Surgery Jeremy Lynch.

July 15, 2007

I Heart & Thoracic Aorta
1 Thoracic Aortic Aneurysms
Causes. Arch of aorta M arfans , ( syphilis) Descending Traumatic, syphilis, athersclerotic Clinical. Ascending Chest pain, aortic regurgitation, obstruction of the SVC, obstruction of

Rx. Type A Type B

3. TOE: ap & aortic regurg ( Ascending aorta) dacron graft ( Distal to L subclavian) Conservative w hypotensive drugs ( to # BP stopping extension of aneurysm)

II Arterial Disease
Can be divided into occlusive or aneurysmal. Most common cause of both is atherosclerosis .

3 Anatomy

the right main bronchus, pulsating mass in front of the chest ! may even ulcerate through the wall Arch Compress trachea or ulcerate i nto it. Liable to stretch the left recurrent laryngeal ! hoarseness. May obstruct left lower lobe ! collapse. Descending Back pain, erosion of vertebrae, press on oesophagus producing dysphagis ! may rupture into it Ix. CXR ( calci cation) , CT/MRI ( extent & size) , aortography dangerous & not done , USS ( aortic valve incompetence) Rx. Excision of aneurysm & graft. Need bypass to perform Cx. Spinal ischamia: loss of ow of radicular artery ! paraplegia

Path. Usually arch, blood dissects in media. Usually Epi. Hypertension, atherosclerosis Clinical. Sudden sev pain in chest, may radiate in to arms, neck, abdomen, or with a
tearing interscapular pain. May be signs of surgical shock ( due to cardiac tamponade or ext rupture) . As dissection progresses origins of main arterial branches may become blocked ! dissapearance of peripheral pulses. Renal vessels: haematuria/anuri. Leg ischaemia. 1 . CXR: widened mediastinum 2. Contrast enhanced CT 1

2 Aortic Dissection

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1 .

Ix.

Urine & blood glucose DM Hbg Anaemia, polycythaemia. ESR, CRP In ammatory/mycotic aneurysms Cholesterol Atherosclerosis ECG Coronary disease

4 Investigations

Echo heart Valvular lesions, mural thrombus, aneurysms, atrial myxoma CXR Bronchial Ca common in end stage vascular disease ( both caused by smoking) , Doppler USS Arterial waveform: monophasic in hardened arteries Duplex USS Imaging Arteriography Site, extent of blockage: if reconstructive surgery/angioplasty contemAngioplasty Dilation by balloon catheter + stenting CT & USS Aneurysms
plated heart size

Open

4. Fasciotomy for compartment syndrome

1 . Direct compression 2. Resuscitation: replace blood 3. Exploration: partial tears may be sutured, division requires saphenous interposition. Avoid using prosthetics due to infx risk

5 Treatment

Def. Abnormal permanent dilatation of an artery or part of an artery or the heart Morphology. May be fusiform, saccular, or false/ pseudoaneurysms ( when there is a sac Types. Saccular Narrow neck: mycotic ( in ammation causes localized weakness) . Fusiform Generalized dilatation: abdominal aorta False Blood leaks out of artery & is contained by ct lined w thrombus ! will either
communicating w the artery lumen)

7 Aneurysm

1 . T reat handicap not the disability : e. g. if seldom needs to walk 500m then don' t need to rx. 2. P rophylactic surgery only appropriate when risk of event outweighs procedure : e. g. when AAA gets big enough.

6 Arterial Trauma
Classi ed. Types.
1 . Closed: extraneous compression e. g. crush injury, fractures of adjacent bones w displacement of artery ( eg. supracondylar fracture) , joint dislocation. 2. Penetration: e. g. stabbing, iatrogenic 1 . Mural contusion w 2 spasm 2. Intimal tear: usually result of stretching of artery. Results in artery buckling & causing localized stenosis which may result in thrombosis or dissection 3. Full thickness tear: paradoxically partial' s bleed copiously whilst completes results in contraction and spasm and so # blood loss
o

Aetiology.
1. 2. 3. 4. 5.

rupture spontaneously or enlarge and rupture AV False aneurysm Dissecting Blood forces passage through break in intima of vessel ! may rupture back in to lumen or out of adventitia. Over this artery segment vessels are deprived of blood Congenital: Berry aneurysms Degenerative: atheroma . Most common cause Traumatic: penetrating bullet or catheterisation ! true or false Infection: mycotic. E. g. tertiary syphilis, salmenollosis, immunode ciency In ammation: subtype of atherosclerotic/ mycotic in which theres an immune response to components in the aneurysm wall ! dense in ammatory forming rind around lumen

Consequences.

Clinical of true aneurysms.

C linic al . Pain,

Treatment. Closed

pallor, pulselessness, paraesthesiae, paralysis, perishing cold . Haemorrhage may be overt or concealed. May develop hypovolaemic shock

1 . Haemorrhage 2. Thrombosis 3. AV stula 4. False aneurysm 5. Compartment syndrome: ischaemic muscle swelling in closed fascial compartment ! exacerbates ischaemia ! Volkmann' s ischaemic contracture

Complications. Ix.

Abdominal: asx, back pain, bloating, swelling pulsatile + expansile, consequence of distal emboli Peripheral: pulsatile swelling, distal ischaemia, thrill bruit, machinery murmur ( AV communication) . Dilated, tortuous, atheromatous artery, mass overlying artery

1 . Treat causation: e. g. open plaster cast, reduce fractures 2. Angiography: discriminated ischaemia due to spasm, intimal tear, arterial disruption 3. Operative exploration: if failure of above, or tear or block. Saphenous V often used to replace areas 2

1 . Rupture: " w diameter 2. Thrombosis 3. Embolism 4. Pressure 5. Infx: become infected or arise as a result of

1 . AXR: calci cation in wall of aneurysm 2. CT/MRI/ USS: size & extent 3. ( Angiography: but underestimates size, and risk of perforation)

7.1 Abdominal Aortic Aneurysm

Rx. Femoral ! distal popliteal bypasses w ligation of feeding vessels

2. Angiography: artery tree distal to aneurysm

8 Atherosclerotic Arterial Disease

Aetiology.
1. 2. 3. 4. 5. 6.
FH S moking : nicotine ( vasopasm) , CO, " platelet stickiness H yperlipidaemia H ypercholesterolaemia H ypertension D iabetes : " Atherosclerosis, " microangiopathy. Presentations:

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2 .

a) Young pt w peripheral gangrene but good pulses in limb. Rx: Control infx and improved diabetic control, local debridement. Last resort is amputation b) Elderly w atherosclerosis: DM results in # prognosis 7. ( and post-menopausal ) 8. Age 9. # E xercise Occlusive arterial disease pattern. Exercise induced pain ( intermittent claudication ) ! rest pain ! gangrene .

Only ix if there is reasonable doubt. Rx. If < 5. 5/6 cm then regular USS. Preop assessment includes coincident cadiac disease ( exercise ECG, echocardiography) , renal disease. Involves open surgery w Dacron graft, or can be done endovascularly w graft ( excludes sac from blood ow. Good for those otherwise un t for surgery) 1 . Renal failure: # blood ow when clamp aorta. Worse if aneurysm spans renal arteries 2. Distal embolization 3. MI: coincident cardiac disease common, and " peripheral resistance w clamping 4. Graft infection: aorto-enteric Ruptured AA. Assume if sev back pain and collapse. includes renal colic. 50% die before hospital, 50% die on the table. Most patients reaching hospital the aneurysm is contained retroperitoneally. Don' t give " uids cos causes more bleeding.

Epi. Common in older , FH, assoc w popliteal aneurysm . Acute aortic expansion ( Pain of rupture without haemodynamic consequences) .

Results in. Angina

9 Coronary Occlusive Disease (Coronary Angina)

Complications of Rx.

10 Mesenteric Occlusive Disease (Mesenteric Angina)

Clinical. Pain after meals, weight loss, fear of eating

11 Cerebral Occlusive Disease

Causes. Stroke, dementia, TIAs

Claim to Fame. The most common peripheral aneurysm Clinical. Generally asx, may cause distal embolization leading to claudication or digital Ix.
infarction. Ex reveals prominent pulsation in popliteal fossa extending proximally. 1 . Duplex USS: extent & size 3

7.2 Popliteal Aneurysm

Clinical. Gripping, tight clamp-like pain in the calf on exercise. Usually one leg in

12 Intermittent Claudication

advance of the other. Pain disappears on resting. . Spinal claudication: Pain present on standing, requires pt to sit down before relieved.

Pathology. Calf pain ( thigh lesion) , buttock pain ( internal iliac) . Bilateral buttock clauRx. Conservative # RFs, weight loss, exercise, foot care Interventional Arteriography ( short, > 70% occlusions amenable by angiography) ,
duplex scanning ( replacing angiography) 1 . Angioplasty: balloon stretch/fractures. Risk of embolization, perforation 2. Thrombolysis: TPA, streptokinase. Not appropriate for acute cos takes time 3. Bypass: Complications inc dissection, embolization thrombosis dication assoc w impotence

Rx. Aspirin.

> 70%: endarterectomy. Complications : death/ stroke, haemorrhage, hypoglossal neuropraxia ( tongue protusion) , reperfusion syndrome ( to brain) , restensosis

Cause. Intermittent spasm of small arteries precipitated by cold exposure. Clinical. White ! blue ! red Aetiology. 1 ( women) , phenomenon ( 2 to c. t. disease usually) , cryoglobulinaemia.
o o

15 Raynaud's

13 Critical Ischaemia
Def.
< 0. 5

Rest pain, ulceration or gangrene assoc w absent pedal pulses , or ABPI

Rx. Conservative

vibrating tools . Cervical rib, atherosclerosis, Beurgers'

Gloves, stop smoking. Surgery

Sympathectomy

Ischaemia. Initially at night ( horizontal) . Relieved by hanging leg over side. As disease progresses becomes continuous Gangrene Sev vascular impairment. Pressure areas ( heel, malleoli, plantar ball of hallux) . Minimal trauma causes abrasions. Ix. Same as claudication

Rest pain

16 Beurger's (Thromboangiitis Obliterans)

Clinical. Similar to atherosclerosis ( As obliterated ! ischaemia) , but in young , heavy

smokers, hands/ ngers. Ulcers, gangrene. Veins/ nerves can also be a ected. Rx: stop smoking.

Rx. Non-operative
supply)

Arteriography & angioplasty, lumbar sympathectomy ( " blood

Needs : good arterial supply to blockage, good vessels below, conduit ( saphenous vein, or PTFE) , patient in good health cos " mortality Amputation Pain not controlled by above, or gangrene + infection

Operative: Reconstructive surgery

17 Embolism

Def. Abnormal undissolved material carried in blood from one part of vascular system to
impact in distant. May be air, fat, tumour, but most commonly thrombus from heart or major vessels . A surgical emergency. Where. Usually bifurcations. Can go to CNS, retina, small intestine, renal ( haematuria, pain in loin) , splenic ( subcostal pain) . Clinical. In a limb: The P' s ( see above) . Contractions develop w time. The block can move distally in the few hours. Skin staining non-blanching on pressure ( irreversible tissue damage)

Where. Bifurcation. Cause. Atherosclerosis + thrombus Presentations.

1. 2. 3. 4.

14 Carotid Artery Disease

Ix.

Amaurosis fugax : uniL blindness lasting minutes Strokes TIA Hypoperfusion: biL may cause critical ischaemia on exertion Clinical. Bruit, evidence of disease elsewhere . Hypoglycaemia, epilepsy, migraine, neoplasm, embolism from heart

Cause.

Rx.

1 . Atrial fibrillation : by far most common 2. Mural thrombus: often post-MI 3. ( Aortic dissection) 4. ( Paradoxical i. e. venous origin)

1 . Duplex USS 2. Angiography 3. MRI of vessels 4. MRI/CT brain 5. Cerebral reactivity: measure in haemodynamic response whilst pt breathes CO ( a vasodilator) 6. ECG/echo heart

1 . Assessment: if resolving ( re-appearance of pulses) consider thrombolysis. If no blood supply and neuro s then surgery. After 24h, or skin staining, successful revascularization is unlikely. 2. Heparinization: as soon as diagnosis made 3. Surgical embolectomy: open, closed ( Fogarty catheter: pass line pst clot, in ate, then pull back) 4. Thrombolysis: if likely a thrombus in situ

18 Cold injury

Rx.

Pathology. Capillary sludging and thrombus Rx. Gentle warming, heparin, abx. Local amputation

1 . Neuropathic: abx for infection, wide local excision & drainage of necrotic tissue 2. Ischaemic: angiography & consideration of plasty or bypass

19 Diabetic Foot

At a Glance

III Venous Disorders of Lower Limb

20 Anatomy

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3.

Path. Ischaemia ( macro & micro) , neuropathy ( sensory, motor, autonomic) , sepsis ( " gluClinical. Neuropathic Ischaemic Ix.
cose promotes bacterial growth) sent, sepsis Sensory, trophic skin, plantar ulceration, Charcot' s, pulses often pre-

Rest pain, painful ulcers over P areas, hx of intermittent claudication, absent pulses
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Prevention. Do Wash & dry feet, inspect daily, care of toenails, anti-fungal powder Do not Barefoot, ill- tting shoes, hot-water bottles, ignore injury
5

1 . ABPI: may be falsely elevated due to sclerosis 2. XR: osteomyelitis 3. Arteriography

Systems. Deep Inside deep fascia. Tributaries drain into popliteal ! femoral ! ext iliac ! Super cial
iliac ! IVC Outside fascia, draining skin/super cial tissues. 1 . Long saphenous ( from dorsum foot) 2. Short saphenous ( lat lower limb) .

Perforators. Super cial ! deep. Medial/ lat tibia above ankle, and one mid-thigh. Calf pump. Empties deep veins, so then super cial veins ! deep veins

21 Pathology

Cause. Valvular incompetence: usually physical ( such as thrombus) ! " resistance to

return ow. Incompetence breeds incompetence.

Ix.

Previous DVT, " venous P due to compression ( e. g. pelvic tumour, pregnancy) , AVS stula, tricuspid incompetence HPC. Cosmetic, tiredness, aching, throbbing, swelling ankles, esp after standing Ex. Must be standing. Inspect medial gaiter for deep venous insu ciency ( haemosiderin, eczema, lipodermatosclerosis) . Port-wine stain ( AVS malformations) . Saphena varix ( saphenofemoral dilation, thrill) . Tap Test for Super cial Valve incompetence ( feel saphenofemoral and tap peripherally. If no valves then feel it. ) Trendelenburg' s test. 1 . Doppler probe: poor ow 2. Duplex US: diagnose 3. Venography: tourniquet on ankle to occlude super cial, inject contrast into dorsum of foot ! up deep system ! observe super cial re ux 1 . Graded compression stockings ( minor varicosities, pregnant, un t) 2. Sclerotherapy: compressed for 2w after to enable brosis. Small/ mod sized. 3. Surgical: Indications include haemorrhage, varicosities grossly dilated/ otherwise symptomatic, skin s, incompetent perforators. Involves disconnecting great saphenous from femoral vein, dividing terminal branches of great saphenous. Recurrence is due to failure original diagnosis or defect in technique. bandage. Due to minor trauma. Lie pt down w leg elevated & apply pressure
o

2o

22 Varicose Veins

Rx.

Cx. Haemorrhage Phlebitis

Tender, hard, in amed skin, may be pyrexial, can have 2 bacterial. Rx: bed rest w elevated foot of bed, pressure bandage, abx ( if needed) , systemic anticoagulation

worms. Rx. Can embolise, ligate/ divide.

Def. Dilated veins of the pampiniform plexus ( in the testes) Description. L usually. Associated w renal Ca, infertility. May be painful. bag of

23 Varicocele

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nails

5 .

M alleolar are = red in am mation from m elleolus. O nychogryposis = dam aged toe-

Def. Abn dilated & lengthened super cial veins, due to incompetent perforator veins or Classi cation. 1 o Majority. : = 2: 1 . Accentuated by pregnancy
6 super cial valves.

Cause. Incompetence of valves of deep venous system . Aetiology. 1 o Congenital lack of valves 2 o Venous hypertension ( DVT) , AVS stula. Clinical.

24 Deep Venous Insu ciency

1 . Swelling ( Esp lower leg) due to transudation of uid across capillaries

2. 3. 4. 5.

Ix.

Super cial varicose veins ( 2 perforator incompetence) Haemosiderin pigmentation ( broken down hbg) Eczema, pruritis Lipodermatosclerosis: thick brous tissue ( due to in ammation) ! inverted champagne bottle 6. Ulceration ( poor skin nutrition)
o

Where. Often medial malleolus Appearance. Ragged edge. May have white rim around ( previous scarring) . SCC can
arise in these ulcers ( Marjolin' s) . Venous ( 90%) , ischaemic, neuropathic, malignant, systemic-related, AVS stulaassociated, gumma of syphilis Rx. Con ne pt to bed w foot elevation to abolish " P. Keep clean. Abx only if gross infection. Unfortunately if old then prolonged bed is dangerous. Also: tight bandaging ( empties super cial resulting in more e cient pump ! " O to area) . Once healed t graduated compression stockings.
2

Rx. None, can only rx the super cials.

1 . Venography: identify perforators that can be treated

2. Duplex sonography

25 Venous Ulceration

26 DVT
Predominantly a medical condition. Ix. Nb. Duplex unreliable below knee. D-dimer has signi cant false + ve rate Prophylaxis. Early post-op mobilisation, pneumatic compression, TED stockings, heparin, avoid OCP Rx & prevention. Heparin

IV 15: Head Injury

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6 .

Cause. Venous ulceration is due to venous hypertension 2 to incompetence of deep veins.

Ask about past possible DVTs.
o
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Types. 1 o Direct result of trauma.

28 Brain Injuries

Di use: shearing movements ! axon damage + rupture of small vessels Localized: brain impacts against the skull Coup & contre-coup: the opposite side of the brain damaged as it rebounds o skull. Laceration: brain impacts on sharp bony edges o 2 After initial event, result of hypoxia, hypercapnia, hypotension ( ischaemia) , haemorrhage, meningitis. In-hospital mortality.

29 Cerebral Perfusion

CPP = BP ? ICP " ICP and hypotension in trauma victims reduces blood ow ! ischaemia ! re ex increase in systemic pressure & bradycardia ( Cushing' s re ex ) Cerebrovascular resistance. Arteriolar vasodilatation with: " P CO , " pH. If reduction in cerebral blood volume wanted therapeutically ( e. g. cerebral oedema) : pt hyperventilated. Conversely hypercapnia in presence of oedema might exacerbate brain injury.
2
Ta b l e 1 .

Systemic arterial pressure. Autoregulation by cerebral arterioles Intracranial pressure. Skull is a closed compartment:

27 Types of Fractures
Usually simple penetrating: debridement & suture. If skull also penetrated br may also be lacerated: consciousness not necessarily lost Skull Crushing or other sev force. Usually linear fracture of skull vault. Skull XR: fracture is an important indicator of the force of injury & risk of IC haemorrhage Paranasal sinuses: CSF rhinorrhoea Usually open as overlying dura breached. Anosmia if fracture across cribriform plate. Risk of meningitis. Petrous temporal bone: CSF otorrhoea or rhinorrhoea Involvement of inner ear causes deafness. Leak usually self-limiting Temporal bone: middle meningeal vessels Causing extradural haemorrhage. Depressed fractures Fragment of bone below level of surrounding bone. Rx: can leave it if not troublesome. Elevate if e. g. contaminated, haematoma Ant/middle cranial fossae: Orbital haematoma Looks like a black eye ( racoon eye) . Suggested by: subconjuctival haemorrhage, absence of grazing of the surrounding skin, con ned to margin of orbit, mild exophthalmos, bilateral haematoma 8

Scalp injuries

Initial Assessment. Hx Mechanism of injury, immediate condition ( GCS, vital signs, pupils, limb moveEx

30 Management of Head Injury

Ix

ments) , in condition after rst assessment, prior condition ( diabetes - ?hypo) Major injuries: ABC. Conscious level. Details in the book . GCS ( Note how high each goes: Count to 4: open your eyes. Count to 5: talking jive. Count to 6: feels the pricks ) : i. Eye opening 4: Spontaneous 3: To command 2: To pain 1 : None ii. Verbal response e 5: Oriented 4: Confused conversation 3: Inappropriate words 2: Incomprehensible 1 : None iii. Motor response 6: Obeys command 5: Localizes pain 4: Withdraws from pain 3: Abnormal exion to pain 2: Extension response to pain 1 : Non 1 . Skull XR: indicated when LoC, impaired GCS, amnesia, scalp swelling, laceration to bone, hx of high energy impact, persistent vomiting, headache 2. Cervical spine XR: unconcious pts 3. CT: indicated if sev head injuries, CSF rhinorrhoea or otorrhoea, penetrating, bilateral orbital haematoma ( Battle sign)

Immediate Rx. Correct problems in initial assessment: e. g. draining pneumothorx, venCerebral oedema IC haemorrhage Hypoxia Infection: 2 to fractures Hyrocephalus Delayed management. In book
o

Deterioration.

tilation, laporotomy.

Hyperpyrexia Cooling blankets Amnesia Longer, the worse prognosis of mental function Epilepsy Penetrating open wounds w cortical scarring

33 Brain Death
Details in the book.

31 Traumatic Intracranial Bleeding

I C B leed

E xtrad

S ub dural Acute C hronic

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S ubar Intrac Intrave

V Oesophagus
34 General Abdominal Colic
1 . Biliary tract: stone in Hartmann' s pouch, cystic duct, ampulla of Vater 2. Renal tract: Ureteric colic due to stone, blood clot or tumour, bladder colic in acute retention due to enlarged prostate 3. Intestinal: obstruction, appendicular colic 4. Uterus: parturition, menstruation, ectopic pregnancy in fallopian tube

8 .

headache ! deeper coma ( due to cerebral compression by extradural clot. ) Ex Signs of " ICP. Also localizing signs: explore the side of the dilated pupil , hemiparesis/hemiplegia or ts ( uncommon) , boggy scalp haematoma Ix CT Rx Emergency: burr hole made and clot evacuated. Diathermy to bleeding point. Mannitol. Subdural. C re s cent shaped CT scan 1 . Acute : lacerated brain or torn vessels. Sev ( coma) . Rx: craniotomy & release of clot 2. Chronic : post-trivial injury, elderly pt ( small brain) . Tear in cerebral vein. Clinical: expanding mass ( mental deterioration, headaches, vomiting, drowsiness, coma) . Rx: evacuation Subarachnoid haemorrhage. Meningeal irritability w headache, neck sti ness, Kernig' s sign. Congenital B erry aneurysms, Rx: analgesics, bed rest Intracerebral haemorrhage. If exerting mass e ect and " ICP then evacuate. Assoc w " BP. Intraventricular haemorrhage. Childhood, sev head injury

Extradural. Often tear in middle meningeal artery. C onvex CT scan Hx Talk & die . Minor head injury causing temp concussion ! lucid interval !

35 Dysphagia
Causes.
1 . Local

Lumen Foreign Body Wall Atresia, in ammatory ( 2 re ux esophagitis) ,

Meningitis

32 Other Complications of Head Injury

Open fractures. Rx: abx. Via nasal : penicillin ( Pneumococcus ) . Complicating open fracture : 2nd G cephalosporin ( e. g. cefuroxine) 9

Enlarged LNs, thoracic artery aneursym, bronchial Ca, retrosternal goitre 2. General: myasthenia gravis, bulbar palsy, bulbar poliomyelitis, diphtheria, hysteria Hx. Previous re ux oesophagitis suggests peptic stricture. Malignancy has short hx. Ex. Look for Plummer-Vinson ( smooth tongue, anaemia, koilonychia) , LNs, upper abdo mass ( cardia mass)

Outside Wall

o caustic stricture , achalasia , Plummer-Vinson w oesophageal web, pharyngeal pouch , esophageal tumour

Ix.

1 . Barium swallow 2. Oesophagoscopy + biopsy

Who. Children, mentally disturbed. Most can pass out unless sharp or irregular Cx. Penetration Rx. Usually conservative: serial Xrs

36 Foreign Bodies

Ix.

37 Perforation of the Oesophagus: Rare

Classi cation. From within
1 . Foreign body 2. Iatrogenic ( oesophagoscopy, dilatation/biopsy, echocardiography) : pain + dysphagia + subcut emphysema From without ( Wounds) Spontaneous Lower thoracic oesophagus ( B oerhaave' s syndrome) . Sev pain in chest, dorsal spine, or upper abdo ( acute mediastinitis) . Pt collapsed & cyanosed. Rigid abdomen. Surgical Emphysema 1 . CXR: gas in neck and mediastinum, uid & gas in pleural cavity 2. Gastrogra n swallow

Rx.

1 . CXR: dilated oesophagus as a mediastinal mass, air- uid level, pneumonitis from aspiration. 2. Barium swallow: gross dilatation & tortuosity leading to unrelaxing narrowed segment at lower end ( bird' s beak) . Absent gastric bubble 3. Oesophagoscopy: enormous sac of oesophagus w stagnant food 4. Oesophageal manometry: aperistalsis, failure of relaxation of LOS 1 . Heller' s: cardiomyotomy ( similar to Ramstedt' s) 2. Endoscopic dilatation of OJ w hydrostatic bag

Clinical. Dysphagia. Caused by Fe-de cient anaemia ( smooth tongue, koilonychia, spoon Rx. Anaemia : Fe. Web : dilatation.
web in upper. Premalignent.

40 Plummer Vinson Syndrome

shaped nails) . Middle aged . Hyperkaritinization of the oesophagus w formation of

Ix.

Rx. Cervical perforation

Conservative. Abx, NBM, IV drip. Abscess formation in sup mediastinum needs drainage. Thoracic rupture Immediate suture. Prognosis related to time after event

41 Pharyngeal Diverticula
Def. Diverticula ( others are v rare) of the oesophagus btw the 2 parts of the inf pharyngeal constrictor ( weak) . As it enlarges it displaces the oesophagus laterally. Clinical. Elderly . Dysphagia, regurgitation of food collected in pouch, palpable neck swelling, foetor, aspiration pneumonia. Ix. Barium swallow Rx. Cervical incision w excision of pouch + pos myotomy of cricopharyngeus

38 Caustic Stricture

Epi. Accidental/ suicidal with strong acids/alkalis. Mid/lower usually. Rx. Alkali ingestion w vinegar & bicarbonate of soda. Gastrostomy ( rest the oesoph-

agus) . Steroids ( # scars) . Dilatation of strictures w bougies after 3w. If impassable then bypass op.

39 Achalasia of the Cardia

Claim to Fame. Similar to Hirschprungs of rectum Path. Neuromuscular failure of relaxation of the lower end of the oesophagus on swal-

Cause. Incompetent cardiac sphincter Cx. Ulceration, in ammation, strictures Associations. S liding hernias , repeated vomiting ( esp w duodenal ulcer so " acidity) , Ix.
NG intubation, resection of cardia, ectopic acid-secreting gastric mucosa in oesophagus 1. 2. 3. 4. Oesophagoscopy + biopsy ( exclude Ca) 24h pH studies Acid infusion test: give HCl triggers similar pain to re ux Barium swallow: outline of hernia . Cholecystitis, peptic ulcer, angina

42 Re ux oesophagitis

lowing, with progressive dilatation, tortuosity, incoordination of peristalsis, hypertrophy of the oesophagus above. Clinical. Most often 30s. Indistinguishable from Chagas' ( Trypanosoma cruzi destroys ganglion cells) . Progressive dysphagia over m' s to y' s, sometimes assoc w spasm like pain. Regurgitation of uids from the dilated oesophageal sac ! aspiration pneumonia. Malignant possible. Pt' s often eat small amounts + often, & wash down w water.

10

Rx. Medical

Surgical

Weight loss, smoking, corsets, antacids, H receptor antagonists ( cimetidine) , PPIs ( omeprazole) , prokinetics ( metoclopramide)
o o 2

Ix.

. Enteritis, neonatal intestinal obstruction, intracranial birth injury, overfeeding ( vomiting)

1 . USS 2. Abdo XR 3. ( Barium meal: shouldering of pyloric antrum) iting Correct dehydration & hypochloraemic metabolic acidosis caused by vomV good results

a) Repair of hernia, fundoplication ( can now be done laparoscopically) b) Stricture: endoscopic balloon dilatation

Rx. Medical

43 Tumours
See oncology notes.
T umours

Ramstedt's pylorotomy

B enign L eiomyom a

M alignant 1o C arcinom a L eiomyosarcom a L eio= sm ooth muscle 2o

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9 .

Types. Partial, complete, usually 2nd part ( near ampulla of Vater) Clinical. Antenatal polyhydramnios. Birth : vomiting, distended stomach. Assoc. Downs in 30% . Oesophageal atresia, pyloric stenosis, congenital intestinal obstruction Ix. Plain AXr. Rx. Duodenojejunostomy

47 Duodenal Atresia

44 Barrett's

48 Peptic ulcer

Def. Metaplasia to columnar. RF. , smoking

Pathology. Disturbance btw acid/ pepsin & mucosal barrier Sites. Duodenum ( 80%) ( 1 st part obviously. Cos # protection there. " Acid

45 Presbyoesophagus

Clinical. Old ppl. Upper : dysphagia of solids + liquids. Lower : constipation Path. Dysfunctional peristalsis Ix. Barium: corkscrew dysmotility

VI Stomach and Duodenum

Clinical. 3-4w, most , projectile non-bilious vomiting, failure to gain weight, dehydra-

production ) > stomach ( lesser curve. N ormal acid production ) > oesophagus Aetiology. H pylori usually, Zollinger-Ellison ( gastrin-like-peptide secreting tumour of the pancreas) , NSAIDs, steroids, smoking, stress, blood group A RF. Duodenum : 30-40s, ( after menopause) . Gastric : : = 3: 1 Clinical. Asx. Pain: epigastric, attacks last for d ! w' s, can radiate in to back ( indicates posterior ulcer) , usually couple h' s after meal ( may be immediate) , can wake pt in early morning, aggravated by milk & alkalis. Heartburn, nausea, vomiting, wt loss. Acute Presentation ( q common) : Without cause, or NSAIDs, acute stress, head injury ( Cushing' s ulcer) . Sudden pain, haemorrhage, perforation. May become chronic. Gastric Pain after eating( ! weight loss) Duodenal Pain relieved by eating

Ix.

46 Congenital Hypertrophic Pyloric Stenosis

tion, constantly hungry, rabbit pellets, visible peristalsis, palpable tumour ( 90%) ( esp after vomiting a feed) 11

1 . Endoscopy: hour glass stomach 2. H pylori : biopsy + urease test ( add radiolabeled urea to biopsy sample releases ammonia) , C-urea breath test ( give labelled urea to pt to measure CO created by H pylori ) , serological 3. Barium meals 4. Faecal occult blood
1 3 13 2

Eradicate H pylori : e. g. omeprazole, clarithromycin/amoxicillin, metronidazole. Acid reduction. Prostaglandins ( e. g. misoprostol) . Avoid alcohol, smoking, aspirin. Rest, sedation. Surgical Gastric ulcers : remove ulcer & gastrin-secreting zone ( Bilroth I) . Duodenal : remove the bulk of the acid secreting area of the stomach i. e. partial gastrectomy w closure of duodenum and gastrojejunostomy, or by dividing the vagi. Post-gastrectomy cx inc: a) Small-stomach syndrome ( fullness) b) Bilious vomiting c) Anaemia: due to Fe de ciency d) Dumping: fainting, vertigo, sweating after food ( mimics a hypoglycaemic) , probably an osmotic e ect due to osmotic contents passing rapidly in to the jejunum e) Steatorrhoea: not mixed adequately w pancreatic/ biliary secretions Post-vagotomy syndromes inc: 1 . Steatorrhoea 2. Diarrhoea 3. Stomal ulceration Cx. Perforation, stenosis, haemorrhage, chronicity ( brosis) , malignant change

Rx. Medical

Clinical. Profuse non-bilious vomiting, may contain food. Dehydration, wasting. The Ix.
stomach you can hear, the stomach you can hear and see, and the stomach you can hear, see and feel : succusion splash ! visible peristalsis ! grossly hypertrophied stomach

1 . Barium meal: dilated stomach, narrow outlet, delay in emptying 2. ABG: hypochloraemic alkalosis . Ca pylorus: shorter hx, painless, gross stomach dilation, mass at pylorus Rx. Correction of dehydration and electrolyte depletion, daily gastric lavage, vitamin C ( ulcer stops absorption of ascorbic acid) . Surgical : partial gastrectomy, or vagotomy + pyloroplasty/gastro-enterostomy
o

51 Management of GI Haemorrhage

Claim to Fame. Was common, but now # cos PPIs Clinical. Hx of ulcer. Sudden onset v sev pain, may refer to shoulders, aggravated by
movement ( pt lies rigidly still) . P eritonism. Nausea, haematemesis, melaena. May be shocked. Abdomen rigid ( board-like) , tender, silent. PR: pelvic tenderness. If > 1 2h features of generalized peritonitis w paralytic ileus, distended abdo, shock. Can have a pos wall perforation: in to lesser sac ! muted presentation.

49 Perforated Peptic Ulcer

1 . CXR: gas under diaphragm 2. CT: should not delay laporotomy . Perforated appendicitis, acute cholecystitis, acute pancreatitis, MI Rx. Can be treated conservatively 1 . NG tube: empty stomach 2. Opiates, Abx, PPIs 3. Surgery: suturing omental plus to seal the perforation, lavage of peritoneal cavity 4. Control of H pylori Prognosis. Mortality: 5-1 0%

Ix.

Actually means. Duodenal ulceration causing obstruction of rst part of duodenum

12

50 Pyloric Stenosis: Uncommon

F igu re

1 0 .

Reassurance, morphine Vital sign monitoring Treat shock w blood transfusion. CVP line insertion IV PPIs When bleeding stops can drink milk Surgical Indications: i. Clinical: > 60y, chronic hx, relapse on medical rx, serious coexisting conditions, continued melaena/ haematemesis, > 4 units blood needed ii. Endoscopic: active bleeding, visible vessel, clot adherent to ulcer, unidenti able source of blood in stomach Method: gastric ulcer ! partial gastrectomy or excision, duodenal ! pyloroplasty & undersewing Notes: mortality is 1 0%, rx of varices is considered in ch. 30.

Rx. Conservative
1. 2. 3. 4. 5.

4. Technetium scan: Meckel' s 5. ( Selective visceral angiography: obscure cases) 6. ( Laporotomy)

52 Stomach Tumours
Tum our
F igu re 1 1 .

M alignant

B enign

Diagnose Source. Aetiology Central ( haemophlia, leukaemia, anticoagulant, thrombocytopenia) , or

Summary : assessment & replacement of blood loss, diagnosis of source, rx and control of bleeding Assessment. Shock if pulse > 1 00 and systolic < 1 00 ( although di erent for hypertensives) , postural drop in BP, # CVP. Take G+ S. Distinguish old from recent bleeding. Local : 1 . Oesophagus: peptic oesophagitis, varices 2. Stomach: ulcer, acute erosions ( e. g. NSAIDs) , Mallory-Weiss, tumours 3. Duodenum: ulcer, erosion by pancreatic tumour 4. SI: tumour, Meckel' s 5. Colon: tumour, diverticulitis, angiodysplasia, colitis Hx Ulcer, DH, alcoholism ( erosion, Mallory-Weiss) Ex Purpura ( bleeding tendency) , cirrhosal tendency, circumoral telangiectasia ( HHT)

1o AdenoC a S tromal L ymphom a H odgkins

2 o Adenom a S trom al Vascular: haeman.

F igu re

1 2 .

See oncology notes

Path. Uncommon, from the interstitial cells of Cajal, c-kit mutation Assoc. Type I NF Ix.
1. 2. 3. 4. Endoscopy Endoscopic USS CT Staging: PET

52.1 GI Stromal Tumours

Ix

1 . Hbg estimation ( only after body volume restored) 2. E ndoscopy : can inject adrenaline into ulcers, and band varices 3. Colonoscopy

Rx. Surgical Excision Chemo Glivec

13

VII Mechanical Obstruction

53 Mechanical Obstruction (cf. Paralytic)
Classi cation. Speed of onset Acute, chronic, acute-on-chronic Site High, low Nature Simple, strangulating ( blood supply cut o ) Aetiology Age

Op

Non-viable : remove it. Small bowel : can anastomose. Large bowel : temporary colostomy ( if distant end cannot reach then close it - Hartmann' s) cos of " bacteria & # blood supply here

54 Closed Loop Obstruction 55 Adhesive Obstruction

from this is very rare.

Def. Complete distal obstruction & valve-like obstruction proximally, e. g. volvulus

1 . Lumen: faecal impaction, gallstone ileus, food bolus, parasites, intussusception. . . 2. Wall: congenital Atresia, Crohns, tumours, diverticulitis. . . 3. Outside: strangulated hernia, volvulus, adhesions 1 . Neonatal: congenital atresia & stenosis, imperforate anus, volvulus, Hirschsprung' s, meconium ileus 2. Infants: intussusception, Hirschsprung' s, strangulated hernia, Meckel' s 3. Young/ middle age: strangulated hernia, adhesions, Crohns 4. Elderly: strangulated hernia, carcinoma, diverticulitis, impacted faeces

Claim to Fame. Three-quarters of all small bowel obstruction. Large bowel obstruction

56 Volvulus

Def. Twisting around its mesenteric axis. Most commonly sigmoid, caecum, rectum Aetiology. Abnormally mobile loop ( e. g. congenital failure of rotation) , abnormally
loaded loop ( e. g. constipation) , loop xed at apex by adhesions, loop of bowel w narrow mesenteric attachment.

Clinical.
1. 2. 3. 4.

AXr Barium follow through Water-soluble contrast enema CT Sigmoidoscopy, colonoscopy Rx. Acute: urgent cos of risk of strangulation.

Ix.

( due to bacteria) Ex. Dehydrated ( if vomiting) . " Temperature suggests strangulation. Peristalsis. Look for hernias , abdominal scar ( adhesions ) . Tinkling bowel sounds. M ust do P R ( obstructing mass, intussusception, Ca) . Strangulation features. Toxic appearance ( " pulse, " temperature) , continuous pain ( peritonitis develops) , tenderness + rigidity, bowel sounds absent ( peritonism) , " WCC 1. 2. 3. 4. 5.

C olicky pain : small bowel paraumbilical, large bowel suprapubic D istension ( gas builds up) : may be less in small bowel Absolute constipation ( o atus, o faeces) : a late feature of small bowel, early of lb Vomiting : early in high, late in chronic or low. Becomes faeculant in late stages

Untreated ! gangrene. Rx. Soft tube passed through sigmoidoscope to decompress. Laporotomy if fails, might need to remove some bowel.

Epi. Elderly, constipated. > . Rare in UK ( 2% obstructions) Clinical. Sudden colicky pain. Ix. Xr: large oval gas shadow left side, may be bent in on itself co ee bean .

56.1 Sigmoid Volvulus

56.2 Caecal Volvulus

Aetiology. Congenital malrotation. Clinically. Acute onset pain in RIF w rapid abdominal distension Ix. AXr: grossly dilated caecum often in LUQ Rx. Laporotomy & untwisting or hemicolectomy Aetiology. Adhesions, remnant of vitellointestinal duct Rx. Early operation w untwisting, rx underlying cause.

Pre-op preparation

1 . NG tube to decompress 2. IV uids 3. Abx

56.3 Small Intestinal Volvulus in Adults

14

57 Mesenteric Vascular Occlusions

Mesenteric embolus Mesenteric arterial thrombosis Mesenteric venous thrombosis: assoc w portal hypertension, OCP Non-occlusive: cardiac failure Path. Infarction, bleeding, gangrene ! perforation. Intestinal angina. Steatorrhoea. Clinical. Triad of acute colicky pain, rectal bleeding, shock ( blood loss) in elderly AF patient. Tender abdomen, mass may be felt ( infarcted bowel) Rx. Blood transfusion, resection of gangrenous bowel, revascularization w saphenous vein. May need permanent TPN in young if extensive resection.

Aetiology.
1. 2. 3. 4.

59.1 Hirschsprung's Disease

Path. Also termed aganglionic megacolon . Absence of ganglion cells in Auerbach &
stubborn constipation in infancy. PR: narrow empty rectum, above which faecal impaction felt. Ix. AXr, barium enema ( narrow rectal segment) , rectal wall biopsy ( absence of ganglion cells) . Acquire megacolon ( sev constipation at 1 -2y) Rx. Obstructed: colostomy. Elective surgery to resect & anastomose aganglionic.

Clinical. Acute obstruction in neonate. Failure to pass meconium. Can present with

Meissner. Rectum ! sometimes extending to large bowel. Functional obstruction.

58 Neonatal Intestinal Obstruction

58.1 Intestinal Atresia
Rx. Resection & anastomoses

59.2 Anorectal Atresias

Assoc. Fistula Clinical. Anus may be absent Rx. Reconstruction

Classi cation. Intestinal atresia, meconium ileus, NEC, Hirschprung' s, Anorectal Clinical. Continuous bile-stained vomiting. Constipation, distension, peristalsis.

58.2 Volvulus Neonatorum ( Malrotation) 58.3 Meconium Ileus

Def. Congenital malrotation Rx. Laporotomy untwisting. Adhesions ( Ladd' s bands) divided

Assoc. 80% have CF Clinical. Acute obstruction in rst days. May have palpable loop. Ix. AXr: obstruction & Ground glass meconium Rx. Gastrogra n PR to emulsify. Otherwise enterotomy, resections.

ceptum. Path. Ileocolic ( through IC valve into colon) in 75%. Blood supply cut o ! gangrene Aetiology. Infants/ young children. Postulated Peyer' s patches act as foreign body ( hence can be preceeded by viral infx) . In adults may be polyp etc. Clinical. > . Paroxysms of abdominal colic with screaming & pallor. Vomiting, passage of redcurrant jelly ( blood/slime) . Palpation reveals sausage-shaped tumour. If neglected, sx of strangulated obstruction ( " mortality at this stage) . Ix. Barium enema

Def. Prolapse of bowel into lumen of adjoining. The prolapsing bowel is the intussu-

59.3 Intussusception

Rx. Non-op May be treated by barium enema ( the pressure forces it back) Op Reduce at laporotomy, resection may be necessary.

Claim to Fame. Premature infants, due to ischaemia ! bacterial invasion. 25% morBlood/mucus passed PR. Cx. Perforation, resolve with stricture formation Ix. AXr: distended loops, gas bubbles in bowel wall. Rx. Medical: resus, TPN, abx. Resection: failure to respond or cx.

59 Necrotizing Enterocolitis
tality

VIII Appendicitis
infection. A retrocaecal appendix is most common.

Surgical Talk

Clinical. Generalized sepsis, vomiting, listlessness. Distended, tense abdomen.

Claim to Fame. Commonest emergency surgical presentation requiring operation Path. Obstruction ( by faecolith, or lymphoid hypertrophy, or rarely tumour) followed by Clinical. Pain initially colicky due to obstructed appendix ! RIF constant due to peritonitis. Tenderness, guarding. Fever, anorexic, nausea, vomiting. Clinical diagnosis. 15

Rx. Appendicectomy: incision at McBurney' s point, open up skin subcut tissues, ext

oblique, int oblique, trasversus abdominus, peritoneum. Divide blood vessels, ligate appendix at base, suck pus/blood out. . Mesenteric adenitis: enlargement of mesenteric LNs causing pain, fever, tenderness. Ix: leucocytosis ( c. f. raised neutrophil) RIF mass. Appendix, gynaecological, caecal ca, soft tissue tumour ( e. g. sarcoma) , LN mass, TB, actinomycosis, iliac aneurysm

Ix. Cx.

3. Fistulas: penetrate adjacent gut or bladder, or be perianal. 4. Malabsorption: vitamin de ciencies, resections. 5. Diarrhoea: in ammation and mucosal ulceration, colonic/rectal involvement, bacterial overgrowth in obstructed segments. May have blood. 6. Perianal disease 1 . Anaemia, faecal occult blood, # albumin, " in ammatory markers 2. Small bowel enema: strictures, stula, cobblestone 3. Technetium labeled leucocyte scan: taken up in in amed segments
o

IX The Small Intestine

60 Meckel's Diverticulum
Clinical Presentations.
1. 2. 3. 4. 5. tion, 2ft from the caecum, 2in.

Def. Remnant of vitello-intestinal duct. Antimesenteric border of ileum. 2% of popula( Asymptomatic nding at op or autopsy) Acute in ammation ( identical to appendicitis) Perforation by foreign body Intussusception ( ileo-ileal) Peptic ulceration due to contained ectopic gastric epithelium. Melaena in children at 1 0 y/o. 6. Patent vitello-intestinal duct. 7. Raspberry tumour at the umbilicus ( persistent umbilical extremity of the duct) 8. Vitello-intestinal band: causing obstruction or volvulus

1 . Renal calculi: 2 hyperoxaluria ( cos usually excreted in bile) due to steatorrhoea 2. Biliary calculi: interruption of bile salt circulation due to resection 3. Primary sclerosing cholangitis, sacroilitis, pyoderma gangreosum, uveitis Rx. Surgery avoided cos malabsorption may follow extensive resections of the bowel Medical Conservative: nutritional support, elemental diet. Acute episodes : steroid, immunosuppression ( azathioprine) , parental nutrition, TNF- . Mild symptoms : 5aminosalicylate drugs ( e. g. sulfasalazine) , steroids, metronidazole Surgical Indicated for sev/ recurrent obstructive symptoms, & rx for stulae into bladder or skin. Surgery should be as conservative as possible cos further resections usually necessary ( it just recurs) Prognosis. Recurrence is 50% in 1 0y

62 Tumours of the SI
Tumours
B enign M alignant

Aetiology. Environment ( smoking, urban living) , Genetic ( FH) Pathology. Can be any part of GIT. Small bowel in 2/3s w the lower ileum being the
Acutely bowel red, swollen. Mucosal ulceration + intervening oedema = cobblestone. Thickened wall, " LNs. Skip areas. Microscopic Fibrosis, lymphoedema, chronic in ammatory in ltrate through the whole thickness of wall. Non-caseating foci w ssuring ulcers extending deep through wall ! these may form abscesses or stulae. Clinical. Most common 20-40y. = . Abdominal pain and diarrhoea. 1 . Acute: similar to appendicitis w RIF pain and vomiting. May have perforation or haemorrhage. 2. Obstruction: due to post-in ammatory brosis. commonest site.

61 Crohn's
Macroscopic

Adenom a S trom al L ipoma H am artom a

1o AdenoC a L ymphom a C arcinoid S trom al

2o

F igu re

1 3.

H amartom a: e. g. Peutz-J eghers

Bleeding Obstruction Intussusception Volvulus

62.1 Carcinoid

Def. Amine Precursor Uptake and Decarboculation ( APUD) tumour. 1 0% association w

MEN-I. Most commonly appendix, but can be anywhere in GI tract & occasionally lung. Secrete 5HT. Rarely ( but can be) symptomatic until have metastasized to liver ( where they secrete their hormone directly in to the circulation)

16

Pathology. Macroscopic Clinical.

Yellowish submucosal nodule. Surface ulceration. Extension to serosa leads to brosis & obstruction Microscopic Kultshitzky cells. V slow growing ( presents > 40y) . 4% of the appendix metastasize, or may present early w obstruction. 1 . Flushing ( 80%) w attacks of cyanosis, chronic red faced, often precipitated by stress, food or alcohol 2. Diarrhoea ( 70%) , profuse, noisy 3. Abdo pain ( 40%) due to mesenteric brosis resulting in partial obstruction 4. Bronchospasm 5. Abnormalities in the hrt ( valve stenosis) , hepatomegaly
o

muscle coats ( unlike Meckel' s) . Most common in sigmoid & descending. Unusual < 40y ( acquired) . = . Common in West ( # bre) . Diverticulosis is usually asx Pathogenesis. # Fibre diet ! " P in colon ! hypertrophy muscle ! " sigmoid colon ! herniation of the mucosa at sites of weakness ( where vessels enter wall)

Def. Outpouchings of mucous membrane. They are false because they lack normal

65 Diverticulosis Coli & Diverticulitis

66 Diverticulitis
Cx.
1 . Perforation: a) Peritoneal causing peritonitis b) Pericolic gutters causing pericolic abscess c) Adjacent structures forming stula 2. Chronic infx w in ammatory brosis ! obstructive symptoms 3. Haemorrhage: erosion of a vessel

Ix.

1 . 5-HIAA urinary concentration ( the breakdown product of 5HT) 2. CT/ USS liver for 2 s 3. Radiolabelled octreotide scintigraphy Rx. Resection in early cases, w removal of liver deposits. Palliation ( w more extensive deposits) by chemo-embolization. Octreotide ( somastatin analogue) inhibits 5HT release. Radiotherapy.

Clinical.

X The Colon
63 Constipation
1. 2. 3. 4. 5. Organic: Ca colon, diverticular disease Painful anal conditions: ssures, piles Adynamic bowel: Hirschprung' s, senility, SC injuries, myxoedema, Parkinsons Drugs: Aspirin, opiate, anticholinergics, ganglion blockers Habit & diet: dehydration, starvation, lack of bulk, dyscheua ( faulty habit)

Ix.

1 . Acute diverticulitis: Left sided appendicitis : low central abdo pain shifting to LIF, fever, vomiting, tenderness, guarding, bleeding. Pericolic abscess : like an appendix abscess ( so tender mass, swinging fever, leucocytosis) 2. Chronic diverticulitis: mimics Ca colon w: in bowel habit, obstruction, blood/mucus PR. Ex reveals tender LIF & thickened mass in region of sigmoid colon. 3. Diverticular disease: asx, grumbling abdo pain, constipation, Fe-de cient anaemia 4. Sudden severe haemorrhage: rarer 5. colovesical stula: passage of gas bubbles: rarer

1. 2. 3. 4.

64 Diarrhoea
1. 2. 3. 4. 5. 6. 7. Speci c infx: food poisoning, dysentery, cholera, viral In ammation: UC, Crohns, tumours, diverticular Drugs: Abx, abx-induced colitis, erythromycin, purgatives, digitalis Loss of absorptive surface: resections, sprue & coeliac, idiopathic steatorrhoea Pancreatic dysfunction Post-gastrectomy & vagotomy General diseases: anxiety, thyrotoxicosis, uraemia, Carcinoid, Zollinger-Ellison

Rx. Acute d ivertic ulitis

Fibreoptic sigmoidoscopy ( rigid' s do not visualize diverticula) USS: abscess Colonoscopy Barium enema: ( D on' t perform in acute phase ) globular outpouchings showing signet ring appearance cos of lling defect produced by contained pellets of faeces ( faecoliths) . Saw-tooth : narrowed segment due to oedema and thickening. 5. CT: in acute phase . Ca

Conservative: uids, abx ( met, pen, gen) . Pericolic abscess : diagnosed by CT & drained. General peritonitis : laporotomy + resection. Acute obstruction : laporotomy + resection + colostomy Chronic d ivertic u lar disease Conservative: laxatives, " roughage diet. If sx persist: laporotomy. Colovesival stula : resection + loop colostomy ( before anastomosis)

17

67 Angiodysplasia

vein) . Elderly. Caecum, ascending colon. Clinical. Asx usually. Bleeding: continuous, chronic blood loss. Ix. Colonoscopy ( bright red lesions) , mesenteric angiogram ( in actively bleeding pt' s) Rx. Blood transfusion if " blood loss, electrocoagulation, resection ( sometimes)

Def. 1 or more small mucosal or submucosal vascular malformations ( usually dilated

. Dysenteries, carcinoma Cx. Local Toxic dilatation, haemorrhage, stricture, malignant , perianal disease General Toxaemia, weight loss, anaemia. Autoimmune: arthritis, uveitis, dermatoRx. Medical
logical ( pyoderma gangrenosum= ulcers on shins, skin rashes, ulceration of legs) , 1 sclerosing cholangitis Malignant . Colon Ca risk
o

68 Colitis
1. 2. 3. 4.

UC/Crohns Abx-associated: e. g. pseudomembranous due to C di cile Infections Ischaemic

" Protein diet, vitamins. Blood transfusion. Diarrhoea : codeine phosphate. Acute attack : Systemic corticosteroids. Maintain remission : salicylates. Surgery Indications: fulminating disease not responding to medical rx, chronic not responding to rx, prophylaxis against malignant , complications. Usually total colectomy & removal of rectum ! permanent ileostomy or ileo-anal anastomosis

69 Ulcerative Colitis

Perianal common Perianal disease rare Bleeding uncommon Often profuse haemorrhage Transmural Mucosal Thickened bowel wall No thickening No polyps Pseudo-polyps Fistulas No stula' s Malignant rare Malignant common Granulomas No granulomas
Ta b l e 2 .

Crohn's Colitis

UC

70 Crohn's Colitis

Clinical. Mimics UC. Unlike UC commonly becomes adherent to adjacent structures w

abscess formation & stulas. Perianal disease. Rx. Similar to Crohn' s of SI. Extensive bowel involvement may require total excision w permanent ileostomy ( no anastomosis is made, risk of recurrence, sepsis, stulation) ,

71 Tumours
T umours B enign M alignant

40y. Only large bowel. Path. Oedema, haemorrhage ! ulceration. Edematous islands of mucosa btw ulcers form pseudopolyps. Wall is brotic, w loss of haustrations. No skip lesions. Microscopically : crypt abscesses, break down in to ulcers w base lined w granulation tissue. Clinical. Fulminant, intermittent or chronic. Bloody/mucus diarrhoea. Cramp-like abdo pains. Nothing on ex except tenderness in LIF, blood on glove. Sev attacks : toxaemia, sev bleeding, risk of perforation, anorexia, wt loss. Distinguish btw functional : functional bowel disease pt' s don' t get up at night Associations. Uveitis, pyoderma gangrenosum, sclerosing cholangitis, arthropathy

Def. In ammatory disease of the rectum, extending variably proximal. > . Peaks 20-

Adenom a Polyp Papill L ipom a N eurof H aeman

1o C arcinoma L ymphom a C arcinoid

2o

F igu re

1 4.

See oncology notes

72 Familial Adenomatous Polyps

Ix.

1. 2. 3. 4. 5.

AXR: megacolon? Sigmoidoscopy + biopsy: oedema of mucosa w contact bleeding in early mild cases Colonoscopy Barium enema: ragged surface ( ulceration + pseudopolyps) , loss of haustrations Ex of stools

Claim to Fame. Rare but inevitably progresses to Ca. Dominant. Clinical. Polyps start in adolescence, sx of bleeding and diarrhoea commence early 20s,
malignant change 20-40y. Hypertrophy of the retinal pigment layer. the skull Rx. Total colectomy w excision of the rectum, formation of an ileo-anal pouch.

Gardener's syndrome . Variant where associated w desmoid tumours and osteomas of

18

73 HNPCC

Claim to Fame. 5% of colorectal Ca. Dominant. Right sided, occur < 50y.

74 Colostomy

5. Lateral space small bowel obstruction: due to failure to obliterate the space btw the terminal colon & lat abdo wall 6. Psychological Stoma appliances. Bag ( collects faeces) , adhesive ange ( cut to t stoma) . Pt' s can live normal life w little risk of leakage or odour.

XI Rectum & Anal Canal

75 Bright Red Rectal Bleeding
1 . Haemorrhoids 2. Fissure-in-ano 3. Tumours 4. Diverticular 5. UC 6. Trauma 7. Angiodysplasia 8. Rarely higher up bleeding may produce red blood

76 Haemorrhoids

Anatomy. Anal cushions are highly vascular tissue lining anal canal, supplied by rectal Def. A vascular cushion, covered in a layer of mucosa and containing a branch of the Pathology. Abn anal cushions, congested ( as a result of straining) . In lithotomy position
F igu re 1 5 .

artery. Draining veins form saccules just below dentate line ! sup rectal vein. superior rectal artery and a tributary of the superior rectal vein.

Indications. Divert faeces to allow healing of an anastomosis or stula ( avoid contaminaTypes. Loop

tion) , decompress a dilated colon as a prelude to resection, removal of the distal colon & rectum

Cx.

Antimesenteric border opened to surface. Rod often used to stop colon falling back. Temporary. End Divide colon & bring proximal end to the surface. May be de nitive rx for total rectal excision, or following perforated diverticular disease where diseased bowel is removed & 1 anastomosis undesirable. Double Barreled Proximal & distal brought out adjacent w intervening colon removed . ( Not commonly used, except in sigmoid volvulus, cos distal bowel usually too shor t)
o

1. 2. 3. 4.

Retraction: colon disappears back down Stenosis: due to ischaemia, poor technique Paracolostomy hernia Prolapse: colon intussuscepts out

Ix.

tumour ( commonest is pregnancy, rectal Ca) , cardiac failure, purgative use, chronic constipation ( straining) Clinical. Bleeding ( bright red, occurring at defecation) , may be " " . Mucus discharge, pruritus ani. Pain is only a feature if undergo thrombosis. Other pain may be due to: ssure-in-ano, perianal haematoma, perianal or ischiorectal abscess, tumour of anal margin. 1 . Examination + PR ( prolapsing piles obvious) 2. Proctoscopy: int Haemorrhoids 3. Sigmoidoscopy

Grading. 1 o bleed but don' t prolapse 2 o prolapse on defecation, reduce spontaneously 3 o remain prolapsed, pt reduces them 4 o Thrombosed Predisposing. Factors that " congestion of sup rectal veins : compression by pelvic

usually at 3, 7, 1 1 O' clock.

19

Cx.

4. Barium enema: exclude Ca 5. Colonoscopy Anaemia ( sev bleeding) Thrombosis: when prolapsing piles gripped by the anal sphincter - venous return occluded & thrombosis of pile occurs. Size of plums. Painful.

79 Anorectal Abscess
Classi cation.
1. 2. 3. 4. Perianal: infx of hair follicle Submucous: infected ssure or laceration of anal canal Ischiorectal: infection of an anal gland Pelvirectal: spread from pelvic abscess ( rare) Rx. Drainage to prevent rupture or stula

Rx. Conservative Avoid straining, daily motion, laxatives Medical LA, steroids Surgical
o o o o o o

Cx of haemorrhoidectomy.

i. Sclerotherapy: 1 / 2 injected above dentate line ( painless) ii. Banding ( rubber) : falls away in 4d. 1 /2 iii. Ectomy: 3 /4 Thrombosed, strangulated pt w foot of bed elevated, opiate analgesia, can do haemorrhoidectomy 1 . Retention: due to anal discomfort 2. Stricture: if excessive skin/mucosa excised 3. Post-op haemorrhage: may be reactionary ( post-op) , 2 ( week later) . May not be visible. Rx: blood transfusion if severe, might need packing 4. Perianal haematoma ( thrombosed external pile ) : thrombosis in inf rectal venous plexus. Rx: evacuate.
o

80 Fistula-in-ano

Def. Fistula : abn connection btw 2 epithelial surfaces ( e. g. hollow viscus and surface of Aetiology. Abscess, Crohns, UC, Ca. Classi cation. Relation to internal and external anal sphincters:
the body) . Sinus : granulating track leading from source of infection to a surface

Def. Sinus containing hairs Description. May become infected ! pilonidal abscess. May have chronic discharge Claim to Fame. Common in ngers of hairdressers Rx. Excision

77 Piloidal sinus

F igu re

1 6.

G oodsall' s law

78 Fissure-in-ano
line.

PR. Need to determine path of stula tract. Rx. Super cial/ low level anal stulae laid open & left to heal by granulation ( no loss of continence as not dividing sphincters) . High stulae ( supraphincteric, and trans sphincteric close to anorectal ring) only lower part laid open ! seton passed through upper part so xed by scarring ! can repeatedly tighten this.

Clinical. Persistent discharge of pus. Ex reveals opening. Internal opening may be felt

Def. Tear in anal margin, usually follows passage of constipated stool. Usually pos midConstipation ( due to pain) . May be sentinel pile ( torn tag of anal epithelium) . PR may be impossible w/ o anaesthetic. 1 0% anterior midline, 90% posterior midline. Rx. May heal spontaneously. Laxatives + uid. LA+ lubricant gives relief. GTN cream ( relaxes the smooth muscle of the sphincter. SE: headache) . Sphincterotomy: can divide int sphincter submucosally under GA. Recurrence needs excision.

Clinical. Acute anal pain, stinging, lasts for a while after passing stool. Slight bleeding.

81 Stricture of Anal Canal

Classi cation.
1. 2. 3. 4. 5. Congenital Traumatic: post-op In ammatory: lymphogranuloma inguinale, Crohn' s, UC Post-irradiation Neoplasm

20

Rx. Underlying pathology. May need dilatation, reconstruction, defunctioning colostomy,

excision ( Ca) .

Ix. Biopsy Rx. Excise villous and adenomatous

82 Rectal Prolapse

sphincter. Rx. Partial : Excision of redundant mucosa. Complete : Can xate rectum in pelvis by wrapping mobilized rectum in polyvinyl sponge.

Classi cation. Partial Mucosa only. Occurs in infants: reassurance as self-limiting. Complete All layers. Usually elderly . Incontinence also, due to stretching of

86 Ca Rectum

Path. = . 20+ . Predisposing. Adenoma, FAP, UC Macroscopic.

83 Pruritus Ani
Local causes within anus or rectum: e. g. lack of cleanliness, " sweating Skin diseases: scabies pediculosis, fungal General diseases assoc w pruritus: DM, Hodgkins, obstructive jaundice Idiopathic: often due to continued scratching Rx. Underlying cause. Hydrocortisone ointment, hygiene

Causes.
1. 2. 3. 4.

Spread. Local

Papilliferous Ulcerating ( commonest) Stenosing ( usually rectosigmoid) Colloid Microscopic. 90% adenoCa, 9% colloid. Remainder anaplastic carcinoma simplex. Circumferentially around lumen, muscular, adjacent organs ( prostate, bladder. . . ) Lymphatic Regional LNs along inf mesenteric vessels Blood Liver, lungs Transcoelomic Peritoneal cavity Staging. Dukes:
Type

84 Tumours
T umours

B enign

M alignant

2o
Ta b l e 3.

Adenom a Papilloma lip om a E ndom etriom a AdenoC a S C C M elanom a C arcinoid L ym phom a

F igu re 1 7.

A B C D

5y Surv.

90% 60% 30% 5-1 0%

Con ned to mucosa Through wall Lymph nodes Distant

Description

Surgery Surgery C hemo Praying

o

Rx

No te : A lso give ra d io the ra py fo r rec ta l ( not colon ) C a .

Clinical. Local sx ( Constipation+ diarrhoea ( 80%) , bleeding, tenesmus, mucus, pain) , 2 Ix.
deposits, general Ca e ects

85 Rectal Polyps
Types. Metaplastic polyp
truly Metaplastic 2-3 mm sessile, wart-like. Often multiple, always benign, not

Adenomatous polyp Benign polyp, may undergo malignant Villous adenoma Can grow large, produces " mucus, may undergo malignant Pseudopolyp Assoc w colitis. Is oedematous mucosa against an ulcerated wall Juvenile polyp Children & young adults. Looks like a cherry on a stalk. Always
benign. May bleed & prolapse

Rx. Curative
21

1 . Sigmoidoscopy + biopsy 2. Barium enema 3. USS: liver mets, ascites . Benign, prolapsed Ca sigmoid tumour, ovarian/ uterine tumours, prostate/ cervix extending tumours, diverticular, endometriosis, lymphogranuloma inguinale, amoebic granuloma, faeces Upper 2 thirds: anterior resection ( resection + anastomosis)

22

C a Rect um

Lower third: less than 5cm from anal verge then abdominoperineal excision of the rectum and terminal colostomy. Radiotherapy Palliative Resect primary. Colostomy might be necessary for obstruction ( but doesn' t relieve bleeding etc. ) . Inoperable : Radiotherapy, diathermy, laser.

Path. Sev loss of uid, electrolytes, into lumen ! vomitus. Gross distension impairs blood
abdomen ( noisy abdomens in mechanical obstruction) . Relatively painless. Beware that it may merge in to obstruction caused by adhesions post-op. If symptoms commence after already passing motions then likely mechanical. Ix. AXr: gas distributed through small and large bowel ( in mechanical localized loops seen)

c) P ost-op : after every lap. Lasts 24-48h.

Clinical. Post-op stage of peritonitis/major surgery. 4 features of obstruction. Silent

supply.

XII Peritonitis
1 . Exterior: e. g. penetrating wound, laporotomy ( 30%) 2. Intra-abdominal viscera: gangrene ( e. g. acute appendicitis ( 20%) ) , perforation ( e. g. peptic ulcer ( 20%) ) 3. Blood stream: septicaemia 4. Female genital tract Causes. Absorption of toxins from in amed surface, paralytic ileus, gross abdominal distension predisposes to pneumonia & collapse ( due to elevation of diaphragm)

Aetiology.

Rx. Prophylaxis Established

NG suction NG suction. Pethidine ( unlike others, has little e ect on motility) . Stubborn : metoclopramide ( dopamine agonist) , erythromycin.

Clinical.

Ix.

Sx of the 1 , sev pain aggravated by movement, shoulder tip pain possible, " temperature, " pulse, rigid wall, rebound tenderness, silent abdomen, tenderness on PR. Advanced : distended & tympanic, free uid, toxic.
o

C onstant pain ( aggrav by movement) , guarding, rigidity, sounds .

o bowel

XIV Hernias

1. 2. 3. 4.

FBC Amylase ( pancreatitis) CXR: gas under diaphragm CT: free gas, pinpoint source of peritonitis . Obstruction, ureteric/ biliary colic, pneumonia, MI, haemorrhage, AA leakage

XIII Paralytic Ileus

Def. Obstruction due to lack of motility Aetiology.
1 . Re ex paralytic: ANS supply interference ( e. g. fractures to spine, retroperitonal haemorrhage, intestinal ischaemia, ureteric colic) 2. Peritonitis: toxic paralysis of intrinsic N plexuses a) Metabolic: sev # K, uraemia, diabetic coma b) Drugs: Anticholinergics, anti-parkinsonsian 22

F igu re

1 8 .

87 De nitions

Conservative

Truss only if v poor condition.

Hernia. A protusion of an organ or part of an organ through a defect in the wall of the Strangulated. Sev pain in the hernia of sudden onset, & central abdo colicky pain. Sx of
obstruction: vomiting, distension, absolute constipation. Tender, tense hernia that cannot be reduced & has no cough impulse. Overlying skin in amed, oedematous. Signs of obstruction: distension, tenderness, noisy bowel sounds. cavity containing it, into an abnormal position.

89 Femoral Hernia

Anatomy. Gap 1 . 5cm in length lying at medial extremity of the femoral sheaf containing

88 Inguinal Hernia
May be congenital Always acquired Strangulate commonly cos narrow neck Rarely ( wide necked) Scrotum extension often Rarely Not reduce on lying readily Spontaneously Recurs uncommon More common Lateral inf. epig Medial
Ta b l e 4.

Indirect

Direct

femoral artery & vein. Boundaries: Anteriorly Inguinal lig Medial Sharp edge of lacunar part of inguinal lig Lateral Femoral vein Posteriorly Pectineal ligament of Astley Cooper Epi. : = 4: 1 Clinical. > ( wider pelvis) , middle aged/elderly. Never congenital, although rarely occur in children. Globular swelling below and lateral to PT. Enlarges on standing, coughing, may disappear on lying down. Narrow neck, sharp medial border: strangulation v common.

Anatomy of canal. Contains Spermatic cord ( round lig in ) , ilioinguinal nerve Anteriorly Skin, super cial fascia, ext oblique aponeurosis Posteriorly Medially: Conjoint tendon ( the fused common aponeurotic insertion of
the int oblique and transzersus abdo muscles into the pubic crest) . Laterally: transversalis fascia Above Lowest bers of int oblique Below Inguinal lig Int ring Where spermatic cord pushes through transversalis fascia, demarcated medially by inferior epigastric Ext ring V-shaped defect in ext oblique aponeurosis Indirect hernia. Controlled by pressing over internal inguinal ring ( 1 . 5cm above femoral pulse, felt half way btw ASIS and PS) . If protudes through ext ring can be felt above and medial to PT. May be due to persistence of processus vaginalis, present young. Narrow ring. Direct hernia. Not controlled by pressure over int ring.

90 Richter's Hernia

obstructed, although this part can become necrotic or perforate. Rx. Excision of sac & closure

Def. Only part of wall herniated through, where it is then strangulated. But not

91 Umbilical Hernia
tained in translucent sac.

Exophthalmos. Failure of midgut to return to abdominal cavity in fetal life. Bowel conRx. Immediate surgical repair. If massive then protect in dressing & repair later

Def. Acquired hernia above/ below umbilicus. Obese, middle aged, multiparous . Prone
to strangulation.

92 Para-umbilical Hernia

Rx. Infants Adults

Excise hernial sac at 1 y ( herniotomy) Excision of sac & repair of inguinal canal

93 Epigastric Hernia
Def. Defects in linea alba above the umbilicus.
23

Rx. Surgical repair not carried out unless persists past 2y

94 Congenital Umbilical Hernia

About. Strangulation is rare cos wide neck Rx. If good general condition then dissecting out & suturing individual layers of the abdo
wall. Large hernias w polypropylene mesh.

95 Incisional Hernia

In ammatory: hepatitis, portal pyaemia & liver abscess, leptospirosis, actinomycosis Parasitic: amoebic hepatitis & abscess, hydatid Neoplastic: primary, secondary Cirrhosis: portal, biliary, cardiac, haemochromatosis Haemopoietic diseases & reticuloses: lymphoma, leukaemia, polycythaemia Metabolic: amyloid, Gauchers Also check. The spleen ( cirrhosis, polycythaemia, leukaemia, amyloid) and LNs ( lymphoma)

2. 3. 4. 5. 6. 7.

99 Jaundice
Metabolism.

96 Unusual Hernias
Thin, elderly . Through obturator canal. Pressure on obturator nerve may cause pain down thigh Spigelian Passes up through arcuate line into the lat border of the lower part of the pos rectus sheaf. Tender mass to one side of the lower abdo wall

Obturator

97 Acquired Hiatal Hernias

Types. Sliding ( 90%) , rolling ( 1 0%) . The hernia part covered by peritoneal sac. Obese,
1 . Mechanical: cough, dyspnoea, palpitations, hiccup 2. Re ux: Incompetence of cardiac sphincter 3. Oesophagitis: strictures, dysphagia, bleeding Rx. Conservative ( raise head of bed) , medical ( PPI, H receptor) surgical ( Nissens) . Sliding : symptomatically. Rolling : if develop volvulus then repair.
2
F igu r e 1 9 .

Clinical.

middle aged, elderly, .

XV Liver
Clinical. Normally impalpable except in infants. Causes.
1 . Congenital: Riedel' s lobe, polycystic

Classi cation. Prehepatic Haemolytic e. g. spherocytosis Hepatic Hepatitis ( viral, leptospirosis, glandular fever) , cirrhosis, cholestasis from Posthepatic
drugs ( e. g. chlorpromazine) , liver poisons ( e. g. paracetamol) , tumours
o o

98 Liver Enlargement

1 . Lumen: gallstones 2. Wall: congenital atresia of cbd, traumatic stricture, 1 / 2 sclerosing cholangitis, tumour of bile duct 3. Outside wall: pancreatitis, Ca head of pancreas, Ca ampulla of Vater, cholecystitis

24

Ix.

Ix summary. Exclusion of pre-hepatic causes haptoglobin level, reticulocyte count, Coombs Liver synthetic function prothrombin time, albumin Liver cell damage transaminases, GGT, transferase Bile duct obstruction ALP, USS bile ducts, PTC, ERCP, MRCP, CT Intrahepatic mass cross-sectional imaging such as CT + needle biopsy

1 . Serum bilirubin: > 35 mol/L in jaundice 2. Bilirubin: conjugated in post-hepatic 3. Bilirubin in urine: posthepatic and dark ( only excreted by kidney in water soluble form, hence not present in pre-hepatic. ) 4. Bilirubin in faeces: " in prehepatic and hepatic cos large amounts secreted into gut. In posthepatic it is obstructed from entering faeces, hence pale . 5. Haemolytic blood tests: rbc fragility, Coombs, reticulocyte count 6. " ALP in obstructive 7. Serum proteins: in hepatic jaundice has reversed albumin/ globulin level 8. Haptoglobins: low in pre-hepatic ( binds free hbg after haemolysis) 9. " Transaminases in hepatitis and active cirrhosis 1 0. Prothrombin time: normal in pre-hepatic, # but correctable ( vit K) in hepatic, and # advanced hepatic 1 1 . USS: gallstones ( except missed in bile ducts) 1 2. CT/ MRI 1 3. Biopsy: hepatitis, cirrhosis suspected 1 4. MRCP 1 5. ERCP 1 6. Percutaneous transhepatic cholangiography ( PTC) : cannulate bile duct

102 Acute Infections

Can arise from: Portal ( usually diverticular sepsis, appendicitis) Biliary, resulting from ascending cholangitis Arterial: general septicaemia ( unusual) Adjacent infections: e. g. subphrenic abscess or acute cholecystitis

103 Pyogenic Liver Abscess

Aetiology. Infection in the portal territory ! portal pyaemia, or infection in the biliary
tree. E coli, Strep faecalis, Strep milleri. Portal Pyaemia Focus of intra abdo sepsis. Rare since abx. Biliary Infection Sev suppurative cholangitis ( Charcot' s intermittent hepatic fever : pyrexia, rigors, jaundice) 2 gallstone impaction in the cbd. Clinical. Insidious, w malaise. Rigors, high swinging temperature, tender palpable liver, jaundice. Previous hx of abdo sepsis such as Crohns.
o

Ix.

Rx. Liver abscess : drain under USS guidance. Smaller : parental abx. Biliary infx : Urgent
drainage of bile ducts by either endoscopic sphincterotomy or percutaneous transhepatic drainage, IV uids to prevent hepatorenal syndrome.

1 . Blood culture

2. USS/ CT: abscesses, source of pyaemia

Riedel's lobe Big, downward R lobe Polycystic liver Assoc w polycystic kidneys. Functions normally. Discomfort. Haemorrhage into cysts, cholangitis are complications

100 Congenital Abnormalities

104 Amoebic Liver Abscess

Aetiology. Entamoeba histolytica infection of colon. Abscess in liver is sterile. Ix. CT, USS. Rx. Metronidazole.

Aetiology. Penetrating wounds, cloded crush injury Ix. Ct useful to distinguish btw ruptured spleen Rx.

101 Liver Trauma

105 Hydatid Disease of the Liver

Claim to Fame. Liver is source of 75% hydatid cysts in body Path. Dogs infected w Echinococcus granulosus after eating sheep o al ( therefore " in Clinical. Symptomless mass. Active may:
sheep rearing countries) ! tapeworms ! humans eat ! liver. i. Rupture in to peritoneal ( peritonitis) / pleural ( haemoptysis) /alimentary ( pass in faeces) /biliary ii. Become infected iii. Jaundice due to pressure on intrahepatic bile ducts. ( Malaise, pruritus)

1 . Conservative: blood transfusions, observation 2. Continued bleeding: laporotomy ( packing, suturing liver, tie o arterial branches) , abx cover 25

XR liver: clear zone, ecks of calci cation USS/ CT: localize Serological Eosinophilia Rx. Leave calci ed cysts alone. Others : Albendazole ( shrinkage) . Failure to respond : surgery.

Ix.

1. 2. 3. 4.

Hepatic C irrhosis ( commonest by far) Posthepatic (Budd-Chiari) Idiopathic venous thrombosis ( OCP, haematologCx.
ical. . . ) , tumour ( block hepatic veins) 1 . Collateral portosystemic drainage: i. L gastric ! oesophageal ii. Obliterated umbilical vein to sup/inf epigastric veins ( caput medusa ) iii. ( Retro) peritoneal & diaphragmatic anastomoses iv. Between sup & inf rectal veins 2. Splenomegaly: due to congestion. Get leucopenia, thrombocytopenia ( spleen more active) 3. Ascites. ( Other causes of ascites include: heart failure, renal failure, liver failure, carcinomatosis, chronic peritonitis e. g. TB ) E ects of liver failure. Jaundice, encephalopathy 1. 4. 5. 6. 7.

Def. Chronic hepatic injury. Healing by regeneration & brosis. Aetiology.

1. 2. 3. 4.
o o

106 Cirrhosis

Consequences.

Parenchymal: alcoholic, viral ( B, C) Metabolic: haemochromatosis, Wilsons Biliary: 1 biliary cirrhosis, 2 to prolonged biliary cirrhosis Hepatic venous out ow obstruction: Budd-Chiari, sev chronic congestive cardiac failure 5. Other: chronic active hepatitis, schistosomiasis, nutritional, idiopathic parental nutrition related, non-alcoholic steatohepatitis

Management of ascites.
1. 2. 3. 4. 5.

1 . Hepatocellular failure: impaired protein synthesis ( " prothrombin time, # albumin) , impaired toxin metabolism ( encephalopathy) , impaired bilirubin metabolism ( jaundice) 2. Portal hypertension 3. Ascites: # albumin & " portal P 4. Malignant change

Paracentesis: immediate relief. Need to replace protein being removed Diet: # Na, " protein, IV albumin Diuretics Iatrogenic portal-systemic shunt: portal vein to vena cava Liver transplant: for intractable ascites Hepatorenal syndrome. Renal failure. Partly due to depletion of IV volume. Prevention : Avoid uid depletion, maintain a good intra-op diuresis w mannitol infusion.

LFTs 2. Liver synthetic tests 3. Liver biopsy Fibreoptic endoscopy: varices Splenic venogram: site of portal obstruction IVC-agram: hepatic venous occlusion MR angiography, CT angiogram: same as splenic venography Rx. Uncomplicated: underlying condition ( e. g. cirrhosis managed by well balanced diet, low alcohol) . Varices on endoscopy : sclerosant injection Management of haemorrhage from varices. 50% mortality: liver further damaged by hypotension, " encephalopathy Prophylaxis -blockers ( # portal venous pressure) , band ligation, sclerosant injection Diagnose includes gastric erosions. Endoscopy. Immediate rx Blood transfusion. Enema to # blood absorption from gut, withholding protein.

Ix.

Stopping haemorrhage

107 Portal Hypertension

2

Def. > 50 cm H O Aetiology. Obstruction to drainage. ( Remember this classi cation travels the opposite
way to jaundice classi cation. ) Prehepatic Congenital, portal vein thrombosis in neonatal ( spreading from infx) , occlusion by tumour or pancreatitis

1 . Endoscopic variceal band ligation or sclerotherapy: risk of perforation, stenosis ( injections 2. IV vasopressin: # portal venous pressure. Give GTN to # myocardial ischaemia 3. Balloon tamponade: Sendstaken Blakemore tube. Rebleeding common after removal 4. Trans-jugular intrahepatic portosystemic shunt ( TIPS) : metal stent passed through liver to open passage btw hepatic vein and portal vein ! decompress portal system. Causes encephalopathy. 5. Oesophageal transection: oesophagus + varices divided at cardio-oesophageal junction by stapling gun, to prevent the anastomoses 6. Porto-caval shunt: surgical anastomoses of portal vein to IVC to shunt portal blood directly to systemic venous circulation. Encephalopathy.

26

Liver transplant

Candidate

Mixed ( 75%) Cx.

Tum ours

Faceted one against the other, and can be grouped into 2 or more series all of the same size ( generations )

108 Liver Neoplasms

1 o m alig 2 o m alig ( m ost com mon) B enign H C C F ibrolam ellar cacinom a C holangioC a. Portal: gut S yst Direct: G B H aem ang. Aden. F N D
F igu re 2 0 .

F N D: focal nodular hyperplasia

See oncology notes

Clinical.

1 . Silent 2. Impaction in gallbladder: either in Hartmann' s pouch or cystic duct ! water absorbed from bile ! concentrated ! chemical cholecystitis. If stone impacts in Hartmann' s pouch when GB empty then walls of GB may continue to secrete mucus ! distends to form a mucocele . 3. Choledocholithiasis: common bile duct, may produce intermittent or compete obstruction w pain & jaundice 4. Gallstone ileus: ulceration through the wall of the GB ! may pass or get stuck in distal ileum ( narrowest part) . Rare.

Epi. 20% of 1 s of liver. Path. AdenoCa of intrahepatic bile system. Clinical. Jaundice, may complicate primary sclerosing cholangitis. Spread throughout
o

108.1 Cholangiocarcinoma
liver and to nodes.

Rx. Relieve jaundice: stent at ERCP.

XVI Gallbladder and Bile Ducts

109 Congenital
Most important is biliary atresia: neonatal jaundice

110 Gallstones
Types. Cholesterol (20%)
Solitary oval stone, or 2 stones. Appearance radiating crystals. May be assoc w " cholesterol. Correlation w OCP, pregnancy, obesity, # dietary bre, removal of terminal ileum e. g. in Crohns ( interruption of enterohepatic circulation) . This supersaturated bile is lithogenic . Pigment (1 -2%) Calcium bilirubinate. Small, black, irregular, multiple, gritty. Haemolytic anaemias ( e. g. spherocytosis) .

Ix.

Impaction of the stone in Hartmann' s pouch ( out-pouching of the wall of the gallbladder at the junction of the neck of the gallbladder and the cystic duct) or cystic duct or common duct. Following which the calculus either falls back or is passed along the duct. Pain caused by contractions of the smooth muscle against the stone: rises to plateau w colicky exacerbations which last many hrs. R subcostal, may be epigastric, or band across upper abdo. Radiation to scapula, shoulder. Vomiting, sweating. Acute cholecystitis 95% gallstone origin. Stone remain impacted in GB outlet ! GB wall in ammation ! cholecystitis ! pus lled. Pain persistent, intensifying. Fever, leucocytosis. Tender upper abdomen, palpable mass in region of GB ( GB wrapped in in ammatory adhesions to adj organs) . Empyema, perforation may occur. May press against CBD causing jaundice . Chronic cholecystitis Almost all gallstone related. In ammation, wall thickening. Recurrent bouts of abdo pain due to mild cholecystitis fever. Experienced after fatty meals ( ! CCK) . CBD stones May be asx. Often biliary colic w obstructive jaundice , pale stools, dark urine. Attacks for h' s ! d' s. Attack ceases when small stone passed. Cx: i. Ascending cholangitis: infx causing jaundice, pain, fever , rigors ii. 2 biliary cirrhosis is: w jaundice ( Ca pancreas, acute hepatitis, other) , w/o jaundice ( renal colic, intestinal obstruction, angina pectoris) Perforation Peritonitis Empyema Swinging pyrexia Courvoisier's law. If in the presence of jaundice the GB is palpable, the cause is unlikely to be stones , cos of brosing of the GB.
o

Biliary colic

1. 2. 3. 4.

USS: presence of gallstones, thickened wall of GB, dilatation of the CBD AXr: gallstones in 1 0% Upper GI endoscopy: exclude peptic ulcer, hiatus hernia LFTs: " ALP w gallstones

27

Rx. Acute cholecystitis

5. MRCP 6. ERCP: allows extraction, sphincterotomy. Not normally GA 7. IV/oral cholangiography: largely superseded

Clinical. Painless progressive obstructive jaundice. Epigastric pain, steatorrhoea, weight

loss. May be hepatomegaly. MRCP/ ERCP/CT biopsy Rx. Slow growing. Can palliate w endoluminal stenting at ERCP. or surgical bypass. Poor prognosis.

Cx of Cholecystectomy.

90% resolve on abx, pain relief. Elective lap cholecystectomy 6w later. If diagnosis in doubt : laporotomy is performed. Empyema : requires emergency drainage. Perforation : needs urgent surgery. Chronic cholecystitis Cholecystectomy, operative cholangiogram performed by injecting radio-opaque dye: if stones found then remove them ( ?open op now) & insert T-tube 1 0d post-operatively. T-tube removed 1 0d after provided a check cholangiogram taken con rms clear tubes. Alternatively can do lap exploration of CBD, or wait until post-op ERCP & extract using Dormia basket/balloon. Obstructive jaundice due to stones ERCP & removal using Dormia/ balloon. Subsequent cholecystectomy. Giving vit K before helps clotting ( lacking cos not absorbed in bile-poor gut) . Non-surgical Dissolution w ursodeoxycholic acid : small, non-calci ed stones. Lithotripsy : but passage causes colic. Symptomless : cholecystectomy not usually advised unless comorbidity. 1 . Leakage of bile: due to injury to bile ducts inside or out of liver. Rx: ERCP and stenting ! if fails then perc drain 2. Jaundice: missed stones, inadvertent injury, cholangitis/pancreatitis

XVII Pancreas
114 Acute Pancreatitis
Aetiology. GET SMASH' N:
G allstones, E thanol , Trauma, Steroids, Mumps, Autoimmune ( e. g. SLE) , Scorpion bites, Hyperlipidaemia ( hyperparathyroidism, hypothermia, hereditary) , Neoplasia Path. Autodigestion, due to release of digestive enzymes. E. g. once trypsin released from trypsinogen, it cleaves other pro-enzymes. Re ux important ( hence assoc w bile stones) . Liquefying necrotic material & in ammatory exudate collects in the lesser sac: pseudocyst ( walled by stomach in front & necrotic pancreas behind) . Liberated enzymes: i. Trypsin: autodigestion ii. Lipase: fat necrosis iii. Amylase: high serum level Clinical. Gallstone: usually middle aged/ elderly. Alcoholic: < 40y. Rapid onset epigastric pain radiating into the back. Pt sits forward, repeated retching is common. Profuse vomiting. Shocked. May be feverish. May have jaundice. Grey-Turner' s sign ( few days after attack) . . Acute cholecystitis, perforated peptic ulcer

111 Gallbladder Polyps

Pathology. If single, consider malignant lesion, risk " w size Clinical. Asx. If near Hartmann' s then may produce gallstone-like pain Rx. Symptomatic, or large: cholecystectomy.

112 Ca Gallbladder
noma

Ix.

Pathology. Assoc 85% w gallstones. 50% of porcelain gallbladders . 90% adenocarciClinical. Resembling chronic cholecystitis. Rx. Resection/ liver resection, but poor prognosis unless found incidentally at chole.

113 Cholangiocarcinoma
Pathology. Increasing. Assoc w IBD. , > 50y. Adenocarcinomas

1 . Serum amylase: acutely 5 raised, returns to normal after 2/3 d ( normal in 30%) . Urinary amylase elevated for longer. ( Also high in many conditions inc: impaired renal excretion, DKA, perforated peptic ulcer, cholecystitis, intestinal obstruction. . . ) 2. FBC: leucocytosis, anaemia 3. " Blood glucose 4. " Serum bilirubin 5. ABG: hypoxia 6. # Serum calcium: due to fat soponi cation 7. CT: pancreatitis, necrotic, abscess, pseudocyst 8. AXR: absence of free gas ( distinguish from in perforation) 9. USS: gallstones, dilatation of cbd Rx. ICU

28

Path. Haemorrhagic necrosis, systemic release of vasoactive peptides & enzymes. Acute
lung failure. Acute renal failure ( toxins, # volume) .
G las g ow C riteria

115 Severe Acute Pancreatitis

.

2. 3. 4. 5.

Cx.

Analgesia: pethidine Fluid replacement Resting the pancreas: NBM, nasogastric aspiration if vomiting TPN/NJF Abx Prophylaxis against gastric erosions: sucralfate, H rec antagonist Endoscopic sphincterotomy: gallstone pancreatitis Surgery. Avoided early. Later , operative debridement of necrotic pancreas. Pseudocyst : drainage. Gallstone origin : cholecystectomy.
2

Supportive.
1. 2. 3. 4. 5. 6. 7.

1 . Age > 55 2. Hyperglycaemia: Pancratic dysfunction 3. Leucocytosis: In ammatory 4. Urea > 1 6: Renal damage 5. PO < 8 kPa: ARDS 6. Calcium < 2: Fat sequestration 7. Albumin < 32: In ammatory 8. Lactate dehydrogenase > 600 9. " Transaminases: Gallstones PANCREAS: PaO2 < 8 kPa, Age over 55, Neutrophilia, Calcium, ( low) Raised Urea, Enzyme elevation: LDH, AST/Albumin 32g/L, Sugar ( glucose 1 0 mmol/ L)
2

Rx.

AXr: calci cation, calculi CT: enlargement, irregular consistency ERCP: dilation & irregularity of pancreatic duct Endoscopic USS + aspiration cytology: standard technique for examining head of pancreas 6. Exocrine function tests: faecal elastase Analgesia Diet: # fat w pancreatic enzymes Insulin for DM Surgery if attacks v frequent: partial pancreatectomy Painless obstructive jaundice: Roux-en-Y reconstruction, Whipples

1. 2. 3. 4. 5.

117 Pancreatic Cysts

perforation ( rare) Clinical. Firm, large, rounded, upper abdo swelling. Rx. True : surgical excision. False : drainage

Classi cation. True ( 20%) Congenital polycystic disease, retention, Hydatid, Neoplastic False ( lesser sac) Trauma, following acute pancreatitis, due to pos gastric ulcer

1. 2. 3. 4. 5. 6. 7. 8.

Abscess formation w pancreatic necrosis: pyrexia, leucocytosis Pseudocyst: fullness/discomfort in stomach, palpable mass GI bleeding from erosions Renal failure: shock Pulmonary: acute lung injury ( ARDS) Further attacks DM: due to necrosis Fat embolus

118 Pancreatic Tumours

Tumours
M alignant B enign

1o Adenocarc. C ystadenoC . Islet-cell

2 o : stomach, bile d. Adeno C ystaden,

Islet cell tum our Z ollinger Insulin. G lucag.

Def. Gradual destruction of the functional tissue Aetiology. Alcoholism. Hypercalcaemia ( rarely) Clinical. Asx. Recurrent abdo pain relieved by leaning forward. Steatorrhoea. Diabetes. Ix.
Obstructive jaundice. 1 . Amylase: may be elevated in attacks of pain.

116 Chronic Pancreatitis

F igu re

2 1 .

See oncology notes

119 Multiple Endocrine Neoplasia

Type 1 .
29 1 . Parathyroid hyperplasia

Pancreas Insulinoma Pituitary tumour Peptic-acid producing: Zollinger -Ellison Adrenocortical, carcinoid Type 2. Medullary cell carcinoma of thyroid & phaeochromocytoma plus: a Hyperparathyroidism b Neuro bromata (& marfanoid habitus)

2. 3. 4. 5.

XVIII The Spleen

120 Splenomegaly
Classi cation.
1 . Enlarged L kidney: resonant as covered by bowel 2. Ca cardia: sx of gastric obstruction 3. Enlarged L lobe of liver 1 . Infectious: viruses ( glandular fever) , bacterial ( typhus, typhoid, septicaemia) , protozoal ( malaria, schistosomiasis) , parasitic ( hydatid) 2. Haematological: Leukaemia ( chronic myeloid , chronic lymphocytic) , lymphoma , myelofibrosis / ITP/ polycythaemia rubra vera , haemolytic anaemia 3. P ortal hypertension 4. Metabolic & collagen disease: amyloid ( 2 RA) , storage disorders ( e. g. Gauchers) 5. Cysts, abscesses, tumours ( uncommon)
o

119.1 Islet Cell Tumours

Claim to Fame. Rare, but have interesting metabolic e ects. MEN syndrome. Path. APUD. G lucagon ( ) , insulin ( ) , somatostatin ( ) , pancreatic polypeptide
( F) , serotonin ( enterochroma n)

Path. 80% benign, 1 0% malig, 1 0% multiple. Clinical. When pt hungry or during exercise. Often early morning. Excessive appetite w
gross weight gain. coma

119.2 Insulinoma
CNS phenomena

Weak, sweating, trembling, epilepsy, confusion, hemiplegia, Hunger, abdo pain, diarrhoea

GI phenomena Whipple's Triad. Ix.

Indications. Rupture, massive splenomegaly, haematological disease ( haemolytic May be useful. Portal hypertension, autoimmune haemolytic anaemia, myelo brosis, Cx.
trauma, Gauchers 1 . Gastric dilatation: due to gastric ileus and accumulation of swallowed air. NG tube placed to prevent. 2. Thrombocytosis: aspirin 3. Post-splenectomy sepsis: Prophylactic immunization w meningococcal, H In uenzae type B, annual u vaccines, prophylactic low dose penicillin. anaemia inc spherocytosis, thrombocytopenia purpura) , tumours/ cysts

121 Splenectomy

1 . Induced by starvation, exercise 2. Hypoglycaemia in attack 3. Relieved by sugar

1 . " Insulin w hypoglycaemia 2. " C-peptide: rule out exogenous insulin ( # ) 3. CT, MR, endoscopic USS: localization Rx. Excision. May require Whipples

122 Ruptured Spleen

Clinical.
1 . Massive bleeding 2. Peritonism from blood loss: abdo pain di use or L ank, shoulder tip pain 3. Delayed rupture: hours ! days. Due to haematoma growing then rupturing Ix. Clinical diagnosis ! procede to laporotomy 1 . CXR 2. AXR: stomach bubble displaced to R 3. USS: free uid, intrasplenic haematoma

119.3 Gastrinoma
Ix.
tion ! peptic ulcers

Path. Malignant ( 30%) . Secretes gastrin-like into blood stream ! " gastric HCl excre1 . " Serum gastrin 2. " Basal acid output: measured by NG aspiration 3. Localization Rx. Excision , or if impossible PPIs.

30

Rx.

4. CT: laceration of spleen 5. Urinalysis for blood 1 . Blood transfusion 2. Emergency splenectomy: if hopelessly pulped 3. Suturing of spleen/packing: if minor laceration

Ix. May mimic Ca on mammography. USS diagnoses. Core biopsy

Epi. Childbearing. Classi ed. Periductal mastitis

o

125 Acute in ammation

In ammatory occuring around dilated milk ducts. Smoking ( ! di erent bacterial ora) . Pain, discharge. May have cellulitis, nipple retraction, or mass. Rx: abx ( usually uclox) Acute bacterial mastitis Commonest. Most often during lactation. Cellulitis or abscess 2 staph aureus. Pain, swelling, tenderness, erythema. Rx: cellulitis : abx & continue breast feeding. Abscess : aspiration

XIX Breast
123 Symptoms
Lump
1. 2. 3. 4. 5.

Discharge

Ca, cyst, broadenoma, broadenosis. Less commonly: Fat necrosis, other cysts, other tumours ( duct papilloma, hamartoma, lipoma) Bloody: papilloma, Ca, Paget' s. Clear: intraduct papilloma Multicoloured: duct ectasia - Y/B/G Milly: lactation, galactorrhoea Purulent: abscess
C lear, bloody, single duct require further ix

Def. Fibroadenosis or brocystic disease is the most common cause of breast lumps in

126 Fibroadenosis

Mastalgia

a) Non-cyclical: Abscess, Ca, Tietze' s ( chondritis of the costal cartilage) , chest wall lesions b) Cyclical: idiopathic. Lumpy, tender. Worse premenstually, relieved by menstruation. Young . Rx: conservative lionelic acid, # ca eine, consider HRT] , medical ( danazol - anti-gonadotrophin, tamoxifen, LHRH) Duct ectasia Ducts being nipple dilated ( ectasia) & engorged Nipple inversion 1 , or 2 to duct ectasia or Ca Gynaecomastia Physiological in neonates, puberty. Imbalance of oestrogens. May have surgery if embarrasing ( liposuction, excision) . Causes : drugs ( digoxin, spironolactone, cimetidine, E , androgens) , cirrhosis, renal failure, hypogonadism, suprarenal tumours, testiculr tumours, idiopathic.
o o 2

women of reproductive age. The peak incidence is between 35 and 50 years of age. It is rare before 25 years. The term embraces a spectrum of histologic changes, and may encompass many patients who have cystic lesions detected clinically or sclerotic breast lesions detected on mammography as discussed elsewhere. Path. Histologically it is characterized by overgrowth of both brous stroma, and of epithelial elements i. e. ducts and lobules, in di ering proportions. These changes may be considered as abberations of normal breast involution and not part of a disease process. The condition may be due to a disordered or imbalanced response to endogenous sex hormones. Only in those cases showing marked epithelial hyperplasia - epitheliosis - is the risk of breast carcinoma thought to be increased. Clinical. Typically, patients present with one or more lumps in the breast which may be painful, and frequently, bilateral. The size and pain usually vary with the menstrual cycle. One or more of these elements may be absent. Cysts are more common in perimenopausal women. They are usually single. The presence of multiple, di use cysts may be referred to as Schimmelbusch' s disease. The discharge varies from clear to green but should not be bloodstained. On palpation, a cyst may be recognised by its smooth texture and characteristic tense uctuation. Rx. Aspiration ! excision biopsy to exclude Ca. Pain that is localised, is normally relieved by excision. Pain that is di use, cannot be relieved by excision. In these cases, bromocriptine, or danazol, may be helpful.

Clinical. Painless, irregular, rm lump, hx of trauma ( e. g. surgery) . Can have retraction,

skin thickening: can look just like Ca. Usually regressses with time, may leave cyst.

124 Traumatic Fat Necrosis

127 Cysts
Epi. Common perimenopausally, uncommon post-menopausally
31

Clinical. Short hx of painful tender swelling in the breast. May be multiple, bilateral.
Mammography: well-de ned rounded opacities Rx. Aspirate to dryness. Uniformly blood stained ! cytology. If mass remains then FNA.

Types. Lingual

128 Fibroadenoma
Path.

N ot a neoplasm , but an aberration of normal development. Stromal & epithelial components. No " malignancy, majority resolve over years Clinical. All ages, peak in 30s. Discrete, rm, mobile lump. Highly mobile ` breast mice' , not attached to skin. Can be multiple. Rx. Triple assesment

Beneath tongue. V rare Fluctuant swelling in or near midline neck. Moves upwards on tongue protrusion. Moves up on swallowing. Rx: remove surgically together with remnants of thyroglossal tract. Thyroglossal stula Opening onto skin midline. Discharge. Infection. Rx: excise Physiology. Think it as a ecting upmodulating the response to adrenaline
T h yro g lo s s al c ys t

132 Causes of Goitre

Graves causes hyperplasia. Hashmimotos causes infkammatory swelling 1 . Di usely Swollen : GravEs' ( hypErthyroid) , HashimOtO' s ( HypOthyroid) , " Demand ( # Iodine, puberty, pregnancy) , multinodular colloid goitre with nodules too small to feel 2. Multiple nodules : Multinodular colloid goitre ( commonest thyroid swelling in nals, hyperthyroid) , cysts, adenomas 3. Solitary nodule ( ominous, esp if , cold) : thyroglossal cyst ( small, smooth, midline, moves up w tongue extrusion) , tumour, dominant nodule in multinodular goitre

Path. True neoplasms that can be benign or malignant. Rarely met, but can recurr Clinical. Firm, discrete lump, recent increase in size Rx. Wide excision
locally. Can arise from intracannalicular broadenomas.

129 Phyllodes (=leaf)

130 Intraduct Papilloma

Path. Benign, may be multiple, subareolar usually Clinical. Watery-clear or blood stained discharge from a single duct. May be mass Rx. Excision

133 Multinodular Goitre

Path. Some follicles w hyperactive epithelium, some atrophic. May be eu- ( vast majority)
or hyperthyroid ( 2 ) . Enlarged, irregular, nodular. Autoimmune. Clinical. Middle aged women. Dysphagia ( usually solids) SoB ( worse on exertion & bending forward) Orthopnoea, hoarseness ( P on one recurrent laryngeal N) Stridor ( P on both recurrent N) Facial congestion ( + ve Pemberton' s sign)
o

XX Thyroid
Note: left out non-surgical aspects in these notes

Ix.

131 Congenital

Cx.

1 . TSH assay 2. CT scan neck & thoracic outlet: size, retrosternal extension Tracheal displacement/ compression Haemorrhage into a cyst: pain & swelling Toxic Malignant ( rare)

Embryology. Originating in oor of pharynx, descends through tongue ( foramen

caecum) . Failure to descend results in ectopic thyroid tissue. Radioiodine scan must be performed to ensure that the thyroid gland works before removing this tissue.

32

134 Colloid Goitre (Endemic Goitre)

Aetiology. # I : Derbyshire in UK
2

135 Hyperplasia
o

Occurs in. 1 hyperthyroidism ( Graves' ) Path. Smooth, uniformly enlarged, hyperactivity of acinar cells. V vascular, # colloid.
Lymphocyte in ltration

136 Clinical Features in Thyroid Disease

F igu re

H yp erthyroid. Nb . hoarse voice indicates in ltration of the larynx ! A lwsys perform laryngoscopy pre-surgery. A F occurs in older hearts t hat can' t cope.
2 3.

Goitre features.

Thyroid swelling Retrosternal goitre: palpate w neck fully extended. Can block venous return to SVC: engorgement of jugular veins ! oedema of upper body. Tracheal displacement: check for stridor Vocal cord integrity: indirect laryngoscopy Regional nodes Physiological state

137 Investigations
F igu re 2 2 .

H ypothyroid

1 . Serum free T3/ T4

33

2. TSH 3. Thyroid scintogram: radioiodine studies of thyroid ( I injected and gland scanned with detector to map areas of high uptake) . Hot, cold nodules. 4. Thyroid antibodies: Hashimoto' s, Graves' 5. Thyroid USS: solid or cystic swelling. 6. FNA + core biopsy 7. " Serum cholesterol in myxoedema 8. ECG 9. CT
1 31

Radioactive iodine

2-3m. Not for < 45y cos of theoretical risk of malignancy.

140 Thyroid Tumours

Tumours M alignant 1o B enign Follicular adenoma

138 Outline Rx of Goitre

Multinodular Goitre

Papillary Follicular A naplastic M edullary L ym phoma Papill Follic M ixed

F igu re 2 4.

Thyroidectomy in enlarged euthyroid, nodular goitre if sx of tracheal compression. Give T4 after to # size. Young : advised cos of risk of haemorrhage into thyroid cyst ( risk of acute tracheal compression) . Cosmetic. Elderly : long standing asx then leave alone. Single euthyroid nodule May be: benign, malignant, cyst. FNA, isotope, USS distinguish cyst from nodule. Aspirate cysts. Take out all other cos of malignant risk.

Hot nodules. 1 0%. Can become thyrotoxic Cold. Don' t become thyrooxic. Might be Ca Epi. : = 2: 1 , often arise in Goitres, previous radiation. Di erentiated Thyroid Cancer. = Papillary & Follicular. 90% of all Ca. V good progTypes. Papillary (60%) Follicular ( 30%) Medullary
nosis nosis. Young, good prognosis, slow growing, late lymphatic spread. Young/ middle aged, blood stream ( ! bone) , slightly worse prog-

1 40.1 Benign Adenoma

139 Hyperthyroidism Rx
See Kumar for medical rx. Majority given carbimazole until euthyroid. Relapse after medical rx ( 50%) is indication for repeat medical, -ectomy, or radioactive iodine Surgery Limited to teens/20s. Increasingly total thyroidectomy to # risk of recurrence. Cx: 1 . Hormonal: a) H ypoparathyroidism : Sx of paraesthesiae, tetany few days post-op. Rx: IV Ca gluconate, oral calcium, vit D. Parathormone is not used. b) T hyroid crisis ( massive release of T4 from gland) : now rare. May have mania, hyperpyrexia, death. Rx: sedation, propanolol, IV iodine, cooling w ice. c) H ypothyroidism d) Failure : late recurrence of hyperthyroidism 2. Damage to anatomical structures: a) Recurrent laryngeal N : 1 N ( hoarseness) , 2 Ns ( complete loss of voice, serious narrowing of airway. May need permanent tracheostomy) b) Trachea c) Pneumothorax 3. General a) H aemorrhage : Compress the trachea. Acute SoB & stridor, shock. Rx: emergency decompression of neck ( on the ward! ) then theatre. b) Sepsis c) Post-op chest infx d) Hypertrophic scarring

1 40.2 Thyroid Carcinoma

Parafollicular C cells ( ! calcitonin, the tumour marker) , familial, MEN-II syndrome ( phaeochromocytoma, parathyroid tumour, neuro broma ) . Multicentric in familial forms, both lobes. FNA. Anaplastic Elderly, rapid local spread to trachea, lymph, blood Clinical. Lump, rapid growing. Dysphagia uncommon ( indicates anaplastic) . Pain, hoarseness, cervical LNs. Euthyroid usually. Ix: core-needle biopsy, FNA

Rx.

1 . Well di erentiated : Surgery Lobectomy if # chance of recurrence ( e. g. small papillary w/ o LN spread) . Total for others. Must render euthyroid rst. Stop antithyroid drugs before surgery & give KI ( # vascularity) Medical Carbimazole, beta-blockers Radio-iodine ablation Also taken up by occult mets. Give w total thyroidectomy. Cx: oedema, thyroiditis.

34

2. Medullary : exclude other MEN-II Ca. Total thyroidectomy + LN dissection. Prophylactic thyroidectomy in rel with germ-line RET mutations 3. Anaplastic : 1 YS < 1 5%. Palliate w radiotherapy & tracheostomy

TSH suppression Post-op Monitoring Thyroglobulin should be undetectable

Rx. Medical Hypertension, renal failure Nephrectomy Recurrent pain, infection, haematuria

141 Riedel's Thyroiditis

Claim to Fame. Common ( 50% of 50 y/o' s) . Clinical. Asx. Aching pain in loin. Ix.
Haematuria is absent .

144 Renal Cysts

Claim to Fame. V rare, gland only slightly enlarged but woody-hard. Mistaken cliniRx. Wedge resection if tracheal compression.
cally for thyroid Ca, but histologically brous.

1 . Urine is clear 2. USS: cystic mass 3. IVU: round lling defect Rx. Infection or malignancy suspected : aspiration, & serial CTs

4. CT

XXI Kidney & Ureter

Aetiology. During kidney' s ascent from pelvis Clinical. Firm mass in pelvis, recurrent UTI Ix. IVU Claim to Fame. of lump in pelvic: not good to remove!

145 Haematuria

142 Horseshoe Kidney

Classi cation. General E. g. Anticoagulant Speci c

senting in childhood) . PKD1 is commonest mutation. Associated. Liver cysts ( 30%) , lungs, spleen, pancreas. Intracranial Berry aneurysms ( subarachnoid haemorrhage) Clinical. Middle age: 1 . Abdominal mass 2. Haematuria 3. UTI 4. Renal failure: headache, lassitude, anaemia, vomiting 5. Hypertension 6. Intracranial haemorrhage

Path. Multiple cysts throughout renal substance. Dominant ( a recessive form exists, pre-

143 Polycystic Disease

1 . Kidney : trauma, polycystic, glomerulonephritis, TB, infarction ( emboli) , stone, tumour 2. Ureter : stone, tumour 3. Bladder : trauma, cystitis, stone, tumour, bilharzia 4. Prostate : prominent vessels in BPH 5. Urethra : trauma, stone, tumour Hx. Loin pain suggests renal origin. Colicky suggests stone in renal pelvis or ureter. Terminal bleeding w sev pain & frequency suggests bladder calculus. Prostatic bleeding: likely to be initial or terminal & painless. Independent of urination suggests urethral. Sore throat suggests acute nephritis. Check if on anticoagulant therapy.

Ix.

1 . Urine microscopy: red cells excludes haemoglobinuria, beeturia. Cytology for malignancy 2. IVU: renal lesion, lling defect 3. USS: tumours, calculi, collecting system & bladder lesions 4. Cystoscopy: bladder, prostate lesion

Ix.

Clinical. Loin pain, tenderness, haematoma ( causing abdo distension due to ileus) . Ix.
1 . Urine: haematuria 2. IVU: extravasation of contrast outside renal outline, distortion of calyces

146 Injury to Kidney

1 . USS

2. " U&E

3. IVU: elongated spidery calyces stretched out 35

Rx. Penetrating injuries Surgical exploration Blunt Conservative: bed rest, observe urine serially Nephrectomy If: life threatening bleeding, sev hypotension, symptomatic lack of
function ( e. g. UTIs, stones)

3. USS: renal tear 4. CT: visceral injuries

147 Hydronephrosis
Bilateral if obstruction at or below bladder 1 . Within the lumen: e. g. calculus 2. Wall: e. g. TCC 3. Outside wall: e. g. retroperitoneal brosis, extrinsic Ca Without obstruction Vesico-ureteric re ux Clinical. Asx. Dull, aching pain. Acute attacks of pain resembling ureteric colic ( esp after drinking large volumes) . Infection ( pain, rigors, sev loin pain) . Bilateral : uraemia. Presentation w underlying cause ( e. g. calculus) . Kidney may be palpable. Cx. Infection ( pyonephrosis) , stone formation ( in stagnant urine) , hypertension ( 2 ischaemia) , renal failure ( if bilateral destruction) , traumatic rupture of hydronephrotic pelvis
o

Composition. Calcium oxalate ( 60%)

2. Excess of normal constituents : inadequate urine volume ( dehydration) , Increased excretion of Ca ( hypercalciuria, can be 2 to " Ca or, usually, idiopathic) 3. Presence of abn constituents : Infections ( esp in presence of obstruction) , foreign bodies, vit A de ciency ( causes hyperkeratosis producing epithelium upon which stones form) , cystinuria ( cystine stone formation) 4. Lack of inhibitors of stone formation : # Citrate, # Mg RFs. # Fluid intake, poor diet, sedentary lifestyle
o

Aetiology. 2 o obstruction

Ix.

Rx.

1 . USS: dilated 2. CT: cause 3. IVU: enlarged pelvis, swollen club-like calyces. Kidney may not secrete contrast. 4. Diuretic renography: ( furosemide given ! MAG3 injection) distinguishes btw obstructed/non-obstructed system. Info concerning function of each kidney. 5. Retrograde pyelogram: via catheter inserted into ureter at cystoscopy 1 . Percutaneous drainage or Retrograde passage of double pigtail ureteric stent 2. Removal of underlying cause: if neuromuscular can operate to widen the pelviureteric junction ( pyeloplasty) 3. Nephrectomy: poorly functioning kidney w good contralateral side
Incorporated teaching notes

Spiky surface ! traumatized epithelium ! blood colours stone brown. Opaque. Associated with: Hypercalciuria: absorptive ( " intestinal) , renal leak, resorptive ( demineralisation of bone " PTH) Hypercalcaemia: most 2 " PTH Hyperoxaluria: " absorption due to short gut syndrome Hypocitraturia Hyperuricosuria: Ca oxalate crystals form on surface of uric acid crystals Calcium phosphate ( 1 0%) Seen in renal tubular acidosis ( failure to acidify urine ! alkaline) . Opaque. Triple phosphate ( 20%) Calcium, ammonium, magnesium, phosphate. Found in infected urine. Staghorn calculus. Due to urease producing bacteria ( produce ammonia) . Opaque Uric acid & urate (5%) Smooth. Note if pure urate ( unusual) then translucent. Assoc w gout Cystine (1 %) Cystinuria ( recessive disorder) . Radiolucent Clinical. Pain, but may be Asx. Calyces : dull loin pain. PUJ impaction or ureter : ureteric colic ( unable to lie still, continuous pain w sharp exacerbations) . Haematuria. Stones Lodge. PUJ, pelvic brim, entrance of ureter into bladder.
o

Ix.

Diagnostic
1. 2. 3. 4.

148 Urinary Tract Calculi

Aetiology.
phosphate stones) , cystinuria ( cysteine stones) 1 . Inadequate drainage : hydronephrosis

Epidemiology. 20-50 years, : = 3: 1 , caucasians/asians, FH, renal tubular acidosis ( Ca

1 . Urine M&C: bacteria, cystine 2. Analysis of stone 3. Uric acid estimation: gout & uric acid stones 4. Serum Ca Cx. Hydronephrosis, infection, anuria ( impaction of calculi both sides) 36

Underlying cause

Haematuria KUB: stones in 90%. All calcium stones are opaque USS: V good for detecting renal, but not ureteric stones. Hydronephrosis. IVU: remember stones may be obscured by contrast so do KUB rst. Not possible if renal impairment. 5. CT: replacing IVU 6. MAG3: obstruction, function 7. MRU ( ?)

Rx Options.

Rx Speci c. Ureteric calculi

1 . Watchful waiting: annual KUB. Not suitable for staghorn 2. Medical dissolution: uric acid stones ! sodium bicarbonate to alkalinise urine. Cystine stones ! alkalinise urine + " uid + D-penicillamine to convert cystine to more soluble compounds 3. ESWL ( extracorporeal shock wave lithotripsy) : Need analgesia. Cx: haematuria, infection, obstruction, peri-renal haematoma. ContraI: pregnancy, coagulopathy 4. Uteroscopy: preferred for ureteric stones. Graspers to remove fragments, laser, lithoclast. 5. Percutaneous nephrolithotomy: neproscope inserted percutaneously ! stone fragmented ( manually or with lithoclast) . For stones > 3cm. 6. Open/laporoscopic: occasionally large stones in presence of staghorn calculus & non-functioning kidney

Cause. Recurrent infections causing scarring. More common in childhood, due to: vesicoClinical. Infection sx. Subclinical: incontinence at night. Ix.
ureteric re ux ( de cient valve) , intrarenal re ux ( ducts don' t open oliquely)

151 Re ux Nethropathy

1 . Micturating cystogam: contrast put in to bladder 2. Indirect micturating cystogram: An isotope ( MAG3) scan showing di erential function of kidneys 3. IVU: scarring, clubbing ( reversal of normal cupping of calyces) 4. DMSA scan: scaring Rx. Cause. Abx prophylaxis.

Analgesia ( NSAID: e. g. PR diclofenac) , oral uids & diet. Conservative : majority will pass spontaneously within 6 weeks. -adrenoceptor antagonist ( e. g. tamsulosin) to promote smooth muscle relaxation & promote passage. Active : ESWL ! Uteroscopy ! Laporoscopic or open operation. Renal calculi If small can leave alone. Larger: ESWL. Acute calculous anuria Percutaneous nephrostomy or retrograde ureteric stenting. Uraemic: dialysis. Infected obstructed kidney Emergency. Sx: loin pain, initially colicky but becomes constant. Ix: USS for hydronephrosis. Rx: nephrostomy, abx ( ceph & gent) , HDU monitoring. Delay stone management until infection controlled. Cause Infection, obstructive lesions, parathyroid tumours, drink lots of uid.

152 Pyonephrosis
1. 2. 3. 4.

USS kidney IVU: enlarged renal shadow, little/no function DMSA: quantify function after treatment MAG3 renography: function, obstruction Rx. Urgent drainage by percutaneous nephrostomy. If no residual function then remove kidney

Aetiology. Infected hydronephrosis, kidney becomes bag of pus. Pyuria ( pus in urine) Ix.

149 Urinary Tract Infections

Upper tract Lower tract
Haematogenous, or 2 to lower tract Ascending up urethra
o

Def. Cortical abscess, haematogenous infection usually Staph . Clinical. Pyrexia, toxaemia, pain in loin, kidney may be palpable Ix.
1 . Urine: sterile unless bursts 2. FBC: leucocytosis 3. CT/ USS: con rm Rx. Percutaneous drainage abx

153 Carbuncle of Kidney

Urine M&C&sensitivity: invariably bowel ora. Pus w no growth = Ca. USS bladder & kidneys: obstruction, dilatation of upper tracts KUB: exclude stone Cystoscopy: bladder diverticula & other defects Rx. Abx ( consider prophylactic) . " Fluids. Underlying causes.

Aetiology. : urethral or prostatic obstruction, catheterization. Clinical. Dysuria, frequency, urgency. Haematuria. Loin pain. Ix. : multiple episodes. : 1 episode.
1. 2. 3. 4.

150 Cystitis

Def. Usually 2 to rupture of carbuncle Clinical. Constitutional evidence of acute infection, di use tender bulge in loin. Ix.
o

154 Perinephric Abscess

1 . KUB: loss of psoas shadow due to retroperitoneal oedema

37

2. IVU: may show renal cortical abscess or a pyonephrosis 3. CT: localization & drainage Rx. Drainage: percutaneous or open ( if perc fails)

Rx. Replenish IV volume

3. Urine: blood, protein, M&C. ( Blood + protein: consider acute nephritis)

155 Renal TB

extensive destruction. Ureter becomes in ltrated & in amed. Obstruction leads to pyonephrosis. Autonephrectomy may occur. May become tuberculous cystitis. Clinical. Young adult, immigrant. Early: dysuria, frequency, pyuria, haematuria. Advanced: fever, night sweats, loss of weight, anaemia.

Path. Lesions at junction of cortex & medulla. Enlarge ! caseate ! rupture in to calyx !

1 . Assess: JVP, postural hypotension 2. Rapid infusion of uid 3. CVP catheter Dopamine & diuretics If rehydration unsuccessful in inducing diuresis give furosemide. If this fails * ATN or acute cortical necrosis likely. Hyperkalaemia CA gluconate, insulin + dextrose

Ix.

1 . Urine: sterile acid pyuria. Acid fast bacilli on Ziehl-Nielson stain. Culture takes 3 weeks. 2. IVU: failure of calyceal lling, irregularity of calyces, patchy calci cation 3. CXR: lung Ca 4. Cystoscopy: decreased bladder size, oedematous mucosa w tubercles Rx. Anti-TB Cx. Healing causes brosis which may cause strictures.

157 Chronic Renal Failure

Congenital posterior urethral valves Prostatic hyperplasia/ Ca Urethral stricture Cervical Ca Urothelial tumour Clinical. Malaise, weakness, confusion, hiccups w pallor, hypertension, uid overload. Ix. Those of ARF. Finding Cause. Rx. Absence of correctable then dialyse.

Surgical Causes. Pre-renal Renal artery stenosis Post-renal ( obstructive)

1. 2. 3. 4. 5.

156 Acute Renal Failure

* P re- renal

Def. # GFR, retention of nitrogenous waste ( " U, " C) , acidosis, reduced urine output Aetiology.

Ix.

Acute tubular necrosis Acute tubular necrosis Acute cortical necrosis due to ischaemia Myoglobin released after crush injury Drugs: e. g. abx ( gentamicin, NSAIDs) Post-renal Obstruction at any level from tubules to urethra Clinical. Anuria uncorrected by bladder catheterization ( rst consider blocked catheter) 1 . " Urea, " creatinine, " K 2. Renal tract doppler USS: small suggests prior renal disease

Renal

GFR should be 60-80 mmHg. In hypertensives, elderly, pre-existing renal disease ( e. g. DM) , NSAIDs, ACEIs autoregulation may be impaired. 1 . Fluid loss : blood loss, plasma loss ( e. g. burns) , electrolyte loss ( e. g. vomiting) 2. Impaired circulation : general factors ( e. g. hypotension) , local factors ( e. g. aortic dissection & exclusion of renal arteries)

158 Renal Tumours

Tumours
K idney

Renal Pelvis M alignant 1o 2o Papillom a T C C S C C

B enign Adenom a H aem angiom a

N ephroblast oma Adenoca

F igu re 2 5 .

159 Nephroblastoma (Wilms')

Path. Anaplastic. Children < 5 usually. Spindle cells. Assoc. Bilateral in 5-1 0%, congenital ( aniridia, hemihypertophy, macroglossia)
38

Clinical. Rapid growth ! large mass in loin. Weight loss, anorexia, fever, hypertension.
Mets. Ix. USS: solid from cyst. CT: staging. Rx. Nephrectomy. Early : cytotoxic chemo. Later : radiotherapy. 80% 5YS

to P against adj ureter) Clinical. Most asx. pis en deux . Ix. IVU, cystoscopy. Rx. Conservatively

Cx. UTI ( Stagnant urine) , calculus formation, malignant , hydronephrosis ( rarely, due

XXII Bladder
160 Urachnal Anomalies
1 . Fistula: urinary discharge at the stula 2. Diverticulum: outpouching of the bladder 3. Cyst: urachnus persists but is closed above and below Rx. Excision

Types.

( catheter) Clinical. Triad of pain ( suprapubic, maybe tip of penis) , frequency, haematuria ( end of ow) Ix. KUB, cystoscopy Rx. ESWL

Aetiology. Of same types as renal stones. Due to stasis/ infection, foreign body

164 Bladder Stone

165 Tumours
T umours

161 Bladder Exstrophy

May die of pyelonephritis. Rx. Complex reconstruction

B enign T C papillom a

M alignant 1o T C C ( 9 0 % ) S C C Adeno
F igu re 2 6 .

Def. Failure of fusion of structures forming ant abdo wall. Clinical. Infant incontinent.

2o

Types. Intraperitoneal Penetrating wound or crush injury *Extraperitoneal Bladder might be torn by spicule in a pelvic fracture. Clinical. Intraperitoneal : Peritonitis w generalized extravasation. Extraperitoneal :

162 Rupture of Bladder

1 65.1 Transitional Cell Papilloma

Nature. Recur seed elsewhere, malignant Rx. Resection. Regular surveillance.

extravastion of blood & urine causes painful swelling. . Rupture of urethra: anterior displacement of prostate. Ix. CT, Cystography, urethrography ( urethral injury) Rx. Surgical suturing of rupture. Foley catheter. Drainage, abx.

XXIII 43: Prostate

Clinical. Obstructive

166 Benign Enlargement

Poor/ intermittent stream, hesitancy, terminal dribbling. May get haematuria due to congestion of prostatic vein plexus. Eventually: retention ( see below )

About. Most 2 to out ow obstruction. 95% in

obstructed)
o

163 Diverticulum of Bladder

( as men usually ones that get

39

Detrusor instability Frequency, urgency, nocturia Renal Failure Drowsy, headache, impairment of intellect. Ex. If uraemic: pale, wasted, dry furred tongue. Large bladder. PR: enlarged, palpable Ix.
sulcus. 1. 2. 3. 4. 5. 6. 7. 24h frequency/volume chart Serum U&E: renal failure Hbg: uraemia inhibits bone marrow PSA Urinalysis: leucocytes. Culture: a cx. Urine ow assessment USS: bladder enlargement, hydronephrosis, hydro-ureter, residual urine in bladder post-voiding

Clinical. Acute bacterial

Fever, rigors, perineal pain, di culty voiding, UTI sx. Pain on ejaculation, blood in semen. PR: enlarged, tender prostate. Epididymitis accompanies often. Rx: e. g. cipro oxacin, trimethoprim Chronic bacterial Recurrent UTIs. Prostate feels rmer. Ix: urine. Rx: Abx Chronic pelvic pain syndrome Pain in perineum, scrotum, tip of penis, pain on ejaculation/micturition. Frequency, incomplete emptying. Rx: pelvic oor relaxation, -blockers, NSAIDs, abx, prostatic massage

Cx. Prostatic Retention, haemorrhage Bladder Diverticula, stone, UTI Renal Hydronephrosis, uraemia Rx. Conservative Bladder training Medical -adrenergic antagonists ( e. g. tamsulosin) ( relaxation of s. m. of bladder) , Surgical
5 -reductase inhibition ( e. g. drotestosterone)
1

Aetiology. Congenital valves in region of prostatic urethra, brosis of prostate

169 Bladder Neck Obstruction

170 Posterior Urethral Valves

nasteride) ( blocks conversion testosterone ! dihy-

Clinical. Hydronephrosis, retention in childhood. Ix. Antenatal USS, micturating cystogram Rx. Surgical incision

1 . Transurethral prostatectomy: using diathermy or laser. # Morbidity. Cx: Haemorrhage: post-op irrigation & warming of pt TUR syndrome: absorption of " water causes hyponatraemia & confusion Infection: common if catheterized pre-op. Prophylactic abx. Retrograde ejaculation: almost certain Impotence: 5-1 5% Bladder neck stenosis: due to stricturing of neck Incontinence: uncommon. Happens if damage to sphincter Recurrent UTIs: re-growth of malignant 2. Open: if prostate v large, or co-existent intravesical pathology

171 Bladder Neck Fibrosis

Sx of hypertrophy but without enlargement. Endoscopic incision.

172 Urinary Retention

Presentation. Acute Suprapubic pain, inability to pass urine, suprapubic mass. Aetiology. General Local
mass may be pulsatile Chronic Painless dribbling incontinence inc AAA, as

167 Prostate Cancer

See oncology notes

* P ost-op ( in pain. Give opiates & sit pt over bed, or catheterize) , CNS disease, drugs ( e. g. anticholinergics, TCAs)

168 Prostatitis

Organisms. Faecal: E Coli, Strep faecalis . Can have non-bacterial prostatitis, and nonin ammatory ( prosatodynia) , these both termed chronic pelvic pain syndrome 40

1 . Lumen: e. g. stone 2. Wall: e. g. urethral stricture 3. Outside: e. g. prostatic hyperplasia , prostate malignancy, faecal impaction, pregnancy, pelvic tumour

Asses general condition of pt. Rx. Benign enlargement Prostatectomy if general condition satisfactory. If renal
damage/poor general condition then catheterize, perhaps permanently. Malignant disease If met spread: hormone therapy. Endoscopic prostatectomy for localized tumours, or large tumours with persisting sx. Urethral Stricture Dilate with bougies under anaesthetic. Rarely impassable: suprapubic. Chronic retention Catheterize, left in to allow renal function to improve. Fluids may be needed to rx the diuresis that follows relief of hydronephrosis. Bleeding is common following decompression.

1 . XR pelvis: calculus, bony 2 s 2. PSA 3. Does catheter pass? If not, then stricture Assess degree of renal damage. Uraemic sx/ si? Ix: U&C
o

Ix.

175 Testicular Torsion

Epi. Most common btw 1 2-27y. " in undescended testes Path. Twists within tunica vaginalis, blood supply compromised Clinical. V sev sudden onset pain, no sx of UTI Ix. Dipstix, m+ c. Rx. Surgical exploration: if infarction then orchidectomy, if not then x both
suture

sides w a

XXV Other

XXIV Testicular
173 Hydrocoele

Surgical Talk

Def. Fluid in testes btw the tunica vaginalis & tunica albuginea Clinical. Can get above, transilluminates Cause. 1 o Majority. Children: patent processus vaginalis. Adults: TV produces uid. 2 o Trauma, infx, malignancy. Develop rapidly Rx. Leave if asx, can plicate tunica vaginalis.

174 Epididymo-orchitis
Def. In ammation of testis & epidimytis due to infx. Cause. Young ( mumps) , young adults ( STI) , old ( UTI) Clinical. Acute onset sev testicular pain, Malaise, fever, discharge, UTI sx. Tender, red,
warm testis.
F igu re 2 7.

I: H artm anns.

41