PACES
Alasdair Scott
BSc (Hons) MBBS PhD
2012
dr.aj.scott@gmail.com
Medicine
Contents
Cardiology .................................................................................................................................................................................. 3
Pulmonology ............................................................................................................................................................................ 16
The Medical Abdomen ............................................................................................................................................................. 30
Neurology................................................................................................................................................................................. 49
Shorts ....................................................................................................................................................................................... 71
© Alasdair Scott, 2012
2
Cardiology
Contents
General Cardio Tips ................................................................................................................................................................... 4
Aortic Stenosis ........................................................................................................................................................................... 5
Mitral Regurgitation .................................................................................................................................................................... 6
Aortic Regurgitation ................................................................................................................................................................... 7
Mitral Stenosis ........................................................................................................................................................................... 8
Rheumatic Fever........................................................................................................................................................................ 9
Infective Endocarditis ................................................................................................................................................................. 9
Valve Replacement .................................................................................................................................................................. 10
Valve Prostheses: Key Facts ................................................................................................................................................... 11
Atrial Fibrillation ....................................................................................................................................................................... 12
AF: Key Facts .......................................................................................................................................................................... 13
Pacemakers ............................................................................................................................................................................. 14
Chronic Heart Failure ............................................................................................................................................................... 15
© Alasdair Scott, 2012
3
General Cardio Tips
Examination
Viva
Midline Sternotomy
Completion
 Observation chart
 Drug chart
 12-lead ECG
Positive Finding
Metallic click
Murmur
Vein harvest on legs
Old scar, young pt.
Immunosuppression
Nothing
Indications
Mechanical valve
Tissue valve
Valvotomy
CABG
Repair of congenital defect
Heart transplant
Trauma: tamponade, aortic
IMA CABG
Tissue valve
Cardiac Causes of Clubbing
 Infective endocarditis
 Congenital cyanotic heart disease
 Fallot’s Tetralogy
 VSD
 Pulmonary stenosis
 RVH
 Overriding aorta
 Transposition of the Great Vessels
 Atrial myxoma
 Assoc. c̄ Carney Complex / LAME Syndrome
 Lentigines: spotty skin pigmentation
 Atrial Myxoma
 Endocrine tumours: pituitary
 Schwannomas
Collapsing Pulse
 Caused by hyperdynamic circulation
 AR
 Thyrotoxicosis
 Pregnancy
 Anaemia
Absent Radial Pulse





Dead
Trauma
Thrombosis or embolism
Coarctation of the aorta
Takayasu’s Arteritis
Impalpable Apex Beat: COPD




COPD
Obesity
Pericardial effusion
Dextrocardia
Features of Pulmonary HTN





↑ JVP
Left parasternal heave
Loud P2 + PSM of TR
Pulsatile hepatomegaly
Ascites and peripheral oedema
Heart Sounds




S1: mitral valve closure
S2: aortic valve closure
S3: rapid ventricular filling of dilated left ventricle
S4: atrial contraction against stiff ventricle
© Alasdair Scott, 2012
Presentation
 On peripheral inspection…
 The pulse…
 On examination of the precordium…
 Significant negatives
 Absence of CCF
 Disease severity
 Evidence of cause
 Differential Dx
 Hx
Discussion
 Ix
 Rx
Hx






Symptoms: dyspnoea, chest pain, palpitations, syncope
LVF: PND, orthopnoea
IE: fever, wt. loss, night sweats
CV Risk: smoking, DM, lipids, HTN, FH
PMH: rheumatic fever
DH: antiplatelet agents, statins
Ix
ECG
 Evidence of ischaemia
 Arrhythmia
Blood
 FBC: anaemia exacerbates cardiac symptoms
 U+E: renovascular disease
 NT-proBNP: heart failure
 Fasting lipids and glucose: cardiac risk
Imaging
 CXR
 Cardiomegaly
 Pulmonary oedema
 Valve calcification
 Echo
 Dx
 Valve function
 LV Function
 Cardiac catheterisation
 Evaluate coronary arteries
Mx
General
 MDT: GP, cardiologist, cardiothoracic surgeon, dietician,
specialist nurses
 Optimise CV risk: statins, anti-HTN, DM, anti-plat
 Monitor: regular f/up and echo
Specific
Surgical
4
Aortic Stenosis
Examination
Viva
Peripheral Inspection
Hx: Clinical Symptoms of Severe AS
 Often nothing specific
 Angina: 50% dead in 5yrs
 Syncope: 50% dead in 3yrs
 Dyspnoea: 50% dead in 2yrs
Pulse
 Slow-rising (anacrotic)
 Narrow pulse pressure (<30mmHg)
Precordium




Pacemaker
Aortic thrill
Apex: Forceful, non-displaced (pressure overload)
Heart Sounds
 Quiet A2
 Early syst. ejection click if pliable (young) valve
 S4 (forceful A contraction vs. hypertrophied V)
 Murmur
 ESM
nd
 Right 2 ICS
 Sitting forward in end-expiration
 Radiates to carotids
Clinical Signs of Severe AS
 Quiet / absent A2
 S4
 Narrow pulse pressure
 Decompensation: LVF
Significant Negatives
 Infective endocarditis
 LVF
 Indicators of severity
Differential




Aortic sclerosis: no radiation, normal pulse character
MR
HOCM: valsalva ↑s murmur, squatting ↓s murmur
Right-sided: PS
Causes
 Age-related senile calcification
 Bicuspid aortic valve
 Rheumatic heart disease
Ix
ECG
 LVH
 Arrhythmias
Blood: FBC, U+E, NT-proBNP, lipids, glucose
CXR
 Calcified AV
 LVH
 Pulmonary oedema
Echo + Doppler
 Severity
 Cause: Bicuspid valve, thick calcified cusps
 LV function
 Other valve function
Echo Features of Severe AS (AHA 2006)
2
 Valve area <1cm
 Pressure gradient >40mmHg
 Jet velocity >4m/s
Cardiac Catheterisation
 Valve gradient
 Assess coronaries (needed if surgery planned)
Mx
General
 MDT: GP, cardiologist, cardiothoracic surgeon,
dietician, specialist nurses
 Optimise CV risk: statins, anti-HTN, DM, anti-plat
 Monitor: regular f/up and echo
Surgical: Valve Replacement ± CABG
 Indications
 Symptomatic AS
 Severe asymptomatic AS c̄ ↓ EF (<50%)
 Severe AS undergoing CABG or other valve op
 Mortality: 3-5% depending on pts. EuroSCORE
Other Options
 TAVI: Transcatheter Aortic Valve Implantation
 Balloon valvuloplasty
© Alasdair Scott, 2012
5
Mitral Regurgitation
Examination
Viva
Peripheral Inspection
Ix
 Warfarin medic alert bracelet
Pulse
 AF
ECG
 Arrhythmias
 LVH
 P-mitrale
Blood: FBC, U+E, NT-proBNP, lipids, glucose
Precordium
 Left parasternal heave (RVH)
 Apex: displaced
 Volume overload as ventricle has to pump
forward SV and regurgitant volume
 → eccentric hypertrophy
 Heart Sounds
 Soft S1
 S2 not heard separately from murmur
 ± loud P2 (if PTH)
 Murmur
 Blowing PSM
 Apex
 Left lateral position in end expiration
 Radiates to the axilla
CXR
 LA and LV hypertrophy
 Mitral valve calcification
 Pulmonary oedema
Echo + Doppler
 Severity
 LV function
 Other valve function
Echo Features of Severe MR (AHA 2006)
 Jet width >0.6cm
 Systolic pulmonary flow reversal
 Regurgitant volume >60ml
Clinical Signs of Severe MR
 LVF
 AF
Cardiac Catheterisation
 Assess coronaries (needed if surgery planned)
Significant Negatives
Mx
 Infective endocarditis
 Indicators of severity: AF, LVF
Differential
 AS
 VSD
 Right-sided: TR
Causes




Functional: LV dilatation (e.g. 2O to HTN or idiopathic)
Annular calcification → contraction
Rheumatic heart disease
Mitral valve prolapse
General
 MDT: GP, cardiologist, cardiothoracic surgeon,
dietician, specialist nurses
 Optimise CV risk: statins, anti-HTN, DM, anti-plat
 Monitor: regular f/up and echo
Specific
 AF: rate control and anticoagulate
 Emboli: anticoagulate
 ↓ afterload
 ACEi or β-B (esp. carvedilol)
 Diuretics
Surgical
 Valve replacement or repair
 Aim to replace the valve before significant LV dilation
and dysfunction.
 Indications
 Symptomatic
Prognosis
 Often asymptomatic for >10yrs
 Symptomatic: 25% mortality @ 5yrs
© Alasdair Scott, 2012
6
Aortic Regurgitation
Examination
Viva
Peripheral Inspection
Ix
Eponymous Signs
 Quincke’s: capillary pulsation in nail beds
 Corrigan’s: visible vigorous carotid pulsation
 De Musset’s: head nodding
 Traube’s: pistol-shot sound over femorals
 Duroziez’s
 Systolic murmur over the femoral artery c̄
proximal compression.
 Diastolic murmur c̄ distal compression
 Mueller’s: systolic pulsations of the uvula
 Rosenbach’s: systolic pulsations of the liver
ECG
 LVH
 LV strain: lateral T wave inversion
Cause
 Marfanoid: tall, thin, long arms, high-arched palate
 Ank spond: cervical kyphosis
Pulse
 Collapsing pulse
 Wide pulse pressure: e.g. 180/45
Precordium
 Aortic thrill
 Apex: displaced (volume overload)
 Heart Sounds
 Soft S2
 ± S3
 Murmur
 High-pitched EDM
 LLSE (3rd left IC parasternal)
 Sitting forward in end-expiration
 Possible Additional Murmurs
 Ejection systolic flow murmur
 Austin-Flint murmur
 Rumbling MDM @ apex 2O regurgitant jet
fluttering the anterior mitral valve
Clinical Signs of Severe AR
 Collapsing pulse
 Wide pulse pressure
 LVF
Significant Negatives
 Infective endocarditis
 Indicators of severity, LVF, wide PP, collapsing pulse
Differential
 MS
 Right-sided: PR, TS
Blood
 Standard: FBC, U+E, NT-proBNP, lipids, glucose
 AI disease: ESR, HLA-B27, ANA
CXR
 Cardiomegaly
 Pulmonary oedema
Echo + Doppler
 Severity
 Jet width (>65% of outflow tract = severe)
 Regurgitant jet volume
 Premature closing of the mitral valve
 Cause: bicuspid valve, vegetations, dissection
 LV function
 Other valve function
Cardiac Catheterisation
 Assess coronaries (needed if surgery planned)
 Grade severity
Mx
General
 MDT: GP, cardiologist, cardiothoracic surgeon,
dietician, specialist nurses
 Optimise CV risk: statins, anti-HTN, DM, anti-plat
 Monitor: regular f/up and echo
Specific
 ↓ afterload
 ACEi or β-B (esp. carvedilol)
 Diuretics
Surgical: Valve Replacement
 Aim to replace the valve before significant LV dilation
and dysfunction.
 Indications
 Symptomatic: NYHA >2
 LV dysfunction
 Pulse pressure >100mmHg
 ECG changes: T inversion in lateral leads
 LV enlargement on CXR or EF <50%
Causes
Chronic
 Bicuspid aortic valve
 Rheumatic heart disease
 Autoimmune: Ank spond, RA
 Connective tissue: Marfan’s, Ehler’s Danlos
Acute
 Infective endocarditis
 Type A aortic dissection
© Alasdair Scott, 2012
7
Mitral Stenosis
Examination
Viva
Peripheral Inspection
Ix
 Middle-aged female
 Warfarin medic alert bracelet
 Malar Flush: CO → backpressure + vasoconstriction
ECG
 P-mitrale
 AF
Pulse
Bloods: FBC, U+E, NT-proBNP, lipids, glucose
Precordium
CXR
 LA hypertrophy → splaying of carina
 Calcified mitral valve
 Pulmonary oedema
 AF
 Left parasternal heave: RVH 2O to PHT
 Apex: Tapping (palpable S1), non-displaced
 Heart sounds
 Loud S1
 ± loud P2 (if PHT)
 Early diastolic opening snap
 Murmur
 Rumbling MDM
 Apex
 Left lateral position in end expiration
 With the Bell
 Radiates to the axilla
 Pre-systolic accentuation if pt. in sinus rhythm
 Atrial contraction
 Possible Additional Murmurs
O
 ± Graham Steell murmur (EDM 2 to PR)
Clinical Signs of Severe MR
 Malar flush
 Longer murmur
 LVF
Significant Negatives
 Infective endocarditis
 Severity: LVF, malar flush, long murmur
 Evidence of PHT
 Malar flush
 ↑ JVP c̄ large V waves
 Left parasternal heave
 Loud P2
Differential
 AR
 Right-sided: PR, TS
Causes
 Rheumatic heart disease
 Other causes are rare
 Prosthetic valve
 Congenital
© Alasdair Scott, 2012
Echo + Doppler
 Severity
 Cusp calcification
 LV function
 Other valve function
 TOE: left atrial thrombus if intervention planned
Echo Features of Severe MR (AHA 2006)
2
 Valve orifice <1cm
 Pressure gradient >10mmHg
 Pulmonary artery systolic pressure >50mmHg
Cardiac Catheterisation
 Assess coronaries (needed if surgery planned)
 Grade severity
Mx
General
 MDT: GP, cardiologist, cardiothoracic surgeon, dietician,
specialist nurses
 Optimise CV risk: statins, anti-HTN, DM, anti-plat
 Monitor: regular f/up and echo
Specific
 Consider rheumatic fever prophylaxis: e.g. Pen V
 AF
 Rate control: β-B
 Anticoagulate (4% stroke risk /yr)
 Diuretics provide symptom relief
Surgical
 Indicated in mod–severe MS (asympto and symptomatic)
 Percutaneous balloon valvuloplasty
 Rx of choice
 Suitability depends on valve characteristics
 Pliable, minimally calcified
 CI if left atrial mural thrombus
 Surgical valvotomy / commissurotomy: valve repair
 Valve replacement if repair not possible
8
Rheumatic Fever
Infective Endocarditis
Pathophysiology
Normal Valves → Acute Endocarditis
 Ab cross-reactivity following S. pyogenes infection → T2
hypersensitivity reaction (molecular mimicry).
 Abs cross-react c̄ myosin, muscle glycogen and SM cells
 Path: Aschoff bodies and Anitschkow myocytes.
Dx: revised Jones Criteria
 Evidence of GAS infection plus:
 2 major criteria, or
 1 major + 2 minor
Risk Factors
 IVDU
 Skin wounds
 Immunosuppression: CRF, DM
Organisms
 S. aureus
 S. epidermidis
Evidence of GAS infection
 +ve throat culture
 Rapid strep Ag test
 ↑ ASOT or DNase B titre
 Recent scarlet fever
Cardiac Disease → Subacute Endocarditis
Major Criteria
 Pancarditis
 Arthritis
 Subcut nodules
 Erythema marginatum
 Sydenham’s chorea
Organisms
 S. viridans
 S. bovis (do colonoscopy for colonic neoplasm)
 HACEK → culture negative IE
Ix
Minor criteria
 Fever
 ↑ESR or ↑CRP
 Arthralgia
 not if arthritis is a major
 Prolonged PR interval
 not if carditis is a major
 Prev rheumatic fever
 Bloods: FBC, ESR, ASOT
 ECG
 Echo
Rx





Bed rest until CRP normal for 2wks
Benpen 0.6-1.2mg IM for 10 days
Analgesia for carditis/arthritis: aspirin / NSAIDs
Add oral pred if: CCF, cardiomegaly, 3rd degree block
Chorea: Haldol or diazepam
Prognosis
 Attacks last ~ 3mo
 60% c̄ carditis develop chronic rheumatic heart disease.
 Recurrence ppted by
 Further strep infection
 Pregnancy
 OCP
 Valve disease: regurgitation → stenosis
 Mitral (70%)
 Aortic (40%)
 Tricuspid (10%)
 Pulmonary (2%)
Secondary Prophylaxis
 Prevent recurrence
 Pen V 250mg/12h PO for 5-10yrs
Risk Factors
 Prosthetic valves
 Valve disease
Clinical Features
Hands
 Clubbing
 Splinters
 Janeway lesions
 Oslers nodes
Other
 Fever
 Roth spots
 Splenomegaly
 Haematuria
Cardiac
 New / changing murmur
 MR: 85%
 AR: 55%
Dx: Duke Criteria
 2 major
 1 major + 3 minor
 All 5 minor
Major
1. +ve Blood Culture
 Typical organism in 2 separate cultures, or
 Persistently +ve cultures, e.g. 3, >12h apart
2. Endocardial Involvement
 +ve echo: vegetation, abscess, dehiscence
or
 New valvular regurgitation
Minor
1. Predisposition: cardiac lesion, IVDU
2. Fever >38
3. Emboli: septic infarcts, splinters, Janeway lesions
4. Immune: GN, Osler nodes, Roth spots, RF
5. +ve blood culture not meeting major criteria
Empiric Rx
 Acute severe: Fuclox / vanc + gent IV
 Subacute: Benpen + gent IV
Prophylaxis
 Abx prophylaxis solely to prevent IE not
recommended
© Alasdair Scott, 2012
9
Valve Replacement
Examination
Viva
Peripheral Inspection
Hx
General
 Audible valve click
 Anticoagulation → bruising
 Warfarin alert bracelet
 Anaemia
Scars
 Midline sternotomy: CABG, AVR, MVR
 Left lat. inf. thoracotomy: MVR, mitral valvotomy
 Neck scars from line insertion
 Groin / femoral scars from angiography
 Vein harvesting scar on the medial leg
 May have had CAGB too
Pulse
 Variable
 AF suggests mitral valve replacement due to MS
 Time prosthetic clicks c̄ pulse
 Occur in time = mitral valve
Precordium
Two Main Questions
1. When and where is the closing prosthetic sound?
2. Are there any murmurs?
Starr-Edwards: 3 artificial sounds
 Quieter click as valve opens
 Loud thud as valve closes
 Rumbling sound as ball rolls in cage
 DH: warfarin dosing + interactions
 Look @ pts. yellow warfarin book
Ix
Bedside
 ECG
Blood
 FBC: anaemia – MAHA, bleeding
 U+E: renovascular disease
 NT-proBNP: heart failure
 Fasting lipids and glucose: cardiac risk
 INR: warfarin
Imaging
 CXR: heart failure
 Echo + Doppler
 Valve regurgitation or stenosis
 Peri-valvular leak
 Vegetations
 LV function
 Other valve function
Discussion
 Valve complications
 Valve types
 Infective endocarditis
Tilting disc or bileaflet: 1 artificial sound
 High-pitched click as valve closes
Biological Valve
 Often normal heart sounds
Aortic
 Lub-Click
 ± systolic flow murmur
 Abnormal: AR (EDM)
Mitral
 Click-Dub
 ± diastolic flow murmur
 Abnormal: MR (PSM)
Murmurs
 Well-seated valves may have soft flow murmurs
 Aortic: systolic
 Mitral: diastolic
 Poorly-seated valves → regurgitation
 Aortic: diastolic
 Mitral: systolic
Significant Negatives




Signs of infective endocarditis
Signs of heart or valve failure
Anaemia
Bruising
© Alasdair Scott, 2012
10
Valve Prostheses: Key Facts
Mechanical
Types
 Ball and cage: e.g. Starr-Edwards
 Tilting disc: e.g. Bjork-Shiley
 Bileaflet: e.g. St. Jude
Features
 Longer life-span: ~20yrs
 Require oral anticoagulation: Warfarin INR 3-4
Use
 Bileaflet valves are most commonly used
 Younger pts. to minimise need for revision.
 Already on warfarin: e.g. AF
Biological
Types
 Porcine valves: e.g. Carpentier Edwards
 Bovine pericardium sewn into a metal frame
 Discontinued
Features
 Less durable cf. mechanical valves: ~10yrs
 Don’t require long-term oral anticoagulation
 Take aspirin
Use
 Older patients
 Women of child-bearing age
 Bleeding risk: e.g. peptic ulcer, frequent falls
© Alasdair Scott, 2012
Indications
 Mainly left-sided valve dysfunction
 AS most commonly
 Factors to consider
 Severity of valve dysfunction
 Severity of heart function
 Co-morbidities
 Pt. choice
 Mechanical or prosthetic
 Age
 Tolerance of long-term anticoagulation
 E.g. pregnancy, falls
 Pt. choice
Complications
Complications of surgery
 Operative mortality: 5%
Complications of valve
 Thromboembolism: 1-2% per annum despite warfarin
 Anaemia: warfarin and haemolysis
 Bleeding: minor – 7%/yr, major – 3%/yr
 Infective endocarditis
 Early: Staph. epidermidis
 Late: Strep. viridans
nd
 May require 2 valve replacement
 Mortality: 60%
 NB. avoid erythromycin if on warfarin
 Failure
 Chronic: stenosis or incompetence
 Acute: dehiscence, breakage, thrombus
11
Atrial Fibrillation
Examination
Viva
Peripheral Inspection
Hx
 Symptoms: palpitations, dyspnoea, chest pain
 Aware of specific onset
 Causes
 Warfarin: look @ yellow book
General
 Warfarin alert bracelet
Cause
 ↑T4: tremor, thin, palmar erythema, sweating, eye signs
 MS: mitral flush
ECG
 Confirm Dx: irregularly irregular, no P waves
 Cause: ischaemia, P-mitrale
Pulse
 Irregularly irregular
Bloods
 FBC: pneumonia, sepsis
 U+E: ↓K
 TFTs: ↓TSH, ↑fT4
 Troponin
 D-dimer: PE
Precordium
 MS: MDM
 MR: PSM
 Other murmurs
Completion
 Respiratory examination: pneumonia
 Exercise pt. to bring out any murmur
CXR
 Pulmonary oedema
 Calcified mitral valve
 Pneumonia
Echo
 Valve pathology
 LV function
 TOE: left atrial thrombus
Significant Negatives




Ix
Murmur
Evidence of thyrotoxicosis
LVF
Bruising from warfarin
Causes
Common
 IHD
 Rheumatic heart disease
 Thyrotoxicosis
 Hypertension
© Alasdair Scott, 2012
Other
 Pneumonia
 PE
 Post-op
 Hypokalaemia
 Alcohol
 RA
12
AF: Key Facts
Clinical Points
Anticoagulation
Differential of Irregularly Irregular Pulse
CHA2-DS2-VAS Score
 AF
 Multiple ventricular ectopics
Clinical Distinction
 Exercise pt.
 AF: pulse stays irregularly irregular
 VE: ↑ HR → regular pulse
 ↓ diastole time closes window for ectopics
Pulse Deficit
 Difference in HR @ wrist and @ apex
 Rapid ventricular rate → ↓ diastolic filling → ↓CO
AF Control
 Time the apical rate: target <100 @ rest
Mx
Acute AF ≤48hrs
 Haemodynamically unstable → cardioversion
 Stable
 Rate control: diltiazem or metoprolol
 Start LMWH
 Cardiovert: DC or medical (flec or amiodarone)
 Determines necessity of anticoagulation in AF
 Dabigatran may be cost-effective alternative to warfarin
CHA2-DS2
 CCF
 HTN
 Age≥75 (2 points)
 DM
 Stroke or TIA (2 points)
VAS
 Vascular disease
 Age: 65-74yrs
 Sex: female
Score
 0: aspirin
 ≥1: Warfarin (INR 2-3)
Warfarin
Contraindications
 Bleeding diathesis
 Compliance issues: dosing, monitoring
 Risk of falls
 PUD
 Pregnancy
 Pt. choice
Paroxysmal AF
Complications
 Bleeding
 Osteoporosis
Persistent AF
Advice
 Requires regular monitoring and titration of dose
 Avoid certain foods: e.g. grapefruit
 Care starting new meds
 Wear medic alert bracelet
 Come to hospital if uncontrolled bleeding
 Recurrent episodes lasting <7d
 Pill in pocket: flecainide or amiodarone
 Prevention: β-B or sotalol
 Lasting >7d
Rhythm control
 Younger pts., treated precipitants
 ≥3wks anticoagulation c̄ Warfarin first or TOE to
exclude mural thrombus
 Cardioversion: DC or medical
 May need maintenance anti-arrhythmic
Rate control
st
 1 : β-B or rate-limiting CCB
 2nd: add digoxin (not monotherapy)
Permanent AF
 Failed cardioversion / unlikely to succeed
 Rate control
Other options
 Radiofrequency ablation of AV node
 Maze procedure
 Pacing
© Alasdair Scott, 2012
13
Pacemakers
Examination
Viva
Peripheral Inspection
Hx
 Groin scars from catheter insertion
 Medic alert bracelet
 Arrhythmia
 Syncope
 Palpitations
 Dyspnoea
 Cardiac arrest
 Type of pacemaker
Pulse
 AF
Precordium
 Left infraclavicular incisional scar
 Palpable pacemaker
 Large: may be implantable defibrillator
 ± murmur: esp. AS
Significant Negatives




AF
LVF
Valvular pathology
Complications of pacemaker: infection, erosion
Ix
ECG
 Pacing spikes
 May be absent if pt. producing adequate intrinsic
rhythm
 Evidence of ischaemia
CXR
 Visualise pacemaker
 Count leads
 Thick leads suggests implantable defibrillator
Echo
 LV function
 Valve pathology
 Structural abnormalities indicating cause
Pace Makers
Permanent Pacing Indications
 Complete AV block
 Mobitz Type 2
 Symptomatic bradycardia: e.g. sick sinus syndrome
 Drug-resistant tachyarrhythmias
 Biventricular pacing in chronic heart failure
Letters
st
 1 : chamber paced (A, V, D)
 2nd: chamber sensed (A, V, D)
 3rd: response (Inhibited, Triggered, Dual)
Single Lead
 One lead senses and responds
 E.g. VVI
Dual Lead
 Sense and respond in either chamber
Biventricular
 Leads to both ventricles ± RA
 Used for cardiac resynchronisation therapy in HF
Implantable defibrillator: may be incorporated into any pacemaker
© Alasdair Scott, 2012
Complications
 Insertion
 Bleeding
 Arrhythmia
 Post Insertion
 Erosion
 Lead migration
 Pocket infection
 Malfunction
14
Chronic Heart Failure
Definition
 CO is inadequate for body’s requirements despite
adequate filling pressures.
Left
Causes
 1: IHD
 2: Idiopathic dilated cardiomyopathy
 3: Systemic HTN
 4: Mitral and aortic valve disease
Symptoms
 Fatigue
 Exertional dyspnoea
 Orthopnoea + PND
 Nocturnal cough (± pink, frothy sputum)
 Wt. loss and muscle wasting
Signs
 Cold peripheries ± cyanosis
 Often in AF
 Cardiomegaly c̄ displaced apex
 S3 + tachycardia = gallop rhythm
 Wheeze (cardiac asthma)
 Bibasal creps
Right
Causes
 LVF
 Cor pulmonale
 Tricuspid and pulmonary valve disease
Symptoms
 Anorexia and nausea
Signs
 ↑JVP + jugular venous distension
 Tender smooth hepatomegaly (may be pulsatile)
 Pitting oedema
 Ascites
New York Classification
1.
2.
3.
4.
No breathlessness
Breathless c̄ moderate exertion
Breathless c̄ mild exertion
Breathless at rest
Ix
Bloods: FBC, U+E, NT-proBNP, lipids, glucose
NT-proBNP
 Secreted from ventricles in response to ↑ stretch and ↑HR
 ↑ levels is most accurate diagnostic indicator of HF
 NICE recommends that heart failure is not Dx w/o ↑ BNP
CXR: ABCDEF
 Alveolar shadowing
 Kerley B lines
 Cardiomegaly (cardiothoracic ratio >50%)
 Upper lobe Diversion
 Effusions
 Fluid in the fissures
ECG
 Ischaemia
 Hypertrophy
 AF or other arrhythmia
Echo: the key investigation
 Global systolic and diastolic function
 Ejection fraction normally ~60%
 Focal / global hypokinesia
 Hypertrophy
 Valve lesions
Mx
General
 MDT: GP, cardiologist, physio, dietician, specialist nurses
 Optimise CV risk: statins, anti-HTN, DM, anti-plat
 Monitor: regular f/up and echo
Specific
 1st: β-B + ACEi + loop diuretic
 Bisoprolol
 Lisinopril
 Frusemide
 2nd: add Spironolactone
 3rd: consider digoxin
 4th: consider cardiac resynchronisation therapy
Surgery
 LVAD
 Heart transplant
Trials Showing Drug Benefit in Heart Failure




© Alasdair Scott, 2012
ACEi: Consensus 1
ARB = ACEi: ELITE-2
β-B: CIBIS-2, MERIT-2
Spironolactone: RALES
15
Pulmonology
Contents
COPD ....................................................................................................................................................................................... 17
COPD: Key Facts..................................................................................................................................................................... 18
Asthma ..................................................................................................................................................................................... 19
Pulmonary Fibrosis .................................................................................................................................................................. 21
Bronchiectasis.......................................................................................................................................................................... 22
Bronchiectasis: Causes ........................................................................................................................................................... 23
Pleural Effusion ........................................................................................................................................................................ 24
Lung Cancer ............................................................................................................................................................................ 25
Lobectomy and Pneumonectomy ............................................................................................................................................ 25
Lung Cancer: Key Facts .......................................................................................................................................................... 26
Pneumonia ............................................................................................................................................................................... 27
Pneumonia: Key Facts ............................................................................................................................................................. 28
Old TB ...................................................................................................................................................................................... 29
© Alasdair Scott, 2012
16
COPD
Examination
Viva
Peripheral Inspection
Hx





Paraphernalia
 Inhalers
 Peak flow meter
 Nebuliser
General
 Airflow obstruction
 Pursed lip breathing
 Splinting diaphragm
 Cushingoid
 Cyanosed
 Cachetic
Specific
 Hands
 Tar staining
 CO2 retention flap
 Bounding pulse
 Face
 Plethora: ↑Hb
 Central cyanosis
Chest





Barrel-shaped
↓ cricosternal distance
↓ expansion bilaterally
PN: resonant
Auscultation
 ↓ breath sounds
 Expiratory wheeze
 Prolonged expiratory phase
Evidence of Hyperexpansion
 ↓ cricosternal distance
 Loss of cardiac dullness
 Palpable liver edge
Extra
Cor Pulmonale
 ↑ JVP
 Left parasternal heave: RV hypertrophy
 Loud P2 ± S3
 MDM of tricuspid regurg
 Ascites and pulsatile hepatomegaly
 Peripheral oedema
Significant Negatives
 CO2 retention
 Cor pulmonale
 Clubbing: could indicate Ca
Differential
 Chronic asthma
 Bronchiectasis
© Alasdair Scott, 2012
Symptoms: cough, sputum, dyspnoea
Limitation: exercise tolerance
Cause: smoking Hx, FHx
Control: exacerbations, admissions
Therapy: inhalers, vaccinations, home O2
Definitions
 Chronic bronchitis
 Cough productive of sputum on most days for ≥3mo on ≥2
consecutive years
 Emphysema
 Histological description of alveolar wall destruction c̄
airway collapse and air trapping
Ix
Bedside
 PEFR
 BMI: independent mortality RF in COPD
 Sputum: MC+S
Spirometry: obstructive
 ↑ TLC and residual volume (RV)
 FEV1 <80%
 FEV1:FVC <0.7
 ↓ transfer factor
Bloods
 FBC: polycythaemia, ↑ WCC in exacerbations
 ABG: Type 2 resp failure
 CRP: if infective exacerbation
 Albumin: malnutrition
 α1-AT levels: if young and FHx
Imaging
 CXR
 Acute
 Consolidation
 Pneumothorax
 Chronic
 Hyperinflation: >10 posterior ribs, flat diaphragm
 PHT: prominent pulmonary As, peripheral oligaemia
 Bullae
 Echo
 Cor pulmonale
Other
 6 minute walk
 ECG: RVH
Discussion
 Chronic COPD Mx
 GOLD classification
 LTOT
 Acute exacerbation Mx
 Ventilation
 Prognosis
 BODE index
17
COPD: Key Facts
Chronic Mx
Mx of Acute Exacerbations
GOLD Classification
 Global Initiative for Obstructive Lung Disease
 Multidimensional classification to tailor therapy to pt.




Parameters
 mMRC dyspnoea score
 Airflow limitation
 No. of exacerbations per year
Controlled O2 Therapy
Sit-up
24% O2 via Venturi mask: SpO2 88-92%,
Vary FiO2 and SpO2 target according to ABG
Aim for PaO2 >8 and ↑ in PCO2 of <1.5kPa
mMRC Dyspnoea Score
1. SOB only on vigorous exertion
2. SOB on hurrying or walking up stairs
3. Walks slowly or has to stop for breath
4. Stops for breath after <100m / few min
5. Too breathless to leave house or SOB on dressing
Nebulised Bronchodilators
 Air driven c̄ nasal specs
 Salbutamol 5mg/4h
 Ipratropium 0.5mg/6h
Airflow Limitation
1. Mild: FEV1 >80% (but FEV/FVC <0.7 and symptomatic)
2. Mod: FEV1 50-79%
3. Severe: FEV1 30-49%
4. Very Severe: FEV1 <30%
Steroids (IV and PO)
 Hydrocortisone 200mg IV
 Prednisolone 40mg PO for 7-14d
General Mx
Abx
 If evidence of infection
 Doxy 200mg PO STAT then 100mg OD PO for 5d
MDT
 GP, dietician, physio, resp physician, specialist nurses
 Regular review 1-2x / yr
NIV if no response
 Repeat nebs and consider aminophylline IV
 Consider NIV (BiPAP) if pH<7.35 and/or RR >30
 Consider invasive ventilation if pH<7.26
 Depends on pre-morbid state: exercise capacity,
home O2, comorbidity
Smoking Cessation: single most important intervention
 Specialist nurse and support programme
 Nicotine replacement therapy
 Varenicline: partial nicotinic agonist
Pulmonary Rehabilitation Therapy
 Tailored exercise programme
 Disease education
 Psychosocial support
Co-morbidities
 Nutritional assessment and dietary support
 CV risk Mx
 Vaccination: pneumococcal and seasonal influenza
Medical Mx
 Principal Therapies
 Anti-muscarinics: short- or long-acting
 β-agonists: short- or long-acting
 Inhaled corticosteroids: in combination c̄ β-B
 Other Therapies
 Theophylline or Roflumilast: PDIs
 Carbocisteine: mucolytic
 Home emergency pack for acute exacerbations
 LTOT
 Aim: PaO2 ≥8 for ≥15h / day (↑ survival by 50%)
 Indications
 Sable non-smokers c̄ PaO2 <7.3
 PaO2 <8 + cor pulmonale or polycythaemia
Surgical Mx
 Recurrent pneumathoraces or large bullae
 Bullectomy or lung reduction surgery
© Alasdair Scott, 2012
Ix




PEFR
Bloods: FBC, U+E, ABG, CRP, cultures
Sputum culture
CXR: infection, pneumothorax
Discharge






Spirometry
Establish optimal maintenance therapy
GP and specialist f/up
Prevention using home oral steroids and Abx
Pneumococcal and Flu vaccine
Home assessment
BODE Index
 Multidimensional tool to predict mortality in COPD
 Uses multiple independent risk factors
 BMI
 Obstruction: FEV1
 Dyspnoea: MRC score
 Exercise capacity: 6 min walk
Mortality
 15% in-hospital mortality
18
Asthma
Examination
Viva
Peripheral Inspection
Hx




Symptoms: cough, dyspnoea, wheeze, diurnal variation
Limitations: exercise, sleep, work
Cause: atopy, exercise, cold, smoking
Control: SABA use, attacks, admissions, ITU
 Check peak flow diary
 Therapy: oral steroid use, check inhaler technique
 Assocs.
 GORD: dyspepsia
 Churg-Strauss: recent onset, rash, neuropathy
Paraphernalia
 Inhalers
 Peak flow meter
 Nebuliser
General
 Cushingoid
Specific
 Oral thrush
Definition
 Episodic, reversible airway obstruction due to bronchial
hyper-reactivity to a variety of stimuli.
Chest
 Harrison sulcus
 Auscultation
 Usually normal
 May be ↓ AE and mild wheeze
Significant Negatives
 CO2 retention
 Cor pulmonale
 Clubbing: could indicate Ca
Differential
 Normal
 Pulmonary oedema: cardiac asthma
 COPD
Ix
Bedside
 PEFR
Bloods
 FBC (eosinophila)
 ↑IgE
 Aspergillus serology
CXR: hyperinflation
Spirometry: obstructive
 ↓ FEV1, ↑RV
 FEV1:FVC < 0.75
 ≥15% improvement in FEV1 c̄ β-agonist
PEFR monitoring / diary
 Diurnal variation >20%
 Morning dipping
Atopy: skin-prick testing, RAST
Mx
General
 MDT: GP, specialist nurses, respiratory physician
 Technique for inhaler use
 Avoidance: allergens, smoke (ing), dust
 Monitor: Peak flow diary (2-4x/d)
 Educate
 Liaise c̄ specialist nurse
 Need for Rx compliance
 Emergency action plan
Medical: 5-stage BTS Guidelines
Well Controlled
 No exacerbations
 No reliever therapy: no PRN salbutamol
 No night time waking
 <20% diurnal variation
 Normal lung function
© Alasdair Scott, 2012
19
Acute Severe Asthma
Presentation
Mx
 Acute breathlessness and wheeze
Hx




Ix
Precipitant: infection, travel, exercise?
Usual and recent Rx?
Previous attacks and severity: ICU?
Best PEFR?
 PEFR
 ABG
 PaO2 usually normal or slightly ↓
 PaCO2 ↓
 If PaCO2 ↑: send to ITU for ventilation
 FBC, U+E, CRP, blood cultures
Assessment
Severe
 PEFR <50%
 Can’t complete sentence in one breath
 RR >25
 HR >110
Life Threatening
 PEFR <33%
 SpO2 <92%, PCO2 >4.6kPa, PaO2 <8kPa
 Cyanosis
 Hypotension
 Exhaustion, confusion
 Silent chest, poor respiratory effort
 Tachy-/brady-/arrhythmias
Differential
 Pneumothorax
 Acute exacerbation of COPD
 Pulmonary oedema
Admission Criteria
 Life-threatening attack
 Feature of severe attack persisting despite initial Rx
 May discharge if PEFR > 75% 1h after initial Rx
1.
2.
3.
4.
5.
O2, Nebs and Steroids
Sit-up
100% O2 via non-rebreathe mask (aim for 94-98%)
Nebulised salbutamol (5mg) and ipratropium (0.5mg)
Hydrocortisone 100mg IV or pred 50mg PO (or both)
Write “no sedation” on drug chart
If Life Threatening
 Inform ITU
 MgSO4 2g IVI over 20min
 Nebulised salbutamol every 15min (monitor ECG)
If Improving
 Monitor: SpO2 @ 92-94%, PEFR
 Continue pred 50mg OD for 5 days
 Nebulised salbutamol every 4hrs
IV Rx if No Improvement in 15-30min:
Nebulised salbutamol every 15min (monitor ECG)
Continue ipratropium 0.5mg 4-6hrly
MgSO4 2g IVI over 20min
Salbutamol IVI 3-20ug/min
Consider aminophylline
 Load: 5mg/kg IVI over 20min
 Unless already on theophylline
 Continue: 0.5mg/kg/hr
 Monitor levels
 ITU transfer for invasive ventilation





Monitoring
 PEFR every 15-30min
 Pre- and post-β agonist
 SpO2: keep >92%
 ABG if initial PaCO2 normal or ↑
Discharge When
 Been stable on discharge meds for 24h
 PEFR >75% c̄ diurnal variability <20%
Discharge Plan




TAME pt.
PO steroids for 5d
GP appointment w/i 1 wk.
Resp clinic appointment w/i 1mo
© Alasdair Scott, 2012
20
Pulmonary Fibrosis
Examination
Viva
Peripheral Inspection
Hx
General
 Clubbing
 Cushingoid
 No sputum
 Tachypnoea, central cyanosis
Evidence of Specific Cause
 RA: rheumatoid hands, nodules
 SS
 Sclerodactyly, calcinosis
 Microstomia, beak nose, telangiectasia
 SLE: malar rash
 AS: kyphosis
 Sarcoidosis: EN
 Radiation: tattoos on chest
Chest
 ± thoracotomy scar: single lung Tx
 Tracheal shift towards fibrosis: upper lobe
 Fine end-inspiratory crackles
 No change c̄ coughing
Extras
 Cor pulmonale
Significant Negatives
 Cyanosis
 Cor pulmonale
 Specific cause: e.g. RA hands or sclerodactyly
Differential
 Bronchiectasis
 Chronic lung abscess




HPC: dyspnoea, cough, sputum, wt. loss
Cause: arthritis, radiation, occupation, hobbies
DH
Smoking status
Ix
Bedside
 PEFR
 ECG: RVH
Blood
 FBC: anaemia exacerbates dyspnoea
 ABG: ↓PaO2, ↑PaCO2
 IPF: ↑ESR, ↑CRP, ANA (30%), RF (10%), ↑Ig
 EAA: +ve se precipitins
 CTD: C3/C4, CCP (RF, ANA), scl-70, centromere
 Sarcoid: se ACE, Ca2+
Imaging
 CXR: reticulonodular shadowing, ↓ lung volume
 HRCT: fibrosis, Honeycomb Lung
Spirometry: restrictive
 ↓TLC¸ ↓RV, ↓FEV and ↓FVC
 FEV1:FVC >0.8
 ↓ transfer factor
Other
 Echo: PHT
 BAL: may indicate disease activity
 ↑ lymphocytes > PMN: better prognosis
 Lung biopsy: usual interstitial pneumonia
Mx
Causes
Upper
 Aspergillosis : ABPA
 Pneumoconiosis: Coal, Silica
 Extrinsic allergic alveolitis
 Negative, sero-arthropathy
 TB
Lower
 Sarcoidosis (mid zone)
 Toxins: BANS ME
 Asbestosis
 Idiopathic pulmonary fibrosis
 Rheum: RA, SLE, SS, Sjogren’s, PM/DM
Drugs: BANS ME
 Bleomycin, Busulfan
 Amiodarone
 Nitrofurantoin
 Sulfasalazine
 MEthotrexate
MDT: GP, pulmonologist, physio, psych, palliative care,
specialist nurses, pts. family
Rx specific cause
 EAA: steroids
 Sarcoidosis: steroids
 Connective tissue disease: steroids
Supportive care
 Stop smoking: single most beneficial strategy
 Pulmonary rehabilitation
 LTOT
 Symptomatic Rx
 Anti-tussives: e.g. codeine phosphate
 Heart failure: diuretics, β-B, ACEi
Surgery: lung Tx offers only cure for IPF
Prognosis
 IPF: 50% 5yr survival
Panther Study
 Pred + AZA + NAC → ↑ mortality: trial arm stopped
 NAC alone: trial arm still running
© Alasdair Scott, 2012
21
Bronchiectasis
Examination
Viva
Peripheral Inspection
Hx
General
 Clubbing
 Sputum pot
 Small and young: CF
 Cachexia
 LNs
 Tachypnoea
Ix
Evidence of Specific Cause
 RA: rheumatoid hands
 Yellow nails
 CF: young pt., nasal polyps
 Hypogammaglobulinaemia: splenomegaly
 IBD: abdominal scars
Chest
 ± thoracotomy scar
 Portacath or Hickman line / scars: CF
 Coarse, wet crackles
 May change with cough
 Localised / patchy: 2O to infection
 Widespread: 2O to systemic disease
 ± monophonic wheeze
 Dextrocardia
Extras
 Cor pulmonale
Completion
 Examine the nose for polyps
 Examine the abdomen for scars and splenomegaly
Significant Negatives
 Cor pulmonale
 Specific cause: e.g. RA hands
Differential
 Idiopathic pulmonary fibrosis
 Chronic lung abscess
Causes
Congenital
 CF
 PCD / Kartagener’s
 Young’s: azoospermia + bronchiectasis
 Hypogammaglobulinaemia: XLA, CVID, SAD
Acquired
 Idiopathic
 Post-infectious: pertussis, TB, measles
 Obstruction: tumour, foreign body
 Associated: RA, IBD (esp. UC), ABPA
 HPC: dyspnoea, cough, sputum, haemoptysis, wt. loss
 Cause: recurrent infections, arthritis, diarrhoea
 Smoking status
Bedside
 PEFR
 Dipstick: proteinuria – amyloidosis
Sputum: MC+S, cytology
Blood
 FBC: ACD
 Serum Ig: may do provocative testing
 Aspergillus: RAST, precipitins, ↑IgE, eosinophilia
 RA: anti-CCP, RF, ANA
Imaging
 CXR: tramlines and ring shadows (bunch of grapes)
 HRCT
 Signet ring sign: thickened dilated bronchi +
smaller adjacent vascular bundle
 Pools of mucus in saccular dilatations
Spirometry
 Obstructive
Other
 Bronchoscopy + mucosal biopsy
 Focal obstruction
 PCD
 CF sweat test
 Aspergillus skin prick testing
Complications





Cachexia
Pulmonary HTN
Massive haemoptysis
Type 2 respiratory failure
Amyloidosis
Mx
Conservative
 MDT: GP, pulmonologist, physio, dietician, immunologist
 Physio: postural drainage, active cycle breathing, rehab
Medical
 Abx
 Exacerbations: e.g. cipro for 7-10d
 May use prophylactic azithromycin
 Bronchodilators: nebulised β agonists
 Treat underlying cause
 CF: DNAase, pancreatin (Creon), ADEK vitamins
 ABPA: Steroids
 Immune deficiency: IVIg
 Vaccination: flu, pneumococcus
Surgical
 May be indicated in severe localised disease or obstruction
© Alasdair Scott, 2012
22
Bronchiectasis: Causes
Cystic Fibrosis
PCD and Kartagener’s
 Autosomal recessive defect in ciliary motility
 Poor mucociliary clearance → chronic recurrent
inflammation and bronchiectasis.
 ↓ sperm motility in males → infertility
Genetics
 Incidence: 1/2500 live Caucasian births
 Carrier frequency: 1/25
 Autosomal recessive
 Mutation in CFTR gene on Chr 7
 Commonly ∆F508
Kartagener’s Syndrome
 Situs inversus + PCD (~50% of individuals c̄ PCD)
 Situs inversus
 Chronic sinusitis
 Bonchiectasis
Pathophysiology
 → ↓ luminal Cl secretion and ↑ Na reabsorption →
viscous secretions.
 Bronchioles → bronchiectasis
 Pancreatic ducts → DM, malabsorption
 GIT → Distal Intestinal Obstruction Syndrome
 Liver → gallstones, cirrhosis
 Fallopian tubes → ↓ female fertility
 Seminal vesicles → male infertility
Young’s Syndrome
 Bronchiectasis
 Rhinosinusitis
 Azoospermia (no sperm in semen) → ↓ fertility
Hypogammaglobulinaemia
 Primary immune deficiency due to ↓ Ig
Dx
 Genetic screening for common mutations
 Immunoreactive trypsinogen (neonatal screening)
 Sweat test: Na and Cl > 60mM
 False +ve: hypothyroidism, Addison’s
 Faecal elastase: tests pancreatic exocrine function
Ix
Presentation
 Recurrent sinopulmonary infections → bronchiectasis
 Diarrhoea
 Commonly encapsulates: pneumococcus, haemophilus
Causes
 Bloods: FBC, LFTs, clotting, ADEK levels, glucose
tolerance test
 Sputum MC+S
 CXR: diffuse tramlines and rings
 Abdo US: fatty liver, cirrhosis, pancreatitis
 Spirometry: obstructive defect
 Aspergillus serology / skin test (20% develop ABPA)
X-linked Agammablobulinaemia: Bruton’s
 X-linked recessive mutation of Bruton’s tyrosine kinase
 Failure to generate mature B cells → ↓ Ig
 Rx: pooled Ig → passive immunity
Mx
Common Variable Immunodeficiency
 Commonest 1O immune deficiency: 1/5000
 Splenomegaly: 25-50%
 Normal IgM, ↓IgG, ↓IgA
MDT: GP, gastro and resp physicians, physio, dietician,
specialist nurse
Specific Antibody Deficiency: SAD
 Normal Ig levels but inability to make specific antibodies
Chest
 Physio: postural drainage, active cycle breathing
 Abx: acute infections and prophylaxis
 Mucloytics: DNAse
 Segregate from other CF pts.: risk of transmission
 Pseudomonas
 Burkholderia
 Vaccination: flu, pneumococcus
 Advanced: heart-lung transplant
Yellow Nail Syndrome
GI
 Pancreatic enzyme replacement: pancreatin (Creon)
 ADEK supplements
 Insulin
Other
 Rx of complications: e.g. DM
 Fertility and genetic counselling
 DEXA osteoporosis screen
Prognosis
 Mean survival 35yrs but rising
 Poorer prognosis if infected c̄ Burkholderia cepacia
© Alasdair Scott, 2012





Very rare
Yellow dystrophic nails
Pleural effusions
Lymphoedema: lymphatic hypoplasia
Bronchiectasis
Allergic Bronchopulmonary Aspergillosis
 T1 and T3 HS reaction to Aspergillus fumigatus
 Bronchoconstriction → bronchiectasis
Presentation
 Dyspnoea, wheeze
 Productive cough
 Bronchiectasis
Ix
 ↑IgE and eosinophilia
 +ve skin prick test or RAST
Rx
 Prednisolone + bronchodilators
23
Pleural Effusion
Examination
Viva
Peripheral Inspection
Hx
 Symptoms: SOB, pleurisy
 Cause
 Fever, sputum
 Smoking, wt. loss, haemoptysis
 Previous MI, orthopnoea, PND
 Hepatitis
Paraphernalia
 Chest drain
Evidence of Specific Cause
 Cancer: clubbing, cachexia, LNs
 Pneumonia: febrile
 CCF: ↑JVP, S3, ascites, ankle oedema
 CLD: clubbing, leukonychia, spiders, gynaecomastia
 CTD: rheumatoid hands, malar rash
Chest




Tracheal shift: away from lesion
↓ expansion unilaterally
PN: stony dull
Auscultation
 ↓ AE
 ↓ VR
Significant Negatives
 Absence of
 Fever
 Clubbing
 ↑ JVP and peripheral oedema
 Features of CTD
Differential of Dull Lung Base
 Consolidation: bronchial breathing + crackles
 Collapse: ↑ VR
Causes
Transudate
Modified Starling’s Forces
Protein <25
Usually bilateral
Causes
- CCF
- Renal failure
- ↓ albumin
- Hypothyroidism
- Meig’s syn.
Exudate
↑ Capillary Permeability
Protein >35
Often unilateral
Causes
- Infection: pneumonia, TB
- Ca: 1O or 2O
- Inflammation: RA, SLE
- Infarction: PE
- Trauma
Ix
Sputum: MC+S, cytology
Imaging
 CXR
 Dependent homogenous opacification c̄ meniscus
 Unilateral or bilateral
 Cardiomegaly
 Coin lesions
 Hilar LNs
 Apical TB
 US: may guide pleurocentesis
 Volumetric CT
Blood
 FBC: ↓Hb
 U+E: ↑ Cr
 LFTs: ↓ albumin
 TFT: ↑TSH
 ESR: ↑ in CTD
 Ca: ↑ in Ca
Diagnostic Pleurocentesis
 Percuss upper boarder and go 1-2 spaces below
 Infiltrate down to pleura c̄ lignocaine + aspirate c̄ 21G
needle
 Send for
 Chemistry: protein, LDH, pH, glucose, amylase
 Bacteriology: MCS, auramine stain, TB culture
 Cytology
 Immunology: RF, ANA, complement
Light’s Criteria for Dx of an Exudative Effusion
 Effusion : serum protein ratio >0.5
 Effusion : serum LDH ratio >0.6
 Effusion LDH is 0.6 x ULN
Empyema: turbid fluid, ↓ glucose and pH <7.2
Pleural Biopsy
 If pleural fluid is inconclusive
 CT-guided c̄ Abrams needle
Mx
 Rx underlying cause
 May use drainage if symptomatic (≤2L/24h)
 Repeated aspiration or ICD
 Pleurodesis c̄ talc if recurrent malignant effusion
 Persistent effusions may require surgery
© Alasdair Scott, 2012
24
Lung Cancer
Lobectomy and Pneumonectomy
Peripheral Inspection
Examination
General
 Cachexia
 Hoarse voice or stridor
Peripheral Inspection
Hands
 Clubbing ± HPOA
 Tar staining
 Claw hand c̄ wasting of interossei
Chest
Face
 Anaemia
 Horner’s
 Plethora
Neck
 LNs: check axilla too
 Dilated veins
Chest
 Thoracotomy scar
 Radiotherapy square burn + tattoo
 Acanthosis nigricans
Collapse
 Tracheal deviation towards lesion
 ↓ expansion
 PN: dull
 Auscultation
 ↓ or absent AE
 ± crackles
 ↑ VR
Effusion
 Tracheal deviation away
 ↓ expansion
 PN: stony dull
 Auscultation: ↓ AE
 ↓ VR
Extras
 Hepatomegaly or spinal tenderness
Complications
 SVCO
 Plethoric, oedematous face and upper limbs
 Dilated neck and chest veins
 Stridor
 RLNP: hoarse voice c̄ bovine cough
 Pancoast Tumour
 Horner’s
 Claw hand c̄ interossei wasting
 Dermatomyositis
 Clubbing
 Cachexia
 Scars
 Lateral thoracotomy
 Clamshell: double lung Tx
 Chest drains
 Chest wall asymmetry / deformity
Pneumonectomy
Tracheal + apex shift
- To abnormal side
Throughout abnormal side
- ↓ expansion
- Dull percussion
- NO breath sounds
Lobectomy
Tracheal shift
- Mainly upper lobectomy
- To abnormal side
Focal signs
- ↓ expansion
- Dull percussion
- Reduced breath sounds
Completion
 History to establish cause
 CXR
Viva
Differential
 Lobectomy / pneumonectomy
 Scar but normal lung
 Thoracotomy: abscess, empyema, biopsy, wedge
 Transplant: ? other lung normal
Indications for Lobectomy / Pneumonectomy
 90% for non-disseminated bronchial carcinoma
 Other
 Bronchiectasis
 COPD: lung-reduction surgery
 TB: historic, upper lobe
Operative Mortality
 Lobectomy: 7%
 Pneumonectomy: 12%
↑ risk c̄
 ↑ ASA grade
 Age >70
 Poor resp function
 FEV1:FVC <55%
Discussion
 Lung Ca
 TB
Differential
 Consolidation
 Collapse
 Effusion
© Alasdair Scott, 2012
25
Lung Cancer: Key Facts
Epidemiology
Ix
Pathology
1. Bloods
 FBC: anaemia, ↑WCC if consolidation
 U+E: ↓ Na (SIADH or Addison’s)
 LFTs: deranged LFTs 2O to liver mets
 Bone profile: ↑ Ca2+ (bone mets, ↑PTHrP)
 3rd commonest malignancy in men and women
 Commonest cause of cancer death
Non-Small Cell Lung Cancer
 SCC: 35%
 Highly related to smoking
 Centrally located
 PTHrP → ↑ Ca2+
 Adenocarcinoma: 25%
 RF: female non-smokers
 Peripherally located
 80% present c̄ extrathoracic mets
 Large-cell: 10%
Small Cell Lung Cancer: 20%
 Highly related to smoking
 Central location
 80% present c̄ advanced disease
 Ectopic hormone secretion
Hx
 Symptoms
 Cough + haemoptysis
 Dyspnoea
 Chest pain
 Anorexia and wt. loss
 Smoking
 Occupational expose
Complications
Local
 Recurrent laryngeal N. palsy
 Phrenic N. palsy
 SVCO
 Horner’s (Pancoast’s tumour)
 AF
Paraneoplastic
 Endo
+
 ADH → SIADH (euvolaemic ↓Na )
 ACTH → Cushing’s syndrome
 Serotonin → carcinoid (flushing, diarrhoea)
 PTHrP → 1O HPT (↑Ca2+, bone pain) – SCC
 Rheum
 Dermatomyositis / polymyositis
 Neuro
 Cerebellar degeneration
 Peripheral neuropathy
 Derm
 Acanthosis nigricans
 Trousseau syndrome: thrombophlebitis migrans
Metastatic
 Pathological #
 Hepatic failure
 Confusion, fits, focal neuro
 Addison’s
© Alasdair Scott, 2012
2. Dx of Mass
 CXR
 Coin lesions
 Effusion
 Consolidation or collapse
 Hilar LNs
 Bony mets
 Contrast-enhanced volumetric CT thorax
3. Determine Cell Type
 Cytology
 Induced sputum
 US-guided pleurocentesis
 Histology
 Percutaneous FNA: adenocarcinoma
 Endoscopic transbronchial biopsy: SCC
4. Staging
 CT: neck, thorax, upper abdo ± brain
 PET
 Radionucleotide bone scan
 Thoracoscopy, mediastinoscopy + LN sampling
5. Pulmonary Function Tests
 Assess fitness for surgery
 Pneumonectomy CI if FEV1 <1.2L
Mx
General
 MDT
 Stop smoking
 Optimise nutrition and CV function
NSCLC
 Surgery
 Rx of choice if no metastatic spread
 Stage 1/2:~25%
 Wedge resection, lobectomy, pneumonectomy
 Curative Radio: if poor cardiorespiratory function
 Chemo: platinum-based + biologics
SCLC
 Usually disseminated @ presentation
 Some benefit c̄ chemo
Palliative Care
 Analgesia: opiates for pain and cough
 Radiotherapy: haemoptysis, bone or CNS mets
 SVCO: dex + radio or intravascular stent
 Persistent effusions: chemical pleurodesis
Prognosis
 NSCLC: 50% 5ys w/o spread; 10% c̄ spread
 SCLC: 1-1.5yrs median survival treated; 3mo untreated
26
Pneumonia
Examination
Viva
Peripheral Inspection
Hx





 Symptoms
 Fever, rigors, anorexia, malaise
 Cough + sputum ± haemoptysis
 Pleurisy
 Smoking
 Travel and contacts
 Immunosuppression: HIV, steroids
Ill looking
Febrile
↑RR, ↑HR, AF
Cough
Rusty sputum
Chest: Consolidation
 ↓ expansion
 PN: dull
 Auscultation
 Bronchial breathing
 ↓ AE
 Focal coarse crackles
 Pleural rub
 ↑VR
Extras
 Para-pneumonic effusion
 Erythema multiforme: mycoplasma
Differential
 Collapse
 Effusion
Ix
Bedside
 Sputum MC+S, cytology
 Urine
 Pneumococcal Ag
 Hb: cold agglutinins → haemolysis
Bloods
 FBC: ↑ WCC
 U+E: dehydration, ↓Na
 CRP: trend
 LFT: ↑LFTs in mycoplasma, Legionella
 Culture: 25% positive
 Paired Sera: Mycoplasma, Chlamydia, Legionella
 ABG
CXR
 Consolidation c̄ air bronchogram
 Effusion
 Cavities: esp. S. aureus
Other
 Pleurocentesis
 BAL
Mx
 Assess severity and Mx accordingly
Specific
 Abx
 Analgesia
Supportive
 Oxygen
 Fluids
 Chest physio
Complications
 Septic shock + MOF: ITU
 Para-pneumonic effusion or empyema: drainage
 Respiratory failure: ventilation
 Abscess: drainage
f/up
 CXR @ 6 wks
 Check for underlying Ca and resolution
 Smoking cessation
 Pneumovax (23 valent)
 ≥65yrs
 Chronic HLRP failure or conditions
 Immunosupp: DM, hyposplenism, chemo, HIV
 Re-vaccinate every 6yrs
© Alasdair Scott, 2012
27
Pneumonia: Key Facts
Epidemiology
 Incidence: 1/100
 Mortality: 10% in hospital, 30% in ITU
Anatomic Classification
Bronchopneumonia
 Patchy consolidation of different lobes
Lobar Pneumonia
 Fibrosuppurative consolidation of a single lobe
 Congestion → red → grey → resolution
Severity: CURB-65 (only if x-ray changes)





Confusion (AMT ≤8)
Urea >7mM
Resp. rate >30/min
BP <90/60
≥65
Score
 0-1 → home Rx
 2 → hospital Rx
 ≥ 3 → consider ITU
Other Markers of Severity
 WCC: <4 or >12
 Temp: >38 or <32
 PaO2: <8KPa
 AF
 Multiple lobar involvement
Complications




Septic shock and MOF
Para-pneumonic effusion / empyema
Abscess: S. aureus, Klebsiella, anaerobes
Respiratory failure
SIRS
Aetiological Classification
Community Acquired Pneumonia
 Commonest organisms
 Pneumococcus: 50%
 Mycoplasma: 6%
 Haemophilus: esp. if COPD
 Chlamydia pneumonia
 Viruses: 15%
 Other organisms
 S. aureus
 Moraxella
 Legionella
 Rx: amoxicillin + clarithromycin
Hospital Acquired Pneumonia
 >48hrs after hospital admission
 Common organisms
 Pseudomonas
 MRSA
 Gm-ve enterobacteria
 Rx: co-amoxiclav or tazocin ± vanc
Inflam response to a variety of insults manifest by ≥ 2 of:
 Temperature: >38°C or <36°C
 Heart rate: >90
 Respiratory rate: >20 or PaCO2 <4.6 KPa
 WCC: >12x109/L or <4 x109/L or >10% bands
Sepsis
 SIRS caused by infection
Severe Sepsis
 Sepsis c̄ at least 1 organ dysfunction or hypoperfusion
Septic Shock
 Severe sepsis with refractory hypotension
MODS
 Impairment of ≥2 organ systems
 Homeostasis cannot be maintained without therapeutic
intervention.
Aspiration
 ↑ Risk: stroke, bulbar palsy, ↓GCS, GORD, achalasia
 Typically posterior segment of RLL
 Orgnaisms: anaerobes
 Rx: co-amoxiclav
Immunocompromised
 PCP: co-trimoxazole
 TB: RIPE
 Fungi: amphotercin
 CMV/HSV: ganciclovir
Atypical Pneumonia
 Refers to organisms which cause atypical generalised
symptoms and bronchopneumonia
 Fever, headaches, myalgia
 Poor correlation between clinical and x-ray findings
 Often intracellular: mycoplasma, Chlamydia, Legionella
© Alasdair Scott, 2012
28
Old TB
Examination
TB: Key Facts
Chest
Pathophysiology
Inspection
 Asymmetry: absent ribs
 Scars
 Thoracoplasty
 Supraclavicular fossa: phrenic nerve crush
Primary TB
 Childhood or naïve TB infection
 Organism multiplies @ pleural surface → Ghon Focus
 Macros take TB to LNs
 Nodes + lung lesion = Ghon complex
 Mostly asympto: may → fever and effusion
 Cell mediated immunity / DTH controls infection in 95%
 Fibrosis of Ghon complex → calcified nodule
(Ranke complex)
O
 Rarely may → 1 progressive TB (immunocomp)
Palpation
 Tracheal deviation towards apical fibrosis
 ↓ expansion
PN: dull
Auscultation
 ± bronchial breathing
 ↓ AE
 Crackles
 ↑VR
Viva
Past Mx of TB
 It was believed that lower PAO2 would inhibit TB
proliferation.
  inducing apical collapse was a treatment
Techniques
 Plombage: insertion of polystyrene balls into thoracic
cavity
 Phrenic nerve crush: diaphragm paralysis
 Thoracoplasty: rib removal to collapse lung
 Apical lobectomy
Complications of Old TB
 Aspergilloma in old TB cavity
 Bronchiectasis
 LN compression of large airways
 Traction from fibrosis
 Scarring predisposed to bronchial Ca
Current Mx of TB
Initial Phase (RHZE): 2mos
 RMP: hepatitis, orange urine, enzyme induction
 INH: peripheral sensory neuropathy, ↓PMN
 PZA: hepatitis, arthralgia (CI: gout, porphyria)
 EMB: optic neuritis → loss of colour vision first
Continuation Phase (RH): 4mos
 RMP
 INH
Primary Progressive TB
 Resembles acute bacterial pneumonia
 Mid and lower zone consolidation, effusions, hilar LNs
 Lymphohaematogenous spread → extra-pulmonary and
milliary TB
Latent TB
 Infected but no clinical or x-ray signs of active TB
 Non-infectious
 May persist for years
 Weakened host resistance → reactivation
Secondary TB
 Usually reactivation of latent TB due to ↓ host immunity
 May be due to reinfection
 Typically develops in the upper lobes
 Hypersensitivity → tissue destruction → cavitation and
formation of caseating granulomas.
Dx
Latent TB
 Tuberculin Skin Test
 If +ve → IGRA
Active TB
 CXR
 Mainly upper lobes.
 Consolidation, cavitation, fibrosis, calcification
 If suggestive CXR take ≥3 sputum samples (one AM)
 May use BAL if can’t induce sputum
 Microscopy for AFB: Ziehl-Neelsen stain
 Culture: Lowenstein-Jensen media (Gold stand)
PCR
 Can Dx rifampicin resistance
 May be used for sterile specimens
Tuberculin Skin Test
 Intradermal injection of purified protein derivative
 Induration measured @ 48-72h
 False +ve: BCG, other mycobacteria, prev exposure
 False –ve: HIV, sarcoid, lymphoma
Interferon Gamma Release Assays (IGRAs)
 Pt. lymphocytes incubated c̄ M. tb specific antigens →
IFN-γ production if previous exposure.
 Will not be positive if just BCG (uses M. bovis)
 E.g. Quantiferon Gold and T-spot-TB
© Alasdair Scott, 2012
29
The Medical Abdomen
Contents
Chronic Liver Disease .............................................................................................................................................................. 31
CLD: Key Facts ........................................................................................................................................................................ 32
Ascites ..................................................................................................................................................................................... 33
Medical Jaundice ..................................................................................................................................................................... 34
Liver Transplant ....................................................................................................................................................................... 35
Hepatomegaly .......................................................................................................................................................................... 36
Splenomegaly .......................................................................................................................................................................... 37
Myloproliferative Disorders ...................................................................................................................................................... 38
Spleen and Splenectomy ......................................................................................................................................................... 38
Enlarged Kidneys ..................................................................................................................................................................... 39
Cystic Renal Disease ............................................................................................................................................................... 40
RCC / Hypernephroma ............................................................................................................................................................ 40
Renal Transplant...................................................................................................................................................................... 41
Renal Transplant: Key Facts ................................................................................................................................................... 42
Renal Replacement Therapy ................................................................................................................................................... 43
Renal Access ........................................................................................................................................................................... 44
CRF: Key Facts........................................................................................................................................................................ 45
CRF: Specific Causes .............................................................................................................................................................. 46
Inflammatory Bowel Disease ................................................................................................................................................... 47
IBD: Key Facts for Medicine .................................................................................................................................................... 48
© Alasdair Scott, 2012
30
Chronic Liver Disease
Examination
Viva
Peripheral Inspection
Hx
General
 Jaundice
 Ascites
 Cachexia
 Tattoos and track marks
 Pigmentation
Hands
 Clubbing (esp. in PBC)
 Leukonychia
 Terry’s nails (white proximally, red distally)
 Palmer erythema
 Dupuytren’s contracture
Face




Pallor: ACD
Xanthelasma: PBC
Keiser-Fleischer rings
Parotid enlargement (esp. c̄ EtOH)
Trunk
 Spider naevi
 Gynaecomastia
O
 Loss of 2 sexual hair
Ankles
 Peripheral oedema
Abdomen
Inspection
 Distension ± Para- / umbilical hernia
 Dilated veins
 Drain scars
Palpation
 ± hepatomegaly
 ± splenomegaly
 Shifting dullness
Significant Negatives
 Evidence of decompensation
 Jaundice
 Encephalopathy: asterixis, confusion
 Foetor hepaticus: ammonia and ketones
 Hypoalbuminaemia: oedema and ascites
 Coagulopathy: bruising
 Evidence of SBP: esp. if ascites
 Cause: xanthelasma, pigmentation, KF rings, tattoos
CLD Differential
 Common
 EtOH
 Viral
 NASH
 Rarer
 Genetic: HH
 AI: AH
 Drugs: methotrexate
© Alasdair Scott, 2012
 Cause
 EtOH
 Sexual Hx, IVDU, transfusions
 FH
 Other AI disease: e.g. DM, thyroid
 DH
Ix
Initial Workup
 Urine: dip ± MC+S (? UTI)
 Bloods: FBC, U+E, LFTs, INR, glucose
 Ascitic tap: chemistry, cytology, MC+S, SAAG
 PMN >250mm3 indicates SBP
 US + PV duplex
 Liver size and texture
 Focal lesions
 Ascites
 Portal vein flow
Liver Screen
 EtOH: MCV, GGT, AST:ALT >2
 Viral: Hep B and C serology
 NASH: lipids
 AutoAbs: SMA, AMA, pANCA, ANA
 Ig: ↑IgG – AIH, ↑IgM – PBC
 Genetic: caeruloplasmin, Ferritin, α1-AT
 Ca: AFP, Ca 19-9
Other
 Liver biopsy
 MRCP: PSC
Rx
General
 MDT: GP, hepatologist, dietician, palliative care, family
 EtOH abstinence
 Good nutrition
 Cholestyramine for pruritus
 Screening
 HCC: US + AFP
 Varices: OGD
Specific
 HCV: interferon-α + ribavarin
 PBC: ursodeoxycholic acid
 Wilson’s: penicillamine
 HH: venesection, desferrioxamine
Complications
 Varices: β-B, banding
 Ascites: fluid and salt restrict, spiro, fruse, tap, daily wt
 Coagulopathy: Vit K, FFP, platelets
 Encephalopathy: avoid sedatives, lactulose, rifaximin
 Sepsis / SBP: tazocin or cefotaxime
 Avoid gent: nephrotoxicity
 Hypoglycaemia: dextrose
 Hepatorenal syndrome: IV albumin + terlipressin
31
CLD: Key Facts
Causes
 Common
 Chronic EtOH
 Chronic HCV (and HBV)
 NAFLD / NASH
 Other
 Congenital: HH, Wilson’s, α1ATD, CF
 AI: AH, PBC, PSC
 Drugs: Methotrexate, amiodarone, isoniazid
 Neoplasm: HCC, mets
 Vasc: Budd-Chiari, RHF, constrict. pericarditis
Complications
1.
2.
3.
4.
Liver failure / decompensation
SBP
Portal HTN: SAVE
HCC
Child-Pugh Grading of Cirrhosis
 Evaluates prognosis in Cirrhosis
 Graded A-C using severity of 5 factors
 Albumin
 Bilirubin
 Clotting
 Distension: ascites
 Encephalopathy
Score
A: 5-6
B: 7-9
C: 10-15
1yr Mortality
0
20
50
Tx Mortality
10
30
80
Decompensation
Precipitants → HEPATICS
 Haemorrhage: e.g. varices
 Electrolytes: ↓K, ↓Na
 Poisons: diuretics, sedatives, anaesthetics
 Alcohol
 Tumour: HCC
 Infection: SBP, pneumonia, UTI, HDV
 Constipation (commonest cause)
 Sugar (glucose) ↓: e.g. low calorie diet
General Mx
 HDU or ITU
 Rx any precipitant
 Good nutrition: e.g. via NGT c̄ high carbs
 Thiamine supplements
 Prophylactic PPIs vs. stress ulcers
Monitoring
 Fluids: urinary and central venous catheters
 Bloods: daily FBC, U+E, LFT, INR
 Glucose: 1-4hrly + 10% dextrose IV 1L/12h
Mx Complications
 Ascites: daily wt, fluid and Na restrict, diuretics, tap
 Coagulopathy: Vit K, FFP, platelets
 Encephalopathy: avoid sedatives, lactulose, rifaximin
 Sepsis / SBP: tazocin or cefotaxime
 Hypoglycaemia: dextrose
 Hepatorenal syndrome: IV albumin + terlipressin
© Alasdair Scott, 2012
Encephalopathy
Pathophysiology
 ↓ hepatic metabolic function
 Diversion of toxins from liver directly into systemic
system.
 Ammonia accumulates and pass to brain where
astrocytes clear it causing glutamate → glutamine
 ↑ glutamine → osmotic imbalance → cerebral oedema.
Presentation
 Asterixis, Ataxia
 Confusion
 Dysarthria
 Constructional apraxia
 Seizures
Ix: ↑ plasma NH4
Rx




Nurse in well lit, calm environment
Correct any precipitants
Avoid sedatives
Lactulose
 ↓ nitrogen-forming bowel bacteria
 2-4 soft stools/d
 Rifaximin PO: kill intestinal microflora
Hepatorenal Syndrome
 Renal failure in pts. c̄ advanced CLF
Pathophysiology: “Underfill theory”
 Cirrhosis → splanchnic arterial vasodilatation → effective
circulatory volume → RAS activation → renal arterial
vasoconstriction.
 Persistent underfilling of renal circulation → failure
Classification
 Type 1: rapidly progressive deterioration (survival <2wks)
 Type 2: steady deterioration (survival ~6mo)
Rx
 IV albumin + terlipressin
 Haemodialysis as supportive Rx
 Liver Tx is Rx of choice
SBP
Presentation
 Pt. c̄ ascites and peritonitic abdomen
 Complicated by hepatorenal syn. in 30%
Common organisms: E. coli, Klebsiella, Streps
Ix: ascites PMN >250mm3 + MC+S
Rx: Tazocin or cefotaxime until sensitivities known
Prophylaxis: high recurrence  cipro long-term
Poor Prognosis




Worsening encephalopathy
↑ age
↓ albumin
↑ INR
32
Ascites
Examination
Viva
Peripheral Inspection
Hx
Cause
 Signs of CLD
 CCF: ↑ JVP, bibasal creps, peripheral oedema
 Nephrotic: periorbital oedema
 Budd Chiari: abdo pain, hepatomegaly, jaundice
Ix
Abdomen
 Shifting dullness
 Portal HTN: splenomegaly
Completion
 CVS and Resp for CCF
 Urine dip: proteinuria in nephrotic syndrome
Significant Negatives
 CLD
 Acute liver failure / decompensation
 Cause: ↑ JVP, periorbital oedema
Causes of Ascites
Commonest
 Cirrhosis
 CCF
 Carcinomatosis
Serum Ascites Albumin Gradient
 SAAG = Se albumin – Ascites Albumin
SAAG ≥1.1g/dL = Portal HTN (97% accuracy)
 Cirrhosis in 80%
SAAG <1.1g/dL
 Neoplasia: e.g. peritoneal mets or ovarian Ca
 Inflammation: pancreatitis
 Nephrotic syndrome
 Infection: TB peritonitis
Portal HTN
 Portal pressure >10mmHg (norm 5-10)
 80% cirrhosis in UK
Pre-hepatic
 Portal vein thrombosis
 PV, ET
 PNH
 Nephrotic syndrome
Hepatic
 Cirrhosis
Post-hepatic
 Cardiac: RHF, TR, constrictive pericarditis
 Budd-Chiari (hepatic vein thrombosis)
© Alasdair Scott, 2012
 SBP: fever, abdo pain
 Cause
 Liver disease
 Cardiac failure, MI
Bedside
 Urine: dip ± MC+S
 Exclude nephrotic syn.
 ? UTI
Bloods
 FBC
 U+E
 LFTs: esp. albumin
 INR
 Glucose
 Liver screen
Ascitic tap
 Chemistry
3
 Cytology: malignancy, PMN (>250/mm = SBP)
 Bacteriology: MC+S, Ziehl-Neelson Stain
 SAAG
US + PV duplex
 Liver size and texture
 Focal lesions
 Ascites
 Portal vein flow
Rx
General
 EtOH abstinence
 Daily wts: aim for ≤0.5kg/d reduction
 Fluid restrict: <1.5L/d
 Low Na diet: 40-100mmol/d
Diuretics
 Spironolactone
 Add frusemide if response poor
Therapeutic Paracentesis
 Temporary insertion of pig-tail drain or Bonnano catheter
 Indications
 Respiratory compromise
 Pain / discomfort
 Renal impairment
 Risks
 Severe hypovolaemia: replenish albumin
 SBP
Refractory Ascites
 TIPSS
 Transplant
SBP
 Rx: Tazocin or cefotaxime until sensitivities known
 Prophylaxis: high recurrence  cipro long-term
33
Medical Jaundice
Examination
Viva
Peripheral Examination
Hx
Cause
 CLD
 Pancreatic Ca: cachexia, Virchow’s node
 Haemolysis: pallor
Pre-hepatic
 Anaemia: tired, SOB, palpitations, ankle swelling
 FH: HS
 CTD: arthritis
Abdomen
Hepatic
 EtOH intake
 Foreign travel: Hep A
 Blood transfusions, IVDU, sex: Hep B and C
 Sore throat: EBV
 Drug Hx: OCP, Abx, neuroleptics, OTCs




Excoriations and pruritus
Splenomegaly
Hepatomegaly
Palpable gallbladder: Ca head of pancreas
Completion
 Urine dip: look for BR, urobilinogen and Hb
Significant Negatives
 Acute liver failure / decompensation
 CLD
 Organomegaly
Differential
Ix
 CLD: EtOH, viral, NAFLD
 Splenomegaly
 Haemolysis
 CLD ( → portal HTN)
 Viral hepatitis: e.g. EBV
 Hepatomegaly
 Hepatitis
 CLD
 No CLD or organomegaly
 Biliary obstruction
 Haemolysis
 Drugs: fluclox, OCP
 Gilberts
Urine Dip
Pre-hepatic
No BR (acholuric)
↑ urobilinogen
Hb
Haemosiderin
 Haemolysis
 CLD
 Gallstones
Hepatic
Un- / Conjugated
CLD
Hepatitis
- EtOH
- Viral
Drugs
- Paracetamol
- Statins
- Anti-TB
Post-hepatic
Conjugated
Gallstones
Ca Head Panc
LNs @ porta hepatis
- Ca
- TB
Post Hepatic
↑↑cBR
No urobilingoen
Imaging
 Abdo US + PV duplex
 MRCP, CT, MRI
Other
 Liver biopsy: check clotting first
Rx: Cause
Pre-hepatic
 Splenectomy
Other Causes
Pre-hepatic
Haemolysis
- PNH
- MAHA
- Malaria
- G6PD
Hepatic
↑cBR
↑ urobilinogen
Bloods
 FBC and film ± DAT: haemolysis
 U+E: hepatorenal syndrome
 LFTs
 Conjugated vs. unconjugated BR
 Hepatocellular dysfunction LFTs
 Cholestatic LFTs
 Clotting: ↑INR in CLD and Vit K deficiency
 Liver screen
Commonest Causes
Pre-hepatic
Unconjugated
Haemolysis
- AIHA
- HS
- SCD
Post-hepatic
 Dark urine, pale stools
 Itching
 Stones: RUQ pain or biliary colic
 Malignancy
 Wt. ↓ and ↓ appetite
 Change in bowel habit: esp. steatorrhoea
 Back pain
Hepatic
Congenital
AI
Ca: 1O, 2O
Vasc
↓ BR excretion
© Alasdair Scott, 2012
Post-hepatic
PBC
PSC
Cholangio Ca
Drugs
- OCP
- Augmentin, fluclox
Hepatic
 EtOH: abstinence + support
 Viral: supportive or anti-virals
 Drugs: avoid
Post-Hepatic
 PBC / PSC: ursodeoxycholic acid
 Stones / Ca: relieve obstruction
34
Liver Transplant
Examination
Viva
Peripheral Inspection
Hx
 Cause
 EtOH
 Sexual Hx, IVDU, transfusions
 FH
 Other AI disease: e.g. DM, thyroid
 DH
 Transplant
 Cadaveric or live segmental
 Any complications
 Current health
 Acute rejection: fever, graft pain
 Immunosuppression
 Infection: e.g. CMV pneumonitis
 Skin Ca
 DH
General
 Evidence of CLD
 Pigmentation: HH
 Tattoos and needle marks: Hep B/C
Immunosuppressant Stigmata
 Cushingoid
 Skin tumours: AKs, SCC (100x ↑ risk), BCC and MM
 Gingival hypertrophy: ciclosporin
Abdomen
 Mercedes-Benz scar
Significant Negatives
 Evidence of CLD or cause for Tx
 Evidence of immunosuppression
 Absence of features of liver failure = working Tx
Differential for Mercedes Benz Scar
 Hepatobiliary surgery
 Liver transplant
 Segmental resection
 Whipples’: pancreaticoduodenectomy
Ix
Bloods
 FBC: infection
 U+E: ciclosporin can → renal impairment
 LFTs: assess graft function
 Clotting
 Fasting glucose: tacrolimus and steroids → DM
 Drug levels: ciclosporin, tacrolimus
Other
 Liver biopsy: if rejection suspected
Top Causes for Liver Tx
 Cirrhosis
 Acute liver failure
 Hep A, B
 Paracetamol overdose
 Malignancy
Success of Liver Tx
 80% 1-yr survival
 70% 5-yr survival
Immunosuppression Regimen
 Tacrolimus / ciclosporin
 Azathioprine
 Prednisolone ± withdrawal @ 3mo
© Alasdair Scott, 2012
35
Hepatomegaly
Examination
Viva
Peripheral Inspection
Hx
Cause
 CLD
 EtOH: palmar erythema, Dupuytren’s
 HH: skin discolouration
 Ca: cachexia
 CCF: ↑ JVP, bibasal creps, ascites, peripheral oedema
 Haematological: pallor, bruising, purpura, LNs
Abdomen
Hepatomegaly
 Define fingerbreadths below costal margin at which liver
edge palpable.
 Moves inferiorly on inspiration
 Can’t get above it
 Dull PN
 Features to note
 Edge: smooth, craggy, nodular
 Tenderness
 Pulsatile
 Percuss above and below to confirm enlargement
 Auscultate for liver bruit
 HCC
Other
 Splenomegaly
 Inguinal nodes
 Ascites
Completion
 CVS and Resp: CCF
Significant Negatives
 Splenomegaly
 Acute liver failure / decompensation
 Cause: CLD, ↑JVP, pallor, bruising, LNs
Common Causes
 Hepatitis: EtOH, viral, NAFLD
 CLD
 Congestion 2O to cardiac failure
Other Causes: MACHO





Malignancy: 2O
Anatomical: Riedel’s lobe, hyperexpanded chest
Congestion: TR, Budd Chiari
Haem: leukaemia, lymphoma, myeloproliferative, SCD
Other: sarcoidosis, amyloidosis, Gaucher’s, ADPKD
© Alasdair Scott, 2012
 Hepatitis / CLD: EtOH, viral exposure, FH
 Cardiac: dyspnoea, PND, previous MI, rheumatic fever
 Haem: tiredness, bruising, infections, bone pain
Ix
Urine dip
 BR, urobilinogen
 Proteinuria: amyloid
Bloods
 FBC
 ↓Hb: malignancy, chronic disease
 Lymphocytosis: hepatitis viruses, EBV (atypical)
 U+E: CCF → renal impairment
 LFT
 Clotting
 Liver screen
Imaging
 Abdo US + PV and hepatic duplex
 Liver size and texture
 Focal lesions
 Ascites
 Portal vein flow
 Hepatic veins: thrombosis
 CT: e.g. for tumour
 MRI: good quality images of liver parenchyma
Liver Biopsy
 Check clotting first
 Nodular Pattern
 Micronodular: EtOH, HH, Wilson’s
 Macronodular: viral
 Iron: Pearl’s stain
 Copper: Rhodamine stain
 α1ATD: PAS stain (α1AT globules accumulate in liver)
 Amyloid: apple-green birefringence c̄ Congo Red
 Granulomata: PBC
Rx: Cause






EtOH: abstinence + support
Viral: supportive or anti-viral therapy
HH: venesection ± desferrioxamine
Wilson’s: penicillamine
CCF: ACEi, β-B and diuretics
Haematological: monitoring or chemo
36
Splenomegaly
Examination
Viva
Peripheral Inspection
Hx
Palpation
 Splenomegaly
 Can’t get above it
 Moves inferiorly toward RIF on respiration
 Notch
 Dull PN
 Not ballotable
 Size: big or small?
 Hepatomegaly?
 Inguinal nodes?
Film
 MF: leukoerythroblastic c̄ teardrop poikiolcytes
 CLL: smear cells
 Haemolysis: spherocytes, reticulocytosis
 Haem: tiredness, bruising, infections, bone pain
Cause
 CLD: EtOH, viral exposure, FH
 Haematological: pallor, bruising, purpura, LNs, cachexia
 Infections: fever, sore throat, jaundice, foreign travel
 Cervical, axilla, inguinal
 Inflammation: arthritis
 Portal HTN: CLD signs
 IE: splinter’s, clubbing
Haematological Ix
 Felty’s Syndrome: rheumatoid hands
FBC
Abdomen
 CML: ↑↑↑WBC – PMN, basophils, myelocytes
 MF: pancytopenia
Inspection
 CLL: lymphocytosis
 Asymmetry
 Haemolysis: ↓ Hb, ↑MCV, ↑RDW
Completion
 Cardio and Resp exam: IE and sarcoid
 Urine dip: haematuria (IE), proteinuria (amyloid)
Significant Negatives





Hepatomegaly
Haem: pallor, bruising, LNs
CLD
IE: splinters, clubbing
RA hands: Felty’s Syndrome
Other Bloods
 DAT
 U+E and urate: ↑ malignancy → uropathy
Imaging
 Abdo US
 CT chest and abdomen
 PET scan
Histology / Cytology
 LN biopsy
 BM aspirate or trephine biopsy (MF)
Genetic Analysis
 CML: Ph Chr, t(9:22)
 MF: Jak2+ in 50%
Infective Ix
Big Spleen: limited differential Dx




Myeloproliferative: CML, MF
Lymphoproliferative: CLL, lymphoma
Infiltrative: amyloidosis, Gaucher’s
Developing world: malaria, visceral leishmaniasis
Small Spleen: all causes of isolated splenomegaly
Common
 Haem: myelo- / lympho-prolif disorders, haemolysis
 Portal HTN: mostly 2O to cirrhosis
 Infection: EBV
Other
 Infection: herpes viruses, hepatitis virus, IE, malaria
 Inflammation: RA, SLE, Sjogren’s
 Rare: sarcoidosis, amyloidosis, Gaucher’s, CVID
Hepatosplenomegaly
 As for isolated splenomegaly except for inflammatory
causes
© Alasdair Scott, 2012
Urine Dip
 Haematuria: IE
Bloods
 FBC: lymphocytosis (may be atypical in EBV)
 U+E: renal impairment in IE
 Thick and thin films
Imaging
 Abdo US
 Echo: IE
Liver Ix
Bloods
 FBC
 LFT
 Clotting
 Liver screen
Imaging
 Abdo US + PV duplex
37
Myloproliferative Disorders
Spleen and Splenectomy
CML
Anatomy




 Clonal proliferation of myeloid cells
 15% of leukaemia
Symptoms





Hypermetabolism: wt. loss, fever, night sweats, lethargy
Massive HSM → abdo discomfort
Bruising / bleeding (platelet dysfunction)
Gout
Hyperviscosity
Function: part of the mononuclear phagocytic system




Phagocytosis of old RBCs, WBCs
Phagocytosis of opsonised bugs: esp. encapsulates
Antibody production
Sequestration of formed blood elements
 Platelets, lymphocytes and monocytes
 Haematopoiesis
Philadelphia Chromosome
 Reciprocal translocation: t(9;22)
 Formation of BCR-ABL fusion gene
 Constitutive tyrosine kinase activity
 Present in >80% of CML
 Discovered by Nowell and Hungerford in 1960
Ix
 ↑↑WBC
 PMN and basophils
 Myelocytes
 ± ↓Hb and ↓plat (accelerated or blast phase)
 ↑urate
 BM cytogenetic analysis: Ph+ve
Rx
 Imatinib: tyrosine kinase inhibitor
 → >90% haematological response
 80% 5ys
 Allogeneic SCT
 Indicated if blast crisis or TK-refractory
Primary Myelofibrosis
 Clonal proliferation of megakaryocytes → ↑ PDGF →
Myelofibrosis
 Extramedullary haematopoiesis: liver and spleen
Symptoms
Ix




Elderly
Massive HSM
Hypermetabolism: wt. loss, fever, night sweats
BM failure: anaemia, infections, bleeding




Film: leukoerythroblastic c̄ teardrop poikilocytes
Cytopenias
BM: dry tap (need trephine biopsy)
50% JAK2+ve
Rx
 Supportive: blood products
 Splenectomy
 Allogeneic BMT may be curative in younger pts.
Prognosis
 5yr median survival
© Alasdair Scott, 2012
Intraperitoneal structure lying in the LUQ
Measures 1x3x5 inches
Weighs ~7oz
Lies anterior to ribs 9-11
Hypersplenism
 Pancytopenia due to pooling and destruction w/i an
enlarged spleen.
 Anaemia, bruising, infections
 Sequestration crisis in SCD → hypovolaemic shock
Hyposplenism
Causes
 Splenectomy
 Coeliac disease
 IBD
 SCD
Film




Mx
↑ platelets transiently after splenectomy
Howell-Jolly bodies
Pappenheimer bodies
Target cells
 Immunisations
 Pneumovax
 HiB
 Men C
 Yrly flu
 Daily Abx: Pen V or erythromycin
 Warning: Alert Card and/or Bracelet
Splenectomy
Indications
 Trauma
 Rupture: e.g. 2O to EBV
 AIHA
 ITP
 HS
 Hypersplenism
Complications
 Redistributive thrombocytosis → early VTE
 Temporary post-op aspirin prophylaxis
 Gastric dilatation: transient ileus
 May disturb gastro-omental vessel ligatures
 Prophylactic NGT post-op
 Left lower lobe atelectasis
 Pancreatitis: tail shares blood supply c̄ spleen
 ↑ susceptibility to infections
 Encapsulates: haemophilus, pneumo, meningo
38
Enlarged Kidneys
Examination
Viva
Peripheral Inspection
Hx
 ADPKD: FH, loin pain, haematuria, headaches
 RCC: haematuria, loin pain
 Compensatory hypertrophy: previous infections, stones
Renal Impairment
 HTN
 Pallor
Renal Replacement Therapy
 AV fistula (or scar)
 Tunnelled dialysis lines (or scar)
 Tenchkhoff catheter (or scar)
Immunosuppressant Stigmata
 Cushingoid
 Skin tumours: AKs, SCC, BCC and MM
 Gingival hypertrophy: ciclosporin
Abdomen
Inspection
 Nephrectomy scar
 Rutherford Morrison scar
 Tenchkhoff catheter (or scar)
Palpation
 Palpable Kidney
 Flank mass
 Can get above it
 Ballotable
 Moves inferiorly c̄ respiration
 Resonant PN
 Hepatomegaly
 Renal Transplant
Auscultation
 Renal bruit
Completion
 External genitalia: hydrocele 2O to RCC
 Urine dip: proteinuria, haematuria
 CVS: mitral valve prolapse
Significant Negatives
 Unilateral enlargement
 Hepatomegaly
 Evidence of RRT or immunosuppression
Ix
Urine
 Dip: haematuria, proteinuria
 Cytology
Bloods
 FBC: ↓Hb 2O to ESRF
 U+E: ↓eGFR, electrolyte disturbance
 Bone profile: ↓Ca, ↑ PO4, ↑PTH
Imaging
 Abdo US
 Confirm renal enlargement
 Cysts
 Hydronephrosis
 Masses
 Liver enlargement
 CT/MRI
 MRA: Berry aneurysms
 CT abdo: esp. if RCC suspected
Other
 Genetic studies to look for mutation in
 PKD1 gene on Chr 16: 85%
 PKD2 gene on Chr 4: 15%
 Family screen
Mx of ADPKD
General
 ↑ water intake, ↓ Na, ↓ caffeine (may ↓ cyst formation)
 Monitor U+E and BP
 Genetic counselling
 50% chance of transmission
 10% are de novo mutations
 MRA screen for Berry aneurysms
Medical
 Rx HTN aggressively: <130/80 (ACEi best)
 Rx infections
Differential
Surgical: Nephrectomy
 Recurrent bleeds or infections
 Abdominal discomfort
Bilateral
 ADPKD
 Bilateral RCC (5%)
 Bilateral cysts: e.g. in VHL
 Amyloidosis
ESRF in 70% by 70yrs
 Mx complications: CRF HEALS
 Dialysis or transplant
Unilateral
 Simple renal cyst
 RCC
 Compensatory hypertrophy
 + contralateral nephrectomy: ADPKD
© Alasdair Scott, 2012
39
Cystic Renal Disease
RCC / Hypernephroma
ADPKD
Epidemiology
Epidemiology
 Prev: 1:1000
 5% of ESRF in UK
 Genetics
 PKD1 gene on Chr 16: 85%
 PKD2 gene on Chr 4: 15%
 Involve cell-cell interactions
Risk Factors
Presentation
 Age: 30-50s
 HTN
 Recurrent UTIs
 Loin pain: cyst haemorrhage or infection
 Haematuria
Pathology
Extra-Renal Involvement
 Hepatic cysts → hepatomegaly
 Intracranial Berry aneurysms → SAH
 MV Prolapse: mid-systolic click + late systolic murmur
Prognosis
 70% ESRF by 70yrs
 90% of renal cancers
 Age: 55yrs
 Sex: M>F=2:1





 Adenocarcinoma from proximal renal tubular epithelium
 Clear Cell (glycogen) subtype: 70-80%
Presentation




Presentation
 Perinatal
 Oligohydramnios: may → Potter sequence
 Clubbed feet, pulm. hypoplasia, cranial
abnormalities
 Bilateral abdominal masses
 HTN and CRF
Extra-Renal Involvement
 Congenital hepatic fibrosis → Portal HTN
Prognosis
 ESRF by 20yrs
 Need Tx
Simple Renal Cysts




Common: 1/3 of pts over 60yrs
May present as renal mass and haematuria
Contain fluid only: no solid elements
Main differential is RCC
50% incidental finding
Triad: Haematuria, loin pain, loin mass
Invasion of L renal vein → varicocele (1%)
Cannonball mets → SOB
Paraneoplastic Features





ARPKD
Epidemiology
 Prev: 1:40000
 Genetics: PKHD1 (fibrocystin) gene on Chr6
Smoking
Obesity
HTN
Dialysis: 15% of pts. develop RCC
4% heritable: e.g. VHL syndrome
EPO → polycythaemia
PTHrP → ↑ Ca
Renin → HTN
ACTH → Cushing’s syn.
Amyloidosis
Spread
 Direct: renal vein
 Lymph
 Haematogenous: bone, liver and lung
Ix
 Blood: polycythaemia, ESR, U+E, ALP, Ca
 Urine: dip, cytology
 Imaging
 CXR: cannonball mets
 US: mass
 IVU: filling defect
 CT/MRI
Mx
 Medical
 Reserved for pts. c̄ poor prognosis
 Temsirolimus (mTOR inhibitor)
 Surgical
 Radical nephrectomy
 Consider partial if small tumour or 1 kidney
 Prognosis: 45% 5ys
Dialysis Associated Renal Cysts
 Seen after prolonged dialysis
 2O to obstruction of renal tubules by oxalate crystals
 ↑ risk of RCC in cyst: 15% of pts on haemodialysis
Tuberous Sclerosis (Bourneville’s Disease)
 AD condition c̄ hamartomas in skin, brain, eye, kidney
 Skin: nasolabial adenoma sebaceum, ash-leaf
macules, peri-ungual fibromas
 Neuro: ↓IQ, epilepsy, astrocytoma
 Renal: cysts, angiomyolipomas
© Alasdair Scott, 2012
Von Hippel-Lindau




Autosomal Dominant
Renal and pancreatic cysts
Bilateral renal cell carcinoma
Haemangioblastomas
 Often in cerebellum → cerebellar signs
 Phaeochromocytoma
 Islet cell tumours
40
Renal Transplant
Examination
Viva
Peripheral Inspection
Hx
 Cause
 DM
 GN
 Transplant
 Cadaveric or live
 Any complications: e.g. urinary leaks, infection
 Current health
 Acute rejection: fever, graft pain
 Graft function: Cr levels, BP, urine output
 Immunosuppression
 Infection: e.g. CMV pneumonitis
 Skin Ca
 CV risk
 DH
Renal Impairment
 HTN
 Pallor
Renal Replacement Therapy
 AV fistula (or scar)
 Tunnelled dialysis scars
 Tenchkhoff catheter scars
Immunosuppressant Stigmata
 Cushingoid
 Skin tumours: AKs, SCC (100x ↑ risk), BCC and MM
 Gingival hypertrophy: ciclosporin
Cause
 DM
 Finger pricks from BM monitoring
 Insulin marks on abdomen, lipodystrophy
 Cystic Kidney Disease
 Nephrectomy scars or ballotable kidneys
 Connective Tissue Disease
 SLE, SS, RA
Abdomen
Inspect
 Rutherford Morrison Scar in RIF
 Nephrectomy scars
 Tenchkoff catheter scars
Palpate
 Smooth oval mass under scar
 Dull PN
 Can get below it
 Doesn’t move with respiration
Ix
Urine
 Dip: haematuria, proteinuria
 MC+S
Bloods
 FBC: infection
 U+E: eGFR – look @ trend
 LFTs: ciclosporin can → hepatic dysfunction
 Fasting glucose: tacrolimus is diabetogenic
 Drug levels: ciclosporin, tacrolimus
Other
 Renal biopsy: if rejection suspected
Discussion
 Renal failure: causes, Ix, Mx
 Renal replacement therapy
 Renal Tx: complications, immunosuppression
Auscultate
 Renal bruit over transplant
Completion
 Dipstick: haematuria and proteinuria
 Drug chart: any potentially nephrotoxic drug (e.g. ACEi)
 BP: HTN common post-Tx
Significant Negatives
 Evidence of immunosuppression
 Signs of a cause: DM and PKD
 Working Tx
 Renal replacement therapy not in use
 No pain over Tx site
Gum Hypertrophy Differential





Drugs: ciclosporin, phenytoin, nifedipine
Familial
AML
Scurvy
Pregnancy
© Alasdair Scott, 2012
41
Renal Transplant: Key Facts
Commonest Indications for Renal Tx




Diabetic nephropathy
GN
Polycystic Kidney Disease
Hypertensive nephropathy
Assessment





Virology: CMV, HIV, VZV, hepatitis
Co-morbidities: esp. CVD
ABO
anti-HLA Abs: may be acquired from blood transfusion
Haplotype
 Importance: HLA-DR > HLA-B > HLA-A
 2 alleles @ each locus → 6 possible mismatches
 ↓ mismatches → ↑ graft survival
 Pre-implantation cross-match
 Recipient serum vs. donor lymphocytes
Contraindications




Active infection
Cancer
Severe co-morbidity
Failed pre-implantation x-match
Complications
Post-op




Bleeding
Graft thrombosis
Infection
Urinary leaks
Rejection
Hyperacute rejection: minutes
 Path: ABO incompatibility
 Presentation: thrombosis and SIRS
Acute Rejection: <6mo
 Path: Cell-mediated response
 Presentation
 Fever and graft pain
 ↓ urine output
 ↑ Cr
 Rx: Responsive to immunosuppression
Chronic Rejection: >6mo
 Presentation: Gradual ↑ in Cr and proteinuria
 Path: Interstitial fibrosis + tubular atrophy
 Rx: supportive, not responsive to immunosuppression
Types of Graft
 Cadaveric: brainstem death c̄ CV support
 Non-heart beating donor: no active circulation
 Live-related
 Optimal surgical timing
 HLA-matched
 Improved graft survival
 Live unrelated
Immunosuppression
 Pre-op: campath / alemtuzumab (anti-CD52)
 Post-op
 Short-term: prednisolone
 Long-term: tacrolimus or ciclosporin
Drug Toxicity
Ciclosporin: calcineurin inhibitor (blocks IL2 production)
 Nephrotoxic: may contribute to chronic rejection
 Gingival hypertrophy
 Hypertrichosis
 Hepatic dysfunction
Tacrolimus: calcineurin inhibitor (blocks IL2 production)
 < nephrotoxicity cf. ciclosporin
 Diabetogenic
 Cardiomyopathy
 Neurotoxicity: e.g. peripheral neuropathy
Steroids → Cushing’s Syndrome
Prognosis
 t½ for cadaveric grafts: 15yrs
 t½ for HLA-identical live grafts: >20yrs
↓ immune Function
 ↑ risk of infection: CMV, PCP, fungi, warts
 ↑ risk of malignancy
 Skin: SCC, BCC, MM, Kaposi’s
O
 Post-Tx lymphoproliferative disease (2 EBV)
Cardiovascular Disease
 Hypertension
 Atheromatous vascular disease
 A leading cause of death
© Alasdair Scott, 2012
42
Renal Replacement Therapy
Indications
 Suggested to start when GFR<15ml/min + symptoms
 Psychological preparation necessary
 PD vs. HD depends on med, social and psych factors




20% annual mortality
Cardiovascular disease
Malnutrition
Infection
 uraemia → granulocyte dysfunction → ↑ sepsisrelated mortality
 Amyloidosis
 β2-microglobulin accumulation
 Carpal tunnel, arthralgia
 Renal cysts → RCC
Haemodialysis
Mechanism
Counter-current flow
 Blood flows on one side of semipermeable membrane
 Dialysate flows in the opposite direction on the other
side.
 Solute transfer by diffusion
Ultrafiltration
 Fluid removal by creation of –ve transmembrane
pressure by decreasing the hydrostatic pressure of the
dialysate.
 Use a Vas Cath
 Blood filtered across a highly permeable membrane by
hydrostatic pressure and water and solutes are removed
by convection.
 Ultrafiltrate is replaced by isotonic replacement.
Peritoneal Dialysis
Mechanism
 Dialysate introduced into peritoneal cavity by Tenchkhoff
catheter.
 Uraemic solutes diffuse into fluid across peritoneum
 Ultrafiltration: addition of osmotic agent (e.g. glucose)
 ~3L 4x /day c̄ ~4h dwell times
Types
 CAPD: fluid exchange during day c̄ long dwell @ night
 APD: fluid exchanged during night by machine c̄ long
dwell throughout day.
Advantages
 Simple to perform
 Requires less equipment
 Easier @ home or on holiday
 Less haemodynamic instability  useful if cardio disease
Disadvantages
st
 Disequilibration syndrome (usually only 1 dialysis)
 Rapid changes in plasma osmolarity → cerebral
oedema
 n/v, headache and ↓GCS
 Fluid balance: BP↓, pulmonary oedema
 Electrolyte imbalance
 Aluminium toxicity (in dialysate) → dementia
 Psychological factors
© Alasdair Scott, 2012
 Usually only used in ITU
 Takes longer cf. HD but there is less haemodynamic
instability.
Mechanism
General Dialysis Complications
Complications
Haemofiltration
 Inconvenience
 Body image
 Anorexia
Complications





Peritonitis
Exit site infection
Catheter malfunction
Obesity (glucose in dialysate)
Mechanical: hernias and back pain
43
Renal Access
AV Fistula
Tunnelled Cuffed Catheter
Examination
Tessio Lines
Inspection
 Swelling c̄ surgical scar over distal forearm or @ elbow
 Evidence of use: needle marks
 Evidence of infection
Palpation
 Check if painful
 Temperature
 Palpable thrill
Auscultate
 Audible bruit
 Two lines tunnelled under skin and entering IJV
Disadvantages
 May have ↑ recirculation cf. AVF
 Lower flow rates
 ↑ risk of infection and thrombosis
Complications
 Adverse events @ insertion: e.g. pneumothorax
 Line or tunnel infection
 Blockage
 Retraction
Significant Negatives
 Evidence of infection, stenosis, aneurysm
Viva
Definition
 Surgically created connection between artery and vein
 Radio-cephalic @ wrist = Cimino-Brescia
 Brachio-cephalic @ the elbow
 Venous limb (from machine) is proximal
 Side-to-side anastomosis c̄ ligation of the distal vein
Advantages
 High flow rates, low recirculation (<10%)
 Low infection rates
 Less chance of stenosis cf. grafts
Disadvantages
 Take ~6 weeks to arterialise
 Affect pts. body image
 Must take care: avoid shaving, don’t take BP/blood here
Complications
 Thrombosis and stenosis
 Infection
 Bleeding
 Aneurysm
Steal syndrome
 Distal tissue ischaemia
 Pallor, pain, ↓ pulses
 May → necrosis
 ↓ wrist:brachial pressure index
 Rx: banding (plication)
© Alasdair Scott, 2012
44
CRF: Key Facts
Complications: CRF HEALS
Features
 Kidney damage ≥3mo indicated by ↓ function
 Symptoms usually only occur by stage 4 (GFR<30)
 ESRF is stage 5 or need for RRT
Classification
Stage
1
2
3
4
5
GFR
>90
60-89
30-59
16-29
<15
Cardiovascular disease
Renal osteodystrophy
Fluid (oedema)
HTN
Electrolyte disturbances: K, H
Anaemia
Leg restlessness
Sensory neuropathy
Renal Osteodystrophy
Causes
Common
 DM
 HTN








Other
 RAS
 GN
 CTD: SLE, SS, RA
 Polycystic disease
 Drugs: e.g. analgesic nephropathy
O
 Pyelonephritis: usually 2 to VUR
 Myeloma and amyloidosis
Ix
Urine
 Dip: haematuria, proteinuria, glycosuria
 PCR
 Normal = <20mg/mM
 Nephrotic = >300mg/mM
 BJP: myeloma
Function
 FBC: ↓Hb
 U+E: ↓ eGFR
 Bone: ↓Ca, ↑PO4, ↑PTH, ↑ALP
Renal Screen
 DM: fasting glucose, HbA1c
 ESR
 Immune
 SLE: ANA, C3, C4
 Goodpasture’s: anti-GBM
 Vasculitis: ANCA
 Hepatitis: viral serology
 Se protein electrophoresis
Imaging
 CXR: pulmonary oedema
 Renal US
 Usually small (<9cm)
 May be large: polycystic, amyloid
 Bone X-rays: renal osteodystrophy (pseudofractures)
 CT KUB: e.g. cortical scarring from pyelonephritis
Renal biopsy: if cause unclear and size normal
 Histology subtype
 Amyloid: apple-green birefringence c̄ Congo Red
Features
 Osteoporosis: ↓ bone density
 Osteomalacia: ↓ mineralisation of osteoid (matrix)
 2O/3O HPT → osteitis fibrosa cystica
 Subperiosteal bone resorption
 Acral osteolysis: short stubby fingers
 Pepperpot skull
 Osteosclerosis of the spine → Rugger Jersey spine
 Sclerotic vertebral end plate c̄ lucent centre
 Extraskeletal calcification: e.g. band keratopathy
Mechanism
 ↓ 1α-hydroxylase → ↓ vit D activation → ↓Ca → ↑PTH
 Phosphate retention → ↓Ca and ↑PTH (directly)
 ↑PTH → activation of osteoclasts ± osteoblasts
 Also acidosis → bone resorption
General Mx
 Rx reversible causes
 Stop nephrotoxic drugs
 Na, K, fluid and PO4 restriction
Optimise CV Risk
 Smoking cessation, exercise
 Statin + antiplatelet
 Rx DM
Specific Mx
Hypertension
 Target <140/90 (<130/80 if DM)
 In DM kidney disease give ACEi/ARB (inc. if normal BP)
Oedema: frusemide
Bone Disease
 Phosphate binders: calcichew, sevelamer
 Vit D analogues: alfacalcidol (1 OH-Vit D3)
 Ca supplements
 Cinacalcet: Ca mimetic
Anaemia
 Exclude IDA and ACD
 EPO to raise Hb to 11g/dL (higher = thrombosis risk)
Restless Legs: clonazepam
© Alasdair Scott, 2012
45
CRF: Specific Causes
Diabetic Nephropathy
 Commonest cause of ESRF: >20%
 Advanced / ESRF occurs in 40% of T1 and T2 DM
Myeloma
Pathology
 Excess production of monoclonal Ab ± light chains
(excreted and detected in 60% as urinary BJP).
 Light chains block tubules and have direct toxic
effects → ATN.
 Myeloma also assoc. c̄ ↑↑Ca2+
Pathology
 Diabetic nephropathy describes conglomerate of lesions
occurring concurrently.
 Hyperglycaemia → hypertrophy and ROS production
 Hallmark is glomerulosclerosis and nephron loss
 Nephron loss → RAS activation → HTN
Presentation
 ARF / CRF
 Amyloidosis
Clinically
 Microalbuminuria
 30-300mg/d or albumin:creatinine >3mg/mM
 Strong independent RF for CV disease
 Progresses to proteinuria: albuminuria >300mg/d
 Usually coexists c̄ other micro- and macro-vasc disease
Screening
 T2DMs should be screened for microalbuminuria 6moly
Mx
 Good glycaemic control delays onset and progression
 UKPDS: UK Prospective Diabetes Study
 DCCT: Diabetes Control and Complications Trial
 Control HTN: BP target 130/80
 ACEi/ARB: even if normotensive
 Stop smoking
 Combined kidney pancreas Tx possible in selected pts
Rx
 Ensure fluid intake of 3L/d to prevent further
impairment
 Dialysis may be required in ARF
Renovascular Disease: RAS
Cause




Presentation





Rheumatological Disease
RA
 NSAIDs → ATN
 Penicillamine and gold → membranous GN
 AA amyloidosis occurs in 15%
SLE
 Involves glomerulus in 40-60% → ARF/CRF
Pathogenesis
 Immune complex deposition → T3 hypersensitivity
 Typically membranous GN
 Proteinuria and ↑BP
Rx
Atherosclerosis in 80%
Fibromuscular dysplasia
Thromboembolism
External mass compression
Ix
Refractory hypertension
Renal bruits
Worsening renal function after ACEi/ARB
Flash pulmonary oedema (no LV impairment on echo)
Other signs of PVD
 CT/MR angio
 Renal angiography
Rx
 Rx medical CV risk factors
 Angioplasty and stenting
 AVOID ACEi/ARB
 Proteinuria: ACEi
 Aggressive GN: immunosuppression
Diffuse Systemic Sclerosis
 Renal crisis: malignant HTN + ARF
 Commonest cause of death
 Rx: ACEi if ↑BP or renal crisis
© Alasdair Scott, 2012
46
Inflammatory Bowel Disease
Examination
Viva
Peripheral Inspection
Hx
 Symptoms
 Wt. loss, fever, malaise
 Abdominal pain
 Diarrhoea, blood and/or mucus PR
 Peri-anal disease: abscesses, fistulae
 Extra-intestinal: EN, arthritis, iritis, gallstones, PSC
 Therapy
 Admissions
 Medical therapy
 Operations
General
 Often young female pt.
 Laparotomy scars
 Malnutrition or wt. loss
 Cushingoid
 Pallor
Hands
 Clubbing
 Leukonychia
 Beau’s lines
Eyes
 Pale conjunctivae
 Iritis, episcleritis
Mouth
 Aphthous ulcers
 Gingival hypertrophy (ciclosporin)
Legs
 Erythema nodosum
 Pyoderma gangrenosum
Abdominal
Inspection
 Scars
 May be multiple and atypical in Crohn’s
 Healed stoma sites
 Healed drain sites
 Stomas or healed stoma sites
 Enterocutaneous fistulae
Palpation
 Tenderness
 RIF mass
 ± hepatomegaly
Completion
 Inspect perineum for perianal disease
 Examine for extra-intestinal features
 Large joint monoarthritis
 Sacroileitis
 Bronchiectasis
Differential




Ix
Bloods
 FBC: ↓Hb, ↑WCC
 U+E: dehydration, ↓K
 LFTs: ↓ albumin, deranged LFTs
 Clotting: ↑INR
 ↑ ESR, ↑ CRP: used to monitor activity
 Haematinics: Fe, B12, folate
Markers of Activity in CD
 ↓Hb, ↑ESR, ↑CRP, ↑WCC, ↓albumin
Stool
 Culture + CDT: exclude infective causes
 Campy, Yersinia, Shigella, C. diff, TB
Imaging
 AXR
 Toxic megacolon in UC
O
 Bowel obstruction 2 to strictures in Crohn’s
 Contrast studies
 Ba or Gastrograffin enema in UC
 Small bowel follow-through in Crohn’s
 MRI: perianal disease in Crohn’s
Endoscopy
 Ileocolonoscopy + regional biopsy
 Ix of choice
 Safe in acute disease
 Distinguish UC from Crohn’s
 Assess disease severity
 Wireless capsule endoscopy
Discussion





Clinicopathological distinction between UC and CD
Main complications of IBD
Extra-intestinal manifestations
Definition and Mx of severe exacerbation
Chronic Mx
Crohn’s
UC
Malabsorption: coeliac
Mid-line lap: FAP
© Alasdair Scott, 2012
47
IBD: Key Facts for Medicine
Pathology
Macroscopic
Location
Distribution
Strictures
Complications
UC
Crohn’s
UC
Crohn’s
Rectum + colon
± backwash ileitis
Contiguous
No
Mouth to anus
esp. terminal ileum
Skip lesions
Yes
Toxic megacolon
Haemorrhage
Malignancy
- CRC
- Cholangiocarcinoma
VTE
Fistulae
Perianal abscess
Strictures
Malabsorption
Microscopic
Inflammation
Ulceration
Mucosal
Shallow, broad
Fibrosis
Granulomas
Pseudoplyps
Fistulae
None
None
Marked
No
Transmural
Deep, thin, serpiginous
→ cobblestone mucosa
Marked
Present
Minimal
Yes
Toxic dilatation
Extra-Intestinal Features
Skin
 Clubbing
 Erythema nodosum
 PG (esp. UC)
Acute Severe Exacerbation
Mouth
 Aphthous ulcers
Dx: True-Love and Witts Criteria
Eyes
 Anterior uveitis
 Episcleritis
Joints
 Large joint arthritis
 Sacroileitis
Hepatic




Other
 AA amyloidosis
 Oxalate renal stones
 Symptoms
 BMs >6 x /d
 Large PR bleed
 Systemic Signs
 ↑ HR >90
 Pyrexia >37.8
 Laboratory Values
 ↓ Hb <10.5g/dL
 ESR >30mm/Hr
Mx
Fatty liver
Chronic hepatitis → cirrhosis
Gallstones (esp. CD)
PSC + cholangiocarcinoma (esp. UC)
General
 Resus: Admit, NBM, IV hydration
 Hydrocortisone: 100mg IV QDS + PR if rectal disease
 Thromboprophylaxis: LMWH
 Dietician review
Mx of Mild-Mod Disease
Monitoring
 Bloods: FBC, ESR, CRP, U+E
 Vitals + stool chart
 Daily examination
Induction
Crohn’s
 Abx: metronidazole PO or IV
 Consider parenteral nutrition
 Improvement: → oral pred (40mg/d)
 Refractory: methotrexate ± infliximab
UC
 Improvement: → oral pred + 5-ASA
 Refractory: ciclosporin or infliximab
Indications for Surgery
 Obstruction
 Megacolon
 Perforation
 Severe GI bleeding
 Failure to respond to medical therapy
© Alasdair Scott, 2012
MDT: GP, gastroenterologist, dietician, nurses, surgeon
Nutrition: ADEK vitamins, high fibre diet (esp. CD)
UC
CD
Oral
Oral
1: 5-ASAs
2: prednisolone
3: ciclosporin / infliximab
1: Ileocaecal: budesonide
1: Colitis: sulfasalazine
2: prednisolone (tapering)
3: methotrexate
4: infliximab / adalimumab
Topical: Enemas / foams
- 5-ASA
- Pred
Maintenance
UC
CD
1: 5-ASA
2: axathioprine
3: infliximab / adalimumab
1: azathioprine
2: methotrexate
3: infliximab / adalimumab
48
Neurology
Contents
Parkinson’s Disease ................................................................................................................................................................ 50
Parkinsonism: Key Facts ......................................................................................................................................................... 51
Cerebellar Syndrome ............................................................................................................................................................... 52
Cerebellar Syndrome: Key Causes ......................................................................................................................................... 53
UMN Signs ............................................................................................................................................................................... 54
Cord Disease ........................................................................................................................................................................... 55
Acute Stroke: Key Facts .......................................................................................................................................................... 56
Non-Acute Stroke: Key Facts .................................................................................................................................................. 57
Multiple Sclerosis ..................................................................................................................................................................... 58
Motor Neurone Disease ........................................................................................................................................................... 59
LMN Signs ............................................................................................................................................................................... 60
Peripheral Polyneuropathy ...................................................................................................................................................... 61
Diabetic Neuropathy ................................................................................................................................................................ 62
Charcot-Marie-Tooth Syndrome .............................................................................................................................................. 62
Myasthenia Gravis ................................................................................................................................................................... 63
GBS ......................................................................................................................................................................................... 63
Facial Nerve Palsy ................................................................................................................................................................... 64
Facial Nerve Palsy: Key Causes ............................................................................................................................................. 65
Facial Anaesthesia................................................................................................................................................................... 65
Abnormal Pupils ....................................................................................................................................................................... 66
Visual Fields............................................................................................................................................................................. 67
Ophthalmoplegia ...................................................................................................................................................................... 68
Hearing Loss ............................................................................................................................................................................ 69
Speech ..................................................................................................................................................................................... 70
© Alasdair Scott, 2012
49
Parkinson’s Disease
Examination
Viva
Inspection
Hx
 Asymmetrical resting tremor: 5Hz
 Exacerbated by counting backwards
 Hypomimia (↓ facial expression)
 Extrapyramidal posture
 Symptoms: tremor, rigidity, akinesia
 Autonomic
 Postural hypotension
 Urinary problems, constipation
 Hypersalivation
 ADLs
 Handwriting, buttons, shoe-laces
 Getting in and out of a car
 Sleep
 Turning in bed
 Insomnia
 Daytime sleepiness
 Complications
 Depression
 Drug SEs: esp. motor fluctuations
 Cause
 Sudden onset
 Eye or balance problems
 Visual hallucinations, ↓ memory
 DH
 FH
Arms
 Demonstrate bradykinesia
 Tone
 Cogwheel rigidity
 Enhanced by synkinesis
 Normal power and reflexes
 Coordination
 May be abnormal if MSA
Eyes
 Movements
 Nystagmus: MSA
 Vertical gaze palsy: PSP
 Saccades
 Slow initiation and movement
Extras
 Glabellar tap
 Gait
 Slow initiation
 Shuffling
 Hurrying: festination
 Absent arm swing
 Write sentence and draw spiral
 BP lying and standing
Completion
 Mini mental state examination
 Drug chart
 Abdominal examination: hepatomegaly + signs of CLD
Causes
 Idiopathic PD
 Parkinson Plus Syndromes
 Progressive supranuclear palsy
 MSA
 Lewy Body Dementia
 Corticobasilar degeneration
 Multiple infarcts in the substantia nigra
 Wilson’s disease
 Drugs: neuroleptics and metoclopramide
Ix
Bloods
 Caeruloplasmin: ↓ in Wilson’s
Imaging
 CT / MRI: exclude vascular cause
 DaTscan
 Ioflupane I123 injection
 Binds to dopaminergic neurones and allows
visualisation of substantial nigra
 Can exclude other causes of tremor: e.g. BET
Mx
General
 MDT: neurologist, PD nurse, physio, OT, social worker,
GP and carers
 Assess disability
 e.g. UPDRS: Unified Parkinson’s Disease Rating Scale
 Physiotherapy: postural exercises
 Depression screening
Specific
 L-DOPA + Carbidopa or benserazide
 Da agonists: ropinerole, pramipexole
 Apomorphine: SC rescue drug
 MOA-B inhibitors: rasagiline
 COMT inhibitors: tolcapone
 Amantidine
 Anti-muscarinics: procyclidine
Adjuncts
 Domperidone: nausea
 Quetiapine: psychosis
 Citalopram: depression
Other
 Deep brain stimulation
 Basal ganglia disruption
© Alasdair Scott, 2012
50
Parkinsonism: Key Facts
Idiopathic PD
Other Causes of Parkinsonism
Epidemiology
Multisystem Atrophy
 Mean onset 65yrs
 2% prevalence
Pathophysiology
 Destruction of dopaminergic neurones in pars
compacta of substantia nigra.
 β-amyloid plaques
 Neurofibrillary tangles: hyperphosphorlated tau
Features: TRAPPS PD
 Asymmetric onset: side of onset remains worst
Pathology
 Papp-Lantos Bodies: α-synuclein inclusions in glial cells
Features
 Autonomic dysfunction: postural hypotension
 Parkinsonism
 Cerebellar ataxia
If autonomic features predominate, may be referred to as Shy
Drager Syndrome
Progressive Supranuclear Palsy
 Tremor: ↑ by stress, ↓ by sleep
 Postural instability → falls
 Rigidity: lead-pipe, cog-wheel
 Vertical gaze palsy
 Akinesia: slow initiation, difficulty c̄ repetitive movement,
 Pseudobulbar palsy: speech and swallowing problems
micrographia, monotonous voice, mask-like face
 Parkinsonism
 Postural instability: stooped gait c̄ festination
 Symmetrical onset
 Postural hypotension: + other autonomic dysfunction
 Tremor is unusual
 Sleep disorders: insomnia, EDS, OSA, RBD
 Psychosis: esp. visual hallucinations
Corticobasilar Degeneration
 Depression / Dementia / Drug SEs
 Unilateral parkinsonism: esp. rigidity
 Aphasia
Sleep Disorder
 Astereognosis: cortical sensory loss
 Affects ~90% of PD pts.
 → Alien limb phenomenon: autonomous arm
 Insomnia + frequent waking → EDS
movements
 Inability to turn
 Restless legs
Lewy Body Dementia
 Early morning dystonia (drugs wearing off)
 Nocturia
Pathology
 OSA
 α-synuclein and ubitquitin Lewy Bodies in brainstem and
 REM Behavioural sleep Disorder
neocortex
 Loss of muscle atonia during REM sleep
 Violent enactment of dreams
Features
 Da SEs: insomnia, drowsiness, EDS
 Fluctuating cognition
 Visual hallucinations
Autonomic Dysfunction
 Parkinsonism
 Combined effects of drugs and neurodegeneration
 Postural hypotension
Vascular Parkinsonism
 Constipation
 Sudden onset
 Hypersalivation → dribbling (↓ ability to swallow saliva)
 Parkinsonism worse in legs than arms
 Urgency, frequency, nocturia
 Pyramidal signs
 ED
 Prominent gait abnormality
 Hyperhidrosis
L-DOPA SEs: DOPAMINE
 Dyskinesia
 On-Off phenomena = Motor fluctuations
 Psychosis
 ABP↓
 Mouth dryness
 Insomnia
 N/V
 EDS (excessive daytime sleepiness)
Motor Fluctuations
 End-of-dose: deterioration as dose wears off c̄
progressively shorter benefit.
 On-Off effect: unpredictable fluctuations in motor
performance unrelated to timing of dose.
© Alasdair Scott, 2012
Causes of Tremor
 Resting: parkinsonism
 Intention: cerebellar
 Postural
 Worse c̄ arms outstretched
 BET
 Endocrine: ↑T4
 Alcohol withdrawal
 Toxins: β-agonists
 Sympathetic: anxiety
Benign Essential Tremor
 AD
 Occur with movement and worse c̄ anxiety, caffeine
 Doesn’t occur c̄ sleep
 Better c̄ EtOH
51
Cerebellar Syndrome
Examination
Viva
Gait
Hx





Arms Outstretched
 Ataxia
 Rebound
DaNISh
 Dysdiadochokinesia: hands and feet
 Nystagmus + Rapid Saccades
 Saccades: overshoot
 Intention tremor and dysmetria
 Slurred speech
Completion










Walk
Heal-to-Toe
On tip toes
On heal
Romberg’s
Cranial nerves: brainstem stroke, MS, CPA lesion
Peripheral nervous system: MS
Signs of CLD
Drug chart: phenytoin
Causes: DAISIES





Demyelination
Alcohol
Infarct: brainstem stroke
SOL: e.g. schwannoma + other CPA tumours
Inherited: Wilson’s, Friedrich’s, Ataxia Telangiectasia,
VHL
 Epilepsy medications: phenytoin
 System atrophy, multiple
Neurophysiology
 Cerebellar signs are ipsilateral
 Bilateral cerebellar signs more likely to represent a
global pathology
 Alcohol
 MS
 Phenytoin
 Cerebellar vermis lesion
 Ataxic trunk and gait
 Normal arms
MS: paraesthesia, visual problems, muscle weakness
Alcohol consumption
Infarct: onset, stroke risk factors
Schwannoma: hearing loss, vertigo, tinnitus, ↑ICP
FH
DH
Ix
ECG
 Arrhythmia
Bloods
 EtOH: FBC, U+E, LFT
 Thrombophilia: clotting
 Wilson’s: ↓ caeruloplasmin
CSF
 Oligoclonal bands
Imaging
 MRI is best to visualise the posterior cranial fossa
Other
 CPA lesion: pure tone audiometry
Mx
General
 MDT: GP, neurologist, radiologist, neurosurgeon,
specialist nurses, physio, OT
 CV Risk
 ↓ EtOH
Specific
 MS: methylprednisolone
 EtOH: Pabrinex, tapering course of chlordiazepoxide
 Infarct: consider thrombolysis
 Schwannoma: gamma-knife, surgery
 Wilson’s: penicillamine
Nystagmus
 Cerebellar Cause
 Fast phase towards lesion
 Maximal looking towards lesion
 Vestibular Cause
 Fast phase away from lesion
 Maximal looking away from lesion
© Alasdair Scott, 2012
52
Cerebellar Syndrome: Key Causes
Lateral Medullary Syndrome / Wallenberg’s
Friedrich’s Ataxia
Cause
 Occlusion of vertebral artery or PICA
Pathophysiology
 Auto recessive mitochondrial disorder
 Progressive degeneration of
 Dorsal column
 Spinocerebellar tracts and cerebellar cells
 Corticospinal tracts
 Onset in teenage years
 Assoc. c̄ HOCM and mild dementia
Features
 Signs are ipsilateral apart from body anaesthesia to pain
Structure
Nucleus Ambiguus
- motor to CN 9/10
Inferior cerebellar peduncle
Vestibular nucleus
Spinothalamic tract
Spinal trigeminal nucleus
Sympathetic fibres
Symptom
Dysphagia
Ataxia
Nystagmus
Vertigo
↓ Pain: contralateral
↓ Pain: ipsilateral
Horner’s
DANVAH
 Dysphagia
 Ataxia
 Nystagmus
 Vertigo
 Anaesthesia: dissociated pain loss
 Horner’s syndrome
Vestibular Schwannoma
Pathophysiology
 Benign, slow-growing tumour of superior vestibular nerve
 SOL → CPA syndrome: 80% of CPA tumours
 Assoc. c̄ NF2
Presentation
 Unilat SNHL, tinnitus ± vertigo
 ↑ICP: headache
 Ipsilateral CN 5, 6, 7 and 8 palsies and cerebellar signs
 Facial anaesthesia + absent corneal reflex
 LR palsy
 LMN facial nerve palsy
 SNHL
 DANISH
Ix
Rx
 MRI of cerebellopontine angle
Main Features
 Pes cavus
 Bilateral cerebellar ataxia
 Leg wasting + areflexia but extensor plantars
 Loss of vibration and proprioception
Additional Features
 High-arched palate
 Optic atrophy and retinitis pigmentosa
th
 HOCM: ESM + 4 heart sound
 DM in 10%: dip the urine
Ataxia Telangiectasia
 Autosomal recessive
 Defect in DNA repair
 Onset in childhood / early adult
Features
 Progressive ataxia
 Telangiectasia: conjunctivae, eyes, nose, skin creases
 Defective cell-mediated immunity and Ab production
 Infections
 Lymphoproliferative disease
Wilson’s
 AR mutation of ATP7B gene on Chr13
Features: CLANK
 Cornea: Keiser-Fleischer rings
 Liver: CLD
 Arthritis
 Neuro: parkinsonism, ataxia, psychiatric problems
 Kidney: Fanconi’s syn
 Gamma-knife
 Surgery
CPA Tumour Differential




Vestibular Schwannoma
Meningioma
Cerebellar astrocytoma
Metastases
Von Hippel-Lindau
 Renal cysts
 Bilateral renal cell carcinoma
 Haemangioblastomas
 Often in cerebellum → cerebellar signs
 Phaeochromocytoma
 Islet cell tumours
© Alasdair Scott, 2012
53
UMN Signs
Examination
Viva
Inspection
Hx
 Walking aids
 May have disuse atrophy and contractures
 Limb position
 Leg: extended, internally rotated c̄ foot plantar flexed
 Arm: flexed, internally rotated, supinated
Gait
 Unilateral → circumducting
 Bilateral → scissoring
UMN Signs
 ↑ tone
 Pyramidal distribution of weakness
 Leg: extensors stronger than flexors
 Arm: flexors stronger than extensors
 Hyper-reflexia
 Extensor plantars
Sensation
 Examine for sensory level: suggests cord lesion
Completion
 CN: evidence of MS
 Cerebellum: evidence of MS




MS: tingling, eye problems, ataxia, other weakness
Cord compression: back pain, fever, wt. loss
Trauma
FH
Ix
MRI
 Cord and brain
Further Ix Depend on Cause
 MS
 LP: oligoclonal bands
 Abs: MBP, NMO
 Evoked potentials
 Compression
 FBC: infection
 CXR: malignancy
 DRE
 SCDC
 B12 level
 Pernicious anaemia Abs: IF, parietal cell
Mx
Bilateral LL: Spastic Paraparesis
Common
 MS
 Cord compression
 Cord Trauma
 CP
Supportive
 MDT: GP, neurologist, radiologist, neurosurgeon,
specialist nurses, physio, OT
 Orthoses
 Mobility aids
 Urinary: ICSC
 Contractures: baclofen, botulinum injection, physio
Other
 Familial spastic paraparesis
 Vascular: e.g. aortic dissection → Beck’s syndrome
 Infection: HTLV-1
 Tumour: ependymoma
 Syringomyelia
Mixed UMN and LMN Features
 MND
 Ataxia, Friedrich’s
 SCDC: B12
 Taboparesis
Unilateral LL
Hemisphere → Spastic Hemiparesis
 Stroke
 MS
 SOL
 CP
Hemicord → Spastic Hemiparesis or Monoparesis
 MS
 Cord Compression
© Alasdair Scott, 2012
54
Cord Disease
Cord Compression
Syringomyelia
Key Features
Characteristics
 Syrinx: tubular cavity in central canal of the cord.
 Symptoms may be static for yrs but then worsen fast
 e.g. on coughing, sneezing as ↑ pressure →
extension
 Commonly located in cervical cord
 Syrinx expands ventrally affecting:
 Decussating spinothalamic neurones
 Anterior horn cells
 Corticospinal tracts
 Pain
 Local, deep
 Radicular
 Weakness
 LMN @ level
 UMN below level
 Sensory level
 Sphincter disturbance
Causes




Ix
Trauma: vertebral #
Infection: epidural abscess, TB
Malignancy: breast, thyroid, bronchus, kidney, prostate
Disc prolapse: above L1/2
 MRI is definitive modality
 CXR for primaries
Causes
 Blocked CSF circulation c̄ ↓ flow from posterior fossa
 Arnold-Chiari malformation (cerebellum herniates
through foramen magnum)
 Masses
 Spina bifida
 2O to cord trauma, myelitis, cord tumours and AVMs
Cardinal Signs
1. Dissociated Sensory Loss
 Loss of pain and temperature → scars from burns
 Preserved touch, proprioception and vibration.
 Root distribution reflects syrinx location
 Usually upper limbs and chest: “cape”
2. Wasting/weakness of hands ± Claw hand
3. Loss of reflexes in upper limb
4. Charcot joints: shoulder and elbow
Rx
 This is a neurosurgical emergency
 Malignancy
 Dexamethasone IV
 Consider chemo, radio and decompressive
laminectomy
 Abscess: abx and surgical decompression
Cauda Equina Lesions
 Pain
 Back pain
 Radicular pain down legs
 Weakness
 Bilateral flaccid, areflexic lower limb weakness
 Sensation
 Saddle anaesthesia
 Sphincters
 Incontinence / retention of faeces / urine
 Poor anal tone
Causes and Mx as above
Anterior Spinal Artery / Beck’s Syndrome
 Infarction of spinal cord in distribution of anterior spinal
artery: ventral 2/3 of cord.
 Causes: Aortic aneurysm dissection or repair
 Effects
 Para- / quadri-paresis
 Impaired pain and temperature sensation
 Preserved touch and proprioception
© Alasdair Scott, 2012
Other Signs




Ix
UMN weakness in lower limbs c̄ extensor plantars
Horner’s syndrome
Syringobulbia: cerebellar and lower CN signs
Kyphoscoliosis
 MRI spine
Surgery
 Decompression at the foramen magnum for Chiari mal
Human T-lymphotropic Virus-1
 Retrovirus
 ↑ prevalence in Japan and Caribbean
Features
 Adult T cell leukaemia / lymphoma
 Tropical spastic paraplegia / HTLV myelopathy
 Slowly progressing spastic paraplegia
 Sensory loss and paraesthesia
 Bladder dysfunction
55
Acute Stroke: Key Facts
Definition
 Rapid onset focal neurological deficit of vascular origin
lasting >24hrs.
Pathogenesis
 Ischaemic: 80%
 Atheroma: large or small vessel
 Embolism: cardiac or atherothromboembolism
 Haemorrhagic: 20%
Clinical Features: Bamford Classification
TACS: carotid / MCA and ACA territory
 Hemiparesis and/or hemisensory deficit
 Homonymous hemianopia
 Higher cortical dysfunction
 Dominant: aphasia
 Non-dominant: neglect, apraxia
PACS: carotid / MCA and ACA territory
 2/3 of TACS criteria, usually
 Homonymous hemianopia
 Higher cortical dysfunction
Acute Management
Resuscitate
 Ensure patent airway: consider NGT
 NBM until swallowing assessed by SALT
 Don’t overhydrate: risk of cerebral oedema
 BM: exclude hypoglycaemia
Monitor
 Glucose: 4-11mM: sliding scale if DM
 BP: Rx of HTN can → ↓ cerebral perfusion
 Neuro obs
Bloods
 FBC: infection (sepsis may → stroke)
 U+E: electrolyte disturbances may mimic stroke
 Glucose: exclude hypoglycaemia
 Clotting: ↑ or ↓ INR may indicate cause
Imaging
 Urgent CT/MRI
 Diffusion-weighted MRI is most sensitive for acute infarct
 CT will exclude primary haemorrhage
Medical
 Consider thrombolysis if 18-80yrs and <4.5hrs since
POCS: vertebrobasilar territory
onset of symptoms
 Any of
 Alteplase (rh-tPA)
 Cerebellar syndrome
 → ↓ death and dependency (OR 0.64)
 Brainstem syndrome
 CT 24h post-thrombolysis to look for haemorrhage
 Homonymous hemianopia
 Aspirin 300mg PO/PR once haemorrhagic stroke
excluded ± PPI
LACS: infarct around basal ganglia, internal capsule, thalamus
 Clopidogrel if aspirin sensitive
and pons
 Pure motor: post. limb of internal capsule
Surgery
 Pure sensory: post. thalamus (VPL)
 Neurosurgical opinion if intracranial haemorrhage
 Mixed sensorimotor: internal capsule
 May coil bleeding aneurysms
 Dysarthria / clumsy hand
 Decompressive hemicraniectomy for some forms of
 Ataxic hemiparesis: ant. limb of internal capsule
MCA infarction.
Differential





Head injury
↑ or ↓ glucose
SOL
Infection
Drugs: e.g. opiate OD
© Alasdair Scott, 2012
Stroke Unit
 Specialist nursing and physio
 Early mobilisation
 DVT prophylaxis
Secondary Prevention
Rehabilitation
56
Non-Acute Stroke: Key Facts
Stroke Work-Up
ECG ± 24hr Tape
 Arrhythmia
 Old ischaemia
Bloods
 FBC: ↑ or ↓ Hb
 U+E: association c̄ renovascular disease
 Glucose: exclude DM
 Lipids: CV risk
 Clotting and thrombophilia screen
 Vasculitis: ESR, ANA
Thrombophilia Screen
 FBC, clotting, fibrinogen concentration
 APC resistance / F5 Leiden
 Lupus anticoagulant
 Anti-cardiolipin Abs
 Assays for protein C and S and AT3 activity
 PCR for prothrombin gene mutation
Imaging
 CXR
O
 Cardiomegaly 2 to HTN
 Aspiration
 Carotid doppler
 Echo
 Mural thrombus
 Regional wall motion abnormality
 ASD, VSD: paradoxical emboli
Rehabilitation
 Must occur on a dedicated stroke unit
MENDS
 MDT: physio, SALT, dietician, OT, specialist nurses,
neurologist, family
 Eating
 Screen swallowing: refer to specialist
 NG/PEG if unable to take oral nutrition
 Screen for malnutrition (MUST tool)
 Supplements if necessary
 Neurorehab: physio and speech therapy
 Botulinum can help spasticity
 DVT Prophylaxis
 Sores: must be avoided @ all costs
Prognosis @ 1yr
 10% recurrence
 PACS
 20% mortality
 1/3 of survivors independent
 2/3 of survivors dependent
 TACS is much worse
 60% mortality
 5% independence
Secondary Prevention
 Risk factor control as above
 Start a statin after 48h
 Aspirin / clopi 300mg for 2wks after stroke then either
 Clopidogrel 75mg OD (preferred option)
 Aspirin 75mg OD + dipyridamole MR 200mg BD
 Warfarin instead of aspirin/clopidogrel if
 Cardioembolic stroke or chronic AF
 Start from 2wks post-stroke (INR 2-3)
 Don’t use aspirin and warfarin together.
 Carotid endarterectomy if good recovery + ipsilat
stenosis ≥70%
© Alasdair Scott, 2012
57
Multiple Sclerosis
Definition
 A chronic inflammatory condition of the CNS characterised by multiple plaques of demyelination disseminated in time and
space.
Epidemiology




Lifetime risk: 1/1000
Age: mean @ onset = 30yrs
Sex: F>M = 3:1
Race: rarer in blacks
Aetiology
 Genetic (HLA-DRB1), environmental, viral (EBV)
Pathophysiology
 CD4 cell-mediated destruction of oligodendrocytes →
demyelination and eventual neuronal death.
 Initial viral inflam primes humoral Ab responses vs. MBP
 Plaques of demyelination are hallmark
Classification




Relapsing-remitting: 80%
Secondary progressive
Primary progressive: 10%
Progressive relapsing
Presentation: TEAM




Tingling
Eye: optic neuritis (↓ central vision + eye move pain)
Ataxia + other cerebellar signs
Motor: usually spastic paraparesis
Clinical features
Sensory:
 Dys/paraesthesia
 ↓ vibration sense
 Trigeminal neuralgia
Motor:
 Spastic weakness
 Transverse myelitis
Eye:




Cerebellum:
 Trunk and limb ataxia
 Scanning dysarthria
 Falls
Diplopia
Visual phenomena
Bilateral INO
Optic neuritis → atrophy
GI:
 Swallowing disorders
 Constipation
Sexual/GU:
 ED + anorgasmia
 Retention
 Incontinence
Lhermitte’s Sign
 Neck flexion → electric shocks in trunk/limbs
Optic Neuritis
 PC: pain on eye movement, rapid ↓ central vision
 Uhthoff’s: vision ↓ c̄ heat: hot bath, hot meal, exercise
 o/e: ↓ acuity, ↓ colour vision, white disc, central scotoma,
RAPD
INO / ataxic nystagmus / conjugate gaze palsy
 Disruption of MLF connecting CN6 to CN3
 Weak adduction of ipsilateral eye
 Nystagmus of contralateral eye
 Convergence preserved
© Alasdair Scott, 2012
Ix
 MRI: Gd-enhancing or T2 hyper-intense plaques
 Gd-enhancement = active inflammation
 Typically located in periventricular white matter
 LP: IgG oligoclonal bands (not present in serum)
 Abs
 Anti-MBP
 NMO-IgG: highly specific for Devic’s syn.
 Evoked potentials: delayed auditory, visual and sensory
Diagnosis: clinical
 Demonstration of lesions disseminated in time and space
 May use McDonald Criteria
Differential
Inflammatory conditions may mimic MS plaques:
 CNS sarcoidosis
 SLE
 Devic’s: Neuromyelitis optica (NMO)
 MS variant c̄ transverse myelitis and optic atrophy
 Distinguished by presence of NMO-IgG Abs
Mx
 MDT: neurologist, radiologist, physio, OT, specialist
nurses, GP, family
Acute Attack
 Methylpred 1g IV/PO /24h for 3d
 Doesn’t influence long-term outcome
 ↓ duration and severity of attacks
Preventing Relapse: Disease Modifying
 IFN-β: ↓ relapses by 30% in RRMS MS
 Glatiramer: similar efficacy to IFN-β
Preventing Relapse: Biologicals
 Natalizumab: anti-VLA-4 Ab
 ↓ Relapses by 2/3 in RRMS
 Alemtuzumab (Campath): anti-CD52
nd
 2 line in RRMS
Symptomatic
 Fatigue: modafinil
 Depression: SSRI (citalopram)
 Pain: amitryptylline, gabapentin
 Spasticity: physio, baclofen, dantrolene, botulinum
 Urgency / frequency: oxybutynin, tolterodine
 ED: sildenafil
 Tremor: clonazepam
Prognosis
Poor prognostic signs:
 Older female
 Motor signs @ onset
 Many relapses early on
 Many MRI lesions
58
Motor Neurone Disease
Examination
Viva
Inspection
Ix
 Wasting and fasciculation
 Esp. tongue fasciculation
Tone
 Spastic
 Brain/cord MRI: exclude structural cause
 Cervical cord compression → myelopathy
 Brainstem lesions
 EMG: fasciculation
 LP: exclude inflammatory cause
Power
Diagnostic Criteria
 Revised El Escorial Criteria
Reflexes
Mx
Sensation: NORMAL
General
 MDT: neurologist, physio, OT, dietician, specialist nurse,
GP, family
 Discussion of end-of-life decisions
 E.g. Advanced directive
 DNAR
 Weak
 Absent and/or brisk
 E.g. absent knee jerks c̄ extensor plantars
Completion
 Speech
 Bulbar: nasal
 Pseudobulbar: hot-potato
 Jaw-jerk
 Bulbar: absent
 Pseudo-bulbar: brisk
 Eye movements: MND does not involve the eyes
Differential




Cervical cord compression → myelopathy
Brainstem lesions
Polio: asymmetrical LMN paralysis
Mixed UMN and LMN Signs
 MND
 Ataxia, Friedrich’s
 SCDC: B12
 Taboparesis
Specific
 Riluzole: antiglutamatergic that prolongs life by ~3mo
Supportive
 Drooling: amitriptyline
 Dysphagia: NG or PEG feeding
 Respiratory failure: NIV
 Pain: analgesic ladder
 Spasticity: baclofen, botulinum
Prognosis
 Most die w/i 3yrs
 Bronchopneumonia and respiratory failure
 Worse prog: elderly, female, bulbar involvement
Classification
Amyotrophic Lateral Sclerosis: 50%
 Corticospinal tracts → UMN and LMN signs + fasciculation
Progressive Bulbar Palsy: 10%
 Only affects CN 9-12 → bulbar palsy
Progressive Muscular Atrophy: 10%
 Anterior horn cell lesion → LMN signs only
 Distal to proximal
 Better prognosis cf. ALS
Primary Lateral Sclerosis: 30%
 Loss of Betz cells in motor cortex → mainly UMN signs
 Marked spastic leg weakness and pseudobulbar palsy
 No cognitive decline
© Alasdair Scott, 2012
59
LMN Signs
Examination
Ix
LMN Signs
Peripheral Neuropathy
 See below




Wasting
Fasciculation
Hypotonia
Hyporeflexia
Causes
 Pathology anywhere from anterior horn to muscle itself
Bilateral, Symmetrical and Distal
 Motor Peripheral Polyneuropathy
 ± sensory disturbance
 = Mixed Peripheral Polyneuropathy
Proximal Myopathy
 Bloods
 DM: glucose, HbA1c
 Muscle damage: CK, ESR, AST, LDH
 Endocrine: TSH, Ca, 9am cortisol, IGF-1
 Abs: anti-Jo1
 CXR: paraneoplastic
 EMG
 Genetic analysis
 Muscle biopsy
Differential
 HMSN
 Paraneoplastic
 Lead poisoning
 Acute: GBS, Botulism
Mononeuropathy
 Bloods
 DM: glucose, HbA1c
 B12, folate
 Vasculitis: ESR, ANA, ANCA
 EMG + nerve conduction
Bilateral, Symmetrical and Proximal
Radiculopathy / Plexopathy
 MRI
 Proximal myopathy
Differential
 Inherited: muscular dystophy
 Inflammation
 Polymyositis
 Dermatomyositis
 Endocrine
 Cushing’s Syndrome
 Acromegaly
 Thyrotoxicosis
 Osteomalacia
 Diabetic Amyotrophy
 Drugs: alcohol, statins, steroids
 Malignancy: paraneoplastic
Unilateral
Isolated to single limb + no sensory signs
 Old polio
Localised to group of muscles c̄ same supply
 Segmental: nerve roots, plexus
 Peripheral: mononeuropathy
Hand Wasting
 Anterior horn: syringomyelia, MND, polio
 Roots (C8 T1): spondylosis
 Brachial Plexus
 Compression: cervical rib
 Avulsion: Klumpke’s palsy
 Neuropathy
 Generalised: HMSN
 Mononeuritis multiplex: DM
 Compressive mononeuropathy
 Muscle
 Disuse: RA
 Distal myopathy: myotonic dystrophy
© Alasdair Scott, 2012
60
Peripheral Polyneuropathy
Examination
Viva
Sensory
Hx





 Time-course
 Precise symptoms
 Ataxia: B12
 Painful dysesthesia: EtOH, DM
 Assoc. events
 D&V: GBS
 ↓wt: Ca
 Arthralgia: connective tissue
 Travel, EtOH, drugs
Bilateral, symmetrical
Glove and stocking distribution: length dependent
↓ tendon reflexes: loss of ankle jerks in DM
Signs of trauma or joint deformity (Charcot’s joints)
Loss of proprioception → +ve Romberg’s
Motor
 Bilateral, symmetrical
 LMN weakness
 Wasting and fasciculation
 ↓ tone
 Hyporeflexia
Completion




Drug chart
Dipstick: glucose
Gait + Romberg’s test
CN
Causes
Mainly Sensory
 DM
 Alcohol
 B12 deficiency
 CRF and Ca (paraneoplastic)
 Vasculitis
 Drugs: e.g. isoniazid, vincristine
Mainly Motor
 HMSN / CMT
 Paraneoplastic: Ca lung, RCC
 Lead poisoning
 Acute: GBS and botulism
Ix
Dipstick: glucose
Bloods
 DM: Glucose, HBA1c
 EtOH: FBC ± Film, LFTs, GGT
 CRF: U+E
 B12, folate
 Vasculitis: ESR, ANA, ANCA
 Thyroid disease: TFTs
Imaging
 CXR: exclude paraneoplastic phenomena
Other
 Nerve conduction studies
 Demyelination → ↓ conduction speed
 Axonal degeneration → ↓ conduction amplitude
 Electromyography
 Genetic: PMP22 gene in CMT
 Nerve biopsy
Mx
General
 MDT: GP, neurologist, specialist nurses, physio, OT
 Foot care and careful shoe choice
 Splinting joints can prevent contractures
Specific
 Optimise glycaemic control: DCCT, UKPDS trials
 Replace nutritional deficiencies
 Avoid EtOH or other precipitants
 Vasculitis: steroids and other immunosuppressants
 Neuropathic pain: amitriptyline, gabapentin
 GBS: IVIg
© Alasdair Scott, 2012
61
Diabetic Neuropathy
Charcot-Marie-Tooth Syndrome
Examination of the Lower Limbs
= Peroneal Muscular Atrophy
= Hereditary Motor and Sensory Neuropathy
Inspection
Examination
 Evidence of finger pricks from BM monitoring
 Peripheral vascular disease
 Charcot joints
Inspection
 Pes cavus
 Symmetrical distal muscle wasting
 → claw hand
 → champagne bottle leg
 Thickened nerves: esp. common peroneal around
fibula
Motor
 Bilateral loss of ankle jerks
 2O to sensory neuropathy
 Mononeuritis multiplex
 Foot drop
Motor
 High-stepping gait: foot drop
 Weak foot and toe dorsiflexion
 Absent ankle jerks
Sensory
 Distal sensory loss in stocking distribution
Completion
 Examine the fundi
 Examine the upper limbs and cranial nerves
 Sensory neuropathy
 Mononeuritis multiplex
 CN3
 CN6
 Ulnar nerve
 Urine dip: glucose, proteinuria
Pain: esp. @ night
Glycaemic control
Complications of insulin
Other micro- and macro-vascular complications
Pathophysiology
 Metabolic: glycosylation, ROS, sorbitol accumulation
 Ischaemia: loss of vasa nervorum
 Urine: glucose, ACR
 Blood
 Glucose
 HbA1c
 U+E
Rx




Viva
Hx
 Family Hx
 Group of inherited motor and sensory neuropathies
Hx
Ix
 Variable loss of sensation in a stocking distribution
Pathophysiology
Viva




Sensory
MDT: GP, endocrinologist, neurologist, DNS
Good glycaemic control
Amitriptyline, Gabapentin
Capsaicin cream
Femoral Neuropathy / Amyotrophy
 Painful asymmetric weakness and wasting of quads c̄ loss
of knee jerks
 Dx: nerve conduction and electromyography
HMSN1
 Commonest form
 Demyelinating
 AD mutation in the peripheral myelin protein 22 gene
HMSN2
 Second commonest form
 Axonal degeneration
 Autosomal dominant
Ix
 Nerve conduction studies
 HMSN1: demyelination → ↓ conduction velocity
 HMSN2: axonal degeneration → ↓ amplitude
 Genetic testing
 HMSN1: Peripheral myelin protein 22 (PMP22)
gene
Mx: Supportive
 MDT: GP, neurologist, specialist nurses, physio, OT
 Foot care and careful shoe choice
 Orthoses: e.g. ankle braces
Autonomic Neuropathy
 Postural hypotension – Rx: fludrocortisone
 Gastroparesis → early satiety, GORD, bloating
 Diarrhoea – Rx: codeine phosphate
 Urinary retention
 ED
© Alasdair Scott, 2012
62
Myasthenia Gravis
GBS
Examination
Classification
 AIDP: acute autoimmune demyelinating
polyneuropathy
 Miller-Fisher: ophthalmoplegia + ataxia + areflexia
Inspect
 Thymectomy scar
Eyes
 Bilateral ptosis: worse on sustained upward gaze
 Complex ophthalmoplegia
Pathophysiology
 Molecular mimicry: Abs x-react c̄ ganglioside
 Bacteria: C. jejuni, mycoplasma
 Viruses: CMV, EBV
Facial Movements
 Myasthenic snarl on smiling
Voice
 Nasal
 Deterioration: ask pt. to count to 50
Features
 Symmetrical ascending flaccid paralysis
 Sensory disturbance: paraesthesia
 Autoimmune neuropathy: labile BP
Limbs
 Fatiguability: repeatedly flap arm
Completion
 Assess respiratory muscle function: spirometry (FVC)
Viva
Ix
 Abs: Anti-AChR, Anti-MuSK
 EMG: ↓ response to titanic train of impulses
 Tensilon test: improvement c̄ edrophonium
(anticholinesterase)
 TFTs: Graves in 5%
 CT mediastinum: thymoma in 10%
Associations
 <50, female
 AI disease: DM, RA, Graves, SLE
 >50, male
 Thymoma
Mx
Acute
 Plasmapheresis or IVIg
 Monitor FVC: consider ventilation
Ix




Evidence of infection: e.g. stool MC+S
Anti-ganglioside Abs
LP: ↑↑ CSF protein
Nerve conduction studies: demyelination
Mx
Supportive
 Airway / ventilation: ITU if FVC < 1.5L
 Analgesia: NSAIDs, gabapentin
 Autonomic: may need inotropes, catheter
 Antithrombotic: TEDS, LMWH
Immunosuppression
 IVIg
 Plasma exchange
Physiotherapy
 Prevent flexion contractures
Prognosis
 85% complete recovery
 10% unable to walk alone at 1yr
 5% mortality
Chronic
 Pyridostigmine
 Immunosuppression: steroids and azathioprine
 Thymectomy: benefit even if no thymoma
LEMS




Abs vs. VGCC
Often paraneoplastic: e.g. SCLC
Lower limb girdle weakness
Weakness improves on repetitive testing
Bilateral Ptosis





MG
Myotonic dystrophy
Congenital
Senile
Bilateral Horner’s (rare)
© Alasdair Scott, 2012
63
Facial Nerve Palsy
Examination
Viva
Inspection
Hx





 Symptoms
 Eye dryness
 Drooling
 ↓ taste: ageusia
 Hyperacusis
 Cause
 Onset: rapid in Bell’s
 Rash or external ear pain
 Hx of DM
 SOL: headache, nausea
 Other CN: vertigo, tinnitus, diplopia
 Limb weakness
 Rash, fever
Unilateral facial droop
Absent nasolabial fold
± absent forehead creases
? scar or parotid mass
Ear rash
Weakness
 Raising eyebrows: frontalis
 Screwing up eyes: orbicularis oculi
 Bell’s sign: eyeball rolls back on closure
 Smiling: orbicularis oris
UMN or LMN?
 UMN → sparing of frontalis and orbicularis oculi
 Due to bilateral cortical representation
Other CN Involvement
 NB. other CN involvement seen in 8% of Bell’s Palsy
Pons → Millard-Gubler Syndrome
 CN6 nucleus → ipsilateral lateral rectus palsy
 CN7 nucleus → ipsilateral LMN facial palsy
 Corticospinal tracts → contralateral hemiparesis
CPA: ipsilateral CN 5, 6, 7 and 8 palsies and cerebellar signs
 Facial anaesthesia + absent corneal reflex
 LR palsy
 LMN facial nerve palsy
 SNHL
 DANISH
Auditory Canal → CN8
Completion
 If UMN: likely stroke
 Examine limbs for ipsilateral spasticity
 Examine visual fields: ipsilateral homonymous
hemianopia
 If LMN: likely Bell’s Palsy
 Look in ears
 Examine PNS, CN and cerebellar function
 Test taste
Causes







75% Idiopathic Bell’s Palsy
Supranuclear: vascular, MS, SOL
Pontine: vascular, MS, SOL
CPA: vestibular Schwannoma, meningioma, 2O
Intra-temporal: Ramsay Hunt, Cholesteatoma, trauma
Infra-temporal: Parotid tumour, trauma
Systemic
 Neuropathy: DM, Lyme, Sarcoidosis
 Pseudopalsy: MG
Bilateral Facial Nerve Palsy
 Bilateral Bell’s
 Sarcoidosis
 GBS
 Lyme
 Pseudopalsy: MG, Myotonic dystrophy
© Alasdair Scott, 2012
Aguesia and Hyperacusis
 Chorda tympani and nerve to stapedius arise just distal
to geniculate ganglion w/i the temporal bone.
 Loss of these functions indicates a proximal lesion
 Common in Ramsay Hunt: VZV @ geniculate ganglion
Ix
Urine Dip: glucose
Bloods
 DM: glucose, HbA1c
 Serology: VZV and Lyme
 Abs: anti-ACh receptor
Imaging
 MRI posterior cranial fossa
Other
 Pure tone audiometry
 LP: exclude infection
 Nerve conduction studies
 May predict delayed recovery when performed @
2wks.
Mx
 Prednisolone w/i 72hrs
 Valaciclovir if VZV suspected
 Protect eye
 Dark glasses
 Artificial tears
 Tape closed @ night
Prognosis
 Incomplete paralysis: recovers completely w/i wks
 Complete: 80% get full recovery
 Remainder have delayed recovery or permanent
neurological / cosmetic abnormalities.
Complications: Aberrant Neural Connections
 Synkinesis: e.g. blinking causes up-turning of mouth
 Crocodile tears: eating stimulates unilateral lacrimation,
not salivation
64
Facial Nerve Palsy: Key Causes
Facial Anaesthesia
Bell’s Palsy
Examination
 75% of Facial Palsies
 Dx of exclusion
 Inflammatory oedema → compression of CNVII in
narrow facial canal
 Probably of viral origin (HSV1)
Features
 Sudden onset
 Complete LMN facial palsy
 Ageusia: corda tympani
 Hyperacusis: stapedius
 Assoc. c̄ other CN involvement in 8%
Ramsay Hunt Syndrome
 American neurologist James Ramsay Hunt in 1907
 Reactivation of VZV in geniculate ganglion of CNVII
Features
 Preceding ear pain or stiff neck
 Vesicular rash in auditory canal ± TM, pinna, tongue,
hard palate (no rash = zoster sine herpete)
 Ipsilateral facial weakness, ageusia and hyperacusis
 May affect CN8 → vertigo, tinnitus, deafness
Mx
 If Dx suspected give valaciclovir and prednisolone w/i
first 72h
 ↓ absent sensation in trigeminal distribution
 Note modality
 Note which trigeminal branch
 Weak masseter and temporalis
 Jaw jerk
 Brisk: UMN
 Absent: LMN
 Loss of corneal reflex
Viva
Causes
Supranuclear
 Demyelination
 Infarct
 SOL
Nuclear
 CPA lesion: c̄ other CN palsies
 Lateral medullary syndrome: loss of pain and temp
Peripheral: mononeuropathy
 DM, sarcoid, vasculitis
 Cavernous sinus
 Ophthalmic and maxillary divisions
 Bilateral
Prognosis
 Rxed w/i 72h: 75% full recovery
 Otherwise: 1/3 full recovery, 1/3 partial, 1/3 poor
Cholesteatoma
 Locally destructive expansion of stratified squamous
epithelium within the middle ear.
 Usually 2O to attic perforation in chronic suppurative OM
Presentation
 Foul smelling white discharge
 Vertigo, deafness, headache, pain, facial paralysis
 Appears pearly white c̄ surrounding inflammation
Complications
 Deafness (ossicle destruction)
 Meningitis, cerebral abscess
Management
 Surgery
Lyme Disease
 Borellia burgdorferi
 Early Local: Erythema migrans + systemic malaise
 Late Disseminated
 CN palsy: esp. facial palsy
 Polyneuropathy
 Meningoencephalitis
 Arthritis
 Myocarditis
 Heart block
© Alasdair Scott, 2012
65
Abnormal Pupils
Horner’s Syndrome
Examination
Face: PEAS
 Ptosis: partial (superior tarsal muscle)
 Enophthalmos
 Anhydrosis
 Small pupil
 NO ophthalmoplegia
Neck Scars
 Central lines
 Carotid endarterectomy
Hands
 Complete claw hand + intrinsic hand weakness
 ↓ / absent sensation in T1
Completion
 Cerebellum, CNs and PNS
Differential
Central
 MS
 Wallenberg’s
Pre-ganglionic (neck)
 Pancoast’s tumour: T1 nerve root lesion
 Trauma: CVA insertion or carotid endarterectomy
Post-ganglionic
 Cavernous sinus thrombosis
O
 Usually 2 to spreading facial infection via the
ophthalmic veins
 CN 3, 4, 5, 6 palsies
Oculomotor Nerve Palsy
Features




Complete ptosis: LPS
Eye points down and out: unopposed SOB and LR
Dilated pupil, doesn’t react to light: unless spared
Ophthalmoplegia and diplopia
Medical vs. Surgical
 Parasympathetic fibres originate in Edinger Westphal
Nucleus and run on periphery of oculomotor nerve.
 Receive rich blood supply from external pial vessels
 These fibres are affected late in ischaemic causes
(medical) but early in compression (surgical).
Medical
 Mononeuritis: e.g. DM
 MS
 Infarction in midbrain
 Weber’s: CN3 palsy + contralateral hemiplegia
 Migraine
Surgical
 ↑ ICP: transtentorial herniation compresses uncus
 Cavernous sinus thrombosis
 Posterior communicating artery aneurysm: painful
© Alasdair Scott, 2012
Holmes-Adie (Myotonic) Pupil
 Dilated pupil that has no response to light and sluggish
response to accommodation.
 ↓ or absent ankle and knee jerks
 Benign condition, more common in young females
Argyll Robertson Pupil
Features
 Small, irregular pupils
 Accommodate but doesn’t react to light
 Atrophied and depigmented iris
Extras
 Offer to look for sensory ataxia: tabes dorsalis
 Dip the urine: glucose
Causes
 Quaternary syphilis: RPR or TPHA
 DM
RAPD / Marcus Gunn Pupil
Features
 Minor constriction to direct light
 Dilatation on moving light from normal to abnormal eye.
Features of Optic Atrophy





↓ visual acuity
↓ colour vision: esp. red desaturation
Central scotoma
Pale optic disc
RAPD
Causes: CAC VISION
 Commonest: MS and glaucoma
Congenital
 Leber’s hereditary optic neuropathy
 Epi: mitochondrial, onset 20-30s
 PC: attacks of acute visual loss, sequential in each
eye ± ataxia and cardiac defects
 HMSN / CMT
 Friedrich’s ataxia
 DIDMOAD
Alcohol and Other Toxins
 Ethambutol
 Lead
 B12 deficiency
Compression
 Neoplasia: optic glioma, pituitary adenoma
 Glaucoma
 Paget’s
Vascular: DM, GCA or thromboembolic
Inflammatory: optic neuritis – MS, Devic’s, DM
Sarcoid / other granulomatous
Infection: herpes zoster, TB, syphilis
Oedema: papilloedema
Neoplastic infiltration: lymphoma, leukaemia
66
Visual Fields
Visual Pathway






Retina
Optic nerve
Optic chiasm: nasal fibres decussate
Optic tract
LGN of thalamus
Optic radiation
 Superior field: temporal
 Inferior field: parietal
 Visual cortex
Ix
 Perimetry
 CT/ MRI brain
Homonymous Hemianopia
 Retrochiasmatic
 Greater defect = larger lesion or closer to chiasm
 Contralateral
Extras




Examine for ipsilateral hemiparesis
Examine for cerebellar signs
Right: test for neglect
Left: test for aphasia
Bitemporal Hemianopia
 Chiasmatic lesion
Extras
 Take Hx and examine for features of endocrine disease
 Prolactinoma
 Acromegaly
 Cushing’s
Causes
 Pituitary tumour
 Compresses from below → descending visual loss
 Craniopharyngioma
 Compresses from above → ascending visual loss
 Benign suprasellar tumour originating from
Rathke’s pouch.
 Calcified as arises from odontogenic epithelium
Monocular Blindness
 No vision in one eye
 Check counting fingers, movement and light perception
 Lesion proximal to optic chiasm
 Eye itself: cornea, vitreous, retina
 Optic nerve: i.e. optic neuropathy
Hx
 Speed of onset
 Vascular risk factors
Vascular Territory
 MCA Stroke
 MCA supplies the optic radiation in the temporal
and parietal lobes
 Hemiparesis
 Higher cortical dysfunction: neglect, aphasia
 PCA Stroke
 PCA supplies occipital lobe and visual cortex
 Homonymous hemianopia c̄ macula sparing
 Branch of MCA supplies part of visual cortex
 No hemiparesis
 May have cerebellar signs
Causes
 Vascular: ischaemia or haemorrhage
 SOL: tumour, abscess
 Demyelination: MS
© Alasdair Scott, 2012
67
Ophthalmoplegia
Examination
Internuclear Ophthalmoplegia
H Test: Left Eye
Examination




Failure of ipsilateral adduction
Nystagmus in the contralateral abducting eye
May be bilateral
Convergence preserved
Neurophysiology
 To maintain convergent gaze, MLF yokes together the
nuclei of CN3 and 6.
 Pontine centre for lateral gaze initiates movement and
outputs to CN3 nucleus and CN6 nucleus via the MLF
 Failure of adduction is ipsilateral to MLF lesion
Causes




Key Elements
 Inspect the eye
 Ptosis
 Alignment
 Pupil sizes
 Ask pt. to tell you if they get double vision
 Use H to test movements noting:
 Ophthalmoplegia
 Diplopia: do cover test
 Nystagmus
 Saccades: vertical and horizontal
Complex Ophthalmoplegia
 Dx of exclusion
 Ophthalmoplegia doesn’t fit a single pattern
Causes




Diplopia
 Maximal in direction of pull of affected muscle
 Cover test: outer image disappears c̄ affected eye
Simple Palsies
3rd Nerve




Complete ptosis
Down and out in rest position
± dilated, non-reactive pupil
Diplopia maximal: in and up
MS
Infarct: ischaemic or haemorrhagic
Syringomyelia
Phenytoin toxicity
Ix
DM: Mononeuritis multiplex
MS
Myasthenia gravis
Thyrotoxicosis
 Urine dip: glucose
 Bloods
 DM: glucose + HbA1c
 TFT: ↓TSH
 MG: anti-AChR antibodies
 MRI Brain
 Plaques in the periventricular white matter
4th Nerve





Slight head tilt: ocular torticollis
Appear normal in rest position
Failure to depress eye in adduction
Diplopia maximal down and in
Ask if pt. has trouble walking down stairs
6th Nerve




Appear normal in resting position
Failure to abduct
Diplopia maximal in abduction
Commonly a false localising sign of ↑ ICP: contralateral
lesion
Causes
 Central NS: MS, vascular, SOL
 Peripheral NS: DM (mononeuritis), compression, trauma
Ix
 Urine dip: glucose
 Bloods: glucose + HbA1c
 Imaging: MRI brain
© Alasdair Scott, 2012
68
Hearing Loss
Examination
 USE a 512Hz TUNING FORK
Rinne’s Test
 Positive: AC > BC
 Negative: BC > AC
 True: conductive deafness
 False: complete SNHL
Weber’s Test
 Normal: central
 SNHL: lateralises to normal ear
 Conductive: lateralises to abnormal ear
Causes
Conductive
 Impaired conduction anywhere between auricle and
round window.
 Canal obstruction: wax, FB
 TM perforation: trauma, infection
 Ossicle defects: otosclerosis, infection
 Fluid in middle ear
SNHL
 Defects of cochlea, cohlear N. or brain
Congenital
 Alports: SNHL + haematuria
 Jewell-Lange-Nielsen: SNHL + long QT
Acquired
 Presbyacussis
 Drugs: gentamicin, vancomycin
 Infection: meningitis, measles
 Tumour: vestibular schwannoma
© Alasdair Scott, 2012
69
Speech
Examination
Abnormalities
Aims to Test
Dysarthria
 Dysphonia: impaired production of voice sounds
 Dysarthria: impaired articulation of sound → words
 Dysphasia: impairment of language
Quick Screen
 Ask: How did you get here today?
 Listen to volume, rhythm, clarity and content
 Any striking abnormality?
Dysarthria
 Lesion in tongue, lips, mouth or disruption of NM pathway
Pseudo-bulbar
 Bilateral UMN lesions → spastic dysarthria
 Difficulty c̄ lingual sounds
 “Hot Potato speech”
 Brisk jaw jerk
 Causes
 CVA: e.g. bilateral internal capsule infarcts
 MS
 MND
 Repetition
 Yellow lorry: test lingual sounds
Bulbar
 Baby hippopotamus: labial sounds
 Unilateral LMN weakness
 The Leith police dismisseth us: multiple processes
 Palatal weakness → nasal “Donald Duck” speech
 Count to thirty: muscle fatigue in MG
 Causes
 Brainstem infarct
Dysphonia
 MND
 Voice: quiet or hoarse
 GBS
 Cough: bovine
 Say Ahh: vocal cord tension
Cerebellar
 Slurred, drunken speech
Dysphasia
 Name three objects: nominal dysphasia
 Three stage command: receptive dysphasia
 Avoid visual clues by instructing from behind
 Repeat sentence: Today is Thursday
 Tests for conductive dysphasia
Extras
 Dominant parietal lobe lesions → dyslexia, dysgraphia
and dyscalcula.
 Read a paragraph: dyslexia
 Write a sentence: dysgraphia
Dysphonia
 Hoarse voice
 Bovine cough
Cause
 Local cord pathology: laryngitis, tumour, nodule
 Recurrent laryngeal N. palsy
Dysphasia
Expressive
 Broca’s area: frontal lobe
 Non-fluent speech
 Comprehension intact
Receptive
 Wernicke’s Area: temporal lobe
 Fluent but meaningless speech
 Comprehension impaired
Conductive
 Damage to arcuate fasciculus connecting Broca’s and
Wernicke’s areas.
 Comprehension intact
 Unable to repeat words or phrases
© Alasdair Scott, 2012
70
Shorts
Contents
Psoriasis .................................................................................................................................................................................. 72
Dermatitis ................................................................................................................................................................................. 73
Cutaneous Manifestations of DM............................................................................................................................................. 73
Skin Malignancy ....................................................................................................................................................................... 74
Neurofibromatosis .................................................................................................................................................................... 75
Tuberous Sclerosis .................................................................................................................................................................. 75
Spot Skin Diagnoses ............................................................................................................................................................... 76
Rheumatoid Hands .................................................................................................................................................................. 77
RA: Key Facts .......................................................................................................................................................................... 78
Systemic Sclerosis ................................................................................................................................................................... 79
Systemic Lupus Erythematosus .............................................................................................................................................. 80
Ankylosing Spondylitis ............................................................................................................................................................. 81
Marfan’s Syndrome .................................................................................................................................................................. 82
Tophaceous Gout .................................................................................................................................................................... 83
Osteoarthritis............................................................................................................................................................................ 83
Thyrotoxicosis .......................................................................................................................................................................... 84
Hypothyroidism ........................................................................................................................................................................ 85
Acromegaly .............................................................................................................................................................................. 86
Cushing’s Syndrome ................................................................................................................................................................ 87
Addison’s Disease ................................................................................................................................................................... 88
Steroids: Key Facts .................................................................................................................................................................. 89
Neuro Shorts ............................................................................................................................................................................ 89
© Alasdair Scott, 2012
71
Psoriasis
Examination
Viva
Skin
Hx
 Symmetrical, well-defined salmon-pink plaques
 Silvery, micaceous scale
 Locations
 Extensors
 Behind ears
 Scalp
 Umbilicus
 Sites of trauma: Kobner phenomenon
 Skin staining from Rx
 Coal tar: brown
 Dithranol: purple
Nails




Discolouration
Pitting
Onycholysis
Subungual hyperkeratosis
Joints
 Evidence of inflammatory arthropathy
Completion
 Inspect common areas and assess joints
 Assess for Auspitz sign
 Pinpoint bleeding on scraping scale
 Hx
Differential




Psoriasis
Bowen’s Disease
Lichen planus
Dermatitis
Other Differentials
Onycholysis
 Psoriasis
 Fungal infection
 Trauma
 Thyrotoxicosis
Pitting
 Psoriasis
 Fungal infection
 Lichen planus
Kobner Phenomenon
 Psoriasis
 Lichen planus
 Viral warts
 Vitiligo
 Sarcoid
© Alasdair Scott, 2012
 Symptoms
 Itch
 Arthritis
 Triggers
 Smoking
 Stress
 Injury
 Drugs: β-B, EtOH
 Treatments
 Topical
 Phototherapy
 Systemic
Pathogenesis




T4 T cell-driven hypersensitivity reaction
Hyperkeratosis
Parakeratosis (nuclei in the stratum corneum)
Intra-epidermal microabscess (of Munro)
Subtypes
 Guttate
 Drop-like lesions on trunk
 Commoner in children after Strep infection
 Pustular: generalised or palmo-plantar
 Erythroderma
 Flexural: not scaly
Psoriatic Arthritis






Seronegative arthritis develops in 10-40%
Asymmetric oligoarthritis
Distal arthritis
Symmetric polyarthritis: may mimic RA
Spondylitis
Arthritis mutilans
Mx
General
 MDT: GP, dermatologist
 Avoid precipitants: EtOH, β-B, smoking, stress
Topical
 Emollients: epaderm, dermol, diprobase
 Steroids: betometasone
 Vit D analogues: calcipotriol
 Combination: Dovobet
 Coal Tar: inpt. Use mainly
 Dithranol
Phototherapy
 PUVA
 Narrow-band UVB
Systemic
 Cytotoxics: ciclosporin, methotrexate
 Retinoids: acetretin
 Biologics: anti-TNF
72
Dermatitis
Cutaneous Manifestations of DM
Examination
Examination
Skin
Hands




Erythematous lichenified patches
Predominantly flexors
Excoriations
Painful fissures: esp. hands
Differential




Just hands: irritant contact dermatitis
Atopic eczema
Discoid: well-demarcated patches on trunk and limbs
Seborrhoeic dermatitis
Viva
Hx
 Atopy: asthma, hay fever, allergies
 Patch testing: house dust mites, animal dander
 Effect of diet
 Cheiroarthropathy
 Tight waxy skin that limits finger extension
 Prayer sign
 Granuloma annulare
 Flesh-coloured papules in annular configuration
 Usually on dorsum of hand
 10% assoc. c̄ DM
 Glucose skin prick testing marks
Injection Sites
 Shoulders, abdomen and thighs
 Lipodystrophy
Shins
 Necrobiosis lipoidica diabeticorum
 Well-demarcated waxy, bruise-like plaques
 Prominent blood vessels
 90% female
Feet
Mx
General
 MDT: GP, dermatologist
 Avoid precipitants
Adjuvants
 Antihistamines: pruritis
 Abx: 2O infection
 Charcot’s Joints
 Ulcers: heel, metatarsal heads, digits
Other
 Infections: candida, cellulitis
 Eruptive tendon xanthoma: 2O to hyperlipidaemia
Topical
 Emollients: dermol, epaderm, diprobase
 Soap substitutes: dermol, epaderm
 1st: steroids
 2nd: tacrolimus
Phototherapy
Systemic: only if severe
 Steroids
 Ciclosporin
© Alasdair Scott, 2012
73
Skin Malignancy
BCC
Malignant Melanoma
Examination
Examination
Lesions
 On face in sun-exposed areas
 Pearly nodule c̄ rolled, telangiectactic edge
Pt. Characteristics
 Fair skin c̄ freckles
 Blue Eyes
 Light hair
Viva
Natural Hx
 Commonest skin cancer
 2O to sun exposure
 Slow growing locally destructive: “rodent ulcer”
 Do not metastasise
Mx
 Superficial: curettage
 Deep: surgical excision ± radiotherapy
SCC
Examination
Lesion
 Sun-exposed area
 Ulcerated lesion c̄ everted edge
 Actinic keratosis: irregular, crusty, warty lesions
 Bowen’s: red/borwn, scaly plaques
Extras
 Examine regional LNs
 Examine rest of skin for other lesions
Viva
Evolution
 Actinic keratosis → Bowen’s → SCC
Risk Factors
 Sun exposure
 Immunosuppression: e.g. ciclosporin
 Genetic: xerodermapigmentosum
 Chronic trauma: Marjolin’s ulcer
Dx
Mx
 Excisional biopsy
Lesion
 Asymmetry
 Boarder: irregular
 Colour: non-uniform
 Diameter > 6mm
 Evolving / Elevation
Extras
 Regional LNs
 Fundoscopy
 Liver
NB. Glass ye + ascites: ocular melanoma
Viva
Risk Factors
 Sun exposure: esp. when young
 Low Fitzpatrick skin type
 ↑ no. of common moles
 +FH
 ↑ age
 Immunosuppression
Classification
 Superficial spreading: 80%
 Lentigo maligna melanoma: elderly
 Acral lentiginous: Blacks, soles, palms
 Nodular: younger, new lesion
 Amelanotic: delayed Dx
Staging
 Breslow Depth
 Clark’s Levels
Mx




Excision biopsy for staging
O
2 excision margin depends on stage
± lymphadenectomy
± adjuvant chemo
 Surgery ± radiotherapy
© Alasdair Scott, 2012
74
Neurofibromatosis
Tuberous Sclerosis
Examination
Examination
Skin
Skin




Facial adenoma sebaceum: perinasal angiofibromata
Periungual fibromas: hands and feet
Shagreen-patch: roughened leathery skin over sacrum
Ash-leaf macule: hypopigmented macule on trunk
 Fluoresce c̄ UV/Wood’s lamp
 Café-au-lait spots
 Café-au-lait spots
 ≥6, >15mm diameter
 Axillary freckling
 Neurofibromas: gelatinous, violaceous nodules
Eyes
 Lisch nodules: melanocytic hamartomas of the iris
Extras




Extras
 Fundus: retinal phakomas (dense white patches)
 Lungs: cystic lung disease
 Abdomen
 Renal enlargement 2O to cysts
 Transplanted kidney
 Signs of phenytoin use (80% epileptic)
 Gingival hypertrophy
 Hisutism
Visual acuity: optic glioma
Back: scoliosis
BP: RAS + phaeochromocytoma
Palpable nerves + peripheral neuropathy
Viva
Epidemiology
 Autosomal dominant
 NF1
 Chr 17
 1/2500
 NF2
 Chr 22
 1/35,000
Complications




Epilepsy
Sarcomatous change: 5%
Scoliosis: 5%
Learning difficulty: 10%
Viva
Epidemiology
 Autosomal dominant
 Chr 16
Ix




Skull films: railroad track calcification
CT/MRI brain: tuberous masses in cortex
Abdo US: renal cysts
Echo: cardiomyopathy
Mx
 MDT: GP and neurologist
 Excise some neurofibromas
 Complications
 Yearly BP and cutaneous review
 Epilepsy Rx
 Genetic counselling
Differential of Café-au-Lait Spots
 NF
 McCune Albright
 Case-au-lait spots
 Polyostotic fibrous dysplasia
 Endocrinopathy → precocious puberty
 Tuberous Sclerosis
© Alasdair Scott, 2012
75
Spot Skin Diagnoses
Hereditary Haemorrhagic Telangiectasia
Erythema Multiforme
= Osler-Weber-Rendu Syndrome
Examination
 Multiple telangiectasia on face, lips and buccal mucosa
 Cyanosis: large pulmonary AVMs
 No signs of CREST
Differential
 HHT
 CREST
 CLD
 Ataxia telangiectasia
Viva
Features
 Autosomal dominant
 Multiple telangiectasias
 AVMs
 Lungs
 Liver
 Brain
Complications
 Haemorrhage
 Epistaxis
 GI haemorrhage
 Haemoptysis
 SAH
 High output cardiac failure
 May have ↑ risk of CRC if SMAD4 mutation
Examination
 Symmetrical targetoid lesions
 Especially on the extensor surfaces of peripheries
Differential of lesions c̄ central clearing
 EM
 Discoid eczema
 Tinea
Viva
Causes
 Infections
 HSV (70%)
 Mycoplasma
 Drugs
 Sulfonamides
 NSAIDs
 Allopurinol
 Penicillin
 Phenytoin
Stevens-Johnson Syndrome and TEN
 Severe variants of EM
 Nearly always drug-induced
 SJS: blistering mucosa
 TEN: generalised erythema followed by erpidermal
necrosis and desquamation
 Rx: dexamethasone, IVIg
Erythema Nodosum
Peutz-Jeghers
Examination
 Small pigmented macules on lips, oral mucosa, palms
and soles
Differential
 Peutz-Jeghers
 Carney Complex
 McCune-Albright
 Simple freckles
Viva
Features
 Autosomal dominant mutation of STK11 gene on Chr
19
 Mucocutaneous macules
 GI hamartomatous polyps
Complications
 GI hamartomas
 Intussusception
 GI bleeding
 Pancreatic endocrine tumours
 ↑ risk of cancer: esp. CRC (~20% life-time risk)
© Alasdair Scott, 2012
Examination
 Tender, blue/red, smooth shiny nodules
 Commonly found on shins
 Can be anywhere c̄ SC fat
 Older lesions leave a bruise
Extras
 Parotid swelling: sarcoidosis
 Red, sore throat: streptococcal infection
 Joint pains, oral ulceration: Behcet’s
Viva
Causes
 Systemic disease
 Sarcoidosis
 IBD
 Behcet’s
 Infection
 Streptococcal infection
 TB
 Drugs
 Sulphonamides
 OCP
Other skin manifestations of sarcoidosis
 Red/brown nodules and papules
 Lupus pernio: brown plaques, commonly on the nose
76
Rheumatoid Hands
Hand Examination
Viva
Look
Hx
Feel
Ix
 Hands
 Skin: joint erythema, palmar erythema
 Joint Swelling: MCPs and PIPs
 Muscle wasting: interossei, thenar eminence
 Deformity
 Surgical Scars: e.g. carpal tunnel release
 Wrist
 Elbow: nodules
 Hot swollen painful joints = active synovitis
Move
 Fixed flexion on prayer position
 ↓ ROM
Function
 Precision
 Power
 Aids
Presentation
 Symmetrical deforming polyarthropathy
 Signs of active synovitis
 Signs of cause
 Rheumatoid nodules
 Psoriatic plaques
Differential
 Psoriatic arthritis
 Jacoud’s arthropathy
Systemic Examination
 Skin: steroid use
 BP and pulse
 ↑ risk of AF
 ↑ risk of cardiovascular disease
 Eyes
 Epi-/scleritis
 Keratoconjunctivits sicca
 Anaemia
 Neck: x-rays for atlanto-axial sublucxation
 Heart: pericardial rub
 Lungs
 Pulmonary fibrosis
 Percuss for effusions
 Pleural rub
 Abdomen: splenomegaly
 Urine dip: nephrotic syndrome amyloid or DMARDs)
© Alasdair Scott, 2012
 Symptoms
 Early morning stiffness
 Pain
 Swelling
 Affect on life
 Extra-articular features: aNTI CCP OR RF
 Treatments tried so far + any complications
Bloods
 FBC: ↓Hb, ↓PMN
 ↑ESR and ↑CRP
 Immune
 RF: +ve in 70%
 Anti-CCP: 98% specific, 75% sensitive
 ANA: +ve in 30%
 HLA-DR3/4
X-Ray
 Soft tissue swelling
 Periarticular osteopenia
 Loss of joint space
 Periarticular erosions
 Deformity
Mx
MDT: GP, physio, OT, rheumatologist, orthopod
Conservative
 Physio
 OT: aids and splints
Medical
 Analgesia
 Steroids: IM, PO or intra-articular
 DMARDS
 Biologicals
 Other
 CV risk
 Prevention of PUD and osteoporosis
Surgical
 Carpal tunnel decompression
 Tendon repairs and transfers
 Ulna stylectomy
 Arthroplasty
77
RA: Key Facts
Extra-Articular Features: aNTI CCP OR RF
 Nodules
 Tenosynovitis: de Quervains and atlanto-axial
subluxation
 Immune: vasculitis, amyloidosis, Sjogren’s, AIHA
 Cardiac: pericarditis ± effusion
 Carpal tunnel
 Pulmonary: fibrosis, effusions
 Ophthalmic: episcleritis, scleritis, Sjogren’s
O
 Renal: nephrosis 2 to amyloidosis
 Raynaud’s
 Felty’s: RA + ↓PMN + splenomegaly
Rheumatoid Factor
 Anti-IgG IgM
 Present in ~70% c̄ RA
 Also present in ~10% of normal people and in other
diseases
 Sjogren’s: 100%
 SLE: ≤40%
 Higher titres associated c̄
 More severe disease
 Erosions
 Extra-articular manifestations
Seronegative RA
Anatomy of Rheumatoid Hands
 Boutonierre’s: rupture of central slip of extensor
expansion → PIPJ prolapse through “button-hole”
created by the two lateral slips.
 Swan: rupture of lateral slips → PIPJ hyper-extension
DMARDs
Atlanto-Axial Subluxation
 All can → BM suppression
Drug
Methotrexate
Sulfasalazine
Hydroxychloroquine
Penicillamine
Gold
Side Effects
BM suppression
Hepatotoxic
Pulmonary fibrosis
BM suppression
Skin rashes
Hepatitis
↓ sperm count
Retinopathy
Drug-induced lupus
Nephrotic syndrome
Nephrotic syndrome
 RA c̄ absence of RFs
 ~30% of pts are seronegative
 May have non-classical RFs (e.g. IgG vs. IgG)
 40% +ve for anti-CCP
 Less severe disease c̄ and much less likely to have
extra-articular features.
Monitor
FBC
LFTs
CXR
FBC
LFTs
Visual acuity
Urine
Urine
Biologicals
Indications
 Severe RA not responding to DMARDs
Anti-TNF
 Screen and Rx TB first: tuberculin skin test, CXR
 Give c̄ hydrocortisone to ↓ hypersensitivity
 Agents
 Infliximab (Remicade)
 Etanercept (Enbrel)
 Adalimumab (Humira)
 SEs
 Hypersenstivity → rash
 Opportunistic infection: TB
 Rheumatoid tenosynovitis → weakening of ligaments
supporting the top of the cervical spine
 Posterior subluxation of the odontoid peg can compress
the spinal cord
 Chronic: progressive spastic tetraparesis
 Acute: inhibitory impulses via vagus N. can →
cardiac arrest
 Pre-operatively
 Main risk is during intubation
 Arrange upper cervical spine radiograph in gentle
flexion
Anti-CCP Abs
 Cyclic Citrullinated Peptide
 Derived from collagen
 Citrullination of arginine 2O to inflammation
 Specificity: 98%
 Sensitivity: 75%
American College of Rheumatology Criteria
4/7 of
 Morning stiffness >≥1h
 Arthritis in 3+ joint areas
 Arthritis of the hands
 Symmetrical
 Rheumatoid nodules
 +ve RF
 Radiographic changes
B-cell Depletion: Rituximab (anti-CD20 mAb)
 Screen and Rx TB first: tuberculin skin test, CXR
 Opportunistic infections
 TB
 Viral reactivation: Hep B, PML
© Alasdair Scott, 2012
78
Systemic Sclerosis
Examination
Hx
 Symptoms
 Swallowing difficulty or reflux
 Hands change colour in the cold
 Shortness of breath
 Hypertension
 Arthralgia
Hands
 Scleroderma
 Tight skin
 Can you move skin between your fingers?
 Sclerodactyly
 Calcinosis
 Raynaud’s phenomenon → ulceration
Face
 Beaked nose: “nasal skin tethering”
 Microstomia
 Ask pt. to open and close mouth
 Perioral furrowing
 Telangiectasia
 En coup de sabre: scar down central forehead
Extras
 BP: HTN
 Lungs: pulmonary fibrosis
 Cardiac: pulmonary HTN
 ↑ JVP
 Parasternal heave
 Loud P2
 Peripheral oedema and ascites
 Morphea: patches of sclerotic skin
 Localised scleroderma
Completion
 Hx
 Extra features
Classification
 Localised: morphea
 Systemic
 Diffuse (30%)
 Limited (70%): including CREST
Limited
 Distribution limited to below elbows and knees and face
 Slow progression: yrs
 Pulmonary HTN in ~15%
 CREST
 Calcinosis
 Raynaud’s phenomenon
 Esophageal dysmotility
 Sclerodactlyly
 Telangiectasia
Diffuse
 Widespread cutaneous and early visceral involvement
 Rapid progression: months
Ix
Urine
 GN: proteinuria and haematuria
ECG
 Arrhythmias
 RV strain
Bloods
 FBC: anaemia
 U+E: renal impairment
 Abs
 ANA: +ve in 90%
 Centromere: limited (80%)
 Scl70 (topoisomerase): diffuse (70%)
Imaging
 Hand radiographs: calcinosis
 CXR: fibrosis
 HRCT: fibrosis
 Echo: pulmonary HTN
Other
 Lung function tests: restrictive pattern
 Ba swallow: dysmotility
Mx
MDT: GP, rheumatologist, pulmonologist, cardiologist
Specific
 Immunosuppression used for organ involvement or
progressive skin disease.
Raynaud’s
 Gloves and hand-warmers
 CCBs: e.g. nifedipine
 Severe: prostacyclin infusion
Renal
 Aggressive blood pressure control
 ACEi
GI
 PPI for reflux
Pulmonary Hypertension
 Sildenafil
 Bosentan: dual endothelin receptor antagonist
Prognosis
 50% 5 year survival
 Mortality: respiratory failure and renal impairment
© Alasdair Scott, 2012
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Systemic Lupus Erythematosus
Examination
Viva
Face
Hx
 Malar “butterfly” rash: spares nasolabial folds
 Discoid rash ± scarring
 Hyperkeratotic papules
 Oral ulceration
 Anaemia
 Systemic: fever, wt. loss, fatigue
 Photosensitivity rashes
 Arthralgia
Features
 Multisystem inflammatory disease characterised by a
T3 hypersensitivity reaction against circulating immune
complexes.
 F>>M = 9:1
 ↑ in Afro-Caribbeans and Asians
Hands
 Vasculitic lesions: nail fold infarcts
 Raynaud’s phenomenon: digital ulceration
 Jacoud’s arthropathy
 Mimics RA
 Due to tendon contractures
 Reducible on extension
Skin
 Purpura
 Livedo reticularis
Extras
 Eyes: keratoconjunctivitis sicca
 Lungs
 Pleural rub
 Pleural effusion
 Fibrosis
 Cardio: pulmonary HTN
 Renal
 HTN
 Dipstick for nephrotic syndrome
 Neurology
 Focal neurology
 Chorea
Ix
Urine dip
 GN: proteinuria, haematuria
Bloods
 FBC: anaemia
 U+E: GN
 ESR
 Abs
 ANA: 100%
 dsDNA: 60% sensitive but very specific
 Anti-cardiolipin and lupus anticoagulant
 Complement
Disease Activity
 ↑ ESR
 ↑ CRP suggests infection
 ↓ C3, C4
 ↑ dsDNA titre
Mx
MDT: GP, rheumatologist in specialist SLE clinics
Mild disease: cutaneous and joints only
 Topical corticosteroids
 Sun cream
 Hydroxychloroquine
Moderate disease: + organ involvement
 Prednisolone
 Azathioprine
Severe Disease
 AIHA, nephritis, pericarditis, CNS disease
 High-dose methylprednisolone
 Cyclophosphamide
© Alasdair Scott, 2012
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Ankylosing Spondylitis
Examination
Viva
Back
Hx
 Thoracic kyphosis + neck hyperextension
 “Question mark posture”
 ↓ ROM throughout spine
 Protruberent abdomen: diaphragmatic breathing
 Symptoms
 Back pain: relieved by exercise
 Morning stiffness
 Anterior chest pain: costochondritis
 Eye pain
 Shortness of breath
 Cause
 Rashes
 Diarrhoea
Tests of Movement
 ↑ occiput to wall distance: >5cm
 Schober’s Test: <5cm
 ↓ chest expansion: <5cm
 Measure @ nipples
Tests for Sacroiliitis
 Direct pressure
 Sacroiliac stretch
 Pain on adduction of hip, c̄ hip and knee flexed
Extras





Anterior uveitis
Apical pulmonary fibrosis
Aortic regurgitation
Achilles tendonitis
Psoriatic plaques: psoriasis can → spondylitis
Completion
 ECG: AV block (10%)
 Dipstick: proteinuria in amyloidosis
 Hx
Differential
 Ankylosing spondylitis
 Psoriatic arthritis
 Other seronegative spondyloarthropathy
Ix
ECG
 AV block
Bloods
 FBC: anaemia
 ↑ ESR
 ↑ CRP
 Test for HLA-B27 allele (+ve in 95%)
Imaging
 Spine
 Sacroileitis: sclerosis, erosions
 Bamboo spine
 Syndesmophytes
 Ligament calcification
 Periosteal bone formation
 CXR
 Fibrosis
Other
 DEXA scan
 Osteoporosis in 60%
Mx
Conservative
 Exercise and physio
Medical
 NSAIDs
 Local steroid injections
 Anti-TNF in severe disease
 Bisphosphonates for osteoporosis
Surgery
 Hip replacement if involved
 Spinal osteotomy: rare
© Alasdair Scott, 2012
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Marfan’s Syndrome
Examination
Viva
General
Hx
Hands
Genetics
 Tall c̄ long arms
 Arm-span > height
 Arachnodactyly: encircle waste c̄ hands
 Hyperextensible joints
 Pulse
 Radio-radio delay: coarctation
 Collapsing
Face
 Cardiac problems
 Family history
 Autosomal dominant
 Chromosome 15
 Defect in the fibrillin protein
Ix
 High-arched palate
 Lens dislocation: upwards
Chest
 Pectus carinatum or excavatum
 Scars from cardiothoracic surgery
 Murmur
 AR: pitched early diastolic
 MVP: mid-systolic click, late systolic murmur
Completion
 Formally compare arm-span to height
 Palpate for thyroid mass
 Hx
 Phaeo: episodic headache, sweating, tachycardia
 Echo: aortic root dilatation
 Genetic testing
Mx
Surveillance
 Monitoring of aortic root size c̄ yearly TTE
Rx
 β-B and ACEi: slow aortic root dilatation
 Pre-emptive aortic root surgery: prevent dissection /
rupture
 Screen family members
Differential
 Marfan’s
 MEN2b
 Homocystinuria
 ↓ IQ
 Downward lens dislocation
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Tophaceous Gout
Osteoarthritis
Examination
Examination
 Asymmetric oligoarthritis of small joints of hands and feet
 Esp. 1st MTP
 Gouty tophi: joints, ears, tendons
 ↓ ROM and function
Extras





BMI: obesity
HTN
Drug chart: thiazides, cytotoxics
LNs: lymphoproliferative disorder
CRF: renal replacement therapy
Differential
 Pseudogout
 Septic arthritis
 Calcinosis from CREST
 Elderly pt.
 Walking stick
Hands
 Asymmetrical distal interphalangeal joint deformity
 Fixed flexion
 Squaring of the CMC joint of the thumb
 Heberden’s nodes: distal
 Bouchard’s nodes: proximal
 Disuse atrophy
 ↓ function
Extras
 Other joint involvement and scars
Differential
Viva
 OA
 Distal inflammatory arthritis: e.g. psoriatic
Hx




General
Drug Hx
Diet: beef, pork, lamb, seafood
EtOH
CV risk: smoking, lipids, BP, DM, FH
Cause
 Urate excess
 Drugs
 Drinking EtOH
 Diet: purine rich foods
 Decreased excretion: CRF
 Death of cells: leukaemia, lymphoma, psoriasis
Viva
Hx
 Pain and stiffness
 Esp. after rest
 Worse @ end of day
 Night pain
 Loss of function
 ADLs
 Other joint involvement
 Social circumstances
Radiographic Features
Ix
Bloods
 Lipids
 Glucose
 Urate levels
X-ray
 Punched-out peri-articular erosions
Joint aspiration
 Negatively birefringent needle-shaped crystals
Mx
Acute
 Remove cause and ↑ hydration
 1st: indomethacin or diclofenac
 2nd: colchicine
 3rd: steroids





Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
Deformity
Mx
Conservative
 ↓ wt. if affects wt. bearing joints
 Physio
 OT
 Social services if unable to perform ADLs
Medical
 Paracetamol
 NSAIDs ± weak opioids
Surgical
 Joint arthroplasty
Chronic
 Modify precipitants
 Allopurinol: XO inhibitor
 Mx cardiovascular risk
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Thyrotoxicosis
Examination
Viva
General
Hx
 Symptoms of thyrotoxicosis
 Heat intolerance, sweating
 ↑ appetite, ↓wt.
 Diarrhoea
 Anxious, irritable
 Visual problems, eye pain
 Oligomenorrhoea
 Triggers
 Child-birth
 Stress
 Infection
 Other AI disease
 Vitiligo
 T1DM
 Addison’s
 Thin
 Anxious
Periphery






Thyroid acropachy
Palmer erythema
Hot, sweaty palms
Tachycardia or AF
Pre-tibial myxoedema
Proximal myopathy
Neck
 Smooth, diffuse goitre
 May have bruit
Eyes
Ix
Non-specific
 Lid-lag
 Lid retraction (↑ tone of sup. tarsal muscle)
Bloods
 FBC: may be mild anaemia and neutropenia in Graves’
 TFTs: ↓TSH, ↑fT4, ↑fT3
 Abs: TSH, TPO
 Other: ↑ Ca, ↑ ESR, glucose (exclude DM)
Graves’
 Soft tissue swelling and Chemosis
 Exophthalmos
 Ophthalmoplegia: esp. upgaze
 Exposure keratopathy
 Optic atrophy
Completion




Cardiovascular examination: risk of heart failure
Examine the eyes for evidence of optic atrophy
Observation chart
Hx
Differential
 Graves’
 Thyrotoxic phase of a thyroiditis
 Simple colloid goitre
NB. Pts. c̄ Graves’ are often hyperthyroid but may become
eu- or hypo-thyroid.
Imaging
 CXR: retrosternal goitre
 US: assess for nodularity
 Radionucleotide scan (Tc or I)
 ↑ uptake in Graves’
 ↓ uptake in thyroiditis
Mx
Medical
 Propranolol
 Carbimazole
 Titrate according to TFTs, or
 Block and replace: ↓ risk of hypothyroidism
 Treat for ~12-18mo: ~30% remain euthyroid
Radioiodine
 CI: pregnancy, around children
 SE
 May worsen thyroid eye disease
 Most pts. become hypothyroid
Thyroidectomy
 SE
 Haematoma
 Recurrent laryngeal nerve injury
 Hypoparathyroidism
 Hypothyroidism
Thyroid Eye Disease
 Stop smoking: worsens the prognosis
 Symptomatic: artificial tears, dark glasses, elevate bed
 Severe
 High-dose steroids
 Surgical decompression
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Hypothyroidism
Examination
Viva
General
Hx
 Large body habitus
 Depressed mentation
 Gruff voice
 Symptoms
 Cold intolerance
 Appetite but ↑ wt.
 Constipation
 Menorrhagia
 Lethargy, tiredness
 Depression
 Cause
 Neck pain
 Iatrogenic
 Drugs
 Radioiodine
 Surgery
 Associated AI disease
 Vitiligo
 T1DM
 Addison’s
Skin
 Dry skin
 Other AI disease: vitiligo
Periphery




Cool
Bradycardia
Proximal myopathy
Slow-relaxing reflexes
Face





Coarse, puffy looking features
“Peaches-and-cream” complexion
Loss of lateral eyebrows
Xanthelasma
Thin hair
Neck
 Goitre
 Thyroidectomy scar
Completion
 Cardiac exam: evidence of failure
 Neurological exam
 Carpal tunnel syndrome
 Ataxia
 Observation chart
 Hx
Differential
 No goitre
 Atrophic thyroiditis
 Radioactive iodine
 Drugs: e.g. amiodarone
 Goitre: Hashimoto’s
 Scar: thyroidectomy
Other Differentials
Smooth Goitre
 Simple colloid goitre
 Hashimoto’s
 Graves’
Ix
Bloods
 FBC: ↑MCV ± macrocytic anaemia
 U+E: ↓Na
 TFTs: ↑TSH, ↓fT4
 Abs: TPO
 Other: ↑ cholesterol, glucose (exclude DM)
CXR
 Pericardial effusion
 CCF
Mx
 Thyroxine
 Titrate to clinical response and TSH
 If elderly introduce slowly to prevent precipitation
of angina / MI.
 Clinical improvement takes ~2wks
Causes of Hypothyroidism
Primary
 Autoimmune: 1O atrophic and Hashimoto’s thyroiditis
 Iatrogenic: rugs, surgery radioiodine
 Iodine deficiency: e.g. Derbyshire neck
 Genetic: thyroid agenesis
Secondary
 Hypopituitarism (v. rare)
Nodular Goitre
 Multinodular goitre
 Multiple adenomas
Solitary nodule
 Dominant nodule of a multinodular goitre
 Adenoma
 Malignancy
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Acromegaly
Examination
Viva
Hands
Hx





 Symptoms
 Headaches
 Problems c̄ vision
 Change in appearance
 Hat and ring size ↑
 Pain or paraesthesia in hands
 Snoring, stop breathing when sleeping (OSA)
 Associations
 Polyuria and polydipsia
 Chest pain, SOB, palpitations
 Change in bowel habit
 Cardiac risk factors
Spade-like: compare directly c̄ your own
Tight rings
↑ skin fold thickness
Boggy, sweaty palms: if active
Thenar wasting + loss of sensation: carpal tunnel syn.
Arms
 ↑BP
Face






Coarse facial features: large nose, big ears
Prominent supra-orbital ridges
Macroglossia
Widely spaced teeth: “show me your gums”
Prognathism: inspect from side
Look up nose for scars
Extras





Eyes: bitemporal hemianopia
Neck: goitre + ↑ JVP
Armpits: acanthosis nigricans
Abdomen: organomegaly
Myopathy: stand from chair w/o using hands
Completion




Urine dip: glycosuria
ECG: LVH and ischaemia
See any previous photographs
Hx
Macroglossia




Acromegaly
Amyloidosis
Hypothyroidism
Down’s syn.
Acanthosis Nigricans
 Endocrine
 Obesity and metabolic syndrome
 DM
 Cushing’s
 Acromegaly
 Malignancy
 Gastric Ca
 Pancreatic Ca
Ix
Urine dip: glycosuria
ECG: LVH, ischaemia
Bloods
 ↑ IGF-1
 Glucose tolerance test: non-suppression of GH
 Other pituitary hormones: TFT, PRL, testosterone
 Glucose
Imaging
 CXR: cardiomegaly
 MRI of pituitary fossa: pituitary adenoma
Other
 Visual perimetry
Complications
 IGT and DM
 Cardiovascular disease: leading cause of death
 CRC
Mx
General
 MDT: GP, endocrinologist, neurosurgeon
 CV risk
1st line: trans-sphenoidal excision
 Complications
 Meningitis
 Diabetes inspidus
 Panhypopituitarism
2nd line: medical therapy
 Somatostatin analogues: octreotide
 GH antagonist: pegvisomant
 Da agonists: cabergoline
3rd line: radiotherapy
Follow upyYearly
 Bloods: GH, PRL
 Visual fields
 ECG
 ± MRI head
© Alasdair Scott, 2012
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Cushing’s Syndrome
Examination
Viva
Hands
Hx
 Thin skin: compare c̄ your own
 Evidence of cause: e.g. RA
 Symptoms
 Headaches
 Visual disturbance
 Wt. gain
 Bruising
 Cause
 Steroid use
 Smoking
Arms
 BP
Face
 Moon face: “Cushingoid facies”
 Acne
 Hirsutism
Abdomen
 Central obesity
 Purple striae
Extras
 Proximal myopathy: stand from sitting
 Back
 Inter-scapular fat pad
 Palpate spine for tenderness (crush #)
 Kyphosis
Completion
 Urine dip: glycosuria
 Visual fields: bitemporal hemianopia
 Respiratory exam: wheeze, fine crackles
Significant Negative
 Pigmentation
 Signs of cause: RA, clubbing, COPD
Differential
 Cushing’s syndrome: effects of ↑ corticosteroids
 Cushing’s disease
 Bilateral adrenal hyperplasia 2O to ACTHsecreting pituitary tumour
 Usually a basophilic microadenoma
Causes
ACTH-independent
 Steroids: commonest by far
 Adrenal adenoma / carcinoma / hyperplasia
 Carney complex
ACTH-dependent
 Cushing’s disease
 SCLC
Ix
Urine dip: glycosuria
Confirm ↑ cortisol
 24h urinary free cortisol
 Loss of diurnal variation: ↑ midnight cortisol
 Low dose-dexamethasone suppression test
Investigate Cause
 ACTH levels
 ↑: pituitary adenoma or ectopic ACTH
 ↓: iatrogenic or adrenal
 High-dose dexamethasone suppression test
 >50% cortisol suppression if pituitary adenoma
 MRI pituitary fossa ± whole body CT
 Bilateral inferior petrosal sinus vein sampling
 Distinguish between ectopic ACTH and CD.
Complications
 Steroid complications
 Osteoporosis
 HTN and CV risk
Mx
General Mx
 Control BP
 Anti-DM
 Bisphosphonates
Cause
 Pituitary adenoma: trans-sphenoidal excision
 Adrenal adenoma: adrenelectomy
 Ectopic ACTH
 Tumour excision
 Metyrapone: inhibits cortisol synthesis
© Alasdair Scott, 2012
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Addison’s Disease
Examination
Viva
Main Signs
Hx
 Medic alert bracelet
 Hyperpigmentation
 Palmar creases
 Scars
 Buccal mucosa
 Postural hypotension
 Symptoms
 Wt. loss + anorexia
 Lethargy, depression
 Dizziness, faints
 Cause
 Other AI disease: DM, vitiligo
 TB
Extras
 Signs of AI disease
 DM
 Vitiligo
 Hyperthyroidism
 Signs of TB
Ix
Bloods
 U+E: ↓Na, ↑K
 ↓ glucose
 Abs: 21-hydroxylase (+ve in 80% c̄ AI disease)
Confirm Dx
 8am cortisol: low
 8am ACTH: high
 SynACTHen test: no ↑ in cortisol
Other
 CXR: TB
 AXR: adrenal calcification
Mx
Acute
 0.9% NS IV rehydration
 100mg hydrocortisone IV
 Rx cause: e.g. infection
Chronic
 Replace
 Hydrocortisone
 Fludrocortisone
 Pt. education and advice
 Don’t stop steroids suddenly
 ↑ dose during illness / stress
 Wear medic alert bracelet
 Carry steroid card
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Steroids: Key Facts
Neuro Shorts
Side Effects
Hemiballismus
MSK
 Proximal myopathy
 Osteoporosis
Features
 Involuntary flinging motions of the extremities
 Continuous and random
 Isolated to one side of the body
Endocrine
 HPA suppression
 Obesity
 DM
Metabolic
 Na and fluid retention
 HTN
 Hypokalaemia
Immune
 ↑ susceptibility to infection
CNS
 Depression
 Psychosis
Eye
 Cataracts
 Glaucoma
Management Considerations
 Use steroid-sparing agents where possible
 Use lowest dose possible
 Don’t stop suddenly or rapidly ↓ dose
 Withdraw gradually if used >2-3wks
 ↑ dose if stressed: illness or trauma
 Caution c̄ other drugs: e.g. NSAIDs
 Consider osteoporosis and PUD prophylaxis
Cause
 Damage to the subthalamic nucleus
 Usually a small infarct in diabetics
 MS
Mx
 Often resolves spontaneously
 Haloperidol
Benign Essential Tremor
Features
 Action / postural tremor
 Worse with movement
 Exacerbating factors
 Anxiety
 Caffeine
 Relieving factors
 Alcohol
 Sleep
Cause
 Autosomal dominant
Mx
 Alcohol
 Propranolol
 Primidone: anti-epileptic
Advice to Patients




Don’t stop steroids suddenly
Consult doctor when unwell
Carry a steroid card / alert bracelet
Avoid OTCs: e.g. NSAIDs
© Alasdair Scott, 2012
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Surgery
Contents
Superficial Lesions ................................................................................................................................................................... 91
Abdomen................................................................................................................................................................................ 105
Breast ..................................................................................................................................................................................... 128
Vascular ................................................................................................................................................................................. 134
Musculoskeletal ..................................................................................................................................................................... 150
Practical Surgery.................................................................................................................................................................... 168
Surgical Radiology ................................................................................................................................................................. 178
Instruments ............................................................................................................................................................................ 195
Key Anatomy.......................................................................................................................................................................... 217
© Alasdair Scott, 2012
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Superficial Lesions
Contents
Lump Examination ................................................................................................................................................................... 92
Skin Lumps .............................................................................................................................................................................. 93
Goitre ....................................................................................................................................................................................... 95
Diffuse Goitre: Key Facts ......................................................................................................................................................... 96
Solitary Thyroid Nodules .......................................................................................................................................................... 97
The Neck.................................................................................................................................................................................. 98
Midline and Anterior Triangle Lumps ....................................................................................................................................... 99
Posterior Triangle Lumps ....................................................................................................................................................... 100
Cervical Lymphadenopathy ................................................................................................................................................... 101
Salivary Glands ...................................................................................................................................................................... 102
Hypertrophic and Keloid Scars .............................................................................................................................................. 103
Digital Clubbing ...................................................................................................................................................................... 103
© Alasdair Scott, 2012
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Lump Examination
Key Points
Site
Size
Shape
Colour
Consistency
Contour
Cough impulse
Tenderness
Temperature
Transilluminence
Tethering
Fluctuance
Pulsatility
Spread (LNs)
Notes
 Is it intradermal or subcutaneous?
 Intradermal
 Cannot draw skin over lump
 Sebaceous cyst, neurofibroma, dermatofibroma
 Subcutaneous
 Can move lump independently from skin
 Lipoma, ganglion, lymph node
 Fluctuance: assess c̄ press test
 Consider auscultating for bowel sounds or bruits (AVMs).
Completion
 Examine draining lymph nodes
 Examine neurovascular function distal to lump.
 Look for similar lumps elsewhere
Hx
Onset
 When and why did you notice it?
 Any predisposing event: e.g. trauma?
Continued Symptoms
 What symptoms does it cause: e.g. pain?
 How has it changed?
 Have you noticed other lumps?
Treatments and Cause
 What treatments have you tried?
 What do you think the cause is?
© Alasdair Scott, 2012
92
Skin Lumps
Lump
Pathology
Features
Lipoma
Benign tumour of mature adipocytes
Inspection
Sarcomatous change probably doesn’t
occur.
Liposarcomas arise de novo
- Older pts.
- Deeper tissues of the lower limbs
Sebaceous
cyst
Epithelial-lined cyst containing keratin
Viva
Mx
Occur anywhere fat can expand
- i.e. NOT scalp or palms
- inc. spermatic cord,
submucosa
Dercum’s Disease / Adiposis dolorosa
- Multiple, painful lipomas
- Assoc. peripheral neuropathy
- Obese, postmenopausal women
Non-surgical
May be a scar from recurrence
Familial Multiple Lipomatosis
Madelung’s Disease
Palpation
Soft
Subcutaneous
Imprecise margin
Fluctuant
Inspection
Occur @ sites of hair growth
- Scalp, face, neck, chest, back
- NOT soles or palms
Central Punctum
Two histological subtypes
1) Epidermal Cyst
- Arise from hair follicle infundibulum
Ganglion
2) Trichilemmal Cyst / Wen
- Arise from hair follicle epithelium
- Often multiple
- May be autosomal dominant
Palpation
Cystic swelling related to a synovial-lined
structures: joint, tendon
Inspection
Myxoid degeneration of fibrous tissue
Contain thick, gelatinous material
Seborrhoeic
keratosis
Benign hyperplasia of basal cell layer
- Hyperkeratosis: corneum thickening
- Acanthosis: spinosum thickening
- Hyperplasia of basal cells
© Alasdair Scott, 2012
Surgical Excision
Firm
Smooth
Intradermal
Can be found anywhere
Often dorsum of hand or wrist
May be scar from recurrence
Weakly transilluminable
Soft
Subcutaneous
May be tethered to tendon
Stuck on appearance
Dark brown
Greasy
Bannayan-Zonana Syndrome
- Autosomal dominant
- Multiple lipomas
- Macrocephaly
- Haemangiomas
Complications
- Infection: pus discharge
- Ulceration
- Calcification
Non-surgical
Surgical Excision
Cock’s Peculiar Tumour
- Large ulcerating trichilemmal cyst
on the scalp
- Resemble an SCC
Gardener’s Syndrome: FAP +
- Thyroid tumours
- Osteomas
- Dental abnormalities
- Epidermal cysts
Differential
- Bursae
- Cystic protrusion from synovial cavity of
arthritic joint.
Non-Surgical
- Aspiration followed by
3wks of immobilisation
Surgical Excision
- Recurrence in 50%
- Neurovasc damage
Palpation
Non-surgical
Surgical: superficial shaving or cautery
93
Lump
Pathology
Features
Neurofibroma
Benign nerve sheath tumour arising
from schwann cells.
Inspection
Solitary or multiple
Pedunculated nodules
Palpation
Fleshy consistency
Pressure can → paraesthesia
Examine skin: Café-au-Lait Spots
Examine the eyes: Lisch nodules
Examine the axilla: Freckles
Examine the cranial nerves (esp. 8)
BP
Extras
Papilloma
Pyogenic
granuloma
Overgrowth of all layers of the skin c̄ a
central vascular core.
Skin tag / fibroepithelial polyp
Rapidly growing capillary haemangioma.
Inspection
Palpation
Epidermal-lined cyst deep to the skin
Congenital / Inclusion Cyst
- Developmental inclusion of
epidermis along lines of skin fusion
- Midline of neck and nose
- Medial and lateral ends of eyebrows
Inspection
Benign neoplasm of dermal fibroblasts
Benign overgrowth of hair follicle cells
Cytologically similar to well-differentiated
SCCs
© Alasdair Scott, 2012
Possible assoc. c̄ prev trauma
More common in pregnancy
Smooth spherical swelling
Sites of embryological fusion
Scar from recurrence
Child / young adult: congenital
Soft
Non-tender
Subcutaneous
Inspection
Can occur anywhere
Mostly on the lower limbs of young to
middle-aged women
Palpation
Keratoacanthoma
Local regrowth is common
Excision + diathermy to
control bleeding.
Most commonly on hands, face, gums
and lips.
Bright red hemispherical nodule
May have serous / purulent discharge
Soft
Bleed very easily
Palpation
Acquired / Implantation Cyst
- Implantation of epidermis in dermis
- Often 2O to trauma (e.g. piercing)
Dermatofibroma
Mx
Surgical excision only
indicated if malignant
growth suspected.
Pedunculated
Flesh coloured
Neither pyogenic, nor a granuloma
Dermoid Cyst
Viva
NF 1: von Recklinghausen’s
- AD, Chr 17
- Cafe-au-lait spots (>6, >15mm)
- Freckling
- Neurofibromas
- Lisch nodules (iris)
Non-surgical
- regression is uncommon
Surgical
- curettage c̄ diathermy of
the bases
Adult: acquired
- Ask re. trauma
Congenital
- CT to establish extent
- Surgical excision
Acquired
- Surgical excision
Differential
- Malignancy: melanoma, BCC
Excision + histology
Small, brown pigmented nodule
Firm, woody feel: characteristic
Intradermal: mobile over deep tissue
Fast-growing
Dome-shaped c̄ a keratin plug
Intradermal
Regress w/i 6wks
Excise to reduce scarring
and obtain histology
94
Goitre
Thyroid Examination
Viva
Preparation
Goitre Differential




Ensure exposure down to the clavicles
Position pt. away from a wall
Are you comfortable: not too hot or cold?
Hoarse voice: recurrent laryngeal nerve palsy
General Inspection




Nervous/agitated or slow/lethargic
Body habitus
Sweaty
Skin and hair condition
Hands





Thyroid acropachy
Palmar erythema
Temperature, sweating
Fine tremor: piece of paper on out-stretched hands
Pulse: rate and rhythm (AF in thyrotoxicosis)
Eyes
 Sympathetic Overstimulation
 Lid Retraction: sclera between iris and upper lid
 Lid Lag
 Graves
 Oedema: periorbital and chemosis
 Exophthalmos: inspect from above and side
 Ophthalmoplegia: esp. upgaze palsy
Exophthalmos Differential
 Orbital cellulitis
 Trauma
 Masses: meningioma, glioma
 Carotid cavernous fistula: pulsatile exophthalmos
 Idiopathic orbital inflammatory disease
Diffuse Enlargement
 Smooth
 Simple colloid goitre
 Graves
 Thyroiditis: Hashimoto’s, de Quervain’s, Riedel’s
 Nodular
 Multinodular goitre
 Multiple adenomas
Solitary Nodule
 Dominant nodule of a multinodular goitre
 Adenoma
 Malignant
O
 1 : papillary, follicular, medullary, anaplastic
 2O: breast
 Cyst
Commonest Causes of
Hyperthyroidism
 Graves’ (~2/3)
 Toxic Multinodular Goitre ( = Plummer’s)
Hypothyroidism
 Primary atrophic
 Hashimoto’s thyroiditis
 Iodine deficiency: commonest Worldwide
Hx
 Thyroid status
 Compression symptoms: dysphagia, difficulty breathing
 Previous thyroid medications or surgery
Neck
Ix
Inspect: from front and side.
 Look for collar scars
 Ask pt. stick out tongue and swallow water
 Look in mouth for lingual thyroid
Bloods
 TFTs: TSH, fT3, fT4
 Other: FBC, Ca2+, calcitonin, ESR
 Antibodies: anti-TPO, TSH
Palpate: from behind
 Palpate masses: can you get under it?
 Repeat the swallow and protrusion test
 Lymphadenopathy
 Check for tracheal deviation.
Imaging
 CXR: goitre and mets
 High resolution US
 CT
 Radionucleotide (Tc or I) scan: hot vs. cold
Percuss: for retrosternal extension
Histology or cytology
 FNAC (can’t distinguish adenoma vs. follicular Ca)
 Biopsy
Auscultate: thyroid bruits (Graves’)
Legs
 Pretibial myxoedema: brown swelling above lat. malleoli
 Proximal myopathy: ask pt. to stand from chair (Graves)
 Ankle reflexes: kneel on chair
 Slow relaxing: hypothyroidism
 Brisk: hyperthyroidism
Completion
 Observation chart
 History
© Alasdair Scott, 2012
Laryngoscopy
 Important pre-op to assess vocal cords
Discussion





Multinodular goitre
Graves’
Thyroiditis
Thyroid Nodules
Thyroid surgery
95
Diffuse Goitre: Key Facts
Multinodular
Smooth
Features
Simple Colloid Goitre
 Commonest goitre in UK
 Progression of simple diffuse goitre to nodular
enlargement.
 Middle-aged women
 Positive family Hx
 Over-activity in parts may → mild thyrotoxicosis
 Plummer’s Syndrome
 Malignant change occurs in 5% of untreated MNGs
 Hyperplasia of gland 2O to ↑TSH release
Causes
 Iodine deficiency: commonest worldwide
 ↑ physiological demand: pregnancy, puberty
 Goitrogens: e.g. Li, uncooked cabbage
Rx
Mx
 Not usually required
 Thyroxine or ↑ dietary iodine
 Most pts. don’t require intervention
Non-Surgical
 Thyroxine → regression in 50-70%
 Suppress TSH
 Toxic Multinodular Goitre
 Propranolol + carbimazole
 Radioiodine
Surgical
 Indications: 5 Ms
 Mechanical obstruction
 Malignancy
 Marred beauty: cosmetic reasons
 Medical Rx failure: thyrotoxicosis
 Mediastinal extension: can’t monitor changes
 Procedure
 Total thyroidectomy
 Removes risk of malignant change in thyroid
remnant.
Plummer’s vs. Graves
Plummer’s
 Older
 Nodular enlargement
 No extra features
 AF in 40%
 No assoc. AI disease
Graves’
 Younger
 Diffuse enlargement
 Extra Features
 Eye signs
 Dermopathy
 Acropachy
 AF relatively uncommon
 Assoc. c̄ AI disease
Grave’s Disease: ↑ uptake
Epidemiology
 Prev: 0.5%
 60% of cases of thyrotoxicosis
 Sex: F>>M=9:1
 Age: 40-60yrs
Features
 Diffuse goitre c̄ bruit
 Triggers: stress, infection, child-birth
 Ophthalmopathy
 Oedema: periorbital and chemosis
 Exophthalmos → exposure keratopathy
 Ophthalmoplegia: esp. upgaze palsy
 Optic neuropathy: ↓ acuity and RAPD
 Dermopathy: pre-tibial myxoedema
 Acropachy: periosteal reaction (clubbing is soft tissue)
Pathology of Eye Disease
 Exophthalmos
 Retro-orbital inflammation and lymphocytic
infiltration → orbital oedema
O
 2 to anti-TSH abs
 Lid-lag
 Not Graves’ specific
 Sympathetic overstimulation → restrictive
myopathy of LPS
Associations
 T1DM
 Vitiligo
 Pernicious anaemia
Rx
 Medical: propranolol + carbimazole
 Radioiodine
 Surgical: subtotal or total thyroidectomy
Thyroiditis: ↓ uptake




© Alasdair Scott, 2012
Hashimoto’s
de Quervain’s
Subacute lymphocytic: post-partum
Riedel’s
96
Solitary Thyroid Nodules
Benign
Pathology
Follicular Adenoma
Thyroid Cyst
Features
2-4cm mass
± thyrotoxicosis
Indistinguishable from follicular Ca on FNAC
- need excision histology to confirm Dx
True cysts are rare
Mostly colloid degeneration, necrosis or
haemorrhage w/i benign or malignant tumours
Only benign if abolished by aspiration
Mx
Hot
- <3cm: radioiodine
- >3cm: surgical excision
Cold: excision
Cytology can be false negative in 30%
<4cm: aspirate and review in 6/12
Surgical Excision
- >4cm
- Blood-stained aspirate
- Recurrence after aspiration
Malignant
Disease
Papillary
Frequency
80%
Age
20-40
Assoc. c̄
irradiation
Follicular
10%
F>M = 3:1
Cell Origin
Follicular cells
Tg tumour marker
40-60
Follicular cells
Spread
Nodes and lung
- JDG node =
lateral aberrant
thyroid
Mx
Total thyroidectomy +
T4 to suppress TSH
± node excision
± radioiodine
May be multifocal
Blood → bone
and lungs
>95% 10ys
Total thyroidectomy +
T4 suppression +
Radioiodine
Tg tumour marker
Medullary
Anaplastic
Lymphoma
5%
30% are familial
- e.g. MEN2
MEN2: young
Sporadic: 40-50
Rare
F>M = 3:1
>60
5%
Thyroid Nodule Facts





F>M = 4:1
4th and 5th decades
10% malignant in middle aged
50% malignant in young and elderly
FNAC is most important Ix
Ix: Triple Assessment
 Clinical examination
 US
 FNAC
Rapid growth
>95% 10ys
Do phaeo screen pre-op
Thyroidectomy +
Node clearance
Consider radiotherapy
Usually palliative
Aggressive: local,
LN and blood.
May try thyroidectomy +
radiotherapy
Parafollicular C-cells
CEA and calcitonin
markers
Undifferentiated
follicular cells
Lymphocytes
- MALToma in Hashi’s
<1% 10ys
Chemoradiotherapy
Complications of Thyroid Surgery
Early




Reactionary haemorrhage → haematoma
Recurrent laryngeal nerve palsy
Hypocalcaemia
Thyroid storm
Late
 Hypothyroidism and hypoparathyroidism
 Recurrence of disease
 Keloid scar
Isotope scan: used if pt. is hyperthyroid
Men 1: Wermer Syndrome
 Pituitary adenoma
 Parathyroid hyperplasia or adenoma
 Pituitary endocrine tumour
Men 2




Medullary thyroid Ca
Phaeochromocytoma
A: hyperparathyroidism
B: marfanoid habitus
© Alasdair Scott, 2012
Practicalities of Thyroid Surgery





Render euthyroid pre-op c̄ antithyroid drugs
Stop 10 days prior to surgery (they ↑ vascularity)
Alternatively just give propranolol
Check for phaeo pre-op in medullary carcinoma
Laryngoscopy: check vocal cords pre- and post-op
97
The Neck
Examination
Preparation
 Ensure exposure down to the clavicles
 Position pt. away from wall
Inspect: Scars, Sinuses, Masses
 Neck
 Look very carefully for scars: collar incision
 Look for masses: which triangle?
 Does mass move on swallowing or tongue
protrusion?
 Mouth
 Lingual thyroid
 Ranula (ruptured salivary gland → mucocele)
 Eyes
 Thyroid eye disease
Differential
Position
Anywhere
Midline
Ant. Triangle
Post. Triangle
Ix
Solid
Cystic
Lipomas and Sebaceous Cysts
Ectopic thyroid tissue Thyroglossal Cyst
Thyroid isthmus mass
Inclusion dermoid
LNs
Branchial Cyst
Chemodectoma
Laryngocele
Goitre
Parotid tumour
LNs
Cystic Hygroma
Cervical Rib
Pharyngeal Pouch
Pancoast tumour
 US shows consistency
 FNAC or core biopsy
 Consider CT / MRI to define relations
Palpate




Best from behind the pt.
Palpate while pt. swallowing and protruding tongue
Assess for lymphadenopathy
Tracheal deviation
Percuss
 Retrosternal extension
Auscultate
 Listen over lump for bruits.
 Gurgle of pharyngeal pouch
Hx
Onset
 When and why did you notice it?
 Any predisposing event: e.g. trauma?
Continued Symptoms
 What symptoms does it cause: e.g. pain?
 How has it changed?
 Have you noticed other lumps?
Treatments and Cause
 What treatments have you tried?
 What do you think the cause is?
If no obvious masses / skin lesions
 Check neck pulses and listen for bruits
 Test sensation and neck movements
Completion
 If goitre → asses thyroid status
 Lump history
© Alasdair Scott, 2012
98
Midline and Anterior Triangle Lumps
Lump
Pathology
Presentation
Viva
Mx
Thyroglossal Cyst
Persistence of any part of the thyroglossal duct
which marks the developmental descent of the
thyroid from the foramen caecum
Young pt.
Differential
- Thyroid nodule and masses
- Dermoid / epidermal cysts
- Subhyoid bursa
Sistrunk’s Operation
- Inject patent tract c̄ dye at start
- Excise cyst and patent tract
- Need to central portion of hyoid
as tract runs through it.
Ectopic thyroid tissue can be found anywhere
along this path of descent.
Cysts may contain thyroid tissue which can
undergo malignant change → papillary Ca
Fluctuant midline neck lump
Usually subhyoid
Protrusion of tongue → elevation
Swallowing → elevation
May see opening of a thyroglossal
sinus
Following removal there will be a
transverse incision just above the
thyroid cartilage.
Branchial Cyst
Failed fusion of 2nd and 3rd branchial arches
Young pt.
Lined by squamous epithelium
Ant. margin of SCM at junction of
upper and middle thirds
Epidemiology
- Rare
- M=F
st
- 40% in 1 decade
Complications
- Infection
- Sinus formation
- Development of Ca
- Recurrence post-op
Complications
- Infection
- Sinus formation
- Recurrence post-op
Contain “glary” fluid c̄ cholesterol crystals
Firm, fluctuant ovoid swelling
Opaque on transillumination
Surgical Excision
- Bonney’s blue dye can be
injected into fistula to allow more
accurate excision
- May be difficult due to proximity
of carotids
Medical
- Sclerotherapy is an option
May be opening from branchial sinus
Chemodectoma
Very rare
Ant. triangle @ the angle of the jaw
Tumour of the paraganglion cells of the carotid
bodies: measure pH and PaO2 and PaCO2
Pulsatile
Moves laterally but not vertically
Located @ the carotid bifurcation
Pressure can → syncope
Ix
- Duplex US
- Angiography: splaying
- CT / MRI
Surgical Excision
Ultrasonic surgical dissection
Radiotherapy
- Large tumours
- Unfit for surgery
Mostly benign (5% malignant)
May be bilateral
© Alasdair Scott, 2012
99
Posterior Triangle Lumps
Lump
Pathology
Presentation
Viva
Mx
Cystic Hygroma
Congenital multicystic lymphatic malformation
Usually paediatric
Lobulated cystic swelling
Soft and fluctuant
Compressible
Transilluminate brilliantly
↑s in size when infant coughs / cries
Complications
- Obstruction of swallowing
- Respiratory obstruction
Surgical excision
Hypertonic saline sclerosant
Symptoms
- Regurgitation
- Dysphagia
Non-surgical
- If small and asymptomatic
Look in the oropharynx
- Cyst may extend into
retropharyngeal space
Pharyngeal Pouch
Herniation of pharyngeal mucosa through its
muscular coat at its weakest point.
- Pulsion diverticulum
Elderly patient
Killian’s dehiscence
- Between thyro- and crico-pharyngeal muscles
that form the inferior constrictor
Palpation → gurgling
Left sided cystic swelling
Hallitosis
Complications
- Aspiration → pneumonia
- Diverticular neoplasia (<1%)
Surgical: Dohlman’s Procedure
- Minimally invasive endoscopic
stapling
Ix
- Ba swallow
Cervical Rib
Overdevelopment of transverse process of C7
Hard swelling: mostly asymmpto
Occur in 1:150
Can → vascular symptoms
- Due to subclavian A. compression
- Subclavian steal
- Raynaud’s
Surgical excision
Can → neurological symptoms
- Compress lower roots of brachial
plexus, T1 or stellate ganglion
- Wasting of intrinsic hand muscles
- Paraesthesia along medial arm
© Alasdair Scott, 2012
100
Cervical Lymphadenopathy
Examination
Viva
Key Features
History





 Symptoms from the lumps
 e.g. EtOH-induced pain
 General symptoms
 Fever, malaise, wt. loss
 Systemic disease
 PMH
 Previous operations
 Social history
 Ethnic origin
 HIV risk factors
Consistency
Number
Fixation
Symmetry
Tenderness
Technique






Ask pt. to drop chin to relax muscles
Chin backwards → pre-auricular
Down anterior cervical chain
Supra- and infra-clavicular nodes
Up posterior cervical chain
Mastoid → occipital nodes
Causes: LIST




Additional Examination





Face and scalp for infection or neoplasm
Chest exam: infection or neoplasm
Breast examination
Formal full ENT examination
Rest of reticuloendothelial system
Lymphoma and Leukaemia
Infection
Sarcoidosis
Tumours
 ENT
 Breast
 Lung
 Gastric
Infection
 Bacterial
 Tonsillitis, dental abscess
 TB
 Bartonella henselae (Cat scratch disease)
 Viral
 EBV
 HIV
 Protozoal
 Toxoplasmosis
Ix
Blood
 FBC, ESR, film (atypical lymphocytes)
 TFTs, serum ACE
 Monospot test, HIV test
Radiological
 US
 CT scan
Pathology
 FNAC
 Excision biopsy
© Alasdair Scott, 2012
101
Salivary Glands
Examination
Viva
Inspection
Hx
 Skin changes: swelling, scars, sinuses
 Swelling / discrete lump
 Parotid or submandibular?
 Bilateral or unilateral?
 Facial asymmetry
 Inside the mouth c̄ a pen torch
 Stenson’s duct opposite the 2nd maxillary molar
 Wharton’s duct adjacent to the frenulum linguae
 Inflammation, stone, pus
Palpation




Any tenderness?
Palpate from behind
Test muscle fixity: ask pt. to clench teeth
Palpate for cervical lymphadenopathy
Completion
 Bimanual palpation of parotid and submandibular ducts
for stones.
 Bimanual palpation of submandibular gland
 Test CN7
 Perform full ENT examination
Differential
Diffuse Swelling of Whole Gland
 Infection: Parotitis
 Autoimmune: Sjogren’s
 Infiltration: Sarcoid
 Systemic: Chronic liver disease, DM, anorexia, bulimia
Localised Swelling
 Calculus
 Lipoma
 Salivary gland neoplasm
 Leukaemia: ALL




Pain or swelling related to food: calculi
Fever / malaise: mumps
Dry eyes / mouth: Sjogren’s
SOB: sarcoid
Salivary Gland Neoplasms
Features
 80% in the parotid gland
 80% benign: 80% are pleiomorphic adenomas
 Only 60% of submandibular gland tumours are benign
Common Types
 Benign
 Pleiomorphic adenoma: 80%
 <50yrs
 Adenolymphoma: Warthin’s tumour
 >50yrs
 Smoking is important risk factor
 Malignant
st
 1 : Mucoepidermoid
 2nd: Adenoid cystic
Malignant Features





Ix
Facial nerve palsy
Rapid growth and pain
Hyperaemic, hot skin
Hard consistency
Fixity to skin or underlying muscle
 FNAC
 MRI: determine deep lobe involvement
Rx
 Benign
 Superficial: superficial parotidectomy
 Deep: total parotidectomy
 Malignant
 Total parotidectomy ± adjuvant radiotherapy
Complications
 Immediate
 Facial nerve injury
 Reactionary haemorrhage
 Early
 Temporary facial weakness: neuropraxia
 Salivary fistula
 Loss of pinna sensation: greater auricular nerve
damage.
 Late: Frey’s Syndrome (gustatory sweating)
 Facial sweating while eating
 Re-innervation of divided sympathetic nerves by
fibres from the secretomotor branch of
auriculotemporal branch of CNV3
© Alasdair Scott, 2012
102
Hypertrophic and Keloid Scars
Digital Clubbing
Features
Causes
 Scar more prominent than surrounding skin
Hypertrophic






Scar confined to wound margins
Across flexor surfaces and skin creases
Appear soon after injury and regress spontaneously
Any age: commonly 8-20yrs
M=F
All races
Keloid






Scar extends beyond wound margins
Earlobes, chin, neck, shoulder, chest
Appear months after injury and continue to grow
Puberty to 30yrs
F>M
Black and Hispanic
Wound Associations





Infection
Trauma
Burns
Tension
Certain body areas
Gastrointestinal




CLD: esp. PBC
IBD: esp. Crohn’s
Coeliac disease
GI lymphoma
Respiratory
 Chronic suppurative lung disease
 CF / bronchiectasis
 Abscess
 Empyema
 Malignancy: adenocarcinoma or mesothelioma
 Pulmonary fibrosis
Cardiac
 Infective endocarditis
 Congenital cyanotic heart disease
 Fallot’s
 Transposition
 Atrial myxoma: e.g. in Carney Complex
Miscellaneous
 Familial
 Thyroid acropachy
 Axillary artery aneurysms and brachial AVMs
Pathophysiology
Mx
Non-surgical
 Mechanical pressure therapy
 Topical silicone gel sheets
 Intralesional steroid and LA injections
Surgical
 Revision of scar c̄ closure by direct suturing
© Alasdair Scott, 2012
 Exact aetiology unknown
 Platelet clumps and megakaryocytes bypass the lungs
and impact in digital capillaries.
 They release growth factors such as PDGF → clubbing
Stages




1: bogginess of the nail bed
2: loss of the nail angle
3: ↑ curvature
4: expansion of the distal phalanx
103
Abdomen
Contents
Abdominal Examination ......................................................................................................................................................... 105
Inguinal Hernia ....................................................................................................................................................................... 106
Inguinal Hernia: Key Facts ..................................................................................................................................................... 107
Incisional Hernia .................................................................................................................................................................... 108
Umbilical and Paraumbilical Hernia ....................................................................................................................................... 109
Epigastric Hernia.................................................................................................................................................................... 110
Examination of a Scrotal Lump .............................................................................................................................................. 111
Hydrocele ............................................................................................................................................................................... 112
Epididymal Cyst ..................................................................................................................................................................... 113
Varicocele .............................................................................................................................................................................. 113
Testicular Tumour .................................................................................................................................................................. 114
Stomas ................................................................................................................................................................................... 115
Stomas: Key Facts ................................................................................................................................................................. 116
Surgical Scars ........................................................................................................................................................................ 117
Colonic Resections ................................................................................................................................................................ 119
Inflammatory Bowel Disease ................................................................................................................................................. 122
IBD: Key Facts for Surgery .................................................................................................................................................... 123
Surgical Jaundice................................................................................................................................................................... 124
Right Iliac Fossa Mass ........................................................................................................................................................... 125
Abdominal Masses................................................................................................................................................................. 126
© Alasdair Scott, 2012
104
Abdominal Examination
The Abdomen
Set-Up
 Pt. exposed from nipples to pubis
 Lying flat
Inspection
Peripheral Stigmata
General
 General condition of the pt.
 Jaundice (BR >50mM), pallor (Hb <7g/dL)
 Cachexia
 Abdominal distension
 Abdominal asymmetry
 Drains, stomas, scars
 Ask pt. to cough and lift head from bed
Hands
CLD
1. Clubbing
2. Leukonychia
3. Terry’s nails
 White ground glass nail
 Loss of lunula
 Pink tips
4. Palmer erythema
5. Dupuytron’s contracture
6. Asterixis
Abdominal Clubbing ∆∆
 Cirrhosis: esp. c̄ PBC
 IBD
 Coeliac
 GI lymphoma
Distension: fat, fluid, flatus, faeces, foetus
Scars: describe location and healing
Stomas: site, contents, lumens, spout
Drains: contents, type
Asymmetry: masses
Palpation
 Kneel on floor and look @ pts. face for pain
 Superficial, then deep
 Describe any masses
 Liver
 Note consistency, edge, tenderness, pulse
 Percuss
 Spleen
 Role pt. towards you
 Percuss if palpable
 Kidneys
 Left then right
 Ballot c̄ respiration
 AAA
 Just to left on midline, above the umbilicus
Percussion
Anaemia
 Koilonychia
 Pale palmer creases
 Percuss any masses or organomegaly
 If distended, percuss for shifting dullness
Pulse and BP
Auscultate
 Bowel sounds
 Aortic bruits
Face
Eyes









Keiser Fleischer rings
Pale conjunctivae
Jaundice
Xanthelasma
Palpate Ankles for Oedema
Completion
Mouth
 Telangiectasia: HHT
 Pigmented macules: Peutz-Jehgers
 Stomatitis and glossitis
 Ulceration
 Jaundice





Digital rectal examination
External genitalia
Stand pt. to examine hernial orifices
Dipstick the urine
Look at the observation chart
Neck
 Inspect for scars: venous lines
 Sit forward and palpate for lymphadenopathy: esp.
Virchow’s node in left supraclavicular fossa
Back
 Inspect back c̄ pt. sitting forward
 Spider naevi
 Scars: e.g. loin incisions
Chest
 Spider naevi
 Gynaecomastia
 Loss of axillary hair
© Alasdair Scott, 2012
Spider Naevi
 Central arteriole c̄ radiating vessels
 Fill from the centre
 Telangiectasia fill from edge
 Distribution of SVC
 >4 abnormal
 ∆∆: CLD, OCP, pregnancy
105
Inguinal Hernia
Examination
Viva
Set-Up
Groin Lump Differential
 Expose pt. from umbilicus to knees
 Begin c̄ pt. standing
Inspection
 Look for any masses in groins. Ask pt. to cough.
 Comment on appearance of mass
 Site, size
 Features of inflammation (suggesting strangulation)
 Look for any scars
 Previous hernia operations
 Appendicectomy: ? risk factor for direct hernia
Palpation




Check if pt. in any pain.
Palpate from the side of the pt.
Palpate mass for cough impulse
Define anatomy: relation to pubic tubercle?
 Above (and medial): inguinal hernia
 Below (and lateral): femoral hernia
 Does mass extend into scrotum?
 Inguinoscrotal hernia are more likely to be indirect
 Auscultate for bowel sounds
 Hernia may lack bowel sounds if it just contains fat.
Repeat Inspection and Palpation c̄ pt. Supine
 Does the mass disappear when lying down?
Test for Direct vs. Indirect Hernia
 Ask pt. to reduce hernia
 Place 2 fingers over deep ring and ask pt. to cough.
 Mid pt. of ing. lig. or 1.5cm above femoral pulse
 Hernia controlled = indirect
 Not controlled = direct
 Not an accurate test: definitive determination in theatre.
Wash hands
Complete Examination
 Examine external genitalia: incidental lumps, testes
 Examine contralateral groin
 Examine abdomen
 Evidence of ↑ IAP: masses, ascites
 Other hernias: paraumbilical, umbilical
© Alasdair Scott, 2012
Tissue
Skin
Fat
Connective tissue
Nerves
Lymphatics
Veins
Arteries
Inguinal canal
Femoral canal
Testes
Lump
Sebaceous cyst, psoas abscess
Lipoma
Fibroma
Neuroma of femoral N.
LN
Saphena varix
Femoral artery aneurysm
Inguinal hernia
Hydrocele or lipoma of the cord
Femoral hernia
Undescended testis
4 distinguishing features of an inguinal hernia
 Above and medial to pubic tubercle
 Cough impulse
 Reducible
 Bowel sounds
Hx





Predisposing factors: cough, straining, lifting
Pain
Reducible
Episodes of obstruction or strangulation
Previous repairs
Mx
Conservative
 Manage RFs: e.g. constipation, cough
 Weight loss
 Elasticated corset or truss
Surgical
 Open: Lichtenstein Tension Free Mesh
 Lap: TEP or TAPP mesh
Discussion







Difference between direct and indirect inguinal hernia
Difference between inguinal and femoral hernias
Inguinal canal anatomy
Contents of the spermatic cord
Recovery from inguinal hernia repair
Operative techniques
Complications of repair
106
Inguinal Hernia: Key Facts
Definition
Surgery
Anatomy
Open
 Open can be done under LA or GA: day case
 RCS recommends the Lichtenstein Tension Free
Mesh Repair
 Less recurrence cf. older Shouldice Repair
 Protrusion of a viscus or part of a viscus into an abnormal
position through a defect in its containing cavity.
Inguinal Canal




Ant: ext. oblique + int. oblique for lateral 3rd
Post: transversalis fascia + conjoint tendon for medial 3rd
Floor: inguinal ligament
Roof: arching fibres of transversus and int. oblique
Femoral Canal





Med: lacunar ligament
Lat: femoral vein
Ant: inguinal ligament
Post: pectineal ligament (of Cooper)
Contents: fat and Cloquet’s Node
Contents of Inguinal Canal
 M: spermatic cord + ilioinguinal N.
 F: round lig., ilioinguinal N., gen branch of genfem N.
Contents of Spermatic Cord




3 layers of fascia
3 arteries + 3 veins
2 nerves
3 other things
Operative Distinction
 Indirect: arise lateral to inf. epigastric vessels
 Direct: arise medial to inguinal ligament, through
Hesselbach’s Triangle
 Med: rectus abdominis muscle
 Lat: inf. epigastric artery
 Inf: inguinal ligament
Classification of Inguinal Hernias
 Open and lap approaches: lap if bilateral / recurrent
 Mention risk of testicular damage when consenting pt.
NB. In children, simple ligation and division of the patent
processus suffices: no mesh needed.
Lap
 2 main techniques
 Totally ExtraPeritoneal (TEP)
 Trans-Abdominal Pre-Peritoneal (TAPP)
 Better for bilateral hernia
Complications
Early




Urinary retention
Haematoma / seroma formation: 10%
Infection: 1%
Intra-abdominal injury (lap)
Late
 Recurrence: <2%
 Ischaemic orchitis: 0.5%
O
 2 thrombosis of pampiniform plexus
 Chronic groin pain / paraesthesia: 5%
Post-Op Recovery







Pee before leaving
Early mobilisation is important
Can be painful: given good analgesia
Avoid constipation: lactulose
Keep the area clean and dry: wash carefully
Can bathe immediately
Work in 1-2wks (6wks if heavy lifting)
Indirect: 80%





Commoner in young
Congenital patent processus vaginalis
Emerge through deep ring
Same 3 coverings as cord and descend into the scrotum
Can strangulate
Direct: 20%






Commoner in elderly
Acquired: weak posterior wall of canal
Emerge through Hesselbach’s triangle
Can acquire internal and external spermatic fascia
Rarely descend into scrotum
Rarely strangulate
Clinical Distinction
Femoral Hernia




Commoner in females (wider femoral canal)
Middle aged and elderly
Neck is inferior and lateral to pubic tubercle
High risk of obstruction and strangulation
Mx
 50% risk of strangulation w/i 1mo
 Urgent surgery
Elective: Lockwood Low Approach
 Low incision over hernia c̄ herniotomy and
herniorrhaphy (suture ing. ligt. to pectineal ligt.)
Emergency: McEvedy High Approach
 Cameron, BJS 1994
 High approach in inguinal region to allow inspection
 56% of direct hernias were wrongly classified as indirect on
and resection of non-viable bowel.
examination by consultant surgeons.
 Then herniotomy and herniorrhaphy
© Alasdair Scott, 2012
107
Incisional Hernia
Examination
Viva
Inspection
Hx





Pt. may be overweight
Describe scars + drain sites
Any evidence of inflammation (e.g. from strangulation)
Ask pt. to lift head off bed
Ask pt. to cough
Palpation




Any tenderness?
Feel for presence of defect
Ask pt. to cough while feeling for an impulse
Is the defect present along the whole length of the scar?
 Size of defect relates to risk of strangulation
 If a lump is present, can it be reduced?
Auscultate
 For bowel sounds




Previous surgery
Post-operative wound infection or other complications
Co-morbidities → ↑ risk: e.g. chronic cough
Discomfort or episodes of obstruction
Definition
 Extrusion of peritoneum and abdominal contents through
a previously acquired defect.
Complications




Intestinal obstruction: often intermittent
Become irreducible
Strangulation
Pain or discomfort
Risk Factors
Pre-operative
 ↑ age
 Comorbidities: DM, renal failure
 Drugs: steroids, chemo, radio
 Obesity or malnutrition
 Malignancy
Intra-operative
 Surgical technique/skill (major factor)
 Too small suture bites
 Inappropriate suture material
 Incision type (e.g. midline)
 Placing drains through wounds
Post-operative
 ↑ IAP: chronic cough, straining, post-op ileus
 Infection
 Haematoma
Mx
 Surgery is not appropriate for all patients.
 Must balance risk of operation and recurrence c̄ risk of
obstruction / strangulation and pt. choice.
 Usually broad-necked  low risk of strangulation
Conservative
 Manage RFs: e.g. constipation, cough
 Weight loss
 Elasticated corset or truss
Surgical
 Pre-Op
 Optimise cardiorespiratory function
 Encourage wt. loss
 Nylon mesh repair: open or lap
© Alasdair Scott, 2012
108
Umbilical and Paraumbilical Hernia
Examination
Viva
Inspection
Hx









Pt. may be overweight
Ask pt. to lift head off bed and to cough
Note any associated skin damage: e.g. ulceration
Note any overlying scars: may indicate recurrence
Palpation





Any tenderness?
Feel for presence of defect
Try to asses size
Ask pt. to cough while feeling for an impulse
If a lump is present, ask pt. to reduce it.
Predisposing factors: pregnancy, ascites, obesity
Pain
Reducible
Episodes of obstruction or strangulation
Previous repairs
Paraumbilical
Pathogenesis
 Acquired defect in the linea alba just above or below the
umbilicus
 Commoner in obese, middle-aged pts.
 Neck is commonly narrow
 Prone to becoming irreducible or strangulated
 Typically contain omentum ± large or small bowel
 May be large → necrosis of the skin
Risk Factors
 Obesity
 Pregnancy
 Ascites
 Fibroids
 Bowel distension
Mx
 Surgery advised due to high risk of strangulation
 Rx concurrent medical problems
 Mayo Repair
 Mobilise sac and reduce contents
 Double-breast the linea alba ± sublay mesh
Umbilical
Pathogenesis
 Congenital defect in the umbilical scar (cicatrix)
 Typically congenital: 3% of live births
Risk Factors
 Afro-Caribbean
 Trisomy 21
 Congenital hypothyroidism
Can recur in adults: pregnancy, ascites
Mx
 Usually asymptomatic and resolve by 2-3yrs
 Surgical repair advocated if no resolution by 3yrs
Other Congenital Defects
Gastroschisis
 Protrusion of abdo contents through defect in abdo wall
to the right of the umbilicus.
 Not usually assoc. c̄ other abnormalities
 Promt surgical repair after fluid resuscitation
Exomphalos
 Protrusion of abdominal contents w/i in a 3-layered sac
 Commonly assoc. c̄ other defects: cardiac, anencephaly
© Alasdair Scott, 2012
109
Epigastric Hernia
Examination
Viva
Inspection
Hx
 Midline lump above the umbilicus when the pt. coughs or
lifts head from bed.
 Typically small: “pea shaped”
 Associated scars?
 Incisional hernia or previous repairs





Predisposing factors: pregnancy, obesity
Symptoms
Reducible
Episodes of obstruction or strangulation
Previous repairs
Palpation
 Any pain?
 Feel for cough impulse
 Establish size of the defect
Differential
 Incisional hernia: ?scar
 Divarication of the recti
 Widening of gap between recti muscles
 Not a hernia
Features
 Abnormal protrusion of abdominal contents through a
defect in the linea alba between the xiphisternum and
umbilicus.
 Usually contain extraperitoneal fat or omentum
 Commoner in young (20-50yrs)
Symptoms





May be asymptomatic
May be confused for upper GI pathology
Pain: may ↑ after meals or exercise
Nausea and early satiety
Abdominal bloating
Mx
Conservative
 Manage RFs: e.g. constipation, cough
 Weight loss
Surgical
 Reduce hernial contents and excise sac
 Suture or mesh repair
© Alasdair Scott, 2012
110
Examination of a Scrotal Lump
Set Up
 Best to examine pt. standing: won’t miss a varicocele
Inspection
 Skin: scars, erythema, blue tinge, ulcers
 Groin lumps or scars
 Ask pt. to cough
Palpation: 4 Key Questions
1. Can you get above it?
 Can’t get above an inguinoscrotal hernia
2. Is it tender?
 Torted testis or hydatid of Morgagni
 Epididymo-orchitis
 Strangulated hernia
3. Is testis palpable separately?
 No



 Yes


Tumour
Orchitis
Hydrocele
Varicocele
Spermatocele / epididymal cyst
4. Does it transilluminate?
 No



 Yes


Tumour
Testis
Varicocele
Hydrocele
Spermatocele
Diagnostic Pathway
Can you get above it?
No
Inguinoscrotal Hernia
Yes
Is it separately palpable?
No
Does it transilluminate?
No
Tumour
Orchitis
Haematocele
© Alasdair Scott, 2012
Yes
Hydrocele
Yes
Does it transilluminate?
No
Varicocele
Spermatocele
Sperm granuloma
Epididymitis
Yes
Epididymal cyst
111
Hydrocele
Examination
Viva
Inspection
Hx
 Swollen scrotum






Palpation




Can get above it.
Cannot feel testis separately
Firm / tense
Transilluminates
Duration
Pain, discomfort or other symptoms
Previous testicular masses or infections
Recent trauma
Treatment so far
Co-morbidities: e.g. heart failure
Definition
 Accumulation of fluid w/i the tunica vaginalis
 Remnant of the processus vaginalis that accompanied the
testicle during its descent.
 Forms one of the adult coverings of the testis
Anatomical Classification
Vaginal
 Accumulation in the tunica vaginalis that doesn’t extend up
the cord
Congenital
 Proximal part of processus has not obliterated and the sac
communicates directly c̄ the peritoneum.
Infantile
 Processus is obliterated at the deep ring but still extends up
the cord
Hydrocele of the Cord
 Fluid accumulates around the ductus deferens.
 Can be hard to distinguish from an inguinal hernia as it may
extend proximal to the superficial ring.
 Testicular traction will pull it inferiorly (cf. inguinal hernia)
Aetiological Classification
Primary
 Caused by a patent processus vaginalis
 Commonest type
 Young men, large, tense
Secondary
 Vaginal type can be caused by a variety of pathologies
 Testicular tumours
 Epididymo-orchitis
 Trauma
 Torsion
Ix
 US to exclude malignancy
Mx
Non-Surgical
 Watch-and-wait (ensure no Ca)
 Aspiration: symptom relief only as will accumulate
Surgical
 Lord’s Repair: plication of the tunica vaginalis
 Jaboulay’s Repair: eversion of the sac
© Alasdair Scott, 2012
112
Epididymal Cyst
Varicocele
Examination
Examination
Inspection
Inspection
 Normal appearing scrotum
Palpation




Can get above it
Separate from testis: typically above and behind
Firm
Transilluminates
 Unless it’s a spermatocele
Viva
 Normal appearing scrotum
Palpation







Pt. must be standing
Can get above mass
Separate from testis
Feels like a bag of worms
Doesn’t transilluminate
May have palpable cough impulse
Often disappear on lying supine
Viva
Hx
 Duration
 Pain, discomfort or other symptoms
 Treatment so far
Features
 Retention cyst of a tubule of the rete testis or the
epididymis.
 Often multiple
 May contain sperm: spermatocele
 Generally asymptomatic
Mx
Hx
 Duration
 Pain, discomfort or other symptoms
 Treatment so far
Pathophysiology
 Dilated veins of the pampiniform plexus
 98% left sided, 50% bilateral
 1O: occur in up to 15% of young men
 Often around puberty
 Anatomical cause: ? nutcracker syndrome
 2O: varicoceles suddenly appearing in older men can be
sinister
 Retroperitoneal disease affecting the testicular V.
 E.g. renal cell carcinoma extending into L renal V.
 Don’t disappear when pt. lies supine
Non-surgical
 If the cyst isn’t troublesome it shouldn’t be removed
 There is a risk of operative damage and post-op
fibrosis → subfertility
Symptoms
Surgical
 Very large or painful cysts can be removed
 Excision of the entire epididymis may be indicated to
prevent the recurrence of painful cysts.
98% Occur on the Left
 Dragging sensation, exacerbated by exertion
 Subfertility: commonest surgically correctable cause
 Left testicular vein is more vertical where it joins the left
renal vein, cf. to the obliquity of the right testicular V.
where it joins the IVC.
 Left renal vein can be compressed by the colon
 Left testicular vein is longer than the right
 Left testicular vein often lacks a terminal valve to prevent
backflow.
Mx
Non-surgical
 Scrotal support
 Transfemoral radiological embolisation of the testicular
vein
Surgical
 Often advised as the problem usually gets worse c̄ age
and can → subfertility
 Palomo operation
 High approach c̄ transverse incision slightly above
and medial to ASIS
 Vein exposed and ligated.
 Inguinal approach: ligation of veins in the inguinal
canal
 Laparoscopic approach also possible
© Alasdair Scott, 2012
113
Testicular Tumour
Examination
Viva
Inspection
Hx






 Enlarged testis may be visible
Palpation





Can get above mass
Inseparable from testis
Hard, irregular, nodular
Non-tender
Doesn’t transilluminate
Presentation






Completion




Examine contralateral scrotum
Abdo exam: hepatomegaly
Chest exam: thoracic mets
Examine for abdominal lymphadenopathy
Differential
 Testicular tumour
 Chronic infection → scarring: orchitis, TB
 Chronic, calcified hydrocele
Pain, discomfort
SOB: lung mets
Back pain: para-aortic node involvement
Haematospermia
Hydrocele
Previous history: tumour, infection
Commonest malignancy in men 15-45yrs
Painless lump or dull ache in one testis in young man
Occasionally a Hx of trauma accompanying discovery of mass.
10% present c̄ acutely painful testis
Haematospermia
2O hydrocele
Classification
 95% are germ cell tumours
 Only 50% are pure cell populations
 Pure seminomatous: 50%
 Non-seminomatous: teratoma is commonest
 Other types include
 Yolk sac: commonest testicular tumour in children
 Choriocarcinoma
 Leydig or Sertoli Cell
 May secrete oestrogens → gynaecomastia
 Lymphoma: NHL is commonest testicular mass >60yrs
Present
Markers
Early
Late
Ix




Seminoma: 40%
30-40yrs
Usually normal
DXT to para-aortic LNs
± single dose of cisplatin
DXT + combi chemo: BEP
Teratoma
20-30yrs
↑AFP + ↑βhCG in 90%
Observation or 1-2 cycles
of chemo
Combination chemo: BEP
Tumour markers: AFP, βhCG, placental ALP
CXR: mets
US scrotum: diagnostic
CT abdomen: staging
Mx
 All testicular tumours are treated c̄ orchidectomy
 Groin incision c̄ early clamping of spermatic cord to prevent
seeding
Seminoma
 Early: DXT to para-aortic nodes
 Late: DXT + combination chemo
Teratoma
 Early: observation
 Late: combination chemo (Bleomycin, Etoposide, cisPlatin)
© Alasdair Scott, 2012
114
Stomas
Examination
Viva
Inspection
Definition
 Site
 Contents of bag
 Solid stool
 Semi-formed or liquid stool
 Urine
 Appearance
 Spout
 Lumens
 Rod
 Mucosal health
 Scars
 No scars suggests colonoscopy assisted
trephine colostomy
Palpate
 Palpate for parastomal hernia
Complete Examination
 Remove bag to closely inspect and digitate stoma
 No. of lumens
 Health of mucosa and surrounding skin
 Strictures
 Prolapse
 Examine the perineum
 Artificial union between conduits or between a conduit
and the outside.
Hx





Surgery
Output
Pain
Complications
Psychosexual function
Indications
 Exteriorisation
 Perforated or contaminated bowel: e.g. Hartmann’s
 Permanent: e.g. AP resection
 Diversion
 Protection of distal anastomosis
 Contamination: e.g. faecal peritonitis
 Anatomical: e.g. ileorectal anastomosis
 Acute Crohn’s
 Urinary diversion following cystectomy
 Decompression: bypass of distal obstructing lesion
 Feeding: gastrostomy / jejunostomy
 Lavage: e.g. appendicostomy
Quick Distinction
Ileostomy
RIF
Spout
Watery contents
Perm: Proctocolectomy
Temp: Anterior resection
Colostomy
LIF
Flush
Formed faeces
Perm: AP resection
Temp: Hartmann’s
Discussion
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© Alasdair Scott, 2012
Pt. preparation
Complications
Rehabilitation
Classification
115
Stomas: Key Facts
Ileostomy
Located in RIF
Small bowel content is an irritant  ileostomies are spouted
Type
End Ileostomy
Loop Ileostomy
Features
Permanent: Panproctocolectomy (no anus)
Temporary: Total colectomy
Temporary stoma to defunction distal bowel
May be supported by bridge or rod
Surgery
Proctocolectomy
Total colectomy c̄ later IPAA
Anterior resection
Bowel rest
Indication
UC
FAP
Colon Ca
Crohn’s
Colostomy
Located in LIF or RUQ (transverse loop colostomy)
Flush with skin surface
Type
End Colostomy
Loop Colostomy
Features
Permanent: AP resection (no anus)
Temporary: Hartmann’s
RUQ:
Defunctioning transverse colostomy to cover a distal
anastomosis: rarely performed
LIF:
Apex of sigmoid exteriorised w/o a resection for
inoperable Ca rectum which is likely to obstruct.
Patient Preparation
 Explanation of the indications and complications
 Liaison c̄ Stoma Nurse to arrange siting
Siting
 Done c̄ pt. standing up to ensure pt. can see stoma.
 Avoid
 Bony prominences
 Skin folds/creases
 Waistline
 Old wounds
 Umbilicus
 Choose
 A site that is accessible to the pt.
 Ideally below the belt line for concealment
 w/i the rectus: ↓ risk of hernia or prolapse
Complications
Early
 Haemorrhage
 Ischaemia
 High output (can → ↓K+)
 Loperamide ± codeine to thicken output
 Parastomal abscess
 Stoma retraction
Delayed
 Parastomal hernia (on lateral side)
 Obstruction: adhesions or herniation through lateral
space around stoma
 Dermatitis (esp. ileostomy)
 Stoma prolapse
 Stenosis or stricture
 Fistulae
 Psychosexual dysfunction
© Alasdair Scott, 2012
Surgery
AP resection
Hartmann’s
Anterior resection
Decompression
Indication
Colon Ca
Diverticulits
Colon Ca
Patient Rehabilitation
 Aim for a normal diet
 Good skin care and cleanliness
 Psychosexual support
Classification
 Anatomical classification according to location
 Tracheostomy
 Gastroscopy
 Jejunostomy
 Ileostomy
 Caecostomy
 Colostomy
 Urostomy
Urostomy
 Fashioned following total cystectomy
Ileal Conduit: Incontinent
 Ureters attached to a portion of resected ileum which is
exteriorised as a spouted stoma.
 Bowel continuity maintained by primary anastomosis.
 Urine collected in a bag.
Indiana Pouch: Continent
 Pouch created from ~2ft of resected ascending colon and
portion of ileum which includes the ileocaecal valve.
 Ureters anastomosed to colonic end and ileal end
exteriorised as spouted stoma.
 Ileocaecal valve prevents urinary leak from the pouch.
 Pt. self-catheterises to drain pouch.
116
Surgical Scars
Look For
Examination
 Give correct technical name where possible
 Otherwise describe anatomical location and orientation
 Comment on whether it looks well healed or recently
formed
 Ask pt. to lift head off bed and cough: incisional hernia
 Don’t guess the operation unless asked to by the
examiner.
Name
Midline Laparotomy
- Skin
- Camper’s fascia
- Scarpa’s fascia
- Linea alba
- Transversalis fascia
- Pre-peritoneal fat
- Peritoneum
Right Paramedian
Appearance
 Stoma and drain scars: bowel surgery
 Vasc. access scars: AAA, graft
Use
Emergency
- Perforated DU
- Trauma
- Ruptured AAA
- Hartmann’s
Elective
- Colectomy
- AAA
- Vascular bypass
Not commonly used
now as closure
techniques have
improved
Features
Good access
Bloodless line
Minimal nerve and muscle injury
Long midline scar
↑ pain
Closure: PDS, blunt J shaped suture, en mass
Jenkin’s Rule
- Length of suture = 4x length of incision
- 1cm bite, 1cm apart
~3cm lateral to the midline
Rectus sheath opened and rectus displaced
laterally.
- Rectus slips back to cover the defect
Time consuming
Kocher’s (Subcostal)
Open cholecystectomy
L Kocher’s used for
splenectomy
Rooftop
Hepatobiliary Surgery
- liver Tx
- Whipple’s
- liver resection
Gastric surgery
Pfannenstiel
Gynae surgery
Lower Urinary Tract
McBurney’s: Oblique
Lanz: Transverse
Appendicectomy
Muscle splitting
- Skin
- Camper’s fascia
- Scarpa’s fascia
- External oblique
- Internal oblique
- Transversus
- Transversalis fascia
- Pre-peritoneal fat
- Peritoneum
© Alasdair Scott, 2012
Longer to close than a midline as the incision is
closed in 3 layers.
May be modified to a Mercedes Benz incision
Lanz incision favoured: hidden in skin crease
Both follow Langer’s Lines
Risk of injury to ilioinguinal and iliohypogastric
nerves may predispose to inguinal hernia
117
Name
Thoracoabdominal
Use
Oesophagogastrectomy
Features
Transverse Muscle
Splitting
Right Hemicolectomy
Limited access cf. midline incision
↓ damage to rectus
- segmental nerve supply means the muscle
can be cut transversely w/o weakening
Inguinal Hernia
Incision
Open Inguinal Hernia
Repair
Incision over the inguinal ligament
Follow’s Langer’s Lines
Orchidectomy
High rates of chronic neuropathic pain
Emergency Femoral
Hernia
Allows inspection of peritoneal cavity c̄ easy
conversion to laparotomy if necessary
McEvedy
- Modified
Appearance
“Half” a Pfannenstiel
Loin
Nephrectomy
Vascular Access
Bypass
Embolectomy
EVAR / TEVAR
Stent Insertion
Femoral Endarterectomy
Angioplasty
© Alasdair Scott, 2012
118
Colonic Resections
Right Hemicolectomy
Features
Indication: tumours in the cecum and proximal ascending colon
Scars
 Midline laparotomy
 Transverse muscle splitting
 Laparoscopic ports
Stoma: none
Anastomosis: ileocolic
Differential: midline laparotomy differential
Extended Right Hemicolectomy
Features
Indication: tumours in the distal ascending colon or transverse colon
Scars
 Midline laparotomy
 Laparoscopic ports
Stoma: none
Anastomosis: ileocolic
Differential: midline laparotomy differential
Left Hemicolectomy
Features
Indication: tumours in the descending colon
Scars
 Midline laparotomy
 Laparoscopic ports
Stoma: none
Anastomosis: colocolic
Differential: midline laparotomy differential
Hartmann’s Procedure
Features
Indication: obstruction or perforation 2O to sigmoid tumour or diverticulitis
Description
 Emergency procedure
 Sigmoid colectomy
 Proximal bowel exteriorised as an end colostomy
 Distal bowel oversewn to form a rectal stump
 May be reversed after 3-6mo (>50% of pts. aren’t reversed)
Scars
 Midline laparotomy
 May have previous stoma scar in LIF if it has been revered
Stoma: single lumen colostomy in the LIF
Differential: APR
© Alasdair Scott, 2012
119
Abdomino-Perineal Resection
Features
Indication: rectal Ca < 4-5cm from anal verge
Description
 Sigmoid, rectum and mesorectal nodes removed via abdominal incision
 Anus removed via perineal incision
Scars
 Midline laparotomy
 No anus
Stoma: single lumen colostomy in the LIF
Differential
 Hartmann’s Procedure
Anterior Resection
Features
Indication: rectal Ca >4-5cm from anal verge
Description
 Excision of part of the rectum and sigmoid colon
 May be high or low depending on site of tumour
 + Total mesorectal excision for tumours in the middle or lower 1/3
 Rectal blood supply is poor  colorectal anastomosis covered by
temporary loop ileostomy.
Scars
 Midline laparotomy
 Laparoscopic port scars
 Scar or stoma in RIF
Stoma: double lumen loop ileostomy in RIF
Differential
 End Ileostomy
 Panproctocolectomy: UC, FAP
 Subtotal colectomy: acute severe UC
 Cystectomy and ileal conduit
 Loop Ileostomy
 Temporary diversion: Crohn’s
© Alasdair Scott, 2012
120
Subtotal Colectomy
Features
Indication: acute severe UC
Description
 All colon excised except distal sigmoid and rectum.
 Temporary end ileostomy
 Rectosigmoid stump may be exteriorised as mucus fistula
 Followed after ~3mo by either:
 Completion proctectomy + IPAA or permanent end ileostomy
 Ileorectal anastomosis (IRA)
Scars
 Midline laparotomy
 Laparoscopic port sites
Stoma: single lumen end ileostomy in RIF
Differential
 End Ileostomy
 Panproctocolectomy: UC, FAP
 Cystectomy and ileal conduit
 Loop Ileostomy
 Temporary diversion: anterior resection or Crohn’s
Panproctocolectomy
Features
Indication: UC or FAP
Description
 All colon, rectum and anus removed
 Permanent end ileostomy
Scars
 Midline laparotomy
 Laparoscopic port sites
Stoma: single lumen end ileostomy in RIF
Differential
 End Ileostomy
 Subtotal colectomy: acute severe UC
 Cystectomy and ileal conduit
 Loop Ileostomy
 Temporary diversion: anterior resection or Crohn’s
© Alasdair Scott, 2012
121
Inflammatory Bowel Disease
Examination
Viva
Inspection
Hx
Peripheral
 General
 Malnutrition or wt. loss
 Cushingoid, evidence of steroids
 Hands
 Clubbing
 Leukonychia
 Beau’s lines
 Eyes
 Pale conjunctivae
 Iritis, episcleritis
 Mouth
 Aphthous ulcers
 Gingival hypertrophy
 Legs
 Erythema nodosum
 Pyoderma gangrenosum
Abdominal
 Scars
 May be multiple and atypical in Crohn’s
 Healed stoma sites
 Healed drain sites
 Stomas or healed stoma sites
 Enterocutaneous fistulae
Palpation
 Tenderness
 RIF mass
 ± hepatomegaly
Completion
 Inspect perineum for perianal disease
 Examine for extra-intestinal features
 Large joint monoarthritis
 Sacroileitis
 Bronchiectasis
 Symptoms
 Wt. loss, fever, malaise
 Abdominal pain
 Diarrhoea, blood and/or mucus PR
 Peri-anal disease: abscesses, fistulae
 Extra-intestinal: EN, arthritis, iritis, gallstones, PSC
 Therapy
 Admissions
 Medical therapy
 Operations
Ix
Bloods
 FBC: ↓Hb, ↑WCC
 U+E: dehydration, ↓K
 LFTs: ↓ albumin, deranged LFTs
 Clotting: ↑INR
 ↑ ESR, ↑ CRP: used to monitor activity
Stool
 Culture + CDT: exclude infective causes
 Campy, Yersinia, Shigella, C. diff, TB
Imaging
 AXR
 Toxic megacolon in UC
O
 Bowel obstruction 2 to strictures in Crohn’s
 Contrast studies
 Ba or Gastrograffin enema in UC
 Small bowel follow–through in Crohn’s
 MRI: perianal disease in Crohn’s
Endoscopy
 Ileocolonoscopy + regional biopsy
 Ix of choice
 Safe in acute disease
 Distinguish UC from Crohn’s
 Assess disease severity
 Wireless capsule endoscopy
Discussion
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© Alasdair Scott, 2012
Clinicopathological distinction between UC and CD
Main complications of IBD
Extra-intestinal manifestations
Definition of severe exacerbation
Indications for surgery in UC and CD
Surgical options for UC and CD
122
IBD: Key Facts for Surgery
Complications
Pathology
UC
Crohn’s
Distribution
Strictures
Rectum + colon
± backwash ileitis
Contiguous
No
Mouth to anus
esp. terminal ileum
Skip lesions
Yes
Microscopic
Inflammation
Ulceration
Mucosal
Shallow, broad
Fibrosis
Granulomas
Pseudoplyps
Fistulae
None
None
Marked
No
Transmural
Deep, thin, serpiginous
→ cobblestone mucosa
Marked
Present
Minimal
Yes
Macroscopic
Location
UC
Crohn’s
Toxic megacolon
Fistulae
- esp. perianal
Perianal abscess
Strictures
Malabsorption
Haemorrhage
Malignancy
- CRC
- Cholangiocarcinoma
VTE
Hepatobiliary
 Fatty liver
 Chronic hepatitis → cirrhosis
 Gallstones
 PSC (3% of UC) and cholangiocarcinoma
Definition of Severe Exacerbation
Surgical Options for UC
Truelove and Witts Criteria
Principles
 Symptoms
 BMs >6 x /d
 Large PR bleed
 Systemic Signs
 ↑ HR >90
 Pyrexia >37.8
 Laboratory Values
 ↓ Hb <10.5g/dL
 ESR >30mm/Hr
Toxic dilatation
 Curative intent
 IPAA or IRA offer continence but suffer from ↑ BMs, pouchitis
and risk of malignancy.
Subtotal colectomy c̄ end ileostomy ± mucus fistula




Indications for Surgery
Operation of choice for acute severe colitis
All colon excised except distal sigmoid and rectum.
Rectosigmoid stump may be exteriorised as mucus fistula
Followed after ~3mo by either:
 Completion proctectomy + IPAA or end ileostomy
 Ileorectal anastomosis (IRA)
Proctocolectomy and permanent ileostomy
UC
Acute Severe
 Megacolon: ≥6cm on AXR
 Perforation: 30-40% mortality
 Severe GI bleeding
Chronic
 Medical Mx failure
 Malignancy
 Maturation failure in children
 Rectum and anus excised c̄ all of colon
 Only performed for pt. choice or when pt. is not suitable for
restorative procedure
 ↑ age
 Impaired sphincter function
Restorative Proctocolectomy
 Proctocolectomy or completion proctectomy
 Construction of ileal reservoir which is anastomosed to anus
 Ileal pouch anal anastomosis (IPAA)
 Usually covered by a diverting loop ileostomy
 May check pouch anastomosis c̄ water soluble contrast
Crohn’s
Acute Severe
 Obstruction 2O to stenosis
 Perforation
 Severe GI bleeding
Chronic
 Peri-anal disease: fistulae and abscesses
 Intra-abdominal abscesses
 Medical Mx failure: temporary defunction
 Entero-cutaneous fistulae
© Alasdair Scott, 2012
Surgical Options for Crohn’s
Principles
 80% need ≥1 operation in their life
 Never curative
 Must be as conservative as possible: avoid short gut syndrome
Procedures





Ileocaecectomy
Drainage of intra-abdominal abscesses
Stricturoplasty
Colonic defunctioning for failed medical therapy
Occasionally a subtotal colectomy + permanent end ileostomy
may be needed.
123
Surgical Jaundice
Examination
Viva
Inspection
Hx
Peripheral
 Cachexia
 Signs of chronic liver disease
 Look in sclera and at frenulum (of tongue): jaundice
 Palpate for Virchow’s node
Post-hepatic: most likely in surgery exam
 Dark urine, pale stools
 Itching
 Stones: RUQ pain or biliary colic
 Malignancy
 Wt. ↓ and ↓ appetite
 Change in bowel habit: esp. steatorrhoea
 Back pain
Abdominal
 Ascites
 Dilated abdominal veins
 Umbilical / para-umbilical hernia
Hepatic
 EtOH intake
 Foreign travel: Hep A
 Blood transfusions, IVDU, Sex: Hep B and C
 Sore throat: EBV
 Drug Hx: OCP, Abx, neuroleptics, OTCs
Palpation
 Hepatomegaly
 Splenomegaly
 Palpable gallbladder
Pre-hepatic
 Anaemia: tired, SOB, palpitations, ankle swelling
 FH
Completion
 Check temp: obstruction complicated by infection
 Dipstick urine: bilirubin, urobilinogen, Hb
Commonest Differentials
Pre-hepatic
Unconjugated
Haemolysis
- SCD
- HS
- AIHA
Hepatic
Un- / Conjugated
Hepatitis
- EtOH
- Viral
Decompensated CLD
Drugs
- Paracetamol
- Statins
- Anti-TB
Post-hepatic
Conjugated
Gallstones
Ca Head Panc
LNs @ porta hepatis
- Ca
- TB
Definition
 Yellow discoloration of the skin and mucus
membranes caused by the accumulation of bile
pigments.
 Normal BR = 3-17uM
 Visible jaundice = 50uM (3 x ULN)
 Very high levels usually have a hepatic cause
Ix of Post-Hepatic Jaundice
Urine
 ↑↑BR, no urobilinogen
Bloods
 LFTs: ↑cBR ↑↑↑ALP, ↑AST/ALT, ↑GGT
 Clotting: ↑ INR
 Auto-Abs: AMA, pANCA, ANA
Imaging
 US
 Underlying hepatic disease
 Dilated ducts: >6mm
 Gallstones
 Pancreatic mass or lymphadenopathy
 MRCP
 ERCP
 CT: staging tumour
Causes of Post-Op Jaundice
Pre-hepatic: haemolysis after a transfusion
Hepatic
 Halogenated anaesthetics
 Sepsis
 Intra- / post-operative hypotension
Post-hepatic
 Biliary injury: e.g. in Lap Chole
© Alasdair Scott, 2012
124
Right Iliac Fossa Mass
Examination
Viva
Inspection
Hx
Peripheral
 Hands and Arms
 Clubbing
 AV fistula
 Eyes
 Pallor
 Jaundice
 Neck
 LNs: e.g. Virchow’s node
Abdominal
 Asymmetry
 Scars: esp. Rutherford Morrison
Palpation













Differentiate mass before continuing c̄ rest of exam
Site, size, shape
Consistency: firm, soft
Edge: well or poorly defined
Surface: smooth, irregular, nodular
Relations
Can you get above and below it?
Does it move c̄ respiration?
Attachment to skin
Attachment to abdominal muscles
Ask pt. to lift head while palpating
Cough impulse
Inguinal nodes
Percussion
 Resonant: e.g. bowel or retroperitoneal
 Dull





Duration of mass and how it has changed
Abdominal symptoms
Gynae symptoms
Systemic symptoms
Co-morbidities and previous operations
Differential of RIF Mass
Commonest
 Transplanted kidney
 Caecal Ca
 Crohn’s or Appendix mass or abscess
 Incisional hernia (mass c̄ scar)
Skin and Soft Tissues
 Sebaceous cyst
 Lipoma
 Sarcoma
Gynaecological
 Ovarian tumour
 Fibroid uterus
Male Reproductive System
 Undescended or ectopic testis ± tumour
Urological System
 Ectopic kidney
 Bladder diverticulum
Blood Vessels
 External iliac or common iliac artery aneurysm
 LNs
Radiological Ix
Auscultation
 Bruits
 Bowel sounds
US
CT
 1st line
 Distinguish bowel mass from pelvic mass
 ID any LNs and abnormal blood vessels
 Best to view abdominal wall masses
 Good to assess extent of intra-abdominal malignancy
MRI
 Good for pelvic masses
Other Ix
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© Alasdair Scott, 2012
Bloods
FBC, U+E, LFT
Mantoux
CXR, AXR
US / CT guided biopsy
125
Abdominal Masses
Epigastric
RUQ
Abdominal Wall and Soft Tissue
 Sebaceous cyst
 Lipoma
 Sarcoma
Intra-abdominal
 Hepatomegaly
 Hepatic mass: cyst, abscess,
hepatoma
 Gallbladder
 Right kidney
Abdominal Wall and Soft Tissue
 Sebaceous cyst
 Lipoma
 Epigastric hernia
 Sarcoma
GIT




Gastric Ca
Hepatomegaly
Ca pancreas
Pancreatic pseudocyst
Vascular
 AAA
LUQ
Abdominal Wall and Soft Tissue
 Sebaceous cyst
 Lipoma
 Sarcoma
Intra-abdominal
 Splenomegaly
 Left kidney
 Gastric Ca
RIF
LIF
Commonest
 Transplanted kidney
 Caecal Ca
 Crohn’s or Appendix mass or
abscess
 Incisional hernia (mass c̄ scar)
Commonest
 Faecal mass
 Colon Ca
 Diverticular Mass
 Transplanted Kidney
Abdominal Wall and Soft Tissue
 Sebaceous cyst
 Lipoma
 Sarcoma
Abdominal Wall and Soft Tissue
 Sebaceous cyst
 Lipoma
 Sarcoma
Gynaecological
 Ovarian tumour
 Fibroid uterus
Gynaecological
 Ovarian tumour
 Fibroid uterus
Male Reproductive System
 Undescended or ectopic testis
 ± tumour
Male Reproductive System
 Undescended or ectopic testis
 ± tumour
Urological System
 Ectopic kidney
 Bladder diverticulum
Blood Vessels
 External iliac or common iliac artery
aneurysm
 LNs
Suprapubic
Abdominal Wall and Soft Tissue
 Sebaceous cyst
 Lipoma
 Sarcoma
Urological
 Bladder
 Bladder mass
 Bladder diverticulum
Urological System
 Ectopic kidney
 Bladder diverticulum
Blood Vessels
 External iliac or common iliac
artery aneurysm
 LNs
Gynae
 Gravid uterus
 Fibroid uterus
 Ovarian Tumour
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Breast
Contents
Breast Examination ................................................................................................................................................................ 128
Breast Lumps ......................................................................................................................................................................... 129
Post-Mastectomy Breast ........................................................................................................................................................ 130
Breast Reconstruction ........................................................................................................................................................... 131
Gynaecomastia ...................................................................................................................................................................... 132
© Alasdair Scott, 2012
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Breast Examination
Set Up
 Request a chaperone
 Expose pt. from waist up and start c̄ her sitting up
 Ask pt. if they have noticed lump in breast: which breast?
Inspection
Breast
 Positions
 Hands relaxed by sides
 Leaning forwards
 Hands behind head
 Hands pressing hips
 Shape: asymmetry, masses
 Skin
 Scars: periareolar, submammary
 Radiotherapy tattoos
 Eczema, erythema, ulceration
 Peau d’orange, dimpling
 Accessory nipples: look along the milk line
 Nipple: inversion, discharge, discolouration, destruction
Peripheral
 Axillae: LN dissection
 Arm: lymphoedema
 Abdomen / Suprapubic: DIEP or TRAM flap harvest
 Back: lat-dorsi flap harvest
Palpation
Breast
 Pt. @ 45O with hand behind head, start c̄ normal breast
 Any pain or discharge?
 Palpate each breast quadrant, subareolar area and the axillary tail
 If lump found: SSS CCC TTTT FS
 Ask pt. to push inwards on her hip to assess tethering
Axillae
 Right axilla: hold pts. right arm with your right hand (and vice versa)
 Gently palpate axillary node:
 Apical
 Anterior
 Posterior
 Medial
 Lateral
Supraclavicular and cervical nodes
Lateral Chest Wall
 Inflatable port sites for implants
Completion
 Palpate / percuss spine for tenderness, masses
 Examine abdomen for hepatomegaly
 Percuss and auscultate lungs for signs of mets: e.g. effusion
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Breast Lumps
Ix of a Lump: Triple Assessment
Classification of Breast Disease
Hx and Examination
Malignant
Presentation
 Lump
 Breast pain
 Skin or nipple changes
 Mets
 Bones: bone pain, #s
 Lungs: dyspnoea
 Liver: abdo pain
 Brain: headache, seizures
Risk Factors: BOOBYS
 Bleeding: early menarche (<13), late menopause (>55)
 Oestrogen: OCP, HRT
 Other breast disease: previous Ca, DCIS, atypia
 Breast feeding: protective
 Young ‘un: first child >35yrs (↑ risk)
 Sister: FH of Ca breast
Radiology
 <35yrs: US
 >35yrs: US + mammography
 Oblique and craniocaudal
 MRI
 Multifocal disease
 Cosmetic implants
Pathology
 Solid lump: Tru-Cut biopsy
 Cystic lump: FNAC
 Reassure if clear fluid
 Send cytology if bloody fluid
 Core biopsy residual mass
 Core biopsy if +ve cytology
Other Ix
 Bloods: FBC, LFTs, ESR, bone profile
 Imaging: help staging
 CXR
 Liver US
 CT scan
 Breast MRI
 Bone scan and PET-CT
 May need wire-guided excision biopsy
© Alasdair Scott, 2012
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Ductal carcinoma NOS: ~70% of cancers
Lobular carcinoma: ~20% of cancers
Other: mucinous, medullary, papillary
Phylloides tumours
Benign
Congenital
 Supernumerary nipples
 Hypoplasia
Stromal Tumour: fibroadenomas
Epithelial Lesions
 ANDI: fibroadenosis, cysts
 Papillomas
 Cystic disease
Inflammatory Lesions
 Mastitis
 Abscess
 Fat necrosis
 Duct ectasia and periductal mastitis
Commonest Single Breast Lumps
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Fibroadenoma
Cyst
Fat necrosis
Cancer
Features of a Malignant Lump
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Irregular, nodular surface
Poorly defined edge
Hard / scirrhous consistency
Painless
Fixation to skin or chest wall
Nipple involvement
129
Post-Mastectomy Breast
Examination
Viva
Inspection
Hx
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Note asymmetry
Describe scar
Look at surrounding skin and axilla
Evidence of radiotherapy
Ask pt. to press her hips: pec major present
Arm lymphoedema
Palpate
 Remaining breast
 Axilla
 Supraclavicular fossa
 What happened?
 Presentation
 Risk factors
 Surgery
 How are things now?
 Post-op pain, anaesthetised skin (@ T1)
 Arm swelling
 Psych
 Symptoms of mets
 What will happen in the future?
 Chemo and radiotherapy
 Reconstruction
Indications for Mastectomy
Completion
 Palpate / percuss spine for tenderness, masses
 Examine abdomen for hepatomegaly
 Percuss and auscultate lungs for signs of mets
 Modern oncological breast surgery involves breast
conservation wherever possible.
 Typically WLE and SNB
 Mastectomy may be considered if
 Pt. preference
 Multifocal disease
 Large lump in small breast: e.g. >4cm
 Large area DCIS: e.g. >4cm
 Nipple involvement
Types of Mastectomy
 Simple mastectomy
 Removal of breast alone: commonest type
 Still need to Mx the axilla
 Other types not performed as no survival benefit
 Modified radical: breast, pec minor, axilla
 Radical: breast, pec minor and major, axilla
 Extended radical: radical + internal mammary LNs
Pt. Preparation
Physical
 Mark side prior to anaesthetic
 Explanation including use of suction drain to close cavity
and ↓ risk of haematoma or seroma formation.
 There will be an anaesthetised patch of skin in the upper
medial part of the arm
 Division of intercostobrachial nerve (T1)
Psychological
 Pts. should see breast care nurse pre-op
 Options for reconstruction should be discussed
Drain Removal Post-op
 Typically 2 drains: axilla and site of surgery
 Left for 3-5d or until draining <50ml/d
 Pts. can go home c̄ drains and district nurse support.
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Breast Reconstruction
Examination
Viva
Inspection
Hx
General
 Note asymmetry
 Arm lymphoedema
 Evidence of radiotherapy
 Evidence of axillary clearance / radiotherapy
Flap Reconstruction
 Scars extend over back or abdominal wall
 Recess on back where lat dorsi has been removed
 Ask pt. to lift head of bead (when lying supine) to see
recess in the rectus muscle
Implant Reconstruction
 Rounder shape than normal breast
 Breast usually lies higher
 Becker implant may have palpable SC filling port in the
axilla
 As for mastectomy
Timing
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Immediate: single operation
Delayed
↑ pt. decision time
Avoidance of detrimental effects of adjuvant therapy
Techniques
 Tissue expansion reconstruction c̄ implants
 Autologous tissue reconstruction c̄ myocutaneous flaps
Implants
Advantages
Simpler technique
Primary or delayed
Disadvantages
Cosmetic result not as good
Requires plenty of available skin
Lies higher than other breast
Late Complications
- Capsular contracture
- Implant leakage
- Infection requiring removal
Myocutaneous Flaps
Advantages
Useful when little remaining
skin or muscle
Good cosmetic result
Primary or delayed
Disadvantages
↑ blood loss
↑ op time and complications
Use of rectus impossible if pt.
has had abdo surgery
Late complications
- flap necrosis and infection
Types of Myocutaneous Flap
Latissimus Dorsi myocutaneous flap
 Pedicled: skin, fat, muscle and blood supply
 LD mobilised and tunnelled medially to form neo-breast
 Supplied by thoracodorsal A. via subscapular A.
 Often augmented c̄ an implant
Transverse Rectus Abdominis Myocutaneous (TRAM) Flap
 Pedicled: inf. epigastric A.
 Or free: attached to internal thoracic A
 No implant necessary and combined tummy tuck
 CI if poor circulation: smokers, obese, PVD, DM
 Risk of abdominal hernia
Deep Inferior Epigastric Perforator (DIEP) Flap
 Evolution of the TRAM flap
 Free: skin and fat only, no muscle
 Spares the rectus: ↓ pain and ↓ risk of hernia
 May not be possible if small perforators
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Gynaecomastia
Examination
Viva
Inspect
Causes of Gynaecomastia: 3Ps
 Unilateral or bilateral breast swelling
Palpation
 Must feel glandular tissue to differentiate from pseudogynaecomastia (fat).
Completion
 Look for cause
 External genitalia
 Thyroid examination
 Evidence of CLD
 Visual fields
 Take Hx
 Prescription and recreational drugs
Potions
 Recreational
 Marijuana
 Diazepam
 Anabolic steroids
 Prescription
 Spiro
 Digoxin
 Captopril
 Verapamil
 Ranitidine
Physiological
 Especially at puberty where breast tissue may be
unilaterally or bilaterally enlarged.
 Usually resolves by adulthood
Pathological
 ↓ androgen production: hypogonadism
 Hyperprolactinaemia
 Renal failure
 Testicular atrophy
 Post-orchitis
 Bilat torsion
 Klinefelter’s: XXY
 ↑ oestrogens
 ↑ production
 Sex-cord stromal tumours
 Lung Ca
 ↑ peripheral aromatisation
 Chronic liver disease
 Thyrotoxicosis
Ix
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Testicular Ca: AFP, βhCG
Hypogonadism: testosterone and LH levels
Prolactinoma: PRL level
TFTs
Suggestions of Breast Ca
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© Alasdair Scott, 2012
1% of breast Ca occurs in men
Older age
FH
Unilateral gynaecomastia
Firm or hard nodules w/i breast tissue
Axillary LNs
132
Vascular
Contents
Venous Examination .............................................................................................................................................................. 134
Varicose Veins ....................................................................................................................................................................... 135
Post-Phlebitic Limb: Chronic Venous Insufficiency ............................................................................................................... 136
Arterial Examination ............................................................................................................................................................... 137
Chronic Limb Ischaemia ........................................................................................................................................................ 138
Abdominal Aortic Aneurysm .................................................................................................................................................. 139
Popliteal Aneurysm ................................................................................................................................................................ 140
Aneurysms: Key Facts ........................................................................................................................................................... 140
False Aneurysm ..................................................................................................................................................................... 141
Amputations ........................................................................................................................................................................... 141
Carotid Artery Disease ........................................................................................................................................................... 142
Vascular Effects of the Diabetic Foot..................................................................................................................................... 143
Gangrene ............................................................................................................................................................................... 143
Raynaud’s Phenomenon ....................................................................................................................................................... 144
Thoracic Outlet Obstruction ................................................................................................................................................... 144
Peripheral Ulcer Examination ................................................................................................................................................ 145
Venous Ulcer ......................................................................................................................................................................... 146
Ischaemic Ulcer ..................................................................................................................................................................... 146
Neuropathic Ulcer .................................................................................................................................................................. 147
Lymphoedema ....................................................................................................................................................................... 148
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Venous Examination
Set-Up
 Expose pt. from groin to toes
 Examine c̄ pt. standing
Inspection
Skin Changes and Scars
 Scars: esp. in groin creases
 Chronic Venous Insufficiency: HAS LEGS
 Haemosiderosis
 Atrophie blanche
 Swelling
 Lipodermatosclerosis
 Eczema
 Gaiter ulcers
 Stars, venous
Site and Size of Varicosities
 Medial and above knee: great saphenous
 Posterior and below knee: short saphenous
 Few varicosities + prominent skin changes: calf perforators
Palpation
Great Saphenous Vein Anatomy
SFJ
- 2 finger breaths below and
lat. to pubic tubercle
Mid-thigh perforator of
Hunter
Calf perforators of Cockett
- draining into post. ach vein
Great Saphenous
- Passing anterior to medial
malleolus
 Pitting oedema
 Palpate varicosities
 Tenderness: thrombophlebitis
 Induration: thrombosis
 Saphena varix @ SFJ
 Two finger breaths below and lateral to pubic tubercle
 Bluish tinge, disappears on lying flat
 May have cough impulse (Cruveihier’s Sign)
 Tap test (Chevrier’s Test)
 Tap proximally and feel for impulse distally
 Distal pulses: PTA, DPA
Auscultation
 Bruit over varicosity: AVM
Doppler
 Place probe @ SFJ/SPJ and squeeze calf
 Normally hear only half second whoosh when pressure released.
 Long whoosh suggests valve incompetence.
Completion
 Trendelenberg or Tourniquet Test
 Examine abdomen + PR
 Pelvis in females
Tourniquet / Trendelenberg’s Test
 Position pt. supine, elevate leg and milk veins.
 Apply tourniquet as high up thigh as possible or compress SFJ
 Stand pt.
 Controlled: incompetence above tourniquet
 Release tourniquet to confirm filling
 Uncontrolled: incompetence below tourniquet
 e.g. SPJ or calf perforators
 Repeat test with tourniquet just below knee
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Varicose Veins
Pathophysiology
 One-way flow from sup → deep maintained by valves
 Valve failure → ↑ pressure in sup veins → varicosity
 Fibrous tissue invades tunica intima and media,
breaking up the SM
 Prevents maintenance of vascular tone → dilatation
 3 main sites where valve incompetence occurs
 SFJ: 3cm below and 3cm lateral to pubic tubercle
 SPJ: popliteal fossa
 Perforators: draining GSV
 Chronic venous insufficiency is distinct and results from
incompetency in the deep system itself.
 May co-exist c̄ varicose veins
Causes
Primary / Idiopathic: 95%
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Prolonged standing
Pregnancy
Obesity
OCP
Secondary: 5%
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Valve destruction: DVT, thrombophlebitis
Obstruction: pelvic mass, DVT
AVM
Syndromes
Syndromes
Klippel-Trenaunay-Weber
 Abnormality of the deep venous system
 Varicose veins
 Port wine stain
 Bony and soft tissue hypertrophy of the limbs
Parkes-Weber Syndrome
 Multiple AVMs c̄ limb hypertrophy
 AVMs can → high-output HF
Symptoms
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Cosmetic defect
Pain, cramping, heaviness
Tingling
Bleeding: may be severe
Swelling
Ix
Duplex US
Indications
 Previous Hx of DVT
 Signs of chronic venous insufficiency
 Suggests deep venous disease for which the
varicosity may be the collateral.
 Recurrent varicose veins
 Difficulty in deciding whether GSV or SSV is incompetent
Preparation for Surgery
 FBC, U+E, clotting, G+S
 CXR
 ECG
© Alasdair Scott, 2012
Definition
 Tortuous, dilated veins of the superficial venous
system
CEAP Classification
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Classification of Chronic Venous Disease
Clinical signs (1-6 + sympto or asympto)
Etiology
Anatomy
Pathophysiology
Mx
Conservative
 Lose wt. and regular exercise
 Avoid prolonged standing
 Class II graduated Compression Stockings
 18-24mmHg
 Skin care: emollients
Minimally Invasive Therapies
Indications
 Small below knee varicosities not involving GSV or
SSV
Techniques
 Local or GA
 Injection sclerotherapy: 1% Na tetradecyl sulphate
 Endovenous laser or radiofrequency ablation
Post-Operatively
 Compression bandage for 24hrs
 Compression stockings for 1mo
Surgery
Indications
 SFJ incompetence
 Major perforator incompetence
 Symptomatic: ulceration, skin changes, pain
Procedures
 Trendelenberg: saphenofemoral ligation
 SSV ligation: in the popliteal fossa
 LSV stripping: no longer performed due to potential
for saphenous nerve damage.
 Multiple Avulsions
 Cockett’s Operation: perforator ligation
 SEPS: Subfascial Endoscopic Perforator Surgery
Post-op
 Bandage tightly and elevate for 24h
 D/C c̄ compression stockings and told to walk daily.
Complications
 Early
 Haematoma: esp. groin
 Wound sepsis
 Nerve damage: e.g. long saphenous
 Late
 Superficial thrombophlebitis
 DVT
 Recurrence: 10% @ 5yrs
135
Post-Phlebitic Limb: Chronic Venous Insufficiency
Examination
Viva
Inspection
Hx
HAS LEGS
 Haemosiderosis
 Atrophie blanche
 Swelling
 Lipodermatosclerosis
 Eczema
 Gaiter ulcers
 Stars, venous
Varicose Veins
 Often present as collaterals bypassing the obstruction
Palpation
 Pitting oedema
Completion
 Perthes’ Test
 Abdominal exam + PR
 Pelvic exam in women
Perthes’ Test
 Tests for deep venous occlusion
 High tourniquet around pts. leg + walking for 5min
 Deep obstruction → swelling and pain
 Previous DVT
 Orthopaedic surgery
 Complicated obstetric course
 Venous Claudication
 “Bursting” pain in the leg after exercise
 Relieved by rest and elevation of limb (cf. arterial)
Causes
 Reflux following DVT: 90%
 Obstruction following DVT: 10%
Venous Gangrene
 Rare complication of DVT in the iliofemoral segment
 3 phases
 Phlegmasia alba dolens: white leg
 Phlegmasia cerulea dolens: blue leg
 Gangrene 2O to acute ischaemia
Lipodermatosclerosis
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Panniculitis
Venous HTN → extravasation of fibrin and red cells
Poor tissue oxygenation → ulceration and fat necrosis
Inverted champagne bottle appearance
 Chronic inflam → fibrosis → distal shrinkage
 Venous obstruction → proximal leg swelling
Ix of Deep Venous Disease
 Duplex: reflux and occlusion
 Venography
 Ascending: patency and perforator incompetence
 Descending: reflux
 Ambulatory venous pressures
Surgical Options
Reflux
 Trahere Transplantation
 Transplant segment of axillary vein c̄ valve into
deep venous system of leg
 Wrap c̄ PTFE cuff
 Kistner Operation
 Valvuloplasty of damaged valves
Obstruction
 Palma operation
 Use contralateral GSV and anastomose to
femoral vein to bypass iliofemoral obstruction
© Alasdair Scott, 2012
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Arterial Examination
Lower Limb
Upper Limb
Set-Up
Inspection
 Expose pt. from groin to toes
 Start @ the toes unless told otherwise
Inspection
 Colour: pallor or cyanosis
 Trophic changes
 Muscle atrophy,
 Shiny dry skin
 Nail dystrophy and loss of hair
 Ulcers
 Between toes
 Base of 1st and 5th metatarsals
 Heel (ask re. pain before lifting…)
 Gangrene
 Scars
 Medial thigh and leg
 Vascular access (vertical groin)
 Midline sternotomy or laparotomy
 Axilla
Palpation
 Temperature: feel c̄ backs of both hands
 Pulses: as present, reduced or absent
 Feel pulses bilaterally if possible for comparison
 Aorta: just above the umbilicus
 Femoral: mid-inguinal point
 Popliteal: between the heads of gastrocnemius
 Dorsalis pedis: lat. to extensor hallux longus
tendon (absent in ~5% of people)
 Post tib: postero-inferior to medial malleolus
 Graft + distal pulses: is the graft patent?
 Capillary refill: <2s
Hands and Arms
 Tobacco staining
 Colour
 Trophic changes
 Ulcers and gangrene
 Scars
Face and Neck
 Corneal arcus, xanthelasma
 High arched palate
 Scar over carotids
Chest
 Mid-line sternotomy scar
Palpation
 Temperature
 Pulses: rate and rhythm
 Radial: lat. to FCR tendon @ wrist
 Ulna: lat. to FCU
 Brachial: medial to biceps tendon
 Carotid: ant. to SCM at the thyroid cartilage
 Radio-radial delay
 Radio-femoral delay
 Stenosis, coarctation, dissection
Auscultate for Bruits
 Carotids
 Graft
Completion
Auscultate for Bruits
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Aorta and renal vessels
Iliac: midway from umbilicus to inguinal ligament
Femoral
Course of SFA if popliteal can’t be palpated
Grafts
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Examine the rest of the vascular system
Assess the pulses with a hand-held doppler
Cardiovascular and neurological examination
BP of both arms
Difference >20mmHg suggests stenosis, CoA or
dissection.
Buerger’s Angle and Test
 Lift leg to 45O and observe for pallor and venous
guttering
 <20O = severe ischaemia
 Buerger’s Test: reactive hyperaemia on lowering the leg
 2O to vasodilatation of the microcirculation in
response to ischaemia
Completion
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Examine the rest of the vascular system
Assess the pulses with a hand-held doppler
Measure the ABPI
Cardiovascular and neurological examination
 DM neuropathy
 Valve disease
© Alasdair Scott, 2012
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Chronic Limb Ischaemia
Presentation
Ix
Intermittent Claudication
 Cramping pain after walking a fixed distance
 Pain rapidly relieved by rest
 Calf pain = superficial femoral disease (commonest)
 Buttock pain = iliac disease: internal or common
Bedside
 ABPI ± exercise ABPI (↓ by 0.2 in PVD)
 ECG
Critical Limb Ischaemia: Fontaine 3 or 4
 Ankle artery pressure <50mmHg (toe <30mmHg)
 And either:
 Persistent rest pain requiring analgesia for ≥2wks
 Ulceration or gangrene
 Rest pain
 Especially @ night
 Usually felt in the foot
 Pt. hangs foot out of bed
 Due to ↓ CO and loss of gravity help
 Tissue loss: ulceration, gangrene
Leriche’s Syndrome: Aortoiliac Occlusive Disease
 Atherosclerotic occlusion of abdominal aorta and iliacs
 Triad of:
 Buttock claudication and wasting
 Erectile dysfunction
 Absent femoral pulses
Intermittent Claudication vs. Spinal Claudication
Path
Site
Pain
Exam
Arterial
Vascular insufficiency
Usually calf or buttock
Set distance: reproducible
Worse up stairs
Cramping
Eased by standing rest
Evidence of PVD
Spinal
Nerve compression
Ill-defined / whole leg
Positional onset
Better up stairs
Burning pain
Eased sitting forward
Normal
Blood
 FBC: anaemia may worsen symptoms
 U+E: renovascular disease
 Glucose: DM
 Lipids: hypercholesterolaemia
Imaging: assess site, extent and distal run-off
 Colour duplex US
 CT / MR angiogram: gadolinium contrast
 Digital subtraction angiography
 Invasive  not commonly used for Dx only.
 Used for therapeutic angioplasty or stenting
Non-Surgical Mx
 Walk through pain: may use exercise programs
 Optimise risk factor profile
 Smoking cessation
 Control HTN, lipids and BP
 Lose wt.
 Antiplatelet and statin for all pts.
 Foot care
Prognosis
 ~80% improve or stay the same
 20% deteriorate, 1% lose their limb
 60% mortality @ 5yrs: cardiovascular disease
Interventional
 Angioplasty ± stenting
 Chemical sympathectomy
Surgical Mx
 Endarterectomy
 Bypass grafting
 Amputation
Risk Factors
Modifiable
 Smoking
 BP
 DM control
 Hyperlipidaemia
 ↓ exercise
Non-modifiable
 FHx
 PMH
 Male
 ↑ age
 Ethnicity
Bypass Grafting
Indications
 V. short claudication distance (e.g. <100m)
 Symptoms greatly affecting pts. QoL
 Development of rest pain
Classification
Clinical
Calcification: CRF, DM
Normal
Asymptomatic
Claudication
Rest pain
Ulceration and gangrene
Fontaine
Fontaine 1
Fontaine 2
Fontaine 3
Fontaine 4
ABPI
>1.4
>1
0.8-1
0.6-0.8
0.3-0.6
<0.3
Pre-op Assessment
 Need good optimisation as likely to have
cardiorespiratory co-morbidities.
Practicalities
 Need good proximal supply and distal run-off
 Saphenous vein grafts preferred below the IL
 More distal grafts have ↑ rates of thrombosis
Classification
 Anatomical: fem-pop, fem-distal, aortobifemoral
 Extra-anatomical: axillo-fem / -bifem, fem-fem
crossover
© Alasdair Scott, 2012
138
Abdominal Aortic Aneurysm
Examination
Viva
Inspection
Hx
 Midline pulsating mass: esp. on deep inspiration
 Abdominal scars
 Presentation: usually incidental finding
 Symptoms
 Abdominal or back pain
 Tenderness over aneurysm
 Distal embolic events
 Leak
 Other peripheral or cardio-vascular disease
 CV risk factors
Palpation
 Pulsatile and expasile mass on deep palpation in the
epigastrium.
 Expansile: moves fingers laterally c̄ each pulse
 Estimate size using lateral margins of index fingers
 Palpate for other aneurysms
 Course of common iliacs
 Femorals
 Popliteals
Definition
 Abnormal dilatation of the abdominal aorta to >50% of
its normal diameter = ≥3cm
Risk Factors





Auscultation for Bruits
 Aortic
 Renal
 Iliac
Completion
 Cardiovascular system
 Peripheral vascular system
Ix
Male
Age >60yrs (prevalence: ~5%)
Smoking
HTN
FHx
 Abdo US: used for surveillance and screening
 CT/MRI: Ix of choice
 Angio: useful to delineate relationship of renal arteries
When to Operate
 Repair aims to avoid complications
 Operate when risk of complications, esp. rupture, > risk
of surgery.
Indications
 Symptomatic aneurysms
 Asymptomatic
 ≥5.5cm
 Expanding >1cm/yr
Complications
 Death
 MI
 Renal failure
 Spinal or mesenteric ischaemia
 Distal trash from thromboembolism
 Anastomotic leak
 Graft infection
 Aortoenteric fistula
Operative Mortality
 Open
 Emergency: 50%
 But only 50% reach hospital alive
 Elective: 5% (lower in specialist centres)
 ↑ if IHD, LVF, CRF, COPD
 EVAR: 1%
EVAR




© Alasdair Scott, 2012
↓ perioperative mortality (1% vs. 5%)
No mortality benefit after 5yrs
Significant late complications: e.g. endoleaks
EVAR not better cf. medical care in unfit pts.
139
Popliteal Aneurysm
Aneurysms: Key Facts
Examination
Definition
Inspection
 Pulsatile popliteal swelling
 Ischaemic patches on foot: emboli
Palpation
 If asked just to examine the pulses, start c̄ femorals
 Comment on presence and character
 Aneurysmal popliteals are very easily palpable
 Popliteal aneurysm ≥2cm in diameter
 50% bilateral: examine the other knee
 Distal pulses may not be palpable
Completion
 Complete peripheral vascular examination
 Abdominal examination for AAA
 Present in 50%
Viva
Presentation
 Popliteal aneurysms represent 80% of all non-aortic
aneurysms
 Lump behind the knee
 50% present c̄ distal limb ischaemia: thromboembolism
 <10% rupture
Mx
Surgical Indications
 Symptomatic aneurysms
 Aneurysms containing thrombus
 Aneurysms >2cm
Mx
 Acute: embolectomy or fem-distal bypass
 Stable: excision bypass
 Abnormal dilatation of a blood vessel > 50% of its
normal diameter.
Classification
True Aneurysm
 Dilatation of a blood vessel involving all layers of the
wall and is >50% of its normal diameter
 Two different morphologies
 Fusiform: e.g AAA
 Saccular: e.g Berry aneurysm
False Aneurysm
 Collection of blood around a vessel wall that
communicates c̄ the vessel lumen.
 Usually iatrogenic: puncture, cannulation
Dissection
 Vessel dilatation caused by blood splaying apart the
media to form a channel w/i the vessel wall.
 Used to be classified as “dissecting aneurysms” but not
technically correct as represents a different pathology.
Causes
Congenital
 ADPKD → Berry aneurysms
 Marfan’s, Ehlers Danlos
Acquired
 Atherosclerosis
 Trauma: e.g penetrating trauma
 Inflammatory: Takayasu’s aortitis, HSP
 Infection
 Mycotic: SBE
 Tertiary syphilis (esp. thoracic)
 Salmonella typhi: assoc. c̄ AAA
Complications





Rupture
Thrombosis
Distal embolisation
Pressure: DVT, oesophagus, nutcracker syndrome
Fistula: IVC, intestine
UK Small Aneurysms Trial
 Powell, Greenhalgh et al., Lancet 1996
 Asymptomatic aneurysms between 4-5.5cm should be
monitored.
 Aneurysms ≥ 5.5cm should undergo repair.
 Risk of rupture
 <5.5cm: 1% /yr
 ≥5.5cm: 10% /yr
Screening
 MASS trial revealed 50% ↓ aneurysm-related mortality
in males aged 65-74 screened c̄ US.
 UK men offered one-time US screen @ 65yrs
© Alasdair Scott, 2012
140
False Aneurysm
Amputations
Examination
Examination
Inspection
Inspection
 Pulsatile mass in the groin
 Surgical scars or puncture sites
Palpation
 Pulsatile, expansile swelling
 Define the anatomical location
 Usually mid-inguinal point
 Palpate distal pulses
Auscultate for a Bruit
Viva
True vs. False Aneurysm
 Often useful to draw this
 Aneurysm is an abnormal dilatation of a blood vessel
 Stump anatomical level
 Stump health
 Evidence of chronic vascular disease
Palpation
 Soft tissue under skin should move freely over the bone
 Proximal pulses
Move
 Ask pt. to actively flex and extend the knee joint above
the amputation
 Many pts. have a fixed flexion deformity after
BKA
 Ask to look @ prosthesis and see pt. walk c̄ it.
Completion
 Examine other limb for signs of PVD
True: involves all layers of arterial wall
False
 Collection of blood around a vessel wall that
communicates c̄ the lumen
 i.e. a pulsating haematoma
 Fibrous tissue forms around haematoma → false sac
which communicated c̄ vessel lumen
Aetiology
 Occurs after vessel a laceration / puncture
 Traumatic or iatrogenic
 Usually in the common femoral A. following
puncture for a radiological procedure.
Mx
 Ultrasound compression
 Thrombin injection
 Surgical repair
Viva
Indications: 4D’s




Dead: PVD (90%), thrombangiitis obliterans
Dangerous: sepsis, malignancy
Damaged: trauma, burns, frostbite
Damned nuisance: pain, neurological damage
Considerations




Psychosocial implications
Future mobility: 200% more effort to walk after AKA
OT involvement
Level of amputation must be high enough to ensure
healing of the stump.
 But ↑ mortality c̄ AKA vs. BKA
Procedures
 Toe: with the metatarsal head
 Ray Amputation
 Incision on either side of affected digit to the base
of the metatarsal
 Creates a V shape and narrows foot
 Heals by 2O intention
 Used if necrosis of digit and muscles of the foot.
 Forefoot: transmetatarsal
 Below knee: aids rehabilitation
 Above knee
 Hindquarter / hemipelvicotomy
Complications
 Pts. often have co-morbidities → ↑ risk
 Esp. CVD
Early






© Alasdair Scott, 2012
Mortality: ~20% for AK
Haemorrhage
Infection: cellulitis, gangrene, osteomyelitis
Scar contractures → fixed flexion
Phantom limb pain: try gabapentin
Poor stump shape inhibiting prosthesis
141
Carotid Artery Disease
Examination
Viva
Two Possible Options
Hx
 Previous TIA: esp. amaurosis fugax
 Amaurosis fugax will be ipsilateral to stenosis
 Previous stroke
 Other CV and PV disease
 CV risk factors
Carotid Endarterectomy Scar
 Beneath the angle of the mandible
 Parallel to SCM
Carotid Bruit
 Along course of common carotid: medial to SCM in the
anterior triangle
 Best heard in expiration
Completion
 If heard bilaterally, listen over precordium to exclude AS
 Full peripheral vascular examination
 Neurological examination: cerebrovascular event
Ix
Bedside
 Urine dip: proteinuria in renovascular disease
 ECG: ischaemic changes, AF
Blood
 FBC: anaemia may worsen symptoms
 U+E: renovascular disease
 Glucose: DM
 Lipids: hypercholesterolaemia
Imaging
 Carotid Duplex US: site and size of stenosis
 MRA: more detailed carotid anatomy
 Echo: CVD
 CT or MRI brain: infarcts
Complications of Carotid Stenosis
TIA
 Sudden neurological deficit of vascular origin lasting
<24h (usually lasts <1h) c̄ complete recovery
 Microemboli from the plaque
Stroke
 Sudden neuro deficit of vascular origin lasting >24h
 3rd leading cause of death in the West
 Carotid atheroembolism is the commonest cause
Mx
 Pts c̄ severe symptomatic stenosis should have CE
ASAP after the neurological event.
Conservative
 Aspirin or clopidogrel
 Control risk factors
Surgical: Endarterectomy
 Symptomatic (ECST, NASCET)
 ≥70% (5% stroke risk per yr)
 ≥50% if low risk (<3%, typically <75yrs)
 6 fold reduction in stroke rate @ 3yrs
 Asymptomatic (ACAS, ACST)
 ≥60% benefit if low risk
Complications
 3% risk of stroke or death
 Haematoma
 MI
 Nerve injury
 Hypoglossal: ipsilateral tongue deviation
 Great auricular: numb ear lobe
 Recurrent laryngeal: hoarse voice, bovine cough
© Alasdair Scott, 2012
142
Vascular Effects of the Diabetic Foot
Gangrene
Examination
Examination
Inspection
Inspection




 Wet


 Dry



Bilateral signs of chronic arterial disease
Amputations: esp. digits
Charcot joints
Ulceration
Palpation
 Pulses may be preserved due to calcification
 ↓ sensation in stocking distribution
Putrefaction
Ill-defined, spreading edge
Dry and shrunken
Well demarcated
Features of PVD
Palpation
 Temperature
 Distal pulses
Completion
 Examine the peripheral nervous system
 Urinalysis: proteinuria
 Fundoscopy: retinopathy
Viva
Definition
 Irreversible tissue death from poor vascular supply.
Viva
Classification
 Wet: tissue death + infection
 Dry: tissue death only
 Pregangrene: tissue on the brink of gangrene
Hx






Control
Complications
Claudication
Previous operations
Other vascular disease
Other vascular risk factors
Causes of Gangrene
 DM: commonest
 Embolism and thrombosis
 E.g. foot trash in AAA repair
 Raynaud’s
 Thrombangiitis obliterans
 Injury: extreme cold, heat, trauma or pressure
Diabetic Foot Syndrome
 Microvascular disease
 Macrovascular disease
 Predominantly below knee cf. non-DM occlusive
disease.
 Neuropathy
 Infection and osteomyelitis
Aetiology of Diabetic Ulcers
Mx
 Take cultures
 Debridement (including amputation)
 Benzylpenicillin ± clindamycin
Synergistic Gangrene




 Neuropathic: 45-60%
 Ischaemic: 10%
 Mixed neuroischaemic: 25-45%
Involves aerobes + anaerobes
Fournier’s: perineum
Meleney’s: post-op ulceration
Both progress rapidly to necrotizing fasciitis and
myositis
Preservation of Pulses
 Calcification in the walls of the vessels: mediasclerosis
 Preserves the pulses until late
 → abnormally high ABPI
 Use toe pressure instead: <30mmHg
 Similar effect is seen in CRF
Problems c̄ Diabetics Undergoing Angiography
 Often have a degree of renal impairment which can be
dramatically worsened c̄ contrast agents.
 Metformin must be stopped prior to the procedure to
prevent lactic acidosis
© Alasdair Scott, 2012
Gas Gangrene
 Clostridium perfringes myositis
 RFs: DM, trauma, malignancy
Presentation
 Toxaemia
 Crepitus from surgical emphysema
 Bubbly brown pus
Rx
 Debridement (may need amputation)
 Benzylpenicillin + metronidazole
 Hyperbaric O2
143
Raynaud’s Phenomenon
Thoracic Outlet Obstruction
Examination
Examination
Key Questions
Inspection




 Arm: ↓ venous outflow
 Oedema: pitting
 Cyanosis
 Pallor
 Hand: ↓ arterial inflow
 Raynaud’s
 Patchy gangrene
 Fingertip necrosis
 Hand and Arm: neurological complications
 Complete claw hand
 T1 sensory loss
 Radicular pain
What is the main problem you have c̄ your hands?
When do symptoms occur?
Is it precipitated by any specific weather conditions?
Can you describe the colour changes your fingers go
through?
Inspection




Usually bilateral
Dry, red skin
Brittle nails
Ulceration or gangrene on the pulps
Palpation
 Normal radial pulse
Palpation
 Palpate for cervical rib above the supraclavicular fossa
 Disappearance of radial pulse on abduction and
external rotation of arm
Completion
 Ask about symptoms and look for signs of secondary
causes of Raynaud’s phenomenon
Viva
Viva
Differential of Thoracic Outlet Obstruction
 Arterial: Raynaud’s
 Venous: axillary vein thrombosis or trauma
 Neurological: cervical spondylosis, Pancoast’s tumour
Definitions
 Phenomenon: characteristic cold-induced changes
assoc. c̄ vasospasm
 Disease: primary Raynaud’s phenomenon occurring in
isolation
 Syndrome: secondary Raynaud’s phenomenon assoc.
c̄ other disease
Colour Changes
 Cold- or emotion-induced
 White → Blue → Crimson
Pathogenesis
Ix




X-Ray: cervical rib
Duplex in abduction
Arteriograms of subclavian artery may show kinking
Nerve conduction studies
Aetiology
 Congenital: cervical rib
 Acquired: clavicle #, pathological enlargement of 1st rib
 Overactive α sympathetic receptors
 Or, fixed obstruction in vessel wall
Secondary Causes: BADCAT






Blood: polycythaemia, cryoglobulinemia, cold agglutinin
Arterial: atherosclerosis, thrombangiitis obliterans
Drugs: β-B, OCP, ergotamine
Cervical rib: → thoracic outlet obstruction
Autoimmune: SLE, RA, SS
Trauma: vibration injury
Mx
Conservative
 Wear gloves and avoid cold
 Stop smoking
Medical
 CCBs: e.g. nifedipine
 IV prostacyclin
Surgical
 Cervical sympathectomy
 Amputate gangrenous digits
© Alasdair Scott, 2012
144
Peripheral Ulcer Examination
Inspection: BEDS
3s
Ulcer Edges
 Site
 Size
 Shape
Base
 Granulation tissue
 Slough
 Floor: bone, tendon, fascia
Edge





Sloping: healing – usually venous
Punched-out: ischaemic or neuropathic
Undermined: pressure necrosis or TB
Rolled: BCC
Everted: SCC
Discharge
 Serous
 Purulent
 Sanguinous
Surroundings
 Cellulitis
 Excoriations
 Sensate
 LNs
Palpation
 Limb pulses
 Sensation around the ulcer
Completion
 Examine contralateral side
 Distal neurovascular examination
 ABPI: must be >0.8 for compression bandaging
Causes








Venous: 75%
Arterial: 2%
Mixed arteriovenous: 15%
Neuropathic
Pressure
Vasculitis: e.g. PAN
Malignancy: SCC, Marjolin’s
Systemic: pyoderma gangrenosum
© Alasdair Scott, 2012
145
Venous Ulcer
Ischaemic Ulcer
Examination
Examination
Inspection
Inspection
 Site: medial malleolus
 Size: variable, can be v. large
 Base
 Shallow
 Pink granulation tissue
 Edge: sloping edge
 Discharge: seropurulent
 Surroundings
 Signs of chronic venous insufficiency: HAS LEGS
 Varicose veins
Palpation
 Painless
 Warm surroundings
 Sensate
Viva
Causes




Valvular disease
Varicose veins
Deep vein reflux: e.g. post DVT
Outflow obstruction
 Often post DVT
 Muscle pump failure
 Stroke
 Neuromuscular disease
Ix




ABPI if possible
Duplex ultrasonography
Biopsy may be necessary: esp. if persistent ulcer
Look for malignant change: Marjolin’s ulcer
Mx
 Refer to leg ulcer community clinic
General Measures
 Optimise risk factors: nutrition, smoking
 Analgesia
 Bed rest + elevate leg
4 layer compression bandaging if ABPI >0.8
 Construction
 Non-adherent dressing + wool bandage
 Crepe bandage
 Blue line bandage: light compression
 Cohesive compression bandage
 Change bandages 1-2 x/wk
 Once healed use grade 2 compression stockings for life
Other Options
 Pentoxyfylline PO: ↑ microcirculatory blood flow
 Desloughing c̄ larval therapy
 Topical antiseptics: Manuka honey
 Surgical: split-thickness skin grafts
© Alasdair Scott, 2012
 Site
 Tips of and between toes
 Base of 1st and 5th metatarsals
 Heel
 Size: mm-cm
 Base
 Deep: may be down to bone
 May be slough but no granulation tissue
 Edge: punched-out
 Surroundings
 Pale
 Trophic changes
Palpation




Painful
Cold surroundings
Sensate
Reduced or absent distal pulses
Viva
Causes
Large Vessel
 Atherosclerosis
 Thombangiitis obliterans (Buerger’s Disease)
Small Vessel
 DM
 PAN
 RA
Mx
Analgesia
 Can be extremely painful
 Combination of drugs administered regularly
 Based on the analgesic ladder: titrate to pain
 Paracetamol + NSAIDs
 Weak opioids: e.g. codeine
 Strong opioids: e.g. morphine
Risk Factor Modification
 Stop smoking
 Control DM and HTN
 Optimise lipids
Medical
 Avoid drugs which may worsen symptoms: e.g. β-B
 Low-dose aspirin
 IV prostaglandins
 Chemical lumbar sympathectomy
 Chemical ablation of L1-L4 paravertebral ganglia
 Inhibit sympathetic-mediated vasoconstriction
 Relief of pain
 Often unsuccessful in DM: neuropathy
146
Neuropathic Ulcer
Examination
Inspection
 Site: pressure areas
 Tips of and between toes
 Base of 1st and 5th metatarsals
 Heel
 Size: variable
 Shape: corresponds to shape of pressure point
 Base: may be deep c̄ bone exposure
 Edge: punched-out
 Surroundings
 Skin looks normal
 Charcot’s joints
 May be signs of PVD if co-existent arterial disease
Extras
 Blood sugar testing marks on fingers
 Insulin injection marks on the abdomen
Palpation




Normal temperature
Normal peripheral pulses
Absent sensation around ulcer
Absent ankle jerks
Completion
 Full peripheral vascular exam
 Cranial and peripheral neuro exam
Viva
Causes
Any cause of peripheral neuropathy
 DM
 Alcohol
 B12
 CRF
 Drugs: e.g. isoniazid, vincristine
 Every vasculitis
Pathophysiology
 Sensory neuropathy: distal limb damage not felt by pt.
 Motor neuropathy: wasting of intrinsic foot muscles and an altered foot shape
 Claw toes + prominent metatarsal heads
 Autonomic neuropathy: ↓ sweating → cracked, dry foot
© Alasdair Scott, 2012
147
Lymphoedema
Examination
Viva
Inspection
Limb Swelling Differential





Gross leg swelling
Bilateral or unilateral
Thick, indurated skin
Lichenification
Yellow nail discoloration
Palpation
 Initially: pitting
 Later: non-pitting
 Palpate for inguinal nodes
Completion
 Exclude RHF
 ↑ JVP
 Hepatomegaly
 Take a Hx: esp. re hereditary conditions
Bilateral
 ↑ Venous Pressure
 RHF
 Venous insufficiency
 Drugs: e.g. nifedipine
 ↓ Oncotic Pressure
 Nephrotic syndrome
 Hepatic failure
 Protein losing enteropathy
 Lymphoedema
 Myxoedema
 Hyper- / hypo-thyroidism
Unilateral
 Venous insufficiency
 DVT
 Infection or inflammation
 Lymphoedema
Lymphoedema
 Collection of interstitial fluid due to blockage or absence
of lymphatics.
Primary
 Congenital absence of lymphatics
 May or may not be familial
 Presentation
 Congenital: evident from birth
 Praecox: after birth but <35yrs
 Tarda: >35yrs
Milroy’s Syndrome: 2% of primary lymphoedema
 Familial AD subtype of congenital lymphoedema
 F>M
Secondary: FIIT
 Fibrosis: e.g. post-radiotherapy
 Infiltration
 Ca: prostate, lymphoma
 Filariasis: Wuchereria bancrofti
 Infection: TB
 Trauma: block dissection of lymphatics
Mx
© Alasdair Scott, 2012
 Conservative
 Skin care
 Grade 3 compression stockings
 Treat or prevent cellulitis
 Physio
 Raise leg as much as possible
 Surgical
 Debulking operation
 Bypass procedures
148
Musculoskeletal
Contents
Hip Examination ..................................................................................................................................................................... 150
Knee Examination .................................................................................................................................................................. 151
Osteoarthritis: Key Facts ....................................................................................................................................................... 152
Hip Arthroplasty ..................................................................................................................................................................... 153
Knee Arthroplasty .................................................................................................................................................................. 154
Knee Ligament Damage ........................................................................................................................................................ 154
Hallux Valgus ......................................................................................................................................................................... 155
Lesser Toe Deformities .......................................................................................................................................................... 155
Charcot Joints ........................................................................................................................................................................ 156
Gait ........................................................................................................................................................................................ 157
Popliteal Swellings ................................................................................................................................................................. 157
Shoulder Examination ............................................................................................................................................................ 158
Hand Examination.................................................................................................................................................................. 159
Dupuytren’s Contracture ........................................................................................................................................................ 160
Carpal Tunnel Syndrome ....................................................................................................................................................... 161
Rheumatoid Hands ................................................................................................................................................................ 162
OA Hands .............................................................................................................................................................................. 163
Ulnar Nerve Palsy .................................................................................................................................................................. 164
Radial Nerve Palsy ................................................................................................................................................................ 164
Mallet Finger .......................................................................................................................................................................... 165
Trigger Finger ........................................................................................................................................................................ 165
Back Examination .................................................................................................................................................................. 166
Lumbar Disc Herniation ......................................................................................................................................................... 167
© Alasdair Scott, 2012
149
Hip Examination
Set-Up
 Pt. should be in their underwear
 Note presence of walking aids
 Start c̄ pt. standing
Look
Gait
 Antalgic: ↓ stance-phase on affected side
 Trendelenberg: sideways lurch of trunk to bring body wt. over limb
Examine Pt. Standing
 Skin
 Scars: esp. lateral and posterior
 Bruising, erythema
 Shape
 Soft tissue or bony swelling
 Muscle wasting: esp. gluteals
 Deformity: coxa vara or valga
Trendelenberg Test
 Negative: pelvis tilts slightly up on unsupported side.
 Positive: pelvis drops on the unsupported side
 Pathology of contralateral abductor mechanism
Examine Pt. Supine
 Square the pelvis and measure leg lengths
 True length: ASIS to medial malleolus
 Apparent length: xiphisternum to medial malleolus
 Galeazzi Test: tibial vs. femoral shortening.
+ve Trendelenberg Test
 Abductor wasting 2O chronic pain
 Sup. gluteal N. injury: surgery
 Structural: DDH
True Shortening
 #: e.g. NOF
 Hip dislocation
 Growth disturbance of tibia/fibula
 Osteomyelitis, #s
 Surgery: e.g. THR
 SUFE
 Perthes’ disease
Feel
 Palpate for tenderness:
 ASIS, iliac crests and pubic rami
 Greater trochanter
Move





Abduction: 45
Adduction: 30
Flexion: 130
Internal rotation: 20
External rotation: 45
Thomas’ Test
 Caution if hip arthroplasty on non-test side
 Forced flexion can → dislocation
 Assesses for fixed flexion deformity
 Masked by compensatory movement in pelvis or lumbar spine
 Obliterate lumbar lordosis
 Angle between thigh and bed = fixed flexion deformity
Completion
 Examine the knee and spine
 Perform a neurovascular assessment (esp. pulses).
 AP and lateral radiographs of the pelvis
© Alasdair Scott, 2012
Apparent Shortening
 Scoliosis of the spine
Hip pain
 Pain from hip joint usually felt in
groin or ant. thigh.
 Pain @ back of hip is usually
referred from lumbar spine.
Fixed Flexion Deformity
 Osteoarthritis
 # NOF
Features in OA of the Hip
 ± Trendelenberg gait or +ve Test
 Pain
 Stiffness
 ↓ ROM: esp. internal rotation
 Fixed flexion deformity
150
Knee Examination
Set-Up
 Pt. should be in their underwear
 Note presence of walking aids
 Start c̄ pt. standing
Look
Gait




Antalgic
Stiff: pelvis rises during swing phase
Varus thrust: medial collateral
Valgus thrust: lateral collateral
Examine Pt. Standing
 Skin
 Scars: arthroscopic ports, KR (midline longitudinal), menisectomy
 Bruising, erythema
 Shape
 Swelling: knee and popliteal fossa (Baker’s Cyst)
 Muscle wasting: quads, hamstrings
 Measure quads circumference @ 15cm from tib tuberosity
 Deformity
 Genu vara (bow legged): OA
 Genu valga (knock-knee): RA
Examine Pt. Supine
Feel
 Temperature
 Effusion: sweep test and ballot
 Palpate
 Position knees @ 90O
 Joint line for tenderness: meniscal pathology
 Patella, tendon and tibial tuberosity
 Popliteal fossa
Knee Effusion
 Synovial fluid: synovitis
 Blood
 90% = ACL rupture
 PCL rupture, intra-articular #, meniscal tear
 Bleeding diathesis
 Pus: septic arthritis
Move
 Straight leg raise
 Extensor lag
 Hyperextension
 Fixed flexion deformity
 Passive flexion of knee while palpating joint for crepitus
 Normal range = 0-140
Special Tests
 Cruciate Ligaments
 Ant + Post drawer tests: observe for posterior sag first = PCL tear
 Lachman’s: ACL, more sensitive cf. drawer test
 (Pivot shift test: only do in theatre under anaesthetic)
 Collateral Ligaments
 In partial flexion ~30O (relax the joint capsule) and full extension
 Valgus stress (medial lig.) and varus stress (lateral lig.)
 Menisci
 (McMurray test)
 (Apley grind test)
Completion
 Examine the hip and ankle.
 Perform a neurovascular assessment: esp. pulses
 Standing AP and lateral and skyline radiographs of the knee
© Alasdair Scott, 2012
151
Osteoarthritis: Key Facts
Definition
 Degenerative joint disorder in which there is
progressive loss of hyaline cartilage and new bone
formation at the joint surface and its margin.
Mx
MDT
 GP, physio, OT, dietician, orthopod
Aetiology / Risk Factors
Conservative
 Lifestyle: ↓ wt., ↑ exercise
 Physio: muscle strengthening
 OT: walking aids, supportive footwear, home mods
Classification
Medical
 Analgesia
 Paracetamol
 NSAIDs: e.g. arthrotec (diclofenac + misoprostol)
 Tramol
 Joint injection: local anaesthetic and steroids
 Age (80% >75yrs)
 Obesity
 Joint abnormality
 Primary: no underlying cause
 Secondary: obesity, joint abnormality
Symptoms
 Affects: knees, hips, DIPs, PIPs, thumb CMC
 Pain
 Worse c̄ movement
 Background rest/night pain
 Worse @ end of day
 Stiffness
 Especially after rest: joint “gelling”
 Lasts ~30min (e.g. AM)
 Deformity: e.g. genu varus
 ↓ ROM
Pathophysiology
 Softening of articular cartilage → fraying and fissuring
of smooth surface → underlying bone exposure.
 Subchondral bone becomes sclerotic c̄ cysts.
 Proliferation and ossification of cartilage in unstressed
areas → osteophytes.
 Capsular fibrosis → stiff joints.
Ix
Exclude Rheumatological Disease
 FBC
 ESR
 RF, ANA
Check Renal Function
 Important before prescribing NSAIDs: esp. in elderly
 U+E
X-ray Changes
 Loss of joint space
 Osteophytes
 Subchondral cysts
 Subchondral sclerosis
 Deformity
© Alasdair Scott, 2012
Surgical
 Arthroscopic Washout
 Mainly knees
 Trim cartilage
 Remove loose bodies.
 Realignment Osteotomy
 Small area of bone cut out
 Useful in younger (<50yrs) pts. c̄ medial knee OA
 High tibial valgus osteotomy redistributes wt. to
lateral part of joint.
 Arthroplasty: replacement (or excision)
 Arthrodesis: last resort for pain management
 Novel Techniques
 Microfracture: stem cell release → fibro-cartilage
formation
 Autologous chondrocyte implantation
OA vs. RA
OA
Pathology
- Degenerative
- Negative serology
RA
Pathology
- Inflammatory
- Positive serology
Clinical
- Asymmetric
- Large joints
- Early AM stiffness <30min
- Worse PM
- Hands: DIPJs and PIPJs
- No extra-articular features
Clinical
- Symmetric
- Small joints
- Early AM stiffness >1hr
- Worse AM
- Hands: PIPJs and MCPJs
- Extra-articular features
Radiology
- Osteophytes
- Subchondral sclerosis
- Subchondral cysts
- Mild deformity
Radiology
- Soft tissue swelling
- Periarticular osteopenia
- Periarticular erosions
- Severe deformity
152
Hip Arthroplasty
History
 Pioneered in 60s by Sir John Charnley
Types
THR
 Replace femoral head, neck and acetabulum
 Usually elective joint arthroplasty
Hemi-arthroplasty
 Replace femoral head and neck only
 May be uni- or bi-polar
Resurfacing
 Replacement of surface of femoral head
Complications
Immediate
 Nerve injury
 Fracture
 Cement reaction
Early
 DVT: up to 50% w/o prophylaxis
 Deep infection: 0.5-1.5%
 Must remove metalwork before revision.
 Dislocation (3%): squatting and adduction
Late




Loosening: septic or aseptic
Leg length discrepancy
Metalosis
Revision: most replacements last 10-15yrs
Prostheses
Cemented: e.g. Thompson
 Recommended by NICE
Uncemented: e.g. Austin-Moore
 Easier to revise (may be useful in younger pts.)
Techniques
Posterior Approach
 Access joint and capsule posteriorly, reflecting of the
short external rotators.
 Gives good access
 May have higher dislocation rate
 Sciatic N. may be injured → foot drop
Anterolateral Approach
 Incision over greater trochanter, dividing fascia lata.
 Abductors are reflected to access joint capsule.
 May have lower dislocation risk
 Sup. Gluteal N. may be injured → Trendelenberg gait
Preventing DVT
 DVT is commonest complication of THR
 Peak incidence @ 5-10d post-op
Pre-Op
 TED stocking
 Aggressive optimisation: esp. hydration
 Stop OCP
Intra-Op
 Minimise length of surgery
 Using pneumatic compression boots
Post-Op
 LMWH: also rivaroxaban and dabigatran
 Early mobilisation
 Good analgesia
 Physio
 Adequate hydration
Hip Resurfacing
Advantages
 Metal-on-metal bearings wear less
 Larger head → ↓ dislocation / ↑ stability
 Preserve bone stock making revision easier
Disadvantages
 Cobalt and chromium metal ion release may cause
pathology (e.g. leukaemia)
 Risk of NOF # if mal-positioned
Indications
 May be used in young (<65), active people who are
expected to outlive the replacement.
© Alasdair Scott, 2012
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Knee Arthroplasty
Knee Ligament Damage
Types
Haemarthrosis Differential
 Can be uni- or bi-compartmental
 Cemented: UK
 Uncemented: Europe
Aim
 Primary goal is to reduce pain
The Surgery
 Performed under tourniquet
 PCL is usually preserved
 ACL is usually sacrificed
 Prosthesis is specifically designed to provide
some compensation for this
 Metal prosthesis and an ethylene articular disc.
 Patella surface can be re-surfaced.
 Knee bending after 2-3 days.
 10 days hospital stay
Complications
Immediate
 Fracture
 Cement reaction
 Vascular injury
 SFA
 Popliteal and genicular vessels
 Nerve injury
 Peroneal nerve → foot drop (1%)
Early
 DVT
 Up to 50-70% w/o prophylaxis
 25% c̄ prophylaxis
 Deep infection: 0.5-15%
 Must remove metalwork before revision.
Late
 Loosening: septic or aseptic
 Periprosthetic #s
 ↓ ROM and instability
 Loss of ACL
Surgical Mx of RA in the Knee
 Indicated in failed medical Mx
 Synovectomy and debridement
 Can be done arthroscopically
 Removal of pannus and cartilage
 Supracondylar osteotomy
 Total knee arthroplasty
Primary Spontaneous
 w/o trauma
 May be 2O to coagulopathy
Secondary to Trauma
 Immediate knee swelling
 80% ACL injury
 10% 2O to patellar dislocation
 10%
 Meniscal tear
 Capsular tear
 Osteochondral #
Knee Locking Differential




Meniscal tear
Cruciate ligament injury
Osteochondritis dissecans: adolescents
Loose body
Presentation of ACL Injury





Assoc. c̄ deceleration and rotational movements
Hears a pop or feels something tear
Inability to continue sport or activity
Haemarthrosis w/i 4-6h
Instability / giving way following injury
Unhappy Triad of O’Donoghue
 ACL
 MCL
 Medial Meniscus
Mx of Meniscal Tear
 Depends on
 Age
 Chronicity of injury
 Location and type of tear
Non-Surgical
 Symptomatic Rx: e.g. analgesia
Surgical
 Arthroscopic or open
 Partial meniscectomy
 Meniscal repair
Mx of ACL Rupture
Non-Surgical
 Rest and phyio to strengthen quads and hamstrings
 Not enough stability for many sports
Surgical
 Gold-standard is autograft repair
 Usually semitendinosus ± gracilis (can use patella)
 Tendon threaded through heads of tibia and femur and
held using screws.
© Alasdair Scott, 2012
154
Hallux Valgus
Lesser Toe Deformities
Examination
Look
 Hallux
 Unilateral or bilateral
 Estimate degree of valgus
 Rotation: nail faces medially
 Bunion
 Prominence of 1st metatarsal head ± bursa
 Evidence of inflammation: bursitis
 Extras
 Hammer toes
 Callosities on heel
Feel
 Inflammation of bunion
 Localised tenderness
 e.g. OA of MTPJs
Aetiology
 Imbalance between intrinsic and extrinsic toe muscles
 Intrinsic: lumbricals
 Extrinsic: long flexors and extensors
 F>M
 Commoner in pts. c̄ RA
 ↑ c̄ age
Move
 Assess ROM of toe joints
Completion
 Assess ROM of other toe joints
 Assess gait
 Examine shoes: abnormal weight-bearing
Mx
 Non-surgical: appropriate footwear
 Surgical correction
 Flexor-to-extensor tendon transfer
 Arthrodesis
 Resection of proximal phalangeal head
Viva
Aetiology
 Familial tendency
 ↑ enclosed / pointed shoes
 Assoc. c̄ RA
Ix
 Wt. bearing x-rays
 Degree of valgus
 OA of MTPJ
Mx
Non-surgical
 Appropriate footwear: wide, soft
 Physio
Surgical
 Bunionectomy
 1st metatarsal realignment osteotomy
 Excision arthroplasty
© Alasdair Scott, 2012
155
Charcot Joints
Examination
Look
 Swelling
 Deformity
 Pressure necrosis
Feel
 Joint is not tender or warm
 May feel crepitus
 Subluxation or dislocation of the joint
Move
 Abnormal
Completion
 Neurological examination of the limb
 Esp. pain and proprioception
 Dip urine for glucose
Viva
Definition
 Progressive destructive joint arthropathy
 2O to disturbance of sensory innervation to the joint
 Painless deformed joint resulting from repetitive minor
trauma.
Causes
Peripheral
 DM
 Peripheral N. injury
 Leprosy
Central
 Syringomyelia
 Tabes dorsalis
© Alasdair Scott, 2012
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Gait
Popliteal Swellings
Phases
Examination
1.
2.
3.
4.
Initial contact / heel strike
Stance
Toe off
Swing
Abnormalities
Gait
Antalgic
Trendelenberg
Parkinsonian
Broad-based
High stepping
Spastic
Description
↓ stance
↑ swing
Hips dip
Shoulders lurch to
contralateral side
Slow initiation
Shuffling steps
Poor arm swing
Slow turn
Lurches to one side
Foot strikes c̄ ball and
slaps the ground
Internal rotation
Hips adducted
Cause
Pain
Weak abductors
Describe the Lump
 Visible popliteal swelling
 Describe as for lump
 SSS CCC TTTT FPS
 Pulsatile: swelling overlying popliteal A.
 Expansile: popliteal aneurysm
 Fluctuant and transilluminable: cystic
Completion
 Continue c̄ knee exam: signs of OA
 Neurovascular assessment
Parkinsonism
Viva
Cerebellar lesions
Common peroneal
L5 disc
UMN
Differential





Skin + s/c tissue: lipoma
Artery: popliteal aneurysm
Vein: saphena varix @ SPJ
Nerve: tibial nerve neuroma
Enlarged bursae
 Above knee joint line
 Assoc. c̄ semimembranosus
 Baker’s Cyst
Baker’s Cyst
 Posterior herniation of knee joint capsule
 Assoc. c̄ degenerative knee joint disease
 Located below knee joint line
Dx: US
Mx
© Alasdair Scott, 2012
 Aspiration possible: high recurrence
157
Shoulder Examination
Set-Up
 Expose chest and shoulders
Look
Inspect shoulder girdle and axilla
 Skin: scars, bruising, erythema
 Shape
 Wasting: deltoid, supra- and infra-spinatous
 Clavicular deformity
 Joint swelling
 Deformity
 Joint dislocation
 Scapula location
 Winging of the scapula
Feel






Temperature
Along clavicle from SCJ to ACJ
Acromion and coracoid (2cm inf. + med. to clavicle tip)
Biceps tendon in bicipital groove
Scapular spine
Humoral head and greater and lesser tuberosities.
Winging: Seratus Anterior Weakness
 Long-thoracic nerve damage: e.g.
axillary surgery
 Upper brachial plexus injury
 Muscular dystrophy: e.g. FSH
Shoulder Differential: Pain ± ↓ROM
 Rotator cuff: tear, tendonitis
 Subacromial bursitis
 Adhesive capsulitis (frozen shoulder)
 Joints: synovitis, OA, dislocation
 Humeral head: #, dislocation
 Referred pain from diaphragm
Move: active then passive
Functional screen
 Ask pt. to put both hands behind the head
 Ask pt. to reach behind back and touch shoulder blades
Abduction and adduction
 First 25O of abduction is supraspinatous, rest is deltoid
 Palpate acromion tip during abduction to determine GHJ movement
 Abduction at GHJ is ~80O, rest is scapula rotation.
 Pain
 60-120O = impingement or rotator cuff tendonitis
 140-180 = AC osteoarthritis
Flexion and Extension
Internal and external rotation
 External rotation most commonly ↓d in frozen shoulder
Special Tests
 Jobe’s Empty Can Test: Supraspinatus
 Shoulder flexed @ 90O, thumb pointing down, forced flexion of shoulder
 Infraspinatus + Teres Minor
 Elbow flexed @ 90O, forced external rotation of shoulder
 Gerber’s Lift Off: Subscapularis
 Dorsum of hand placed against lumbar spine, pt. attempts to lift hand off against resistance
 Scarf Test: AC Joint Dysfunction
 Place pt’s. hand on contralateral shoulder
 Examiner pushes pt’s. flexed elbow posteriorly, eliciting discomfort
 Hawkin’s Test Shoulder: Impingement
O
 Shoulder and elbow flexed @ 90 .
 Examiner pushes hand down
 Apprehension Test: GHJ Instability
 Shoulder is abducted and externally rotated to 90O
 Apprehension occurs as shoulder is slowly externally rotated
Completion
 Examine the cervical spine and elbow
 © Perform
a neurovascular assessment
Alasdair Scott, 2012
158
Hand Examination
Set-Up
 Expose pts. arms up to elbow
 Lay hands on a pillow
Look
 Dorsum and palms
Skin





Scars: palm and carpal tunnel
Erythema
Calcinosis and tophi
Ulceration
Ganglia
Muscle Wasting
 Median nerve: thenar eminence
st
 Ulnar nerve: 1 dorsal interroseus
Joints Swellings
 Heberden’s: distal
 Bouchard’s: proximal
Deformities
 RA
 Boutonniere’s
 Swan neck
 Z-thumb
 Ulnar deviation @ the MCPs
 MCP volar subluxation
 Dupuytron’s
 Trigger Finger
 Mallet Finger
 Claw Hand
Nails
 Onycholysis
 Pitting
 Subungual hyperkeratosis
Extras
 Elbows: rheumatoid nodules, psoriatic plaques
 Scalp and behind ears: psoriatic plaques
Feel




Temperature
Joints: pain and swelling
Tendons: palm for nodules or thickening.
Muscles
 Median nerve: thenar eminence
 Ulnar nerve: 1st dorsal interroseus
Autonomous Sensory Areas
 Median: pulps of index and middle fingers
 Ulnar: pulp of little finger
 Radial: 1st dorsal web space
Move
 Wrist
 Prayer and reverse prayer positions
 Check that fingers are opposed in prayer position
 Thumb
 Abduction
 Fingers
 Abduction and adduction (cross fingers for luck)
 Opposition
 Grip
Autonomous Motor Supply
 Median: abductor pollicis brevis
 Ulnar: 1st dorsal interosseous
 Radial: MCP extension
Function
 Fasten and unfasten button.
 Pick up coin from flat surface
 Write name
Special Tests
Median Nerve
 Tinel’s
 Phalen’s
Ulnar Nerve
 Froment’s: flexion of thumb @ IPJ = weak ADductor policis
de Quervain’s tenosynovitis (APL + EPB tendonitis)
 Finkelstein’s
Completion
 Neurovascular status of the upper limb.
 AP and lateral radiographs
© Alasdair Scott, 2012
159
Dupuytren’s Contracture
Examination
Viva
Look
Hx





Often bilateral and symmetrical
Tethering or pitting of palmar skin
Visible tendon cords
Surgical scars: Z plasties
Fixed flexion of MCP and PIP joints
 Usually little and ring fingers
 Garrods Pads
 Thickening of dorsal skin over PIPJ
Feel
 Palpate thickened tendons
 Note fixation to skin
Move
 Assess ROM
 Note fixed deformities by loss of passive ROM
 Ask pt. to lay hand flat on table
Function
 Ask pt. to pick up a coin and do up a button
Completion
 Abdominal exam for signs of CLD
 Hx and Drug chart
 Other features of diffuse fibromatosis
Differential
 Skin contracture: look for scar from previous wound
 Congenital contracture of little finger
 Ulnar nerve palsy: ↓ sensation, +ve Froment’s sign




Associations
Function
Previous therapy
Other features of diffuse fibromatosis
Associations: BAD FIBERS








Bent penis: Peyronie’s (3%)
AIDS
DM
FH: AD
Idiopathic : commonest
Booze: ALD
Epilepsy meds and epilepsy: phenytoin
Reidel’s thyroiditis and other fibromatoses
 Ledderhose disease
 Fibrosis of plantar aponeurosis
 5% c̄ dupuytren’s
 Retroperitoneal fibrosis
 Smoking
Pathophysiology
 Local microvessel ischaemia → ↑ xanthine oxidase
activity → ROS production.
 ROS → myofibroblast proliferation → collagen 3
formation
 Chronic inflammation → continued fibrosis
Non-Surgical Mx
 Physiotherapy
 Allopurinol may help
Surgical Mx
Indication
 MCP or PIP contracture >30O
Procedures
 Fasciotomy
 Partial fasciectomy
 Z-plasty to lengthen wound
 Post-op physio
 Can damage ulnar nerve
 Often recurs
 Dermofasciectomy + full-thickness skin grafting
 Lowest risk of recurrence
 Arthrodesis and amputation
© Alasdair Scott, 2012
160
Carpal Tunnel Syndrome
Examination
Viva
Look
Hx
 Wasting of thenar eminence
 Scars from previous surgery over flexor retinaculum
 Symptoms
 Tingling / pain in thumb, index and middle fingers
 Pain worse @ night or after repetitive actions
 Relieved by shaking / flicking hand
 Causes
 Hypothyroidism
 Pregnancy
 RA
 Previous treatments
Feel
 Test light touch over finger pulps
 Test light touch over the thenar eminence
Move
 Opponens pollicis
 Abductor pollicis brevis
Special Tests
Causes: I WRIST






 Tinel’s
 Phalen’s
Completion
 Hx
 Look for underlying cause and associations
Differential
 More proximal median nerve lesion
 Cervical root lesion
 E.g. cervical disc herniation
Ix
Idiopathic: commonest
Water: pregnancy, hypothyroidism
Radial #
Inflammation: RA, gout
Soft tissue swelling: lipomas, acromegaly, amyloidosis
Toxic: DM, EtOH
 Not typically necessary
 Nerve conduction studies
 Determine lesion location
 Determine lesion severity
 US
Non-surgical Mx
 Mx of underlying cause
 Wrist splints
 Neutral position
 Esp. @ night
 Local steroid injections
Surgical Mx
 Carpal tunnel decompression by division of the flexor
retinaculum
Complications
 Scar formation: high risk for hypertrophic or keloid
 Scar tenderness: up to 40%
 Nerve injury
 Palmar cutaneous branch of the median nerve
 Motor branch to the thenar muscles
 Failure to relieve symptoms
Other Locations of Median Nerve Entrapment
 Pronator syndrome
 Entrapment between two heads of pronator teres
 Anterior interroseous syndrome
 Compression of the anterior interosseous branch
by the deep head of pronator teres
 Muscle weakness only
 Pronator quadratus
 FPL
 Radial half of FDP
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Rheumatoid Hands
Examination
Viva
Look
Hx
Hands
 Skin: joint erythema, palmar erythema
 Joint Swelling: MCPs and PIPs
 Muscle wasting: interossei, thenar eminence
 Deformity
1. Ulnar deviation @ the MCPs
2. Boutonniere deformity
3. Swan neck deformity
4. Z thumb
5. MCP volar subluxation
 Symptoms
 Early morning stiffness
 Pain
 Swelling
 Affect on life
 Extra-articular features: aNTI CCP Or RF
 Treatments tried so far + any complications
Extra-Articular Features: aNTI CCP Or RF









Surgical Scars
 Wrist: carpal tunnel release
 Thumb: joint replacement
 Dorsum: tendon transfer
 Ulna stylectomy
Wrist
 Radial deviation
 Volar subluxation of the ulnar styloid
Elbow
 Rheumatoid nodules
Feel
 ↑ temperature of swollen joints = active synovitis
 Joint tenderness
 Median nerve sensation
Move
 Fixed flexion on prayer position
 ↓ ROM
Special
 Finkelstein’s
 Tinel’s and Phalen’s
Function




Precision: unbutton shirt, pick up coin from table
Power: squeeze fingers
Writing
Walking aids, splints, wheelchair
Completion
 Hx
 Examine for other features of RA
Presentation
 Symmetrical deforming polyarthropathy
 Signs of active synovitis
 Signs of cause
 Rheumatoid nodules
 Psoriatic plaques
Differential
 Psoriatic arthritis
 Jacoud’s arthropathy
© Alasdair Scott, 2012
Nodules
Tenosynovitis: de Quervains and atlanto-axial subluxation
Immune: vasculitis, amyloidosis
Cardiac: pericarditis ± effusion
Carpal tunnel
Pulmonary: fibrosis, effusions
Ophthalmic: episcleritis, scleritis, Sjogren’s
Raynaud’s
Felty’s: RA + ↓PMN + splenomegaly
Ix
Bloods
 FBC: ↓Hb, ↓PMN
 ↑ESR and ↑CRP
 Immune: RF, anti-CCP, ANA, HLA-DR3/4
X-Ray
 Soft tissue swelling
 Periarticular osteopenia
 Loss of joint space
 Periarticular erosions
 Deformity
Mx
MDT
 GP, physio, OT, rheumatologist, orthopod
Conservative
 Physio
 OT: aids and splints
Medical
 Analgesia
 Steroids: IM, PO or intra-articular
 DMARDS
 Biologicals
 Other: CV risk, prevention of PUD and osteoporosis
Surgical
 Carpal tunnel decompression
 Tendon repairs and transfers
 Ulna stylectomy
 Arthroplasty
Anatomy of Rheumatoid Hands
 Boutonierre’s: rupture of central slip of extensor
expansion → PIPJ prolapse through “button-hole” created
by the two lateral slips.
 Swan: rupture of lateral slips → PIPJ hyper-extension
162
OA Hands
Examination
Viva
Look
Hx
 Heberden’s nodes: swelling of DIPJs
 Bouchard’s nodes: swelling of PIPJs
 Squaring of the thumb CMC
Move
 ↓ ROM of passive and active motion
Function
 Unbutton shirt
 Pick up coin from table
 Writing
Completion
 Hx
 Examine other joints for OA
 Hips, lumbar spine, knees
Differential
 RA hands
 Tophi
 Symptoms
 Pain
 Stiffness
 Affect on life
 Other joint disease
 Treatments so far
OA of the Hands
 Typically affects
 Thumb CMC
 PIPJs
 DIPJs
 Bouchard’s Nodes are strongly assoc. c̄ polyarticular OA
Mx of OA Hands
Non-Surgical
 Physiotherapy
 Analgesia
Surgical
 Joint arthrodesis
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Ulnar Nerve Palsy
Radial Nerve Palsy
Examination
Examination
Look
Look
 Partial claw hand: little and ring fingers
 Wasting
 Hypothenar eminence
 Dorsal interossei
Feel
 Loss of sensation in ulnar distribution
Move
 Weak abduction and adduction of fingers
 Weak flexion of DIPJ in little and ring fingers
Special
 Froment’s
 Weak adductor pollicis → flexion of thumb IPJ
 Compensation by FPL
 Elbow flex test
 Full elbow flexion for 1min
 → paraesthesia in little and ring fingers
Completion
 Examine neck: brachial plexus injury
 Examine PNS of affected limb
Viva
Causes of Ulnar Nerve Palsy
Anatomical Compression
 Cubital tunnel syn.: elbow
 Guyon’s canal syn.: wrist
Trauma
 Supracondylar #s of humerus
 Elbow dislocation
 Wrist drop: holds hands out in front, palms down
Feel
 Loss of sensation over the first dorsal interosseous
 May be sensory loss over dorsal forearm
Move
 Low
 Loss of MCP extension
 Preserved PIPJ extension: lumbricals
 High: + wrist weakness
 Very high: + triceps weakness
Completion
 Examine neck: brachial plexus injury
 Examine PNS of affected limb
Viva
Causes
Very High → triceps paralysis + wrist drop + finger drop
 Just below brachial plexus
 Compression: crutches
High → wrist drop + finger drop
 Occur at spiral groove
 Mid-shaft humerus #, Saturday night palsy
Low → finger drop
 Occur at elbow
 Only involve posterior interosseous nerve  sensation
preserved
 Local wounds, # or dislocation
Ulnar Paradox
 Proximal lesions → paralysis of ulnar half of FDP
 → ↓ marked clawing of hand
Mx
Non-surgical
 Avoid repetitive flexion-extension of elbow
 Avoid prolonged elbow flexion
 Night splinting of elbow in extension
Surgical
 Ulnar nerve decompression
 Medial epicondylectomy
© Alasdair Scott, 2012
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Mallet Finger
Trigger Finger
Examination
Examination
Look
Look
 Flexion deformity of distal phalanx of one or more
fingers
Move
 Terminal phalanx cannot be actively extended
 Can be passively extended
Viva
Aetiology
 Damage to extensor tendon of terminal phalanx.
 e.g. avulsion # due to hyperflexion injury when catching
a cricket ball
Mx
 X-ray: look for avulsion @ base of distal phalanx
 Splint c̄ distal phalanx in extension for 6wks to allow
tendon reattachment.
 If avulsed bone is large may fix it c̄ a Kirschner wire
 Flexion of middle or ring finger
Feel
 Palpate over palm proximally to digit for nodule.
 ~ @ level of transverse palmar crease
Move
 Test active movement of finger
 Snap on passive forced extension
Viva
Pathology
 Tendon nodule which catches on proximal side of
tendon sheath → triggering on forced extension.
 Often FDS tendon
Causes
 Idiopathic
 Trauma
 Activities requiring repetitive forceful flexion
 e.g. use of heavy shears
 2O to RA
Mx
 Steroid injection: often recurs
 Tendon release by sheath incision
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Back Examination
Set-Up
 Expose pt. to waist
 Begin c̄ pt. standing
Look




Assess gait
Spinal curvature
Paraspinal and trapezius muscle bulk
Wall-tragus test if neck hyperflexion
Feel
 Paraspinal muscle bulk and tenderness
 Spine palpation: masses, steps
 Spine percussion: tenderness
Move
 Cervical spine movement
 Lateral flexion: normally ~30O
 Forward flexion: Schober’s Test
 Mark 5cm below and 10cm above levels of PSIS (sacral dimples, ~S2)
 Maximum flexion should lengthen line by ≥5cm
Lie pt. Supine
 Assess back rotation c̄ arms folded across chest
 Measure leg lengths: apparent length discrepancy in scoliosis
Sacroileitis Tests
 Lateral compression
 Stretch: adduction of hip, c̄ hip and knee flexed
Straight Leg Raise
 Demonstrates lumbosacral nerve root irritation
 Record angle @ pain onset
 Lesague’s Sign
 ↑ pain c̄ foot dorsiflexion
Quick Neurological Assessment of Lower Limb
 Power
 L4: foot inversion and dorsiflexion
 L5: great toe dorsiflexion
 S1: foot eversion and plantar flexion
 Reflexes
 S1: Ankle
 Sensation
 L5: great toe and medial dorsum
 S1: little toe and lateral sole
Completion
 Complete neurological examination of lower limb
 Especially perineal sensation
 Consider a PR: exclude cauda equina compression
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Lumbar Disc Herniation
Examination
Viva
Look
Hx
 Gait: half-flexed, painful back
 Loss of normal lumbar lordosis
 Posture: sciatic list
 Attempt to ↓ nerve root compression by leaning
to one side to open up the neural foramen
Feel
 Erector spinae spasm or tenderness
Move
 Pre-existing lumbar spondylosis
 Rupture of annulus fibrosis c̄ herniation of nucleus
pulposus into spinal canal
Special Tests
 Positive straight leg raise
Neurological
Risk Factors
 Distal weakness and sensory loss
Root
L5
S1
Sensory
Inner foot dorsum
Outer foot sole
Completion
Occupation
Pain: site, radiation, associated injury, worse / better
Neurology: weakness, numbness and paraesthesia
Sphincter disturbance
Hx or features of malignancy
Effect on lifestyle
Previous Rx: analgesia, physio, surgery
Pathophysiology
 ↓ ROM: limited by pain
Disc
L4/5
L5/S1







Motor
Hallux exten
Foot eversion
+ plantarflex
Reflex
Ankle
 Complete neurological examination of lower limb
 Especially perineal sensation
 Consider a PR: exclude cauda equina compression
Physiological
 ↑ age
 Poor posture
 Poor aerobic fitness
Occupational
 Heavy manual labour
 Frequent bending, lifting, twisting
 Repetitive or static work postures
Psychosocial
 Depression
Non-Surgical Mx
Conservative
 Max 2d bed rest
 Education: keep active, how to lift / stoop
 Physiotherapy: “back school”
 Psychosocial issues re. chronic pain and disability
 Warmth
Medical
 Analgesia: paracetamol ± NSAIDs ± codeine
 Muscle relaxant: low-dose diazepam (short-term)
 Facet joint injections
Surgical Mx
Indications
 Progressive neurological deficit
 Severe incapacitating pain
 Failure of non-surgical options
Procedures
 Percutaneous microdiscectomy
 Endoscopic discectomy
 Hemilaminotomy + discectomy
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Practical Surgery
Contents
Minimal Access Surgery ........................................................................................................................................................ 169
Enhanced Recovery After Surgery ........................................................................................................................................ 169
Surgical Complications .......................................................................................................................................................... 170
Laparoscopic Cholecystectomy ............................................................................................................................................. 171
Inguinal Hernia Repair: Hernioplasty ..................................................................................................................................... 171
Appendicectomy .................................................................................................................................................................... 172
Nissen Fundoplication ........................................................................................................................................................... 172
Gastrectomy........................................................................................................................................................................... 173
Ivor-Lewis Oesophagectomy ................................................................................................................................................. 173
Whipple’s: Pancreaticoduodenectomy................................................................................................................................... 173
Abdominal Aortic Aneurysm .................................................................................................................................................. 174
Carotid Endarterectomy ......................................................................................................................................................... 174
Bypass Grafting ..................................................................................................................................................................... 175
Transurethral Resection of the Prostate ................................................................................................................................ 175
Surgical Procedures Summary .............................................................................................................................................. 176
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Minimal Access Surgery
Enhanced Recovery After Surgery
Advantages
ERAS
Smaller Incisions
 ↓ post-op pain
 ↓ risk of wound infection
 Faster post-op recovery
 ↓ hospital stay
 Better cosmesis
May allow better visualisation and access
 Can visualise and operate on pelvic organs in lap
appendicectomy.
 Dx and fix contralateral hernia in lap hernia repair.
 Commonly employed in colorectal and orthopaedic
surgery
Aims
 Optimise pre-op preparation for surgery
 Avoid iatrogenic problems (e.g. ileus)
 Minimise adverse physiological / immunological
responses to surgery
 ↑ cortisol and ↓ insulin (absolute or relative)
 Hypercoagulability
 Immunosuppression
 ↑ speed of recovery and return to function
 Recognise abnormal recovery and allow early
intervention
Disadvantages







Different anatomy
↓ tactile feedback (can’t feel colon tumours)
2D view of 3D structures
Technically challenging and old skills may be lost
Complications (e.g. haemorrhage) may be harder to Mx
Expensive
May take longer
Common Procedures





Lap cholecystectomy
Lap appendicectomy
Lap hernia repair
Lap colectomy (~25%)
Lap fundoplication
Relative Contraindications
 Pneumoperitoneum may not be tolerated by pts. c̄
severe cardiorespiratory insufficiency.
 ↓ venous return, ↓ diaphragm movement
 Bleeding disorders
 Shocked patients
 Multiple adhesions
© Alasdair Scott, 2012
Pre-op: optimisation
 Aggressive physiological optimisation
 Hydration
 BP (↑ / ↓)
 Anaemia
 DM
 Co-morbidities
 Smoking cessation: ≥4wks before surgery
 Admission on day of surgery, avoidance of prolonged
fast
 Carb loading prior to surgery: e.g. carb drinks
 Fully informed pt., encouraged to participate in recovery
Intra-op: ↓ physical stress




Short-acting anaesthetic agents
Epidural use
Minimally invasive techniques
Avoid drains and NGTs where possible
Post-op: early return to function + mobilisation



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
Aggressive Rx of pain and nausea
Early mobilisation and physiotherapy
Early resumption of oral intake (inc. carb drinks)
Early discontinuation of IV fluids
Remove drains and urinary catheters ASAP
169
Surgical Complications
Surgical Complications
Wound Infection
 5-7d post-op
 Organisms: S. aureus and Coliforms
Immediate (<24h)
 Intubation → oropharyngeal trauma
 Surgical trauma to local structures
 Primary or reactive haemorrhage
Early (1d-1mo)






Secondary haemorrhage
VTE
Urinary retention
Atelectasis and pneumonia
Wound infection and dehiscence
Antibiotic association colitis (AAC)
Late (>1mo)
 Scarring
 Neuropathy
 Failure or recurrence
Colonic Surgery
 Early





 Late


Ileus
AAC
Anastomotic leak
Enterocutaneous fistulae
Abdominal or pelvic abscess
Adhesions → obstruction
Incisional hernia
Haemorrhage Classification
 Primary: continuous bleeding starting during surgery
 Reactive
 Bleeding at the end of surgery or early post-op
 2O to ↑ CO and BP
 Secondary
 Bleeding >24h post-op
 Usually due to infection
Operative Classification
 Clean: incise uninfected skin w/o opening viscus
 Clean/Cont: intra-op breach of viscus (not colon)
 Contaminated: breach of viscus + spillage or opening
of colon
 Dirty: site already contaminated – faeces, pus, trauma
Risk Factors
 Pre-operative
 ↑ Age
 Comorbidities: e.g. DM
 Pre-existing infection: e.g. appendix perforation
 Pt. colonisation: e.g. nasal MRSA
 Operative
 Op classification and wound infection risk
 Duration
 Technical: pre-op Abx, asepsis
 Post-operative
 Contamination of wound from staff
Mx
Wound Dehiscence
Presentation
 Occurs ~10d post-op
 Preceded by serosanguinous discharge from wound
Risk Factors
 Pre-Operative Factors
 ↑ age
 Smoking
 Obesity, malnutrition, cachexia
 Comorbs: e.g. BM, uraemia, chronic cough, Ca
 Drugs: steroids, chemo, radio
 Operative Factors
 Length and orientation of incision
 Closure technique: follow Jenkin’s Rule
 Suture material
 Post-operative Factors
 ↑ IAP: e.g. prolonged ileus → distension
 Infection
 Haematoma / seroma formation
Mx
© Alasdair Scott, 2012
 Regular wound dressing
 Abx
 Abscess drainage
 Replace abdo contents and cover c̄ sterile soaked
gauze
 IV Abx: cef+met
 Opioid analgesia
 Call senior and arrange theatre
 Repair in theatre
 Wash bowel
 Debride wound edges
 Close c̄ deep non-absorbable sutures (e.g. nylon)
 May require VAC dressing or grafting
170
Laparoscopic Cholecystectomy
Principals
1. Establish Pneumoperitoneum
 Dissect down to and open the peritoneum @ umbilicus
 Insert lap port and establish pneumoperitoneum
 Insert 3 further ports under direct vision
 Epigastrium
 R costal margin
 R flank
2. Identify and Clip CA and CD
 Retract gallbladder upwards and identify Calot’s triangle
 Sup: inferior edge of liver
 Med: CHD
 Inf: cystic duct
 Contains: cystic artery, Calot’s/Lund’s node ±
aberrant RHA
 Key to ID cystic duct and cystic artery and differentiate
from CBD and RHA – “critical view of safety”
 Clip CD and CA.
 May use operative cholangiogram to confirm absence
of stones in CBD.
3. Dissect and Remove GB
 Gallbladder dissected off liver and removed via
umbilical port.
Complications





Conversion to open procedure: 5%
CBD injury: 0.3%
Bile leak
Retained stones
Intra-abdominal haemorrhage
 May be controlled by compressing the hepatic
artery in the free edge of the Foramen of Winslow
 Pringle’s Manoeuvre
Jaundice After Cholecystectomy
Post-hepatic
 Gallstone retention
 Biliary sepsis
 Thermal injury:  blunt dissection preferred
 Ligation of common hepatic or common bile duct
Pre-hepatic
 Haemolysis after transfusion
Hepatic
 Halogenated anaesthetics
Inguinal Hernia Repair: Hernioplasty
 6% of all general surgical operations
 15% of all general surgical outpt. consultations
Open: Lichtenstein Repair
 Can be performed under LA or GA
1. Enter inguinal canal
 Skin incised along Langer lines from external ring ~5cm
towards ASIS.
 Incise Camper’s (fatty), then Scarpa’s (membranous)
 Incise external oblique to enter inguinal canal.
2. Mobilise and retract spermatic cord
3. Identify and dissect hernial sac
 Dissect hernial sac off cord
 May incise carefully and check for viscera
 Invaginate sac into peritoneal cavity.
4. Cover defect and posterior wall c̄ tension-free mesh
Laparoscopic Repair
2 Main Repair Techniques
 Totally ExtraPeritoneal (TEP)
 Use balloon to blunt dissect extraperitoneal
space posterior to recti.
 Reduce hernial sac and cover defect c̄ mesh
 Trans-Abdominal Pre-Peritoneal (TAPP)
 Mesh placed through incision in peritoneum
Advantages
 Allows ID and repair of contralateral hernia which may
or may not have been diagnosed.
 Quicker recovery
 ↓ acute pain
 ↓ complications
 ↓ chronic pain
Disadvantages
 Technically challenging
 Longer operation
 More expensive
Complications
 Early




 Late


Urinary retention
Haematoma / seroma formation: 10%
Infection: 1%
Intra-abdominal injury (lap)
Recurrence (<2%)
Ischaemic orchitis: 0.5%
 2O thrombosis of pampiniform plexus
 Chronic groin pain / paraesthesia: 5%
Post-op
 Day cases unless co-morbidities
 Discharge c̄ mild analgesics and mild laxatives
 Return to work @ 1-2wks
© Alasdair Scott, 2012
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Appendicectomy
Nissen Fundoplication
Open
Aim
1. Access the peritoneum
 Transverse (Lanz) incision centred on McBurney’s point
 Incise Camper’s and then Scarpa’s fascia
 Muscle splitting incisions through abdominal muscles
 Incise transversalis fascia, pre-peritoneal fat and
peritoneum.
2. Deliver caecum and find appendix
 ID caecum and follow taenia coli convergence at
appendicular base.
 Prevent reflux, repair diaphragm
Procedure
 Usually laparoscopic approach
 Wrap gastric fundus around lower oesophagus
 Close any diaphragmatic hiatus
Complications
 Gas-bloat syn.: inability to belch / vomit
 Dysphagia if wrap too tight
3. Ligate mesoappendix and excise appendix
 Identify, clamp, divide and ligate Mesoappendix and
appendicular artery.
 Clamp, divide and ligate appendix @ base.
 Cauterise appendix mucosa and bury stump in caecum
c̄ purse-string (absorbable suture)
4. Peritoneal lavage and close abdomen
 Close abdomen in layers
If appendix is macroscopically normal
 Remove anyway
 20% have microscopic inflammation
 Avoids appendicitis in the future
 Search for other cause
 Meckel’s
 Gynae pathology
Complications
 Abscess formation
 Right hemicolectomy (e.g. for carcinoid, caecal
necrosis)
Laparoscopic
Advantages
 Visualise and operate on pelvic organs
 ↓ pain and quicker recovery
 ↓ wound infection
 Improved cosmesis
Commonest Appendix Positions




Retrocaecal: 65%
Pelvic:30%
Subcaecal:3%
Anteileal: 2%
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Gastrectomy
Ivor-Lewis Oesophagectomy
 Two-stage surgical procedure for removing tumours of
the distal two 3rds of the oesophagus.
Antrectomy
 Bilroth I: simple anastomosis
 Billroath II / polya: duodenal stump oversewn +
gastrojejunostomy
Procedure
 1st: abdominal roof-top incision
 Assess for sub-diaphragmatic spread
 Mobilisation of the stomach to form a gastric
conduit
 Resect para-oesophageal and cardiac LN
 2nd: right thoracotomy
 Mobilisation and resection of the oesophagus
 End-to-end anastomosis of gastric conduit to
remaining oesophagus
Whipple’s: Pancreaticoduodenectomy
Total Gastrectomy
Subtotal Gastrectomy
 Performed for Ca of the head of the pancreas
 Removal of:
 Gastric antrum
 Gallbladder
 Head of the pancreas
 Proximal duodenum
 Regional lymph nodes
Complications
Physical
 Ca: ↑ risk of gastric Ca
 Reflux or bilious vomiting (improves c̄ time)
 Abdominal fullness
 Stricture
 Stump leakage
Metabolic
 Dumping syndrome
 Abdo distension, flushing, n/v, fainting, sweating
 Early: osmotic hypovolaemia
 Late: reactive hypoglycaemia
 Blind loop syndrome → malabsorption, diarrhoea
 Overgrowth of bacteria in duodenal stump
 Vitamin deficiency
 ↓ parietal cells → B12 deficiency
 Bypassing proximal SB → Fe + folate deficiency
 Osteoporosis
 Wt. loss: malabsorption of ↓ calories intake
© Alasdair Scott, 2012
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Abdominal Aortic Aneurysm
Carotid Endarterectomy
Open Repair
Indications
 Exposure of aorta through midline laparotomy
 Aortic and iliac clamping
 Replacement of aneurysmal segment c̄ dacron
graft
Complications
 Mortality
 Elective: 5%
 Emergency: 50%
 MI
 Renal failure
 Anastomotic bleeding
 Graft infection
 Spinal or mesenteric ischaemia
 Distal trash from thromboembolisation
 Aortoenteric fistula
Endovascular Repair: EVAR
 Can be carried out under regional anaesthesia or
GA
 Involves interventional radiology and vascular
surgeons
 Endograft inserted through femoral artery over a
guide-wire into the aneurysmal segment.
 Proximal and distal stents are expanded → fixation
 Symptomatic (ECST, NASCET)
 ≥70% (5% stroke risk per yr)
 ≥50% if low risk (<3%, typically <75yrs)
 Perform w/i 2wks of presentation
 Asymptomatic (ACAS, ACST)
 ≥60% benefit if low risk
Principals
 Usually performed under LA
 LA allows direct monitoring of neurological status
 Under GA, transcranial US can monitor MCA flow
 EEG may also be used under GA
 Internal, external and common carotid arteries are clamped.
 May use temporary shunt to ensure cerebral perfusion
 Lumen of internal carotid opened and plaque is removed.
Complications




7% risk of stroke or death w/i 30d
Haemorrhage → haematoma
MI
Hypoglossal nerve damage: rare
 Tongue deviates towards affected side
 Fasciculations
Complications
 MI
 Spinal or mesenteric ischaemia
 Renal failure
 Graft migration or stenosis
 Endoleaks: leak into aneurysm sac
 1: perigraft leakage at proximal/distal
attachment
 2: retrograde flow from collaterals – lumbar,
IMA
 3: leakage between graft components
 4: leakage through graft fabric
Advantages
 ↓ perioperative mortality (0.5-2% vs. 5%)
 ↓ stress in high risk pts.
 ↓ hospital stay
 Improved cosmesis
Disadvantages
 No data on long-term outcomes
 Not all aneurysms amenable
 E.g. need adequate infra-renal neck
(≥15mm)
 ↑ in late procedure-related complications
 Life-long monitoring c̄ CT for endoleaks
 No ↓ all-cause mortality at 5yrs due to fatal
endograft failures (EVAR 1 and DREAM).
 No ↓ all-cause mortality vs. medical therapy for pts.
ineligible for open repair (EVAR 2)
 More expensive
© Alasdair Scott, 2012
174
Bypass Grafting
Transurethral Resection of the Prostate
Indications
Indications
 V. short claudication distance
 Symptoms greatly affecting pt’s. QoL
 Development of rest pain
Practicalities
 Need good proximal supply and distal run-off
 More distal grafts have ↑ rates of thrombosis
 Saphenous vein graft preferred below inguinal lig
 Either reversed or valves destroyed in situ
 Must tie off tributaries first
 Prosthetic grafts may be employed
 Above IL: Dacron
 Below IL: PTFE
Procedures
 Aorta / double iliac occlusion
 Aorto-bifem
 Axillo-fem (less stressful to pt.)
 Single iliac
 Aorto-fem
 Fem-fem crossover
 Axillo-fem
 SFA / PF
 Fem-pop
 Fem-distal (distal to popliteal, i.e. tibial A.)
Complications
 Haematoma
 Distal embolism
 Thrombosis
© Alasdair Scott, 2012
 Surgical Rx of choice for BPH when medical Rx has failed.
Principals
 Performed under spinal anaesthetic
 Cystoscopic inspection
 Locate external urethral sphincter and use as distal
resection landmark
 Electrosurgical resection of prostatic tissue under direct
vision
 Send chippings for histology
 Insert 3-way catheter post-op to irrigate bladder
Complications
Immediate
 TUR syndrome
 Absorption of large quantity of fluids → ↓Na
 Haemorrhage
Early
 Haemorrhage
 Infection
 Clot retention: requires bladder irrigation
Late





Retrograde ejaculation: common
ED: ~10%
Incontinence: ≤10%
Urethral stricture: LUTS following TURP
Recurrence
175
Surgical Procedures Summary
Upper GI
Name
Dohlman’s Procedure
Nissen Fundoplication
Heller’s
cardiomyotomy
Ramstedt’s
pyloromyotomy
Ivor-Lewis
Whipple’s
Pathology
Pharyngeal pouch
GORD
Achalasia
Congenital pyloric
stenosis
Oesophageal Ca
Pancreatic Ca
Procedure
 Minimally invasive endoscopic stapling
 Wrap fundus around distal oesophagus
 Longitudinal incision through muscularis
propria @ the LOS
 Longitudinal incision through muscularis
propria @ the pylorus
 Two-stage oesophagectomy
 Pancreaticoduodenectomy
Pros and Cons
Can → dysphagia
Can → GORD
Lower GI
Name
Mayo Repair
Pathology
Umbilical Hernia
Lockwood Approach
Femoral Hernia
McEvedy Approach
Femoral Hernia
TEP
TAPP
Inguinal Hernia
Inguinal Hernia
Lat. Sphincterotomy
Anal fissure
Delorme’s Procedure
Rectal prolapse
Procedure
 Double-breast the linea alba ± sublay
mesh.
 Low incision over hernia c̄ herniotomy and
herniorrhaphy.
 High approach in inguinal region
 Herniotomy and herniorrhaphy
 Totally ExtraPeritoneal lap hernia repair
 Trans-Abdominal Pre-Peritoneal lap
hernia repair
 Division of internal anal sphincter @ 3
O’clock
 Perineal approach c̄ mucosal excision
Pros and Cons
Used electively
Used in emergency situation
Allows inspection and
resection of non-viable bowel
Used when medical Mx fails
SE: minor faecal incontinence
Vascular
Name
Trendelenberg Op
Cockett’s Op
Trahere Transplantation
Pathology
Varicosities
Varicosities
Chronic
venous
insufficiency
Procedure
 SFJ ligation
 Perforator ligation
 Transplant of axillary vein c̄ valve into
deep venous leg veins
 Venous valvuloplasty
 Bypass venous obstruction c̄ contralateral
GSV
Pros and Cons
Name
Palomo Operation
Pathology
Varicocele
Pros and Cons
Lord’s Repair
Jaboulay’s Repair
Dartos Pouch
Procedure
Hydrocele
Hydrocele
Undescended
testis
Procedure
 High retroperitoneal approach for ligation
of testicular veins
 Transverse incision at the level of the
ASIS centred on the mid-inguinal point.
 Plication of the tunica vaginalis
 Eversion of the tunica vaginalis
 Mobilisation of testis and placement in a
s/c pouch via a hole in the dartos muscle.
Kistner Operation
Palma Operation
Urology
Dartos prevents retraction
Head and Neck
Name
Sistrunk’s Operation
© Alasdair Scott, 2012
Pathology
Thyroglossal
cyst
Procedure
 Excision of cyst and thyroglossal duct
Pros and Cons
176
Surgical Radiology
Contents
Achalasia ............................................................................................................................................................................... 178
Oesophageal Cancer ............................................................................................................................................................. 178
Pharyngeal Pouch: Zenker’s Diverticulum ............................................................................................................................. 179
Sliding Hiatus Hernia ............................................................................................................................................................. 179
Small Bowel Obstruction ........................................................................................................................................................ 180
Large Bowel Obstruction ....................................................................................................................................................... 181
Volvulus ................................................................................................................................................................................. 182
Other AXRs ............................................................................................................................................................................ 182
Perforated Viscus................................................................................................................................................................... 183
Tension Pneumothorax .......................................................................................................................................................... 183
Diverticulosis .......................................................................................................................................................................... 184
Colorectal Cancer .................................................................................................................................................................. 184
Ulcerative Colitis .................................................................................................................................................................... 185
Crohn’s Disease..................................................................................................................................................................... 185
Gallstones .............................................................................................................................................................................. 186
Nephrolithiasis ....................................................................................................................................................................... 188
Subdural or Extradural Haematoma ...................................................................................................................................... 189
Digital Subtraction Angiogram ............................................................................................................................................... 190
Cervical Spine ........................................................................................................................................................................ 191
Hip Fracture ........................................................................................................................................................................... 191
Shoulder Dislocation .............................................................................................................................................................. 192
Femoral and Tibial Fractures ................................................................................................................................................. 192
Colles’ Fracture ...................................................................................................................................................................... 193
Other Fractures ...................................................................................................................................................................... 193
Fracture Complications .......................................................................................................................................................... 194
© Alasdair Scott, 2012
177
Achalasia
Oesophageal Cancer
Image
Image
 Proximal dilatation of the oesophagus c̄ smooth distal
tapering – the bird’s beak appearance.
 May be food particles visible.
 Significant negative: apple-core stricture suggestive of
oesophageal SCC.
 Occurs in ~3% of pts c̄ achalasia
 Irregular, shouldered stricture of the oesophagus
 An “apple-core” lesion
 Where?
 Distal third: adenocarcinoma (commoner)
 Proximal third: SCC
Key Facts
Key Facts
Epidemiology
 M>F = 5:1
 ↑ in Transkei and China
Definition
 Focal motility disorder of the oesophagus caused by
degeneration of the myenteric plexus of Auerbach
Pathophysiology
 65% adenocarcinoma
 Lower 3rd
 GORD → Barrett’s → dysplasia → Ca
 35% SCC
 Upper and middle 3rds
 Assoc. c̄ EtOH and smoking
 Commonest type worldwide
 Spread
 Local → LNs → blood
Causes
 Usually idiopathic
 May be 2O to Chagas disease
Presentation




Ix
Dysphagia to liquids then solids
Retrosternal cramps
Regurgitation: esp. @ night ± aspiration pneumonia
Wt. loss
Major Risk Factors








Ba swallow
CXR: wide mediastinum + double RH boarder
Manometry: failure of relaxation + ↓peristalsis
OGD: exclude oesophageal SCC
GORD → Barrett’s
EtOH and smoking
Achalasia
Plummer-Vinson: 20% risk of SCC
Presentation
Mx
 Progressive dysphagia
 Wt. loss
 Upper 3rd: hoarseness + bovine cough
 Med: CCB, nitrates
 Int: botox injection, endoscopic balloon dilatation
 Surg: Heller’s cardiomyotomy (open or lap)
Ix
 Dx: OGD + biopsy
 Staging: CT, EUS, laparoscopy, mediastinoscopy
Mx
 MDT
 Oesophagectomy: 25% have resectable tumours
 Ivor-Lewis 2 stage
 McKeown 3 stage
 15% 5 year survival
 Palliation: 75% of pts.
 Analgesia
 Laser coagulation
 Stenting
 5% 5 year survival
© Alasdair Scott, 2012
178
Pharyngeal Pouch: Zenker’s
Diverticulum
Sliding Hiatus Hernia
Image
 Dilated pouch (the hernia) below a smooth, short,
symmetric, ring-like constriction (the GOJ).
 May be assoc. c̄ smooth area f concentric narrowing in
the distal oesophagus: reflux-stricture.
 Significant negative: apple-core stricture
Image
 Contrast filling of blind-ended pouch adjacent to and in
continuity c̄ the oesophagus.
Key Facts
Pathophysiology
 Out-pouching between crico- and thyro-pharyngeal
components of the inf. pharyngeal constrictor.
 Pulsion diverticulum
 Area of weakness = Killian’s dehiscence
Key Facts
Classification
 Sliding (80%)
 Gastro-oesophageal junction slides up into chest
 Often assoc. c̄ GORD
 Rolling (15%)
 Gastro-oesophageal junction remains in
abdomen but a bulge of stomach rolls into chest
alongside the oesophagus
 LOS remains intact so GORD uncommon
 Can → strangulation
 Mixed (5%)
Presentation




Dysphagia
Swelling on left side of neck
Regurgitation
Halitosis
Mx
 Excision
 Dohlman’s Procedure: endoscopic stapling
Presentation
 Often asymptomatic
 Sliding hernias → GORD: dyspepsia
 Rolling hernias → strangulation
Ix




CXR: gas bubble and fluid level in chest
Ba swallow: diagnostic
OGD: assess for oesophagitis
24h pH + manometry
 Exclude dysmotility or achalasia
 Confirm reflux
Rx
 Conservative: ↓wt., raise head of bed, stop smoking
 Medical: PPIs, H2RAs
 Surgical
 If intractable symptoms despite medical Rx.
 Should repair rolling hernia (even if asympto)
as it may strangulate.
© Alasdair Scott, 2012
179
Small Bowel Obstruction
Image
 Dilated loops of bowel ≥3cm in width
 Centrally located
 Valvulae coniventes: lines go completely across
 Valvular flaps projecting into SB lumen
 Many loops
 Many fluid level
 State orientation of pt.: erect or supine
 No gas in LB
Mx
Resuscitate: Drip and Suck
 Admit
 NBM
 Aggressive rehydration c̄ 0.9% NS
 Significant 3rd space losses
 On-going requirements
 Electrolyte disturbances
 Catheterise: aim for 0.5ml/kg/hr
 NGT
 Decompress upper GIT
 Stops vomiting
 Prevents aspiration
 Analgesia: e.g. paracetamol + codeine phosphate
 Abx: if evidence of strangulation or perforation
Differential
Common
 Mechanical
 Adhesions: 60%
 Hernias
 Non-mechanical / Ileus
Hx





Other
 Intraluminal
 Impacted faeces
 FB
 Gallstone
 Mural
 Benign stricture
 Malignant stricture
 Congenital atresia
 Extra-mural
 Pancreatic pseudocyst
 Abscess
 Congenital bands
 Ileus
 Post-op
 Peritonitis
 Pancreatitis / local inflammation
 Poisons: e.g. TCAs
 Metabolic: ↓K, ↓Na, ↓Mg, uraemia
 Mesenteric ischaemia
Vomiting
Absolute constipation
Colicky abdominal pain
Abdominal distension
Past Hx: surgery or hernias
Examination




Dehydration
Features of strangulation or perforation
Surgical scars and hernias
Bowel sounds: mechanical vs. non-mechanical
Ix
Bloods
 FBC, CRP, amylase: inflammatory markers
 U+E: dehydration and electrolyte abnormalities
 VBG: ↑ lactate indicates strangulation
 G+S, clotting: anticipation of surgery
Imaging
 AXR
 Erect CXR
 CT c̄ oral contrast: transition point
 Gastrograffin follow-thru: may be therapeutic if
adhesional obstruction
Mx
Mechanical
 Regular clinical examination: signs of strangulation
 Consider need for parenteral nutrition
 ~80% resolve w/o surgery
 Laparotomy + adhesiolysis ± resection ± stoma
 Failure of conservative Mx: up to 72hrs
 Development of sepsis
 Peritonitis
 Evidence of strangulation
Ileus
 Correct any underlying abnormalities
 Electrolytes
 Drugs
 Consider need for parenteral nutrition
© Alasdair Scott, 2012
180
Large Bowel Obstruction
Image
Resuscitate: Drip and Suck
 Admit
 NBM
 Aggressive rehydration c̄ 0.9% NS
 Significant 3rd space losses
 On-going requirements
 Electrolyte disturbances
 Catheterise: aim for 0.5ml/kg/hr
 NGT
 Decompress upper GIT
 Stops vomiting
 Prevents aspiration
 Analgesia: e.g. paracetamol + codeine phosphate
 Abx: if evidence of strangulation or perforation
 Dilated loops of bowel ≥6cm in width
 Peripherally located
 Haustra: lines go partially across
 Sacculations caused by shorter taenia coli
 No gas in rectum
Differential
Common
 Mechanical
 Carcinoma: 60%
 Diverticular stricture: 20%
 Volvulus
Other
 Intraluminal
 Impacted faeces
 FB
 Mural
 Benign stricture
 Malignant stricture
 Extra-mural
 Adhesions
 Hernia
 Abscess
 Haematoma
 Tumour: e.g. ovarian
 Ileus
 Pseudo-obstruction: Ogilvie’s syndrome
 Metabolic: ↓K, ↓Na, ↓Mg, uraemia
 Poisons: e.g. TCAs
 Mesenteric ischaemia
Hx
 Symptoms
 Vomiting
 Absolute constipation
 Colicky abdominal pain
 Abdominal distension
 Cause
 Ca: change in bowel habit, ↓wt., PR bleed
 Diverticulitis
Examination





Dehydration
Features of strangulation or perforation
Masses: neoplastic or inflammatory
Bowel sounds: mechanical vs. non-mechanical
PR: rectal mass, impacted stool, blood
Ix
Bloods
 FBC, CRP, amylase: inflammatory markers
 U+E: dehydration and electrolyte abnormalities
 VBG: ↑ lactate indicates strangulation
 G+S, clotting: anticipation of surgery
Imaging
 AXR
 CT c̄ oral contrast: transition point
 Gastrograffin enema: mechanical obstruction
Mx
 Regular clinical examination: signs of strangulation
 Consider need for parenteral nutrition
 Non-surgical: endoscopic stenting
 May offer bridge to surgery (CREST Trial)
 Surgical
 Indications
 Closed loop obstruction
 Obstructing neoplasm
 Strangulation or perforation
 Failure of conservative Mx
 Hartmann’s procedure
O
 Colectomy + 1 anastomosis
 Palliative bypass procedure
© Alasdair Scott, 2012
181
Volvulus
Other AXRs
Image
Chronic Pancreatitis
 Inverted U / Coffee bean sign
 Emerging from LIF: sigmoid (commoner)
 Emerging from RIF: caecal
Key Facts
Pathophysiology




Long mesentery c̄ short base predisposes to torsion
Vascular supply may be compromised → strangulation
↑ risk in psychogeriatric pts.: disease and Rx
Typically a long Hx of constipation
Presentation
 Often elderly pts. c̄ comorbidities
 Grossly distended, tympanic abdomen
Mx
 Resuscitate: drip and suck
 Sigmoid
 Detorse c̄ flatus tube
 May need sigmoid colectomy
 Often recurs
 Caecal
 ~ 10% can be detorsed by colonoscopy
  often needs surgery
 Caecostomy
O
 Right hemi c̄ 1 ileocolic anastomosis
Gastric Volvulus
Film
 Gastric dilatation
 Double bubble on erect films
 Horizontal speckled calcification @ ~ L1/L2
Differential: Pancreatic Ca
Causes
 Alcohol
 Genetic: CF, HH
 Immune: lymphoplasmacytic sclerosing pancreatitis
 ↑ TGs
 Structural: obstruction by stone
AAA
 Fusiform calcification in the midline
Gallstones
 Cluster of circular calcifications @ ~L1
Rigler’s Triad
 SBO
 Pneumobilia
 Gallstone in RIF
Rigler’s Sign
 Air on both sides of bowel wall
 Looks like double contrast
 Is falciform ligament also visible?
Foreign Bodies
 Unstable: theatre
 Stable
 Endoscopic removal
 Watch and wait c̄ serial radiographs
 Batteries
 Oesophagus: remove
 Stomach: safe
 Large sharp objects
 May consider laparotomy
Presentation
 Vomiting
 Pain
 Failed attempts to pass NGT
Risk Factors
 Rolling hiatus hernia
 Gastric / oesophageal surgery
Mx
 Endoscopic manipulation
 Emergency laparotomy
© Alasdair Scott, 2012
182
Perforated Viscus
Tension Pneumothorax
Image
Image
Differential
Extras
 Air under the diaphragm
 Rigler’s Sign




Spontaneous: perforated DU
Iatrogenic: laparotomy / laparoscopy
Traumatic
Miscellaneous: e.g. via female genital tract
Key Facts
Presentation
 Sudden onset, severe epigastric pain
 Vomiting
 Peritonitic abdomen
Ix
 Absent peripheral lung markings
 Mediastinal shift away from abnormality
 Surgical emphysema
 Evidence of cause: e.g. rib #s
Key Facts
Mx: surgical emergency
 Decompressive thoracostomy
 14G Venflon in 2nd ICS mid-clavicular line
 Continue resuscitation of pt.
 Insert a chest drain
Clinical Signs
 Bloods
 FBC, CRP, amylase
 U+E
 G+S, clotting
 Imaging
 Erect CXR
 Upright for 15min first
 70% show free air
 AXR: Rigler’s sign
Mx: surgical emergency
Resuscitation
 Admit
 NBM
 Aggressive fluid resuscitation
 3rd space + on-going losses
 Titrate to UO
 NGT
 Abx: local guidelines (probably cef+met)
 Analgesia: morphine + cyclizine
Preparation for Surgery
 Anaesthetist and book theatre
 Bloods: clotting + G&S
 Consent
 DVT prophylaxis
 ECG: if >55yrs or cardiovascular disease






Respiratory distress
↑JVP, ↓BP
Tracheal shift + displaced apex
Hyper-resonance to percussion
↓ breath sounds
↓ vocal resonance
Pathophysiology
 One way flap valve allows air to be drawn into pleural
cavity on each inspiration without escape.
 Mediastinal shift compresses the great vessels,
preventing filling of the heart → shock.
Types of Pneumothorax
Traumatic
 Open: may be sucking
 Closed
 Either may be under tension
Spontaneous
 1O: no underlying lung disease
 2O: underlying lung disease
Laparotomy
 DU: abdominal washout + omental patch repair
 GU: excise ulcer and repair defect
 Send specimen for histology to exclude Ca
Conservative
 May consider if pt. isn’t peritonitic
 Careful monitoring, fluids, Abx
 Omentum may seal perforation spontaneously
f/up
 Test and Treat for H. pylori: +ve in ~90% of perfed DUs
© Alasdair Scott, 2012
183
Diverticulosis
Colorectal Cancer
Image
Image
 Typically double-contrast enema
 Out-pouchings of mucosa
 Especially around sigmoid colon
Extras
 Typically double-contrast enema
 Apple-core stricture c̄ shouldered margins
Extras
 Evidence of perforation
 Evidence of obstruction: proximal flow of contrast
 Evidence of UC: lead-piping
 Evidence of stricturing
 Evidence of perforation: contrast leak
Key Facts
Key Facts
Definition
Risk Factors
 Out-pouching of tubular structure
 False: composed of mucosa only





Diet: ↓ fibre + ↑ refined carbohydrate
IBD: CRC in 15% c̄ pancolitis for 20yrs
Familial: FAP (5), HNPCC (2), Peutz-Jeghers (19)
Smoking
Genetics
 No relative: 1/50 CRC risk
 One 1st degree: 1/10
 NSAIDs / Aspirin (300mg/d): protective
Pathophysiology
 30% of Westerner’s by 60yrs
 F>M
 High intraluminal pressures → herniation of mucosa
through muscularis propria @ points of weakness
where perforating arteries enter.
 May be part of Saint’s Triad
 Diverticular disease
 Hiatus hernia
 Cholelithiasis
Presentation (left-sided)






Diverticular Disease
 Altered bowel habit
 Left-sided colic: relieved by defaecation
 Rx
 High-fibre diet, mebeverine may help
 Elective laparoscopic sigmoid colectomy
Diverticulitis
 Left-sided abdominal pain and localised tenderness
 Pyrexia
Ix
 CT has very high sensitivity and specificity
 Water soluble contrast studies may occasionally be
helpful
Hinchey Grading
 1: small confined pericolic abscess (<5% mortality)
 2: large abscesses extending into pelvis (<5%)
 3: purulent peritonitis (~15%)
 4: faecal peritonitis (~45%)
Mx




Resus: admit, NBM, fluids, Abx
1-2: surgery rarely needed
3: on table washout may suffice
4: Hartmann’s
Other Complications
 Perforation
 Abscess
 Fistula
 Bleeding
 Stricture
Prognosis
 10-30% recurrence w/i a decade
© Alasdair Scott, 2012
Change in bowel habit
PR mass: 60%
Obstruction: 25%
Tenesmus
PR bleed
Systemic: wt. loss, malaise
Dukes Staging
 Sir Cuthbert Dukes: St. Mary’s Pathologist
Spread
Confined to bowel wall
Through bowel wall but no LNs
Regional LNs
Distant mets
A
B
C
D
% 5ys
90
60
30
<10
Mx




MDT
Colonoscopy: allows biopsy to grade tumour
Stage c̄ CT or MRI
60% amenable to radical therapy
 Excision depends on lymphatic drainage, mobility
of bowel and blood supply @ excision margins.
 Laparoscopic resection under ERAS pathway is
current standard of care.
 Adjuvant 5-FU for Dukes C: ↓ mortality by 25%
Screening
 FOB
 60-75yrs
 Home testing every 2yrs + colonoscopy if +ve
 ↓ risk of dying from CRC by 25%
 Flexi Sig
 Introduced in 2011/12
 55-60yrs
 One of flexi sig
 ↓ mortality by ~45%
184
Ulcerative Colitis
Crohn’s Disease
Image
Image




 Small bowel follow through or enteroclysis
 Replaced by CT enterography or CT enteroclysis
 Rose-thorn ulcers
 String sign of Kantor: narrow terminal ileum
 Cobble-stoning: ulceration of mural oedema
 Skip lesions
Usually a double contrast enema
Lead-piping: no haustra
Mucosal thickening ± thumb-printing
Pseudopolyps
Extras
 Transition point to normal bowel
 Apple-core lesion
Extras
 Evidence of perforation: contrast leak
Key Facts
Key Facts
Pathology





Pathology
Mucosal inflammation
Contiguous disease: rectum proximally
Broad, shallow ulceration
Pseudopolyps: islands of regenerating mucosa
No strictures, fistulae, granulation
 Transmural, non-caseating granulomatous inflammation
 Non-contiguous: anywhere from mouth to anus
 Predilection for terminal ileum
 Deep, serpiginous ulceration + mucosal oedema
 → cobblestone mucosa
 Prominent strictures, fistulae
Severe Attack: Truelove and Witts Criteria
 Hx: motions >6/d + large PR bleed
 o/e: temp >37.8 + HR >90
 Ix: ESR >30 + Hb <10.5
Severity
 Clinical: ↑ temp, ↑HR, wt. loss
 Ix: ↑EXR/CRP, ↑WCC, ↓albumin, ↓Hb
Acute Mx




Resus: NBM, IV hydration, analgesia
Hydrocortisone: IV + PR
LMWH
Monitoring: examination, stool chart, bloods
 Improving: PO steroids + mesalazine
 Deteriorating: ciclosporin, infliximab, surgery
Acute Mx






Complications
 Toxic megacolon
 Haemorrhage
 Ca: CRC in 15% c̄ pancolitis @ 20yrs
Resus: NBM, IV hydration, analgesia
Hydrocortisone: IV ± PR
Abx: metronidazole
LMWH
Dietician review: elemental diet or parenteral nutrition
Monitoring: examination, stool chart, bloods
 Improving: PO steroids
 Deteriorating: methotrexate, infliximab, surgery
Complications




Fistulae
Strictures
Abscesses
Malabsorption
Extra-Intestinal Features of IBD
© Alasdair Scott, 2012
Skin
 Clubbing
 Erythema nodosum
 PG (esp. UC)
Mouth
 Aphthous ulcers
Eyes
 Anterior uveitis
 Episcleritis
Joints
 Large joint arthritis
 Sacroileitis
Hepatic




Other
 AA amyloidosis
 Oxalate renal stones
Fatty liver
Chronic hepatitis → cirrhosis
Gallstones (esp. CD)
PSC + cholangiocarcinoma (esp. UC)
185
Gallstones
Imaging
Key Facts
US
Epidemiology
 Stones → acoustic shadow
 Dilated ducts: >6mm
 ± stones in ducts
 Inflamed GB: wall oedema




~8% of the population >40yrs
Incidence ↑ over last 20yrs: western diet
Slightly ↑ incidence in females
90% of gallstones remain asymptomatic
Formation
ERCP
 Endoscopic retrograde cholangiopancreatography
 Side-viewing endoscope
 Cannulation of sphincter of Oddi
 Injection of radiocontrast allows biliary tree
imaging
 Film
 Filling defects: stones
 Duct dilatation
 Stricturing
 PSC
 Lap chole
 Cholangiocarcinoma
 Extrinsic compression: Ca pancreas
 Therapeutics
 Sphincterotomy + trawling of ducts allows stone
removal.
 Strictures may be stented or dilated
 Complications
 Pancreatitis: 5%
 Bleeding: esp. in jaundiced pts.
 Check clotting first
 Bowel perforation
 Contrast allergy
MRCP
 MR cholangiopancreatography
 Non-invasive and no contrast necessary
 No therapeutic capabilities: Dx only
 Film
 Filling defects
 Strictures
 Duct dilatation
General Composition
 Phospholipids: lecithin
 Bile pigments (broken down Hb)
 Cholesterol
Aetiology
 Lithogenic bile: Admirand’s Triangle
 Biliary sepsis
 GB hypomotility → stasis
 Pregnancy, OCP
 TPN, fasting
Cholesterol Stones: 20%
 Large
 Often solitary
 Formation ↑ according to Admirand’s Trangle
 ↓ bile salts
 ↓ lecithin
 ↑ cholesterol
 Risk factors
 Female
 OCP, pregnancy
 ↑ age
 High fat diet and obesity
 Racial: e.g. American Indian tribes
 Loss of terminal ileum (↓ bile salts)
Pigment Stones: 5%
 Small, black, gritty, fragile
 Calcium bilirubinate
 Associated c̄ haemolysis
Mixed Stones: 75%
 Often multiple
 Cholesterol is the major component
PTC
 Percutaneous transhepatic cholangiography
 Injection of contrast into biliary tree via needle
directly through skin.
 Not commonly performed now
 Contrast fills from proximal to distal (cf. ERCP)
 Look for presence of needle cannulating a duct.
 No endoscope visible
Complications
In the Gallbladder
1. Biliary Colic
2. Acute cholecystitis ± empyema
3. Chronic cholecytsitis
4. Mucocele
5. Carcinoma
6. Mirizzi’s syndrome
In the CBD
1. Obstructive jaundice
2. Pancreatitis
3. Cholangitis
In the Gut
1. Gallstone ileus
© Alasdair Scott, 2012
186
Pancreatitis
Acute Cholecystitis
Common Causes
Pathogenesis
Presentation
Presentation
 Gallstones: 45%
 Alcohol: 25%
 Idiopathic: 20% (?microstones)




 Stone or sludge impaction in Hartmann’s pouch
 → chemical and / or bacterial inflammation
 5% are acalculous: sepsis, burns, DM
Vomiting + severe epigastric pain
Fever
Hypovolaemia
Bruising: Cullen’s and Grey-Turner’s




Modified Glasgow Criteria
 Valid for EtOH and Gallstones
 Assess severity and predict mortality
 Ranson’s criteria are only applicable to EtOH and can
only be fully applied after 48hrs.
PANCREAS
 PaO2
 Age
 Neutrophils
 Ca2+
 Renal function
 Enzymes
 Albumin
 Sugar
Ix
<8kPa
>55yrs
>15 x109/L
<2mM
U>16mM
LDH>600iu/L
AST>200 iu/L
<32g/L
>10mM
1 = mild
2 = mod
3 = severe
 Urine: ↑ cBR, ↓ urobilinogen
 Bloods
 FBC, amylase, CRP (>150 in 1st 48hrs = severe)
 U+E: dehydration
 LFTs: cholestatic picture
 Ca, glucose, ABG: scoring
 Imaging
 CXR: exclude perfed DU, ARDS
 AXR: sentinel loop, pancreatic calcification
 US: gallstones + dilated ducts
 Contrast CT: Balthazar severity score
Ix
Continuous severe RUQ pain → right scapula
Fever
Murphy’s sign
Boas’ sign: hyperaesthesia below R scapula
 Urine: ↑ cBR, ↓ urobilinogen
 Bloods
 FBC, amylase, CRP
 U+E: dehydration
 LFTs
 Clotting and G+S: anticipation of surgery
 Imaging
 Erect CXR: exclude perfed DU
 US: stones, inflammation, dilated ducts
Mx
Conservative
 NBM
 IV hydration and correction of electrolyte abnormalities
 Analgesia: e.g. paracetamol + pethidine
 Abx: cefuroxime + metronidazole
 80-90% settle over 24-48hrs
Surgical
 If <72hrs: may perform “hot gallbladder”
 Otherwise, elective lap chole @ 6-12wks
Empyema
 High fever
 RUQ mass
 Percutaneous drainage: cholecystostomy
Mx
 Principals
 Mx @ appropriate level: e.g. ITU if severe
 Constant reassessment is key: esp. fluid balance
 Conservative
 Aggressive fluid resuscitation + UO monitoring
 NBM + NGT
 Analgesia: pethidine via PCA
 Penems if suspicion of sepsis
 Interventional
 ERCP may be needed if 2O to gallstones
Complications
 Early



 Late





Hypovolaemia → shock and renal failure
SIRS → ARDS and DIC
Metabolic: ↑ glucose, ↓Ca
Pseudocyst: 20%
Pancreatic necrosis, infection and abscess
Bleeding: e.g. from splenic artery
Thrombosis: e.g. portal vein
Fistula formation: e.g. pancreatico-cutaneous
© Alasdair Scott, 2012
187
Nephrolithiasis
Image
Key Facts
IVU
Stone Types





Failure of distal flow of contrast
Standing column of contrast
Clubbing of calyces
Delayed, dense nephrogram
Visible stone
Ask to see KUB control film
 90% of stones radio-opaque
Technical
 600x radiation dose of KUB
 Urograffin contrast injection
 Immediate film + 30min + 1h
Contraindications to IVU





Contrast allergy
Pregnancy
Severe asthma
Metformin
Significant renal impairment
Alternative
 Non-contrast CT-KUB is gold standard
 99% of stones visible
 Calcium oxalate: 75%
 Triple phosphate (struvite): 15%
 Ca Mg NH4 – phosphate
 May form staghorn calculi
 Assoc. c̄ proteus infection
 Urate: 5% (radiolucent)
 Double if confirmed gout
 Cystine: 1% (faint)
 Assoc. c̄ Fanconi Syn.
Pathophysiology
 ↑ concentration of urinary solute
 ↓ urine volume
 Urinary stasis
Common Anatomical Sites
 Pelviureteric junction
 Pelvic brim
 Vesicoureteric junction
Ureteric Colic
 Severe loin pain radiating to the groin
 Assoc. c̄ n/v
 Pt. cannot lie still
Mx
Initial
 Analgesia
 IV or oral fluids
Conservative: <5mm in lower 1/3 of ureter
 90-95% pass spontaneously
 Sieve urine for OPD stone analysis
Medical Expulsive Therapy: 5-10mm
 Nifedipine or tamsulosin
 Most pass w/i 48h
Active Stone Removal
 Indications
 Stones >10mm
 Persistent obstruction
 Renal insufficiency
 Infection
 Procedures
 Extracorporeal shockwave lithotripsy
 Ureterorenoscopy + Dormier basket removal
 Percutaneous nephrolithotomy
 Lap or open stone removal
Febrile c̄ Renal Obstruction
 Surgical emergency
 Percutaneous nephrostomy or ureteric stent
 IV Abx: e.g. cefuroxime 1.5g IV TDS
© Alasdair Scott, 2012
188
Subdural or Extradural Haematoma
Imaging
Key Facts
Axial Non-Contrast CT Head
Brain Injury
 Extradural: lentiform opacification
 Subdural: sickle-shaped opacification
Extras
 Midline shift
 Associated cerebral contusion: coup + contra-coup
 Associated sub-arachnoid haemorrhage
 Colour of haematoma
 White (hyperdense): acute
 Pale grey (hypodense): chronic (~3wks)
 Ask to bony window to accurately assess for skull #
Primary
 Occurs @ time of injury as result of direct injury
 Diffuse
 Concussion: temporary ↓ in brain function
 Diffuse axonal injury
 Focal
 Contusion
 Intracranial haemorrhage
Secondary
 Occur after primary injury
 Causes
 ↑ ICP
 Infection
 Hypoxia or hypercapnoea
 Hypotension
Monroe-Kelly Doctrine
 Cranium is rigid box  total volume of intracranial contents
must remain constant if ICP is not to change.
 ↑ in volume of one constituent → compensatory ↓ in
another:
 CSF
 Blood (esp. venous)
 These mechanisms can compensate for a volume change
of ~100ml before ICP ↑.
 As autoregulation fails, ICP ↑ rapidly → herniation.
Cushing Reflex: imminent herniation
 Hypertension
 Bradycardia
 Irregular breathing
NICE Indications for Head CT





Basal or depressed skull #
Amnesia >30min retrograde
Neurology: seizures, focal weakness, blown pupil
GCS: <13 @ scene or <15 2h after trauma
Sickness: persistent vomiting
Any amnesia or LOC + 1 of
 Dangerous mechanism
 >65yrs
 Coagulopathy
© Alasdair Scott, 2012
189
Digital Subtraction Angiogram
Image
 Vessel stenosis
 Distal filling by collaterals
Extras
 Aortoiliac occlusion → Leriche Syndrome
Key Facts
Definitions
Acute: ischaemia <14d
 Incomplete: limb not threatened (e.g. thrombosis)
 Complete: limb threatened (e.g. embolism)
 Loss of limb unless intervention w/i 6hrs
 Irreversible: requires amputation
Chronic: stable ischaemia >14d
 Critical: ankle pressure <50mmHg + either
 Persistent pain requiring opioid analgesia
 Ulceration or gangrene
Presentation
Acute
 Pain
 Pulseless
 Pallor
 Cold
 Paraesthesia
 Paralysis
Chronic
 Asymptomatic
 Intermittent claudication
 Rest pain
 Ulceration and gangrene
 Leriche Syndrome
 ED + buttock claudication
Risk Factors
Modifiable
 Smoking
 BP
 DM control
 Hyperlipidaemia
 ↓ exercise
Non-modifiable
 FH and PMH
 Male
 ↑ age
 Genetic
Mx of Chronic Ischaemia
 Non-surgical
 CV risk factor control
 Antiplatelet agents
 Analgesia
 Graded exercise programs: walk through pain
 Interventional
 Angioplasty ± stenting
 Surgical
 Reconstruction
 Endarterectomy
 Amputation
Mx of Acute Ischaemia




Resus: NBM, hydration, analgesia
UH IVI: prevent thrombus extension
Angiography: only if incomplete occlusion
Surgery
 Embolectomy c̄ Fogarty catheter
 Emergency reconstruction
 Complications
 Reperfusion injury → compartment syndrome
 Chronic pain syndromes
 Treat cause
 e.g. warfarinise
 Mx CV risk
© Alasdair Scott, 2012
190
Cervical Spine
Hip Fracture
Imaging
Imaging
 Views
 Lateral
 AP
 Open-mouth “Peg” view
 Adequacy
 Must see C7-T1 junction
 May need swimmer’s view c̄ abducted arm
 Alignment: 4 lines
 Ant. vertebral bodies
 Ant. vertebral canal
 Post. vertebral canal
 Tips of spinous processes
 Bones: shapes of bodies, laminae, processes
 Cartilage: IV discs should be equal height
 Soft tissue
 Width of soft tissue shadow anterior to upper
vertebrae should be 50% of vertebral width.
Clearing the C-Spine
Clinical Clearance
Indication: NEXUS Criteria
 Neurological deficit
 Spinal tenderness in the midline
 Altered consciousness
 Intoxication
 Distracting injury
Method
 Examine for bruising or deformity
 Palpate for deformity and tenderness
 Ensure pain-free active movement
Radiological Clearance
Indications
 Pt. doesn’t meet criteria for clinical clearance
Modalities
 Radiograph initially
 Clear if normal radiograph and clinical exam
 CT C-spine if abnormal radiograph or clinical exam




Need orthogonal views: AP + Lat
Follow Shenton’s lines
Intra- or extra-capsular?
Displaced or non-displaced: Garden classification
Extras
 Osteopaenic?
 Osteoarthritic?
 Check for pelvic ring #s
Key Facts
Epidemiology




50% >80yrs
F>M=3:1
30% mortality @ 1yr
50% never regain pre-morbid functioning
Classification
 Intracapsular: subcapital, transcervical, basicervical
 Extracapsular: Intertrochanteric, subtrochanteric
Garden Classification of Intracapsular Fractures
1. Incomplete #, undisplaced
2. Complete #, undisplaced
3. Complete #, partially displaced
4. Complete #, completely displaced
Initial Mx: Optimise the Pt.








Resus: hydration, neurovascular status, analgesia
Anaesthetist and book theatre
Bloods: FBC, U+E, clotting, x-match 2u
CXR
DVT prophylaxis
ECG
Films: orthogonal x-rays
Get consent
Surgical Mx
Intracapsular
 1,2: ORIF c̄ cancellous screws
 3,4:
 <55: ORIF c̄ screws.
 f/up in OPD and do arthroplasty if AVN
develops (in 30%)
 >55: THR or hemiarthroplasty
Extracapsular
 ORIF c̄ DHS
Discharge
 Involve OT and physios
 Discharge when mobilisation and social circumstances
permit.
Specific Complications




© Alasdair Scott, 2012
AVN of fem head in displaced #s: 30%
Non / mal-union: 10-30%
Infection
Osteoarthritis
191
Shoulder Dislocation
Femoral and Tibial Fractures
Imaging
Imaging
 Typically anterior dislocation c̄ humeral head located
antero-inferiorly.
 Bankhart lesion: damage to glenoid labrum
 Hill-Sachs lesion: cortical depression in posterolateral
part of humeral head.
 Request AP and lateral
Key Facts
Mx
Key Facts
Presentation
 Severe pain
 Loss of shoulder contour
 Humeral head palpable in infraclavicular fossa
Mx




Resuscitate
Analgesia
Assess NV deficit: 5% axillary nerve injury
Reduction under sedation: e.g. propofol
 Hippocratic: Longitudinal traction c̄ arm in 30O
abduction and counter traction @ the axilla
 Kocher’s: external rotation of adducted arm,
anterior movement, internal rotation
 Sling for 3-4wks
 Physio
Complications
 Recurrent dislocation
 90% of pts. <20yrs with traumatic dislocation
 Axillary N. injury
 Resuscitate and Mx life-threatening injuries first
 Assess neurovascular status of limb
 Urgent angiography if distal pulses compromised
 X-match: femoral – 4u, tibial – 2u
 Open
 Analgesia: morphine and metoclopramide
 Assess: NV status + photo
 Asepsis: wash, cover c̄ sterile soaked gauze
 Alignment: reduce and splint
 Abx: augmentin 1.2g IV
 Anti-tetanus
 Debridement and fixation in theatre
 ORIF
 Ex-Fix
Gustillo Classification of Open #s
1. Wound <1cm in length
2. Wound ≥1cm c̄ minimal soft tissue damage
3. Extensive soft tissue damage
Clostridium perfringes




Most dangerous complication of open #
Wound infections and gas gangrene
± shock and renal failure
Rx: debride, benpen + clindamycin
Other Complications
 Femoral
 Hypovolaemic shock
 NV: SFA and sciatic nerve
 Tibial
 NV injury
 Compartment syndrome
 Fat embolism
© Alasdair Scott, 2012
192
Colles’ Fracture
Other Fractures
Imaging
Monteggia




Extra-articular # of the distal radius
Dorsal displacement of distal fragment
Dorsal angulation of distal fragment
± avulsion of ulna styloid
Extras
 ↓ radial height (normal = 11mm)
 ↓ radial inclination (normal = 22O)
 Loss of volar tilt (normal = 11O volar)
Key Facts
Eponym
 Described clinically by Irish surgeon Abraham Colles in
1814.
 Dinner fork deformity
Mx
 Resuscitate + Mx life-threating injuries
 Assess NV injury: median N. and radial A.
 Reduction + fixation
 Haematoma block or Bier’s block (c̄ prilocaine)
 Dorsal backslab c̄ 3-point pressure
 Fracture clinic appointment for ortho assessment
 # of proximal 3rd of ulna shaft
 Anterior dislocation of radial head at capitellum
 May → palsy of deep branch of radial nerve → weak
finger extension but no sensory loss
Galleazzi
 # of radial shaft between middle and distal 3rds
 Dislocation of distal radio-ulna joint
Supracondylar Humeral #
Classification
 Extension: distal fragment displaces posteriorly
 Flexion: distal fragment displaces anteriorly
Complications
 NV: brachial artery and median nerve mainly
 Compartment syndrome
 Malunion: gunstock deformity (cubitus varus)
Proximal Humerus #
 Surgical neck: axillary nerve damage
 Shaft: radial nerve → wrist drop
 Mx: collar and cuff or ORIF
Specific Complications





Median N. injury
Frozen shoulder / adhesive capsulitis
Tendon rupture: esp. EPL
Carpal tunnel syn.
Mal- /non-union
Distal Fibula
Weber Classification
 Relation of # to joint line
 A: below joint line
 B: at joint line
 C: above joint line
 B and C represent possible injury to the syndesmotic
ligs between tib and fib → instability
Growth Plate
 Damage to physis → abnormal bone growth
 SH2 is commonest (~75%)
 SH5: biggest risk to physis
Salter-Harris Classification
1. Straight across
2. Above
3. Lower
4. Through
5. CRUSH
Pelvic Fracture
Young and Burgess Classification
 Lateral compression: ipsilateral pubic rami #s
 AP compression: open book #
 Vertical shear: inherently unstable
© Alasdair Scott, 2012
Complications
 Haemorrhage
 Urethral injury
 Bladder injury
193
Fracture Complications
General Complications
Nerve Injury
Tissue Damage
 Haemorrhage and shock
 Infection
 Muscle damage → rhabdomyolysis
Seddon Classification
 Neuropraxia: temporary interruption of conduction
 Axonotmesis
 Disruption of axon c̄ preservation of connective tissue
framework
 Recovery possible
 Neurotmesis
 Disruption of entire nerve fibre
 Recovery incomplete
Anaesthesia
 Anaphylaxis
 Damage to teeth
 Aspiration
Prolonged Bed Rest
 Chest infection, UTI
 Pressure sores and muscle wasting
 VTE
 ↓ BMD
Compartment Syndrome
 Oedema → ↑ compartment pressure → vascular compromise
 Compartment pressure > capillary pressure → ischaemia
 Pain > clinical findings and pain on passive stretch
Mx
Specific Complications
Immediate
 Neurovascular damage
 Visceral damage
Early
 Compartment syn.
 Infection (worse if assoc. c̄ metalwork)
 Fat embolism → ARDS
Late






Problems c̄ union
AVN
Growth disturbance
Post-traumatic osteoarthritis
Complex regional pain syndromes
Myositis ossificans
 Elevate limb and remove bandages and cast
 Fasciotomy
Problems c̄ Union
 Delayed union: union takes longer than expected
 Non-union: # fails to unite
 Mal-union: # unites in imperfect position
Causes: 5Is
 Infection
 Ischaemia
 Interfragmentary movement
 Interposition of soft tissue
 Intercurrent illness
Mx
 Optimise biology: infection, bone graft, blood supply, bone
graft, BMPs
 Optimise mechanics: ORIF
Myositis Ossificans




Heterotopic ossification of muscle @ sites of haematoma
formation
→ restricted, painful movement
Commonly affects the elbow and quadriceps
Rx: excise
Complex Regional Pain Syndrome 1: Sudek’s Atrophy
Presentation
 Wks – months after injury
 Affects neighbouring area
 Pain, hyperalgesia and allodynia
 Vasomotor: hot and sweaty or cold and cyanosed
 Skin: swollen or atrophic
 NM: weakness, contractures
Mx
© Alasdair Scott, 2012
 Usually self-limiting
 May need amitriptyline / gabapentin
194
Instruments
Contents
Vascular Access .................................................................................................................................................................... 196
Phlebotomy ............................................................................................................................................................................ 198
Airways and Breathing ........................................................................................................................................................... 199
Perioperative Mx .................................................................................................................................................................... 202
General Surgery..................................................................................................................................................................... 205
Urology................................................................................................................................................................................... 209
Trauma and Orthopaedics ..................................................................................................................................................... 212
Miscellaneous ........................................................................................................................................................................ 216
© Alasdair Scott, 2012
195
Vascular Access
Peripheral Venous Cannula
Triple Lumen Central Venous Catheter
Indication
Indication
 Peripheral administration of fluid and drugs
Features
Colour
Yellow
Blue
Pink
Green
Grey
Brown
Gauge
24
22
20
18
16
14
Flow Rate (ml/min)
15
30
60
90
230
270
Poiseuille’s Law
 Flow rate
 Proportional to the r4
 Inversely proportional to length
Method
 Inserted into a peripheral vein under ANTT
Complications




Haematoma
Malplacement
Blockage
Superficial thrombophlebitis
 CVP measurement: fluid balance
 Drugs requiring central administration
 Amiodarone, mannitol
 TPN
Method
 Inserted using the Seldinger technique under US
 Trendelenberg position
 Sterile
 Under LA
 Use US guidance
 Order a CXR afterwards
 Internal jugular, Subclavian and Femoral veins
Complications
Immediate
 Pneumothorax
 Arrhythmia
 Malposition into an artery
Early
 Haematoma formation
 Infection
 Catheter occlusion
Late
 Thrombosis
 Sympathetic chain → Horner’s syndrome
 Phrenic nerve damage → hiccough, weak diaphragm
Other Procedures Using Seldinger Technique
 Angiography
 Chest drain insertion
 Percutaneous endoscopic gastrostomy
© Alasdair Scott, 2012
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PICC Line
Tessio Catheter
Indication
 Haemodialysis
Indication
 Long-term central access: abx, chemo, TPN
Method
 Inserted into a peripheral vein: e.g. cephalic
 Advanced until the tip sits in the SVC.
 X-ray to confirm position
Complications
Early
 Arrhythmias
 Bleeding
Late
 Thrombosis
 Catheter occlusion
 Infection
Hickman Line
Features




Tunnelled subcutaneously
Cuffs promote tissue reaction → better seal
Arterial limb takes blood to machine
Venous limb takes dialysed blood back to pt.
Method
 Sterile insertion under x-ray guidance
 Arterial limb sits more proximally to ↓ recirculation
Complications
Early
 Pneumothorax
 Arrhythmias
 Bleeding
Late
 Thrombosis
 Catheter occlusion
 Infection
Port-a-Cath
Indication
 Long-term central access: abx, chemo, TPN, dialysis
Method
Indications
Complications
Features
 Tunnelled under skin to enter IJV and lay in SVC
Early
 Pneumothorax
 Arrhythmias
 Bleeding
 Long-term chemotherapy or antibiotics




Centrally placed catheter
Subcutaneous port made of self-sealing silicone rubber
Accessed c̄ 90O Huber point needle
V. low infection risk as skin breech is very small
Late
 Thrombosis
 Catheter occlusion
 Infection
© Alasdair Scott, 2012
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Phlebotomy
Blood Culture Bottles
Indications
 Investigate a patient c̄ pyrexia
Features
 Red: anaerobic culture medium
 Blue: aerobic culture medium
Method






Take blood using ANTT
Replace needle with a clean one
Wipe top of bottles c̄ alcohol
Fill anaerobic (red) bottle first
Fill in pt. details and send to path lab
Some hospitals have specific teams that take cultures
Post-Op Pyrexia
Early: 0-5d post-op
 Blood transfusion
 Physiological: SIRS from trauma: 0-1d
 Pulmonary atelectasis:24-48hr
 Infection: UTI, superficial thrombophlebitis
 Drug reaction
Delayed: >5d post-op
 Collections
 Pneumonia
 DVT / PE
 Wound infection: 5-7d
 Anastomotic leak: 7d
Examination of Post-Op Febrile Pt.








Observation chart, notes and drug chart
Wound
DRE
Legs
Chest
Lines
Urine
Stool
Vacutainers
Purple
 Contains: EDTA
 Prevents clotting and keep cells alive
 Use
 FBC, CD4, cross-match
 i.e. things you want to do c̄ cells
Yellow
 Contains: Activated gel
 Promotes clotting
 Gel facilitates easy separation of serum and red
cells.
 Use
 Serum chemistries, enzymes
Red
 Contains: Nothing, glass tube
 “a clotted sample”
 Use
 Immunology, Abs, Ig, protein electrophoresis
Green
 Contains: Li heparin
 Anticoagulant
 Use
 Plasma chemistries, enzymes
Blue
 Contains: Citrate
 Chelates Ca2+, preventing clotting
 Use
 Coagulation determinates
 Special
 Ca2+ is added back to sample to allow clotting.
 Therefore need precise blood volume
Grey
 Contains
 Fluoride: inhibit glycolysis
 Oxalate: anticoagulate
 Use
 Glucose
Black
 Contains: citrate
 Anticoagulant
 Use
 ESR
 Special
 Need precise blood volume
Order of Draw






© Alasdair Scott, 2012
Blood cultures
Blue
Yellow
Green
Purple
Grey
198
Airways and Breathing
Endotracheal Tube
McKintosh Laryngoscope
Indications
 To acquire a definitive airway in elective or emergency
situations
 Abdominal surgery
 Head injury
Features
 Cuffed
 Adults
 Secured tube and prevents aspiration
 Uncuffed
 Children
 Avoid damaging the larynx
 Size
 Female: 7.5
 Male: 8.5
 Double lumen
 Allow single lung ventilation
 Used in thoracic surgery
 Radio-opaque line: blue
Method
 Pt. is pre-oxygenated, sedated and a muscle relaxant
may be used.
 Inserted into the trachea under direct vision using a
laryngoscope.
 Crichoid pressure may ↓ risk of aspiration
 Bougi may be used for difficult airways
 Smaller
 Anterior curvature
 Can feel tracheal rings with tip
 Position confirmed and tube secured c̄ tape
Indications
 ET intubation
Features
 Handle + light source
 Removable blade: come in different sizes
 McKintosh = Curved (preferred)
 Miller = Straight
Method




Pt. is appropriately sedated and muscle relaxed.
Inserted with left hand, tongue displaced laterally
Tip inserted into valecular
Light source allows direct vision of vocal cords for
intubation.
Complications
 Oropharyngeal trauma
 Laryngeal trauma
 C-spine injury: e.g. c̄ atlanto-axial instability
Check Position
 Inspect for symmetrical chest movements
 Listen over epigastrium for gurgling
 Listen over each lung for air entry
 Use CO2 monitor
 CXR: just above carina
Complications
Early





Oropharyngeal trauma
Laryngeal trauma
C-spine injury: e.g. c̄ atlanto-axial instability
Oesophageal intubation
Bronchial intubation
Delayed
 Sore throat
 Tracheal stenosis
 Difficult wean
Definitive Airway
 Airway which is protected from aspiration
Types
 Orotracheal or nasotracheal airway
 Surgical: tracheostomy, cricothyroidotomy
© Alasdair Scott, 2012
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Temporary Tracheostomy Tube
Laryngeal Mask Airway
Indications
 Non-definitive airway used in short day-case surgery
where a pt. doesn’t require intubation.
 May also be used in an emergency situation if not able
to insert ET tube.
Features
 Inflatable cuff to create a seal over the larynx
Method
Indications
 Definitive surgical airway
 Acutely: maxillofacial injuries
 Electively: ITU pts. c̄ prolonged ventilation
Features




Obturator
Cuff to prevent aspiration
Flange to secure to pts. neck
Insufflation port.
Method
 Transverse incision ~1cm above sternal notch
 Dissect through fascial planes and retract ant. jugular
veins and strap muscles
 Divide thyroid isthmus
 Stoma fashioned between 2nd and 4th tracheal rings by
removing anterior portion of tracheal ring
 Insert trachy c̄ obturator
 Secure with tapes.
Advantages over ET Tube






Easier to wean pts.
No need for sedation
↓ discomfort
Easier to maintain oral and bronchial hygiene
↓ risk of glottis trauma
↓ dead space  reduces work of breathing
Complications
Immediate
 Haemorrhage
 Surgical trauma: oesophagus, recurrent laryngeal N.
 Pneumothorax
Early





Tracheal erosion
Tube displacement
Tube obstruction
Surgical emphysema
Aspiration pneumonia
Late
 Tracheomalacia
 Tracheo-oesophageal fistula
 Tracheal stenosis
© Alasdair Scott, 2012




Cuff is deflated and lubricated c̄ aquagel
Inserted c̄ open end pointing down towards the tongue
Sits in orifice over the larynx
Cuff inflated and tube secured with tape
Complications




Dislodgement
Leak
Pressure necrosis in airway
Aspiration: non-definitive airway
Oropharyngeal / Guedel Airway
Indications
 Airway adjunct used in pts. with impaired level of
consciousness to maintain a patent airway
 e.g. during extubation
Method
 Sized from incisors to angle of mandible
 Insert upside down and rotated once in the oral cavity
Complications
 Oropharyngeal trauma
 Gagging → vomiting
Nasopharyngeal Airway
Indications
 Airway adjunct used in pts. with impaired level of
consciousness to maintain a patent airway
Method
 Sized according to diameter of pts. little finger
 Inserted into the nasopharynx using a rotational action
 Safety pin and flared end prevents the tube becoming
irretrievable.
Complications
 Bleeding: trauma to nasal mucosa
 Intracranial placement
Contraindications
 Absolutely contraindicated in pts. c̄ facial injuries or
evidence of basal skull #
 Racoon eyes
 Battles’ Sign: mastoid bruising
 Haemotympanum
 SCF rhinorroea or otorrhoea
200
Oxygenation
Ventilation
Nasal Prongs
Types
 1-4L/min = 24-40% O2
Simple Face Mask
 Variable O2 concentration depending on O2 flow rate
Non-rebreathing Hudson Mask
 Reservoir bag allows delivery of high concentrations of
O2.
 60-90% at 10-15L
Venturi Mask
 Uses the Bernoulli Principle
 ↑ speed of flow → ↓ pressure
 Altering O2 flow speed can entrain a known
concentration of air for dilution
 Provide precise O2 concentration at high flow rates
 Yellow: 5%
 White: 8%
 Blue: 24%
 Red: 40%
 Green: 60%
 Non-invasive: tight-fitting mask
 Invasive: ET or tracheostomy
Indications
 Respiratory failure refractive to less invasive Rx
 At risk airway
 Elective post-op ventilation
 Physiological control (e.g. hyperventilation in ↑ICP)
Complications






Cardiovascular compromise
Pneumothorax
Fluid retention
VILI
VAP
Complications of artificial airway: e.g. tracheal stenosis
CPAP
 Tight fitting mask connected to reservoir or high O2 flow
allowing FiO2 ~1.
 Positive pressure is applied continuously to the patient’s
airway.
 Benefits
 Recruitment of collapsed lung units
 ↓ shunt → ↑PaO2
 ↑ lung volume → improved compliance → ↓ work
of breathing.
 CPAP usually has little effect on PaCO2
© Alasdair Scott, 2012
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Perioperative Mx
Ryles Nasogastric Tube
Feeding NG Tube
Indications
Indications
 Draining the stomach
 Part of the “drip and suck” for the management of bowel
obstruction.
 Pts. c̄ persistent vomiting: e.g. pancreatitis
Features




Wide-bore
Stiffer
Radio-opaque line
Metal tip
Metal Tip
 Acts as lead point to facilitate advancement of NGT
 Weights the NGT down in the stomach
 Radio-opaque on x-ray aiding visualisation
Method
 Size tube by measuring from tip of pts nose to
epigastrium, going around the ear.
 Gain consent and explain the procedure
 Lubricate the tip c̄ aquagel
 Insert the tube and ask pt. swallow c̄ water when they
feel it at the back of their throat.
 Secure c̄ tape when position confirmed
Check Location
 Aspirate gastric contents and check pH (<4)
 Insufflate air and auscultate for bubbling
 Best not to do this in bowel obstruction
 CXR: tip below diaphragm
Complications
 Nasal trauma
 Malposition: airway, cranium (CI in cribriform plate #s)
 Blockage
Contraindication
 Any suspicion of basal skull #
 Provide enteral nutrition
 Catabolic: sepsis, burns, major surgery
 Coma/ITU
 Malnutrition
 Long-term feeding
 Dysphagia: stricture, stroke
Features
 Fine-bore
 Soft silicone
 Contains radio-opaque guide-wire to stiffen the tube
and aid insertion.
Method
 Size tube by measuring from tip of pts nose to
epigastrium, going around the ear.
 Gain consent and explain the procedure
 Lubricate the tip c̄ aquagel
 Insert the tube and ask pt. swallow c̄ water when they
feel it at the back of their throat.
 Remove guidewire and secure c̄ tape when position
confirmed
Check Location
 Aspirate gastric contents and check pH (<4)
 Insufflate air and auscultate for bubbling
 CXR: tip below diaphragm
Complications
NGT
 Nasal trauma
 Malposition: airway, cranium (CI in basal skull #s)
 Blockage
Feeding
 Refeeding syndrome
 Electrolyte imbalance
 Feed intolerance → diarrhoea
Contraindication
 Any suspicion of basal skull #
© Alasdair Scott, 2012
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Types of Nutritional Supplementation
Refeeding Syndrome
 Life-threatening metabolic complication of refeeding via
any route after a prolonged period of starvation.
Enteral Nutrition
 Oral supplements
 Polymeric: e.g. osmolite, jevity
 Intact proteins, starches and long-chain FAs
 Disease Specific
 e.g. ↓ branched chain AAs in hepatic
encephalopathy
 Elemental
 Simple AAs and oligo/monosaccharides
 Require minimal digestion and used if abnormal
GIT: e.g. in Crohn’s
Parenteral Nutrition
 May be “Total” or used to supplement enteral feeding
 Combined c̄ H2O to deliver total daily requirements
Indications
 Unable to swallow: e.g. oesophageal Ca
 Prolonged obstruction or ileus (>7d)
 High output fistula
 Short bowel syndrome
 Severe Crohn’s
 Severe malnutrition
Delivery
 Delivered centrally as high osmolality is toxic to veins
 Short-term: CV catheter
 Long-term: Hickman or PICC line
Pathophysiology
 ↓ carbs → catabolic state c̄ ↓insulin, fat and protein
catabolism and depletion of intracellular PO4
 Refeeding → ↑ insulin in response to carbs and ↑
cellular PO4 uptake.
 → hypophosphataemia
 Rhabdomyolysis
 Respiratory insufficiency
 Arrhythmias
 Shock
 Seizures
Chemistry
 ↓K, ↓Mg, ↓PO4
At-Risk Patients
 Malignancy
 Anorexia nervosa
 Alcoholism
 GI surgery
 Starvation
Rx
 Identify at-risk pts in advance and liaise c̄ dietician
 Parenteral and oral PO4 supplementation
 Rx complications
Monitoring
 Standard
 Wt., fluid balance and urine glucose daily
 Zn, Mg weekly
 Initially
 Blood glucose, FBC and U+E 3x /wk
 LFTs 3x /wk
 Once stable
 Blood glucose, FBC and U+E daily
 LFTs weekly
Contents
 2000Kcal: 50% fat, 50% carb
 10-14g nitrogen
 Vitamins, minerals and trace elements
Complications
 Line-related
 Pneumothorax / haemothorax
 Cardiac arrhythmia
 Line sepsis
 Central venous thrombosis → PE or SVCO
 Feed-related
 Villous atrophy of GIT
 Electrolyte disturbances: e.g. refeeding syndrome
 Hyperglycaemia and reactive hypoglycaemia
 Vitamin and mineral deficiencies
© Alasdair Scott, 2012
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Thromboembolic Deterrent Stockings
Major Fluids
Indications
Crystalloid
 Used to prevent VTE
 All patients undergoing surgery
 All immobile pts
Method
 Available in different sizes
 Width: widest point of calf
 Length: heel to buttock fold
 Often used in conjunction c̄ LMWH
NS
 0.9% NaCl = 9g/L
 154mM NaCl
 Use: normal daily fluid requirements + replace losses
5% Dextrose
 50g dextrose /L
 Use: normal daily fluid requirements
Complications
Dextrose-Saline
 4% dextrose = 40g/L
 0.18% NaCl = 31mM NaCl
 Use: normal daily fluid requirements
Preventing DVT
Hartmann’s / Ringer’s Lactate
 Na: 131mM
 Cl: 111mM
 K: 5mM
 Ca: 2.2mM
 Lactate / HCO3: 29mM
 Use: Trauma, Burns (Parkland)
 Contraindicated in pts c̄ arterial disease
 DVT is commonest complication of THR
 Peak incidence @ 5-10d post-op
Pre-Op
 Pre-op VTE risk assessment
 TED stockings
 Aggressive optimisation: esp. hydration
 Stop OCP 4wks pre-op
Intra-Op
 Minimise length of surgery
 Use minimal access surgery where possible
 Intermittent pneumatic compression boots
Post-Op
 LMWH
 Early mobilisation
 Good analgesia
 Physio
 Adequate hydration
Daily Requirements
 3L dex-saline c̄ 20mM K+ in each bag
 1L NS + 2L dex c̄ 20mM K+ in each bag
 Each bag over 8h = 125ml/h
Problems
 Give 1L NS → ~210ml remaining IV
 Give 1L D5W → ~70ml remaining IV
 Acidosis or electrolyte disturbances
 Fluid overload
Colloid
Synthetic
 Gelofusin
 Volplex
 Haemaccel
 Voluven
Natural
 Albumin
 Blood
Use
 Fluid challenge
 Hypovolaemic shock
 Burns: Muir and Barclay
Problems
 Anaphylaxis
 Volume overload
© Alasdair Scott, 2012
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General Surgery
Surgical Drains
Indications
 Prophylactic
 Prevent fluid accumulation
 Therapeutic
 Drainage of established collections
 Drain a viscus: e.g. bladder
 Collect blood for autotransfusion
Robinson
 Type: closed, passive
 Use: abdominal surgery
 Risk of infection
 Contamination: faeces or pus
Types
Open or Closed
 Open
 e.g. corrugated rubber or plastic sheets
 Fluid collects into dressing or stoma bag
 Closed
 e.g. chest drains, Robinson or Redivac
 Tube attached to a container
Redivac
 Type: closed, active
 Use
 Breast surgery: prevent seroma or haematoma
 Thyroid surgery: risk of haematoma
Active or Passive
 Active: driven by suction
 e.g. Redivac drain
 Passive: no suction, driven by pressure differential
 e.g. Robinson drain
Removal




Remove drain once drainage stopped or <25ml/d
Perioperative bleeding and haematoma: 24-48hrs
Intestinal anastomosis: >5d
T-tube: 6-10d
 T-tube cholangiogram first to ensure distal
patency of CBD
 Shortening: removal of drain by 2cm/d to allow tract to
heal gradually.
Bile Bag
 Type: closed, passive
 Use
 NGT
 T-tube
Complications
 May ↑ risk of infection
 Damage may be caused by mechanical pressure or
suction.
 May limit pt. mobility.
Pemrose Drain
 Type: open, passive
 Use: abdominal surgery
Tissue Drain
 Type: open, passive
 Use: large cavities
© Alasdair Scott, 2012
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Sutures
Dever’s Retractor
Suture Types
Monofilament
 Advantages
 ↓ risk of infection
 ↓ friction in tissues
 Disadvantages
 Harder to handle: stiff and has more memory
 Knots may slip
 Less tensile strength
Braided
 Advantages
 Easier to handle: less memory
 Knots slip less
 Greater tensile strength
 Disadvantage
 ↑ risk of infection
 ↑ friction in tissues
Indications
 Surgical instrument used in open abdominal surgery to
retract viscera and ↑ the field of view
Method
 Curved end inserted into abdomen and placed carefully
to retract the viscera.
 Can be bent to a suitable shape
Complications
Natural
 Damage to skin and internal structures
Absorbable
 Catgut / Chromic
Self-Retaining Retractor
Non-absorbable
 Silk: braided suture that may be used to secure drains
Synthetic
Absorbable
Name
Monocryl
Vicryl
Material
Poliglecaprone
Polyglactin
Construction
Mono
Braided
PDS
Polydioxanone
Mono
Use
Subcuticular skin closure
Subcutaneous closure
Bowel anastomosis
Closing abdominal wall
Non-Absorbable
Name
Prolene
Material
Polypropelene
Construction
Mono
Ethilon
Metal
Nylon
Steel
Mono
Clips or mono
Use
Skin wounds
Arterial anastomosis
Skin wounds
Skin wounds
Sternotomy closure
Suture Removal







Indications
 Used to retract a surgical excision and retain the
incision open.
 E.g. in hernia repair or and appendicectomy
Complications
 Compression of nerves of vessels
Needle Holders
Further away from heart = longer time
Face and neck: 3-5d
Scalp: 5-7d
Trunk: 10d
Arms: 7d
Legs 10-14d
Pts. c̄ poor wound healing may need longer
Needles
 Straight: hand-held, used for skin closure
 Curved: require needle-driver
 Diameter
 Fine: GI and vascular surgery
 Medium: general closure
 Heavy: hernia repair
 Tip
 Blunt: abdominal wall closure
 Shape
 J-shaped: abdominal wall closure
© Alasdair Scott, 2012
Indications
 Forceps designed to hold the needle, allowing the
surgeon to suture accurately.
206
Disposable Proctoscope
Disposable Rigid Sigmoidoscope
Indications
 Investigation and management of pts. c̄ perianal
pathology: e.g. haemorrhoids, low rectal Ca
 Examination of the anal canal and lower rectum ±
biopsy
 Therapeutic: banding, sclerotherapy
Features
 Obturator to aid insertion
 Attachment for a light source
Method
 Consent pt. and explain procedure.
 Examine perineum and perform DRE c̄ pt. in left-lateral
position.
 Lubricate scope c̄ aquagel, attach light source
 Hold in left hand and insert into the rectum.
Complications
 Haemorrhage
 Perforation
Indications
 Allows endoscopic examination of the rectum and rectosigmoid junction c̄ possible biopsy.
 Can be used in the outpatient or inpatient setting
 Investigation of
 Rectal bleeding
 Colonic Neoplasia
 IBD
Features
 Graduated plastic tube c̄ an obturator to aid insertion
Method
Shouldered / Gabriel Syringe
 For good views a suppository should be given prior to
examination
 Consent pt. and explain procedure.
 Examine perineum and perform DRE c̄ pt. in left-lateral
position.
 Ensure no obstruction to scope
 Lubricate scope c̄ aquagel and insert into anal canal
 Remove obturator
 Attach light source, bellows and eye piece and
insufflate air
 Visualise mucosa as scope withdrawn
Complications
Indications
 Injection of haemorrhoids with 5% phenol in almond oil
 Sclerosant
Method
 Consent and explain procedure to pt.
 Pt. placed in left lateral position and syringe used c̄
proctoscope to enable haemorrhoid visualisation
 2ml of phenol is injected above dentate line: insensitive
Complications
Immediate
 Pain if injected below dentate line
 Damage to nearby structures
 Primary haemorrhage
 Perforation
 Mechanical: pushing against bowel wall
 Pneumatic: over-inflation
 Bleeding
PR Bleeding Differential
Commonest
 Perianal: haemorrhoids, fissure
 Diverticular disease
 Malignancy
Other
 IBD
 Infection
 Upper GI bleed
 Angiodysplasia
Late
 Prostatitis
 Impotence
© Alasdair Scott, 2012
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Laparoscopic Port
Circular Bowel Stapler
Indications
 Access the abdomen during laparoscopic surgery
 E.g. lap chole
Features
 Trocar ± sharp blades
 CO2 insufflation port
 Instrument port with rubber flanges
Method
 Small incision made in the abdominal wall
 Either trocar used to enter abdomen or surgical entry is
made
 Laparoscope usually inserted @ the umbilicus
 Abdomen inflated c̄ CO2: cheap, soluble, inert gas
Complications
 Visceral trauma on insertion
Advantages of MAS
Smaller Incisions
 ↓ post-op pain
 ↓ risk of wound infection
 Faster post-op recovery
 ↓ hospital stay
 Better cosmesis
May allow better visualisation and access
 Can visualise and operate on pelvic organs in lap
appendicectomy.
 Dx and fix contralateral hernia in lap hernia repair.
Disadvantages of MAS






Different anatomy
↓ tactile feedback (can’t feel colon tumours)
2D view of 3D structures
Technically challenging and old skills may be lost
Complications (e.g. haemorrhage) may be harder to Mx
Expensive
© Alasdair Scott, 2012
Indications




Rectal anastomosis
Gastrectomy
Haemorrhoids
Rectal prolapse
Features
 Anvil sutured into proximal limb c̄ purse string suture
 Anvil fits into stapler and provides counterpoint for
staple insertion.
Complications
 Anastomotic leak
Checking the Integrity of an Anastomosis
Intra-operative
 Fill pelvic cavity with saline
 Insufflate rectum c̄ air and look for bubbles in the saline.
Post-operative
 Water-soluble contrast enema
208
Urology
General Catheterisation Indications
Diagnostic
 Measure urine output
 Sterile urine sample
 Renal tract imaging
Therapeutic
 Urinary retention
 Immobile patients
 Bladder irrigation
 Intermittent decompression of neuropathic bladder
Foley Catheter
Features
 One port for drainage and one to fill the distal balloon c̄
sterile water.
 Distal balloon sits in the bladder and prevents
displacement of the catheter.
 Material
 Usually latex
 Silastic better for long-term placement
 ↓ blockage and ↓ infection
Method
 Consent and explain the procedure to the patient.
 Use smallest diameter possible to achieve adequate
drainage
 French = circumference of catheter in mm
 Male: 16-18F
 Female: 12-14F
 Clean perineal area
 Use ANTT and insert the catheter c̄ the aid of instilagel
 Ensure that urine is draining before inflating the balloon
(10ml of water)
 Replace foreskin to prevent paraphimosis
 May give a STAT dose of Gentamicin IV to prevent
transient bacteraemia.
Mx of Non-draining catheter
 Bypassing catheter: consider condom catheter
 Blocked: flush c̄ 20ml sterile 0.9% NS or consider 3way
 Slipped into prostatic urethra: flushes but won’t drain
 Catheter has perforated the lower tract on insertion and
is not in the bladder
 Renal or pre-renal failure
TWOC
 After 24-72 hrs in AUR
 May be performed as a urology outpt. if retention likely.
 Tamsulosin ↓s risk of retention after TWOC
Indications for Long-Term Catheterisation
 Chronic bladder outlet obstruction
 Neurogenic bladder c̄ chronic retention
 Complications of incontinence
 Refractory skin breakdown
 Palliative care
 Pt. preference
Clean Intermittent Self-Catheterisation
 Alternative to indwelling catheter in CUR
 Also useful in pts. who fail to void after TURP
Indications
 Chronic retention
 Neuropathic bladder
 MS
 DM neuropathy
 Spinal trauma
Complications
 Early
 Creation of false tract
 Urethral rupture
 Paraphimosis
 Haematuria
 Delayed
 Infection
 Blockage
Contraindications
 Urethral trauma
 Blood @ urethral meatus
 High-riding prostate
 Scrotal haematoma
 Pelvic fracture
Other Catheter Types
 Coude catheter: angled tip may help in big prostates
 Condom catheter
© Alasdair Scott, 2012
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3-Way Irrigation Foley Catheter
Acute Urinary Retention (AUR)
Indication
Clinical Features
 Irrigate bladder in pts @ risk of clot retention
 E.g. after TURP or in pts c̄ haematuria
 Suprapubic tenderness
 Palpable bladder
 Dull to percussion
 Can’t get beneath it
 Large prostate on PR
 Check anal tone and sacral sensation
 <1L drained on catheterisation
Features
 3 ports
 Balloon inflation
 Drainage (middle)
 Irrigation
Suprapubic Catheter
Ix
 Blood: FBC, U+E, PSA (prior to PR)
 Urine: dip, MC+S
 Imaging
 US: bladder volume, hydronephrosis
 Pelvic XR
Mx
Conservative
 Analgesia
 Privacy
 Walking
 Running water or hot bath
Indications
 Urethral injuries
 Urethral obstruction
 BPH
 Ca prostate
Method
 US guided insertion of catheter under LA
 Trocar inserted into catheter and unit advanced through
skin.
Complications
 Viscus perforation
 Haemorrhage
 Malignancy seeding
Catheterise
 Use correct catheter: e.g. 3-way if clots
 STAT gent cover
 Hrly UO + replace: post-obstruction diuresis
 Tamsulosin: ↓ risk of recatheterisation after retention
 TWOC after 24-72h
 May d/c and f/up in OPD
 More likely to be successful if predisposing factor
and lower residual volume (<1L)
TURP
 Failed TWOC
 Impaired renal function
 Elective
Advantages





↓ UTIs
↓ stricture formation
TWOC w/o catheter removal
Pt. preference: ↑ comfort
Maintain sexual function
Disadvantages
 More complex: need skills
 Serious complications can occur
CI
 Known or suspected bladder carcinoma
 Undiagnosed haematuria
 Previous lower abdominal surgery
 → adhesion of small bowel to abdo wall
© Alasdair Scott, 2012
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JJ or Ureteric Stent
Indication
 Relieve ureteric obstruction
 Stones
 Tumours
 May be inserted intra-op during renal Tx
Method
 Retrograde: cystoscopic guidance
 Anterograde: percutaneous
Complications
 Infection
 Blockage
 Displacement / migration
© Alasdair Scott, 2012
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Trauma and Orthopaedics
Chest Drain Tube and Trocar
Chest Drain Bottle
Indications
Indications
 Drainage of the pleural cavities
 PTX
 Traumatic
 Ventilated
 Following needle decompression of tension
 Persistent after aspiration
 Pleural effusion: malignant, pus, blood, lymph
 Post-op: thoracotomy, post-oesophagectomy
Method





Consent and explain procedure to pt.
Commonly insert smaller drains c̄ Seldinger technique
Morphine analgesia
Clean and drape area
ID safe triangle: 4th-6th ICS, just anterior to mid-axillary
line, posterior to pectoralis major muscle.
Infiltrate 1% lignocaine to rib below and pleura of ICS.
Check that air or fluid can be aspirated.
Make small 1cm incision just above rib below, blunt
dissect c̄ Spencer-Wells down to pleura, sweep finger
to clear adhesions and check location.
Attach drain to bottle and advance it into pleural cavity,
directing it postero-inferiorly.
Close wound and ICD using modified mattress suture.
Get patient to cough and take deep breaths, check for
swinging and bubbling.
CXR to check location.






 As for chest drain tube
Method
 Fill bottle to prime level c̄ sterile water
 Connect to drain to bottle
 Underwater seal allows one-way flow out of pleural
cavity
 May add suction → active drainage
Complications
 Lifting the bottle above the pt can → retrograde flow
into chest.
 Complications of chest tube insertion
Complications
Early




Pain due to inadequate analgesia
Haemorrhage due to NV bundle damage
Organ perforation
Incorrect location: e.g. abdomen
Late




Failure: bronchopleural fistula
Long-thoracic N. damage → winged scapula
Wound infection
Blockage
Removal
 Remove when no longer swinging or bubbling and CXR
confirms resolution of PTX
 Using two people, remove in forced expiration and use
mattress suture to close wound.
 CXR to check no new PTX.
© Alasdair Scott, 2012
212
Fracture Plate
Hemi-Arthroplasty Prosthesis: Austin Moore
Indications
 Internal fixation of fractures
 This particular type can be used to fix tibial #s
Method
 Requires open reduction
 Plate aligned with orientation of bone
 Screws used to fix plate to bone
Complications
 Relate to #, procedure and the plate
The Plate
 Infection
 Failure
 Malposition of the remodelled fracture
Other Types of Fixation







POP
Continuous traction: collar and cuff
External fixation
Intramedullary nail
K wires
DHS
Cannulated screws
Indications
 Intracapsular # NOF: Garden 3/4
Features
 Fenestrated stem for osseous integration
 Non-cemented
 Shouldered
 Large head
Method




Placed in theatre under GA
Posterior or anterolateral (commonest) approaches
Head of femur resected femoral shaft reamed
Stem is cemented (Thompson) or uncemented (Austin
Moore)
 Head relocated and joint function and stability assessed
before closure.
Complications of the Prosthesis
 Complications involve the fracture, the procedure and
the prosthesis.
Early




Cement reaction
Deep infection
Fracture
Dislocation (3%): squatting and adduction
Late
 Loosening: septic or aseptic
 Failure: stem #
 Revision: most replacements last 10-15yrs
© Alasdair Scott, 2012
213
Total Arthroplasty Prosthesis
Indications
 OA hip
Features
 Femoral component with small head
 Polyethylene acetabular component
 Most are cemented
Method






Placed in theatre under GA
Posterior or anterolateral (commonest) approaches
Head of femur resected
Acetabulum and femoral shaft are reamed
Stems and cups are trialled to find most suitable
Head relocated and joint function and stability assessed
before closure.
Complications of the Procedure and Prosthesis
Immediate
 Nerve injury
 Fracture
 Cement reaction
Early




DVT: up to 50% w/o prophylaxis
Deep infection
Must remove metalwork before revision.
Dislocation (3%): squatting and adduction
Late
 Loosening: septic or aseptic
 Failure: stem #, wear
 Revision: most replacements last 10-15yrs
© Alasdair Scott, 2012
Intramedullary Nail
Indications
 Form of internal fixation used in the Mx of long-bone #s
 Femur, tibia, humerus
Features
 Titanium or titanium alloy
 Screws insert proximally and distally provide rotational
and longitudinal stability
 Curve fits contour of tibia
Dynamisation
 Removal of one or more screws in order to allow
collapse
 ↑ loading of fracture site → quicker union
Method
 Inserted under GA
 Nail hammered into medulla of bone
 Screws lock nail in place
Complications of the Prosthesis




Fracture during nail insertion
Infection
Fat embolus
Delayed or non-union
Fat Embolism Syndrome
 Presentation: SOB, petechial rash, confusion
 Typically 24-72h between injury and onset
 Resp: dyspnoea ± chest pain
 Petechial rash: upper anterior trunk, arms, neck
 CNS: headache, confusion, agitation
 Renal: oliguria, haematuria
 Ix
 ABG: hypoxia, hypocapnoea
 FBC: ↓ plats, ↓Hb
 CT chest
 Mx
 Supportive: O2, volume resuscitation
 Steroids
214
Stiff Neck Collar
Mannitol
Indications
Indications
 Stabilise the cervical spine in trauma pts.
 Used c̄ two sandbags and tape
Features
 Comes flat packed and must be assembled
 Hole at front allows access to the trachea
Method
 Sized by measuring the number of fingers from the
clavicle to the angle of the mandible
 “Key dimension” then compared to the sizing peg on the
hard collar.
 Osmotic diuretic
 Lower intracranial pressure
 ↓ IOP in hyphema
Method
 Given centrally
Complications
 May ↑ ICP in the long-term
 CI in severe cardiac failure and pulmonary oedema
Complications
 Incorrect placement
 Neck not in neutral alignment
 Chin not flush c̄ end of chin piece
Clearing the C-Spine
Clinical Clearance
 Indication: NEXUS Criteria
 Neurological deficit
 Spinal tenderness in the midline
 Altered consciousness
 Intoxication
 Distracting injury
 Method
 Examine for bruising or deformity
 Palpate for deformity and tenderness
 Ensure pain-free active movement
Radiological Clearance
 Indications
 Pt. doesn’t meet criteria for clinical clearance
 Modalities
 Radiograph initially
 Clear if normal radiograph and clinical
exam
 CT C-spine if abnormal radiograph or clinical
exam
© Alasdair Scott, 2012
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Miscellaneous
Swan Ganz Catheter
Tru-Cut Biopsy Needle
Indications
Indications
 Flow directed pulmonary artery catheter
 Measure the pulmonary capillary wedge pressure
 Indirect measure of LA filling pressure
 Measure cardiac output
 Used in cardiogenic or septic shock when accurate
haemodynamic data is required
 Its use has not been shown to improve outcome
 Used to take histological specimens from lesions
 Part of triple assessment of breast lumps
 Liver
 Kidney
 Prostate: transrectally
Method




Consent and explain procedure to pt.
Anaesthetise area c̄ LA
Needle advanced under US guidance
Spring handle is pressed, advancing the specimen tray
into the target lesion
 Further pressure fires the surrounding sheath, obtaining
a biopsy
Method
 Used in the intensive care setting
 Inserted into a central vein.
Fogarty Embolectomy Catheter
Complications
 Bleeding
 Pain
 Cancer seeding
Renal Biopsy
Indications
Indication
 Mx of acutely ischaemic limb 2O to embolus
Method
 Vascular access gained to femoral artery @ groin.
 Catheter passed distal to embolus
 Balloon is inflated and catheter withdrawn.
CI





Unexplained ARF/CRF
Acute nephritic syndrome
Unexplained proteinuria / haematuria
Systemic disease c̄ renal involvement (e.g. SLE)
Suspected Tx rejection




Abnormal clotting
Single kidney (except Tx)
Small kidneys from CRF (↑ bleeding risk + too late)
Renal neoplasms
Procedure
 Stop aspirin (1wk) and warfarin (2d) in advance
 Check FBC, clotting and G&S
 US-guided Tru-Cut needle biopsy
Complications
 Macroscopic haematuria in 1%
 Transfusion needed in 0.1%
© Alasdair Scott, 2012
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Key Anatomy
Contents
Chest Wall ................................................................................................................................................................................. 218
Thoracic Cavity .......................................................................................................................................................................... 219
Inguinal Region.......................................................................................................................................................................... 220
Abdominal Wall and Surface Anatomy ...................................................................................................................................... 221
The Bowel.................................................................................................................................................................................. 222
Abdomen Neurovascular Supply ............................................................................................................................................... 223
Gastrointestinal Adnexae .......................................................................................................................................................... 223
Urinary Tract .............................................................................................................................................................................. 224
Head and Neck .......................................................................................................................................................................... 225
The Thigh .................................................................................................................................................................................. 226
The Leg ..................................................................................................................................................................................... 227
The Arm ..................................................................................................................................................................................... 228
© Alasdair Scott, 2012
217
Chest Wall
Surface Landmarks





Superior angle of scapula : T2
Inferior angle of scapula: T8
Sternal angle: T4/5
Subcostal plane: L3
Nipples: 4th ICS
Surface Markings
 Pleura: 8th, 10th and 12th ribs
 Lung: 6th, 8th and 10th ribs
Oblique fissure
 T4 in midline posteriorly
 5th rib laterally
 6th costal cartilage anteriorly
Horizontal fissure
 Follows contour of 4th rib anteriorly
The Breast
 Attached between rib 2-6
 Axillary tail follows lower margin of pec major
Breast
 Mammary glands and connective tissue stroma
 Anterior to ribs 2–6 and extend superolaterally to the
mid-axillary line.
Mammary glands
 Ducts and secretory lobules converge to form 15-20
lactiferous ducts which each open onto the nipple.
Connective tissue
 Surrounds mammary glands
 Suspensory lgts. (of Cooper) are continuous with the
dermis and support the breast.
 Layer of loose connective tissue (retromammary space)
separates the breast from the deep fascia and allows
some movement over the underlying structures.
Arterial Supply
 Laterally: vessels from the axillary artery
 Medially: branches from the internal thoracic artery
nd
th
 2 – 4 intercostals via superficial perforating branches
Lymphatic Drainage
 75% drain superolaterally into axillary nodes
 Remainder into deep parasternal nodes
Thoracic Plane: T4/5 – Sternal Angle






Aortic arch: beginning and end
SVC enters the RA
Bifurcation of the pulmonary arterial trunk
Carina
2nd costosternal joint
Division of superior and inferior mediastinum
© Alasdair Scott, 2012
218
Thoracic Cavity
The Diaphragm
Recurrent Laryngeal Nerve
Superior Mediastinum
Chylothorax
 3 main openings
 Aortic hiatus: T12
 Oesophagus: T10
 Vena Cava: T8
 Congenital hernia
 Morgagni: anterior
 Bochdalek: posterior
Boundaries
 Sup: thoracic inlet
 Inf: angle of Louis: T4/5 (Thoracic Plane)
 Lat: pleura
 Ant: manubrium
 Post: T1-4
Contents
 Arteries: aortic arch and branches
 Veins: brachiocephalics, SVC
 Nerves: vagi, phrenics, L recurrent laryngeal
 Organs: thymus, trachea, oesophagus, thoracic duct,
LNs
Anterior Mediastinum
 Anterior to pericardium
 Thymus and LNs
Posterior Mediastinum





Descending aorta
Azygous vein and hemiazygous
Thoracic duct
Esophagus
Sympathetic trunks
 RLN supplies all intrinsic laryngeal muscles except
cricothyroid (external branch of sup. laryngeal N.)
 Left nerve recurs around the ligamentum arteriosum
(remnant of ductus arteriosum)
 Right nerve recurs around right subclavian artery
 Damage may occur during thyroid or parathyroid surgery
or due to bronchogenic Ca
 Unilateral palsy → hoarseness (bilat → aphonia)
 Thoracic duct drains whole lymphatic field below
diaphragm and left half of lymphatics above it.
 Surgical procedures involving the posterior mediastinum
or neck can → lymph leak into thoracic cavity.
Venous System at the Thoracic Outlet
 Subclavian veins join internal jugular veins behind SCJs
 Brachiocephalic veins form SVC behind right 1st
sternocostal joint.
 SVC enters RA @ right 3rd sternocostal joint
Oesophagus
 25cm long muscular tube (40cm from GOJ → lips)
Path
 Starts at level of cricoid cartilage (C6)
 Lies in the visceral column in the neck
 Runs in posterior mediastinum and passes through right
crus of diaphragm @ T10.
 Continues for 2-3cm before entering the cardia
4 locations of narrowing
 Level of cricoid: junction c̄ pharynx
 Posterior to aortic arch
 Posterior to left main bronchus
 LOS
Histology
rds
 Divided into 3 : reflects change in musculature from
striated → mixed → smooth.
 Lined by non-keratinising squamous epithelium.
 Z-line: transition from squamous → gastric columnar
Gastro-oesophageal Sphincter
 3 main components to prevent reflux
 LOS: 4cm long hypertrophied smooth muscle
 Extrinsic Sphincter: skeletal muscle of R crus of
diaphragm
 Physiologic sphincter
 Distal component projects into abdominal cavity
and ↑ IAP → compression
 Angle of His also forms valve preventing reflux.
© Alasdair Scott, 2012
219
Inguinal Region
Deep Ring
 1.5cm above femoral pulse, or
 Mid-point of inguinal ligament (ASIS → PT)
Superficial Ring
 Split in external oblique aponeurosis just superior and medial to the pubic tubercle.
Inguinal canal







4cm long
Floor: inguinal ligament
Roof: arching fibres of internal oblique and transversus abdominis
Anterior: external oblique aponeurosis + internal oblique for lateral 3rd
Posterior: transversalis fascia + conjoint tendon for medial 3rd
Laterally: deep ring
Medially: pubic tubercle
Conjoint tendon: combined insertion of internal oblique and transversus abdominis into pubic crest and pectineal line
Contents
 M: ilioinguinal N. + spermatic cord
 F: ilioinguinal N. + genital branch of genitofemoral N. + round lig. of uterus
Ilioinguinal N. (L1)
 Enters canal directly through anterior wall: does not pass through the deep ring
 Exits through the superficial ring
 Supplies skin at the root of the penis and the scrotum (or the labia majus) and small area of skin of upper inner thigh.
Genital branch of the genitofemoral N. (L1/2)
 Supplies cremaster muscle and scrotal skin or the labia majus.
Spermatic Cord
 3 layers of fascia
 External spermatic: from external oblique
 Cremasteric: from internal oblique
 Internal spermatic: from transversalis fascia
 3 arteries
 Testicular: from aorta
 Cremasteric: from inf. epigastric
 Artery of the vas: from inf. vesicular A.
 3 veins
 Pampiniform plexus (R→IVC, L→ Left renal)
 Cremasteric vein
 Vein of the vas
 2 nerves
 Nerve to cremaster: from genito-femoral N.
 Sympathetic fibres from T10-11
 (Ilioinguinal N. is on the cord)
 3 other structures
 The vas deferens
 Lymphatics of the testis (→para-aortic nodes)
 Obliterated processus vaginalis
Femoral Sheath
 In femoral triangle, femoral artery, vein and lymphatics
are enclosed w/I femoral sheath.
 Sheath continuous superiorly c̄ transversalis fascia
 Each structure has its own compartment
 Most medial compartment = femoral canal
 Ant: inguinal ligament
 Post: pectineal lig (lig. of Cooper) + pectineus
 Med: lacunar lig. and pubic bone
 Lat: femoral vein
 Contents: fat and Cloquet’s node
Operative Anatomy
Inferior epigastric vessels
 Arise from external iliac vessels immediately
superior to inguinal ligament.
 Can be seen passing deep to the posterior wall
(transversalis fascia)
 Sac arises lateral to vessels = indirect hernia
 Sac arises medial to vessels = direct hernia
Hesselbach’s triangle
 Area of entry for direct hernias through posterior wall
 Laterally: inf. epigastric artery
 Medially: rectus abdominis muscle
 Inferiorly: inguinal ligament
© Alasdair Scott, 2012
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Abdominal Wall and Surface Anatomy
Abdominal Wall
Surface Anatomy
Layers
 Skin
 Camper’s fascia: fatty
 Scarpa’s fascia: membranous
 External oblique
 Internal oblique
 (nerves and vessels)
 Transversus abdominis
 Transversalis fascia
 Pre-peritoneal fat
 Parietal peritoneum
L1: Transpyloric Plane of Addison
 Midway between jugular notch and pubic symphysis
 9th costal cartilage
 Pyloric orifice and D1
 DJ flexure
 Fundus of the gallbladder
 Left and right colic flexures
 Neck of the pancreas
 Lower part of left renal hilum, upper part of right
 Origin of the SMA and coeliac trunk
Innervation
 Intercostal nerves: T7-T11
 Subcostal nerve: T12
 Ilio-inguinal and ilio-hypogastric nerves: L1
Blood Supply
 Superiorly
 Superficial: musculophrenic A
 Deep: superior epigastric A.
 Both terminal branches of int. thoracic A.
 Inferiorly
 Superficial: superficial epigastric + superficial
circumflex iliac As.: branches of the femoral A.
 Deep: Inf. epigastric + deep circumflex iliac As.:
branches of the external iliac A.
Rectus Sheath
 Arcuate line of Douglas: midway between umbilicus and
pubic symphysis
 Above the arcuate line the sheath completely encloses
the rectus muscle.
 Below the arcuate line the sheath is deficient posteriorly
and the rectus is in direct contact c̄ transversalis fascia.
 This arrangement allows expansion of pelvic contents
into the abdomen.
 Semilunar lines: aponeurosis of ext. oblique at its line of
division to enclose the rectus.
© Alasdair Scott, 2012
L3: Subcostal Plane
th
 Joins lowest points of the 10 ribs
 Origin of IMA
L4: Intercristal Plane
 Joins the highest points of the iliac crests
 Bifurcation of the aorta
Surface Markings
Umbilicus
 Inconsistent position
 Normally L3/L4 disc
Liver
 Upper border at the level of the fifth ICS on each side
 Lower border from tip of 10th rib on right to just medial
to mid clavicular line in the left 5th ICS
Gallbladder
 Where the mid clavicular line meets the right costal
margin: 9th costal cartilage
Spleen
 Underlies ribs 9-11 on the left.
221
The Bowel
Duodenum
 4 parts
 Mostly retroperitoneal
D1
D2
D3
D4
 Duodenal cap
 Commonest place for DUs
 Overlapped by gallbladder
 Stones can erode into D1 → ileus
 Descending part
 Contains Major Duodenal Papilla (mid → hind gut)
 Inferior part
 Can be compressed by SMA aneurysm
 Ascending part
 Ends at DJ flexure / Ligament of Trietz
PUD Perforation
 Posterior DU can erode into GDA → massive
haematemesis
 Anterior DU → pneumoperitoneum and peritonitis
Jejunum
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Proximal 2/5
Larger diameter + thicker wall
Less prominent arcades
Longer vasa recta
Ileum
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Distal 3/5
Narrower diameter + thinner wall
More prominent arcades
Shorter vasa recta
Appendix
 Base is consistently found @ confluence of the caecal
taenia coli
 Position of rest of appendix is highly variable
 Retro-caecal: 75%
 Sub-caecal and pelvic: 20%
 Retro- or pre-ileal: 5%
 Appendicular artery runs in the mesoappendix and is a
branch of the ileocolic artery.
Appendicitis Pain
 Initially visceral pain carried by sympathetic afferents in the
lesser splanchnic nerve which refers to T10 dermatome
 Later peritonitis → somatic pain and localisation to RIF.
Meckel’s Diverticulum
 Ileal remnant of vitellointestinal duct
 Joins yoke sac to midgut lumen
 A true diverticulum
 2 inches long
 2 ft from ileocaecal valve on antimesenteric border
 2% of population
 2% symptomatic: PR bleed, diverticulitis, intussusception
 Contain ectopic gastric or pancreatic tissue
© Alasdair Scott, 2012
Distinguishing Features of Large Bowel
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Large diameter
Condensation of longitudinal muscle → taenia coli
Epiploic appendages
Sacculations / Haustra
Rectum
 12cm
 Sacral promontory to levator ani muscle
 The 3 tenia coli fuse around the rectum to form a
continuous muscle layer.
Anal Canal
 4cm
 Levator ani muscle to anal verge
 Upper 2/3 of canal
 Lined by columnar epithelium
 Insensate
 Sup. rectal artery and vein
 Internal iliac nodes
 Distal 1/3 of canal
 Lined by squamous epithelium
 Sensate
 Middle and inf. rectal arteries and veins
 Superficial inguinal nodes
 Dentate line = squamomucosal junction
 White line = where anal canal becomes true skin
Anal Sphincters
Internal
 Thickening of rectal smooth muscle
 Involuntary control
External
 Three rings of skeletal muscle
 Deep
 Superficial
 Subcutaneous
 Voluntary control
Anorectal Ring
 Deep segment of external sphincter which is
continuous c̄ puboretalis muscle (part of levator ani)
 Palpable on PR ~5cm from the anus
 Demarcates junction between anal canal and rectum.
 Must be preserved to maintain continence
Common Areas for Collections
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Subphrenic recess
Hepatorenal recess: Morrison’s pouch
Lesser sac
Paracolic gutters
Small bowel (interloop spaces)
Pelvis: Pouch of Douglas
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Abdomen Neurovascular Supply
Gastrointestinal Adnexae
Arteries
Liver
L1: Coeliac Trunk
 Left gastric
 Common hepatic
 Splenic
L1: SMA
 Inf. pancreaticoduodenal
 Ileal and jejunal vessels
 Middle colic
 Right colic
 Ileocolic
L1: Renal Vessels
L3: IMA
 Left colic
 Sigmoidal branches
 Superior rectal artery
Marginal Artery of Drummond
 Anastomotic artery between middle colic and ascending
branch of left colic
 May maintain hind-gut blood supply even when IMA
stenosed.
 Functionally divided by line through gallbladder fossa
and IVC.
 Split into 8 Couinaud segments
 4 on Right
 3 on Left
 Caudate lobe is functionally distinct
Gallbladder
 Stores and concentrates ~50ml of bile
 Supplied by cystic artery but also receives rich supply
from the gallbladder bed: gangrene is  rare
Calot’s Triangle
 Sup: inferior edge of liver
 Med: CHD and RHD
 Inf: cystic duct
 Contains
 Cystic artery
 Calot’s/Lund’s node
 Aberrant RHA
Nerves
Sympathetic
 Thoracic an d lumbar splanchnic nerves
Parasympathetic
 Vagus nerve
 Pelvic splanchnic nerves
Splanchnic Nerves
 Greater Splanchnic Nerve (T5-T10): foregut
 Lesser Splanchnic Nerve (T10-T11): midgut
 Least Splanchnic Nerve (T12): kidneys
 Lumbar Splanchnic Nerve (L1-L2): hindgut
Enteric NS
 Independent of CNS but does receive some
sympathetic and parasympathetic input.
 Two layers
 Myenteric plexus of Auerbach
 Submucosal plexus of Meisner
Lymphatics
 Follow arteries
 Para-aortic nodes associated c̄ each major branch
 Drain superiorly to cisterna chyli → thoracic duct
© Alasdair Scott, 2012
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Urinary Tract
Ureter Course
 25cm long
 Start at renal pelvis: L1 on left, slightly lower on right
 Runs inferiorly on the psoas muscle anterior to the tips
of the transverse processes of the lumbar vertebrae
 Cross sacroiliac joints passing anterior to iliac
bifurcation
 Pass posteriorly to the ischial spines then anteriorly to
the bladder.
Ureteric Narrowings
 Pelviureteric junction
 Crossing the iliac vessels at the pelvic brim
 Vesicoureteric junction
Male Urethra
 20cm long
 4 main parts
 Pre-prostatic: internal urethral sphincter
 Prostatic
 Openings of ejaculatory ducts
 Widest part
 Membranous
 External urethral sphincter
 Narrowest part
 Spongy: longest part (for most)
Coverings of the Vas Deferens in the Scrotum
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Skin
Superficial scrotal fascia (Dartos fascia)
External spermatic fascia
Cremasteric fascia
Internal spermatic fascia
Pre-peritoneal fat
Tunica vaginalis
Vas
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Head and Neck
Neck Fascia
Superficial: platysma
Investing
 Completely surrounds neck
 Encloses SCM and trapezius
Pre-vertebral
 Surrounds vertebral column and associated muscles
Pre-tracheal
 Surrounds trachea, oesophagus and thyroid
Carotid Sheath
 Surrounds internal carotid, internal jugular + CNX
Thyroid Gland
Lies over 3rd-4th tracheal cartilages
Invested in pretracheal fascia
Strap muscles lie anterior
Parathyroid glands posteriorly
2 arteries
 Sup. thyroid (ECA)
 Inf. thyroid (thyrocervical trunk)
 3 veins: sup, middle and inf. thyroid veins
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Larynx
Innervation
 Motor
 Recurrent laryngeal N. supplies all intrinsic
muscles except cricothyroid
 External branch of superior laryngeal N. supplies
cricothyroid.
 Sensory
 Int. branch of superior laryngeal N.: above folds
 Recurrent laryngeal N.: below folds
Branches of the External Carotid Artery
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Superior thyroid
Ascending pharyngeal
Lingual
Facial
Occipital
Posterior auricular
Superficial temporal
Maxillary
Facial Nerve
 Arises in medulla and emerges between pons and
medulla to travel in the internal auditory canal.
 Exits the internal auditory canal and forms the geniculate
ganglion in the middle ear
 Traverses the length of the temporal bone, giving off 3
branches
 Greater superficial petrosal N.: lacrimation
 Nerve to stapedius: lesions → hyperacusis
 Chorda tympani: anterior 2/3 taste
 Exists temporal bone via stylomastoid foramen and runs
into parotid gland.
 Gives off nerves to post. belly of digastric and stylohyoid
 Divides into 5 motor branches
 Temporal
 Zygomatic
 Buccal
 Mandibular
 Cervical
 Upper motor neurone lesions spare the forehead as
suprapontine crossover → bilateral representation
Semon’s Law
 Transection of RLN
 → complete paralysis c̄ cords half aducted /
abducted
 Cannot speak or cough
 Trauma but not transection of RLN
 → partial paralysis c̄ cords adducted
 Cannot breath if bilateral
Triangles of the Neck
Anterior
 Ant. margin of SCM
 Midline
 Ramus of the mandible
 Roof: investing fascia
Submandibular
 Mental process
 Ramus of the mandible
 Line between two angles of the mandible
Posterior
 Post. margin of SCM
 Ant. margin of trapezius
 Mid 1/3 of clavicle
© Alasdair Scott, 2012
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The Thigh
Hip Joint
Structure
 Ball and socket synovial joint between the head of the femur and the lunate surface of the acetabulum.
 Lgt. teres connects fovea on femoral head to acetabular fossa and transmits the artery lgt. teres (from obturator A.).
 Fibrous capsule composed of three lgts (ilio-, ischio and pubofemoral lgts.) and extends from margin of acetabulum to
intertrochanteric line of the femur.
Muscles
Movement
Segment
Nerve
Muscles
Flexion
L2/3
Femoral
Iliopsoas
Rectus femoris
Sartorius
Extension
L4/5
Inf. gluteal
Gluteus maximus
Adduction
L2/3
Obturator
Adductors
Abduction
L4/5
Sup. gluteal
Gluteus minimus
Gluteus medius
Int. rotation
L2/3
Obturator
Adductors
Ext. rotation
L5/S1
Various
Short ext. rotators
Gluteus maximus
Blood Supply to the femoral head
1. Intramedullary vessels
2. Retinacular vessels from the medial and lateral circumflex femoral arterie
 Distal → proximal in the capsule.
3. Artery of the ligamentum teres from the obturator artery (only contributes in children)
Femoral Triangle: SAIL
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Lateral: medial margin of Sartorius
Medial: medial margin of Adductor longus
Base: Inguinal Ligament
Floor: pectineus and adductor longus
Apex: continuous c̄ Hunter’s canal
Contents: femoral N., A., V. and canal
Hunter’s (Adductor) Canal
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Anterolateral: vastus medialis
Posterior: adductor longus and magnus
Roof and medially: Sartorius
Contents: SFA, femoral V., saphenous nerve
Anterior Compartment of the Thigh
Function
 Flex the hip: L2-3
 Extend the knee: L3-4
Nerve
 Femoral N.: L2-L4
Muscles
 Iliopsoas
 Sartorius: ASIS → pes anserinus
 Rectus femoris: AIIS → patellar lgt.
 Vastus muscles
Medial Compartment of the Thigh
Gluteal Region
Muscles
 Abductors: superior gluteal N.
 Gluteus medius
 Gluteus minimus
 Extensor: inferior gluteal N.
 Gluteus maximus
 Short external rotators
 Piriformis
 Obturator internus
 Quadratus femoris
 Gemelli: inf. + sup.
Sciatic N.: L4-S3
 Enters via greater sciatic foramen below piriformis
 Found in lower medial quadrant of gluteal region
 Motor
 Hamstrings
 Hamstring part of adductor magnus
 Muscles of leg and foot
 Sensory
 Lateral leg and foot
 Sole and dorsum of foot
© Alasdair Scott, 2012
Function
 Adduct and externally rotate the hip: L2-3
Nerve
 Obturator N.: L2-L4
Muscles
 Pectineus (femoral N.)
 Adductor brevis, longus and magnus
 Gracilis
 Obturator externus
Posterior Compartment of the Thigh
Function
 Extend the hip: L4-5
 Flex the knee: L5-S1
Nerve
 Tibial division of sciatic.: L4-S3
Muscles
 Biceps femoris
 Semitendinosus
 Semimembranosus
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The Leg
The Knee Joint
Posterior Compartment of the Leg
Structure
 Weight-bearing articulation between femur and tibia
 Articulation between patella and femur
 ↓ tendon wear
 ↑ moment around knee joint.
Function
 Plantarflexion of the foot: S1-2
 Flex the toes and invert the foot
Menisci
 2 fibrocartilaginous menisci
 Medial meniscus attached at its margin to medial
collateral lgt.
Bursae
 Suprapatellar bursa: continuous c̄ joint capsule
 Subcutaneous prepatellar bursa
 Can → housemaids knee
 Deep and superficial infrapatallar bursae
Ligaments
 Patellar lgt.: inf. patella to tibial tuberosity
 Collaterals: medial and lateral
 Anterior cruciate
 Prevents anterior displacement of the tibia
relative to the femur
 Posterior cruciate
 Prevents posterior displacement of the tibia
relative to the femur
Muscles
Movement
Segment
Nerve
Muscles
Flexion
L5/S1
Sciatic (Tibial)
Hamstrings
- biceps femoris
- semimem
- semiten
Sartorius ( fem)
Extension
L3/4
Femoral
Quads
- Vastus muscles
- Rectus femoris
Popliteal Fossa
 Superior
 Medial: semitendinosus and semimembranosus
 Lateral: biceps femoris
 Inferior
 Medial: medial head of gastrocnemius
 Lateral: lateral head of gastrocnemius + plantaris
 Floor: capsule of knee joint
 Roof: deep fascia (continuous c̄ fascia lata)
Nerve
 Tibial nerve
Muscles
 Superficial
 Gastrocnemius
 Plantaris
 Soleus
 Deep
 Popliteus
 FHL
 FDL
 Tibialis posterior (L5)
Lateral Compartment of Leg
Function
 Evert the foot: S1
Nerve
 Superficial fibular N.
Muscles
 Fibularis longus
 Fibularis brevis
Anterior Compartment of Leg
Function
 Dorsiflexion of the foot: L5-S1
 Extension of the toes and eversion of the foot: S1
Nerve
 Deep fibular N.
 Supplies skin between great and 2nd toe
Muscles
 Tibialis anterior
 EHL
 EDL
 Fibularis tertius
Contents
 Popliteal artery and vein
 Tibial nerve
 Common fibular nerve
Blood Supply
 Popliteal artery → anterior + posterior tibial arteries
 Anterior tibial
 Supplies anterior compartment of leg
 Palpable as dorsalis pedis A.
 Posterior tibial
 Supplies posterior compartment of leg
 Gives rise to fibular A. (supplies lat compartment)
 Palpable behind the medial malleolus
© Alasdair Scott, 2012
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The Arm
Brachial Plexus
 C5-T1
 Roots leave vertebral column between scalenus
anterior and medius.
 Divisions occur under the clavicle, medial to coracoid
process.
 Plexus has intimate relationship c̄ subclavian and
brachial arteries.
 Median N. is formed anterior to brachial artery.
Anatomical Snuff Box
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Lateral: APL and EPB
Medial: EPL
Proximal: radial styloid process
Floor: scaphoid and trapezium
Contents: radial artery, cephalic vein, dorsal cutaneous
branch of radial nerve.
Carpal Tunnel
C5
Lat
MC
C6
Post
C7
Axillary
Median
Radial
C8
Med
T1
Divisions (6)
Roots (5)
Cords (3)
Trunks (3)
Ulnar
 Carpal tunnel formed by flexor retinaculum and carpal
bones.
 Contains
 4 tendons of FDS
 4 tendons of FDP
 1 tendon of FPL
 Median N.
 Median N. supplies LLOAF (aBductor pollicis brevis)
 Palmer cutaneous branch travels superficial to flexor
retinaculum → spares sensation over thenar area.
Anterior Compartment of the Arm
 Function: forearm flexion (C5-6)
 Nerve: musculocutaneous
 Muscles
 Biceps brachii
 Coracobrachialis
 Brachialis
Posterior Compartment of the Arm
 Function: forearm extension (C7)
 Nerve: radial
 Muscle: triceps
Antecubital Fossa
 Superficial: median cubital vein
 Deep
 Radial nerve
 Brachial artery
 Median nerve
Anterior Compartment of the Forearm
 Function: wrist and finger flexion (C7-8)
 Nerve: mostly median N.
 Muscles
 Superficial
 Pronator teres
 FCR
 Palmaris longus
 FDS
 FCU (ulnar N.)
 Deep
 FDP (ulnar and median Ns.)
 FPL
 Pronator quadratus
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