CASE-BASED

TEACHING NOTES
SURGERY CBT

Date Topic Lecturer Date Topic Lecturer

01-Sep- 1)AAA - case, images and Prof Leahy 29-Sep-15 18)Orthopedics-fracture Mr Denis
15 discussion management Collins
02-Sep- 2)Diverticular Disease Mr Deasy/Mr 30-Sep-15 Clinical Problem solving Waqas/Michael
15 Hamid
30-Sep-15 19)Gall bladder disease
02-Sep- Clinical Problem solving Waqas/Michael 01-Oct-15 Surgical Grand Rounds Surgical teams
15
03-Sep- Surgical Grand Rounds Surgical teams 01-Oct-15 CBT Prof Hill
15
03-Sep- Approach to emergencies Gozie Offiah 02-Oct-15 20)Melanoma/ Mr Barry O
15 reconstructive surgery Sullivan
04-Sep- 3)Jaundice Prof Murray 05-Oct-15 21)Acute abdomen Prof Hill
15
07-Sep- 4)Intracranial TBC 06-Oct-15 22)Haematuria (Renal TBC
15 Haemorrhage Tract ca&urolithiasis)
08-Sep- 5)Colorectal Cancer Ms Faul 07-Oct-15 23)Post-op TBC
15 Complications
09-Sep- 6)Breast Malignancies and Mr Power 07-Oct-15 Clinical Problem solving Waqas/Michael
15 Reconstruction
09-Sep- Clinical Problem solving Waqas/Michael 08-Oct-15 Surgical Grand Rounds Surgical teams
15
10-Sep- Surgical Grand Rounds Surgical teams 08-Oct-15 CBT Prof Hill
15
10-Sep- CBT Prof Hill 09-Oct-15 24) Oesophageal & TBC
15 Gastric Cancer
11-Sep- 7)Venous disease [PVD] Mr Naughton 12-Oct-15 25)Intestinal TBC
15 Obstruction
14-Sep- 8)Spinal Surgery Mr Prasanna for 13-Oct-15 26)Acute Scrotum & TBC
15 Prof Bolger testicular Lumps
15-Sep- 9)Acute urinary TBC 14-Oct-15 27)Hernias TBC
15 retention/prostate
16-Sep- 10)Inflammatory Bowel Ms McNamara 14-Oct-15 Clinical Problem solving Waqas/Michael
15 Disease
16-Sep- Clinical Problem solving Waqas/Michael 15-Oct-15 Surgical Grand Rounds Surgical teams
15
17-Sep- Surgical Grand Rounds Surgical teams 15-Oct-15 CBT: 28)GI Stomas Prof Hill
15
17-Sep- CBT Prof Hill 16-Oct-15 29)Radiology Waqas
15
18-Sep- 11)Peripheral Arterial Mr Moneley 19-Oct-15 30)Thoracic Surgery TBC
15 Disease
21-Sep- 12)Skin Malignancies Mr Nadeem Ajmal 20-Oct-15 31)Renal transplant and TBC
15 AV fistula
23-Sep- 13)Thyroid-Approach to Prof Hill 21-Oct-15 32) Lower GI Bleed TBC
15 management
23-Sep- Clinical Problem solving Waqas/Michael 21-Oct-15 Clinical Problem solving Waqas/Michael
15
24-Sep- Surgical Grand Rounds Surgical teams 22-Oct-15 Surgical Grand Rounds Surgical teams
15
24-Sep- CBT: 14)Pancreatitis Prof Hill 22-Oct-15 33)CBT: Vascular Prof Hill
15 Surgery
25-Sep- 15)Upper GI bleed Mr Ali Naqi 23-Oct-15 34)Revision Waqas
15
25-Sep- 16)Necrotising Fasciitis
15
28-Sep- 17)Orthopaedics-Elective TBC
15 case

Tuesday 1/9/2015
1.AAA

CASE
HPC
67, M
incidental finding fr abd exam pulsatile expansile abd mass
kept under sveillance (yearly CT scan)
no cplications
no pain, no emboli
0.4cm increase fr Jan July
new dissection flap in the AAA sac
scheduled and consented for operations after scans

young Marfans, Ehler Danlos

triple AAA VS N: expansile( fingers pushed to the side transversely & APly) crudeLy estimate size
complications:
o rupture
likelihood based on size
px: acute back pain
Ix: gold standard is screening cheap & to avoid radiations
acute: CT angiogram to make sure none of contrast is leaking out, US is for surveillance purposes
o emboli
trash foot (through distal embolisation of microemboli) blue spots on distal extremities
acute ischaemc limb (by forming emboli)
***know pre renal, renal, post renal for EVAR: pre-renal harder surgery

RF
Ex smoker for 50yrs
Age, Male
HTN
FHx: SAH cud be berry, traumatic or vascular
Diabetes, not so much a RF per se ,but contributes to PVD (wh is a RF)

CT angiogram
At level of renal artery: aorta diameter N
AAA (6cm)
At level of below aortic bifurcation (aneurysm)

Pseudo: trauma and iatrogenic (puncture fr angiography for cardiac stenting, IVDU etc), infection
Pain: from compression on nerves, annoying discomfort if not asymptomatic VS severe flank pain in acute rupture

Arteriosclerosis due to:

Atherosclerosis
BP chronic HTN
Calcification

MX
Atherosclerosis (VASCULAR case)
Carotid: TIA or stroke
Aorta: low back pain or asymp
Peripheral arterial dzs in legs: IC or rest pain
Qx to ask is the same!
symptoms
assocd: carotid artery atherosclerosis, angina, MI
RF: smoking, high chol, HTN, fam hx, diabetes

Wednesday 2/9/2015
2.DIVERTICULAR DISEASE

CASE
HPC
A 75y/o lady presents to the ED with complaint of lower abd pain L

DDX
Diverticulitis: fever (X), bleeding per rectum (X), constipation (Y)
UTI: easy to r/o dysuria(X), freq (Y, on water tab), smelly urine (X)
Obstruction: pass wind/ bowel open?, distended bowel? (Y) Vomiting? (X)
Colorectal ca: not likely but must r/o weight loss (X), blood in stool (X), tenesmus (mass)
Hernia: activity (weightlifting), chronic cough or comorbidities, severity of pain, mass in groin?, vomiting? (X), not passing wind? Hx
of bowel surgery?
Ischaemic: < likely on L, severity (8-9), recent surgery?, jelly-like black stool, RF AFib
IBD blood in stool, mucosal stool
IBS, PID, renal colic, constipation
Ovarian: abscess, rupture, cysts

Hx
SOCRATES
Colicky pain: obstruction of a viscus
Malaise, unwell, sweating + dehydrated
HR 125/min, BP 80/50mmHg, RR 24/min, T 38.1C, SaO2 96% [EWS]
o unstable, hypovolaemic (cold peripheries, no fever) or septic (fever) shock (early, cold peripheries, later warm peripheries)
o SIRS!
2 or > of:
pyrexia >38 or hypothermia <36
tachycardia >90/min
tachypneoa >20/min or requirement for mechanical ventilation
WCC>12 or <4
Acutely altered mental status (newly added)
Blood glucose >6.6 in absence of diabetes (newly added)
***shock increased glucose: decreased insulin sensitivity increase blood glucose
o SEPTIC SHOCK
SIRS + documented source of infection
Severe sepsis if altered organ perfusion or evidence of dysfx of one or > organs
CVS (lactate > 1.2mmol/L)
Resp (PaO2 / FiO2 <30 or PaO2 < 9.3kPa)
Renal UO < 120ml over 4hours
CNS (GCS < 15 in absence of sedation / neurological lesion)

EXAM
generalised tenderness & guarding marked on LIF
cough: no hernias
present bowel sounds
DRE: soft faeces, no mass, no blood

MX
Resuscitate: O2, 2 large bore IV lines, take bloods, fluids
Investigations:
o high CRP & WCC
o FBC Hg, pL (may need to go to theatre), neutrophils
o U&E urea & Cr (dehydration), Na, K, Cl (derangements correct)
o ABG/ VBG Lactate (part of sepsis6)
o Amylase r/o pancreas pathology, slightly increase doesnt mean pancreatitis
o Urinalysis bedside (r/o UTI)
 o LFTs liver pathology
Imaging:
o ECG
o Erect CXR: free air VS PFA: does not help with ddx
o CT Abd: black (air): pneumoperitoneum from perforated bowel may be seen w CXR but > obvious w CT
MX
IV Ab: abdominal infection: tazocin
Urine input output hourly monitoring!
CT Abdomen confirm dx
Control source of sepsis
Surgery laparotomy & Hartmanns procedure (most commonly done after emergency sigmoid resection)

Friday 4/9/2015
3.JAUNDICE

CASE
85y/o, yellowing of skin, itching, weight loss, dark urine, night sweats

HPC
sudden onset
painless VS painful distinguish obstruction VS other pathology
fever Charcots triad ascending cholangitis
pale stools, dark urine
steatorrhea chronic pancreatitis (fat digestion problem)

RF
fam hx rare, depends on popn
alcohol: alcoholic hep, chirrosis (decompensated)
IVDU
meds: chemotherapy drugs: DILI (drug-induced liver injury) augmentin, methotrexate
travel hx: Hep A(foodborne) & E (oral, pork products liver failure)
infections: EBV (cause hepatitis but with no jaundice), malaria, leptospirosis
sexual hx: Hep B
***try to figure out this jaundice is due to chronic pre-existing liver dzs VS new onset pathology

IMPRESSION
malignancy?
o ca of head of pancreas, cholangiocarcinoma, mets in liver blocking biliary tree
gallstones?
PSC
o small intrahepatic ducts blocked, autoimmune, AMA (M/PD2 subtype +ve: PBC), ANCA (not diagnostic), MRCP
(DIAGNOSTIC: areas of structuring & dilatation)
IgG4 +ve cholangiopathy?
o elderly, jaundice, pruritus TX: corticosteroids
LNs compressing on biliary tract?

INVESTIGATION
Bloods
FBC
o thrombocytopaenia leukopaenia (bile digests fat & fat-soluble VIts (ADEK), K interferes with INR

Imaging
US INR can be low
o large spleen, nodular liver
EUS (strictured ampulla biopsied) can get to lower CBD
TAUS: CBD VS veins use Doppler which will be present in portal veins not CBD
CT-show calcified stones can go straight to MRCP
ERCP
o Risk: pancreatitis (1%)
o Both diagnostic & therapeutic: cannulate ampulla, wire confirmed to go to pancreas VS biliary tree using Xray, dye
contrast light up biliary tree, brushes takes cells, repeat ERCP and place plastic stents in first (not metal stucked
into tissues)
Monday 7/9/2015
4.INTRACRANIAL HAEMORRHAGE
Refer Neurosurgery for the final med exam lecture

Tuesday 8/9/2015
5.COLORECTAL CA
HPC
Collapsed, followed by 3 episodes of vomiting
3months hx or rumbling sensation in abdomen
1month hx of worsening weakness & low energy
9kg weight loss over 3 months despite N appetite

EXPECTED FEATURES
timeline
associated pain majority painless
tenesmus uncomfortable feeling of incomplete evacuation RED FLAG!

RF
Environmental factors
IBD: UC>Crohn
Genetic susceptibility: 100% - all cancer has mutations/ loss of genes
o mismatch repair gene inactivation, microsatellite instability : BAT26
o APC-mutation & loss, KRAS-mutation, SMAD2/4-loss, TP53-mutation & loss
o 10-15% familial (Amsterdams criteria to determine if pt should be tested for familial risk of colorectal ca: synchronous (2
cancers present at the same time) VS metachronous (2 cancers present at different time))
o ex: Lynch syndrome/ HNPCC, FAP, Gardeners
Polyps
o Adenoma
o Sessile or pedunculated

PMH: nil
PSH: Varicose vein removal & partial gastrectomy for PUD (no complications)
MEDS: No meds & NKDA
FHx: Bro died from colorectal ca at age 78
SHx: Non-smoker, drink 3ppints per day

EXAM
pale, pallor of palmar creases & conjunctival pallor
midline abdominal scar from previous PUD surgery
bowel sounds present
no organomegaly
no other masses felt

DDX
colorectal ca
anaemia
recurring PUD
GI lymphoma
diverticulitis
IBD (expecting diarrhea)
gastric ca rumbling points to small bowel or colorectal, not so much upper GI
BPH

INVESTIGATIONS
Blood
Hb low, others N
Others
FOB negative
CT TAP obstructing proximal ascending colon tumour with ileo-colic nodal involvement
CT brain N outrule intracerebral bleeding further use of med mght be CId if present
OGD hiatus hernia & gastritis (commenced on PPI)
 Colonoscopy circumferential fungating tumour in ascending colon and non-bleeding internal haemorrhoids

DX
FOB: looks for blood in stool +ve: called for screening colonoscopy +ve: refer for surgery
Screening test (FIT test) starts at 70y/o
o earlier if has fam hx & symptomatic
tenesmus (rectal), bleedg PR [mixed-rectal area or x? bright red- haemorrhoids or tarry black?]
change in bowel habit for >6weeks, weight loss, symptoms of Fe defy anaemia, Peutz Jegher syndrome (intussusception-rare!)
colonoscopy 10yrs back, pain, L (obstruction-sigmoid because narrowest, bleeding)

STAGING
TNM
CT TAP metastatic or not
CEA biomarker- only if tumour produces it
Colonoscopy report
Able to reach caecum?
Can see appendix orifice?
Can see terminal ileum?
Any mucosal abN?
Types of polyps if present
hyperplastic polyps: usually in sigmoid & rectum, present in numerous no, 20-30
adenomatous polyps: mosaic pattern
villous (finger-like, flatter) VS tubular VS sessile serrated (can lift with saline & snare it around n away, higher risk, very flat, R colon,
difficult to pick up, followed up > closely because progreee > quickly!) (if low grade dysplasia, can completely remove in 5yrs,
colonoscopy in a yr if small, if large in size, clear them all and redo colonoscopy in a yr to look for any recurrence, if has ca in polyps:
colonoscopy in a yr unless has invasion)
Tumour if present:
circumferential
obstructing
where?
tattooed distal to the lesion: marked for laparoscopy
biopsy taken? Results: type of ca- adenoca usually, if adenoma(go back & rebiopsy- might miss the adenoca area)

TX
Surgical (open or laparoscopic)
Adjuvant or neoadjuvant
Haemorrhoids
o high fiber diet, increase liquid, refer if persist

MX
Non-metastatic
Resect
Blood supply. Why important? lymphatic follow blood supply, need to be cleared, anastomosis for good blood supply, no tension &
good approximation of the two sites
Based on location
tumour in ascending colon R hemicolectomy
hepatic flexure
middle of L colon extended R hemicolectomy
L side: L hemicolectomy: > difficult because marginal/ colonic arteries are short
APR: tumour far down, low in rectum, anal canal resected too with end permanent colostomy (for good clearance cylindrical
margin) VS Hartmanns procedure (residual rectal stump, reversible resection)
Metastatic
LN
liver: resection if only one lobe affected, done same time with colon resection
lung

Surgical options
1)Total Mesorectal Excision (TME)
removal of rectum and its mesentery (fatty tissues & LNs- removal of the mesentery improves prognosis and reduce risk of distant
mets) (rectum only: anterior resection)
2)Total mesocolonic Excision

Colon surgery VS
Rectal surgery
1)Rigid sigmoidoscopy to measure length from anal verge to colon
2)Lower 2/3 tumours in rectum (rectum is 50cm) give radiotherapy

MRI of pelvis: to assess location of tumour & stage of (T1, T2- surgery) T3, T4- radiotherapy first to shrink tumours)
Pts with radiotherapy will always has stoma RT will damage anastomosis
Smaller space: if cancer grow out towards lateral wall, will take N tissues (kidneys, small bowel, bony pelvis) with u if do not give RT
first shrink improve margin
 Chemotherapy: enhance radiotherapy

Post-op
ERAS protocol
mainly in colorectal surgery
high carbohydrate before surgery & two mornings post-op: enhance recovery & mobilisation

PROGNOSIS
Stage I: 90%
aim to dx patient at earlier stage

Qx for pts with colostomy

Do u still have an anus? NO: APR, Yes: colectomies or Hartmanns
Temporary ileostomy/ de-functioning loop ileostomy indicated due to if theres a leak from anastomosis, prevent sepsis
Wednesday, 9/9/2015
6.BREAST MALIGNANCIES AND RECONSTRUCTION
Refer Breast Cancer lecture

Thursday, 7/10/2015
BREAST DISEASE
CASE 1
HPC
38y/o F 3 week hx of breast lump on outer quadrant of L breast while in shower
No FamHx
RF
Smoker Painful lump (not painful)
Breastfeeding High BMI
Early menarche Fam/ personal hx of ovarian ca
Prev hx of breast ca HRT
Nulliparity OCP
***No RFs Benign lesion?

EXAM
Lump

INVESTIGATION
Mammogram
not recommended <35, do US instead)
nice rounded well demarcated edges : fibroadenoma
Histology
confirm fibroadenoma

MX
Depends on:
Size: >2.5-3cm
Location: On bra line
Symptoms: symptomatic
Excise

Triple assessment
Clinical
HX & exam
Radiological
Mammogram
US
MRl
Histological
FNAC
Core biopsy
Wire excision biopsy

CASE 2
HPC
74y/o F with a 3wks hx of rash on L breast
noted tiny blood discharged in her bra a week before
PMH
Breast ca invasive ductal ca 17yrs ago: lumpectomy & axillary clearance + chemo T on same breast

What else would you like to know?

Clinical
Hx
From rash or nipple? From nipple
Lumps? No
Nipple inverted? No, lil bit crusty
Assymmetry of breast and nipple? No
Itchy? No
Exam
Rash: Multiple 0.5-1mm small erythematous flat rock hard lesions around crusted nipples with no secondary signs
Radiology
Benign findings: N breast tissue with focal areas of skin thickening with altered echogenicity at the site of skin lesions
S4/S5: ca
S2/3: fibroadenoma
S1: benign
*R in radiology
*B in pathology

Histology
Skin biopsy
punch biopsy of cutnaeous lesion
findings:
o Intact, slightly hyperkeartotic, but otherwise unremarkable epidermis wh overlies a dermal tumour nodule
o grade 2 ductal carcinoma
o ER +ve: tamoxifen
o PR: moderate to strong +ve
o HER 2: 0

MX
Mastectomy for recurrent IDC
VS Pagets: oedematous rash around nipple

CASE 3
HPC
6months before with daughter who was dxd with breast ca
2weeks later:
70y/o F with swollen L arm

Where will u go from here?

DDX
Complication of axillary clearance? Never had surgery before
DVT
LNpathy
Mets from breast

Clinical
Hx Exam of breast
Progressive? Y- arm to fingers now Fungating tumour of nipple crusting nipple
Functional? Difficult Peau de orange: puckering of skin around nipple
Breast lump? Not sure Tethering of skin: Coopers ligament
Axillary nodal enlargement

Mammogram
Irregular mass

MX
Straight to mastectomy for comfort measures + palliative care
Died after a year

Prognosis
 Poor

Stage
IIIc
CT TAP for mets

MX
Medical
Surgical
Axillary surgery
SLNB: blue dye and radio tracer
o Frozen section of SLN takes 20minutes
o Stain nodes malignant or not
o If +ve axillary clearance
***Next: see how far has the dye travels
Axillary clearance levels
Level 1
Level 2
Level 3: axillary clearance (high comorbidity)
***Lymphadema: major complication

Post-surgery
Haematoma drainage
Drainage stay for 3-5 days
Haemovac drain: 400ml evacuation Jackson Pratt drain (closed suction)

o Usually has blood in

o Preferred
o Patient goes home with this
Breast conserving surgery or also called:
Wide local excision
Lumpectomy
Segmentectomy
Partial mastectomy

Who get breast reconstruction?

Full mastectomy
Breast conserving surgery (depends)
Risk reducing surgery: pts with BRCA 1 or 2 positive without breast ca
Breast not properly

Partial or full
Immediate or delayed

Implants
Silicone/saline
Expander (blow it up every 2-3weeks): for pts with small breast can blow up to any size pts want
Exam: feel implants look for any leaking implants

Flap (autologous tissue reconstruction)

Source Free: no blood supply Pedicle: with blood supply
Back Abd DIEP (Deep Inf Epigastric TRAM
latissimus dorsi (LD) flap : pedicle DIEP Perforator)
can be uni or bilateral Buttocks TRAM
Thigh SGAP SIEA
 TUG: inner thigh IGAP

Exam
Always look for scar on thigh, back, abd

Reconstruction prior to nipple tattoo

Exam
Always ask patient if it is a fake nipple
WLE can also cause fibrosis of nipple & skin around nipple (normal: breast tissue and nipple still intact)
Double mastectomy (Angelina Jolie surgery- soft tissue removal with skin intact): horizontal scars on both breast base,
exam for local recurrence (no lumps on soft tissue not breast cause no breast there)
Lumps on pts with mastectomy (mastectomy scar, bulging with puckered skin)
o Haematoma
o serroma
***Futher evaluate with US
Friday, 11/9/2015
7.PERIPHERAL VASCULAR DZS

CASE
56y/o M c/o small black spot on tip of 2nd toe of his R foot & referred to Beaumont for CT angiogram
HPC
c/o calf pain: cramping pain, spread to feet
o worse on walking, relieved by rest, progressed to rest pain before admission
o cold for months permanently
limited mobility uses crutches
reduced pulses in both feet
hx of multiple ulcer
reduced sensation in R foot

PMH
T2DM & hyperlipidaemia at age 34
HTN
IHD, MI in 2009
Ongoing PAD in both legs- reduced mobility
Asthma
Gastritis & esophagitis

FHx
Mother RIP late 60s fr vasc dzs
Father rip age 78 MI
Grandma had DM & lost both legs
Sister has DM

SHx
Ex smoker: 27pack years, stopped 6yrs ago
Never drank
Diet goos
ADLs impaired

Qx
Symptoms
o claudication: pain at rest?
o **rest pain: occurring at night time, at sole of foot, relieved when hang feet at the end of the bed (vasodilation of
veins in leg), sharp pain VS burning(neuropathic) critical ischaemia req urgent intervention
o where is the pain? Back of calf
o progression of walking distance? 20m
o ulcers
RF
o Diabetes
o Smoking
o Hyperchol
o Heart dzs
o Male
 o Buergers dzs not a RF
Exam: all toes necrotic with gangrene formation

INVESTIGATIONS
Vital signs
FBC - HB, PVC, MCV, MCH anaemia
Blood glucose
Doppler present/absent pulses
ABI
o 0.7: IC
o 1
o >1: diabetes, vascular dzs
Exercise test
CTRA
MRA (gold standard, depends on pts), narrowing of SFA & dilatation distal to it, diseased common iliac artery
MX
Surgery- amputation

TUTORIAL
Hx
Claudication? indicating vasc dzs
VS
Spinal pathology worse when standing up

Duration
Progression, if has deteriorates or not

Rest pain?
Tissue loss (ulcer, necrosis)? distinguish from venous & neuropathic ulcer!

RF

Investigation
Blood test anaemia, RF (hypercholesterolaemia, diabetes)
o ABI
o N-1
o 0.7-IC
o 0.3-ischaemia, necrosis
Exercise studies + ABI before & after exercise
MRA/CTA

Tx
Best Medical Therapy (BMT)
Aspirin
Statin (cholesterol-lowering + vasodilatation-improve perfusion + anti-inflammatory)
BP monitoring (ACE-I)
exercise: improve symptoms

Vasodilator: Pletal (cilostazol)

Intervention
Endovascular (90%) ballooning up artery
Complication: access related bleeds, AV fistula formation, dissections
+ve: lower morbidity & mortality than open
VS
Open
anatomical bypasses: replicate N anatomy, aorto-bifemoral or popliteal artery
extra-anatomical bypasses: fem-fem bypass, axillo-bifemoral has diseased artery ex: occluded iliac branch
Monday 14 Sept 2015
8.SPINAL SURGERY
CASE
MK is a 38y/o woman who presented with a 3 day hx of intense lower back pain radiatg down the right leg, on a b/g of
back pain post-RTA 1yr ago managed with physiotherapy and analgesia. What else would you like to know?
Red flags
Cauda equina syndrome symptoms
Unexplained wt loss
Fever
Pathological factor
Hx of weight loss
Age: young (malignancy) VS elderly (mets, osteoporosis)

DDX
Non-spinal cord symptoms below spinal level
Cauda equine syndrome
Spinal pathology < likely
Trauma
Compression
Malignancy
Haemorrhage

HPC
Sharp intense pain 10/10, progressively worse
Bowel incontinence, anal leakage (mostly mucus), she cant hold it for long
Mild saddle anaesthesia
No hx of cancer, lost 5kg intentionally
No associated fever, no recent hx of trauma
No indication of immunosuppression immunosuppressed > prone to spinal infections (especially in diabetes) (back
pain, tenderness, fever)

NEXT STEP
Neurological exam: tenderness on pcussion of spine + LL exam
R vibration altered, clonus, movements 3/5
Which level? L4/L5
DRE: both reduced sphincter laxity & anal wink

INVESTIGATIONS
Blood: blood cultures (infection- if fever, rigors), anaemia, blood glucose (diabetic)
ECG & MRI/ CT spine (one or another)

MRI results:
Lateral view of lumbosacral MRI (CSF bright T2-weighted)
compression at level L4/L5
disc herniation
cauda equina syndrome

TX
 decompression
discectomy: risk (bleeding, infections-IV Ab, damage to surrounding structures-dura (CSF leak))
Surgery
if present with compression of nerves + instability if decompress nerve, might exacerbate instability
do not do surgery in every cases
if asymp, if only back pain: do not do fusion
back pain, tenderness, MRI show new collapsed fracture surgery
kyphoplasty?- blow catheter up: new tech: good for compression fracture
Sciatica
<6weeks: conservative
>6weeks: LA + local epidural injections into sciatic nerve
sciatica without neurological signs most probably iatrogenic from interventions
Post-op
monitoring after surgery: ask about 3 pain (pain pt presented with, associated disability & autonomic fx)
Ex: Sciatica leg pain, foot drop, bladder fx
Tuesday 15/9/2015
9.ACUTE URINARY RETENTION/ PROSTATE

CASE
MH, 76y/o 1hr post TURP
TURP performed for BPH causing chronic urinary retention
**BPH: not a clinical dx, a histological dx: hyperplasia of prostatic cells

HPC
Acute urinary retention in Jan 2015
An episode of incomplete emptying & retention suprapubic pain & P lasting 3hrs relieved after placement of
urinary catheter in Beaumont
Prior has several months hx of:
o urinary leakage small amounts, nothing bother him or caused him any embarrassment
o urgency after sitting for prolonged periods of time: eg having to rush to bathroom after an hr drive
Denied any hx of hesitancy, nocturia, dysuria
Of note:
o he has had no back pain, no neurological deficits in LL & no recent UTIs or infections or any recent operations
o he is currently on escitalopram for depression & anxiety
***importance of neurological assessment?
***drugs: SSRI increase tightening of pelvic floor

MEDS
tamsulosin
alpha blocker increase risk of cataract surgery (intraoperative floppy iris syndrome- suspensory ligament becomes
floppy increase risk of complication (greater pain afterwards, increased hospitalisation))
relax smooth muscles around bladder neck & prostate allow pee easier 1st line in voiding problems
used in patients with moderate systems
no effects on surgical decision
escitalopram, zopiclone, atorvastatin, lactulose (since Jan for constipation: a RF!)

RF
Smoking: a RF for prostatic carcinoma not BPH
His long term catheter has been changed on 3 occasions due to irritation and discomfort increase risk on infection &
increase of likelihood of bladder denervation (lazy bladder). Catheter changes bladder form active to passive!
o self-intermittent catheterization in chronic & spinal injuries: empty bladder, remove catheter let bladder
works on its own
TURP (done with GA or sometimes LA) complication:
o TUR syndrome
o Transient over activity of bladder house condition!
PSA: June 2010 5.3 (acceptable provided DRE is done)
o >70: PSA <6.5
o 60-70: PSA <4.5
o 50-60: PSA <3.5
o PSA: a protein specific to prostate, but x to prostatic ca. bigger prostate = > PSA.
o Based on age-ranged or density (> or equal to 1/5 bladder size?)
now undergoing slow bladder irrigation
Causes of urinary retention
Acute Chronic
BPH BPH
Prostatic carcinoma Scarring from previous urethral or prostate surgery
Urethral stricture Pelvic malignancy
Med: anti-cholinergics, TCA, anti-arrhythmics Spinal injury
Post-op scarring
Infection: prostatitis Post volume residual greater than 3mths > 200mls?
Neurological: cauda equina syndrome due to denervation of bladder
Acute on chronic retention retention up to 1/2L, not able to empty fully later
Prognosis: depends on P but chronic is associated with renal failure > than acute
Indications for surgery:
Recurrent UTIs
Bladder stones
Obstructive nephropathy
high P systems

TX
Acute:
Decompression
urinary catheterization- CI in pts who have had recent urologic surgery e.g. radical prostatectomy
suprapubic cytostomy & catheter if failed urinary catheterization or CI e.g. recent urologic surgery, acute prostatitis,
urethral stricture dzs, severe benign prostatic hyperplasia, or other anatomic abN

Long term:
Medical
alpha1-adrenergic antags: Tamsulosin (Flomax)
5alpha reductase inhibitors: finasteride reduce conversion of testosterone to DHT
***DHT is a substrate that allows prostate enlargement blocked: shrink to 30-35% + reduction in PSA by half by
6months (check if pt is on this drug or not! It may mask actual PSA level)
Surgical
TURP
prostatectomy
o radical: done for cancer, taking unblocked resections
o simple: millens prostatectomy, umbilical incision, take unblocked resections

Classify retention: does not alter immediate tx/mx

Painful VS painless
High P
o poor compliance in bladder (change in P / change in vol)- as bladder fill, P starts shooting up instead of maintained
at low P ex in spinal injuries or spina bifida hydronephrosis acute renal failure req dialysis
VS low P
Spontaneous: usually acute
VS precipitated: generally acute (same outcome), high fluid or diuretics-drink intake
Voiding lower urinary tract symptoms
o hesitancy, straining, dysuria, intermittent flow, terminal dribbling (outpouching urethra), weak flow
VS storage lower urinary tract symptoms
o urgency, freq, nocturia
***can be overlaps between two, do test:
measure electroactivity of bladder with two electrodes into urethra & one into back passage
pt with BPH obstruction of prostatic ca: steady truout at the end shows overactivity

IPSS (international prostate symptom score)

0-7: mild
8-20: moderate
21-35: severe
***monitor progression: improvement or deterioration, allow communication to patients
Wednesday, 16/9/2015
10.IBD

HPC
Mrs SC 52 y/o F, admitted w 4wk hx of RUQ w central radiation, intermittent sharp graded 8/10
+diarrhea in 4 wks, worse last 2 wks, mucus & blood mixed w stools, porridge make pain better

PE
tiredness, nausea, abd tenderness, bloating, fecal incontinence last 2 wks

PMH
crohns- resectn of term ileum, ileocaecal valve, appendix & prox section of large colon may still have some
bg crohns left (passing blood per rectum)
endometriosis
gall stones

MEDS
furosemide
***not on ASA can not tolerate but usually given to prevent Crohns dzs recurrence

ALLERGIES
penicillin

SHx
32py smoker
does not drink
no recent travel
married 2 children
mom die d fr bowel ca at age 62
father died fr MI at age 52
bro die at age 52

DDX
acute flare of crohn
IBS
Bowel ca
GE

Blood test
Amylase 34
Hg 13.9
WCC 8.1 CRP 6.9
INVESTIGATION
Stool culture -ve
ECG
PFA
Awaiting MRE (magnetic resonance enterography): done with oral contrast visualize area of inflamed
bowel (including small bowel) VS stricture or active dzs
+Can do small bowel follow tru
+Can do capsule endoscopy (if no strictures!)

IMPRESSION
IBS component complicating background IBD

MX
IV hydrocortisone
Enoxaparin prophylaxis
PLAN
Discharge
Switch IV hydrocortisone to PO prednisolone tapering dose for 2week

CROHNS
Age Peak in 20s & 60s, 70s
Presentation Abd pain Across lower abd
(hindgut pain)
Vomiting (if dev strictures)
Can present with signs of
obstruction (caecal valve prolapse
due to thickened terminal ileum)
Strictures & adhesion
Crampy pain around periumbilical
area + change in bowel motions +
mouth ulcers + hx of perianal dzs +
jt dzs
Pathology Full thickness transmural
inflammation (anywhere in bowel)
granuloma
Fistula
adhesions
Colonoscopy Findings Skipped lesion
Surgery Usually ileocaecectomy
UC
Young: toxic megacolon affecting whole colon
but usually most common in caecum thinnest +
high P: dilation of colon (transverse colon
usually maximally dilated) dxd on PFA (bloody
diarrhea, may x have prev dx) tx with meds
if inflammatory marker goes up + peritonitic
surgery
Reduced bowel motion significantly bowel
might have stop working instead of resolved
symptoms. Careful!
No granuloma
Not across whole bowel wall (starts in rectum &
works all the way back to ileum backwash
ileitis (MRE)
Usually Total abd colectomy

True love & witts score

Severity of IBD
Assess weight loss: important!

MX
Toxic megacolon Surgery precedes dx (before perforate!)
UC Regularly scoped to look for dysplasia: higher risk of malignancy pouch + loop
ileostomy for 3 months ileostomy can be reversed
Crohns Irreversible stoma in most cases
Strictures Inflammatory respond to meds (anti TNFs, immunomodulator)
Fibrotic do not. Refer to surgeons. Can do terminal ileactomy + anastomosis. Medical
team follow up from there. Large proportion dev endoscopic dzs (recurrent dzs) just prior
to the anastomosis (at small bowel just prox to anastomosis with large bowel) not
symptomatic, mostly do not req surgery

Tx:
Stricture plasty: open up longitudinal & close it up transversely or by putting 2 bowel
together larger lumen
 Not removing any part of bowel. (if already have prev bowel resection: need at least
220cm small bowel to survive, in neonates: <.) (< small bowel left hypertrophy + > villi
+ > absorption ability)
Surgery
osubtotal colectomy
ototal abd colectomy: fr caecum to upper mid sigmoid above rectum + rectum stump left
+ end-ileostomy RISK: rectal stump blow-out? Present with signs of infection
Chronic UC Medically mx
+ pelvic surgery after 6months (pt gets well, symptoms improve, Hg need to get back to N)
J-pouch (IPAA- ileal pouch anal anastomosis) make new rectum fr small bowel
4-9 bowel motions in pts with J-pouch but CONTROLLED vs urgencies if left untreated

Not done in Crohns. Why?

NO POUCH IN CROHNS risk of recurrence ***Only done If no evidence of IBD or
perianal dzs
Friday, 18/9/2015
11.PERIPHERAL ARTERIAL DISEASE (PAD)

CASE
JJ 85y/o for presented to vasc clinics 2 days ago for exam of bilateral venous ulcers & for wound dressings.
Ongoing for 22years, with worst instance in 2012
***>75% of LL ulceration = venous!

HPC
Ulcer hx
duration
first symptom that brought him to notice the ulceration
any other assocd symptoms
Pain
Pain at ulcer site at lower bilaterally medial aspects, 6months ago, sharp pain prior to ulcer before skin breaks out
Relieved by physiotherapy, exacerbated by walking
No pain follow dressing
No cramping or tingling sensation: PVD or neuropathy
Previous instances of varicose eczema
Attended CRC for 11days in 2012 for ulcer tx: daily ice-pack application & potassium permanganate solution
(antiseptic)
Several previous infected ulcers
o recurrent infections, bleeding, change in surrounding skin & discharge (foul smelling oozing discharge, how much
discharge, change in discharge in terms of colour and smell superimposed infection)
o progression: persisted all along for 22 years or times of improvements in between

PMH
Stroke
Pseudoaneurysm in PA
Decompensated CCF
RHF
Pulm HTN
Afib
HTN
Hyperlipidaemia
CVA in 2013
Hypothyroidism
***mainly arterial dzs might have arterial component too

PSH
Had removal of varicose veins (to reduce venous HTN form his superficial system)

FHx
Daughter: varicose eczema & has had varicose vein removed

SHx
 Alcohol 3pints/wk
Former smoker: quit 40yrs ago
Reduced activity, due to breathlessness
Vasc nurse change dressings at home 2x weekly

COMPLICATION
Marjolins ulcer
o Malignancy of venous ulcer (SCC)
o Presentation: non-healing ulcer (never improve) with suspicious clinical features do biopsy to rule out
malignancy

EXAM
bilateral dressings & bandages from ankle to knee
not significantly obese
gait slow but steady w walking stick
skin changes: ulcer
Inspection of ulcer
VENOUS ARTERIAL NEUROPATHIC
Presentation Painful Painful Painless
Site Gaiter area Toes, foot and Pressure area
ankle
Size & shape Large, irregular in medial side Small,
Increasing in circular
size?
Edge Sloping edges (healing ulcers) Punched out Punched out
**Rolled edges in malignancy (humps on the sides)
+whitish epithelialization on the edges (healing)
Exudate level High Low
Base Granulation tissue: composed of loose connective Necrotic Bone or muscle exposed
tissue with neovasc- new capillaries & blood vessels +
neutrophils, appear reddish (indicated healing
Yellow or greying slough of exudates or necrotic tissue
on top (infected)
Surrounding Cellulitis? inflammed angry-looking
skin Chronic lipodermatosclerosis
Chronic ischaemia: shiny skin
Pulses
Capillary refill
Examine for peripheral neuropathy
Examine draining lymph nodes
-inguinal if LL (below inguinal ligaments)
superficial (shape of T drainage) or deep

Palpation
bilateral femoral pulses present
ideally palpate all 4 pulses of LL
ABI: if suspicious of venous or arterial
In venous ulcer dzs: If ABI if already very bad, we do not want to compress further more (need decompression to
reduce venous HTN)

Mx
Aim Surgery
To reduce venous HTN dissecting SFJ
Bone protection & wound healing perforating veins removed to reduce venous P
o Compression dressings (has lesser P as it goes up) debridement if necrotic & extensive wounds
o ex: 4 layered Profore graduated compression if not epithelializing skin graft
bandage if infected, put on maggots & larvae
non-adherent dressing over ulcer + wool bandage negative pressure wound dressing if chronic wound
crepe bandage
blue-line bandage Prevention is surgery & exercise
adhesive bandage to prevent the other layers from
slipping
Elevate legs improve oedema
 Ab tx, only if ulcer infected take swabs for C&S +
silver dressings

Q&A
Can have venous ulcers without varicose veins due to damage to DEEP venous system
Aetiology
o Traumatic, acute ulcers
o Infection: SA
o Venous VS arterial VS neuropathic VS malignant
o Auto-immune: pyoderma gangrenosum
Trendelenburg Test
o To determine SFJ competency
o Deep system- femoral draining to aorta
o Superficial-femoral SFJ
**perforating vein communicate bet deep & superficial incompetent superficial congested (natural flow from
superficial to deep reversed)
Monday, 21/9/2015
12.SKIN MALIGNANCIES

Histopathology results
Centrally on skin surface, well circumscribed, slightly raised black lesion measuring 7x6mm

MALIGNANT MELANOMA
Definition: a malignant neoplasm of melanocytes
RF
o Pale skin , freckles, fair hair
o multiple benign naevi
o atypical naevi
o sun / UV exposure
o presentation: ABCDE
asymmetry
border
colour
diameter
examination

Staging
GLASGOW system BRESLOW thickness
oMajor: change in size, irregular pigment o depth of tumour, measure in mm from epidermis to the max
or outline depth of tumour
oMinor: Diameter> 6mm, inflammation, o define prognosis
oozing/ bleeding, change in sensation <1mm 95-100%
>4mm 50%

Types
o Superficial spread
o Nodular
o Lentigo
o Acral

Mx
Surgery Adjuvant therapy
Immunotherapy Radiotherapy
CT scan to r/o mets disease if IFN in mets or recurrent dzs Important in mets dzs &
>1mm thickness Ipilimumab palliative symptoms control:
oWide local excision if perform vRaf (new) bone/ brain mets
w a margin of 1-3cm
oSLN biopsy if tumour >1mm in
 absence of regional LNpathy

NON MELANOMA
most common (1/3 of skin cancers)
BCC & SCC

Embryology
Ectoderm epidermis, skin appendages
Neural crest cells melanocytes , Schwann cells
Mesoderm (most bottom layer, can spread laterally) Dermis, hair papilla
> superficial = non-melanoma (SCC originates from keratinocytes)

Actinic Epithelial (keratinocytes) dysplasia

keratosis Small no progress to SCC

Tx
Surgery
Cryotherapy
Topical
oDiclofenac (Solaraze) : inihibit COX pathway
o5-FU: cytotoxic (Efudex)
oImiquimod: increase IFN alpha (Aldara)
oIngenol Mebutate (Picato): new, sterol derivatives
SCC in situ Malignant tumout of keratinocytes
(Bowens Small no dev to SCC
dzs) Beware of non-steroid responsive dermatosis
Aetiology
oUV, carcinogens (arsenic), HPV16, chronic wound or dermatosis

Tx
oTopical 5-FU & imiquimod
oCryotherapy
oCurettage
+LA, with defined border, full thickness together with layer of fat excised
oExcision
oPDT (photodynamic therapy)
only done in Beaumont-photochemical rxn with methylaminolavulanyl acid (AVL)-<
invasive, used in BCC as well)
oRadiotherapy
oLaser (CO2, destructive)
SCC malignant tumour of keratinocytes
locally invasive
potential to mets
describe: raised lesion with keratotic ulcerating centre, sloping margin (VS BCC raised rolled
edges)

RF
oUV, chronic wounds (Marjolins ulcer), scars, burns, ulcer/ sninus tract, SCC in situ,
immunosuppressed pt, palmar & palmar ulcer
Poor prognostic indicator
osize>20mm (large)
othickness >4mm, Clark IV (deep)
operineural invasion
 olymphatic or vascular invasion
ohistological differentiation
ohistologic subtype
ogenetic profile (EGFR)
olocation = ear or lip (midface)
orecurrent lesions
oimmunosuppression

Tx
osurgical excision (1st line in SCC): margin 4mm if lesion <2cm, margin 6mm + if lesion >
2cm
*if pigmented lesion, 2mm incision margin, for NMSC, 4mm
oMohs micrographic surgery/ excision with histological control excise send off to lab
soak in paraffin layer visualize first layer (in vertical sections) excise layer by
layer until no > malignant cells seen
oradiotherapy
ocurettage & cautery
BCC malignant tumour of basal cells of epidermis (stratum basale)
raised rolled edges, well defined margin, pearly
rarely mets
slow growing, locally invasive

Aetiology
ogenetic predisposition, UV, carcinogens-arsenic, Gorlins syndrome (PTCH1 mutation-
medullobastoma in childhood, benign fibroma in uterus & heart), immunosuppression
Poorer prognosis
olarger size, location central face, histological subtype (morphoeic, infiltrative,
micronodular), pernineural/ perivascular invasion, immunosuppression
o biopsy if not sure adequate margin excision or not

Tx
oSurgical excision
standard excision with 4-5mm margin
MOhs micrographic surgery
oDestructive techniques
Curettage & cautery, cryosurgery, CO2 laser, imiquimod, PDT, radiotherapy
oSystemic therapy
new: Vismodegib (new): inhibit Hedgehog activation & subseq SMO-GLI pathway
oFlaps
flap usually from pre or post-auricular and supraclavicular
non-vascularised area use local flap

EXERCISE
Pic1 Ulcerated 2cmm lesion on leg, surrounding skin erythematous & scaly SCC
Mx: full thickness skin graft
Pic2 Keratotic 2cm on area of actinic (sun-damaged)
Dx: actinic keratosis
Pic 3 Single lesion on scalp of bald man about 2cm diameter, well defined margin, ulcerated centre,
exam for pus, bleeding & mets, mobility
Pic 4 Single non-healing wound preauricularly 1cm, ulcerated Bowens
Pic 5 Raised-edge single lesion (nodule) 1cm, keratotic plaques in centre kerato acanthoma
(histology controversial: regress spontaneously usually
Pic 6 Ulcerating fungating lesion on lower lip of a farmer SCC (excise with cm, full thickness
of lips)
**follow up of SCC: NICE guidelines every 3months in first 2 yrs, n every 6months for 5 yrs
Wednesday, 23/9/2015
13.THYROID: APPROACH TO MANAGEMENT

EXAMINE THIS PATIENTS NECK IN THE PERSPECTIVE OF THYROID GLAND

General
Bilateral neck swelling
No skin changes
From front:
o Ask to swallow water + stick tongue out: moves with swallowing

Palpate (from behind): are you sore anywhere?

I can feel a swelling in the area of the thyroid gland
Is the thyroid gland enlarged?
Is it nodular or not?
Is there >1 nodule? multinodular goiter? (in most cases, if solitary nodule would have been operated
already!)

ask to swallow: palpate thyroid gland: moves upon swallowing

LN papillary thyroid carcinoma (usually present with LNpathy)
***sub mental, submandibular, pre auricular, post auricular, deep cervical chain, supraclavicular

Percuss
I would like to percuss for retrosternal extension
Put arm above shoulder narrow thoracic inlet (clavicle, spine of scapula) compress venous system
EJV becomes > prominent succussion [Pembertons sign]

Chest
trachea: central?
auscultate: thyroid bruit (in hyperthyroidism)

Qxs
DDX

EXAMINE THIS PATIENTS THYROID STATUS/ DISEASE

Start with hands
Hands:
 o HYPER: tremor, thyroid acropachy (clinical clubbing with radiological findings of erosion underneath
periosteum), palmar erythema, warm hands, moist /sweaty skin, pulse (tachycardia or AFib)
Arm: proximal myopathy
Eyes:
o Lid lag (delay of eyelid coming down)
o lid retraction (superior eye lid retracted back [staring appearance] due to sympathetic overdrive
stimulating levator palpebrae superioris muscle innervated by nerve of Muller)
o exophthalmos (deposit of fat in orbit that pushes eyeball forward Graves disease. Surgery will not
reverse exophthalmos)
o proptosis (prominence of eyeball)
Legs: pretibial myxedema

***HYPO: vv

Surgical Indication
risk of cancer
compression of airway
cosmesis
failed medical therapy
Post-op
Test for any residual tissue
o radioactive iodine taken up by thyroid cells
if patient is on Eltroxin will falsely prevent iodine uptake need to stop prior to RAI but may
render patient hypothyroid!
o measure thyroglobulin

THYROID DISEASE

CASE
M,Admitted via ED 62 days ago? Reason: Not feeling right
***lost?
o What has happened over the 60days
o Have you had any operations?
o Is there any major medical conditions I shouldve known of?
o What drugs are you on?

Appetite loss
Weight loss of 2stones
Diarrhea
Agitated
Breathless
Palpitations? No Has had defibrillator before
Thursday, 24/9/2015
14.PANCREATITIS
CASE 1
F, 78
(Last Monday) 2days admission following:
HPC
since end of July (chronic) cannot hold food in unwell
(vomiting) opain: chronic (since end of July) L constant abdomen relieved
+++weight loss with medication
+++constipation oblockage
+++can pass gas oobstruction
mitotic lesion of gastric oscan done in Navan a month ago
poor food intake, only fluids
Suspected (recurrent) gall stones

PMH
gall stones
PSH
cholecystectomy (GB out??) & stone removal once here in 2007, stones came back once a year in July
have you had a US scan done? Y
have you had a MRI scan done? Y, in Mater to remove stone. When was the last time?
A endoscopic test in Beaumont ERCP

SUMMARY
Mrs. Mc Donald a 78y/o lady admitted on Monday with a history of upper abdominal pain associated with nausea &
vomiting, constipation and weight loss persistent since July

DDX
Acute GB dzs
Pancreatitis
PUD

INVESTIGATIONS
Appropriate blood test: LFTs, amylase
US
OGD

Baseline haematological
o FBC: WCC (infective or inflammatory)
& biochemical parameters
o U&E
CASE 2
Sharon, 47
HPC
Abd pain +N&V
o upper abd +dyspepsia
o sharp, radiates to the back +change in bowel habit? N
o came on suddenly +are u taking any Rennie? (Irish antacids) N
o very severe +when did u last drink alcohol? N

DDX
Pancreatitis
o Severity
RANSON
GLASGOW

***LONG CASE pass/fail Q(x)s

DVT: dx & mx
low urinary output: mx
fluid replacement in unwell patient
complication of central line (pneumothorax)

Friday, 25/9/2015
15.UPPER GI BLEED

CASE
M, 58
ED 28 Jan

HPC PSH
coffee ground vomiting: slow laparotomy for DU in 2011: oversewing of gastroduodenal artery
bleeding ongoing for a while
malaena(dark tarry stool) MEDS & ALLERGY
o dark, foul smelling freq NSAIDS for headache
o no evidence of fresh blood not compliant to meds
6 episodes haematemesis NKDA
o no evidence of fresh red blood
collapse S/FHx
epigastric pain Alcohol abuse- 60units/ week
confused Increased over previous 3/52, since death of wife
Smoking 20py
No fam hx of PUD or upper GI pathology
DDX
Bleeding PUD
Oesophageal varices (4%) alcoholic liver dzs
Oesophagitis, gastritis, duodenitis
Mallory Weiss tear
Malignancy rare (GIST-50% present with bleeding)
Dielufouy lesion- torturous mucosal arterioles bleeding
AVM

Other queries:
appetite loss

PHYSICAL EXAMINATION
HR N, O2 sats N tachypnea, hypotensive, T N
Pale, diaphoretic, tremulous
GCS 14/15 GCS <8: unconscious, (respiratory) muscle not working airway collapse
***BP normal but hypotensive on beta blocker??
***UNSTABLE: Bleeding + SBP <100
 Abd: soft, non-tender, no guarding/ rigidity, DRE: malaena
CVRESP: N

ED MX
Stabilisation Investigation: Bloods Investigations: Others
ABC FBC- Hg, pL, cross & U&E: renal impairment from
2 large IV bore (14: 3-5minutes saline), (15: match at least 6units hypovolaemia
6-7minutes) (if unstable) ABG
o IV fluids: Hartmanns Coagulation profile
o still hypotensive colloid LFT CXR
o if normotensive, keep on crystalloid ono free air under diaphragm
Catheterize: monitor urine output kidney OGD
end organ: reflects haemodynamic stability olarge ulcer at D1
Vitals + pulse pressure (SBP-DBP) narrow ono adherent clot
if not responding to resuscitation ono visible vessel
PPI infusion: 80mg STAT + 8mg/hour
continuous infusion decrease rate of Admitted to ward for close
recurrence monitoring and repeat bloodwork
Pabrinex + Librium
PROGRESSION
Hb 7.6 after 6units of RBC infusion
Continuing malaena
Drowsy & confused
o Pabrinex & Librium continued
Repeat OGD
o active bleeding: injected with adrenaline (injected in 4 quadrants in ulcer tamponade bleeding)
o injection therapy successful
***other options: coagulation with diathermy, clip, angio-embolization (CT coeliac angiogram)

Angiogram showed unusual arterial anatomy to duodenum

o tortuous inferior branches from common hepatic artery (glue/lipidol to 1 st branch)
o if he had become unstable overnight: for emergency laparotomy & distal gastrectomy
o BUT embolization was successful
open duodenum see active bleeding (posterior > likely to bleed, anterior ulcer > likely to perforate)
posteriorly = gastroduodenal artery stitch above, below & anterior vessel

MX
Day 13 of admission: doing well, Hb 8.7
Discharge with:
o triple therapy: esmoprazole 40mg bd, clarithromycin 500mg tds, amoxicillin 500mg tds
o thiamine 100mg tds
o galfer 1 tab od
Advise to stop drinking & NSAID avoidance
Follow up in OGD in 10/52 monitor ulcer healing
Represented 10days later with worsening epigastric pain
Acute pancreatitis 2y to alcohol

CRITERIAS
Rockall score
oevaluating severity & predicting mortality
osurgery indicates: initial score > or = 3., final score > or = 6
ohigh mortality a/w scores >8
Blatchford score
odetermine benefits of interventions
Baylor bleeding score
 PUD OGD Forests classification
orecurrence likelihood (Ia-2b high risk)

OGD DECISION
Unstable & cant stabilize
OGD ASAP!
Can be stabilized
OGD within 24hours

MX PRINCIPLES
ulcer bleeding or not
stable or not
unstable = urgent OGD find active bleeding
still unstable angiography embolization
no facility laparotomy (not an option in unstable patient!!)
Mallory-Weiss tear Varices
resuscitation resuscitation
start on PPI PPI
OGD find bleeding tear OGD + variceal band ligation unresolved still Sengstaken
inject or banding Blakemore tube inflation to tamponade artery later do TIPPS by
unresolved still radiologist (stent insertion) [if not working disjunction of OD
angioembolisation or surgery junction (circular stapler?) and re-anastomose] or liver transplant
16.NECROTISING FASCIITIS
Hx PE
HPC Pulses present weak & thread on both legs
Pain & swelling of R lower leg Boggy/ crepitus
+redness & swelling Very hot
bitten by insect while jogging Extremely tender
390c, diaphoretic, tachycardic
PMH
TIIDM x 5yrs, not well controlled
PSH
Appendicectomy 14
SHx
Smoke 10/day

DDX
Necrotising fasciitis cellulitis
Thrombophlebitis osteomyelitis
DVT ruptured baker syndrome
Lymphaedema compartment syndrome

INVESTIGATIONS RESULTS
FBC: WCC WCC raised
ESR, CRP pL low
Swab for C&S INR increased
PFA CRP increased
Septic screen: blood cultures ***infection
D-dimers

Who to call in ED?

ICU: septic shock radiology do not order kill pts
general surgeons: necrotising fasciitis oosteomyelitis: bone scan
anaesthesia: DIC onecrotising fasciitis: dx
plastic surgeons skin graft microbiology

MX
Stabilize:
 MOVI- monitor, O2, vitals, IV line
Sepsis 6
Give: Take:
O2 bloods (lactate + FBC)
-fluids: bolus of 250mls 5-10min another blood cultures (swab/tissue/pus)
250mls call anaesthetist NA urine (strict fluid balance, in & out)
-Ab: clindamycin + tazocin + flagyl (metronidazole)
IV access 2 wide large bore
IV Morphine 5mg
O2 100%
Paracetamol 1g QDS
Take blood cultures Ab

TX
Debridement: every tissues/ muscles or vasculature necrotic
**can also get necrotizing fasciitis on abd (Seen on diabetic, at areas of insulin injection)
dress wound: Vaccuum-assisted Closure (VAC)
Skin graft: split thickness skin graft

Radiology findings
XRay black (gas). Grey (musc). White (bone) gas in muscles
CT: pocket of gasses
Monday, 28/9/2015
17.ORTHOPAEDICS: ELECTIVE CASE

CASE
F, 80 4days post hemi-arthroplasty following mechanical fall recovering well with physiotherapy

HPC
severe pain on L groin heavy dragging, 10/10, no radiation, movements make it worse
no neurological disturbances- numbness, visual disturbances

chest pain

no hx of falls of prev dx of OA (no pain, stiffness, weakness)

no walkg difficulty in past
no DM
no slippery floor

no hx of HRT

PMH
HTN since 16years, Afib sin ce15yrs, hysterectomy

MEDS
Warfarin, Amiodarone 20g OD, bb blocker & ARBS, Eltorxin 50mcg
NKDA

FHx
no RA, OA, mom had MI at age of 54y/o, died fr stroke at 78

SHx
Lives in bungalow with stairs
Non smoker and occasional drinker
Wear glasses for short-sightedness

DDX
Mechanical fall
 OA
RA
CVA
Gait disorder

PE
Inspection Vitals LL Exam
Sit comfortable on chair RR 17, HR 110, On compression stocking
CVS on neck BP111/69, T67, CVS: Neurological: intact sensation
Urinary catheter N, RESP: N L hip externally rotated with reduced ROM
Walking frame

INVESTIGATIONS
Bloods
Group n cross match
Coag prof
TFTs
RFTs
Other
ECG
CXR of hip: neck of femur displaced
MX
On admission Post-op
IV lines Analgesia
ATLS- CAB Ab
Analgesia LMWH
Vit K to reverse warfarin effect 5mg (INR on Hip Xray
admission >2) Temperature monitoring
Warfarin stopped Bowel movement & urine output monitoring
TED stocking
Give tranexamic acid on day of surgery Urine catheter still in due to immobility
Vit D
Physiotherapy

COMPLICATIONS
Avascular necrosis of femoral head
PE, DVT
Non-union
OA
o Stages of OA: joint space narrowing subchondral sclerosis subchondral cysts osteophytes
formation bones know one trick

CLASSIFICATION
Garden Classification*
Hip Xray
Intracapsular fracture of NoF
Angulated or x?
Template ball a 25mm diameter metal ball as a scaling marker (to standardize size of bone)

***Common joints to be asked in exam: HIP KNEE SHOULDER

PHYSICAL EXAM
General exam of LL
Symmetrical, muscle wasting, fasciculation, walking supports, scars, swelling

Ask to walk
 normal gait
antalgic: trendelenburg with pain
trendelenburg gait: due to weakness of abductor or post hemiarthrosplasty, can have hip replacement on
both legs!

Lying supine
Thomas test: fixed flexion deformity: lordosis of lower back abN
bends knee: N hip flexion
adduction & abduction
tone
passive flexion internal rotation 10degrees (look for resistance), external rotation

knee
o effusion: if small effusion, empty (stroke hand medially upwards), if large effusion do patellar tap
o apprehension test
o medial & lateral collateral
o stability: bend knee to 10degree, hold under knee, move knee sideways
o ACL/ PCL: drawer test, pen test: (PCL tear, diminished or nil angle between pen & knee)
o Lachman test: ACL

Tuesday, 29/9/2015
18.ORTHOPAEDICS: FRACTURE MANAGEMENT

CASE
Fracture of the radius HPC
M, 39y/o ED fall from roof Pain
26ft land on concrete floor severe, electric fall radiate to elbow 10/10 relieved
impact on R body by paracetamaol
pain on R wirst, ribs & pelvis swelling on wrist jt
no head injury, no vomiting, no alcohol use loss of fx, movements limited, bruising

PMH/PSH
laparotomy in 2002 stab injury

MEDICATIONS & ALLERGY

15mg methadone, 2mg temazepam
NKDA

F/SHx
Gardener, right-handed, non drinker, smokes 80cigs/day (50pack years)

PHYSICAL EXAMINATION
Vitals stable, GCS 12
R hand finger movement limited to pain

Xray
Wrist: Smiths fracture (distal fragment of radius facing palmar aspect)
Radius ulnar N
Carvical, lumbar, thoracic spine N

MX
Admit Monday ORIF
Analgesia K-wiring fixates bone
IV fluid ***usually would put plates in
Ted stocking
 Fracture reduced (morphine & propofol)

PROGRESSION
1day post-op
worsened pain. refractory to analgesia
Physical examination
wrist in backslab n swollen
tenderness on r pelvis & ribs

TX (for any fracture)

Reduce: analgesia + anaesthesia re-allign
Maintain the reduction
Stabilisation
rehabilitation

Other possible injury

Head injury
Calceneus fracture
Spinal fracture (lumbar especially)
deceleration injury
o aortic dissection

30/9/2015, Wednesday
19.GALL BLADDER DISEASE

CASE 1
51y/o (occupation) admitted 3days ago due to acute cholecystitis with b/g of gall stones removed by ERCP
in August

HPC PMH
epigastric sharp pain constant radiation go to back In August for ERCP
relieved by analgesia & lying on L side no hx of GORD, recent endoscopy ve
pain associated with jaundice, pale stool, dark PSH
urine and non-bilious womit Fractures of mandible
no fever or rigors MEDICATIONS & ALLERGY
no excess alcohol intake PPI & gaviscon, NKDA
no fam hx of liver or IBD SHx
Non-smoker, occassional drinker

Q/A
How to prepare patient for an ERCP
Explain procedure & consent
o under sedation
o risk: bleeding, infection, perforation, mild pancreatitis (most common!)
NPO
Check appropriate meds
Check coag screen is N
Check FBC is N (pL)
Put IV cannula in L arm (doc on L patient, patient faces doc)
Prophylactic Ab

Laparoscopic cholecystectomy
Explain the procedure
Ask if patients understand why they are undergoing the procedure
Do they understand the procedure
oGA oSmall risk of infection
oKey hole surgery to remove GB oAs in other operations, risk of bleeding
 oAbout 45mins oCan go home as a day case
oMight consider open surgery for safety oWill have 4 incisions sutures are
oVery rarely can damage duct to GB, can be repaired easily absorbable: no need to remove

CASE 2
Examination
A tube in RUQ (or upper or lower half) drains into a bag (cholestostomy tube)
Content of bag is either:
ofaeces
ourine
obile
ohaemoserous
opus

Hx
80 y/o M admitted 7weeks ago c/o pain on stomach
Never smoke
PMH NAD

DDX
Perforated GB with sepsis collection of bile in GB and outside drained if GB heals over do laparoscopic
cholecystectomy if not, may do open but risk (elderly, sepsis) might mx conservatively

Friday, 2/10/2015
20.MELANOMA RECONSTRUCTIVE SURGERY

CASE
76 M presented in OPD with history of resection of MM 17months ago

HPC
smooth round hard nodule w crustgon surface
apigmented
no assocd symptoms
didn notice any chanage
no LNpathy
UV exposure, lived in America & swam outside
Got bad sunburn as a child

PMH
HTN & hypercholesterolaemia

PSH
Multiple BCC excised in USA on face
MOHS for nasal BCC time-consuming, only for high risk pts
Scalp SCC
***margin 5mmm (99% non-recurrence) or escision VS cosmetic (face)

MED & ALLERGIES

Amlodipine 10mg Atorvastation 20mg
NKDA

SHx
Never smoked, drink occassionally

FHx
No skin cancers in fam

MX
 Punch biopsy in drogh showg malignant invasive mesenchymal tumour
Wide local incision on scalp
Breslow 4mm
Clarks V
Nodular malignant melanoma
Follow-up
CT PET scan lesion of left adrenal
Mets MM
June 15: laparoscopic L adrenalectomy
Follow up in dermatology OPD

PHYSICAL EXAM
Split thickness skin graft on vertex of scalp
Opaque
15x10cms
oval shaped, no surroundg erythema

MM
Types
Stage: AJCC

TX
Surgery Systemic
wide local IMN-IFN a (benefit very marginal)
excision Monoclonal AB ipilimumab (anti CTLA4, expensive, response to mets dzs),
depends on pembrolizimab (anti-PD1)
breslow Targeted therapy
thickness oMAP kinase pathway V600 BRAF : BRAF inihibitor [vemurafenib, dabrafenib]
SLN if >1mm ChemoT
oTopical or systemic
o5-FU, doxorubicin or cisplatin
RadioT pallaitive
ILN
***synergistic effect with multi drugs therapy ipilimumab + BRAF inhibitor

DISCUSSION
1)Lump on scalp
DDX
BCC (most common)
SCC
MM
Benign lesion : lipoma, unstable skin, keratotic lesion
Osteosarcoma

2)Subtypes of MM
Superficial spreading-most common
Lentigo MM-Hutchinsons freckles
Nodular melanoma
Acral lentigous- palms & soles

3)RF
Association with pancreatic & breast Cancer
Sun exposure

4)Investigation
 Moles - MM
Hx & exam (ABCDE)
Incisional biopsy allow Breslow evaluation & AJCC staging (III & IV mets)
Stage Lesion depth Margin Prognosis
0 <0mm local incision
I 0-1mm 1cm WLE 98%
II 1-4mm 1-2cm WLE + SLB
SLB -ve 95-97%
III-IV >4mm 2-4cm WLE+ SLB 56%
Mets Adjuvant therapy <50%

Look for mets

oCT PET scan of head, neck, CT TAP (If sentinel node biopsy +ve & >1mm lesion)
SLN
oInject radioisotope Technicium 99
oLymphosynctiography: look where methylene blue dye goes
oIncise at area of isotope excise to look presence of blue dye
oBenefit controvesial, tell us the prognosis but does not affect survival: no known curative tx
oIf ve: monitor clinically only if suspicious do repeat CT scan

Monday, 5/10/2015
21.ACUTE ABDOMEN

CASE 1
HPC
75y/o M presented to OD with acute onset abd pain asscod w 4d hx of nausea, vomiting & heartburn

DDX
GI
Cardiac
oatypical MI
diabetics, females, age >70, CHF, renal impairment heartburn, nausea, 50% has SOB do ECG &
cardiac biomarker troponin]
oQx
Pain:exact location of pain, type, radiation, onset, relieving factors (GTN spray), aggravating (exertion)

S/FHx
Ex smoker quit 28yrs ago, 56pack yr hx
No alcohol use
Part time bus driver
Lives w wife
Fam hx T2DM & CV

Cardiac RF
Smoking, DM, fam hx, hyperchol, HTN, renal impairment

EXAM
HR 75, RR 16, BP 158/90, O2 96%
Gend abd tenderness worse in RUQ
oMurphys sign +ve
ono guarding or rigidity
obowel sounds present
***Elderly has poorer immune response may not be tachycardic
Impression:
Perforated DU
Ruptured AAA
Acute cholecystitis
Acute pancreatitis
Basal pneumonia

***In elderly with abd pain:

oCholecystitis
oAppendicitis [retrocaecal - >difficult to dx]
oMesenteric/ bowel ischaemia
40-50% MR due to delayed or misdx
RF: Very severe pain, pain out of proportion to physical examination findings, hx of Afib with abd pain,
recent MI
Investigation: Bloods [LACTATE, WCC] + Imaging [Mesenteric/ CT angiography]

INVESTIGATIONS
CXR
Air under diaphragm

CASE 2
21y/o M pilot
Presented to ED w 1day hx of abd pain

HPC
Thursday morning started centrally around umbilicus
Gradually moved to RIF
Severity progressed to 9/10
Exacerbated by movement
+dizziness felt weak & shaky, couldnt walk
+anorexia
+nausea- one episode of vomiting in ED during IV line insertion
+no recent change in bowel habits (last opened that morning), diarrhea, urine changes, no hx hernia or groin
lump

DDX
Appendicitis
GE
Testicular torsion
Ureteric calculi
First presentation of IBD
Gynae causes if female
oEctopic pregnancy: pregnancy test, pelvic US [ectopic or heterotopic pregnancy- due to increased use of
assisted reproductive techniques radiologists scan throughout abd]

PMH/ PSH
No med hx- yearly check ups normal

PHYSICAL EXAM
Vitals: HR 65, BP 131/68, RR 16, T 36.6
Abd exam
oCentral abd tenderness
oRIF: guarding and rebound tenderness
Medical causes of an acute abd
REFERRED PAIN
From genitalia: testicular torsion
From thorax:
MI, pneumothorax, Pneumonia,
PE
METABOLIC/ ENDOCRINE
Diabetes, DKA
Acute intermittent porphyria
Uraemia
Sickle cell crisis
Hereditary angioedema
bradykinin production increased vasodilation presented with
upper airway symptoms
investigation: C1-esterase inhibitor level

Tuesday, 6/10/2015
22.HAEMATURIA: RENAL TRACT CA & UROLITHIASIS

CASE 1
45y/o F 6d hx of R sided flank pain on a b/g of recurrent UTI

HPC
Pain-1st presentation
Back to groin, initially L now R
Radiated from loin to groin
Colicky
Preceeding acute pain, several days of dull aches
Intermittent & building up to increase in duration to constantly present
10/10
not relieved or exacerbated by anythg
assoc w
ofever, malaise, rigors, 4x vomiting food, no blood, constipation, diarrhea, urine cloudy/ frothy with
urgency & retention, 3 months hx of fatigue and nausea, UTI annually over 4 yrs no admissions
denied diarrhea, denies large amout of alcohol use

INVESTIGATIONS
FBC: non-specific, only inform if anaemic
CRP
Lactate VBG
U&E not tell much unless bilateral ureteric malignancy
serum Cr
Serum & urine spot amylase
Serum Ca corrected for serum Alb
Phosphate, Mg, urate
BHcg
LFT- bilirubin, ALT, ALP, AST
Urine dipstick for pH microscopic
MSU-culture & sensitvity
DX TESTS
Plain abd radiograph
ocalculi that contains calcium radiodense
oradiodensity of stones in decreasing order
ca phosphate > calcium oxalate > struvite > cystine
completely radiolucent stones: uric acid, triamterene, indinavir suspected based on pt;s hx and/or
urine pH (pH <6: gout, drug hx: triamterene, indinavir) and the dx may be confirmed by USS, CT-KUB or
MRU

MX
ABC
Analgesia iv paracetamol
Ab
oIV esomoprazole: epigastric pain

DEFINITIVE TX
W&W <5cm/ non obstructg calculi will pass spotaneously

CASE 2
85y/o presented 7days ago for radical cystoprostatectomy & ileal conduit formation on a background of long standing
hx of haematuria, 5 days post op and doing well

HPC
terminal dribbling
weight loss, night sweats
frequency: 4hourly and nocturia x1 night/ small volume once started
obstructive symptoms: hesitancy/ weak stream/ terminal dribbling
small amount of fresh blood early in stream
3 episodes of frank haematuria over past 3months
denies: blood clots, dysuria, signs of anaemia, fevers/loss in appetite, abd pain/ loin pain, easy bruising/ bleedg, vomit

PMH/ PSH
TURBT June:well differentiated transitional cell ca
TURBT Jan: leukoplacia and multifocal renal carcinoma
COPD
PF
Resected melanoma, R sided hernia repair

MEDS & ALLERGIES

Non compliant to seretide, Clexane, paracetamol, ranitidine, ondansetron
NKDA

FHx
Sister has colon ca
no renal disease
no deafness Alports syndrome

PHYSICAL EXAM
Vitals: BP 162/60, RR 16, HR 60, Temperature 36.9, O2 sats 96%
General
alert, breathing comfortably & appears pale
IV lines, midline laparotomy with staples: no erythema or oozing
Close
drain in LIF
 stoma in RIF spouted, pink and slightly oedematous stoma, light haematuria in 3 stents visible, contains yellow to
light red liquid consistent with urine & slight haematuria
epidural site on patients back
old scar in RIF prev hernia operation

DDX
Transitional cell ca of bladder
Ureteric calculi

INVESTIGATIONS
Urine cytology: malignant cells
Cystoscopy

DISCUSSION
Haematuria definition
visible or non-visible
non-visible
o dipstick or microscopic
o microscopic > sensitive, risk of having malignancy is equal
Risk stratifying
stone: obstructive, mx of stones
malignancy: kidney, bladder, prostate, ureteric
UTI malignancy risk factors:
o Chemical exposure: benzene (mobile factory), aromatic hydrocarbons [occupational]
o Age >50
o Fam hx
o Smoking
o Presence of visible (higher risk) or non-visible
Dx
Low risk: US
High risk: CT urogram if came back saying bladder underfilled/ x fully extended cystoscopy (an endoscopic
technique)

upper tract: Cystoscopy

lower tract: Imaging (MRI), also useful for pregnant lady

Investigations
FBC, renal profile, >50, DRE done considering PSA, urine protein Cr ratio (leaking protein from renal, ratio >2g per day
do Cr clearance test)
CT: resources issue, want to min radiation

Aetiologies
Stone
size, location & presentation
find underlying cause
non contrast CT
Most common sites of obstruction
o uteropelvic
o uterovesicular
o intersectn of ureter & iliac vessels radiograph at pelvic brim
chance of stone passing spontanoeously:
o 4mm or < :80%
o 3mm or < :94 %

Mx
Presentations determine mx
Septic
o due to stasis
o if crack stones & manipulating ureter septic shock
o gram ve bugs in UTI has thin layer of polysaccharides
acts on toll-like rec 4 drive t-cells wild activate
macrophages overwhelming immune response
o so just drain instead of cracking stones
Non-Septic
o obstructive stones: diaphoretic, tachycardic
o resuscitate (IV fluids, analgesia) imaging with non-
contrast ct scan show obstructing stones causing
hydronephrosis
o LEAVE stone alone for now
o Go for percutanous nephrostomy of JJ stents
 o JJ stents (US) on GA, put in big camera wired up to
kidney and place stent in
o VS percutaneous nephrostomy (EU) by IR through 11th
-12th ribs using US with LA [advantage: LA, faster, with
percutaneous nephrostomy on, can still insert JJ stent in
drain into bag
***no difference in outcomes, both effective drainage of
kidney
o Ab: broad spectrum Ab until C&S results out
o Specific: E.coli, Proteus (makes urease that cleave urea
into ammonia), klebsiella, gram -ves, pseudomonas
o 3rd gen ceph: cefotaxime
o aminoglycosides: gentamicin (mainstay for gram ve
sepsis)
o tazocin
o if resistant to gentamicin: merapenem, carbopenem

Tx options
Roles of alpha-blockers in stone
Most trials: alpha blocker relax smooth muscle mainstay for stone passage
o alpha blocker relax the peristaltic movement for stone to pass down
o in prostate acts on alpha 1 A receptor
BUT SUSPEND (spontaneous urinary stone passage enabled by drugs) trial says otherwise
***pain from stones is due to ureter contraction (peristaltic waves)

Shockwave lithotripsy
water as medium dev focal point of blast within generator exert shockwave impulse blast stones

PCNL
especially for staghorn stones (non-calcium (alminum, phosphate, Mg based)), similar to bouerhaeve in heart, soft
stones, sticking wire into stones sent to theatre laser stones with camera guidance, usually for large kidney stones,
dont really do for ureteric stones

Wednesday, 7/10/2015
23.POST-OP COMPLICATIONS
General Specific
Immediate Asphyxia Reaction haemorrhage
(<24hours) o Suture dehiscence
1-2weeks Pulmonary complications Secondary haemorrhage
o Pneumonia o Wound haematoma
o PE Anastomosis leakage
Urinary complication Complications specific to types of
o UTI surgery
Long term Nutritional

CASE 1
Allan Hegan, M, 50, porter, Dublin
PC
Admitted for 5 weeks now for investigation of incidental findings of Barretts oesophagus
during routine endoscopy fro chronic gastritis and is 2weeks post-oesophagectomy on
2/9/2015

HPC
Previous HPC
Dysphagia N
Change in bowel habit N
Wt loss N
Bleeding per rectum N

Post-Op
 Had unstable airway
Not intubated, put on nebulisers and physioT
VRE & MRSA infections post-op
Anastomotic leakage chylothorax
Put on Ab
No VTE

Mx Post-Op
Put on chest drain
Put on analgesia to allow cough

PMHx
***Always ask HTN, Diabetes, Asthma
***Any other medical conditions that I should know about?
TIIDM
Cerebral aneurysm

PSHx
15/4: First endoscopy chronic gastritis
o Yearly endoscopy for surveillance
o Managed on triple therapy
Coil for cerebral aneurysm (severe headache)
Sports injury
o Left ligaments & tendon repair

Medications
Glucophage BD

Allergy
Penicillin
Erythromycin

FHx
TypeIIDM
Both parents alive, 82y/o
SHx
Smoke 10-15cigarretes, stopped now

EXAM
A drainage bag draining purulent yellowish fluid consistent with chyle (lymphatics) from the upper
back via a pig tail tube due to chylothorax complicating laparoscopic oesophagectomy
Thoracotomy scar on the back and scars for laparoscopic ports on central abdomen
A tube that goes into abdomen on lower abdomen consistent with a jejunostomy (small bowel area)
VS
PEG tube in upper abdomen (stomach area)
Under water seals for chest drain

Jejunostomy
Composition 3000 calorie/ day
30mmol of Na, 30mmol of Cl
May need to increase based on fluid balance
Indications Nutritional supplement
Jejunostomy (upper) when not able to utilise GI
 tract
PEG tube (lower)to rest bowel
Complication Infection
s Displaced
Blockage

Scar following oesophagectomy

Types of oesophagectomy
3-staged oesophagectomy
a.Resect whole length of oesophagus
b. Mobilise stomach
c. Anastomose stomach to upper
oesophagus

Location of Type of scar

scar
Abdomen Laparoscopic
ports
Chest Ivor-Lewis
Left side of Transthoracic
neck

Friday, 9/10/2015 [Wans presentation]

24.GASTRECTOMY: GASTRIC & OESOPHAGEAL CARCINOMA
CASE 1
Ms MM, a 78 years old lady from Navan
Currently 9 days post- subtotal gastrectomy
Admitted 2 weeks ago with repeated episodes of vomiting & abdominal pain
B/G recent incidental finding of gastric carcinoma

HPC
Went to ED about 2 weeks ago (22/09/15)
Repeated episodes of vomiting Abdominal pain
Started since 2 months ago,
2-3 times per day
Become progressively
worse and more frequent
each time after eating
Contents of vomit mainly
food that she ate
beforehand
No blood or bile
No dyspepsia
Since 3 moths ago (end of June)
Pain worse in upper abdomen, constant dull pain, no radiation
Pale stool
No jaundice, dark urine, right shoulder pain
No relieve by sitting forward
Denied any heartburn
No chest pain/ chest tightness or underlying cardiac condition
No syncope
Bowel & bladder normal
B/G of recurrent gallstones with previous lap cholecystectomy
Denied any systemic symptoms- weight loss, night sweats, fever
Background
Referred to Mater Hospital in June for ERCP procedure, where stone was
found in CBD; which then followed by sphincterectomy + stenting
Repeat ERCP was scheduled in August. However, this procedure cannot
be completed as the endoscope could not pass through the pylorus due to
obstruction & ulceration. Biopsy was taken.

PMH/ PSH
Gallstones (2007)
Laparoscopic cholecystectomy (2007)
 TAH + BSO
ERCP + sphicnterctomy + stenting (June 2015)
MEDICATIONS
NAD
NKDA
FHx
Sister had gastric cancer and died at 65
SHx
Stopped smoking 2-3 years ago, with about 40-45 pack years
Occasional drinker
She lives with her husband, who is currently not very well
No children

DDX
1. Gastric carcinoma
2. Small bowel obstruction
3. Choledocholithiasis
4. Cholangitis
5. Pancreatitis

PHYSICAL EXAM
General inspection Closed inspection
Sitting comfortably on the chair, alert, breathing Laparatomy scar (cover with dressing)
comfortably Jejunostomy feeding tube on LLQ
Cannula on her left hand, with IV line attach T tube on RUQ
TED stockings
Incentive spirometry on the bedside
INVESTIGATIONS
Bloods (at admission) Other
Hb 12.1 Urea 4 ERCP
MCV 86 Na+ 132 o June- CBD stone, pancreatic duct not opacified; + sphincterectomy +
MCH 30 K+ 3.7 stent
PLT 288 Creatinine 67 oAugust- incidental finding of gastric tumour; bx taken
WCC 14.4 Amylase 41 Biopsy- gastric adenocarcinoma, grade 3, poorly differentiated
CRP 33.5 Bilirubin 21 CT TAP
PT 12.8 ALT 40 oIrregular thickening of prepyloric area, dilated intrahepatic duct &
INR 1.33 ALP 95 dilated CBD
aPTT 39.4 CXR
MRCP
Tube cholangiogram CBD exploration, repeat cholangiogram, extraction
of residual stones

MANAGEMENT
Gastric carcinoma
Surgical excisions (gold std)
oSub-total gastrectomy
Choledocholithiasis
Tube cholangiogram

THEORIES
Gastric Tumour
TYPES TREATMENTS
1) Adenocarcinoma- mucosa Surgical excision Total or Partial Gastrectomy with
Most common, >50 y/o, M>F lymph node dissection
2) GIST- Connective tissue Chemotherapy for disseminated disease
3) Carcinoid tumour Neuroendocrine- Palliative with limited radiotherapy
4) Lymphoma- Lymphoid tissue
CASE 2
Mr AE, a 50 year old man from Dublin
Currently week 5 post elective oesophagectomy
B/g of Barrets oesophagus detected through surveillance endoscopy for persistent & progressive gastritis.

HPC Background & Initial symptoms

Elective admission 5 weeks ago Since 10 years ago
(02/09/2015) Repeated heartburn, intermittent central abdominal pain radiated to
Presented to Beaumont Hospital LUQ
for surveillance OGD in April Constant, sharp pain
where suspicious lesions was Worse when lying flat and after eating
found in his oesophageous. Sometime relieved by antacids
Dx with oesophageal carcinoma a/w bloating, belching
No nausea, dysphagia, odynophagia, hemaetemesis, blood pr, urinary
Since surgery symptoms, bowel change
Procedure went well Not related to drinking alcohol, no chest tightness
Had a few complications post-op, Denied any systemic symptoms ie weight loss, fever, night sweats
transferred to ICU 1 week post Pain became progressively worse after 5-6 months until 1 day, he was
op for 2 and weeks presented to ED as the pain was very severe and not relived by
Had anastomoses leak antacids.
No DVT Had OGD + CLO test and was diagnosed with gastritis & barrets
Pain management good oesophagus
Undergone a course of Triple Therapy
Symptoms improved after that, still got recurrent intermittent
heartburn but not as frequent as previously; could manage it with PP!.
Had routine surveillance OGD every 2 years, and the most recent one
was in April
PMH
Type 2 diabetes managed well with OHA
High cholesterol
Asthma ventolin inhaler PRN
Appendicectomy
PSH
Cerebral aneurysm (2010) coiling
Sports injury
MEDICATIONS
Metformin
Lipitor
Salbutamol inhaler (Ventolin) PRN
Allergic to penicillin & eryhtromycin
FHx
Father has T2DM
SHx
Stopped smoking 2 days before surgery
o About 25 pack-years
Occasional drinker
Lives with her wife & 2 daughters

PHYSICAL EXAM
General inspection
Sitting comfortably on the bed, alert, breathing comfortably
Cannula on his left hand, with IV line attach
Incentive spirometry on the bedside
Close inspection
4 laparoscopic scars
1 big thoracotomy scars at the back on right side with drainage tube attached to it
Jejunostomy feeding tube on LLQ
Appendectomy scar (Mc Burneys)
INVESTIGATIONS
OGD + Biopsy
oConfirm oesophageal adenocarcinoma
CT staging

MANAGEMENT
Endoscopic mucosal resection
Surgery Ivor Lewis procedure

THEORIES
Oesophageal Tumour
TYPES TREATMENTS
1) Adenocarcinoma 1) Surgical resection +/- neoadjuvant (chemo/ radiotherapy)
Most common in western world Ivor Lewis (abd/ thorax opened)
Lower 1/3 of the oesophagus McKeown 3 phase oesophagectomy (abd/thorax/neck)
a/w GORD, Barrets Transhiatal resection (abd/neck) -low oes, early, no LN
Radio-insensitive 2) Chemotherapy
2) Squamous cell carcinoma Metastases, adenocarcinoma
May occur anywhere in the oesophagus 3) Radiotherapy
radiosensitive Better for SCC
4) Palliative

DISCUSSION
DDX
Gastric ca: fam hx, ovarian ca (BRCA carrier), Lynch syndrome, FAP
PUD
Pancreatitis: hx of gall stones in GB if had cholecystectomy can have choledocholithiasis
Choledocholithiasis
Primary Secondary
Within 2years post cholecystectomy Asymptomatic after 2years post cholecystectomy, and develop after that
Pancreatic ca
Gastric lymphoma
GIST
Duodenal ca (D1 or D2)

ASSESSMENT OF GASTRIC CA
Stage: to determine tx & prognosis
Other comorbidities: fit for surgery or not

INVESTIGATION
CT abdomen & thorax:
bulky tumour +
LNpathy + dilated bile
ducts
Histology
***Disclose dx & discuss
mx (involve MDT)
Staging
o CT-PET scan: mets (metabolicly active cells)
o EUS: depth of stomach wall invasn by tumour & involvement of LNs around stomach
sample from LN if +ve of malignancy remove
o Laparoscopy
CT scan sensitivity is very poor, do staging lapasroscopy can avoid unnecessary
laparotomy because can detect peritoneal mets

MX
Neodajuvant therapy Gastrectomy
o 3cycles of chemoT + 3 > cycles based on histopathology (response to chemoT) o After gall stones removal
o different regimes (Mc Donald regime, etc) o If has recurrent stones later
o MAGIC Trial: (adenocarcinoma of gastric & oesophagus)
Neoadjuvant therapy: R0 no microscopic disease left behind, R1 no choledocholeduodenostom
gross disease left (possible microscopic mets), R2 y or endoscopic
o This pt was not sent for neoadjuvant therapy due to gastric outlet obstruction sphincterotomy for dilation
 & presence of stones in bile duct (has to explore to look for bile duct Roux of bile duct
en Y not possible with bile production) o Leave T-tube (multiple
o WALSH Trial: (adenocarcinoma + squamous) stones left for 2-3weeks,
Neo + radiochemotherapy superior than surgical alone remove stones via T-tube if
o CROSS Trial (adenocarcinoma) present)
Neo + radiochemotherapy superior than surgical alone
o Chemo VS chemoradiotherapy

CASE 2
Barretts
Metaplasia of epithelial lining (squamous) to columnar (0-1.5%)
Also look for foci of dysplasia (high risk of dysplasia development)
o Low grade
Tx: used to do biopsy every 3-6months
Now: biopsy again and seen by 2 histopathologist (mapping techniques)
Treated with radiofrequency ablation Surveillance VS radiofrequency (SURF)
EMR (endoscopic mucosal resection) if has nodal or ulcer development
o High grade malignancy risk high
EMR
MDT discussion for tx with findings of staging investigations (CT scan, EUS = T1N0)
T1: no chemoT
surgical resection (ESD- endoscopic submucosal dissection) without LN involvement (not in Ireland)
or surgical excision (oesophagectomy)
Ivor Lewisor
transhiatal
3-staged 3 incision (abdomen thorax L neck)
2-staged -
Tumour of low oesophagus & late stage only
Squamous ca
Work up as above
Definitive chemoT - 50% responded
Monday, 12/10/2015 [Syiras presentation]
25.INTESTINAL OBSTRUCTION

CASE 1: LBO
Qx to ask
Able to pass flatus?
Distended abdomen?
Vomiting?
o distal obstruction: only profuse if
o proximal: dehydrated quickly

Investigations
PFA:
gas in lumen of bowel (periphery)
air fluid levels only seen in SBO (content is liquid VS solid in large bowel air seen on same level)
***SBO
closed loop obstruction (closed by competent ileocaecal valve on noside, by the obstruction on another side)
can dilate and perforate if continously obstructed! place stent in
Incompetent valve: backflow into small bowel no closed loop obstruction

Mx
Stent bowel to decompress

Aetiology
Diverticular dzs
o diverticulitis, esp sigmoidal
o strictures secondary
Tumour
Intussusception
Hernia
 Volvulus

Rectocoele? Does not cause obstruction cause obstructive defaecation (tenesmus instead)

CASE 2: SBO
Aetiology
Adhesions RF: previous hx of surgery
Fibrin and pro-inflammatory markers activated secondary to trauma or injury from
surgeries form adhesions
Lots of adhesion between bowel: not obstructing most of the time
One string-like adhesions one of bowel goes under it obstructed
Hernia Inguinal, incisional, femoral (< likely than inguinal, but > likely in women VS inguinal (12x >
common in male))
Cough impulse

Femoral
> likely to obstruct
Femoral canal borders:
oAnterior: inguinal ligament
oMedial: lacunar
oPosterior: pectineal ligament
oLateral: Femoral vein
***3 rigid sides to femoral hernia, the only expansion is femoral vein > likely tu get
stucked!

Other types
Umbilical: In children, repair after 2years (< than that, resolve itself as grows)
Paraumbilical hernia: Adult
Obturator: goes through obturator foramen in posterior pelvis lost weight dev
potential space
Spigelian: hernia through spigelian fascia at lateral border of rectus (tenderness around
lateral border of transversus abdominis)
Diaphragmatic
oSliding: goes up
oParaesophageal: goes up alongside
Pantaloon: direct + indirect coexist
Indirect: goes through indirect path as scrotal takes
Direct: coming through posterior wall
Volvulus Rotation of small bowel on its axis around its blood supply closed loop obstruction + cut
blood supply

Types:
Small bowel: internal hernias or adhesional obstruction
Malrotation: SBO R, cacecum middle, LB below
Sigmoid volvulus: elderly, concomittant constipation, in ursing home poor immobilisation,
recurrent decompress with scope, resect due to recurrence
Caecal volvulus
Intra-abd Pelvic abscess with partial obstruction
abscess
Foreign bodies Dentures
Razor blades
Gall stone ileus
oCholecystitis fistula between GB and duodenum galls tones transcends into small
bowel, stucked at ileocoecal valve air in biliary tree (pneumobilia) + SBO
Mesenteric Subacute intestinal ischaemia fibrosis & scarring of small bowel due to lack of blood
ischaemia supply narrow area of strictures forming obstructed
Intussusceptio Telescoping of one bowel into next segment
 n Cause: mesenteric adenitis (a child with chronic RIF pain, distnded abd, redcurrant jelly
stools, groin + mesenteric nodes enlarged) bowel tried to push the lump formed
pushed itself into lumen of distal bowel
Radiation
enteritis

Investigations
PFA
SBO
o Air fluid levels: air > central than peripheral
o Valvulae coniventae: lines across whole bowel diameter
LBO
o Air down in pelvis, more peripheral
o Haustration
o Coffee bean sign (air in sigmoid)
CT: Transition point?, dilated loops of bowel, bowel could be completely fluid-filled

Mx
Evidence of strangulation: high lactate, rebound tenderness
o Tx with NG, IV fluid, decompress, usually resolve in 7-? hours, if not surgery
Adhesional obstruction usually in small bowel: NG
o Scope only for LBO, +if malignancy query
o Not done in small bowel: risk of perforation

Difference between paralytic ileus and mechanical

Mech: something is in the way
Ileus: bowel does not work correctly, but there is no structural prob causing it
On PFA: bowel dilatation

Tuesday, 13/10/2015
26.ACUTE SCROTUM AND TESTICULAR LUMPS

DDX
Testicular torsion
Epidydimo-orchitis
Hydrocoele
Varicocoele
Indirect inguinal hernia
Strangulated hernia
Testicular cancer
Foreign bodies

ACUTE TESTICULAR TORSION

Congenital
All born with female sex as default sex depends on activation of SYR (sex-determining region Y) genes
Omphalocoele
Undescended testis
deep inguinal ring
superficial inguinal ring
brings processus of vaginalis degenerates tunica vaginalis formed secreting fluid (hydrocoele)
if processus of vaginalis communicating hydrocoele (patent processus vaginalis)
***Before processus of vaginalis closes around it can have torsion (intravaginal)
***Torsion can also occur in utero: vanishing testis (initially seen in prenatal US)
***abN suspension of testis

Acquired
Genital femoral nerve testicular atrophy

Twisting if the testicle on spermatic cord

o blood supply to tecticle interrupted
o irreversible damage occurs after 6hours
 Suspect in nay young male with testicular pain is torsion until proven otherwise

***Communicating hydorocoele
VS
Indirect hernia
hole is bigger bowel contect can fall over into the space

HPC
Severe pain of sudden onset
Reddish testis high lying and tender with thickened spermatic cord
Torsion of testicular or epididymal appendage

+preceeding trauma
+limping
+abd pain: referred pain
+N&V

WORKUP
Suspicion of testicular torsion
immediate surgical intervention
No role of US or other imaging

MX
surgery
o untwist testis and fix in the scrotum
o also fix opposite testis to avoid future torsion
o Orchidectomy must be performed if the testis is non-viable to prevent dveeopment of Abodies
o Non-absorbable sutures
maintain 3d configuration and 3 point fixation does not twist or displaced
Risk: small risk of suture abscess
adequate analgesia
antiemetics N&V
PROGNOSIS
Consequences
re-twisting of testicles: very low risk
infarction of testicles
loss of testicle
infection
infertility
cosmestic deformity

Time elapsed
<6hours: 90-100% salvage rate
12-24hours: 20-50%

EPIDYDIMO-ORCHITIS
bimodal distribution: adolescent and male >60s
adolescent: with mumps
young sexually active : STI
o Chlamydia trachomatis and Neisseria gonorrhoea
chronic bladder outflow obstruction: UTI
o Escherichia coli and Proteus mirabilis
Haematogenous infection & sexually-transmitted
Mx:
o Broad spectrum Ab according to local guidelines for STI and UTIs
o Bloods: increased WCC
o Analgesia, scrotal elevation, local ice therapy and oral NSAIDs
o Prehns sign: Lift scrotal up relieved in epidydimitis, not in torsion +ve Prehns sign (give constant pull on
spermatic cord)
o Complicated by abscess: not given Ab low pH and Ab could not penetrate abscess layer surgical drainage

HYDROCOELE
Serous fluid between 2 layers of tunica vaginalis
 Asymp
Palpable scrotal mass
1y
o congenital or infantile
-assocd with patent processus vaginalis
Usually resolve spontaneously in in fants below age of 1 year
o Adults
Due to slow accumulation of serous fluis
Excessive production or impaired reabsorption
Secondary
o Due to associated tumour or infection
Mx
o US
esp if suspicion of an underlying tumour
o if small and asymptomatic: no tx
o if large: surgery

INDIRECT INGUINAL HERNIA

young men, above & medial to pubic tubercle
palpate with tip of finger

STRANGULATED HERNIA
tenderness, induration & erythema
fullness/ mass above scrotum (unilateral, if bilateral think of bilateral indirect inguinal hernia)

VARICOCOELES
Spaghetti-like

Wednesday, 14/10/2015
27.HERNIAS

PE
+ve cough impulse was confirmed
3x4cm oblong non-tender swelling in R groin, well defined margins
Reducible on applying P and reappeared with increased abdominal P
Ring occlusion test:
o Occlude deep ring while lying down
o Push hernia back while standing (go medially and upward to inguinal ligament) bulge medially = direct hernia
o Impulse can be occluded at the deep ring = indirect hernia
Hernia contents: bowel gurgling
Abdominal exam was soft, tender, no other masses
***Femoral hernia > likely to strangulate: tight borders (ligaments), only room for expansion is on the femoral vein side

INVESTIGATIONS
PFA: bowel obstruction
CT scan: bowel ischaemia, peritonitis, if spigelian hernias suspected does not change mx
o Bowel ischaemia: resect, anastomose, and usual hernia repair

MX
Indication for laparoscopic herniorraphy
Recurrence
Bilateral inguinal
Inguinal hernias in females can cover inguinal ring with meshes
Open Lichtenstein repair

MESHES
Types Indication Contraindication
Permanent Open inguinal repair in most all of Bassini procedure
 o Made or prolene or polyester time Bowel perforation or necrosis
Absorbable
o Biomeshes

COMPLICATIONS
Scrotal haematoma - common
Wound infection - big deal
Urinary retention - common in elderly
ensure patients voided before discharged
Chronic groin pain from entrapment of ilio-
inguinal nerve or deep stitching to
periosteum (firm fixation) causing
discomfort- both is rare
Testicular atrophy caused by inadvertent
damage to testicular artery
Mesh migration
o stitch mesh in place but still need to be tension free
o stitch to inguinal ligament and wrap around spermatic cord,
coming out into abdominal cavity through deep inguinal ring
Recurrence rates <1%
o infection most important risk for recurrence
o poor operative technique
o avoidance of mesh for reinforcement of weak musculature
o patients condition sucha s chronic cough, constipation or
bladder outlet obstruction

OTHER HERNIAS
Strangulated Septic form bowel ischaemia
Content: omentum, not bowel
May cause bowel obstruction
Richters hernia Only one side of bowel herniated into hernia sac
Patient has partial bowel obstruction with ability to pass flatus still
Hiatus hernia Part of stomach protruded through
Present with GORD symptoms
Mx
o fundoplication: wrap stomach around lower part of oesophagus and stitch them restrict acid
reflux
o Indication
pH manometry: N
no neurological problem
pH studies for 24hours (Demeester score >7.5)
Femoral hernia F>M
Difficult to distinguish from inguinal hernia
Swelling of local ligaments in femoral canal
Operate only when irreducible, not an emergency in most cases
Mx
o Widen femoral ring (careful not to damage the content, especially femoral nerve)
o Reduce back in
o Place mesh overlying femoral ring
Incisional hernia Real problem
In laparotomy wound: dehiscence of linea alba + RF: overweight patients
Superficial dehiscence: does not predispose to hernia but wound infection
o Usually seen in inguinal indirect: weak wall (patent processus vaginalis)
Deep dehiscence of fascial layer
o Usually seen in incisional hernia
o RF: patient with abdomen left open over long period of time (due to bowel dilation, to prevent
abdominal compartment syndrome do laparostomy predispose to incisional hernia)
Cause infection and possible septic shock
Enterotomy to repair dehiscence
Large incisional hernia: use corset/ truss to cover, still used now
Obturator Defect in linea semilunaris: usually small amount of fat herniated or sometimes bowel
hernia Dx: CT scan or high clinical suspicion, difficult to dx
Relief with thigh flexion
Hip abduction or internal rotation causes pain (symptomatic)
Spigelian hernia

PROSTATE MALIGNANCY
Know anatomy
Fx: provide volume for ejaculation
Cross section:
Stellate-shaped urethra
Prostate cancer peripherally asymptomatic
BPH surrounds urethra symptomatic

PSA
Active Bound PSA
proPSA
Inactive free PSA (5-50%), complexed PSA (50-95%)
o <15-20% ration of free to complexed PSA
Specific to prostate, not to prostatic cancer increased in prostitis, etc
There are other markers for to detect prostate ca now
Age-specific
Age PSA levels
<40 <2
40-50 <2.5
51-60 <3.5
61-70 < 4.5
>70 <6.5
***Increase with age

Screening
Risk Age Screening frequency
Low risk >5 Annually with serum PSA >2.5
0 Every 3years with PSA <2.5
Average risk 45
High risk 40

Biopsy
TRUS (transrectal US-guided systematic) needle biopsy
12 biopsies
Tru-cut biopsy
Complications: blood in urine, back passage and during ejaculation, UTI

Grading system: prognostic, based on biopsy histology

Gleason grading Going to be changed to Epstein grading

Outcome of PSA testing

False negative: might miss 1 in 3 cancers

Dx
2 abN PSA
o Look at PSA velocity
abN PSA + abN DRE [size, presence of median sulcus, nodules, textures (firm or soft), tenderness (prostitis)]

Staging
Clinically DRE: TNM staging
T1
T2
T3
 T4: invasive to rectum
Imaging Local imaging
MRI of prostate
o Look for presence of malignancy
o Unilateral or bilateral
o Extension to capsule or LNs or local

Mets
o Spinal cord compression radiotherapy to alleviate pain
o MRI of LN mets
o Bone scan (PSA >20) from bone mets: technecium 99, increased radiotracer uptake in axial or
appendiceal? Skeleton

Tx options
Watch & wait Elderly, >70, not fit
Low stage cancer
Clinically localized
Life expectancy <10years
Active 50-70 year-old patients
surveillance Indications
o Low grade and low volume
o PSA N
o Negative DRE
No exposure to risk of active interventions
Constantly reaffirming with repeated biopsy
Radical 150 degree lying supine
retropubic Form new bladder neck
prostatectomy Join back to urethra 10% develop incontinence, 70-80% develop erectile dysfunction

Laparoscopic
Robotic prostatectomy: better outcome in potency, but higher risk for blood loss and longer hospital
stay
Late complication: diversion colostomy
Surgery better for local disease than radiation
Radiation EBRT
Brachytherapy: 64 holes + MRI fusion image introduction of 1-125 seeds of radioactive palletes
***Transperineal biopsy (in between scrotal & anus)
New options Cryotherapy
Laser treatment
HIFU: high intensity focused US

Not recommended, under trials

Anti-androgens Indication: mets disease

LHRH
Acts at level of hypothalamus
LH stimulates Leydig cells
FSH if blocked heart disease (check cardiac status)
LHRH analogues LHRH antagonists Others
Bolus of agonists negative Abarelix Finasteride
feedback to anterior pituitary Monthly injections Prevents T conversion to
hypothalamus reduced ***Giving LHRH analogues and active metabolite
testosterone antags will not shut whole dihydrotestosterone
But takes a week or two testosterone production
Ex: Leuprolide, goserelin adrenal gland production of Non steroidal antiandrogens
SE: flare? Always give anti- testosterone (fluconazole can Block binding of T and DHT
androgenic with it inhibit adrenal glands!) to the androgen receptor
Ex: Flutamide, bicalutamide,
Given every 3-5months
nilutamide

Situations
CASE 1
53y/o healthy M requesting a PSA test
Symptoms
RF
Advise
o If PSA abN but no cancer lifelong surveillance monitoring healthcare burden
o PSA is cheap, widely available, acceptable to most men, easy to interpret
o PSA is not prostate cancer specific
o Normal value does not rule out cancer
o Many patients fall into grey area
o Advise on advantage and disadvantages
o Should be delayed by 6 weeks in any acute UTI, prostatitis, recent cystoscopy or TURP
o Repeat abN PSA 6

PSA just above normal (3.5)

Repeat PSA
Biopsy
o For patients with persistent RF
o Limitations: sampling areas multifocality of prostate cancer predispose to sampling errors

CASE 2 CASE 3
60y/o, PSA 6.3, biopsy shows single sample +ve for prostate 56y/o with symptoms of prostatic outflow
ca in 1 out of 12 biopsies high grade malignancy
Low grade surgery
Active surveillance radiation
Surgery not brachytherapy because potentially has big prostate

Prostate cancer GP referral guidelines

Referral criteria
50-70 years old or 40years old with +ve fam hx
DRE
PSA: repeat in 6 weeks if abN with low RFs
Urinalysis

New update
urine marker PCa3

15/10/2015
28.GI STOMAS
Hartmanns procedure
Resection of diseased part of bowel where proximal part of bowel brought out as stoma and distal end oversewn

CASE 1
Patrick Bell, 75y/o retired driver
HPC
12 days post-Hartmanns procedure with a colostomy construction for a perforated sigmoid stricture
Referred by GP 12 days ago with severe colicky lower abdominal pain
Had experienced similar pain on 2 previous occasions this year, once 4 months ago and once 4weeks ago, but this time
his pain did not resolve
He had noticed no change in bowel habit, no constipation or problems passing flatus, no vomiting, malaena or
haematochezia

Constipation in past 3 weeks prior to admission

Weight loss of 2 stones over previous month

EXAM
A stoma bag on the LIF of single lumen, flushed with skin and consisting of fecal materials
Describe:
Criteria ILEOSTOMY COLOSTOMY
Location RIF LIF
Bowel loops Spout Flushed with skin
Single lumen
2 loops
o for bowel rest, reversible
 o Part of bowel resected (midway) and brought out to decompress bowel
o One loop looking distally and another looking proximally
Content Semi-liquid Fecal

Complications of stoma
Retraction
Prolapse
Stenosis
Erythema or infection of surrounding skin
Mechanical complications of para-stomal hernias (swelling or bulge around stoma, ask patients to bulge)
High-output stoma
Psychological

CASE 2
HPC
M, 50s
4weeks admission:
o Any procedures?
Had an operation for bladder tumour: 14days post-cystectomy
o Any major problems after operation?
o When are you due home?
6weeks ago had blood mixed with in urine
Only once, does not happen with every urination
PMH
Prostate problem in the past

EXAM
Ileal conduit on R lower abdomen with drainage bag draining into urinary catheter
Clips on: Within 2 weeks
Pink lines on wounds: >6months

CASE 3
EXAM
Midline laparotomy scar
Tube draining mid level on lower abdomen of brownish yellow liquid most likely bile
Has clear urine in urinary catheter not likely to be urostomy
Consistent with percutaneous GB draining
Friday, 16/10/2015
29.RADIOLOGY
CASE SCENARIO
1.NG tube placement
2.SBO
3.Gastric outlet obstruction
No bilious vomiting so
probably above D2
4.A 70 y/o lady was referred by GP with
complaints of projectile vomiting for the
past 3 weeks. The vomitus contained
mostly undigested food contents
Impression
Upper GI obstruction above
level of umbilicus
3.A 80y/o f from nursing home if
transferred to ED c/o increasing abd
distention for the past 3days. She has
background hx of
DX & INVESTIGATIONS MX & COMPLICATIONS
PFA Test aspirate pH
Tube should descend onto the thorax in midline, <4 gastric placement
below the diaphragm
Bisects carina
Crosses the diaphragm
PFA NPO, NG tube decompression,
Jejunum: valvulae conniventes, broader lumen than IV fluid, Foleys catheter and monitor
ileum urine output, analgesia
Ileum: smaller, featureless Ileum likely to be dilated after
appendicectomy, same tx as jejunum
Clexane or enoxaparine, TED
stocking, PPI prevent stress ulcer
PFA NG drain, fluid resuscitate
Dilated and fluid filled stomach Hypokalaemic, hypochloric
Sometimes see J shaped stomach alkalosis from vomiting
Succusion splash sign
Aetiology: gastric ca after chronic fibrosis formation
Investigation Mx
CT Abd NG tube to decompress
Dilated stomach sometimes can see dilated stomach
stomach in PFA succussion splash signs
ABG Aetiology
Hypochloraemic metabolic alkalosis (losing gastric acid) Gastric cancer
Urine Gastric ulcer chronic
Paradoxical acidosis (pH body alkalotic renal preserve fibrosis & structuring
H+ ion but kidney increase H+ ion)
PFA Mx
Dilated large bowel coffee bean sign: sigmoid Resuscitate
volvulus Flexible sigmoidoscopy and
Bubble coming from L side of abd going to R abd: decompress
 puffy wing sign Endoscopic de-torsion
Why sigmoid colon? Fixed on mesentery, common in
elderly (chronic constipation redundant and floppy Complications
sigmoid wall muscles) Ischaemia of bowel
If necrotic resection
4.Patient presented to the ED with PFA
complaint of bleeding PR. On DRE a hard Foreign body, gone above level sphincter hard to bring
mass was palpated in the lumen so a Xray out
was requested
5.35 y/o man c/o sudden onset severe PFA
abdominal pain for 6hours Air under diaphragm
Impression
Perforated bowel perforated DU
6.25 y/o M stabbed in the chest presented CXR Mx
with SOB Tension L-sided pneumothorax (hyperluscent, no Needle decompression: large bore
pulmonary markings) needle at 2nd IS MCL
***Ideally should not be CXR-ed, clinical dx Chest drain: 4th between A &
midaxillary line
On Xray: chest drain placement
(radio-opaque line gap: eye/
opening: in side chest or not)
expanded lungs

Complications
Drains can fall out may develop
subcutaneous emphysema
7.35 F with L flank pain radiating to the Impression Complications
groin Ureteric calculi Hydronephrosis

Investigation Types
Urine dipstick: microscopic haematuria, proteinuria Calcium oxalate: radiopaque
CT-KUB: non-contrast and low radiation Some are radiolucent (ex: urate,
VS CT Abdomen & pelvis xanthine not seen on PFA)
8.85 y/o F from nursing home being Investigations Mx
treated in hospital for LRTI, has PFA Decompression
increasing abdominal distention Dilated large bowel Remove underlying cause
CT scan: look for transition point (point of obstruction)
Impression In mechanical aetiology: stricture, diverticular stricture, Aetiology
Pseudo-obstruction: colonic tumour dilated to caecum if competent ileocaecal valve Trauma
obstruction without underlying In pseudo-obstruction: no mechanical obstruction (whole Burns
mechanical causes large bowel dilated functional causes) Recent surgery
Med: opioid, clozapine
Resp failure
Electrolytes distrubances
DM
Uraemia
Monday, 19/10/2015
30.THORACIC SURGERY
SCENARIOS IMAGING
CASE 1 Erect CXR 1 CT Thorax
Stabbed M, young Describe:
oA Erect CXR 2
oB fluid level
oC No loss of costophrenic angles
oD No mediastinal or tracheal deviation
oE Right perihilar white blob
Chest drain: 5th ICS, MAL?
o Or go from out in o Count anterior ribs! Difficult though
o Drain should be in upper chest to drain air
Always describe the obvious first
findings or abnormalities CXR 3
Distinguish edge of lungs from Lung apex outline lower than N: pneumothorax
medial edged of scapula Skin clips for chest drain
Lung markings
CASE 2 CXR 4 Mediastinum
50y/o M one day post op 2 AP Large air area: stomach - brought
stage oesophagectomy Fracture of 6th anterior rib stomach up into thorax
o Linear cut post-op trauma Smiling aliens
ECG electrodes
Multiple lines
o Skin clips for thoracotomy wound Post-op
o 2 Chest drains - one with blob at end, CXR 5
 one doesnt Opacity and haziness in R lower lobe:
o Hole in 2nd drain: inside lungs pneumonia
o ET tube: ventilated - correct position,
as long as not in any one of main
bronchi unilateral lung collapse
o Central line: into SVC
o NG tube
CASE 3 CXR 5
24y/o boy c/o chest pain V signs of Naclerio from ruptured oesophagus
after multiple episodes of A focal, sharply marginated region of paraspinal radiolucency on L side immediately
vomiting. He had been above diaphragm
drinking heavily Possibly has neck crepitus: Macklers triad [vomiting + chest pain + subcutaneous
Mallory-Weiss tear? emphysema]
Aspiration
Pneumomediastinum CT Thorax
secondary to Boerhaave Pockets of fluids
syndrome Swallow test
No extravasation of contrast
CASE 4 CXR 6
64y/o F with reflux PA
symptoms and SOB Opacification on L lower zone
Patchy consoldation on R lower zone

CT Thorax
Bubble of air Air on R: colon hiatus hernia
Goes past liver
CASE 5 CXR 7
72y/o M presented to ED AP
with persistent vomiting Calcification on L lower edge
and chest pain
CT Thorax
paraoesophageal stomach herniation volvulus
Borchardts triad: severe epigastric pain + retching without vomiting, inability to pass
NGT
Side CT Thorax

MX
Decompress
CHEST DRAINS
Function
To relieve air, fluid or blood

Location
Intercostal muscles
5th space Mal
2nd space MCL

Indications
Pneumothorax- spontaneous/ Aetiology
traumatic Burst bleb
Radiolucency on CXR

Tension
Mediastinal shift P on venous drainage tracheal deviation
Traumatic
Air from lungs of outside
Other Haemothorax
Haemopneumothorax
Effusions

Insertion
Analgesia: Pethidine, voltarol +/- sedation

Mechanism of drain collection

 Under water seal (2cm): ensure one-way air flow (OUT of lungs)
If hameopneumothorax
o 2 bottles: collection of blood first + underwater seal
o Can apply suction
o Collection + water-seal + suction control

Examples
Atrium system

Following placement
Bubbling
Oscillating
Persistent bubbling
o Airleak
o Drain Out
Stop bubbling
o Blocked
o All air has been drained out
***Do CXR to confirm

Persistent air leak

Lung laceration
Bleb or bubble
BPF: bronchopleural fistula

Tx: by suction

Critical points
Measure output from chest drains
Bottle change
Clamping drain
Removal
Subcutaneous emphysema

Tuesday, 20/10/2015
31.RENAL TRANSPLANT & AV FISTULA

CASE
49 y/o female with hx of recurrent UTI and stone formation despite ESWL for 10 years
Hx of HTN, appendectomy

PE
Flank lump
Risbergs kidney incision: incision on linea semilunaris
AV fistula
Catheter
***Simultaneous kidney-pancreas transplant: in RF + IDDM

THEORY

ESRD Definition Types of transplant

GFR <15mL/min/1.73m2 or permanent
renal replacement therapy (RRT)
Common aetiology
Diabetic nephropathy, HTN, GN, PCKD
Autologous - within an individual - skin or stem cells
Syngeneic - between genetically identical pair: identical twins, inbred
strains of mice
Allogeneic - between individuals of same species
Xenograft - between different species

Classification of aetiology Donor types

Vascular: RAS, vasculitis Cadaveric donor: heart beating (better) / non heart beating
Glomerular: 1y: IgA, FSGS Living related donor program: mono/dizygotic twins; familial
 Tubulo-interstitial Living non-related donor program: spousal; altruistic
Obstructive
Time taken to transplant
Cold ischaemia time (CIT)
Time during which donor tissue is kept chilled w/o vascular supply
following procurement (<24hours)
Warm ischaemia (WIT)
Time taken between warming of donor tissue to physiological temp until
anastomosis of vascular supply (<30mins) NB! Ischaemic reperfusion
injury

THE IMMUNE SYSTEM

Transplanted organ recognized as foreign by the immune system
blood group Ag: ABO, expressed as endothelial cells
Interstitial infiltrate with tubulitis
Endothelial arteritis
Host-graft adaptation

3 major types of graft rejection (solid transplant)

TYPES PATHOPHYSIOLOGY TIME OF ONSET
Hyperacute Preformed Ab and ABO mismatches (ABO, MHC-I) Minutes to days
Irreversible
Avoid by prescreening recipients for Abs to donor tissue: ABO/
cross test
Does recipient has donor-reactive Ab?
Recipient serum + donor lymphocytes monitor cell death
(indicated presence of cytotoxic Ab in serum -cross match
Acute T cell mediated Days to weeks
Present with hematuria, oliguria, anuria, infection, pain, graft
enlargement, decrease GFR, HTN, fluid retention, high
creatinine, malaise
Ask about compliance taking anti rejection medications
Do doppler USS to dx failing transplant, look at flow travelling
away and towards the probe, look at resistive index <0.7
Biopsy
Chronic Macrophages cytokines T-cells, AB week - months - years Week to months or years

ACUTE due to differences in HLA (human leukocyte Ag) mismatches and miHAs (minor histocompatibility Ag)
REJECTION female anti-male minor H-Y responses
mainly mediated by T cells
depleted T cells
***Importance of HLA matching increase survival
CHRONIC Gradual decline in renal function associated with interstitial fibrosis, vas changes, and minimal
REJECTION mononuclear cell infiltration
A positive b-cell crossmatch or a positive flow crossmatch against donor B or T cells is considered by
some to be predictive of chronic rejection and poorer long-term graft survivals
Clinical presentation
oVery tender transplant +/- graft enlargement associated with increase in Cr
oFever
oFatigue, malaise
oHaematuria
oOliguria
oDecreased blood flow in renography
Check compliance to anti-transplant medications
Investigate renal failure
Imaging (Doppler US: look at flow in vessels resistive index (RI<0.7 = Normal)
Biopsy: confirm rejection and type

Direct VS Indirect Allorecognition

Direct Indirect
 Intact donor MHC Donor MHC peptides
molecules
Diversity of TCR Limited TCR usage
specificities
High precursor frequency Oligospecific response
Inhibited by Cyclosporin Poorly inhibited by
A Cyclosporin A

BANFF CLASSIFICATION: standard dx of renal allograft rejection

TREATMENT
Anti Rejection Drugs
Steroids, antibiotics, immunosuppressants
 DRUG CLASS/DRUG MECHANISM OF ACTION

Calcineurin inhibitor (CNI) CNIs block the intracellular T-cell signals responsible for the production of cytokines. CsA and TAC depend on different
intracellular mediators to achieve their action, but the target for both is calcineurin, making CsA and TAC prodrugs in
the sense that they must bind to an intracellular intermediary in order to do their job.

Cyclosporine (CsA) CsA binds to cyclophilin; complex inhibits calcineurin phosphatase and T-cell activation.
Tacrolimus (TAC) TAC binds to FKBP12; complex inhibits calcineurin phosphatase and T-cell activation.

Corticosteroid Steroid receptors are found in cyotplasm complexed with a HSP

(glucocorticoid) Corticosteroids interrupt multiple steps in immune activation because of the ubiquitous expression of corticosteroid
Prednisone receptors. Corticosteroids inhibit antigen presentation, cytokine production, and proliferation of lymphocytes.
Methylprednisolone +psychological effects

Antimetabolite Antimetabolites inhibit synthesis of the purine building blocks of DNA, namely guanine and adenine.

Azathioprine (AZA) AZA converts 6-mercaptopurine to tissue inhibitor of metalloproteinase, which is converted to thioguanine nucleotides
that interfere with DNA synthesis; thioguanine derivatives may inhibit purine synthesis.

Mycophenolate mofetil (MMF) MMF inhibits synthesis of guanosine monophosphate nucleotides and blocks purine synthesis, preventing proliferation
of T and B cells somewhat selectively because these cell lines lack a common rescue pathway for purine synthesis.

Mammalian target of mTOR inhibitors act by blocking the serine-threonine kinase mTOR.
rapamycin (mTOR) inhibitor
Sirolimus (SRL) SRL binds to FKBP12; complex inhibits target of rapamycin and interleukin-2-driven T-cell proliferation.

Everolimus (ERL) ERL binds to FKBP12; complex inhibits target of rapamycin and interleukin-2-driven T-cell proliferation.

Monoclonal antibody Monoclonal antibodies are monospecific antibodies made by one type
of immune cell that are all clones of a unique parent cell that specifically bind to a target cell.

Muromonab CD3 (OKT3) OKT3 binds to CD3 associated with T-cell receptor, leading to initial activation and cytokine release, followed by
blockade of function, lysis, and T-cell depletion.

Polyclonal antibody Polyclonal antibody preparations are purified immunoglobulin preparations derived from animals after immunization
with human thymocytes. The polyclonal antibodies currently available are all ATGs obtained by immunization of horses
(equine antithymocyte globulin [eATG]) or rabbits (rATG).

Rabbit antithymocyte globulin rATG blocks T-cell membrane proteins (CD2, CD3, CD45, and so forth), causing altered function, lysis, and prolonged T-
(rATG) cell depletion.

Interleukin (IL)-2 receptor The anti-IL-2R mAbs are specific for the alpha subunit (Tac/CD25) of IL-2Rs on activated T cells. They saturate IL-2Rs
antagonist and, thus, are competitive antagonists of IL-2-induced T-cell proliferation.

Daclizumab Daclizumab binds to and blocks the IL-2R alpha chain (CD25 antigen) on activated T cells, depleting them and
inhibiting IL-2-induced T-cell activation.

Basiliximab Basiliximab binds to and blocks the IL-2R alpha chain (CD25 antigen) on activated T cells, depleting them and
inhibiting IL-2-induced T-cell activation.

Surgical
Induction Initial maintenance prophylaxis with cyclosporine A/ tacrolimus - best current practice but requires
therapy monitoring serum levels
MMF has replaced azathioprine with increased efficacy, therapeutic index and is non-nephrotoxic. Can
reduce both CyA and steroids if used in conjunction with MMF
Long-term graft survival rates with tacrolimus and MMF not yet clear
Sirolimus still used in infancy but though t very useful in ealr transplant rejection
Transplant connection of renal A V and ureter from transplant kidney to recipient
nephrectomy not usually indicated unless causing problem/to make space for new kidney
from living or deceased donor
Contraindication Complications
current infection Delayed graft funct
mets cancer DM, HTN
severe cardiac disease Rejection
Still syndrome
Ureteric stenosis
Infection
Skin cancer to sunburn

Current trends in renal immunosuppression

Greater use of Ab induction in USA
Polyclonal (Rabbit ATG)
Anti CD25 (Basiliximab, Daclizumab)
Minimisation of maintenance drugs to reduce long -term toxicities (Steroids, CNI)
New drugs
GENERIC BRAND FDA INDICATION
Alefacept 12
Amevive Treatment of moderate-to-severe chronic plaque psoriasis in adults who are candidates for systemic
therapy or phototherapy
Alemtuzumab2 Campath Treatment of B-CLL
ASKP1240 Not FDA approved
Azathioprine Imuran Adjunctive therapy in prevention of rejection of kidney transplants; mx of active rheumatoid arthritis
Basiliximab Simulect Prevention of acute rejection in kidney transplantation
Belatacept Nulojix Prevention of acute rejection in renal transplant recipients
Bortezomib Velcade Treatment of multiple myeloma; treatment of relapsed or refractory mantle cell lymphoma
Cyclosporine Neoral Prevention of acute rejection in renal transplant recipients
Eculizumab Soliris Treatment of PNH to reduce hemolysis and aHUS
Efalizumab 12
Raptiva Management of moderate to severe chronic plaque psoriasis in adults
Everolimus Afinitor, Treatment of advanced renal cell cancer (Afinitor); treatment of subependymal giant cell astrocytom
Zortress associated with tuberous sclerosis (Afinitor); treatment of advanced, metastatic or unresectable pancreatic
neuroendocrine tumors (Afinitor); prophylaxis of organ rejection in patients at low-moderate
immunologic risk receiving renal transplants (Zortress)
Mycophenolate Mofetil Cellcept Prophylaxis of organ rejection concomitantly with cyclosporine and corticosteroids in patients receiving
allogeneic renal cardiac, or hepatic transplants
Mycophenolate Sodium Myfortic Prophylaxis of organ rejection concomitantly with cyclosporine and corticosteroids in patients receiving
allogeneic renal transplantation
Horse or Rabbit anti- Atgam or Treatment of corticosteroid resistant rejection in kidney transplantation
thymocyte Globulin Thymoglobulin
Rituximab Rituxan Treatment of CD20-positive non-Hodgkins lymphomas ; Treatment of moderately- to severely-active
rheumatoid arthritis in adult patients with inadequate response to one or more TNF antagonists; Treatment
of Wegeners granulomatosis; Treatment of microscopic polyangiitis
Sirolimus Rapamune Prevention of acute rejection in renal transplant recipients
Sotrastaurin, AEB-0711 Not FDA approved
Tacrolimus Prograf Prevention of acute rejection in renal transplant recipients
Tacrolimus Prolonged Astragraf XL Preventing organ rejection in kidney transplant recipients, as combination therapy with mycophenolate
Release mofetil and corticosteroids, with or without tasiliximab induction
Tolfacitinib1 Xeljanz Treatment of moderate to severe rheumatoid arthritis
Voclosporin Not FDA approved
1
No longer being investigated for transplantation;
2
Withdrawn from United States Market. FDA: Food and Drug Administration; B-CLL: B-cell chronic lymphocytic leukemia; PNH: Paroxysmal nocturnal
hemoglobinuria; aHUS: Atypical hemolytic uremic syndrome.
Wednesday, 21/10/2015
32.LOWER GI BLEED

CASE
70y/o M collapsed into secondary to massive bleeding PR
o Bright red lower GI? Not really, aortoduodenal fistula can also be bright
o Diverticular bleed from ascending colon can be dark

MX
Fluid resuscitation STABLE NOW
o Colloid: stays in circulation longer, patients can have Next?
reactions to it, > expensive Hx
o Crystalloid: safer to give, cheaper o FHx: bleeding disorders: no fam hx of bowel ca
Types: Hartmanns solution (contains o MEDS: NSAIDS, anticoagulants, antipL: not on
131mmol/mol, Na, 5mmol/mol K, 111mmol/mol medications
Cl) o PMH: liver disease (portal hypertension): no liver
Urinary catheter disease
High flow O2 o PSH: surgery to stomach or aorta (aortoduodenal
fistula): no previous surgeries
o SHx: not a smoker, non-drinker
Physical examination
o Urine: 40mls/hour

INVESTIGATIONS
 OGD: gastroscopy (90% of upper GI bleeding settles spontaneously)
Aetiology of lower GI bleed form a source of upper GI
Perforation of PUD
Oesophageal/ duodenal varices
Aortoduodenal fistula
***Role of PPIs (might miss findings if given before OGD), but still given first now
BIOCHEMICAL
o Blood: Hg 9.2, WCC 10, pL 200, aPTT, PT N
o LFTs: N
o U&E: N
SITUATION
INR 10
On warfarin for AFib
Hx of severe diverticular
disease
Had colonoscopy a year ago
with documented severe
diverticular disease
Patient stable
haemodynamically
Documented liver disease
Stable
DRE shows big massively
bleeding rectal tumour
Stable
PMH: Angiodysplasia (abN
submucosal vessels- usually
veins) in R-sided colon
VS Dieulofoy lesions
(arterioles)
Not bleeding anymore now,
stopped
Colonoscopy clear
Not on any meds
No PMH
Proctoscopy shows big
internal & external
haemorrhoids with arterial
bleeding
Small bleeding
o Anal fissures: common
(usually main PC is not
bleeding but excruciating
pain persisted for an hour
after defecation refractory
to analgesia, topical
steroid works)
Aetiology of lower GI bleed from a source of lower GI bleed
Anorectal bleeding- anal fissures, haemorrhoids (most common)
Angiodysplasias
Colorectal cancer
IBD
Colitis
Iatrogenic
MANAGEMENT
Prothrombin complex concentrates (PCC): works quickly
Give fresh frozen plasma
Theatre for colectomy
Wait & watch: 90% settles with conservative mx
Resuscitate blood lost
Send home
Transfer to medical care of gastroenterologists: investigate cause (surgically stable)
Embolize varices
TIPSS
Long term: liver transplant
Colonoscopy + biopsy pathology (tissue dx)
Staging
MDT discussion need of neoadjuvant chemotherapy for 6 weeks before operation
Angioembolization
doesnt work
Sclerosing agents (coagulate vessels) or clip vessels
doesnt work
Surgical resection: R hemicolectomy
Consent: complication death (<0.1%), risk of anastomotic leak (5% on R colon, >
with lower rectal excision: 5-10%)
Conservative medical intervention (minimal) haemorrhoidectomy
Grades
oI: conservative: Conservative: high fibre diets, stool softeners
oI-II: refractory to conservative and medical: sclerosing agents (phenol)
oII-III: Banding
Not improving: Haemorrhoidectomy
oFergusons procedure: close
VS
oMilligan-Morgan: leave open to heal
***Embolization (only done when u can x visualize source of bleeding)
Recurrence rates: very high (50%)
Conservative: as above
Medical: GTN (headaches SE) now use > Ca channel blockers for 6weeks
Surgical
A.Colostomy
B.APR
C.Proctectomy
D.Internal sphincterotomy
E.Botox injection: 50units on both sides (temporary for 6months - a year)
not working
A.Colostomy
B.APR
C.Proctectomy
 D.Internal sphincterotomy: divide 2/3rd of internal sphincter allow relaxation with
quick healing
E.Botox injection
not working
A.Colostomy
B.APR
C.Proctectomy
D.Internal sphincterotomy: another sphicterotomy (do endoanal US to define
sphincter anatomy >)
E.Botox injection
AD fistula Gastro-surgeons must be onboard
Resuscitate: high flow O2, catheterize, all monitors on
Unstable, no cause found Theatre
IR: angiogram embolization of vessels if found (angioembolization takes 6hours,
must be stable for prior CT)
Exploratory laparotomy segmental clamps of large & small bowel to see if blood
is collecting in any of the segments resect based on arterial supply
On table angiogram: with assistance of IR look for leaking of contrasts
If suspecting bleeding from upper intestines or proximal lower GI
SMA: R colon contrast leaking, IMA: L colon

Thursday, 22/10/2015
33.VASCULAR SURGERY

PULSES
Types
DORSALIS PEDIS
Located by drawing an imaginary line between two malleoli
From midpoint of this line, draw a perpendicular line to first interdigital web
Middle third of this line = palpate dorsalis pedis
Or
Palpate lateral to extensor hallucis longus tendon

POSTERIOR TIBIAL
Halfway between medial malleolus and tip of calcaneus

PERONEAL PULSE
In 10%, lateral to lateral malleolus

INVESTIGATION
Hx
o Look for claudication
ABI
o Critical ischaemia: <0.3
 o Claudication: <0.5
o Normal: 1
Imaging
o MRA

CASE 1: ACUTE LIMB ISCHAEMIA

IR, 70y/o F from Drogheda who is day 4 post-op for an emergency brachial embolectomy for acute UL ischaemia
BIBA form OLLH, Drogheda 4 days ago when she was experiencing R arm heaviness associated with pallor, paraesthesia
(pains and needles), coldness as well as an impalpable R radial arterial pulse
She initially presented to her GP last Friday due to worsening SOB and chest tightness and was referred to OLOL the
same day for tx as an exacerbation of her CHF
During her admission, she developed the above symptoms the next morning. A CT angiogram showed an occlusion at
the level of elbow and she was consequently started on 5000IU warfarin

Impression
Emboli from heart

Aetiology
AFib
Qx:
Symptoms: palpitations or irregular heartbeats? YES
RF: HTN, diabetics, family history, smoker
Meds: Warfarin

CASE 2: CHRONIC LIMB ISCHAEMIA

PC, 73y/o F

HPC
bad circulation in the legs
Changes in legs: pale, since last 6months, gradually progressive, pain when asleep, hang legs out of bed relieved the pain
When last able to walk? 5years before

RFs
HTN, DM, smoker, family history (father had MI at 67), hypercholesterolaemia (on meds)
PMH: MI between operations, 6 years ago (+TIAs, +CVAs, cardiac events)
IC lasting for 10years and gradually worsening in the R leg with her claudication distance before the amputation being
only 10yards
Friday, 23/10/2015
34. REVISION
SCENARIO IMAGE INVESTIGATION/ MANAGEMENT
CASE 1 For open wound injury
VAC (Vacuum-assisted Closure)

CASE 2
40y/o pt brought to ED of hx of
stabbing in the R side of chest
On exam he was cold and clammy
with a thread pulse of 125m/min
and BP of 90/60mmHg
Breath sounds were absent on the R
side
What does the CXR shows?
CXR PE
Right-sided haemothorax Distinguish pneumothorax VS
Patient lying down air level in haemothorax percussion:
stomach hyperresonane in pneumothorax,
dull in haemothorax
Mx
Bloods for group, cross & match
Chest drain give 1500mls blood
STAT
CASE 3 If patient is on warfarin and INR is
70y/o man in nursing home 3.5, give Vitamin K and recombinant
Subdural haematoma: crescent- prothrombin inhibitors
shaped and midline shift

CASE 4 Ask to cough to confirm

2cm bulge around umbilicus Reducible or not: reducible
through linea alba paraumbilical palpate to assess size of defect
hernia True umbilical hernia: only in
paediatrics

CASE 5 Complete dehiscence

Mildly distended abdomen with Partial dehiscence
midline laparotomy scar that is
healing by secondary intention A large lump above umbilicus
incisional hernia

CASE 6 Consistent with end-colostomy

A stoma flushed to the skin of one APR or Hartmanns distinguish
lumen not attached to the bag with presence of anal stump
The skin surrounding the stoma is
healthy

CASE 7
A spouted stoma on the right side of
abdomen of two lumens consistent
with loop-ileostomy
Surrounding skin is healthy
CASE 8
A spouted (3-4cm) stoma on right
side of abdomen with healthy
surrounding skin consistent with
end-ileostomy
No visible peristalsis

CASE 9 Complications
Central line Displacement
3lumens into venous: IJV Trauma to surrounding structures
(subclavian is another option) Pneumothorax

CASE 10 Mx
CT Abd & pelvis NG tube for decompression
Small bowel dilatation (central, Antibiotics
valvulae conniventae) SBO

CASE 11
CXR
o PA view
o Chest drain into 2nd ICS
o Subcutaneous emphysema:
crepitation on palpation

CASE 12
Examination of groin: SFJ
competence
Trendelenburgs test: patient lying
down raise leg up to empty veins
tourniquet just below SFJ
paient stand up incompetence
below SFJ if veins has not fill up VS if
filled up (competent)
Duplex combined with Doppler US
Examination of gaiter area medially:
looking for ulcers, haemosiderin
pigmentation, lipodermatosclerosis,
venous eczema, oedema
Mx
Conservatively with TED stocking
If SFJ is incompetent: ligation of
saphenous vein strip saphenous
vein up to level of the knee (not
below knee because chance of
damaging saphenous nerve very
high)
Multiple avulsion phlebectomy
Sclerotherapy
Anterior view
Multiple dilated torturous veins on
posterior and lateral aspect of legs
No visible skin changes
Varicosities are not pulsatile
CASE 13 Multiple diverticular (most
Colonoscopy common in sigmoid) diverticular
Bloating abdominal discomfort on disease
and off
Alternating bowel habit

CASE 14 Complication
ERCP scope into duodenum with Pancreatitis
injected dye dilated CBD + filling Perforation
defects caused by stones presence Bleeding
VS Ascending infection in to biliary
MRCP: no scope, only shows tract
reconstruction of biliary tracts

CASE 15
2hours after biopsy of a lung nodule,
your pt complaints of SOB and has
an SAO2 of 85% on room air
CXR
Increased in radiolucency and
hyper-expanded right lung area
consistent pneumothorax on right
lung
Mediastinal shift
Tension pneumothorax
(mediastinal & tracheal shift, cyanotic
patient) VS spontaneous
pneumothorax

Mx
Decompression with a needle on 2nd
ICS MCL
CASE 16
M, RTA
Biconvex hyperdensity Extradural
haematoma

CASE 17
NG tube
Fx: enteral feeding (difficulty
swallowing)

CASE 18 NG tube for feeding VS decompression

NG tube Size
Fx: decompression for SBO, ileus What is connected to the tube: feed
or suction
CASE 19
PEG Tube
Percutaneous insertion under US
guidance
Fx: nutrition

CASE 20 Normal: 2 ports

3way Foley catheter
o 1 port to inflate balloon
o 1 for irrigation haematuria post
TURP: prevent haemostasis
forming clots
o 1 for drainage
CASE 21
Colonoscopy: tumour

CASE 22
Perianal abscess

CASE 23
External haemorrhoids, perianal
ahaematoma

Trash foot: ischaemia