Surgery Crashcourse PDF

Surgery
Crashcourse
Chim Ming Yam Thomas HKU MBBS 16
Year 5

Reference:
Teaching materials, Pastpapers, Teaching by Doctors/Professors
Teaching from UCH (Senior clerkship)
UCH note, Andre Tan note
Bailey & Love, etc
Uptodate, Medscape, etc

Table of Content
Table of Content .................................................... 1 CTS Valvular Surgery .......................................... 154
General Intro .......................................................... 3 CTS Atrial Myxoma ............................................. 156
General Surgery for Malignancy ............................ 4 CTS Thymoma .................................................... 157
General Hx Taking .................................................. 6 GI FB Ingestion/Esophageal Perforation ............ 159
General PE ............................................................. 7 GI Dysphagia ...................................................... 163
General Surgical Infection ...................................... 8 GI GERD ............................................................. 167
General Surgical Emergency ................................ 12 GI Esophageal CA ............................................... 170
General Metabolic Response to Surgery ............. 14 GI Vomiting ........................................................ 176
General Fluid Mx .................................................. 18 GI Gastric Cancer ............................................... 179
General Blood Transfusion ................................... 21 Gastric Polyp: ............................................ 187
General Common Bedside Procedures ................ 22 GIST ........................................................... 188
General Minimal Invasive Surgery ....................... 27 GI Upper GI Bleeding ......................................... 190
General Radi Exam ............................................... 30 PU disease ................................................. 198
General Surgical Nutrition ................................... 32 GI Lower GI Bleeding ......................................... 205
General Surgical Oncology ................................... 43 Diverticular disease ................................... 211
General Tubes & Drains ....................................... 46 GI Lower Abdominal Pain .................................. 215
General Suture ..................................................... 57 Appendicitis .............................................. 222
General Surgical Cx .............................................. 61 GI Intestinal Obstruction .................................... 225
OSCE Script Scrubbing ......................................... 62 Mechanical Bowel Obstruction ................. 225
OSCE Script Foley ................................................. 63 GI Mechanical SBO ............................................. 230
Breast Exam ......................................................... 65 GI Mechanical LBO ............................................. 233
H&N Clinical Demo .............................................. 70 Obstructing CRC: ....................................... 234
H&N Thyroid & Parotid Exam .............................. 72 Volvulus ..................................................... 238
Skin Lumps & Bumps Exam .................................. 75 Intussusception ......................................... 240
Skin Lumps & Bumps ........................................... 77 GI Functional IO ................................................. 242
Cutaneous: .................................................. 79 Paralytic Ileus ............................................ 242
Subcutaneous: ............................................ 85 Pseudo-Obstruction .................................. 243
Skin Ulcer: ................................................... 88 GI Endoscopy ..................................................... 244
Malignant: ................................................... 90 GI Colorectal Surgery ......................................... 248
Misc: ............................................................ 94 Peri-op Mx: ................................................ 249
Urology Clinical Demo ......................................... 95 Stoma: ....................................................... 253
Urology Hernia, Groin LN, PR Exam ..................... 99 GI Colonic Polyp ................................................. 258
Hernia: ...................................................... 103 GI Colorectal Cancer .......................................... 259
Vascular Exam .................................................... 109 GI Neuroendocrine Tumor ................................. 271
Breast Benign Breast Disease ............................ 115 GI Anorectal Conditions ..................................... 274
Breast Cancer ..................................................... 118 GI Fecal Incontinence ......................................... 281
CTS Chest Trauma .............................................. 130 HBP Hepatomegaly ............................................ 283
Specific: ..................................................... 133 HBP HCC ............................................................. 285
CTS Surgical Tx of IHD ........................................ 143 HBP CholangioCA ............................................... 295
CTS Cardiopulmonary Bypass ............................ 152 HBP Metastatic CA to Liver ................................ 296

HBP Portal HT .................................................... 297 DVT ............................................................ 515
HBP Liver Failure & Transplant ........................... 302 SVT ............................................................ 517
HBP MBO ........................................................... 308 Vascular PVD ...................................................... 518
HBP Pancreatic Cancer: ...................................... 314 Vascular Acute LL Ischemia ................................ 524
HBP Gallstone .................................................... 317 Vascular Aneurysm, AAA ................................... 528
HBP Acute Cholecystitis ..................................... 320 PseudoAneurysm ...................................... 532
HBP Acute Cholangitis ....................................... 325 Vascular Carotid Stenosis ................................... 534
HBP Imaging for Cholecystitis/Cholangitis ......... 330 Misc ................................................................... 537
HBP RPC ............................................................. 333 Extra ................................................................... 543
HBP Peritonitis ................................................... 335
H&N Thyroid Nodule .......................................... 339
Thyroid Cancer: ......................................... 346
H&N Neck Swelling ............................................ 354
H&N H&N Cancer .............................................. 356
H&N H&N Conditions ........................................ 360
Neuro ICP ...................................................... 362
Hydrocephalus .......................................... 366
Neuro Brain Tumor ............................................ 368
Neuro ICH .......................................................... 371
Neuro Paraplegia ............................................... 378
Neuro Head Injury ............................................. 384
Neuro Brainstem Death ..................................... 391
Plastic Intro ........................................................ 395
Plastic Burn ........................................................ 408
Plastic Wound Healing & Infection .................... 420
Urology Testicular Torsion .................................. 427
Urology Hematuria ............................................ 430
Urology Urinary Stone ....................................... 436
Urology Urinary Retention ................................. 449
Urology BPH ....................................................... 458
Urology Prostatic Cancer ................................... 468
Urology Bladder Cancer ..................................... 478
Urinary Diversion: ..................................... 481
Urology RCC ....................................................... 483
Other Renal Tumors: ................................. 488
Urology Testicular CA ......................................... 489
Urology UTI ........................................................ 491
Urology Urinary Incontinence ............................ 500
Urology Erectile Dysfunction ............................. 504
Vascular Venous Disease .................................... 510
CVI ............................................................. 511

General Intro
Modern Surgery - Basis:
Control of Pain: Anaesthesia
Control of Infection: Sterilization, Anti-septic, Aseptic technique
Control of Bleeding: Hemostasis (Cauterization, Ligatures, Sutures, Stapler, Sealant)
Surgery Outcome measures:
Harm: Morbidity (Peri-operative), Mortality (Intra-op, 30-day, Hospital), Hospital stay, Pain level,
Duration of recuperation/recovery
Benefit: Survival (Disease-free, Overall), Functional improvement (Sx, QOL, Satisfaction)
Laparoscopic Fundoplication: For GERD
Nissen vs Toupet
Natural Orifice Transluminal Endoscopic Surgery (NOTES):
Eg.Penetrate Stomach to cut gall bladder
Advantage: No external wound
Peroral Endoscopic Myotomy (POEM): For Esophageal Achalasia
Maxillary Swing: For NPC
LDLT: Left Lateral Section Graft for a Child
Right Lobe Graft an Adult
Double Equipoise: Recipients benefit vs Donors risk

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General Intro
General Surgery for Malignancy
Cancer in HK: Leading cause of Death (30.6%) & Hospitalization
M:F = 1.11:1 (Incidence), 1.99:1 (Death)
Age at Presentation: <18: <1%; >60: >61.6%
Life time risk: Male: 1 in 4 (incidence); 1 in 8 (death)
Female: 1 in 5 (incidence); 1 in 15 (death)
Cancer death: ing
Public hospital: Cancer In-Pt: 36%
Incidence-to-Mortality ratio: 0.9 (Liver/Pancreas), 0.85 (Lung), 0.8 (Esophagus)
Prostate CA ing: 1.Ppl getting Older; 2.Better Screening
Surgeons role: Prevention, Diagnosis, Staging, Tx (Cure, Cytoreduction, Palliation),
Manage associated problems (Tx/Non-Tx related)
Screening: Simple tests across a healthy population to identify individuals with the disease
Screening programs undertaken only when:
-Effectiveness demonstrated
-Resources are sufficient to cover target group
-Facilities exist for Diagnosis and Tx & FU
-Prevalence is high enough to justify cost-effectiveness
High Risk groups: Colorectal CA: FHx, IBD;
Breast CA: FHx; Liver CA: HBV
Screening: Colorectal CA: Stool for occult blood, Sigmoidoscopy, Colonoscopy;
Breast CA: Mammography; Liver CA: AFP, USG
Cancer prevention: Avoid Carcinogenesis: Smoking, Alcohol, Radiation, Environmental/Occupational Carcinogens
PA & Healthy lifestyle (diet)
Vaccination
Presenting S/S: Asymptomatic detected by Screening: Colorectal CA, Breast CA, Liver CA, Cervical CA
Bleeding: GI bleeding, Hemoptysis, Hematuria
Obstruction: Intestinal obstruction, Obstructive Jaundice
Mass effect: Palpable Mass, Pain
Systemic Sx: Anorexia, Weight Loss, Lethargy, Fever
Dx/Staging: Hx, PE, Lab test (Urine/Stool/Sputum, Blood-including Tumor markers),
Radiology/Endoscopy/Laparoscopy/Surgery, Pathology study (Cytology, Biopsy)
Liver CA staging: T1: Solitary, 2cm, Without Vascular invasion
T2: Any 1 of Multiple in One lobe/2cm/With Vascular invasion + Other 2 as in T1
T3: Any 2 of the above + Remaining 1 as in T1
T4: Multiple in >1 lobe, or Invasion of Major branch or Portal/Hepatic vein or Adjacent Organs
N1: Regional LN; M1: Distant Metastasis
Stage I Stage II Stage IIIA Stage IIIB Stage IVA Stage IV
T1 T2 T3 T1/2/3+N1 T4+Any N Any T/N+M1
Staging & Tx: Choice of Tx (Neoadjuvant therapy, Extent of Surgery, Adjuvant therapy),
Prognosis, Monitoring Tx, Comparison of Tx results
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Mx Multidisciplinary:
Surgery, Endoscopic therapy, Radiologic procedures, Chemo, RT, Immunotherapy
Surgical section: Primary mode of Curative Tx (Best chance); Low resection rate in some CA (eg.Liver/Esophagus)
Secondary mode of Curative Tx After failure of Non-operative therapy (eg.NPC, H&N, Anal CA)
Part of Multi-modality Tx Combined with Chemo, RT, Immunotherapy
Palliative Tx For Obstruction, Bleeding, other Sx
Other Procedures: Open Biopsy for Histologic Dx/Staging
Surgical Bypass for Obstruction
Neurolytic therapy for Pain relief
Palliation of other Cx, eg. Bleeding
Facilitate other Tx modalities: Insertion of Central line for Chemo
Insertion of devices for Local RT
Tx for Cx of Non-surgical Tx
Non-operative Tx: Endoscopic, Radiologic, Chemo (Systemic/Regional), Molecular Target therapy,
RT (External/Internal-Brachytherapy), Immunotherapy
Ablative Therapy: Radiofrequency Ablation for HCC: (Cool-tip)
High Frequency Alternating current (480 kHz) across uninsulated needle electrode
Excites electrons to Vibrate at high frequency> Generate heat to temp exceeding 60 C
USG guidance: Percutaneous, Laparoscopic/Thoracoscopic, Open surgery
Neoadjuvant Therapy: Downstage disease, Resection rate, Chance of cure
Adjuvant Therapy: Prevent/Delay Recurrence
Therapy for Post-op Recurrence: Survival, Palliation
Outcome Measures: Cure: 5-year-disease-free Survival (according to stage)
Survival: 5-year Survival
Palliation: QOL
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General Hx Taking
ABC: Approach, Basic skills, Competence
CEO: Control situation, Extract most info, Obtain useful data
Hx Taking-20min: Introduction (2), Presenting Sx (5), HPI (5), PMH (1), Drug Hx (1), FHx(1), Review of Systems (3),
Social Hx (1), Summary (1)
Situation: Pen/Notepad, Good timing, Privacy, Quiet/Comfortable environment, Avoid distraction
Attitude: Establish communication, Show trying to help, Watch Facial expression/Posture,
Observe reaction, Read between lines for True message
Avoid: Hostility, Impatience, Misled by Interpretation/Diagnosis, Interruption, Leading Q (Give Open Q)
Introduction: Self-Intro, Ask Pt Name, Record Age/Occupation, Short friendly chat
Presenting Sx: Chief Complaint (C/O): Clearly define, Precise recording, Date/Duration, Hidden Sx
HPI: Site, Radiation, Type, Effect, Onset, Duration, Characteristic, Severity,
Provoking/Relieving factors, Progression, Accompaniment
PMH: All Illness/Operations, Date/Duration, Cx, Progression, Present Tx
Drug Hx: Medication & Allergy (Previous/Active Medication, Progression/Control, S/E, Allergy)
Allergy: Seafood vs Iodine (contrast), Egg vs Vaccines (incubated in eggs)
FHx: Genetic, Infection, Illness/Date/Age, Cause of death, Direct/Indirect effect
Review of Systems: Summarize findings, Clarify facts, Link complaints, Enquire other systems, Hidden complaints
Social/Personal Hx: Occupation, Smoking/Drinking, Eating/Health habits, Recent travel,
Home/Family/Financial/Caring status, Psychological profile
Summary: Recap main idea, Relate info, Record facts, List active problems, Ddx, Plan Ix/Tx

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General Hx Taking
General PE
6 C: Consent, Chaperone, Comfort, Calm, Controlled, Complete (go through other systems too)
APEEP: Approach, Posture, Exposure, Examination skills, Purposeful
General: Vital, Neurological, Psychological, Nutritional, Circulation, Cutaneous, Lymphatic, Specific
Vital: Age, Pulse, BP, Temp, Respiration, BW, Height
Neurological: Consciousness, Orientation, Mental level; Symmetry, Function, Muscle Power, Sensory, Reflex
Consciousness: Alert/Conscious, Confused/Semi-Conscious, Comatose
Psychological: Distressed; Mood, Affect, Insight, Memory, Specific
Nutritional: Obese, Well/Under-Nourished, Cachexic; Hydration; Ankle Edema
Slender: No Fat; cf Cachexic Muscle wasting
Circulation: Skin Temp (Good circulation-Warm), Central/Peripheral Cyanosis, Pallor, Jaundice, Ankle Edema
Cutaneous: Pigmentation, Inflammation, Induration, Edema, Ulceration, Tightness, Lesions, SC Nodules,
Scratch Marks, Scars, Nails
Pigmentation: Tanned> Sporty/Outdoor Pt> May prone to certain diseases
Induration: Red & Swollen; cf Edema: Not Red but Swollen
Scratch marks Itchiness: Jaundice, Uremia, Dermatological, Psychiatric
Notice the areas: If localized on area reachable by Pt hand, possibly Scratch mark
Petechiae: Hematological, Limb Strangulation (Venous strangulation)
Lymphatic: Palpation of LN in >2 areas: Neck, Axilla, Groin, others
Specific: Finger Clubbing, Spider Nevi, Palmar Erythema, Gynecomastia, Prominent Vessels, Cushingoid,
Splinter Hemorrhage, Sputum, Urine, Stool
Palmar Erythema: All areas Pale white except Protruding part is Red
Abdominal Distention: If due to Fat, since Fat is Superficial, Umbilicus will be buried
If due to Internal structure, Umbilicus will be Flattened/Everted
Umbilical Hernia: Congenital defect; cf Paraumbilical Hernia: Usually Acquired

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General PE
General Surgical Infection
Surgical Infection: Unlikely to respond to Non-Surgical Tx (must be Excised/Drained)
Avascularized space (Appendicitis, Empyema, Gas gangrene, Abscess)> Antibiotics cant reach
Occur at Operated site
Pathogenesis: 3 elements: Infectious agent, Susceptible host, Closed Unperfused space
Infectious agent: Aerobic: Gram stain is a Quick way to further differentiate
Gram +ve: Streptococcus, Staphylococcus
Gram ve: E.coli, Klebsiella
Anaerobic: Bacteroides
Opportunistic: Pseudomonas, Fungi
Community vs Hospital acquired
Susceptible host: Body defense mechanism:
Local defense: Skin, Mucous membrane
Specific Immunity: Cell-mediated, Hormone-mediated
Non-specific Immunity: WBC (Phagocytes, Macrophages)
IC host:
Immunodeficiency disorder: Acquired, Congenital
Burn, Trauma, Malignancy
DM, CRF
Drugs: Steroid, Cytotoxic agent
Closed Space: Poorly Vascularized space in tissue (wound)
Natural space
Cycle of Events: Entry into Body> Apposition to Cell wall> Overcoming Local defense> Accumulation/Spread
> Outwitting Immune response> Cellular Injury> Persistence> Death of host (Multiorgan Failure)
Spread: Necrotizing Infection: Along Anatomical path, eg. Clostridial myonecrosis, Necrotizing fasciitis
Abscess: Breaching of Natural Boundary> Fistula/Sinus
Phlegmons/Superficial infection: Edema
Lymphatic: Lymphangitis
Bloodstream: IV drug abuse: Empyema, IE; Brain Abscess, Liver Abscess
Bacteremia: Bacteria in Blood
Transient Bacteremia: Clinically Insignificant, except in Prosthesis/Rheumatic Heart disease
Septicemia: Serious infection from both Bacteremia & Toxemia
Usually Gram ve (eg. E-coli), which can produce Endotoxin
SIRS: Systemic Inflammatory Response Syndrome:
Temp: or (Hypothermia-<36C is worse than Pyrexia>38C)
HR: (Tachycardia)
RR: (Tachypnea)
WBC: or (Neutropenia is worse than Neutrophilia)
Leucocytosis (>12) or Leucopenia (<4)
Sepsis: SIRS + Documented infective source
Severe Sepsis: Sepsis + Organ dysfunction
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Dx: Identify source of Sepsis
PE, Blood test (WBC, Blood gas analysis-Acidosis/Resp failure,
Coagulation profile (Coagulopathy), Blood Culture (Always obtain before starting Antibiotics)
Other tests based on suspicion (eg. Sputum, Urine, etc)
Imaging: CXR, US, CT, Radionuclide scan; Aim: Identify source of Sepsis
Tx principle: Septic foci: Surgical Excision/Drainage
Incision & Drainage: Superficial abscess: Surgical drainage
Deep abscess: CT/US guided Percutaneous Catheter drainage, Surgical drainage
Excision: Appendicectomy, Cholecystectomy
Antibiotics: Not necessary for Simple infection
Required if infection Spread/Persist
Body support: IV fluid, Nutrition, Circulatory support
Nosocomial: Hospital-acquired
Surgical team: Operating room attire: caps, mask, gown & gloves
Surgical Behavior
Aseptic operating technique
Cutaneous/Respiratory infection (MRSA in nose)
Hand Scrubbing
Hand Washing: Mandatory after all contact with infected patients
OT: Design of Operating room, eg.Ventilation
Air pressure in OT is higher than outside> Air will rush out
Air Sampling for Bacterial load
Sterilization of Equipment/Instrument
Patient: Treat Pre-existing infection before Elective operation
Skin Commensals:
Pre-op Baths (esp need to wash Umbilicus)
Body Hair (Clipping better than Shaving> Less Abrasion) immediately before op
Skin preparation (Antiseptic cleansing of skin included in operative field)
Universal precaution:
Never hand over sharp objects hand-to-hand; Put in a tray
Wear gloves/protective devices when having close contact with Pt body fluid
Never Recap needles
Prophylactic Antibiotics:
Aim: Surgical wound infection
Choice: Use 1st line Antibiotics to emergence of resistant strain
Consider Cost-effectiveness, Efficacy, Safety
Urological: Based on Urine culture
Colorectal: Gram ve Aerobe, Anaerobe
Prosthetic: S.aureus
Use only if Risk is justified:
Not indicated for Clean operation, except Prosthesis/RHD/Prosthetic Valve
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Appropriate Dose/Time:
Achieve Therapeutic level before Incision; IV
<2h before operation: At Induction of Anesthesia
Stop dosing before Risk of S/E outweigh Benefits
Stopped a few hours before operation
Surgical Wound Infection: Bacterial Contamination during/after surgery; Usually confined to SC tissues
Infection Rate: Clean: 1.5%; Clean Contaminated: 7.7%; Contaminated: 15.2%; Dirty: 40%
RF: Abdominal operation, Operation >2h, Contaminated operation,
>3 pre-existing medical conditions
Occurrence: Usually between 5th 10th days after surgery
Prevention: Careful operative technique; Contamination; Prophylactic Antibiotic;
Contaminated wound: Delayed 1 closure, or 2 closure (let it close itself)
Tx: Open wound for drainage, Wound swab
Perianal abscess: Tenderness, Swelling, Erythema, Induration (Not Fluctuation)
Furuncle: Infected Hair follicles
Tx: Incision & Drainage
Carbuncle: Starts as Furuncles, but spread through Dermis & SC tissue in a myriad of connecting tunnels
Site: *Back of Neck, In DM Pt
Organism: Staphylococcus, Anaerobic Diphtheroids
Tx: Excision & Antibiotic
Cellulitis: Common Invasive Non-Suppurative infection of Connective tissue; *Streptococcus;
Clinical: Erythematous, Edematous skin; may cause Lymphangitis
Tx: Rest, Elevation (Swelling), Packs; Antibiotics
Myositis: Localized vs Diffuse
Organism: S.aureus, Clostridium (Gas gangrene)
Gas Gangrene: Begin <3 days after injury; Rapid progression
Clincal: Pain, Edema, Purulent Exudate, Crepitus (best way to show extent)
Profound Toxemia, Extensive underlying Muscle Necrosis (Compartment syndrome)
Tx: Extensive Debridement, Hyperbaric O2, Antibiotics
Necrotizing Fasciitis: Invasive Infection of Fascia
Multiple pathogens:
Microaerophilic Streptococcus, Staphylococcus, Gram ve (Klebsiella, Pseudomonas),
Anaerobes (Bacteroides), Clostridium
Pathogenesis: Infectious Thrombosis (vessels between Skin and Deep circulation):
Skin Necrosis, Fascial/SC Necrosis
Clinical: Skin: Hemorrhagic Bullae
Fascial Necrosis: Usually Wider than Skin appearance
Crepitus
Toxemia
Tx: Surgical Debridement: Remove all Avascular skin/fascia, may require repeated debridement
Antibiotics: Broad spectrum
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Circulatory support: Blood/Plasma Transfusion
Antibiotics Tx: Indication: Surgeon decision based on clinical impression of Microbial infection
Organism:
Specimen Culture: Relevant culture (Blood/Urine/Sputum) before Start of Tx
Agent: Empirical therapy: Culture takes time
Choice depend on Local Antibiotic Sensitivity pattern
Single (Specific vs Broad-spectrum) agent or Combined agents
Avoid overuse of Broad-spectrum in emergency situation
Route: Make sure drug can reach site of infection in adequate concentration
Can eat> Oral preparation; Life-threatening> IV
Dosage: Calculated based on BW
Drugs excreted through Kidneys: May need adjustment in RF Pt
For some drugs (eg. Aminoglycosides), Serum drug level can be checked
Duration: Determined by Clinical response, Past exp,
Lab indications of recovery (Eg. ve Culture, Subsidence of Fever)
Course of Antibiotics: 5-7 days
Agent Adjustment: When No Clinical response to Initial Empirical therapy
Or Culture result indicates Resistance + Clinical evidence of Persistence

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General Surgical Emergency
Common in HK: Appendicitis, Cholecystitis, Acute Urinary retention (BPH), Ruptured aneurysm,
GI bleeding due to ulcer
Surgeons role: Remove dead/infected tissue, Drain pus, Relieve obstruction (remove lesion/bypass),
Repair defect, Control bleeding, Remove blood clots
Classification: Surgical infection, Obstruction of lumen, Perforation/Rupture, Bleeding, Trauma
Surgical Infection: Infections that best treated by Operative intervention, or, those follow Surgical procedures
Abscess: Confined infection, surrounded by Pyogenic membrane
Empyema: Abscess in anatomic cavity, eg. Empyema of gallbladder
Classical signs: Redness, Swelling, Temperature, Tenderness
Deep-seated: May not show the classical signs; eg. Liver abscess
Localized: Skin, SC tissue, Liver, etc
Organ: GB (Cholecystitis), Appendix (Appendicitis)
Sepsis: Systemic response to Infection, eg. Hemodynamic instability, Mental confusion, Tachypnea
20% associated with Bacteremia
SIR: Systemic Inflammatory Response Syndrome: Early response to Injury, Infective or Non-infective
Bacteremia: Bacteria in bloodstream
Septic Shock: Hypotension, Organ Failure
Dx: Hx & PE: Some conditions (SC abscess, Typical Acute Appendicitis) are Obvious
Ix: Elevated WBC count
Imaging studies for selected Pt (CT scan for abscess, US scan for Acute Cholecystitis)
Abscess Imaging:
CT: Contrast Rim enhancement (pyogenic membrane is hypovascular)
X-ray: Air-fluid Level
Tx: Antibiotics
Drainage (I&D, Surgical, Interventional radiology-Percutaneous drainage)
Percutaneous drainage: Pigtail catheter; Elastic recoil end> Wont slip out easily
Coil> Longer length inside> more side holes> drain better
Surgical removal of diseased organ: Appendectomy (Laparoscopic)
Lumen Obstruction: Bowel, Artery, Urological system, Biliary system
Cause: Mass in lumen, Mass from wall, Extrinsic compression, Twist of tubular structure
Bowel: Small bowel: *Adhesion band (Fibrous adhesion after surgery/inflammation/trauma),
Tumor (uncommon), Hernia (either by Hernia neck or Twisted bowel)
Large bowel: *Cancer, Volvulus
Cardinal Sx: Abdominal Pain, Distention, Vomiting (earlier if upper GI), Constipation (earlier if lower GI)
AXR: Erect + Supine film; Erect: Multiple Fluid level; Supine: Dilated bowels
Large bowel: Sigmoid Volvulus: Coffee-bean appearance
Assess if Ileocecal valve is Competent too
Competent: May perforate cecum (fecal peritonitis emergency)
Incompetent: Reflux back to Small bowel (dilate), perforation rare
Artery: Ischemia, progress to Gangrene
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LL: PVD, Embolism (eg. From AF)
Intestine: Thrombosis, Embolism, Strangulation
Acute LL Ischemia: 6P: Pulseless, Pain, Pallor, Paraesthesia, Paralysis, Perishing Cold
Urological system: BPH> Acute Urinary retention
PE: Dullness in Suprapubic region
Tx: Bladder catheterization (Foley; Inflated balloon keeps it inside UB)
Biliary system: Cystic duct: By Gallstone> Acute Cholecystitis
CBD: Acute Cholangitis, Acute Biliary Pancreatitis
PE: Acute Cholecystitis: RUQ Pain, Fever, Murphys sign; GB maybe not palpable
Acute Cholangitis: Charcots Triad (RUQ pain, Fever, Jaundice)
Dx: US
Tx: Acute Cholecystitis: Laparoscopic Cholecystectomy
Acute Cholangitis: ERCP, EPT (Endoscopic Papillotomy)
Perforation/Rupture:
Spontaneous Perforation: Hollow viscus, eg. Ulcer perforation
Free gas under diaphragm in X-ray, Resonant upon percussion
Spontaneous Rupture: Involve Build-up of pressure, eg. Ruptured AAA, Ruptured HCC
Traumatic (Blunt trauma, Penetrating trauma)
Bleeding: GI: *Ulcer bleeding
Tx: Therapeutic endoscopy
Intracranial: Trauma, CVA
Bleeding may not be massive, but Pressure effect can be lethal
Tx: Craniotomy
In General: Spectrum varies in different countries
Urgency varies, some immediately life-threatening (Ruptured aneurysm, Massive bleeding)
Non-op Tx is available for some conditions

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General Metabolic Response to Surgery
Metabolic response: Operation is a form of Tissue Trauma & Stress
Bodys response is to ensure Survival from Acute Stress & Recovery
Magnitude of Response is dependent on Degree of Trauma/Stress
Response is at the consumption of bodys store of Energy & Protein
Stress: Skin Excision, Muscle/Fascia Division, Tissue Trauma, Bleeding, Hypothermia,
Bacterial Contamination, Exposure of Viscera to Air
(Low Room Temperature & Humidity in OT: For better performance of Surgeons/Equipment)
(Infused fluid/blood for bleeding may be Cold and render the patient further Hypothermic)
Consequences:
Tissue Trauma: Inflammatory response
Bleeding: Hypotension, Hypoperfusion of vital organs, Blood transfusion (Immunosuppressive)
Hypothermia: Vasoconstriction, CO, Coagulopathy
Bacterial Contamination: Infection
Exposure of Viscera: Fluid loss, Hypothermia
Desiccation of Wound: Infection (layer of dry/necrotic tissue is vulnerable to invasion)
Objective of Metabolic response: Attenuate consequences of Stress and achieve Homeostasis
Heal Wounds
Failed Wound Healing:
Abdominal: Evisceration
Anastomosis: Bowel> Peritonitis> Mortality
BV> Bleeding, Loss of Organ function
Phases of Metabolic Response:
Ebb phase: Metabolic response To operation
Flow phase: Metabolic response After operation
Anabolic phase: Recovery from operation
Ebb phase: Catecholamine/Glucagon> Blood Glucose, Lactate, FFA
Cardiac Output> Oxygen Consumption, Organ Hypoxia/Ischemia
Core Temperature> Oxygen Consumption
Outcome: Succumb from Ischemia, Lack of Oxygen/Nutrient supply to major organs
Survive if Injury is Not Severe and Homeostasis is achieved by bodys response
OR, Prompt Resuscitation is given, BP/CO maintained, Complete homeostasis achieved
Flow phase: Metabolic response aims at Wound healing & Restoration of function
Hypermetabolism: Catecholamine, Glucagon & Cortisol in blood
CO, Blood flow
Clinical Manifestation: HR/Pulse rate, RR, Body Temp
Purpose: Blood flow> promote Wound healing/maintain Vital organs
Wound healing: Inflammatory reaction> Removal of Debris/Blood clot/Bacteria by MQ
> Formation of new BV, Collagen, Epithelium
Immediate:
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Early stage: Cytokine released from MQ is responsible for Vasodilation, Blood flow,
Leakage of fluid from Capillaries, Migration of WBC across BV wall into site of injury
Signs of Inflammation: Erythema, Edema, Induration
macr
opha

Cytokines from MQ: ge

Intermediate stage:
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Late stage:

Prerequisite for Perfect Wound healing:
Supply of Nutrients for Actively dividing cells: aa, Glucose, FA
Supply of O2
Good Tissue Blood supply & Venous drainage
Minimal Necrotic debris
2014 MCQ 36: 3 phases of Wound Healing: Inflammatory, Proliferation, Matrix remodeling
Supply of Nutrients w/o Feeding:
Glycogen store in Liver/Muscle> depleted quickly
Pt usually Not allowed to eat after operation, or Low appetite
Mobilization of aa from Muscle and FA from Body Fat> Weight Loss
Mobilization of aa from Muscle> Malaise/Muscle Weakness, including Resp muscles
> Predisposition to Bronchopneumonia> Mortality from Chest infection
Cytokines Production:
IL1, IL6, IL8, IL12, TNF released by MQ accumulate in wound
Important for Local Inflammatory response and promotion of Wound Healing
Massive cytokine production if tissue trauma is extensive
Absorption of cytokines into systemic circulation:
SIRS + Aggravation of clinical sign of Hypermetabolism
SIRS: Body Temperature >38C, HR >90/min, RR >20/min or PaCO2 <32mmHg, WBC count >12x109/l
Multi-organ Failure: Leakage of Fluid from Capillary into Interstitial space> Tissue Edema> Nutrient/Oxygen
Thrombi within terminal branches of artery> Ischemia
Tissue Ischemia in organs> MQ infiltration> Cytokine production
Organs involved: Brain: Encephalopathy; Nerve: Polyneuropathy
Muscle: Myopathy of critical illness; Lung: ARDS
Heart: Shock, Peripheral Edema; Kidney: ATN
GI tract: Delayed Gastric emptying, Stress ulcer, Paralytic ileus
Blood: DIC
Flow Phase: Catecholamine/Glucagon/Cortisol/Insulin> N/ Glucose/FFA, N Lactate> O2 consumption
CO/Core Temp> O2 consumption> CO2/Heat production
Aldosterone/ADH> Fluid Retention
IL-1/IL-6/TNF spillage from wound> SIRS> Multi-organ failure
Metabolic response: Beneficial for Recovery; Cost maybe Substantial;
SIRS will subside if Serious/Continuing/Superimposed insult (Infection/Bleeding) is eradicated
Page 16
Anabolic phase: Recovery, Nutrient intake, Loss of Retained fluid,
Restoration of lean body Mass, BW, Fat store & Well being
Summary:

Surgeons Strategy: No effective strategy to eliminate metabolic response entirely
Supportive measures are essential
Perfect surgery is essential to Metabolic response
Blood Loss, Blood Transfusion requirement, Tissue trauma,
Amount of Hematoma & Necrotic tissue, Do Leak-proof Anastomosis
In Ebb phase: Prompt Fluid/Blood replacement to maintain BP/CO, Adequate Oxygen supply & Ventilation
Cardiovascular support by Inotropes, Antibiotics, Maintenance of Normothermia
In Flow phase: Warm Room Temperature, Cardiovascular support by Inotropes,
Respiratory support by Respirator, PPI to prevent Stress ulcers in stomach, Nutritional support,
Hemodialysis, Steroid (short duration, avoid infection), NSAID, Adequate Pain relief,
Mobilization, Chest Physiotherapy,
Timely re-operation for surgical Cx (eg. Infection/Bleeding)
Intestinal Anastomosis: Restore Bowel Continuity by Suturing
Weight loss after Major operation?: Tissue trauma is Extensive, Breakdown of Muscle/Fat for mobilization for repair,
Oral intake due to Poor appetite
Debility Inevitable?: Yes, but the duration can be reduced if proper care is given
Multi-organ Failure?: Massive Blood loss> Ischemic injury
Massive Transfusion> Immunosuppression> Infection
Massive Tissue Trauma> SIRS> Multi-organ failure

Page 17
General Fluid Mx
Total Body water: Contributes to 60% BW (30kg of water in 50kg man)
Extracellular fluid: 25% BW
40% Total body water
Interstitial vs Intravascular (plasma) = ~ 4:1; ie. Only some of fluid we gave goes to blood
Intracellular fluid: 35% BW
60% Total body water

Fluid Therapy: Standard: 2D / 1S Q8H for all; 5% Dextrose, 0.9% Normal Saline
(UCH: For Resuscitation, usually give Normal Saline but Not Dextrose
Dextrose distribution to Intravascular volume Not enough)
Correct for lots of Pt, Simple; But Nave, Not what u want if u were the Pt
Provide Maintenance

10kg infant: 960ml/day About 1L
50kg adult: (960 + 480 + 720) ml/day = 2160ml day About 2L
Fluid/Electrolyte Loss:
Surgical Pt: Poor Intake due to Pain, Vomiting/Diarrhea, Bleeding
Fasting: Before Pt gets IV fluid started before waiting:
To be seen by A&E doctor (2-4h)
For Blood & X-ray results (1-2h)
For decision of Admission (?1h)
Porter to transfer patient (?1h)
Seen by intern in wards & IV cannula set successfully (1-2h)
Failure to absorb GI fluid: Bowel secrete lots of fluid everyday; If cant reabsorb> Fluid loss
Mechanical Large bowel obstruction, Paralytic ileus
Page 18
General Fluid Mx/Blood Transfusion

3rd Space Loss: Vasodilatation & Capillary Permeability
Due to Endotoxin/Exotoxin/Cytokines/Complement activation due to tissue inflammation
Sequestration of up to several liters of fluid into Interstitial space
Important element of Septic shock
Assessment of IV fluid loss:

Types of Fluid:
Crystalloid Solution: Aqueous solution with Low Molecular Weight Ions/Glucose
Rapidly equilibrate throughout ECF, Intravascular half-life 20-30min
Cheaper; Examples: 0.9% NS, 5% dextrose
Colloid Solution: High Molecular Weight substances (eg. Protein, Glucose Polymer)
Maintain Oncotic pressure, Intravascular half-life 3-6h
More Expensive, More S/E: eg. Allergy & Bleeding tendency
Components: Blood derived: Albumin, Plasma protein
Synthetic: Gelofusine (Gelatin), Haemacele (Hetastarch), Dextran
Crystalloid vs Colloid:
IV Volume: Crystalloid required is 3-4x of Colloid
Colloid is more effective for Rapid restoration of IV volume (Maintain BP)
ECF Volume: Crystalloid is preferred (more distributed to ECF)
Most Surgical Pt: Extracellular deficit>Intracellular deficit
Rapid admin of Large amount of Crystalloid: Prone to Tissue Edema
Composition of IV fluid: Unit: mmol; 0.9% NaCl contains 154 Na
Give slowly to avoid pH exceeding buffer capacity (eg. NaCl, Dextrose), esp in Acidosis
Avoid Hartmanns solution (Lactated Ringers solution) in Renal Failure, HyperK
Page 19
(Excess NaCl causes HyperCl Acidosis)
Rate of Replacement: Depends on Hemodynamic status and any On-going loss

Rule of Thumb: Replace in small aliquots & Re-assess, eg. 500ml over 2h & Re-assess
Concern of Overload: Elderly, CHF/CRF,
Post-op (Catecholamine/ADH/Aldosteronedue to Stress> Na/H2O retention, K secretion)
Electrolyte Mx: Daily requirement: Na: 1 -2 mmol / kg / day - usually included in fluid replacement already
K: 1 mmol / kg / day - Prone to Deficiency
Ca: 5 mmol / day - usually stable
Mg: 1 mmol /day - usually stable
Mx of average 60kg Adult: 2D/1S +10mmol KCL each bottle (500ml) Q6H
HypoK: CVS effect is most prominent:
Arrhythmia, commonest cause of AF in post-op Pt
ECG changes: T wave Flattening/Inversion, ST Depression, Prolong PR interval
Cardiac contractility
Neuromuscular:
Ileus of large/small bowel, Muscle Weakness
Cause: Lack of replacement - commonest cause
2D/1S Q8H most commonly given
K supplement required if Pt will not be eating well for a few days
2D/1S + 10mmol KCL each pint Q8H / Q6H <<< this order seems long> Doctors are Lazy
Why not replacing K?: Laziness!!!
Others: Alkalosis
Drugs: Insulin, -agonist effect, Diuretics, Laxatives
Renal loss: Diuresis, Ketoacidosis, HypoMg
GI loss: Vomiting, Diarrhoea, IO, High output intestinal Fistula
K Replacement: Slow K tablet (600mg = 8mmol KCL)
Syrup KCL (1gm = 13.3mmol/KCL)
Plasma K level <3mmol/L is Serious: IV replacement required to avoid Arrhythmia
Rate of IV should Not exceed 10mml/hr in non-ICU setting (may induce Arrhythmia too)
Recheck after 20-30mmol of IV KCL

Page 20
General Blood Transfusion
Risk of Transfusion: Hemolytic reactions: ABO incompatibility (1/6000)
Febrile reaction (3%)
Urticaria (1%)
Anaphylaxis (1/150,000)
ARDS (<1/10000)
Immunosuppression (esp concerned in Surgical Pt> can Chance of Cancer Recurrence)
Infectious Cx: Hepatitis (1/150 1/5000)
AIDS (1/200,000)
CMV, EBV
Bacterial (chance if blood given over 4h)
(Unknown)
Indication: Danger of Anemia outweigh risk of transfusion
Sx of Anemia is severe
Usually indicated if Hb <7 g/dL
Varies according to Pt Age & Co-morbidities
Low Threshold: Very Old, Age >80
Underlying IHD, keep above 8 g/dL usually
Pt in Shock with active Bleeding
High Threshold: Young Pt
After Curative Cancer surgery
Immunosuppression, chance of Recurrence (esp in CRC 2004 MCQ 85)
Blood Types:
Whole Blood: Contain Plasma & include All elements of blood
More effective Volume Resuscitation
Platelet viability & Factor V, VIII activity after storage
Packed Cell: Separated from Plasma
FFP & Platelet extracted for other purpose
Chance of volume Overload
Preferred for correction of Anemia
Massive Transfusion: Transfuse 1-2 times of Pt blood volume (>10 units) (2010 SAQ 11)
Cx: {CCMHH/Massive HCC Hemorrhage}
Coagulopathy
Citrate toxicity (HypoCa & Cardiac dysfunction)
Hypothermia
Metabolic alkalosis (Citrate & Lactate converted to Bicarbonate in Liver)
HyperK (2011 MCQ 85)

Page 21
General Common Bedside Procedures
Venepuncture
Arterial Puncture: Blood taking ABG
(Radial A) Catheter insertion BP monitoring
Allen test
Allen Test: Test for Occlusion of Radial/Ulnar A
Raise hand in the Air
1 of them is Compressed after blood has been Forced out of Hand by Clenching a Fist
Failure of blood to Diffuse into Hand when Opened: The Artery Not Compressed is Occluded
Use: A Cx of Radial A Blood Sampling/Cannulation is Disruption of A (Obstruction by Clot)
Those who lack Dual supply are at much Greater Risk of Ischemia
Risk can be by performing Allen's test beforehand
Ppl who have Single blood supply in 1 hand often have Dual supply in the other
(Also done before Heart Bypass Surgery if want to use Radial A as Graft)

(Lecturer: Better dont use 45> Higher risk of Double Puncture; Use Smaller Angle)
Insertion of IV Cannula:
Administration of IV Drugs/Fluid
Preferred site: Dorsal Vein of Hand (Start from Distal site and move Proximal if Fail)
Choose appropriate Cannula Size that suits the Vein:
Smaller Needle: Less Stiff (More difficult to puncture), but Less Painful
LA: Pros: Pain
Cons: Make procedure more Difficult (Difficult to see the Vein)
Use: Good when inserting Large bore Cannula, eg. 14, 16 gauge
Important: Good Lighting, Put down Side Gate of Bed
Look at Transparent part of Needle: If see Blood flushing back, Stop advancing
Do NOT leave the Tourniquet on! (Can cause Gangrene; Will lose job!)
Cx: Thrombopheblitis
Drip site infection: Small Abscess, Cellulitis, Infected Leg
Gangrene (beware of Pt with PVD)
Bleeding
Insertion of Central Venous Catheter:
Vein Choice: Usually IJV
Neurosurgeons may go for Subclavian V (Avoid Cx due to Thrombosis)
In Pt with Poor Hemostasis, use Femoral Vein (Easier to stop bleeding)
LA
Page 22
Aseptic technique: Sterile Gloves
Prep Skin with Antiseptics & Covered with Sterile Towels/Drapes
(Can cause IE if Poor Aseptic technique!)
Seldinger technique:

Internal Jugular Approach:
Central Inferior Approach (Anaesthesist):
Easy Insertion; Beware of chance of Pneumothorax

Central Medial Approach (Most common):

Posterior Inferior Approach:

Subclavian Approach:
Page 23

Triple-Lumen Catheter Set: If want more Access
CXR: Always done afterward to check for Pneumo/Hemo-thorax
Cx: Pain
Intravascular Injection of LA
Bleeding: Carotid/Subclavian A
Femoral Approach if Bleeding Tendency
AV Fistula
Pneumothorax/Hemothorax
Central line Infection: Sepsis, IE
Embolization: Air, Guidewire (Always hold on Guidewire! Or Use Forceps)
Foleys Catheter Insertion:
Painful procedure; Invasive Physiological & Psychologically
Urinary Tract is Sterile: Aseptic technique also important (usually Clorhexidine)
Instillgel for Awake Pt
Fr 12 Catheter usually adequate
Inflate Balloon with Water (Not Saline)
(Wear Gloves!)
Difficulty: BPH: Larger Size may help (Small may Not be stiff enough> Only Coil around)
Lots of Lubricants, Wait
Urethral Stricture from Previous Urethral operation/instrumentation: Try Smaller one
Phimosis: May need Dilatation with Forceps
Cx: UTI
Passage of Catheter into False tract
Bleeding: Urethral Trauma, or Hematuria from Rapid UB Decompression
Failure to Deflate Balloon if Inflated with Saline & Crystallized
Pull out by Pt with Balloon still Inflated
Page 24
Inflation of Balloon within Urethra
Suprapubic Catheter Insertion:

NB: In Urethral Trauma:
Dont use Foley catheter (may convert Partial into Complete Tear)
Suprapubic catheter is preferred (2010 MCQ 79) (2009 MCQ 22)
Contraindicate: Bladder Not Distended
Previous Pelvic Surgery (may have Adhesion)
Coagulopathy
Cx: Pain, Infection, Bleeding, Bowel Perforation
Abd Paracentesis: Diagnostic: Culture for Infection, Cytology for Malignancy, Blood for Bleeding(controversial)
Therapeutic: Relief of Abd Distention
Cx: Bleeding from Puncture: Vessel in Abd Wall
Spleen, Liver (beware for Organomegaly)
Bowel Perforation
Hypotension from Large Fluid Shift (Replace with Albumin/Colloid if drain Large amount)
Thoracentesis (Chest Tapping):
Sit up/Semi-recumbent position
LA, Aseptic technique
Site: Usually 8th/9th ICS, Higher if Diaphragm pushed up (eg. By Organomegaly)
Refer to CXR for Level of Puncture!

Cx: Pain, Pneumothorax, Bleeding (Vessel/Lung/Solid Organ Injury)
Chest Drain Insertion:
Indication: Pneumothorax, Massive Pleural Effusion, Hemothorax, Empyema
Sit up Pt if possible
Consider O2 supplement
Adequate Analgesia (LA & IV)
Page 25
Adequate Skin Incision
Usually Anterior to MAL at 5th ICS but Not always (Always refer to CXR)
Do Not use Trocar Chest Drain anymore to drill!
3 bottles system:
Page 26
General Minimal Invasive Surgery
Evolution Hx: Mini-Laparotomy> Hand-port assisted> Total Laparoscopic> Single Port Surgery
> Natural Orifice Extraction of Specimen> Natural Orifice Surgery
MIS Type: Laparoscopic, Endoscopic, TransLuminal
Laparoscopic: Benign/Malignant
Elective/Emergency
Subspecialty-orientated
(Except for Vascular Surgery: Endovascular Surgery)
General rules: Work through Monitor
Camera unit looking at body Cavity (except for Surgery like Total ExtraPeritoneal Repair)
Space is Maximized by Gas Insufflation by CO2 (Inert, can be removed by body)
Instrument Manipulation
Pros & Cons: (2013 MCQ 18)
Pros: Smaller Wound, Less Bleeding, Less Adhesive IO, Better Post-op Pain, Faster Recovery,
Shorter Hospital stay, Better QOL, Economical considerations, Cosmetic,
Good for Teaching (can be projected to lecture theatre)
Cons: Visual Spatial Retraining required (2D view for Standard Laparoscope),
Loss of Tactile Sensation (Surgeon need to adapt), CO2 Narcosis, Collateral Injuries,
Bleeding (difficult to stop Bleeding), Longer op time??(Now is comparable), Cost
Preparation: Routine Pre-op assessment, CardioPulmonary function, Antibiotics Prophylaxis, GA,
DVT Prevention, Prepared for Conversion
Contraindications:
Uncorrected Coagulopathy
Huge Tumor
Poor CardioPulmonary reserve:
PneumoPeritoneum> IntraAbd P> Venous return> CO
Need Airway Pressure for Anesthetists
Equipment: Monitors (HD)
Insufflators: CO2
Camera unit: 3CCD, 1080p
Laparoscopic instruments
5/12/13 mm port for Telescope
Usually 5mm port is enough, unless need to put in Staplers
At least 2x 3-5mm ports for operation
Extra Ports, Extra Wound for Specimen Retrieval
Problems: GA, PneumoPeritoneum, Equipment dependent, Assistant dependent, Surgeon dependent
PneumoPeritoneum:
Monitored (12-15 mmHg)
Impaired Circulation
CO2 Retention (eg. In COPD Pt)
Air Embolism (Mistakenly insufflate vessels; This technique Not used in QMH so Not a problem)
Page 27
DVT
Specific Cx: Conversion
Iatrogenic Injuries from Ports Insertion
Problems with PneumoPeritoneum
Port site Recurrence? (Not common)
Endoscopy: Location
Flexible/Rigid
Diagnostic: White Light
Narrow Band Imaging (Blue light, Good for visualizing Abnormal Vessels)
ChromoEndoscopy: IndigoCarmine, Lugols Iodine
To detect Flat & Diminutive Mucosal lesions
Lugols Iodine: A type of Vital dye (only taken up by specific cell type) (Green if taken up)
Stains Normal Squamous Epithelium (Abnormal if Not stained)
Usually for Esophageal/Anal Squamous Mucosa
IndigoCarmine: A type of Contrast dye
Highlight tissue Topography by Pooling crevices & depressions
Not absorbed but form pools; Usually for Columnar Mucosal lesions
Therapeutic: Biopsy, Polypectomy, Hemostasis,
Endoscopic Mucosal Resection EMR, Endoscopic Submucosal Dissection ESD
EMR: Inject Saline or Methylene Blue (can act as Marker) to raise the Mucosa
No need to close Wound (If Submucosa Not breeched, it will heal by itself)
Cx: Upper Endoscopy:
Aspiration, OverSedation (Resp Arrest), Perforation (Esophagus), Bleeding, Missed Pathology
Colonoscopy:
Related to Bowel Preparation: Overload, Electrolytes
Sedation-related
Procedure-related (Perforation rate: 0.1%)
TransLuminal Surgery:
ESD: Malignant/Pre-Malignant
Confined to Submucosal lesion (SM1, SM2?)
Procedure:
Lesion identified by ChromoEndoscopy
Submucosal layer Marked & Elevated by Saline/Methylene Blue
Marking by Needle Knife/Diathermy
Dissection of submucosal layer
Natural Orifice TransLuminal Surgery:
Via natural Orifice: Mouth, Vagina, Anus
No External Wound
Robotic Surgery: Da Vinci system
Console, Arms; 6 Axis movement, better than human Wrist; Movement Stabilizer
Potential Use: Urological Surgery, Cardiac Surgery, Vascular Anastomosis, Rectal Surgery?
Page 28
Pros: Movement Freedom, Filtered Movement (Tremor filtered), Minimized Paradoxical Movement,
Shorter Time?
Cons: Expensive (Even just the Disposable materials cost $5000 per Pt), Maintenance, Time for Setup
Page 29
General Radi Exam
CXR:
Rib Fracture:
Mx: Analgesia & O2 therapy
Chest Drain
Wont do Open Surgery to fix the Ribs
PneumoPeritoneum: Perforated Viscus: eg. PPU, Appendicitis, Diverticulosis
Normal in Post-op period
PPU Mx: Laparoscopy
AD:
CXR: Widened Mediastinum
Ix: Urgent CT Thorax preferably with Abdomen
AXR:
IO: If see Large Bowel Obstruction, look for Dilated Small Bowel (Incompetent Ileocecal valve)
Small Bowel features: Valvulae Conniventes
Mx: May consider a CT scan if Pt Stable: Help Surgery planning
Stoma to relieve Obstruction (May resect CRC in the same time)
GE: May have Non-specific Dilation of Bowel (esp after given Buscopan)
IO Not resolved: QM: Gastrografin (a Water-soluble Contrast) followthrough
Others: May just directly proceed to Surgery
Gastric Outlet Obstruction:
Double Bubble Sign (1 Gastric Bubble on Left, 1 Bubble on Right) Duodenal Obstruction
NG tube output: Non-Bile stained
Common causes: Chronic Ulcer or Gastric CA
Barium Meal may show a U-shaped Stomach
AAA: May see Calcification outline
Pt may often complain Left side Pain (esp for Infrarenal?)
Stable: CT and prepare for EVAR
Acute Cholecystitis: AXR: Uncommon to see Gallstone; Mainly to rule out other things
Then do US
Mx: Antibiotics if Fever, Laparoscopic Cholecystectomy
If Pt too ill, may do a PTC first
Liver Abscess: May present with picture of Acute Cholangitis
Common in Pt with DM
Common Pathogens: E.coli, Klebsiella
Ix: CXR/AXR
US Abdomen: If see Normal GB & CBD, but SOL in Liver> Contrast CT
Contrast CT
Mx: IV Antibiotics (Empirical: 3rd gen Cephalosporin + Metronidazole)
Percutaneous Drainage (Surgical Drainage seldom done now)
Serial CT scan (If Persistent, also think about Malignancy)
Page 30
General Radi Exam
GERD: May see Gliding Hiatus Hernia
AXR: Airfilled structure behind Heart shadow with Fluid level
Ddx: Hiatus Hernia, Lung Abscess, Diaphragmatic Hernia
Lateral film to confirm
Dx: Upper Endoscopy
Tx: Usually PPI
If want to offer Surgery, usually need more Workup (eg. 24h Acid study)
Ischemic Bowel: May happen in, eg. Hx of AF with Poor Compliance on Warfarin
PE: Generalized Tenderness, Absent Bowel sound
PR: Blood-stained Stool
ABG: Metabolic Acidosis
AXR: Non-specific findings
Dilated Bowel (Ileus)
Linear Lucencies seen in Bowel wall consistent with Bowel wall Gangrene; Risk of Perforation
Mx: CT / Emergency Laparotomy
Pelvic X-ray:
Urethral Injury:
Trauma Series: Also do CXR, C-spine X-ray
Dont: Do Not do Foley in Urethra Injury
Cervical X-ray:
Foreign Body Ingestion:
If present with Fever, suspect Abscess formation
Cervical X-ray: Fish bone can Not be seen (only Chicken & Pork bone)
Purpose is for Soft tissue Swelling

Page 31
General Radi Exam
General Surgical Nutrition
Malnutrition:
Definition: Gross Underweight: Weight for Height <80% of ideal weight
Recent Weight Loss of 10% over 3 months
BMI <18.5 (More conveniently used than above 2 definitions)

Severity:
Gross Malnutrition:
(Hx: May complain of difficulty to fit usual Clothes/Belts)
Can be recognized readily by PE
Severe Wasting & Loss of SC Fat
Loss of Cheek Fat, Obvious Intercostal space, Sarcopenia (Loss of Muscle Mass)
Manifestation of Deficiency of Vitamins & Minerals are sometimes obvious
Less Severe Malnutrition:
Can be detected by Anthropometric & Lab studies
Measurement of Nutritional Status:
Measure of Static Calorie reserve:
Triceps skinfold, Subscapular skinfold
Measure SC Fat Thickness by Skin fold Caliper

Measure of Static Protein reserve:
Midarm circumference, Psoas muscle density & area on CT (L4 level)
Page 32

Measure of Circulating Protein status:
Long half-life protein (Albumin)
Short half-life protein (Transferrin, Prealbumin, Retinol-binding protein)
Measure of Immune function:
Delay Hypersensitivity skin reaction, Total Lymphocyte count
Assessment of Nutritional status:
Hx: Dietary Hx
Significant Weight Loss within last 6 months
>10% Loss of usual BW or 4.5kg
Compare with ideal weight, BMI <10th percentile
Beware Pt with Ascites/Edema
Pt who are or expected to fast for >7 days
PE: Sunken Eyes
Loose Skin, Tissue Turgor
Evidence of Muscle wasting
Depletion of SC Fat
Peripheral Edema
Features of Vitamin deficiency, eg. Nail & Mucosal changes
Ecchymosis & Easy Bruising
Anthropometry:
BMI (<19, or >10%)
Triceps-skin fold
Mid arm muscle circumference
Bioelectric impedance
Hand grip dynamanometry
Biochemical Estimations:
Albumin <30 mg/dl (half life 21d)
Pre-albumin <12 mg/dl (half life 2d)
Transferrin <150 mmol/l (half life 7d)
Total Lymphocyte count <1800/mm3
Skin Anergy testing
Scoring System: Nutrition Risk Index = 1.519 x albumin (g/l) + 0.417 x [current weight/usual weight] x 100
<83.5 considered as Severely malnourished
Malnutrition Universal Screening Tool (MUST)
Subjective Global Assessment (SGA)
Page 33
Predisposing Cause:
Oral intake: Usually due to Anorexia or Diseases obstructing Upper GI, eg. CA Esophagus
Loss of Apetitie, Alcoholism, Inability to feed (Trauma, Stroke, Dementia),
Disease of Oropharynx/Esophagus, Dysphagia
GI Loss: Intestinal Fistula, Obstruction, Inflammation, Diarrhea
Catabolism: Burn, Acute Pancreatitis, Sepsis, Cancer Cachexia, Organ Failure, Major Surgery (Trauma)
Cancer Cachexia: Substances that alters Taste sensation & Substances that induce Wasting
Risk to Pt: Implications: Poor Wound & Anastomosis Healing
Impaired Resp muscle function
Impaired Cardiac function
Gut smooth muscle atrophy
Impaired host defenses
Influence on Outcome of Surgery:
Cx rate by 4x, Mortality rate by 6x

HypoProteinemia:
Renders Pt unable to handle excess Salt/Water intake
Bowel Edema inhibits GI function
Wound Edema inhibits Healing
Impairs CV response to Shock
Muscle wasting: Impairs Ventilating capacity, Susceptibility to Ventilatory Failure & Chest Infection
Wasting & Weakness of Resp muscles> Unable to Breathe & Cough efficiently
Surgery induces Proteolysis> Aggravates Wasting
Atelectasis & Sputum Retention occur esp in Post-op (Also factor of Wound Pain)
Impaired Cell-mediated immunity:
Susceptibility to Infection
Means to avert Malnutrition:
Nutrient intake
Eradicate cause of Malnutrition, eg. Drainage of Abscess, Resection of Cancer
Eradication involves Surgery itself too> Peri-op Nutritional support important
Peri-op Nutritional Support:
Rationale: Operation induces Catabolic response to Surgery, Proteolysis & Immunocompetence
Intensive Nutritional therapy can Net Catabolic response to Surgery, Protein Synthesis
which is critical for maintaining Muscular, Resp, Metabolic & Immunologic functions
Page 34
Efficacy: With Parenteral Nutrition
RR 21% for Major Cx, RR 32% for Case-fatality, Save hospital cost
Indication: Malnourished Pt undergoing Major Surgery
All Pt undergoing Major operations with Long period (>7 days) of Fasting after Surgery
Post-op Cx: Catabolism, Absent oral food intake
Means: Pre-op: Oral/Enteral/Parenteral (~2 weeks)
In general Oral/Enteral is preferred Less Expensive & Less Cx
If GI tract Not functional, Parenteral is chosen
Optimum duration 2 weeks: Partially corrects Nutritional deficiency
If too Long, Cancer absorb & grow faster
Post-op: Parenteral then Enteral/Oral
Parenteral immediately after Surgery when CV condition is Stable
Once GI function returns, give Oral/Enteral
Enteral Nutrition:
Always more preferred to Parenteral feeding:
More Physiological
Less Cx
Prevent Gut Mucosal Atrophy and therefore Bacterial translocation
Less Costly
Shown to ICU & Hospital stay
Indication: Functioning GI tract that can be used safely (>100 cm Small bowel, Normal Absorptive function)
Burn, Upper GI tract obstruction (Portion distal to CA Esophagus/Stomach still functional),
Chemo/RT for lesions other than GI tract (Poor Appetite, so Enteral better than Oral)
Admin by Tube when: Pt unable to Swallow
Pt unwilling to eat due to Cancer/Tx-induced Anorexia
Contraindication:
Ileus, IO, High output Fistula >500 ml/day, Bowel Ischemia, Short gut syndrome (<100 cm),
Intractable Diarrhea
Route:
*Nasogastric/Nasoduodenal/(Nasojejunal) tube:
Radioopaque tube/marker at tip; Must be identified before feeding given
Can be advanced into Duodenum to avoid Regurgitation & Aspiration

Gastrostomy: Percutaneous Endoscopic Gastrostomy (PEG), Open Gastrostomy
(LT NG tube use can cause Reflux Esophagitis; PEG may be better in this situation)
Page 35

Jejunostomy:

Pros Cons
NG tube Easy to insert/reinsert Easily dislodged
Suitable for Temporary use Requires Normal Gastric emptying
Cheap Risk of Aspiration
Allows bolus feeding Nasal Necrosis
NJ tube Suitable for Delayed Gastric emptying Requires Endoscopic/Fluoroscopic
Less risk of Aspiration guidance for insertion
Easily dislodged
Requires patent GI tract
Bolus feeding Not possible
Requires Feeding pump
Nasal Necrosis
Open Gastrostomy Easy to reinsert Requires Laparotomy
Large bore More Invasive
Allows Bolus feeding
Permanent/Temporary
Socially more acceptable
PEG Same as Open Gastrostomy Not possible in those with:
Except GA & Laparotomy Not required Obstructed Oropharynx
Trismus
Risk of Bowel/Liver perforation
Jejunostomy Same as Open Gastrostomy Bolus feeding Not possible
Bypass Stomach/Pancreas Requires Laparotomy
Formula:
Polymeric: Whole/Intact Protein, Polysaccharide/Starch, TG, Electrolytes, Trace Elements & Vitamins
Suitable for >90% Pt with near normal GI absorptive function
1 cal/ml, minimally Hyperosmolar (300 Osm/kg), used in most instances
Eg. Isocal, Osmolite, Ensure
Monomeric (Elemental diet): (Readily Absorbable)
Free a.a., Oligopeptides, Oligosaccharides, Medium-chain TG
Page 36
Minimal Intraluminal Hydrolysis
Suitable for Pt with severe Pancreatic Exocrine Insufficiency, or Short Gut syndrome
1 cal/ml, Hyperosmolar, used in GI Fistula, Pancreatic disease
Minimal Intestinal & Pancreatic Stimulation, but Hyperosmolar (Induce Diarrhea)
Eg. Peptamen
Special Formula for different diseases:
DM: Glucern Low Glucose
Chronic Liver disease: Aminoleban BCAA
COPD: Pulmocare Low Carbohydrate
Uremia: Nephro Nitrogen
GI disease: Peptamen Elemental diet
Admin: Starts at a dilute strength, eg. Half strength & Low volume, ie. <30 ml/h
Allow intestine to adapt to the Nutrient & Avoid Diarrhea
Continuous infusion (by Gravity or preferably by Pump) preferred to Bolus feeding
Bolus feeding is Convenient but may lead to Aspiration (Regurgitation from Full Stomach)
Solution must Not be allowed to stand at Room Temp >6h (Bacterial Contamination)
Check Residual volume in Stomach every 4h in Continuous feeding or Before each Bolus feeding
If Fluid volume >50% of infusion, temporarily withhold feeding to avoid Full Stomach
Avoid feeding in Supine/Flat position (Aspiration)
Assessment: Poor Tolerance indicated by: Vomiting, Abdominal distension, Diarrhea
Gastric residue >50% volume given in previous 4h feeding> Withhold feeding
Cx (overall 12%):
Tube-related:
Malposition: Inadvertent insertion of Catheter into Bronchial tree:
Drowning if feeding is given without Awareness of Erroneous positioning
Perforation into Pleural cavity leading to Pneumothorax/Hydrothorax
Blockage
Sinusitis
Nasal Ulceration
GI: Distention/Bloating: Over-feeding
Gas formation (Fermentation of food that Not absorbed immediately)
Cramping, Intestinal colic
Diarrhea: Failure to absorb what is given or Hyperosmolarity of content
Vomiting: Delayed Gastric emptying & Over-feeding
Infectious: GE (Bacterial Contamination)
Aspiration Pneumonia
RF for Aspiration: Sensorium, GastroEsophageal Reflux, Over-feeding
Metabolic: Dehydration: Diarrhea, Sequestration of fluid inside bowel
Electrolyte disturbance: Diarrhea
(Hyperglycemia)
(Contraindications to PEG: (MCQ)
Page 37
KM Chu: Gastrectomy
Previous Upper Abd Surgery
Candidates for Esophageal CA surgery (PEG may damage stomach, cause adhesion))
Parenteral Nutrition: Pros: Allows Greater Caloric intake
Feasible in Pt without a Functional GI tract:
Paralytic Ileus, Short Gut syndrome, High output Fistula,
Coexisting Abdominal Trauma, Severe Pancreatitis,
Non-occlusive Ischemic Entercolitis, SMA syndrome, Crohns (active phase)
Cons: More Cx compared to Enteral Nutrition
Requires more Expertise
More Expensive
Composition: Protein: Amino acid 300 mg N/kg/day
Carbohydrate: Glucose 30 cal/kg/day
Fat: Long-chain Triglyceride, Medium-chain Triglyceride, Atmost 1 g/kg/day
Protein:Calorie Ratio: 1 g N : 100-150 Kcal
NB: Calorie provided by Carbohydrate & Fat should Not exceed a total of 30 cal/kg/day
TG are derived from Soya beans; They are Foreign to Pt
Long-chain: Deposited in Liver, Body Fat & Reticulo-endothelial system
Medium-chain: Not deposited in Liver; Only a small amount taken up by RES
Better It induces Lower incidence of Fatty Liver & Saturation of RES
Usually used in combination with Long-chain TG
Long-chain TG is still needed for Normal cell function & formation
Route: Parenteral Nutrition means Nutrition given to Venous system
Peripheral Parenteral Nutrition (PPN) vs Total (Central) Parenteral Nutrition (TPN)
- Peripheral vein Nutrition
Low Dextrose, Lipid base (Fat Emulsion provides 60% of Calorie)
Fat Emulsion Irritating effect of Amino acid on vein wall
Otherwise Peripheral vein will be thrombosed immediately
Lower Osmolarity, Larger Volume load
Undesirable: Even with Fat Emulsion, still thrombosed in 1-2 days
Full dose of Parenteral Nutrition cant be given (Can only give Diluted solution)
Suitable: Short term use in anticipation of Rapid GI tract recovery & Oral nutrition
For Low Caloric requirements
- Central vein Nutrition/Total Parenteral Nutrition
Provide Full Nutritional support (Full dose can be given)
High Dextrose concentration
Higher Osmolarity, Smaller Fluid load
Large volume of blood flows at a High rate in SVC
Amino acids & Glucose are diluted rapidly> Irritating effect to vein wall greatly
Concentrated solution can be given, Worry of overloading the circulation
(SVC better than Brachiocephalic veinLarger, and better than RANo Arrhythmia)
Page 38
Means: Catheter (silicone) with tip in Central vein (eg. Hickman/Broviac Catheter)
Insertion by Puncturing method or Cut-down (Direct exposure) method
Site of Insertion: Puncturing: Subclavian vein/IJV
Direct Exposure: Cephalic vein/EJV
Usually Silicone Catheter is employed
Least Irritative to Vein, Less Thrombogenic, probably Less susceptible to Infection
CXR to confirm Position of Catheter tip

IV fluid administration set/tubing
Bag/Bottle containing Nutrients
Either separately in Individual Bottles or Mixed in a Bag (3 in 1 TPN bag)
Admin: Principle: Caloric source (Carbohydrate/Fat) infused with Protein (Amino acid) simultaneously
to spare Amino acid for Protein synthesis/Anabolism
Slow, regulated by Infusion pump (eg. 24h)
Avoid overloading the circulation or administering too many nutrients inadvertently
3-in-1 TPN system or 2 bags in Y connection (More Cumbersome, Less used nowdays)
3-in-1 TPN system Y connection system

Cx: Related to Catheter:
Catheter Sepsis: Source of Bacteria usually Skin, sometimes Contaminated Nutrient
Dx: Culture Catheter tip & Nutritional solution
Tx: Prompt cessation of Parenteral Nutrition & Catheter Removal
(Recommendation to avoid Line Sepsis: Change every 7 days)
Catheter Embolism: Tip segment of Catheter is dislodged into SVC,
and migrates into Pulmonary artery
Tx: Retrieval by Wire basket under Radiological guidance
Page 39

Air Embolism
Catheter Blockage
Arrhythmia
Related to Percutaneous Puncture:
Pneumothorax: Pleura is punctured during Percutaneous Insertion into Subclavian V
Hydrothorax: Catheter inserted into Pleural cavity instead of SVC
Hemothorax: Catheter induces Bleeding/Injury to Subclavian A/V
Cardiac Tamponade: Catheter puncturing into Pericardial sac
Arterial puncture, Brachial plexus injury, Thoracic duct injury
Related to Nutrients:
Excessive Glucose (Hyperglycemia):
Fatty Liver: Glucose Not utilized promptly> Converted to Fat> Deposited in Liver
CO2: Oxidation> CO2 production
Normally Not problematic, except in Elderly with COPD
Phagocytic function: Hyperglycemia (>12 mmol/l) can suppress MQ function
Ketoacidosis: Hyperglycemia induces a condition similar to uncontrolled DM
Excessive Fat (HyperLipidemia):
Fatty Liver: Fat (esp Long-chain TG) are Not immediately utilized
Saturation of RES: Infused Fat are foreign to Pt; Susceptibility to Infection
Excessive Nitrogen (HyperAmmonemia):
Uremia: Excessive aa are Not utilized for Anabolism but converted to Urea
Cholestasis
Prescription:
Protein: Amino acid solution 300 mg N/kg/day
Glucose & Fat: 30 cal/kg/day
Vitamin (multi): 5-10 ml
Trace Mineral: 10 ml
Electrolytes: Na, K, PO4, Mg
5 Steps to determine regime:
Calculate Daily Fluid requirement
Calculate Daily Caloric requirement & Proportion of Carbohydrate to Fat
Calculate Protein requirement
Calculate Electrolyte requirement
Determine Additives
Daily Fluid requirement:
Pre-existing Loss
Page 40
Daily Maintenance: Calculated by BW, 30ml/kg/day
On-going Loss: Based on IO chart (drains output)
Insensible Loss (by 10% for every 1C in Temp)
Caloric requirement:
Total Energy Expenditure (TEE) = Basal Energy Expenditure (BEE) x Stress factor x Activity factor
BEE estimation:
Harris-Benedict Equation: Gender, BW, Height, Age, Activity level
Male: BEE = 66 + (13.7W) + (5H) (6.8A)
Female: BEE= 655 + (9.6W) + (1.8H) (4.7A)
Schofield Equation:
25-30 kcal/kg/day
Stress Factor: Elective Surgery +10%, Peritonitis +15%, Fever per 1C +13%, Trauma +30%,
Severe Sepsis +60%, >40% Burn +100%
Activity Factor: Bedbound +20%, Ambulant +30%, Active +50%
Content: Carbohydrate usually form 60-75% of calories
Fat usually form 25-40%
Energy values: Glucose 4.1 kcal/g, Fat 9.3 kcal/g, Protein 4.1 kcal/g, Alcohol 7.1 kcal/g
Protein requirement:
6.25g of protein contains 1g of Nitrogen
Daily protein requirement: Estimate 1-1.5g/kg/day
Up to 2.5g/kg/day in severely catabolic Pt
Calorie to Nitrogen Ratio: 150cal : 1g Nitrogen
80-100cal: 1g Nitrogen in severely catabolic Pt
Aim to maintain +ve Nitrogen balance
Electrolyte requirement:
mmol/kg/day: Na 1-2, K 1, Mg 0.1, Ca 0.1, Phosphate 0.4
Additives: Vitamins: Water soluble Vitamins: Vit B1, B2, B6 & B12, Vit C, Biotin & Folic acid
Fat soluble Vitamins: Vit A, D, E, K
Trace element:
Iron, Zinc, Manganese, Copper, Chromium, Selenium, Molybdenum, Fluoride, Iodide
Available from Commercial preparations, eg. Soluvit N, Vitalipid N, Addamel N
Monitoring of Pt with Nutritional Supplement:
Clinical: Temp, Pulse, Urine output
Look for Signs of Dehydration/Fluid overload
Input/Output chart
BW
Haemostix
Biochemistry: CBC, LFT, RFT
Line care
Special Circumstances in Nutritional supplement:
Major Burns: Cery Catabolic, marked Calorie & Protein requirement
Page 41
Pancreatitis: Calorie & Protein requirement
Recent trials suggest Early feeding may result in Infectious Cx
Liver Failure: Some evidence with the use of Branched chain amino acids (BCAA) & use of Aromatic a.a.
Renal Failure: Volume, Protein, K & PO4
HF: Volume
COPD & DM: Carbohydrates
Factors affecting Outcome of Surgery:
Pre-morbid condition: Organ function reserve, Nutritional status
Surgical technique
Nutritional Repletion:
Nutritional repletion is one of the methods to improve Outcome of Surgery
Improve Wound healing, /Overcome Infectious Cx, Improve Mobilization

Page 42
General Surgical Oncology
Intro: Surgical Tx is the most successful method of Cancer therapy currently available
Recent advances in GA, Peri-op ICU care, Nutritional therapy & Innovation of Surgical technique
have improved Cancer cure rate by Surgery
Why Surgery able to Cure Cancer:
Scope of Cancer Surgery should include Cancer itself
together with a rim of tissues containing No gross tumour (Tumour-free resection margin)
in order to remove Microscopic spread, and Regional LN
Cancer: Aberration of Cell growth
Cells survive & multiply indefinitely
Growth without orderly Histology of primary organ
Non-functional
Spread, invade & destroy tissue locally
Spread to distant organs via Bloodstream/Lymph
Replace & destroy distant organs
6 Mutations for a Normal cell converting into a Cancer cell:
Self-sufficiency for Growth signals
Insensitivity to Anti-growth signals
Evasion of Apoptosis
Limitless ability to replicate
Sustained Angiogenesis
Tissue Invasion & Metastasis
Spread of Cancer: Local: Primary site & adjacent tissues/organ
Regional: LN
Distant: Lung, Bone
Cause of Mortality: Cancer Invasion of organ of origin, adjacent organs or distant sites> Loss of organ function
Cancer Cachexia: Anorexia
Progressive, Involuntary Weight Loss
Muscle wasting, Lethargy, Malnutrition
Anergy
Infection
Terminal event
Outcome Measurement:
Hospital Mortality rate
No. of Pt who die from operation during same hospital admission for surgery,
irrespective of Cause of death & Duration of hospital stay
30-day operative Mortality rate
No. of Pt who die within 30 days of surgery
Hospital Mortality rate is more accurate
Many Pt can survive beyond 30 days in ICU even with Cx that eventually lead to death
(5-year) Disease-free Survival rate:
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Proportion of Pt surviving without Recurrence of Cancer
(5-year) Overall Survival rate:
Proportion of Pt surviving after operation irrespective of Cause
Pt surviving but with Recurrence of Cancer are counted as Survivors
QOL: How life of Pt is affected by operation
Current 5-year Overall Survival rate of most Cancers treated by Surgery:
Tends to be better for Early-stage Cancer
Hospital Mortality rate 1-5%
Breast 85% (Good Screening & Chemo), Liver 55%, Colon 50%, Lung 45%, Pancreas 20%
Reason for Not having 100% Survival rate:
Operative Mortality esp Major operation
Microscopic spread via Bloodstream/Lymphatic already present at Time of surgery
Radical Surgery can eradicate Lymphatic spread but Not Hematogenous spread
New growth/recurrence from Occult foci still possible after Curative surgery
Resection Tumour-free margin is Not always attainable
Eg. Cancer is close to Indispensable Viscera/BV
Mobilization of Cancer & Organ bearing Cancer may lead to Dissemination of Cancer cells
Loss of organ/limb/tissue function as a part of operation may affect Survival/QOL
Basic Principles to improve Survival rate:
Principles: Complete Extirpation of tumour with good Tumour-free resection margin (1-2cm)
Minimum Manipulation of tumour & tumour-bearing organ
Clearance of Lymphatic drainage which may harbor Microscopic/Macroscopic spread
Minimum disruption of organ function
Minimum Blood loss & Blood transfusion
Determinants of Survival after Cancer Surgery:
Overall, Pt Survival rate is dependent on Tumour stage, Blood Loss volume,
Requirement of Blood transfusion, and Function of Organ bearing the tumour
Tumour stage: Tumor-Node-Metastasis (TNM) staging at time of surgery
Most widely used system that provides a Prognostic guide
Used for Comparison of Tx results between Centres/Methods
Blood Loss volume:
Dependent on Experience & Technique of Surgeon & Difficulty of operation
Major blood loss is undesirable:
Hypotension, Hypoperfusion of major organs, Postoperative Organ Failure,
Need for Massive Blood transfusion
Blood Transfusion & Cancer Recurrence:
Transfusion> Immunosuppression & Loss of control of Microscopic foci> Rapid Recurrence
Loss of immune control of Cancer cell
due to Transfused Histocompatibility Ag inducing Specific Immunologic Non-reactivity
Organ dysfunction:
May occur when part of organ bearing the tumour is removed
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Eg. If 80% of Liver with Liver Cancer is removed, Pt may lapse into Liver Failure,
which may shorten Survival period if Liver does Not regenerate rapidly
(Also can be due to Physiological disturbance induced by Massive Bleeding)
Consequence: Poor QOL, Need for Medication, Hospital Cost, Mortality
Others: Completeness of Tumour Clearance
Close Surveillance after surgery
Prompt Tx of Recurrence
Compliance of Pt to Tx & FU
Possible to treat Cancer Recurrence after Surgery:
Depending on Site, Size & Number of Cancer Recurrence
Some Recurrence can be treated by Surgery again or other modalities
However, Recurrence must be Small before re-Tx is possible
Close Surveillance is necessary after all cancer operations
Imaging possible sites of spread & Measurement of serum tumour marker levels
Possible to Prevent Cancer Recurrence after Curative Surgery:
Adjuvant Chemo/RT can avoid Recurrence in some but Not all Pt
Due to S/E of Chemo & RT, Adjuvant Chemo should be given to Pt at High risk of Recurrence
Regional LN metastases in Resected margin
Vascular permeation by Cancer cells on Histological exam
Advanced TMN stage
Genetic marker
(Eradication of Microscopic foci by Extirpation of organ:
Liver Transplant, Total Colectomy, Total Pancreatectomy
ST Fan: The above Cancers tend to be Multifocal)

Page 45
General Tubes & Drains
Definition: Mechanical conduit to allow passage of substance (gas/liquid/pus)
from body to external environment
(Not always a Tube, eg. Corrugated drain)
Classification:
Open vs Close:
Open: Connected into Environment
Close: Connected into Container/Bag
Pros: Infection rate, Accurate measurement of output
Active vs Passive:
Passive: Drain by use of Natural difference, eg. Gravity, Capillary action
Active: Drain by use of Suction force, eg. Vacuum
Pros: Better Tissue Apposition, Effective Evacuation, Less debris blockage
Cons: Higher chance of Tissue Erosion (Not used in Abd cavity)
Must be Close system (No Open Active drain)
Size: Diameter of tubes are often numbered as Multiples of 2
Unit: French (Fr/Ch): 24Fr = 24/pi = ~8mm
Material: Red Rubber: eg. Sengstaken tube, Corrugated drain
Latex Rubber: Irritative, Stimulate Fibrotic reaction
Silicon Rubber: Expensive, but Inert, Harder, Suitable for LT use; eg. LT Foley
Plastic
Indications: Diagnostic (eg. Abdominal tapping)
Monitor (eg. Foley catheter, CVP)
Prophylactic
Therapeutic: Decompression (eg. Ryles tube)
Drainage (eg. Tubal drain)
Administration of Drugs/Fluid (eg. Hickmans catheter)
Purpose of Drains:
Withdrawal of fluid:
Robinson drain, JP drain, Chest drain
Apposition of tissues to remove a potential space by suction:
Chest drain (Appose Parietal & Visceral pleura to seal any Visceral pleural holes)
Cx: Immediate: Trauma at insertion
Early: Dislodged drain
Inadequate drainage (Incorrect placement, Too small, Blocked lumen)
Late: Infection
Erosion of adjacent tissues
Retained Foreign body during difficult removal
Mechanical: Trauma at Insertion & Removal
Erosion of adjacent tissue: Fistula, Hemorrhage, Perforation
Herniation through tract
Page 46
Anastomotic Leak: Place too near the Anastomoses
Physiological: Infection
Loss of Fluid & Electrolytes (excessive/inadequate)
Pain
Restricted Mobility
Malfunctioning: Migration & Dislodgment
Blockage (Externally by Kinking, Compression/Internally by Tissue/Clot
Suction Failure
Identification: Clinical photo: Specific features: Waveform of Corrugated drain, Grenade of JP drain
Specific color: NBT is Pink, Pigtail is White, T-tube is Yellow (Foley-like)
Bedside: Site: Nose, Neck, Chest, Abdomen, Main-wound
Output: NBT & PTBD Bile (Golden Yellow or Deep Green)
R/D Blood stained fluid
Marked on Bedside bag
Vascular Access: Eg. CVP line, Hickman, Port-A-Cath
Specific Cx: Pneumothorax, Bleeding, Dysrhythmias
Seldinger technique:
Insert Guidewire into introducing needle
Wider bore cannula passed over the wire after removing the introducing needle
Then remove the Guidewire
Central Venous Catheter/Central line:
Triple Lumen/Double Lumen
Indication: CVP monitoring
Administration of Fluid/Medications
Rapid Infusion
Infusion of Hypertonic solutions & Medications that could damage veins
Hemodialysis
Transvenous Cardiac Pacing
Serial Venous blood assessment
CVP: Normal: Usually 2-6 mmHg; Normally <10mmHg/8cmH2O
: Overhydration which Venous return
HF/PA Stenosis which limit venous outflow> Venous congestion
PPV, Straining, etc
: Hypovolemic Shock from Hemorrhage, Fluid shift, Dehydration
NPV which occurs when Pt demonstrates Retractions
or Mechanical NPV which is sometimes used for High SCI
Site: Catheters placed into major veins, eg. Internal jugular, Subclavian, Femoral vein
Contraindicate:
Bleeding tendency, Ipsilateral Carotid A Aneurysm
Procedure:
From Ear to Medial end of Clavicle, lie inbetween 2 heads of SCM
Page 47
Use of 14/16 Angiocatheter
Head down & turned to opposite side
Sterile the Neck
Insert Angiocatheter 0.5-1cm Lateral to Carotid pulse
Advance Angiocatheter towards Ipsilateral Nipple
and Maintain gentle aspiration till a Gush of Dark red blood is aspirated
Gently withdraw stylet of angiocatheter while pushing angiocatheter into position
and connect to infusion
Check Backflow to ensure its in vascular space
Never advance beyond Clavicle
Lie flat & Check 1st reading
CXR to exclude Pneumothorax
Maintain patency with infusion of fluid
Cx: Pneumothorax, Air Embolism, Thrombosis, Arterial puncture,
Hematoma, Pseuoaneurysm, Infection, Thoracic duct injury
Hickman Catheter/Line: (LT Tunneled Central line)
External Central line tunneled under the skin with a cuff
By Surgery or under X-ray guidance
Use: Administration of Medication/Fluid/Nutrition, Blood sampling
Site: Cephalic vein, IJV

Procedure:
Incision to identify the vein
Made incision over the vein and Insert the catheter
Make another skin incision to create SC tunnel
X-ray guidance to confirm the position of catheter
Secure the catheter
Keep Sterile over the Heparin lock
Maintain patency with flush of Heparin Saline
Port-A-Cath: Central line that has a port buried under the skin that must be accessed percutaneously

Ryles tube/NG tube:
Indication: Administration of Enteric Nutrition/Drugs
Page 48
(Not for LT Enteral feeding, due to MicroAspiration Pneumonia & Discomfort)
Decompression of Gastric & Bowel content (eg. in IO)
Prevent Aspiration (eg. Intra-op)
Contraindicate: Skull base Fracture, Severe Facial injury
Procedure: Prop up/Sit up
Measure from Pts Nose to Ear down to Xyphoid process
Lubricate the tip of tube, Insert into one of the Nostrils, Aim downwards & backwards
When arrive to Posterior pharyngeal wall, Pt will gag and then ask them to swallow
Comfirm Site: Gargling sound upon injection of Air (Listen on stomach with Stethoscope)
Aspirate fluid & Check pH (pH 5.5) (Litmus paper; Normal Gastric pH 2-4)
CXR/High AXR (Should cross diaphragm)
Entriflex tube/Enteral Feeding tube (NasoDuodenal/NasoJejunal tube):
Differ from NGT by: With Guidewire, Weighted end, Smaller in caliber
Administration of Nutrition, Fluid or Medications by NasoEnteric route
for Pt who have intact GI tract but physically unable to have oral feeding
8-12 Fr
Bedside/Endoscopy; Must be placed past Pylorus to facilitate absorption
(Confirm Site: Cross midline on CXR/High AXR)

Foley Catheter: 10F 28F; 1 French unit = 0.33mm
Type:
Material: Latex: Short term (max 2 weeks), Yellow tube
Silicon: Longer term (max 4 weeks), Transparent
Port: (Standard is 2-way)
3-way: Additional Irrigation channel, for Hematuria Pt
Indication: Monitoring
Therapeutic: AROU (eg. BPH, Post-spinal anesthesia)
Unable to self urinate due to paralysis
Pt undergoing Urethral surgery
Pauls tube/Condom Catheter:
(Pros: Less Invasive)
(Cons: Can dislodge when Pt has Morning Erection)
Chest Drain:
Indication: Pneumothorax, Hemothorax, Pleural Effusion/Empyema, Post-thoracic surgery
Simple Pneumothorax:
Ipsilateral Chest wall movement, Hyperresonace on percussion, Breath sound,
Surgical Emphysema
Open Pneumothorax:
Page 49
Penetrating Chest injury with Open wound over Chest wall
If Length of wound > Diameter of Trachea, Air will suck into Thoracic cavity through the wound
Occlusive dressing> Taped 3 sides to create an 1-way valve
Only allow air to escape during expiration, but Not suck in during inspiration
Insert Chest drain at another site
Tension Pneumothorax:
Need to recognize early since it will cause death!
Signs: Trachea deviation to oppsite side, Hypotension, CVP, Cyanotic
Do Not wait for CXR to confirm Dx
Needle decompression at 2nd ICS, MCL
Chest drain insertion
Site: Safe zone: Lateral border of Pectaralis major
Anterior border of Latissimus dorsi
Horizontal line of Nipple
Below Axilla
th
5 ICS, Anterior to MidAxillary line
Aim: Aim at Apex if for Pneumothorax
Aim at Base if for Drainage of fluid
Size: 24 Fr: For Effusion & Air
28 Fr: For Blood & Pus
Procedure: Get Consent
Sit up 45 with Arm Flexed & Put behind & above head
Monitor SaO2 + Give O2
Sterile the Chest wall, Locate the Insertion site, Give LA
Make incision over Chest wall
Use Blunt dissection through Intercostal muscle into Pleural cavity
Sudden give way & gush of air blood
Put in finger to free adhesions around if any
Introduce the tube inside, Connect to underwater seal suction bottle, Anchor the drain
CXR

3-bottle Chest Drain System:
Page 50

Chamber:
Collecting chamber:
Collect Pleural fluid
Water Seal chamber:
Prevent air being sucked in by ve Pleural pressure during Inspiration
Swinging should be looked for as a Rise & Fall of fluid level in the tube
Bubbling should be looked for in Water Seal chamber
Presence of Bubbling indicates Air Leak
Air Leak Meter (1-5) provide a way to measure the Leak & Monitor over time

Swinging Bubbling Interpretation
Indicates Air Leak (From Lung like Pneumothorax, or from Circuit)
Indicates Resolution of Air Leak & Effusion, with Lung Re-expansion
X X
Make sure Tube is Not obstructed
X May be seen in Partial/Total Pneumonectomy & in Stiff Lungs
Indicates a possible Connection/System Air Leak
Can temporarily occlude chest tube right at skin exit
X
If Bubbling continues, Leak is External to Pt
Hissing sound may point to the Leak
(In Pt with Pneumothorax, if Pleurodesis is done successfully, Swinging may disappear)
Page 51
Suction Control chamber:
Amount of Vacuum is directly proportionate to Depth of tip of Central tube under water surface
It should always be Bubbling
(Volume of Liquid inside the chamber determines the Max Suction force that can be applied
If 10cm water, the Max suction force is -10 cmH2O regardless of pump setting how High
Avoid over-suction)
(But if Pump setting is Lower than Amount of water,
Suction force is directly proportional to Pump setting)
Operative Wound Drains:
Eg. R/D, JP drain, Minivac
Indication: Anticipated fluid collection in a Closed space> Prevent Seroma formation
Eg. Pelvic surgery, Modified Radical Mastectomy
Robinson drain (R/D): (Tubal drain)
After major Abd surgery, eg. Laparotomy for perforated viscus, TEMS
Features: Side-hole, Radio-opaque line along Transparent tube, Free drainage to BSB

Jackson-Pratt drain (JP drain): (Flat drain)
A Closed drainage system attached to a Suction bulb; Flat tube with Side-hole
Eg. MRM
The bulb must be deflated to provide suction

Ddx Minivac:
Smaller suction bulb & tube than JP drain
Eg. After Femoral-Femoral Bypass
(Redivac drain:
Connected to Glass bottles)
Infected Abscess Cavity Drain:
Eg. Pigtail, Corrugated drain
Principle of Abscess Mx: I&D + Antibiotics
Pigtail catheter: Indication: Deep seated collection, eg. Liver Abscess, Pelvic collection, Renal pelvis drainage
Imaging guided insertion & removal
Page 52
Whitish tube, Small caliber, with Side-hole (Avoid Tissue Trauma, Drainage Surface Area)
(Can be locked after placement to prevent dislodgement)

Corrugated drain:
Useful for SC Abscess
Cut a strip of rubber to fit loosely and Push this into the depth of the wound
Waveform, Rubbery, White/Orange in colour

Yeates drain:
Only available form of Open Passive drain in QM (Corrugated drain No longer used)
Row of Straws - Surface area & Lumen provides Capillary action drainage
Hepatobiliary drainage:
Eg. NBT, PTBD, Cholecystostomy tube, T- tube
Indication: Relieve obstruction (Benign/Malignant)
Provide drainage to relieve Sepsis (eg. Cholangitis, Cholecystitis)
NasoBiliary tube (NB tube):
Placed via ERCP
Pink in colour! Also with Sidehole
Relative Contraindication for NBT: Confused Pt
Otherwise similar efficicacy as Internal Stent
Have to remove within same admission
PTBD: Placed under imaging guidance
Prerequisite: Dilated ducts
Intrahepatic ducts> CBD> Ampulla of vater> Duodenum
Can facilitate PTC

Cholecystostomy tube:
Placed Surgically/Percutaneously to drain Gallbladder
Indication: Mx of Acute Cholecystitis in Frail Pt (Not fit for GA)
Page 53
T-tube: The opening of CBD is closed around T-tube; For Decompression of Biliary system
Pros: Act as Safety valve for Bile drainage in case of Temporary obstruction after ECBD
Facilitate Post-op PTC (Cholangiogram) / Choledocoscope

Tenckhoff Catheter: Catheter placed into Peritoneal cavity for Peritoneal Dialysis
(Usually placed on Left side in Virgin Abdomen, if Right side is reserved for Renal Transplant)
(Transplant on Right side: Wider choice of vessels for Reconstruction
Vessels more Horizontal (UCH: Superficial) for Anastomosis)
(Some may recommend putting Donor kidney at Recipients Contralateral side
So that Renal Pelvis & Ureter are more Anterior in case Future Surgery required)
Cx: Intra-op: Bleeding (If damage Inferior Epigastric arery), Perforation (Bowel, Sigmoid, Bladder), etc
Post-op: (Adhesive IO is Uncommon due to Catheter Inserion itself, as the tip is put into Pelvis)
(Failure: UCH: Local data show that 50% fail at 5-years, usually due to Omental wrapping (blockage)
Need Tenckhoff Revision with Omentectomy (Fix to Anterior wall))
Tracheostomy:
Indication: Airway obstruction Failed intubation,
eg. Severe Facial injury, H&N Cancer
Required LT Mechanical Ventilation
Type: Surgical Tracheostomy
Percutaneous Tracheostomy
Surgical Tracheostomy:
GA in operative theatre
Supine with Neck extended
Neck collar Transverse incision over neck, 2 fingers above Sternal notch
Split Strap muscles, Retract Thyroid gland, Identify Trachea
Longitudinal incision over 2nd-4th Tracheal ring
Insert Tracheotomy tube, Inflate the Balloon
Confirm position by checking for presence of End tidal CO2
Hemostasis, Secure the tube, CXR to exclude Pneumothorax & Look for the position
Type:
Temporary vs Permanent
Cuffed vs Uncuffed:
Cuffed: Closed circuit for Ventilation
Inflated when using Ventilator
Deflated when using Speaking valve
Uncuffed: Used for Pt with Tracheal problems, Young Children
Allow air around tube for Vocalization (May be possible without Speaking valve)
(Easier to insert in Emergency)
Page 54
Fenestrated or Not:
Fenestrated: Opening in Inner tube
Allow speech through Upper airway when External tube is blocked
Pros: For Pt with difficulty in using a Speaking valve
Cons: Risk of Granuloma formation at Fenestration site
Disposable vs Reusable Inner Cannula
Cx: GA risk
Wound Cx (eg. Infection, Bleeding)
Wrong position
Tube Blockage/Displacement
Surgical Empysema, Pneumothorax, Injury to surrounding structures (eg. Thyroid, RLN, Vessels)
Tracheomalacia
Sengstaken Blakemore tube:
Use in Esophageal Variceal bleeding (Temporary Hemostasis)
Kept in Refrigerator (Otherwise will be too Soft for Insertion)
Contraindicate: Suspected Esophageal Rupture/Stomach Perforation, (Esophageal Stricture, Large Hiatal Hernia)
Channels: Gastric Balloon: Traction to compress on GEJ to Blood flow to Esophageal Varices
(Should Not remain inflated for too long to avoid Necrosis)
Esophageal Balloon: Additional Bleeding control if Traction alone cant stop bleeding
Gastric Aspiration: Monitor Bleeding
(Esophageal Aspiration: For Saliva & Monitor Leakage
If present, this is called Minnesota tube)
Procedure: Estimate the Length of insertion from Nose to Ear down to Xiphoid process
Sit up the Pt, Lubricate tube with jelly, Insert like Ryles tube
Inject 200-250ml Water + Methylene blue into Stomach balloon
Blue dye is to visualize Leakage if Balloon bursts
Inject Air into Esophageal balloon 30-40mmHg
Connect the Gastric & Esophageal aspirate to bedside bags
Release the pressure of Esophageal balloon every hour

Linton tube: For Gastric Varices
Larger Gastric Balloon, No Esophageal Balloon
Analgesic: Eg. On-Q system, PCA (Pt Controlled Analgesia)
For Post-op Pain control
Placed intra-operatively
On-Q system:
Page 55

Page 56
General Suture
Ideal Suture: Minimal Tissue reaction
Smoothness Minimum Tissue drag
Low Capillarity (Ability of fluid to travel along the suture)
Max Tensile strength
Ease of handling Minimum Memory
Knot security
Consistency of Performance
Predictable Performance
Cost Effectiveness
Suture Size: Size refers to Diameter of suture strand
The more 0, the Smaller the strand diameter (eg. 4-0 or 0000 is Larger than 5-0 or 00000)
Classification: Natural vs Synthetic
Monofilament vs Multifilament (Braided)

Absorbable vs Non-absorbable
Monofilament vs Braided:
Monofilament:
Pros: No Capillary action, Less Infection risk, Smooth tissue passage, Higher Tensile strength
Cons: Has Memory, More Throws required, (More easily damaged/nicked)
Braided:
Pros: Better Handling, Better Knot security
Cons: Has Capillary action, Infection risk (Harbor Bacteria between strands), Less Smooth passage,
Less Tensile strength
But: Can be coated for Smoother passage
Can be impregnated with Antibiotics to Infection risk
Absorbable vs Non-Absorbable:
Absorbable: Defined by Loss of Tensile strength (rather than Absorption of Mass, which takes Longer time)
(Medscape: Lose 50% Tensile strength within 4 weeks via Hydrolytic/Proteolytic process)
Eventually absorbed within living tissue
Natural: Absorption via Enzyme-mediated Proteolytic process
> More Inflammation & Scarring
Synthetic: Usually absorbed via Hydrolytic process> Less Inflammation
2 Main characteristics: Tensile strength retention, Absorption rate
Natural: Gut suture (Catgut from Sheep GI submucosa)
Plain gut: Regular Plain gut
Fast-absorbing gut (Heat-treating gut) (Epidermal use only)
Chromic gut: Treated with Chromic oxide (Brown) to delay Absorption
Page 57
General Suture
Synthetic: Vicryl: Vicryl
Coated Vicryl: Help tissue passage, Accuracy of Knot placement, Incarceration
Coated Vicryl Rapide: Coated Vicryl ionized with Gamma rays
Currently Fastest-absorbing Synthetic suture in existence
Coated Vicryl Plus: Coated with Antimicrobial
PDS II: Commonly used to approximate Soft tissue
Monocryl: Most commonly used in Subcuticular skin closure
Others: Caprosyn, Biosyn, Dexon II/Dexon S, Maxon
(Quill/V-Loc: Barbed suture: Self-anchoring with No knots required)

Suture Configuration Reactivity Memory Time to 50% of Original Strength
Plain gut Monofilament High Low 5-6 days
Chromic gut Low 14 days
Polyglytone 6211 (Caprosyn) Low Medium 5-7 days
Poliglecaprone 25 (Monocryl) Medium 7-10 days
Glycomer 631 (Biosyn) High 4 weeks
Polydioxanone (PDS II) High 4 weeks (Longer than Vicryl)
Polyglactin 910 (Polysorb, Vicryl) Braided Medium 2-3 weeks
Polyglycolic acid (Dexon II) Low
Polyglyconate (Maxon) Low
(Green color by Covidien, Purple color by Ethicon)
Non-Absorbable:
Defined by maintaining Tensile strength in tissue for at least a period of time (eg. 60 days)
Silk, Linen & even Nylon will lost Tensile strength over a period of time
Polyester, Polyethylene, Polybutester, Polypropylene & Steel are truly Non-absorbable
Permanent; Encapsulated by Fibroblasts through Cell-mediated reaction
Only used when LT support is required
Removed when used for Skin
Tissue reaction generally Low (except Silk)
Natural: Silk: Behaves like a very Slow absorbable suture
Lost all Tensile strength within 1 year, Cant detect in tissue after 2 years
Strong Tissue reaction & High Capillarity encouraging Infection
Cotton
Stainless Steel: Least Reactive, Most Tensile strength, Does Not harbor Bacteria
Difficult to Handle (Highest rate of Surgeon exposure to Transmissible diseases)
Synthetic: Nylon: Monofilament (Ethilon) or Braided (Surgilon)
Good Memory & Little Tissue reaction, but Poor Knot security
(2013 MCQ: Good for Skin closure in Adult after Abd Surgery)
Page 58
General Suture
Prolene: Minimal Tissue reaction, Good Knot security among most Monofilaments
(2004 MCQ 86)
Polyester (Mersilene, Ethibond)
Suture Configuration Reactivity Memory Handling
Cotton Twisted High Low Good
Silk Braided
Polyester, uncoated (Mersilene) Medium
Polyester, coated (Surgidac, Ti-Cron, Ethibond)
Nylon Multifilament (Nurolon, Surgilon)
Nylon Monofilament (Monosof-Dermalon, Ethilon) Monofilament Low Medium Fair
Polybutester (Novafil (uncoated), Vascufil (coated))
Polypropylene (Surgipro, Surgipro II, Prolene, Surgilene) High Poor
Stainless Steel
Needle:
Needle Point:

Needle Curvature:
Page 59
General Suture

Page 60
General Suture
General Surgical Cx
Clavien Classification of Surgical Cx:
Grade I: Any deviation from normal post-op course
without need for Pharmacological Tx or Surgical/Endoscopic/Radiological interventions
NB: Allowed therapeutic regimens:
Drugs as AntiEmetics, Antipyretics, Analgesics, Diuretics, Electrolytes, and Physiotherapy
This grade also includes Wound infections opened at bedside
Grade II: Requiring Pharmacological Tx with drugs other than such allowed for Grade I Cx
NB: Blood transfusions & TPN are also included
Grade III: Requiring Surgical, Endoscopic or Radiological intervention
IIIa: Intervention Not under GA
IIIb: Intervention under GA
Grade IV: Life-threatening Cx, requiring IC/ICU management
NB: Including CNS Cx (Brain Hemorrhage, Ischemic Stroke, SAH; But exclude TIA)
IVa: Single organ dysfunction (including Dialysis)
IVb: Multiorgan dysfunction
Grade V: Death

Page 61
General Surgical Cx
OSCE Script Scrubbing
Script Action
Before scrubbing, I should have put on the surgical outfit
Suppose Im wearing the outfit, there should be no sleeves
Now I will get a package of gown Get a gown package
And check its integrity, expiry date, and sterile indicator
And then open its first layer Open first layer
Then I will get a pack of appropriate-sized gloves Get gloves
And unpack it on top of gown pack Unpack gloves on top of gown pack
And now I will proceed to hand washing
First I will do a Pre-wash (Mimic) Pre-wash
I will get some Hibiscrub and rub from hand to 2cm above
elbow
And then rinse it
And now I will perform a proper scrubbing
I will get some Hibiscrub, (Mimic) Get Hibiscrub, rub till 2cm above elbow
Rub it and make a good lather,
Up to 2cm above elbow
And then I will get a sterile brush to brush the nails as if they (Mimic) Brush nails
have 4 edges
And then I will rub each finger as if it has 4 surfaces (Mimic) Rub fingers
And then I will start rubbing hands & forearms Keep rubbing palms while talking
I will spend 1 min on each hand, and half a min on each
forearm
Palm-to-palm, palm-to-dorsum, finger webs, finger tips, (Mimic) Hand washing
wrists, and forearms up to elbow but not beyond
And then rinse it off (Mimic) Rinse
And now I will proceed to gowning
First I will open this second layer R hand take up fold of gloves
L hand open up the paper wrap (starting from away)
And place the gloves under the gown R hand put gloves under gown
And then dry the hands Dry with paper towel
And then I will wear the gown up Take gown, insert hands, let gown fall open, wear it
And ask for assistance to tie it up (Pull sleeves yourself dont wait for slow assistant)
Now I will put on the gloves by closed method Put on gloves
Finally I will ask for assistance to tie up the last knot R hand takes up card
L hand grabs L string> Pulls out + Hold tight
Assistant grab the card, let go R hand, turn
anticlockwise, re-catch string & tie

Page 62
OSCE Script Scrubbing
OSCE Script Foley
Script Action
First I will greet the Pt, explain the procedure, and obtain
informed conset
, ,
Then I will draw a curtain, (Mimic) Draw curtain
And expose Pt from umbilicus to knee (Mimic) Properly position & Expose Pt
Then I will obtain a Foley catheter set, (Mimic) Get a Foley set
And check its integriy & expiratory date
Ill open the 1st layer, (Mimic) Open 1st layer
And then wash my hands and put on sterile gloves (Mimic) Wash hands, Put on sterile gloves
nd
Then Ill open the 2 layer, (Mimic) Open 2nd layer
And check the equipments: 1 large bowl, 1 kidney dish, 2 Arrange the equipments
small round dish, 3 artery forceps and 2 drapes
I will put 5 gauzes in a small round dish Put 5 gauzes in a small round dish
And I will ask assistance to pour Aqueous Hibitane into it, (Mimic) Ask assistance to pour Aqueous Hibitane
And Sterile water into another dish into it, Pour Sterile water into another
Then I will ask assistance to prepare a 14F Foley catheter, (Mimic) Ask assistance to get these
20ml Syringe and 2% Xylocaine Jelly But self arrange these
I will now check the competence of Foley catheter balloon Check competence of Foley balloon
by injecting 10ml of air or water
Ok~ Release balloon
I will now clean the Pt, starting from Glans, then Dorsum of Take 1st Artery foceps & Hold a gauze
penis, Ventral side of Penis, Scrotum, Perineum, and Rub from clean to dirty areas accordingly
Surrounding skins Dispose the gauze
And I will repeat again Grab another gauze (can do with left hand)
I will now drape the Pt Take a drape, hold 2 nearest corners, release it
(2 Drapes) First aiming at root of penis 1st one below, with cranial over root of penis
Then aiming at tip of penis 2nd one above, with caudal over tip of penis
Then expose it 2nd drape up, 1st drape up, 2nd drape grab penis up,
put 1st drape underneath
(1 Drape) Put drape on; Flurry side on top to absorb water,
Longer side covering caudal side
And then I will hold the penis with a gauze Use 3rd gauze to hold shaft of penis
And then retract the prepuce Use 4th gauze to retract prepuce & clean glans
And then clean the glans again Use 2nd Artery forcep to hold a gauze & clean glans
I will now apply some Xylocaine Jelly around meatal opening, Put on plastic tip, Apply some near meatal opening
Wait for a while, (No action during speaking Wait for a while)
and then inject some more into the meatus, Inject some into meatus
And milk the jelly down & wait for 5 min Milk jelly down
Page 63
OSCE Script Foley
Repeat action 1 more time (to show that you are
not injecting all jelly in 1 go)
Assume time is up Unstrip whole Foley and put into Kidney dish
I will now insert the Foley catheter with No touch technique Put dish below Penis
Use 3rd Artery forcep to clamp on Foley above tip
While inserting Ill look at Pts face Keep inserting, watch Pt face when say that part
Ill also ask assistance to prepare a Sterile sample bottle (Mimic Asking) Take the Sterile sample bottle
I will insert all the way down & Look for urine to come out Insert almost fully
Whe the urine comes out, I will obtain the urine for Take sample bottle and mimic taking samples
microscopy, culture & sensitivity, biochemistry, and cytology
I will inject 10ml of water to inflate the balloon Inject 10ml water into balloon
And note Pt face Watch Pt face for a sec
Now I will let the residual urine to flow out and note the Pull out Foley a bit until resistance, Outflow put into
amount kidney dish
I will reduce the prepuce Reduce prepuce
I will ask for a bedside bag (Mimic) Ask assistance for a BSB
In the meantime I will remove drape & clean up Pt Remove drape, with wiping action to clean up
Then I will connect the catheter to BSB, Tale BSB and connect to Foley
And stick it over medial thigh or lower abdomen Stick over upper medial thigh (allow some length)
And allow some length for Morning erection
Finally I will help Pt dress up and its done
Foley Insertion Trick: Apply a bit upward & outward traction force to straighten Penis
Insert Foley with rotational movement rather than direct pushing
If still Not ok, ask assistance to perform DRE to aid your insertion

Page 64
OSCE Script Foley
Breast Exam
OSCE: In Ward, 90% cases are Breast CA (esp if Middle-aged or Elderly)
Young Pt with Benign Breast lesions seldom join Examination
Normal Physiology:
Neonate: Breast Development, Lactation, Abscess Formation
Before Menarche: Breast develop in Size, Asymmetrical
Young Female: in Size in 2nd Half of Menstruation, Following Ovulation, Mild Pain/Tenderness
Pregnancy: Size & Texture change profoundly, Difficult for Clinical assessment
Hx: Presentation: *Breast Lump, Breast Pain, Discrete Abnormality area, Skin texture change, Nipple Discharge,
Nipple Retraction, (Axillary Mass)
RF: Previous Breast Surgery, Previous Breast Complaint (Some Benign Breast disease can CA risk),
FHx of Breast/Ovarian CA,
Regular Breast Screening (start at 40)/Check-up (start at 30), Last Mammogram/US
O&G Hx: Menarche, Menopause (Menstrual status), LMP (Possibility of Pregnancy RT contraindicated),
Pregnancies, Age at 1st Pregnancy, Breastfeeding, (Any Ovulation Induction),
Hormonal intake (OCP, HRT)
Lump: Duration, Fluctuating Size (Fibrocystic disease), Painful/Tender
Pain: Mastodynia/Mastalgia
Site: In Lump/1 breast/Both breasts
Cyclical/Non-Cyclical: Cyclical: Fibrocystic disease
Non-Cyclical: Muscular Pain, Costochondritis, Non-specific
(<5% Breast Cancer Pt present with Mastalgia)
Nipple: Spontaneous Discharge or only on Expression
Color, Nature of Discharge
Unilateral (more worrying) or Bilateral
Crack/Eczema around Nipple
Distortion/Retraction (ask if the retraction is Congenital)
Other relevant Hx for Mx of Breast CA:
Fit for Surgery?: Performance status, Warfarin/Aspirin,
Hx of RA (C1/C2 Subluxation on Intubation)
Fit for RT?: SLE/Scleroderma
Examination: Introduction, ask for Consent (2 Marks in OSCE for Intro & 3C!)
GE: Very brief; Look for Cachexia, Enlarged Neck LN, Alopecia (Post-Chemo)
Exposure: All of the top half of Trunk (till Waist)
Position: In OPD: Sitting (60) Ideal for Inspection> Then Lying Ideal for Palpation
Reason: Most Ideal Posture for each Exam, also OPD Bed cant be Elevated
In Ward: *Semi-recumbent (45) Compromise of 2 Posture for both Inspection & Palpation
Breast: Resting Position: Supine: Breast fall Sideways Upright: Breast Peduncle
Boundary: Clavicle, Sternum, Inframammary fold/crease (Bra line), MAL
Inspection:
Flow: Inspect for Asymmetry at Bed End
Page 65
Breast Exam
Raise arm above head: Exposure: Axilla, Inframammary region
Look for Dimpling (May ask Pt to lean forward to exacerbate it)
Elevate Breast to check Inframammary region if obscured by Pendulum breast (Ulnar side )
Press on Hip (): Look for Tethering (Mass moving with Pectoralis muscle)

1. Size/Shape/Symmetry: Regular & Symmetrical, Distorted
2. Skin: Scar (Axilla, Areola complex, Inframammary), Lump/Nodule, Dimpling (Superficial), Ulceration,
Erythema (may be Inflammatory Breast CA), Eczema (Raised), Peau dorange (Lymphedema),
Discoloration (RT), Dilated Veins (Mondors disease: Thrombophlebitis of Superficial V; Rare)
Possible Signs of Breast Cancer:

Scar: BCT: May see 1 Breast Scar & 1 Axillary Scar
If see Lumpectomy Scar but No Axillary Scar: Either Benign or DCIS
Breast Size will, unless Reconstruction done (Uncommon in HK for BCT)
Mastectomy:
Usually 1 Scar for both Breast Mass & Axillary LN (Usually Transverse, or Circular if with Flap)
Bilateral Mastectomy: Synchronous Cancer
Prophylaxis: BRCA, Pt preference (Avoid CA, or for Symmetry)
Reconstruction:
No Reconstruction: No breast anymore
Myocutaneous Flap:
TRAM (Transverse Rectus Abdominis):
Note for Reposition of Umbilicus & Scar above Pelvis (Large Transverse)
Can give rise to Higher Cups (Abundant Fat)
LD (Latissimus dorsi):
Note for Scar at the Back (Transverse at Ipsilateral side)
Page 66
Breast Exam
Usually just Cup A Breast (Few Fat, Small skin)
(If see at least Cup B but Not TRAM, there may be an Implant)
(Prosthetic Implant)
Nipple Reconstruction: Not commonly done; Create Nipple-Areolar Complex on Flap
Biopsy Scar: Small, usually incorporated in Excisional Scar (to prevent Seeding)
Pleural Tap: In Pleural Effusion after Lung Mets
Reduction Mammoplasty: Breast Reduction (Correct Large & Pendulous Breast, or for Symmetry)
(Scar shape like an Inverted T)
Pigmentation after RT:

Dark Skin (Rectangular); May palpate Scar tissue too
Usually done after BCT, or for Breast CA with High Recurrence rate (eg. T3/T4 Tumor)
3. Nipples/Areola: Change with Age, Darken in Pregnancy
Areolar Skin: Natural, Montgomery Tubercles (Portion of Areolar glands on Skin surface)
(Areolar glands/Montgomery glands: Sebaceous glands in Areola)
Nipple: Retracted, Cracked, Eczematous (Pagets Unilateral; True Eczema - Bilateral),
Over-Pigmented, Obvious Discharge
(Duct Ectasia: Bilateral, Display Transverse Slit Pattern)
4. Axilla/Arms/Neck: Enlarged LN, Distended Veins, Arm Lymphedema
Accessory/Supernumerary Nipples along Mammary line from Axilla to Groin
Most common site for Accessory Nipple: Just below Normal Nipple
Visible Ectopic breast tissue in Anterior Axillary Fold
Most common site for Accessory Breast tissue: Axilla
Palpation: Say , Not !
Normal Breast first; Tell & Explain to Pt!
Feel with Palmar surface of fingers (Pulps) with hand flat
Feel Whole breast: Systemic examination of 4 Quadrants & Axillary tail (at Ant. Axillary Fold)
Examine Ipsilateral Axilla before proceeding to another Breast (help ddx Benign/Malignant)

1 hand for Stabilization, 1 hand for Palpation (dont Poke, dont Squeeze)
Method: Vertical Strips: Preferred (by QMH BS Surgeons, and taught in Tally)
Circular: May miss Axillary Tail (Taught by IB Lecturer)
Spokes of the Wheel: May miss Periphery (if Radial out from Centre)
Page 67
Breast Exam

Lump: NB: Hard Mass under Reconstructed Breast: Local Recurrence or Fat Necrosis
Site: Quadrant (*Upper Outer), or better say what Oclock & cm from Nipple
Size (cm):
Shape: Round, Regular, Irregular
Consistency: Soft, Hard (previous Paraffin Augmentation> Rock Hard), Cystic (Fluctuant)
Surface:
Edge:
Tenderness: Usually Inflammatory or Cystic (CA usually Painless)
Temperature:
Overlying Skin:
Fixation/Mobility:
Skin: Gently pinch up skin overlying lesion
Tethering: Skin Indents when moving the lump (Deeper)
Fibroadenoma: High Mobility (Breast Mice)
Fixation: Lump cant be moved at all without moving skin (Attached to Skin)
Muscle (Pectoralis Major): More Specific to Breast CA than Skin attachment (Skin can be Sebaceous Cyst)
Ask Pt to place hands on Hips
> Pick up Lump gently between 2 fingers> Assess Mobility in 2 dimensions
Ask Pt to press Firmly onto Hips> Reassess Mobility in 2 dimensions
Mobility will if attached to Deep tissue
NB: Breast CA attaching to Pectoralis =/= Invade through Pectoralis Not necessarily T4
Nipple: Nipple Discharge is seldom associated with Invasive CA
(No need to Milk Breast if No Complaint of Discharge Not much added value to Dx)
(If need to do, better do at the end of exam)
Milk the Breast: Can ask Pt to express the Discharge herself
Doctor: Use 2 s radial side to massage breast toward Nipple
Do at different Dimension
Not necessary to Squeeze on Nipple (Just massage the ducts)
Discharge: Site: Unilateral/Bilateral
Duct: Note how many Ducts having Discharge by observing Nipple (Look for No. of spots)
Single Duct (more worrying) vs Multiple Duct
Nature: Thick/Thin, Cloudy/Clear, Blood stained
Ddx: Normal: No Discharge, or Serous Discharge on Hard Palpation
Tally: Bright blood: Duct Papilloma, CA
Yellow Serous: Fibrocystic disease
Serous: Physiological (eg. Early Pregnancy)
Page 68
Breast Exam
Milky: Lactation (Physiological/Hyperprolactinemia)
Green: Duct Ectasia
Significant Causes:
DCIS, Duct Papilloma, Duct Ectasia
NB: Uptodate: Malignancy causing of Bloody discharge with No other findings: *DCIS (2002 EMQ)
Axilla: Hold Right Elbow/Arm with Right hand> Feel Right Axilla with Left hand; Vice versa for Left
Rmb to hold Arm Not Forearm (Must let Pt rest Arm fully> Dont cross joint)
If Pt is Supine, just hold Forearm in the air & allow Arm to rest on Bed
LN groups: *Anterior: Pectoral group
Medial Axillary wall along Lateral Thoracic artery
Drains Breast (Main drainage)
Posterior: Subscapular group
Medial Axillary wall behind Anterior group, with Subscapular artery
Drains Axillary tail & Posterior Upper Trunk
Lateral: Humeral group
Medial side of Axillary vein
NB: Actually quite Superior; True Lateral is Skinfold
Central: In Adipose tissue over Base of Axilla
Drains above 3 groups of nodes
Apical: Axillary Apex
Drains all above nodes

NB: Focus on Medial & Anterior dimension (ie. Pectoral group) (Higher chance to detect LN Mets)
Features: Number (LN might be Matted though), Size, Consistency, Mobility
Other Exam: Supraclavicular LN other Cervical LN (Check if SCN +ve)
Chest (Pleural effusion), Abdomen (Hepatomegaly), Bone (Tenderness, usually over Spine)
Testis if Gynecomastia (can be due to Estrogen from Testicular CA)
At the End: Draw Curtain and go away to allow Pt to dress herself

Page 69
Breast Exam
H&N Clinical Demo
Hx: External: *Mass, Ulcer, Tumor, Pain, Discharge, Bleeding
Internal: Dysphagia, Airway problem, Hoarseness, Ear Sx, Facial asymmetry
Mass: Location, Size, Shape, Overlying skin, Consistency, Transillumination (for Cyst), Organ of origin
Also Mobility, Tenderness
Attachment/Origin: Muscle: Ask Pt to Tense up the muscle> becomes Less mobile
Bone: Hard, Fixed
Sebaceous cyst: Well-defined; Similar to Lipoma; If see Punctum, quite definitive for Sebaceous cyst
Ear-Keloid scar: Ear piercing (Wound)> Inflammation/Infection> Mass; Cartilage commoner than Earlobe
Painless Firm nodules with Dilated veins, attached to Skin
Ulcer: Location, Size, Base, Edge, Discharge/Bleeding
No Epidermis; May see Yellowish Serous Discharge, Pigmented changes
Cause: Ischemia: Eg. Atherosclerosis; Not common cause in H&N region Rich Blood supply in H&N
Infection: Chronic infection less likely, also due to rich blood supply
Cancer: H&N least protected from Sunlight> Skin cancer common (*BCC)
Tumour: CA Tongue (Non-healing ulcer=Malignancy), CA Larynx, CA Hypopharynx
Facial Asymmetry:
Pan-CN7 palsy: No Wrinkles (Frontalis raises Eyebrows)
Swollen Red Conjunctiva (Cant close eyes> Dry eye> Lacrimal secretions not distributed evenly)
(Normal opening of eye = Intact CN3 for upper eyelid)
Also Buccinator, Risorius, Platysma
Cause: eg. Parotid gland carcinoma
CT: Obliterated line between Parotid & Masseter (just external to mandible) = Infiltration
OC/Oropharynx: Inspection: Open mouth widely (cant examine adequately in Trismus)
Say Ahh> Contract Tensor veli palatini> Raise soft palate
Good Lighting, Spatula, Gloves; Front-Back, Outside-Inside, or Top-Down
Check Hard/Soft palate, Gingivo-buccal Sulcus (Lips/Teeth), Alveolus, Tonsils,
Gingiva, Retromolar trigone, Floor of mouth, Opening of Salivary ducts
Tongue base (Cant see; At Posterior Oropharynx) vs FOM (under tongue)
Note for Abnormal mucosa / Mass / Ulcer / Bleeding / Discharge
Palpation: Consistency, Stones at Salivary ducts, Bimanual palpation of Submand Gland
Posterior tongue: Sometimes Palpable but not easily seen
Torus palatinus: Mistakenly thought as cancer for referral by GP
Asymptomatic, Benign Bony Hard growth (arise from bone); No need Tx
Torus mandibularis (Less common)
Submandibular Sialolithiasis:
Swelling during Meal; Opening on either side of Frenulum
Submandibular abscess:
IC Pt presenting to A&E: High fever, Neck pain, Swollen Red Anterior Neck
Classical CT of abscess: Swelling, Rim enhancement, Central Hypodense region
Obstructed Duct (Submandibular duct, Biliary tract, Urinary tract)> Infected
Page 70
H&N Clinical Demo
Hemangioma of Tongue:
Intact overlying mucosa> Not ulcer
Soft (Collapsible), Purple: Blood inside (ie. Vascular problem)
Surgical excision to prevent bleeding after biting in the future
CA Tongue: Tongue Edge (May see Indentations by teeth), Dorsum (Uncommon)
Other CA: Alveolus, Buccal mucosa, Floor of mouth, Maxilla, Soft palate, etc
Ameloblastoma: Slowly enlarging Mandibular mass; Bony hard on palpation
Clench teeth: Open bite (Mal-occlusion)
Resect the mandibular bone> Free Fibula Osteocutaneous Flap> Plant teeth by dentist
Neck:
Neck Mass:
Central: Thyroglossal cyst, Tumour from isthmus of Thyroid
Lateral: *Cervical LN (Very common): *Infection, Primary/Metastatic tumor
NB: TB lymphadenopathy is Not contagious (just reside in LN)
Thyroid tumour, Salivary gland tumor,
Schwannoma (Uncommon), Carotid body tumor (Uncommon),
Branchial cyst (Uncommon; Congenital, Anterior border of SCM, present as infection)
Neck LN Level: 1 to 6; Only applicable for LN, not other pathology; Level 2-4 are along IJV, under SCM
IA: Submental
IB: Submandibular
II: Upper Jugular
IIA: Subdigastric
IIB: Supraretrospinal / Submuscular recess
III: Middle Jugular
IV: Lower Jugular
V: Posterior Triangle
VA: Spinal accessory
VB: Transverse cervical
VI: Pretracheal
Level 2 LN Mets vs Parotid tumour:
Parotid gland very Superficial (just under skin and SC fat)> Well-circumscribed
LN is Deeper (covered by SCM)> Lesion not so Well-circumscribed

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H&N Clinical Demo
H&N Thyroid & Parotid Exam
Neck MBBS Exam: Thyroid, LN, Thyroglossal cyst
Head MBBS Exam: Parotid, Oral cavity (eg. Ulcer)
Thyroid Exam:
Introduction, Informed Consent, Chaperone, Curtain
Classical American description of (Assess for any Sweat Palm & Hoarseness)
Hand Hygiene
Position: Sit on chair
Exposure: H&N region, Upper chest/Shoulder
Preparation: A cup of water, Explain the use
Flow: Neck exam: Thyroid, Cervical LN, Pressure signs
Eye exam: Eye signs
General exam: Sweaty Palm, Pulse, Tremor, (Clubbing), (Pretibial Myxedema)
Inspection: In Front
Symmetry
Swelling: Anterior/Lateral Neck Swelling
Surgical Scar: Eg. Transverse Scar over Lower Anterior Neck (Thyroidectomy, Parathyroidectomy, etc)
Neck Dissection Scar over Lateral Neck
(Others): Skin changes (RT changes): Early (Sunburn-like), Late (Brown Pigmentation, may Harden)
Dilated veins
Body Build: Affect Visibility of Nodules (maybe missed in Obese Pt)
Swallow Water: Thyroid move up with Swallowing (embedded in Pretracheal fascia); Beware for NPO Pt!
(Tongue Tug): Only done for Upper Anterior Mass if suspect Thyroglossal cyst
Palpation: At Behind
Thyroid: Palpate from Cricoid level (Thyroid cartilage not related) down to Suprasternal notch
Upper pole: Above Cricoid
Lower pole: Below Cricoid
Isthmus: Overlying 2nd-3rd-(4th) Tracheal ring
Goitre: Diffuse Swelling, Lobularity, Consistency, Surface (Smooth/Nodular, Any Dominant nodules)
NB: Most Pt in Surgery OSCE have Nodular Goitre, even for some Graves Pt
Mass: Size, Location, Origin (Move with swallowing), Shape, Surface, Consistency, Tenderness,
Mobility, Fixation, Overlying Skin changes
(Thrill): Graves (Ddx: Carotid body tumor, AVM)
Extension: Palpate for Lower border upon 2nd Swallowing
If cant define> Percussion & Pembertons sign to confirm Retrosternal extension (*Left)
Cervical LN: May be Nodal Mets from Thyroid CA
Submental> Submandibular> Preauricular> Postauricular> Occipital> Jugular Chain
> Posterior Triangle (Posterior border of SCM, Clavicle, Trapezius)> Supraclavicular
Landmark: Inferior border of Hyoid: Divides Upper/Middle Jugular LN
Inferior border of Cricoid: Divides Middle/Lower Jugular LN
Elevate shoulder> Palpate groove between 2 heads of SCM for Supraclavicular LN
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H&N H&N/Thyroid Exam
Tracheal Deviation
Check if suspect Retrosternal Extension:
Percussion: L/R Paratracheal area (Compare both sides; Extension usually 1 side only)
Look for Dullness
Often Not Sensitive unless Large mass (most Retrosternal extension still Resonant)
Pressure signs:
Pembertons sign:
Raise both arms above Ear level for 45s 1 min
> Valsalva maneuver (optional; Often Not necessary)
> Thoracic inlet narrowed> Compromise Venous return> Flushing (engorged veins)
Airway Obstruction
Hoarseness (RLN involvement) (If Hoarseness, Usually Malignant, unless its Iatrogenic after Surgery)
Auscultation: Check Thyroid Bruit if suspect Diffuse Toxic Goitre/Graves
Ddx: Thyroid Bruit: Can be auscultated from Isthmus too
Carotid Bruit: Louder over Carotid, may radiate up to Angle of Jaw
Aortic Stenosis: Can be auscultated over Aortic area
Eye signs:
Lid Retraction: Most common Eye sign in Thyrotoxicosis; White Sclera can be seen
Lid Lag: White Sclera, Jerky downward movement
Exophthalmos: Graves; Stand behind Pt to look down the plane
Soft Tissue: Swollen/Edematous
Conjunctiva: Red/Edematous
Diplopia: Ophthalmoplegia (esp SOM is predominantly affected)> Check EM esp Upper Outward gaze
Other GE: Signs of HyperT
Hand: Feel for Sweat/Elevated Temp
Look for Thyroacropachy
Pulse: Tachycardia, AF, Collapsing pulse
BP (SBP, Pulse volume with Collapsing property)
Stretch out hands to check for Fine Tremor (Can put a paper above to make it prominent)
(Reflex): Brisk Jerk (HyperT) vs Slow Relaxation (HypoT)
LL: Pretibial Myxedema, Knee Jerk
Parotid mass: Unilateral: Tumor (Benign Pleomorphic adenoma/Warthins tumor; Malignant)
Duct Blockage, eg. Salivary Calculus
Bilateral: Mumps, Alcoholism, Sjogrens syndrome
Warthins tumor (10%)
Drug (eg. Phenytoin)
Bulimia nervosa
Pseudo-Parotidomegaly (Masseter Hypertrophy)
Examination:
Lesion side:
Scar: FNA Scar
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Modified Blair Incision Scar: May signify CA ex Pleomorphic Adenoma
Mass:
Check Origin:
Palpate Angle of Mandible; Mass behind angle> Likely Parotid rather than due to Obesity
Rmb to check:
Contralateral Parotid
Cervical LN
CN7 (5 motor branches)
Intra-oral Exam:
Inspection:
Any Bulging over Palatoglossal groove (But not as Red in Tonsillitis), which may deviate Uvula
Any Pus discharge from 2nd upper molar (Opening of Parotid duct) (Use Spatula)
Palpation:
Palpate Deep Parotid lobe (Medial to CN7)
(Other Salivary glands)

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Skin Lumps & Bumps Exam
Hx: Duration, Origin, Progression, Persistence, Sx, Multiplicity (>1 lump)
Progression: If variable size> Cyst, Hernia; If growing (Slow vs Fast)
Sx: Paresthesia
Approach to PE: Introduction, Consent, Exposure (Pt self-exposure for sensitive area), Ask if lump is painful
Perform without permission> Bodily assault
Inspection (6 S): Site & Number (Solitary/Multiple), Shape, Size, Surface,
Condition of Skin & surrounding tissue, Scars
Site
Shape: Regular/Irregular, Invading/Protruding
Tan shape: Usually Deeper structures (eg. Lipoma)
Dome shape: Usually Superficial structures
Exception: Area where Skin is attached to SC tissue directly
Eg. Forehead/Scalp, Palm/Sole, Breast, Buttock
HH Tuen: Face (Facial skin attaches to muscles)
Skin on back (Held down by lots of fibrous tissue)
Clue: May still see the lesion separating Skin from SC over Edges
Size: Longest dimension and the one perpendicular to it
Surface: Rough/Irregular/Smooth surface
Condition: Ulcer, Red, Edematous, Extra hair, Pigmentation/Depigmentation, Texture change, Bleeding,
Discharge, Pushing/Extending toward surrounding tissue
Scar: Foreign body Granuloma, Surgical Scar
Palpation: 2 T, 1 S, CAMFRT
2 T: Tenderness, Temperature (Use dorsal hand to feel as skin is thinner)
(For very hot things, if use palm to touch> reflexive grip> more damage; If use back> withdraw)
1 S: Reconfirm the Size, (Also define Border by palpating surrounding)
C: Consistency:
Soft: Lipoma, Fluid-filled Cysts
Firm: Semi-solid Cysts (Sebaceous cyst), Tense Cysts (Small Ganglion), others
Hard: Malignancy
Calcification: Mineralized Mass (eg. Gouty Tophi), Bone Mass (eg. Exostosis)
A: Attachment to superficial/deeper structures
Checking Origin:
Observe Shape
Run skin over () it: If Skin origin/attachment, overlying skin cant be pinched/run
Tense up Muscle: Deeper to muscle: Disappear
Superficial to muscle: More Prominent
Fixed to muscle: Less Mobile
NB: Neuroma: Move Hand; Tinel Sign (Pins & Needles sensation upon tapping on Irritated Nerve)
M: Mobility; Assess in 2 Perpendicular planes
Mobility: Fibrous adhesion, Attachment to Muscle/Bone/Deep structures, etc
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Skin Lumps & Bumps
in 1 plane: Eg. Horizontally Mobile but Longitudinally Immobile:
Eg. Nerve origin (eg. Neuroma), Tendon origin (eg. Ganglion)
F: Fluctuation; Due to Fluid
Use 2 fingers to clamp the lump, another finger to press down on middle; 2 fingers feel for force
R: Regional LN (Painful-Inflammatory, Painless-Tumor)
T: Transillumination; Shine lesion from Side (Not Top) with a torch (Make sure no escape of light)
Clear Fluid: Whole lesion lights up (Lots of reflection)
Special tests: Transillumination (for Medium/Large lumps)
Pulsatility (for certain sites, eg. Neck, Abdomen)
Slippage sign (if suspect Lipoma)
Compressibility (if suspect AVM, Hemangioma) (Vascular lesions blanch on pressure, then refill)
Reducibility (if suspect Hernia)
Auscultation (for certain sites, eg. Neck, Abdomen)
Request I would complete my examination by:
Regional LN exam
Others: If Sebaceous cyst/Lipoma: Looking for other Lumps elsewhere
If Hand Mass (eg. Ganglion): Above + Ask for Hand dominance + Occupational Hx

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Skin Lumps & Bumps
Skin Lumps & Bumps
Layer of Tissue Origin:
Layer Skin SC layer Muscle/Tendon Bone/Joint
Examples Sebaceous Cyst Lipoma Ganglion Exostosis
Origin of Tissue Pathology:
Origin Epithelium Gland Fat Vessel Nerve Bone
Examples Keratosis Sebaceous Cyst Lipoma Hemangioma Neurofibroma Exostosis
Skin: Epidermis: Stratum corneum, Keratinocytes (Squamous cells), Basal layer
Dermis: Hair Follicles, Nerves, BV, Sweat Glands, Lymphatic
Benign vs Malignant:
Benign In Young, except Static or Grow in Do Not Well defined Raised/ No Enlarged
Melanoma & proportion with Pt Ulcerate/Bleed Regular border Flat Regional LN
Sarcoma
Malignant More common in in Size Do Irregular/Poorly Usually Enlarged
Elderly Arise from Preexisting Ulcerate/Bleed defined border Raised Regional LN
lesions, eg. Naevus, Scar
Lesion Characteristics:
Site, Shape, Size, Surface, Edge, Consistency,
Temp, Color, Fluctuation, Ulceration, Transillumination, Pulsatility
Logical Approach: Inspection, Palpation, Deduction with good reasoning, Final conclusion of Clinical Dx
Should appreciate Wide spectrum of Presentation
Further Ix (eg. FNAC, Biopsy) if indicated
Important to ddx between Benign & Malignant
Indication for Surgery:
Malignancy, Premalignant or with Malignant Potential,
Symptomatic Benign lesion, ing Size, Prevent Infection/Cx,
Cosmesis
Consideration for Operation:
Indications for Operation
Advantage for Surgery > Conservative Tx
Extent of Excision: Simple Excision
Excision + Reconstruction
Minimal Access Surgery
Anesthesia: LA/GA/Regional Block/IVA/IVS (IV Sedation)
Day Surgery/InPt Surgery
LA: Lignocaine: 1% = 10 mg/ml
Dose limit: Without Adrenaline: 3 mg/kg (Some say 4 mg/kg)
With Adrenaline: 7 mg/kg
NB: Adrenaline Not used at End arteries: Digital block, Penile block, (sometimes Earlobe)
Fast onset (within 2-5 min), Lasts 1-2h
Bupivacaine (Marcaine):
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Skin Cutaneous Lesions
Dose limit: Without Adrenaline: 2 mg/kg
With Adrenaline: 2.5 mg/kg
Slower onset (5-10 min), but more Long-lasting (4-8h)
More Cardiotoxic (Never injected into Vein)

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Cutaneous:
Sebaceous Cyst: (Retention Cyst due to Obstruction of Sebaceous duct)
General term referring to either:
Epidermoid Cyst
Pilar Cyst: 90% on Scalp, *Female, AD inheritance tendency, Often Multiple
Technically Not True Sebaceous Cyst:
Contains Keratin, Not Sebum
Originates from Epidermis/Hair Follicles, Not Sebaceous glands
PE: Hemispherical Cutaneous Swelling
(Cutaneous lesion, but may mimic Subcutaneous lesion on appearance)
(Various Presentation, eg. can be Tanned over the Back due to Thick Dermis)
Punctum in 50% (Specific but Not Sensitive)
Bluish Tint sometimes present
Attach to Skin
Creamy Smelly Content:
Yellowish-White Fatty material (Keratin) resembling Cottage Cheese & Epithelial cells
Not Fluid, thus its Firm, No Fluctuation, No Transillumination
Site: Common over Face & Scalp, but can be Anywhere (Any Hair bearing area)
Except Palms & Soles (No Hair follicles) (2005 MCQ 8)
Cx: Infection (Can present as Inflamed Cyst), Ulceration, Calcification,
Sebaceous Horn: Hardening of Slow discharge from Wide punctum, if Not washed away
Cocks peculiar tumor: Infected Ulcerated Sebaceous cyst; Can mimic SCC
Association: Gardners syndrome (Familial Colorectal Polyposis; AD disease)
Multiple Colonic Polyps
Multiple Extracolonic tumors:
Sebaceous Cysts, Osteoma, Desmoid tumor, Thyroid Cancer, etc
Tx: Excision with Elliptical incision to include Punctum
Recurrence is due to incomplete removal with wall of cyst left behind
Incision & Drainage if Infected
(Adhesion makes it more difficult to Excise, so Incision to regress it first)
Incision Avulsion
Papilloma: Origin: Squamous vs Basal cell
Classical Description: Projection on Skin surface (a Protruding mass)
May convert into Malignancy: Squamous into SCC, Basal cell into BCC (Less Invasive)
1. Skin Tags: Multiple Small Papillomata
Frequently on Trunk, Neck, Axilla, Groin
(Henry Tuen: Those on Neck may be due to rubbing by collar of shirts)
Color: Darker: Pigmentation due to Friction
Redder: Rich Vasculature (May Bleed)
Tx: Excision under LA
Small one can be treated by Fine Ligature around Base> Necrosis
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2. Squamous: Most are Viral in origin (Warts Caused by HPV Usually Infectious via Contact): (2007 EMQ 13)
Common warts (Verruca vulgaris), Plantar warts (Verruca plantaris), Flat warts, etc
Warts: Common in Young & on Hands, Feet, Neck; Usually in Crops
Often see Multiple lesions (Scratch> Touch another body part> Spread)
Warty Growth of Brownish Color
Rough, Irregular, Finger-like protrusion (active growing), Scaly
Tx: Excision, Cauterization, Curettage, Laser
Variants: Soft Papilloma (around Eyelid of Elderly)
Cutaneous Papilloma, Fibroepithelial Polyp (more Whitish & Firm due to Fibrous tissue)
Keratin Horn (Excessive Keratin Formation in Elderly)
Congenital Papilloma (Naevus Verrucosus)
Plantar Wart (in Sole, usually Multiple, Painful) (Warty Spike: Characteristic for Wart)
(If Skin Cancer in Sole, think SCC)
NB: Plantar Wart can be Painful (2003 MCQ 67)
3. Basal Cell: Seborrheic, Senile Wart, Seborrheic Keratosis
Seborrheic Keratosis:
Benign Skin lesion of Epidermal Basal cell Maturation; (Common in OSCE)
Elderly
Forehead, Face, Trunk; Usually Multiple
Pigmented, Circular/slightly Irregular but Well defined, Flattened/Raised, Warty, Hard
Stuck on Appearance (Attach to very Superficial area) (Like a Rough Surface Papule/Plaque)
Can be Itchy/Inflamed
(Histology: 2007 EMQ 15: Basaloid cells with a mixture of Squamous cells
Keratin-filled invaginations & Horn cysts are seen)
Tx: Curettage/Excision, Cryotherapy, Shaving (Shave from Epidermal layer)
Nevus: Benign
Tx: Excision (Mainly Cosmetic reason; If Large Nevus, may have risk of Malignant transformation)
Keloid & Hypertrophic Scar:
Fibroplasia >> 3 weeks
High content of Type III Collagen
Remain Immature
Disorganized Collagen pattern
Blood flow
Scar: Normal Scar
Hypertrophic Scar: Overgrowth of Scar but confined to original wound
Keloid: Extend beyond original wound
Keloid Scar: Claw-like, Cancer-like in Greek
Proliferate beyond confinement of Original lesion
Develop 3 months to years later
Midline, Shoulders, Earlobes (Ear ring), Upper Arms & Cheeks
(Metal Necklace/Crucifix> Contact Dermatitis by Nickel> Keloid over Chest)
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Familial (Rmb to ask FHx)
More common in Woman & Pigmented Skin (seldom seen in White)
Accelerate Growth during Puberty & Pregnancy (2007 MCQ 82)
Do Not Regress (Some may Regress in Size after Menopause)
Related to TGF-, TNF, IL-1
Hypertrophic Scar:
More common in Children
Appear 1 month after Injury
Associate with Excess Wound Tension & Deep Wounds
Elevated but Limited to Original Wound
Will Regress (2002 MCQ 19) (Lecturer: Need 2-3 years to mature)
in TGF-1, FGF & IGF-1
More Responsive to Tx
NB: Can be Itchy/Painful (2002 MCQ 19)
Mx: Observe, Topical Steroid, Intralesional Steroid Injection, Pressure therapy, Silicone Gel,
Surgery, ? Laser, Irradiation, Topical Vit A/E, Zine oxide, AntiNeoplastic agent, IFN, ? Cryotherapy
(Hypertrophic Scar: Zig-zag Excision to Tension of wound upon Stretching)
(Keloid: Irradiation after Surgery can Recurrence but chance of Malignant transform)
NB: Intralesional Steroid was most effective (2009 MCQ 58) (Not sure about Current data)
Vascular Birthmarks/Anomalies:
Soft, Blanchable (Classical feature of Vascular lesion)
Classification: (Old way of Classification is Confusing & Best avoided)
1. Vascular Tumors: Usually arise in Neonatal period; Usually involute spontaneously
*Infantile Hemangioma: (2007 MCQ 56)
Often just called Hemangioma; Previously called Strawberry Hemangioma
Normal at Birth
Rapid growth in Neonatal period (Birth to 4 weeks), Slows down by 6-12 months
Spontaneous Complete Involution in 50% by Age 5, 70% by Age 7, Additional 3-5 years in others
(NB: Even with Complete Involution, its possible there are some Scarring left on skin)
Others: Congenital Hemangioma (Present at birth): RICH, NICH
Kaposiform HemangioEndothelioma
2. Vascular Malformations: Present at birth; Do Not involute
Slow flow: Capillary, Venous, Lymphatic
High flow: Arterial
Capillary: Portwine Stain: Present at Birth, Little Change
Ddx: Salmon Patch: Aka Nevus simplex, Nevus Flammeus, Macular stain, Stork bites
Present at Birth, But disappear by Age of 1; (Usually at Back of Neck)
Venous: Venous malformation: Cavernous in Nature, (More Thickened)
Present at Birth, (sometimes Post-Traumatic)
No Involution
Larger with Time
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NB: Henry Tuen: Blue Tint, Telangiectasia, Soft, Fluctuant, a bit Warm
Arterial: AVM: High Blood Flow
Variable Size
(Usually Multiple Feeders: Chance of Recurrence)
Lymphatic: Small vessel Lymphatic malformation (Lymphangioma circumscriptum)
Large vessel Lymphatic malformation (Cystic Hygroma)
Association: Some may be Familial/Syndromal
Eg. PHACES syndrome
KlippelTrnaunay syndrome:
Rare Congenital syndrome affecting BV/Lymph vessels, esp over Limbs
Portwine stain
Venous/Lymphatic Malformations (eg. VV)
Soft-tissue/Bone Hypertrophy
Parkes Weber syndrome:
Similar to KTS but with AVM
Hemangioma (Vascular Tumor) Vascular Malformations
Clinical: Usually Absent at birth All present at birth, though May Not be evident
30% present as Red Macule
Rapid Postnatal Proliferation Proportionate to skin growth (Slow progression)
Slow Spontaneous Involution May expand due to Trauma, Sepsis, Hormonal
Usually present Lifelong
F:M = 3:1 F:M = 1:1
Cellular Plump Endothelium, Turnover Flat Endothelium, Slow Turnover
Mast cell Normal Mast cell count
MultiLaminated BM Normal Thin BM
Capillary tubule formation in vitro Poor Endothelial growth in vitro
Hematological Primary Platelet Trapping> Thrombocytopenia Primary Venous Stasis
(Kasabach-Merritt syndrome) Localized Consumptive Coagulopathy
Radiological Well-circumscribed, Intense Lobular-Parenchymal Diffuse, No Parenchyma
(Angiography) Staining with Equitorial vessels Low-flow: Phleboliths, Ectatic channels
High-flow: Enlarged Tortuous A with AV Shunting
Skeletal Infrequent Mass effect on adjacent Bone Low-flow: Distortion/Hypertrophy/Hypoplasia
Hypertrophy Rare High-flow: Destruction/Distortion/Hypertrophy
Cx: (Depend on Location & Size)
Systemic (esp if Large):
High output HF
Bleeding diathesis: Kasabach-Merritt syndrome in Hemangioma
Coagulopathy/DIC in AVM
Local: Bleeding, Infection (Not common unless ulcerated)
Cutaneous: Disfigurement
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Extracutaneous: Liver
Eyes: Amblyopia
Larynx: Airway obstruction
NB: Asso. with Cutaneous Hemangioma in Beard distribution
Bone, etc
Tx: Conservative (Observation)
Drugs: BB (Oral Propranolol) (New Tx), Steroid, etc
Procedural: Laser, Sclerotherapy, Embolization
Surgical: Excision
Pyogenic Granuloma: Cutaneous Vascular Proliferation simulating Vascular Tumor (Pyogenic is a misnomer)
Dark Red nodule of Granulation tissue & PMN
Usually Single
Hx of Minor Trauma/Infection
Rapid growth; Easy Contact Bleeding
Often in Hands, Arms, Face
Ddx: Amelanotic Melanoma (esp when Granuloma is Ulcerated)
Tx: Non-Surgical: Silver Nitrate cauterization
Surgical: Curettage, Excision
KeratoAcanthoma (Molluscum Sebaceum): (Uncommon)
Rapid growing Benign tumour, which may be confused as SCC
Middle Age/Elderly; Face/Hands
Firm Hemispherical Nodule
Rapid Growth into Roundish, Slightly Umbilicated Mass (Central Depression/Ulceration-like)
2007 EMQ 14: Epidermal Endophytic proliferation under prominent Hyperparakeratosis,
with Central Keratotic core
May reach a Size up to 2 cm in 6 weeks time
Summit Ulcerate with Crust formation on Ulcer Crater
Spontaneous Healing with Scar (it will involute)
Tx: Excision with Histological confirmation
(Always suspect Malignancy due to its Ulceration-like appearance)
Cutaneous Horn: Can arise from Viral Wart, Solar Keratosis, SCC
Can asso. with Malignancy (2005 MCQ 57, 2003 MCQ 67)
Tx: Excision
Gorlin syndrome: Benign skin lesion on Scalp (Nevoid BCC syndrome)
Can become Malignant (BCC)
Tx: Excision of area with Malignant transformation
Sebaceous Nevus: Present at Birth (Congenital), More obvious at Puberty
Raised, Hairless, Yellow/Orange plaque in H&N region esp Scalp
(2002 MCQ 27: Not typically Brown/Black)
May give rise to BCC in Later life (Not during Childhood Not urgent to treat) (2002S MCQ 20)
Tx: Excision
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Turban Tumor: Benign tumor of Sweat gland
Slow growing, Mainly in H&N region
Tx: Excision
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Subcutaneous:
Dermoid Cyst: Formed by Epidermal cells sequestrated beneath skin
Acquired Implantation Dermoid: (2012 EMQ)
Epithelium driven beneath Skin by Puncture Wound> Forming Cystic lesion
Clinical: May see Scar above it
Firm/Tense Consistency; Often Tender
May attach to Scarred Skin
Site: *Fingers
Tx: Excision to avoid Infection (Avoid using Adrenaline due to risk of Digital Ischemia)
Congenital Sequestration Dermoid: (2002 EMQ 20)
Developmental Cyst due to Inclusion of Embryonic Epithelium at sites of Embryonic Fusion
Present at Birth, but May Not be apparent in Childhood
Clinical: Soft Consistency
Not attached to Skin, sometimes attached to Deep structures
Need pre-op evaluation of Depth of Cyst; If cant get below it, order a scan
Site: *External Angular region, Periauricular region, Midline of H&N
Tx: Excision to avoid Infection (after ruling out underlying involvement)
Lipoma: Common Benign tumour of Adipocytes
Clinical: Single/Multiple (Lipomatosis)
Site: Usually Subcutaneous (Not attached to Skin), Sometimes Intramuscular, Others Uncommon
Can occur at any site where Fat exists, eg. Trunk, Neck, Shoulders, Arms, Thighs
Palpation: *Encapsulated (well-circumscribed) or Diffuse
Smooth/Lobulated
Soft (Sometimes Firm, depending on Nature of Fat)
Fluctuant (Pseudo-Fluctuance in Large tumor)
Mobile, Slippery (Slip sign: Gently sliding fingers off edge of tumor)
Painless
NB: For Intramuscular Lipoma, it may become more prominent if muscle is contracted
For Lipoma over Flank, Lumbar Hernia can be a ddx if Cough Impulse present
Association:
MadeLungs disease:
Benign Symmetric Lipomatosis
Extensive Symmetric Fat deposits in H&N and Shoulder Girdle area
Rare; Usually in Male with Alcohol abuse
Dercums disease/Adiposis dolorosa:
Multiple Painful Lipoma (2002 EMQ 2) on Limbs (sometimes Trunk)
Asso. with Peripheral Neuropathy
Others: Eg. Cowdens disease
Cx: Pain: Ddx: Nerve compression (usually by Large tumor)
Fat Necrosis
Dercums disease
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Malignant Risk (Sarcomatous change to Liposarcoma):
Size: Large (>5 cm), Rapidly growing
Site: Retroperitoneum, Intramuscular (Thigh, Shoulder)
Mechanical interference depending on site
Tx: Observation
Surgery:
Excision:
Linear Incision (cf Elliptical Incision for Sebaceous cyst to include Punctum) along skin crease
Usually if <10 cm, LA is sufficient
Liposuction:
May consider in Large Lipoma (eg. >4 cm) with Avulsion to avoid Big Scar
Fibroma: True Fibroma Rare
Mostly combine with other Mesodermal tissue:
FibroLipoma, FibroMyoma, NeuroFibroma, DermatoFibroma
Single/Multiple (as in NeuroFibromatosis)
Consistency depend on Proportion of Fibrous tissue (More Fibrous> Firmer)
Tx: Conservative/Excision
DermatoFibroma: If see Firm Mass attached to Skin, Ddx Hypertrophic Scar/Keloid
Neurofibroma: Arise from c.t. of Nerve Sheath
Usually in SC layer, (but can have Multi-plane involvement including Cutaneous)
Can be moved in Lateral direction if attached to Major Nerve
May also arise from Nerve Endings (not necessarily Major Nerves)
Sx of Pain/Paresthesia (Can elicit Tinel Sign)
Single/Multiple, Soft to Firm with variable Depth/Size (Neurofibromatosis)
(May have Pressure Necrosis)
Sarcomatous change may occur
Tuberous Sclerosis:
Dominantly Inherited
Sebaceous Adenoma, Fibroma, Hypopigmentation
Mental Retardation, Seizures
Ganglion: Misnomer (Not related to Nerve)
Excessive use of Tendon> Excessive Pressure> Worn out> Ballooning
Clinical: Localized Painless Cystic Swelling containing Clear Gelatinous Fluid (weakly transilluminant)
Firm/Tense if Small, Soft & Fluctuant if Large
Often communicates adjacent to Tendon Sheath/Joint Capsule
Mobility: when Pt tenses up Muscles
(Reducibility): May slip between deep structures when pressed
Site: Mostly found on Dorsum of Wrist & Foot (Tendon over Corner), occasionally on Flexor surface
Tx: Conservative if Asymptomatic & Small
Excision if Symptomatic (High Recurrence Rate, since its Degenerative)
Glioma/Neuroma/Schwannoma:
Page 86
Semi-Mobile: Mobile in 1 direction (Sideway), but Not in another direction (Longitudinal)
Tinel sign: Press> Paresthesia distal to lesion
Nevus of Ota: (Not taught, but appeared in MCQ/EMQ as a potential choice)
Blue Hyperpigmentation on Face, due to Entrapment of Melanocytes in Upper 1/3 of Dermis
Unilateral, involving areas of Ophthalmic & Maxillary branches of Trigeminal nerve
Sclera is involved in 2/3 cases
F>M
Other Names: Congenital Melanosis Bulbi, Nevus Fuscoceruleus Ophthalmomaxillaris,
Oculodermal Melanocytosis

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Skin Ulcer:
Skin Ulcer: Infection, Trauma, Ischemia/Venous HT, AI, Drug Reaction, Malignancy
Malignant: Cis: Bowens disease, Extramammary Pagets disease
(Also Pre-malignant: Actinic/Solar Keratosis, Arsenic Dermatitis)
Skin Cancer: BCC, SCC, Melanoma
Skin Appendageal tumour: Angiosarcoma
Hx: Age
Hx of presenting Sx: Rapid growing, Bleeding, Recent change
PMH
Systemic Sx
Ulcer: Site
Number, Satellite lesions
Shape, Size, Edge, Base, Induration, Color
Involvement of Surrounding structures
Other associated features
Regional LN
Benign Ulcer:
Furunculosis: Deep Abscess of Hair Follicles
S. aureus
Common in Young
Boil (Furuncle) or Carbuncle
Tx: Topical/Systemic Antibiotic
Impetigo: S. aureus, Hemolytic Streptococcus
Common in Young
Blisters with Pus
Tx: Topical/Systemic Antibiotics
HSV: HSV I (Orofacial) & HSV II (Genital)
Self limiting
dsDNA virus
Virus remain in Sensory nerve Ganglion
Recurrence is common
Tx: Acyclovir, Famciclovir, Valaciclovir
Shingles: VZV
Same virus as Chickenpox
Virus remain in Dorsal root/Cranial nerve Ganglion
Painful Vesicles grow along Dermatome
Recur in IC Pt
PostHerpetic Neuralgia
Tx: Acyclovir, Famciclovir, Analgesia
Syphilis: Spirochete Treponema pallidum
STD
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Stage: Primary, Secondary, Latent & Tertiary stages
Primary: Painless Chancre with Indurated Edge asso. with Regional Lymphadenopathy
Secondary: Fever, Generalized Unwell, Non-Itchy Rash, Generalized Lymphadenopathy
Latent: Relapse of Skin Eruption & Condylomata involve Genitalia, Palms & Soles
Tertiary: Chronic Granuloma (Gumma), Neurosyphilis, Cardiovascular Syphilis
Tuberculous Chancre:
Spread by Droplet
Direct Inoculation
More common in Exposed areas, eg. Face/Limbs
No previous exposure to TB
ve Mantoux test
Dx: Culture/PCR
Tx: AntiTB therapy
Yaws: Treponema pallidum pertenue
Tropical disease, Not Sexually transmitted
Transmit by Skin contact or from Mucous membrane
Primary, Secondary, Tertiary stages
Tx: Penicillin
Pressure Sores: Tissue Anoxia from Prolonged Immobilization
Over Pressure points, eg. Sacrum, Bony prominence
Tx: Wound care, Debridement, Ambulation
Venous Ulcer: Venous HT in Legs
Eczema, Edema, Pigmentation, Ulceration
Result from Minor Trauma
Vary in Size & On Medial Ankle
Well defined margin & Edge is Not Raised/Rolled
Ischemic Ulcer: Arteriosclerosis of Leg vessels
Painful Ulcers
Intermittent Claudication, Coldness, Numbness, Paresthesia
Well defined Edges with Slough
More on Shin, Dorsum & Foot
Pyoderma Gangrenosum:
Non-Infective Inflammatory Ulcer
Immune disorder (May be associated with, eg. IBD)
Resulted from Minor Trauma
Febrile & Toxic
Painful
Ulcerate Rapidly
Tx: Steroid, Minocycline, Cyclosporin

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Malignant:
Primary: *BCC, SCC, Malignant Melanoma (Not so common in Asians), Cutaneous Sarcoma,
Other less common Appendageal tumors
Secondary: Skin Metastasis of Lung/Breast/Kidney/Pancreas, Sister Joseph Nodules around Umbilicus
Bowens disease: Intradermal CA (SCC-in-situ), may proceed to SCC
Chronic UV Light damage
Solitary Rough Patch
Well defined, Slightly Raised & Red plaque with Adherent Scales
Slowly grow
Sun exposed areas
Tx: Cryotherapy, Excision, RT, Topical 5-FU, Photodynamic therapy
Pagets disease of Nipple:
Paget cells arise from Mammary ducts to Nipple Epidermis
Erythema & Eczematous lesion of Nipple> Erosion & Ulceration
50-60 yo
97% has underlying Breast CA
47% present with Breast Mass (93% Invasive Cancer, 7% DCIS)
53% without a Mass (34% Invasive Cancer, 65% DCIS)
Bilateral Pagets disease had been reported
Shave Biopsy, Incisional Biopsy
Tx: BCT RT, Mastectomy, RT alone
Extramammary Pagets disease:
Peno-Scrotal region
Underlying Malignancy
Tx: Wide Excision, CO2 Laser Ablation
Solar Keratosis/Actinic Keratosis:
Rough Scaly patches over Sun exposed areas (usually H&N, Back of Hands)
Due to Excessive UV exposure over many years
May Regress, Persist, or progress to SCC
Tx: Topical Procedures, Excision
BCC: Common Tumor of Low-grade Malignancy
Derived from Basal cells of Lower Epidermis
Age: Middle/Elderly
RF: Fair Skin & Sunlight
Clinical: Typical Raised Rolled Edge with Central Ulceration (Rodent Ulcer)
Classically Pearly in Caucasians; Usually Pigmented in Asians (Lecturer: 80%)
Painless, Slow Growth; (Relatively more well defined than SCC)
Serous Discharge/Bleeding occasionally; May see Telangiectasia changes
Locally Invasive (unless Squamous Differentiation)
Site: Anywhere, but Mainly on Face
Mostly above a Line from Ear lobe to Corner of Mouth
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Commonest around Inner Canthus of Eye (R Yeung: Depth of Invasion can be deep here)
Variants: Cystic, Nodular, Squamous Differentiation
(NB: Superficial BCC has better prognosis (2011 MCQ 28))
Tx: Excision (3-5 mm margin) Local Flap/Skin Graft
RT (usually for Palliative care)
(Cryotherapy)

SCC: Malignant tumour arising from Keratinocytes & may Metastasize
Less Common, but More Malignant & Rapid growth
Arise de novo or in pre-existing Skin lesion (Marjolins Ulcer)
Irregular, Raised Ulcer & Everted Edge
Base Indurated & Fixed to underlying structure
Site: Anywhere but Common in H&N, Limbs
Spread by Direct Infiltration, Lymphatics & Bloodstream
RF: UV Irradiation, X-ray Irradiation, Chemical contact (Polycyclic hydrocarbons, Mineral oils, Tars),
Chronic Scars, HPV virus, Immunosuppressants, Albinism, Xeroderma Pigmentosum,
Bowens disease
NB: Med 2011 MCQ 79: Arsenic exposure asso. with Multifocal SCC & Bowens disease
Tx: Local: Wide Local Excision (1-2 cm margin)
Regional: LN Dissection, Adjuvant RT
Marjolins Ulcer:
Arise from Chronic Wounds/Scars
Usually No distant Metastasis
Tx: Same as for SCC (Wide Local Excision)
Malignant Melanoma:
Fair Skin, Sunlight
Arise de novo or from Pigmented Nevus (Mole/)
RF: Sun Exposure, Fair Skin, >20 Nevi, 1st degree Relatives of Afflicted persons
Type (2005 MCQ 48):
Superficial Spreading Melanoma (Most common type in US)
Nodular Melanoma (Most Aggressive)
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Lentigo Maligna Melanoma (Lentigo Maligna is in-situ; Lentigo Maligna Melanoma is Invasive)
Acral Lentiginous Melanoma (Most common type in Non-White Asians & Black; Hairless skin)
Others: Subungal Melanoma, Desmoplastic Neurotropic Melanoma
Signs of Malignancy in Benign Nevus:
in Size, /in Pigmentation,
Ulcerate/Weep/Bleed, Itchy/Burning Sensation,
Spread of Pigmentation, Enlargement of LN
Any Suspicion> Biopsy (better Excisional Biopsy to document Depth)
ABCDE: Asymmetrical
Border Irregular
Color (usually Multiple colors Variegation in Color)
Diameter (Moles >6 mm are more likely Melanoma) (But all Melanoma began as Small dot)
Enlarging/Elevation
EFG: For Nodular Melanoma (Most Aggressive): Elevated, Firm, Growing
Spread: Local Extension, Lymphatic (Satellite/In transit lesion), Hematogenous
Prognosis: Breslows Classification of Depth of Invasion:
<0.75 mm: Good Prognosis
0.75-1.5 cm: Metastatic Potential
>1.5 cm: Highest risk of Regional LN involvement & Poorest Survival
Regional & Systemic Spread
Tx: Surgical Excision (Primary/LN) (1-3 cm margin), Chemo, RT, Immunotherapy
Tx of LN: Regional Metastasis: Lymphadenectomy
Elective vs Therapeutic LN Dissection
Sentinel LN
Tumour Thickness: 1-4 mm
Sentinel LN:
Morton et al: 1st site of Metastasis
If +ve then for Selective Lymphadenectomy
Intraoperative Mapping with Blue dye RadioLymphoScintigraphy
Radioactive Colloid Sulphur
Adjuvant Therapy: (Generally Not Effective)
RT: Mainly for Palliation
Chemo: Low response rate
Dacarbazine (DTIC)
Limb Perfusion: Melphalan, Hyperthermic Perfusion
For Multiple Local/Intransit Recurrence
Interferon
Vaccine therapy
Anticytotoxic T-lymphocyte Ag-4 (Anti-CTLA-4) mAb (Ipilimumab)
DermatoFibroSarcoma Protuberans:
Locally Aggressive Malignant Dermal tumor
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Painless Irregular Blue/Red Hard Solid Mass/Plaque/Nodule
Slow growing
No previous Trauma/Wound/Scar at abnormal area
Common in Trunk, Metastasis Not common
Tx: Wide Excision RT
Angiosarcoma: Rare but Aggressive Malignant tumour arise from Vascular origin
Affect H&N region, Mainly Elderly Male
Ulcerate & Bleed
Red/Purple plaque
May Metastasize, Usually present Late
Tx: Surgery + RT

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Misc:
Ingrowing Toe Nail: Painful Infection of overhanging Nail fold Laterally
RF: Tight Shoes, Cutting Nails too Short & Convexly, Occasionally run in Families
(Stuffy/Tight Shoes> Edematous Tissue> Soft Flesh> Nails push in)
Tx: Conservative
(If cut the Superficial Nails only> Nails grow> Become Spike-like)
(Correct Action: Push tissue aside to allow corner to come out)
Wedge Excision including Excision of Germinal Matrix
Nail Avulsion: Only for Frequent Recurrence

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Urology Clinical Demo
Urology Exam: Kidney: Palpation, Renal Tenderness
Bladder: Distention
External Genitalia: Penis, Scrotum, Testis
PR Examination: Prostate
Kidney anatomy: Injury: Usually Avulsion of Pedicle
Bladder anatomy: Preperitoneal; Distention> Slip up into anterior abdominal wall
GU Exam: Abdominal exam of Kidney & UB (bimanual palpation)
Genital exam is always a sensitive situation
Adequate exposure vs Overexposure causing distress to Pt; Chaperon
Never make jokes, casual talk or joke about genitalia
Face is easily seen by Pt> Sudden change of Facial exposure> A lot of Stress
Kidney Exam: Bimanual palpation; Normally not palpable
Right hand> Front> Just below subcostal region
Left hand> Underneath
Can only feel lower pole of kidney; Ureter not palpable
UB Exam: Bimanual palpation; PV + Abdomen or PR + Abdomen
Urinary Retention: Bladder capacity: 300-400 ml
Male Genitalia: Equipment: Glove, Drapes, Penlight
Hair distribution: Inverted Triangle (Male), Triangle (Female); Coarser than Scalp hair
Abundant in Suprapubic region, could extend up to Umbilicus
Possible to note distribution around Scrotum down to Anal orifice
Caution when using Scrotal skin for Urethral replacement
PE: Start from Tip of Penis: Try to retract Prepuce (Phimosis, Paraphimosis), Hypospadias
Abnormality of Foreskin/Scarring: Smegma
Color, Texture of Glans:
Circumcised Pt: Erythematous & Dry
Uncircumcised: Wet, Mucosa-like
Mass/Ulcer may hide unnoticed behind Glans
Urethral Meatus: Stenosis, Discharge, Warts, Stone
Palpate Penile shaft between fingers for Induration, Plaque, Curvature, Tenderness
Slight curvature is normal
Should be Soft & Free of Nodularity
Strip Urethra for Discharge, Hard Fibrotic areas
Chordee (Ventral curvature): Common in Children with Hypospadias
Phimosis: Prepuce cant be fully retracted over Glans penis
Can be complicated by Balanitis Xerotica Obliterans (BXO)
Paraphimosis: Prepuce trapped behind Glans penis (ie. Cant be reduced to cover Glans normally)
Peyronie disease: Semi-rigid state (or Flaccid); Pain & Hard Plaque on dorsal side
Not common in Orientals
Urethral opening: NGU Urethritis: Red, Discharge like Condense Milk
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Hypospadias: Hooded foreskin, Ventral chordee, Downward shift of Urethral meatus
Ambiguous genitalia, Penile CA, Warts, Syphilitic Chancre
Self Exam: Esp for Pt with Undescended testes
Scrotal Exam: Examination for Palpable/Visible abnormality
Angiokeratomas are common (Reddish dots in Senile Pt), but No clinical significance
Palpation of the Cord, Vas deferens, Epididymis, Testis
Varicocele: Swelling above testis that feel like a Bag of Worm (in standing position)
Swelling:
Hx: Onset, Painful, Present all the time, Growing larger, Any Irritative Urinary Sx
Logic: Feel for Spermatic cord Possible to get above Swelling?
If Yes (Spermatic cord Above Mass)> True Scrotal Swelling
If Not (Below Mass/Not Palpable)> Arise from Groin (eg. Indirect Inguinal Hernia)
Palpable Testis? (No, may be lesion surrounding testis, eg. Hydrocele)
Inflammatory? (Heat, Red, Pain)
Cystic? Fluctuation, Transillumination
True Scrotal Swelling: Solid, Inflammatory or Cystic
Inspection: Unilateral/Generalized swelling, Redness of Scrotal skin, Enlarged veins on standing
Palpation: Site (Epididymis/Testis), Size, Consistency, Tenderness, Feel for a bag of worms
Transillumination:
Fluid-containing Hydrocele/Epididymal cyst
Ddx: Skin lesions
Spermatic Cord: Funiculitis, Varicocele, Inguinal-Scrotal Hernia
Epididymis: Epididymal Cyst, Epididymitis
Testis: Painless: Hydrocele, Testicular Tumor
Painful: Orchitis, Torsion
Varicocele: Enlargement of Pampiniform Venous Plexus; Severe> Atrophic testis> Asymmetry
Bag of Worm felt on Standing; (May in Size during Valsalva)
*Left side (Left Renal Vein clamped between SMA & Aorta)
Can be due to Nut-cracker syndrome, but need to Exclude Renal Mass (esp if Late onset)
Torsion: Blue Dot sign: Torsion of Testicular Appendage; Young boys; Just observation/symptomatic Tx
Hydrocele: Fluid in Tunical Vaginalis
Can get above, Transillumination, Fluctuance +ve, Testis Not palpable
(On Coughing, instead of Cough impulse, may trigger Cremasteric Reflex & Lift it up a bit)
Need US to examine Testis (See if Normal Testis or Testicular Tumor)
Primary vs Secondary Hydrocele
Secondary: Testicular Tumor, Torsion, Epididymo-Orchitis
Tx: (Surgery Indication is based on Pt preference, eg. if Symptomatic)
Needle Aspiration High Recurrence
Jaboulay procedure (Hydrocele sac Everted & Anchored with Sutures)
(Alternative: Lords Plication of the sac Plicate the redundant Tunica vaginalis)
(High Ligation of PPV is done in Congenital Hydrocele due to PPV)
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Idiopathic Scrotal Edema: Allergic response in Children
Testicular Tumor:
Enlarged Firm Non-Tender Testis
Surgery: Inguinal Radical Orchidectomy
Acute Painful Scrotal swelling:
Torsion vs Epididymo-orchitis
In teenager: Assumed to be Torsion until proven otherwise
Female Urethra: Dorsal position, with Thigh abducted
Inspection: Appearance of Urethral orifice, Stress incontinence
Palpation: Pass a finger into vagina and feel for floor of urethra for Induration
Inguinal Hernia exam:
Rectal Exam: Glove, Lubricant, Drapes
Positioning: Knee Chest position (Massage Prostate; Not for Ill Pt)
Standing position with Flexed Hip
*Supine with Lithotomy position (if want Bimanual, Cystoscopy)
**Left lateral position
Use drapes but retain good visualization of the area; Warn Pt before inserting finger
Anus, Rectum, Prostate:
Inspection of Perianal area:
Skin excoriation, Inflammation, Pilonidal hair/Dimpling (not common in Orientals)
Pilonidal cyst: Cyst/Abscess on Intergluteal cleft of buttock, which contain hair & skin debris
Painful; May form Pilonidal sinus
Inspection of Anus:
Skin tags, Skin condition, Fistula, Fissure, Hemorrhoid, Prolapse
Anal reflex
Finger Examination of Rectum: Insert with palmar side in front and feel for anal tone, then turn around
Anal tone: Muscular sphincter should grip on examining finger
Rectal lumen: Posterior, Lateral, Anterior: Irregularity, Nodule, Polyp, Mass, Tenderness
Female: Cervix anteriorly often confused as anterior Rectal mass
Cervix: Size, Shape, Position mobility, Smoothness
Bear Down: Feel for Nodule/Tenderness
Fecal Load: Note Status & Consistency of Fecal load
Glove: Look for color of Feces, Blood (fresh, stale, melena), Mucus, Pus
Anal Reflex: Scratch Perianal area> Sphincter contraction
Bulbocavernosus/Bulbospongiosus Reflex:
Bulvocavernosus is an older term for Bulbospongiosus
Squeeze Glans/Tug Foley> Sharp twitch in Bulbar muscles (Feel Anal sphincter contraction)
Prostate Exam: Anterior to Rectum, within Palpable range of PR exam
Normal size: 20 g; Seminal vesicle should be palpable
Feel for: Size (finger breadth), Consistency (*Rubbery), Median Groove (MG), any Hard Irregular nodule
Report of Hard nodule is equivalent to CA Prostate
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Normal Prostate: Smooth, Firm, Just slightly movable
Median Groove: Usually quite Shallow, esp with BPH
Rubbery/Boggy sensation: BPH
PR Exam:
Anal Warts, Perianal Abscess, Hemorrhoids
Pilonidal sinus: Not common (Not as hairy as Caucasians)
Prostate CA, Prostatitis
Kidney: Ballot; Renal tenderness: Sitting position> Gentle tapping for Renal angle at the back
UB: Inspect for distention over Suprapubic region; Percuss for dullness
External Genitalia: Exposure down to Mid-thigh
Inspection: Loss of Hair> Hypogonadism
Penis: Squeeze Penis> Milk along course of Urethra
Discharge, Abnormal appearance of Glans, Retract prepuce, Coronal Sulcus,
Urethral opening, Penile shaft, Fibrous tissue (Peyronie), Induration (Stricture, Stones)
Scrotum: Both anterior & posterior
Testes: Left side first; 2 hands to fix testes> Palpate gently
Then Epididymis> Cord> Vas deferens
(If suspect Hypogonadism, measure Size of Testes by Orchidometer; 22-25 ml for normal Asian)
Standing: Look for Varicocele, Ask Pt to cough to check for Inguinal Hernia
PR Exam: Inspect Sacral-Coccygeal, Perianal area
Check for Perianal region Sensation, Anal reflex
Warn Pt of discomfort; Loosen anal tone> Insert
Rotate to feel for Posterior side first> Lateral side> Anterior side
Feel for Prostate, (Seminal vesicle)
Check gloves
Acute Prostatitis: 3 Glass Test for Culture & Urinalysis, eg. WBC count
VB-1 (Voided Bladder-1): 5-10 ml; Urethral flora
Void 100-200 ml
VB-2 (=MSU): 5-10 ml; Vesical flora
Massage the Prostate at Knee-chest position
VB-3: 5-10 ml; Prostatic flora
Dx Prostatitis: Culture result of VB-3 should >> VB-1, VB-2 to establish the dx of Prostatitis
Prostate CA: DRE, PSA assay, Transrectal US, Biopsy

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Urology Hernia, Groin LN, PR Exam
Hernia Hx:
c/o Swelling: Duration, Reducibility (appear when strain, cough, stand up, walking), Unilateral/Bilateral,
Pain (Locally or Midline of abdomen/colic), Extension to Scrotum (tight feeling),
Predisposing factors (Intra-abdominal P: 5F, Chronic Cough, Constipation, Urinary Straining),
Previous Operation (Opposite side> Generalized Weakness; Same side> Recurrence; Incisional)
{Clerk case Exp: Some Pt may complain of Pain only after Meal Peristaltic Pain}
Reducible Mass: Clinically presumed as Hernia until proven otherwise
Direct Inguinal Hernia: May be Bilateral (Weakened anterior abdominal wall)
Groin Anatomy: Inguinal Ligament: Between ASIS & Pubic tubercle
Pubic tubercle: 2 Palpation methods
1. *From Umbilicus down to Symphysis, then go Lateral along Upper border to Edge
(Be gentle Spermatic Cord may be Tender at where it cross Pubic tubercle)
2. If difficult in Obese Pt, Flex & Abduct Hip to trace along Adductor Longus Tendon
> Pubic tubercle is Just above Tendon Insertion point on Pubic bone
SIR: Palpable Above & Medial to Pubic Tubercle
DIR: 1 cm above Midpoint of Inguinal Ligament (between ASIS & Pubic Tubercle)
(J Poon/KY Wong: 2.5 cm above Midpoint of Inguinal Ligament) (1 Finger breadth)
NOT Mid-Inguinal point (between ASIS & Pubic Symphysis) (Femoral pulse)

Femoral Canal: From below, place Right Index finger on Femoral Pulse (Femoral A)
Middle finger will lie on Femoral V, Ring finger will lie on Femoral Canal

Inferior Epigastric vessels: Surgical Landmark to differentiate DIH & IIH
DIH: Medial to Inferior Epigastric
IIH: Lateral to Inferior Epigastric
Approach: Confirm Hernia: Cough Impulse
Ddx FH/IH: Palpate for Neck of Hernia
Ddx DIH/IIH: Occlusion test
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GE: Nicotine Stain (Chronic Coughing), Cachetic, Thin
Hernia PE:
Exposure: Privacy; Umbilicus to Mid-thigh; Cover External genitalia until necessary to expose
Position: Standing (Hernia most prominent) / Supine (best opportunity to reduce hernia)
Look: (Ask Pt to Stand for the 1st time)
(Speed): DIH: Usually appear quickly upon standing (& Easy to Reduce)
IIH/FH: Depend on Neck of Hernia
Scars: Open: Oblique Scar above Inguinal Ligament Medially (Can be Faint)
Laparoscopic: 3 ports; Usually 2 at/near Midline (bigger superior port is Camera port)
The remaining one can be near Midline or near Lesion side
(Near Lesion side is Easier; Midline good for Bilateral Repair)
Other Abd Scar: May affect decision to use Laparoscopic Repair
Swelling: Unilateral/Bilateral
Scrotum: Any Extension to Scrotum (This rules out Femoral Hernia)
(DIH if Large enough can also extend to Scrotum but Rare)
Cough impulse: Cough for 1st time, Focus (look carefully!) at complained side & opposite side
(May ask Pt to turn head away to cough)
Feel: Cough Impulse: Palpate Bilaterally & Ask Pt to Cough for 2nd time
Border: Upper Border: Cant get above for Hernia
Lower Border: Whether it can be separated from Testis (Cant separate> Think Hydrocele)
(Ask Pt to lie Supine)
Reduction: Pt need to Lie down to reduce (Some DIH may be reduced spontaneously upon lying down)
Purpose: To determine Neck of Hernia and for Occlusion Test
Dont reduce it yourself (might be painful) (Unless Examiner requires you to do it)
Ask Pt to reduce it, or ask Examiner if Pt cant
(Technique):
May put Pt in 20 Trendelenburg position (Allows Gravity to help retract herniated tissue)
2 hands: Guide proximal portion through fascial defect + Apply Gentle pressure distally
Direction: DIH: Upward & Straight back; IIH: Upward, Lateral & Backward
rd
Neck of Hernia: Ask Pt Cough for the 3 time to confirm Neck
Groin Hernia: Inguinal Hernia vs Femoral Hernia
Inguinal: Above & Medial to Pubic tubercle (Neck of Hernia =/= DIR)
Femoral: Below & Lateral to Pubic tubercle (Sac may turn upward, but Not Neck)
(Femoral Hernia Uncommon, but if it is, No need Occlusion Test anymore)
NB: Significance: IH require Incision above Inguinal Ligament, while FH is below
Some examiners may want you to comment on Size of Neck
(Reduction for the 2nd time)
Occlusion test: Occlude DIR to differentiate DIH & IIH
Left hand for Right Hernia, vice versa
Rest Left hand on Iliac crest, use left Thumb to occlude point of DIR
Keep the thumb & Ask Pt to Stand up (for the 2nd time) Cough (for the 4th time)
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DIH: Hernia appear upon Standing or Cough Impulse seen
(Andre Tan: Poor accuracy; Sometimes can still be IIH)
IIH: Nth appear
> Appear after removing Thumb ( Cough for the 5th time again)
NB: Suggested flow by UCH Dr Wu: Take Right Hernia as example
Right Index finger locate Pubic tubercle & stay there
Left Index finger locate ASIS & stay there
Right Thumb press on ASIS
Left Thumb press on above apparent Mid point, with other Fingers grasping on Iliac crest)
(Percussion & Auscultation):
For Bowel sounds (To differentiate content Bowel or Omentum)
Further Exam: External genitalia: Any Testicular Atrophy, (Undescended Testis)
(Due to Testicular A damage or Pampiniform plexus Thrombosis)
Abd Exam: Ascites (or other causes of Distension), (IO, AROU)
PR Exam: BPH, (Impacted stool)
Resp Exam: COPD
Groin LN Hx: Duration, Pain, Enlargement, Sx of Anus/LUT/LL, Lumps or LN elsewhere (Neck, Axilla)
Painful: Acute Lymphadenitis, cf Chronic Lymphadenitis & Malignancy
Irreducible: cf Hernia
PE: Exposure: Same as Hernia
Position: Supine
Look: Swelling
Acute inflammation (Red, Shiny), Sinus, Wounds
Feel: Local: Number, Size, Discrete/Matted, Consistency, Tenderness, Mobility, Groups of LN involved
Matted: TB, Metastatic spread
Consistency: Hard (Malignant), Rubbery (Lymphoma)
Groups of Groin LN:
3 superficial groups, Drain to Cribriform fossa
Medial: External genitalia, Anus
Lateral: Lateral thigh, Buttock
Vertical: Along Great Saphenous
Back of heel drain into back of thigh (deep)
NB: Testes do Not drain to Inguinal LN; They drain to Para-aortic LN
Other: LL, Other LN (Neck, Axilla), Abdomen (Liver, Spleen), PR
Rectal Exam:
Local:
Anal Pain: Nature (sharp/dull), Continuous/Intermittent (eg. only with defecation),
PR Bleeding (bright red/fresh/altered), Other bowel Sx
Anal Swelling:
Present all the time or only when Straining (prolapsing but reducible),
Painful/Tender/Throbbing, Bleeding/Discharge
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Instrument: Gloves, Lubricants (eg. AquaGel), Gauze/Tissue paper
Position: Left Lateral (Simms),
Prone Jack-knife (need special bed, good for anal operation-Hemorrhoidectomy)
Exposure:
Look: Perineum: Scar, Fistula opening
Perianal: Fissure, External hemorrhoid
Anal Fissure: *Posterior Midline (80%), 20% Anterior Midline, *Female
Feel: Lubricated gloved finger
Direction: Toward Umbilicus
Feel for perianal area first, and make Pt psychologically prepared
Rectal Lesion: Intraluminal/Extraluminal, Level (upper/lower borders), Size & %Circumference, Shape,
Consistency, Mobility, POD or RVP, Blood/Mucus/Color of stool on glove
Level: Report: Lower border is xx cm above anal verge, Upper border is xx cm above anal verge
If cant palpate upper border> Report Beyond the reach of my index finger
Shape: Polypoid, Ulcerative, Plaque
RVP/RUP: Rectovesical pouch in Male, Rectouterine pouch/Pouch of Douglas in Female
Bimanual: Rectoabdominal, also do Rectovaginal for Female
Glove: Blood> Mucosal lesion
Proctoscopy: British call it Proctoscope, but in fact it only looks at Anal area (ie. Anoscope, as called in US)
New one: Self-illuminating proctoscope
Internal hemorrhoid can only be checked by Proctoscope, Not DRE
Direction: Toward Umbilicus
Procedure: ALWAYS do DRE before insertion of instruments
NEVER advance without an Obturator
Insertion> Removal of Obturator> Inspection upon Withdrawal (circular motion)
Because opening is a tunnel vision, during withdrawal, slowly observe the wall
Aim: Internal hemorrhoid, Internal orifice of fistula
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Hernia:
Protrusion of an organ through an opening
in the wall of the cavity in which it is normally contained
Groin Hernia: More common in Male due to Abdominal Wall Deficiency caused by Testicular Descent
Usually Soft & Squishy
May hear Bowel sound on Auscultation if Bowel present in Large Hernia Sac & Not Strangulated
Reducibility is most diagnostic (but note Femoral Hernia often Irreducible)
Content: Usually Bowel, May be Omentum, Rarely part of Bladder
Irreducible: Incarcerated: Adhesions within Sac due to Long-standing Hernia> Chronically Irreducible
Obstructed: IO with Intact Blood supply
Strangulated: Blood supply cut off> Ischemia; Lumen Obstruction (Richters Hernia No IO)
Often Tender & Red Lump (Note Pain may be Non-Localized)
Risk: FH > IIH > DIH (The smaller the defect, the Higher the risk)
Reduction en Masse:
Rare but Serious Cx of Manual Reduction
Peritoneal sac & Constricting neck are reduced into abdomen without relieving the Constriction
Bowel may progress to IO & Strangulation despite apparent Reduction
(Both Hernia contents & Hernia sac are reduced)

Indirect Inguinal Hernia:
Most common, All Age (Often in Children, but can be in Adults), Both Sex (still M>F)
Origin: Above Inguinal Ligament, over Deep/Internal Inguinal Ring; (R>L)
Due to Patent Processus Vaginalis (together with Weakened Fascia at DIR)
May extend into Scrotum if large
Direct Inguinal Hernia:
Less common, Usually in Male >40, Uncommon in Female
Origin: Above Inguinal Ligament, Near Superior/External Inguinal Ring
Hesselbachs Triangle area (Weakest part of abdominal wall):
Inferior: Inguinal Ligament
Lateral: Inferior Epigastric vessels
Medial: Lateral border of Rectus sheath
(Least likely to Strangulate No ring-like structure)
Femoral Hernia: Least common, Usually Female (Female Pelvis wider; But Most common Hernia in F is still IH)
Affect Femoral Canal rather than Inguinal Canal
(Due to Dilated Femoral Ring> Come out from Saphenous opening)
Below Inguinal Ligament, Appear more Lateral than Inguinal Hernia
Usually Smaller & Firmer than IH, Often No Cough Impulse & Irreducible (Narrow Canal)
Commonly mistaken for Enlarged Groin LN (or Lipoma)
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If feel Cough Impulse: Need to ddx from Thrill on Coughing of Saphena Varix
Higher risk of Strangulation
Ddx:

Skin, Soft tissues: Lipoma, Sebaceous cyst
Groin LN: Vary in Consistency, Number, Size; Irreducible, Below Inguinal Ligament
Undescended Testis: Usually above Inguinal Ligament; Check for presence of Testis in Scrotum
Spermatic Cord: Encysted Hydrocele (ie. Does not go to Scrotum), Lipoma (quite common)
Saphena Varix: Very Soft, Disappear completely on Palpation/Lying down; VV over LL
Also has Cough Impulse
Femoral A Aneurysm: Firm & Pulsatile
Psoas Abscess: Rare nowadays; Classically due to extension of TB Abscess from Lumbar spine
Dx: Clinical Dx
(Indefinite Hernia on PE):
Option 1: Proceed to Surgery just based on Hx
Option 2: Book Imaging: MRI: Best but Long waiting list
US: Quick, but Less Accurate & Need Pt cooperation (Valsalva)
Tx of Inguinal Hernia Repair: (Note that Inguinal Hernia in Paedi is different; Tx only requires High Ligation of PPV)
Strengthen Posterior wall of Inguinal Canal
Tension free most important
Mesh Repair most common (Induce Fibrosis)
Terminology: Herniotomy: Just Excision of Hernia sac after reducing content; Usually in Paedi Pt
Herniorraphy: Herniotomy + Strengthening of Posterior wall
Eg. Fascia Transversalis by Double Breasting the Layer (Shouldice Repair)
Hernioplasty: Herniotomy + Strengthening of Posterior wall by putting a Mesh
Open Repair: (Gold standard is Open Mesh Repair under LA)
Type: *Mesh Repair: Lichtenstein Repair (Tension Free Inguinal Herniorrhaphy with Mesh)
Pros: Tension Free (Avoids approximation of tissues)> Recurrence
Suture Repair: Bassini Repair, Shouldice Repair
(May consider in Contaminated wounds Mesh contraindicated)
Pros: Can be done in LA
Direct Repair, Easy & Effective
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NB: (In Open Repair, canNot directly see Inferior Epigastric vessels)
Laparoscopic Repair:
Mesh is placed in Preperitoneal space; Larger Mesh than Open as the space is Larger
Mesh may be stabilized by Suture, Tissue Glue, or No need extra stabilization at all
Needoscopic Repair: Even Smaller wounds than Conventional Laparoscopy
2 Types: TransAbdominal PrePeritoneal (TAPP):
Easier: Larger working space, Familiar Anatomic Landmarks visible
*Totally Extra-Peritoneal (TEP):
Enter Preperitoneal space without entering Peritoneal Cavity> Adhesive IO
Pros: Wound & Nerve Pain (Post Herniorraphy Pain syndrome/Inguinodynia)
MESH put in Preperitoneal space below Transversalis Fascia rather than under Skin
> Less Nerve Entrapment of IlioInguinal & IlioHypogastric Nerve
Faster Recovery & Discharge
Post-op Cx (in experienced hands)
Cons: Higher Recurrence in Non-expert, Needs GA
Indication: Bilateral Repair (3 ports at midline> Can repair both sides with same ports)
Recurrent Hernia (Scarring in Inguinal canal> More difficult to do Open Repair)
Other Laparoscopic procedure required (for other conditions)
NB: Now recognized as a good alternative even in 1st presentation in specialized centres
(Often done as 1st line in QMH & TWH)
Contraindications:
Absolute: GA contraindications
Relative: Previous Abd Surgery
Large Scrotal Hernia
(Less optimal for Emergency Surgery for Incarceration/Strangulation)
Cx: Anesthesia related
Mesh related: Erosion, Migration, etc
Early: AROU (common)
Hematoma/Seroma (common; Mild Swelling & Discomfort; Resolves spontaneously)
Bleeding, Infection
Injury to surroundings: Pain, Paresthesia, Impotence (Spermatic cord injury)
Late: Chronic Pain
Ischemic Orchitis & Testicular Atrophy
Recurrence
Tx of Femoral Hernia Repair:
Primary Closure of Femoral Ring Under Tension (eg. McVay)
Plug Hernioplasty Tension free Repair (Mesh Repair)
Other Hernia:
Pantaloon: Both DIH & IIH; Hernia
Sliding: Herniation of Posterior Peritoneum with underlying Retroperitoneal structures
Ie. Hernia sac partially formed by wall of viscus (Cecum/Sigmoid, Bladder)
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Richters: AntiMesenteric wall of intestine protrudes through a defect
Only 1 intestinal wall protrudes, ie. Lumen is partly outside partly inside, still Patent
Can result in Strangulation without IO (or with partial IO signs, eg. Flatus, Vomiting)
(Essential Surgery: Can occur in 30% of Strangulated Femoral Hernia)

Umbilical: Hernia through Umbilical ring
Congenital Umbilical Hernia:
Commonly seen in Infants, usually resolve by Age of 5
Repair indicated if seen in Older Children/Adults, >2 cm, Incarcerated
Acquired Umbilical Hernia (ParaUmbilical Hernia):
In Adults, asso. with Ascites, Pregnancy, Obesity
(NB: Most surgeons prefer the term ParaUmbilical Hernia; Do Not say Umbilical Hernia in Adults)
Epigastric: Hernia through Linea alba above Umbilicus
Littres: Hernia involving Meckels diverticulum
Spigelian: Hernia through Linea semilunaris (Lateral edge of Rectus abdominis) {Spigelian Semilunaris}
Small, prone to Strangulation (2012 MCQ 9)
Amyand's: Hernia sac containing Appendix {Amyands Appendix}
Obturator: Hernia through Obturator canal (F>M)
Howship-Romberg sign: Pain along Medial aspect of Proximal Thigh on Hip IR
Due to Nerve compression caused by an Obturator Hernia
NB: Risk of Strangulation Lower than Femoral Hernia? (2004 MCQ 84)
Lumbar: Petits Hernia: Hernia through Inferior Lumbar Triangle
Grynfeltts Hernia: Hernia through Superior Lumbar Triangle
Sciatic/Gluteal: Hernia through Sciatic foramen
Incisional: Can be Incarcerated but Never Strangulate
Parastomal
Internal: Hernia into/involving Intra-abdominal structure
Hiatal Hernia
Diaphragmatic Hernia:
(Tx: Primary closure Double Mesh Repair; The mesh facing Peritoneum is Inert Avoid IO)
Other Essential Anatomy:
Ilioinguinal nerve:
Travels on top of Spermatic cord (Pass through SIR but Not DIR, ie. Not formally through canal)
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If cut, Numbness of Inner Thigh/Lateral Scrotum; Usually goes away in 6 months
(Some may deliberately cut it to avoid Risk of Entrapment & Post-op Pain)
Ilioinguinal Block Surface Landmark:
Needle insertion 2 cm Above & 2 cm Medial to ASIS
Inguinal canal: Male: Spermatic cord & Ilioinguinal nerve (2003 MCQ 32)
Female: Round ligament & Ilioinguinal nerve
Boundary: (2011 MCQ 10) (2010 MCQ 9) (2003 MCQ 32)
Anterior: External oblique Aponeurosis (Reinforced in Lateral 1/3 by Internal oblique)
Posterior: Transversalis Fascia (Reinforced in Medial 1/3 by Conjoint tendon)
Roof: Internal oblique & Transversus abdominis (arching fibres before as Conjoint tendon)
Floor: Inguinal ligament, and Lacunar ligament medially

Spermatic cord content:
3 A: Testicular artery, Cremasteric artery, Artery to Vas deferens
3 N: Genital branch of GenitoFemoral nerve (Anterior Scrotal skin, Cremasteric reflex)
Sympathetic & Visceral afferent fibres
Ilioinguinal nerve (Actually its outside Spermatic cord but within Inguinal canal)
3 Others: Vas deferens
Testicular Pampiniform Venous Plexus
Testicular Lymphatics
3 Layers: External Spermatic Fascia
Cremasteric Fascia (Cremasteric muscle is derived from Internal Oblique Muscle)
Internal Spermatic Fascia
Inguinal Ligament (Pouparts Ligament):
Derived from External Oblique Aponeurosis
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Conjoint Tendon:
Aponeurotic attachments of Internal oblique & Transversus abdominis to Pubic tubercle
Arcuate Line: Demarcates Lower Limit of Posterior Rectus Sheath
~1/3 distance from Umbilicus to Pubic Crest
Above it: Anterior sheath by External & Internal, Posterior sheath by Internal & Transversus
Below it: All 3 aponeuroses make up Anterior sheath; No Posterior sheath
ie. Rectus abdominis rests directly on Transversalis fascia
Femoral canal border: (2007 MCQ 36)
AnteroSuperior: Inguinal ligament
Posterior: Pectineal ligament
Medial: Lacunar ligament
Lateral: Femoral vein
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Urology Hernia
Vascular Exam
Disease of Arterial System: *Occlusion (Acute, *Chronic), Aneurysm
Arterial Occlusive Disease:
Hx: Sx of Ischemia
Acute LL Ischemia: 6P: Pain, Pallor, Perishing Cold, Pulselessness, Paraesthesia, Paralysis
Exam: Signs of Perfusion, Turbulence, Absent Flow
Questions: Arterial Occlusive Disease? (dont be mistaken by, eg, Sciatica/Neurogenic Claudication)
Acute/Chronic?
How Severe? (can wait?)
Level of Main Occlusion?
Why has this disease?
(Answer these 5 questions in Conclusion of Hx presentation)
Pt: Age, Gender, Occupation (important! Cant walk may affect occupation), Past Health/Medication
C/O: Sx: Intermittent Claudication, Rest Pain, Ulcer/Gangrene; WONT have Swelling
Duration, Progression, Aggravation/Relief
PVD Exam: Introduction, Ask for Consent, Ask if any Pain anywhere
GE: General State, Ambulation/Gait (can walk or not!), Pallor/Jaundice/LN
Exposure: Up till Groin region (Access site of Angioplasty)
LL:
Inspection: Intermittent Claudication: May have No Clinical signs on Inspection
Severe LL Ischemia:
Trophic Signs: Thin Brittle Nails, Atrophic Skin/Toe (shiny), Loss of Hair
Color
Tissue Loss/Ulcers: Toes, Heel, Pressure points of Foot/Ankle
Surgical Scars for Bypass Surgery/Fasciotomy, Previous Toe Amputation
Ischemic Ulcer: Size, Site, Surface, Edge, Base, Surrounding
(Arterial: Punched-out Edge, Whitish Base)
Palpation:
1. Capillary Return of Toes
2. Temperature (differences between both sides? )
3. Peripheral Pulse:
Normal: ++ Diminished: + Absent:
(NB: Formative Exam MCQ: Normal LL Peripheral Pulse practically rule out PVD)
Axillary & Subclavian pulses are more difficult to detect
Angle of Mandible: Where Carotid bifurcates; Site for Auscultation for Bruit
Femoral pulse: Palpate by both hands (8 fingers) at the point
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Vascular Exam

NB: May also palpate Vessel wall when palpating pulse for any Sclerotic change
(In Emergency Bleeding):
Cut Greater Saphenous Vein in FRONT of Medial Malleolus for Venous Line Insertion
Avoid cutting Posterior Tibial Artery which is Behind Medial Malleolus
4. Buergers test: {Elevation Pallor, Dependent Rubra}
Pale on Elevation, Dependency Hyperemia
Pt lying supine, Elevate 1 leg to 45 and wait for 30s, Note for Pallor on foot
(CU note: Slowly Elevate until Pallor develops and measure the Vascular Angle)
Elevation: In Normal circulation, Toe stays Pink even if elevate 90
In Ischemia, Vascular Angle (Angle of leg raise before becoming Pale)
Vascular Angle <20 indicate Severe Ischemia
(Venous Guttering may also be noticed)
Reverse: In Arterial disease, Put leg down: Pale> Cyanotic> Red-Orange
Reactive Hyperemia: Arteriole dilatation to remove metabolic waste
Further Exam:
UL: UL Pulse, BP
(NB: If UL affected, think of Buergers disease; May notice Gangrenous Fingertips)
H&N: Carotid Pulse, Carotid Bruit
CVS exam
Abd exam: AAA, Renal Bruit, Femoral Bruit
Varicose vein (VV): Definition: Dilated Tortuous (Elongated) Palpable Superficial/SC Veins! (Usually >4 mm)
*Female (3.5:1): Pregnancy aggravate VV + More Symptomatic in Female (Cosmetic concern)
Cause:
Primary: Sapheno-Femoral Incompetence
Long/Short Saphenous V
Secondary: Secondary to DVT
(Acting as Collaterals in Damaged/Occluded/Absent Deep V)
(Usually Severe Skin changes and Not many VV)
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Vascular Exam

Hx: Sx of Uncomplicated VV (Cosmetic, Swelling, Dull ache, Night cramps)
Cx: Itchiness/Eczema, Pigmentation, Venous Ulceration,
Lipodermatosclerosis (Can restrict Swelling by Edema at distal leg)
Past Hx of DVT, Fractures, IV Drug abuse, Pelvic Surgery, CA
Previous Surgery & Recurrence
PE:
Exposure: Expose both Legs fully (From Groin to Toe), Undress any Wound Dressings
Position: Stand with (, 90) ( also ok)
Inspection: Distribution, Scar, (Color), Cx of CVI, Saphena Varix
VV distribution: LSV, SSV, Deep, Perforators, Combination
SSV: Posterior to Lateral Malleolus, passing Posteriorly over Lateral Calf to Popliteal fossa
LSV: Anterior to Medial Malleolus, passing up to Medial Knee, then up Medial Thigh to SFJ
Scar
(Color): Locally Red: Superficial Thrombophlebitis
Generalized White: Phlegmasia alba dolens (White Leg)
(Rare) Occlusion of Deep Vein system (*DVT)
> Rely on Superficial system for Drainage (but Inadequate)
> Edema, Pain, White appearance
Generalized Blue: Phlegmasia cerulea dolens (Blue Leg)
(Very Rare) Progression from White Leg> Occlusion of Superficial Vein system as well
> Edema & Loss of Venous outflow impede Arterial flow> Ischemia
Reticular Veins/Telangiectasia (Spider Veins)
Pitting Edema
Eczema/Itchiness
Pigmentation: Hemosiderin Deposition secondary to RBC stasis (Venous HT> RBC forced into tissue)
Lipodermatosclerosis:
Scarring of Skin & Fat
Chronic Hemosiderin> Fibrin Deposition> Thickened/Shiny Skin
> Skin around Ankle constrict (Can restrict Edema at distal leg)
> Inverted Champagne-bottle shape
Atrophy Blanche:
Healed Ulcer> White Patch/Paler areas
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Vascular Exam
Ulceration: *Around Medial Malleolus Gaiter Area
Venous HT> Leucocyte Leakage> Proteolytic lesion> Ulcer
Features: Shallow, Sloping Edge (Healing), Pink/Pale Purple/Brown,
Granulation tissue at Base with Serous Discharge
Painless, Warm limb, Pulses still palpable
Saphena Varix: May see a Bulge at Saphenous opening (SF Incompetence)
SFJ: Not at Mid-Inguinal point (Femoral A)
2-4 cm Inferior & Lateral to Pubic Tubercle (Lecturer & CU: 2 cm, Asians?)
Palpation: Ask if any Pain in LL
(Palpate VV course/distribution):
Feel for: Varicosities (May be more Palpable than Visible esp in Fat Legs)
Perforator defect (Can feel a dermal defect)
(Tenderness (Phlebitis), Hardness (Thrombosis))
Palpation for Pitting Edema & Lipodermatosclerosis
Exclude co-existing Arterial disease (Part 1):
Temp: Feel Temp of both LL with Back of hand; Should be Warm
(Saphena Varix): Soft & Compressible; Reducible on Lying
Cough test: Cough Impulse (More prominent upon Valsalva Maneuver/Cough)
(Tap test): Place fingers of 1 hand at Lower limit of LSV (Usually Medial Knee)
Tap above with your another hand (Usually SFJ)
Percussion Impulse: Indicate Incompetence of Superficial veins (LSV)
(In general, can place a finger at any point of VV> Tap it Proximally> Feel for Fluid Thrill)
(If Tap below & Feel above, Easier to feel for Thrill, but only indicate that 2 parts are connected)
(Direction test): Empty a short section of vein> Vein will refill when release top finger if valve incompetent
Usually Not done
(Pt change to Supine position: See if Varix reduced, check Pulse, prepare for Tourniquet Test)
Exclude co-existing Arterial disease (Part 2):
Pulse: Offer to quick feel for Pedal Pulse; Should be present
Special tests:
- (Trendelenburg test):
(Used to be done by Finger, but now is regarded an interchangeable term as Tourniquet Test)
Test for SF Incompetence only
Leg raise to Empty vein> Exert pressure on SFJ with Finger> Ask Pt to Stand
If veins do Not refill: SFJ Incompetent (Release of Pressure can confirm)
If veins Refill: Presence of Distal Incompetent Perforators
SFJ may or may not be Incompetent
- Tourniquet test: (Unreliable Below Knee; Replaced by Doppler US now to locate Perforating veins)
Visual test: If in Obese Pt cant see Veins, Dont do
Flow: Pt Lie down
Elevate Leg to Empty Veins
(If Veins do Not empty on Elevation, May signify AV Fistula although Rare> Auscultate)
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Ask Pt or someone to hold the elevated Leg (or, place the leg on own Shoulder)
Apply Venous Tourniquet (Focus on tying Medial side for LSV, ie. Knot over opposite side)
(Tourniquet only compress Superficial veins but Not very tight to occlude Deep veins)
Phase 1: Ask Pt to stand up
Determines any Incompetence Below Tourniquet
+ve: Rapid Filling of Veins
Imply: Incompetence Below Tourniquet (Deep/Perforating veins below)
False +ve: Poor Tourniquet technique (Too Loose)
ve: No Rapid Filling of Veins
Imply: No Incompetence Below Tourniquet
(Reflux blocked by Tourniquet> Only Normal Slow Fill from Capillary)
Phase 2: Release Tourniquet (Dont wait for too Long after Phase 1)
Determines any Incompetence Above Tourniquet
+ve: Rapid Filling of Veins
Imply: Incompetence Above Tourniquet (eg. If applied below SFJ, implies SFJ incompetence)
ve: No Rapid Filling of Veins
Imply: No Incompetence Above Tourniquet
False ve: Waited too Long after Phase 1 (Fully filled in 1st phase already)
Number of Tourniquets:
*Single Tourniquet Exam: Apply 1 Tourniquet only
Apply on Upper Thigh (Apply as close to Groin as possible):
If VV controlled: SFJ Incompetence; No need to proceed further
(Probably the most accurate part of the test)
If Not, repeat Above Knee:
If VV controlled: Mid-Thigh Perforators; No need to proceed further
If Not, repeat Below Knee:
If controlled: Knee Perforators, SPJ
If Not: Mid-Calf Perforators (5, 10, 15 cm above Medial Malleolus)
NB: Problem of Single Tourniquet is, if there are both SFJ Incompetence & Mid-Calf Perforators,
then Competence of Perforators in between them (ie. Thigh, Knee) cant be assessed
Multiple Tourniquet Exam (eg. Triple Tourniquet Test):
For Coexisting Communications?
Can be Confusing thus often Not advised
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Vascular Exam
- (Perthes Test): Painful & Rarely used test for Deep Vein Patency (but may help pick up Chronic DVT)
Empty Vein> Place Tourniquet around Thigh> Pt Stand up
> Pt rapidly Stand up & down on their toes (Muscle Pumping action)
Results: Veins Less Prominent: Patent & Competent Calf Perforators & Deep V
Veins Filling & Painful: Deep V/Perforators Incompetence/Occlusion
To Complete the Exam:
Handheld Doppler with Calf Squeeze Maneuver
(Extra): Abdomen Exam & PR Exam for Mass compressing IVC/Iliac Veins
Groin LN
Neurological Exam if Neuropathic Foot suspected
Auscultate over sites of Marked Venous Clusters for Continuous Bruit of AV Fistula
Reticular V/Spider V: Smaller, No Swelling (Just below Skin Surface), Not Painful, Can be more Distal
Reticular V: Non-Palpable Subdermal Vein 4 mm
Telangiectasia/Spider V:
Dilated Intradermal Venules <1 mm
Chronic Venous Pigmentation & Ulcer:
Size, Site, Surface, Edge, Base, Surrounding
Venous Ulcer: Typical Gaiters area
Pigmentation, Size, Sloping Edge, Slough/Granulation at Base, Visible VV/Previous Surgery
Chronic Ulcer may> Malignant; Underlying Dermato/Rheumato-logical disorder? Need Biopsy
Ulcers:
Arterial: Trophic signs, /Absent Pulse, Painful, Pressure Areas
Venous: CVI signs, Good Pulse, Less Painful, Gaiters area
NB: Most common ulcer (2009 MCQ 35, 2005 MCQ 78)
Neurogenic/Neuropathic:
Painless, Neuropathy
Malignant: Irregular, Raised Edges (SCC), Groin LN
Marjolins Ulcer: SCC develops in Edge of Longstanding Ulcer
NB: Biopsy taken from Edge
Infection: Chronic Osteomyelitis, Syphilis, (TB)
Trauma

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Vascular Exam
Breast Benign Breast Disease
Benign Breast disease:
Account for 90% of Clinical Presentation related to Breast
Classification by Clinical Features:
Physiological Swelling & Tenderness, Nodularity, No definite Mass, Mastalgia, Breast Lumps,
Nipple Discharge, Infection
Physiological Cyclical Swelling & Tenderness:
Premenstrual Breast Tenderness with Mild Swelling
Result from Variation in Plasma concentration of Gonadotrophic & Ovarian hormones
Fibroadenosis
Nodularity: General pattern of Persistent Lumpiness, or Nodularity that is generally Normal
Fibrocystic change/Fibroadenosis:
Not a disease but a general term of a group of anomalies/Sx
Aberrations of Normal Development & Involution (ANDI)
Main Benign Dx in Women of 30-40 yo
Cyclical Mastalgia, Lumpiness, Nodularity
As Age, Cysts become more Frequent
Can also develop areas of such pronounced Nodularity that presence of a Lump may be felt
S/S: Dense Irregular Lumpy Cobblestone Consistency
More marked in UOQ
Persistent Intermittent Breast Discomfort:
Breast feel Full, Mastalgia (Dull Heavy Pain/Tenderness)
Premenstrual Tenderness & Swelling, Breast Discomfort improve after Menstrual period
Itching Nipple Sensation
Tx for Cyclical Mastalgia: (2002 MCQ 64, etc)
Gamolenic acid (Evening Primrose oil): 1st line Specific Tx in Asian (HKU study in 1999)
Nipple Discharge:
Galactorrhea Milk
Abnormal Nipple Discharge: (May stain the Bra)
Blood/Brown: Papilloma, Papillary Cancer, DCIS
Yellowish/Green: Infection, Abscess
Serous/Colorless: Physiological, Ductal Ectasia
(Unilateral breast Single duct is more worrying than Bilateral breast Multiple ducts)
Additional Ix to consider: Ductogram, Ductoscopy
Breast Infection:
Postpartum Engorgement
Lactational Mastitis & Breast Abscess
Chronic Recurrent Subareolar Abscess
Acute Mastitis associated with Macrocystic Breasts
Extrinsic Infection (Cellulitis)
NB: Smoking Risk of Breast Abscess & Risk of developing Fistula from Abscess (2014 MCQ 3)
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Palpable Lump: Clinically Benign Breast lesions are Distinct, Persistent, Relatively Unchanging
Common: *Macrocysts, Galactoceles (Milky cyst in Lactating F), Fibroadenomas
Rarer: Lipoma
Fat Necrosis (Usually due to Traffic accident or Kicked by baby)
Diabetic Mastopathy (Hardening of breast tissue due to DM; Very Rare)
Skin lesions: Sebaceous Cyst
Other Benign Breast disease:
Sclerosing Adenosis
Radial Scars & Complex Sclerosing lesions
Cyst: Accumulations of Fluid
*Breast Lumps in Women of Age 30-50
Typically Round/Oval, Smooth Edges
Complex Cysts contain Debris
Aspiration to confirm Nature
Hormonal variations: Normal Menstrual Cycles, Post-Menopausal (HRT)
Fibroadenoma: *Benign Tumors; Aka Breast Mouse
Any time after Puberty, but occur most frequently in 20-30
Painless, Well-circumscribed, Mobile tumor with Rounded/Lobulated/Discoid configuration
Multiple in 10-15%, and can become quite Large
Will Not Regress with time, but tend to Grow
Estimated Incidence of Malignancy is 0.12-0.3%
Confirmed on Core Biopsy, then Observation with Serial US/Mammography (2003 EMQ 1)
Giant Fibroadenoma: >5 cm, May display Rapid Growth, Require Excision usually in Young
Galactocele: Milk-filled Cyst from Overdistension of Lactiferous duct
Present as Firm Non-Tender Mass in Breast, commonly Upper quadrants
Diagnostic Aspiration often Curative
Breast Infection & Inflammation:
Lactational Mastitis, Postpartum Engorgement, Chronic Recurrent Subareolar Infections,
Acute Mastitis asso. with Macrocysts, Mondors disease
NB: Chronic Cystic Mastitis (2003 MCQ 33):
Includes Papillomatosis, Blunt duct adenosis, Sclerosing adenosis, Apocrine Metaplasia
But Not Mondors disease
Mx: Mastitis May progress to Abscess: Needle Aspiration, Incision & Drainage, Antibiotics
Chronic Abscess from Duct Ectasia: Require Duct Excision
Proliferative Breast disease:
Change in Breast conferring Risk of developing Carcinoma
Slight risk(x 1.5-2): Moderate/Florid Epithelial Hyperplasia
Sclerosing Adenosis/Radial Scar
Small duct Papillomas
Moderate risk (x 4-5): Atypical Ductal Hyperplasia
Atypical Lobular Hyperplasia
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Presence of FHx Risk, eg. x 10 for Atypical Hyperplasia
NB: Atypical Ductal Hyperplasia:
Pre-malignant lesions? (2005 MCQ 87, 2004 MCQ 87)
Uptodate: Not considered as Pre-malignant lesions
Some others: Pre-malignant lesions
30% have DCIS
Tx by Excision (2012 EMQ)
Phyllodes tumor: Rare, predominantly Benign Tumor
Almost exclusive in Female; Any Age but commonly Pre-menopausal
Fibroepithelial tumor Both Epithelial & Stromal component
Same Histological spectrum with Fibroadenoma (2003 MCQ 50)
Usually Benign, but can be Malignant or Borderline (2003 MCQ 50: 10% Malignant)
Clinical: Fast-growing, Large Size, but usually No Metastasis
Non-Tender, Firm, Mobile, Well-circumscribed
Overlying skin may be Shiny/Translucent; Large tumor may even erode skin> Fungating Mass

NB: Usually Solitary (2003 MCQ 50)
Tx: Surgery: Wide Local Excision (2014 MCQ 5) (2012 EMQ) (2009 MCQ 48)
Mastectomy in selected cases
NB: LN involvement is Rare; SLNB/ALND usually Not required
Adjuvant: RT: Not necessary for Benign Phyllodes
May consider for Borderline/Malignant Phyllodes
Chemo: Benefits Controversial; Only in few selected cases
Hormonal Tx: Not Effective (Regardless of Hormone receptor status)

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Breast Cancer
RF: ( Doctor: Most important: Gender
2nd : with Age
rd
3 : Previous Hx of Breast CA
4th: FHx: 1st degree relative with Early onset)
Sex: Female (100x of Male)
Age: In HK, risk starts to after Age 40 (cf 50 in Caucasian), with Advanced Age
(Janice Tsang: with Age until 45-50, then Less steeply)
Race: Whites > Blacks > Asians
Hormonal: Early Menarche (<12), Late Menopause (>55), Pregnancy after Age 30, Nulliparity,
OCP/HRT (CA Risk if prolonged use), (Ovulation Induction?)
Breastfeeding is protective
Genetic: FHx of Breast/Ovarian Cancer (esp 1st degree relative, Young onset)
Genetic Predisposition (BRCA1/BRCA2, p53 mutation, PALB2 (new), etc)
BRCA: BRCA1: 85% Breast, 50% Ovarian; Risk of Bilateral; Slight Prostate & Colon CA
Breast Cancer: 65% (51-75%) by Age 70
2nd Primary: 40-60% Lifetime (vs 5% to have Contralateral CA in normal ppl)
Ovarian Cancer: 39% (22-51%) (Prophylactic Resection also Breast CA risk)
BRCA2: 85% Breast, 10% Ovarian; Male risk
Breast Cancer: 45% (33-54%) by Age 70
Ovarian Cancer: 11% (4-18%) by Age 70
Male Breast CA: 6% Lifetime risk
Risk of: Prostate, Laryngeal, Bile duct, Stomach, Colon (minimal), Melanoma,
Pancreatic Cancer (1.5-3x risk)
PMH: Cancer: Previous Breast Cancer, Ovarian Cancer, (Endometrial Cancer); Cervical Cancer Risk
Benign Breast disease/Premalignant condition:
ADH (Atypical Ductal Hyperplasia), LCIS, DCIS, Proliferative Fibrocystic changes
Lifestyle: Smoking, Alcohol (Additive to HRT, Hormone +ve Breast Cancer risk),
Diet (Animal Fat: May have Estrogen & may lead to Obesity), Obesity (High BMI/Post-M BMI),
Sedentary Lifestyle, High SES
Others: (Previous RT to breasts, etc)
Epidemiology: Crude Incidence in HK: ing
Death rate in HK: Stable
Cancer Registry 2014 (2011 data): 1 in 17
Distribution: UOQ: 48% LOQ: 11%
UIQ: 15% LIQ: 6%
Areolar: 17% Diffuse: 3%
(Multicentric Cancer: Cancer in different quadrants)
(Multifocal Cancer: Cancer in same quadrant; All come from 1 original tumor)
Screening: (US for Age <40, Mammogram for Age >40, Both if Suspicious)
MMG Screening:
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Aim: Detect Breast CA at Early Asymptomatic stage whereby appropriate Tx can lead to Cure
in Mortality:
Combined estimation of all RCT: Mortality rate of Breast CA of 28%
Age 50-74: Mortality up to 24%
Age <50: Not Conclusive; of 23% but only noticeable after a delay of 10 years
(But note in Public Healths view, its Not Cost-effective since detection Lower than in West)
(In Breast Cancer doctors view, its worthy as its shown to Mortality)
Standard Screening Guidelines: (American College of Surgeons)
Age 30: Yearly Breast Exam by a Doctor
Age 40: Mammogram every 2 years, Yearly Breast Exam by a Doctor
Age 50: Mammogram every year, Yearly Breast Exam by a Doctor
All include Monthly Self Breast Exam
Exception: Higher likelihood of getting Breast Cancer:
Candidates: High risk families (FHx), Known BRCA mutation, etc
Screening: Annual Mammogram MRI starting at Age 30 (2005 MCQ 72)
Limitations in use of Mammogram:
Women with Dense breasts
Prosthesis & Injections give for Cosmetic reasons
Women in HK tend to have Breast Cancer at a Younger age (40s) (2004 MCQ 34)
Younger women have Denser breasts
Generally have Denser breasts
Guidelines taken in HK & many Asian countries:
Voluntary Screening Yearly with Starting Age 40
Can consider screening earlier with in the 30s if FHx
Includes US as part of screening (No proven studies)
Dx Triple Assessment:
Clinical, Imaging, Cytological/Histological
On No account should any 1 parameter (esp Cytology) Alone to be used to decide definitive Tx
Triple Assessment Maximize Sensitivity of Dx (Sensitivity 99.6%, Specificity 93%)
Clinical: Hx & PE: 50-85%
Radiology: MMG US: 90%
Pathology: FNA/Core Biopsy: 91%
(A Kwong: In practice, if really suspect Malignancy, do Core Biopsy directly
Histological Dx: Can help ddx DCIS vs Invasive CA
FNAC usually only if high likelihood of Benign
Only PMH advocates FNAC first even if suspect Malignancy)
Triple Assessment is +ve if Any of above is +ve, but ve when All 3 ve
Hx & PE
Imaging: MMG US Breast (in Pre-M women)
MRI Breast (for High risk women)
Mammography:
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Cranio-Caudal (CC) view
MedioLateral Oblique (MLO) view: Trapezius seen

Assessment:
Symmetry
Mass lesion:
Malignant features:
Spiculated Mass with Poor outline or Comet sign
Comet sign: Enhancing lesion with a tail (directed towards Nipple)
MicroCalcifications! (<0.5 mm):
Malignant features:
Stellate pattern, Clusters (>5/mm2), Segmental, Pleomorphic
(NB: Intraductal Calcifications: (2005 EMQ 25)
Pleomorphic, Fine Linear or Branching; Highly Suspicious of Malignancy)
Architectural distortions (of contour), (Tent sign, Nipple changes, MLO view for Enlarged LN)
Limitations:
Implant, Elderly Lady, Injection Implant (In the past some inject Paraffin for implant)
US Breasts:
Used in Conjunction with Mammography! (ie. MMG supplemental US)
Commonly used in our locality to add Dx of Breast lesion
Good for Breasts with High Density (in the Young)
Pros: Good at Mass lesions & Cysts, Easy to use, Fast, Cheap
Cons: Operator dependent, Less Accurate in picking up MicroCalcifications
Suspicious features:
Irregular Edge, Taller than Wider, Not Compressible
Complicated Cystic lesions (eg. Intracystic Papilloma vs Intracystic CA)
(Ill-defined Hypoechoic Mass with Heterogeneous Internal Echoes & Posterior shadowing)
MRI Breasts:
Indication:
Screening Women at High Risk of Breast Cancer
Identify extent or Residual disease after Excision which show +ve margins
Evaluate questionable Suspicious lesions seen on Mammography/US
Identify Pt with Clinically occult tumor presenting with LN +ve
Monitor result of Neoadjuvant therapy
Histology: Confirms Histology, Check Grade of Tumor, Check ER/PR/HER-2 status
Palpable Lumps:
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FNAC: (Usually done when suspect likely Benign; Can skip if think Malignant)
Cytology Reporting Categories:
(C0: No cells)
C1-C5: C1 Inadequate, C2 Benign, C3 Atypia but probably Benign,
C4 Suspicious of Malignancy, C5 Malignant
*Core Biopsy: Trucut Biopsy, Vacuum-assisted Core Biopsy (Mammotome)
Excisional Biopsy
NonPalpable Lumps: Image-guided Biopsy, Wire-guided Excision (Hookwire)
Guidance: Stereotactic (Mammogram) (better for Calcification)
US-guided (better for Mass lesion)
MRI-guided
(Isotope in KWH)
Staging: CT, Bone scan
PET/CT
Histology:
Histological Type:
In-situ CA: DCIS (Significance of In-situ CA is that they dont spread> Affect Mx)
Invasive CA: Invasive Ductal (NOS) (80%)
Invasive Lobular (3%)
Special types: Tubular/Cribriform, Papillary, Mucinous, Medullary
(LCIS: Premalignant condition rather than Cancer)
DCIS: 2-5% Incidence in Symptomatic Pt
5% in Screening (DCIS usually Central; Calcification enables Early Radiological detection)
20-50% Progress to Invasive CA
High grade/Comedo DCIS: 50% evolve into Invasive CA within 5 years
Non-Comedo DCIS: 30% develop Invasive CA within 10-15 years
Risk depend on Grading: Low, Intermediate, High
High Grade DCIS may have focus of Invasive CA within a Mass of High Grade Cancer
(Sentinel LN/ALND are usually Not considered in DCIS, unless in High grade DCIS)
(A Kwong: In practice most surgeons will do SLN Biopsy for High grade DCIS
More difficult to perform SLN Biopsy after Mastectomy if find Microinvasion)
Van Nuys Prognostic Index:
May be used to guide Tx decision for DCIS (but Not adopted in QMH)
Scoring based on Tumor Size, Margin width, Tumor Grade
(Margin: Previously ve margin is defined as 10 mm; Consistent with previous pastpapers
Nowadays tend to be Smaller; Uptodate suggests 2 mm as ve)
NB: 50% Centrally located; May present as Bloody Nipple discharge (2002 EMQ 11)
LCIS: Usually Innocent Bystander (Incidental finding during Biopsy), Not associated with Calcification
1/3 Bilateral
12x Risk of CA of Both Breast (Most risk still related to Invasive Ductal rather than Lobular CA)
As Precursor & RF; This is NOT Cancer!
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(Invasive Lobular CA:
Compared with Invasive Ductal CA, tend to be:
Multicentric/Bilateral, More differentiated, Hormone-receptor +ve, Arise in older women,
Metastasize later, and Spread to unusual locations (eg. meninges, peritoneum, GIT))
Receptor status:
(NB: Breast Cancer may have Heterogeneity
May have different ER/PR/HER2 status from Excision sample vs previous Biopsy)
(Janice Tsang: HER2 is worst, Triple ve is 2nd worst)
Hormone Receptor (ER/PR):
2/3 +ve (Either ER or PR +ve): Benefit from Adjuvant Hormonal therapy
1/3 ve (Both ER & PR ve): Risk of Relapse; More Chemo-sensitive
(Usually Young women in PreMenopausal state)
HER 2: 25% +ve; (Usually Young; Risks of Metastasis)
ImmunoHistoChemistry (IHC) staining:
IHC 3+: +ve
IHC 1+: ve
IHC 2+: Equivocal (1/3 chance of +ve)
Need FISH to confirm (+ve if FISH +ve)
(FISH vs DISH: FISH needs to view under Dark field
DISH (Dual ISH) is Chromogenic (Can see under LM)
Benefit from Adjuvant Herceptin
1-year adjuvant Trastuzumab after Adjuvant Chemo significantly improves DFS & OS
Concurrent with Taxanes in adjuvant setting in High risk Pt with HER-2 overexpressed tumor
Staging:
TNM: T: Important to recognize Size of Mass
T1: <2 cm
T2: 2-5 cm
T3: >5 cm
T4: a: Chest wall involvement (Invasion through Pectoralis) (Not just adhesion)
b: Skin involvement (Skin Ulceration, Peau dorange)
c: Both Chest wall & Skin involvement
d: Inflammatory Breast CA
(Simple Skin Dimpling or Nipple Retraction do Not upstage the tumor)
N: Clinical by Feature: (Thus No need to mention Size of LN in PE)
N1: Mobile Ipsilateral Axillary LN
N2: Fixed/Matted Ipsilateral Axillary LN
N3: Ipsilateral SCN
(Actually: N3a for InfraClavicular LN
N3b for Internal Mammary + Axillary LN
N3c for SCN)
Pathological by Number:
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N1: 1-3
N2: 4-9
N3: 10
Note: Spread to Contralateral LN is M1
M: Metastasis to Lung (Pleural Effusion), Liver (Hepatomegaly), Bone (Tenderness)
(Metastasis commonly to Lung, Bone, Liver, Brain)
(UCH: Isolated Bone Metastasis has better Prognosis than Visceral involvement)
Staging:
I: IA: T1
IB: T0 N1mi, T1 N1mi
II: IIA: T0-1 N1, T2 N0 (2011 EMQ 7: T1N1 is Stage II)
IIB: T2 N1, T3 N0
III: IIIA: T0-3 N2, T3N1
IIIB: T4
IIIC: N3
IV: M1
Tx: Curative, Palliative
Surgery, RT, Chemo, Hormonal Manipulation (Endocrine therapy), Molecular Targeted therapy
Choice: Type of Initial Surgical Tx, Age, Menopausal status, Tumor Size, No. of involved LN,
Tumor Grade, Estrogen receptor status, HER2 gene Amplification
NB: Axillary LN status is the most significant prognostic indicator (Carter 1989) (2010 MCQ 2)
Surgical Tx: Aim: Loco-Regional control, Cosmesis
3 dimensions: Primary Excision of Tumor/Breast, LN clearance, Reconstruction
1. Primary Excision of Tumor/Breast:
Breast Conservation Therapy (BCT):
Breast Conserving Surgery (BCS) + Adjuvant RT
BCS: Wide Local Excision/Lumpectomy + LN clearance (originally defined by ALND)
Lumpectomy:
Complete Surgical resection of Primary tumor with goal of ve margins
SSO & ASRO consensus guideline for Stage 1 & 2 Invasive Breast CA:
ve margins optimize Ipsilateral Breast Tumor Recurrence
Risk is Not significantly by Wider margins
(Standard margin used to be 1cm; Now Non-touching margin is ok)
(Surgeon preference; In QM, usually <5mm)
Guidance: Palpation guidance (Clinically palpable disease)
Imaging guidance (Clinically Not palpable) (eg. Hookwire guidance)
RT: Whole Breast Irradiation: 5000 rad, Boost dose 1000 rad, Last 5 weeks
Evidence of Lumpectomy alone vs BCT vs Mastectomy NSABP-B06 (Landmark study):
Compare 3 groups: MRM (standard of care at that time), BCT, Lumpectomy alone
Note that All Pt underwent ALND
At 20-year FU: No difference in Overall Survival, DFS, Distant DFS
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Difference in Local Recurrence:
Higher Local Recurrence in Lumpectomy alone (39.2%)
Lower Local Recurrence in BCT (14.3%) (Never Lumpectomy alone in CA!)
Slightly Lower Local Recurrence (Chest wall Recurrence) in MRM (10.2%)
Contraindications:
Absolute:
RT is Contraindicated:
Pregnancy (Teratogenic; Most absolute contraindication; 3rd trimester may be ok?)
Active CTD (esp Scleroderma & SLE) (Risk of Breast Fibrosis & Chest wall Necrosis)
(Some may consider as Relative Contraindication)
Previous Breast/Chest wall Irradiation (May lead to Excessively High Radiation dose)
Persistent +ve margins after Surgical attempts
Multicentric Cancer (except few situations like Large breast)
Relative:
Tumor Size too Large (eg. >5 cm): BCS will Not result in a good Cosmetic result
Appropriate Tumor size-to-Breast Ratio is important
Cancer underneath Nipple/Nipple involvement:
(Need to resect Nipple Areolar Complex)
(May Not be contraindicated in Large breast; Can do Central Lumpectomy)
(Multifocal Cancer) (May Not be Contraindication nowadays, but is so in those old Pastpaper)
(Total) Mastectomy:
Entire Breast tissue other contents removed
Margin for Breast tissue:
UCH: Clavicle, Sternum, LD (MAL landmark), Upper Rectus sheath, Retromammary fascia
NAC is usually resected along with a skin paddle to achieve a Flat chest wall closure
Different variants (Most commonly MRM & Simple Mastectomy)
Modified Radical Mastectomy (MRM):
Entire Breast tissue removed + Axillary LN dissection (standard is Level 1 & 2)
Simple Mastectomy:
Aka Total Mastectomy; Entire Breast tissue removed Sentinel LN removal
Traditional approach:
Radical Mastectomy: MRM with En bloc resection of Pectoralis major (Old type of surgery)
(Extended Radical Mastectomy:
Radical Mastectomy + Resection of Internal Mammary LN)
Modern variants:
Skin-sparing Mastectomy (Breast tissue removed through Conservative Incision around Areola)
Nipple-sparing Mastectomy (Nipple-Areola complex preserved):
Selective Low risk Pt, No Nipple involvement, Prophylactic Mastectomy
2. LN clearance:
Axillary LN Dissection (ALND): Previously a standard of care for all Pt with Invasive Breast Cancer
Landmark: Pectoralis Minor
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Level 1: Lateral to Minor: Pectoral (Anterior), Subscapular (Posterior)
Level 2: Posterior to Minor: Central nodes
Level 3: Medial to Minor: Apical nodes
Extent: Standard Level 1 & 2 Clearance
Level 3: Not removed unless Suspicious/Palpable Adenopathy present
Skip metastasis to Level 3 LN without Lower Axillary involvement is Rare
Cx: Vessel & Nerve damage:
Exam Q: ThoracoDorsal Bundle (supply LD), Long Thoracic Nerve (supply SA),
Others: IntercostoBrachial Nerves (Medial Upper Arm Sensation) (often sacrificed?),
Medial & Lateral Pectoral Nerves,
Axillary Vein, Brachial Plexus (uncommon)
Lymphedema (Regular Gentle Skin massage & Skin protection may help avoid) (2009 MCQ 46)
(Axillary web syndrome/Cording:
Thrombosed Lymphatic vessels> Webs/Cords; Localized in Axilla or spread down arm
Pain, Tightness, Limitation of ROM; Risk of Lymphedema)
Sentinel LN Biopsy (SLNB): Suitable for Early stage Cancer to avoid Full ALND which has Cx
Find the 1st LN(s) which drain the tumor indicated by Color Dye (eg. Blue dye) or RadioIsotopes
(Actually many different ways to identify SLN, depending on individual centres)
(Many places use dual methods of Color + Isotopes; UCH usually single method by Color)
Can be checked Intra-op by, eg. Frozen section
(Thus often done first & wait for Frozen section while operating on tumor/breast part)
If SLN +ve:
ACBS 2011: Recommend to convert to ALND
ASCO 2014 update: If just 1-2 SLN +ve: ALND if planning Mastectomy
ALND usually avoided if planning BCT
(A Kwong: Consideration for Upfront SLNB before Surgery is Controversial
May consider in Pt requiring Reconstruction esp LD Flap, Before Neoadjuvant Tx)
Indication: ACBS recommendations:
Invasive Breast CA: Virtually all clinically LN ve T1-2 disease
Limited data: T3, Multifocal/Multicentric, Prior RT, Prior Breast/Axillary Surgery
DCIS: Whom Mastectomy is required, Whom Invasive disease is suspected
Contraindications:
ASCO recommendations:
Locally Advanced (T3/T4), Inflammatory Breast CA, DCIS if BCT is planned, Pregnant
3. Reconstruction:
Indication: Cosmetic concern, Coverage if excessive skin removal after surgery
Usually only in some Pt after Mastectomy
Western countries may do mini-flaps after BCT too (Oncoplastic Surgery)
Timing: Immediate, Delayed
Immediate:
Generally Better Cosmetic results: Skin-sparing/Nipple-sparing may be offered in selected Pt
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Delayed: Recommended if Post-op RT is likely, Reconstructive Surgeon Unavailable
Method: Autologous (Flaps), Prosthesis (Implants)
Implants: Type: Tissue Expander
Saline Implant
Silicon Implant
(NB: Easier Surgery but in Stages
May need to have LD Flap Reconstruction
Asymmetry more common)
Myocutaneous Flaps:
Using Pt Skin, Muscle, Fat & Blood supply to reconstruct a new breast
Vs No Reconstruction:
Pros: Better Cosmesis: Breast Size (unlike barely Skin graft), Better Symmetry
Cons: Longer & More complicated Surgery
Tissues: TRAM Flap: Transverse Rectus Abdominis Myocutaneous Flap
(Pros: Bigger Size)
Pedicle TRAM Flap vs Free TRAM Flap (eg. If Long body)
LD Flap: Latissimus Dorsi Flap
(Pros: Less Morbidity Wont penetrate Peritoneum)
DIEP Flap: Deep Inferior Epigastric Perforator Flap
(Idea of Pros over TRAM Flap: Risk of Hernia)
4. Post-op: Drains inserted to avoid Seroma
Neoadjuvant Therapy:
(Pt selection consideration):
Eligibility for Primary Surgery:
Inoperable: Locally Advanced CA (Stage 3A-3C) often Not amenable to Upfront Resection
(A Kwong: Stage 4: No Survival benefit to do Surgery)
Operable: Early Stage CA (Stage 1-2) if BCS Not cosmetically possible
Cancer Subtypes:
Pt with High likelihood of response, ie. HER2 +ve disease, Triple ve disease
Clinical Status:
Pt with Contraindications to Surgery at Dx but Surgery is Anticipated at Later date, eg. Pregnant
Chemo: Size of tumor: Easier Surgery, Chance for BCT instead of Mastectomy
Doxorubicin & Taxane most commonly used but No consensus on optimal agent
Improved Local control & Disease-free survival,
esp in Pt who achieve Complete Remission before surgery (~20-28%; 66% in 1 trial)
No improvement in LT Survival
Hormonal manipulation (Endocrine therapy) less effective than Chemo
At least 4 cycles of Chemo needed
Post-op Chemo usually given
Adjuvant Therapy:
1. Chemo: CMF, Anthracycline-based, Taxanes
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Usually IV injection (bolus over few min, or infusion over several h); Oral drugs Less Effective
Usually once every 3 weeks
Choice (Janice Tsang):
Before era of Anthracyclines, use CMF (Cyclophosphomide, Methotrexate, 5-FU)
Anthracycline-based is now standard
Eg. AC (Adriamycin + Cyclophosphamide) in US
FAC (5-FU + AC) in French
(Adriamycin is given in HER2 +ve Pt (more responsive))
May add Taxanes (esp if LN +ve)
Indication: Age of presentation before Menopause (Consensus <40, sometimes Asians take <45)
T Size 2cm (T2) (For HER2, T Size 1cm)
LN +ve (Anthracycline-based + Taxanes)
Triple ve
Lymphovascular Invasion in Histology
Ki-67 14% (ie. Luminal B type) (This one Not yet in guideline)
S/E: N/V, Injection site reaction, Hair Loss, BM suppression (Infection risk), Allergy, Heart, Numbness
2. Hormonal Therapy:
Oral drugs: Tamoxifen (for Pre-M & Post-M), Aromatase Inhibitors (for Post-M only)
Modalities:
Tamoxifen (Nolvadex) (TMX):
Gold standard (1st line Endocrine therapy)
ER blocker (SERM); Inhibits Cancer growth by Competitive Antagonism of Estradiol binding
Inexpensive; Also some Beneficial Effect on Blood Lipids LDL
S/E: Menopausal Sx, Vaginal discharge
Risk of Uterine Cancer (Endometrial CA) & ThromboEmbolism (DVT)
(Risk of Uterine Cancer is Low; Routine FU screening is done in HA)
Aromatase Inhibitors (AI):
Agents: Non-Steroidal: Anastrozole (Arimidex), Letrozole (Femara)
Steroidal: Exemestane (Aromasin)
Inhibitors of Estrogen production (in Muscle, Fatty tissue)
Suppress plasma Estrogen levels in post-M women by inactivating Aromatase,
the enzyme responsible for Estrogen synthesis from Androgen substrates
(Can also use in Surgical Menopause women, eg. BRCA +ve with Bilateral Oopherectomy)
Proved to be more potent than TMX (Blocking Estrogen production vs Receptor function)
Adjuvant use of AI prolongs DFS when compared to TMX alone
Expensive, Neutral Effect on Lipids
S/E: Menopausal Sx, Myalgia/Arthalgia
Risk of Osteoporosis (A Kwong: Also Joint Pain), HC, LT Safety Not well established
(Others: Fulvestrant: Estrogen receptor Antagonist
Other Hormonal Manipulation: Surgery (Oopherectomy), Ovarian Irradiation)
Tx Regimen: (HA only sponsors 5 years of Tx, though studies show additional benefits in 10-year Tx)
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(Names: Up front therapy: AI first
Extended therapy: 10 years
Switching therapy: Switch from Tamoxifen to AI within 5 years
Either due to going from Pre-M to Post-M
Or Cant afford up front AI)
Pre-Menopausal:
Tamoxifen for 5 years first
If still Pre-M: Tamoxifen for another 5 years, ie. a total of up to 10 years
If now Post-M: Either continue Tamoxifen till up to a total of 10 years
Or switch to AI till up to a total of 10 years
(NB: For PeriMenopausal Pt, may choose to switch to AI after 2.5 years of Tamoxifen)
Post-Menopausal:
Tamoxifen for 10 years (HA: 5 years)
AI for 5 years (Up front therapy)
Tamoxifen for 5 years, then switch to AI for up to 5 years
Tamoxifen for 2-3 years, then switch to AI for up to 5 years
(Pt may alternate between TMX & AI if cant tolerate S/E)
3. Biologics:
Trastuzumab (Herceptin):
Anti-HER2 humanized mAb; Only applied in HER2 overexpressed tumor (HER2 +ve)
Duration: 1 year (2-year does Not have additional Survival benefit, but more S/E)
Major S/E: Cardiotoxicity (4%)
Others: Bevacizumab, Lapatinib
(Not currently approved for use in adjuvant setting for Breast Cancer)
4. RT: 25 Tx to intact breast 5 more to original site (tumor bed)
Axilla & Back of Neck in some Pt
Local Recurrence from 30% to <10%
Palliation for involvement of Bone, Brain, etc
Indication: All Wide Local Excision/Lumpectomy (as part of BCT)
Post-Mastectomy RT in High risk Pt:
+ve margins
Large tumor >5cm (T3), High grade tumor, Lymphovascular permeation
4 LN +ve (ie. pN2) (Also need prophylactic Axillary RT)
S/E: Theoretically Small area of Lung & Heart treated No LT problem with modern techniques
Skin reaction (Sunburnt) preventable with Radiogel
Some Fibrosis in treated Breast & Chest wall
Cx: Skin Burn - preventable with Radiogel
Infection, Lung Fibrosis, Heart, Lymphedema, Skin discoloration
Other Drugs: Anti-Emetics
Bisphosphonates: Zometa, Bondronate
Infertility issue: Pt often Not told of this S/E, but Pt who had Breast Cancer may still want a family
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No evidence that Pregnancy after Breast Cancer Breast Cancer Recurrence
Pre-Surgery/Chemo Egg harvesting & storage can be offered
Surveillance: Mammogram + US
Tumor Markers (CEA, CA 15.3): Not Indicated in Guideline, but used in QMH for Research
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CTS Chest Trauma
Chest Trauma: Common: 2/3 major Blunt trauma> Thoracic injury
Account for 25% Trauma deaths
Mortality: 10%
2/3 of these deaths occur in Hospital
Up to 1/3 of trauma deaths Preventable
<15% Chest Trauma require Surgical intervention
Why will Pt die?:

Classification: Blunt: High Velocity impact
Low Velocity impact
Crush injury
Penetrating: Sharp instrument (knife)
Gun shot
Blunt:
High Velocity impact: eg. Deceleration type Automobile accident
Intrathoracic bell clanger effect
Shear force> Tear
Aorta: Tear at fixed points above AV, or more frequently at Posterior Chest wall
Trachea: Main Bronchi beneath Aortic arch are subject to similar force & may rupture
Neck impact may transect Trachea
May have No Bony injury
Low Velocity impact:
Causes Direct damage to Bony thorax, Contusion of underlying Lungs/Myocardium
Does not usually create Stress/Compression forces enough to hurt Aorta/Bronchi/Diaphragm,
although Liver/Spleen may be ruptured by a direct blow over Lower part of Thoracic cage
When sudden, forceful compression of thoracic cage AP diameter & Transverse diameter,
ve Intrapleural Pressure ensures that Lungs remain in contact with Chest wall
Lateral motion pulls 2 Lungs apart> Traction on Trachea at Carina
Rupture occurs when Elasticity of Tracheobronchial tree is exceeded
If Glottis is closed at the moment of impact, Intrabronchial Pressure may suddenly
Greatest Tension develops in Larger Bronchi & Tendency to Rupture
Mechanisms of Chest wall injury Possible Thoracic Common asso. injuries
Injury Visceral injuries
High Velocity Chest wall often Intact, Ruptured Aorta Head & FacioMaxillary
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impact or Fractured Sternum, Cardiac Contusion injuries
(Deceleration) or Bilateral Rib Fractures with Anterior Major airway injury Fractured Cervical Spine
Flail (Steering wheel) Ruptured Diaphragm Lacerated Liver/Spleen
Long Bone Fractures
Low Velocity Lateral: Pulmonary Contusion Lacerated Liver/Spleen if
impact Unilateral Fractured Ribs involved Ribs 6-12
(Direct blow) Anterior: Cardiac Contusion
Fractured Sternum
Crush injury AnteriorPosterior: Ruptured Bronchus Fractured Thoracic Spine
Bilateral Rib Fractures Anterior Flail Cardiac Contusion Lacerated Liver/Spleen
Lateral:
Ipsilateral Fractures Flail Pulmonary Contusion Lacerated Liver/Spleen
Possible Contralateral Fractures
Penetrating: Damage to Vital structures, Hemothorax, Pneumothorax
Knife & Gunshot wounds are common in Penetrating injuries
Extent of damage depends on Size, Shape, Stability, Velocity of missile
Cause death by damage to Vital structures or severe Hemorrhage
Mass of penetrating object, Damage
Spectrum:
Chest wall injury:
Rib Fraucture, Sternal Fracture, Clavicular Fracture, Vertebral Fracture, Scapular Fracture,
Soft tissue injury
Pleural cavity injury:
Hemothorax, Pneumothorax
Airway injury
Parenchymal Lung injury:
Contusion, Laceration, Hematoma
Heart & Great vessel injury:
Cardiac tamponade
Others: Diaphragmatic injury, Esophageal injury
Mortality:
Immediate: Disruption of Heart, Great vessel injury
Within few hours:
Major Airway injury/Airway obstruction, Tension Pneumothorax,
Hemorrhage/Massive Hemothorax, Cardiac tamponade, Penetrating Chest injury
Late: Pulmonary Cx, Sepsis, Missed injuries
The Deadly Dozen:
Lethal Six: Airway obstruction, Tension Pneumothorax, Open Pneumothorax, Flail chest,
Massive Hemothorax, Cardiac tamponade
Hidden Six: Airway disruption, Lung Contusion, Diaphragm injury, Cardiac Contusion, Aortic disruption,
(Esophageal disruption)
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Clinical Evaluation:
Inspection: Neck vein distension: Cardiac tamponade, Tension Pneumothorax
Paradoxical Chest wall movement: Flail chest
Palpation: Tracheal deviation: Tension Pneumothorax, Massive Hemothorax
SC Emphysema: Airway injury, Parenchymal Lung injury
Percussion: HyperResonance: Pneumothorax
Stony Dullness: Hemothorax
Auscultation: Distant Heart sound: Cardiac tamponade
Breath sound: Lung Collapse, Pneumothorax, Hemothorax
Ix: Mainly CXR & CT
CXR: Classically Easy Fast
CT: Rapid evaluation, Accurate for Lung Contusions & Occult HemoPneumothorax,
May be diagnostic for Blunt Aortic injury nowadays
Angiography: Gold standard for Dx of Blunt Aortic injury
Pulmonary Angiography remains important for Dx of PE
Echo: Evaluate Unstable Pt for possible Cardiac injury or to detect fluid/blood in Pericardium,
to evaluate Heart valves, and to assess Ventricular function
Bronchoscopy
MRI
ATLS in Practice: Primary Survey: Is Pt dying?
Immediate threats corrected as identified
Secondary Survey: Is Pt going to die?
In-depth search for Potential threats
Definitive Care
Primary: Airway: Obstruction
Breathing: Tension Pneumothorax, Open Pneumothorax, Flail chest
Circulation: Massive Hemothorax, Cardiac tamponade
Dx & Tx must go hand-in-hand!
Secondary: Airway: Tracheo-Bronchial Injury
Breathing: Simple Pneumothorax, Hemothorax, Lung Contusion, Diaphragm Injury
Circulation: Cardiac Contusion, Aortic Disruption, Mediastinal Traversing Wounds
Examination, Erect CXR, ECG, ABG, Pulse Oximetry; High index of suspicion
ABC principle: A: Oropharyngeal airway, ET tube, Bronchoscope, Tracheostomy
B: Artificial Respiration, Evacuation of HemoPneumothorax,
Stabilization of Unstable Chest wall, Mechanical Ventilation
C: IV infusion of fluid, Restore Acid-Base status & Electrolytes, Inotropic support,
External/Internal Cardiac massage, Immediate Surgery to stem Hemorrhage
Tx: Simple Therapeutic procedures (Non-op):
Majority of Pt
Analgesia, Pulmonary Hygiene, Endotracheal intubation, Chest drain insertion
Endotracheal intubation:
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Indicated when Airway is compromised by Direct Trauma, Aspiration of Bood/Gastric contents,
or a Depressed Level of Consciousness
Oral intubation is the preferred method
Cricothyroidotomy:
Tracheostomy is usually Not performed in a lifesaving situation
Needle Decompression/Tube Thoracostomy:
Perform Needle Thoracostomy immediately on identification of Tension Pneumothorax,
followed by Tube Thoracostomy asap
Thoracotomy/Sternotomy:
<10% Blunt chest injuries, 15-30% Penetrating chest injuries
Indications for Immediate operation:
Massive Hemothorax:
>1500 ml blood returned on insertion of Chest tube
Ongoing Bleeding from chest:
>200 ml/h for 4h
Evidence of Cardiac tamponade
Penetrating Transmediastinal chest wounds
Chest wall disruption/Impalement wounds to chest
Massive Air leak from Chest tube
Major Tracheobronchial injury
Great vessel injury with Unstable Hemodynamics
Approach: Performed through 4th & 5th ICS using Anterolateral approach
For Abdominal injury:
Descending Thoracic Aorta is clamped
If BP improves to >70 mmHg, Pt is transported to OT for Laparotomy
If BP remains <70 mm Hg, further Tx is Futile
For Cardiac injury:
Pericardium is opened Longitudinally & Anterior to Phrenic nerve
Heart can then be rotated out of Pericardium for Repair
Specific:
Tension Pneumothorax:
Progressive +ve Pressure within Pleural cavity, causing Lung collapse & CVS Unstability
Occurs when air enters Pleural space without a means of exit 1-way-valve air leak
Ipsilateral Lung Collapse> Mediastinum displaced to Opposite Lung> Venous return> CO
Cause: Penetrating injury to chest
Blunt trauma with Parenchymal Lung injury
Mechanical Ventilation with High airway pressure
Spontaneous Pneumothorax
Clinical Dx: Severe Resp distress
Unilateral Absence of Breath sounds
Tracheal deviation
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Tachycardia/Hypotension
Neck vein distention
Cyanosis (Late manifestation)
CXR: Large Pneumothorax, Mediastinal shift
Tx: Emergency! Should Not be delayed by waiting for X-ray
Immediate Decompression (2nd ICS at MCL, with Large-bore needle)
Convert Tension Pneumothorax into Simple Open Pneumothorax
Followed by Chest drain insertion (usual Drainage site, Not Decompression site)
Simple Pneumothorax:
Occur in 10-30% Blunt trauma, ~100% Penetrating trauma
Easily missed: Delayed presentation
Gradual Sx?
(Lecturer: On CXR, beware of Horizontal level Pleural Effusion + Coexisting Gas above
Also note any Surgical Emphysema)
Progression to Tension Pneumothorax possible esp with PPV
Chest drain: Monitor + Tx
At 4th/5th ICS just Anterior to MAL
(Early Chest drain; If too Late, may already Intrap Lung Stiff Lung)
Open Pneumothorax:
Caused by Impalement injury or Penetrating wound
Large Open defect in Chest wall (>3 cm diameter)
Equilibration between Intrathoracic & Atmospheric pressure
Loss of ve pressure> Lung Collapse> Hypoventilation & Hypoxia
S/S usually proportional to Size of defect
Tx: Cover defect with a sterile Occlusive dressing
Taped on 3 sides to act as a flutter-type valve (Allow air out but Not air in)
Chest tube insertion (remote from the wound)
Intubate (if Unstable/Resp distress)
Definitive Surgical debridement & closure of defect
Hemothorax:
Source of Bleeding:
Intercostal arteries, Internal thoracic arteries, Pulmonary parenchyma (Lung Laceration),
Hilar vessels, Aorta/Pulmonary artery, Heart chambers
Easily missed: Delayed presentation, Gradual Sx?
Progression: (Fibrin clots can lead to Fibrothorax> Restrictive Lung function)
(Also can progress to Empyema once infected)
X-ray: Blunt Costophrenic angle (>500ml)
Hazy Lung field
Tx: Monitor + Chest drain insertion
Fluid replacement
Thoracotomy Indication: 1500ml blood is initially drained (indicates Massive bleeding)
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Drainage of >200ml/h for 2-4h (indicates Ongoing bleeding)
Persistent Blood transfusion is required (Shock!)
Massive Hemothorax:
Blunt vs Penetrating
Hypovolemic vs Tension
Common in Penetrating Trauma:
Each Hemithorax can hold up to 3L of blood
Intercostal & Internal mammary vessels are most commonly injured
Neck veins can be Flat (Hypovolemia) or Distended (Mechanical effects of Intrathoracic blood)
Hilar/Great vessel disruption> Severe Shock
Dx: Hemorrhagic Shock
Flat Neck veins
Unilateral Absence/ of Breath sounds
Unilateral Dullness to Percussion
CXR: Unilateral White out (Opacification)
Tx: Rapid Fluid Resuscitation
Establish Large bore IV access & have Blood available for Infusion before decompression
Decompression of Chest cavity
Tube Thoracotomy with Large tube catheter (36F/40F) in 5th ICS
Intubate a Pt in Shock/Resp difficulty
Operative Intervention (Thoracotomy):
If 1500ml blood evacuated initially
Ongoing B eeding of >200ml/h for 2-4h
Failure to achieve complete drainage, or Clotted Hemothorax
(Clot can lead to Empyema or Fibrosis later)
(Consider Early VATS for Incompletely drained or Clotted Hemothorax)
Rib Fractures: Need careful search for asso. Intra/Extra-thoracic injuries:
Lung Contusion, Hemo/Pneumothorax, Blunt Cardiac injury
In 35-40% Thoracic Trauma
Important:
Location: (Lecturer: Middle Third is ok
Upper Third may be associated with Brachial plexus injury, Subclavian BV injury
1st Rib is Deep; Fracture of 1st rib signifies Severe Impact
Lower Third may be associated with Abdominal Visceral Injury, eg. to Liver)

Age: Younger Pt: Greater transfer of force
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Higher risk of injury to underlying Viscera
(Young ppl has Strong Bones, so if Fracture, must be High impact)
Elderly Pt: Poor Rehabilitation potential and/or Lung function
High risk for Atelectasis & Pneumonia
Conservative Tx:
Pain control (Epidural Anesthesia, PCA, or Intercostal nerve blocks)
Pitfalls: Dx is Clinical (Local Severe Tenderness); ve X-rays do Not exclude Fractures
Aggressive Analgesia is critical, but must Avoid Resp depression
Delayed Cx do occur, Appropriate FU is mandatory
Flail Chest: Aka Stove-in Chest (2001 MCQ 29)
Multiple Rib Fractures resulting from Direct High Energy Impact (Blunt Force)
A segment of Chest wall does Not have Bony continuity with the rest of Thoracic cage
Paradoxical motion of Chest wall with Inspiration & Expiration
(Uncommonly observed in practice due to Thick Chest wall?)
Dx: 2 Ribs fractured in 2 places, often may lead to Paradoxical motion of Chest wall segment
Risks: High risk for Pneumothorax/Hemothorax
Frequently go into Resp Failure:
Paradoxical motion of chest wall
Underlying Lung injury
Severe Pain with Restricted chest wall movement
Asso. Abdominal injuries occur in ~15% Pt with Flail chest
Tx: Mechanical Ventilation is usually necessary:
Immediately intubate for Resp distress
Consider intubation for Hemodynamic instability
Adequate Analgesia for Pain control
(Provide aggressive Pulmonary Hygiene, inc. Incentive Spirometry & Cough-deep breathing
Adequate Pain control & CPAP may preclude intubation)
(M Hsin: With Improvement in Ortho techniques,
now there is a trend of advocating Early Operative Mx vs Conservative Mx)
NB: 2001 MCQ 29: Can include Intubation, PPV, Tracheostomy, Rib Fracture Fixation
But Not Thoracoplasty
Lung Contusion: Most common potentially lethal chest injury
Caused by Hemorrhage into Lung parenchyma
Commonly asso. with Fractured Ribs
Children more frequently No Fractures (due to Resilience of Chest wall)
Sx: Few Resp Sx
Mainly Chest Pain, Dyspnea
Hemoptysis Rare
Natural progression:
Worsening Hypoxemia for first 24-48h
Radiographic: Radiographic findings show Lung Haziness/Infiltration of Lung segments
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CXR findings can be Delayed (within 24-48h) & Non-segmental
CT thorax more accurate
Tx: Conservative: (Usually treat conservatively in ICU with Ventilation support)
Supportive with Supplemental O2
Physiotherapy
Pain control: Mild Analgesic
Broad spectrum Antibiotics
Mechanical Ventilation when necessary
(Embolization is difficult as often Multiple; Lobectomy is avoided unless Not possible)
TracheoBronchial Injuries:
Unusual (1%) but potentially Fatal injury
Frequently Missed injury
Penetrating/Blunt Trauma
(Pressure from Blunt Trauma more evenly distributed)

Most Pt die at scene (Asphyxia); High Mortality from asso. injuries
More minor injuries can cause Late sequelae:
Granuloma formation with subsequent Stenosis
Persistent Atelectasis
Recurring Pneumonia
Site: Cervical Tracheal injuries:
Present with Upper airway obstruction & Cyanosis unrelieved with O2
Local Pain, Dysphagia, Cough, Hemoptysis
SC Emphysema
(Blunt transection is Uncommon, tends to occur at Cricotracheal junction)
Thoracic Tracheal/Bronchial injuries (80% within 2cm of Carina)
Intrapleural Laceration:
Persistent Dyspnea, Massive Air leak, Massive Pneumothorax
(Does Not reexpand with Chest drain)
Intraparenchymal injuries: Usually seal spontaneously if Lung is adequately expanded
Extrapleural Rupture into Mediastinum:
Pneumomediastinum, SC Emphysema
Resp distress may be Minimal, esp with Partial Bronchial transections
Partial Bronchial disruptions:
25% will go undetected for 2-4 weeks
Persistent Atelectasis/Recurrent Pneumonia/Suppuration prompt further Ix
Radiographic signs:
Peri-bronchial Air
Deep Cervical Emphysema (Radiolucent line along Prevertebral fascia (Early & Reliable sign))
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Fallen Lung: Lung Collapse Laterally with Pneumomediastinum
(Normally in Pneumothorax, Collapsed Lung recoils inward toward Hilum)

Others: Pneumothorax
Pleural Effusion
SC Emphysema
(Fractures of Ipsilateral Ribs 1-5, Mediastinal Hematoma)
Tx: Securing the Airway: Intubation
(Almost always indicated, though conversion to PPV often exacerbates massive airleak)
Immediate operation (Primary Repair):
Mucosa-to-Mucosa closure, with Non-absorbable Interrupted Polypropylene sutures
Airway obstruction: eg. Foreign body, Laryngeal injury, External Compression (eg. Mediastinal Bruising/Swelling)
Cause: Relaxation of Tongue into Posterior Pharynx in Unconscious Pt
Loose Dentures/Avulsed Teeth, Lacerated tissue, Secretions, Blood pooling in mouth
Laryngeal Trauma> Expanding Neck Hematoma/Edema
Tracheal tears/transections
Signs: Stridor/Hoarseness, SC Emphysema, Altered Mental status, Accessory muscle use,
Air hunger/Resp distress, Apnea, Cyanosis (sign of preterminal Hypoxemia)
Tx: Early Intubation
Cricothyroidotomy/Tracheostomy
Blunt Cardiac Injury: A spectrum of injury to heart:
Myocardial Contusion, Rupture of a Cardiac Chamber/Septum, Valve disruption
Cardiac Contusion:
Esp Sternum
Risk of: Arrhythmias, Stunning, Bleed/Aneurysm (Late Rupture)
Monitor: Echo, Enzymes
Cx: Critical injury causing Hemodynamic instability is Rare
*Dysrhythmias: Tachycardia, Premature Atrial contractions, AF, PVC
Others: Acute HF, Valvular injury, Cardiac Rupture
Tx: Close Monitoring
ICU care
Treat Arrythmias, HF
Surgical Repair
Cardiac Tamponade: Penetrating (more common) or Blunt injury
Volume of Pericardial cavity is much Less than that of Pleural cavity
75-100 ml of blood can produce Tamponade physiology in Adult
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PE: Classic Signs (Becks Triad): Uncommon; Present in only 33% Pt
JVD, Hypotension, Muffled Heart sounds
(All due to Impaired Ventricular Diastolic function & CO)
Shock/Ongoing Hypotension without Blood Loss: More common
Others: Pulsus paradoxus (A)
Kussmauls sign (V)
Pulseless Electrical Activity (on ECG)
Dx: Transthoracic Echo:
(Pericardial Fluid with Diastolic Failure of RV)
(If available, FAST US exam should be performed to identify Pericardial fluid)
Tx: Emergency Pericardiocentesis:
A pigtail catheter with multiple holes is placed via Sub-xyphoid approach
(Alternative Pericardial window through Median Sternostomy)
Traumatic Aortic Disruption:
Defined as a Tear in wall of Aorta (Contained by Adventitia of artery & Parietal pleura)
Mechanism of injury is Rapid Deceleration (eg. Fall from Height, High speed Vehicle crash)
Usually located near Ligamentum Arteriosum (85%) (Its fixed while Aorta flicks around> Tear)
(2006 MCQ 51, 2004 MCQ 76: Aortic arch proximal to Left Subclavian artery)
Most die before reaching the hospital (90% Immediate death)
Survivors: Contained Hematoma (PseudoAneurysm; But can dissect further later)
Signs: Asymmetry in Upper extremity BP (& Upper extremity HT)
Widened Pulse Pressure
Chest wall Contusion
Posterior Scapular Pain, Intrascapular Murmur
Ix: CXR: Up to 15% Pt will have Normal CXR
Important: Widened Mediastinum (>8 cm) (Most Consistent finding)
Loss of AortoPulmonary window
Blurring of Aortic Knob
Deviation of Trachea to Right
Depression of Left Mainstem Bronchus (>40 from Horizontal)
Fracture of first 3 Ribs, Scapula, or Sternum
Left Pleural Effusion
(Presence of Pleural cap, usually on the Left but occasionally Bilaterally)
(Elevation & Rightward shift of Right mainstem Bronchus)
(Deviation of NG tube (Esophagus) to Right is an Infrequently matching but suggestive sign)
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Aortography:
Gold standard for Dx historically
CT Thorax:
Valuable Dx tool for Aortic Injury (more commonly used than Aortography now)
Tx: Surgery: Urgent Surgical Repair is indicated
Endovascular Aortic Stent grafts:
Available at some centers
Pros: Avoid Thoracotomy in Pt with significant asso. Pulmonary compromise
Non-op: Conservative Supportive measures/Interventional Radiology procedures
may be considered for Poor-risk/Elderly Pt
Diaphragm Injury: Left > Right
Missed/Delayed Dx (CXR is diagnostic in only 25-50% cases of Blunt Trauma)
GI herniation to chest
Mortality 25-40% (Due to Severity of asso. injuries)
Trauma:
Blunt Trauma:
Blunt> Large Radial tears> Herniation
Left Hemidiaphragm is involved in 65-80% cases
Diaphragmatic Ruptures are markers for asso. Intra-abdominal injuries
Penetrating Trauma:
Smaller wound but tend to enlarge over time
These injuries need Surgical repair when diagnosed
Do Not heal spontaneously
Can produce Herniation/Strangulation of Intestine as Late sequelae

(Repair from Abdomen easier than from Chest> Pulling Abdominal content is Easier)
Ix: CXR, UGI contrast studies, CT, DPL fluid coming out from Chest drain, Endoscopy/MIS
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Tx: Diaphragmatic tears require Repair (2006 MCQ 73: Hernia can occur after Trauma)
Acute Repair via Laparotomy in most cases
(with Non-absorbable Interrupted Horizontal mattress sutures)
Thoracotomy: Reduce Large defects in Chronic Herniation
Prosthetic material/Flaps are Rarely needed
Esophageal Rupture: Resulting from Penetrating Trauma
Blunt Esophageal injury is Rare (<0.1% incidence)
Presentation: SC Emphysema, Mediastinal Emphysema, Pleural Effusion, RetroEsophageal Air
Tx: Surgical Repair is indicated
Sternal Fracture: 4-8% of Chest Trauma
40% will have asso. Rib Fractures
25% will have asso. Long bone injury
Usually in Body; Rarely displaced
Show up on Lateral x-ray
Symptomatic Tx
Mediastinal Traversing Wounds:

Hemodynamics:
Unstable (~50%):
Mortality ~40%
Assume: Ongoing Hemorrhage, Tension Pneumothorax, Cardiac tamponade
Mx: Bilateral Chest drains urgent EOT
Stable: Mortality ~20%
Exclude: Vascular, Airway, Esophageal injury
Penetrating injury in Chest:
Entry wound in 1 Hemithorax
Exit wound/Missile in Contralateral Hemithorax
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Dx: Examination + CXR
Surgical consultation is Mandatory
Other Chest Trauma Conditions:
SC Emphysema: (SC Emphysema on Neck can compress on BV)

(Suction on Chest drain or even add another drain; May make Incisions to massage air out)
Traumatic Asphyxia
Pitfalls: Simple Pneumothorax can progress to a Tension Pneumothorax
Simple Hemothorax can progress to a Clotted Hemothorax leading to an Empyema
Undiagnosed Diaphragmatic injury can result in
Pulmonary compromise or Entrapement & Strangulation of Peritoneal contents
Delayed Dx of Aortic injury
can result in a Rupture of Contained Hematoma & Rapid death from Exsanguination
Underestimating Severity of Rib Fractures/Pulmonary Contusion
can lead to Severe Resp Insufficiency, esp in Elderly Pt
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CTS Surgical Tx of IHD
Anatomy of Coronary arteries:

Branch: Left Main Coronary: Left Anterior Descending (LAD) (aka Anterior Interventricular A)
Diagonals (D)
Left Circumflex (LCX)
Obtuse Marginal (OM)
Right Coronary: Posterior Descending artery (PDA) (aka Posterior Interventricular A)
Variation:
Coronary Artery Dominance:
70% Right dominant: Supplied by RCA
10% Left dominant: Supplied by LCX
20% Co-dominant: Supplied by both
Supply to Papillary muscles:
AnteroLateral Papillary M: Usually 2 blood supplies LAD & LCA
More usually Resistant to Coronary Ischemia
PosteroMedial Papillary M: Usually only by PDA> More susceptible to Ischemia
ie. MI involving PDA is more likely to cause MR
Manifestations of CAD:
Stable Angina
Acute Coronary syndrome: Unstable Angina, NSTEMI, STEMI
Sudden Death
Approach:
Hx & PE: Determine Low, Intermediate, High risk Pt
Dx by:
Low/Intermediate risk Pt:
Able to Exercise: Stress test Exercise ECG
Not able to Exercise: CT coronary, MRI, Stress Echo, Perfusion study
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High risk Pt:
Coronary Angiogram:
Significant Stenosis: Vessels narrowed >50% diameter in Conventional Angiogram
(CT Angiogram is Inferior to Conventional Angiogram, due to Calcifications)
Risk Stratification:
Perfusion study & Viability study:
SPECT scan, PET scan, MRI, Stress Echo
Anatomical study:
CT, Coronary Angiogram with Functional Flow reserve
Tx options for Stable Angina:
Medical Tx: A: Aspirin & AntiAnginal therapy
B: BB & BP
C: Cigarette Smoking & Cholesterol
D: Diet & DM
E: Education & Exercise
PCI
CABG
Revascularization:
Indications: Sx Not controlled by optimum Medical therapy
Prognostic ground by Anatomy & Ischemic region
Benefits vs Risks:
Extent of disease & 5-yr survival:
Single vessel 90-95%, 2 vessels 88%, 3 vessels 70%, Left Main disease 50%
Interfering RF: LV function, Extent of Ischemia, Anatomy of lesion, Arrhythmia, DM,
Recent MI, etc
M&M: PCI: Mortality 1-2%, Morbidity very Low
CABG: Mortality <2%, Morbidity <5%
PTCA vs Medical Therapy:
Although PTCA/S rates of 85-90% are commonplace,
No study has ever shown a benefit in Survival/subsequent MI for PTCA over Medical Tx
in Pt with Stable Angina
However improvement in Sx & Exercise tolerance were demonstrated
Development of Coronary Stent:
1977: Balloon PTCA
1993: Coronary metal stent: Self expanding metal stent
2001: Coated stent: Stent with Heparin coating is an example
2003: Drug-eluting stent: eg. Cypher stent
Sirolimus-eluting stent can limit in-stent Restenosis due to Endothelium overgrowth
CABG Indications: Classical description: Left Main disease
Triple vessels disease with LV dysfunction
In reality: The more the RF, CABG will be better than PCI
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2004 ACC/AHA Guidelines:
Class I: Should be done
Class IIa: Reasonable to do
Class IIb: Is Considered
Class III: Not helpful & May be harmful
Asymptomatic/Mild Angina:
Class I: Left Main stenosis 50%
Left Main equivalent: Proximal LAD + Proximal Circumflex, both 70%
Triple-vessel disease (EF <50%)
Class IIa: Proximal LAD stenosis with 1- or 2-vessel disease
Class IIb: 1- or 2-vessel disease Not involving Proximal LAD
Stable Angina:
Class I: (The 3 Class I above)
2-vessel disease with Proximal LAD stenosis
+ Either EF <50%, or Demonstrable Ischemia (on Non-invasive testing)
1-/2-vessel disease without Proximal LAD stenosis,
but with a Large territory at risk (Viable Myocardium)
+ High risk criteria on Non-invasive testing
Disabling Angina refractory to Medical therapy
Class IIa: Proximal LAD stenosis with 1-vessel disease
but with a Moderate territory at risk + Demonstrable Ischemia
Unstable Angina/NSTEMI:
Class I: Proximal LAD stenosis with 1-vessel disease
but with a Moderate territory at risk + Demonstrable Ischemia
Ongoing Ischemia despite maximal Medical therapy
Class IIa: Proximal LAD stenosis with 1- or 2-vessel disease
Class IIb: 1- or 2-vessel disease Not involving LAD
Summary:
Indication:
Triple vessel disease Impaired LV function
Symptomatic Pt Not suitable for PTCA/S
Post-MI Cx: Post-Infarction VSD, LV Aneurysm & Recurrent VF
Ischemic MR
Compelling Anatomy of Coronary lesions: Left Main coronary artery stenosis
Proximal LAD long lesions
Non-Indication:
Triple vessel disease
MI
CAD with good LV function
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Angina Sx despite maximal Medication
CABG considerations: Approach
Harvest of Conduits
On-pump vs Off-pump for Anastomosis
Approach: Median Sternotomy
MIS: MIDCAB, Robotic
CardioPulmonary Bypass:
Aim: Bloodless & Motionless Surgical field
Non-pulsatile Arterial blood flow
Blood components Trauma
Hemodilution
Foreign surface exposure
Inflammatory response trigger
General Stress response, eg. Hypothermia
Myocardial Protection:
Artificial Heart Arrest Cardioplegia: (Most effective way to Myocardial O2 demand 2009 MCQ 83)
Protect heart tissues against Ischemia
Provide a Motionless & Bloodless field
Allow Revival of arrested heart
Anastomosis: Distal Anastomosis: End to side, Sequential graft
(Done first for On-pump CABG)
Proximal Anastomosis: Aorta, Y-graft
Conduits for Bypass Surgery: (Common: LIMA, Radial artery, LSV)
Vein: LSV, SSV
Arm vein
Artery: Internal Mammary artery
Radial artery (Non-dominant hand)
Gastroepiploic artery & Inferior Epigastric artery
Xenograft
Artificial conduits (Gortex)
Venous grafts: LSV: Good Length, Easy to harvest, Mild S/E
Patency rate 10 years 50%
Can be harvested by Minimally Invasive method
SSV: Difficult to harvest, otherwise same as LSV
Arm vein: Easy to harvest, but Poor Patency rate
Cryopreserved vein: Not popular, Not easily available
Vessel Harvest:
Traditional Open Vessel Harvest:
Longitudinal incision up to 70cm is made along Thigh (& Leg) for Harvest of Saphenous vein
Wound Cx rate 0-20%: Deep wound Infection/Wound Gangrene, Superficial Infection,
Leg wound Edema, Wound Pain, Keloid Scar
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Endoscopic Leg vein Harvest system (VirtuoSaph):
Developed by Terumo Cardiovascular; FDA approved Class II medical device
Videoscopic minimal invasive technique
Endoscopic dissection inside SC tunnel; 3-4 Small incisions (2cm) along medial side of leg
Pros: Faster wound healing
Wound Cx esp in High risk Pt, eg. DM, Neuropathy, PVD
Pain
Hospital stay
Improved Cosmesis
Vein Quality & Patency rate can be good as traditional technique
Cons: Longer operation Learning curve
Instrument Failure Vein damage
CO2 air embolism Rare & Subclinical
Cost
Arterial grafts: Internal Mammary artery: Pedical graft (No need to cut origin)
Left: More difficult to harvest
The Best conduit Good Patency rate >90% at 10 years (2012 MCQ 44)
Usually anastomosed to LAD
Better Survival rate & Less Cx (KL Ho: Aiming at doing this in every CABG)
Right: Anatomically difficult for grafting
Bilateral IMA Cx & Timing
Radial artery: Arterial graft theoretically more patent than Venous graft
Patency ~70% in 10 years
Bilateral can be used; Can be harvested by Minimally invasive method
Rare risk of Hand Ischemia (Need Allens test before surgery)
Off-pump CABG (an Alternative Approach):
CABG with beating heart
Learning curve & training
Stabilizer
Eradicate S/E from Cardiopulmonary Bypass
? Optimal Anastomoses
Multiple vessels disease more difficult
Pros: Bleeding, Renal Failure, Stroke
Cons: No. of Grafts, LT Patency, Technical demanding
Use: High risk Pt
Evidence: Lower Mortality: ?
Lower CNS/Stroke rate: No
Lower Hospital Cost: Yes
Lower General Cx: ?
LT graft patency rate: ??
Results reproducible: ?
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Post-op drugs: GTN: Prevent Spasm of IMA
No specific duration, usually stop next day
Diltiazem: Prevent spasm of RA
Usually stop when Oral diltiazem started
Last for 3-6months
Aspirin: Early Aspirin improve Early Vein graft Patency
Best to take within 6h after operation, No benefit if >48h
BB: Early resume BB Post-op AF
LLD: Improve Vein graft LT patency
Outcome: Survival: 1 year 95%, 5 year 88%, 10 year 75%, 15 year 60%
Angina Relief: 1 year 95%, 10 year 50%
End-point at 5 years:
Recurrence of Angina 20%, MI 6%, Reoperation 3%, Death 8%
End-point at 10 years:
Recurrence of Angina 40%, MI 14%, Reoperation 11%, Death 19%
CABG vs:
Medical Tx: Pros: Survival in TVD with Impaired LV function
Disease-free Survival
PTCA/S: Pros: Better Survival in selected cases: TVD, Left main lesion, Impaired LV
Lower Recurrence: CABG: 10-year 15%, 15-year 25%
PTCA: 6-month 30%, 5-year 50%
Cons: Higher Risk
RF affecting CABG: Age
Female
Vasculopathy
DM, HT, HyperCholesterolemia
Neurological dysfunction (CVA)
Critical pre-op status: Shock, VF, AMI, Failed PTCA, Unstable Angina
Impaired LV function
Chronic Lung disease
Re-operation
Risk Stratification in Adult Cardiac Surgery:
Mortality, Morbidity, Critical events, Costs, Functional Status post-op, Pt Satisfaction
EuroScore Risk Stratification:
Pt related RF:
Age >60 (every 5 years: 1 extra pt): 1
Female: 1 (2013 MCQ 87) (2012 MCQ 43)
COPD: 1
Extra-cardiac Vasculopathy: 2
Neurological dysfunction: 2
Creatinine >200 umol/l: 2
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Previous Heart Surgery: 3
Active Endocarditis: 3
Critical Pre-operative State: 3
Cardiac RF:
Unstable Angina on IV Nitrate: 2
Moderate LV dysfunction EF 30-49%: 1
Severe LV dysfunction EF <30%: 3
MI within 90 days: 2
Pulmonary SBP >60 mmHg: 2
Operative RF:
Emergency: 2
Other than isolated CABG: 2
Surgery of Aorta: 3
Post-infarct VSD: 4
Post-CABG Cx: 30%: Atrial Arrhythmias
5%: Ventricular Arrhythmias, Leg wound Infection, MI, Resp Failure/Infection
3%: Bleeding, Sternal wound Infection, Stroke
2%: Renal Failure
Risk Stratification according to EuroScore:
1-2%
Major Risk: Bleeding, CVA, MI, Arrhythmia, Infection, ARF
Peri-op MI:
Cause: Poor Myocardial protection technique
Graft occlusion
Emboli to grafts
Dx: Chest Pain Not accurate
ECG: New Q-wave, ST changes
Echo: Now Regional wall movement abnormality
Enzyme: CKMB >5x Normal, TnI >10x Normal
Mx: Depends on Hemodynamic status:
Stable & Suspicious: LMWH
Unstable: IABP, Coronary Angiogram, ? Redo
AF: Up to 40% Pt will have post-op AF
RF: Old Age, COPD, Withdrawal of BB
Problems: Lose 20% CO
Risk of ThromboEmbolism >48h
Preventive measures: Keep K, Mg Normal
Resume BB
Use of Amiodarone, Sotalol, Mg
Stroke: In general 3% risk of Stroke in CABG Pt
Prolong Hospital stay, M&M
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Higher Risk in Pt with: Hx of Stroke, Old Age, Carotid artery disease, Emergency operation,
Atherosclerotic Aorta
Detection & Prevention: Off-pump CABG, Alternative Cannulation, Special device,
Circulatory arrest, etc
CT Brain: For Dx & Tx if Hemorrhage
Special Occasions: Primary CABG for STEMI
Post-MI Shock
Acute Post-MI Mechanical Cx: MR, VSD
Chronic: Aneurysm, HF
Acute MI:
Primary CABG for STEMI is Less common:
Gold period usually passed when arrive at OT
Advance of Primary PCI
Post-MI CABG: Best to delay 3-7 days if Stable & Pain Free
Possible due to Reperfusion injury
Post-MI Shock: 0.2% of MI
>40% Myocardium is lost before developing Shock
High 30-day Mortality 70%
SHOCK trial state that CABG would have better 1 year survival compared to Medical Tx
Surgical Mortality is 50%
Tendency is stabilize and then CABG later
Acute Post-MI Mechanical Cx:
Acute MR: Post MI with Papillary muscle Rupture: 3/4 Posterior (sole blood supply), 1/4 Anterior
Chronic CAD with Papillary muscle dysfunction: With Annular dilation
Clinical: Pt will develop SOB & Shock at Day 3-5 post MI
Dx: New PSM
CXR: Congested Lung field
Echo: Confirmation
Tx: Support with Inotropes & IABP (Intra-Aortic Balloon Pump)
Urgent Surgery: Mitral valve Repair/Replacement CABG
High Mortality without Surgery: Total Rupture: 75% in 24h
Partial Rupture: 30% in 24h
Post-MI VSD: Anterior 60%, Posterior 40%: Commonly with Acute total LAD blockage
L-to-R shunt (via Ventricles): Desaturation & Low CO, Shock
Similar Presentation & Work-up as Acute MR
Tx: Support with Inotropes & IABP
Surgery: High Mortality without Surgery: 50% in 1st day
Tendency is Delayed Surgery if Stable until Fibrosis around VSD
Timing: Urgent Surgery: Operative Mortality 30-40%
Delayed Surgery: Operative Mortality 5-10%
Chronic Problems from MI:
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Success of Primary PCI Incidence of Acute Mechanical Cx
Pt survive Longer after IHD/MI
Translate to more Chronic problem
LV Aneurysm: Transmural Infarction with Fibrous Scar
Problems: Affect LV efficiency, LV clots, Pt may have SOB
Sx: HF, VF, Thromboembolism, Angina
Location: Apex 85%, Posterior 15%
Tx: LV Aneurysmectomy/Ventriculoplasty:
Surgical resection with ~10% Mortality
Clinical studies showed improve in EF, Sx of SOB but Not Survival
HF: Repeated MI, Progressive deterioration of function
Require Mechanical support:
Extra-corporeal membrane oxygenation (ECMO)
Left ventricular assist device (LVAD)
Heart transplant
Misc:
2013 MCQ 90: IABP is useful in Pt with Unstable Angina + Cardiogenic Shock

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CTS Cardiopulmonary Bypass
Components: Venous cannulation Heparin
Reservoir
Pump Negative Suction
Oxygenation
Filter (Remove air bubbles produced in oxygenator & tissue debris)
Heat exchange system
Arterial cannulation
Perfusion system (supply Oxygenated blood & Cardioplegic solution to arrested heart)

Yellow & Green line: Collect blood sucked out from operation field
Pump it back to reservoir to Blood Loss
NB: Ventilator is Not a component (2011 MCQ 5)
Indications:
Open Heart Surgery: Purpose: Bloodless operation field (Not Motionless)
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IVC Thrombectomy: In HCC/RCC with IVC thrombosis
Hypothermia: Can control Temp of blood by Heat exchange system before entering back to Pt circulation
Sites of Cannulation: Note: Femoral cannulation when No Open Heart Surgery
Venous: RA, SVC + IVC, Femoral Vein
Arterial: Aorta, Innominate Artery (Brachiocephalic Artery), Subclavian Artery, Femoral Artery
Cardioplegia: Fibrillator to induce VF
Apply Cross Clamp on Aorta: Distal to Aortic Sinuses, Proximal to Arterial Cannulation
Cut Aorta open: Proximal to Cross Clamp
Cannulation to Aortic Sinuses; Connect to Perfusion System
Infusion of Oxygenated Blood & Cardioplegic Solution
Potassium as the vital ingredient in Cardioplegic solution (2007 MCQ 75)
Hypothermia to Metabolic demand of Myocardium
Local Hypo: Add Ice to operation field, and
Systemic Hypo: Temp of Extracorporeal blood controlled by Heat exchange system

Indications: (Cardioplegia is the most effective way to Myocardial O2 demand 2009 MCQ 83)
Surgery with High risk of Air Embolism:
Eg. MVR, AVR
VSD repair
Type A AD repair (In Type B AD, Cross Clamp is applied Proximal & Distal to lesion)
Rationale:
Aorta has to be clamped to prevent Air Embolism
> No oxygenated blood supply from Arterial cannulation to Aortic sinuses
Separate oxygenated blood supply is needed for the heart
Cardioplegia is needed to Metabolic demand of heart
Not indicated in Right Heart Surgery (eg. TVR, PVR):
Air is absorbed in Veins
Cannulation:
Antegrade Cannulation: Aortic Sinuses
Retrograde Cannulation: Coronary Sinuses
Indications: Severe Proximal occlusion of Coronary arteries
AVR of Severe AR (Oxygenated blood in Aortic sinuses reflux back to LA)
Cons: May Not achieve Full perfusion
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CTS Valvular Surgery
Types of Surgery: Valvotomy: Open/Closed
Valvuloplasty & Annuloplasty
Valve Replacement
Valvotomy: Splitting of Stenotic valve
Closed: Employs Mechanical dilator
Good relief for MS up to 10 years
Contraindication: LA thrombus present, Previous Embolus, Chronic AF
Open: Employs Open Heart technique
Splitting fused commissures under direct vision
Useful if + Reconstruction or LA thrombus suspected
Conservative Valve Surgery:
Annuloplasty: Employs Open Heart technique
Reduction of dilated annulus by Suture/Ring
Valvuloplasty: Reconstruction of Valve leaflet & Chordae tendinae
Valve Replacement: In majority of cases as valve lesions often too disorganized structurally
Principles: Mechanical valve prosthesis is 1st choice
Bioprosthesis for >65 years & those unable to take AntiCoagulants
Bypass Surgery if CAD coexist
2 Types: Factors affecting decision: Durability, Cx related to Prosthesis, Cx related to AntiCoagulation,
Age & Preference of Pt
Tissue: Theorectically No need for LT AntiCoagulation
Homograft:
Human Cadervic Aortic & Pulmonary valve
Good Durability
Hetrograft:
Animal heart valve or Reconstruct from animal Pericardium
Problem of Calcification & Suspect Durability
Mechanical:
Need for Lifelong AntiCoagulation as prone to Thrombus formation
Ball in cage valve: Starr-Edwards prosthesis
Tilting disc valve: Medtronic & Bjork Shiley
Bileaflet valve: Carbomedic & St. Jude valve
Comparison:
Mechanical Tissue
Primary Valve Lower (10-year Failure rate 3-4%) Higher (10-year Failure rate 20-30%)
Failure Occasionally 50% at 13 years
Sudden & Disastrous Gradual
AntiCoagulant Essential & Lifelong Only for 6 weeks post-op
Good if with Comorbidities: (Good for Elderly; No need )
Large Atrium
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I/A thrombus
Chronic AF
ThromboEmbolism Higher but now approaching Low 1-4%
Tissue valve
Hemodynamic Depend on Type (Bileaflet best) Theoretically better
performance Unobstructed Laminar flow but Restriction
of Orifice area by Mounting & Stiffening of
Leaflets with Preservation process
(Operative Mortality for Single Valve: 2%
Nowadays, Re-operation is No Longer a Contraindication for choosing valves)
(Pt with Mechanical valves on Warfarin, can be switched to IV Heparin during Pregnancy)
(In Pt with Mitral valve disease with AF,
Mechanical valve is better if unlikely can control by RFA ablation during Valvular surgery
Eg. Size (Large Atrium), Duration (Chronic AF))
Operative Mortality (<30 days):
Careful Pt selection prevents High operative Mortality
Unfavourable factors:
Myocardial dysfunction, Concurrent CAD, Concurrent PVD,
Pulmonary/Hepatic/Renal dysfunction, Poor nutritional state
Results of Valve Replacement:
Surgical Mortality: Mitral: 2-7%
Aortic: 2-5%
Mitral + Aortic: 5-10%
Sx: Very good improvement esp in Stenotic lesions
Usually up by 1-2 class NYHA
Survival: Improves in most cases
Mitral: 5-year survival 86% (Surgical) vs 55% (Medical)
10-year survival 75% (Surgical) vs 22% (Medical)
Problems in Valve Replacement:
AntiCoagulation:
Inadequate: Thrombosis of valve> Embolization
ThromboEmbolic Rate per Annum:
Aortic: Mechanical 1.2%, Xenograft 0.5%
Mitral: Mechanical 3.5%, Xenograft 1.3%
Excessive: Cerebral & GI Bleeding
Prosthetic Endocarditis: Difficult to eradicate
Misc:
Heart Transplant: Monitored by Surveillance Endomyocardial Biopsies for Rejection (2006 MCQ 77)
Potential Non-Invasive methods for detecting Rejection under research

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CTS Atrial Myxoma
Atrial Myxoma: (Asked in 2014 MCQ 17, 2002S MCQ 82)
Most common type of Primary Heart tumor (2003 MCQ 26)
Arise from Endocardium (from Primitive Multipotent Mesenchymal cells)
75% LA (2006 MCQ 48), 25% RA
More common in Female
10% Familial (AD inheritance) (eg. Carney Complex)
Tx: Surgical Removal (May need Valvular Repair too)
Misc:
2002S MCQ 83: Most common Malignant Primary Chest wall tumor: Chondrosarcoma
Constrictive Pericarditis:
Cause (2001 MCQ 20):
Viral Infection
Post-Cardiac Surgery, Post-RT
CTD (eg. RA, SLE)
Post-Infectious (eg. TB)
Others: Malignancy, Trauma, Drug-induced, Asbestosis, Sarcoidosis, Uremic Pericarditis
But Not: Myxedema

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CTS Atrial Myxoma
CTS Thymoma
Epidemiology: Usually Age 40-60
M:F similar incidence
No known RF, but Strong association with MG & other Paraneoplastic syndromes
Presentation:
Incidental finding on Imaging in Asymptomatic Pt
Thoracic Sx: Related to Tumor Size & Effects on adjacent organs:
Chest Pain, SOB, Cough, Phrenic nerve palsy, SVCO, etc
Paraneoplastic syndromes asso. with Thymic neoplasms:
Paraneoplastic syndromes may occur before Thymoma, at the same time, or after Tx
*MG
Uptodate: Neuromuscular: MG, Polymyositis, Sensory Neuropathy, Stiff person syndrome,
NMO, Isaacs syndrome (Neuromyotonia), Eaton Lambert syndrome,
Hemichorea
Hematologic: Pure red cell aplasia, Agranulocytosis, Hemolytic Anemia, Pernicious Anemia,
Acquired HypoGammaglobulinemia
Dermatologic: Alopecia areata, Pemphigus, Scleroderma, Oral Lichen planus, Vitiligo
Endocrine: Addisons disease, Cushing syndrome, Panhypopituitarism, Thyroiditis
Misc:
Cardiac: Myocarditis
Renal: NS (*MCD)
Rheumat: RA, Sarcoidosis
GI: Hepatitis, GI pseudoobstruction, UC
MG: Up to 50% Thymoma Pt; Rare in Thymic CA
Thymectomy usually results in attenuation of severity of MG, although some Sx may persist
Pure red cell aplasia:
5-15% Thymoma Pt; Usually seen in tumors with Spindle cell morphology
Immunodeficiency:
<5% Thymoma Pt have HypoGammaglobulinemia or Pure white cell aplasia
Good syndrome: Acquired HypoGammaglobulinemia with asso. Thymoma
Ddx of Mediastinal Mass:
Anterior Mediastinal Mass: (2007 MCQ 16)
Thymoma/Thymic Cancer, Retrosternal Thyroid, Lymphoma, Mediastinal Germ cell tumor
NOT Neurogenic Tumor
Middle Mediastinal Mass: (2005 MCQ 65):
Lymphoma, Bronchogenic cyst, Pericardial cyst, Esophageal Duplication cyst, etc
NOT Neurogenic Tumor
Posterior Mediastinal Mass:
*Neurogenic tumor (eg. Ganglioneuroma) (2003 MCQ 43)
WHO classification based on Histology:
Peter Yu: Determined by % Spindle cells vs % Lymphocytes (Lymphocyte, Prognosis)
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CTS Thymoma
Affect Prognosis (Thus Thymectomy is necessary to assess Histology)
Type A: Bland Spindle cells, Few Lymphocytes
Type AB: Mixed Thymoma with 2 components, 1 resembling Type A, 1 resembling Type B
Type B1: Epithelial cells with Vesicular nuclei & Small nucleoli, Abundant Lymphocytic population
Type B2: Predominantly Lymphocytic Thymoma, with Scattered plump cells with Vesicular nuclei
Type B3: Predominantly composed of Polygonal/Round Epithelial cells with mild atypia
Thymic CA: Highly Atypical cells with Cytoarchitectural features resembling CA seen in other organs
Although many Lymphocytes in Stroma, they are B cell & mature T cell, Not immature T cell
Masaoka Staging: Based on Extent of Primary tumor, Presence of Invasion into adjacent structures, Dissemination
(Thymoma can be Behaviorally Malignant even Histologically Benign)
In general: Encapsulated tumors (WHO type A & AB) are associated with Stage 1 or 2 disease
Others are more frequently asso. with Stage 3 or 4 disease
Stage 1: Completely Encapsulated both macroscopically & microscopically
Stage 2: Transcapsular invasion
Stage 3: Pericardial/Lung involvement
Stage 4: Disseminated disease
Tx: Resectable disease:
Surgery: Standard approach for Surgery is via Median Sternotomy
MIS Not recommended except in specialized centres with experience
Post-op RT:
May be considered if have High risk of Recurrence
Potentially Resectable disease
Recurrent disease
Unresectable disease
Second Primary Cancer:
Pt with Thymoma are at risk for development of 2nd Malignancies
Eg. B cell Lymphoma, GI Cancer, Soft tissue Sarcoma

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CTS Thymoma
GI FB Ingestion/Esophageal Perforation
Intro: 800 Pt/year
FB ingestion common in Chinese due to eating habit (Bone dissected in mouth)
Common FB in HK: Fish bone (75%)
Chicken bone (2nd most common)
Pork bone + others
Female predominance (2 to 1): (2001 MCQ 52)
Reason unknown (Ladies talk during eating? Ladies like to eat fish more than Men?)
Identify Cx: Perforation (80% in Cervical Esophagus): Look out for Surgical Emphysema
Abscess formation: Look out for Tenderness, Fever
NB: Lam HC 2003 paper for PWH cases:
Abscess requires CT for evaluation
Upper Endoscopy also required for Abscess due to FBI
But which is done first? (2005 MCQ 37, 2003 MCQ 24)
(If FB sensation resolved, CT first?)
AortoEsophageal Fistula (Uncommon but Lethal)
Presents initially with Sentinel Bleeding (small amount), then Catastrophic Hematemesis
(KM Chu: Whenever Bleeding identified, Pt must be admitted even for Minor bleeding)
Hx: Types of FB ingestions, eg. Hx of Fish/Chicken ingestion
Important for subsequent Ix Fish bone would Not show up on X-ray since Not Calcified
Time of ingestion: Longer the duration, more likely that FB is swallowed
FB can only be identified on Endoscopy in 1/3 Symptomatic Pt with Hx of FB ingestion
For most, Bone would have passed already
Site of Sx: Accurate indication of site of FB impaction
Dysphagia: Esp if impaction is in Cricopharyngeus region
Pain
Other Sx would point to Cx of FB impaction:
Eg. Abscess: Fever, Chills, Rigors, Significant Pain in Neck region
PE: GE: GC: Distress (points to Cx)
Temp, BP/P, Vital signs
Direct Laryngoscopy
Neck Exam (If No abnormalities detected on Laryngoscopy)
Redness, Swelling, Temp, Tenderness
Surgical Emphysema Indicates Perforation
Ix: Lateral Neck X-ray:
FB: Fish bone would Not be seen on X-ray (usually)
Calcified FB like Chicken bone
Absence of FB on Lateral Neck means that the FB has most probably passed
Soft tissue swelling:
Esophagus start at Cricopharyngeus at C6
80% impact above Cricopharyngeus (2001 MCQ 52)
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GI Foreign body Ingestion/Esophageal Perforation
20% impact at or below Cricopharyngeus (Mostly Proximal Esophagus)
Retropharyngeal space Edema:
Compare width of space with width of Vertebral body
Wider than Vertebral body = Abnormal
Perforation:
Free gas
Hyoid bone:
Do Not mistaken it to be FB
Esophageal Perforation:
Cause: Iatrogenic: Endoscopy, Dilatation, Intubation
Intrinsic: CA, Peptic Esophagitis
Traumatic: FBI, Post-surgical, Caustic injury, Blunt/Penetrating Trauma
Spontaneous: Boerhaaves syndrome/Emetogenic
Clinical:
Sx: Chest Pain, N/V or Hematemesis, SOB
Signs: Sepsis, Surgical Emphysema, Hydro-Pneumothorax, Hammans sign
Ix: CXR: Hydro-Pneumothorax
Mediastinal Air
Endoscopy/Contrast study:
Site & Size of Perforation
Endoscopy:
Medscape: Usually Contraindicated (Simon Law: Can be done by experienced Endoscopist)
Contrast study:
Medscape: Gastrografin has 90% Sensitivity but still can have False ve in up to 20% Pt
Barium asso. with Severe Mediastinitis; May use if Gastrografin ve
CT: Collections, Mediastinal Air, Effusion, Pneumothorax
Mx: Resuscitation & Antibiotics
Conservative: In Stable Pt with very Localized Leak Selective
Drainage
Surgical Repair (usually for Early Dx)
Esophagectomy (rarely done, ? Cancer)
Endoscopic Stenting
Outcome: Depends on Timely Dx & Tx
Mx of Esophageal Perforation due to FBI:
Old protocol: Urgent Surgery within 24h
New protocol: Conservative Mx
Eat: NPO if there is Perforation (Contamination would occur)
IV access: If Cant eat: Give IV fluid
Give IV TPN if prolonged Fasting expected
Monitor: Temp, BP/P, SpO2
SaO2: Tx: O2 therapy: Nasal Cannula is 1st line, O2 Mask is 2nd line
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Ventilation: PEEP can help against Atelectasis to O2
RR & TV can Ventilation to CO2
Post-op Atelectasis: Most common Pulmonary Cx after General Surgery
Post-op Alveoli collapse More common if Hx of Smoking & Lung diseases
Prevention: Pre-op: Incentive Spirometer (eg. Triflow: Inspiration> Bring up 3 balls)
Smoking Cessation (Suggest to stop for at least 1 week pre-op)
(Airway secretion> Less Hostile to GA)
Post-op: Adequate Pain control (Best is Epidural, 2nd is PCA, etc)
Incentive Spirometer, Coughing Exercise
Early Mobilization
Avoid Fluid overload
Others: NGT
Urinary Catheter (Normal Urinary output in Adults: 0.5 ml/kg/h)
Drugs: IV Antibiotics
Ix: Contrast studies:
Site: Esophagus: Swallow
Stomach + Duodenum: Meal
Small bowel: Followthrough: Single Contrast swallowed
Enema: Nasojejunostomy, then Double Contrast injected
More Sensitive but more Uncomfortable
Large bowel: Enema
Contrast Medium:
Barium: Good for suspected Obstruction esp in Upper GI
(Gastrografin will lead to Chemical Pneumonitis when aspirated)
Gastrografin: Good for Perforation (Barium can lead to Barium Peritonitis/Mediastinitis)
Other Tx: eg. If Round object is swallowed (if passed C6, shall Not cause obstruction in Normal ppl),
can just monitor via Serial X-ray
If Sharp object is swallowed, need Surgery (2013 MCQ 72)
Caustic ingestion: Acid vs Alkali (Textbooks often say Alkali is worse; Simon Law: Both bad)
Acid: Coagulation Necrosis> Formation of Eschar> Protect underlying tissue
Alkali: Liquefactive Necrosis (Saponification of Fat & Solubilization of Proteins)
Toxicology
Cx (2013 SAQ 1, etc):
Acute: Laryngeal Edema, Pneumonitis
Esophageal/Gastric Perforation, adjacent organs
Metabolic disturbance
Late: Stricture (as early as 2 weeks)
Cancer Risk
Sx: Dysphagia, Sore throat, Drooling of Saliva, Burn to mouth & lips, SOB, Signs of Perforation
Mx: Initial: Resuscitation
Endoscopy: Careful (by experienced Endoscopist; Otherwise may lead to Perforation)
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Length, Circumference (Stricture prediction)
Contrast study
NB: For Pt in Resp distress, if Acute Airway obstruction is suspected, do Laryngoscopy
If Laryngeal Edema, Intubation is Contraindicated
Need Tracheostomy (2014 MCQ 29) (2013 SAQ 1)
Definitive: No Perforation: Support, NG tube, PPI
Steroid?
Early assessment for Dilatation esp for Circumferential Burn
Severe Long Stricture may need Replacement
Perforation: Surgical Tx
Boerhaave syndrome:
Esophageal Rupture due to Vomiting
Site: *Left PosteroLateral wall of Lower Esophagus (2011 MCQ 44)
Lecturer: At Upper & Lower Esophagus: Affect Left Lung
At Middle Esophagus: Affect Right Lung

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GI Dysphagia
Dysphagia: Sensation of Difficulty of Swallowing, involving any structures of Upper GI, from Lips to LES
Oropharyngeal: Passage of food from Mouth to Esophagus (Transfer Dysphagia)
Esophageal: Passage of Bolus from Upper Esophagus to Stomach (Difficulty in Propagation)
Anatomy: Striated muscles: Tongue, Oropharynx, UES, Upper 5% of Esophagus
Smooth muscles: Distal 50-60% of Esophagus
Mixed: Middle 35-40% of Esophagus
Swallowing Phase: Oral: Voluntary, Mastication, Tongue Movement
Pharyngeal: Involuntary, Oropharyngeal
Esophageal: Involuntary, Peristalsis
Cause:
Oropharyngeal Dysphagia:
Mechanical/Structural:
Tumor (Hypopharyngeal Cancer)
Others: Inflammation (Pain, Abscess), Zenker Diverticulum (Pharyngeal pouch)
Functional/Neuromuscular:
May be Isolated or part of Bulbar/Pseudobulbar Palsy; More common than Mechanical
CVA, Parkinsonism, MS, MND, MG, Myositis, etc
Esophageal Dysphagia:
Mechanical:
IntraLuminal: Foreign Body Ingestion
IntraMural: Esophageal Cancer
Benign Stricture: Reflux Stricture, Caustic Stricture, Radiation Stricture
Others: Esophageal Webs (eg. Plummer-Vinson syndrome),
Schatzki Rings (Lower Esophageal Rings)
Extrinsic: Mediastinal Mass: Lung Cancer, Large Goitre, Mediastinal LN
Vascular: Thoracic AA, Dysphagia lusoria (Aberrant R Subclavian A)
Functional:
Primary: Achalasia
Spastic Motility disorders: Diffuse Esophageal Spasm,
Nutcracker Esophagus, etc
Secondary: Scleroderma, DM (Autonomic Neuropathy), (Chagas disease)
(Others: Esophagitis, eg. Reflux, Infectious (Candidiasis), Radiation, Medication, Chemical (Alcohol))
Approach to Dysphagia:
Real Dysphagia?:
Globus Hystericus/Pharyngis Feeling of sth in throat but in fact No
Nature of Dysphagia:
Solid or Liquid initially
Progressive (eg. CA, Stricture) or Intermittent (eg. Webs, Rings, Spasm, Nutcracker)
Oropharyngeal vs Esophageal Dysphagia:
Oropharyngeal:
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GI Dysphagia
Inability to Chew/Propel food into pharynx (Difficulty in initiating Swallowing),
Drooling of Saliva/Food, Coughing & Regurgitation (even Nasal Regurgitation),
Swallowing with a Gurgling noise, Dysphagia within 1s,
Need of repeated Swallowing/Dysarthria/Dysphonia (Voice may sound Nasal in Bulbar palsy)
Esophageal:
Substernal/Epigastric region, Chest Pain, Delayed Regurgitation,
Level of Dysphagia usually Above actual physical obstruction
Mechanical (Anatomical) vs Functional (Motility):
Onset Progression Type of Bolus Response to Bolus Temp
Mechanical Gradual/Sudden Often Solid Often Regurgitation No
Functional Usually Gradual Variable Solid/Liquid Usually pass with Liquid, May vary with
Swallowing Temp of food
Mechanical often Solid more difficult, Functional often Liquid more difficult
Any Odynophagia:
Esophagitis, Esophageal Spasm, Scleroderma, etc
(May occur Late in Achalasia or Esophageal Cancer)
Sx of Cx: Aspiration Pneumonia, Anemia (Tumor bleeding, Plummer-Vinson syndrome, Ulcer),
Locally Advanced Tumor, Metastasis, etc
Predisposing Conditions:
Reflux Sx, Weight Loss (Cancer, much later in Achalasia), RF of Cancer,
Sx/Hx of Systemic diseases (Neurological diseases, Scleroderma),
Medication (eg. Bisphosphonate), Past Caustic Ingestion, Immunosuppression (Candida)
Pharyngeal Pouch/Diverticulum: aka Zenkers Diverticulum; *Elderly
Diverticulum of pharyngeal mucosa just above Cricopharyngeal muscle (ie. Above UES)
Occlusive Mechanism:
Uncoordinated Swallowing, Impaired Relaxation & Spasm of UES
> Pressure in Distal Pharynx> Outpouching through point of Least Resistance

Achalasia: Degeneration of Nitric oxide releasing neurons> Unopposed action of ACh> No LES Relaxation
Epidemiology: Incidence: 1 per 100,000 in Westernized countries
From Infancy to 9th decade, majority Age 20-40
No Sex predilection
Cause: Loss of Myenteric ganglionic cells
HLA DQw1
HSV Infection
Secondary Causes:
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GI Dysphagia
Pseudo-Achalasia: Cancer of GEJ
Paraneoplastic syndrome
Infiltrative disorders: Amyloidosis, Sarcoidosis
Chagas disease: Trypanosoma Cruzi (more common in South America)
Sx: Mixed Dysphagia, Weight Loss, Regurgitation/Cough esp when Recumbent (eg. Nocturnal),
Chest discomfort/Pain (Vigorous Achalasia)
Ix: CXR: No Gastric Bubble (Not diagnostic; Can occur in Normal ppl)
(Others: Eg. Fluid level due to Stasis in Esophagus)
Barium Swallow:
Classical Rats Tail or Birds Beak appearance, with Proximal dilatation
Endoscopy:
Dilated Esophagus
Stasis of Food & Secretions, Frothy Fluid
LES appears Tight
Up to 40% Normal
Possibility of Malignant Stricture (PseudoAchalasia)
(Simon Law: Achalasia is a functional obstruction
Endoscopy may get through with some efforts
If cant, think of PseudoAchalasia) (2005 EMQ 9)
High Resolution Manometry (HRM):
36 circumferential channels 1cm apart, 12 sensors/channel, 432 data points, 2.75mm diameter
Features (2004 SAQ 1): Aperistalsis
LES Pressure (>45 mmHg)
Incomplete LES Relaxation (>8 mmHg)
Pressurized Esophageal body
Tx: Objectives: LES pressure, while minimizing chance of Reflux
Drugs: Nitrate
CCB
Endoscopic:
Balloon dilatation
Botulinum toxin injection:
Irreversible binding to pre-synaptic cholinergic receptors> Inhibits ACh release
Botox vs Dilatation: Higher need for further procedure (47% vs 25%)
(Simon Law: Efficacy gradually ; Not so preferred now but its a Safe procedure)
Good for those with very High Surgical risk (2005 EMQ 8)
Myotomy:
Heller Myotomy (traditional approach)
Thoracoscopic Myotomy
Laparoscopic + Dor Patch: (Laparoscopic surgery with Fundoplication is the current standard)
Anti-Reflux Surgery done at the same time (Reflux risk from 40% to 10%)
Robotic assisted Myotomy
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Peroral Endoscopic Myotomy (POEM) (New; Cons: Risk of Reflux as Anti-Reflux Surgery Not done)
Esophagectomy (Ultimate Tx)
Diffuse Esophageal Spasm: aka Cockscrew Esophagus (appearance on Barium Swallow X-ray)
Uncoordinated Contractions of Esophagus; Can cause Non-Cardiac Chest Pain

Epiphrenic Diverticulum:
Due to Dysfunction of LES
Food trapped in Pouch may be Regurgitated when lie down to sleep at night

Pill-induced Ulceration: Eg. Tetracycline, Slow K

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GI GERD
GastroEsophageal Reflux Disease:
Montreal Definition: Condition which develop when reflux of stomach contents cause troublesome Sx/Cx
ie. Can be Dx in primary care on the basis of Sx, without further Ix
Esophageal syndromes:
Symptomatic syndromes:
Typical Reflux syndrome, Reflux Chest Pain syndrome
Syndromes with Esophageal injury:
Reflux Esophagitis, Reflux Stricture, Barretts Esophagus, AdenoCA
Extra-Esophageal syndromes:
Established Associations:
Reflux Cough, Reflux Laryngitis, Reflux Asthma, Reflux Dental Erosion
Proposed Associations:
Pharyngitis, Sinusitis, Idiopathic Pulmonary Fibrosis, Recurrent Otitis media
Non-Erosive Reflux Disease (NERD):
Endoscopy ve Reflux disease should be reserved for individuals who satisfy GERD definition,
but who do Not have either Barretts Esophagus
or definite Endoscopic Esophageal Mucosal breaks (Erosion/Ulceration)
Los Angeles Classification for Esophagitis: (2011 SAQ 2)
Grade A: 1 Mucosal break 5 mm long, that does Not extend between Tops of 2 Mucosal folds
Grade B: 1 Mucosal break >5 mm long, that does Not extend between Tops of 2 Mucosal folds
Grade C: 1 Mucosal break that is Continuous between Tops of 2 Mucosal folds,
but which involves <75% of circumference
Grade D: 1 Mucosal break which involves 75% of esophageal circumference
Prevalence: 2.5-4.8% in HK
Pathophysiology: Pump: Motility, Saliva, Gravity, Anatomy
Valve: Pressure, Length, Position
Reservoir: Pressure, Dilatation, Emptying, Secretion
Anti-Reflux Barrier:
LES pressure: If persistently Low, far end of spectrum
Transient LES relaxation (TLESR): Non-swallow-related Reflex Relaxation
75% of Reflux episodes in GERD
(Simon Law: Vagal Reflex due to Distention Belching?)
Anatomy: Hiatal Hernia, Crural Diaphragm, Length of Intra-abd Esophagus, Angle of His
3 Types of Hiatal Hernia: (2006 MCQ 73)
*Type 1: Sliding; (GEJ herniated above diaphragm)
Type 2: ParaEsophageal; (GEJ still Normal position, but Fundus herniated up from side)
(Pure Type 2 Uncommon; Usually Elderly; Risk of Strangulation)
Type 3: Mixed
Sx: Heartburn: Substernal discomfort, Radiation of Pain towards Mouth
Precipitated by Meals & Recumbence, Ameliorated with Antacid
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Regurgitation
Dx: Chinese GERDQ:
7 items: Frequency & Severity of Heartburn & Regurgitation
Frequency & Severity of Acidity feeling in Stomach
Frequency of use of Antacid
PPI test
Endoscopy
Barium: Non-specific (Ix but Not Dx), Looks at Structural problems (Stricture, Hiatal Hernia)
Manometry & 24h pH monitoring
DeMeester score: Normal <14.72 (95th percentile)
Indication: Dx in doubt, eg. Extra-Esophageal manifestations
Research
When Planning for Surgery
Mx: Lifestyle modification:
Stop Smoking, Alcohol
Diet: Avoid Chocolate, High Fat diet, Coffee, Tea, Cola, Acid juices, Peppermint
Size of Meal
Lose Weight
Avoid Tight Clothing
Elevate Head of Bed
Drugs: Antacid
H2RA: Cimetidine, Ranitidine, Famotidine
Mucosa Protectant: Sucralfate
PPI: Omeprazole, Lansoprazole, Esomeprazole, Rabeprazole
(Simon Law: Take the pills 30 min before meal
Deals with pH of Reflux contents, but Not preventing Reflux directly)
(KH Tong: PPI is the only proven drug)
Surgery (Anti-Reflux procedures):
Require Definite Dx by Esophageal Manometry & 24h pH monitoring before Surgery
Complete vs Partial Fundoplication:
Partial: Dor Fundoplication (Anterior 180)
Toupet Fundoplication (Posterior 270)
Complete: Nissen Fundoplication (360)
NB: Vagus is preserved during Surgery
Vagotomy will lead to Gastroparesis> Reflux
Barretts Esophagus:
Definition: Presence of an Abnormal segment of Metaplastic Columnar epithelium in Esophagus
Biopsies showed Intestinal Metaplasia (2005 MCQ 86: Not Fundic)
Replacement of Lower Esophageal Squamous mucosa by Columnar mucosa
Specialized Intestinal Metaplasia characterized by Goblet cells
(2012 MCQ 7: Salmon Pink patch with No visible nodules on Endoscopy)
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Risk of Cancer: 30-125x Normal population
0.5-1% per Pt per year, or 1 per 100-180 Pt years of FU
NB: 2005 MCQ 86: Barrett also risk of CRC
Type: Long-segment >3 cm (from GEJ)
Short-segment <3 cm
Ultra-short segment (Intestinal Metaplasia at Cardia)
Mx: Screening (Conservative approach)
RFA (Halo system) (If just Targeted Burn of Mucosa, Low risk of causing Stricture)
High dose PPI post-RFA: (No Acid> Heal with Squamous Mucosa)
EMR

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GI GERD
GI Esophageal CA
Esophagus Anatomy: 25 cm long from Cricopharyngeus (C6) to GEJ
Anatomical Division:
Cervical: Cricopharyngeus to Thoracic Inlet (Suprasternal notch)
Thoracic: Upper (Inlet to Carina/Azygos vein)
Middle
Lower (Below Midway between Carina & GEJ/Below Inferior Pulmonary veins)
Abdominal: Hiatus (diaphragm level) to GEJ; Considered as part of Lower Thoracic
3 Natural Narrowings:
Cricopharyngeus
Aortic Arch & Left Main Bronchus Compression
Diaphragmatic Hiatus & LES
Blood supply: Upper Esophagus: Inferior Thyroid A/V (2009 MCQ 81: Also supplies Upper 2/3 Trachea)
Middle Esophagus: Esophageal branches from Aorta, (Bronchial A);
Azygos V, (Hemiazygos V, Bronchial V)
Lower Esophagus: Left Gastric A, (Inferior Phrenic A); Left Gastric V
Lymphatic: Upper Esophagus: Cervical nodes, Upper Mediastinal nodes
Middle Esophagus: Mediastinal nodes, Left Gastric & Celiac axis nodes
Lower Esophagus: Lower Mediastinal nodes, Left Gastric & Celiac axis nodes
(Bi-directional drainage)

Epidemiology: M>F
SCC more common Worldwide & in Chinese, while ADC is replacing SCC in Caucasians in USA
RF: HK: Hot Soup/Beverage 14%, Salted Fish/Pickled Vegetables 29%,
Infrequent Green Vegetables 15%, Smoking 44%
Infrequent Citrus Fruit 26%, Alcohol 48%
China: Nitrosamine/Nitrite, Micronutrient deficiencies (eg. Selenium),
Mouldy food/Fungal toxin (eg. Aflatoxin), HPV, Genetics, Smoking, Alcohol
Regions: Henan, Hebei
Others: Jiangsu, Shanxi, Shaanxi, Fujian, Anhui, Sichuan
Alcohol Flushing response:
36% Asians have mutation in ALDH2 (Normal ALDH2 decompose Acetaldehyde to Acetate)
Normal ALDH2: Non-Flusher; Normal Risk of CA
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Heterozygous ALDH2 mutation: Flusher; High Risk
Homozygous ALDH2 mutation: Flusher ++; Low Risk (Cant tolerate Alcohol> Drink Less)
Selenium: Low Selenium level accounts for 26% of population with Esophageal or Cardia CA
But Not for Non-Cardia AdenoCA?
West: Rate of Rise of Esophageal Cancer is Fastest among different Cancer
RF for SCC vs ADC: {Combined from various lectures & sources}
Smoking Alcohol GERD Obesity RT for Breast CA Hx of HN Cancer Low SES Very Hot
Caucasian Achalasia Caustic Injury Poor Nutrition Beverage
Plummer-Vinson
SCC +++ +++ ++++ ++ +
+++
ADC ++ + ++++ ++
Main RF for ADC: Obesity, GERD, Barretts Esophagus, Smoking, (Alcohol - GERD)
Specific Predisposing Conditions:
Barretts Esophagus (AdenoCA)
Achalasia (Due to Chronic Retention & Fermentation of food?)
Lye Corrosive Strictures
Plummer-Vinson syndrome (CA over Cervical Esophagus)
Tylosis (HowelEvans syndrome; Familial Palmoplantar Keratoderma asso. with CA Esophagus)
Why GERD Less in Asia: Same Factors at a Lower Scale
Acidity of Gastric content is , either Spontaneously or by H. pylori Infection
Low Fat Diet, Obesity, No. of TLESRs (Transient Lower Esophageal Sphincter Relaxation)
Prevalence of Hiatal Hernia is Low, Esophageal Motility disorders are Moderate
Pathology:
Site: Middle 1/3 Esophagus (Most common overall & in SCC)
Lower 1/3 Esophagus (2nd most common overall, Most common in ADC)
Upper 1/3 Esophagus (Least common)
Spread: Direct Invasion: eg. RLN, Phrenic nerve, Trachea/Bronchi, Pericardium, Aorta
(No Serosa> Facilitate Extra-Esophageal Extension)
Lymphatic
Hematogenous: Liver, Lung, Bone
Macroscopic: *Fungating, Ulcerative, Infiltrative
Siewert Classification for AdenoCA around GEJ: (Junctional region defined as 5 cm above & below true GEJ)
Type I: Esophageal: 1-5 cm above GEJ
Type II: True Cardia: 1 cm above GEJ to 2 cm below GEJ
Type III: Subcardia (Gastric): 2-5 cm below GEJ
Endoscopic Definition of GEJ:
Simon Law: Upper border of Gastric Fold; Not necessarily Squamo-Columnar junction
Screening: In the old days: Balloon/Sponge Cytology
New method: Lugols Iodine & Narrow Band Imaging (NBI)
Sx: *Dysphagia: Painless Progressive Dysphagia, initially Solid food but later Liquid food (within 4 weeks time)
Pt can usually tell level of obstruction
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(Esophagus is quite distensible since No Serosa> At least 2/3 diameter occluded to have Sx)
Regurgitation
Weight Loss: Early Weight Loss as Dysphagia affects Nutrition
Not necessarily due to Constitutional Sx (ie. Appetite may be ok)
Other Uncommon Sx:
Odynophagia:
Due to Distension, Ulceration or Muscle spasm
Epigastric/Retrosternal Pain/Discomfort
Bleeding/Anemia:
Usually Not Severe if due to Ulceration alone
Rarely Severe Hematemesis due to Aorto-Esophageal Fistula
Hoarseness (RLN invasion by Primary tumor/LN Metastases)
Persistent Cough (Aspiration/Direct Invasion):
(eg. Recurrent Regurgitation
Vocal cord Paralysis due to RLN involvement
TracheoEsophageal Fistula/BronchoEsophageal Fistula)
Bone Pain (Metastasis)
PE: Usually Normal, unless Metastatic disease (eg. to Neck LN, to Liver)
Possible signs: Cachexia, Pallor, Cervical LN (Henry Tuen: Usually just up to Level 4-6)
Any Signs of Liver Metastasis
Any Signs of Aspiration Pneumonia/Lung Metastasis
(Surgery concern: Kyphoscoliosis: May affect Thoracotomy/Thoracoscopic Surgery
Abd Scars: Esophagectomy need Abd Conduit)
Ix: (Basic: CBC for Anemia/Aspiration Pneumonia
Electrolytes/RFT for Electrolyte disturbance, Dehydration (Cr more than Urea)
LFT for Liver Metastasis, Nutrition (Albumin)
TFT to document Thyroid Function before Surgery (may damage Thyroid)
CXR)
Dx: Upper Endoscopy with Biopsy (Gold standard):
Distance from Incisor, Obstruction, Biopsy, Cytology, Feeding tube Insertion
Barium Swallow:
(Rarely done now; Barium more preferred than Ionic Contrast to avoid Cx to airway if Fistula)
May be done if OGD cant pass through
Stenosis, Proximal dilatation, Sinuses, Shouldering, Level
Staging: EUS, Bronchoscopy, CT Thorax + Abdomen, PET (2009 MCQ 9, etc)
Laparoscopy only considered for AdenoCA (eg. CA Cardia/Stomach, for Peritoneal Mets)
EUS FNA:
For Staging (T staging & N staging) (>80% accurate)
Regional LN: More Controversial than T staging
Done in QMH
Not done in UCH (Doubtful significance; Can be Surgically removed anyway)
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Typical EUS can see 5 layers in Normal Esophagus/Stomach; (White-Black-White-Black-White)
1st (HyperEchoic) layer is Superficial Mucosa
2nd (HypoEchoic) layer is Deep Mucosa (Muscularis mucosae)
3rd (HyperEchoic) is Submucosa
4th (HypoEchoic) is Muscularis propia
5th (HyperEchoic) is Adventitia/Serosa
(Pros: Better Resolution of walls than CT
Can see Relationship with Aorta Any Invasion)
Bronchoscopy:
Useful to rule out Tracheal/Bronchial Invasion which signify T4, esp for SupraCarinal tumor
Tumor Infiltration, Obstruction, Fistula
CT: Wall thickening, Aortic Infiltration, Airway Infiltration, Level, Distant Metastases
Pre-op status: Nutrient status: Must be assured before Surgery (Albumin, Lymphocyte count, Creatinine)
Also CardioPulmonary status
Reasons for Difficult Tx:
Late Presentation/Disease Stage
Early spread of disease
Deep seated organ anatomically with important surrounding structures
Elderly population with Co-morbid diseases
Curative Tx:
1. Surgery:
Endoluminal Surgery (eg. EMR):
For Early lesions (But most Esophageal Cancer in HK presents Late, seldom applicable in HK)
Esophagectomy:
Open:
TransHiatal Esophagectomy (THE):
Abdominal + Cervical Incision with Blunt Mediastinal dissection through Hiatus
Pros: Avoid Thoracic Incision Resp Cx
Cons: Its a Blind operation: Inadequate Mediastinal LN Dissection
Risk of Injury to RLN, Azygous vein, Left Bronchus, etc
(Not good for SCC which is Higher up than AdenoCA, thus seldom done in HK)
TransThoracic Esophagectomy (TTE):
*2-phase (Lewis-Tanner/Ivor-Lewis): Abdominal + Right Thoracic Incision
Phase 1: Upper Midline Laparotomy (Supine)
Mobilize Stomach
Phase 2: Right Thoracotomy (Left Lateral position)
Mobilize & Resect Esophagus
Pull Gastric tube up for Anastomosis (Colon/Jejunum if previous Gastrectomy)
(Anastomosis in Chest, cf Neck for McKeown or THE)
3-phase (McKeown): Abdominal + Right Thoracic + Cervical Incision
(Phase 3: Neck Excision for Anastomosis of Cervical Esophagus & Gastric tube)
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(Phase 2 usually done first, then simultaneous Phase 1 & 3, so just need to turn Pt once)
(May be used for more Proximal tumor; Also permit Cervical Lymphadenopathy)
Minimal Invasive Esophagectomy:
Laparoscopic + Thoracoscopic
(Henry Tuen: 2 Thoracoscopic, 3 Laparoscopic pots with Upper Midline Laparotomy)
(Its possible to be partially MIS, eg. Video-assisted Thoracoscopic Esophagectomy)
(PLO: PharyngoLaryngoEsophagectomy may be done for Cervical Esophageal CA)
LN dissection: 3 fields of LN: Field 1: Abdominal (Upper Abdominal)
Field 2: Mediastinal
Field 3: Cervical
Standard 2-field dissection (Field 1-2) for SubCarinal tumor
Extended 3-field dissection (Field 1-3) for SupraCarinal tumor (or Cervical LN Mets detected)
Cx: Medical: Resp: Pneumonia, Atelectasis, Consolidation, Sputum Retention
Cardiac: Arrhythmia (eg. AF)
Surgical: Intra-op Injury to Lung/Trachea/Bronchus, Thoracic duct (Chylothorax), RLN (Vocal cord palsy)
Anastomotic Leak (1 week post-op) (May result in Mediastinitis in Thoracic Anastomosis)
(Cervical Anastomosis more preferred in Pt with High risk for Anastomotic Leak)
Ischemic conduit (Stomach/Colon/Jejunum)
GER, Hiatal Herniation: Can lead to Anastomotic PU, Stricture (Gastric outlet obstruction)
2. ChemoRT: Neoadjuvant, Adjuvant (No evidence of Survival benefit?)
Simon Law: In Stage 2-3 operable CA:
SCC: Neoadjuvant ChemoRT (Superior to Neoadjuvant Chemo alone)
AdenoCA: Type I: Neoadjuvant ChemoRT (But Type I less common in HK)
Type II & III: Adjuvant ChemoRT (ie. Similar as Gastric CA)
Type II & III seldom involve Mediastinal LN
UK: Tend to do Neoadjuvant + Adjuvant
Palliative Tx:
1. Surgical:
Endoscopic: Dilatation, Stent: Useful for Strictures, TracheoEsophageal Fistula
Ablative therapy: eg. Laser therapy, (Ethanol Injection)
Stenting: (Only for Palliative; If going to do Surgery, just use Temporary Feeding tube for Dysphagia)
Type: Plastic: Rigid & Traumatic, Smaller & Lower Patency Rate
Eg. Atkinson Stent
Metallic: Self-Expanding Metallic Stent (SEMS)
Flexible & Less Traumatic, Larger & Higher Patency Rate
More Cost Effective (RCT study), but more Expensive
Eg. Wallstent, Z-stent, Ultraflex stent
Cx: Early: Failure to deploy/expand, Misplacement, Immediate Perforation
Chest Pain
Bleeding
Late: Stent Migration
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GI Esophageal CA
Stent Occlusion: Tumor in-growth, Food impaction
Tracheal Erosion/Fistula (Late Perforation)
VATS/Open: Resection (Surgical Debulking), Bypass (rarely done nowadays)
2. Non-Surgical:
Chemo: Classically 5-FU & Cisplatin
RT: External beam vs Brachytherapy via Endoscopy
Tx by Staging: Stage 1: Surgery
Stage 2: Usually Surgery or Neoadjuvant ChemoRT followed by Surgery in QM
Stage 3: Usually Neoadjuvant ChemoRT followed by Surgery in QM
Stage 4: Palliative

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GI Esophageal CA
GI Vomiting
Definition:
Vomiting: Nausea & Autonomic Sx such as Salivation,
followed by Forceful Abdominal & Thoracic Muscle Contraction associated with Retching
Involve Emetic Center (Vomiting Center)
Regurgitation: Sudden, Effortless Return of Small amount of Gastric contents into Pharynx/Mouth
Rumination: Repetitive, Effortless Regurgitation of recently ingested food into mouth,
followed by Re-chewing & Reswallowing or Expulsion
Vomiting Ddx:
Drugs: Chemo, Narcotic Analgesics, Antibiotics
Disorders of GIT & Peritoneum: Mechanical Obstruction, Functional disorders, RT, Peritonitis
CNS disorders: ICP, Emotional response, Psychiatric disorders, Middle Ear conditions
Endocrine & Metabolic: Pregnancy, Uremia, Others
Infection: GE, Otitis Media
Post-op
Cyclic Vomiting
Others: MI, Alcohol Abuse
Acute vs Chronic:
Acute: Abdominal: IO, Pseudo-Obstruction, Acute Pancreatitis, Acute Cholecystitis
Infection: GE
Toxins: S. aureus, Bacillus cereus (Rice products), etc
Metabolic: Renal Failure, Ketoacidosis, Addisons disease
CNS disorders
Vestibular disorders
Pregnancy
Drugs: Narcotics, Digitalis, Chemo, Metronidazole, etc
Ix: Abd Pain: Amylase: Pancreatitis
Erect & Supine AXR: Obstruction (Mechanical or Pseudo)
US: Cholecystitis
CT, MRI
Fever, Diarrhea: Food Poisoning
Abnormal Mental status: CNS causes
Review all Drugs taken
Chronic: Gastric: Mechanical: PU, Gastric Cancer, Gastric Lymphoma, Pancreatic disease,
Crohns disease
Functional: Gastroparesis (DM, Scleroderma, Metabolic, Idiopathic), Drugs,
After Gastrectomy, Post-Viral, AN
Small bowel Dysmotility/Intestinal Pseudo-Obstruction:
Drugs, Scleroderma, DM, Amyloidosis (Chronic Nausea), Jejunal Diverticulosis,
Small bowel Myopathy/Neuropathy
Psychogenic Vomiting: After Emotional Stress
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GI Vomiting
Bulimia Nervosa
CNS disorders
Drugs
Metabolic: HyperT, Addisons disease
Idiopathic
Mechanical Obstruction:
High: Frequent Vomiting, No Distention, Intermittent Pain but Not Classic Crescendo type
Eg. Duodenum
Middle: Moderate Vomiting & Distention, Intermittent Pain (Crescendo, Colicky) with Free Intervals
Eg. Ileum
Low: Vomiting Late, Feculent, Marked Distention, Variable Pain (May Not be Classic Crescendo type)
Eg. Ileocecal Valve
Upper GIT Obstruction:
Nature of Vomitus: Bile-stained (Distal to Ampulla of Vater) or Not Bile-stained (Proximal)
Bulge (Distention) in Epigastrium
Succussion Splash
Vomiting & Weight Loss, Gradual Onset, Elderly: Consider Gastric CA with Outlet Obstruction
Cx of Vomiting: HypoK, Dehydration, Metabolic Alkalosis, Emetogenic Injury like Mallory-Weiss Tear
Tests for Gastric Emptying:
Barium X-ray Imaging
CT/MRI for Change in Gastric Volume
Scintigraphy: Radio-labelled isotope Meal/Drink (Victoria Tan: Best test)
Real time US (Research purpose)
Gastric Impedance (Research purpose)
Drugs for Nausea/Vomiting:
AntiHistamines: Dimenhydrinate, Promethazine, Meclizine,
Cyclizine (Vestibular/Motion Sickness)
AntiCholinergics: Scopolamine (Vestibular/Motion Sickness)
Phenothiazines: Prochlorperazine, Chlorpromazine
Haloperidol (Very Effective but lots of S/E)
Dopaminergic Antagonists: Metoclopramide, Domperidone
5HT3 Antagonists: Ondansetron
5HT4 Agonist: Cisapride, Mosapride, Itopride
Erythromycin (Prokinetic effect)
Misc:
X-ray:
Coiled Spring Sign:
Severely Air-dilated Small Bowel
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GI Vomiting

String-of-Pearls Sign:
Appear Late in Small Bowel Obstruction

Haustral pattern:
Large Bowel
(Often Not connected in Centre)

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GI Gastric Cancer
Gastric Malignancy: *AdenoCA, Lymphoma (eg. MALT Lymphoma), Mesenchymal Tumor (eg. GIST)
Gastric AdenoCA:
Epidemiology: ing Incidence but still the 2nd Leading cause of Cancer Deaths worldwide
High Incidence in Asia, eg. Japan, Korea, China; M>F
4th Leading cause of Cancer Deaths in HK
RF: Genetic: Hereditary (eg. E-Cadherin mutation)
Environmental: Dietary Factors:
Harmful: N-nitroso compounds, Preserved/Smoked/Salted food
Protective: Trace elements (eg. Selenium), Vit C, Fresh Fruit & Vegetables
Smoking, (Alcohol can induce Gastritis)
H. pylori (The only Bacteria classified as Group 1 Carcinogen by WHO)
Atrophic Gastritis, Pernicious Anemia, (Chronic GU), Adenomatous Polyps, Menetriers disease
Previous Partial Gastrectomy (>15 years) (Due to Bile Reflux in Remnant Gastric Mucosa)
Others: EBV (Asso. with Unusual form of Gastric Cancer Lymphoepithelioma-like CA)
Common Variable ImmunoDeficiency (CVID)
NB: These 2 conditions Risk of both Lymphoma & Cancer (2006 MCQ 5)
Natural Hx: Acute Gastritis> Chronic Gastritis> Atrophic Gastritis> Intestinal Metaplasia> Dysplasia> Cancer
Macroscopic Morphology:
Borrmanns Classification (1926): No Prognostic Significance
Type 1: Polypoid
Type 2: Fungating, (Ulcerated with Sharp Raised margins)
Type 3: Ulcerative (with poorly defined infiltrative margins)
Type 4: Infiltrative (including Linitis Plastica)

Linitis Plastica:
A Special Morphology Leather Bottle Stomach
Diffuse Submucosal Infiltration
Mucosa may appear Normal on Endoscopy (Predominantly Intramural lesion)
Thick Rigid wall (due to Diffuse Infiltration & Fibrosis)> Stomach could Not be Insufflated
Dx: Endoscopy (Bite into Mucosa), EUS, CT
Ddx: Lymphoma
Mode of Spread: Direct Invasion: eg. Pancreas (Posterior), Colon (Inferior), Spleen (Left), Liver (Anterior)
*Lymphatic
Transcoelomic: Peritoneal Seedlings (Deposits are Small> CT may Not detect)
Ascites: Likely Peritoneal Mets (But Absence does Not exclude Mets)
Krukenberg tumour (Ovarian Mets)
Hematogenous: *Liver, Lung, etc
Clinical Features: Notoriously difficult to make Early Dx
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(Epigastric Pain + Anorexia/Weight Loss: Early Endoscopy to exclude Early Gastric CA)
Asymptomatic
Symptomatic: Epigastric Pain/Discomfort, PostPrandial Fullness/Dyspepsia
Nausea/Vomiting (Anorexia with Mild Nausea is common; Prominent N/V in GOO)
Cachexia: Anorexia, Weight Loss (Can also be due to Malnutrition), Malaise, Weakness
Abdominal Mass (Bulky Advanced tumour, Omental Secondaries, Krukenberg)
Cx: Bleeding: Anemia, Melena, Hematemesis
Obstruction: GOO: Distending Discomfort, Vomiting
Enlarged Stomach with Succussion Splash
CA Cardia: Dysphagia, Early Satiety
Perforation: Acute Peritonitis (Uncommon)
Paraneoplastic: Acanthosis Nigricans:
Brown-Black, Poorly defined, Velvety Hyperpigmentation of Thickened Skin
Flexor areas: Body Folds of Neck, Armpits, Groin, Navel, Forehead
Also seen in other Benign conditions:
Common: DM, Obesity
Uncommon: Cushing, Acromegaly, PCOS, other states of HyperInsulinemia
Others: Migratory Thrombophlebitis (Trousseau sign), DVT,
(Diffuse Seborrheic Keratoses (Leser-Trlat sign))
Metastatic disease:
Peritoneal: Abdominal Distention (Malignant Ascites)
Sister Josephs Nodule (Metastatic Tumor Nodule at Umbilicus; May + Periumbilical Erythema)
Blumers Shelf (Shelflike Mass on DRE/Vaginal Exam) (Peritoneal Deposits in POD/RV pouch)
Pleural: Dyspnea (Pleural Effusion, Lymphangitis Carcinomatosis)
LN: Troisiers Sign: Virchows node (Left SCN) + Intra-abdominal Malignancy
Left Axillary LN (Irishs node) (Uncommon, in Widespread Mets)
Organ: Liver: Jaundice (*Biliary Obstruction by LN, Multiple Liver Secondaries)
Hepatomegaly
Kidney: ARF/Hydronephrosis (Malignant Ureteric Obstruction)
Ovary: Abdominal Mass (Krukenberg tumor)
Ix: Dx: Upper Endoscopy & Biopsies; Barium Meal seldom required nowadays
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2 Basic Q after Dx: Stage?
Fit for Surgery/Tx?
Blood Tests: CBC
LRFT
Tumour Markers (CEA more common than CA 19.9) NOT for Dx, but helpful for FU Assessment
(Private sector may check CA 72.4 too)
Imaging: CXR
EUS (best for T & N staging)
US Upper Abdomen
CT Thorax, Abdomen, Pelvis

(Role of PET scan controversial)
Laparoscopy: For Peritoneal Metastases (More accurate than CT) (2002S MCQ 6)
Staging:
TNM classification: UICC/AJCC, JGCA
T staging: Depth of Invasion
Tis: Cis
T1: Invades Mucosa (T1a) or Submucosa (T1b)
T2: Invades Muscularis propria
T3: Invades Subserosa
T4: Invades Serosa (T4a) or adjacent structure (T4b)
N staging: Different UICC/AJCC vs Japanese system
UICC/AJCC:
N1: 1-6 regional LN involved
N2: 7-15 regional LN involved
N3: >15 regional LN involved
JGCA: 3 tiers depending on Location of tumor (Upper, Middle, Lower part of Stomach)
N1: PeriGastric LN closest to Primary tumor
N2: Distant PeriGastric LN, along main supplying artery
N3: LN outside the normal lymphatic pathway,
only involved in Advanced tumor or by Retrograde Lymphatic flow due to blockage
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M staging: Distant LN metastasis (Retropancreatic, Para-aortic, Portal, Retroperitoneal, Mesenteric),
Peritoneal seedling, Liver or other distant Metastasis
Staging:
Stage 1: IA: T1
IB: T2N0, or T1N1
Stage 2: IIA: T3N0, or T2N1, or T1N2 (2006 EMQ 2: T3N0 is Stage 2)
IIB: T4aN0, or T3N1, or T2N2, or T1N3
Stage 3: IIIA: T4aN1, or T3N2, or T2N3
IIIB: T4bN0, or T4bN1, or T4aN2, or T3N3
IIIC: T4bN2, or T4bN3, or T4aN3
Stage 4: M1
NB: Only Stage 4 is Not-resectable; T4 can still potentially be resectable (2012 MCQ 22)
Tx: In general, depend on GC (Fitness for GA) & Clinical Stage
Resection is Mainstay of Curative Tx (Only hope for Cure for Resectable disease)
In HK, 70% present Stage III
Tx of Early Gastric Cancer (ie. T1 lesion, Limited to Mucosa):
Rare in HK; ing Frequency in Japan (Picked up by Screening Endoscopy)
Endoscopic Mucosal Resection (EMR) or Endoscopic Submucosal Dissection (ESD) as Alternative
(Indication: T1aN0M0, Well-differentiated, <3cm without Ulcer or <2cm with Ulcer)
Laparoscopic Gastrectomy
EMR: Single Channel Scope (Injection Needle> Injected Submucosal Saline> Snare)
Dual Channel Scope (Grasping Forceps)
Cap Method (Cap> Suction & Snaring)
(There are modified techniques to use EMR for Larger lesion
But Margin & Depth control are Poorer & Less accurate than ESD
In UCH, usually used for lesions <1cm)
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ESD: For Polypoid/Large lesion

Marking: (Perilesional marking by Energy source, as Margin may be blurred after Injection)
Injection: (Submucosal Injection: Gelofusine (Colloid stays Longer than Saline)
+ Indigo carmine as stain
+ Adrenaline (Hemostasis & Stain stays Longer))
Dissection & Complete Resection
(UCH: ESD is just like an advanced version of EMR
Well developed by Japanese, cf Caucasians developed EMR
Cx: Stomach: Hemorrhage (up to 4%); Seen in re-scope, Not severe
Esophagus: Perforation can also occur (1-2%, manageable by clips)
Post-op: PPI Infusion, Monitor Hb; Some centers may re-scope)
Tx of Gastric Cancer without Systemic Metastases (Resectable Gastric Cancer):
1. Surgery: Gastric Resection with D2 LN dissection (ie. Radical Gastrectomy): Only hope for Cure
Gastrectomy:
Total Radical Gastrectomy:
For Proximal lesion
Distal Radical Gastrectomy:
For Distal lesion
Distal Radical Gastrectomy =/= Distal Simple Gastrectomy
Artery Ligation:
Radical: Left & Right Gastric artery, Left & Right GastroEpiploic artery
Ie. Remnant branch by Short Gastric arteries (from Splenic A) (2011 MCQ 24)
Simple: Only Right Gastric & Right GastroEpiploic
Pros: Stomach part easier to anastomose to Jejunum, cf Esophagus does Not have Serosa
Less M&M, Better Functional reserve
Total Gastrectomy has No proven advantages in Distal lesion by RCT
(Others: Eg. Proximal Radical Gastrectomy may be done in some CA Cardia cases)
LN dissection: Japanese: D1 dissection = Limited Lymphadenopathy, removing Tier 1 LN
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D2 dissection = Systematic Lymphadenopathy, removing Tier 1-2 LN
D3 dissection = Extended Lymphadenopathy, removing Tier 1-3 LN
(At least D2 dissection is considered Curative; Generally D number > N stage)
Reconstruction:
Billroth I (End-to-End GastroDudenostomy):
After Distal Gastrectomy
Pros: No Malabsorption (Duodenal continuity important for preventing loss of Fat-soluble Vitamins)
Cons: No protection against Bile Reflux
More difficult procedure (difficult to mobilize Duodenum) (only in some centres, eg. QMH)
(KM Chu: In QMH, more preferred than Billroth II if possible)
Billroth II/Polya (GastroJejunostomy):
After Distal Gastrectomy
Pros: Less Tension than Billroth I
Cons: No protection against Bile Reflux
Some Malabsorption (cf Billroth I)

Roux-en-Y anastomosis:
After Distal/Total Gastrectomy
Pros: Can prevent Bile Reflux
Cons: Higher chance of Leak (2 anastomoses)
Malabsorption
May have Roux stasis syndrome for Distal Gastrectomy (may require completion Gastrectomy)
NB: (After Total, some may make a Jejunal pouch for better reservoir; Not proven by RCT?)
Distal Total
Cx: Early: Anastomotic Leak, Hemorrhage, Pancreatic Leak, CBD injury,
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Post-Splenectomy Infection
Late: PostPrandial Sequelae:
Early Satiety
Dumping syndrome: Rapid Gastric Emptying
Early Dumping (within 15-30 min):
Osmotic load from Stomach into Small Bowel
> Rapidly draws fluid into Small Bowel
> GI upset (N/V, Cramping due to Acute distension, Diarrhea)
Hypovolemic Sx
Late Dumping (1-3h): Reactive HyperInsulinemia> Hypoglycemic attack
Diarrhea
Bile Reflux if No Bile diverting reconstruction (ie. Billroth I & II)
Malnutrition:
General: More due to Intake due to PostPrandial sequelae & Appetite
Specific: Vit B12 deficiency (Acid to release B12, Intrinsic Factor)
B12 supplement required for both Distal & Total Gastrectomy (2012 MCQ 22)
Fe deficiency (Acid> Conversion of Fe3+ to Fe2+> Fe absorption)
(Vit D, Ca in Elderly)
NB: Both Billroth II & Roux-en-Y can cause Malabsorption of Fat-soluble Vitamins
Afferent Limb syndrome:
Occurs in Billroth II reconstruction
IO of afferent jejunal loop> PostPrandial Epigastric Pain & Nausea
Non-bilious Vomiting; Bilious Vomiting if obstruction relieved
Cx: Pancreatitis/Cholangitis/Obstructive Jaundice, Duodenal perforation
(Prophylactic Cholecystectomy:
May be considered
Dissection of Vagal nerve branches in Gastrectomy> Biliary stasis> Gallstones
ERCP is contraindicated in Roux-en-Y anastomosis, so Prophylaxis for Cholangitis)
2. Chemo/RT:
Adjuvant Chemo:
Survival benefit for Advanced disease (Small but Statistically significant)
Adjuvant ChemoRT:
1 +ve Trial (Survival Benefit)
Critics: Inadequate LN Dissection (10% D2, 36% D1, 54% D0)
(ie. ChemoRT was just a substitute for Inadequate surgery)
Significant Toxicity
Neoadjuvant Chemo:
1 +ve RCT, Selected Pt
Tx of Advanced disease Not Curable by Resection (Palliative Tx):
General: Supportive Care, Pain Control, Psychological Support
Surgery: Mainly for Bleeding & Obstruction
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Palliative Resection for Bleeding (& GOO)
Palliative Bypass (GastroJejunostomy) for GOO
Endoscopic Stenting for GOO:
Good if Short Expected Survival (Surgical Cx, Quicker Discharge, Also for Comorbid)
If Long Expected Survival, Bypass is better (No recurrent admission for Stent revision)
Chemo:
Systemic Chemo:
Survival benefit in comparison to Supportive Care Alone
Even Best Supportive Care only 3-4 months
Agent: Best regimen: ECF (Epirubicin, Cisplatin, 5-FU) (or variant)
Mitomycin was used too
NOT Cyclophosphamide (2005 MCQ 51)
Should consider QOL as well
Regional Intra-arterial Chemo
(Target therapy: Trastuzumab may help in HER2 amplified Gastric Cancer, esp Diffuse type)
Pt Unfit for Surgery, High Medical Risks:
Supportive Care
Endoscopic Metallic Stenting for Outlet Obstruction
Chemo
Value of Diagnostic Imaging for GI Cancer:
Staging: Eg. CXR, CT Abdomen, PET (Not applicable to All; May have False ve Glycolysis Not )
Dx: IO AXR
MBO US Hepatobiliary system
Malignant Obstructive Uropathy US Kidneys
Monitoring response to Tx:
Eg. CT Abdomen, PET (Not applicable to All tumors)

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GI Gastric Cancer
Gastric Polyp:
Types:
Hyperplastic Polyp (Most common in most sources)
NB: Menetriers disease may mimic Hyperplastic Polyps (2006 MCQ 6)
Fundic Gland Polyp (KM Chu: Most common?)
If Fundic Gland Polyposis (Multiple Sessile Polyps confined to Body of Stomach)
Mostly Sporadic
Some may be Asso. with FAP: Do Colonoscopy to exclude FAP
Adenomatous Polyp:
Malignant potential 5-10% (esp if >2cm: Up to 40%)
Polypectomy: Done if certain to be Mucosal Polyp (Snare on the Mucosal stalk)
If suspect, dont do; May lead to Perforation
Can perform EUS if uncertain

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GI Gastric Cancer
GIST
GastroIntestinal Stromal Tumor:
Site: Stomach (60-70%) > Small bowel (Jejunum/Ileum > Duodenum) > Large bowel > Esophagus
Presentation: Most common: Upper GIB (2003 MCQ 80)
(Mucosal defect can be visualized; Wont have UGIB if No defect)
Others: Pain/Discomfort, Early Satiety/Abd Fullness Sensation, Mass, Perforation, etc
Carneys Triad: GIST, Pulmonary Chondroma, Extra-Adrenal Paraganglioma
Usually in Young Female; Not to be confused with Carneys Complex/Syndrome
Dx: EUS: >90% GIST
Ddx: Main Ddx: Leiomyoma (& Rarely Leimyosarcoma):
Both GIST & Leiomyoma arise from Muscularis propia layer (2011 EMQ 20)
Much less common than GIST
Others: Hemangioma, Lipoma, Schwannoma, Neurofibroma, Paraganglioma,
Carcinoid, Desmoid, Ectopic Pancreas
(NB: On Endoscopy, GIST & all these may be shown as Submucosal Mass
EUS is helpful to ddx GIST & Leiomyoma from those arising from other layers)
Histology: Rmb Cat & Dog
Classical: IHC stain for c-kit mutation:
GIST: CD 117 (c-kit) +ve; Also CD 34 +ve in 60% GIST
Leiomyoma: Desmin +ve, Actin +ve
Schwannoma: S100 +ve
New: Dog 1
Malignant Risk Assessment:
with Size >5 cm, >5 mitosis / 50 HPF, ExtraGastric location, Extension into adjacent organs
NIH consensus Classification (Old one)
Armed Forces Institute of Pathology (AFIP):
Risks of Progressive disease
Mitosis Size (cm)
Gastric Duodenum Small bowel Large bowel
5/50 HPF 2 0
2-5 Very Low
5-10 Low High Moderate High
>10 Moderate High
>5/50 HPF 2 - - - High
2-5 Moderate High
>5 High
Tx: Surgery:
Resection: Majority by Laparoscopic Surgery (unless Big Size)
LN dissection usually Not needed (LN spread Uncommon)
GIST morphology:
Extragastric Tumor
Intragastric Tumor: May need Endoscopic Guidance (eg. Blue dye) to help localization
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Dumbbell Tumor: Beware Not to miss the other side
Targeted therapy:
Imatinib: Useful in GIST with c-Kit mutation (c-kit is a Tyrosine Kinase)
Metastatic GIST:
1st line Tx; Response rate: 60%
Significant breakthrough GIST was notorious for Resistance to Chemo & RT
Adjuvant therapy:
Survival, Recurrence
Controversy is regarding Duration of Adjuvant therapy:
In existing studies, once Adjuvant therapy stopped, Recurrence
Old study: 1-year regimen
Current standard: 3-year regimen
Ongoing trial: 5-year regimen (Expected to be better)
Neoadjuvant therapy:
Indication: Local Invasion requiring Down-staging for Less Morbidity
Location: In D2, if can downstage, just Local Resection, cf Whipple
S/E: *Facial Edema, Depigmentation, Rash, etc; (Almost all TKI have Skin S/E)
nd
2 line: Sunitinib (Sutent)
Metastasis/Recurrence: (2007 MCQ 59, 2005 MCQ 89, 2004 MCQ 63)
Usually *Liver or Peritoneum
Uncommon to Lungs
Rarely to Regional LN

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GI Gastric Cancer
GI Upper GI Bleeding
Cause of Upper GIB:
Top 5: *Peptic Ulcer (DU/GU)
Gastritis/Duodenitis/Erosions (Erosive Gastritis)
Esophageal/Gastric Varices (Portal HT, usually >30 mmHg) (GV < EV, also bleed less than EV)
Mallory-Weiss Syndrome (Association with Alcohol is Not common in HK)
Benign/Malignant Gastric Tumor (Bleeding Not common presentation)
(CA, GIST, rarely Gastrinoma, etc)
Others:
Esophagus:
Esophagitis, Esophageal Ulcer (Rare), Esophageal Tumour
Stomach: Portal Hypertensive Gastropathy (Asso. with Portal HT, but =/= Gastric Varices)
Gastric Antral Vascular Ectasia (GAVE; Watermelon Stomach)
(Appearance similar but mainly over Antrum; Asso. with Portal HT, CRF, CTD)
Dieulafoys lesion (Exulceratio Simplex):
Large Tortuous Arteriole in Submucosa; *Proximal Stomach, SB; Occult (By Angiogram)
Intestine: Stomal Ulcer
Duodenal/Jejunal Diverticulum, Jejunal Ulcer
Angiodysplasia (more common in Colon), other Vascular Malformation
AortoEnteric Fistula (usually present as Collapse)
(Eg. AortoDuodenal Fistula after AA Graft, AortoEsophageal Fistula after Eso Perforation)
Crohns disease (seldom in Upper GI)
HBP: Hemobilia (usually after PTBD), Hemosuccus Pancreaticus
Cause of Severe UGIB:
DU/GU, Esophageal/Gastric Varices, Stomal Ulcer, AortoDuodenal Fistula, Dieulafoys lesion
Factitious Bleeding/Bleeding from Non-GI sources:
Swallowed Blood from Epistaxis
Hemoptysis
Oral Bleeding lesions
Bleed themselves & Swallow the Blood (Psychiatric)
Presentation: Depend on Volume & Location of Bleeding
Acute GIB:
Vomitus: Hematemesis
Coffee Ground Vomiting (Color of MetHb, converted by Acid)
NG tube: Coffee ground/Fresh blood from NG tube
(If NG tube clean, usually Lower down, but still can be DU with Competent Pylorus)
Stool: Melena (Tarry Stool) (Color of Hematin, converted by Intestinal Bacteria)
Black, Tarry, Loose, Sticky, Malodorous; Represent Degraded blood in intestine
Usually Upper GI (Above Ligament of Treitz), but can be down to SB or even Right Colon
Usually Cathartic, so Pt describe Loose Stools/Diarrhea (Blood is Laxative)
(Constipated Melena is Uncommon but still possible)
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Need to rule out other causes of Black Stool, including Iron/Bismuth Ingestion & Food
More likely to be Constipated (Formed stool), Usually Green Black Stool
Hematochezia (Fresh PR Bleeding):
Usually Lower GIB (esp Hemorrhoid)
If both Melena + Fresh PR Bleeding: Hemodynamic Instability
Chronic GIB: Occult Bleeding (usually present with Anemic Sx)
Small amount:
Unsuspected Fe deficiency Anemia
Occult blood in Stool during routine checkup
Moderate amount:
Anemic Sx: Lethargy, Dizziness, Palpitation, Angina, Dyspnea
Abnormal Stool Color
Abnormal Ix: Low Hb, Low MCV, Fe studies, FOBT +ve
Initial Assessment:
Assess Urgency/Severity of situation Very important:
Very Severe:
Hypotension, Tachycardia, Agitation, Confusion/Drowsiness/Coma
May have Bradycardia in Severe GIB Vagal Slowing of Heart
Moderate to Severe:
Postural Hypotension: Indicate at least 20% in Blood Volume
Hematocrit may Not reflect degree of Blood Loss
Expressed in terms of Erythrocyte Volume as a % of Total Blood volume
Does Not until Blood volume is restored, usually in 24-48h
Action:
Mod-Severe:
Resuscitation
ABC, Central Venous line, Fluid Resuscitation (Colloid, Blood product), Oxygen,
Monitor Vital signs & Urine output, ICU for Severe cases
Mild: Proceed to Hx & PE
Hx: Bleeding: Nature, Onset, Rate, Duration, Previous Episodes
Aggravating factor/Associated Sx:
Early Satiety: Malignancy, PU
Vomiting (eg. After Alcohol): Mallory-Weiss Tear
Epigastric Pain: PU, Erosions, Malignancy
Weight Loss, Anorexia: Malignancy
Painful Dysphagia: Esophagitis/Esophageal Ulcer
Painless Dysphagia: Malignancy
PMH:
PU/GIB: Ulcer Recurrence, Common in Pre-H. pylori era
H. pylori testing, Tx & FU:
Unlikely PU except Hp still +ve; But still possibility of Hp ve PU (esp in Elderly)
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Cirrhosis: HBsAg status, Sx of Cirrhosis (eg. Ascites, Jaundice, Easy Bruising)
Bleeding Tendency:
Cancer, Recent Nose Bleeding, etc
GI Surgery: Stomal Ulcer, PU in Remaining Stomach, Ulcer in Small intestine
Irradiation (Enteritis)
Drug:
Analgesic: Aspirin, NSAID, Dipyridamole; (Pt may Not know they are taking these Drugs, eg. TCM)
Clues: Pt with IHD, Chest Pain, CVA, Minor Stroke, TIA, Joint Pain,
Seen by Orthopedic doctor, Given Analgesic by doctor together with Antacid,
Given Injections
AntiCoagulant, AntiPlatelet
Cardiac Drugs BB
Fe: Black Stool (Black Formed Stool, Not Melena)
Others:
Alcohol
Caustic substance
PE: Confirm C/C: Examine Vomitus, Examine Material from NG tube
PR Exam: Fresh Melena (Hb + Hematin) vs Old Melena (Hematin alone)
Fast/Ongoing Slow/Stopped
Assess General status:
Pallor (Hemocue), Tachycardia (Pulse), Hypotension (including Postural BP), Hydration status
GE: Stigmata of Chronic Liver disease, Malignancy, Hereditary Vascular anomalies, Cervical LN
Abdomen: Epigastric Tenderness, Abd Mass, Liver & Spleen Size, PR Exam
Simple Ix:
CBC: Hb
MCV: In Acute Bleeding, usually Normal (Later may be High Reticulocytes)
If Low: Slightly Chronic with Fe deficiency, or Thalassemia
Platelet: Maybe High (Reactive) or Low (Cirrhosis)
RFT: Electrolyte: Usually Normal
Urea, Creatinine: Urea abnormally Higher than Creatinine
Combined effect of Blood Absorption & Hypovolemia
Clotting: PT, APTT
Mx: Resuscitation: Early Recognition of Hypovolemic Shock, Earliest Sign is Tachycardia
Dx: Hx, PE, Ix
Tx
Principle: Empirical
Specific: Replace Blood lost, Find out Cause, Control Bleeding (Do them Simultaneously)
Blood Loss & Shock:
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Blood Loss (ml) Blood Loss (%BV) Pulse (bpm) BP RR Urine Output (ml/h) Mental Status
Class 1 <750 <15% <100 N N >35 Slightly Anxious
Class 2 750-1500 15-30% >100 N 30-40 Mildly Anxious
Class 3 1500-2000 30-40% >120 20-30 Anxious, Confused
Class 4 >2000 >40% >140 14-20 Confused, Lethargic
(Dont start Resuscitation until Hypotension, Start when see Tachycardia!)
(UCH: Normally Urine output should be >30 ml/h for Adults)
Resuscitation: Secure ABC
NPO, NG tube in selected Pt (eg. Risk of Aspiration in Unconscious)
Large bore IV Cannula
Colloids/Crystalloids, Group O Rh ve Blood if necessary
Blood taking for: T&S, Haemocue, CBC, LRFT, PT/APTT
(Haemocue: Machine in ward to measure Hb level Quickly)
(In CRF, Pt has Chronic Anemia, so Low Hb does Not signify Bleeding)
Erect CXR
Monitor: Shock Chart hourly, BP & Pulse, RR,
CVP line (Swan-Ganz catheter for PAWP),
Urine Output, Foley Catheter (Urine output 0.5 ml/kg/h),
(Useful indicator of Success of Resuscitation in Normal Kidney Pt)
Core Temp (Hypothermia> Clotting factor function),
Cardiac monitor, Pulse Oximeter
Replace Blood Lost:
Should do quickly Regardless of other Mx plans
Endoscopic therapy only stop Further bleeding, does Not replace Blood lost
Do Not wait for Upper Endoscopy; Anticipate problem instead of waiting; Treat aggressively
Dx in Acute Phase: Acute DU & GU Bleeding will Stop Spontaneously in 70%-80%
Identify Pt in Shock Require Resuscitation
Identify Pt with Ongoing Bleeding Require Immediate Endoscopy
General Guideline:

Features suggestive of Active/Ongoing Bleeding: (2009 SAQ 12, etc)
Hematemesis, Fresh blood aspirated from NG tube, Fresh PR Bleeding, Tachycardia,
Fresh Melena
Role of OGD: Verification of Bleeding Source
Stratification of Pt according to risk of Rebleeding
Therapeutic Intervention: Definitive, or Temporizing before Definitive Surgery
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Endoscopic Predictors of Persistent/Recurrent Bleeding:
Endoscopic Stigmata of Recent Hemorrhage (ESRH) (Forrests Classification)
Bleeding Type Appearance Rebleeding Risk
UGIB Lecture UCH note, Andre Tan,
Endoscopy Lecture Medacad Wiki
Active Ia Spurting (arterial?) 80-90% 90%
55%
Ib Oozing (venous?) 30% 20%
Recent IIa Visible Vessel 20-50% 43% 40%
IIb Adherent Clot 20-30% 22% 20%
IIc Flat Pigmented Spot 10% 10%
(Hematin over Base)
No III No Stigmata 0-2% 5% 5%
(Clean Ulcer Base)
(Therapeutic Endoscopy: Type Ia, Ib, IIa, IIb)
Find out Cause: 1st line: *Upper Endoscopy!, Barium Meal
nd
2 line: Angiogram, Small bowel Series, Radioisotope (Red cell) Scan, *Colonoscopy,
Capsule Endoscopy, Double Balloon Enteroscopy
Radioisotope Bleeding Scan:
Radioisotope Bleeding Scans may be Diagnostic when Bleeding distal to Ligament of Treitz
Ready Availability, Low Cost, No Cx
As little as 5 ml of Intra-luminal blood will give a +ve Scan
Allow Sequential Scans & Probability of Bleeding site Identification
Detect Intermittent/Slow Bleeding (Not shown by Angiography), Bleeding rate 0.5 ml/min
Delayed Scan may identify site of Blood Pooling only, Not site of Bleeding (Major Cons)
Angiography: Can detect Bleeding at a rate of 0.5-2.0 ml/min
Localize a site of Bleeding in 50-72% of Pt with Massive Hemorrhage,
but only in 25-50% of Pt when Active Bleeding has Slowed/Stopped
Can also diagnose Non-bleeding lesion like Angiodysplasia & Small bowel tumors
But Low yield for Small bowel Angiodysplasia
(Can help plan Surgery)
Capsule Endoscopy:
Capsule & Transmitter, Receiver & Recorder, Workstation; 2 Cameras, 4 pic/s
Examine Entire Small bowel, Diagnostic only, Cx, Expensive
Indication: Obscure GIB/Fe deficiency Anemia
Abnormal Imaging of Small bowel
Recurrent Abd Pain
? Chronic Diarrhea
FU Evaluation of Crohn, Celiac, Small Intestinal Polyposis
Summary: Celiac disease, Crohns disease, Small bowel Tumors,
NSAID induced GI damage, Polyposis syndromes
Contraindication:
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In Pt with Known/Suspected GI Obstruction/Strictures (Capsule may be stuck)
In Pt with Pacemakers or other Implantable Electromedical devices
In Pt with Swallowing disorders
Severe Motility problems
Un-cooperative & Unreliable
Other Limitations:
Sub-optimal Visual clarity due to Fluids
Long Viewing Time of video, up to 2h
Inability to take Tissue Biopsy
Inability to perform to & fro Exam May Miss lesions
Inability to perform Therapeutics
Difficult to determine Exact site
Slow Transit time resulting in Incomplete data acquisition (Battery used up)
Double Balloon Enteroscopy:
Technique: Reason for Difficulty is Elastic nature of Looped intestine
Role of Flexible overtube with a balloon was to Prevent Stretching of Shortened intestine
Intubated intestine is Shortened by gentle Withdrawal of Endoscope,
while Balloon at its tip is Inflated to grip the intestine
Approach: Anterograde: Mouth to Ascending Colon
Retrograde: Anal Approach
Pros: Accessory Channel & Tip Deflection Capability> Biopsy & Therapeutic Interventions possible!
Medical conditions can be treated with Non-surgical Endoscopic Tx:
Bleeding, Mucosal Neoplastic lesions, Benign Strictures of Crohn's in Distal small intestine
Single Balloon Enteroscopy:
Balloon attached to Overtube only
Up & Down Angulation of scope
DBE SBE
Operator 2 1/2
Time Slower Intubation Faster Intubation
User Friendly ++ +++
Depth ++++ ++
Holding in Ileocecal valve +++ ++
Total Enteroscopy (Japan) Yamamoto et al: 78%+ (Can get in Deeper) Tsujikawa et al: 25%
Tx to Control Bleeding:
Endoscopic Tx: Injection with Adrenaline & others
Thermal methods
Hemoclips
Argon Plasma Coagulation APC
Band Ligation
Endoloops
Sengstaken Blakemore tube
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Medical Tx: Only proven for Bleeding Esophageal Varices (Octreotide, Terlipressin)
Empirical PPI until Dx, 72/24h IV Infusion Post-Endoscopic Tx for Ulcers
Surgery
Ulcer: Duodenal, Gastric & Stomal Ulcers account for 25-50% of Non-Variceal Upper GIB
Ulcer still bleed May Not have Warning Sx
Ulcers High on Lesser Curve & in Postero-Inferior wall of Duodenal Bulb bleed more easily
Major causes: H. pylori
NSAID/Aspirin
Associated factors: Elderly, Multiple Comorbidities, Warfarin, Stress, Steroid
Gastritis/Duodenitis/Erosions:
Drug induced: Aspirin, NSAID (Local + Systemic effect)
Almost all Pt on Aspirin develop Mild Hemorrhagic Gastritis within 24h
Bleeding is Minimal & Not Clinically apparent
Adaptation & Healing occur
Bleeding can be Acute (within first few days) or Chronic (after some months)
Usually Self limiting after Removal of Drug
Enteric-coated Aspirin still can cause Bleeding Systemic effect
Alcohol induced:
Acute, Chronic
Maybe in Pt with Existing Cirrhosis & Portal HT
Stress Gastritis: ICU Pt: Resp Failure, Hypotension, Sepsis, Renal Failure, Thermal Burns, Peritonitis, Jaundice,
Neurological Trauma
All Pt with Endoscopic Gastritis
2-10% Pt with Significant Bleeding
Esophageal/Gastric Varices:
Very High Mortality! 5% of cases of Upper GIB but 80% of Mortality
Can Not distinguish from Hx
Clue: Usually with underlying Cirrhosis, Liver disease
Present with Fresh Large volume Hematemesis
May present with Coffee ground Vomiting (Rare)
Gastric Varices may accompany Esophageal Varices, or alone, usually in Fundus
Mallory-Weiss Tear: Near GEJ in Gastric/Esophageal Mucosa
Retching, usually with Hx of Vomiting foodstuffs
Hx of Alcohol intake
Repeated Vomiting: Pt on Chemo
Esophagitis/Esophageal Ulcer:
Cause: Acid Reflux: Obese, Middle Age
Irradiation: Malignancy
Infectious: Candida, Herpes virus (DM, Chemo, HIV, other IC state)
Pill-induced: Elderly, Psychiatric Pt esp Tetracycline
Sclerotherapy-induced: Post-Endoscopic Intervention (Seldom done now, use Banding more)
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Caustic substance Ingestion
Malignancy: Malignancy of Stomach, Esophagus or Duodenum are Uncommon causes of Upper GIB
Bleeding usually Self-limited
(Endoscopic Tx usually Not needed for Tumor Bleeding, often worse when touch the tumors
Consider Absolute Alcohol injection if Acute Severe Gastric CA Bleeding
Esophageal CA usually No Tx as prone to Perforation)
Angiodysplasia: aka Vascular Ectasia
Less common in Stomach & Duodenum than Colon
In Elderly, Aortic valve disease, CRF, Hereditary Hemorrhagic Telangiectasia, Prior RT
An Unusual variant is called Gastric Antral Vascular Ectasia (GAVE) or Watermelon Stomach
Confirmed by Endoscopic Appearance & Histology
(Tx: Usually Argon Plasma Coagulation)

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PU disease
Anatomy of Stomach:
Antrum: No Rugae, Smooth
Body: Rugae
Fundus: No Rugae, Mucosal fold
Peptic Ulcer: Ulcers developing along Upper GI tract due to Gastric juice (Acid & Pepsin) action
Cause:
Important: H. pylori
NSAID
Others: Other Infection
Other Drugs: Steroid, Bisphosphonates, Clopidogrel, Chemo, etc
(Risk esp if combined with NSAID)
Illicit drug: Cocaine, Methamphetamine
Hormonal: Gastrinoma (Zollinger-Ellison syndrome), etc
Post-Surgical
RT
Inflammatory: Crohns disease, Sarcoidosis
Mechanical: Duodenal obstruction
Comorbid/Stress Ulcers:
Eg. Burn: Curling ulcer
ICP: Cushing ulcer
Hiatus Hernia: Cameron ulcer
Site: In ing Order of Frequency:
Duodenum (*D1)
Stomach (Pyloric Antrum, Lesser Curvature) (Always requires Biopsy to rule out Malignancy)
Esophagus (in Reflux Esophagitis)
Stoma (Anastomotic Stomal Ulcer over GastroJejunostomys Jejunal side)
Depth:
Acute: Mucosa affected only
Usually related to Stress, eg. Severe Burn, Brain damage, Aspirin, etc
Chronic: Involvement of Submucosa/Muscle Coat
Dx of H. pylori:
Biopsy: Site: 3 bites at Antrum (Highest density of H. pylori)
Proximal Stomach if taken PPI/Antibiotics
FU: GU: Always repeat Endoscopy & Biopsy until Ulcer healed
May miss Gastric CA in 1st Biopsy due to Sampling Error
DU: (If Solitary DU over D2 without NSAID use, think Malignancy)
(Benign in D2 if: Multiple DU, NSAID use)
(Also note it can be CA Ampulla)
Rapid Urease test (eg. CLO test):
Contains mixture of Urea + Distilled water + pH indicator
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If Biopsy contains Bacteria, Urease will split Urea into Ammonia & CO2> Change pH
Phenyl red used as pH indicator: Red if +ve (Alkaline)
Yellow if ve (Acidic)
Histology
(Culture: Less commonly used
High Specificity but Low Sensitivity; May Not always be able to grow H. pylori)
Non-Invasive:
Urea Breath test:
Accurate test, but should Not be used in 1st presentation (May miss other pathologies)
Useful for FU of Eradication
Procedure:
Swallow Isotope labeled Urea: H. pylori will split Urea into Ammonia & Labeled CO2
Ask Pt to exhale into test tube
Radioactive (C14) vs Non-Radioactive (C13):
C14: Cheaper (Easier to measure Radioactivity)
But cant be used in Pregnancy/Young Children
C13: More Expensive (Requires Mass Spectrometer for measurement)
(Serology: Does Not reflect Active Infection; Ab can persist despite Infection Eradication
Do Not use to monitor for success of Eradication
Useful for Epidemiology)
(Others: Stool for Ag, PCR for Ag)
Ulcer Pain: Epigastric Burning/Gnawing Pain
Relationship with Meal time:
GU: Pain precipitated by food
Pain during meal (Gastric acid production as food enters)
Nausea & Weight Loss more common in GU
DU: Hunger Pain that improves with Food/Antacid
Initially improves with Eating (Pyloric sphincter closes> Acid Not reaching Duodenum)
Pain appears ~2-3h after meal (Begins to release digested food into Duodenum)
Nocturnal Pain May flare at Night & wake Pt up (Nighttime peak in Acid secretion)
PUD-related Cx: Bleeding > Perforation > Gastric outlet obstruction
Ulcer Bleeding: Most common cause of Upper GIB
20% Pt will continue to bleed actively on presentation (Triage is important)
Blood in Stool:
Melena: Black color due to Hematin (Converted by GI bacteria)
Old: Totally Black
Bleeding slow or has stopped (Takes time for Bacteria to change Hb to Hematin)
Fresh:
Mixture of Hb & Hematin> Mixture of Black & Red (Tinge of Red in Black)
Active/Fast bleeding (Not enough time for conversion)
Fresh PR Bleed:
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Massive Acute Bleeding
No Bacteria in Gut (eg. Taken a lot of Antibiotics)
Blood in Vomitus:
Coffee Ground Vomiting:
MetHb (Converted by Acid)
Likely Bleeding has stopped (Need time for conversion to MetHb)
Fresh Hematemesis:
Active Bleeding
Fresh Blood from NGT:
Active Bleeding
Tx of Bleeding PU:
No Stigmata (ESRH III Clean Ulcer Base):
Start Feeding, Early Discharge
H2 Blocker, PPI: Hasten Healing of Ulcers, PPI Infusion for Higher pH (Stabilize Clot)
(Give H2RA if Low risk of Rebleeding, PPI if High risk of Rebleeding)
Eradication Therapy: If H. pylori +ve
Therapeutic Endoscopy (ESRH Ia, Ib, IIa, IIb):
Method:
Common:
Injection: Adrenaline: Tamponade effect on BV (Normal Saline also works)
Attract Platelet Aggregation
Vasoconstriction

Thermal: Heater Probe (Coaptation of walls of BV)
Others:
Metal Clipping:
Not always useful (Eg. Cant stop Oozing Ulcer)
Helpful in Mallory Weiss, Visible Vessels
(Band Ligation & Sclerotherapy:
Not used to treat Ulcer disease, but for Varices)
Argon Plasma Coagulation:
Good for Superficial Minor Bleeding only
Hemospray:
Latest technology; Nano powder
Expensive, but work well for Coagulopathy Pt with Large area of Bleeding
After Therapeutic Endoscopy: (2009 SAQ 12, etc)
NPO + IV fluid
Monitor Vital signs & Rebleeding
Drug: Low risk of Rebleeding: H2RA
High risk of Rebleeding: PPI infusion (pH> Stabilize clot to Rebleeding)
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(UCH: Re-scope may be done within 1-2 days; Biopsy may be done during re-scope)
Rebleeding:
5-10%
Mostly within 3 days after Endoscopic therapy (Keep Pt in hospital for 3 days before discharge)
(cf those do Not require Therapeutic Endoscopy> Can be discharged the next day)
Signs of possible Rebleeding:
ing Pulse rate, in Hb level,
Hematemesis, Fresh Blood aspirated from NG tube, Pass Fresh Melena again
High Risk Pt: (2003 SAQ 5)
Old Age >60
Shock on Presentation (2003 MCQ 41)
Hb <8.0 g/dl on Presentation, Need Blood Transfusion >4 units
Coagulopathy
Comorbidity, Already Hospitalized (InPt) for other conditions
Large Ulcer >2 cm
Ulcer at Posterior Inferior D1 (GDA), (High Posterior) Lesser Curve (Anterior Left Gastric A)
Surgical Tx: Indication: Unavailability of Therapeutic Endoscopist
Massive Bleeding
Failed Therapeutic Endoscopy
Rebleed after Therapeutic Endoscopy
Plication: Cant isolate the bleeder under Ulcer base for Ligation> Do Plication instead
(Needle passed through tissue under vessel> Tie; Cant directly ligate since cant isolate it)
Additional procedure:
Choice depend on: Condition of Pt, Experience of Surgeon, Type of Ulcer
- DU: Vagotomy + Pyloroplasty:
Acid secretion to Chance of Rebleeding
Good for Elderly Pt for Acid control: Poor PPI Compliance, Etiology often Not due to H. pylori
Vagotomy:
Proximal Gastric (Highly Selective) Vagotomy: (Uncommon nowadays)
Divide Small branches along Lesser Curvature
Only denervate Acid producing body,
while preserving Innervation to Pylorus & GB
Cons: More technically demanding, Higher chance of Recurrence
*Truncal Vagotomy: Faster procedure for Pt who are Unstable; Need Pyloroplasty
Pyloroplasty: Cut Pylorus> Convert Longitudinal cut into Transverse Closure
Widen Pyloric opening to Gastric Emptying (Counter Truncal Vagotomy S/E)
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- GU: Partial Gastrectomy:
Billroth I Gastrectomy:
Pylorus Removed; Proximal Stomach Anastomosed directly to Duodenum

Billroth II Gastrectomy: GastroJejunostomy
Greater Curvature connected to First part of Jejunum in side-to-side manner
Often follow Antrectomy

PPU: Perforation
Penetration: A form of Perforation which Ulcer bed tunnels into adjacent organ
DU: Tend to penetrate posteriorly into Pancreas
GU: Tend to penetrate into Left Hepatic lobe
Ix: Erect CXR:
PneumoPeritoneum:
80% Pt with Perforation will have PneumoPeritoneum
Absence of Free Gas does Not exclude Perforation of Viscus
Do Surgery directly if compatible Hx & PE even if Erect CXR is Normal; CT Not needed
Cause:
Most common cause in HK: PPU
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Others: Small Bowel: Foreign body causing Perforation
Small Bowel Metastasis from Lung CA (classical presentation)
Large Bowel: Perforation of Diverticulum
Closed Loop obstruction in Colonic CA (due to Cecal Perforation)
Etc
Others:
PneumoGastrogram:
NGT> Pump in 200 ml of air> Air would go into Peritoneal cavity> Free gas on CXR
Cons: If Pt has Spontaneous Seal (Covered by Omentum; Pt may not even require Surgery),
this method would convert Sealed Perforation to Open Perforation
Contrast study (Gastrografin Contrast Meal):
Indicated in specific groups of Pt (Repeatedly refried in MCQ)
Prognostic Factors: Delayed Presentation >24h
Shock/Hypotension on presentation
Co-morbidity
NB: If High risk, do Gastrografin meal to check if its sealed spontaneously; If Not> Surgery
If Low risk, or Spontaneous sealing demonstrated: Conservative Tx
CT: Non-invasive
Provides other possible Dx
Sensitive in detecting Small pockets of air Not visible on X-ray
Poor Prognostic Factors:
Age >70
Shock at admission (2009 MCQ 88, 2007 MCQ 25, 2006 MCQ 56, etc)
Delaying initiation of surgery for >12h after presentation
Renal insufficiency
Cirrhosis (2012 MCQ 21)
Concurrent medical illness (eg. CVD, DM)
IC state
Location of Ulcer (Mortality of perforated GU is 2x of DU)
Mx: QM Protocol:
Initial Mx: NPO + IV fluid
Monitor: BP/P
NG tube to BSB, Q1H aspiration
Foley to BSB, hourly urine output
Initial Ix: CBC, LRFT, Glucose, Amylase, Astrup (CBC + ABG), PT/APTT/INR, T&S
Hemocue stat
Erect CXR
Drugs: Pantoprazole 40 mg ivi stat & 40 mg Q12H
Zinacef 1.5 g ivi stat & 750 mg ivi Q8H
Flagyl 500 mg ivi stat & 500 mg ivi Q8H
Surgery:
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DU: Omental Patch Repair (Graham patch) (No risk of Malignancy, thus No need Biopsy/Resection)
GU: Emergent Gastrectomy (usually Partial) often performed in Elderly Pt
Unstable Pt: May do an Edge Biopsy + Simple closure/Omentopexy first
Elective Gastrectomy later
(NB: Subhepatic Drains may be inserted post-op, but its Controversial)

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GI Lower GI Bleeding
Lower GIB: Bleeding from Gut Distal to Ligament of Treitz
Source: Colon/Rectum/Anus, Small Bowel
Upper GIB can present with similar features as Lower GIB
Characteristics: Occult/Overt
Acute/Chronic
Massive/Slow Bleeding
Obscure GIB
(Classical: Blood mixed with stool: Right-sided Colon (Feces still Fluid)
Blood streak on stool: RectoSigmoid Colon (Feces quite Solid)
Blood on Towel Paper: Blood after Defecation, signifying below Sphincter (Anal conditions)
Blood & Mucus: Colitis (Any inflammation, including Cancer))
Outlet Bleeding: Fresh blood, Separated from Stool, Amount variable (usually small), Anorectal Sx,
Usually No Hemodynamic disturbance, Assessed & managed as OutPt
Common Causes: Hemorrhoids, Fissure-in-ano, Rectal Ulcer, Colorectal Neoplasm, Proctocolitis, IBD, Radiation,
Infection
Acute Lower GIB: Annual Incidence of Lower GIB requiring Hospitalization: 20-27 per 100,000
M>F; Incidence with Age (200x from 3rd decade to 9th decade)
Mx: Resuscitation & Stabilization of Hemodynamics
Localization of Bleeding site
Therapeutic Intervention: Endoscopic, Angiographic, Surgery
(Bleeding stopped Spontaneously in 75% Pt)
Resuscitation: Venous Access
IV Crystalloid solution to expand Intravascular volume
Crossmatch & Blood Transfusion in case of Massive Bleeding
Monitor Hemodynamic status
(Hx/PE/Ix should Not delay Resuscitation)
Hx: Severity & Duration of Bleeding
GI Sx: Abd Pain & Change in Bowel Habit
Anorectal Sx
Systemic Sx
Hx of Previous Bleeding episodes
Previous Ix
Significant Comorbid conditions (Heart/Liver diseases)
Medications (NSAID, AntiCoagulant)
Social Hx & FHx
PE: Hemodynamic status (BP, Pulse, RR)
Abd Exam (usually Normal findings), Rectal Exam, Proctoscopy
Ix & Monitor: Monitor of Hemodynamics: BP, Pulse, Urine output (Foley), Central Venous pressure
Blood tests: Hb & Hematocrit (May be Normal if Not yet Hemodilution),
LRFT, Coagulation profile, T&S
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Localization:
Exclusion: Proctoscopy/Sigmoidoscopy: Exclude Bleeding from Anorectal pathology
Upper Endoscopy: Exclude Upper GIB
? NG tube: Bile-stained Aspiration excludes Bleeding from Upper GI
(Not commonly done)
Method: Endoscopy, Angiography, Radionucleotide scan (RBC, Sulphur Colloid),
Other Imaging (CT, Small Bowel Contrast)
(Failure in Localization in 8-12%)
1. Endoscopy: Upper Endoscopy (Exclude Upper GIB), Colonoscopy, Enteroscopy,
Intra-op Endoscopy (Colonoscopy/Enteroscopy)
Colonoscopy:
Accurate tool to evaluate Lower GIB: Diagnostic yield 75-90%
Low Cx rate
Therapeutic procedure possible
Bowel Preparation: (Pass out the blood so wont obscure view)
Improve Diagnostic yield without Morbidity
Not feasible in Unstable Pt
(Even cant localize exact bleeders, can try to localize transition zone
Eg. If No blood after in Transverse colon, likely Descending/Sigmoid colon)
Therapeutic Colonoscopy:
Most Colonic bleeding stop Spontaneously (>80%) (cf Upper GIB like Bleeding Ulcers)
Therapeutic Modalities: Sclerotherapy (Sclerosant Injection), Vasoconstrictors Injection,
Heater Probe, ElectroCoagulation, Laser, HemoClips
Argon beam Coagulation
Effective in Angiodysplasia & Diverticulitis
2. Angiography:
Selective Catheterization of SMA, IMA & Celiac artery by Seldinger technique
(In practice, Radiologists may suggest doing CTA esp at night)
Bleeding >1 ml/min can be detected
+ve test: Extravasation of Contrast
Diagnostic yield 27-67% (Can stain up bowel segment for surgery)
Cx: Contrast Allergy, Renal Failure, Bleeding from Puncture site
Therapeutic Angiography: (Controversial; Main use of Angiography still Localization)
Embolization: Risk of Bowel Ischemia & Infarction (Thus usually Not done)
Vasopressin Injection: Cardiac S/E
3. Radionuclide scan: (Uncommon, Limited usefulness)
Technetium (Tc-99) labeled: Sulphur Colloid, Tagged RBC (RBC scan)
Labeled RBC Not cleared rapidly & Not taken up by Liver & Spleen
High Sensitivity (detect Bleeding >0.1 ml/min): 80-98%
No Therapeutic value
Screening tool to Confirm Bleeding prior to Angiography for Non Life threatening Bleeding
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(Sensitive but Less Specific; Still need other tools for Accurate Localization)
Surgery: Required in 15-20% Pt with Acute Lower GIB
Indication: Hemodynamic Instability, Transfusion requirement (6 units of blood),
Persistent Bleeding, Rebleeding within 1 week
Type: With Localization: Segment Resection
Without Localization: Subtotal Colectomy if Bleeding is from Colon
Intra-op Colonoscopy/Enteroscopy for Localization
Outcome: Segmental Resection with Localization: Rebleeding 0-15%, Mortality 0-13%
Blind Segmental Resection: Rebleeding up to 75%
Subtotal Colectomy: Mortality 0-40%
Common Causes of Lower GIB:
Cause Diverticular Angiodysplasia Colitis Neoplasm (including Anorectal Small Bowel Upper GI
disease Post-Polypectomy) disease
Frequency (%) 17-40 2-30 9-11 7-33 4-10 2-9 0-11
Large Bowel: Diverticular disease
Angiodysplasia (Vascular Ectasia)
Colitis: Infective (eg. Dysentery), Radiation, IBD, Ischemic (Life-threatening)
Neoplasm
Post-Polypectomy
Anorectal sources: Hemorrhoids, Rectal Ulcer, Rectal Varices
Small Bowel: Meckels Diverticulitis
Vascular lesion: Angiodysplasia, Hemangioma
Small bowel Tumor
Small bowel Ulcer (NSAID-induced, esp for Slow-releasing drugs)
Crohns disease
AortoEnteric Fistula
NB: Intussusception can also give GIB
Upper GI: Massive Bleeding from Upper GI sources
Diverticular disease: About 17% Pt with Diverticulosis experience Bleeding
Due to Ruptured Vasa Rectum
Bleeding usually from a Single Diverticulum (usually over the Edges)
Severity vary
Bleeding stop Spontaneously in 80-85%
Dx: Endoscopy, Angiography
Tx: Endoscopic therapy, Surgical Resection
Rebleeding: 20-30%
Semi-elective Surgery after 2nd Bleeding episodes
Angiodysplasia: Acquired condition associated with Degeneration due to Aging: Mostly in Elderly (2/3 >70yo)
Ectasia of vessels lying in Submucosa
Can occur throughout Whole Colon (*Right Colon)
Bleeding Less Severe than Diverticular Hemorrhage, but tend to be Intermittent
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Bleeding stop in 85-90%; Rebleeding 25-85%
Association: Hereditary Hemorrhagic Telangiectasia (Osler-Weber-Rendu disease)
HHT: Genetic disorder with Vascular Malformations in Skin/Mucous membrane
Aortic Stenosis (Heydes syndrome: GIB from Angiodysplasia in presence of AS)
(AS induces VWD-2A by depleting vWF in blood> Angiodysplasia prone to GIB)
Tx: Endoscopic Surgery; Not necessary in Non-bleeding Angiodysplasia
Colitis: IBD, Infective Colitis, Radiation Colitis, Idiopathic Ulcers
Infective: Bacteria: EnteroHemorrhagic E. coli (eg. O157:H7), Shigella, Salmonella, Campylobacter,
Yersinia, Clostridium
Viral: CMV
Fungal: Cryptosporidia
Parasite: Amoeba, Giardia
IBD: UC: Usually present with Bloody Diarrhea
Usually Not Life threatening
6-10% Pt with UC have Lower GIB enough to necessitate Emergency Surgery
Tx: High chance of Rebleeding: Surgery recommended, Total Colectomy in Emergency
CD: Life threatening Lower GIB Uncommon
Usually due to Colitis
Tx: Total Colectomy: Anastomosis depend on extent of Rectal involvement
Segmental Small bowel Resection: For Bleeding from Small bowel
Radiation ProctoColitis: (2014 SAQ 1)
Damage of Rectal Mucosa
Formation of Vascular Telangiectasia
Presentation: Acute: Within 6 weeks
Chronic: Up to 30 years after exposure
1-5% necessitate Hospitalization
Tx: (Sucralfate Enema)
Endoscopic Tx: InfraRed Coagulation, Argon beam Coagulation, Laser
Formalin: Local application of 4% Formalin
Surgery: For Unstoppable Bleeding: Diversion, Proctectomy (High M&M)
Anorectal Sources: ~10% Pt: Hemorrhoids, Fissure-in-ano, Anal/Rectal Ulcer
Rectal & Proctoscopic Exam
Rectal Varices: Associated with Portal HT; Severe Bleeding
Tx: Local therapy: Injection Sclerotherapy
Surgery: Shunting for Uncontrolled Bleeding
Obscure GIB: Bleeding of Unknown Origin that persist/recur after a ve initial Endoscopy (OGD/Colonoscopy)
Repeat Upper Endoscopy & Colonoscopy
Repeated Endoscopy identified 35% Bleeding lesions
(KM Chu: Mostly due to lesions in Small bowel
Obscure lesions, eg. Dieulafoys lesion
Bleeding from surrounding organs
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Eg. Hemobilia:
Iatrogenic: Post-PTBD due to injury to Hepatic A/Portal V branches
Spontaneous: Bile duct tumor
Pancreatic Hemorrhage:
Pancreatic Tumor
Hemorrhagic Pancreatitis wont present as Obscure GIB)
Bleeding from Small Bowel:
~5% Pt
Cause: Angiodysplasia
JejunoIleal Diverticula, Meckels Diverticulum
Neoplasm (eg. GIST)
Ulcers (Drug-related, eg. NSAID)
Infection (TB, Typhoid Ulcer)
Crohns Enteritis, Radiation Enteritis
Dx: Angiography (over SMA): Difficult to Interpret
(More preferred than RBC scan in Bleeding >1ml/min)
RBC scan: Sensitive (Can pick up minor bleed) but Not Specific
SB Enema/Enteroclysis: Low yield (10%), Can Not detect Vascular lesions
CT
Enteroscopy (KM Chu: In urgent setting, perform PE first, then directly Intra-op Enteroscopy)
NB: (KM Chu: For Bleeding that has stopped:
Young Pt: Consider Meckel scan
Others: Controversial, vary in different centres
QMH: CT first, then Capsule Enteroscopy)
- Enteroscopy: Sonde, Push, Intra-op, Double Balloon
Push: (Historical nowadays; Not used)
Upper Endoscopy beyond DJ flexure
Pediatric Colonoscope
Long Endoscope with Overtube (more rigid)
Length of Jejunum examined vary
Procedures Well tolerated with Few Cx
Channel for Therapeutic measures
Yield: 30% (p=0.0625)
(Sonde: Small Endoscope; Insert & Allow Peristalsis to bring it down
Requires Long time (8h) for Peristalsis to bring it down; Uncomfortable> Uncommon now)
Capsule: Diagnostic Capsule that take Color video images
Signal of its Location transmitted & detected by a sensor
11 out of 20 Pt with Small bowel lesions detected by Capsule Endoscopy
No additional Dx made by Push Enteroscopy
(KM Chu: Almost No Morbidity, except rarely Capsule Retention)
Double Balloon:
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Long Enteroscope
Specialized Balloons & Over-tube
Tip of scope can be smoothly inserted to reach area of Dx
Pass from Mouth & from Anus to Completely examine Small bowel
Biopsy & Therapeutic procedures can be performed
Intra-op: In situations without prior Localization
Colonoscopy: Foley catheter inserted through Appendicotomy/Enterotomy
Bowel preparation by on table Antegrade Irrigation
Effluent from Anus
Allow Complete examination of Small bowel
Route: TransAnal, PerOral,
Through Enterotomy (Middle of Small bowel), Laparoscopic assisted
Summary: Successful Mx of Lower GIB require Aggressive Resuscitation & Localization of Bleeding site
Surgery is indicated in Massive & Continuous Bleeding
Bleeding from Small bowel is Difficult to Localize

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Diverticular disease
Diverticula:
True: Contains all layers of GI wall; eg. Meckels diverticulum (2012 MCQ 39)
Often Congenital
False: Only involve Mucosa & Submucosa, but Not Muscular layers/Adventitia
Often Acquired
eg. Colonic diverticulum (Exception: Ride sided Diverticula are often True Diverticula)
Colonic Diverticular disease:
Epidemiology:
Prevalence: Race: Common in Western (Prevalence: 60% in Age >70), Less in Asians & Africans
Proposed to be due to Low Fiber diet & Intra-luminal pressure
with Age (Weakening of Collagen structure with Age):
Age <60: 30%
Age 80: 60%
Site: Western: 90% in Sigmoid (Smallest Diameter, ie. by Laplace Law, Highest Intraluminal Pressure)
Asian: Right sided Diverticulosis more common (2x of Left sided Diverticulosis)
Does Not occur in Rectum
Saints Triad: 5% Pt with Diverticular disease have associated Gallstone & Hiatus Hernia
Diverticulosis:
Clinical: *Asymptomatic (2006 MCQ 14: 75%)
Symptomatic in ~20%
(In Mild Diverticulitis, may just have vague Abd cramps, Distension, Flatulence)
(Subsequent Ix may pick up Diverticulosis, either related to the Sx or as Incidental finding)
Dx: Barium Enema/Colonoscopy
Barium Enema:
Diverticula, Saw-tooth appearance (Thickening of Circular muscle fibres of Intestine)

NB: Better than Colonoscopy to delineate Extent of Colonic lesions (2006 MCQ 14)
Mx: Dietary advice
Diverticular disease: Symptomatic Diverticulosis
Cx: Diverticulitis (can become Recurrent)
Perforation> Pericolic Abscess, Peritonitis
Hemorrhage
IO: Sigmoid: Due to Progressive Fibrosis causing Stricture
Small bowel: Due to Adherent loops of Small bowel on Pericolitis
Fistula formation
Acute Uncomplicated Diverticulitis:
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10-25% Pt developed Diverticulitis
Clinical: Abd Pain (LLQ) with Local Peritonism & Fever (Triad of LLQ Pain, Fever, Leucocytosis)
RLQ Pain may occur in Cecal Diverticulitis, mimicking Appendicitis; Differentiated by CT scan
Dx: (Basic: WBC, ESR, Erect CXR for Perforation, AXR)
CT Abdomen & Pelvis with IV Contrast
Avoid Colonoscopy (Risk of Perforation)
Barium Enema also Not preferred (Risk of Barium Peritonitis if Perforated)
Mx: IV Antibiotics usually enough
Need to Exclude CA Colon after Acute episode
Colonoscopy
Barium Enema: If Stricture/Tortuous Sigmoid
Diverticulitis with Perforation:
Hincheys Classification (for Left side Diverticulitis only):
I: Confined Peri-colic Abscess
II: Distant Abscess (Pelvic/Retroperitoneal)
III: Generalized Purulent Peritonitis
IV: Generalized Fecal Peritonitis
Mx: Vigorous Resuscitation with IV Antibiotics
Percutaneous Drainage for Abscess
Consideration for operation:
Not responding to Antibiotics
Poor Vital signs (High Fever, Tachycardia, Hypotension, Oliguria)
Generalized Peritonitis (III & IV)
Surgical Options: Emergency Laparotomy & Resection: High Morbidity & Stoma rate
Shift from Resection to Conservative Surgery: Laparoscopic approach feasible
Conventional Strategy:
Hinchey I: Consider 1 stage Elective Surgery after Acute episode
Hinchey II: Elective 1 stage Surgery
Hinchey III & IV: 1 stage: Hartmanns operation
2nd line: Resection with Primary Anastomosis
2 stage: Resection with Primary Anastomosis + Stoma> Closure of Stoma
2nd line: Hartmann> Re-anastomosis
3 stage: Diverting Stoma> Resection> Reversal of Stoma
Problem: Significant M&M, High Permanent Stoma rate (30-75%)
Current Understanding:
Emergency Resection:
Class IV or Fail to improve after Peritoneal Lavage
Options: Resection & Anastomosis Stoma On table colon Lavage (1 stage) (preferred if ok)
Hartmanns operation> Re-anastomosis (2 stage) (2007 EMQ 24)
3 stage operation Rarely done
Decision of Anastomosis:
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Surgeon experience, Hemodynamic, Peritoneal Contamination, Pt factor
Laparoscopic Resection feasible
Elective Resection after Diverticulitis:
More reports suggest Elective Resection Not Mandatory (Interval Colectomy)
Recurrence after 1st episode: 10-30 % in 1st decade (2014 MCQ 10, 2006 MCQ 14)
Outcomes of >2 episodes of attacks are Not worse
Elective Resection: IC, ? Recurrent attack
Decision of Elective Surgery should be individualized (Rafferty J, et al. DCR 2006):
Age & Medical Morbidities
Frequency & Severity of Attacks
Persistent Sx after Acute episode
Complicated Diverticulitis
CA could Not be excluded
IC (Risk of Cx) (2014 MCQ 10) (2006 MCQ 14)
Young Pt (Age 50) (Risk of Cx) (2006 MCQ 14)
Laparoscopic Drainage & Peritoneal Lavage:
Firstly reported in 1996
Reserved for Hinchey II & III
Laparoscopy to improve Risk Stratification
Peritoneal Lavage & Drainage; Drains placed near affected colon
No Emergency Colonic Resection
IV Antibiotics
Elective Sigmoid Resection considered later
Hinchey I-III (in Laparoscopic specialist hands):
Franklin et al. World J Surg Diverticulitis with Peritonism at 4 quadrants of abdomen
2008 (n=40) Hinchey 2: 12.5%, Hinchey 3: 80%, Hinchey 4: 7.5%
Bretagnol et al. J Am Coll Surg Consecutive Pt with Perforated Sigmoid Diverticulitis
2008 (n=24) Hinchey 2: 21%, Hinchey 3: 75%, Hinchey 4: 4.2%
Myers et al. BJS 2008 (n=92) Out of 1257 total / the only prospective series
Generalized Peritonitis & Radiological evidence of perforation
(Hinchey 4 excluded)
Hinchey 2: 27%, Hinchey 3: 72%
All 3 studies: No Acute Resection
Mortality: Nil in first 2 studies, 3% in Myers et al. BJS 2008
Summary: Avoid Unnecessary Laparotomy, Resection, Stoma & their Cx
Controversial in Hinchey IV
Fistula disease: Inflammation erode into adjacent organs
Type: *ColoVesical: (Classically can see Air in Bladder in AXR/CT)
Male: Pneumaturia, Fecaluria, Recurrent UTI (can be Polymicrobial)
(In Male with Recurrent UTI, suspect ColoVesical Fistula)
Female: Protected by Uterus
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ColoVaginal (Post-Hysterectomy)
Mx: Control Sepsis by Antibiotics & Drainage
Elective Colon Resection & Repair of adjacent structure
Stricture: Results of Recurrent attacks
Change of Bowel habit
Differentiation between Malignant Stricture may be difficult
Mx: Elective Resection
Diverticular Bleeding: Common cause of Severe GIB
Intermittent Bleeding; Majority Self-limiting
Ddx: Angiodysplasia (Top ddx; Usually Right sided Bleeding, cf Left sided Diverticular bleeding)
Severe Colitis, Rectal Ulcer, Aorto-Enteric Fistula in previous Aortic Surgery
Mx: Resuscitation & Transfusion
Upper Endoscopy to Exclude Upper GIB
Colonoscopy: Identify Bleeding site (may be difficult)
Intubate Ileocecal valve to Exclude Small bowel Hemorrhage
(Avoid mistakenly resect Large bowel if its due to Small bowel Bleeding)
Therapeutic for Hemostasis (may be difficult esp difficult to localize bleeder)
Helps to decide where to resect if for operation
Localization/Regionalization before Surgery:
RBC scan: Detect Bleeding >0.1 ml/min
Mesenteric Angiogram:
Detect Bleeding >1 ml/min
Embolization Not recommended due to High risk of Bowel Gangrene
Intra-op Endoscopy
Urgent Colectomy: (2006 MCQ 14: <10% Acute Diverticular Bleeding need Urgent Surgery)
Indication: Unstable Hemodynamic despite adequate Resuscitation
Excessive Blood Transfusion (>6 units)
Frequent Rebleeding
Subtotal/Total Colectomy if Fail to identify Bleeding site

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GI Lower Abdominal Pain
Abd Visceral Pain:
`
Lower Abdominal Pain:
Site: Left/Right Iliac Fossa, Suprapubic, Diffuse
Character: Intestinal Colic:
(Pain during Peristaltic wave only)

Ureteric Colic: Between Plateau (Last Longer), there are Background Pain

Constant
Intermittent
Duration: Acute, Subacute, Chronic, Recurrent
Onset: Sudden (Ectopic Pregnancy), Insidious, On & Off
Radiation: Appendicitis: Paraumbilical/Epigastric Pain> SHIFT to Right Iliac Fossa
(Note Appendix pointing to Pelvic cavity may give Suprapubic Pain)

Ureteric Colic: Flank region> shoot down to Groin region (Radiate, not Shift)
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Testicular Torsion: Pain radiate upward to Groin from Scrotum
(Rmb always check Scrotum in Young boy with Groin Pain)

Associated Sx: GI: Nausea/Vomiting, Constipation, Diarrhea,
Recent Bowel Habit change, Blood/Mucus in Stool
(Note: Nausea/Vomiting can be Non-specific; Can Not define a GI origin if just this Sx)
Urinary: Frequency, Urgency, Dysuria, Hematuria, Passage of Sand/Stone,
Urine Retention, Urethral Discharge
Gynecological: Time & Menstrual Flow of LMP, Sexual Hx, Dysmenorrhea,
Abnormal Vaginal Discharge/Bleeding
Systemic: Fever, Appetite/Weight Loss, Tachycardia, Postural Dizziness
Causes by System:
GI: Distal Small Bowel: Meckels Diverticulum, Mesenteric Adenitis, (Small Bowel Tumor Rare)
Meckels Diverticulum: (2012 MCQ) (2010 MCQ 6) (2006 MCQ 16)
Rule of 2: 2% Population, M:F=2:1, Presentation first 2 years (ie. in Young),
2 inches, 2 feet from Ileocecal Valve,
2 types of Ectopic tissue (Gastric, Pancreatic)
Cx: Ectopic PU, Meckels Diverticulitis, Perforation
Mesenteric Adenitis: Often after URTI (2007 MCQ 29)
Clinically difficult to ddx from Appendicitis
Appendix: Appendicitis: Simple, Gangrene, Perforation, Abscess
(Rmb to rule out Cecal Diverticulitis & Mesenteric Adenitis)
Surgery is the Only Tx (except Milder form Appendicular Mass)
Appendicular Mass: Right Iliac Fossa Pain for few days (Not so Acute), Low grade Fever
Appendix wrapped around by Omentum> Mass
Antibiotics helpful
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Ileocolic: Crohns disease & Cx (Abscess, Perforation, Stricture)
Infection: Gastroenteritis
Specific: TB & Cx (Stricture, Perforation, Abscess, Fistula)
{TTAA} Typhoid & Cx (Stricture, Perforation)
Actinomycosis & Cx (Fistula)
Amoebiasis & Cx (Abscess, Perforation)
Colonic Cancer: AdenoCA of Cecum & Ascending Colon & Cx (Obstruction, Perforation)
(Can cause Acute IO> Pain)
Cecal Diverticulitis & Cx (Abscess, Perforation):
Mainly Asians, Few in Caucasians; Also difficult to ddx from Appendicitis
Intussusception
Sigmoid Colon: Sigmoid Volvulus
Sigmoid Diverticulitis & Cx (Stricture, Abscess, Fistula) (Important Ddx of LLQ Pain)
Malignancy AdenoCA & Cx (Obstruction, Perforation, Abscess)
Rectum: Amoebiasis & Cx (Abscess, Perforation) (2005 MCQ 74)
Cancer (AdenoCA)
Non-Specific Abdominal Pain (usually Self-limiting)
(In Short: Distal Ileum: Meckels Diverticulitis, Mesenteric Adenitis
Appendix: Appendicitis
Colon: Colitis (Infective, IBD), Diverticulitis, Cancer, Intussusception, Volvulus)
Urological:
Ureter & Bladder: Infection: Bacterial (LUTI), Parasitic (Schistosomiasis), TB
Stone
Neoplasm: Benign (Rare), Transitional Cell Carcinoma
> Partial Obstruction of Ureter or Non-specific Bladder Pain
Urethra & Prostate (AROU Acute Retention of Urine):
BPH, CA Prostate, Urethral Stricture, Urethral Stone
(Chronic Urinary Retention: Wont cause Acute Distention> Seldom Painful)
Testis: Torsion, Acute Epididymo-orchitis
US Doppler: Torsion (No blood supply) vs Epididymo-orchitis (Hyperemic)
Gynecological:
Cx of Pregnancy: Ectopic Pregnancy, Abortion/Threatened Abortion
(O&G: Threatened usually Painless; Inevitable/Incomplete may be Painful)
PID & Cx: Chronic/Subacute Pain if Tubo-Ovarian Abscess formed (accompanied by High Fever)
Ovarian Cyst & Cx: Seldom Pain unless Cx, eg. Hemorrhage, Torsion
Uterine Fibroid & Cx: Seldom Pain unless Cx, eg. Hemorrhage, Torsion of Pedunculated Fibroid
Endometriosis & Cx: Related to Menstrual Cycle (Dysmenorrhea during Period),
Rupture/Torsion of Endometriotic Cyst (Chocolate Cyst in Ovary)
Ovarian/Uterine CA & Cx
Others: Abdominal wall (Hernia, etc), Retroperitoneal structure (Soft tissue, Vessels, Nerves, etc),
Upper Abdomen (PPU with GI content tracked down)
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Causes by Timing:
Acute:
Common Causes:
GI: Non-Specific Abd Pain, Appendicitis & Cx,
Mesenteric Adenitis, GE, Intussusception (in Children), Cx (IO/Perforation) of Colorectal CA,
Meckels Diverticulitis, Cecal Diverticulitis, Sigmoid Diverticulitis, Sigmoid Volvulus
Uro: LUTI, Ureteric Obstruction (Stone), AROU
OG: Ectopic Pregnancy (Not Commonest but Life-Threatening)
Other Pregnancy Cx (eg. Abortion/Threatened Abortion), Acute PID & Cx
Ovarian Cyst Cx, Endometriotic Cyst Cx,
Less Common Causes:
GI: Cx of Crohns disease, Cx of Ileocolic/Colorectal Infection (Typhoid, TB, Amoeba)
Uro: Other causes of Ureteric Obstruction (Neoplasm), Testicular Torsion, Acute Epididymo-Orchitis
OG: Cx of Uterine Fibroid, Cx of Uterine/Ovarian Malignancy
Recurrent Acute:
GI: Non-specific Abd Pain, Mesenteric Adenitis, Intussusception (Pathological Lead point),
Crohns Ileocolitis, Sigmoid Diverticulitis, Sigmoid Volvulus
Uro: LUTI, Ureteric Colic, AROU, Testicular Torsion
OG: Torsion of Ovarian Cyst, Torsion of Pedunculated Uterine Fibroid, Acute PID, Endometriosis & Cx
Subacute: GI: Non-specific Abd Pain, Crohns Ileocolitis, Specific GI infection (TB, Amoeba, Actinomycosis),
Small Bowel/Colorectal Malignancy
Uro: LUTI by Parasites/TB, Ureteric Colic/LUTI due to TCC of LUT
OG: Uterine/Ovarian Malignancy, Endometriosis, PID, Ovarian cyst, Uterine fibroid
Chronic: GI: Non-specific Abd Pain, Crohns Ileocolitis
OG: Chronic PID, Endometriosis
PE: GE: Body Temp (Infection)
Vital Signs BP & Pulse (Tachycardia due to Infection, Septic/Hypovolemic Shock)
Pallor, Nutritional status
Cervical LN (esp Left, for Malignancy)
Abd Exam: Inspection: Distention, Mass
Palpation: Sign of Peritonitis, Mass
Percussion: Ascites
Auscultation: Bowel Sound, Fetal Heart Sound
Other: PR, PV Speculum, Doppler US/Doptone (Fetal Heartbeat)
Ix: Blood Test: Hb/WBC/Hct: (Hb may be High in Early Ectopic Pregnancy)
Electrolyte: (Imbalance in Vomiting, Diarrhea)
RFT: (Even Normal RFT Cant exclude Urological causes)
Type & Screen
Optional: Amylase, ABG, Coagulation profile, LFT, Tumor Markers
Urine: Pregnancy Test: (Can be weakly +ve in Ectopic Pregnancy)
MSU: Routine & Microscopy (Urinalysis), Culture & Sensitivity
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EMU: For TB
Urine Cytology
Microbiology: Stool, Vaginal Swab (exclude PID), Blood (exclude Septicemia if High Fever)
Plain X-ray: KUB: Stone
AXR (E&S): >3 Air-fluid level: IO (Mechanical obstruction or Ileus, ddx by Auscultation)
Coffee Bean Sign: Sigmoid Volvulus
CXR (Erect): Perforated Viscus Free gas below Diaphragm
US: Hydronephrosis, Ovarian Cyst, Intussusception (Bulls Eye Sign)
CT: Sigmoid Diverticulitis, GI Abscess, Pelvic Abscess
Contrast Study: Barium Enema: Do Not use in Acute Pain (can lead to Barium Peritonitis)
Look for Diverticulum, Stricture, Intussusception
IVU: Proximal Dilatation of Proximal Pelvicalyceal system due to Stone
Endoscopy: Sigmoidoscopy/Colonoscopy: Sigmoid Volvulus (can do Decompression), Colorectal Cancer
Contraindicated in Peritonitis or Suspected Bowel Perforation
Laparoscopy: Can be both Diagnostic & Therapeutic; Useful for Unstable Pt
Mx Plan: Hx/PE/Ix> Resuscitation > Conservative Tx > Discharge
> Further Ix> Medical Tx, Elective Surgery
> Emergency Op/Intervention
Resuscitation: IV Fluid Blood product replacement, O2, Correct Electrolyte & Acid-base Imbalance,
IV Antibiotics after Culture if Septicemia,
Close Monitoring for Vital (Hourly BP/P, Urine Output CVP), Correct Underlying Cause
When: Unstable Hemodynamics due to:
Hemorrhagic Shock: Eg. Ectopic Pregnancy
Hypovolemic Shock: Severe Vomiting Diarrhea without adequate Fluid Replacement
Eg. IO, Severe GE
Septic Shock: Any Infective condition with Septicemia/Perforated Viscus/Abscess
Emergency:
Non-Op: UnCx Intussusception: Hydrostatic Reduction (in Children) under US guidance
UnCx Sigmoid Volvulus: Sigmoidoscopic Decompression Rectal Tube Insertion
Op: Meckels Diverticulitis: Diverticulectomy Small bowel Resection
Appendicitis: Appendicectomy (+ Drainage if Abscess)
Small Bowel/Ileocolic Perforation due to GI Infection:
SB/Ileocolic Resection & Anastomosis (+ Drainage if Abscess)
Crohns with Perforation/Abscess: Abscess Drainage, Small Bowel Resection Anastomosis
Cecal Diverticulitis: Cecal Diverticulectomy IleoCecectomy & Anastomosis
Intussusception (Failed Hydrostatic Reduction or with Cx): Sigmoid Resection & Colostomy
Sigmoid Volvulus (Failed Endoscopic Reduction or with Cx): Sigmoid Resection & Colostomy
Sigmoid Diverticulitis (Failed Initial Antibiotics, Perforation): Sigmoid Resection & Colostomy
CRC with Acute IO: Resection Anastomosis
Testicular Torsion: Orchidopexy Orchidectomy (Orchidopexy for Contralateral Testis too)
Ectopic Pregnancy: Salpingectomy
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Abortion: Suction & Evacuation
Torsion/Hemorrhagic Ovarian Cyst: Ovarian Cystectomy Oophorectomy
Torsion/Hemorrhagic Uterine Fibroid: Myomectomy
Cx Endometriotic Cyst: Cystectomy
PID with Abscess: Drainage of Tubo-ovarian Abscess
Others PPU: Patch Repair or Gastrectomy
Medical Tx: Crohns disease: 5-ASA (Mesalazine), Steroid
GE: Rehydration Antibiotics
Specific GI Infection: Antibiotics or Anti-TB Tx
st
UnCx 1 episode of Sigmoid Diverticulitis: Antibiotics
Non-Specific Abdominal Pain
UTI: Antibiotics (Recurrent UTI: Ix for underlying cause)
Acute Epididymo-Orchitis: Antibiotics
PID: Antibiotics
Threatened Abortion
Elective Surgery: Appendiceal Mass: Antibiotics
Interval Appendicectomy Controversial (Lecturer prefer Not to do)
Chance of 2nd episode is Rare
CRC: Resection & Anastomosis
Recurrent Sigmoid Diverticulitis: Sigmoid Resection & Anastomosis
Ureteric Colic due to:
Calculus: Spontaneous Passage, Endoscopic Removal,
ESWL (Extracorporeal Shock Wave Lithotripsy), Open Surgery
TCC: Resection
AROU due to BPH, CA Prostate, Urethral Stricture, Urethral Stone
Ovarian Cyst: Cystectomy
Uterine Fibroid: Myomectomy/Hysterectomy
Endometriotic Cyst: Cystectomy THBSO
(Total Hysterectomy with Bilateral Salpingo-Oophorectomy)
Ovarian/Uterine CA: Resection
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Summary Table:
Causes Acute Acute Recurrent Subacute Chronic
NSAP +
Meckels + Cx Ectopic mucosa Ectopic mucosa
Mesenteric Adenitis +
Appendicitis & Cx +
Crohns disease + Cx + +
Acute GE +
TB + Cx
Typhoid + Cx
Actinomycosis +
Amoeba + Cx
CRC + Cx
Cecal Diverticulitis & Cx +
Intussusception + & Cx
Sigmoid Volvulus + & Cx +
UTI (Bacterial) +
UTI (TB, Schistosomiasis) +
Ureteric Stone
+
Ureteric/Bladder TCC
AROU
Testicular Torsion +
Acute Epididymo-Orchitis
Ectopic Pregnancy +
Abortion/Threatened +
PID + & Cx +
Ovarian Cyst + Cx +

Uterine Fibroid + Cx +
Endometriosis + Cx +
Ovarian/Uterine Cancer + Cx +

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Appendicitis
Pathophysiology: Obstruction of Appendiceal lumen> Intraluminal Pressure
> Continuous secretion of Fluids & Mucus from mucosa & Stagnation of this material
> Intestinal Bacteria within Appendix multiply
> Recruitment of WBC & Formation of Pus> Subsequent Higher Intraluminal Pressure
> Ultimately leading to Venous outflow obstruction
> Appendiceal wall Ischemia> Loss of Epithelial integrity allowing Bacterial Invasion of wall
Within a few hours, this localized condition may worsen due to Thrombosis of Appendicular BV
> Perforation & Gangrene of Appendix> PeriAppendicular Abscess/Peritonitis
2003 MCQ 47: Can occur in Non-obstructed Appendix too
Cause: Lymphoid Hyperplasia secondary to IBD/Infection (Childhood/Young Adults)
Fecal stasis & Fecaliths (Elderly) (Also can be due to Scarring)
Parasites (esp Eastern countries)
Rarely Foreign bodies/Neoplasms (Asso. with CA Cecum but Rare)
Hx: Classic Hx of Anorexia & Periumbilical Pain followed by Nausea, RLQ Pain & Vomiting
occurs in only 50% of cases
Nausea & Anorexia are common but Non-specific
Vomiting if occurs must be after onset of Pain (cf IO)
Diarrhea/Constipation may occur in 18% Pt (Not Sensitive/Specific)
Abd Pain: Most common Sx
Typically begin as Periumbilical/Epigastric Pain, migrating to RLQ
Pt usually lie down, flex hips, and draw knees up to movement (Fetal position)
Inflamed Appendix near UB/Ureter can cause Irritative Voiding Sx & Hematuria/Pyuria
PE: Rebound Tenderness, Pain on Percussion, Rigidity, Guarding
Accessory Signs:
Rovsing sign:
RLQ Pain with Palpation of LLQ
Suggests Peritoneal irritation in RLQ precipitated by Palpation at remote location
Obturator sign:
RLQ Pain with IR & ER of Flexed Right Hip
Suggests that Inflamed Appendix is located deep in Right hemipelvis
Psoas sign:
RLQ Pain with Extension of Right Hip or with Flexion of Right Hip against Resistance
Suggests that Inflamed Appendix is located along the course of Right Psoas muscle
ie. Retroperitoneal/Retrocecal
(Dunphy sign):
Sharp Pain in RLQ elicited by Voluntary Cough
May be helpful in making Clinical Dx of Localized Peritonitis
Similarly, RLQ Pain in response to Percussion of remote quadrant of abdomen,
or to Firm percussion of Pt heel, suggests Peritoneal inflammation
(Markle sign):
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Pain elicited in a certain area of abdomen
when Standing Pt drops from Standing on Toes to Heels with a jarring landing
DRE: No evidence of useful info in evaluation
But Failure to perform DRE is frequently cited in successful malpractice claims
Appendicitis & Pregnancy:
During Pregnancy, Appendix migrates in Counterclockwise direction toward Right Kidney
Rise above Iliac crest at ~4.5 months gestation
RLQ Pain dominate in 1st trimester, RUQ/Right Flank Pain may occur in Latter half of Pregnancy
Nausea/Vomiting & Anorexia are common in pregnancy in 1st trimester,
But their appearance in Later gestation should raise suspicion
Ix: CBC & DC: WBC, Neutrophilia
CRP
Urinalysis
Pregnancy Test: Rule out Ectopic Pregnancy in Young women
US: May be used as Primary Diagnostic Modality (To confirm but Not exclude Acute Appendicitis)
Esp in Paediatric Pt with concern of Exposure to Radiation
Features: Thickened & Fluid filled Appendix

Fecalith Hyperechoic with Acoustic shadow
CT: Most important Imaging
Can also show Appendiceal Abscess
May see Pericecal Mass with Fluid, Thickened Appendix wall, Infiltration of Mesenteric Fat

Tx: NPO, IV access & Fluid for Dehydration/Sepsis
Analgesic & AntiEmetic
IV Antibiotics (2004 MCQ 81: Cephalosporin)
Appendicitis: Appendectomy
*Laparoscopic
Open: Gridiron incision, Others (Rutherford-Morrison (extension), Lanz, Battle (rare))
Appendiceal Mass:
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Pt with Phlegmon/Small Abscess:
After IV Antibiotic, Interval Appendectomy can be performed 4-6 weeks later
(NB: Whether doing Interval Appendectomy or Not is Controversial)
Pt with Larger well-defined Abscess:
After Percutaneous drainage with IV Antibiotics, can be discharged with Catheter in place
Interval Appendectomy can be performed after Fistula is closed
Pt with Multicompartmental Abscess:
Require Early Surgical Drainage
NB: If Abscess is in Pelvis, Transrectal drainage is a good option (2005 MCQ 4)

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GI Intestinal Obstruction
IO: Dynamic obstruction vs Adynamic obstruction
Mechanical Obstruction:
Physical barrier to Aboral progress of intestinal contents
Ileus: Failure of Peristalsis to Propel Intestinal contents with No Mechanical barrier
(NB: In the old days, Ileus is a general term of Disruption to Peristalsis
Nowadays Ileus is specific to Paralytic Ileus
Gallstone Ileus & Meconium Ileus are Misnomers now)
(NB 2: Pseudo-obstruction & Mesenteric Vascular Occlusion also cause Adynamic IO
Peristalsis is present (Not Paralytic), but in Non-propulsive form)
Mechanical Bowel Obstruction
Pathophysiology: Proximal bowel Distention with Gas & Fluid
Gas: Swallowed Air, Gas production from Bacteria
Fluid: GI Secretions; Bowel dilation also secretory activity> Hypersecretion
Altered Motility Accumulation of secretions Peristalsis both Above & Below obstruction
Below: Peristalsis lead to Frequent Loose Stools & Flatus early in the course
Above: Initially: Peristalsis try to overcome obstruction
Eventually: Dilate> Peristaltic strength> Flaccidity & Paralysis
Dehydration & Electrolyte disturbance
Hypersecretion, Loss of fluid to Extracellular space & Peritoneal cavity
Bacterial Overgrowth
Gas production
Eventually can transmigrate through Gangrenous bowel to cause Peritonitis/Septic Shock
Compromise Blood supply> Necrosis & Perforation of bowel
Tension> Venous Congestion> Bowel wall Edema> Capillary Rupture/Hemorrhage
(Accelerated in Close loop/Strangulating Obstruction)
Volvulus & Intussusception can cause Arterial compromise> Faster Gangrene
Classification:
By Degree: Partial/Incomplete (usually due to Adhesion) vs Complete obstruction
By Onset: Acute: Usually in SBO
Sudden onset of Severe Colicky Central Abd Pain & Distension,
Early Vomiting & Constipation
Chronic: Usually LBO
Lower Abd Colic & Absolute Constipation followed by Distension
(AoC: Short Hx of Distension & Vomiting against background of Pain & Constipation)
(Subacute: Imply Incomplete obstruction)
By Cause: Intraluminal, Intramural, Extrinsic
By Site: *Small bowel obstruction (SBO) vs Large bowel obstruction (LBO)
By Blood Supply:
Simple obstruction:
Obstruction of Lumen, usually at 1 point only; (Usually Adhesion, Tumor, Stricture)
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Strangulating obstruction: Blood supply to Bowel Impaired (Emergency)
Cause: Primary: Mesenteric Infarction
Secondary: External: Interperitoneal Adhesions/Bands, Hernial Rings
Interrupted Blood flow: Volvulus, Intussusception
Intraluminal Pressure: Closed Loop obstruction
Closed Loop obstruction:
Lumen Occlusion in at least 2 points; (Can be seen in Hernia/Adhesions/Volvulus?)
Classically seen in LBO with competent Ileocecal valve
Can lead to Strangulation/Perforation> Emergency
(Perforation is most likely at Cecum, due to Laplace law)
Cause: By Age
By Site
By Obstruction Mechanism
Clinical:
4 Cardinal Sx: Colicky Abd Pain, Abd Distention, Nausea/Vomiting, (Absolute) Constipation
Pain: Paroxysms of 4-8 min intervals, Less frequent in Distal obstruction
Centre in SBO while Lower abdomen in LBO
With ing Distension, may become Mild Constant Diffuse Pain
Severe Persistent Pain may indicate Strangulation
Pain may Not be significant in Post-op Simple obstruction & Paralytic Ileus
Vomiting: More common in Proximal obstruction (May even be the only Sx in Gastric outlet obstruction)
Vomitus: Bilious in Proximal (if distal to Ampulla of Vater) (Greenish)
Feculent in Distal (Distal Small bowel & Large Bowel)
(Feculent: Foul Smelling Vomitus due to Fermentation by Bacteria
=/= Feces; True Fecal Vomiting only occur with Fistula)
Timing: Jejunum: Early & Persistent
Ileum: Recurrent, initially Bilious, later Feculent (Enteric Bacteria overgrowth)
LBO: Late feature
Distension: The more Distal, the Higher degree of distension
Visible Peristalsis may be present in SBO
Constipation:
Absolute: Neither Feces nor Flatus is passed
Cardinal feature of Complete obstruction
Relative: Only Flatus is passed (esp if obstruction is High)
Note some Pt may pass Flatus/Feces after Onset of obstruction,
due to Evacuation of Distal bowel contents
(Constipation may be Absent in:
Richters Hernia, Gallstone Obturation, Mesenteric Vascular Occlusion,
Obstruction asso with Pelvic Abscess,
Partial obstruction (Fecal Impaction/Colonic CA; often Diarrhea))
Severity depends on Site:
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High Small Bowel: Early Profuse Vomiting with Rapid Dehydration
Minimal Abd Distension (Little Fluid level on AXR)
Low Small Bowel: Pain is predominant, with Central Distension
Vomiting is delayed
Large Bowel: Early Pronounced Distension
Mild Pain, Late Vomiting & Dehydration
Signs:
Bowel sound: Initially Hyperactive, eventually as it becomes Hypotonic, or Gangrene
Visible Peristalsis
Dehydration: *SBO, due to repeated Vomiting & Fluid Sequestration (3rd space)
DRE: Empty
Hard stool (Fecal impaction)
Rectal Mass (Rectal Cancer)
Grossly Spacious (Functional, eg. Pseudo-obstruction)
Others:
Fever: May indicate Onset of Ischemia, Intestinal Perforation,
or Inflammation associated with the disease causing IO
Peritoneal Signs:
May Indicate Infarction/Perforation
Cx: Bowel Strangulation, Bowel Perforation, Electrolyte disturbance, Aspiration Pneumonia
HypoK: Not common; Usually Proximal obstruction
Vomiting: Dehydration
HypoK
HypoCl Metabolic Alkalosis with paradoxical Aciduria
Note if K, Amylase & LDH, may associate with Strangulation
Features of Strangulation: (2015 SAQ 11)
Clinical: Sharper Constant Pain, Peritoneal Signs/Shock, Tachycardia, Fever & WBC,
Blood in Vomitus/Stool, (K, Amylase, LDH), (Metabolic Acidosis)
(If in External Hernia: Tense Tender Irreducible lump with No Cough impulse)
(If Localized RLQ Pain, think Closed Loop obstruction> Impending Cecal Ischemia & Perforation)
Imaging: Thumbprinting, Loss of Mucosal pattern,
Gas within Bowel wall or Intrahepatic branches of Portal Vein may be seen
Past Hx: Previous episodes of IO
Previous Abd/Pelvic operation
Hx of Cancer or Abd/Pelvic Radiation
Hx of Abd Inflammatory condition
(Others: Fever (Infection/Strangulation), Changing Bowel Habits (eg. CRC), Flatus,
Rectal Bleeding, Dietary Habits (Fibre - Diverticulosis/CRC), etc)
PE: Assessment of Vital signs & Hydration status
Abd Exam: Surgical Scars, External Hernia, Abd Mass, Peritoneal Signs, Auscultation
(Rmb to assess Groin area in Abd Exam!)
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DRE: Feel for any Mass, Stool impaction
Lab Test:
CBC: Neoplasm may cause Anemia; WBC may indicate Infection/Sepsis
Electrolytes: Loss of Electrolytes, esp in Vomiting
ABG: Metabolic Acidosis (Usually signify Bowel Ischemia), Metabolic Alkalosis (Vomiting)
RFT: Hydration status (Urea/Creatinine will be High)
Amylase: (Rule out Pancreatitis/Pancreatic Irritation)
Imaging:
CXR (Erect): Exclude Perforation with PneumoPeritoneum
Resp Cx: Aspiration Pneumonia due to Vomiting
Atelectasis/Lung Collapse due to Abd distension
AXR (S&E): Supine film for Gas pattern, Erect film for Air-Fluid level
(Supine film is more important as Bowel lie flat & best view of Gas pattern)
Dilated Bowel Loops:
Size: Small bowel: >3 cm
Large bowel: >6 cm
Cecum: >9 cm (Risk of Closed loop obstruction> Indication for Surgery)
Pattern: Jejunum: Central, Pronounced Valvulae conniventes (Concertina effect)
Distal Ileum: No characteristics
Cecum: Rounded gas shadow in Right Iliac fossa (No Haustrations)
Large Bowel: Few Peripheral Loops
Haustral folds: Do Not cross whole lumen
(Spaced Irregularly)
(Indentations Not opposite to each other)
Air Fluid levels present in Erect film:
Normal: Up to 3 Fluid level seen: Fundus of stomach, Duodenum cap, Terminal Ileum
IO: >3 Fluid level in Adults likely IO (>5 in Children)
(May be Absent in Proximal SBO)
Gas in Colon & Level of cut off:
SBO: No Colonic gas
LBO: Cecal gas present, but No Rectal gas
Evidence of Strangulation:
Thumb Printing
Pneumatosis Cystoides Intestinalis (Gas Cyst in Bowel Wall; Due to Gas Gangrene)
Free Peritoneal Gas?
Any Massive Dilatation of Colon
Any Air in Biliary Tree (CholecystoEnteric Fistula> Gallstone Ileus)
Contrast CT: More Sensitive than Plain AXR
Level of Obstruction (Transition between Dilated & Collapsed Loop)
Lesions (eg. Tumor, Foreign bodies)
Viability of Bowel: IV Contrast taken up by Bowel wall: Viable (2015 SAQ 11)
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Reduced Contrast Enhancement: Suspect Bowel Ischemia
SBO: Some Controversy on use:
Adhesive IO can just treat conservatively to see if will improve
Strangulated Inguinal Hernia needs Urgent OT rather than CT
Usually do in Virgin Abdomen, but will operate anyway
Common Indication: Suspicious of Non-adhesive cause
Detect Cx
LBO: Useful if Colonoscopy fails to locate Obstructive tumor
Staging
Contrast Study: Water soluble Contrast (Gastrografin) Follow-through (SBO) or Enema (LBO)
Differentiate Complete & Partial Obstruction
(UCH: If by 4h on Serial AXR, Contrast has reached Large bowel
Its likely a Subacute IO with Partial obstruction which will likely resolve)
(Water soluble Contrast Enema in LBO can help ddx Mechanical & Pseudo-obstruction)
? Therapeutic effect (Hyperosmolar effect> May resolve Partial Obstruction)
Dont do Barium study: Precipitate Complete Obstruction, Barium Peritonitis
Endoscopy: Usually Contraindicated May aggravate IO & Risk of Bowel perforation
Exception: For decompression in Volvulus & Pseudo-obstruction
For Obstructing CRC: Localization of Obstructive tumor
Exclude Synchronous tumor/polyps distal to obstruction
Stenting
Can be used to investigate for underlying causes after IO resolved

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GI Mechanical SBO
Etiology Adult causes distinguished into 3 categories for different Mx:
Adhesion: Usually Conservative
External Hernia
Virgin Abdomen without External Hernia: Usually need Laparotomy
1. *Adhesion: Hx of Abd Surgery (Less common after Laparoscopic Surgery):
Appendectomy, Colorectal Surgery, Cholecystectomy, Gastroduodenal Surgery,
Gynecological Surgery
2. External Hernia: (Most common cause of SBO in Virgin abdomen (Not opened up before))
Inguinal Hernia, Femoral Hernia, Paraumbilical Hernia
Incisional Hernia: Requires Laparotomy
3. Virgin Abdomen without External Hernia: (Difficult & No point to think Usually need Laparotomy anyway)
Intraluminal:
Bezoar: Food Bolus: Usually in Elderly
PhytoBezoar: Indigestible Plant material
Usually after previous Gastric Surgery (Impaired Digestion/Motility)
(2012 MCQ 40) (2007 MCQ 44)
TrichoBezoar: Hair Ball; Usually in Psychiatric Pt
LactoBezoar: Inspissated Milk; Usually in Premature Infants receiving Formula Milk
PharmacoBezoar: Usually in Overdose of Sustained-release drugs
Foreign body
Gallstone
Parasite: Eg. Ascaris, Tape worms, esp after giving AntiHelminthic; Worms Uncommon in HK now
Intramural:
Tumor: Not so common
Primary: Small bowel tumor: Lymphoma (Commonest SB Malignancy), GIST, CA
(NB: IO in SB Lymphoma is Uncommon, due to Lack of Desmoplastic reaction)
Cecum CA (commonest, but actually Large bowel lesion)
Secondary
Benign Stricture:
Crohns disease, Radiation Enteritis, Anastomotic, (Drug-induced)
Intussusception
Extrinsic: (For Extrinsic Causes of SBO, Adhesion & External Hernia are more common)
Internal Hernia:
Eg. Obturators Hernia:
Usually Female, esp Multiparous/Elderly (2012 MCQ 40)
May asso. with Pain on Hip movement; May have Howship-Romberg sign on PE

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Congenital Adhesion band (between Meckels diverticulum & Umbilicus)
Volvulus
Extrinsic Mass: Lymphoma/LN metastasis, Peritoneal Carcinomatosis, etc
(SMA syndrome: Duodenum compressed by SMA; Rare)
Adhesive Obstruction:
Most common Cause of SBO in Developed countries
Usually Clinical features of SBO with Previous Abdominal Surgery (Usually Intraperitoneal)
Hx of Abd Surgery does Not mean Pt can only have Adhesive IO
Think more if Pt has: Recurrent SBO
Anemia (may indicate Tumor)
Previous Gastrectomy/Incomplete Denture (think Bezoar)
Cause: Congenital, Post-Inflammation, Formed after Abdominal Surgery
Prevention: Gentle handling of bowel during Surgery
Removal of Powder from Gloves
? use Saline Lavage
Sodium Hyaluronate Bioresorbable Membrane (Seprafilm):
Not used commonly: Expensive, also Minimal Invasive Surgery can avoid Adhesion
Use in Pt with Multiple surgeries before
Tx: Non-Op Tx Success Rate: 50% (HK Choi: Resolution in Adhesive IO with Gastrografin is 70%)
Indication for Surgery: Non-Responsive to Conservative Tx, Clinical features of Strangulation
Algorithm: Trial Conservative Tx
Gastrografin meal & follow-through if No response to Conservative Tx within 48h:
Gastrografin draws water from bowel> Cause bowel distension, force open obstructed site
May help to overcome obstruction for some Pt
Serial X-ray See Contrast goes down eventually
Limitations: Does Not help for Complete obstruction (Need Operation)
May sometimes worsen Sx but Never perforate; Ryles tube relieves fluid
Surgical Tx:
Presence of Cx
Suspicion of Bowel Strangulation or Gastrografin shows Complete obstruction
Enterolysis Bowel resection
Suspicion of cause Not by Adhesion
Controversy:
Duration of Conservative Tx (QMH: ~48h)
Admin of Water Soluble Contrast: (Adopted in QMH)
Differentiate Partial from Complete Obstruction
Therapeutic effect? Operating rate?
Shorten Hospital Stay
Mx: Urgent Surgery vs Conservative Tx
Indication for Urgent Surgery:
Incarcerated/Strangulated Hernia, Suspected/Proven Strangulation, Peritonitis,
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PneumoPeritoneum, Pneumatosis Cystoides Intestinalis, Closed Loop Obstruction,
Volvulus with Peritoneal Signs
Conservative Tx: For Partial Obstruction: Adhesion, Crohns disease, Radiation Stricture, Disseminated Cancer
(Also indicated in Ileocecal Intussusception, Sigmoid Volvulus, Fecal Impaction)
NPO
Drip & Suck: IV Fluid & Electrolytes
Nasogastric Decompression (Hazard of Vomitus Aspiration, Distension)
(Foley to monitor Urine output)
Antibiotics may be given if suspect Perforation, or as preparation for Surgery
Nutrition when prolonged Fasting is anticipated
Frequent Monitor of Vital signs, Abdominal signs & X-rays
Resolution of Obstruction:
Less Abdominal Distention, Nasogastric Output, Passage of Flatus & Bowel movement,
Resolution in AXR
Unresolved Obstruction: Surgical Tx (Duration of Conservative Tx Controversial, usually 48h)
Surgery Laparotomy:
Enterolysis (Lysis of Adhesions & Release of Constricting Bands)
Hernia Repair
(May be done in Local Exploration without a need for Laparotomy if bowel seems viable)
Foreign bodies (Bezoars, Gallstones): Break down & push to Colon, Enterotomy & Removal
Stricturoplasty
Bowel Resection: Strangulation with Gangrenous bowel, Unhealthy bowel
Bypass
(UCH: Indicated: Complete obstruction
Strangulation
Virgin Abdomen Except due to External Hernia
Adhesive IO failed to resolve <48h
Outline: Assess Site & Cause of obstruction
Assess Viability of bowel (Pink, Peristalsis, Pulsation of Mesenteric)
If doubtful, use Warm Saline packing for 30min to see if viable again
Surgical Intervention)
Prognosis: Mortality: Non-Strangulating Obstruction: 2%
Strangulating Obstruction: 10-30%

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GI Mechanical LBO
About 15% of IO; Usually at Sigmoid Colon
A lesion at Ileocecal Valve present as Small Bowel Obstruction
Competence of Ileocecal Valve determine Clinical features of Distal Colon Obstruction
Competent Ileocecal Valve can cause Closed Loop Obstruction
Competent Incompetent
(CEA may Not in Early CRC; Usually in Metastasis, as CEA escapes from Portal circulation)
Cause: Top 3: *Neoplasm (90%), Volvulus, Diverticulitis (Stricture, Abscess)
Others: Intraluminal: Fecal Impaction
Intramural: Other Strictures: Anastomotic, Radiation, Ischemic, IBD, Endometriotic
Intussusception
Extrinsic: Metastasis, Pelvic/ExtraPeritoneal Tumor
Pseudo-obstruction
Mx Principles (UCH tutorial):
General approach:
Assess Cause & Location of obstruction
Assess Bowel Viability esp Cecum
(Chance of developing Closed loop obstruction if Cecum Not viable)
Bowel decompression
Indication for Laparotomy:
IO Not resolved, Cx, Closed loop obstruction

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Obstructing CRC:
10-20% Pt with CRC present with IO
Characteristics: More Advanced CA, Elderly with Comorbidity, High Op M&M, Worse Prognosis (2011 MCQ 11)
Site: Sigmoid & Descending Colon: 58%
Ascending & Transverse Colon: 38%
Rectum: 4%
Right side CA: Right colon has Wider Diameter (~2.5x Left colon) & Fluid Fecal content> Less IO
Tumor may grow Large> 10% cases may have palpable Mass
Anemia is common, as well as Constitutional Sx
Left side CA: Often present with IO
Change in Bowel habit Excessive Mucus secretion & Diarrhea may follow Constipation
Palpable Mass often Not Tumor itself but Impacted feces
May complain of Blood & Mucus in stool
RectoSigmoid: May give Tenesmus
Mx: Resuscitation
Dx: Clinical, AXR, CT, Sigmoidoscopy/Colonoscopy, Contrast Enema
Lower GI Endoscopy:
Diagnostic
Therapeutic: Decompression in Sigmoid Volvulus & Pseudo-obstruction, Stenting
Caution: Avoid Excessive Insufflation of Gas (May cause Perforation) (2010 SAQ 8)
CT: IV Contrast, Rectal Contrast
Site of Obstruction (Transition of Dilated Loop & Collapsed Loop)
Mass lesion
Perfusion of Bowel wall
Distant disease in case of Malignancy
Non-op Tx Insertion of Metallic Stent: (Usually tried before resorting to Stoma/Bypass in Non-operable)
Made of Metal Alloys
Self Expanding Mechanism (up to 22 mm diameter on full expansion)
Insert & Deploy under Endoscopic/Fluoroscopic guidance (Usually use both together nowadays)
Site: Most applicable to Descending & RectoSigmoid colon obstructive tumor (ie. Left-sided CA)
Rationale: High Risk of Stent Migration if too Proximal/Distal
R-sided: Benefit of Bridging to Surgery Not as great as in Left-sided CA
Lower Rectum: May induce Tenesmus
Use: Bridge to Surgery: (2010 SAQ 8)
Avoid/Delay Emergency Surgery, Elective Operation with Bowel Preparation,
More time to Stage the disease, Lower Operative M&M,
Stoma rate
Definitive Palliation (Unresectable, Metastatic disease):
Avoid Surgery, Avoid Stoma
(UCH: Can be Prophylactic in Locally advanced CA to prevent Acute IO after ChemoRT)
Contraindications:
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Peritonism:
Concern of Gangrene/Perforation
Does Not help with Relief of obstruction
Need proper exam of Proximal bowel
Distal Rectal Cancer (<8 cm to Anal verge): (2013 MCQ 48)
Distal end of Stent will be close to Anal canal> Discomfort & Tenesmus> Pt dont tolerate
Benign Stricture (relative):
Stent Not planned to be removed unless Resection done
Chance of Perforation Higher
If Tumor, bowel wall thickened; If Benign, bowel wall may Not be thick/strong
Surgery: Resection: Primary Anastomosis, Without Anastomosis
Non-Resection: Proximal Diverting Stoma
Bypass (eg. IleoTransverse Bypass for Right-sided obstruction)
(IleoSigmoid Bypass for Left-sided obstruction Not so preferable
Blind loop is too Long)
Determinant of Procedures:
Pt Factors: GC & Nutritional status, Hemodynamic status, Any Sepsis
Condition of Remaining bowel
Tumor Factors: Site of lesion (Right Colon vs Left Colon vs Rectum)
Invasion to adjacent structures
Any Perforation/Contamination of Peritoneal cavity
Surgeon Factors: Experience in Bowel Resection & Anastomosis in Emergency
1. Right-sided Obstruction (Cecum to Splenic Flexure):
Resectable:
Pt Stable: Mostly Resection & Anastomosis (Right/Extended Right Colectomy)
(Mortality 17%, Anastomotic Leakage 10% (6% in Elective surgery))
Pt/Bowel condition Not Favorable:
Resection without Anastomosis
(UCH: Ileocolostomy only if Pt unstable or severely contaminated Peritoneal cavity)
Non-Resectable (eg. Duodenal/Ureter Invasion):
Stoma (Loop Ileostomy) (or Colostomy if competent valve?)
Bypass (IleoTransverse Bypass)
2. Left-sided Obstruction (Distal to Splenic Flexure):
Factors to consider:
Competence of Ileocecal valve (Closed Loop Obstruction> Perforation)
Heavy Bacterial & Fecal load in Proximal Colon
Edematous Unhealthy Proximal Colon
Poor GC of Pt: Malignancy & Malnutrition, Dehydration
Primary Anastomosis is Risky (Fecal Peritonitis)
LB-LB anastomosis in Left-sided lesion (cf SB-LB in Right-sided lesion)
SB has more abundant & predictable blood supply than LB
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Dilated LB proximal to obstruction is Edematous
Colonic vs Rectal tumors:
Colonic tumors: Mostly Resectable
Rectal tumors: Emergency LAR very difficult & Not advised
If Rectal tumor can cause obstruction, likely Locally Advanced Rectal CA
Need Neoadjuvant ChemoRT before Surgery
Decompress with Stoma pre-op too
3-stage: (Oldest technique; Not commonly performed now)
Defunctioning (Transverse) Colostomy (Diversion before Staged Resection)
Resection & Anastomosis
Closure of Colostomy
Pros: Short 1st operation, Most Conservative for Frail Pt, Lowest risk of Leakage
Cons: Multiple operations, LT Survival cf Primary Resection, Mortality 20%
Indication: Very ill pt, Local Invasion, Obstructive Rectal CA
2-stage: Primary Resection without Anastomosis + Stoma
Re-anastomosis & Closure of Stoma
Resection with End Colostomy (Hartmann)

Usually Hartmanns procedure, then Reverse Stoma with Anastomosis
Paul-Mikulicz procedure to create Double Barrel Stoma is Uncommon
Pros: Vs 3-stage: Shorter Hospital stay, Early Removal of tumor
Vs 1-stage: Anastomotic Risk in stage 1 of the operation
nd
Cons: 2 operation (Re-anastomosis) may be difficult, Some may have Permanent Stoma
Up to 40% Pt did Not have Bowel continuity restored due to various reasons
1-stage: True 1-stage: Primary Resection & Anastomosis
In Reality: Often do Diversion Stoma to protect Anastomoses in Emergency
(ie. Primary Resection + Anastomosis + Stoma, then Close Stoma)
Pros: Avoidance of Stoma
Cons: Higher Anastomotic Leakage risk (4%)
Can Risk by on-table Lavage to mimic Bowel preparation
Longer operation; Mortality same as 2-stage (10%)
Type: Segmental Resection with Primary Anastomosis On table Lavage:
Segmental Resection: Left Hemicolectomy, Sigmoid Colectomy, Anterior Resection
On table Lavage: Tube into Cecum via Appendix, Instill Saline, Flush Stool out
Controversial/Optional:
? Safe Anastomosis, but No proof?
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Takes Extra Hour
Stoma: Easier & Higher chance to close than Hartmann
Pros: Less disturbance on Bowel motion
Cons: Time consuming, Complex procedure
Subtotal Colectomy with Anastomosis of Ileum & Distal Colon/Rectum: (2nd line)
Subtotal: Tumor + Colon Proximal to Tumor; Alternatively Total Colectomy
Pros: Remove Synchronous tumors
Metachronous tumors in Proximal colon
Safer Anastomosis
Cons: Frequency of Post-op Diarrhea (BO few times a day)
Higher Permanent Stoma rate
Usually indicated if with Perforated Cecum or Synchronous tumors
Prognosis of Emergency Surgery for Colonic Obstruction:
Mortality >10%: Comorbidity, Advanced Malignancy

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Volvulus
Twisting/Axial Rotation of a portion of bowel along its Mesenteric Axis
Can cause LBO (SBO if Cecal) with possible Impairment of Circulation
Site: Occur commonly at Sigmoid (65%) or Cecum (30%)
Typically attached to Long Floppy Mesentery Fixed to Retroperitoneum with Narrow Base
Others: Transverse Colon, IleoSigmoid Knotting
Cecal: F>M; Usually Clockwise
May present with Sx of SBO
(AXR: Gas-filled Ileum Distended Cecum)
(Mx Surgery: Decompress Cecum with Needle then reduce Volvulus
Fix Cecum to Right Iliac Fossa (Cecopexy) or Cecostomy)
Sigmoid: Usually Elderly Male; Nearly always Anti-Clockwise
Common in Asia due to High Fibre diet
1/3 Pt either have Mental illness or are Institutionalized:
Poor Mobility, Poor Bowel Function (Constipation)
> Stool accumulate & stretch Sigmoid
> Longer Mesentery, Redundant
> Prone for Sigmoid Colon to twist around it
(Common in Pt with Chronic Constipation with Laxative Abuse)
(Predisposing Factors: Band of Adhesion, Overloaded Pelvic Colon, Long Pelvic Mesocolon,
Narrow Attachment of Pelvic Mesocolon)
AXR: Dilated Sigmoid:
Coffee Bean Sign: Single Grossly distended Gas-filled loop of bowel arising from Pelvis
running diagonally across abdomen from R to L with 2 Fluid levels
Apex of Loop positioned High in abdomen
Inverted U sign: 3 dense curved lines (Walls of Enlarged loop) converge toward
Stenosis over Left part of Sacrum
Haustral markings usually Lost
(If Distended Ileal Loops in a Distended Sigmoid Compound Volvulus/IleoSigmoid Knotting)
Barium Enema: Birds Beak or Ace of Spade Sign (Less commonly seen now)

Tx: Non-op Tx: Sigmoidoscopic/Colonoscopic Decompression Flatus tube Insertion: (Successful rate 80%)
Scope pass around point of twisting (QMH: Do Colonoscopy; Sigmoidoscopy Not available)
Suck all gas out (Sigmoid loop decompressed)
Undo the kink when decompressed
Flatus tube: Often sudden Gush of Air/Fluid upon Decompression with Rectal Tube
Recurrence: 50%
(UCH: 90%; Early Surgical Intervention within same episode often considered)
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Surgical Resection:
Indication: Perforation: Indicated in Peritonitis
Strangulation: Colonoscopy shows Bowel Ischemia
Unhealthy Mucosa, No good for Decompression
Failed Decompression

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Intussusception
Occur when 1 portion of gut become Invaginated within an immediately adjacent segment
Proximal (Intussusceptum) over Distal (Intussuscipiens) bowel due to Peristalsis

Major cause of SBO in Children, Less common in Adults
In Children: Usually Idiopathic (No Pathological Lead Point identified)
May have preceding URTI/GE (Adenovirus/Rotavirus) (2004 MCQ 4)
(Enlarged Peyers Patch proposed to be a possible Lead point)
Usually Ileo-Cecal/Ileo-Colic (Distal Ileum into Cecum)
Tx by Pneumatic/Hydrostatic Reduction
In Adults: A lesion is usually found as Leading Point (80% cases due to Polypoid tumor)
Usually Ileo-Ileal (MIMS HK)
Surgery usually Indicated (Can recur if Not excised)
Clinical: IO
Rectal Bleeding (Red Currant Jelly Stool Stool mixed with Blood & Mucus) often Late sign
Exudation of Mucus & Blood due to Vascular compromise
Sausage-shaped Mass may be palpated (often RUQ)
(Concavity toward Umbilicus, that Harden on Palpation)
Dances Sign: Retraction of RLQ
Imaging:
AXR: Dilated Small bowel, Intussusceptum in RUQ (Like a Tumor)

US: PseudoKidney sign:
Longitudinal US appearance of Intussuscepted segment of bowel
Fat containing Mesentery which is dragged into Intussusception, containing BV,
is reminiscent of Renal hilum, with Renal parenchyma formed by Edematous bowel
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Crescent in a Doughnut sign/Target sign:
Transverse US appearance of Intussusception
Doughnut is formed by Concentric alternating Echogenic & Hypoechogenic bands
Echogenic bands are formed by Mucosa & Muscularis
Hypoechoic bands are formed by Submucosa
Crescent is formed by Mesentery which is dragged into Intussusception
Its naturally located at only 1 side of bowel> Forms a Crescent which is Echogenic
Its the Transverse equivalent of Pseudokidney sign

Central Ring: Lumen & Wall of Intussusceptum
Middle Ring: Mesenteric Fat
Outer Ring: 1 & 2 which are bowel wall of Intussusceptum & Intussuscipiens

Intussusception in Children can be reduced with Water under US control
Post-reduction Fluid filled bowel

Tx: Adult: Surgery (for Pathological Lead point)
Children: Hydrostatic Reduction

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GI Functional IO
Paralytic Ileus
Causes:
By Site (Lecturer):
Intraperitoneal: *Post-op, Peritonitis/Intra-Abdominal Abscess, Inflammatory/Infective condition,
Intestinal Ischemia
Retroperitoneal: Retroperitoneal Hematoma/Infection, Aortic/Spinal/Urological operations,
Pancreatitis
Extra-abdominal: Metabolic abnormalities: Electrolyte Imbalance (K, Ca), Sepsis, Uremia, HypoT,
Lead Poisoning, Porphyria
Medications: Opiates, AntiCholinergics, AntiHistamines, Catecholamines
Spinal Injury & Operation
Causes of Adynamic obstruction (another way of classification):
Congenital: Prematurity, Mucosal Enzyme deficiency, Neurovascular defects (eg. Hirschsprung)
Acquired Peritonitis, Retroperitoneal lesions, Chronic IO, Simple handling of Gut (eg. Laparotomy),
Drugs (eg. Opiate, Metoclopramide), Systemic (Electrolyte Imbalance, Sepsis, Toxemia),
Neurovascular defects (eg. Mesenteric Arterial Thrombosis)
Post-op Ileus: Temporary inhibition of GI motor function post-op
Usually after major Abdominal surgery, but can also occur after Extra-abdominal surgery
Involves all segments of gut, except Esophagus
Gastric & Small bowel motility return within 24-48h
Large bowel motility return within 72-96h
If prolonged Ileus, Look out for Cx or possible Mechanical obstruction
Eg. Intra-abd Sepsis with Anastomotic Leakage, Infected Hematoma
Clinical: Abdominal Distention, Constipation, Vomiting (Non-projectile),
Abdominal Pain: Diffuse, Constant & Less Severe (Usually even Absent)
Sluggish/Absent Bowel sounds
Clinical features associated with the cause
AXR: Diffuse Intestinal Gas, Rectal Gas present
Mx: Usually Conservative Mx
NPO, IV Fluid, Nasogastric Decompression, Identify & Treat Predisposing Cause
(Postop Ileus can be shortened with Thoracic Epidural LA
Non-opioid group Analgesic> Less Postop Ileus than Systemic Opioid-based Analgesic)
Monitor & Assess by Daily AXR & PE
(Need to consider Intra-abdominal Cx or underlying Mechanical cause if prolonged)
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Pseudo-Obstruction
Aka Ogilvies Syndrome
Massive Colon Dilatation in Absence of Mechanical Obstruction (but similar S/S)
Autonomic dysfunction (Imbalance): Sympathetic overactivity or Parasympathetic interruption
Motility (Colon), Distended Abdomen, Pain can be Absent/Mild
(In some the Ileum may be Hyperactive> thus can mimic Mechanical Obstruction)
(But in fact, although Peristalsis, they are in Non-propulsive form)
Can tell by difference of Bowel sounds, Dilation of bowel from Left to Right side
Cause: Usually associated with Bedridden Pt with Severe ExtraColonic diseases/Trauma:
Post-op, Trauma, Electrolytes disturbance, Sepsis, Cardiopulmonary diseases,
HypoT, NM disease
Surgical: Pelvic Surgery 15%, Trauma 11%, Orthopedic Surgery 7%, C-section 4%, CV Surgery 4%
Medical: Infection 10%, Cardiac disease 10%, Neurological disease 9%, Pulmonary disease 6%,
Metabolic disease (HypoK stop bowel from moving) 5%, Renal Failure 4%
Dx: (Dx by Exclusion; Must exclude Mechanical IO)
AXR: Severe Gaseous Distention of Colon (May see Large Rectal distension)
Water Soluble Contrast Enema: Can ddx PseudoObstruction & Mechanical Obstruction
Colonoscopy: Diagnostic + Therapeutic; (May see Gush of Air upon Decompression)
Mx: To exclude Mechanical Obstruction
Conservative Tx, Correct underlying conditions, NG tube feeding & Enemas
Drug: Neostigmine (Parasympathomimetic):
Slow dose Injection/Infusion
Beware of S/E esp Bradycardia; Atropine must be available
Guanethidine (Adrenergic Blocker)
Naloxone
Erythromycin
QMH: Not given as its only Transient; (Even give in other hospitals, usually Colonoscopy first)
Procedure: Colonoscopic Decompression Flatus Tube (Rectal tube) insertion
Surgery: Colostomy, Cecostomy (Only reason for use nowadays; For Recurrent cases (Bedbound Pt))
Stitch Cecum on Bowel wall Insert Catheter into it (Cecum is most gas-distended part)
(Relieve IO temporarily but Not dealing with underlying cause)
(Resection is last resort)

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GI Endoscopy
Endoscopy: Exam of Interior of Hollow organ/cavity of body
Rigid (Shorter: Ureter, Nasal cavity, Otocavity) or Flexible
Components: Light delivery system (Illumination), Lens system (Transmission of Image),
Viewing system (Eyepiece, Video), Procedure (Working Channel)
Type:
Resp Tract: NasoPharyngoscopy, Laryngoscopy, Bronchoscopy
GIT: OGD, Small Bowel Enteroscopy, Sigmoidoscopy, Colonoscopy
(Note: Rigid Sigmoidoscopy is ~25cm, can only go up to Sigmoid colon (Cover Rectum)
Flexible Sigmoidoscopy is ~60cm, up to Descending colon (Cover Sigmoid))
Biliary Tract: ERCP, Choledoscopy
Urinary Tract: Cystoscopy, Ureteroscopy
Application: Diagnostic: Exam Biopsy
EUS: FNAC/Trucut Biopsy
Staging of Tumor (T stage)
Therapeutic
Therapeutic Endoscopy:
Upper GIT:
Hemostasis: Variceal Bleeding: Injection Sclerotherapy (use Sclerosant), Banding
Ulcer Bleeding: Injection therapy:
Adrenaline: Tamponade effect (Surrounding tissue Compress BV)
Platelet Aggregation
Vasoconstriction
Thermocoagulation
Clipping (usually used with others, seldom alone)
Removal of Mucosal lesions:
Pedunculated Polyps: Polypectomy
Early Tumor: ESD: Endoscopic Submucosal Dissection:
Inject Gelofusine/Saline to elevate, then Resect; No Size Limitation
EMR: Endoscopic Mucosal Resection
Injection-/Cap-/Ligation-assisted; Usually for Size <2cm
Facilitation of Feeding: Stenting/Insertion of Feeding tube, PEG
Misc: Removal of Foreign bodies, Dilatation of Stricture
Lower GIT:
Hemostasis: Tumor/Angiodysplasia/Diverticulosis: Clipping/Thermocoagulation
Removal of Mucosal lesions: Similar to that of Upper GIT
Tumor Obstruction: Stenting
Misc: Sigmoid Volvulus/Pseudo-obstruction: Decompression + Flatus tube Insertion
Biliary:
Obstruction: Stone: Endoscopic Sphincterotomy, Basket/Balloon Retrieval,
Pigtail Stent Insertion
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GI Endoscopy
Tumor: Metallic Stent
Respiratory: Assisted Intubation, Removal of Foreign bodies, Clearance of Sputum,
Stent for Tumor Obstruction
Urinary: Lithotripsy, Insertion of Ureteric Stent, Resection of Bladder Tumor, TURP
Pt Preparation: Consent: Indication
Procedure
Risk: Aspiration, Perforation, Bleeding, Contrast Allergy, Procedure-related Cx
Position
Sedation (Most Public Hospitals No Sedation, except QMH), Analgesic
Position: OGD: Doctor stand on Left; Pt Left Lateral position
ERCP: Doctor stand on Left; Pt Semi-Prone position; X-ray machine nearby
Colonoscopy: Left Lateral with Knee-Chest
Cystoscopy: Lithotomy position
Safety: MouthGuard (BiteBlock): Prevent Pt Biting on Endoscope
Neck Collar: Protect Doctor Thyroid
(Doctor More Exposure than Pt Several procedures per day)
Goggles: Protect from Radiation (Cataract)
Gown
Examples:
OGD:
Mallory Weiss Tear: Along GE Junction
Perforation: Boerhaave syndrome
Achalasia: Barium Study: Dilatation of Esophagus with Rat Tail appearance
OGD: Tightly closed GE Junction
Foreign Body: If see Chicken Bone on Cervical X ray> Refer to Endoscopist quickly
Fish Bone: Usually over Epiglottis, Vallecula, L/R Piriform Fossa
May cause Injection (looks like Polyps)
Stomach CA: Rolled Edge, Irregular Border, Central Crater (Tumor)
Region: Cardia, Fundus, Greater/Lesser Curvature, Incisura (), Antrum
Ulcer: Take Biopsy for every GU (Not routine for DU)
Re-scope until Ulcer Heal (Cancer: Non-healing Ulcer)
GIST: Submucosal lesion with Intact Mucosa
Can check by EUS in Esophagus, or usually CT to assess genuine Size & delineate cause
GERD: May see Hiatus Hernia over GE Junction
Barrett: Map-like
More prominent on Narrow Band Imaging
Anastomotic Stricture: May see Whitish Scar tissue
Metastatic Esophageal CA:
Ryles Tube or Palliative Stenting
Stenting: Use 1: Open up Obstruction
Use 2: Bypass Fistula (eg. BronchoEsophageal)
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GI Endoscopy
PEG
Colonoscopy:
Diverticulosis: Cx: Perforation, Infection, Bleeding, Stricture
Angiodysplasia: Spider-like vessels
Colon CA: Rolled Edge, Irregular Border, Central Crater
Polyp: Can do Snaring to cut Single Small Polyp
Perforation rate (Uptodate):
Screening Colonoscopy: 0.01-0.1% (usually quote 0.1%) (2011 MCQ 13)
Anastomotic Stricture dilation: 0-6%
Crohn disease Stricture dilation: 0-18%
Stent placement: 4%
Colonic decompression tube placement: 2%
Colonic EMR: 0-5%
ERCP: Configuration: Side-view scope
ERCP with Fluoroscopy:
CBD: If Size comparable to ERCP> Dilated
Conclusion Fluoroscopy after ERCP:
ERCP Not seen
Bronchoscopy:
Foreign Body
Vocal Cord: LN causing Vocal cord Palsy
Esophageal CA invading to Tracheal Wall:
Note C-cartilage signify Anterior wall, Smooth Muscle over Posterior wall (near Esophagus)
EUS & FNAC: For Lung CA
Cystoscopy:
Cystitis
Polyp
Stones
TURP
Ureteric Stent
KUB vs AXR: AXR: Bowel shadow
KUB: Kidney shadow, need to see Pelvic brim
Ureter course: Right L2, Left L1
Tip of Transverse process
SI joint
Pelvic brim
Endoscopy:
End-view vs Side view scopes:
Usually use End-view scopes, occasionally use Side-view scopes for Specific examinations:
ERCP: Need to cannulate Ampulla of Vater, which is on Medial wall of Duodenum
Use Side-view scope Except in Pt with previous Billroth II (End-view easier)
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GI Endoscopy
Difficulty visualizing Side wall of Duodenum during Therapeutic Endoscopy
Video vs Fibreoptic scopes:
Now use Video scopes instead of Fibreoptic scopes:
Fibreoptic scopes: Would see Black dot if any fibre malfunctions
Inconvenient since need to look down through eye piece
Insufflation & Aspiration channels:
Double Channel Endoscope is preferred for Massive Bleeding
Suction Not impaired during Insufflation
No Insufflation channel in:
Bronchoscope:
Cartilage in airway Not collapsible, thus No need Air for distension
Choledochoscope:
Irrigation channel instead for irrigation of Bile ducts with Saline
Used in Exploration of Bile duct, which is usually done in failed ERCP for Stone
After Exploration, T-tube is left for CBD stones exam post-op for Cholangiogram at 1 week
T-tube is left for 6 weeks to create a Fibrous tract before removal
Easy channel for Cholangiogram or Removal of Stones by Choledochoscope
Cystoscopy:
Insufflate Saline, otherwise Bubbles will be created in Urine
Panendoscopy:
Imaging of whole aerodigestive tract including Laryngoscope, Bronchoscope, Upper Endoscopy
Used in H&N tumour 10-20% have lesions in other parts of Aerodigestive tract (Same RF)
As same scope (Bronchoscope) is used for whole Panedoscopy,
Bronchoscopy done first,
Esophagus visualized last Bronchus is Sterile, do Not want to contaminate Bronchus
During Examination of Esophagus,
O2 would be pumped in through working channel to distend for examination
Flexible Tip of Endoscope:
Do J-maneuver to visualize Cardia, Fundus & Incisura of Lesser curvature (Common site of GU)

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GI Endoscopy
GI Colorectal Surgery
Bowel Preparation: UCH: Fluid diet 2 days before OT, Oral Purgative 1 day before OT
Klean Prep (Polyethlene Glycol PEG):
Isosmotic solution; Need to drink lots of water
Commonly used nowadays; Subjective Cons: Metallic taste
Fleet Prep (Sodium Phosphate):
Hyperosmotic solution; Draw water from Pt
Potential Cx include Dehydration & Electrolyte disturbance
Contraindicated in Renal Insufficiency (due to Phosphate content)

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GI Colorectal Surgery
Peri-op Mx:
Pre-op:
Pre-op Assessment: Hx
PE
Ix: Blood tests, ECG, CXR, other Imaging studies
Consent & Counseling
Pre-Anesthetic Clinic: Discussion of Anesthetic Risk
Optimize Medical Comorbidities
Anticipation of Peri-op problems
Arrangement of HDU/ICU care
Admission: Ix
Consent
Identification
Marking (eg. Mark Hernia when Pt is awake by asking him to cough)
Bowel preparation
Stoma siting (Pt is awake)
Resuscitation/Nutritional supplement/Correct Anemia
Right before Surgery & Upon Induction of GA:
Identification of Pt
Identification of operation
Consent checking
Antibiotics prophylaxis
DVT prophylaxis
(In HK, usually Intermittent Pneumatic Cuff during op & Compression stocking post-op)
(LMWH for High risk Pt)
NG tube Insertion
Urinary Catheterization
Medications: Aspirin, Clopidogrel, Prasugrel, Abciximab, Dipyridamole
Rivaroxaban
Warfarin (Can bridge to Heparin & Resume Warfarin post-op)
Steroid (Cover Addisonian crisis with Hydrocortisone)
CV Comorbidities: AF
VHD (Mechanical valve or Not; If AS, is it severe to cause Cx under GA as Vasodilation CO)
HT
Pacemaker (Ask Manufacturer Sales to adjust Pacemaker mode to Not sensing Diathermy)
CHF (NYHA classification)
IHD
CV Risk Stratification: (Refer to lecture)
Step 4: Good Functional Capacity? (4 METs)
4 METs: Jogging at 6.44 km/h
Revised Cardiac Risk Index (Refer to lecture)
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GI Peri-op Mx
Previous PCI: Balloon Angioplasty: <14 days: Delay for Elective/NonUrgent surgery
>14 days: Proceed to surgery with Aspirin
Bare-Metal Stent: <30-45 days: Delay for Elective/NonUrgent surgery
>30-45 days: Proceed to surgery with Aspirin
Drug-eluting Stent: <1 year: Delay for Elective/NonUrgent surgery
>1 year: Proceed to surgery with Aspirin
Rationale: Risk of operation is acceptable if only 1 Anti-Platelet
Resp Comorbidities: COPD
Asthma
Bronchiectasis
Chronic Smoker (Chest Physiotherapy needed pre-op/post-op)
DM: Glycemic control
Ketoacidosis
Electrolyte imbalance
Risk of IHD, HT, PVD, Autonomic & Peripheral Neuropathy, Renal impairment
HyperT: Tachycardia
Labile BP
Arrhythmia
Thyroid Storm
Neurological Comorbidities:
Epilepsy (May need to adjust medication)
CVA
Parkinsons disease
Chronic Liver disease:
Bleeding tendency
Encephalopathy
Risk of Infection
HypoAlbuminemia
HepatoRenal syndrome
Child-Pugh score:
Child B: Higher risk after Surgery
Prone to Encephalopathy esp if have post-op Cx (Anastomotic Leak, Bleeding, etc)
Child C: Do Not operate (Risk too High)
Renal Failure: Correct underlying cause
Avoid Fluid overload
Avoid HyperK
Avoid Nephrotoxic drugs
Prone to Infection
Need for Temporary Dialysis
Need to switch from CAPD to HD (preserve vascular access)
Rheumatoid disease: VHD
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GI Peri-op Mx
Anemia
Pulmonary Fibrosis
Renal impairment
Steroid use
AtlantoAxial Instability:
Prone to C1/2 subluxation during Intubation when HyperExtend Neck
Solution: Awake Fibreoptic Intubation
Post-op:
Post-op care:
Monitoring: General ward vs HDU/ICU
Non-invasive vs Invasive
Pain control: LA (eg. Marcaine/Bupivacaine infiltration before wound closure), PCA, Epidural, Oral Analgesic
Antibiotics: 24h vs Full course (Depends on Degree of Contamination)
DVT prophylaxis:
TED stocking vs Heparin (LMWH for 7 days)
Chest Physiotherapy & Mobilization
Things done during Ward Rounds:
Talk to Pt
Abd Exam, Check Stoma, Wound, etc
Character of drain output
Vital signs
IO: Intake, Urinary output, Output from NG tube/Stoma/Drains
Blood tests, X-ray
Resumption of Oral intake:
Enhanced Recovery Protocol (Fast-track Surgery)
(Resume Oral intake once regain Consciousness, Step up gradually if can tolerate)
Conscious state
Abd distension
Flatus
AXR
Fever: (2014 EMQ, etc)
Day 1-3: *Atelectasis (2012 MCQ 10), SIRS, Transient Bacteremia
Day 4-6: Chest, Wound, Urinary (2011 EMQ 17), Line Infection
Day 7 onward: Chest Infection
Anastomotic Leak (CC Foo: Can occur as early as Day 2-3, but unlikely Day 1 Fever so fast)
Intra-abdominal collection
DVT
Hypotension:
Hypovolemia: Hemorrhage (Check Abd distension, Drain output, Hemocue)
3rd space loss (eg. Peritonitis)
Fluid loss from NG tube, Drains, Stoma
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GI Peri-op Mx
Cardiogenic
Sepsis: Anastomotic Leak/Intra-abdominal collection
PE
Oliguria:
Pre-Renal: Fluid Loss, Hemorrhage
Renal: Sepsis & Multiorgan dysfunction syndrome (MODS) (Consult ICU for temporary dialysis)
Nephrotoxic drugs
UTI
Post-Renal: Any obstruction along urinary tract
Blocked Foley (Flush it/Change it)
Paralytic Ileus: Abd Surgery: CC Foo: Last 1-2 days after Laparoscopic surgery
Longer if Open, Long Surgery, Emergency Surgery, Manipulation
Intra-abdominal Sepsis: Leak, Infected Hematoma
Electrolyte imbalance
Autonomic dysfunction (eg. Epilepsy, Parkinson)
Drug-induced (eg. Opioid)
Cx after Colorectal Surgery:
Related to GA
Medical: MI, CVA, PE, Chest Infection
Surgical: Hemorrhage/Vascular injury
Visceral injury: Small bowel, Duodenum, Ureter, Bladder
Anastomosis: Leak, Bleeding, Stricture
Stoma Cx
Urogenital dysfunction (Rectal surgery) (May injure Sacral nerve/Hypogastric plexus)
Paralytic Ileus
IO (Internal Herniation, Loop of bowel stuck at Fascia during closure, Hernia, Stoma defect)
Bowel Ischemia
Fistula (RectoVaginal, ColoCutaneous, etc) (eg. Staple Anastomosis caught Vagina)
Wound Infection

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GI Peri-op Mx
Stoma:
Indication:
Common: Protection of Distal Anastomosis
Tx of Anastomotic Leak
Large bowel obstruction
Others: Bowel Perforation
Abd/Perineal Trauma, Rectal Injury
Diverticular disease, IBD, Cx from Radiation
Complex Anorectal disease
Fecal Incontinence
Motility & Functional disorders including Idiopathic MegaRectum & MegaColon
Infection: Necrotizing Fasciitis, Fourniers Gangrene
Congenital disorders: Imperforate Anus, Hirschsprungs disease, NEC, Intestinal Atresias
Type: Temporary vs Permanent
Ileostomy vs Colostomy
Loop vs End
Others: Gastrostomy, Jejunostomy, Esophagostomy, etc
(Urostomy, eg. Ileal conduit)
Temporary vs Permanent:
Permanent (usually End):
Absolute: When No distal bowel remaining (eg. APR)
Relative: When Pt/Surgeon factors are against Reversal of Stoma (eg. Hartmann)
Temporary (usually Loop):
Decompressing:
Relief of IO causing Proximal dilatation
Defunctioning/Diverting:
To Effects of Anastomotic Leak
The Lower the Anastomosis, the Higher the Leakage risk, the More need for Stoma
To rest an inflamed distal portion, eg. Acute Crohns
Ileostomy vs Colostomy (in general):
Ileostomy Colostomy
Location (usual) RLQ RUQ/LUQ for Transverse Colostomy
LLQ for End Colostomy
Mucosa Sprout (Nipple shape) to Irritation Flush to skin
(More Pinkish when Fresh) (More Reddish when Fresh)
(Smaller diameter) (Larger diameter)
Output Small bowel Fluid (watery) Stool (feculent)
Cons Fluid & Electrolytes disturbances Odor from Output
Skin Irritation from Output More Parastomal Hernia & Prolapse
End: Ileostomy: Eg. After PanProctocolectomy for Severe Ulcerative Colitis, FAP, etc
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GI Stoma

Colostomy: (Large bowel content Less Irritative to Skin No need Sprout)
(Ddx between APR & Hartmann: Absence/Presence of Anus)

Loop: Wall of intestine partially separated> Open into 2 holes
Easier Closure with the Intact wall
Ileostomy: Pros over Loop Colostomy: Easier to Site & Close, Less Bulky

Colostomy: In Fresh Stoma, can see a Stoma Rod passed through the window Colostomy Bridge

Transverse Colon:
Mobile & Location relatively more predictable: Easier to do Defunctioning
Pros over Ileostomy in Emergency:
Can just make a Trephine Incision over RUQ, No need Formal Laparotomy
Sigmoid Colon:
Can also be used but Seldom
May have Lateral Peritoneal Adhesion> Need Mobilization before use, cf Transverse Colon
Double Barrel: Proximal limb & Distal limb completely separated
Proximal limb excretes Feces
Distal limb (Mucous Fistula) excretes Mucous
At Same site or Different site
If at Same site, may seem grossly indistinguishable from Loop Stoma
Can be Proximal Ileostomy + Distal Colostomy too (eg. Cecum removed)
Ileostomy
Colostomy:
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GI Stoma

Loop End: Modified version of Double Barrel:
Size of Opening (Skin defect)
Tension from Vascular pedicle to Distal bowel (Open up Anti-Mesenteric side)
Ileostomy
Colostomy:

Preparation:
Psychological: Explain Indications of Stoma
Temporary or Permanent
Provide info, eg. reading material, video, online resources, patient support group, etc
Show the Appliances & Stoma related products
Site of Stoma: Assessed at Sitting & Standing position
At summit of Infra-umbilical bulge
Within Rectus muscle (To Parastomal Herniation)
Avoid: Groin, Waistline, Costal margin, Umbilicus
Skin creases, Bony prominence
Scar (Risk of Hernia)
Leave a 5 cm margin of smooth skin around the site
Attention to Beltline & Pant Height
Pre-op: Mark potential Stoma site with Purple Round Ink
Cx: Early:
Ischemic/Gangrenous Stoma (Stomal Necrosis):
Most common Early Cx; Ischemia most often noticed within 24h post-op
Caused by: Tension/Inadequacy of Mesenteric vasculature to intestinal end
Trauma during creation
Asso. with Obesity & Higher BMI
Severity varies: Whole Stoma extending below Fascia, or only a portion above skin level
Mx: Can put in an Endoscope to see Extent
Above Fascia: Superficial: Watch & Wait
Top layer may slough leaving Red viable Stoma
Below Skin level: Debridement may be needed
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GI Stoma
Below Fascia: Urgent Surgery
(Dusky Stoma Mucosa)

Mucocutaneous Separation:
Detachment of Stomal tissue from surrounding Peristomal skin
Due to Poor Healing, Tension, Infection
Severity varies: Partial (only a portion of circumference), or Complete
Superficial (only Skin level), or Full thickness (extends to Fascia level)
NB: The more Severe, the more likely Retraction will occur
With healing, likelihood of Stenosis is High
IO: Adhesions, Volvulus, Internal Herniation, Incarcerated Parastomal Hernia
High output Stoma:
Definition: Daily output 500 ml/day (Similar to High output Fistula)
Electrolyte imbalance, Dehydration
Early or Late:
Skin Irritation/Dermatitis:

Peristomal Infection:

Late: Retraction: (Tension on Stoma too High; Prevention: Adequate Mobilization)

Prolapse:
RF: Intra-abdominal pressure, Obesity
Stomal opening too Large, Stoma outside Rectus muscle
Double-barrel Loop ostomies
Mx: Conservative: Reduction (Can be done by Pouching system, Hernia support belt)
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GI Stoma

Stomal Stenosis:
May observe Ribbon-like stool or Projectile evacuation
Mx: Low Residue diet, Stool Softeners, Liquids
Digital dilatation (Can teach Pt to do it)
Surgery

Parastomal Hernia:
RF: Pt factors: Obesity
Others: Aging, Steroid, Wound Infection, Recurrent Intra-abdominal Pressure, etc
Surgical: Emergency Stoma, Open/Laparoscopic, Abd wall strength, etc
Mx: Conservative
Surgical: Primary/Mesh Repair (Special mesh may be used to Infection risk)
Stone formation: (Not a commonly quoted Cx)
Loss of Fluid, Na & HCO3
HyperUricemia
Acidic Urine
Ileostomy Care: Need special attention to avoid Dehydration & Obstruction
Drink plenty of fluid
Use AntiDiarrheal agents prn to Output volume
Avoid Fibrous food, such as Whole Vegetables/Citrus Fruits
Avoid formation of Indigestible Bolus obstructing Stoma
Irrigating Stoma with Warm Saline from inserted Foley catheter
may relieve obstruction & dehydration
Water soluble Contrast Enema may be diagnostic & therapeutic
Change of Stoma Bag:
New bag every 3 days (But for old bag, still need to pour out content when filled)
Too Frequent: Skin Irritation, Financial burden

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GI Stoma
GI Colonic Polyp
Classification:
Non-Neoplastic:
*Hyperplastic:
Traditionally regarded as Non-Neoplastic (For MBBS level, regard as Non-Neoplastic)
Now ing evidence that it may belong to the Larger group Serrated Polyps
(NB: Some call it Metaplastic polyp? Term seen in 2011 MCQ 13)
Mucosal: Small, usually <5 mm
Endoscopically resemble adjacent Flat mucosa; Histologically Normal mucosa
No Clinical significance
Inflammatory PseudoPolyps:
Often occurs in IBD
Submucosal (some may be Neoplastic):
Eg. Lymphoid aggregates, Lipoma, Leiomyoma, etc
Hamartomatous:
Disorganized Mass of Normal tissues
Traditionally regard as Non-Neoplastic (But some may develop dysplasia> CRC)
Eg. Juvenile polyps (Usually removed due to risk of Bleeding)
Peutz-Jeghers polyps (Usually Benign, but Malignant transformation possible)
Others: Cronkhite-Canada syndrome, Cowden syndrome, etc
Neoplastic:
Serrated: Heterogenous group of Polyps with variable Malignant potential
Eg. Hyperplastic polyps
Traditional Serrated Adenomas
Sessile Serrated Polyps/Adenomas
Adenomatous:
Most common classically Neoplastic Polyps (Its by definition Dysplastic)
Adenomatous Polyp:
Morphological/Endoscopic Classification:
Sessile, Pedunculated, Flat, Depressed
Pathological Classification:
*Tubular: Tubular component 75%
Villous: Villous component 75%
Risk of Malignancy Higher than Tubular Adenoma (2014 MCQ 11, etc)
Tubulovillous: Villous component 26-75%
Mckittrick-Wheelock Syndrome:
Rare Cx of Hypersecretory Rectosigmoid Villous Adenoma (2014 MCQ 11, 2011 MCQ 13, etc)
Secretory Diarrhea> Dehydration (PreRenal ARF), HypoNa, HypoCl, HypoK, Metabolic Acidosis
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GI Colonic Polyp
GI Colorectal Cancer
CRC: HK Cancer Registry 2011: Commonest Cancer in HK (replacing Lung CA), 2nd Cause of Death
RF:
1. Non-modifiable:
Age: >50
Genetic predisposition:
Hereditary syndromes:
Familial Adenomatous Polyposis (FAP): (<1%)
AD; Germline mutations in Adenomatosis polyposis coli (APC) gene on Chr 5
Multiple Colonic & Rectal Adenomatous polyps at Teenage (2012 MCQ 45)
Polyps >100; Attenuated variants have 20-100 polyps
100% lifetime risk of CRC
Polyps may also develop in other parts of GIT, esp Duodenum & Peri-ampulla region
Other ExtraGI manifestations: (2007 SAQ 3)
Thyroid Papillary CA, Congenital Hypertrophy of RPE
Type (Same FAP gene): Classical FAP
Attenuated FAP
Gardner syndrome (Mesodermal tumor, eg. Osteoma)
Turcot syndrome (CNS tumor)
Hereditary Non-polyposis Colorectal Cancer (HNPCC): (<10%)
AD; Aka Lynch syndrome (Lynch syndrome I: Only CRC; Lynch II: Also Extracolonic)
Mutations of DNA mismatch repair genes (Mainly hMLH1 & hMSH2)
Usually Right-sided Colonic tumor
Extracolonic: Endometrium (2nd common) /Ovary, Stomach/Small bowel, Upper tract TCC, etc
Amsterdam II Diagnostic Criteria
Other Polyposis syndromes:
MYH asso. Polyposis, Hamartoma Polyposis
(Peutz-Jeghers syndrome only has Small risk)
Personal/FHx of CRC or Adenomatous polyps:
Personal Hx:
CRC: In first 5 years after resection of primary CRC,
Metachronous CRC: Rate of 3-5%
Metachronous Adenoma: Rate of 25-40%
(NB: Metachronous: Primary tumors >6 months apart)
Adenoma: Size: Large (Andre Tan: >1 cm; UCH: >1.5 cm)
Histology: Tubulovillous/Villous (2014 MCQ 11, etc), severe Dysplasia
Number: Multiple
FHx: FHx +ve in 10-15% cases
2x in 1st degree relative with CRC >60 yo, or 2 2nd degree relatives
4x in 1st degree relative with CRC <55 yo, or 2 1st degree relatives
IBD: Longstanding UC asso. with CRC; Recent studies show that CD probably similar risk as UC
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Racial Background (eg. Ashkenazi Jews)
2. Modifiable (Environmental):
Diet: High in: Red Meat, Preserved food (Nitrosamine),
Refined Sugar/Fat (Oxidative byproducts)
Low in: Fibre (Bowel transit time> Contact with Carcinogens),
Vitamins & Minerals (AntiOxidants)
Smoking, Alcohol
Obesity
NSAID may be protective
3. (Others in Clinical Oncology Lecture by Janice Tsang):
DM & Insulin Resistance
Cholecystectomy (asso. with R-sided Colon Cancer)
Presence of CAD
Pathogenesis of Sporadic Cancer:
Chromosomal Instability pathway (Adenoma Carcinoma sequence) 60-70%
Microsatellite Instability pathway 15%
Site distribution: 2/3 Distal to Splenic flexure, 1/3 in Rectum:
30% Rectum, 20% Sigmoid, 15% Descending
10% Transverse
25% Ascending
(Morphology: *Scirrhous/Annular Apple-core lesions (More common in Left colon)
Polypoid (More common in Right colon as more space to grow)
Ulcerated
Nodular)
Clinical:
Asymptomatic: Detection by Screening
Local:
Right-sided (Tend to present Late):
Fe deficiency Anemia
Abd Mass, (Abd Pain)
Left-sided: Change in Bowel habits & IO:
Progressive Constipation (Annular Stenosis)
Alternating Constipation & Diarrhea
(Blood & Mucus in stool> Tend to be Loose stool)
(Diarrhea more predictive than Constipation as Constipation is common in Elderly)
(Bacteria degradation of Proximal stools> Overflow Diarrhea after Constipation)
Stool: in Stool caliber
PR bleed
Mucus (Mucoid stools)
(Palpable Mass: Can be Tumor itself or Impacted Feces)
Rectosigmoid:
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Tenesmus: Sense of Incomplete Defecation/Intense desire to pass stool,
accompanied by Pain & Involuntary Straining,
with Nothing or Little Mucus/Loose stool despite Straining
Feeling of Residue is Not correlated with Actual presence of Residual feces or Not
Local Pain may be due to Sacral plexus invasion
Constitutional
Cx: IO, Perforation (Peritoneal signs), Abscess
Fistula: EnteroVesical Fistula: Fecuria, Pneumaturia, Recurrent UTI
Others (Stomach, Uterus/Vagina, Skin)
Urinary Sx, Ureteric obstruction
Metastasis:
Liver: Hepatomegaly, RUQ Pain, Jaundice (Less common; Usually Parenchymal involvement)
LN: Jaundice (Porta hepatis), Duodenal obstruction, Ureteric obstruction
Peritoneum:
Ascites (Carcinomatosis peritonei)
Others: Lung, Bone, Brain, etc
Screening:
1. Candidates: Based on Risk stratification
No well-defined guideline in HK yet (Centre for Health Protection mainly quotes from CEWG)
Average Risk (No RF):
Should start at Age 50 (Age group: 50-75)
High risk: Gene of Hereditary Bowel diseases:
FAP: Start at 12; By Flexible Sigmoidoscopy every 2 years
HNPCC: Start at 25; By Colonoscopy every 1-2 years
1 1st degree relatives having CRC diagnosed at age 60:
Start at 40, or 10 years before Age at Dx of the Youngest affected relative
By Colonoscopy every 3-5 years
2. Modalities:
Fecal Occult Blood Test (FOBT):
Annual/Biennial screening (Every 1-2 years)
(Only done in Average Risk population?)
Rely on detection of Peroxidase in blood
False +ve: Peroxidase in dietary constituents, eg. Red Meat, some Raw Vegetables, etc
False ve: High dose Vit C may block Peroxidase reaction
May need Dietary restriction
Format: Guaiac based (FOT), Fecal Immunochemical test (FIT)
By Endoscopist:
Flexible Sigmoidoscopy: (Not done in QMH)
5-yearly recommended for Average Risk population
More Sensitive than FOBT, Also Therapeutic
Flexible Colonoscopy:
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10-yearly recommended for Average Risk population
More Sensitive than Sigmoidoscopy, but also more Expensive
(KY Wong: Problems with Colonoscopy:
May Not visualize up to Ileocecal valve in 5% Pt, eg. with Redundant Sigmoid
Poorer Localization than Barium, esp Inconvenient Laparoscopic Surgery
If Planning operation: Mark with Dye so that can see through Serosa
Or, On-table Colonoscopy)
Surveillance after Baseline Colonoscopy if Polyps identified: (Med 2014 MCQ 26, 2015 MCQ 28)
Small (<1 cm) Hyperplastic polyps in Rectum/Sigmoid: 10 years
1-2 Small (<1 cm) Tubular Adenomas: 5-10 years
Otherwise: 3 years
By Radiologist: (KY Wong: If just for Reassurance purpose, may book these instead of doing Endoscopy
Not for Colitis evaluation: Not good for Mucosal lesions
May need Biopsy at Terminal Ileum for Crohns disease)
Barium Enema
CT Colonoscopy:
(Application: Some Centres now recommend replacing Barium Enema with CT Colonoscopy
In QMH, usually 3rd line after considering Colonoscopy & Barium Enema)
Plain CT, with 3D reconstruction of Endoluminal views
Air pumped through Rectum for Inflation
Fecal tagging: May give solution to coat any residual feces Not cleared by Laxative
Ix: Blood:
CBC Fe studies
LRFT
Tumor Markers:
CEA: Andre Tan: >90% CRC produce CEA
QMH lab cutoff: >3.0
Useful as pre-op baseline (May help early detection of Post-op Recurrence)
Recurrence: CEA in 60-70% cases (2013 MCQ 17)
False +ve: Physiological: Pregnancy
Benign: Smoking, Bronchitis, Cholangitis
Malignant: Lung CA, Breast CA, other GI CA, etc
For Dx:
Colonoscopy:
1st line, Diagnostic & Therapeutic
Diagnostic: Visualize, Biopsy, Detect Synchronous lesions (Primary tumors <6 months apart)
(Synchronous Cancer in 5% cases> Dont just do Sigmoidoscopy)
Therapeutic: Polypectomy, Stenting
CT Colonoscopy:
Need IV contrast, Air & Contrast Enema
Detect 1cm tumor
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Double-contrast Barium Enema + Sigmoidoscopy:
Classically can see an Apple core lesion with Barium Enema
Need Rigid Sigmoidoscope to examine Rectum & to instill Air & Contrast
Staging Imaging:
CT Abdomen + Pelvis:
Local T staging, N staging
Liver metastasis (UCH: 20% on presentation; May check by US abdomen too)
Peritoneal seeding, Ascites
Cx like Hydroureter/Hydronephrosis, IO
Endorectal US/MRI pelvis:
For Rectal CA staging; Important in assessing operability & selection for Neoadjuvant ChemoRT
MRI: Accurate in assessing Rectal Cancer:
Mesorectal margins (distance accurately defined)
LN within/outside Mesorectum
Extramural Vascular invasion
After ChemoRT
For Recurrent disease
CXR/CT Thorax:
Lung metastasis
Others: Bone scan, PET scan
Staging:
Dukes Staging (Old):
A: Within Bowel wall
B: Invades through Bowel wall
C: Regional LN metastasis
(D: Distant Metastasis; Not in original Dukes staging)
TMN Staging: T for Depth, N for Number
T: T1: Invades Submucosa
T2: Invades to Muscularis propria but Not through it (2013 SAQ 7)
T3: Invades through Muscularis to Subserosa
T4: Invades through Serosa & to other organs
N: N1: 1-3 LN (2013 SAQ 7)
N2: 4
M: M1: Distant Metastasis
AJCC Staging:
Stage I: T1-2
Stage II: T3-4
Stage III: N1-2
Stage IV: M1
Tx:
Surgery:
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- Principles: En-bloc resection of tumor with adequate margins:
For Colonic tumors, 5 cm margin proximally & distally
For Rectal tumors, usually 5 cm proximally, 1 cm (UCH) or 2 cm (Andre Tan) distally
Lymphatic spread is usually in Proximal direction in CA Rectum
Excision of Vascular pedicle & accompanying Lymphatics (lymphatics follow arteries)
Tension Free & Good Blood supply Anastomosis
(SB-LB anastomosis is more reliable than LB-LB anastomosis)
(Excise all parts supplied by the BV to be divided, eg. part of Terminal Ileum in Right Hemi,
as those parts will be Ischemic anyway, and risky to do Anastomosis on them)
(Usually, the Lower the Anastomosis, the Higher the Leakage risk)
- Peri-op Preparation:
Mechanical Bowel Preparation:
Current evidence does Not show its benefit in ing Surgical site Infection/Anastomotic Leak
(Not done in QMH, but may be done in other centres even No evidence)
Single dose of IV Antibiotics on Induction 2-3 Post-op doses
Prolonged Antibiotics Not necessary
Prophylactic therapy against DVT
- Approach:
Open: Conventional; Preferred in Complicated CRC
Laparoscopic: Feasible in Uncomplicated CRC (RCT proven)
Pros: Pain, Duration of Ileus, Quicker Recovery, Inflammatory response,
Hospital stay (2011 MCQ 17)
Cons: Cost, Longer operation time, Technically more difficult
NB: No significant difference in Cx, Peri-op Mortality, Recurrence, Survival
Robotic: Feasible in Rectal Surgery
- Tumor Site: (Can be quite confusing between different references; Below mainly based on UCH & B&L)
(Marginal artery of Colon links all SMA & IMA vessels)

Cecum, Ascending Colon:
Right Hemicolectomy:
Structures: 5-10 cm of Terminal Ileum, Cecum (with Appendix), Ascending colon,
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Proximal 1/3 of Transverse Colon (including Hepatic Flexure)
Vessels: Ileocolic A, Right Colic A, Right branch of Middle Colic A

Proximal Transverse Colon (including Hepatic Flexure):
Extended Right Hemicolectomy:
Structures: Similar to Right Hemicolectomy, with Whole Transverse Colon
(Some may only include part of Transverse Colon, Not to Splenic Flexure)
Vessels: Ileocolic A, Right Colic A, whole Middle Colic A

Mid Transverse Colon:
Extended Right Hemicolectomy
Transverse Colectomy:
Excision of whole Transverse Colon (with both flexures), Ligate Middle Colic A
UCH: Generally avoided due to problem of Blood supply & Tension?
Distal Transverse Colon (including Splenic Flexure):
Controversy on the optimal surgery to be performed
Extended Right Hemicolectomy, with Ligation of Ascending branch of Left Colic A
(Splenic Flexure has Dual Blood supply:
Left branch of Middle Colic A from SMA, Ascending branch of Left Colic A from IMA)
Left Hemicolectomy, with Ligation of Left branch of Middle Colic A
UCH: May be difficult to obtain Tension Free Anastomosis between Transverse Colon & Rectum
Blood supply of Colon is Inconstant (Left Colic A absent in 6%, Middle Colic absent in 22%)
Thus may be Less preferable than Extended Right Hemicolectomy type?
Left (Superior) Segmental Colectomy:
Structures: Distal Transverse Colon (including Splenic Flexure), Descending Colon
(Some only include Proximal part of Descending Colon)
Vessels: Left branch of Middle Colic A, Left Colic A
Descending Colon, Sigmoid Colon:
Left Hemicolectomy:
Structures: Distal 1/3 Transverse Colon (including Splenic Flexure), Descending Colon,
Sigmoid Colon
(Some may just excise up to Splenic Flexure)
Vessels: IMA at its origin (ie. Left Colic A, Sigmoid branches, Superior Rectal A),
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(Left branch of Middle Colic A)
Left Segmental Colectomy:
Descending Colon: Some may just excise Descending Colon & Ligate Left Colic A
Sigmoid Colon: Some may just excise Sigmoid Colon (Sigmoid Colectomy)
Some do High Anterior Resection: Sigmoid Colon, Upper Rectum
Ligate Sigmoid A & Superior Rectal A
Rectum: Sphincter-sparing (LAR) vs Sphincter-sacrificing (APR):
Anal sphincter can be spared if Distal margin is >1-2 cm above Sphincter complex
(5 cm above Anal verge)
Determinants of Sphincter Preservation:
Level of tumor, Body build, Position & Fixity of tumor, Gender, Differentiation,
Surgeons technique & experience
Anterior Resection of Rectum (Sphincter preserving):
IMA ligated (Usually High/Flush Ligation at its origin)
Sigmoid & whole/part of Rectum resected
(Not Descending Colon Left branch of Middle Colic A extends its supply to it)
3 Types:
High AR: Margin above Peritoneal reflection
Low AR (LAR): Margin below Peritoneal reflection
Ultra Low AR: Anastomosis to Upper end of Anal canal (just above Anal sphincter)

Technique Mesorectal Excision:
Total Mesorectal Excision (TME): (2013 SAQ 7: Achieve Circumferential margin)
Standard in Middle & Lower Rectal tumors
Pros: Local Recurrence & Survival, due to more radical removal in Lateral margin
Cons: Anastomotic Leakage rate> Usually need Temporary Defunctioning Stoma
Upper Rectal tumor: Wide Mesorectal Excision with 5 cm distal margin may be enough
Reconstruction:
For better Reservoir function
Colonic J pouch: Colon folded back on itself to form a J,
then the 2 limbs opened & stitched together
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Coloplasty: Alternative, done when difficult creating Colonic J pouch
AbdominoPerineal Resection (APR): (No Anus anymore, cf Hartmanns operation)
Complete Removal of Rectum & Anus via a Combined Abdominal & Perineal approach,
followed by construction of a Permanent End Colostomy
(It was the standard Tx for Mid & Lower Rectal tumors until development of LAR)
Hartmanns operation:
Resection of Sigmoid Colon & Upper Rectum,
with construction of End Colostomy & Closure of Rectal Stump
Originally indicated for Upper & Middle Rectal tumors when LAR Not yet developed
Now usually as Emergency procedure for various complicated colorectal conditions
Local Surgery for Lower Rectal CA: (Higher Recurrence Lymphatics Not dealt with)
Eg. Full thickness TransAnal Excision, TransAnal Endoscopic Microsurgery
Indication: T1 tumor with minimal Submucosal involvement on EUS (2012 MCQ 38)
Well differentiated, No Lymphovascular permeation
Clear Resection margin feasible, Within reach from Anal verge
Extended Excision Pelvic Exenteration:
For Locally advanced tumor (T4)
Also remove GenitoUrinary organs
- Cx: General: Cardiopulmonary Cx, DVT/PE, Infection (UTI esp if Retention, Wound, Phlebitis, Pneumonia)
Early: Accidental Injury to other Abdominal/Pelvic organs (Immediate Cx)
Infection/Sepsis/Abscess
Hemorrhage (esp if Splenic injury)
Anastomotic Leakage:
Usually Day 7-10, as Suture dissolves
Can lead to Fecal Peritonitis
RF: Pt factors: IC (including Steroid), Malnutrition, Poor Hemodynamics, etc
Local factors: Previous RT, Local Sepsis, etc
Surgery factors: Site of Anastomosis: Colon vs Rectum
Timing of operation: Emergency vs Elective
Surgeon technique
Prolonged Ileus
Early Stoma Cx
Late: Diarrhea (due to Short Bowel)
(If too much Terminal Ileum resected, may also Vit B12 deficiency & Bile Salt Diarrhea)
(Bile Salt Diarrhea is due to Enterohepatic circulation)
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Impotence/Urinary Incontinence (Damage of Pelvic nerves esp in Rectal Surgery) (2013 SAQ 7)
Adhesive IO
Anastomotic Stricture
Late Stoma Cx
Other Surgery:
Surgery for Cx: Surgery for Obstructing CRC (see IO section), Surgery for Perforated CRC (eg. Hartmanns op)
Surgery for Metastasis:
Isolated Liver Metastasis
Isolated Lung Metastasis (Less common; Usually Disseminated) (2007 EMQ 12, 2005 EMQ 17)
NB: Wedge resection is preferred for Stable Peripheral metastases 3 cm
cf Lobectomy in preferred in Primary Lung CA, as Local Recurrence is an issue
Wedge resection needs 1 cm margin, often cant be achieved for Central lesions
Surgery for Palliation:
Resection for Sx control such as Bleeding, Pain, Obstruction, Perforation
Other choices of Palliation for Obstructing CRC: Stenting, Bypass, Stoma
Neoadjuvant therapy:
Rectal CA: (2013 SAQ 7)
ChemoRT: (Good evidence for T3/T4 disease)
Can downstage tumor> Ability to preserve sphincter, to resect previously unresectable tumor
Colon CA:
Chemo: May be useful in Stage 4 Pt to Resectability of Primary tumor & Metastasis
RT Not done for Colon CA: Risk of Small bowel irradiation if RT above Peritoneal reflection
Adjuvant Therapy: (Also similar principle for Tx of Metastatic CRC (mCRC))
Consideration: Tumor features: T, N, Grade, No. of LN, Margins, K-ras status
Pt Characteristics: Age, Co-morbidities, Performance status, Prior therapy
Pt Preference: Work/Family/Self
Other RF: Perforation, IO
Clinical Trials: Guidelines, Evidence-based data
Toxicity profile
Molecular profile: Eg. K-ras status
Chemo: (Janice Tsang: Magic Number 6 months (24 weeks))
Common Regimen:
FOLFOX4: 5-FU, Leucovorin, Oxaliplatin; (2-weekly cycle x 12 cycles)
XELOX: Xeloda (Capecitabine), Oxaliplatin; (3-weekly cycle x 8 cycles)
Colon CA: Indicated for Stage 3 (Duke C), Controversial for Stage 2 (for some High risk Stage 2)
Rectal CA: Usually in the form of ChemoRT, in general for Stage 2 & 3
Fluoropyrimidine analog:
5-Fluorouracil (5-FU):
Backbone of Tx; Often 5-FU based Chemo with Combination
May be given with adjunct:
Leucovorin: Folinic acid
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Synergistic effect by inhibiting Thymidylate synthetase
(V. Lee: Prolong 5-FU binding & action to Thymidylate synthetase)
(Note that when use with Methotrexate, the purpose is to S/E
Leucovorin rescue Target is Dihydrofolate Reductase DTFR)
(Levamisole: Not used nowadays due to serious Agranulocytosis)
S/E: Severe Diarrhea, Maculopapular rash, etc
Capecitabine (Xeloda):
Oral Prodrug of 5-FU
(Tegafur?)
Platinum analog:
Oxaliplatin (Eloxatin):
S/E: Peripheral Neurotoxicity, Myelosuppression
Topoisomerase I Inhibitor: (Often as 2nd line to replace Oxaliplatin)
Irinotecan (Camptosar):
Derived from Camptothecin
S/E: Severe Diarrhea
Target therapy: (Mainly in mCRC; Still Not common in Adjuvant setting)
Anti-VEGF: Tumour development is dependent on Angiogenesis
Angiogenesis is regulated by Pro-angiogenic (VEGF) & Anti-angiogenic (eg. Endostatin) factors
VGFR is over-expressed in various tumors, esp CRC, Lung Cancer & Inflammatory Breast cancer
High % of CRC overexpresses VEGF: Poor Prognosis
Bevacizumab (Avastin):
Use in combination with Chemo in Metastatic CRC
Improved objective response, DFS & OS
S/E: Bleeding, Hypertension, Proteinuria
Uncommon but may be Severe: Thromboembolic events
Anti-EGFR: EGFR is a transmembrane glycoprotein of TK growth factor family
EGFR is expressed in High levels with Gene amplification in various tumors, eg. CRC, H&N
(Almost always present in CRC; No need to order tests for it)
EGFR expression: Poor Prognosis, mCRC
Cetuximab (Erbitux, C-225): (2006 MCQ 7)
mAb blocking EGFR
Efficacy in mCRC determined by RAS mutation status (esp K-ras; Also N-ras):
RAS wild type: Documented benefit
RAS mutant type: No benefit (Phase III CRYSTAL trial: FOLFIRI C-225)
S/E: Acneiform Rash
Panitumumab
(Others: Apart from the above mAb, TKI probably Not available in HK now:
Ziv-aflibercept (Zaltrap): VEGF Inhibitor
Regorafenib (Stivarga): New drug approved on 2012; Last resort if all medications fail)
RT: Only for Rectal CA (Usually Stage 2/3):
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NIH consensus 1990:
Adjuvant ChemoRT for Stage 2 & 3 disease
Controversies & Current Status:
Need depends on Local Recurrence rate of the centre
Pre-op ChemoRT preferred (Less Toxicity, Tumor can be downstaged)
Regimen of RT & Chemo varies
Palliation: Palliative Surgery (including Ablative therapy)
Palliative Chemo (Systemic, Intrahepatic Infusion, Embolization)

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GI Neuroendocrine Tumor
Neuroendocrine Tumor (NET):
Heterogeneous group of Neoplasms; Terminology has been confusing
(Revision Lecture)
Classification:
Unknown Primary site
Known Primary site:
Indolent Biology:
Well-differentiated NET (Carcinoid, Atypical Carcinoid, many Primary sites)
Well-differentiated Pancreatic NET (Islet cell tumor)
Medullary CA of Thyroid
Paraganglioma
Pheochromocytoma
Aggressive Biology:
Small cell & Large cell Neuroendocrine Lung cancer
High-grade Poorly-differentiated Neuroendocrine CA
Extrapulmonary Small cell CA (many primary sites)
Merkel cell tumor of Skin
Neuroblastoma
Carcinoid: Slow-growing type of Neuroendocrine tumor (Well-differentiated NET)
NB: The term Carcinoid is now reserved for Well-differentiated NET in GI tract only?
But many previous data may be combined with other NET, making separation difficult
Site: Foregut: GI: Stomach, Pancreas (Regarded as Pancreatic NET now)
Resp: Lung, Bronchus (Not regarded as Carcinoid now?)
*Midgut: Small bowel (*Ileum, Jejunum), Appendix
Rarely in Duodenum (2014 MCQ 23)
Hindgut: Rectum, (GU structures)
NB: Traditionally Small Bowel (*Ileum) > Rectum > Appendix > Colon > Stomach
But: Rectal Carcinoid is ing since implementation of Screening Colonoscopy
In Asia/Pacific, Hindgut Carcinoid is more common than Midgut Carcinoid (Uptodate)
Carcinoid syndrome: Typically asso. with Metastatic Carcinoid of Midgut (esp Liver metastasis)
Clinical: Vasomotor changes: Flushing
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GI Hypermotility: Diarrhea
Others: Bronchospasm, Hypotension, etc
Skin: *Flushing (Kinins, Histamine, Kallikreins, others),
Telangiectasia, Cyanosis, Pellagra (Excessive Tryptophan metabolism)
GI: *Diarrhea & Cramping (Serotonin)
Heart (Carcinoid Heart disease):
Valvular lesions (Serotonin): Right Heart > Left Heart
Resp: Bronchoconstriction
Tx of Metastatic GI Carcinoid (Uptodate):
Potentially Resectable disease (Limited Hepatic Metastases): (2015 MCQ 21)
Complete Resection of Primary tumor & Metastases with Curative intent
Resectability:
Pt factors
Tumor factors: No Diffuse Bilobar involvement, No Extrahepatic metastases
Low grade (High grade G3 tumor is Contraindication)
Liver factors: Adequate Liver Function
Unresectable: Asymptomatic + Low Tumor burden: Observe
Symptomatic, or High Tumor burden: Somatostatin analog (2015 MCQ 20)
NB: Effective for Carcinoid Heart disease (2015 MCQ 19)
Progression despite Somatostatin analog:
Hepatic predominant disease:
Surgical Tx: Non-Curative Debulking
Non-Surgical Liver-directed Tx: Local Ablation (eg. RFA)
Regional therapy (eg. TACE) (2015 MCQ 19)
Non-Hepatic predominant disease:
Systemic Tx: Everolimus
Radiolabeled Somatostatin analog
Others: IFNa, Chemo
Guest Lecture:
GI NeuroEndocrine Tumors:
Somatostatin receptor based imaging (Octreoscan) vs PET/CT
Gastric NeuroEndocrine Tumors:
Mostly Functionally Inactive
Well differentiated type 1 is classical in Pt with Hx of Pernicious Anemia
Pancreatic NeuroEndocrine Tumors:
Insulinoma: Mostly Benign
Gastrinoma: Mostly Malignant
May be part of MEN1 syndrome
2003 MCQ 85: Peri-op Localization Imaging: EUS, CT, MRI, Arteriography
Misc:
Insulinoma:
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Ix: Fasting evaluation: (2009 MCQ 40, 2008 MCQ 29, etc)
72h Fast is standard (Some propose 48h fast as an Alternative, but Less Accurate)
Results: Insulin, Glucose
C-peptide: Can help ddx Endogenous vs Exogenous Hyperinsulinism
Proinsulin
Screening for Sulphonylurea ve
Imaging: (2010 SAQ 12)
US/CT/MRI Abdomen
EUS
Arteriography
Somatostatin receptor scintigraphy
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GI Anorectal Conditions
Basic Anal Anatomy:

Margin: Proximal margin: Puborectalis muscle of Anorectal Ring (Anorectal junction)
Distal margin: Anal verge (Anal canal epithelium meets true Perianal Skin)
Anal canal: Anatomical: Anal verge to Dentate Line (Anatomical Anal canal is Anoderm)
Surgical: Anal verge to Puborectalis muscle (Once resect beyond it> Incontinence)
Lines: Dentate/Pectinate Line: Divides Upper & Lower Anal canal
Hiltons White Line (Intersphincteric groove):
Below Dentate Line; Between External (Levator Ani muscle) & Internal sphincter muscle
Also the Transition from Non-keratinized to Keratinized Stratified Squamous epithelium
Cancer: Anal: At/Above Dentate Line
Uptodate: Anal canal SCC is by convention the Anal canal Cancer
Anal canal AdenoCA is treated as Rectal AdenoCA
Anal margin: Below Dentate Line, Above Anal verge
Perianal: Arising from Skin, within 5 cm radius of Anal verge
Upper vs Lower Anal Canal (by Dentate Line):
Upper Half or 2/3: Endodermal origin; Columnar epithelium
Supply: SRA, Inferior Hypogastric plexus (Thus Internal Hemorrhoid Painless)
Internal Iliac LN
Lower Half or 1/3: Ectodermal origin; Squamous epithelium
Supply: MRA/IRA, Inferior Rectal nerves (Thus External Hemorrhoid Painful)
Superficial Inguinal LN (once below Hiltons White Line)
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GI Common Anorectal Conditions

Common Sx: Bleeding (usually Fresh blood), Anal Pain, Discharge, Prolapse, Perianal Mass, Pruritis ani,
Incontinence
Pain: Sharp/Dull/Burning, Constant/Intermittent,
Associated with Bowel movement/Activity/Bleeding
Bleeding: Onset & Duration, Characteristics (Bright Red/Dark), On Paper/In Bowel/On Stool/In Stool,
Black Tarry Stool, Associated with Bowel Movement/Pain
PE: GE, Abdominal, Perianal, DRE, Proctoscopy
Anorectal Exam: Left Lateral Position: Prone Jackknife Position:

Ix: Endoscopy: Rigid Sigmoidoscopy, Flexible Endoscopy
TransRectal US: Staging of Rectal Cancer
Assess Sphincter Muscles in Pt with Fecal Incontinence
Assess Complex Fistula
Contrast Study: Barium Enema, Defecography (In Pt with Constipation), Fistulogram
Other Imaging: CT, MRI (Most accurate technique for Evaluation of Primary track of Fistula & any Extensions)
Anorectal Physiology Test:
For Ix of Constipation & Incontinence:
Anorectal Manometry, ElectroMyogram, Pudendal Nerve Latency Test
For Documentation after Tx
Hemorrhoid/Pile: Cushion of Vascular tissue at Anal Canal:
Aid in Continence (act as a plug), Protect Sphincter/Anus from Trauma of Defecation
(Bleeding: Bright Red blood rather than usual Dark Red Venous blood, due to Shunting)
Prevalence: 4.4% of US population see physicians for Symptomatic Hemorrhoid
49/100k US population undergo Hemorrhoidectomy annually
Etiology: Constipation, Straining, Pregnancy, Low Fibre Diet, FHx
Type: External: Distal to Dentate line, Squamous Epithelium (Skin), Nerve endings
Internal: Proximal to Dentate line, Columnar Epithelium (Mucosa), No Nerve endings
Internal: 1st degree: No Prolapse (If symptomatic, usually Bleeding)
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2nd degree: Prolapse out of Anal canal, and Reduce Spontaneously
rd
3 degree: Require Manual Reduction
4th degree: Cant be Reduced
Sx: *Bleeding, *Prolapse, Mucus Discharge
Pain only when Cx present (Thrombosis)
Assessment: DRE: Exclude other lesions; (Cant dx early Hemorrhoid like 1st degree)
Proctoscopy: For Dx & Assessment of Severity
Exclude Proximal bowel lesion
Suggested Tx: 1st /2nd degree: Diet, Banding, Sclerotherapy, InfraRed
rd
3 degree: Diet, Banding, Sclerotherapy, Surgery
4th degree: Hemorrhoidectomy
External: Conservative (eg. Lifestyle modification)
Surgical: Hemorrhoidectomy Perianal skin tag Excision
(External Hemorrhoids can become Skin tags)
Non-op: Diet Modification: High Fibre Diet
Warm Bath (eg. Sitz Bath): For Prolapsed Hemorrhoid; (Relieve Painful Perianal conditions)
Ointment & Suppositories: Lubricants, Antiseptics, Anti-inflammatory, LA, Steroid
Eg. Anusol, Ultraproct, Micronised Purified Flavonoid Fraction (MPFF)
Office Procedure:
Banding (Rubber Band Ligation)
(Tenesmus is normal after banding; Sloughs off in 1 week)
(Mostly Safe; Cx: Pain, Rarely Necrotizing Pelvic Sepsis in IC Pt)
(Contraindications: External Pile (Make sure Pile above Dentate Line), Coagulopathy)
Sclerotherapy (by Sclerosing agent, classically 5% Phenol in Almond oil) (S/E: Ulcer, etc)
InfraRed Coagulation (Not commonly used)
Surgery: (SH Lo: Stapled usually preferred first, unless:
4th degree
High risk Pt, eg. Post-TURP (Risk of Rectal perforation), Genital Prolapse, etc)
Conventional Hemorrhoidectomy:
(Done in Prone Jacknife position)
Use: Severe Hemorrhoid (3rd/4th degree), Mixed Internal & External, Failure of other Tx,
Pt Preference, In conjunction with another procedure
Cx: Pain!, Bleeding, Urinary Retention, Fecal Impaction, Infection (Uncommon),
Anal Tags, Anal Stenosis (if took too much Skin), Incontinence (if took too much M)
Stapled Hemorrhoidopexy:
(Done in Lithotomy position)
Mechanism:
Use Stapling device to remove a ring of Rectal Mucosa & Submucosa,
with Creation of Mucosal Anastomosis above Dentate line
Hemorrhoids are Not excised, but pulled back into Anal canal from Prolapsed position
? Interruption of Blood supply to Hemorrhoid
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Pros: Less Pain, Less Analgesic requirement, Quicker Recovery, Shorter Hospital Stay,
Higher Pt Satisfaction, Less Post-op Bleeding/Wound Cx
Cons: Cx can be serious: Rectal Perforation, Severe Pelvic Sepsis, Rectovaginal Fistula
More Recurrence than Conventional Hemorrhoidectomy
Transanal Hemorrhoidal Artery Ligation (Newer technique)
(CC Foo: No wound> Less Pain, Less Cx
But Higher Cost: Need a Special Proctoscope but prone to damage after use
If cant identify & ligate all suppliers in 1 go, may need extra op)
Anal Fissure/Fissure-in-ano:
Split in the Anoderm at Dentate line
90% at Posterior Midline (Poor Blood Supply) (2010 MCQ 10); Anterior Midline in 10% Women
Chronic Fissure: Associated with Sentinel Pile, Hypertrophic Papilla,
Visualization of Internal Sphincter Muscles at Base of Fissure
Etiology: Hard Stool, Tight Internal Anal Sphincter, Ischemia of overlying Anoderm at Posterior Midline
If Atypical Position & Multiple: IBD (2014 MCQ 14), TB, Syphilis, HIV, CMV
NB: 2006 MCQ 15: Can be caused by CD, TB, Cryptogenic Infection, Iatrogenic Post Anorectal op
Not by Amoeba
Clinical: Pain on Defecation, Fresh Rectal Bleeding
Dx by Spreading the Buttock to reveal the Fissure (Clinical Dx, No need Ix)
Rectal Exam & Proctoscopy: Painful, Not indicated
st
Tx: Medical: 1 line
Bulk agent, Stool Softener, Topical Anesthetic
Newer Topical agent to Internal Anal Sphincter Pressure:
Nitroglycerin (2014 MCQ 14), CCB, Botulinum Toxin
Surgical: Lateral Internal Sphincterotomy Commonest Surgery for Anal Fissure
Healing rate 95% (2005 MCQ 21)
Incontinence 0-15%, mostly Minor with Flatus Incontinence
Anorectal Abscess:
Etiology: *Cryptoglandular Infection
Specific Infection: IBD, TB, Actinomycosis, Foreign Body, Surgery, Malignancy
Clinical: Pain, Swelling, Drainage, Constipation, Urinary Difficulties
Site: PeriAnal 20% InterSphincteric 18% IschioRectal 60% SupraLevator 2%
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Tx: Incision & Drainage of Abscess
Little role for Antibiotics (except Severe Cellulitis, VHD, Prosthetic Valves, Immunosuppression)
? Primary Fistulotomy (50% will eventually develop Fistula)
Anal Fistula/Fistula-in-ano:
Abnormal Tract communicating Rectum or Anal Canal
Cyrptoglandular Infection
Classification: InterSphincteric, TranSphincteric, ExtraSphincteric, SupraSphincteric (above Levator ani)
ExtraSphincteric: Might be Iatrogenic

Clinical: Drainage, Pain, Bleeding, Swelling, in Pain with Drainage, External Opening
PR: Induration with Cord-like structure
Dx: Clinical Exam
MRI in cases of: Complicated High Fistula, Recurrent Fistula, When Anatomy is Not obvious
Tx: Simple Low Fistula: Fistulotomy/Fistulectomy
Risk of Incontinence should be told
Complicated High Fistula or Transphincteric Fistula with significant Muscle involvement:
Seton (Staged procedure), Endorectal Advancement Flap,
Anal Fistula Plug, Ligation of Intersphincteric Fistula Tract (LIFT)
Cx: Incontinence, Recurrence
Pruritus ani: Occur in 1-5% population, Common in 5th/6th decade
Itchiness in Perianal region; Scratching lead to Excoriation & Secondary Infection
Etiology: Personal Hygiene, Diet, Systemic disease, Dermatological condition, Neoplasm, Infection,
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Psychogenic, Drugs, Diarrhea, Idiopathic
Approach: Identify Etiology & Treat appropriately
Idiopathic: Reassurance, Keep Perianal Skin Dry, Avoid Soap & Local applications,
Avoid Prolonged Topical Steroid, Dietary change
Rectal Prolapse: Full Thickness Protrusion of Rectum through Anal Sphincters
Internal Prolapse: Rectum Intussuscepts but does Not pass beyond Anus
Occur in any Age but more common at Extremes of life
Anatomical Abnormalities:
Rectal Intussusception, Deep cul de sac, Loss of Rectal Fixation, Redundant Sigmoid,
Levator ani Diastasis, Patulous Anal Sphincter, Pudendal Neuropathy
Etiology: Neurological disorder, Parity, 25-50% associated with Constipation
Childhood: Cystic Fibrosis, Whooping Cough, Developmental abnormalities, Malnutrition
Clinical: Incontinence, Constipation, Protrusion, Bleeding, Discharge, Sensation of Incomplete Emptying,
Rectal Pressure/Tenesmus
Tx: Abdominal Repair: Rectal Fixation, Sigmoid Resection, Proctectomy,
Combination of Rectal Fixation & Sigmoid Resection
Perineal Repair: Full Thickness Resection, Mucosal Resection with Muscular Reefing,
Anal Encirclement
Pilonidal Sinus: M:F = 4:1; Greatest incidence between Puberty & 40yo
Etiology: Congenital, Acquired
Site: *Natal Cleft (2005 MCQ 88)
Tx: Incision & Drainage of Abscess, Wide Excision of Sinus to Fascia,
Z-Plasty & Myocutaneous Flap for Complex & Recurrent disease, Meticulous Hair Control
Anal Neoplasm:
Epidermoid CA of Anal Canal (usually SCC):
RF: Anal Intercourse, STD, HPV Infection
Presentation:
Bleeding, Pain, Anal Mass
Staging: T1: 2 cm
T2: >2 cm, 5 cm
T3: >5 cm
T4: Adjacent organs, eg. Vagina, Urethra, Bladder
NB: For Anal canal AdenoCA: Stage as Rectal CA if >2 cm above Dentate line
Tx: ChemoRT (2015 EMQ 4, 2010 EMQ 13)
APR (Abdominal Perineal Resection) for Residual/Recurrent disease
NB: For Anal canal AdenoCA: Treat as Rectal CA, ie. by Surgery (usually APR)
Prognosis: 5 year Survival: 80-90%
Melanoma: Anal Melanoma account for 1% of all Melanoma
Anal Margin Cancer: (Uptodate prefers grouping them into Perianal Skin Cancer)
SCC, Basal cell CA, Kaposis Sarcoma
Perianal Skin Cancer:
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Tx: For T1N0 well differentiated CA clearly separated from Anal canal:
Wide Local Excision RT (if High risk Histology)
NB: T1 = Size 2 cm with 2 High risk features
For T2 or Sphincter function may be compromised by Surgery:
ChemoRT (2005 EMQ 2)
Surgery for Persistent/Recurrent disease
Rectal Carcinoid (2015 EMQ 6, 2010 EMQ 15):
Tx: T1 (Size 2 cm, Limited to Mucosa/Submucosa):
T1a (Size <1 cm):
Endoscopic resection
T1b (Size 1-2 cm):
Low risk: Transanal Excision or Advanced Endoscopic resection
High risk: Radical resection
T2 (Size >2 cm, or invades Muscularis propria):
Radical resection (LAR/APR)

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GI Fecal Incontinence
Fecal Incontinence: Involuntary Loss of Feces
Cause:
Anal sphincter injury:
Obstetric injury (May involve both Direct Sphincter injury & Pudendal nerve injury)
eg. Vaginal delivery (~10% women will have Fecal Incontinence in sometimes of their life)
(Instrumental delivery, Occipito-Posterior position, are other RF)
Anorectal Surgery:
eg. Lateral Internal Sphincterotomy (up to 14%), Anal Fistulotomy (up to 45%)
Anorectal disease:
Rectal prolapse (Chronically dilate Anal sphincter)
Distal Rectal tumor (Can cause Overflow Incontinence)
Chronic Inflammation (eg. IBD, Radiation Proctitis; Can Rectal Compliance)
Neurological disease:
CNS: eg. Neurodegeneration (eg. Dementia), Stroke, MS
ANS/PNS: eg. DM
Assessment:
Hx: HPI, Obstetric Hx, etc
Useful tool: Wexner Fecal Incontinence Score
Fecal Incontinence Quality of Life Score (FIQOL)
PE: Look for Scar over Perineum
DRE can assess Anal tone & any Anal Mass
Endoanal US: Structural imaging of Anal canal including Anal sphincters
Anorectal Manometry:
Evaluate Functional status of Anal sphincters
Tx: Conservative:
Lifestyle modification
Biofeedback:
Provide training to improve strength of Pelvic floor muscle & Coordination during defectaion
(Info about bodys performance is detected & displayed back to Pt by instruments)
(Success rates 50-90%)
Medical Tx:
Anti-Motility agent, Regular Enema use, etc
Surgical:
Sphincteroplasty: Conventional
Aim: Repair defect of Anal sphincter
Incision made anterior to anus> Dissect down to Sphincter level
Identify & Repair Sphincter defect, in Overlapping or End-to-End fashion
ST outcome (by Wexner scores) improves, but deteriorates with time
Perianal Injection of Bulking agent:
Aim: Augment Anal sphincter to improve Fecal Incontinence
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Bulking agent: Autologous Fat, Collagen, Teflon (PTFE),
Bioabsorbable materials (eg. Stabilized Hyaluronic acid NASHA Dx)
Injected into Submucosa of Anal canal or Intersphincteric space
LT outcome is good
Tx related S/E: Common: Proctalgia 14%, Fever 8%
Serious: Rectal Abscess 1%, Prostatic Abscess 1%
Sacral Nerve Stimulation:
Electrode placed adjacent to S3 nerve root through Sacral foramen
Impulse generator implanted in Buttock
LT outcome also good
Artificial Anal sphincter:
Aim: Provide External Pressure by a deflatable cuff
which connected a pressure regulating balloon implanted anterior to bladder
Significant Risk of Device-related Infection (up to 76% in 1 case series)
Magnetic Sphincter Augmentation:
Relatively New modality (first performed on human in 2008)
Magnetic sphincter: A series of Titanium beads, each with a magnetic core,
linked with individual titanium wires to form a ring
Placed around External Anal sphincter to provide additional closing pressure of Anal sphincter
Lt outcome also encouraging

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HBP Hepatomegaly
Ddx: Malignant: Primary Liver Malignancy: HCC, CholangioCA, Others (eg. Primary Hepatic Lymphoma)
Secondary Liver Metastasis: Metastasis from GIT, Metastasis from other Primary
Hematological Malignancy: Chronic Leukemia, Lymphoma, MPN
Benign: (All causes of Cirrhosis can potentially lead to Hepatomegaly, except Chronic Viral Hepatitis)
(The following subcategories are Not definite, just to aid memory)
Non-Tender:
Nodular:
Benign Tumor: Hemangioma, Adenoma, Focal Nodular Hyperplasia
(Hemangioma is common, but rarely as Large as causing Hepatomegaly)
Cyst: Simple Cyst, Polycystic Liver (*ADPKD Associated with PKD; ADPLD Isolated)
Smooth:
Fatty Liver: Alcoholic SteatoHepatitis (Any Alcoholic Liver disease can cause Hepatomegaly)
NAFLD NASH
Biliary diseases: PBC, PSC, Biliary Atresia in Paedi
(Actually any Biliary obstruction can potentially lead to Hepatomegaly)
Metabolic: Wilsons disease, Hemochromatosis, Glycogen/Lysosomal Storage disease, etc
Infiltrative: Sarcoidosis, Amyloidosis, etc
Tender: Venous Congestion: Cardiac Cirrhosis/Congestive Hepatopathy (CHF, RHF), Budd-Chiari
Acute Hepatitis (Viral, Drug-induced, Toxin, Autoimmune, etc)
Infection: Liver Abscess, Infectious mononucleosis, Malaria, Hydatid cyst, TORCH, etc
(Note HCC & Secondary Liver Metastases can be Tender too)
Misc: Post-transplant: Compensatory Hepatomegaly, PTLD (asso. with EBV, but its Not Malignancy)
Iatrogenic: Post-PVE/ALPPS
Hx: Pain, Change of Bowel Habit, other GI Sx, Tea-color Urine
Systemic Sx of Malignancy (Anorexia, Nausea, Weight Loss), Fever
Systemic review of other systems (Screen for Common Cancer in Breast, Lung, GI, GU, etc)
Past Hx of Chronic Liver disease
Social Hx: Alcohol
FHx: Any Malignancy
PE: GE: Cachexia, Pallor, Jaundice, Lymphadenopathy, Stigmata of Chronic Liver disease
Abd Exam: Hepatomegaly: Size, Tenderness, Consistency (HCC may not be Hard), Surface, Edge, Bruit
Other Organomegaly (Spleen: Portal HT/Hemat Malignancy) (Kidney: PKD), Mass, Ascites
PR Exam: (Rmb to feel for Rectal CA, Prostate/Cervical CA, Pelvic deposits from Peritoneal Mets)
Characteristics: (In general)
Diffuse Smooth Firm: Alcoholic Liver disease, Hematological Malignancy
Irregular Hard: HCC, CholangioCA, Secondary Malignancy
Ix: Blood tests: CBC (Chronic Blood Loss from GI Cancer, Splenomegaly, Hemat Malignancy),
LFT, Coagulation (Cirrhosis), Hepatitis Serology (B&C),
Tumor Markers (AFP, CEA, CA 19.9)
Imaging: CXR, US (initial Ix), CT, MRI
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HBP Hepatomegaly
Endoscopy: For Suspected GI Primary: Upper Endoscopy, Colonoscopy
Biopsy: (Low risk but Serious Cx: Hemorrhage, Tumor Seeding)
FNAC, Trucut Core Biopsy
Mx: Surgical/NonSurgical (depend on Cause)
Misc:
Hepatic Adenoma: (2012 MCQ 15)
Most common Liver tumour in Young women on OCP
Typically Asymptomatic until Rupture
CT: Density: Fresh Hemorrhage (Hyperdense), Fat (Hypodense), Isodense
Well marginated
Homogenous Arterial Enhancement upon Contrast
Tx: Surgery if feasible (Benign but very small risk of transformation to HCC)

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HBP Hepatomegaly
HBP HCC
Hepatocellular CA:
Incidence: Commonest Primary Liver Cancer (80%)
Second Commonest Cancer Death in HK
Also common in other countries in Asia & Africa, Less common in Western countries
M:F = 4:1 (Male more likely to develop HCC)
Usually Age >50 but can occur in Young
Cause: HBV: 80% of HCC in HK are HBsAg +ve; Risk of HCC is 100x Higher in HBV carrier
Can cause HCC without Cirrhosis (Carcinogenic virus)
HCV: Common in Japan & Western countries
Risk of HCC in Chronic HCV Infection (Must gone through Cirrhosis to cause HCV)
Alcohol: High Alcohol consumption Risk of HCC, may also be due to Alcoholic Cirrhosis
Alcohol also has Synergistic effect with HCV Infection in development of HCC
Cirrhosis: All Cirrhosis regardless of Etiology can lead to HCC
(Thus NAFLD & DM are also potential RF)
Toxins: Aflatoxin: Fungal Toxin, may contaminate Corn, Soybeans, Peanuts
Less important role in HK; More in Rural China
Others: Contaminated Drinking water (Pond-ditch water), Betel nut chewing
Others: Sex Hormones (?? OCP & Androgens in Non-Cirrhotic Liver,
possibly via Hepatic Adenoma with Malignant Transformation)
Parasites (eg. Schistosomiasis) (cf CholangioCA frequently asso. with Clonorchiasis)
Genetic (eg. Hemochromatosis)
Pathology: 3 Macroscopic types: Massive, Nodular, Diffuse (May be Smooth in Diffuse type)
Massive: In Non-Cirrhotic Liver, In Young Age group
Large tumor with adjoining Nodules
Variegated cut surface
Nodular: Multiple Greyish White, Yellow or Brown Nodules in Cirrhotic Liver
Diffuse: Least common; Indistinguishable from Cirrhosis
Histologic variant Fibrolamellar HCC:
Uncommon; Associated with Young Female, Good Prognosis
No background of Chronic Liver disease, AFP usually Normal
Rapid growing Vascular tumor:
Blood supply mainly from Hepatic Artery (cf Normal Liver depends more on Portal Vein)
High Propensity for Venous Invasion (Portal & Hepatic veins)
Portal Vein: (UCH: Most important predictor of Tumor Recurrence)
Tumor thrombus spread through Liver via PV blood flow
(Thus Anatomic Resection of Liver segment based on PV)
Retrograde spread of Tumor thrombus to Main PV
can cause complete PV Thrombosis & Portal HT
Hepatic Vein: Invasion Less common than Portal Vein
Account for Distant Metastasis
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HBP HCC
Metastasis: Intrahepatic Metastasis to rest of Liver via Portal Venous Circulation
(Lymphatic Metastasis in 1/4 Pt)
Peritoneal Metastasis (Rare)
Distant Metastasis via Hepatic vein Dissemination, eg. Lung, Bone, Adrenal
Frequent association with Cirrhosis (80% in HK)
Screening for Small HCC:
Candidates: HBV/HCV carrier, Cirrhosis, Family members of HCC
Modalities: AFP, US
AFP: Level can correlate with Tumor Size (but some tumor may Not secrete AFP)
Overall Sensitivity 70-75%, Screening Sensitivity 50%
US: Should Not miss tumor >2 cm
1-2 cm: Depend on Operator
<1 cm: Usually Not detectable
Interval: 6 months (to 12 months)
Mean Tumor Volume Doubling Time ~6 months (200 days) for Small HCC
(Tiffany Wong: 3 months)
90% detection rate
Clinical:
Asymptomatic/Subclinical:
Screening with AFP & US in HBsAg carrier/Cirrhotic Pt
Incidental finding on Abdominal Imaging
Local S/S:
RUQ Pain: Liver is Insensitive to Pain
May occur in Large HCC, Hemorrhage (Internal Bleed> Capsular distension), Necrosis, Infection
NB: Most common Sx (Med 2014 MCQ 27)
Hepatomegaly:
May be Absent, depending on Size & Segment affected
Jaundice: Cholestatic: Intrinsic: Direct Duct Invasion/Infiltration
Dislodged Necrotic tumor debris
Hemobilia due to Tumor Hemorrhage
Extrinsic: Compression by Tumor Mass
Compression by LN (over porta hepatis)
Hepatitic: Pre-existing Cirrhosis
Acute flair of Chronic Hepatitis
Others: Compressive/Invasive Sx on surrounding structures (eg. Stomach, Diaphragm, etc)
Constitutional Sx
Ruptured HCC: Intraperitoneal Hemorrhage> Acute Abdomen; (Uncommon but High Mortality)
Liver Cirrhosis Decompensation:
Ascites, Variceal Bleeding, Hepatic Encephalopathy
(NB: HCC can also cause Budd-Chiari syndrome)
Paraneoplastic: Fever (NB: Some does not classify Fever as Paraneoplastic)
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HBP HCC
HyperCa (Due to PTHrP secretion, or Osteolytic lesions in Bones)
Hypoglycemia (Due to IGF secretion, as tumor has High Metabolic demand)
Polycythemia (Due to EPO production; Note most HCC Pt are Anemic though)
Diarrhea (UCH says due to Serotonin-like substances, Andre Tan says due to Gastrin)
Metastasis: Lung, Bone, Adrenal, etc
(Andre Tan: Low Incidence, Mortality rarely due to Metastasis)
Ix:
1. Blood tests:
CBC
LFT: Non-specific, may reflect underlying Cirrhosis, or isolated ALP due to SOL effect
Clotting profile
AFP: Diagnostic level of HCC: >400 ng/ml (Diagnostic if with Imaging)
Can be Normal in 40% Small HCC (<20 ng/ml? Andre Tan: <5 ng/ml)
False +ve: Pregnancy, Infant, some Germ cell tumor, Cirrhosis, Hepatitis, etc
(CL Lai: Ddx HCC vs Post-Reactivation by LFT pattern, US, Serial AFP)
(UCH: In case of HCC surveillance with Normal Baseline AFP,
any in AFP >20 ng/ml should use Triphasic CT for Early HCC Not detected by US)
HBV/HCV Serology: (Dr. Chok: NBNC HCC in HK only ~5%)
2. Imaging: (HCC can be diagnosed by Imaging even without Histology)
US: UCH: Typically Hyperechoic/Heterogeneous (mosaic pattern) lesion
with Hypoechoic border of Fibrous Capsule
Can evaluate Portal vein status too; Doppler may also show Vascularity in tumor
(May also see Cirrhotic Nodule, Ascites)
Triphasic CT: Most common Diagnostic Imaging
3 phases: QMH: Non-contrast, Arterial, Portal Venous
UCH/Andre Tan/Medscape: Arterial, Portal Venous, Late/Delayed
Features: Typical: Arterial Enhancement with Rapid Portal Venous Washout!
Hypodense in Non-Contrast phase
Hyperdense in Arterial phase
Hypodense in Portal Venous phase
NB: In Normal Liver, 2/3 Blood supply from Portal Vein, 1/3 from Hepatic A
In HCC, almost 90% Blood supply from Hepatic A
> More Hyperdense than nearby Liver tissue in Arterial phase
Others: Central Necrosis in Large tumor (Internal Mosaic pattern Variable Attenuation)
NB: CT can also check Vascular invasion, Biliary invasion, LN involvement, Metastasis, Volumetry, etc
Hepatic Arteriography:
Typical Neovascularization; For Uncertain cases after CT (Rarely done nowadays)
Post-Lipiodol CT:
Inject via Arteriogram, Repeat CT in 2 weeks for Uptake by Tumor
Lipiodol will be retained in HCC as HCC does Not contain Kupffer cells to ingest Lipiodol
For Uncertain cases after CT & Hepatic Arteriography
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HBP HCC
MRI: Alternative to CT; May also be useful in Uncertain Dx after CT
3. FNAC/Trucut Biopsy: (Usually Not done)
Risk of Tumor cell Seedling along Needle tract (May make Pt unsuitable for Transplant)
ONLY for Unresectable cases
4. Liver Reserve Assessment:
Child-Pugh score:
(Only Childs A & Good Childs B can be considered for Resection)
(Used in Pt with Cirrhosis)
Indocyanine (ICG) Clearance test:
IV injection of special dye (Indocyanine Green) excreted solely by Liver to Bile
ICG R15 test Measures ICG Retention after 15 min
Best test for Liver Function Reserve if Planning for Surgical Excision
Cutoff: Major Hepatectomy (>3 segments): <14% (New suggested cutoff 20%)
(Minor Hepatectomy: 22%)
(SH Lam: Measures Dynamic Liver Function Membrane Excretory activities of liver cells
Only used in HK, Southeast Asia, Japan
Not good for Jaundice Pt: Both ICG & Bilirubin compete for excretion pathway
No value in Deep Jaundice Pt)
NB: In the past, Bromsulphthalein was used as the dye
CT Volumetry: (Can be done in ordinary CT)
Estimated Residual Liver Volume % (ERLV%), in terms of % of Estimated Standard Liver Volume
Need to be 30% in Non-Cirrhotic Liver, (40% in Cirrhotic Liver)
(SH Lam: Data from Liver Transplant
Standard Liver volume related to Body surface area in the population
Very useful in Normal Liver, eg. CholangioCA)
5. Metastasis Screening:
CM Lo: Usually Not done in 1st HCC presentation unless suspicion
PET: Only Dual Tracer PET is useful
FDG picks up Poorly-differentiated HCC
11C Acetate picks up Well-differentiated HCC
11C Acetate only available in Sanatorium
Cyclotron only in Sanatorium, and 11C Acetate has Short half-life
(Specificity only 50% for <1 cm lesions)
Staging: (CM Lo: BCLC Staging: Absolutely Not applicable in Asia
HCV/Alcohol are more common causes in the West
Poor Resection technique in the West
APASL guideline is more reasonable)
Tx: Based on Assessment of:
General status:
Aim to define whether Pt is Fit for GA
Age
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HBP HCC
Concomitant Medical disease
Hidden Medical disease: ECG, Spirometry (sometimes), Astrup, BG, RFT, etc
Tumor status:
Extent, ie. Size, Number, Location, Vascular Invasion, Extrahepatic spread
(QM now: Whether still confined to 1 side of Liver or Not; Size doesnt matter)
Liver Function status:
Aim to define whether Liver Function is sufficient for Hepatectomy (2014 SAQ 6)
PE, Liver Biochem (Albumin, Bilirubin), PT, Platelet, Child-Pugh score, ICG clearance test
Surgical (Curative): Partial Hepatic Resection, Liver Transplant, Local Ablative therapy (originally Palliative)
Surgical Resection: 1st choice; 5-year Survival 50%
Operative Mortality rate 1-5% (usually due to Post-op Liver Failure), Morbidity rate 30%
Factors affecting LT survival after Partial Hepatectomy:
Tumor Stage, Blood transfusion, Liver Function
Indication:
Standard: Only 20% Resectable
Unilobar disease
Absence of Main Portal vein/IVC Invasion
Absence of Distant Metastasis
Adequate Liver function: Childs A, ICG R15 <14%
QM: Individualized decision; eg. Even with Tumor thrombus in Portal vein, can still aim at Curative
Technique:
Non-Anatomic (Wedge) Resection:
Limited resection of a small portion of Liver without respect to vascular supply
Anatomic Resection:
Involve removing 1 Segments of Liver (Based on theory of Intrahepatic PV metastasis)
Segmentectomy
Right Hepatectomy: Segment 5-8
Right Trisegmentectomy/Trisectionectomy: Segment 4-8
Left Lateral Segmentectomy: Segment 2-3
Left Hepatectomy: Segment 2-4
Left Trisegmentectomy/Trisectionectomy: Segment 2-5 & 8
Central Hepatectomy: Segment 4, 5, 8
Caudate Lobe can be removed as an Isolated Resection or a component of above
Cx: Liver-related (2013 SAQ 3):
Bleeding
Ischemic damage to Liver remnant
(Prolonged rotation leading to twisting of inflow & outflow pedicles)
Iatrogenic Rupture:
May lead to Massive Bleeding, Peritoneal seeding, Disseminated CA cells
Liver Failure
Portal vein thrombosis
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HBP HCC
Wound Dehiscence
Infection: Wound Infection (usually Staphylococcus aureus, Pseudomonas aeruginosa)
Chest Infection
Infected Ascites
Biliary Fistula (less common nowadays)
Abscess: Perihepatic, Subphrenic (less common nowadays)
General: Resp: PE, Atelectasis, ARDS, Pleural Effusion
CVS: MI, DVT
GI: Bleeding, Fistula, Small bowel IO
Recurrence: After 3 years, ~50% (47.6%; Still common)
High due to Lack of established Adjuvant therapy in Prevention of Recurrence
Mainly in Liver remnant due to IntraHepatic Mets via Portal vein, or Multicentric tumor
Median Post-Resection Recurrence Time: 13.5 months
Need regular 3-monthly Surveillance with Serum AFP & CT for Recurrence
Early detection of Recurrence allow Tx with Re-resection, Local Ablation or TACE
Liver Augmentation (For Low ERLV):
(QM: Currently mainly in Non-Cirrhotic Pt, eg. Childs A
Consider if Liver transplant Not available)
Portal vein Embolization (PVE):
Traditional method; Can be done Percutaneously (Can avoid GA risk) or Surgically
(Cant do PVE if Portal vein Not patent?)
Associating Liver Partition and Portal vein Ligation for Staged Hepatectomy (ALPPS):
New method; 2-staged Hepatectomy
Pros: Much Shorter time needed to boost up future remnant liver volume than PVE
Cons: Originally criticized for High M&M
Now accepted for HCC & Secondary from CRC, but Not CholangioCA (High risk of Bile Leak)
Liver Transplant:
Good for those in association with Cirrhosis (Child B/C Cirrhosis) (Treat both HCC & Cirrhosis)
Main Limitation is Availability of Donor Organ
Indication:
Milan criteria: (Mainly in Child C Cirrhosis)
1 lesion 5 cm, or 3 lesions 3 cm (If >5 cm, likely to have Circulating Cancer cells)
No Macroscopic Venous Invasion (in Imaging studies)
No Extrahepatic Metastasis (Distant Metastasis)
UCSF extended criteria
Bridging therapy:
RFA may be used to Shrink disease/Slow progression until donor liver available
Local Ablative Therapy:
Can be done as a procedure rather than a Surgery, or incorporated intra-op
(Intention of Local Ablation: Curative, Bridging, Palliative, etc)
May be good for Small HCC in those with Poor Liver status/Poor GC
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HBP HCC
Type: Physical Ablation: Heat: RFA, Microwave, HIFU
Cold: Cryotherapy
Chemical Ablation: Ethanol
1. Percutaneous Ethanol Injection:
US-guided, for 3 tumors of 3 cm (UCH: Usually Small lesions <2 cm)
First technique but now Less popular
Pros: Good for Soft Hypervascular tumor
No Heat Sink Effect near BV, Wont cause Biliary Stricture
Cons: Multiple sessions needed (cf RFA usually only 1)
Effect Not well predicted
2. Radiofrequency Ablation (RFA):
Most common Ablative technique used now
Induces Tumor destruction by heating tumor tissue to >60C
Cool-tip RF system (Radionics) using disposable electrodes (17G)
(Now also have Cluster probe to Area)
US/CT-guidance
(NB: In US, when heating tissue, can see White stuff flowing in vessels
These are Nitrogen bubbles, as Solubility with Temp)
Indication: HCC <5 cm
Satisfactory Liver Function reserve
Laparoscopic/Open approach for HCC near Viscera
UCH: Size: Usually Ablation Zone is ~5x5x5 cm3 for RFA, ~6.5x5x5 cm3 for Microwave
To get an adequate margin of 1 cm, the lesion must be 3 cm
For Larger lesion, can do Open/Laparoscopic Ablation with Summation method:
Not Percutaneous:
Need many punctures, Difficult to Locate, Liver moves with Respiration
But still better Not >8 cm: SIRS (due to Necrotic tissues), Hemoglobinuria
3. Microwave ThermoAblation:
UCH: Pros: Higher Rate of Energy output than RFA:
Heat Sink Effect (Anything that flows can bring away Heat Energy):
Good effect even near great BV
Faster Heat (~6 min, cf ~24 min in RFA)
Cons: Cost (2-3x of RFA)
4. Cryotherapy:
Historical method for Liver Ablation, but now Not popular due to High Cx & Low Efficacy
UCH: Mechanism: Immediate: Water Crystallization
Dehydration with Toxic metabolite concentration
Protein Denaturation
Delayed: Vascular Stasis & Thrombosis
Late: Inflammatory cascade & Apoptosis
2 Major Cx: Cryo-shock: Due to toxic metabolites released from cells upon rupture
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HBP HCC
Bleeding: Volume Expands when Freezing> Rupture BV
5. High Intensity Focused US (HIFU):
(Not a Standard Tx universally, but practiced in QM)
NonSurgical (Palliative):
1. Local Ablation
2. Transcatheter Arterial ChemoEmbolization (TACE) (aka TransArterial ChemoEmbolization) ():
Procedure: Done by Interventional Radiologist
Vascular access via Common Femoral artery
Selective Angiogram over Celiac trunk SMA to identify Feeding arteries
(In some Pt, Right Hepatic artery may arise from SMA)
Selectively cannulates Feeding arteries to the tumor & Delivers High Local doses of Chemo
Targets tumor as it derives major blood supply from Hepatic artery
Embolization: Feeding artery is occluded with, eg. Gel foam
Mainly to prevent Systemic Toxicity, Also imposes Partial Ischemia
(NB: Sometimes may do TAC without Embolization, eg.
Intended to avoid obliterating BV to prolong Tx
Noticed Portal vein blockage in Venous phase)
Agents: Drugs: Cisplatin, Doxorubicin, Mitomycin C, Epirubicin, etc
Carrier agents: Lipiodol (TOCE Transarterial Oily ChemoEmbolization; Non-occlusive itself)
Lipiodol is preferentially uptaken & retained in Tumor cells
Drug Eluting Bead (New; Embolic effect to induce Tumor Ischemia; Self-paid)
Indication: Bilobar/Unilobar Unresectable tumors
Reasonable Liver Function (Bilirubin <50 umol/l) (Otherwise Ischemic damage leads to Failure)
Absence of Main Portal vein Thrombosis (& IVC)
(Absence of Complete obstruction; Liver will be totally Ischemic if Portal vein obstructed)
Absence of Distant Metastasis
NB: CL Lai: Also Contraindicated if Large HCC >10 cm or Diffuse HCC
Cx: Post-Embolization Syndrome: (Due to Hepatocyte & Tumor Necrosis)
Fever, Nausea, Abd Pain, AST/ALT after TACE (CL Lai: AST >2x ALT, due to Tumor Necrosis)
Common, Self-limiting within 1 week; (If Fever >1 week, do US to rule out Liver Abscess)
UCH: Routine H2 blocker after TACE
Liver Failure (CL Lai: 30%) (Esp in those with Cirrhosis; Monitor Coagulation profile)
Other Uncommon Severe Cx:
Liver Abscess, Ischemic Cholecystitis, Pancreatitis, Bowel wall Necrosis, Tumor Rupture
(Special Note on Shunting HCC:
If shunt to Portal vein, can still do TACE
If shunt to Hepatic vein, TACE is Contraindicated: Systemic Lipiodol Embolus may lead to PE
CL Lai: Severe AV shunting is a Contraindication; TACE Not effective Probably metastasized already)
Other TransArterial therapy:
RadioEmbolization:
TheraSphere Glass beads loaded with Radioactive Yttrium delivered angiographically
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HBP HCC
Very Expensive (Need to ship in Radioisotope)
3. Systemic Therapy:
Sorafenib (Nexavar, BAY-43-9006):
The only proven effective Systemic therapy (SHARP Trial)
Multikinase Inhibitor: AntiAngiogenic (Anti-VEGF), Pro-apoptotic, RAF kinase inhibitory activity
Efficacy: Survival by 2-3 months
Mainly Disease Stabilization (ie. Progression Free Survival)
Response rate only 3%
Very Expensive
S/E: (Well tolerated in general)
Diarrhea
Hand-Foot syndrome (Most common S/E in Asian):
Aka Chemotherapy-induced Acral Erythema or PalmoPlantar Erythrodysesthesia
On Palms & Soles: Erythema, Swelling, Desquamation
Numbness/Paresthesia
Fatigue
Bleeding tendency
Other Systemic Tx of Unproven Benefit (No Survival benefit):
Chemo: Epirubicin/Doxorubicin
Hormonal therapy:
Tamoxifen: ER, PR & Androgen receptors are expressed in HCC
Frequently used before due to its good Tolerability & Oral administration
But failed to demonstrate Survival benefit
Octreotide
Immunotherapy:
Interferon: No demonstrable benefit with significant Toxicities
Ruptured HCC:
Dx: US, CT (better)
Mx: Resuscitation
1st choice Tx is TransArterial Embolization
If Uncontrolled Bleeding> Laparotomy: Resection, (Local Ablation)
Prognosis:
Survival:
5-year Survival Rate:
Partial Hepatectomy: 50%
Transplantation: 75%
RFA: 40%
TOCE: 15%
Systemic therapy: <5%
Prognosis after Resection of Small & Large HCC:
<5 cm: 1-year 87.4%, 3-year 76.5%, 5-year 61%
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HBP HCC
>5 cm: 1-year 65.9%, 3-year 40.7%, 5-year 32.5%
Advanced HCC with Supportive Tx: Median Survival 2-4 months
Important Prognostic Factors:
Pre-op AST >50 U/L = More adverse prognosis
TNM stage
Comorbidities (important cause of post-op Mortality even with good Liver function reserve)
Blood transfusion requirement
(>90% Not needed nowadays due to newer techniques, eg. Ultrasonic dissector (CUSA))
Venous invasion
Operation time (Chance of Contamination & Infection)
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HBP HCC
HBP CholangioCA
CholangioCA: Malignancy of Biliary duct system; IntraHepatic vs ExtraHepatic (PeriHilar vs Distal ExtraHepatic)
(But in QM/HKU, the term CholangioCA is applied to IntraHepatic duct only?!)
AdenoCA of IntraHepatic Bile duct account for 5-20% of Primary Liver Malignancy
Mostly occur in >50yo
Lymphatic spread more common (cf HCC)
(2 Types: Mass-forming type, Stricture type)
RF: Parasites: Clonorchis sinensis (esp in HK)
Hepatolithiasis: Association with RPC (common in Orientals)
Chronic IBD: Association with UC (common in Westerners)
(PSC is strongly associated with UC (80% PSC has UC))
(PSC can develop CholangioCA)
(Congenital Liver disorders:
Choledochal Cyst, Caroli disease, Congenital Hepatic Fibrosis)
(Thorotrast: Old Radiocontrast agent that can cause CholangioCA, HCC, Angiosarcoma)
Anatomical Classification:
IntraHepatic 20%
*Hilar (Klatskin) 40%:
Bismuth-Corlette Classification of Hilar CholangioCA:
Type I: Below Confluence of Right & Left Hepatic ducts
Type II: Involves Confluence of Right & Left Hepatic ducts
Type III: Involves either Right or Left Hepatic duct AND extends to Secondary radicals
Type IV: Involves Secondary radicals of BOTH Right & Left Hepatic ducts
Distal ExtraHepatic 40%
Clinical: RUQ Pain, Hepatomegaly, Jaundice
IntraHepatic: Usually Insidious without Jaundice; Often presents Late
ExtraHepatic: Early Jaundice; (CA Gallbladder commonly asso. with Gallstones)
Anorexia, Weight Loss, Fever
Dx: Tumor Markers: CarcinoEmbryonic Antigen (CEA), Ca 19.9
US, CT (Hypodense in Arterial phase, cf HCC), MRI
FNAC/Trucut Biopsy (Only for Unresectable cases)
Tx: Hepatic Resection is Tx of choice (Resectability rate ~20%)
Other Tx: No proven effect (even Liver Transplant it Not very Effective)

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HBP CholangioCA
HBP Metastatic CA to Liver
Metastatic CA to Liver: Commoner than Primary Liver Cancer
Commonest site form GIT (Portal Venous Circulation): Colorectal, Stomach, Pancreas
Clinical: Hepatomegaly Sx from Primary
RUQ Pain
General features of Malignancy: Anorexia, Weight Loss, Cachexia
Ascites suggest Peritoneal Seedling from GI/Gynecological primary
Dx: CEA or CA 19.9 in some cases with Primary GI Malignancy; (CA 15.3 if Breast CA)
(Amine levels, eg. 5-HIAA, for Carcinoid tumor)
US, CT (usually Hypoattenuating), MRI, PET
Ix for Primary: CXR, Endoscopy, CT Abdomen
Biopsy: FNAC/Trucut (Only for Inoperable cases)
Tx: Surgical:
Colorectal Metastasis:
Hepatic Resection can Survival in Resectable Liver Metastasis
Solitary or 4 Metastases all located within 1 lobe
5-year Survival 25% (ppt: 40%), 1/3 Recurrence in Liver remnant
Metastasis from Carcinoid/other Neuroendocrine tumors:
Resection may be Palliative by alleviating Sx due to Secretion of VIP, and may also Survival
Other Metastasis:
Resection of Liver Metastasis from Stomach/Pancreas is Not justified due to Poor Prognosis
NonSurgical:
Colorectal Metastasis:
Systemic Chemo/TACE may be indicated in Unresectable Metastasis (Response rate 20-30%)
Other Metastasis:
Use of Chemo depend on response of type of Tumor to Chemo
TACE may be useful for NeuroEndocrine tumour Metastasis (But Not as effective as HCC)
(Note that Tx of Metastatic Carcinoid tumor may include Somatostatin Analog)

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HBP Metastatic CA to Liver
HBP Portal HT
Definition: Portal pressure gradient >5 mmHg
Due to obstruction of portal blood
draining from Splanchnic circulation back to Systemic circulation
Portal pressure gradient (PPG) = Portal vein pressure Central venous pressure
PPG >10mmHg: Ascites
PPG >12mmHg: Variceal Bleeding
PPG 6-10mmHg: Subclinical Portal HT
Normal direction of flow of Splanchnic circulation:

Pathophysiology: PPG is the result of interaction between Portal blood flow & Vascular resistance to flow
Ohms Law

LT outcome of Portal vein Thrombosis: (Note that Acute Thrombosis is Life threatening due to Venous Gangrene)
Cavernous Transformation (Single channel PV turned into Multiple Tortuous Venous channels)
Collaterals Formation (Coronary vein is dilated)
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HBP Portal HT
Cause & Classification:
Prehepatic 20%:
Thrombophlebitis of Umbilical vein
Congenital Absence of PV
Malignant invasion of PV
Intrahepatic 80%:
Cirrhosis
Congenital Hepatic Fibrosis
Posthepatic: Budd-Chiari syndome
Constrictive Pericarditis
Recognition of Portal HT:
By Measurement of Portal Pressure: (Seldom done clinically)
Cannulation of a branch of Mesenteric vein at Laparotomy
Wedge Hepatic Venous Pressure
Percutaneous Transhepatic cannulation of Portal vein
By Clinical manifestation of Portal HT:
Due to: Back pressure effect on viscera leading to:
Splenomegaly
Ascites
Hepatomegaly in case of Post-hepatic cause
Dilatation of pre-existing Collaterals between Portal & Systemic circulation
Around Umbilicus: Caput medusae
At Lower end of Esophagus: Varices
At Rectum & Anal canal: Rectal Varices (Not easy to see)
Extraperitoneal surfaces: Silent

(Possible CT features:
Splenomegaly: Splenic tip crosses MAL
Cirrhotic Liver: Nodular Liver, Shrunken Liver (eg. doesnt cross Xiphisternum),
(Omentum between Liver & Anterior wall)
Recannulation of Umbilical vein)
Esophageal Varices: Collateral between Portal & Systemic circulation becomes Dilated (Varices)
But they are Thin wall veins & could Not support Large volume of Portal blood flowing through
Rupture may occur esp for Varices located at GEJ> Massive Bleeding
Variceal wall Tension may be the cause of Rupture
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HBP Portal HT
Dx: Barium Swallow
Upper Endoscopy
Bleeding Esophageal Varices:
Clinical: Hematemesis, Melena, Shock
Dx by Upper Endoscopy:
Active Bleeding from Varices, or
Blood clot on Varices indicating Recent Bleeding, or
Esophageal Varices only & Absence of other Bleeding source in Stomach/Duodenum
Tx of Bleeding Varices:
Aim: To stop bleeding if its seen to be present by Endoscopy
Majority of Bleeding already stop spontaneously by the time Pt is admitted into hospital
To restore/maintain normal BP/P, Urine output & Hematocrit
so that organ function, including Liver, is maintained
To prevent Hepatic Coma in cases of Cirrhosis
Blood breakdown product in gut absorbing into portal blood may lead to Hepatic Coma
Strategy at Admission:
IV fluid & blood replacement
Vasopressin/Terlipressin + Nitroglycerin
Upper Endoscopy: If Active bleeding is seen, insert Sengstaken-Blakemore tube
If Clear view at Upper Endoscopy, Experienced Endoscopist,
Injection Sclerotherapy/Banding can be an Alternative Tx now
If Active bleeding is Not seen, continue Supportive Tx
Correct Bleeding Tendency:
FFP infusion
Platelet concentrates infusion
Anti-Hepatic Coma Tx: Enema, Neomycin, Lactulose, Rifaximin (New but Expensive)
Antibiotic
Risk of Emergency Endoscopic Tx of Bleeding Varices:
Aspiration Pneumonia, Prolonged Hypotension,
Serious Cx 10-20%, Procedure related Mortality 2%
Sengstaken-Blakemore tube:
3 lumen: Gastric balloon, Esophageal balloon, Gastric aspiration channel
Stop Bleeding by Compression of GEJ & Interruption of blood flow from Gastric V to Azygos V
Inflation of Gastric balloon by 200ml
Traction by 1 lb weight
Do Not exceed 24h
Efficacy 90%
Problems: Incorrect position of Gastric balloon:
In Esophagus> Perforation of Esophagus
(Some may have a 4th Esophageal Aspiration channel to monitor for this)
Inadequate Traction> Continuation of Bleeding
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HBP Portal HT
Inadequate Size> Slipping out of Esophagus> Asphyxia, Laceration of Esophagus
(ST Fan: Traction weight should Not be >25 cm from ground
Even if slips out, wont go beyond Length of Esophagus)
Pt Saliva cannot empty into Stomach> Aspiration of Saliva into Trachea
Too Heavy & Prolonged Traction> Necrosis of GEJ
Drugs: Efficacy: Vasopressin 50%, Terlipressin 60%, Somatostatin 65%, Octreotide 65%
Vasopressin: Acts by ing Portal blood pressure by constricting Splanchnic arterioles
May induce Ischemia to Small bowel> Abd Pain
May induce MI
Nitroglycerin used to counteract vasoconstrictive S/E
Strategy after Stabilization: Aim to prevent Recurrent Bleeding
Means: Obliteration of Esophageal varices by Injection Sclerotherapy/Banding
Reduction of Portal vein pressure by creation of Shunt
between Portal vein (or its branches) to IVC (or its branches)
Reduction of blood flow to Stomach & Esophagus
by division & detachment of BV around GEJ, ie. Devascularization
Replacement of Liver if its Irreversibly damaged by diseases, ie. Liver transplantation
Injection Sclerotherapy:
Via Endoscope
Fine needle puncture of Varices
Sclerosant: Ethanolamine oleate, Sodium Tetradecyl sulphate
Banding:

Devascularization:

Shunt created by Surgery:
Examples: Porto-Caval shunt, Spleno-Renal shunt, Mesenterico-Caval shunt
Risk: Hepatic Encephalopathy (since Nitrogenous products are diverted away from Liver)
Liver Atrophy (since Gut hormones No longer goes into Liver)
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HBP Portal HT

Pros of Selective Shunt: Maintain Blood supply to Liver & Prevent Liver Atrophy
Risk of Hepatic Encephalopathy
Shunt created by Radiology: (Wont affect future Liver Transplant Surgery; No Scars)
Transjugular Intrahepatic Porto-systemic Shunt (TIPS)
Risk: Hepatic Encephalopathy
Choice of procedure:
Injection Sclerotherapy/Banding
All cases
Shunt created by Surgery:
Recurrence of Bleeding after Injection Sclerotherapy/Banding
For Childs A Liver function
Shunt created by Radiology:
In preparation for Liver transplantation
Devascularization: (ST Fan: Often a last resort esp if Liver transplant Not available)
For Childs C Liver function
Liver transplantation:
For Childs C liver function
Mx Protocol:
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HBP Portal HT
HBP Liver Failure & Transplant
Indication: Fulminant Liver Failure, AoC Liver Failure, Chronic Liver Failure, Metabolic disease,
Small Unresectable HCC
Fulminant Liver Failure:
Definition: Hepatic Encephalopathy within 8 weeks of Onset of Acute Liver Failure,
in Pt without Previous Liver disease (NB: HBV Carrier state counts as Liver disease)
(Severe, but still potentially Reversible, cf Hyperacute or Chronic)
Contraindication to Transplant:
Uncontrolled Infection: eg. Severe BronchoPneumonia, Fungal Septicemia
Cerebral Edema & Coning
Acute Hepatic Failure:
Classification System:

Cause: Drug Intoxication: Paracetamol, Halothane; (Western)
Food Poisoning: Amanita phalloides; (Rural)
Hepatitis: Hep A, B, E; (Developing countries)
Wilsons disease
Clinical: Early: Malaise, Anorexia, Vomiting, Jaundice, Tea-color Urine
Late: Hypotension/Vasodilation, Resp Failure, Renal shutdown, Cerebral Edema,
Invasive Infection, Bleeding Tendency, Impaired Conscious state (Fulminant Failure)
(Systems): Brain: Hepatic Encephalopathy, Cerebral Edema, Intracranial HT
Lungs: Acute Lung Injury, ARDS
Heart: High output state, Frequent Subclinical Myocardial Injury
Liver: Loss of Metabolic function
: Gluconeogenesis: Hypoglycemia
Synthetic Capacity: Coagulopathy
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Lactate Clearance: Lactic Acidosis
Ammonia Clearance: HyperAmmonemia
Portal HT: May be prominent in Subacute disease & confused with Chronic disease
Pancreas: Pancreatitis, esp in Paracetamol-related disease
Adrenal: Inadequate Glucocorticoid Production contributing to HT
Kidney: Frequent Dysfunction/Failure
BM: Frequent Suppression, esp in Viral & Sero ve disease
Systemic: Circulating WBC: Impaired function with Immunoparesis contribute to Sepsis risk
SIRS: High Energy Expenditure/Rate of Catabolism
Lab: AST & ALT, INR, Serum Bilirubin, Blood Ammonia, Serum Urea, BG
(Metabolism of Ammonia into Urea> Urea; Not reliable RFT indicator in Liver Failure)
Kings College Criteria for Liver Transplant:
Paracetamol:
pH <7.3 (Irrespective of grading of Encephalopathy) (Med 2003 MCQ 27)
Or All 3 of: Grade 3-4 Encephalopathy
PT >100s (INR >6.5)
Serum Creatinine >300 umol/L (3.4 mg/dL)
Non-Paracetamol:
PT >100s (INR >6.5) (Irrespective of Grade of Encephalopathy)
Or Any 3 of: Age <10 or >40
Etiology (Non-A/B Hepatitis, Halothane, Idiosyncratic ADR, Wilson)
Period of Jaundice to Encephalopathy >7 days
PT >50s (INR >3.5)
Serum Bilirubin >300 umol/L (17.5 mg/dL)
(Antidote for Paracetamol Overdose/Suicide:
N-acetylcysteine
Give early & for even Lower dosage for Pt at Risk for Liver disease)
Hepatic Encephalopathy Staging:
Stage Mental status Tremor EEG
1 Euphoric (sometimes Depression), Fluctuant Mild Confusion, Slight Usually Normal
Slowness of Mentation & Affect, Untidy, Slurred Speech,
Sleep Rhythm Disorder
2 Accentuation of Stage 1, Drowsiness, Inappropriate behavior, Present Abnormal
Able to maintain Sphincter control (Easily elicited) Generalized Slowing
3 Sleep most of the time but Arousable, Speech Incoherent, Usually Present if Always Abnormal
Marked Confusion Pt can cooperate
4 Not Arousable, May/May Not respond to Painful stimuli Usually Absent Always Abnormal
AoC Liver Failure:
Definition: Acute Hepatic insult manifesting as Jaundice (Bilirubin >90mol/L) & Coagulopathy (INR >1.5),
complicated within 4 weeks by Ascites/Encephalopathy,
in a Pt with Previously diagnosed/undiagnosed Chronic Liver disease
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Cause: Acute Exacerbation/Flare of Chronic Hepatitis B
Cirrhosis with Acute Deterioration: Hepatic function Decompensation> Death
Chronic Liver Failure:
Cause Cirrhosis of any Etiology:
Hep B, Hep C, Alcoholism, Primary/Secondary Biliary Cirrhosis, AI Hepatitis, Budd-Chiari
Cx of Cirrhosis:

Clinical: Malaise, Jaundice, Ascites & Infection (SBP), Bleeding Esophageal Varices, Coma
Lab: Platelet & WBC, Serum Albumin, INR, Serum Bilirubin
Indication for Transplant:
Worsening Liver Function: INR, Bilirubin, Albumin
Cx of Cirrhosis: Esophageal Bleeding, Intractable Ascites, Unresectable HCC
Strategy for Widening Liver Donor Pool:
2010 data: LDLT 60.8%, DDLT (Whole Graft) 34%, DDLT (Split) 3.1%, DDLT (Reduced Size) 1.5%,
Sequential LT 0.6%
Brainstem Death:
Dx: Fixed & Dilated Pupils, Not responding to Light
Absent Corneal Reflexes
No Motor response to Painful Stimuli
No Reflex activity except SC origin
No OculoCephalic Reflex (Dolls eyes)
No Vestibulo-Ocular Reflex
No Gag/Cough Reflex to Bronchial Stimulation
No Resp movement if Mechanical Ventilation stopped to ensure pCO2 >60 mmHg
Feasibility of Liver Donation:
No HBV/HCV/HIV Infection
No ExtraCranial Malignancy
Organ Preservation Solution:
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(Keeping Hypothermia is very important!)
University of Wisconsin Solution (UW Solution) at 4C:
Components:
HydroxyEthyl Starch HES: Support Colloidal Pressure
Lactobionate: Prevent Cell Swelling
Glutathione: Inhibit Oxygen Free Radical Generation
Adenosine: Enhance ATP Synthesis after Reperfusion
Allopurinol: Inhibit Oxygen Free Radical Generation
Others
Flush: In-situ, Bench
Viability: Hepatocytes 25%, Bile ducts 15%
Histidine-Tryptophan-Ketoglutarate Solution (HTK Solution):
Very different Components, but very similar Function
Orthotopic Liver Transplant:
Anastomoses: SupraHepatic IVC, InfraHepatic IVC, Portal Vein, Hepatic Artery, Bile duct
Technical Cx of Liver Transplant:
Bleeding, Reperfusion Injury, Air Embolism, Anastomosis Stenosis, Graft Failure
Priority of Brain-dead Organ:
According to Urgency
Pt with Fulminant Hepatic Failure will get first
Chronic Liver Failure Pt are prioritized according to Liver Function Grading
Liver Function Grading:
Child-Pugh Classification:
Bilirubin(umol/L) Prolonged PT(s) Albumin(g/L) Ascites HE
Score: 1 point 17-34 1-4 >35 None None
Score: 2 points 34-51 5-6 28-35 Slight 1-2
Score: 3 points >51 >6 <28 Moderate/More 3-4
Grade A: 5-6
Grade B: 7-9
Grade C: 10-15
Model of End-stage Liver Disease (MELD) Score:
Serum Creatinine, Serum Bilirubin, INR
Equation: 3.8 x loge (Bilirubin [mg/dl]) + 11.2 x loge (INR) + 9.6 x loge (Creatinine [mg/dl]) + 6.4
Brain-dead Organ Donation Rate:
HK: 4-6/million-year
Demand: 15-20/million-year
LDLT: Feasibility: Age <50
No HBV/HCV/HIV infection
No Medical disease
Altruism Real (Selflessness, No reward)
Remnant Liver 30% Total Liver volume
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Remnant Liver Regenerate to almost 100% in 3 months
Left vs Right Liver Donation:
Main difference Remnant Liver: 2/3 in Left Liver Donation, 1/3 in Right Liver Donation
Applicability: Limited in Left Donation (Only from Large to Small Body Size Recipient)
Adult-to-Child LDLT by Left Lateral Segment Donor Operation:

Adult-to-Adult LDLT using Right Liver Graft with Middle Hepatic Vein:

Cost & Benefit:
Recipient: Benefit: Life-saving, Life improvement, Earlier operation, Planned operation, Healthy Graft
Cost: Small-for-Size Graft
Donor: Benefit: Satisfaction
Cost: Mortality (R 0.5%, L 0.1%), Morbidity 15%, Surgical Scar, Long term Morbidity?
Morbidity: Cholestasis, Biliary Injury, Wound Infection, Hemorrhage, DVT/PE,
Portal HT, Scar, Pressure Ulcer, Financial burden, School
Post-op Drug for Recipient:
Immunosuppressant: IL-2 Antagonist (Simulect), Steroid, Cyclosporine/FK506,
Sirolimus/Everolimus, MMF
Antibiotics (Septrin against PCP)
AntiFungal (Ketoconazole/Fluconazole)
AntiViral (Acyclovir for CMV (50% coverage; Ganciclovir is expensive), AntiViral for HBV/HCV)
Immunosuppression:
Risk: Risk of Opportunistic Infection, eg. CMV, TB
Risk of Malignancy
Drug Specific S/E:
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Steroid: Moon Face, Osteonecrosis
Cyclosporine: Hairy Face, Nephrotoxicity
FK506: Nephrotoxicity, Neurotoxicity
MMF: Leucopenia
Sirolimus: HyperLipid
Current Trend of Practice:
Avoidance of Steroid
Dosage of Immunosuppressants
Long term Outcome: 5-year Survival 85%, Good QOL, Good Employment
Recurrence of original disease possible, Disease Transmission from Donor to Recipient possible

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HBP MBO
Malignant Biliary Obstruction (MBO):
Biliary tract Obstruction by Cancer Growth within/around Biliary tract
Cause of Biliary obstruction:
Benign vs Malignant:
Benign: Stone
Benign Stricture: TB, AI, Iatrogenic
Trauma
Parasites
Other causes of Cholestasis (PBC, etc)
Malignant: PeriAmpullary CA: Pancreatic head, Duodenum, Ampulla of Vater, Distal CBD
(Among these, CA Ampulla has best Prognosis as it presents Earlier)
CA Gallbladder: Cystic duct LN, Direct Infiltration of CBD, Tumor Fragments
CholangioCA at Hilum (Klatskin tumor)
HCC: Direct Infiltration, Compression, Tumor Fragments in CBD
Secondary Hilar LN from GI malignancy, Lymphoma
Mechanism of obstruction:
Intraluminal:
Stones, Parasites, Foreign body, Blood clot, Mucus, Tumor cast
Intramural: Malignant: CA Ampulla, CA CBD, Klatskins tumor
Benign: Stricture (Post-op, RPC), Choledochal cyst
Extrinsic: Malignant: CA Head of Pancreas, CA Duodenum, CA Gallbladder, HCC, Porta Lymphadenopathy
Benign: Mirizzi syndrome, Chronic Pancreatitis, Pancreatic Cyst
Level of obstruction:
Hilum: Klatskins tumor, Stone, CA GB, Mirizzis syndrome, RPC, PSC, HCC, Porta Lymphadenopathy
Mid-CBD: CA CBD, CA Head of Pancreas, Stone, Lymphadenopathy
Distal CBD: Periampullary CA (CA Ampulla, CA Head of Pancreas, CA Distal CBD, CA Duodenum),
Stone, Choledochal Cyst, Bile duct Stricture, Chronic Pancreatitis, Pancreatic Cyst

Pathology of Jaundice + Epigastric Mass:
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HBP Malignant Biliary Obstruction
Liver: Hepatomegaly secondary to Biliary Obstruction
Hepatomegaly due to Metastases or HCC (Hard, Irregular surface)
LN: LN Metastases to Celiac Axis or Porta Hepatis
Note although Pancreatic Cancer of Body/Tail wont cause MBO directly,
If LN Mets occur, can still cause MBO
Stomach: CA Stomach with Metastatic LN in Porta Hepatis
Distended Stomach due to Duodenal Obstruction by Tumor which Obstruct Bile duct as well
Liver Mass with Obstructive Jaundice:
SH Lam: If due to Compression, usually Mass situated near Confluence site of L & R Hepatic duct
From Anterior Liver: Segment 4/5
From Posterior Liver: Caudate segment (Uncommon)
MBO Pathophysi: Disruption of Endoplasmic reticulum & Canalicular membrane
Destruction of Hepatocytes
Reticulin> Collagen (Fibrosis), Portal HT
Consequence: Impaired Protein Synthesis, Impaired Clotting Factor Synthesis,
Impaired Gluconeogenesis, Impaired Ketogenesis,
Endotoxemia (Liver cant clear Gut Toxins), Reticulo-Endothelial function,
Cell-mediated Immunity
Clinical: Bleeding Tendency (Due to Impaired Vit K absorption, or even Liver Failure)
Poor Wound Healing & Poor Anastomosis Healing (Protein)
Renal Failure (HepatoRenal syndrome)
Infection (Biliary Sepsis)
Bleeding Gastric Erosion
Presentation: Tea-Color Urine (usually 1st Sx noticed; Dark Urine), Yellow Sclera & Skin, Weight Loss
UCH: In Prolonged Cholestasis (usually in MBO),
Conjugated Bilirubin will bind Irreversibly to Albumin (-bilirubin)
Cant excrete by Kidneys; Longer Half-life (14 days, as Albumin)
Account for Persistent HyperBilirubinemia despite successful Drainage
PE: Jaundice, Stigmata of Chronic Liver disease, Pruritus, Courvoisiers Law, Troisiers sign,
Hepatomegaly, Sister Joseph nodule, Ascites
Lab Test:
Blood test: Normal value: Bilirubin 20, AST/ALT/Albumin 40, Amylase/Creatinine 120
Tumor Marker: (Not useful during MBO; Mainly for Research purposes)
AFP: ULN 10 ng/ml
Malignant: HCC (70-90%), CholangioCA (10%)
Benign: Hepatitis, Cirrhosis, Biliary tract obstruction, Alcoholic Liver disease
CEA: ULN 5 ng/ml
Malignant: CRC (30-70%), Gastric CA, Pancreatic CA, Lung CA, Breast CA
Benign: Smoking, Liver disease (Obstructive Jaundice, Hepatitis, Alcohol),
Bowel disease, PU, Pancreatitis, Renal Failure, Fibrocystic Breast disease
CA 19.9: ULN 37 U/ml
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Malignant: Pancreatic CA (72-79%), Biliary CA (67-73%), Gastric CA (42-62%),
CRC (19-41%), Non-Gastric, HCC, Breast, Lung, Renal, Prostatic, Ovarian,
Lymphoma
Benign: Benign Biliary diseases, Benign Pancreatic diseases
CA 125: ULN 35 U/ml
Malignant: Ovarian CA (80%), other Gynecological Malignancies, Pancreatic CA (60%),
Other GI Malignancies
Benign: Benign Pancreatic & Liver disease
DUPAN-2: ULN 150 U/ml
Malignant: Pancreatic & Biliary tract Cancer (70%)
Benign: Benign Hepatobiliary diseases (Hepatitis, Cholelithiasis)
Imaging:
1. US/CT/MRI:
US Liver/Abdomen:
GB: Features of Acute Cholecystitis:
GB wall thickening (>3 mm), Pericholecystic fluid, Sonographic Murphy sign, GB distension
(Mild GB distension can be Normal, Fasting will mildly distend GB)
Biliary tree:
IHD/CBD dilatation Stones; (CBD dilated if >8 mm) (Bile duct is Hypodense, cf Hyperdense BV)
Liver: Liver Mass/Echogenicity, (Liver Consistency Fatty/Cirrhotic)
Pancreas: Pancreatic Mass (Difficult, may see Head only)
Others: Ascites, Splenomegaly, PV Thrombosis by Doppler
CT Abdomen Pelvis, CT Liver (Triphasic), CT Pancreas (Thin cut):
(Normally cant see Intrahepatic ducts; Dilated ducts are near Portal veins)
Characteristics of Primary tumor (T staging):
Size, Relationship with surrounding organs & vessels
LN
Distant Metastasis
Liver volume (in case of Hepatectomy)
MRI Abdomen/Liver (Not usually ordered in Public hospital)
2. EUS: Identification of Mass in Pancreas, Bile duct & GB
Assessment of Vascular & LN involvement
FNA for suspected lesion
Highly Operator Dependent (Not routine in UCH)
3. Cholangiogram: Use: Delineate Anatomy of Biliary tree, Stones, Strictures (Benign/Malignant)
MRCP: Only diagnostic
ERCP: (Dilated duct: Compare with Scope diameter which is ~1 cm)
Less common: PTC (also serves as PTBD)
T-tube Cholangiogram
(4.) PET: Pros: Differentiation between Cancer & Inflammation
Identification of LN/Distant Spread
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Important for Pre-op Staging & Selection for Laparotomy
Mx: Establish Dx, Delineate Level & Cause of obstruction, Treat Suppurative Cholangitis, Definitive Tx
Algorithm: Treat Sepsis
Assess Resectability, Pt fitness, Liver function
Resectable vs Non-Resectable (Palliation)
Mx of Cholangitis: Resuscitation
Treat Sepsis with IV Antibiotic
Biliary Decompression: Endoscopic vs Percutaneous
Definitive Mx
Surgery for MBO: Purpose: Removal of Tumor, Relief of Obstruction (Biliary, Enteric), Pain control
Assessment: General Status, Tumor Status
Assessment of Operability:
General Status Assessment: Aim to define if Pt is Fit for Surgery
Age (Not Absolute Contraindications; Physiological Age more important)
Concomitant Medical diseases
Hidden Medical illness (Spirometry, ECG, BG, RFT)
(CV status, Nutrition, Fluid & Electrolytes, Sepsis, Coagulopathy)
Tumor Status Assessment: Aim to define if Tumor is still confined to organ of origin
PE, US, CT, MRI
Signs of Inoperability:
Clinical: Left Supraclavicular LN, Irregular Surface Hepatomegaly, Umbilical Nodule, Ascites,
Rectovesical Pouch Deposit
Radi: Liver Secondaries, LN Mets, SMV/PV/SMA Encasement (Can be done in QMH)
(1/3 CRC Mets to Liver with Surgery + Adjuvant Chemo can be cured
but Pancreatic CA Mets to Liver is Incurable (even Gemcitabine just Survival))
Laparotomy if: GC is Fit + Tumor is Confined
No Promise of Resection until Laparotomy finding show No Spread
(Look for Peritoneal Nodules after Laparotomy before Resection
Can send for Frozen section to rule out Malignancy if see Nodules)
Surgical Risk:
Post-op Mortality: Past 26-28%; Now 3-5%
Cause: Cancer Cachexia (Malnutrition)
Liver function Impairment (Liver Failure)
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Superimposed Biliary Infection (esp Stent) (Biliary Sepsis)
Measures to Surgical Cx:
Nutritional Support
Vit K
FFP (during Surgery)
Antibiotic cover
Mannitol, Dopamine to prevent Renal Failure,
H2 Antagonist
Measures to Post-op Surgical Cx:
Pre-op PTBD, Pre-op Endoscopic drainage
Relief of Biliary Obstruction before Surgery:
ERCP & Endoprosthesis, PTBD
Target Level: Serum Bilirubin <50 umol/L or <20 umol/L for Concomitant Partial Hepatectomy
Endoprosthesis (Biliary Stenting):
(Tiffany Wong: 1st line for Distal CBD obstruction)

PTBD: (Drain the site of future remnant; Sometimes may drain both to control Sepsis)
Type: Simple External: Above level of Obstruction, Drain out directly
External-Internal: Both Drain out + Drain into Duodenum
Pros: Maintain Physiological Bile function, More difficult to Slip out
Cons: Easier Ascending Infection
Amount: Double PTBD may be needed for Hilum Tumor (Drain both Left & Right Hepatic Duct)
(UCH: Comment of PTBD at Bedside:
Exit Site (Sometimes may also help predict which side is drained)
Wound condition
Content: Normally a bit Greenish
In prolonged obstruction, may be Yellow
Note any Blood/Pus
Only needed for the side of Liver to preserve
Ie. No need to drain the side with CholangioCA?)
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Radical Dissection: Tumor & Part of Organ of Origin, Regional LN, Tumor-Free Resection Margin
(cf HCC which does Not need LN Dissection)
In general: Whipple operation: CA Pancreas, Distal CBD CholangioCA, CA Duodenum, CA Ampulla
(NB: QMH: Routine HepaticoJejunostomy for adequate LN clearance
Other Centres: Only when Cystic duct stump involved)
Radical Cholecystectomy: CA GB
Major Hepatectomy + Caudate Lobectomy with Confluence of Hepatic ducts: Klatskin tumour
Bypass: Single Bypass: CholedochoJejunostomy (CBD) or HepaticoJejunostomy (CHD)

(Roux-en-Y method can prevent Reflux Cholangitis)
Double Bypass: + GastroJejunostomy (for Gastric Outlet Obstruction)

Triple Bypass: + PancreaticoJejunostomy (or PancreaticoGastrostomy) (Rarely done now)
Stent/PTBD vs Surgical Bypass:
Stent: Lower initial M&M, More Late Biliary Cx, More Intervention
Bypass: Higher Early M&M, Better LT results

Technical details:
Whipple operation: PPPD vs Classical Whipple
In general, if Resection margin is adequate, can consider PPPD

Page 313
HBP Pancreatic Cancer:
Pancreatic Cancer: 95% from Exocrine Pancreas; Only 2% tumors of Exocrine Pancreas are Benign
80% are AdenoCA
75% in Head/Neck, 15-20% in Body, 5-10% in Tail
Metastatic Site: Typically first to regional LN, then to Liver, less commonly to Lung
Can also invade adjacent organs directly or spread in peritoneum
Bone Metastasis uncommon
Cause: 40% Sporadic, 30% related to Smoking, 20% related to Dietary factors, 5-10% Hereditary
Smoking, DM (2x risk), Obesity & Dietary factors, Chronic Pancreatitis, Genetic factors
(Alcohol is Not an independent RF, unless leading to Chronic Pancreatitis)
Hereditary RF: 5-10% Pt with Exocrine Pancreatic Cancer have a 1 relative with the disease
RF: Hereditary Pancreatitis
Inherited Cancer Susceptibility syndromes:
BRCA/PALB2, Peutz-Jeghers syndrome, FAMMM syndrome, Ataxia Telangiectasia,
Lynch syndrome/FAP, Familial Pancreatic Cancer
Other Inherited RF: ABO blood group (Higher risk in Non-O blood groups)
Clinical: Initial Sx often Non-specific & Subtle in onset> Early Dx is difficult
Non-Specific: Anorexia, Weight Loss, Malaise, Nausea, Fatigue
Causes of Weight Loss:
Cancer-associated Anorexia
Subclinical Malabsorption (Duct obstruction> Exocrine Insufficiency)
Significant Malabsorption can present with Diarrhea & Steatorrhea
Nausea & Early Satiety (Gastric outlet obstruction & Delayed emptying)
Pain: Epigastric Pain, Back Pain
Epigastric Pain: Common, sometimes with Radiation to Midback/Lower-back
Back Pain: May raise suspicion of Tumor arising in Body/Tail of Pancreas
Can be worrisome Retroperitoneal Invasion of Splanchnic nerve plexus
Often Unrelenting & Night Pain is predominant complaint
Discomfort may after Eating & when Lying flat
Jaundice: CA of Head of Pancreas: Sx of Painless Obstructive Jaundice may present early
CA of Body/Tail of Pancreas: Usually Late sign, either due to Large tumor or LN metastasis
Thrombotic tendency:
Migratory Thrombophlebitis (Trousseau sign of malignancy), Venous Thrombosis,
Non-Bacterial Thrombotic Endocarditis
Depression: More common in Pancreatic CA than other Abd tumors
Ix: Lab: CBC: Usually Non-specific; Some may have Mild NcNc Anemia, Thrombocytosis
LFT: Esp in those with Obstructive Jaundice
Amylase/Lipase: in <25-50% cases
5% Pt can present with Acute Pancreatitis
Elderly with 1st Acute Pancreatitis without known RF> Consider CA
Tumor Markers: CA 19.9: More Sensitive, Prognostic/FU value
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HBP Pancreatic Cancer
CEA: Not Sensitive & Specific
Imaging: CT: Mainstay of Dx tool (CT Pancreas: Thin cut, cf usually CT abdomen)
US: Transcutaneous (TUS), Endoscopic (EUS)
ERCP
MRI/MRCP
PET
Biopsy: Controversial (If Biopsy usually done as EUS-FNA)
Tx: Surgery: PancreaticoDuodenectomy (Whipple procedure):
Resection: Pancreatic Head, Duodenum, GB (& CBD), Antrum of Stomach
Reason: They share a common blood supply
Anastomosis: GastroJejunostomy, PancreaticoJejunostomy, HepaticoJejunostomy

Distal Pancreatectomy:
Good for Tumors in Body/Tail, but they usually present Late (ie. High Unresectability rate)
Total Pancreatectomy:
Least commonly performed & Highest associated Mortality rate
Indicated when Tumor involve Neck of Pancreas
LN Distribution & Involvement in Cancer of Head of Pancreas:

Chemo: Gemcitabine was the most useful single agent (Used to be the standard Tx alone)
1st line by FDA: Gemcitabine + Erlotinib
Others: 5-FU, Capecitabine, Paclitaxel
Palliative: Pain: Narcotic Analgesic, Celiac Plexus Neurolysis, RT (Does Not Survival)
Jaundice: Endoscopic Stenting
Duodenal obstruction: GastroJejunostomy, or Endoscopic Stenting if Not fit for Surgery
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LT Survival of Pancreatic Head Cancer:
After Radical Resection: 1-year 66% 5-year 27%
Palliative Bypass: 1-year 10% 5-year 0%

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HBP Gallstone
Gallstones (Cholelithiasis):
Gallstones are Hard, Pebble-like deposits that form inside GB, with Variable Size
(Note: Some surgeons like referring Gallstones only as stones in GB; cf CBD stones)
Epidemiology: 12% M, 24% F
70-80% Asymptomatic
10-30% Symptomatic:
Epigastric Pain, esp after Fatty meals, ie. Fat Intolerance, Bloating sensation
Natural Hx: Asymptomatic: Development of Sx: 1-2% per year
Initial presentation with Cx: <5%
Symptomatic: Recurrent Sx: 60-70% in 2 years
Major Cx: 1-2% per year
Type: Content:
Content
Cholesterol Bilirubinate Palmitate Organic
+ Stearate Matrix
Cholesterol 50-80% 10% <5% <5%
Stone
Pigment 5-30% 30-90% 25% 15%
Stone
Organic Matrix: Mucin, Glycoprotein, Carbohydrate
Cholesterol Stones:
Most common type of Stones in West
Pale & Hard
Pure: <10%; Usually Radiolucent
Mixed
Pigment Stones:
Made from too much Bilirubin in Bile
Bile culture/Stone culture commonly +ve
Usually Mixed; Often Radioopaque
Brown: Polymerized Unconjugated Bilirubin; Mainly Biliary Infection; More Mud-like; Can be CBD-in situ
Black: Unpolymerized Unconjugated Bilirubin; Mainly Chronic Hemolysis; Usually Harder
RF: Cholesterol: Classical description 5F: Fair (White ppl), Female, Forty (means starting from 40), Fat, Fertile
Demographics: Westerners
Female
Age: Biliary Cholesterol Secretion, Bile Salt Secretion
Obesity, Metabolic syndrome, (DM): Biliary Cholesterol Secretion
Drugs: Estrogen: Mainly Biliary Cholesterol Secretion
Fibrate: Biliary Cholesterol Secretion
Pigment: Demographics: Asians, Rural area, Age
Cirrhosis: Heme (Splenomegaly> RBC sequestration), Bile Acid Secretion
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HBP Gallstone
Black: Chronic Hemolysis: Hereditary Spherocytosis, Thalassemia, Sickle cell disease, etc
Brown: Chronic Biliary Tract Infection/Parasitic Infection (eg. RPC)
Both: GB HypoMotility leading to Biliary Stasis (Viscosity as water absorbed, Prone to Infection):
Pregnancy (Progesterone)
Prolonged Fasting with TPN
Previous Gastrectomy/Vagotomy/Gastric Bypass
Drugs: Somatostatin: Bile Salt Secretion
Terminal Ileal Disease (Crohns) / Resection / Bypass: Bile Reabsorption> Bile Acid pool size
(BMT/Solid organ Transplant)
Ix: Liver US, CT
Cx: In GB: Biliary Colic, Acute Cholecystitis, Mucocele of GB, Empyema of GB, GB Cancer,
GB Gangrene (Cystic Artery Thrombosis)
In Bile duct: Obstructive Jaundice, Acute Cholangitis, Acute Pancreatitis
Perforation to other sites:
Bowel: Gallstone ileus (from CholedochoDuodenal Fistula)
Liver bed: Liver Abscess
CBD: Mirizzi syndrome
Mx: Options: Non-Surgical: Oral bile acid dissolution, ESWL, Percutaneous CholecystoLithotomy,
Contact dissolution with MTBE
Surgical: Cholecystectomy (Open/Laparoscopic), Cholecystostomy
Comparison:
Surgical Non-Surgical
Morbidity & Disability Anesthesia General None/Sedation
Therapy Duration Hours Months
Morbidity 5-10% Variable
Hospitalization 1-7 days None
Disability Weeks None
Applicability Stone diameter Any Small (<2cm)
Stone type Any Radiolucent, Cholesterol
Obstructed Cystic duct Yes No
Recurrence None High (10-20% per year)
Cholecystectomy: (Prof Lo: GB in Symptomatic Gallstone is often Non-functional already anyway)
Gold standard (Note that nowadays, Laparoscopic Cholecystectomy is gold standard)
Pt selection: Acceptable operative risk
Mortality (elective) <0.5%: Age <65: <0.05%
Age >80: Up to 5%
Morbidity 5-10%
Disability: Weeks
Indications of Cholecystectomy:
Symptomatic Gallstone disease
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HBP Gallstone
Asymptomatic Gallstone disease Not indicated for operation Except:
Calcified GB (Porcelain GB) Risk of GB Cancer
Young Pt with Sickle cell disease (Risk of Gallstone + Risk of Cx (Sickle cell crisis))
Emergency Cholecystectomy in Sickle cell disease often has High Mortality rate
(Prof Lo: Not for Thalassemia, Hereditary Spherocytosis; Wont have Risk of Cx)
Long-term TPN (Risk of Gallstone, Risk of Cholecystitis (even Acalculous))
Classical Textbook Description (Not all implemented):
Risk of Recurrent Attack: Hereditary Hemolytic disease, Chronic TPN
Risk of GB Malignancy: Suspicious GB Polyp on US:
Size >1cm, or meeting Morphological criteria
Porcelain GB
Chronic Salmonella Infection/Colonization
During other Surgery: Whipple operation
Liver transplant
Gastric Surgery (controversial): Bariatric surgery, Gastric Bypass
Before Transplant (eg. Heart transplant)
Algorithm for Symptomatic Gallstones (Biliary Pain):
Evaluate Surgical Risk:
Low: Cholecystectomy
High: Non-Surgical therapy if: Patent Cystic duct, Radiolucent Stone, Small Stone
Observe if otherwise
Mirizzi syndrome: Gallstone impacted in Cystic duct/Neck of GB, causing Compression of Common Hepatic duct
Classification:
Type I: No Fistula present
IA: Presence of Cystic duct
IB: Obliteration of Cystic duct
Type II-IV: Fistula present (Cholecysto-Choledochal Fistula)
II: Defect <33% of CBD diameter
III: Defect 33-66% of CBD diameter
IV: Defect >66% of CBD diameter
(Mx: Type I: May attempt Laparoscopic Cholecystectomy
Type II: Open Cholecystectomy with ECBD
Only Partial Cholecystectomy can safely avoid damaging bile duct
Repair Fistula with GB wall)

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HBP Gallstone
HBP Acute Cholecystitis
Acute Cholecystitis:
Epidemiology: Middle aged (>50), *F (for Calculous Cholecystitis, Not for Acalculous Cholecystitis)
Cause:
Common: Calculous Cholecystitis: Gallstones
Acalculous Cholecystitis: Ischemic damage to GB; Mostly in Critically Ill Pt
Uncommon: Primary/Metastatic Neoplasms
Acalculous Cholecystitis: Infectious agents
Pathogenesis: Acute Inflammation of GB:
Mechanical: Intraluminal Pressure & Distention with resulting Ischemia
Chemical: Release of Lysolecithin & other local tissue factors
Bacterial
Obstruction of Cystic duct
Cx of Gallstone disease
Calculous: Chemical Irritation/Inflammation of Obstructed GB
Protective Glycoprotein Mucus layer disrupted> Exposed to Direct Detergent action of Bile salts
GB Dysmotility develop; Distention & Intraluminal Pressure compromise Blood flow
Later in the course Bacterial Contamination develop
Acalculous: Cystic Artery is an End Artery with No Collateral circulation
Other Contributing factors may cause Cystic duct Obstruction without Frank Stone formation
(Tx is also by Cholecystectomy)
Sx: Epigastric/RUQ Pain
May be Exacerbated by Deep Inspiration/Movement, May be preceded by Biliary Colic
(Often Vague Abd Pain or even No Pain in Acalculous Cholecystitis)
Mild Fever/Chill
Nausea/Vomiting
Signs: Typically RUQ Tenderness, Fever, Leukocytosis (Latter 2 may be Minimal)
Murphy Sign (Right Subcostal Pain with Inspiratory Arrest with Palpation)
Palpable GB
Guarding/Rebound due to Local Peritonitis (Peritoneal signs can be Marked)
Usually No Jaundice
Mild Jaundice: May occur Secondary to Edema of Bile ducts & surrounding LN,
from Coexisting retained CBD Stone,
or External Compression of CBD by Stone within GB/Cystic duct (Mirizzi syndrome)
Ix: Blood:
CBC: Leucocytosis
LFT: Usually just Mildly
Imaging:
US: Any Gallstones: Echogenic with Acoustic shadow, Move freely with Positional changes
(Impacted Gallstones in Cystic duct is diagnostic but seldom seen)
Features of GB Inflammation:
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GB wall thickening >3mm
Pericholecystic fluid
Sonographic Murphy sign
(GB distension: >4x10cm, or AP diameter >5cm)
CT Abdomen:
Useful if suspect Abscess/Neoplasm
(Biliary Scintigraphy/HIDA scan)
ERCP: If evidence of Biliary Obstruction
Tx:
- Initial Conservative Mx:
NPO, IV fluid, Blood tests & T&S, Antibiotics, Analgesic, Monitoring (BP/P, Temp, Urine output)
NB: 2002 MCQ 44: Metronidazole is Not always necessary
- Surgery:
1. Cholecystectomy:
Approach: Open vs Laparoscopic
Timing: Early vs Delayed
Approach: Open: Kochers incision (Right Subcostal Transverse muscle cutting incision)
Laparoscopic: Standard approach 4 ports; (Newer: Needlescopic, 3 ports, 2 ports, single port)
Pros: Less Pain, Shorter Hospital stay (usually 1 day),
Faster Recovery/Early return of GI function, Better Cosmesis
Cons: Technically Demanding (Inflammation can cause Adhesion, Edema, etc)
Higher Conversion Rate (from Laparoscopic to Open):
Prof Lo: 3-8% in general; In Acute Cholecystitis, can be up to 30%
Has to be accepted to prevent Serious Cx
More Serious Cx:
Bile duct Injury (0.4-0.8%):
Bile Leakage (Early) (2010 MCQ 41)
Biliary Stricture (Late)
(Contra: Absolute: Known GB Cancer
Relative: Previous Abd Surgery
Complicated Gallstone disease (eg. Mirizzi syndrome)
Bleeding Tendency, Pregnancy, etc)
Timing: 2-3 days vs 2-3 months
(Urgent: Indication: Gangrenous/Emphysematous Cholecystitis, Perforation with Peritonitis)
Early: Within 48-72h; Current Standard
Pros: Avoid Urgent operation (Pt may fail Conservative Tx & Develop Cx)
Avoid Recurrent Sx (Pt may develop another attack before scheduled operation)
Avoid Re-admission
Shorter Hospital stay
NB: Early Cholecystectomy is Safe without ing risk of Cx (CM Lo: Early is Better!)
Just an Early decision, but Not an Emergency Surgery
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Delayed: Conservative Tx first, Interval Surgery in 8-12 weeks; Traditional thinking
Pros: Avoid MisDx, Easier Dissection, Less Septic Cx, Less Serious Cx
Cons: More difficult due to Chronic Inflammation/Fibrosis becoming predominant
2. Cholecystostomy:
Drainage of GB
Open/Percutaneous
Indication: High Surgical risk (Percutaneous No need GA), Unstable Hemodynamics,
Difficult Cholecystectomy
Contra: Perforation/Gangrene
(Contamination Not localized in GB, Not useful to drain it alone?)
PostCholecystectomy syndrome:
Persistent Sx after Cholecystectomy
Cause: Technical Cx of Cholecystectomy
Missed pathology which is the real cause of original Sx
Stomach, Duodenum, Liver, Bile duct, Pancreas, Hepatic Flexure of Colon
Ix: CBC, LRFT, Amylase
Upper Endoscopy
US/CT
ERCP
HAG SMA
Extra:
Cholesterol Polyps: Cholesterol Stones adhered to GB wall (Not true polyps)
Seen on US: Iso-echoic lesion attached to GB wall
Does Not cast Acoustic shadowing
May detach from the wall to form real Gallstone and induce Sx/Cx
If Symptomatic, Cholecystectomy is advised
Special Entities of Cholecystitis:
Emphysematous Cholecystitis:
Gas-producing Bacteria, eg. Clostridium, E.coli
Often in DM Pt, Often asso. with Acalculus Cholecystitis
Ix: Can see in Plain AXR, but CT is better; (Air Not seen in GB Lumen but in GB Wall)
Tx: Emergent Surgery needed
Chronic Cholecystitis:
Due to incompletely resolved Acute Cholecysitis; GB became Contracted & Fibrotic
May accompany Cholesterolosis & Adenomyomatosis
Cholesterolosis:
Due to deposition of Cholesterol in GB mucosa,
producing either Cholesterol Polyps or White flecks on mucosa,
with Cholesterol-induced inflammation in surrounding mucosa (Strawberry GB)
Adenomyomatosis (Cholecystitis glandularis proliferans):
Developmental defect resulting in Hyperplasia of Smooth muscle bundles,
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with Diverticulum formation of epithelial lining (Rokitansky-Aschoff sinuses)
The sinuses can be plugged with bile & get inflamed
Cx of Cholecystitis:
Empyema & Hydrops:
Empyema: Progression of Acute Cholecystitis with Persistent Cystic Duct Obstruction
> Superinfection of Stagnant Bile with Pus-forming Bacteria
Clinical picture resemble Cholangitis with High Fever, Severe RUP Pain
Emergent Surgery needed
Hydrops/Mucocele:
Prolonged Cystic duct Obstruction> Progressive Distention of GB
> Mucus (Mucocele) or Clear Transudate (Hydrops) produced by Mucosal cells
Can be Asymptomatic, NonTender RUQ Mass may be palpated
Gangrene & Perforation:
Gangrene: Due to Ischemia with underlying GB Distention, Vasculitis, DM, Empyema, Torsion
Predispose to Perforation (Though Perforation can happen without Gangrene)
Perforation: *Localized: Contained by Omentum/Adhesions from recurrent Inflammation
Free: Less common but High Mortality
Sudden Transient relief of RUQ Pain (GB Decompress),
Then Signs of Generalized Peritonitis
Fistula & Gallstone Ileus:
Fistula: *Duodenum
Can be diagnosed as Pneumobilia on Plain AXR
Gallstone Ileus: Mechanical IO due to passage of Large Gallstone into Bowel lumen
Usually enter Duodenum via CholecystoEnteric Fistula
Obstruction usually at Ileocecal valve
AXR: Pneumobilia, Dilated Bowel, Abnormal position of Gallstone
Tx: Enterotomy
Do NOT perform Cholecystectomy in such Acute setting
Inflammatory Mass over Cholecystoduodenal Fistula
> Dissection & Duodenal closure extremely difficult
Limey (Milk of Ca) Bile & Porcelain GB:
Limey Bile: Ca Precipitation due to High conc of Ca salts
Diffuse Hazy Opacification of Bile or Layering effect on Plain AXR
Porcelain GB: Ca salt deposition within wall of Chronically inflamed GB
Detected by Plain AXR
Chance of development into GB Cancer
GB Anatomy:
Calots Triangle:
Boundary: Superior: Inferior border of Liver (Segment 5)
Medial: Common Hepatic duct
Lateral: Cystic duct
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(NB: Original description: Cystic artery as Inferior border, rather than Liver as Superior border)
Content: Artery: Cystic artery, Accessory Right Hepatic artery
Bile duct: Accessory Hepatic ducts
LN: Lunds node/Mascagnis LN:
Sentinel LN of GB; in Size in Cholecystitis/Cholangitis
In space below Cystic artery; Removed along with GB in Cholecystectomy
(NB: Dissection of Calots Triangle is ill-advised until Ligation & Division of Cystic artery & Cystic duct)
Cystic duct: On ERCP, Cystic duct appears Tortuous
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HBP Acute Cholangitis
Acute Cholangitis:
Epidemiology: Middle-aged/Elderly, *F in Middle Aged while No difference in Elderly
Pathogenesis: Bacterial Infection superimposed on Biliary Obstruction (Both elements needed for Cholangitis)
Bacteria in Bile: Gram ve Rods, Enterococci, (Anaerobes)
Bile Duct Obstruction: Partial Obstruction is Worse Allow Reflux of Bacteria from Duodenum
*Stones: From GB vs From Intrahepatic duct (RPC)
Tumor: Internal Obstruction (Tumor fragments) vs External Compression (more common)
Stricture: Congenital, Infection, Post-op (eg. After Cholecystectomy, Bilio-Enteric Anastomosis),
Post-traumatic
Pressure: Normal Ductal Pressure 7-14 cmH2O
Biliary Pressure >25 cmH2O: Bacteria Reflux to Veins & Lymphatics> Bacteremia & Shock
Bacteria Isolated: Organisms Bile (%) Stone (%) Blood (%)
E. coli 7 22 71
Klebsiella sp 17 18 14
Enterobacter sp 8 8 5
P. aeruginosa 7 9 4
Citrobacter sp 3 1 2
Proteus sp 3 1 0
Acinetobacter sp 1 3 0
Bacteroides sp 1 1 1
Enterococcus sp 17 12 0
Streptococcus sp 8 9 0
Staphylococcus sp 2 6 3
Clostridium sp 2 1 0
Candida sp 4 1 0
Others 0 8 0
Clinical: *Charcots Triad: RUQ Pain, Fever, Jaundice
Reynalds Pentad: Charcots Triad, Hypotension, Mental Confusion
Suggest Sepsis (due to Cholangio-Venous Reflux)
(Always think about Cholangitis if see Deranged LFT + Hypotension + Mental Confusion)
Nausea/Vomiting, (Peritoneal Signs Not as Marked as in Cholecystitis)
Ix: Blood:
CBC: Hb, WCC, Platelets (Infection, Look for DIC)
LRFT, Amylase (Look for concurrent Pancreatitis)
Pattern of Liver Chemistries in Biliary Obstruction:
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(For Acute, in very Early stage, can be Hepatitic picture)
Clotting Profile (PT, aPTT)
Blood Culture
Urine:
Urinalysis (UTI, Bilirubin)
Imaging:
Plain AXR (Pneumobilia)
Abd US: Non-Invasive, Bedside, Sensitive for Dilated Bile ducts & Gallstones (Prof Lo: 95%)
(But Not good to evaluate Distal CBD, due to obscuration from Duodenal Gas
Good for Cholecystitis, Less good for Cholangitis)
False ve: Small CBD Stones
CBD has Not enough time to dilate in Acute Obstruction
ERCP: Current Gold standard
MRCP
CT Abdomen
Others: EUS, Helical CT Cholangiography, PTC, Cholescintigraphy (HydroxyIminoDiacetic Acid Scan)
Tx: Initial & Conservative: Resuscitation, Antibiotics
Biliary Decompression & Drainage: Endoscopic, Surgical, Radiological
(Definitive Tx of Gallstones)
1. Medical Tx: NPO, IV fluid, Blood tests & T&S, Antibiotics, Analgesic, Monitoring (BP/P, Temp, Urine output)
Successful in ~70% cases of Acute Cholangitis due to Gallstone
Stones may disimpact spontaneously, either into Duodenum or back into CBD
If Not successful, Emergency intervention can salvage most Pt; Overall Mortality rate 10%
Current policy of QMH: Early Endoscopic intervention asap to Overall Mortality
Clinical manifestation of Failure of Conservative Tx:
Temp/Pulse, BP, Urine output, Sensorium, Abd Tenderness/Guarding
RR/Hypoxia are Subtle changes, which signify worsening Sepsis
IV Antibiotics: Empirical: Gram ve, Aerobic & Anaerobic
Penicillin: Piperacillin, Augmentin
Cephalosporin: Ceftazidime
Quinolones: Ciprofloxacin, Levofloxacin
Metronidazole
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Guided by Blood Culture/Sensitivity
(Most Antibiotics have Poor Excretion in Biliary system, esp for Obstructive system)
(Quinolone has good Excretion but Not very helpful)
(Antibiotics alone as Monotherapy Not good)
For Parasitic Infection: Treat to prevent Recurrence of Cholangitis
*Clonorchis sinensis (Clonorchiasis):
Endemic in Asian countries
Transmission: Ingestion of Raw Fish
Cx: Cholangitis, IntraHepatic Duct Stones, Pancreatitis, CholangioCA
Dx: Stool Exam
Tx: Praziquantel
Ascaris Lumbricoides:
Tx: Mebendazole
2. Drainage:
ERCP: Lower Risk than Surgical Drainage: Mortality 10% vs 32%, Morbidity 34% vs 66%
st
1 choice (MRCP takes too Long for Dx, and Not Therapeutic)
Combination of Endoscope with Fluoroscopy
(Posture: Prone, Head to Right)
(Contraindicated in very Frail Pt, certain Gastrectomy such as Roux-en-Y)
Pros: Diagnostic: Direct Visualization
Brushing, Biopsy
Therapeutic: Sphincterotomy, Stone Removal, Stenting
Cx: Sedation/Anesthesia-related, Contrast-related
Pancreatitis: Due to Contrast injection (P); Also Edema when removing Stone
Risk if there is cannulation of Pancreatic duct
Cholangitis
Bleeding: Esp with Sphincterotomy
Perforation (0.3%): *Duodenum
Intraperitoneal: During Scope insertion
(Side scope> more risky; Ordinary OGD risk is only 0.01%)
Pt may have intense Pain, Pneumoperitoneum
Retroperitoneal: During Manipulation of CBD, Papillotomy
Usually Small hole by Guidewire; Conservative Mx
To open Sphincter:
Sphincterotomy:
Time honored
Bleeding/Perforation (Pt may have Coffee ground Vomiting after ERCP)
LT consequence (Ascending Infection risk> Prophylactic Cholecystectomy)
Balloon Spincteroplasty:
Preserve Sphincter function
Cant Extract Large Stones, Pancreatitis
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(Usually for those with Bleeding Tendency, Young who Dont want to take out GB yet)
Stone Extraction:
Basket, Balloon Catheter
Mechanical Lithotripsy (Lithotripter) for Large Stones
Failure of Stone Clearance Keep Drainage:
Endoscopic Biliary Stenting (Endoprosthesis)
NasoBiliary (NB) Drain: (Uncommon; Not done in QM anymore)
Good for ICU Pt (Can Monitor Bile system Output)
Pros: Can visualize Bile output
Can inject Contrast to perform Cholangiogram directly
Cons: Uncomfortable, Pt may pull it out
Electrolyte Loss through Bile
IF ERCP fail:
Consider Surgical/Radiological Drainage quickly
Surgical: Exploration of CBD (T-tube may be placed afterward)
Radiological: PTBD (QMH: Usually Not done for Gallstone disease, Unless Not fit)
ECBD: Decompression by Exploration of CBD (ECBD)
(Open up> Choledoscope> T-tube before finishing)
Indication: Failure of Medical Tx/Endoscopic Drainage, Deterioration despite Endoscopic Drainage
Function of T-tube after ECBD:
Decompress Bile duct
Prevent Bile Leakage from Suture Line
For Post-op Cholangiogram to check residual stone
Allow Access for Removal of residual stone
T-tube induces formation of a Fibrous tract

Conduit for Choledochoscopy Enable Extraction of Residual CBD Stones
Action after T-tube Cholangiogram:
Any Residual CBD stone: (2005 MCQ 29: T-tube should be left in situ for weeks)
ve> Spigot T-tube> Any Fever:
Fever +ve: Release Spigot> Re-do Cholangiogram for possible CBD stone
Fever ve: Keep T-tube Spigot for 4-6 weeks> Remove T-tube
+ve: Keep T-tube for 6-8 weeks> Choledochoscopy via Fibrous T-tube tract
Cx of T-tube:
Over-drainage: High bile output> Dehydration, Electrolyte disturbance
Under-drainage: Acute Cholangitis/Biliary Sepsis
Malposition, Displacement, Dislodgement
Leakage: Biliary Peritonitis (can occur with premature removal of T-tube)
Contrast-related Cx: If perform Cholangiogram
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PTBD: 3rd line, if Failed ECRP in a Pt with High Surgical risk
3. Definitive Cholecystectomy for Gallstones:
Interval or Concomitant Cholecystectomy
(Prof: Nowadays, usually Combined ERCP + Laparoscopic Cholecystectomy
for concomitant GB stone & CBD stone)
Unresolved Sepsis after Initial Mx & Drainage:
Appropriate choice & dosage of Antibiotic
Undrained segment
Blocked Stent
Cx, eg. Liver Abscess, Cholecystitis

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HBP Imaging for Cholecystitis/Cholangitis
Role of Imaging Department:
Obstructive vs Non-Obstructive, Localization of Obstruction site,
Identify Possible Cx, Offer Minimally Invasive Interventions
Imaging Modalities: Plain AXR: Not Sensitive
US: 1st Modality of choice
Cholangiography
CT, MRI: Reserve for Complicated cases
Plain AXR: Calcified Gallstones (10-20%) (Not very Sensitive)
Air in Biliary Tree/GB Wall (Pneumobilia)
Soft Tissue Mass (Liver Abscess)
Bowel Dilatation (Gallstone Ileus/Small Bowel Obstruction)
US: Pros: No Ionizing Radiation, Cheap, Safe, Portable, Quick (Experienced Operators),
GB Evaluation, Sensitive & Accurate for Intra/Extra-Hepatic Bile duct Dilatation,
Image-guided Intervention
Cons: Operator dependent
Visualization impeded by Pneumobilia, Soft Pigmented Stones, Previous op
Previous op: Abd Scars, Surgical Clips, Drainage tube, Duodenal Gas, Ileus
Features: Clinical scenario is very Important when interpreting figures
Normal: GB: <3mm thick
CBD: <6mm in Diameter
Gallstones: Mobile (cf GB Polyps), Echogenic with Acoustic Shadowing
>95% Accuracy in detecting Gallstones >1mm
GB wall Edema: GB wall >3mm
Non-Specific: Hepatitis, CHF, Nearby Inflammation (eg. Pyelonephritis),
Albumin, Tumor
PeriCholecystic fluid: May be seen in Acute Cholecystitis
GB wall Thickening + PeriCholecystic fluid but No Stones: Acalculous
Also look for Dilated Duct, Ductal Stones, Pneumobilia, Liver Abscess

Cholangiography: Direct/Indirect introduction of Contrast medium into Ductal system
Can be Invasive, Ionizing Radiation
ERCP: Endoscopic Retrograde CholangioPancreatogram
Direct Cannulation of CBD via Scope
Diagnostic Therapeutic
Possible Cx: Pancreatitis, Perforation
PTC: Percutaneous Transhepatic Cholangiogram
Mostly replaced by MRCP
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Performed as PreTx roadmap
Possible Cx: Vascular/Organ Injury
T-tube Cholangiogram:
Performed After Cholecystectomy & Exploration of CBD to look for Residual Stone
CT: Rarely required
Cross-sectional display of Intra-Abd organs
Pros: Not limited by Gas, Clips, Drainage tubes
Detect other abnormalities apart from Dilated ducts & Stones
Indication: Suboptimal US
Cx such as GB Perforation with PeriCholecystic Abscess, Empyema
Evaluation of other Abdomen & Pelvis Pathology
CT-guided Interventions
Cons: Ionizing Radiation, IV Contrast-related Cx, Not Sensitive for Cholangitis, Relatively Expensive,
Not Portable
Examples: Normal: Perfusion Abnormality:

Wall Edema: Emphysematous Cholecystitis:

Dilated IHD: Pneumobilia:

Ductal Stones: Liver Abscess:

MRI: Pros: No Ionizing Radiation, True Multi-planar images, Better Contrast Resolution than CT,
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Tissue Characterization, MR Abdomen/MRCP
Indication: Unsuccessful ERCP
ERCP Contraindicated: Previous Gastric/Bypass operation
Evaluation of other Abd Pathology needed
Cons: Inferior Spatial Resolution than CT, Longer Scanning time,
Availability & Accessibility, Pt Cooperation,
Claustrophobic, Stone vs Air Bubble,
Medical Implant (Pacemakers, Cochlear Implants) (Many Implants now are MRI-compatible)
MRCP: Heavily T2-weighted sequence
No Contrast needed, Non-Invasive

PeriCholecystic fluid: Wall Edema & PeriCholecystic Inflammation:

Note: In MBO, may notice Double duct sign (Dilated CBD + Pancreatic duct) in PeriAmpullary CA

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HBP RPC
Recurrent Pyogenic Cholangitis:
Definition: Repeated attacks of Bacterial infection of Biliary tract
as a result of Stones & Strictures in the bile ducts, esp in Intrahepatic segments
Epidemiology: Rare in Western countries, Incidence in Asian migrants, Common in South East Asia
Young & Lower SES groups
No Gender preponderance
Pathogenesis: Entry of Bowel organisms into Bile ducts
Initiate Inflammation in Portal Triad> Necrosis of Hepatocytes
CholangioHepatitis> Fibrosis, Abscess formation
Stone formation, Stricture formation
Chacteristics: Infection, Stricture, Stone
Infection: Classical Causative organism: Clonorchis sinensis: Liver Fluke, Flat worm
Bacterial Infection can occur upon Biliary obstruction
Stone: Bilirubinated Stones
Infected Bile becomes an Insoluble precipitate from a supersaturated solution
Stricture: More common in Left Main Hepatic duct or Segmental ducts
Main duct Stricture usually Short-segment
(Left duct: Longer, more Horizontal angle cf Right duct more oblique)
Intrahepatic Strictures usually Long-segment
Proximal dilatations behind Strictures
Clinical: Cholangitis picture (If High Fever, may imply Main duct obstruction> More urgent drainage)
Ix: US: CBD caliber, SOL inside Liver, Location of Stones, Presence of Pneumobilia,
Periportal Echogenicity (Blood flow)
CT: (Relationship of Bile duct, Hepatic artery, Portal vein: From Anterior to Posterior)
MRI: T1W: Enhancement of ductal walls on Contrast-enhanced T1W images
T2W: Bile: High intensity signal
Stones: Signal void
Good for showing Ductal dilatation
ERCP: (Classically Left duct RPC: CBD dilatation, Left-sided ducts dilatation, Normal Right-sided ducts)
(cf PBC: Fine calibers, 2nd-3rd Gen Biliary ducts, Both sides affected)
PTC
Mx: Initial Mx for Acute Attack:
Fluid Resuscitation, IV Antibiotics (2nd Gen Cephalosporin), Analgesics:
Common pathogens: E. coli, Klebsiella spp, Pseudomonas, Anaerobes
Conservative Tx only successful in 30% cases
Urgent Biliary decompression:
Radiologically, Endoscopically, Laparotomy
(Note: If Failed ERCP, go to ECBD straight away
PTBD: Only available in office hours
Small caliber (Fr 7), cant achieve adequate immediate relief
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HBP RPC
Dislodgement possible)
Non-op approach:
ECRP + Insertion of Endoprosthesis
(Biliary Stents: Straight stent: Less commonly used; Larger caliber but Poor Anchorage
Pigtail stent: Flexible, Good Anchorage)
Operative approach:
ECBD: Drainage of Pus & Infected Bile, Removal of Stones within CBD
(Surgeons will put a T tube & a Tubal drain after ECBD
If houseman being asked to remove Tubal drain
Note Labeling of Bag
Note Content of Bag (Remove drain connecting to Serous Bag, Not Bile)
Definitive Tx:
Aim: Remove Biliary ductal Stones
Enlarge/Bypass Strictures
Provide adequate Biliary drainage
Provide Permanent Percutanenous access to Biliary tract
Options:
HepaticoJejunostomy:
Allow passage of bile, sludges & stones into Small bowel
HepaticoJejunostomy with a Cutaneous Stoma (ie. HepaticoCutaneous Jejunostomy):
Provides a Percutaneous route for Future Stone Removal via Choledoscopy
(Not an Open Stoma; Just a marking for Entry site; Only use when needed)
Hepatectomy:
For destroyed liver segment
Intrahepatic Strictures & Stones
Multiple Liver Abscess
CholangioCA
Cx: Liver Abscess
CholedochoDuodenal Fistula
Acute Pancreatitis
Portal vein thrombosis
Biliary Cirrhosis: May need Liver Transplant in some Pt
CholangioCA
Tx outcomes:
ST: Immediate Stone Clearance: 90%
Final Stone Clearance: 98%
10% had concomitant CholangioCA
LT: Stone Recurrence: 9%
5-year Survival: With CholangioCA: 9%
Without CholangioCA: 93% (thus Prophylactic Hepatectomy important)
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HBP RPC
HBP Peritonitis
Diffuse Abd Pain:
Cause: GE, Constipation, Uncomplicated IO, Peritonitis,
Pt who Fail/Reluctant to describe Abd Pain in details, Medical causes (eg. Porphyria)
(NB: Always think of Chest Pathology if No Abd finding in Significant Abd Pain, eg. AD)
Peritoneum: A layer of Polyhedral-shaped Squamous cells of ~3 mm thick
Anatomically a Closed sac for Free movement of Abd viscera
Bidirectional Semi-permeable membrane
Exchange surface area of 1m2
~100ml of Peritoneal fluid
Peritoneal fluid travel cephalad toward Diaphragm by Diaphragmatic Pump
Potential Sac: R & L SubPhrenic spaces, L SubHepatic space, R Subhepatic space (Morisons pouch),
Lesser sac, L&R ParaColic glutters, InterLoop space, Pelvis

Innervation: Visceral & Somatic Sensory pathways
Visceral Pain: Dull, Crampy, Poorly Localized Pain
Cause: Ischemia, Stretching, Compression, Traction, Chemical Irritation of Visceral Peritoneum
Fibre: Slow C fibers in Sympathetic nerves
Somatic Pain: Sharp & Well-localized Pain
Cause: Irritation of Parietal Peritoneum
Fibre: Fibers of Somatic nerves
Response to Infection:
3 ways: Rapid Absorption of Bacteria via Diaphragmatic Stomata & Lymphatics
Opsonization & Destruction of Bacteria via Complement cascade
Localization of Bacteria within Fibrin to promote Abscess Formation
2 organs: Liver: Filter Portal circulation (Liver Abscess)
Spleen: Filter Systemic circulation
4 cells: Mast cells: Histamine, Vasodilatation, Influx of Fluid, Complement, Ig
MQ: Fc & C3 receptors, Secrete Cytokines, Phagocytosis
PMN: Phagocytosis
Peritoneal Mesothelial cells:
Downregulate Fibrinolysis in the presence of Inflammation
Facilitate Entrapment & Isolation of Bacteria within Fibrin Matrix
Peritonitis: Inflammation of Peritoneum; One of Commonest Surgical Emergency
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HBP Peritonitis
Classification: Primary, Secondary, Tertiary
Primary: Extra-Peritoneal source (often Hematogenous spread):
*SBP, TB Peritonitis, Peritonitis associated with CAPD (Usually Skin Organisms)
Primary Bacterial Peritonitis:
More in Children & F; Usually encountered in Medical ward
Bacteriology: Usually Single organism:
S. pneumoniae, Group A Streptococcus, Enteric organisms (*E. coli)
Seldom Anaerobes High O2 Tension in Ascitic fluid
RF: *Ascites! (Good medium for Bacterial growth)(Children may Not have Ascites),
Malnutrition, Intra-Abdominal Malignancy, Immunosuppression,
Splenectomy, Chronic Liver & Renal disease
Difficult to ddx from Secondary Bacterial Peritonitis; May have Hx of similar attacks
Dx: Presence of Bacteria from Abdominal Tapping
Exclusion of Secondary Peritonitis:
CT (usually good enough)
Laparoscopy Laparotomy
Chronic: TB, Actinomycosis
Secondary: Intra-Peritoneal source:
Perforated Hollow Viscus, Bowel Ischemia, PID, Complicated IO
Acute Secondary Chemical Peritonitis:
Chemical Irritation: Gastric Juice, Bile, Urine, Blood
(Eg. For Stomach, Lower Bacterial load while more Extreme pH than Colonic content)
Prone to be Followed by Bacterial Infection within 6-12h
(If see Urine, since its Sterile, may Not need Emergent Surgery though still need later)
(If see Blood, Emergent Surgery or Not depend on degree of Bleeding)
Acute Secondary Bacterial Peritonitis:
Account for Most Peritonitis
Localized (Contained by Omentum) vs General Peritonitis
If Generalized & Severe, Mortality 20-60%
Bacteriology: Usually Mixed organisms
Gram ve: E.coli, Klebsiella, Proteus, Pseudomonas
Gram +ve: Enterococcus, Staphylococcus, Streptococcus, Clostridium
Cause: Perforation of GIT, Ischemia of Abd organ (eg. Bowel),
Severe Inflammation of Abd organ:
eg. Diverticulitis, Pancreatitis, Cholecystitis, Cholangitis
(Example: Mild: PPU, Low Bacterial count
Localized: Appendicitis, Salpingitis, Cholecystitis
Severe: Large bowel Perforation, Anastomosis Leakage,
Mesenteric Infarction followed by Bowel Perforation)
Tertiary: Opportunistic Infection with Normally Non-Pathogenic Gut Flora
Associated with Prolonged use of Antibiotics in Persistent Intra-Abdominal Infection:
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HBP Peritonitis
Candida, Enterococcus, Staphylococcus
Pathology Danger of General Peritonitis
Peritoneum become Edematous, Hyperemic, Covered with Fibrinous Exudate
> Sequestration of Large amount of Protein rich fluid (Peritoneum is Large & Vascularized)
Septicemia (Whole body Vasodilation> Fluid loss), Endotoxemia (Impair Organ function)
Hypovolemia & Shock
Clinical:
Primary Pathology
Peritonitis: Burning Pain, Initially Localized & Later Spread
Movement & Coughing Exacerbate Pain (Pt may lie still & breathe slowly) (2011 MCQ 89)
Tenderness, Rebound, Guarding
Absence of Bowel sound (Ileus)
In Severe Peritonitis, Smooth muscles of Small Bowel Irritated> Paralytic Ileus
> Gas & Fluid in Gut Not absorbed
> Abd Distention (Not due to merely Fluid Leak from Vasodilation)
Fever, Tachycardia, Tachypnea
Septic Shock
Ix: Blood test: CBC, LRFT, Clotting profile, T&S,
Amylase (Very High: Pancreatitis; A bit High: Any Serious Abd Pathology),
? ABG (More important in Bowel Ischemia) (Will reveal Acidosis)
(No point to take ABG in Shock; Take in Stable Pt)
Paracentesis for Ascitic Fluid Analysis:
Used in Primary Peritonitis
Usually Not needed in Secondary Peritonitis (unless need to exclude HemoPeritoneum early)
Erect CXR, AXR: Check for Free Gas (Supine CXR can Not pick up Free Gas)
US: (Check for Cholecystitis, Help Localize Ascites for Aspiration)
CT: (If suspect Perforation, use Water-soluble Contrast)
Endoscopy: (Large Bowel Ischemia)
ECG: (Exclude AMI)
Tx: IV fluid Replacement
NG tube/Urinary Catheter/O2
Pain Relief
Broad Spectrum Antibiotics: (Switch to Specific Antibiotics after confirming Pathogens)
Primary: Cover both Gram +ve & ve
Secondary: Cover both Gram ve & Anaerobe
Close Monitoring for Change of condition
Surgery: Usually needed for Secondary Peritonitis, but Not for Primary Peritonitis
Drainage: Percutaneous Drainage of Abd Abscess
ERCP for Biliary Drainage
Operation: Laparoscopic Surgery
PPU Repair, Cholecystectomy, Bowel Resection
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HBP Peritonitis
Laparotomy
Planned Abd Re-Exploration:
2nd look Laparotomy following Resection for Intestinal Infarction
Planned Repeated Laparotomy for Peritoneal Toilet (Necrosectomy, Abscess Drainage)
Re-Exploration & Closure of Pt with Abd Compartment Syndrome
Special Situation:
Peritonitis in Elderly:
Poor Historian, Confused or Demented
Hx Inaccurate (Rely on Care-provider)
Peritoneal Signs may be Mild (Weak Abd Muscles)
High index of Suspicion: Abd Pain, Abd Distention
Fever, Leucocytosis, Acidosis, Sepsis of Unexplained cause
Acute Abdomen in ICU:
ICU Pt often Sedated & Intubated
Found Unconscious at home
Missed Injury
Post-op Surgical Cx
Abd Cx: Acalculous Cholecystitis, PPU, GIB, Ischemic Bowel
Peritonitis in the Tropics:
Typhoid Fever: Enteritis, Perforation
Amoebiasis: Colitis & Perforation, Liver Abscess
Ascariasis: IO in Children, Biliary Obstruction, Pancreatitis
Peritonitis in HIV Pt:
Related to IC state:
TB Peritonitis, Perforated Colon from CMV Colitis, CMV Cholecystitis,
Bowel Obstruction/Perforation from Lymphoma
Peritonitis in Pregnancy:
Natural Reluctance to operate
Enlarged Uterus alter Location of organs
Cecum & Appendex is pushed to RUQ
Surgeon has 2 Pt: Mother & Fetus
Should work closely with Obstetricians & Anaesthesiologists

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HBP Peritonitis
H&N Thyroid Nodule
Anatomy:

B Lang: On palpation, first identify Cricoid: Upper pole above it, Lower pole below it
In US: Can see Thyroid, LN, Trachea (& Vocal cord), CCA, IJV, sometimes Vagus N
Cant see RLN (too Small), Esophagus (obscured by Tracheal gas)
Zuckerkandl's tubercle (2014 MCQ 26) (2010 MCQ 25):
Posterior extension of Lateral lobes
Important Surgical Landmark for RLN
Embryology: 2005 MCQ 66: Derived from Endoderm between 1st & 2nd Branchial arches
NB: 2003 MCQ 14: First Branchial arch will form Body & Short process of Incus
Prevalence: Extraordinary common
Depend on: Iodine Deficiency, Gender, Age, Ionizing Radiation,
Method of Detection (Autopsy/USG > Palpation)
Palpable vs Non-palpable:
Goitre: Simple Goitre (Endemic/Sporadic): Diffuse Hyperplastic, Nodular
Toxic Goitre: Diffuse Toxic (Graves disease), Toxic Nodular (Plummer syndrome),
Toxic (Functioning/Follicular) Adenoma
Neoplastic Goitre: Benign, Malignant
Thyroiditis: Bacterial (Acute Suppurative), Viral (Subacute),
Hashimoto (Lymphocytic or AI), Riedel
Others
Definition of Simple Non-Toxic Nodular Goitre:
Thyroid Enlargement, Not a result of Neoplasia/Inflammation, No Thyroid Dysfunction,
Uninodular/Multinodular Goitre
Thyroid Incidentaloma:
US-detected Thyroid Nodules
Definition: Non-Palpable (Vaguely Palpable) Thyroid Nodules:
Experience of Examiner, Size & Location of Nodule,
Body build of Pt, Presence of Enlarged Thyroid gland
Usually Small (<10-15 mm)
Incidentally discovered during Imaging for Unrelated conditions (usually US)
Mx:
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H&N Thyroid Nodule

Indication of Thyroidectomy:
Neoplasm, Toxic nodule, Symptomatic/Retrosternal, Pt request
Presentation: Neck Swelling/Mass, Pain/Discomfort, Local Pressure Sx, Autonomous function,
Voice disturbance, Incidental: Imaging (US, CXR, CT/MRI, PET) vs PE
Pathology: 70% Nodular Goitre: Colloid Cyst/Nodule, Hemorrhage Cyst,
Hyperplastic/Adenomatous Nodule, Cystic Degeneration
15% Benign Follicular Adenoma: Mainly Non-toxic with Small number Toxic
10% Well-differentiated Thyroid CA
5% Miscellaneous: Other Thyroid Malignancies, Hashimoto Thyroiditis
Clinical RF for Malignancy:
Age & Sex (Extremes of Age, Male) (<45 yo, even if Papillary CA widespread, only Stage 2),
Geographic, FHx,
Previous Neck Irradiation,
Pressure Sx, RLN Palsy (Hoarseness),
Solitary vs Multiple Nodules,
Nodule Characteristics (Size/Rapid enlargement, Consistency/Hard, Fixation),
Cervical Lymphadenopathy
Dx/Ix: Ultrasensitive TSH + Free T4
US
FNAC (Clinically/US find Nodule> FNAC)
Blood Test: ESR, Ab (Anti-TPO, ATA/Anti-Thyroglobulin Ab),
Calcitonin (Tumor marker for Medullary Thyroid CA), Genetic testing
Diagnostic Imaging: CXR (Thoracic Inlet), Scintigraphy (2D Radioisotope Imaging), CT/MRI, PET
Endoscopy: Direct Laryngoscopy & OGD
Surgery: Thyroidectomy
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H&N Thyroid Nodule

US: B-mode Real-time Scanner: 7.5/10 mHz probes
Non-Invasive, Convenient, Repeatable, Absence of Radiation hazard
High Sensitivity (Most Sensitive Test for Thyroid Nodules) but Low Specificity
Distinguish Cystic from Solid lesion, Extend PE, Guide Needle Aspiration
Can Not confirm Dx
Use: For All Pt with Goitre/Palpable Nodule; Not performed as Screening test
Features of Malignancy: (2015 MCQ 12)
Risk Stratification> Guide Selection for FNAB (useful in MNG)
Hypoechoic Solid: Microcalcification: Tall>Width (Elongated shape):

Coarse Calcification: Irregular Margin: (Chaotic) Intranodular Flow:
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H&N Thyroid Nodule

Features of Benign Nodule:
Isoechoic: Thin Halo: Complex:

Spongioform: Cystic: Comet Tails:

FNAC: OutPt procedure + US guidance
Accuracy: 90-95%
Avoid Unnecessary Diagnostic Thyroidectomy
Classification: Insufficient: Repeat
Benign: Observe
Suspicious: Operate (Also for Follicular lesion usually operate)
Malignant: Operate
Cytopathy:

(Papillary CA: 2012 MCQ 55: Can be diagnosed by FNAC
2003 EMQ 8: Psammoma bodies is a classical feature)
Follicular Lesion/Neoplasm: (Need Dx by Histology)
20-30% Malignant
Follicular Adenoma, Adenomatous Nodule, Follicular CA, Papillary CA (Follicular Variant)

(Follicular lesion) (Capsular Invasion) (Vascular Invasion)
Diagnostic Accuracy:
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H&N Thyroid Nodule
Cytology Results (%) Probability of Malignancy (%)
Benign (ve) 65 <1
Malignant (+ve) 5 >99
NonDiagnostic (Unsatisfactory) 20 <3
Suspicious (Indeterminate) 10 20
Sensitivity dependent on Risk of Malignancy for those with ve FNA without Thyroidectomy
Can be as Low as 66% & Miss 1/3 of Thyroid Malignancy
The Addictive effect of Clinical Judgment
Bethesda Thyroid FNA Classification: Offer Pre-op guidance in Mx of Thyroid Nodules
Diagnostic category Risk of Malignancy Usual Mx
I. Non-Diagnostic 1-4 Repeat FNA
II. Benign 0-3 Clinical FU
III. AUS/FLUS 5-15 Repeat FNA
IV. Follicular Neoplasm 15-30 Surgical Lobectomy
V. Suspicious of Malignancy 60-75 Surgical Lobectomy + Frozen Section
Completion Total Thyroidectomy if Malignant
VI. Malignant 97-99 Total Thyroidectomy
(AUS/FLUS: Atypia/Follicular Lesion of Undetermined Significance)
Molecular Basis:
BRAF, RET/PTC, RAS, TRK, Galectn-3, p53, Proteomics
BRAF: 40%-64%; RET/PTC: 15%
Panel of Mutations (Asuragen miRInformTM)
Specific but Not Sensitive: High PPV (Rule-in test)
Cytological Sensitivity from 77% to 87%
Gene Expression Classifier (167 genes) (Veracyte Afirma):
Sensitivity 92% & Specificity 52% (Rule-out test)
Combined with Conventional FNAC, For Indeterminate/Suspicious Nodule
Indication: Any Firm, Palpable, Solitary or Clinically Worrisome Nodules (UCH: Usually if >1 cm)
Dominant/Atypical Nodules in Multinodular Goitre
Complex/Recurrent Cystic Nodules
Nodule associated with Palpable/US Abnormal LN
Nodules with Suspicious US features:
Microcalcification, Rounded Shape, Hypoechoic Solid, Irregularity, Perilesional Flow
Surgical Tx without FNAC:
Large/Symptomatic Thyroid Nodule (>4 cm)
Solitary Hyper-Functioning Nodule
Multinodular Goitre with Compressive Sx
Graves disease with Thyroid Nodule
High-risk Pt with Nodule: FHx, MEN II, Radiation Exposure to H&N
Radioisotope Scintigraphy:
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H&N Thyroid Nodule
IV Technetium (Tc-99m) & Gamma camera
10-20% Cold Nodules are Malignant
Hot/Warm Nodules: Rarely Malignant
Radiation Exposure, Expensive, Low Specificity & Sensitivity
To determine: If a Nodule in a Thyrotoxic Pt is Functioning
Functional Status of a Follicular lesion as shown by FNAC
Functional Status of Nodules in a Multinodular Goitre

Surgical Tx:
Hemithyroidectomy (Unilateral Lobectomy):
1 lobe + Isthmus + Pyramidal lobe
For Uninodular Goitre
Safe, Minimal Morbidities, Dx & Cure
Avoid Reoperation on field of Previous Surgery
Reoperation on Contralateral Lobe without added Difficulty
Only 5-10% chance of HypoT
Total Thyroidectomy (Bilateral Thyroidectomy):
For Mutinodular Goitre (Bilateral Nodules)
Additional Surgical Risk
Recurrence
Need Thyroxine Replacement
Others: Partial Thyroidectomy: Nodulectomy; Part of Thyroid lobe/Isthmus or Pyramidal lobe
Subtotal Lobectomy: 1 lobe except 1-5 g remnant
Bilateral Subtotal Thyroidectomy: Both lobes except 2-10 g remnant
Near-Total Thyroidectomy (Dunhill procedure):
Unilateral Total Lobectomy + Contralateral Subtotal Lobectomy
<1 g remnant (spare the remnant around RLN to avoid Nerve injury)
MAS Thyroidectomy:
Minimal Access Surgery
Type: TransCervical, TransAxillary, TransAreolar, Non-Endoscopic
RCT of Video-assisted Thyroidectomy vs Conventional:
Needs Longer OT time but Less Post-op Pain & Better Aesthetic results
(UCH: Still an evolving technique; In UCH wont do for Thyroid CA)
Cx of Thyroidectomy:
General: GA related
Wound Infection (<1%), Bleeding
Specific:
RLN: Vocal cord dysfunction:
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H&N Thyroid Nodule
Hoarseness of Voice:
Type: Transient (within few weeks): 5%
Permanent: 1-2%
(B Lang: Quoted as 1/3 Pt with Vocal cord dysfunction will be permanent)
Cause: RLN injury
(Can occur without cutting RLN, eg. due to Traction, Ischemia, Ligation, etc)
Weakened/Abnormal Voice (QMH Protocol: 10%)
(Can affect breathing if Bilateral RLN injury but Rare)
(SLN injury: Relatively Asymptomatic, but can affect High pitch range of Voice professionals)
Parathyroid:
HypoPTH: Can be Asymptomatic or with HypoCa S/S (2011 EMQ 16)
HypoCa S/S: Tetany, Peri-oral Paresthesia (2004 MCQ 45), etc
Type: Transient: 5-10%
Permanent: 1-2%; (If >6 months usually Permanent; May need Vit D, Ca)
More often after Thyroidectomy for Cancer:
Due to Extent of Surgery & Central compartment LN dissection
(Eg. Disrupted blood supply, Gland damage/removal)
Can be significantly by Liberal Parathyroid Autograft (done in UCH)
Thyroid: HypoT: Total Thyroidectomy: HypoT is an Outcome, rather than a Cx
HemiThyroidectomy: (Usually wont lead to HypoT, unless other side Atrophic)
Thyroid storm (usually in Pt with uncontrolled HyperT) (2002 MCQ 90)
Airway: Resp distress due to Hematoma (<1%)
(Hematoma compress on Vein> Laryngeal Edema; Not direct compression on Airway)
Mx: Open wound & Evacuate clot (2001 MCQ 49) (Even before Intubation)
NB: Potential causes of Resp distress after Thyroidectomy (2003 MCQ 53):
Aspiration, Laryngeal Edema, Wound Hematoma, Tracheomalacia
But Not Unilateral RLN damage
Wound: Wound Cx (Hypertrophic Scar, Keloid)

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H&N Thyroid Nodule
Thyroid Cancer:
Incidence: USA: 1.9% of all Cancer; Lifetime Risk: 1% for F, 0.25% for M; 0.26% of all Cancer Death
HK: 2.4% of all new Cancer; M:F = 3:10, 5th most common Cancer in F
6.8 in 100,000 (3.1 in 100,000 for M; 10.1 in 100,000 for F); 0.3% of all Cancer Death

Histologic Types:
Primary: Well-differentiated (WDTC):
Papillary (60-70%):
Variants: Papillary MicroCA, Encapsulated variant, Follicular variant,
Diffuse Sclerosing, Oxyphilic cell (Hurthle cell) type
NB: 2006 MCQ 54: Also Tall cell, Columnar cell
But Not Minimally Invasive
Follicular (10-20%)
Poorly differentiated (Insular) (5%)
Undifferentiated (Anaplastic) (5%)
Medullary CA (5-10%)
Others (1%): Thyroid Lymphoma (very Hard), Squamous Cell, Metastatic, etc
Secondary: Rare (eg. Breast)
Presentation: Primary Tumour:
Thyroid Mass/Nodule: Palpable/Symptomatic
Hoarseness: RLN Palsy
Incidental Nodules by Imaging
Metastases:
Cervical LN: (60% Pre-op US may show Enlarged LN)
Level 1: Rare; Usually very Metastatic or Anaplastic CA
Level 2: Up to Spinal Accessory nerve, Not up to Parotid; (Upper pole tumor?)
Level 3-4: Mostly involved
Level 5: Usually only 5a
Level 6: Pretracheal, Paratracheal
From Hyoid bone to Brachiocephalic A, bound by Carotid A
Distant Metastases: Bone, Lung, etc
Occult MicroCA in Thyroidectomy specimens
Occult/Minimal:
Occult: Clinically Not obvious but discovered by Pathologist
Minimal: 1 cm in diameter
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H&N Thyroid Nodule
Asso. with Excellent Prognosis
Not all Occult CA are MicroCA
(Mx like Benign disease, Hemi/Total, No need RAI ablation/FU, Wont die from this)
Tx Strategy:
Modalities: Surgery: Thyroidectomy for Primary Tumor
Cervical LN dissection
Adjuvant: Radioactive Iodine (After Total/Near-Total Thyroidectomy)
T4 suppressive therapy (TSH to <0.03)
External beam irradiation (For Incomplete resection)
Chemo (Not that useful) (Doxorubicin as a Radiation sensitizer)
Related to Histology:
Well-differentiated CA: Papillary Thyroid CA: Cervical LN
Follicular Thyroid CA: Hematogenous spread
Availability of Effective Adjuvant Therapies
Medullary Thyroid CA: Familial & Sporadic cases
Early Nodal & Distant Metastases
Anaplastic CA: Locally Invasive
High Incidence of Distant Metastases
Lack of Effective Adjuvant Therapies
Well-differentiated Thyroid CA:
Cause (2002S MCQ 1):
Radiation: 17.5% Thyroid Cancer Incidence at Autopsy in Nagasaki & Hiroshima
Iodine Intake: More Papillary CA in I-rich region while more Follicular CA in I-depleted region
Incidence of Papillary CA after adding Iodine to drinking water
Outcome/Prognosis:
Low risk High risk
% of Pt 85-90 10-15
Mortality (10-20 years) 2-5% 40-50%
Recurrence 10% 45%
Related to Prognostic scoring (AGES, AMES, GAMES, DAMES, etc)
Excellent Prognosis in Low risk group
But Relapses do occur years later
Distant Metastasis can be completely controlled by I131
High risk Pt: (Mainly used to predict Survival; Sometimes also correlates with Risk of Recurrence?)
Papillary CA: Age >40 (B Lang: 45), Tumor Size >1 cm (B Lang: 2 cm),
Extrathyroidal Primary Tumour, Multifocal Tumors,
Distant Metastasis, Incomplete Excision
Follicular CA: Widely Invasive, Distant Metastasis
Tx: Total (or Near-Total) Thyroidectomy with Complete Resection
Neck Dissection: Routine Central Neck Dissection
Therapeutic Lateral Neck Dissection
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H&N Thyroid Nodule
Post-op I131 Ablation & Scanning
T4 Suppressive therapy (TSH <0.03)
External Irradiation for Incomplete Resection/Residual Tumour (R2)
(Can make Neck very Stiff, thus Not routinely given to all Cancer Pt)
Prognostic Scoring Systems:
AMES by Lahey Clinic: Age >40 (M) or >50 (F), Distant Metastasis, Extrathyroidal extension,
Size >5 cm
20-year survival: Low risk 99%, High risk 61%
AGES by Mayo Clinic: Age >45, High grade, Extrathyroidal, Size >4 cm
(Replaced Metastasis with Tumor Grading; Represent Risk in Scores)
(Used in UCH)
MACIS by Mayo Clinic: Score = 3.1 (if Age <40) or 0.08 x Age (if Age >40)
+ 0.3 X T size (cm max diameter)
+ 1 (if incompletely resected)
+ 1 (if locally invasive)
+ 3 (if distant spread)
(After modifying AGES system) (Used in QMH)
(Grading is removed Difficulty to replicate result in other centers)
20-year survival: <6: 99%
6-6.99: 89%
7-7.99: 56%
>8: 24%
Others: DAMES by Karolinska Hospital, GAMES by MSKCC, etc
TMN Staging: Young Age Pt have Good Risk regardless of TNM staging
(Better Prognosis than Elderly even same TNM staging)
Results obtained from Retrospective Cohort studies on RF for Survival
45 yo: Arbitrary; Different staging systems use different cut off age
T: T1: 2 cm
T1a: 1 cm
T1b: >1 cm but 2 cm
T2: >2 cm but 4 cm
T3: >4 cm, or
(Minimal Extrathyroidal extension, eg. Sternothyroid muscle, Perithyroid Soft tissues)
T4a: Any size extending beyond Thyroid capsule
to invade SC Soft tissues, Larynx, Trachea, Esophagus, or RLN
T4b: Invades Prevertebral Fascia, or Encases Carotid artery/Mediastinal vessel
N: N1: Regional LN (ie. Central compartment, Lateral Cervical, Upper Mediastinal LN)
N1a: Level VI (Pretracheal, Paratracheal, Prelaryngeal/Delphian LN)
N1b: Unilateral/Bilateral/Contralateral Cervical LN (I-V), or Superior Mediastinal LN (VII),
or Retropharyngeal LN
M: M1: Distant Metastasis
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H&N Thyroid Nodule
Stage Grouping: (Adapted from American Cancer Society)
For WDTC: Depends on Age, TNM
For Medullary: Depends on TNM
For Anaplastic: All Anaplastic CA are considered Stage IV
Stage Pt <45 yo Pt 45 yo
I Any T or N, with M0 T1
II Any T or N, with M1 T2
T3
III
T1-3, N1a
T1-3, N1b
A
T4a
IV
B T4b
C M1
Tx:
1. Surgery:
Thyroidectomy: HemiThyroidectomy (Lobectomy) vs Total/Near-Total Thyroidectomy (Radical Thyroidectomy)
Rationale for:
Total: Risk of Multifocality (30-80%) (B Lang: Up to 40%),
Recurrence & Improve Survival (?), (Prevents Anaplastic changes),
Facilitate I131 Tx, Enhance Thyroglobulin (Tg) Monitoring
Hemi: Surgical Morbidity, Overall Survival Not adversely affected
In Reality: Almost always do Total Thyroidectomy for CA Gold standard
Some centers, including UCH, may do Hemi for Low risk Pt
QMH: For Small Nodules <1 cm
Cervical LN Dissection:
Therapeutic/Prophylactic
Extent: Observe
Ipsilateral Paratracheal (Unilateral Central Compartment)
Central compartment
Selective Neck
Modified Radical Neck (including Functional Neck)
NB: LN metastasis is common, but does Not influence Prognosis in Young Pt <45 yo
Trend is for Limited LN clearance (cf other Solid tumors)
(Aggressiveness of Dissection Not proven to influence Survival/Nodal Recurrence)
Central Compartment (Prophylactic/Routine):
Pretracheal & Paratracheal LN dissection
Prophylactic dissection: Controversial; (Usually in Papillary CA, Not needed in Follicular CA)
Rationale concerning it in Pre-op N0 Papillary CA:
For: Recurrence, Avoid Reoperation (can lead to Higher rate of RLN injury)
UCH: Routine Central Compartment LND for N0 Papillary CA; The only advocators?
90% N0 Pt have Pathological LN +ve
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H&N Thyroid Nodule
Risk of HypoPTH can be by Liberal Parathyroid Autograft
(Take out Parathyroid glands and put in the Central compartment)
Against: No Survival benefit demonstrated, Upfront RLN injury rate may be Higher
QM: Ipsilateral Paratracheal LND more preferred
Bilateral Paratracheal LND may jeopardize blood supply to Parathyroid
Lateral Compartment (Therapeutic) (Done if detected LN metastasis pre-op):
Type: Functional/Modified Neck Dissection (Functional is Type 3 Modified Neck dissection)
Selective Neck Dissection (eg. Level 2-4 for N1b disease at UCH)
Excision of LN (Berry-picking) (Seldom done anymore)
(Prophylactic Neck Dissection Not done anymore)
2. Adjuvant therapy: Post-op Adjuvant I131
External Beam Irradiation (Incomplete Resection, Anaplastic CA)
Thyroxine Suppressive therapy
Low dose T4 to suppress TSH down to <0.03 U/l,
while avoiding HyperT in Hemithyroidectomy (thus Low dose)
and also serves as T4 replacement in Total Thyroidectomy
(UCH: Half dose of usual replacement, ie. 50 mg/day)
Adjuvant RAI: ONLY after Total Thyroidectomy (otherwise remaining Thyroid tissue will take up the RAI)
T3 should be withdrawn 2 weeks beforehand to allow TSH to
To facilitate uptake by residual/metastatic disease
T3 is preferred to T4 due to its Shorter Half life
Indication: Stages 3 & 4
Stage 2: All Pt <45 yo, Most Pt >45 yo
Stage 1: Selected Pt with:
Multifocality, Nodal metastases, Extrathyroidal/Vascular invasion,
Aggressive variants
Algorithm: RAI ablation (30-100 mCi):
A few weeks (1 month) after operation (post op inflammation affect Iodine uptake)
Post-therapy scan (5-8 days after ablation):
Measure uptake of Iodine in Neck (rationale by radiologists)
Whole-body scan (6-12 months after ablation):
M1 Pt: Therapy to distant metastases (100-200 mCi)
(?) Repeat every 6 months
Postop Mx in UCH:
High risk: TSH> Neck Scan:
ve: T4 Suppression> Monitor (Neck Exam, CXR, US, TFT, Tg)
+ve: Remnant Ablation> 4-6 weeks> WBS> I131 therapy> Monitor
Low risk: T4 suppression> Monitor
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H&N Thyroid Nodule

Tx pathway in QMH:
Total/Near-Total Thyroidectomy
T4 to T3
T3 withdrawal (2 weeks) (Alternative: A shot of hsTSH injection, but its Expensive)
Remnant Ablation
Post-therapy scan
Whole body scan
Uptake of Distant Metastasis: Iodine therapy
No Uptake: FU
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H&N Thyroid Nodule

FU (Lifelong):
Neck Exam
Blood Tests:
TFT (TSH, Free T4) (Ensure adequate TSH suppression)
Tg Assay: Components: Serum Tg: Basal (Routine FU)
Stimulated (During T4 Withdrawal or hsTSH administration)
Anti-Tg: If can affect Accuracy of Tg asssay
Useful mainly after Total Thyroidectomy (B Lang: Also ok for Near-Total)
? False +ve common
Suspension of T4 Suppression unnecessary
Imaging:
Routine:
US Neck FNAC (Once every 2 years? Quite often done in SOPD)
CXR: (Often done; Advocated by Oncologists, but B Lang doesnt like it because:
Recurrence is more commonly in the form of LN recurrence
Even Lung Recurrence, often too Small to be picked up by CXR)
If suspect Recurrence:
Whole body Scintigraphy (I131 WBS) (Nowadays less commonly done?)
PET: If Tg but Normal WBS (Nowadays may directly proceed to PET if Tg?)
Follicular Thyroid CA: LN metastases 10-15% (4x Less than Papillary)
Hematogenous spread: Lungs (for Younger Pt), Bone (for Older Pt)
Page 352
H&N Thyroid Nodule
Presented with Distant metastasis
Present as Follicular lesion identified by FNAC:
Hemithyroidectomy
Frozen section Not routinely performed: Diagnostic info in 13%
Surgical procedure modified in 3.3%
Misguided intervention in 5%
(Unless Big Nuclei> Suspecting Follicular variant of Papillary Thyroid CA)
Wait for Paraffin section (5-7 days later)
For Widely-invasive or Angio-invasive Follicular CA (beyond Capsule or invade Vessels)
> Completion Total Thyroidectomy
For Minimally invasive (Encapsulated) Follicular CA
> Observation
Present with Distant metastasis:
Histological confirmation of Metastases
Detection of Primary tumor
Total Thyroidectomy
Adjuvant therapy: Ablation, RAI therapy, T4 suppression therapy
Medullary Thyroid CA (MTC):
Calcitonin (Basal/Stimulated) as Marker
Total Thyroidectomy, Central + Lateral Neck Dissection
Familial cases (1/3) (B Lang: 50%): MEN IIA, MEN IIB, Familial MTC
Genetic Analysis: RET Proto-oncogene
Prophylactic Thyroidectomy at 5-10 years
Anaplastic CA: Elderly with Poor Comorbid state
Aggressive & Rapidly Growing (can easily compromise Airway)
Locally Advanced disease, Frequent Distant Metastases
Lack of Effective Tx; ChemoRT + Resection; Invariable Palliative & Fatal

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H&N Thyroid Nodule
H&N Neck Swelling
Neck Mass: Benign: Congenital, Infective
Malignant: Primary, Secondary
Dx: Age
Rate of growth
Clinical features: Location
Consistency, Transillumination (eg. Cystic Hygroma)
Size, Mobility, Surface, Edge
Tenderness, Pulsation (eg. Carotid body tumor)
SCF Mass: Secondary deposits from Primary Malignancies in GIT
Small Primary Papillary Cancer of Thyroid may present with Lower Neck LN metastasis
Other causes of LN enlargement
Lateral Neck Mass: Upper Neck: Salivary gland pathology
Under cover of SCM: LN Inflammatory/Neoplastic
Other Lesions: Branchial cleft cysts, Neurofibroma, Carotid body tumor, etc
Midline Neck Mass: Lower Neck: Lesions from Thyroid gland
Upper Neck: Thyroglossal cyst
Ix: FNAC
Endoscopy: If suspect Metastatic LN,
Endoscopic Exam in upper aerodigestive tract is mandatory
Examine Sites of possible Primary tumour with Biopsy if indicated
Imaging: Plain X-rays, CT, MRI, Angiography
CT/MRI: May give additional clues to Dx of Neurofibroma, Salivary gland tumor, etc
Can determine extent of disease & Help plan Surgery too
Angiography/MRA: Useful if suspect Carotid body tumor
Tx: Depends on Nature of Mass
Congenital lesion:
In general should be removed surgically at appropriate Age
Eg. Cystic Hygroma, Branchial cyst, Thyroglossal cyst
Otherwise their in Size may lead to Functional disturbances later
LN: Should be investigated first rather than excised
FNAC usually gives a clue about Etiology of Lymphadenopathy
For Malignant LN, all efforts should be spent to find Primary tumor
Eg. In Southern Chinese, if FNAC shows Undifferentiated SCC, think NPC as a ddx
If IgA VCA & EA are High, Endoscopic Exam with Random Biopsies of NP
Excision LN Biopsy: Done as last resort or when suspect Lymphoma (sent as fresh specimen)
Infection related LN: Treated with Antibiotics
TB LN: Treated with Anti-TB
Subsequent Mx: For Tx of Recurrence (Benign/Malignant) & Mx of Sequel of Surgery
If LN treated for unknown primary by Surgery/RT,
Pt should be followed up regularly to locate the Primary tumor when becomes apparent
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H&N Neck Swelling
Misc:
Carotid body tumor:
Clinical: Typically Mobile Laterally but Not Vertically (2006 MCQ 9)
Shamblin Staging:
Grade I: Localized with Minimal Vascular attachment
Grade II: Partially surrounds Carotids
Grade III: Encases Carotids; Surgical removal is difficult
NB: Malignant transformation can occur (2006 MCQ 9)

Page 355
H&N Neck Swelling
H&N H&N Cancer
Sub-regions in H&N: Nasal cavity, Nasopharynx, Oropharynx, Oral cavity, Hypopharynx, Larynx-Trachea,
Para-Nasal sinuses, Salivary glands, Skull base
H&N Cancer Problems:
Large numbers of Important & Vital organs concentrated in a Small area
Most frequently exposed region of body
Anatomical disruption will affect Morphology & Physiology
(YW Chan: In HK, Most common is Tongue Cancer, 2nd is NPC)
Major Function: Vision, Airway, Taste, Swallowing, Speech
Vision: VA Unilateral/Bilateral
Dry eye Post-Irradiation
Epiphora Lacrimal duct Drainage system
Diplopia EOM/Periorbital
Dystopia - Loss of Orbital floor
Airway: Temporary Swelling (eg. due to RT, Surgery)
Permanent Tumor/Stricture
Taste: Temporary Post Chemo
Permanent After Irradiation/Surgery (Taste sensation can be lost if No Saliva)
Swallowing: Voluntary phase usually affected by Tumors in H&N region
Usually Immediately after Glossectomy/Pharyngectomy
Sometimes Delayed presentation after RT
Speech: Phonation Post Laryngectomy
Articulation Post Glossectomy/Nasal Surgery/Paranasal sinus Surgery
External Appearance:
Inevitably exposed regions of body
Systemic Metastasis Uncommon, Reasonable Life Expectancy
Majority of H&N Cancer require both Resection & Reconstruction
Aim of H&N Surgery:
Resection: Oncologically clear, yet preserve important organ functions> Margins of Resection
Margins of Resection:
Facial BCC: 3-5 mm
SCC: 10-15 mm
Melanoma: 5-50 mm
DermatoFibrosarcoma Protuberans: 30-50 mm
Reconstruction: Choose Best option for Individual Pt
Tools for Reconstruction:
Ladder of Reconstruction
From Simple to Difficult
Does Not take into account the Aesthetic & Functional result of Reconstruction
Reconstructive Ladder:
Ladder:
Page 356
H&N H&N Cancer
Lecturer: Direct Closure
Skin Graft
Local Flap
Distant Flap
Free Flap
Wiki: Healing by Secondary Intention
Primary Closure
Delayed Primary Closure
Split Thickness Skin Graft (STSG)
Full Thickness Skin Graft
Tissue Expansion
Random Flap
Axial Flap
Free Flap
Graft vs Flap: Graft: Need to develop its own blood supply from Recipient bed
Flap: Need to bring along its own blood supply from its BV
Skin Graft: Pros: Simple
Thin & Pliable
Minimal Donor site Morbidity
Cons: Need well-vascularized bed
Poor Tolerance to Infection
Secondary Contracture
Tissue Expansion: Eg. for Scalp lesions

Local Flaps: Pros: Simple
Good Color & Texture match
Minimal Donor site Morbidity
Cons: Sometimes difficult design
Partial/Complete Necrosis
Transposition Flap:

Bilobed Flap:
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H&N H&N Cancer

(Other Examples in Lecture:
Rhomboid Flap
Mustarde Flap (move whole face medially to cover medial canthus))
Regional/Distant Flaps:
Pectoralis Major Flap DeltoPectoral Flap Latissimus Dorsi Flap

Microvascular Free Flaps:
Pros: Particular Flap for Particular Defect
Cons: Longer operative time, Expertise, Risk of Flap Necrosis (2-3%)

H&N Function Reconstruction:
Page 358
H&N H&N Cancer
Vision: Protection of Functioning eye during Anaesthesia
Eye shield
Chloramphenicol ointment
Tarsorraphy (Temporary stitch to protect the eyes)

Knowing the Anatomy
Airway:
Swallowing:
Oral:

Oropharynx:
Hypopharynx:
Speech: Esophageal Speech, Pneumatic device, Electronic device, Speaking valves
(NB: Alternative to Surgery: Radical RT
Metastatic H&N Cancer: Systemic Chemo: Platinum-based, eg. Carboplatin + 5-FU
Target therapy: Cetuximab)
Misc:
Neck dissection:
Radical Neck Dissection (RND):
LN level I-V
Sternocleidomastoid Muscle (SCM)
Spinal Accessory Nerve (SAN)
Internal Jugular Vein (IJV)
NB: The original historical procedure also removes Submandibular gland (2009 MCQ 53)
Modified RND (MRND):
Similar to RND but preserve 1 Non-Lymphatic structures (ie. SCM, SAN, IJV)
Selective Neck Dissection (SND):
Cervical Lymphadenectomy which preserve 1 LN group routinely dissected in RND
Examples: SND (I-III): Common in Oral cavity Cancer (SupraOmohyoid Neck Dissection)
SND (II-IV): Common in Oropharyngeal, Hypopharyngeal, Laryngeal Cancer
Central compartment dissection: Common in Thyroid Cancer
Extended Neck Dissection (END):
In addition to RND, remove 1 additional LN groups/Non-Lymphatic structures
Tongue Cancer: LN spread to Level 1-4 (2009 MCQ 54)
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H&N H&N Cancer
H&N H&N Conditions
Tongue Ulcer Biopsy:
Take at Edge: Can have comparison with nearby Normal tissue
Higher chance of +ve findings; If take at Central may just take Necrotic tissue
Easier to suture edge for stopping bleeding after biopsy

CA Gingiva:
If in Mandible:
If Loosening of Teeth:
Spread into socket, signifying possible spread to Marrow of Mandible
Need Segmental Mandibulectomy
If Numbness:
May spread to Inferior Alveolar Nerve already

Submandibular Stone:
More Stone in Submandibular than Parotid: More Viscous, Direction of flow is Anti-gravity

Metastatic Cervical LN of unknown Primary:
Cervical LN metastasis confirmed SCC by FNAC, with ve Panendoscopy finding
R Tsang: NPC (but usually can tell in FNAC)
Oropharyx (Tonsil, Tongue Base)
Supraglottic Larynx
Hypopharynx (esp Post-cricoid region)
Thyroid (Lateral Aberrant Thyroid CA)
Ix: PET
Tonsil Biopsy, Targeted Biopsy

Hugh Goitre with Tracheal compression:
Do Fibreoptic Intubation
Better Not Tracheostomy
(Difficult to locate Trachea as it may be deviated, Profuse Bleeding from Thyroid tissue)

T1 N0 M0 Laryngeal SCC:
Tx options: Open Surgery (Partial Laryngectomy), Endoscopic Surgery, RT
Comparison: Cure rate similar
Open: Scar, Need Tube feeding for a while (Avoid Choking, Fistula)
Endoscopic: No Scar, Can eat the next day, Shorter Hospital stay
Laser is Expensive but Shorter Hospital stay may make it Cheaper
RT: Preserve Vocal cord Function (Phonation, Prevention of Aspiration)
RT Cx, Most Expensive (5/week x 6 weeks)

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H&N H&N Conditions
T3 N2 Supraglottic SCC (N2 Already a Stage 4 disease):
Tx options: ChemoRT: Organ preservation protocol (good for Younger Pt)
70% successful, 30% require Salvage Laryngectomy
Surgery + RT: Total Laryngectomy + adjuvant RT
5-yr Survival: 50%

Page 361
H&N H&N Conditions
Neuro ICP
Normal ICP: Infant: 1.5-6 mmHg (Lower than Adult because Fontanelles not yet closed)
Young Children: 3-7 mmHg
Adult: 7-15 mmHg (Supine value; Note Elevation of head will further ICP)
(ICP >15: Abnormal)
(ICP >20: Pathological; Prognosis start to get Worse)
(ICP <4: Cerebral Hypotension?)
Monro-Kellie-Burrows Doctrine: Intracranial Contents = Blood + Brain + CSF
Cranial compartment is Incompressible, and Volume inside Cranium is Fixed volume
Volume Equilibrium: Any in volume of 1 of the contents
must be Compensated by in volume of another
Compensatory Mechanism for Intracranial HT: Venous Blood & CSF
(Venous Blood leave to Jugular Vein, CSF leave to SC)
(CSF buffer first Asymptomatic; When CSF buffer exhausted, Venous blood buffer)
Untreated ICP: Cerebral Ischemia, Brain Herniation, Brainstem Insult, Resp Arrest, Coma
Almost Certain Death if Untreated
ICP & Volume: Talk & Die phenomenon
ICP Exponentially with in Intracranial Volume
Initially High Compliance, then Low to the critical point of 25mmHg, then No Compliance
Brain CT: Over Basal Cistern, normally should see a Happy Brain, with CSF around Brainstem
If see Unhappy Brain, probably Brainstem is already being compressed by Brain; Emergency!
Cause of Intracranial HT:
Mass Lesions: Tumor, Hematoma, Abscess
Hydrocephalus: Communicating (eg. CSF production by Choroid plexus Tumor)
Obstructive (eg. SOL, Aqueductal Stenosis, Chiari malformation)
Focal/Diffuse Brain Swelling (Cerebral Edema)
Hyperemia
Venous Congestion (eg. Cerebral Venous Sinus/SVC/IJV thrombosis/obstruction)
Idiopathic Intracranial HT (aka Benign Intracranial HT, PseudoTumor Cerebri)
Cerebral Perfusion Pressure:
CPP = MAP ICP
(Min should be kept >60 mmHg) (2014 MCQ 57)
Cerebral Blood Flow: CBF = CPP/CVR (Cerebrovascular Resistance: 1/Radius4, Length, Viscosity)
Do NOT blindly Hyperventilate (Although ICP, Hypocapnia> Vasoconstriction> CVR> CBF)
CBF Proportional to Cerebral Metabolism (with Hypercapnia & Acidosis)
Autoregulation: CBF is regulated via Alterations in CVR to maintain Perfusion
Within a range of MAP, CBF is Constant
Eg. High Systemic BP> Cerebral Arteriolar Vasoconstriction to Prevent Hyperperfusion
Beware that in Hypertensive Pt, do Not BP dramatically, May compromise CBF
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Neuro ICP

(Wilson Ho: In Normal Autoregulation, if MAP, ICP will )
Cerebral Ischemia: 90% of Head Injury Death
Ischemia: Acidosis, Excitatotoxicity, Free Radicals Generation
Loss of Membrane Potential: Cerebral Edema
CBF (ml/200g tissue/min) 45-65 <25 15 10
Condition Normal Brain at Rest Isoelectric EEG Physiological Paralysis Cell Death
Clinical Features:
Cardinal: Headache, Vomiting, Blurring of Vision, Deterioration in Consciousness, Papilledema (Late)
Cushing Reflex: Cushing Triad: HT, Bradycardia, Irregular (& Slow) Respiration
NB: Often only the HT component occurs, with BP reaching 200 mmHg
Ddx from HT Encephalopathy, which has Tachycardia & BP can be >210 mmHg
Due to Abrupt in ICP; Often a Late feature (Imminent Death)
Elicited by stimulation of Mechanically Sensitive regions in Paramedian Caudal Medulla
NB: Sluggish Dilated Pupils can also be a sign of ICP (2006 MCQ 64)
GCS: Objective, Reproducible, Quantitative
3 Components: Eye Opening, Motor Response, Verbal Response
(For Verbal response, if Pt is Intubated/Tracheostomized, ie. Cant Speak, then Score = 1)
Concept of Monitoring: Clinical (GCS), ICP, Jugular SaO2, Transcranial Doppler, Study of Metabolism
ICP Monitoring:
Indication: No reliable Clinical monitoring (eg. Sedation, Muscle Paralysis)
GCS 8 (Considered Comatose> Need Intubation> Cant monitor by GCS anymore)
Relative Contraindication:
Awake, Coagulopathy
Method: Ventricular ICP Monitor: Hydraulic system, Manometric principle
Gold standard!
Pros: Allow CSF Drainage
Cons: Infection, Invasive, Difficult with Cerebral Edema
Others: Parenchymal/Subdural/Epidural ICP Monitor
Mx: Resuscitation: Airway (Patency), Breathing (Oxygen Supply), Cardiovascular (MAP)
Non-operative/Medical therapy
Removal of Mass lesion
Modalities to ICP: Enhanced Venous Drainage, Controlled Hyperventilation, Mannitol/Diuretics, Steroid,
CSF Drainage, Evacuation of Mass lesion, Decompressive Craniectomy, Barbiturate,
Page 363
Neuro ICP
Induced Hypothermia
{3 Physical, 3 Medical, 3 Surgical}
1. Physical:
Enhanced Venous Drainage (Positioning):
Avoid Neck Rotation
Head Elevation (30-45; Not to 90 because Arterial Pressure to Brain will)
Remove Neck Collar if not indicated
Avoid Jugular Compression, Avoid in Intrathoracic/Abdominal Pressure
Controlled Hyperventilation:
CO2> Vasoconstriction> ICP
But be careful! Vasoconstriction> CVR> CBF
Keep PaCO2 3.0-3.5 kPa (26-30 mmHg) (ie. Attain Normocapnia) (2011 MCQ 54)
Avoid Excessive & Prolonged Hyperventilation (PaCO2 <2.8 kPa)
NB: 2006 MCQ 30: Alkalemia (eg. from Resp Alkalosis from Hyperventilation) can ICP
Induced Hypothermia:
Basal Metabolism (Might help some Pt, Not routine) (Cool core body temp to 32-33C)
S/E: Coagulopathy
(BP: ICP & MAP = CPP = Better?
TBI may Impair Vasoreactivity (Loss of Autoregulation):
Pressure Active: MAP> ICP
Pressure Passive: MAP> ICP
Autoregulation has Limit

CPP Optimization:
CPP <70 mmHg: Pressor Infusion
CPP >110 mmHg: BP)
2. Medical:
Diuretics:
Mannitol: Mechanisms: Plasma Expanding effect (Improve Rheology by Viscosity)
Osmotic Diuretic effect
Commonly 100 ml 20% IV (Bolus administration of 0.25-2 g/kg)
(Osmotherapy: Mannitol 0.25-1.5 g/kg IV or 0.5-2.0 ml/kg
+ 23.4% Hypertonic Saline (repeat every 1-6h as needed))
Caution: Hypotension (Do NOT use in Shock) & HyperOsmolarity (HyperNa)! (2011 MCQ 54)
Monitor: Foleys Catheter
(NB: Prolonged use will be useless as Interstitial P will to achieve equilibrium
Page 364
Neuro ICP
Gradual withdrawal to avoid Rebound Cerebral Edema)
Loop Diuretics (eg. Frusemide)
Hypertonic Saline? (May help avoid Shock after Mannitol; Details under research now)
Steroid: Vasogenic Cerebral Edema
For Tumor (Vasogenic + Cytotoxic Edema), NOT for Trauma/Stroke (Cytotoxic Edema only)
Use in SC Injury: Controversial
S/E: PU, Immune, Cushing syndrome
Barbiturate Coma: eg. Thiopentone
Mechanism: Neuronal Activities & Cerebral Metabolism
CBF & ICP (Alteration in Vascular tone)
Inhibition of Free Radical mediated Lipid Peroxidation
High dose: Loading dose 5-20 mg/kg (10 mg/kg x 30 min)
Maintenance dose 1-4 mg/kg/h (1 mg/kg/h)
(Before resorting to this, IV Sedation can be used to attain Quiet state too)
S/E: Hypotension, Myocardial Depression
Monitor: ECG
Progesterone: Cerebral Edema M>F, due to Progesterone in F?
Stabilize BBB, Oxidative Stress, Apoptosis
() NMDA, (+) GABA, Unlike Steroid (Not many S/E in Progesterone)
RCT in 2008: ICP & Mortality for GCS <9 within 8h
(Not yet standard, still under research)
3. Surgery: Removal of Mass lesions: Hematoma, Brain Tumor, Abscess
Decompressive Craniectomy
CSF Drainage for Hydrocephalus

Page 365
Neuro ICP
Hydrocephalus
CSF: Balance: Production: Choroidal Plexus of Lateral, 3rd (roof), 4th Ventricles; 500 ml/day (0.35 ml/min)
Absorption: Arachnoid Granulations
Function: Buoyancy, Protection, Chemical Stability, Prevention of Brain Ischemia, Clearing waste
Not as a main Nutritional source of brain
Content: Higher Na & Cl conc than plasma, but Less K, Ca, Glucose, Protein
Cause: CSF Production, CSF Absorption, Obstruction of CSF Flow
Obstructive: Posterior fossa tumor, Tumor compressing 3rd ventricle
Communicating:
Production:
Choroid plexus tumor
Absorption:
Meningitis, IVH
Clinical:
Paedi: Macrocephaly (Cross percentile)
Full/Tense percentile
Developmental delay
Ix: US: Usually feasible in those <1 yo (Fontanelle Not yet closed)
CT: Good but Risk of Radiation
MRI
(LP: Contraindicated for Obstructive Hydrocephalus Risk of Coning
Therapeutic in Communicating type Transient relief)
Tx: External Ventricular Drainage
Shunting: Commonest: Ventriculo-Peritoneal (VP) shunt
2nd Common: Ventriculo-Atrial shunt (put into SVC; If gets into RA, can cause Arrhythmia)
Others: Ventriculo-Pleural shunt, (Lumbo-Peritoneal shunt)
Cx: Infection:
Presentation: Sepsis
ICP (Shunt usually blocked)
Abd distension (Due to Pseudocyst)
Mx: Evaluation: Exclude Coexisting Blocked Shunt
Exclude Distal End Infective Foci (eg. Abdominal Sepsis)
Shunt Tapping Obtain CSF specimen
Antibiotics
Consider Externalize/Remove Shunt (Re-insert Antibiotic-impregnated Shunt)
Blockage: Valve: If Blockage distal to Valve, its Non-compressible
If Blockage proximal to Valve, its Compressible but doesnt Rebound
NB: Valve pumping is Not accurate, sensitive nor specific
Never pump valve Can block it (Even Neurosurgeons seldom do)
In suspicion: Hx/Clinical (Parents may tell), Shuntogram, Baseline scan
Dislodgement
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Neuro ICP
Overshunting:
(Brain get away from Skull> Headache features of ICP; Subdural Hematoma)
Slit Ventricle syndrome:
(Stiff Ventricle> Subtle change in Ventricle Size may already imply ICP; Be vigilant!)
Others:
VP: Abdominal Pseudocyst
VA: Higher Cx rate
Can lead to Cardiac Thrombus, Shunt Nephritis, etc; (Wont cause Systemic Fluid overload)
VPleural: Pleura is Not a good surface for Absorption; Can have Pleural Effusion
rd
3 Ventriculostomy:
Perforation made to connect 3rd ventricle to Subarachnoid space
Good for Pt with Obstructive Hydrocephalus or Blocked Shunt

Misc:
Flow Void in MRI T1W with Contrast:
Fast flowing structures will Not show Hyperintensity
ICA, Basilar arteries are Hypointense even with Contrast

Page 367
Neuro ICP
Neuro Brain Tumor
Presentation: ICP, Focal Neurological deficit, Epilepsy, Others
ICP:
Cause: Mass effect, Cerebral Edema, CSF Obstruction, Ischemia, Venous Congestion
Sx: Generalized Headache: Worse in Morning (Sleep: Hypoventilate, Lie Flat)
Transient Relief after Vomiting (due to Hyperventilation?)
(May be worsened by Coughing/Sneezing? Med 2014 MCQ 65)
Nausea & Vomiting, Conscious level
Late: Papilledema & Cushing Triad
Focal Neurological deficit:
Loss of Neuronal Function, Location-specific (Clinical Localization of lesion)
Neuronal Destruction, Pressure Effect, Edema (may be reversed with Steroid)
(If in Frontal lobe: Usually present Late Sx Not so obvious)
Epilepsy: Supratentorial lesion! (Not Infratentorial lesion)
Partial Seizure, Grand-mal Seizure, Complex Partial Seizure (TLE)
Others: Facial Pain, Hypopituitarism & Bitemporal Hemianopia
NB: CNS Malignancy seldom metastasize outside CNS (2006 MCQ 90)
Brain Herniation: Uncal, Tonsillar, Central, Cingulate
Uncal: Uncus of Temporal lobe
CN3 Palsy: Dilated Ipsilateral Pupil, Contralateral Hemiplegia
Brainstem Compression
Impaired Consciousness
Kernohans Notch: Ipsilateral Hemiplegia (False Localizing Sign)
Tonsillar: Posterior Fossa Mass
Cardiopulmonary Arrest, Impaired Consciousness, Decorticate/Decerebrate Posture
Central: Downward Displacement of Diencephalon
Bilateral Small Pupils, Cheyne-Stokes Respiration, Unconscious
Cingulate: Displaced Cingulate gyrus
Subfalcine Shift, ACA may be Compromised
Non-Specific Clinically
Tumor Type: Primary: Benign, Intermediate (Histologically Benign, Clinically Aggressive), Malignant
(Not always Clear-cut)
Secondary (Metastasis): Commonest in Adults!
By Cellular Origin:
Neuroepithelial tissue, Meninges (Meningioma), Pituitary Tumor,
Nerve Sheath cells (Acoustic Neuroma), Lymphoid cells (Lymphoma),
Germ cell (Teratoma), Malformative Tumor (Craniopharyngioma), others
Incidence: Adult: 80-85% Supratentorial, 15-20% Infratentorial
Metastases, Glioma, Meningioma
Children: 40% Supratentorial, 60% Infratentorial
Medulloblastoma (prone to CSF metastasis), Cerebellar Astrocytoma
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Ix: CT, MRI, Angiogram; May do CT with Contrast, fMRI & Tractography; No role for Skull X-ray
Contrast CT: Meningioma: Homogenously Intense Dural-based Mass (High Vascularity, No BBB)
Tx: Medical: AntiConvulsant: Tx/Prophylaxis (If Hx of Epilepsy); Not for Infratentorial lesions!
Steroid (Dexamethasone): Cerebral Edema
Ulcer Prophylaxis, Immunosuppression!, DM!
Surgery: Surgical Resection: Maximal Removal within Safety limit
Cytoreduction; Preservation of Function
Resection Margin
CSF Shunting for Hydrocephalus: Posterior Fossa lesions
Leptomeningeal Mets, CSF Mets!
Radiation: Delivery: TeleRT (External Beam)
BrachyRT (Interstitial Implant)
Fractionation: Fractionated (Hyper, Hypo), Single Dose
Radiosurgery:
Concentrated dosage with Minimal spread, cf. External Beam
X-Knife: Linear Accelerator
Gamma-Knife: Gamma Particles
(Cyber Knife: In HK, only in Private sector; Useful for Moving body parts, eg. Lung)
Brain Metastasis: Commonest Intracranial Tumor
ing Incidence! 25% Cancer Pt
Route: Hematogenous, Direct Invasion
Common Origin: *Lung (2002S MCQ 10), Breast, Renal Cell, Colon
Dx: Radiological Dx
Ddx: Brain Metastasis, Primary Brain Tumor, Brain Abscess
Histology crucial
Tx: Aim: Symptomatic Palliation, Prolonged Life Expectancy, QOL
- Brain Mets: Tend to do Surgery if:
Safe to Remove, Young Age, Sth to Palliate, Still have Good Function,
Reasonable Life Expectancy, Original Cancer under Control
If Not, maybe just RT
Survival: Untreated 1 month
Surgery + WBRT: Solitary Brain Metastasis, Good Functional Status, Stable Systemic disease
10-12 months
- Glioma: Neuroepithelial Tissue Neoplasm:
*Astrocytoma (Low-grade/Anaplastic/Glioblastoma Multiforme), Oligodendrocytoma,
Ependymoma, Pineal Cell Tumor, Neuronal Tumor,
Embryonal Tumor (Primitive NeuroEpithelial Tumor PNET)
Astrocytoma: Grade 1-4
Glioblastoma Multiforme (grade 4): Very Malignant, Life span 12-14 months
Surgery: Safe Maximal Removal: Preserve Life & Function
Very Little Margin
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Neuro Brain Tumor
Chemo: Grade 3/4 Glioma
ChemoIrradiation with Temozolomide
Standard therapy, Alkylating agent
Concomitant use with ERT, then Adjuvant therapy for 6 cycles
S/E: BM Suppression
Anti-Angiogenesis agent, eg. Bevacizumab
- Pituitary Tumor: Pituitary Adenoma:
Etiology Unknown
10-15% of Primary Brain Tumor; 20-25% at Autopsy
70% Endocrinologically Secreting
Cut-off for Micro- vs Macro-Adenoma: 1cm
Evaluation: Clinical Assessment, Contrast MRI Dynamic studies, Visual Field (Clinical & Perimetry),
Endocrine Evaluation (Hypopituitarism, Hypersecretion)
Surgery: 1st line for: Symptomatic Non-secreting Adenoma
ACTH-secreting Adenoma
GH-secreting Adenoma
Not for Prolactinoma
Prompt relief from Excess Hormone Secretion & Mass effect
Approach: *Transcranial, TransSphenoidal (Transnasal, Sublabial)
Microscopic, Endoscopic
Cx of TransSphenoidal Surgery:
Mortality (Rare), Endocrine (DI, Hypopituitarism), Visual Loss, CSF Leakage & Meningitis,
Vascular Injury & CVA, ENT Sx, ICH, etc
Radiation: Indication: Unfit for Surgery
Large Tumor/Persistent Hormonal Hyperfunction despite Surgery
Conventional RT/Radiosurgery
Medical: Acromegaly: Useful for Refractory cases or when Surgery is Not feasible
Somatostatin analog, DA Antagonist, GH Receptor Blocker (Pegvisomant)
Cushing: Ketoconazole, Metyrapone, Mitotane
Use is limited by S/E, Expensive, Lack of Efficacy
Can buy time & use to treat cases Not amenable to Surgery
Pituitary Apoplexy: Hemorrhagic Infarct of Tumor; Neurosurgical Emergency!
Presentation: Variable Onset of Severe Headache, Meningismus (looks like SAH), Vertigo,
Visual defect, Altered Consciousness
Sx may occur Immediately or over 1-2 days
st
- Meningioma: 1 choice: Surgery
Recurrence affected by Extent of Resection & Histology
Benign, Atypical, Malignant
Adjunct: Radiosurgery or Wide-field ERT
- Acoustic Neuroma: Surgery, Radiosurgery
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Neuro Brain Tumor
Neuro ICH
Headache & LOC:
Coma: Severe Impairment of Arousal
Inability to Obey Commands, Speak or Open Eyes to Pain
GCS = E1 M5 V2
Impaired Brainstem reflex
Decorticate Posturing: Red Nucleus involved (Disinhibited), cf. Decerebrate Posturing
Motor response with ing Brainstem involvement down to Medulla
Pathophysi: Consciousness Needs: Cerebral Hemispheres, RAS (Brainstem, Hypothalamus, Thalamus)
2 Components: Arousal, Content
Cause: Intracranial: Traumatic, Vascular, Infective, Neoplastic
> Mainly due to ICP or Seizure
Extracranial: Metabolic, Drugs/Toxin, Vascular Occlusion, Resp/Cardiac Insufficiency,
Psychiatric
Headache: Pain Sensitive Structures: The Brain itself feels No Pain
Intracranial: Venous Sinus, Cortical Veins, Basal Arteries, Dura Mater
Extracranial: Scalp Vessels & Muscles, Orbital content, Mucous Membrane,
(Referred Pain) External/Middle Ear, Teeth/Gum
Migraine: Usually Unilateral, Photophobia, See Stars, Red & Watery Eyes
Life-threatening Cause:
Sudden ICP, Very Distinct Onset
Severe Pain, Consciousness, Vomiting, Focal Deficit,
Meningism (Neck Stiffness, Kernigs Sign, Photophobia)
Mx Principle: Resuscitation (ABC), Abort Seizure if any (Seizure can ICP due to Hyperemia), Control ICP,
Ix for Cause, Treat underlying pathology
Correction of Coagulopathy in ICH Pt:
Warfarin: FFP
or Prothrombin complex concentrate (Faster than FFP, but risk of DIC)
and IV Vit K (Can take up to 24h to normalize INR)
Warfarin & Emergency Neurosurgical Intervention:
Above + rFVIIa (Contraindicated in Acute ThromboEmbolic disease)
Heparin/LWWH: Protamine sulphate ()
(Can cause Flushing, Bradycardia, Hypotension, esp in Pt allergic to Fish)
Platelet dysfunction/Thrombocytopenia:
Platelet Transfusion and/or DDAVP
Stroke:
Type: Ischemic: Vessel Occlusion, Embolism, Arteritis, Blood disorder
Not usually Painful (Unless Swelling in very late stage)
Hemorrhagic: Intracerebral Hemorrhage (HT usually cause this), SAH
Headache common
Ischemic Stroke:
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Mx: Prevention, Acute Tx for Brain Attack (tPA Thrombolysis, Therapeutic window 3-6h), Rehab
ICA Occlusion: Can cause Malignant MCA Infarct (Large area of Infarct can have Pressure Effect> ICP)
Ddx ICA & ECA on Angiography: ECA has branches, ICA doesnt
Carotid Stenosis: 1st line: Anti-Platelet
Surgery: Failed Medical therapy, Endarterectomy, Endovascular therapy
Intracerebral Occlusion & Stenosis: Endovascular Endarterectomy, Endovascular Stenting
Mx of Established Cerebral Infarct:
Dont do Thrombolysis/Revascularization any more!!
BBB Not Intact> Can transform to Hemorrhagic Stroke
ICP Control, Decompressive procedure
Decompressive Craniectomy for Massive Cerebral Infarct: Supratentorial Hemispheric Infarct
Candidate: Potential for good neurological recovery
Young (About <55)
Non-dominant hemisphere
Problems: Hydrocephalus, Brainstem Compression
Surgical option: Ventriculostomy, Suboccipital Craniectomy, Infarctectomy
Hemorrhagic Stroke:
Location:
Ganglionic/Putaminal: HT, Surgery saves Life, Poor Functional Outcome, Pt Selection
Cerebellar: Hydrocephalus (dont miss it), Brainstem Compression, Urgent Surgery
(Ddx from Brainstem Hematoma on Imaging:
Hypodense structure, ie. Brainstem, before the Hematoma)
Brainstem, Thalamus: Poor Prognosis, Minimal role for Surgery
Lobar: Underlying Pathology? (eg. AVM, Tumor)
Surgery provide Histology & Good Outcome
Cause: *HT (50-90%)
Pathogenesis: Formation & Rupture of Microaneurysm (Charcot-Bouchard Aneurysm)
Medial Degeneration (Lipo/FibrinoHyalinosis)
(WM Lui: Hypothetical reason for HT to affect BG/Cerebellum/Thalamus/Brainstem:
Perforators subjected to High P there; Not Angulation-related)
Vascular lesion: Aneurysm, AVM, Cavernoma
Hemorrhagic Infarct, Amyloid Angiopathy, Tumor, Bleeding Tendency,
Sympathomimetic Abuse, Venous Sinus Thrombosis, Moyamoya disease
Acute Mx: Factors: Age, Location of Hematoma, Neurological status, Etiology, General Health
Tx: ABC, ICP control (Medical), Surgical Decompression (CSF Drainage, Clot Evacuation)
(WM Lui: BP control: Controversial
Study 1: Rapid control down to SBP 140 Not harmful,
even slightly better (Rebleeding risk)
Study 2: Equivocal
WM Lui: Rapid control of BP at least Not inferior to leaving it
Previous Fear for Inadequate Cerebral Perfusion is Not very justified
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Neuro ICH
Prevent Rebleeding:
Transamine: Limited evidence, but No harm anyway
Novel7: More evidence, but Expensive & some Risk of MI)
Surgery: Depend on pre-op GCS:
Not indicated: GCS 3-5, GCS 13-15
May be indicated: GCS 6-12
Not Absolute, affected by:
Age, Pre-morbid conditions, Coagulation status, General conditions, Hematoma Location
STICH trial: Surgical Trial in Intracerebral Hemorrhage
Early Surgery vs Initial Conservative Tx in Pt with spontaneous Supratentorial ICH
Findings: 1033 Pt were randomized to Early Surgery (503) or Initial Conservative Tx (530)
Favorable outcome at 6 months: Early Surgery 26%, Conservative 24%, p=0.414
Interpretation: No overall benefit from Early Surgery compared with Initial Conservative Tx
Recent Advances in Mx of ICH:
Minimally Invasive interventions
Simple Clot Aspiration
Fibrinolytic agents enhancing Clots Lysis & Catheter drainage
Infusion of Urokinase/TPA: Promoted Clot Lysis
Absorption without producing Neurotoxicity
Improved outcome for some Pt who have suffered an ICH
Mx of Putaminal ICH:
Conservative Mx
ABC
Control ICP: Head up, Mannitol/Glycerol
Control HT: <180 mmHg; Prevent Rebleeding
Mx of Cerebellar Hemorrhage:
Evacuation of Hematoma: Brainstem compression, Hematoma >3 cm, Obliteration of Cistern
EVD: Small Hematoma, Hydrocephalus
(NB: Houncefield unit: +130: Calcification
+80: Hematoma)
SAH: Cause: *Traumatic SAH
Spontaneous SAH: Aneurysm (75%), AVM (5%), Tumor/Bleeding Tendency (5%),
Idiopathic (15%)
Cerebral Aneurysm: 2-5% Adult; Arterial Bifurcation
Hemodynamic Stress, Congenital Weakness, Abnormal Circle of Willis
Presentation: Rupture (SAH): Sudden Severe Thunderclap Headache (*Occipital region)
Other Sx: N/V, Photophobia (2011 MCQ 52), etc
LOC
Meningism (Ddx Meningitis): Neck Stiffness
Fundi (SubHyaloid Hemorrhage)
Mass Effect: CN3 Palsy Surgical 3rd Nerve (PComA), Visual Loss (Ophthalmic A)
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Neuro ICH
Thromboembolism
WFNS Grading of SAH: Good Grade: 1-3 Poor Grade: 4-5
Grade 1 2 3 4 5
GCS 15 13-14 7-12 3-6
Motor Deficit + +/
Dx: CT: Careful if Delayed presentation (Very Sensitive at first but Less useful afterward)
ve Imaging cannot exclude Dx (Proceed to LP if clinically suspicious)
Lesions: Hyperdensity in: Anterior InterHemispheric Fissure, Suprasellar Cistern, Prepontine Cistern,
Sylvian Fissure
NB: Blood over Posterior Brain (Pt lying supine during CT)
Blood over Basal region (Standing)
LP: Useful if CT ve
Blood: Need to ddx between SAH vs Traumatic Tap
Classically 3-bottle Test:
True SAH: All 3 bottles have same amount of blood
Traumatic Tap: Blood amount with successive bottles
Xanthochromia:
Yellowish CSF due to Bilirubin
MRI: Not Sensitive at Early stage
Ix after Dx of Spontaneous SAH Angiography:
DSA, CTA (Usually done first Non-Invasive), MRA
Cx after SAH:
Rebleeding: Day 1: 4% Day 2: 2% Day 14: 20%
Identify & Secure Aneurysm EARLY (2007 MCQ 90)
Vasospasm (Sympathetic overactivation)
Hydrocephalus
SIADH
Seizure
Cardiac dysfunction:
Arrhythmia (If asso. with HypoK can be Life-threatening VT), LV Systolic dysfunction, MIs
Due to Sympathetic Surge: Neurogenic Hyperactivity + Systemic Catecholamines
SAH Pt usually need ECG; Note MI is uncommon but Troponin may False +ve
Tx of Ruptured Aneurysm: Microsurgical Clipping, Endovascular Coiling, (Flow-Diverters)
Clipping: Extra-luminal approach (Open Surgery)
Titanium Clip, Obliteration of Aneurysm Neck, Reconstruct Arterial lumen
Intra-op Rupture rate about 5%
Coiling: Endo-luminal approach
Guglielmi Detachable Coil (GDC) Embolization
Endovascular Tx more preferred than Open surgery if possible
Further Advancement: Stent-assisted Coiling
International Subarachnoid Aneurysm Trial (ISAT): Clipping vs Coiling
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Endovascular Coiling can improve chances of Independent Survival compared to Clipping
At 1 year: 22.6 % RR reduction, 6.9% Absolute Risk reduction
Can be generalized to this population of Pt
Vasospasm after SAH:
Delayed Cerebral Ischemia due to Blood in CSF
Start on Day 4, Peak on Day 7-10 (2007 MCQ 90), Resolve within 2-3 weeks
High M&M (Med 2003 MCQ 66: Delayed Cerebral Infarction is a major cause of M&M)
Tx: CCB: Nimodipine (2007 MCQ 90)
(Preferential on Cerebral vessels without causing much systemic Hypotension)
Triple-H therapy (HT, Hemodilution, Hypervolemia)
Angioplasty (Mechanical/Chemical)
Hydrocephalus after SAH:
Early or Delayed; Obstruction of CSF flow
CSF Drainage procedure (Dont Drain Too Much May provoke Rebleeding)

Main issues with SAH:
Ruptured Aneurysm, Prevent Re-rupture, Treat as a time bomb, High clinical suspicion,
Earliest Dx (CT/LP), Identify cause (Aneurysm), Treat cause, Treat Cx
Cerebral Vascular Malformation:
AVM, Cavernous Angioma, Venous Angioma, Capillary Telangiectasia
Cerebral AVM: Abnormally developed A & V, No Intervening Capillary> AV Shunting
Arterialized Veins, Venous Varix, A/W Aneurysm
Presentation: Hemorrhage (Mortality 10%, Morbidity 30%), Seizure, Ischemia (Vascular Steal)
Headache, Others (Bruit, Hydrocephalus, HF)
Risk of Hemorrhage:
Risk of Bleeding = 3% per year
Risk of Bleeding Once = 1 (Annual Risk of Not Bleeding)Remaining Years to Live
= 1 (0.97)Remaining Years to Live
Martin-Spetzler Grading of AVM: Sum of all points
Size: <3 cm 1
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Neuro ICH
3-6 cm 2
>6 cm 3
Eloquence Area: Non-Eloquent 0
Eloquent 1
Venous Drainage: Superficial Only 0
Deep 1
Tx: Aim: Prevent Bleeding, Seizure Control, Neurological function
Modality: Surgical Excision, Embolization, Radiosurgery, Combination
Surgery: Cure is immediate if Total Resection is achieved
Recommended for Grade 1-3 lesions
Outcome:
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
No Deficit 100% 95% 84% 73% 69%
Minor Deficit 5% 12% 20% 19%
Major Deficit 4% 7% 12%
Embolization: (WM Lui: Seldom performed now; Higher risk of Cx than Surgery)
Less Invasive than Surgery and can reach lesions that are Inaccessible surgically
Risk of Embolic Stroke exists
Rarely achieves complete eradication
Stereotactic Radiosurgery (SRS):
Pros: Non-Invasive
Can access all anatomic locations of brain
Cons: Only for Small lesions (The Smaller, the Better response)
May require 2 years for a full destructive effect
Cant be used to treat Aneurysm but can be used for AVM
Combined Tx:
Total Eradication may require >1 modalities
Cavernous Angioma: Lower Bleeding risk, DSA ve (do MRI; Popcorn lesion), Surgical Excision
Conclusion:
Consider Vascular Cause whenever:
Sudden Severe Headache, LOC, Signs of ICP, Focal Neurological deficit
SAH: Clinical suspicion, Early Tx of Aneurysm, Rebleeding, Vasospasm, Hydrocephalus
AVM: Hemorrhage, Seizure, Vascular Steal, Multimodality Tx
Ischemic Stroke: Brain Attack, Role of Thrombolysis, Role of Surgery,
Correct Underlying cause to prevent Recurrence
Hemorrhagic Stroke: Commonest cause is HT, Consider other Underlying pathology,
Conservative Tx for most, Surgery in selected cases
Moya Moya disease:
Definition: Chronic occlusive cerebrovascular disease
Characterized by Progressive Stenosis of Proximal ICA
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Enlargement of Proximal Penetrating arteries
Hallmark: Angiographic appearance of Dilated Collateral vessels: Moya Moya ("puff of smoke")

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Neuro ICH
Neuro Paraplegia
Lower SC lesion: Cord: UMNL
Conus Medularis: Mixed UMNL & LMNL
Cauda Equina: LMNL
Sphincter Dysfunction: Irreversible unless very Early Intervention!
Bladder: Painless AROU (If Painful, consider other causes, eg. BPH)
Bowel: Constipation
Saddle Anesthesia: Saddle Area: S2, S3-S5

Injury Level vs Extent of Paralysis:
Brachial Plexus Involved: Quadriplegia
Brachial Plexus Spared: Paraplegia
Complete Cord Transection:
Complete Paralysis & Sensory Loss below, Sphincter Dysfunction
Central Cord Syndrome:
Segmental Loss: Decussating Secondary Sensory Neurons affected
Anterior Horn cells involved Late
UL Pain/Numbness
Long Tract Sign: Medial Fibres affected first
Sacral Sparing (Reverse of Sacral Anesthesia), Bladder usually preserved

Anterior Cord Syndrome:
Paraplegia, Spinothalamic Loss, Intact Posterior Column
Posterior Cord Syndrome:
Rare; Pain & Paresthesia in UL & Trunk, Mild UE Paraparesis
Spinal Shock: 2 Meanings:
Flaccid Paralysis & Areflexia for 1-2 weeks after Injury
Hypotension: Interruption of Sympathetics, Vasodilation, Bradycardia
Other Problems: Neurogenic Bladder: UTI, Reflux Nephropathy
Anal Function: Constipation
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Neuro Paraplegia
Sexual Function
Temp Control: Impaired Homeostasis
Spasticity & Spasm: No Descending Control
Hyperactive Spinal Reflex, Spastic Muscle Tone, Limb Deformity
Difficult Rehab
Pressure Sores
Autonomic Dysreflexia: Lesion above T5/6, Late problem
Stimuli Full Bladder> Sympathetic response> Vasoconstriction> HT
Vagal Bradycardia
SOL: By Location: Extradural, Intradural Extramedullary, Intradural Intramedullary
By Pathology: Neoplasm: Primary, Secondary
Traumatic: Bone Fragment, Hematoma
Degenerative: Prolapsed IV Disc, Osteophyte
Infective: Abscess, TB Spine
Cystic: Arachnoid Cyst, Syringomyelia
Vascular: AVM
Non-Compressive Cause: Transverse Myelitis: Dx by Exclusion; LP High CSF Protein
Cord Ischemia: Aortic Surgery
Clinical Features: Slowly Progressive: Tumor
Acute Onset: Vascular, Trauma
Chronic with Acute Exacerbation: Degeneration, Tumor
Background Health: Malignancy, Sepsis/Immunosuppression
Mechanism of Injury:
Stable: Vertical Compression (eg. Load fall onto Head)
Hinge Injury (eg. Blow to Head) with Ligaments Intact
Unstable: Hinge Injury (eg. Blow to Head) with Ligaments Disrupted
Shearing Injury (eg. Fall from Height)

Spinal Trauma: Assume Cervical Spine Injury in Unconscious Pt
Sx: Pain, Neurological Deficit
Signs: Tenderness over Spinous process, Step between Spinous process,
Spinal Shock, Flaccid Limbs (Muscle Weakness & Areflexia),
Sensory Level, Painless Retention of Urine,
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Neuro Paraplegia
Lax Anal Tone, Priapism
Injury: Neurological Injury: Complete/Incomplete Cord lesion
Potential for further Deterioration
Bony & Ligamentous Injury: Stability, Hematoma, Further Neurological damage
Cervical Spine X-ray: Lateral view, Anterior view, Open-mouth view (for C1/C2)
Tx Principle: Resuscitation, Protect & Stabilize Spine,
Assume Multiple Injury/Head Injury, Methylprednisolone IV for Cord Injury,
(Controversial; Not a Standard)
Surgery to Decompress SC, Mechanical Stabilization,
Prevent/Treat Cx, Rehab
Spinal Tumor:
Classification: Extradural: Metastatic Tumor, Primary Bone Tumor
Intradural Extramedullary: Meningioma, Nerve Sheath Tumor
Intradural Intramedullary: Astrocytoma, Ependymoma
X-ray: AP view: Loss of Pedicle, Widening of Interpedicular Distance, Thinning of Pedicle

Oblique view: Widening of Intervertebral Foramen

Myelography: Epidural Block:
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Neuro Paraplegia

Intradural Extramedullary Block:

Intradural Intramedullary Block:

Mx Principle: Surgical Resection within Safety limit, Adjuvant for some (RT),
Primary RT in selected cases (Mets), Stabilization of Bone Column,
Close FU
Degenerative Spine:
Spondylosis: Osteoarthritic change of Cervical Spine:
Disc Degeneration, Apophyseal Joint Damage, Instability, Joint Hypertrophy,
Narrow Spinal Canal
Myelopathy: Cord Compression (eg. Central Disc Herniation), Complete/Incomplete, Chronic Progressive,
Acute Exacerbation (eg. Trauma with pre-existing Spinal Stenosis)
Tx Principle: Conservative: Physiotherapy, Analgesia
Surgery if: Progressive Neurological deficit, Myelopathy/Radiculopathy, Intractable Pain
Anterior Approach: Decompression Fusion
Posterior Approach: Laminectomy for Wide Cord Compression
Foraminotomy for Nerve Root Decompression
Other conditions causing Paraplegia:
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Neuro Paraplegia
Spinal Dysraphism: Failure of closure of Posterior arch
80% in Lumbosacral area
Epidemiology: Incidence varies with Geographic Location
5% Incidence if Sibling affected
? Folate deficiency
Asso. abnormalities: Hydrocephalus, Chiari type II malformation (Cerebellar Herniation)
Type: Spina Bifida Cystica (Myelomeningocele, Meningocele), Spina Bifida Occulta

(Benign Skin Dimple: Common; Usually Small, Round, Midline, Close to Anus
Otherwise, Investigate for Spinal dysraphism)
Myelomeningocele:
Urgent Repair if No skin cover
Chance of Infection if Delayed Repair >24h
Antenatal Dx: Blood, Amniotic: AFP, AChE
Fetal US
Tethered Cord Syndrome:
Common in Spina Bifida Occulta
Anchoring of Lower end of SC by, eg. Tight/Fatty Filum Terminale, Lipoma
Tight Filum, LipoMyeloMeningocele, Diastematomyelia
Low-lying Conus Medullaris, Cord under Tension as Spine Lenghthen
Clinical: Progressive Neurological deficit:
LL LMNL, Sphincter Dysfunction, Pain, Scoliosis, Foot Deformity
Clinical Deterioration at Growth Spurt
Ix: Cutaneous signature: Pigmentation, Tuft of Hair, Skin dimple
Early MRI: MRI spine to confirm pathology
MRI brain to exclude Hydronephrosis & Cerebellar Herniation (Arnold Chiari)
Urodynamic study
Tx: Prophylactic Surgery: Detethering before Clinical Deterioration
Spinal Extradural Abscess: Pyogenic, TB
Spinal Vascular Malformation:
Presentation: Spontaneous Hemorrhage
Progressive Paraparesis, Venous HT, Vascular Steal Phenomenon
Tx: Surgical Excision, Endovascular Embolization
Cystic Pathology: Arachnoid Cyst, Syringomyelia
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Neuro Paraplegia
Syringomyelia: Cystic cavitation of SC
Cause: Congenital: Chiari malformation, Basilar invagination
Neoplastic
Post-traumatic
Clinical: Sensory Loss: Dissociated Sensory Loss
Pain: Cervical & Occipital
Weakness: LMNL of Hand & Arm
Painless Arthopathies (Charcots joints)
Tx: Correction of Primary pathology
Shunting

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Neuro Paraplegia
Neuro Head Injury
Traumatic Brain Injury:
Scalp & Skull injury, Primary Brain injury, Secondary Brain injury
Damage: Scalp Laceration, Skull Fracture,
EDH, SDH, Traumatic SAH,
Cerebral Contusion, Diffuse Axonal injury
Scalp Injury:
Scalp Layers: Skin, Cutaneous Fascia, Aponeurosis (or Muscle), Loose Areolar tissue, Pericranium
Cx: Bleeding (a lot), Infection, Scalp Loss, Cosmesis
Tx: Hemostasis: Suturing
(G Leung: When doing suture, rmb to suture the Aponeurosis layer too (Site of BV)
If Not doing suture, Evert the area (rather than just pressing it))
Debridement & Surgical Toilet: Remove Foreign bodies
Skull Fracture:
By Nature:
Linear vs Comminuted:
Linear Skull Fracture:
Epidural Hematoma, Brain Contusion
Conservative if Closed
Compound vs Closed:
(Compound: Communication with Skin/Air Sinus)
Depressed or Not:
Depressed Skull Fracture:
Dura/Brain Laceration, CSF leak & infection, Epilepsy, Neurological deficit
Need Surgery (if Severe)
By Location: Skull Vault, Skull Base
Basal Skull Fracture: Margin between Anterior & Middle Fossa: Lesser wing of Sphenoid bone
Margin between Middle & Posterior Fossa: Petrous Temporal bone
Anterior Skull Base Fracture: (Relatively more common)
Blood: Periorbital Ecchymoses (Raccoons eyes)
CSF: CSF Rhinorrhea: Ddx from Nasal discharge:
Glucose
2 Transferrin (Specific, but Not in QM)
In CT, CSF leak may also lead to Pneumocephaly
CN palsy: Olfactory nerve injury
Other Cx: Traumatic Aneurysm
Carotid-Cavernous Fistula (2010 MCQ 51)
Middle Skull Base Fracture:
Blood: Hemotympanum
Post-auricular Ecchymoses (Battles sign)
CSF: CSF Rhinorrhea (Middle Ear> Eustachian tube)
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Neuro Head Injury
CSF Otorrhea (If Tympanic membrane perforated)
CN palsy: CN 7, 8 palsy
Cx: CSF Leak, Meningitis
CN Palsy
Traumatic Aneurysm
Carotid-Cavernous Fistula
Tx: Conservative:
Bed Rest 5-7 days
Prophylactic Antibiotics: Controversial!
Duration of Tx? Which Antibiotic? Resistant organisms?
(In QM, If No CSF Leak, Wont give)
Aggressive Tx if proven Meningitis!
Role of Surgery?:
MRI/CT Cisternogram
Primary Brain Surgery:
Diffuse Injury: Concussion, Diffuse Axonal injury
Focal Injury: Brain Contusion (Coup, Contrecoup)
Concussion: Mild form of Diffuse injury
Brief/No LOC (<6h)
No CT abnormality!
Good prognosis
Post-concussion Sx (eg. Dizziness, Headache, etc)
Acceleration/Deceleration Injury:
Acceleration:
Translational Acceleration: Angular Acceleration: (Worse)

Strain: Surface strain: Skull-Brain relative motion, Subdural Hematoma
Deep strain (Brain deformation): Diffuse axonal injury (DAI), Post-concussion syndrome
DAI: Rotational Acceleration injury (shearing of axons)
Diffuse Cerebral Edema; May have prolonged Coma
No SOL on CT! (CT may be Normal on Early scan; MRI for Dx)
Hemorrhagic foci in: Corpus callosum, Midbrain
Pathology: Axonal Retraction Balls, Microglial Stars, White matter degeneration
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Neuro Head Injury

Contact Injury: Skull Deformation: Skull Fracture, Epidural Hematoma, Coup Brain Contusion
Shockwave Propagation: Contre-coup Brain Contusion

Cerebral Contusion:
Focal injury
Traumatic ICH (bruising)
Usually at Polar regions:
Frontal (due to Crista galli) or Temporal (due to Petrous bone) poles (more Superficial)
Salt and Pepper on CT
Enlarge/Coalesce with time
Coup/Contre-coup
Secondary Brain Injury:
Pathogenesis: ICP , CPP, CBF
Brain Swelling, NT release, Free Radicals, Ca influx, Cell death, etc
- Systemic: Hypotension, Hypoxia
BG, Electrolytes, Acid-Base
Pyrexia
- Intracranial: Hematoma (Epidural, Subdural, Intracerebral)
Hydrocephalus, Epilepsy, Brain Swelling, Hyperemia

Epidural Hematoma (EDH): (Often in Younger Pt, as Dura Not so firmly attached to Bone)
Skull Fracture
Middle Meningeal arteries (Rapidly Expanding Hematoma after Tearing of Meningeal arteries)
Clinical: Classic presentation: Brief LOC, Lucid interval, Rapid deterioration
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Neuro Head Injury
Talk & Die!
Uncal Herniation: Ipsilateral Dilated Non-reactive Pupil
Contralateral Hemiparesis
False Localizing sign: Kernohans phenomenon
Opposite Cerebral peduncle> Ipsilateral Hemiparesis
(In the past may rely on clinical signs to decide which side to operate
Now with CT, will be able to operate on correct side)
CT: Biconvex Lens (Lentiform) shape
Tx: Craniotomy (Evacuate clot, Coagulate bleeding site) (2014 MCQ 61)
(cf Burr hole for liquid blood in SDH)
Subdural Hematoma (SDH): (Often in Elderly Pt, due to Cerebral Atrophy)
Tearing of Bridging Veins (Venous blood, thus Slower than EDH)
CT: Crescent shape
Density depends on Acute/Subacute/Chronic (Blood gradually hemolyzed> Less Dense)

(For Subacute SDH, can diagnose by Contrast CT or MRI)
(Hyperdense blood may sink> May show like Right photo in Supine CT)
Acute SDH: 2 Types
With Brain Laceration: Acceleration injury
No Lucid interval
High Morality
Tearing of Bridging vessel: Less Primary Brain injury
Lucid interval +
Better Prognosis
Chronic SDH:
Elderly, Head trauma Hx < 50%, Bleeding tendency, Alcoholics
Elderly prone to SDH even with Minor injury:
Cerebral Atrophy> Emissary Veins Stretched> Prone to Rupture
Bilateral in 25%
ICP, Focal deficit (eg. Hemiparesis), Seizure
Anorexia is a common Sx? (Affect Satiety centre)
Tx: Burr hole drainage
Mx of Unconscious Trauma Pt:
Possible Scenarios: Mainly Head Trauma> LOC
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Neuro Head Injury
Mainly Extracranial injuries> Hypotension/Hypoxia> LOC
Both Cranial & Extracranial injuries
etc
May be already Unconscious before the accident?
ATLS Principles: ABCDE
Airway: Prevent Aspiration (Careful with C-spine)
Breathing: O2 & CO2
Circulation: Stop Bleeding, Restore MAP & CPP
Disability: Neurological status
Exposure/Environment: Extracranial injury
ABC before ICP!:
Assume Multiple Injuries; Resuscitation first, Neurosurgical intervention if Stable
Neurological status:
Clinical observations:
GCS

(M=5: Raise above Clavicle, or across Midline)
(M=3: Components of IR, Pronation, etc)
Pupil Size & Reaction
Limb Weakness
Cushings Reflex
CT
(SXR) (In Unconscious Pt, dont mess around with Skull X-ray; Need CT anyway)
Severity of Head Injury:
Mild: GCS 14-15
Moderate: GCS 9-13
Severe: GCS 3-8
(NB: GCS <5: 80% die or remain vegetative
GCS >11: 90% complete recovery)
Red Flags: Low/ing GCS, Focal Neurological deficit, Skull Fracture, Epilepsy, CSF leak
Potential Intracranial pathology, Further deterioration
Indication for CT: Deterioration in Consciousness
Focal Neurological deficit/Seizure
Penetrating Skull injury/Skull fracture
Mechanism of injury
Coagulopathy, on AntiPlatelets (Aspirin, Clopidogrel, etc)
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Neuro Head Injury
NB: Low threshold for Plain CT Brain
Traumatic Brain Injury:
Primary insult (Fixed) vs Secondary insult (Potentially Avoidable/Reversible)
Tx Principles: ICP monitoring, Control ICP, Surgical Tx,
Others: Nutritional support
Seizure prophylaxis: Early phase (1st week)
Ulcer prophylaxis (H2 blocker)
Concept of Monitoring:
Clinical, ICP, Advanced Monitoring Techniques
ICP Monitoring:
Indication: GCS <9 (Intubated/Sedated)
Absence of Clinical monitoring: Once Intubated & Sedated, Cant use GCS to monitor)
Evolving pathology: Anticipating future deterioration
Abnormal CT
Normal CT (2 RF): Age >40, SBP <90 mmHg, Unilateral/Bilateral Motor signs
Monitoring Methods:
Clinical (most useful): GCS
External Ventricular Drainage: Gold standard; Allow CSF drainage
Cx: Bleeding, Infection
Subdural
Parenchymal: Microsensor
Modalities to ICP:
Enhanced Venous Drainage (Head up 30-45), Osmotherapy, Normocapnia,
Surgical Decompression, Barbiturate Coma, Induced Hypothermia
Not Steroid!
Control Seizure!: RF: Penetrating injuries
SDH, Contusion
Correct Metabolic causes
AntiConvulsant, eg. Phenytoin
Systemic Care: Metabolic disturbances, eg. BG
Extracranial injuries
Evolution of Cranial injuries
DVT, Pneumonia, Cushings Ulcer, etc
Advanced Monitoring:
Jugular Venous Oxygen Saturation (SjO2):
SjO2 CBF/CMRO2
>75%: Cerebral Hyperemia (Many blood brain, so excess O2 in Venous blood)
<45%: Global Ischemia
Transcranial Doppler (TCD):
Velocity CBF/Calibre
Velocity in Vasospasm
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Neuro Head Injury
Regional CBF: Work by Thermal coupling principle
Continuous Monitoring & Invasive
Microdialysis: Measure Metabolites in Interstitial space
MRI?: Not done in Acute setting
Summary:

(Dont sedate Pt with GCS >8 even though they are shouting, coz cant monitor GCS anymore)

Page 390
Neuro Head Injury
Neuro Brainstem Death
Preconditions: Irremediable Structural Brain damage
eg. Trauma, CVA
Confirmed by Imaging
Comatose (GCS 3/15)
Apneic on Ventilator (ie. Totally depends on Ventilator for breathing)
Exclusion Criteria (2013 MCQ 21):
Main Criteria: Primary Hypothermia (HA: <35C; US: <32.2C)
Arterial Hypotension (US: SBP <90 mmHg)
Metabolic & Endocrine disturbances (eg. HypoT, Hypoglycemia)
NB: HyperNa due to DI is well recognized to be due to Brainstem death
Its presence does Not preclude Dx of death (unless Profound HyperNa?)
(G Leung suggests that need to give DDAVP to rule out DI?)
Other Criteria Depressant Drug/Poison?:
Sedatives, Barbiturate Coma
Alcohol, Drug overdose
Muscle Relaxant (Nerve stimulator)
Recent GA/Resuscitation
When to consider issuing BSD:
All Preconditions met
No Exclusion criteria
At least Comatose for 4h
2 separate examinations with 2h apart
2 different doctors: At least 1 is Intensivist/Neurologist/Neurosurgeon
Another 1 is at least 6 years post-graduation
No Conflict of Interest (eg. Not attending Graft Recipient)
Not Authorizing/Proposing Organ Harvest
Test: No response to Deep Central Pain
Absence of Brainstem Reflex
Apnea
Test for Motor response:
Deep Central Pain (Jaw), Not Peripheral Pain (Limbs)
Lazaruss sign
Compatible findings:
Extensor Plantar Reflex
Deep Tendon Reflex
Sweating, Blushing, Tachycardia
Stable BP
DI
Test for Brainstem Reflexes:
Pupillary Light Reflex:
Page 391
Bilateral Fixed & Dilated Pupils
Corneal Reflex:
Absent
OculoVestibular Reflex (Caloric Test):
Exclude Perforated Ear drum
Clear access to Tympanic membrane (Blood!)
Tested at least 1 side
At least 20 ml ice-cold water
Procedure: Head up to 30C, Wait for 1 min for response, Wait >5 min before other side

OculoCephalic Reflex (Dolls Eye):
Do NOT do if Cervical spine stability Uncertain!

Gag & Cough Reflex:
Cough Reflex: Bronchial Suction
Gag Reflex: Bilateral Posterior Pharyngeal Wall
Apnea Test: No Spontaneous Respiration despite PCO2 >8.0 kPa & Arterial pH <7.30
(CO2 is the Strongest Ventilation Stimulator)
Maintain Oxygenation by Diffusion (Just try to PCO2 without jeopardizing PO2)
Aborted if: Pt breaths
Significant Hypotension
Significant Cardiac Arrhythmia
Should be done LAST & when Brain death reasonably certain because PCO2 will ICP
Procedure:
Page 392
Pre-oxygenate 100% O2 for 10 min
Restore PaCO2 5.3kPa
Disconnect Ventilator
O2 at 6L/min via No. 14 Fr suction catheter passed to carina
For ~10 min
PaCO2 3mm Hg/min
Confirmed with Blood Gases
Further Confirmatory Tests:
Required if: Cause Unclear
Metabolic/Drug Effect
Inadequate Clinical test: eg. Facial Trauma, Unstable C-spine, Perforated Ear drum
Severe COPD/CHF
Tests: EEG:
(ElectroCerebral Silence)
DSA:
(High ICP> Blood cant flow up ICA into Brain)

Radionucleotide scan:

Transcranial Doppler (TCD):
Time of Death: When Brain death is Declared:
If No Confirmatory test: Time of 2nd Clinical test
If Confirmatory test: Time of Confirmatory test
NOT the Time of:
Disconnection from Ventilator
After Organ Removal
Asystole
Brain Death in Children:
Caution!
PE similar
Young brain more Resilient
Confirmatory tests
Page 393
Observation period depends on Age:
Newborn: Wait 7 days
7 days 3 months: Wait 48h (+ EEG)
3-12 months: Wait 24h (+ EEG)
>12 months: Wait 12h
Locked-in syndrome: aka CerebroMedullary disconnection, Ventral Pontine syndrome
Cause: Trauma, Metabolic, CVA
(ie. Pontine problems)
Clinical: Arousal & Awareness are Intact
Tetraplegia & No Facial movement, but can blink eyes (GCS: often E4)
Vegetative state: A Wakefulness Unconscious state (Has Arousal but No Awareness)
Not Coma, Not Death
Persistent Vegetative state (>4 weeks)
Permanent Vegetative state (>12 months)
US vs UK
Organ Donation Criteria for Deceased Donor: (2002 MCQ 71)
No Age limit in general
Death:
Brain Death: Can donate both Organs & Tissue
Cardiac death: Mostly can donate Tissue only, eg. Cornea, Skin, Bone
Adequate Organ function
No Severe/Systemic Infection, No HIV
Cancers are Contraindicated
Exception: Primary Brain tumors (2002 MCQ 71) (Unless Metastasized beyond Brainstem)
Cornea donation (Excludes Hemat malignancy or Ocular/Peri-ocular tumors)

Page 394
Plastic Intro
Plastic Surgery: Plastic: Ancient Greek Plastikos meaning mold form
Surgical operations from head to toe
Optimal tissue handling, design & reshape for Forms & Restoration of function as Primary goal
Plastic & Reconstructive Surgery vs Aesthetic Surgery
Basic Principles: Basic principles of wound closure
Skin Anatomy & Blood supply
Concepts of Angiosomes
Classification & Designs of Flaps
Resection & Reconstruction
Reconstruction Ladder
Autogenous tissues & Implants
Wound Closure:
Type: Primary Closure: Wound closed surgically soon after creation
Delayed Primary Closure: Wound remains open for a few days before Surgical closure
Risks of Infection in Contaminated wounds
Secondary Closure: Wound closures over time by Contracture
Indicated for infected & contaminated wound
Allows Drainage of fluid
Allows Debridement with dressing
Prolonged Inflammatory phase & Healing, Scarring & Contracture
Secondary Revision of Scar in selected Pt
Closure Techniques:
Ensure Hemostasis
Ensure Viability of tissue
Obliterate Dead space (eg. by putting drain)
Good approximation of tissue in Layers (ie. Muscle to Muscle, Skin to Skin, etc)
Use of Subcuticular closure or Fine dermal interrupted suturing to minimize Scar & Stitch marks
Avoid Tension/Pressure on wound
Appropriate timing for stitches removal
Langers Relaxed Tension Lines:
Natural skin lines with minimal tension
Usually Perpendicular to lines of muscle pulling
Incision Parallel to Langers lines has Less tension, hence Less widening & hypertrophy
Short Elliptical incision will result in Dogears at both ends
Page 395
Plastic Intro
(Diameter Ratio of 1-to-4 better than 1-to-2)
Skin Anatomy & Blood supply:
Skin: Epidermis, Dermis, Subdermis
Blood supply to skin: Fasciocutaneous vessels, Perforating branches through muscles,
Subdermal plexus, Subepidermal
(Axial> Random)
Concept of Angiosomes:
An Angiosome is a composite unit of skin & underlying tissue supplied by a source vessel
Flaps are designed based on knowledge of Angiosomes of respective region
A Flap contains 1 Angiosomes
Area outside Angiosome territory will Not be supplied by source vessel

Lower Abdominal Flap Blood supply:

4 Zones of Lower Abd Flap (Zone I must survive, Zone II & III partially, Zone IV cant survive)
Graft vs Flaps:
Graft: Autograft from same individuals
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Plastic Intro
Allograft from same species, eg. Cadaveric Liver & Kidney transplant
Xenograft from another species, eg. Procine skin graft
Skin Graft: Split thickness vs Full thickness

STSG Epidermis & Easier take Greater Donor site healed by Larger area of Donor site
Partial Dermis Contraction Epithelization
FTSG Epidermis & Improved Less Donor site closed Preferred for Facial defects,
Entire Dermis Cosmesis Contraction primarily Hands, over Joints
(The less Dermis taken, the more Contraction afterwards)
Flaps: Flap is Transfer of tissue with Preservation of its original Blood supply
Classification Various ways:
According to Blood supply:
Random, Axial, Reverse Flow Flap

According to Design of Flap:
Advancement, Transposition, Rotation, Interpolation
Examples:
Page 397
Plastic Intro
Rotational Flaps:

Bilobe Flap: Good at Nose region

According to Proximity of tissue:
Local (eg. Skin Flap), Regional (eg. Forehead), Distant (eg. LD Flap), Free (eg. Free TRAM)
According to tissue transferred:
Cutaneous (eg. Skin Flap), Fasciocutaneous (eg. Radial Forearm), Myocutaneous (eg. TRAM),
Osteomyocutaneous (eg. Fibula)
Vascular Pattern of Muscle & Flap Designs:

Other common examples: Rectus abdominis (Type III), Pectoralis major (Type V)
Flap survival depends on preserved vasculature!
Z-plasty for Scar Revision:
Based on Elasticity of skin & Undermining of surrounding tissue
Skin can be stretched & rotated
Pros: Lengthening of Scar, Change direction of Scar, Break Pulling effect on Scar
Cons: New Scars
Modification: Multiple Z plasty, W plasty
Page 398
Plastic Intro

Resection & Reconstruction:
Surgical approach:
Open Surgery
Minimal Invasive Surgery (minimize scar)
Other destructive devices (No direct incision)
Cauterization, Cryosurgery, Topical agents, Laser ablation
Area to be resected determined primarily by Pathology; Reconstruction comes second
Reconstruction: Reconstruction Ladder: Primary Closure> Skin Graft> Local Flap> Pedicle Flap> Free Flap
From Simple to Complicated procedures
Balanced by: Amount of tissue loss
Complexity of procedures
Expertise available
Cosmetic & Functional outcomes
Autogenous Tissue vs Implant:
Autogenous Tissue:
Depends on Availability of tissue, Donor site morbidity, Less Infection once taken,
Lifelong, Living tissue with possibility of healing
Implant: Foreign body Reaction, Infection, Extrusion, Material Fatigue & Breakage, Capsular Fibrosis,
Cost
Problems of Excessive Wound Healing:
Hypertrophic Scar:
Excessive Scar tissue that does Not extend beyond Boundaries of Incision/Wound
Caused by Prolonged inflammation, Excessive tension; More common in African & Asian
Tx: Observation over time, Corticosteriod injection, Pressure therapy, Surgical Excision
Keloid: Excessive Scar formation that extends beyond the Boundaries of original wound
Etiology mostly unknown; More common in African & Asian; May be Inherited & Familial
More common in Ear lobes & Tension area
May develop months or years later
Tx: Surgical Excision is rarely successful
Corticosteriod injection with in size
RT may be indicated in severe case
Recurrence is common
Common Diseases in Plastic Surgery:
Page 399
Plastic Intro
Congenital, Skin Cancer, Trauma/Facial Fracture/Burn, H&N/Craniofacial,
Breast/Trunk & Abdomen, Hand & Extremities, Microsurgery, Aesthetic
Congenital: Cleft Lips & Palates
Craniofacial syndromes & Microtia
Soft tissue tumors
Hemangioma & Vascular Malformation
Melanocytic lesions & Pigmentation
Others
Cleft Lip & Palate:
Critical development of Lip & Palate occurs during 4 -5 weeks of gestation
Repair of Cleft Lip at 3 months:
Surgical correction of muscle misalignments, Restoration of mucosa & skin
Repair of Cleft Palate at 9 months:
Surgical closure of Soft & Hard palate
Multi-disciplinary approach for Speech, Hearing, Facial growth & Dental development
Microtia: External ear develops from 6 auricular hillocks on 1st & 2nd Branchial arches
Abnormal growth results in variable degree of Microtia
Staged operative procedures at Age 8-10
Skin pocket for outer lying & Costocartilage graft for structural support
Mainly for Cosmetic improvement & No functional effect on hearing
Hemangioma & Pigmented Lesions:
Small lesions can be excised & closed primarily
Large lesions need Resection & Reconstructive procedures: Skin graft/Flaps
Non-surgical modality of Tx can be considered for different pathology
Eg. Laser, Sclerotherapy, Embolization
Skin Cancer: Curative Resection with adequate margin
BCC 3-5 mm margin, SCC 1-2 cm margin
Intraoperative Frozen section guidance in selected cases
Resection followed by Primary closure/Reconstruction, depending on Size of defect
Follow principle of Reconstruction Ladder
FTSG for Facial defect:
Wide Excision of Skin Cancer on Face
Primary closure may be impossible or Cause deformities on Facial anatomy
Use of Local Flap/Skin graft
FTSG from Neck: Need vascular recipient bed
Provide good Cosmetic outcome: Color match, Contour, Texture
Burn & Scald Injury: Recovery depends on Depth & Extent of injury & remaining Regenerative power
Infection & Poor wound care will adversely affect wound healing
Scar formation & Contracture will affect final Cosmetic & Functional outcomes
Acute care: Wound care & Skin grafting
Late care: Scar Mx & Reconstructive procedures
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Plastic Intro
Principles of Care in Burn Mx:
Acute: Fluid/Electrolytes balance & replacement, Wound dressing & Skin grafting,
Prevention of Infection, Pain control
Late: Prevention & Mx of Scar, Correction of Contractures (eg. FTSG for Ectropion),
Improve Functional activities, Adjuvant therapy (eg. Hair & Eyebrow transplant)
Facial Trauma: Soft tissue injuries
Bony Fractures
Asso. injuries
Note: Priority of Tx is important for Life threatening condition

Mx: Control of Life threatening condition: Airway & Bleeding, Associated injuries
Detailed Hx & PE: Soft tissue Swelling & Wound
Bony deformities & Fractures
Neurological & Functional assessment
Imaging: Plain X-ray
CT 3D reconstruction
Mx: Wound closure & Skin coverage
Restore Bony deformities
Scar Revision
Bony Fracture:
Assessment Form & Function:
Asso. injury, Tenderness, Crepitation, Mobility, Displacement,
Diplopia (EOM Entrapment), Malocclusion, Nerve injuries, Septal Hematoma, Dentition
Soft tissue care & Wound closure:
Adequate cleansing
Removal of Foreign bodies
Good Viability
Layered closure
Release of Tension
Accurate Apposition of wound
Reconstruction Ladder
Late Secondary Revision of Scar
Mx of Bony Fractures:
Good apposition of Fracture site to reform shape
Reduction of Fracture: Close vs Open
Page 401
Plastic Intro
Fixation of unstable fracture for healing: Internal vs External
Bone grafting for tissue/volume loss
Close Reduction of Nasal Fracture:
Nasal Fracture with Displacement/Depression
GA/IVS/LA
Aim to achieve alignment for dorsum & septum (Restore Central prominence of Nasal pyramid)
Post-op Nasal packing & Nasal splint for Protection & Temporary support

Operative Reduction & Fixation:
Incision & Manipulation
Fixation with Plates/Screws/Wire
Aim for Anatomical Reduction
Release of Soft tissue Entrapment
Regain occlusion of upper & lower jaw
Bone graft for tissue loss
Reduction of Zygomatic Fracture:
Close Reduction through Temporal incision
Elevation of displaced segment
Additional Plating if Fracture Reduction unstable:
Frontozygomatic
Infraorbital rim
Open Reduction & Rigid Fixation of Mandibular Fracture:
Imbalanced muscle pull results in Displacement & Instability
Normal occlusion as Primary aim
Open Reduction & Rigid Fixation allows Early Mobilization of jaw
Symphyseal, Body, Angle, Subcondylar

Eyelid Reconstruction:
Entropion: Inversion of Lid margin
Ectropion: Outward turning of Lid margin
More common, Secondary to Scarring/Trauma/Burn
Release of Scar & Vertical Lengthening with FTSG
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Plastic Intro
Post-Resection: Trauma, Surgical
Blepharoptosis: Aging, Muscle disease (Congenital/Acquired)
Technique: Restore Anatomical structure:
Align Lid margin
Suturing of Tarsal plate
Avoid vertical pull on eyelid
Secure Canthal ligament
Avoid damage to Lacrimal drainage system
Defect up to 1/3 can be closed primarily
Larger defect require Local Flaps/Skin graft
Nasal Reconstruction:
Replacement of tissue with similar tissue:
Nasal lining, Bone & Cartilage support, Skin/Soft tissue coverage
Respect Aesthetic subunits of Nose:
Dorsum, Lateral side wall (2), Tip, Columella, Alar (2), Soft triangle (2)

Using Bilobe Local Flap for Nose Reconstruction after Cancer Resection:

Late Reconstructive Surgery:
Scar Revision
Rhinoplasty of deformed nose
Restoration of lost tissue
Breast Surgery: Post Cancer Reconstruction of Breast
Augmentation
Reduction
Others: Gynecomastia, Asymmetry (eg. Poland syndrome)
Page 403
Plastic Intro

Breast Reconstruction:
Reform Breast shape after Mastectomy
Primary (Immediate)
Secondary (Delayed)
Reconstruction for Skin coverage
After Surgery with Skin defects
Cx of Radionecrosis of skin Chest wall
Common Methods of Post Mastectomy Reconstruction:
Autogenous tissue:
Latissmus Dorsi Myocutaneous Flap (LD)
Transverse Rectus Abdominus Myocutaneous Flap (TRAM)
Pedicle, Free, Deep Inferior Epigastric Perforator Flap (DIEP)

Implants Muscle Flap, eg. LD
Nipple & Areola Reconstruction & Tattooing
Breast Augmentation:
Aim: To Size of Breast to improve Body contouring
To correct Ptosis of breasts
To correct Asymmetry
Methods: Gel implants
Saline implants
Preoperative counselling & examination of breast for other pathology is essential
Pocket Position: Submuscular, Subglandular
Surgical Approach: Periareolar, Axillary, Inframammary
Cx: Hematoma, Seroma, Infection, Change in Nipple Sensibility, Asymmetry, Wrinkling,
Capsular Contracture, Rupture, Cutaneous Scarring, Extrusion, Mammographic interference
Capsular Contracture:
Page 404
Plastic Intro
Essentially a basic wound healing phenomenon common to all wound
Capsule wall is laid down around Prosthesis,
Myofibroblasts causes Collagen bundles to pull together & contracting on the prosthesis
Result in Deformities & Pain
Apparently more Host-related than Implant-related
Correction with Closed/Open Capsulotomy Exchange of Implant
Reduction Mammoplasty:
Excessive Large Breasts:
Neck & Shoulder Pain
Restriction of PA
Difficulty in bra & clothing fitting
Psychosocial Embarrassment
Preoperative Medical Hx, PE & Mammogram
Potential problem:
Additional Scar over Subareolar & Inframammary fold
Inability to Breastfeed
Change in Nipple Sensibility
Microvascular Surgery:
Allow Free tissue transfer from Distant site
H&N Reconstruction
Replantation Surgery
Complex Reconstruction
Face Transplant:
Problems & Challenges:
Technical problem
Dynamic function vs Static form
Rejection of Graft
Complexity of tissue transfer: Skin, Muscle, Nerve
Ethical issues
Failure outcomes
Hand Surgery: Congenital, Trauma, Scar release
Aesthetic Surgery: Reshape Facial appearance:
Blepharoplasty, Rhinoplasty, Face & Brow Lift, Fillers & Injectables, Botox
Reshape Body shape:
Breast Augmentation, Liposuction, Body Sculpture
Anti-Aging procedures:
Laser
Surgical procedures: Minimal approach, Conventional operation
Botox
Chemical peels
Fillers
Page 405
Plastic Intro
Others: Hair Transplant
Rhinoplasty: Aesthetic assessment of Nose & Face
Common Concerns: Nasal Length, Radix projection, Nasal tip contour/projection,
Chin projection, Position & Width of Alar, Deviation of Nasal septum
Techniques:
Concealed Incision
Reduction of Excessive Bony/Cartilage Framework
Sculpturing of Nasal tip
Augmentation of Nasal volume: Autogenous tissue, Implants

Cx: Hematoma, Infection, Resorption of Graft, Displacement of Graft, Skin Necrosis & Scarring,
Extrusion of Implants, Asymmetry
Blepharoplasty: Correct Blepharoptosis
Periocular Rejuvenation: Resection of Lax Skin
Removal of Periorbital Fat
Browlift & Cheek/Face Lift
Upper, Lower or Both
Others: Creation of Double Eyelid

Body Contouring:
Indication: Obesity that failed Weight Reduction program
Localized Excessive Fat deposit
Lax skin & SC tissue
Liposuction to remove Excessive Fat
Skin Resection & Redrapping of Lax skin
Abdominoplasty, Total Lower body Lift
Cx: Scar after Skin Excision
Hematoma & Seroma
Page 406
Plastic Intro
Infection
Excessive Blood Loss & Hypovolemia
Fat Embolism
Contour Irregularity
Damage to surrounding structures
Pigmentation changes
Sensation changes
Loss of Donor tissue, eg. TRAM
Non-surgical Techniques:
Botulinum Toxin:
Produced by Clostridium botulinum
Act on Presynaptic Cholinergic Neuromuscular Endplates
to inhibit release of Acetylcholine resulting in Muscle Paralysis
Wrinkles & Muscle bulk
Action Reversible in 3-4 months
Fillers:
Injected into tissue for Volumetric Augmentation
Fat/Dermis/Synthetic material
Selection of Pt for Elective Aesthetic Surgery:
Medical Contraindications
Realistic understanding & expectation of outcomes
Psychological/Emotional interference
Technical expertise & artistic judgment of surgeon
Balance between Risks & Benefits: Short term/Long term
Plastic Surgery as an Art & Science:
Values of: Life & Death
Form & Function
Benefit & Risk
Beauty & Nature
Donor & Recipient

Page 407
Plastic Intro
Plastic Burn
Burn Injury: Thermal injury, Chemical burn, Electrical injury (Entry site & Exit site),
Exfoliating skin disease (eg. SJS, TEN, Erythema nodosum), Cold injury, Radiation injury
Scald Injury: A form of Thermal Burn resulting from Hot Fluids, eg. Boiling water/Hot drinks, Steam
Hx: Age
Coexisting medical problems
Mechanism of injury (eg. Explosion can cause Burn + Blunt Trauma)
Thermal Temp & Contact time
Chemical Alkaline/Acidic
Degree of burn
Area involved
Inhalational injury (rmb to ask for SOB in Hx)
Other associated injury
Burn Depth Type Layers involved Appearance Sensation
st
1 degree Superficial Epidermis Soft Painful
(eg. Sunburn) (No Scarring) Red without Blisters
Blanch with pressure
2nd degree Superficial Partial Into Superficial (Papillary) Redness clear Blisters Very Painful
Thickness dermis Blanch with pressure
Deep Partial Into Deep (Reticular) Yellow to White Blisters Painful/Anesthetic
Thickness dermis Less blanching (Pressure & Discomfort)
3rd degree Full thickness Through Entire dermis, Stiff Anesthetic
into Fat, Muscle, Bone White/Brown/Black Red
No blanching
(No Blisters No Exudate from
dead dermis)
(If No heal by 3 wks, assume 3)
(Nowadays PRS surgeons dont use Degree but use Type to describe Depth, cf A&E doctors)
(4th degree is described by some but Not universally used)
(Depth can be Mixed as involvement may be different at different parts)
(NB: Good if Pt yelling (Nerve alive), Blisters (Skin alive))
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Size of Burn: % of Total Body Surface Area (TBSA) affected by Partial/Full thickness burns (>1 degree)
Method: Rule of Nines is Easy to rmb but only accurate in Adults (2008 SAQ 1)
Lund and Browder charts may be more accurate (Not taught in lecture)
In Palmar method, Size of Pts handprint (Palm & Fingers) is ~1% of TBSA
(Paedi Block C)
Problematic Anatomical Areas: Face, Perineum, Hands & Feet, Circumferential burns
Classification of Burns Severity (Paedi Block C):
Burn Severity/Age Children/Elderly Adults
Minor <10% TBSA <15% TBSA
Full thickness <2% TBSA Full thickness <2% TBSA
Moderate 10-20% TBSA 15-25% TBSA
Full thickness <10% TBSA (non-critical areas) Full thickness <10% TBSA (non-critical areas)
Severe >20% TBSA >25% TBSA
Full thickness >10% TBSA Full thickness >10% TBSA
Burns in Critical areas Burns in Critical areas
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Complicated Burns Complicated Burns
(Critical areas: Face, Hands, Feet, Perineum)
Inhalation Injury:
Causes Effects Signs
Hot Air Laryngeal obstruction (due to Edema) Stridor, Voice, Soot
Smoke Mucosal slough Fever, Rhonchi, Sputum
Hot particles Infection
Aspiration Bronchiolar plugging
Atelectasis
Irritant gases Pulmonary Edema Rales, Hypoxia,
Alveolar Capillary defect Cyanosis

Suspicion if:
Scenario: Confined space
Trapped in Fire scene
Sign of Inhalation injury:
Burn of Nose, Mouth, Face (Facial burn)
Singed Nasal Hair ()
Carbonaceous Sputum
Hoarseness, Dysphonia
Dyspnea, Stridor
Rales, Rhonchi, Wheezing
Ix: Bronchoscopic finding (Lecturer does this; Can do Endoscopic Intubation if confirm injury)
CarboxyHb (2001 MCQ 41) (May be misleading in Smokers)
Pathophysiology of Burn Injury:
Myocardium depression
LV contractility
CO
Cellular Transmembrane potential> Na & K fluxes> Cell swelling
Transient in Capillary permeability to Protein & Water (usually <24h)
(This causes Persistent Edema as Protein & Water are left in 3rd space after 24h)
(This is also the reason why Crystalloid is given in first 24h Parkland formula)
(Lecturer: Studies have tried to use Colloid and results are still good)
in Pulmonary vascular permeability
Mortality: Burn Size: Age:
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Initial Burn Mx (Paedi Block C):
ABC
Identify & Treat asso. injuries (Explosions)
Remove Pt from source, Protect rescuer, Drop roll-over
Initial Cooling with Cold (Not Ice) water, Cover with Sterile dressing, Leave Blisters intact
Brush off any Metal/Powder, Copius Irrigation for Chemical burns
Advance Burn Life Support:
Hx taking: Obtain essential info before intubation:
Pt identity
AMPLE Hx: Allergy Hx, Medication Hx, Past Health, Last food & drink, Event of injury
Event of Injury: When, Where (Open/Close area), Thermal agent, Why,
Mx before arrival
Primary Survey:
Airway with C-spine control:
Open Airway, Remove Foreign body/Debris
100% O2 by mask
Naso/Oral- tracheal intubation in suspect Inhalation injury
Pulse oximetry, EtCO2
Breathing: Confirm Bilateral Air entry
Breath sounds
CXR (esp in suspected Inhalation injury)
Circulation:
Fluid Resuscitation indicated if: Adult %TBSA >20%, Children %TBSA >10%
Insert 2 Large bore IV catheter (prefer on un-burn skin)
Site preference: Peripheral V > Femoral V > IJV> Subclavian V
Get Weight of Pt in kg, Estimate %TBSA (Rmb that 1 burn doesnt count)
Adult Resuscitation: Parkland formula (2006 MCQ 39, etc)
Hartmanns solution (Ringers Lactate solution) 4 ml/kg/%TBSA burned
Give of total volume over first 8h from time of burn injury
Give 2nd of total volume over the following 16h
Close monitoring
Titrate to maintain BP & Urine output of at least 30 cc/h
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Disability: Assess Level of Consciousness by AVPU method
Assess Pupil Size
Exposure & Environmental control:
Remove all Clothing/Jewelry if Not done
Prevent Hypothermia by wrapping Pt with clean dry sheet & warm blankets
Check Body Temp
Identify asso. injury by Secondary Survey
Secondary Survey:
Head-to-Toe, System-to-System PE:
To identify Trauma
To identify Circumferential Burn on Torso & Extremities
(Risk of Compartment syndrome in Full thickness Circumferential Burn; Do Escharotomy)
Assess Ventilatory Excursion regularly:
To determine if Chest Escharotomy is required (To allow Chest Expansion)
Lab study: CBC, Electrolytes, Creatinine, Glucose; (If Low Hb, watch out for Internal Hemorrhage)
CXR
ECG
ABG with CoHgb level (in Inhalation injury)
Medication: Tetanus prophylaxis
Narcotic Analgesic in small IV dose:
Morphine 2 mg IVI q 5min until comfort achieved in Adult (Smaller dose in Children)
Monitor RR, Pulse oximetry, during administration of Narcotic
PU prophylaxis (Burn Pt may develop Stress Peptic Ulcer Curlings Ulcer)
Burn wound care: Cover with clean dry cloth (No ice/cold water soaks, No wet dressings/sheets)
Keep Pt warm
For Delayed transfer: Wash wounds & debride loose tissue
Topical Antimicrobial (Silver Sulfadiazine) and Gauze wrap
Monitor need for Escharotomies (or Decompression of limb)
Escharotomy: Treat/Prevent Compartment syndrome in 3 burns
Standard Wound Dressing:
(Burn Set: Thick layers of gauze to soak Exudate, SSD cream, etc)
Documentation & Record:
Proper & prompt documentation is necessary for safety case Mx
Accurate documentation & record also ensure seamless care after transfer
American Burn Association Guidelines for Transfer:
Partial thickness (2 burns >10% TBSA)
Full thickness (3 burns, in any age group)
Burns to Face, Hands, Feet, Genitalia or Major Joints
Electrical, Chemical or Inhalation burns
Pt with pre-existing medical disorders compromising outcome
Pt with burns & concomitant Trauma; Follow local regional medical control & triage protocols
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Pt requiring extensive social, emotional or LT rehabilitation support
Pediatric burns without qualified personnel/equipment
Burn Centre: Burn Centre: QMH, PWH
Burn Facility: RH, KWH, QEH, TMH
Admission Criteria:
Adult >20% TBSA, Children >12%
Associated Inhalation injury requiring ICU care
Major Functional/Cosmetic implication
Significant pre-existing medical disorders
which can complicate Mx/prolong Recovery/affect Mortality
Admission to ICU: Airway injury requiring Intubation
Hemodynamic Instability
Multiple Trauma
(Lecturer: In other cases, tend Not to put Pt in ICU, due to High prevalence of MDR bacteria)
Topical agents: Silver Sulfadiazine cream/Silver Nitrate solution (Tend Not to use on Face White marks)
Paraffin oil
Vaseline
Neomycin cream
Choice of Dressing: Pt, Wound condition, Cost, Manpower
Debridement Absorb Filling Shielding from Insulate wound Moisten
action Exudate Cavity Bacteria bed wound bed
Emollient Impregnated
N/A
Medication Impregnated
Hydrocolloids Sheet N/A
Paste N/A
Hydroselective Sheet N/A
Transparent Adhesives N/A X
Alginate N/A
Semipermeable Polyurethane Foam N/A N/A X
Hydrogels N/A (Sheet form)
Dressing Materials: Emollient Impregnated Dressing Jelonet
Medication Impregnated Dressing Sofratulle
Hydrocolloids Dressing DuoDerm
Alginate dressing Kaltostat
Transparent Adhesive Dressing Opsite
Hydrogel Intrasite Gel
Emollient Impregnated Dressing: eg. Jelonet
Indication/Guideline: Partial thickness wound
Skin donor site
Abrasion, Skin tears, Laceration
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Change every 8-24h
Pros: Easy to use, Inexpensive, Non-adhesive,
Can be use with Topical Antibiotic/Ointments/Cream
Cons: Require Secondary dressing
Medication Impregnated Dressing: eg. Sofratulla, Bactigras, Inadine
Indication/Guideline: Partial thickness wound
Abrasion, Skin tears, Laceration
Change every 8-24h
Pros: Easy to use, Inexpensive, Non-adhesive
May cause Allergy reaction
May cause Selection of bacteria
Hydrocolloids Dressing: eg. DuoDerm, Restore, Tegasorb, comfeel, J&J Ulcer Dressing
Indication/Guideline: Partial thickness wound Stage 3 & Clean Stage 4 pressure ulcer
Wound with Necrosis, Slough & Exudate
Characteristic Odor & Yellowish Exudate
Allow 1-2 inch margin, Taping edges
Change every 3-7 days
Pros: Comfortable, Impermeable to External Bacteria, Support Autolysis
Mild to Moderate Absorptive
Diminish Local Friction
Cons: Not for wounds with Infection or Exposed Bone/Tendon
Non- transparent
May curl
Hydroselective Dressing: eg. Cutinova hydro
Indication/Guideline: Superficial & Partial thickness burn wound, Leg & Diabetic Ulcer
Wound with Moderate to High Exudate
Allow 1-2 inch margin, Taping edges
Pros: Hydro-selective wound dressing, Inherently adhesive, Waterproof,
Permeable to Oxygen & Moisture vapour, Semi-transparent,
High absorption capacity, Bacterial barrier Risk of Secondary Infection
Cons: Not for wounds with Infection or Exposed Bone/Tendon
Not recommended for Dry wound
Mode of Action:
Selectively absorbs mainly Water
Leaves Pts own GF/other Natural proteins in the wound
GF & other Natural proteins are known to be essential agents in wound healing
Wound fluid is retained under Compression
Moist wound environment
Transparent Adhesives Dressing: eg. Opsite
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Indication/Guideline:
Minor Superficial burn, Laceration, Donor site, Stage 1 pressure ulcer, Dry Necrotic wound
As Secondary dressing in some situations
Defat surrounding with Alcohol as needed; Shave Hair before apply
Pros: Impermeable to External Bacteria & Fluid, Promote Autolysis
Transparent, Comfortable
Diminish Local Friction
Cons: Non-absorptive
Contraindicated in wounds with Fragile skin/Infected wounds
Alginate Dressing: eg. Kaltostat, Sorbalgon
Indication/Guideline: Wound with Moderate to Large amount of Exudate,
Wounds that require packing & absorption
Wound with combination of Exudate & Necrosis
Change every 8-96h
Use Gauze pad or Transparent film as Secondary dressing
Pros: Very good absorptive power, Fill dead space, Support debridement
Easy to apply
Not recommended for Dry/Lightly Exuding wound
Can dry wound bed
Semipermeable Polyurethane Foam Dressing: eg. Allevyn
Indication/Guideline: Partial & Full thickness wounds with Minimal to Moderate Exudate
Around drain wound
Change every 8h
Protect intact surrounding skin with skin sealant to prevent Maceration
Pros: Non-adherent, Manage Light to Moderate amount of Exudate
Easy to apply
Not recommended for Dry wound or wound with Sinus tract
Hydrogels Dressing: eg. Intrasite Gel
Indication/Guideline: Partial & Full thickness wounds with Necrosis/Sloughs
Burn & Tissue damage by Radiation
Change every 8-48h
Protect intact surrounding skin with skin sealant to prevent Maceration
Tape border of sheet form hydrogel dressing
Pros: Non-adherent, Comfort, Soothing cooling, Fill Dead space, Promote Autolysis
Transparent to Translucent
Can be use with Infection present
Not recommended for Heavy Exudate wound
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Silver Dressing: Antimicrobial activities
Aquacel Silver
Acticoat Nanocrystalline Silver (more Expensive)
Acticoat: Effective Antimicrobial barrier dressing
Nanocrystalline coating of Silver rapidly kills a Broad spectrum of bacteria in as little as 30 min
Acticoat dressing consists of 3 layers:
Absorbent inner core + Outer layers of Silver coated, Low adherent polyethylene net
Nanocrystalline silver protects wound site from Bacterial contamination
Inner core helps maintain Moist environment optimal for wound healing
Features: Nanocrystalline Silver Antimicrobial barrier,
Fast acting, Long lasting, Effective barrier to >150 pathogens,
Helps prevent Infection, Risk of Colonization,
Effective barrier to bacterial penetration, Helps maintain Moist wound environment,
Easy to use, Low adherent
Aquacel Silver: Provides Immediate & Sustained Antimicrobial activity to kill:
Pseudomonas aeruginosa, S. aureus, MRSA, VRE & other wound pathogens
Offers unique gelling properties of Hydrofiber technology
enabling dressing to gel on contact with wound fluid> Large fluid-absorption capacity
Locks bacteria within the gelled AQUACEL Ag fibres away from wound bed
Medical Honey: Standardized Antibacterial Honey (Medihoney)
Effective against a Broad spectrum of bacteria, including Antibiotic-resistant strains
Provides Moist wound environment to assist in healing & creates a barrier against bacteria
Pros: Provides an Antibacterial barrier
Effective against >200 clinical strains including MRSA, MSSA, VRE, etc
Provides a Moist wound environment
Fast, Effective Autolytic debriding action for Removal of Slough & Necrotic tissue
Rapidly removes Malodour
Risk of Infection
Non adherent thus Trauma & Pain during dressing changes
Natural product
PseudoEschar: Adherent surface layer of Exudates which adheres to wound
Typically in Deeper burns with use of Topical Antibiotic creams
This film is hard to get off & also hard to distinguish from process of wound conversion
Wound Type:
Necrotic wounds:
Covered with devitalized epidermis, frequently Black
Sloughy wounds:
Contain a layer of viscous adherent slough, generally Yellow
Granulating wounds:
Contain significant amounts of Highly vascularized Granulation tissue, generally Red/Deep Pink
Epithelializing wounds:
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Pink wound margin (Epithelialization from surrounding skin), or
Isolated Pink islands on surface (Epithelialization from remains of Hair follicles/Sweat glands)
Hypertrophic Scar: Erythematous, Pruritic, Raised Fibrous lesions
Typically do Not expand beyond boundaries of initial injury
May undergo partial Spontaneous resolution
Common after Thermal injuries & other injuries that involve Deep Dermis
Burn Pain: Severity of Burn Pain
CanNot predict from Depth/Area of burn
Linked to Psychological Morbidity
Characteristics: Unpredictable Severity & Nature of Pain over time
At the time of burn injury, Immediate Intense Pain irrespective of Depth of burn
Primary Hyperalgesia (Peripheral mechanism)
Secondary Hyperalgesia (Central mechanism)
Neuropathic Pain can develop (even after wounds heal)
Types: Background, Breakthrough & Procedural Pain
Background Pain:
Poorly correlates to Severity of burns
Continuous & Constant
If Not controlled well, Risk of development of Chronic Pain
Managed by Simple Analgesic
Severity with time
May have Neuropathic Pain component
Procedural Pain:
Pain during procedures such as Physiotherapy, Dressing or Surgery like Debridement
Short lasting
Often intense
Strong Analgesic required
GA may be considered if necessary
Progression: Background Pain:
Gradually as burn wounds heal
Pain may with time due to Infection or Development of Neuropathic Pain
LT sequelae:
Sensory Loss
Abnormal Sensation
Chronic Pain syndromes
Psychological morbidity
Common Analgesic for Burn Pain:
Opioids: Morphine, Fentanyl
Non-opioid Analgesics: NSAIDs, Paracetamol, Ketamine, TCA, AntiConvulsants,
Membrane Stabilizers, 2 agonists, Lignocaine
Nutrition: Paediatric Pt: Basal Metabolic rate + 15-40 kcal/%burn
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Age 16-59: Basal (~25 kcal/kg) + 40 kcal/%burn
Age >60: Basal (~20 kcal/kg) + 65 kcal/%burn
Cx (2004 MCQ 78): Organ Failure, Stress ulcer (Curlings ulcer), Sepsis, Wound infection, Chest infection
Organ Failure: Resp failure, Renal failure, Cardiac failure, Coagulopathy
Prevention:
Chest Physiotherapy, Adequate Hydration, Nutrition, Fluid balance
Sepsis: Wound infection, Pneumonia, Line Sepsis, UTI from Catheter, Other causes (eg. SBE, GIT)
Wound Infection:
Gram +ve: Staphylococcus, Streptococcus, Enterococcus, Diphtheroids, Candida albicans
Gram ve: Escherichia coli, Klebsiella, Pseudomonas aeruginosa, Acinetobacter
Ix: Wound swab, Tissue culture, Blood culture
Tx: Antibiotics, Dressing, Topical agents, Debridement, Skin graft
Surgery: (Purpose is to promote Wound Healing & for Functional concern
For Non-critical areas, usually offered if estimated healing time required >3 weeks
Associated with Risk of Hypertrophic Scar)
Acute Care: Debridement
Skin graft Partial thickness, Full thickness
Flap coverage
(Cadaveric skin may be used as a Dressing, Not a Transplant & No need Immunosuppression)
Pre-op Consideration for Burn Pt:
Extent of burn injury
Fluid Loss
Other injuries: Esp Cardiovascular & Respiratory
Airway Edema
CO poisoning
Temp control
Initial Resuscitation
Rehabilitation: Scar Mx
Physiotherapist
Occupational therapist
Scar Mx: Silicone, Pressure therapy, Splintage
Resurfacing (CO2 Laser/Dermabrasion), Release Skin graft/Flaps, Tissue Expansion
Other Cx: Discoloration: Observe
Alopecia: Hair graft or Wigs
Loss of Eyebrows: Hair graft
Draw book session:
Before dressing: Aspirate Blisters (for Culture)
Apply Antiseptics
Debride Necrotic tissue
Apply Silver Sulphadiazine cream (2014 MCQ 49, 2009 MCQ 57: Recommended for Deep Burns)
Apply Vaseline gauze, then apply a Thick layer of gauze on it
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Give Analgesics (if give Morphine, need Admission)
Change of Wound dressing:
Every 1 day if apply Silver cream, Every 2-3 days if standard dressing
Bacterial Infection usually wont set in too quickly, may take a week, unless very Dirty
Tetanus prophylaxis
Major burn: Peptic Ulcer prophylaxis
NG tube Nutrition (More Nutrition than Usual)
Antibiotic Prophylaxis is generally NOT needed

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Plastic Wound Healing & Infection
Etiology of Wound:
External: Traumatic, Thermal, Chemical, Iatrogenic, Surgical
Local: Vascular, Pressure, Neuropathy, Infective, Malignant
Wound Healing: Fetus: Regeneration
Neonate-Adult: Fibrosis/Scarring
A complex interactive process involving various Cell types, Soluble factors & Matrix components
Hemostasis, Inflammation, Cellular Migration & Proliferation,
Protein Synthesis & Wound Contraction, Remodeling

4 Phases: Hemostasis: Platelet & Fibrin
Inflammation: PMN, MQ
Proliferation: Collagen from Fibroblast
Remodeling: Re-alignment of Collagen to Tensile strength

(Even after good healing, Tensile strength is only 80% of Normal skin)
Wound Healing Intention:
Primary: Acute wound with Apposed wound edge, eg. Surgical Incision
Secondary: Wounding with Tissue Loss & Separated Edge
Granulation tissue fills up space, Epithelialization from periphery
Wound contraction helps to shrink wound size, eg. Skin abscess post I&D
Epithelialization: Process of reforming Superficial epithelial surface of skin
Re-establishment of Barrier function
Incisional wound with minimal gap will re-epithelialize in 48-72h
Wider wound will re-epithelialize from periphery and from Remnant of epithelial appendages
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Skin grafting/Surgical repair with apposition of wound edge will speed up Epithelialization

Factors affecting Wound healing: (Lecture modified from S Guo. Factors Affecting Wound Healing. 2010)
Local: Infection (2003 MCQ 29: Major cause), Foreign bodies, Arterial/Venous insufficiency,
Radiation, Trauma, Malignancy
Systemic: Aging
Nutritional deficiency:
Carbohydrate/Protein/Amino acid: Eg. Arginine (2011 MCQ 27, etc), Glutamine
Vitamins/Micronutrients/Trace Elements
Diseases: DM, Organ failure (Renal/Uremia, Liver/Jaundice, Cardiac/CVD, Lung/COPD), Anemia
NB: Any conditions leading to Hypotension/Hypovolemia/Edema/Anemia
Oxygenation is important in all phases of Wound Healing
Drugs: Steroids, NSAID, Chemo
Smoking/Alcohol
NB: Not affected by: 2011 MCQ 27: HyperCa
2005 MCQ 28: LT use of OHA
2002S MCQ 3: AntiThrombin III deficiency
2001 MCQ 38: Ventilator support
Nutrition & Wound healing:

Critical role of Nutrition recognized since Hippocrates time
Carbohydrate, Fat, Protein, Vitamin, Mineral
Protein-calorie Malnutrition most common
Energy Requirement:
Sex, Age, Body Size & Weight, Climate, PA, Pathological state
Basal Metabolism: Male: 1600-1800 kcal
Female: 1300-1500 kcal
Post-operative: 40 kcal/kg
Cx: 50 kcal/kg
Hyper-metabolic states: 60 kcal/kg
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Dietary Composition:
50% Carbohydrate, 40% Fat, 10% Protein
Carbohydrate: Primary source of energy in body/wound healing process
Pathological state impairing wound healing: Hypoglycemia: Energy production
Hyperglycemia: WBC Chemotaxis
Fats: Fatty acids essential component of Phospholipids & Prostaglandins
Protein: Structural proteins, Enzymes, Hormones, Ab, Hb & Nucleoproteins
9 Essential amino acids: Histidine, Isoleucine, Leucine, Lysine, Methionine, Phenylalanine,
Threonine, Tryptophan, Valine
Vitamins: Water soluble: B & C
Fat soluble: A, D, E, K
Minerals: Macro: Na, K, Cl, Ca, Mg, PO4
Micro: Fe, Cu, Zn, I
Nutrition Support: Maintain/Improve Nutritional status
Correct Nutritional deficiency
Promote rapid healing & recovery
Minimize Cx
Host resistance to infection
Indication: Severe Catabolic states, eg. Burns
Malnourished Pt before surgery, eg. CA Esophagus/Stomach
Post GI/Abdominal surgery (Ileus)
GIT disease, eg. Short gut, Crohns
Unconsciousness
Anorexia
Nutritional Assessment:
ABCD: Anthropometrics, Biochemical measures, Clinical data & Health Hx,
Dietary Hx including intake data
Anthropometrics:
Objective measurements, minimally Height/Weight> IBW
BMI = Weight/Height
BMI for Asians = 18.5-22.9
Triceps skin fold
Biochemical measures:
Serum albumin = Visceral protein store, Half-life of ~21 days
Protein Loss, ie. Wounds, Secretions, Drains or Metabolic Stress (Sepsis)
Low serum albumin:
M&M
Interstitial Edema may occur, interfering with delivery of O2 & other nutrients to wounds
Clinical data & Health Hx:
Signs: Muscle wasting
Dietary habits, Food preferences
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Usual BW, recent changes in weight
Appetite & problems with food intake/elimination
Dietary Hx including intake data
CHO & Fat Needs: Primary energy source of wound healing and for preventing protein degradation
Usual recommendation: 100-600 g CHO/Day
Hyperglycemia impairs wound healing
Protein Needs: Adequate protein intake is necessary for tissue repair
Usual recommendation: 1.5-3 g of Pro/kg (depending severity of wound)
Decision Making for Rout of Feeding:

Providing Dietary Needs:
Use GI tract if possible!
Nutritionally balanced pre- & post- op diet
Provide Nutrition asap after Surgery
Intake of foods that are High in Calories & Protein
Supplement meals with commercially prepared Oral supplements
Choosing a Feeding Formula:
Integrity of Pts GI system
Type of nutrients as related to Pts digestive & absorptive capacity
Calorie & Protein density requirements
Electrolytes content of Formula, ie. for Pt with Renal/Liver disease
Cost of Formula
Formula available:
Standard: Compleat, Enercal Plus (1 cal & 1.5 cal), Ensure, Isocal/Osmolite, IsoSource Std. (1.2 cal),
IsoSource 1.5 cal, Jevity/Ultracal, Osmolite HN
Special: Glucerna, Nepro, Pulmocare, Resource Fruit Beverages, Thicken Up, Suplena
Monitoring of Tube Feeding:
Biochemistry Fluid Balance Nutritional Assessment Nutritional Intake
Electrolytes I/O charts Weight I/O charts
Urea Weight Edema/Dehydration Food charts
LFT Serum proteins Diet Hx
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Blood glucose I/O Liaison with Nursing
Gastric residuals staff
Stool output
Wound Infection: Pain, Erythema, Edema, Temp
Prevention: Every surgical wound is contaminated by bacteria
3 sources: Surgical team, Pt, Operative environment
Surgical Team:
Clothing: Mask
Gloves (Bloodborne viruses, eg. HBV/HIV): Beware of integrity, Double gloves?
Eye shield: Lightweight/Not obstructing, Anti-fog
Scrubbing: Povidone-iodine (Betadine): Rapid onset of action, Broad spectrum, Short effect
Chlorhexidine gluconate: Longer acting
Brushes: May cause skin abrasions
Meticulous Surgical techniques:
Gentle tissue handling
Careful Hemostasis to prevent
Hematoma formation
Irrigation of surgical field to dilute/ bacterial load
Pt Preparation: The longer the hospital stay, the higher the chance of hospital acquired infection
Pre-existing Pneumonia, Drip site infection
Colonization by Antibiotic resistant bacteria
Special attention: Smoker, DM/CRF/Immunosuppressant, Aspirin/AntiCoagulants
Shaving: Hair adjacent to operative site to be removed
Shaving often causes injury to the skin, ing wound infection rates
Perform as near to the time of surgery as possible
Clippers
Antisepsis: Use sterilized sponge forceps to apply
Povidone iodine
Aqueous based Chlorhexidine gluconate (Blue 0.05%, Yellow 0.015%)
Alcohol based Chlorhexidine gluconate (Pink)
(Beware of Accumulation & Subsequent Burn injury)
Drapes: Protect from contamination from periphery
Sterilized cotton drapes
Protection diminished when Wet
Plastic drape
Dirty Trauma wounds
Entry into Nasal cavity/Oropharynx/Bowel, etc
Cardiac indications (Heart valves/Vegetations)
Operative Environment:
Design of operating theatre
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Behavior in the theatre
Preparation of operating instruments
Design of OT:
Concept of Zones:
Outer zone: Pt reception area
Clean zone: Area between reception & theatre suite
Aseptic zone: The operating area
Dirty zone: Disposal areas & corridors
Air flow: Maintain Humidity/Temp/Air circulation
Directional air flow
Air pumped into the room through filters
Passed out through vents in the periphery and Does not return
Behavior in OT:
Minimal number of people should be in the operating room
Must Not contaminate Sterile instruments
Sterilization of Instruments:
Complete destruction & removal of all viable microorganisms, including viruses & spores
Damage to organic substances
Applied to inanimate objects only
By Steam:
Autoclaves
Steam under pressure: 134C (30 lb in. -2) for a hold time of 3 mins
121C (15 lb in. -2) for a hold time of 15 mins
Effective against Bacteria (including TB), Viruses (HBV / HCV / HIV)
and Heat-resistant Spores (Clostridium tetani & C. perfringens)
Ethylene oxide:
C2H4O, 20-60C, 2-24h
Highly penetrative, Non-corrosive, Broad-spectrum cidal action
Toxic, Irritant, Mutagenic & Carcinogenic
For delicate items, eg. Electrical equipment, Flexible fibre endoscopes, etc
Irradiation:
-rays or accelerated electrons
Dosage of 25 kGy
Suitable for sterilization of large batches of similar products (catheters, syringes, etc)
Wound Infection Tx:
Daily dressing with Antiseptic solution
Irrigation of a cavity/sinus exists
Wound swab send for culture
Empirical Antibiotics, Streamline after culture results available
Removal of Foreign bodies/Debridement of Necrotic tissue
Wound healing by Secondary Intention
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How to take a Swab:
Page 426
Urology Testicular Torsion
Testicular Torsion: Torsion of Spermatic cord structures & subsequent Loss of blood supply to Ipsilateral Testis
Urological Emergency
Usually a disease of Adolescents & Neonate
May be associated with Testicular Malignancy esp in Adult
Relative in Broadness of Testis compared to Blood supply> Torsion
Cause:

Extravaginal Torsion:
*Neonates
Testes may freely rotate before development of Testicular Fixation via Tunica vaginalis
Tunica vaginalis Not yet secured to Gubernaculum> Torsion with Spermatic cord as a unit
Not associated with Bell Clapper Deformity
*Intravaginal Torsion:
*Adolescents
Weight of Testis after Puberty & Sudden Contraction of Cremasteric muscles
Bell Clapper Deformity: Attachment of Tunica vaginalis to Testis is inappropriately High
> Spermatic cord can rotate within it> Intravaginal Torsion
Occur in 17% M, Bilateral in 40%
Can result in Long axis of Testis being oriented Transversely,
rather than Cephalocaudal
Abnormal Mesentery between Testis & Blood supply can predispose to Torsion
if Testis is Broader than Mesentery
Contraction of Spermatic muscles shortens Spermatic cord> May initiate Testicular Torsion
Pathophysiology: Twisting of Testis> Venous Occlusion/Engorgement & Arterial Ischemia/Infarction
(Venous affected first> Swelling; Eventually Arterial Ischemic Necrosis> Non-viable)
Degree of Torsion affect Viability of Testes (Complete Torsion: 360)
Duration of Torsion affect Immediate Salvage & Late Testicular Atrophy
Salvage is most likely if <6h (90-100%)
Salvage rate significantly after 12h (50%)
Testicular Necrosis develop in most Pt if >24h (0-10%)
Dx: Clinical Dx (Diagnostic testing should Not delay Tx)
Hx: Sx: Pain: Sudden onset of Severe Unilateral Scrotal Pain followed by Inguinal/Scrotal Swelling
Pain may radiate to Abdomen (Sometimes may only have Abd Pain but No Scrotal Pain)
Pain may lessen as Necrosis becomes more Complete
N/V: 1/3 Pt also have GI upset with Nausea/Vomiting
(NB: Pt rarely report Voiding difficulties/Painful Urination)
Trigger: Torsion can occur with Sports/PA, Can be related to Trauma in 4-8% cases, Can be Spontaneous
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In some, Scrotal Trauma/Disease (including Torsion of Appendix testis or Epididymitis)
may precede Occurrence of subsequent Testicular Torsion
Previous: Previous episodes of Recurrent Acute Scrotal Pain that resolved spontaneously:
Intermittent Torsion & Detorsion
PE: Swollen, Tender, High-riding Testis with Abnormal Transverse lie & Loss of Cremasteric reflex
Prehns sign usually ve (Lifting up the Testis will Not relieve, or even worsen Pain)
Can also check location of Epididymis (normally Posterior-superior)
(2006 MCQ 41, etc: Epididymis may Not be palpable separately)
Others: Enlargement & Edema of Testis/Scrotum, Scrotal Erythema, Fever (uncommon)
NB: Opposite Testis may have Abnormal Lie too (ie. Bell Clapper Deformity) (2006 MCQ 41, etc)
Ix: Lab: (Not usually done unless Low suspicion of Testicular Torsion?)
Urinalysis: Exclude UTI & Epididymitis; WBC count Not reliable
CBC: WBC count usually Normal but can in Torsion
Imaging: Doppler US: Commonly done before Surgery
/Absent blood flow
Reperfusion phenomenon (Detorsion): Vascularity
Nuclear Medicine: Seldom done since too Slow
Ddx: Torsion of Testicular/Epididymal Appendage:
Usually occur in boys aged 7-12 years (Pre-adolescent)
Systemic Sx are Rare
Usually Localized Tenderness only in Upper pole of Testis (Pinpoint Tenderness)
Occasionally Blue Dot sign present in light-skinned boys
(ie. a Tender Nodule with Blue discoloration on Upper pole of Testis)
Cremasteric Reflex still active; No Nausea/Vomiting; Normal Blood flow on Doppler US
Over time can cause Local Inflammation which looks like Epididymitis on US
Usually Conservative Tx (Testis Not affected by Necrotic Testicular Appendix; No need Surgery)
Epididymitis/Orchitis/Epididymo-orchitis:
Most commonly occur from Reflux of Infected urine or from STD by Gonococci & Chlamydia
(2002 MCQ 22: HPV is Not a common organism)
Occasionally develop after Excessive Straining/Lifting & Reflux of Urine (Chemical Epididymitis)
Gradual onset, Often accompanied by Systemic Sx associated with UTI (Fever, Urinary Sx)
Prehns sign: Elevation of Scrotum can relieve Pain by Epididymitis but Not Testicular Torsion
May Not be Reliable
Pyuria, Bacteriuria, or Leukocytosis possible
If just Epididymitis but Not Orchitis, Testis is Not painful (Just Tender Superior portion)
(Constipation: Can cause Testicular Pain; Consider in Normal PE
Taught in Paedi Urology in Paedi Surgery, but Not listed as Ddx in usual sources)
Hydrocele: Usually associated with Patent Processus vaginalis
Usually Painless Swelling
Scrotal contents can be visualized with Transillumination
Hernia: May be diagnosed by careful examination of Inguinal canal
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Hernia with Acute Pain likely Incarcerated/Strangulated
Testis Tumor: Rarely accompanied by Pain, Rarely Acute Presentation
Idiopathic Scrotal Edema:
Scrotal skin is Thickened, Edematous, often Inflamed
Testis Not Tender, and is of Normal Size & Position
Trauma/Hematoma
Varicocele
Others: Spermatocele, Appendicitis, Henoch-Schonlein Purpura, etc
Tx: Analgesia
Temporary measure:
Manual Detorsion: Elevate & Turn Medially
May be attempted but usually Difficult & Unsuccessful
Surgical Fixation is needed eventually anyway
Surgical Exploration:
Viable: Orchidopexy
Not Viable: Orchidectomy
Do Contralateral Orchidopexy as well

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Urology Hematuria
Red Color Urine: Food (eg. Beetroot Red/Pink), Drugs (Rifampicin, etc)
Tea color Urine? (Jaundice)
Told by GP to have Blood in Urine (Microscopic) or See Frank Blood in Urine (Gross)
Hemoglobinuria or Myoglobinuria
PseudoHematuria Menstruation
(Porphyria: Urine may change Color after exposure to Sunlight)
(Drugs: Brown Urine: Nitrofurantoin, Phenothiazines
Pink Urine: Phenindione, Phenolphtalein (laxatives)
Black: Methyldopa)
Hematuria: Microscopic: 3 RBC/HPF
Gross: Whether from UG system (Surgical) or from Kidney Parenchyma (Medical)
Possible from Kidney Calyx to Urethra Opening
Hematuria is always a Red Flag demanding careful evaluation & Must Not be ignored
Microscopic Hematuria:
Usually discovered on Routine exam by Dipstick Urinalysis
Dipstick: Sensitivity 91-100%, Specificity 65-99%
False +ve: Menstrual blood in Female, Dehydration which concentrate RBC, Exercise
False ve: pH <5.1, Vit C, Bacteriuria, Captopril, etc
MUST be confirmed by Urine Microscopy!
Microscopy:
Epithelial RBC & Glomerular RBC
Epithelial: Smooth, Round & Normal morphology
Glomerular: Dysmorphic, Irregular Shape with Minimal/Uneven Hb distribution
(Distorted by Osmotic Stress during passage through Nephron)
Dysmorphism: Mainly in cell membrane
Acanthocytes with typical Ring-formed Cell bodies
with 1 blebs of different Size/Shape

Medical Hematuria often associated with Proteinuria, RBC Casts, etc
RBC Casts: RBC trapped in Cylindrical mold of Gelled Tamm-Horsfall mucoprotein
(TM Chan: Presence indicates more severe Glomerular Hematuria)

Cause:
Benign: Benign Idiopathic Hematuria
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Urology Hematuria
Exercise-induced Hematuria (Not Rhabdomyolysis)
Renal Parenchymal disease
Bleeding Tendency
Urological disease:
Stones, Infection (UTI), Tumor
Trauma
PKD
BPH: Vascular Prostate may bleed; Often diagnosed by Exclusion
(CA Prostate does Not bleed commonly Not near Urethra)
Other Cystitis: Post-Irradiation Cystitis, Hemorrhagic Cystitis (Cyclophosphamide)
Misc: Nutcracker syndrome, Endometriosis of Urinary tract, etc
Approach: Is it Hematuria?
Medical/Surgical?
Origin & Nature of Bleeding in Urological system
Hx: Urine:
Blood Timing:
Whole Stream: Above Urinary sphincter (Kidney, Ureter, Bladder)
Initial Stream: Lecture note: Anterior Urethra
PBL Tutor guide: Posterior Urethra
Terminal Stream: Prostate (Prostatic Urethra), Bladder Neck
(End of voiding> Neck Collapse> Abrase lesions)
(NB: 2004 EMQ 12: Bladder Stone: Dysuria, Voiding difficulty, Terminal Hematuria)
Micturition Independent: Distal Urethra beyond Urinary sphincter (Anterior Urethra, Meatus)
Clot: Clot: Signify Extraglomerular cause (& Hematuria Severity)
Vermiform Clot: Bleeding in UUT> Clotting in Ureter> Worm-like shape
Stone
Other Sx:
Pain: Silent/Painless Hematuria: Tumor, or Renal Parenchymal disease (Smoky Urine)
Loin Pain/Colic: Ureteric Stone passage or Bleeding with Clot Colic in Upper tract
(Pyelonephritis can also give Loin Pain)
LUTS: Bladder Pathology (*Cystitis), BPH
Bleeding related:
Anemia: Severity of Hematuria
(Shock: Usually Upper tract Bleeding from Kidneys
Many space in Retroperitoneum to hold blood
Cf Bladder can only hold 500 ml of blood; Further bleeding> Tamponade)
HemoSpermia: Prostate CA (Locally Advanced already)
Social/FHx: Smoking, Occupational Exposure to Carcinogen (Dye, Petroleum),
FHx of Kidney disease (PKD), Stone disease, TB, etc,
Outdoor worker with Heavy Sweating may predispose to Urinary Calculi formation
PE: GE: Looking for Rash (CTD), Skin Bruise (Bleeding Tendency), HT
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Urology Hematuria
High Fever: Suggest Serious Infection (Pyelonephritis, Cystitis, Prostatitis)
Abd Exam: Mass esp Kidney Mass/Distended Bladder
DRE: Pelvic Mass; (Dont forget DRE!)
Most Pt present in Urology Clinic had No other +ve signs at all (Just Hematuria)
Important!: *Cause of Gross Hematuria in Age >50: Bladder Cancer
Gross Hematuria in Adult: Regarded as Malignancy until proven otherwise
Demand Immediate Urologic Exam
Ix: Blood: CBC: Any Hb, WBC
RFT: Any Renal impairment
Also affect Imaging option using Contrast, Surgery option of Partial/Radical Nephrectomy
Clotting profile
Urine: Urinalysis Protein, Glucose (DM Pt may present as Recurrent UTI)
Microscopy & Bacterial Culture
EMU x AFB
Cytology: ve result can NOT rule out Cancer (Low grade CA hardly shed any cells)
(+ve: Most likely High grade TCC CA/Cis)
Lower Tract Imaging:
Cystoscopy:
Main stay of Ix for all cases presented with Gross Hematuria
Flexible scope with 16 Fr Size allow procedure under LA in clinic setting
Small pathology (Papillary TCC of 1 mm) could be seen & detected (Not by US, etc)
Biopsy could be taken for Analysis
Bleeding from Upper tract seen from Ureteric Jet
Upper Tract Imaging:
IVU, US, CTU, MRU (Inferior to CTU, but No Irradiation Good for Pregnancy)
(Some may consider KUB & Bedside US as Basic Imaging, IVU/CTU/MRU as standard workup)
US IVU CT MRI
Contrast No Yes Yes Yes/No
X-ray ** ***
Cost * ** *** ****
Availability **** **** **** **
Renal function dependency * **** **** *
Cortex *** * **** ****
Ureter * **** **** ****
Surrounding condition ** * **** ****
KUB: Difference from AXR: Superiorly above Upper pole of Kidney (T12)
Inferiorly shows Pubic symphysis
May be used for Initial Screening
Urinary Stones
(Sensitivity of detecting a Radioopaque Stone is just 50% in real Clinical practice)
Calcification in Bladder: Bladder Stones usually more compact & fall by gravity
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Urology Hematuria
If near upper wall, either CA or Stones in Bladder Diverticulum)
SOL features: Abnormal Calcifications, Abnormal Renal Contour,
Loss of Psoas Shadow (Retroperitoneal Edema),
Bowel displacement, Bone qualities/Pedicles
IVU: Economic way for Upper Tract Imaging
Conventional Radiography machine; Gradually replaced by CTU
Good for detecting Filling defect in Collecting system & Ureter
Cons: Not Sensitive for detection of Renal lesion <3 cm
Unable to give Coronal & Sagittal image
Unable to detect Small Bladder lesion
Phase: Control film: Plain KUB
Nephrogram phase (1 min):
Kidney Size, Outline
Pyelogram phase (5 min):
Any Dilated calyces/pelvis (Hydronephrosis), Any Filling defects
(10 min film with Abd Compression:
May or May Not be done; Can show Calyces better)
Release film (Abdominal compression is released):
Ureters: Any Hydroureter, Filling defects
Cystogram: Bladder: Any Filling defects, Any Abnormal appearance
(Fir/Christmas tree appearance in Neurogenic bladder)
Post-micturition: Any Residual urine in bladder after voiding (Any Retention)
US: Good for Solid Mass Renal lesion, Hydronephrosis, Bladder lesions, Prostate Size measurement
Difficult to define Ureteric lesion (Obscured by nearby structures)
Small Size machine now available, can perform at Bedside (Modern Electronic Stethoscope)
Preliminary Screen tool for Hematuria
CT: Non-Contrast CT (NCCT) is now Standard Ix for Renal Colic to define pathology:
Level, Size, Density, Degree of Obstruction of Calculi
CTU (Contrast CT) can define all significant Upper tract pathology
including Calculi, Urothelial Tumor & Anatomy of Urological system
Reconstruction with different plane possible
MRI: Expensive Ix
No Irradiation
Image Inferior to CT for moving organs like Kidney
Good for Contraindication to CT/IVU
Pregnant Women, Contrast Allergy, Children, Renal impairment, etc
Urine Cytology: Fresh Urine needed
Could be detected in High Grade TCC before Gross lesion become noticeable (Cis of Bladder)
Low detection rate in Low Grade Cancer
TCC: High Grade Sensitivity 80-100%, Specificity 71-100%
Low Grade Sensitivity 13-75%, Specificity 20-50%
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Urology Hematuria
Overall Sensitivity 50%
Normal, Atypical, Suspicious, Malignant
Brush Cytology Sensitivity 90%, (Invasive, may cause Bleeding/Perforation)
Interpretation of results depend on Experience of Pathologist
Atypical Cytology (sometimes may be just due to Irritative effect)
Invasive Ix: Perform only in Undefined Dx when Suspicious of Serious pathology, eg. Cancer, Stricture
Retrograde Pyelogram (via Cystoscopy)
UreteroCystoscopy
RF for significant disease in Microscopic Hematuria:
Smoking Hx, Occupational exposure to Chemicals/Dyes (Benzenes, Aromatic Amines),
Hx of Gross Hematuria, Age >40, Hx of Urologic disease, Hx of Irritative Voiding Sx, Hx of UTI,
Analgesic Abuse, Hx of Pelvic Irradiation
Irradiation Cystitis: Occur at least a period after Irradiation for Cancer in Pelvis
Seen in Pt with Cervical & Colorectal Cancer after Irradiation
Could be associated with Neurogenic & Structural changes
Sometimes Difficult to manage:
Bleeding from Inflammatory change, or Secondary Bladder Cancer development
Hemorrhagic Cystitis: Occur in Pt with Hematological Malignancy with Chemo
Could be associated with Drugs like Cyclophosphamide/Ifosfamide (during/after Chemo)
(Usually given Mesna as adjuvant to detoxify the toxic metabolites)
Could be related to Viral Cystitis
Exercise-induced Hematuria:
Hematuria after Strenuous Exercise
Resolved after Rest
In Marathon Runner, Contact Sports, etc
Actual Cause Unknown
? Friction Abrasion of Collapsed Bladder with Dehydration during Running
Ix required to Rule out significant pathology
Tx:
Conditions to require Referral to Nephrologists:
Urological Cause Excluded
Evidence of ing GFR, CRF (eGFR <30 ml/min), Significant Proteinuria
Young HT (<40) with Isolated Hematuria (ie. Absence of significant Proteinuria)
Visible Hematuria with Intercurrent URTI
(Bladder Irrigation: May be done after Clot Evacuation to prevent Clot formation)
Severe Hematuria: Transfusion
Lower tract: Endoscopic Transurethral Hemostasis + Deal with underlying pathology
Upper tract: Urgent Contrast CT/Angiogram to locate source
Embolization
Surgery (eg. Nephrectomy)
Elective Operations: Superficial Bladder tumor: TURBT
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Urology Hematuria
Muscle invasive Bladder tumor: Radical Cystectomy
Upper tract TCC: Radical NephroUreterectomy
Renal tumor: Radical Total/Partial Nephrectomy
CA Prostate: Radical Prostatectomy/RT
Tx for Urinary Tract Tumor:
RCC: Radical/Nephron-sparing (Partial) Nephrectomy
(Nowadays always aim to preserve Renal function by Partial as 1st line if possible)
TCC: Upper tract: NephroUreterectomy
Bladder: Superficial Tumor: TURBT BCG
(M. bovis can trigger immune clearance of residual cancer cells?)
Invasive Tumor: Radical Surgery (ie. Radical Cystectomy)
Urinary Diversion
Asymptomatic Microscopic Hematuria:
Mx Guideline: Assessment of Asymptomatic MicroHematuria Pt to Exclude Benign causes:
Infection, Menstruation, Vigorous Exercise, Medical Renal disease, Viral illness, Trauma,
Recent Urological procedures
Careful Hx, PE, Lab Exam
Once Benign causes ruled out, Urologic Evaluation
Hematuria workup: Flexible Cystoscopy, Upper Tract Imaging
No Pathological source of Asymptomatic Microscopic Hematuria is found in 37.3-80.6% Pt
Latest series showed only 1.9% in all cases of Asymptomatic Microscopic Hematuria
Common RF for Urinary Malignancy in Microscopic Hematuria:
M, >35 yo?
Occupational Exposure to Chemicals, Dye, (Benzenes/Aromatic Amines)
Hx of: Gross Hematuria, Urologic disorders, Irritating Voiding Sx, Pelvic Irradiation,
Chronic UTI, Foreign body
Hx of Exposure to Carcinogenic, Cytotoxic Drugs

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Urology Hematuria
Urology Urinary Stone
Urinary Stone: *Renal Calculi (Nephrolithiasis)
Ureteral Calculi (almost always originate in Kidneys, but may grow after dislodged)
(Bladder Calculi is often considered as a different entity with different pathophysiology)
Type:
Alkaline Urine:
Ca Stone (75%) (*Ca Oxalate, CaPO4):
HyperPTH, GI absorption of Ca, Renal Ca Leak, Renal PO4 Leak,
HyperUricosuria, HyperOxaluria, HypoCitraturia, HypoMagnesuria
Struvite Stone (MgNH4PO4) (15%):
Asso. with Chronic UTI with Gram ve rods with Urease (generating Alkaline urine)
Eg. Proteus (2010 MCQ 78) (2009 MCQ 21), Pseudomonas, Klebsiella (2003 MCQ 9)
Not E.coli
Urine pH may be >7
Look for underlying Anatomical abnormalities too (Also Foreign body, Neurogenic Bladder)
(Note UTI Not necessarily must be Struvite stone; Bacteria can also form Nidus for any stones)
Acidic Urine:
Uric acid Stone (6%):
Asso. with Urine pH <5.5, High Purine intake, Malignancy (Rapid cell turnover)
Some Pt may have Gout
Cystine Stone (2%):
Due to Intrinsic Metabolic defect
RF: Intrinsic (Hereditary):
Polygenic, RTA, Cystinuria
Age & Sex: Peak Age 3-5th decade
M:F = 3:1
Caucasians > other ethnicities
Extrinsic: Geography: Desert, Tropical area
Climate: Peak Incidence July-August, Dry climate may asso. with Stone
Water intake
Diet: Ca
Occupation
Obesity
Pathophysiology:
Process of Urolithiasis:
Chemical Nucleation: Homogenous vs Heterogenous Nucleation
Crystal Aggregation
Crystal Growth
Stone Formation
Factors other than Solute concentration:
Inhibitors of Urolithiasis:
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Nucleation Inhibitors: Citrate
Aggregation Inhibitors: Mg, Citrate, Nephrocalcin, Tamm-Horsfall protein, Bikunin,
Uropontin
Urine pH
Urinary Stasis: Homogenous vs Heterogenous Nucleation
Common Stone Chemistry:
Ca-containing Stones:
Ca oxalate: Ca(COO)2 60%
Hydroxyapatite: Ca5(PO4)3(OH) 20%
Brushite: CaHPO42H2O 2%
Non-Ca-containing Stones:
Urate: C 5H 4N 4O 3 7%
Struvite: NH4MgPO46H2O 7%
Cystine: 1-3%
Others: 1-3%
Pathogenesis of Urolithiasis:
HyperCalciuria:
Absorptive
Renal
Resorptive: Primary HyperPTH, TB/Sarcoidosis, Malignancy-asso. HyperCa, Steroid
HyperOxaluria:
Primary: Primary HyperOxaluria Type I (Lack AGT), Type II (Lack GPHPR)
AR; ESRD by Age 15 in 50% Pt; Tx by Combined Liver & Kidney transplants
Enteric: Fat Malabsorption states:
Small bowel resection, JejunoIleal bypass, Bypass Surgery for Bariatric purposes
Mechanism: Enterohepatic circulation> Bile salts Loss
Preferential Saponification of Fat> Takes away Ca but leaves Oxalate
Dietary
Idiopathic
Urate: Enzyme degrading urate (Uricase) absent in humans
No known urinary inhibitors exist
Solubility greatly depends on Urine pH (other 2 factors Urine Volume & [Urate])
At pH 6.5: >90% Urate remains Soluble
At pH 5.5: 50% crystallizes
Effects of HyperUricosuria:
Gouty diathesis: Urate acid crystallization (pH <5.5)
(Normal Urate level but Acidic Urine> Likely to form Urate stones)
HyperUricosuric Ca Nephrolithiasis (HUCN):
Ca oxalate formation through Heterogenous Nucleation (pH >5.5)
(High Urate level but Normal pH Urine> Likely to form Ca stones rather than Urate stones)
Binding of GAGs that inhibit Ca oxalate aggregation
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Cause:
Excess Dietary Purine intake (Animal protein)
Gout (HyperUricemia)
LPD/MPD
Hereditary deficiency of HGPRT (Lesch-Nyhan syndrome)
HypoCitraturia:
Caused by primarily Metabolic Acidotic states
Acidosis Urinary Citrates
Renal tubular absorption
Synthesis in Peritubular cells
Cause: Distal RTA, Chronic Diarrheal states with Alkali Loss, Thiazide-induced, Idiopathic,
Excessive Animal Protein Diet
Low Urine pH:
Predisposes to Uric acid stone formation
Now believed to be due to impaired Ammonium excretion into Urine in Pt
Underlying cause is now believed to be related to Insulin resistance
Cystinuria: AR
Defect in Intestinal & Renal tubular absorption of dibasic aa, one of which is Cystine
Infection Stones:
Composed primarily of Mg, NH4, PO4
In addition may contain Hydroxyapatite or Carbonate apatite
Formed in Alkali conditions (pH >7.2)
In presence of Urease: (Chemical equation)
Majority of Staghorn Stones are composed of Struvite Stones
Bacteria: Proteus, Klebsiella, Pseudomonas, Staphylococcus, Mycoplasma/Ureaplasma
Misc Stones:
Xanthine stones
Ammonium acid urate stones
Medication-related stones:
Indinavir: HIV drugs; Radiolucent in X-ray + Invisible on CT
Triamterine, Silicate, Thiazides, Carbonic anhydrase inhibitors, Topiramate
Sx: (Renal stones are mostly Asymptomatic if Not dislodged)
Acute Ureteral/Renal Pelvis Obstruction:
Acute onset of Severe Flank Pain radiating to Groin,
Gross/Microscopic Hematuria, Nausea/Vomiting
Staghorn Stone:
Branched Kidney stone occupying Renal Pelvis & Calyceal system
Often relatively Asymptomatic; Manifest as Infection & Hematuria rather than Pain
Asymptomatic Bilateral obstruction manifesting as Renal Failure uncommon
Pain: Location & Quality related to Position
Severity related to Degree of obstruction, Presence of Ureteral Spasm & Infection
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(Mechanism: Peristalsis, with Prostaglandin as Neurotransmitter
Distended Pelvic-Calyceal system
Asso. Infection Pyelonephritis/Pyonephritis)
Location: Site of Impaction: Calyces, PUJ, Pelvic Brim, Broad Ligament, VUJ
PelviUreteric junction:
Mild-Severe Deep Flank Pain without Radiation (Renal Capsule distention)
Ureter: (Referred Pain to T12-L2)
Abrupt Severe Colicky Pain (Often Not relieved by Simple Analgesic)
(>90% Renal colic are due to Stones; Remaining may be others like Tissues, Clots)
(Pain often out of proportion to signs No guarding, etc)
Upper Ureter (PelviUreteric junction to L5 Transverse process):
Radiate to Flank & Lumbar area
May mimic Cholecystitis/Cholelithiasis (R), PUD/Gastritis/Pancreatitis (L)
Mid Ureter (Below to Inferior border of SIJ):
Radiate anteriorly & caudally
May mimic Appendicitis (R), Diverticulitis (L)
Distal Ureter (Below to VUJ):
Radiate to Groin, Testicle in M, Labia majora in F
Referred from Ilioinguinal/Genitofemoral nerves
VesicoUreteric junction (VUJ):
May also cause Irritative voiding Sx, eg. Frequency, Dysuria
Intramural Ureter:
May appear like Cystitis/Urethritis
Suprapubic Pain, Frequency, Urgency, Dysuria, Strangury, Pain at Penis tip, (Bowel Sx)
May be confused with PID, Ovarian cyst Rupture, Torsion, Menstrual Pain
Bladder:
Usually Asymptomatic, passed relatively easy during Urination
(If Renal stone is Small enough to dislodge into UB, usually <1 cm, can pass Urethra)
(Bladder stone can accumulate to almost 5 cm)
Rarely may have Positional Urinary Retention
Ball-valve effect at UB outlet> Obstruction on Standing, Relieved by Recumbence
Time: Acute onset typically Early in Morning or At Night, waking Pt from sleep
(If begins during the day, tends to start slowly & insidiously)
Usually Steady, ingly Severe, Continuous,
sometimes with intermittent Paroxysms of even more Excruciating Pain
Usually reach Max 1-2h after onset
Sustained Max Pain (Constant phase, 1-4h) until treated/relieved spontaneously
N/V: Common innervation pathway of Renal pelvis, Stomach & Intestines
through Celiac axis & Vagal nerve afferents
Signs: Usually Minimal physical signs
May have Fever/Septic state, Loin Tenderness, Ballottable Kidney
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Cx: UTI: Abscess formation, Severe Kidney Infection ing Renal function, Urosepsis
(In very Sick Pt, think of Stone + Pyelonephritis, as both can lead to Pain)
Hematuria
Obstructive Nephropathy: Renal Function Loss due to Longstanding obstruction
Ureteral Perforation, Extravasation of Urine
Urinary Fistula, Ureteral Scarring & Stenosis
Pathophysi of Unilateral Complete obstruction:
Timing 0-90 min 90 min 4h 4-18h
Renal Blood Flow Continue to
Mechanism Afferent Glomerular Arteriolar in Afferent Arteriolar Resistance:
Dilatation: Large portions of Cortical Vascular bed perfusion
- Stimulation of Tubuloglomerular
feedback mechanism, due to Na Angiotensin II is important mediator of Preglomerular
delivery to Macula densa Vasoconstriction occurring during 2nd & 3rd phases of
- Changes in Interstitial P within kidney UUO
- Release of Vasodilators like PGE2, NO Other Vasoconstrictors: TXA2, Endothelin
GFR
Not only due to Perfusion of individual glomeruli,
but also Global in Filtration related to
Underperfusion of many glomeruli
Collecting system (from 6.5 to 50-70 mmHg) Remains
pressure Half initial level of 30 mmHg after 24h
with Gradual resolution over 4-6 weeks
Mechanism Back pressure from obstruction initially
Compensatory mechanisms to Pressure build-up:
Dilatation of Renal pelvis & Collecting system
Afferent Vasoconstriction
Pyelotubular & Tubulovenous Reflux
Dilatation of Lymphatics with Shunting or Urine into Perirenal Lymphatics
Tubular Na: Impaired Active transport due to No. & Effectiveness of Na transporters
changes Natriuretic substances
Fractional Na excretion
K: Excretion with in GFR
Impaired Urinary concentration & dilution capabilities
Ix: Urinalysis: Look for Hematuria & Infection
Urine Crystals & pH may also give clues of Nature of calculi
pH: pH >7.5 may suggest Infection Lithiasis; pH <5.5 may suggest Uric acid Lithiasis
Crystals: Tetrahedral Envelopes: Ca oxalate (dihydrate)
Hourglass: Ca oxalate (monohydrate)
Rectangular Coffin-lid: Struvite
Hexagonal crystal: Cystine
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Amorphous fibers/Irregular plates: Uric acid
Needle shaped: Brushite

Blood studies:
CBC: WBC: Mild Leucocytosis can accompany Renal Colic attack
But High index of suspicion of Infection if High WBC, even if Afebrile
RFT: Creatinine to evaluate Renal Function
Also predicts Contrast-induced Nephrotoxicity (Affect Imaging choice)
(Others): Uric acid: HyperUricosuria
Ca: HyperCa; If so, check PTH too
K & HCO3: may suggest dRTA (asso. with CaPO4 stones)
Imaging:
US IVU NCCT
Contrast No Yes No
X-ray ** ***
Cost * ** ***
Availability **** **** ****
Renal function dependency ****
Renal stone *** **** ****
Ureteral stone * **** ****
Surrounding condition ** * ****
KUB: (Rmb Not to miss Urethral stones below Pubic symphysis)
May see Radio-opaque Stones (80-90% Renal stones are Radio-opaque)
Miss 10% stones: Radiolucent stones: Urate, Xanthine, Indinavir
Mildly Radio-opaque stones: Cystine, Struvite
Not all Calcifications seen are necessarily Urinary Stones
False +ve: Eg. Phlebolith (Round, sometimes with Lucent centre), Stool
Kidney: Size, Any Renal Opacities
Ureter: Trace along Tips of Transverse process, across SIJ (may be a bit medial?),
touches Ischial spine level (VUJ), then medially into Bladder
Proximal Ureter above SIJ, Middle over SIJ, Distal below SIJ
Bladder: Any Bladder stones
Never make Dx with KUB alone! (Not necessarily Stone, Not necessarily in Kidney/Ureter)
Make suggested Dx: Location, Size, Advise further workup to confirm
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US: Done on Kidney/Bladder
Stones: Echogenic rim, Posterior Acoustic shadow
Obstruction features: Hydronephrosis (Indirect evidence of obstruction)
Thin Cortical Thickness (Secondary info of renal function)
(Bladder stone vs VUJ stone:
Difficult to tell on KUB if opacity located over VUJ area
Unilateral Hydronephrosis on US favors VUJ stone
Also Bladder stone more Mobile while VUJ stone more Impacted?)
IVU: Used to be criterion standard; Can visualize Stones (Filling defects) & Dilated urinary system
Time-honored Ix: Scout, Nephrogram, 5 min, 10 min, PM
Compression, Prone views
Give info about Function, Direct evidence of obstruction
Involves Contrast with Risk of Anaphylaxis
NCCT: (Replaced IVU nowadays) (Contrast Not used Obscure Ca-containing stones)
Quick, Identifies >95% stones, Also gives Extra-urologic info
Ddx Stones from Phleboliths:
Halo sign: Hypodense shadow surrounding Hyperdensity Edema outside Stones
Comet sign: Tail-like tubular structures signifying vessel
CTU: Contrast CT: Not used in Acute Loin Pain evaluation
But standard Ix in workup of Gross Hematuria/Renal Mass
May add Delayed/Urogram phase (CTU) to outline Ureters
Retrograde Pyelogram:
Requires use of Cystoscopy, thus Invasive
In selective situation where excretion of Contrast canNot be used to outline Urologic tract
Eg. Pt with Renal Failure
Can intervene at same time, eg. Insertion of Ureteral Stents to relieve obstruction
Functional Renal Scan:
Little role in Acute Loin Pain evaluation
Useful in assessing differential function (esp in Prolonged obstruction)
Used in Surgery planning; May Not salvage the kidney if Low function
(DTPA scan: If <15%, consider as Non-functional)
Tx: Stone <5 mm has High chance of Spontaneous passage, while >1 cm unlikely to pass itself
(Only treat Small stones if do Not pass out after eg. 1 month, or Symptomatic)
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Indication for Intervention:
Absolute: Obstructive Pyelonephritis (Emergency)
Unremitting Pain
Deterioration of Renal function
Anuria due to Ureteral obstruction
Bilateral Stones, Solitary Kidney
Relative: Large Ureteral Stones (>7 mm) are unlikely to pass spontaneously
Occupational requirement (eg. Airline Pilot)
Transplant Kidney
Principles:
Stone Factors:
Size, Number, Composition, Unilaterality/Bilaterality
Pt Factors: Function of Renal unit
Anatomy of Renal unit: Caliceal Anatomy, Obstruction, Renal anomalies
Pt fitness for Anesthesia
Body habitus
Underlying Bleeding Tendency
Susceptibility for Radiation
Surgeon Factors:
Specific technology available or Not
Initial Mx: Fluid Rehydration
Pain control:
Narcotics Not good: Rapid onset of Analgesia,
But Nausea/Vomiting, Excessive Sedation, Potential for Abuse
NSAID: Inhibition of Prostaglandin synthesis prevents potentiation of nociceptors
Collecting system pressure
Should Not be utilized in Renal Insufficiency (Exacerbate in RBF)
AntiEmetic if Nausea/Vomiting
Antibiotics if complicated by UTI
Drainage: Indication: Uncontrolled Pain, Uncontrolled Sepsis, Renal Failure
Both options are feasible, depend on individual hospital preference
Internal Stent (JJ Stent):
X-ray guidance, Done in OT, Invasiveness Need Cystoscopy
Less Coagulation dependency, Pt discomfort Lower Stent Irritation
(JJ stent can dilate Ureter)
External Percutaneous Nephrostomy (PCN):
X-ray/US guidance, Done in Bedside, Invasiveness Potential organ injury
More Coagulation dependency, Pt discomfort Indwelling Catheter
Definitive Mx Stone Removal:
1. Medical:
Medical Expulsive Therapy (MET):
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For Small Ureteric stone (Distal Ureter, <1 cm); Can be used in OutPt
Rationale based on Muscle spasm, Local Edema, Inflammation, Infection
(Promote Spontaneous passage while Sx associated with passage)
Agents: -blocker (Terazosin, Tamsulosin) (Most Effective)
CCB (Nifedipine) (also good) + Steroid
(Dissolution of Calculi): (Not often done clinically; Alkalization may be used as Prevention)
Ca stones: Can Not be dissolved with current medical therapy
Uric acid/Cystine stones: Can dissolve by Alkalization of Urine (eg. K citrate) (2002S MCQ 78)
2. Surgical: From below: URSL: () (Basket, US, Laser Fragmentation, etc)
(Usually for Ureteric Stone, unless Flexible URSL)
From above: ESWL: () (Non-Invasive!)
(For <2 cm Renal Stone, <1 cm Ureteric Stone)
PCNL: (For >2 cm Renal Stone)
Extracorporeal ShockWave Lithotripsy (ESWL):
Minimally Invasive technique utilizing Shockwave for Stone Fragmentation for body to pass out
Can be done with only Analgesic
May require Repeated procedures (Only fragment to the point of dose limit, then next session)
Components:
Shockwave generator: Electrohydraulic (Spark gap), Piezoelectric, Electromagnetic
Focusing system: Basic Geometric principle is an Ellipse
Electrohydraulic: Metal Ellipsoid
Piezoelectric: Ceramic crystals arranged within Hemispherical dish
Electromagnetic: Acoustic Lens (Siemens system), Cylindrical Reflector (Storz system)
Coupling mechanism: Minimize dissipation of Energy as Shockwave traverse skin surface
Water medium: Density similar to Soft tissue, Readily available
Traditionally by Water bath, Now Water-filled drums/cushions
Imaging/Localization unit: *Fluoroscopy, US
Pros & Cons:
Pros: Minimally Invasive, No need Anesthesia, Can be performed Multiple times
Cons: Indirect, Subject to Stone Skin distance,
May Not work for Hard stones (eg. Cystine, Brushite),
Limitations by Renal Anatomy (Diverticulum, Lower pole)
Factors affecting outcome:
Size: Good for <2 cm
Adding JJ stent may secure drainage from obstruction by fragments if tackle Large stones
Composition: Good for Radio-opaque Soft stones (Ca oxalate dihydrate, MgNH4PO4)
Limited Efficacy in Ca oxalate monohydrate, Cystine
Hard stones can be predicted on CT (Very Hyperdense)
May require US-guided localization or Contrast for Radiolucent stones, eg. Uric acid
Location: Good for Kidney (esp Upper/Middle Calyx) & Upper Ureter
Lower-pole: Stone-free rate due to difficulty in passing stones from here
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Distal Ureter: Fragmentation Less Effective (More difficult to access)
Skin to Stone distance:
Efficacy poorer in Obese Pt
Contraindication:
Absolute: Pregnancy
Active Urosepsis
Bleeding tendency
Ureteral obstruction distal to stones (Cant pass Stent)
Lower Cx rate:
Renal Rupture (Rare), Hematoma (common but Severe ones <1%)
Transient Hematuria/Dysuria/Renal colic may occur post-op too
(Stein Strasse: Stone Street; Stone fragments lining up in Ureter causing obstruction)

Ureteroscopy (UreteroRenoScopic Lithotripsy URSL):
Good for Stones of 1-2 cm, lodged in Lower Calyx or below
<5 mm: Retrieved by Basket
Tightly impacted stones/>5 mm:
Fragmented by Endoscopic Direct-contact Fragmentation device
(Usually Laser; Others like Pneumatic drill, etc)
(or Manipulated proximally for ESWL)
JJ Stent may be placed after Ureteroscopy
Better Fragmentation than ESWL: Can deal with Cystine stone, Hard stone
But needs Anesthesia, mildly Higher Cx rate, eg. Perforation/Avulsion, UTI, Ureteric Stricture
Flexible URSL: Aka Retrograde IntraRenal Surgery (RIRS)
Can tackle Renal Stones (usually utilize Laser to melt stones into powder)
May be the last resort if PCNL contraindicated
Pros: Minimally Invasive, Direct Fragmentation of stone, Body habitus independent,
Can be used in Pt with Bleeding tendency
Cons: Requires Anesthesia & Radiation, Technology driven (Expensive & Delicate),
(Time consuming (Multiple sessions needed) for Large stones)
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Percutaneous NephroLithotomy (PCNL):
Reserved for Large/Complex stones or Failure of above 2 modalities
Good for Stones >2 cm
(Use Lithoclast, a Pneumatic device to crush the Stones like , then retrieved)
(Not to the extent of very Small fragments, otherwise will dislodge to Ureter)
Sandwich therapy: May combine with ESWL for Complex stones (eg. Staghorn)
More Invasive, Higher Cx rate (Beware of Bowel Perforation)
(Not good for Pt with Poor Lung Function as its done in Prone positioning
Experienced urologists may be able to do in Supine positioning)
Pros: Stone free rates least limited by Caliceal Anatomy
Direct Stone Fragmentation: Stone Composition Not a concern
Cons: Requires Anesthesia (in most centres)
Bleeding Tendency Contraindicated
Body Habitus may be a hindrance
Open/Laparoscopic Surgery:
Rarely done nowadays
Kidney: Pyelolithotomy, Anatrophic Nephrolithotomy
Ureter: UreteroLithotomy
NB: Nephrectomy may be considered if Non-Functional Kidney
LT Prevention (esp for Recurrent Stones)
General: Avoid Intensive Sweating (Dehydration)
Avoid Exposure to Intensive Sunlight (Skin produce more Vit D)
Do more Exercise
Diet (Long term Compliance is important):
Fluid intake
Drink More than you think is enough: 2500-3000 ml/day, Urine output >2000 ml/day
Water is the Best fluid; Tea, Cola drinks should be avoided
Low-Ca & Low-Oxalate diet (eg. Diary products?)
Low-Ca diet only actually Urinary Oxalate Excretion if No Oxalate Restriction
Na Restriction (Low Salt intake)
Low-Animal Protein (Purine, Acid)
Citrus Fruit intake (Citrate help Stone Recurrence)
Others: Low-Carbohydrate, High-Fiber, etc
Drugs: Alkalinizing agents, Ca binder, Diuretics, Ca supplement, Allopurinol, Urease inhibitor
Bladder Stone: Stone Removal: Cystolitholapaxy (Stone Crushing)
Not ESWL (Stone will be knocked around)
Regular Cystoscopy FU may also help detect Cx SCC
Staghorn Stone:
Definition: Stone fragment filling Renal pelvis and extending to Renal calyces
Classification:
Borderline: Filling Pelvis & 1 Calyx
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Partial: Filling 2 Calyces & Renal Pelvis
Complete: Filling entire Renal calyceal system (80% of RCS)
Volume determination with CT reconstruction
Composition: Struvite, Cystine, Ca oxalate monohydrate, Uric acid
Prognosis: 10-year Mortality: Untreated 28%, Treated 7.2%
Renal Failure: 36% in 177 Pt treated conservatively
RF: Solitary Kidney, Hx of previous Stone disease, Urinary diversion,
Neurogenic Bladder
Renal-related death: With Stone clearance: 0%
Without Stone clearance: 3%
Refuse Tx: 67%
Untreated Struvite Staghorn stone eventually destroy the kidney
Mx: Classification
Selection Criteria:
Stone Size: 3 cm
Localization: Branched Calculus
Anatomy: Calyceal Neck Stenosis
Radiodensity
Indications:
ESWL monotherapy:
Minor Stone burden, Peripheral Stone load, Narrow Collecting system,
Difficult PCNL (Urinary diversion, Children, etc)
PCNL monotherapy:
Major Stone burden, Central Stone load, Enlarged Collecting system,
Difficult ESWL (Radiolucent, Cystine, etc)
Summary:
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Extra:
IVU: Maidens Waist deformity: Medialization of Ureters, signifying Retroperitoneal Fibrosis

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Urology Urinary Retention
LUT: M: UB, Prostate, Urethra
F: UB, Urethra
Components:
Bladder: Detrusor, Trigone
Urinary Sphincter Mechanism:
Proximal Sphincter Mechanism: Bladder Neck
Distal Sphincter Mechanism:
Urethral Smooth muscle: Tonically Active; Relax in response to Nitric Oxide
Intrinsic RhabdoSphincter: Most Important; Horseshoe look(Muscles dominant Anteriorly)
PeriUrethral musculature: PeriUrethral component of Levator ani/PuboUrethral Sling
Relatively Insignificant in F due to Vagina
Activated along with Rest of Levator ani in Stress condition
> Augment Urethral Occlusion Pressure
(In the old days used Internal & External sphincter; Now use Bladder Neck & Rhabdosphincter)
Normal Voiding Function:
Storage & Periodic Elimination of Urine is dependent upon activity of 2 functional unit in LUT:
Reservoir, Outlet
Storage: Accommodation of Urine at Low Pressure and with appropriate Sensation
Bladder Outlet remain Closed at Rest & during Intra-abd Pressure
No Involuntary Bladder Contraction
Emptying: Coordinated Contraction of Bladder Smooth muscle of adequate Magnitude & Duration
Lowering of Resistance at the level of Smooth & Striated Sphincter
Absence of Anatomic Obstruction
Neural Control of LUT:
Coordinated act with Spinal Reflexes & Higher centre control
Brain: Cerebral cortex (Somatic control)
Tonically Inhibitory signals from Frontal lobe to PMC
Prevent Bladder Emptying until a Socially acceptable time & place
Urge to Urinate
Excitatory signals to PMC when Urination is appropriate
Pontine Micturition Centre PMC (Autonomic control)
Coordinate activities of Urinary Sphincter & Bladder to work in Synergy
Excitatory (Facilitate Voiding): Sphincter Relaxation & Detrusor Contraction
Modulated by Excitatory/Inhibitory influence from Brain
Can be affected by Emotion (Incontinence when Excited/Scared)
Usually Brain will take control over PMC at 3-4 yo (Toilet training for Children)
(Before Brain take control, PMC is influenced by Primitive Voiding Centre)
SC: Intermediary between Pons & Sacral SC
Sacral Reflex Centre: Primitive Voiding Centre at Sacral SC
Involuntary Detrusor Contraction with Coordinated Voiding when Excited
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> Continuous cycle of Bladder Filling & Emptying in Infants/Young
Voiding control eventually dominated by Brain (Voluntary Continence)
PNS: Sympathetic: Lumbar level (T10-L2)
(Hypogastric) Inhibit Bladder, Excite Bladder Base & Urethra
Parasympathetic: Sacral level (S2-S4)
(Pelvic) Excite Bladder & Relax Urethra
Somatic: Pudendal Nerve (S2-S4)
(Important) Excite External Sphincter (& Pelvic floor muscles)
Motivation to Void: Bladder Sensation: Unpleasantness & Anxiety of Extreme Bladder Filling
1st Sensation of Filling: Bladder Capacity 40%
Sensation is Indistinct, Easily Disregarded
st
1 Desire to Void: Bladder Capacity 60%
Feeling that lead to pass urine in next convenient moment,
But can Delay if necessary
Strong Desire to Void: Bladder Capacity 90%
Persistent desire to void without Fear of Leakage
Perception of Bladder Fullness modified by Psychological state of mind
in Anxiety, with Distraction
Reflex pathway:
Guarding Reflex (Storage):
Afferent: Low-level Vesical Afferent activity (Pelvic Nerve)
Efferent: External Sphincter Contraction (Somatic nerves)
Internal Sphincter Contraction (Sympathetic nerves)
Detrusor Inhibition (Sympathetic nerves)
Sacral Parasympathetic Outflow Inactive
Central: Spinal Reflexes
Voiding Reflex (Emptying):
Afferent: High-level Vesical Afferent activity (Pelvic Nerve)
Efferent: Inhibition of External Sphincter activity
Inhibition of Sympathetic outflow
Activation of Parasympathetic outflow to Bladder
Activation of Parasympathetic outflow to Urethra
Central: SpinoBulboSpinal Reflex
Retention of Urine: NOT Anuria/Oliguria
No Urine Production:
Pre-Renal Cause: Dehydration, Shock
Renal Cause: ARF
Post-Renal: Obstructive Uropathy
Type: Acute (AROU): Sudden Onset, Painful
Chronic (CROU): Usually Painless, Vague Lower Abd Distention
AoC (Esp if Painful Retention with High First Catheterization urine volume)
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AROU:
Causes:
Obstruction:
Extrinsic: M: Prostatic Enlargement: *BPH, Prostate CA, Prostatitis (also Painful to urinate)
F: Pelvic Organ Prolapse: Also note Hx of Surgery for Stress Incontinence (eg. TVT/Sling)
Fecal Impaction
Pelvic Mass (Gyne Mass, Retroverted Gravid Uterus), GI/Retroperitoneal Mass
Intramural:
Tumor: Bladder Neck
UTI (Can lead to Edema, STD can cause Stricture, also too painful to urinate too)
Stenosis: Bladder Neck Stenosis (Can be Iatrogenic after Previous Prostate Surgery),
Urethral Stricture (Iatrogenic or Infection/Inflammation)
Phimosis/Paraphimosis
Intraluminal:
Stone
Clot Retention (Severe Gross Hematuria; Bladder CA can cause AROU even Not at Bladder Neck)
Foreign body
(Lecturer: Cause of SupraVesical Obstruction:
Pelvic Tumor obstructing both Ureters, Bilateral Ureteral Stone, Bilateral Ureteral Tumor)
Neurological: Detrusor HypoContractility: (Detrusor problem)
Peripheral Nerve lesions:
DM (Diabetic Cystopathy), Cauda equina syndrome, Vaginal childbirth, Pelvic injury,
Nerve damage or Anesthesia related in Pelvic/Lower Abdominal Surgery
Detrusor Sphincter Dyssynergia: (Sphincter problem)
SC lesions: Trauma, Infection, Transverse Myelitis, Stroke, MS
(Note: Must rule out Cord Compression presenting as AROU)
Drugs
Others: Fowlers syndrome (Urethral Sphincter dysfunction)
Precipitating Factor: Underlying Pathology
Precipitated by:
Drugs: AntiCholinergics (eg. Cough Suppressants)
-Adrenergic (eg. Nasal Decongestant)
(Others: AntiHistamines, AntiDepressants, Alcohol)
Too Painful to Urinate:
Painful PeriAnal conditions (eg. Thrombosed Hemorrhoid, PeriAnal Abscess),
UTI, Fecal Impaction
Hx taking: Confirm Urinary Retention: Check First Catheterized Urine Volume
(Usually need to be at least 400-500ml; If >1L, suspect CROU)
Painful vs Painless Retention of Urine (Acute vs Chronic)
First episode or Recurrent episodes
Previous Urinary Sx: LUTS, UTI Sx, Hematuria (Tumor, Stone, Clot), Renal Colic
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Associated Sx:
BO status (Fecal Impaction, Painful Perianal conditions)
Neurological: LL Weakness/Numbness, Overflow Incontinence/Fecal Incontinence,
PeriAnal Numbness (Cauda equina syndrome)
Constitutional Sx/Bone Pain (Metastatic Prostate Cancer, Bladder Cancer)
Medication:
BPH Medication: Eg. -Blockers, 5-reductase Inhibitors
AntiCholinergics
Previous Hx of Prostate Surgery (eg. TURP) or Urethral Instrumentation
Hx of STD esp Gonococcal/Non-Gonococcal Urethritis
Hx of CVA/Parkinsonism/Spinal Surgery/DM (Neurogenic Bladder)
PE: Vital Signs & GE: Septic? Uremic?
Palpable UB (If Not yet Catheterized)
Swelling below Umbilicus: *Distended UB, Pregnancy, Pelvic Tumor
If Distended UB, will Disappear after Catheterization
(If Distended UB up to Umbilicus, may have CROU background)
Urethral Catheter: Any Gross Hematuria
Any Hydronephrosis
Any Hernia (Cx from Urinary Retention)
Any Phimosis
DRE: Anal Tone (Cord Compression or Cauda equina) & PeriAnal Sensation
Prostate Estimated Size
Does Not correlate with Sx Severity, Urodynamic obstruction & Tx outcome
Magnitude of UnderEstimation with ing Prostate Size from 25% to 50% or more
Intravesical Extension Not measurable
Best Size Assessment TransRectal US Prostate:
Volume assessment by assuming ellipse: T x AP x L x /6 cm3
(Volume can affect Tx options in BPH
If too Large, Simple Prostatectomy/Enucleation rather than TURP)
Any Clinical features of Suspicious Prostate CA (5 features)
Prostate Tenderness (Prostatitis)
Fecal Impaction
Any Painful PeriAnal conditions
LL Neurological deficit
Ix: Blood: CBC: WBC count
RFT: Serum Creatinine
Electrolyte status, esp HypoNa
Urinary Retention> Na Loss in Urine, while Volume Retention
Dont check PSA in AROU
PSA in AROU; PSA Half-life 2-5 days> Need to repeat test 1 month later
(Even suspect Prostatic CA, No hurry to check; Deal with AROU first)
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Urine: MSU: WBC, RBC, Culture
Imaging: KUB X-ray: Bladder stone, Urethral stone
Osteosclerotic Bone lesions if Prostate CA
US: Bilateral Hydronephrosis
Uroflowmetry: Not sufficient to diagnose Outlet Obstruction
Can Not distinguish Obstruction from Poor Detrusor Contractility
Voided Volume >150ml (Valid study)
Max Flow rate (Qmax): >20ml/s: Normal (for M)
<10ml/s: Abnormal
Residual Urine >100ml: Clinically significant
Normal vs Abnormal
Urodynamic study: Study Function of LUT
Usually Uroflowmetry + Cystometry + Video-Urodynamic studies for obstruction
Components: Uroflowmetry
Cystometry: IntraVesical P, Rectal P (Abd P), Detrusor P (deduced)
Post-void Residual volume
Leak Point Pressure
Pressure Flow study
Urethral Pressure Profilometry
Sphincter EMG (almost never done in Public hospitals)
Video-Urodynamic studies

Dx of Obstructed Voiding: Low Uroflow rate with High Detrusor Pressure
Page 453
(ie. Need both Uroflowmetry & Cystometry)

Tx: (MK Yiu: Very Early on, Warm Water Bath may help a bit if impending AROU)
Bladder Emptying:
Prompt Bladder Decompression:
Urethral Catheterization:
3 Types of Foley Catheter:
Straight tip catheter: Ordinary type
Coude tip catheter: Can pass through Enlarged Prostate easier
3-way catheter: 3rd channel for Irrigation, eg. after surgery to wash away blood/clot

(Lumen: Central for Output; Side with Marking for Balloon, No Marking for Input)
Solution to inflate Balloon:
Use Pure Water
Dont use Normal Saline May crystalize> Cant deflate balloon
(If accidentally used Saline, may cut Foley & Use Guidewire to take out crystals)
(If unsuccessful, Puncture Balloon with Guidewire)
(If still Not successful, use Suprapubic Needle Puncture to puncture balloon)
If canNot pass into bladder:
Use Bigger gauge catheter for Enlarged Prostate (Stiffer, so Easier to pass through)
Use Smaller gauge catheter for Urethral Stricture
False Urethral Passage (False Tract):
If push too hard during Insertion, may lead to Urethral injury (False tract) (esp in Stricture)

Coude tip Foley may be used (12 oclock position, so avoid False tract at 6 oclock position)
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Failed Foley Insertion:
Suprapubic Catheterization (US guidance)
(MK Yiu: Puncture at 2 finger breadths above Pubic Symphysis, pointing Downward
If just above Pubis, may hit Prostate/Most Vascular part of Bladder Neck)
Other: Foley guide
Flexible Cystoscopy Urethral dilatation
IO chart (Intake & Output chart) to monitor for Cx:
Post-obstructive Diuresis: Urine output >200ml/h
Theories behind:
Excretion of Fluid solutes such as Na, Urea retained during Retention status
Persistence of Tubular concentrating defect
prevents maintenance of Medullary interstitial solute gradient
Poor Responsiveness of Collecting duct to ADH
Accumulation of Natriuretic substances such as ANP, Urea
Over-aggressive replacement for fluid output
(Fluid Replacement (Pt may have HypoNa Dehydration), Monitor Hematuria (common after AROU))
Trial without Catheter (TWOC):
Take off Catheter
Timing for TWOC: At least 2 days
May give -blocker in Men
55% with SR alfuzosin voided spontaneously after Foley removal, vs 29% in placebo groups
Failed:
LT Catheterization
Clean Intermittent (Self-) Catheterization (CISC if smart Pt, or by others if good family support)
TURP if due to BPH
Treat underlying Cause:
Reversible Causes: Stop precipitating drugs, Relieve Constipation, Antibiotics for UTI, etc
Strangury: Sx of Painful Frequent Urination of Small volume,
that are Expelled Slowly only by Straining & despite sense of Urgency,
usually with Residual feeling of Incomplete Emptying, and few drops of blood at the end
Neurogenic Cause of Voiding Dysfunction:
Brain: Atherosclerosis, CVA, Parkinson, MS, Cerebral Palsy, Trauma/Tumor/Infection, Dementia
SC: Trauma, Tumor, Vertebral Disc disease, Transverse Myelitis, MS, Congenital (eg. Bifida)
Bladder: DM, Alcoholism
In Short: Spinal Shock, Cauda equina syndrome, Detrusor Sphincter DysSynergia,
Acontractile Bladder (Detrusor UnderActivity): Disc Compression
Surgical damage (eg. Anterior Resection)
Autonomic Neuropathy (DM, Alcoholism)
Post-op Urinary Retention:
4-25%
More common after LUT, Perineal, Gynecological, Anorectal Surgery
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Contributing factors: Traumatic Instrumentation: Outlet Resistance
Bladder OverDistention: Impaired Bladder Sensation, Bladder Contractility
Nociceptive Inhibitory Reflex
Pre-existing Outlet Obstruction
Fowler syndrome: Young Women in their 30s
Urinary Retention without overt Neurological disease
Presented with Lower Abd Distention
Painless Retention of Urine
Dx: Bladder volume >1L with No Sensation of Bladder Distention
? Due to Sphincter dysfunction
Neurogenic Bladder:
SupraPontine Brain lesion:
Loss of Voiding control while Primitive Voiding Reflex is Intact
Cause: Stroke, Tumor, PD, Hydrocephalus,
Shy-Drager syndrome (a type of Multiple System Atrophy; Wide-open Bladder Neck)
Clinical: Spastic Bladder (Detrusor Hyperreflexia/Overactivity) (No Inhibition from Brain)
> Urge Incontinence with Normal Sphincter function (In Synergy)
(Note: If Afferent in Brain damaged, No sensation of Urgency felt but only Incontinence)
InfraPontine SupraSacral SC lesion (LMNL):
Spinal Shock initially> Spasticity after several weeks
Clinical: Irritative Sx, even Urge Incontinence (No Inhibition from Brain)
May have Paradoxical Contractions of External Sphincter (No Coordinated control from PMC)
ie. DSD Detrusor Sphincter DysSynergia (Can lead to Paradoxical Urinary Retention)
Bladder Pressure> Can cause Ureteric Reflux!
Note: If above T6, may have Autonomic Dysreflexia (Loss of Inhibition on Splanchnic bed T5-T8)
Sacral Cord/Peripheral nerve lesion:
Bladder: Areflexia, Tone (Compliance) with time
Sphincter: External Sphincter still retain some Fixed Tone though Not under Voluntary control
Bladder Neck often Competent (Intact Sympathetic) but Non-relaxing
Clinical: Urinary Retention, Overflow Incontinence
If Sensory Neurogenic Bladder: No Sense of Fullness
If Motor Neurogenic Bladder: Detrusor Areflexia
Autonomic Dysreflexia:
Develops if SCI above T6 level
Pathophysi: Strong Sensory input carried into SC via intact Peripheral nerves (Usually Bladder/Bowel)
Evokes Massive Reflex Sympathetic surge from Thoracolumbar Sympathetic nerves
Widespread Vasoconstriction esp over Splanchnic vasculature> Peripheral Arterial HT
Brain detects it via Baroreceptors in Neck
Brain actions: Send down Descending Inhibitory impulses (but cant pass through SCI at T6)
HR via intact Vagus N, but compensatory Bradycardia Not enough against HT
Results: Sympathetic prevails below level of injury: Eg. HT, Sweating
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Parasympathetic prevails above level of injury: Eg. Bradycardia, Flushing of UL

Page 457
Urology BPH
Benign Prostatic Hyperplasia:
Etymology: LUTS: Sx; Note Prostatism is Not an appropriate term to use
BPE: Enlargement; Detected on DRE
BPO: Obstruction; Functional term; Detected by Urodynamic studies
BPH: Hyperplasia; Need Histological Dx (By Pathologists)
Relationship: LUTS occur in 50-75% Men with BPO
At least 1/3 Men with LUTS do Not have BPO
Epidemiology: MK Yiu: BPH: Start at 3rd decade
LUTS: Takes 2-3 more decades to manifest
Pt concern (in order): Fear of Cancer!, Disruption of Sleep, Discomfort, Embarrassment
Cause: Genetics: Familial inheritance, esp Large Prostate present at Young
Aging! (LUTS in both sex with Age)
Androgen! & other Growth factors
Diet, Obesity & BMI are strong determinant of Disease Severity
Pathology:
Histology: Hyperplastic process in Transitional zone (Proliferation of Stromal + Epithelial components)
Stromal component:
Smooth muscle & Collagen (Prostatic & Bladder base Smooth muscle)
Functional Obstruction (Dynamic) (Intermittent Sx)
Affected by Blocker
Smooth muscle tone controlled by Sympathetics (1 adrenoceptors)
1 Blocker: Relaxation of Smooth muscles> Pressure on Bladder Neck & Urethra
1 receptor subtypes: 1A: Involved in contraction of Prostate gland/urethra
1B: Asso. with Vasoconstriction
1D: Have Not yet been identified exactly

Epithelial component:
Anatomical Obstruction (Static)
Affected by 5-reductase Inhibitor
DHT (Dihydrotestosterone):
Active Metabolite of Testosterone by 5-reductase, Major stimulus in BPH
(Age-related in Estrogen may contribute to BPH by ing DHT receptor expression)
Gross Appearance:
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A: Isolated Middle lobe Enlargement
B: Isolated Lateral lobe Enlargement
C: Lateral & Middle lobe Enlargement
D: Posterior Commissural Hyperplasia (Median Bar) (Small Prostate on DRE)
Bladder outlet obstruction> Detrusor overactivity:
Morphological changes:
Detrusor wall thickening, Collagen content, Hypertrophy of Neurons,
& Alteration of Adrenoceptors, Abnormal Intracellular connections
Functional changes:
Ischemia, Partial denervation, Reorganization of Spinal Micturition Reflex, NT imbalance,
Supersensitivity of Muscarinic receptors to ACh,
Changes in Electrical properties of Detrusor Smooth muscle cells
Presentation:
AROU: Male AROU >90% due to BPH
LUTS: Voiding Sx (Old term: Obstructive), Storage Sx (Old term: Irritative)
Sx List: (NB: If Pt is Storage Sx predominant with little Voiding Sx, be more vigilant of other causes)
Storage Sx: Bladder Instability secondary to obstruction
Frequency, Urgency, Urgency Incontinence, Nocturia (MK Yiu: 2/night)
Voiding Sx: Obstruction
Hesitancy, Weak stream, Intermittency/Splitting/Spraying, Straining/Slow stream,
(Lower Abd Distention)
Post-micturition:
Terminal Dribbling (Counselling: to urinate, Compress Perineum, Urethral milking),
(Sense of) Incomplete Emptying
Assessed by IPSS score (International Prostate Sx Score; 7 Sx + QOL assessment): (2010 SAQ 2)
Storage: Frequency, Urgency, Nocturia
Voiding: Straining, Weak Stream, Intermittency, Sense of Incomplete Emptying
Score: Mild (0-7), Moderate (8-19), Severe (20-35); Each Sx/QOL is 0-5 score
(Subjective; No strong correlation with Uroflowmetry measurements)
Ddx of LUTS:
Bladder outlet obstruction/dysfunction
Detrusor dysfunction, Neurological condition
Overactive Bladder syndrome (OAB)
Medical illness: DM, CHF, etc
Bladder disease: Stone, Cancer, Interstitial Cystitis, Ketamine Cystitis
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Inflammatory: UTI/Prostatitis/STD, etc
Polydipsia
Sensory Urgency syndrome
Pelvic Mass, Urethral disease, etc
(NB: If Elderly Pt with Nocturia only, also think Nocturnal Polyuria due to ADH in Elderly)
Other Cx: Gross Hematuria, UTI (Fever/Dysuria), Renal impairment (Uremic Sx),
Bladder/Urethral Stone (Strangury)
Consequence of obstruction:
Retention of Urine (Acute/Chronic), Recurrent UTI, Formation of Bladder Stone (Urinary Stasis),
HydroUreter & HydroNephrosis, Renal impairment, (Overflow Incontinence), (Hernia)

PE: Misc: GE & Abd Exam: Rule out distended bladder
Inspect Urethra: Rule out obvious Stenosis
Neuro Exam: Anal tone & Focused Neurologic exam may be considered
DRE: Feel for: Size, Median sulcus, Asymmetry/Irregularity, Nodularity, Abnormal Firmness
Features: Smooth Enlarged, Median sulcus present, Rubbery, Non-Tender, Mobile Mucosa
Size Estimation:
Small: 10-30 cc Normal No more than 1 Finger width either side of midline
Medium: 30-50 cc 1+ 1-2 Finger widths either side of midline
Large: 50-70 cc 2+ 2 Finger widths either side of midline
Very Large: 70-90 cc 3+ 2-3 Finger widths either side of midline
>90 cc 4+ 3+ Finger widths either side of midline
Ix: Urine test
Blood test: RFT, PSA (2010 SAQ 2)
Flow rate & Residual urine
Further Ix: US upper urinary tract, US prostate
Urinalysis: Required to rule out Dx other than BPH which may cause LUTS
PPV for Cancer or other Urologic Dx: 4-26%
Presence of Bacteria/Pus cells: Further Ix/Urologic assessment
Presence of Blood (Microscopic Hematuria): Cytology, Cystoscopy, Upper tract imaging
Urine for Cytology (option needed for predominant Irritative Sx, esp Chronic Smoking)
(Others: Glucose for any DM (can cause Polyuria), Protein for any Proteinuria)
PSA: in 25% Pt with BPH
Tend to progressively with Age & Prostatic volume
Role in LUTS:
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Predict prostate volume (Baseline value also predicts future prostate growth)
Predict risk for BPH progression
Chart the therapeutic course for BPH
Rule out Prostate Cancer
Guide who should be referred
Markers of Risk of BPH progression:
Enlarged Prostate Size (>30 cc)
PSA (as a surrogate for Prostate Size) 1.5 ng/ml
Age >50 years
Moderate IPSS Sx (>8)
Flow rate study: Optional test
Not necessary prior to institution of Watchful waiting/Medical therapy
Helpful in Pt with complex Medical Hx and in those requiring Invasive Tx
Should have >150 ml urine passed
Residual urine <50 ml in Normal cases
NB: Men with Qmax <10 ml/s more likely to benefit from Surgery (Obstruction)
Poor flow canNot distinguish between Detrusor Failure vs BOO
Normal flow rates but significant Urinary Sx More likely to have Non Prostatic cause
Require more extensive Ix
US: Indication: Kidney: If 1 S/S, or Hx of Upper UTI, Hematuria, Stone disease, Renal impairment
Prostate: If Tx success depends on Anatomical character of prostate
Tx: Goal: Treat bothersome Sx
Identify Risk of Progression & Prevent Cx
Improve health-related QOL
Identify Pt who need to be referred to a Urologist
Guideline Recommendations:
Initial Mx: AUA recommended Standard (to be managed by Watchful Waiting):
Mild Sx of BPH (IPSS Score 7)
Moderate/Severe Sx Score 8, Not bothered by their Sx
Tx options for Bothersome Moderate/Severe Sx of BPH:
Watchful waiting, Medical Tx, Minimal Invasive Tx, Surgical Tx
Watchful waiting: Education & Reassurance
Avoid Decongestants, other Drugs
Lifestyle changes: (Aim to relieve Urinary Sx, rather than Direct effect on Prostate)
Avoid bladder irritants (eg. Caffeine, Alcohol)
Cut back on Evening fluids
Avoid/Treat Constipation
Smoking cessation
Others: Bladder Retraining (eg. Timed voiding), Pelvic Floor Exercises, etc
Not Recommended in Guideline but may be tried?:
Over-the-counter Phytotherapy
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Medical Tx: EAU guideline 2011:
-blocker: 1st line Tx of male LUTS; Offered to Men with Moderate-Severe LUTS
5ARI: Men with Moderate-Severe LUTS + Enlarged Prostate
Can prevent Disease progression & Need for Surgery
Only suitable for LT Tx
AntiMuscarinic: Considered in Men with Moderate-Severe LUTS with mainly Storage Sx
Combination:
-blocker + 5ARI:
Men with Moderate-Severe LUTS + Enlarged Prostate + Qmax
Not recommended for ST therapy <1 year
-blocker + AntiMuscarinic:
Considered in Moderate-Severe LUTS if Sx relief insufficient in either alone
1 Blocker: Block 1 receptors in Prostatic & Urethral smooth muscle> Relax> Improve Urine flow
Similar Efficacy: About 70% Pt have Improvement in Sx
Cf TURP: 90% Pt Improvement in Sx, 80% have Improvement in Flow rate
Different S/E profiles
Use: Pros: Rapidly improve Sx & Urinary flow
Fast Onset, Max effect in 2-4 weeks
60-80% have Improvement:
Major Sx Improvement 34-42%, (Placebo effect 11-20%)
Modest Improvement in Flow rate (2.2-4.8 ml/s)
Cons: Do Not Prostate Size or affect PSA
Do Not overall LT risk of Urinary retention or Need for Surgery
Acceptable option for Pt with Moderate/Severe LUTS & Small prostates
Failure rate may in Men with Medium-Large prostates (overall 5-yr failure rate 15-40%)
Drugs:
Non-Selective:
PhenoxyBenzamine (Obsolete now): 10 mg bid
Block both 1 & 2 adrenoceptors
Severe S/E: Eg. Dizziness, Weakness, Palpitation
Selective 1: (Nowadays Terazosin more preferred as its once daily; Prazosin good if also HT)
Short acting: Short Half life (Prazosin: 2.5h): 2-3x daily
Prazosin (Minipress) 2 mg bid, IR Alfuzosin (Xatral) 2.5 mg tid, Indoramin 20 mg bid
Long acting: Longer Half life (Terazosin 12h, Doxazosin 16h): Once daily
Terazosin (Hytrin) 5 or 10 mg qd, Doxazosin (Cardura) 4 or 8 mg qd, Alfuzosin SR 10 mg qd
Uroselective/Subtype selective 1:
UroSelectivity 1 subtype: BPH tissue: -1A 85%, 1D-14%
Detrusor: -1D
Selectivity for 1 subtypes (1A, 1D) in Prostate:
Tamsulosin (Harnal) 0.4 mg qd, Silodosin 8 mg qd
S/E: Less Systemic S/E like Postural Hypotension
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But prone to Retrograde Ejaculation
Tamsulosin: 0.4 mg/day: 8.4% 0.8 mg/day: 18.1%
Common S/E: Usually well tolerated
Dizziness 10-19% (direct action on Brain), Syncope 0-1%
Postural Hypotension 5-11%
Asthenia 10%, Nasal congestion 5%, Headache 5-10%
Retrograde Ejaculation (esp Tamsulosin, 3-10%)
Erectile dysfunction (Actually may cause or improve ED!)
Dose Titration & 1st dose effect (S/E in First few days)
5ARI: Inhibition of 5-reductase> Conversion of Testosterone to DHT
Intraprostatic DHT> Prostate Size
Slow Onset: Take 3-6 months for Maximal effect (Tell Pt to expect Slow onset of effect)
Improvements generally seen after ~6 months & Continue to build beyond 2 years of therapy
(NB: Usually as 2nd line therapy; Effective in those with Large Prostate, High PSA, Hematuria)
Drugs: Finasteride (Proscar): 5 mg daily; Inhibit type 2 5ARI
Dutasteride (Avodart): 0.5 mg daily; Inhibit both type 1 & 2 (Shrink more)
Efficacy: Sx (30% from Baseline)
Only seen in Men with Large Prostate >40 g (Thus often as 2nd line)
Prostate Size 20-30% for Prostate >35-40 g
Improve Urinary stream
Risk of AROU & Surgery (>50%)
Others: BPH-related Hematuria
??Peri-op Bleeding after TURP (Vascularity)
S/E: Usually Well tolerated
Erectile Dysfunction, Libido, Ejaculate volume, (Gynecomastia)
Serum PSA level by 50% (Complicating Cancer Detection> Need to adjust Cutoff)
EPIC study comparing Finasteride & Dutasteride:
Impotence Libido Ejaculation Gynecomastia Headache Dizziness Malaise,
disorders Fatigue
Dutasteride 55 (7%) 39 (5%) 10 (1%) 9 (1%) 11 (1%) 6 (<1%) 12 (1%)
(n=813)
Finasteride 69 (8%) 46 (6%) 12 (1%) 9 (1%) 9 (1%) 11 (1%) 12 (1%)
(n=817)
2 Drugs Comparison:
Finasteride: Serum DHT by 70%
Dutasteride: Serum DHT by 90%
Similar S/E; Also PSA Reduction by 50%
Dutasteride achieve Greater & More Rapid DHT Suppression
No well-controlled comparison between 2 drugs; True benefits over Finasteride Unknown
Combination therapy: Efficacy, S/E also a bit
Finasteride MTOPS study (Medical Therapy Of Prostate Sx):
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BPH Progression: Doxazocin 39%, Finasteride 34%, Combination 67%
Combination therapy is Superior in Sx & Improve Stream, & Risk of AROU/Surgery
Combination therapy particularly Effective in Pt with Large Prostate
Dutasteride CombAT study (Combination of Avodart & Tamsulosin):
Men at risk of progression randomized to Tamsulosin, Dutasteride, Combination
1st time in a trial that 5ARI monotherapy shows improvement over -blocker monotherapy
at 15-month time point
Benefit Profile:
-blockers: Improve Sx/Flow, Onset of Sx relief in 1-2 weeks,
Maintain Sx/Flow improvements
5ARI: Improve Sx/Flow, Maintain Sx/Flow improvements, Prevent Sx progression,
PV, Maintain in PV, LT Risk of AROU & Surgery
Combination: All (just like adding Onset of Sx relief in 1-2 weeks to 5ARI)
Suggested Approach:
Start -blocker for immediate relief:
FU in 1-3 months, Important to monitor for:
Conservative measures, Compliance, S/E & Efficacy (Sx, Bother)
Consider adding 5ARI or start with Combination therapy for LT benefit:
Measure Baseline PSA
FU in 6-9 months: Monitor as above, repeat PSA
Also acceptable to: Start 5ARI monotherapy if Pt is ok waiting Longer for Sx improvement
Start Both drugs together
Other Tx for LUTS:
AntiMuscarinic:
Can be safely given to carefully selected Men with OAB/Storage Sx & BPH
Combination of AntiMuscarinic agents & -blocker may improve Storage & Voiding Sx
Avoid treating Men with Large PVR urine volumes (200 mL) (Panel consensus: >250-300 mL)
PDEI: Good Level 1 evidence from 4 clinical trials clearly showing improvement of LUTS
Tadanafil is recently FDA approved
Improve Urinary Sx scores, but Do Not improve Flow rates
Combination of blockers & PDEI: May have Synergistic effect improving LUTS
But may lead to Symptomatic Hypotension
Therapy for Men with both ED & LUTS
Surgery: Referral to Urologist:
Indications for Surgery in Pt with Cx:
AROU/CROU: Note that for AROU, its reasonable to first start -blocker,
then Trial of voiding without catheter 48h later
Hematuria, Infection, Bladder Stone
Upper tract obstruction Renal Insufficiency (Absolute indication; PP MCQ repeatedly)
*Failure of optimal Medical therapy/Inability to tolerate:
Driven by Pt perception, satisfaction, risk of progression
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Efficacy: -blockers should show Efficacy within ~1 month (may vary with dose titration)
5ARI should show Efficacy within ~6 months
Cancer concern:
Baseline PSA or Abnormal DRE
Consistently ing PSA
TURP: Classical Still Gold standard for comparison with other Alternatives
Relieve Bladder Outlet Obstruction by Removal of Prostate tissues obstructing Prostatic Urethra
Improve LUTS in 90% Pt
Area: Proximally to Bladder Neck (thus always Retrograde Ejaculation)
Distally to before Verumontanum (Ridge near Ejaculatory duct entrance)
Do Not cut beyond Verumontanum: Will damage RhabdoSphincter
Indication: Recurrent AROU/Recurrent UTI/Recurrent Hematuria from Prostate
Bladder Stone
Obstructive Uropathy (Renal Impairment)
Failed Medical therapy/Pt cannot tolerate Drug Tx for LUTS
(Large Bladder Diverticulum: Not indicated for TURP specifically but indicated for Surgery)
(Procedure in UCH:
Cystoscopy for visualization, Fluid for distension
Diathermy like a Half-Loop to slice out pieces of tissues till Surgical Capsule seen
Flush out tissues from bladder (Dislodged from Prostate during cutting into Bladder)
Weigh & Send for Histology
Must flush out all tissues/clots, otherwise will block Foley later
Hemostasis (If perforate, Venous bleeding can usually be stopped by Foley traction)
3-way Foley insertion (Irrigation to prevent Clot formation)
Rmb to release prepuce after Foley insertion, to avoid Paraphimosis
Foley for 1-2 weeks after surgery helps prevent Urethral Stricture formation)
Cx: Peri-op:
Aesthetic Cx
Perforation: (Perforation of Prostate Capsule can lead to Bleeding difficult to control)
(Can injure adjacent organs peri-op, Can form Fistula post-op)
Bleeding: Post-op Transfusion is Rare
UTI/Sepsis: Esp for Pt on Prolonged Catheter Drainage
TUR syndrome: Rare (QM: 0.1%; Papers: <1%); (Can be Life Threatening)
Spinal Anesthesia instead of GA may help evaluate Pt Intra-op condition
3 Components:
Fluid overload (Need Lasix)
Dilutional HypoNa (HypoOsmolar Irrigation fluid)
Glycine Toxicity (and HyperAmmonemia, as Glycine metabolized to Ammonia):
Cant use Saline, coz Ionic solution will make Monopolar Non-functional
Cut-off of Glycine fluid use in UCH: 10 bags, 2L/bag
S/E: Retinal Toxicity (Early), Cardiac Toxicity (Late)
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Sx: Early: Visual disturbance! (Transient Blindness; UCH: Color change),
Headache, Agitation, Tachypnea, Burning sensation in Face & Hands
Late: N/V, Confusion, Seizure, Pulmonary Edema/Resp distress, Coma
BP (due to Cerebral Edema affecting Autoregulation)
Post-op: {2 Sex, 1 Incontinence, 3 Obstruction}
Retrograde Ejaculation: Incompetent Bladder Neck; 70-90% (Very common)
(Actually is S/E rather than Cx; Need to warn Pt before surgery)
Erectile dysfunction (UCH: ~40%)
Permanent Stress Incontinence 1% (Usually wont cut to Verumontanum)
Bladder Neck Stenosis: Small Prostate
Urethral Stricture: Nowadays, No.1 cause of Urethral Stricture is Iatrogenic
(Tx: Urethral Sounding)
(Post-TURP Voiding difficulty:
Bladder Neck Stenosis
Coaptation of Prostate (Regeneration)
Urethral Stricture at Membranous Urethra, or near Navicular Fossa)
Recurrence/Re-Tx rate (1-2% per year)
TURis Bipolar TUR In Saline:
Similar to Conventional TURP
Use of Bipolar Diathermy (Vaporization of prostate tissue with mushroom head)
Pros: Can use Normal Saline as Irrigant
NO TUR syndrome (But still has Fluid overload)
Less effect on Pacemakers (Current wont go through Pt body)
Good Hemostatic function; Post-op minimal bleeding from bladder irrigation
Cons: More Expensive (Pt may need to Pay)
PVP Green Laser Prostatectomy (PhotoVaporization Prostatectomy):
High power Laser Vaporization of Prostate tissue
Use of Normal Saline
? Better Hemostasis
NO Histology (Need to rule out Prostate CA for Pt with Clinical suspicion)
(Take Longer time)
HOLEP Holmium Laser Enucleation of Prostate:
Use of Laser cutting to enucleate Prostate Stroma
Need Morcellation of Huge Prostatic tissues enucleated & placed in Bladder
Histology available
Less Blood Loss for Huge Prostate (UCH: Laser usually for Bleeding Tendency Pt)
Minimal Invasive Therapies:
Balloon dilatation of Prostate:
Device is located in Prostatic Urethra by Palpation of Balloon in Bulbar Urethra
90F Balloon is then inflated to dilate Prostatic urethra
Prostatic Stent: (2011 EMQ)
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Cystoscopic insertion of an expanding Urolume stainless steel prostatic stent
Open Stent maintains Patency of Prostatic urethra & gradually Epithelializes
TULIP transurethral delivery system:
In-built US system allows precise visualization of treated area
Endoscopic Laser Ablation of Prostate
Side-firing delivery probe inserted through Cystoscope> Laser Energy applied under vision
TransUrethral Needle Ablation (TUNA):
Use Radiofrequency antennae to deliver High Temp to prostate without Anesthesia
TransUrethral Microwave Thermotherapy (TUMT):
Prostatron microwave delivery catheter passed per urethra
and located in prostatic urethra by Inflation of Catheter balloon
Rectal Temp is monitored by means of a device inserted into Rectum
MemoKath:
Thermo-expandable Coil (Ni-Titinium alloy)
Lower end expand upon 55C, Softened for extraction at Cold water Temp
8 year result A/V from UK on 211 Pt
23% Failure which required removal
An option in Pt Not fit for OT
Other Endoscopic Approach for Prostate Resection:
Bipolar, Plasmakinetic (PK) vaporization, or Enucleation of prostate
Holmium Laser Enucleation of Prostate (HOLEP)
Laparoscopic Simple Prostatectomy
STEP (Single Port Transvesical Enucleation of Prostate)
Holmium Laser Vaporization
Rationale for Alternative method to TURP:
Prevent TUR syndrome
Able to resect Bigger prostate (eg. >100g size) safely
Minimal blood loss
Minimal post-op irritative Sx
To be one of the viable options for Tx

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Urology Prostatic Cancer
Prostate Anatomy:

Prostatic CA: *Peripheral zone (2003 MCQ 40)
(Thus Prostatic Cancer does Not commonly present as AROU unless Advanced)
(But Advanced Prostatic Cancer more commonly presents as Bone Pain)
BPH: *Transition zone
Epidemiology: Used to be a Rare disease in HK, said to be a disease of the West
ing in Prevalence
From 2008 onward: Rank 3rd among Male Cancer, 5th among Male Cancer death
Possible reasons for the trend: Ageing population (Median Age: 73)
Western lifestyle
Health Awareness with More Screening PSA tests
More Pt are diagnosed with Prostate CA, & More Pt are dying with the disease too
Lifetime Risk 1 in 31 for HK (before Age 75), Death 1 in 287 (before Age 75)
Histological Incidence: 10% Men of Age 50
RF: Age
FHx
Race (eg. High in Australian)
Dietary (High saturated) Fat, Obesity, Manner of Food Preparation
? Vitamin deficiencies (D, E)
Protective Factors: Isoflavonoids, Green Tea, Lycopene, Selenium, Vit E, Exercise, ? Coffee (4-6 cup Recurrence)
NB: 2006 MCQ 59: Other Protective Factors: Cirrhosis, Enough Vit D intake, Rural Dweller
Isoflavonoids (Huang Tong):
Rich in Soybean Product; Bean curd (To-Fu), Soybean or Soybean Milk
Epidemiological studies showed consumption related to Risk of Prostate Cancer
Exact mechanism Not completely clear
Green Tea Polyphenols (Duo Fen):
Recognized to have Anti-oxidant properties
Might block the pathway that lead to Androgen synthesis
Green Tea Polyphenol (GTP) shown to inhibit Prostate CA carcinogenesis in mouse model
Regulate Apoptosis & Angiogenesis & Gene expression, etc, in Lab studies
Spread: Direct: Bladder, Seminal vesicle
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LN: Pelvic, Para-aortic
Blood: Prostatic Venous Plexus to Vertebral Venous Plexus
Clinical:
*Asymptomatic
Local Sx:
LUTS: Sx of LUT obstruction may Not be present:
Hesitancy, Weak Stream, Nocturia
Post-Renal Failure, Uremia, Confusion
Hematuria (due to BPH in 90% cases)
Systemic:
Bone Pain
Anemia
DRE for Prostate: Cancer located in Peripheral zone and could be detected when Cancer volume >0.2 ml
18% of all cancer detected by suspected DRE
Abnormal DRE asso. with Higher Gleason Score and should consider Biopsy
Only fair reproducibility; Urologist usually use DRE & PSA together for Prostate CA detection
Features: Size: 3 Finger breadth is already Enlarged
Regular/Irregular
Consistency: Firm/Rubbery in BPH, Hard in CA
Nodule: Affect T staging (Palpable At least T2; Unilateral <50% lobe T2a, >50% T2b)
Median Sulcus: Affect T staging (T2c if Absent Median Sulcus Both lobes involved)
Mobility of Rectal Mucosa
POD deposits, etc
Nodule on DRE: Could be Cancer with Normal/Abnormal PSA
BPH, Prostate Calculi, Prostatitis, Tumor
Only 30% PPV
Initial Ix:
CBC: Any Anemia
LRFT: Renal Function, Any Bone Metastasis
Urinalysis: Any Hematuria, Concurrent UTI
PSA: Glycoprotein excreted by Prostate Glandular Epithelial cells, Majority to Semen, Some to Blood
Liquefy Semen after Ejaculation; Used in Forensic Medicine for Rape cases (Organ specific)
Enzymatically Inactive PSA remains as Free form (fPSA)
Organ Specific but Not Cancer Specific; Cancer gives Serum PSA 10x of Benign Prostate tissue
Also in: BPH (Correlate with Prostate Size?), Prostatitis/UTI, AROU (due to Small Infarct?)
Ejaculation, Cycling
Iatrogenic: After Prostate Massage, Biopsy, Cystoscopy; (Not after DRE)
(Bed Rest can PSA)
Normal <4 ng/ml; Cutoff with Age (Prostate Size with Age)
Interpretation for Serum PSA:
PSA level <4 4-10 >10
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Interpretation Normal 20% CA chance, consider Biopsy >50% CA chance, Biopsy indicated
(4 is an arbitrary figure from population studies; Normal value does Not rule out Cancer)
(WK Ma: In HK data, for PSA 4-10 CA risk ~12%, for PSA >10 CA risk ~20%)
Attempts to PSA Sensitivity: (Not routine, often Not done)
Age-adjusted PSA:
Age 40-49 50-59 60-69 70-79
PSA Cutoff 2.5 3.5 4.5 6.5
Percent Free PSA: (Not done in HA hospitals?)
Total PSA = Free PSA + Complexed PSA (more specific for CA)
% of fPSA in CA Prostate as Total PSA
Can be used in those with Total PSA 4-10 ng/ml & Non-suspicious DRE
% Free PSA 0-10% 10-15% 15-20% 20-25% >25%
Probability of Cancer 56% 28% 20% 16% 8%
0-10%: High risk (Biopsy warranted) (in fact cut-off may be set at Free/Total PSA <0.15)
>25%: Low risk
(Complexed PSA: >3.75 ng/ml)
PSA density:
PSA/Volume in cc: CA: >0.15 ng/ml
PSA velocity/PSA doubling time:
Velocity: CA: >0.75 ng/ml/year
P2PSA, Prostate Health Index (PHI):
PHI: Isoform of PSA proPSA more Specific for Prostate CA
PCA3:
Gene base Urine test for Prostate specific mRNA overexpressed in some Cancer cells
(66x over adjacent Benign tissue)
Candidate for PSA test:
Prostate CA Pt for FU
BPH Pt if Implication of test explained
High risk group, eg. Pt with FHx of Prostate CA
Do Not screen if Life expectancy <10 years (OverTreat Many will die of other diseases)
These do Not apply to Pt with Clinical disease like Palpable Nodule, etc
Pre-test Precaution:
No Urological instrumentation for 1 week, including Catheters, but Not DRE
No Ejaculation for 48 hours
No Cycling for 1 week
No Recurrent UTI (Need to wait for 6 weeks if recent UTI)
Screening: Started to popularize in 90s in HK
Now PSA Screening is also included in Health check package
No guideline for Screening in HK
Many of our Family Physician had Poor knowledge of significance of PSA
Eg. PSA Screening for Pt at 80 yo & Refer to urologist for Mx
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MK Yiu Advice:
If you do have Prostate CA, Early Detection chance of dying by at least 31%
ERSPC: 2012 data; Relative Reduction in Risk of Death 29%
Number Needed to Screen: 1055; Cancer Needed to Diagnose: 37
Cons: High chance of being diagnosed & treated for disease which may Not harm you
But: If you are diagnosed with Indolent disease, Tx can be avoided at least for some time
Recommendations quoted by WK Ma: (Some studies show Improved Survival while some do Not?)
American Cancer Society:
Do Not recommend Mass screening,
but Men should be given opportunity for shared decision making about testing
Annual PSA & DRE from 50 years (45 in Higher risk groups)
American Medical Association:
Mass screening premature
Annual PSA & DRE from 50 years (40 in Higher risk)
United States Preventive Services Task Force:
Insufficient evidence to recommend for or against screening
National Health Service:
Screening will Not be offered
until there is clear evidence that screening will bring about more benefit than harm
Ireland: Screening recommended (RCSI guidelines)
Prostate Biopsy: (Sensitivity 90% Still may miss Central gland or Anterior tumor)
Indication: Only if there is Benefit if Biopsy could help in Pt Oncological outcome
Not indicated if No Clinical obvious disease/If Dx do Not result in Survival
Current Practice: (2007 MCQ 19)
Palpable Nodule/Disease in Prostate
Clinical Metastatic disease for Dx
Pt with PSA if Dx would affect Tx decision (75 yo)
(NB: Previous Biopsy with Abnormal Histology can also be an indication for Prostate Biopsy
Eg. Atypical Small Acinar Proliferation, Prostatic Intraepithelial Neoplasia
But AdenoCA on TURP specimen is Not an indication)
(NB: If persistent PSA, but TRUS biopsy ve for 2 times, No need further biopsies)
Biopsy: US guided in most cases (TransRectal US TRUS Biopsy)
MRI-guided, Robotic assisted in some Specialized center with Facilities, Not general use
No of Biopsies: 10-12 in current practice
Lesion-directed Biopsy, Random Systematic Biopsy
Should be labeled from different areas of Prostate Important in Tx decision
(May spare Cavernous Nerve to preserve Erectile function)
Cx: Bleeding: PR Bleeding, Hematuria, Hemospermia
UTI/Sepsis (GI Bacteria; 3% can have Sepsis; Can be Severe!!)
(Australian use Trans-perineal Biopsy Infection Risk)
AROU (Prostatitis> Swollen Prostate can cause Urinary Retention)
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NB: No evidence of Biopsy tract seeding in CA Prostate
Preparation:
For Bleeding: Check CBC, Clotting profile
Stop AntiPlatelet/AntiCoagulant
For Infection: Save Urine to ensure Sterile
Bowel Preparation (QMH: Fleet Enema the night before)
Antibiotic Prophylaxis (Fluoroquinolone + Metronidazole)
MRI-US Fusion guided Biopsy:
Image created in MRI suite, imported to 3D US machine for analysis & fusion
For Dx of lesions in Difficult areas, For FU in Pt with Active Surveillance
Cons: Some Error due to Fusion
Gleason Score: Primary Site + Secondary Site; (Sum of 2 most prevalent islands of Prostate Cancer: 2-10)
3+3 (Most common, Low risk); Any Grade 4 will be regarded as High risk
No. of Core
% of Involvement
Grade 1: Well-defined individual Glandular Nodules, Closely arranged, Uniform, Separate from each
Grade 2: Relatively Well-defined, but possible Minimal Extension of Neoplastic Acini
to Periphery of Tumor Nodule in NonCancerous Prostatic tissue
Grade 3: Infiltrate NonCancerous Prostatic tissue; Marked Variation in Size & Organization
Grade 4: Markedly Atypical cells with Extensive Infiltration into surrounding tissues
Grade 5: No Glandular Differentiation; Sheets of Undifferentiated Cancer cells
Radiological Ix:
Pelvic/Lumbar Spine X-ray
Renal US (if Raised Renal profile)
TRUS Prostate Biopsy
TRUS: Hypoechoic lesion is Malignant in 17-57% cases
39% Isoechoic, 1% Hyperechoic
CanNot use as a Dx tool Only use as a guide for TRUS-guided Biopsy
Bone scan: In presence of PSA >20 (Bone Metastasis is likely) (2002 MCQ 41), or Bone Pain
MRI prostate: Poor Specificity without Endorectal coil; (More preferred than CT)
(Need to wait for 3 weeks after Prostate Biopsy, otherwise just show Post-Biopsy changes)
MK Yiu: MRI & Bone scan only in High risk disease with PSA >10, or Lower risk disease with PSA >20
Role: Staging, Detection (Before Biopsy, After ve Biopsy, HGPIN/ASAP), Localization,
Risk Stratification
Staging:
T: T1: Asymptomatic, No Clinical Signs
T1a: <5% TURP chippings
T1b: >5% TURP chippings
T1c: PSA indicating TRUS biopsy
T2: Palpable, Confined to Prostate
T2a: Less than Half of 1 lobe
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T2b: More than Half of 1 lobe
T2c: Both lobes
T3: Locally Invasive
T3a: Extracapsular Invasion
T3b: Seminal vesicle Invasion
T4: Structures other than Seminal vesicle (eg. Bladder, Levator muscles, Pelvic wall)
N: N1: Regional LN
M: M1: M1a: Non-Regional LN
M1b: Bone
M1c: Other Sites, or if >1 Site
Natural Hx of Prostate CA:

Tx: Principles: The Young: Curative Tx for Localized disease
The Old (Life <10 years): Prolong Survival to Live with the cancer & Die of other disease
Advanced disease: Prolong Survival as much as possible
Options: Active Surveillance: Curative Intent
Low risk disease Old Pt, Young Pt want to avoid Cx of ED & Incontinence
Monitor PSA, Regular Biopsy; Intervene with Tx if disease begins to progress
Watchful Waiting: Palliative intent
Advanced Age, Life-limiting Comorbidities, Life Expectancy <10 years
Palliative Tx provided if Local/Metastatic Progression occurs
Surgery Radical Prostatectomy (Curative)
RT External Beam RT/Brachytherapy
Hormonal therapy (Castration Medical/Surgical)
Chemo
Others Cryotherapy, HIFU, Immunotherapy (Sipuleucel-T), etc
Tx of Localized disease (T1/2): >90% can be cured by Radical Tx in 10 years (90-95% by Surgery, 85-90% by RT)
Active Surveillance, Watchful Waiting
Surgery Radical Prostatectomy:
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Common Tx for Localized disease
Pathology Excised from Pt and results of Tx more Reassuring for Pt
FU with PSA is a reliable way
Complex Major operation requiring Expertise for good results
Morbidity of ED & Urinary Incontinence
Prostatectomy in HK Public Hospitals:
3 Main types: Open Retropubic Prostatectomy
Perineal Prostatectomy
Minimal Invasive Prostatectomy (Laparoscopic/Robotic Prostatectomy)
Mostly do Radical Retropubic Prostatectomy (RRP) (can be done in various approaches)
Prerequisites:
Confirmed Histological Dx
At least 10 years Life expectancy post procedure
(For Life Expectancy <5 years, No difference in Survival outcome cf Watchful Waiting)
ve Bone scan ve MRI
No Absolute PSA or Gleason score cut-off
(In the past, PSA >20 is contraindicated; Now can still be considered in selected Pt)
Pt fully counselled & aware of possible Cx & Alternative Tx options
Cx: Mortality Low (<0.3%)
Important: Erectile Dysfunction 30% even with Good Nerve Sparing
(NB: No Ejaculate even with Erection as both Vas deferens are cut)
Urinary Incontinence (10%)
Others: Bladder Neck Stenosis (<5%)
Bleeding
Rectal Injury (Minimal risk <1%)
Problems related to GA
(Nerve Sparing Prostatectomy:
Avoid damaging Vesico-Prostatic Angle)
RT: External Beam RT:
No need to have operation
30% Pt have Residual disease, but No significant LT survival disadvantage compared to RRP
No Histology> Anxiety from Pt
No significant Continence problem, but still have Erectile Dysfunction (up to 30%)
Long term Cx of RT: Cystitis, Proctitis (up to 10%)
Brachytherapy:
Uncommon in HK
Less Damaging effect to Surrounding tissue
Need Experts in RT & Urology to perform in Co-operation
Difficult to Assess Cure
Tx for Advanced Prostate CA:
Watchful Waiting
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Locally Advanced disease (T3/4):
RT + ADT recommended (2013 EMQ)
Radical Prostatectomy + Extended Pelvic LN Dissection as alternative in selected Pt
Metastatic disease (Systemic Tx):
ADT
CRPC (Castration-Resistant Prostate Cancer):
Chemo (eg. Docetaxel + Prednisone), New class AntiAndrogens & others
Prevention of Bone Loss: Bisphosphonate & mAb RANK Ligand Inhibitor (Denosumab)
(MK Yiu: Nowadays may offer Radical Local Tx in Pt with OligoMetastases too)
Androgen Deprivation Therapy ADT (Androgen Ablation):
Types: Bilateral Orchidectomy (Surgical Castration)
GnRH Analog/Antagonist (Medical Castration)
AntiAndrogen
Others: Combined Androgen Blockade (CAB): Castration + AntiAndrogen
Estrogen therapy
Rationale: Testosterone stimulate Growth in >90% of Prostate Tumor
Suppress Secretion of Testosterone/Inhibit its effects at Androgen receptor can Control Growth
Used for years in Advanced Prostate CA for many years to Delay Progression & Palliative Sx
Now also considered in Recurrence & Non-Metastatic disease
Considerations:
For: Hormonal Tx palliate Cancer-related Sx
Prolong Time to Clinical Progression
? Influence Survival
Against: S/E: Acute & Chronic, Accumulative
Expense
Prolonged Tx often required
Influence on tumor biology?
Hormonal Control of Androgen pathway:
Hypothalamus: GnRH Agonist (by Downregulation) / GnRH Antagonist (by Direct Inhibition)
Testes: Orchidectomy
Prostate: AAs, 5-reductase Inhibitors
(Pituitary: Estrogen Not used anymore due to lots of Cardiovascular S/E)
Surgical Castration Bilateral Orchidectomy:
Pros: Gold standard
Highest level of Testosterone control!
Surgical procedure is Simple
Can be performed under LA
Cons: ve Psychological effect as Castration
Irreversible!
Broad spectrum of S/E: Vasomotor, Sexual, Metabolic & CVD, Bone Loss
Medical Castration:
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(Note that GnRH = LHRH)
GnRH agonist:
Can cause Transient of LH at first few days after initiation (Flare phenomenon)
Need to premedicate with AntiAndrogen to prevent Flare phenomenon
Regimen offered from 1-monthly to 1-yearly
Route: IM injection: Leuprolide, Triptorelin
SC implant: Histrelin, Goserelin
GnRH antagonist: (Newer)
Directly suppress LH (and thus Testosterone) & Avoid Flare phenomenon
Degarelix (SC injection)
Pros: Avoid Flare (No need combination with AntiAndrogens), Lower CVS risk
Cons: More Expensive, Only Monthly injection available in HK (cf 6-monthly for Agonist)
AntiAndrogens:
Compete for Testosterone & DHT binding sites within Prostate cells
More commonly used in combination with GnRHa
Monotherapy alternative to Castration in Symptomatic, Locally Advanced, NonMetastatic CA
Pros: Prevent Osteoporosis, Prevent Loss of Musculature, Preserve Potency
Cons: Less Effective than Castration in Metastatic Prostatic CA
Specific Toxicity
Type: NonSteroidal: Flutamide, Bicalutamide, Nilutamide
(Steroidal)
S/E: Fatigue 14% Hot Flush 50-80%
Erectile Dysfunction 50-100% Cognitive function 0-50%
Bone Fracture 6-9% Anemia 81%
Gynecomastia 16% Abnormal LFT with AntiAndrogen 22%
Immunotherapy:
Sipuleucel T (Activated Dendritic cells; Activate CD8 T cells to kill Tumor cells)
Expensive, Not available in HK
RT for Metastatic disease:
Urgent Tx for SC Compression by Tumor
Fixation Surgery for Pathological Fracture
Pain relieving (Irradiation for Local control of Sx)
2nd line Tx for Metastatic disease (CRPC):
AntiAndrogen with various dose, Ketoconazole, Steroid, Strontium 89, Bisphosphonates,
Chemo Taxotere (Docetaxel)
New Medical Therapeutic Options for CRPC:
Sipuleucel T, Alpharadin (Radium 223), Abiraterone, MDV3100, Prostvac
(Alpharadin, MDV3100 are AntiAndrogen
Prevent Androgen synthesis at All level, as Tumor cells can produce Androgen too)
Prevention of Skeletal Related Events:
Zoledronic acid:
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Pros: Prevent skeletal related events (33% vs 44%)
BMD & Pathological Fracture (13% vs 22%)
Prolong time to skeletal event
Bone Pain in 80%
QOL
Cons: Osteonecrosis of Jaw
Denosumab:
BMD & /Delay SREs when compared to Zoledronic acid
FU Surveillance after Tx:
PSA (2011 MCQ ?2)

Page 477
Urology Bladder Cancer
Highest Recurrence rate among all Malignancy
Urothelium: 3-7 cell thick
Epidemiology: Age: Median Age at Dx: 73
Incidence with Age
M:F = 2.7:1
Cause: No convincing evidence of Hereditary factor yet
*TCC: >90% (Most common in Industrialized countries America, Europe, Asia)
Can arise from Renal Pelvis to Urethra, but usually in Bladder
RF: *Smoking (7.2x) (accounts for 50% of all Bladder Cancer)
Industrial exposure to Aromatic amines:
Dyes/Paints/Inks, Organic Solvents, Petroleum, Leather dust/Rubber/Textile
Occupation: Painting, Driving Trucks, Working with Metal
Iatrogenic: RT to Pelvis
Chemo with Cyclophosphamide (by Acrolein)
Analgesic: esp Phenacetin, but its Not used nowadays
(MK Yiu: Others also possible)
(Coffee 1.3x)
(? Weak Connection between Artificial Sweeteners & Bladder Cancer, eg. Saccharin, Cyclamate)
SCC: 5% (Most common Worldwide)
RF: Developed countries: Persistent Inflammation from LT indwelling Foley catheter/Stones
Eg. Pt with SCI requiring LT indwelling catheter 12-20x risk
Developing countries: Infection (Schistosomiasis Schistosoma haematobium)
Other RF: Bladder Diverticula, Bladder Exstrophy
AdenoCA: <2%; Arise from Urachal remnants
2005 SAQ 10: Typically develops on Anterior dome of Bladder
Most Aggressive among 3 Histological types of Bladder CA
Clinical:
Hematuria: 80-90% present with Painless Gross Hematuria
Consider All Pt with Painless Gross Hematuria have Bladder Cancer until proven otherwise
Suspect Bladder Cancer if any Pt presents with Unexplained Microscopic Hematuria
LUTS: 20-30% Pt have Irritative Bladder Sx like Dysuria, Urgency, Frequency
May be caused by Cis or Muscle-invasive Bladder Cancer
50% SCC may have Bacteriuria
Bladder Neck Cancer may have Obstructive Sx
Advanced disease:
Pain: Pelvic Pain: Local Invasion
Bone Pain: Bone Metastasis
Flank Pain: Ureteral obstruction
LL Edema from Iliac vessel Compression
PE: Usually Insignificant; Rarely a Mass may be palpable in Abd/Pelvic/Rectal/Bimanual Exam
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Ix: (Blood): CBC: May show Anemia, WBC
LFT: Baseline for BCG vaccine Tx (Systemic absorption can cause Acute Hepatitis)
Also for possible Liver Metastasis
Bone Profile: Any Bone Metastasis
RFT: Baseline before Intravesical therapy
Urine: Urinalysis: RBC, WBC, Protein
Urine Culture: Exclude UTI
Cytology: Non-Invasive method for Dx, but Low Sensitivity (esp Poor for Low grade)
(NB: First Morning sample is Not used, since cells are distorted overnight)
NB: High grade: Sensitivity 80-100%, Specificity 71-100%
Low grade: Sensitivity 13-75%, Specificity 20-50%
Brush Cytology: 90% (But Invasive & May cause Bleeding/Perforation)
Tumor Markers: Most are More Sensitive but Less Specific than Cytology; Not commonly done
Cystoscopy: Main modality for Dx: Low risk, Can take Biopsy, Can resect Papillary tumors
(Comment: Papillary appearance, Size (compare with Scope), Site,
Pedunculated?, Satellite lesions?)
Imaging: Upper Tract Imaging: For Hematuria workup; CTU, IVU, US
CTU/IVU also help detect any Synchronous Proximal lesions
Staging: T: Cis
Ta: Papillary tumor confined to Epithelium
T1: Invasion into Lamina propria
T2: Invasion into Muscularis propria
T3: Involvement of Perivesical Fat
T4: Involvement of adjacent organs (eg. Prostate, Rectum, Pelvic sidewall)
(NB: Ta is Proliferative and tends to grow into lumen of bladder
Cis is Dysplastic, just caught in an Early stage before invasion; Higher risk of Progression)
N: N+: LN Metastasis (In TCC, once LN +ve, already Stage 4 disease)
M: M+: Metastasis
Tx:
1. Non-Muscle-Invasive Disease/Superficial Bladder Tumor (Ta, T1, Cis):
TURBT Intravesical BCG
Surgery:
TURBT: TransUrethral Resection of Bladder Tumor
1st line to diagnose/stage/treat visible tumors (2013 SAQ 2)
(Sometimes may use NBI in addition to White-light Cystoscopy)
(Also with Deep muscle Biopsy)
Radical Cystectomy:
Typically reserved for Muscle-Invasive disease, unless:
Large Tumor Bulk (Endoscopic Eradication Not feasible)
Prostatic Urethra involvement
Cis/T1 High grade tumor Persistence despite adequate Intravesical Tx
Page 479
(NB: Recurrence: Same Stage/Grade
Progression: Advanced Recurrence, eg. Ta> T1
Cis has High Progression Risk> Some may advocate Early Cystectomy)
Immunotherapy & Chemo:
Intravesical instillation of BCG vaccine or Chemo after TURBT/Biopsy
(Usually 2-4 weeks after procedure so UB healed to avoid Systemic distribution)
Intravesical BCG: (Not available in China due to fear of Biological weapon; Only use Mitomycin C)
Induces Non-specific, Cytokine-mediated Immune response to Foreign protein
Indicated in Intermediate to High risk Pt (Scoring system available):
Andre Tan: High grade (2010 MCQ 80), Primary/Coexisting Cis (2010 MCQ 80),
Tumor Size 3 cm, Multiple Primary sites, Multiple Recurrences,
Prostatic urethral involvement
UCH: Grade 3, Size 3 cm, 3 lesions, etc
2 weeks after TURBT until Hematuria controlled (ie. Epithelialized) (to avoid Sepsis)
Induction with Maintenance for 1 year (But only 20-30% Pt compliant due to Irritative Sx)
Recurrence & Progression:
Induce Chemical Cystitis> Recruit Inflammatory cells/Cytokines to attack tumor cells
S/E: Cystitis (Irritative LUTS), BCG Sepsis (Not responsive to routine Antibiotics)
Contraindication: IC state, Uncontrolled Hematuria, Post-RT, etc
Intravesical Mitomycin C (MMC):
Single instillation within 24h of TURBT is Routinely done
(Risk of Cancer cells seeding when flush bladder during TURBT)
May also be used as an alternative to BCG
But Poorer Efficacy: Only Recurrence, but Not Progression
Others: IFN / may be used/added after BCG failure
Chemo: Intravesical Valrubicin, Intravesical Docetaxel
2. Muscle-Invasive Disease (T2 or above):
Surgery:
Radical Cystectomy: (2003 MCQ 58)
Radical CystoProstatectomy for M:
Bladder, Peritoneal covering, Perivesical Fat, Distal Ureters, Prostate,
Seminal vesicles, Vas deferens, sometimes Membranous or Entire Urethra
Anterior Pelvic Exenteration for F:
Cystectomy, Urethrectomy, Hysterectomy, Salpingo-oophorectomy,
Partial Anterior Vaginectomy
Both include Regional LN dissection
Pelvic Lymphadenectomy:
25% Pt undergoing Radical Cystectomy have LN Metastasis at time of Surgery
Bilateral Pelvic Lymphadenectomy (PLND) performed with Radical Cystectomy
Urinary Diversion (after Cystectomy):
Incontinent: *Ileal conduit, Colonic conduit
Page 480
Continent: Indiana pouch (Ileocecal valve for Continence; Empty by Catheter)
Orthotopic Neobladder (Void by Valsalva)
RT: Inferior to Cystectomy
Chemo: Neoadjuvant Chemo may be given before Surgery/RT but Controversial
Prognosis:
Superficial Bladder CA:
Risk of Progression: Tumor Grade/Stage, depending primarily on Tumor Grade
with Tumor grade: Grade I 10-15%, Grade II 14-37%, Grade III 33-64%
Cis: Poorer Prognosis, Recurrence rate 63-92%
Diffuse Cis: Ominous finding, with >70% progressing to Muscle-invasive disease
5-year Survival with Stage:
Ta, T1, Cis: 82-100%
T2: 63-83%
T3a: 67-71%
T3b: 17-57%
T4: 0-22%
Metastatic TCC: Poor Prognosis; 2-year survival only 5%
Cystoscopy Surveillance:
Indication: CMC: CA Bladder after complete TURBT
CA Bladder after Radical RT
Upper tract TCC after NephroUreterectomy
Urinary Diversion:
Diversion of urinary pathway from its natural path
Temporary vs Permanent
Temporary: Suprapubic Cystostomy, Nephrostomy
Permanent:
Incontinent:
Ileal conduit

Others: Colonic conduit: Ileum is better as can make a Rosebud (Sprout) to minimize Skin Irritation
May be done if Previous Pelvic Irradiation (Avoid Irradiated Ileum)
Usually by Transverse Colon
Cutaneous Ureterostomy
Continent:
Rectal Bladder (eg. UreteroSigmoidostomy):
Page 481
Internal Diversion to GIT; Continence depends on Anal sphincter
Obsolete now
(UreteroSigmoidostomy)
Continent Catheterizable Diversion (Continent Cutaneous Diversion):
External Diversion to a Catheterizable Cutaneous Stoma
(Dr. So: If Bladder Cancer spread to Prostate, need to take out Urethra too
CystoProstatectomy + Urethrectomy)
Indiana pouch:
Ascending Colon as pouch + Terminal Ileum as Efferent limb + Ileocecal valve aids Continence

Others:
Koch pouch, Penn pouch, etc
Orthotopic Neobladder:
Internal Diversion still through Urethra
(Dr. So: If No Prostatic Urethra involvement, just CystoProstatectomy> Can use Neobladder)
(Dr. So: Often Incomplete voiding (Need to compress Abdomen to help)
Bowel is designed to be Not contractile to prevent Urine Reflux
May still need CISC (And need to wash out Mucus too)

Bowel segment:
Dr. So: Usually avoid Large bowel:
Bacteria may form Carcinogenic Nitrosamine products from Urea from Urine
Jejunum Not used:
Severe Metabolic derangement (Electrolyte disturbance, HypoCl Metabolic Acidosis)
Also Location is too High up
Page 482
Urology RCC
Renal Cell Carcinoma:
Most common type of Kidney Cancer in Adults (90% of all Primary Renal Cancer)
Lack of Early warning signs, Diverse Clinical manifestations, Resistance to Chemo & RT
M:F = 2:1, Peak Incidence 60-70
Pathology: Mainly arise from Proximal Renal Tubular Epithelium (2006 SAQ 7)
Types: Clear cell CA (70-80%): Proximal tubules, with Abnormal Chromosome 3p
Papillary RCC (10-15%)
Chromophobe RCC (3-5%)
Others Rare, eg. Collecting duct CA
RF: Hereditary 4%: VHL syndrome
AD inheritance; Chr 3p (2006 SAQ 7)
RCC (Clear cell), Pheochromocytoma, Pancreatic Cysts & Islet cell tumors,
Retinal Angiomas, CNS Hemangioblastomas (usually Cerebellar),
Endolymphatic sac tumors, Epididymal Cystadenomas
Hereditary Papillary RCC (MET mutation)
Others
Sporadic:
Environmental:
Smoking (1.4-2.5x):
Dose-dependent fashion; Doubles the Risk & contributes to as many as 1/3 of all cases
Exposure to Cadmium, Nitrosamine, Aflatoxin B
Occupational Exposure:
Leather tanners, Shoe workers, Petroleum products workers, Asbestos exposure
Health conditions:
Obesity
HT
Tuberous sclerosis
Acquired Renal Cystic disease (LT Dialysis) (30x) (2009 EMQ 18)
Renal transplant:
With its asso. with Immunosuppression, Renal transplant confers an 80x in Risk of RCC
Clinical:
Asymptomatic: Incidental Radiological finding 50% (MK Yiu: 70%)
Local S/S: Classical Triad: Hematuria 40%, Flank Pain 40%, Palpable Abd/Flank Mass 25%
Only 10-15% Pt have all 3 components (indicative of Advanced disease)
(Usually present as Hematuria; Pain & Mass when Large enough)
Systemic: Weight Loss 33%, Fever 20%, Night Sweats, Malaise
Paraneoplastic: (2002S MCQ 36) (Ada Ng: 1/3 Pt can have Paraneoplastic manifestations)
HT 20% (Renin)
Anemia, Polycythemia (EPO)
HyperCa 5% (PTHrP)
Page 483
Urology RCC
Stauffer syndrome (Non-Metastatic Liver dysfunction; usually Cholestatic)
Polyneuromyopathy, Amyloidosis

Cx: Left: Varicocele (Extension to Left Renal vein> Occlude Left Testicular vein)
Right: IVC extension> LL Edema, Ascites, Liver dysfunction, etc
Metastasis: Esp Hematogenous, eg. *Lung, Bone, Liver, Brain, etc
Ddx of Renal Mass: Renal Cysts
Benign Tumor: Angiomyolipoma (Actually Harmatoma rather than Tumor), Oncocytoma,
(Medullary Fibroma, Metanephric/Papillary Adenoma, Cystic Nephroma)
Malignant Tumor:
Primary: RCC (Ada Ng: 90%), Upper tract TCC, (SCC, Lymphoma)
Paedi: Wilms tumor/Nephroblastoma, (Sarcoma), etc
Secondary: Metastasis
Infection: Abscess, TB (Uncommon to present as Renal Mass),
Xanthogranulomatous Pyelonephritis (XGP) (Uncommon)
Others
Ix: Lab: Urinalysis
CBC
RFT
Electrolytes, Serum Ca
(Tests based on presentation)
Imaging:
US: Dr. So:
Cystic vs Solid
Solid: Heterogeneous (Further Ix) or Not
Cyst: Simple (No need FU)
Complicated (eg. Septum, Calcification, Solid component) (Further Ix)
Intermediate: Serial US to monitor
Echogenic lesion without Acoustic shadow = Fat-containing lesion
In Kidney, it suggests Angiomyolipoma (But if Fat content of AML is Low, it can mimic RCC)
CT: Often sufficient to make presumptive Dx (Often can rule out AML)
Can evaluate: Size, Extent, Renal Capsule, Renal vein & IVC, etc
LN, Liver, Contralateral Kidney, etc
Thickened Irregular walls & Contrast Enhancement may suggest RCC
NCCT: RCC may appear Hypo-, Iso- or Hyper-attenuating relative to rest of kidney
CECT: Usually Solid (sometimes Cystic with Thick Septa & Wall Nodularity)
Page 484
Urology RCC
Contrast Enhancement (>20 HU)
(Usually mildly Contrast Enhanced, cf Renal Cortex; Compare with Psoas)
Attenuation suggestive of Necrosis may be present
Central Hypoattenuating Scar may suggest Oncocytoma (typical feature)
CTU: May be done if suspect TCC
Bosniak Classification for Renal Cyst:
I: Simple Cyst: Features: Homogenous, Water content, Sharp interface
No Wall thickening, Calcification, or Enhancement
No need FU
II: Mostly Benign: No need FU
IIF: Minimally Complicated: Serial imaging to monitor
III: Indeterminate: >50% Malignant potential; Surgery required
IV: Malignant: >90% Malignant potential; Surgery required
Non-uniform, Enhancing Thick wall, Nodular wall, Solid in Cyst
MRI
CXR: Rule out Lung Metastasis (Affects Tx decision with Surgery or Not) (2011 SAQ 6)
MK Yiu: Radiographic Staging of RCC
can be done with a High quality CT abdomen + Routine CXR in most cases
Bone Scan:
If suspect Bone Metastasis (eg. Symptomatic, Ca/ALP)
PET: Controversial
(MK Yiu: Dont do unless suspecting Tumor Thrombus, Distant Metastasis outside Kidney
Contralateral Kidney, even Normal, always shown to have Uptake)
Biopsy: FNAC may be done in suspicious Renal Cyst
Core Biopsy usually Not done to avoid Tumor seeding
Rather do Post-op tissue Dx in Resectable lesions
May be done if clinical/radiological suspicion of RCC Low
MK Yiu: For a 3cm Renal Mass, there is a 70% chance of RCC; Can do Surgery without Biopsy
Biopsy Cons: False ve, Bleeding, Confused Histology
Except for Lymphoma, Abscess, Metastasis
Staging:
TNM:
T: T1: Tumor 7 cm, limited to kidney
T1a: Tumor 4 cm
T1b: Tumor >4 cm, 7 cm
T2: Tumor >7 cm, limited to kidney
T3: Tumor extends into Major veins (eg. IVC), Adrenal gland or Perinephric tissues
but Not beyond Gerota fascia
T4: Tumor beyond Gerota fascia
N: N0, N1, N2
M: M0, M1
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Urology RCC
Stage: Stage 1: T1N0
Stage 2: T2N0
Stage 3: T3N0/T3N1
Stage 4: T4, N2, M
Tx:
1. Localized disease:
Surgery:
Partial Nephrectomy (Nephron-sparing surgery):
Slightly Higher Local Recurrence, but can preserve more Renal function
Indication: Absolute: Pt who will be anatomically/functionally Anephric if Radical Nephrectomy:
Single Kidney, Bilateral tumors, Severe Renal Failure
Relative: Conditions which may compromise future function of Contralateral kidney
Moderate Renal Failure, Renal Stone, Recurrent Pyelonephritis, etc
Elective: Small Peripheral tumor
Classically 4 cm (T1a), nowadays expand to 7 cm (ie. All T1)
AUA: Recommended as standard for all T1 tumors nowadays
Approach: Open: Better if difficult, eg. Single Kidney, near Renal Hilum (2014 EMQ 20)
Laparoscopic: Technically demanding; Done in Large centres
Radical Nephrectomy:
En bloc removal of Kidney with Gerotas Fascia, Ipsilateral Adrenal, Regional LN
(Regional LN dissection: Not yet routine No survival benefit; Do if suspect LN +ve)
Standard for T2/T3
(MK Yiu: If surgeon skill good, can still try Nephron-sparing surgery for T2/T3 if possible)
Approach: Laparoscopic: Standard (esp if <10 cm)
Open
(NephroUreterectomy for Upper tract TCC:
Remove Kidney + Ureter + Bladder cuff
Rationale: Ureter No use after Nephrectomy anyway
Ureter surveillance with URSL is troublesome (At least Spinal Anesthesia)
If cut Ureter, just need Bladder surveillance by Cystoscopy)
(Upper Tract TCC has Worse Prognosis than Bladder TCC:
Ureter is Thin; Fast to invade)
Ablative therapy:
Not mainstay; May be considered in Pt with High Surgical risk
2. Advanced disease:
Chemo: Not useful Low response rate (~4-6%)
Immunotherapy:
INF-: INF- + Cytoreductive Nephrectomy is Superior to INF- alone in Metastatic disease
IL-2: Effective but High Toxicity
Targeted therapy:
Kinase Inhibitor:
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Urology RCC
Sunitinib, Pazopanib, Sorafenib, Axitinib
Anti-VEGF mAb:
Bevacizumab (in combination with IFN)
mTOR inhibitor:
Temsirolimus, Everolimus
Surgery Cytoreductive Nephrectomy:
Resect tumor as much as possible to tumor load to improve Immunotherapy/Target therapy
RT: For Palliation
Extensive disease or Poor overall condition
4500-5500 cGy

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Urology RCC
Other Renal Tumors:
AngioMyoLipoma (AML):
Malformation including mature Adipose tissue, Smooth muscle & Thick-walled vessels
30% AML in Pt with Tuberous Sclerosis
Clinical: 50% Pt with Tuberous Sclerosis develop AML, often Multicentric
Presence of even a Small amount of Fat within a Renal lesion on CT,
virtually Excludes RCC and is Diagnostic of AML
Massive Retroperitoneal Hemorrhage (Risk with Pregnancy)
Tx: Small (<4 cm) & Asymptomatic AML:
Imaging FU every 6-12 months
Larger (>4 cm) Symptomatic AML:
Selective Embolization (2010 MCQ 82), or Partial Nephrectomy
Xanthogranulomatous Pyelonephritis (XGP):
Rare Serious type of Chronic Pyelonephritis,
characterized by a Destructive Mass invading Renal parenchyma
Associated with UTI, Renal Stone, etc
(If Pt with Longstanding/Recurrent Stones present with Renal Mass, think XGP & SCC)
(Usually in case of Staghorn stones Often Asymptomatic/Subtle Infection)
May present as Renal Mass, and can involve adjacent structures
May mimic Renal Tumor radiologically May be a Dx after Nephrectomy
Pathologically characterized by Lipid-laden Foamy MQ
Tx is by Nephrectomy (Antibiotics No use)

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Urology RCC
Urology Testicular CA
Epidemiology: Overall Not very common (2000 new cases UK/year 1% all cancers)
Primarily affects Young Men: Peak 20-44
Curable in >90% cases
Presentation: Painless Unilateral Swelling
Scrotal Swelling after Minor Trauma
Scrotal/Lower Abd Pain
Hydrocele
Endocrinological effects: Gynecomastia/Breast Tenderness, Libido
In 10% presenting Sx due to Metastatic disease: Neck Mass, Cough/SOB, GI/Back/Bone Pain
Classification:
Germ cell tumor 95%:
Seminoma 40%
Non-Seminomatous 60%:
Most Non-Seminomas contain cells from at least 2 subtypes, including the following:
ChorioCA: Rare; Aggressive, Likely to metastasize
Embryonal CA: Accounts for 20% of cases; Likely to metastasize
Teratoma: Usually Benign in Children; Rarely metastasize
Yolk sac CA: Most common in Young Boys; Rare in Men
Non-Germ cell tumor 5%
Leydig cell tumors
Sertoli cell tumors
Others
RF: Age
Cryptorchidism (3-5% chance of Cryptorchid Testis developing Cancer)
FHx
Race
? Trauma
? Orchitis
Workup: (Usually Clinical Dx/US; Biopsy is Not needed)
Serum Tumor Markers:
At initial presentation
Serum bHCG, AFP, LDH are most important tumor markers (2014 SAQ 9) (Useful for Staging)
Following markers to assess success of Tx
AFP has a Half life of 5-7 days, HCG has a Half life of 36h
US: Optional Most tumors are diagnosed based on PE finding
Performed to ensure correct Dx,
or to establish Dx in Pt in whom Testicular exam cant differentiate Scrotal structure
(Usually Hypoechoic with Microcalcifications)
In setting of Teratoma elements,
US images may demonstrate well-defined structures of Ectodermal differentiation
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Urology RCC
CT: Abdomen + Pelvis:
Important for Staging
Left-sided NSGCT: Typically first to Left Para-aortic, then Pre-aortic LN inferior to Renal BV
Right-sided: Spread to Para-caval & Inter-aortocaval LN inferior to Renal BV
CXR/CT thorax:
Usually obtained to help identify any possible Lung Metastasis
Semen Analysis: Offer Opportunity to obtain Semen Analysis & Sperm Banking for Future Fertility concerns
Can be performed before/after Orchidectomy
Tx options can significantly impact Future Fertility (esp Chemo)
TNM Staging:
T: pT0: No evidence of primary tumour, eg. Histological scar in testis
pTis: Carcinoma in situ (CIS, TIN)
pT1: Limited to Testis & Epididymis without Vascular/Lymphatic invasion
May invade into Tunica albuginea but Not Tunica vaginalis
pT2: Limited to Testis & Epididymis with Vascular/Lymphatic invasion,
or Extending through Tunica albuginea with involvement of Tunica vaginalis
pT3: Invades Spermatic cord Vascular/Lymphatic invasion
pT4: Invades Scrotum Vascular/Lymphatic invasion
N: (Usually spread to Para-aortic LN first)
M: M0
M1: 1a: NonRegional LN, or Lung (2014 SAQ 9)
1b: Others
S (Serum tumor markers):
S0 (Normal), S1, S2, S3
Tx: Complicated, depends on TNM
In general: Seminoma: Localized: Inguinal Orchidectomy RT to LN
With LN: Inguinal Orchidectomy + Platinum based Chemo
Non-Seminomatous tumor: Inguinal Orchidectomy RPLND Chemo
Orchidectomy:
Simple, Subcapsular: Usually Bilateral; For Sex Reassignment, CA Prostate
Inguinal: Usually Unilateral; For CA Testis
(Want to touch Artery first If Manipulate Testis first can lead to Tumor seeding)
(Counseling: Orchidectomy
Risk of Infertility/Subfertility
May need Sperm banking (Before Surgery, or 3 months before Chemo)
May need Adjuvant Chemo)
(Prosthetic Testes: Not done in Orchidectomy for Castration in CA Prostate
Usually for Young Pt with CA Testes)

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Urology RCC
Urology UTI
Dysuria Ddx: UTI (Cystitis/Prostatitis/Urethritis), AROU (eg. BPO, Urethral Stone), Bladder/Urethral Stone
UTI:
Organisms:
Community acquired UTI in F: E.coli 85%
Staphylococcus saprophyticus 10-30% in Young Adult F
Community acquired UTI in M: E.coli 25%
Majority caused by Proteus & Providencia
Enterococci & Coagulase ve Staphylococcus 20%
Nosocomial UTI: Tend to be Multi-drug Resistant
E.coli 50%, Enterococcus faecalis, Pseudomonas, Citrobacter, Serratia
Anaerobes: 88% of Scrotal, Prostatic, PeriNephric Abscess
Fungal Infection: *Candida albicans
Kidney is Most frequently involved organ in Systemic Candidiasis
DM, IC, Foreign body (eg. Catheter)
TB: Has been identified from Kidney to Genitals
Most commonly in Epididymis & Prostate
Renal involvement in 52-68% of Pt with Pulmonary Miliary TB
Route of Infection:
*Ascending Infection: From Rectum to Vagina/Urethra, From Urethra to Bladder, From Bladder to Kidney
Hematogenous spread: Distal source foci of Infection, eg. IE, Pulmonary TB
Staphylococcus, TB
Eg. Renal Abscess
Direct Extension from Neighbouring organs
Bacterial Virulence Factors:
Bacterial Adherence: Pili/Fimbriae express Adhesins that attach to Glycolipids of host cells
Type I Pili: Commonest type of Pili expressed in E.coli
Found in: Majority of isolates that produce Cystitis!
50% of isolates that produce Pyelonephritis
P Pili: Bind preferably to Urothelium of Upper Urinary tract
Found in: 80% of isolates causing Pyelonephritis! {P Pili for Pyelonephritis}
30% of isolates causing Cystitis
Toxin: Hemolysins: Cause Lysis of RBC
Lead to more Lethal UTI
Urease: Pseudomonas, Klebsiella, Proteus, Staphylococcus saprophyticus
Provide Energy source for Bacteria
Alkaline environment (Ammonia)
Promote formation of Struvite Stone (Infectious)
Host Factors:
Urine: Bactericidal to most species
Acidity
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Urology UTI
Very Dilute Urine (High Fluid intake)
Inhibitory factor: Tamm-Horsfall Glycoprotein
Produced by Tubular Epithelial cells of Ascending Loop of Henle & Distal tubule
Bind to Bacteria & Inhibit their Adherence to Urothelium
Bind to Neutrophils & Enhance Phagocytosis
Washout Mechanism:
By Regular Voiding with Minimal Residual Urine
Jeopardized by: Low Urine output, Bladder Outlet Obstruction, Vesico-Ureteric Reflux,
Neurogenic Bladder, Bladder Diverticulum, Catheter
Genetic (Lewis blood group Ag):
Secretor phenotype control Fucosylation of Cell membrane protein
Bacterial Adherence to Urothelium
Urine Collection: ing Risk of Contamination (ie. Lowest risk: Suprapubic Aspiration)
Suprapubic Aspiration: Infant/Paraplegics
Urethral Catheterization: For Female; Risk of UTI secondary to Catheterization: OPD 0.5-1%, Hospital 10-20%
*MSU: Meticulous techniques
Urinalysis: Leukocyte Esterase: +ve: >4 WBC/HPF; Sensitivity 75-90% for UTI
Invalid in Neutropenic Pt!
Nitrite: Surrogate marker of Bacteriuria
Reduction of Nitrate to Nitrite by Urease-producing Bacteria (Not All)
Urine must stay in Bladder >1h
False ve with Low Colony-count Infection/Dilute Urine
WBC >10/HPF is Indicative of Inflammation (1 HPF = 1/30,000 ml)
Sterile Pyuria: Stone: KUB
Tumor: Urine Cytology + Flexible Cystoscopy/CTU
TB: EMU x AFB
Vaginal Epithelial cells: Suggest Contamination
Significant Bacteriuria (EAU):
Cutoff: Magic figure: >105/ml Urine
>103/ml MSU in Female Uncomplicated Cystitis
>104/ml MSU in Female Uncomplicated Pyelonephritis
>105/ml MSU in Female or >104/ml MSU in Male Complicated UTI
Suprapubic Tap Urine: Any growth (usually done in Infant)
Asymptomatic Bacteriuria:
>105/ml Urine, 2 Consecutive specimens
No Bacteriuria =/= No UTI:
Pyonephrosis with Complete Obstruction, Chronic Prostatitis,
Renal Abscess, Partially treated UTI on Antibiotics
Classification (Isolated/Unresolved/Recurrent Infection):
Isolated: Infection is Isolated from Previous Infection by >6 months
Unresolved: Bacterial Resistance:
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Urology UTI
Primary
Acquired Resistance from Initially Susceptible Bacteria
Inadequate dosage/length of therapy
Pt Non-Compliance
2 different species (1 of them may be resistant to the prescribed Antibiotics)
Renal Failure: Renal Concentrating Ability
Staghorn Stone: Bacterial load is too Big
Recurrent: UTI following Resolution of Initial Infection
ve Culture after Cessation of therapy for a certain period
Reinfection vs Bacterial Persistence
Reinfection: Recurrent Infection from Source Outside Urinary tract
Same or Different organism
Responsible for >95% of Recurrent UTI in Women
25% of Women with 1st UTI will have Reinfection
Bacterial Persistence (Relapse):
Same organism
Source Within Urinary tract
Imply an Anatomic Anomaly:
Infection Stones, Chronic Bacterial Prostatitis, Infected Atrophic Kidney,
Duplex Kidney, Foreign body,
Fistula (Can be due to Diverticulosis, CRC, IBD; Sx: Pneumaturia, Fecoturia)
Classification (Complicated vs Uncomplicated):
Complicated: Anatomic/Functional abnormality of Urinary tract
Ability of Host to mount an Effective response to Pathogen
UTI that is at Moderate to High risk of Sepsis & Significant Morbidity
Example: Indwelling Catheter, Recent Hospitalization, Neurogenic Bladder, Bladder Outlet Obstruction,
Vesico-Ureteric Reflux, Pregnancy/DM/IC state, Multi-drug Resistant organism
Common UTI:
Acute Uncomplicated Cystitis:
Usually Young Adult Female
50% Women had a UTI by late 20s
0.5-0.7 episodes/person-year among Sexually active Women
Sx: Classical: Dysuria, Frequency, Urgency, Transient Hematuria
No Vaginal Discharge
Exclude: STD, Pyelonephritis (High Fever/Chills, Loin Pain)
Tx: Empirical therapy can be started without further Urine Culture/Ix
Tx depend on: Probable pathogens & Antibiotic Resistance patterns in the Locality,
Recent Antibiotic use, Allergy/Side effect, Cost
(In HK:
E.coli: Low Resistance in Augmentin (4%) & Nitrofurantoin(1%)
GP usually prescribe Cotrimoxazole & Levofloxacin (but both Resistance >30%)
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Urology UTI
Proteus: 100% Resistant to Nitrofurantoin (Thus do Not give in Male UTI)
Augmentin & Levofloxacin are useful
3-day therapy: Septrin (85%) or Fluoroquinolones (95%)
Single-dose therapy associated with High Recurrence rate
7-day therapy with Nitrofurantoin:
Less active than Septrin/Fluoroquinolones against Gram ve Rods other than E. coli
Inactive against Proteus & Pseudomonas
(-lactam Not recommended due to High prevalence of ESBL, unless given Clavulanate)
Complicating Factors:
Sx >1 week, Recurrent/Unresolved UTI, Pregnancy, Elderly, DM/IC state,
Anatomic/Functional GU tract abnormalities
Note: 20% of Women with UTI will develop a 2nd Infection within 6 months
Recurrent Uncomplicated Cystitis:
Majority are Reinfection with No Anatomic Urinary tract abnormalities
RF: Previous episodes of Cystitis
Recent Sexual activity (60x odds 48h after Sex)
Use of Spermicidal agents (2-3x odds; Postulation: Disrupt Normal Flora)
Tx: Antibiotics:
Pt-initiated therapy:
(Give Antibiotics to Pt to self-medicate when Sx appear; Pt must be Intelligent enough)
Clear understanding of Length of therapy
Sx of Tx Failure (ie. Pt know that need to see a doctor when certain Sx appear)
Continuous Low-dose Prophylaxis:
(Done in those with Frequent Recurrent UTI
Give regular Antibiotics to Bacterial load even in Asymptomatic phase
Cons: May develop Antibiotic Resistance)
2 Symptomatic UTI within 6 months, or 3 Symptomatic UTI within 12 months
Recurrent UTI by 95%
If Discontinued: 60% become Reinfected
Post-Coital Prophylaxis
Cranberry Juice:
Not due to Benzoic acid
ProAnthoCyanidins inhibit Attachment of Bacteria to Urothelium
200-750ml daily Cranberry Juice/Concentrate Tablets
Risk of Recurrent UTI by 12-20% (Lower Efficacy than Antibiotics, but almost No S/E)
High Withdrawal
Other Options: Doubtful benefit
Logical: High Fluid Intake, Frequent Voiding/Post-Coital Voiding
Evidence?: Wiping pattern
Vaginal Douching (Vaginal Irrigation)
(Avoid it! It will chance of Recurrent UTIDisrupt Normal Flora)
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Urology UTI
? Topical Estriol cream in Post-Menopausal Women
Asymptomatic Bacteriuria:
School Girls 1-2%, Young Female (Both Pregnant/Non-pregnant) 5%,
Community Female >65yo 20-25%, Community Male >65yo 10%,
Institutionalized Elderly 20-50%, LT Catheters 100%
Elderly UTI:
RF for Bacteriuria:
Impaired Elimination (Constipation & Drug-induced Urinary Retention),
Cystocele/BPH, Poor Perineal Hygiene (eg. Fecal Soiling),
Neurologic impairment & Poor Mobility, Post-Menopausal changes
Non-specific Sx: May present with Non-specific Sx of Sepsis
GC/Delirium, Poor Appetite, Nausea/Vomiting, Diarrhea, Fever
Tx: 1 week Antibiotics is recommended for Cystitis (Prolonged Antibiotics)
For Elderly Men with UTI, Frequent association with Prostatitis
Pregnancy UTI: UTI is a significant RF for Low-birth Weight & Prematurity
Asymptomatic Bacteriuria may progress to Symptomatic UTI in 15-45%
Impaired Immune response
Should be treated with Nitrofurantoin/-Lactam
Contraindicated!: Quinolone, Septrin
Approach: Treat Asymptomatic Bacteriuria & FU with Monthly Urine Culture till Delivery
Male UTI: Much Less common than Female UTI
Higher rate in Infant & Uncircumscribed Children
Often Complicated?
Ix if: Failed Tx, Recurrent UTI (Chronic Prostatitis?), Hx of Voiding Difficulty/AROU,
Persistent Microscopic Hematuria, (Elderly)
Focus: Ix focus on LUT
Tx: 7-10 days Tx if Prostate Not infected
Prostatitis: 6 weeks of Antibiotics
Quinolones preferred: Excellent Prostatic Penetration
Catheter-related UTI:
25% of Hospitalized Pt undergo Urinary Catheterization
5% develop Bacteriuria each day after Catheterization (Change Catheter every 2 weeks)
Definition: >102 CFU/ ml
Biofilm: (Colonization on Surface> Secrete Glycocalyx for protection)
UTI account for up to 40% Nosocomial Infection
Catheter-related UTI account for most:
Pt with Nosocomial UTI have Hospital stay extended by 3 days
3x more likely to Die during Hospitalization
Organisms causing Nosocomial UTI are easily Transmissible between Pt
Highly Antibiotic-Resistant
Lack of proper Hand Washing by Medical staff is largely responsible for Transmission
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Urology UTI
Prevention: Avoid Unnecessary Catheterization:
Temporary Relief of Bladder Outlet Obstruction
Urine output Monitoring in Critically Ill Pt
Prolonged Surgical procedure under Anesthesia
Urinary Incontinence in Pt with Open Sacral/Perineal Wound
Do Not keep Catheter Longer than Necessary
Alternatives: Suprapubic Catheterization
External Condom Catheters (Risk of Bacteriuria 12% per month)
Aseptic Insertion of Urinary Catheter
Closed Drainage system
Wear Gloves when manipulating bags
Wash hands between Pt
Silver Alloy Catheters: AntiBacterial
Used in High risk Pt, eg. Long duration of Catheterization, IC state
Systemic Antibiotics: May be useful in Pt with Catheterization for 3-14 days
Not recommended as routine Prophylaxis
Eradicate Bacteriuria before Surgery
Urethritis:
Cause: Infectious STD:
Gonococcal: Neisseria gonorrheae
Non-Gonococcal: Chlamydia trachomatis, Ureaplasma urealyticum,
Mycoplasma hominis, Trichomonas vaginalis
Post-Traumatic: 2-20% following CISC (Clean Intermittent Self-Catheterization)
Incidence: M=F
Sx: 4 days to 2 weeks after Infection
Urethral Discharge, Dysuria, Itchiness
Up to 50% Female can be Asymptomatic! (Late sequelae may happen)
Cx: F PID: 10-40%
Infertility, Ectopic Pregnancy, Newborn Infection (eg. Chlamydial Conjunctivitis/Pneumonia)
M: 1-2%
Urethral Stricture, Prostatitis, Acute Epididymitis, Infertility
Tx: Antibiotics:
Empirical Tx of Both GU + NGU
If No coverage of NGU: 50% risk of Post-Gonococcal Urethritis
Gonococcal Urethritis: Ceftriazone (Rocephin) 250mg imi x 1
Cedax 400mg po x 1
Chlamydial Urethritis: Doxycycline 100mg po 2x/day x 7 days
Erythromycin 500mg po 4x/day x 7 days
Azithromycin (Zithromax) 1gm po x 1
Further: Treat the Partners, Screen for other STD, Education
Prostatitis: Type: Acute Bacterial Prostatitis <5%
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Urology UTI
Chronic Bacterial Prostatitis
Chronic Pelvic Pain syndrome (CPPS): (Chronic Non-bacterial Prostatitis)
Inflammatory: WBC in EPS/VB3/Semen
Non-inflammatory: No WBC
Acute Bacterial Prostatitis:
Serious & sometimes Life-threatening
Dramatic Presentation: Fever/Chills, Back & Pelvic Pain, Dysuria/Frequency
DRE: Exquisitely Tender & Swollen Prostate (Clinical Dx already)
Most common: E.coli 80%
Fluoroquinolone Suprapubic Catheterization
No Urethral Instrumentation!
Prostatic Abscess:
IC Pt
Deroofing by TURP/TRUS-guided Drainage
Chronic Bacterial Prostatitis:
Recurrent UTI with GU Pain
DRE: Usually Normal
4-Glass Test: (Not usually performed; Necessity to classify Chronic Prostatitis is questioned)
EPS: Expressed Prostate Secretion >10 WBC/HPF (Suggest Inflammation)
VB3: 10x VB2 (Suggest Chronic Bacterial Prostatitis rather than Cystitis)

Frustrating to both Urologists & Pt; Relapse is common
Tx: Drug of choice: Quinolones
Duration: 6-12 weeks
Frequent Relapse: Consider LT Antibiotics
Chronic Pelvic Pain syndrome:
(Note Chronic Pelvic Pain syndrome is only used in M; For F, just called Chronic Pelvic Pain)
Same Sx as CBP but ve Culture
(Some have questioned the necessity to distinguish Inflammatory & Non-inflammatory)
Inflammatory (Non-Bacterial): (Type 3a)
Most common: 8x Incidence of CBP
>10 WBC/HPF (in EPS)
Postulation: Urine Reflux into Prostatic ducts
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Urology UTI
Infectious agents, eg. Chlamydia, Ureaplasma
Tx: Trial of Antibiotics, Cover Chlamydia/Ureaplasma
Blockers may improve LUTS, NSAID for Pain Relief,
TUMT (TransUrethral Microwave Thermotherapy)
Non-Inflammatory (Prostadynia): (Type 3b)
Not only ve Culture, but also No WBC
50% meet Diagnostic criteria of Major Depression
Postulation: Bladder Neck Spasm/Pelvic floor Muscle Spasm
Urine Reflux into Prostatic ducts
Epididymo-Orchitis:
*Children: Rule out Testicular Torsion
Usually Abacterial
If Urinalysis/Culture ve: Do Not need Antibiotics
Young Adult: Chlamydia: Doxycycline
Gonococcus: Single-dose IM Rocephin
Sexual partners need to be treated
Age >35: E.coli is the most common organism
Quinolone x 14 days
If Sx persist: Consider Prostatic involvement
TB Infection: TB Urinary tract is Secondary Infection from Primary Pulmonary TB
Only 1/4 Pt have known Hx of TB
Sx usually arise 10-15 years after Primary Infection
Constitute 15-20% ExtraPulmonary TB
Manifestation: Kidneys: Abscess, Fibrosis
Non-functioning Kidney (AutoNephrectomy)
Ureter: Strictures
Bladder: Cystitis, Contracted Bladder
Epididymis: Hematogenous spread
Abscess, Sinus, Beading of Vas deferens
Infertility: Obstructive Azoospermia
Prostate: Nodules
Asymptomatic
S/S: Chronic & Non-Specific
Frequency, Dysuria, Loin Pain
Suprapubic Pain, Fever
Scrotal Sinus with Discharge
Epididymal/Prostatic Nodules
Beading of Vas deferens
Ix: Early Morning Urine
AFB Smear: Sensitivity 52%, Specificity 89-96%
Culture: Sensitivity 65%, Specificity 100%
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Urology UTI
LJ medium 4-8 weeks
BACTEC 460 medium (Radiometric) 2-3 days
PCR: Sensitivity >90%, Specificity >95%
Only 6h
Tx: Isoniazid + Rifampicin + Ethambutol + Pyrazinamide x 2 months
Then Isoniazid + Rifampicin x 4-7 months
According to Sensitivity

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Urology UTI
Urology Urinary Incontinence
Urinary Incontinence:
Definition: Involuntary Loss of Urine as a Social/Hygienic problem, & Objectively Demonstrable
(Range in Severity from Dribbling Small amount of Urine to Continuous Urinary Incontinence)
Prevalence: Prevalence with Age (Not a part of Normal Aging)
25-30% of Community Dwelling Older Women
10-15% of Community Dwelling Older Men (Stronger Continence mechanism)
50-75% of Pt Never describe Sx to Physician
80% of Urinary Incontinence can be Cured/Improved
Nocturia: Complaint of Wake at Night 1 times to Void Each Void Preceded & Followed by Sleep
(Often has Insomnia too)
Enuresis: Any Involuntary Loss of Urine
Nocturnal Enuresis: Involuntary Loss of Urine during Sleep
Pediatrics would be up to 10-12% at Age of 5 (5 yo 12%, 12 yo 5%)
Most improved when growing Older
Bladder Function: Storage (Filling): Efficient & Low-pressure Filling, Lower pressure Storage,
Perfect Continence
Voiding: Periodic Voluntary Urine Expulsion at Low pressure
Bladder Filling & Urine Storage:
Accommodation of Urine at Low pressure
Bladder outlet Closed at Rest & when in Intra-abdominal Pressure
Absence of Involuntary Bladder Contractions! (If Detrusor Instability> Urge Incontinence)
Bladder Emptying (Voiding):
Coordinated Contraction of Bladder Smooth muscle of adequate magnitude
Concomitant Lowering of Resistance at level of Sphincter muscle
Absence of Anatomic Obstruction
Voiding with Normal Contraction:
Actual Organizational Center for Micturition Reflex in an intact Neural axis in Brainstem
Initiation of Micturition in Adult by IntraVesical Pressure for Involuntary Emptying
Voluntary Emptying involve Inhibition of Somatic Neural Efferent activities
Micturition Reflex:
A Reflex at level of SC with Stimulation by Full Bladder,
with Sudden Complete Relaxation of Sphincter muscles,
& Immediately followed by Detrusor Contraction
Organized in Pontine Micturition centre
Voluntary Control at Cortical level
Continence of Urine: Depend on Normal CNS, SC Control, and Anatomically Normal LUT
Mechanism: Anatomical Support by Intact Pelvic floor that hold Bladder Neck & Urethra in place
(esp important in Female)
Intrinsic Urethral Mechanism:
Coaptation of Mucosa, Compression by Submucosa & by Sphincters (Internal/External)
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Less important issue in Man (with Prostate as part of Continent device)
Anatomical: Congenital: Duplex Ureter with InfraSphincteric Insertion (below External Sphincter)
Infection
Iatrogenic: Post-Prostatectomy Sphincteric Injury
Birth Injury: Vesical Vaginal Fistula, Stress Incontinence, etc
Neoplastic
Compliance:
Concept: Change in Volume/Change in Pressure
Compliance: Large Volume change with Little in Pressure
Compliance: Small change in Volume resulted in Large in Pressure
(How Thick, How Big, How Elastic)
Mechanism: Change in Compliance by: Process that Alter ViscoElasticity/Elasticity of wall
Filling at rate Exceeding rate of Stress Relaxation
Filling beyond limits of Distensibility
These changes can be largely altered by Neurologic & Structural status
Cause of Bladder Compliance:
Neurogenic:
MDS (Miller-Dieker syndrome), Shy-Drager syndrome (MSA with Autonomic Failure),
SupraSacral SC injury/lesion, Radical Hysterectomy, AbdominoPerineal Resection
Non-Neurogenic (ie. Collagen):
Chronic Indwelling Catheter, Bladder Outlet Obstruction,
Chronic Cystitis (eg. Radiation, TB, Bilharzial (Schistosomiasis), Ketamine)
Surgical option Bladder Augmentation (Augmentation Cystoplasty):
Enteric segment (usually Ileal in UCH) augmented to Bladder to Capacity
Often need Intermittent Catheterization:
Wash out Mucus produced from Bowel (Mucus is nidus for Stone formation)
Pt may have Difficulty in voiding (Not enough Detrusor strength)
Metabolic derangement may be a Cx too (Bowel Absorption/Secretion in Bladder)
Ketamine Cystitis: Pt with Hx of Chronic Ketamine Abuse
Small Low Compliance Bladder (due to Inflammatory Fibrotic change)
Present with Urge Incontinence & Frequency of Urine
Ureter Obstruction could result in Obstructive Uropathy
(Cystoscopy can be difficult, as its Painful to distend the Small bladder during Cystoscopy)
Type of Urinary Incontinence:
Stress Incontinence (Typically if Prolonged Labor> Disrupt Pelvic floor)
Urge Incontinence
Overflow Incontinence (Typically in CROU Pt due to BPH)
Functional Incontinence
Others: Post-Micturition Dribbling:
Can teach Perineal Compression to force out drops in Bulbar Urethra
Giggle Incontinence (*Children; Laughter induced Involuntary Detrusor Contraction)
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Enuresis
Polyuria
Stress Incontinence: Caused by Sphincter Weakness (eg. Post-Prostatectomy in Male),
or more commonly in Female with Urethral HyperMobility/Intrinsic Sphincter Deficiency
Involuntary Loss of Urine due to Intra-abdominal Pressure: Coughing, Sneezing, Laughing
Urge Incontinence: Overactive Bladder (OAB), Detrusor Overactivity
A Strong sense to void followed by Involuntary Loss of Urine
Sx Severity could be affected by Stress & Anxiety
Mixed with Stress Incontinence in many clinical cases (Mixed Incontinence)
Overactive Bladder (OAB):
Cause: Idiopathic Detrusor Overactivity
NonNeurogenic Detrusor Overactivity (Secondary to Bladder Pathology):
Bladder Outlet Obstruction (eg. BPH, Urethral Stricture), Bladder Stone/Foreign Body,
Bladder Tumor (eg. CIS Bladder), Infection & Inflammation (Cystitis)
Neurogenic Detrusor Overactivity:
CVA, PD, Brain Tumor, Traumatic Head Injury, MS
SC lesions: Injury, Tumor, Transverse Myelitis, MDS
Overflow Incontinence:
Caused by OverDistention of Bladder
Overflow with Frequent/Constant Dribbling
Can be Obstructive (eg. BPH), or Hypotonic Detrusor (eg. Drugs, SCI, Diabetic Cystopathy)
Significant Post-voiding Residual Urine & Palpable Bladder
Functional Incontinence:
Leaking of Urine due to Inability of getting into Toilet
Esp in Elderly
Cognitive/Physical/Environmental Limitations
Dx of Exclusion as other types might be present in Functionally Limited individuals
Cause: Impaired Mobility, Dementia, Lack of Carer
Potentially Reversible & Transient Causes: {DIAPPERS}
D: Delirium
I: Infection
A: Atrophic Vaginitis/Urethritis
P: Pharmaceuticals
P: Psychological disorder
E: Endocrine disorder
R: Restricted Mobility
S: Stool Impaction (more commonly cause Retention of Urine than Incontinence)
Drug/Food Causes of Incontinence:
Urge: Diuretics, Caffeine, Alcohol
Overflow: AntiCholinergics, agonists, agonists, Sedative/AntiDepressant
Stress: ACEI (causing Cough)
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Approach: Hx: Age, Onset, Severity, Nature of problem
General & Neurological
Mental state
Relevant PMH include any Hx of Surgery done on Neurological or Gyne/Urological system
Examination: Above Waist: Abd Exam (For Palpable Bladder, Mass), General Neurological Exam
Genital Exam: Atrophy, Cystocele, Rectocele, Pelvic Mass, Skin Excoriations
PR: Feel for Anal Tone Fecal Soiling
Fecal Impaction & Rectal Mass
Anal Reflex, Cough Reflex, etc
BulboCarvernosus Reflex in S2-S4 (Squeeze Glans Penis/Tug Foley> Anal sphincter Contraction)
Brain disease like PD, MS, CVA
Neurological sign of Sensory, Motor, Reflex abnormalities
Ix: Frequency/Volume Chart
Flow rate & Residual volume (Normal <50ml)
Lab: Urinalysis (with Culture if Infection suspected)
RFT
Fasting Glucose (Sometimes may need to rule out DM if suspected)
Urodynamic: Gold standard, only for Complicated cases
Urodynamic Evaluation:
Flowmetry: Flow rate & Residual volume
Filling phase: Instability or Hypotonia
Voiding phase: Obstruction
Video: To look at Shape of Bladder & Bladder Neck
EMG: Striated Sphincter
LPP (Leak Pressure Point), UPP (Urethral Pressure Profilometry)
Tx: Treat according to Cause
Urge Incontinence:
Bladder Training, AntiMuscarinic, Intervention (eg. Botox Injection, Bladder Augmentation)
Stress Incontinence:
Pelvic floor Exercise, Surgery with Sling/TVT/Artificial Urinary Sphincter
Other Tx: Foley Catheter (esp for Overflow Incontinence), TransVaginal Tape, Artificial Urinary Sphincter

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Urology Erectile Dysfunction
Rule of Nine: Age: Sexual Activity:
30 x9 =27 2 weeks for 7 times
90 x9 =81 8 weeks for 1 time??
Anatomy & Mechanism of Erection:

Physiology of Erection:
Psychogenic Stimulation (Brain> SC> Penis)
> Neurogenic Activation (Cavernosus Nerve S2-S4)
> Relaxation of Smooth muscle
Dilatation of Penile Arterioles with Blood filling
> Engorgement of Corpora Cavernosal Sinus
> Stretching of Tunica albugenia
> Emissary Venous Occlusion
> Further of Pressure by Contraction of IschioCavernosus muscles
Biochemistry of Penile Smooth muscle Relaxation & Erection:
Relaxation of Cavernous Smooth muscle is the Key to Erection
Nitric oxide released in terminals of Cavernous Nerve entering Smooth muscle
> Stimulate Production of cGMP
Cyclic GMP activate Protein Kinase G, Open K channel, Close Ca channel
Smooth muscle regain its Tone when cGMP is Degraded by PDE5 (Can treat by PDE5I)
Erectile Dysfunction:
Definition: Inability to achieve/maintain Erection of sufficient Rigidity for satisfactory Sexual intercourse
NB: All Men have had incidence of Erection Failure asso. with Anxiety/Alcohol/Fatigue
This is Not Erection Dysfunction (No need Tx)
Conditions for Tx: >3 months, >50% times
Varying Presentation: No Erection at all, Only Half an Erection & Fail to Penetrate,
Failure to Keep Erection, Vary in different times
Classification:
Organic: Vasculogenic: Arteriogenic, Cavernosal, Mixed
Page 504
Neurogenic: eg. Trauma, at various level from SC to Cavernosus nerve
Anatomic
Endocrinologic: eg. DM, Androgen deficiency
Psychogenic: Generalized:
Generalized Unresponsiveness:
Primary Lack of Sexual Arousability
Aging-related Decline in Sexual Arousability
Generalized Inhibition:
Chronic disorder of Sexual Intimacy
Situational:
Partner-related:
Lack of Arousability in Specific relationship
Lack of Arousability owing to Sexual object preference
High Central Inhibition owing to Partner Conflict/Threat
Performance-related:
Associated Sexual Dysfunction (Premature Ejaculation)
Situational Performance Anxiety (eg. Fear of Failure)
Psychological Distress-related/Adjustment-related:
Asso. with ve Mood state (eg. Depression) or Major Life Threat (Death of Partner)
Pathophysiology: Prevalence with Aging
Sx of many Underlying important diseases (DM, IHD)
Condition affect Penile N/Artery/Endothelium/Smooth muscle/Tunica albuginea can cause ED
Endothelial Dysfunction is a common Final pathway to ED in Pt with HyperLipid, DM, HT, CRF
Drugs most commonly asso. with ED include AntiAndrogen, AntiDepressant, AntiHT
Typical Pt in Urology Clinic:
55 yo; DM, HT
Gradual Deterioration of Erectile function for 1 year
Now already Unable to Maintain Erection to have satisfactory intercourse
Prevalence in GP population:
Atherosclerosis 40%, HT 52%, IHD 61%, DM 64%, PVD 86%, Severe Depression 90%
(PP: It has the greatest % of Organic causes among Male Sexual dysfunctions including
Anorgansmia, Low Sexual desire, Premature Ejaculation, Retarded Ejaculation)
Hx: Confirm Dx: Sexual Hx
Ascertain Severity: IIEF score (International Index of Erectile Function)
Identify treatable conditions!: DM, HT, HyperLipid, Hypogonadism, Depression
Identify causes which may be amenable to Specific Tx:
Vascular anomalies need Reconstructive Surgery
Endocrine problem & Psychogenic cause need Tx
Sexual Hx: Clarify Sx: Erectile/Ejaculation/Orgasm/Desire problems
Psychosocial content
Chronology
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Severity
Define Pt Need & Expectation
Medical Hx: Aging, HT, DM, Arteriosclerosis (HyperLipid), Smoking, Depression, Pelvic Injury,
Neurologic/Endocrine diseases, Recreational Drugs, other Drug Hx
Drugs: Tranquillizers, AntiDepressant, Anti-HT (BB, Thiazide), Recreational
Misc: AntiAndrogen, Clofibrate, Cimetidine, Digoxin, Indomethacin
Psychogenic vs Organic:
Organic: More Gradual onset: Affect Non-Coital Erection
Psychogenic: Often Sudden onset: Ask for any Nocturnal/Early Morning Erection
Onset Circumstances Waking & Libido & Relationship Sexual
Nocturnal Erection Ejaculation problems Development
Organic 75% Gradual (Progressive) All Impaired Normal No Normal
Psychogenic Sudden (Isolated Situation Normal Normal / Yes Abnormal
25% event) Specific Impaired
PE: Usually Not need to be Complete
Genital Exam
BP
2 Sexual characteristics: Gynecomastia, Body Hair Distribution, Fat Distribution
Blood test: FBS, Lipid profile
Testosterone: Libido, Testis; (Not a routine test, check if suspicious)
RF: Risk of developing ED: CAD 1.9x, DM 2.6x, PVD 5.1x
Endocrine Test: Rare
Referred as Failed Oral therapy may need Endocrine workup
If Testosterone Normal: Full Endocrine Evaluation usually Unnecessary
Prolactin Assessment
Thyroid disease
Pituitary & Hypothalamic disease
Vascular Test: Unnecessary in most cases
Indication only for: Penile Vascular Surgery required, Medical Legal reason, Pt Request
Doppler US: Penile Arterial Sufficiency & Veno-occlusive dysfunction
DICC (Dynamic Infusion PharmacoCavernosometry & Cavernosography)
Penile Arteriography
Nocturnal Penile Tumescence (NPT) Test
Like the original Stamp test
Man achieve Rigid Erection 4-5x during Night
RigiScan: Now usually reserved for Medical Legal cases
(eg. Rape, Industrial Accident for Compensation purpose)
Flow: Medical & Psychological Hx (IIEF5, etc): Identify Psycho/Sexual cases
Identify Organic causes & RF
PE: Penile/Prostate, Neurological/Hypogonadism
Lab Test: Standard LRFT, Glucose/Lipid profile, Testosterone if indicated
Page 506
Mx:
1. General Advice & Measures for ED:
Smoking & Alcohol
Exercise
Identify & Treat treatable Causes: IHD, PVD, DM, etc
Manage Psychological aspect of ED (Be it Cause or Effect)
2. PsychoSexual Counseling:
Mainstay Tx for Couple with PsychoSexual, Relationship & Performance problem
Often Restore Sexual function
Additional Physical measure may be needed
Drug may help overcome Psychological problem by demonstrating Erection is possible
3. Local Tx: 1st line: PDE5I, Vacuum device, Sex therapy
2nd line: Penile Injection of Alprostadil (pharmaceutical name of PGE1)
rd
3 line: Combination
4th line: Penile Prosthesis, Vascular Surgery, etc; (Rare in HK)
PDE5I:
Mechanism:
Nitric oxide from Cavernous nerve cGMP> Muscle Relaxation
PDE5I (Analog of cGMP) prevent Degradation of cGMP by PDE5
NB: Sexual Stimulation from Cavernous nerve is still required for Erection
Sildenafil: Recommended dose is 50 mg, Taken as needed, About 60 min before Sexual activity
Based on Efficacy & Toleration, Dose may be to 100 mg, or to 25 mg
Work in as Fast as 25 min; Remain Active at 4-5h Post-dose
Importance of Pt Education: Sexual Stimulation is still required
Trial up to 6-8 times
(Effectiveness: 70%)
Contraindication: (2002S MCQ 38: Diabetic Retinopathy is Not a contraindication)
Pt on any form of Nitrate! (Can cause Irreversible Hypotension)
Unstable Angina, Severe Heart disease, Severe Carotid disease
Retinitis Pigmentosa
Comparison of different PDE5I: Similar Onset & Efficacy; Max Dosing Frequency 1/day
Sildenafil (Viagra), Vardenafil (Levitra):
Excellent Selectivity for PDE5 vs all PDE, except for PDE6
> Leading to Uncommon Visual S/E with Bluish & Blurred Vision (2%)
Tadalafil (Cialis):
Excellent Selectivity for PDE5 vs all PDE, except PDE11
> Produce Muscular Discomfort & Backache (9% in 20 mg dose)
Longer Half-life (17.5h vs 4-5h of the other 2 drugs); Effective Duration 36h
Common S/E:
Headache, Flushing, Indigestion, Nasal Congestion {Sx of Vasodilation}
Headache with all drug up to 15%
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More effect with dose
All are Transient & Well tolerated
Drug preference base on Speed, Duration & Perceived ability to provide Rigid Erection
PDE5I Effect on CVS:
No Nitrate (Dont take Nitrate!)
No clinically relevant effect on Hemodynamics & Cardiac function
No effect on Cardiac drugs
No Incidence of MI
No effect on Coronary A blood flow
IntraCorporal Injection:
Alprostadil (Cavarjet) Smooth muscle Relaxation
Onset: 5-20 min after injection
May need Titration form 5g to 20g
Not more than 3x/week with 24h interval
Effective in 72.6 % of cases
Priapism: Rare but need to know (>4h)
Start with 5-20 g
Penile Prosthesis:
Used as a Last resort
Irreversible damage to Corpus Cavernous tissue
Malleable Implant: Simple Surgery & Low Cost
Inflatable Implant: More Expensive, but more Natural Erection & Better Cosmetic effect
90%-95% of Inflatable Prosthesis Implants produce Erections suitable for intercourse
Satisfaction rates with Prosthesis are very High (Typically 80%-90% of Men)
S/E: Bleeding, Infection, Erosion of Prosthesis which require Removal
Rarely Mechanical Failure leading to Re-operation & Removal
Comparison of Tx options:
Tx Pros Cons
Counseling Non-Invasive, Resolve Conflict High Recurrence rate
Oral Drugs (PDE5I) Non-Invasive, 60-70% Efficacy Systemic S/E, Nitrate Contraindications
Vacuum device Minimally Invasive Unnatural Erection, Absence of Spontaneity, Petechiae,
Pain, Cold Penis
IntraCavernous Injection 90% Efficacy More Invasive, Priapism, Fibrosis, Pain
Prosthesis High Success rate Require Surgery & Anesthesia, Infection, Fibrosis
Vascular Surgery Restore Natural Erection Low Efficacy of Venous Surgery, Arterial Bypass limited to
selected Pt, Require Anesthesia & Extensive workup
Premature Ejaculation:
Definition: Ejaculate Earlier than he/his partner would like him to
Master & Johnson: Ejaculate before his Partner achieve Orgasm
Some other define: Ejaculate within 2 min of Penetration
Tx: SSRI, TCA, PDE5I, LA agent, IntraCavernosal Injection
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Dapoxetine:
Short-acting SSRI, On Demand
Approved in 2008 for On-demand Tx of Premature Ejaculation in 7 European countries
Not yet approved by FDA
2-3x Delay in Ejaculatory Latency
S/E: Nausea, Diarrhea, Dizziness, Drowsiness

Page 509
Vascular Venous Disease
LL Venous System: Superficial Venous System:
2 Major veins: Great/Long Saphenous vein (LSV), Small/Short Saphenous vein (SSV)
Deep Venous System:
Anterior & Posterior Tibial veins, Popliteal vein, Femoral vein
2 systems separated by Deep fascia, connected via Perforator veins
1-way valves which allow blood flow from Superficial to Deep veins only
Anatomy: IVC & Common Iliac V are Valveless:
If Valve in External Iliac V is Absent Congenitally/Damaged> High Pressure on SFJ Valve
Saphenous Opening: 2-4 cm below & lateral to Pubic tubercle
(VV Lecturer & CU: 2 cm) (B&L/UCH & Andre Tan: 2.5 cm)
Perforators: Besides SaphenoFemoral & SaphenoPopliteal junctions
Typically 1 over Mid-Thigh, several over Calves
Calf: Connect to Posterior Tibial V instead of Anterior Tibial V

Perforators:

LSV: 1: Hunterian (Mid-thigh)
2: Dodd (Mid-thigh (~1 hand breadth above knee?))
3: Boyd (Below Knee (~1 hand breadth below knee?))
4&5: Upper & Lower Paratibial perforators
(Not often mentioned clinically)
6: Cockett I, II, III (5, 10, 15 cm above Medial malleolus)
(Note that they are actually from Posterior Arch V)
Ankle: May/Kuster
SSV: Mid-calf perforators
Tributaries near SFJ:
Page 510
Vascular Venous Disease CVI

(During Trendelenburg operation, these potential collaterals are also Ligated)
Disease: Incompetence (Valvular), Obstruction (Thrombosis)
(Incompetence of 1 valve will put Extra pressure on Next valve> More Incompetence)
CVI
Chronic Venous Insufficiency:
Impairment in Venous Return (Venous Stasis)
Etiology:
Congenital
Primary: Postural (Stand a lot> Higher Venous Pressure in leg; Ask for Occupation!)
Secondary: Post-Thrombotic (Thrombosis> Recanalization> Valves destroyed)
Post-Traumatic
(Venous Pressure: Compression, Congenital Venous Malformation,
Pulsating Varicosities due to AV Fistula or Severe TR)
Pathophysiology: Vein Physiology: Hydrostatic Pressure, Valvular Competence, Muscle Pump
Ambulatory Venous HT (Chronically Venous Pressure, High even during Exercise)

Venous Reflux> Venous HyperPressure> Capillary HyperPressure
> Diffusion process + Leukocyte-Damaging process> Fluid Accumulation (Edema)
Clinical: Mild: VV
Mod: Swelling (Does Not happen in Foot due to Thick Extensive Fibrous network)
Eczema (Due to RBC Extravasation)
Pigmentation (Hemosiderin deposition due to Breakdown of Extravasated RBC)
Severe: Leg Ulceration
VV: Dilated Tortuous (Elongated) Palpable Superficial veins
Clinical manifestation of underlying CVI
Sx: Disfigurement, Swelling & Ache, Cx (Bleeding, Thrombosis)
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CEAP Classification of Chronic Venous Disease:
Clinical: C0: No clinical signs
C1: Telangiectasia/Reticular veins
C2: VV
C3: Edema (without Skin changes)
C4: Skin changes (Pigmentation/Eczema, Lipodermatosclerosis) without Ulceration
C5: Healed Ulcer
C6: Active Ulcer
Etiology: Congenital (EC), Primary (EP), Secondary (ES)
Anatomy: Superficial (AS), Perforator (AP), Deep (AD)
Pathophysi: Reflux (PR), Obstruction (PO), Both
Sx: Asymptomatic, Cosmetic
Dull aching Pain, Leg Heaviness, Itching in Lower extremities
Exacerbate with Long period of Standing/Hot Weather, Relieve with Elevation
PE: SFJ Incompetence: Palpable Thrill, Valsalva Maneuver, Cough
Tourniquet Exam
Ix: US: Handheld Doppler US (Bedside/Clinic), Duplex US (Vascular Lab; Gold standard)
(Bidirectional Flow: Valvular Incompetence)
(Do at Standing position)
(Both to confirm level of reflux, and exclude DVT which is a Contraindication to Surgery)
Others Unnecessary: Plethysmography, Venography
Tx of VV:
1. Conservative: Principle: Venous Pressure
Elevation
Postural Adjustment
Graduated Compression Stockings
(Usually Below-Knee, because most Pt cant tolerate Above-Knee)
(Create a Pressure Gradient> Ankle subjected to Higher Pressure)
(Must exclude PVD by palpating LL pulses before suggesting Compression stocking)
(Drug: Daflon Venotonic drug (Also for Hemorrhoid))
2. Surgery: Principle: Ligate Incompetent Perforators, Remove Diseased Veins
Conventional: Typically Trendelenburg operation + Stripping Avulsion
Deal with Superficial Venous Incompetence:
LSV: Trendelenburg operation: High Ligation of SFJ including all Tributaries
Stripping: Recurrence: Reflux from Thigh Perforators or Neovascularization
Limited to Thigh to avoid damaging Saphenous Nerve below knee
SSV: High Ligation of SPJ
Usually No need Stripping (Avoid damaging Sural Nerve)
Deal with Varicosities:
Leave them alone (Mild VV may regress after controlling Superficial Venous Incompetence)
Stab Avulsion
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Deal with Perforator Incompetence: Uncommonly done
Ligation of Perforators (Perforator Interruption):
Approach: Open: Lintons procedure (obsolete)
Endoscopic: Subfascial Endoscopic Perforator Surgery (SEPS)
(May be indicated in Severe CVI Not controlled by Superficial Venous Surgery)
(WK Cheng: Nowadays seldom do SEPS anymore as its Not very effective)
MIS: Similar Efficacy & Recurrence, but other outcomes better; Often Self-financed
Deal with Incompetence:
Modalities: (Done under US guidance)
Heat based: Endovenous Laser Tx (EVLT), RFA (VNUS Closure)
Non-Heat based: Glue (VenaSeal) (Active ingredient: Cyanoacrylate)
Pros: Less LA, Less Post-op Analgesic
No need Stocking
Burn damage to Skin/Nerve (Pros of Glue)
Immediate discharge
Cons: More Expensive
Deal with Varicosities:
Injection Sclerotherapy
Avulsion (ie. MIS approach for Superficial Venous Incompetence + Avulsion Surgery)
Contraindications:
Eg. Deep Vein problems (eg. Hx of DVT) (Will Impair Venous Drainage)
Cx: Recurrence
Bleeding, Infection
Nerve injury: LSV Stripping can damage Saphenous nerve> Medial Leg/Ankle Paresthesia
SSV if Stripped can damage Sural nerve
Thrombophlebitis (in Residual veins)
DVT: Conventional Surgery: Standard DVT risk as in General Surgery due to Immobility
Endovenous Surgery: Slightly Higher DVT risk, esp if catheter goes beyond SFJ
Intra-op US guidance & Post-op Duplex required for evaluation
Tx of Reticular Varicosis/Spider Veins:
Injection Sclerotherapy: (Better for SC veins)
Inject Sclerosant Detergents (Surfactants) (1% Sodium Tetradecyl sulphate, aka Sotradecol)
Irreversible Full Thickness Mural Denaturation> Reabsorption
Not recommended as Primary Tx
Compression after Sclerotherapy is Essential
External Laser: (Better for Cutaneous veins)
Severe CVI: Post-Thrombotic/Post-Phlebitic Syndrome, Chronic Venous Stasis, Chronic Venous HT
C4-C6: Pigmentation, Edema, Eczema, Ulceration
Venous Ulcers: After Minor injury
Often Painless, well-defined border, Shallow Ulcer with Yellowish base, Medial/Lateral Malleoli
Etiology: Fibrin Cuff vs Leucocyte Adhesion Theory
Page 513
(Fibrinogen leaks into tissue & forms cuffs in Capillary
> Prevent diffusion of O2 & Nutrients to skin> Local Ischemia)
Tx: Venous Pressure: Posture (Leg elevation)
Dress Ulcers: Bandage (Compress Dressing), Antibiotics if Infection
Lifestyle: Exercise, Diet to Weight
Topical Ulcer Tx: Skin Grafts
Superficial Venous Surgery: Superficial Reflux
Deep Vein Reconstruction: Deep Reflux (Rarely done)
Superficial vs Deep Venous Insufficiency:
Superficial Venous Insufficiency Deep Venous Insufficiency
Etiology Primary VV Late Cx of DVT
Pathogenesis Incompetent Perforator veins: Incompetent Deep veins:
Blood flow from Deep to Superficial Pressure in Deep system
system > Blood flow from Deep to Superficial system
(NB: Associated Perforators may lead to Secondary VV)
Skin Changes Mild Severe
Prognosis Better response to Surgery Worse response to Surgery
(WK Cheng: Concept now is that Superficial Venous Insufficiency can lead to Severe CVI too)

Page 514
DVT
Site: >90% in LL veins
Others: Pelvic veins, UL veins (Central Line, Thoracic Outlet syndrome)
Risk of Emboli dependent on Extent of Venous Thrombus
Cause Virchows Triad:
Venous Stasis, Endothelial damage, HyperCoagulability
RF: Malignancy: *Nonsurgical cause (YLK: Always suspect this!)
Surgery: Esp Orthopedic
Trauma: SCI, LL Fracture, Multiple Trauma
Immobilization: AMI, CHF, Paralytic Stroke, Post-op convalescence
(YLK: In Chinese, No cases of DVT ever due to Long-Haul Flight >4h)
Pregnancy: Antepartum/Postpartum; Also note for AntiPhospholipid syndrome
(YLK: Estrogen> Clotting factors to prepare for Delivery by Bleeding)
Estrogen: OCP, HRT
Hypercoagulable state:
Inherited: Protein S & C deficiency, Anti-thrombin III deficiency, Dysfibrinogenemia
Acquired: AntiPhospholipid, SLE, MPD, DIC, HyperHomocysteinemia (can be Inherited)
Central Venous Catheter: Eg. Low Femoral Vein Catheterization
Others: Age, Obesity, Previous/FHx of DVT, VV
Clinical: Silent (PhleboThrombosis)
ThromboPhlebitis: Signs of Acute Inflammation (Swelling, Tender, Warmth, Redness)
Homans Sign (Ankle Dorsiflexion while Knee Extended> Calf Pain):
Low Sensitivity/Specificity; Also chance to dislodge thrombus?
Venous Gangrene
Dx: 50% DVT are Silent
Venous Duplex (Gold standard):
If ve, can do D-dimer to exclude DVT (But if D-dimer +ve, do 2nd Duplex or Venography)
Venogram (Previous Gold standard too; Replaced by Duplex)
Cx: Acute: PE
Chronic: PostThrombotic Syndrome
CVI (Clot Recanalization> Valve destroyed)/Chronic Venous Obstruction> Venous HT
Tx: Goal: Prevent PE, Relieve Acute Sx, Prevent Recurrent DVT, Prevent Post-Thrombotic sequelae
Conservative: Bed Rest, Elevation, AntiCoagulation
AntiCoagulant: (2013 SAQ 8)
IV Heparin/SC LMWH for 5 days, followed by Oral AntiCoagulants (Warfarin) for 3 months
LMWH: Greater Anti-Xa activity
PK Advantage: Less binding to Plasma Proteins/Mc, More Predictable,
Longer t1/2, Better Bioavailability, Dose-Independent Clearance
Warfarin: Has initial Prothrombotic effect; Use after Heparin effect achieved
Risk of Fatal PE: 0.3-0.4%
Aggressive: Catheter-directed Thrombolysis (usually for those with Venous Gangrene)
Page 515
Vascular Venous Disease DVT
Venous Thrombectomy
Prophylaxis: Stasis: Physical: Posture, Stocking, Intermittent Pneumatic Compression
Trauma: Avoid
Coagulability: Drugs: Heparin (Low dose, SC)
IVC Filters: Not a Tx of DVT, but to prevent PE
Indications: Recurrent PE despite adequate AntiCoagulation
AntiCoagulation Contraindicated
Uptodate: Absolute: Active Bleeding
Severe Bleeding diathesis, PLT <50
Recent/Planned/Emergent Surgery/Procedure, Major Trauma
Hx of Intracranial Hemorrhage
Hx of Heparin-induced Thrombocytopenia (2002S MCQ 84)
Relative: Recurrent Bleeding from Multiple GI Telangiectasia
Intracranial/Spinal tumors
PLT <150
Large AAA with concurrent Severe HT
Stable AD
(NB: For Distal DVT below Popliteal veins, if AntiCoagulation is Contraindicated,
Surveillance US may be acceptable)

Page 516
Vascular Venous Disease DVT
SVT
Superficial Vein Thrombophlebitis:
Thrombus formation in Superficial vein> Inflammation in surrounding tissue
Often occurs in Great Saphenous vein & its tributaries
Can also occur in veins of UL/Neck (usually due to IV cannulation & Drug administration)
Cause: *Prothrombotic conditions
VV
AI disease (esp Buergers disease & SLE)
Infective: Suppurative Phlebitis (Cx of IV cannulation)
Trauma
Special entity Thrombophlebitis migrans:
Recurrent Migratory form (eg. from 1 leg to another)
Asso. with Malignancy (Trousseaus sign of Malignancy), esp AdenoCA (*Pancreas, Lungs)
Clinical: Previous Hx of SVT, DVT, PE
Painful Cord-like Swelling
Induration, Erythema & Tenderness correspond to Dilated Superficial veins
May also have signs of CVI, PE
Ix: Doppler US: Rule out concomitant DVT, Assess Location of Thrombus
Vein Biopsy: Dense Inflammatory cell Infiltration & Thickened wall
Other Ix for PE & Malignancy
Tx: Usually Self-limiting, Resolution within 1 month
Conservative to relieve Pain & Swelling:
NSAID, Compression stockings, AntiCoagulant (if also DVT/PE), Local Heat & Elevation
Surgical Excision of involved veins if Conservative measures fail
Treat underlying causes

Page 517
Vascular Venous Disease SVT
Vascular PVD
PVD Problems: Leg Pain, Foot Ulcer/Gangrene
Arterial Occlusive disease:
Acute Occlusion: Embolism, Thrombosis, Trauma
Chronic Occlusion: Atherosclerosis, Vasculitis, Entrapment
Atherosclerotic Occlusive disease:
RF: Smoking, DM, HT, HyperLipidemia, FHx (HyperHomocysteinemia)
Comorbidity: IHD, Stroke, Renal HT, AA
Atherosclerosis is a Systemic disease! (PVD is also an independent RF for CVD)
Chronic LL Ischemia (Chronic Arterial Occlusion):
Non-Critical Limb Ischemia:
Asymptomatic vs Symptomatic (Intermittent Claudication)
Critical Limb Ischemia:
Definition by Presentation + Objective Measurement
Presentation:
Persistent Rest Pain requiring regular Opioid Analgesic for 2 weeks,
or presence of Tissue Loss (Ulceration/Gangrene) of Foot/Toe
Objective Measurement:
Resting Systolic Ankle Pressure <50 mmHg, or Systolic Toe Pressure <30 mmHg
Ankle Brachial Index 0.4
Severity Classification:
Asymptomatic
Intermittent Claudication
Rest Pain
Tissue Loss (Ulcer/Gangrene)
Intermittent Claudication:
Pain in Muscle groups (*Calf, Thigh; Uncommonly Buttock, Arm)
After Walking for a specific distance Claudication Distance (Reproducible)
Worse when Hurrying, Up/Down Hill/Stairs
Relieved by Short Rest
Cause: Inadequate blood supply to Muscle groups (Muscle Ischemia) when Demand
Basal Metabolic Rate is still maintained> Not an emergent threat
In General: Single-level Stenosis/Occlusion: Claudication
Multi-level Stenosis/Occlusion: Rest Pain, Tissue Loss
Hx: Speed of Onset: May reflect Etiology
Fast: Embolism
Slow: Thrombosis in-situ, Atherosclerosis
Muscle groups: Level of Stenosis/Occlusion
Walking distance: Severity; Often Unreliable/Subjective
Progression: Worsening, Stable, Improvement
(Relapse & Remission possible, due to opening up of Collateral
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Vascular PVD
But ultimately will get worse)
Lifestyle impact
Ddx: Other Causes of Vascular Claudication:
Buergers disease, Takayasus Arteritis, Ergot Toxicity, Vasospasm
Neurogenic Claudication (Spinal Stenosis):
Also Exercise-induced Leg Pain
But asso. with Neurological Sx (eg. Paresthesia), Relieved by Spinal Flexion
Claudication distance more variable
Normal Pulses
OA: Pain on 1st step
Ischemic Rest Pain:
Inadequate blood supply to Skin (Skin & SC tissues Ischemia) (Muscles have Rich blood supply)
Occur in areas furthest from blood supply
Pain in Toes, Forefoot, Ankle; (Not Calf; If Rest Pain in Calf, already Irreversible change in Foot)
Pain at Rest, Aggravated by Elevating Leg, Relieved by placing Leg in Dependent position
At Night: Frequently Worse: Lack of Gravity-induced in Arterial blood flow
Lower MAP/Perfusion pressure during sleep
Pt may need to sleep in a Chair to keep foot in Dependent position
Edema is NOT a classic feature of Rest pain
Cause: Hypoxia of Cutaneous nerves
Critical Ischemia, Not a Severe form of Claudication
Ischemic Ulcer/Gangrene:
Tissue Loss manifested by Painful Ulcer or Gangrene (Dry/Wet)
Usually over Pressure areas (Toes, Heel, etc)
(Toes, Bunion area, Metatarsal heads, Lateral Malleolus)

Arterial Ulcer:
Painful Deep Punch-out Ulcer worse at Night, over Toes/Heels/Shins, Lack Granulation tissues
Usually arise from Minor Traumatic wounds with Poor Healing
Skin Dry & Scaly, Hair Sparse/Absent, Toe nail thickened, /Absent Pulse
Elastic Stocking Contraindicated! (Thus must ddx from Venous Ulcer)
DM: Peripheral Arterial Disease: Macrovascular (usually Infra-Popliteal), Microvascular
Peripheral Neuropathy (Neuropathic Ulcer may be Painless)
Prone to Sepsis, Poor Healing, Poor Glycemic Control
Gangrene: Cyanotic, Anaesthetic tissue associated with or progressing to Necrosis
Occurs when arterial blood supply falls below minimal metabolic requirements
Dry: Hard, Dry texture; Often has a clear demarcation between Viable & Necrotic tissue
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Vascular PVD
Occurs in Pt with Atherosclerotic disease
Safe, can be allowed to autoamputate after demarcation with precautions against Infection
Wet: Infected Dry Gangrene
Edematous (Moist & Swollen), Indistinct margin (Cellulitis), frequently Blistered, may see Pus
Often occurs in Diabetics with Sensation & Unrecognized Trauma
Require Emergent Surgical Debridement/Amputation (Can cause Sepsis)
Clinical Evaluation: Arterial disease? Acute/Chronic? Severity? Site of Obstruction? Reason?
Major Level of Obstruction:
AortoIliac: Large vessels, Claudication (Thigh, Calf), Impotence (Internal Iliac), Absent Femoral pulse
(Sometimes may have AortoIliac Bruit)
Leriche syndrome:
Triad of Buttock Claudication, Impotence in Men, Absent Femoral pulses
FemoroPopliteal:
Claudication (Calf), Tissue Loss, Absent Popliteal pulse
Distal: Small vessels, Tissue Loss; Prognosis is Worse than Large vessels disease
(Foot Claudication rarely occurs alone, but may occur in Buergers disease?)
Assessment of LL Ischemia:
Pt: RF: Elderly, Cardiac/Pulmonary dysfunction, Smoker
Limb: Limb at Risk Rest Pain/Tissue Loss > Absolute Indication for Intervention
Limb Not Threatened Claudication > Relative Indication for Intervention
Ix: Basic Lab Ix, Pre-op Assessment
Handheld Doppler US: (In QMH, usually just proceed to Duplex)
Ankle-Brachial (Pressure) Index, Segmental BP, Waveform Analysis

ABI: Ankle-Brachial Systolic Pressure Ratio: Assess Severity of Ischemia
Procedure:
Pt Supine
Ankle Pressure: Pneumatic pressure cuff applied just above Ankle in Lower Calf
Handheld Doppler over Posterior Tibial & Dorsalis pedis
Inflate cuff till Arterial signal disappear, then slowly deflate until re-appear
Take the Highest reading of the 2 Ankle Pressures
Brachial Pressure also measured for Both arms (ie. 1 Ankle 2 Readings + 2 Arm Readings)
Formula:
Highest Systolic Ankle Pressure (DP/PT) Highest Systolic Brachial Pressure (R/L)
Value: Progressive Lower value: Worsen Arterial disease
Normal: 1.0-1.1 (UCH: 0.9-1.2) (SBP of LL usually slightly Higher than UL)
Claudication: 0.6 0.2 (0.4-0.9)
Rest Pain: 0.3 0.1 (0.2-0.4)
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Tissue Necrosis: 0.1 0.1 (0-0.2)
Limitation:
Significant Bilateral Subclavian Stenosis
Long-standing Renal Failure or *DM: Calcinosis of Arteries
(ABI >1.2 may suggest Incompressible Calcified wall; May do Toe Pressure Index instead)
Venous signal confused with Arterial signal
Triphasic/Biphasic/Monophasic signals
Treadmill Exercise Testing:
Resting ABI may be nearly Normal in Mild PVD with Intermittent Claudication only
Measuring ABI before & after Treadmill Exercise will show ABI
(Andre Tan: >0.2 = Claudication)
Segmental Pressure:
Cuffs at Above Ankle, Mid Calf & Mid Thigh
Sequential Inflation & Deflation of each cuff
(UCH: Pressure >20 mmHg across segments suggestive of significant Stenosis)
Duplex US: Non-Invasive Vascular Lab
US-based; Segmental Pressure, Waveform Analysis, ABI (Ankle-Brachial Index), Exercise Test
Duplex US is 1st line now, cf Angiography; (Good for Large vessels)
Arteriography: Indicated Only when Surgery planned; Not used for Dx (ie. Not for Claudication)
(May be shown for Interpretation to get distinction in OSCE)
DSA, MRA (Expensive), CTA (Radiation, Difficult to interpret Contrast from Calcification)
Tx of Intermittent Claudication (Important!!):
Atherosclerosis is a Systemic disease> Not only treating Claudication
RF Modification + AntiPlatelet + Exercise usually enough for many Pt
Improve Survival:
RF Mod: Smoking Cessation, DM control, HT control, Lipid lowering therapy (Statin)
Drugs: AntiPlatelet (Purpose is to Survival but Not to improve Sx, ie. Risk of MI, Stroke)
Improve Sx: (Improve Walking distance)
Exercise: Stimulate Collateral formation to improve Sx
Supervised Regular Exercise (Exercise Advice alone Not helpful); Avoid Strenuous Exercise
Drugs: Vasoactive Drugs Effectiveness still Controversial
(Lecturer: Only Pletaal has been shown to have some use, but Cardiac S/E)
Naftidrofuryl (Praxilene):
5HT antagonist; Improves Aerobic metabolism & possibly RBC & Platelet aggregation
4 RCT show that its better than Placebo, but Clinical effect is Small
Pentoxyphylline/Pentoxifylline (Trental):
2 RCT show No significant difference from Placebo No clinical evidence
Cilostazol (Pletaal): (2009 MCQ 31)
PDE III Inhibitor; Intracellular cAMP, both Vasodilator & AntiPlatelet actions
4 RCT show better than Placebo/Trental in QOL & Small of ABI; Strong evidence
Contraindicated in HF of any Severity
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Vascular PVD
Endovascular
Surgery
Intervention for Chronic Arterial Obstruction:
(Main Tx is usually Endovascular Angioplasty vs Bypass Grafting Surgery)
Indication: Disabling Claudication, Limb Salvage (Critical Ischemia) (Target is to avoid Amputation)
1. Local procedures Endarterectomy:
Cut Intima (and a bit of Media)
Larger vessels, Short segments, Stenosis (rather than total Occlusion)
Mainly done on Iliac/Carotid (more accessible)
2. Percutaneous Transluminal Angioplasty (Balloon Angioplasty Stenting):
Pros: Low Risk (can be done under LA), Repeatable, Short Recovery, Cost?, Low M&M
Limitations: Durability (Long Stenosis, Occlusion), Stents (do Not improve Patency),
Drug-Eluting?
More suitable for TASC type A/B/(C) of AortoIliac or FemoroPopliteal lesions,
but Surgery for Advanced Type D lesions (and some Type C lesions)
(Angioplasty in general is more effective for Focal Stenotic lesions & Large vessels)
(Subintimal Angioplasty: New technique to tackle Longer segment Stenosis)
Stent: Recurrence, In-stent Restenosis, Stent Fractures
3. Arterial Bypass: (Less commonly done nowadays; 2nd line to PTA)
(Below Knee Bypasses are reserved for Limb salvage; Usually Not done for Claudication
Also Vein cuff may be done for Below Knee Bypasses)
Anatomical vs ExtraAnatomical:
Anatomical:
AortoIliac, AortoFemoral, FemoroPopliteal
Better Patency rate, but need a Major Abd Surgery in AortoIliac disease
ExtraAnatomical:
FemoroFemoral (from 1 Leg to another), AxilloFemoral (from Arm to Leg)
Usually for Old Pt with Aorto- disease which Abd Surgery is to be avoided
Bypass Graft:
Biological Graft:
Autograft: Long Saphenous Vein (Either Reverse it or Cut the valves)
(Takes Longer time to harvest vein than Prosthetic
Surgeons use the excuse of preserving the vein for CABG)
NB: 2001 MCQ 36: Autologous Vein graft is 1st choice for FemoroPopliteal Bypass
Allograft: Dacron coated Umbilical Vein (No Longer used)
Synthetic Graft: (White Tube, cf Yellow tube for Drains)
Dacron Graft: Fabric
For Large vessels (No need to care about Patency in Large vessels)
Woven (No Leaks, but Poor Handling) vs Knitted (Good Handling, but Leaks)
Gortex Graft: Polymer (PolyTetraFluoroEthylene PTFE graft)
Difficult to Suture, but better Patency (ve charge> Repel Platelets)
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Vascular PVD
For Small vessels (2nd choice after Veins for Below Knee)
4. Amputation: Only after Neovascularization (Otherwise Wound can Not heal> Wet Gangrene)
(Unless Debridement for Wet Gangrene)
Level of Amputation depends on Vascularity, Indication, etc
BKA: Long Posterior Flap/Skew Flaps
Tibia divided 7 cm below Tibial Tuberosity, Fibular divided Higher
All Vessels Ligated/Transfixed
Perfusion of Posterior Flap is essential for Healing
Pros: Maintain Knee Joint (Higher Rehabilitation potential; Can walk a bit easier)
Cons: Prone to Stump Necrosis (Poor Collaterals)
AKA: Equal Anterior & Posterior Myocutaneous Flaps
Femur divided 1 hands breath (11 cm) above knee joint
Transfix/Ligate SFA/SFV separately with 0 Silk/Prolene
Divide Sciatic nerve High
Close in 2 layers of Vicryl
Pros: Excellent Healing potential
Cons: Poor Mobility (good for those Not expecting to walk again)
Buergers disease (ThromboAngiitis Obliterans): (2007 MCQ 39)
Young (30-40), Male, Smokers
Uncommon; More prevalent in Mediterranean/Middle East/Asia than Caucasians
AI Pan-Arteritis; Medium & Small Sized Arteries & Veins; LL>UL
Clinical: Rest Pain, Digital Ulcer, Gangrene
Dx: Clinical Dx
Arteriogram: Tree Trunk configuration, Corkscrew Collateral development
Tx: Reconstruction seldom possible; Stop Smoking is effective (2007 MCQ 39)
Summary: Elderly: Think Atherosclerosis
Young: Smoker: Think Buergers disease
Non-Smoker: Think Entrapment syndrome
Arterial diseases Common Pitfalls:
MisDx of Claudication
Toe Amputation Before Neovascularization
Delay Recognition of Acute Ischemia
Beware of Leg Pain
Treating the Angiogram: Intervention for Asymptomatic disease
Tx Summary:
Asymptomatic: Do Not treat
Leg Pain: Acute Ischemia: Revascularization
Chronic Ischemia: Indications> Revascularization
Tissue Loss: Do Not Amputate> Indications> Revascularization

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Vascular PVD
Vascular Acute LL Ischemia
Acute Arterial Occlusion:
Acute Limb Ischemia (Andre Tan definition):
Sudden in Limb perfusion that causes a potential threat to Limb viability
in Pt who present within 2 weeks of Acute event (If >2, consider Chronic Ischemia)
Emergency; Prompt Dx & Tx; Blood flow must be re-established within 4-6h
Skeletal muscle can only withstand up to 6h of Warm Ischemic Time
Pt with preceding PVD can tolerate a bit Longer due to established Collaterals
Delay: Loss of Limb/Loss of Life
Cause: Acute Embolism, Acute Thrombosis, Trauma
*Embolism: Note that Emboli can propagate after causing obstruction
Cause: *Cardiac: AF, Recent MI, VHD (& Prosthetic heart valves)
Non-Cardiac: Ulcerated Atherosclerotic Plaque, Aneurysm
(Uncommon to cause complete arterial occlusion)
Site: Tend to lodge at Bifurcations
*Femoral Artery, Popliteal Artery (2nd)
Others: Aortic Bifurcation (Saddle Embolus> Can block both branches> Affect both LL),

External & Internal Iliacs, Arm
Acute Thrombosis:
Lecturer: Pre-existing ASOD, Previous Bypass, Acute Dissection
Cause: Thrombosis on Ulcerated Atheromatous plaque (Acute on Chronic PVD)
UCH: Usually precipitated by BP
Ddx from Embolism: Important as Tx is different
Ischemia may be Less Severe as Collaterals formed around chronically stenosed BV
May have Claudication Hx
Chronic PVD features on Contralateral limb, No source of Embolus identified
Uncommon: Vasculitis, AntiPhospholipid syndrome (Hypercoagulability), Ergotism
Vascular Trauma (Arterial Injury):
Penetrating vs Blunt
(Also Iatrogenic: Due to Endovascular Diagnostic/Interventional procedures)
High index of Suspicion; Recognize signs of Acute Ischemia; Arteriography if in doubt
Note that Compartment syndrome can result from Trauma too
Penetrating:
(Can cause development of AV Fistula that shunts blood away)
Distal pulse may be Normal
In doubt: Angiography
Blunt: Adjacent to Fractures
Intimal tear> Thrombosis
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(Only Intimal tear, as Media & Adventitia have Elastin to resist stretching)
Often Delayed Dx
Spasm should only be diagnosed at operation
In doubt: Angiography

(Others: Dissecting Aneurysm
Vasoconstrictive Drug: Adrenaline in ICU Pt, Ergot for Migraine)
Presentation 6P: {3 Sx, 3 Signs}: Pain, Paresthesia, Paralysis; Pallor, Pulseless, Perishing Cold
(Sensitivity to Ischemia: Nerves > Muscle > Skin > Bone
Thus Pain & Paresthesia develop relatively Early)
Pain: Acute Pain, starts at Distal part & progresses Proximally
in Severity with Time, but eventually may as Nerves die
Ask for Hx of Previous Claudication Pain (may develop Acute Thrombosis)
Paresthesia: Starts with Paresthesia (Glove & Stocking pattern), eventually Complete Sensory Loss
Progression (Andre Tan):
Light touch> Vibration> Proprioception> (late) Deep Pain> Pressure sense
Pallor: Color may be Pale Pink, but in Severe Ischemia can be Marble-white (esp in Embolism)
Andre Tan: Other Colors: Pale> Cyanosis> Mottling> Fixed Cyanosis & Mottling
Mottling/Marbling (patches of Blue on White):
Deoxygenation of Stagnant blood
Surrounding areas of Pallor due to Vasoconstriction
Duskiness: Deoxygenation of Stagnant blood
If Fixed staining (ie. Does Not blanch on P), then limb is Non-viable
Black: Gangrene
Discoloration usually affects a Large part of Distal Limb
(cf Chronic Ischemia may affect only 1 toe)
Site of Arterial Occlusion usually 1 joint above Line of demarcation
Pulselessness: If feel at least 1 good pulse, unlikely Ischemic but still possible
If cant feel pulse, assess with Handheld Doppler (can have flow without palpable pulse)
Paralysis: Initially Heavy limb, Later Muscle Turgidity in Irreversible Ischemia
Total Paralysis occurs Late, usually limb is Non-viable
Detects Late as Intrinsic Foot muscles are paralyzed before Leg muscles
(Toe movements are mainly controlled by Leg muscles)
Can assess Viability by a cut: Viable usually Shiny & Twitch, Dead usually Dull & wont twitch
Reperfusion of Dead muscle is dangerous (Circulation of Toxic metabolites)
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Severity Classification:
Category Viable Threatened Non-viable
Marginally Threatened Immediately Threatened
Pain Mild Moderate Severe (Rest pain) Variable (Anesthesia)
Capillary refill Intact Intact/Delayed Delayed Absent (Fixed stain)
Motor deficit None None Partial Complete
Sensory deficit None Mild Partial Complete
Arterial & Both Audible Both Inaudible
Arterial Inaudible, Venous Audible
Venous Doppler
Description Not immediately Salvageable if promptly Salvageable if immediately Not Salvageable
threatened treated revascularized Amputation
Hx: How Acute? How Long? Is the Leg Viable?
Pre-morbid state
Previous Claudication?
Embolic source? (AF, Angina, MI, AAA)
Pulses present in other leg?
Always think of: Aortic Dissection/Aortic Emboli (Back Pain, Young age, Marfans)
PE: AF? AAA?
Viable/Non-viable: Gangrene (usually Acute or Chronic)/Fixed Mottling/Blistering?
Capillary Return
Calf: Soft/Hard (Compartment Syndrome)
Any Sensory/Motor function
Any Pulses in the other leg?
Note: Is it worthwhile to Revascularize/Amputate
Acute Mx:
Resuscitation: Oxygenation, IV Hydration
Doppler US: Severity, Level of obstruction
Early AntiCoagulation:
Start quickly if suspicion of Acute Limb Ischemia is High to avoid Clot propagation
IV Heparin (Bolus/Infusion): Bolus 3000-5000 units, then Infusion at 1000 units/h
LMWH may be an alternative to IV Heparin
Aspirin/Statin if No Contraindications
Analgesia
Measure to improve existing Perfusion:
Keep foot dependent
Avoid Pressure to heel, Extremes of Temp
Max tissue oxygenation (O2 supplementation)
Correct Hypotension
Treat other asso. conditions
Ix: Pre-op Ix: Blood test: CBC, RFT, Clotting, T&S, ABG (Lactic Acidosis), CK (Muscle Necrosis)
ECG: MI, Arrhythmia
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CXR: Aneurysm, Widened Mediastinum
Cardiac enzymes if suspect AMI
Anaesthetic assessment
NB: Other special tests may Delay Tx: Eg. Duplex, IADSA (Intra-Arterial DSA)
Angiography: Embolism is often a Clinical Dx (No need Angiography if High suspicion of Embolism)
Can be done if Viability Not Immediately threatened
On-table Angiography may be done in Immediately Threatened limb (Emergent OT)
(Duplex Scan: May be useful if suspect Aneurysms)
Definitive Revascularization Tx: Urgent (2011 MCQ 90)
Surgery (Embolectomy vs Bypass) vs Thrombolysis
Examples: Thrombo-Embolism: Embolectomy under LA
Thrombosis in-situ/Atherosclerosis: Angiogram Angioplasty Thrombolysis Bypass
Thrombosed Popliteal Aneurysm: Thrombolysis (Risk of Bleeding & Stroke >1%)
Fasciotomy
Surgery: Embolectomy (Fogarty Embolectomy Catheter) (For Embolism)
Bypass (Endarterectomy may Not be ok for long segment Thrombosis)
Others: Prophylactic Fasciotomy (Prevent Compartment syndrome)
Primary Amputation if Non-viable
Endovascular procedure:
Intra-arterial Thrombolysis (For Thrombosis & Some Embolism, eg. in diseased artery)
Intra-arterial Local infusion vs Systemic infusion
Streptokinase, Urokinase, Tissue Plasminogen activator
(Streptokinase less used now as it may trigger Ab response> Anaphylaxis)
Effective alternative Tx to Surgery
Cons: Takes time (Longer than Embolectomy)
Need Interventional Radiologist/Facilities
May need further procedure Bypass, Angioplasty
Intracranial Bleeding: 1-2%
Angioplasty, Stenting
Cx: Compartment syndrome, Electrolyte Imbalance (HyperK), Rhabdomyolysis/Renal Failure
(Tx-related Cx: Eg. Reperfusion Injury, Stroke)
Vascular Trauma: ATLS Protocol: ABC + Resuscitate
Signs: Hard Signs: Absent Pulses (assess by Doppler), Ischemic Limb, Active Bleeding,
Expanding Hematoma
Soft Signs: Small Hematoma, Hx of Shock at scene, Unexplained Hypotension
Mx: Explore: If Unstable, Penetrating Injury (with on-table Angiogram), Septic Wound,
Active Hemorrhage + Fasciotomy
CTA: If Stable or Blunt Trauma
Role of Endovascular Technique: Embolization/Covered Stents

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Vascular Aneurysm, AAA
Aneurysm:
Definition: Permanent Localized Dilatation of Artery by 50%in diameter (Abd Aorta: Normally ~2 cm)
Classification: Mostly True Fusiform Atherosclerotic Aneurysms
By Form: Fusiform: Uniform
Saccular: Bulging on 1 side
Dissecting: Not exactly an aneurysm; Used in Old textbooks

By Structure: True: 3 layers: Intima, Media, Adventitia
(Wall) False: Single layer of Fibrous tissue
Hematoma formed Outside Arterial wall contained by Surrounding tissue
Due to Wall defect (No complete Arterial wall)

(By Etiology: Atheromatous, Mycotic (Bacterial), Collagen disease, Traumatic)
Cx: Rupture, Thrombosis, Embolism, Infection, Pressure effects
(Aneurysm in Large vessels usually Rupture, while in Small vessels usually ThromboEmbolism)
2003 MCQ 59: Organism in Mycotic Aneurysm: *Staphylococcus aureus, Salmonella, etc
AAA: M>F (2006 MCQ 23: Usually Elderly Male)
97% InfraRenal, 95% associated Atherosclerosis, 20% associated Aneurysms (*Popliteal)
Expansion: LaPlaces Law ~5 mm/year
Risk of Rupture at 5 years: <5 cm (20%), >5 cm (50%, 10% per year)
Pathology: Loss of Elastin & Smooth muscle cells
Disruption of ECM
Deposition of Adventitial Collagen
Thickening
Inflammatory Infiltrate
Cause (Multi-factorial):
Mechanical: Degeneration, BP
Enhancement of Proteolytic activity (MMP)
Genetic: Marfan, Ehlers-Danlos IV
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AI
Infection
Clinical: *Asymptomatic: Incidental, Pulsatile Abd Mass
Symptomatic: Pain! (Impending Rupture)
(Abd/Back Pain; Expanding Pain =/= Rupture Pain)
PE: Confirm AAA: Mass above Umbilicus, Expansile Pulsation, (Bruit: Nonspecific, in small % of Pt)
Extent of AAA: Size, Upper Border (Goes into Rib cage: Likely SupraRenal),
Lower Border (Iliac Involvement if bulge into Iliac fossa)
Cardiovascular: Pulse, Heart, BP
Check for concomitant Aneurysms, eg. Iliac (Rarely Isolated), Femoral, Popliteal
(Embolization): Cholesterol Embolism: (Usually due to Distal Aneurysms, eg. Popliteal)
Blue Toe Syndrome/Trash Foot: Cyanotic toes while Palpable Pedal Pulse
Livedo Reticularis: Mottled Reticulated Vascular pattern on Skin
Ix: AXR: Aneurysm visible if Calcified outline, but 25% Not Calcified; Not always needed
US: Standard Imaging tool; Good for Bedside Screening
Good for Size Documentation, May see Mural Thrombus
Contrast CT: Good for Pre-op Planning
Can better define Aortic Size, assess Extent (eg. Suprarenal Extension, Visceral A involvement)
Angiography: May Underestimate Diameter Mural Thrombus may Luminal Size
Good for determining Stent Graft placement & Monitor Endoleaks/Migration
Indication: 2001 MCQ 26: Aneurysm involving Iliac bifurcation is Not an indication
Screening: US screening beneficial in Men over 65: Mortality in Men (AAA-related deaths)
Op Considerations:
Indication: Sx: Any Sx = Urgent (Pain, Ureteric Obstruction, Embolism, etc)
Leaking/Ruptured AAA
Size: >5 cm (Asian) (or >5.5 cm Caucasian) (or if Saccular) (Thoracic AA: 6 cm)
Expanding (>0.5 cm/year)
Small: Surveillance (Eventually need Repair when Large)
Contraindicate: Medical Risk: Associated diseases
Limited Life Expectancy
NB: Age is Not a Contraindication
Op Mortality: Risk of Op: Intact Aneurysm 3-5%
Risk of Rupture: Ruptured Aneurysm >50%, UnOp Rupture 100%
Pre-op Preparation: (Exam Q: If just allow doing 3 tests, do CXR, ECG, CT)
General: Blood tests, ECG, CXR
Cardiac: Cardiac Assessment/Intervention
Preparation: Monitors, Blood
Major Op Mortality: MI! (2002S MCQ 22)
Surgical Tx: Open Repair: Aneurysmectomy + Inlay Graft
*Endovascular Aneurysm Repair (EVAR): Aortic Stent Graft
(BB can Peri-op Cardiovascular M&M)
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(Graft: Tube/Bifurcation Graft; Autogenous Saphenous Vein for Popliteal Aneurysm)
Open Repair: (Dacron graft is commonly used) (2007 MCQ 32, 2004 MCQ 71, 2003 MCQ 27)
Cx: Early:
*General: Cardiac: Clamp/Declamp
Respiratory
Specific: Hemorrhage
Bowel Ischemia: (Higher risk for Ruptured AAA repair) (2009 SAQ 5, etc)
Site: Small bowel: Aka Mesenteric Ischemia
Abd Pain prominent; Bleeding Later
*Large bowel: Aka Colonic Ischemia/Ischemic Colitis
Mild Abd Pain; Rectal Bleeding typical
Cause: IMA Ligation/Occlusion by Graft
(If SMA has disease> Prone to Ischemia once IMA tied)
ThromboEmbolism
Renal Failure
Impotence: Sympathetic N damaged; Can have Retrograde Ejaculation
Paraplegia: Spinal Ischemia
Distal Embolism: Cholesterol Embolism
Late: Graft Infection, Anastomotic Aneurysm, Graft-Duodenal Fistula
EVAR: 1st line nowadays
(Exception: CTD such as Marfan
Very Young Pt Open Repair is Definitive, while EVAR may need re-op)
(Insert Guide wire via Femoral A> Inflate Stent below Renal A so Not to cover it
> Add Extension to Short Leg> Complete Long Leg)
(PE after EVAR: Access Site Scar: Vertical/slightly Oblique Scar over Groin
Abd: Non-Expansile Mass)
Selection Criteria: (Cut off varies with different guidelines) (2014 SAQ 8, etc)
Neck: Length >15 mm, Diameter <32 mm, Angulation <60
Iliac: Length, Diameter
Lumen: Significant Thrombus/Calcification
Access Tortuosity

(2002 MCQ 11: Aneurysm involving Aortic bifurcation is Not an contraindication)
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NB: Also applicable in Thoracic AA (TEVAR has Lower risk than Open Repair), Ruptured AA
(Variants: Fenestrated EVAR: Personalized Branched device with Holes to permit branches
But Self-financed & Takes time to wait for synthesis
Use: Suprarenal, ThoracoAbdominal, Short Neck, etc)
Endoleaks (Major Cx & Cons of EVAR):
Type I: Peri-Graft Leakage at Proximal/Distal Attachment sites; Unacceptable
*Type II: Retrograde flow from Collaterals (eg. IMA, Lumbar arteries); More acceptable
Type III: Overlapping parts of Stent (Connection between components)
Type IV: Through Graft Wall due to Quality (Porosity) of material
EVAR vs Open Repair: Significant Short term Mortality
30 day Mortality: EVAR 1.7%, Open 4.7% (2004 MCQ 72)
4 year Aneurysm-related Mortality: EVAR 4%, Open 7%
NB: 2005 MCQ 59: Rupture of AAA may still occur despite EVAR
Ruptured AAA: Only 1 in 3 reach Hospital
Surgical Emergency
Immediate Dx Operation (Any Pt with Shock & Abd Distention> Think of AAA)
Mortality: Op Mortality >50% (2004 MCQ 72), Overall Mortality >80%
Type: *Retroperitoneal: Tamponade effect of Retroperitoneum> Formation of Hematoma
Moderate Hypotension + Resistance by Retroperitoneum tissue
> Temporary bleeding cessation> May reach hospital Alive (<50%)
Intraperitoneal: Free Bleeding> Usually Death before reaching hospital
Into Duodenum: GIB: Aorta-Enteric Fistula with Massive Hematemesis/Hematochezia
Into IVC: HF: Aorta-Caval Fistula with High Output HF & Venous Congestion
Clinical: Triad of Rupture (<50% cases):
Pain: Acute Severe Abd/Back/Flank Pain
May radiate to Back/Flank/Groin (esp Left side)
Mass: Pulsatile (may be masked)
Shock: Transient/Profound
Mx: Treat Hemorrhagic Shock (Permissive Hypotension <100 mmHg is usually preferred)
(Dont boost BP too High with Adrenaline> May convert Stable Leak into Free Rupture)
Large bore IV
Crossmatch Blood/FFP
Immediate Operation
Do Not waste time in Ix (Dont consult Cardiologists or anyone else)
Algorithm:
Dx & Resuscitate:
Open: Unstable/Lack of Expertise: Direct to OT (2010 MCQ 73)
EVAR: Stable: Contrast CT (Planning, Ordering, EVAR if suitable) (2011 MCQ 31)
Unstable: Aortic Balloon (CT in Hybrid OT, Planning on Table, EVAR if suitable)
Specific Cx: Cardiac
Respiratory
Page 531
Renal Failure (Shock)
Bleeding Tendency (Massive Transfusion)
Paralytic Ileus (Retroperitoneal Hematoma)
Jaundice (Bleeding + Transfusion)
SupraRenal/ThoracoAbdominal Aneurysm: More Complicated Op but Shorter time (Kidneys/Bowels die soon)
Issues: High Aortic Clamp: Proximal HT
Critical Ischemic Time: Visceral/Renal
Vital branches: Spinal Ischemia
Tx: Bypass, Re-implant Visceral arteries
(NB: Fenestrated Aortic Stent Graft:
Pros: Custom-made; Have holes over Graft
Cons: Takes time to manufacture)
Popliteal Aneurysm (2003 MCQ 11):
Most common form of Peripheral Artery Aneurysm; Asso. with AAA
50% Bilateral
Thrombosis is a significant Cx; Rupture is Rare
Tx: Usually treat Conservatively unless Symptomatic, eg. causing Embolism
Surgery: Open, Endovascular Stent Graft (but prone to Kinking thrombosis as Knee often bends)
(Subclavian-Carotid Bypass in TEVAR:
If Left Subclavian artery is covered, risk of Vertebral artery Stroke
Prophylactic Bypass just before TEVAR to Risk of Stroke)
Splenic Artery Aneurysm (2005 MCQ 71):
Associated with: Female, Pregnancy, Portal HT, Systemic HT
NOT Chronic Pancreatitis
PseudoAneurysm
Hematoma due to Arterial Leaking, which is contained by surrounding tissues
Usually occur after Vascular puncture
RF: Inadequate Manual compression
Others: Large bore sheaths, Postprocedural Anticoagulation, etc
Tx (2006 MCQ 65):
Conservative:
(Observation): Spontaneous resolution is uncommon
May be considered if Small <2 cm; Monitor by Serial imaging
US-guided compression (2011 MCQ 29, 2010 MCQ 72)
US-guided injection of Thrombin (More Effective; DVT is a potential Cx)
Surgical: Indication: Large, or expanding rapidly
At site of Vascular Anastomosis
Occurs Spontaneously
Threatens/Causes Skin Necrosis
May be Infected (2006 MCQ 32: *Staphylococcus) (2001 MCQ 53: *MSSA)
Failure of Minimally Invasive procedure
Page 532
Tx of Infected PseudoAneurysm (2001 MCQ 43) (2015 SAQ 4):
Involves Antibiotics, Ligation of Arteries, Resection of PseudoAneurysm, Drainage of Abscess
Not In-situ Bypass

Page 533
Vascular Carotid Stenosis
Pathophysiology: Plaque at Carotid bifurcation
Flow reduction
Embolization
Ix: Angiogram was Gold standard
But nowadays Duplex US has replaced it (Very seldom order Angiogram now)
Duplex: Look for Peak Systolic Velocity, End Diastolic Velocity, Velocity Spectrum
B mode to look at Plaque:
HypoEchoic: High Lipid content> Unstable> Stroke risk
HyperEchoic: Fibrotic Plaque (more Mature)> Lower risk of Stroke
Ulcerated: Also High Stroke risk
In Private Hospital:
Stroke Package (MRA Brain) often offered in addition
Medical Tx (2011 SAQ 7):
Aspirin, Statin
Preventive Surgery: Purpose: Stroke Prevention (Not treating anything)> Thus need to consider Pros & Cons
Options: Carotid Endarterectomy (CEA), Carotid Artery Stenting (CAS)
- Indication:

Recommendation based on NASCET trial:
Primary Prevention (Asymptomatic Pt):
In Asymptomatic Pt >60% Stenosis: (NB: For simplicity, some memorize it as 70%)
Do Surgery> Absolute Risk Reduction of 5% within 5 years (From 10% to 5%)
Controversial: Not recommended in Europe
Recommended in USA (Significant but Low benefit)
QMH: Consider in selected High risk Pt
Secondary Prevention (Symptomatic Pt):
In Symptomatic Pt >70% Stenosis with Good Recovery (also Symptomatic for <6 months):
Do Surgery> Absolute Risk Reduction of 15% within 2 years (From 26% to 9%)
Cx rate must be <6% (2011 SAQ 7)
In Symptomatic Pt 50-69% Stenosis with Good Recovery:
Do for Men (Absolute Risk Reduction of 4.6% within 2 years)
Cx rate must be <3%
- Timing: Preferably performed asap after the last ischemic event, ideally within 2 weeks
- Options: Pt should remain on AntiPlatelet before & after Surgery
Page 534
For CAS, Dual AntiPlatelets immediately before & for 1 month after stenting
Carotid Endarterectomy (CEA):
Gold standard
Relative Contraindications (Uptodate):
RT-induced Stenosis, Previous Radical Neck dissection
Unacceptably High Surgical risk (eg. Unstable Cardiac status)
Surgically Inaccessible lesion (eg. Intracranial, Intrathoracic)
Contralateral Vocal cord Paralysis from previous CEA
Severe Recurrent Carotid Stenosis
NB: Can be done in LA/GA
Systemic Heparinization always needed (2006 MCQ 76, 2003 MCQ 57)
Dose (2016 MCQ 2: 100 units/kg)
Carotid Shunt: Help prevent Cerebral Ischemia during Arterial Clamping (2005 MCQ 42)
Timing: Usually Selective (if signs of Cerebral ischemia appears on Neuromonitoring)
LA: Can monitoring Clinically (2005 MCQ 42)
GA: Needs other Ix for Neuromonitoring
Eg. EEG, Transcranial Doppler, Stump pressure measurement
Vein patch may be necessary if ICA is Small
Carotid Artery Stenting (CAS):
ing popularity
Slightly worse than CEA on Short term Meta-analysis currently
Recommended in selected Pt (ESO recommendation): (2012 MCQ 30) (2011 SAQ 7)
Contraindications to CEA (eg. Multiple Comorbidities)
Re-stenosis after earlier CEA
Stenosis at Surgically Inaccessible site (eg. Intracranial)
Radiation-induced Stenosis
Contraindications (Uptodate):
Absolute: Visible Thrombus within lesion
Inability to gain Vascular Access
Active Infection
Relative: Severe Plaque Calcification, Circumferential Carotid Plaque (2012 MCQ 30)
Heavily Calcified Aortic arch
Severe Carotid Tortuosity
Near occlusion of Carotid artery (ie. String sign)
Inability to deploy a Cerebral Protection device
Age >80
NB: If Pt on Warfarin (eg. for AF), Prefer CEA:
If do Stenting, need Dual AntiPlatelet> Bleeding risk if already on Warfarin
- Cx (2011 SAQ 7): Stroke (esp CAS), CN Injury (Only in CEA; Injury to CN9/10/12), Cardiac Cx, Reperfusion Injury
(2013 MCQ 70: Injury to Vagus Nerve can lead to Hoarseness, Dysphagia)
Misc:
Page 535
EC-IC bypass: May be done in NPC Pt with Carotid Stenosis due to RT (But CAS is better?)
Page 536
Misc
General GE: Thin/Fat, Nutritional status, Catheter, Color, Puffiness
Ryles tube: Original brand name of NG tube; Good name if not sure where the tube is heading(G/D/J)
PCD: (Intermittent) Pneumatic Compression Device
Passive muscle movement of leg> Reduce Stasis> Prevent DVT
Tracheostomy: General Indications:
Known obstruction (eg.Laryngeal CA)
Unconsciousness (Tongue fall back, Pharyngeal tone Throat region maybe obstructed)
LT Ventilation (Breathing problem, eg. Respiratory drive, Chronic pulmonary disease)
Endotracheal tube: Max 7-10 days> NOT for LT use
(May cause Tracheomalacia Flaccidity of cartilage> Collapse in Expiration)
Pulmonary toileting: Suction of Sputum
Yellow bag: Can be Foley, PTBD
Moya Moya Syndrome: Similar to Moya Moya Disease, but Stenosis not in ICA (eg. In MCA)
Bowel Opening: BSS: B=Brown, S=Small amount, S=Soft; BNO=No Bowel Opening
Ranula: A type of Mucocele on Floor of Mouth(except Plunging/Cervical Ranula though Uncommon)
Due to Rupture of Salivary duct by Local Trauma(Sublingual, Submandibular, Minor gland)
Cervical: Spilled Mucin dissects through Mylohyoid Muscle> Separate Sublingual & Submandibular space
Cystic Hygroma/Lymphatic Malformation:
Congenital Multiloculated Lymphangioma; Benign
Classically found in Left Posterior Triangle, but can be anywhere
Large Goitre with Compressive Sx:
Choking is very common(before Dysphagia/Dysphonia)
Tracheal Deviation: If cant palpate Trachea, Palpate Cricoid(or Thyroid cartilage)
Goitre usually wont extend across Cricoid
Tx: Dont give Thionamide: May TSH> Exacerbation Compression
Dont give Radioactive Iodine: Cause Swelling> Exacerbate Compression
Surgery indicated
Mammography: To orientate the film:
CC: The Label side is Lateral
MLO: The Label side is Upper
The Tail seen in Upper part of MLO film: Pectoralis Major
In Breast Cancer, Breast Size may seem to :
Calcification> Overexposed film> Other areas appear Dark> Appear like Smaller
Peter Yu:
DECAF Approach: Dx, Exclusion, Cx, Aetiology, Facilitate Mx
GIB: Apart from GI Sx & Anemic Sx, ask for Hypo-Oxygenation Sx(Chest Pain, Claudication)
Night Sweat: Not Constitutional Sx, but B Sx(Lymphoma); Also in TB
Exercise Tolerance: 2
Carotid A Stenosis: 4 features: Amaurosis fugax, Hemiparesis(Partial)/Hemiplegia(Complete),
Sensory disturbance, Verbal Impairment(Expressive/Receptive)
Page 537
Misc
Atherosclerosis & HT: Apart from being RF for Atherosclerosis, if Recurrent HT> may indicate RAS
Facilitate Mx: Ask Q to assess possible S/E, in order to decide Tx
Eg. Allergy, Liver disease, Renal disease, Hx of GIB/Dyspepsia(for Aspirin, etc), etc
Carotid A Stenosis: Dx: Carotid Bruit Exclusion: Aortic Stenosis, Thyroid Bruit
Cx: Residual Neurological deficit
Aetiology/Association: Xanthoma/Xanthelasma, Nicotine staine, BP,
Precordium(Sustained Apex Beat in LVH), Fundus,
AAA, Renal Bruit, LL Vascular Exam,
Urine Multistix(Protein & Glucose)
Breast Mass in QM: Monday & Tuesday admission in K14N
CA Breast Malignancy Features:
Inspection: Skin Dimpling, Visible Lump, Peau dorange, Erythema (Inflammatory),
Ulcer, Recent Nipple Retraction, Blood-stained Nipple Discharge, Eczema (Paget)
Palpation: Hard, Irregular, Fixed, Axillary Lymphadenopathy
Exam for Mets: Pleural Effusion, Hepatomegaly, Spinal Tenderness, Supraclavicular LN, Neurological Exam
Acute Flare up of Chronic Hepatitis:
ALT: >2x or >5x ULN
External Hemorrhoid: Painful, due to Nerve supply
Mucus: Describe to Pt as 'Nasal Secretion'
Signify Irritation of Mucosa(Inflammatory disease, Malignancy)
Angiodysplasia: May have long Hx of Bleeding of Unknown Origin
Bleeding: Ascending Colon: Liquid Stool: All mixed together
Descending Colon: Semi-Liquid Stool: Blood among Brown Stool
Rectum: Formed Stool: Blood on Stool
Above Anal Sphincter: Bleed during Defecation
Below Anal Sphincter: Bleed even after Defecation
Constipation RF: Standing, Sitting on Toilet(but Not for usual Sitting)
DM
Other Hemorrhoid RF: Chronic Coughing/Heavy Lifting
For Fresh PRB: Sigmoidoscopy is good enough for Screening usually
Kissing Ulcer: Lysozymes released in Ulcer site can cause Ulcer in another site
Common in Duodenum
If see Polyps in Sigmoidoscopy, do Colonoscopy
Midgut: Referred Pain to Umbilicus(T10)
Bowel Sound: Can Not rule out Paralytic Ileus, because may Not be Generalized Ileus
Electrolyte Disturbance: Vomiting: Lose K (Due to Loss of Acid)
Diarrhea: Lose both Na & K
Always check Amylase in Acute Abdomen:
Acute Pancreatitis does Not need Laparotomy; Initial Tx is Medical
Amylase level: Usually >10x Normal in Acute Pancreatitis
If just mildly Elevated:
Page 538
Misc
Small bowel Inflammation/Perforation: Amylase released from Portal Circulation
Decreased Renal Excretion
Conservative Tx: In District Hospitals, can wait up to 5 days (Most Obstruction relieve in 3-5 days)
(If Op Tx immediately, may cause future IO too)
In QMH, usually will have further Ix, eg. Gastrografin Follow-through

Ulcer Edge: Sloping: Signify Healing in Venous Ulcer
Punched: Poor Healing in Arterial Ulcer
Rolled: May be Malignancy
Hematuria:

Urology: Always rule out Stone & Tumor (Other diseases can refer to Medical)

Gross Hematuria:
20% Malignancy

Microscopic Hematuria:
5% Malignancy

TB Bladder:
Thimble Bladder(Fibrosis> Small Bladder; Similar to Ketamine Cystitis): Small Frequent Void
Characteristic: Sterile Pyuria (WBC but cant culture anything; Can be Tumor too)

Hematuria Mx(after presenting to A&E):
1.Vital signs, Hx, PE
2.Ix:
Blood: CBC, RFT
Urine: Routine Microscopy & Culture(if Urinalysis Leukoesterase/Nitrite +ve), EMU for AFB, Cytology
KUB(Stone, Osteoblastic lesion in Prostate CA Mets)
Upper Tract Imaging(US/IVU/CTU)(for Hydronephrosis)
IVU less commonly done now: Takes long time, Image Not clear
Usually US(Routine in QMH) or CTU
CTU: Cons Contrast: Anaphylaxis, Nephrotoxicity, Lactic Acidosis in Metformin user
Cystoscopy(Abnormal Mucosal lesion, eg. Carcinoma in-situ)

Ureteric Stricture: Primary: PUJO (Pelvi-Ureteric Junction Obstruction) Usually in Children
Secondary: Infection, Tumor, Radiation, etc

6 S of Oral Cancer (Leukoplakia):
Smoking, Spirits (Alcohol), Spices, Sepsis, Syphilis, Sharp/Sore Teeth
Sunlight: For H&N Cancer in general
Page 539
Misc

Pyelonephritis: Medical Tx
Pyonephrosis: Emergency; May be associated with rapid deterioration, Sepsis, Renal Failure
Resuscitation & Antibiotics first
After stabilizing Hemodynamics, Emergency Nephrostomy for drainage
CEA Cut off: Non-Smoker <3, Smoker <5
Small bowel Lymphoma:
Often Non-obstructing with paradoxical bowel dilatation, cf GIST or Leiomyoma
Cons of Diathermy in Minor OT:
Painful (even with LA)
Infected Cyst: I&D with Interval Excision
Cyst wall Not well defined during inflammation
Diathermy: Cut: Continuous
Coag: Intermittent
Paedi PUD: OGD waiting time Shorter than UBT
Malignancy is Not a big concern
Septic Looking: High Fever, Facial Flushing, Tachycardia
Resection Report:
R0 Resection: Macroscopic + Microscopic Clearance
Surgeons find it clear, then send to Pathologists, and then report as Clear Margin
R1 Resection: Macroscopically clear but Microscopically unclear
R2 Resection: Macroscopically residual tumor
Fever vs Feverish: SH Lau: Fever is sign, Feverish is Sx
Things to look for in Post-Laparotomy Pt:
Wound (Dry?), Abd distension, Peritoneal signs (Post-op Peritonitis?), Bowel sounds resumed?
Flumacil () before Contrast CT:
Renal protective effect
GCS Assessment by Dr. YW Fan:
Greet & Rock Pt to wake him up
Open Pupils & Shine Light: Must be able to wake him up
Also take the chance to examine Pupils
Put both arms in Preparatory position (Neutral position between Flexion & Extension)
Press & Roll over Supraorbital nerve (Wilson Ho: May lead to Hematoma; Sternum better)
Pain stimulus in Head region:
In Cervical spine injury, if stimulate Spinal Sensory dermatomes,
Motor response in limbs may be due to Reflex arc actions
May Not reflect Consciousness level
Observe: Eye opening
Arm: M5: Flexion above Clavicle
M4: Flexion Not beyond Clavicle (W Ho: Not to Sternum)
M3: Flex a bit initially but then drop down (W Ho: Flex UL, Extend & IR LL)
Page 540
Misc
(WM Lui: M4 will have Shoulder Abduction; M3 just Decorticate)
M2: Extension (Brainstem involvement) (Decerebrate)
M1: No movement
Observe both UL
Brain Abscess: If suspect Brain Abscess right next to Ventricular wall, canNot wait (get Urgent Contrast CT)
If Abscess rupture into Ventricles> Ventriculitis & Empyema> Can die
Adrenal Incidentaloma:
B Lang: Biopsy is Not done Cant ddx Adenoma vs Carcinoma
Do Serial CT: Consider Excision if Interval changes, etc
Unmatched Blood: O +ve blood in HK
Safe: Men
Elderly Women
In Young Women, may sensitize Pt> Risk of Hydrops fetalis in later Pregnancy
May give Anti-RhD
Fasting: Pt fasted for >24h will utilize Glucose by Proteolysis (2002 MCQ 17)
Washington: Carbohydrate stores (Liver & Muscle Glycogen stores) are exhausted after 24h fast
In first few days of starvation, caloric needs are supplied by Protein degradation
Protein is converted to Glucose via Hepatic Gluconeogenesis
Brain preferentially used this endogenously produced Glucose
Within about 10 days of starvation, Brain adapts to use Fat as its fuel source
It relies on Ketoacids produced by Liver
This adaptation to Ketone usage has a Protein sparing effect
There will be in Basal Energy expenditure
Tx of Hyperhidrosis (2002S MCQ 85) (2006 SAQ 8):
AntiCholinergic drugs
Botulinum toxin injection
Iontophoresis (by Electric current)
Endoscopic Thoracic Sympathectomy
Not CCB
Thoracoscopic Cervico-Dorsal Sympathectomy:
Indication (2001 MCQ 4):
Raynauds phenomenon, Hyperhidrosis, Reflex Sympathetic Dystrophy, Intractable Angina
Not Acute Brachial Emboli
S/E & Cx: (2006 SAQ 8)
S/E (2001 MCQ 11):
Compensatory Sweating over other parts of body is common
Gustatory Sweating
Cx: Chest procedures related, eg. Bleeding, Wound Infection, Pneumothorax
GA related
Horners syndrome
Cardiac effect similar to Beta-blockade when Surgery is extensive
Page 541
Misc
Suboptimal outcome

Page 542
Misc
Extra
Menetriers disease: aka HypoProteinemic Hypertrophic Gastropathy
Rare, Acquired, Premalignant disease of Stomach
Associated with Excessive Secretion of TGF-
Characteristics: Massive Gastric Folds, Excessive Mucous Production with resultant Protein Loss,
Little/No Acid Production
Ludwigs Angina: Rapidly Progressive Severe Cellulitis of Bilateral Submandibular & Sublingual spaces
Infection usually originate from Dental Infection (esp Lower 2nd & 3rd Molars)
Emergency; Obstruction due to: Submandibular Swelling
Tongue (Pushed Up & Back by Sublingual & Submental Sweling)
Sx: Malaise, Fever, Swelling, Dysphagia, Odynophagia, Dysphonia, Stridor, Trismus, Drooling
Campbell de Morgan Spots:
Aka Cherry Angioma/Senile Angioma
AV Fistula at Dermal Capillary level
Usually occur in Skin on Trunk of Elderly
No Significance, Frequency with Age

Signs of Basilar Fracture:
Periorbital Ecchymosis (Racoon Eyes/Panda sign)
Retroauricular Ecchymosis (Battless sign)
CSF Leaks (Rhinorrhea or Otorrhea)
CSF contain Glucose while Nasal mucus does Not
Halo Test: Put a drop of Bloody Nasal discharge on Filter paper
If contain both CSF & Blood> Double Halo Sign
2 Rings Central ring of Blood with Paler Outer ring of CSF
CN7 Palsy
Subconjunctival Hemorrhage (Can Not see Posterior limit of Bleed; Ddx Corneal Bleed)
Hemotypanum
Primary Cardiac Sarcoma:
Exremely Rare
10-25% Malignant
Age: 20-80 (Mean 40)
Most common site: Left Atrium
WHO Classification 2004:
Angiosarcoma
Undifferentiated Pleomorphic Sarcoma (Malignant Fibrous Histiocytoma)
Other 4 are even Rarer
Cardiac Rhabdomyosarcoma:
Extremely Rare; ~5% of all Cardiac Sarcoma
Tx: Surgery, Adjuvant Chemo/RT, Role of Heart Transplant controversial
Page 543
Extra
Prognosis: Worse than Non-Cardiac Sarcoma

Page 544
Extra

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Surgery

Rate of Replacement: Depends on Hemodynamic status and any On-going loss

Measure SC Fat Thickness by Skin fold Caliper

Can be advanced into Duodenum to avoid Regurgitation & Aspiration

3-in-1 TPN system Y connection system

(Scar shape like an Inverted T)

Pigmentation after RT:

(Both Hernia contents & Hernia sac are reduced)

(Pressure from Blunt Trauma more evenly distributed)

(Often Not connected in Centre)

(Pain during Peristaltic wave only)

(Note Appendix pointing to Pelvic cavity may give Suprapubic Pain)

(Rmb always check Scrotum in Young boy with Groin Pain)

Resection with End Colostomy (Hartmann)

(Dusky Stoma Mucosa)

(Marginal artery of Colon links all SMA & IMA vessels)

ExtraSphincteric: Might be Iatrogenic

T-tube induces formation of a Fibrous tract

Autoregulation has Limit

(High ICP> Blood cant flow up ICA into Brain)

Symphyseal, Body, Angle, Subcondylar

(Toes, Bunion area, Metatarsal heads, Lateral Malleolus)

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