1. health and fitness
2. disease

3. TOE: ap & aortic regurg
Surgery
Jeremy Lynch. July 15, 2007
Rx.
Type A ( Ascending aorta) dacron graft
Type B ( Distal to L subclavian) Conservative w hypotensive drugs ( to # BP stop-
I Heart & Thoracic Aorta
II Arterial Disease
ping extension of aneurysm)
Can be divided into occlusive or aneurysmal. Most common cause of both is atherosclerosis .
1 Thoracic Aortic Aneurysms
Causes.
Arch of aorta M arfans , ( syphilis)
Descending Traumatic, syphilis, athersclerotic
Clinical.
Ascending Chest pain, aortic regurgitation, obstruction of the SVC, obstruction of
3 Anatomy
the right main bronchus, pulsating mass in front of the chest ! may even ulcerate
through the wall
Arch Compress trachea or ulcerate i nto it. Liable to stretch the left recurrent
laryngeal ! hoarseness. May obstruct left lower lobe ! collapse.
Descending Back pain, erosion of vertebrae, press on oesophagus producing dysphagis ! may rupture into it
Ix. CXR ( calcication) , CT/MRI ( extent & size) , aortography dangerous & not
done , USS ( aortic valve incompetence)
Rx. Excision of aneurysm & graft. Need bypass to perform
Cx. Spinal ischamia: loss of ow of radicular artery ! paraplegia
2 Aortic Dissection
Path. Usually arch, blood dissects in media. Usually
Epi. Hypertension, atherosclerosis
Clinical. Sudden sev pain in chest, may radiate in to arms, neck, abdomen, or with a
Ix.
F igu re
4 Investigations
tearing interscapular pain. May be signs of surgical shock ( due to cardiac tamponade
or ext rupture) . As dissection progresses origins of main arterial branches may become
blocked ! dissapearance of peripheral pulses. Renal vessels: haematuria/anuri. Leg
ischaemia.
1 .
Urine & blood glucose DM
Hbg Anaemia, polycythaemia.
ESR, CRP Inammatory/mycotic aneurysms
Cholesterol Atherosclerosis
ECG Coronary disease
1 . CXR: widened mediastinum
2. Contrast enhanced CT
1
Echo heart Valvular lesions, mural thrombus, aneurysms, atrial myxoma
CXR Bronchial Ca common in end stage vascular disease ( both caused by smoking) ,
4. Fasciotomy for compartment syndrome
Open heart size
1 . Direct compression 2. Resuscitation: replace blood
3. Exploration: partial tears may be sutured, division requires saphenous interposition. Avoid using prosthetics due to infx risk
Doppler USS Arterial waveform: monophasic in hardened arteries
Duplex USS Imaging
Arteriography Site, extent of blockage: if reconstructive surgery/angioplasty contemplated
7 Aneurysm
Angioplasty Dilation by balloon catheter + stenting
CT & USS Aneurysms
Def. Abnormal permanent dilatation of an artery or part of an artery or the heart
Morphology. May be fusiform, saccular, or false/ pseudoaneurysms ( when there is a sac
communicating w the artery lumen)
5 Treatment
Types.
Saccular Narrow neck: mycotic ( inammation causes localized weakness) .
Fusiform Generalized dilatation: abdominal aorta
False Blood leaks out of artery & is contained by ct lined w thrombus ! will either
1 . T reat handicap not the disability : e. g. if seldom needs to walk 500m then don' t
need to rx.
2. P rophylactic surgery only appropriate when risk of event outweighs procedure : e. g. when AAA gets big enough.
rupture spontaneously or enlarge and rupture
AV False aneurysm
Dissecting Blood forces passage through break in intima of vessel ! may rupture
back in to lumen or out of adventitia. Over this artery segment vessels are deprived
of blood
6 Arterial Trauma
Classied.
Aetiology.
1 . Closed: extraneous compression e. g. crush injury, fractures of adjacent bones w displacement of artery ( eg. supracondylar fracture) , joint dislocation.
2. Penetration: e. g. stabbing, iatrogenic
1.
2.
3.
4.
5.
Types.
1 . Mural contusion w 2 spasm
2. Intimal tear: usually result of stretching of artery. Results in artery buckling &
causing localized stenosis which may result in thrombosis or dissection
3. Full thickness tear: paradoxically partial' s bleed copiously whilst completes results
in contraction and spasm and so # blood loss
o
Congenital: Berry aneurysms
Degenerative: atheroma . Most common cause
Traumatic: penetrating bullet or catheterisation ! true or false
Infection: mycotic. E. g. tertiary syphilis, salmenollosis, immunodeciency
Inammation: subtype of atherosclerotic/ mycotic in which theres an immune
response to components in the aneurysm wall ! dense inammatory forming rind
around lumen
Clinical of true aneurysms.
Consequences.
Abdominal: asx, back pain, bloating, swelling pulsatile + expansile, consequence of
distal emboli
Peripheral: pulsatile swelling, distal ischaemia, thrill bruit, machinery murmur ( AV
communication)
. Dilated, tortuous, atheromatous artery, mass overlying artery
1 . Haemorrhage 2. Thrombosis 3. AV stula 4. False aneurysm
5. Compartment syndrome: ischaemic muscle swelling in closed fascial compartment !
exacerbates ischaemia ! Volkmann' s ischaemic contracture
C linic al . Pain,
pallor, pulselessness, paraesthesiae, paralysis, perishing
cold . Haemorrhage may be overt or concealed. May develop hypovolaemic shock
Complications.
Treatment.
Closed 1 . Treat causation: e. g. open plaster cast, reduce fractures
2. Angiography: discriminated ischaemia due to spasm, intimal tear, arterial disruption
3. Operative exploration: if failure of above, or tear or block. Saphenous V often
used to replace areas
Ix.
2
1 . Rupture: " w diameter
2. Thrombosis 3. Embolism 4. Pressure
5. Infx: become infected or arise as a result of
1 . AXR: calcication in wall of aneurysm
2. CT/MRI/ USS: size & extent
3. ( Angiography: but underestimates size, and risk of perforation)
7.1 Abdominal Aortic Aneurysm
2. Angiography: artery tree distal to aneurysm
Rx. Femoral ! distal popliteal bypasses w ligation of feeding vessels
8 Atherosclerotic Arterial Disease
Aetiology.
1.
2.
3.
4.
5.
6.
F igur e
FH
S moking : nicotine ( vasopasm) , CO, " platelet stickiness
H yperlipidaemia
H ypercholesterolaemia
H ypertension
D iabetes : " Atherosclerosis, " microangiopathy. Presentations:
a) Young pt w peripheral gangrene but good pulses in limb. Rx: Control infx and
improved diabetic control, local debridement. Last resort is amputation
b) Elderly w atherosclerosis: DM results in # prognosis
7. ( and post-menopausal )
8. Age
9. # E xercise
Occlusive arterial disease pattern. Exercise induced pain ( intermittent claudication ) ! rest pain ! gangrene .
2 .
Epi. Common in older , FH, assoc w popliteal aneurysm
9 Coronary Occlusive Disease (Coronary Angina)
.
Acute aortic expansion ( Pain of rupture without haemodynamic consequences) .
Only ix if there is reasonable doubt.
Rx. If < 5. 5/6 cm then regular USS. Preop assessment includes coincident cadiac disease
( exercise ECG, echocardiography) , renal disease. Involves open surgery w Dacron graft,
or can be done endovascularly w graft ( excludes sac from blood ow. Good for those
otherwise unt for surgery)
Results in. Angina
10 Mesenteric Occlusive Disease (Mesenteric Angina)
Complications of Rx.
1 . Renal failure: # blood ow when clamp aorta. Worse if aneurysm spans renal
arteries
2. Distal embolization
3. MI: coincident cardiac disease common, and " peripheral resistance w clamping
4. Graft infection: aorto-enteric
Ruptured AA. Assume if sev back pain and collapse. includes renal colic. 50% die
before hospital, 50% die on the table. Most patients reaching hospital the aneurysm is
contained retroperitoneally. Don' t give " uids cos causes more bleeding.
Clinical. Pain after meals, weight loss, fear of eating
11 Cerebral Occlusive Disease
Causes. Stroke, dementia, TIAs
7.2 Popliteal Aneurysm
12 Intermittent Claudication
Claim to Fame. The most common peripheral aneurysm
Clinical. Generally asx, may cause distal embolization leading to claudication or digital
Clinical. Gripping, tight clamp-like pain in the calf on exercise. Usually one leg in
Ix.
.
advance of the other. Pain disappears on resting.
Spinal claudication: Pain present on standing, requires pt to sit down before
relieved.
infarction. Ex reveals prominent pulsation in popliteal fossa extending proximally.
1 . Duplex USS: extent & size
3
Pathology. Calf pain ( thigh lesion) , buttock pain ( internal iliac) . Bilateral buttock clau-
Rx. Aspirin.
Rx.
Conservative # RFs, weight loss, exercise, foot care
Interventional Arteriography ( short, > 70% occlusions amenable by angiography) ,
15 Raynaud's
> 70%: endarterectomy. Complications : death/ stroke, haemorrhage,
hypoglossal neuropraxia ( tongue protusion) , reperfusion syndrome ( to brain) , restensosis
dication assoc w impotence
duplex scanning ( replacing angiography)
1 . Angioplasty: balloon stretch/fractures. Risk of embolization, perforation
2. Thrombolysis: TPA, streptokinase. Not appropriate for acute cos takes time
3. Bypass: Complications inc dissection, embolization thrombosis
Cause. Intermittent spasm of small arteries precipitated by cold exposure.
Clinical. White ! blue ! red
Aetiology. 1 ( women) , phenomenon ( 2 to c. t. disease usually) , cryoglobulinaemia.
o
vibrating tools
Cervical rib, atherosclerosis, Beurgers'
.
13 Critical Ischaemia
Def.
Rx.
Conservative Gloves, stop smoking. Surgery Sympathectomy
Rest pain, ulceration or gangrene assoc w absent pedal pulses , or ABPI
< 0. 5
Rest pain Ischaemia. Initially at night ( horizontal) . Relieved by hanging leg over
16 Beurger's (Thromboangiitis Obliterans)
side. As disease progresses becomes continuous
Gangrene Sev vascular impairment. Pressure areas ( heel, malleoli, plantar ball of
Clinical. Similar to atherosclerosis ( As obliterated ! ischaemia) , but in young , heavy
hallux) . Minimal trauma causes abrasions.
smokers, hands/ ngers. Ulcers, gangrene. Veins/ nerves can also be aected. Rx: stop
smoking.
Ix. Same as claudication
Rx.
Non-operative Arteriography & angioplasty, lumbar sympathectomy ( " blood
supply)
17 Embolism
Operative: Reconstructive surgery Needs : good arterial supply to blockage,
Def. Abnormal undissolved material carried in blood from one part of vascular system to
good vessels below, conduit ( saphenous vein, or PTFE) , patient in good health cos
impact in distant. May be air, fat, tumour, but most commonly thrombus from
heart or major vessels . A surgical emergency.
Where. Usually bifurcations. Can go to CNS, retina, small intestine, renal ( haematuria,
pain in loin) , splenic ( subcostal pain) .
Clinical. In a limb: The P' s ( see above) . Contractions develop w time. The block can
move distally in the few hours. Skin staining non-blanching on pressure ( irreversible
tissue damage)
" mortality
Amputation Pain not controlled by above, or gangrene + infection
14 Carotid Artery Disease
Where. Bifurcation. Cause. Atherosclerosis + thrombus
Presentations.
Cause.
1.
2.
3.
4.
Amaurosis fugax : uniL blindness lasting minutes
Strokes
TIA
Hypoperfusion: biL may cause critical ischaemia on exertion
Clinical. Bruit, evidence of disease elsewhere
. Hypoglycaemia, epilepsy, migraine, neoplasm, embolism from heart
Ix.
1 . Duplex USS 2. Angiography 3. MRI of vessels 4. MRI/CT brain
5. Cerebral reactivity: measure in haemodynamic response whilst pt breathes CO
( a vasodilator)
6. ECG/echo heart
o
Rx.
2
4
1 . Atrial fibrillation : by far most common
2. Mural thrombus: often post-MI
3. ( Aortic dissection) 4. ( Paradoxical i. e. venous origin)
1 . Assessment: if resolving ( re-appearance of pulses) consider thrombolysis. If no
blood supply and neuro s then surgery. After 24h, or skin staining, successful
revascularization is unlikely.
2. Heparinization: as soon as diagnosis made
3. Surgical embolectomy: open, closed ( Fogarty catheter: pass line pst clot, inate,
then pull back)
4. Thrombolysis: if likely a thrombus in situ
18 Cold injury
Rx.
1 . Neuropathic: abx for infection, wide local excision & drainage of necrotic tissue
2. Ischaemic: angiography & consideration of plasty or bypass
Pathology. Capillary sludging and thrombus
Rx. Gentle warming, heparin, abx. Local amputation
19 Diabetic Foot
III Venous Disorders of Lower Limb
At a Glance
20 Anatomy
F igur e
3.
Path. Ischaemia ( macro & micro) , neuropathy ( sensory, motor, autonomic) , sepsis ( " glucose promotes bacterial growth)
Clinical.
Neuropathic Sensory, trophic skin, plantar ulceration, Charcot' s, pulses often present, sepsis
Ischaemic Rest pain, painful ulcers over P areas, hx of intermittent claudication,
Ix.
absent pulses
F igu re
1 . ABPI: may be falsely elevated due to sclerosis
2. XR: osteomyelitis
3. Arteriography
4.
Systems.
Deep Inside deep fascia. Tributaries drain into popliteal ! femoral ! ext iliac !
Prevention.
Do Wash & dry feet, inspect daily, care of toenails, anti-fungal powder
Do not Barefoot, ill-tting shoes, hot-water bottles, ignore injury
iliac ! IVC
Supercial Outside fascia, draining skin/supercial tissues.
1 . Long saphenous ( from dorsum foot) 2. Short saphenous ( lat lower limb) .
5
Perforators. Supercial ! deep. Medial/ lat tibia above ankle, and one mid-thigh.
Calf pump. Empties deep veins, so then supercial veins ! deep veins
2 o Previous DVT, " venous P due to compression ( e. g. pelvic tumour, pregnancy) ,
AVS stula, tricuspid incompetence
HPC. Cosmetic, tiredness, aching, throbbing, swelling ankles, esp after standing
Ex. Must be standing. Inspect medial gaiter for deep venous insuciency ( haemosiderin,
eczema, lipodermatosclerosis) . Port-wine stain ( AVS malformations) . Saphena varix
( saphenofemoral dilation, thrill) . Tap Test for Supercial Valve incompetence ( feel
saphenofemoral and tap peripherally. If no valves then feel it. ) Trendelenburg' s test.
21 Pathology
Cause. Valvular incompetence: usually physical ( such as thrombus) ! " resistance to
return ow. Incompetence breeds incompetence.
Ix.
22 Varicose Veins
1 . Doppler probe: poor ow
2. Duplex US: diagnose
3. Venography: tourniquet on ankle to occlude supercial, inject contrast into dorsum
of foot ! up deep system ! observe supercial reux
Rx.
1 . Graded compression stockings ( minor varicosities, pregnant, unt)
2. Sclerotherapy: compressed for 2w after to enable brosis. Small/ mod sized.
3. Surgical: Indications include haemorrhage, varicosities grossly dilated/ otherwise
symptomatic, skin s, incompetent perforators. Involves disconnecting great saphenous from femoral vein, dividing terminal branches of great saphenous. Recurrence
is due to failure original diagnosis or defect in technique.
Cx.
Haemorrhage Due to minor trauma. Lie pt down w leg elevated & apply pressure
bandage.
Phlebitis Tender, hard, inamed skin, may be pyrexial, can have 2 bacterial. Rx:
o
bed rest w elevated foot of bed, pressure bandage, abx ( if needed) , systemic anticoagulation
23 Varicocele
Def. Dilated veins of the pampiniform plexus ( in the testes)
Description. L usually. Associated w renal Ca, infertility. May be painful. bag of
worms. Rx. Can embolise, ligate/ divide.
24 Deep Venous Insuciency
F igur e
nails
5 .
Cause. Incompetence of valves of deep venous system .
Aetiology.
1 o Congenital lack of valves
2 o Venous hypertension ( DVT) , AVS stula.
Clinical.
M alleolar are = red in am mation from m elleolus. O nychogryposis = dam aged toe-
Def. Abn dilated & lengthened supercial veins, due to incompetent perforator veins or
supercial valves.
Classication.
1 o Majority. : = 2: 1 . Accentuated by pregnancy
1 . Swelling ( Esp lower leg) due to transudation of uid across capillaries
6
2.
3.
4.
5.
Ix.
Where. Often medial malleolus
Appearance. Ragged edge. May have white rim around ( previous scarring) . SCC can
Supercial varicose veins ( 2 perforator incompetence)
Haemosiderin pigmentation ( broken down hbg)
Eczema, pruritis
Lipodermatosclerosis: thick brous tissue ( due to inammation) ! inverted champagne bottle
6. Ulceration ( poor skin nutrition)
o
1 . Venography: identify perforators that can be treated
Rx. None, can only rx the supercials.
arise in these ulcers ( Marjolin' s)
. Venous ( 90%) , ischaemic, neuropathic, malignant, systemic-related, AVS stulaassociated, gumma of syphilis
Rx. Conne pt to bed w foot elevation to abolish " P. Keep clean. Abx only if gross infection. Unfortunately if old then prolonged bed is dangerous. Also: tight bandaging
( empties supercial resulting in more ecient pump ! " O to area) . Once healed t
graduated compression stockings.
2. Duplex sonography
2
25 Venous Ulceration
26 DVT
Predominantly a medical condition.
Ix. Nb. Duplex unreliable below knee. D-dimer has signicant false + ve rate
Prophylaxis. Early post-op mobilisation, pneumatic compression, TED stockings, heparin, avoid OCP
Rx & prevention. Heparin
IV 15: Head Injury
F igur e
6 .
Cause. Venous ulceration is due to venous hypertension 2 to incompetence of deep veins.
Ask about past possible DVTs.
o
F igu re
7
7.
28 Brain Injuries
Types.
1 o Direct result of trauma.
Diuse: shearing movements ! axon damage + rupture of small vessels
Localized: brain impacts against the skull
Coup & contre-coup: the opposite side of the brain damaged as it rebounds o
skull.
Laceration: brain impacts on sharp bony edges
o
2 After initial event, result of hypoxia, hypercapnia, hypotension ( ischaemia) ,
haemorrhage, meningitis. In-hospital mortality.
29 Cerebral Perfusion
Systemic arterial pressure. Autoregulation by cerebral arterioles
Intracranial pressure. Skull is a closed compartment:
CPP = BP ? ICP
" ICP and hypotension in trauma victims reduces blood ow ! ischaemia ! reex
increase in systemic pressure & bradycardia ( Cushing' s reex )
Cerebrovascular resistance. Arteriolar vasodilatation with: " P CO , " pH. If reduction
in cerebral blood volume wanted therapeutically ( e. g. cerebral oedema) : pt hyperventilated. Conversely hypercapnia in presence of oedema might exacerbate brain injury.
2
Ta b l e
1 .
30 Management of Head Injury
27 Types of Fractures
Initial Assessment.
Hx Mechanism of injury, immediate condition ( GCS, vital signs, pupils, limb move-
Scalp injuries Usually simple penetrating: debridement & suture. If skull also pene-
ments) , in condition after rst assessment, prior condition ( diabetes - ?hypo)
trated br may also be lacerated: consciousness not necessarily lost
Skull Crushing or other sev force. Usually linear fracture of skull vault. Skull XR:
fracture is an important indicator of the force of injury & risk of IC haemorrhage
Paranasal sinuses: CSF rhinorrhoea Usually open as overlying dura breached.
Anosmia if fracture across cribriform plate. Risk of meningitis.
Petrous temporal bone: CSF otorrhoea or rhinorrhoea Involvement of inner ear
causes deafness. Leak usually self-limiting
Temporal bone: middle meningeal vessels Causing extradural haemorrhage.
Depressed fractures Fragment of bone below level of surrounding bone. Rx: can
leave it if not troublesome. Elevate if e. g. contaminated, haematoma
Ant/middle cranial fossae: Orbital haematoma Looks like a black eye ( racoon
eye) . Suggested by: subconjuctival haemorrhage, absence of grazing of the surrounding
skin, conned to margin of orbit, mild exophthalmos, bilateral haematoma
Ex Major injuries: ABC. Conscious level. Details in the book . GCS ( Note how high
each goes: Count to 4: open your eyes. Count to 5: talking jive. Count to 6: feels
the pricks ) :
i. Eye opening 4: Spontaneous 3: To command 2: To pain 1 : None
ii. Verbal response e 5: Oriented 4: Confused conversation 3: Inappropriate words 2:
Incomprehensible 1 : None
iii. Motor response 6: Obeys command 5: Localizes pain 4: Withdraws from pain 3:
Abnormal exion to pain 2: Extension response to pain 1 : Non
Ix 1 . Skull XR: indicated when LoC, impaired GCS, amnesia, scalp swelling, laceration to bone, hx of high energy impact, persistent vomiting, headache
2. Cervical spine XR: unconcious pts
3. CT: indicated if sev head injuries, CSF rhinorrhoea or otorrhoea, penetrating,
bilateral orbital haematoma ( Battle sign)
8
Immediate Rx. Correct problems in initial assessment: e. g. draining pneumothorx, ven-
Hyperpyrexia Cooling blankets
Amnesia Longer, the worse prognosis of mental function
Epilepsy Penetrating open wounds w cortical scarring
tilation, laporotomy.
Deterioration.
Cerebral oedema
IC haemorrhage
Hypoxia
Infection: 2 to fractures
Hyrocephalus
Delayed management. In book
33 Brain Death
o
Details in the book.
31 Traumatic Intracranial Bleeding
V Oesophagus
I C B leed
E xtrad
S ub dural
S ubar Intrac Intrave
Acute C hronic
F igur e
34 General Abdominal Colic
8 .
Extradural. Often tear in middle meningeal artery. C onvex CT scan
Hx Talk & die. Minor head injury causing temp concussion ! lucid interval !
1 . Biliary tract: stone in Hartmann' s pouch, cystic duct, ampulla of Vater
2. Renal tract: Ureteric colic due to stone, blood clot or tumour, bladder colic in acute
retention due to enlarged prostate
3. Intestinal: obstruction, appendicular colic
4. Uterus: parturition, menstruation, ectopic pregnancy in fallopian tube
headache ! deeper coma ( due to cerebral compression by extradural clot. )
Ex Signs of " ICP. Also localizing signs: explore the side of the dilated pupil,
hemiparesis/hemiplegia or ts ( uncommon) , boggy scalp haematoma
Ix CT
Rx Emergency: burr hole made and clot evacuated. Diathermy to bleeding point.
Mannitol.
Subdural. C re s cent shaped CT scan
1 . Acute : lacerated brain or torn vessels. Sev ( coma) . Rx: craniotomy & release of clot
2. Chronic : post-trivial injury, elderly pt ( small brain) . Tear in cerebral vein. Clinical:
expanding mass ( mental deterioration, headaches, vomiting, drowsiness, coma) . Rx:
evacuation
Subarachnoid haemorrhage. Meningeal irritability w headache, neck stiness, Kernig' s
sign. Congenital B erry aneurysms, Rx: analgesics, bed rest
Intracerebral haemorrhage. If exerting mass eect and " ICP then evacuate. Assoc w
" BP.
Intraventricular haemorrhage. Childhood, sev head injury
35 Dysphagia
Causes.
1 . Local
Lumen Foreign Body
Wall Atresia, inammatory ( 2 reux esophagitis) ,
o
caustic stricture , achalasia , Plummer-Vinson w oesophageal web, pharyngeal pouch , esophageal
tumour
Outside Wall Enlarged LNs, thoracic artery aneursym, bronchial Ca, ret-
rosternal goitre
2. General: myasthenia gravis, bulbar palsy, bulbar poliomyelitis, diphtheria, hysteria
Hx. Previous reux oesophagitis suggests peptic stricture. Malignancy has short hx.
Ex. Look for Plummer-Vinson ( smooth tongue, anaemia, koilonychia) , LNs, upper abdo
mass ( cardia mass)
32 Other Complications of Head Injury
Ix.
Meningitis Open fractures. Rx: abx. Via nasal : penicillin ( Pneumococcus ) . Complicating open fracture : 2nd G cephalosporin ( e. g. cefuroxine)
9
1 . Barium swallow
2. Oesophagoscopy + biopsy
36 Foreign Bodies
Ix.
37 Perforation of the Oesophagus: Rare
Rx.
Who. Children, mentally disturbed. Most can pass out unless sharp or irregular
Cx. Penetration
Rx. Usually conservative: serial Xrs
Classication.
From within Ix.
1 . Foreign body
2. Iatrogenic ( oesophagoscopy, dilatation/biopsy, echocardiography) : pain + dysphagia + subcut emphysema
From without ( Wounds)
Spontaneous Lower thoracic oesophagus ( B oerhaave' s syndrome) . Sev pain in
chest, dorsal spine, or upper abdo ( acute mediastinitis) . Pt collapsed & cyanosed.
Rigid abdomen. Surgical Emphysema
1 . CXR: gas in neck and mediastinum, uid & gas in pleural cavity
2. Gastrogran swallow
Rx.
Cervical perforation Conservative. Abx, NBM, IV drip. Abscess formation in sup
mediastinum needs drainage.
Thoracic rupture Immediate suture. Prognosis related to time after event
38 Caustic Stricture
Epi. Accidental/ suicidal with strong acids/alkalis. Mid/lower usually.
Rx. Alkali ingestion w vinegar & bicarbonate of soda. Gastrostomy ( rest the oesoph-
agus) . Steroids ( # scars) . Dilatation of strictures w bougies after 3w. If impassable then
bypass op.
39 Achalasia of the Cardia
Claim to Fame. Similar to Hirschprungs of rectum
Path. Neuromuscular failure of relaxation of the lower end of the oesophagus on swal-
lowing, with progressive dilatation, tortuosity, incoordination of peristalsis, hypertrophy of the oesophagus above.
Clinical. Most often 30s. Indistinguishable from Chagas' ( Trypanosoma cruzi destroys
ganglion cells) . Progressive dysphagia over m' s to y' s, sometimes assoc w spasm like
pain. Regurgitation of uids from the dilated oesophageal sac ! aspiration pneumonia.
Malignant possible. Pt' s often eat small amounts + often, & wash down w water.
1 . CXR: dilated oesophagus as a mediastinal mass, air-uid level, pneumonitis from
aspiration.
2. Barium swallow: gross dilatation & tortuosity leading to unrelaxing narrowed segment at lower end ( bird' s beak) . Absent gastric bubble
3. Oesophagoscopy: enormous sac of oesophagus w stagnant food
4. Oesophageal manometry: aperistalsis, failure of relaxation of LOS
1 . Heller' s: cardiomyotomy ( similar to Ramstedt' s)
2. Endoscopic dilatation of OJ w hydrostatic bag
40 Plummer Vinson Syndrome
Clinical. Dysphagia. Caused by Fe-decient anaemia ( smooth tongue, koilonychia, spoon
shaped nails) . Middle aged . Hyperkaritinization of the oesophagus w formation of
web in upper. Premalignent.
Rx. Anaemia : Fe. Web : dilatation.
41 Pharyngeal Diverticula
Def. Diverticula ( others are v rare) of the oesophagus btw the 2 parts of the inf pharyn-
geal constrictor ( weak) . As it enlarges it displaces the oesophagus laterally.
Clinical. Elderly . Dysphagia, regurgitation of food collected in pouch, palpable neck
swelling, foetor, aspiration pneumonia.
Ix. Barium swallow
Rx. Cervical incision w excision of pouch + pos myotomy of cricopharyngeus
42 Reux oesophagitis
Cause. Incompetent cardiac sphincter
Cx. Ulceration, inammation, strictures
Associations. S liding hernias , repeated vomiting ( esp w duodenal ulcer so " acidity) ,
Ix.
NG intubation, resection of cardia, ectopic acid-secreting gastric mucosa in oesophagus
Oesophagoscopy + biopsy ( exclude Ca)
24h pH studies
Acid infusion test: give HCl triggers similar pain to reux
Barium swallow: outline of hernia
. Cholecystitis, peptic ulcer, angina
10
1.
2.
3.
4.
Rx.
Medical Weight loss, smoking, corsets, antacids, H receptor antagonists ( cimeo
o
2
tidine) , PPIs ( omeprazole) , prokinetics ( metoclopramide)
Surgical a) Repair of hernia, fundoplication ( can now be done laparoscopically)
b) Stricture: endoscopic balloon dilatation
.
Ix.
Enteritis, neonatal intestinal obstruction, intracranial birth injury, overfeeding
( vomiting)
1 . USS 2. Abdo XR
3. ( Barium meal: shouldering of pyloric antrum)
Rx.
Medical Correct dehydration & hypochloraemic metabolic acidosis caused by vomiting
43 Tumours
Ramstedt's pylorotomy V good results
See oncology notes.
47 Duodenal Atresia
T umours
B enign
M alignant
L eiomyom a
1o
2o
C arcinom a L eiomyosarcom a
F igu re
9 .
L eio= sm ooth muscle
44 Barrett's
Def. Metaplasia to columnar. RF. , smoking
45 Presbyoesophagus
Clinical. Old ppl. Upper : dysphagia of solids + liquids. Lower : constipation
Path. Dysfunctional peristalsis
Ix. Barium: corkscrew dysmotility
VI Stomach and Duodenum
Types. Partial, complete, usually 2nd part ( near ampulla of Vater)
Clinical. Antenatal polyhydramnios. Birth : vomiting, distended stomach.
Assoc. Downs in 30%
. Oesophageal atresia, pyloric stenosis, congenital intestinal obstruction
Ix. Plain AXr. Rx. Duodenojejunostomy
48 Peptic ulcer
Pathology. Disturbance btw acid/ pepsin & mucosal barrier
Sites. Duodenum ( 80%) ( 1 st part obviously. Cos # protection there. " Acid
production )
> stomach ( lesser curve. N ormal acid production ) > oesophagus
Aetiology. H pylori usually, Zollinger-Ellison ( gastrin-like-peptide secreting tumour of
the pancreas) , NSAIDs, steroids, smoking, stress, blood group A
RF. Duodenum : 30-40s, ( after menopause) . Gastric : : = 3: 1
Clinical. Asx. Pain: epigastric, attacks last for d ! w' s, can radiate in to back ( indicates
posterior ulcer) , usually couple h' s after meal ( may be immediate) , can wake pt in
early morning, aggravated by milk & alkalis. Heartburn, nausea, vomiting, wt loss.
Acute Presentation ( q common) : Without cause, or NSAIDs, acute stress, head injury
( Cushing' s ulcer) . Sudden pain, haemorrhage, perforation. May become chronic.
Gastric Pain after eating( ! weight loss)
Duodenal Pain relieved by eating
Ix.
46 Congenital Hypertrophic Pyloric Stenosis
1 . Endoscopy: hour glass stomach
2. H pylori : biopsy + urease test ( add radiolabeled urea to biopsy sample releases
ammonia) , C-urea breath test ( give labelled urea to pt to measure CO created
by H pylori ) , serological
3. Barium meals
4. Faecal occult blood
1 3
Clinical. 3-4w, most , projectile non-bilious vomiting, failure to gain weight, dehydra-
tion, constantly hungry, rabbit pellets, visible peristalsis, palpable tumour ( 90%) ( esp
after vomiting a feed)
11
13
2
Rx.
Medical Eradicate H pylori : e. g. omeprazole, clarithromycin/amoxicillin, metron-
idazole. Acid reduction. Prostaglandins ( e. g. misoprostol) . Avoid alcohol, smoking,
aspirin. Rest, sedation.
Surgical Gastric ulcers : remove ulcer & gastrin-secreting zone ( Bilroth I) . Duodenal : remove the bulk of the acid secreting area of the stomach i. e. partial gastrectomy w closure of duodenum and gastrojejunostomy, or by dividing the vagi.
Post-gastrectomy cx inc:
a) Small-stomach syndrome ( fullness)
b) Bilious vomiting
c) Anaemia: due to Fe deciency
d) Dumping: fainting, vertigo, sweating after food ( mimics a hypoglycaemic) , probably an osmotic eect due to osmotic contents passing rapidly in to the jejunum
e) Steatorrhoea: not mixed adequately w pancreatic/ biliary secretions
Post-vagotomy syndromes inc:
1 . Steatorrhoea
2. Diarrhoea
3. Stomal ulceration
Cx. Perforation, stenosis, haemorrhage, chronicity ( brosis) , malignant change
Clinical. Profuse non-bilious vomiting, may contain food. Dehydration, wasting. The
Ix.
stomach you can hear, the stomach you can hear and see, and the stomach you can
hear, see and feel: succusion splash ! visible peristalsis ! grossly hypertrophied
stomach
1 . Barium meal: dilated stomach, narrow outlet, delay in emptying
2. ABG: hypochloraemic alkalosis
. Ca pylorus: shorter hx, painless, gross stomach dilation, mass at pylorus
Rx. Correction of dehydration and electrolyte depletion, daily gastric lavage, vitamin C
( ulcer stops absorption of ascorbic acid) . Surgical : partial gastrectomy, or vagotomy +
pyloroplasty/gastro-enterostomy
o
51 Management of GI Haemorrhage
49 Perforated Peptic Ulcer
Claim to Fame. Was common, but now # cos PPIs
Clinical. Hx of ulcer. Sudden onset v sev pain, may refer to shoulders, aggravated by
Ix.
movement ( pt lies rigidly still) . P eritonism. Nausea, haematemesis, melaena. May be
shocked. Abdomen rigid ( board-like) , tender, silent. PR: pelvic tenderness. If > 1 2h
features of generalized peritonitis w paralytic ileus, distended abdo, shock. Can have a
pos wall perforation: in to lesser sac ! muted presentation.
1 . CXR: gas under diaphragm
2. CT: should not delay laporotomy
. Perforated appendicitis, acute cholecystitis, acute pancreatitis, MI
Rx. Can be treated conservatively
1 . NG tube: empty stomach
2. Opiates, Abx, PPIs
3. Surgery: suturing omental plus to seal the perforation, lavage of peritoneal cavity
4. Control of H pylori
Prognosis. Mortality: 5-1 0%
50 Pyloric Stenosis: Uncommon
Actually means. Duodenal ulceration causing obstruction of rst part of duodenum
F igu re
12
1 0 .
4. Technetium scan: Meckel' s
5. ( Selective visceral angiography: obscure cases)
6. ( Laporotomy)
Rx.
Conservative 1.
2.
3.
4.
5.
Reassurance, morphine
Vital sign monitoring
Treat shock w blood transfusion. CVP line insertion
IV PPIs
When bleeding stops can drink milk
Surgical Indications:
i. Clinical: > 60y, chronic hx, relapse on medical rx, serious coexisting conditions,
continued melaena/ haematemesis, > 4 units blood needed
ii. Endoscopic: active bleeding, visible vessel, clot adherent to ulcer, unidentiable
source of blood in stomach
Method: gastric ulcer ! partial gastrectomy or excision, duodenal ! pyloroplasty &
undersewing
Notes: mortality is 1 0%, rx of varices is considered in ch. 30.
52 Stomach Tumours
Tum our
F igu re
Summary : assessment & replacement of blood loss, diagnosis of source, rx and control
of bleeding
Assessment. Shock if pulse > 1 00 and systolic < 1 00 ( although dierent for hypertensives) , postural drop in BP, # CVP. Take G+ S. Distinguish old from recent bleeding.
2 o Adenom a S trom al Vascular: haeman.
1o
AdenoC a S tromal L ymphom a H odgkins
Diagnose Source.
Aetiology Central ( haemophlia, leukaemia, anticoagulant, thrombocytopenia) , or
Local :
1 . Oesophagus: peptic oesophagitis, varices
2. Stomach: ulcer, acute erosions ( e. g. NSAIDs) , Mallory-Weiss, tumours
3. Duodenum: ulcer, erosion by pancreatic tumour
4. SI: tumour, Meckel' s
5. Colon: tumour, diverticulitis, angiodysplasia, colitis
Hx Ulcer, DH, alcoholism ( erosion, Mallory-Weiss)
Ex Purpura ( bleeding tendency) , cirrhosal tendency, circumoral telangiectasia
( HHT)
Ix 1 . Hbg estimation ( only after body volume restored)
2. E ndoscopy : can inject adrenaline into ulcers, and band varices
3. Colonoscopy
B enign
M alignant
1 1 .
F igu re
1 2 .
See oncology notes
52.1 GI Stromal Tumours
Path. Uncommon, from the interstitial cells of Cajal, c-kit mutation
Assoc. Type I NF
Ix.
1.
2.
3.
4.
Endoscopy
Endoscopic USS
CT
Staging: PET
Rx.
Surgical Excision
Chemo Glivec
13
VII Mechanical Obstruction
53 Mechanical Obstruction (cf. Paralytic)
Classication.
Speed of onset Acute, chronic, acute-on-chronic
Site High, low
Nature Simple, strangulating ( blood supply cut o)
Aetiology 1 . Lumen: faecal impaction, gallstone ileus, food bolus, parasites, intussusception. . .
2. Wall: congenital Atresia, Crohns, tumours, diverticulitis. . .
3. Outside: strangulated hernia, volvulus, adhesions
Age 1 . Neonatal: congenital atresia & stenosis, imperforate anus, volvulus,
Hirschsprung' s, meconium ileus
2. Infants: intussusception, Hirschsprung' s, strangulated hernia, Meckel' s
3. Young/ middle age: strangulated hernia, adhesions, Crohns
4. Elderly: strangulated hernia, carcinoma, diverticulitis, impacted faeces
Op Non-viable : remove it. Small bowel : can anastomose. Large bowel : temporary
colostomy ( if distant end cannot reach then close it - Hartmann' s) cos of " bacteria
& # blood supply here
54 Closed Loop Obstruction
Def. Complete distal obstruction & valve-like obstruction proximally, e. g. volvulus
55 Adhesive Obstruction
Claim to Fame. Three-quarters of all small bowel obstruction. Large bowel obstruction
from this is very rare.
56 Volvulus
Def. Twisting around its mesenteric axis. Most commonly sigmoid, caecum, rectum
Aetiology. Abnormally mobile loop ( e. g. congenital failure of rotation) , abnormally
loaded loop ( e. g. constipation) , loop xed at apex by adhesions, loop of bowel w
narrow mesenteric attachment.
Clinical.
1.
2.
3.
4.
C olicky pain : small bowel paraumbilical, large bowel suprapubic
D istension ( gas builds up) : may be less in small bowel
Absolute constipation ( o atus, o faeces) : a late feature of small bowel, early of lb
Vomiting : early in high, late in chronic or low. Becomes faeculant in late stages
( due to bacteria)
Ex. Dehydrated ( if vomiting) . " Temperature suggests strangulation. Peristalsis. Look for
hernias , abdominal scar ( adhesions ) . Tinkling bowel sounds. M ust do P R
( obstructing mass, intussusception, Ca) .
Strangulation features. Toxic appearance ( " pulse, " temperature) , continuous pain
( peritonitis develops) , tenderness + rigidity, bowel sounds absent ( peritonism) , " WCC
Ix.
1.
2.
3.
4.
5.
AXr
Barium follow through
Water-soluble contrast enema
CT
Sigmoidoscopy, colonoscopy
Rx. Acute: urgent cos of risk of strangulation.
Pre-op preparation 1 . NG tube to decompress
2. IV uids
3. Abx
56.1 Sigmoid Volvulus
Epi. Elderly, constipated. > . Rare in UK ( 2% obstructions)
Clinical. Sudden colicky pain.
Ix. Xr: large oval gas shadow left side, may be bent in on itself coee bean.
Untreated ! gangrene.
Rx. Soft tube passed through sigmoidoscope to decompress. Laporotomy if fails, might
need to remove some bowel.
56.2 Caecal Volvulus
Aetiology. Congenital malrotation.
Clinically. Acute onset pain in RIF w rapid abdominal distension
Ix. AXr: grossly dilated caecum often in LUQ
Rx. Laporotomy & untwisting or hemicolectomy
56.3 Small Intestinal Volvulus in Adults
Aetiology. Adhesions, remnant of vitellointestinal duct
Rx. Early operation w untwisting, rx underlying cause.
14
57 Mesenteric Vascular Occlusions
Aetiology.
1.
2.
3.
4.
Mesenteric embolus
Mesenteric arterial thrombosis
Mesenteric venous thrombosis: assoc w portal hypertension, OCP
Non-occlusive: cardiac failure
Path. Infarction, bleeding, gangrene ! perforation. Intestinal angina. Steatorrhoea.
Clinical. Triad of acute colicky pain, rectal bleeding, shock ( blood loss) in
elderly AF patient. Tender abdomen, mass may be felt ( infarcted bowel)
Rx. Blood transfusion, resection of gangrenous bowel, revascularization w saphenous vein.
May need permanent TPN in young if extensive resection.
58 Neonatal Intestinal Obstruction
Classication. Intestinal atresia, meconium ileus, NEC, Hirschprung' s, Anorectal
Clinical. Continuous bile-stained vomiting. Constipation, distension, peristalsis.
58.1 Intestinal Atresia
Rx. Resection & anastomoses
58.2 Volvulus Neonatorum ( Malrotation)
Def. Congenital malrotation
Rx. Laporotomy untwisting. Adhesions ( Ladd' s bands) divided
58.3 Meconium Ileus
Assoc. 80% have CF
Clinical. Acute obstruction in rst days. May have palpable loop.
Ix. AXr: obstruction & Ground glass meconium
Rx. Gastrogran PR to emulsify. Otherwise enterotomy, resections.
59.1 Hirschsprung's Disease
Path. Also termed aganglionic megacolon. Absence of ganglion cells in Auerbach &
Meissner. Rectum ! sometimes extending to large bowel. Functional obstruction.
Clinical. Acute obstruction in neonate. Failure to pass meconium. Can present with
stubborn constipation in infancy. PR: narrow empty rectum, above which faecal
impaction felt.
Ix. AXr, barium enema ( narrow rectal segment) , rectal wall biopsy ( absence of ganglion
cells)
. Acquire megacolon ( sev constipation at 1 -2y)
Rx. Obstructed: colostomy. Elective surgery to resect & anastomose aganglionic.
59.2 Anorectal Atresias
Assoc. Fistula
Clinical. Anus may be absent
Rx. Reconstruction
59.3 Intussusception
Def. Prolapse of bowel into lumen of adjoining. The prolapsing bowel is the intussu-
ceptum.
Path. Ileocolic ( through IC valve into colon) in 75%. Blood supply cut o ! gangrene
Aetiology. Infants/ young children. Postulated Peyer' s patches act as foreign body ( hence
can be preceeded by viral infx) . In adults may be polyp etc.
Clinical. > . Paroxysms of abdominal colic with screaming & pallor. Vomiting, passage of redcurrant jelly ( blood/slime) . Palpation reveals sausage-shaped tumour. If
neglected, sx of strangulated obstruction ( " mortality at this stage) .
Ix. Barium enema
Rx.
Non-op May be treated by barium enema ( the pressure forces it back)
Op Reduce at laporotomy, resection may be necessary.
59 Necrotizing Enterocolitis
VIII Appendicitis
Claim to Fame. Premature infants, due to ischaemia ! bacterial invasion. 25% mortality
Clinical. Generalized sepsis, vomiting, listlessness. Distended, tense abdomen.
Blood/mucus passed PR.
Cx. Perforation, resolve with stricture formation
Ix. AXr: distended loops, gas bubbles in bowel wall.
Rx. Medical: resus, TPN, abx. Resection: failure to respond or cx.
Surgical Talk
Claim to Fame. Commonest emergency surgical presentation requiring operation
Path. Obstruction ( by faecolith, or lymphoid hypertrophy, or rarely tumour) followed by
infection. A retrocaecal appendix is most common.
Clinical. Pain initially colicky due to obstructed appendix ! RIF constant due to peritonitis. Tenderness, guarding. Fever, anorexic, nausea, vomiting. Clinical diagnosis.
15
Rx. Appendicectomy: incision at McBurney' s point, open up skin subcut tissues, ext
oblique, int oblique, trasversus abdominus, peritoneum. Divide blood vessels, ligate
appendix at base, suck pus/blood out.
. Mesenteric adenitis: enlargement of mesenteric LNs causing pain, fever, tenderness.
Ix: leucocytosis ( c. f. raised neutrophil)
RIF mass. Appendix, gynaecological, caecal ca, soft tissue tumour ( e. g. sarcoma) ,
LN mass, TB, actinomycosis, iliac aneurysm
IX The Small Intestine
60 Meckel's Diverticulum
Def. Remnant of vitello-intestinal duct. Antimesenteric border of ileum. 2% of population, 2ft from the caecum, 2in.
Clinical Presentations.
1.
2.
3.
4.
5.
( Asymptomatic nding at op or autopsy)
Acute inammation ( identical to appendicitis)
Perforation by foreign body
Intussusception ( ileo-ileal)
Peptic ulceration due to contained ectopic gastric epithelium. Melaena in children
at 1 0 y/o.
6. Patent vitello-intestinal duct.
7. Raspberry tumour at the umbilicus ( persistent umbilical extremity of the duct)
8. Vitello-intestinal band: causing obstruction or volvulus
Ix.
Cx.
commonest site.
Macroscopic Acutely bowel red, swollen. Mucosal ulceration + intervening
oedema = cobblestone. Thickened wall, " LNs. Skip areas.
Microscopic Fibrosis, lymphoedema, chronic inammatory inltrate through the
whole thickness of wall. Non-caseating foci w ssuring ulcers extending deep
through wall ! these may form abscesses or stulae.
Clinical. Most common 20-40y. = . Abdominal pain and diarrhoea.
1 . Acute: similar to appendicitis w RIF pain and vomiting. May have perforation or
haemorrhage.
2. Obstruction: due to post-inammatory brosis.
1 . Anaemia, faecal occult blood, # albumin, " inammatory markers
2. Small bowel enema: strictures, stula, cobblestone
3. Technetium labeled leucocyte scan: taken up in inamed segments
1 . Renal calculi: 2 hyperoxaluria ( cos usually excreted in bile) due to steatorrhoea
2. Biliary calculi: interruption of bile salt circulation due to resection
3. Primary sclerosing cholangitis, sacroilitis, pyoderma gangreosum, uveitis
Rx. Surgery avoided cos malabsorption may follow extensive resections of the bowel
Medical Conservative: nutritional support, elemental diet. Acute episodes : steroid,
immunosuppression ( azathioprine) , parental nutrition, TNF- . Mild symptoms : 5aminosalicylate drugs ( e. g. sulfasalazine) , steroids, metronidazole
Surgical Indicated for sev/ recurrent obstructive symptoms, & rx for stulae into
bladder or skin. Surgery should be as conservative as possible cos further resections
usually necessary ( it just recurs)
Prognosis. Recurrence is 50% in 1 0y
o
62 Tumours of the SI
Tumours
B enign
M alignant
Adenom a S trom al L ipoma H am artom a
61 Crohn's
Aetiology. Environment ( smoking, urban living) , Genetic ( FH)
Pathology. Can be any part of GIT. Small bowel in 2/3s w the lower ileum being the
3. Fistulas: penetrate adjacent gut or bladder, or be perianal.
4. Malabsorption: vitamin deciencies, resections.
5. Diarrhoea: inammation and mucosal ulceration, colonic/rectal involvement, bacterial overgrowth in obstructed segments. May have blood.
6. Perianal disease
1o
2o
AdenoC a L ymphom a C arcinoid S trom al
F igu re
1 3.
H amartom a: e. g. Peutz-J eghers
Bleeding
Obstruction
Intussusception
Volvulus
62.1 Carcinoid
Def. Amine Precursor Uptake and Decarboculation ( APUD) tumour. 1 0% association w
MEN-I. Most commonly appendix, but can be anywhere in GI tract & occasionally
lung. Secrete 5HT. Rarely ( but can be) symptomatic until have metastasized to liver
( where they secrete their hormone directly in to the circulation)
16
Pathology.
Macroscopic Yellowish submucosal nodule. Surface ulceration. Extension to serosa
leads to brosis & obstruction
Microscopic Kultshitzky cells. V slow growing ( presents > 40y) . 4% of the
appendix metastasize, or may present early w obstruction.
Clinical.
Ix.
1 . Flushing ( 80%) w attacks of cyanosis, chronic red faced, often precipitated by
stress, food or alcohol
2. Diarrhoea ( 70%) , profuse, noisy
3. Abdo pain ( 40%) due to mesenteric brosis resulting in partial obstruction
4. Bronchospasm
5. Abnormalities in the hrt ( valve stenosis) , hepatomegaly
1 . 5-HIAA urinary concentration ( the breakdown product of 5HT)
2. CT/ USS liver for 2 s
3. Radiolabelled octreotide scintigraphy
Rx. Resection in early cases, w removal of liver deposits. Palliation ( w more extensive
deposits) by chemo-embolization. Octreotide ( somastatin analogue) inhibits 5HT
release. Radiotherapy.
65 Diverticulosis Coli & Diverticulitis
Def. Outpouchings of mucous membrane. They are false because they lack normal
muscle coats ( unlike Meckel' s) . Most common in sigmoid & descending. Unusual < 40y
( acquired) . = . Common in West ( # bre) . Diverticulosis is usually asx
Pathogenesis. # Fibre diet ! " P in colon ! hypertrophy muscle ! " sigmoid colon ! herniation of the mucosa at sites of weakness ( where vessels enter wall)
66 Diverticulitis
Cx.
o
Clinical.
X The Colon
63 Constipation
1.
2.
3.
4.
5.
Organic: Ca colon, diverticular disease
Painful anal conditions: ssures, piles
Adynamic bowel: Hirschprung' s, senility, SC injuries, myxoedema, Parkinsons
Drugs: Aspirin, opiate, anticholinergics, ganglion blockers
Habit & diet: dehydration, starvation, lack of bulk, dyscheua ( faulty habit)
64 Diarrhoea
1.
2.
3.
4.
5.
6.
7.
Specic infx: food poisoning, dysentery, cholera, viral
Inammation: UC, Crohns, tumours, diverticular
Drugs: Abx, abx-induced colitis, erythromycin, purgatives, digitalis
Loss of absorptive surface: resections, sprue & coeliac, idiopathic steatorrhoea
Pancreatic dysfunction
Post-gastrectomy & vagotomy
General diseases: anxiety, thyrotoxicosis, uraemia, Carcinoid, Zollinger-Ellison
1 . Perforation:
a) Peritoneal causing peritonitis
b) Pericolic gutters causing pericolic abscess
c) Adjacent structures forming stula
2. Chronic infx w inammatory brosis ! obstructive symptoms
3. Haemorrhage: erosion of a vessel
Ix.
1 . Acute diverticulitis: Left sided appendicitis: low central abdo pain shifting to LIF,
fever, vomiting, tenderness, guarding, bleeding. Pericolic abscess : like an appendix
abscess ( so tender mass, swinging fever, leucocytosis)
2. Chronic diverticulitis: mimics Ca colon w: in bowel habit, obstruction,
blood/mucus PR. Ex reveals tender LIF & thickened mass in region of sigmoid
colon.
3. Diverticular disease: asx, grumbling abdo pain, constipation, Fe-decient anaemia
4. Sudden severe haemorrhage: rarer
5. colovesical stula: passage of gas bubbles: rarer
1.
2.
3.
4.
Fibreoptic sigmoidoscopy ( rigid' s do not visualize diverticula)
USS: abscess
Colonoscopy
Barium enema: ( D on' t perform in acute phase ) globular outpouchings showing
signet ring appearance cos of lling defect produced by contained pellets of faeces
( faecoliths) . Saw-tooth: narrowed segment due to oedema and thickening.
5. CT: in acute phase
. Ca
Rx.
Acute d ivertic ulitis Conservative: uids, abx ( met, pen, gen) . Pericolic
abscess : diagnosed by CT & drained. General peritonitis : laporotomy + resection.
Acute obstruction : laporotomy + resection + colostomy
Chronic d ivertic u lar disease Conservative: laxatives, " roughage diet. If sx
persist: laporotomy. Colovesival stula : resection + loop colostomy ( before anastomosis)
17
67 Angiodysplasia
.
vein) . Elderly. Caecum, ascending colon.
Clinical. Asx usually. Bleeding: continuous, chronic blood loss.
Ix. Colonoscopy ( bright red lesions) , mesenteric angiogram ( in actively bleeding pt' s)
Rx. Blood transfusion if " blood loss, electrocoagulation, resection ( sometimes)
logical ( pyoderma gangrenosum= ulcers on shins, skin rashes, ulceration of legs) , 1
sclerosing cholangitis
Malignant . Colon Ca risk
Def. 1 or more small mucosal or submucosal vascular malformations ( usually dilated
68 Colitis
1.
2.
3.
4.
Crohn's Colitis
UC
Perianal common
Perianal disease rare
Bleeding uncommon Often profuse haemorrhage
Transmural
Mucosal
Thickened bowel wall
No thickening
No polyps
Pseudo-polyps
Fistulas
No stula' s
Malignant rare
Malignant common
Granulomas
No granulomas
Ta b l e
Acute attack : Systemic corticosteroids. Maintain remission : salicylates.
Surgery Indications: fulminating disease not responding to medical rx, chronic not
responding to rx, prophylaxis against malignant , complications.
Usually total colectomy & removal of rectum ! permanent ileostomy or ileo-anal
anastomosis
70 Crohn's Colitis
Clinical. Mimics UC. Unlike UC commonly becomes adherent to adjacent structures w
abscess formation & stulas. Perianal disease.
Rx. Similar to Crohn' s of SI. Extensive bowel involvement may require total excision w
permanent ileostomy ( no anastomosis is made, risk of recurrence, sepsis, stulation) ,
71 Tumours
T umours
B enign
2 .
Def. Inammatory disease of the rectum, extending variably proximal. > . Peaks 20-
40y. Only large bowel.
Path. Oedema, haemorrhage ! ulceration. Edematous islands of mucosa btw ulcers form
pseudopolyps. Wall is brotic, w loss of haustrations. No skip lesions. Microscopically :
crypt abscesses, break down in to ulcers w base lined w granulation tissue.
Clinical. Fulminant, intermittent or chronic. Bloody/mucus diarrhoea. Cramp-like abdo
pains. Nothing on ex except tenderness in LIF, blood on glove. Sev attacks : toxaemia,
sev bleeding, risk of perforation, anorexia, wt loss. Distinguish btw functional : functional bowel disease pt' s don' t get up at night
Associations. Uveitis, pyoderma gangrenosum, sclerosing cholangitis, arthropathy
Ix.
1.
2.
3.
4.
5.
AXR: megacolon?
Sigmoidoscopy + biopsy: oedema of mucosa w contact bleeding in early mild cases
Colonoscopy
Barium enema: ragged surface ( ulceration + pseudopolyps) , loss of haustrations
Ex of stools
o
Rx.
Medical " Protein diet, vitamins. Blood transfusion. Diarrhoea : codeine phosphate.
UC/Crohns
Abx-associated: e. g. pseudomembranous due to C dicile
Infections
Ischaemic
69 Ulcerative Colitis
Dysenteries, carcinoma
Cx.
Local Toxic dilatation, haemorrhage, stricture, malignant , perianal disease
General Toxaemia, weight loss, anaemia. Autoimmune: arthritis, uveitis, dermato-
M alignant
Adenom a Polyp Papill L ipom a N eurof H aeman
1o
2o
C arcinoma L ymphom a C arcinoid
F igu re
1 4.
See oncology notes
72 Familial Adenomatous Polyps
Claim to Fame. Rare but inevitably progresses to Ca. Dominant.
Clinical. Polyps start in adolescence, sx of bleeding and diarrhoea commence early 20s,
malignant change 20-40y. Hypertrophy of the retinal pigment layer.
Gardener's syndrome . Variant where associated w desmoid tumours and osteomas of
the skull
Rx. Total colectomy w excision of the rectum, formation of an ileo-anal pouch.
18
73 HNPCC
Claim to Fame. 5% of colorectal Ca. Dominant. Right sided, occur < 50y.
74 Colostomy
5. Lateral space small bowel obstruction: due to failure to obliterate the space btw the
terminal colon & lat abdo wall
6. Psychological
Stoma appliances. Bag ( collects faeces) , adhesive ange ( cut to t stoma) . Pt' s can live
normal life w little risk of leakage or odour.
XI Rectum & Anal Canal
75 Bright Red Rectal Bleeding
1 . Haemorrhoids 2. Fissure-in-ano 3. Tumours
4. Diverticular 5. UC 6. Trauma 7. Angiodysplasia
8. Rarely higher up bleeding may produce red blood
76 Haemorrhoids
Anatomy. Anal cushions are highly vascular tissue lining anal canal, supplied by rectal
artery. Draining veins form saccules just below dentate line ! sup rectal vein.
Def. A vascular cushion, covered in a layer of mucosa and containing a branch of the
superior rectal artery and a tributary of the superior rectal vein.
Pathology. Abn anal cushions, congested ( as a result of straining) . In lithotomy position
F igu re
Indications. Divert faeces to allow healing of an anastomosis or stula ( avoid contamina-
tion) , decompress a dilated colon as a prelude to resection, removal of the distal colon
& rectum
Types.
Loop Antimesenteric border opened to surface. Rod often used to stop colon falling
back. Temporary.
End Divide colon & bring proximal end to the surface. May be denitive rx for
total rectal excision, or following perforated diverticular disease where diseased
bowel is removed & 1 anastomosis undesirable.
Double Barreled Proximal & distal brought out adjacent w intervening colon
removed . ( Not commonly used, except in sigmoid volvulus, cos distal bowel usually
too shor t)
o
Cx.
1.
2.
3.
4.
usually at 3, 7, 1 1 O' clock.
1 5 .
Retraction: colon disappears back down
Stenosis: due to ischaemia, poor technique
Paracolostomy hernia
Prolapse: colon intussuscepts out
Grading.
1 o bleed but don' t prolapse
2 o prolapse on defecation, reduce spontaneously
3 o remain prolapsed, pt reduces them
4 o Thrombosed
Predisposing. Factors that " congestion of sup rectal veins : compression by pelvic
tumour ( commonest is pregnancy, rectal Ca) , cardiac failure, purgative use, chronic
constipation ( straining)
Clinical. Bleeding ( bright red, occurring at defecation) , may be " " . Mucus discharge,
pruritus ani. Pain is only a feature if undergo thrombosis. Other pain may be due to:
ssure-in-ano, perianal haematoma, perianal or ischiorectal abscess, tumour of anal
margin.
Ix.
19
1 . Examination + PR ( prolapsing piles obvious)
2. Proctoscopy: int Haemorrhoids
3. Sigmoidoscopy
Cx.
79 Anorectal Abscess
4. Barium enema: exclude Ca
5. Colonoscopy
Classication.
Anaemia ( sev bleeding)
Thrombosis: when prolapsing piles gripped by the anal sphincter - venous return
occluded & thrombosis of pile occurs. Size of plums. Painful.
Rx.
Conservative Avoid straining, daily motion, laxatives
Medical LA, steroids
Surgical i. Sclerotherapy: 1 / 2 injected above dentate line ( painless)
ii. Banding ( rubber) : falls away in 4d. 1 /2
iii. Ectomy: 3 /4
Thrombosed, strangulated pt w foot of bed elevated, opiate analgesia, can do
haemorrhoidectomy
o
o
o
o
o
o
1.
2.
3.
4.
Perianal: infx of hair follicle
Submucous: infected ssure or laceration of anal canal
Ischiorectal: infection of an anal gland
Pelvirectal: spread from pelvic abscess ( rare)
Rx. Drainage to prevent rupture or stula
80 Fistula-in-ano
Def. Fistula : abn connection btw 2 epithelial surfaces ( e. g. hollow viscus and surface of
the body) . Sinus : granulating track leading from source of infection to a surface
Aetiology. Abscess, Crohns, UC, Ca.
Classication. Relation to internal and external anal sphincters:
Cx of haemorrhoidectomy.
1 . Retention: due to anal discomfort
2. Stricture: if excessive skin/mucosa excised
3. Post-op haemorrhage: may be reactionary ( post-op) , 2 ( week later) . May not be
visible. Rx: blood transfusion if severe, might need packing
4. Perianal haematoma ( thrombosed external pile) : thrombosis in inf rectal venous
plexus. Rx: evacuate.
o
77 Piloidal sinus
Def. Sinus containing hairs
Description. May become infected ! pilonidal abscess. May have chronic discharge
Claim to Fame. Common in ngers of hairdressers
Rx. Excision
78 Fissure-in-ano
Def. Tear in anal margin, usually follows passage of constipated stool. Usually pos midline.
Clinical. Acute anal pain, stinging, lasts for a while after passing stool. Slight bleeding.
Constipation ( due to pain) . May be sentinel pile ( torn tag of anal epithelium) . PR
may be impossible w/ o anaesthetic. 1 0% anterior midline, 90% posterior midline.
Rx. May heal spontaneously. Laxatives + uid. LA+ lubricant gives relief. GTN cream
( relaxes the smooth muscle of the sphincter. SE: headache) . Sphincterotomy: can
divide int sphincter submucosally under GA. Recurrence needs excision.
F igu re
1 6.
G oodsall' s law
Clinical. Persistent discharge of pus. Ex reveals opening. Internal opening may be felt
PR. Need to determine path of stula tract.
Rx. Supercial/ low level anal stulae laid open & left to heal by granulation ( no loss of
continence as not dividing sphincters) . High stulae ( supraphincteric, and trans
sphincteric close to anorectal ring) only lower part laid open ! seton passed through
upper part so xed by scarring ! can repeatedly tighten this.
81 Stricture of Anal Canal
Classication.
1.
2.
3.
4.
5.
20
Congenital
Traumatic: post-op
Inammatory: lymphogranuloma inguinale, Crohn' s, UC
Post-irradiation
Neoplasm
Rx. Underlying pathology. May need dilatation, reconstruction, defunctioning colostomy,
Ix. Biopsy
Rx. Excise villous and adenomatous
82 Rectal Prolapse
86 Ca Rectum
excision ( Ca) .
Classication.
Partial Mucosa only. Occurs in infants: reassurance as self-limiting.
Complete All layers. Usually elderly . Incontinence also, due to stretching of
sphincter.
Rx. Partial : Excision of redundant mucosa. Complete : Can xate rectum in pelvis by
wrapping mobilized rectum in polyvinyl sponge.
83 Pruritus Ani
Path. = . 20+ .
Predisposing. Adenoma, FAP, UC
Macroscopic.
Papilliferous
Ulcerating ( commonest)
Stenosing ( usually rectosigmoid)
Colloid
Microscopic. 90% adenoCa, 9% colloid. Remainder anaplastic carcinoma simplex.
Spread.
Local Circumferentially around lumen, muscular, adjacent organs ( prostate,
Causes.
1.
2.
3.
4.
Local causes within anus or rectum: e. g. lack of cleanliness, " sweating
Skin diseases: scabies pediculosis, fungal
General diseases assoc w pruritus: DM, Hodgkins, obstructive jaundice
Idiopathic: often due to continued scratching
Rx. Underlying cause. Hydrocortisone ointment, hygiene
bladder. . . )
Lymphatic Regional LNs along inf mesenteric vessels
Blood Liver, lungs
Transcoelomic Peritoneal cavity
Staging. Dukes:
84 Tumours
Type
A
B
C
D
T umours
B enign
M alignant
2o
Adenom a Papilloma lip om a E ndom etriom a AdenoC a S C C M elanom a C arcinoid L ym phom a
F igu re
1 7.
85 Rectal Polyps
Types.
Metaplastic polyp 2-3 mm sessile, wart-like. Often multiple, always benign, not
truly Metaplastic
Adenomatous polyp Benign polyp, may undergo malignant Villous adenoma Can grow large, produces " mucus, may undergo malignant Pseudopolyp Assoc w colitis. Is oedematous mucosa against an ulcerated wall
Juvenile polyp Children & young adults. Looks like a cherry on a stalk. Always
benign. May bleed & prolapse
Ta b l e
3.
5y Surv.
90%
60%
30%
5-1 0%
Description
Conned to mucosa
Through wall
Lymph nodes
Distant
Rx
Surgery
Surgery
C hemo
Praying
No te : A lso give ra d io the ra py fo r rec ta l ( not colon ) C a .
Clinical. Local sx ( Constipation+ diarrhoea ( 80%) , bleeding, tenesmus, mucus, pain) , 2
Ix.
o
deposits, general Ca eects
1 . Sigmoidoscopy + biopsy
2. Barium enema
3. USS: liver mets, ascites
. Benign, prolapsed Ca sigmoid tumour, ovarian/ uterine tumours, prostate/ cervix
extending tumours, diverticular, endometriosis, lymphogranuloma inguinale, amoebic
granuloma, faeces
Rx.
Curative 21
Upper 2 thirds: anterior resection ( resection + anastomosis)
22
C a Rect um
Lower third: less than 5cm from anal verge then abdominoperineal excision of
the rectum and terminal colostomy. Radiotherapy
Palliative Resect primary. Colostomy might be necessary for obstruction ( but
doesn' t relieve bleeding etc. ) . Inoperable : Radiotherapy, diathermy, laser.
XII Peritonitis
Aetiology.
1 . Exterior: e. g. penetrating wound, laporotomy ( 30%)
2. Intra-abdominal viscera: gangrene ( e. g. acute appendicitis ( 20%) ) , perforation
( e. g. peptic ulcer ( 20%) )
3. Blood stream: septicaemia
4. Female genital tract
Causes. Absorption of toxins from inamed surface, paralytic ileus, gross abdominal distension predisposes to pneumonia & collapse ( due to elevation of diaphragm)
Clinical.
C onstant pain ( aggrav by movement) , guarding, rigidity,
sounds .
c) P ost-op : after every lap. Lasts 24-48h.
Path. Sev loss of uid, electrolytes, into lumen ! vomitus. Gross distension impairs blood
supply.
Clinical. Post-op stage of peritonitis/major surgery. 4 features of obstruction. Silent
abdomen ( noisy abdomens in mechanical obstruction) . Relatively painless. Beware
that it may merge in to obstruction caused by adhesions post-op. If symptoms commence after already passing motions then likely mechanical.
Ix. AXr: gas distributed through small and large bowel ( in mechanical localized loops
seen)
Rx.
Prophylaxis NG suction
Established NG suction. Pethidine ( unlike others, has little eect on motility) .
Stubborn : metoclopramide ( dopamine agonist) , erythromycin.
XIV Hernias
o bowel
Sx of the 1 , sev pain aggravated by movement, shoulder tip pain possible, " temperature, " pulse, rigid wall, rebound tenderness, silent abdomen, tenderness on PR.
Advanced : distended & tympanic, free uid, toxic.
o
Ix.
1.
2.
3.
4.
FBC
Amylase ( pancreatitis)
CXR: gas under diaphragm
CT: free gas, pinpoint source of peritonitis
. Obstruction, ureteric/ biliary colic, pneumonia, MI, haemorrhage, AA leakage
XIII Paralytic Ileus
Def. Obstruction due to lack of motility
Aetiology.
1 . Reex paralytic: ANS supply interference ( e. g. fractures to spine, retroperitonal
haemorrhage, intestinal ischaemia, ureteric colic)
2. Peritonitis: toxic paralysis of intrinsic N plexuses
a) Metabolic: sev # K, uraemia, diabetic coma
b) Drugs: Anticholinergics, anti-parkinsonsian
F igu re
22
1 8 .
87 Denitions
Conservative Truss only if v poor condition.
Hernia. A protusion of an organ or part of an organ through a defect in the wall of the
cavity containing it, into an abnormal position. Strangulated. Sev pain in the hernia of sudden onset, & central abdo colicky pain. Sx of
obstruction: vomiting, distension, absolute constipation. Tender, tense hernia that
cannot be reduced & has no cough impulse. Overlying skin inamed, oedematous.
Signs of obstruction: distension, tenderness, noisy bowel sounds.
88 Inguinal Hernia
Indirect
Direct
May be congenital
Always acquired
Strangulate commonly cos narrow neck Rarely ( wide necked)
Scrotum extension often
Rarely
Not reduce on lying readily
Spontaneously
Recurs uncommon
More common
Lateral inf. epig
Medial
Ta b l e
4.
Anatomy of canal.
Contains Spermatic cord ( round lig in ) , ilioinguinal nerve
Anteriorly Skin, supercial fascia, ext oblique aponeurosis
Posteriorly Medially: Conjoint tendon ( the fused common aponeurotic insertion of
the int oblique and transzersus abdo muscles into the pubic crest) . Laterally:
transversalis fascia
Above Lowest bers of int oblique
Below Inguinal lig
Int ring Where spermatic cord pushes through transversalis fascia, demarcated
medially by inferior epigastric
Ext ring V-shaped defect in ext oblique aponeurosis
Indirect hernia. Controlled by pressing over internal inguinal ring ( 1 . 5cm above femoral
pulse, felt half way btw ASIS and PS) . If protudes through ext ring can be felt above
and medial to PT. May be due to persistence of processus vaginalis, present young.
Narrow ring.
Direct hernia. Not controlled by pressure over int ring.
Rx.
Infants Excise hernial sac at 1 y ( herniotomy)
Adults Excision of sac & repair of inguinal canal
89 Femoral Hernia
Anatomy. Gap 1 . 5cm in length lying at medial extremity of the femoral sheaf containing
femoral artery & vein. Boundaries:
Anteriorly Inguinal lig
Medial Sharp edge of lacunar part of inguinal lig
Lateral Femoral vein
Posteriorly Pectineal ligament of Astley Cooper
Epi. : = 4: 1
Clinical. > ( wider pelvis) , middle aged/elderly. Never congenital, although rarely
occur in children. Globular swelling below and lateral to PT. Enlarges on standing,
coughing, may disappear on lying down. Narrow neck, sharp medial border: strangulation v common.
90 Richter's Hernia
Def. Only part of wall herniated through, where it is then strangulated. But not
obstructed, although this part can become necrotic or perforate.
Rx. Excision of sac & closure
91 Umbilical Hernia
Exophthalmos. Failure of midgut to return to abdominal cavity in fetal life. Bowel contained in translucent sac.
Rx. Immediate surgical repair. If massive then protect in dressing & repair later
92 Para-umbilical Hernia
Def. Acquired hernia above/ below umbilicus. Obese, middle aged, multiparous . Prone
to strangulation.
93 Epigastric Hernia
Def. Defects in linea alba above the umbilicus.
23
94 Congenital Umbilical Hernia
Rx. Surgical repair not carried out unless persists past 2y
95 Incisional Hernia
About. Strangulation is rare cos wide neck
Rx. If good general condition then dissecting out & suturing individual layers of the abdo
wall. Large hernias w polypropylene mesh.
2.
3.
4.
5.
6.
7.
Inammatory: hepatitis, portal pyaemia & liver abscess, leptospirosis, actinomycosis
Parasitic: amoebic hepatitis & abscess, hydatid
Neoplastic: primary, secondary
Cirrhosis: portal, biliary, cardiac, haemochromatosis
Haemopoietic diseases & reticuloses: lymphoma, leukaemia, polycythaemia
Metabolic: amyloid, Gauchers
Also check. The spleen ( cirrhosis, polycythaemia, leukaemia, amyloid) and LNs ( lymphoma)
99 Jaundice
Metabolism.
96 Unusual Hernias
Obturator Thin, elderly . Through obturator canal. Pressure on obturator nerve
may cause pain down thigh
Spigelian Passes up through arcuate line into the lat border of the lower part of the
pos rectus sheaf. Tender mass to one side of the lower abdo wall
97 Acquired Hiatal Hernias
Types. Sliding ( 90%) , rolling ( 1 0%) . The hernia part covered by peritoneal sac. Obese,
middle aged, elderly, .
Clinical.
1 . Mechanical: cough, dyspnoea, palpitations, hiccup
2. Reux: Incompetence of cardiac sphincter
3. Oesophagitis: strictures, dysphagia, bleeding
Rx. Conservative ( raise head of bed) , medical ( PPI, H receptor) surgical ( Nissens) .
Sliding : symptomatically. Rolling : if develop volvulus then repair.
2
F igu r e
XV Liver
1 9 .
Classication.
Prehepatic Haemolytic e. g. spherocytosis
Hepatic Hepatitis ( viral, leptospirosis, glandular fever) , cirrhosis, cholestasis from
drugs ( e. g. chlorpromazine) , liver poisons ( e. g. paracetamol) , tumours
98 Liver Enlargement
Posthepatic 1 . Lumen: gallstones
2. Wall: congenital atresia of cbd, traumatic stricture, 1 / 2 sclerosing cholangitis,
tumour of bile duct
3. Outside wall: pancreatitis, Ca head of pancreas, Ca ampulla of Vater, cholecystitis
Clinical. Normally impalpable except in infants.
Causes.
o
1 . Congenital: Riedel' s lobe, polycystic
24
o
Ix.
1 . Serum bilirubin: > 35 mol/L in jaundice
2. Bilirubin: conjugated in post-hepatic
3. Bilirubin in urine: posthepatic and dark ( only excreted by kidney in water soluble
form, hence not present in pre-hepatic. )
4. Bilirubin in faeces: " in prehepatic and hepatic cos large amounts secreted into gut.
In posthepatic it is obstructed from entering faeces, hence pale .
5. Haemolytic blood tests: rbc fragility, Coombs, reticulocyte count
6. " ALP in obstructive
7. Serum proteins: in hepatic jaundice has reversed albumin/ globulin level
8. Haptoglobins: low in pre-hepatic ( binds free hbg after haemolysis)
9. " Transaminases in hepatitis and active cirrhosis
1 0. Prothrombin time: normal in pre-hepatic, # but correctable ( vit K) in hepatic, and
# advanced hepatic
1 1 . USS: gallstones ( except missed in bile ducts)
1 2. CT/ MRI
1 3. Biopsy: hepatitis, cirrhosis suspected
1 4. MRCP
1 5. ERCP
1 6. Percutaneous transhepatic cholangiography ( PTC) : cannulate bile duct
Ix summary.
Exclusion of pre-hepatic causes haptoglobin level, reticulocyte count, Coombs
Liver synthetic function prothrombin time, albumin
Liver cell damage transaminases, GGT, transferase
Bile duct obstruction ALP, USS bile ducts, PTC, ERCP, MRCP, CT
Intrahepatic mass cross-sectional imaging such as CT + needle biopsy
100 Congenital Abnormalities
Riedel's lobe Big, downward R lobe
Polycystic liver Assoc w polycystic kidneys. Functions normally. Discomfort. Haemorrhage into cysts, cholangitis are complications
101 Liver Trauma
Aetiology. Penetrating wounds, cloded crush injury
Ix. Ct useful to distinguish btw ruptured spleen
Rx.
102 Acute Infections
Can arise from:
Portal ( usually diverticular sepsis, appendicitis)
Biliary, resulting from ascending cholangitis
Arterial: general septicaemia ( unusual)
Adjacent infections: e. g. subphrenic abscess or acute cholecystitis
103 Pyogenic Liver Abscess
Aetiology. Infection in the portal territory ! portal pyaemia, or infection in the biliary
tree. E coli, Strep faecalis, Strep milleri.
Portal Pyaemia Focus of intra abdo sepsis. Rare since abx.
Biliary Infection Sev suppurative cholangitis ( Charcot' s intermittent hepatic fever :
pyrexia, rigors, jaundice) 2 gallstone impaction in the cbd.
Clinical. Insidious, w malaise. Rigors, high swinging temperature, tender palpable liver,
jaundice. Previous hx of abdo sepsis such as Crohns.
o
Ix.
1 . Blood culture
2. USS/ CT: abscesses, source of pyaemia
Rx. Liver abscess : drain under USS guidance. Smaller : parental abx. Biliary infx : Urgent
drainage of bile ducts by either endoscopic sphincterotomy or percutaneous transhepatic drainage, IV uids to prevent hepatorenal syndrome.
104 Amoebic Liver Abscess
Aetiology. Entamoeba histolytica infection of colon. Abscess in liver is sterile.
Ix. CT, USS. Rx. Metronidazole.
105 Hydatid Disease of the Liver
Claim to Fame. Liver is source of 75% hydatid cysts in body
Path. Dogs infected w Echinococcus granulosus after eating sheep oal ( therefore " in
sheep rearing countries) ! tapeworms ! humans eat ! liver.
Clinical. Symptomless mass. Active may:
i. Rupture in to peritoneal ( peritonitis) / pleural ( haemoptysis) /alimentary ( pass in
faeces) /biliary
ii. Become infected
iii. Jaundice due to pressure on intrahepatic bile ducts. ( Malaise, pruritus)
1 . Conservative: blood transfusions, observation
2. Continued bleeding: laporotomy ( packing, suturing liver, tie o arterial branches) ,
abx cover
25
Ix.
1.
2.
3.
4.
XR liver: clear zone, ecks of calcication
USS/ CT: localize
Serological
Eosinophilia
Rx. Leave calcied cysts alone. Others : Albendazole ( shrinkage) . Failure to respond :
surgery.
106 Cirrhosis
Def. Chronic hepatic injury. Healing by regeneration & brosis.
Aetiology.
1.
2.
3.
4.
Parenchymal: alcoholic, viral ( B, C)
Metabolic: haemochromatosis, Wilsons
Biliary: 1 biliary cirrhosis, 2 to prolonged biliary cirrhosis
Hepatic venous outow obstruction: Budd-Chiari, sev chronic congestive cardiac
failure
5. Other: chronic active hepatitis, schistosomiasis, nutritional, idiopathic parental
nutrition related, non-alcoholic steatohepatitis
o
o
Consequences.
1 . Hepatocellular failure: impaired protein synthesis ( " prothrombin time, # albumin) ,
impaired toxin metabolism ( encephalopathy) , impaired bilirubin metabolism ( jaundice)
2. Portal hypertension
3. Ascites: # albumin & " portal P
4. Malignant change
Management of ascites.
1.
2.
3.
4.
5.
Paracentesis: immediate relief. Need to replace protein being removed
Diet: # Na, " protein, IV albumin
Diuretics
Iatrogenic portal-systemic shunt: portal vein to vena cava
Liver transplant: for intractable ascites
Hepatorenal syndrome. Renal failure. Partly due to depletion of IV volume. Prevention : Avoid uid depletion, maintain a good intra-op diuresis w mannitol infusion.
107 Portal Hypertension
Def. > 50 cm H O
Aetiology. Obstruction to drainage. ( Remember this classication travels the opposite
2
way to jaundice classication. )
Prehepatic Congenital, portal vein thrombosis in neonatal ( spreading from infx) ,
occlusion by tumour or pancreatitis
Hepatic C irrhosis ( commonest by far)
Posthepatic (Budd-Chiari) Idiopathic venous thrombosis ( OCP, haematological. . . ) , tumour ( block hepatic veins)
Cx.
1 . Collateral portosystemic drainage:
i. L gastric ! oesophageal
ii. Obliterated umbilical vein to sup/inf epigastric veins ( caput medusa)
iii. ( Retro) peritoneal & diaphragmatic anastomoses
iv. Between sup & inf rectal veins
2. Splenomegaly: due to congestion. Get leucopenia, thrombocytopenia ( spleen more
active)
3. Ascites. ( Other causes of ascites include: heart failure, renal failure, liver failure,
carcinomatosis, chronic peritonitis e. g. TB )
Eects of liver failure. Jaundice, encephalopathy
Ix.
LFTs 2. Liver synthetic tests 3. Liver biopsy
Fibreoptic endoscopy: varices
Splenic venogram: site of portal obstruction
IVC-agram: hepatic venous occlusion
MR angiography, CT angiogram: same as splenic venography
Rx. Uncomplicated: underlying condition ( e. g. cirrhosis managed by well balanced diet,
low alcohol) . Varices on endoscopy : sclerosant injection
Management of haemorrhage from varices. 50% mortality: liver further damaged by
hypotension, " encephalopathy
Prophylaxis -blockers ( # portal venous pressure) , band ligation, sclerosant injection
Diagnose includes gastric erosions. Endoscopy.
Immediate rx Blood transfusion. Enema to # blood absorption from gut, withholding protein.
Stopping haemorrhage 1 . Endoscopic variceal band ligation or sclerotherapy: risk of perforation, stenosis
( injections
2. IV vasopressin: # portal venous pressure. Give GTN to # myocardial ischaemia
3. Balloon tamponade: Sendstaken Blakemore tube. Rebleeding common after
removal
4. Trans-jugular intrahepatic portosystemic shunt ( TIPS) : metal stent passed
through liver to open passage btw hepatic vein and portal vein ! decompress
portal system. Causes encephalopathy.
5. Oesophageal transection: oesophagus + varices divided at cardio-oesophageal
junction by stapling gun, to prevent the anastomoses
6. Porto-caval shunt: surgical anastomoses of portal vein to IVC to shunt portal
blood directly to systemic venous circulation. Encephalopathy.
26
1.
4.
5.
6.
7.
Liver transplant Candidate
Mixed ( 75%) Faceted one against the other, and can be grouped into 2 or more
Cx.
108 Liver Neoplasms
Tum ours
1 o m alig
2 o m alig ( m ost com mon)
B enign
H C C F ibrolam ellar cacinom a C holangioC a. Portal: gut S yst Direct: G B H aem ang. Aden. F N D
F igu re
2 0 .
F N D: focal nodular hyperplasia
See oncology notes
108.1 Cholangiocarcinoma
Epi. 20% of 1 s of liver.
Path. AdenoCa of intrahepatic bile system.
Clinical. Jaundice, may complicate primary sclerosing cholangitis. Spread throughout
o
liver and to nodes.
Rx. Relieve jaundice: stent at ERCP.
XVI Gallbladder and Bile Ducts
109 Congenital
Most important is biliary atresia: neonatal jaundice
110 Gallstones
Types.
Cholesterol (20%) Solitary oval stone, or 2 stones. Appearance radiating crystals.
May be assoc w " cholesterol. Correlation w OCP, pregnancy, obesity, # dietary
bre, removal of terminal ileum e. g. in Crohns ( interruption of enterohepatic circulation) . This supersaturated bile is lithogenic.
Pigment (1 -2%) Calcium bilirubinate. Small, black, irregular, multiple, gritty.
Haemolytic anaemias ( e. g. spherocytosis) .
series all of the same size ( generations)
1 . Silent
2. Impaction in gallbladder: either in Hartmann' s pouch or cystic duct ! water
absorbed from bile ! concentrated ! chemical cholecystitis. If stone impacts in
Hartmann' s pouch when GB empty then walls of GB may continue to secrete
mucus ! distends to form a mucocele .
3. Choledocholithiasis: common bile duct, may produce intermittent or compete
obstruction w pain & jaundice
4. Gallstone ileus: ulceration through the wall of the GB ! may pass or get stuck in
distal ileum ( narrowest part) . Rare.
Clinical.
Biliary colic Impaction of the stone in Hartmann' s pouch ( out-pouching of the
wall of the gallbladder at the junction of the neck of the gallbladder and the cystic
duct) or cystic duct or common duct. Following which the calculus either falls back
or is passed along the duct. Pain caused by contractions of the smooth muscle
against the stone: rises to plateau w colicky exacerbations which last many hrs. R
subcostal, may be epigastric, or band across upper abdo. Radiation to scapula,
shoulder. Vomiting, sweating.
Acute cholecystitis 95% gallstone origin. Stone remain impacted in GB outlet !
GB wall inammation ! cholecystitis ! pus lled. Pain persistent, intensifying.
Fever, leucocytosis. Tender upper abdomen, palpable mass in region of GB ( GB
wrapped in inammatory adhesions to adj organs) . Empyema, perforation may
occur. May press against CBD causing jaundice .
Chronic cholecystitis Almost all gallstone related. Inammation, wall thickening.
Recurrent bouts of abdo pain due to mild cholecystitis fever. Experienced after
fatty meals ( ! CCK) .
CBD stones May be asx. Often biliary colic w obstructive jaundice , pale
stools, dark urine. Attacks for h' s ! d' s. Attack ceases when small stone passed.
Cx:
i. Ascending cholangitis: infx causing jaundice, pain, fever , rigors
ii. 2 biliary cirrhosis
is: w jaundice ( Ca pancreas, acute hepatitis, other) , w/o jaundice ( renal colic,
intestinal obstruction, angina pectoris)
Perforation Peritonitis
Empyema Swinging pyrexia
Courvoisier's law. If in the presence of jaundice the GB is palpable, the cause is
unlikely to be stones, cos of brosing of the GB.
o
Ix.
27
1.
2.
3.
4.
USS: presence of gallstones, thickened wall of GB, dilatation of the CBD
AXr: gallstones in 1 0%
Upper GI endoscopy: exclude peptic ulcer, hiatus hernia
LFTs: " ALP w gallstones
5. MRCP
6. ERCP: allows extraction, sphincterotomy. Not normally GA
7. IV/oral cholangiography: largely superseded
Rx.
Acute cholecystitis 90% resolve on abx, pain relief. Elective lap cholecystectomy
6w later. If diagnosis in doubt : laporotomy is performed. Empyema : requires emergency drainage. Perforation : needs urgent surgery.
Chronic cholecystitis Cholecystectomy, operative cholangiogram performed by
injecting radio-opaque dye: if stones found then remove them ( ?open op now) &
insert T-tube 1 0d post-operatively. T-tube removed 1 0d after provided a check
cholangiogram taken conrms clear tubes. Alternatively can do lap exploration of
CBD, or wait until post-op ERCP & extract using Dormia basket/balloon.
Obstructive jaundice due to stones ERCP & removal using Dormia/ balloon.
Subsequent cholecystectomy. Giving vit K before helps clotting ( lacking cos not
absorbed in bile-poor gut) .
Non-surgical Dissolution w ursodeoxycholic acid : small, non-calcied stones.
Lithotripsy : but passage causes colic. Symptomless : cholecystectomy not usually
advised unless comorbidity.
Cx of Cholecystectomy.
1 . Leakage of bile: due to injury to bile ducts inside or out of liver. Rx: ERCP and
stenting ! if fails then perc drain
2. Jaundice: missed stones, inadvertent injury, cholangitis/pancreatitis
111 Gallbladder Polyps
Pathology. If single, consider malignant lesion, risk " w size
Clinical. Asx. If near Hartmann' s then may produce gallstone-like pain
Rx. Symptomatic, or large: cholecystectomy.
112 Ca Gallbladder
Pathology. Assoc 85% w gallstones. 50% of porcelain gallbladders. 90% adenocarcinoma
Clinical. Resembling chronic cholecystitis.
Rx. Resection/ liver resection, but poor prognosis unless found incidentally at chole.
113 Cholangiocarcinoma
Pathology. Increasing. Assoc w IBD. , > 50y. Adenocarcinomas
Clinical. Painless progressive obstructive jaundice. Epigastric pain, steatorrhoea, weight
loss. May be hepatomegaly. MRCP/ ERCP/CT biopsy
Rx. Slow growing. Can palliate w endoluminal stenting at ERCP. or surgical bypass.
Poor prognosis.
XVII Pancreas
114 Acute Pancreatitis
Aetiology. GET SMASH' N:
G allstones, E thanol , Trauma, Steroids, Mumps,
Autoimmune ( e. g. SLE) , Scorpion bites, Hyperlipidaemia ( hyperparathyroidism,
hypothermia, hereditary) , Neoplasia
Path. Autodigestion, due to release of digestive enzymes. E. g. once trypsin released from
trypsinogen, it cleaves other pro-enzymes. Reux important ( hence assoc w bile
stones) . Liquefying necrotic material & inammatory exudate collects in the lesser sac:
pseudocyst ( walled by stomach in front & necrotic pancreas behind) . Liberated
enzymes:
i. Trypsin: autodigestion
ii. Lipase: fat necrosis
iii. Amylase: high serum level
Clinical. Gallstone: usually middle aged/ elderly. Alcoholic: < 40y. Rapid onset epigastric
pain radiating into the back. Pt sits forward, repeated retching is common. Profuse
vomiting. Shocked. May be feverish. May have jaundice. Grey-Turner' s sign ( few days
after attack) .
. Acute cholecystitis, perforated peptic ulcer
Ix.
1 . Serum amylase: acutely 5 raised, returns to normal after 2/3 d ( normal in 30%) .
Urinary amylase elevated for longer. ( Also high in many conditions inc: impaired
renal excretion, DKA, perforated peptic ulcer, cholecystitis, intestinal obstruction. . . )
2. FBC: leucocytosis, anaemia
3. " Blood glucose
4. " Serum bilirubin
5. ABG: hypoxia
6. # Serum calcium: due to fat soponication
7. CT: pancreatitis, necrotic, abscess, pseudocyst
8. AXR: absence of free gas ( distinguish from in perforation)
9. USS: gallstones, dilatation of cbd
Rx. ICU
28
115 Severe Acute Pancreatitis
2.
3.
4.
5.
Path. Haemorrhagic necrosis, systemic release of vasoactive peptides & enzymes. Acute
lung failure. Acute renal failure ( toxins, # volume) .
G las g ow C riteria
.
AXr: calcication, calculi
CT: enlargement, irregular consistency
ERCP: dilation & irregularity of pancreatic duct
Endoscopic USS + aspiration cytology: standard technique for examining head of
pancreas
6. Exocrine function tests: faecal elastase
1 . Age > 55
2. Hyperglycaemia: Pancratic dysfunction
3. Leucocytosis: Inammatory
4. Urea > 1 6: Renal damage
5. PO < 8 kPa: ARDS
6. Calcium < 2: Fat sequestration
7. Albumin < 32: Inammatory
8. Lactate dehydrogenase > 600
9. " Transaminases: Gallstones
PANCREAS: PaO2 < 8 kPa, Age over 55, Neutrophilia, Calcium, ( low) Raised Urea,
Enzyme elevation: LDH, AST/Albumin 32g/L, Sugar ( glucose 1 0 mmol/ L)
117 Pancreatic Cysts
1.
2.
3.
4.
5.
6.
7.
perforation ( rare)
Clinical. Firm, large, rounded, upper abdo swelling.
Rx. True : surgical excision. False : drainage
Rx.
1.
2.
3.
4.
5.
2
Supportive.
Analgesia: pethidine
Fluid replacement
Resting the pancreas: NBM, nasogastric aspiration if vomiting
TPN/NJF
Abx
Prophylaxis against gastric erosions: sucralfate, H rec antagonist
Endoscopic sphincterotomy: gallstone pancreatitis
Surgery. Avoided early. Later , operative debridement of necrotic pancreas. Pseudocyst :
drainage. Gallstone origin : cholecystectomy.
Cx.
1.
2.
3.
4.
5.
6.
7.
8.
2
Abscess formation w pancreatic necrosis: pyrexia, leucocytosis
Pseudocyst: fullness/discomfort in stomach, palpable mass
GI bleeding from erosions
Renal failure: shock
Pulmonary: acute lung injury ( ARDS)
Further attacks
DM: due to necrosis
Fat embolus
Analgesia
Diet: # fat w pancreatic enzymes
Insulin for DM
Surgery if attacks v frequent: partial pancreatectomy
Painless obstructive jaundice: Roux-en-Y reconstruction, Whipples
Classication.
True ( 20%) Congenital polycystic disease, retention, Hydatid, Neoplastic
False ( lesser sac) Trauma, following acute pancreatitis, due to pos gastric ulcer
118 Pancreatic Tumours
Tumours
M alignant
1o
B enign
2 o : stomach, bile d. Adeno C ystaden,
Adenocarc. C ystadenoC . Islet-cell
116 Chronic Pancreatitis
Z ollinger Insulin. G lucag.
F igu re
2 1 .
See oncology notes
Def. Gradual destruction of the functional tissue
Aetiology. Alcoholism. Hypercalcaemia ( rarely)
Clinical. Asx. Recurrent abdo pain relieved by leaning forward. Steatorrhoea. Diabetes.
119 Multiple Endocrine Neoplasia
Ix.
Type 1 .
Obstructive jaundice.
1 . Amylase: may be elevated in attacks of pain.
1 . Parathyroid hyperplasia
29
Islet cell tum our
2.
3.
4.
5.
XVIII The Spleen
Pancreas Insulinoma
Pituitary tumour
Peptic-acid producing: Zollinger -Ellison
Adrenocortical, carcinoid
Type 2. Medullary cell carcinoma of thyroid & phaeochromocytoma plus:
a Hyperparathyroidism
b Neurobromata (& marfanoid habitus)
120 Splenomegaly
119.1 Islet Cell Tumours
Classication.
Claim to Fame. Rare, but have interesting metabolic eects. MEN syndrome.
Path. APUD. G lucagon ( ) , insulin ( ) , somatostatin ( ) , pancreatic polypeptide
.
1 . Enlarged L kidney: resonant as covered by bowel
2. Ca cardia: sx of gastric obstruction
3. Enlarged L lobe of liver
1 . Infectious: viruses ( glandular fever) , bacterial ( typhus, typhoid, septicaemia) , protozoal ( malaria, schistosomiasis) , parasitic ( hydatid)
2. Haematological: Leukaemia ( chronic myeloid , chronic lymphocytic) , lymphoma ,
myelofibrosis / ITP/ polycythaemia rubra vera , haemolytic anaemia
3. P ortal hypertension
4. Metabolic & collagen disease: amyloid ( 2 RA) , storage disorders ( e. g. Gauchers)
5. Cysts, abscesses, tumours ( uncommon)
( F) , serotonin ( enterochroman)
119.2 Insulinoma
Path. 80% benign, 1 0% malig, 1 0% multiple.
Clinical. When pt hungry or during exercise. Often early morning. Excessive appetite w
gross weight gain.
CNS phenomena Weak, sweating, trembling, epilepsy, confusion, hemiplegia,
coma
GI phenomena Hunger, abdo pain, diarrhoea
Whipple's Triad.
Ix.
1 . Induced by starvation, exercise
2. Hypoglycaemia in attack
3. Relieved by sugar
1 . " Insulin w hypoglycaemia
2. " C-peptide: rule out exogenous insulin ( # )
3. CT, MR, endoscopic USS: localization
Rx. Excision. May require Whipples
119.3 Gastrinoma
Path. Malignant ( 30%) . Secretes gastrin-like into blood stream ! " gastric HCl excreIx.
tion ! peptic ulcers
1 . " Serum gastrin 2. " Basal acid output: measured by NG aspiration
3. Localization
Rx. Excision , or if impossible PPIs.
o
121 Splenectomy
Indications. Rupture, massive splenomegaly, haematological disease ( haemolytic
anaemia inc spherocytosis, thrombocytopenia purpura) , tumours/ cysts
May be useful. Portal hypertension, autoimmune haemolytic anaemia, myelobrosis,
trauma, Gauchers
Cx.
1 . Gastric dilatation: due to gastric ileus and accumulation of swallowed air. NG tube
placed to prevent.
2. Thrombocytosis: aspirin
3. Post-splenectomy sepsis: Prophylactic immunization w meningococcal, H Inuenzae
type B, annual u vaccines, prophylactic low dose penicillin.
122 Ruptured Spleen
Clinical.
1 . Massive bleeding
2. Peritonism from blood loss: abdo pain diuse or L ank, shoulder tip pain
3. Delayed rupture: hours ! days. Due to haematoma growing then rupturing
Ix. Clinical diagnosis ! procede to laporotomy
1 . CXR
2. AXR: stomach bubble displaced to R
3. USS: free uid, intrasplenic haematoma
30
Rx.
Ix. May mimic Ca on mammography. USS diagnoses. Core biopsy
4. CT: laceration of spleen
5. Urinalysis for blood
1 . Blood transfusion
2. Emergency splenectomy: if hopelessly pulped
3. Suturing of spleen/packing: if minor laceration
125 Acute inammation
Epi. Childbearing.
Classied.
Periductal mastitis Inammatory occuring around dilated milk ducts. Smoking
( ! dierent bacterial ora) . Pain, discharge. May have cellulitis, nipple retraction,
or mass. Rx: abx ( usually uclox)
Acute bacterial mastitis Commonest. Most often during lactation. Cellulitis or
abscess 2 staph aureus. Pain, swelling, tenderness, erythema. Rx: cellulitis : abx &
continue breast feeding. Abscess : aspiration
XIX Breast
123 Symptoms
Lump Ca, cyst, broadenoma, broadenosis.
Less commonly: Fat necrosis, other cysts, other tumours ( duct papilloma, hamartoma, lipoma)
Discharge C lear, bloody, single duct require further ix
1 . Bloody: papilloma, Ca, Paget' s.
2. Clear: intraduct papilloma
3. Multicoloured: duct ectasia - Y/B/G
4. Milly: lactation, galactorrhoea
5. Purulent: abscess
Mastalgia a) Non-cyclical: Abscess, Ca, Tietze' s ( chondritis of the costal cartilage) , chest wall
lesions
b) Cyclical: idiopathic. Lumpy, tender. Worse premenstually, relieved by menstruation. Young . Rx: conservative [lionelic acid, # caeine, consider HRT] , medical
( danazol - anti-gonadotrophin, tamoxifen, LHRH)
Duct ectasia Ducts being nipple dilated ( ectasia) & engorged
Nipple inversion 1 , or 2 to duct ectasia or Ca
Gynaecomastia Physiological in neonates, puberty. Imbalance of oestrogens. May
have surgery if embarrasing ( liposuction, excision) . Causes : drugs ( digoxin, spironolactone, cimetidine, E , androgens) , cirrhosis, renal failure, hypogonadism, suprarenal
tumours, testiculr tumours, idiopathic.
o
o
2
124 Traumatic Fat Necrosis
Clinical. Painless, irregular, rm lump, hx of trauma ( e. g. surgery) . Can have retraction,
skin thickening: can look just like Ca. Usually regressses with time, may leave cyst.
o
126 Fibroadenosis
Def. Fibroadenosis or brocystic disease is the most common cause of breast lumps in
women of reproductive age. The peak incidence is between 35 and 50 years of age. It is
rare before 25 years.
The term embraces a spectrum of histologic changes, and may encompass many
patients who have cystic lesions detected clinically or sclerotic breast lesions detected
on mammography as discussed elsewhere.
Path. Histologically it is characterized by overgrowth of both brous stroma, and of
epithelial elements i. e. ducts and lobules, in diering proportions. These changes may
be considered as abberations of normal breast involution and not part of a disease process. The condition may be due to a disordered or imbalanced response to endogenous
sex hormones. Only in those cases showing marked epithelial hyperplasia - epitheliosis
- is the risk of breast carcinoma thought to be increased.
Clinical. Typically, patients present with one or more lumps in the breast which may be
painful, and frequently, bilateral. The size and pain usually vary with the menstrual
cycle. One or more of these elements may be absent.
Cysts are more common in perimenopausal women. They are usually single. The
presence of multiple, diuse cysts may be referred to as Schimmelbusch' s disease. The
discharge varies from clear to green but should not be bloodstained.
On palpation, a cyst may be recognised by its smooth texture and characteristic
tense uctuation.
Rx. Aspiration ! excision biopsy to exclude Ca. Pain that is localised, is normally
relieved by excision. Pain that is diuse, cannot be relieved by excision. In these cases,
bromocriptine, or danazol, may be helpful.
127 Cysts
Epi. Common perimenopausally, uncommon post-menopausally
31
.
Clinical. Short hx of painful tender swelling in the breast. May be multiple, bilateral.
Mammography: well-dened rounded opacities
Rx. Aspirate to dryness. Uniformly blood stained ! cytology. If mass remains then FNA.
128 Fibroadenoma
Path.
N ot a neoplasm , but an aberration of normal development. Stromal & epithelial
components. No " malignancy, majority resolve over years
Clinical. All ages, peak in 30s. Discrete, rm, mobile lump. Highly mobile ` breast mice' ,
not attached to skin. Can be multiple.
Rx. Triple assesment
129 Phyllodes (=leaf)
Path. True neoplasms that can be benign or malignant. Rarely met, but can recurr
locally. Can arise from intracannalicular broadenomas.
Clinical. Firm, discrete lump, recent increase in size
Rx. Wide excision
130 Intraduct Papilloma
Path. Benign, may be multiple, subareolar usually
Clinical. Watery-clear or blood stained discharge from a single duct. May be mass
Rx. Excision
XX Thyroid
Note: left out non-surgical aspects in these notes
131 Congenital
Types.
Lingual Beneath tongue. V rare
Fluctuant swelling in or near midline neck. Moves
upwards on tongue protrusion. Moves up on swallowing. Rx: remove surgically
together with remnants of thyroglossal tract.
Thyroglossal stula Opening onto skin midline. Discharge. Infection. Rx: excise
Physiology. Think it as aecting upmodulating the response to adrenaline
T h yro g lo s s al c ys t
132 Causes of Goitre
Graves causes hyperplasia. Hashmimotos causes infkammatory swelling
1 . Diusely Swollen : GravEs' ( hypErthyroid) , HashimOtO' s ( HypOthyroid) , " Demand
( # Iodine, puberty, pregnancy) , multinodular colloid goitre with nodules too small to
feel
2. Multiple nodules : Multinodular colloid goitre ( commonest thyroid swelling in nals,
hyperthyroid) , cysts, adenomas
3. Solitary nodule ( ominous, esp if , cold) : thyroglossal cyst ( small, smooth, midline,
moves up w tongue extrusion) , tumour, dominant nodule in multinodular goitre
133 Multinodular Goitre
Path. Some follicles w hyperactive epithelium, some atrophic. May be eu- ( vast majority)
or hyperthyroid ( 2 ) . Enlarged, irregular, nodular. Autoimmune.
Clinical. Middle aged women.
Dysphagia ( usually solids)
SoB ( worse on exertion & bending forward)
Orthopnoea, hoarseness ( P on one recurrent laryngeal N)
Stridor ( P on both recurrent N)
Facial congestion ( + ve Pemberton' s sign)
o
Ix.
Cx.
Embryology. Originating in oor of pharynx, descends through tongue ( foramen
caecum) . Failure to descend results in ectopic thyroid tissue. Radioiodine scan must be
performed to ensure that the thyroid gland works before removing this tissue.
32
1 . TSH assay
2. CT scan neck & thoracic outlet: size, retrosternal extension
Tracheal displacement/ compression
Haemorrhage into a cyst: pain & swelling
Toxic Malignant ( rare)
134 Colloid Goitre (Endemic Goitre)
Aetiology. # I : Derbyshire in UK
2
135 Hyperplasia
Occurs in. 1 hyperthyroidism ( Graves' )
Path. Smooth, uniformly enlarged, hyperactivity of acinar cells. V vascular, # colloid.
o
Lymphocyte inltration
136 Clinical Features in Thyroid Disease
H yp erthyroid. Nb . hoarse voice indicates in ltration of the larynx ! A lwsys perform
laryngoscopy pre-surgery. A F occurs in older hearts t hat can' t cope.
F igu re
2 3.
Goitre features.
Thyroid swelling
Retrosternal goitre: palpate w neck fully extended. Can block venous return to
SVC: engorgement of jugular veins ! oedema of upper body.
Tracheal displacement: check for stridor
Vocal cord integrity: indirect laryngoscopy
Regional nodes
Physiological state
137 Investigations
F igu re
2 2 .
1 . Serum free T3/ T4
H ypothyroid
33
2. TSH
3. Thyroid scintogram: radioiodine studies of thyroid ( I injected and gland scanned
with detector to map areas of high uptake) . Hot, cold nodules.
4. Thyroid antibodies: Hashimoto' s, Graves'
5. Thyroid USS: solid or cystic swelling.
6. FNA + core biopsy
7. " Serum cholesterol in myxoedema
8. ECG
9. CT
1 31
Radioactive iodine 2-3m. Not for < 45y cos of theoretical risk of malignancy.
140 Thyroid Tumours
Tumours
138 Outline Rx of Goitre
M alignant
B enign
1o
Follicular adenoma
Papillary Follicular A naplastic M edullary L ym phoma Papill Follic M ixed
Multinodular Goitre Thyroidectomy in enlarged euthyroid, nodular goitre if sx of
tracheal compression. Give T4 after to # size. Young : advised cos of risk of haemorrhage into thyroid cyst ( risk of acute tracheal compression) . Cosmetic. Elderly : long
standing asx then leave alone.
Single euthyroid nodule May be: benign, malignant, cyst. FNA, isotope, USS distinguish cyst from nodule. Aspirate cysts. Take out all other cos of malignant risk.
139 Hyperthyroidism Rx
See Kumar for medical rx.
Majority given carbimazole until euthyroid. Relapse after medical rx ( 50%) is indication for repeat medical, -ectomy, or radioactive iodine
Surgery Limited to teens/20s. Increasingly total thyroidectomy to # risk of recurrence.
Cx:
1 . Hormonal:
a) H ypoparathyroidism : Sx of paraesthesiae, tetany few days post-op. Rx: IV Ca
gluconate, oral calcium, vit D. Parathormone is not used.
b) T hyroid crisis ( massive release of T4 from gland) : now rare. May have mania,
hyperpyrexia, death. Rx: sedation, propanolol, IV iodine, cooling w ice.
c) H ypothyroidism
d) Failure : late recurrence of hyperthyroidism
2. Damage to anatomical structures:
a) Recurrent laryngeal N : 1 N ( hoarseness) , 2 Ns ( complete loss of voice,
serious narrowing of airway. May need permanent tracheostomy)
b) Trachea
c) Pneumothorax
3. General
a) H aemorrhage : Compress the trachea. Acute SoB & stridor, shock. Rx: emergency decompression of neck ( on the ward! ) then theatre.
b) Sepsis c) Post-op chest infx d) Hypertrophic scarring
F igu re
2 4.
1 40.1 Benign Adenoma
Hot nodules. 1 0%. Can become thyrotoxic
Cold. Don' t become thyrooxic. Might be Ca
1 40.2 Thyroid Carcinoma
Epi. : = 2: 1 , often arise in Goitres, previous radiation.
Dierentiated Thyroid Cancer. = Papillary & Follicular. 90% of all Ca. V good prognosis.
Types.
Papillary (60%) Young, good prognosis, slow growing, late lymphatic spread.
Follicular ( 30%) Young/ middle aged, blood stream ( ! bone) , slightly worse prognosis
Medullary Parafollicular C cells ( ! calcitonin, the tumour marker) , familial,
MEN-II syndrome ( phaeochromocytoma, parathyroid tumour, neurobroma ) . Multicentric in familial forms, both lobes. FNA.
Anaplastic Elderly, rapid local spread to trachea, lymph, blood
Clinical. Lump, rapid growing. Dysphagia uncommon ( indicates anaplastic) . Pain,
hoarseness, cervical LNs. Euthyroid usually. Ix: core-needle biopsy, FNA
Rx.
34
1 . Well dierentiated :
Surgery Lobectomy if # chance of recurrence ( e. g. small papillary w/ o LN
spread) . Total for others. Must render euthyroid rst. Stop antithyroid drugs
before surgery & give KI ( # vascularity)
Medical Carbimazole, beta-blockers
Radio-iodine ablation Also taken up by occult mets. Give w total thyroidectomy. Cx: oedema, thyroiditis.
TSH suppression Post-op
Monitoring Thyroglobulin should be undetectable
2. Medullary : exclude other MEN-II Ca. Total thyroidectomy + LN dissection. Prophylactic thyroidectomy in rel with germ-line RET mutations
3. Anaplastic : 1 YS < 1 5%. Palliate w radiotherapy & tracheostomy
141 Riedel's Thyroiditis
Claim to Fame. V rare, gland only slightly enlarged but woody-hard. Mistaken clinically for thyroid Ca, but histologically brous.
Rx. Wedge resection if tracheal compression.
XXI Kidney & Ureter
142 Horseshoe Kidney
Aetiology. During kidney' s ascent from pelvis
Clinical. Firm mass in pelvis, recurrent UTI
Ix. IVU
Claim to Fame. of lump in pelvic: not good to remove!
143 Polycystic Disease
Path. Multiple cysts throughout renal substance. Dominant ( a recessive form exists, pre-
senting in childhood) . PKD1 is commonest mutation.
Associated. Liver cysts ( 30%) , lungs, spleen, pancreas. Intracranial Berry aneurysms
( subarachnoid haemorrhage)
Clinical. Middle age:
1 . Abdominal mass
2. Haematuria
3. UTI
4. Renal failure: headache, lassitude, anaemia, vomiting
5. Hypertension
6. Intracranial haemorrhage
Ix.
1 . USS
2. " U&E
Rx.
Medical Hypertension, renal failure
Nephrectomy Recurrent pain, infection, haematuria
144 Renal Cysts
Claim to Fame. Common ( 50% of 50 y/o' s) . Clinical. Asx. Aching pain in loin.
Ix.
Haematuria is absent .
1 . Urine is clear 2. USS: cystic mass 3. IVU: round lling defect
Rx. Infection or malignancy suspected : aspiration, & serial CTs
4. CT
145 Haematuria
Classication.
General E. g. Anticoagulant
Specic 1 . Kidney : trauma, polycystic, glomerulonephritis, TB, infarction ( emboli) , stone,
tumour
2. Ureter : stone, tumour
3. Bladder : trauma, cystitis, stone, tumour, bilharzia
4. Prostate : prominent vessels in BPH
5. Urethra : trauma, stone, tumour
Hx. Loin pain suggests renal origin. Colicky suggests stone in renal pelvis or ureter. Terminal bleeding w sev pain & frequency suggests bladder calculus. Prostatic bleeding:
likely to be initial or terminal & painless. Independent of urination suggests urethral.
Sore throat suggests acute nephritis. Check if on anticoagulant therapy.
Ix.
1 . Urine microscopy: red cells excludes haemoglobinuria, beeturia. Cytology for malignancy
2. IVU: renal lesion, lling defect
3. USS: tumours, calculi, collecting system & bladder lesions
4. Cystoscopy: bladder, prostate lesion
146 Injury to Kidney
Clinical. Loin pain, tenderness, haematoma ( causing abdo distension due to ileus) .
Ix.
1 . Urine: haematuria
2. IVU: extravasation of contrast outside renal outline, distortion of calyces
3. IVU: elongated spidery calyces stretched out
35
3. USS: renal tear
4. CT: visceral injuries
o
Rx.
Penetrating injuries Surgical exploration
Blunt Conservative: bed rest, observe urine serially
Nephrectomy If: life threatening bleeding, sev hypotension, symptomatic lack of
function ( e. g. UTIs, stones)
147 Hydronephrosis
Aetiology.
2 o obstruction Bilateral if obstruction at or below bladder
o
Rx.
1 . USS: dilated 2. CT: cause
3. IVU: enlarged pelvis, swollen club-like calyces. Kidney may not secrete contrast.
4. Diuretic renography: ( furosemide given ! MAG3 injection) distinguishes btw
obstructed/non-obstructed system. Info concerning function of each kidney.
5. Retrograde pyelogram: via catheter inserted into ureter at cystoscopy
1 . Percutaneous drainage or Retrograde passage of double pigtail ureteric stent
2. Removal of underlying cause: if neuromuscular can operate to widen the pelviureteric junction ( pyeloplasty)
3. Nephrectomy: poorly functioning kidney w good contralateral side
148 Urinary Tract Calculi
Incorporated teaching notes
Epidemiology. 20-50 years, : = 3: 1 , caucasians/asians, FH, renal tubular acidosis ( Ca
phosphate stones) , cystinuria ( cysteine stones)
Aetiology.
1 . Inadequate drainage : hydronephrosis
Composition.
Calcium oxalate ( 60%) Spiky surface ! traumatized epithelium ! blood colours
stone brown. Opaque. Associated with:
Hypercalciuria: absorptive ( " intestinal) , renal leak, resorptive ( demineralisation
of bone " PTH)
Hypercalcaemia: most 2 " PTH
Hyperoxaluria: " absorption due to short gut syndrome
Hypocitraturia
Hyperuricosuria: Ca oxalate crystals form on surface of uric acid crystals
Calcium phosphate ( 1 0%) Seen in renal tubular acidosis ( failure to acidify
urine ! alkaline) . Opaque.
Triple phosphate ( 20%) Calcium, ammonium, magnesium, phosphate. Found in
infected urine. Staghorn calculus. Due to urease producing bacteria ( produce
ammonia) . Opaque
Uric acid & urate (5%) Smooth. Note if pure urate ( unusual) then translucent.
Assoc w gout
Cystine (1 %) Cystinuria ( recessive disorder) . Radiolucent
Clinical. Pain, but may be Asx. Calyces : dull loin pain. PUJ impaction or ureter :
ureteric colic ( unable to lie still, continuous pain w sharp exacerbations) . Haematuria.
Stones Lodge. PUJ, pelvic brim, entrance of ureter into bladder.
o
1 . Within the lumen: e. g. calculus
2. Wall: e. g. TCC
3. Outside wall: e. g. retroperitoneal brosis, extrinsic Ca
Without obstruction Vesico-ureteric reux
Clinical. Asx. Dull, aching pain. Acute attacks of pain resembling ureteric colic ( esp
after drinking large volumes) . Infection ( pain, rigors, sev loin pain) . Bilateral : uraemia.
Presentation w underlying cause ( e. g. calculus) . Kidney may be palpable.
Cx. Infection ( pyonephrosis) , stone formation ( in stagnant urine) , hypertension ( 2
ischaemia) , renal failure ( if bilateral destruction) , traumatic rupture of hydronephrotic
pelvis
Ix.
2. Excess of normal constituents : inadequate urine volume ( dehydration) , Increased
excretion of Ca ( hypercalciuria, can be 2 to " Ca or, usually, idiopathic)
3. Presence of abn constituents : Infections ( esp in presence of obstruction) , foreign
bodies, vit A deciency ( causes hyperkeratosis producing epithelium upon which
stones form) , cystinuria ( cystine stone formation)
4. Lack of inhibitors of stone formation : # Citrate, # Mg
RFs. # Fluid intake, poor diet, sedentary lifestyle
Ix.
Diagnostic 1.
2.
3.
4.
Haematuria
KUB: stones in 90%. All calcium stones are opaque
USS: V good for detecting renal, but not ureteric stones. Hydronephrosis.
IVU: remember stones may be obscured by contrast so do KUB rst. Not possible if renal impairment.
5. CT: replacing IVU
6. MAG3: obstruction, function
7. MRU ( ?)
Underlying cause 1 . Urine M&C: bacteria, cystine
2. Analysis of stone
3. Uric acid estimation: gout & uric acid stones
4. Serum Ca
Cx. Hydronephrosis, infection, anuria ( impaction of calculi both sides)
36
Rx Options.
1 . Watchful waiting: annual KUB. Not suitable for staghorn
2. Medical dissolution: uric acid stones ! sodium bicarbonate to alkalinise urine.
Cystine stones ! alkalinise urine + " uid + D-penicillamine to convert cystine to
more soluble compounds
3. ESWL ( extracorporeal shock wave lithotripsy) : Need analgesia. Cx: haematuria,
infection, obstruction, peri-renal haematoma. ContraI: pregnancy, coagulopathy
4. Uteroscopy: preferred for ureteric stones. Graspers to remove fragments, laser,
lithoclast.
5. Percutaneous nephrolithotomy: neproscope inserted percutaneously ! stone fragmented ( manually or with lithoclast) . For stones > 3cm.
6. Open/laporoscopic: occasionally large stones in presence of staghorn calculus &
non-functioning kidney
Rx Specic.
Ureteric calculi Analgesia ( NSAID: e. g. PR diclofenac) , oral uids & diet. Con-
servative : majority will pass spontaneously within 6 weeks. -adrenoceptor antagonist ( e. g. tamsulosin) to promote smooth muscle relaxation & promote passage.
Active : ESWL ! Uteroscopy ! Laporoscopic or open operation.
Renal calculi If small can leave alone. Larger: ESWL.
Acute calculous anuria Percutaneous nephrostomy or retrograde ureteric
stenting. Uraemic: dialysis.
Infected obstructed kidney Emergency. Sx: loin pain, initially colicky but
becomes constant. Ix: USS for hydronephrosis. Rx: nephrostomy, abx ( ceph &
gent) , HDU monitoring. Delay stone management until infection controlled.
Cause Infection, obstructive lesions, parathyroid tumours, drink lots of uid.
149 Urinary Tract Infections
Upper tract Haematogenous, or 2 to lower tract
Lower tract Ascending up urethra
o
150 Cystitis
Aetiology. : urethral or prostatic obstruction, catheterization.
Clinical. Dysuria, frequency, urgency. Haematuria. Loin pain.
Ix. : multiple episodes. : 1 episode.
1.
2.
3.
4.
Urine M&C&sensitivity: invariably bowel ora. Pus w no growth = Ca.
USS bladder & kidneys: obstruction, dilatation of upper tracts
KUB: exclude stone
Cystoscopy: bladder diverticula & other defects
Rx. Abx ( consider prophylactic) . " Fluids. Underlying causes.
151 Reux Nethropathy
Cause. Recurrent infections causing scarring. More common in childhood, due to: vesicoureteric reux ( decient valve) , intrarenal reux ( ducts don' t open oliquely)
Clinical. Infection sx. Subclinical: incontinence at night.
Ix.
1 . Micturating cystogam: contrast put in to bladder
2. Indirect micturating cystogram: An isotope ( MAG3) scan showing dierential function of kidneys
3. IVU: scarring, clubbing ( reversal of normal cupping of calyces)
4. DMSA scan: scaring
Rx. Cause. Abx prophylaxis.
152 Pyonephrosis
Aetiology. Infected hydronephrosis, kidney becomes bag of pus. Pyuria ( pus in urine)
Ix.
1.
2.
3.
4.
USS kidney
IVU: enlarged renal shadow, little/no function
DMSA: quantify function after treatment
MAG3 renography: function, obstruction
Rx. Urgent drainage by percutaneous nephrostomy. If no residual function then remove
kidney
153 Carbuncle of Kidney
Def. Cortical abscess, haematogenous infection usually Staph .
Clinical. Pyrexia, toxaemia, pain in loin, kidney may be palpable
Ix.
1 . Urine: sterile unless bursts
2. FBC: leucocytosis 3. CT/ USS: conrm
Rx. Percutaneous drainage abx
154 Perinephric Abscess
Def. Usually 2 to rupture of carbuncle
Clinical. Constitutional evidence of acute infection, diuse tender bulge in loin.
Ix.
o
1 . KUB: loss of psoas shadow due to retroperitoneal oedema
37
2. IVU: may show renal cortical abscess or a pyonephrosis
3. CT: localization & drainage
Rx. Drainage: percutaneous or open ( if perc fails)
3. Urine: blood, protein, M&C. ( Blood + protein: consider acute nephritis)
Rx.
Replenish IV volume 1 . Assess: JVP, postural hypotension
2. Rapid infusion of uid
3. CVP catheter
Dopamine & diuretics If rehydration unsuccessful in inducing diuresis give
furosemide. If this fails * ATN or acute cortical necrosis likely.
Hyperkalaemia CA gluconate, insulin + dextrose
155 Renal TB
Path. Lesions at junction of cortex & medulla. Enlarge ! caseate ! rupture in to calyx !
extensive destruction. Ureter becomes inltrated & inamed. Obstruction leads to
pyonephrosis. Autonephrectomy may occur. May become tuberculous cystitis.
Clinical. Young adult, immigrant. Early: dysuria, frequency, pyuria, haematuria.
Advanced: fever, night sweats, loss of weight, anaemia.
Ix.
1 . Urine: sterile acid pyuria. Acid fast bacilli on Ziehl-Nielson stain. Culture takes 3
weeks.
2. IVU: failure of calyceal lling, irregularity of calyces, patchy calcication
3. CXR: lung Ca
4. Cystoscopy: decreased bladder size, oedematous mucosa w tubercles
Rx. Anti-TB
Cx. Healing causes brosis which may cause strictures.
156 Acute Renal Failure
Def. # GFR, retention of nitrogenous waste ( " U, " C) , acidosis, reduced urine output
Aetiology.
GFR should be 60-80 mmHg. In hypertensives, elderly, pre-existing
renal disease ( e. g. DM) , NSAIDs, ACEIs autoregulation may be impaired.
1 . Fluid loss : blood loss, plasma loss ( e. g. burns) , electrolyte loss ( e. g. vomiting)
2. Impaired circulation : general factors ( e. g. hypotension) , local factors ( e. g. aortic
dissection & exclusion of renal arteries)
Renal Acute tubular necrosis
Acute tubular necrosis
Acute cortical necrosis due to ischaemia
Myoglobin released after crush injury
Drugs: e. g. abx ( gentamicin, NSAIDs)
Post-renal Obstruction at any level from tubules to urethra
Clinical. Anuria uncorrected by bladder catheterization ( rst consider blocked catheter)
* P re- renal
Ix.
1 . " Urea, " creatinine, " K
2. Renal tract doppler USS: small suggests prior renal disease
157 Chronic Renal Failure
Surgical Causes.
Pre-renal Renal artery stenosis
Post-renal ( obstructive) 1.
2.
3.
4.
5.
Congenital posterior urethral valves
Prostatic hyperplasia/ Ca
Urethral stricture
Cervical Ca
Urothelial tumour
Clinical. Malaise, weakness, confusion, hiccups w pallor, hypertension, uid overload.
Ix. Those of ARF. Finding Cause. Rx. Absence of correctable then dialyse.
158 Renal Tumours
Tumours
Renal Pelvis
K idney
B enign
Adenom a H aem angiom a
Papillom a T C C S C C
M alignant
1o
2o
N ephroblast oma Adenoca
F igu re
2 5 .
159 Nephroblastoma (Wilms')
Path. Anaplastic. Children < 5 usually. Spindle cells.
Assoc. Bilateral in 5-1 0%, congenital ( aniridia, hemihypertophy, macroglossia)
38
Clinical. Rapid growth ! large mass in loin. Weight loss, anorexia, fever, hypertension.
Mets.
Ix. USS: solid from cyst. CT: staging.
Rx. Nephrectomy. Early : cytotoxic chemo. Later : radiotherapy. 80% 5YS
XXII Bladder
160 Urachnal Anomalies
Types.
1 . Fistula: urinary discharge at the stula
2. Diverticulum: outpouching of the bladder
3. Cyst: urachnus persists but is closed above and below
Rx. Excision
Cx. UTI ( Stagnant urine) , calculus formation, malignant , hydronephrosis ( rarely, due
to P against adj ureter)
Clinical. Most asx. pis en deux . Ix. IVU, cystoscopy. Rx. Conservatively
164 Bladder Stone
Aetiology. Of same types as renal stones. Due to stasis/ infection, foreign body
( catheter)
Clinical. Triad of pain ( suprapubic, maybe tip of penis) , frequency, haematuria ( end
of ow)
Ix. KUB, cystoscopy
Rx. ESWL
165 Tumours
T umours
B enign
161 Bladder Exstrophy
T C papillom a
Def. Failure of fusion of structures forming ant abdo wall. Clinical. Infant incontinent.
May die of pyelonephritis.
Rx. Complex reconstruction
T C C ( 9 0 % ) S C C Adeno
2 6 .
extravastion of blood & urine causes painful swelling.
Rupture of urethra: anterior displacement of prostate. Ix. CT, Cystography, urethrography ( urethral injury)
Rx. Surgical suturing of rupture. Foley catheter. Drainage, abx.
Nature. Recur seed elsewhere, malignant Rx. Resection. Regular surveillance.
XXIII 43: Prostate
.
163 Diverticulum of Bladder
obstructed)
2o
1 65.1 Transitional Cell Papilloma
Types.
Intraperitoneal Penetrating wound or crush injury
*Extraperitoneal Bladder might be torn by spicule in a pelvic fracture.
Clinical. Intraperitoneal : Peritonitis w generalized extravasation. Extraperitoneal :
o
1o
F igu re
162 Rupture of Bladder
About. Most 2 to outow obstruction. 95% in
M alignant
( as men usually ones that get
166 Benign Enlargement
Clinical.
Obstructive Poor/ intermittent stream, hesitancy, terminal dribbling. May get
haematuria due to congestion of prostatic vein plexus. Eventually: retention ( see
below )
39
Detrusor instability Frequency, urgency, nocturia
Renal Failure Drowsy, headache, impairment of intellect.
Ex. If uraemic: pale, wasted, dry furred tongue. Large bladder. PR: enlarged, palpable
Ix.
Clinical.
Acute bacterial Fever, rigors, perineal pain, diculty voiding, UTI sx. Pain on
ejaculation, blood in semen. PR: enlarged, tender prostate. Epididymitis accompanies often. Rx: e. g. ciprooxacin, trimethoprim
Chronic bacterial Recurrent UTIs. Prostate feels rmer. Ix: urine. Rx: Abx
Chronic pelvic pain syndrome Pain in perineum, scrotum, tip of penis, pain on
ejaculation/micturition. Frequency, incomplete emptying. Rx: pelvic oor relaxation, -blockers, NSAIDs, abx, prostatic massage
sulcus.
1.
2.
3.
4.
5.
6.
7.
24h frequency/volume chart
Serum U&E: renal failure
Hbg: uraemia inhibits bone marrow
PSA
Urinalysis: leucocytes. Culture: a cx.
Urine ow assessment
USS: bladder enlargement, hydronephrosis, hydro-ureter, residual urine in bladder
post-voiding
Cx.
Prostatic Retention, haemorrhage
Bladder Diverticula, stone, UTI
Renal Hydronephrosis, uraemia
Rx.
Conservative Bladder training
Medical -adrenergic antagonists ( e. g. tamsulosin) ( relaxation of s. m. of bladder) ,
1
5 -reductase inhibition ( e. g. nasteride) ( blocks conversion testosterone ! dihydrotestosterone)
Surgical 1 . Transurethral prostatectomy: using diathermy or laser. # Morbidity. Cx:
Haemorrhage: post-op irrigation & warming of pt
TUR syndrome: absorption of " water causes hyponatraemia & confusion
Infection: common if catheterized pre-op. Prophylactic abx.
Retrograde ejaculation: almost certain
Impotence: 5-1 5%
Bladder neck stenosis: due to stricturing of neck
Incontinence: uncommon. Happens if damage to sphincter
Recurrent UTIs: re-growth of malignant 2. Open: if prostate v large, or co-existent intravesical pathology
167 Prostate Cancer
See oncology notes
169 Bladder Neck Obstruction
Aetiology. Congenital valves in region of prostatic urethra, brosis of prostate
170 Posterior Urethral Valves
Clinical. Hydronephrosis, retention in childhood.
Ix. Antenatal USS, micturating cystogram
Rx. Surgical incision
171 Bladder Neck Fibrosis
Sx of hypertrophy but without enlargement. Endoscopic incision.
172 Urinary Retention
Presentation.
Acute Suprapubic pain, inability to pass urine, suprapubic mass. inc AAA, as
mass may be pulsatile
Chronic Painless dribbling incontinence
Aetiology.
General * P ost-op ( in pain. Give opiates & sit pt over bed, or catheterize) , CNS
disease, drugs ( e. g. anticholinergics, TCAs)
Local 1 . Lumen: e. g. stone
2. Wall: e. g. urethral stricture
3. Outside: e. g. prostatic hyperplasia , prostate malignancy, faecal
impaction, pregnancy, pelvic tumour
168 Prostatitis
Organisms. Faecal: E Coli, Strep faecalis . Can have non-bacterial prostatitis, and noninammatory ( prosatodynia) , these both termed chronic pelvic pain syndrome
40
175 Testicular Torsion
Ix.
1 . XR pelvis: calculus, bony 2 s
2. PSA
3. Does catheter pass? If not, then stricture
Assess degree of renal damage. Uraemic sx/ si? Ix: U&C
o
Asses general condition of pt.
Rx.
Benign enlargement Prostatectomy if general condition satisfactory. If renal
Epi. Most common btw 1 2-27y. " in undescended testes
Path. Twists within tunica vaginalis, blood supply compromised
Clinical. V sev sudden onset pain, no sx of UTI
Ix. Dipstix, m+ c.
Rx. Surgical exploration: if infarction then orchidectomy, if not then x both
suture
damage/poor general condition then catheterize, perhaps permanently.
Malignant disease If met spread: hormone therapy. Endoscopic prostatectomy for
localized tumours, or large tumours with persisting sx.
Urethral Stricture Dilate with bougies under anaesthetic. Rarely impassable:
suprapubic.
Chronic retention Catheterize, left in to allow renal function to improve. Fluids
may be needed to rx the diuresis that follows relief of hydronephrosis. Bleeding is
common following decompression.
XXIV Testicular
XXV Other
Surgical Talk
173 Hydrocoele
Def. Fluid in testes btw the tunica vaginalis & tunica albuginea
Clinical. Can get above, transilluminates
Cause.
1 o Majority. Children: patent processus vaginalis. Adults: TV produces uid.
2 o Trauma, infx, malignancy. Develop rapidly
Rx. Leave if asx, can plicate tunica vaginalis.
174 Epididymo-orchitis
Def. Inammation of testis & epidimytis due to infx.
Cause. Young ( mumps) , young adults ( STI) , old ( UTI)
Clinical. Acute onset sev testicular pain, Malaise, fever, discharge, UTI sx. Tender, red,
F igu re
warm testis.
41
2 7.
I: H artm anns.
sides w a