3.

TOE: ap & aortic regurg

Surgery
Rx.
Type A  ( Ascending aorta) dacron graft
Jeremy Lynch. July 15, 2007 Type B  ( Distal to L subclavian) Conservative w hypotensive drugs ( to # BP stop-
ping extension of aneurysm)

I Heart & Thoracic Aorta II Arterial Disease

Can be divided into occlusive or aneurysmal. Most common cause of both is atheroscle-
1 Thoracic Aortic Aneurysms rosis .
Causes.
Arch of aorta  M arfans , ( syphilis)
Descending  Traumatic, syphilis, athersclerotic
3 Anatomy
Clinical.
Ascending  Chest pain, aortic regurgitation, obstruction of the SVC, obstruction of
the right main bronchus, pulsating mass in front of the chest ! may even ulcerate
through the wall
Arch  Compress trachea or ulcerate i nto it. Liable to stretch the left recurrent
laryngeal ! hoarseness. May obstruct left lower lobe ! collapse.
Descending  Back pain, erosion of vertebrae, press on oesophagus producing dys-
phagis ! may rupture into it
Ix. CXR ( calcication) , CT/MRI ( extent & size) , aortography dangerous & not
done , USS ( aortic valve incompetence)
Rx. Excision of aneurysm & graft. Need bypass to perform
Cx. Spinal ischamia: loss of ow of radicular artery ! paraplegia

2 Aortic Dissection
Path. Usually arch, blood dissects in media. Usually
F igu re 1 .

Epi. Hypertension, atherosclerosis

Clinical. Sudden sev pain in chest, may radiate in to arms, neck, abdomen, or with a
tearing interscapular pain. May be signs of surgical shock ( due to cardiac tamponade
4 Investigations
or ext rupture) . As dissection progresses origins of main arterial branches may become Urine & blood glucose  DM
blocked ! dissapearance of peripheral pulses. Renal vessels: haematuria/anuri. Leg Hbg  Anaemia, polycythaemia.
ischaemia.
Ix. ESR, CRP  Inammatory/mycotic aneurysms
1 . CXR: widened mediastinum Cholesterol  Atherosclerosis
2. Contrast enhanced CT ECG  Coronary disease

1
Echo heart  Valvular lesions, mural thrombus, aneurysms, atrial myxoma 4. Fasciotomy for compartment syndrome
CXR  Bronchial Ca common in end stage vascular disease ( both caused by smoking) , Open 
heart size 1 . Direct compression 2. Resuscitation: replace blood
Doppler USS  Arterial waveform: monophasic in hardened arteries 3. Exploration: partial tears may be sutured, division requires saphenous interposi-
Duplex USS  Imaging tion. Avoid using prosthetics due to infx risk
Arteriography  Site, extent of blockage: if reconstructive surgery/angioplasty contem-
plated
Angioplasty  Dilation by balloon catheter + stenting 7 Aneurysm
CT & USS  Aneurysms Def. Abnormal permanent dilatation of an artery or part of an artery or the heart
Morphology. May be fusiform, saccular, or false/ pseudoaneurysms ( when there is a sac
communicating w the artery lumen)
5 Treatment Types.
1 . T reat handicap not the disability : e. g. if seldom needs to walk 500m then don' t Saccular  Narrow neck: mycotic ( inammation causes localized weakness) .
need to rx. Fusiform  Generalized dilatation: abdominal aorta
2. P rophylactic surgery only appropriate when risk of event outweighs pro-
cedure : e. g. when AAA gets big enough. False  Blood leaks out of artery & is contained by ct lined w thrombus ! will either
rupture spontaneously or enlarge and rupture
AV  False aneurysm
6 Arterial Trauma Dissecting  Blood forces passage through break in intima of vessel ! may rupture
back in to lumen or out of adventitia. Over this artery segment vessels are deprived
Classied. of blood
1 . Closed: extraneous compression e. g. crush injury, fractures of adjacent bones w dis- Aetiology.
placement of artery ( eg. supracondylar fracture) , joint dislocation. 1. Congenital: Berry aneurysms
2. Penetration: e. g. stabbing, iatrogenic 2. Degenerative: atheroma . Most common cause
Types. 3. Traumatic: penetrating bullet or catheterisation ! true or false
1 . Mural contusion w 2 spasm
o 4. Infection: mycotic. E. g. tertiary syphilis, salmenollosis, immunodeciency
2. Intimal tear: usually result of stretching of artery. Results in artery buckling & 5. Inammation: subtype of atherosclerotic/ mycotic in which theres an immune
causing localized stenosis which may result in thrombosis or dissection response to components in the aneurysm wall ! dense inammatory forming rind
3. Full thickness tear: paradoxically partial' s bleed copiously whilst completes results around lumen
in contraction and spasm and so # blood loss Clinical of true aneurysms.
Consequences. Abdominal: asx, back pain, bloating, swelling pulsatile + expansile, consequence of

1 . Haemorrhage 2. Thrombosis 3. AV stula 4. False aneurysm distal emboli
 Peripheral: pulsatile swelling, distal ischaemia, thrill bruit, machinery murmur ( AV
5. Compartment syndrome: ischaemic muscle swelling in closed fascial compartment ! communication)
exacerbates ischaemia ! Volkmann' s ischaemic contracture
C linic al . Pain, pallor, pulselessness, paraesthesiae, paralysis, perishing

. Dilated, tortuous, atheromatous artery, mass overlying artery
cold . Haemorrhage may be overt or concealed. May develop hypovolaemic shock Complications.
Treatment. 1 . Rupture: " w diameter
Closed  2. Thrombosis 3. Embolism 4. Pressure
5. Infx: become infected or arise as a result of
1 . Treat causation: e. g. open plaster cast, reduce fractures
2. Angiography: discriminated ischaemia due to spasm, intimal tear, arterial dis- Ix.
ruption 1 . AXR: calcication in wall of aneurysm
3. Operative exploration: if failure of above, or tear or block. Saphenous V often 2. CT/MRI/ USS: size & extent
used to replace areas 3. ( Angiography: but underestimates size, and risk of perforation)

2
7.1 Abdominal Aortic Aneurysm 2. Angiography: artery tree distal to aneurysm
Rx. Femoral ! distal popliteal bypasses w ligation of feeding vessels

8 Atherosclerotic Arterial Disease

Aetiology.
1. FH
2. S moking : nicotine ( vasopasm) , CO, " platelet stickiness
3. H yperlipidaemia
4. H ypercholesterolaemia
5. H ypertension
6. D iabetes : " Atherosclerosis, " microangiopathy. Presentations:
a) Young pt w peripheral gangrene but good pulses in limb. Rx: Control infx and
improved diabetic control, local debridement. Last resort is amputation
b) Elderly w atherosclerosis: DM results in # prognosis
7.  ( and post-menopausal  )
8. Age
9. # E xercise
Occlusive arterial disease pattern. Exercise induced pain ( intermittent claudica-
tion ) ! rest pain ! gangrene .
F igur e 2 .

Epi. Common in older  , FH, assoc w popliteal aneurysm

. Acute aortic expansion ( Pain of rupture without haemodynamic consequences) .
Only ix if there is reasonable doubt.
9 Coronary Occlusive Disease (Coronary Angina)
Rx. If < 5. 5/6 cm then regular USS. Preop assessment includes coincident cadiac disease Results in. Angina
( exercise ECG, echocardiography) , renal disease. Involves open surgery w Dacron graft,
or can be done endovascularly w graft ( excludes sac from blood ow. Good for those
otherwise unt for surgery)
Complications of Rx. 10 Mesenteric Occlusive Disease (Mesenteric Angina)
1 . Renal failure: # blood ow when clamp aorta. Worse if aneurysm spans renal Clinical. Pain after meals, weight loss, fear of eating
arteries
2. Distal embolization
3. MI: coincident cardiac disease common, and " peripheral resistance w clamping
4. Graft infection: aorto-enteric
Ruptured AA. Assume if sev back pain and collapse.

includes renal colic. 50% die
11 Cerebral Occlusive Disease
before hospital, 50% die on the table. Most patients reaching hospital the aneurysm is Causes. Stroke, dementia, TIAs
contained retroperitoneally. Don' t give " uids cos causes more bleeding.
7.2 Popliteal Aneurysm 12 Intermittent Claudication
Claim to Fame. The most common peripheral aneurysm
Clinical. Generally asx, may cause distal embolization leading to claudication or digital Clinical. Gripping, tight clamp-like pain in the calf on exercise. Usually one leg in
infarction. Ex reveals prominent pulsation in popliteal fossa extending proximally. advance of the other. Pain disappears on resting.
Ix.

. Spinal claudication: Pain present on standing, requires pt to sit down before
1 . Duplex USS: extent & size relieved.

3
Pathology. Calf pain ( thigh lesion) , buttock pain ( internal iliac) . Bilateral buttock clau- Rx. Aspirin. > 70%: endarterectomy. Complications : death/ stroke, haemorrhage,
dication assoc w impotence hypoglossal neuropraxia ( tongue protusion) , reperfusion syndrome ( to brain) , resten-
Rx. sosis
Conservative  # RFs, weight loss, exercise, foot care
Interventional  Arteriography ( short, > 70% occlusions amenable by angiography) ,
duplex scanning ( replacing angiography)
15 Raynaud's
1 . Angioplasty: balloon stretch/fractures. Risk of embolization, perforation Cause. Intermittent spasm of small arteries precipitated by cold exposure.
2. Thrombolysis: TPA, streptokinase. Not appropriate for acute cos takes time Clinical. White ! blue ! red
3. Bypass: Complications inc dissection, embolization thrombosis Aetiology. 1 ( women) , phenomenon ( 2 to c. t. disease usually) , cryoglobulinaemia.
o o

vibrating tools
13 Critical Ischaemia

. Cervical rib, atherosclerosis, Beurgers'
Rx.
Def. Rest pain, ulceration or gangrene assoc w absent pedal pulses , or ABPI Conservative  Gloves, stop smoking. Surgery  Sympathectomy
< 0. 5
Rest pain  Ischaemia. Initially at night ( horizontal) . Relieved by hanging leg over
side. As disease progresses becomes continuous
Gangrene  Sev vascular impairment. Pressure areas ( heel, malleoli, plantar ball of
16 Beurger's (Thromboangiitis Obliterans)
hallux) . Minimal trauma causes abrasions. Clinical. Similar to atherosclerosis ( As obliterated ! ischaemia) , but in young  , heavy
Ix. Same as claudication smokers, hands/ ngers. Ulcers, gangrene. Veins/ nerves can also be aected. Rx: stop
Rx. smoking.
Non-operative  Arteriography & angioplasty, lumbar sympathectomy ( " blood
supply)
Operative: Reconstructive surgery  Needs : good arterial supply to blockage, 17 Embolism
good vessels below, conduit ( saphenous vein, or PTFE) , patient in good health cos Def. Abnormal undissolved material carried in blood from one part of vascular system to
" mortality impact in distant. May be air, fat, tumour, but most commonly thrombus from
Amputation  Pain not controlled by above, or gangrene + infection heart or major vessels . A surgical emergency.
Where. Usually bifurcations. Can go to CNS, retina, small intestine, renal ( haematuria,
pain in loin) , splenic ( subcostal pain) .
14 Carotid Artery Disease Clinical. In a limb: The P' s ( see above) . Contractions develop w time. The block can
move distally in the few hours. Skin staining non-blanching on pressure ( irreversible
Where. Bifurcation. Cause. Atherosclerosis + thrombus tissue damage)
Presentations. Cause.
1.
Amaurosis fugax : uniL blindness lasting minutes 1 . Atrial fibrillation : by far most common
2.
Strokes 2. Mural thrombus: often post-MI
3.
TIA 3. ( Aortic dissection) 4. ( Paradoxical i. e. venous origin)
4.
Hypoperfusion: biL may cause critical ischaemia on exertion
Clinical. Bruit, evidence of disease elsewhere Rx.


. Hypoglycaemia, epilepsy, migraine, neoplasm, embolism from heart 1 . Assessment: if resolving ( re-appearance of pulses) consider thrombolysis. If no
blood supply and neuro
s then surgery. After 24h, or skin staining, successful
Ix. revascularization is unlikely.
1 . Duplex USS 2. Angiography 3. MRI of vessels 4. MRI/CT brain 2. Heparinization: as soon as diagnosis made
5. Cerebral reactivity: measure
in haemodynamic response whilst pt breathes CO 2 3. Surgical embolectomy: open, closed ( Fogarty catheter: pass line pst clot, inate,
( a vasodilator) then pull back)
6. ECG/echo heart 4. Thrombolysis: if likely a thrombus in situ

4
18 Cold injury Rx.
1 . Neuropathic: abx for infection, wide local excision & drainage of necrotic tissue
Pathology. Capillary sludging and thrombus 2. Ischaemic: angiography & consideration of plasty or bypass
Rx. Gentle warming, heparin, abx. Local amputation

19 Diabetic Foot At a Glance

III Venous Disorders of Lower Limb
20 Anatomy

F igur e 3.

Path. Ischaemia ( macro & micro) , neuropathy ( sensory, motor, autonomic) , sepsis ( " glu-
cose promotes bacterial growth)
Clinical.
Neuropathic  Sensory, trophic skin, plantar ulceration, Charcot' s, pulses often pre-
sent, sepsis
Ischaemic  Rest pain, painful ulcers over P areas, hx of intermittent claudication,
absent pulses
Ix. F igu re 4.

1 . ABPI: may be falsely elevated due to sclerosis

2. XR: osteomyelitis Systems.
3. Arteriography Deep  Inside deep fascia. Tributaries drain into popliteal ! femoral ! ext iliac !
Prevention. iliac ! IVC
Do  Wash & dry feet, inspect daily, care of toenails, anti-fungal powder Supercial  Outside fascia, draining skin/supercial tissues.
Do not  Barefoot, ill-tting shoes, hot-water bottles, ignore injury 1 . Long saphenous ( from dorsum foot) 2. Short saphenous ( lat lower limb) .

5
Perforators. Supercial ! deep. Medial/ lat tibia above ankle, and one mid-thigh.
Calf pump. Empties deep veins, so then supercial veins ! deep veins
21 Pathology
Cause. Valvular incompetence: usually physical ( such as thrombus) ! " resistance to
return ow. Incompetence breeds incompetence.
22 Varicose Veins
2 o  Previous DVT, " venous P due to compression ( e. g. pelvic tumour, pregnancy) ,
AVS stula, tricuspid incompetence
HPC. Cosmetic, tiredness, aching, throbbing, swelling ankles, esp after standing
Ex. Must be standing. Inspect medial gaiter for deep venous insuciency ( haemosiderin,
eczema, lipodermatosclerosis) . Port-wine stain ( AVS malformations) . Saphena varix
( saphenofemoral dilation, thrill) . Tap Test for Supercial Valve incompetence ( feel
saphenofemoral and tap peripherally. If no valves then feel it. ) Trendelenburg' s test.
Ix.
1 . Doppler probe: poor ow
2. Duplex US: diagnose
3. Venography: tourniquet on ankle to occlude supercial, inject contrast into dorsum
of foot ! up deep system ! observe supercial reux
Rx.
1 . Graded compression stockings ( minor varicosities, pregnant, unt)
2. Sclerotherapy: compressed for 2w after to enable brosis. Small/ mod sized.
3. Surgical: Indications include haemorrhage, varicosities grossly dilated/ otherwise
symptomatic, skin
s, incompetent perforators. Involves disconnecting great saphe-
nous from femoral vein, dividing terminal branches of great saphenous. Recurrence
is due to failure original diagnosis or defect in technique.
Cx.
Haemorrhage  Due to minor trauma. Lie pt down w leg elevated & apply pressure
bandage.
Phlebitis  Tender, hard, inamed skin, may be pyrexial, can have 2 bacterial. Rx:
o

bed rest w elevated foot of bed, pressure bandage, abx ( if needed) , systemic antico-
agulation

23 Varicocele
Def. Dilated veins of the pampiniform plexus ( in the testes)
Description. L usually. Associated w renal Ca, infertility. May be painful. bag of
worms. 
Rx. Can embolise, ligate/ divide.

24 Deep Venous Insuciency

M alleolar  are = red in am mation from m elleolus. O nychogryposis = dam aged toe- Cause. Incompetence of valves of deep venous system .
Aetiology.
F igur e 5 .

nails

Def. Abn dilated & lengthened supercial veins, due to incompetent perforator veins or 1 o  Congenital lack of valves
supercial valves. 2 o  Venous hypertension ( DVT) , AVS stula.
Classication. Clinical.
1 o  Majority.  :  = 2: 1 . Accentuated by pregnancy 1 . Swelling ( Esp lower leg) due to transudation of uid across capillaries

6
 2. Supercial varicose veins ( 2 perforator incompetence)
o
3. Haemosiderin pigmentation ( broken down hbg)
4. Eczema, pruritis
5. Lipodermatosclerosis: thick brous tissue ( due to inammation) ! inverted cham-
pagne bottle
6. Ulceration ( poor skin nutrition)
Ix.
1 . Venography: identify perforators that can be treated
Rx. None, can only rx the supercials.
2. Duplex sonography
Where. Often medial malleolus
Appearance. Ragged edge. May have white rim around ( previous scarring) . SCC can
arise in these ulcers ( Marjolin' s)


. Venous ( 90%) , ischaemic, neuropathic, malignant, systemic-related, AVS stula-
associated, gumma of syphilis
Rx. Conne pt to bed w foot elevation to abolish " P. Keep clean. Abx only if gross infec-
tion. Unfortunately if old then prolonged bed is dangerous. Also: tight bandaging
( empties supercial resulting in more ecient pump ! " O to area) . Once healed t
2

graduated compression stockings.

25 Venous Ulceration
26 DVT
Predominantly a medical condition.
Ix. Nb. Duplex unreliable below knee. D-dimer has signicant false + ve rate
Prophylaxis. Early post-op mobilisation, pneumatic compression, TED stockings, hep-
arin, avoid OCP
Rx & prevention. Heparin

IV 15: Head Injury

F igur e 6 .

Cause. Venous ulceration is due to venous hypertension 2 to incompetence of deep veins.

o

Ask about past possible DVTs. F igu re 7.

7

Ta b l e 1 .
27 Types of Fractures
Scalp injuries  Usually simple penetrating: debridement & suture. If skull also pene-
trated br may also be lacerated: consciousness not necessarily lost
Skull  Crushing or other sev force. Usually linear fracture of skull vault. Skull XR:
fracture is an important indicator of the force of injury & risk of IC haemorrhage
Paranasal sinuses: CSF rhinorrhoea  Usually open as overlying dura breached.
Anosmia if fracture across cribriform plate. Risk of meningitis.
Petrous temporal bone: CSF otorrhoea or rhinorrhoea  Involvement of inner ear
causes deafness. Leak usually self-limiting
Temporal bone: middle meningeal vessels  Causing extradural haemorrhage.
Depressed fractures  Fragment of bone below level of surrounding bone. Rx: can
leave it if not troublesome. Elevate if e. g. contaminated, haematoma
Ant/middle cranial fossae: Orbital haematoma  Looks like a black eye ( racoon
eye) . Suggested by: subconjuctival haemorrhage, absence of grazing of the surrounding
skin, conned to margin of orbit, mild exophthalmos, bilateral haematoma
8
28 Brain Injuries
Types.
1 o  Direct result of trauma.
 Diuse: shearing movements ! axon damage + rupture of small vessels
 Localized: brain impacts against the skull
 Coup & contre-coup: the opposite side of the brain damaged as it rebounds o
skull.
 Laceration: brain impacts on sharp bony edges
2  After initial event, result of hypoxia, hypercapnia, hypotension ( ischaemia) ,
o
haemorrhage, meningitis. In-hospital mortality.
29 Cerebral Perfusion
Systemic arterial pressure. Autoregulation by cerebral arterioles
Intracranial pressure. Skull is a closed compartment:
CPP = BP ? ICP
" ICP and hypotension in trauma victims reduces blood ow ! ischaemia ! reex
increase in systemic pressure & bradycardia ( Cushing' s reex )
Cerebrovascular resistance. Arteriolar vasodilatation with: " P CO , " pH. If reduction
2
in cerebral blood volume wanted therapeutically ( e. g. cerebral oedema) : pt hyperventi-
lated. Conversely hypercapnia in presence of oedema might exacerbate brain injury.
30 Management of Head Injury
Initial Assessment.
Hx  Mechanism of injury, immediate condition ( GCS, vital signs, pupils, limb move-
ments) ,
in condition after rst assessment, prior condition ( diabetes - ?hypo)
Ex  Major injuries: ABC. Conscious level. Details in the book . GCS ( Note how high
each goes: Count to 4: open your eyes. Count to 5: talking jive. Count to 6: feels
the pricks ) :
i. Eye opening 4: Spontaneous 3: To command 2: To pain 1 : None
ii. Verbal response e 5: Oriented 4: Confused conversation 3: Inappropriate words 2:
Incomprehensible 1 : None
iii. Motor response 6: Obeys command 5: Localizes pain 4: Withdraws from pain 3:
Abnormal exion to pain 2: Extension response to pain 1 : Non
Ix 
1 . Skull XR: indicated when LoC, impaired GCS, amnesia, scalp swelling, lacera-
tion to bone, hx of high energy impact, persistent vomiting, headache
2. Cervical spine XR: unconcious pts
3. CT: indicated if sev head injuries, CSF rhinorrhoea or otorrhoea, penetrating,
bilateral orbital haematoma ( Battle sign)
Immediate Rx. Correct problems in initial assessment: e. g. draining pneumothorx, ven- Hyperpyrexia  Cooling blankets
tilation, laporotomy. Amnesia  Longer, the worse prognosis of mental function
Deterioration. Epilepsy  Penetrating open wounds w cortical scarring
 Cerebral oedema
 IC haemorrhage
 Hypoxia


Infection: 2 to fractures
Hyrocephalus
o
33 Brain Death
Delayed management. In book Details in the book.

31 Traumatic Intracranial Bleeding

E xtrad
I C B leed

S ub dural S ubar Intrac Intrave

V Oesophagus
Acute C hronic
F igur e 8 . 34 General Abdominal Colic
Extradural. Often tear in middle meningeal artery. C onvex CT scan 1 . Biliary tract: stone in Hartmann' s pouch, cystic duct, ampulla of Vater
Hx  Talk & die. Minor head injury causing temp concussion ! lucid interval ! 2. Renal tract: Ureteric colic due to stone, blood clot or tumour, bladder colic in acute
headache ! deeper coma ( due to cerebral compression by extradural clot. ) retention due to enlarged prostate
3. Intestinal: obstruction, appendicular colic
Ex  Signs of " ICP. Also localizing signs: explore the side of the dilated pupil, 4. Uterus: parturition, menstruation, ectopic pregnancy in fallopian tube
hemiparesis/hemiplegia or ts ( uncommon) , boggy scalp haematoma
Ix  CT
Rx  Emergency: burr hole made and clot evacuated. Diathermy to bleeding point.
Mannitol.
35 Dysphagia
Subdural. C re s cent shaped CT scan Causes.
1 . Acute : lacerated brain or torn vessels. Sev ( coma) . Rx: craniotomy & release of clot 1 . Local
2. Chronic : post-trivial injury, elderly pt ( small brain) . Tear in cerebral vein. Clinical: Lumen  Foreign Body
expanding mass ( mental deterioration, headaches, vomiting, drowsiness, coma) . Rx:
evacuation Wall  Atresia, inammatory ( 2 reux esophagitis) ,
o
caustic stricture , acha-
lasia , Plummer-Vinson w oesophageal web, pharyngeal pouch , esophageal
Subarachnoid haemorrhage. Meningeal irritability w headache, neck stiness, Kernig' s tumour
sign. Congenital B erry aneurysms, Rx: analgesics, bed rest
Outside Wall  Enlarged LNs, thoracic artery aneursym, bronchial Ca, ret-
Intracerebral haemorrhage. If exerting mass eect and " ICP then evacuate. Assoc w rosternal goitre
" BP.
2. General: myasthenia gravis, bulbar palsy, bulbar poliomyelitis, diphtheria, hysteria
Intraventricular haemorrhage. Childhood, sev head injury Hx. Previous reux oesophagitis suggests peptic stricture. Malignancy has short hx.
Ex. Look for Plummer-Vinson ( smooth tongue, anaemia, koilonychia) , LNs, upper abdo
32 Other Complications of Head Injury Ix.
mass ( cardia mass)

Meningitis  Open fractures. Rx: abx. Via nasal : penicillin ( Pneumococcus ) . Compli- 1 . Barium swallow
cating open fracture : 2nd G cephalosporin ( e. g. cefuroxine) 2. Oesophagoscopy + biopsy

9
36 Foreign Bodies Ix.
1 . CXR: dilated oesophagus as a mediastinal mass, air-uid level, pneumonitis from
Who. Children, mentally disturbed. Most can pass out unless sharp or irregular aspiration.
Cx. Penetration 2. Barium swallow: gross dilatation & tortuosity leading to unrelaxing narrowed seg-
Rx. Usually conservative: serial Xrs ment at lower end ( bird' s beak) . Absent gastric bubble
3. Oesophagoscopy: enormous sac of oesophagus w stagnant food
4. Oesophageal manometry: aperistalsis, failure of relaxation of LOS
37 Perforation of the Oesophagus: Rare Rx.
Classication. 1 . Heller' s: cardiomyotomy ( similar to Ramstedt' s)
2. Endoscopic dilatation of OJ w hydrostatic bag
From within 
1 . Foreign body
2. Iatrogenic ( oesophagoscopy, dilatation/biopsy, echocardiography) : pain + dys-
phagia + subcut emphysema 40 Plummer Vinson Syndrome
From without  ( Wounds) Clinical. Dysphagia. Caused by Fe-decient anaemia ( smooth tongue, koilonychia, spoon
Spontaneous  Lower thoracic oesophagus ( B oerhaave' s syndrome) . Sev pain in shaped nails) . Middle aged  . Hyperkaritinization of the oesophagus w formation of
chest, dorsal spine, or upper abdo ( acute mediastinitis) . Pt collapsed & cyanosed. web in upper. Premalignent.
Rigid abdomen. Surgical Emphysema Rx. Anaemia : Fe. Web : dilatation.
Ix.
1 . CXR: gas in neck and mediastinum, uid & gas in pleural cavity
2. Gastrogran swallow
Rx. 41 Pharyngeal Diverticula
Cervical perforation  Conservative. Abx, NBM, IV drip. Abscess formation in sup Def. Diverticula ( others are v rare) of the oesophagus btw the 2 parts of the inf pharyn-
mediastinum needs drainage. geal constrictor ( weak) . As it enlarges it displaces the oesophagus laterally.
Thoracic rupture  Immediate suture. Prognosis related to time after event Clinical. Elderly  . Dysphagia, regurgitation of food collected in pouch, palpable neck
swelling, foetor, aspiration pneumonia.
38 Caustic Stricture Ix. Barium swallow
Rx. Cervical incision w excision of pouch + pos myotomy of cricopharyngeus
Epi. Accidental/ suicidal with strong acids/alkalis. Mid/lower usually.
Rx. Alkali ingestion w vinegar & bicarbonate of soda. Gastrostomy ( rest the oesoph-
agus) . Steroids ( # scars) . Dilatation of strictures w bougies after 3w. If impassable then
bypass op. 42 Reux oesophagitis
Cause. Incompetent cardiac sphincter
39 Achalasia of the Cardia Cx. Ulceration, inammation, strictures
Claim to Fame. Similar to Hirschprungs of rectum Associations. S liding hernias , repeated vomiting ( esp w duodenal ulcer so " acidity) ,
NG intubation, resection of cardia, ectopic acid-secreting gastric mucosa in oesophagus
Path. Neuromuscular failure of relaxation of the lower end of the oesophagus on swal- Ix.
lowing, with progressive dilatation, tortuosity, incoordination of peristalsis, hyper-
trophy of the oesophagus above. 1.
Oesophagoscopy + biopsy ( exclude Ca)
Clinical. Most often 30s. Indistinguishable from Chagas' ( Trypanosoma cruzi destroys 2.
24h pH studies
ganglion cells) . Progressive dysphagia over m' s to y' s, sometimes assoc w spasm like 3.
Acid infusion test: give HCl triggers similar pain to reux
pain. Regurgitation of uids from the dilated oesophageal sac ! aspiration pneumonia. 4.
Barium swallow: outline of hernia
Malignant
possible. Pt' s often eat small amounts + often, & wash down w water.

. Cholecystitis, peptic ulcer, angina

10
Rx.

. Enteritis, neonatal intestinal obstruction, intracranial birth injury, overfeeding
Medical  Weight loss, smoking, corsets, antacids, H receptor antagonists ( cime-
o o
2
( vomiting)
tidine) , PPIs ( omeprazole) , prokinetics ( metoclopramide) Ix.
Surgical  1 . USS 2. Abdo XR
a) Repair of hernia, fundoplication ( can now be done laparoscopically) 3. ( Barium meal: shouldering of pyloric antrum)
b) Stricture: endoscopic balloon dilatation Rx.
Medical  Correct dehydration & hypochloraemic metabolic acidosis caused by vom-
iting
43 Tumours Ramstedt's pylorotomy  V good results
See oncology notes.
T umours
47 Duodenal Atresia
Types. Partial, complete, usually 2nd part ( near ampulla of Vater)
B enign M alignant
Clinical. Antenatal polyhydramnios. Birth : vomiting, distended stomach.
L eiomyom a 1o 2o Assoc. Downs in 30%
C arcinom a L eiomyosarcom a

. Oesophageal atresia, pyloric stenosis, congenital intestinal obstruction
F igu re 9 . L eio= sm ooth muscle Ix. Plain AXr. Rx. Duodenojejunostomy

44 Barrett's 48 Peptic ulcer

Def. Metaplasia to columnar. RF.  , smoking Pathology. Disturbance btw acid/ pepsin & mucosal barrier
Sites. Duodenum ( 80%) ( 1 st part obviously. Cos # protection there. " Acid production )
> stomach ( lesser curve. N ormal acid production ) > oesophagus
45 Presbyoesophagus Aetiology. H pylori usually, Zollinger-Ellison ( gastrin-like-peptide secreting tumour of
the pancreas) , NSAIDs, steroids, smoking, stress, blood group A
Clinical. Old ppl. Upper : dysphagia of solids + liquids. Lower : constipation RF. Duodenum : 30-40s,  (  after menopause) . Gastric :  :  = 3: 1
Path. Dysfunctional peristalsis Clinical. Asx. Pain: epigastric, attacks last for d ! w' s, can radiate in to back ( indicates
Ix. Barium: corkscrew dysmotility posterior ulcer) , usually couple h' s after meal ( may be immediate) , can wake pt in
early morning, aggravated by milk & alkalis. Heartburn, nausea, vomiting, wt loss.
Acute Presentation ( q common) : Without cause, or NSAIDs, acute stress, head injury
( Cushing' s ulcer) . Sudden pain, haemorrhage, perforation. May become chronic.
Gastric  Pain after eating( ! weight loss)
VI Stomach and Duodenum Ix.
Duodenal  Pain relieved by eating
1 . Endoscopy: hour glass stomach
46 Congenital Hypertrophic Pyloric Stenosis 2. H pylori : biopsy + urease test ( add radiolabeled urea to biopsy sample releases
ammonia) , C-urea breath test ( give labelled urea to pt to measure CO created
1 3 13

Clinical. 3-4w, most  , projectile non-bilious vomiting, failure to gain weight, dehydra-
2

by H pylori ) , serological
tion, constantly hungry, rabbit pellets, visible peristalsis, palpable tumour ( 90%) ( esp 3. Barium meals
after vomiting a feed) 4. Faecal occult blood

11
Rx.
Medical  Eradicate H pylori : e. g. omeprazole, clarithromycin/amoxicillin, metron-
idazole. Acid reduction. Prostaglandins ( e. g. misoprostol) . Avoid alcohol, smoking,
aspirin. Rest, sedation.
Surgical  Gastric ulcers : remove ulcer & gastrin-secreting zone ( Bilroth I) . Duo-
denal : remove the bulk of the acid secreting area of the stomach i. e. partial gastrec-
tomy w closure of duodenum and gastrojejunostomy, or by dividing the vagi.
Post-gastrectomy cx inc:
a) Small-stomach syndrome ( fullness)
Clinical. Profuse non-bilious vomiting, may contain food. Dehydration, wasting. The
stomach you can hear, the stomach you can hear and see, and the stomach you can
hear, see and feel: succusion splash ! visible peristalsis ! grossly hypertrophied
stomach
Ix.
1 . Barium meal: dilated stomach, narrow outlet, delay in emptying
2. ABG: hypochloraemic alkalosis


. Ca pylorus: shorter hx, painless, gross stomach dilation, mass at pylorus
o

b) Bilious vomiting Rx. Correction of dehydration and electrolyte depletion, daily gastric lavage, vitamin C
c) Anaemia: due to Fe deciency ( ulcer stops absorption of ascorbic acid) . Surgical : partial gastrectomy, or vagotomy +
d) Dumping: fainting, vertigo, sweating after food ( mimics a hypoglycaemic) , prob- pyloroplasty/gastro-enterostomy
ably an osmotic eect due to osmotic contents passing rapidly in to the jejunum
e) Steatorrhoea: not mixed adequately w pancreatic/ biliary secretions
Post-vagotomy syndromes inc:
1 . Steatorrhoea
51 Management of GI Haemorrhage
2. Diarrhoea
3. Stomal ulceration
Cx. Perforation, stenosis, haemorrhage, chronicity ( brosis) , malignant change

49 Perforated Peptic Ulcer

Claim to Fame. Was common, but now # cos PPIs
Clinical. Hx of ulcer. Sudden onset v sev pain, may refer to shoulders, aggravated by
movement ( pt lies rigidly still) . P eritonism. Nausea, haematemesis, melaena. May be
shocked. Abdomen rigid ( board-like) , tender, silent. PR: pelvic tenderness. If > 1 2h
features of generalized peritonitis w paralytic ileus, distended abdo, shock. Can have a
pos wall perforation: in to lesser sac ! muted presentation.
Ix.
1 . CXR: gas under diaphragm
2. CT: should not delay laporotomy


. Perforated appendicitis, acute cholecystitis, acute pancreatitis, MI
Rx. Can be treated conservatively
1 . NG tube: empty stomach
2. Opiates, Abx, PPIs
3. Surgery: suturing omental plus to seal the perforation, lavage of peritoneal cavity
4. Control of H pylori
Prognosis. Mortality: 5-1 0%

50 Pyloric Stenosis: Uncommon

Actually means. Duodenal ulceration causing obstruction of rst part of duodenum F igu re 1 0 .

12
 4. Technetium scan: Meckel' s
5. ( Selective visceral angiography: obscure cases)
6. ( Laporotomy)
Rx.
Conservative 
1.Reassurance, morphine
2.Vital sign monitoring
3.Treat shock w blood transfusion. CVP line insertion
4.IV PPIs
5.When bleeding stops can drink milk
Surgical  Indications:
i. Clinical: > 60y, chronic hx, relapse on medical rx, serious coexisting conditions,
continued melaena/ haematemesis, > 4 units blood needed
ii. Endoscopic: active bleeding, visible vessel, clot adherent to ulcer, unidentiable
source of blood in stomach
Method: gastric ulcer ! partial gastrectomy or excision, duodenal ! pyloroplasty &
undersewing
Notes: mortality is 1 0%, rx of varices is considered in ch. 30.

52 Stomach Tumours
Tum our
F igu re 1 1 .
M alignant B enign
Summary : assessment & replacement of blood loss, diagnosis of source, rx and control 1o 2 o Adenom a S trom al Vascular: haeman.
of bleeding
Assessment. Shock if pulse > 1 00 and systolic < 1 00 ( although dierent for hyperten- AdenoC a S tromal L ymphom a H odgkins
sives) , postural drop in BP, # CVP. Take G+ S. Distinguish old from recent bleeding.
Diagnose Source.
F igu re 1 2 .

Aetiology  Central ( haemophlia, leukaemia, anticoagulant, thrombocytopenia) , or See oncology notes

Local :
1 . Oesophagus: peptic oesophagitis, varices 52.1 GI Stromal Tumours
2. Stomach: ulcer, acute erosions ( e. g. NSAIDs) , Mallory-Weiss, tumours Path. Uncommon, from the interstitial cells of Cajal, c-kit mutation
3. Duodenum: ulcer, erosion by pancreatic tumour
4. SI: tumour, Meckel' s Assoc. Type I NF
5. Colon: tumour, diverticulitis, angiodysplasia, colitis Ix.
Hx  Ulcer, DH, alcoholism ( erosion, Mallory-Weiss) 1. Endoscopy
Ex  Purpura ( bleeding tendency) , cirrhosal tendency, circumoral telangiectasia 2. Endoscopic USS
( HHT) 3. CT
4. Staging: PET
Ix  Rx.
1 . Hbg estimation ( only after body volume restored)
2. E ndoscopy : can inject adrenaline into ulcers, and band varices Surgical  Excision
3. Colonoscopy Chemo  Glivec

13
 VII Mechanical Obstruction Op  Non-viable : remove it. Small bowel : can anastomose. Large bowel : temporary
colostomy ( if distant end cannot reach then close it - Hartmann' s) cos of " bacteria
& # blood supply here

53 Mechanical Obstruction (cf. Paralytic)

Classication. 54 Closed Loop Obstruction
Speed of onset  Acute, chronic, acute-on-chronic Def. Complete distal obstruction & valve-like obstruction proximally, e. g. volvulus
Site  High, low
Nature  Simple, strangulating ( blood supply cut o)
Aetiology  55 Adhesive Obstruction
1 . Lumen: faecal impaction, gallstone ileus, food bolus, parasites, intussusception. . . Claim to Fame. Three-quarters of all small bowel obstruction. Large bowel obstruction
2. Wall: congenital Atresia, Crohns, tumours, diverticulitis. . . from this is very rare.
3. Outside: strangulated hernia, volvulus, adhesions
Age 
1 . Neonatal: congenital atresia & stenosis, imperforate anus, volvulus,
Hirschsprung' s, meconium ileus
56 Volvulus
2. Infants: intussusception, Hirschsprung' s, strangulated hernia, Meckel' s Def. Twisting around its mesenteric axis. Most commonly sigmoid, caecum, rectum
3. Young/ middle age: strangulated hernia, adhesions, Crohns
4. Elderly: strangulated hernia, carcinoma, diverticulitis, impacted faeces Aetiology. Abnormally mobile loop ( e. g. congenital failure of rotation) , abnormally
loaded loop ( e. g. constipation) , loop xed at apex by adhesions, loop of bowel w
Clinical. narrow mesenteric attachment.
1. C olicky pain : small bowel paraumbilical, large bowel suprapubic
2. D istension ( gas builds up) : may be less in small bowel 56.1 Sigmoid Volvulus
3. Absolute constipation ( o atus, o faeces) : a late feature of small bowel, early of lb
4. Vomiting : early in high, late in chronic or low. Becomes faeculant in late stages Epi. Elderly, constipated.  >  . Rare in UK ( 2% obstructions)
( due to bacteria) Clinical. Sudden colicky pain.
Ex. Dehydrated ( if vomiting) . " Temperature suggests strangulation. Peristalsis. Look for Ix. Xr: large oval gas shadow left side, may be bent in on itself coee bean.
hernias , abdominal scar ( adhesions ) . Tinkling bowel sounds. M ust do P R Untreated ! gangrene.
( obstructing mass, intussusception, Ca) . Rx. Soft tube passed through sigmoidoscope to decompress. Laporotomy if fails, might
Strangulation features. Toxic appearance ( " pulse, " temperature) , continuous pain need to remove some bowel.
( peritonitis develops) , tenderness + rigidity, bowel sounds absent ( peritonism) , " WCC
Ix. 56.2 Caecal Volvulus
1.
AXr Aetiology. Congenital malrotation.
2.
Barium follow through Clinically. Acute onset pain in RIF w rapid abdominal distension
3.
Water-soluble contrast enema
4.
CT Ix. AXr: grossly dilated caecum often in LUQ
5.
Sigmoidoscopy, colonoscopy Rx. Laporotomy & untwisting or hemicolectomy
Rx. Acute: urgent cos of risk of strangulation.
Pre-op preparation  56.3 Small Intestinal Volvulus in Adults
1 . NG tube to decompress Aetiology. Adhesions, remnant of vitellointestinal duct
2. IV uids
3. Abx Rx. Early operation w untwisting, rx underlying cause.

14
57 Mesenteric Vascular Occlusions
Aetiology.
1. Mesenteric embolus
2. Mesenteric arterial thrombosis
3. Mesenteric venous thrombosis: assoc w portal hypertension, OCP
4. Non-occlusive: cardiac failure
Path. Infarction, bleeding, gangrene ! perforation. Intestinal angina. Steatorrhoea.
Clinical. Triad of acute colicky pain, rectal bleeding, shock ( blood loss) in
elderly AF patient. Tender abdomen, mass may be felt ( infarcted bowel)
Rx. Blood transfusion, resection of gangrenous bowel, revascularization w saphenous vein.
May need permanent TPN in young if extensive resection.
58 Neonatal Intestinal Obstruction
Classication. Intestinal atresia, meconium ileus, NEC, Hirschprung' s, Anorectal
Clinical. Continuous bile-stained vomiting. Constipation, distension, peristalsis.
58.1 Intestinal Atresia
Rx. Resection & anastomoses
58.2 Volvulus Neonatorum ( Malrotation)
Def. Congenital malrotation
Rx. Laporotomy untwisting. Adhesions ( Ladd' s bands) divided
58.3 Meconium Ileus
Assoc. 80% have CF
Clinical. Acute obstruction in rst days. May have palpable loop.
Ix. AXr: obstruction & Ground glass meconium
Rx. Gastrogran PR to emulsify. Otherwise enterotomy, resections.
59 Necrotizing Enterocolitis
Claim to Fame. Premature infants, due to ischaemia ! bacterial invasion. 25% mor-
tality
Clinical. Generalized sepsis, vomiting, listlessness. Distended, tense abdomen.
Blood/mucus passed PR.
Cx. Perforation, resolve with stricture formation
Ix. AXr: distended loops, gas bubbles in bowel wall.
Rx. Medical: resus, TPN, abx. Resection: failure to respond or cx.
15
59.1 Hirschsprung's Disease
Path. Also termed aganglionic megacolon. Absence of ganglion cells in Auerbach &
Meissner. Rectum ! sometimes extending to large bowel. Functional obstruction.
Clinical. Acute obstruction in neonate. Failure to pass meconium. Can present with
stubborn constipation in infancy. PR: narrow empty rectum, above which faecal
impaction felt.
Ix. AXr, barium enema ( narrow rectal segment) , rectal wall biopsy ( absence of ganglion
cells)


. Acquire megacolon ( sev constipation at 1 -2y)
Rx. Obstructed: colostomy. Elective surgery to resect & anastomose aganglionic.
59.2 Anorectal Atresias
Assoc. Fistula
Clinical. Anus may be absent
Rx. Reconstruction
59.3 Intussusception
Def. Prolapse of bowel into lumen of adjoining. The prolapsing bowel is the intussu-
ceptum.
Path. Ileocolic ( through IC valve into colon) in 75%. Blood supply cut o ! gangrene
Aetiology. Infants/ young children. Postulated Peyer' s patches act as foreign body ( hence
can be preceeded by viral infx) . In adults may be polyp etc.
Clinical.  >  . Paroxysms of abdominal colic with screaming & pallor. Vomiting, pas-
sage of redcurrant jelly ( blood/slime) . Palpation reveals sausage-shaped tumour. If
neglected, sx of strangulated obstruction ( " mortality at this stage) .
Ix. Barium enema
Rx.
Non-op  May be treated by barium enema ( the pressure forces it back)
Op  Reduce at laporotomy, resection may be necessary.
VIII Appendicitis Surgical Talk
Claim to Fame. Commonest emergency surgical presentation requiring operation
Path. Obstruction ( by faecolith, or lymphoid hypertrophy, or rarely tumour) followed by
infection. A retrocaecal appendix is most common.
Clinical. Pain initially colicky due to obstructed appendix ! RIF constant due to peri-
tonitis. Tenderness, guarding. Fever, anorexic, nausea, vomiting. Clinical diagnosis.
Rx. Appendicectomy: incision at McBurney' s point, open up skin subcut tissues, ext
oblique, int oblique, trasversus abdominus, peritoneum. Divide blood vessels, ligate
appendix at base, suck pus/blood out.


. Mesenteric adenitis: enlargement of mesenteric LNs causing pain, fever, tenderness.
Ix: leucocytosis ( c. f. raised neutrophil)


RIF mass. Appendix, gynaecological, caecal ca, soft tissue tumour ( e. g. sarcoma) ,
LN mass, TB, actinomycosis, iliac aneurysm
3. Fistulas: penetrate adjacent gut or bladder, or be perianal.
4. Malabsorption: vitamin deciencies, resections.
5. Diarrhoea: inammation and mucosal ulceration, colonic/rectal involvement, bacte-
rial overgrowth in obstructed segments. May have blood.
6. Perianal disease
Ix.
1 . Anaemia, faecal occult blood, # albumin, " inammatory markers
2. Small bowel enema: strictures, stula, cobblestone
3. Technetium labeled leucocyte scan: taken up in inamed segments
Cx.

IX The Small Intestine

1 . Renal calculi: 2 hyperoxaluria ( cos usually excreted in bile) due to steatorrhoea
o

2. Biliary calculi: interruption of bile salt circulation due to resection

3. Primary sclerosing cholangitis, sacroilitis, pyoderma gangreosum, uveitis
Rx. Surgery avoided cos malabsorption may follow extensive resections of the bowel
60 Meckel's Diverticulum Medical  Conservative: nutritional support, elemental diet. Acute episodes : steroid,
immunosuppression ( azathioprine) , parental nutrition, TNF-  . Mild symptoms : 5-
Def. Remnant of vitello-intestinal duct. Antimesenteric border of ileum. 2% of popula- aminosalicylate drugs ( e. g. sulfasalazine) , steroids, metronidazole
tion, 2ft from the caecum, 2in. Surgical  Indicated for sev/ recurrent obstructive symptoms, & rx for stulae into
Clinical Presentations. bladder or skin. Surgery should be as conservative as possible cos further resections
1. ( Asymptomatic nding at op or autopsy) usually necessary ( it just recurs)
2. Acute inammation ( identical to appendicitis) Prognosis. Recurrence is 50% in 1 0y
3. Perforation by foreign body
4. Intussusception ( ileo-ileal)
5. Peptic ulceration due to contained ectopic gastric epithelium. Melaena in children
at 1 0 y/o. 62 Tumours of the SI
6. Patent vitello-intestinal duct. Tumours
7. Raspberry tumour at the umbilicus ( persistent umbilical extremity of the duct)
8. Vitello-intestinal band: causing obstruction or volvulus B enign M alignant

Adenom a S trom al L ipoma H am artom a 1o 2o

61 Crohn's AdenoC a L ymphom a C arcinoid S trom al
Aetiology. Environment ( smoking, urban living) , Genetic ( FH)
H amartom a: e. g. Peutz-J eghers
Pathology. Can be any part of GIT. Small bowel in 2/3s w the lower ileum being the F igu re 1 3.

commonest site.  Bleeding

Macroscopic  Acutely bowel red, swollen. Mucosal ulceration + intervening  Obstruction
oedema = cobblestone. Thickened wall, " LNs. Skip areas.  Intussusception
Microscopic  Fibrosis, lymphoedema, chronic inammatory inltrate through the  Volvulus
whole thickness of wall. Non-caseating foci w ssuring ulcers extending deep
through wall ! these may form abscesses or stulae. 62.1 Carcinoid
Clinical. Most common 20-40y.  =  . Abdominal pain and diarrhoea. Def. Amine Precursor Uptake and Decarboculation ( APUD) tumour. 1 0% association w
1 . Acute: similar to appendicitis w RIF pain and vomiting. May have perforation or MEN-I. Most commonly appendix, but can be anywhere in GI tract & occasionally
haemorrhage. lung. Secrete 5HT. Rarely ( but can be) symptomatic until have metastasized to liver
2. Obstruction: due to post-inammatory brosis. ( where they secrete their hormone directly in to the circulation)

16
Pathology. 65 Diverticulosis Coli & Diverticulitis
Macroscopic  Yellowish submucosal nodule. Surface ulceration. Extension to serosa Def. Outpouchings of mucous membrane. They are false because they lack normal
leads to brosis & obstruction
muscle coats ( unlike Meckel' s) . Most common in sigmoid & descending. Unusual < 40y
Microscopic  Kultshitzky cells. V slow growing ( presents > 40y) . 4% of the ( acquired) .  =  . Common in West ( # bre) . Diverticulosis is usually asx
appendix metastasize, or may present early w obstruction.
Clinical. Pathogenesis. # Fibre diet ! " P in colon ! hypertrophy muscle ! " sigmoid colon ! her-
niation of the mucosa at sites of weakness ( where vessels enter wall)
1 . Flushing ( 80%) w attacks of cyanosis, chronic red faced, often precipitated by
stress, food or alcohol
2. Diarrhoea ( 70%) , profuse, noisy
3. Abdo pain ( 40%) due to mesenteric brosis resulting in partial obstruction 66 Diverticulitis
4. Bronchospasm Cx.
5. Abnormalities in the hrt ( valve stenosis) , hepatomegaly
1 . Perforation:
Ix.
a) Peritoneal causing peritonitis
1 . 5-HIAA urinary concentration ( the breakdown product of 5HT) b) Pericolic gutters causing pericolic abscess
2. CT/ USS liver for 2 s o

c) Adjacent structures forming stula

3. Radiolabelled octreotide scintigraphy
Rx. Resection in early cases, w removal of liver deposits. Palliation ( w more extensive 2. Chronic infx w inammatory brosis ! obstructive symptoms
deposits) by chemo-embolization. Octreotide ( somastatin analogue) inhibits 5HT 3. Haemorrhage: erosion of a vessel
release. Radiotherapy. Clinical.
1 . Acute diverticulitis: Left sided appendicitis: low central abdo pain shifting to LIF,
fever, vomiting, tenderness, guarding, bleeding. Pericolic abscess : like an appendix
abscess ( so tender mass, swinging fever, leucocytosis)
2. Chronic diverticulitis: mimics Ca colon w:
in bowel habit, obstruction,
X The Colon blood/mucus PR. Ex reveals tender LIF & thickened mass in region of sigmoid
colon.
3. Diverticular disease: asx, grumbling abdo pain, constipation, Fe-decient anaemia
4. Sudden severe haemorrhage: rarer
63 Constipation 5. colovesical stula: passage of gas bubbles: rarer
Ix.
1. Organic: Ca colon, diverticular disease 1.
Fibreoptic sigmoidoscopy ( rigid' s do not visualize diverticula)
2. Painful anal conditions: ssures, piles 2.
USS: abscess
3. Adynamic bowel: Hirschprung' s, senility, SC injuries, myxoedema, Parkinsons 3.
Colonoscopy
4. Drugs: Aspirin, opiate, anticholinergics, ganglion blockers 4.
Barium enema: ( D on' t perform in acute phase ) globular outpouchings showing
5. Habit & diet: dehydration, starvation, lack of bulk, dyscheua ( faulty habit) signet ring appearance cos of lling defect produced by contained pellets of faeces
( faecoliths) . Saw-tooth: narrowed segment due to oedema and thickening.
5. CT: in acute phase
64 Diarrhoea

. Ca
Rx.
1. Specic infx: food poisoning, dysentery, cholera, viral
2. Inammation: UC, Crohns, tumours, diverticular Acute d ivertic ulitis  Conservative: uids, abx ( met, pen, gen) . Pericolic
3. Drugs: Abx, abx-induced colitis, erythromycin, purgatives, digitalis abscess : diagnosed by CT & drained. General peritonitis : laporotomy + resection.
4. Loss of absorptive surface: resections, sprue & coeliac, idiopathic steatorrhoea Acute obstruction : laporotomy + resection + colostomy
5. Pancreatic dysfunction Chronic d ivertic u lar disease  Conservative: laxatives, " roughage diet. If sx
6. Post-gastrectomy & vagotomy persist: laporotomy. Colovesival stula : resection + loop colostomy ( before anasto-
7. General diseases: anxiety, thyrotoxicosis, uraemia, Carcinoid, Zollinger-Ellison mosis)

17
67 Angiodysplasia

. Dysenteries, carcinoma
Cx.
Def. 1 or more small mucosal or submucosal vascular malformations ( usually dilated Local  Toxic dilatation, haemorrhage, stricture, malignant
, perianal disease
vein) . Elderly. Caecum, ascending colon.
Clinical. Asx usually. Bleeding: continuous, chronic blood loss. General  Toxaemia, weight loss, anaemia. Autoimmune: arthritis, uveitis, dermato-
logical ( pyoderma gangrenosum= ulcers on shins, skin rashes, ulceration of legs) , 1 o

Ix. Colonoscopy ( bright red lesions) , mesenteric angiogram ( in actively bleeding pt' s) sclerosing cholangitis
Rx. Blood transfusion if " blood loss, electrocoagulation, resection ( sometimes) Malignant
. Colon Ca risk
Rx.
68 Colitis Medical  " Protein diet, vitamins. Blood transfusion. Diarrhoea : codeine phosphate.
Acute attack : Systemic corticosteroids. Maintain remission : salicylates.
1. UC/Crohns Surgery  Indications: fulminating disease not responding to medical rx, chronic not
2. Abx-associated: e. g. pseudomembranous due to C dicile responding to rx, prophylaxis against malignant
, complications.
3. Infections Usually total colectomy & removal of rectum ! permanent ileostomy or ileo-anal
4. Ischaemic anastomosis

69 Ulcerative Colitis 70 Crohn's Colitis

Crohn's Colitis UC Clinical. Mimics UC. Unlike UC commonly becomes adherent to adjacent structures w
Perianal common Perianal disease rare abscess formation & stulas. Perianal disease.
Bleeding uncommon Often profuse haemorrhage Rx. Similar to Crohn' s of SI. Extensive bowel involvement may require total excision w
Transmural Mucosal permanent ileostomy ( no anastomosis is made, risk of recurrence, sepsis, stulation) ,
Thickened bowel wall No thickening
No polyps Pseudo-polyps
Fistulas
Malignant
rare
No stula' s
Malignant
common
71 Tumours
Granulomas No granulomas T umours

Ta b l e 2 . B enign M alignant

Def. Inammatory disease of the rectum, extending variably proximal.  >  . Peaks 20- Adenom a Polyp Papill L ipom a N eurof H aeman 1o 2o
40y. Only large bowel.
Path. Oedema, haemorrhage ! ulceration. Edematous islands of mucosa btw ulcers form C arcinoma L ymphom a C arcinoid
pseudopolyps. Wall is brotic, w loss of haustrations. No skip lesions. Microscopically : F igu re 1 4.

crypt abscesses, break down in to ulcers w base lined w granulation tissue.

Clinical. Fulminant, intermittent or chronic. Bloody/mucus diarrhoea. Cramp-like abdo See oncology notes
pains. Nothing on ex except tenderness in LIF, blood on glove. Sev attacks : toxaemia,
sev bleeding, risk of perforation, anorexia, wt loss. Distinguish btw functional : func-
tional bowel disease pt' s don' t get up at night 72 Familial Adenomatous Polyps
Associations. Uveitis, pyoderma gangrenosum, sclerosing cholangitis, arthropathy Claim to Fame. Rare but inevitably progresses to Ca. Dominant.
Ix. Clinical. Polyps start in adolescence, sx of bleeding and diarrhoea commence early 20s,
1. AXR: megacolon? malignant change 20-40y. Hypertrophy of the retinal pigment layer.
2. Sigmoidoscopy + biopsy: oedema of mucosa w contact bleeding in early mild cases
3. Colonoscopy Gardener's syndrome . Variant where associated w desmoid tumours and osteomas of
4. Barium enema: ragged surface ( ulceration + pseudopolyps) , loss of haustrations the skull
5. Ex of stools Rx. Total colectomy w excision of the rectum, formation of an ileo-anal pouch.

18
73 HNPCC 5. Lateral space small bowel obstruction: due to failure to obliterate the space btw the
terminal colon & lat abdo wall
Claim to Fame. 5% of colorectal Ca. Dominant. Right sided, occur < 50y. 6. Psychological
Stoma appliances. Bag ( collects faeces) , adhesive ange ( cut to t stoma) . Pt' s can live
normal life w little risk of leakage or odour.
74 Colostomy

XI Rectum & Anal Canal

75 Bright Red Rectal Bleeding
1 . Haemorrhoids 2. Fissure-in-ano 3. Tumours
4. Diverticular 5. UC 6. Trauma 7. Angiodysplasia
8. Rarely higher up bleeding may produce red blood

76 Haemorrhoids
Anatomy. Anal cushions are highly vascular tissue lining anal canal, supplied by rectal
artery. Draining veins form saccules just below dentate line ! sup rectal vein.
Def. A vascular cushion, covered in a layer of mucosa and containing a branch of the
superior rectal artery and a tributary of the superior rectal vein.
Pathology. Abn anal cushions, congested ( as a result of straining) . In lithotomy position
F igu re 1 5 .
usually at 3, 7, 1 1 O' clock.
Indications. Divert faeces to allow healing of an anastomosis or stula ( avoid contamina- Grading.
tion) , decompress a dilated colon as a prelude to resection, removal of the distal colon 1 o  bleed but don' t prolapse
& rectum 2 o  prolapse on defecation, reduce spontaneously
Types. 3 o  remain prolapsed, pt reduces them
Loop  Antimesenteric border opened to surface. Rod often used to stop colon falling 4 o  Thrombosed
back. Temporary.
End  Divide colon & bring proximal end to the surface. May be denitive rx for Predisposing. Factors that " congestion of sup rectal veins : compression by pelvic
total rectal excision, or following perforated diverticular disease where diseased tumour ( commonest is pregnancy, rectal Ca) , cardiac failure, purgative use, chronic
bowel is removed & 1 anastomosis undesirable.
o constipation ( straining)
Double Barreled  Proximal & distal brought out adjacent w intervening colon Clinical. Bleeding ( bright red, occurring at defecation) , may be " " . Mucus discharge,
removed . ( Not commonly used, except in sigmoid volvulus, cos distal bowel usually pruritus ani. Pain is only a feature if undergo thrombosis. Other pain may be due to:
too shor t) ssure-in-ano, perianal haematoma, perianal or ischiorectal abscess, tumour of anal
Cx. margin.
1. Retraction: colon disappears back down Ix.
2. Stenosis: due to ischaemia, poor technique 1 . Examination + PR ( prolapsing piles obvious)
3. Paracolostomy hernia 2. Proctoscopy: int Haemorrhoids
4. Prolapse: colon intussuscepts out 3. Sigmoidoscopy

19
 4. Barium enema: exclude Ca
5. Colonoscopy
79 Anorectal Abscess
Cx. Classication.
 Anaemia ( sev bleeding) 1.
Perianal: infx of hair follicle
2.
Submucous: infected ssure or laceration of anal canal
 Thrombosis: when prolapsing piles gripped by the anal sphincter - venous return 3.
Ischiorectal: infection of an anal gland
occluded & thrombosis of pile occurs. Size of plums. Painful. 4.
Pelvirectal: spread from pelvic abscess ( rare)
Rx. Rx. Drainage to prevent rupture or stula
Conservative  Avoid straining, daily motion, laxatives
Medical  LA, steroids
Surgical  80 Fistula-in-ano
i. Sclerotherapy: 1 / 2 injected above dentate line ( painless)
o o
Def. Fistula : abn connection btw 2 epithelial surfaces ( e. g. hollow viscus and surface of
ii. Banding ( rubber) : falls away in 4d. 1 /2
o o the body) . Sinus : granulating track leading from source of infection to a surface
iii. Ectomy: 3 /4
o o
Aetiology. Abscess, Crohns, UC, Ca.
Thrombosed, strangulated  pt w foot of bed elevated, opiate analgesia, can do Classication. Relation to internal and external anal sphincters:
haemorrhoidectomy
Cx of haemorrhoidectomy.
1 . Retention: due to anal discomfort
2. Stricture: if excessive skin/mucosa excised
3. Post-op haemorrhage: may be reactionary ( post-op) , 2 ( week later) . May not be
o

visible. Rx: blood transfusion if severe, might need packing

4. Perianal haematoma ( thrombosed external pile) : thrombosis in inf rectal venous
plexus. Rx: evacuate.

77 Piloidal sinus
Def. Sinus containing hairs F igu re 1 6. G oodsall' s law
Description. May become infected ! pilonidal abscess. May have chronic discharge Clinical. Persistent discharge of pus. Ex reveals opening. Internal opening may be felt
Claim to Fame. Common in ngers of hairdressers PR. Need to determine path of stula tract.
Rx. Excision Rx. Supercial/ low level anal stulae laid open & left to heal by granulation ( no loss of
continence as not dividing sphincters) . High stulae ( supraphincteric, and trans
sphincteric close to anorectal ring) only lower part laid open ! seton passed through
upper part so xed by scarring ! can repeatedly tighten this.
78 Fissure-in-ano
Def. Tear in anal margin, usually follows passage of constipated stool. Usually pos mid-
line. 81 Stricture of Anal Canal
Clinical. Acute anal pain, stinging, lasts for a while after passing stool. Slight bleeding. Classication.
Constipation ( due to pain) . May be sentinel pile ( torn tag of anal epithelium) . PR 1. Congenital
may be impossible w/ o anaesthetic. 1 0% anterior midline, 90% posterior midline. 2. Traumatic: post-op
Rx. May heal spontaneously. Laxatives + uid. LA+ lubricant gives relief. GTN cream 3. Inammatory: lymphogranuloma inguinale, Crohn' s, UC
( relaxes the smooth muscle of the sphincter. SE: headache) . Sphincterotomy: can 4. Post-irradiation
divide int sphincter submucosally under GA. Recurrence needs excision. 5. Neoplasm

20
Rx. Underlying pathology. May need dilatation, reconstruction, defunctioning colostomy, Ix. Biopsy
excision ( Ca) . Rx. Excise villous and adenomatous

82 Rectal Prolapse 86 Ca Rectum

Classication. Path.  =  . 20+ .
Partial  Mucosa only. Occurs in infants: reassurance as self-limiting. Predisposing. Adenoma, FAP, UC
Complete  All layers. Usually elderly  . Incontinence also, due to stretching of Macroscopic.
sphincter.
Rx. Partial : Excision of redundant mucosa. Complete : Can xate rectum in pelvis by Papilliferous

wrapping mobilized rectum in polyvinyl sponge. Ulcerating ( commonest)

Stenosing ( usually rectosigmoid)

Colloid

83 Pruritus Ani Microscopic. 90% adenoCa, 9% colloid. Remainder anaplastic carcinoma simplex.
Spread.
Causes. Local  Circumferentially around lumen, muscular, adjacent organs ( prostate,
1.Local causes within anus or rectum: e. g. lack of cleanliness, " sweating bladder. . . )
2.Skin diseases: scabies pediculosis, fungal
3.General diseases assoc w pruritus: DM, Hodgkins, obstructive jaundice Lymphatic  Regional LNs along inf mesenteric vessels
4.Idiopathic: often due to continued scratching Blood  Liver, lungs
Rx. Underlying cause. Hydrocortisone ointment, hygiene Transcoelomic  Peritoneal cavity
Staging. Dukes:
84 Tumours Type 5y Surv. Description Rx

A 90% Conned to mucosa Surgery

T umours B 60% Through wall Surgery
B enign M alignant 2o C 30% Lymph nodes C hemo
D 5-1 0% Distant Praying
Adenom a Papilloma lip om a E ndom etriom a AdenoC a S C C M elanom a C arcinoid L ym phom a Ta b l e 3. No te : A lso give ra d io the ra py fo r rec ta l ( not colon ) C a .
F igu re 1 7.

Clinical. Local sx ( Constipation+ diarrhoea ( 80%) , bleeding, tenesmus, mucus, pain) , 2 o

deposits, general Ca eects

85 Rectal Polyps Ix.
1 . Sigmoidoscopy + biopsy
Types. 2. Barium enema
Metaplastic polyp  2-3 mm sessile, wart-like. Often multiple, always benign, not 3. USS: liver mets, ascites
truly Metaplastic

. Benign, prolapsed Ca sigmoid tumour, ovarian/ uterine tumours, prostate/ cervix
Adenomatous polyp  Benign polyp, may undergo malignant
extending tumours, diverticular, endometriosis, lymphogranuloma inguinale, amoebic
Villous adenoma  Can grow large, produces " mucus, may undergo malignant
granuloma, faeces
Pseudopolyp  Assoc w colitis. Is oedematous mucosa against an ulcerated wall Rx.
Juvenile polyp  Children & young adults. Looks like a cherry on a stalk. Always Curative 
benign. May bleed & prolapse  Upper 2 thirds: anterior resection ( resection + anastomosis)

21
22 C a Rect um

Lower third: less than 5cm from anal verge then abdominoperineal excision of
the rectum and terminal colostomy. Radiotherapy
Palliative  Resect primary. Colostomy might be necessary for obstruction ( but
doesn' t relieve bleeding etc. ) . Inoperable : Radiotherapy, diathermy, laser.
c) P ost-op : after every lap. Lasts 24-48h.
Path. Sev loss of uid, electrolytes, into lumen ! vomitus. Gross distension impairs blood
supply.
Clinical. Post-op stage of peritonitis/major surgery. 4 features of obstruction. Silent
abdomen ( noisy abdomens in mechanical obstruction) . Relatively painless. Beware
that it may merge in to obstruction caused by adhesions post-op. If symptoms com-
mence after already passing motions then likely mechanical.

XII Peritonitis Ix. AXr: gas distributed through small and large bowel ( in mechanical localized loops
Rx.
seen)

Aetiology. Prophylaxis  NG suction

1 . Exterior: e. g. penetrating wound, laporotomy ( 30%) Established  NG suction. Pethidine ( unlike others, has little eect on motility) .
2. Intra-abdominal viscera: gangrene ( e. g. acute appendicitis ( 20%) ) , perforation Stubborn : metoclopramide ( dopamine agonist) , erythromycin.
( e. g. peptic ulcer ( 20%) )
3. Blood stream: septicaemia
4. Female genital tract
Causes. Absorption of toxins from inamed surface, paralytic ileus, gross abdominal dis-
tension predisposes to pneumonia & collapse ( due to elevation of diaphragm) XIV Hernias
Clinical. C onstant pain ( aggrav by movement) , guarding, rigidity, o bowel
sounds .
Sx of the 1 , sev pain aggravated by movement, shoulder tip pain possible, " temper-
o

ature, " pulse, rigid wall, rebound tenderness, silent abdomen, tenderness on PR.
Advanced : distended & tympanic, free uid, toxic.
Ix.
1.
FBC
2.
Amylase ( pancreatitis)
3.
CXR: gas under diaphragm
4.
CT: free gas, pinpoint source of peritonitis


. Obstruction, ureteric/ biliary colic, pneumonia, MI, haemorrhage, AA leakage

XIII Paralytic Ileus

Def. Obstruction due to lack of motility
Aetiology.
1 . Reex paralytic: ANS supply interference ( e. g. fractures to spine, retroperitonal
haemorrhage, intestinal ischaemia, ureteric colic)
2. Peritonitis: toxic paralysis of intrinsic N plexuses
a) Metabolic: sev # K, uraemia, diabetic coma
b) Drugs: Anticholinergics, anti-parkinsonsian F igu re 1 8 .

22
87 Denitions Conservative  Truss only if v poor condition.
Hernia. A protusion of an organ or part of an organ through a defect in the wall of the
cavity containing it, into an abnormal position. 
Strangulated. Sev pain in the hernia of sudden onset, & central abdo colicky pain. Sx of 89 Femoral Hernia
obstruction: vomiting, distension, absolute constipation. Tender, tense hernia that Anatomy. Gap 1 . 5cm in length lying at medial extremity of the femoral sheaf containing
cannot be reduced & has no cough impulse. Overlying skin inamed, oedematous. femoral artery & vein. Boundaries:
Signs of obstruction: distension, tenderness, noisy bowel sounds.
Anteriorly  Inguinal lig
Medial  Sharp edge of lacunar part of inguinal lig
88 Inguinal Hernia Lateral  Femoral vein
Posteriorly  Pectineal ligament of Astley Cooper
Indirect Direct Epi.  :  = 4: 1
May be congenital Always acquired Clinical.  >  ( wider  pelvis) , middle aged/elderly. Never congenital, although rarely
Strangulate commonly cos narrow neck Rarely ( wide necked) occur in children. Globular swelling below and lateral to PT. Enlarges on standing,
Scrotum extension often Rarely coughing, may disappear on lying down. Narrow neck, sharp medial border: strangula-
Not reduce on lying readily Spontaneously tion v common.
Recurs uncommon More common
Lateral inf. epig Medial
Ta b l e 4.
90 Richter's Hernia
Anatomy of canal. Def. Only part of wall herniated through, where it is then strangulated. But not
Contains  Spermatic cord ( round lig in  ) , ilioinguinal nerve obstructed, although this part can become necrotic or perforate.
Anteriorly  Skin, supercial fascia, ext oblique aponeurosis Rx. Excision of sac & closure
Posteriorly  Medially: Conjoint tendon ( the fused common aponeurotic insertion of
the int oblique and transzersus abdo muscles into the pubic crest) . Laterally:
transversalis fascia 91 Umbilical Hernia
Above  Lowest bers of int oblique Exophthalmos. Failure of midgut to return to abdominal cavity in fetal life. Bowel con-
Below  Inguinal lig tained in translucent sac.
Int ring  Where spermatic cord pushes through transversalis fascia, demarcated Rx. Immediate surgical repair. If massive then protect in dressing & repair later
medially by inferior epigastric
Ext ring  V-shaped defect in ext oblique aponeurosis
Indirect hernia. Controlled by pressing over internal inguinal ring ( 1 . 5cm above femoral 92 Para-umbilical Hernia
pulse, felt half way btw ASIS and PS) . If protudes through ext ring can be felt above
and medial to PT. May be due to persistence of processus vaginalis, present young. Def. Acquired hernia above/ below umbilicus. Obese, middle aged, multiparous  . Prone
Narrow ring. to strangulation.
Direct hernia. Not controlled by pressure over int ring.
Rx.
Infants  Excise hernial sac at 1 y ( herniotomy) 93 Epigastric Hernia
Adults  Excision of sac & repair of inguinal canal Def. Defects in linea alba above the umbilicus.

23
94 Congenital Umbilical Hernia 2.
3.
Inammatory: hepatitis, portal pyaemia & liver abscess, leptospirosis, actinomycosis
Parasitic: amoebic hepatitis & abscess, hydatid
Rx. Surgical repair not carried out unless persists past 2y 4.Neoplastic: primary, secondary
5.Cirrhosis: portal, biliary, cardiac, haemochromatosis
6.Haemopoietic diseases & reticuloses: lymphoma, leukaemia, polycythaemia
7.Metabolic: amyloid, Gauchers
95 Incisional Hernia Also check. The spleen ( cirrhosis, polycythaemia, leukaemia, amyloid) and LNs ( lym-
About. Strangulation is rare cos wide neck phoma)
Rx. If good general condition then dissecting out & suturing individual layers of the abdo
wall. Large hernias w polypropylene mesh.
99 Jaundice
Metabolism.
96 Unusual Hernias
Obturator  Thin, elderly  . Through obturator canal. Pressure on obturator nerve
may cause pain down thigh
Spigelian  Passes up through arcuate line into the lat border of the lower part of the
pos rectus sheaf. Tender mass to one side of the lower abdo wall

97 Acquired Hiatal Hernias

Types. Sliding ( 90%) , rolling ( 1 0%) . The hernia part covered by peritoneal sac. Obese,
middle aged, elderly,  .
Clinical.
1 . Mechanical: cough, dyspnoea, palpitations, hiccup
2. Reux: Incompetence of cardiac sphincter
3. Oesophagitis: strictures, dysphagia, bleeding
Rx. Conservative ( raise head of bed) , medical ( PPI, H receptor) surgical ( Nissens) .
2

Sliding : symptomatically. Rolling : if develop volvulus then repair.

F igu r e 1 9 .

Classication.
XV Liver Prehepatic  Haemolytic e. g. spherocytosis
Hepatic  Hepatitis ( viral, leptospirosis, glandular fever) , cirrhosis, cholestasis from
drugs ( e. g. chlorpromazine) , liver poisons ( e. g. paracetamol) , tumours
98 Liver Enlargement Posthepatic 
1 . Lumen: gallstones
Clinical. Normally impalpable except in infants. 2. Wall: congenital atresia of cbd, traumatic stricture, 1 / 2 sclerosing cholangitis,
o o

Causes. tumour of bile duct

3. Outside wall: pancreatitis, Ca head of pancreas, Ca ampulla of Vater, cholecys-
1 . Congenital: Riedel' s lobe, polycystic titis

24
Ix.
1 . Serum bilirubin: > 35  mol/L in jaundice
2. Bilirubin: conjugated in post-hepatic
3. Bilirubin in urine: posthepatic and dark ( only excreted by kidney in water soluble
form, hence not present in pre-hepatic. )
4. Bilirubin in faeces: " in prehepatic and hepatic cos large amounts secreted into gut.
In posthepatic it is obstructed from entering faeces, hence pale .
5. Haemolytic blood tests: rbc fragility, Coombs, reticulocyte count
6. " ALP in obstructive
7. Serum proteins: in hepatic jaundice has reversed albumin/ globulin level
8. Haptoglobins: low in pre-hepatic ( binds free hbg after haemolysis)
9. " Transaminases in hepatitis and active cirrhosis
1 0. Prothrombin time: normal in pre-hepatic, # but correctable ( vit K) in hepatic, and
# advanced hepatic
1 1 . USS: gallstones ( except missed in bile ducts)
1 2. CT/ MRI
1 3. Biopsy: hepatitis, cirrhosis suspected
1 4. MRCP
1 5. ERCP
1 6. Percutaneous transhepatic cholangiography ( PTC) : cannulate bile duct
Ix summary.
Exclusion of pre-hepatic causes  haptoglobin level, reticulocyte count, Coombs
Liver synthetic function  prothrombin time, albumin
Liver cell damage  transaminases, GGT, transferase
Bile duct obstruction  ALP, USS bile ducts, PTC, ERCP, MRCP, CT
Intrahepatic mass  cross-sectional imaging such as CT + needle biopsy
100 Congenital Abnormalities
Riedel's lobe  Big, downward R lobe
Polycystic liver  Assoc w polycystic kidneys. Functions normally. Discomfort. Haem-
orrhage into cysts, cholangitis are complications
101 Liver Trauma
Aetiology. Penetrating wounds, cloded crush injury
Ix. Ct useful to distinguish btw ruptured spleen
Rx.
1 . Conservative: blood transfusions, observation
2. Continued bleeding: laporotomy ( packing, suturing liver, tie o arterial branches) ,
abx cover
25
102 Acute Infections
Can arise from:
 Portal ( usually diverticular sepsis, appendicitis)
 Biliary, resulting from ascending cholangitis
 Arterial: general septicaemia ( unusual)
 Adjacent infections: e. g. subphrenic abscess or acute cholecystitis
103 Pyogenic Liver Abscess
Aetiology. Infection in the portal territory ! portal pyaemia, or infection in the biliary
tree. E coli, Strep faecalis, Strep milleri.
Portal Pyaemia  Focus of intra abdo sepsis. Rare since abx.
Biliary Infection  Sev suppurative cholangitis ( Charcot' s intermittent hepatic fever :
pyrexia, rigors, jaundice) 2 gallstone impaction in the cbd.
o
Clinical. Insidious, w malaise. Rigors, high swinging temperature, tender palpable liver,
jaundice. Previous hx of abdo sepsis such as Crohns.
Ix.
1 . Blood culture 2. USS/ CT: abscesses, source of pyaemia
Rx. Liver abscess : drain under USS guidance. Smaller : parental abx. Biliary infx : Urgent
drainage of bile ducts by either endoscopic sphincterotomy or percutaneous transhep-
atic drainage, IV uids to prevent hepatorenal syndrome.
104 Amoebic Liver Abscess
Aetiology. Entamoeba histolytica infection of colon. Abscess in liver is sterile.
Ix. CT, USS. Rx. Metronidazole.
105 Hydatid Disease of the Liver
Claim to Fame. Liver is source of 75% hydatid cysts in body
Path. Dogs infected w Echinococcus granulosus after eating sheep oal ( therefore " in
sheep rearing countries) ! tapeworms ! humans eat ! liver.
Clinical. Symptomless mass. Active may:
i. Rupture in to peritoneal ( peritonitis) / pleural ( haemoptysis) /alimentary ( pass in
faeces) /biliary
ii. Become infected
iii. Jaundice due to pressure on intrahepatic bile ducts. ( Malaise, pruritus)
Ix. Hepatic  C irrhosis ( commonest by far)
1.
XR liver: clear zone, ecks of calcication Posthepatic (Budd-Chiari)  Idiopathic venous thrombosis ( OCP, haematolog-
2.
USS/ CT: localize ical. . . ) , tumour ( block hepatic veins)
3.
Serological
4.
Eosinophilia Cx.
Rx. Leave calcied cysts alone. Others : Albendazole ( shrinkage) . Failure to respond : 1 . Collateral portosystemic drainage:
surgery. i. L gastric ! oesophageal
ii. Obliterated umbilical vein to sup/inf epigastric veins ( caput medusa)
iii. ( Retro) peritoneal & diaphragmatic anastomoses
106 Cirrhosis iv. Between sup & inf rectal veins
2. Splenomegaly: due to congestion. Get leucopenia, thrombocytopenia ( spleen more
Def. Chronic hepatic injury. Healing by regeneration & brosis. active)
Aetiology. 3. Ascites. ( Other causes of ascites include: heart failure, renal failure, liver failure,
1. Parenchymal: alcoholic, viral ( B, C) carcinomatosis, chronic peritonitis e. g. TB )
2. Metabolic: haemochromatosis, Wilsons Eects of liver failure. Jaundice, encephalopathy
3. Biliary: 1 biliary cirrhosis, 2 to prolonged biliary cirrhosis
o o
Ix.
4. Hepatic venous outow obstruction: Budd-Chiari, sev chronic congestive cardiac
failure 1.
LFTs 2. Liver synthetic tests 3. Liver biopsy
5. Other: chronic active hepatitis, schistosomiasis, nutritional, idiopathic parental 4.
Fibreoptic endoscopy: varices
nutrition related, non-alcoholic steatohepatitis 5.
Splenic venogram: site of portal obstruction
Consequences. 6.
IVC-agram: hepatic venous occlusion
7.
MR angiography, CT angiogram: same as splenic venography
1 . Hepatocellular failure: impaired protein synthesis ( " prothrombin time, # albumin) ,
impaired toxin metabolism ( encephalopathy) , impaired bilirubin metabolism ( jaun- Rx. Uncomplicated: underlying condition ( e. g. cirrhosis managed by well balanced diet,
dice) low alcohol) . Varices on endoscopy : sclerosant injection
2. Portal hypertension Management of haemorrhage from varices. 50% mortality: liver further damaged by
3. Ascites: # albumin & " portal P hypotension, " encephalopathy
4. Malignant change
Management of ascites. Prophylaxis   -blockers ( # portal venous pressure) , band ligation, sclerosant injec-
tion
1.
Paracentesis: immediate relief. Need to replace protein being removed Diagnose 

includes gastric erosions. Endoscopy.
2.
Diet: # Na, " protein, IV albumin
3.
Diuretics Immediate rx  Blood transfusion. Enema to # blood absorption from gut, with-
4.
Iatrogenic portal-systemic shunt: portal vein to vena cava holding protein.
5.
Liver transplant: for intractable ascites Stopping haemorrhage 
Hepatorenal syndrome. Renal failure. Partly due to depletion of IV volume. Preven- 1 . Endoscopic variceal band ligation or sclerotherapy: risk of perforation, stenosis
tion : Avoid uid depletion, maintain a good intra-op diuresis w mannitol infusion. ( injections
2. IV vasopressin: # portal venous pressure. Give GTN to # myocardial ischaemia
3. Balloon tamponade: Sendstaken Blakemore tube. Rebleeding common after
107 Portal Hypertension removal
4. Trans-jugular intrahepatic portosystemic shunt ( TIPS) : metal stent passed
Def. > 50 cm H O through liver to open passage btw hepatic vein and portal vein ! decompress
portal system. Causes encephalopathy.
2

Aetiology. Obstruction to drainage. ( Remember this classication travels the opposite 5. Oesophageal transection: oesophagus + varices divided at cardio-oesophageal
way to jaundice classication. ) junction by stapling gun, to prevent the anastomoses
Prehepatic  Congenital, portal vein thrombosis in neonatal ( spreading from infx) , 6. Porto-caval shunt: surgical anastomoses of portal vein to IVC to shunt portal
occlusion by tumour or pancreatitis blood directly to systemic venous circulation. Encephalopathy.

26
 Liver transplant  Candidate Mixed ( 75%)  Faceted one against the other, and can be grouped into 2 or more
series all of the same size ( generations)
Cx.
108 Liver Neoplasms 1 . Silent
2. Impaction in gallbladder: either in Hartmann' s pouch or cystic duct ! water
Tum ours absorbed from bile ! concentrated ! chemical cholecystitis. If stone impacts in
Hartmann' s pouch when GB empty then walls of GB may continue to secrete
1 o m alig 2 o m alig ( m ost com mon) B enign mucus ! distends to form a mucocele .
3. Choledocholithiasis: common bile duct, may produce intermittent or compete
H C C F ibrolam ellar cacinom a C holangioC a. Portal: gut S yst Direct: G B H aem ang. Aden. F N D obstruction w pain & jaundice
4. Gallstone ileus: ulceration through the wall of the GB ! may pass or get stuck in
F N D: focal nodular hyperplasia
distal ileum ( narrowest part) . Rare.
Clinical.
F igu re 2 0 .

See oncology notes Biliary colic  Impaction of the stone in Hartmann' s pouch ( out-pouching of the
wall of the gallbladder at the junction of the neck of the gallbladder and the cystic
duct) or cystic duct or common duct. Following which the calculus either falls back
108.1 Cholangiocarcinoma or is passed along the duct. Pain caused by contractions of the smooth muscle
Epi. 20% of 1 s of liver.
o against the stone: rises to plateau w colicky exacerbations which last many hrs. R
subcostal, may be epigastric, or band across upper abdo. Radiation to scapula,
Path. AdenoCa of intrahepatic bile system. shoulder. Vomiting, sweating.
Clinical. Jaundice, may complicate primary sclerosing cholangitis. Spread throughout Acute cholecystitis  95% gallstone origin. Stone remain impacted in GB outlet !
liver and to nodes. GB wall inammation ! cholecystitis ! pus lled. Pain persistent, intensifying.
Rx. Relieve jaundice: stent at ERCP. Fever, leucocytosis. Tender upper abdomen, palpable mass in region of GB ( GB
wrapped in inammatory adhesions to adj organs) . Empyema, perforation may
occur. May press against CBD causing jaundice .
Chronic cholecystitis  Almost all gallstone related. Inammation, wall thickening.
Recurrent bouts of abdo pain due to mild cholecystitis  fever. Experienced after
XVI Gallbladder and Bile Ducts fatty meals ( ! CCK) .
CBD stones  May be asx. Often biliary colic w obstructive jaundice , pale
stools, dark urine. Attacks for h' s ! d' s. Attack ceases when small stone passed.
Cx:
109 Congenital i. Ascending cholangitis: infx causing jaundice, pain, fever , rigors
ii. 2 biliary cirrhosis
o

Most important is biliary atresia: neonatal jaundice

is: w jaundice ( Ca pancreas, acute hepatitis, other) , w/o jaundice ( renal colic,
intestinal obstruction, angina pectoris)
Perforation  Peritonitis
110 Gallstones Empyema  Swinging pyrexia
Types. Courvoisier's law. If in the presence of jaundice the GB is palpable, the cause is
Cholesterol (20%)  Solitary oval stone, or 2 stones. Appearance radiating crystals. unlikely to be stones, cos of brosing of the GB.
May be assoc w " cholesterol. Correlation w OCP, pregnancy, obesity, # dietary Ix.
bre, removal of terminal ileum e. g. in Crohns ( interruption of enterohepatic circu- 1. USS: presence of gallstones, thickened wall of GB, dilatation of the CBD
lation) . This supersaturated bile is lithogenic. 2. AXr: gallstones in 1 0%
Pigment (1 -2%)  Calcium bilirubinate. Small, black, irregular, multiple, gritty. 3. Upper GI endoscopy: exclude peptic ulcer, hiatus hernia
Haemolytic anaemias ( e. g. spherocytosis) . 4. LFTs: " ALP w gallstones

27
 5. MRCP
6. ERCP: allows extraction, sphincterotomy. Not normally GA
7. IV/oral cholangiography: largely superseded
Rx.
Acute cholecystitis  90% resolve on abx, pain relief. Elective lap cholecystectomy
6w later. If diagnosis in doubt : laporotomy is performed. Empyema : requires emer-
gency drainage. Perforation : needs urgent surgery.
Chronic cholecystitis  Cholecystectomy, operative cholangiogram performed by
injecting radio-opaque dye: if stones found then remove them ( ?open op now) &
insert T-tube 1 0d post-operatively. T-tube removed 1 0d after provided a check
cholangiogram taken conrms clear tubes. Alternatively can do lap exploration of
CBD, or wait until post-op ERCP & extract using Dormia basket/balloon.
Obstructive jaundice due to stones  ERCP & removal using Dormia/ balloon.
Subsequent cholecystectomy. Giving vit K before helps clotting ( lacking cos not
absorbed in bile-poor gut) .
Non-surgical  Dissolution w ursodeoxycholic acid : small, non-calcied stones.
Lithotripsy : but passage causes colic. Symptomless : cholecystectomy not usually
advised unless comorbidity.
Cx of Cholecystectomy.
1 . Leakage of bile: due to injury to bile ducts inside or out of liver. Rx: ERCP and
stenting ! if fails then perc drain
2. Jaundice: missed stones, inadvertent injury, cholangitis/pancreatitis
111 Gallbladder Polyps
Pathology. If single, consider malignant lesion, risk " w size
Clinical. Asx. If near Hartmann' s then may produce gallstone-like pain
Rx. Symptomatic, or large: cholecystectomy.
112 Ca Gallbladder
Pathology. Assoc 85% w gallstones. 50% of porcelain gallbladders. 90% adenocarci-
noma
Clinical. Resembling chronic cholecystitis.
Rx. Resection/ liver resection, but poor prognosis unless found incidentally at chole.
113 Cholangiocarcinoma
Pathology. Increasing. Assoc w IBD.  , > 50y. Adenocarcinomas
28
Clinical. Painless progressive obstructive jaundice. Epigastric pain, steatorrhoea, weight
loss. May be hepatomegaly. MRCP/ ERCP/CT biopsy
Rx. Slow growing. Can palliate w endoluminal stenting at ERCP. or surgical bypass.
Poor prognosis.
XVII Pancreas
114 Acute Pancreatitis
Aetiology. GET SMASH' N: G allstones, E thanol , Trauma, Steroids, Mumps,
Autoimmune ( e. g. SLE) , Scorpion bites, Hyperlipidaemia ( hyperparathyroidism,
hypothermia, hereditary) , Neoplasia
Path. Autodigestion, due to release of digestive enzymes. E. g. once trypsin released from
trypsinogen, it cleaves other pro-enzymes. Reux important ( hence assoc w bile
stones) . Liquefying necrotic material & inammatory exudate collects in the lesser sac:
pseudocyst ( walled by stomach in front & necrotic pancreas behind) . Liberated
enzymes:
i. Trypsin: autodigestion
ii. Lipase: fat necrosis
iii. Amylase: high serum level
Clinical. Gallstone: usually middle aged/ elderly. Alcoholic: < 40y. Rapid onset epigastric
pain radiating into the back. Pt sits forward, repeated retching is common. Profuse
vomiting. Shocked. May be feverish. May have jaundice. Grey-Turner' s sign ( few days
after attack) .


. Acute cholecystitis, perforated peptic ulcer
Ix.
1 . Serum amylase: acutely 5  raised, returns to normal after 2/3 d ( normal in 30%) .
Urinary amylase elevated for longer. ( Also high in many conditions inc: impaired
renal excretion, DKA, perforated peptic ulcer, cholecystitis, intestinal obstruction. . . )
2. FBC: leucocytosis, anaemia
3. " Blood glucose
4. " Serum bilirubin
5. ABG: hypoxia
6. # Serum calcium: due to fat soponication
7. CT: pancreatitis, necrotic, abscess, pseudocyst
8. AXR: absence of free gas ( distinguish from in perforation)
9. USS: gallstones, dilatation of cbd
Rx. ICU
115 Severe Acute Pancreatitis 2.
3.
AXr: calcication, calculi
CT: enlargement, irregular consistency
Path. Haemorrhagic necrosis, systemic release of vasoactive peptides & enzymes. Acute 4. ERCP: dilation & irregularity of pancreatic duct
lung failure. Acute renal failure ( toxins, # volume) . 5. Endoscopic USS + aspiration cytology: standard technique for examining head of
G las g ow C riteria . pancreas
6. Exocrine function tests: faecal elastase
1 . Age > 55
2. Hyperglycaemia: Pancratic dysfunction Rx.
3. Leucocytosis: Inammatory 1. Analgesia
4. Urea > 1 6: Renal damage 2. Diet: # fat w pancreatic enzymes
5. PO < 8 kPa: ARDS
2 3. Insulin for DM
6. Calcium < 2: Fat sequestration 4. Surgery if attacks v frequent: partial pancreatectomy
7. Albumin < 32: Inammatory 5. Painless obstructive jaundice: Roux-en-Y reconstruction, Whipples
8. Lactate dehydrogenase > 600
9. " Transaminases: Gallstones
PANCREAS: PaO2 < 8 kPa, Age over 55, Neutrophilia, Calcium, ( low) Raised Urea,
Enzyme elevation: LDH, AST/Albumin 32g/L, Sugar ( glucose 1 0 mmol/ L) 117 Pancreatic Cysts
Supportive. Classication.
1.
Analgesia: pethidine True ( 20%)  Congenital polycystic disease, retention, Hydatid, Neoplastic
2.
Fluid replacement False ( lesser sac)  Trauma, following acute pancreatitis, due to pos gastric ulcer
3.
Resting the pancreas: NBM, nasogastric aspiration if vomiting perforation ( rare)
4.
TPN/NJF
5.
Abx Clinical. Firm, large, rounded, upper abdo swelling.
6.
Prophylaxis against gastric erosions: sucralfate, H rec antagonist
2
Rx. True : surgical excision. False : drainage
7.
Endoscopic sphincterotomy: gallstone pancreatitis
Surgery. Avoided early. Later , operative debridement of necrotic pancreas. Pseudocyst :
drainage. Gallstone origin : cholecystectomy.
Cx. 118 Pancreatic Tumours
1. Abscess formation w pancreatic necrosis: pyrexia, leucocytosis Tumours
2. Pseudocyst: fullness/discomfort in stomach, palpable mass
3. GI bleeding from erosions M alignant B enign
4. Renal failure: shock
5. Pulmonary: acute lung injury ( ARDS) 1o 2 o : stomach, bile d. Adeno C ystaden, Islet cell tum our
6. Further attacks
7. DM: due to necrosis Adenocarc. C ystadenoC . Islet-cell Z ollinger Insulin. G lucag.
8. Fat embolus

116 Chronic Pancreatitis

F igu re 2 1 .

See oncology notes

Def. Gradual destruction of the functional tissue
Aetiology. Alcoholism. Hypercalcaemia ( rarely)
Clinical. Asx. Recurrent abdo pain relieved by leaning forward. Steatorrhoea. Diabetes.
Obstructive jaundice.
119 Multiple Endocrine Neoplasia
Ix. Type 1 .
1 . Amylase: may be elevated in attacks of pain. 1 . Parathyroid hyperplasia

29
 2.
Pancreas Insulinoma
3.
Pituitary tumour
4.
Peptic-acid producing: Zollinger -Ellison
XVIII The Spleen
5.
Adrenocortical, carcinoid
Type 2. Medullary cell carcinoma of thyroid & phaeochromocytoma plus: 120 Splenomegaly
a  Hyperparathyroidism

.
b  Neurobromata (& marfanoid habitus) 1 . Enlarged L kidney: resonant as covered by bowel
2. Ca cardia: sx of gastric obstruction
3. Enlarged L lobe of liver
119.1 Islet Cell Tumours Classication.
Claim to Fame. Rare, but have interesting metabolic eects. MEN syndrome. 1 . Infectious: viruses ( glandular fever) , bacterial ( typhus, typhoid, septicaemia) , proto-
Path. APUD. G lucagon (  ) , insulin (  ) , somatostatin (  ) , pancreatic polypeptide zoal ( malaria, schistosomiasis) , parasitic ( hydatid)
( F) , serotonin ( enterochroman) 2. Haematological: Leukaemia ( chronic myeloid , chronic lymphocytic) , lymphoma ,
myelofibrosis / ITP/ polycythaemia rubra vera , haemolytic anaemia
3. P ortal hypertension
4. Metabolic & collagen disease: amyloid ( 2 RA) , storage disorders ( e. g. Gauchers)
119.2 Insulinoma
o

5. Cysts, abscesses, tumours ( uncommon)

Path. 80% benign, 1 0% malig, 1 0% multiple.
Clinical. When pt hungry or during exercise. Often early morning. Excessive appetite w
gross weight gain. 121 Splenectomy
CNS phenomena  Weak, sweating, trembling, epilepsy, confusion, hemiplegia,
coma Indications. Rupture, massive splenomegaly, haematological disease ( haemolytic
GI phenomena  Hunger, abdo pain, diarrhoea anaemia inc spherocytosis, thrombocytopenia purpura) , tumours/ cysts
Whipple's Triad. May be useful. Portal hypertension, autoimmune haemolytic anaemia, myelobrosis,
trauma, Gauchers
1 . Induced by starvation, exercise Cx.
2. Hypoglycaemia in attack
3. Relieved by sugar 1 . Gastric dilatation: due to gastric ileus and accumulation of swallowed air. NG tube
placed to prevent.
Ix. 2. Thrombocytosis: aspirin
1 . " Insulin w hypoglycaemia 3. Post-splenectomy sepsis: Prophylactic immunization w meningococcal, H Inuenzae
2. " C-peptide: rule out exogenous insulin ( # ) type B, annual u vaccines, prophylactic low dose penicillin.
3. CT, MR, endoscopic USS: localization
Rx. Excision. May require Whipples
122 Ruptured Spleen
119.3 Gastrinoma Clinical.
Path. Malignant ( 30%) . Secretes gastrin-like into blood stream ! " gastric HCl excre- 1 . Massive bleeding
tion ! peptic ulcers 2. Peritonism from blood loss: abdo pain diuse or L ank, shoulder tip pain
3. Delayed rupture: hours ! days. Due to haematoma growing then rupturing
Ix. Ix. Clinical diagnosis ! procede to laporotomy
1 . " Serum gastrin 2. " Basal acid output: measured by NG aspiration 1 . CXR
3. Localization 2. AXR: stomach bubble displaced to R
Rx. Excision , or if impossible PPIs. 3. USS: free uid, intrasplenic haematoma

30
 4. CT: laceration of spleen Ix. May mimic Ca on mammography. USS diagnoses. Core biopsy
5. Urinalysis for blood
Rx.
1 . Blood transfusion
2. Emergency splenectomy: if hopelessly pulped
125 Acute inammation
3. Suturing of spleen/packing: if minor laceration Epi. Childbearing.
Classied.
Periductal mastitis  Inammatory occuring around dilated milk ducts. Smoking
( ! dierent bacterial ora) . Pain, discharge. May have cellulitis, nipple retraction,
or mass. Rx: abx ( usually uclox)
XIX Breast Acute bacterial mastitis  Commonest. Most often during lactation. Cellulitis or
abscess 2 staph aureus. Pain, swelling, tenderness, erythema. Rx: cellulitis : abx &
o

continue breast feeding. Abscess : aspiration

123 Symptoms
Lump  Ca, cyst, broadenoma, broadenosis. 126 Fibroadenosis
Less commonly: Fat necrosis, other cysts, other tumours ( duct papilloma, hamar-
toma, lipoma) Def. Fibroadenosis or brocystic disease is the most common cause of breast lumps in
women of reproductive age. The peak incidence is between 35 and 50 years of age. It is
Discharge  C lear, bloody, single duct require further ix rare before 25 years.
1 . Bloody: papilloma, Ca, Paget' s. The term embraces a spectrum of histologic changes, and may encompass many
2. Clear: intraduct papilloma patients who have cystic lesions detected clinically or sclerotic breast lesions detected
3. Multicoloured: duct ectasia - Y/B/G on mammography as discussed elsewhere.
4. Milly: lactation, galactorrhoea Path. Histologically it is characterized by overgrowth of both brous stroma, and of
5. Purulent: abscess epithelial elements i. e. ducts and lobules, in diering proportions. These changes may
Mastalgia  be considered as abberations of normal breast involution and not part of a disease pro-
cess. The condition may be due to a disordered or imbalanced response to endogenous
a) Non-cyclical: Abscess, Ca, Tietze' s ( chondritis of the costal cartilage) , chest wall sex hormones. Only in those cases showing marked epithelial hyperplasia - epitheliosis
lesions - is the risk of breast carcinoma thought to be increased.
b) Cyclical: idiopathic. Lumpy, tender. Worse premenstually, relieved by menstrua- Clinical. Typically, patients present with one or more lumps in the breast which may be
tion. Young  . Rx: conservative [lionelic acid, # caeine, consider HRT] , medical painful, and frequently, bilateral. The size and pain usually vary with the menstrual
( danazol - anti-gonadotrophin, tamoxifen, LHRH) cycle. One or more of these elements may be absent.
Duct ectasia  Ducts being nipple dilated ( ectasia) & engorged Cysts are more common in perimenopausal women. They are usually single. The
presence of multiple, diuse cysts may be referred to as Schimmelbusch' s disease. The
Nipple inversion  1 , or 2 to duct ectasia or Ca
o o
discharge varies from clear to green but should not be bloodstained.
Gynaecomastia  Physiological in neonates, puberty. Imbalance of oestrogens. May On palpation, a cyst may be recognised by its smooth texture and characteristic
have surgery if embarrasing ( liposuction, excision) . Causes : drugs ( digoxin, spironolac- tense uctuation.
tone, cimetidine, E , androgens) , cirrhosis, renal failure, hypogonadism, suprarenal
2 Rx. Aspiration ! excision biopsy to exclude Ca. Pain that is localised, is normally
tumours, testiculr tumours, idiopathic. relieved by excision. Pain that is diuse, cannot be relieved by excision. In these cases,
bromocriptine, or danazol, may be helpful.

124 Traumatic Fat Necrosis 127 Cysts .

Clinical. Painless, irregular, rm lump, hx of trauma ( e. g. surgery) . Can have retraction,
skin thickening: can look just like Ca. Usually regressses with time, may leave cyst. Epi. Common perimenopausally, uncommon post-menopausally

31
Clinical. Short hx of painful tender swelling in the breast. May be multiple, bilateral.
Mammography: well-dened rounded opacities
Rx. Aspirate to dryness. Uniformly blood stained ! cytology. If mass remains then FNA.
128 Fibroadenoma
Path. N ot a neoplasm , but an aberration of normal development. Stromal & epithelial
components. No " malignancy, majority resolve over years
Clinical. All ages, peak in 30s. Discrete, rm, mobile lump. Highly mobile ` breast mice' ,
not attached to skin. Can be multiple.
Rx. Triple assesment
129 Phyllodes (=leaf)
Path. True neoplasms that can be benign or malignant. Rarely met, but can recurr
locally. Can arise from intracannalicular broadenomas.
Clinical. Firm, discrete lump, recent increase in size
Rx. Wide excision
Types.
Lingual  Beneath tongue. V rare
 Fluctuant swelling in or near midline neck. Moves
T h yro g lo s s al c ys t
upwards on tongue protrusion. Moves up on swallowing. Rx: remove surgically
together with remnants of thyroglossal tract.
Thyroglossal stula  Opening onto skin midline. Discharge. Infection. Rx: excise
Physiology. Think it as aecting upmodulating the response to adrenaline
132 Causes of Goitre
Graves causes hyperplasia. Hashmimotos causes infkammatory swelling
1 . Diusely Swollen : GravEs' ( hypErthyroid) , HashimOtO' s ( HypOthyroid) , " Demand
( # Iodine, puberty, pregnancy) , multinodular colloid goitre with nodules too small to
feel
2. Multiple nodules : Multinodular colloid goitre ( commonest thyroid swelling in nals,
hyperthyroid) , cysts, adenomas
3. Solitary nodule ( ominous, esp if  , cold) : thyroglossal cyst ( small, smooth, midline,
moves up w tongue extrusion) , tumour, dominant nodule in multinodular goitre

130 Intraduct Papilloma

Path. Benign, may be multiple, subareolar usually
133 Multinodular Goitre
Clinical. Watery-clear or blood stained discharge from a single duct. May be mass Path. Some follicles w hyperactive epithelium, some atrophic. May be eu- ( vast majority)
Rx. Excision or hyperthyroid ( 2 ) . Enlarged, irregular, nodular. Autoimmune.
o

Clinical. Middle aged women.

 Dysphagia ( usually solids)
 SoB ( worse on exertion & bending forward)
 Orthopnoea, hoarseness ( P on one recurrent laryngeal N)
XX Thyroid  Stridor ( P on both recurrent N)
 Facial congestion ( + ve Pemberton' s sign)
Ix.
Note: left out non-surgical aspects in these notes
1 . TSH assay
2. CT scan neck & thoracic outlet: size, retrosternal extension
131 Congenital Cx.
 Tracheal displacement/ compression
Embryology. Originating in oor of pharynx, descends through tongue ( foramen  Haemorrhage into a cyst: pain & swelling
caecum) . Failure to descend results in ectopic thyroid tissue. Radioiodine scan must be  Toxic

performed to ensure that the thyroid gland works before removing this tissue.  Malignant
( rare)

32
134 Colloid Goitre (Endemic Goitre)
Aetiology. # I : Derbyshire in UK
2

135 Hyperplasia
Occurs in. 1 hyperthyroidism ( Graves' )
o

Path. Smooth, uniformly enlarged, hyperactivity of acinar cells. V vascular, # colloid.

Lymphocyte inltration

136 Clinical Features in Thyroid Disease

F igu re H yp erthyroid. Nb . hoarse voice indicates in ltration of the larynx ! A lwsys perform
2 3.

laryngoscopy pre-surgery. A F occurs in older hearts t hat can' t cope.

Goitre features.
 Thyroid swelling
 Retrosternal goitre: palpate w neck fully extended. Can block venous return to
SVC: engorgement of jugular veins ! oedema of upper body.
 Tracheal displacement: check for stridor
 Vocal cord integrity: indirect laryngoscopy
 Regional nodes
 Physiological state

137 Investigations
F igu re 2 2 . H ypothyroid 1 . Serum free T3/ T4

33
2. TSH Radioactive iodine  2-3m. Not for < 45y cos of theoretical risk of malignancy.
3. Thyroid scintogram: radioiodine studies of thyroid ( I injected and gland scanned
1 31

with detector to map areas of high uptake) . Hot, cold nodules.

4. Thyroid antibodies: Hashimoto' s, Graves'
5. Thyroid USS: solid or cystic swelling. 140 Thyroid Tumours
6. FNA + core biopsy
7. " Serum cholesterol in myxoedema Tumours
8. ECG
9. CT M alignant B enign

1o Follicular adenoma

138 Outline Rx of Goitre Papillary Follicular A naplastic M edullary L ym phoma Papill Follic M ixed

Multinodular Goitre  Thyroidectomy in enlarged euthyroid, nodular goitre if sx of F igu re 2 4.

tracheal compression. Give T4 after to # size. Young : advised cos of risk of haemor-
rhage into thyroid cyst ( risk of acute tracheal compression) . Cosmetic. Elderly : long
standing asx then leave alone. 1 40.1 Benign Adenoma
Single euthyroid nodule  May be: benign, malignant, cyst. FNA, isotope, USS dis- Hot nodules. 1 0%. Can become thyrotoxic
tinguish cyst from nodule. Aspirate cysts. Take out all other cos of malignant risk. Cold. Don' t become thyrooxic. Might be Ca

139 Hyperthyroidism Rx 1 40.2 Thyroid Carcinoma

See Kumar for medical rx.
 Majority given carbimazole until euthyroid. Relapse after medical rx ( 50%) is indica-
tion for repeat medical, -ectomy, or radioactive iodine
Surgery  Limited to teens/20s. Increasingly total thyroidectomy to # risk of recurrence.
Cx:
1 . Hormonal:
a) H ypoparathyroidism : Sx of paraesthesiae, tetany few days post-op. Rx: IV Ca
gluconate, oral calcium, vit D. Parathormone is not used.
b) T hyroid crisis ( massive release of T4 from gland) : now rare. May have mania,
hyperpyrexia, death. Rx: sedation, propanolol, IV iodine, cooling w ice.
c) H ypothyroidism
d) Failure : late recurrence of hyperthyroidism
2. Damage to anatomical structures:
a) Recurrent laryngeal N : 1 N ( hoarseness) , 2 Ns ( complete loss of voice,
serious narrowing of airway. May need permanent tracheostomy)
b) Trachea
c) Pneumothorax
3. General
a) H aemorrhage : Compress the trachea. Acute SoB & stridor, shock. Rx: emer-
gency decompression of neck ( on the ward! ) then theatre.
b) Sepsis c) Post-op chest infx d) Hypertrophic scarring
Epi.  :  = 2: 1 , often arise in Goitres, previous radiation.
Dierentiated Thyroid Cancer. = Papillary & Follicular. 90% of all Ca. V good prog-
nosis.
Types.
Papillary (60%)  Young, good prognosis, slow growing, late lymphatic spread.
Follicular ( 30%)  Young/ middle aged, blood stream ( ! bone) , slightly worse prog-
nosis
Medullary  Parafollicular C cells ( ! calcitonin, the tumour marker) , familial,
MEN-II syndrome ( phaeochromocytoma, parathyroid tumour, neurobroma ) . Multi-
centric in familial forms, both lobes. FNA.
Anaplastic  Elderly, rapid local spread to trachea, lymph, blood
Clinical. Lump, rapid growing. Dysphagia uncommon ( indicates anaplastic) . Pain,
hoarseness, cervical LNs. Euthyroid usually. Ix: core-needle biopsy, FNA
Rx.
1 . Well dierentiated :
Surgery  Lobectomy if # chance of recurrence ( e. g. small papillary w/ o LN
spread) . Total for others. Must render euthyroid rst. Stop antithyroid drugs
before surgery & give KI ( # vascularity)
Medical  Carbimazole, beta-blockers
Radio-iodine ablation  Also taken up by occult mets. Give w total thyroidec-
tomy. Cx: oedema, thyroiditis.

34
 TSH suppression  Post-op Rx.
Monitoring  Thyroglobulin should be undetectable Medical  Hypertension, renal failure
2. Medullary : exclude other MEN-II Ca. Total thyroidectomy + LN dissection. Pro- Nephrectomy  Recurrent pain, infection, haematuria
phylactic thyroidectomy in rel with germ-line RET mutations
3. Anaplastic : 1 YS < 1 5%. Palliate w radiotherapy & tracheostomy
144 Renal Cysts
141 Riedel's Thyroiditis Claim to Fame. Common ( 50% of 50 y/o' s) . Clinical. Asx. Aching pain in loin.
Haematuria is absent .
Claim to Fame. V rare, gland only slightly enlarged but woody-hard. Mistaken clini- Ix.
cally for thyroid Ca, but histologically brous.
1 . Urine is clear 2. USS: cystic mass 3. IVU: round lling defect 4. CT
Rx. Wedge resection if tracheal compression. Rx. Infection or malignancy suspected : aspiration, & serial CTs

145 Haematuria
XXI Kidney & Ureter Classication.
General  E. g. Anticoagulant
Specic 
142 Horseshoe Kidney 1 . Kidney : trauma, polycystic, glomerulonephritis, TB, infarction ( emboli) , stone,
tumour
Aetiology. During kidney' s ascent from pelvis 2. Ureter : stone, tumour
Clinical. Firm mass in pelvis, recurrent UTI 3. Bladder : trauma, cystitis, stone, tumour, bilharzia
Ix. IVU 4. Prostate : prominent vessels in BPH
5. Urethra : trauma, stone, tumour
Claim to Fame.

of lump in pelvic: not good to remove! Hx. Loin pain suggests renal origin. Colicky suggests stone in renal pelvis or ureter. Ter-
minal bleeding w sev pain & frequency suggests bladder calculus. Prostatic bleeding:
likely to be initial or terminal & painless. Independent of urination suggests urethral.
143 Polycystic Disease Sore throat suggests acute nephritis. Check if on anticoagulant therapy.
Ix.
Path. Multiple cysts throughout renal substance. Dominant ( a recessive form exists, pre- 1 . Urine microscopy: red cells excludes haemoglobinuria, beeturia. Cytology for malig-
senting in childhood) . PKD1 is commonest mutation. nancy
Associated. Liver cysts ( 30%) , lungs, spleen, pancreas. Intracranial Berry aneurysms 2. IVU: renal lesion, lling defect
( subarachnoid haemorrhage) 3. USS: tumours, calculi, collecting system & bladder lesions
4. Cystoscopy: bladder, prostate lesion
Clinical. Middle age:
1 . Abdominal mass
2. Haematuria
3. UTI
4. Renal failure: headache, lassitude, anaemia, vomiting
146 Injury to Kidney
5. Hypertension Clinical. Loin pain, tenderness, haematoma ( causing abdo distension due to ileus) .
6. Intracranial haemorrhage Ix.
Ix. 1 . Urine: haematuria
1 . USS 2. " U&E 3. IVU: elongated spidery calyces stretched out 2. IVU: extravasation of contrast outside renal outline, distortion of calyces

35
 3. USS: renal tear 2. Excess of normal constituents : inadequate urine volume ( dehydration) , Increased
4. CT: visceral injuries excretion of Ca ( hypercalciuria, can be 2 to " Ca or, usually, idiopathic)
o

Rx. 3. Presence of abn constituents : Infections ( esp in presence of obstruction) , foreign

Penetrating injuries  Surgical exploration bodies, vit A deciency ( causes hyperkeratosis producing epithelium upon which
stones form) , cystinuria ( cystine stone formation)
Blunt  Conservative: bed rest, observe urine serially 4. Lack of inhibitors of stone formation : # Citrate, # Mg
Nephrectomy  If: life threatening bleeding, sev hypotension, symptomatic lack of RFs. # Fluid intake, poor diet, sedentary lifestyle
function ( e. g. UTIs, stones)
Composition.
Calcium oxalate ( 60%)  Spiky surface ! traumatized epithelium ! blood colours
stone brown. Opaque. Associated with:
147 Hydronephrosis  Hypercalciuria: absorptive ( " intestinal) , renal leak, resorptive ( demineralisation
Aetiology. of bone " PTH)
 Hypercalcaemia: most 2 " PTH
o

2 o obstruction  Bilateral if obstruction at or below bladder  Hyperoxaluria: " absorption due to short gut syndrome
1 . Within the lumen: e. g. calculus  Hypocitraturia
2. Wall: e. g. TCC  Hyperuricosuria: Ca oxalate crystals form on surface of uric acid crystals
3. Outside wall: e. g. retroperitoneal brosis, extrinsic Ca Calcium phosphate ( 1 0%)  Seen in renal tubular acidosis ( failure to acidify
Without obstruction  Vesico-ureteric reux urine ! alkaline) . Opaque.
Clinical. Asx. Dull, aching pain. Acute attacks of pain resembling ureteric colic ( esp Triple phosphate ( 20%)  Calcium, ammonium, magnesium, phosphate. Found in
after drinking large volumes) . Infection ( pain, rigors, sev loin pain) . Bilateral : uraemia. infected urine. Staghorn calculus. Due to urease producing bacteria ( produce
Presentation w underlying cause ( e. g. calculus) . Kidney may be palpable. ammonia) . Opaque
Cx. Infection ( pyonephrosis) , stone formation ( in stagnant urine) , hypertension ( 2 o
Uric acid & urate (5%)  Smooth. Note if pure urate ( unusual) then translucent.
ischaemia) , renal failure ( if bilateral destruction) , traumatic rupture of hydronephrotic Assoc w gout
pelvis
Ix. Cystine (1 %)  Cystinuria ( recessive disorder) . Radiolucent
1 . USS: dilated 2. CT: cause Clinical. Pain, but may be Asx. Calyces : dull loin pain. PUJ impaction or ureter :
3. IVU: enlarged pelvis, swollen club-like calyces. Kidney may not secrete contrast. ureteric colic ( unable to lie still, continuous pain w sharp exacerbations) . Haematuria.
4. Diuretic renography: ( furosemide given ! MAG3 injection) distinguishes btw Stones Lodge. PUJ, pelvic brim, entrance of ureter into bladder.
obstructed/non-obstructed system. Info concerning function of each kidney. Ix.
5. Retrograde pyelogram: via catheter inserted into ureter at cystoscopy Diagnostic 
Rx. 1.
Haematuria
1 . Percutaneous drainage or Retrograde passage of double pigtail ureteric stent 2.
KUB: stones in 90%. All calcium stones are opaque
2. Removal of underlying cause: if neuromuscular can operate to widen the pelvi- 3.
USS: V good for detecting renal, but not ureteric stones. Hydronephrosis.
ureteric junction ( pyeloplasty) 4.
IVU: remember stones may be obscured by contrast so do KUB rst. Not pos-
3. Nephrectomy: poorly functioning kidney w good contralateral side sible if renal impairment.
5. CT: replacing IVU
6. MAG3: obstruction, function
7. MRU ( ?)
148 Urinary Tract Calculi Incorporated teaching notes Underlying cause 
Epidemiology. 20-50 years,  :  = 3: 1 , caucasians/asians, FH, renal tubular acidosis ( Ca 1 . Urine M&C: bacteria, cystine
phosphate stones) , cystinuria ( cysteine stones) 2. Analysis of stone
3. Uric acid estimation: gout & uric acid stones
Aetiology. 4. Serum Ca
1 . Inadequate drainage : hydronephrosis Cx. Hydronephrosis, infection, anuria ( impaction of calculi both sides)

36
Rx Options. 151 Reux Nethropathy
1 . Watchful waiting: annual KUB. Not suitable for staghorn
2. Medical dissolution: uric acid stones ! sodium bicarbonate to alkalinise urine. Cause. Recurrent infections causing scarring. More common in childhood, due to: vesico-
Cystine stones ! alkalinise urine + " uid + D-penicillamine to convert cystine to ureteric reux ( decient valve) , intrarenal reux ( ducts don' t open oliquely)
more soluble compounds Clinical. Infection sx. Subclinical: incontinence at night.
3. ESWL ( extracorporeal shock wave lithotripsy) : Need analgesia. Cx: haematuria,
infection, obstruction, peri-renal haematoma. ContraI: pregnancy, coagulopathy Ix.
4. Uteroscopy: preferred for ureteric stones. Graspers to remove fragments, laser, 1 . Micturating cystogam: contrast put in to bladder
lithoclast. 2. Indirect micturating cystogram: An isotope ( MAG3) scan showing dierential func-
5. Percutaneous nephrolithotomy: neproscope inserted percutaneously ! stone frag- tion of kidneys
mented ( manually or with lithoclast) . For stones > 3cm. 3. IVU: scarring, clubbing ( reversal of normal cupping of calyces)
6. Open/laporoscopic: occasionally large stones in presence of staghorn calculus & 4. DMSA scan: scaring
non-functioning kidney Rx. Cause. Abx prophylaxis.
Rx Specic.
Ureteric calculi  Analgesia ( NSAID: e. g. PR diclofenac) , oral uids & diet. Con-
servative : majority will pass spontaneously within 6 weeks.  -adrenoceptor antago-
nist ( e. g. tamsulosin) to promote smooth muscle relaxation & promote passage.
152 Pyonephrosis
Active : ESWL ! Uteroscopy ! Laporoscopic or open operation. Aetiology. Infected hydronephrosis, kidney becomes bag of pus. Pyuria ( pus in urine)
Renal calculi  If small can leave alone. Larger: ESWL. Ix.
Acute calculous anuria  Percutaneous nephrostomy or retrograde ureteric 1.
USS kidney
stenting. Uraemic: dialysis. 2.
IVU: enlarged renal shadow, little/no function
Infected obstructed kidney  Emergency. Sx: loin pain, initially colicky but 3.
DMSA: quantify function after treatment
becomes constant. Ix: USS for hydronephrosis. Rx: nephrostomy, abx ( ceph & 4.
MAG3 renography: function, obstruction
gent) , HDU monitoring. Delay stone management until infection controlled. Rx. Urgent drainage by percutaneous nephrostomy. If no residual function then remove
Cause  Infection, obstructive lesions, parathyroid tumours, drink lots of uid. kidney

149 Urinary Tract Infections 153 Carbuncle of Kidney

Upper tract  Haematogenous, or 2 to lower tract
o Def. Cortical abscess, haematogenous infection usually Staph .
Lower tract  Ascending up urethra Clinical. Pyrexia, toxaemia, pain in loin, kidney may be palpable
Ix.
1 . Urine: sterile unless bursts
150 Cystitis 2. FBC: leucocytosis 3. CT/ USS: conrm
Rx. Percutaneous drainage abx
Aetiology.  : urethral or prostatic obstruction, catheterization.
Clinical. Dysuria, frequency, urgency. Haematuria. Loin pain.
Ix.  : multiple episodes.  : 1 episode. 154 Perinephric Abscess
1.Urine M&C&sensitivity: invariably bowel ora. Pus w no growth = Ca. Def. Usually 2 to rupture of carbuncle
o

2.USS bladder & kidneys: obstruction, dilatation of upper tracts

3.KUB: exclude stone Clinical. Constitutional evidence of acute infection, diuse tender bulge in loin.
4.Cystoscopy: bladder diverticula & other defects Ix.
Rx. Abx ( consider prophylactic) . " Fluids. Underlying causes. 1 . KUB: loss of psoas shadow due to retroperitoneal oedema

37
 2. IVU: may show renal cortical abscess or a pyonephrosis 3. Urine: blood, protein, M&C. ( Blood + protein: consider acute nephritis)
3. CT: localization & drainage Rx.
Rx. Drainage: percutaneous or open ( if perc fails) Replenish IV volume 
1 . Assess: JVP, postural hypotension
2. Rapid infusion of uid
155 Renal TB 3. CVP catheter
Dopamine & diuretics  If rehydration unsuccessful in inducing diuresis give
Path. Lesions at junction of cortex & medulla. Enlarge ! caseate ! rupture in to calyx ! furosemide. If this fails * ATN or acute cortical necrosis likely.
extensive destruction. Ureter becomes inltrated & inamed. Obstruction leads to Hyperkalaemia  CA gluconate, insulin + dextrose
pyonephrosis. Autonephrectomy may occur. May become tuberculous cystitis.
Clinical. Young adult, immigrant. Early: dysuria, frequency, pyuria, haematuria.
Advanced: fever, night sweats, loss of weight, anaemia.
Ix. 157 Chronic Renal Failure
1 . Urine: sterile acid pyuria. Acid fast bacilli on Ziehl-Nielson stain. Culture takes 3 Surgical Causes.
weeks.
2. IVU: failure of calyceal lling, irregularity of calyces, patchy calcication Pre-renal  Renal artery stenosis
3. CXR: lung Ca Post-renal ( obstructive) 
4. Cystoscopy: decreased bladder size, oedematous mucosa w tubercles 1. Congenital posterior urethral valves
Rx. Anti-TB 2. Prostatic hyperplasia/ Ca
Cx. Healing causes brosis which may cause strictures. 3. Urethral stricture
4. Cervical Ca
5. Urothelial tumour
Clinical. Malaise, weakness, confusion, hiccups w pallor, hypertension, uid overload.
156 Acute Renal Failure Ix. Those of ARF. Finding Cause. Rx. Absence of correctable then dialyse.
Def. # GFR, retention of nitrogenous waste ( " U, " C) , acidosis, reduced urine output
Aetiology.
* P re- renal  GFR should be 60-80 mmHg. In hypertensives, elderly, pre-existing 158 Renal Tumours
renal disease ( e. g. DM) , NSAIDs, ACEIs autoregulation may be impaired. Tumours
1 . Fluid loss : blood loss, plasma loss ( e. g. burns) , electrolyte loss ( e. g. vomiting)
2. Impaired circulation : general factors ( e. g. hypotension) , local factors ( e. g. aortic K idney Renal Pelvis
dissection & exclusion of renal arteries) B enign M alignant Papillom a T C C S C C
Renal 
 Acute tubular necrosis Adenom a H aem angiom a 1o 2o
 Acute tubular necrosis
 Acute cortical necrosis due to ischaemia N ephroblast oma Adenoca
 Myoglobin released after crush injury
 Drugs: e. g. abx ( gentamicin, NSAIDs)
F igu re 2 5 .

Post-renal  Obstruction at any level from tubules to urethra

Clinical. Anuria uncorrected by bladder catheterization ( rst consider blocked catheter) 159 Nephroblastoma (Wilms')
Ix.
1 . " Urea, " creatinine, " K Path. Anaplastic. Children < 5 usually. Spindle cells.
2. Renal tract doppler USS: small suggests prior renal disease Assoc. Bilateral in 5-1 0%, congenital ( aniridia, hemihypertophy, macroglossia)

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Clinical. Rapid growth ! large mass in loin. Weight loss, anorexia, fever, hypertension. Cx. UTI ( Stagnant urine) , calculus formation, malignant
, hydronephrosis ( rarely, due
Mets. to P against adj ureter)
Ix. USS: solid from cyst. CT: staging. Clinical. Most asx. pis en deux . Ix. IVU, cystoscopy. Rx. Conservatively
Rx. Nephrectomy. Early : cytotoxic chemo. Later : radiotherapy. 80% 5YS

164 Bladder Stone

XXII Bladder Aetiology. Of same types as renal stones. Due to stasis/ infection, foreign body
( catheter)
Clinical. Triad of pain ( suprapubic, maybe tip of penis) , frequency, haematuria ( end
of ow)
160 Urachnal Anomalies Ix. KUB, cystoscopy
Types. Rx. ESWL
1 . Fistula: urinary discharge at the stula
2. Diverticulum: outpouching of the bladder
3. Cyst: urachnus persists but is closed above and below 165 Tumours
Rx. Excision T umours

B enign M alignant
161 Bladder Exstrophy T C papillom a 1o 2o
Def. Failure of fusion of structures forming ant abdo wall. Clinical. Infant incontinent.
May die of pyelonephritis. T C C ( 9 0 % ) S C C Adeno
Rx. Complex reconstruction F igu re 2 6 .

162 Rupture of Bladder 1 65.1 Transitional Cell Papilloma

Nature. Recur seed elsewhere, malignant

Types. Rx. Resection. Regular surveillance.
Intraperitoneal  Penetrating wound or crush injury
*Extraperitoneal  Bladder might be torn by spicule in a pelvic fracture.
Clinical. Intraperitoneal : Peritonitis w generalized extravasation. Extraperitoneal :
extravastion of blood & urine causes painful swelling.


. Rupture of urethra: anterior displacement of prostate. Ix. CT, Cystography, ure-
thrography ( urethral injury)
XXIII 43: Prostate
Rx. Surgical suturing of rupture. Foley catheter. Drainage, abx.
166 Benign Enlargement
163 Diverticulum of Bladder Clinical.
Obstructive  Poor/ intermittent stream, hesitancy, terminal dribbling. May get
About. Most 2 to outow obstruction. 95% in
o
 ( as men usually ones that get haematuria due to congestion of prostatic vein plexus. Eventually: retention ( see
obstructed) below )

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 Detrusor instability  Frequency, urgency, nocturia Clinical.
Renal Failure  Drowsy, headache, impairment of intellect. Acute bacterial  Fever, rigors, perineal pain, diculty voiding, UTI sx. Pain on
Ex. If uraemic: pale, wasted, dry furred tongue. Large bladder. PR: enlarged, palpable ejaculation, blood in semen. PR: enlarged, tender prostate. Epididymitis accompa-
sulcus. nies often. Rx: e. g. ciprooxacin, trimethoprim
Ix. Chronic bacterial  Recurrent UTIs. Prostate feels rmer. Ix: urine. Rx: Abx
1. 24h frequency/volume chart Chronic pelvic pain syndrome  Pain in perineum, scrotum, tip of penis, pain on
2. Serum U&E: renal failure ejaculation/micturition. Frequency, incomplete emptying. Rx: pelvic oor relax-
3. Hbg: uraemia inhibits bone marrow ation,  -blockers, NSAIDs, abx, prostatic massage
4. PSA
5. Urinalysis: leucocytes. Culture: a cx.
6. Urine ow assessment
7. USS: bladder enlargement, hydronephrosis, hydro-ureter, residual urine in bladder
post-voiding
169 Bladder Neck Obstruction
Cx. Aetiology. Congenital valves in region of prostatic urethra, brosis of prostate
Prostatic  Retention, haemorrhage
Bladder  Diverticula, stone, UTI
Renal  Hydronephrosis, uraemia 170 Posterior Urethral Valves
Rx. Clinical. Hydronephrosis, retention in childhood.
Conservative  Bladder training
Ix. Antenatal USS, micturating cystogram
Medical   -adrenergic antagonists ( e. g. tamsulosin) ( relaxation of s. m. of bladder) ,
1

5  -reductase inhibition ( e. g. nasteride) ( blocks conversion testosterone ! dihy- Rx. Surgical incision
drotestosterone)
Surgical 
1 . Transurethral prostatectomy: using diathermy or laser. # Morbidity. Cx: 171 Bladder Neck Fibrosis
 Haemorrhage: post-op irrigation & warming of pt
 TUR syndrome: absorption of " water causes hyponatraemia & confusion Sx of hypertrophy but without enlargement. Endoscopic incision.
 Infection: common if catheterized pre-op. Prophylactic abx.
 Retrograde ejaculation: almost certain
 Impotence: 5-1 5%
 Bladder neck stenosis: due to stricturing of neck 172 Urinary Retention
 Incontinence: uncommon. Happens if damage to sphincter
 Recurrent UTIs: re-growth of malignant
Presentation.
2. Open: if prostate v large, or co-existent intravesical pathology Acute  Suprapubic pain, inability to pass urine, suprapubic mass.

inc AAA, as
mass may be pulsatile
Chronic  Painless dribbling incontinence
167 Prostate Cancer Aetiology.
See oncology notes General  * P ost-op ( in pain. Give opiates & sit pt over bed, or catheterize) , CNS
disease, drugs ( e. g. anticholinergics, TCAs)
Local 
168 Prostatitis 1 . Lumen: e. g. stone
2. Wall: e. g. urethral stricture
Organisms. Faecal: E Coli, Strep faecalis . Can have non-bacterial prostatitis, and non- 3. Outside: e. g. prostatic hyperplasia , prostate malignancy, faecal
inammatory ( prosatodynia) , these both termed chronic pelvic pain syndrome impaction, pregnancy, pelvic tumour

40
Ix. 175 Testicular Torsion
1 . XR pelvis: calculus, bony 2 s
o

2. PSA Epi. Most common btw 1 2-27y. " in undescended testes

3. Does catheter pass? If not, then stricture Path. Twists within tunica vaginalis, blood supply compromised
Assess degree of renal damage. Uraemic sx/ si? Ix: U&C Clinical. V sev sudden onset pain, no sx of UTI
Asses general condition of pt. Ix. Dipstix, m+ c.
Rx. Rx. Surgical exploration: if infarction then orchidectomy, if not then x both sides w a
suture
Benign enlargement  Prostatectomy if general condition satisfactory. If renal
damage/poor general condition then catheterize, perhaps permanently.
Malignant disease  If met spread: hormone therapy. Endoscopic prostatectomy for
XXV Other
localized tumours, or large tumours with persisting sx.
Urethral Stricture  Dilate with bougies under anaesthetic. Rarely impassable:
suprapubic.
Chronic retention  Catheterize, left in to allow renal function to improve. Fluids
may be needed to rx the diuresis that follows relief of hydronephrosis. Bleeding is
common following decompression.

XXIV Testicular Surgical Talk

173 Hydrocoele
Def. Fluid in testes btw the tunica vaginalis & tunica albuginea
Clinical. Can get above, transilluminates
Cause.
1 o  Majority. Children: patent processus vaginalis. Adults: TV produces uid.
2 o  Trauma, infx, malignancy. Develop rapidly
Rx. Leave if asx, can plicate tunica vaginalis.

174 Epididymo-orchitis
Def. Inammation of testis & epidimytis due to infx.
Cause. Young ( mumps) , young adults ( STI) , old ( UTI)
Clinical. Acute onset sev testicular pain, Malaise, fever, discharge, UTI sx. Tender, red, F igu re 2 7. I: H artm anns.
warm testis.

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