomy.
Submandibular lumps
These are usually secondary to infection e.g. jugulo-digastric with tonsillitis. Rarely you may have • Tumours • Impacted salivary stones (post-parandial pain and swelling). Do a plain XR or sialogram to detect as 80% are radio-opaque.
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Posterior Triangle lumps Common lumps here include 1. Cervical rib 2. Cystic hygroma 3. Subclavian artery aneurysm
Cervical rib “Enlarged costal element from the C7 vertebra.” This is fairly common (1:150) but only 10% are symptomatic Causes a variety of syndromes 1. VASCULAR - compression of subclavian • Thrombosis • Raynauds • Arm claudication 2. NEUROLOGICAL - pressure on the brachial plexus • Paraesthesia • Weakness
Cystic hygroma “Collection of lymphatic cysts behind the clavicle.” Often notices AT BIRTH Treatment with either with injection of sclerosing hypertonic saline or excision.
Parotid Lumps Lumps in the parotid can either be due to • Swelling of the WHOLE gland e.g. mumps, bacterial infection, sarcoid (uveoparotid syndrome), chronic liver disease • LOCALISED swelling (usually neoplastic) Pathology This really concerns the neoplasic processes:
PRIMARY - benign (pleiomorphic adenoma), malignant (pleiomorhic adenosarcoma, adenocarcinoma) SECONDARY - from lymphoma/mets
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Clinical Features • There will be a LUMP/swelling +/- a facial palsy (LMN type) Investigations • 2 investigations are important: FNA and CT scan Treatment • Superficial/radical parotidectomy • Radiotherapy The most important complication post-op is a FACIAL PALSY
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Thyroid Surgery Surgeons are usually concerned about GOITRES
“Any enlargement of the thyroid gland.”
Causes may be divided as follows:
! ! !
1. CONGENITAL 2. ACQUIRED • Simple • Toxic • Inflammatory!
!
1. Congenital
2 most common are:
1. Lingual thyroids • Residual tissues at the base of the tongue 2. Thyroglossal cysts • Remnant thyroid tissue • Midline, smooth and cystic mass that moves upwards on swallowing
2. Acquired
Smooth
Nodular
Simple
Simple goitre
Multinodular goitre
Toxic
Grave’s disease
Toxic multinodular goitre
Inflammatory
Acute suppurative DeQuervain’s Riedel’s Hashimoto’s
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1. Acute suppurative thyroditis • Staph/strep infection of the thyroid 2. DeQuervainʼs thyroiditis • Viral infection. non-suppurative 3. Riedelʼs thyroditis • Woody fibrosis and infiltration with scar tissue • Associated with retro-peritoneal fibrosis 4. Autoimmune/Hashimotoʼs thyroditis • Lymphatic infiltration of gland due to antibodies against thyroglobulin • Hyperthyroidism followed by hypothyroidism • Associated with LYMPHOMA
Thyroid Neoplasms
May be: • Benign - follicular adenoma • Malignant:
Occurrence
Age
Associations
Prognosis
Papillary
70%
Young
Multi-focal and poor response to radio-iodine surgery
OK
Follicular
15%
Older
Good response to radio-iodine
Excellent
Medullary
10%
Any
MEN Type II
Good if no nodes
Anaplastic
5%
Older
Aggressive Possible to shrink with radiotherapy
V. poor
! Investigations
Modalities
Tests + Findings
Cultures
-
Bloods - ABG
-
Bloods - Venous Imaging
Thyroid function (T4, TSH, thyroid auto-antibodies) All other bloods CXR (thoracic inlet view) Ultrasound (solid vs. cystic)
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Modalities Scopic/Biopsy
Functional/Special
Tests + Findings FNA & Tru-Cut Radio-isotope scan (hot vs. cold areas) Laryngoscopy pre-op (determine if laryngeal nerves involves) -
Thyroid Surgery
This is indicated for 3 reasons A. Problem goitres e.g. pressure symptoms B. Relapsing hyper-function C. Malignancy e.g. medullary The operation is a subtotal thyroidectomy and involves removing ⅞ of the gland via a collar incision.
Complications
GENERAL Specific - Immediate
Think in terms of ABCDE Haemorrhage (beware tension haematoma) Laryngeal oedema Nerve damage
Specific - Early
Hypocalcaemia
Specific - Late
Hypothyroidism Keloid scaring Recurrence
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Hernias A hernia may be defined as -
“Protrusion of a viscus and itʼs covering through a defect into an abnormal position.”
It essentially has 3 components: 1. Sac (neck, body and fundus) 2. Contents (bowel, omentum) 3. Defect
There are a number of important terms used to describe them: • • • •
REDUCIBLE - “sac may be returned to original cavity” IRREDUCIBLE - “sac unable to be returned to original cavity” OBSTRUCTED - “contains obstructed bowel” STRANGULATED - “contains bowel whose blood supply has become compromised.”
There are many types depending on location/defect e.g. inguinal (direct and indirect), femoral, incisional, umbilical/paraumbilical, epigastric, Spigelian, obturator, lumbar and parastomal
Inguinal Hernias The inguinal canal is the oblique passage taken through the abdominal wall by the testis/round ligament.
It is ~ 4cm in length and moves from: • INTERNAL/DEEP RING - pierces the transversalis fascia (1-2 cm above mid-inguinal point) • EXTERNAL/SUPERFICIAL RING - piereces external defect in external oblique aponerosis (just above pubic tubercle)
Relations: • ANTERIOR - muscle, superficial fascia and skin • POSTERIOR - transversalis fascia (lateral ½) and conjoint tendon (medial ½) • SUPERIOR - internal oblique and transversus abdominis © Podmedics 2010
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• INFERIOIR - inguinal ligament
In an inguinal hernia 1. SAC - peritoneum 2. CONTENTS - nothing, bowel, omentum, bladder 3. DEFECT • DIRECT INGUINAL HERNIA - posterior wall • INDIRECT INGUINAL HERNIA - along the canal! Epidemiology • Very common (R > L) • M:F = 9:1 • All ages at risk Risk factors 1. Congenital e.g. patent processus vaginalis 2. Acquired • Increased IAP e.g. obesity, chronic cough, straining • Weakness in wall e.g. previous incision
Clinical features
Symptoms: • In an emergency - pain +/- features of obstruction • History of lump • Dull dragging pain in the groin/scrotum Signs: • Is it reducible? • Can it be controlled by pressure over the internal ring?
Note: important differential for a lump in the groin: • • • • • •
Femoral hernia Lymphadenopathy Vascular e.g. saphena varix or femoral aneurysm Psoas abscess Undescended/ectopic testes Lipoma
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Investigation
This is not usually necessary. USS, MRI and herniography may be used
Management
Modalities CONSERVATIVE
MEDICAL SURGICAL
Specifics Decrease intra-abdominal pressure e.g. loose weight, treat cough, laxatives Rarely - hernial truss 1. Open 2. Laparoscopic In this operation you must 1. Define, inspect and excise the sac 2. Close defect and tension-free repair e.g. suture (herniorrhaphy), mest (hernioplasty)
Complications
GENERAL Specific - Immediate
Think in terms of ABCDE Bleeding Viscus perforation
Specific - Early
Infection Haematoma
Specific - Late
Recurrence Chronic groin pain Ischaemic orchitis
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Femora Hernia The important anatomy to be aware of here is that of the FEMORAL CANAL.
Important points here: • Canal is ~ 1.5 cm • Part of femoral sheath together with femoral artery and nerve • Boundaries: ANTERIOR: inguinal ligament POSTERIOR: pectineal ligament MEDIAL: lacunar ligament LATERAL: femoral vein
Femoral hernias are much more common in women (female pelvis) and are commonly acquired in old age. Importantly they like to obstruct.
Aetiology !
All are acquired (same risk factors as above)!
Clinical features Symptoms • Emergency - features of obstruction • Non-emergency - history of lump in the groin Femoral vs. Inguinal
Femoral: INFERIOR AND LATERAL TO PUBIC TUBERCLE Inguinal: MEDIAL AND SUPERIOR TO PUBIC TUBERCLE
Management
Modalities
Specifics
CONSERVATIVE
-
MEDICAL
-
SURGICAL
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Incisional Hernias ʻThis a hernia through a previously acquired defect.”
Risk factors for their development
1. PRE-OPERATIVE e.g. high pre-op risk factor profile 2. OPERATIVE e.g. sutures used, midline incisions, skill 3. POST-OPERATIVE e.g. increased IAP due to haematoma or prolonged ileus
Clinical features There will be a history of previous injury/procedure +/- complications. On examination look for • Scar • Mass protruding through the scar on cough/head tilt
Management
Modalities CONSERVATIVE MEDICAL SURGICAL
Specifics Reduce intra-abdominal pressure Corset Normal principles
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Umbilical/Para-umbilical
CONGENITAL
INFANTILE
ADULT
Defect
Abdominal wall
Incomplete fusion of umbilicus to abdominal wall
Linea alba
Types
Exomphalos Gastroschisis
Umbilical
Paraumbilical
Prematurity is biggest risk factor
Afro-Caribbean Downʼs syndrome Congenital hypothyroidism
Obesity Multiparity Middle age
Obvious at delivery
Asymptomatic Often self-resolve
Above/below umbilicus Frequenctly obstructs
Resuscitation Surgical repair
Reassurance Surgical repair if not closed by 3 years
Surgical repair (Mayo)
Epidemiology
Features Treatment
Rare Types of Hernia
Epigastric hernia • Pea-sized swelling caused by a defect in linea alba • ABOVE umbilicus • Treatment is surgical Spigelian hernia • Protrusion through linea semilunaris (rare cause of a mass in right lower quatrant) • Usually tender • Treatment is surgical. Obturator • Protrusion through obturator canal (felt in femoral canal or vagina) • Cause pain over the medial knee • Commonly obstructs Lumbar • Following loin incisions
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Vascular Surgery
Clinical Anatomy To understand and talk about vascular disease you need a passable knowledge of vascular anatomy. Here we will basically cover: 1. Venous drainage of the lower limb 2. Arterial supply to the lower limb
1. Venous drainage of the lower limb Blood drains from the lower limb in 2 systems: 1. 2. a. b. c.
DEEP SUPERFICIAL Great/long saphenous Small/short saphenous Tributaries
The long saphenous vein Pathway: • Dorsum of foot (venous arch) • Anterior to medial malleolus • Up medial calf and thigh • Drain into sapheno-femoral junction • Important peforators • 3 calf-perforators • 1 mid-thigh perforator (Hunterian)
The short saphenous vein Pathway: • Dorsum of foot • Posterior to malleolus • Up back of calf • Drain inconsistently into deep veins at politeal fossa
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The sapheno-femoral junction Landmark: 4cm lateral and below the pubic tubercle.
2. Arterial supply to the lower limb The basic arterial tree is shown below
abdominal aorta
L2 internal iliac external iliac 5cm distal to inguinal ligament common femoral
deep femoral superficial femoral
posterior tibial anterior tibial
lateral plantar dorsalis pedis
medial plantar
Anterior tibial artery → anterior compartment Peroneal artery → lateral compartment Posterior tibial artery → posterior 2 compartments
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Venous Disorders The basic conditions to cover here are: 1. Varcose veins 2. Lymphoedema
Varicose veins “Long, tortuous and dilated veins of the superficial venous system”
Most common site is LOWER LIMB (may also occur in abdominal wall, anus, vulva and pampiniform plexus)
Epidemiology • Very common • F>M Aetiology This may be divided into 3 sets of risk factors:
Specific Proximal venous obstruction
Destruction of valves Increased flow
Abdominal/pelvic malignancy Ascites Pregnancy Thrombosis Overactive muscle pump AV malformation e.g. Kippel-Trenaunay
The most common sites of incompetence are • • • •
Sapheno-femoral junction Mid-thigh perforators Sapheno-popliteal junction Calf perforators
Varicose veins must be described in terms of their distribution e.g. long saphenous, short saphenous, medial calf, mixed
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Clinical Features Patients most often complain about cosmetic problem. Some get mild pain and ankle swelling. Important skin changes most commonly occur in the GAITER REGION (lower medial ⅓ of leg) • • • •
Lipodermatosclerosis (induration and thickening) Eczema Haemosiderosis Ulceration
Investigations
Modalities
Tests + Findings
Cultures
-
Bloods - ABG
-
Bloods - Venous Imaging
Scopic/Biopsy Functional/Special
Pre-surgical set (FBC, U&E) Colour duplex scanning (shows valvular and perforator incompetence) Venography (obstructions) Ultrasound (demonstrates reflux into superficial veins) Cough test Tredelenburg/Tourniquet test
Management
Surgery is required for patients with sapheno-femoral incompetence or major perforator damage.
Modalities CONSERVATIVE
MEDICAL SURGICAL
Specifics Treat underlying cause e.g. relieve constipation, lose weight Graded support stockings Injection sclerotherapy (small veins as an outpatient) 1. Ligation operation (long saphenous → Trendelenburg procedure, short saphenous, perforators) 2. Stripping 3. Multiple avulsion 4. Endoscopic divison (SEPS)
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Complications of varicose vein surgery
Most are performed as DAY CASE SURGERY.
GENERAL Specific - Early Specific - Intermediate Specific - Late
Think in terms of ABCDE Haematoma Infection Nerve damage e.g. saphenous in stripping Recurrence
Lymphoedema This may be split into: !
PRIMARY (congenital < 1y, praecox < 35y, tarda > 35y)
!
SECONDARY • Previous surgery e.g. axillary clearance • Malignant obstructing disease • Radiotherapy • Infection (parasites/multiple previous episodes of cellulitis)
There is usually as history of limb swelling that is worse on standing. The oedema is NON-PITTING and usually unilateral. Consider primary type if bilateral. • Associated skin changes: secondary infection, fissuring, hyperkeratosis.
Aims of management are: a. Allow function • e.g. skin care, physiotherapy, prevention of infection b. Decrease swelling • e.g. compression, debulking operations, bypass operations !
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Arterial Disorders In this section we shall cover: 1. 2. 3. 4. 5. 6.
Limb ischaemia Carotid artery disease Aneursyms Aortic dissection AV fistulas Vasospastic conditions
Limb Ischaemia “A spectrum of ischaemic changes resulting from atherosclerotic process.”
These changes may lead to: 1. Narrowing → CHRONIC ISCHAEMIA 2. Thrombosis secondary to rupture → ACUTE ISCHAEMIA/ACUTE-ON-CHRONIC ISCHAEMIA
This changes are formally classified using the Fontaine Classification
Stage 2: Intermittent claudication
Symptoms:
STAGE
Symptoms
Stage 1
Asymptomatic
Stage 2
Intermittent claudication
Stage 3
Ischaemic rest pain
Stage 4
Ulceration/ gangrene
This is a muscular, cramp-like pain experienced on walking and relieved by rest. There also be rest pain at night that is relieved by walking or hanging the leg. Site • Calf (femoral disease) • Buttock (iliac disease) Signs: INSPECTION Signs
Loss of hair Pale, discoloured skin Muscle wasting Venous guttering ULCERS Necrotic toes Nail changes
Special Vascular angle/ Buergerʼs angle Buergerʼs test/venous filling time
PALPATION Temperature Capillary refill Pulses
AUSCULTATION Bruits in: - aorta - iliac - adductor canal
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Note: • Ulcers are typically described as “punched out with pale granulation tissue and an erythematous halo.” • Inspect all pressure areas (heel, malleoli, in between toes) • Dorsalis pedis is non-palpable in 10% people. • Walk test = treadmill for 5 mins and stop when maximal claudication. Mearure ABPI ( > 20% drop significant)
Investigations
Modalities Cultures Bloods - ABG Bloods - Venous Imaging
Scopic/Biopsy Functional/Special
Tests + Findings Urine dipstick (renal disease) FBC (baseline), U&Es (renal function), clotting, lipids, G&S Dopplex (triphasic vs. biphasic vs. monophasic) ABPI MRA / spiral CT Angiography (advance guide wire to aorta then inject to visualise arterial tree) - look for 1. Level of blockage 2. Collateral blood supply ECG
Management Modalities CONSERVATIVE MEDICAL SURGICAL
Specifics Treat underlying risk factors Aspirin 75mg O.D. (clopiodgrel if contra-indicated) 1. ENDOVASCULAR e.g. PTA - best for iliac and superficial femorals, stents and PTFE/Dacron grafts 2. BYPASS SURGERY (autologous veins below inguinal ligament or synthetic above) Types 1. Anatomical e.g. fem-pop 2. Extra-anatomical e.g. axiloofemoral 3. Endarterectomy 4. Amputation 5. Sympathectomy (chronic pain in small vessel disease)
Amputations is indicated for 1. Lethal limb (ischaemia, tumour) 2. Dead limb (PVD, extensive loss) 3. Useless limb (fixed flexion deformity, vestigial fingers) © Podmedics 2010
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Acute Limb Ischaemic This is a SURGICAL EMERGENCY
Aetiology • Thrombosis 60% e.g. previously stenosed vessel • Embolism 30% e.g. from LA thrombus, air, cholesterol • Others e.g. trauma, vasospastic disorders, aortic dissection, popliteal aneurysm It is important to tell the difference between thrombosis and embolism
Thrombotic
Embolic
Hx of claudication/rest pain
Recent MI, atrial fibrillation, aneurysm
Onset over hours
Onset over seconds
Signs of chronic vascular insufficiency
No evidence of previous disease
Hard arteries. No bruits
Soft artery. Bruits
Clinical features The 6 Pʼs
1. 2. 3. 4. 5. 6.
Pallor (marble white → mottled with branching → mottled and non-blanching → fixed staining) Pain Pulselessness Perishing with cold Paraesthesia (severe sign) Paralysis (severe sign)
Management
First...Resuscitate the patient
Modalities CONSERVATIVE
Specifics Analgesia Fluids NBM © Podmedics 2010
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Modalities MEDICAL
SURGICAL
Specifics Antibiotics Heparinisation Thrombolysis (tPA or streptkinase) 1. Endovascular e.g. angioplasty, stenting, embolectomy 2. Emergency reconstruction + fasciotomy 3. Amputation
The precise first line guidelines depend on whether the event is EMBOLIC or THROMBOTIC.
1. Thrombotic • Thrombolysis 2. Embolic
• Embolectomy with Fogarty catheter • Then..thrombolysis (in unsuccessful)!
Post-operative care
All patients require heparin for 48 hours then long-term anticoagulation.
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Carotid Artery Disease Patients with significant carotid stenosis are at increased risk of
1) Stroke - “Sudden neurological deficit of vascular origin > 24h.” ! 2) Transient Ischaemic Attack (TIA) - “Sudden neurological deficit of vascular origin < 24h.”
Clinical Features Most are asymptomatic and picked up on cardiovascular examination (bruit or thrill) If they do present with a neurological event it will be of the ANTERIOR CIRCULATION (unilateral weakness, dysphasia/dysarthria, visual defects)
Investigations • Duplex doppler scan is most important Others - intravenous/arterial DSA, MRA
Management • Based upon trial data from NASCET and ECST.
Modalities
Specifics
CONSERVATIVE
Control risk factors for all patients
MEDICAL
Aspirin (clopidogrel) for all patients
SURGICAL
ENDARTERECTOMY if stenosis > 70% Transluminal angioplasty is alternative
Note • Risk of stroke with stenosis > 70% = 5% per year • Never operate if < 30% stenosis
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Aneurysmal Disease “An aneurysm is an abnormal dilatation of a blood vessel.”
It may be classfied as: a. TRUE aneurysm - involves ALL layers and > 50% diameter. b. FALSE aneurysm - dilated blood vessel representing a haematoma around an area of damage. c. DISSECTING aneurysm - blood tracking into layers of vessel wall.
Process CONGENITAL ACQUIRED
Examples
-
Berry aneurysms in Circle of Willis
Degenerative
Atheroscerotic (infrarenal AAA)
Infective
Syphilis (thoracic)
Mycotic
Bacterial endocarditis
Inflammatory Traumatic
Trauma
Connective tissue disease
Ehlers-Danlos Marfanʼs Pseudoxanthoma elasticum
Specific types covered here include 1. AAA 2. Others e.g. thoracic, popliteal, femoral 3. Dissecting aneurysms
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Abdominal aortic aneurysms These are the most common type of aneurysms and occur just below the renal arteries. Epidemiology • Elderly • Male > female Clinical features Symptoms: • 75% are asymptomatic • Patients may complain of • Bloating • Pulse/mass in abdomen • Emergency presentation • Epigastri/umbilical pain radiating to the back, flank or into the groin • Acute limb ischaemia • “Blue-toe syndome” • Aortointestinal fistula Signs: This obviously depends on the situation General: patient may have known vasculopathy. Present hypotensive and shocked Specific • Abdominal tenderness • Left midline expansile and pulsatile mass • Bruits over aneurysm Investigations
Modalities
Tests + Findings
Cultures Bloods - ABG Bloods - Venous Imaging
Scopic/Biopsy Functional/Special
If unwell If unwell: EMERGENCY e.g. FBC, U&Es, clotting, LFTs, CXM - 10 units CT scan/MRI Ultrasound Plain abdominal xray (poor but may be signs of calcification) Arteriography may be used to describe relations of vessel ECG © Podmedics 2010
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Management
Obviously in the case of rupture this is an EMERGENCY with a very poor survival. Aim to keep systolic less than 80 mmHg
Modalities CONSERVATIVE MEDICAL SURGICAL
Specifics < 5cm should have serial ultrasounds/CT Treat co-exisiting risk factors This may be either to PREVENT complications or deal with rupture 1. Conventional grafts (aorta clamped above and below then disease portion replaced with dacron graft). Mortality ~ 5% 2. Endovascular repair (EVAR) - endoprosthesis introduce through a femoral arteriotomy
Guideline for surgery based upon ʻUK small aneurysm trialʼ. Indications include 1. Symptomatic 2. Asymptomatic • > 5.5cm in diameter • Expanding > 1cm per year • Complicated e.g. emboli
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Aortic Dissection “Split of the intima and internal media such that blood is able to enter and track up and down the vessel wall.”
Leading to 1. Double lumen formation that may occlude vital branches e.g. coronaries, carotids, renal 2. Haemorrhage 3. Undermining of attachments e.g. aortic valve → aortic incompetence
Classification There are 2 types:! ! ! !
Type A (70%): ascending aorta and arch Type B (30%): discending aorta affected distal to left subclavian
Clinical features Symptoms • Sudden severe chest pain that is tearing in nature and radiaed to back • Features of hypotension due to haemorhage • Features of other vessel involvement e.g. hemiplegia (carotids), paraplegia (spinal arteries), renal (anuria and haematuria) Signs • General: shocked patient • Specific: differening BP between each arm Investigations
Modalities
Tests + Findings
Cultures Bloods - ABG Bloods - Venous Imaging
If unwell If unwell: EMERGENCY e.g. FBC, U&Es, clotting, LFTs, CXM - 10 units CXR (mediastinal widening + L. pleural effusion) Echo (aortic regurgitation) CT scan - investigation of choice but patient must be stable
Scopic/Biopsy Functional/Special
ECG (signs of infarct)
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Management
This is a SURGICAL EMERGENCY and the patient may very well require resuscitation.
Ultimately management will depend on the type of dissection:
!
Type A: require surgical management e.g. replacement of aortic root.
! Type B: Conservative treatment e.g. β-blockers to prevent further extension. + revascularisation of secondary ischeamia
Other types of aneurysm
Locations
Presentation
Treatment
Ascending thoracic aorta 1. 2. 3. 4. Arch of aorta
Classically caused by syphilis - now atherosclerosis and Marfansʼs 1. 2. 3. 4.
Descending thoracic aorta
Chest pain SVC obstruction Aortic regurgitation Obstruction to R main bronchus
Hoarse voice Compression of trachea Ulceration into trachea Compression of L bronchus
1. Back pain 2. Compression of oesophagus 3. Erosion into oesophagus
Popliteal
ACUTE LIMB ISCHAEMIA
Femoral
ACUTEL LIMB ISCHAEMIA
Saphenous vein bypasss graft
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AV fistulae “An abnormal connection between the arterial and the venous system.” They may be either large (macrofistulae) or small (microfistulae)
Aetiology 1. Congenital - rare • Localised e.g. in head and neck • Multiple e.g. Kippel-Trenaunay syndrome 2.
Acquired • Trauma • Renal fistula
Clinical features/Investigations
1. Superficial • These are palpable as soft, pulsatile swelling that have a machinery bruit on auscultation. 2. Deep • Detected on CT/angiography.
Management
Modalities CONSERVATIVE
Specifics Left to resolve spontaneously
MEDICAL SURGICAL
Embolisation Occlusion of feeding vessel and excison
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Vasospastic disorders “A group of conditions that affect the small arteries of the distal extremities.”
1. Raynaudʼs disease - idiopathic disease and normal arterioles. A bilateral process (usually of women) that involves episodes of vasospasm leading to colour changes in the digits 1. Digital pallor (vasoconstriction) 2. Cyanosis (arterioles have relaxed but no venules) 3. Reactive hyperaemia (complete reversal)
2. Raynaudʼs phenomenon - underlying disease of the arterioles. Associated with • • • • •
Vibrating tools Connective tissue disease (SLE, RA, scleroderma) Haematological conditions - polycythaemia, cryoglobulinaemia Cervical rib Drugs e.g. beta blockers and ergot alkaloids
Management
Modalities CONSERVATIVE
MEDICAL SURGICAL
Specifics Remove cause Heated gloves/socks Avoidance of cold Nifedipine 5HT antagonists Sympathectomy (symptoms usually return within 6 months)
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Orthopaedics
Basic Fractures Definition and Classifications
“A fracture is a break in the continuity of the bone.”
Further classified as: 1. Simple fracture - skin is intact 2. Open/compound fracture - skin broken with bone out 3. Complicated fracture - neurovascular compromise
When talking about a fracture talk about:
1. FRACTURE LINE e.g. transverse, oblique, spiral, crush, comminuted, greenstick, avulsion
2. SHIFT or DISPLACEMENT e.g. lateral, medial 3. TILT or ANGULATION e.g. degree of lateral or medial 4. TWIST or ROATIONS
Fracture Aetiology There are 3 important mechanisms 1. Trauma (direct, indirect, avulsion) 2. Stress e.g. continual pressure on 1 area 3. Pathological i.e. low energy that normal would not fracture bone. Indicated underlying pathology e.g. osteoporosis, malignancy
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Clinical Features
These are fairly obvious but it is important to always do a NEURO-VASCULAR examination.
Investigations Most of the time this is an X-ray. But… • Obtain 2 views (lateral and AP) • Joint above and below If pathological fracture or scaphoid you may need CT or bone scan.
Management First… RESUSCITATE THE PATIENT (see ATLS chapter)
1. REDUCE
Alignment is more important than opposition 1. Manipulation e.g. Collesʼ 2. Traction (skin or skeletal) 3. Open (if intra-articular or complicated)
2. FIX
CONSERVATIVE e.g. slings/plaster/collar&cuff SURGICAL 1. Internal fixation 2. External fixation
3. WAIT FOR UNION
This depends on good bone healing 1. 2. 3. 4. 5.
4. REHABILITATE
Haematoma formation Organisation of haematoma and fibroblastic infiltration Callus formation Consolidation of lamellar bone Remodeling
Basically involves graded-exercise therapy and physio.
Rules of thumb for bone healing Upper limb: 6-8 weeks Lower limb: 12 weeks Children: ½ the time
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Complication of fractures
GENERAL
Specific - Immediate
Specific - Early
Blood loss Fat embolus Visceral damage e.g. rib fractures Nerve damage Vascular damage Infection Compartment syndrome - always suspect with pain on passive stretching or if poor perfusion Rx - remove bandaging or fasciotomy If not treated may result in Volkmannʼs ischaemic contracture
Specific - Late
Joint stiffness and later osteo-arthritis Problems with union e.g. mal-union, delayed union, non-union Avascular necrosis e.g. NOF, scaphoid, talus Reflex sympathetic dystrophy/Sudekʼs atrophy Myositis ossificans (elbow)
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The Hip SI joint
Iliac crest
ASIS Superior pubic rami
Obturator foramen
Pubic tubercle
Inferior pubic rami Pubic symphysis
Greater trochanter
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Type
Muscles
FLEXORS
Psoas major Rectus femoris Sartorius Pectineus
EXTENSORS
Gluteus maximus Hamstrings
ABDUCTORS
Gluteus medius Gluteus minimus
ADDUCTORS
Adductor longus Adductor brevis Adductor magnus
LATERAL ROTATORS
Gluteus maximus assisted by obturators
MEDIAL ROTATORS
Anterior fibres of gluteus medius and minimus
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Fractured Neck of Femur Very common fracture - particularly in elderly, osteoporotic individuals. Mortality is approx. 30% in 6 months following a fracture.
Classification These may be 1. INTRACAPSULAR • Subcapital • Trans-cervical 1. EXTRACAPSULAR • Basicervical • Inter-trochanteric • Sub-trochanteric
The intracapsular fractures are then further classified using GARDENʼS CLASSIFICATION
I
II
III
IV
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Clinical features
Symptoms • Hip pain • Unable to weight bear Signs • Shortened (pulled up by ileo-psoas) • Externally rotated (gluteus maximus) Remember to consider cause and effect of the fall • Cause e.g. UTI, pneumonia, MI, arrhythmias • Effects e.g. aspiration, dehydration, head injury
Investigations
Modalities
Tests + Findings
Cultures
-
Bloods - ABG
-
Bloods - Venous
Imaging
Scopic/Biopsy Functional/Special
FBC (infection) U&E (electrolytes disturbance, dehydration) G&S/CXM - 2 units AP pelvic xray + lateral of affected side CXR (cause) ECG (signs of infarct)
Management
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Modalities CONSERVATIVE
Specifics Analgesia (consider 5lb skin traction) Fluids NBM Post-operative - physiotherapy + OT assessment
MEDICAL SURGICAL
Treat cause 1. INTRACAPSULAR “I, II - screw, III, IV - Austin-Moore” I/II - Cannulated screw or dynamic III/IV - Hemiarthroplasty (Austin-Moore - uncemented, Thompson cemented) 2. EXTRACAPSULAR Dynamic hip screw
Complications
GENERAL Specific - Early Specific - Intermediate Specific - Late
Think in terms of ABCDE Deep vein thrombosis Infection Avascular necrosis Mal-union Acetabular wear from hemiarthroplasty (so THR if severe OA)
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Important other fractures for finals Fractures at the Wrist
1. Collesʼ fracture • Fracture of distal radius with shortening, dorsal displacement and angulation of the distal fragment. • M.O.A. - fall on outstreched hand • Rx: • Closed reduction followed by immobilisation in forearm cast for 6 weeks • Check position with XRay 1 week after.
2. Smithʼs fracture • Fracture of distal radius with shortening, anterior displacement and angulation of the distal fragment • Rx • Try closed reduction • Often requires open reduction and fixation with a butress plate.
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3 uncommen intra-articular fractures are: • Bartonʼs fracture: fracture subluxation of the distal radius • Galeazzi fracture: distal radial fracture + dislocation of the radio-ulnar joint • Monteggia fracture: proximal ulnar fracture with dislocattion of the radial head
3. Scaphoid fracture • Fracture of scaphoid bone • M.O.A. - fall on outstretched hand • Clinical features: Pain and swelling in the wrist + tenderness in the anatomical snuffbox/telescoping of the tumb. • Most important complication: avascular necrosis of proximal portion • Investigations: AP and lateral X-rays of wrist. Diagnosis often uncertain ∴ repeat after 10 days. • Rx • Immobilise in scaphoid plaster (if displaced/non-union internal fixation with a Herbet screw)
4. Bennettʼs fracture • Intra-articular fracture dislocation of the first metacarpal bone • Very common thumb injury • Rx • Usually requires fixation with K-wire/screw
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Upper limb fractures/dislocations
1. Shoulder dislocation • Most common is an anterior and inferior dislocation. • Posterior dislocations in association with epileptic fit/electric shock • Clinical features of pain and decreased movement, together with a loss of deltoid contour and the arm being held internally rotated and abducted • Most important complications - axillary nerve damage • Investigation: AP and axial (Y-view) X-rays • Treatment • Reduction e.g. modified Kocherʼs method • Immobilize with broad sling
2. Proximal humeral fracture • Often occurs in elderly • M.O.A - RTA, fall from standing height • Treatment is usually CONSERVATIVE - collar-and-cuff + physiotherapy • If comminuted then needs ORIF
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Lower limb fractures
Tibial Plateau Fracture • Often complex fractures caused by high-impact injuries • May be classified using the Schatzker system (Type I-IV) • Requires ORIF due to possible articular consequences
Tibial Fracture
• High energy fractures that are associated with large amounts of soft tissue injury. • The most important complications are: • COMPARTMENT SYNDROME • Common peroneal injury (proximal)! • Test sensation to first toe web space and dorsiflexion movement of the great toe.
• Treatment is with: • Plaster • Intramedullary nail • External fixation e.g. Ilizarov frame
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The Knee The structures that are most often affected by pathology in the knee are: • • • •
BONES e.g. arthritis! KNEE CAP e.g. recurrent dislocation MENISCI e.g. meniscal injuries CRUCIATE LIGAMENTS e.g. ACL and PCL injuries
Osteoarthritis of the Knee Epidemiology • Very common • Older people • May be related to trauma Clinical features
Symptoms: • Pain, stiffness and swelling made worse by use of the joint. ʻJoint locking + painful give-wayʼ due to loose bodies. Signs • LOOK: varus/valgus deformity, swelling • FEEL: effusion, tenderness over joint lines, crepitus • MOVE: movement-fixed flexion deformity Management
Modalities CONSERVATIVE
MEDICAL SURGICAL
Specifics Weight loss Analgesia Walking stick + foam heel wedges Physiotherapy Variety of procedures possible 1. Arthroscopy (determine extent + wash-out - may provide up to 1 year of relief) 2. Osteotomy (particularly good for younger patients where medial only side is affected - last 8-10 years) 3. Total knee replacement
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Recurrent patellar dislocations Patella is a mobile sesamoid bone within the quadriceps tendon
There are 2 types: 1.! Full dislocation: always lateral following direct trauma to medial side. Knee locked in 30-40 degree flexion + pain + swelling 2.!
Subluxation: patella felt to ʻpopʼ out turning. Momentary pain and swelling 24h later
Important to due a SKYLINE x-ray to reveal a OSTEOCHONDRAL fracture.
Meniscal injuries These occur when the meniscus becomes ʻtrapped between joint surfaces.ʼ
The distribution is: • Medial meniscus 70% (less mobile than lateral) • Lateral meniscus 25% • Both 5% Clinical features Symptoms: • History of twisting injury • Pop/click or tearing sensation • Swelling Signs • LOOK: swelling, wasted quadriceps • FEEL: effusion, tenderness at joint line • MOVE: springy feel in a locked knee. McMurrayʼs test Management Modalities CONSERVATIVE MEDICAL SURGICAL
Specifics Analgesia/anti-inflammatories (creams etc) Physiotherapy Indicated for failure of conservative 1. Arthroscopy (diagnostic and therapeutic to excise the tear) © Podmedics 2010
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Cruciate Ligament Injury 1. ACL Injury
Common. Occur following twisting and valgus strain e.g. men - football, women - skiing. • There is often co-existant damage to medial collateral ligament and medial meniscus Clinical features • Only diagnoses 70% Management
Modalities CONSERVATIVE MEDICAL SURGICAL
Specifics Intensive rehabilitation Brace Arthroscopy (diagnosis and reconstruction) 1. Extra-articular strengthening - strength lateral side of knee with fascia 2. Intra-articular strengthening - ACL replaced with variety of materials e.g. bovine collagen, autologous patellar
2. PCL Injury
Not common. Usually occurs in RTA when tibia is forced posteriorly on femoral condyles.
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Neurosurgery In this section we shall be looking at: a. Spinal cord compression b. Neurological tumours c. Hydrocephalus For information on intracranial bleeds please see trauma section
Clinical Anatomy
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Spinal Cord Compression THIS IS A MEDICAL EMERGENCY “Compression of the spinal cord”
Clinical features Structure Symptoms
Vertebral body
Malignancy (primary/secondary) Osteoporosis Abscess e.g. Pottʼs
Vertebral disc
Acute intervertebral disc rupture Chronic degenerative disease
Spinal cord
Tumour
Blood vessels
Haematoma (e.g. warfarin therapy)
• Sudden onset back pain • Neurological phenomena: 1. Leg weakness 2. Sensory loss 3. Painless urinary retention
Pathology
Signs This will usually be an upper motor neurone pattern. • • • •
Increased tone Weakness in a pyramidal distribution Hyper-reflexia Up-going plantars
+ a SENSORY LEVEL. Note: with sudden onset spinal compression there may be spinal shock (LMN pattern)
Investigations
Modalities Cultures Bloods - ABG Bloods - Venous Imaging
Tests + Findings Urine dipstick (? BJP) FBC (anaemia), U&Es, clotting (coagulopathy), Calcium (malignancy) MRI (to look at presence/degree of spinal compression) CT for bone injuries
Scopic/Biopsy
-
Functional/Special
-
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Management
The management depends on the cause. The key is EARLY INTERVENTION - this offers the best chance of recovery.
Modalities CONSERVATIVE
MEDICAL SURGICAL
Specifics Neurological observations Analgesia Fluids NBM if for surgery Metastases - steroids, bisphosphonates, radiotherapy Abscess - antibiotics 1. Disc prolapse - decompression 2. Abscess - drainage 3. Metastases - surgical decompression
Cauda Equina Syndrome This is a particular form of compression where the problem is with the cauda equina. As the cauda equina is made up of nerves that have come from the spinal cord the signs may be different: • LMN signs e.g. weakness with absent reflexes • Bladder and bowel dysfunction Treatment is as for above.
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Neurological Tumours There are lots of different tumours that affect the brain and spinal cord. They are rare but may be divided into: 1. PRIMARY • Benign • Malignant 2. SECONDARY (most common)
Table of the most common tumours and their features
Origin Glioma
Primary from glial cells 1. 2. 3. 4.
Meningioma
Characteristics
Surgery where possible
Astrocytomas Medulloblastomas Ependymomas Oligodendromas
Primary from arachnoid cells
Treatment
Palliation
Benign and slow growing
Surgery where possible Palliation
Acoustic Neuroma
Primary from schwann cells of CN VIII. Note: usually unilateral. Bilateral if with NF
Pituitary Tumours
Adenomas
Press on
Surgery but risk of nerve damage.
1. 8th nerve (deafness) 2. 5th/7th nerve (facial numbness and weakness) 1. Endocrine abnormalities e.g. hypopituitarism, Cushingʼs syndrome
Medical hormonal manipulation Surgical - removal
2. Visual abnormalities e.g. biltemporal hemianopia Lymphoma
B cell T cell
Association with AIDS
Radiotherapy Poor survival
Metastases
Breast, lung, kidney and malignant melanoma
V. common
Palliative e.g. steroids
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Hydrocephalus “Raised CSF pressure within the ventricular system that is characterised by dilated cerebral ventricles.”
Note: the intraventricular pressure may either be NORMAL or RAISED
Types: 1.
Communicating hydrocephalus • Obstruction within subarachnoid space → dilatation in entire system • e.g. meningitis, subarachnoid haemorrhage, congenital abnormality in arachnoid villi.
2.
Non-communicating hydrocephalus • Obstruction within the ventricular system • E.g. aqueduct stenosis, intraventricular tumours.
Acute hydrocephalus present with features of a raised ICP e.g. headache, visual disturbance Signs would be • Loss of physiological cupping • Blurring of disc margins • Engorged pulsatile veins Chronic hydrocephalus present with characteristic features • • • •
Enlarging head circumference Sun-set eyes Tense fontanelle Cranial nerve palsies
Investigation The most important study here is MRI
Management
Established hydrocephalus required drainage. This may be 1. Temporary e.g. to an extraventricular dran 2. Permanent e.g. peritoneum, right atrium, pleural cavity
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Urology
Clinical Anatomy The Kidney • These are retroperitoneal organs • Contains a hilum into which goes the renal artery, renal vein, pelvis of ureter, nerves and lymphatics. • Contains adrenal glands on superior aspect. • Structure: 1. Pelvis 2. Major calyces 3. Minor calyces (collecting ducts discharge here) Blood supply • Renal artery from aorta • Renal vein into IVC • Para-aortic lymph nodes The Ureter • 25 cm in length and split into 3 parts: 1. Abdominal 2. Pelvic 3. Intravesical Blood supply: • Segmental blood supply from all arteries along itʼs course There are 3 important sites of narrowing 1. Pelvis of kidney (PUJ) 2. Pelvic brim 3. Ureteric orifice (VUJ)
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The testicles/scotum
Common presentations Renal tract stones Also known as nephrolithiasis/renal calculi
Epidemiology • Very common to see • Any age • M:F = 2:1 Aetiology
Can form anywhere in the system (kidney to urethra) Aetiology can be linked to 3 basic factors:
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1. Increased solute concentration
Hypercalcaemia Hyperoxaluria (tea, spinach, rhubarb) Hyperuricaemia Cystinuria Thiazides decreasing calcium excretion
2. Increased urine concentration
Dehydration Increased dietary protein Diuretics
3. Stasis
UTIs Congenital tract abnormalities e.g. pelvic-ureteric junction obstruction/ horse-shoe kidney
Types of stone
1. 2. 3. 4. 5.
Calcium oxalate (75%) - spikey and radio-opaque [metabolic/idiopathic] Triple phosphate (17%) - large, radio-opaque may form staghorn calculus [proteus UTIs] Uric acid (5%) - smooth, brown, radio-lucent [hyperuricaemia] Hydroxyapatite (1%) Cysteine (1%) - yellow, crystalline, semi-opaqe [renal tubular defects, cystinuria]
Clinical Features
NOTE: a febrile patient with renal obstructed is a SURGICAL EMERGENCY
Symptoms: • Asymptomatic • Ureteric colic: severe pain from loin to groin • Associated with pyrexia, vomiting, rigors +/- blood in urine • Features of infection: polyuria, dysuria Signs: • General: moving around on the bed, febrile, • Specific: loin tenderness is a feature of infection above the stone
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Investigations
Modalities Cultures Bloods - ABG Bloods - Venous
Imaging
Tests + Findings Urine: MC & S, dipstick (haematuria, infection), 24h collection for ions FBC (leucocystosis) U&Es (dehydration) Specific levels of Ca2+, Mg2+, urate, phoshate Plain KUB (85% are radio-opaque) IVU (control, immediate, 20 min
Scopic/Biopsy
-
Functional/Special
-
Management Definitive management will depend on the size of the stone • If stone < 5mm in lower ⅓ then will pass - send pt. home • If stone > 5mm - operative intervention
Modalities CONSERVATIVE
MEDICAL INTERVENTIONAL
Specifics Analgesia (e.g. diclofenac/pethidine/morphine) Encourage oral intake/I.V. fluids Home if pain resolved and stone < 5mm If infection - cefuroxime and metronidazole If stone > 5mm or pain not resolved 1. Kidney - ESWL, percutaneous nephrolithotomy, open removal 2. Ureter - Ureteroscopic removal, ultrasound/laser 3. Bladder - lithotripsy or open
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Haematuria “The passage of blood in the urine.”
2 types: • Microscopic • Macroscopic
Or may be divided according to aetiology:
1. FALSE e.g. beetroot, rifampicin, porphyria, PV/PR bleed
2. TRUE 1. General • Coagulopathy, HSP, anticoagulants 2. Kidney • Stones, tumours, infections 3. Ureter • Stones, tumours, infections 4. Bladder • Stones, tumours, infections 5. Prostate • Stones, tumours, BPH 6. Urethra • Stones, tumours, infections, trauma
Clinical features It is important to determine the following in the history 1. 2. 3. 4. 5.
Timing (beginning, end or throughout) Painful vs. painful Clots? Other obstructive symptoms Drug history and clotting defects
Investigations
Modalities Cultures Bloods - ABG
Tests + Findings Urine: MC & S, dipstick, urine cytology -
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Modalities Bloods - Venous
Imaging Scopic/Biopsy Functional/Special
Tests + Findings FBC (leucocytosis) U&Es (renal function) Clotting (? coagulopathy) IVU Renal USS Flexible cystoscopy and biopsy CT scan -
Management
• Treat the cause
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Acute Urinary Retention This is a common - particularly in the post-operative setting.
The aetiology may be:
IN THE LUMEN
1. ACUTE 2. CHRONIC 3. Acute-on chronic
IN THE WALL
Clinical Features OUTSIDE THE WALL Symptoms: • Progressive reduction in ability to pass water • Suprapubic pain
SYSTEMIC
Stones Cots (with clot retention) Tumours (bladder, prostate, urethra) Infection Trauma Constipation Fibroids Cauda equina syndrome Drugs (e.g. EtOH, anticholinergics)
Signs: • General: patient agitated and in pain • Specific: Palpable bladder that may extend up to umbilicus • Always do a PR for constipation, prostate and rectal tone • Neurological examination as well.
Investigations
Modalities Cultures Bloods - ABG Bloods - Venous
Imaging Scopic/Biopsy Functional/Special
Tests + Findings Urine MC & S, dipstick If unwell FBC (leukocytosis) U&E (renal function) G&S PSA CXR & KUB (? stones) USS (residual volume, size of bladder and hydronephrosis) ECG
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Management
Modalities CONSERVATIVE
MEDICAL INTERVENTIONAL
Specifics Mobilise + run tap Treat underlying cause IV fluids for secondary diuresis Catheterise (+ shot of gentamicin) TWOC only > 24 hrs 1. Suprapubic catheter 2. Emergency TURP
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Kidney and Bladder Topics covered here 1. Renal transplantation 2. Renal cell carcinoma 3. Bladder carcinoma
Renal Transplantation Kidneys may be obtained from: 1. Live related donor 2. Cadaveric donor (brainstem death or non-heart beating donor)
The most important indication is END STAGE RENAL FAILURE (GFR < 10ml/min).
Suitable candidates should be • • • • •
Young Fit for anaesthesia Suitable anatomy Compliant with post-op immunosuppression Suitable anatomy
Recipient
Donor
Normal pre-op
Normal pre-op
Specific bloods - ABO screen, HLA matching (A, B, DR), cross-match with donor lymphocytes
Specific bloods - ABO screen, HLA matching (A, B, DR), cross-match Infectious screen - HIV, CMV, HTLV-1, hepatitis, syphilis
Imaging - USS, KUB,
Imaging - IVU, USS, MRA
Procedure The operation occurs in 2 parts. 1. Remove donor kindey 2. Anatastomosis in recipient with: • Renal vein → external iliac vein • Renal artery → external iliac artery Note: may be palpated in the abdomen. © Podmedics 2010
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There will be 2 scars: 1. Loin scar for a nephrectomy 2. Rutherford-Morrison incision for anastamosis
Post-operatively • Immunosupression using steroids, azothioprine and cyclosporine.
GENERAL
Think in terms of ABCDE
Specific - Immediate
Hyperacute rejection
Specific - Early
Accelerated rejection
Specific - Late
Acute rejection - “flu-like symptoms and graft tenderness.” Chronic rejection Tumours (skin cancers/lymphomas) Complications of immunosuppressive treatment (steroids, infection and malignancy) UTIʼs
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Renal Tumours Renal tumours may be: a. BENIGN (e.g. cysts) b. MALIGNANT
Epidemiology • They are uncommon • Present late middle age • M>F = 2:1 Aetiology • Carcinogens → TCC • Stones → SCC • Hypernephroma in Von Hippel-Lindau Syndrome
LOCATION PELVIS
TYPES
CHARACTERISTICS
Transitional cell carcinoma
Associated with carcinogens Highly malignant
Squamous cell carcinoma
Associated with chronic stones
Papilloma KIDNEY
Hypernephroma (Grawitz tumour)
Most common types (80%) Adenocarcinoma Large & aggressive
Nephroblastoma (Wilmʼs tumour)
Large tumours in children
Clinical features
Symptoms: • General: weight loss, PUO • Specific • Microscopic haematuria • Rarely - loin pain, loin mass and haematuria • Metastatic symptoms Signs: • General: anaemia • Specific • Mass in loin © Podmedics 2010
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• • • •
Varicocele (tumour spreads along renal vein obstructing left testicular vein) Hypertension Polycythaemia Hypercalcaemia
Investigations
Modalities Cultures Bloods - ABG Bloods - Venous
Imaging
Scopic/Biopsy Functional/Special
Tests + Findings Urine dipstick (haematuria) If unwell FBC (anaemia of chronic disease, polycythaemia) U&Es (renal function) LFTs (mets) Ca2+ Clotting CXR (mets - cannonball) IVU (filling defect, hydronephrosis, renal mass) Renal USS (demonstrate mass and look at IVC) CT (staging) ECG
Management
Modalities CONSERVATIVE MEDICAL INTERVENTIONAL
Specifics Palliation with radiotherapy and chemotherapy Radio/chemo are never curative 2 operations 1. Nephro-uretectomy (TCC - removal of entire 1 side, one scar in loin and second in groin) 2. Nephrectomy (other tumours - may require chest apporach!)
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Bladder Carcinoma Epidemiology • Common in middle aged and elderly • M:F = 4:1 Aetiology Important predisposing factors are smoking, dye exposure and chronic irritation say with schistosomiasis.
Pathology 1. 2. 3. 4.
Transitional cell carcinoma (90%) - solid or papillary Squamous (7%) - associated with chronic irritation Adenocarcinoma (2%) Sarcoma
There is a detailed staging system that it is not necessary to know - most are pT1 (invasion of sub-epithelial tussie) or pT2 (involvement of superficial muscle) They may also be classified according to differentiation eg. G1 (well), G2 (intermediate), G3 (poor)
Clinical features
Symptoms: • General: Weight loss, anorexia • Specific • Painless haematuria • Urinary retention (clots or bladder neck obstruction) • Uraemic symptoms Signs: Usually there are NONE. • General: anaemia • Specific: • Bladder mass • Lymphadenopathy • Features of metastases e.g. papable liver, abnormal chest examination
Management This depends on the stage 1. Trans Urethral Resection of Bladder Tumour (TURBT) - Tis, T1, T2 • Adjuvants - Intravesical chemotherapy, immunotherapy using Montreal strain of BCG 2. Cystectomy with re-implantation of ureters through an ileal conduits • Adjuvants - Radiotherapy © Podmedics 2010
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Prostate Disease In this section we shall talk about 1. Prostatitis 2. Benign Prostatic Hyperplasia 3. Carcinoma of the prostate
Prostatitis “Infection and inflammation of the prostate.”
May be ACUTE or CHRONIC
Most common organisms are • Strep. feacalis • E. coli • Chlamydia
Clinical features Symptoms: • General: malaise, fever/rigors • Specific • Pain (prostadynia) • Haetospermia • Retention • Features of urinary tract infection e.g. dysuria, discharge Signs • General: pyrexia • Specific • Tender prostate on PR • Tender testicles in epididymo-orchitis Investigation as you might expect e.g. FBC, CRP and MSU
Definitive treatment is antibiotics e.g. ciprofloxacin
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Benign Prostatic Hyperplasia (BPH)# “Benign and profuse nodular proliferation of the musculofibrous and glandular layers of the prostate”
Epidemiology • Very common and get worse with advancing years Aetiology
There are 2 theories behind itʼs development a. HORMONE THEORY - reduced testosterone and proportional increase in oestrogen → hyperplasia b. NEOPLASTIC THEORY - benign neoplastic enlargement
Clinical features
Symptoms: • Obstructive symptoms e.g. poor stream, hesitancy, post micturation dribbling • Symptoms due to bladder retention e.g. frequency, nocturia, overflow incontinence, infection, stones Signs: • Smoothly enlarged prostate with definable median sulcus. Invesigations
Modalities Cultures Bloods - ABG Bloods - Venous
Imaging
Scopic/Biopsy Functional/Special
Tests + Findings Urine dipstick & MC & S FBC (Hb low if uraemia) U&E (renal function) PSA KUB & IVU USS of kidneys and bladder (residual volume, hydronephrosis) Transrectal ultrasound Urodynamics (pressure/flow cystometry)
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Management
Modalities CONSERVATIVE MEDICAL
INTERVENTIONAL
Specifics Address drinking habits 1. Alpha blockers e.g. Tamsulosin α1c 2. 5α reductase inhibitors e.g. Finasteride Indicated if severely affecting QOL. 1. Trans Urethral Resection of Prostate (excise lateral and middle lobes with diathermy cutting loop) Send chipping to histology 2. Trans Urethral Incision of Prostate - youger patients 3. Trans Urethral ElectroVaporisation of Prostate 4. Laser Prostatectomy (Nd: YAG - lower risk of impotence and retrograde ejaculation) 5. Open - if very large 6. Transurethral Microwave Thermotherapy
Carcinoma of Prostate Epidemiology • Most common cancer in men • 60% over 80 have it at autopsy Aetiology Involves age-dependent alteration in oestrogen and androgens
Pathology • These are always ADENOCARCINOMAS and affect the outer zone of the gland. !
!
Note: malignant spread causes osteosclerotic lesions on XR)
• It is staged using the GLEASON SYSTEM (based upon two worsed affected areas)
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• Obstructive symptoms • Sympoms of spread e.g. back pain, SOB, pathlogical fracture Signs: • Prominent nodule on PR Investigations Modalities Cultures Bloods - ABG Bloods - Venous
Imaging
Scopic/Biopsy Functional/Special
Tests + Findings Urine dipstick & MC & S FBC (anaemia of chronic disease) U&E (renal function) Alk phosphate PSA CXR, spine/skull/pelvic radiographs USS of prostate/liver CT scan Bone scan Transrectal biopsy -
Quick notes on the PSA • A proteolytic enzyme that is part of the ejaculate • Values increased with: age, infection (UTI, prostatitis), TURP, post-ejaculation Treatment
Modalities CONSERVATIVE
Specifics “Watch and wait” stategy (PSA & PR) For palliation DXT used
MEDICAL
INTERVENTIONAL
1. LHRH analogue e.g. Goserelin (Zoladex) 2. Anti-androgens e.g. cyproterone acetate 3. Radiotherapy for spinal mets 1. TURP 2. Radical prostatecctomy and lymph clearance 3. Brachytherapy
Note: old treatment is bilateral or orchidectomy
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The Scrotum In this section we look at: a. Torison of the testicle b. Undescended testicles c. Lumps in the scrotum
Testicular Torsion
“A twisting of the spermatic cord that cuts off the blood supply to the testicle and surrounding structures within the scrotum.”
This is a SURGICAL EMERGENCY! 4-6 hours window in which testicle is salvageable
Usually affects affects children and young adults.
Aetiology • Trauma • Lack of a bare area attaching testicle to scrotum predisposed to torsion. This is know as a CLAPPER BELL TESTICLE
Clincal features Symptoms: • Extreme pain in scrotum (unilateral) • Lower abdominal pain (T10 innervation_ Signs: • Hot and swollen testicle • Extreme tenderness • HIGH RIDING and TRANSVERS in lie Managment • Direct patient to theater ASAP (do not perform US) • Procedures i. Untwisting of testicle with salvage ii. Orchidectomy
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Undescended Testicles The testicles should normally be present in scrotum at birth
Epidemiology • 3% are undescended at birth • 1% after 1 year • Prematurity increases the risk hugely. There are a number of possible results
1. Crytoorchidism - “complete lack of testicles from the scrotum” ! 2. Retractile testes - “norma genitalia but overactive cremasteric reflex.” • Testes may be persuaded in scrotum with warm hand • No treatment except reassurance 3. Maldescended testes - “testicles stopped descending down normal path.” • • • •
Scrotum is underdeveloped and flat Testicle will be small There will a patent processus vaginalisis (+/- a hernia) Always require repair
4. Ectopic testicles - “testes in an abnormal site.” • Common sites: abdomen, superficial inguinal pouch, root of penis Complications • • • •
Infertility Prone to trauma/torsion (superficial site) Hernias Malignancy (replacing it does not help this)
Management
• ORCHIDOPLEXY (< 2y) - Dantos pouch procedure
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Lumps in the Scrotum
This is v. common for exams.
Always ask yourself 4 questions:
a. Can you get above it? • If not then it must be from above → inguinal hernia b. Is the testis separate from the lump? • What structure is it from? - testis or epididymis/cord c. Is the lump tender? • Epidido-orchitis is most common ! d. Does the lump transilluminate? • Cystic things transulluminate e.g. hydrocele/varicole • Tumours/spermatoceles/haematocele do not
Brief notes on each conditions
Hydrocele “A collection of serous fluid within the tunica vaginalis.” May be PRIMARY (congenital and associated with patent processus, large) or SECONDARY (reaction to other pathology in testis, small) Rx • Infants - leave until 1y as most will resolve spontaneously • Adults - should resolve spontaneously if not aspirate and send for cytology • Drainage and excision in theatre Varicocele “Dilated veins of the pampiniform plexus.” May be PRIMARY (idiopathic) or SECONDARY (left sided renal tumour). Present with bag of worms scrotum and a dull ache (L > R) Rx • Conservative • Surgical • Clip the testicular vein © Podmedics 2010
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Haematocele “Blood within the tunica vaginalis” Rx • Conservative • Surgical - drain Epididimo-orchitis “Infection and inflammation of the testis and surrounding structures.” Occurs in association with • Mumps (usually 1 week post-parotitis) • Ascending infection e.g. UTI, prostatitis • STD e.g. Chluamydia Present in a similar fashion to testicular tumours: • Importat differences are systemic features (fever, unwell), features of UTI/STD, secondary hydrocele Definitive treatment • Analgiesia, bed rest, scrotal support • Ciprofloxacin Sperm granuloma • Painful lump post-vasectomy Epididymal cyst • Tender cystic lump coomon in middle-aged and elderly. May be bilateral
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Testicular Cancer
Epidemiology • Tumour of young men Aetiology • Increased risk with undescended testicles and infertility
Pathology
“Teratomas for Troops (young), Seminomas for Sergeants (older)”
1. Seminomas • Solid and slow growing tumours • Radiosensitive 2. Teratomas • Solid or cystic • Secrete α-fetoprotein Rare types • • • •
Choriocarcinomas (HCG producing) Leydig cell tumours (secrete androgen) Sertoli adenomas (secrete oestrogens) Lymphomas (elderly with poor prognosis)
Clinical features Symptoms: • Asymptomatic • Lump Signs: • Heavy, irregular lump • Non-tender
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Investigations
Staging is via the Royal Marsden Classification
Modalities
Tests + Findings
Cultures
-
Bloods - ABG
-
Bloods - Venous
Imaging
Scopic/Biopsy Functional/Special
FBC (anaemia of chronic disease) U&E (renal function) 2 tumour markers 1. α-fetoprotein 2. β-HCG CXR (mets) USS scrotum CT abdomen (staging) Never perform a percutaneous biopsy (seeding) -
Treatment
Modalities CONSERVATIVE
MEDICAL INTERVENTIONAL
Specifics Important adjuncts - Conservation of other testicle for fertility - Cryopreservation of semen - Prosthesis Chemotherapy and radio-therapy may be offered to para-aortic nodes 1. Inguinal orchidectomy +/- lymph node dissection
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Appendix Common abdominal scars + Roof-top = Mercedes-benz
Roof-top Roof-top Loin Roof-top
Subcostal/ Kocherʼs Midline
Loin
R. paramedian
Loin
L. paramedian
Lanz
Grid-iron
Pfannenstiel
Inguinal
+ always look for lapaoscopy scars!
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Common drugs
Drug
Dose
ANALGESIA
Drug
Dose
HYPNOTICS
Paracetamol
1g Q.D.S.
Zopiclone
3.75-7mg nocte
Aspirin
300mg Q.D.S.
Temazepam
10-20mg nocte
Diclofenac
50mg T.D.S.
Codeine phosphate
30mg Q.D.S.
ANTI-HISTAMINES
Morphine
5-10mg / 4h
Chlorphenamine
10mg IV/4mg PO
Tramadol
50mg / 4h
Cetirizine
5-10mg/24h PO
Pethidine
50mg / 4h ANTI-ACIDS
ANTI-EMETICS
Cimetidine
800mg nocte
Cyclizine
50mg T.D.S.
Ranitidine
300mg nocte
Metaclopramide
10mg T.D.S.
Omeprazole
20mg
Ondansetron
4mg T.D.S.
Lansoprazole
30mg
ANTIBIOTICS
ANTI-DIARRHOEALS
Amoxicillin
500mg T.D.S.
Loperamide
4mg stat then 2mg with each motion
Flucloxacillin
500mg Q.D.S.
Codeine phosphate
30mg Q.D.S.
Erythromycin
500mg Q.D.S.
Ciprofloxacin
500mg B.D.
Cefuroxime
1.5 g I.V.
Metronidazole
500mg I.V.
ANTI-COAGULANTS Unfractionated heparin
5000U B.D. s.c.
Enoxaparin
DVT prophylaxis 20-40mg/24 s.c.
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© Podmedics 2010
