Surgery PDF

Surgery 2012 v2
Alasdair Scott
BSc (Hons) MBBS MRCS PhD
2018
alasdair@scottsnotes.co.uk
www.scottsnotes.co.uk
© Alasdair Scott, 2018

Table of Contents
1. Perioperative Management ..................................................................................... 1
2. Fluids and Nutrition ............................................................................................... 11
3. Trauma .................................................................................................................. 17
4. Upper GI Surgery .................................................................................................. 25
5. Hepatobiliary Surgery ............................................................................................ 35
6. Lower GI Surgery .................................................................................................. 43
7. Perianal Surgery .................................................................................................... 59
8. Hernias .................................................................................................................. 65
9. Superficial Lesions ................................................................................................ 70
10. Breast Surgery .................................................................................................... 81
11. Vascular Surgery ................................................................................................. 86
12. Urology ................................................................................................................ 95
13. Orthopaedics ..................................................................................................... 110
14. Ear, Nose and Throat ........................................................................................ 132
15. Ophthalmology .................................................................................................. 145
i
Perioperative
Management
Contents
Pre-Operative Assessment and Planning .............................................................................................................. 2
Specific Pre-operative Complications .................................................................................................................... 3
Anaesthesia ........................................................................................................................................................... 4
Analgesia ............................................................................................................................................................... 4
Enhanced Recovery After Surgery ........................................................................................................................ 5
Surgical Complications .......................................................................................................................................... 5
Post-op Complications: General ............................................................................................................................ 6
Post-op Complications: Specific ............................................................................................................................ 7
Post-op Pyrexia...................................................................................................................................................... 8
Deep Venous Thrombosis ..................................................................................................................................... 9
Other Common Post-Operative Presentations .................................................................................................... 10
1
Pre-Operative Assessment and Planning
Aims Preparation
• Informed consent
• Assess risk vs. benefits NBM
• Optimise fitness of patient • ≥2h for clear fluids, ≥6h for solids
• Check anaesthesia / analgesia type c̄ anaesthetist
Bowel Prep
Pre-op Checks: OP CHECS • May be needed in left-sided ops
• Operative fitness: cardiorespiratory comorbidities § Picolax: picosulfate and Mg citrate
• Pills § Klean-Prep: macrogol
• Consent • Not usually needed in right-sided procedures
• History • Necessity is controversial as benefit of minimising
§ MI, asthma, HTN, jaundice post-op infection might not outweigh risks
§ Complications of anaesthesia: DVT, § Liquid bowel contents spilled during surgery
anaphylaxis § Electrolyte disturbance
• Ease of intubation: neck arthritis, dentures, loose § Dehydration
teeth § ↑ rate of post-op anastomotic leak
• Clexane: DVT prophylaxis
• Site: correct and marked
Prophylactic Abx
• Use
§ GI surgery (20% post-op infection if elective)
Drugs § Joint replacement
• Give 15-60min before surgery
Anti-coagulants • Regimens: (see local guidelines)
• Balance risk of haemorrhage c̄ risk of thrombosis § Biliary: Cef 1.5g + Met 500mg IV
• Avoid epidural, spinal and regional blocks § CR or appendicetomy: Cef+Met TDS
§ Vascular: co-amoxiclav 1.2g IV TDS
AED § MRSA+ve: vancomycin
• Give as usual
• Post-op give IV or via NGT if unable to tolerate orally
DVT Prophylaxis
OCP / HRT • Stratify pts according to patient factors and type of
• Stop 4wks before major / leg surgery surgery.
• Restart 2wks post-op if mobile • Low risk: early mobilisation
• Med: early mobilisation + TEDS + 20mg enoxaparin
β-Blockers • High: early mobilisation + TEDS + 40mg enoxaparin +
• Continue as usual intermittent compression boots perioperatively.
• Prophylaxis started @ 1800 post-op
• May continue medical prophylaxis at home (up to
1mo)
Pre-op Investigations
Bloods ASA Grades

• Routine: FBC, U+E, G+S, clotting, glucose • Normally healthy
• Specific • Mild systemic disease
§ LFTs: liver disease, EtOH, jaundice • Severe systemic disease that limits activity
§ TFT: thyroid disease • Systemic disease which is a constant threat to life
§ Se electrophoresis: Africa, West Indies, Med
• Moribund: not expected to survive 24h even c̄ op
• Cross-match
§ Gastrectomy: 4u
§ AAA: 6u
Cardiopulmonary Function
• CXR: cardiorespiratory disease/symptoms, >65yrs
• Echo: poor LV function, Ix murmurs
• ECG: HTN, Hx of cardiac disease, >55yrs
• Cardiopulmonary Exercise Testing
• PFT: known pulmonary disease or obesity
Other
• Lat C-spine flexion and extension views: RA, AS
• MRSA swabs
2
Specific Pre-operative Complications
Diabetes Jaundice
• Best to avoid operating in jaundiced pts.
↑ Risk of post-operative complications • Use ERCP instead
• Surgery → stress hormones → antagonise insulin
• Pts. are NBM Risks
• ↑ risk of infection • Pts. c̄ obstructive jaundice have ↑ risk of post-op renal
• IHD and PVD failure \ need to maintain good UO.
• Coagulopathy
Pre-op • ↑ infection risk: may → cholangitis
• Dipstick: proteinuria
• Venous glucose Pre-op
+
• U+E: K • Avoid morphine in pre-med
• Check clotting and consider pre-op vitamin K
IDDM • Give 1L NS pre-op (unless CCF) → moderate diuresis
• Urinary catheter to monitor UPO
Practical Points • Abx prophylaxis: e.g. cef+met
• Put pt. first on list and inform surgeon and
anaesthetist Intra-op
• Some centres prefer to use GKI infusions • Hrly UO monitoring
• Sliding scale may not be necessary for minor ops • NS titrated to output
§ If in doubt, liaise c̄ diabetes specialist nurse
Post-op
Insulin • Intensive monitoring of fluid status
• ± stop long-acting insulin the night before • Consider CVP + frusemide if poor output despite NS
• Omit AM insulin if surgery is in the morning
• Start sliding scale
§ 5% Dex c̄ 20mmol KCl 125ml/hr Anticoagulated Patients
§ Infusion pump c̄ 50u actrapid • Balance risk of haemorrhage c̄ risk of thrombosis
§ Check CPG hrly and adjust insulin rate • Consult surgeon, anaesthetist and haematologist
• Check glucose hrly: aim for 7-11mM • Very minor surgery may be undertaken w/o stopping
• Post-op warfarin if INR <3.5.
§ Continue sliding-scale until tolerating food • Avoid epidural, spinal and regional blocks if
§ Switch to SC regimen around a meal anticoagulated,
• In general, continue aspirin/clopidogrel unless risk of
NIDDM bleeding is high – then stop 7d before surgery
• If glucose control poor (fasting >10mM): treat as
IDDM Low thromboembolic risk: e.g. AF
• Omit oral hypoglycaemics on the AM of surgery • Stop warfarin 5d pre-op: need INR <1.5
• Eating post-op: resume oral hypoglycaemics c̄ meal • Restart next day
• No eating post-op
§ Check fasting glucose on AM of surgery High thromboembolic risk: valves, recurrent VTE
§ Start insulin sliding scale • Need bridging c̄ LMWH
§ Consult specialist team ore. restarting PO Rx § Stop warfarin 5d pre-op and start LMWH
§ Stop LMWH 12-18h pre-op
Diet Controlled § Restart LMWH 6h post-op
• Usually no problem § Restart warfarin next day
• Pt. may be briefly insulin-dependent post-op § Stop LMWH when INR >2
§ Monitor CPG
Emergency Surgery
• Discontinue warfarin
Steroids • Vit K .5mg slow IV
• Request FFP or PCC to cover surgery
Risks
• Poor wound healing COPD and Smoking
• Infection
• Adrenal crisis Risks
• Basal atelectasis
Mx • Aspiration
• Need to ↑ steroid to cope c̄ stress • Chest infection
• Consider cover if high-dose steroids w/i last yr
• Major surgery: hydrocortisone 50-100mg IV c̄ pre- Pre-op
med then 6-8hrly for 3d. • CXR
• Minor: as for major but hydrocortisone only for 24h • PFTs
• Physio for breathing exercises
• Quit smoking (at least 4wks prior to surgery)
3
Anaesthesia Analgesia
Principals and Practical Conduct Necessity
• Aims: hypnosis, analgesia, muscle relaxation • Pain → autonomic activation → arteriolar constriction →
• Induction: e.g. IV propofol ↓ wound perfusion → impaired wound healing
• Muscle Relaxation • Pain → ↓ mobilisation → ↑ VTE and ↓ function
§ Depolarising: suxamethonium • Pain → ↓ respiratory excursion and ↓ cough →
§ Non-depolarising: vecuronium, atracurium atelectasis and pneumonia
• Airway Control: ET tube, LMA • Humanitarian considerations
• Maintenance
§ Usually volatile agent added to N2O/O2 mix General Guidance
§ E.g. halothane, enflurane • Give regular doses at fixed intervals
• End of Anaesthesia • Consider best route: oral when possible
§ Change inspired gas to 100% O2 • PCA should be considered: morphine, fentanyl
§ Reverse paralysis: neostigmine + atropine
• Follow stepwise approach
(prevent muscarinic side effects)
• Liaise c̄ Acute Pain Service
Pre-medication: 7As Pre-Op

• Epidural anaesthesia: e.g. c̄ bupivacaine
• Anxiolytics and Amnesia: e.g. temazepam
• Analgesics: e.g. opioids, paracetamol, NSAIDs
• Anti-emetics: e.g. ondansetron 4mg / metoclop 10mg End-Op
• Antacids: e.g. lansoprazole • Infiltrate wound edge c̄ LA
• Anti-sialogue e.g. glycopyrolate (↓ secretions) • Infiltrate major regional nerves c̄ LA
• Antibiotics
Post-Op: stepwise approach
Regional Anaesthesia 1. Non-opioid ± adjuvants

• May be used for minor procedures or if unsuitable for § Paracetamol
GA § NSAIDs
• Nerve or spinal blocks - Ibuprofen: 400mg/6h PO max
§ CI: local infection, clotting abnormality - Diclofenac: 50mg PO / 75mg IM
• Use long-acting agents: e.g. bupivacaine
2. Weak opioid + non-opioid ± adjuvants
§ Codeine
Complications of Anaesthesia § Dihydrocodeine
§ Tramadol
Propofol Induction
3. Strong opioid + non-opioid ± adjuvants
• Cardiorespiratory depression § Morphine: 5-10mg/2h max
§ Oxycodone
Intubation § Fentanyl
• Oro-pharyngeal injury c̄ laryngoscope
• Oesophageal intubation Spinal or Epidural Anaesthesia
• ↓ SE as drugs more localised
Loss of pain sensation •
st
1 line for major bowel resection
• Urinary retention • Caution
• Pressure necrosis § Respiratory depression
• Nerve palsies § Neurogenic shock → ↓BP
Loss of muscle power

• Corneal abrasion
• No cough → atelectasis + pneumonia
Malignant Hyperpyrexia
• Rare complication ppted by halothane or
suxamethonium
• AD inheritance
• Rapid rise in temperature + masseter spasm
• Rx: dantrolene + cooling
Anaphylaxis
• Rare
• Possible triggers
§ Antibiotics
§ Colloid
§ NM blockers: e.g. vecuronium
4
Enhanced Recovery After Surgery Surgical Complications
ERAS Immediate (<24h)
• Commonly employed in colorectal and orthopaedic • Intubation → oropharyngeal trauma
surgery • Surgical trauma to local structures
• Primary or reactive haemorrhage
Aims
• Optimise pre-op preparation for surgery Early (1d-1mo)
• Avoid iatrogenic problems (e.g. ileus) • Secondary haemorrhage
• Minimise adverse physiological / immunological • VTE
responses to surgery • Urinary retention
§ ↑ cortisol and ↓ insulin (absolute or relative) • Atelectasis and pneumonia
§ Hypercoagulability • Wound infection and dehiscence
§ Immunosuppression • Antibiotic association colitis (AAC)
• ↑ speeded of recovery and return to function
• Recognise abnormal recovery and allow early
Late (>1mo)
intervention
• Scarring
• Neuropathy
• Failure or recurrence
Pre-op: optimisation
• Aggressive physiological optimisation
§ Hydration
§ BP (↑ / ↓)
§ Anaemia
§ DM
§ Co-morbidities
• Smoking cessation: ≥4wks before surgery
• Admission on day of surgery, avoidance of prolonged fast
• Carb loading prior to surgery: e.g. carb drinks
• Fully informed pt., encouraged to participate in recovery
Intra-op: ↓ physical stress

• Short-acting anaesthetic agents
• Epidural use
• Minimally invasive techniques
• Avoid drains and NGTs where possible
Post-op: early return to function and

mobilisation
• Aggressive Rx of pain and nausea
• Early mobilisation and physiotherapy
• Early resumption of oral intake (inc. carb drinks)
• Early discontinuation of IV fluids
• Remove drains and urinary catheters ASAP
5
Post-op Complications: General
Haemorrhage Classification Wound Infection
• Primary: continuous bleeding starting during • 5-7d post-op
surgery • Organisms: S. aureus and Coliforms
• Reactive
§ Bleeding at the end of surgery or early Operative Classification
post-op • Clean: incise uninfected skin w/o opening viscus
O
§ 2 to ↑ CO and BP • Clean/Cont: intra-op breach of viscus (not colon)
• Secondary • Contaminated: breach of viscus + spillage or opening of
§ Bleeding >24h post-op colon
§ Usually due to infection • Dirty: site already contaminated – faeces, pus, trauma
Risk Factors
Post-op Urinary Retention • Pre-operative
§ ↑ Age
Causes § Comorbidities: e.g. DM
• Drugs: opioids, epidural/spinal, anti-AChM § Pre-existing infection: e.g. appendix perforation
• Pain: sympathetic activation → sphincter § Pt. colonisation: e.g. nasal MRSA
contraction • Operative
• Psychogenic: hospital environment § Op classification and wound infection risk
§ Duration
§ Technical: pre-op Abx, asepsis
Risk Factors
• Post-operative
• Male
§ Contamination of wound from staff
• ↑ age
• Neuropathy: e.g. DM, EtOH
Mx
• BPH
• Regular wound dressing
• Surgery type: hernia and anorectal
• Abx
• Abscess drainage
Mx
• Conservative
§ Privacy
§ Ambulation Wound Dehiscence
§ Void to running taps or in hot bath
§ Analgesia Presentation
• Catheterise ± gent 2.5mg/kg IV stat • Occurs ~10d post-op
• TWOC = Trial w/o Catheter • Preceded by serosanguinous discharge from wound
§ If failed, may be sent home c̄ silicone
catheter and urology outpt. f/up. Risk Factors
• Pre-Operative Factors
§ ↑ age
Pulmonary Atelectasis § Smoking
• Occurs after every nearly every GA § Obesity, malnutrition, cachexia
• Mucus plugging + absorption of distal air → § Comorbs: e.g. BM, uraemia, chronic cough, Ca
collapse § Drugs: steroids, chemo, radio
• Operative Factors
Causes § Length and orientation of incision
• Pre-op smoking § Closure technique: follow Jenkin’s Rule
• Anaesthetics ↑ mucus production ↓ mucociliary § Suture material
clearance • Post-operative Factors
• Pain inhibits respiratory excursion and cough § ↑ IAP: e.g. prolonged ileus → distension
§ Infection
§ Haematoma / seroma formation
Presentation
• w/i first 48hrs
Mx
• Mild pyrexia
• Replace abdo contents and cover c̄ sterile soaked gauze
• Dyspnoea
• IV Abx: cef+met
• Dull bases c̄ ↓AE
• Opioid analgesia
• Call senior and arrange theatre
Mx • Repair in theatre
• Good analgesia to aid coughing § Wash bowel
• Chest physiotherapy § Debride wound edges
§ Close c̄ deep non-absorbable sutures (e.g. nylon)
• May require VAC dressing or grafting
6
Post-op Complications: Specific
General Surgery Vascular
Cholecystectomy Arterial Surgery

• Conversion to open: 5% • Thrombosis and embolisation
• CBD injury: 0.3% • Anastomotic leak
• Bile leak • Graft infection
• Retained stones (needing ERCP)
• Fat intolerance / loose stools Aortic Surgery
• Gut ischaemia
Inguinal Hernia Repair • Renal failure
• Early • Aorto-enteric fistula
• Haematoma / seroma formation: 10% • Anterior spinal syndrome (paraplegia)
• Intra-abdominal injury (lap) • Emboli → distal ischaemia (trash foot)
• Infection: 1%
• Urinary retention Breast
• Late • Arm lymphoedema
§ Recurrence: 0.5% • Skin necrosis
§ Ischaemic orchitis: 0.5% • Seroma
§ Chronic groin pain / paraesthesia: 10-20%
Urological
Appendicectomy • Sepsis
• Abscess formation • Uroma: extravasation of urine
• Fallopian tube trauma
• Right hemicolectomy (e.g. for carcinoid, caecal Prostatectomy
necrosis)
• Urinary incontinence
• Erectile dysfunction
Colonic Surgery • Retrograde ejaculation
• Early • Prostatitis
§ Ileus
§ Anastomotic leak
§ Enterocutaneous fistulae ENT
§ Abdominal or pelvic abscess
• Late Thyroidectomy
§ Adhesions → obstruction • Wound haematoma → tracheal obstruction
§ Incisional hernia • Recurrent laryngeal N. trauma → hoarse voice
§ Transient in 1.5%
Post-op Ileus § Permanent in 0.5%
• Causes § R commonest (more medial)
§ Bowel handling • Hypoparathyroidism → hypocalcaemia
§ Anaesthesia • Thyroid storm
§ Electrolyte imbalance • Hypothyroidism
• Presentation
§ Distension Tracheostomy
§ Constipation ± vomiting • Stenosis
§ Absent bowel sounds • Mediastinitis
• Rx • Surgical emphysema
§ IV fluids + NGT
§ TPN if prolonged Orthopaedic Surgery
Anorectal Surgery Fracture Repair
• Anal incontinence
• Mal-/non-union
• Stenosis
• Osteomyelitis
• Anal fissure
• Avascular necrosis
• Compartment syndrome
Small Bowel Surgery
• Short gut syndrome (≤250cm)
Hip Replacement
• Deep infection
Splenectomy • VTE
O
• Gastric dilatation (2 gastric ileus) • Dislocation
§ Prevent c̄ NGT • Nerve injury: sciatic, SGN
• Thrombocytosis → VTE • Leg length discrepancy
• Infection: encapsulated organisms
Cardiothoracic Surgery
• Pneumo-/haemo-thorax
• Infection: mediastinitis, empyema
7
Post-op Pyrexia
Causes Pneumonia
Early: 0-5d post-op Cause

• Blood transfusion • Anaesthesia → atelectasis
•
O
Physiological: SIRS 2 to trauma, 0-1d • Pain → ↓ cough
• Pulmonary atelectasis: 24-48hrs • Surgery → immunosuppression
• Infection: UTI, superficial thrombophlebitis, cellulitis
• Drug reaction Rx
• Chest physio: encouraging coughing
Delayed: >5d post-op • Good analgesia
• Pneumonia • Abx
• VTE: 5-10d
• Wound infection: 5-7d
• Anastomotic leak: 7d Collection
• Collection: 5-20d
Presentation
• Malaise
Examination of Post-Op Febrile Pt. • Swinging fever, rigors
• Observation chart, notes and drug chart • Localised peritonitis
• Wound • Shoulder tip pain (if subphrenic)
• Abdo + DRE
• Legs Locations
• Chest • Pelvic
• Lines • Subphrenic
• Urine • Paracolic gutters
• Stool • Lesser sac
• Hepatorenal recess (Morrison’s space)
• Small bowel (interloop spaces)
Ix
• Urine: dip + MCS Ix
• Blood: FBC, CRP, cultures ± LFTs • FBC, CRP, cultures
• Cultures: wound swabs, CVP tip for culture • US, CT
• CXR • Diagnostic lap
Rx
• Abx
• Drainage / washout
Cellulitis
• Acute infection of the subcutaneous connective tissue
Cause: β-haemolytic Streps + staph. aureus
Presentation
• Pain, swelling, erythema and warmth
• Systemic upset
• ± lymphadenopathy
Rx
• Benpen IV
• Pen V and fluclox PO
8
Deep Venous Thrombosis
Epidemiology Preventing DVT
• DVTs occur in 25-50% of surgical patients without
thromboprophylaxis Pre-Op
• Pre-op VTE risk assessment
Risk Factors: Virchow’s Triad • TED stockings
• Blood Contents • Aggressive optimisation: esp. hydration
§ Surgery → ↑ plats and ↑ fibrinogen • Stop OCP 4wks pre-op
§ Dehydration
§ Malignancy Intra-Op
§ Age: ↑ • Minimise length of surgery
• Blood Flow • Use minimal access surgery where possible
§ Surgery • Intermittent pneumatic compression boots
§ Immobility
§ Obesity
Post-Op
• Vessel Wall
• LMWH
§ Damage to veins: esp. pelvic veins
§ Previous VTE • Early mobilisation
• Good analgesia
• Physio
Signs • Adequate hydration
• Peak incidence @ 5-10d post-op
• 65% of below knee DVTs are asymptomatic
• Calf warmth, tenderness, erythema, swelling
• Mild pyrexia
• Pitting oedema
Differential
• Cellulitis
• Ruptured Baker’s cyst
Ix
• D-Dimers: sensitive but not specific
• Compression US (clot will be incompressible)
• Thrombophilia screen if:
§ No precipitating factors
§ Recurrent DVT
§ Family Hx
Dx
• Assess probability using Wells’ Score
• Low-probability → perform D-dimers
§ Negative → excludes DVT
§ Positive → Compression US
• Med / High probability → Compression US
Rx
Anticoagulate
• Therapeutic LMWH: enoxaparin 1.5mg/kg/24h SC
• Start warfarin using Tait model: 5mg OD for first 4d
• Stop LMWH when INR 2.5
• Duration
§ Below knee: 6-12wks
§ Above knee: 3-6mo
§ On-going cause: indefinite
Graduated Compression Stockings

• Consider for prevention of post-phlebitic syndrome
9
Other Common Post-Operative Presentations
Dyspnoea / Hypoxia Hypotension
Causes Immediate Mx
• Previous lung disease • Tilt bed head down, give O2
• Atelectasis, aspiration, pneumonia • Assess fluid status
• LVF
• PE Causes: CHOD
• Pneumothorax (e.g. due to CVP line insertion) • Cardiogenic
• Pain → hypoventilation § MI
§ Fluid overload
Ix • Hypovolaemia
• FBC, ABG § Inadequate replacement of fluid losses
• CXR § Haemorrhage
• ECG • Obstructive
§ PE
• Distributive
Rx
§ Sepsis
• Sit up, give O2, monitor SpO2
§ Neurogenic shock
• Rx cause
Mx
• Hypovolaemia → fluid challenge
Reduced Urine Output § 250-500ml colloid over 15-30min
• Haemorrhage → return to theatre
Causes • Sepsis → fluid challenge, start Abx
• Post-renal • Overload → frusemide
§ Commonest cause • Neurogenic → NA infusion
§ Blocked / malsited catheter
§ Acute urinary retention
• Pre-renal: hypovolaemia Hypertension
• Renal: NSAIDs, gentamicin • Continue anti-hypertensives during peri-operative
• Anuria usually = blocked or malsited catheter period
• Oliguria usually = inadequate fluid replacement
Causes
Mx • Pain
• Information • Urinary retention
§ Op Hx • Previous HTN
§ Obs chart: UO
§ Drug chart: nephrotoxins
Rx
• Examination
• Rx cause
§ Assess fluid status
§ Examine for palpable bladder • May use labetalol 50mg IV every 5min (200mg max)
§ Inspect drips, drains, stomas, CVP
• Action
§ Flush c̄ 50ml NS and aspirate back Acute Confusional State
§ Fluid challenge • Agitation, disorientation, attempts to leave hospital
Common Causes: DELIRIUM

Nausea and Vomiting • Drugs: opiates, sedatives, L-DOPA
• Causes • Eyes, ears and other sensory deficits
§ Obstruction • Low O2 states: MI, stroke, PE
§ Ileus • Infection
§ Emetic drugs: e.g. opioids • Retention: stool or urine
• Consider NGT, AXR and ondansetron 4mg IV TDS • Ictal
• Under- hydration / -nutrition
• Metabolic: Na, AKI, glucose, EtOH withdrawal
↓ Na
• What was pre-op level? Mx
• Common Causes: • May need sedation: midazolam / haldol
§ S(I)ADH: pain, nausea, opioids, stress • Nurse in well-lit environment
§ Over administration of IV fluids • Rx cause
• Correct slowly
§ Acute: 1mM/h
§ Chronic:15mM/d
10
Fluids and Nutrition
Contents
Fluid Homeostasis ............................................................................................................................................... 12
Crystalloid ............................................................................................................................................................ 13
Colloid .................................................................................................................................................................. 13
Fluid Problems ..................................................................................................................................................... 14
Nutrition................................................................................................................................................................ 15
Refeeding Syndrome ........................................................................................................................................... 16
11
Fluid Homeostasis
Body Composition Fluid Balance
• Total water: 60% of 70kg = 42L
§ 2/3 intracellular = 28L Input Output
§ 1/3 extracellular = 14L Water 1500 Urine 1500
- Plasma = 3L (21% of ECF) Food 1000 Stool 300
- Interstitial = 10L Metabolism 300 Insensible 1000
- Transcellular = 1L
- lungs
- sweating
Total 2800ml Total 2800ml
Starling’s Forces = =
40ml/kg/d 40ml/kg/d
Osmotic Pressure
• Pressure which needs to be applied to prevent the Other Values
inflow of water across a semipermeable membrane. • Minimum UO = 0.5ml/kg/h = ~30ml/h
• i.e. the ability of a solute to attract water. • Na requirement = 1.5-2mmol/kg/d = 100mmol/d
• Oncotic pressure: form of osmotic pressure exerted • K requirement = 1mmol/kg/d = 60mM/d
by proteins.
Fluid Regimens
Hydrostatic Pressure
• Pressure exerted by a fluid at equilibrium due to the
Daily Requirements
force of gravity. +
• 3L dex-saline c̄ 20mM K in each bag
+
• 1L NS + 2L dex c̄ 20mM K in each bag
• Each bag over 8h = 125ml/h
Distribution
• Distribution between the ECF and ICF is driven by
Replace other losses
differences in osmotic pressure only.
• Vomiting and Diarrhoea
• Distribution w/i the ECF is determined by Starling’s
• NGT
forces.
• Drains
§ Capillary and interstitial oncotic pressure. O
§ Capillary and interstitial hydrostatic pressure. • Fever (+500ml for each C)
§ Filtration coefficient (capillary permeability) • Tachypnoea
• High-output stomas
3rd Space Losses → ↓ ECF

•
rd
Bowel obstruction → ↓ fluid reabsorption → 3 space
CVP Monitoring
loss • Indicates RV preload and depends on
• Sudden diuresis on day 2-3 post op = recovery of § Venous return
ileus § Cardiac output
•
rd
Peritonitis → ascites → 3 space loss • ↑ CVP
§ ↑ circulating volume
§ ↓CO: i.e. pump failure
• ↓ CVP
§ ↓ circulating volume
• Normal value: ~5-10cmH2O
• Single reading is not as useful as serial measurements
before and after fluid challenge.
§ Unchanged: hypovolaemic
§ ↑ that reverses after 30min: euvolaemic
§ Sustained ↑ >5cmH2O: overload / failure
• Passive leg raising may be more useful than fluid
challenge in determining response to fluids.
§ Sustained ↑ in CVP suggests heart failure.
12
Crystalloid Colloid
Normal Saline Physiology
• Contain large molecular wt. molecules
Contents • Gelatin
• 0.9% NaCl = 9g/L • Dextrans
• 154mmol NaCl • Preserves oncotic pressure \ remains intravascular →
preferential ↑ in intravascular volume
pH: 5-6
Synthetic
Use • Gelofusin
• Normal daily fluid requirements + replace losses • Volplex
• Haemaccel
• Voluven
5% Dextrose
Natural
Contents • Albumin
• 50g dextrose /L • Blood
Use Use
• Normal daily fluid requirements • Fluid challenge: 250-500ml over 15-30min
• Hypovolaemic shock
• Mount Vernon Formula
§ (wt. x %burn)/2 = ml colloid per unit time
Dextrose-Saline
Problems
Contents • Anaphylaxis
• 4% dextrose = 40g/L
• Volume overload
• 0.18% NaCl = 31mM NaCl • Can interfere c̄ cross-matching therefore take blood for
x-match before using.
Use
• Normal daily fluid requirements
Hartmann’s / Ringer’s Lactate
Contents
• Na: 131mM
• Cl: 111mM
• K: 5mM
• Ca: 2.2mM
• Lactate / HCO3: 29mM
Use
• Resuscitation in trauma pts.
st
• Parkland’s formula: 4 x wt x %burn = mL in 1 24hrs
pH
• pH = 6.5 but Hartmann’s is an alkalinising solution
• Lactate is not an acid in itself: it’s a conjugate base
• Given exogenously as sodium lactate
• Lactate metabolised in liver → HCO3 production
• The Cori Cycle
Daily Requirements
+
• 3L dex-saline c̄ 20mM K in each bag
+
• 1L NS + 2L dex c̄ 20mM K in each bag
• Each bag over 8h = 125ml/h
Problems
• Give 1L NS → ~210ml remaining intravascularly
• Give 1L D5W → ~70ml remaining intravascularly
• Acidosis or electrolyte disturbances
• Fluid overload
13
Fluid Problems
Assessing Fluid Status Ileostomy
• Hx: balance chart, surgery, other losses, thirsty • Ileal fluid composition
• Impression: drowsy, alert § Na: 130mM
• Inspection: drips, drains, stomas, catheters, CVP § Cl: 110mM
§ K: 10mM
Examination § HCO3: 30mM
• Normal output: 10-15mL/Kg/d = ~700ml/d
• IV volume
§ CRT • High output = >1000ml/d
§ HR • Ileum will adapt to limit fluid and electrolyte losses
§ BP lying and standing • Fluids
§ JVP § 0.9% NS +KCl
• Tissue perfusion § Daily requirements + replaces losses, titrated to
§ Skin turgor UO
§ Oedema: ankle, pulmonary, ascites § Serial U+Es guide electrolyte replacement
§ Mucus membranes • High Output
• End-organ § Loperamide
§ UO, ↑U+Cr § Codeine
§ Consciousness
§ Lactate
Reduced Urine Output Post-op
Other Tests
• PCWP: indirect measure of left atrial pressure Causes
• CVP • Post-renal
§ Commonest cause
Post-operative Fluids § Blocked / malsited catheter
§ Acute urinary retention
Problems • Pre-renal: hypovolaemia
• Renal: NSAIDs, gentamicin
• ↑ADH, ↑aldosterone, ↑cortisol → Na +H2O conservation
+ • Anuria usually = blocked or malsited catheter
• ↑ K : tissue damage, transfusion, stress hormones
• Oliguria usually = inadequate fluid replacement
Solutions
Mx
• Use UO (aim>30ml/h) to guide fluid replacement but
may need to ↓ maintenance fluids to 2L first 24h post- • Information
op § Op Hx
+ § Obs chart: UO
• Avoid K supplementation for first 24h post-op
§ Drug chart: nephrotoxins
• Examination
Cardiac or Renal Failure § Assess fluid status
§ Examine for palpable bladder
Problem § Inspect drips, drains, stomas, CVP
• RAS activation → Na and H2O retention • Action
§ Flush c̄ 50ml NS and aspirate back
Solution § Fluid challenge
• Avoid fluids c̄ Na → give 5% dextrose
Suspect Catheter Problem
• Flush c̄ 50ml NS and aspirate back
Bowel Obstruction
• Pts. have significant third space losses c̄ loss of both
water and electrolytes. Suspect Pre-renal Problem
• Likely to need significantly more than standard daily • Fluid challenge
requirements. § 250-500ml colloid bolus over 15-30min
• Regimen § Look for CVP or UO response w/i minutes
§ 0.9% NS c̄ 20-40mm KCl added to each bag
§ Titrate rate of fluid therapy to clinical findings on
serial examination.
§ Serial U+Es guide electrolyte replacement
Pancreatitis
• Inflammation → significant fluid shift into the abdomen.
• Pts require aggressive fluid resuscitation and
maintenance
§ Insert urinary catheter and consider CVP
monitoring
§ 0.9% NS c̄ 20-40mm KCl added to each bag
§ Keep UO >30ml/h
§ Serial U+Es guide electrolyte replacement
14
Nutrition
Assessment Parenteral Nutrition
• May be “Total” or used to supplement enteral feeding
Clinical • Combined c̄ H2O to deliver total daily requirements
• Hx
§ Wt. loss
§ Diet Indications
• Examination • Prolonged obstruction or ileus (>7d)
§ Skin fat • High output fistula
§ Dry hair • Short bowel syndrome
§ Pressure sores • Severe Crohn’s
§ Cheilitis • Severe malnutrition
2
§ Wt. and BMI (<20kg/m )
• Severe pancreatitis
• Unable to swallow: e.g. oesophageal Ca
Anthropometric
• Skin-fold thickness
• Arm circumference
Delivery
• Delivered centrally as high osmolality is toxic to veins
Ix § Short-term: CV catheter
• Albumin § Long-term: Hickman or PICC line
• Transthyretin (prealbumin) • Sterility is essential: use line only for PN
• Phosphate
Monitoring
Requirements (/kg/24h) • Standard
• Calories: 20-40 Kcal § Wt., fluid balance and urine glucose daily
• Carb: 2g § Zn, Mg weekly
• Fat: 3g • Initially
• Protein: 0.5-1g § Blood glucose, FBC, U+E + PO4 3x /wk
• Nitrogen:0.2-0.4g § LFTs 3x /wk
• Once stable
Enteral Nutrition § Blood glucose, FBC, U+E + PO4 daily
§ LFTs weekly
Delivery
• PO is best
§ Consider semi-solid diet if risk of aspiration Contents
• Fine bore NGT (9 Fr) • 2000Kcal: 50% fat, 50% carb
• Percutaneous Endoscopic Gastrostomy • 10-14g nitrogen
• Jejunostomy • Vitamins, minerals and trace elements
• Build up feeds gradually to prevent diarrhoea
Feeds Complications
• Oral supplements • Line-related
• Polymeric: e.g. osmolite, jevity § Pneumothorax / haemothorax
§ Intact proteins, starches and long-chain FAs § Cardiac arrhythmia
• Disease-specific § Line sepsis
§ e.g. ↓ branched chain AAs in hepatic § Central venous thrombosis → PE or SVCO
encephalopathy • Feed-related
• Elemental § Villous atrophy of GIT
§ Simple AAs and oligo/monosaccharides § Electrolyte disturbances
§ Require minimal digestion and used if abnormal - Refeeding syndrome
GIT: e.g. in Crohn’s - Hypercapnoea from excessive CO2
production
Indications § Hyperglycaemia and reactive hypoglycaemia
§ Line sepsis: ↑ risk c̄ TPN
• Catabolic: sepsis, burns, major surgery
§ Vitamin and mineral deficiencies
• Coma/ITU
• Malnutrition
• Dysphagia: stricture, stroke
Complications
• NGT
§ Nasal trauma
§ Malposition or tube blockage
• Feeding
§ Feed intolerance → diarrhoea
§ Electrolyte imbalance
§ Aspiration
§ Refeeding syndrome
15
Refeeding Syndrome
Definition
• Life-threatening metabolic complication of refeeding
via any route after a prolonged period of starvation.
Pathophysiology
• ↓ carbs → catabolic state c̄ ↓insulin, fat and protein
catabolism and depletion of intracellular PO4
• Refeeding → ↑ insulin in response to carbs and ↑
cellular PO4 uptake.
• → hypophosphataemia
§ Rhabdomyolysis
§ Respiratory insufficiency
§ Arrhythmias
§ Shock
§ Seizures
Chemistry
• ↓K, ↓Mg, ↓PO4
At-risk Patients
• Malignancy
• Anorexia nervosa
• Alcoholism
• GI surgery
• Starvation
Prevention
• Identify and monitor at-risk patients
• Liaise c̄ dietician
Rx
• Identify at-risk pts in advance and liaise c̄ dietician
• Parenteral and oral PO4 supplementation
16
Trauma
Contents
Primary Survey ........................................................................................................................................................... 18
Secondary Survey....................................................................................................................................................... 19
Shock .......................................................................................................................................................................... 19
Life-Threatening Chest Injuries ................................................................................................................................... 20
O
2 Survey Chest Injuries ............................................................................................................................................. 20
Abdominal Trauma...................................................................................................................................................... 21
Head Injury.................................................................................................................................................................. 22
Burns........................................................................................................................................................................... 23
Hypothermia................................................................................................................................................................ 24
17
Primary Survey
ADDRESS PROBLEMS IN ORDER CABDE Circulation
• Two-large bore cannulae (14/16G) in each ACF
Airway and C-Spine • FBC, U+E, x-match (6U), clotting, VBG
Airway Assessment
• Check for airway compromise • Inspection: pale, sweaty, active bleeding
§ Ask pt. a question • Vascular status: BP, HR, JVP, heart sounds, cardiac
§ Stridor mon
§ Orofacial injury or burns • End-organ: consciousness, UO
§ Visualise airway and use suction if necessary
• Manoeuvres to open airway Sites of Haemorrhage
§ Jaw thrust • Chest
• Adjuncts if compromise / potential compromised • Abdomen
§ NPA: gag reflex present • Pelvis: use pelvic binder
§ OPA: no gag reflex (stop tongue swallowing) • Floor
• Emergency airways
§ Needle cricothyroidotomy or surgical cric Mx
• Definitive airways (no risk of aspiration) • If haemodynamic compromise give 2L warmed
§ Endotracheal tube Hartmann’s stat.
§ Tracheostomy • Consider further colloid / blood
• Insert CVP and catheter (after PR) to guide resus
C-Spine
• Maintain in-line cervical support to keep neck stable Response
• Place pt. in hard-collar and sandbags c̄ tape • Assess response to fluids using UO, lactate, BP
Rapid
Breathing • Usually <20% loss
• Start 15L O2 via non-rebreathe mask (Hudson) • Slow fluid to maintenance if haemodynamically
stable
Assessment
• SpO2 Transient
• Inspection of chest • 20-40% loss
• Position of trachea • On-going losses or inadequate resuscitation
• RR and chest expansion
• Breath sounds, vocal resonance None
• Percussion • Exsanguinating haemorrhage → theatre
• ABG • Consider non-haemorrhagic shock
§ Tamponade
Tension Pneumothorax § Pneumothorax
• Signs
§ Respiratory distress
§ ↑JVP and ↓BP Disability
§ Tracheal deviation + displaced apex
§ ↓ air entry and ↓ VR Assessment
§ Hyperresonant percussion
• Assess consciousness using AVPU or GCS
• Rx: immediate decompression
nd • Pupil responses
§ Insert large-bore venflon into 2 ICS, mid-
clavicular line.
§ Insert ICD later
Exposure
Open Sucking Chest Wounds
• Convert to closed wound by covering with damp Assessment
occlusive dressing stuck down on 3 sides. • Completely undress pt.
• Perform log-role and PR
§ Feel for high riding prostate (urethral rupture)
§ Look for bleeding
• Prevent hypothermia
REPEAT 1O SURVEY AGAIN!
18
Secondary Survey Shock
History
Haemorrhagic Shock
• Allergies
• Circulating blood volume = 7% body mass
• Medication
• PMH
• Last ate / drunk % ml RR HR BP UO Mental
• Events 1 0-15 750 ↔ ↔ ↔ ↔ Normal
2 15-30 750-1500 >20 >100 ↔ <30 Anxious++
3 30-40 1500-2000 >30 >120 ↓ 5-20 Confused
Examination 4 >40 >2000 >35 >140 ↓↓ <5 Lethargic
• Head-to-toe examination
• Examine every system
Ix Neurogenic Shock
• Trauma series • Disruption of sympathetic nervous system
§ C-spine: lat + peg
§ CXR Causes
§ Pelvis • Spinal anaesthesia
• FAST scan (Focussed Assessment c̄ Sonography in • Hypoglycaemia
Trauma) • Cord injury above T5
• CT: when pt. is stable. • Closed head injuries
Presentation
Assessing C-spine Radiographs • Hypotension
• Views • Bradycardia
§ Lateral • Warm extremities
§ AP
§ Open-mouth Peg view Mx
• Adequacy • Vasopressors: vasopressin and norad
§ Must see C7-T1 junction • Atropine: reverse the bradycardia
§ May need swimmer’s view c̄ abducted arm
• Alignment: 4 lines
§ Ant. vertebral bodies
§ Ant. vertebral canal Spinal Shock
§ Post. vertebral canal • Acute spinal cord transection
§ Tips of spinous processes • Loss of all voluntary and reflex activity below the level of injury
• Bones: shapes of bodies, laminae, processes
• Cartilage: IV discs should be equal height Presentation
• Soft tissue • Hypotonic paralysis
§ Width of soft tissue shadow anterior to upper • Areflexia
vertebrae should be 50% of vertebral width. • Loss of sensation
• Urinary retention
Clearing the C-Spine
Clinical Clearance
• Indication: NEXUS Criteria
§ Fully alert and orientated
§ No head injury
§ No drugs or alcohol
§ No neck pain
§ No abnormal neurology
§ No distracting injury
• Method
§ Examine for bruising or deformity
§ Palpate for deformity and tenderness
§ Ensure pain-free active movement
Radiological Clearance
• Indications
§ Pt. doesn’t meet criteria for clinical clearance
• Modalities
§ Radiograph initially
- Clear if normal XR and clinical exam
§ CT C-spine if abnormal XR or clinical exam
19
Life-Threatening Chest Injuries 2O Survey Chest Injuries
Differential: ATOMIC Rib #
th th
• Airway obstruction • Usually 5 -9 ribs
• Tension Pneumothorax • # of upper 4 ribs = high energy trauma
• Open pneumothorax (sucking) • Complications
• Massive haemothorax § Pneumothorax
• Intercostal disruption and pulmonary contusion § Lacerate thoracic or abdominal viscera
• Cardiac Tamponade • Rx: good analgesia
§ NSAIDs + opioids
§ Intrapleural analgesia
Massive Haemothorax § Intercostal block
• Accumulation of >1.5L of blood in chest cavity
• Usually caused by disruption of hilar vessels
Sternal #
• Usually MVA driver vs. steering wheel
Presentation
• Risk of mediastinal injury
• Signs of chest wall trauma
• Rx
• ↓BP
§ Analgesia, admit, observe
• ↓ expansion
§ Cardiac monitor
• ↓ breath sounds and ↓VR § Troponin: rule out myocardial contusion
• Stony dull percussion
Pulmonary Contusion
Mx
• Usually due to rapid deceleration injury or shock waves
• X-match 6u
• May → ARDS
• Large-bore chest drain c̄ hep saline for autotransfusion
• Pres: dyspnoea, haemoptysis, respiratory failure
• Thoracotomy if >1.5L or >200ml/h • Ix
§ CXR: opacification
Flail Chest § Serial ABGs: ↓ PaO2:FiO2 ratio
• Ant. or lat. # of ≥2 adjacent ribs in ≥2 places • Rx: O2, ventilate if necessary
• Flail segment moves paradoxically c̄ respiration
• ↓ Oxygenation Myocardial Contusion
§ Underlying pulmonary contusion • Direct blunt trauma over precordium
§ ↓ Ventilation of affected segment • Ix
§ ECG: abnormal, arrhythmias
Ix § ↑ troponin
• CXR / CT chest: pulmonary contusion (white) • Rx: bed rest, cardiac monitoring, Rx arrhythmias
• Serial ABGs: ↓PaO2:FiO2 ratio
Contained Aortic Disruption
Rx • Rapid deceleration injury (80% immediately fatal)
• O2 • Pres: initially stable but → hypotensive
• Good analgesia: PCA, epidural • Ix
• Persistent respiratory failure: PPV § CXR: wide mediastinum, deviation of NGT
§ CT
Cardiac Tamponade • Rx: cardiothoracic consult
• Disruption of myocardium or great vessels → blood in the
pericardium → ↓ filling and contraction → shock Diaphragmatic Injury
th
• Usually results from penetrating trauma • Consider in penetrating injuries below 5 rib or high
energy compression.
Presentation • Ix: CXR (visceral herniation), CT
• Beck’s Triad
§ ↑ JVP / distended neck veins Oesophageal Disruption
§ ↓ BP • Usually penetrating trauma
§ Muffled heart sounds • → mediastinitis
• Pulsus paradoxus: SBP fall of >10mmHg on inspiration • Ix
• Kussmaul’s sign: ↑ JVP on inspiration § CXR: pneumomediastinum, surgical
• Intensely restless pt. emphysema
§ CT
Ix
• US: FAST or transthoracic echo Tracheobronchial Disruption
• CXR: enlarged pericardium • Presentation
• ↑CVP >12mmHg § Persistent pneumothorax
• ECG: low voltage QRS ± electrical alternans § Pneumomediastinum
• Rx: thoracotomy
Mx
• Pericardiocentesis: spinal needle in R subxiphoid space
O
aiming at 45 towards the R tip of left scapula
• Thoracotomy may be needed
20
Abdominal Trauma
Mechanisms Damage Control Surgery
• Penetrating
§ All require exploration as tract may be deeper Aim
than it appears. • Early Mx of abdominal trauma should focus on “damage
• Blunt control” to limit physiological stress.
§ Have a high index of suspicion for taking to § Control haemorrhage: ligation and packing
theatre. § Control contamination
§ Stabilise in ITU
Specific Ix
Spleen
Urine Dip • Kehr’s Sign
O
• Haematuria suggests injury to renal tract § Shoulder tip pain 2 to blood in the peritoneal
cavity.
§ Left Kehr sign is classic symptom of ruptured
FAST Scan spleen
• Replacing DPL in most centres • Classification
• Check for fluid in the abdomen, pelvis and pericardium. § 1: capsular tear
§ 90% sensitive for free fluid § 2: Tear + parenchymal injury
• Can be extended to look for pneumothoraces § 3: Tear up to the hilum
§ 4: Complete fracture
Diagnostic Peritoneal Lavage • Mx
• Advantages and Disadvantages § Haemodynamically unstable: laparotomy
§ 98% sensitive for intra-abdominal haemorrhage § Stable 1-3: observation in HDU
§ Useful if FAST unavailable § Stable 4: consider laparotomy
§ May be better for identifying injury to hollow viscus - Suture lac or partial / complete
§ Unable to identify retroperitoneal injury splenectomy
• Insert urinary catheter and NGT
§ Decompression to minimise risk of injury Liver
• Midline incision through skin and fascia @ 1/3 distance • Conservative if capsule is intact
form umbilicus to pubic symphysis (arcuate line). • Suture laceration
• Carefully dissect to the peritoneum and insert a urinary • Partial hepatectomy
catheter. • Packing
• Instil 10ml/kg warmed Hartmann’s
• Drain fluid back into bag and send sample to lab.
3 Bowel
• +ve = >100,000 RBCs/mm , bile/intestinal contents
• Resection may be required
Indications for Laparatomy Bladder (often assoc. c̄ pelvic injury)

• Unexplained shock
• Intraperitoneal rupture requires laparoscopic repair c̄
• Peritonism: rigid silent abdomen
urethral and suprapubic drainage
• Evisceration: bowel or omentum
• Extraperitoneal rupture can be treated conservatively c̄
• Radiological evidence of intraperitoneal gas
urethral drainage.
• Radiological evidence of ruptured diaphragm
• Give prophylactic Abx
• Gunshot wounds
• +ve DPL or CT
Urethra
• Classification
§ Anterior
- Spongy urethra (penile + bulbar)
- Occur following straddling injuries or
instrumentation
§ Posterior
- Membranous urethra
- Occur following pelvic #s
• Presentation
§ Often assoc. c̄ pelvic fracture
§ Blood in the urethral meatus or scrotum
§ Perineal bruising
§ High-riding prostate
§ Inability to micturate + palpable bladder
• Ix
§ Retrograde urethrogram
• Mx
§ Suprapubic catheter
§ Surgical repair
21
Head Injury
Epidemiology History
• Head injury, alone or in combination c̄ other injuries, is • LOC
the commonest cause of trauma death (50%) • Amnesia: anterograde worse
• Nausea / vomiting
Primary Brain Injury • Fits
• Occurs at time of injury and is a result of direct or indirect • Focal neurology
injury to brain tissue. • Mechanism
• Drugs: e.g. antiplats, warfarin
Diffuse
• Concussion / Mild Traumatic Brain Injury Examination
§ Temporary ↓ in brain function • GCS: E4, V5, M6
§ Headache, confusion, visual symptoms, amnesia, § 3-8 = coma
nausea § 9-12 = moderate head injury
• Diffuse Axonal Injury § 13-15 = mild head injury
§ Shearing forces disrupt axons • Scalp lacerations
§ May → coma and persistent vegetative state
§ Autonomic dysfunction → fever, HTN, sweating Basal Skull #
• CSF rhinorrhoea or otorrhoea (Test: halo sign)
Focal • Battle sign: bruised mastoid
• Contusion • Pando sign: bilateral orbital bruising
§ E.g. coup and contra-coup • Haemotympanum
§ May have focal neurological deficit
Ix
• Intracranial Haemorrhage • C-spine
§ Extradural • CT Head
§ Subdural
§ Basal or other skull #
§ Subarachnoid
§ Amnesia: > 30min retrograde (before event)
§ Parenchymal haemorrhage and laceration
§ Neurological deficit: e.g. seizures
§ GCS: <13 @ scene, <15 2h later
Secondary Brain Injury § Sick: vomiting > 1
• Occurs after primary injury. • Bloods: FBC, U+E, glucose, clotting, EtOH level, ABG
Causes Mx
• Hypoxia • Neurosurgical consult if +ve CT
• Hypercapnoea • Admit if
• Hypotension § LOC >5min
• ↑ ICP § Abnormalities on imaging
• Infection § Difficult to assess: EtOH, post-ictal
§ Not returned to GCS 15 after imaging
Monroe-Kelly Doctrine § CNS signs: persistent vomiting, severe headache
•
Cranium is rigid box \ total volume of intracranial • Neuro obs: half hrly until GCS 15/15
contents must remain constant if ICP is not to change. § GCS, pupils, TPR, BP
• ↑ in volume of one constituent → compensatory ↓ in • Analgesia: codeine phosphate 30-60mg PO/IM QDS
another: • Suture scalp lacs
§ CSF • Abx: if open / base of skull #
§ Blood (esp. venous)
• These mechanisms can compensate for a volume Intubate if
change of ~100ml before ICP ↑. • GCS ≤ 8
§ As autoregulation fails, ICP ↑ rapidly → herniation. • PaO2 <9KPa on air / <13KPa on O2 or PCO2 >6KPa
• Spontaneous hyperventilation: PCO2 <4KPa
Cerebral Blood Flow • Respiratory irregularity
• CBF µ CPP x radius of vessels
• CPP = MABP – ICP Rx ↑ ICP
• ↑ ICP → ↓CPP → ↓CBF • Elevate bed
§ Autoreg → vasodilatation → ↑ volume → ↑ICP… • Good sedation, analgesia ± NM block
• Prevent or attenuate this vicious circle by • Neuroprotective ventilation
§ Ventilate to normocapnoea: 4.5KPa • Mannitol or hypertonic saline
§ IV fluid to normovolaemia
§ Mannitol bolus acutely
Discharge Advice
• Stay with someone for first 48hrs
Cushing Reflex: imminent herniation • Give advice card advising return on:
• Hypertension § Confusion, drowsiness, LOC, fits
• Bradycardia § Visual problems
• Irregular breathing § V. painful headache that won’t go away
§ Vomiting
22
Burns
Risk Factors Mx
• Age: children and elderly • Based on ATLS principals
• Co-morbidities: epilepsy, CVA, dementia, mental illness • Specific concerns c̄ burns
• Occupation § Secure airway
§ Manage fluid loss
Classification § Prevent infection
Superficial Airway
• Erythema • Examine for respiratory burns
• Painful § Soot in oral or nasal cavity
• E.g. sunburn § Burnt nasal hairs
§ Hoarse voice, stridor
• Flexible laryngoscopy can be helpful
Partial Thickness
• Consider early intubation + dexamethasone (↓ inflam)
• Heal w/i 2-3wks if not complicated
• Superficial
§ No loss of dermis
Breathing
§ Painful • 100% O2
§ Blisters • Exclude constricting burns
• Deep • Signs of CO poisoning
§ Loss of dermis but adnexae remain § Headache
§ Healing from adnexae: e.g. follicles § n/v
§ V. painful § Confusion
§ Cherry red appearance
Full Thickness • ABG
§ COHb level
• Complete loss of dermis
§ SpO2 unreliable if CO poisoning
• Charred, waxy, white, skin
• Anaesthetic
Circulation
• Heal from the edges → scar
• Fluid losses may be huge
• 2x large-bore cannulae in each ACF
• Bloods: FBC, U+E, G+S/XM
Complications • Start 2L warmed Hartmann’s immediately
• Formula guide additional fluid requirements in burns pts.
Early
• Infection: loss of barrier function, necrotic tissue, SIRS st
Parkland Formula to guide replacement in 1 24hrs
• Hypovolaemia: loss of fluid in skin + ↑ cap permeability • 4 x wt. (kg) x % burn = mL of Hartmann’s in 24h
• Metabolic disturbance: ↑↑K, ↑↑myoglobin, ↑Hb → AKI • Replace fluid from time of burn
• Compartment syndrome: circumferential burns •
st
Give half in 1 8h
• Peptic ulcers: Curling’s ulcers • Best guide is UO: 30-50mL/h
• Pulmonary: laryngeal oedema, CO poisoning, ARDS
• Renal and hepatic impairment Muir and Barclay Formula to guide fluid replacement
• (wt. x % burn)/2 = mL of Colloid per unit time
Intermediate • Time units: 4, 4, 4, 6, 6, 12 = 36hrs total
• VTE • May need to use blood
• Pressure sores
Burn Treatments
Late • Analgesia: morphine
• Scarring • Dress partial thickness burns
• Contractures § Biological: e.g. cadaveric skin
• Psychological problems § Synthetic
§ Cream: e.g. Flamazine (silver sulfadiazine) +
sterile film
Assessment • Full thickness burns
§ Tangential excision debridement
§ Split-thickness skin grafts
Wallace Rule of 9s: % body surface area burnt • Circumferential burns may require escharotomy to
• Head and neck: 9% prevent compartment syndrome.
• Arms: 9% each • Anti-tetanus toxoid (0.5ml ATT)
• Torso: 18% front and back • Consider prophylactic Abx: esp. anti-pseudommonal
• Legs: 18% each
• Perineum: 1%
• (Palm: 1%)
NB. may also use Lund and Browder charts
23
Hypothermia
Definition Ix
•
O
Core (rectal) temperature <35 C • Rectal / ear temperature
• FBC, U+E, glucose
• TFTs, blood gas
Pathophysiology • ECG
• Body heat is lost via 4 mechanisms § J waves: between QRS and T wave
§ Arrhythmias
1. Radiation: 60%
§ Infra-red emissions Mx
• Cardiac monitor
2. Conduction: 15% • Warm IVI 0.9% NS
§ Direct contact • Urinary catheter
O
§ 1 means in cold water immersion • Consider Abx for prevention of pneumonia
§ Routine if temp <32 and >65yrs
3. Convection: 15%
§ Removes warmed air from around the body Slowly Rewarm
§ ↑d in windy environments • Reheating too quickly → peripheral vasodilatation and
shock.
4. Evaporation: 10% •
O
Aim for 0.5 C /hr
§ Removal of warmed water • Passive external: blankets, warm drinks
§ ↑ in dry, windy environments
• Active external: warm water or warmed air
• Active internal: mediastinal lavage and CPB
§ Severe hypothermia only
Aetiological Classification
• Primary: environmental exposure
• Secondary: change in temperature set-point Complications
§ E.g.: age-related, hypothyroidism, autonomic
• Arrhythmias
neuropathy
• Pneumonia
• Coagulopathy
• Acute renal failure
Presentation
O
Mild: 32 – 35 C
• Shivering
• Tachycardia
• Vasoconstriction
• Apathy
O
Moderate: 28 – 32 C
• Dysrhythmia, bradycardia, hypotension
• J waves
• ↓ reflexes, dilated pupils, ↓ GCS
O
Severe: <28 C
• VT → VF → Cardiogenic shock
• Apnoea
• Non-reactive pupils
• Coagulopathy
• Oliguria
• Pulmonary oedema
24
Upper GI Surgery
Contents
Dysphagia ............................................................................................................................................................ 26
Oesophageal Cancer ........................................................................................................................................... 27
GORD .................................................................................................................................................................. 28
Hiatus Hernia ....................................................................................................................................................... 28
Peptic Ulcer Disease............................................................................................................................................ 29
Upper GI Bleeding ............................................................................................................................................... 30
Perforated Peptic Ulcer ........................................................................................................................................ 31
Gastric Outlet Obstruction.................................................................................................................................... 31
Gastric Cancer ..................................................................................................................................................... 32
Other Gastric Neoplasms..................................................................................................................................... 33
Zollinger-Ellison Syndrome .................................................................................................................................. 33
Bariatric Surgery .................................................................................................................................................. 34
25
Dysphagia
Oesophageal Anatomy Achalasia
• 25cm long muscular tube (40cm from GOJ → lips) • Pathophysiology
• Starts at level of cricoid cartilage (C6) § Degeneration of myenteric plexus (Auerbach’s)
• In the neck lies in the visceral column § ↓ peristalsis
• Runs in posterior mediastinum and passes through § LOS fails to relax
right crus of diaphragm @ T10. • Cause
O
• Continues for 2-3cm before entering the cardia § 1 / idiopathic: commonest
O
• 3 locations of narrowing § 2 : Chagas’ disease (T. cruzii)
§ Level of cricoid • Presentation
§ Posterior to left main bronchus and aortic arch § Dysphagia: liquids then solids
§ LOS § Regurgitation (esp. at night)
rds
• Divided into 3 : reflects change in musculature from § Substernal cramps
striated → mixed → smooth. § Wt. loss
• Lined by non-keratinising squamous epithelium. • Comps: Chronic → oesophageal SCC in 3-5%
• Z-line: transition from squamous → gastric columnar • Ix
§ Ba swallow: dilated tapering oesophagus
- Bird’s beak
§ Manometry: failure of relaxation + ↓ peristalsis
Causes § CXR: widened mediastinum, double RH border
§ OGD: exclude malignancy
Inflammatory • Rx:
• Tonsillitis, pharyngitis § Med: CCBs, nitrates
• Oesophagitis: GORD, candida § Int: botox injection, endoscopic balloon
• Oral candidiasis dilatation
• Aphthous ulcers § Surg: Heller’s cardiomyotomy (typically lap)
Neurological / Motility Disorders Pharyngeal Pouch: Zenker’s Diverticulum

• Local • Outpouching between crico- and thyro-pharyngeal
§ Achalasia components of the inf. pharyngeal constrictor.
§ Diffuse oesophageal spasm § Area of weakness = Killian’s dehiscence.
§ Nutcracker oesophagus • Defect usually occurs posteriorly but swelling usually
§ Bulbar / pseudobulbar palsy (CVA, MND) bulges to left side of neck.
• Systemic • Food debris → pouch expansion → oesophageal
§ Systemic sclerosis / CREST compression → dysphagia.
§ MG • Pres: Regurgitation, halitosis, gurgling sounds
• Rx: excision, endoscopic stapling
Mechanical Obstruction
• Luminal Diffuse Oesophageal Spasm
§ FB • Intermittent severe chest pain ± dysphagia
§ Large food bolus • Ba swallow shows corkscrew oesophagus
• Mural
§ Benign stricture
§ Web (e.g. Plummer-Vinson) Nutcracker Oesophagus
§ Oesophagitis • Intermittent dysphagia ± chest pain
§ Trauma (e.g. OGD) • ↑ contraction pressure c̄ normal peristalsis
§ Malignant stricture
§ Pharynx, oesophagus, gastric Plummer-Vinson Syndrome
§ Pharyngeal pouch • Severe IDA → hyperkeratinisation of upper 3 of
rd
• Extra-Mural oesophagus → web formation

§ Retrosternal goitre • Pre-malignant: 20% risk of SCC
§ Rolling hiatus hernia
§ Lung Ca
§ Mediastinal LNs (e.g. lymphoma) Oesophageal Rupture
§ Thoracic aortic aneurysm • Iatrogenic (85-90%): endoscopy, biopsy, dilatation
• Violent emesis: Boerhaave’s syndrome
• Carcinoma
• Caustic ingestion
Ix
• Trauma: surgical emphysema ± pneumothorax
• Upper GI endoscopy
• Ba swallow
Features
• Manometry
• Odonophagia
• Mediastinitis: tachypnoea, dyspnoea, fever, shock
• Surgical emphysema
Mx
• Iatrogenic: PPI, NGT, Abx
• Other: resus, PPI, Abx, antifungals, debridement +
formation of oesophago-cutaneous fistula c̄ T-tube
26
Oesophageal Cancer
Staging: TNM
Epidemiology
• Tis: carcinoma in situ
• Incidence: 12/100,000, increasing (↑ Barrett’s)
• T1: submucosa
• Age: 50-70 yrs
• T2: muscularis propria (circ / long)
• Sex: M>F = 5:1
• T3 adventicia
• Geo: ↑ Iran, Transkei, China
• T4: adjacent structures
• N1: regional nodes
Risk Factors • M1: distant mets
• EtOH
• Smoking
• Achalasia
Rx
• Discuss in an MDT
• GORD → Barrett’s
§ Upper GI surgeon + gastroenterologist
• Plummer-Vinson
§ Radiologist
• Fatty diet
§ Pathologist
• ↓ vit A+C § Oncologist
• Nitrosamine exposure § Specialist nurses
§ Macmillan nurses
Pathophysiology § Palliative care
• 65% adenocarcinoma
rd
§ Lower 3 Surgical: oesophagectomy
§ GORD → Barrett’s → dysplasia → Ca • Only 25-30% have resectable tumours
• 35% SCC • May be offered neo-adjuvant chemo before surgery to
rds
§ Upper and middle 3 downstage tumour: e.g. cisplatin + 5FU
§ Assoc. c̄ EtOH and smoking • Approaches
§ Commonest type worldwide § Ivor-Lewis (2 stage): abdominal + R
thoracotomy
Presentation § McKeown (3 stage): abdominal + R
• Progressive dysphagia: solids → liquids (esp. bread) thoracotomy + left neck incision
§ Often alter dietary habit → soft food → § Trans-hiatal: abdominal incision
exacerbation of wt. loss. • Prognosis
• Wt. loss § Stage dependent
• Retrosternal chest pain § ~15% 5ys
• Lymphadenopathy
• Upper 3 :
rd Palliative
§ Hoarseness: recurrent laryngeal N. invasion • Majority of pts.
§ Cough ± aspiration pneumonia • Laser coagulation
• Alcohol injection + ↓ Ascites (spiro)
Spread • Stenting and Secretion reduction (e.g. hyoscine patch)
• Direct extension, lymphatics and blood • Analgesia: e.g. fentanyl patches
• 75% of pts have mets @ Dx • Radiotherapy: external or brachytherapy
• Referral
§ Palliative care team
Ix § Macmillan nurses
• Bloods
• Prognosis
§ FBC: anaemia
§ 5ys <5%
§ LFTs: hepatic mets, albumin
§ Median: 4mo
• Diagnosis
§ Upper GI endoscopy: allows biopsy
§ Ba swallow: not often used, apple-core
stricture Benign Tumours
• Staging: TNM • Leiomyoma
§ CT • Lipomas
§ EUS • Haemangiomas
§ Laparoscopy / mediastinoscopy: mets • Benign polyps
27
GORD
Pathophysiology Rx
• LOS dysfunction → reflux of gastric contents →
oesophagitis. Conservative
• Lose wt.
Risk Factors • Raise head of bed
• Hiatus hernia • Small regular meals ≥ 3h before bed
• Smoking • Stop smoking and ↓ EtOH
• EtOH • Avoid hot drinks and spicy food
• Obesity • Stop drugs: NSAIDs, anti-AChM, nitrates, CCB, TCAs
• Pregnancy
• Drugs: anti-AChM, nitrates, CCB, TCAs Medical
• Iatrogenic: Heller’s myotomy • OTC antacids: Gaviscon, Mg trisilicate
• 1: Full-dose PPI for 1-2mo
Symptoms § Lansoprazole 30mg OD
• 2: No response → double dose PPI BD
Oesophageal • 3: No response: add an H2RA
• Retrosternal pain: heartburn § Ranitidine 300mg nocte
§ Related to meals • Control: low-dose acid suppression PRN
§ Worse lying down (e.g. @ night) / stooping
§ Relieved by antacids Surgical: Nissen Fundoplication
• Belching • Indications: all 3 of:
• Regurgitation § Severe symptoms
• Acid brash, water brash § Refractory to medical therapy
• Odonophagia § Confirmed reflux (pH monitoring)
Extra-oesophageal Nissen Fundoplication

• Nocturnal asthma • Aim: prevent reflux, repair diaphragm
• Chronic cough • Usually laparoscopic approach
• Laryngitis, sinusits • Mobilise gastric fundus and wrap around lower
oesophagus
Complications • Close any diaphragmatic hiatus
• Oesophagitis • Complications
• Ulceration: rarely → haematemesis, melaena, ↓Fe § Gas-bloat syn.: inability to belch / vomit
§ Dysphagia if wrap too tight
• Benign stricture: dysphagia
• Barrett’s oesophagus
§ Intestinal metaplasia of squamous epithelium Hiatus Hernia
§ Metaplasia → dysplasia → adenocarcinoma
• Oesophageal adenocarcinoma
Classification
Differential Dx
Sliding (80%)
• Oesophagitis
• Gastro-oesophageal junction slides up into chest
§ Infection: CMV, candida
§ IBD • Often assoc. c̄ GORD
§ Caustic substances / burns
• PUD Rolling (15%)
• Oesophageal Ca • Gastro-oesophageal junction remains in abdomen but
part of stomach rolls into chest alongside oesophagus
Ix • LOS remains intact so GORD uncommon
• Isolated symptoms don’t need Ix • Can → strangulation
• Bloods: FBC
• CXR: hiatus hernia may be seen Mixed (5%)
• OGD if:
§ >55yrs Ix
§ Persistent symptoms despite Rx • CXR: gas bubble and fluid level in chest
§ Anaemia • Ba swallow: diagnostic
§ Loss of wt. • OGD: assess for oesophagitis
§ Anorexia • 24h pH + manometry: exclude dysmotility or
§ Recent onset progressive symptoms achalasia
§ Melaena
§ Swallowing difficulty
§ OGD allows grading by Los Angeles
Rx
• Lose wt.
Classification
• Ba swallow: hiatus hernia, dysmotility • Rx reflux
• 24h pH testing ± manometry • Surgery if intractable symptoms despite medical Rx.
§ pH <4 for >4hrs § Should repair rolling hernia (even if asympto)
as it may strangulate.
28
Peptic Ulcer Disease
Presentation Surgery for PUD
• Epigastric pain
§ DU Concepts
- Before meals and at night • No acid → no ulcer
- Relieved by eating • Acid secretion stimulated by gastrin (from antral G
§ GU cells) and vagus N.
- Worse on eating (→ ↓ wt.)
- Relieved by anatacids Vagotomy
• Truncal
Risk Factors § ↓ acid secretion directly and via ↓ gastrin
• H. pylori § Prevents pyloric sphincter relaxation
• NSAIDs, steroids § \ must be combined c̄ pyloroplasty (widening
• Smoking, EtOH of pylorus) or gastroenterostomy
• Stress (GU) • Selective
§ Cushing’s ulcers: head injury § Vagus nerve only denervated where it supplies
§ Curling’s: ulcers: burns lower oesophagus and stomach
§ Nerves of Laterjet (supply pylorus) left intact
Pathology
• Punched out ulcers Antrectomy c̄ Vagotomy
• Usually background of chronic inflammation • Distal half of stomach removed.
• DU • Anastomosis:
§ 4x commoner cf. GU § Billroth 1: directly to duodenum
st
§ 1 part of duodenum (cap) § Billroth 2 /Polya: to small bowel loop c̄
• GU duodenal stump oversewn
§ Lesser curvature of gastric antrum
Subtotal Gastrectomy c̄ Roux-en-Y
Complications • Occasionally performed for Zollinger-Ellison
• Haemorrhage
§ Haematemesis or melaena
§ Fe deficiency anaemia Physical Complications
• Perforation: peritonitis • Ca: ↑ risk of gastric Ca
• Gastric Outflow Obstruction • Reflux or bilious vomiting (improves c̄ time)
§ Vomiting • Abdominal fullness
§ Colic • Stricture
§ Distension • Stump leakage
• Malignancy
§ ↑ risk c̄ H. pylori infection Metabolic Complications
§ Actual malignant transformation probably • Dumping syndrome
doesn’t occur
§ Abdo distension, flushing, n/v, fainting,
sweating
Ix § Early: osmotic hypovolaemia
• Bloods: FBC, urea (↑ in haemorrhage) § Late: reactive hypoglycaemia
13
• C breath test • Blind loop syndrome → malabsorption, diarrhoea
• OGD (stop PPIs >2wks before) § Overgrowth of bacteria in duodenal stump
§ CLO / urease test for H. pylori • Vitamin deficiency
§ Biopsy all ulcers to check for malignancy § ↓ parietal cells → B12 deficiency
• Gastrin levels if Zollinger-Ellison suspected § Bypassing proximal SB → Fe + folate
deficiency
Mx § Osteoporosis
• Wt. loss: malabsorption of ↓ calories intake
Conservative
• Lose wt.
• Stop smoking and ↓ EtOH
• Avoid hot drinks and spicy food
• Stop drugs: NSAIDs, steroids
• OTC antacids
Medical
• OTC antacids: Gaviscon, Mg trisilicate
• H. pylori eradication: PAC 500 / PMC 250
• Acid suppression
§ PPIs: lansoprazole 30mg/d
§ H2RAs: ranitidine 300mg nocte
29
Upper GI Bleeding
Hx
• Previous bleeds
Management
• Dyspepsia, known ulcers
• Liver disease or oesophageal varices Resuscitate
• Dysphagia, wt. loss
• Head down
• Drugs and EtOH
• 100% O2, protect airway
• Co-morbidities
• 2 x 14G cannulae + IV crystalloid infusion up to 1L.
• Bloods: FBC, U+E (↑ urea), LFTs, clotting, x-match 6u,
o/e
ABG, glucose
• Signs of CLD
• PR: melaena
• Shock?
§ Cool, clammy, CRT>2s Blood if remains shocked
§ ↓BP (<100) or postural hypotension (>20 drop) • Group specific or O- until x-matched
§ ↓ urine output (<30ml/h)
§ Tachycardia
§ ↓GCS
Variceal Bleed
Common Causes • Terlipressin IV (splanchnic vasopressor)
• PUD: 40% (DU commonly) • Prophylactic Abx: e.g. ciprofloxacin 1g/24h
• Acute erosions / gastritis:20%
• Mallory-Weiss tear: 10%
• Varices: 5%
• Oesophagitis: 5% Maintenance
• Ca stomach / oesophagus:<3% • Crystalloid IVI, transfuse if necessary (keep Hb≥10)
• Catheter + consider CVP (aim for >5cm H2O)
Rockall Score: (Prof T Rockall, St. Mary’s) • Correct coagulopathy: vit K, FFP, platelets
• Prediction of re-bleeding and mortality • Thiamine if EtOH
• 40% of re-bleeders die • Notify surgeons of severe bleeds
• Initial score pre-endoscopy
§ Age
§ Shock: BP, pulse
§ Comorbidities Urgent Endoscopy
• Final score post-endoscopy Haemostasis of vessel or ulcer
§ Final Dx + evidence of recent haemorrhage • Adrenaline injection
§ Active bleeding
• Thermal / laser coagulation
§ Visible vessel
§ Adherent clot • Fibrin glue
• Initial score ≥3 or final >6 are indications for surgery • Endoclips
Oesophageal Varices Variceal bleeding:

• Portal HTN → dilated veins @ sites of porto-systemic • 2 of: banding, sclerotherapy, adrenaline, coagulation
anastomosis: L. gastric and inferior oesophageal • Balloon tamponade c̄ Sengstaken-Blakemore tube
veins § Only used if exsanguinating haemorrhage or failure
• 30-50% c̄ portal HTN will bleed from varices of endoscopic therapy
• Overall mortality 25%: ↑ c̄ severity of liver disease. • TIPSS if bleeding can’t be stopped endoscopically
Causes of portal HTN

• Pre-hepatic: portal vein thrombosis
• Hepatic: cirrhosis (80% in UK), schisto (commonest
After endoscopy
worldwide), sarcoidosis. • Omeprazole IV + continuation PO (↓s re-bleeding)
• Post-hepatic: Budd-Chiari, RHF, constrict pericarditis • Keep NBM for 24h → clear fluids → light diet @ 48h
• Daily bloods: FBC, U+E, LFT, clotting
Bleed Prevention • H. pylori testing and eradication
•
O
1 : β-B, repeat endoscopic banding • Stop NSAIDs, steroids et.c.
O
• 2 : β-B, repeat banding, TIPSS
Indications for Surgery
Transjuglar Intrahepatic Porto-Systemic Shunt • Re-bleeding
(TIPSS) • Bleeding despite transfusing 6u
• IR creates artificial channel between hepatic vein and • Uncontrollable bleeding at endoscopy
portal vein → ↓ portal pressure.
• Initial Rockall score ≥3, or final >6.
• Colapinto needle creates tract through liver
parenchyma which is expand using a balloon and
• Open stomach, find bleeder and underrun vessel.
maintained by placement of a stent. NA. Avoid 0.9% NS in uncompensated liver disease (worsens
• Used prophylactically or acutely if endoscopic therapy ascites). Use blood/albumin for resus and 5% dex for
fails to control variceal bleeding. maintenance.
30
Perforated Peptic Ulcer Gastric Outlet Obstruction
Pathophysiology Cause
• Perforated duodenal ulcer is commonest • Late complication of PUD → fibrotic stricturing
st
§ 1 part of the duodenum: highest acid conc • Gastric Ca
§ Ant. perforation → air under diaphragm
§ Post. perforation can erode into GDA → bleed Presentation
§ ¾ of duodenum retroperitoneal \ no air under • Hx of bloating, early satiety and nausea
diaphragm if perforated.
• Outlet obstruction
• Perforated GU § Copious projectile, non-bilious vomiting a few
• Perforated gastric Ca hrs after meals.
§ Contains stale food.
Presentation § Epigastric distension + succussion splash
• Sudden onset severe pain, beginning in the
epigastrium and then becoming generalised. Ix
• Vomiting • ABG: Hypochloraemic hypokalaemic met alkalosis
• Peritonitis • AXR
§ Dilated gastric air bubble, air fluid level
Differential § Collapsed distal bowel
• Pancreatitis • OGD
• Acute cholecystitis • Contrast meal
• AAA
• MI Rx
• Correct metabolic abnormality: 0.9% NS + KCl
Ix • Benign
• Bloods § Endoscopic balloon dilatation
§ FBC, U+E, amylase, CRP, G+S, clotting § Pyloroplasty or gastroenterostomy
§ ABG: ? mesenteric ischaemia • Malignant
• Urine dipstick § Stenting
• Imaging § Resection
§ Erect CXR
- Must be erect for ~15min first
- Air under the diaphragm seen in 70% Hypertrophic Pyloric Stenosis
- False +ve in Chailaditi’s sign
§ AXR Epidemiology
- Rigler’s: air on both sides of bowel wall • Sex: M>F=4:1
• Race: ↑ in Caucasians
Mx
Presentation
Resuscitation • 6-8wks
• NBM • Projectile vomiting minutes after feeding
• Aggressive fluid resuscitation • RUQ mass: olive
§ Urinary Catheter ± CVP line • Visible peristalsis
• Analgesia: morphine 5-10mg/2h max
§ ± cyclizine Dx
• Abx: cef and met • Test feed: palpate mass + see peristalsis
• NGT • Hypochloraemic hypokalaemic metabolic alkalosis
• US
Conservative
• May be considered if pt. isn’t peritonitic Mx
• Careful monitoring, fluids + Abx • Resuscitate and correct metabolic abnormality
• Omentum may seal perforation spontaneously • NGT
preventing operation in ~50% • Ramstedt pyloromyotomy: divide muscularis propria
Surgical: Laparotomy
• DU: abdominal washout + omental patch repair
• GU: excise ulcer and repair defect
• Partial / gastrectomy may rarely be required
§ Send specimen for histo: exclude Ca
Test and Treat

• 90% of perforated PU assoc. c̄ H. pylori
31
Gastric Cancer
Epidemiology Spread
• Incidence: 23/100,000 • w/i stomach: linitis plastica
• Age: 50s • Direct invasion: pancreas
• Sex: M>F=2:1 • Lymphatic: Virchow’s node
• Geo: ↑ in Japan, Eastern Europe, China, S. America • Blood: liver and lung
• Transcoelomic
Risk Factors § Ovaries: Krukenberg tumour (Signet ring morph)
• Atrophic gastritis (→ intestinal metaplasia) § Sister Mary Joseph nodule: umbilical mets
§ Pernicious anaemia / AI gastritis
§ H. pylori Ix
• Diet: ↑ nitrates – smoked, pickled, salted (↑ Japan) • Bloods
§ Nitrates → carcinogenic nitrosamines in GIT § FBC: anaemia
• Smoking § LFTs and clotting
• Blood group A • Imaging
• Low SEC § CXR: mets
• Familial: E. cadherin abnormality § USS: liver mets
• Partial gastrectomy § Gastroscopy + biopsy
§ Ba meal
• Staging
Pathology § Endoluminal US
• Mainly adenocarcinomas § CT/MRI
• Usually located on gastric antrum § Diagnostic laparoscopy
• H. pylori may → MALToma
Mx
Classification
Medical Palliation
Depth of Invasion • Analgesia: e.g. fentanyl patch
• Early gastric Ca: mucosa or submucosa • PPI
• Late gastric Ca: muscularis propria breached • Secretion control
• Chemo: epirubicin, 5FU, cisplatin
Microscopic Appearance • Palliative care team package
• Intestinal: bulky, glandular tumours, heaped
ulceration Surgical Palliation
• Diffuse: infiltrative c̄ signet ring cell morphology • Pyloric stenting
• Bypass procedures
Borrmann Classification
• Polypoid / fungating Curative Surgery
• Excavating • EGC may be resected endoscopically
• Ulcerating and raised • Partial or total gastrectomy c̄ roux-en-Y to prevent bile
• Linitis plastica: leather-bottle like thickening c̄ flat reflux.
rugae § Spleen and part of pancreas may be removed
Symptoms Prognosis
• Usually present late • Overall: 5ys <10%
• Wt. loss + anorexia • Surgery: 20-50% 5ys
• Dyspepsia: epigastric or retrosternal pain/discomfort
• Dysphagia
• n/v
Signs
• Anaemia
• Epigastric mass
• Jaundice
• Ascites
• Hepatomegaly
• Virchow’s node (= Troisier’s sign)
• Acanthosis nigricans
Complications
• Perforation
• Upper GI bleed: haematemesis, melaena
• Gastric outlet obstruction → succession splash
32
Other Gastric Neoplasms Zollinger-Ellison Syndrome
Benign Pathophysiology
• Benign polyps: adenomas • Gastrin-secreting tumour (gastrinoma) most
• Leiomyoma commonly found in the small intestine or pancreas.
• Lipomas • ↑ Gastrin → ↑HCL→ PUD + chronic diarrhoea
• Haemangiomas § Diarrhoea due to inactivation of panc enzymes
• Schwannomas • ECL proliferation can → carcinoid tumours
• 60-90% of gastrinomas are malignant
Malignant • 25% assoc. c̄ MEN1
• Lymphoma
• Carcinoid Presentation
• GIST • Abdominal pain and dyspepsia
• Chronic diarrhoea / Steatorrhoea
• Refractory PUD
Gastrointestinal Stromal Tumour
• Commonest mesenchymal tumour of the GIT Ix
• >50% occur in the stomach. • ↑ gastrin c̄ ↑↑ HCl (pH<2)
• MRI/CT
Epidemiology • Somatostatin receptor scintigraphy
• M=F
• ~60yrs Rx
• ↑ c̄ NF1 • High dose PPI
• Surgery
Pathology § Tumour resection
• Arise from intestinal cells of Cajal § May do subtotal gastrectomy c̄ Roux en Y
§ Located in muscularis propria
§ Pacemaker cells
• OGD: well-demarcated spherical mass c̄ central
punctum
Presentation
• Mass effects: abdo pain, obstruction
• Ulceration: → bleeding
Poor Prognosticators
• ↑ size
• Extra-gastric location
• ↑ mitotic index
Mx
• Medical
§ Unresectable, recurrent or metastatic disease
§ Imatinib: kit selective tyrosine kinase inhibitor
• Surgical
§ Resection
Carcinoid Tumours
• Diverse group of neuroendocrine tumours of
enterochromaffin cell origin
• May secrete multiple hormones
• 10% occur in the stomach
Gastric Carcinoids
• Atrophic gastritis → ↓ acid production → ↑ gastrin →
ECL hyperplasia → carcinoid tumour
• Gastrinomas may also → carcinoid
Gastric Lymphoma
• Commonest site for extranodal lymphoma
• Most commonly MALToma due to chronic H. pylori
gastritis
• H. pylori eradication can be curative
33
Bariatric Surgery
Benefits
• Sustained wt. ↓
• Symptom improvement
§ Sleep apnoea
§ Mobility
§ HTN
§ DM
Indications
• All the criteria must be met
§ BMI ≥40 or ≥35 c̄ significant co-morbidities that
could improve c̄ ↓ wt.
§ Failure of non-surgical Mx to achieve and
maintain clinically beneficial wt. loss for 6mo.
§ Fit for surgery and anaesthesia
§ Integrated program providing guidance on diet,
physical activity, psychosocial concerns and
lifelong medical monitoring
§ Well-informed and motivated pt.
st
• If BMI >50, surgery is 1 -line Rx
Laparoscopic Gastric Banding

• Inflatable silicone band around proximal stomach →
small pre-stomach pouch.
§ Limits food intake
§ Slows digestion
• At 1yr 46% mean excess wt. loss
Roux-en-Y Gastric Bypass

• Oesophagojejunostomy allows bypass of stomach,
duodenum and proximal jejunum.
• Alters secretion of hormones influencing glucose
regulation and perception of hunger / satiety.
• Greater wt. loss and lower reoperation rates.
• Complications
§ Dumping syndrome
§ Wound infection
§ Hernias
§ Malabsorption
§ Diarrhoea
34
Hepatobiliary Surgery
Contents
Gallstones ............................................................................................................................................................ 36
Biliary Colic .......................................................................................................................................................... 36
Acute Cholecystitis............................................................................................................................................... 37
Chronic Cholecystitis ........................................................................................................................................... 37
Rarer Gallstone Disease ...................................................................................................................................... 37
Obstructive Jaundice ........................................................................................................................................... 38
Pancreatic Carcinoma.......................................................................................................................................... 38
Acute Pancreatitis ................................................................................................................................................ 39
Complications of Acute Pancreatitis .................................................................................................................... 40
Chronic Pancreatitis ............................................................................................................................................. 40
Pancreatic Endocrine Neoplasia .......................................................................................................................... 41
Pancreatic Malformations .................................................................................................................................... 41
Cholangiocarcinoma ............................................................................................................................................ 42
Hydatid Cyst......................................................................................................................................................... 42
35
Gallstones Biliary Colic
Epidemiology Pathogenesis
• ~8% of the population >40yrs • Gallbladder spasm against a stone impacted in the neck of
• Incidence ↑ over last 20yrs: western diet the gallbladder – Hartmann’s Pouch.
• Slightly ↑ incidence in females • Less commonly, the stone may be in the CBD
• 90% of gallstones remain asymptomatic
Presentation
Formation • Biliary colic
§ RUQ pain radiating → back (scapular region)
General Composition § Assoc. c̄ sweating, pallor, n/v
• Phospholipids: lecithin § Attacks may be ppted. by fatty food and last <6h
• Bile pigments (broken down Hb) • o/e may be tenderness in right hypochondrium
• Cholesterol • ± jaundice if stones passes in to CBD
Aetiology Differential
• Lithogenic bile: Admirand’s Triangle • Cholecystitis / other gallstone disease
• Biliary sepsis • Pancreatitis
• GB hypomotility → stasis • Bowel perforation
§ Pregnancy, OCP
§ TPN, fasting Ix
• Same work up as cholecystitis as may be difficult to
Cholesterol Stones: 20% differentiate clinically.
• Large • Urine: bilirubin, urobilinogen, Hb
• Often solitary • Bloods: FBC, U+E, amylase, LFTs, G+S, clotting, CRP
• Formation ↑ according to Admirand’s • Imaging
Trangle § AXR: 10% of gallstones are radio-opaque
§ ↓ bile salts § Erect CXR: look for perforation
§ ↓ lecithin § US:
§ ↑ cholesterol - Stones: acoustic shadow
• Risk factors - Dilated ducts: >6mm
§ Female - Inflamed GB: wall oedema
§ OCP, pregnancy • If Dx uncertain after US
§ ↑ age § HIDA cholescintigraphy: shows failure of GB filling
§ High fat diet and obesity (requires functioning liver)
§ Racial: e.g. American Indian tribes • If dilated ducts seen on US → MRCP
§ Loss of terminal ileum (↓ bile salts)
Rx
Pigment Stones: 5% • Conservative
• Small, black, gritty, fragile § Rehydrate and NBM
• Calcium bilirubinate § Opioid analgesia: morphine 5-10mg/2h max
• Associated c̄ haemolysis § High recurrence rate \ surgical Rx favoured
• Surgical
Mixed Stones: 75% § Laparoscopic cholecystectomy
• Often multiple
• Cholesterol is the major component
Complications
In the Gallbladder
• Biliary Colic
• Acute cholecystitis ± empyema
• Chronic cholecytsitis
• Mucocele
• Carcinoma
• Mirizzi’s syndrome
In the CBD
• Obstructive jaundice
• Pancreatitis
• Cholangitis
In the Gut
• Gallstone ileus
36
Acute Cholecystitis Chronic Cholecystitis
Pathogenesis Symptoms: Flatulent Dyspepsia
• Stone or sludge impaction in Hartmann’s pouch • Vague upper abdominal discomfort
• → chemical and / or bacterial inflammation • Distension, bloating
• 5% are acalculous: sepsis, burns, DM • Nausea
• Flatulence, burping
Sequelae • Symptoms exacerbated by fatty foods
• Resolution ± recurrence § CCK release stimulates gallbladder
• Gangrene and rarely perforation
• Chronic cholecystitis Differential
• Empyema • PUD
• IBS
Presentation • Hiatus hernia
• Severe RUQ pain • Chronic pancreatitis
§ Continuous
§ Radiates to right scapula and epigastrium Ix
• Fever • AXR: porcelain gallbladder
• Vomiting • US: stones, fibrotic, shrunken gallbladder
• MRCP
Examination
• Local peritonism in RUQ Mx
• Tachycardia c̄ shallow breathing • Medical
• ± jaundice § Bile salts (not very effective)
• Murphy’s sign • Surgical
§ 2 fingers over the GB and ask pt. to breath in § Elective cholecystectomy
§ → pain and breath catch. Must be –ve on the § ERCP first if US shows dilated ducts and stones
L
• Phlegmon may be palpable
§ Mass of adherent omentum and bowel
• Boas’ sign
§ Hyperaesthesia below the right scapula Rarer Gallstone Disease
Ix Mucocele
• Urine: bilirubin, urobilinogen
• Neck of gallbladder blocked by stone but contents remains
• Bloods sterile
§ FBC: ↑ WCC
• Can be very large → palpable mass
§ U+E: dehydration from vomiting
• May become infected → empyema
§ Amylase, LFTs, G+S, clotting, CRP
• Imaging
§ AXR: gallstone, porcelain gallbladder
§ Erect CXR: look for perforation Gallbladder Carcinoma
§ US • Rare
- Stones: acoustic shadow • Associated c̄ gallstones and gallbladder polyps.
- Dilated ducts (>6mm) • Calcification of gallbladder → porcelain GB
- Inflamed GB: wall oedema • Incidental Ca found in 0.5-1% of lap choles.
• If Dx uncertain after US
§ HIDA cholescintigraphy: shows failure of
GB filling (requires functioning liver) Mirizzi’s Syndrome
• MRCP if dilated ducts seen on US
• Rare
• Large stone in GB presses on the common hepatic duct
Mx → obstructive jaundice.
• Conservative • Stone may erode through into the ducts
§ NBM
§ Fluid resuscitation
§ Analgesia: paracetamol, diclofenac, codeine
§ Abx: cefuroxime and metronidazole
Gallstone Ileus
§ 80-90% settle over 24-48h • Large stone (>2.5cm) erodes from GB → duodenum
O
§ Deterioration: perforation, empyema through a cholecysto-duodenal fistula 2 to chonic inflam.
• Surgical • May impact in distal ileum → obstruction
§ May be elective surgery @ 6-12wks (↓ • Rigler’s Triad:
inflam) § Pneumobiliia
§ If <72h, may perform lap chole in acute § Small bowel obstruction
phase § Gallstone in RLQ
• Empyema • Rx: stone removal via enterotomy
§ High fever • NB. Bouveret’s syn. = duodenal obstruction
§ RUQ mass
§ Percutaneous drainage: cholecystostomy
37
Obstructive Jaundice Pancreatic Carcinoma
Causes Risk Factors: SINED
• 30% stones • Smoking
• 30% Ca head of the pancreas • Inflammation: chronic pancreatitis
• 30% Other • Nutrition: ↑fat diet
§ LNs @ porta hepatis: TB, Ca • EtOH
§ Inflammatory: PBC, PSC • DM
§ Drugs: OCP, sulfonylureas, flucolox
§ Neoplastic: Cholangiocarcinoma
§ Mirizzi’s syndrome
Pathology
• 90% ductal adenocarcinomas
• Present late, metastasise early
Clinical Features § Direct extension to local structures
• Jaundice § Lymphatics
§ Clinically evident at ~50mM § Blood → liver and lungs
§ Seen at tongue frenulum first (affinity for elastin) • 60% located in head, 25% body, 15% tail
• Dark urine, pale stools
• Itch (bile salts)
Presentation
• Typically male >60yrs
Ix • Painless obstructive jaundice: dark urine, pale stools
• Urine • Epigastric pain: radiates to back, relieved sitting
§ Dark forward
§ ↑ bilirubin • Anorexia, wt. loss and malabsorption
§ ↓ urobilinogen
• Acute pancreatitis
• Bloods
• Sudden onset DM in the elderly
§ FBC: ↑ WCC in cholangitis
§ U+E: hepatorenal syndrome
§ LFT: ↑cBR, ↑↑ ALP, ↑AST/ALT Signs
§ Clotting: ↓ vit K → ↑ INR • Palpable gallbladder
§ G+S: may need ERCP • Jaundice
§ Immune: AMA, ANCA, ANA • Epigastric mass
• Imaging • Thrombophlebitis migrans (Trousseau sign)
§ AXR • Splenomegaly: PV thrombosis → portal HTN
- May visualise stone • Ascites
- Pneumobilia suggests gas forming
infection Courvoisier’s Law
§ US • In the presence of painless obstructive jaundice, a
- Dilated ducts >6mm palpable gallbladder is unlikely to be due to stones.
- Stones (95% accurate)
- Tumour Ix
§ MRCP or ERCP
• Bloods: cholestatic LFTs, ↑Ca19-9 (90% sens), ↑Ca
§ Percutaneous Transhepatic Cholangiography
• Imaging
§ US: pancreatic mass, dilated ducts, hepatic
Mx of Stones mets, guide biopsy
• Conservative § EUS: better than CT/MRI for staging
§ Monitor LFTs: passage of stone may → § CXR: mets
resolution § Laparoscopy: mets, staging
§ Vitamins ADEK • ERCP
§ Analgesia § Shows anatomy
§ Cholestyramine § Allows stenting
• Interventional § Biopsy of peri-ampullary lesions
§ If no resolution, worsening LFTs or cholangitis
§ ERCP c̄ sphincterotomy and stone extraction Rx
• Surgical • Surgery
§ Open / lap stone removal c̄ T tube placement § Fit, no mets, tumour ≤3cm (≤10% of pts)
- T tube cholangiogram 8d later to confirm § Whipple’s pancreaticoduodenectomy
stone removal. § Distal pancreatectomy
§ Delayed cholecystectomy to prevent recurrence § Post-op chemo delays progression
§ 5ys = 5-14%
Ascending Cholangitis • Palliation
• May complicate CBD obstruction § Endoscopic / percutaneous stenting of CBD
• Charcot’s triad: fever/rigors, RUQ pain, jaundice § Palliative bypass surgery:
• Reynolds pentad: Charcot’s triad + shock + confusion (a) cholecystojejunostomy +
• Mx gastrojejunostomy
§ Cef and met § Pain relief – may need coeliac plexus block
st
§ 1 : ERCP
nd
§ 2 : Open or lap stone removal c̄ T tube drain Prognosis
• Mean survival <6mo
• 5ys = <2%
38
Acute Pancreatitis
Pathophysiology Ix
• Pancreatic enzymes released and activated in vicious • Bloods
circle → multi-stage process. § FBC: ↑WCC
• Oedema + fluid shift + vomiting → hypovolaemic § ↑amylase (>1000 / 3x ULN) and ↑lipase
shock while enzymes → autodigestion and fat - ↑ in 80%
necrosis - Returns to normal by 5-7d
• Vessel autodigestion → retroperitoneal haemorrhage § U+E: dehydration and renal failure
• Inflammation → pancreatic necrosis § LFTs: cholestatic picture, ↑AST, ↑LDH
2+
• Super-added infection: 50% of pts. c̄ necrosis § Ca : ↓
§ Glucose: ↑
§ CRP: monitor progress, >150 after 48hrs = sev
Epidemiology § ABG: ↓O2 suggests ARDS
• 1% of surgical admissions
th th • Urine: glucose, ↑cBR, ↓urobilinogen
• 4 and 5 decades
• Imaging
• 10% mortality § CXR: ARDS, exclude perfed DU
§ AXR: sentinel loop, pancreatic calcification
Aetiology § US: Gallstones and dilated ducts, inflammation
• Gallstones (45%) § Contrast CT: Balthazar Severity Score
• Ethanol (25%)
• Idiopathic (20%): ?microstones Conservative Mx
• Trauma • Manage at appropriate level: e.g. ITU if severe
• Steroids • Constant reassessment is key
• Mumps + other infections: Coxsackie B § Hrly TPR, UO
• Autoimmune: e.g. PAN 2+
§ Daily FBC, U+E, Ca , glucose, amylase ABG
• Scorpion (Trinidadian)
• Hyperlipidaemia (I and V), ↑Ca, Hypothermia Fluid Resuscitation
• ERCP: 5% risk • Aggressive fluid resus: keep UO >30ml/h
• Drugs: e.g. thiazides, azathioprine • Catheter ± CVP
Symptoms Pancreatic Rest

• Severe epigastric pain → back • NBM
§ May be relieved by sitting forward • NGT if vomiting
• Vomiting • TPN may be required if severe to prevent catabolism
Signs Analgesia
• ↑HR, ↑RR • Pethidine via PCA
• Fever • Or morphine 5-10mg/2h max
• Hypovolaemia → shock
• Epigastric tenderness Antibiotics
• Jaundice • Not routinely given if mild
• Ileus → absent bowel sounds • Used if suspicion of infection or before ERCP
• Ecchymoses • Penems often used: e.g. meropenem, imipenem
§ Grey Turners: flank
§ Cullens: periumbilical (tracks up Falciform) Mx Complications
• ARDS: O2 therapy or ventilation
Differential • ↑ glucose: insulin sliding scale
• Perforated DU • ↑/↓Ca
• Mesenteric infarction • EtOH withdrawal: chlordiazepoxide
• MI
Interventional Mx: ERCP
Modified Glasgow Criteria •
O
If pancreatitis c̄ dilated ducts 2 to gallstones
• Valid for EtOH and gallstones • ERCP + sphincterotomy → ↓ complications
• Assess severity and predict mortality
• Ranson’s criteria are only applicable to EtOH and can
only be fully applied after 48hrs.
Surgical Mx
PANCREAS Indications
• • Infected pancreatic necrosis
PaO2 <8kPa 1 = mild
• Pseudocyst or abscess
• Age >55yrs 2 = mod
9 • Unsure Dx
• Neutrophils >15 x10 /L 3 = severe
2+
• Ca <2mM
Operations
• Renal function U>16mM
• Laparotomy + necrosectomy (pancreatic debridement)
• Enzymes LDH>600iu/L • Laparotomy + peritoneal lavage
AST>200 iu/L • Laparostomy: abdomen left open c̄ sterile packs in ITU
• Albumin <32g/L
• Sugar >10mM
39
Complications of Acute Chronic Pancreatitis
Pancreatitis
Causes: AGITS
• Alcohol (70%)
Early: Systemic • Genetic
• Respiratory: ARDS, pleural effusion § CF
• Shock: hypovolaemic or septic § HH
• Renal failure • Immune
• DIC § Lymphoplasmacytic sclerosing pancreatitis
• Metabolic (↑IgG4)
2+
§ ↓ Ca • Triglycerides ↑
§ ↑ glucose • Structural
§ Metabolic acidosis § Obstruction by tumour
§ Pancreas divisum
Late (>1wk): Local Presentation

• Pancreatic necrosis • Epigastric pain
• Pancreatic infection § Bores through to back
• Pancreatic abscess § Relieved by sitting back or hot water bottle →
§ May form in pseudocyst or in pancreas erythema ab igne
§ Open or percutaneous drainage § Exacerbated by fatty food or EtOH
• Bleeding: e.g. from splenic artery • Steatorrhoea and wt. loss
§ May require embolisation • DM: polyuria, polydipsia
• Thrombosis • Epigastric mass: pseudocyst
§ Splenic A., GDA or colic branches of SMA
- May → bowel necrosis
§ Portal vein → portal HTN
Ix
• ↑ glucose
• Fistula formation
§ Pancreato-cutaneous → skin breakdown • ↓ faecal elastase: ↓ exocrine function
• US: pseudocyst
• AXR: speckled pancreatic calcifications
Pancreatic Pseudocyst
• CT: pancreatic calcifications
• Collection of pancreatic fluid in the lesser sac
surrounded by granulation tissue
• Occur in 20% (esp. in EtOH pancreatitis) Rx
• Presentation • Diet
§ 4-6wks after acute attack § No EtOH
§ Persisting abdominal pain § ↓ fat, ↑ carb
§ Epigastric mass → early satiety • Drugs
• Complications § Analgesia: may need coeliac plexus block
§ Infection → abscess § Enzyme supplements: pancreatin (Creon)
§ Obstruction of duodenum or CBD § ADEK vitamins
• Ix § DM Rx
§ Persistently ↑ amylase ± LFTs • Surgery
§ US / CT § Indications
• Rx - Unremitting pain
§ <6cm: spontaneous resolution - Wt. loss
§ >6cm - Duct blockage
- Endoscopic cyst-gastrostomy § Procedures
- Percutaneous drainage under US/CT - Distal pancreatectomy, Whipple’s
- Pancreaticojejunostomy: drainage
- Endoscopic stenting
Complications
• Pseudocyst
• DM
• Pancreatic Ca
• Pancreatic swelling → biliary obstruction
• Splenic vein thrombosis → splenomegaly
40
Pancreatic Endocrine Neoplasia Pancreatic Malformations
Epidemiology Ectopic Pancreas
• 30-60yrs • Meckel’s diverticulum
• ~15% assoc. c̄ MEN1 • Small bowel
Insulinoma
• Fasting / exercise-induced hypoglycaemia Pancreas Divisium
• Confusion, stupor, LOC • Failure of fusion of dorsal and ventral buds
• ↑ insulin + ↑ c-peptide + ↓glucose • → bulk of pancreas drains through smaller accessory
duct.
Gastrinoma → Zollinger-Ellison • Usually asymptomatic
• Hypergastrinaemia → hyperchlorhydria → PUD and • May → chronic pancreatitis
chronic diarrhoea (inactivation of pancreatic enzymes)
Glucagonoma Annular Pancreas

• ↑ se glucagon → mild DM • Fusion of dorsal and ventral buds around duodenum
• Characteristic blistering rash • May present c̄ infantile duodenal obstruction.
§ Necrolytic migratory erythema
VIPoma / Verner-Morrison / WDHA Syn.

• Watery Diarrhoea
• Hypokalaemia
• Achlorhydria
• Acidosis
Somatostatinoma
• Somatostatin
§ Inhibits glucagon and insulin release
§ Inhibits pancreatic enzyme secretion
• Features
§ DM
§ Steatorrhoea
§ Gallstones
• Usually v. malignant tumour c̄ poor prognosis
41
Cholangiocarcinoma Hydatid Cyst
Pathology Pathophysiology
• Rare bile duct tumour • Zoonotic infection by Echinococcus granulosus
• Adenocarcinoma • Occurs in sheep-rearing communities
• Typically occur @ confluence of right and left hepatic • Parasite penetrates the portal system and infects the
ducts: called “Klatskin” tumours liver → calcified cyst
Risk Factors Presentation

• PSC • Mostly asymptomatic
• Ulcerative colitis • Pressure effects
• Choledocholithiasis § Non-specific pain
• Hep B/C § Abdominal fullness
• Choledochal cysts § Obstructive jaundice
• Lynch 2 • Rupture
• Flukes § Biliary colic
§ Jaundice
§ Urticaria
Presentation § Anaphylaxis
• Progressive painless obstructive jaundice •
O
2 infection
§ Gallbladder not palpable
• Steatorrhoea
• Wt. loss
Ix
• Eosinophilia
• CT
Ix
• Cholestatic LFTs
• CA 19-9
Rx
• Medical: albendazole
• Surgical cystectomy
Rx § Indicated for large cyst
• Poor prognosis: no curative Rx
• Palliative stenting by ERCP
42
Lower GI Surgery
Contents
Paediatric Conditions ........................................................................................................................................... 44
Small Bowel Neoplasms ...................................................................................................................................... 45
Carcinoid Tumours............................................................................................................................................... 45
Acute Appendicitis ............................................................................................................................................... 46
Inflammatory Bowel Disease: Pathology and Presentation ................................................................................. 47
Ulcerative Colitis: Management ........................................................................................................................... 49
Crohn’s Disease: Management............................................................................................................................ 50
Diverticular Disease ............................................................................................................................................. 51
Bowel Obstruction: Causes and Investigation ..................................................................................................... 52
Bowel Obstruction: General Management ........................................................................................................... 53
Bowel Obstruction: Specific Management ........................................................................................................... 54
Colorectal Carcinoma: Pathology and Presentation ............................................................................................ 55
Colorectal Carcinoma: Ix, Mx and Prevention...................................................................................................... 56
Familial CRC Syndromes..................................................................................................................................... 57
GI Polyps ............................................................................................................................................................. 57
Mesenteric Ischaemia .......................................................................................................................................... 58
Lower GI Bleed .................................................................................................................................................... 58
43
Paediatric Conditions
Meckel’s Diverticulum Intussusception
• Ileal remnant of vitellointestinal duct • Portion of intestine (the intussusception) is
§ Joins yoke sac to midgut lumen invaginated into its own lumen (the intussuscipiens)
Features Cause
• A true diverticulum • Hypertrophied Peyer’s patch
• 2 inches long • Meckel’s
• 2 ft from ileocaecal valve on antimesenteric border • HSP
• 2% of population • Peutz-Jeghers
• 2% symptomatic • Lymphoma
• Contain ectopic gastric or pancreatic tissue
Presentation
Presentation of Symptomatic Meckel’s • 6-12mo
• Rectal bleeding: from gastric mucosa • Colicky abdo pain:
• Diverticulitis mimicking appendicitis § Episodic inconsolable crying, drawing up legs
• Intussusception § ± bilious vomiting
• Volvulus • Redcurrent jelly stools
• Malignant change: adenocarcinoma • Sausage-shaped abdominal mass
• Raspberry tumour: mucosa protruding at umbilicus
§ A vitello-intestinal fistula Mx
• Littre’s Hernia: herniation of Meckel’s • Resuscitate, x-match, NGT
• US + reduction by air enema
Dx • Surgery if not reducible by enema
• Tc pertechnecate scan +ve in 70% (detects gastric
mucosa) NB. Intussusception rarely occurs in an adult
• If it does, consider neoplasm as lead-point
Rx
• Surgical resection
Mesenteric Adenitis
• Viral infection / URTI → enlargement of mesenteric
LNs
• → pain, tenderness and fever
• Differentiating features
§ Post URTI
§ Headache + photophobia
§ Higher temperature
§ Tenderness is more generalised
§ Lymphocytosis
44
Small Bowel Neoplasms Carcinoid Tumours
Benign: 35% Pathology
• Lipoma • Diverse group of neuroendocrine tumours of
• Leiomyoma enterochromaffin cell origin capable of producing 5HT
• Neurofibroma • May be derived from
• Haemangioma § Foregut: respiratory tract
• Adenomatous polyps (FAP, Peutz-Jeghers) § Midgut: stomach, ileum, appendix
§ Hindgut: colorectum
Malignant: 65% (only 2% of GI malignancies) • May secrete: 5-HT, VIP, gastrin, glucagon, insulin, ACTH
§ Hind gut tumours rarely secrete 5-HT
• Adenocarcinoma (40% of malignant tumours)
• Carcinoid syndrome suggest bypass of first-pass
• Carcinoid (40% of malignant tumours)
metabolism and is strongly assoc. c̄ metastatic disease.
• Lymphoma (esp. c̄ Coeliac disease: EATL)
• 10% part of MEN1
• GIST
• Sites
§ Appendix: 45%
Presentation § Ileum: 30%
• Often non-specific symptoms so present late § Colorectum: 20%
• N/V, obstruction § Stomach: 10%
• Wt. loss and abdominal pain § Elsewhere in GIT
• Bleeding § Bronchus: 10%
• Jaundice from biliary obstruction or liver mets. • Consider all as malignant
Imaging
• AXR: SBO Presentation
• CT
Local
Endoscopy • Appendicitis
• Push enteroscopy • Intussusception or obstruction
• Wireless capsule endoscopy • Abdominal pain
Carcinoid Syndrome: FIVE HT

• Flushing: paroxysmal, upper body ± wheals
• Intestinal: diarrhoea
• Valve fibrosis: tricuspid regurg and pulmonary stenosis
• whEEze: bronchoconstriction
st
• Hepatic involvement: bypassed 1 pass metabolism
• Tryptophan deficiency → pellagra (3Ds)
Ix
• ↑ urine 5-hydroxyindoleacetic acid
• ↑ plasma chromogranin A
• CT/MRI: find primary
Rx
• Symptoms: octreotide or loperamide
• Curative
§ Resection: tumours are v. yellow
§ Give octreotide to avoid carcinoid crisis
Carcinoid Crisis
• Tumour outgrows blood supply or is handled too much →
massive mediator release
• Vasodilatation, hypotension, bronchoconstriction,
hyperglycaemia
• Rx: high-dose octreotide
Prognosis
• Median survival is 5-8yrs (~3yrs if mets present)
45
Acute Appendicitis
Definition Differential
• Inflammation of the vermiform appendix ranging from • Surgical
oedema to ischaemic necrosis and perforation. § Cholecystitis
§ Diverticulitis
§ Meckel’s diverticulitis
Epidemiology
• Gynae
• Incidence: 6% lifetime incidence, commonest surgical
§ Cyst accident: torsion, rupture, haemorrhage
emergency
§ Salpingitis / PID
• Age: rare <2yrs, maximal peak during child, ↓ § Ruptured ectopic
thereafter
• Medical
§ Mesenteric adenitis
Pathogenesis § UTI
• Obstruction of the appendix § Crohn’s
§ Faecolith most commonly
§ Lymphoid hyperplasia post-infection Ix
§ Tumour (e.g. caecal Ca, carcinoid) • Dx is principally clinical
§ Worms (e.g. Ascaris lumbicoides, Schisto)
• Bloods: FBC, CRP, amylase, G+S, clotting
• Gut organisms → infection behind obstruction
• Urine
• → oedema → ischaemia → necrosis → perforation
§ Sterile pyuria: may indicate bladder irritation
§ Peritonitis
§ Ketones: anorexia
§ Abscess
§ Exclude UTI
§ Appendix mass
§ β-HCG
• Imaging
Pattern of Abdominal Pain § US: exclude gynae path, visualise inflamed
appendix
Early inflammation → appendiceal irritation § CT: can be used
• Visceral pain is not well localised cf. somatic pain. • Diagnostic lap
• Nociceptive info travels in the sympathetic afferent
fibres that supply the viscus Mx
• Pain referred to the dermatome corresponding to the • Fluids
spinal cord entry level of these sympathetic fibres. • Abx: cef 1.5g + met 500g IV TDS
• Append = midgut = lesser splanch (T10/11) = umb • Analgesia: paracetamol, NSAIDs, codeine phosphate
• Certain Dx → appendicectomy (open or lap)
Late inflammation → parietal peritoneum irritation • Uncertain Dx → active observation
• Pain localised in RIF
Complications
Symptoms
• Colicky abdo pain Appendix Mass
§ Central → localised in RIF • Inflamed appendix c̄ adherent covering of omentum
§ Worse c̄ movement and small bowel
• Anorexia • Dx: US or CT
• Nausea (vomiting is rarely prominent) • Mx
• Constipation / diarrhoea § Initially: Abx + NBM
§ Resolution of mass → interval appendicectomy
Signs § Exclude a colonic tumour: colonoscopy
• Low-grade pyrexia: 37.5 – 38.5
• ↑HR, shallow breathing Appendix Abscess
• Foetor oris • Results if appendix mass doesn’t resolve
• Guarding and tenderness: @ McBurney’s point • Mass enlarges, pt. deteriorates
§ +ve cough / percussion tenderness • Mx
• Appendix mass may be palpable in RIF § Abx + NBM
• Pain PR suggests pelvic appendix. § CT-guided percutaneous drainage
§ If no resolution, surgery may involve right
Special Signs hemicolectomy.
Rovsing’s Sign Perforation

• Pressure in LIF → more pain in RIF • Commoner if faecolith present and in young children
(as Dx is often delayed)
• Deteriorating pt. c̄ peritonitis.
Psoas Sign
• Pain on extending the hip: retrocaecal appendix
Cope Sign
• Flexion + internal rotation of R hip → pain
§ Appendix lying close to obturator internus
46
Inflammatory Bowel Disease: Pathology and Presentation
Epidemiology Pathology
UC Crohn’s UC Crohn’s
Prev 100-200 50-100 /100,000 Macroscopic

/100,000 Location Rectum + colon Mouth to anus
Age 30s 20s ± backwash ileitis esp. terminal ileum
Sex F>M (just) Distribution Contiguous Skip lesions
Aet Concordance = Concordance = Strictures No Yes
10% 70%
Smoking Smoking ↑ risk Microscopic
protective TH1/TH17- Inflammation Mucosal Transmural
TH2-mediated mediated Ulceration Shallow, broad Deep, thin, serpiginous
→ cobblestone mucosa
Fibrosis None Marked
Granulomas None Present
Pseudoplyps Marked Minimal
Fistulae No Yes
47
Presentation
UC Crohn’s
Symptoms
Systemic Fever, malaise, anorexia, wt. loss in active disease
Abdominal • Diarrhoea • Diarrhoea (not usually bloody)
• Blood ± mucus PR • Abdominal pain
• Abdominal discomfort • Wt. loss
• Tenesmus, faecal urgency
Signs
Abdominal • Fever • Aphthous ulcers, glossitis
• Tender, distended abdomen • Abdominal tenderness
• RIF mass
• Perianal abscesses, fistulae, tags
• Anal / rectal strictures
Extra- Skin Joints
abdominal - Clubbing • Arthritis (non-deforming, asymmetrical)
- Erythema nodosum • Sacroiliitis
- Pyoderma gang (esp. UC) • Ank spond
HPB
Eyes • PSC + cholangiocarcinoma (esp. UC)
- Iritis • Gallstones (esp. Crohn’s)
- Conjunctivitis • Fatty liver
- Episcleritis Other
- Scleritis • Amyloidosis
• Oxalate renal stones (esp. Crohns)
Complications • Toxic megacolon • Fistulae

§ Diameter >6cm § Entero-enteric/colonic → diarrhoea
§ Risk of perforation § Enterovesical → frequency, UTI
• Bleeding § Enterovaginal
• Malignancy § Perianal → “pepperpot” anus
§ CRC in 15% c̄ pancolitis for 20yrs • Strictures → obstruction
• Cholangiocarcinoma • Abscesses
• Strictures → obstruction § Abdominal
• Venous thrombosis § Anorectal
• Malabsorption
§ Fat → Steatorrhoea, gallstones
§ B12 → megaloblastic anaemia
§ Vit D → osteomalacia
§ Protein → oedema
• Toxic megacolon and Ca may occur (< cf. UC)
48
Ulcerative Colitis: Management
Ix Inducing Remission in Mild / Mod Disease
• Bloods: • OPD-based
§ FBC: ↓Hb, ↑WCC
§ LFT: ↓albumin Oral Therapy
§ ↑CRP/ESR •
st
1 line: 5-ASAs
§ Blood cultures •
nd
2 line: prednisolone
• Stool
§ MCS: exclude Campy, Shigella, Salmonella…
Topical Therapy: mainly left-sided disease
§ CDT: C. diff may complicate or mimic
• Proctitis: suppositories
• Imaging
• More proximal disease: enemas or foams
§ AXR: megacolon (>6cm), wall thickening
§ CXR: perforation • 5-ASAs ± steroids (prednisolone or budesonide)
§ CT
§ Ba / gastrograffin enema Additional Therapy: steroid sparing
§ Lead-pipe: no haustra • Azathioprine or mercaptopurine
§ Thumbprinting: mucosal thickening • Infliximab: steroid-dependent pts
§ Pseudopolyps: regenerating mucosal island
• Ileocolonoscopy + regional biopsy: Baron Score Maintaining Remission
st
• 1 line: 5-ASAs PO – sulfasalazine or mesalazine
Severity § Topical Rx may be used in proctitis
nd
• 2 line: Azathioprine or mercaptopurine
Truelove and Witts Criteria § Relapsed on ASA or are steroid-dependent
§ Give 6-mercaptopurine if azathioprine intolerant
rd
Mild Mod Severe • 3 line: Infliximab / adalimumab
Motions <4 4-6 >6

Emergency Surgery
PR bleed small moderate large • 20% require surgery at some stage
Temp Apyrexic 37.1-37.8 >37.8 • 30% c̄ colitis require surgery w/i 5yrs
HR <70 70-90 >90
Indications
Hb >11 10.5-11 <10.5
• Toxic megacolon
ESR <30 >30 • Perforation
• Massive haemorrhage
Acute Severe UC • Failure to respond to medical Rx
• Resus: Admit, IV hydration, NBM
• Hydrocortisone: IV 100mg QDS + PR Procedures
• Transfuse if required • Total / subtotal colectomy c̄ end ileostomy ± mucus
• Thromboprophylaxis: LMWH fistula
• Monitoring • Followed after ~3mo by either
§ Bloods: FBC, ESR, CRP, U+E § Completion proctectomy + Ileal-pouch anal
§ Vitals + stool chart anastomosis (IPAA) or end ileostomy
§ Twice daily examination § Ileorectal anastomosis (IRA)
§ ± AXR • Panproctocolectomy + permanent end ileostomy
• Acute colitis op mortality: 7% (30% if perforated)
NB. RCTs show no benefit of Abx: not routinely
recommended Elective Surgery
• May use: megacolon, perforation, uncertain Dx
Indications
Acute Complications • Chronic symptoms despite medical therapy
• Perforation • Carcinoma or high-grade dysplasia
• Bleeding
• Toxic megacolon (>6cm) Procedures
• VTE • Panproctocolectomy c̄ end ileostomy or IPAA
• Total colectomy c̄ IRA
Improvement → oral therapy
• Switch to oral pred + a 5-ASA Surgical Complications
• Taper pred after full remission • Abdominal
§ SBO
No Improvement → rescue therapy § Anastomotic stricture
• On day 3: stool freq >8 or CRP >45 § Pelvic abscess
§ Predicts 85% chance of needing a colectomy • Stoma: retraction, stenosis, prolapse, dermatitis
during the admission • Pouch
• Discussion between pt, physician and surgeon § Pouchitis (50%): metronidazole + cipro
• Medical: ciclosporin, infliximab or visilizumab (anti-T § ↓ female fertility
cell) - Faecal leakage
• Surgical
49
Crohn’s Disease: Management
Ix Inducing Remission in Mild / Mod Disease
• Bloods: (top 3 are severity markers) • OPD treatment
§ FBC: ↓Hb, ↑WCC
§ LFT: ↓albumin Supportive
§ ↑CRP/ESR • High fibre diet
§ Haematinics: Fe, B12, Folate • Vitamin supplements
§ Blood cultures
• Stool
Oral Therapy
§ MCS: exclude Campy, Shigella, Salmonella… st
• 1 line
§ CDT: C. diff may complicate or mimic
§ Ileocaecal: budesonide
• Imaging
§ Colitis: sulfasalazine
§ AXR: obstruction, sacroileitis nd
• 2 line: prednisolone (tapering)
§ CXR: perforation rd
§ MRI • 3 line: methotrexate
th
§ Assess pelvic disease and fistula • 4 line: infliximab or adalimumab
§ Assess disease severity
§ Small bowel follow-through or enteroclysis Perianal Disease
§ Skip lesions • Occurs in ~50%
§ Rose-thorn ulcers • Ix: MRI + EUA
§ Cobblestoning: ulceration + mural oedema • Rx
§ String sign of Kantor: narrow terminal ileum § Oral Abx: metronidazole
• Endoscopy § Immunosuppression ± infliximab
§ Ileocolonoscopy + regional biopsy: Ix of § Local surgery ± seton insertion
choice
§ Wireless capsule endoscopy Maintaining Remission
§ Small bowel enteroscopy •
st
1 line: azathioprine or mercaptopurine
nd
• 2 line: methotrexate
rd
• 3 line: Infliximab / adalimumab
Severe Attack
Surgery
Assessment • 50-80% need ≥1 operation in their life
• ↑temp, ↑HR, ↑ESR, ↑CRP, ↑WCC, ↓albumin • Never curative
• Should be as conservative as possible
Management
• Resus: Admit, NBM, IV hydration Indications
• Hydrocortisone: IV + PR if rectal disease • Emergency
• Abx: metronidazole PO or IV § Failure to respond to medical Rx
• Thromboprophylaxis: LMWH § Intestinal obstruction or perforation
• Dietician Review § Massive haemorrhage
§ Elemental diet • Elective
- Liquid prep of amino acids, glucose and § Abscess or fistula
fatty acids § Perianal disease
§ Consider parenteral nutrition § Chronic ill health
• Monitoring § Carcinoma
§ Vitals + stool chart
§ Daily examination Procedures
• Limited resection: e.g. ileocaecal
Improvement → oral therapy • Stricturoplasty
• Switch to oral pred (40mg/d) • Defunction distal disease c̄ temporary loop ileostomy
No Improvement → rescue therapy Complications

• Discussion between pt, physician and surgeon • Stoma complications
• Medical: methotrexate ± infliximab • Enterocutaneous fistulae
• Surgical • Anastomotic leak or stricture
Short gut
• <1-2m small bowel
• Features
§ Steatorrhoea
§ ADEK and B12 malabsorption
§ Bile acid depletion → gallstones
§ Hyperoxaluria → renal stones
• Rx
§ Dietician
§ Supplements or TPN
§ Loperamide
50
Diverticular Disease
Definitions Mx of Acute Diverticulitis
• Diverticulum = out-pouching of tubular structure • Mild Attacks
• True = composed of complete wall (e.g. Meckel’s) § Can be treated at home c̄ bowel rest (fluids
• False = composed of mucosa only (pharyngeal, only) and co-amoxiclav ± metronidazole
colonic) • Admit if
• Diverticular disease: symptomatic diverticulosis § Unwell
• Diverticulitis: inflammation of diverticula § Fluids can’t be tolerated
§ Pain can’t be controlled
Epidemiology • Medical
§ NBM
• 30% of Westerner’s have diverticulosis by 60yrs
§ IV fluids
• F>M
§ Analgesia
§ Antibiotics: cefuroxime + metronidazole
Pathophysiology § Most cases settle
• Assoc. c̄ ↑ intraluminal pressure • Surgical
§ Low fibre diet: no osmotic effect to keep stool § Indications
wet - Perforation
• Mucosa herniates through muscularis propria at points - Large haemorrhage
of weakness where perforating arteries enter. - Stricture → obstruction
• Most commonly located in sigmoid colon § Procedure
• Commoner in obese pts. - Hartmann’s to resect diseased bowel
§ Uniting factor in Saint’s Triad? - May consider lap washout for Hinchey 3
- Hiatus Hernia
- Cholelithiasis Other Complications
- Diverticular disease
Perforation
Symptoms of Diverticular Disease • Sudden onset pain (± preceding diverticulitis)
• Altered bowel habit ± left-sided colic • Generalised peritonitis and shock
§ Relieved by defecation • CXR: free air under diaphragm
• Nausea • Rx: Hartmann’s
• Flatulence
• Rx Haemorrhage
§ High fibre diet, mebeverine may help • Sudden, painless bright red PR bleed
§ Elective resection for chronic pain
• Ix: mesenteric angiography or colonoscopy
• Rx
Diverticulitis § Usually stops spontaneously
• Inspissated faeces → obstruction of diverticulum § May need transfusion
• Elderly pt. c̄ prev Hx of constipation § Colonoscopy ± diathermy / adrenaline
§ Embolisation
Presentation § Resection
• Abdominal pain and tenderness
§ Typically LIF Abscess
§ Localised peritonitis • Walled-off perforation
• Pyrexia • Swinging fever
• Localising signs: e.g. boggy rectal mass
Ix • Leukocytosis
• Bloods • Rx: Abx + CT/US-guided drainage
§ FBC: ↑WCC
§ ↑CRP/ESR Fistulae
§ Amylase • Enterocolic
§ G+S/x-match • Colovaginal
• Imaging • Colovesicular: pneumaturia + intractable UTIs
§ Erect CXR: look for perforation • Rx: resection
§ AXR: fluid level / air in bowel wall
§ Contrast CT
Strictures
• Endoscopy
• After diverticulitis, colon may heal c̄ fibrous strictures
§ Flexi Sig
§ Colonoscopy: not in acute attack • Rx
O
§ Resection (usually c̄ 1 anastomosis)
Hinchey Grading of Perforated Diverticulitis § Stenting
1 Small confined pericolic Surgery rarely

abscesses needed
2 Large abscess extending into May resolve w/o
pelvis surgery
3 Generalised purulent peritonitis Surgery needed
4 Generalised faecal peritonitis Surgery needed
51
Bowel Obstruction: Causes and Investigation
Classification Presentation
• Simple • Abdominal Pain
§ 1 obstructing point + no vascular compromise § Colicky
§ May be partial or complete § Central but level depends on gut region
• Closed Loop § Constant / localised pain suggests
§ Bowel obstructed @ two points strangulation or impending perforation
- Left CRC c̄ competent ileocaecal valve • Distension
- Volvulus § ↑ c̄ lower obstructions
§ Gross distension → perforation • Vomiting
• Strangulated § Early in high obstruction
§ Compromised blood supply § Late or absent in low obstructions
§ Localised, constant pain + peritonism • Absolute Constipation: flatus and faeces
§ Fever + ↑WCC
Examination
Commonest Causes • ↑HR: hypovolaemia, strangulation
• Dehydration, hypovolaemia
SBO • Fever: suggests inflammatory disease or strangulation
• Adhesions: 60% • Surgical scars
• Hernia • Hernias
• Mass: neoplastic or inflammatory
LBO • Bowel sounds
• Colorectal Neoplasia: 60% § ↑: mechanical obstruction
• Diverticular stricture: 20% § ↓: ileus
• Volvulus: 5% • PR
§ Empty rectum
§ Rectal mass
§ Hard impacted stool
Other Causes § Blood from higher pathology
Non-Mechanical = Paralytic Ileus (usually SB) Ix

• Post-op • Bloods
• Peritonitis § FBC: ↑WCC
• Pancreatitis or any localised inflammation § U+E: dehydration, electrolyte abnormalities
• Poisons / Drugs: anti-AChM (e.g. TCAs) § Amylase: ↑↑ if strangulation/perforation
• Pseudo-obstruction § VBG: ↑ lactate in strangulation
• Metabolic: ↓K, ↓Na, ↓Mg, uraemia § G+S, clotting: may need surgery
• Mesenteric ischaemia • Imaging
§ Erect CXR
Mechanical § AXR: ± erect film for fluid levels
• Intraluminal § CT: can show transition point
§ Impacted matter: faeces, worms, bezoars • Gastrograffin studies
§ Intussusception § Look for mechanical obstruction: no free
§ Gallstones flow
• Intramural § Follow through or enema
§ Benign stricture § Follow through may relieve mild
- IBD mechanical obstruction: usually adhesional
- Surgery • Colonoscopy
- Ischaemic colitis § Can be used in some cases
- Diverticulitis § Risk of perforation
§ May be used therapeutically to stent
- Radiotherapy
§ Neoplasia
§ Congenital atresia AXR Findings
• Extramural
§ Hernia SBO LBO
§ Adhesions Diameter ≥3cm ≥6cm (caecum ≥9)
§ Volvulus (sigmoid, caecal, gastric) Location Central Peripheral
§ Extrinsic Compression Markings Valvulae coniventes Haustra
- Pseudocyst - completely across - partially across
- Abscess LB Gas Absent Present
- Haematoma - not in rectum
- Tumour: e.g. ovarian No. of loops Many Few
- Congenital bands (e.g. Ladd’s) Fluid levels Many, short Few, long
Ileus
• Both small and large bowel may be visible
• No clear transition point
52
Bowel Obstruction: General Management
Medical Surgical
Resuscitate: “Drip and Suck” Indications

• NBM • Closed loop obstruction
• IV fluids: aggressive as pt. may be v. dehydrated • Obstructing neoplasm
• NGT: decompress upper GIT, stops vomiting, • Strangulation / perforation → sepsis, peritonitis
prevents aspiration • Failure of conservative Mx (up to 72h)
• Catheterise: monitor UO
Principals
Therapy • Aim to treat the cause
• Analgesia: may require strong opioid • Typically involves resection of the obstructing lesion
• Antibiotics: cef+met if strangulation or perforation • Colon has not been cleansed therefore most surgeons
• Gastrograffin study: oral or via NGT utilise a proximal ostomy post-resection.
• Consider need for parenteral nutrition • Pts. c̄ substantial comorbidity or unresectable tumours
may be offered bypass procedures.
Monitoring • Endoscopically placed expanding metal stents offer
• Regular clinical examination is necessary to ensure palliation or a bridge to surgery allowing optimisation.
that the pt. is not deteriorating.
§ ↑ distension Procedures
§ ↑ pain or tenderness • Must consent pt. for possible resection ± stoma
§ ↑ HR/ ↑RR • SBO: adhesiolysis
• Repeat imaging and bloods • LBO
• Non-operative Mx successful in ~80% of pts. c̄ SBO § Hartmann’s
O
w/o peritonitis § Colectomy + 1 anastomosis + on table lavage
• Pts. c̄ LBO are more likely to need surgery. § Palliative bypass procedure
§ Transverse loop colostomy or loop ileostomy
§ Caecostomy
53
Bowel Obstruction: Specific Management
Sigmoid Volvulus (80% of volvulus) Paralytic Ileus
Pathophysiology Presentation
O
• Long mesentery c̄ narrow base predisposes to torsion • Adynamic bowel 2 to the absence of normal
O
• Usually due to sigmoid elongation 2 to chronic peristalsis
constipation • Usually SBO
• ↑ risk in neuropsych pts.: MS, PD, psychiatric • Reduced or absent bowel sounds
§ Disease or Rx interferes c̄ intestinal motility • Mild abdominal pain: not colicky
• → closed loop obstruction
Cause
Presentation • Post-op
• Commoner in males • Peritonitis
• Often elderly, constipated, co-morbid pts. • Pancreatitis or any localised inflammation
• Massive distension c̄ tympanic abdomen • Poisons / Drugs: anti-AChM (e.g. TCAs)
• Pseudo-obstruction
AXR • Metabolic: ↓K, ↓Na, ↓Mg, uraemia
• Characteristic inverted U / coffee bean sign • Mesenteric ischaemia
Mx Prevention
• Often relieved by sigmoidoscopy and flatus tube • ↓ bowel handling
insertion • Laparoscopic approach
§ Monitor for signs of bowel ischaemia following • Peritoneal lavage after peritonitis
decompression.
• Sigmoid colectomy occasionally required Mx
§ Failed endoscopic decompression • Conservative “drip and suck” Mx
§ Bowel necrosis • Correct any underlying causes
• Often recurs \ elective sigmoidectomy may be § Drugs
needed § Metabolic abnormalities
• Consider need for parenteral nutrition
• Exclude mechanical cause if protracted
Caecal Volvulus
• Assoc. c̄ congenital malformation where caecum is
not fixed in the RIF. Colonic Pseudo-obstruction / Ogilvie’s Syn.
• Only ~10% of pts. can be detorsed c̄ colonoscopy
§ \ typically requires surgery Presentation
•
O
Right hemi c̄ 1 ileocolic anastomosis • Clinical signs of mechanical obstruction but no
• Caecostomy obstructing lesion found
• Usually distension only: no colic
Cause
Gastric Volvulus • Aetiology unknown
• Assoc. c̄
Triad of gastro-oesophageal obstruction § Elderly
• Vomiting → retching c̄ regurgitation of saliva § Cardiorespiratory disorders
• Pain § Pelvic surgery: e.g. hip arthroplasty
• Failed attempts to pass an NGT § Trauma
Risk Factors Ix
• Congenital • Gastrograffin oral/enema: exclude mechanical
§ Bands cause
§ Rolling / Paraoesophageal hernia
§ Pyloric stenosis Mx
• Acquired • Neostigmine: anti-cholinesterase
§ Gastric / oesophageal surgery • Colonoscopic decompression: 80% successful
§ Adhesions
Ix
• Gastric dilatation
• Double fluid level on erect films
Mx
• Endoscopic manipulation
• Emergency laparotomy
54
Colorectal Carcinoma: Pathology and Presentation
Epidemiology Pathology
rd
• 3 commonest cancer • 95% adenocarcinoma
nd
• 2 commonest cause of cancer deaths (16,000/yr) § Others: lymphoma, GIST, carcinoid
• Age: peak in 60s • Location
• Sex: rectal Ca commoner in men § Rectum: 35%
• Geo: Western disease § Sigmoid: 25%
§ Caecum and ascending colon: 20%
§ Transverse: 10%
Pathophysiology
§ Descending: 5%
• Proximal tumours: sessile or polypoid
Colonic Adenomas • Distal tumours: annular stenosing
• Benign precursors to CRC
• Characterised by dysplastic epithelium
• Classification Spread
§ Tubular: small, pedunculated, tubular glands • Local
§ Villous: large, sessile, covered by villi • Lymphatic
§ Tubulovillous: mixture • Blood (liver, lungs)
• Presentation • Transcoelomic
§ Typically asymptomatic
§ Large polyps can bleed → IDA Presentation
§ Villous adenomas can → ↓K +
hypoproteinaemia Left
• Malignant potential • Altered bowel habit
§ ↑ size
• PR mass (60%)
§ ↑ dysplasia
• Obstruction (25%)
§ ↑ villous component
• Bleeding / mucus PR
• Tenesmus
APC et al.
• -ve regulator of β-catenin (component of WNT
Right
pathway)
• Anaemia
• APC binds to and promotes degradation of β-catenin.
• Wt. loss
• APC mutation → ↑ β-catenin → ↑ transcription of
genes which promote cell proliferation. • Abdominal pain
• Proliferation → mutation of other genes which
promote growth and prevent apoptosis Either
§ KRAS (proto-oncogene) • Abdominal mass
§ p53 (TSG) • Perforation
• Haemorrhage
Adenoma → Carcinoma Sequence (Vogelstein) • Fistula
• First hit: mutation of one APC copy
• Second hit: mutation of second APC copy Examination
§ → adenoma formation • Palpable mass: per abdomen or PR
• Additional mutations in adenoma → malignant • Perianal fistulae
transformation: e.g KRAS, p53 • Hepatomegaly
• Anaemia
Other Aetiological Factors • Signs of obstruction
• Diet: ↓ fibre + ↑ animal fat / protein
• IBD: CRC in 15% c̄ pancolitis for 20yrs
• Familial: FAP, HNPCC, Peutz-Jeghers
• Smoking
• Genetics
§ No relative: 1/50 CRC risk
st
§ One 1 degree: 1/10
• NSAIDs / Aspirin (300mg/d): protective
55
Colorectal Carcinoma: Ix, Mx and Prevention
Ix Surgery
• Bloods • Use ERAS pathway
§ FBC: Hb • Pre-operative bowel prep (except R sided lesions)
§ LFTs: mets § E.g. Kleen Prep (Macrogol: osmotic laxative)
§ Tumour Marker: CEA (carcinoembryonic Ag) the day before and phosphate enema in the
• Imaging AM.
§ CXR: lung mets • Consent: discuss stomas
§ US liver: mets • Stoma nurse consult for siting
§ CT and MRI
- Staging Principals
- MRI best for rectal Ca and liver mets • Excision depends on lymphatic drainage which follows
§ Endoanal US: staging rectal tumours arterial supply.
§ Ba / gastrograffin enema: apple-core lesion
• Mobility of bowel and blood supply at cut ends is also
• Endoscopy + Biopsy important.
§ Flexi sig: 65% of tumours accessible
• Hartmann’s often used if obstruction.
§ Colonoscopy
• Laparoscopic approach is the standard of care
Rectal Ca
Staging • Neo-adjuvant radiotherapy may be used to ↓ local
recurrence and ↑5ys
Dukes (Sir Cuthbert Dukes: St. Mark’s pathologist) • Anterior resection: tumour 4-5cm from anal verge
§ Defunction c̄ loop ileostomy
Spread % 5ys • AP resection: <4cm from anal verge
A Confined to bowel wall 90 • + Total mesorectal excision for tumours of the
B Through bowel wall but no LNs 60 middle and lower third.
C Regional LNs 30 § Aims to ↓ recurrence
§ ↑ anastomotic leak and faecal incontinence
D Distant mets <10
Other Tumours
TNM
• Sigmoid: high anterior resection or sigmoid colectomy
• TIS: carcinoma in situ
• Left: left hemicolectomy
• T1: submucosa
• Transverse: extended right hemicolectomy
• T2: muscularis propria
• Caecal / right: right hemicolectomy
• T3: subserosa
• T4: through the serosa to adjacent organs
• N1: 1-3 nodes
• N2: >4 nodes Other Rx
• Local excision: e.g. Transanal Endoscopic Microsurg
• Bypass surgery: palliation
• Hepatic resection: if single lobe mets only
Grading
• Stenting: palliation or bridge to surgery in obstruction
• Grading from low to high
• Chemo
• Based on cell morphology
§ Adjuvant 5-FU for Dukes’ C ↓ mortality by 25%
• Dysplasia, mitotic index, hyperchromatism
- i.e. LN +ve pts.
§ High grade tumour
§ Palliation of metastatic disease
Mx
• Manage in an MDT
• Confirmation of Dx
• Stage c̄ CT or MRI NHS Screening for CRC
• 60% amenable to radical surgery
FOB Testing
• Introduced in 2006
• 60-75yrs
• Home FOB testing every 2yrs: ~1/50 have +ve FOB
• Colonoscopy if +ve: ~1/10 have Ca
• Lindholm et al. BJS 2008
§ Screening ↓ risk of dying from CRC by 25%
Flexible Sigmoidoscopy
• Introduced in 2011/12
• 55-60yrs
• Once only flexi Sig
• Atkin et al. Lancet 2010
§ ↓ CRC incidence by 33%
§ ↓ CRC mortality by 43%
56
Familial CRC Syndromes GI Polyps
Familial Adenomatous Polyposis Inflammatory Pseudopolyps
• Autosomal dominant • Regenerating islands of mucosa in UC
• APC gene on 5q21
Hyperplastic Polyps
Presentation • Piling up of goblet cells and absorptive cells
• 100-1000s of adenomas by ~16yrs • Serrated surface architecture
§ Mainly in large bowel • No malignant potential
§ Also stomach and duodenum (near ampulla)
• 100% develop CRC, often by ~40yrs Hamartomatous
• May be assoc. c̄ congenital hypertrophy of the retinal • Tumour-like growths composed of tissues present at
pigment epithelium (CHPRE) site where they develop.
• Sporadic or part of familial syndromes
Variants • Juvenile polyp: solitary hamartoma in children
• Attenuated FAP: <100 adenomas, later CRC (>50yrs) § “Cherry on a stalk”
• Gardener’s (TODE)
§ Thyroid tumours Neoplastic
§ Osteomas of the mandible, skull and long • Tubular or villous adenomas
bones • Usually asymptomatic
§ Dental abnormalities: supernumerary teeth • May have blood / mucus PR, tenesmus
§ Epidermal cysts
• Turcot’s: CNS tumours: medullo- and glio-blastomas
Other Hamartomatous Polyposis Syndromes
Mx
• Prophylactic colectomy before 20yrs
• Total colectomy + IRA
Juvenile Polyposis
§ Requires life-long rectal stump surveillance • Autosomal dominant
• Proctocolectomy + IPAA • >10 hamartomatous polyps
• Remain @ risk of Ca in stomach and duodenum • ↑ CRC risk: need surveillance and polypectomy
§ Regular endoscopic screening
Cowden Syndrome
• Auto dominant
• Macrocephaly + skin stigmata
Hereditary Non-Polyposis Colorectal Cancer • Intestinal hamartomas
• Autosomal dominant
• ↑ risk of extra-intestinal Ca
• Mutation of mismatch repair enzymes
§ E.g. MSH2 on Chr 2p
• Commonest cause of hereditary CRC: 3% of all CRC
Presentation
• Lynch 1: right sided CRC
• Lynch 2: CRC + gastric, endometrial, prostate, breast
Dx: “3, 2, 1, rule”

• ≥3 family members over 2 generations c̄ one <50yrs
Peutz-Jeghers Syndrome
• Autosomal dominant
• STK11 mutation
Presentation
• ~ 10-15yrs
• Mucocutaneous hyperpigmentation
§ Macules on palms, buccal mucosa
• Multiple GI hamartomatous polyps
§ Intussusception
§ Haemorrhage
• ↑ Ca risk
§ CRC, pancreas, breast, lung, ovaries, uterus
57
Mesenteric Ischaemia Lower GI Bleed
Acute Causes
Causes Common / Important

• Arterial: thrombotic (35%), embolic (35%) • Rectal: haemorrhoids, fissure
• Non-occlusive (20%) • Diverticulitis
O
§ Splanchnic vasoconstriction: e.g. 2 to shock • Neoplasm
• Venous thrombosis (5%)
• Other: trauma, vasculitis, strangulation Other
• Inflammation: IBD
Presentation • Infection: shigella, campylobacter, C. diff
• Nearly always small bowel • Polyps
• Triad • Large upper GI bleed (15% of lower GI bleeds)
§ Acute severe abdominal pain ± PR bleed • Angio: dysplasia, ischaemic colitis, HHT
§ Rapid hypovolaemia → shock
§ No abdominal signs Ix
• Degree of illness >> clinical signs • Bloods: FBC, U+E, LFT, x-match, clotting, amylase
• May be in AF • Stool: MCS
• Imaging
Ix § AXR, erect CXR
• Bloods § Angiography: necessary if no source on
§ ↑Hb: plasma loss endoscopy
§ ↑WCC § Red cell scan
§ ↑ amylase • Endoscopy
§ Persistent metabolic acidosis: ↑lactate st
§ 1 : Rigid proctoscopy / sigmoidoscopy
• Imaging nd
§ 2 : OGD
rd
§ AXR: gasless abdomen § 3 : Colonoscopy: difficult in major bleeding
§ Arteriography / CT/MRI angio
Mx
Complications • Resuscitate
• Septic peritonitis • Urinary catheter
• SIRS → MODS • Abx: if evidence of sepsis or perf
• PPI: if upper GI bleed possible
Mx • Keep bed bound: need to pass stool may be large
• Fluids bleed → collapse
• Abx: gent + met • Stool chart
• LMWH • Diet: keep on clear fluids (allows colonoscopy)
• Laparotomy: resect necrotic bowel • Surgery: only if unremitting, massive bleed
Chronic Small Bowel Ischaemia

• Cause: atheroma + low flow state (e.g. LVF) Angiodysplasia
• Presentation: • Submucosal AV malformations
§ Severe, colicky post-prandial abdo pain • 70-90% occur in right colon
- “gut claudication” • Can affect anywhere in GIT
§ PR bleeding
§ Malabsorption Presentation
§ Wt. loss
• Elderly
• Mx: angioplasty
• Fresh PR bleeding
Chronic Large Bowel Ischaemia Ix

• Cause: follows low flow in IMA territory • Exclude other Dx
• Presentation § PR exam
§ Lower, left-sided abdominal pain § Ba enema
§ Bloody diarrhoea § Colonoscopy
§ Pyrexia • Mesenteric angiography or CT angiography
§ Tachycardia
• Tc-labelled RBC scan: identify active bleeding
• Ix
§ ↑WCC
§ Ba enema: thumb-printing Rx
§ MR angiography • Embolisation
• Complications • Endoscopic laser electrocoagulation
§ May → peritonitis and septic shock • Resection
§ Strictures in the long-term
• Mx
§ Usually conservative: fluids and Abx
§ Angioplasty and endovascular stenting
58
Perianal Surgery
Contents
Key Anatomy........................................................................................................................................................ 60
Minor Anal Conditions .......................................................................................................................................... 60
Haemorrhoids ...................................................................................................................................................... 61
Anal Fissure ......................................................................................................................................................... 62
Fistula in Ano ....................................................................................................................................................... 62
Peri-anal Sepsis / Abscess .................................................................................................................................. 63
Pilonidal Sinus ..................................................................................................................................................... 63
Anal Carcinoma ................................................................................................................................................... 64
Rectal Prolapse.................................................................................................................................................... 64
59
Key Anatomy Minor Anal Conditions
Rectum
Perianal Haematoma
• 12cm
• Sacral promontory to levator ani muscle
• The 3 tenia coli fuse around the rectum to form a
Definition
continuous muscle layer. • Subcutaneous bleeding from a burst venule caused
by straining or the passage of hard stool.
• Also called an external pile: a misnomer
Anal Canal
• 4cm Presentation
• Levator ani muscle to anal verge
• Tender blue lump at the anal margin
• Upper 2/3 of canal
• Pain worsened by defecation or movement
§ Lined by columnar epithelium
§ Insensate
§ Sup. rectal artery and vein Rx
§ Internal iliac nodes • Analgesia + spontaneous resolution
• Lower 1/3 of canal • Evacuation under LA
§ Lined by squamous epithelium
§ Sensate
§ Middle and inf. rectal arteries and veins Proctalgia Fugax
§ Superficial inguinal nodes • Young, anxious men
• Dentate line = squamomucosal junction • Crampy anorectal pain, worse @ night
• White line = where anal canal becomes true skin • Unrelated to defecation
• Assoc. c̄ trigeminal neuralgia
• Rx
Anal Sphincters § Reassurance
§ GTN cream
Internal
• Thickening of rectal smooth muscle
• Involuntary control Perineal Warts
• Commonly seen in MSM
External • Condylomata accuminata
• Three rings of skeletal muscle § HPV
§ Deep § Rx: podophyllin paint, cryo, surgical excision
§ Superficial • Condylomata lata
§ Subcutaneous § Syphilis
• Voluntary control § Rx: penicillin
Anorectal Ring
• Deep segment of external sphincter which is Pruritis Ani
continuous c̄ puboretalis muscle (part of levator ani) • 50% idiopathic
• Palpable on PR ~5cm from the anus • Poor hygiene
• Demarcates junction between anal canal and rectum. • Haemorrhoids
• Must be preserved to maintain continence • Anal fissure
• Anal fistula
• Fungi, worms
• Crohn’s
• Neoplasia
60
Haemorrhoids
Definition Symptoms
• Disrupted and dilated anal cushions • Fresh painless PR bleeding
§ Bright red
§ On paper, on stool, may drip into pan
Pathophysiology
• Pruritis ani
• Anal cushion: mass of spongy vascular tissue
• Lump in perianal area
• Positioned @ 3, 7 and 11 O’clock
• Severe pain = thrombosis
§ Where the three major arteries that feed the
vascular plexuses enter the anal canal
• Gravity, straining → engorgement and enlargement of Examination
anal cushions • Full abdo exam, palpating for masses
• Hard stool disrupts connective tissue around • Inspect perianal area: masses, recent bleeding
cushions. • DRE: can’t palpate piles unless thrombosed
• Cushions protrude and can be damaged by hard stool • Rigid sig to identify higher rectal pathology
§ → bright red (capillary) bleeding. • Proctoscopy (also allows Rx)
• Haemorrhoids arise above dentate line \ not painful
• May be gripped by anal sphincter → thrombosis Differential
§ Strangulated piles are acutely painful • Perianal haematoma
§ May ulcerate or infarct • Fissure
• Abscess
Causes • Tumour (must exclude in all cases)
• Constipation c̄ prolonged straining
• Venous congestion may contribute Mx
§ Pregnancy
§ Abdominal tumour Conservative
§ Portal HTN
• ↑ fibre and fluid intake
• Stop straining @ stool
Classification
st
• 1 degree: never prolapse Medical
nd
• 2 : prolapse on defecation but spontaneously reduce • Topical preparations
rd
• 3 : prolapse on defecation but require digital § Anusol: hydrocortisone
reduction § Topical analgesics
th
• 4 : remain permanently prolapsed • Laxatives: lactulose, fybogel
Interventional
• Injection c̄ sclerosant (5% phenol in Almond oil)
§ Injection above dentate line
§ SE: impotence, prostatitis
• Banding → thrombosis and separation
§ SE: bleeding, infection
• Cryotherapy
§ SE: watery discharge post-procedure
• Infra-red coagulation
Surgical: Haemorrhoidectomy
• Excision of piles + ligation of vascular pedicles
• Discharge c̄ laxatives post-op
• SE: bleeding, stenosis
Mx of Thrombosed Piles
• Analgesia
• Ice-packs
• Stool softeners
• Topical lignocaine jelly
• Pain usually resolves in 2-3wks
• Haemorrhoidectomy is not usually necessary
61
Anal Fissure Fistula in Ano
Definition Definition
• Tear of squamous epithelial lining in lower anal canal • Abnormal connection between ano-rectal canal and
the skin.
Causes
•
O
Mostly trauma 2 to the passage of hard stool Pathogenesis
O
§ Assoc. c̄ constipation • Usually occur 2 to perinanal sepsis
§ Spasm of internal anal sphincter contributes to § Blockage of intramuscular glands → abscess
pain and → ischaemia + poor healing § Abscess discharges to form a fistula
§ Commoner in women • Associations
• Rarer causes, often → multiple ± lateral fissures § Crohn’s
§ Crohn’s § Diverticular disease
§ Herpes § Rectal Ca
§ Anal Ca § Immunosuppression
Presentation Classification
• Intense anal pain • High: cross sphincter muscles above dentate line
§ Especially on defecation • Low: cross sphincter muscles below dentate line
§ May prevent pt. from passing stools
• Fresh rectal bleeding Goodsall’s Rule
§ On paper mostly • Determines path of fistula tract
• Fistula anterior to anus track in a straight line (radial)
Examination • Fistula posterior to anus always have internal opening
• PR often impossible at the 6 o’clock position → curved track
• Midline ulcer is seen
Anterior
§ Usually posterior @ 6 O’clock
§ May be anterior
• May be a mucosal tag – sentinel pile
§ Usually posterior @ 6 O’clock
• Groin LNs suggest complicating factor: e.g. HIV
Mx
• If fissure recurrent, chronic or difficult to Rx the patient
requires EUA.
Conservative
• Soaks in warm bath Posterior
• Toileting advice
• Dietary advice: ↑ fibre and fluids
Presentation
Medical • Persistent anal discharge
• Laxatives: lactulose + fybogel • Perianal pain or discomfort
• Topical → resolution in 75%
§ Lignocaine Examination
§ GTN ointment • May visualise external opening: may be pus
§ Diltiazem cream • Induration around the fistula on DRE
• EUA + botulinum toxin injection • Proctosopy may reveal internal opening
Surgical: Lateral partial sphincterotomy Ix

• Division of internal anal sphincter @ 3 O’clock • MRI
• Pre-op anorectal US and manometry • Endoanal US
• V. rarely performed
• Complications Rx
§ Minor faecal/flatus incontinence (= GTN)
• Extent of fistula must first be delineated by probing the
§ Perianal abscess
fistula @ EUA
NB. Lord’s operation (anal dilatation under
Low Fistula
anaesthesia) is no longer used due to high rates of
• Fistulotomy and excision
incontinence. O
§ Laid open to heal by 2 intention
High Fistula
• Fistulotomy could damage the anorectal ring
• Suture – a seton – passed through fistula and
gradually tightened over months
§ Stimulates fibrosis of tract
§ Scar tissue holds sphincter together
62
Peri-anal Sepsis / Abscess Pilonidal Sinus
Pathogenesis Definition
• Anal gland blockage → infection → abscess • Pilonidal: lat “nest of hair”
§ E.g. coli, bacteroides • Sinus: blind ending tract, lined by epithelial or
• May develop from skin infections granulation tissue, which opens onto an epithelial
§ E.g. sebaceous gland or hair follicle surface.
§ Staphs
Pathophysiology
Associations • Hair works its way beneath skin → foreign body
• Crohn’s reaction → formation of abscess
• DM • Usually occur in the natal cleft.
• Malignancy
Risk Factors
Classification • M>F=4:1
• Perianal: 45% • Geo: Mediterranean, Middle east, Asians
§ Discrete local red swelling close to the anal • Often overweight c̄ poor personal hygiene
verge • Occupations c̄ lots of sitting: e.g. truck drivers
• Ischiorectal: ≤30%
§ Systemic upset
§ Extremely painful on DRE
Presentation
• Interphincteric / intermuscular: >20% • Persistent discharge of purulent or clear fluid
• Pelvirectal / supralevator: ~5% • Recurrent pain
§ Systemic upset • Abscesses
§ Bladder irritation
Rx
Presentation
• Throbbing perianal pain Conservative
§ Worse on sitting • Hygiene advice
• Occasionally a purulent anal discharge • Shave / remove hair from affected area
Examination Surgical
• Perianal mass or cellulitic area • Incision and drainage of abscesses
• Fluctuant mass on PR • Elective sinus excision
• Septic signs: fever, tachycardia § Methylene blue to outline tract
§ Recurrence in 4-15%
Rx
• Abx may suffice if Rx instigated v. early in course
• Most cases require EUA c̄ I&D
§ Wound packed
O
§ Heals by 2 intention
§ Daily dressing for 7-10d
• Look for an anal fistula which complicates ~30% of
abscesses.
63
Anal Carcinoma Rectal Prolapse
Epidemiology Definition
• Relatively uncommon: 250-300 cases/yr in the UK • Protrusion of rectal tissue through the anal canal.
Pathology Classification
• 80% SCCs
§ Others: melanomas, adenocarcinomas Type 1: Mucosal prolapse
• Anal margin tumours • Partial prolapse of redundant mucosa
§ Well differentiated keratinising lesions • Common in children: esp. c̄ CF
§ Commoner in men • Essentially large piles \ same Rx
§ Good prognosis
• Anal canal tumours
Type 2: Full thickness prolapse
§ Arise above dentate line
§ Poorly differentiated, non-keratinising • Commoner cf. type 1
§ Commoner in women • Usually elderly females c̄ poor O&G Hx
§ Worse prognosis
• Spread Presentation
§ Above dentate line → internal iliac nodes • Mass extrudes from rectum on defecation
§ Below dentate line → inguinal nodes § May reduce spontaneously or require manual
reduction
Aetiology • May become oedematous and ulcerated
• HPV (16, 18, 31, 33) is important factor § → pain and bleeding
§ ↑ incidence in MSM • Faecal soiling
§ ↑ incidence if perianal warts • Assoc. c̄ vaginal prolapse and urinary incontinence
Presentation Examination
• Perianal pain and bleeding • Visible prolapse: brought out on straining
• Pruritis ani • ± excoriation and ulceration
• Faecal incontinence • ↓ sphincter tone on PR
§ 70% have sphincter involvement @ • Assoc. uterovaginal prolapse
presentation
• May → rectovaginal fistula Ix
• Sigmoidoscopy to exclude proximal lesions
Examination • Anal manometry
• Palpable lesion in only 25% • Endoanal US
• ± palpable inguinal nodes • MRI
Ix Rx
• ↓ Hb (ACD)
• Endoanal US Partial Prolapse
• Rectal EUA + biopsy • Phenol injection
• CT / MRI: assess pelvic spread • Rubber band ligation
• Surgery: Delorme’s Procedure
Rx
• Chemoradiotherapy: most pts Complete Prolapse
§ 50% 5ys • Conservative
• Surgery: reserved for § Pelvic floor exercises
§ Tumours that fail to respond to radiotherapy § Stool softeners
§ GI obstruction • Surgery
§ Small anal margin tumours w/o sphincter § Abdominal Approach: Rectopexy
involvement - Lap or open
- Mobilised rectum fixed to sacrum c̄
mesh
§ Perineal Approach: Delorme’s Procedure
- Resect mucosa and suture the two
mucosal boundaries.
64
Hernias
Contents
Hernia Definitions................................................................................................................................................. 66
Inguinal Hernia ..................................................................................................................................................... 67
Femoral Hernia .................................................................................................................................................... 68
Incisional Hernia .................................................................................................................................................. 68
Other Hernia Types.............................................................................................................................................. 69
65
Hernia Definitions
Term Definition
Hernia Protrusion of a viscus or part of a viscus through the walls of its containing cavity into an
abnormal position.
Reducible Sac can return to the abdominal cavity either spontaneously or c̄ manipulation.
Irreducible Sac cannot be reduced despite pressure or manipulation.
Strangulated Blood supply of contents is compromised due to pressure at the neck of the hernia.
Sliding hernia Part of the sac is formed by bowel (e.g. caecum or sigmoid): take care when excising the
sac.
Maydl’s hernia Herniating double loop of bowel. Strangulated portion may reside as a single loop inside the
abdomen.
Littre’s hernia Hernial sac containing strangulated Meckel’s diverticulum.
Amyand’s Inguinal hernia containing strangulated appendix
Richter’s Only part of circumference of bowel is within sac

Most commonly seen with femoral hernias.
Can strangulate w/o obstructing.
Pantaloon Simultaneous direct and indirect hernia.
Herniotomy Excision of hernial sac
Herniorrhaphy Suture repair of hernial defect
Hernioplasty Mesh repair of hernial defect
66
Inguinal Hernia
Epidemiology Clinical Features
• 3% of adults will require hernioplasty
• ~4% of male neonates have hernia (↑ c̄ prems) Children
• M>>F = 9:1 (descent of testes) • Lump in groin which may descend into scrotum
• Majority present in 50s. • Exacerbated by crying
• Commonly obstruct
Pathology Adults
• Lump in groin, exacerbated by straining/cough
• Commoner on R (?damage to ilioinguinal N. @
• May be clear ppting event: e.g. heavy lifting
appendicectomy → muscle weakness)
• Dragging pain radiating to groin
• 5% bilateral
• 8-15% present as emergency c̄ • May present c̄ obstruction/strangulation
strangulation/obstruction
Questions
• Reducible?
• Ever episodes of obstruction / strangulation?
Aetiology • Predisposing factors: cough, straining, lifting?
• Occupation and social circumstances?
Congenital: patent processus vaginalis
• Processus vaginalis should obliterate following
descent of the testes.
• If it stays patent it may fill with Mx
§ Fluid → hydrocele
§ Bowel/omentum → indirect hernia Non-surgical
• Rx RFs: cough, constipation
Acquired: mainly things which ↑IAP • Lose weight
• Chronic cough: COPD, asthma • Truss
• Prostatism
• Constipation Surgical
• Severe muscular effort: e.g. heavy lifting • Tension-free mesh (e.g. Lichtenstein repair) better
• Previous incision/repair cf. suture repair (e.g. Shouldice repair)
• Ascites / obesity § Recurrence ~0.5% vs. 10%
• Appendicectomy • Open approach can be done under LA or GA
• Lap approach allows bilateral repair and improved
cosmesis. Also preferred for recurrent hernias.
Classification • O
1 unilateral repairs should be open (NICE)
• Children only require sac excision (herniotomy)
Indirect
• 80%: commoner in young Complications
• Congenital patent processus vaginalis • Early
• Emerge through deep ring § Haematoma / seroma formation: 10%
• Same 3 coverings as cord and descend into the § Intra-abdominal injury (lap)
scrotum § Infection: 1%
• Can strangulate § Urinary retention
• Late
Direct § Recurrence (~0.5%)
§ Ischaemic orchitis: 0.5%
• 20%: commoner in elderly
§ Chronic groin pain / paraesthesia: 5-10%
• Acquired
• Emerge through Hesselbach’s triangle
• Can acquire internal and external spermatic fascia
• Rarely descend into scrotum
• Rarely strangulate
Ix
• US if Dx in doubt
67
Femoral Hernia Incisional Hernia
• Protrusion of viscus through the femoral canal • Hernia arises through a previously acquired defect
Epidemiology Epidemiology
• F>M • 6% of surgical incisions
§ Inguinal hernias still more common in F
• Middle aged and elderly
Risk Factors
Aetiology Pre-operative
• Acquired: ↑ intra-abdominal pressure • ↑ age
• Femoral canal larger in females due to shape of pelvis • Obesity or malnutrition
and changes in its configuration due to childbirth • Comorbidities: DM, renal failure, malignancy
• Drugs: steroids, chemo, radio
Clinical features Intra-operative

• Surgical technique/skill (major factor)
§ Too small suture bites
Painless groin lump
§ Inappropriate suture material
• Neck inferior (and lateral) to the pubic tubercle. • Incision type (e.g. midline)
• Cough impulse. • Placing drains through wounds
• Often irreducible (tight boarders)
Post-operative
Commonly present c̄ obstruction or strangulation • ↑ IAP: chronic cough, straining, post-op ileus
• Tender, red and hot • Infection
• Abdo pain, distension, vomiting, constipation • Haematoma
Mx Mx
• 50% risk of strangulation w/i 1mo • Surgery is not appropriate for many patients.
• Urgent surgery • Must balance risk of operation and recurrence c̄ risk of
obstruction / strangulation and pt. choice.
Elective: Lockwood Approach • Usually broad-necked \ low risk of strangulation
• Low incision over hernia c̄ herniotomy and
herniorrhaphy (suture ing. ligt. to pectineal ligt.) Conservative
• Manage RFs: e.g. constipation, cough
Emergency: McEvedy Approach • Weight loss
• High approach in inguinal region to allow inspection • Elasticated corset or truss
and resection of non-viable bowel.
• Then herniotomy and herniorrhaphy Surgical
• Pre-op
§ Optimise cardiorespiratory function
§ Encourage wt. loss
• Mesh repair: open or lap
68
Other Hernia Types
Umbilical Features Management
• Congenital • Usually resolves by 2-3yrs
• 3% of live births • Surgical repair if no closure.
• Defect in the umbilical scar • Can recur in adults: pregnancy or gross
ascites
Risk Factors
• Afro-Caribbean
• Trisomy 21
• Congenital hypothyroidism
Paraumbilical Features Management

• Acquired: middle aged obese men • Mayo (double-breast linea alba c̄ sutures) /
• Defect through linea alba just above or mesh repair
below umbilicus
• Small defect ® strangulation (often
omentum)
Risk Factors
• Chronic cough
• Straining
Epigastric Features Management

• Young M>F • Mesh/suture repair
• Pea-sized swelling caused by defect in
linea alba above the umbilicus.
• Usually contains omentum: can strangulate
Spigelian Features
• Hernia through linea semilunaris
• Hernia lies between layers of abdo wall
• Palpable mass more likely to be colon Ca
Obturator Features
• Old aged F>M
• Sac protrudes through obturator foramen
• Pain on inner aspect of thigh or knee
• Frequently present obstructed / strangulated
Lumbar Features
• Middle-aged M>F
• Typically follow loin incisions
• Hernias through sup./inf. lumbar triangles
Sciatic Features
• Hernia through lesser sciatic foramen
• Usually presents as SBO + gluteal mass
Gluteal Features
• Hernia through greater sciatic foramen
• Usually presents as SBO + gluteal mass
69
Superficial Lesions
Contents
Skin Lumps .......................................................................................................................................................... 71
Malignant and Pre-malignant Skin Lesions.......................................................................................................... 73
Neck Lumps: General Approach .......................................................................................................................... 74
Anterior Triangle Lumps....................................................................................................................................... 74
Midline Neck Lumps............................................................................................................................................. 75
Posterior Triangle Lumps ..................................................................................................................................... 75
Cervical Lymphadenopathy ................................................................................................................................. 76
Hypertrophic and Keloid Scars ............................................................................................................................ 76
Thyroid Lumps ..................................................................................................................................................... 77
Benign Thyroid Disease ....................................................................................................................................... 78
Malignant Thyroid Disease .................................................................................................................................. 79
Salivary Glands .................................................................................................................................................... 80
70
Skin Lumps
Lump Pathology Features Viva Mx
Lipoma Benign tumour of mature adipocytes Inspection Occur anywhere fat can expand Dercum’s Disease / Adiposis dolorosa Non-surgical
- i.e. NOT scalp or palms - Multiple, painful lipomas
Sarcomatous change probably doesn’t - inc. spermatic cord, submucosa - Assoc. peripheral neuropathy Surgical Excision
occur. - Obese postmen women
May be a scar from recurrence
Liposarcomas arise de novo Familial Multiple Lipomatosis
- Older pts.
- Deeper tissues of the lower limbs Palpation Soft Madelung’s Disease
Subcutaneous
Imprecise margin Bannayan-Zonana Syndrome
Fluctuant - Multiple lipomas
- Macrocephaly
- Haemangiomas
Sebaceous Epithelial-lined cyst containing keratin Inspection Occur @ sites of hair growth Complications Non-surgical
cyst - Scalp, face, neck, chest and back - Infection: pus discharge
Two histological subtypes - NOT soles or palms - Ulceration Surgical Excision
Central Punctum - Calcification
1) Epidermal Cyst
- Arise from hair follicle Cock’s Peculiar Tumour
infundibulum - Large ulcerating trichilemmal cyst on the
scalp
2) Trichilemmal Cyst / Wen Palpation Firm - Resemble an SCC
- Arise from hair follicle epithelium Smooth
- Often multiple Intradermal Gardener’s Syndrome: FAP +
- May be autosomal dominant - Thyroid tumours
- Osteomas
- Dental abnormalities
- Epidermal cysts
Ganglion Cystic swelling related to a synovial Inspection Can be found anywhere Differential Non-Surgical
lined structures: joint, tendon 90% on dorsum of hand or wrist - Bursae - Aspiration followed by
Dorsum of ankle - Cystic protrusion from synovial 3wks of immobilisation
Myxoid degeneration of fibrous tissue May be scar from recurrence cavity of arthritic joint.
Weakly transilluminable Surgical Excision
Contain thick, gelatinous material - Recurrence can be 50%
Palpation Soft - Neurovascular damage
Subcutaneous
May be tethered to tendon
Seborrheic Benign hyperplasia of basal epithelial Stuck on appearance Non-surgical
keratosis layer Dark brown
- Hyperkeratosis: keratin layer Greasy
thickening
- Acanthosis: prickle layer thickening
71
Lump Pathology Features Viva Mx
Neurofibroma Benign nerve sheath tumour arising Inspection Solitary or multiple NF 1: von Recklinghausen’s Surgical excision only indicated
from schwann cells. Pedunculated nodules - AD, Chr 17 if malignant growth suspected.
- Cafe-au-lait spots (>6)
Palpation Fleshy consistency - Freckling Local regrowth is common
Pressure can → paraesthesia - Neurofibromas
Extras Examine the eyes - Lisch nodules (iris)
Examine the axilla
Examine the cranial nerves (esp. 8)
BP
Papilloma Overgrowth of all layers of the skin c̄ Skin tag / fibroepithelial polyp Excision + diathermy to control
a central vascular core. bleeding.
Pedunculated
Flesh coloured
Pyogenic Rapidly growing capillary Inspection Most commonly on hands, face, gums Possible assoc. c̄ prev trauma Non-surgical
granuloma haemangioma. and lips. More common in pregnancy - regression is uncommon
Bright red hemispherical nodule
Neither pyogenic, nor a granuloma May have serous / purulent discharge Surgical
Palpation Soft - curettage c̄ diathermy of
Bleed very easily the bases
Dermoid Cyst Epidermal-lined cyst deep to the skin Inspection Smooth spherical swelling Child / young adult: congenital Congenital
Sites of embryological fusion - CT to establish extent
Congenital / Inclusion Cysts Scar from recurrence Adult: congenital - Surgical excision
- Developmental inclusion of - Ask re. trauma
epidermis along lines of skin fusion Acquired
- Midline of neck and nose - Surgical excision
- Medial and lateral ends of eyebrows Palpation Soft
Non-tender
Acquired / Implantation Cyst Subcutaneous
- Implantation of epidermis in dermis
O
- Often 2 to trauma (e.g. piercing)
Dermato- Benign neoplasm of dermal Inspection Can occur anywhere Differential Excision + histology
fibroma fibroblasts Mostly on the lower limbs of young to - Malignancy: melanoma, BCC
middle-aged women
Small, brown pigmented nodule

Palpation Firm, woody feel: characteristic
Intradermal: mobile over deep tissue
Kerato- Benign overgrowth of hair follicle cells Fast-growing Regress w/i 6wks
acanthoma Cytologically similar to well- Dome-shaped c̄ a keratin plug Excise to reduce scarring and
differentiated SCCs Intradermal obtain histology
72
Malignant and Pre-malignant Skin Lesions
Malignant Melanoma Squamous Cell Carcinoma
• Ulcerated lesion c̄ hard, raised everted edges
Epidemiology • Sun exposed areas
• F>M = 1.5:1
• UK incidence = 10 000/yr and 2000 deaths/yr Causes
§ ↑ 80% in 20yrs • Sun exposure: scalp, face, ears, lower leg
• May arise in chronic ulcers: Marjolin’s Ulcer
Features • Xeroderma pigmentosa
• Asymetry
• Boarder: irregular Evolution
• Colour: non-uniform • Solar/actinic keratosis → Bowen’s → SCC
• Diameter >6mm • Lymph node spread is rare
• Evolving / Elevation
Rx
Risk Factors • Excision + radiotherapy to affected nodes
• Sunlight: esp. intense exposure in early years.
• Fair skinned (low Fitzpatrick skin type)
• ↑ no. of common moles
• +ve FH
Actinic Keratoses
• ↑ age • Irregular, crusty warty lesions.
• Immunosuppression • Pre-malignant (~1%/yr)
Classification Rx
• Superficial Spreading: 80% • Cautery
§ Irregular boarders, colour variation • Cryo
§ Commonest in Caucasians • 5-FU
§ Grow slowly, metastasise late = better • Imiquimod
prognosis • Photodynamic phototherapy
• Lentigo Maligna Melanoma
§ Often elderly pts.
§ Face or scalp Bowen’s Disease
• Acral Lentiginous • Red/brown scaly plaques
§ Asians/blacks • Typically on the legs of older women
§ Palms, soles, subungual (c̄ Hutchinson’s sign) • SCC in situ
• Nodular Melanoma
§ All sites Rx
§ Younger age, new lesion • As for AKs
§ Invade deeply, metastasis early = poor prog
• Amelanotic
§ Atypical appearance → delayed Dx
Basal Cell Carcinoma
Staging and Prognosis • Commonest cancer
• Pearly nodule c̄ rolled telangiectactic edge
• Breslow Depth
§ Thickness of tumour to deepest point of dermal • May ulcerate
invasion • Typically on face in sun-exposed area
§ <1mm = >75% 5ys § Above line from tragus → angle of mouth
§ >4mm = 50% 5ys
• Clark’s Staging Behaviour
• Stratifies depth by 5 anatomical levels • Low-grade malignancy → very rarely metastasise
§ Stage 1: Epidermis • Locally invasive
§ Stage 5: sc fat
Rx
Metastasis • Excision
• Liver § Mohs: complete circumferential margin
• Eye assessment using frozen section histology
• Cryo/radio may be used.
Mx
O
• Excision + 2 margin excision depending on Bres
depth
• ± lymphadenectomy
• ± adjuvant chemo (may use isolated limb perfusion)
Poor prognostic indicators

• Male sex (more tumours on trunk cf. females)
• ↑ mitoses
• Satellite lesions (lymphatic spread)
73
Neck Lumps: General Approach Anterior Triangle Lumps
Diagnosis Branchial Cysts
nd
• 85% of neck lumps are LNs: esp. if present < • Embryological remnant 2 branchial cleft
3wks
§ Infection: EBV, tonsillitis, HIV Presentation
§ Ca: lymphoma or mets • Age <20yrs
• 8% are goitres • Ant. margin of SCM at junction of upper and middle 3
rd
• 7% other: e.g. sebaceous cyst or lipoma • May become infected → abscess

• May be assoc. c̄ branchial fistula
Ix: Triple Assessment
• Clinical assessment Pathology
• Imaging: US • Lined by squamous epithelium
• Cyto/Histo: aspiration or biopsy • Contain “glary” fluid c̄ cholesterol crystals
Anterior triangle Rx
• Ant. margin of SCM • Med
• Midline § Abx for infection
• Ramus of the mandible § Sclerotherapy c̄ OK-432 can be used
• Roof: investing fascia • Surgical excision
• Floor: pre-vertebral fascia § Definitive Rx
§ May be difficult due to proximity of carotids
Causes
• Pulsatile
§ Carotid artery aneurysm Branchial sinus or fistula
rd
§ Tortuous carotid artery • Small opening in lower 3 of neck on ant. margin of SCM
§ Carotid body tumour (chemodectoma) • Between tonsillar fossa and ant. border of SCM
• Non-pulsatile • May discharge mucus
§ Branchial cysts
§ Laryngocele
§ Goitre Carotid Body Tumour: Chemodectoma
§ Parotid tumour (lump in postero-superior
• Very rare
area)
• Carotid bodies
§ Located @ carotid bifurcation
+
§ Detect pO2, pCO2 and H
Submandibular Triangle
• Mental process Presentation
rd
• Ramus of the mandible • Just anterior to upper 3 of SCM.
• Line between two angles of the mandible • Pulsatile
• Move laterally but not vertically
Causes • May be bilateral
• Salivary stone • Pressure may → dizziness and syncope
• Sialadenitis • Mostly benign (5% malignant)
• Salivary tumour
Ix: Doppler or angio: splaying of bifurcation
Posterior Triangle Rx: extirpation by a vascular surgeon

• Post. margin of SCM
• Ant. margin of trapezius
• Mid 1/3 of clavicle. Laryngocele
• Cystic dilatation of the laryngeal saccule
Causes • Congenital or acquired
• LNs • Exacerbated by blowing
• Cervical ribs
• Pharyngeal pouch
• Cystic hygromas
• Pancoast’s tumour
Midline Lumps
• <20yrs
§ Thyroglossal cyst
§ Dermoid cyst
• >20yrs
§ Thyroid isthmus mass
§ Ectopic thyroid tissue
74
Midline Neck Lumps Posterior Triangle Lumps
Dermoid Cyst Cervical ribs
• Developmental inclusion of epidermis along lines of • Overdevelopment of transverse process of C7
skin fusion. • Occur in 1:150
Presentation Presentation
• Common <20yrs • Mostly asymptomatic
• Found at junctions of embryological fusion • Hard swelling
§ Neck midline • ↓ radial pulse on abduction and external rotation of arm
§ Lateral angles of eyebrow • Can → vascular symptoms
§ Under tongue § Compresses subclavian A
• Contains ectodermal elements § Raynaud’s
§ Hair follicles, sebaceous glands § Subclavian steal
§ ↓ venous outflow → oedema
Rx: excision • Can → neurological symptoms
§ Compresses lower trunk of brachial plexus, T1
nerve root or stellate ganglion.
Thyroglossal Cyst § Wasting of intrinsic hand muscles
§ Paraesthesia along medial border of arm
• Cyst formed from persistent thyroglossal duct
§ Path of thyroid descent from base of tongue
Presentation Pharyngeal Pouch: Zenker’s Diverticulum

• Can be located anywhere between foramen caecum • Herniation of pharyngeal mucosa through its muscular
and the thyroid coat at its weakest point.
§ Usually just inferior to the hyoid: subhyoid § Pulsion diverticulum
§ Or, just above the hyoid: suprahyoid • Killian’s dehiscence
• Fluctuant lump that moves up c̄ tongue protrusion § Between thyro- and crico-pharyngeal muscles that
form the inferior constrictor
• Can become infected → thyroglossal fistula
Presentation
Rx
• Swelling on left side of neck
• Sistrunk’s Op: excision of cyst and thyroglossal
duct with segment of hyoid bone • Regurgitation and aspiration
• Halitosis
• Gurgling sounds
• Food debris → pouch expansion → oesophageal
compression → dysphagia.
Ix: barium swallow
Rx
• Excision and cricopharyngeal myotomy
• Endoscopic stapling
Cystic Hygroma
• Congenital multiloculated lymphangioma arising from the
jugular lymph sac
Presentation
• Infants
• Lower part of post. triangle but may extend to axilla.
• ↑ in size when child coughs/cries
• Transilluminates brilliantly
Rx: excision or hypertonic saline sclerosant

• May recur
75
Cervical Lymphadenopathy Hypertrophic and Keloid Scars
Key Features Features
• Consistency • Scar more prominent than surrounding skin
• Number
• Fixation Hypertrophic
• Symmetry • Scar confined to wound margins
• Tenderness • Across flexor surfaces and skin creases
• Appear soon after injury and regress spontaneously
Additional Examination • Any age: commonly 8-20yrs
• Face and scalp for infection or neoplasm • M=F
• Chest exam: infection or neoplasm • All races
• Breast examination
• Formal full ENT examination Keloid
• Rest of reticuloendothelial system • Scar extends beyond wound margins
• Earlobes, chin, neck, shoulder, chest
History • Appear months after injury and continue to grow
• Symptoms from the lumps • Puberty to 30yrs
§ E.g. EtOH-induced pain • F>M
• General symptoms • Black and Hispanic
§ Fever, malaise, wt. loss
• Systemic disease
§ PMH Wound Associations
§ Previous operations • Infection
• Social history • Trauma
§ Ethnic origin • Burns
§ HIV risk factors • Tension
• Certain body areas
Causes: LIST
• Lymphoma and Leukaemia Mx
• Infection
• Sarcoidosis
Non-surgical
• Tumours
• Mechanical-pressure therapy
• Topical silicone gel sheets
Infection • Intralesional steroid and LA injections
• Bacterial
§ Tonsillitis, dental abscess
§ TB
Surgical
§ Bartonella henselae (Cat-scratch disease) • Revision of scar c̄ closure by direct suturing
• Viral
§ EBV
§ HIV
• Protozoal
§ Toxoplasmosis
Ix
Blood
• FBC, ESR, film (atypical lymphocytes)
• TFTs, serum ACE
• Monospot test, HIV test
Radiological
• US
• CT scan
Pathology
• FNAC
• Excision biopsy
76
Thyroid Lumps
Congenital Thyroid Disease Ix
• Lingual thyroid
• Ectopic thyroid tissue Bloods
• Thyroglossal cyst • TFTs: TSH, fT3, fT4
2+
• Other: FBC, Ca , LFTs, ESR
Embryology • Antibodies: anti-TPO, TSH
• Thyroid migrates from its origin at the foramen
caecum at the base of the tongue. Imaging
§ Passes behind the hyoid bone • CXR: goitres and mets
rd th
§ Lies anterior to 3 -4 tracheal rings in the • High resolution US
pretracheal fascia. • CT
• Leaves behind the thyroglossal cyst which atrophies • Radionucleotide (Tc or I) scan (hot vs. cold)
§ Persistence → thyroglossal cyst
• Ectopic thyroid tissue can be found anywhere along Histology or cytology
this descent
• FNAC (can’t distinguish adenoma vs. follicular Ca)
• Biopsy
Goitre Differential
Laryngoscopy
Diffuse • Pre-operative assessment of vocal cords
• Simple colloid goitre
§ Endemic: iodine deficiency
§ Sporadic: autoimmune, hereditary,
goitrogens (e.g. sulphonylureas)
• Graves’
• Thyroiditis
§ Hashimoto’s
§ De Quervain’s
§ Subacute lymphocytic (e.g. post-partum)
• (multinodular goitre c̄ nodules too small to palpate)
Multinodular
• Multinodular colloid goitre (commonest)
• Multiple cysts
• Multiple adenomas
Solitary nodule
• Dominant nodule in multinodular goitre
• Adenoma (hot or cold)
• Cyst
• Malignancy
77
Benign Thyroid Disease
Disease Clinical Features Cause Management
Simple goitre Diffuse painless goitre Endemic Thyroxine
Mass effects: - iodine deficiency
- dysphagia Total or subtotal
- stridor Sporadic thyroidectomy if
- SVC obstruction - autoimmune pressure symptoms.
- goitrogens (e.g.
Usually euthyroid, may →hypothyroid sulphonylureas)
- hereditary (dyshormogenic)
Multinodular Evolves from long-standing simple As for simple goitre Thyroxine
goitre goitre.
Mass effects.
Euthyroid (or subclinical hyperthyroid) Total or subtotal
thyroidectomy if
pressure symptoms.
Plummer’s Multinodular goitre Autonomous nodule develops on Carbimazole
Toxic Thyrotoxicosis background multinodular goitre Radioiodine
multinodular Uneven iodine uptake with hot nodule Total or subtotal
goitre thyroidectomy.
Graves’ Diffuse goitre c̄ bruit Autoimmune (T2 hypersensitivity) Propanolol
Ophthalmopathy - anti-TSH Carbimazole
Dermopathy Radioiodine
Thyrotoxicosis Thyroidectomy
Assoc. c̄ other AI disease (T1DM, PA)
↑ uptake on radionucleotide scan
Hashimoto’s Diffuse painless goitre Autoimmune (T2 and T4) Levothyroxine
thyroiditis May have transient thyrotoxicosis, then - anti-TPO, -Tg
hypothyroidism
Assoc. c̄ other AI disease (T1DM, PA)
de Quervain’s Diffuse painful goitre Viral: Coxsackie common Self-limiting
Preceding viral URTI common
Thyrotoxicosis → hypo → eu Autoimmune
↓ iodine uptake
Subacute Diffuse painless goitre Autoimmune Self-limiting
lymphocytic May occur post-partum
Thyrotoxicosis → hypo → eu
Riedel’s Firm, fixed, irregular thyroid mass Autoimmune fibrosis Conservative
thyoiditis Mass effects
Assoc. c̄ retroperitoneal fibrosis
Follicular Single thyroid nodule Hemithyroidectomy
adenoma ± thyrotoxicosis (majority are cold)
May get pressure symptoms
Thyroid cysts Solitary thyroid nodule Aspiration or excision
Asympto or pressure symptoms
Can → localised pain due to cyst bleed
78
Malignant Thyroid Disease
Disease Frequency Age Cell Origin Spread Mx
Papillary 80% 20-40 Follicular cells Nodes and lung Total thyroidectomy
- JDG node = ± node excision
Assoc. c̄ Tg tumour marker lateral aberrant ± radioiodine
irradiation thyroid T4 to suppress TSH
Often multifocal >95% 10ys

Follicular 10% 40-60 Follicular cells Blood → bone and Total thyroidectomy +
F>M = 3:1 lungs T4 suppression +
Tg tumour marker Radioiodine
>95% 10ys
Medullary 5% MEN2: young Parafollicular C-cells Do phaeo screen pre-op
30% familial Sporadic: 40-50 Thyroidectomy +
- e.g. MEN2 CEA and calcitonin Node clearance
markers Consider radiotherapy
Anaplastic Rare >60 Undifferentiated Rapid growth Usually palliative
F>M = 3:1 follicular cells
Aggressive: local, May try thyroidectomy +
LN and blood. radiotherapy
<1% 10ys
Lymphoma 5% Lymphocytes Chemoradiotherapy
- MALToma in Hashi’s
Presentation Complications of Thyroid Surgery

• Non-functional (cold)
• Painless neck mass Early
• Cervical mets • Reactionary haemorrhage → haematoma (<1%)
• Compression symptoms § Can → airway obstruction.
§ Dysphagia § Call anaesthetist and remove wound clips
§ Stridor § Evacuate haematoma and re-explore wound
§ SVC obstruction • Laryngeal oedema
§ Damage during intubation or surgical
Risk factors for malignancy in thyroid manipulation
§ Can → airway obstruction
nodules • Recurrent laryngeal nerve palsy (0.5%)
• Solitary § Right RLN more common (oblique ascent)
• Solid § Damage to one → hoarse voice
• Younger § Damage to both → obstruction needing
• Male tracheostomy
• Cold • Hypocalcaemia (3-5%)
• Radiation exposure § Usually parathyroid dysfunction but may be
permanent if parathyroids removed.
§ Presents @ 24-48hrs
- Tingling in fingers and lips
Thyroid Surgery - Wheeze / stridor → airway obstruction
- Chvostek’s and Trousseau’s
Indications: 5 Ms § Rx: 10ml 10% Ca gluconate IV
• Mechanical obstruction • Thyroid storm
• Malignancy § Severe hyperthyroidism
• Marred beauty: cosmetic reasons § Rx: propranolol, antithyroid drugs, Lugol’s
• Medical Rx failure: thyrotoxicosis iodine and hydrocortisone sodium succinate
• Mediastinal extension: can’t monitor changes
Late
Practicalities • Hypothyroidism
• Render euthyroid pre-op c̄ antithyroid drugs • Recurrent hyperthyroidism
§ Stop 10 days prior to surgery (they ↑ • Keloid scar
vascularity)
§ Alternatively just give propronalol
• Check for phaeo pre-op in medullary carcinoma
• Laryngoscopy: check vocal cords pre- and post-op
Procedure
• Collar incision
79
Salivary Glands
History Salivary Gland Neoplasms
• Swelling/pain related to food: calculi • 80% are in the parotid (80% are superficial)
• Malaise, fever, mumps • 80% are pleiomorphic adenomas
• Dry eyes/mouth: Sjogrens (Sicca, Mickulicz) • Deflection of ear outwards is classic sign
• CN VII palsy = malignancy
Causes of Salivary Gland Enlargement
• Whole gland Classification
§ Parotitis • Benign
st
§ Sjogren’s / Sicca Syndrome § 1 : Pleiomorphic adenoma
nd
§ Sarcoid § 2 : Adenolymphoma (Warthin’s)
§ Amyloid • Malignant (CN7 palsy + fast growing)
st
§ ALL § 1 : Mucoepidermoid
nd
§ Chronic liver disease § 2 : Adenoid cystic
§ Anorexia or bulimia
• Localised Ix
§ Tumours • ENT examination
§ Stones • US ± CT
• FNAC
Acute Parotitis
• Viral: mumps, coxsackie A, HIV Pleiomorphic Adenoma
• Bacterial: S. aureus • Commonest salivary gland neoplasm (80%)
- Assoc. c̄ calculi and poor oral hygiene • Presentation
§ 90% occur in parotid
Calculi § Occur in middle age
• Recurrent unilateral swelling and pain § F>M
§ Benign and slow growing
• Worse on eating
• Histo: different tissue types (hence name)
• Red, tender, swollen gland (80% submandibular)
• Rx: superficial parotidectomy
• Ix: plain x-ray or sialography
• Rx: gland excision
Adenolymphoma (Warthin’s tumour)
• Benign soft cystic tumour
• Older men
• Rx: enucleation
Adenoid-cystic carcinoma
• One of the commonest malignant salivary tumours
• Highly malignant and often incurable
• Rapid growth
• Hard fixed mass
• Pain
• Facial palsy
Surgery
• Superficial or radical parotidectomy
• Facia lata face lift for facial palsy
Complications
• Facial palsy
• Salivary fistula
• Frey’s Syndrome (gustatory sweating)
§ Redness and sweating skin over parotid area
§ Occurs in relation to food (inc. thinking)
§ Auriculotemporal branch of CN V3 carries
sympathetic fibres to sweat glands over parotid
area and parasympathetic fibres to the parotid
§ Reinervation of divided sympathetic nerves by
fibres from the secretomotor branch of
auriculotemporal branch of CN V3
80
Breast Surgery
Contents
Breast Cancer: Pathology, Presentation and Assessment .................................................................................. 82
Breast Cancer: Management ............................................................................................................................... 83
Other Breast Disease........................................................................................................................................... 84
81
Breast Cancer: Pathology, Presentation and Assessment
Epidemiology Presentation
• Affects 1/10 women • Lump: commonest presentation of Ca breast
• 20 000 cases/yr in UK § Usually painless
• Commonest cause of cancer death in females 15-54 § 50% in upper outer quadrant
• Second commonest cause of cancer deaths overall § ± axillary nodes
• Skin changes
§ Paget’s: persistent eczema
Aetiology / Risk Factors § Peau d’orange
• Nipple
Family Hx § Discharge
• 10% Ca breast is familial § Inversion
st
§ One 1 degree relative = 2x risk • Mets
• 5% assoc. c̄ BRCA mutations § Pathological #
§ BRCA1 (17q) → 80% breast Ca, 40% + ov Ca § SOB
§ BRCA2 (13q) → 80% breast Ca § Abdominal pain
§ Seizures
Oestrogen Exposure • May present through screening
• Early menarche, late menopause
• HRT, OCP (Million Women Study) Differential
• First child >35yrs • Cysts
• Obesity • Fibroadenomas
• DCIS
Other Factors • Duct ectasia
• Proliferative breast disease c̄ atypia
• Previous Ca breast Triple Assessment: any breast lump
• ↑ age (v. rare <30) • Hx and Clinical Examination
• Breast feeding is protective • Radiology
§ <35yrs: US
Pathology § >35ys: US + mammography
• Pathology
§ Solid lump: tru-cut core biopsy
DCIS/LCIS
§ Cystic lump: FNAC (green / 18G needle)
• Non-invasive pre-malignant condition
- Reassure if clear fluid
• Microcalcification on mammography
- Send cytology if bloody fluid
• 10x ↑ risk of invasive Ca
- Core biopsy residual mass
- Core biopsy if +ve cytology
Invasive Ductal Carcinoma, NST/NOS
• Commonest: ~70% of cancers
• Feels hard (scirrhous) Other Ix
• Bloods
§ FBC, LFTs, ESR, bone profile
Other subtypes
• Imaging: help staging
• Invasive lobular: ~20% of cancers
§ CXR
• Medullary: affects younger pts, feels soft
§ Liver US
• Colloid/mucinous: occur in elderly § CT scan
• Inflammatory: pain, erythema, swelling, peau d’orange § Breast MRI: multifocal disease or c̄ implants
• Papillary § Bone scan and PET-CT
• May need wire-guided excision biopsy
Phyllodes Tumour
• Stromal tumour
• Large, non-tender mobile lump
Clinical Staging
• Stage 1: confined to breast, mobile, no LNs
• Stage 2: Stage 1 + nodes in ipsilateral axilla
Spread • Stage 3: Stage 2 + fixation to muscle (not chest wall)
• Direct extension → muscle and/or skin LNs matted and fixed, large skin involvement
• Lymph → p’eau d’orange + arm oedema • Stage 4: Complete fixation to chest wall + mets
• Blood →
§ Bones: bone pain, #, ↑Ca
§ Lungs: dyspnoea, pleural effusion
TNM Staging
§ Liver: abdo pain, hepatic impairment • Tis (no palpable tumour): CIS
§ Brain: headache, seizures • T1: <2cm, no skin fixation
• T2: 2-5cm, skin fixation
• T3: 5-10cm, ulceration + pectoral fixation
Screening • T4: >10cm, chest wall extension, skin involved
• Every 3yrs from 47-73 • N1: mobile nodes
• Craniocaudal and oblique views • N2: fixed nodes
• ↓ breast Ca deaths by 25%
• 10% false negative rate.
82
Breast Cancer: Management
Principals Nottingham Prognostic Index
• Manage in an MDT c̄ an individual approach • Predicts survival and risk of relapse
§ Oncologist • Guides appropriate adjuvant systemic therapy
§ Breast surgeon • (0.2 x tumour size) + histo grade + nodal status
§ Breastcare nurse § Histo grade: Bloom-Richardson system (1-3)
§ Radiologist
§ Histopathologist Systemic Rx
• Try to enrol pts. in a trial
• Factors: age, fitness, wishes, clinical stage Radiotherapy
§ 1-2: surgical • Post-WLE: ↓ local recurrence
§ 3-4: chemo and palliation
• Post-mastectomy: only if high risk of local recurrence
§ Large, poorly differentiated, node +ve
Surgery • Axillary: node +ve disease
• Aim = gain local control • Palliation: bone pain
• Two options
§ WLE + radiotherapy (80% treated like this) Chemotherapy
§ Mastectomy • Pre-menopausal, node +ve, high grade or recurrent
- Typically large tumours >4cm tumours.
- Multifocal or central tumours • Neo-adjuvant chemo improves survival in large tumours
- Nipple involvement • 6 x FEC: 5-FU, Epirubicin, Cyclophosphamide
- Pt. choice • Trastuzumab (anti-Her2) is used if Her2+ve
- Not radical: no longer used § SE: cardiac toxicity
• Same survival, but WLE has ↑ recurrence rates
Endocrine Therapy
Sentinel Node Biopsy: gold standard • Used in ER or PR +ve disease: ↓ recurrence, ↑ survival
• 5yrs of adjuvant therapy
Rational • Tamoxifen
• SN = first node that a section of breast drains to. § SERM: antagonist @ breast, agonist @ uterus
• If clinically –ve axillary LNs, no need for further § SE: menopausal symptoms, endometrial Ca
dissection if SN is clear. • Anastrazole / Letrozole
§ Aromatase inhibitor → ↓ oestrogen
Procedure § Better cf. tamoxifen if post-men (ATAC trial)
• Blue dye / radiocolloid injected into tumour § SE: menopausal symptoms
• Visual inspection / gamma probe @ surgery to ID SN • If pre-menopausal and ER+ve may consider ovarian
• SN removed and sent for frozen section ablation or GnRH analogues (e.g. goserelin)
• If node +ve → axillary clearance or radiotherapy
Treating Advanced Disease (Stage 3-4)
Evidence • Tamoxifen if ER+ve
• 2 RCTs compared SNB vs. SNB + axillary clearance • Chemo for relapse
• No differences in overall or disease-free survival • Her2 +ve tumours may respond to trastuzumab
• ↓ morbidity c̄ SNB alone
§ Lymphoedema Supportive
§ Pain • Bone pain: DXT, bisphosphonates, analgesia
§ Numbness • Brain: occasional surgery, DXT, steroids, AEDs
• Lymphoedema: decongestion, compression
Other Axillary Options
• For clinically -ve axilla options include Reconstruction
O
§ Axillary sampling • Offered either at 1 surgery or as delayed procedure.
- Removal of lower nodes
- Clearance or DXT if +ve Implants: silastic or saline inflatable
§ Axillary clearance
- Can be done to various levels Lat dorsi myocutaneous flap
• Pedicled flap: skin, fat, muscle and blood supply
Surgical Complications • Supplied by thoracodorsal A. via subscapular A.
• Haematoma, seroma • Usually used c̄ an implant
• Frozen shoulder
• Long-thoracic nerve palsy Transverse rectus abdominis myocutaneous flap
• Lymphoedema • Gold-standard
• Upper inner arm numbness • Pedicled (inf. epigastric A.)
§ Intercostobrachial nerve injury
• Or free: attached to internal thoracic A
• No implant necessary and combined tummy tuck
• CI if poor circulation: smokers, obese, PVD, DM
• Risk of abdominal hernia
Nipple Tattoo
83
Other Breast Disease
Congenital Mastalgia
• Amastia: complete absence of breast and nipple
• Hypoplasia more common: some asymmetry Cyclical
normal • ~35yrs
• Accessory nipples • Pre-menstrual pain
§ Can occur anywhere along the milk line • Relieved by menstruation
§ Present in 1% • Commonly in upper outer quadrants bilaterally
Gynaecomastia Non-cyclical
• Occurs in 30% of boys at puberty • ~45yrs
• Hormone secreting tumours: e.g. sex-cord • Severe lancing breast pain (often left)
testicular • May be assoc. c̄ back pain
• Chronic liver disease: hypogonadism + ↓E2
metabolism
Rx
• Drugs: spironolactone, digoxin, cimetidine
• Reassurance + good bra for most
st
• 1 line: EPO (contains gamma-linoleic acid)
• OCP
• Topical NSAIDs (e.g. ibuprofen)
• Bromocriptine
• Danazol
• Tamoxifen
Inflammatory
Disease Patient Presentation Treatment

Acute Mastitis Usually lactating Painful, red breast Fluclox alone in early stages
May → Abscess (lump near nipple) Fluclox + I&D if fluctuant
abscess
Fat Necrosis Associated with previous trauma Analgesia
Painless, palpable, non-mobile mass No f/up necessary
May calcify simulating Ca
Duct Ectasia Post-menopausal Slit-like nipple Need to distinguish from Ca
Duct dilatation - 50-60yrs Often bilateral
± peri-areolar mass Surgical duct excision if mass
Thick white/green discharge present or discharge
May be calcified on mammography troublesome
Close f/up
Periductal Smokers Painful, erythematous sub-areolar mass Broad-spectrum Abx
Mastitis 30yrs Assoc. with inverted nipple ± purulent discharge
May → abscess or discharging fistula
Benign Epithelial Lesions

Benign 30-50yrs Pre-menstrual breast nodularity and pain Triple assessment.
Mammary Often in upper outer quadrant
Dysplasia - Tender “lumpy-bumpy” breasts Reassurance
Analgesia
Aberration of Normal Development and Good bra
Involution (ANDI) ± evening primrose oil
- Fibroadenosis
- Cyst formation Danazol may occasionally be
- Epitheliosis (hyperplasia) used
- Papillomatosis
Cystic Disease Peri-menopausal >40 Distinct, fluctuant round mass Aspiration: green-brown fluid
Often painful
Persistence or blood → triple
assessment.
Duct Papilloma 40-50yrs Common cause of bloody discharge Triple assessment.
Not usually palpable Excise due to ↑ risk of Ca
84
Stromal Tumours

Fibroadenoma <35yrs Commonest benign tumour Reassurance + f/up if <2.5cm
Rare post-menopause Painless, mobile, rubbery mass Shell-out surgically
↑ in Blacks Often multiple and bilateral - >2.5cm
- FH of breast Ca
Popcorn calcification - Pt. choice
Phyllodes tumour 50s+ Large, fast growing mass WLE
Mobile, non-tender
Epithelial and connective tissue
elements
Malignant Conditions
Disease Clinical Treatment

DCIS Presents as Microcalcification on mammogram WLE + radiotherapy
Rarely assoc. with symptoms:
- lump Extensive or multifocal → mastectomy + reconstruction
- discharge + SLNB
- eczematous change = Paget’s disease
→ Ca @ 1%/yr (10x ↑ risk) in ipsilateral breast
Paget’s Unilat, scaly, erythematous, itchy Usually underlying invasive or DCIS breast cancer.
+/- palpable mass (invasive carcinoma) Mastectomy + radio ± chemo/endo
LCIS Incidental biopsy finding (no calcification) Bilateral prophylactic mastectomy or close watching c̄
Often bilat (20-40%) mammographic screening
Young women
↑ risk Ca risk (x10) in both breasts
85
Vascular Surgery
Contents
Chronic Limb Ischaemia: Presentation and Classification ................................................................................... 87
Chronic Limb Ischaemia: Investigation and Management ................................................................................... 88
Acute Limb Ischaemia.......................................................................................................................................... 89
Carotid Artery Disease ......................................................................................................................................... 90
Aneurysms ........................................................................................................................................................... 90
Popliteal Aneurysm .............................................................................................................................................. 90
Abdominal Aortic Aneurysms ............................................................................................................................... 91
Thoracic Aortic Dissection ................................................................................................................................... 92
Gangrene ............................................................................................................................................................. 92
Varicose Veins ..................................................................................................................................................... 93
Leg Ulcers ............................................................................................................................................................ 94
Leg Swelling......................................................................................................................................................... 94
86
Chronic Limb Ischaemia: Presentation and Classification
Incidence Presentation
• 5% of males >50yrs have intermittent claudication
Intermittent Claudication
• Cramping pain after walking a fixed distance
Cause • Pain rapidly relieved by rest
• Atherosclerosis • Calf pain = superficial femoral disease (commonest)
§ Typically asymptomatic until 50% stenosis • Buttock pain = iliac disease (internal or common)
• (vasculitis and fibromuscular dysplasia are v. rare
causes) Critical Limb Ischaemia: Fontaine 3 or 4
• European working group definition (1991)
• Ankle pressure <50mmHg (toe <30mmHg) and
Atherosclerosis Summary either:
• Endothelial injury: haemodynamic, HTN, ↑ lipids § Rest pain requiring analgesia for ³2 wks
• Chronic inflammation - Especially @ night
§ Lipid-laden foam cells produce GFs, cytokines, - Usually felt in the foot
ROS and MMPs - Pt. hangs foot out of bed
§ → lymphocyte and SMC recruitment - Due to ↓ CO and loss of gravity help
• SM proliferation: conversion of fatty streak to § Ulceration or gangrene
atherosclerotic plaque
Leriche’s Syndrome: Aortoiliac Occlusive Disease
NB. Arteriosclerosis = general arterial hardening • Atherosclerotic occlusion of abdominal aorta and iliacs
Atherosclerosis = arterial hardening specifically • Triad
due to atheroma. § Buttock claudication and wasting
§ Erectile dysfunction
§ Absent femoral pulses
Atheroma Pathology
• Fibrous cap: SM cells, lymphocytes, collagen Buerger’s Disease: Thromboangiitis Obliterans
• Necrotic centre: cell debris, cholesterol, Ca, foam • Young, male, heavy smoker
cells • Acute inflammation and thrombosis of arteries and
veins in the hands and feet → ulceration and
gangrene
Risk Factors
Signs
Modifiable Non-modifiable • Pulses: loss of pulses and ↑ CRT (norm ≤2sec)
• Smoking • FH and PMH • Ulcers: painful, punched-out, on pressure points
• BP • Male • Nail dystrophy / Onycholysis
• DM control • ↑ age • Skin: cold, white, atrophy, absent hair
• Hyperlipidaemia • Genetic • Venous guttering
• ↓ exercise • Muscle atrophy
• ↓ Buerger’s Angle
§ ≥90: normal
§ 20-30: ischaemia
Associated Vascular Disease § <20: severe ischaemia
• IHD: 90% • +ve Buerger’s Sign
• Carotid stenosis:15% § Reactive hyperaemia due to accumulation of
• AAA deoxygenated blood in dilated capillaries
• Renovascular disease
• DM microvascular disease
Clinical Classification
Fontaine Rutherford
• Asympto (subclinical) • Mild claudication
• Intermittent claudication • Moderate claudication
§ >200m • Severe claudication
§ <200m • Ischaemic rest pain
• Ischaemic rest pain • Minor tissue loss
• Ulceration / gangrene • Major tissue loss
87
Chronic Limb Ischaemia: Investigation and Management
Ix Conservative Mx
• Most pts. c̄ claudication can be managed conservatively
Doppler Waveforms • ↑ exercise and employ exercise programs
• Normal: triphasic • Stop smoking
• Mild stenosis: biphasic • Wt. loss
• Severe stenosis: monophasic • Foot care
• Prog: 1/3 improve, 1/3 stay the same, 1/3 deteriorate
ABPI
Medical Mx
Clinical Fontaine ABPI • Risk factors: BP, lipids, DM
Calcification: CRF, DM >1.4 § β-B don’t worsen intermittent claudication but use
Normal ≥1 c̄ caution in CLI
Asymptomatic Fontaine 1 0.8-0.9 • Antiplatelets: aspirin / clopidogrel
Claudication Fontaine 2 0.6-0.8 • Analgesia: may need opiates
Rest pain Fontaine 3 0.3-0.6 • (Parenteral prostanoids ↓ pain in pts. unfit for surgery)
Ulceration and gangrene Fontaine 4 <0.3
Endovascular Mx
NB. Falsely high results may be obtained in DM / CRF • Percutaneous Transluminal Angioplasty ± stenting
due to calcification of vessels: mediasclerosis • Good for short stenosis in big vessels: e.g. iliacs, SFA
• Use toe pressure with small cuff: <30mmHg • Lower risk for pt.: performed under regional anaesthesia
as day case
Walk test • Improved inflow → ↓ pain but restoration of foot pulses is
• Walk on treadmill @ certain speed and incline to required for Rx of ulceration / gangrene.
establish maximum claudication distance.
• ABPI measured before and after: 20% ↓ is sig Surgical Reconstruction
Bloods Indications
• FBC + U+E: anaemia, renovascular disease • V. short claudication distance (e.g. <100m)
• Lipids + glucose • Symptoms greatly affecting pts. QoL
• ESR: arteritis • Development of rest pain
• G+S: possible procedure
Pre-op assessment
Imaging: assess site, extent and distal run-off • Need good optimisation as likely to have cardiorespiratory
• Colour duplex US co-morbidities.
• CT / MR angiogram
• Digital subtraction angiography Practicalities
§ Invasive \ not commonly used for Dx only. • Need good proximal supply and distal run-off
§ Used when performing therapeutic • Saphenous vein grafts preferred below the IL
angioplasty or stenting
• More distal grafts have ↑ rates of thrombosis
Other Classification
• ECG: ischaemia
• Anatomical: fem-pop, fem-distal, aortobifemoral
• Extra-anatomical: axillo-fem / -bifem, fem-fem crossover
Other
• Endarterectomy: core-out atheromatous plaque
• Sympathectomy: chemical (EtOH injection) or surgical
§ Caution in DM c̄ neuropathy
• Amputation
Prognosis
1yr after onset of CLI

• 50% alive w/o amputation
• 25% will have had major amputation
• 25% dead (usually MI or stroke)
Following amputation
• Perioperative mortality
§ BK: 5-10%
§ AK: 15-20%
• 1/3 → complete autonomy
• 1/3 → partial autonomy
• 1/3 → dead
88
Acute Limb Ischaemia
Definitions General Mx
• Acute: ischaemia <14d • In an acutely ischaemic limb discuss immediately c̄ a
• Acute on chronic: worsening symptoms and signs senior as time is crucial.
<14d • NBM
• Chronic: ischaemia stable for >14d • Rehydration: IV fluids
• Analgesia: morphine + metoclopramide
Severity • Abx: e.g. co-amoxiclav if signs of infection
• Incomplete: limb not threatened • Unfractionated heparin IVI: prevent extension
• Complete: limb threatened • Complete occlusion?
§ Loss of limb unless intervention w/i 6hrs § Yes: urgent surgery: embolectomy or bypass
• Irreversible: requires amputation § No: angiogram + observe for deterioration
Causes Angiography
• Thrombosis in situ (60%) • Not performed if there is complete occlusion as it
§ A previously stenosed vessel c̄ plaque rupture introduces delay: take straight to theatre.
• If incomplete occlusion, pre-op angio will guide any
§ Usually incomplete ischaemia
distal bypass.
• Embolism (30%)
§ 80% from left atrium in AF
§ Valve disease Embolus Mx
§ Iatrogenic from angioplasty / surgery
§ Cholesterol in long bone # 1. Embolectomy
§ Paradoxical (venous via PFO) § Under regional anaesthesia or GA
§ Typically lodge at femoral bifurcation § Wire fed through embolus
§ Often complete ischaemia § Fogarty catheter fed over the top
• Graft / stent occlusion § Balloon inflated and catheter withdrawn,
• Trauma removing the embolism.
• Aortic dissection § Adequacy confirmed by on-table angiography
2. Thrombolysis
Presentation: 6Ps § Consider if embolectomy unsuccessful
• Pale § E.g. local injection of TPA
• Pulseless
• Perishingly cold 3. Other options
• Painful § Emergency reconstruction
• Paraesthesia § Amputation
• Paralysis
Post-embolectomy
• Anticoagulate: heparin IVI → warfarin
Thrombosis vs. Embolus • ID embolic source: ECG, echo, US aorta, fem and
pop
Thrombosis Embolus • Complications
Onset Hrs-days Sudden § Reperfusion injury
Severity Less severe Profound - Local swelling → compartment
- collaterals ischaemia syndrome
O
Embolic source Present - Acidosis and arrhythmia 2 to ↑K
- often AF - ARDS
Claudication Hx Present Absent - GI oedema → endotoxic shock
Contralat Absent Present § Chronic pain syndromes
pulses
Dx Angiography Clinical
Rx Thrombolysis Embolectomy + Thrombosis Mx
Bypass surgery Warfarin • Emergency reconstruction if complete occlusion
• Angiography + angioplasty
Ix • Thrombolysis
• Blood • Amputation
§ FBC, U+E, INR, G+S
§ CK
• ECG
Manage Cardiovascular Risk Factors
• Imaging
§ CXR
§ Duplex doppler
§ CT angio
89
Carotid Artery Disease Aneurysms
Definitions Definition
• Stroke: sudden neurological deficit of vascular origin • Abnormal dilatation of a blood vessel >50% of its
lasting >24h normal diameter.
• TIA: sudden neurological deficit of vascular origin
lasting <24h (usually lasts <1h) c̄ complete recovery Classification
• True Aneurysm
Pathogenesis § Dilatation of a blood vessel involving all layers
• Turbulent flow → ↓ shear stress @ carotid bifurcation of the wall and is >50% of its normal diameter
promoting atherosclerosis and plaque formation. § Two different morphologies
• Plaque rupture → complete occlusion or distal emboli - Fusiform: e.g AAA
• Cause 15-25% of CVA/TIA - Saccular: e.g Berry aneurysm
• False Aneurysm
Presentation § Collection of blood around a vessel wall that
• Bruit communicates c̄ the vessel lumen.
• CVA/TIA § Usually iatrogenic: puncture, cannulation
• Dissection
§ Vessel dilatation caused by blood splaying
Ix apart the media to form a channel w/i the
• Duplex carotid Doppler vessel wall.
• MRA
Causes
Mx • Congenital
§ ADPKD → Berry aneurysms
Conservative § Marfan’s, Ehlers-Danlos
• Aspirin or clopidogrel • Acquired
• Control risk factors § Atherosclerosis
§ Trauma: e.g. penetrating trauma
Surgical: Endarterectomy § Inflammatory: Takayasu’s aortitis, HSP
• Symptomatic (ECST, NASCET) § Infection
§ ≥70% (5% stroke risk per yr) - Mycotic: SBE
§ ≥50% if low risk (<3%, typically <75yrs) - Tertiary syphilis (esp. thoracic)
§ Perform w/i 2wks of presentation
• Asymptomatic (ACAS, ACST) Complications
§ ≥60% benefit if low risk • Rupture
• Thrombosis
Complications of Endarterectomy • Distal embolization
• Stroke or death: 3% • Pressure: DVT, oesophagus, nutcracker syndrome
• HTN: 60% • Fistula (IVC, intestine)
• Haematoma
• MI
• Nerve injury
• Hypoglossal: ipsilateral tongue deviation Popliteal Aneurysm
• Great auricular: numb ear lobe • Less common cf. AAA
• Recurrent laryngeal: hoarse voice, bovine cough • 50% of pts. c̄ popliteal aneurysm also have AAA
Stenting Presentation
• Less invasive: ↓ hospital stay, ↓ infection, ↓ CN injury • Very easily palpable popliteal pulse
• There is concern over ↑ stroke risk, esp. pts. >70yrs • 50% bilateral
• Meta-analysis shows no sig difference in mortality vs. • Rupture is relatively rare
CEA @ 120d • Thrombosis and distal embolism is main complication
• Younger pts. have best risk / benefit ratio § → acute limb ischaemia
Mx
• Acute: embolectomy or fem-distal bypass
• Stable
§ Elective grafting + tie off vessel
§ Stenting
90
Abdominal Aortic Aneurysms
Epidemiology AAA Rupture
• Prevalence: ~5% >50yrs
• Mortality: 10,000 deaths/yr Rupture Rates
• Sex: M>F=3:1 • <5.5cm = 1% / yr
• >6cm = 25% / yr
Pathology • ↑ risk if:
• Dilatation of the abdominal aorta ≥3cm § ↑BP
• 90% infrarenal § Smoker
• 30% involve the iliac arteries § Female
§ Strong FH
Presentation Rupture Presentation
• Usually asympto: discovered incidentally
• Sudden onset severe abdominal pain
• May → back pain or umbilical pain radiating to groin
§ Intermittent or continuous
• Acute limb ischaemia § Radiates to back or flanks (don’t dismiss as
• Blue toe syndrome: distal embolisation colic)
• Acute rupture • Collapse → shock
• Expansile abdominal mass
Examination
• Expansile mass just above the umbilicus Mx: a surgical emergency
• Bruits may be heard • High flow O2
• Tenderness + shock suggests rupture • 2 x large bore cannulae in each ACF
§ Give fluid if shocked but keep SBP
Ix <100mmHg
• AXR: calcification may be seen § Give O- blood if desperate
• Abdo US: screening and monitoring § Blood: FBC, U+E, clotting, amylase, xmatch
• CT / MRI: gold-standard 10u
• Angiography • Instigate the major haemorrhage protocol
§ Won’t show true extent of aneurysm due to • Call vascular surgeon, anaesthetist and warn theatre
endoluminal thrombus. • Analgesia
§ Useful to delineate relationship of renal arteries • Abx prophylaxis: cef + met
• Urinary catheter + CVP line
Mx • If stable + Dx uncertain: US or CT may be feasible
• Take to theatre: clamp neck, insert dacron graft
Conservative
Mortality
• Manage cardiovascular risk factors: esp. BP
• 100% w/o surgery
• UK Small Aneurysm Trial suggested that AAA <5.5cm
• 50% c̄ surgery
in maximum diameter can be monitored by US (/CT)
§ <4cm: yearly monitoring
§ 4-5.5cm: 6 monthly monitoring
Surgical
• Aim to treat aneurysm before it ruptures.
§ Elective mortality: 5%
§ Emergency mortality: 50%
• Operate when risk of rupture > risk of surgery
• Indications
§ Symptomatic (back pain = imminent rupture)
§ Diameter >5.5cm
§ Rapidly expanding: >1cm/yr
§ Causing complications: e.g. emboli
• Open or EVAR
§ EVAR has ↓ perioperative mortality
§ No ↓ mortality by 5yrs due to late endograft
failures.
§ EVAR not better than medical Rx in unfit pts.
Screening
• MASS trial revealed 50% ↓ aneurysm-related mortality
in males aged 65-74 screened c̄ US.
• UK men offered one-time US screen @ 65yrs
91
Thoracic Aortic Dissection Gangrene
• Blood splays apart the laminar planes of the media to • Death of tissue from poor vascular supply.
form a channel w/i the aortic wall.
Classification
Aetiology • Wet: tissue death + infection
• Atherosclerosis and HTN cause 90% • Dry: tissue death only
• Minority caused by connective tissue disorder • Pregangrene: tissue on the brink of gangrene
§ Marfan’s, Ehlers Danlos
§ Vitamin C deficiency Presentation
• Black tissues ± slough
Presentation • May be suppuration ± sepsis
• Sudden onset, tearing chest pain
§ Radiates through to the back Gas Gangrene
O
§ Tachycardia and hypertension (1 + • Clostridium perfringes myositis
sympathetic)
• RFs: DM, trauma, malignancy
• Distal propagation → sequential occlusion of branches
• Presentation
§ Left hemiplegia
§ Toxaemia
§ Unequal arm pulses and BP
§ Haemolytic jaundice
§ Paraplegia (anterior spinal A.)
§ Oedema
§ Anuria
§ Crepitus from surgical emphysema
• Proximal propagation § Bubbly brown pus
§ Aortic regurgitation
• Rx
§ Tamponade
§ Debridement (may need amputation)
• Rupture into pericardial, pleural or peritoneal cavities § Benzylpenicillin + metronidazole
§ Commonest cause of death § Hyperbaric O2
Stanford Classification Synergistic Gangrene

Type A: Proximal • Involves aerobes + anaerobes
• 70% • Fournier’s: perineum
• Involves ascending aorta ± descending • Meleney’s: post-op ulceration
• Higher mortality due to probable cardiac involvement • Both progress rapidly to necrotising fasciitis + myositis
• Usually require surgery
Mx
Type B: Distal • Take cultures
• 30% • Debridement (including amputation)
• Involves descending aorta only: distal to L SC artery • Benzylpenicillin ± clindamycin
• Usually best managed conservatively
Ix
• ECG: exclude MI
• TTE / TOE: can use in haemodynamically unstable pts
• CT/MRI: not suitable for unstable pts.
Mx
Resuscitate
Investigate
• Bloods: x-match 10u, FBC, U+E, clotting, amylase
• ECG: 20% show ischaemia due to involvement of the
coronary ostia
• Imaging
§ CXR
§ CT/MRI: not if haemodynamically unstable
§ TOE: can be used if haemodynamically unstable
Treat
• Analgesia
• ↓SBP
§ Labetalol or esmolol (short t½)
§ Keep SBP 100-110mmHg
• Type A: open repair
§ Acute operative mortality: <25%
• Type B: conservative initially
§ Surgery if persistent pain or complications
§ Consider TEVAR if uncomplicated
92
Varicose Veins
Definition CEAP Classification
• Tortuous, dilated veins of the superficial venous • Chronic venous disease can be classified according to
system § Clinical signs (1-6 + sympto or asympto)
§ Etiology
Pathophysiology § Anatomy
§ Pathophysiology
• One-way flow from sup → deep maintained by valves
• Valve failure → ↑ pressure in sup veins → varicosity
• 3 main sites where valve incompetence occurs: Conservative Mx
§ SFJ: 3cm below and 3cm lateral to pubic • Treat any contributing factors
tubercle § Lose weight
§ SPJ: popliteal fossa § Relieve constipation
§ Perforators: draining GSV • Education
- 3 medial calf perforators (Cockett’s) § Avoid prolonged standing
- 1 medial thigh perforator (Hunter’s) § Regular walks
• Class II Graduated Compression Stockings
Causes § 18-24mmHg
§ Symptomatic relief and slows progression
• Skin care
Primary § Maintain hydration c̄ emollients
• Idiopathic (congenitally weak valves)
§ Treat ulcers rapidly
§ Prolonged standing
§ Pregnancy
§ Obesity Minimally Invasive Therapies
§ OCP
§ FH Indications
• Congenital valve absence (v. rare) • Small below knee VVs not involving GSV or SSV
Secondary Techniques
• Valve destruction → reflux: DVT, thrombophlebitis • Local or GA
• Obstruction: DVT, foetus, pelvic mass • Injection sclerotherapy: 1% Na tetradecyl sulphate
• Constipation • Endovenous laser or radiofrequency ablation
• AVM • Glue ablation
• Overactive pumps (e.g. cyclists)
• Klippel-Trenaunay Post-Operatively
§ PWS, varicose veins, limb hypertrophy • Compression bandage for 24hrs
• Compression stockings for 1mo
Symptoms
• Cosmetic defect Surgical Mx
• Pain, cramping, heaviness
• Tingling Indications (rarely performed nowdays)
• Bleeding: may be severe • SFJ incompetence
• Swelling • Major perforator incompetence
• Symptomatic: ulceration, skin changes, pain
Signs
• Skin changes Procedures
§ Venous stars • Trendelenberg: saphenofemoral ligation
§ Haemosiderin deposition • SSV ligation: in the popliteal fossa
§ Venous eczema • LSV stripping: no longer performed due to potential
§ Lipodermatosclerosis (paniculitis) for saphenous nerve damage.
§ Atrophie blanche • Multiple avulsions
• Ulcers: medial malleolus / gaiter area • Perforator ligation: Cockett’s operation
• Oedema • Subfascial endoscopic perforator surgery (SEPS)
• Thrombophlebitis
Post-op
Ix • Bandage tightly
• Duplex ultrasonography • Elevate for 24h
§ Anatomy • Discharged c̄ compression stockings and instructed to
§ Presence of incompetence walk daily.
§ Caused by obstruction or reflux
• Surgery: FBC, U+E, clotting, G+S, CXR, ECG
Complications
• Haematoma (esp. groin)
Referral Criteria • Wound sepsis
• Bleeding • Damage to cutaneous nerve (e.g. long saphenous)
• Pain • Superficial thrombophlebitis
• Ulceration • DVT
• Superficial thrombophlebitis • Recurrence: may approach 50%
• Severe impact on QoL
93
Leg Ulcers Leg Swelling
Definition Differential
• Interruption in the continuity of an epithelial surface
Bilateral
Causes • ↑ Venous Pressure
• Venous: commonest • RHF
• Arterial: large or small vessel • Venous insufficiency → stasis
• Neuropathic: EtOH, DM • Drugs: e.g. nifedipine
• Traumatic: e.g. pressure • ↓ Oncotic Pressure
• Systemic disease: e.g. pyoderma gangrenosum • Nephrotic syndrome
• Neoplastic: SCC • Hepatic failure
• Protein losing enteropathy
Venous: 75% • Lymphoedema
• Painless, sloping, shallow ulcers • Myxoedema
• Usually on medial malleolus: “gaiter area” • Hyper- / hypo-thyroidism
• Assoc. c̄ haemosiderin deposition and
lipodermatosclerosis Unilateral
• RFs: venous insufficiency, varicosities, DVT, obesity • Venous insufficiency
• DVT
Arterial: 2% • Infection or inflammation
• Lymphoedema
• Hx of vasculopathy and risk factors
• Painful, deep, punched out lesions
• Occur @ pressure points Lymphoedema
§ Heal • Collection of interstitial fluid due to blockage or
§ Tips of, and between, toes absence of lymphatics
th
§ Metatarsal heads (esp. 5 )
• Other signs of chronic leg ischaemia Primary
• Congenital absence of lymphatics
Neuropathic • May or may not be familial
• Painless c̄ insensate surrounding skin • Presentation
• Warm foot c̄ good pulses § Congenital: evident from birth
§ Praecox: after birth but <35yrs
§ Tarda: >35yrs
Complications
• Osteomyelitis Milroy’s Syndrome
• Development of SCC in the ulcer (Marjolin’s ulcer) § Familial AD subtype of congenital
lymphoedema
Ix § F>M
• ABPI if possible
• Duplex ultrasonography Secondary: FIIT
• Biopsy may be necessary • Fibrosis: e.g. post-radiotherapy
§ Look for malignant change: Marjolin’s ulcer • Infiltration
§ Ca: prostate, lymphoma
Mx of Venous Ulcers § Filariasis: Wuchereria bancrofti
• Refer to leg ulcer community clinic • Infection: TB
• Focus on prevention • Trauma: block dissection of lymphatics
§ Graduated compression stockings
§ Venous surgery Ix
• Optimise risk factors: nutrition, smoking • Doppler US
• Lymphoscintigraphy
Specific Rx • CT / MRI
• Analgesia
• Bed Rest + Elevate leg Mx
• 4 layer graded compression bandage (if ABPI >0.8) • Conservative
• Pentoxyfylline PO § Skin care
§ ↑ microcirculatory blood flow § Compression stocking
§ Improves healing rates § Physio
§ Treat or prevent comorbid infections
Other Options (no proven benefit) • Surgical: debulking operation (rarely performed)
• Desloughing: e.g. larval therapy, hydrogel
• Topical antiseptics: iodine, Manuka honey
• Split-thickness skin grafting may be considered
94
Urology
Contents
Urinary Tract Obstruction ..................................................................................................................................... 96
Urethral Stricture .................................................................................................................................................. 96
Obstructive Uropathy ........................................................................................................................................... 96
Urinary Retention ................................................................................................................................................. 97
Haematuria .......................................................................................................................................................... 98
Peri-Aortitis .......................................................................................................................................................... 98
Urolithiasis: Pathophysiology and Presentation ................................................................................................... 99
Urolithiasis: Ix and Mx ........................................................................................................................................ 100
Renal Tumours .................................................................................................................................................. 101
Bladder Tumours ............................................................................................................................................... 102
Benign Prostatic Hypertrophy ............................................................................................................................ 103
Prostate Cancer ................................................................................................................................................. 104
Prostatitis ........................................................................................................................................................... 105
Urinary Incontinence .......................................................................................................................................... 105
Undescended Testes ......................................................................................................................................... 106
Testicular Torsion .............................................................................................................................................. 106
Lumps in the Groin and Scrotum ....................................................................................................................... 107
Testicular Tumours ............................................................................................................................................ 108
The Penis ........................................................................................................................................................... 109
95
Urinary Tract Obstruction Urethral Stricture
Causes Aetiology
• Trauma
Luminal § Instrumentation
• Stones § Pelvic #s
• Blood clots • Infection: e.g. gonorrhoea
• Sloughed papilla • Chemotherapy
• Balantitis xerotica obliterans
Mural
• Congenital / acquired stricture Presentation: voiding difficulty
• Tumour: renal, ureteric, bladder • Hesitancy
• Neuromuscular dysfunction • Strangury
• Poor stream
Extramural • Terminal dribbling
• Prostatic enlargement • Pis en deux
• Abdo / pelvic mass / tumour
• Retroperitoneal fibrosis Examination
• PR: exclude prostatic cause
Presentation • Palpate urethra through penis
Acute • Examine meatus
• Upper Urinary Tract
§ Loin pain → groin Ix
• Lower Urinary Tract • Urodynamics
§ Bladder outflow obstruction precedes § ↓ peak flow rate
suprapubic pain c̄ distended palpable bladder § ↑ micturition time
• Urethroscopy and cystoscopy
Chronic • Retrograde urethrogram
• Upper Urinary Tract
§ Flank pain Mx
§ Renal failure (may be polyuric) • Internal urethrotomy
• Lower Urinary Tract • Dilatation
§ Frequency, hesitancy, poor stream, terminal • Stent
dribbling, overflow incontinence
§ Distended, palpable bladder ± large prostate
PR
Ix Obstructive Uropathy
• Bloods: FBC, U+E
• Urine: dip, MC+S Pathogenesis
• Imaging • Acute retention on a chronic background may go
§ US: hydronephrosis or hydroureter unnoticed for days due to lack of pain.
§ Anterograde / retrograde ureterograms • Se Cr may be up to 1500uM
- Allow therapeutic drainage • Renal function should return to normal over days
§ Radionucleotide imaging: renal function • Some background impairment may remain.
§ CT / MRI
Complications
Mx
Upper Urinary Tract Hyperkalaemia
• Nephrostomy Metabolic acidosis
• Ureteric stent
Post-obstructive diuresis
Lower Urinary Tract • Kidneys produce a lot of urine in the acute phase
• Urethral or suprapubic catheter after relief of obstruction.
§ May be a large post-obstructive diuresis • Must keep up c̄ losses to avoid dehydration.
Complications of Ureteric Stents Na and HCO3 losing nephropathy

Common • Diuresis may → loss of Na and HCO3
• Infection • May require replacement c̄ 1.26% NaHCO3
• Haematuria
• Trigonal irritation
Infection
• Encrustation
Rare
• Obstruction
• Ureteric rupture
• Stent migration
96
Urinary Retention
Causes Chronic Urinary Retention (CUR)
Obstructive Classification
• Mechanical • High Pressure
§ BPH § High detrusor pressure @ end of micturition
§ Urethral stricture § Typically bladder outflow obstruction
§ Clots, stones § → bilateral hydronephrosis and ↓ renal function
§ Constipation • Low Pressure
• Dynamic: ↑ smooth muscle tone (α-adrenergic) § Low detrusor pressure @ end of micturition
§ Post-operative pain § Large volume retention c̄ very compliant
§ Drugs bladder
§ Kidney able to excrete urine
Neurological § No hydronephrosis \ normal renal function
• Interruption of sensory or motor innervation
§ Pelvic surgery Presentation
§ MS • Insidious as bladder capacity ↑↑ (>1.5L)
§ DM • Typically painless
§ Spinal injury / compression • Overflow incontinence / nocturnal enuresis
• Acute on chronic retention
Myogenic • Lower abdo mass
• Over-distension of the bladder • UTI
§ Post-anaesthesia • Renal failure
§ High EtOH intake
Mx
Acute Urinary Retention (AUR) High-Pressure

• Catheterise if
Clinical Features § Renal impairment
• Suprapubic tenderness § Pain
• Palpable bladder § Infection
§ Dull to percussion • Hrly UO + replace: post-obstruction diuresis
§ Can’t get beneath it • Consider TURP before TWOC
• Large prostate on PR
§ Check anal tone and sacral sensation Low-Pressure
• <1L drained on catheterisation • Avoid catheterisation if possible
§ Risk of introducing infection
Ix • Early TURP
• Blood: FBC, U+E, PSA (prior to PR) § Often do poorly due to poor detrusor function
• Urine: dip, MC+S § Need CISC or permanent catheter
• Imaging
§ US: bladder volume, hydronephrosis
§ Pelvic XR Suprapubic Catheterisation
Mx Advantages
• ↓ UTIs
Conservative • Avoids risk of urethral stricture formation
• Analgesia • TWOC w/o catheter removal
• Privacy • Pt. preference: ↑ comfort
• Walking • Maintain sexual function
• Running water or hot bath
Disadvantages
Catheterise • More complex
• Use correct catheter: e.g. 3-way if clots • Serious complications can occur
• ± STAT gentamicin cover
• Hrly UO + replace: post-obstruction diuresis CI
• Tamsulosin: ↓ risk of recatheterisation after retention • Known or suspected bladder carcinoma
• TWOC after 24-72h • Undiagnosed haematuria
§ May d/c and f/up in OPD • Previous lower abdominal surgery
§ More likely to be successful if predisposing § → adhesion of small bowel to abdo wall
factor and lower residual volume (<1L)
TURP Clean Intermittent Self-Catheterisation

• Failed TWOC • Alternative to indwelling catheter in AUR and CUR
• Impaired renal function • Also useful in pts. who fail to void after TURP
• Elective
97
Haematuria Peri-Aortitis
False Aetiology
• Beetroot • Idiopathic retroperitoneal fibrosis
• Rifampicin • Inflammatory AAAs
• Porphyria • Perianeurysmal RPF
O
• PV bleed • RPF 2 to malignancy: e.g. lymphoma
Idiopathic Retroperitoneal Fibrosis

True • Autoimmune vasculitis
• Fibrinoid necrosis of vasa vasorum
General • Affects aorta and small/medium sized retroperitoneal
• HSP vessels.
• Bleeding diathesis • Ureters are embedded in dense, fibrous tissue →
bilateral obstruction
Renal
• Infarct Associations
• Trauma: inc. stones • Drugs: β-B, bromocriptine, methysergide, methyldopa
• Infection • AI disease: thyroiditis, SLE, ANCA+ vasculitis
• Neoplasm • Smoking
• GN • Asbestos
• Polycystic kidneys
Presentation
Ureter • Middle–aged male
• Stone • Vague loin, back or abdo pain
• Tumour • ↑ BP
• Chronic urinary tract obstruction
Bladder
• Infection Ix
• Stones • Blood: ↑U and Cr, ↑ESR/CRP, ↓Hb
• Tumour • US: bilateral hydronephrosis + medial ureteric
• Exercise deviation
• CT/MRI: peri-aortic mass
Prostate § Biopsy: exclude Ca
• BPH
• Prostatitis Rx
• Tumour • Relieve obstruction: retrograde stent placement
• Ureterolysis: dissection of ureters from retroperitoneal
Urethra tissue.
• Infection • ± immunosuppression
• Stones
• Trauma
• Tumour
Clinical Features
• Timing?
§ Beginning of stream: urethral
§ Throughout stream: renal / systemic, bladder
§ End of stream: bladder stone, schisto
• Painful or painless?
• Obstructive symptoms?
• Systemic symptoms: wt. loss, appetite
Ix
• Bloods: FBC, U+E, clotting
• Urine: dip, MC+S, cytology
• Imaging
§ Renal US
§ IVU
§ Flexible cystoscopy + biopsy
§ CT/MRI
§ Renal angio
98
Urolithiasis: Pathophysiology and Presentation
Epidemiology Presentation
• Lifetime incidence: 15%
• Young men Ureteric Colic
§ Peak age: 20-40yrs • Severe, sudden onset loin pain radiating to the groin
§ Sex: M>F=3:1 • Assoc. c̄ n/v
• Pt. cannot lie still
Pathophysiology Bladder or Urethral Obstruction

• ↑ concentration of urinary solute • Bladder irritability: frequency, dysuria, haematuria
• ↓ urine volume • Strangury: painful urinary tenesmus
• Urinary stasis • Suprapubic pain radiating → tip of penis or in labia
• Pain and haematuria worse at the end of micturition
Common Anatomical Sites Other Possible Features

• Pelviureteric junction • UTI
• Crossing the iliac vessels at the pelvic brim • Haematuria
• Under the vas or uterine artery • Sterile pyuria
• Vesicoureteric junction • Anuria
Stone Types Examination

• Calcium oxalate: 75% • Usually no loin tenderness
§ ↑ risk in Crohn’s • Haematuria
• Triple phosphate (struvite): 15%
§ Ca Mg NH4 – phosphate
§ May form staghorn calculi
§ Assoc. c̄ proteus infection
• Urate: 5% (radiolucent)
§ Double if confirmed gout
• Cystine: 1% (faint)
§ Assoc. c̄ Fanconi Syn.
Associated Factors
• Dehydration
O
• Hypercalcaemia: 1 HPT, immobilisation
• ↑ oxalate excretion: tea, strawberries
• UTIs
• Hyperuricaemia: e.g. gout
• Urinary tract abnormalities: e.g. bladder diverticulae
• Drugs: frusemide, thiazides
99
Urolithiasis: Ix and Mx
Urine Initial Rx
• Dip: haematuria • Analgesia
• MC+S § Diclofenac 75mg PO/IM or 100mg PR
§ Opioids if NSAIDs CI: e.g. pethidine
Blood • Fluids: IV if unable to tolerate PO
• FBC, U+E, Ca, PO4, urate • Abx if infection: e.g. cefuroxime 1.5mg IV TDS
Conservative: <5mm in lower 1/3 of ureter

• 90-95% pass spontaneously
Imaging • Can discharge pt. c̄ analgesia
• Sieve urine to collect stone for OPD analysis
Non-contrast CT-KUB
• 99% of stones visible
• Gold standard Medical Expulsive Therapy (MET)
KUB XR Indications
• 90% of stones radio-opaque • Stone 5-10mm
• Urate stones are radiolucent, cysteine stones are faint • Stone expected to pass
USS: hydronephrosis Drugs

• Nifedipine or tamsulosin
• ± prednisolone
IVU • Most pass w/i 48h, 80% w/i 30d
• 600x radiation dose of KUB XR
• IV contrast injected and control, immediate and serial Active Stone Removal
films taken until contrast @ level of obstruction
• Abnormal findings Indications
§ Failure of flow to the bladder • Low likelihood of spontaneous passage: e.g. >10mm
§ Standing column of contrast • Persistent obstruction
§ Clubbing of the calyces: back pressure • Renal insufficiency
§ Delayed, dense nephrogram: no flow from • Infection
kidney
• CI Extracorporeal Shockwave Lithotripsy (SWL)
§ Contrast allergy • Stones <20mm in kidney or proximal ureter
§ Severe asthma
• SE: renal injury may → ↑BP
§ Metformin
• CI: pregnancy, AAA, bleeding diathesis
§ Pregnancy
Ureterorenoscopy (URS) + Dormier Basket Removal
Functional Scans
• Stone >10mm in distal ureter or if SWL failed
• DMSA: dimercaptosuccinic acid
• Stone >20mm in renal pelvis
• DTPA: diethylenetriamene penta-acetic acid
• MAG-3
Percutaneous Nephrolithotomy (PNL)
• Stone >20mm in renal pelvis
• E.g. staghorn calculi: do DMSA first
Prevention
• Drink plenty Lap or Open Surgery: rare
• Treat UTIs rapidly
• ↓ oxalate intake: chocolate, tea, strawberries
Febrile c̄ Renal Obstruction
• Surgical emergency
• Percutaneous nephrostomy or ureteric stent
• IV Abx: e.g. cefuroxime 1.5g IV TDS
Rx Summary
• Conservative: stone <5mm in distal ureter
• MET: stone 5-10mm and expected to pass
• Active: stones >10mm, persistent pain, renal
insufficiency
st nd
Location Size 1 line 2 line
Pelvis >20mm PNL or URS SWL
<20mm SWL URS, PNL
Proximal >10mm URS or SWL
ureter <10mm SWL URS
Distal ureter >10mm URS SWL
<10mm URS or SWL
100
Renal Tumours
Renal Cell Carcinoma / Hypernephroma Transitional Cell Carcinoma
Epidemiology Epidemiology
nd
• 90% of renal cancers • 2 commonest renal cancer
• Age: 55yrs • Age: 50-80yrs
• Sex: M>F=2:1 • Sex: M>F=4:1
Risk Factors Risk Factors

• Obesity • Smoking
• Smoking • Amine exposure (rubber industry)
• HTN • Cyclophosphamide
• Dialysis (15% of pts. develop RCC)
• 4% heritable: e.g. VHL syndrome Pathology
• Highly malignant
Pathology • Locations
•
Adenocarcinoma from proximal renal tubular epithelium § Bladder: 50%
•
Subtypes § Ureter
§ Clear Cell (glycogen): 70-80% § Renal pelvis
§ Papillary: 15%
§ Chromophobe: 5% Presentation
§ Collecting duct: 1% • Painless haematuria
• Frequency, urgency, dysuria
Presentation • Urinary tract obstruction
• 50% incidental finding
• Triad: Haematuria, loin pain, loin mass Ix
• Systemic: anorexia, malaise, wt. loss, PUO • Urine cytology
• Clot retention • CT/MRI
• Invasion of L renal vein → varicocele (1%) • IVU: pelviceal filling defect
• Cannonball mets → SOB
Mx
Paraneoplastic Features • Nephrouretectomy
• EPO → polycythaemia • Regular f/up: 50% develop bladder tumours
• PTHrP → ↑ Ca
• Renin → HTN
• ACTH → Cushing’s syn. Nephroblastoma: Wilm’s Tumour
• Amyloidosis
• Childhood tumour of primitive renal tubules and
mesenchymal cells
Spread • May be assoc. c̄ Chr 11 mutation
• Direct: renal vein • May be assoc. c̄ WAGR syndrome
• Lymph § Wilms, Aniridia, GU abnormalities, Retardation
• Haematogenous: bone, liver and lung
Presentation
Ix • 2-5yrs
• Blood: polycythaemia, ESR, U+E, ALP, Ca • 5-10% bilat
• Urine: dip, cytology • Abdo mass (doesn’t cross the midline)
• Imaging • Haematuria
§ CXR: cannonball mets
• Abdo pain
§ US: mass
• HTN
§ IVU: filling defect
§ CT/MRI
Robson Staging Other Neoplasms

• Confined to kidney
• Involves perinephric fat, but not Gerota’s fascia Benign
• Spread into renal vein • Cysts: very common
• Spread to adjacent / distant organs • Renal papillary adenomas
• Oncocytoma: eosinophilic cells c̄ numerous
Mx mitochondria
• Medical • Angiomyolipoma: seen in tuberous sclerosis
§ Reserved for pts. c̄ poor prognosis
§ Temsirolimus (mTOR inhibitor) Malignant
• Surgical • SCC: assoc. c̄ chronic infected staghorn calculi
§ Radical nephrectomy
§ Consider partial if small tumour or 1 kidney NB. Benign tumours commonly require nephrectomy to
exclude malignancy.
Prognosis: 45% 5ys
101
Bladder Tumours
Epidemiology Ix
• Incidence: 1:5000/yr • Urine: dip (sterile pyuria), cytology
• Sex: M>F=4:1 • IVU: filling defects
• Cystoscopy c̄ biopsy: diagnostic
Pathology • Bimanual EUA: helps to assess spread
• Transitional cell carcinomas account for 90% • CT/MRI: helps stage
• SCCs: assoc. c̄ schistosomiasis
• Adenocarcinoma Mx
• Depends on histological grade and the presence of
Natural Hx dissemination.
• Low-Grade Tumours
§ 80% TIS, Ta and T1 (Superficial)
§ Non-invasive, generally not life-threatening • 80% of all pts.
§ High rate of recurrence • Diathermy via transurethral cystoscopy / Transurethral
• High-Grade Tumours Resection of Bladder Tumour (TURBT)
§ 20% • Intravesicular chemo: mitomycin C
§ Invasive and life-threatening • Intravesicular immunotherapy: Bacille Calmette-
§ High recurrence rates Guérin
Risk Factors T2, T3 (Invasive)

• Smoking • Radical cystectomy c̄ ileal conduit is gold standard
• Amine exposure (rubber industry) • Radiotherapy: worse 5ys but preserves bladder
• Previous renal TCC § Salvage cystectomy can be performed
• Chronic cystitis • Adjuvant chemo: e.g. M-VAC
• Schistosomiasis (SCC) • Neoadjuvant chemo may have a role
• Urechal remnants (adenocarcinomas)
§ Embryological remnant of communication T4
between umbilicus and bladder • Palliative chemo / radiotherapy
• Pelvic irradiation • Long-term catheterisation
• Urinary diversions
Presentation
• Painless haematuria Complications
• Voiding irritability: dysuria, frequency, urgency • Massive bladder haemorrhage
• Recurrent UTIs • Cystectomy → Sexual and urinary malfunction
• Retention and obstructive renal failure
Follow-Up
Examination • Up to 70% of bladder tumours recur therefore
• Anaemia intensive f/up is required.
• Palpable bladder mass • History, examination and regular cystoscopy
• Palpable liver • High-risk tumours: every 3mo for 2yrs, then every 6mo
• Low-risk tumours: @ 9mo, then yrly
TNM Staging
• 80% confined to mucosa Prognosis
• 20% penetrate muscle (↑ mortality) • Depends on age and stage
• TIS, Ta and T1: 95% 5ys
TIS Carcinoma in situ Not felt at EUA • T2: 40-50% 5ys
Ta Confined to epithelium Not felt at EUA • T3: 25% 5ys
T1 Tumour in lamina propria Not felt at EUA • T4: <1yr median survival
T2 Superficial muscle involved Rubbery
thickness
T3 Deep muscle involved Mobile mass
T4 Invasion of prostate, uterus or Fixed mass
vagina
Spread
• Local → pelvic structures
• Lymph → iliac and para-aortic nodes
• Haem → bones, liver and lungs
Histological Classification
• Grade 1: well differentiated
• Grade 2: intermediate
• Grade 3: poorly differentiated
102
Benign Prostatic Hypertrophy
Epidemiology Mx
• 70% @ 60yrs
• 90% @ 80yrs Conservative
• ↓ caffeine, EtOH
• Double voiding
Pathophysiology • Bladder training: hold on → ↑ time between voiding
• Benign nodular or diffuse hyperplasia of stromal and
epithelial cells Medical
• Affects inner (transitional) layer of prostate (cf. Ca) • Useful in mild disease and while awaiting TURP
st
§ → urethral compression • 1 : α-blockers
• DHT produced from testosterone in stromal cells by § Tamsulosin, doxazosin
5α-reducatase enzyme. § Relax prostate smooth muscle
• DHT-induced GFs → ↑ stromal cells and ↓ epithelial § SE: drowsiness, ↓BP, depression, EF, wt. ↑,
cell death. extra-pyramidal signs
nd
• 2 : 5α-reductase inhibitors
§ Finasteride
Presentation § Inhibit conversion of testosterone → DHT
§ Preferred if significantly enlarged prostate.
• Storage Symptoms
§ SE: excreted in semen (use condoms), ED
§ Nocturia
§ Frequency
§ Urgency Surgical Mx
§ Overflow incontinence • Indications
• Voiding Symptoms § Symptoms affect QoL
§ Hesitancy § Complications of BPH
§ Straining • TURP
§ Poor stream/flow + terminal dribbling § Cystoscopic resection of lateral and middle
§ Strangury (urinary tenesmus) lobes
§ Incomplete emptying: pis en deux § ≤14% become impotent
•
O
Bladder stones (2 to stasis) • Transurethral incision of prostate (TUIP)
•
O
UTI (2 to stasis) § < destruction → ↓ risk to sexual function
§ Similar benefits to TURP if small prostate
(<30g)
• Tranurethral ElectroVaporisation of Prostate
Examination § Electric current → tissue vaporisation
• PR • Laser prostatectomy
§ Smoothly enlarged prostate § ↓ ED and retrograde ejaculation
§ Definable median sulcus § Similar efficacy as TURP
• Bladder not usually palpable unless acute-on-chronic • Open retropubic prostatectomy
obstruction § Used for very large prostates (>100g)
Ix TURP Complications
• Blood: U+E, PSA (after PR)
• Urine: dip, MC+S
Immediate
• Imaging
• TUR syndrome
§ Transrectal US ± biopsy
§ Absorption of large quantity of fluids → ↓Na
• Urodynamics: pressure / flow cystometry
• Haemorrhage
• Voiding diary
Early
• Haemorrhage
• Infection
• Clot retention: requires bladder irrigation
Late
• Retrograde ejaculation: common
• ED: ~10%
• Incontinence: ≤10%
• Urethral stricture
• Recurrence
103
Prostate Cancer
Epidemiology Gleason Grade
• Commonest male Ca • Score two worst affected areas
rd
• 3 commonest cause of male Ca death • Sum is inversely proportional to prognosis
• Prevalence: 80% of men >80yrs
• Race: ↑ in Blacks TNM Stage
Pathology TIS Carcinoma in situ

• Adenocarcinoma T1 Incidental finding on TURP or ↑PSA
• Peripheral zone of prostate T2 Intracapsular tumour c̄ deformation of prostate
T3 Extra-prostatic extension
Presentation T4 Fixed to pelvis + invading neighbouring structures
• Usually asymptomatic N1-4 1 or more lymph nodes involved
• Urinary: nocturia, frequency, hesitancy, poor stream,
M1 Distant mets, e.g. spine
terminal dribbling, obstruction
• Systemic: wt. loss, fatigue
• Mets: bone pain Prognostic Factors
• Help determine whether to pursue radical Rx
Examination • Age
• Hard irregular prostate on PR • Pre-Rx PSA
• Loss of midline sulcus • Tumour stage
• Tumour grade
Spread
• Local: seminal vesicles, bladder, rectum Mx
• Lymph: para-aortic nodes • Difficult to know which tumours are indolent and will not
• Haem: sclerotic bony lesions → mortality before something else.
• Radical therapy assoc. c̄ significant morbidity.
Ix
• Bloods: PSA, U+E, acid and alk phos, Ca Conservative: Active Monitoring
• Imaging • Close monitoring c̄ DRE and PSA
§ XR chest and spine
§ Transrectal US + biopsy Radical Therapy
§ Bone scan
• Radical prostatectomy (+ goserelin if node +ve)
§ Staging MRI
§ Performed laparoscopically c̄ robot
- Contrast enhancing magnetic
§ Only improves survival vs. active monitoring if
nanoparticles ↑s detection of affected
<75yrs
nodes.
• Brachytherapy: implantation of palladium seeds
• SEs: ED, urinary incontinence, death (0.2-0.5%)
PSA
• Proteolytic enzyme used in liquefaction of ejaculate
Medical
• Not specific for prostate Ca
• Used for metastatic or node +ve disease
§ ↑ c̄ age, PR, TURP, and prostatitis
• LHRH analogues
• >4ng/ml: 40-90% sensitivity, 60-90% specificity
§ E.g. goserelin
§ Only 1-in-3 will have Ca
§ Inhibit pituitary gonadotrophins → ↓ testosterone
• Normal in 30% of small cancers
• Anti-androgens
§ E.g. cyproterone acetate, flutamide
Symptomatic
• TURP for obstruction
• Analgesia
• Radiotherapy for bone mets / cord compression
Screening c̄ PSA
• Population based screening not recommended in UK
• PSA not an accurate tumour marker
• ERSPC trial showed small mortality benefit, PLCO trial
showed no benefit.
• Must balance mortality benefit c̄ harm caused by over
diagnosis and over treatment of indolent cancers.
104
Prostatitis Urinary Incontinence
Aetiology Male
• S. faecalis • Usually caused by prostatic enlargement
• E. coli § Urge incontinence or dribbling may result from partial
• Chlamydia retention.
§ Retention may → overflow (palpable bladder after
Presentation voiding)
• TURP and pelvic surgery may weaken external urethral
• Usually >35yrs
sphincter.
• UTI / dysuria
• Pain
§ Low backache Women
§ Pain on ejaculation • Stress Incontinence
• Haematospermia § Leakage from incompetent sphincter when IAP ↑
• Fever and rigors § Loss of small amounts of urine when coughing
• Retention § Pelvic floor weakness
• Malaise • Urge Incontinence / Overactive Bladder
§ Can’t hold urine for any length of time
§ May have precipitant: arriving home, running water,
Examination coffee
• Pyrexia § Dx: urodynamic studies
• Swollen / boggy / tender prostate on PR
• Examine testes to exclude epididymo-orchitis Mx
• Check
Ix § PR: faecal impaction
• Blood: FBC, U+E, CRP § Palpable bladder after voiding: retention c̄ overflow
• Urine: dip, MC+S § UTI
§ DM
Rx § CNS: MS, Parkinson’s stroke, spinal trauma
• Analgesia § Diuretics
• Levofloxacin 500mg/d for 28d • Stress Incontinence
§ Pelvic floor exercises
§ Ring pessary
§ Duloxetine
§ Surgery: tension-free vaginal tape
• Urge Incontinence
§ Bladder training
§ Wt. loss
§ Anti-AChM: tolterodine, imipramine
105
Undescended Testes Testicular Torsion
Epidemiology Aetiology
O
• 3% @ birth • Usually 2 to some exertion or minor trauma
• 1% @ 1yr • Occurs because testicle doesn’t have a large “bare area”
• Unilateral 4x commoner cf. bilateral to attach to scrotal wall.
§ Should have genetic testing if bilateral § Tunica vaginalis invests whole of testicle
- Noonan’s, Prader-Willi § Free-hanging “clapper bell” testicle can twist on
• Commoner in prems: incidence up to 30% its mesentery.
Normal Descent Presentation

• Testes remain in abdomen (retroperitoneal) until 7mo • Usually 10-25yrs
• Gubernaculum connects inferior pole of testis to • Sudden onset severe pain in one testis
scrotum. • May have lower abdominal pain (testis supplied by T10)
• Testis descends through inguinal canal to scrotum c̄ • Assoc. c̄ n/v
an out-pouching of peritoneum: processus vaginalis. • May be Hx of previous testicular pain or torsion
Classification Examination
• Inflam of one testis: hot, swollen, extremely tender
Cryptorchidism • Testis rides high and lies transversely
• Complete absence of testis from scrotum
• Anorchism = absence of both testes Differential
• Epididymo-orchitis
Retractile Testis § Older pt.
• Normal development but excessive cremasteric reflex § UTI symptoms
• Testicle often found at external inguinal ring § More gradual onset
• Will descend: no Rx required • Torted Hydatid of Morgagni
§ Remnant of Mullerian duct
Maldescended Testis § Younger pt.
• Found anywhere along normal path of descent § Less pain
§ Tiny blue dot visible on scrotum
• Testis and scrotum are usually under-developed
• Tumour
• Often assoc. c̄ patent processus vaginalis
• Trauma
• Strangulated hernia
Ectopic Testis • Appendicitis
• Found outside line of descent
• Usually in sup. inguinal pouch (ant. to external
oblique aponeurosis)
Ix
• Abdominal, perineal, penile, femoral triangle • Doppler US may demonstrate absence of flow
§ Must not delay surgical exploration
Complications
• Infertility
Mx
• Surgical emergency
• 10x ↑ risk of malignancy (remains after surgery)
§ 4-6h window from onset of pain to salvage testis
• ↑ risk of trauma
• Inform senior
• ↑ risk of torsion
• NBM
• Assoc. c̄ hernias (90%) or urinary tract abnormalities
• IV access
§ Analgesia
Mx § Bloods: FBC, U+E, G+S, clotting
• Restores potential for spermatogenesis • Surgery
• Makes Ca easier to Dx § Consent for possible orchidectomy
§ Bilateral orchidopexy: suture testes to scrotum
Surgical: Orchidopexy by Dartos Pouch Procedure • If no torsion found and epididymo-orchitis Dx, take fluid
• Perform before 2yrs sample from scrotum for bacteriology and Rx c̄ Abx.
• Mobilisation of testis and cord
• Removal of patent processus
• Testicle brought through a hole made in the dartos
muscle to lie in a subcutaneous pouch.
• Dartos prevents retraction.
Hormonal
• β-HCG may be tried if testis is in inguinal canal.
106
Lumps in the Groin and Scrotum
Differential Epididymo-Orchitis
• Can’t get above: inguinoscrotal hernia
• Separate, cystic: epididymal cyst Aetiology
• Separate, solid: varicocele, sperm granuloma, • STI: Chlamydia, gonorrhoea
epididymitis • Ascending UTI: E. coli
• Testicular, cystic: hydrocele • Mumps
• Testicular, solid: tumour, orchitis, haematocele
Features
Epididymal Cyst • Sudden onset tender swelling
• Develop in adulthood • Dysuria
• Contain clear or milky (spermatocele) fluid • Sweats, fever
• Lie above and behind testis
• Remove if symptomatic Examination
• Tender, red, warm, swollen testis and epididymis
Varicocele § Elevating testicle may relieve pain
•Dilated veins of pampiniform plexus • Secondary hydrocele
•Presentation • Urethral discharge
§ Feel like bag of worms in the scrotum
§ May be visible dilated veins Ix
§ ↓ size on lying down • Blood: FBC, CRP
§ Pt. may c/o dull ache • Urine: dip, MC+S (fist catch may be best)
§ May → oligospermia (↓ fertility) • Urethral swab and STI screen
• Pathology • US: may be needed to exclude abscess
O
§ 1 : Left side commoner: drain into left renal vein
O
§ 2 : left renal tumour has tracked down renal
Complications
vein → testicular vein obstruction.
• May → infertility
• Mx
§ Conservative: scrotal support
§ Surgical: clipping the testicular vein (open or Mx
lap) • Bed rest
• Analgesia
Sperm Granuloma • Scrotal support
• Painful lump of extravasated sperm after vasectomy • Abx: doxycycline or cipro
• Drain abscess if present
Hydrocele
• Collection of serous fluid w/i tunica vaginalis
• Primary
§ assoc. c̄ patent processus vaginalis
§ Commoner, larger, tense, younger men
• Secondary
§ Tumour, trauma, infection
§ Smaller, less tense
• Ix
§ US testicle to exclude tumour
• Mx
§ May resolve spontaneously
§ Surgery
- Lord’s Repair: plication of the sac
- Jaboulay’s Repair: eversion of the sac
§ Aspiration
st
- Usually recur so not 1 line.
- Send fluid for cytology and MC+S
Haematocele
• Blood in the tunica vaginalis
• Hx of trauma
• May need drainage or excision
107
Testicular Tumours
Epidemiology Staging: Royal Marsden Classification
• Commonest male malignancies from 15-44yrs • Disease only in testis
• Whites > Blacks = 5:1 • Para-aortic nodes involved (below diaphragm)
• Supra- and infra-diaphragmatic LNs involved
Presentation • Extra-lymphatic spread: lungs, liver
• Painless testicular lump
§ Often noticed after trauma Ix
• Haematospermia • Tumour markers
O
• 2 hydrocele § Useful for monitoring
• Mets: SOB from lung mets § ↑AFP and ↑hCG in 90% of teratomas
• Abdo mass: para-aortic lymphadenopathy § ↑hCG in 15% of seminomas
• Hormones: gynaecomastia, virilisation § Normal AFP in pure seminomas
• Contralateral tumour in 5% • Scrotum US
• Staging
§ CXR
Risk Factors § CT
• Undescended testis
§ 10% occur in undescended testes NB. Percutaneous biopsy should not be performed as it may
• Infant hernia → seeding along needle tract
• Infertility
Mx
Pathology • If both testes are abnormal, semen can be
cryopreserved
Germ Cell: 95% of tumours
• Pure Seminomas: 40% Seminomas
§ Commonest single subtype • Stage 1-2: inguinal orchidectomy + radiotherapy
§ 30-40yrs § Groin incision allows cord clamping to prevent
§ ↑ βhCG in 15% seeding
§ ↑ placental ALP in some • Stage 3-4: as above + chemo (BEP)
§ Very radiosensitive § Bleomycin, Etoposide, cisPlatin
• Non-seminomas (inc. mixed): 60%
§ Mixed: commonest NSGCT
Non-seminomas / Teratomas
§ Teratoma
• Stage 1: inguinal orchidectomy + surveillance
- Arise from all 3 germ layers
• Stage 2: orchidectomy + chemo + para-aortic LN
- Common and benign in children
dissection
- Rare and malignant in adults: 15-30yrs
• Stage 3: orchidectomy + chemo
- Secrete βhCG and/or AFP
- Chemosensitive
§ Yolk Sac Close f/up to detect relapse
- Commonest testicular tumour in children • Typically w/i 18-24mo
§ Choriocarcinoma • Repeat CT scanning and tumour markers
- ↑↑ βhCG
Prognosis
Sex-cord Stromal • Stage 1: 98% 5ys
• Leydig Cell • Stage 2: 85% 5ys
§ Mostly benign • Stage 4: 60% 5ys
§ May secrete androgens or oestrogens
• Sertoli Cell
§ Mostly benign
§ May secrete oestrogens
Lymphoma / Leukaemia
• NHL: commonest malignant testicular mass >60yrs
• ALL: commonest malignant testicular mass <5yrs
108
The Penis
Balanitis Penile Cancer
• Acute inflammation of the foreskin and glans
• Cause: Strep, Staph infection, Candida (DM) Epidemiology
• RFs: DM, young children c̄ tight foreskin • Incidence: 1:100,000/yr in UK
• Rx: hygiene advice, Abx, circumcision • Geo: commoner in Far East and Africa
Aetiology
Phimosis • V. rare if circumcised
• Foreskin occludes the meatus • Risk factors
• Children § HPV (16, 18, 31) infection
O
§ Chronic irritation 2 to smegma
§ Pres: recurrent balanitis and ballooning
§ Mx: Gentle retraction, steroid creams,
circumcision Pathology
• Adults • Erythroplasia of Querat: penile CIS
§ Pres: dyspareunia, infection • SCC
§ Mx: circumcision
§ Assoc. c̄ balanitis xerotica obliterans: thickening Presentation
of foreskin and glans → phimosis + meatal • Chronic fungating ulcer
narrowing • Bloody / purulent discharge
• 50% have inguinal nodes at presentation
Paraphimosis Mx
• Tight foreskin is retracted and becomes irreplaceable. • Medical
• ↓ venous return → oedema and swelling of the glans § Early growths c̄ no urethral involvement
§ Can rarely → glans ischaemia § DXT and iridium wires
• Causes: catheterisation, masturbation, intercourse • Surgical
• Mx: § Amputation required if urethral involvement
§ Manual reduction: use ice and lignocaine jelly § Lymph node dissection
§ May require glans aspiration or dorsal slit
Hypo- / epi-spadias
• Developmental abnormality of the position of the urethral
opening
• Hypospadia: opens on ventral surface of penis
• Epispadia: opens on dorsal surface
109
Orthopaedics
Contents
Bone and Fracture Physiology ........................................................................................................................... 111
Fracture Classification ....................................................................................................................................... 111
Fracture Management: 4Rs ............................................................................................................................... 112
Fracture Complications ...................................................................................................................................... 113
Hip Fracture ....................................................................................................................................................... 115
Distal Forearm Fractures ................................................................................................................................... 116
Scaphoid Fractures ............................................................................................................................................ 116
Radial and Ulna Shaft Fractures ........................................................................................................................ 116
The Shoulder ..................................................................................................................................................... 117
Supracondylar Fractures of the Humerus .......................................................................................................... 118
Femoral and Tibial Fractures ............................................................................................................................. 119
Ankle Injuries ..................................................................................................................................................... 119
Knee Injuries ...................................................................................................................................................... 120
Osteoarthritis...................................................................................................................................................... 121
Back Pain ........................................................................................................................................................... 122
Osteochondritis .................................................................................................................................................. 123
Traction Apophysitis........................................................................................................................................... 123
Osteochondritis Dissecans ................................................................................................................................ 123
Avascular Necrosis ............................................................................................................................................ 123
The Limping Child .............................................................................................................................................. 124
Acute Osteomyelitis ........................................................................................................................................... 125
Septic Arthritis .................................................................................................................................................... 125
Bone Tumours ................................................................................................................................................... 126
Brachial Plexus Injuries...................................................................................................................................... 128
Other Nerve Injuries ........................................................................................................................................... 128
Carpal Tunnel Syndrome ................................................................................................................................... 129
Minor Hand Conditions ...................................................................................................................................... 130
Minor Leg and Foot Conditions .......................................................................................................................... 131
110
Bone and Fracture Physiology Fracture Classification
Composition Classification
• Traumatic #
Cells: osteoblasts, osteoclasts, osteocytes, OPCs § Direct: e.g. assault c̄ metal bar
§ Indirect: e.g. FOOSH → clavicle #
Matrix § Avulsion
• Organic = osteoid (40%) • Stress #
§ Collagen type I § Bone fatigue due to repetitive strain
§ Resists tension, twisting and bending § E.g. foot #s in marathon runners
• Inorganic (60%) • Pathological #
§ Calcium hydroxyapatite § Normal forces but diseased bone
§ Resists compressive forces - Local: tumours
- General: osteoporosis, Cushing’s, Paget’s
Classification Describing a fracture: PAID

• Radiographs must be orthogonal: request AP and lat. films.
• Need images of joint above and joint below #.
Woven Bone
• Disorganised bone that forms the embryonic
skeleton and fracture callus. • Demographics
§ Pt. details
§ Date radiograph taken
Lamellar Bone § Orientation and content of image
• Mature bone that can be of two types:
§ Cortical/compact: dense outer layer • Pattern
§ Cancellous/trabecular: porous central
• Transverse • Crush
layer
• Oblique • Greenstick
• Spiral • Avulsion
• Multifragmentary
Formation
• Anatomical Location
Intramembranous Ossification
• Direct ossification of mesenchymal bone models • Intra- / extra-articular
formed during embryonic development. • Dislocation or subluxation
• Skull bones, mandible and clavicle.
• Deformity (distal relative to proximal)
Endochondral Ossification § Translation
• Mesenchyme → cartilage → bone § Angulation or tilt
• Most bones ossify this way § Rotation
§ Impaction (→shortening)
Fracture Healing • Soft Tissues

§ Open or closed
§ Neurovascular status
Reactive Phase (injury – 48hrs)
§ Compartment syndrome
• Bleeding into # site → haematoma
• Inflammation → cytokine, GF and vasoactive
• ? Specific # classification/type
mediator release → recruitment of leukocytes and
§ Salter-Harris
fibroblasts → granulation tissue
§ Garden
§ Colles’, Smith’s, Galeazzi, Monteggia
Reparative Phase (2 days – 2 wks)
• Proliferation of osteoblasts and fibroblasts →
cartilage and woven bone production → callus
formation.
• Consolidation (endochondral ossification) of
woven bone → lamellar bone
Remodelling Phase (1wk – 7yrs)

• Remodelling of lamellar bone to cope c̄
mechanical forces applied to it (Wolff’s Law: “form
follows function”)
Healing Time
• Closed, paediatric, metaphyseal, upper limb: 3wks
• “Complicating factor” doubles healing time
§ Adult
§ Lower limb
§ Diaphyseal
§ Open
© Alasdair Scott, 2018 111

Fracture Management: 4Rs
1: Resuscitation 3: Restriction
Principles Principles
• Follow ATLS guidelines • Interfragmentary strain hypothesis dictates that tissue
O
• Trauma series in 1 survey: C-spine, chest and pelvis formed @ # site depends on strain it experiences.
O
• # usually assessed in 2 survey • Fixation → ↓ strain → bone formation
• Assess neurovascular status and look for dislocations • Fixation also → ↓ pain, ↑ stability, ↑ ability to function.
• Consider reduction and splinting before imaging
§ ↓ pain Methods
§ ↓ bleeding • Non-rigid
§ ↓ risk of neurovascular injury § Slings
• X-ray once stable § Elastic supports
• Plaster
Open fractures require urgent attention: 6As § POP
• Analgesia: M+M § In first 24-48h use back-slab or split cast due to
• Assess: NV status, soft tissues, photograph risk of compartment syndrome
• Antisepsis: wound swab, copious irrigation, cover with • Functional bracing
betadine-soaked dressing. § Joints free to move but bone shafts supported
• Alignment: align # and splint in cast segments.
• Anti-tetanus: check status (booster lasts 10yrs) • Continuous traction
• Abx § e.g. collar-and-cuff
§ Fluclox 500mg IV/IM + benpen 600mg IV/IM • Ex-Fix
§ Or, augmentin 1.2g IV § Fragments held in position by pins/wires which
are then connected to an external frame.
Mx: debridement and fixation in theatre § Intervention is away from field of injury.
§ Useful in open #s, burns, tissue loss to allow
wound access and ↓ infection risk.
Gustillo Classification of Open #s
§ Risk of pin-site infections
• Wound <1cm in length
• Internal fixation
• Wound ≥1cm c̄ minimal soft tissue damage § Pins, plates, screws, IM nails
• Extensive soft tissue damage § Usually perfect anatomical alignment
§ ↑ stability
Clostridium perfringes § Aid early mobilisation
• Most dangerous complication of open #
• Wound infections and gas gangrene
• ± shock and renal failure 4: Rehabilitation
• Rx: debride, benpen + clindamycin
Principles
2: Reduction • Immobility → ↓ muscle and bone mass, joint stiffness
• Need to maximise mobility of uninjured limbs
Principles • Quick return to function ↓s later morbidity
• Displaced #s should be reduced
§ Unless no effect on outcome, e.g. ribs Methods
• Aim for anatomical reduction (esp. if articular surfaces • Physiotherapy: exercises to improve mobility
involved) • OT: splints, mobility aids, home modification
• Alignment is more important than opposition • Social services: meals on wheels, home help
Methods
• Manipulation / Closed reduction
§ Under local, regional or general anaesthetic
§ Traction to disimpact
§ Manipulation to align
• Traction
§ Not typically used now.
§ Employed to overcome contraction of large
muscles: e.g. femoral #s
§ Skeletal traction vs. skin traction
• Open reduction (and internal fixation)
§ Accurate reduction vs. risks of surgery
§ Intra-articular #s
§ Open #s
§ 2 #s in 1 limb
§ Failed conservative Rx
§ Bilat identical #s
112 © Alasdair Scott, 2018

Fracture Complications
General Complications Specific Complications
Tissue Damage Immediate
• Haemorrhage and shock • Neurovascular damage
• Infection • Visceral damage
• Muscle damage → rhabdomyolysis Early
Anaesthesia • Compartment syn.
• Anaphylaxis • Infection (worse if assoc. c̄ metalwork)
• Damage to teeth • Fat embolism → ARDS
• Aspiration Late
Prolonged Bed Rest • Problems c̄ union
• Chest infection, UTI • AVN
• Pressure sores and muscle wasting • Growth disturbance
• DVT, PE • Post-traumatic osteoarthritis
• ↓ BMD • Complex regional pain syndromes
• Myositis ossificans
Neurological Complications Problems with union

• Severance is rare, usaully stretching over bone edge
• Seddon classification describes three types of injury Delayed Union: union takes longer than expected
Non-union: # fails to unite
Neuropraxia
• Temporary interruption of conduction w/o loss of axonal Causative Factors: 5 Is
continuity. • Ischaemia: poor blood supply or AVN
• Infection
Axonotmesis • ↑ interfragmentary strain
• Disruption of nerve axon → distal Wallerian degeneration. • Interposition of tissue between fragments
• Connective tissue framework of nerve preserved. • Intercurrent disease: e.g. malignancy or malnutrition
• Regeneration occurs and recovery is possible.
Non-union Classification
Neurotmesis • Hypertrophic
• Disruption of entire nerve fibre § Bone end is rounded, dense and sclerotic
• Surgery required and recovery not usually complete. • Atrophic
§ Bone looks osteopenic
Common Palsies
Injury Palsy Test/Result Management
• Optimise biology: infection, blood supply, bone
Ant. shoulder dislocation Axillary N. Numb chevron
Humeral surgical neck Weak abduction graft, BMPs
# humeral shaft Radial N. Waiter’s tip • Optimise mechanics: ORIF
Elbow dislocation Ulnar N. Claw hand
Hip dislocation Sciatic N. Foot drop Malunion: # healed in an imperfect position
# neck of fibula Fibular N. Foot drop • Poor appearance and/or function
Knee dislocation • E.g. Gunstock deformity
Compartment Syndrome
• Osteofacial membranes divide limbs into muscle Avascular Necrosis
compartments • Death of bone due to deficient blood supply.
• Oedema following # → ↑ compartment pressure → ↓ • Sites: femoral head, scaphoid, talus
venous drainage → ↑ compartment pressure • Consequence: bone becomes soft and deformed →
• Compartment pressure > capillary pressure → ischaemia pain, stiffness and OA.
• Muscle infarction → • X-ray: sclerosis and deformity.
§ Rhabdomyolysis and ATN
§ Fibrosis → Volkman’s ischaemic contracture
Myositis Ossificans
Presentation
• Heterotopic ossification of muscle @ sites of
• Pain > clinical findings haematoma formation
• Pain on passive muscle stretching • → restricted, painful movement
• Warm, erythematous, swollen limb • Commonly affects the elbow and quadriceps
• ↑ CRT and weak/absent peripheral pulses • Can be excised surgically
Rx Pellegrini-Stieda disease
• Elevate limb • Form of MO
• Remove all bandages and split/remove cast • Calcification of the superior attachment of MCL @
• Fasciotomy the knee following traumatic injury.

Complex Regional Pain Syndrome Type 1
= Reflex Sympathetic Dystrophy, Sudek’s Atrophy
Definition Rx
• Complex disorder of pain, sensory abnormalities, • Usually self-limiting
abnormal blood flow, sweating and trophic changes in • Refer to pain team
superficial or deep tissues. • Amitryptilline, gabapentin
• No evidence of nerve injury. • Sympathetic nerve blocks can be tried.
Causes CRPS Type II (= Causalgia)

• Injury: #s, carpal tunnel release, ops for Dupuytren’s • Persistent pain following injury caused by nerve
• Zoster, MI, Idiopathic lesions.
Presentation
• Wks – months after injury
• NOT traumatised area that is affected: affects a
NEIGHBOURING area.
• Lancing pain, hyperalgesia or allodynia
• Vasomotor: hot and sweaty or cold and cyanosed
• Skin: swollen or atrophic and shiny.
• NM: weakness, hyper-reflexia, dystonia, contractures
Growth Disturbance
• In children, damage to the physis (growth plate) can result in abnormal bone growth.
• The Salter-Harris classification (1963) categorises growth plate injuries:
Salter Harris Classification
• Straight across
• Above
• Lower
• Through
• CRUSH
• ↑ing risk of growth plate injury

• SH 1: e.g. SUFE. Normal growth c̄ good reduction.
• SH 4: union across physis may interfere c̄ bone growth
• SH 5: crush → physis injury → growth arrest

Hip Fracture
Epidemiology Classification
• 80/100,000 • Intracapsular: subcapital, transcervical, basicervical
• 50% in >80yrs • Extracapsular: Intertrochanteric, subtrochanteric
• F>M = 3:1
Garden Classification of Intracapsular Fractures
Pathophysiology • Incomplete #, undisplaced
• Old = osteoporosis c̄ minor trauma (e.g. fall) • Complete #, undisplaced
• Young = major trauma • Complete #, partially displaced
• Complete #, completely displaced
Osteoporosis Risk Factors: Age + SHATTERED
• Steroids
• Hyper- para/thyroidism
• Alcohol and Cigarettes
• Thin (BMI<22)
• Testosterone low
• Early Menopause
• Renal / liver failure
• Erosive / inflame bone disease (e.g. RA,
myeloma)
• Dietary Ca low / malabsorption, DM
Presentation
• O/E: shortened and externally rotated
• Key Qs:
§ Mechanism
§ RFs for osteoporosis / pathological #
§ Premorbid mobility
§ Premorbid independence
§ Comorbidities
§ MMSE Surgical Management
Initial Management Intracapsular

• Resuscitate: dehydration, hypothermia • 1,2: ORIF c̄ cancellous screws
• Analgesia: morphine, fascia iliaca block • 3,4:
• Assess neurovascular status of limb § <55: ORIF c̄ screws.
• Imaging: AP and lateral films - f/up in OPD and do arthroplasty if AVN
• Prep for theatre develops (in 30%)
§ Inform Anaesthetist and book theatre § 55-75: total hip replacement
§ Bloods: FBC, U+E, clotting, X-match (2u) § >75: hemiarthroplasty
§ CXR - Mobilises: cemented Thompson’s
§ DVT prophylaxis: TEDS, LMWH - Non-mobiliser: uncemented Austin Moore
§ ECG
§ Films: orthogonal X-rays Extracapsular
§ Get consent • ORIF c̄ DHS
Imaging Discharge
• Ask for AP and lateral film • Involve OT and physios
• Look @ Shenton’s lines • Discharge when mobilisation and social circumstances
• Intra- or extra-capsular? permit.
• Displaced or non-displaced
• Osteopaenic? Specific Complications
• AVN of fem head in displaced #s (30%)
Key Anatomy • Non / mal-union (10-30%)
• Capsule attaches proximally to acetabular margin • Infection
and distally to intertrochanteric line. • Osteoarthritis
• Blood supply to fem head:
§ Retinacular vessels, in capsule, distal → Prognosis
prox • 30% mortality @ 1yr
§ Intramedullary vessels
• 50% never regain pre-morbid functioning
§ Artery of ligamentum teres.
• >10% unable to return to premorbid residence
• If retinacular vessels damaged there is risk of
• Majority will have some residual pain or disability.
AVN of the femoral head → pain, stiffness and OA

Distal Forearm Fractures Scaphoid Fractures
Colles’ Fracture Clinical Features
• FOOSH
Clinical Features • Pain in anatomical snuffbox
• Fall onto an outstretched hand • Pain on telescoping the thumb
• Most common in elderly females c̄ osteoporosis
• Dinner fork deformity Specific Management
• Request scaphoid x-ray view
Radiographic Features • If clinical hx and exam suggest a scaphoid #, it should
• Extra-articular # of dist. radius (w/i 1.5” of joint) initially be treated even if the x-ray is normal.
• Dorsal displacement of distal fragment § # may become apparent after 10 days due to
localised decalcification.
• Dorsal angulation of distal fragment
• Place wrist in scaphoid plaster (beer glass position)
§ Normally 11 degrees volar tilt
• If initial x-ray is negative, pt. returns to # clinic after 10
• ↓ radial height (norm =11mm)
O days for re-xray.
• ↓ radial inclination (norm =22 )
§ # visible → plaster for 6 wks
• ± avulsion of ulna styloid
§ No visible # but clinically tender → plaster for 2
• ± impaction wks
§ # not visible and not clinically tender → no plaster
Specific Management
• Examine for neurovascular injuries as median nerve Specific Complications
and radial artery lie close. • Main risk is AVN of the scaphoid as blood supply runs
• If much displacement → reduction distal to proximal.
§ Under haematoma block, IV regional § → stiffness and pain at the wrist
anaesthesia (Bier’s block) or GA.
§ Disimpact and correct angulation.
§ Position: ulnar deviation + some wrist flexion
§ Apply dorsal backslab: provide 3-point Radial and Ulna Shaft Fractures
pressure
• Re X-Ray – satisfactory position?
Classification
§ No: ortho review and consider MUA ± K
• Monteggia
wires rd
§ # of proximal 3 of ulna shaft
§ Yes: home c̄ # clinic f/up w/i 48hrs for
§ Anterior dislocation of radial head at capitellum
completion of POP
§ May → palsy of deep branch of radial nerve →
• 6 wks in POP + physio weak finger extension but no sensory loss
• If comminuted, intra-articular or re-displaces:
§ Surgical fixation c̄ ex-fix, Kirschner-wires or
• Galleazzi
ORIF and plates. § # of radial shaft between mid and distal 3
rds
§ Dislocation of distal radio-ulna joint

Specific Complications
• Median N. injury Specific Management
• Frozen shoulder / adhesive capsulitis • Unstable fractures
• Tendon rupture: esp. EPL § Adults: ORIF
• Carpal tunnel syn. § Children: MUA + above elbow plaster
• Mal- /non-union • Fractures of forearm should be plastered in most stable
• Sudek’s atrophy / CRPS position:
§ Proximal #: supination
§ Distal #: pronation
§ Mid-shaft #: neutral
Other Distal Forearm Fractures
Smith’s / Reverse Colles’

• Fall onto back of flexed wrist
• Fracture of distal radius c̄ volar displacement and
angulation of distal fragment.
• Reduce to restore anatomy and POP for 6wks
Barton’s Fracture
• Oblique intra-articular # involving the dorsal aspect
of distal radius and dislocation of radio-carpal joint
• Reverse Barton’s involves the volar aspect of the
radius

The Shoulder
Shoulder Dislocation Impingement Syndrome / Painful Arc
Classification Pathology
• Anterior • Entrapment of supraspinatus tendon and subacromial
§ 95% of shoulder dislocations. bursa between acromion and grater tuberosity of
§ Direct trauma or falling on hand humerus.
§ Humeral head dislocates antero-inferiorly • → subacromial bursitis and/or supraspinatous tendonitis
• Posterior
§ Caused by direct trauma or muscle Presentation
contraction (seen in epileptics). O
• Painful arc: 60-120
• Weakness and ↓ ROM
Associated Lesions • +ve Hawkin’s test
Bankart Lesion Ix
• Damage to anteroinferior glenoid labrum. • Plain radiographs: may see bony spurs
• US
Hill-Sachs Lesion • MRI arthrogram
• Cortical depression in the posterolateral part of the
humeral head following impaction against the Rx
glenoid rim during anterior dislocation. • Conservative
• Occurs in 35-40% of anterior dislocations. § Rest
§ Physiotherapy
Presentation • Medical
• Shoulder contour lost: appears square § NSAIDs
• Bulge in infraclavicular fossa: humeral head § Subacromial bursa steroid ± LA injection
• Arm supported in opposite hand • Surgical
• Severe pain § Arthroscopic acromioplasty
Differential of Painful Arc

Specific Management
• Impingement
• Assess for neurovascular deficit: esp. axillary N.
• Supraspinatous tear or partial tear
§ Sensation over “chevron” area before and
• AC joint OA
after reduction.
§ Occurs in 5%
• X-ray: AP and transcapular view Frozen Shoulder: Adhesive Capsulitis
• Reduction under sedation (e.g. propafol)
§ Hippocratic: Longitudinal traction c̄ arm in Presentation
O
30 abduction and counter traction @ the • Progressive ↓ active and passive ROM
O
axilla § ↓ ext. rotation <30
O
§ Kocher’s: external rotation of adducted arm, § ↓ abduction <90
anterior movement, internal rotation • Shoulder pain, esp. @ night (can’t lie on affected side)
• Rest arm in a sling for 3-4wks
• Physio Cause
• Unknown, may follow trauma in elderly
Complications • Commonly assoc. c̄ DM
• Recurrent dislocation
§ 90% of pts. <20yrs with traumatic dislocation
Rx
• Axillary N. injury
• Conservative: rest, physio
• Medical
§ NSAIDs
Recurrent Shoulder Instability § Subacromial bursa steroid ± LA injection
TUBS: Traumatic Unilateral dislocations with a Rotator Cuff Tear

O
Bankart lesion often require Surgery • 2 to degeneration or a sudden jolt or fall
• Mostly young patients: 15-30yrs • Partial tears → painful arc
• Surgery involves a Bankart repair • Complete tear
§ Shoulder tip pain
AMBRI: Atraumatic Multidirectional Bilateral § Full range of passive movement
shoulder dislocation is treated with Rehabilitation, but § Inability to abduct the arm
§ Active abduction possible following passive
may require Inferior capsular shift O
abduction to 90
§ Lowering the arm beneath this → sudden drop
- “drop arm” sign
Rx: open or arthroscopic repair

Supracondylar Fractures of the Humerus
Presentation Specific Complications
• Common in children after FOOSH
• Elbow very swollen and held semi-flexed. Neurovascular Injury
• Sharp edge of proximal humerus may injure brachial • Brachial artery
artery which lies anterior to it. • Radial nerve
• Median nerve: esp. anterior interosseous branch
Classification § Supplies deep forearm flexors (FPL, lateral half
of FDP and pronator quadratus)
Extension
• Commonest type Compartment syndrome
• Distal fragment displaces posteriorly • Monitor closely during the first 24h
• Gartland further classified extension type: • Pain on passive extension of the fingers (stretches
§ Type 1: non-displaced flexor compartment) is early sign.
§ Type 2: angulated c̄ intact posterior cortex • Mx: try extension of the elbow, surgical Rx may be
§ Type 3: displaced c̄ no cortical contact needed.
• Volkmann’s ischaemic contracture can result →
fibrosis of flexors → claw hand.
Flexion
• Less common
• Distal fragment displaces anteriorly Gunstock Deformity
• Valgus, varus and rotational deformities in the coronal
plane do not remodel and → cubitus varus.
Specific Management • Cubitus varus deformity is referred to as a “gunstock”
• Ensure there is no neurovascular damage deformity.
§ If radial pulse absent or damage to brachial
artery suspected, take urgently to theatre for
reduction ± on-table angiogram.
§ Median nerve is also vulnerable
• Restore the anatomy

§ No displacement → flex the arm as fully as
possible and apply a collar and cuff for 3wks –
triceps acts as sling to stabilise fragments.
§ Displacement → MUA + fixation with K-wires
+ collar and cuff with arm flexed for 3wks.

Femoral and Tibial Fractures Ankle Injuries
Specific Management Ligament Strains
• Resus and Mx life-threatening injuries first. • Typically twisting inversion injury
• X-Match § Strains anterior talofibular part of lateral
§ Tibial #: 2 units collateral ligament
§ Femoral #: 4 units • Medial deltoid ligament strains are rare.
• Assess neurovascular status: esp. distal pulses • May be assoc. c̄ malleolar avulsion #s
• If open
§ Abx and ATT
§ Take to theatre urgently for debridement,
Ankle Fracture
washout and stabilisation
• Fixation methods
§ Intramedullary nail Ottowa Ankle Rules
§ Ex-fix • X-ray ankle if pain in malleolar zone + in any of:
§ Plates and screws § Tenderness along distal 6cm of posterior tib /
§ MUA c̄ fixed traction for 3-4mo fib including posterior tip of the malleoli.
§ Inability to bear weight both immediately and in
ED
Specific Complications
• Hypovolaemic shock Weber Classification
• Neurovascular
• Relation of fibula # to joint line
§ SFA: swelling and check pulses
• A: below joint line
§ Sciatic nerve
• B: at joint line
• Compartment syndrome
• C: above joint line
• Respiratory complications
• Weber’s B and C represent possible injury to the
§ Fat embolism
syndesmotic ligaments between tib and fib →
§ ARDS
instability
§ Pneumonia
Mx
• Weber A
§ Boot or below-knee POP
• Non-displaced Weber B/C
§ Below-knee POP
• Displaced Weber B/C
§ Closed reduction and POP if anatomical
reduction achieved
§ ORIF if closed reduction fails

Knee Injuries
History Arthroscopy
• Mechanism • Direct vision of inside of knee joint by arthroscope
• Swelling • Can examine knee under anaesthesia (↓ muscle tone)
§ Immediate = haemarthrosis = # or torn • Meniscal tears can be trimmed or repaired.
cruciates
§ Overnight = effusion = meniscus or other lgt
Mx of Ruptured ACL
• Pain / tenderness
§ Joint line = meniscal
§ Med/lateral margins = collateral lgts. Conservative
• Locking: meniscal tear → mechanical obstruction • Rest
• Giving way: instability following lgt. injury • Physio to strengthen quads and hamstrings
• Not enough stability for many sports
Surgical
Knee Haemarthrosis • Gold-standard is autograft repair
O
• 1 : spontaneous bleeding
• Usually semitendinosus ± gracilis (can use patella
§ Coagulopathy: warfarin, haemophilia
O tendon)
• 2 : trauma
• Tendon threaded through heads of tibia and femur
§ ACL injury: 80%
and held using screws.
§ Patella dislocation: 10%
§ Meniscal injury: 10%
- Outer third where its vascularised
§ Osteophyte #
Unhappy Triad of O’Donoghue

• ACL
• MCL
• Medial Meniscus
Mx of acutely injured knee

• Full examination of acutely swollen knee after injury is
difficult.
• Take x-ray to ensure no #s
§ Fluid level indicates a lipohaemarthrosis and
indicates either a # or torn cruciate.
• If no # → RICE + later re-examination for pathology
• If meniscal or cruciate injury suspected → MRI

Osteoarthritis
Definition Pathophysiology
• Degenerative joint disorder in which there is • Softening of articular cartilage → fraying and fissuring
progressive loss of hyaline cartilage and new bone of smooth surface → underlying bone exposure.
formation at the joint surface and its margin. • Subchondral bone becomes sclerotic c̄ cysts.
• Proliferation and ossification of cartilage in unstressed
Aetiology / Risk Factors areas → osteophytes.
• Age (80% > 75yrs) • Capsular fibrosis → stiff joints.
• Obesity
• Joint abnormality Differential
• Septic
Classification • Crystal
• Primary: no underlying cause • Trauma
• Secondary: obesity, joint abnormality
X-ray Changes
Symptoms • Loss of joint space
• Affects: knees, hips, DIPs, PIPs, thumb CMC • Osteophytes
• Pain: worse c̄ movement, background rest/night pain, • Subchondral cysts
worse @ end of day.
• Stiffness: especially after rest, lasts ~30min (e.g. AM) • Subchondral sclerosis
• Deformity • Deformity
• ↓ ROM
Bloods
Signs • CRP may be mildly elevated
• Bouchards and Heberdens nodes
§ ‘Pouchards’ (prox), ‘Heberdips’ (dist.) • Ca, PO4 and ALP all normal
• Thumb CMC squaring
• Fixed flexion deformity Rx
History MDT: GP, physio, OT, dietician, orthopod
• Pain severity, night pain
• Walking distance Conservative
• Analgesic requirements • Lifestyle: ↓ wt., ↑ exercise
• ADLs and social circumstances • Physio: muscle strengthening
• Co-morbidities • OT: walking aids, supportive footwear, home mods
• Underlying causes: trauma, infection, congenital
Medical
• Analgesia
§ Paracetamol
§ NSAIDs: e.g. arthrotec (diclofenac +
misoprostol)
§ Tramadol
• Joint injection: local anaesthetic and steroids
Surgical
• Arthroscopic Washout
§ Mainly knees
§ Trim cartilage
§ Remove loose bodies.
• Realignment Osteotomy
§ Small area of bone cut out
§ Useful in younger (<50yrs) pts. c̄ medial
knee OA
§ High tibial valgus osteotomy redistributes
wt. to lateral part of joint.
• Arthroplasty: replacement (or excision)
• Arthrodesis: last resort for pain management
• Novel Techniques
§ Microfracture: stem cell release → fibro-
cartilage formation
§ Autologous chondrocyte implantation

Back Pain
Mechanical Pain Spondylolisthesis
• Soft tissue injury → dysfunction of whole spine → muscle • Displacement of one lumbar vertebra on another
spasm → pain. § Usually forward
• May have inciting event: e.g. lifting § Usually L5 on S1
• Younger pts. c̄ no sinister features • May be palpable
Mx Causes
• Conservative • Congenital malformation
§ Max 2d bed rest • Spondylosis
§ Education: keep active, how to lift / stoop • Osteoarthritis
§ Physiotherapy
§ Psychosocial issues re. chronic pain and disability Presentation
§ Warmth: e.g. swimming in a warm pool • Onset of pain usually in adolescence or early
• Medical adulthood
§ Analgesia: paracetamol ± NSAIDs ± codeine § Worse on standing
§ Muscle relaxant: low-dose diazepam (short-term) • ± sciatica, hamstring tightness, abnormal gait
Disc Prolapse Dx: Plain radiography

• Herniation of nucleus pulposus through annulus fibrosus
Rx
Presentation • Corset
• L5 and S1 roots most commonly compressed by prolapse • Nerve release
of L4/5 and L5/S1 discs. • Spinal fusion
• May present as severe pain on sneezing, coughing or
twisting a few days after low back strain Spinal Stenosis
• Lumbago: low back pain
• Developmental predisposition ± facet joint
• Sciatica: shooting radicular pain down buttock and thigh osteoarthritis → generalized narrowing of lumbar
spinal canal.
Signs
• Limited spinal flexion and extension Presentation
• Free lateral flexion • Spinal claudication
• Pain on straight-leg raise: Lesague’s Sign § Aching or heavy buttock and lower limb pain
• Lateral herniation → radiculopathy on walking
• Central herniation → corda equina syndrome § Rapid onset
§ May c/o paraesthesiae/numbness
L4/5 → L5 Root Compression § Pain eased by leaning forward (e.g. on bike)
• Weak hallux extension ± foot drop • Pain on spine extension
§ In foot drop due to L5 radiculopathy, weak
inversion (tib. post.) helps distinguish from Ix: MRI
peroneal N. palsy.
• ↓ sensation on inner dorsum of foot Rx
• Corsets
L5/S1 → S1 Root Compression • NSAIDs
• Weak foot plantarflexion and eversion • Epidural steroid injection
• Loss of ankle-jerk • Canal decompression surgery
• Calf pain
• ↓ sensation over sole of foot and back of calf Neurosurgical Emergencies
Ix: MRI (emergency if cauda equina) Acute Cord Compression
• Bilateral pain: back and radicular
Rx • LMN signs at compression level
• Brief rest, analgesia and mobilisation effective in ≥90% • UMN signs and sensory level below compression
• Conservative: brief rest, mobilisation/physio • Sphincter disturbance
• Medical: analgesia, transforaminal steroid injection
• Surgical: discectomy or laminectomy may be needed in Acute Cauda Equina Compression
cauda-equina syndrome, continuing pain or muscle
• Alternating or bilateral radicular pain in the legs
weakness.
• Saddle anaesthesia
• Loss of anal tone
Lumbar Microdiscectomy
• Bladder ± bowel incontinence
• Commonest procedure for disc prolapse
• Microscopic resection of the protruding nucleus pulposus
Rx
• Posterior approach c̄ pt. in prone position.
• Large prolapse: laminectomy / discectomy
• May be performed endoscopically
• Tumours: radiotherapy and steroids
• Abscesses: decompression

Osteochondritis Traction Apophysitis
• Idiopathic condition in which bony centres of
children/adolescents become temporarily softened due Osgood-Shlatter’s
to osteonecrosis. • Tibial tuberosity apophysitis + patellar tendonitis
• Pressure → deformation • Children 10-14yrs, M>F=3:1
• Bone hardens in new, deformed position • Assoc. c̄ physical activity
• Symptoms: pain below knee, esp c̄ quads contraction
Radiography • X-ray: tuberosity enlargement ± fragmentation
• Initially: ↑ density / sclerosis • Rx: rest, consider POP
• Then: patchy appearance
Sinding-Larsen’s Disease
Scheuermann’s Disease • Traction tendinopathy with calcification of proximal
• Vertebral ring epiphyses attachment of patellar tendon
• Auto dom • Children 8-10yrs
• Vertebral tenderness and kyphosis
• X-ray: wedge-shaped thoracic vertebra Sever’s Disease
• Calcaneal apophysitis
Kohler’s Disease • 8-13yrs
• Navicular bone • Symptoms: pain behind heal + limping
• Children 3-5yrs • Rx: physio
• Pain in mid-tarsal region → limp
Kienbochs Disease
• Lunate bone Osteochondritis Dissecans
• Adults • Piece of bone and overlying cartilage dissects off into
• Pain over lunate, esp. on active movement joint space.
• Impaired grip • Commonly knee (med. fem. condyle), also elbow, hip
and ankle.
• Young adult / adolescent
Friedberg’s Disease • Symptoms: pain, swelling, locking, ↓ ROM
nd rd
• 2 /3 metatarsal heads • X-ray: loose bodies, lucent crater
• Around puberty • Mx: arthroscopic removal
• Forefoot pain worse c̄ pressure
Panner’s Disease
• Capitulum of humerus Avascular Necrosis
Perthes’ Disease Causes
• Hip • # or dislocation
• SCD, thalassaemia
• SLE
• Gaucher’s
• Drugs: steroids, NSAIDs

The Limping Child
Aetiology Perthes’ Disease
O
• DDH • Osteochondritis of the femoral head 2 to AVN.
• Transient synovitis
• Septic arthritis Epidemiology
• Perthes’ • 4-10yrs
• Slipped Capital Femoral Epiphyses • M>F=5:1
• JIA / Still’s Disease
Presentation
• Insidious onset
DDH • Hip pain initially, then painless
• Congenital hip joint deformity in which the femoral • 10-20% bilateral
head is or can be completely / partially displaced.
Ix
Epidemiology • X-rays normal initially
• Incidence: 1/1000 • ↑ density of femoral head
• Sex: F>M § Becomes fragmented and irregular
§ Flattening and sclerosis
• Bone scan is useful
Predisposing Factors
• FH
Mx
• Breach presentation
• Detected early and < half femoral head affected
• Oligohydramnios
§ Bed rest and traction
• More severe
Presentation § Maintain hip in abduction c̄ plaster
• Screening
§ Femoral or pelvic osteotomy
• Asymmetric skin folds
• Limp / abnormal gait
Ix
Slipped Capital Femoral Epiphysis
• Postero-inferior displacement of femoral head
• US is v. specific
epiphysis
• 10-15yrs
Mx: maintain abduction • Two main groups
• Double nappies § Fat and sexually underdeveloped
• Pavlik harness § Tall and thin
• Plaster hip spica
• Open reduction: derotation varus osteotomy Presentation
• Slip may be acute, chronic or acute-on-chronic
• Acute
Transient Synovitis: Irritable Hip § Groin pain
• Commonest cause of acute hip pain in children § Shortened, externally rotated leg
§ All movements painful
Presentation • 20% bilateral
• 2-12yrs
• Sudden onset hip pain / limp Ix
• Often following or with viral infection • Confirm Dx by x-ray
• Not systemically unwell
Mx
Ix • Acute: reduce and pin epiphysis
• PMN and ESR/CRP are normal • Chronic: in situ pinning
• -ve blood cultures § Epiphyseal reduction risks AVN
• May need joint aspiration and culture
Complications
Mx • Chondrolysis: breakdown of articular cartilage
• Rest and analgesia § ↑ risk c̄ surgery
• Settles over 2-3d

Acute Osteomyelitis Septic Arthritis
Pathophysiology Pathophysiology
• Source: local or haematogenous. • Source: local or haematogenous.
• Organisms • Organisms
§ Staph § Staph: 60%
§ Strep § Streps
§ E. coli § Gonococcus
§ Pseudomonas § Gm-ve bacilli
§ Salmonella (in SCD) • RFs
• RFs § Joint disease (e.g. RA)
§ Vascular disease § CRF
§ Trauma § Immunosuppression (e.g. DM)
§ SCD § Prosthetic joints
§ Immunosuppression (e.g. DM)
§ Children Symptoms
- Rich blood supply to growth plate
• Acutely inflamed tender, swollen joint.
- \ usually affects metaphysis
• ↓ROM
• Systemically unwell
Symptoms and Signs
• Pain, tenderness, erythema, warmth, ↓ROM Investigations
• Effusion in neighbouring joints
• Joint aspiration for MCS
• Signs of systemic infection 3
§ ↑↑ WCC (e.g. >50,000/mm ) : mostly PMN
• ↑ESR/CRP, ↑WCC, Blood cultures
Investigations • X-ray
• ↑ESR/CRP, ↑WCC
• +ve blood cultures in 60% Management
• X-ray: • IV Abx: vanc + cefotaxime
§ Changes take 10-14d
• Consider joint washout under GA
§ Haziness + ↓ bone density
• Splint joint
§ Sub-periosteal reaction
• Physiotherapy after infection resolved
§ Sequestrum and involucrum
• MRI is sensitive and specific
Complications
Management • Osteomyelitis
• Arthritis
• IV Abx: Vanc + cefotaxime until MCS known
• Ankylosis: fusion
• Drain abscess and remove sequestra
• Analgesia
Differential
• Crystal arthropathy
• Reactive arthritis

Bone Tumours
Bony Mets
• Commonest bone tumours
• Bronchus, thyroid, breast, kidney and prostate
• Usually radiolucent (except prostate which is sclerotic)
• Usually axial skeleton (contains red marrow)
• Present with pain or pathological #
§ Path # → internal fixation
§ Pain → radiotherapy
Tumour-like Non-neoplastic Conditions
Lesion Clinical Features Location X-ray

Fibrous Dysplasia 0-30 Long bones “Ground Glass” lytic lesion
F>M Ribs
↑ # risk Skull Shepherds crook deformity of
prox. femur
McCune Albright’s Usually mono-ostotic
- Polyostotic fibrous dysplasia
- Precocious puberty (females)
- Café-au-lait spots
Simple bone cyst <20 Prox metaphysis of Well-defined lytic lesion
Lump migrates down shaft from humerus or femur Cortex can fall into cyst →
original growth plate site. “fallen fragment”
Aneurysmal bone cyst <30yrs MRI shows multiple fluid levels
Pain
Fibrous cortical defect Children Dist femur
and non-ossifying Non-painful, benign Prox tibia
fibroma Spontaneously regress Often multiple
Benign Cartilaginous Neoplasms

Osteochondroma 10-20 Knee Cartilage-capped bony
(exostosis) M>F = 3:1 outgrowth
Commonest benign bone tumour
May be related to previous trauma
Enchondroma / 10-40 Hands O sign
Chondromas M=F Feet - Oval lucencies c̄
radiodense rim
Ollier Disease = multiple enchondromas
Endosteal scalloping
Maffucci Syn = Enchondromatosis + multiple soft-
tissue haemangiomas
Multiple enchondromas have risk of malignant

transformation
Chondroblastoma 10-20 Epiphysis Radiolucent with sclerotic
M>F = 2:1 Knee border
Malignant Cartilaginous Neoplasms

Chondrosarcoma >40 Pelvis Lytic lesion
Pain + lump Axial skeleton Fluffy “popcorn calcification”
Arise de novo or from chondromas
70% 5ys

Benign Bone-forming Neoplasms

Osteoma Lump Skull
Usually solitary Facial bones
Multiple in Gardner syn
Osteoid osteoma M>F = 2:1 Lower limb Lytic lesion c̄ central nidus and sclerotic rim
Teens and 20s Diaphyseal cortex
Severe nocturnal pain relieved
by aspirin
Hot on bone scan
Osteoblastoma Pain unresponsive to aspirin Spine
Giant Cell Tumour 20-40 Knee Soap bubble appearance
/ Osteoclastoma (After fusion of growth plate) Abut joint surface Solitary, expansile, lytic lesion
F>M
Malignant Bone-forming Neoplasms

Osteosarcoma Adolescents Knee Periosteal Elevation:
M>F = 2:1 Metaphysis - Sunburst appearance
O
Commonest 1 bone tumour - Codman’s triangle
Pain, warm, bruit
o
May arise 2 to Paget’s or irradiation
Ewing’s Sarcoma <20 Long bone diaphysis Lytic tumour
Painful, warm, enlarging mass Onion-skin periosteal
Systemic: fever, ↑ESR, anaemia, ↑WCC reaction

Brachial Plexus Injuries Other Nerve Injuries
Anatomy Radial Nerve (C5-T1)
• C5-T1
• Roots leave vertebral column between scalenus Low Lesions: posterior interosseous nerve
anterior and medius. • Site: # around elbow or forearm
• Divisions occur under the clavicle, medial to coracoid § E.g. # head of radius
process. • Loss of extension of CMC joints (finger drop)
• Plexus has intimate relationship c̄ subclavian and • No sensory loss
brachial arteries. Median N. is formed anterior to
brachial artery. High Lesions
• Site: # shaft of humerus where N. is in radial groove.
C5 • Wrist drop
Lat • Loss of sensation to dorsum of thumb root (snuff box)
MC
• Triceps functions normally
C6
Post Axillary Median Very High Lesions
C7
Radial • Site: axilla – e.g. crutches or Sat night palsy
C8 • Paralysis of triceps and wrist drop
Med Ulnar
T1 Ulnar Nerve (C8-T1)

Roots (5) Divisions (6)
Trunks (3) Cords (3)
Site
• Elbow: cubital tunnel
• Wrist: in Guyon’s Canal
Causes
• Direct: e.g. shoulder girdle #, penetrating or iatrogenic
injury Effects
• Indirect: e.g. avulsion or traction injuries • Intrinsic hand muscle paralysis → claw hand
• Ulnar paradox: lesion at elbow has less clawing as
th th
FDP is paralysed, decreasing flexion of 4 /5 digits.
Leffert Classification • Weakness of finger ad/abduction (interossei)
• Open
• Sensory loss over little finger
• Closed
§ Supraclavicular
§ Infraclavicular Tests
• Radiation-induced • Can’t cross fingers for luck
• Obstetric • Froment’s Sign: flexion of thumb IPJ when trying to
§ Upper hold onto paper held between thumb and finger.
§ Lower § Indicates weak adductor policis.
§ Mixed
High (C5/6): Erb’s Palsy Median Nerve (C5-T1)

• Abductors and external rotators paralysed
• Waiter’s tip position Injury Above the Antecubital Fossa
• Loss of sensation in C5/6 dermatomes • Can’t flex index finger IPJs (e.g. on clasping hands)
• Can’t flex terminal thumb phalanx (FPL)
Low (C8/T1): Klumpke’s Paralysis • Loss of sensation in median distribution
• Paralysis of small hand muscles
• Claw hand Injury at the Wrist
• Loss of sensation in C8/T1 dermatomes • Typically affects abductor pollicis brevis
Carpal Tunnel Syndrome

Carpal Tunnel Syndrome
Anatomy Ix
• Carpal tunnel formed by flexor retinaculum and carpal • Not usually performed
bones. • Nerve conduction studies
• Contains • US
§ 4 tendons of FDS
§ 4 tendons of FDP
Non-surgical Mx
§ 1 tendon of FPL
• Mx of underlying cause
§ Median N.
• Wrist splints
• Median N. supplies LLOAF (aBductor pollicis brevis)
§ Neutral position
• Palmer cutaneous branch travels superficial to flexor
§ Esp. @ night
retinaculum → spares sensation over thenar area.
• Local steroid injections
Surgical Mx
Causes • Carpal tunnel decompression by division of the flexor
• F>M retinaculum
• Primary / idiopathic
• Secondary Complications
• Water: pregnancy, hypothyroidism
• Scar formation: high risk for hypertrophic or keloid
• Radial #
• Scar tenderness: up to 40%
• Inflammation: RA, gout
• Nerve injury
• Soft tissue swelling: lipomas, acromegaly, amyloidosis § Palmar cutaneous branch of the median nerve
• Toxic: DM, EtOH § Motor branch to the thenar muscles
• Failure to relieve symptoms
Symptoms
• Tingling / pain in thumb, index and middle fingers Other Locations of Median Nerve Entrapment
• Pain worse @ night or after repetitive actions • Pronator syndrome
• Relieved by shaking / flicking Entrapment between two heads of
• Clumsiness pronator teres
• Anterior interroseous syndrome
§ Compression of the anterior interosseous
Signs branch by the deep head of pronator teres
• ↓ sensation over lateral 3½ fingers § Muscle weakness only
• ↓ 2-point touch discrimination § Pronator quadratus
§ Early sign of irreversible damage § FPL
• Wasting of thenar eminence § Radial half of FDP
§ Late sign of irreversible damage
• Phalen’s flexing and Tinel’s tapping

Minor Hand Conditions
Dupuytren’s Contracture Trigger Finger
• Progressive, painless fibrotic thickening of palmar • Tendon nodule which catches on proximal side of
fascia. tendon sheath → triggering on forced extension.
• → Fixed flexion deformity
The Patient • Usually ring and middle fingers
• M>F • Assoc. c̄ RA
• Middle age / elderly • Rx: steroid injection (high recurrence) or surgery
• Skin puckering and tethering
• Fixed flexion contracture of ring and little fingers
• Often bilateral and symmetrical Ganglion
• MCP and IP joint flexion
• Smooth, multilocular cystic swellings
• Mucoid degeneration of joint capsule or tendon sheath
Associations: BAD FIBERS • May be in communication c̄ joint capsules / tendons
• Bent penis: Peyronies (3%)
• AIDS
Presentation
• DM
• 90% located on dorsum of wrist.
• FH: AD
• Subdermal, fixed to deeper structures.
• Idiopathic: commonest § Limits planes of movement
• Booze: ALD • May cause pain or nerve pressure symptoms
• Epilepsy and epilepsy meds (phenytoin)
• Reidel’s thyroiditis and other fibromatoses
Management
§ Ledderhose disease
• 50% disappear spontaneously
- Fibrosis of plantar aponeurosis
• Aspiration ± steroid and hyaluronidase injection
- 5% c̄ dupuytren’s
• Surgical excision
§ Retroperitoneal fibrosis
• Smoking
Differential
• Lipoma
Management
• Fibroma
• Conservative: e.g. physio / exercises
• Sebaceous cyst
• Fasciectomy
§ e.g. when hand can’t be placed flat on the
table.
§ Z-shaped scars: prevent contracture
§ Can damage ulnar nerve
§ Usually recurs
Differential
• Skin contracture: old laceration or burn
• Tendon fibrosis, trigger finger
• Ulnar N. palsy

Minor Leg and Foot Conditions
Meralgia Paraesthetica Hallux Valgus
• Entrapment of lat. cutaneous nerve of thigh • Great toe deviates laterally @ MTP joint
§ Between ASIS and inguinal ligament • Pressure of MTP against shoe → bunion
nd
• Pain ± paraesthesia on the lateral thigh • ↑ wt. bearing @ 2 metatarsal head
• No motor deficit § → pain: “Transfer metatarsalgia”
• ↑ risk c̄ obesity: compression by belts, underwear § → hammer toe
§ Relieved by sitting down
• Can occasionally be damaged in lap hernia repair Aetiology
• Pointed shoes
• Wearing high heals
Chondromalacia Patellae
• Predominantly young women Mx
• Patellar aching after prolonged sitting or climbing • Conservative: bunion pads, plastic wedge between
stairs great and second toes.
• Pain on patellofemoral compression: Clarke’s test • Surgical: metatarsal osteotomy
• Ix: no abnormality on X-ray
• Rx: vastus medialis strengthening
Lesser Toe Deformities
Baker’s Cyst
• Popliteal swelling arising between the medial head of
gastrocnemius and semimembranosus muscle
• Herniation from joint synovium
O
• Usually 2 to OA
• Rupture: acute calf pain and swelling
§ DVT differential
Morton’s Metatarsalgia / Neuroma

• Pain from pressure on an interdigital neuroma
between the metatarsals.
• Pain radiates to medial side of one toe and lateral side
of another.
• Rx: neuroma excision

Ear, Nose and Throat
Contents
Audiometry ......................................................................................................................................................... 133
Otalgia................................................................................................................................................................ 133
Otitis Media ........................................................................................................................................................ 134
Cholesteatoma ................................................................................................................................................... 135
Tinnitus .............................................................................................................................................................. 135
Vertigo................................................................................................................................................................ 136
Adult Hearing Loss............................................................................................................................................. 137
Hearing Loss in Children.................................................................................................................................... 138
Miscellaneous Ear Conditions............................................................................................................................ 138
Allergic Rhinosinusitis ........................................................................................................................................ 139
Sinusitis.............................................................................................................................................................. 139
Nasal Polyps ...................................................................................................................................................... 140
Fractured Nose .................................................................................................................................................. 140
Epistaxis............................................................................................................................................................. 141
Tonsillitis ............................................................................................................................................................ 142
The Larynx ......................................................................................................................................................... 143
Paediatric Airway Issues .................................................................................................................................... 143
Facial Nerve Palsy ............................................................................................................................................. 144

Audiometry Otalgia
• Quantify loss and determine its nature.
Otitis Externa
Pure tone audiometry (PTA) Presentation

• Headphones deliver tones at different • Watery discharge
frequencies and strengths in a sound-proofed • Itch
room. • Pain and tragal tenderness
• Pt. indicates when sound appears and
disappears. Causes
• Mastoid vibrator → bone conduction threshold. • Moisture: e.g. swimming
• Threshold at different frequencies are plotted to • Trauma: e.g. fingernails
give an audiogram. • Absence of wax
• Hearing aid
Tympanometry Organisms
• Measures stiffness of ear drum • Mainly pseudomonas
- Evaluates middle ear function • Staph aureus
• Flat tympanogram: mid ear fluid or perforation
• Shifted tympanogram: +/- mid ear pressure Management
• Aural toilet c̄ drops
§ Betamethasone for non-infected eczematous OE
Evoked response audiometry § Betamethasone c̄ neomycin
• Auditory stimulus c̄ measurement of elicited § Hydrocortisone c̄ gentamicin
brain response by surface electrode. § Acidifying drops
• Used for neonatal screening (if otoacoustic
emission testing negative)
Malignant Otitis Externa
• Life-threatening infection which can → skull osteomyelitis
• 90% of pts. are diabetic (or other immune compromise)
• Presentation
§ Severe otalgia which is worse @ night
§ Copious otorrhoea
§ Granulation tissue in the canal
• Rx
§ Surgical debridement
§ Systemic Abx
Bullous Myringitis
• Painful haemorrhagic blisters on deep meatal skin and TM.
• Assoc. c̄ influenza infection
TMJ Dysfunction
Symptoms
• Earache (referred pain from auriculotemporal N.)
• Facial pain
• Joint clicking/popping
• Teeth-grinding (bruxism)
• Stress (assoc. c̄ depression)
Signs
• Joint tenderness exacerbated by lateral movements of an
open jaw.
Investigation
• MRI
Management
• NSAIDs
• Stabilising orthodontic occlusal prostheses

Otitis Media
Classification Chronic Suppurative OM
• Acute: acute phase
• Glue ear / OME: effusion after symptom regression Presentation
• Chronic: effusion > 3mo if bilat or > 6mo if unilat • Painless discharge and hearing loss
• Chronic suppurative OM: Ear discharge c̄ hearing
loss and evidence of central drum perforation. o/e
• TM perforation
Organisms
• Viral Rx
• Pneumococcus • Aural toilet
• Haemophilus • Abx / Steroid ear drops
• Moraxella
Complications
• Cholesteatoma
Acute OM
Presentation Mastoiditis
• Usually children post viral URTI • Middle-ear inflam → destruction of mastoid air cells and
• Rapid onset ear pain, tugging @ ear. abscess formation.
• Irritability, anorexia, vomiting
• Purulent discharge if drum perforates Presentation
• Fever
o/e • Mastoid tenderness
• Bulging, red TM • Protruding auricle
• Fever
Imaging: CT
Rx
• Paracetamol: 15mg/kg Rx
• Amoxicillin: may use delayed prescription • IV Abx
• Myringotomy ± mastoidectomy
Complications
• Intratemporal
§ OME
§ Perforation of TM
§ Mastoiditis
§ Facial N. palsy
• Intracranial
§ Meningitis / encephalitis
§ Brain abscess
§ Sub- / epi-dural abscess
• Systemic
§ Bacteraemia
§ Septic arthritis
§ IE
OME
Presentation
• Inattention at school
• Poor speech development
• Hearing impairment
o/e
• Retracted dull TM
• Fluid level
Ix
• Audiometry: flat tympanogram
Rx
• Usually resolves spontaneously,
• Consider grommets if persistent hearing loss
§ SE: infections and tympanosclerosis

Cholesteatoma Tinnitus
• Sensation of sound w/o external sound stimulation
Definition
• Locally destructive expansion of stratified Causes
squamous epithelium within the middle ear. • Specific
§ Meniere’s
Classification § Acoustic neuroma
• Congenital § Otosclerosis
•
O
Acquired: 2 to attic perforation in chronic § Noise-induced
suppurative OM § Head injury
§ Hearing loss: e.g. presbyacusis
• General
Presentation § ↑BP
• Foul smelling white discharge § ↓Hb
• Headache, pain • Drugs
• CN Involvement § Aspirin
§ Vertigo § Aminoglycosides
§ Deafness § Loop diuretics
§ Facial paralysis § EtOH
o/e Hx
• Appears pearly white c̄ surrounding inflammation • Character: constant, pulsatile
• Unilateral: acoustic neuroma
Complications • FH: otosclerosis
• Deafness (ossicle destruction) • Alleviating/exacerbating factors: worse @ night?
• Meningitis • Associations
• Cerebral abscess § Vertigo: Meniere’s, acoustic neuroma
§ Deafness: Meniere’s, acoustic neuroma
Mx • Cause: head injury, noise, drugs, FH
• Surgery
Examination
• Otoscopy
• Tuning fork tests
• Pulse and BP
Ix
• Audiometry and tympanogram
• MRI if unilateral to exclude acoustic neuroma
Mx
• Treat any underlying causes
• Psych support: tinnitus retraining therapy
• Hypnotics @ night may help

Vertigo
Definition Ménière’s Disease
• The illusion of movement
Pathology
• Dilatation of endolymph spaces of membranous
Causes labyrinth (endolymphatic oedema)
Peripheral / Vestibular Central Presentation

• Meniere’s • Acoustic neuroma • Attacks occur in clusters and last up to 12h.
• BPV • MS • Progressive SNHL
• Labyrinthitis • Vertebrobasilar • Vertigo and n/v
insufficiency / stroke • Tinnitus
Head injury • Aural fullness
• Inner ear syphilis
Ix
Drugs (central/ototoxic) • Audiometry shows low-freq SNHL which fluctuates
• Gentamicin
• Loop diuretics Rx
• Metronidazole • Medical
• Co-trimoxazole § Vertigo: cyclizine, betahistine
• Surgical
§ Gentamicin instillation via grommets
§ Saccus decompression
Hx
• Is it true vertigo or just light-headedness?
§ Which way are things moving?
• Timespan Vestibular Neuronitis / Viral Labyrinthitis
• Assoc. symptoms: n/v, hearing loss, tinnitus,
nystagmus Presentation
• Follows febrile illness (e.g. URTI)
• Sudden vomiting
• Severe vertigo exacerbated by head movement
Examination and Tests
• Hearing
• Cranial nerves Rx
• Cerebellum and gait • Cyclizine
• Romberg’s +ve = vestibular or proprioception • Improvement in days
• Hallpike manouvre
• Audiometry, calorimetry, LP, MRI
Benign Positional Vertigo: BPV
Pathology
• Displacement of otoliths in semicircular canals
• Common after head injury.
Presentation
• Sudden rotational vertigo for <30s
- Provoked by head turning
• Nystagmus
Causes
• Idiopathic
• Head injury
• Otosclerosis
• Post-viral
Dx
• Hallpike manoeuvre → upbeat-torsional nystagmus
Rx
• Self-limiting
• Epley manoeuvre
• Betahistine: histamine analogue

Adult Hearing Loss
Conductive Acoustic Neuroma / Vestibular Schwannoma
• Impaired conduction anywhere between auricle and
round window. Pathology
• Benign, slow-growing tumour of superior vestibular N.
External canal obstruction • Acts as SOL → Cerebellopontine angle syndrome
• Wax § 80% of CPA tumours
• Pus • Assoc. c̄ NF2
• Foreign body
Presentation
TM perforation • Slow onset, unilat SNHL, tinnitus ± vertigo
• Trauma • Headache (↑ICP)
• Infection • CN palsies: 5,7 and 8
• Cerebellar signs
Ossicle defects
• Otosclerosis Ix
• Infection • MRI of cerebellopontine angle
• Trauma § MRI all pts. c̄ unilateral tinnitus / deafness
• PTA
Inadequate eustachian tube ventilation of middle
ear Differential
• Meningioma
• Cerebellar astrocytoma
Sensorineural • Mets
• Defects of cochlea, cohlear N. or brain.
Rx
Drugs • Gamma knife
• Aminoglycosides • Surgery (risk of hearing loss)
• Vancomycin
Post-infective Otosclerosis
• Meningitis • AD condition characterised by fixation of stapes at the
• Measles oval window.
• Mumps • F>M=2:1
• Herpes
Presentation
Misc. • Begins in early adult life
• Meniere’s • Bilateral conductive deafness + tinnitus
• Trauma • HL improved in noisy places: Willis’ paracousis
• MS • Worsened by pregnancy/ menstruation/ menopause
• CPA lesion (e.g. acoustic neuroma)
• ↓B12 Ix
• PTA shows dip (Caharts notch) @ 2kHz
Rx
• Hearing aid or stapes implant
Presbyacussis
• Age-related hearing loss
Presentation
• >65yrs
• Bilateral
• Slow onset
• ± tinnitus
Ix: PTA
Rx: hearing aid

Hearing Loss in Children Miscellaneous Ear Conditions
Congenital Causes Congenital Anomalies
st nd st
• 1 and 2 branchial arches form auricle while 1
Conductive branchial groove forms external auditory canal.
• Anomalies of pinna, external auditory canal, TM or • Malfusion → accessory tags/auricles and preauricular
ossicles. pits, fistulae or sinuses.
• Congenital cholesteatoma • Sinuses may get infected, mimicking a sebaceous cyst.
• Pierre-Robin
Pinna Haematoma
SNHL • Blunt trauma → subperichondrial haematoma.
• Autosomal Dominant • Can → ischaemic necrosis of cartilage and subsequent
§ Waardenburgs: SNHL, heterochromia + fibrosis to “cauliflower ears”.
telecanthus • Mx: aspiration + firm packing to auricle contour.
• Autosomal recessive
§ Alport’s: SNHL + haematuria
§ Jewell-Lange-Nielson: SNHL + long QT
• X-linked
Exostoses
§ Alport’s • Smooth, symmetrical bony narrowing of external canals.
• Infections: CMV, rubella, HSV, toxo, GBS
• Ototoxic drugs Path
• Bony hypertrophy due to cold exposure
• e.g. from swimming / surfing
Perinatal
• Anoxia
Symptoms
• Asympto unless narrowing occludes → conductive
• Cerebral palsy
deafness.
• Kernicterus
• Infection: meningitis
Rx: conservative or surgical widening
Acquired Causes
Wax: Cerumen Auris
• OM/OME rd
• Secreted in outer 3 of canal to prevent maceration
• Infection: meningitis, measles
• Wax accumulation can → conductive deafness.
• Head injury
• Mx
§ Suction under direct vision c̄ microscope
§ Syringing after 1wk softening with olive oil
Universal Neonatal Hearing Tests
• Detection and Mx of hearing loss before 6mo
improves language.
• Tests TM Perforation
§ Otoacoustic emissions
§ Audiological brainstem responses. Causes
• OM
• Foreign body
• Barotrauma
• Trauma

Allergic Rhinosinusitis Sinusitis
Classification Pathophysiology
• Seasonal: hay-fever (prev = 2%) • Viruses → mucosal oedema and ↓ mucosal ciliary
O
• Perennial actions → mucus retention ± 2 bacterial infection
• Acute: Pneumococcus, Haemophilus, Moraxella
Pathology • Chronic: S. aureus, anaerobes
• T1HS IgE-mediated inflam from allergen exposure
→ mediator release from mast cells. Causes
O
• Allergens: pollen, house dust mites (perennial) • Majority are bacterial infection 2 to viral
O
• 5% 2 to dental root infections
Symptoms • Diving / swimming in infected water
• Sneezing • Anatomical susceptibility: deviated septum, polyps
• Pruritus • Systemic Disease
• Rhinorrhoea § PCD / Kartagener’s
§ Immunodeficiency
Signs
• Swollen, pale and boggy turbinates Symptoms
• Nasal polyps • Pain
§ Maxillary (cheek/teeth)
§ Ethmoidal (between eyes)
Ix § ↑ on bending / straining
• Skin-prick testing to find allergens • Discharge: from nose → post-nasal drip c̄ foul taste
- Don’t perform if prone to eczema • Nasal obstruction / congestion
• RAST tests
• Anosmia or cacosmia (bad smell w/o external source)
• Systemic symptoms: e.g. fever
Mx
Imaging
Allergen Avoidance • Nasendoscopy ± CT
• Regularly washing bedding (inc. toys) on high
heat or use acaricides.
• Avoid going outside when pollen count high. Mx
st
1 Line Acute / Single Episode
• Anti-histamines: cetirazine, desloratidine • Bed-rest, decongestants, analgesia
• Or, beclometasone nasal spray • Nasal douching and topical steroids
• Or, chromoglycate nasal spray (children) • Abx (e.g. clarithro) of uncertain benefit
2
nd
Line: intranasal steroids + anti-histamines Chronic / recurrent
• Usually a structural or drainage problem.
rd
3 Line: Zafirlukast • Stop smoking + fluticasone nasal spray
• Functional Endoscopic Sinus Surgery
rd - If failed medical therapy
4 Line: Immunotherapy
• Aim to induce desensitisation to allergen
• OD SL grass-pollen tablets → ↑ QOL in hay-fever Complications (rare)
• Injection immunotherapy • Mucoceles → pyoceles
• Orbital cellulits / abscess
Adjuvants • Osteomyelits – e.g. Staph in frontal bone
• Intracranial infection
• Nasal decongestants: Pseudoephedrine,
§ Meningitis, encephalitis
Otrivine
§ Abscess
§ Cavernous sinus thrombosis

Nasal Polyps Fractured Nose
The Patient Anatomy
rd
• Male, > 40yrs • Upper 3 of nose has bony support
• Lower 2/3 and septum are cartilaginous.
Sites
• Middle turbinates Hx
• Middle meatus • Time of injury
• Ethmoids • LOC
• CSF rhinorrhoea
Symptoms • Epistaxis
• Watery, anterior rhinorrhoea • Previous nose injury
• Purulent post-nasal drip • Obstruction
• Nasal obstruction • Consider facial #, check for
• Sinusitis § Teeth malocclusion
• Headaches § Diplopia (orbital floor #)
• Snoring
Ix
Signs • Cartilaginous injury won’t show and radiographs don’t
• Mobile, pale, insensitive alter Mx.
Associations Mx
• Allergic / non-allergic rhinitis • Exclude septal haematoma
• CF • Re-examine after 1wk (↓ swelling)
• Aspirin hypersensitivity • Reduction under GA c̄ post-op splinting best w/i 2wks
• Asthma
Septal haematoma
Single Unilateral Polyp • Septal necrosis + nasal collapse if untreated
• May be sign of rare but sinister pathology § Cartilage blood supply comes from mucosa
§ Nasopharyngeal Ca • Boggy swelling and nasal obstruction
§ Glioma • Needs evacuation under GA c̄ packing ± suturing.
§ Lymphoma
§ Neuroblastoma
§ Sarcoma
• Do CT and get histology
Nasal Polyps in Children

• Rare <10yrs old
• Must consider neoplasms and CF
Mx
• Drugs
§ Betamethasone drops for 2/7
§ Short course of oral steroids
• Endoscopic polypectomy

Epistaxis
Causes Posterior / Major Epistaxis
• 80% unknown • Posterior packing (+ anterior pack)
• Trauma: nose-picking / #s § Pass 18/18G Foley catheter through the nose
• Local infection: URTI into nasopharynx, inflate c̄ 10ml water and pull
• Pyogenic granuloma forward until it lodges.
§ Overgrowth of tissue on Little’s area due to § Admit pt. and leave pack for ~48hrs.
irritation or hormonal factors. • Gold standard is endoscopic visualisation and direct
• Osler-Weber-Rendu / HHT control: e.g. by cautery or ligation.
• Coagulopathy: Warfarin, NSAIDs, haemophilia, ↓plats,
vWD, ↑EtOH After the Bleed
• Neoplasm • Don’t pick nose
• Sit upright, out of the sun
Classification • Avoid bending, lifting or straining
• Anterior • Sneeze through mouth
• Posterior • No hot food or drink
• Avoid EtOH and tobacco
Initial Mx
• Wear PPE
• Assess for shock and manage accordingly
• If not shocked Osler-Weber-Rendu / HHT
§ Sit up, head tilted down • Autosomal dominant
§ Compress nasal cartilage for 15min. • 5 genetic subtypes
• If bleeding not controlled remove clots c̄ suction or by
blowing and try to visualise bleed by rhinoscopy Features
• Telangiectasias in mucosae
Anterior Epistaxis § Recurrent spontaneous epistaxis
• Usually septal haemorrhage: Little’s area / § GI bleed (usually painless)
Kisselbach’s plexus • Internal telangiectasias and AVMs
§ Ant. Ethmoidal A. § Lungs
§ Sphenopalatine A. § Liver
§ Facial A. § Brain
• Insert gauze soaked in vasoconstrictor + LA • Rarely
§ Xylometazoline + 2% lignocaine § Pulmonary HTN
§ 5min § Colon polyps: may → CRC
• Bleeds can be cauterised c̄ silver nitrate sticks
• Persistent bleeds should be packed with Mericel pack
§ Refer to ENT if this fails or if you can’t visualise
the bleeding point.
§ They may insert a posterior pack or take pt. to
theatre for endoscopic control.

Tonsillitis
Symptoms Strep Throat Complications
• Sore throat
• Fever, malaise Peritonsillar Abscess (Quinsy)
• Typically occurs in adults
Signs • Symptoms
• Lymphadenopathy: esp. jugulodigastric node § Trismus
• Inflamed tonsils and oropharynx § Odonophagia: unable to swallow saliva
• Exudates § Halitosis
• Signs
§ Tonsillitis
Organisms § Unilateral tonsillar enlargement
• Viruses are most common (consider EBV) § Contralateral uvula displacement
• Group A Strep: pyogenes § Cervical lymphadenopathy
• Staphs • Rx
• Moraxella § Admit
§ IV Abx
Mx § I&D under LA or tonsillectomy under GA
• Swabbing superficial bacteria is irrelevant and can
→ overdiagnosis.
• Analgesia: Ibuprofen / Paracetamol ± Difflam Retropharyngeal Abscess
gargle • Rare
• Consider Abx only if ill: use Centor Criteria • Presentation
§ Pen V 250mg PO QDS (125mg TDS in § Unwell child c̄ stiff, extended neck who refuses to
children) or erythromycin for 5/7 eat or drink
• NOT AMOXICILLIN → MACPAP RASH IN EBV § Fails to improve c̄ IV Abx
§ Unilateral swelling of tonsil and neck
Centor Criteria • Ix
• Guideline for admin of Abx in acute sore throat / § Lat. neck x-rays show soft tissue swelling
tonsillitis / pharyngitis § CT from skull-base to diaphragm.
• Rx
1 Point for each of § IV Abx
• Hx of fever § I&D
• Tonsillar exudates
• Tender anterior cervical adenopathy
• No cough Lemierre’s Syndrome
• IJV thrombophlebitis c̄ septic embolization most
Mx commonly affecting the lungs.
• 0-1: no Abx (risk of strep infection <10%) • Organism: Fusobacterium necrophorum
• 2: consider rapid Ag test + Rx if +ve • Rx
• ≥3: Abx § IV Abx: pen G, clinda, metro
Tonsillectomy Scarlet Fever

• “Sandpaper”-like rash on chest, axillae or behind ears
12-48h after pharyngotonsillitis.
Indications
• Circumoral pallor
• Recurrent tonsillitis if all the below criteria are met
• Strawberry tongue
§ Caused by tonsillitis
• Rx
§ 5+ episodes/yr
§ Start Pen V/G and notify HPA.
§ Symptoms for >1yr
§ Episodes are disabling and prevent normal
functioning
• Airway obstruction: e.g. OSA in children Rheumatic Fever
• Quinsy • Carditis
• Suspicion of Ca: unilateral enlargement or • Arthritis
ulceration • Subcutaneous nodules
• Erythema marginatum
Methods • Sydenham’s chorea
• Cold steel
• Cautery
Post-streptococcal Glomerulonephritis
Complications • Malaise and smoky urine 1-2wks after a pharyngitis
• Reactive haemorrhage
• Tonsillar gag may damage teeth, TMJ or posterior
pharyngeal wall.
• Mortality is 1/30,000

The Larynx Paediatric Airway Issues
Functions Laryngomalacia
• Phonation • Immature and floppy aryepiglottic folds and glottis →
• Positive thoracic pressure: inc. auto-PEEP laryngeal collapse on inspiration
• Respiration
• Prevention of aspiration Presentation
• Stridor: commonest cause in children
Laryngitis § Presents w/i first wks of life.
• Usually viral and self-limiting • Noticeable @ certain times
•
O
2 bacterial infection may develop § Lying on back,
• Symptoms: pain, hoarseness and fever § Feeding
• o/e: redness and swelling of the vocal cords § Excited/upset
• Rx: Supportive, Pen V if necessary • Problems can occur c̄ concurrent laryngeal infections or
c̄ feeding.
Laryngeal Papilloma
•
O
Pedunculated vocal cord swellings 2 to HPV Mx
• Present c̄ hoarseness • Usually no Rx required but severe cases may warrant
surgery.
• Usually occur in children
• Rx: laser removal
Recurrent Laryngeal N. Palsy Epiglottitis

• Supplies all intrinsic laryngeal muscles except for
cricothyroideus. Symptoms
§ Ext. branch of sup laryngeal N. • Sudden onset
• Responsible for ab- and ad-uction of vocal folds • Continuous stridor
• Drooling
Symptoms • Toxic
• Hoarseness
• “Breathy” voice c̄ bovine cough Pathogens: haemophilus, Group A Strep
• Repeated coughing from aspiration (↓ supraglottic
sensation) Rx
• Exertional dyspnoea (narrow glottis) • Don’t examine throat
• Consult c̄ anaesthetists and ENT surgeons
Causes • O2 + nebulised adrenaline
• 30% are cancers: larynx, thyroid, oesophagus, • IV dexamethasone
hypopharynx, bronchus • Cefotaxime
• 25% iatrogenic: para- / thyroidectomy, carotid • Take to theatre to secure airway by intubation
endarterectomy
• Other: aortic aneurysm, bulbar / pseudobulbar
palsy Foreign Body
• Sudden onset stridor in a previously normal child.
Laryngeal SCC • Back slaps and abdominal thrusts.
• Incidence: 2000/yr in uk • Needle cricothyrotomy in children
• Associations: smoking, EtOH • Can only exclude foreign body in bronchus by
bronchoscopy
Presentation
• Male smoker
• Progressive hoarseness → stridor Subglottic Stenosis
• Dys-/odono-phagia • Subglottis is narrowest part of respiratory tract in
• Wt. loss children.
• Symptoms: stridor, FTT
Ix • Causes
• Laryngoscopy + biopsy (inc. nodes) § Prolonged intubation
• MRI staging § Congenital abnormalities
• Rx
Mx § Mild: conservative
• Based on stage § Severe: Tracheostomy or partial tracheal
• Radiotherapy resection
• Laryngectomy
After total laryngectomy

• Pts have permanent tracheostomy
§ Speech valve
§ Electrolarynx
§ Oesophageal speech (swallowed air)
• Regular f/up for recurrence

Facial Nerve Palsy
Bell’s Palsy Other Causes of Facial Palsy
• Inflammatory oedema from entrapment of CNVII in
narrow facial canal May be suggested by
• Probably of viral origin (HSV1). • Bilateral symptoms (Lyme, GBS, leukaemia,
• 75% of facial palsy sarcoid)
• UMN signs: sparing of frontalis and orbicularis oculi
Features • Other CN palsies (but seen in 8% of Bell’s)
• Sudden onset: e.g. overnight • Limb weakness
• Complete, unilateral facial weakness in 24-72h • Rashes
§ Failure of eye closure (Bell’s Sign) →
dryness and conjunctivitis Intracranial Lesions
§ Drooling, speech difficulty • Vascular, MS, SOL
• Numbness or pain around ear § Motor cortex → UMN signs
• ↓ taste (ageusia) § Brainstem nuclei → LMN signs
• Hyperacusis: stapedius palsy • Cerebellopontine angle lesion
th th th
§ May be accompanied by 5 , 6 , and 8 CN
Ix palsies
• Serology: Borrelia or VZV Abs
• MRI: SOL, stroke, MS Intratemporal Lesions
• LP • Otitis media
• Cholesteatoma
Mx • Ramsay Hunt Syndrome
• Protect eye
§ Dark glasses Infratemporal
§ Artificial tears • Parotid tumours
§ Tape closed @ night • Trauma
• Give prednisolone w/i 72hrs
§ 60mg/d PO for 5/7 followed by tapering Systemic
• Valaciclovir if zoster suspected (otherwise antivirals • Peripheral neuropathy
don’t help). § Demyelinating: GBS
• Plastic surgery may help if no recovery § Axonal: DM, Lyme, HIV, Sarcoid
• Pseudopalsy: MG, botulism
Prognosis
• Incomplete paralysis usually recovers completely
w/i wks.
• With complete lesions, 80% get full recovery but
the remainder have delayed recovery or permanent
neurological / cosmetic abnormalities.
Complications: Aberrant Neural Connections

• Synkinesis: e.g. blinking causes up-turning of
mouth
• Crocodile tears: eating stimulates unilateral
lacrimation, not salivation
Ramsay Hunt Syndrome

• American neurologist James Ramsay Hunt in 1907
• Reactivation of VZV in geniculate ganglion of CNVII
Features
• Preceding ear pain or stiff neck
• Vesicular rash in auditory canal ± TM, pinna,
tongue, hard palate (no rash = zoster sine herpete)
• Ipsilateral facial weakness, ageusia, hyperacusis,
• May affect CN7 → vertigo, tinnitus, deafness
Mx
• If Dx suspected give valaciclovir and prednisolone
w/i first 72h
Prognosis
• Rxed w/i 72h: 75% recovery
• Otherwise: 1/3 full recovery, 1/3 partial, 1/3 poor

Ophthalmology
Contents
Pupils ................................................................................................................................................................. 146
Optic Atrophy / Optic Neuropathy ...................................................................................................................... 147
Red Eye: History, Examination and Differential ................................................................................................. 148
Visual History ..................................................................................................................................................... 148
Red Eyes: Specific Diseases ............................................................................................................................. 149
Sudden Loss of Vision ....................................................................................................................................... 151
Gradual Visual Loss ........................................................................................................................................... 152
The Eye in DM ................................................................................................................................................... 153
Cataracts............................................................................................................................................................ 154
The Retina ......................................................................................................................................................... 154
The External Eye ............................................................................................................................................... 155
Orbital Swellings ................................................................................................................................................ 155
Refractive Errors ................................................................................................................................................ 156
Strabismus / Squint / Tropia............................................................................................................................... 156
Eye Trauma ....................................................................................................................................................... 157
Floaters, Flashes and Haloes ............................................................................................................................ 157
Allergic Eye Disease .......................................................................................................................................... 158
Tropical Eye Disease ......................................................................................................................................... 158
Eye Signs in Systemic Conditions ..................................................................................................................... 159
Ophthalmic Pharmacology ................................................................................................................................. 159

Pupils
Afferent Defect Horner’s Syndrome
• Johann Horner (1831-1886), Swiss ophthalmologist
Features
• No direct response but intact consensual response Features: PEAS
• Cannot initiate consensual response in contralateral • Ptosis: partial (superior tarsal muscle)
eye. • Enophthalmos
• Dilatation on moving light from normal to abnormal eye • Anhydrosis
• Small pupil
Causes
• Total CN II lesion Causes
• Central
Relative Afferent Pupillary Defect § MS
§ Wallenberg’s Lateral Medullary Syndrome
• = Marcus-Gunn Pupil
• Pre-ganglionic (neck)
§ Pancoast’s tumour: T1 nerve root lesion
Features § Trauma: CVA insertion or CEA
• Minor constriction to direct light • Post-ganglionic
• Dilatation on moving light from normal to abnormal eye. § Cavernous sinus thrombosis
• RAPD = Marcus Gunn Pupil O
§ Usually 2 to spreading facial infection via the
ophthalmic veins
Causes § CN 3, 4, 5, 6 palsies
• Optic neuritis
• Optic atrophy
• Retinal disease Argyll Robertson Pupil
Efferent Defect Features
• Small, irregular pupils
Feature • Accommodate but doesn’t react to light
• Dilated pupil does not react to light • Atrophied and depigmented iris
• Initiates consensual response in contralateral pupil
• Ophthalmoplegia + ptosis Cause
• DM
Cause • Quaternary syphilis
rd
• 3 nerve palsy
§ The pupil is often spared in a vascular lesion
(e.g. DM) as pupillary fibres run in the periphery.
Differential of a fixed dilated pupil

• Mydriatics: e.g. tropicamide
• Iris trauma
• Acute glaucoma
• CN3 compression: tumour, coning
Holmes-Adie Pupil
Features
• Young woman c̄ sudden blurring of near vision
• Initially unilateral and then bilateral pupil dilatation
§ Dilated pupil has no response to light and
sluggish response to accommodation.
§ A “tonic” pupil
Ix
• Iris shows spontaneous wormy movements on slit-lamp
examination
§ Iris streaming
Cause
• Damage to postganglionic parasympathetic fibres
• Idiopathic: may have viral origin
Holmes-Adie Syndrome
• Tonic pupil + absent knee/ankle jerks + ↓ BP

Optic Atrophy / Optic Neuropathy
Features
• ↓ acuity
• ↓colour vision (esp. red)
• Central scotoma
• Pale optic disc
• RAPD
Causes: CAC VISION

• Commonest: MS and glaucoma
Congenital
• Leber’s hereditary optic neuropathy
§ Epi: mitochondrial, onset 20-30s
§ PC: attacks of acute visual loss, sequential in
each eye ± ataxia and cardiac defects
• HMSN / CMT
• Friedrich’s ataxia
• DIDMOAD
• Retinitis pigmentosa
Alcohol and Other Toxins

• Ethambutol
• Lead
• B12 deficiency
Compression
• Neoplasia: optic glioma, pituitary adenoma
• Glaucoma
• Paget’s
Vascular: DM, GCA or thromboembolic

Inflammatory: optic neuritis – MS, Devic’s, DM
Sarcoid / other granulomatous
Infection: herpes zoster, TB, syphilis
Oedema: papilloedema
Neoplastic infiltration: lymphoma, leukaemia

Red Eye: History, Examination and Differential
Visual History Differential
Site Mechanical Inflammation Infection

Vision
• Blurred
Lids Ectropion Blepharitis Preseptal cellulitis
Entropion Chalazion Orbital cellulitis
• Distorted
FB / Trichiasis
• Diplopia
Conjunctiva Sub conj haem Allergic conjunct Conjunctivitis
• Field defect / Scotoma
• Floaters, Flashes
Sclera Perforation Chemical burn
Episcleritis
Scleritis
Sensation Cornea Foreign body Keratitis
• Irritation Abrasion
• Pain Ant Chamber Acute glaucoma Iritis / uveitis Endophthalmitis
• Itching
• Photophobia
• FB
Presentation Summary
Appearance Acute Anterior Conjunctivitis
• Red: ?distribution
Glaucoma Uveitis
• Lump
• Puffy lids
Pain +++ ++ +/-
Photophobia ++ +
Discharge Acuity ↓ ↓ normal
• Watering Cornea hazy/cloudy normal normal
• Sticky Pupil large small normal
• Stringy IOP ↑↑ normal normal
Key Examination Questions

• Inspect from anterior to posterior
• Is acuity affected?
• Is the globe painful?
• Pupil size and reactivity?
• Cornea: intact, cloudy? Use fluorescein
Signs of Serious Disease

• Photophobia
• Poor vision
• Corneal fluorescein staining
• Abnormal pupil

Red Eyes: Specific Diseases
Acute Closed Angle Glaucoma Anterior Uveitis / Acute Iritis
• Blocked drainage of aqueous from anterior chamber
via the canal of Schlemm. Pathophysiology
• Pupil dilatation (e.g. @ night) worsens the blockage. • Uvea is pigmented part of eye and included: iris,
• Intraocular pressure rises from 15-20 → >60mmHg ciliary body and choroid.
• Iris + ciliary body = anterior uvea
Risk Factors • Iris inflammation involves ciliary body too.
• Hypermetropia
• Shallow ant. chamber Symptoms
• Female • Acute pain and photophobia
• FH • Blurred vision (aqueous precipitates)
• ↑age
• Drugs Examination
§ Anti-cholinergics • Small pupil initially, irregular later
§ Sympathomimetics • Circumcorneal injection
§ TCAs • Hypopyon: pus in anterior chamber
§ Anti-histamines • White (keratic) precipitates on back of cornea
• Talbots test: ↑pain on convergence
Symptoms
• Prodrome: rainbow haloes around lights at night-time. Associations (most have no systemic associations)
• Severe pain c̄ n/v
• Seronegative arthritis: AS, psoriatic, Reiter’s
• ↓ acuity and blurred vision • Still’s / JIA
• IBD
Examination • Sarcoidosis
• Cloudy cornea c̄ circumcorneal injection • Behcet’s
• Fixed, dilated, irregular pupil • Infections: TB, leprosy, syphilis, HSV, CMV, toxo
• ↑ IOP makes eye feel hard
Mx
Ix • Refer to ophthalmologist
• Tonometry: ↑↑ IOP (usually >40mmHg) • Prednisolone drops
• Cyclopentolate drops: dilates pupil and prevents
Acute Mx: Refer to Ophthalmologist adhesions between iris and lens (synechiae)
• Pilocarpine 2-4% drops stat: miosis opens blockage
• Topical β-B (e.g. timolol): ↓ aqueous formation
• Acetazolamide 500mg IV stat: ↓ aqueous formation
• Analgesia and antiemetics
Subsequent Mx
• Bilat YAG peripheral iridotomy once IOP ↓ medically

Episcleritis Corneal Abrasion
• Inflammation below conjunctiva in the episclera • Epithelial breech w/o keratitis
• Cause: trauma
Presentation
• Localised reddening: can be moved over sclera Symptoms
• Painless / mild discomfort • Pain
• Acuity preserved • Photophobia
• Blurred vision
Causes
• Usually idiopathic Ix
• May complicate RA or SLE • Slit lamp: fluorescein stains defect green
Rx: Topical or systemic NSAIDs Rx

• Chloramphenicol ointment for infection prophylaxis
Scleritis
• Vasculitis of the sclera Corneal Ulcer + Keratitis (corneal inflam)
Presentation Causes: bacteria, herpes, fungi, protozoa, RA

• Severe pain: worse on eye movement • Dendritic ulcer = Herpes simplex
• Generalised scleral inflammation • Acanthamoeba: protazoal infection affecting contact
§ Vessels won’t move over sclera lens wearers swimming in pools.
• Conjunctival oedema (chemosis)
Presentation
• Pain, photophobia
Causes • Conjunctival hyperaemia
• Wegener’s • ↓ acuity
• RA • White corneal opacity
• SLE
• Vasculitis Risk factors: contact lens wearers
Mx Ix: green c̄ fluorescein on slit lamp

• Refer to specialist
• most need or corticosteroids or immunosuppressants Rx: refer immediately to specialist who will
• Take smears and cultures
Complications: • Abx drops, oral/topical aciclovir
• Scleromalacia (thinning) → globe perforation • Cycloplegics/mydriatics ease photophobia
• Steroids may worsen symptoms: professionals only
Conjunctivitis Complications
• Scarring and visual loss
Presentation
• Often bilateral c̄ purulent discharge
§ Bacterial: sticky (staph, strep, Haemophilus) Ophthalmic Shingles
§ Viral: watery • Zoster of CNV1
• Discomfort • 20% of all Shingles (only commoner in thoracic
• Conjunctival injection dermatomes)
§ Vessels may be moved over the sclera
• Acuity, pupil responses and cornea are unaffected. Presentation
• Pain in CNV1 dermatome precedes blistering rash
Causes • 40% → keratitis, iritis
• Viral: adenovirus • Hutchinson’s sign
• Bacterial: staphs, chlamydia, gonococcus § Nose-tip zoster due to involvement of
• Allergic nasociliary branch.
§ ↑ chance of globe involvement as nasociliarry
Rx nerve also supplies globe
• Bacterial: chloramphenicol 0.5% ointment • Ophthalmic involvement
• Allergic: anti-histamine drops: e.g. emedastine § Keratitis + corneal ulceration (fluorescein
stains)
§ ± iritis

Sudden Loss of Vision
Key Questions Central Retinal Artery Occlusion
• Headache associated: GCA
• Eye movements hurt: optic neuritis Presentation
• Lights / flashes preceding visual loss: detached retina • Dramatic unilateral visual loss in seconds
• Like curtain descending: TIA, GCA • Afferent pupil defect (may precede retinal changes)
• Poorly controlled DM: vitreous bleed from new vessels • Pale retina c̄ cherry-red macula
Causes
Anterior Ischaemic Optic Neuropathy (AION) • GCA
• Optic nerve damaged if posterior ciliary arteries • Thromboembolism: clot, infective, tumour
blocked by inflammation or atheroma.
• Pale / swollen optic disc Rx
• If seen w/i 6h aim is to ↑ retinal blood flow by ↓ IOP
Causes § Ocular massage
• Arteritic AION: Giant Cell Arteritis § Surgical removal of aqueous
• Non-arteritic AION: HTN, DM, ↑ lipids, smoking § Anti-hypertensives (local and systemic)
Optic Neuritis Retinal Vein Occlusion
Symptoms Central
• Unilateral loss of acuity over hrs – days • Commoner than arterial occlusion
• ↓ colour discrimination (dyschromatopsia) • Causes: arteriosclerosis, ↑BP, DM, polycythaemia
• Eye movements may hurt • Pres: sudden unilat visual loss c̄ RAPD
• Fundus: Stormy Sunset Appearance
Signs § Tortuous dilated vessels
• ↓ acuity § Haemorrhages
• ↓ colour vision § Cotton wool spots
• Enlarged blind-spot • Complications
• Optic disc may be: normal, swollen, blurred § Glaucoma
• Afferent defect § Neovascularisation
• Prognosis: possible improvement for 6mo-1yr
Causes
• Multiple sclerosis (45-80% over 15yrs) Branch
• DM • Presentation: unilateral visual loss
• Drugs: ethambutol, chloramphenicol • Fundus: segmental fundal changes
• Vitamin deficiency • Comps: retinal ischaemia → VEGF release and
• Infection: zoster, Lyme disease neovascularisation (Rx: laser photocoagulation)
Rx
• High-dose methyl-pred IV for 72h Retinal Detachment
• Then oral pred for 11/7 • Holes/tears in retina allow fluid to separate sensory
retina from retinal pigmented epithelium
O
• May be 2 to cataract surgery, trauma, DM
Vitreous Haemorrhage
Presentation: 4 F’s
Source • Floaters: numerous, acute onset, “spiders-web”
• New vessels: DM • Flashes
• Retinal tears / detachment / trauma • Field loss
• Fall in acuity
• Painless
Presentation
• Small bleeds → small black dots / ring floaters
• Large bleed can obscure vision → no red reflex, retina Fundus: grey, opalescent retina, ballooning forwards
can’t be visualised
Rx
Ix • Urgent surgery
• May use B scan US to identify cause • Vitrectomy + gas tamponade c̄ laser coagulation to
secure the retina.
Mx
• VH undergoes spontaneous absorption Causes of transient visual loss
• Vitrectomy may be performed in dense VH • Vascular: TIA, migraine
• MS
• Subacute glaucoma
• Papilloedema

Gradual Visual Loss
Causes Chronic Simple (Open-Angle) Glaucoma
Common Pathogenesis
• Diabetic retinopathy • Depends on susceptibility of pt’s. retina and optic
• ARMD nerve to ↑ IOP damage.
• Cataracts • IOP >21mmHg → ↓blood flow and damage to optic
• Open-angle Glaucoma nerve → optic disc atrophy (pale) + cupping
Rarer Presentation
• Genetic retinal disease: retinitis pigmentosa • Peripheral visual field defect: superior nasal first
• Hypertension • Central field is intact \ acuity maintained until late
• Optic atrophy § Presentation delayed until optic N. damage is
irreversible
Screen if High Risk

Age-Related Macular Degeneration (ARMD) • >35yrs
• Commonest cause of blindness >60yrs
• Afro-Caribbean
• 30% of >75yrs will have dry AMD
• FH
• Drugs: steroids
Risk Factors • Co-morbidities: DM, HTN, migraines
• Smoking • Myopia
• ↑ age
• Genetic factors Ix
• Tonometry: IOP ≥21mmHg
Presentation • Fundoscopy: cupping of optic disc
• Elderly pts. • Visual field assessment: peripheral loss
• Central visual loss
Mx
Dry ARMD: Geographic Atrophy • Life-long f/up
• Drusen: fluffy white spots around macula
• Degeneration of macula Eye-drops to ↓ IOP to baseline
• Slow visual decline over 1-2yrs st
• 1 line: β-blockers
§ Timolol, betaxolol
Wet ARMD: Subretinal Neovascularisation § ↓ aqueous production
• Aberrant vessels grow into retina from choroid and → § Caution in asthma, heart failure
haemorrhage • Prostaglandin analogues
• Rapid visual decline (sudden / days / wks) c̄ distortion § Latanoprost, travoprost
• Fundoscopy shows macular haemorrhage → scarring § ↑ uveoscleral outflow
• Amsler grid detects distortion • α-agonists
§ Brimonidine, apraclonidine
Ix § ↓ aqueous production and ↑ uveoscleral
• OCT: optical coherence tomography outflow
§ Gives high resolution images of the retina • Carbonic anhydrase inhibitors
§ Dorzolamide drops, acetazolamide PO
Mx for Wet AMRD • Miotics
• Photodynamic therapy § Pilocarpine
• Intravitreal VEGF inhibitors
§ Bevacizumab (Avastin) Non-medical Options
§ Ranibizumab (Lucentis) • Laser trabeculoplasty
• Antioxidant vitamins (C,E) + zinc may help early • Surgery (trabeculectomy) is used if drugs fail
ARMD § New channel allows aqueous to flow into
conjunctival bleb
Tobacco-Alcohol Amblyopia
• Due to toxic effects of cyanide radicals when
combined with thiamine deficiency. Commonest Causes of Blindness Worldwide
• Pres: Optic atrophy, loss of red/green discrimination, • Trachoma
scotomata • Cataracts
• Rx: vitamins may help • Glaucoma
• Keratomalacia: vitamin A deficiency
• Onchocerciasis
• Diabetic Retinopathy

The Eye in DM
The Problem Fundoscopy Findings
• DM is leading cause of blindness up to 60yrs
• 30% have ocular problems @ presentation Background Retinopathy: Leakage
• BP < 130/80 and normoglycaemia → ↓ diabetic • Dots: microaneurysms
retinopathy • Blot haemorrhages
• Hard exudates: yellow lipid patches
Pathogenesis
Pre-proliferative Retinopathy: Ischaemia
Cataract • Cotton-wool spots (infarcts)
• DM accelerates cataract formation • Venous beading
• Lens absorbs glucose which is converted to sorbitol by • Dark Haemorrhages
aldose reductase. • Intra-retinal microvascular abnormalities
Retinopathy Proliferative Retinopathy

• Microangiopathy → occlusion • New vessels
• Occlusion → ischaemia → new vessel formation in • Pre-retinal or vitreous haemorrhage
retina • Retinal detachment
§ Bleed → vitreous haemorrhage
§ Carry fibrous tissue c̄ them → retinal Maculopathy
detachment • Caused by macular oedema
• Occlusion also → cotton wool spots (ischaemia) • ↓ acuity may be only sign
• Vascular leakage → oedema and lipid exudates • Hard exudates w/i one disc width of macula
• Rupture of microaneurysms → blot haemorrhage
Screening
• All diabetics should be screened annually
• Fundus photography
• Refer those c̄ maculopathy, NPDR and PDR to
ophthalmologist
§ 30% NPDR develop PDR in 1yr
Ix
• Fluorescein angiography
Mx
• Good BP and glycaemic control
• Rx concurrent disease: HTN, dyslipidaemia, renal
disease, smoking, anaemia
• Laser photocoagulation
§ Maculopathy: focal or grid
§ Proliferative disease: pan-retinal (macula
spared)
CN Palsies
• CNIII and VI palsies may occur
• In diabetic CNIII palsy the pupil may be spared as its
nerve fibres run peripherally and receive blood from pial
vessels.

Cataracts The Retina
• Outer pigmented layer in contact c̄ the choroid
Presentation • Inner sensory layer in contact c̄ vitreous
• Increasing myopia • At centre is fovea
• Blurred vision → gradual visual loss
• Dazzling in sunshine / bright lights Optic Disc
• Monocular diplopia
Colour
Causes • Should be pale pink
• ↑Age: 75% of >65s • Paler in optic atrophy
• DM
• Steroids Contour
• Congenital • Margins blurred in papilloedema and optic neuritis
§ Idiopathic
§ Infection: rubella
Cup
§ Metabolic: Wilson’s, galactosaemia
• Physiological cup lies centrally and should occupy 1/3
§ Myotonic dystrophy
of disc diameter
• Cup widening and deepening in glaucoma
Ix
• Visual acuity
• Dilated Fundoscopy
• Tonometry
Retinitis Pigmentosa
• Blood glucose to exclude DM • Most prevalent inherited degeneration of the macula
• Various modes of inheritance
§ Mostly AR
Mx § AD has best prognosis
§ X-linked has worst prognosis
Conservative • Affects ~ 1/2000
• Glasses
• Mydriatic drops and sunglasses may give some relief Presentation
• Night blindness
Surgery • ↓↓ visual fields → tunnel vision
• Consider if symptoms affect lifestyle or driving (<6/10) • Most are registrable blind (<3/60) by mid 30s
• Day-case surgery under LA
§ Phacoemulsion + lens implant Fundoscopy
• 1% risk of serious complications • Pale optic disc: optic atrophy
§ Anterior uveitis / iritis • Peripheral retina pigmentation: spares the macula
§ VH
§ Retinal detachment
§ Secondary glaucoma
Associations
§ Endophthalmitis (→ blindness in 0.1%) • Friedrich’s ataxia
• Post-op capsule thickening is common • Refsum’s disease
§ Easily Rx c̄ laser capsulotomy. • Kearns-Sayre Syndrome
• Post-op eye irritation is common and requires drops • Usher’s Syndrome
Retinoblastoma
• Commonest intraocular tumour in children
• 1:15,000 LBs
Inheritance
• Hereditary type differs from non-hereditary type
• AD mutation of RB gene (a TSG)
• Pts. typically have one mutant allele in every retinal
cell; if the other allele mutates → retinoblastoma.
Associations
• 5% occur c̄ pineal or other tumour
• ↑ risk of osteosarcoma and rhabdomyosarcoma
Signs
• Stabismus
• Leukocoria (white pupil) → no red reflex
Rx
• Depends on size
• Options include: chemo, radio, enucleation

The External Eye Orbital Swellings
Inflammatory Lid Swellings Orbital Cellulitis
Stye or hordeolum externum Pathophysiology

• An abscess / infection in a lash follicle which points • Infection spreads locally: e.g. from paranasal sinuses,
outwards. eyelid or external eye.
• Rx: local Abx – e.g. fusidic acid • Staphs, pneumococcus, GAS
Chalazion or hordeolum internum Presentation

• Abscess of the Meibomian glands which points • Usually a child c̄ inflammation of the orbit + lid
inwards onto conjunctiva. swelling
§ Sebaceous glands of eyelid • Pain and ↓ range of eye movement
• Exophthalmos
Blepharitis • Systemic signs: e.g. fever
• Chronic inflammation of eyelid • ± tenderness over the sinuses
• Causes: seborrhoeic dermatitis, staphs
• Features Rx
§ Red eyes • IV Abx: Cefuroxime (20mg/kg/8h IV)
§ Gritty / itchy sensation
§ Scales on lashes. Complications
§ Often assoc. c̄ rosacea • Local extension → meningitis and cavernous sinus
• Rx thrombosis.
§ Clean crusts of lashes c̄ warm soaks • Blindness due to optic N. pressure.
§ May need fusidic acid drops
Entropion Carotid-cavernous fistula

• Lid inversion → corneal irritation • May follow carotid aneurysm rupture c̄ reflux of blood
• Degeneration of lower lid fascia into cavernous sinus.
• Causes: spontaneous, trauma
Ectropion • Presentation
• Low lid eversion → watering and exposure keratitis § Engorgement of eye vessels
• Assoc. c̄ ageing and facial N. palsy § Lid and conjunctival oedema,
§ Pulsatile exophthalmos
§ Eye bruit
Ptosis • Rx: endovascular treatment
• True ptosis is intrinsic LPS weakness
• Bilateral
§ Congenital Exophthalmos / Proptosis
§ Senile
• Protrusion of one or both eyes
§ MG
§ Myotonic dystrophy
• Unilateral Common Causes
rd
§ 3 Nerve palsy • Graves’ Disease
§ Horner’s syndrome (partial) § 25-50%
§ Mechanical: xanthelasma, trauma § ↑ risk in smoker’s
§ Anti-TSH Abs → retro-orbital inflammation and
lymphocyte infiltration → swelling
• Orbital cellulitis
Lagophthalmos • Trauma
• Difficulty in lid closure over the globe which may →
exposure keratitis
Other Causes
• Causes: exophthalmos, facial palsy, injury
• Idiopathic orbital inflammatory disease
• Rx
• Vasculitis: Wegener’s
§ Lubricate eyes c̄ liquid paraffin ointment
• Neoplasm
§ Temporary tarsorrhaphy may be needed if
§ Lymphoma
corneal ulcers develop.
§ Optic glioma: assoc. c̄ NF-1
§ Capillary haemangioma
Pinguecula § Mets
• Yellow vascular nodules either side of the cornea • Carotid-cavernous fistula
Pterygium
• Similar to pinguecula but grows over the cornea → ↓
vision.
• Benign growth of conjunctiva
• Assoc. c̄ dusty, wind-blown life-styles, sun exposure

Refractive Errors Strabismus / Squint / Tropia
Refractive errors arise from disorders of the size and shape Esotropia = convergent squint
of the eye. • Commonest type in children
• May be idiopathic or due to hypermetropia
Myopia: Short-sightedness Exotropia = divergent squint

• Older children
The Problem • Often intermittent
• The eye is too long
• Distant objects are focussed too far forward.
Non-Paralytic Squint
Causes
• Genetic Diagnosis
• Excessive close work in the early decades • Corneal reflection: should fall centrally and
symmetrically on each cornea.
The Solution • Cover test: movement of uncovered eye to take up
• Concave lenses fixation demonstrates manifest squint.
Management: 3 O’s
Astigmatism • Optical: correct refractive errors
• Orthoptic: patching good eye encourages use of
The Problem squinting eye.
• Cornea or lens doesn’t have same degree of • Operations: e.g. resection and recession of rectus
curvature in horizontal and vertical planes. muscles – help alignment and cosmesis.
• Image of object is distorted longitudinally or vertically
The Solution Paralytic Squint

• Correcting lenses • Diplopia is most on looking in direction of pull of
paralysed muscle.
• Eye won’t fixate on covering.
• Cover each eye in turn: which ever eye sees the outer
Hypermetropia: long-sightedness image is malfunctioning
The Problem CNIII

• Eye is too short
• Ptosis (LPS)
• When eye is relaxed and not accommodating, objects
• Fixed dilated pupil (no parasympathetic)
are focussed behind the retina.
• Eye looking down and out
• Contraction of ciliary muscles to focus image →
• Causes
tiredness of gaze and possibly a convergent squint in
§ Medical: DM, MS, infarction
children.
§ Surgical: ↑ ICP, cavernous sinus thrombosis,
posterior communicating artery aneurysm
The Solution
• Convex lenses CNIV
• Diplopia especially on going down stairs
• Head tilt
Presbyopia • Test: can’t depress in adduction
• With age, lens becomes stiff and less easy to deform. • Causes
• Start at about 40yrs and is complete by 60yrs. § Peripheral: DM (30%), trauma (30%),
• Use convex lenses. compression
§ Central: MS, vascular, SOL
CNVI
• Eye is medially deviated and cannot abduct
• Diplopia in the horizontal plane.
• Causes
§ Peripheral: DM, compression, trauma
§ Central: MS, vascular, SOL
• Rx: botulinum toxin can eliminate need for surgery

Eye Trauma Floaters, Flashes and Haloes
• Record acuity of both eyes
• Take detailed Hx of event Floaters
• If unable to open injured eye, instil LA (e.g. tetracaine • Small dark spots in the visual field
1%) • Sudden showers of floaters in one eye may be due to
blood or retinal detachment
Foreign Bodies Causes

• X-ray orbit if metal FB suspected • Retinal detachment
• Fluorescein may show corneal abrasions • VH
• Diabetic retinopathy / Hypertension
Mx • Old retinal branch vein occlusion
• Chloramphenicol drops 0.5% prevent infection • Syneresis (degenerative opacities in the vitreous)
§ Usually coagulase-negative Staphylococcus
• Eye patch
• Cycloplegic drops may ↓ pain Flashes (Photopsia)
§ Tropicamide, cyclopentolate • Either from intraocular or intracerebral pathology
• Headache, n/v: migraine
• Flashes and floater: retinal detachment
Intra-ocular Haemorrhage
• Blood in anterior chamber = hyphaema
• Small amounts clear spontaneously, but some may Haloes
need evacuation. • Usually just diffractive phenomena
• Complicated by corneal staining and glaucoma (pain) • May be caused by hazy ocular media – cataract,
• Keep IOP↓ and monitor corneal oedema, acute glaucoma
• Haloes + eye pain = acute glaucoma
• Jagged haloes which change shape are usually
Orbital Blowout Fracture migrainous.
• Blunt injury → sudden ↑ in orbital pressure c̄
herniation of orbital contents into maxillary sinus.
Presentation
• Ophthalmoplegia + Diplopia
§ Tethering of inferior rectus and inferior oblique
• Loss of sensation to lower lid skin
§ Infraorbital nerve injury
• Ipsilateral epistaxis
§ Damage to anterior ethmoidal artery
• ↓ acuity
• Irregular pupil that reacts slowly to light
Mx
• Fracture reduction and muscle release necessary.
Chemical Injury
• Alkaline solutions are particularly damaging
• Mx
§ Copious irrigation
§ Specialist referral

Allergic Eye Disease Tropical Eye Disease
Seasonal Allergic Conjunctivitis (SAC) Trachoma
• 50% of allergic eye disease
• Small papillae on tarsal conjunctivae Pathophysiology
• Rx • Caused by Chlamydia trachomatis (A,B,C)
§ Antazoline: antihistamine drops: • Spread by flies
§ Cromoglycate: inhibits mast cell degranulation • Inflammatory reaction under lids → scarring → lid
distortion → entropion → eyelashes scratch cornea →
Perennial Allergic Conjunctivitis (PAC) ulceration → blindness
• Symptoms all year c̄ seasonal exacerbations
• Small papillae on tarsal conjunctivae Rx
• Rx: olopatadine (antihistamine and mast-cell • Tetracycline 1% ointment ± PO
stabiliser)
Prevention
Giant Papillary Conjunctivitis • Good sanitation
• Iatrogenic FBs: contact lenses, prostheses, sutures • Face washing
• Giant papillae on tarsal conjunctivae
• Rx: removal of FB, mast cell stabilisers Onchocerciasis (River Blindness)
Pathophysiology
Management of Allergic Eye Disorders • Caused by microfilariae of nematode Onchocerca
volvulus
1. Remove the allergen responsible where possible • Spread by flies
• Fly bites → microfilariae infection → invade the eye →
2. General measures inflammation → fibrosis → corneal opacities and
§ Cold compress synechiae
§ Artificial tears
3. Oral antihistamines: loratadine 10mg/d PO Rx
• Ivermectin
4. Eye drops
§ Antihistamines: antazoline, azelastine
§ Mast cell stabilizers: cromoglycate, Xerophthalmia and Keratomalacia
lodoxamide
• Manifestations of vitamin A deficiency
§ Steroids: dexamethasone
- Beware of inducing glaucoma
§ NSAIDs: diclofenac Presentation
• Night blindness and dry conjunctivae (xerosis)
• Corneal ulceration and perforation
Rx
• Vitamin A / palmitate reverses early corneal changes

Eye Signs in Systemic Conditions Ophthalmic Pharmacology
Hypertensive Retinopathy Mydriatics
• Keith-Wagener Classification
• Tortuosity and silver wiring Anti-Muscarinics
• AV nipping • Tropicamide
• Flame haemorrhages and soft / cotton wool spots § Duration: 3h
• Papilloedema • Cyclopentolate
• Grades 3 and 4 = malignant hypertension § Duration: 24h
§ Preferred for paediatric use
Granulomatous Disorders • Pupil dilatation + loss of light reflex
• TB, sarcoid, toxo, leprosy, brucella • Cycloplegia (ciliary paralysis) → blurred vision
• Uveitis (ant/post) and choroidoretinitis
Sympathomimetics
• Para-hydroxyamphetamine, phenylephrine
Systemic Inflammatory Disease
• May be used c̄ tropicamide
• Conjunctivitis: SLE, reactive arthritis, IBD
• Scleritis / episcleritis: RA, vasculitis, SLE, IBD • Don’t affect the light reflex or accommodation
• Iritis : ank spond, IBD, sarcoid
• Retinopathy: dermatomyositis Indications
• Eye examination
• Prevention of synechiae in ant. uveitis / iritis
Keratoconjunctivitis Sicca / Sjogren’s
• ↓ tear production (Schirmer’s: <5mm in 5min)
• Dry eyes and dry mouth
Caution
•
O O
1 or 2 : SLE, RA, sarcoid • May → acute glaucoma if shallow anterior chamber
• Rx: artificial tears or saliva
Vascular Occlusion Miotics

• Emboli → amaurosis fugax: GCA, carotid
atheroemboli Effect
• Microemboli → Roth spots: infective endocarditis • Constrict the pupil
§ Boat-shaped haemorrhage c̄ pale centre
Pilocarpine
Metabolic • Muscarinic agonist
• Kayser-Fleischer Rings: Wilson’s
• Exophthalmos: Graves’ Use
• Corneal calcification: HPT • Acute closed-angle glaucoma
HIV/AIDS
• CMV retinitis: pizza-pie fundus + flames Other
• HIV retinopathy: cotton wool spots
Tetracaine
• Anaesthetic used to permit examination of a painful
eye
Lubricants
• Hypomellose
• Carbomer (viscotears)
Topical Anti-histamine
• Emedastine
• Antazoline
Chronic Open-Angle Glaucoma

st
• 1 line: β-blockers
§ Timolol, betaxolol
§ ↓ aqueous production
§ Caution in asthma, heart failure
• Prostaglandin Analogues
§ Latanoprost, travoprost
§ ↑ uveoscleral outflow
• α-agonists
§ Brimonidine, apraclonidine
§ ↓ aqueous production and ↑ uveoscleral
outflow
• Carbonic anhydrase inhibitors
§ Dorzolamide drops, acetazolamide PO
• Miotics: Pilocarpine

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Surgery 2012 v2

© Alasdair Scott, 2018

Bloods ASA Grades

Pre-medication: 7As Pre-Op

Regional Anaesthesia 1. Non-opioid ± adjuvants

Loss of muscle power

Intra-op: ↓ physical stress

Post-op: early return to function and

Cholecystectomy Arterial Surgery

Early: 0-5d post-op Cause

Cause: β-haemolytic Streps + staph. aureus

Graduated Compression Stockings

Common Causes: DELIRIUM

3rd Space Losses → ↓ ECF

Hartmann’s / Ringer’s Lactate

REPEAT 1O SURVEY AGAIN!

Clearing the C-Spine

Indications for Laparatomy Bladder (often assoc. c̄ pelvic injury)

NB. may also use Lund and Browder charts

Neurological / Motility Disorders Pharyngeal Pouch: Zenker’s Diverticulum

• Extra-Mural oesophagus → web formation

Extra-oesophageal Nissen Fundoplication

Oesophageal Varices Variceal bleeding:

Causes of portal HTN

Test and Treat

Laparoscopic Gastric Banding

Roux-en-Y Gastric Bypass

Symptoms Pancreatic Rest

Late (>1wk): Local Presentation

Glucagonoma Annular Pancreas

VIPoma / Verner-Morrison / WDHA Syn.

Risk Factors Presentation

Carcinoid Syndrome: FIVE HT

Rovsing’s Sign Perforation

Prev 100-200 50-100 /100,000 Macroscopic

Complications • Toxic megacolon • Fistulae

Motions <4 4-6 >6

No Improvement → rescue therapy Complications

1 Small confined pericolic Surgery rarely

Non-Mechanical = Paralytic Ileus (usually SB) Ix

Resuscitate: “Drip and Suck” Indications

Dx: “3, 2, 1, rule”

Causes Common / Important

Chronic Small Bowel Ischaemia

Chronic Large Bowel Ischaemia Ix

Surgical: Lateral partial sphincterotomy Ix

Irreducible Sac cannot be reduced despite pressure or manipulation.

Littre’s hernia Hernial sac containing strangulated Meckel’s diverticulum.

Amyand’s Inguinal hernia containing strangulated appendix

Richter’s Only part of circumference of bowel is within sac

Pantaloon Simultaneous direct and indirect hernia.

Herniotomy Excision of hernial sac

Herniorrhaphy Suture repair of hernial defect

Hernioplasty Mesh repair of hernial defect

Clinical features Intra-operative

Paraumbilical Features Management

Epigastric Features Management

Small, brown pigmented nodule

Poor prognostic indicators

• 7% other: e.g. sebaceous cyst or lipoma • May become infected → abscess

Posterior Triangle Rx: extirpation by a vascular surgeon

Presentation Pharyngeal Pouch: Zenker’s Diverticulum

Ix: barium swallow