SURGERY Index: 4- Breast: @> Breast lesions bx Screening program c- Indication of prophylactic mastectomy d- lymphedema 2-GIT 3- DD of abdominal pain 4- preoperative assessmentof patients 5- post operative complications. 6- Cx screening programs 7- Tumor markers ) PLAB 1 CourseBreast lesions Fibroadenoma Y The commonest breast tumor in Adolescence and Young women (Common in women aging 15- 35 years) Y Due to sensitivity to estrogen *~-Described as ‘breast mice! >>> discrete, firm, rubbery, non- tender, highly’mobile lumps >> mostly in the upper outer quadrant Y Benigil with no ifietease in risk of malignancy Histopathology: ‘* Proliferation and expansion of the stroma with low cellularity * Another Histological Description: A well circumscribed lump with clear margins and separate from the surrounding fatty tissue. There are overgrowths of fibrous and glandular tissue. * Or: duct-like epithelium surrounded by fibrous bridging. Diagn * ultrasound and FNAC «Ifthe lesion is suspicious >>> aIFibroadenosis (fibrocystic changes) The fost common: reast lesion in 2s in the reproductive age (Peak incidence: 95850) + ‘Lumpy’ breasts (nodularity) ,painful (Mastalgia) with breast size S, + Symptoms may worsen prior to or during menstruation and li fer it (eyelie mastaleta) ©, disappears a er it ( om ‘ic formations with mild epithelial hyperplasia epitheliosis and Fibrocystic Breast Changes %. . Ys Ko} Mammary duct ectasia : 2 > Dilatation of the large breast ducts. > Most common around the menopatise + history of smoking > May present with a tender lump around-the areola +i foul nipple discharge > Brown/ Green/ Coloured per Nipple. » It typically presents with nipple retraction ai Fj >> as the blocked milk ducts may clear more quickly by breastfeedinggas it keeps milk flowing. Flucloxacillin is firsttine (safe for baby) Abcess : fluctulant lunip/ advise thé patient to discard the milk if itis pus-like / Incision and Grainage of abscess with cavity packed open with gauze is recommended if the underlying skin is thin or necrotic Nipple abcess: 2 E S Painful, fluctuating mass over the breast of Rear the nipple ° Duct fistulas 2 Offensive yellow discharge from an area near the nipple ‘Hx of Abscess near this area that was surgically treated PLA Course subscriber: darwishahmed560@gmail.comBreast cyst: . round mass * Asymptomatic or painfull * Similar feature to fibroadenoma except a cyst seen on us Cyclical vs nonéyclical masfalgia * Bilateral (mayworsen on ne side) * Pain usually starts 1 to 3 days before the menstrual cycle starts and settles bythe time menstruation ends * May complain of gefieral swelliig’and lumpiness but no lump is usually found © Management includes bétter fitting bra during the day and a soft supportive bra at night © Other treatment option includes: oral paracetamol, topical NSAIDS,... © Unilateral or focal © Intermittent, burning, stabbing pain which radiates to axilla + HERBIE to menstrual eycles © treatment: amytriptline or gabapentineBreast cancer: + The most common breast mass in postmenopausal » Characteristically a fixed, hard, painless irregular lump. There may be associated nipple inversion or fixed to skin (Peau Worange) or muscle (+) Local, fixed, firm, axillary LNs. +> [EUSESIRUERSIGSROMOEE are the most common type. Histopathology : Invasive intraductal carcinoma of the breast extending to the epithelium Risk factors (e.g. mother) + nulliparity, early menarche) late menopause + combined HRT/ COCPs + past breast cancer + obesity investigation: mammography and core biopsy Hormonal therapy tamoxifen Important side-effects of tamoxifen include an increased risk of endometrial cancer Breast Cx + polyurea/polydepsia/confusion >>> ??? PLA CoursePaget's disease of the breast Insitu carcinoma associated with a reddening and thickening (may resemble of the nipple/areola > histopathology: In situ carcinoma involving the ippISe Bidens > This.is an UHRGOMNIOH breast malignancy with a generally BBUEE BRORACEE than infiltrating ductal carcinoma. Presentation: Old woman with >>> Y Chronic of the nipple ¥ |tching , Erythema and Scale formation (may mimic psoriasis) Y Erosions or ulcers Y Nipple discharge including bleeding v Inverted nipple v |t usually presents unilaterally. Diagnosis is made by punch biopsy i) PLAB 1 Coursediagnosing breast lesions: = Paget's disease : Punch Biopsy. (Punch takes a part of the skin changes). ™ Suspicious Breast lump > FNA followed by Core biopsy. (Core takes entire tissues not only cells as in FNAC) Ductal Papilloma :Galactogram. Fibroadenoma: Clinical + Ultrasound + FNA = 235 YO > Ultrasound. = 9 >35,¥O > Mamniogram Breast Cx Screeninig»program: v The NHS Breast Screening Programme >>> include women aged 50-70 years ¥ Women are offered'a mammogram every 3 years Y If strong Family Hx, BRCAgenes 40-70 YO Annually ‘After the age of 70 years women may still have mammograms but are ‘encouraged to make their own appointments’. Raha:Indication of prophylactic mastectomy: 1) EERE of breast cancer. 2) Inherited (MURBHORNS in Breast Cancer Susceptibility genes (BRCAL and/or BRCA2). These genes are Autosomal Dominant. 3) BRSVIGUBIbTEaSBRAHIERT in one breast. 4) BIOPSY that shows ->, Lobular Carcinoma in Situ and/or atypical hyperplasia | Breast cancer-and pregnancy: Many breast cancers are estrogen receptor-positive but there is no evidence that hormones from pregnancy would worsen the prognosis. “ Breast surgery is considered safe‘in all trimesters of pregnancy. As a delay in surgery could result in growth and possible metastatic spread termination is required is(iPchemothérapy is needed (the mother would be advised to consider ending her pregnancy) ** Tamoxifen is contraindicated in pregnancy. Lymphedema: Upper Limb Lymphoedema due to Axillary Lymph nodes clearance (removal) during radical mastectomy Clinically: Redness and Swelling + Frozen shoulder: ) PLAB 1 Course TreatmentExamoscope: ** Painful, fluctuating mass over the breast or near the nipple >> diagnosis? ** Brown/ Green/ Coloured discharge per Nipple >> diagnosis?? ** History of Trauma to the Breast (redness/ bruises around the lump) + firm, round, solitary and localized lump >> diagnosis?? ** Young lady + Bleeding per nipple + skin changes >> diagnosis? investigation ?? ** Old lady + Bleeding discharge per nipple + eczema-like changes £ Ulcers > >» diagnosis?? investigation? ** young lady Firm, non-tehder, mobile mass in the breast >> diagnosis?? Investigation??. ** lady in the reproductive age + Breast pain (Mastalgia), 7 breast size, lumpiness (nodularity) + tend to appear just before or during menstrual cycle and disappear after it >> diagnosis?? Management?? **old lady+ Fixed, irregular, hard, painless lump + nipple retraction + fixed to skin (Peau d’orange) or muscle"(+) Local, fixed, firm, axillary LNs>> diagnosis? Investigation? ** History of Abscess near nipple + Offensive yellow discharge from area near the nipple >> diagnosis?? ** Prolonged Redness around the areola + Histdry of using antibiotics which may improve symptoms slightly + greenish fluid is aspirated from the breast >> diagnosis?? ** Lady + radical mastectomy + swelling of upper limb >> diagnosis? Structure removed??management?? ** Intermittent, Burning or Stabbing Pain inone part of one breast + radiates to axilla + no palpable masses or lumips’and no enlarged LNs >> diagnosis? ** Lady + delivery 3 wks ago + redness/hotness/ tehderness over a segment of the breast >>> C/o ?? diagnosis?? Management? ** an old lady + concerned about breast CX (has family history) + found to have BRCA 1 gene mutation >> management?? i) PLAB 1 Course neGIT surgical topics: Inguinal hernias 2??? e Risk factors ?? Site 2? types?? Femoral hernia They are found more commonly in women ught to be = and lateral to the pubic tubercle and thus surgical v repaif.even if a evagomatic is necessary 2° © Asmall Bulge at the naval area © Common ia resolves after 2 0 3 years of age Epigastric hernia © Swelling in th between the umbilicus and the xiphisternum in | o. * Buldge atthe site of incision caused by an incompletely- healed surgical wound i Qe Repairing inguinal hernias: % “AEBS Nr» reas, + Symptomatic direct hernia : S| Repair (risk of future strangulation) *|rreducible inguinal hernia: urgent repairManagement of inguinal Hernias (If surgery is required) First time hernias : open inguinal hernia repair The inguinal canal is opened; the hernia is reduced and the defect isrepaired. +A prosthetic mesh placed posterior to the cord structures to reinforce the repair and reduce the risk of recurrence. This‘tmay be via af intra or extra peritoneal route. As in open surgery, 4 mesh is placed. However, it will typically lie posterior to the deep ring. Hernia Surgery ~~ Co y sea, |) XY c a ay . Heriotomy Herniorraphy Hesnloplasty < . ‘ Neckofthe sais Heritony temcray ligated andthe sa ‘ . eecsed ester Wall Posterior Wal Rep — Fear refed with Tes a ‘Done in Infants and or] Prosthesis: sm ieen Examoscope: ¥* Palpable mass at scrotum Reducible Impulse and enlarges on cough >> diagnosis? ** relation of inguinal hernias to pubic tubercle?? ** relation of femoral hernias to pubic tubercle??. ** A patient during check up, found to have an inguinal hernia >> management?? ** a patient with hernia + severe abd pain >> management? PLA Course sRahrirechiatus hernias clinical feature: chest pain, nausea, vomiting and burning sensation in the chest. ChestX-ray: present with an air-fluid level in a mass that is behind-the heart. PLA Course rahe:> Prenatal signs on ultrasound: © Polyhydramnios © Absent fetal stomach bubble SD ¥ If s(ispected during antenatal scans, a wide-calibre feeding tube is passed after birth and checked by X-ray to see if it reaches the stomach oa in the oesophagus. » If not subpected uke birth, the clinical presentation is: * Persistent sal ion L i me * Drooling = S.. * Cough and chokes when fed Ore * Distended abdomen > ) * Cyanosis & aspiration D 2 Examoscope: ** Pregnant lady, US shows, polvtyalSOlgast absent fetal stomach bubble >> diagnosis?? On ray would show the catheter is coiled in the o¢ diagnosis?¥ Abdominal pain that started centrally (Peri-umbilical) then shifted to the Right iiac fossa (MeBumey'S3i26) (Remember that umbilical region and appendicitis share the same dermatome (T10)) However, later on when there is peritoneal irritation, the pain will bEcome localised to its origin (Right iliac fossa). v Nadsea, Vomiting; Loose stools. v Tendepness, Rebound Tenderness over the Right iliac fossa. ¥ Fever, High WECs and CRP. ¥ #ve Rovsing’s sign > applying pressure on the left iliac fossa > pain is felt on the right iliac fossa. As a general rule for hemodynamically stable patients with suspected appendicitis: * Young fit male >> No imaging, straight to thedtte * Young fit woman >> At least an USS before taking to theatre to ensure No gynaecological cause of her symptoms * Anyone above age of 50 >> CT to look for cancer or perforation PLA CourseAnal fissures are longitudinal or elliptical tears of the anal mucosa * intense pain with defecation and FRESH blood streaks covering the Stools +The fear of pain is so intense that they avoid bowel movements (and-get constipated) and the constipation causes anal fissure - FERSGFORSEERAGREERE of the area - thus exam needs tobe done under anaesthesia” > 6 weeks Acute = < 6 weeks, chroni we pee saat ¥ Dietary advice: high-fibre diet with high fluid intake. ¥ Bulk-forming laxatives (1* line) >> if not tlérated then lactulose. v Lubricants such as petroleum jelly may be tried-before defecation. ¥ Topical anaesthetics & Analgesia.> Management of chronic ana fissure 6 west ¥ The above techniques should be continued. v Topical glyceryl trinitrate (GTN) is 1* line treatment >> If not éffective after 8 weeks >> secondary care referral should be cOnsidered for surgery (sphincterotomy) or botulinum toxin. ¥ Atenider mass neat the anus. ¥ Tend to-dévelop in patients with DM, Immunocompromised (e.g. Proloriged steroids intake), Crohn’s disease ¥ The lump is tender, swollen, erythematous and with throbbing pain that is wors¢ on sitting: v There is also feveriand constipation. Management ~ Incision * Drainage “Antibiotics (immediately to prevent the development of fistula) ** Perianal hematoma >> Analgesics, Self-resolving. ** Perianal Abscess >> Incision and Drainage (Acute Surgical Emergency) ) PLAB 1 CourseManagement “> Superficial = Simple = Low Fistula > Lay Open (Fistulotomy). ‘+ Deep = Complex = High = Fistula that crosses internal and external sphincters -> Seton Suture, Ligation of inter- sphincteric fistula tract. Siple Complex Examoscope: ** Patient+ central abd pain + then localized to RT iliac fossa + localized tenderness + high WBCs + nausea and vomiting >> diagnosis?? ** A patient / diabetic + tender mass near the anus + swollen, erythematous + throbbing pain + worse on sitting + fever and constipation >> diagnosis?? Managem *= A patient + severe pain in anus especially ori defecation + blood streaks on the stools and History of constipation >> diagnosis?? ** A patient / diabetic + tender mass near the anus # swollen, erythematous + throbbing pain + on examination a fistula is seen + doesn’t cross the sphinecters >> management? PLA Course rahe:They are associated with constipation and chronic straining, Haemorrhoids can be divided into: Y Internal : Originating from the vascular anal cushions >>> Painless, fresh rectal bleeding YExternal : Originating from perianal vessels (originate below the dentateding) >>> Pain, itching, and swelling Internal + Gradelli No’prolapse out df.anal canal, just prominent blood vessels + Gradellld Prolapse Seen when strains but spontaneously reduces and returns + Grade lil: Prolapse is séenwhen strains requiring manual reduction + GradellV: Prolapse is seen and cannot bémanually reduced ‘3nd Dogroo: Protapee with strain 4nd Degroe: Prolapse out and ‘anc have tobe puched back in ‘cannot be reduced or pushed back inManagement : a, Asymptomatic >>>> NO treatment regardless of the stage b. Conservative and medical management >> ¥ Digital replacement of prolapse haemorrhoid : relieves the pain “¥ Avoid straining and constipation >> laxatives or bulking agent % Local anaesthetic creams and ointments ¥ Surgical: Sclerotherapy: Injection-of a small volume of irritant solution the blood supply to the haemorfhoid eventually «| the size of the haemorrhoid overweeks Banding: Rubber barid like matérial is placed around the neck of the haemorrhoid which Constricts thé Raemorrhoidal vessels which result in shriveling of haemorrhoids Z Stapled haemorrhoid surgery >>> Uses aircular shaped stapling device to remove excess tissue above the haemorthoids and the remaining tissue is stapled inside the rectum Haemorrhoidectomy >>> Excision of haemorrhoids,under GASoa Pesnce ol tmorhets ren itr toh he Showy eam pose tele pat alce epatngtaioe sae = : analgesia and ice packs applied to the area to reduce oedema and inflammation. surgery especially if.patients présent within 72 hours. ERRBRIOREDBY is a scope that visualises the Rectum. In case of internal haemorrhoids (Piles), because interfial haemorrhoids are often too soft to be felt during a rectal é¥am, your doctor might examine the lower portion of your colon and rectum with an anoscope, proctoscope or sigmoidoscope. ° C Examoscope: ** Patient with passing of blood per’rectum while trying to defecate / staining of toilet paper with blood + On examination :no mass felt in the rectum / rectum is empty/ >> diagnosis?? investigation? ** during routine colonoscopy + patient folind to have grade Ill haemorrhoids >> management?? a= sRahinecThe small bowel lies more centrally while the large bowel surrounds the small bowel like a picture frame. Ahe small bowels have valvulae conniventes (small bowel folds from the 2" part of the duodenum & disappear near the distal ileum) / largé bowels have haustra (formed by circumferential contraction of the innérmuscular layer of the colon + start at the caecum and are seen all the way to thé rectum) The haustra are thicker compared to the valvulae conniventes of the small bowel. They also do hot completely transverse the bowels like the valvulae conriventes do. The maximum normatdiameter 6f the small bowel is 30 mm / the maximum normal diameter for the large bowel is 60 mm. Diameters larger than this are features of bowel obstruction. Small bowel obstructions are Mostly caused by adhesions in the developed world. The minority caused by hernias & neoplasia. Large bowel obstructions are mostly caused by colorectal cancers and diverticular strictures. ‘THE DIFFERENCE BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION Large bowel ‘Small Bowel “Peripheral (diameter 6 cm Central ( G4ameter 3 cm max) max) +Vudvuiae coniventae *Presence of haustration ‘ileum: may appear tubelessDiverticulosis -> Outpouches (outward herniations) of the colonic wall. Y precipitating factors: Low fibre diet + (age > 50 Years) Y Diverticulosis mainly affects the sigmoid colon (Lower Left Abdomen). ¥ Itis mainly Asymptomatic. b- Diverticulitis: isthe inflammation of a diverticulum. Sometimes, thestools can be impacted inside the diverticula leading to infection > “Clinical feataves of acute diverticulitis Rapid onset left iliae fossa pain and tenderness + Nausea, vorniting & Diarrhoea Lower gastrointestinal haemorrhage Features of infection such as-fever, raised WBC and CRP » — Investigations: CT of the abdomen and pélvis > Treament: vi mild, uncomplicated diverticulitis : Co-amoxiclav for 7 days or Ciprofloxacin and metronidazole if the patient is penicillin allergic v significant episode >>> hospitalaization and IV antibiotics (cefuroxime + metronidazole) c- Bleeding/ ruptured diverticula ) PLAB 1 CourseFever + Acute abdomen Fever and sepsis are caused by the leakage of the colon content into the peritoneum ~ Peritonitis Management: » Stabilise the patient by IV fluids, IV antibiotics > Urgent-admission tothe surgical ward. ¥ Take FBC “Haemoglobin” to see if blood transfusion is réquired, ¥ CRP to, confirm the presence of infection (diverticulitis), Y¥ Colonoscopy to correct and stop the bleeding source or ¥ even surgery if there is ardiverticular rupture. Diverticula PLA Course er:da sRahrnrecDifferential Diagnoses: 4 Sigmoid Volvulus > Sudden onset colicky lower abdominal pain + Abdominal Distension + Complete Constipation (No flatus or stools pass) + Vomiting. ¢ Inff{¥ssusception > Recurrent Non-specific Abdominal Pain. 4 BowelIschemia > The pain is not as severe as in a perforated diverticulurh (At least initially) + The localization of the pain is poor + Initially, only mild tenderness > No peritonitis “No fever, no severe guarding, rigidity. and tenderness” Until late stages + Hx of AF might be given. Examoscope: ** Sudden onset of severe [EFT lower abdominal pain + develops to generalized abdominal pain + guarding and)rigidity + FEVER + Tachycardia >>> diagnosis?? ** old patient + passing large amount of bright réd blood + Left lower abdominal pain and tenderness / worse after eating + Nausea +The patient’s diet is canned meat + NO rigidity or rebound tenderness + BP: 85/55 + Temperature: 38°C >> diagnosis?? Ihitial step? Management?“ Sudden onset of SEVERE abdominal pain and tenderness which exceed the physical signs. *% Abdominal distension + Absent Bowel Sounds. + The cause is abrupt, likely AF has caused emboli to occlude the blood supply of a large segment of the mesentery. Another possibility is that a patient of myocardial ischemia has developed: Hypotension which has caused low blood reaching the mésentery. % VBG-S,High Lactate % The reslted Gangrene is Irreversible. + treatment=> 02, IV fluids, Analgesics, Antibiotics > then, Urgent Surgery. Ischemic colitis. “ Transient interruption of the blédd supply to the colon. + “Gradual Onset - Over Hours”. “+ Abdominal pain and tenderness that‘are moderate to severe but not as severe asin acute mesenteric ischemia “ The cause is multifactorial e:g..Heart failure, shock, MI. Pain usually starts at the leftilide fossa ‘% Ischemic Colitis is commonest at the Splenic Flexure as this area has fewer collaterals (called: weak spots/ watershed). “ + Bloody diarrhea. treatment > Conservative or Surgical. i) PLAB 1 CourseAcute Mesenteric Ischemia __| Ischemic Colitis Sudden onset ‘Onset is gradual over hours VERY SEVERE pain and Moderately Severe. tenderness Hx of AF or MI Multifactorial (transient interruption of blood supply) e.g. HF. Usually starts at left iliac fossat Bloody diarrhea Urgent Surgery Conservative or Surgical Y Noisy hyperactive bowél’sounds, constipation. Y Chest X-ray would show} multiple air-fluid levels. ¥ The next best step > Urgent'tefer to surgical ward. Y Ina patient with intestinal obstructions, the emergency team’s role is to deliver IV fluids and analgesics and order X-ray and then send the patient tothe surgicalteam. v At surgical ward, they can decide whether the patient needs surgery or conservative maflagement. N.B: If bowel obstruction occurs due to advanced malignancy or as a complication of chemotherapy, conservative treatment is not an option as in most cases it fails. So, the treatment will be: Palliative colostomy. PLA CourseExamoscope: ** old patient + Heart failure/ MI + complaining of abdominal pain/ crampy pain / gradual onset + begun at the lower left abdominal qUadrant + bloody stool >> O/E: generalised tenderness + fever + rectal examination shows blood >>> diagnosis ?? Common site?? ** old patient presents + sudden onset severe and persistent abdominal pain + abdominal dissension / generalised tenderness + absent bowel, sounds. VBG lactate of 6 (high) + ECG > Atrial Fibrillation >> diagnosis?? ** patient + Abdominal pain, distension, tenderness, empty rectum, Noisy hyperactive bowel soundS,constipation + Chest X-ray shows multiple air-fluid levels >>> diagnosis??Risk factors © Age - Older age is the main risk factor for colorectal cancers ‘© Family history of colorectal neoplasia: carcinoma; adenoma under the age of 60 years Past history of colorectal neoplasm: carcinoma, adenoma Inflammatory bowel disease: Uleerative colitis, Crohn's Polyposis syndromes Hereditary non-polyposis colorectal cancer (HNPCC) Diet o Rich’in red meat and fat o Poor in fibre, folate and calcium Sedentary lifestyle / Obesity / Smoking / High alcohol intake History of small-bowel cancer, endometrial cancer, breast cancer oo000000 or ovarian cancer. ical features: * PR bleeding. Deep red'omthe surface of stools. * Change in bowel habit. Difficulty with defecation, sensation of incomplete evacuation, and painful defecation «asin fli fossa * PR bleeding. Typically dark red * Change in bowel habit * Iron deficiency anaemia may be the only elective presentation ) PLAB 1 CourseDisease more likely to be advanced at presentation Emergency presentations Up to 40% of colorectal carcinomas will present as emergencies. * Late bowel obstruction (colicky pain, bloating, bowels not open) * Perforation with peritonitis * Acute PR bléeding Examoscope: ** Old Patient, altered bowel habit, bleeding per rectum, anemia >> diagnosis??tumor marker? ** Risk factors for colorectal CX?? Greatest risk factors? ** old patient + anemia + mass in RT side >> diagnosis ??Hepatobiliary problems Condition Typical location of pain Notes rycolic Right upper quadrant Acute Right upper quadrant cholecystitis, Ascending —_—_—Right upper quadrant cholangitis ‘Acute Epigastrium, radiating pancreatitis through to the back Feeausea by aigalistone lodged in the bile duct ically provoked by eating a fatty meal v ler and inflammatory markers are normal ‘+ Inflattimation/infection of the gallbladder ry to impacted gallstones + Muse positive (arrest of inspiration on alesis ite RUQ) 4 Fever and tajsed inflammatory markers Ascending cholangitisis a bacterial infection of the biliary tree. Charcot's triad of Fight Upper quadrant pain, fever and jaundice Usually due to alcohol or gallstones Pain is often very severe. PLAB1 Course subscriber: darwistiaferds60@gmail.comUpper gastrointestinal tract problems Condition Peptic ulcer disease Typical location of pain Epigestrium Notes There may be a history of NSAID use or alcohol excess. Duodenal ulcers: more common than gastric ulcers, epigastric pain relieved by eating Gastric ulcers: epigastric pain worsened by eating Featyres of upper gastrointestinal haemorrhage may be seen (hdematemesis, melena etc) Lower gastrointestirial tract problems Condition Appendicitis Acute diverticulitis Intestinal obstruction Typical location of pain Right iliac fossa Left lower quadrant Central Notes Pala initial in the Central abdomen before localising to the right illa€ fossa (RIF). Anorexia‘is common. Tachycardia, low-grade pyrexia, tenderness jn’RIF and rébound tenderness Rovsing's sign more pain in RIF than LIF when palpating LIF Colicky pain typically in the LQ. Diarrhoea, sometiiiés'bloody. Fever, raised inflammatoty markers and white cells History of malignancy (intraluminal obstruction)/previous operations (adhesions) Vomiting. Not opened bowels recently noisy bowel soundsUrological causes Condition Notes Renal colic Loin pain radiating to Pain is often severe but intermittent. Patient's are the groin characteristically restless. Visible or non-visible haematuria may be present Acute Loin pain Fever and rigors are common as is vomiting pyelonephritis Urinary retention Suprapubic Caused by obstruction to the bladder outflow. Much more common in men, who often have a history of benign prostatic hyperplasia Gynaecological causes Remember, all women of a reproductive age with abdominal pain>>> ???? Typical location of Condition pain Notes Ectopic pregnancy Rightorleftiliac Typically presentS.with pain and a history of amenorrhoea fossa for the-past 6-9 weeks. Vaginal bleeding may be present inflammatory Bilateral lower _vaginal diScharge and cervical tenderness disease abdominal pain _Dysuria may-also be present. Fever >38° Nist09 of STI Ovarian torsion _Rt or Ltiliac fossa Usually sudden ofset of deep seated colicky abdominal pain. Associated with vomiting and distress. Vaginal examination may. reveal adnexial tenderness. Hx of ovarian cyst PLA Course ee TTAniine (Vascular causes Typical location of Condition pain Notes Ruptured Central abdominal Presentation may be catastrophic (e.g. Sudden collapse) abdominal aortic pain radiating to the or sub-acute (persistent severe central abdominal pain aneurysm back with developing shock) Patients may be shocked (hypotension, tachycardic] Patients may have a history of cardiovascular disease Mesenteric Central abdorninal Patients often have a history of atrial fibrillation or ischaemia pair other cardiovascular disease Diarrhoea, rectal bleeding may be seen ‘A metabolic acidosis is often seen (due to ‘dying’ tissue) PLA Course rahe:preoperative assessment of patients: Hemoglobin Level before Surgery: > Elective Surgery: if Hb is < 10 > Delay “defer” “Postpone” the surgery and for the anemia reasons first. 4 If Hb is< 8 and symptomatic patient - Transfuse Blood and also Defer thesurgery. > Emergency Surgery:= proceed If Hb is < 10 Proceed with the surgery. 4 If Hb is < 8 and syrptomatic'patient > Transfuse Blood and Proceed with the surgery. Patient with history of Ml: All patients with a Hx of MI should not undergo\"Elective” Surgery for at least 6 months after their myocardial infarction-attack. Examoscope: ** Patient, preoperative assessment of eléctive surgery >> DVT 3 months ago, Hg 12.5, History of MI 1 month ago >>> absolute Cl of surgery 2? ** Patient, preoperative assessment of elective suigery >> DVT 3 months ago, Hg 8.5 >>> course of action?? ** Patient, preoperative assessment of elective surgery >> DVT 3 months ago, Hg 7.5 >>> course of action??Pre operative prophylactic antibiotics Y It is known that colon and rectum are stores for fecal matters and thus during colectomy, there is a risk of serious infections. >>>> Therefore, should be given before any surgery that involves colon or rectum. ¥-common regimen: (Cephalosporin) “good coverage ‘against G+ve and -ve. “Good coverage against Anaerobic bacteria”. v en in the a of the first incision made or: Perioperative mavjagement of diabetes mellitus medicines : Preoperative management of antitoagulants: A patient is on warfarin and has surgery in a few days : Stop Warfarin and commence LMWH'=Cow Molecular Weight Heparin [e.g. fondaparinux, enoxaparif{>>>> RBBBRGBAAEIAE Preoperative management before splenectomy: vaccinations prior to splenectomy against the encapsulated bacteria meningococcus and pneumococcus; Due to the successful immunisation program of children, additional vaccination against Haemophilus Influenzde type b All patients with asplenia or hyposplenia aré recommended to receive the annual influenza vaccine >>> Due t6 the high risk of secondary bacterial infection The best time to administer this vaccine is in the autumn months (October or November) prior to the onset of the peak flu season. PLA CourseExamoscope: ** a patient undergoing colectomy >> what are the prophylactic antibiotics used ?? timing?? ++** patient type 2 DM on insulin & sulphanylurea + undergo abdominal surgery >>> what to do with his medications?? ** patient type 2 DM on gliptin + undergo abdominal surgery >>> what to do with his medications?? ** patient type 2 DM on sulphanylurea + undergo abdominal surgery >>> what to do with his medications?? ** A patient is on warfarin and fas surgery ina few days >> management??post operative complications: Complications of Thyroidectomy Damage or removal of parathyroid glands Features ??? Compressing: Hematomia, Tracheomalacia): Soon after the operation (in the first 24 hours) >>> Airway Obstruction. management : Open the surgical incision to evacuate the hematoma IF no response >>> intubation * Unilateral Injury to the Recurrent laryngeal nerve -> Hoarseness of voice * Bilateral Injury to the Recurrentlaryngeal nefve > Aphonia and Airway obstruction. * Injury to the External branch of (supéridr) laryngeal nerve ~ Loss of highpitched sound = (Dysphonia) = (Morte toned voice). “+ Thyroid Storm: Due to manipulation of the thyroid gland during a surgery in a patient with hyperthyroidist). Features: ??? + Wound infection (rare: 1-2%).Tonsillectomy Complications > Sey Bleeding Vs 2ey oF Reactive Bleeeing Examoscope: ** Patient + tingling, numbness, paraesthesia, involuntary spasms of upper extremities after Thyroidectomy >>> diagnosis? ** Patient + has just had Thyroid surgery + develops Shortness of Breath and Stridor >> best next step?? ** Patient after Thyroidectomy + hoarsness >> structure injured?? ** Patient after Thyroidectomy + aphonia and airway obstruction >> structure injured? ** Patient after Thyroidectomy + dysphonia>> structure injured?? ** A patient post Thyroidectomy, came to the ER with abdominal pain, reduced conscious level, tachycardia-and AF >> diagnosis? Drug of choice?? ttt for her palpitation?? ** patient bleeds 6 hours post-tonsillectomy >>> management? ** patient bleeds 6 days post-tonsillectomy >>> management?? Post operative bleeding: 1- Primary Hemorrhage: during thé stiygery or immediately after it. Management: Replacing Blood or réturn to theatre if severe. 2- Reactionary Haemorrhage: bleeding within 24 hours after an operation usually due to slipping of ligatures/ dislodgement of clots/ warming up of the patient leading toa rise in BP into normal. Example: Bleeding while in the recovery room. Management: replacing blood, wound re-exploration. 3- Secondary Haemorrhage : 1-2 weeks post-op (Usually related to infection)Post-operative urine retention: Post-Operative Infection: itis the most common complication following surgery. It does not matter what the type of the surgery is. Generdll, Post-op Infection \s SIRSSESSRIASREERBIESRGH seen, includifgslocal (wound) infection, lung infection (Hospital-acquired pneumonia) and so on Post-Operative(pain control? After an Open surgety: Patient ‘controlled analgesia with Morphine (it can be weaned off Jater). Post-op patient Respiratéry Alkalosisr + A patient on 100% facemask O2-develops respiratory alkalosis 4 Management: Redice thE 02 “ This is a case of hyperoxéria (Excess of 02 with Low CO2 due to rapid 02 delivery via the oxygen mask).post dural puncture headache: with spinal anesthesia used in patients in surgery: Cerebrospinal fluid (CSF) plays the role of a cushion to protect andsupport the brain. Leakage of CSF from the subarachnoid space through a dural breach >3Joss of this support >>> J intracranial pressure >>> headache. This headache appears or} the first or second day after a spinal anesthesia, is usually self limiting and resolves within a week. In the majority of caSes, oral hydration is enough if they can tolerate it >> IV fluids if not drinking enough. Fluids 4 the intracranialpressure >> s| the head pain Examoscope: ** after thyroidectomy, the patient was found hypotensive at the recovery room + blood oozing from the drain >> diagnosis? ** Post-op patient on 100% facemask oxygen >> (pH > 7.45), (PaCO2 < 4.7) and (PaO2 >14) >>>The next step should be ?? PLA Course ranme¢Anastomotic Leak: ¥ After hemicolectomy, one of the common and feared complications is > (Leakage of luminal contents at the site of anastomosis). ¥ It usually occurs 5 to 10 days after the surgery. V {Presentation: severe abdominal pain and tenderness over the site of the anastomosis + fever + reduced bowel sounds. v Risk factors: smoking, immunocompromised (e.g. prolonged use of steroids such as for RA, Asthma, COPD), rectal anastomosis, peritoneal. contaminatron). + investigation of choice: CT abdomen and pelvis ¥ Management:,(to preveht’contamination and sepsis) * Initial management involves NPO+ IV fluids + broad- spectrum antibiotic * Minor leaks: observation arid bowel rest alone, with potential for percutaneous drainage if needed. = For a major leak, afvexploratory laparotomy is required. formation of an abscess Following a closure of a stoma (colostomy), or at the site of surgical wound or skin sutures: > The development of painful fluctuating swelling + fever indicates -> Local Exploration is required. Sometimes followed by > Antibiotics + Drainag PLA CourseAcute Gastric Dilatation: »® ileus of stomach after an abdominal surgery (e.g. Splenectomy), as the blood supply of the stomach might be affected during the >>> accumulation of air inside the stomach clinically: epigastric fullness, tenderness, nausea and Vomiting, and gradually increasing abdominal distension and hypotension *** Why'ié there hypotension? When stomach massively dilates, it compresses the surrounding vessels, sometimes the aorta as well, so the blood pressure drops. management: Insértion of NGT.(Nasogastric Tube). >>>> The NGT will “deflate the stomach” and thus the signs and symptoms would rapidly improve. Examoscope: ** patient + smoker + After hemicolectomy >> 5 days after the surgery + abdominal pain and tenderness + fever + reduced bowel sounds >> diagnosis? ** patient + Following a closure of a storfia+ fever + painful fluctuating swelling at the site of surgical wound or skin Sutures >>> diagnosis?? ** 2 days post splenectomy + a patient develops epigastric fullness, tenderness, nausea and Vomiting + abdominal distension + hypotensive and Tachycardic >>> diagnosis??Paralytic ileus Paralytic ileus is the cessation of Gl tract motility Causes Prolonged surgery, exposure and handling of the bowel Peritonitis and abdominal trauma Electrolyte disturbances Anticholinétgics or opiates Immobilization, a O"0 0 0 Clinical features * Nausea, vomiting & abdominal distension Abdominal X-ray: air-/fluid-filled loops of small &/or large bowel Treatment Y Nasogastric tube to empty.the stomach of fluid and gas if the patient is nauseated or vorpiting Y Adequate hydration by intravenous infusion (‘drip and suck’) v Maintain the electrolyte balance v Reduce opiate analgesia ¥ Encourage the patient to mobilize Y Lactulose or erythromycin may help stimulate bowel movementspelvic abscess > May occur asa general complication of IBD, or asa complication of abdominal surgery. > Diabetes mellitus is a risk factor > The most appropriate diagnostic test: a CT scan. % Management: drainage and antibiotics. Examoscope: ** After surgery + Abdorninal Distension, Nausea, Vomiting, Absent Bowel Sounds + Erect Abdominal X-ray -> air-fluid levels/ dilated small loops >>> diagnosis?? Management?? ** 2 weeks after colectomy + abdominal pain + fever+ diabetic patient >>> diagnosis Elevated WBCs and CRE This is expected post-operatively >>> dil that is needed is to > Repeat WBCs and CRP after 24hours. Stress hyperglycemia: PLA Course rahe:Cx screening programs: 1- Colorectal Cancer Screening: Fecal Immunochemical Test (FIT). 60-74 YO every 2 years in England And 50-74 in Scotland 2- 40-70 YO annually 3- Cervical{Cervix) Caneér Screening: Pap smear?Cytology, HPV 25-49 YO S every 3 years 50-64 > every years. Tumor markers: > Breast Cancer CA 15-3 > Ovarian Cancer CA 125 > Pancreatic Cancer CA 19-9 > Colorectal Cancer CEA “Carcirioembryonic Antigen” > Prostatic Cancer PSA “Prostate Specific Antigen” > Liver HCC & Teratoma (testicles, Ovaries) AFP “Alpha-fetoprotein” » Testicular Seminoma LDH (Lactate Dehydrogenase) > TTF 1 (thyroid transcription factor 1) :pulmonary adenocarcinoma > Thyroid cancer: thyroglobulin (Tg): indiaté recurrent or metastasis of thyroid cancer after a successful removal of the thyroid (during follow-up).But they are not félppful in the DxAngiosarcoma: Purple discolouration surrounding a nodule are suggestive of angiosarcoma. ha ps las JS Aihe gl ade oseld And present with a new mass >>>> recurrence is the DD number 1 subscriber: darwi 560@gmail.comSurgeries: Laparoscopy: the anatomical structure(s) to be pierced while inserting a port (trocar) at the midway point between a is and anterior superior iliac spine is Laparoscopic Surgery Laparoscopic surgery, also called minimally invasive surgery (MIS). Iso known as: ‘CpBand aid surgery hole surgery ‘a modern surgical technique in operations are performed far fror ion through small incisions 515 cm) elsewhere in the a oe sO Laparoscopic cholec pierced is Examoscope: ** structure to be pericied during laparoscopic cholecystectomy?? ** structure to be pericied during laparoscopic procedures, between the umbilicus and ASIS i LAB 1 Coune subscriber: darwishahmed560@gmail.comComplications of laparoscopic cholecystectomy: * abscess or a collection: high CRP and WBC. >>> A GiISEaB would be an ideal investigation. “bile leak: in situations where the laparoscopic cholecystectomy was difficult (e.g. high BMI patient, many previous abdominal ‘gperations causing adhesions, complications during surgery) >>> are ideal in this situation * ERCP >>5 If very high Suspicion of bile leak * MRCP >>> If moderate suspicion of bile leak * CT abdomen >35)IF low suspicion of bile leak and high suspicion of abscess i) PLAB 1 Course ne