walrond's_sessions.pdf
TRANSCRIPT
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Walronds Sessions
Hernias ............................................................................................................................................................................................. 1
Thyroid ........................................................................................................................................................................................... 5
Peripheral Vascular Disease (Arterial Disease) ................................................................................................................8
Colon Cancer .............................................................................................................................................................................. 13
Rectal Cancer .............................................................................................................................................................................. 15
Pancreatitis .................................................................................................................................................................................. 15
Acute Appendicitis ................................................................................................................................................................... 19
Gallstones .................................................................................................................................................................................... 23
Breast ............................................................................................................................................................................................ 28
Intestinal Obstruction ............................................................................................................................................................ 32
Pancreatic Cancer .................................................................................................................................................................... 40
Pancreatitis ................................................................................................................................................................................. 42
Benign Breast Disease ............................................................................................................................................................ 43
Hernias
Definition
Hernia protrusion of an organ with its coverings through an abnormal opening
Types of External Hernias:
Inguinal hernia Direct/ Indirect
Umbilical
Incisional
Femoral
Spigelian
Lumbar
Epigastric (occurs anywhere superior to the umbilicus)
Obturator
Gluteal
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Examination of Hernias:
Introduction
Exposure
Inspection
General Inspection
Obvious/ visible lumps or swellings (?ask pt to stand)
Ask patient to cough does the swelling become more obvious?
Palpation
Ask patient if they are experiencing pain
Cough impulse?
Ask patient if they can push it back in. If no and the hernia is small, try to reduce it yourself
Determine if the inguinal hernia is indirect or direct:
o External inguinal ring halfway along the inguinal ligament between ASIS and pubic
tubercle and ~2cm above
o Reduce the hernia and occlude the external inguinal ring then ask the patient to cough:
o If controlled at the deep ring INDIRECT inguinal hernia
o If it protrudes ABOVE and MEDIALLY to the pubic tubercle DIRECT inguinal hernia
o IF it protrudes BELOW and LATERALLY to the pubic tubercle FEMORAL hernia
NB: Mid-inguinal point halfway between ASIS and pubic symphysis
Case Scenarios:
Case #1: Right Groin Swelling
Introduction
Exposure
Inspection
Ask patient to cough: No cough impulse visible.
Ask patient to cough again and palpate for cough impulse: Positive cough impulse
Ask patient if they can push it back in, if not and a small hernia, you try to reduce it.
RING OCCLUSION TEST:
Find pubic tubercle lateral and inferior to pubic symphysis then locate ASIS then go halfway
between ASIS and pubic tubercle and 2cm superiorly.
Occlude ring with 1-2 fingers not the thumb or palm and make sure the medial side is always
exposed in order to see the protrusion.
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HESSELBACHS TRIANGLE (direct hernias): triangle formed by the inguinal ligament, lacteral border of
rectus abdominis and inferior epigastric artery.
Case #2: Scrotal Mass
Introduction
Exposure
Inspection
Ask patient to cough: No cough impulse visible.
Ask patient to cough again and palpate for cough impulse: Absent cough impulse
Try to palpate above the mass (feel in line with pubic tubercle or just above it at the root of the
penis):
o YES scrotal
Palpate for cord structures. If in doubt, feel opposite side.
o NO Hernia
Ask patient if they can push it back in, if not and a small hernia, you try to
reduce it.
Then state that you cannot perform the ring occlusion test but you think it is
an INDIRECT INGUINAL hernia because these are more common and more
likely to extend into the scrotum.
Case #3: Large left scrotal swelling
Introduction
Exposure
Inspection
Ask patient to cough: No cough impulse visible.
Ask patient to cough again and palpate for cough impulse: Absent cough impulse
Try to palpate above the mass (feel in line with pubic tubercle or just above it at the root of the
penis):
o YES scrotal Palpate for cord structures (if in doubt, feel opposite side)
Transillumination:
o YES Hydrocoele
o NO Is it fluctuant? Are the testes palpable? NO. Consistency? FIRM
Testicular mass TESTICULAR CANCER (common in Caucasian population)
Case #4: Big swelling in scrotum on right side (inguinoscrotal mass)
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Introduction
Exposure
Inspection
Ask patient to cough: No cough impulse visible.
Ask patient to cough again and palpate for cough impulse: Yes at the top but not at the bottom
Ask patient if they can push it back in, if not and a small hernia, you try to reduce it.
(Make sure you do not try to reduce the testes {feel for them})
HERNIA testes palpable
After reducing the hernia the scrotal mass is still present:
Check for hydrocele (fluctuant, can be transilluminated and the testes are not palpable.
Case #5: Left indirect inguinal hernia
Introduction
Exposure
Inspection
Ask patient to cough: No cough impulse visible.
Ask patient to cough again and palpate for cough impulse: Positive cough impulse
Ask patient if they can push it back in, if not and a small hernia, you try to reduce it.
Reducible? YES
Treatment
Surgery:
Herniotomy: removes hernia sac but does nothing about the defect
o Only performed in children
o Persistence of processus vaginalis
o As the child grows, there is closure of the superficial and deep rings by external oblique
muscle
Hernioplasty: the defect is cover with mesh; tension free
Herniorraphy: the defect is sutured; associated with tension
Additional Notes
Irreducible: cough impulse present, no vomiting, usually caused by adhesions of the hernia sac;
NOT AN EMERGENCY
Obstructed: no cough impulse, non-tender, not erythematous and associated with mild pain
Strangulated: no cough impulse, tender, erythematous and painful
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Ricters hernia: hernia involving only a part of the muscle wall eg only the anterior wall is
involved eg Femoral Hernia
Pantaloon hernia: combination of indirect and direct hernia; separated by inferior epigastric
artery
Hydrocoele (fluid collects in the tunica vaginalis)
Jahboulays fluid is drained, excess sac of tunica vaginalis is turned on itself and ligated. Excess
tunica vaginalis is excised.
Thyroid
Examination:
Inspection of neck
Mass e.g. in anterior triangle
Ask patient to swallow. Moves with swallowing mass arising from thyroid
Ask patient to stick their tongue out. Moves with protrusion of tongue thyroglossal cyst
Palpation
Trachea central?
Palpate mass by behind the patient
o Diffuse or symmetric enlargement
o Multinodular symmetric or asymmetric
o Solitary nodule
Ask patient to swallow. Try to get your fingers below the mass as the thyroid moves superiorly
with swallowing. If your fingers get below it no retrosternal involvement
Percussion (for retrosternal extension of thyroid)
After this you can check for other features:
Eyes: Exopthalmos, Lid lag, Ophhalmoplegia (Graves Disease)
Tremors
Cervical lymphadenopathy
Hyperreflexia
Findings on Palpation:
Diffuse, multinodular Multinodular Goitre
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Diffuse, multinodular Graves disease
Thyroid neoplasm eg Toxic adenoma
Hyperthyroidism Graves disease, Thyroid adenoma, Toxic multinodular goitre (rare)
Thyroiditis eg Hashimotos thyroiditis
NB: At the end of the examination, state if the patient is euthyroid, hypothyroid or hyperthyroid.
Scenarios:
1. Diffuse goitre, exophthalmos, lid lag, other signs of hyperthyroidism Graves Disease
2. Big, asymmetric gland Multinodular goitre
3. Right side symmetrically enlarged, left side normal:
a. Clinically euthyroid Solitary nodule
b. Clinically hyperthyroid Toxic nodule
4. Diffuse swelling, euthyroid Physiologic goitre
Management
1. Graves Disease
Investigations: T4, T3 (elevated), TSH (decreased)
Treatment:
Medical: Carbemazole (S/E: agranulocytosis), Propylthiouracil for 1 year (until
euthyroid; NB: they dont stay euthyroid)
Radioactive iodine
o Avoid in young people because of uncertainty of teratogenicity
o Requires lifelong follow up
o Patient is rendered euthyroid but later develops hypothyroidism
Thyroidectomy
o Lifelong thyroxine use after.
2. Multinodular Goitre
Investigations:
Ultrasound
TFTs T4, TSH (normal)
Indications for surgery:
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1. Compressive symptoms:
Hoarseness compression of recurrent laryngeal nerve
Dysphagia compression of oesophagus
Coughing or stridor Compression of trachea 2. Cosmetic reasons
No compressive symptoms and no cosmetic reasons no surgery indicated.
If surgery is needed: Total or Subtotal Thyroidectomy
3. Solitary Nodule
Investigations: Ultrasound, TFTs
If normal do FNAC (malignant potential)
Limitation of FNAC: cannot differentiate follicular adenoma from follicular cancer
Can identify papillary, medullary and anaplastic cancer
4. Thyroid Neoplasms
Management: staging, thyroidectomy
Papillary (most common) Follicular Medullary Anaplastic
Best prognosis -----------------------------------------------------------> Worst prognosis
Commonly in young ----------------------------------------------------> More common in elderly
Cytology/Histology: papillary projections
Papillary cancer Orphan- Annie eyes, Psammoma bodies
Nodular process with hyperthyroidism Radionucleotide scan (otherwise useless)
If warm still need to do FNAC
Thyroidectomy
Preparation for Surgery:
Bloods: FBCs, U&Es, GXM, TFTs
CXR: Thoracic Inlet view for compression
o tracheal deviation, retrosternal extension
ECG: hyperthyroidism can cause arrhythmias
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Indirect laryngoscopy: use mirror to visualize vocal cords
o For comparison pre and post-op
If hyperthyroid:
o Render euthyroid prior to surgery:
o Carbemazole
o Beta blocker (blocks receptors thereby preventing thyroid storm)
Complications:
Haemorrhage haematoma which can cause compression of trachea
o Remove sutures- both superficial and deep ON THE WARD
o Cover with sterile gauze and inform senior
o Return patient to OT secure the bleeding vessel
Nerve damage to recurrent laryngeal nerve stridor, hoarseness
o Superior laryngeal nerve (vocal strength)
Hypoparathyroidism
o Removal of parathyroid glands during surgery hypocalcemia
o Damage to inferior thyroid artery (blood supply to parathyroids)
Tracheomalacia
Pneumothorax
o Caused by damage to apex of lung with removal of retrosternal thyroid
Peripheral Vascular Disease (Arterial Disease)
Presentation
Intermittent claudication/ claudication pain
Rarely: Rest pain, tissue necrosis
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Causes
Atherosclerosis
Buergers disease (in young male smokers, lower and upper limb disease)
Risk factors
Males
Cigarette smoking
Hypertension
Diabetes mellitus
Obesity
Dyslipidemia
Homocysteinemia
How to confirm claudication pain
Ask the patient if the pain goes away at rest.
o NB: can be confused with pain from osteoarthritis (pain at rest, pain made worse
during cold weather, morning stiffness, maybe relieved by walking)
o Another differential: sciatica (back pain shooting down the leg, worse on walking)
Can the pain be localized? (suggests site of the arterial disease/stenosis)
o Calf pain superficial femoral or popliteal arteries are affected
o Thigh pain common femoral, femoral profunda or iliac arteries are affected
o Buttocks Internal iliac artery affected
o Penis (impotence) both internal iliac arteries are compromised
Leriches syndrome: absent femoral pulses, intermittent claudication of the
buttocks muscles, pale cold legs and impotence
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Ask about history of cardiovascular disease eg previous MI, Angina, IHD
Ask about previous stroke, TIA
Ask about renal disease
Examination
General examination
CVS BP (HTN), Carotid bruits, displaced apex beat
ABD abdominal aortic aneurysms
Inspection of Lower limbs:
Hair loss
Shiny skin
Thickened nails
Ulcers
Muscle wasting/atrophy
Palpation:
Temperature
Pulses: dorsalis pedis, posterior tibial, popliteal, femoral
Investigations
Non-Invasive:
1. Ankle:Brachial Pressure Index (ABPI)
ABPI is a non-invasive test comparing the systolic blood pressure in the brachial artery and
the systolic pressure in the dorsalis pedis or posterior tibial artery.
Normal ABPI 0.9-1.0
Intermittent claudiation ABPI 0.5-0.9
Critical Limb ischaemia ABPI
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A 20 mmHg or greater reduction in pressure is considered significant if such a gradient is
present either between segments along the same leg or when compared to the same level of
the opposite leg.
Several blood pressure cuff positions have been employed to detect the level of peripheral
vascular disease. As examples, a significant reduction in pressure:
At the thigh, reflects aortoiliac or superficial femoral artery disease
At the calf, reflects distal superficial femoral artery or popliteal disease
At the ankle, reflects infrapopliteal disease.
In addition, a toe pressure of less than 60 percent of the ankle pressure indicates digital
artery occlusive disease.
3. Duplex Doppler ultrasound anatomy and assessment of floe in the arteries
4. Plethsymography assesses flow through arteries
Scenarios
1. Claudicant with ABPI of 0.6, duplex Doppler USS confirms blockage in superficial femoral artery
Management:
Initially conservative management
NB: 1/3 get worse, 1/3 get better, 1/3 remain the same
Address risk factors; factor modification helps to improve claudication
Control BP, DM, Cholesterol, cessation of smoking
Exercise increase claudication distance (neovascularization and
development of collateral circulation around the area of stenosis)
Drugs:
Antiplatelet agent: Aspirin (stops platelet aggregation)
Statin lipid lowering agent, plaque stabilization, anti-
inflammatory
Trental (Pentoxyphylline) improves flexibility of RBCs
Follow up: repeat ABPIs and monitor claudication distance
Improvement: no indication for surgery
Pain at rest or progression to critical limb ischaemia surgery indicated
If getting worse eg rest pain, do CT angiogram to determine the procedure to be done at
surgery
2. Critical limb ischaemia (CLI) ABPI
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Angiography
Types:
Conventional Angiogram with Digital Substraction (GOLD STANDARD) [requires
interventional radiologist]
CT Angiogram
MR Angiogram
CT Angiogram findings required for surgical intervention:
Good run in and run off good proximal and distal flow to the area of stenosis.
If CT angiogram shows run in but no off and in the presence of rest pain initially
ANALGESIA
Interventions to improve blood supply in atherosclerosis:
By pass grafting for long segment stenosis
o Long saphenous vein is used- is either revered or valvectomy is performed in
situ
Percutaneous Transluminal (Balloon) Angioplasty (PTA) + Stenting for short segment
stenoses
Endarterectomy (vessel is incised and plaque is removed
o Common done on carotid arteries
Indications for Amputation:
Intractable pain
Sepsis
Leg that is a nuisance
3. Dry gangrene of the great toe, angiogram shows no run off
Management:
Betadine dressings (to keep area dry)
Wait for auto-amputation of toe (If the toe is surgically removed, there is poor blood
supply and healing will no occur).
4. Dry gangrene progressing to wet gangrene
Management:
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Is there collateral circulation?
Transcutaneous oxygen insert needle and measure O2, if >60mmHg healing will
occur
Pulse volume recording
If no collateral circulation indication for amputation (determine level eg BKA or AKA)
5. Wet gangrene of the great toe
NB: Surgical Emergency
Management:
Amputate the toe to stop sepsis and cover with antibiotics
Then do CT angiogram to determine if further intervention is needed eg PTA
o If no further intervention is possible to save limb because of compromised
blood supply further amputation to level of adequate blood supply.
Colon Cancer
Investigations
Colonoscopy + Biopsy or Barium enema
Histology
Staging (e.g. tumour on left side of colon)
o CT abdomen
For: Enlarge lymph nodes, invasion into surrounding structures, distant
metastases
o CT pelvis
o CXR or CT chest (lung metastases)
Other tests
Abdominal USS
Bloods: FBC (anaemia), U&Es
Tumour Markers CEA (carcinoembryonic antigen)
Staging
1. TNM
T1 limited to submucosa
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T2 muscularis propria
T3 into the subserosa but not breeching visceral peritoneum or adjacent structures
T4 extending beyond visceral peritoneum and into adjacent structures
N- nodes
M metastases
2. Dukes Classification
A limited to bowel wall
B extending through the bowel wall
C- lymph nodes involved
Modified Dukes: D distant metastases
Scenarios
Tumour in:
1. Sigmoid colon, was confirmed by CT abdomen, no metastases, few local enlarged lymph nodes
Sx: Sigmoid colectomy with removal of regional lymph nodes (mesentery, blood supply and
lymph nodes are removed)
2. caecum Right hemicolectomy
3. Ascending colon Right hemicolectomy
4. Distal transverse and descending colon Left hemicolectomy
5. High rectum Anterior resection
6. Mid rectum Low anterior resection
7. Low rectum Abdominal Perineal Resection (APR) excise rectum and anus; needs permanent
colostomy
Preparation for Sigmoid Colectomy
Informed consent
Bloods: FBC, U&Es, GXM
CXR lung disease which may affect the patient under general anaesthesia while being
ventilated)
ECG Ischaemic heart disease, arrhythmias
DVT prophylaxis
Prophylactic antibiotics
Bowel prep: only if concerned that tumour is too small to be felt
Review the patient in SOPD (6/52 following the surgery)
Wound healed? No hernias
Assess bowel function
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Review staging of tumour (specimen from surgery was sent to histology/pathology)
o Determines need for adjuvant therapy
o Margins clear?
o Nodes that were harvested- were they involved?
o Determine how far the excised tumour had invaded the bowel wall.
If tumour is staged at T3 N1 M0 Adjuvant chemotherapy (if it can be tolerated)
Indications for Adjuvant chemotherapy
anybody that is node positive
controversial stage T3
T4 tumour
Chemotherapy agents
5- fluorouracil (5FU)
Combinations oxycisplatin + 5FU
Five FOX (?)
Radiotherapy
Radiation of the colon is not routinely used because of surrounding structures in abdomen. May be used
in rectal cancer.
Rectal Cancer Investigations: Same as for colon plus Transrectal USS or MRI(not available @QEH)
Adjuvant therapy is usually given before surgery because of difficulty access to tumour without
having to remove anus.
NB: Anal canal 3-5cm; APR 5-7cm
Scenarios:
T1 or T2 tumour with no nodes involved Local resection within the anal canal
Pancreatitis
Causes
(GET SMASHED)
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Gallstones
EtOH (alcohol)
Trauma
Viral Illness e.g. mumps
Drugs e.g. corticosteroids
ERCP
Dyslipidemia
Hyperperfusion states
Idiopathic
Congenital?
Presentation
Epigastric pain radiating to the back, worse on leaning forward
Vomiting, fever
Jaundice
Clinical Features:
Tenderness on palpation of RUQ or epigastrium
Guarding and rebound tenderness
Cullens sign periumbilical ecchymosis
Grey-Turners sign bruising in the flanks
Decreased bowel sounds
Obstructive jaundice (dark urine, pale stools)
Steatorrhea
General Examination
Jaundice, fever, dehydration
CVS: assess for haemodynamic stability tachycardia? Hypotension?
RESP: findings of pleural effusion- occurs due to irritation of diaphragm (may be larger on left than the
right)
Investigations
Bloods:
FBC- elevated white cell count
U&Es
LFTs
Bilirubin
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Alkaline phosphatase (elevated in presence of gallstones)
Serum amylase (Dx: elevated >3x ULN acute pancreatitis)
o Normal 120-130
o Dx: >400
o Severity not dependent on level of rise of serum amylase
Lipases (most specific for acute pancreatitis)
Blood glucose
Other investigations:
USS abdomen gallstones
Erect CXR
Abdominal xray colon cut off sign, sentinel loop (not specific or diagnostic)
CT scan to assess severity of pancreatitis
Ransons Criteria: (>3 severe pancreatitis- manage in ICU)
On Admission 48hrs Post Admission
Glucose > 11mmol/l Calcium < 2.0
Age > 55 Haematocrit- decrease >10%
LDH > 350 PaO2 16 BUN elevated >15%
AST > 250 Base deficit > -4
Sequestration fluid > 6L
Treatment
1. Analgesia NSAIDs (monitor urine output)
Narcotics except morphine (causes spasm of sphincter of Oddi)
2. IV fluids maintenance, deficit and insensible losses
Monitor urine output catheterize
Large fluid requirement CVP line
3. Bed rest, NPO, NG tube (rest the pancreas)
Pancreas stimulated by stomach distension and food passing through the duodenal complex)
4. Nutrition
Enteral vs parenteral
5. Severe pancreatitis antibiotics (prophylaxis against infective necrosis)
6. Treat underlying cause.
Gallstones cholecystectomy
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Stop alchohol use
Parathyroidectomy
7. Monitor for progress and complications.
Complications
Pancreatic insufficiency
Acute renal failure
ARDS
Infected pancreatic necrosis
Pseudocyst
Pancreatic abscess
Pancreatic fistula
UGIB (rare) {splenic vein thrombosis as a result of portal HTN}
Indications for Surgery
Infected pancreatic necrosis debridement
Pancreatic abscess incision & drainage
Treat underlying cause eg gallstones
Complications eg pseudocyst
Pseudocyst
Cyst not lined by epithelium, lined by fibrotic tissue
Cyst contains pancreatic fluid (enzymes enter 2nd part of duodenum and leak out into the
abdomen)
Treatment:
o Wait until they mature (4-6 weeks)
o If they get smaller: drain through through pancreatic duct
o Not resolving: Anastomose onto the back of the stomach
Cysto-gastrostomy or cystojejunostomy
Chronic pancreatitis
Pancreatic ducts become strictured increase pressure severe pain
Severe inflammation pancreatic insufficiency
Causes e.g. alcohol
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Acute Appendicitis Definition
Inflammation of the appendix caused by obstruction of the appendiceal lumen
History
Initially periumbilical pain radiating to the right iliac fossa (RIF)
Nausea, vomiting, anorexia, low-grade fever
Late: signs of dehydration
Examination
Inspection: lie still (because patient experiences pain on moving)
Palpation: RIF pain, rebound tenderness, guarding
DRE: pain (if appendix anterior and to the right of the Pouch of Douglas)
Obturator sign:
Psoas sign:
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Various anatomical locations of appendix
Preileal
Post ileal
Retrocecal
Subcecal
Pelvic
Terms to know
McBurneys point: one third the distance from the ASIS to the umbilicus
Rovsings sign: Palpation of the LLQ results in pain in the RLQ. This occurs because you push
the bowel which causes the appendix to touch the peritoneum.
Interesting points you should know
When would you consider Meckels Diverticulum as a differential diagnosis?
o Mainly in the children
o It is inflammation of the remnant of the vitello-intestinal duct
What is Mittelschmerz?
o Pain in ovulation or mid-cycle
What is Fitz-Hugh-Curtis Syndrome?
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o PID that tracts up the right side to the kidney
Case Scenarios
Case #1:
Hx: 22 year old female complaining of RIF, anorexia. There is no fever.
Exam: mild rebound tenderness and guarding. Normal bowel sounds. DRE- normal.
What is the next step?
o Vaginal exam because of the differential diagnoses of a 22 year old female.
o DDx: ovarian cysts, ovarian torsion, ectopic pregnancy, endometrisos, PID, salpingitis.
The PV exam was normal. What imaging modality would you do?
o Ultrasound of the abdomen
o DDx:
GI: Crohns, gastroenteritis, perforated ulcer, right sided diverticular disease,
perforated right sided colon
GU: UTI- pyleonephritis, cystitis, stones in the ureter, occasionally stones in
the kidneys
Hepatobiliary: cholecystitis, hepatitis, pancreatitis
What investigations would you do in this patient?
o Urinalysis- leukocytes (UTI), blood (stones)
o Pregnancy test
o Blood tests: FBC- WBC
o Radiology: Ultrasound
The ultrasound is mostly used to rule out conditions e.g. stones in kidneys,
cholecystitis, ovarian cysts.
Ultrasound findings of appendicitis: blind ended tubular structure which is
noncompressible. Thickening of the wall >6mm.
o Microbiology and histology
Suppose the ultrasound shows fluid in the RIF. What is the next step?
o CT Scan- more sensitive that ultrasound
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o The next step will then be laparoscopic exploration in females because the rate of
negative appendicitis is very high.
The ultrasound is normal. At laparoscopy you see an inflamed appendix and perform an
appendectomy. What is the main complication of this surgery?
o Early- wound infection- clean contaminated; if appendix ruptures- dirty
o Prevention of wound infection- prophylactic antibiotic to cover gram ve anaerobes
Case #2:
Hx: Young male complaining of a 6 days of umbilical pain which radiates to the RIF. He is complaining of
a fever, vomiting and generalized peritonitis.
How would you manage this patient?
Urinalysis
Blood test: FBC- WBC
Resuscitate and take to operation because this is a case of a ruptured appendicitis.
Case #3:
Hx: Male patient with a 2 week history of RIF noted to have a decreased appetite. Examination reveals a
lump in the right side of his tummy that is tender to touch. A FBC was done with a WBC of 17.
How would you manage this patient?
Imaging- CT scan of the abdomen. In this case the ultrasound would have problems visualizing
the abdominal contents with the matted bowel.
Appendix abscess- percutaneous drainage and antibiotics; 6 weeks later perform a colonoscopy
Of note: interval appendectomy is not necessary unless there are signs of recurrent appendicitis.
Operation is not done at same time because of the inflammatory process causes the vision at
surgery to be decreased.
Case #4:
20 year old male with generalized peritonitis and a WBC 20 is diagnosed with an appendicitis. A 20 year
old female also diagnosed with appendicitis based on history. No peritonitis. Her WBC is 10.
Who goes to theatre first?
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The female goes to theatre first because her appendix has not ruptured. If ruptured there is the
possibility of sepsis which increases the risk of wound infection, adhesions and infertility. In males the
ve appendicitis rate is ~8% while in females this rate is ~30%.
Appendix Tumors
Carcinoid tumor, adenocarcinoma (famous for pseudomyxoma peritoni)
Gallstones
What are the syndromes gallstones can cause?
1. Biliary colic
2. Acute cholecystitis
3. Chronic cholecystitis
4. Obstructive jaundice
5. Cholangitis
6. Pancreatitis
Biliary colic: there is a stone in the cystic duct that continuously lodges and dislodges. The clinical
features include epigastric pain, nausea and vomiting. The epigastric pain that is experienced is caused by
contraction of the gallbladder against the blockage. This pain can mimic that of gastritis and acid reflux.
Patients may experience nausea or vomiting.
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Acute cholecystitis: there is a stone lodged in the cystic duct which does not dislodge as quickly as that
in biliary colic. The gallbladder becomes distended as it is unable to empty bile into the cystic duct. This
affects the blood supply gallbladder with thick walls and distension stasis bacterial proliferation
and inflammation. N.B. Patient should not have jaundice (as the common bile duct is not obstructed)
Chronic cholecystitis: there is stone that is permanently lodged in the cystic duct. There will be recurrent
acute attacks as the stone is still able to dislodge until fibrosis occurs.
Obstructive jaundice: due to choledocholithiasis. There is a stone lodged in the common bile duct.
Clinical features include: icterus, pale stools, dark urine.
Cholangitis: There is stasis and subsequent infection of the common bile duct, due to the stone
remaining lodged in the CBD.
Pancreatitis: There is a stone lodged in the ampulla of vater which blocks the pancreatic duct.
What is the cause of gallstones?
Stasis and supersaturation of bile salts
What are the different types of gallstones?
Mixed (multifaceted)
Pigment (seen mainly in people with sickle cell / haemolytic process)
Cholesterol (seen mainly in people with dyslipidemia or FHH; usually a solitary stone is present)
Mixed > Pigment > Cholesterol
Who gets gallstones?
Five Fs: Fair, Fertile, Forty, Female, Fat (increased oestrogen delays gallbladder emptying)
N.B. Not hard and fast rule
Case Scenarios
Case #1: A patient presents with intermittent epigastric pain, nausea and vomiting due to biliary colic.
On ultrasound the gall bladder is full of stones, there is thickening of the wall and distension. Of note
there is also pericholecystic fluid. There is also a positive sonographic Murphys sign. What is the
management of this patient?
1. Discuss diet (less greasy foods, etc) with the patient
2. Advise patient about surgery (if symptomatic gallstones, do surgery).
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Before removal of the gall bladder check to see if there are stones in the CBD. This can be determined
based on 3 things: history + USS + LFTs (ALP and BILI are elevated).
Case #2: A patient presents with abdominal pain, rebound tenderness, guarding, and a positive Murphys
sign (halting inspiratory effort on palpation of the gallbladder) on examination. The patient is diagnosed
with acute cholecystitis. What is the management of this patient?
1. USS, FBCs, LFTs
2. If within 48 hours of symptoms, perform a cholecystectomy
3. If past 72 hours, the chance of the surgery being performed laparoscopically is decreased.
Administer antibiotics, NPO, perform cholecystectomy. Laparoscopic cholecystectomy may be
difficult and would require to open cholecystectomy.
Complications of acute cholecystitis:
1. Mucocele
2. Empyema
3. Gangrene
4. Perforation
5. Abscess (if walled off) or peritonitis (if not walled off)
Case #3: A patient presents with multiple attacks of acute cholecystitis. On USS the gallbladder wall is
contracted (due to fibrosis). What is the treatment?
1. Cholecystectomy.
Case #4: A patient presents with a history of years of GERD. It was recently realised that is was actually
gallstones. On USS the gallbladder was contracted with thickened walls. What is the management?
1. Make sure there are no stones in the CBD (Check using the history, USS, and blood
investigations FBC, U&Es, LFTs. If any of the 3 above are off, use a cholangiogram to check
(e.g. ERCP or MRCP; if no stones seen do lap. Cholecystectomy but if stones present will require
common bile duct exploration.)
2. At time of surgery, an intraoperative cholangiogram may also be performed
Case #5: A patient presents with a history of yellow eyes, dark urine and pale stools. What is the
management?
1. Bloods: LFTs increased direct bilirubin, increased ALP, increased GGT (more than ALT or
AST)
2. USS: dilatation of common bile duct (not very sensitive for gallstones)
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On ultrasound, stones were seen in the gallbladder but unable to visualize common bile duct. What
is the next step in the management of this patient?
Treatment:
1. ERCP to remove stones which are usually seen as a filling defect (via basket, or sphincterotomy
of ampulla of vater and use of Fogaherty catheter)
2. Then do cholecystectomy.
Case #6: A patient presents with right upper quadrant pain + fever (+/- chills and rigors) + jaundice
(Charcots triad). Patient is diagnosed with cholangitis. What is the management?
1. Most important things are rehydration of IVF and antibiotics (do blood cultures prior to starting
antibiotics)
2. Once the patient is better, perform ERCP and remove the stone
3. Perform cholecystectomy
4. If the patient is unstable, perform an urgent ERCP to decompress the gallbladder
Case #7: A patient presents with pain in the epigastric region, which radiates to the back and is relieved
on leaning forward. The patient is diagnosed with pancreatitis. What is the management?
1. There is NO indication for antibiotics because it is inflammatory and not infective (unlike
cholangitis)
2. Fluid resuscitation
3. Rest pancreas (NPO)
4. If it is mild, wait until it settles, investigate, then remove gallbladder
N.B. ERCP can worsen pancreatitis (do not use for the mild pancreatitis, use more in the severe type)
Additional
Normal size of common bile duct is 6mm.
Rokitansky Aschoff sinuses are pseudodiverticula in the wall of the gallbladder. They may be
microscopic or macroscopic. Histologically they are outpouchings of gallbladder mucosa into
the gall bladder muscle layer and serosal tissue. They are associated with cholelithiasis and
cholecystitis. They form as a result of increased pressure in the gallbladder and recurrent
damage to the wall of the gallbladder.
95% of gallbladders that are taken out are due to chronic cholecystitis.
USS is good at showing dilated ducts. It is also sensitive at differentiating between obstructive
jaundice and normal jaundice.
If the distal common bile duct cannot be visualised on USS, perform ERCP.
Pale stools are an important finding in obstructive jaundice.
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Pain differentiates between jaundice due to gallstones and jaundice due to pancreatic cancer.
There is pain in gallstone jaundice, while pancreatic cancer jaundice is painless.
Acute cholecystitis does not cause jaundice.
Charcots triad = RUQ pain + fever + jaundice
Raynauds pentad = Charcots triad + hypotension + confusion (basically adding the features of
shock)
Cholangitis causes septicaemia.
X-Rays
1. Pneumothorax
If mild, leave it alone and allow to settle. Do X-rays 6 hours apart. 20% of pneumothorax can
resolve on their own. If severe, use a chest tube. After placement of chest tube, it is important
to ensure that the pneumothorax has resolved. Also, ensure that the chest tube is placed
correctly (make sure all holes are inside the chest the last hold always breaks the radiopaque
line, so if this hole is seen on chest X-ray then all the holes are inside the chest)
2. Massive pleural effusion
Homogenous opacification seen on chest xray.
Management:
Thoracocentesis diagnostic (send pleural fluid for cytology, microscopy, culture and
sensitivity) and therapeutic
Insert chest tube
What is the most likely cause of this massive pleural effusion? MALIGNANCY
3. Small and large bowel obstruction
An xray showing both SBO and LBO suggests right colonic distension which is most likely due
to a malignancy.
Additional notes:
Always look at supine abdominal xray first as it allows you to see differentiating
features for small vs large bowel eg plicae circulares, central distribution in SBO.
The erect abdominal xray is good for seeing the air-fluid levels and in detecting
pneumo-peritoneum.
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Normally the liver is seen under the right hemidiaphragm. If a loop of bowel gets
between the diaphragm and liver, this is known as Chilaiditis sign.
Add images from your phone please tanz! (My pictures didnt come out very clear, Jamz has
better pics)
Breast
Risk Factors
ALL of the following must be asked in the history!
Prolonged uninterrupted estrogen cycle
o Age of 1st child
Ideally, first child should be before the age of 20
Ask patient the age of their first child
o No breast feeding
o Early menarche
o Late menopause
o Hormone replacement therapy (HRT)
Persons with 1st degree relatives who have breast cancer
BRCA1 and BRCA2 genes
Obesity
History of proliferative breast disease
o e.g. atypical ductal or lobular hyperplasia
o Ask about previous breast lumps or breast cancer
Examination
Size
Location
Features e.g. irregular, indistinct edges, fixed to skin or surrounding structures
Investigations
Imaging in the presence of clinically palpable lump is only useful for looking for other lesions.
The results of the mammogram wont affect the approach to the lump already discovered
because it should be biopsied regardless
FNAC
Core biopsy
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Incisional biopsy
Excisional biopsy
Vacuum-assisted biopsy (using image guidance such as X-ray, USS)
N.B. Most places in the world do FNAC over core needle because it is less painful.
Staging
If FNAC or core needle shows lump to be cancerous, the next step is to stage:
T1 < 2cm
T2 = 2-5cm
T3 > 5cm
T4 any tumour which is fixed to skin or other structures
Stages 1 and 2 are early disease while stages 3 and 4 are late disease.
N1 < 3 nodes
N2 = 3-10 nodes
Most important prognostic factor in breast cancer is the presence of affected lymph nodes
Ipsilateral lymph node involvement is not a metastasis (it is regional spread). Contralateral node
spread, supraclavicular and cervical nodes are considered metastatic disease???
Common sites of metastases for breast cancer (L2B2):
o Lung
o Liver
o Bone
o Brain
Investigations
CXR
Abdominal USS
o Liver metastases (uncommon in early disease)
Bone scan
o Not very useful in early disease
1 in 1 million positive in early disease
CT scan of chest and upper abdomen
o Covers liver, bone and chest
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CT scan of brain
Treatment
Treatment is locoregional (breast and axillary nodes) and systemic.
None of the tests mentioned previously can detect microscopic disease. Most cancer cells or
mets are only visible at sizes >1 cm, therefore systemic treatment is required to be on the safe
side.
Locoregional Therapy
Locoregional treatment +/- local radiotherapy:
o Breast conservative surgery
o Breast ablative surgery
Cons of breast conservative surgery
o It is well known that patients receiving breast conservative surgery have more recurrences,
have more procedures and are more likely to have future radiotherapy, etc. For these
reasons, most patients (in Barbados) pick breast ablative surgery.
??? Similar mortality rates between those treated with breast conservative and breast ablative
surgery
Resection:
o Small breasts, at least 1cm margin grossly, and 3mm microscopically should be resected
(remember fixation shrinks the tissue)
o Large breasts: aim for wider resection margins
Modified Radical Mastectomy:
o Level 1 Lateral to pectoralis minor
o Level 2 Posterior to pectoralis minor
o Level 3 Superomedial to pectoralis minor
Clinically, large axillary nodes will require axillary dissection (level 1 and 2 usually). For clinically
imperceptible small nodes consider SLNB??? (supposed to be right in 97% of cases (3% will
have skip lesions))
Toilet mastectomy is a palliative mastectomy for a fungating breast mass. It is not a treatment
but just for the purposes of relief (decrease odour, etc)
Systemic Therapy
Types of systemic therapy:
1. Hormonal therapy
2. Chemotherapy
3. Immunotherapy
Hormonal Therapy:
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N.B. Aromatase inhibitors are used in post menopausal women
Side effects of Tamoxifen
o Increased risk of endometrial cancer
o Increased risk for osteoporosis
o Increased risk of venous thromboembolism
o Increased risk of cardiac events
Chemotherapy:
1st line chemotherapy regimen - Adriamycin (Doxorubicin) + Cyclophosphamide
Chemotherapy candidates are those with poor prognostic factors:
o +ve lymph nodes
o High grade tumours
o Young patients (30s and 40s - more aggressive)
o Estrogen negative tumours
Immunotherapy:
Herceptin for Her 2 neu +ve tumours
Handling the non-palpable Lesion on Mammogram
Stereotactically guided core needle biopsy
Hook-wire wide local excision under the guidance of a hook wire placed by the aid of the
radiologist. The surgeon follows the end of this hook wire and does wide local excision.
N.B. Lobular carcinoma in situ is not visible on mammogram. It indicates very high risk for developing
ductal carcinoma in situ not just in original, but also in the contralateral breast.
Approach to high-risk Patient with non-palpable Mammography Finding
Surveillance
o Breast examination twice yearly by surgeon
o Self examination once monthly
o Mammography
Chemoprophylaxis with Tamoxifen
Bilateral mastectomy (drastic)
Additional
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Peau dorange is blockage of the skin lymphatics (there is no skin involvement). Sometimes,
peau dorange is considered T3 automatically.
Walrond: Much evidence to suggest locoregional foci wont metastasize. Some surgeons choose
to remove primary tumour without axillary clearing. Years later, axillary nodes enlarged and
upon subsequent resection there was no evidence of distant metastases, and this group of
patients survived just as long as those who received axillary clearance initially.
Be careful with giving Tamoxifen to patients who have had previous pulmonary embolism.
Doxorubicin is cardiotoxic, so do pretreatment echocardiogram and baseline cardiac function
Ductal carcinoma in situ is not invasive and therefore technically there is no role for axillary
dissection
Lobular carcinoma can be distinguished from ductal carcinoma on FNAC by examining the
appearance of the cells. What you cant tell from FNAC is whether or not it is invasive (biopsy
is needed in this case).
X-ray Session
Endoscopy is used to investigate esophageal cancer. Cannot comment on LES thickening unless
theres an ultrasound probe attached to the main probe. What they can say is that there was
difficulty passing the probe at the upper GI endoscopy from which they infer theres failure of
LES relaxation. Achalasia is diagnosed by manometry. DDx for appearance of achalation on
barium swallow acid reflus, esophageal cancer.
Intracapsular (subcapital) femoral fracture
o Austin Moore prosthesis
Lack of collateral vessels with visible filling defect is suggestive of an acute event such as
thrombosis
Intestinal Obstruction
Types
Gastric outlet obstruction (GOO)
Small bowel obstruction (SBO)
Large bowel obstruction (LBO)
Main symptoms of intestinal obstruction
Abdominal pain
Abdominal distension
Vomiting
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Constipation or obstipation (inability to pass feces or flatus)
Abdominal pain:
Gastric outlet obstruction epigastric pain
Small bowel obstruction periumbilical
Large bowel obstruction ???
Abdominal distension:
Gastric outlet obstruction The patient will more likely not complain about abdominal
distension, but on examination there may be fullness in the abdomen.
Small bowel obstruction There is central distension. If the obstruction is proximally, there is
less distension. If the obstruction is distally, there is more distension.
Large bowel obstruction There will always be distension because the entire small bowel will
also be backed up. Distension may also be seen in the flanks.
Vomiting:
The stomach makes 1.5 L of fluid/day
Gastric outlet obstruction constant vomiting, non-bilious, undigested food)
Small bowel obstruction early in history, constant vomiting, bilious vomiting (this bilious
vomiting is the only way to differentiate between GOO and SBO)
Large bowel obstruction late in history, not constant or often, begins as food, then bile, than
faeculent
Constipation or obstipation:
Patient will not come out and complain about constipation, therefore, ask about not passing
stool (and they may remember)
Small bowel obstruction constipation and obstipation are late features
Large bowel obstruction constipation and obstipation are early features
Gastric Outlet Obstruction
Occurs at the narrowest part
Causes:
o Chronic peptic ulcer disease (causing fibrosis and scarring)
o Gastric cancer
On examination:
o May feel fullness on left side
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o Succession splash (because stomach is full and big with fluid)
o May be associated with Virchows node, Bloomers shelf, Krukenburgs tumour, liver
mass/metastases, Sister Mary Joseph nodule
Investigations:
o FBC
o U&E (may show dehydration) decreased potassium, decreased sodium, decreased
chloride, and increased bicarbonate (metabolic alkalosis)
Treatment:
o Correct electrolyte abnormalities (bombard them with K+ - 60 mEq/L????)
o Rehydrate (normal saline IVF)
o NG tube
After rehydration, other investigation should include endoscopy and barium swallow. Endoscopy
is gold standard. It can differentiation between a malignancy and benign PUD.
o On endoscopy, if a tight stricture is at the pyloris from PUD, the treatment will be
surgery (gastrojejunostomy), PPi (long term Omeprazole), or vagotomy to decrease acid
production
o On endoscopy, if a malignant tumour is found, treatment involved surgery to remove
the tumour
Small Bowel Obstruction
Causes:
o Adhesions (look for scars from previous surgery)
o Hernia (check all hernial orifices femoral hernias are small and difficult to see)
On examination:
o Increased tinkling bowel sounds (if it becomes absent that it meant there is gangrenous
bowel)
Investigations:
o FBC
o U&E dehydration with no specific electrolyte abnormality
Radiological Investigations:
o X-ray supine (dilated loops of small bowel, centrally located with plica circularis) and
erect (air fluid levels)
o N.B. USS is useless as it does not image small bowel well
Treatment:
o Do not take patients to surgery if the cause is adhesions rehydrate and NGT
(decompression)
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o Volvulus surgery
o Intussusception surgery in adults, but no surgery in children. To reduce it, do an air
enema or contrast enema. Only if this fails, do surgery.
Large Bowel Obstruction
Causes:
o Malignancy in colon (more commonly on the left)
o Complicated chronic diverticular disease
o Volvulus of sigmoid colon
o Fecal impaction
o Ogilves syndrome pseduoobstruction seen in the elderly
On examination:
o Increased tinkling bowel sounds
Investigations:
o FBC
o U&E
o X-Ray dilated bowel seen at the periphery and haustra
o Sigmoidoscopy if there is no peritonitis
Treatment:
o Rehydrate
o Sigmoidoscopy can see a malignancy (remove the tumour) or volvulus (ability to
unravel the colon for a period of time)
o If caecum is extremely large on X-Ray (>12cm), take the patient straight to surgery
because there is a risk of perforation (N.B. Caecum will perforate usually in left sided
bowel obstruction)
Additional
The way to determine if it is bile that the person is vomiting, ask if it was green or yellow and
bitter to taste
Pyloris stenosis in children will give projectile vomiting
Paradoxical aciduria due to vomiting there is hypochloremic metabolic alkalosis. To
compensate, the kidney excretes low chloride with bicarbonate. Sodium is lost along with
bicarbonate. With time the patient becomes progressively dehydrated and hyponatremic.
Because of dehydration a phase of sodium retention follows. Sodium is conserved in exchange
for H+ and K+, leading to paradoxical aciduria and hypokalemia
How to localize pain there are two types of peritoneum:
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o Visceral not localized (more diffuse)
o Parietal localized
Foregut mouth 2nd part of the duodenum (ampulla of vater), Midgut 2nd part of
duodenum 3rd part of the transverse colon, Hindgut 3rd part of transverse colon to the end
????
GOO has an outlet so there will be no perforation because the patient is continuously vomiting
through the outlet
Femoral hernias are most common in thin, older women
Closed loop obstruction ISHA MORE
Volvulus know the signs
Features of intussusception red currant jelly stools, mass may be felt, USS can be used
because not much air is in the way (target sign)
X-Ray Session
Intravenous Pyelogram (IVP)
KUB plain X-Ray without contrast. Look for stones (seen as opacities, guided by the
transverse proceses).
Label minutes of time with contrast on each subsequent film
o At 0 mins, the one that lights up 1st is the kidney with good excretion
Know what the previous X-Ray would should before contrast
Round opacifications in kidneys signify dilated calyces
Diagnosis the patient had a hydronephrosis due to obstruction. The ureters are dilated
proximal to the obstruction. Possible causes include a stone in the ureter, ureter cancer,
retrocaval ureter, retroperitoneal fibrosis
Other more sensitive investigation CT pyelogram
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Ortho X-Ray #1
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X-Ray of left arm
Fracture to proximal 1/3 of ulna and dislocation of the radial head (Monteggia fracture)
Treatment open reduction and internal fixation (plate and screws)
Complications radial nerve damage (wrist drop) (posterior interosseus nerve)
Ortho X-Ray #2
X-Ray of knee joint
Gun shot wound
Worry about bleeding and compartment syndrome???
Main concern is blood vessel damage (popliteal artery)
Examine pulses distally to proximally (dorsalis pedis posterior tibial popliteal)
Treatment open reduction and internal fixation (IM rod and traction)
N.B. GSW dont tend to have a lot of infection
Pancreatic Cancer
Function of Pancreas
Endocrine: secretion of insulin, glucagon, somatostatin
Exocrine: trypsin, lipase, amyplase (which aid in digestion)
Tumours of the Pancreas
Adenocarcinoma (ducts arise from exocrine glands)
Insulinoma (islet cell tumour)
Glucagonoma (islet cell tumour)
Somatostatinoma (islet cell tumour)
Gastrinoma of the pancreas
Benign tumours:
o Cystadenoma (cystic or mucinous)
o Pseudopapillary tumours
Presentation of Adenocarcinoma
Weight loss
Jaundice
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o In head of pancreas
o Tail tumours do not have jaundiceusually have distant metastases with severe weight
loss
Yellowing of skin and sclera
Pruritis
Pale stools and dark urine
Steatorrhea (late feature)
Abdominal pain (mild)
Back pain (retroperitoneal location)
Examination
General:- jaundice, weight loss (cachexia), pale mucous membranes (anemia of chronic disease),
dehydration, supraclavicular lymphadenopathy
Abdomen:-
o May feel palpable mass
o RUQ mass (smooth, globular palpable gall bladder) (Courvosiers law in presence
of painless jaundice, a palpable gallbladder is not due to stones)
o Empyema palpable gallbladder, painful, no jaundice
o Obstructive jaundice with palpable gallbladder, painful, no jaundice
Investigations
Urinalysis:- increased bilirubin, decreased urobilinogen
Bloods:- FBC (WBC), U&Es (dehydration), LFTs (ALT, AST mildly increased, ALP, GGT
increased, direct bilirubin increased), PT, PTT (malabsorption of Vitamin K bile needed to
absorb Vitamin K), amylase (normal in cancer)
Radiology:- USS (pre- vs post-hepatic jaundice ducts), CT abdomen, MRCP/ERCP (biopsy from
ERCP brushings), percutaneous transhepatic cholangiography
Staging
Metastases or local invasion
10% or less respond to chemotherapy (Gencitabin)
Not a candidate for surgery palliative treatment
Palliative Treatment
Stenting across tumour using ERCP (to relieve jaundice)
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Growth of tumour blocks the third part of the duodenum stent with gastro-jejunostomy
Double bypass of CBD and duodenum
5% may be curative Whipples procedure
Preparation For Surgery If You Have Obstructive Jaundice
Hydration status hepatorenal syndrome (combined hepatic and renal failure post-op). Give
mannitol IV preop to flush kidneys
Normalize clotting indices (Vitamin K IV/IM or FFP)
ECG/CXR
Prophylactic antibiotics (to prevent infection)
DVT prophylaxis (pancreatic cancer migratory thrombophlebitis procoagulable state)
Pancreatitis
Causes
GET SMASHED
Drugs (steroids, sulfonylureas, Metformin, OCP, hyperlipidemia, increased Calcium
Clinical Examination
Epigastric pain radiating to the back, relieved by sitting forwards
Vomiting
Jaundice
Dehydration
CVS: shock (fluid loss, inflammatory mediators)
Respiratory: Left-sided pleural effusion
Abdomen: epigastric tenderness, rebound, guarding, Grey-Turners sign, Cullens sign (severe
pancreatitis)
Investigations
Urinalysis bilirubin, 12 hour urinary amylase (spot urine is useless)
Bloods FBC, U&Es, serum amylase (3x upper limit of normal (120-130) therefore > 400 is
pancreatitis or a salivary gland tumour), lipase, LFTs
Imaging Abdominal USS (looking for gallstonesdoesnt image pancreas very well. If there are
no gallstones, suspect pancreatitis epigastric pain)
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Management
IVF
Pain analgesia (Narcotic, NSAIDdont use Morphine, it causes a spasm of the sphincter of
Oddi)
Rest pancreas: NPO, NGT to decompress stomach
Where to manage? Depends on severity (Ransons Criteria takes 48 hours to complete)
o Mild < 3 ward
o Severe > 3 HDU/ICU
Nutritional enteral or parenteral
o Jejunostomy
o Nasojejunal tube
Antibiotics prophylaxis for severe pancreatitis
o Meropenem (best penetration) or Imipenem
Complications
Pseudocyst leaking of enzymes into lesser sac enclosed in fibrotic tissue
o Treatment: resolve if smallwait until they mature
Pancreatic abscess surgery of debridement
Infective pancreatic necrosis
Acute renal failure
ARDS
Upper GI bleed (splenic vein thrombosis)
Pancreatic ascites
Pancreatic fistula
Benign Breast Disease
Nipple Discharge
History: duration, colour, lactating, bilateral, number of ducts (benign/physiological,
prolactinoma)
One duct discharging:
o
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o Mammary duct ectasia (most common, green or variable)
Scenario: Brown discharge expressed from one duct. What is the management?:
o Aspirate for cytology
o Mammogram
o Ductogram (inject dye into duct system may visualize papilloma)
Surgery: Microdochectomy and histology
o Local anesthesia
o Cannulate duct with fine metal instrument
o Periareolar incision and removal of duct
Lumps
History: breast cancer
o Age > 35 years
o Family history of cancer
o Time and change in size of lump
o Painless
Risk factors:
o N.B. not OCP use or ionizing radiation (increased risk of thyroid cancernot risk
factors for breast cancer)
o Nulliparity
o Age of first child (ideally < 20 years)
o Family history of breast cancer
o HRT (e.g. Tamoxifen)
o Early menarche
o Late menopause
o Genetics (BRCA-1 or BRCA-2)
Inspection:
o Discharge, tethering, peau dorange, asymmetry
o Axillary nodes, supraclavicular nodes
Differentials:
o Fibroademona: firm, well-circumscribed, +/- lobulations, smooth surface, highly mobile
o Breast cancer: firm, hard, may be mobile, not well circumscribed (irregular borders)
o Cysts: firm, well-circumscribed, mobile (not as mobile as a fibroadenoma), multiple,
fluctuant
Scenario #1: 16 year old with lump in right breast for 4 months. The lump is 3cm and is firm,
lobulated and mobile
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o Diagnosis: fibroadenoma
o Investigations: FNAC, ultrasound
o Treatment: excision (+ histological confirmation)
Scenario #2: 16 year old with lump. On examination the lump is fluctuant
o Diagnosis: cyst
o Investigations: USS (confirms that it is a cyst)
o Management: aspirate the cyst (+ send for cytology)
o After aspiration, there is a risk of recurrence. If there is recurrence, offer excision
Scenario #3: 30 year old with lump in breast. No risk factors. Had for few months. Firm lump
in right upper outer quadrant, mobile, no axillary nodes
o Investigations: core needle biopsy (fibrocystic change may not be representative),
excisional biopsy: fibrocystic change, USS: multiple
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o Management of patient with previous excision biopsy, +ve margins DCIS
o Treatment: all lumps must be excised as there is a risk of developing cancer
Wide excision
Simple mastectomy
LCIS:
o Incidental finding no lump
o High risk of breast cancer
o Surgery: bilateral mastectomy
o Cancer: IDC
4