Académique Documents
Professionnel Documents
Culture Documents
1
4 86
7 86
1. TRAUMA & PERIOPERATIVE CARE 8 5. OESOPHAGEAL DISEASES 87
10 91
1. ADVANCED TRAUMA LIFE SUPPORT 13 1. ANATOMY OF THE OESOPHAGUS 96
2. ABDOMINAL TRAUMA 14 2. PHYSIOLOGY OF SWALLOWING 100
3. CARDIOTHORACIC TRAUMA 18 3. APPROACH TO DYSPHAGIA 101
4. NEUROSURGICAL TRAUMA 21 4. OESOPHAGEAL CANCER
5. MUSCULOSKELETAL TRAUMA 5. GASTRO-OESOPHAGEAL REFLUX DISEASE
6. POST-OPERATIVE COMPLICATIONS 6. BARRETT’S OESOPHAGUS
7. SHOCK 7. ACHALASIA
102
8. PERIOPERATIVE CARE
28 6. UPPER GIT 105
2. LUMPS & BUMPS 34 108
37 1. APPROACH TO BLEEDING UPPER GIT 112
1. HERNIA 40 2. VARICEAL BLEEDING
2. SCROTAL SWELLINGS 41 3. PEPTIC ULCER DISEASE
3. APPROACH TO LUMPS & BUMPS 42 4. GASTRIC CANCER
4. LIPOMA 44 116
5. SEBACEOUS CYST 46 7. LOWER GIT & COLORECTAL DISEASES 118
6. GANGLION 48 130
7. BASAL CELL CARCINOMA 52 1. APPROACH TO BLEEDING LOWER GIT 134
8. SQUAMOUS CELL CARCINOMA 54 2. COLORECTAL CANCER
9. MALIGNANT MELANOMA 55 3. STOMAS
137
10. NEUROFIBROMA 56 4. DIVERTICULAR DISEASE
11. DERMOID CYST 58 5. INFLAMMATORY BOWEL DISEASE (CROHN’S
12. SEBORRHOEIC KERATOSIS DISEASE, ULCERATIVE COLITIS)
59
13. HAEMANGIOMA
60 140
14. PYOGENIC GRANULOMA 8. ANAL & PERIANAL DISORDERS
15. PAPILLOMA 60 142
16. KERATOCANTHOMA 61 1. HAEMORRHOIDS 144
17. KELOID (HYPERTROPHIC SCAR) 61 2. ANAL FISTULA
18. KAPOSI’S SARCOMA 62 3. ANAL FISSURES
19. FIBROSARCOMA 63
20. PYODERMA GANGRENOSUM 9. LIVER DISEASES 145
21. RADIOTHERAPY MARKS 145
1. ANATOMY OF THE LIVER 145
3. SURGICAL INSTRUMENTS & PROCEDURES 64 2. CAUSES OF HEPATOMEGALY 146
65 3. CAUSES FOR A LIVER NODULE ON IMAGING 152
1. DRAINS 67 4. HEPATOCELLULAR CARCINOMA 152
2. CENTRAL VENOUS PRESSURE LINE 5. LIVER METASTASES 153
68
3. NASOGASTRIC TUBE 6. LIVER HAEMANGIOMA 153
4. TRACHEOSTOMY 7. SIMPLE LIVER CYSTS
70 154
5. SENGSTAKEN-BLAKEMORE TUBE (MINNESOTA 8. HEPATIC ABSCESS (PYOGENIC / AMOEBIC)
TUBE) 71 9. ASCITES
6. URINARY CATHETERISATION 72
7. CHEST TUBE 10. PANCREATIC DISEASES
155
4. ABDOMINAL SURGICAL EMERGENCIES 1. ACUTE PANCREATITIS 161
74 2. CHRONIC PANCREATITIS 162
1. APPROACH TO ABDOMINAL PAIN 75 3. PANCREATIC CANCER
2. APPROACH TO ABDOMINAL MASSES
3. INTESTINAL OBSTRUCTION (& MECKEL’S 76
DIVERTICULUM) 82
4. ISCHAEMIC BOWEL 84
5. ACUTE APPENDICITIS
2
166 203
167 203
11. BILIARY TRACT DISEASES 169 14. SALIVARY GLAND SWELLINGS 203
173 204
1. CAUSES OF JAUNDICE 175 1. ANATOMY OF THE PAROTID GLAND 205
2. APPROACH TO OBSTRUCTIVE JAUNDICE 175 2. ANATOMY OF THE SUBMANDIBULAR GLAND 206
3. GALLSTONE DISEASE 176 3. ANATOMY OF THE SUBLINGUAL GLAND
4. ACUTE CHOLECYSTITIS 4. APPROACH TO SALIVARY GLAND SWELLINGS
178
5. GALLBLADDER CANCER 5. SIALOLITHIASIS
178
6. CHOLEDOCHOLITHIASIS 6. SALIVARY GLAND TUMOURS
180 208
7. CHOLANGITIS
8. MIRIZZI’S SYNDROME 15. THYROID DISEASES 209
9. RECURRENT PYOGENIC CHOLANGITIS
10. CHOLANGIOCARCINOMA 1. ANATOMY OF THE THYROID GLAND 211
182 2. APPROACH TO THYROID PROBLEMS 212
12. BREAST DISEASES 182 3. APPROACH TO THE SOLITARY THYROID 215
183 NODULE
1. ANATOMY OF THE BREAST 188 4. THYROID CANCERS
2. PRESENTATION OF BREAST DISEASES 189 5. SURGERY IN BENIGN THYROID DISEASE
3. APPROACH TO A BREAST LUMP 195 216
4. APPROACH TO NIPPLE DISCHARGE 195 16. PERIPHERAL ARTERIAL DISEASES 217
5. BREAST CANCER 222
6. PAGET’S DISEASE OF THE NIPPLE 1. ANATOMY OF THE LOWER LIMB ARTERIES
7. GYNAECOMASTIA 2. ACUTE LIMB ISCHAEMIA 228
3. CHRONIC LIMB ISCHAEMIA
196
13. NECK MASSES
197 17. ABDOMINAL AORTIC ANEURYSM
1. ANATOMY OF THE NECK 197
2. THYROGLOSSAL CYST 197 18. PERIPHERAL VENOUS DISEASES
3. DERMOID CYST 198 230
4. PLUNGING RANULA 199 1. ANATOMY OF THE VENOUS SYSTEM OF THE 232
5. BRANCHIAL CYST/FISTULA 199 LOWER LIMB 233
6. CHEMODECTOMA 200 2. CHRONIC VENOUS INSUFFICIENCY 236
7. PHARYNGEAL POUCH 200 3. VARICOSE VEINS
8. CYSTIC HYGROMA 200 4. VENOUS ULCERS
9. CERVICAL RIB 201
10. NEUROMA/SCHWANNOMA 19. UROLOGICAL DISEASES 238
11. CERVICAL LYMPHADENOPATHY 241
1. APPROACH TO HAEMATURIA
244
2. RENAL CELL CARCINOMA
3. BLADDER TRANSITIONAL CELL CARCINOMA 246
4. UROLITHIASIS 249
5. APPROACH TO ACUTE RETENTION OF URINE 252
6. BENIGN PROSTATIC HYPERPLASIA 256
7. PROSTATIC CANCER
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1. TRAUMA & PERIOPERATIVE CARE
Classes of haemorrhagic shock - gradual transition from one stage to the next
I II III IV
Bld loss : Amt (ml) <750 750-1500 1500-2000 >2000
% <15 15-30 30-40 >40
Ht rate <100 >100 >120 >140
BP Normal Normal/min low Decreased Critical
Cap refill Normal Prolonged Prolonged Prolonged
Resp rate 14-20 20-30 30-40 >35
Ur output (ml/h) >30 20-30 5-15 Oliguric-anuric
Anxious- Confused-
Mental state Sl anxious Mild anxiety
confused lethargic
Crystalloid +
Fluid replacement Crystalloid Crystalloid Blood
blood
Rapid and shallow respirations due to sympathetic nervous system stimulation and acidosis.
Hypothermia due to decreased perfusion and evaporation of sweat.
Some people have only minimal symptoms such as confusion and weakness.
Those on B-blockers, those who are athletic and in 30% of cases with shock due to intra abdominal
bleeding may have a normal or slow heart rate.
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Management
Sources of bleeding apply direct pressure or pressure on proximal pressure point
Suspect occult bleeding e.g. intraperitoneal, retroperitoneal (pelvic #), soft tissue (long bone #)
Venous access – large bore, proximal veins
Restore circulatory volume with rapid crystalloid infusion – Ringer’s lactate
Blood transfusion if not responsive to fluids or response is transient
Reassess frequently
DISABILITY Glasgow coma scale
Eye (E4) Verbal (V5) Motor (M6)
Spontaneous opening 4 Oriented speech 5Obeys 6
Opens to voice 3 Confused 4Purposeful 5
Opens to pain 2 Inappropriate 3Withdraws 4
No response 1 Incomprehensible 2Flexion response 3
No verbal response 1Extension response 2
No response 1
GCS: > 13 (minor); 8-13 (moderate); < 8 (severe)
AVPU score: Alert, Verbal stimuli (responds to), Pain stimuli, Unresponsive
Pupillary reactivity
Call for neurosurgical consult as indicated
EXPOSURE Remove all clothes
Check everywhere for injuries (log-roll to look at the back)
Prevent hypothermia
ADJUNCTS Monitoring
Vital signs – BP, pulse rate, saturation (pulse oximeter)
ECG monitoring
Arterial blood gas
Diagnostic tools
Screening X-ray films (trauma series): CXR, AP pelvis, lateral C-spine
Focused abdominal sonography in trauma (FAST)
Diagnostic peritoneal lavage
Urinary catheter
Functions: decompress bladder, measurement of urinary output
Caution in urethral injury: blood at urethral meatus, perineal ecchymosis/haematoma, high-riding
prostate
SECONDARY SURVEY
When to do secondary survey: Primary survey and resuscitation completed
ABCDEs reassessed
Vital functions returning to normal i.e. no need for active resuscitation at the moment
5
COMPLETE HEAD-TO- Head
TOE EXAMINATION Complete neurological examination
GCS or AVPU assessment
Comprehensive examination of eyes and ears for base of skull fractures
Caution: unconscious patient; periorbital oedema; occluded auditory canal
Maxillofacial
Bony crepitus/deformity, palpable deformity
Comprehensive oral/dental examination
Caution: potential airway obstruction in maxillofacial injury; cribriform plate # with CSF
rhinorrhoea do not insert nasogastric tube
Cervical spine
Palpate for tenderness, any step deformity
Complete neurological examination
C-spine imaging
Caution: Injury above clavicles; altered consciousness (cannot assess accurately); other severe,
painful injury (distracts from cervical spine pain)
Chest
Inspect, palpate, percuss, auscultate
Re-evaluate frequently
Look at CXR
Caution: missed injury; increase in chest tube drainage
Abdomen
Inspect, palpate, percuss, auscultate
Abrasions and ecchymosis – “seat-belt sign”
Lower rib fractures liver and spleen injury
Re-evaluate frequently
Special studies: FAST, DPL (diagnostic peritoneal lavage), CT scan
Caution: hollow viscus and retroperitoneal injuries; excessive pelvic manipulation
Perineum
Contusions, haematomas, lacerations
Urethral blood
DRE: Sphincter tone, high-riding prostate, pelvic #; rectal wall integrity; blood
Vaginal examination: blood, lacerations
Musculoskeletal – extremities
Contusion, deformity
Pain, Perfusion, Neurovascular status
X-rays as appropriate
Caution: potential blood loss is high in certain injuries (e.g. pelvic fracture, femoral shaft
fracture); missed fractures; soft-tissue or ligamentous injuries; examine patient’s back
ADJUNCTS & SPECIAL As required according to suspicion, but should not delay transfer
DX TESTS
FREQUENT RE- Have a high index of suspicion for injuries to avoid missing them
EVALUATION Frequent re-evaluation & continuous monitoring rapidly recognise when pt is deteriorating
PAIN MX Intravenous analgesia as appropriate
6
2. ABDOMINAL TRAUMA
7
3. CARDIOTHORACIC TRAUMA
There are 5 clinical scenarios in chest trauma where bedside procedures are lifesaving: cardiac tamponade, airway
obstruction, flail chest, haemothorax, and pneumothorax.
Diagnostic clues
Enlarged cardiac shadow in CXR (globular heart – very rarely seen)
Small ECG voltages, electrical alternans = alternation of QRS complex amplitude or axis
between beats.
Management
Aggressive fluid resuscitation – helps maintain cardiac output and buys time
Pericardiocentesis: 2D-echo guided or ECG lead-guided (Stop inserting needle when an abrupt
change in the ECG waveform is noted. If the ECG waveform shows an injury pattern (ST segment
elevation), slowly withdraw the needle until the pattern returns to normal, as this change in waveform
suggests that the spinal needle is in direct contact with the myocardium)
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AIRWAY Chin lift or jaw thrust
OBSTRUCTION Remove any foreign body manually, suction blood/secretions
Definitive airway – ETT, cricothyroidotomy, tracheostomy
FLAIL CHEST When 2 or more ribs are fractured at 2 points forming a flail segment that moves
paradoxically with breathing.
Results in hypoxaemia mainly due to underlying pulmonary contusion, contributed to by pain
with restricted chest wall movement.
Management:
Ensure adequate oxygenation and ventilation; judicious fluid therapy (avoid fluid overload);
adequate intravenous analgesia
Consider mechanical ventilation in high risk patients: shock, severe head injury, previous
pulmonary disease, fracture of >8 ribs, age > 65, >3 associated injuries
HAEMOTHORAX Chest tube insertion in the triangle of safety (bound by the lateral border of the pectoralis
major medially, a line just anterior to the mid-axillary line laterally, and the upper border of the
fifth rib inferiorly)
Be wary of sudden cessation of chest tube drainage as tube can get blocked by clot
If blood >1500mls massive haemothorax, call urgent cardiothoracic consult
PNEUMOTHORAX
(TENSION/ OPEN)
Tension pneumothorax = develops when air is trapped in the pleural cavity under positive
pressure, displacing mediastinal structures and compromising cardiopulmonary function
It is a clinical diagnosis (CXR will only delay treatment, and may cause death) – signs of
pneumothorax, hypotension, neck vein distension, severe respiratory distress
Decreased venous return caused by compression of the relatively thin walls of the atria
impairs cardiac function. The inferior vena cava is thought to be the first to kink and restrict
blood flow back to the heart. It is most evident in trauma patients who may be hypovolemic
with reduced venous blood return to the heart.
Immediate needle thoracotomy in second intercostal space in mid-clavicular line
Followed by chest tube insertion
Open pneumothorax occurs in a large chest wall defect with equilibration between intrathoracic
and atmospheric pressure, producing a “sucking chest wound”.
Cover defect with a sterile dressing, taping it down on 3 sides to produce a flutter-valve effect,
letting air out of the pleural cavity but not back in
Insert chest tube (not through the wound)
9
4. NEUROSURGICAL TRAUMA
AIM: prevention of secondary brain injury (from hypotension, hypoxaemia, increased ICP etc) since neuronal death is irreversible.
PATHOLOGIES
Concussion Physiological dysfunction without anatomical or radiological abnormality (Physiological dysfunction is the first
step towards cell death, but is reversible if no further insult occurs)
Usually recovers in 2-3 hours
Contusion Small haematoma <1cm
Intracranial Extradural haemorrhage Lens-shaped haematoma outside the dura (between skull & dura)
haemorrhage Pathology: expanding space-occupying lesion
20% of patients with EDH are alert and well; underlying brain is minimally
damaged, thus drainage gives good results
Crescent shaped haematoma under the dura (between dura & arachnoid)
Subdural haemorrhage More severe than EDH (usu due to nature of injury that causes SDH to
occur – associated with higher impact, thus brain has other injuries)
Most often caused by head injury, when rapidly changing velocities within the
skull may stretch and tear small bridging veins
Generally result from shearing injuries due to various rotational or linear
forces (e.g. shaken baby syndrome, in which similar shearing forces
classically cause intra- and pre-retinal hemorrhages)
Pathology: underlying brain damage in addition to expanding SOL
Removal of blood does not solve brain damage poorer results
Traumatic subarachnoid Star shaped appearance (cisterns)
haemorrhage Usually only small amount of blood conservative tx sufficient
10
PATHOPHYSIOLOGY
Monroe- The CNS & its contents (brain, CSF, blood) are enclosed in a rigid space whose total volume tends to
Kellie remain constant increase in the volume of one component will elevate pressure and decrease the
doctrine volume of one of the other elements
Compensatory mechanisms:
Hyperventilation vasoconstriction of cerebral vessels due to pCO2 blood volume
CSF pushed into spinal canal (but limited volume available)
Removal of any reversible cause of raised ICP will improve cerebral perfusion
Fixed dilated Constrictor fibres to the pupil run in the oculomotor nerve, which exits the brainstem at the upper
pupil midbrain – nerve fibres lie just under the tentorium
Uncus of the temporal lobe sits on the tentorium
In raised ICP, the uncus herniates over the edge of the tentorium, compressing the fibres of the
oculomotor nerve just below
Thus a fixed dilated pupil occurs on the side of the compression due to unopposed sympathetic
supply (dilates the pupil)
Cushing’s A triad of: Widened pulse pressure (HTN)
reflex Irregular breathing (Cheyne-Stokes breathing)
Bradycardia
From Monroe-Kellie doctrine, MAP maintains cerebral perfusion pressure when ICP is raised.
Increase in mean arterial pressure achieved by sympathetic overdrive:
a) Increased heart rate
b) Increased contractility
c) Increased vasoconstriction – increased total peripheral resistance
(a) and (b) increase cardiac output increased BP; (c) increases BP
MANAGEMENT
Assessment
3 important parameters: ABCs, GCS, pupil size
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Severe head injury Must scan to look for reversible causes of raised ICP but stabilise patient first
12
5. MUSCULOSKELETAL TRAUMA
GENERAL POINTS
Extremity trauma tends not to be life-threatening
But occult blood loss can occur in large volumes esp in certain injuries – pelvic # (up to 3L), femoral shaft # (2L)
Need to have high level of suspicion and treat with urgency
Look out for any tachycardia, early signs of shock
Prepare to resuscitate patient
Physical examination
Any limb deformity (can result in kinking of vessels)?
Any joint instability (dislocation of a joint can result in intimal tear in the major vessel running
across it, with thrombosis and occlusion)?
Skin colour/temperature
Post-reduction tibial pulse in knee dislocation – if still absent, do an urgent angiogram!
SOFT TISSUE Types
INJURIES Open: laceration, abrasion
Crushing
Degloving: open or closed
Closed
Wound care
Swabs of the wounds for culture and sensitivity
IV antibiotic prophylaxis
Tetanus toxoid cover
Photograph wound (to prevent re-opening of wound by every doctor that comes to see pt)
Betadine (povidone-iodine) dressing
In OT: generous debridement, irrigation (within 4-8 hours, especially in open fractures),
fracture stabilisation (internal or external fixation depending on Gustilo classification)
Leave wound OPEN
MANAGEMENT Recognise fracture and/or dislocation
OF FRACTURES Complete neurovascular examination of the limb involved before reduction
Appropriate X-rays (at least 2 planes)
Analgesia
Correction of deformity
Temporary immobilisation – backslab, malleable splint
Neurovascular examination; examine for compartment syndrome
Circulation chart
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OPEN FRACTURES
Definition: communication between the # or fracture haematoma and the external environment
Gustilo-Andersen classification
Type I <1cm AND clean
Type II >1cm AND no extensive soft tissue damage, avulsions or flaps
Type IIIA Extensive soft tissue damage, avulsions or flaps but adequate soft tissue
coverage of bone OR High-energy trauma cause regardless of size of wound
Type IIIB Extensive soft tissue loss with periosteal stripping and exposure of bone.
Massive contamination common.
Type IIIC Arterial injury requiring repair
Surgery involves
Generous debridement of the wound with irrigation to decrease bacterial load
Treat any soft-tissue injuries
Stabilise fracture – usually using external fixator
General or specific?
Immediate, early or late?
Local or systemic?
IMMEDIATE Local
(<1 hour post-op) Damage to surrounding structures
Primary haemorrhage (either starting during surgery or following post-op in BP)
Replace blood loss and may require return to theatre to re-explore wound
Systemic
Basal atelectasis (collapse of alveoli):
bronchial secretions post-op & patient does not breathe deeply due to pain
Tx: chest physiotherapy, incentive spirometry
Shock: due to blood loss, or inadequate fluid replacement peri-operatively
AMI, pulmonary embolism
EARLY Local
(first 24-48 hours Pain, hemorrhage
post-op)
Systemic
Atelectasis (commonest cause of mild pyrexia in first 48hr)
Shock, AMI, PE
Nausea & vomiting (analgesia/anaesthesia induced)
Acute confusion: dehydration or sepsis (post-op confusion seen in 40%)
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LATE Local
(between 48 hours Post-op paralytic ileus
to 1 month post-op) Wound or anastomotic dehiscence (POD 7 – 10)
Serosanguinous exudate
Tx: Analgesia, sterile wound dressing, fluid resuscitation, resuture under GA in OT
Mortality up to 30%
Post-op wound infection (usu within 1st week post-op)
Pain, redness, swelling, discharge, usually due to skin staphylococci
Incisional hernia
10-15% of abdominal wounds
Usu asymptomatic, but if painful, consider strangulation (uncommon due to wide neck)
RF: Obesity, poor muscle tone (old age), (increased intra-abdominal pressure (chronic
cough, straining from constipation), wound infection, multiple use of same incision site
Tx: Surgical repair of hernia if strangulated or if enlarging
Bowel obstruction due to adhesions
Fistula formation
Secondary haemorrhage: often as a result of infection (usu 1-2wk post-op)
Systemic
Fever:
Wind (atelectasis), Water (UTI), Walking (DVT/PE), Wound (infxn), Wonder drug (drug fever)
Infections (day 3-5): phlebitis, pneumonia, UTI, abscesses (subphrenic, pelvic)
Acute confusion: exclude dehydration & sepsis
DVT & PE (day 5-7)
POST-OP HAEMORRHAGE
Management
FBC (plt), PT/PTT, GXM & order blood
Give protamine if heparin was used
Give FFP / platelet concentrates if clotting screen abnormal
Consider surgical re-exploration
LATE Usually due to infection damaging vessels at the operation site
Occurs several
days after surgery Management
Treat infection and consider exploratory surgery
15
DVT/PE
16
Prophylaxis/ Treatment Non-pharmacological
Use of inflatable calf pumps intra-operatively in patients undergoing long operations
Early ambulation post surgery
Thromboembolic deterrent (TED) stockings/ intermittent pneumatic leg compression
Pharmacological
Unfractionated heparin or LMW heparin – acute setting
Unfractionated heparin
Potentiates effect of anti-thrombin III, inactivates thrombin (PTT )
Onset: immediate for IV; 30 mins subcutaneously
Efficacy monitored using aPTT
Antidote: protamine sulphate
Side effects: thrombocytopaenia
Surgical
IVC filter (permanent or temporary: remove after 2 weeks of anti-coagulation)
Indications: History of recurrent DVT/PE
Free floating thombus seen on duplex scan
Patient not suitable for anti-coagulation e.g. up to 7 days post-op
Allergy to anti-coagulation
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7. SHOCK
Shock = inadequate tissue & organ perfusion to meet metabolic demands cellular hypoxia
S/S: BP, urine output, tachycardia, diaphoresis, AMS
TYPES OF SHOCK
GENERAL MANAGEMENT
SPECIFIC MANAGEMENT
HYPOVOLAEMIC FBC – Hct (but inaccurate marker of acute blood loss - Hct in alcoholic binge from dieresis)
SHOCK GXM 6 units
U/E/Cr
Trop T (Cardiac enzymes)
Coagulation profile with DIVC screen (PT/PTT, D-dimer)
ABG – metabolic acidosis, lactate, base deficits = poor prognostic factor
UPT – r/o ectopic pregnancy (ask for LMP)
Examine the abdomen for any pulsatile AAA
Fluid resus: 1L crystalloid fast infusion over 1 hr
Assess response
Subsequent colloid or whole blood infusion
CVP line insertion – to guide fluid resus
CARDIOGENIC ECG, Trop T & cardiac enzymes
SHOCK Manage accordingly to cause – refer Emed book
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OBSTRUCTIVE Tension Pneumothorax
SHOCK Decompression: insert 14G cannula over 2nd intercostals space in mid-clavicular line
Cardiac Tamponade
IV fluid bolus 500ml N/S
IV dopamine infusion 5 g/kg/min
Prepare for pericardiocentesis
Pulmonary Embolism
FBC, GXM x 6 units, U/E/Cr, D-dimer
ABG: PaO2 & N/ PaCO2, widened alveolo-arterial PO2 gradient (AaPO2 >20mmHg)
ECG
CXR (Exclude Ddx – pneumothorax, pneumonia, heart failure, tumour, rib #, pleural effusion, collapse)
Pulmonary angiogram (gold standard)
Pain relieve – use opioids with caution (resp depression)
Fluid resus & inotropic support if haemodynamically unstable
Anticoagulation:
IV heparin 5000U bolus OR subcut fraxiparine (0.4ml <50kg, 0.5ml 50-65 kg, 0.6ml >65kg)
Convert to oral warfarin later
Thrombolysis: intra pulm arterial urokinase for 12-24hrs
Surgical: complete IV ligation or partial caval interruption
NEUROGENIC Trauma – site, mechanism, force
SHOCK Neuro exam, DRE – document initial neurological deficits
Immobilize spine in neutral position
C-spine X-ray (AP & lat) – ensure visualization up to C7/T1 junction
Swimmer’s view (visualize C7/T1 jn) & open mouth view (visualize C1/2 injury)
Thoracic & lumbar spine X-ray (AP & lat)
CT scan
MRI later
Titrate fluid resus with urine output
vasopressors if BP does not respond to fluid challenge
IV methyl Prednisolone 30 mg/kg over 15mins, followed by 5.4mg/kg/h for nxt 23 hrs
Indications – non-penetrating spinal cord injury & w/in 8 hrs of injury
Contraindications: <13YO
Pregnancy
Mild injury of the cauda equina / nerve root
Abdominal trauma present
Major life-threatening morbidity
Refer Ortho / NeuroSx
SEPTIC SHOCK SIRS = 2 of the following present: Temp >38 or <36oC
(SIRS + source of HR > 90bpm
sepsis + shock) RR > 20 breaths/min OR PaCO2<32mmHg
WCC>12000/mm3, <4000/mm3,or >10% immature forms
Identify site of infxn – UTI (indwelling cathether), gallbladder dz, peritonitis, pneumonia,
appendicitis, immunocompromised state
FBC, U/E/Cr, DIVC screen (PT/PTT, fibrinogen, D-dimer), blood C/S, ABG, CXR, ECG,
UFEME and urine C/S)
Rapid infusion 1-2L crystalloids
CVP line insertion
If no response to fluid Rx inotropic support
Noradrenaline (drug of choice) - 1 g/kg/min OR
Dopamine 5-20 g/kg/min
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Empirical Abx:
Immunocompetent w/o 3rd gen cephalosporin (IV ceftriaxone 1g) OR
obvious source Quinolones (ciprofloxacin 200mg)
Immunocompromised w/o Anti-pseudomonal ABx (IV ceftazidime 1g) OR
obvious source Quinolone
PLUS aminoglycoside (Gentamicin 80mg)
Gram-positive (burns, FB / IV cefazolin 2g
lines present) IV vancomycin 1g (if IVDA, indwelling cath, pen allergy)
Anaerobic source (intra- IV metronidazole 500mg
abdo, biliary, female + ceftriazone 1g
genital tract, aspiration + IV gentamicin 80mg
pneumonia)
ANAPHYLACTIC Definitions
SHOCK Urticaria – oedematous & pruritic plaques w pale centre & raised edges
Angioedema – oedema of deeper layers of the skin. Non-pruritic. May be a/w numbness & pain
Anaphylaxis – severe systemic allergic rxn to an Ag. Ppt by abrupt release of chemical
mediators in a previously sensitized patient
Anaphylactoid rxn – resembles anaphylactic rxn, but due to direct histamine release from mast
cells w/o need for prior sensitization
Common causes
Drugs – penicililns & NSAIDS commonest, aspirin, TCM, sulpha drugs
Food – shellfish, egg white, peanuts
Venoms – bees, wasps, hornets
Environment – dust, pollen
Infections – EBV, HBV, coxsackie virus, parasites
Stop Pptant
Stop administration of suspected agent / flick out insect stinger with tongue blade
Gastric lavage & activated charcoal if drug was ingested
Airway
Prepare for intubation or cricothyroidectomy – ENT/Anaesthesia consult
Fluid Rx
2L Hartman’s or N/S bolus
Drug Rx
Adrenaline Normotensive – 0.01ml/kg (max 0.5ml) 1:1000 dilution SC/IM
Hypotensive – 0.1ml/kg (max 5ml) 1:10,000 dilution IV over 5 mins
Glucagon Indications: failure of adrenaline Rx OR if adrenaline is contraindicated
e.g. IHD, severe HPT, pregnancy, -blocker use
0.5-1.0mg IV/IM. Can be repeated once after 30mins
Antihistamines Diphenhydramine 25mg IM/IV
Chlorpheniramine 10mg IM/IV
Promethazine 25mg IM/IV
Cimetidine For persistent symptoms unresponsive to above Rx
200-400mg IV bolus
Nebulised For persistent bronchospasm
bronchodilator Salbutamol 2:2 q20-30mins
Corticosteroids Hydrocortisone 200-300mg IV bolus, q 6hr
20
8. PERIOPERATIVE CARE
INPUT / OUTPUT
Normal daily intake Normal daily output
Water
Diet 2300 ml Urine 1400ml (min obligatory volume = 400ml)
Metbolism 200ml Skin loss 500ml (obligatory diffusion & vaporisation)
Sweating in pyrexia / heat can cause several litres extra loss per day
Lung loss 500ml (obligatory)
Faecal loss 100ml
Sodium
Diet 150 mmol/day Stool 5 mmol/day
(range 50 – 300 mmol) Skin transpiration 5 mmol/day (in absence of sweating)
Urine 140 mmol/day (can fall to 15 mmol/day)
Potassium
Diet 100 mmol/day Stool 10 mmol/day (obligatory)
(range 50 – 200 mmol) Skin < 5 mmol/day
Urine 85 mmol/day (rarely falls below 60 mmol/day)
DAILY REQUIREMENTS
Fluid 100 ml/kg/day
Na 2 mmol/kg/day
K 1-2 mmol/kg/day
21
FLUIDS / MAINTENANCE
Body composition
Total body water = 55% body weight
Extracellular fluid = 20% body weight
Blood volume = 7% body weight
Acute blood loss required to produce shock = 25-30% of blood volume
Children have higher water content Thirsty: 1.5L deficit Insensible losses
(higher metabolic rate, greater surface Tachycardia: 3L deficit o Every 100kcal burned =
area to body weight ratio) Hypotensive: 6L deficit 30ml loss through skin
o Losses 10% for every
Holliday-Segar method: deg of fever > 37°C
1st 10 kg – 100 ml/kg/day (5ml /kg/hr) Sweat
2nd 10 kg – 50 ml/kg/day (2ml /kg/hr) GIT
> 20 kg – 20 ml/kg/day (1ml /kg/hr) Urine (normal = 0.5 – 1 ml/kg/hr)
Blood
Respirators
Amount of required (KCl) infused in divided doses over 24h Sample daily IV fluid regimen
Premixed IV fluids are generally available with 20 or 40 mmol of KCl
per 500ml or 1000ml infusion bags 1L NS + 20 mmol KCl +
If concentrations of KCl > 40 mmol in 500ml are required, they 1L D5W + 20 mmol KCl +
should be given via infusion in the ICU with cardiac monitoring 1L D5W + 20 mmol KCL
Added K is not usually required in the 1st 24-48h after surgery (each bag given over 8 h)
because K is released from damaged cells
Total: 154 mmol Na + 60 mmol K
HCT
22
CVP MONITORING
Pressure in RA
Pressure in PA
Pulmonary capillary wedge pressure
(indirect estimate of LA pressure)
Ohm’s Law:
𝑀𝐴𝑃 − 𝐶𝑉𝑃
𝐶𝑂 = × 80
𝑆𝑉𝑅
VENTILATION
Ventilator settings
Tidal Volume = vol of air in each breath (8-12 cm3 /kg)
Rate = no of breaths delivered per min
FiO2 = amt of O2 delivered (N = 40%; the higher it is , the more O2 damage to the lungs)
PEEP = positive end expiratory pressure (opens alveoli that would otherwise collapse in expiration)
o Normal: 3 – 5 cmH2O (physiologic PEEP)
o Therapeutic PEEP can go up to 10 – 35 cmH2O (but too high impedes venous return to the heart)
23
ACID BASE & ELECTROLYTES
Compensation
Respiratory Acute: PCO2 1 mmHg = [HCO3] 0.1 mmol/L Acute: [HCO3] 1-2 mmol/L for
Acidosis Chronic: PCO2 1 mmHg = [HCO3] 0.4 mmol/L every PCO2 by 10 mmHg
Chronic: [HCO3] 4-5 mmol/L
Respiratory Acute: PCO2 1 mmHg = [HCO3] 0.2 mmol/L for every PCO2 by 10 mmHg
Alkalosis Chronic: PCO2 1mmHg = [HCO3] 0.4 mmol/L
24
Hyponatremia Hypernatremia
Signs Confusion Thirst
Seizures Dehydration
Cardiac failure Confusion
Muscle weakness Coma
Nausea, anorexia Seizures
Causes Diuretics (esp thiazides) Fluid loss w/o water replacement (esp burns)
Water excess Saline excess
Diarrhoea / vomiting Diabetes Insipidus
Intestinal fistula DKA
Cardiac failure / Renal failure Conn’s syndrome
SIADH
Addison’s disease
Treatment Rehydration with appropriate sodium- Encourage oral intake
containing IV fluids IV fluids with low sodium content
Diuretics for cardiac failure
Fluid restriction to 1L per day
Hypokalemia Hyperkalemia
Signs Cardiac arrhythmias Cardiac arrhythmias
Muscle weakness Sudden death
Hypotonia (& GI motility paralytic ileus)
Muscle cramps Tetany
Causes Diarrhoea / vomiting Sampling artefact (haemolysis)
Intestinal fistula Drugs (ACEI, spironolactone, suxamethonium)
Diuretics Digoxin poisoning
Renal tubular failure Massive blood transfusion
Cushing’s / exogenous steroids / ACTH KCl excess
Conn’s syndrome Burns
Metabolic alkalosis Rhabdomyolysis
Tumour lysis
Renal failure
Addison’s disease
Metabolic acidosis
Treatment Oral potassium supplements 1. Calcium gluconate 10% (50-100ml)
KCl added to IV fluids 2. Insulin 20 units
+ 250ml 25% dextrose over 4-6 hrs
3. Diuretics
4. 2 adrenergic agonists
5. Sodium bicarbonate (50 – 100ml)
6. Resin (polystyrene sulfonate sodium)
(every g exchanges 3 mmol of Na for K)
7. Hemodialysis (definitive)
25
NUTRITION
REFEEDING SYNDROME
Gastric emptying one of the last aspects of gut function to recover after an operation/major insult
Risk factors: low BMI, duration of reduced intake, degree of weight loss, electrolyte abnormalities
Feeding should be introduced gradually over 48 – 72 hours (Safe to start feeding at 50% of estimated protein and
calorie requirements and build up to full requirements over a 24 – 48 hour period.)
ENTERAL FEEDING
Start at 20ml/h x 6h, then increase by 20-30ml/h and repeat.
Indications:
Proximal small intestine intact & functional
Stimulation of secretory function does not worsen the condition being treated (e.g. small bowel fistula)
Contraindications:
Complete small bowel obstruction
Inadequately treated shock states (risk of intestinal ischemia)
Severe diarrhoea (slow rate of feeding)
Proximal small intestinal fistula
Severe pancreatitis
Routes:
Nasogastric tube feeding
Nasojejunal or nasoduodenal feeding (when gastric emptying is a problem)
Tube enterostomy
Percutaneous endoscopic gastrostomy
Complications: infection at PEG site, blockage/extrusion/removal, peritonitis, aspiration pneumonia
26
TOTAL PARENTERAL NUTRITION
Provision of all nutritional requirements by the intravenous route alone
Due to high osmolality of the mixture, TPN must be given into a central vein
TPN orders:
24 hr feeding volume 2500ml, rate 100ml/hr
5 days a week: kcal from carbohydrate 2500, kcal from fat 0
2 days a week: kcal from carbohydrate 2000, kcal from fat 500
Indications:
Critical illness: where enteral feeding is not established within 5 days
Obstruction of GIT: proximal small bowel obstruction not immediately relieved
Short bowel syndrome:
o Temporary (before adaptation) in < 3m of functional small intestine
o Permanent in < 1m of functional small intestine
Proximal intestinal fistula: facilitate fistula closure
Refractory inflammatory disease of the GIT (e.g. Crohn’s, UC)
Inability to use the GIT: pancreatitis with pseudocysts/abscess where enteral nutrition is not tolerated
Complications:
Catheter-related
o Mechanical: blockage, central vein thrombosis, migration, fracture, dislodgement
o Infective: exit-site infection, line sepsis, infective endocarditis
Metabolic
o Hyperglycaemia
o Deranged liver function: biliary stasis, enzyme induction from amino acid imbalance and excessive calorie
administration, fat deposition in liver
o Hypoglycaemia (too rapid cessation of glucose infusion)
o Hypertriglyceridemia
o Hyperchloraemic acidosis
27
2. LUMPS & BUMPS
1. HERNIA
Hernia = a protrusion of an organ through an opening in the wall of the cavity in which it is normally contained
Lifetime risk = 2-10%
Causes of abdominal wall weakness
- Congenital – normal (due to piercing structures), or patent processus vaginalis
- Acquired – trauma, surgical incision or disease
Consist of 3 parts:
- Sac: pouch of peritoneum (neck & body)
- Coverings of sac: layers of abdominal wall
- Contents
Types:
1) Inguinal (96%) indirect (85%), direct (15%) or pantaloon (direct & indirect)
2) Femoral (4%) & Richter’s hernia (knuckle of bowel wall is strangulated but lumen is patent)
3) Incisional, Parastomal
4) Umbilical, Epigastric (herniation of extra-peritoneal fat)
5) Rare types: Spigelian (herniation of linea semilunaris: lat. border of rectus), Obturator, Lumbar, Gluteal, Internal, Sliding
(herniation of posterior peritoneum with underlying retroperitoneal structures: caecum, sigmoid, bladder)
28
INGUINAL HERNIA: indirect or direct;
29
Anatomy of inguinal canal
- 4 to 6 cm long oblique passage above the inguinal ligament, from the deep to superficial rings.
- Deep inguinal ring lies in the midpoint of the inguinal LIGAMENT & is formed from a defect in the transversalis fascia.
- Superficial ring is a triangular defect in the aponeurosis of the external oblique.
Boundaries:
Ant. wall: aponeurosis of the
external oblique (reinforced in
lat. third by internal oblique)
Post. wall: transversalis fascia
(reinforced in med. third by
conjoint tendon)
Roof: arching fibres of the int.
oblique & transversus
abdominis before they merge as
conjoint tendon
Floor: inguinal ligament and
lacunar ligament medially
Contents:
Ilioinguinal nerve (L1): supplies
skin over root of penis & upper
part of scrotum or skin over mons
pubis & labia majora
♀: round ligament of the uterus
from uterus to labia majora
♂: transmits spermatic cord from
abdomen to testes
Contents:
3 Arteries:
Testicular artery
Artery to the vas deferens
Cremasteric artery
3 Nerves:
Nerve to cremaster
Autonomic nerves (T10)
Genital br of genitofemoral nerve
3 Others:
Vas deferens
Pampiform venous plexus
Lymphatics
30
Complications
Reducible → Irreducible / Incarcerated → Obstructed → Strangulated
- Irreducible/ Incarcerated hernia: contents of hernial sac cannot be replaced into abdomen
- Obstructed: loop of bowel trapped in hernial sac such that its lumen, but not blood supply, is obstructed (no ischaemia
not unduly tender, but with IO)
- Stangulated: blood supply to trapped bowel is cut off, bowel is dead or dying; 6hrs to gangrene.
(acutely tender with s/s of IO;; exception: Richter’s hernia: segment of bowel is trapped & ischaemic but lumen is patent
no IO)
Management
Non-surgical:
Raised intraabdominal pressure
o Weight loss, change jobs, avoid heavy lifting
o Treat medical conditions causing chronic cough, chronic constipation
Truss: for compression of reducible hernia at deep ring (poor pickup rate)
If obstructed/strangulated: NBM, IV drip, NG tube on suction, IV ABx
Surgical:
Hernioplasty/ Herniorraphy with mesh repair (open or laparoscopic)
o Immediately if suspect incarceration to prevent any bowel perforation
Principles: reduce bowel, ±excise hernia sac, reinforce posterior wall
o Lichtenstein tension-free mesh repair (lightweight, polypropylene mesh insertion & suture)
o Shouldice repair (non-mesh technique: 2 continuous back & forth sutures with permanent suture material)
Complications
o 2o to GA: AMI, CVA
o Immediate to early
1. ARU
2. Bruising , bleeding (testicular, cremasteric, artery to vas deferens, inferior epigastric, femoral arteries)
3. Injury to surrounding structures pain, parasthesia, impotence: spermatic cord (vas deferens,
testicular artery), round ligament, ilioinguinal nerve, nerve to cremaster
o Early
1. Infection of wound/ mesh
2. Haematoma (10%; no cough impulse, non-reducible, hard)
3. Wound dehiscence
4. pain
o Late
1. Chronic post-op pain
2. Recurrence of hernia (<0.5%; incomplete dissection, poor tissue, too early mobilization, uncontrolled co-
morbidities)
3. Ischaemic orchitis & Testicular atrophy from testicular artery damage or from pampiniform plexus
thrombosis
31
APPROACH TO AN INGUINAL HERNIA
1. Groin vs Inguinoscrotal a) groin cough impulse
b) inguinoscrotal 1. cough impulse (may not be present in a large one)
2. cannot get above lump
3. cannot separate from testis
2. Risk factors: Increased intra-abdo pressure: chronic cough, BPH, chronic constipation
Also 4Cs: cirrhosis, heart failure, cancer, catheter (dialysis)
3. Complications a) Obstructed/ Strangulated
b) Spontaneous rupture
c) Involved in peritoneal diseases
4. Patient profile - Indirect: M, young, right, increase intraperitoneal fluid
- Direct: M, old, raised intraabdominal pressure
5. Treatment: a) OPEN hernia repair!!!
b) Lap only if 1. Recurrent, 2. Bilateral (2 types of lap: TEP, TAP)
c) Conservative only if: small, easily reducible, direct hernia
6. Post-op complications a) Immediate: bruise, wound hematoma, scrotal hematoma, ARU, pain
b) Later: mesh infection, recurrence (10% /10years), nerve injury, ischemic orchitis
Don gloves, introduce yourself and explain your intention, then expose the patient
STAND patient up, examine both sides
- Mr X is a ___ who appears comfortable at rest.
- I notice a groin / inguinoscrotal lump.
Squat down and examine!
- Inspect as per a lump: (if unable to see, ask the patient)
1. Is lump above or below the inguinal ligament? Any scrotal lump?
2. Estimate the dimensions of the lump
3. Any skin changes? Previous scars (look hard)?
4. Any lump on the other side?
5. Abdominal distension / visible abdo mass?
- Sir, could you turn head and cough? Look for Visible cough impulse (seen in large inguinoscrotal hernias)
- Sir, is there any pain over the groin area? I am going to feel the lump.
Palpate:
1. Can get above the lump?
2. Can feel testis?
3. Lump: consistency (soft, fluctuant), size, temperature, any tenderness?
4. Sir, could you turn head and cough again? Feel for Palpable cough impulse (bilaterally?)
- Sir, could you reduce the lump for me?
o Reducible: The point of reduction is “above and medial to the pubic tubercle” (superficial ring)
o Incarcerated: The patient is unable to reduce the lump.
Lay the patient supine. (supposing you’re standing on patient’s LEFT)
- Reduce the hernia if patient has not done so.
- Locate the Deep inguinal ring: [vice versa for right side]
o Left hand define pt’s pubic tubercle: from umbilicus down pubic symp. to the left 1st bony prominence
o Right hand define the ASIS
o Left hand to the midpoint of inguinal ligament 2cm above
- Keep pressure on deep ring, ask patient to sit up & support his pelvis, then swing over the bed and stand
32
FEMORAL HERNIA
- Uncommon, but more common in females
- Rarely put up for exams as it is operated quickly;
- Femoral hernia is a marble shaped lump below the inguinal ligament and medial to femoral pulse
o usually irreducible; narrow neck risk of strangulation is high
o Usually does not have a cough impulse
- DDx:
o Skin/ soft tissue: cyst, lipoma
o Vascular masses: saphena varix, femoral aneurysm, inguinal LAD
o Hernia: inguinal hernia, obturator hernia
o Other: psoas bursa, ectopic testis
INCISIONAL HERNIA
- Extrusion of the peritoneum and abdominal contents through a weak scar or wound on the abdominal wall
- Physical examination similar, just add:
o lifting head off the bed to exacerbate hernia
o palpate to determine the size of defect
- Similar complications as any hernia
- Risk factors:
o Pre-op: age, immunocompromised, obese/ distended abdomen, Malignancy,
o Intra-Op: poor technique of wound closure, placement of drains
o Post-op: wound haematoma, wound infx, early mobilization, post-op coughing
- Treatment options:
o Not all should undergo repair due to high risk of wound haematoma, infection, dehiscence and recurrent hernia
o Conservative:
- Offer corset or truss
- Weight loss and control the risk factors leading to
o Surgical:
- Offer if complications of hernia are present
- Control CVS & resp. disease; encourage pre-op wt loss
- Principles: dissect the sac and close the defect using mesh overlapping
33
2. SCROTAL SWELLINGS
ANSWER 4 QUESTIONS:
1. Can you get above the swelling?
2. Can you identify the testis and the epididymis?
3. Is the swelling transilluminable?
4. Is the swelling tender?
Cough impulse
Cannot Reducible
get above Hernia
Testis palpable
swelling Opaque
No cough impulse
Not reducible
Infantile hydrocoele
Testis not palpable
Transilluminable
Chronic haematocoele
Can get Non tender Gumma
above Tumour
swelling Testis not definable from Opaque
Torsion
epididymis
Tender Epididymo-orchitis
Acute haematocoele
Transilluminable Hydrocoele
Non-tender Tumour
swelling of testis
34
HYDROCELE
- Points from examination:
o Very swollen scrotum; uniformly enlarged
o Cannot define testis well; no separable from testis
o Maybe firm, tense or lax
o Maybe transilluminable if acute (less in chronic hydrocele)
o Can get above the mass; the superficial ring is distinct
- Definition of hydrocele:
o Excess accumulation of fluid in processus vaginalis (fold of peritoneum as testis descends; usually patent for
fluid to accumulate)
- Types of 1o hydrocele:
o Vaginal hydrocele:
Only in tunica vaginalis & does not extend into the cord
o Hydrocele of the cord
Mass around the cord; attached distally to the testis
Difficult to distinguish from irreducible inguinoscrotal hernia
May extend up and beyond
o Congenital hydrocele: patent processus vaginalis filled with peritoneal fluid
o Infantile hydrocele: hydrocele of cord and congenital hydrocele
- Types of 2o hydrocele
o From testicular tumours
o From torsion
o From trauma
o From orchitis (any inflm)
- Treatment options:
o Conservative:
Watch & wait or Aspiration [tend to reccumulate]
Must exclude a 2o cause
o Surgical:
Lord’s plication of the sac
Jaboulay’s operation to evert the sac
TESTICULAR TUMOUR
- Points from examination:
o Inseparable form the testis; can get above i
o Hard, nodular, irregular, non tender
o Not transilluminable (but maybe a/w hydrocele)
- DDx:
o Chronic infection with scarring
o Long standing hydrocele with calcification,
- Classiccation:
o Mostly seminomas or teratomas
Seminomas: 30-40YO, normal tumour markers, Rx with RT to paraaortic nodes and CT according to
staging
Teratomas: 20-30YO, AFP/ BHCG raised in 90%, Rx with CT
o Others: embryonal carcinoma, choriocarcinoma, yolk sac tumour, Leydig cell tumours (10% malignant ; a/w
gynaecomastia), Sertoli cell tumour (a/w gynaecomastia), Lymphoma (look for lymphoma elsewhere; poor
prognosis)
- Treatment:
o Staging, excision of whole testis with combination chemotherapy
EPIDIDYMAL CYST
- Points from examination:
o Small mass separate from testis; can get above it
o Firm; maybe loculated; transilluminable if large cyst
- Often multiple in the head of epididymis
- May occur as a complication of vasectomy (spermatoceles)
- Treatment:
o Conservative [mainstay]
o Surgical: if painful, very large or frequent recurrences. Complicated by operative damage and fibrosis of
epididymis subfertility
35
VARICOCELE
- Best noticed on palpating the standing patient
- Points from examination:
o Mass is separate from testis; can get above it
o Feels like a bag of worms; +ve cough impulse
o Not transilluminable
- Definition:
o Dilated, tortuous pampiniform plexus
o 98% on Left side: left vein is more vertical, connects to left renal vein, longer than right one, often lacks a
terminal valve
- Causes:
o Idiopathic in younger males around puberty
o In older men with retroperitoneal disease: RCC
- Treatment options:
o Conservative: risk of infertility
o Surgical:
Transfemoral radiological embolization with coil or sclerosant
Excise the surrounding veins via high retroperitoneum, inguinal or laprascopic approach
36
3. APPROACH TO LUMPS & BUMPS
9. Special tests
- Transillumination [only for large lumps; Use pen torch on one side]
- Pulsatility (only for some sites, e.g. Neck, abdomen)
- Place finger on opposite sides of lump
o Expansile: fingers pushed apart
o Transmitted: Fingers pushed in same direction (usually upwards)
- Slip sign – if lipoma is suspected
- Tends to slip away from the examining finger on gentle pressure
- Compressibility / reducibility [if AVM, haemangioma, hernia suspected]
- Compressible: Disappears on pressure, reappears on release (AVM)
- Reducible: Disappears on pressure, reappears with opposing force (hernia)
- Auscultation – only for certain sites / lesions (e.g. neck, abdomen, etc.)
37
Symptoms and signs Diagnostic significance
1. Lump in or on the skin
Size, shape and surface features Epidermal lesions such as warts usually have a surface abnormality but deeper lesions
Revealed by inspection-is the lesion are usually covered by normal epidermis. A punctum suggests the abnormality arises
smooth-surfaced, irregular, exophytic (i.e. from an epidermal appendage, e.g. epidermal (sebaceous) cyst
projecting out of the surface)?
Depth within the skin Tends to reflect the layer from which lesion is derived and therefore the range of
Superficial and deep attachments. Which differential diagnosis (i.e. epidermis, dermis, hypodermis or deeper)
tissue is the swellingderived from?
Character of the margin A regular shaped, discrete lesion is most likely cystic or encapsulated (e.g. benign
Discreteness, tethering to surrounding tumour). Deep tethering implies origin from deeper structures (e.g. ganglion). Immobility
tissues, three-dimensional shape of overlying epidermis suggests a lesion derived from skin appendage (e.g. epidermal
cyst)
Consistency Soft lesions are usually lipomas or fluid-filled cysts. Most cysts are fluctuant unless filled
Soft, firm, hard, 'indurated', rubbery by semi-solid material (e.g.epidermal cysts), or the cyst is tense (e.g. small ganglion).
Malignant lesions tend to be hard and irregular ('indurated') with an ill-defined margin
due to invasion of surrounding tissue. Bony-hard lesions are either mineralised (e.g.
gouty tophi) or consist of bone (e.g. exostoses)
Pulsatility Pulsatility is usually transmitted from an underlying artery which may simply be tortuous
or may be abnormal (e.g. aneurysm or arteriovenous fistula)
Emptying and refilling Vascular lesions (e.g. venous malformations or haemangiomas) empty or blanch on
pressure and then refill
Transilluminability Lesions filled with clear fluid such as cysts 'light up' when transilluminated
Temperature Excessive warmth implies acute inflammation, e.g. pilonidal abscess
2. Pain, tenderness and discomfort These symptoms often indicate acute inflammation. Pain also develops if a non-
inflammatory lesion becomes inflamed or infected (e.g. inflamed epidermal cyst).
Malignant lesions are usually painless
38
3. Ulceration (i.e. loss of Malignant lesions and keratoacanthomas tend to ulcerate as a result of central necrosis. Surface
epidermal integrity with an breakdown also occurs in arterial or venous insufficiency (e.g. ischaemic leg ulcers), chronic infection
inflamed base formed by (e.g. TB or tropical ulcers) or trauma, particularly in an insensate foot
dermis or deeper tissues)
Character of the ulcer margin Benign ulcers-the margin is only slightly raised by inflammatory oedema. The base lies below the
level of normal skin
Malignant ulcers-these begin as a solid mass of proliferating epidermal cells, the centre of which
eventually becomes necrotic and breaks down. The margin is typically elevated 'rolled' and indurated
by tumour growth and invasion
Behaviour of the ulcer Malignant ulcers expand inexorably (though often slowly), but may go through cycles of breakdown
and healing (often with bleeding)
4. Colour and pigmentation
Normal colour If a lesion is covered by normal-coloured skin then the lesion must lie deeply in the skin (e.g.
epidermal cyst) or deep to the skin (e.g. ganglion)
Red or purple Redness implies increased arterial vascularity, which is most common in inflammatory conditions like
furuncles. Vascular abnormalities which contain a high proportion of arterial blood such as Campbell
de Morgan spots or strawberry naevi are also red, whereas venous disorders such as port-wine stain
are darker. Vascular lesions blanch on pressure and must be distinguished from purpura which does
not
Deeply pigmented Benign naevi (moles) and their malignant counterpart, malignant melanomas, are nearly always
pigmented. Other lesions such as warts, papillomata or seborrhoeic keratoses may become
pigmented secondarily. Hairy pigmented moles are almost never malignant. Rarely, malignant
melanomas may be non-pigmented (amelanotic). New darkening of a pigmented lesion should be
viewed with suspicion as it may indicated malignant change
5. Rapidly developing Keratoacanthoma, warts and pyogenic granuloma may all develop rapidly and eventually regress
lesion spontaneously. When fully developed, these conditions may be difficult to distinguish from
malignancy. Spontaneous regression marks the lesion as benign
6. Multiple, recurrent and In certain rare syndromes, multiple similar lesions develop over a period. Examples include
spreading lesions neurofibromatosis and recurrent lipomata in Dercum's disease. Prolonged or intense sun exposure
predisposes a large area of skin to malignant change. Viral warts may appear in crops. Malignant
melanoma may spread diffusely (superficial spreading melanoma) or produce satellite lesions via
dermal lymphatics
7. Site of the lesion Some skin lesions arise much more commonly in certain areas of the body. The reason may be
anatomical (e.g. pilonidal sinus, external angular dermoid or multiple pilar cysts of the scalp) or
because of exposure to sun (e.g. solar keratoses or basal cell carcinomas of hands and face)
8. Age when lesion noticed Congenital vascular abnormalities such as strawberry naevus or port-wine stain may be present at
birth. Benign pigmented naevi (moles) may be detectable at birth, but only begin to enlarge and
darken after the age of 2
39
4. LIPOMA
Inspection
o Can be single, often multiple
o Usually at neck, trunk
o Hemispherical – may appear lobulated
o Scars Implies recurrent lipoma
Palpation
o Smooth or lobulated on firm pressure – bulging between strands of fibrous tissue)
o Soft / firm (depending on nature of fat)
o Well defined edges (may not be regular; series of curves corresponding to each lobule
o Pseudo-fluctuance if large – lipomas are not liquid; but fat maybe more liquid
o Mobile in all directions (if subcutaneous)
o Positive slip sign; No transilluminance / thrill
o Usually in the subcutaneous tissue. [check attachment skin & muscle]
Background Information
Definition: Benign tumour consisting of mature fat cells (distended with fat from over-activity)
o Malignant change does not occur
o Liposarcomas arise de novo; occur in older age (deeper tissues – retroperitoneal, deep tissues of thigh, subscapular)
Liposarcoma classification
1. Well-differentiated
2. Myxoid, round cell (poorly differentiated myxoid)
3. Pleomorphic liposarcoma
Clinical features
o Can occur at all ages (not common in children)
o Slow-growing, never regress
o May be multiple: lipomatosis (multiple continuous lipomata)
Occur in buttocks / neck
Can cause distortion of subcutaneous tissues.
Treatment
o Non-surgical – watch & wait
o Surgical – If patient wants it removed (Pain / peripheral neuropathy – Dercum’s disease, Cosmesis)
Can be removed under LA
Nuchal lipomas (back of the neck): extremely fibrous septae: difficult to excise
If close to joint: LA may not be possible (may communicate with joint)
40
5. SEBACEOUS CYST
Inspection “Mr. X is a young Chinese gentleman…”
Usually solitary (can be multiple) “On inspection, there is a single hemispherical lump in the
Hemispherical middle of the forehead just above the eyebrows”
Site: face, trunk, back, neck, scalp, shoulders (none on palms / soles) “It measures 1 by 1 cm in diameter”
Variable size ; few mm to 4-5 cm “There is a visible punctum over the lump”
May have bluish discolouration “There are no scars, sinuses, ulceration, or discharge seen,
Punctum in apex: in 50% nor any overlying or surrounding skin changes”
May exhibit plastic deformation on palpation
“On palpation, the overlying skin is not warm. It is non-tender.”
Palpation “The surface is smooth, with clearly-defined margins”
Normal Temperature, non-tender (unless inflamed) “The consistency is firm, and it is non-fluctuant”
Smooth surface “The lump is attached to the overlying skin”
Well-defined margins (lies in subcutaneous fat) “It is mobile in all directions”
Tense consistency, may stretch overlying skin ( plastic deformation) “Slip sign is negative”
Non fluctuant, not transilluminable “I would like to complete my examination by…”
Attached to skin, not attached to deeper structures, mobile in all directions “Looking for other lumps elsewhere”
“My provisional diagnosis is a sebaceous cyst”
Background Information My differentials are: Lipoma / Dermoid cyst
Sometimes considered to be similar to epidermoid cyst
o More accurate terminology: pilar / trichilemmal cysts
2 histological types:
o Epidermal cyst: from infundibular portions of hair follicles
o Trichilemmal cyst: from hair follicle epithelium (most common on scalp), frequently multiple (AD inheritance)
Arise from infundibular parts of hair follicles
Definition: Distension of sebaceous glands with sebum from blockage of opening
Clinical features
o Occur in all age groups, rarely present before adolescence
o Slow growing,– may appear suddenly at adolescence
o May become infected: acutely painful, sudden increase in size
o May spontaneously discharge contents through punctum, regress
Point of fixation & discharge along a hair follicle
Point gets pulled inwards on enlargement of the mass – creates punctum
Sebaceous horn may form from hardening of slow discharge from wide punctum
Sebum slowly exudes, dries and hardens into conical spike Inflamed
Sebum usually washed away – horn results only if overlying skin not washed
Cyst
Can be pulled out of skin
Treatment: excision / curettage along with base + histological assessment
Complications
1. Infection (±discharge)
2. Ulceration
3. Calcification (trichilemmal cyst) (may lead to cyst hardening)
4. Sebaceous horn formation, [hardening of a slow discharge of sebum from a large, central punctum.]
5. Malignant change
Treatment
o Non-surgical: leave alone (if small, asymptomatic).
o Surgical
Complete excision of cyst and contents under LA.
Prevention of recurrence: by removal of elliptical portion of skin containing punctum along the lines of Langers.
If at the angle of jaw, be careful of the facial nerve during operation. Damage to zygomatic branch can cause eye ulceration.
41
6. GANGLION
Inspection
Single; may have ovelying scar [recurrent mass]
Hemispherical, flattened,
Near joint capsules, tendon sheaths (90% on wrist, hand – ventral / dorsal)
Variable (0.5 – 6 cm)
Palpation
Normal temperature, non-tender
Smooth surface with Well-defined margins
May be multilocular
Soft & fluctuant if large > firm consistency if small
Weakly transilluminant. (gelatinous material)
Mobility:
o Should assess mobility in 2 perpendicular planes, then with underlying muscles tensed (less mobile when tensed)
o Not attached to overlying skin (mobile over it)
o Attached to fibrous structures of origin [to joint capsule, tendon sheath, intramuscular septum, fixed when tensed]
Reducibility: may slip between deep structures when pressed (appears falsely reduce into joint)
Request
Other similar lumps
Ask which hand is dominant (may affect management)
Occupation
“Mr. X is a young Chinese gentleman, who is alert and comfortable…”
“On inspection, there is a single hemispherical lump on the dorsum of the left wrist”
“It measures 3 by 2 cm”
“There are no scars, ulcerations, or discharge seen, nor any overlying or surrounding skin changes”
“On palpation, the overlying skin is not warm. It is non-tender”
“The surface is smooth, with clearly-defined margins”
“The consistency is soft, and it is fluctuant”
“The lump is not attached to the overlying skin”
“It appears to be attached to underlying muscle, as it is mobile horizontally but not longitudinally”
“It is transilluminant”
“I would like to complete my examination by…”
“Looking for other similar lumps”
“Asking Mr. X for his hand dominance”
“Taking an occupational history”
“My provisional diagnosis is a ganglion”
My differential is a 1. Bursa
2. Cystic protrusions of synovial cavity of arthritic joints
3. Benign giant cell tumours of flexor shealth
(These 2 are normally soft in consistency. Ganglion is more tense.)
Background Information
Definition: Cystic myxomatous degeneration related to synovial lined cavity [joint capsule or tendon sheath]
Origin controversial: pockets of synovium communicating with joint, tendon sheath / degeneration of mucoid fibrous tissue
Site:
o Can occur anywhere in body
o Common in areas of fibrous tissue (e.g. around joints, esp. Dorsal > Volar wrist @ scapholunate joint)
Most common soft-tissue mass in the hand
Types:
1. Simple
2. Compound – chronic inflammation distends tendon sheath above and below the flexor retinaculum.
3. Occult
4. Interosseous
42
Clinical features
o Majority between 20 and 60 years (rare in children)
o Grow slowly over months / years
o Non painful
Differentials
o Bursae (soft)
o Cystic protrusion of synovial cavity in OA (joint will be abnormal)
o Benign giant cell tumours of flexor shealth (Pigmented VilloNodular Synovitis)
o Lipoma
o Sebaceous cyst
Treatment
o Non-surgical
Watch & wait, usually may disappear after a few months.
Aspiration + 3/52 of immobilisation (successful in 30-50%). High chance of recurrence 6-12/12 later.
o Surgical
Complete excision to include neck of ganglion at site of origin. Along the lines of Langers.
Complications
Wound complications: Scar, haematoma, infection
Recurrence <10%
Damage to adjacent neurovascular structures.
Stiffness & Contractures
43
7. BASAL CELL CARCINOMA
Palpation (Important to palpate for mobility: fixation and deep local invasion)
Normal temperature, may be painful / itchy
Firm / solid consistency
should be mobile over underlying structures, confined to skin
o If fixed, immobile deeper invasion
Regional LAD (metastases are extremely rare, to rule out SCC)
A = nodular
B = pigmented
C = sclerosing
D = superficial
44
Background Information
Locally invasive carcinoma of basal layer of the epidermis
Does not metastasize, but can infiltrate adjacent tissues
Common in sun-exposed skin
Pre-disposing factors
o Congenital (rare)
Xeroderma pigmentosum (familial, associated with failure of DNA transcription)
Gorlin’s syndrome (rare autosomal dominant cancer)
o Acquired
Sunlight (especially UV light; UV-B range)
Carcinogens (smoking, arsenic)
Previous RT
Malignant transformation in previous skin lesions (e.g. naevus sebaceous)
Clinical features
o In elderly people (incidence increases with age)
o Rare in dark-skinned races
o Males > females
o Grow very slowly; months / years typically
o May spread radially – leaving central scar
o Persistent nodule / ulcer with central scab (repeatedly falls off, reforms)
o May have itch / pain
o If neglected: deep infected ulcer
Macroscopic appearances:
o Above the skin:
Nodular
Nodulo-ulcerative / Deeply eroding ulcer (“rodent ulcer”)
Cystic
o Not raised above the skin:
Pigmented
Geographical / cicatricial / “bush-fire” (advancing edge, healing centre)
Sclerosing (flat / depressed tumour, ill-defined edge)
Superficial (erythematous scaly patches)
Microscopic features
o Most commonly islands and nests of basaloid cells in dermis
o High mitotic rates, peripheral palisading
o (islands arranged radially with long axes in // alignment)
Differentials
o SqCC
Especially if ulcerated
But if rolled edge: more likely BCC
o Keratoacanthoma (adenoma sebaceum, molluscum pseudo-carcinomatosum)
But scar will be deep (see below)
o If pigmented: malignant melanoma (rare in Singapore)
Treatment
o Raised above skin: excision with 0.5 cm margin (maximum)
o Not raised above skin: wider margin of excision, especially if at inner acanthus of eye, nasolabial fold, nasal floor, ear
Frozen section may be needed to ensure adequate excision
o Alternative:
RT
o Eyes, ears, nasolabial fold lesions: Moh’s chemosurgery
Staged chemosurgery, histological assessment of margins & electrodessication
45
8. SQUAMOUS CELL CARCINOMA
Inspection
Single (may be multiple)
More common on sun-exposed skin – head, neck, arms, hands, trunk
may be of considerable size (> 1 cm)
Round nodule or Circular ulcer or Irregular/ exophytic/ fungating mass
Well defined edges:
o everted (excessive growth raises it above skin)
o dark, red-brown colour (very vascular)
May have central ulceration, Base:
o Necrotic tumour; may be covered with coagulated blood / serum
o Granulation tissue: tends to be pale, unhealthy
o Deep tissues may be exposed
o Depth: variable (may be very deep; especially in soft tissue)
o Can be copious, bloody, purulent, foul-smelling discharge
Surrounding tissue may be oedematous, thickened
Palpation
normal temperature, not tender
usually mobile
o If immobile: invasion into deep structures
Request for:
Examination of local lymph nodes (5% at time of presentation)
o Often enlarged (but may not contain tumour even if enlarged – can be from infection)
Examination for sites of metastases
o Respiratory: lung (pleural effusion)
o Abdominal: liver (hepatomegaly)
Take a history looking for predisposing factors (see below)
Background Information
Carcinoma of the cells of the epidermis forming superficial keratinous squamous layer
Local invasion into epidermis, dermis, adjacent tissues, & lymphatic spread to LNs
Microscopy:
o Tongues of tumours cells spreading in all directions
o “Epithelial pearls” – nest of squamous epithelium, cells are arranged in concentric circles surrounding a central focus of
acellular keratin
Clinical features
o Incidence increases with age (usually elderly male)
o Predisposition:
Congenital:
Xeroderma pigmentosum (AD, failure of DNA transcription)
46
Acquired
Envn: sunlight, Irradiation, Chemicals
Pre-existing lesions: Solar keratosis, Bowen’s disease
Chronic ulcers: old burns, chronic venous ulcers
Immunosuppresion (post-transplant, HIV)
o Usually has been growing for 1 – 2 months before being noticed
Begins as small nodules on skin
As enlargement occurs, centre necroses, sloughs
Nodule turns into ulcer
Ulcer initially circular with prominent everted edges
Subsequently enlarges & changes to any shape
Bleeding (more common with SCC than BCC)
Discharge
Pain (invasion of deep structures)
Lymphadenopathy
Complications
o Infection
o Bleeding (massive / fatal if erosion into large vessel)
47
9. MALIGNANT MELANOMA
Inspection
Usually single (may have satellite lesions around primary lesion)
Site: Limbs, head & neck, trunk, subungual, mucocutaneous junction, mouth, anus
Any colour: pale pink, brown, black, purple (rich blood supply)
Clearly defined but irregular
May ulcerate, discharge
May have surrounding halo: brown (pigment), pink (inflammation)
Types:
o Superficial spreading melanoma (70%):
Legs of women and backs of men
Red, white, blue in colour
Irregular edge
o Nodular type melanoma (15-30%):
On trunk
Polyploidal and raised
Smooth surface with irregular edge
Frequently ulcerated
o Lentigo maligna melanoma:
On face or dorsum of hands & forearms
Underlying lesion is flat, brown-black with irregular outline
Malignant area is thicker and darker
o Acral lentiginous melanoma:
More common in Asians and Blacks
On hairless skin: subungual area, palms, soles
Irregular area of brown/ balck pigmentation
o Others: amelanotic melanoma, intra-cranial melanoma, retinal melanoma
“Beware of the man with the glass eye and hepatomegaly”
Palpation
Normal Temperature, Non-tender
Surface
o If small: smooth epithelium
o If ulcerates: covered with crust (blood + serum)
o If bleeding, / infected: wet, soft, boggy
Firm consistency (small satellite nodules feel hard)
Mobile, moves with skin over deeper structures
Request
Palpation for regional lymphadenopathy
Palpation for other subcutaneous nodules (lying along course of draining lymphatics)
48
Background information
4 commonest types of malignant melanoma
Superficial spreading melanoma (70%)
Nodular melanoma (15 - 30%)
Lentigo maligna melanoma
Acral lentigous melanoma
Microscopic features
Consists of loose nests of melanocytes in basal cell layer:
Invade epidermis (leading to destruction, ulceration) & deeper into dermis, subcutaneous fat
Clinical Features
Very rare before puberty (usually > 20 years old)
Equally in both sexes (but distribution different – see below)
> 25% arise de novo
o Change in surface, size, colour, Halo, satellite nodules
o Ulceration, bleeding
o Itch, No pain
o Lymphadenopathy
Symptoms of distant metastases: LOW, SOB, jaundice
o Lymphatogenouly to: regional LN
o haematogenously to: Lungs [pleural effusion], Liver [hepatomegaly], Brain [focal neurological signs] & Skin and
subcutaneous tissues
Predisposing Factors
Congenital / non-modifiable
o Light skinned race
o Xeroderma pigmentosum
o Dysplastic naevus syndrome (B-K mole, FAMM syndrome) – 100% risk if 2 family members affected
o Large congenital naevi
o FHx in 1st degree relatives (1.5X risk)
Acquired / modifiable
o Sunlight exposure
o Pre-existing skin lesions
Lentigo
> 20 benign pigmented naevi (3 x risk)
o Previous melanoma (3.5 x risk)
49
Request
Examine draining lymph nodes
Take a history for:
o Cardinal symptoms of malignant change in a mole
Rapid increase in size
Itching
Bleeding
Change in colour / shape / thickness
o Predisposing factors
Differentials
Benign
o Moles (pigmented naevus – ↑ melanocytes, ↑ melanin)
o Freckles (normal number of melanocytes, ↑ melanin from each)
o Lentigo (↑ melanocytes, normal amount of melanin from each)
o Pigmented seborrhoeic keratoses
o Dermatofibroma
o Thrombosed haemangioma
Malignant
o Pigmented BCC
Prognosis generally poor – above 3 types of staging, or other indicators of poor prognosis:
a. Elderly
b. Male
c. Lesions on trunk
d. Ulceration
e. Depigmentation, amelanotic
f. Aneuploidy, high mitotic index
Treatment
Prevention (VERY IMPORTANT):
a. Avoidance of causative factors
Surgical excision with wide margins down to deep fascia
a. Main lesion:
i. < 0.76 mm: excise with 1 cm margin
ii. 0.76 – 1.0 mm: excise with 2 cm margin
iii. > 1.0 mm: excise with 3 cm margin
b. Nodal spread:
i. If clinical suspicion, biopsy or FNAC of lymph nodes
ii. If palpable: therapeutic block dissection
Palliation / adjuvant for distant metastases
a. Intralesional BCG therapy
b. Immunotherapy: vaccines (raises anti-melanoma response), monoclonal antibody, cytokine interferon therapy
50
Superficial Spreading Nodular Lentigo Maligna Acral Lentiginous
% 70% 15-30% – Rare
Face;
♂: Back Hairless skin (palms, soles,
Site Trunk Dorsum of hand /
♀: Legs subungual area)
forearm
Red, white, blue
Colour Most often black Brown / black Brown / black
(varying pigmentation)
Edge Irregular Regular outline Irregular Irregular
Shape Palpable, but thin Thick, polypoid, raised Flat Flat
Surface - Smooth - -
• Arises from patch of
Hutchinson’s Lentigo • Rare type
• Frequently ulcerated,
Remarks - • Malignant area usually • Often misdiagnosed as
bleeding
thicker, darker haematoma, paronychia
• Area seldom ulcerates
Pictures
51
10. NEUROFIBROMA
Inspection
Often multiple
Anywhere in skin, subcutaneous tissues, e.g. forearm
Spherical / Pedunculated / Fusiform (long axes lie along length of limb)
Rarely more than few cm
Comment on any café-au-lait spots
Palpation
normal temp., Non-tender
Smooth, Well-defined
Soft/ fleshy, rubbery consistency
Non-fluctuant
If in subcutaneous tissue: mobile within it
Move most freely perpendicular to course of nerve
Request
Look for other similar lesions & other manifestations of NF-1: café-au-lait spots, axillary freckling, lisch nodules, optic glioma
Measure the BP (HPT 2o to phaeochromocytoma, CoA, RAS)
Examination of cranial nerve VII & VIII (acoustic neuroma)
Background Information
Sporadic Neurofibroma
Benign tumour containing mixture of elements from peripheral nerves:
o Neural (ectodermal)
o Fibrous (mesodermal)
Often multiple
History
o Any age (but usually adult)
o Symptoms: usually cause no discomfort, rarely disfiguring
o If related to nerve trunk, may be tender
Patient may get tingling sensations in distribution of nerve
Histology
o Schwann cells: appear as bundles of elongated wavy spindle cells
o Collagen fibrils, myxoid material
o Often not encapsulated (unlike neurilemmomas)
Complications of Neurofibroma
o Pressure effects: spinal cord, nerve root compression
o Deafness: involvement of VIII
o Neurofibrosarcoma (only in NF-1): 5-13 %
o Intra-abdominal effects: obstruction, chronic GI bleeding
o Skeletal changes: kyphoscoliosis, cystic changes, pseudoarthrosis
Treatment (single neurofibroma)
o Non-surgical: leave alone if asymptomatic, patient agreeable
o Surgical: indicated only if malignancy suspected
Local re-growth common (cannot be surgically detached from underlying nerve)
52
Neurofibromatosis I (Von Recklinhausen’s disease)
(Refer to paediatrics notes – neurocutaneous syndromes)
AD, neurocutaneous syndrome; chr 17
Characterised by pigmentary changes, tumours, and skeletal, vascular dysplasias
o Fibroma ≥2 NF or ≥1 plexiform NF
o Iiris harmatomas (Lisch Nodules)
o Bone: dysplasia, pseudoarthrosis
o Relatives
o Optic glioma
o Macules >6; >15mm post-pubertal
o Axillary freckling
Neurofibromata of all sizes (few mm to large subcutaneous nodules), related differently to skin
o Within skin
o Tethered to skin
o Pedunculated
53
11. DERMOID CYST
Inspection
Usually single
Ovoid / spherical
Site:
o Congenital, 1-2 cm usually
Along lines of fusion of ophthalmic & maxillary facial processes
Inner & outer ends of upper eyebrow
o Acquired, 0.5-1 cm usually
Beneath skin likely to be injured e.g. fingers
Scars often present
Palpation
Not warm, maybe tender if infected
Smooth surface, Well-defined margins
Consistency
o Congenital: Soft (not tense / hard)
o Acquired: Hard & tense (sometimes stony hard)
Fluctuant (if large)
Mobile over deeper tissues
o Deep to skin, in subcutaneous tissue
i. Congenital: Not attached to skin or underlying structures
ii. Acquired: may be tethered to scar
Background Information
A dermoid cyst is a cyst deep to the skin, lined by skin
2 different methods of formation:
o Congenital: Accident during antenatal development
o Acquired: Implantation of skin into subcutaneous tissue by injury
Clinical features
Congenital (suspect if in child, young adult)
o Formed intra-utero, when skin dermatomes fuse
o Occur at any point in mid-line, common in neck / face / nose
Particularly along lines of fusion of ophthalmic & maxillary facial processes
Also: inner & outer ends of upper eyebrow
o May be seen at birth
o Distends a few years later, becomes obvious; few symptoms other than cosmetic problems
o Rarely infected
Acquired – Implantation dermoid (suspect if in adult – Browse pg 60)
o Develop when piece of skin survives after being forcibly implanted into subcutaneous tissue
Often by injury: cut, stab, etc.
o Symptoms
Small, tense lump
Painful and tender (in areas subjected to repeated trauma)
Local effects (e.g. problems with grip / touch if on finger)
Also rarely infected
o Differentials
Sebaceous cyst (look for old injury, presence of scar near cyst: more likely dermoid)
Treatment
Congenital
o Surgical treatment; complete excision
o Full extent should first be established with X-ray / CT
Midline cysts may communicate with CSF; must exclude bony defect
Acquired
o Complete excision of cyst
54
12. SEBORRHOEIC KERATOSIS (Senile wart / seborrhoeic wart / verruca senilis / basal cell papilloma)
Inspection
Often multiple
Any part of skin; most found on back & face
Round / oval
Light brown → black
“stuck on appearance”;; appears warty
Varying size; Few mm to 2-3 cm
Distinct margins
Palpation
No warmth, no tenderness
Rough surface (sometimes papilliferous)
More firm than surrounding skin
Attached to skin
Special tests
o May be picked off gently – reveals patch of pale-pink skin, 1-2 surface capillaries (bleed slightly)
(DON’T DO THIS IN EXAM)
Background Information
Benign outgrowth of basal layer of epidermis
o Raised above the level of normal epidermis
Microscopy:
o Hyperkeratosis (thickening of keratin layer)
o Acanthosis (thickening of prickle cell layer)
o Hyperplasia of variably pigmented basaloid cells
Clinical features
Occur in both sexes
More common in elderly people
Begin as a patch,
o increases in area, size over months / years
o May not increase in thickeness
o May suddenly fall off: leave pale-pink patch of skin
Complications:
o May become disfiguring, catch on clothes
o May get infected (may imitate SCC, pyogenic granuloma)
o Seldom bleeds (may cause it to change colour to brown)
Leser-Trelat sign: Sudden onset of multiple seborrhoeic keratoses may imply visceral malignancy
Treatment
Non-surgical
o Can be left alone as it is benign
Surgical – for cosmetic reasons, etc.
o Superficial shaving (lies above level of normal epidermis)
o Cautery
55
13. HAEMANGIOMA
Background Information
Vascular malformations
o Types
Capillary: ⅔ of cases, include the cutaneous haemangiomata, telangiectasias
Predominantly venous: venous angioma
Deeper levels of subcutaneous tissue, may extend into muscle / joint
May have distended veins over the surface of the mass
Empty with pressure, may have bruit
Predominantly lymphatic: lymphangioma circumscriptum
o Features
Develop as abnormal proliferation of embryonic vascular network
Hamartomas
May ulcerate, induce hyperkeratosis in overlying stratum corneum
Many forms of cutaneous haemangiomata: (see table)
o Strawberry naevus (cavernous haemangioma)
o Port-wine stain (naevus vinosus)
o Spider naevus
o Campbell de Morgan spot
Pictures
56
Also
Telangiectasias
o Dilatation of normal capillaries
o Can be secondary to irradiation
o Can be part of hereditary haemorrhagic telangiectasia (Osler-Rendu-Weber syndrome)
Autosomal dominant disease
Overt and occult haemorrhage can present as haematuria, haematemesis, melaena, epistaxis, iron-deficiency
anaemia
Vin rosé patch
o Congenital intradermal vascular abnormality
o Mild dilatation of vessels in sub-papillary dermal plexus
o Can occur anywhere, gives skin pale-pink colour
o Associated with other vascular abnormalities (e.g. haemangiomata, AV fistulae, lymphoedema)
o Usually not disfiguring
57
14. PYOGENIC GRANULOMA
Inspection
Single; usu < 1 cm, bright red
o May be blood-encrusted or Ulceration
Hemispherical; may be sessile / pedunculated
Likely sites to be injured, e.g. hands, face
Bright red; long-standing lesions may be skin-coloured
May have sinuses, associated serous / purulent discharge, Erythema / cellulitis
Request
Take history for previous injury
Rate of growth of lump? (rapid growth in few days)
Treatment
Surgical
o Curettage with diathermy of the base
o Complete excision biopsy
(if recurrent; malignancy e.g. amelanotic melanoma has to be excluded)
Non-surgical
o Regression is uncommon: surgical treatment best option
o Silver nitrate cautery is possible
58
15. PAPILLOMA (skin tags / fibroepithelial polyps)
Inspection
Single / multiple
Variable: from raised plaque to pedunculated polyp
Site: Neck, trunk, face, anus (anywhere on skin)
Variable
Flesh-coloured
Palpation
Not warm, non-tender
Variable: smooth to papilliferous
Soft, not compressible
Arises from skin
Request
Similar lumps elsewhere
Ask for associated conditions: pregnancy, diabetes, intestinal polyposis
Background Information
An overgrowth of all layers of the skin with central vascular core
Not a neoplasm, but a hamartoma (skin tag is a more accurate term)
Increasingly common with age – may be congenital
Clinical features
Catches on cloths, rubs against other body parts
May resemble carcinoma if granulation is excessive
Complications:
o May become red, swollen, and ulcerate
o May become infarcted if injured
o May be infected (contains all skin components – sebaceous glands, etc.)
Treatment
Excision – diathermy, scissors
o Bleeding from central vascular core controlled using single suture / diathermy
59
16. KERATOCANTHOMA (adenoma sebaceum, molluscum pseudo-carcinomatosum)
Inspection
Often found on face
Usually solitary;1 – 2 cm in diameter
Hemispherical or conical, with central crater
Normal skin colour
Palpation
Firm and rubbery (central core is hard)
Confined to skin, freely mobile over subcutaneous tissues
Background information
Benign overgrowth of hair follicle cells with a central plug of keratin
Occur in adults
complain of rapidly-growing lump in skin
Not painful, but can be unsightly
Takes 2 – 4 weeks to grow, regresses in 2 – 3 months
o Central slough appears,
o surrounding skin retracts to form puckered scar
Cause is unknown (may be self-limiting benign neoplasm or post-viral infection)
Treatment:
o Conservative if asymptomatic
o Surgical excision of lesion with histology to r/o SqCC
Hypertrophic scar
o any age – common 8-20 years, ♂=♀, all races
o Excessive amount of fibrous tissue, but confined to scar (between skin edges)
o Located across flexor surfaces, skin creases
o Common, especially if infection / excessive tension
o Only enlarge for 2-3 months, then regress spontaneuosly
o Do not recur if excised and causative factor eliminated
Keloid scar
o puberty to 30 years, ♀>♂, black, hispanic more likely
o Hypertrophy and overgrowth extend beyond original wound
o Located at earlobes, chin, neck, shoulder, chest
o Due to local release of fibroblast growth factors
o Continue to enlarge 6-12/12 after initial injury
o May be tender, unsightly
o Will recur unless special measures taken
60
18. KAPOSI’S SARCOMA
Inspection
Purple papules and plaques
Solitary, but usually multiple
Site: limbs, mouth, tip of nose/ palate or anywhere on the skin or mucosa
Background information
Derived from capillary endothelial cells or from fibrous tisse
Linked to HHV-8
Types:
o Classic Kaposi’s Sarcoma
Confined to skin of lower limbs of elderly Jews
Not fatal
o AIDS associated Kaposi’s Sarcoma
AIDS defining; Found in 1/3 of AIDS patients
1/3 develops a 2nd malignancy e.g. leukaemia/ lymphoma
o Endemic (African) Kaposi’s Sarcoma
Aggressive and invasive fatal tumour
Good response to chemotherapy
o Transplation- associated Kaposi’s Sarcoma
Following high dose immunosuppressive therapy
Often regress when treatment is ended
Treatment
Conservative if asymptomatic. Start anti-retrovirals if HIV +ve
Surgical: local radiotherapy amd chemotherapy (IFN- alpha, doxorubicin, intralesional vinblastine)
19. FIBROSARCOMA
Inspection
Single; Usually limbs (but can be anywhere)
Spherical or hemispherical
If large, vascular: may make skin shiny & pink
May have
o Sinuses & Discharge
o Ulceration
o Erythema / cellulitis
Palpation
Usually feel warmer (abnormal blood supply)
May be tender
Smooth surface (may be bosselated – covered with knobs)
Well-defined margins (indistinct if fast-growing, invasive)
Firm / hard consistency (rarely stony hard; do not ossify)
Usually fixed
May pulsate, have audible bruit, palpable thrill (may be very vascular)
Background Information
Fibrosarcoma is one of the commonest mesodermal soft tissue malignant tumours
o Pure benign fibroma is very rare
History
o More common in elderly (but can occur any age)
o Common complaints
Growth: disfigurement, interference with ROM
Pain
Weakness (infiltration of other structures)
General debility
Prognosis: generally good
61
20. PYODERMA GANGRENOSUM
Inspect
Ulcer with a necrotis base
Irregular bluish red overhanging edges
a/w surrounding erythematous plaques with pustules
Backgound information
more common in males
pyoderma gangrenosum is associated with:
o IBD
o RA
o Myeloproliferative disorders: PRV, myeloma
o Autoimmune hepatitis
Differential diagnosis:
o Autoimmune: rheumatoid vasculitis
o Infectious: tertiary syphilis, amoebiasis
o Iatrogenic: warfarin necrosis
o Others: Behcet’s disease
Treatment:
o Non-surgical: treat underlying condition, saline cleansing, high dose oral or intralesional steroids.
KIV cyclosporine & antibiotics
o Surgical: serial allograft followed by autologous skin graft or muscle flap coverage when necessary
62
21. RADIOTHERAPY MARKS
Background information
High energy X-rays interact with tissue to release electrons that cause local damage to DNA in adjacent cells via oxygen
dependent mechanism.
o Damage is usually irreparable, and normal cells have greater ability to repopulate than tumour cells in this setting
o If reparable, manifests as chromosomal abnormalities
Complications:
o Early:
General: malaise, fatigue, LOA, N/V
Skin changes & temporary hair loss
Bone marrow suppresion, esp. if to long bone and pelvis
GI: diarrhea
o Late:
Skin changes
Heart: IHD
Lung: pneumonitis, pulmonary fibrosis
Bld vssl: radiation arteritis, esp to carotids necrosis, distal ischaemia and vssl rupture
CNS: spinal cord myelopathy
Uro: bladder fibrosis, Renal impairment (depletion of tubular cells)
Abdo: IO 2o to strictures & adhesions,
Genital: infertility
Endocrine: hypothyroidism
Eye: cataracts
Increase incidence of future cancers:
Haematogenous malignancy, e.g. leukemia
Solid tumours: Thyroid cancers
Breast cancers
Minimalising of side effects of radiotherapy:
o Lead shields to eyes, gonads and thyroid
o Dose fractionation (to allow recovery of normal cells)
o Prior chemotherapy (increase sensitivity of tumour cells)
o Regional hypothermia
o Radiolabelled antibody to deliver local radiation to tumour
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3. SURGICAL INSTRUMENTS & PROCEDURES
1. DRAINS
TYPES OF DRAINS
Drains are often made from inert silastic material
They induce minimal tissue reaction
Red rubber drains induce an intense tissue reaction allowing a tract to form
In some situations this may be useful (e.g. biliary t-tube)
Open Active
REMOVAL OF DRAINS
A drain is removed as soon as it is no longer required. The following are general guidelines:
Drains put in to cover perioperative bleeding and haematoma formation, can come out after 24— 48 hours.
Where a drain has been put in to drain an infection (abscess), remove it when fever settles or when there is evidence of complete drainage.
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2. CENTRAL VENOUS PRESSURE LINE
The internal jugular vein (IJV) is accessible, so cannulation of this vein is associated with a lower complication rate than with other approaches.
Hence, it is the vessel of choice for central venous cannulation.
Procedure
1. Use local anaesthetic to numb the venepuncture site.
2. Introduce the large calibre needle, attached to an empty 10 ml syringe.
3. Surface mark the internal jugular vein at the centre of the triangle formed by the two lower heads of the sternocleidomastoid muscle and the
clavicle. Palpate the carotid artery and ensure that the needle enters the skin lateral to the artery.
4. Direct the needle caudally, parallel to the sagittal plane, aiming towards the ipsilateral nipple.
5. While needle is advanced, maintain gentle aspiration.
6. When vein is entered, flush of blood appears in the syringe. Now, cannulate the vein via the Seldinger technique (below).
7. Remove syringe, holding needle firmly in place. Occlude needle to prevent air embolism or bleeding.
8. Advance guide wire, J-shaped end first, into the vessel through the needle.
9. Hold guide wire in place and remove needle. Maintain a firm grip on the guide wire at all times.
10. Use a dilator to enlarge the hole in the vein. Remove the dilator.
11. Thread tip of catheter into the vein through the guidewire.
Grasp the catheter near the skin and advance it into the vein with a slight twisting motion.
12. Advance catheter into final indwelling position. Hold catheter and REMOVE GUIDEWIRE.
13. Check lumen placement by aspirating through all the pigtails and flushing with saline next.
14. Suture the catheter to the skin to keep it in place.
15. Apply dressing according to hospital protocol.
16. The catheter tip should lie in the superior vena cava above the pericardial reflection.
17. Perform check chest X-ray to confirm position and exclude pneumothorax.
Complications
1. Pneumothorax/haemothorax
2. Air embolism - ensure head-down position.
3. Arrhythmias – This happens if cathether “irritates” the heart. Avoid passing guidewire too far, cardiac monitoring during insertion.
4. Carotid artery puncture/cannulation - palpate artery and ensure needle is lateral to it, or use ultrasound-guided placement, transduce needle
before dilating and passing central line into vessel, or remove syringe from needle and ensure blood is venous.
5. Chylothorax- Avoid cannulating the vein on the left side as the thoracic duct lies there.
6. Catheter-related sepsis
65
CANNULATION OF THE SUBCLAVIAN VEIN
The subclavian vein (SVC) may be preferred for central venous access if
1. Patient has a cervical spine injury
2. Line is for long-term use e.g. dialysis, feeding. This site may be more comfortable for the patient.
Technique
1. Place the patient in a supine position, head-down.
2. Turn the head to the contralateral side
(if C-spine injury excluded).
3. Adopt full asepsis.
4. Introduce a needle attached to a 10 ml syringe.
5. Surface mark the subclavian vein 1 cm below the junction
of the middle and medial thirds of the clavicle. Direct the
needle medially, slightly cephalad, and posteriorly behind
the clavicle toward the suprasternal notch.
6. Slowly advance needle while gently withdrawing plunger.
7. When a free flow of blood appears, follow the Seldinger
approach, as detailed previously.
8. The catheter tip should lie in the superior vena cava above
the pericardial reflection.
9. Perform check chest X-ray to confirm position and exclude
pneumothorax.
Complications
As listed for internal jugular venous cannulation. The risk of pneumothorax is far greater with this technique.
Damage to the subclavian artery may occur; direct pressure cannot be applied to prevent bleeding.
Ensure that a chest X-ray is ordered, to identify the position of the line and to exclude pneumothorax.
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3. NASOGASTRIC TUBE
The cuffed endotracheal and tracheostomy tubes should be deflated prior to nasogastric tube insertion.
PRE-PROCEDURE
1. Gather equipment.
2. Don non-sterile gloves.
3. Explain the procedure to the patient and show equipment.
4. If possible, sit patient upright with head forward for optimal neck/stomach alignment. Otherwise, prop the patient up at 45 °.
5. Deflate the endotracheal tube or tracheostomy cuff
6. Determine the size of the nasogastric tube required (usually 14 – 16FG). If aspirating, use as large a tube as possible to reduce the risk of
blocking during use or the formation of a false passage during introduction; if feeding, a smaller tube may be used (eg. 8FG) because it is
more comfortable in the long term.
PROCEDURE
1. Estimate the length of the tube to be inserted: from the bridge of the nose to the tragus of the ear to the point halfway between the
xiphisternum and the navel. Mark the measured length with a marker or note the distance.
2. Examine nostrils for deformity/obstructions (eg. choanal stenosis) to determine best side for insertion. Select the largest nostril for insertion.
3. Lubricate tube with water. The nose may be lubricated with lignocaine gel.
4. Introduce the tube through the nostril horizontally in, passing the tube along the floor of the nose. Resistance may be felt as tip reaches the
nasopharynx, which is the most uncomfortable part of the procedure. In the operation theatre, when the patient is under general anaesthesia,
the McGill’s forceps may be used to guide the tube down.
5. Instruct the patient to swallow (you may offer ice chips/water if not contraindicated) and advance the tube as the patient swallows. Swallowing
of small sips of water may enhance passage of tube into esophagus. If patient is uncooperative, bend his head to elicit a swallowing reflex.
6. Continue to advance the tube down the oesophagus. There should not be resistance. If resistance is met, rotate the tube slowly with
downward advancement towards the closer ear. Do not force the tube down against resistance as this may form a false passage.
7. Withdraw the tube immediately if changes occur in the patient's respiratory status, if the tube coils in the mouth, or if the patient begins to
cough or turns pretty colours.
8. Advance the tube until mark is reached (approximately 40cm). Stop.
9. Check for correct placement by attaching a syringe to the free end of the tube and aspirating a sample of gastric contents to test with litmus,
auscultating the epigastrium while injecting air through the tube, or obtaining an x-ray to verify placement before instilling any
feedings/medications or if you have concerns about the placement of the tube.
10. Secure the tube with adhesive tape.
11. Re-inflate the endotracheal tube or tracheostomy cuff if necessary.
12. If for suction, remove the syringe from the free end of the tube; connect to suction; set machine on type of suction and pressure as prescribed.
13. Document the reason for the tube insertion, type & size of tube, the nature and amount of aspirate, the type of suction and pressure setting if
for suction, the nature and amount of drainage, and the effectiveness of the intervention.
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4. TRACHEOSTOMY
RELATIVE CONTRAINDICATIONS
1. Evidence of infection in the soft tissues of the neck at the prospective surgical site.
2. Medically uncorrectable bleeding diatheses.
3. Gross distortion of the neck anatomy due to hematoma, tumour, thyromegaly, high innominate artery or scarring from previous
neck surgery.
4. Documented or clinically suspected tracheomalacia.
5. Need for positive end-expiratory pressure (PEEP) of more than 15 cm of water.
6. Patient obesity with short neck that obscures neck landmarks.
7. Patient age younger than 15 years.
TYPES OF TRACHEOTOMY
1. Temporary: Portex (cuffed).
2. Permanent: Consist of inner and outer tubes made of stainless steel.
Tracheostomy is more useful in the elective setting compared to endotracheal intubation because:
1. Better tolerated.
2. Avoids risk of laryngeal stenosis
3. Avoids risk of endotracheal obstruction.
PROCEDURE
1. Position the patient. Place rolled towel under the patient’s neck to hyperextend the neck for better exposure.
2. Clean and drape. Clean the skin of the neck from the chin to the suprasternal notch and laterally to the base of the neck and
clavicles. Drape field.
5. Incise skin. In the emergency setting, make a vertical incision 3cm from cricoid cartilage downwards. In the elective setting,
make a tranverse incision 4cm wide, 3cm above the suprasternal notch.
7. Identify the communicating branch of the anterior jugular vein, clamp and ligate the artery (ignore this in an emergency).
10. Incise the trachea between the 2nd and 3rd tracheal rings, making an inverted U-flap incision.
11. Insert tracheal dilator through the tracheostoma and remove the cricoid hooks.
15. Dress wound and secure to the neck using sutures and adhesive tape.
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COMPLICATIONS
During Procedure
1. Bleeding if damage to the innominate or inferior thyroid artery.
2. Damage to surrounding structures, eg esophagus, recurrent laryngeal nerve, brachiocephalic vein.
3. Pneumothorax. Pneumomediastinum.
Immediate post-op
1. Surgical emphysema (refers to the condition that causes air to be trapped under the skin). Subcutaneous emphysema.
2. Obstruction, eg clot, mucus.
3. Bleeding.
4. Dislodgment.
Late post-op
1. Infection .
2. Obstruction, eg dislodgment of tube, crust formation from secretions.
3. Tracheal stenosis.
4. Tracheomalacia.
5. Tracheo-esophageal fistula. Wound breakdown
6. Scarring.
POST-OP CARE
1. Position patient in a propped up position.
2. Prevent obstruction by suction, saline irrigation, mucolytic agents (mucomyst, guaifenesin) and humidified air.
3. Change Portex tube every 3rd day and remove the inner tube for cleaning everyday.
4. Unlock the metal tube every night so that the patient can cough it out if it becomes obstructed.
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5. SENGSTAKEN-BLAKEMORE TUBE (MINNESOTA TUBE)
INDICATIONS
Oesophageal varices
CONTRAINDICATIONS
1. Base of skull fracture
2. Oesophageal tear
3. Severe facial injury
1. Measure the length of the tube. Test balloons. Test patency of the tube.
4. Lubricate and insert the tube through the nose, asking the patient to swallow or drink water to aid in smoother passage of the
tube through the pharynx and oesophagus.
7. Traction.
8. Inflate the oesophageal balloon to 35 – 45mmHg (above portal HTN pressure): use the Y-connector piece with one arm to the
BP set and the other to the syringe to pump in air.
9. Aspirate fluid from the oesophagus through the Ryle’s tube, or if using the Minnesota tube, use the additional lumen provided
(with the additional lumen for aspirating fluid in the oesophagus, the Minnesota tube decreases the likelihood of aspiration
pneumonia occurring).
10. Check the oesophageal balloon pressure hourly and release 5mins hourly.
13. The tube should not be used for more than 72hrs.
COMPLICATIONS
1. Aspiration pneumonia
2. Respiratory obstruction
3. Oesophageal ulceration and rupture
4. Rebleeding
5. Gastric varices not controlled
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6. URINARY CATHETERISATION
1. Relief of acute retention of urine, e.g. benign prostatic hypertrophy, bladder outflow obstruction.
2. Bladder washout, e.g. blood clots causing acute retention of urine.
3. Cystourethrogram.
4. Administration of intra-vesical drugs.
5. As an adjunctive measure pre/post-operatively
a) Pre-operatively:
(i) to drain the bladder so as to improve access to the pelvis in urologic or pelvic surgery.
(ii) to allow accurate measurement of urine output in major surgery.
b) Post-operatively:
(i) to relieve acute urinary retention because post –op pain results in failure of the sphincter to relax.
6. Urinary output monitoring, e.g. in patient with hypovolaemic shock or the critically ill.
CONTRAINDICATIONS
1. Presence of urethral injury, as manifested by:
a) blood from the meatus,
b) scrotal haematoma,
c) pelvic fracture, or
d) high-riding prostate, elicited from a genital and digital rectal examination. (alternative: suprapubic drainage)
2. Urinary tract infection, as an indwelling catheter causes difficulty in treatment.
PROCEDURE
1. Gather equipment.
2. Explain procedure to the patient. Maximize patient’s privacy. Have a chaperone if performing the procedure on a member of the opposite sex.
3. Assist patient into supine position with legs spread and feet together.
4. Open the catheterization kit and catheter.
5. Prepare sterile field. Don the sterile gloves from the kit.
6. Test the balloon at the tip of the catheter.
7. Generously coat the distal portion (2 - 5cm) of the catheter with lubricant.
8. Using the non-dominant hand to come in contact with the patient and the dominant hand to use items from the kit (recall that once your hand
comes in contact with the patient, it is no longer sterile and cannot be used to obtain items from the kit), cleanse the peri-urethral mucosa with
antiseptic-drenched swabs held by forceps. Cleanse anterior to posterior, inner to outer, one swipe per swab, discard away from sterile field.
a) Male: Hold the penis and retract the foreskin. Swab the penis and surrounding area, making sure to cleanse beneath the foreskin.
b) Female: Retract the labia majora. Swab the perineum.
9. Apply sterile drape.
10. Installation of local anaesthesia.
a) Male:
(i) Smear lignocaine gel around the meatus and apply the gel gently into urethra.
(ii) Massage gel carefully down the urethra to sphincter, squeezing the meatus shut
(iii) Wait for for 5 minutes (alternatively, with less anaesthetic effect, smear gel over the catheter tip).
b) Female:
(i) Apply lignocaine gel to urethra or catheter tip.
11. In the male, lift the penis to a position perpendicular to patient's body and apply light upward traction (with non-dominant hand); in the female,
expose the external urethral orifice.
12. Gently insert tip of catheter into the meatus using forceps until 1 to 2 inches beyond where urine is noted to drain into kidney dish. If no urine
appears although the catheter seems to be in the right place, flush with sterile saline as the lumen may be blocked with gel. If this is still
unsuccessful, withdraw and reinsert.
13. Inflate balloon, using correct amount of sterile saline (usually 20 – 30mls but check actual balloon size). This process should be painless. If
patient feels pain, deflate balloon immediately and reposition catheter.
14. Gently pull catheter until inflation balloon is snug against bladder neck.
15. Connect catheter to drainage system.
16. Secure catheter to abdomen or thigh, without tension on tubing.
17. Place drainage bag below level of bladder.
18. Evaluate catheter function and amount, color, odour and quality of urine.
19. Remove gloves. Dispose equipment appropriately. Wash hands.
20. Document size of catheter inserted, amount of water in balloon, patient's response to procedure and assessment of urine.
COMPLICATIONS
1. Infection, which may lead to stone formation.
2. Stricture formation due either to faulty technique or an irritant material used in the catheter.
3. Creation of a false passage due to wrong technique of insertion.
4. Occasionally, irritation of the bladder may cause severe bladder spasms.
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7. CHEST TUBE
Chest tubes are inserted to drain blood, fluid, or air and allow full expansion of the lungs. The tube is placed between the ribs and
into the space pleural space.
The area where the tube will be inserted is anesthetized locally. The patient may also be sedated. The chest tube is inserted through
an incision between the ribs into the chest and is connected to a bottle or canister that contains sterile water (underwater seal).
Suction is attached to the system to encourage drainage. A suture and adhesive tape is used to keep the tube in place.
The chest tube usually remains in place until the X-rays show that all the blood, fluid, or air has drained from the chest and the lung
has fully re-expanded. When the chest tube is no longer needed, it can be easily removed, usually without the need for medications
to sedate or numb the patient. Antibiotics may be used to prevent or treat infection.
INDICATIONS
1. Pneumothorax.
2. Hemothorax.
3. Drainage of pleural effusion.
4. Chylothorax
5. Drainage of empyema/lung abcesses
6. Prophylactic placement of chest tubes in a patient with suspected chest trauma before transport to specialized trauma center
CONTRAINDICATIONS
1. Infection over insertion site
2. Uncontrolled bleeding diathesis/coagulopathy
MATERIALS
1. Iodine & alcohol swabs for skin prep
2. Sterile drapes & gloves
3. Scalpel blade & handle
4. Clamp
5. Silk suture
6. Needle holder
7. Petrolatum-impregnated gauze
8. Sterile gauze
9. Tape
10. Suction apparatus (Pleuravac)/underwater seal apparatus
11. Chest tube (size 32 to 40 Fr, depending on clinical setting)
12. 1% lignocaine with epinephrine, 10 cc syringe, 25- & 22-g needles
PROCEDURE
1. Determine the site of insertion. Locate the triangle of safety; bounded by the lateral border of the pectoris major, 5th or 6th
intercostal space, imaginary vertical line between the anterior and mid axillary lines.
2. Surgically prepare and drape the chest at the predetermined site of the tube insertion.
3. Locally anaesthetized the skin and rib periosteum.
4. Make a 2-3cm transverse incision at the predetermined site and bluntly dissect through the subcutaneous tissues, just over the
top of the rib.
5. Puncture the parietal pleura with the tip of a clamp and put a gloved finger into the incision to avoid injury to other organs and to
clear any adhesions, clots, etc.
6. Clamp the proximal end of the chest tube and advance the tube into the pleural space to the desired length.
7. Look for fogging of the chest tube with expiration or listen to air movement.
8. Connect the end of the chest tube to an underwater seal apparatus.
9. Suture the tube in place.
10. Apply a dressing and tape the tube to the chest.
11. Do a chest X ray
12. Obtain arterial blood gas values and/or institute pulse oximetry monitoring as necessary.
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COMPLICATIONS
Damage to structures:
1. Laceration or puncture of the intrathoracic and/or abdominal organs, all of which can be prevented by using the finger technique
before inserting the chest tube.
2. Damage to the intercostals nerve, artery or vein.
3. Subcutaneous emphysema, usually at tube site.
Equipment:
4. Incorrect intrathoracic or extrathoracic tube position.
5. Chest tube kinking, clogging or dislodging from the chest wall or disconnection from the underwater seal apparatus.
6. Anaphylactic or allergic reaction to surgical preparation or anaesthesia.
Failure:
7. Introduction of pleural infection.
8. Persistent pneumothorax
9. Recurrence of pneumothorax upon removal of the chest tube.
10. Lungs fail to expand due to plugged bronchus; bronchoscopy required.
Recovery from the chest tube insertion and removal is usually complete, with only a small scar. The patient will stay in the hospital
until the chest tube is removed. While the chest tube is in place, the nursing staff will carefully check for possible air leaks, breathing
difficulties, and need for additional oxygen. Frequent deep breathing and coughing is necessary to help re-expand the lung, assist
with drainage, and prevent normal fluids from collecting in the lungs.
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4. ABDOMINAL SURGICAL EMERGENCIES
Others
Appendicitis
74
2. APPROACH TO ABDOMINAL MASSES
Right Kidney Right adrenal gland Liver (see RHC) Pancreas Spleen (see LHC) Descending colon
Hydro/pyonephrosis (see Epigastrium) Cancer
Cancer – RCC Liver (see RHC) Stomach(see Left kidney Diverticular
Polycystic dz Epigastrium) Aorta (see right lumbar) mass/abscess
Single cyst Ascending colon Aortic Aneurysm Faeces
Amyloidosis mass Small intestine
Tuberous sclerosis, Cancer Obstruction Retroperitoneal
VHL Diverticular lNpathy
mass/abscess Mesenteric cyst Lymphoma
Faeces Teratoma
Other malignancies
Orthopaedics Vascular:
Chondroma/sarcom Iliac artery
a of ilium aneurysm
Bony metastasis Iliac lymphadenitis
75
3. INTESTINAL OBSTRUCTION (& MECKEL’S DIVERTICULUM)
Causes of IO
1. Mechanical
76
HISTORY
Consider:
Is there I/O?
Is it functional or mechanical?
Is the bowel strangulated? local peritoneal inflammation
SB or LB obstruction?
4 cardinal symptoms
1. Pain:
- Usually colicky (central griping pain interspersed with periods of no/little pain), 4-5 days duration
- SB: every 2-20min, LB: every 30min or more
- Complete obstruction: constant, sharp pain
- Volvulus: sudden, severe pain
2. Vomiting:
- Pyloric: watery and acid, projectile
- High SB: greenish blue, bile stained
- Lower SB: brown and increasingly foul smelling (feculent = thick brown foul)
- LB: uncommon esp if competent ileocaecal valve, usually late symptom
3. Abdominal distension
- Usu not seen in high obs , esp if pt vomiting
- Closed loop: RIF bulge that is hyperresonant
- SB: distension in centre of abdomen
4. Constipation
- Ask about normal BO frequency
- Early in low obs, late in high obs
- Complete obstipation: cannot even pass flatus
PHYSICAL EXAMINATION
Abdomen:
Dx I/O
Any distension?
Visible peristalsis? – severe obstruction (see browse)
Bowel sounds:
Mechanical: Initially hyperactive/loud resonant/ high-pitch sluggish or absent
Tinkling BS: small bowel obstruction
Ileus: hypo/absent BS
Succussion splash + epigastric tenderness: gastric outlet obstruction
Causes of I/O
SCARS from previous abdominal surgery?
Any masses
Any HERNIAE – inguinal + femoral (more likely strangulated)
DRE: any masses felt, any impacted stools?
Cx of I/O
Any signs of peritonitis: guarding, rebound tenderness, rigid
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ACUTE MANAGEMENT
o Resuscitate if necessary
1. Maintain airway
2. Give supplementary O2 (high flow if susp ischemia)
o Monitor vitals
- Urinary catheter: monitor hourly urine output
o Drip and suck
1. NBM: rest bowel (alone does not give adequate rest as intestine produce up to 9L of fluids per day)
2. NG tube:aspirate stomach contents and then put on constant suction
3. IV drip: rehydrate and correct elec imbalance
o Start broad spectrum ABx [IO affects normal translocation of bacterial flora] – IV Ceftriaxone 1g + Metronidazole 500mg
o Correct acidosis (ischemia), replace K+ as guided by investigations
Rule out surgical emergencies (history/physical examination/investigations) if suspected, immediate consult with GS Reg
1. Obstructed and strangulated abdominal hernia
2. Volvulus (sigmoid, caecal, stomach)
3. Closed-loop obstruction (competent ileocecal valve)
4. Ischaemic bowel with bowel necrosis
5. Perforation/peritonitis
INVESTIGATIONS
Bloods
Assess complications
FBC: any infection, anemia
UECr :
Any dehydration due to:
- Intra-luminal 3rd space loss (damaged enterocytes unable to reabsorb)
- Vomiting (also assess K+ loss: can perpetuate paralytic ileus)
Acute renal failure from dehydration
ABG
- Acidosis from bowel ischaemia
- Alkalosis due to vomiting (more for pyloric stenosis in children)
ECG (+ CE X2 sets) in elderly
Pre-operative
GXM 4 pints of blood
PT/PTT
Imaging
Assess complications
Erect CXR :
1. air under diaphragm
2. aspiration pneumonia
KUB/AXR:
1. Rigler’s Sign = double wall sign (obvious bowel wall due to extra-luminal air)
Blue arrows point to falciform ligament, made visible by a large amount of free air in the
peritoneal cavity. The red arrows demonstrate both sides of the wall of the stomach
(Rigler's sign), a sign of free air. The yellow arrow points to a skin fold.
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Diagnostic
KUB (not AXR)
Dilated = 3cm SB, 5cm LB, 9cm caecum (increase risk of perf)
- Erect: air fluid levels (>6)
- Supine (better): look for small or large bowel dilatation on radiograph
Duodenum: C-shaped
Jejunum/proximal ileum: centrally located, “stack of coins” (plicae circulares aka valvulae conniventes)
Distal ileum: plicae circulares disappears, lead-pipe appearance
Colon: more peripheral, incomplete bands (haustrations due to presence of teniae coli)
Gas present in rectum? No: complete obstruction (may require KUB film)
- Sigmoid volvulus? - Caecal volvulus
Coffee bean sign:
- Closed loop obstruction? Distal lesion with v. distended cecum (thinnest wall; up to 12cm), ileum not dilated
Barium enema
- Gastrografin preferable if risk of perforation; risk of barium peritonitis (100% mortality!)
- Upper GI barium studies contraindicated
Colonoscopy done without bowel prep (not necessary, and also contraindicated, in IO)
CT colonography
d. Sigmoidopexy: fix sigmoid to posterior abdominal wall (rarely done as high risk of recurrence)
Other volvulus
Caecal volvulus: right hemicolectomy with primary ileocolic anastomosis is the surgical procedure of choice (not
endoscopic decompression as only successful in 15-20%. rare to create ileostomy)
Gastric volvulus: gastropexy
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3) Closed loop obstruction (if due to distal tumour)
Resect bowel + primary anastamosis with proximal defunctioning colostomy
Resect bowel + Hartmann’s/Paul-Mikulicz procedure: if bowel is too inflamed/oedematous to anastamose (high risk of
leakage)
Palliative: colonoscopy with stenting
4) Ischaemic bowel
Supportive management e.g. NBM, drip & suck, antibiotics while waiting for collaterals to re-supply bowel, re-establish
peristalsis
Surgical intervention if bowel is non-viable e.g. gangrenous or necrotic
o Will have relook laparotomy in 2-3/7 to ensure good resection of bowel margins??
6) Intussusception
Children: usually due to hypertrophic Peyer’s patches. Administer barium enema: watch intussception reduce on
fluoroscopy
Elderly: usually leading point present (polyp, Ca). Barium enema unlikely to work, or if works recurrence rate is high,
therefore surgery is 1st line treatment
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MECKEL’S DIVERTICULUM
RULE OF 2s
- Like the appendix, Meckel’s diverticulum is a true congenital diverticulum, a vestigial remnant of the vitelline duct
- 2 inches in length, 2cm wide, 2 feet from ileocaecal valve
- Occurs in 2% of the population, ♂>♀ in the ratio of 2:1
- Usually asymptomatic but if often presents at age 2 if symptomatic
- 2 types of ectopic tissue
Pancreatic (6%)
Gastric (60%) – gastric acid secretion can produce inflammation, peptic ulceration & bleeding, strictures with
subsequent IO
May have both types of tissue or other rarer types (jejunal, colonic, rectal, hepatobiliary, etc)
PRESENTATION
- Usually asymptomatic, found incidentally during barium study or open surgery
- Symptomatic:
1) IO (most common presentation): strictures, intussusception, volvulus, omphalomesenteric band
2) Hematochezia (most common in children): usually massive & painless, due to peptic ulceration
3) Diverticulitis: may present exactly like acute appendicitis i.e. periumbilical pain radiating to RIF. Less prone to
inflammation as most Meckel’s have wide base, little lymphoid tissue & are self emptying
4) Others: umbilical fistula, tumour, perforation etc
INVESTIGATION
Blood: As per IO or lower BGIT
Imaging:
- Technetium-99m pertechnetate scan (investigation of choice): isotope given IV, taken up by gastric mucosa, detected by
gamma scan of the abdomen
- Barium studies: small bowel enteroclysis
- CT NOT helpful as hard to distinguish Meckel’s diverticulum from small bowel loops
MANAGEMENT
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4. ISCHAEMIC BOWEL
RISK FACTORS
Occlusive mesenteric ischemia
a. Embolic (most lodge in SMA) – becoming less common
i. Recent MI
ii. Dysarrhythmia (esp AF embolization)
iii. Valvular heart disease
b. Thrombosis (Virchow’s triad) – becoming more common
i. Age >50
ii. CCF
iii. PVD
iv. Hypovolemia
v. Prothrombotic states – more in venous thrombosis (young)
Non-occlusive (no arterial or venous abn, due to vasospasm and constriction) – 20-30% of acute ischemia
a. Poor perfusion states
i. Hypotension
ii. Hypovolemia
iii. CCF
iv. MI
v. Renal failure
b. Compression from ext sources (eg. intraabdominal tumor)
c. Vasculitis
d. Radiotherapy
e. Vasoconstriction
i. digitalis
ii. strangulation (from volvulus/hernia)
Tissue injury can result from one of 2 mechanisms: (1) ischemic injury to the bowel or (2) reperfusion injury
2 Watershed areas:
a) Marginal artery of Drummond / Griffith’s point: SMA and IMA
b) Sudeck’s point: Left colic artery and Superior rectal artery
a) A hyperactive phase occurs first, in which the primary symptoms are severe
abdominal pain and the passage of bloody stools. Many patients get better and
do not progress beyond this phase.
c) Finally, a shock phase can develop as fluids start to leak through the
damaged colon lining. This can result in shock and metabolic acidosis with
dehydration, hypotension, tachycardia and confusion. Patients who progress to
this phase are often critically ill and require intensive care.
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PHYSICAL EXAMINATION
INVESTIGATIONS
Bloods
1. FBC: high Hb/ Hct (due to plasma loss/ hemoconcentration), high TW >15 in 75%
2. ABG: Metabolic acidosis (persistant) – 50%
3. UECr: renal failure, hypovolemia
4. PT/PTT: hypercoagulable states (if present, can add Protein C/S, AT III)
5. Raised amylase / LDH
Imaging
- AXR
1. Submucosal hemorrhage and edema in the colon produce a characteristic thumbprinting
Others
1. ECG: AF, STEMI
2. Colonoscopy: procedure of choice if the diagnosis remains unclear.
a. Ischemic colitis has a distinctive endoscopic appearance;
b. Rule out alternate diagnoses eg infx/IBD
c. Biopsies can be taken
d. Visible light spectroscopy (analyze capillary oxygen levels), performed using catheters placed through the 5 mm channel of
the endoscope, is diagnostic
MANAGEMENT
Acute
1. ABC
a. maintain airway and give high-flow O2
b. establish at least 1 large bore IV line and infuse fluids at maintenance rate (unless patient in shock)
2. Monitoring (as patients are prone to extensive peritonitis, shock, metab acidosis)
a. Urinary catheter to monitor urine output
3. Consider NGT
4. Antibiotics: IV Cephalosporin? and metronidazole
Definitive
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5. ACUTE APPENDICITIS
HISTORY
- Classic: LOA with periumbilical pain which radiates to the RIF, followed by nausea & vomiting (in ½)
- N/V almost always occurs after pain, if it precedes pain, exclude IO
- May have diarrhoea or constipation
- Inflamed appendix near bladder/ureter may cause irritative voiding symptoms & haematuria
- Fever (late): >39deg uncommon in first 24h but common after rupture
PHYSICAL EXAMINATION
- Most specific physical findings: RIF (McBurney’s point) tenderness on percussion, rebound tenderness, rigidity & guarding
- RIF mass may be palpable
- LIF tenderness in patients with situs inversus or lengthy appendix extending to the LIF
Atypical ppt:
- Infants/children may present with inflamed hemiscrotum due to migration of pus through patent processus vaginalis – often
mistaken for acute testicular torsion
- Retrocaecal right flank pain
- Pregnancy pushes appendix up right upper quadrant pain
- Pelvic appendix irritates bladder and rectum suprapubic pain, pain on urination, feeling of need to defaecate
CAUSES
- Obstruction of appendiceal lumen
Faecaliths: calcium salts & faecal debris collect around nidus of faecel material within appendix
Lymphoid hyperplasia: a/w inflammatory (Crohn’s) & infective dz (GE, URTI, IMS, measles)
Less common causes: parasites, TB, tumour, FB
DIFFERENTIAL DIAGNOSES
1) Mesenteric adenitis: self limiting inflammation of mesenteric LNs in RIF, a/w viral infections
2) Meckel’s diverticulitis: inflammation of Meckel’s diverticulum (see below)
3) Terminal ileitis: usually due to Crohn’s disease
4) Typhilitis/caecitis
5) Ischaemic colitis
6) Colon cancer
7) Appendiceal stump appendicitis
8) Psoas abscess
Most frequent misdiagnoses in Females: PID, followed by gastroenteritis and urinary tract infection / in Children: gastroenteritis,
followed by upper respiratory infection and lower respiratory infection.
INVESTIGATIONS
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MANTRELS Score
Characteristic Score
M = Migration of pain to the RLQ 1
A = Anorexia 1
N = Nausea and vomiting 1
T = Tenderness in RLQ 2
R = Rebound pain 1
E = Elevated temperature 1
L = Leukocytosis 2
S = Shift of WBCs to the left 1
Total 10
MANAGEMENT
Delayed diagnosis and treatment account for much of the mortality and morbidity associated with appendicitis.
The rate of perforation varies from 16% to 40%, with a higher frequency occurring in younger age groups (40-57%) and in patients
older than 50 years (55-70%), in whom misdiagnosis and delayed diagnosis are common.
Complications occur in 1-5% of patients with appendicitis, and postoperative wound infections account for almost one third of the
associated morbidity.
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5. OESOPHAGEAL DISEASES
- Structure: mucosa, submucosa, muscularis propria, adventitia (no peritoneal lining except for a short segment of intra-
abdominal oesophagus) very distensible
Muscularis propria is composed of striated muscle in the upper one-third, striated and smooth muscle in the middle third, and
smooth muscle in the lower third
- Blood supply (roughly divided into thirds): Inferior thyroid artery to upper third, oesophageal branches of the aorta to the middle
third, oesophageal branches of left gastric artery to lower third
- Venous return also divided into thirds: Brachiocephalic veins (upper), azygos veins (middle), left gastric vein (lower) --- a
portosystemic anastomosis exists at the lower oesophagus thus leading to formation of varices in portal hypertension
2. PHYSIOLOGY OF SWALLOWING
- The tongue then contracts upwards and backwards pushing the food bolus against the hard palate
- As the base of the tongue is elevated posterior, the epiglottis falls back; at the same time, the pharyngeal muscles contract to
bring the posterior surface of the larynx upwards to make the laryngeal inlet smaller closed off by the epiglottis
- Pharyngeal muscles contract to propel food bolus past the relaxed cricopharyngeus into the oesophagus
- Once in the oesophagus, involuntary contractions of the muscularis propria form peristaltic waves to propel food bolus into
stomach
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3. APPROACH TO DYSPHAGIA
CAUSES OF DYSPHAGIA
- In each anatomic region the dysphagia can be caused by neuromuscular dysfunction (impaired physiology of swallowing) or
mechanical obstruction to the lumen
Oropharyngeal Oesophageal
Functional (Neuromuscular diseases) Functional (Neuromuscular diseases)
Stroke Achalasia
Parkinson’s disease Spastic motor disorders
Brain stem tumours Diffuse oesophageal spasm
Degenerative conditions e.g. ALS, MS Hypertensive lower oesophageal sphincter
Nutcracker oesophagus
Peripheral neuropathy Scleroderma
Myasthaenia gravis
Myopathies e.g. myotonic dystrophy
Others
Oesophagitis: Reflux
Infectious (candida, herpes)
Radiation-induced
Medication-induced
Chemical-induced (alcohol)
- Triad of dysphagia (oes web), glossitis, angular stomatitis (Fe def anemia)
- post menopausal women
- genetic and nutritional factors
- premalignant oes/hypopharynx/oral SCC
- Tx: Fe supplement, Oes dilatation
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HISTORY
I. Dysphagia: a) Difficulty initiating / Food stuck
b) Solids / Liquids initially
c) Progressive (CA, stricture) / Intermittent (webs, rings, oes spasm, nutcracker)
II. Associated symptoms: a) Odynophagia
b) Choke, cough, nasal regurgitation
c) Regurgitation of undigested food
d) Nasal voice
III. Complications
IV. RF
(i) Oropharyngeal
- Presenting complaint is usually of difficulty in initiating swallowing
- May be associated with choking, coughing, nasal regurgitation
- Voice may sound nasal (bulbar palsy)
- Cause of oropharyngeal dysphagia is usu neuromuscular rather than mechanical; stroke is the most common cause
(ii) Oesophageal
- Presenting complaint is that of food “getting stuck” in the throat or chest
- Patient’s localisation of the symptom often does not correspond to actual site of pathology
- Can be due to either neuromuscular dysfunction or mechanical obstruction
(i) Mechanical
1. Patient complains of more difficulty swallowing solids than fluids
2. May have regurgitation of undigested food
3. Recent onset dysphagia that is progressively worsening, with loss of weight high suspicion of oesophageal cancer
- Intermittent symptoms are suggestive of webs, rings
(ii) Neuromuscular
1. Patient complains of more trouble swallowing fluids than solids
2. Dysphagia more long-standing, slowly progressive
3. Intermittent symptoms suggestive of diffuse oesophageal spasm, nutcracker oesophagus
4. May have history of stroke, neuromuscular disease
(a) Oesophagitis: infectious (candida, herpes), post-radiation, chemical-induced (usually alcohol), reflux oesophagitis
(b) Oesophageal spasm
(c) Scleroderma
(d) Achalasia (occurs late)
(e) Oesophageal cancer (occurs late)
(f) Oesophageal rupture/stretching
4. Complications (3)
- Symptoms of anaemia (bleeding from tumour, or as part of Plummer-Vinson syndrome)
- Symptoms of aspiration pneumonia – fever, cough, shortness of breath esp at night
- Locally advanced tumour:
o Hoarseness (recurrent laryngeal nerve)
o Thoracic spine pain (spread posteriorly to thoracic spine)
o SOB (pleural effusion sec to lymphatic blockage by tumor infiltration)
o Fever, cough and haemoptysis (tracheo-oesophageal fistula)
o Haematemesis (invasion into aorta massive bleed) – rare
Always differentiate hematemesis from hemoptysis.
- Mets: Neck lump (LN), jaundice, bone pain
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PHYSICAL EXAMINATION
1. General condition
- Vitals: the patient may be hypovolaemic from vomiting/decreased intake
o Nutrition: presence of cachexia
o Dehydration (mucous membranes, skin turgor, etc)
- Conjunctival pallor: bleeding from tumour, oesophagitis ulcerations, or associated with P-V syndrome
- Scleral icterus: metastases to liver
2. Disease/Causes
- Presence of cervical lymph nodes (esp Virchow’s node)
- Scars/marks over the chest and abdomen suggesting previous radiation
- Palpable mass in abdomen (not likely)
- Neuro examination (esp CN, PD features, myopathy)
- PR examination for malaena
- Bedside swallowing test?
3. Complications of disease
- Signs of pneumonia: patient febrile, may be toxic, lung crepitations, decreased air entry usually over right lower lobe
- Signs of mets: Hepatomegaly, Ascites
4. Treatment
- Tube feeding through NG tube, gastrostomy/jejunostomy – if aspirates seen, what is the colour?
- Total parenteral nutrition
- Surgical scars
MANAGEMENT
1. Stabilise patient
- Resuscitate if patient is haemodynamically unstable
- IV fluids (correct fluid deficits and also any electrolyte derangements)
- Feeding
o Consider feeding with fluids if patient can tolerate it (only having problems with solid food) otherwise consider tube feeding or
TPN need to correct patient’s nutritionally debilitated state
o Keep NBM if patient cannot tolerate even fluids
- Treat any aspiration pneumonia – NBM, IV antibiotics
INVESTIGATIONS
Diagnostic
1. Barium swallow
- Advantage of barium swallow is that it is less invasive than OGD, especially when suspecting webs, diverticula in the oesophagus
where OGD may cause perforation;
- CI in patients with difficulty initiating swallowing high risk of aspiration (therefore, give slowly and carefully)
- Visualisation of obstructive lesions:
o Shouldering of a stricture (benign strictures form a smoother contour whereas malignant strictures form a more right-angled
contour)
o Bird’s beak sign of achalasia
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2. Oesophagogastroduodenoscopy (OGD)
- Advantage is direct visualisation of the lesion and ability to take tissue biopsy (especially useful in malignancy)
- May also be therapeutic (stopping bleeding from a tumour, stenting the lumen, etc)
3. Manometry
- Used to assess oropharyngeal dysphagia (neuromuscular causes) by looking for penetration and aspiration of various consistencies of
food during swallowing
- VFES limited to cervical oesophagus (unable to exclude distal oes lesions)
Supportive
1. Blood investigations:
- Urea, electrolytes, creatinine – electrolyte disturbances from vomiting, poor intake; raised creat and urea in dehydration (creat will be
raised more than urea if patient has prerenal failure from dehydration)
2. CXR
- If patient complains of reflux symptoms and no signs are seen on OGD (see later section on Gastro-oesophageal reflux disease)
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4. OESOPHAGEAL CANCER
EPIDEMIOLOGY
- Third most common gastrointestinal tract cancer in Singapore (1st: CRC, 2nd: gastric)
- M > F, Adenocarcinoma more common in West whereas SCC more in East
- Increasing incidence with age
- Decreasing incidence overall, increasing in distal oes
RISK FACTORS
SCC (70%) Adenocarcinoma (30%)
Modifiable 1. Smoking (100X) 1. Smoking (10X)
2. Alcohol (2X) 2. Obesity GERD Barrett’s
3. Caustic injury [middle 1/3]
4. Diet: Hot drinks, preserved foods (nitrosamines), betel nuts;
vitamin / mineral def (selenium, vit E, beta-carotene)
Non- 1. Achalasia (2-8%) Barrett’s (30-40X, 1% per year) [distal 1/3]
modifiable 2. PV synd (10%) [upper 1/3]
3. Tylosis (AD disorder with keratosis of palms and soles)
4. Oes. diverticulum
5. Irradiation
PATHOLOGY
STAGING
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PRESENTATION
Usually of insidious onset, with earliest symptoms being non-specific e.g. retrosternal discomfort, “indigestion”, and most patients
already have advanced disease when they are diagnosed
– 75% have lymph node involvement at time of diagnosis.
– 50% of patients have unresectable cancer on presentation
1. Dysphagia
- Present in 80% of patients – most common presentation
- Lack of serosa oes is distensible > 60% occlusion is needed before dysphagia occurs (Late presentation – T3/4)
2. LOW (classically withOUT LOA – patient still feels hungry)
3. Regurgitation
Complications
INVESTIGATIONS – 4 OBJECTIVES
(A) Diagnosis
2. Barium swallow
- 92% accuracy in showing mucosal irregularity & annular constrictions but not able to dx malignancy with confidence
- Useful if OGD cannot pass through
(B) Staging (Look very hard for CI of surgery due to high morbidity and mortality)
i. Local
1. Endoscopic ultrasound (ideal in CA oes, rectal, stomach as structures are enclosed)
- If endoscope can pass around the lesion, good for T staging (T) – depth of invasion
- Also to identify enlarged regional lymph nodes (N) – FNA to confirm mets
Suspect LN mets if round, hypoechoic, well-defined borders
2. CT scan or MRI
- Can be used for T, N, and M staging
- CT T: local invasion, regional LN,
CT AP: liver/ adrenals mets, distant LN,
CT Neck: cervical LN
- Upper oes: CT NTAP
Lower oes: CT TAP
3. Bronchoscopy
a. Exclude direct tracheal involvement especially in tumours involving upper two-thirds of oesophagus
b. Laryngoscope : vocal cord paralysis
Look very hard for CI of surgery due to high morbidity and mortality.
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ii. Distant
1. Chest X-ray
- Mets
o Presence of any lung metastases
o Pleural and/or pericardial effusion
- Cx
o Aspiration pneumonia
o Tracheal deviation or extrinsic compression of tracheobronchial system
o Widened superior mediastinum in an upper oesophagus tumour
o Raised hemidiaphragm with phrenic nerve involvement
(C)Complications
3. Liver function tests – low albumin with nutritional deprivation, liver mets (rare)
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TREATMENT
Principles
- Three modalities available – surgery, chemotherapy, radiotherapy – used singly or in combination
- Aims of treatment: Curative or palliative (50%)
- Surgical treatment is usually performed with curative intention, but can also achieve good long-term palliation of symptoms
- Choice of treatment depends on several patient factors: age, co-morbidities, nutritional state, life expectancy, and prognosis
Surgery
- Curative in early lesions and part of multimodal therapy in more advanced stages
- Resection should not be done in patients with distant metastases or contraindications to surgery
1. Endoluminal surgery – for early lesions (Tis, T1a); no attempt to remove any LNs (usually no LN involvement)
i. Endoscopic mucosal resection (EMR) – Cx: bleeding, perf (may be prevented with sufficient saline injection to raise the
mucosa containing the lesion), stricture
ii. Mucosal ablation using photodynamic therapy , Nd-YAG laser, or argon plasma coagulation
2. Oesophagectomy
(ii) Trans-hiatal
Done via two incisions – one in the abdomen and one in the neck
Blunt oesophagectomy, gastric mobilisation, and gastro-oesophageal anastomosis in the neck
Less morbidity than Ivor-Lewis as the chest is not opened, but controversial
No difference in survival between trans-hiatal and I-L modalities; the stage of the cancer when the operation is performed is
a greater factor influencing survival
Oesophagectomies have high mortality (5-10%) and morbidity (25%) rates, thus patients have to be carefully selected in
order to maximise survival benefit from surgery
Complications
Dependent on extent of surgery and incisions used
- Intraoperatively, injury to lung, thoracic duct, RLN can occur
Radiotherapy
- Usually given in combination with chemotherapy
- Primary treatment for poor-risk patients
Palliation for unresectable lesions with obstructive symptoms, pain and bleeding
- SCCs are radiosensitive
- Modalities: External beam radiation or brachytherapy
- Obstructive symptoms may worsen temporarily after radiotherapy due to oedema
- Complications: tracheo-oesophageal fistula, stricture
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Chemotherapy
- Current regimen: 5-Fluorouracil and cisplatin
- Addition of chemotherapy to external beam radiation for unresectable cancers shown to have improved survival compared to
EBRT alone
- Chemotherapy given preoperatively and postoperatively improves survival
Palliative treatment
1. Ablation
o Endoscopic laser fulguration (high frequency electric current)
o Photodynamic therapy is a new treatment option - use of drugs that are absorbed by cancer cells; when exposed to a
special light, the drugs become active and destroy the cancer cells
o Radiofrequency
o Cryotherapy
2. Surgical debulking
3. Bypass surgery rarely done nowadays
4. Stenting to maintain lumen patency and occlude fistulas – endoscopic / radiological?
o Cx: metallic Perf (friable tumor)
Bleeding
Risk of GERD, aspiration lifelong PPI
PROGNOSIS
- 80% mortality at 1 year, overall 5-year survival <10%
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5. GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD / GERD)
EPIDEMIOLOGY
Incidence in Singapore not known
Increasing prevalence, more common in males than females
Singapore Chinese > other races
PATHOPHYSIOLOGY
- Lower oesophageal sphincter is a physiological sphincter with various mechanisms that help to prevent reflux
- Some physiological reflux occurs that is rapidly cleared by peristaltic movements in the oesophagus
- GORD results from various pathophysiological factors (loss of the normal protective mechanisms, or the mechanisms are
overwhelmed) singly or in combination:
I. Motor failure of oesophagus with loss of peristalsis
II. Loss of LES function – decreased tone, hiatal hernia, iatrogenic injury
III. Increased intra-abdominal pressure – obesity, tight garments, large meal
- Acid incites inflammation in lower oesophagus – extent of inflammation increases with increasing duration of contact with acid
- Chronic inflammation results in complications of GORD: oesophagitis, stricture, Barrett’s oesophagus
CAUSES/RISK FACTORS
- Motility disorder of oesophagus e.g. scleroderma
Malfunction of LES
Hiatal hernia (loss of normal LES mechanisms)
Drugs that cause smooth muscle relaxation e.g. calcium channel blockers, sedatives, beta agonists, anticholinergics, etc.
Coffee and smoking also cause LES relaxation.
- Chronically increased intra-abdominal pressure – pregnancy, chronic cough, obesity, constipation, etc
- Eating habits – lying down after a heavy meal
Any cause of decreased gastric emptying
PRESENTATION
- Complications
o Long-standing disease can lead to dysphagia due to stricture formation; dysphagia can also result from an underlying
oesophageal motility disorder; odynophagia suggests oesophagitis with ulceration
o Reflux can also lead to pulmonary symptoms: chronic cough, chest infections (aspiration)
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COMPLICATIONS
1. Pain and spasm
2. Stricture
3. Shortening of oesophagus
4. Dysmotility
5. Haemorrhage (occult > frank)
6. Ulceration
7. Barrett’s oesophagus (see below)
8. Schatzki’s ring (constrictive ring at the squamocolumnar junction composed of mucosa and submucosa)
9. Malignancy (adenocarcinoma arising from Barrett’s oesophagus)
DIAGNOSIS
1. History!! is important as most patients with reflux are seen in the primary setting with no facilities for detailed investigation
- Exclude cardiac cause of chest pain, and exclude malignant cause of dysphagia
- GerdQ questionnaire
2. Oesophageal pH probe
- Confirmatory test for reflux is the ambulatory 24hr oesophageal pH probe especially if oesophagitis is not seen on OGD
- Antimony probe (24hr) most commonly used; alternative is the Bravo capsule (a wireless capsule that is temporarily attached to the
oesophageal wall, 48hr)
- The probe is placed 5cm above the manometrically-determined upper limit of the LES (for the wired probe), or 6cm above the
endoscopically-determined squamocolumnar junction (for the wireless capsule)
- Diagnosis based on the percentage of time in 24hrs the pH reading is below 4 (positive if >5.5%)
- Can have false negative consider repeat test. Either one positive is diagnostic.
3. Oesophagogastroduodenoscopy
- Cannot actually diagnose reflux (poor correlation btw oesophagitis and reflux). Therefore, selective usage.
- Uses:
o Dx: Rule out gastric malignancy/ other conditions mimicking symptoms (in areas with high prevalence of gastric CA)
o Cx: Can visualise and grade oesophagitis if present, and take biopsy specimens for confirmation (see below)
o Ax: May see a hiatal hernia which is associated with reflux (though not all patients with hiatus hernia will have reflux)
5. Manometry
- No value in reflux except for detecting motility disorder (tro achalasia! – will be much aggravated by surgical Tx of reflux)
GRADING OF OESOPHAGITIS
1. Savary-Miller classification
Grade I: One or more supravestibular non-confluent reddish spots, with or without exudates
Grade II: Erosive and exudative lesions, may be confluent but not circumferential
Grade III: Circumferential erosions covered by haemorrhagic and pseudomembranous exudate
Grade IV: Presence of chronic complications such as deep ulcers, stenosis, stricture
Grade V: Barrett’s metaplasia
- Relevance of classification schemes: subjective and dependent on assessment by the endoscopist; also, due to the multitude of
classification schemes available, just mentioning a grade may not have any meaning if the actual abnormalities are not described
- heartburn severity or the symptoms do not reliably predict the severity of erosive esophagitis; older patients experience less symptoms
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TREATMENT
Lifestyle
2. Avoid drugs that relax LES e.g. anticholinergics, muscle relaxants, etc.
Medication
1. Acid suppression therapy: PPI (best! switch ard if patient doesn’t respond to one, rather than increasing dosing frequency) or
H2-receptor antagonists
May require LT tx. If patient stops PPI and symptoms recur, restart PPI first, no need to reinvestigate.
2. Prokinetics to increase LES pressure e.g. domperidone (anti-dopaminergic), metoclopramide (anti-dopaminergic + anti-
serotoninergic)
Surgical
- Indications:
Failure of medical therapy (or incomplete resolution of symptoms)
Oesophagitis with frank ulceration or stricture
Complications of reflux oesophagitis – respiratory complications, Barrett’s oesophagus
Severe symptoms or progressive disease
Compliance problems - patient does not want to be on medication for life (despite good results)
- Goal of surgery:
Increase pressure at the gastro-oesophageal junction but not so much that it prevents food from entering the stomach (too
tight dysphagia)
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- Fundoplication (mainstay of surgical therapy)
Can be done via open surgery or laparoscopic surgery (most laparoscopic now)
a. Nissen fundoplication is the most commonly done – a 360 degree (total) wrap of the fundus around the gastro-
oesophageal junction
b. Partial fundoplications can also be done in patients where oesophageal motility is poor or the oesophagus is
foreshortened; anterior 90 degrees, anterior 180 deg, and posterior 270 deg fundoplications are various options available
- Complications of surgery
1. Perforation – most feared complication, may result in mediastinitis if not promptly detected and repaired intraoperatively
4. “Slipped-Nissen” body of the stomach intussuscepts through the fundoplication, creating an hourglass deformity whereby
the stomach resides both above and below the wrap; usually due to a foreshortened oesophagus unrecognised in the
first operation. Causes severe reflux as pouch above the wrap traps food and serves as reservoir.
5. “Gas bloat syndrome” – patient experiences difficulty burping gas that is swallowed (gas accumulation)
- Outcome of surgery
80-90% Excellent to good (no symptoms, no medications and lifestyle changes required)
10-15% Satisfactory (some residual symptoms)
<5% Unsatisfactory
<1% Mortality
5-40% need for acid suppression therapy at 5 years due to symptoms
- Management of stricture
Rule out malignant cause of stricture by taking biopsy
1. Dilatation (variety of means available – balloon, dilators, etc)
2. Treatment of underlying reflux
3. If resistant to dilatation resection and reconstruction
Others
- Nerve stimulation? of LES to increase tone (still under research)
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6. BARRETT’S OESOPHAGUS
FEATURES
- Diagnosis:
Endoscopy and histology:
The squamocolumnar junction (or Z line) is visible on endoscopy as gastric and intestinal type epithelium is pink and
granular in appearance, but stratified squamous epithelium is smooth and pale
The gastro-oesophageal junction is defined as the point where the gastric folds begin
If the squamocolumnar junction is above the gastro-oesophageal junction (i.e. they do not align) and biopsy of the junction
shows intestinal metaplasia, the patient is diagnosed to have Barrett’s oesophagus
- Complications:
Short segment Barrett’s is defined as the squamocolumnar junction being <3cm above the gastro-oesophageal junction
Long segment Barrett’s the distance between the two junctions is >3cm: associated with more severe reflux, as well as
higher risk of dysplasia and subsequent adenocarcinoma development than short segment Barrett’s
MANAGEMENT
2. Endoscopic surveillance
- Not certain regarding benefit for surveillance if patient has Barrett’s but no dysplasia if 2 scopes in a year reveal no
dysplasia, repeat OGD once every 3 years (half-yearly 3 yearly)
- Main purpose of surveillance is to pick up dysplasia
- If patient has high grade dysplasia, it should be treated (see below), otherwise to undergo intensive surveillance (3 mthly
for at least one year) to detect cancer development
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7. ACHALASIA
FEATURES
- Abnormal peristalsis secondary to absence or destruction of Auerbach’s (myenteric) plexus and failure of the LES to relax;;
affects body and distal oesophagus
- Lacks nonadrenergic, noncholinergic, inhibitory ganglion cells, causing an imbalance in excitatory and inhibitory
neurotransmission. The result is a hypertensive nonrelaxed esophageal sphincter
- Aetiology unknown
- Adults, M:F = 1:1
- Patients present with dysphagia, regurgitation, weight loss, retrosternal chest pain, and recurrent pulmonary infections
- Barium swallow demonstrates “bird’s beak” narrowing of distal oesophagus with proximal dilatation
- Manometric studies (required for diagnosis) show abnormally high pressures at the LES, with incomplete LES relaxation on
swallowing, and lack of progressive peristalsis (often aperistaltic)
TREATMENT
Intrasphincteric injection of botulinum toxin to block the release of acetylcholine at the level of the LES (problem is that it is
not long lasting and only used in patients not fit for surgery)
Pneumatic balloon dilatation (A balloon is inflated at the level of the gastroesophageal junction to blindly rupture the muscle
fibers while leaving the mucosa intact): about 65% of patients improve, 40% response rate at 5 years)
Calcium channel blockers and nitrates (both decrease LES pressure but do not improve LES relaxation. Used in elderly who
are not suitable for surgery/dilatation)
- Surgical treatment (primary Tx):
Laparoscopic Heller cardiomyotomy (much like Ramstedt pyloromyotomy for pyloric stenosis) – good results with 85%
symptom-free after 5 years; there is a 3% chance of developing reflux
addition of fundoplication (partial wrap) helps prevent this
Esophagectomy was the standard treatment in patients with achalasia and a markedly dilated or sigmoid-shaped esophagus
(controversial)
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6. UPPER GIT
CAUSES
Variceal vs Non-variceal!
1. Nature of bleeding
Haematemesis
- [oes] Can be fresh red blood as in variceal bleeding, Mallory-Weiss tear, AV malformation
- [gastric] Coffee grounds vomitus is altered blood (due to gastric acid) and can come from gastric ulcer, gastritis/erosions, or variceal
blood that has entered the stomach [oes]
Malaena
- Altered blood; malaena indicates bleeding from the upper GIT i.e. above the ligament of Treitz
- Different types of malaena:
(a) Fresh malaena – jet black with sheen, tarry, non-particulate (almost liquid in consistency), foul smelling, floats on water –
maroon when you spread it out on gloves
(b) Stale malaena – black-grey, dull, mixed with normal stool, occasionally particulate
(c) Iron stool – greenish hue on rubbing between gloved fingers, particulate.
- If gloved finger is stirred in a cup of water, malaena will “dissolve” completely with no sedimentation and turn the water black, but iron
stool will sedimentate and turn the water green
Frank PR bleeding
- Very brisk upper GI bleed can present as frank PR bleeding as blood passes down so fast it doesn’t get altered
2. Amount of blood
3. Aetiological clues / RF
Gastric ulcer/gastritis/erosions
- Any history of dyspepsia, gastric ulcer (any OGD done in the past showing these problems? On any “gastric” medications?)
- Any drugs that may predispose – NSAIDs, antiplatelets, steroids, anticoagulants, TCM
Varices
- Any history of chronic liver disease
- Previous variceal bleeds
Mallory-Weiss tear
- Binge-drinking with subsequent severe retching and vomiting leading to haemetemesis
Malignancy
- Recent constitutional symptoms e.g. LOA, LOW, malaise
- Early satiety
- Dyspepsia
4. Complications
- Symptoms of anaemia: postural giddiness, shortness of breath, lethargy, effort tolerance, palpitations, chest pain
- AMI esp. if it’s an old patient with previous history of IHD
5. Comorbidities
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PHYSICAL EXAMINATION
1. Vitals!
- Blood pressure, heart rate stable? Any postural hypotension? (Tachycardia is an early sign of shock)
Narrowing pulse pressure (ind systolic hypotension) - check if patient is on BB!!
- RR>20
- Patient’s conscious level – confused? (shock)
- Compare current vitals with vitals in ambulance, ED – is there a worsening trend?
- Urine output: renal perfusion indicates cardiac output
2. General inspection
- Pallor
- Cold clammy peripheries impending shock
- Stigmata of chronic liver disease
3. Peripheries
- Cold clammy peripheries impending shock
- LN (mets)
4. Abdomen
- Any tenderness (not very helpful), epig mass
- Distension (++ blood in stomach)
IMMEDIATE MANAGEMENT
1. Resuscitation
2. Adjuncts
- NG tube if patient is having haematemesis – prevents aspiration, allows gastric lavage prior to OGD (DO NOT insert if suspect varices)
- Catheterisation – monitor I/O balance esp in elderly or when large amount of fluid resuscitation required, or anticipating surgery
- Intubate if: 1) massive uncontrolled active hematemesis
2) signs of decompensation eg. obtunded
3. Early medications
4. Close monitoring
- Monitor for: SHOCK ( HR, BP, urine output, confusion & lethargy)
- HD with hourly para if
Elderly with many comorbidities
Hypotension
5. Emergency oesophagogastroduodenoscopy
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Alternatively, scope the next available OGD (usually following day)
- 3 Indications:
1. Shock / hemodynamic instability (ensure BP is stable before OGD - requires sedation)
2. Active BGIT (esp hematemesis, also fresh malaena)
3. Suspected variceal bleed
Not just low Hb as emergency scope causes more stress.
- Ensure bloods are running before OGD!
- Role of endoscopy
Diagnostic:
confirm UBGIT & identify source of bleeding,
Biopsy (+ CLO test if ulcer)
Therapeutic:
1. Varices: ligation/sclerotherapy, glue
2. Non-variceal: Clip, Coag, Injection
- CI: Perforation - air sufflation during OGD will cause
abdominal compartment syndrome --> decrease venous return --> patient may DIE
splinting of the diaphragm
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2. VARICEAL BLEEDING
1. Resuscitate
- Airway, breathing, circulation
- If patient appears well, look for early signs of shock – tachycardia, postural hypotension
- Look at hydration status
6. Acid suppression
- Increasing intragastric pH increases clot stability, aids haemostasis
- Agents available: omeprazole (Losec), esomeprazole (Nexium), pantoprazole, etc.
7. Antibiotics
- Not given in ulcer bleed
- Risk of sepsis in patients with CLD and bleeding
- Studies have shown that cover with broad spectrum Abx (Gram neg cover) infectious cx, mortality, and also risk of recurrent bleed
- Ceftriaxone, Ciproflox 1g/day
- Preferably started before endoscopy (procedures increase bacteraemia)
8. Emergency endoscopy
- Purpose: confirm diagnosis and institute management
- Needs to be done emergently (on admission) as soon as patient is stabilised since bleeding can be torrential and life-threatening
- Intervene if ESRF present or active bleed (not electively)
- Banding/Ligation is the best modality for oesophageal variceal bleeding (sclerotherapy a/w higher morbidity e.g. mucosal ulceration)
- Gastric varices are usually too large to be banded, sclerotherapy/ Glue (Histoacryl) used instead – risk of embolism from histoacryl
9. Observation
- Keep patient in ICU!
- NBM 2-3/7
- Continue antibiotics and omeprazole
- Continue somatostatin up to the point where haemostasis is achieved or 5 days (exact ideal duration not well studied)
- Antiencephalopathy Tx: Lactulose + Cipro (clear gut to prevent absorption of NH3)
- Anticipate complications:
(a) encephalopathy – fleet and lactulose, treat hypokalaemia from vomiting
(b) aspiration – protect airway; ?benefit of gastric decompression using NG tube
(c) risks of procedure – OGD-related risks
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If bleeding stops, home in around 1/52 Rescope before home! (ligate if rebleed)
If bleeding is not remediable by endoscopic intervention:
A. Insert Sengstaken-Blakemore tube up to 48hr (only temporary) repeat endoscopy 10-12 hours later
If rebleed after 48hr of SBT: consider surgery
C. Shunt surgery
Portocaval shunts (portal vein to IVC)
– side-to-side, end-to-side
Mesocaval shunts (sup mesenteric vein to IVC)
Proximal splenorenal shunt (splenectomy with end-to-
side anastomosis of portal side of splenic vein to left
renal vein)
Distal splenorenal shunt (Warren-Zeppa shunt –
splenic vein divided, splenic side anastomosed end-to- A. Normal liver with normal blood flow. B. End to side spelnorenal shunt.
side to left renal vein) C. End to side portacaval shunt. D. Mesocaval H-graft shunt
Splenectomy
Proximal gastric devascularisation
Selective vagotomy
Pyloroplasty
Oesophageal devascularisation
Oesophageal transection
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II. PROPHYLAXIS OF VARICEAL BLEEDING
In pts with small varices with no risk of bleeding, the use of propranolol is of questionable benefit – repeat OGD to monitor varices.
- cardiac output by β1 blockade and splanchnic blood flow by blocking vasodilating β2 receptors at splanchnic vasculature
- The use of beta-blockers decreases the risk of initial variceal bleeding by approximately 45%, to be continued indefinitely
- The dose: determined by a 20% decrease in baseline resting HR / decrease in HR to 55 bpm / dev adverse effects
- If contraindications to using beta-blockers exist, long-acting nitrates (eg, isosorbide 5-mononitrate) are alternatives
- Band ligation/ Sclerotherapy: not used as primary prevention. as effective as treatment with propranolol
1 Site: varices at the GE junction have the thinnest coat of supporting tissue and are at highest risk of rupture and bleeding
2 Size:
F1: Small straight varices
F2: Enlarged tortuous varices that occupy less than one-third of the lumen
F3: Large coil-shaped varices that occupy more than one-third of the lumen
3 Child’s score – patients with higher Child’s score have higher risk
4 Red signs:
Red wale marks (longitudinal red streaks)
(ESRH) Cherry red spots (flat discrete spots)
Haematocystic spots (raised discrete spots – resemble “blood blisters”)
Diffuse erythema
- Start patient on an ablation regimen (endoscopy with initial ligation/sclerotherapy and subsequent endoscopic monitoring and
repeated ligation/sclerotherapy as required to completely ablate varices)
- If patient bleeds again failed ablation consider surgery (as above – shunts, or Sugiura)
- LT propanolol + PPI
- Refer to Hepato for liver disease
http://www.heart-intl.net/HEART/011507/PortalHypertension.htm
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3. PEPTIC ULCER DISEASE
EPIDEMIOLOGY
- Incidence about 100 per 100,000 per year
- 68% of patients are over 60 years of age
- Overall mortality 7-10%, unchanged for last 20yrs – mostly due to ulcer bleeding esp in elderly with significant comorbidities
H. pylori
- 60% of population are positive for H. pylori by age 21
- About 10-20% of infected patients develop an ulcer
- Accounts for 90-95% of duodenal ulcers, and 50% of gastric ulcers
NSAIDs
- Accounts for most of the rest of ulcer disease not caused by H. pylori
- 30% of patients on NSAIDs will get an ulcer, of which 20% (6% overall) will have a clinically significant ulcer i.e. symptomatic, bleeding
Other factors
- Cigarette smoking
- Alcohol
- Steroids and anticoagulants do not increase the risk of ulcer formation, but increase the risk of bleeding in an existent ulcer
PATHOGENESIS
- An imbalance between mucosal protective mechanisms against acid, and aggressive forces that damage the gastric mucosa
- 2 Aggressive forces: gastric activity and pepsin activity
- 5 Protective mechanisms: mucus secretion, bicarbonate secretion into mucus, robust mucosal blood flow to remove protons, epithelial
regenerative capacity, prostaglandin secretion by mucosa to maintain blood flow
- H. pylori causes a local inflammatory reaction and secretes enzymes that break down the gastric mucosal barrier, and also enhances gastric
acid secretion and decreases bicarbonate production
- NSAIDs impair mucosal prostaglandin production (through non-selective COX inhibition) prostaglandins are important for mucosal
bicarbonate and mucin production and inhibiting gastric acid secretion, as well as maintaining mucosal blood flow
PRESENTATION
2. Symptoms of dyspepsia
(a) Ulcer-like dyspepsia: pain in the upper abdomen is the predominant symptom
(b) Dysmotility-like dyspepsia: non-painful discomfort in upper abdo, a/w upper abdo fullness, early satiety, bloating, belching, nausea
(c) Unspecified dyspepsia
- Pain is usually worse with food in a gastric ulcer, while it is relieved by food in a duodenal ulcer
3. Bleed
- As above, presenting with haematemesis (coffee-grounds vomitus) or malaena
4. Perforation
- Patient presents with sudden generalised abdominal pain that is aggravated by even the slightest movements
- Board-like rigidity, guarding will be present on examination (signs of peritonism)
- Erect CXR will show air under diaphragm
ENDOSCOPY (OGD)
(a) Diagnosis
Confirmation of ulcer disease
Location of ulcer
Biopsy to rule out malignancy – esp gastric (usually 6 bites)
Biopsy of antral tissue for CLO (Campylobacter-like organism) test / rapid urease test for H. pylori: biopsy tissue is placed into a
medium containing urea and an indicator such as phenol red. The urease produced by H. pylori hydrolyzes urea to ammonia, which
raises the pH of the medium, and changes the color of the specimen from yellow (NEGATIVE) to red (POSITIVE).
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(b) Prognostication of bleeding risk (in UBGIT)
Forrest classification (or endoscopic stigmata of recent haemorrhage – ESRH)
Principle: Dual modality better than single (as less risk of recurrent bleed and mortality) --> Usually Injection + Clip/Heater probe
No study proves superiority of either therapy.
Post-endotherapy:
- Monitor for rebleed = drop in Hb (not malaena / vomit blood clots as these are expected. Changes in vitals may be too late.)
- Diet individualised: usually NBM 1-2/7, 3/7 if worrisome, <1/7 if straight forward ulcer
- Re-scope the following day if you’re worried about the outcome from the first scope (notroutine)
- Oralise PPI after 3/7 infusion (if worrisome, can give IV bolus PPI BD)
- TCU 3-4/52 at clinic
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CONSERVATIVE MANAGEMENT
1. Gastroprotection
2. H. pylori eradication
First line triple therapy: omeprazole 40mg BD (for 6 weeks), amoxicillin 1g BD, clarithromycin 500mg BD for 7 days
In penicillin-allergic patients, substitute amoxicillin with metronidazole 400mg BD
Document eradication by endoscopy with CLO test, urea breath test or stool serology testing
Treatment failure occurs in up to 20%
- treat with quadruple therapy: colloidal bismuth subcitrate 120mg QDS, tetracycline 500mg QDS, metronidazole 400mg
BD, omeprazole 20mg BD for 7 days
SURGICAL MANAGEMENT
DUODENAL ULCER
Surgery:
1. Bleed =
a. Duodenotomy + Oversewing/Under-running the bleeding vessel
b. Antiulcer surgery (if patient stable and known case of rebleed/perf)
2. Perforation =
a. Omental patch repair + Bx (small <2cm ulcer / patient unstable)
b. Antiulcer Sx (>2cm or suspect malignancy)
(parietal peritoneum, jejunum serosa, stomach local flap)
3. Definitiveantiulcer surgery
= Duodenectomy + Vagotomy with gastric drainage procedures
- Usually done in elective setting for chronic duodenal ulcers
- Rationale for vagotomy is to eliminate direct cholinergic stimulation to gastric secretion; parietal cells also become less
responsive to histamine and gastrin, and vagal stimulus for gastrin release is abolished
- Vagotomy can be truncal, selective, or highly selective (selecting only those branches that appear to supply peptic cells. does
not require drainage as the Nerves of latarjet that supply the pyloric sphincter are not affected)
- Drainage procedures pyloroplasty (first) or gastrojejunostomy
Usually done with vagotomy as gastric emptying is decreased with denervation.
Pyloroplasty = incise pylorus longitudinally through mucosal layer then suture the incision transversely
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GASTRIC ULCER
Surgery
1. Bleed =
a. Ulcerectomy (if patient unstable, old, unfit)
b. Antiulcer surgery (if patient stable, can tolerate)
2. Perforation =
a. Omental patch repair + Bx (small <2cm ulcer / patient unstable)
b. Antiulcer Sx (>2cm or suspect malignancy)
(parietal peritoneum, jejunum serosa, stomach local flap)
3. Definitive antiulcer surgery = Gastrectomy
a. Partial gastrec if distal ulcer
b. Proximal ½ ulcers may require total gastrec
Can be used in emergency bleed if patient stable, but considered antiulcer Sx as parietal cell mass and antrum (contains
gastrin containing cells) are removed.
Bancroft’s closure (for severe inflammation/scarring that prevents dissection around pylorus. Remove all antral mucosa to
prevent marginal ulcers)
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4. GASTRIC CANCER
EPIDEMIOLOGY
- Fourth most common cancer in males, sixth most common in females in Singapore
- Female to male ratio 2:1
- Incidence 10-18 per 100,000 per year
- Incidence increases steeply after 50 years old
RISK FACTORS
1. Environmental
- Diet: preserved foods (nitrosamines), smoked foods, polycyclic hydrocarbons
- Smoking
- Alcohol
- Occupational exposure: asbestos, heavy metals, rubber
- Low socioeconomic status
2. Genetic
- Blood type A
- HNPCC – Lynch syndrome II
- P53 mutation
- Germline mutation of e-cadherin
- Family history of gastric cancer
PRECURSOR CONDITIONS
2. Gastric polyps
- Highest risk in inflammatory polyps: 75-90%
- 10-20% risk in adenomatous polyps especially in large polyps (>2cm) or those with villous histology
- Also increased risk of adenocarcinoma elsewhere in the stomach
5. H. pylori infection
- 3-6X increased risk of gastric cancer
HISTOLOGY
a) Adenocarcinomas
- Lauren classification:
(a) Intestinal type (most common overall) – occurs in high risk population, distal third of the stomach, in older men; associated with erbB2
and erbB3 receptor stimulation
(b) Diffuse type – occurs in low risk population, proximal third and cardio-oesophageal junction, in younger and female patients; more
aggressive, present later, worse prognosis; associated with K-sam oncogene
b) Non-adenocarcinoma
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MORPHOLOGY
Borrmann’s classification:
LOCATION
- 37% in cardia
- 30% in pyloric channel or antrum
- 20% in body
- 12% in entire stomach
SPREAD
- Lymphatic spread
(a) Regional nodes
(b) Supraclavicular nodes (Virchow’s node)
(c) Umbilical (Sister Joseph’s node)
- Peritoneal seeding to omentum, parietal peritoneum, ovaries (Krukenberg’s tumour), or cul-de-sac / pouch of douglas
(Blumer’s shelf = shelf-like tumor of ant rectal wall DDx tuberculous peritonitis)
PRESENTATION
COMPLICATIONS
- Bleeding
- Gastric outlet obstruction vomiting (dehydration, hypokalaemic metabolic alkalosis, aspiration ± pneumonia)
- Perforation
- Malnutrition
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INVESTIGATIONS
Diagnosis
OGD –visualisation and biopsy (ulcer with heaped-up edges)
Staging investigations
1. CXR/ CT thorax– lung mets
2. Endoscopic ultrasound – gold standard for T staging and good for N staging
3. CT abdo pelvis – good for T, N & M staging
4. Staging laparoscopy prior to operation – picks up small peritoneal metastases that are occult on CT scanning (up to 1/5 of
patients) upstage of disease
Complications
5. FBC – low Hb
6. U/E/Cr – if vomiting, low potassium, low chloride, alkalosis
7. LFTs – albumin as a marker of nutritional status (alb<35 is poor); liver mets
STAGING
CURATIVE TREATMENT
SURGERY
Principles of surgery:
- Wide resection of the tumour to negative margins (at least 6cm margins)
- En-bloc excision of regional lymph nodes
- Choice between total gastrectomy and subtotal gastrectomy
Subtotal gastrectomy leaves a small portion of proximal stomach – easier to anastomose to jejunum than oesophagus since
oesophagus does not have serosa (higher risk of leak)
Subtotal gastrectomy is associated with less morbidity, better functional outcome (some residual reservoir fx preserved)
Total gastrectomy is the resection of choice for proximal tumours (fundus, cardia, body) as well as diffuse-type tumours and
cardio-oesophageal junction tumours
- Reconstruction
Bilroth I (end-to-end gastroduodenostomy) – rarely done (diff to mobilise duodenum to anastomose with residual stomach)
Bilroth II/ Poly-A (gastrojejunostomy) – no protection against biliary reflux into stomach
Roux-en-Y – to prevent biliary reflux; but involves 2 anastomoses, higher chance of leak
Oesophagojejunostomy (after total gastrectomy)
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Complications of gastrectomy:
Early
1. Bleeding
2. Infection
3. Anastomotic leak
4. Injury to surrounding structures eg. pancreas
Late
1. Early satiety
3. Intestinal hurry
a. Inadequate reservoir function leads to poor digestion may have phytobezoar (veg fibre bezoar) formation
4. Dumping syndromes
a. Early dumping syndrome (1/2-1hr after meal): due to increased osmotic load from stomach into small intestine flushing, palpitations,
dizziness, nausea, diarrhoea, hypovolemia (due to rapid entry of water into small intestine)
Treat by eating small frequent meals with low carbo and high protein/fat.
b. Late dumping syndrome (1-3hr later): reactive hyperinsulinaemia alimentary hypoglycaemia (weak, sweat, dizzy).
Treat by eating more carbohydrates.
7. Nutritional deficiency
a. Iron deficiency – mixed picture
i. Loss of intrinsic factor B12 deficiency
ii. Decreased conversion of iron from Fe3+ to Fe2+ by gastric acid decreased iron absorption in terminal ileum
b. Need to supplement with B12 injections and iron supplements
Follow-up
- 2/52-1/12: repeat OGD
- 6/12: detect local recurrence (esp if margin involved), check for B12 deficiency
- 1-2 yr: yearly OGD
CHEMOTHERAPY/RADIOTHERAPY
Adjuvant therapy
5-fluorouracil with chemotherapy
5-fluorouracil with epirubicin for advanced disease
Neoadjuvant therapy
- 5-FU and cisplatin can be used to downstage unresectable, locally advanced disease with a significant increase in resectability (61% 79%)
- For resectable disease: preoperative 5-FU, cisplatin, doxorubicin, methotrexate, followed by intraperitoneal 5-FU
improved resection rates, response rates, median survival
PALLIATIVE THERAPY
- For palliation of symptoms such as pain, bleeding, obstruction
PROGNOSIS
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7. LOWER GIT & COLORECTAL DISEASES
1) Colon
Bleeding diverticulosis
Angiodysplasia
Colorectal carcinoma, polyps
Colitis
- Infective (gastroenteritis, diverticulitis, colorectal TB)
- Inflammatory (UC & Crohn’s)
- Ischaemic
2) Ileum: Meckel’s diverticulum - usually dark red blood
3) Anorectal junction: hemorrhoids
4) Anus: anal fissure
5) Massive Upper GIT bleeding, e.g. bleeding DU
1) Nature of bleeding
Haematochezia
- Mixed with or coating stool
- Torrential or drops, any clots? – Brisk upper GI bleed can present as haematochezia
- Bright red (lower) or darker red (higher)
- Any mucous
Malaena
- Altered blood, indicates bleeding from upper GIT above ligament of Treitz (duodeno-jejunal junction)
- Ask for history as per UBGIT
2) Aetiological clues
Exclude upper GIT cause
- Any malaena, hematemesis, coffee grounds vomitus
- History of PUD, gastritis, varices, Ca stomach, Mallory-Weiss tear, risk factors for each
Bleeding diverticulosis/angiodysplasia
- Usually torrential bleeding that stops spontaneously; altered clots
- History of previous bleeding episodes
Colorectal carcinoma
- Constitutional symptoms: LOW, LOA, fatigue
- Change in bowel habits, tenesmus
- Symptoms of anaemia (chronic occult bleed)
- Previous history/family history of GIT or ovarian cancer
Colitis
- Infective: any fever/chills/rigors, night sweats, N/V, diarrhoea, pain, recent travel/contact history, eating
seafood, previous TB exposure or infection, BCG vaccination status
- Inflammatory: ask about history of UC or Crohn’s, joint, liver, eye & skin manifestations
- Ischaemic: ask about atherosclerotic risk factors, previous AMI, stroke
Hemorrhoids
- bleeding to passing motion, blood coating stool, pain
- Any mass noticed at anus
- History of constipation, hard stools, low fibre diet, chronic straining, recent pregnancy
Coagulopathy
- Any history of bleeding disorders, easily bleeding, petechiae
3) Complications
Symptoms of anemia (may be only presentation!): SOB, postural giddiness, palpitations, chest pain, ↓ effort tolerance,
fatigue, syncope
Symptoms of dehydration & shock: extreme thirst, confusion, pallor, ↓ urine output
May have complication of AMI if old patient with history of IHD
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PHYSICAL EXAMINATION
1. Vitals:
- HR, supine & postural BP –stable? urine output (if catheter in-situ),
- Any fever?
2. General inspection:
- pallor,
- confusion?
3. Peripheries:
- signs of dehydration e.g. capillary refill, dry tongue.
- Any supraclavicular lymph nodes?
- Any skin manifestations of inflammatory bowel disease?
- Stigmata of CLD?
4. Abdomen:
- Scars? Any palpable masses
5. DRE:
- any anal fissures or prolapsed hemorrhoids seen,
- any masses felt,
- any fresh blood or malaena
6. Offer proctoscopy to look for internal haemorrhoids
ACUTE MANAGEMENT
Resuscitation
o Supplemental oxygen, insert 2 large-bore IV cannula with fast infusion of crystalloids (N/S 500ml over ½hr)
o Infuse colloids if ongoing blood loss while waiting for whole blood (GXM)
o Catheterise and monitor urine output, insert NGT on suction to detect UBGIT
o Continuous vital signs monitoring & I/O charting ± CVP & stool chart
o ECG + cardiac enzymes to detect possible AMI
o Take blood for investigations
- FBC: low Hb level (repeat FBC 2-3 hours later or when necessary) – packed cell transfusion
4 pint PCT: give FFP to prevent over-dilution of clotting factors
- UECr: hydration status, any acute renal failure from shock, electrolyte imbalance – replace
- PT/PTT: must correct coagulopathy before trying to stop bleeding – fresh frozen plasma
- LFT: exclude bleeding varices
- ABG: may have metabolic acidosis in shock due to organ ischaemia – IV bicarb, dialysis if severe
- GXM 4 pints
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2. COLORECTAL CANCER
EPIDEMIOLOGY
COMMONEST CANCER IN SINGAPORE
Prevalence in Singapore: 6% (Commonest cancer in M, number 2 cancer in F)
Peak incidence at 60-70 years of age (increase with age)
Increasing incidence through the years.
Chinese more prevalent.
PATHOLOGY
- Almost all tumours are adenocarcinomas
- 90% of tumours are sporadic
- 8% arise in association with hereditary non-polyposis colon carcinoma (HNPCC) and 1% with familial adenomatous polyposis (APC)
- 1% arise in association with long-standing ulcerative colitis (>10 years)
CRC
PATHOGENESIS
Loss of the APC suppressor gene on 5q21 (congenitally absent in patients with familial adenomatous polyposis – APC) is the
earliest event in adenoma formation detected using Protein truncation test
APC is required to break down beta-catenin; with the loss of APC, beta-catenin accumulates and activates various genes in the
nucleus (such as MYC and cyclin D1) which promote cell proliferation
K-RAS (12p12) mutation follows the loss of APC – an activating mutation that causes the RAS to keep delivering mitotic signals
and prevent apoptosis
Loss of tumour suppressor gene at 18q21
Loss of p53 late in carcinogenesis
- The molecular evolution of colon cancer through this pathway occurs through a series of morphologically identifiable stages: localised
epithelial proliferation small adenoma large, more dysplastic adenoma carcinoma in-situ invasive cancer
SITE
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MORPHOLOGY
1. Scirrhous / annular “apple-core” lesions (most common) - more common in the left colon
2. Polypoid – more common in the right colon as there is more space to grow
3. Ulcerated
4. Nodular
SPREAD
RISK FACTORS
Non-modifiable (4)
2. Genetic predisposition
(d) HNPCC (AD) – more common than FAP, accounting for 8% of cancers.
3. Ulcerative colitis
- Increased risk after 10 years of disease if the patient has pancolitis; after 15-20 years if the patient has disease limited to the left colon
4. Adenomatous polyps
- Increased risk if there is a personal history of large (>1cm) adenomatous polyps, and polyps with tubulovillous or villous histology,
particularly if multiple (3-6X increased risk)
- Small (<1cm) tubular polyps do not have increased risk
Modifiable
5. Environmental factors
- Diet:
i. high in red meat, preserved foods (nitrosamines)
ii. high in refined sugar/fat potentially toxic oxidative byproducts by bac degradation
iii. low in fibre decrease stool bulk high fecal retention toxic products in contact with colonic mucosa for longer periods
iv. low in vitamins ACE, minerals lack antioxidants
- Alcohol, smoking
- NSAIDs may be protective against CRC
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HISTORY
A) Presentation
Local:
Right sided 1. Iron deficiency / MCHC anemia – less Fe stores in the body cf folate & B12, so Fe depleted first
(OCCULT 2. Right sided abdo mass
present late) 3. Abdo pain
NO obstruction as stools more liquid and colon more spacious.
Left sided 1. Change in bowel habits (Progressive constipation, alternating constipation and diarrhoea)
(due to MASS 2. Spurious diarrhoea (due to bacteria degradation of prox stools gassy explosive diarrhoea)
EFFECT) 3. Decrease in stool calibre
4. PR bleed (Mixed in stool? / Separate from stool?)
5. I/O
6. Tenesmus = constant intense desire to defaecate. may be painful. defaecation nothing/ small amt of
mucus and loose faeces (due to SOL in lumen/wall of rectum)
7. Mucoid stools (suggests polypoid masses)
Consitutional: LOW, LOA, malaise
Complications:
1. Perforation : Symptoms of peritonism (rigid, guarding, rebound)
2. Intestinal obstruction (4): abdominal distension, abdominal colick pain, vomiting, absolute constipation
3. Haemorrhage
4. Symptoms of fistula, e.g. faecuria/ pneumaturia/ recurrent UTI (colovesical fistula)
5. Involvement of surrounding structures: eg. Rectosigmoid CA: pain, bladder, ureter hydroureter/hydronephrosis, GU
organs (but usually no S/S as uterus wall very thick)
6. Symptoms of infection: abscesses, peritonitis
7. Iron deficiency anaemia (6): fatigue, SOB, CP, palpitations, decreased ET, postural giddiness
Metastasis:
bone pain/ #, LL weakness with loss of sensation, bowel and urinary continence
RHC discomfort (parenchymal involvement most common), jaundice
SOB (pleural effusion most common), decrease ET, orthopnoea
morning headache
Stool Changes
B) Strong-risk factors - Bloody diarrhoea – ddx:
IBD
1. Positive Family history Infective e.g. amoeba, TB, hookworm,
- 1 or more 1st deg relative with CC at age <40 Antibiotic Associated Colitis (C. difficile)
- 2 or more 1st/2nd deg same side relative with CC at any age - Haematochezia = passage of FRESH blood
- Personal or family history of breast, ovarian cancer per anus, usually in or with stools – ddx:
Diverticulitis
2. FAP history / FHx Angiodysplasia (AVM, common in old)
- Diagnosis: Colonoscopy Hemorrhoids
- Can also do Protein truncation test for APC gene mutation Massive upper GI
3. HNPCC: Amsterdam II Criteria – [3, 2, 2, 1] It takes about 14 hours for blood to be broken down within
- ≥3 family members from the same side with HNPCC related cancer, the intestinal lumen; therefore if transit time is less than 14
one of whom is a 1st deg relative of the other 2 hours the patient will have hematochezia, and if greater
(At least 2 of which must be 1st-degree relatives) than 14 hours the patient will exhibit melena. One often-
HNPCC related: stated rule of thumb is that melena only occurs if the
source of bleeding is above the ligament of Treitz.
Colorectal carcinoma,
Endometrial carcinoma,
other related cancers: small bowel, TCC of the upper urinary tract, stomach, ovarian, brain (Turcot syndrome) and
sebaceous gland adenomas or keratoacanthomas (Muir-Torre syndrome).
- 2 successive generations
- ≥1 of the HNPCC related cancers must occur prior to age 50
- FAP is excluded
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SCREENING
PHYSICAL EXAM
1. Abdominal mass
2. Mass on DRE: (rectal mass)
a. hard, non-tender, polypoid, irregular, contact bleeding
b. distance from anal verge >7cm (internal anal sphincter)
3. Complications, Metastases
- Cachexia
- Pallor at nail beds and conjunctiva (anaemia)
- Jaundice, hepatomegaly (irregular surface & nodular edge)
- Cervical lymphadenopathy – Virchow’s node
- Bone tenderness, consolidation or effusion, AMS
121
INVESTIGATIONS
Aims: Diagnose, Stage the cancer & Investigate for complications of cancer
I. DIAGNOSIS
II. STAGING
All CRCs
(a) CT scan of the abdomen and pelvis for colon tumours
- Local T staging & invasion into bladder, ureter, uterus
- Staging of regional and no-regional lymph node involvement
- Metastases to the liver, obvious peritoneal seeding, omental kinking,
- Look for ascites, hydroureter/ hydronephrosis, intestinal obstruction
(b) CXR + CT scan of the chest
(c) Bone scan if symptomatic (more for Ca breast, lung, prostate, thyroid)
(d) CT brain if symptomatic
III. COMPLICATIONS
Imaging
(f) Erect and supine AXR to look for intestinal obstruction (usually large bowel closed loop obstruction) and caecal distension; near perforation
(g) Erect CXR in perforated tumour to detect air under diaphragm
(h) ECG :anaesthesia assessment
122
TNM STAGING
123
TREATMENT
SURGERY
Pre-operative measures
- Bowel prep
Modification of diet – 3 days low residue diet (reduce frequence and volume of stools – low fibre, reduce food that increase
bowel activity), NBM day before operation
Bowel clearance with polyethylene glycol. CI obstruction?
- Prophylactic antibiotics (max at first incision)
ampi/ genta/ metronidazole at induction of anesthesia
No difference shown for doing a staged procedure (i.e. tumour removed with proximal end of colon brought out as a
colostomy) as compared to creating a primary anastomosis
On-table bowel decompression ( irrigation) for clearance of faecal material
Segmental colectomy for the tumour with intraoperative decompression is comparable to subtotal/total colectomy without
decompression with regard to bowel function and rates of complications
124
Tumour Site Surgery Structures Involved (Excision of structures + Division of vessels)
Caecum / Right hemicolectomy Excision of caecum + ascending colon
Ascending colon Ileocolic artery
Right colic artery
Right branch of the middle colic artery
Hepatic flexure / Extended right hemicolectomy (B) Excision of caecum, ascending colon and proximal transverse colon
transverse colon near Ileocolic artery
hepatic flexure Right colic artery
Middle colic artery (at its origin)
Transverse colon Left segmental colectomy (D) Excision of distal transverse colon and proximal descending colon
near splenic flexure Left branch of middle colic artery
Left colic artery
125
16cm High AR:
margin above
peritoneal
Upper 1/3 reflection
Middle 1/3
Low AR: margin
below peritoneal
8cm reflection
Lower 1/3
Ultra low AR:
4cm anastomosis to
the upper end of
Anal canal: the anal canal
2-4cm
Anterior resection = Resection of IMA at its pedicle (with parts of the colon where it supplies – Sigmoid and Rectum)
Not descending colon as the LMCA can extend its supply to it.
For rectal tumours a margin of 5 cm proximally and 2 cm distally is adequate (as it has been found that lymphatic spread of rectal tumours
is predominantly in the proximal direction)
Radial margins are also important as there is a zone of downward spread within the mesorectum (peritoneal investment of the upper
rectum; just anterior to the sacrum)
The anal sphincter can be spared if the distal margin is >1-2cm above the level of the sphincter complex, usually taken to be at the level of
the dentate line (which is 5cm above the anal verge) i.e. distal margin of the tumour must be >7cm from the anal verge
Sphincter-sparing low anterior resection (below the peritoneal reflection); ultra low AR if just above the anal sphincter
Sphincter-sacrificing surgery abdominoperineal resection (entire anus & sphincter complex is dissected, creation of an end colostomy)
- Reconstruction
Formation of a straight coloanal anastomosis in anterior resections is a/w poor function due to the lack of reservoir function
- Mesorectal excision
126
- Extended resections
For locally advanced, adherent tumours (T4), multivisceral resection of organs involved (pelvic exenteration) is associated with improved
local control and overall survival compared with standard resection, though high morbidity of 25-50% is associated
Consider neoadjuvant chemoradiotherapy prior to surgery to downstage disease
- Stoma creation
A defunctioning loop ileostomy (or loop colostomy) is usually created during an low AR as the manipulation of the colon deep within the
pelvic cavity causes increased risk of an anastomotic leak & also poorer blood supply to anastomosis
A defunctioning stoma does not protect against anastomotic leak, but mitigates against disastrous complications of faecal peritonitis
should a leak occur
Closed in 2-6/12 after check with gastrograffin reveals no leak
Neoadjuvant RT with 5-fluorouracil can downstage tumour significantly ability to preserve sphincter, ability to resect previously
unresectable tumour, reduce local recurrence
Good evidence for ≥T3 tumours, CRM<2mm: benefits > risk of RT (esp. that pt becomes too ill to be operated on)
Not possible for colon carcinomas due to risk of small bowel radiation if given above peritoneal reflection
Done before Sx as ChemoRT requires blood supply to work (disrupted during Sx)
Operative complications
- Resection of primary for palliation of symptoms such as bleeding, perforation, obstruction or pain
- Resection of asymptomatic primary is controversial, but may confer survival benefit in a select group of patients where metastatic tumour
burden is restricted to one side? and liver involvement is not extensive
- Isolated liver metastases (synchronous or metachronous) may be resected with survival benefit; neoadjuvant chemotherapy can be given to
downstage the metastases if they are initially resectable
- Lung metastases usually indicate systemic dissemination of disease, but in the rare setting that there is an isolated lung secondary, resection
can provide survival benefit
- Loco-regional recurrence, if detected early with adequate resection, can confer survival benefit
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RADIOTHERAPY
- Role as neoadjuvant therapy in rectal cancer to downstage tumour (in T3/T4)
- Post-operative adjuvant therapy in stage II or III rectal cancer
CHEMOTHERAPY
Adjuvant therapy
- Colon cancer: 5-FU + folinic acid (leucovorin) for 6 months, or 5-FU + levamisole for 12 months in Duke’s C cancer (node
positive);; not recommended in Duke’s B or less
- Rectal cancer: post-operative adjuvant therapy in combination with radiotherapy in stage II or III disease (5-FU based regimen
used)
Palliative therapy
FOLLOW UP
- Follow-up visits 3-monthly for the first 2 years, then 6-monthly for the next three years, and subsequently yearly, measure CEA
at each visit
- Yearly colonoscopy
- CXR and liver ultrasound to detect metastases (recommended frequency not known)
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ASSOCIATED CONDITIONS
- Extraintestinal manifestations
Skin: Epidermoid cysts, Lipoma
Bone: Osteoma of skull/ mandible, Dental abnormalities
Eye: Congenital hypertrophy of retinal pigment epithelium (CHRPE)
Other tumours:
Desmoid tumours (intra-abdominal tumours, treated with CT, RT or HT.)
Thyroid cancer (follicular or papillary type)
Periampullary CA
- Diagnosis
Colonoscopy showing >100 polyps
Genetic testing
- Surveillance
Yearly colonoscopy for at-risk family members from 12y onwards
5 yearly OGD for surveillance of Periampullary Cancer.
Genetic testing of at-risk family members
Affected members should undergo prophylactic proctocolectomy with ileal pouch anal anastomosis (IPAA – involves folding
loops of ileum back on themselves and stitching or stapling them together to form a reservoir pouch which is them
anastomosed to the anus) at ~ 20 YO
- Lynch syndrome type II is associated with increased risk of cancer elsewhere, most commonly endometrial cancer, and also
ovarian, gastric, small bowel, hepatobiliary, and renal pelvis/ureter cancers
o Offer a THBSO with total colectomy if CRC detected
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3. STOMAS
Indications
1. For input: feeding (Percutaneous endoscopic gastrostomy)
2. For output: decompression/ lavage, defunctioning/ diversion, draining/ exteriorization (urine, faeces)
Nursing intervention
- Stoma nurse to perform counselling & discuss best site for stoma placement
Stoma siting
Types of stomas
Temporary
- Decompression – relief of bowel obstruction causing proximal dilatation
- Defunctioning – to reduce effects of anastomotic leak
Esp. after low anterior resection, where risk of anastomotic leakage is high 2o to poor blood supply to anastomotic site
Usually loop ileostomies or colostomies with 2 openings (ileostomies usually on the right side, colostomies in the
epigastric/hypochondriac [transverse colostomy] or left side)
- To rest an inflamed distal portion e.g. acute Crohn’s
Stoma Complications
Early
- Necrosis of terminal bowel (stoma appears dusky (grey black); check by intubating with a glass tube into the stoma to look
at colour of mucosa) refashion stoma
- Obstruction (fecal impaction explore with finger, enema / secondary to adhesion – more in ileostomy)
- Leakage skin erosion, parastomal infection resite
- Bleeding
- Stoma diarrhoea (high output) correct water & electrolyte imbalance (hypoK), add anti-motility agent to thicken output
(loperamide +/- codeine)
http://www.wjgnet.com/1007-9327/7/741.asp
Late
- Prolapse of bowel refashion/refresh
- Parastomal hernia (+ve cough impulse) refashion
- Stenosis (unable to pass finger through) refashion
- Retraction refashion
- Fistulae
- Skin excoriation
- Psychological problems
130
End colostomy This procedure is most commonly performed to manage carcinoma of the lower rectum or anus,
diverticular disease, and rare cases of faecal incontinence that do not respond to medical mx.
For example, a very low rectal cancer will require resection of the rectum and anus
(abdominoperineal excision of rectum). The remaining descending and sigmoid colon is mobilised
and the cut end brought to the abdominal surface at an opening about 2 cm across.
Abdominoperineal excision of the rectum If the anus, rectum, and a portion of the lower colon have not been removed, as in Hartmann's
procedure, two outcomes are possible. In the first, the distal, non-functioning part of the colon and
the rectum can be stapled or sewn closed and left inside the abdomen as a rectal stump. The
proximal colon is then taken out as an end colostomy.
Because the rectum has not been removed, the urge to have a bowel movement may occur.
Mucus and some old stool, if present, will be passed.
If the colostomy is temporary, a second operation is needed to reconnect the two ends.
One stoma is the exit of the functioning part of the colon through which stool and gas pass.
The second stoma opens into the non-functioning portion of the colon and rectum and is called a
mucous fistula. The second stoma is usually small, flat, pink-red in colour, and moist, and it
produces only mucus.
Loop colostomy A loop colostomy was traditionally created to defunction an inflamed sigmoid in diverticular
disease or to defunction a distal anastomosis.It has largely been replaced by loop ileostomy.
A loop of colon is brought to the surface of the body and may be supported on a rod, which is
removed after about five days. The bowel wall is partially cut to produce two openings—of an
afferent limb and an efferent limb. The opening of the afferent limb leads to the functioning part of
the colon, through which stool and gas pass out. The opening of the efferent limb leads into the
non-functioning part of the colon. The stoma site was usually high on the abdomen above the
waistline because the transverse colon was commonly used.
Currently, loop colostomies are more often fashioned from the sigmoid colon to defunction the
rectum (for example, in cancer) or anus (for example, in incontinence).
A loop colostomy may be temporary or permanent.
End ileostomy When the entire colon, rectum, and anus must be removed (panproctocolectomy) an end
ileostomy must be employed. This occurs most commonly in severe ulcerative colitis but also in
familial polyposis and some cases of colorectal cancer (for example, hereditary non-polyposis
colorectal cancer).
The ileum is resected just short of its junction with the caecum, and 6-7 cm of the small bowel is
brought through the abdominal wall, usually in the right iliac fossa. It is everted to form a spout
and then sutured to the bowel wall to protect the skin from the irritating content of the ileal fluid.
After a panproctocolectomy the ileostomy is permanent. Temporary end ileostomy is often used
after an emergency subtotal colectomy, which leaves part of the sigmoid colon and rectum left in
place; for acute ulcerative colitis; acute ischaemic bowel; or neoplastic obstruction of the sigmoid .
Loop ileostomy This type of stoma allows for defunctioning of an obstructed colon (in cancer), defunctioning of a
distal anastomosis (after resection and primary anastomosis either as an emergency or after
radiotherapy), or defunctioning of the anus (in incontinence or perineal involvement in Crohn's
disease). Loop ileostomy has largely replaced loop colostomy because it is easier to site, less
bulky, and easier to surgically close. A loop ileostomy has two openings, and most are temporary.
131
End-loop ileostomy This less commonly performed procedure is used when an end ileostomy cannot be fashioned
safely because the patient is obese or because of unfavourable mesenteric anatomy. The
formation of this stoma is similar to a loop ileostomy, but the efferent limb is short and blind
ended. On inspection at the bedside this type of stoma is indistiguishable from a loop ileostomy.
Double barrel stoma When the caecum is removed, the surgeon might create a double barrel stoma. In essence, this is
an end ileostomy (small bowel) and a mucous fistula (the remaining colon) sited beside each
other. On examination this will look almost identical to a loop ileostomy, however, closer
inspection will show two separate stomas.
Urostomy This is a general term for the surgical diversion of the urinary tract. The main reasons for a
urostomy are cancer of the bladder, neuropathic bladder, and resistant urinary incontinence.
The bladder is usually removed, but this may depend on the underlying condition. Formation of an
ileal conduit is the most common procedure, which constitutes isolation of a segment of ileum.
One end of the ileum is closed and the two ureters are anastomosed to it. Finally, the open end of
ileum is brought out onto the skin as an everted spout and will look similar to an end ileostomy.
Urine drains almost constantly from the kidneys through the ureters and ileal conduit into a bag.
Stoma bags
Some bags have a second opening at the bottom to allow emptying. These are most useful in the period immediately after operation
and in patients who have had ileostomy, who need to drain their bag regularly. Closed bags are used when the faeces are well
formed and are usually only changed once or twice a day. Most patients with a stoma will use an opaque bag, but in the period
immediately after operation a transparent bag is used to observe the new stoma for complications such as persistent oedema or
necrosis. Modern stoma bags are fitted with a carbon or charcoal flatus filter that allows gas to escape to prevent the bag from
ballooning or detaching and neutralises odour.
Complications
Functional problems, such as skin excoriation and stoma noises, are the most common complications and are usually managed by
the stoma nurse. Patients with stoma admitted to hospital with increased or decreased output should be appropriately managed to
exclude any abdominal emergency, with particular emphasis on careful history taking to establish the normal bowel pattern, and
attention to fluid balance.
Most structural problems, such as stoma prolapse, retraction, and parastomal hernia formation can be managed conservatively with
modified bags and specialised belts. Only about 10% of patients with these complications will require further surgery. Patients should
be alert to any change in colour of their stoma. Stomal oedema is normal for several days after surgery, but if the mucosa becomes
dusky or necrotic the surgeon should be contacted promptly.
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Question Answer Stoma
How does the bowel lie in relation to Flush with skin Most likely a colostomy
the external skin?
Raised spout Ileostomy; less commonly a urostomy
How many lumens are present? One End colostomy; end ileostomy; urostomy
Two (separate stomas) Most likely end colostomy with a mucous fistula; double
barrel stoma; rarely bowel stoma and urostomy
What are the contents of the stoma Fully formed stool Colostomy
bag (don't be afraid to feel it)?
Semisolid or liquid stool Most likely ileostomy; colostomy
Urine Urostomy
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4. DIVERTICULAR DISEASE
PATHOLOGY – acquired herniation of colonic mucosa through muscular wall, with a covering of colonic serosa
TERMS
- Diverticulosis coli – presence of acquired pseudodiverticula
- Diverticular disease – symptomatic diverticulosis coli
- Diverticulitis – inflammation of diverticula
EPIDEMIOLOGY
- Increases with age; up to 25% in >70YO (2-5% are <40YO, more in obese M)
- Majority are asymptomatic; 10-30% are symptomatic
- Risk factors – dietary fibre & genetics
- Site
o majority are in the sigmoid colon, right sided are thought to be genetic;
o Asians: 40% right, 60% left, Caucasians: 20% right, 80% left
o not in rectum as taeni coli has fused
PATHOGENESIS
PRESENTATIONS - depends on location of the affected diverticulum, the severity of the inflammatory process, and presence of complications
1. Acute diverticulitis
- Symptoms: LLQ pain, N/V, Constipation / diarrhoea, flatulence/bloating
- Signs: Low grade fever, Tender palpable mass
- Investigation: WBC
2. Chronic diverticulitis
- Recurrent LIF pain
- Irregular bowel habit
- Passage of mucus PR
Elderly and patients on steroids may have no sign even in severe diverticulitis.
There is an increased rate of free perforation (43% vs. 14% in immunocompetent patients), increased need for surgery (58% vs. 33%), and
increased postoperative mortality (39% vs. 2%).
STAGING
- Hinchey classification of complicated acute diverticulitis – need for surgery is reflected by degree of infective complications
Severity staging by CT scanning may allow not only the selection of patients most likely to respond to conservative treatment, but may also predict the risk of
failure of medical therapy and of secondary complications after initial conservative treatment.
Note: current controversy of management for stage 3: hartmann’s vs segmental resection with primary anastomosis with or without defunctioning ileostomy
In the absence of complications and systemic signs and symptoms, patients with mild abdominal tenderness may be treated conservatively.
Conservative treatment typically includes dietary modification and oral or IV antibiotics. This has been shown to be successful in 70% to 100% of patients.
134
Presentation Clinical features Investigations Differentials Management
Acute Diverticulitis - LIF pain – colicky, - FBC – leucocytosis, ↑ ESR Can dev anywhere in GIT. See Conservative
progressing to constant, - Erect CXR to rule out perforation Ddx to RIF/LIF pain - Bed rest
relieved by defecation - AXR – ileus, air-fluid level w/in an - NBM, IV fluid
- LIF tenderness abscess - GI: colitis, GE, IBS, IBD, - Broad-spectrum antibiotics –
- Palpable LIF mass - CT scan w triple contrast (choice) mesenteric ischaemia/ augmentin or metronidazole or
Severity, complication, clinical adenitis, Ca colorectal ciprofloxacin
- Nausea staging - Right colon/redundant (extra - Antispasmodics
- Urinary symptoms Water soluble contrast: IV for bend in descending colon)
vascular lesions, oral for small sigmoid colon: appendicitis After acute phase settled (4-6 wks)
- Pyrexia bowels, enema for large bowels - Transverse colon: PUD, - Colonoscopy – confirm dx &
- Increase pulse rate Features – diverticula elsewhere, pancreatitis, cholecystitis exclude CA colon and/ or
confirm colitis (mesenteric fat - Inflm adj to UT: UTI, stones, - Barium enema is inferior to
infiltration, concentric bowel cancer, cyst/ colonoscopy in terms of image
thickening) but only suggest Angiomyolipoma, quality and is usually only
diverticulitis, pelvic abscess, free hydronephrosis performed if the patient has
gas, extravasated contrast - Lower quad pain in F strictures or an excessively
Cannot tell if inflm is due to (Obgyn): PID, torsion of tortuous sigmoid colon where
diverticula cyst/ ovary, endometriosis, colonoscopy is difficult or
Better than intraluminal ectopic pregnancy dangerous
examinations as bulk of inflm is - Retroperitoneal perf (leg
extraluminal pain): thigh abscess, leg Role of surgery: see below
- Laparoscopy – if diagnosis is in doubt emphysema
- #, infx, inflm,
- Barium enema – CI as barium may
leak out into abdo cavity
- Avoid colonoscopy as risk of
perforation is high (by air insufflations
or instruments) + worsens diverticulitis
Chronic Diverticulitis - Recurrent LIF pain - Rigid sigmoidoscopy – oedematous - CA colon – may coexist. Conservative – see above
- Irregular bowel habits – mucosa & rigidity of rectosigmoid jx Hard to differentiate –
Not a common constipation & bouts of - Flexible sigmoidoscopy – diverticular therefore, ALWAYS exclude Surgical
clinical entity diarrhoea orifices CA colon e.g. histology after Indications:
- Passage of mucus PR - Barium enema – ‘saw-tooth’ bowel resection - Severe / recurrent attacks
appearance, diverticula, strictures - Ischaemic colitis - Possible CA colon
- Ruled out cancer, IBD, - Colonoscopy – exclude differentials - Radiation colitis
ureteric colic, Msk pain etc. (i.e. Ca colon) - Colonic endometriosis Stage: Segmental resection of
affected colon + anastomosis
Generalised peritonitis - Acute onset abdominal - FBC – ↑ TW, ↑Hb (dehydration) - Other causes of peritonitis – Mgmt as for acute abdomen
/ perforation pain – severe & continuous - U/E/Cr – dehydration & ARF perforated PUD/ appendicitis/ - Resuscitate
- Abdominal guarding & - CXR – free gas under diaphragm bowel/ ectopic pregnancy, - Surgical
rigidity ishaemic bowel, acute Peritoneal toilet
- Vomiting pancreatitis, ruptured AA/ Hartmann’s procedure
- Tachycardia hepatoma, torsion of testis/ (Resection of affected
- Pyrexia ovary, pyonephrosis segment
+ End sigmoid colostomy)
Pericolic abscess - May follow acute - FBC – ↑ TW - CT/ US guided percutaneous
diverticulitis - CT – differentiate between aspiration
- LIF tenderness & guarding inflammatory phlegmon (spreading - Surgery – evacuation of pus ±
- LIF mass – may be diffuse inflammation with pus/purulent resection of affected segment
detected on DRE exudates) & pericolic abscess
- Swinging fever
Persistent - LIF pain, tenderness &
inflammatory mass palpable mass
- Fever
- Malaise
Small bowel I/O - Usually temporary, due to
attachment of enteric loop against
area of acute diverticulitis
- Surgery if does not resolve
Large bowel I/O - PHx of recurrent acute - AXR – dilated bowels prox to stenosis - CA colon - NBM, Drip & suck
diverticulitis or irregular - Water soluble contrast enema - Surgery – Resection ± primary
bowel habit anastomosis
- Colicky abdominal pain,
constipation & abdo
distension
Hemorrhage - Usually in the elderly who - Invx as for LGIT bleed – resus, - Anorectal bleed - Resuscitate & correct
have higher density of investigations + colonoscopy & - Angiodysplasia coagulopathy
sigmoid diverticula angiography (both diagnostic AND - Ischaemic colitis - Colonoscopic management:
- Massive bleed (altered therapeutic value) - Colorectal CA adrenaline injection, endoclips on
blood ± clots; not melena) - ± on-table enteroscopy if required - Colitis (inflm or infx) bleeding vessel, heat coagulation
usually right-sided - ± tagged RBC scan (not as sensitive - UBGIT - Radiologic embolisation of site
- Colicky pain as blood is compared to angiogram): RBC tagged - Coagulopathy of bleeding with temp foam
irritative & causes spasm with radioisotope material via angiography
- Surgery – segmental resection;
total colectomy if unable to
localise bleed
Vesicocolic fistula - PHx of chronic diverticulitis - UFEME & urine c/s: confirm UTI and - Other causes of fistula – CA - Surgery – Resection of affected
& UTI organisms (polymicrobial as opposed colon, CA bladder, Crohn’s colon + anastomosis + closure of
- Hx of dysuria, freq, to sterile pyuria in ‘UTI from adj disease, post-irradiation bladder fistula opening
haematuria, pneumaturia, diverticulitis’) necrosis
faecaluria - Cystoscopy – cystitis
- KUB – air in bladder
- Barium enema – diverticular bowel
segment
- Sigmoidoscopy – usually normal
135
Outcomes: well or deteriorate requiring surgery, recurrent episodes, stricture & subacute IO (offer surgery)
Advice to patients:
- 70% of patients will not have recurrence after first attack (after first attack, 1/3 will have second. out of whom 1/3 will have 3 rd)
- Advise high fibre diet (prevents recurrence in >70%) & to drink lots of fluid, weight reduction and exercise
136
5. INFLAMMATORY BOWEL DISEASE (CROHN’S DISEASE, ULCERATIVE COLITIS)
Epidemiology
Bimodal distribution: affects young in the 2nd & 3rd decades
of life, with second onset in the 5th & 6th decades of life
Equal gender predominance
Higher prevalence amongst Ashkenazi Jews & in cooler
climates e.g. Scandinavia, UK, Germany, northern USA
Genetic association
History
GIT: abdominal pain, diarrhea, N/V, bloating, distension,
bloody stools with mucous & pus
Crohn’s fistula: colovesical fistula or coloovarian fistula:
faeces in urine/ pneumaturia, faeces per vaginal/ PID
Non-specific systemic: LOW, LOA, fever, fatigue, symptoms
of anemia, chronic malnutrition
Specific extra-intestinal manifestations
Differential diagnoses
1) Gastroenteritis: exclude with stool microscopy & culture + C.diff toxin
- Bacterial: E. coli, Campylobacter, Salmonella, Shigella, C. difficile
- Parasitic: E. histolytica
- Viral: rotavirus
2) Other infective causes: diverticulitis, colorectal TB
3) Ischaemic colitis
4) Bleeding diverticulosis
5) Colorectal carcinoma
137
CROHN’S DISEASE
P/E: RIF mass, perianal enlarged skin tags/ fistula/ abscesses, anal stricture
Contrast radiographic studies: assess location & extent of disease, look for strictures & fistulae
o Barium studies: small bowel series & enema (cobblestone)
o CT scan with oral & IV contrast
Endoscopy: look for typical features
o Colonoscopy with tissue biopsy (non-caseating granulomas)
o OGD: upper GIT involvement
o Endoanal U/S (EUS): identify fistula tracts
Management
138
ULCERATIVE COLITIS
Investigations
Supportive (looking for complications & assessing severity of disease)
Blood tests
o FBC: anemia, leukocytosis & thrombocytosis indicate more severe disease
o UECr: hypokalemia & dehydration in prolonged diarrhoea
o LFT: hypoalbuminemia due to poor nutritional intake
o CRP, ESR: markers of severity
o Autoantibody assay: p-ANCA ↑ in UC, ASCA ↑ in CD
Radiological
o AXR to evaluate colonic caliber (>6 cm is abnormal)
o CXR to rule out perforation (risk of perforation in acute disease)
Diagnostic (mainly at rectum)
Endoscopy: look for typical features
o Flexible sigmoidoscopy with tissue biopsy: bleeding may occur with contact with scope.
Never do barium enema during a severe acute attack or as a diagnostic test??
Management
Medical: similar to Crohn’s disease
o Mild: PO pred + Mesalazine. If distal dz: Pred retention enema/ steroid foam.
If no improve after 2/52 mod.
o Mod: PO pred (40mg/d x1/52 30mg/d x 1/52 20mg/d x 4/52) + 5-ASA + steroid enema BD.
If no improve after 2/52 severe.
o Severe: IV Hydrocort400mg/d + rectal steroid.
If improve in 5/7 PO pred + 5-ASA. If CRP >45/ >6 stools per day ciclosporin/infliximab/Sx.
Surgical (25% eventually require surgery)
o Indications :
1. Disease refractory to medical therapy with severe & extensive colitis (most common)
2. Serious complications of medical therapy
3. Severe bleeding
4. Perforation
5. Toxic megacolon (colon > 6cm): most common cause of death - Involvement of the muscularis propria in the most
severe cases can lead to damage to the nerve plexus, resulting in colonic dysmotility, dilation, and eventual
infarction and gangrene
6. Malignancy
o Procedure (laparoscopic or open)
Acute setting (uncontrolled bleeding, perf, toxic megacolon, fulminant attack): total colectomy with end ileostomy:
diseased rectum left in-situ with resection & IPAA at later date when patient has regained health & steroids have
been withdrawn (as rectum is extraperitoneum organ and dissection/resection takes a long time). Foley catheter
used to decompress rectum for 3-4 days
IPAA (ileo-pouch anal anastamosis): standard of care for patients with UC who ultimately require colectomy. Avoid
necessity for long term stoma. Crohn’s disease remains an absolute contraindication as overall failure rates
approach 50%
Alternative: Total proctocolectomy with end ileostomy
o Complications:
o Mortality 2-7%, 50% if perforation
o Pouchitis: Tx with Abx (metronidazole + ciproflox X 2/52) + immunosupp.
139
8. ANAL & PERIANAL DISORDERS
1. HAEMORRHOIDS
Anal cushions.They are clusters of vascular tissue (eg, arterioles, venules, arteriolar-
venular connections), smooth muscle (eg, Treitz muscle), and connective tissue lined by
the normal epithelium of the anal canal.
External hemorrhoids are innervated by cutaneous nerves that supply the perianal area.
These nerves include the pudendal nerve and the sacral plexus.
Internal hemorrhoids are not supplied by somatic sensory nerves and therefore cannot
cause pain - internal hemorrhoids can produce perianal pain by prolapsing and causing
spasm of the sphincter complex around the hemorrhoids. Internal hemorrhoids can also
cause acute pain when incarcerated and strangulated
Internal hemorrhoids drain through the superior rectal vein into the portal system.
External hemorrhoids drain through the inferior rectal vein into the inferior vena cava.
Rich anastomoses exist between these 2 and the middle rectal vein, connecting the portal and systemic circulations.
Causes:
1. Decreased venous return / increase intra abd pressure: preg, constipation (low fibre diet) straining
2. Portal hypertension and anorectal varices
3. Increase rectal vein pressure: obesity, prolonged sitting
The most common presentation of hemorrhoids is rectal bleeding, pain, pruritus, or prolapse.
Painless fresh PR bleeding after defecation: coating / dripping, not mixed with stools
External hemorrhoids: not true hemorrhoids, but rather painful thrombosed veins arising distal to the dentate line
Internal hemorrhoids: those arising proximal to the dentate line, usually painless unless prolapsed & strangulated
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Classification & Treatment
Grade 1 Conservative:
Lifestyle modifications
Hemorrhoid protrudes into the anal canal Meds (Daflon) – improves venous tone
but does not prolapse outside the anus,
hyperaemia of mucosa
Grade 2 Surgery:
Rubber band ligation
Hemorrhoid protrudes through the anus Injection sclerotherapy (phenol emoilent oil)
during straining or evacuation but returns
spontaneously
Grade 4
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2. ANAL FISTULA
GOODSALL’S LAW
Posterior ½:
(All fistula tracts with external openings within 3 cm of the anal
verge and posterior to a line drawn through the ischial spines)
Curvilinear
Internal opening in posterior midline (at level of
dentate line)
Anterior ½:
Straight tracts
INVESTIGATIONS
Endoanal U/S (H2O2 aided for hyperechoic effect) – to view course of fistula tract
MRI – able to visualise entire pelvis, beyond the sphincter complex
CT/fistulography (in emergency situation) – for complex fistulas / unusual anatomy
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CRYPTOGLANDULAR THEORY OF PARKS / PARKS CLASSIFICATION
Transsphincteric Low:
Fistulotomy
The common course is low via internal On pts who have good pre-op anal
& external sphincters into the sphincter function
ischiorectal fossa and then to the
perineum.
25% of all anal fistulae
High / anterior fistulae in women:
Other possible tracts include high tract
(Higher risk for post-fistulotomy incontinence)
with perineal opening and high blind
Conservative approach
tract
1. Cutting seton
Reactive suture / elastic placed
through the fistula tract
Tightening of seton tie sequentially
until it cuts through the fistula tract
Fistulotomy (for simple, short tracts) – cut & lay open tract
Fistulectomy – core along tract & remove tract entirely
Seton – for complex, long, high tracts
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4. ANAL FISSURES
An anal fissure is a painful linear tear or crack in the distal anal canal, which, in the short term, usually involves only the
epithelium and, in the long term, involves the full thickness of the anal mucosa.
Most will heal because of good blood supply (within 1 day / 2 days)
If they don’t heal: usu due to spasm of internal sphincter muscle
MANAGEMENT
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9. LIVER DISEASES
The liver has two blood supplies – portal vein (formed from
the joining of the splenic vein and superior mesenteric vein)
and hepatic artery (a branch of the coeliac trunk)
Drainage is via the 3 hepatic veins into the inferior vena cava
2. CAUSES OF HEPATOMEGALY
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4. HEPATOCELLULAR CARCINOMA
EPIDEMIOLOGY
1. Hepatitis B infection (high HBV DNA load, HBeAg positivity increase the risk) – 100X normal population
2. Hepatitis C infection
3. Cirrhosis (of which cirrhosis resulting from hep B, hep C and haemochromatosis are associated with the highest risk): 20-30years following
initial insult
- Others: Aflatoxin ingestion, α-1- antitrypsin deficiency, haemochromatosis, PBC, anabolic steroids, schistosomiasis
Non-cirrhotic HCC – 5% in west, 40% in Asians
PATHOLOGY
- Pathogenesis involves a chronic inflammatory process or ongoing hepatocellular damage with high cellular regeneration, which leads to
rates of genetic mutation in the cells and accumulation of these mutations leading to carcinoma formation
- Two histological subtypes:
Nonfibrolamellar – associated with HBV and cirrhosis
Fibrolamellar – associated with younger patients, more common in females, no association with hep B or cirrhosis, AFP usually normal,
70% resectable, good prognosis
- Metastasises to lymph nodes, bones, lungs and adrenals (more common in intrahepatic lesions >5cm)
PRESENTATION
HCC is frequently diagnosed late in its course because of the absence of pathognomonic symptoms and the liver's large functional reserve.
1. Asymptomatic
- During screening (ultrasound) for chronic hepatitis B carrier
- Investigations for liver cirrhosis (esp with rising AFP levels)
- Incidentally found on imaging of the abdomen
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5. Metastases (low incidence in HCC, mortality rarely from mets)
- Bone pain, Dyspnoea
6. Paraneoplastic syndromes
1. Hypoglycaemia (due to high metabolic demands of tumour, <5% secrete IGF symptomatic hypogly),
2. Erythrocytosis (tumour produces erythropoietin, but most pts are anemic),
3. Hypercalcaemia (osteolytic lesions, tumor secretes PTH-rel protein)
4. Watery diarrhoea (related to secretion of peptides that cause intestinal secretion eg. gastrin. can be severe & intractable)
5. Cutaneous features (eg dermatomyositis, pemphigus foliaceus)
Complications from hepatocellular carcinoma are those of hepatic failure; death occurs from cachexia, variceal bleeding, or (rarely) tumor
rupture and bleeding into the peritoneum.
INVESTIGATIONS
DIAGNOSIS
Biopsy is usu not performed due to risk of tumour seeding (1-2% risk) along the needle track – may render the patient unsuitable for transplant!
Diagnosis is based on clinical, biochemical and radiological tests
- Lipiodol will be retained in HCC even after many days as the HCC does not contain Kupffer cells to ingest lipiodol
- Hepatic angiogram may reveal abnormal blood vessels within the HCC
- CT scan of the liver weeks after lipiodol ingestion will pick up the areas of tumour (where the pre-lipiodol CT may not have
demonstrated the tumour clearly)
- Not commonly used given the need for intraarterial injection
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STAGING (looking for metastases)
In BCLC, staging depends on extent of liver disease, symptoms, liver function, vascular invasion and extrahepatic spread.
1. Very early HCC is currently very difficult to diagnose confidently prior to surgical ablation. In these lesions the absence of
microvascular invasion and dissemination offers the highest likelihood of cure and thus, in Child–Pugh A, patients may theoretically
achieve a 5-year survival of almost 100%.
2. Early stage disease includes patients with preserved liver function (Child–Pugh A and B) with solitary HCC or up to 3 nodules </=3
cm in size. These patients can be effectively treated by resection, liver transplantation or percutaneous ablation with possibility of
long term cure, with 5-year survival figures ranging from 50% to 75%.
3. The intermediate stage consists of Child–Pugh A and B patients with large/multifocal HCC who do not have cancer related symptoms
and do not have macrovascular invasion or extrahepatic spread. Their survival at 3 years without therapy may reach 50%. These are
the optimal candidates for transarterial chemoembolization.
4. Patients who present with cancer symptoms and/or with vascular invasion or extrahepatic spread comprise the advanced stage.
They have a shorter life expectancy (50% survival at 1 year) and are candidates to enter therapeutic trials with new agents
5. Patients with extensive tumor involvement leading to severe deterioration of their physical capacity [WHO performance status>2]
and/or major impairment of liver function (Child–Pugh C), are considered end stage. Their median survival is less than 3 months.
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TREATMENT
- Only about 10-20% of patients with HCC will have disease amenable to surgery
- The only curative treatment for HCC is surgical removal of the tumour
- 2 surgical possibilities:
(a) Resection of tumour (partial hepatectomy)
(b) Liver transplantation
1. Stage of disease
- Cirrhotic patients have higher risk of post-operative mortality (4-14%) compared to non-cirrhotic patients (0-4%) due to
complications such as liver failure, bleeding and infection
- Use of indocyanin green (ICG) – the percentage of ICG remaining in the liver after 15 minutes indicates the level of liver
function. If >15% remains after 15 minutes, the patient cannot tolerate major liver resection (>3 segments removed)
- CT volumetry: residual liver function calculated with a CT liver scan via a computer program
- If patient has cirrhosis, assess the Child’s status only Child’s A and good Child’s B can be considered for resection
- Dependent on tumour size and how much of the liver it takes up, because tumour is non-functional
- A large tumour taking up most of the liver segments being resected translates to smaller amount of functional liver tissue
being resected, while a small tumour means that more functional tissue is removed with the same resection margins
- Resection of the liver results in worsened portal hypertension since the effective portal venous capillary bed has
decreased increased resistance to flow
- Detected during hepatic vein catheterization. Not necessary if clinically sig portal hpt: varices, ascites requiring diuretic
therapy, plt<100000 a/w splenomeg.
- Studies have shown that a normal bilirubin concentration, and the absence of clinically significant portal hypertension are
the best predictors of excellent outcomes after surgery, with almost no risk for postoperative liver failure.
6. Location of tumour
149
a) Hepatectomy
- Problem in patients with cirrhosis is that there is already a “field-change” effect in the liver, thus a new tumour can still
develop in the remnant liver. 75% of HCC are multifocal on diagnosis.
- Requires a fine balance between adequate resection margins and preservation of sufficient functional liver to prevent
liver failure
- Good immediate and short-term results, but not long term (<30% 5-year survival)
- >70% tumor recurrence at 5 years due to dissemination and de novo tumors (eg occurrence of new 1° in the cirrhotic liver)
- Most powerful predictors of recurrence: Microvascular invasion and/or more than one tumors (This suggests that the majority
of recurrences are due to dissemination from the 1° tumor and not metachronous tumors developing in a liver with cirrhosis)
- No effective adjuvant therapy to reduce recurrence rate.
- Solitary recurrence might benefit from repeat resection, but in most patients recurrence after primary resection will be
multifocal because of intra-hepatic dissemination from the primary tumor
- only those patients in whom recurrence is due to de novo oncogenesis can be expected to benefit from salvage
transplantation or repeated resection
b) Transplantation
- Problems with availability of donor organ – the disease might have progressed past being suitable for transplant by the time
donor organ is available
Possibility of “bridging therapy” (radiofrequency ablation) to shrink disease & slow progression until donor liver available
- In hepatitis B carriers, there is a risk for reinfection of the donor liver (high risk factors are HBeAg positivity, high HBV DNA
levels) – can be aggressively treated with anti-viral drugs 2 months before transplant and anti-HBV immunoglobulin long-term
after transplant
PALLIATIVE THERAPY
1. Loco-regional ablation
2. Intra-arterial therapy
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SCREENING FOR CHRONIC HEPATITIS CARRIERS
- Target pop: Hep B / C carriers, Cirrhosis, FHx of HCC, Patients on transplant waiting list (transplant priority if HCC dev, detect
HCC tt exceeds transplant guidelines)
- Combination of 6/12 to yearly Ultrasound + AFP levels
- US is operator dependent & may miss certain areas of the liver where imaging is difficult, but it is not associated with
radiation exposure. (sensitivity 65-80%, specificity 90%)
Features suggestive of HCC include poorly-defined margins and coarse, irregular internal echoes. Small tumors are often
hypoechoic. As the tumor grows, the echo pattern tends to become isoechoic or hyperechoic, indistinguishable from
surrounding liver. Added benefit of assessing patency of the hepatic blood supply and the presence of vascular invasion by
the tumor.
- AFP is also not a perfect screening test as 20% of HCC will not have raised AFP
- Thus the combination of ultrasound and AFP can increase the sensitivity and specificity of screening
- Frequency of screening is controversial, but should be increased in patients at increased risk – HbeAg positivity, high HBV
DNA levels
Frequency determined by tumor growth rate, not by the degree of risk.
- Important as it detects smaller and resectable HCCs increasing survival from 26 to 88/52
- Screen family for chronic hepatitis B carrier status especially if there is a family history! – e.g. mother had hep B/HCC, sibling
has hep B, etc
- Alternatives: des gamma carboxy prothrombin (DGCP aka PIVKA II) – potential marker of portal vein invasion by tumor
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5. LIVER METASTASES
- Still more common than primary liver tumour for malignancy occurring in the liver
- Primaries: Colorectal, gastric, pancreatic, urogenital, breast, lung
TRIPHASIC CT
- Hypodense on arterial phase (as metastases are usu hypovascular compared to hypervascular HCC; spread via portal vein)
- Increasing contrast uptake on portal venous and delayed phases
ROLE OF SURGERY
- Promising results with colorectal and neuroendocrine metastases if isolated resectable metastatic disease – 5-yr survival >50%
- Increasing role in urogenital, breast mets
- Poor results for stomach, oesophageal mets
- Palliation for symptoms in neuroendocrine metastases
6. LIVER HAEMANGIOMA
EPIDEMIOLOGY
- Prevalence 0.4-20%
- Female to male ratio 3:1
PATHOGENESIS
- Vascular malformation that enlarges by ectasia, congenital in origin
PRESENTATION
1. Usually small and asymptomatic, found incidentally
2. Mass effects compressing on surrounding organs
3. Pain from liver capsule stretch
4. Rupture (<1%)
5. Kassabach-Merritt syndrome for large haemangiomas – consumptive coagulopathy, thrombocytopaenia
6. Heart failure from large arteriovenous shunt
DIAGNOSIS
- Radiological
Characteristic features on triphasic CT – slow enhancement of the rims on arterial and portal venous phase, brightest in the
delayed phase
- DO NOT BIOPSY
TREATMENT
- Only for symptomatic or complicated lesions
- Possible role for prophylactic surgery in large, lateral, inferior lesions since there is higher risk for rupture
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7. SIMPLE LIVER CYSTS
EPIDEMIOLOGY
- 50% of cysts are single
- Prevalence 1-3%
- 9:1 female predominance for symptomatic cysts
PATHOGENESIS
- Congenital malformation when an aberrant bile duct loses communication with the rest of the biliary tree and becomes progressively dilated
(fluid within the cyst is not bilious)
- No solid component and not septated (mixed cysts with septations are suggestive of malignancy)
- [Cysts that communicate with the biliary system are called choledochal cysts]
PYOGENIC ABSCESS
- Routes of infection:
- Presentation: RHC pain (capsular stretch) with Spiking fever with chills, rigors. 50% of patients have jaundice, and one-third have
hepatomegaly
- Investigations:
Laboratory:
FBC, U/E/Cr, hepatitis markers
Blood cultures, Melioidosis & amoebic serology/ PCR, Stool ova, cysts and parasites
Tumour markers: AFP, CA 19-9, CEA (may resemble infected tumour on imaging)
If any aspiration done, aspirates for cytology, stains & c/s
Imaging:
US HBS or CT scan (to exclude liver tumour, KIV endoscopy to rule out GI malignancy)
Findings: Irregular lesion with central area of necrosis, air-fluid levels, may be multiloculated. Rim-enhancing appearance on triphasic CT
scan.
- Treatment
1. Resuscitate if necessary
2. Close monitoring of vitals with strict IO charting
3. Antibiotics via PICC
4. Drainage
Drainage if >3cm – open drainage or percutaneous aspiration
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Percutaneous aspiration Open drainage
- Minimally invasive, performed under - Invasive procedure, done under GA
radiologic guidance - Shorter hospital stay
- Can be done under LA - Single procedure
- Longer stay for patient as drainage tube - Not dependent on location
stays in patient for a longer time - Indications:
- May require multiple attempts if unable to Concomitant pathology requiring surgery
completely drain pus e.g. gall stones
- Contraindications: Multiple abscesses or multiloculated
Ascites (pus can leak into peritoneal abscess
cavity) Immunocompromised patient
Uncorrected coagulopathy Failed percutaneous drainage (tube
Proximity to vital structures blocked, or pt not getting better)
Ascites
Ruptured abscess
AMOEBIC ABSCESS
- Causative organism: Entamoeba histolytica (infects the gut, forming ulcers in the colon, then spreads to the liver through the portal vein)
- Transmission is faecal-oral
- Presentation
Usually single abscess
No sepsis, jaundice
Hepatomegaly often present
Complications: rupture into pleural/peritoneal spaces
- Treatment:
Metronidazole (very responsive)
Aspiration if amoebic serology inconclusive; pregnancy (metronidazole contraindicated); suspicion of secondary infection; severe
symptoms from distension or fever; impending rupture
9. ASCITES
Background information
Causes of ascites:
Transudate (<30g/L protein) Exudative (>30g/L)
Cardiac: CCF, RHF, TR, constrictive pericarditis Cirrhosis
Abdo: CLD Malignancy
Renal: ESRF, nephrotic syndrome Infective causes: TB
GIT: protein losing enteropathy Chylous ascites
Treatment of ascites:
o Conservative: low salt diet, diuresis
o Peritoneal tap
o Surgical: shunt sx (TIPSS, peritoneovenous shunt [silastic catheter], Denver shunt when with a subcutaneous pump]
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10. PANCREATIC DISEASES
1. ACUTE PANCREATITIS
DEFINITION
An acute inflammatory process of the pancreas with variable involvement of regional tissues or remote organ systems
EPIDEMIOLOGY
Gallstone: usu very small stones due to edema at the ampulla as stone passes into duod increases pancreatic duct pressure
(no stone in 80% suggesting stone passage)
The disease develops in pts whose alcohol ingestion is habitual over 5-15 years. Alcoholics are usually admitted with an acute
exacerbation of chronic pancreatitis. Occasionally, however, pancreatitis can develop in a patient with a weekend binging habit.
PATHOPHYSIOLOGY
- The initiating event may be anything that injures the acinar cell and impairs the secretion of zymogen granules
Gallstones: obstruction of the pancreatic duct causing interstitial oedema which impairs blood flow to the
pancreatic cells ischaemic cellular injury predisposition to enzyme activation
It is believed alcohol itself results in injury to pancreatic cells through generation of free radicals during its metabolism,
and may sensitise the pancreas to injury by other agents
- The final common pathway inappropriate activation of proenzymes stored within zymogen granules in the pancreatic
cell (trypsin activates most of the proenzymes secreted by the pancreas when they are secreted into the duodenum)
- The activated lytic enzymes destroy the pancreatic acinar cells release of potent cytokines that attract neutrophils and
macrophages themselves secrete pro-inflammatory cytokines
- The cytokine cascade amplifies the local inflammatory response and also results in a systemic inflammatory response
[2 of 4: T>38 / <36, HR> 100, RR>20 or TW>15], may progress to sepsis (if source of infection is found) severe sepsis with
1 organ dysfunction septic shock MODS
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PRESENTATION
Abdominal pain (most consistent, in >90% of patients) – constant epigastric pain, classically radiating to the back
(in 50%), maximal intensity within several hours of onset; usually occurs after a heavy meal; alleviated by sitting up
& leaning forward, worse on movement
Nausea, vomiting, Anorexia
Organ failure
Ask for urine output
Offer to auscultate the lungs for any effusion or ARDS (creps, reduced air entry)
MANAGEMENT STRATEGY
Diagnosis
Severity stratification
156
INVESTIGATIONS
1. Serum amylase
- raised within 12 hours of onset, usually more than 1000 or 3 times normal
- High sensitivity and moderate specificity (specificity increased when cut-off taken at 3 times normal upper limit)
- Returns to normal level 48 to 72 hours after onset – not useful in late diagnosis
2. Serum lipase
- Rises within 8 hours of onset of symptoms and returns to normal after 7-10 days, also 3 times normal
- Thus more useful in late diagnosis of acute pancreatitis
3. Urinary diastase
- Similar function to serum lipase, used when serum amylase is equivocally raised or normal
- elevated for even longer period after onset
Imaging
6. CT AbdoPelvis
1. Only if considering other pathologies eg. CA in elderly (CT may worsen pancreatitis)
2. At ~72hrs of known case of pancreatitis: detect fluid collections; necrosis (IV contrast needs to be given ) Balthazar for severity
Laboratory
Severity/ Cx: 1. FBC (TW for Ranson, Glasgow; haematocrit for Ranson)
2. U/E/Cr (urea for Ranson and Glasgow; electrolyte imbalances, dehydration)
3. Glucose (for Ranson and Glasgow)
4. LFTs (AST for Ranson and Glasgow; albumin for Glasgow; obstructive picture in gallstone pancreatitis)
5. CRP
6. Lactate dehydrogenase (for Ranson and Glasgow)
7. ABG (PaO2 for Ranson and Glasgow; base excess for Ranson)
Etiologies: 8. Ca/Mg/PO4 with albumin (hypercalcaemia – aetiology)
9. Fasting lipids (hyperlipidaemia – aetiology)
10. ECG & cardiac enzymes (rule out AMI as a cause of epigastric pain)
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SEVERITY STRATIFICATION (RANSON, GLASGOW, APACHE II)
V. Balthazar’s CT severity index (consider a CT AP @ ~ 3/7 from onset)
- Grades severity of disease according to CT findings detects h’ge & necrosis
- Not very useful as CT is not usually done in the 1/52 in local context, and disease is still evolving (CT findings lag behind) in the early stages
1. A - Normal
2. B - Enlargement
3. C - Peripancreatic inflammation
4. D - Single fluid collection
5. E - Multiple fluid collections: 50% chance of developing an infection and a 15% chance of dying
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COURSE OF DISEASE
SUPPORTIVE TREATMENT
1. Resuscitate if needed
2. Monitoring
4. Analgesia
- Do not give NSAIDs as they can worsen pancreatitis & cause renal failure (since there is already decreased renal
perfusion in acute pancreatitis)
- Use opioid analgesics (tramadol, pethidine)
NOT morphine (causes increased tone of sphincter of Oddi)
6. Antibiotics
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MONITORING FOR COMPLICATIONS AND TREATING
Local complications:
Systemic complications
o Peritoneal sepsis
o Pancreatic ascites (massive accumulation of pancreatic fluid in peritoneum)
o Intra-abdominal haemorrhage (erosion of splenic vessels)
o Multiple organ failure (ARDS, acute renal failure, hypovolaemic shock, DIVC)
o Hypocalcaemia, hyper/ hypoglycaemia
- ERCP
- No benefit in mild biliary pancreatitis
- Indications:
Severe pancreatitis
Evidence of ductal stones
Cholangitis
No response to treatment within 48 hours
- ERCP should be done within first 48-72 hours for maximum benefit
- Role of surgery
Infected necrotic pancreas (mortality 100% without operation)
Sterile necrotic pancreas (necrosectomy)
Delay surgery till as late as possible for demarcation of necrotic areas (repeated surgeries required)
Diagnostic uncertainty
Complications e.g. intra-abdominal haemorrhage
- Pseudocyst
Operate if larger than 6cm and persisting for more than 6 weeks as the chance of spontaneous resolution is low and risk
of complications (infection, haemorrhage, rupture) is high
Surgery can be open, laparoscopic, endoscopic or percutaneous (radiologically guided)
Endoscopic – internal drainage via a cystogastrostomy, cystoduodenostomy or cystojejunostomy
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MANAGEMENT OF AETIOLOGY & PREVENTION OF RECURRENCE
Chronic, irreversible architectural disruption of the pancreas resulting in chronic epigastric pain and pancreatic insufficiency
Presentation:
a) Pain (85%) – mostly episodic, some have persistent relentless pain
b) Diarrhoea (15%)
c) LOW (sec to anorexia, malabsorption)
d) Newly diagnosed DM (30%)
e) Steatorrhea (late)
Complications:
Local complications: persistent pseudocyst, fistulae, ascites
Chronic pain
Pancreatic insufficiency
o Type I DM
o Steatorrhoea, vitamin deficiency, malnutrition
Pancreatic cancer
INVESTIGATIONS
a) Dx:
a. MRCP (choice!): chain of lakes appearance of pancreatic duct (strictures and cystic dilatations)
b. AXR: calcification
c. EUS
b) Baseline function
a. Secretin injection check for pure pancreatic juice (gold std but invasive)
b. Faecal pancreatic elastase
c) Complications: MRCP (pseudocyst, duodenal stenosis, portal vein thrombosis)
Outline of management
Treat underlying cause (stop alcohol, relieve ductal stricture)
Control blood sugar with insulin
Pancreatic enzyme supplements
Pain relief
Role of surgery
Persistent local complications: pseudocyst, fistulae, local obstruction secondary to fibrosis (CBD, duodenum)
Pain relief (pancreatectomy, coeliac plexus block, thoracic splanchnicectomy)
Relief of pancreatic duct obstruction
o Puestow procedure: side to side pancreatico-jejunostomy
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14. PANCREATIC CANCER
EPIDEMIOLOGY
- Incidence about 3-5 per 100,000 per year in each gender
- Eighth cause of cancer death in Singapore
- 1.7:1 male to female ratio, increase with age
- Very poor prognosis – median survival for unresectable disease is 6 months (80% of patients have unresectable disease at
presentation); overall 5-year survival <3%
ASSOCIATIONS
- Cigarette smoking (most clearly established – 2-5X increased risk)
- Industrial carcinogens – benzidine, betanaphthylamine (dye)
- Diabetes mellitus
- Chronic pancreatitis
- Genetic factors (mutations in K-ras gene, p16 gene)
- Familial cancer syndromes e.g. Peutz-Jeghers (Hereditary intestinal polyposis syndrome, AD, hyperpigmented macules in lips
and oral mucoas), HNPCC, MEN, FAMMM (familial atypical mole multiple melanoma syndrome)
- Lower socioeconomic class
PATHOLOGY
- Most common histology is ductal adenocarcinoma (90% of tumours)
- Anatomic distribution: 75% in the head, 20% in the body, 5% in the tail
- Distinct category of tumours collectively called periampullary tumour (30%):
The periampullary tumours have better tumour biology than pancreatic adenoca
smaller size, better diff, low nodal stage, margins neg, less vascular invasion
Different TNM staging
90% resectability, median survival after Sx is 38mth
PRESENTATION
May be asymptomatic, picked up on imaging for some other purpose
Also
- Recurrent venous thrombosis
- Acute pancreatitis
- Depression
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localized areas of reticulated erythema and hyperpigmentation due
to chronic and repeated exposure to heat: regular application of
heat to the same painful part over a period of at least a few weeks
suggests that the pain is severe and consistent.
IMMEDIATE MANAGEMENT
- Treat any life-threatening complications such as cholangitis, pancreatitis, bleeding
INVESTIGATIONS
DIAGNOSTIC
1. CA 19-9
- Not a screening test for pancreatic cancer as it can be false positive
- Can act as a prognostic marker: high CA 19-9 levels usu associated with unresectable disease with poorer prognosis
- Can be used as a marker for tumour recurrence during post-op follow-up
2. CT scan (MAIN)
- Better sensitivity (85-90%) and equal specificity (90-95%) in diagnosing pancreatic cancer
- 1. Mass lesion within pancreas,
2. Both bile & pancreatic duct dilatation in head of pancreas tumours (double duct sign)
3. GB distension
4. Staging: Extra-pancreatic spread (Involvement of regional LNs, liver metastases, ascites)
3. MRI pancreas with MRCP – MRI pancreas is not superior to CT scan (Diagnosis and staging)
MRCP is useful in delineating biliary system anatomy especially if the system is not obstructed
and there are no therapeutic indications for ERCP (since there are considerable risks with ERCP)
The most difficult clinical situation in which to diagnose pancreatic carcinoma is in the patient with underlying chronic pancreatitis. All of the
above imaging studies may show abnormalities that may not help to differentiate between pancreatic carcinoma and chronic pancreatitis. Even
tumor markers can be elevated in patients with chronic pancreatitis. Often combine multiple imaging modalities, close clinical follow-up, serial
imaging studies, and, occasionally, empiric resection, to diagnose an underlying pancreatic carcinoma
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STAGING [LIVER, LUNGS, PERITONEUM, BONE]
5. Staging laparoscopy – for peritoneal metastases, just before definitive operation for a resectable tumour (since CT/MRI may
miss small peritoneal deposits in ard 25%) if no peritoneal disease found, continue with surgery, otherwise, close up and
abort surgery
TREATMENT
SURGERY
Curative resection
- Improves chances of survival
- Only about 15-20% of patients will have resectable disease at presentation – usu in periampullary / head of pancreas tumours
- However, recurrence rates after surgery are high – 5 year survival only 10 to 30%
- Recent trials: improved survival with adjuvant chemo (5-FU + Folinic acid or gemcitabine)
- Resectable disease:
No metastases (lung, liver, bone, peritoneum)
Patent superior mesenteric vein and portal vein – no longer absolute CI
Definable tissue plane between tumour and superior mesenteric artery as well as coeliac axis
Whipple’s operation
Pancreaticoduodenectomy for head of pancreas or periampullary tumour
Usually preceded by a staging laparoscopy to confirm absence of peritoneal metastases
Removal of the head of the pancreas, duodenum, proximal 15cm of jejunum, common bile duct, gallbladder, distal part of
the stomach and LN removal (impt prog factor)
Common hepatic duct and pancreas are then anastomosed to the jejunum, 45-60cm proximal to the gastrojejunostomy
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- Complications of Whipple’s operation
Mortality rate is 2-7%, with a morbidity rate of up to 20-30% (mostly mild complications)
Intraoperative/early complications
General:
(a) Injury to other organs – liver, kidney, bowel
(b) Bleeding
(c) Infection abscess, sepsis
Specific:
(d) Pancreatitis
(e) Pancreatic anastomotic leak (5-20%)
(f) Biliary anastomotic breakdown
(g) Fistulation, pseudocyst formation may occur due to anastomotic leaks
Late
Surgical:
(a) Gastric stasis with or without pylorus-preserving Whipple’s (25%) – NG decompression, longer hosp stay
(b) Diarrhoea resulting from autonomic nerve injury during lymph node dissection LOW
(c) Dumping syndrome: increased gastric emptying (from antrectomy) causing Nutritional deficiency
Functional:
(d) Long-term exocrine insufficiency resulting in malabsorption and steatorrhoea
(e) Endocrine insufficiency DM
Palliative surgery
1. Endoscopic stenting
- Stenting of obstructed biliary duct
- Stenting of obstructed duodenum
3. Palliative chemotherapy/radiotherapy/chemoradiotherapy
- Not shown to provide good outcomes
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11. BILIARY TRACT DISEASES
1. CAUSES OF JAUNDICE
Hemolytic anemias:
1) Inherited 1) Infective 1) Intraluminal
Thalassemia Acute viral hepatitis (HBV, HAV) Gallstones (painful)
G6DP EBV, CMV Parasites: Ascaris lumbricoides,
Spherocytosis TB schistosomiasis
Sickle-cell anemia 2) Liver cirrhosis/chronic liver disease 2) Mural
2) Acquired Alcoholic liver disease Biliary strictures post ERCP
Infective: malaria Chronic viral hepatitis (HBV, HCV) Biliary strictures from gallstones,
Autoimmune: SLE, Evan’s Metabolic (Wilson’s, chronic pancreatitis
syndrome hematochromatosis) PBC (intrahepatic bile ducts):
Hemolytic uremic syndrome Infiltrative (Sarcoidosis, middle aged ♀
(hemolytic anemia, ARF & amyloidosis) PSC (intra & extrahepatic): ♂
thrombocytopaenia) 3) Hepatotoxic drugs with IBD esp. UC
Alcohol, paracetamol, TCM, Cholangitis (Charcot’s triad)
isoniazid, augmentin, MTX, Choledochal cyst (type I-V)
phenytoin, corticosteroids Distal cholangiocarcinoma
4) Autoimmune hepatitis 3) Extraluminal
SLE Ca head of pancreas (painless, w
5) Inherited ↓/absent activity of UGT distended GB)
(unconjugated hyperbilirubinemia) Other peri-ampullary Ca
Gilbert’s syndrome (cholangio, dudeno, ampullary)
Crigler Najjar 1 & 2 Mirrizi’s syndrome (chronic
6) Inherited impaired biliary excretion cholecystitis)
(conjugated hyperbilirubinemia) 4) Others:
Dubin-Johnson syndrome Biliary atresia
Rotor syndrome Drug-induced: paracetamol,
penicillins, corticosteroids
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2. APPROACH TO OBSTRUCTIVE JAUNDICE
Benign
Intraluminal - Gallstones
- Parasitic infections (recurrent pyogenic cholangitis)
Benign
- Post-instrumentation strictures (ERCP, operation)
- Strictures from other causes (gallstones, chronic pancreatitis)
- Benign papillary fibrosis: prev gallstone passage (can give post cholecystectomy pain, acute pancreatitis)
Mural - Primary sclerosing cholangitis
- Choledochal cyst
Malignant
- Cholangiocarcinoma (distal)
Benign
- Mirizzi syndrome
- Pancreatitis: secondary bile duct compression from edema
Extramural
Malignant
- Head of pancreas cancer
- Periampullary cancer
- Metastases to the porta hepatis
HISTORY
- Confirm jaundice – pt’s sclera are yellow (carotenemia does not result in scleral icterus or elevation of the bilirubin level)
- Establish obstructive jaundice – tea-coloured urine, pale stools
- Exclude pre-hepatic and hepatic jaundice (more importantly hepatic jaundice since it can also cause tea-coloured urine)
Symptoms suggestive of viral hepatitis: prodrome of fever, malaise, arthralgia, myalgia, nausea/vomiting, etc.
Risk factors for viral hepatitis: travel history, ingestion of seafood, family history of hepatitis (esp mother, siblings), blood transfusions,
drug abuse/needle sharing, needlestick injuries, sexual contact
Alcohol intake: shown to affect bile acid uptake and secretion, resulting in cholestasis. Chronic alcohol use may result in fatty liver
(steatosis), hepatitis, and cirrhosis
Drug history: any TCM intake recently, any new medications taken
History of chronic liver disease
- Recurrent spikes of similar jaundice that resolve on their own with time suggest benign obstruction e.g. stones, strictures
- A young patient with painful jaundice usually benign cause
- Previous history of gallstone disease or biliary colic symptoms
- Previous history of surgery to the biliary tract or ERCP
- Malignancy is suggested if the patient is old, jaundice is of new onset and progressively worsening, and there is no associated pain (i.e.
painless progressive jaundice)
- Constitutional symptoms: loss of appetite, loss of weight, malaise
- Metastatic symptoms: bone pain, neck lump, dyspnoea, etc
- Pain is a late symptom of pancreatic CA & tends to be constant and relentless compared to biliary colic which subsides after few hours
3. Complications
- Symptoms of cholangitis: fever, chills, rigors with RHC pain and jaundice
- Pancreatitis (gallstone as cause): abdominal pain radiating to the back with N/V
- Pruritus as a result of bile salt retention
- Decompensation: encephalopathy, hepatic fetor, worsening ascites
- Fat malabsorption: steatorrhoea, fat-soluble vitamin deficiency (A, D, E, K) – especially coagulopathy (very unlikely in acute setting)
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PHYSICAL EXAMINATION
Bloods
Imaging
(Ultrasound versus CT - Both useful in demonstrating dilated biliary system as well as site & cause of obstruction)
MANAGEMENT
The patient is managed as for the causative aetiology (see relevant sections)
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3. GALLSTONE DISEASE
DEFINITION
Gallstone is a generic term for any kind of stone (cholesterol, pigment) in any part of the biliary system (gallbladder, cystic duct,
hepatic duct, common bile duct, etc)
EPIDEMIOLOGY
- Exact incidence in Singapore not known
- In the West: overall 10-15%; 20% in women and 10% in men
- Consistent 2:1 female to male ratio, 1:1 in elderly
- Typical picture (the 5 F’s): Fat, female, forty, fertile, flatulent – refers to cholesterol stones but no longer applies.
Cholesterol stones
- More common in older (peak at 40-50 years) but increasing in younger
- Developed countries – 22% of SG population (18% with signs and symptoms)
- M=F
- From disruption in the solubility equilibrium of bile.
Mixed
- Majority
Biliary sludge
- Microlithiasis suspended in bile; a milieu that predisposes to stone formation
- Can be visualised on the ultrasound scan as layering in the biliary tree
- Sludge is a pre-stone condition, but not all sludge becomes stones
- 20% of biliary sludge will disappear, 60% recur, and 10% form stones
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CLINICAL COURSE
- 80-95% of patients
- Risk of symptom occurrence = 1 to 2% per year
greatest risk in first 5 years of diagnosis – 10% at 5 yrs, 15% at 10 yrs, 18% at 15-20 yrs
7-10% mod, 3-5% severe; the rest minor symptoms
majority do not require removal of the stones or the gallbladder = expectant mx (Risks of Sx > Risks of doing nth)
- Role of surgery: [3]
(a) Suspicious / high risk of MALIGNANCY (causing gallbladder stasis stones) eg. susp gallbladder mass, gallbladder
polyp, porcelain gallbladder prophylactic surgery
(b) IMMUNOCOMPROMISED presentation is abnormal & difficult to detect
(c) Patients with CHRONIC HAEMOLYTIC DISEASE (e.g. sickle cell anaemia, thalassaemia) – as high as 50-60% will
develop symptomatic disease in their lifetime
Symptomatic sequlae
2. Infection
i. Acute / Chronic cholecystitis
ii. Cholangitis
iii. Pancreatitis
3. Gallstone dyspepsia: (non-ulcer dyspepsia) fatty food intolerance, dyspepsia and flatulence not due to other causes
Complications
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2. CT scan
- PTC involves a tube being inserted under radiologic guidance into one of the biliary ducts (must be dilated duct)
- Rarely done now; main indications:
1) Diagnostic: high obstruction not well visualised in ERCP; prev surgery with altered anatomy (eg gastrectomy)
2) Therapeutic: obstructed system that cannot be drained from below;
- Mostly for therapeutic rather than diagnostic purposes
- Complications: bleeding (esp in biliary obs pts due to coagulopathy sec to decreased Vit K abs); leakage of bile when
tube is removed
6. HIDA scan
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TREATMENT
Asymptomatic
- No surgery required unless patient has indications for surgery (see above)
- Expectant management and close follow-up
- Counsel patient about symptoms – biliary colic, acute cholecystitis, obstructive jaundice, etc
Symptomatic
Surgical = Cholecystectomy
- Cholecystectomy is the only way to treat gallbladder stones that are symptomatic (esp if cxs arise high risk of 2nd attack)
- Open or laparoscopic ( preferred)
- Adv of Lap: shorter hospital stay, less pain, less complications post-operatively
- Risks of Lap:
Conversion to open - up to 5%
Due to abnormal anatomy; difficult or complicated dissection; iatrogenic injury.
Conversion rate is higher if there is ongoing infection e.g. cholecystitis – up to 1 in 3 to 1 in 4
Injury to surroundings: bowel & biliary structures e.g. CBD
Haemorrhage
Infection
Spilled bile peritonitis, sepsis
Non-Surgical
All therapeutic regimens retaining the GB have 50% recurrence of stones aft 5yrs (no LT benefit)
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4. ACUTE CHOLECYSTITIS
PATHOPHYSIOLOGY
- Gallstone gets stuck in the cystic duct causing obstruction of biliary flow
- Gallbladder becomes distended and inflamed
- 50% of cultures are sterile (infection occurs eventually. In elderly, DM severe with gas-forming organisms causing emphysematous
cholecystitis)
PRESENTATION
INVESTIGATIONS
2. CT AP
Fat stranding around gallbladder not seen on ultrasound but on CT
Exclude complications (empyema, perforation)
3. FBC: leukocytosis (except elderly) – if severe, indicates complications
4. Amylase (can be raised mildly, if >1000, pancreatitis!),
5. LFT (mild transaminitis)/ UECr (dehydration)
6. CXR, KUB:
Radioopaque gallstones, aerobilia (due to fistula).
Exclude lower lobe pneumonia, perf viscus, abnormal right hemidiaph/thorax.
7. PFO: PT/PTT, ECG
MANAGEMENT
A) Conservative
Cholecysitits usu resolves with medical management (60%), but inflammation may progress complications, including peritonitis.
- Definitive treatment – laparoscopic (better success if within 72hrs of symptom onset) cholecystectomy
B) Timing of cholecystectomy
- Possibilities available:
i. Emergency (immediate; in very sick patients who are not doing well/ not responding to treatment)
ii. Early (within few days of onset – ideally within 5 days)
iii.Delayed/interval (after 6-8 weeks)
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Early Delayed
Advantages Advantages
- Everything done in one admission - Lower risks
- Easier to operate as the gallbladder is oedematous - Better laparoscopic success
Disadvantages
- Ongoing inflammation higher risk of bleeding Disadvantages
- Higher risk of injuring some other structure due to difficulty in - Fibrosis difficulty mobilising gallbladder
visualisation - Need for another admission
- Higher conversion rate to open chole - Chance of recurrence / acute pancreatitis during the time
- Increased risks of post-op infection (20%)
Early surgery has been found to be more beneficial ( mortality, total duration of dz, length of hosp stay, cost)
1. Hydrops/ Mucocele
- Cystic duct obstruction leads to a tense gallbladder filled with mucus (slow distension from continuous mucus secretion)
- May lead to gallbladder wall necrosis if pressure exceeds capillary bld pressure
2. Empyema
- Gallbladder is filled with pus due to bacterial infection of the stagnant bile (cystic duct being obstructed by a stone)
- Patient is usually toxic, requiring urgent surgery
3. Gangrene and perforation – rare due to rich blood supply from hepatic and cystic arteries
- Localised perforation abscess that is confined by the omentum (new mass)
- Free perforation generalised peritonitis and sepsis sudden generalised abdo pain emergency laparotomy
4. Cholecystenteric fistula
- Most commonly occurs in duodenum, then colon, and stomach; after repeated attacks of cholecystitis
- Usually asymptomatic
- On AXR, aerobilia is seen in 40% of cases
- Symptomatic fistulas (malabsorption and steatorrhoea) should be treated with cholecystectomy and fistula closure
5. Gallstone ileus
- Stones causing cholecystenteric fistula pass into the enteric lumen causing intermittent bouts of small bowel obstruction
- Accounts for 1-2% of IO overall
- Ppt: unexplained gradual onset of SB obstruction
- Small stones (<2-3cm) usually pass spontaneously without problems
- If >2.5cm and migrated into gut impact at terminal ileum (commonest), duod, sigmoid colon
- Mortality is 10-15%, mostly in elderly patients in whom gallstone ileus is more common
- Ix: AXR, Barium follow through
- Tx: Small bowel enterotomy proximal to the point of obstruction is usually required to remove the stone (Immediate cholecystectomy
not warranted as <4% of patients will have further symptoms)
PROGNOSIS
- 5% mortality
- Nearly all >60years, with DM
- Causes: 2° cardiovascular pulmonary complications (older), uncontrolled sepsis with peritonitis and intraabdominal abscess
ACALCULOUS CHOLECYSTITIS
- Occurs in very ill patients with prolonged stay in ICU – prolonged fasting, poor nutrition, labile blood pressure, sepsis
- Poor nutrition leads to biliary stasis, while dehydration and hypotension leads to formation of viscous bile and gallbladder ischaemia bile
may get infected cholecystitis
- Treatment involves emergent cholecystectomy / percutaneous cholecystostomy to control acute disease followed by cholecystectomy
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5. GALLBLADDER CANCER
6. CHOLEDOCHOLITHIASIS
PRESENTATION
- Obstructive jaundice – tea-coloured urine, pale stools
- Biliary colic
- If infection sets in cholangitis (see below)
BLOODS
- FBC (check TW for any rise suggestive of infection)
- Amylase (CBD stone may cause pancreatitis)
- LFTs (raised bilirubin – direct; ALP raised more than transaminases – also high if LT due to liver damage)
ULTRASOUND
- Gallstones in gallbladder
- Gallstone in CBD (50% missed, esp in distal CBD)
- Dilated CBD (normally <8-9mm)
>10mm is abnormal
In older patients, post-cholecystectomy, or patients on long-term opiates, the CBD may be larger, up to 11-12mm in size
MANAGEMENT
- If unsure of presence of stone less invasive investigation such as MRCP, EUS
- If likelihood of CBD stone is high ERCP with stone removal
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7. CHOLANGITIS
PRESENTATION
- Classically Charcot’s triad: RHC pain, fever, jaundice (only 50-70% of patients have the classic triad)
- Reynold’s pentad: Charcot’s triad plus mental obtundation and shock
- A surgical emergency! (mention in exams!)
PATHOLOGY
- Usually results from obstruction to the biliary system with infection of stagnant bile
- Most common cause is choledocholithiasis (60%);
Consider benign strictures (instrumentation), malignancy (pancreatic, biliary), foreign body (prev instrumentation), PSC,
choledochocysts, Mirrizi’s, hemobilia, biliary enteric anastomosis
- Common causative organisms are gram negative bacteria and anaerobes – Klebsiella, E. coli, Enterobacter, Enterococcus
- Small proportion (elderly, prev biliary surgery) – anaerobes (bacteriodes, clostridium), developing world – parasites (Clonorchis
sinensis, Ascaris lumbricoides)
COMPLICATIONS
- sepsis
- electrolyte abnormality (dehydration)
- infection
- coagulopathy (Vit K)
MANAGEMENT
1. Resuscitation – “In view of cholangitis being a surgical emergency, I will like to resuscitate the patient who may be in septic
shock”.Anticipate rapid deterioration.
- Inform seniors
- Obtain good intravenous access and fluid resuscitate as appropriate
- Take bloods for investigations – cultures especially
- Close monitoring of vitals in HD/ICU
Hrly para + SpO2 Keep MAP > 65mmHg (or to inform doctors if SBP<100mmHg)
Catheterise and watch urine output (hrly urine output) – hepatorenal! (keep >0.5mg/kg/hr)
CVP line insertion if patient has shock unresponsive to fluid resuscitation (keep 10-12mmHg)
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- Choices for definitive treatment:
(a) Open cholecystectomy with CBD exploration
(b) Laparoscopic cholecystectomy (if CBD exploration is to be performed, need to convert to open – lap CBDE not done
in Singapore must mention during consent taking)
CBD EXPLORATION
- Removal of stones
1. Manual removal with stone-grasping forceps
2. Flushing out stones
3. Dredging stones out using balloon catheter or Dormia basket
4. Lithotripsy
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8. MIRIZZI’S SYNDROME
PATHOLOGY
- Gallstone in the Hartmann’s pouch compressing the common hepatic resulting in obstructive jaundice
- Compression effect is not just physical (the stone) but also contributed by the surrounding inflammation
- One of the caveats to Courvoisier’s law
GRADING
MANAGEMENT
- Grade 1: attempt laproscopic cholecystectomy
- Grades 2-4: open cholecystectomy with CBD exploration
BACKGROUND
Cholangiohepatitis, or recurrent pyogenic cholangitis (RPC), is characterized by:
1. Recurrent bacterial cholangitis
2. Intrahepatic pigment stones
3. Intrahepatic biliary obstruction.
PATHOPHYSIOLOGY
Helminthic infxn (eg Ascaris lumbricoides, Clonorchis sinensis) epithelial damage predispose to seeding of coliforms
into biliary system via bacterial translocation repeated portal bacteraemia cascade of events (biliary stasis,
obstruction, stone formation) recurrent cholangitis
Malnutrition deficiency of enzymes calcium bilirubinate pigment stones formation recurrent biliary obstruction
recurrent cholangitis
HISTORY:
- A history of recurrent attacks of cholangitis – typical hx:
1-2 episodes of fevers, jaundice, and RUQ abdominal pain per year
Hx of prev biliary surgery, endoscopic procedures, or percutaneous biliary drainage procedures.
- Complications of pyogenic cholangitis
cirrhosis with portal hypertension
cholangiocarcinoma
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PHYSICAL EXAMINATION
No specific physical findings are evident in RPC. Dx based on history.
DIFFERENTIALS
Primary Sclerosing Cholangitis
INVESTIGATIONS
For diagnosis
For Complications
Bloods
- FBC
- LFT with ALP>ALT, AST
- Prothrombin time: N/ (if prolonged cholestasis causes fat malabsorption and vitamin K deficiency)
Impt to exclude – correct with parenteral Vit K before invasive procedures
- Blood C/S: bacteremia – results help guide antibiotic choice.
- Ova and parasites: RPC freq a/w Clonorchis infxn – look for it and treat when present.
Radiology
- U/S HBS
segmental biliary dilatation
hepatolithiasis
liver abscesses
helps determine choice of supplemental axial imaging techniques.
- ERCP or PTC – imaging modality of choice for delineating the biliary tree.
- CT scan
centrally dilated bile ducts with peripheral tapering
bile duct stones
pyogenic liver abscesses.
TREATMENT PRINCIPLES:
- Treat current infection
- Biliary drainage
- Management of other complications e.g. dehydration etc
Surgical
- Usual surgical approach includes:
Initial biliary decompression – ERCP sphincterotomy / stent placement
Definitive biliary drainage procedure – e.g. Roux-en-Y choledochojejunostomy
PROGNOSIS
- Death occurs in approximately 15-20% of patients over 5-6 years.
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10. CHOLANGIOCARCINOMA
SITE
- Intrahepatic/peripheral 10%
- Distal 25%
- Perihilar 65% (Altemeier-Klatskin tumour)
Bismuth classification
i. Type I: below confluence of hepatic ducts
ii. Type II: tumour reaching confluence
iii. Type IIIA/B: involving common hepatic duct and either right or left hepatic duct
iv. Type IV: multicentric or involving confluence and both hepatic ducts
ASSOCIATIONS
PRESENTATION
DIAGNOSIS
U/S detects biliary dilatation but not useful for ductal lesions.
- CA 19-9 >100μl/ml (good sensitivity of 89%, specificity 86%)
- Contrast CT
- PTC: when biliary obstruction from distal end. 2 functions: 1) roadmapping for surgery; 2) drainage of obstructed system if
ERCP cannot drain
- ERCP: can obtain brushings for cytology, less bile leak than PTC
- Selective celiac angiography: aid in determination of surgical resectability by identifying tumor involvement with adjacent blood
vessels
CURATIVE TREATMENT
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PROGNOSIS FOR RESECTABLE DISEASE (5-year survival)
- Intrahepatic: 35-45%
- Distal 35-45%
- Perihilar 10-30% (worse prognosis due to early lymphatic spread)
PALLIATION
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12. BREAST DISEASES
- The breast is a modified sweat gland that lies in the subcutaneous tissue of the anterior chest wall between the superficial and
deep layers of the superficial fascia
- The base of each breast extends from the lateral border of the sternum to the mid-axillary line, from the second to the sixth rib
- The axillary tail pierces the deep fascia and enters the axilla
- Each mammary gland consists of 15-20 lobules that are drained by lactiferous ducts that open separately on the nipple
- Fibrous septa (Cooper’s ligaments) interdigitate the mammary parenchyma and extend from the posterior capsule of the breast
to the superficial layer of fascia within the dermis, and provide structural support to the breast (involvement of these ligaments
by malignancy causes dimpling of the overlying skin)
- Lymphatic drainage:
Anatomic/ Surgical division into levels I, II and III by the pectoralis minor muscle:
Level I: lateral to pectoralis minor – usu e first LN where BrCA spreads to
Level II: posterior to pectoralis minor
Level III: medial to pectoralis minor, extending up to apex of axilla
3. Interpectoral (Rotter’s nodes) – between pec major and pec minor muscles
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3. APPROACH TO A BREAST LUMP
HISTORY
1. History of lump
- Site of the lump?
- Single or multiple? – multiple: fibroadenoma / cysts / fibroadenosis.
- When & Why was it first noticed? (Pain, self-examination, etc)?
- Painful or painless?
- Overlying skin changes noted:
Erythema, warmth
Dimpling: shortening of Cooper’s ligaments due to tumor pressure?
Any general asymmetry of the breasts noticed?
Discharge – ind CA invasion
- Duration since first noticed – long duration unlikely CA
- Any increase in size from first noticed to now?
- Any changes in the nipple e.g. retraction
- Nipple discharge? If present, what is the colour and consistency?
- Any other lumps elsewhere – other breast? Axilla? Neck?
- Has the lump been treated before?
RF – to sieve out ppl carrying BrCA gene, ID high risk patient (to continue f/u even if lump benign)
4. Systemic review
- LOA, LOW (constitutional)
- Fever (infective cause)
- Bone pain, SOB, headache (metastasis)
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PHYSICAL EXAMINATION
Preliminaries (HELP)
- Hi: Introduce yourself & ask for permission to examine the breast Check list:
Always have a chaperone to accompany you if you are male - Breast
- Expose patient adequately from the waist up with exposure of axillae - Nipple
- SC LN
- Lighting: good
- Spinal Tap
- Position the patient at 45o or sitting position if a bed is not available - Lung effusion
- Hepatomegaly
Inspection
- General appearance
- Patient’s hands relaxed at her sides – look for:
any asymmetry in the breast contours,
any obvious skin changes
peau d’orange –infiltration of malignant cells into lymphatics causing edema (not compression),
erythema,
puckering
any scars of previous operation or procedure e.g. punch biopsy
- Look for nipple changes (7 D’s):
Discolouration Depression (retraction) Destruction
Discharge Deviation (Duplication – unlikely)
Displacement
- Manouvres:
1. Ask patient to raise her arms (to see the axilla and underside of breasts, and accentuate any tethering to skin dimpling)
2. Ask the patient to contract the pectoralis major (push her hands against her hips) may reveal a previously
unnoticeable lump if tethered to both skin and muscle
3. Press arms down & lean forward the rest of the breast will flop fwd but not the CA that is attached to underlying muscle
Palpation
- Patient should be lying down at 45 degrees to the horizontal with her hand tucked behind her head – this splays the breast out
so it can be palpated properly
- Start with the normal side first!
- Ask for any pain before starting to palpate
- Use one hand to retract and stabilise the breast and palpate with the other
- Palpate in a systematic manner e.g. quadrant by quadrant from centre outwards
- Examine the entire breast including the axillary tail
- When the lump is located, check with the patient whether this is the same lump
1. Fixation to the skin – try to pick up the skin above the lump
2. Fixation to underlying muscle – Move lump in 2 perpendicular directions. Then ask patient to press her hands against
her hips to contract the pectoralis major muscle, then try to move the lump in 2 perpendicular directions. (no need to do if
already attached to chest wall)
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Axillary lymph nodes
185
INVESTIGATIONS
“The evaluation of a breast lump is via the TRIPLE ASSESSMENT All 3 must be concordant for benign to
– (i) Clinical examination;; (ii) Imaging;; and (iii) Histology.” have >99% specificity to r/o malignancy
Imaging
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2. Ultrasound
- Usually used as the 1st investigation in young patients (<35 years old) or pregnant, lactating patients – as mammogram has radiation
(small amount); not the gold standard for screening
- Used when there is a breast lump:
A.Guide procedures e.g. Biopsy, drainage of abscess, aspiration of cyst
B.Evaluates consistency (solid vs cystic) &margins
C. Problems with Mammogram
Localisation of lesion seen in only one mammographic projection
Evaluation of a palpable mass with a negative mammogram
Evaluation in mammographically-difficult areas e.g. chest wall, axilla
- Pitalls:
Operator dependent, non-standardised techniques, poor resolution,
Unable to detect most microcalcifications
- Features of malignancy:
1. Markedly hypoechoeic with + thick echogenic halo
2. Irregular edges; Destruction of surrounding structures
3. Hypoechoeic shadowing; Posterior acoustic shadowing
4. Taller than it is wide (fir-tree appearance; invasion of fascia)
5. High central vascularity – Doppler to evaluate BV
6. Microcalcification (if large number)
Histology
- Options available:
(a) Fine needle aspiration cytology
(b) Core biopsy (Trucut/ mammotome)
(c) Incisional biopsy – remove part of lump (usually not done now except Frozen section intra-op)
(d) Excisional biopsy – remove entire lump
(c) and (d) GA, larger wound.
FNAC is less invasive, less painful, smaller wound (23G needle), does not require any local anaesthetic, cheap, repeatable.
But only cells are obtained with no histology cannot differentiate between in-situ cancer and invasive cancer, requires skilled
cytopathologist
If FNAC shows malignant cells, do frozen section intraop before proceeding with surgery (recommended).
Core biopsy is more invasive, requires local anaesthetic, will result in a larger wound (14G needle), more painful, risk of
complications higher (because biopsy needle is a spring-loaded firing mechanism, improper angling may result in
puncture of the lung or heart), more ex as requires tissue processing.
But can obtain tissue specimen, can stain for ER/PR status better diagnostic value
Should have ‘tissue diagnosis’ if you are subjecting patient to cancer treatment!
- Guided by clinical palpation or radiologic guidance[ more accurate, not 100%]
US guidance
Stereotactic guidance (stereotactic mammotome) – stereotactic = Xray from 2 angles, mammotome = vacuum-assisted biopsy device
(able to sample larger tissue volumes)
MANAGEMENT
- If triple assessment suggests a benign lump (i.e. all 3 are concordant), follow up with physical examination for 1 year (q3-6mths) to ensure
the lump is stable or regresses
- If all 3 concordant for malignancy further staging and treatment
- If 1 or 2 of 3 aspects suggest malignancy further workup, excisional Bx?
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4. APPROACH TO NIPPLE DISCHARGE
CAUSES
HISTORY
INVESTIGATION
MANAGEMENT
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5. BREAST CANCER
EPIDEMIOLOGY
- Most common cancer in females in Singapore:
- Age-standardised incidence 55 per 100,000 in 2002; incidence is half that of the West
- Bimodal age distribution: 45-55YO & older (>75YO)
- Gender ratio is about 100-150 female :1 male
RISK FACTORS
- Non-epithelial tumours arise from supporting stroma (e.g. angiosarcoma, malignant phyllodes tumour, primary sarcomas); very uncommon
- Epithelial tumours arise from cells lining the ducts or lobules, and can be further divided into invasive and non-invasive based on invasion of
the basement membrane
Non-invasive Invasive
Ductal DCIS = malignant IDC
- From terminal duct lobular unit, - 70-80% of invasive breast cancer
- Cause distortion of lobules, - Includes all cancers that cannot be subclassified into a
- Do not invade BM specialised type “no special type”
- Non-palpable, detected microcals - Poorer prognosis than a carcinoma of specialised type
- 35% multicentric, occult invasive ca in 10-20% - 2/3 express ER/PR,
- Progress to CA within 10 yrs ~30% risk; considered - 1/3 overexpress C-erbB2
malignant
- Good prognosis if treated
- Tx similar to IDC
Lobular LCIS = RF ILC
- From terminal duct lobular unit (like DCIS) - 5-10% of invasive cancers
- Do not distort lobular architecture - 10-20% multicentric and/or bilat
- Usually presents with a lump, seldom detected by - Cells morphologically similar to cells of LCIS:
mammo as rarely microcal. monomorphic, bland round nuclei
- 60-80% multicentric and bilateral - Cells invade individually into stroma (due to loss of E-
- Not premalignant, but a marker for increased risk of cadherin, a cell-adhesion molecule)
invasive disease in both breasts (7-10x increased risk) - Similar prognosis to IDC
- If ca develops, will be IDC usually, occurs >15 years
after diagnosis
- Usually proceed with excision biopsy.
Others Specialised types
- Medullary, colloid (mucinous), tubular, papillary
- Better prognosis than IDC
Inflammatory carcinoma
- Presents as erythematous. enlarged, swollen breast w/o palpable mass
- Histologically not specialised
- Diffuse invasion of breast parenchyma by ca cells blocking numerous dermal lymphatic spaces swelling
- No histo features of inflammation
- Very poor prognosis, rapidly fatal
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SPREAD
- Local: skin & subcut tissues, underlying ribs and muscle (chest wall)
- Lymphatics: axillary, internal mammary LNs, supraclavicular LNs
- Haematogenous: lungs, liver, brain, bone, adrenals, ovaries
PRESENTATION
STAGING
T3: >5cm
5 yr Survival
Stage I: 90% (70% in 10 yrs) 95% with adjuvant Rx
Stage II: 60% (40-50%) 76% with adjuvant Rx
Stage III: 30% (20-30%) 50% with adjuvant Rx
Stage IV: 10% (<2%)
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PROGNOSIS
2. Tumor factors
- Stage of disease – tumour size, lymph node involvement [Major prognostic factor]
- Grade of tumour
- Lymphovascular invasion
THERAPEUTIC OPTIONS
Options can be divided into aims of control (with either curative of palliative intent):
- Removal of tumour with clear margins, while achieving good cosmetic result
- Criteria: [Nodal status does not influence decision for WE or SM]
1. Only 1 tumour, not multicentric/ multiple DCIS/ LCIS (multifocal) unless same quadrant
2. No metastatic disease
3. Appropriate tumour size-to-breast ratio (to achieve good cosmetic result) - not about T staging anymore
4. Previously conserved breast
5. Patient must agree to post-operative radiotherapy (daily RT in hosp)
6. No CI to RT
a. not PREGNANT (the only absolute CI)
b. No CTD –underlying inflammation may get worse
c. No previous RT to the chest
- Results: overall survival at 25 years for WEAC comparable to SMAC, with Slightly higher local recurrence rates (for
WEAC: 1% per year, 4% in 5 years)
- Higher risk in younger patients as cancer tends to be more aggressive
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2. Simple mastectomy (if any CI to Wide excision)
Other forms of mastectomy (modified
- Removal of breast tissue, nipple-areolar complex, and overlying skin raical, radical or extended radical
- Ind mastectomy) are not performed anymore.
1. CI to wide excision
2. Patient prefers to remove entire breast
3. Need to remove nipple (WE cannot give good cosmesis)
- Lower rates of local recurrence; similar long term prognosis as WE (Italian trial)
- If done for DCIS, dont need to give adjuvant therapy
3. Axillary clearance
- Purpose of removal: NODAL STAGING (for prognostication) - does not confer survival benefit
- Routinely be done in (1) Clinically palpable LN / detected on US (2) BrCA >/= T2 (5cm)
- Not required for DCIS (theoretically cancer cells are confined to the breast) if diagnosed on excision biopsy / wide
excision. Recommended if diagnosed on Core biopsy (sampling error).
- Complications: see below
- Sentinel lymph node (SLN) biopsy (SLN) is a new standard of care
Only in Early CA (</= 5cm)
Principle: the sentinel lymph node, being the first lymph node draining the breast, is representative of the rest of the
axilla; if the SLN is negative for tumour cells, then the rest of the axillary nodes should be negative as well
o Solitary internal mammary LAD is rare
Use of blue dye (isosulphan blue, methylene blue) or radioactive isotope (Tc-99 sulphur colloid or colloidal albumin)
injected in the area of the breast just before surgery concentrates in the first lymph node (sentinel node) that drains
the breast after 5mins
During the op, look for the SLN by colour, or using a Geiger-Muller counter to detect the node with highest
radioactivity. Send node for frozen section (FS)
If -ve do not clear axilla; if +ve, perform axillary clearance
False –ve rate of SLN Bx <5%; false –ve rate of FS ~ 33% if so, re-explore if histology +ve and do AC
No difference in axillary recurrence between AC vs SLN biopsy
4. Palliative surgery
- Palliative mastectomy for symptoms (bleeding, fungating, infected tumour) - 'toilet mastectomy'
- Surgery at other sites:
Fixation of pathological fractures,
decompression of spinal cord compression,
surgical excision of brain metastases
5. Breast reconstruction
Complications of surgery
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Radiotherapy
2. Palliative
- Brain mets
- Bone mets to painful areas / impending fractures
Chemotherapy (polyCT with 3 drugs is better; 4-6cycles, each over 1/12) - Main purpose: eliminate micrometastasis!
1. Neoadjuvant
(a) Given in Locally advanced breast cancer (stage III) to shrink the tumour before surgical resection
(b) To shrink tumors before breast conserving Sx
- 20% achieve complete clinical response (cCR) i.e. tumour is no longer palpable
further 20% will achieve complete pathological response (cPR) i.e. no more tumour cells = good prognosis
- Place clip into tumour before neoadjuvant therapy to guide surgery in case tumour “disappears”;; operate according to preop staging
- Cx: as for CT drug, e.g. mouth ulcers, N/V, hair loss, immunosuppression (main disadvantage pre-op)
2. Adjuvant
- Start 3/52 after surgery; given in stage III / LABC (LN+ve) & in some early breast cancers depending on stage (see below)
- Premenopausal patients tend to have better response to chemotherapy than hormonal therapy (vice versa for postmenopausal patients)
- Main active agents: anthracyclines (e.g. doxorubicin, epirubicin) and the taxanes (e.g. paclitaxel, docetaxel)
- Common regimens: AC (anthracycline, cyclophosphamide), FAC (5-FU, anthracycline, cyclophosphamide), CMF (cyclophos,
methotrexate, 5-FU)
3. Palliative
- Anthracyclines and taxanes are the mainstay
- Helps to reduce load of disease to alleviate symptoms, increase survival
Hormonal therapy
Targeted therapy
- Herceptin (trastuzumab)
- targets Her-2-neu a.k.a. C-erbB2 receptor (an epidermal growth factor receptor [EGFR] that is overexpressed in 18-20% of cancers)
- Used in C-erbB2 positive tumours, early or late stage
- Her-2-neu indicates worse prognosis Herceptin improves prog to normal
- Side effects of Herceptin: 1. cardiomyopathy & CCF
2. pulmonary toxicity,
3. infusion reactions,
4. febrile neutropaenia
- Avastin (or bevacizumab, targets vascular endothelial growth factor [VEGF] receptor, used in advanced cancer);
- Lapatinib (targets Her-1 and Her-2, used in advanced cancers)
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TREATMENT BY TUMOUR STAGE
1. DCIS
- Same Tx as invasive carcinoma: WE vs SM
- Sentinel LN biopsy if DCIS not very certain (ie diagnosed on Core biopsy)
- ± hormonal therapy (only if WE) to reduce recurrence at surgical site; tamoxifen reduces overall breast cancer risk by
50% in both breast not adjuvant therapy
FOLLOW-UP
- symptoms + P/E
- 3-monthly for first 2 years
- 6-monthly for the next 3 years (i.e. third to fifth years)
- Yearly for another 5 years (to tenth year)
- MMG: same breast 1yr postop; then 2-yrly bilateral mammo for life (previous BC is a strong Risk factor for future Breast cancer)
- CEA and CA15-3 are used in some centres for trending
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BREAST SCREENING
- Presents as erythema and eczematous change of the nipple (not the areola) with crusting exudates, may develop into erosions
and ulcerations
- Often associated with intraductal carcinoma (DCIS) or invasive carcinoma just beneath the nipple
- Malignant cells invade across the epithelial-epidermal junction and enter the epidermis of the nipple, breaking the normal
epidermal barrier thus allowing fluid to be extruded onto the nipple
- Examination and investigations should be targeted towards detecting an underlying tumour – may find a palpable mass and/or
mammographic abnormalities
- Punch biopsy of the nipple may be required
- Prognosis of the underlying cancer is not altered by the presence of Paget’s disease of the nipple
- Treatment should be planned according to the underlying cancer if found
- If no palpable mass or mammographic abnormality is detected, wide excision is an adequate treatment
7. GYNAECOMASTIA
- Causes:
- Physiological: puberty (maybe painful)
- Drugs:
Recreational drugs
Cimetidine (H2 blockers)
Digosin
Spironolactone
Antimicrobials (Isoniazid, ketoconazole)
- Endocrine disorders:
Thyroid disorders
Acromegaly
Hypogonadism (testicular atrophy, Klinefelters’ syndrome)
- Malignancy: testicular tumours, lymphomas
- Chronic liver disease: cirrhosis
- Investigation:
- TFT, testosterone/ LH
- LFT, α-FP, ß-HCG
- Treatment
- Conservative management
- Surgical excision
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13. NECK MASSES
- The neck is composed of two triangles on each side – anterior and posterior triangles
- The anterior triangle is bounded by the lower border of the mandible superiorly, the midline anteriorly, and the anterior border of
the sternocleidomastoid posteriorly
- The posterior triangle is bounded by the posterior border of the sternocleidomastoid anteriorly, the anterior border of the
trapezius posteriorly, and the clavicle inferiorly
- Masses in the neck can be subdivided according to the triangle they occur in as there are pathologies peculiar to each triangle
- Locations: (i) Midline
(ii) Anterior triangle
(iii) Posterior triangle
- In general, enlarged lymph nodes are the most common cause of a lump in the neck, regardless of location
MASSES BY LOCATION
Midline (5)
Approach:
1. Submental lymph node
2. Thyroglossal cyst - Does it move with swallowing – divides the thyroglossal cyst and
3. Thyroid nodule in the isthmus thyroid nodule from the other causes
4. Sublingual dermoid cyst - If it moves with swallowing, does it move with tongue protrusion –
5. Plunging ranula (retention cyst of the sublingual) thyroglossal cyst moves with protrusion but a thyroid nodule does not
6. Rarely, hyoid pathology e.g. bursa
Anterior triangle
1. Lymph node – along anterior border of sternocleidomastoid (levels II, III, IV)
2. Thyroid nodule
3. Submandibular gland mass (see later section on Salivary gland swellings)
4. Branchial cyst + fistula
5. Chemodectoma (carotid body tumour)
6. Carotid aneurysm
7. Pharyngeal pouch
8. Laryngocoele (rare; an air-filled, compressible structure seen in glass-blowers)
Posterior triangle
1. Lymph node (mainly) – level V and supraclavicular lymph node groups
2. Cystic hygroma
3. Cervical rib
4. Brachial plexus neuroma/schwannoma
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2. THYROGLOSSAL CYST
Epidemiology:
Equal in males and females. Occurs mostly in children and adolescents but up to one-third occur in patients older than 20 years.
Pathology:
Cystic expansion of the remnant thyroglossal tract (embryological origin of the thyroid which descends from the foramen caecum on the tongue).
Features:
Smooth, rounded, cystic lump.
75% are in the midline while 25% are slightly to the left or right.
Usually asymptomatic but may become infected.
Complications:
1. Infected with sinus formation and seropurulent discharge (occurs with incision or rupture of cyst)
2. Malignant change (carcinoma of the thyroglossal duct)
Histology:
Cyst with columnar or squamous epithelial lining which may be ciliated.
The cyst may also contain thyroid and lymphoid tissue. If malignancy occurs, it is usually a papillary carcinoma (~90%).
Treatment:
Sistrunk procedure – resection of the (a) cyst and (b) mid-portion of the hyoid bone in continuity and resection of a (c) core of tissue from the
hyoid upwards towards the foramen caecum (remove the entire tract to prevent recurrence!)
3. DERMOID CYST
Pathology:
Can be congenital or acquired.
(i) Congenital – developmental inclusion of epidermis along lines of fusion of skin dermatomes (seen in younger patients, present since birth).
Locations include:
o medial and lateral ends of the eyebrows (internal and external angular dermoid cysts)
o midline of the nose (nasal dermoid cysts)
o midline of the neck and trunk
(ii) Acquired – due to forced inclusion of skin into subcutaneous tissue following an injury, usually on fingers. Seen in older patients, no
previous history of mass, history of trauma to area (may have associated scar).
Histology:
Cyst lined by epidermis, with evidence of adnexal structures such as hair follicles, sebaceous glands and sweat glands.
Features:
Small non-tender mobile subcutaneous lump, may be fluctuant, skin-coloured or bluish.
Management
- Imaging investigations (e.g. XR, U/S, CT) are important especially for cysts on the skull as they can communicate with cerebrospinal fluid.
- Complete surgical excision of the cyst.
4. PLUNGING RANULA
Pathology:
A pseudocyst associated with the
sublingual glands and submandibular ducts.
Ranulas (frog mouth) can be congenital or
acquired after oral trauma.
Treatment:
- Complete resection if possible, often in
continuity with assoc sublingual gland
(but often difficult due to close association with the lingual nerve and submandibular duct).
- If complete resection not possible, marsupialisation (de-roofing the cyst so that it opens into the floor of the mouth) and suturing of the
pseudocyst wall to the oral mucosa may be effective.
Incomplete removal leads to recurrence.
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5. BRANCHIAL CYST/FISTULA
Epidemiology:
Affects both sexes equally, usually in young adults in their 20s.
Pathology:
A branchial cyst is thought to develop because of failure of fusion of the embryonic second and third branchial arches. It is lined
by squamous epithelium.
Features:
- Occurs anterior to the upper or middle third of the sternocleidomastoid muscle.
- Smooth firm swelling that is ovoid in shape, with its long axis running downwards and forwards.
- May be fluctuant, usually not transilluminable (due to desquamated epithelial cell contents).
- Look for fistula in this area – a branchial fistula will run between tonsillar fossa and the anterior neck, passing between the
external and internal carotid arteries.
- Fine needle aspiration of the cyst will yield opalescent fluid with cholesterol crystals under microscopy.
- May be complicated by recurrent infections – purulent discharge, fixation to surrounding structures.
Management:
- If fistula present, perform fistulogram to delineate course.
- Surgical excision of the cyst where possible. (perc drainage rarely permanently successful)
If fistula/sinus present, inject Bonney’s blue dye into tract prior to surgery to allow accurate surgical excision.
- Treatment of infection with antibiotics.
- Complications: cyst recurrence; chronic discharging sinus.
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6. CHEMODECTOMA
Pathology:
A chemodectoma is a tumour of the paraganglion cells (paraganglionoma) of the carotid body located at the bifurcation of the
common carotid artery (into the internal and external carotids).
They are usually benign, but locally invasive; the risk of malignancy is 10%, with metastasis to local lymph nodes (no
histopathological features for malignancy, thus malignant nature can only be diagnosed by presence of metastasis).
Features:
- Solid, firm mass at the level of the hyoid bone (where the bifurcation is) – be gentle during palpation as pressure on the carotid
body can cause vasovagal syncope.
- Mass is pulsatile but not expansile, due to transmitted pulsation from carotids.
- Due to close association with carotid arteries, lump can be moved side to side but not up and down.
- May be bilateral.
Differentials:
- Main differential is carotid artery aneurysm
- Aneurysm can occur at any level but carotid body tumour occurs at the level of the hyoid bone.
- If suspecting aneurysm, (a) listen for bruit, look for (b) signs of Horner’s syndrome, (c) examine the rest of the peripheral
vascular system.
Investigation:
- DO NOT PERFORM FNA
- Angiography (gold standard) – shows a hypervascular mass displacing the bifurcation. May also show vessel compromise by
tumour invasion, and undetected synchronous tumours.
- CT and/or MRI can be used to delineate tumour anatomy in relation to surrounding structures; CT reveals homogenous mass
with intense enhancement following IV contrast administration.
Treatment:
- Surgical excision with pre-operative embolisation (reduces bleeding and complications, and facilitates resection); any enlarged
ipsilateral lymph nodes are also removed due to the small possibility of malignancy
- Radiotherapy is an effective alternative for patients who are unfit for surgery or whose tumours are too large.
7. PHARYNGEAL POUCH
Pathology:
A herniation of the pharyngeal mucosa (pulsion diverticulum) through its muscular coat at the weakest point – Killian’s
dehiscence – between the cricopharyngeus muscle and the lower inferior constrictor muscles.
Features
- Occurs in older patients
- A cystic swelling low down in the anterior triangle, usually on the left
- Squelching sound on deep palpation
- Patient complains of
o halitosis,
o regurgitation of undigested food with coughing
o dysphagia in the neck,
o hoarseness,
o weight loss
- Complications: aspiration pneumonia; diverticular neoplasm (<1%)
Treatment
- Leave it alone if small and asymptomatic
- Minimally invasive treatment: endoscopic cricothyroid myotomy
- Surgical approaches (several available)
o Diverticulectomy + cricothyroidotomy (diverticulectomy associated with risk of mediastinitis, dangerous)
o Diverticulopexy (done in high risk patients, involves suspending the lumen of the pouch in the caudal direction so that food
and secretions cannot enter the pouch; as the diverticulum is still present, the risk for malignancy still remains)
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8. CYSTIC HYGROMA
Pathology:
A cystic hygroma is a congenital cystic lymphatic malformation found in the posterior triangle of the neck, probably formed during
coalescence of primitive lymph elements. It consists of thin-walled, single or multiple interconnecting or separate cysts which
insinuate themselves widely into the tissues at the root of the neck.
Features:
- 50-65% present at birth, but occasionally may present later in childhood or adulthood
- cystic swelling that is soft, fluctuant, and compressible (usually into another part of the cyst), located in the posterior triangle
at the root of the neck
- Classically “brilliantly transilluminable”
- A large cyst may extend deeply into the retropharyngeal space
Complications:
- Cystic hygroma seen on prenatal ultrasound in the first trimester suggests chromosomal abnormality (50% of foetuses, usually
trisomy 21) or other structural abnormalities (33% of foetuses with no chromosomal abnormality, usually congenital heart
anomalies)
- May obstruct delivery
- Compressive problems after delivery – respiratory, swallowing
Management:
- Radiological investigations e.g. CXR, CT to delineate extent of cyst
- Non-surgical treatment – aspiration and injection of sclerosant (usually unsuccessful)
- Surgical excision – partial (to alleviate symptoms) or complete
9. CERVICAL RIB
Features:
- Usually more symptoms than signs as it causes thoracic outlet syndrome (diagram below)
- A hard mass in the posterior triangle at the root of the neck
- Symptoms/signs:
o Arterial: pallor, gangrene or necrosis of the tips of the fingers
o Venous: oedema, cyanosis
o Neurological: complaints of radicular symptoms (pain, paraesthesia), wasting of the small muscles of the hand
- Adson’s test can be done – ask patient to extend neck and rotate it towards side of symptoms radial pulse will be
diminished, occasionally with reproduction of radicular symptoms in the limb
- Diagnosis by CXR
10. NEUROMA/SCHWANNOMA
Features:
- Slow growing tumour arising from peripheral neural structures of the neck e.g. brachial plexus, cervical plexus, vagus nerve,
phrenic nerve, etc.
- Fusiform, is mobile in plane perpendicular to axis of nerve but not parallel
- Usually benign
- May be Tinnel’s positive – tap on the mass for any paraesthesia occurring in distribution of the nerve
- DO NOT PERFORM FNA – excruciatingly painful
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11. CERVICAL LYMPHADENOPATHY
There are six levels of lymph nodes in the neck, and different structures drain to different groups of nodes:
Level Ia – submental
Ib – submandibular
II – long internal jugular vein from skull base to bifurcation of carotids (includes jugulodigastric nodes)
III – along internal jugular vein from carotid bifurcation to omohyoid
IV – along internal jugular vein from omohyoid to clavicle
Va – Posterior triangle
Vb – Supraclavicular
VI – Tracheo-oesophageal groove (not palpable)
VII – Superior mediastinum
Drainage:
- Oral cavity and oropharynx levels I – III
- Thyroid and larynx levels II – VI
- Nasopharynx II – V (usually upper neck – level II and high level V)
CAUSES:
1. Cancer (3): SCC, NPC, Adenocarcinoma
2. Lymphoma
3. TB
Infective Viral (esp 1-2cm firm LN. No need Abx unless obvious infx)
Epstein-Barr virus, cytomegalovirus (infectious mononucleosis); HIV
Bacteria
Streptococcus, Staphylococcus, Klebsiella (from intraoral pathology e.g. dental abscess, tonsillitis)
Tuberculosis
Parasitic
Toxoplasma
Fungi
Actinomycosis
Neoplastic Metastatic Head and neck primary
Nasopharyngeal carcinoma
Oral cavity, oropharynx, larynx, hypopharynx, thyroid, etc.
Other primary sites (4B’s)
Bowel (stomach, colon), breast, bronchus (lung), balls (testicular). Also UL.
Primary - lymphoma
Inflammatory SLE
Kikuchi’s (necrotising lymphadenitis occurring in young females, presenting as painful cervical lymphadenopathy)
Sarcoidosis
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HISTORY
- Age
- RF for CA: smoking, alcohol. Betel nut
- The lump itself
o onset, duration, associated symptoms, lumps elsewhere
o Pain: inflammatory > CA
o Growth pattern / rate of growth:
last few days = infx / inflammatory / haemorrhage into cyst
last few months = CA
- Constitutional symptoms
o Fever, malaise, arthralgia, myalgia (viral prodrome);
o Night sweats, low-grade fever (TB, B symptoms of lymphoma);
o Loss of appetite, loss of weight (chronic infection, malignancy)
- Local symptoms – intra-oral diseases e.g. tooth decay, oral/tongue ulcer, tonsillitis. Use of dentures.
- Past medical history – cancer, TB (contact? Diagnosed? treated or untreated?)
- Social history: travel and contact history, sexual history for HIV, ORAL SEX
PHYSICAL EXAMINATION
Inspection
- SITE
- Size, shape, surface: erythema, discharging sinus (multiple lymph node enlargement with discharging sinuses can be TB or actinomycosis;
sulphur granules seen in actinomycosis)
“Is there any pain? I am going to feel the lump, if any pain, let me know”
Palpate from behind, one side at a time – start at submental, then submandibular, preauricular, postauricular, along anterior border of
sternocleidomastoid, supraclavicular, posterior triangle, lastly occipital. Use pulps of the fingers in a gentle rolling movement.
- Tenderness to palpation
- Consistency – hard, matted nodes are more suspicious for malignancy
- Fixation to overlying skin or underlying structures
INVESTIGATIONS
MANAGEMENT
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14. SALIVARY GLAND SWELLINGS
- Surrounded by tough fibrous capsule – the parotid sheath (thus mumps is painful as the gland swells within a tight envelope)
- Sandwiched between the posterior border of the ramus of the mandible and the mastoid process
- Important structures that pass through the gland in order from lateral to medial:
(i) Facial nerve and its branches
(ii) Retromandibular vein (formed as the maxillary veins drain into the superficial temporal vein)
(iii) External carotid artery (branching into its two terminal branches, the superficial temporal and maxillary arteries)
- Nerve supply:
(i) Parasympathetic secretomotor supply from auriculotemporal nerve carrying postganglionic fibres from the otic ganglion (preganglionic
fibres from inferior salivary nucleus);
(ii) Somatic sensory supply of the gland from auriculotemporal nerve; sensory supply of the capsule from the great auricular nerve.
- Parotid duct (of Stensen) runs 5cm across the masseter (surface marking: along the line joining the intertragic notch to the midpoint of the
philtrum), drains into the mouth opposite to the upper second molar tooth
- Histology: predominantly serous acini, many ducts (other glands have few ducts)
- Consists of a large superficial part & a small deep part that are continuous with one another around the free posterior border of the mylohyoid
- The deep part of the gland is closely associated with the lingual nerve (with the attached submandibular ganglion) above it, and the
hypoglossal nerve and submandibular duct below it – surgery may injure these nerves
- Nerve supply: parasympathetic secretomotor supply from lingual nerve carrying postganglionic fibres from the submandibular ganglion
(preganglionic fibres in superior salivary nucleus)
- Submandibular duct (of Wharton) arises from the superficial part of the gland, runs forwards deep to mylohyoid and drains into the oral
cavity at the sublingual papilla just adjacent to the frenulum
- Histology: mixed serous and mucous acini, few ducts
- A small almond-shaped gland sitting just under the mucosa of the floor of the oral cavity
- Each gland has 15 or so ducts, half of which drain into the submandibular duct, the rest draining directly into the oral cavity
- Nerve supply is similar to the submandibular gland
- Histology: almost solely mucous acini, few ducts
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4. APPROACH TO SALIVARY GLAND SWELLINGS
HISTORY
- About the lump: onset, duration, progress, associated symptoms e.g. pain
o If pain is present, is it precipitated by food ingestion? (suggestive of sialolithiasis)
o Intermittent swelling a/w food (inflammatory)
- Symptoms of infection e.g. fever, malaise; if considering mumps, ask about testicular pain and swelling (orchitis), abdominal
pain (pancreatitis)
- Any noticed asymmetry of the face – incomplete closure of the eye on one side, drooping corner of the mouth, drooling
- Does the patient have symptoms of Sjogren: xerostomia (e.g. cannot eat a piece of biscuit or bread without water),
xerophthalmia
- History of connective tissue disease e.g. rheumatoid arthritis, SLE
PHYSICAL EXAMINATION
Inspect
- Put yourself at the level of the patient’s face and look from front for any asymmetry with an obvious mass on one side
o parotid mass is located between the angle of the jaw and the ear, and lifts the earlobe if large;
o submandibular mass is located just under the mandible
- Look for scars – parotidectomy scar runs anteriorly to the ear, below the earlobe and around posteriorly
before looping forward again under the jaw
- Look for fistula/sinus
- Look at the patient’s face for asymmetry (facial nerve palsy)
“Is there any pain? I am going to feel the lump, if any pain, let me know”
Palpate from behind
Other tests
- Pain
- Fixation to underlying structures or skin
- Hard consistency
- Irregular surface or ill-defined border
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CAUSES OF SWELLING OF THE PAROTID
INVESTIGATIONS
5. SIALOLITHIASIS
Epidemiology
- Stones of the salivary gland that may be impacted within the gland itself or in the duct.
- Usually occurs in males more than females, and between the ages of 30 and 60.
- 80% occur in the submandibular gland (due to its higher mucus and calcium content with a long duct, and slow flow of the saliva against
gravity); 10% occur in the parotid, 7% sublingual.
- Most submandibular gland stones occur in the duct, while 50% of parotid stones occur in the gland itself.
- 80-95% of submandibular stones are radio-opaque and can be seen on an X-ray of the floor of the mouth, and 60% of parotid stones are
radio-opaque.
Presentation
- Complete obstruction
Acute pain & swelling of the gland involved at meal times, rapid onset within minutes of starting to eat, resolves about an hour after the meal.
- Partial obstruction
Occasional symptomatic episodes interspersed by asymptomatic periods of days-weeks, chronically enlarged mass in submandibular region
- Cx: sialadenitis, and even abscess formation worsening of symptoms of pain and redness; systemic symptoms such as fever, chills;
purulent discharge from duct opening
- Stone may be palpable along the duct or at the opening of the duct
Investigations
- CT scan (Noncontrast) – can pick up almost all stones when fine cuts are requested
- Plain X-rays can pick up radio-opaque stones
- Sialogram (rarely done as it is invasive and technically demanding; CT is better. Contraindicated in acute sialadenitis and contrast allergy.)
Management
- General measures:
o Good hydration, good oral hygiene, soft diet, avoid sour food (increase salivation)
o Massage of the gland, milking the duct, application of moist hot towel
o Lifestyle changes: activities that exacerbate the pain eg. Blowing instruments
o Analgesia – NSAIDs such as ibuprofen
- If sialadenitis present:
o Antibiotics– usually to cover Staph and Strept e.g. Augmentin
o Refer specialist treatment if symptoms persist for several days, or sialadenitis persists despite antibiotic therapy
- Surgical removal
o Transoral removal of stones for submandibular duct stones (50% can be removed thus), less for parotid duct stones
o If stones cannot be removed via transoral surgery or is intraglandular, partial gland resection can be performed
- Other options: Lithotripsy, wire basket removal, sialoendoscopy
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6. SALIVARY GLAND TUMOURS
Pathology
Epithelial Non-epithelial
Adenomas (benign) Carcinomas (malignant)
Pleomorphic adenoma Adenoid cystic ca Haemangioma
Warthin’s tumour Pleomorphic adenoca Lymphangioma
Mucoepidermoid ca Neurofibroma
Acinic cell ca Neurilemmoma
Adenoca Lipoma
Squamous cell ca Sarcoma
Undifferentiated Malignant lymphoma
PLEOMORPHIC ADENOMA
Epidemiology:
- Most common benign tumour
- 85% occur in the parotid gland
- Equal sex ratio, occurs in younger patients (<50 years old)
Histology:
Very heterogeneous appearance, containing epithelial cells surrounded by loose stroma with islands of chondromyxoid (mesenchymal
components), and interspersed islands of myoepithelial cells. The tumour appears to be encapsulated, but histology shows multiple sites of
capsular penetration by tumour cells.
Features:
- Slow-growing, painless swelling occurring in the lower pole of the parotid
- Irregular and lobulated surface, texture of cartilage (slightly harder than Warthin’s)
- Does not invade or metastasise
- Cx
o Malignant transformation (carcinoma ex pleomorphic) if left for 10-15 years (1-6% risk)
o If not completely excised, can recur due to frequent capsular penetration (recurrence rate of 2%)
Epidemiology:
- Only occurs in the parotid gland (10% of parotid tumours)
- More common in males than females (4:1)
- Occurs in older patients (>50 years)
- Related to cigarette smoking
Histology:
Consists of cleftlike or cystic spaces lined by two-tiered epithelium, containing mucin, surrounded by a stroma of well-developed lymphoid tissue
with germinal centres.
Features:
- Slowly enlarging, soft to firm cystic fluctuant swelling in parotid tail (inferior)
- Invariably benign with no risk of malignant change
- 10% bilateral (check contralateral side)
Treatment
- Can be left alone if absolutely certain that the entire mass is composed of only Warthin’s tumour cells, since there is no malignant potential
- Superficial parotidectomy if causing trouble to patient
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MALIGNANT TUMOURS
Tumor grade
Nerve involvement
Parotid:
- Total parotidectomy with sacrifice of facial nerve if tumour has infiltrated it (may be grafted with great auricular nerve)
- Radical neck dissection if neck nodes positive
- Postoperative radiotherapy
Submandibular:
- Radical excision of gland with lymphatic clearance of submandibular triangle
- Radical neck dissection if neck nodes positive
- Postoperative radiotherapy
COMPLICATIONS OF PAROTIDECTOMY
1. Intraoperative facial nerve transection – lower motor neurone palsy (in surgery to the submandibular gland, damage to the
hypoglossal and/or lingual nerves can occur intraoperatively)
2. Reactionary haemorrhage: early post-op bleeding due to displacement of a clot in a BV / slippage of a ligature
Early (1 to 30 days)
1. Wound infection
2. Skin flap necrosis
3. Temporary facial weakness (neuropraxia of facial nerve)
4. Salivary fistula
5. Division of great auricular nerve loss of sensation over pinna
6. Trismus (inability to open mouth due to spasm of masseter)
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15. THYROID DISEASES
Structure:
2 lateral lobes joined by an isthmus that lies in front of the 2nd, 3rd and 4th tracheal rings.
Strap muscles of the neck lie superficial to the thyroid gland.
Embryonic origin:
Thyroglossal tract from foramen caecum of the tongue (in the midline, at the junction between anterior two-thirds and posterior
one-third of the tongue) descends close to the hyoid bone expansion of the caudal end of the tract forms the thyroid gland.
Parathyroid glands: 2 superior and 2 inferior glands that lie behind the lateral lobes.
Level VI lymph nodes – first nodes that a thyroid malignancy spreads to; they lie in the tracheo-oesophageal groove and are not
palpable.
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2. APPROACH TO THYROID PROBLEMS
HISTORY-TAKING
209
PHYSICAL EXAMINATION
A. THYROID GLAND
GREET PATIENT, ASK FOR PERMISSION to examine (and listen to the voice – is it hoarse?)
POSITION PATIENT – on a chair with space behind the chair for you to stand.
1. Any swelling? Where is it? (if unable to see, ask patient to swallow)
2. Any scars (thyroidectomy scar may be difficult to spot as it is often hidden in a skin crease)? Sinuses?
3. Any skin changes over the mass?
4. Check if mass moves on swallowing by asking patient to take a sip of water – “Please take a sip of water and hold it in your
mouth, do not swallow until I tell you to.”
5. Check if mass moves on protruding the tongue – “Please open your jaw slightly. Now, without moving your jaw, please stick
your tongue out and back in again.”
NB. A thyroid lump moves only on swallowing; a thyroglossal cyst will move on both swallowing & protrusion of the tongue.
6. Check for plethora of face, distended neck veins – may be due to compressive nature of mass (but rarely seen).
PALPATE FROM BEHIND – one side at a time, the opposite hand stabilises the gland.
Ask for pain before palpating!
1. Characteristics of lump: site (anterior triangle), size (discrete nodule or multinodular enlargement or diffuse enlargement?),
consistency (soft, cystic, hard, multinodular?), mobility (fixed to skin? Fixed to underlying structures?), tenderness.
2. Check swallowing while palpating to confirm mass moves on swallowing.
3. Check tongue protrusion.
4. Palpate lymph nodes
OFFER to do Pemberton’s sign to check for thoracic inlet obstruction; check thyroid status; ask patient about compressive
symptoms.
B. THYROID STATUS
HANDS (get patient to stretch arms out in front of him, palms down)
FACE
NEUROMUSCULAR
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3. APPROACH TO THE SOLITARY THYROID NODULE
Prevalence: About 4-8% of population in US have palpable thyroid nodules; prevalence in Singapore not known.
INVESTIGATIONS
2. ULTRASOUND OF THYROID
- Advantages:
(i) Objective measurement of nodule
(ii) Detection of subclinical nodule/screening – of value in papillary carcinoma since multicentric disease occurs in 15%
(iii) Detection of lymph node enlargement (especially level VI nodes)
(iv) Can define consistency of nodule – solid, cystic, or complex
- Suspicious sonographic features:
(i) Microcalcifications (in psammoma bodies papillary cancer)
(ii) Indistinct margins
(iii) Sonolucent halo around lesion
(iv) Hypoechoeic or anechoeic lesion – carcinoma is almost never hyperechoeic
(v) Increased intranodular vascularity
- Ultrasound still does not provide as good diagnostic value as FNAC
4. RADIO-ISOTOPE SCAN
- Hot nodule: only 1% malignant; but cold nodule: 10-20% malignant
- But not very useful diagnostically
6. CT SCAN OR MRI
- Not routine in thyroid nodular study
- Uses: (i) Evaluating invasion of surrounding structures
(ii) Retrosternal extension
(iii) Lymph node involvement
- Care to be taken with CT as contrast contains iodine and will affect post-op radioactive iodine body scan once given
- MRI has same functions as CT but higher cost
- Soft, small, round nodule with benign FNAC results, non-functional, not causing any symptoms can follow-up and monitor for in size
- A lump >4cm has a greater risk for malignancy
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4. THYROID CANCERS
212
RISK STRATIFICATION:
- Risk factors can be divided into patient factors and disease factors
- Patient factors: Age – >45 years old is high risk; Gender – male is high risk
- Tumour factors:
Size – nodule >4cm has higher risk
Histology – tall cell variant of papillary ca and Hurthle cell variant of follicular ca are considered unfavourable
Extrathyroidal extension into surrounding structures – worse
Lymph node or distant metastases – worse
- Risk helps to guide treatment – low risk patients can undergo hemithyroidectomy without ablative radioiodine therapy post-op, while
high risk patients undergo total thyroidectomy with post-op ablative RAI treatment; treatment in intermediate risk patients is tailored to
the disease, but usually is similar to that in high risk patients
- 5 year survival is also prognosticated by the risk: low risk patients have a survival of 95-98%, intermediate risk patients 88%, and high risk
patients 50%
Advantages of TT:
- Evidence for microfoci of disease and multicentricity of cancer – removal of the entire thyroid decreases risk of recurrence
- Ability to use adjuvant radioiodine to ablate any residual cancer tissue after surgery
- Ability to use radioiodine to detect recurrent disease (normal thyroid picks up iodine better than cancer cells, thus the presence of the thyroid
gland will decrease the ability of RAI to pick up recurrent cancer) and as treatment for recurrence
- Ability to use serum thyroglobulin as a cancer marker for recurrence
Disadvantages of TT:
- Risk of bilateral recurrent laryngeal nerve injury and permanent hypoparathyroidism
- Very low incidence of cancer recurrence in residual thyroid – microfoci probably not clinically significant
- Limited thyroidectomy may spare patient from having to be on lifelong thyroid hormone replacement
Risk stratification helps to guide the extent of surgical resection in differentiated thyroid cancer according to the patient’s disease.
- The removal, en-bloc, of the entire ipsilateral lymphatic structures of the neck, from the mandible superiorly to the clavicle inferiorly, from the
infrahyoid muscles medially to the anterior border of the trapezius laterally
- Classic radical neck dissection (Crile’s) – internal jugular vein, sternocleido-mastoid muscle, and accessory nerve are resected.
Structures not resected: carotid arteries, vagus nerve, hypoglossal nerve, brachial plexus, phrenic nerve
- Modified radical neck
(i) Type I: one of the three structures not removed, usually accessory nerve
(ii) Type II: two of the structures not removed – accessory and IJV
(iii) Type III: all of the three structures not removed
(iv) Extended radical neck dissection: resection of lymph nodes and/or structures not included in the classic neck dissection
- Complications of radical neck dissection:
(i) Injury to nerves – vagus (vocal cord paralysis), cervical sympathetic chain (Horner’s), mandibular branch of facial (lower lip weakness)
(ii) Haematoma bring back to OT to find source of bleeding and stop it
(iii) Salivary fistula (usually when pt has received RT to the neck, and if the upper GI tract was opened during the surgery) – infection can
result
(iv) Wound infection – risk factors: previous irradiation, if upper aerodigestive tract is opened during surgery with salivary contamination,
salivary fistula
(v) Carotid blowout – risk factors: infection, irradiation resus, apply constant pressure all the way to the OT!
(vi) Poor healing – usually in irradiated skin; weakest point is the junction of the trifurcate incision
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Multiple endocrine neoplasia
A group of inherited diseases resulting in proliferative lesions (hyperplasia, adenomas, carcinomas) of multiple endocrine organs.
FEATURES:
- Tumours occur at younger age than sporadic cancers
- Multiple endocrine organs involved, either synchronously or metachronously
- Multifocal tumours in each organ involved
- Tumour usually preceded by asymptomatic stage of endocrine hyperplasia
- More aggressive and higher chance of recurrence compared to sporadic type of tumours in the same organs
MEN 1
- Autosomal dominant inheritance
- Gene involved is the tumour suppressor gene MEN1 located on chromosome 11q13 where mutations cause loss of function of
the gene
- Three P’s:
Parathyroid (95%) – hyperparathyroidism from hyperplasia of parathyroid glands
Pancreas (>40%) – aggressive metastatic tumours (e.g. gastrinoma, insulinoma), leading cause of death in MEN 1 patients
Pituitary (>30%) – most commonly prolactin-secreting macroadenoma; some have growth hormone-secreting tumours
MEN 2
- Autosomal dominant inheritance
- Gene involved is RET protooncogene at 10q11.2 where activating mutations occur
- Two distinct groups of disorders:
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5. SURGERY IN BENIGN THYROID DISEASE
IMMEDIATE (<24HRS)
3. Hyperthyroidism
- Resection of gland can release large amounts of stored thyroid hormone into bloodstream
- May result in thyroid storm (see Management of thyroid storm)
4. Tracheomalacia
- Floppiness of trachea resulting from chronic compression e.g. by large goitre
- Requires intubation to secure airway
1. Infection
- Replacement: 5mmol/6h if symptoms mild, 10ml of 10% calcium gluconate over 30 minutes if severe
- Hypocalcaemia may also occur due to “hungry bone syndrome” after thyroidectomy in long-standing thyrotoxicosis
1. Hypothyroidism
2. Hyperthyroidism (failed treatment)
3. Permanent hypoparathyroidism
4. Hypertrophic scarring or keloid formation – ask patient if he/she has keloids
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16. PERIPHERAL ARTERIAL DISEASES
- External iliac artery continues as the femoral artery after crossing the inguinal ligament
(surface landmark: the mid-inguinal point i.e. midway between the pubic symphysis and the anterior superior iliac spine)
- The femoral artery then divides into the superficial femoral and the profunda femoris (or deep femoral) arteries about 4cm
below the inguinal ligament
- The profunda femoris supplies compartments of the thigh via 2 main branches, the medial & lateral circumflex femoral arteries
- The superficial femoral runs distally and passes through the adductor hiatus to reach the popliteal fossa, where it changes its
name to become the popliteal artery
- The popliteal artery divides into the anterior tibial artery and the posterior tibial (also called tibioperoneal trunk by some), and
the posterior tibial will give off the peroneal artery
-
- The anterior tibial crosses into the anterior compartment of the leg and supplies the muscles there, and then continues as the
dorsalis pedis in the foot (surface landmark: one third of the way down a line joining the midpoint of the two malleoli to
the cleft between the first and second toes)
- The posterior tibial supplies the posterior compartment of the leg and passes posterior to the medial malleolus (surface
landmark: one third of the way down a line joining the medial malleolus to the heel) before dividing into medial and lateral
plantar arteries to supply the sole of the foot
- Refer to diagram – important to know the arrangement of the anterior tibial, posterior tibial and peroneal vessels at the
trifurcation as you may be asked to read an angiogram of these vessels.
- From lateral to medial: Anterior tibial, Peroneal, Posterior tibial
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2. ACUTE LIMB ISCHAEMIA
Acute limb ischemia is defined as a sudden decrease in limb perfusion that causes a potential threat to limb viability
(manifested by ischemic rest pain, ischemic ulcers, and/or gangrene) in patients who present within 2/52 of the acute event (if
>2/52, it is considered chronic ischaemia).
The decrease in perfusion is usually due to sudden occlusion of a feeding arterial vessel, and this may be in a setting of already
narrowed vessel lumen (acute on chronic ischaemia) or in a normal lumen.
CAUSES
1. Arterial embolism
2. Acute thrombosis
3. Arterial trauma
- Increasing incidence of acute arterial occlusion due to endovascular diagnostic or interventional procedures
- Trauma can cause development of an arteriovenous fistula that shunts blood away from the limb
- Fracture or dislocations can stretch an artery and cause an intimal tear while the media and adventitia layers are intact
(because they contain elastin and can stretch) a thrombus forms at the site of the tear where underlying thrombogenic
collagen is exposed
- Compartment syndrome can result from trauma as well
- As blood dissects between the intima and media of the aorta, it can cause occlusion of the aortic branches at their origins
PATHOPHYSIOLOGY
In order of sensitivity to ischaemia, the tissues affected are nerves (most sensitive), muscle, skin, and bone (least sensitive); thus
early signs of ischaemia involve pain and numbness, and muscle paralysis as well as skin changes occur later. The lower limb
can survive about 6 to 8 hours in an ischaemic state before injury becomes irreversible.
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PRESENTATION
The classic 6 P’s of acute limb ischaemia: Pain, Paraesthesia, Pallor, Pulselessness, Paralysis, Perishingly cold
Pain
- Develops acutely
- Starts off in a distal part of the extremity and then progresses proximally, increasing in severity with time
- Further progress leads to decrease in pain as the nerves die off from ischaemia
- Important to ask for any previous claudication pain (10% of claudicants can develop acute ischaemia due to thrombosis of the
stenosed vessel)
Paraesthesia
- Starts off with paraesthesia (develops relatively early in the course of ischaemia) and develops to complete loss of sensation
- Progression: Light touch Vibration Proprioception (late) Deep pain Pressure sense
Pallor
Pulselessness
- If able to feel one good pulse (PT or DP), quite unlikely that the limb is ischaemic, but still possible
- If unable to feel, assess with a handheld Doppler the arterial and venous flow in the limb – there can still be flow without a
palpable pulse
- Also feel the pulses on the other limbs – gives a clue as to whether the cause is embolic or thrombotic (see below)
Paralysis
P/E
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DIFFERENTIATING BETWEEN EMBOLIC AND THROMBOTIC CAUSE (IMPT AS THE MANAGEMENT IS DIFFERENT)
-
Embolic Thrombotic
Identifiable source Present – AF, recent AMI Less common
Claudication hx Negative Positive
Physical findings Contralat pulses present Contralat pulses diminished
White limb (no blood) Dusky limb (collaterals still
supplying limb)
Angiography Minimal atherosclerosis, Diffuse atherosclerosis,
sharp cut-off, few collaterals irregular cut-off, well-developed
collaterals
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ACUTE MANAGEMENT
INVESTIGATIONS
- Pre-operative investigations
- FBC, U/E/Cr, PT/PTT, GXM
- CXR and ECG if patient is older than 40 yrs old
- If suspecting an AMI with mural thrombus, do cardiac enzymes
- Biochemical abnormalities (muscle necrosis): K, CK, lactic acidosis
- ANGIOGRAM
Can be done in pts with viable limb; in pts with threatened limb there is
no time for angiogram may do on-table angiography
High clinical probability of embolism does not need angiography
Useful in
1. confirming an occlusion,
2. cause – thrombotic or embolic
3. pinpointing the level of occlusion and the anatomy
Surgical Endovascular
- Embolectomy - Thrombolysis
- Endarterectomy - Angioplasty
- Bypass grafting - Stenting
- Fasciotomy
- Primary amputation
In general, embolectomy is done for embolic occlusion, while thrombolysis is done for thrombotic occlusion.
Embolectomy
- Can be done under LA but still require anaesthetist to monitor patient as he may be quite sick (e.g. AMI), and hyperkalaemia
with cardiac arrhythmia can occur after reperfusion
- Involves clamping of the involved artery and making an arterotomy
- A Fogarty balloon catheter is inserted into artery until distal to the clot, then balloon is inflated to trawl clot out of the artery
- Check for forward-bleeding and back-bleeding of the vessel (i.e. free spontaneous flow from proximal and distal ends of the
artery when unclamped)
- Flush with heparinised saline
- Check foot – warm foot with good pulse indicates reperfusion
- Important to monitor ECG for any arrhythmias!
- Closure of arterotomy with meticulous haemostasis as patient is on heparin
- Post-op: patient monitored in high-dependency; look out for reperfusion injury
The reperfused muscles become oedematous (due to ROS tt injure cells), ing pressure in the compartments of the leg,
like compartment syndrome
Patient complains of calf pain
Unable to dorsiflex ankle as the anterior compartment is affected first
Requires three compartment fasciotomy to release pressure
- Need to convert to full warfarin anticoagulation, uptitrating dose until INR 2-2.5 before stopping heparin (pt at risk of further
embolic events) discharge patient to anticoagulation clinic for follow-up with warfarin advice
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Catheter directed thrombolysis
- Angiogram done before thrombolysis to locate occlusion
- Thrombolysis catheter inserted into the clot, and the thrombolytic agent is infused (Streptokinase, Urokinase, tPA)
- Patient will be in high-dependency with thrombolytic infusion for 6 hours (~1000-4000 units per minute)
- After 6 hrs, redo angiogram to check for residual clot; if some clot remains, adjust catheter into clot and infuse for 6 more hrs
- After complete lysis of the clot, can do angioplasty
- Takes much longer than embolectomy
- Thrombolysis may be preferred for embolism in a diseased artery, since it may be difficult to trawl out the clot in a diffusely
stenosed vessel – the clot may get caught on a proximal stenosed segment
- CI
Absolute
1. CVA within past 2 months
2. Active bleeding / recent BGIT past 10 days
3. Intracranial trauma/ neuroSx past 3 months
Relative
1. CPR past 10 days
2. Major Sx / trauma past 10 days
3. Uncontrolled HTN
Results:
- Embolectomy has a 20% mortality, almost full success rate
- Thrombolysis has a 10% mortality, only 35% successful
DDx:
- Acute DVT: Phlegmasia cerulean dolens = painful blue edema
- Blue toe syndrome: atheroembolism from AAA or more proximal
- Purple toe syndrome: Cx of warfarin therapy
- Venous insufficiency
- Venous occlusion
- Acrocyanosis
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3. CHRONIC LIMB ISCHAEMIA
Chronic limb ischaemia can be divided into critical and non-critical limb ischaemia, and non-critical ischaemia further subdivided into that
which causes symptoms (usually claudication) and that which is asymptomatic.
Most common cause is atherosclerosis with gradually developing diffuse stenosis of the peripheral arteries resulting in diminished blood supply
to the lower limb (imbalance between supply and demand). Multiple collaterals form to bypass the obstructed vessels as a compensatory
mechanism.
Progression:
Critical limb ischaemia is defined as decrease in limb perfusion that causes a potential threat to limb viability (manifested by ischemic rest
pain, ischemic ulcers, and/or gangrene) in patients who present more than two weeks after the acute event (the converse of the definition of
acute limb ischaemia).
FEATURES:
1. Rest pain requiring regular opioid analgesia (e.g. codeine) lasting >2 weeks
+/- Tissue loss (Gangrene or ulcers over the toes or feet)
I. Rest pain
- Severe pain in the distal portion of the lower limb (usually toes, foot but may involve more proximal areas if disease is severe) occurring
at rest (calf pain without toe pain is not)
- Pain is aggravated or precipitated by lifting the limb, relieved by dependency of the limb – many patients sleep with the leg hanging over
the side of the bed to relieve the pain
- So severe as to disturb sleep at night – blood supply as pt is not in dependent position and decrease BP during sleep
- Not easily controllable with analgesia – requires opioids to control pain
III. Gangrene
- Cyanotic, anaesthetic tissue associated with or progressing to necrosis
- Occurs when arterial blood supply falls below that which is necessary to meet minimal metabolic requirements
- Either dry or wet:
DRY – hard, dry texture. Often has a clear demarcation between viable and necrotic tissue. Occurs in patients with atherosclerotic
disease. Safe and can be allowed to autoamputate after demarcation with precautions against infection.
WET – = infected dry gangrene. Moist, swollen, frequently blistered. Often occurs in diabetics with decreased sensation and
unrecognised trauma, requiring an emergency surgical debridement or amputation.
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NON-CRITICAL LIMB ISCHAEMIA WITH CLAUDICATION
Intermittent claudication is defined as a reproducible discomfort of a defined group of muscles that is induced by exercise and relieved with rest.
Usually described as the patient as a cramping, aching pain in the muscle group on exertion such as walking, and alleviated on stopping (patient does
not have to sit down for pain to go away) – “shop window to shop window”.
- Calf claudication Usually affects the superficial femoral near to the adductor hiatus, or the popliteal artery
- Foot claudication tibial & peroneal arterial disease, but rarely do patients with claudication due to atherosclerosis get foot pain alone (more
common in Buerger’s)
- Thigh claudication common femoral artery or aortoiliac disease
- LeRiche’s syndrome arises from occlusion of the aortoiliacs, and is composed of a classical tetrad of buttock claudication, impotence in men,
absent femoral pulses (and distal pulses), and occasionally presence of aortoiliac bruits.
- Determine “claudication distance” – within a short period of time it is usu fairly constant, but can shorten as the disease progresses
- Need to differentiate the various causes: vascular vs neurogenic vs musculoskeletal
5. Drug history
- Aspirin and statin intake – commonly prescribed for vasculopath
- Any allergies to contrast (for angiography)
- Ergots
6. Social history
- Premorbid function and current function
- Social support and home condition (need to climb stairs?)
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PHYSICAL EXAMINATION
Examine the patient’s lower limbs in a warm room, exposed optimally (from the thighs to the feet, wearing underwear).
Patient is supine with the bed flat.
Look
Feel
Grading of pulses: 2+ normal; 1+ diminished (but may be normal for popliteal); negative if not felt
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Move
1. Buerger’s test
- Lift both legs together to compare
- Holding the heel of the foot, with the pt’s LL straightened, slowly lift the entire LL, looking at the colour of the toes
- Stop when the toes become pale (white)
- Estimate the angle the lower limb makes with the horizontal – this is the Buerger’s angle
Normal lower limb can be raised to 90 degrees without turning white;; if the Buerger’s angle is less than 30-40 degrees,
this indicates critical ischaemia
- There may be venous guttering of the lower limb at this angle as well
- Hold for 1 min (to induce ischemic environment)
- If the patient is lying near the side of the bed, tell the patient that you’re going to put his leg over the edge of the bed
before gently abducting the hip and then letting the leg drop over the edge of the bed
- Look at the leg for reactive hyperaemia (the leg turns purple-red) – due to ischemic env causing increased acidity and
triggering autonomic response
INVESTIGATIONS
225
3. Angiogram (arteriogram)
ASSESSMENT OF SEVERITY
Fontaine system
Stage I: Asymptomatic
Stage IIa: Mild claudication
Stage IIb: Moderate to severe claudication
Stage III: Ischaemic rest pain
Stage IV: Ulceration or gangrene
Conservative
Mainstay for all cases of claudicants, esp. foot and calf claudicants
- RF control
Assessment and treatment to optimise control of CVS risk factors– cardiologist
Antiplatelets [e.g. aspirin] and statins (target lipid levels are much lower)
Smoking cessation – not shown to be useful
- Exercise training to stimulate collateral formation symptoms get better
Exercise at least half to one hour every day
Walk until pain comes, rest 2-3 minutes, walk again
Keep a walk diary recording daily claudication distance in paces
Supervised exercise 3X/wk helps. Advice to exercise alone does not.
- Patient educaton:
Teach patient to go to ED if symptoms of critical ischaemia arises
Podiatrist to teach foot care
- Medications
Craxilen and Cilasterzol shown to increase claud dist - Ex.
Use of Vasteral (methoxyphylline) is controversial
- Monitor regularly with measurement of ABPI
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1. Angioplasty
1. Stenting usually not done for lower limbs except in aortoiliacs (since stent needs to be placed in a vessel which is
relatively fixed and won’t be kinked/bent by movement) – not true: can even stent foot arteries!
2. Angioplasty only effective for focal stenotic lesions and better for large vessels. Problem with angioplasty is that it is
not long-lasting – restenosis can occur
3. New method: subintimal angioplasty – if lumen is so occluded that guide wire cannot pass through, the guidewire is
threaded into the subintimal space to create a dissection around the occluded segment, and this space is then
angioplastied to create a channel parallel to the actual lumen for blood to flow through
2. Bypass grafting
Consider bypass when lesions cannot be treated by angioplasty i.e. lesion extends for long distance through the vessel
and/or no lumen for guide wire to pass through (complete occlusion)
Needs a good “landing zone” for graft distally – if vessel is diffusely diseased, difficult to perform bypass
(C) AMPUTATION
227
17. ABDOMINAL AORTIC ANEURYSM
EPIDEMIOLOGY
PATHOLOGY
RISK OF RUPTURE
- Small aneurysms <5cm have a 2-3% chance of rupture per year, while aneurysm larger than 5.5 cm will have a 10% risk of
rupture per year
75% of aneurysms 7cm or larger will rupture in 5 years
PRESENTATION
PHYSICAL EXAMINATION
INVESTIGATIONS
Imaging: CT AbdoPelvis
Other investigations: FBC, UECr, PT/PTT, GXM for 4 units, ECG & CXR
MANAGEMENT
228
Ruptured AAA
- Very high mortality – nearly 100% if frank rupture (will not get to ED in time)
- Most of the patients who reach the ED (about 50% reach ED alive) have a leaking AAA with a tamponade effect by the
retroperitoneal structures
- High suspicion in unstable hypotensive patient complaining of severe sharp pain radiating to the back; may feel a pulsatile
mass in the abdomen
Non-ruptured AAA
Endovascular stenting
- An alternative to open repair which is less invasive, can be done under GA
- Mortality ~1%, but serious morbidity rate is similar to open repair: 10%
- Involves deployment of a non-porous stent within the aneurysm to form the lumen of the aorta – requires adequate “neck”
proximally and good landing site distally
- Not as good results as open surgery; need to do an angiogram every 6 months to check position of stent (ensure not migrated)
COMPLICATIONS OF SURGERY
Intraoperative/early
1. Acute myocardial infarction – most patients already have atherosclerotic disease of coronary vessels and are at risk of AMI
(responsible for 50-60% of mortality)
2. Stroke (due to hypotension or embolism)
3. Renal insufficiency
4. Colon ischaemia – occurs in 2-6%
5. Trash foot – embolism of thrombus from the aneurysm
6. Infection of graft
7. Spinal cord ischaemia (quite uncommon)
8. Haemorrhage
Late
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18. PERIPHERAL VENOUS DISEASES
- The venous drainage of the lower limb is divided into a deep venous system and a superficial venous system separated by the
deep fascia of the lower limb
- The deep venous system is composed of veins corresponding to the arterial supply e.g. anterior and posterior tibial veins,
popliteal vein, femoral vein
- The superficial venous system is composed of two major veins, the great saphenous vein and the small saphenous vein
230
- Course of the small saphenous vein:
Arises from the lateral end of the dorsal venous arch of the foot
Passes posterior to the lateral malleolus
Runs up the midline of the calf
Pierces the deep fascia over the popliteal fossa to drain into the popliteal vein
- The superficial system and the deep system communicate through communicating veins that contain valves which allow only
one-way flow of blood from the superficial vein into the deep vein
(Foot perforators allow bi-directional flow directed by muscle movements)
Contraction of the calf muscles compresses large venous sinuses in the muscles, squeezing the blood into the popliteal vein
and back to the heart
(The deep veins have many valves to prevent backflow, so blood only flows towards the heart)
During calf muscle relaxation, the intramuscular veins open and suck blood in from the superficial system through the
communicating veins, thus draining the superficial veins
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2. CHRONIC VENOUS INSUFFICIENCY
Chronic venous insufficiency develops when there is venous hypertension, which can result from:
1. Obstruction to venous flow e.g. tumour compression in the pelvis, pregnancy, deep vein thrombosis
2. Dysfunction of venous valves e.g. varicose veins
3. Failure of the “venous pump” – dependent on adequate muscle contraction (stroke, muscular weakness can cause failure) as
well as competent venous valves
1. Venous dilatations[4]
2. Oedema – pitting: The hallmark of CVI; present in all but the earliest stages
Unilateral oedema worsened by dependency (worse at the end of the day) and better with recumbency
3. Skin changes[5]
(a) Hyperpigmentation over medial lower third of the leg (gaiter area) – extravasation with haemosiderin deposits
(b) Atrophie blanche – hypopigmented scars of healed venous ulcers (avascular and fibrotic skin)
(c) Venous stasis eczema – pruritic, weeping, scaling, with erosions and crusting
(d) Lipodermatosclerosis (fats and skin hardening) – a fibrosing panniculitis of the subcutaneous tissue that results in a
firm area of tender, hyperpigmented skin that is fixed to subcutaneous tissue.
Results from severe venous hypertension hemosiderin deposits at fats inflammation chronic inflammation
Starts in the gaiter area and extends circumferentially to surround the leg
If severe can result in an “inverted champagne bottle” appearance of the leg with brawny oedema above and below
the area of lipodermatosclerosis
(e) Cellulitis
SYMPTOMS
1. asymptomatic
2. leg fullness / swelling
3. heaviness,
4. non-specific pain: aching discomfort, dull, shooting
5. nocturnal leg cramps,
6. itch (40%)
7. bursting pain upon standing.
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CEAP CLASSIFICATION OF CHRONIC VENOUS INSUFFICIENCY
3. VARICOSE VEINS
Varicose veins are dilated, tortuous veins of the superficial venous system (secondary to incompetent leg valves
resulting in reflux).
Primary varicose veins: cause is unknown (may be related to posture and components and structure of the vein wall)
GENETIC! (20% risk in gen pop, 50% 1 parent, 80% both parents)
Secondary varicose veins:
1. destruction of the valves by thrombosis (DVT most common secondary cause),
2. proximal venous obstruction,
3. increase in flow and pressure caused by an arteriovenous fistula,
4. pelvic masses – compress on deep veins
PATHOPHYSIOLOGY
- Inherent weakness in the vein wall, leading to dilation and separation of valve cusps so they become incompetent
- This may be aggravated by obstruction to venous return (as above)
HISTORY
Asymptomatic
Symptomatic: local (non specific pain, swelling, itching, heavy legs)
Complications :
1. ulceration +/- cancer
2. thrombophlebitis (= thrombosis inflammation, chemical rather than infective. commonly mistaken as cellulitis)
3. bleeding,
4. hyperpigmentation,
5. eczema,
6. infection (due to dependent oedema)
Risk factors: Ask for Past history of DVT & thrombophlebitis, obstetrics history, family history
233
EXAMINATION
Palpate
1. Feel any dilated varicosities: Direct tenderness that can account for patient’s pain symptoms
(if patient’s varicosities are not tender, warn patient that ankle/calf pain may not go away after surgery as the pain may not
be directly from the veins)
2. Palpate along the course of the saphenous veins and their tributaries to feel any varicosities and for tenderness (may be
more palpable especially in fat legs)
3. Palpate the inguinal region for a saphena varix (compressible lump that refills when released)
4. Do the cough test to feel for reflux at the saphenofemoral junction (2.5 cm below and lateral to the pubic tubercle)
5. Percussion (tap test) – test for valvular incompetence (not a very valuable test) – Ensure good distance between both hands
first, to cover valves in between.
Positive if the distal hand can feel the wave of blood flowing retrogradely after tapping the proximal varicosities (normal: tap
bottom, feel thrill on top)
6. Feel the peripheral pulses!!! of Lower limb to exclude any ischaemia as the management will involve compression of limbs
(ABI >0.8)
Special tests
TOURNIQUET TEST
- Lie the patient down and empty the varicosities & tie a tourniquet just below the SFJ
- Ask the patient to stand up
- Look for filling up of the varicosities above and below the tourniquet
- If the veins dilate above but not below the tourniquet, this indicates that the perforators below the level of the tourniquet are not
incompetent and that the SFJ is incompetent confirm this by releasing the tourniquet and watching the veins dilate
- If veins below the tourniquet are dilated when pt stands up, then the incompetent perforator is below level of the tourniquet
- Repeat the test, placing the tourniquet at different sites:
(i) Mid thigh (just below the Hunterian perforator)
(ii) Below the knee
(iii) Mid-calf
- The incompetent perforator is located between just above the level where the tourniquet prevents dilation of the veins in the
limb on standing
[The alternative is the triple tourniquet test, where three tourniquets are tied with the patient lying down and then released from
the bottom up to locate the site of insufficiency]
TRENDELENBURG TEST
- The SFJ is occluded (landmark is 2.5 cm below and lateral to the pubic tubercle) with the patient lying down
- Get the patient to stand while holding the SFJ occluded
- If varicosities do not fill up, the SFJ is the site of incompetence; if they fill up, there are other sites of incompetence (the SFJ
may or may not be incompetent)
- Tie a tourniquet around the calf or thigh and ask patient repeatedly stand on tiptoe and then relax
- In a person with normal deep venous drainage and competent venous valves in the communicating veins the superficial veins
should drain into the deep veins
- Positive test: patient will complain of pain and stop after ard 20 times because of increased swelling as blood cannot drain out
through the deep veins
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Completing the examination
- Auscultate over the varicosities for any bruit (indicate arteriovenous malformation)
- Examine the abdomen for any mass that may be causing the varicosities
1. Doppler probe is placed along groin crease over SFJ (caution in obese ppl whose groin crease are lower) with patient standing
2. Look for arterial signal then move medially SFJ
3. Squeeze the calf to empty the veins – should hear a whoosh as blood flows through the small saphenous vein
4. When the calf is relaxed there should not be a prolonged sound – a second whoosh >0.5s indicates reflux of blood i.e. there is
valvular incompetence of SFJ (90% accurate prediction)
Can also perform test over popliteal fossa for SPJ but less accurate as the junction is variable. Therefore, you may be getting
signals from the deep perforators instead.
INVESTIGATIONS
- Indications:
1. Recurrent varicose veins
2. Complications of CVI: History of superficial thromobophlebitis
3. Skin manifestations of CVI: Venous eczema, Haemosiderin staining, Venous ulceration , Lipodermatosclerosis,
4. Everyone with varicosities to exclude subclinical DVT
- Ask for
(a) SFJ and SPJ reflux,
(b) perforator, deep venous incompetency
(c) DVT screen
- Can delineate deep and superficial venous systems and locate sites of incompetence
MANAGEMENT
Conservative
1. Lifestyle changes
- Decrease amount of time spent standing
- If due to job, change job or ask for change to position to stand & walking less
2. Graduated compression stockings, usually grade II ensure good pulses
3. Medications e.g. Daflon (only symptomatic, like painkillers)
Indications:
1. Cosmesis – large unsightly varicosities
2. Symptoms – pain, discomfort
3. Complications – signs of chronic venous insufficiency, venous ulceration
Contraindications:
1. Infected ulcers. (slow healing ulcers that are not infected can still operate as it may improve the ulcer)
2. DVT: can rescan after medical treatment. If DVT resolves, can opt for selective stripping.
3. Thrombotic tendencies: patient may dev DVT in the future.
Available modalities:
1. High tie with great saphenous vein stripping, and stab avulsion of varicosities
2. Ultrasound-guided foam sclerotherapy
3. Endovenous laser therapy (burns vein from within)
20% recurrence: due to large number of perforators left over even after stripping.
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4. VENOUS ULCERS
INVESTIGATIONS
MANAGEMENT
Conservative
(a) Non-adherent wound dressing over ulcer (e.g. Menolin) followed by wool bandage – most impt layer to protect ulcer
(b) Crepe bandage
(c) Blue-line bandage (Elset)
(d) Adhesive bandage (Coban)
Aim: ankle pressure around 30mmHg (can vary according to needs)
Nowadays, 2 layer stockings are used too – can achieve the same ankle pressure but not as effective as it loses pressure more
quickly so less consistent pressure.
2. Stockings: Once healed (cannot use with ulcer/wound), compression stockings should be fitted and continued for life
3. Symptomatic: Analgesia
4. Antibiotics if infected
5. Lifestyle
(a) Warn patient to avoid trauma to affected area
(b) Encourage rest and elevate leg
Surgical
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237
19. UROLOGICAL DISEASES
1. APPROACH TO HAEMATURIA
DEFINITION:
- >3 RBC / hpf.
- DDx: haemoglobinuria, myoglobinuria, pseudohaematuria (menstruation), meds causing discoloration (eg rifampicin, phenytoin)
CAUSES
Pre- Drugs Analgesics (NSAIDs)
Renal Anticoagulants
Cytotoxic/immunosuppressive agents (eg cyclophosphamide)
OCP
Penicillin
Quinine
Warfarin
Systemic Bleeding diathesis
Sickle cell disease
Metabolic Hypercalciuria
Hyperuricosuriia
Vascular AV malformations
Renal artery disease – thromboembolism, dissecting aneurysms, malignant
hypertension
Renal vein thrombosis
Renal Vasculitis HSP
PAN
Wegener granulomatosis
Glomerular Post-strep GN
Post-infectious GN
IgA nephropathy
Lupus nephritis
Other GNs
Tubulo- Polycystic kidney disease
interstitial Nephrolithiasis
dz Malignancy – RCC, metastatic
Pyelonephritis
Renal cysts
Post- Infxns of ureter, bladder, prostate, urethra – eg schistosomiasis, TB etc
renal Cancers of ureter, bladder (TCC), prostate, urethra
Nephrolithiasis
HISTORY
Post-renal Causes
3. Severity
- Clots
- S/S of anemia
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4. Frequency + dysuria + haematuria
- DDx: nephrolithiasis (colicky), malignancy, UTI (women & children), bladder outflow obstruction (men e.g. BPH – vascular
prostate may bleed)
PHYSICAL EXAMINATION
INVESTIGATIONS
URINE
1. Urine dipstick
- Causes of false-positive for blood: haemoglobinuria, beetroot, drugs (rifampicin), metabolic (alkaptonuria, porphyria)
2. UFEME (normal (all below 5): RBC 3-5, WBC 2-5, EC <5)
- Confirm presence of red blood cells
- Elevated WBC (pyuria is >5 WBC per hpf), organisms infection
- Casts nephritis
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BLOOD
- Intravenous contrast used to delineate anatomy of the kidneys and urinary system
- Various phases:
(i) Control film – plain KUB
(ii) Tomogram – zoom into kidneys before contrast
(iii) Nephrogram phase (1 min after contrast) – contrast fills kidney parenchyma so kidneys become more visible
measure size, outline
(iv) Pyelogram phase (3-5 min) – contrast fills calyces & pelvis, can detect dilated calyces/pelvis (hydronephrosis), any
filling defects
(v) Release film (abdominal binder which was placed to slow the flow of contrast into the bladder is released) – shows
ureters, any hydroureter, filling defects
(vi) Cystogram - any filling defects, abnormal appearance of the bladder (fir-tree appearance in neurogenic bladder)
(vii) Post-micturition – any residual urine in bladder after voiding
- Contraindicated in:
(a) Contrast allergy
(b) Renal impairment (Cr >200)
(c) Patients on metformin (can cause lactic acidosis; patients need to stop metformin 2 days before and after study)
(d) Patients with asthma (given steroids for 3 days before study)
(e) Pregnancy: ask LMP
14. Cystoscopy
- Detection of bladder tumour (IVU may not pick up small tumours <1cm)
- Biopsy can be taken at the same time
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2. RENAL CELL CARCINOMA
EPIDEMIOLOGY
- 3% of adult malignancy
- Most frequent occurring solid lesion within kidney
- 2:1 male predominance
- Peak incidence 60-70 years
PATHOLOGY
- Most common primary renal tumour (80-85% of all tumours of the kidney)
- Arise from the renal tubular epithelium
- Three cell types:
1. clear cell carcinoma (70-80%),
2. papillary renal cell carcinoma (10-15%),
3. chromophobe renal cell carcinoma (5%)
Other renal tumours: TCC of renal pelvis, Wilms’ tumour, lymphoma
RISK FACTORS
- Smoking
- Exposure to cadmium (industrial)
- Family history
von-Hippel Lindau syndrome clear cell carcinomas
Due to mutation of the VHL gene on chromosome 3p25 resulting in abnormal growth of BV ie. angiomas
(associated with CNS haemangioblastomas (usually cerebellar), bilateral multicentric retinal angiomas,
phaeochromocytomas, etc)
Hereditary papillary RCC (HPRCC) due to mutation of the MET proto-oncogene on chromosome 7q31 multifocal bilateral
papillary carcinomas
- Acquired polycystic kidney disease (secondary to chronic dialysis)
PRESENTATION
1. Local S/S
- Painless gross haematuria is the most common – >50% of cases
- When tumour has grown large enough, dull flank pain and palpable mass may result
Classical triad of RCC: flank pain, painless haematuria, palpable renal mass (indicates late stage disease)
2. Complications
1. May have fever a/w night sweats, LOA, LOW, malaise
2. Polycythaemia occurs in 1-5% (due to increased erythropoietin)
3. For left renal tumour, extension of tumour into left renal vein can cause a left varicocoele as the left testicular vein
becomes occluded
4. Extension into IVC can cause (a) lower limb oedema, (b) ascites, (c) liver dysfunction, (d) pulmonary embolism
5. Paraneoplastic syndromes are uncommon – Cushing’s, hypercalcaemia, hypertension
3. Metastasis
- Symptoms of metastases – lungs, liver, bones, brain, lymph nodes
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INVESTIGATIONS
DIAGNOSTIC
2. Pathological diagnosis
- Needle biopsy usually not done for resectable lesions due to fears of tumour seeding
- In these resectable lesions, a partial or total nephrectomy is often performed, and provides the tissue diagnosis post-
operatively
- In tumours with metastatic disease on presentation, biopsy of the metastatic site may be easier
STAGING
Also,
Bone scan
- Only done if patient complains of bone pain and/or alkaline phosphatase is raised
MRI of abdomen and heart
- Superior to CT for evaluation of IVC and right atrium involvement
T3 Tumour extends into major veins or invades adrenal gland or perinephric tissues, but not
beyond Gerota’s fascia
Prognosis
Stage I (T1N0): >90% 5 year survival
Stage II (T2N0): >75%
Stage III (T3N0/N1): >60%
Metastatic disease: <10%
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TREATMENT
A. RESECTABLE TUMOURS
B. ADVANCED TUMOURS
Immunotherapy
- High dose interleukin-2 – associated with good results in patients whose tumours respond to treatment, as treatment can induce
long-term remissions without relapse. However, associated with high toxicity and often not tolerable
- Cytoreductive nephrectomy performed prior to starting immunotherapy can improve survival
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3. BLADDER TRANSITIONAL CELL CARCINOMA
EPIDEMIOLOGY
- Ninth most common cancer in Singaporean males
- Increasing incidence with age (80% diagnosed in patient >60 years old)
- 4:1 male predominance
PATHOLOGY
- TCC is the most common tumour of the bladder (>90%)
Thought to arise due to exposure to carcinogenic substances in the urine urothelial cancers think FIELD
CHANGE effect, thus urothelial tumours often occur multifocally
Screen ENTIRE urothelium every f/u
Papillary in nature (more differentiated)
- Adenocarcinoma (1%, arises from remnant of the urachus in the dome of the bladder),
- SCC (<5%, due to chronic irritation e.g. long term indwelling catheter or untreated bladder stone)
RISK FACTORS
- Cigarette smoking (Urothelial CA!) – ask secondary smoking
- Industrial chemicals – naphthylamine, aniline-containing dyes, etc
- Occupational (hairdressers – exposure to hair dyes)
- Chronic cystitis (SCC)
Schistosomiasis
Radiation (pelvic)
Chemotherapy (cyclophosphamide)
- Analgesic abuse (phenacetin)
PRESENTATION
- Haematuria most common (90%) – typically gross, painless, intermittent, occurring throughout the stream
- LUTS
– irritative symptoms suggestive of carcinoma in-situ,
- obstructive symptoms: indicate a tumour at the bladder neck or prostatic urethra
- Pain – in locally advanced or metastatic tumour
(a) flank pain due to urinary obstruction,
(b) suprapubic pain due to local invasion,
(c) bone pain due to metastasis
- Constitutional symptoms – LOW, LOA, fatigue
DIAGNOSIS
1. Urine cytology for malignant cells (not very sensitive but very specific)
2. Cystoscopy with cell brushings and biopsy
3. IVU or CT urogram to detect SYNCHRONOUS LESIONS (3% chance of proximal tumour)
STAGING
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MANAGEMENT DEPENDENT ON STAGE
SUPERFICIAL TUMOUR
- Intravesical therapy
- Follow-up:
MUSCLE-INVASIVE0
- Radical cystectomy with urinary diversion
Radical cystoprostatectomy with pelvic lymphadenectomy in male
Anterior exenteration with pelvic lymphadenectomy in female (Cx: perineal hernia)
METASTATIC
Chemotherapy
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4. UROLITHIASIS
STONE COMPOSITION
- Calcium oxalate or calcium phosphate stones – 75%
- Magnesium ammonium phosphate (struvite = MAP) stones – 15%
- Uric acid and cystine stones – 10%
- Can occur at any level in the urinary tract, but most commonly in the kidney
PATHOLOGY
- Most important cause of stone formation is increased urine concentration of the stone’s constituents, such that they exceed their
solubility precipitate as stones
E.g. hypercalciuria with or without hypercalcaemia, hyperuricuria
- Urinary tract infections–
struvite stones form in Proteus vulgaris infections ( splits urea into ammonium), generating alkaline urine
Bacteria can also form nidi for the formation of any kind of stone
Renal stones
- Most often asymptomatic unless the stone gets lodged in the pelviureteric junction causing hydronephrosis and subsequent
infection pyonephrosis
- Vague flank pain may occur. Bleeding?
Ureteric stones
- Even small stones can cause severe symptoms as the ureter is narrow
(a) Classically ureteric colic pain – severe, intermittent loin-to-groin pain
(b) Haematuria – gross or microscopic
(c) Irritative symptoms – frequency, urgency
(d) Can cause upper urinary tract infection Pyonephrosis!
(infected purulent urine in an obstructed collecting system)
fever with C&R, pain, can be very ill (sepsis)
Management:
- Broad spec Abx eg. Ceftriaxone
- DECOMPRESSION using PCN or URS with stenting (no need to remove stone in same setting)
Loin pain DDx: MSK (diff to differentiate)
Bladder stones
- May be asymptomatic
(a) Can cause irritative urinary symptoms – frequency, urgency
(b) Haematuria
(c) If infection is present – dysuria, fever, etc
PHYSICAL EXAMINATION
- In ureteric colic, symptoms are often out of proportion to signs – no guarding, rebound, etc
- If the patient has pyelonephritis, renal punch may be positive (DDx spinal pain by pressing on the spine)
- Otherwise unremarkable examination
246
INVESTIGATIONS
Diagnosis
1. KUB
- May be able to see radio-opaque stone (90% of renal stones are radio-opaque)
- False neg: too small. False positive: Phlebolith (perfectly round, sometimes with lucent centre. Found in pelvis near ureters),
stools
- K: Look at kidney size, any renal stones
- U: Trace path of ureter along tips of transverse processes, across sacroiliac joint, in front of bifurcation of common iliac
arteries and medially into bladder at ischial tuberosity, looking for ureteric stones
- B: Look for bladder stones
2. Intravenous urogram
- Can also help to visualise a stone
- Can show dilated urinary system secondary to stone obstruction – hydroureter and/or hydronephrosis
3. Ultrasound of kidney or bladder
- Features of stone: echogeneic rim, posterior acoustic shadowing
Complications
TREATMENT
CONSERVATIVE
Stones smaller than 5mm can be treated conservatively as 60% will be passed out; only treat if they (a) do not pass out after 4 to 6
weeks, and/or (b) cause symptoms
SURGICAL INTERVENTION
Indications:
- S/S: Constant pain
- Cx:
Obstructs urine flow
Causes urinary tract infection
Damages renal tissue or causes significant bleeding
Increase in size
- Unlikely to resolve with conservative Tx:
Does not pass after one month
Too large to pass spontaneously
247
Types of treatment available: [from top to bottom]
3. Ureterorenoscopy with lithotripsy (URS + LL) (usually laser lithotripsy, can also be done by pneumatic drill, electrohydraulic
means)
- For stones along the ureter
- Retrograde pyelogram to see the stone?
Open surgery (pyelolithotomy or ureterolithotomy) – rarely done; only if failed other management strategies, altered anatomy,
performing open surgery for another reason anyway, non-functioning kidney
Adjuncts:
Double-J stent (or DJ stent) – inserted to stent the urinary system when
- worried that stone fragments after ESWL may cause obstruction e.g. when ESWL used for treatment of a large stone; or if system
is obstructed to begin with, may want to stent to ensure good drainage after surgery
- to prevent stricturing
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5. APPROACH TO ACUTE RETENTION OF URINE
Mechanical Extraluminal (5) Prostate enlargement (benign/malignant/prostatitis) – BPH is the commonest cause!
Faecal impaction
Pelvic tumour, ovarian cyst, fibroid
Pregnancy, retroverted gravid uterus
UV prolapsed
Intramural 54) Tumour of the bladder neck (TCC)
Urethritis (UTI)
Urethral stricture from STD, prev instrumentation
Phimosis
Urethral trauma/rupture
Intraluminal (3) Stones
Blood clot (clot retention in haematuria)
Foreign body
Non- Cord disease/ Cord compression, cauda equina
mechanical injury Multiple sclerosis
neurogenic Tabes dorsalis (Tertiary syphilis)
bladder
Neuropathy Diabetic autonomic neuropathy
Drugs (4A) Anticholinergics (cough medicine, Overactive bladder Tx), antihistamines, anti-depressants, alcohol
Others (3P) Prolonged immobility
Post-anaesthesia
Pain
HISTORY
2. Precipitating factors: (if present, higher the chances of retaining bladder abilities after Tx with TURP) [4]
(a) UTI: dysuria, frequency, urgency, nocturia, haematuria
(b) Constipation
(c) Drugs e.g. cough mixture, antihistamines
(d) Immobility
4. Complications: [3]
- Infection – symptoms of UTI
- Stone disease (if in the bladder, usually asymptomatic)
- Renal failure (more likely in chronic retention) – vomiting, lethargy, drowsiness
249
PHYSICAL EXAMINATION
- General condition
Vitals (fever)
sallow appearance, scratch marks, pedal oedema, etc (uraemia)
- Abdomen
Palpable bladder – tense, dull, rounded, tender, pressure desire to micturate (large bladder up to umb suggests b/g of
chronic retention)
Other pelvic masses – fibroid, gravid uterus, ovarian cyst
Faecal loading
Bilateral enlarged kidneys (hydronephrosis)
- Neurological examination
LMN paralysis of the lower limbs?
Any sensory level present?
INVESTIGATIONS
1. Bloods/Urine
a. Urine dipstick, UFEME and culture/sensitivity (UTI, hematuria)
b. UECr: raised creatinine (renal impairment secondary to obstructive nephropathy)
c. FBC: raised TW (infection) – not usually done
2. Imaging
1) KUB for stones, faecal loading
2) U/S bladder: (1) stones, (2) tumour, (3) prostate volume, (4) intravesical protrusion of prostate
3) U/S kidney, ureters: hydronephrosis, hydroureters (obstructive complication)
PSA
- to be done 4-6/52 later (as ARU can cause raised PSA)
- PSA velocity (rate of rise), free/total PSA, PSA density (= PSA/prostate volume)
- >/= 2 readings 2/52 apart
- Causes of raised PSA
i. cancer
ii. BPH [usually <40]
iii. prostatitis
iv. instrumentation /catheterization >11days
v. ARU
250
TREATMENT
3. Trial-off catheter
- Take off catheter and watch patient’s output, as well as perform bladder scan to measure bladder volume
- If patient cannot pass urine and bladder volume >400ml re-catheterise
- When patient passes urine, can perform
1) uroflow to investigate severity of outlet obstruction, and also do
2) bladder scan post-micturition to check residual volume
251
6. BENIGN PROSTATIC HYPERPLASIA
EPIDEMIOLOGY
- Very common problem in men
- Frequency rises with age after the age of 30, reaching 90% in men older than 80
PATHOLOGY
- Results from proliferation of both the epithelial and stromal components of the prostate with resultant enlargement of the gland
- Commonly occurs in the central zone of the prostate
1) Major stimulus: dihydrotestosterone (produced from testosterone by 5-alpha reductase)
2) Age-related increases in oestrogen levels may also contribute to BPH by increasing the expression of dihydrotestosterone
receptors on prostatic parenchymal cells
- Chronic obstruction leads to hypertrophy of the detrusor muscle and trabeculation of the bladder mucosa as the bladder tries to
empty against increased resistance
252
253
PHYSICAL EXAMINATION
Inspection
- Vitals: BP for HPT? (CRF) Fever? (UTI) Urine output? (CRF)
- Already on IDC? (ARU) Diapers? (incontinence) Hematuria? (UTI, stones)
- Sallow? Anaemia? (of CRF/ underlying malignancy) Cachexia (CA)
- Hernia repair scar? (hernia)
Palpation
- Check for hernias
- Abdominoperineal masses (fecal loading, masses to compress)
- Any ballotable kidneys? (Hydronephrosis, Pyelonephritis)
- Renal punch? (Pyelonephritis)
- Palpable tender bladder in (ARU) non-tender (CRU)
- Pedal/ sacral oedema (CRF)
- Bony tenderness (tumor)
INVESTIGATIONS
Blood
- FBC: anaemia, raised WBC
- UECr: dehydration, raised creatinine renal impairment due to chronic obstruction
- UFEME, cytology, urine c/s: for UTI and screen for cancer
- PSA (done 4-6/52 later to avoid false +ves): normal <4
Imaging
- KUB for bladder stone
- US kidney – hydronephrosis
- US bladder – post-void residual volume >100ml, bladder stone, measure intravesical prostatic protrusion (IPP)
- Cystoscopy to rule out stones, strictures/ bladder neck obstruction or cancer,
- Uroflowmetry to confirm obstruction to urinary outflow (IMPT!!)
1. normal bell shaped curve, saw tooth appearance
2. Volume voided (>100ml to be valid): too low (falsely low peak flow rate), too high (falsely long duration, increase RU)
3. Normal peak flow rate (Qmax) > 15ml/sec
4. Residual urine 0 in young males, can accept up to 50ml in elderly
- ± urodynamic studies, TRUS with biopsy TRO prostate cancer if PSA >10
254
COMPLICATIONS
MANAGEMENT
I. Watchful waiting
- Suitable for patients with minimal symptoms, no complications and normal invx
- Monitor patient’s symptoms and clinical course annually
III. Surgery
Types
- Transurethral resection of prostate (TURP)is the gold standard
- Transurethral incision of the prostate (TUIP): decision made during TURP when the prostate does not appear to be enlarged make small
cuts around the bladder neck area to open it up.
Adv: 50% chance of Retrograde ejaculation
- Laser prostectomy is promising (pending long term results)
- Other techniques do not show good results: stenting, cryoablation, etc.
Indications:
1. Failed medical treatment
2. Significant Complications (4): Refractory urinary retention, Recurrent UTI, Bladder calculi, Obstructive uropathy
3. Recurrent gross haematuria
Aim: to widen bladder neck
Caution: Must rule out Neurogenic bladder / Detrusor hypotonia before TURP!!
Do Urodynamic studies
1. Insert narrow catheter with pressure gauge at the end into
a. Bladder: intravesical pressure
b. Rectum: intraabdominal pressure
Detrusor pressure = a – b
2. Fill up bladder: look for detrusor contractions
3. Cough when erect: stress incontinence
4. Void: detrusor pressure should be sufficient, good flow (Qmax)
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7. PROSTATIC CANCER
EPIDEMIOLOGY
- Prostate Cancer is the 6th commonest cancer among men in Singapore.
- 5th common cancer in Singapore
- Peak incidence between 65 and 75 years of age
PATHOLOGY
- Adenocarcinoma
- Arise in the outer parts of the prostate 70-80% of the time and are thus palpable on digital rectal examination
RISK FACTORS
- Hormonal – growth of tumour can be inhibited by orchidectomy or administration of oestrogens
- Genetic – racial variations in onset and prevalence, family history
- Environmental – industrial chemical exposure, diet containing high animal fat
PRESENTATION
- Asymptomatic (mostly): incidentally picked up on DRE or due to elevated prostate-specific antigen (PSA) level (>100 is highly
suggestive)
- Local symptoms: obstructive LUTS, bladder outlet obstruction; (uncommon as most cancers arise in peripheral zones) haematuria,
haematospermia, new onset erectile dysfunction
- Metastatic symptoms – lower back pain (from Batson’s venous plexus)
PHYSICAL EXAMINATION
DIAGNOSIS
STAGING
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TREATMENT
1. Radical prostatectomy
- Open, laparoscopic or robot-assisted
- Open – retropubic or perineal approaches
2. Radiotherapy
- External beam radiotherapy (EBRT) or Brachytherapy
METASTATIC DISEASE
1. Androgen ablation
A. Castration (decrease Testosterone by 90-95%)
a. Surgical orchidectomy
b. Medical – LHRH agonist (luteinizing hormone releasing hormone)
i. 7-10 days: hormone flare (raised testosterone)
ii. After: pituitary stops signaling testicles castration level testosterone
B. Anti-androgen
a. Non-steroidal e.g. Flutamide
b. Steroidal – cyproterone acetate
C. Combined androgen blockade (A + B)
D. Oestrogen therapy (diethylstilbestrol)
a. binds Testosterone-R at hypothalamus decrease LHRH
b. S/E: CVS
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