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197 Cards in this Set

  • Front
  • Back
What are the recommendations for breast ca screening?
actively targets women aged 50-69
recommended for all women aged 40 and over
free two-view mammogram every 2 years (by BreastScreen Australia)
What is the current participation rate for breast screening in Australia, and what is the aim?
Aim for 70% participation
currently 54.9% in 50-69 aged group
What is the National Bowel Cancer Screening Program?
recommended for all average risk Australians over aged 50
medicare covers screening at ages 50, 55 or 65
mail out FOBT samples to lab, free of cost
positive FOBT advised to contact dr for colonoscopy
What is the efficacy of doing FOBT every 2 years?
reduces death from colon cancer by up to 30%
What are the two kinds of FOBT?
immunochemical FOBT- preferred screening due to no restriction on diet or medication
Guaiac FOBT- must not consume red meat, certain fruit and veg such as raw broccoli, vit C sups, aspirin or NSAIDs 3 days prior
What are the uncertainties, risks and benefits around prostate ca screening?
uncertainties: early detection and treatment does not offer survival benefit
risk: cause damage with biopsy, cause anx and depression, cause stress on self and family, cause financial burden
How does the lower oesophageal sphincter work?
high pressure zone interposed between positive pressure environment of abdomen and the negative pressure of thorax

when sphincter relaxes, peristaltic wave approaches it with bolus, then contracts again when bolus in stomach
What is the pathology of lower oesophageal sphincter in GORD?
no tone, appearing patuous

or has tone, but damaged by acid or other refluxed stomach contents
How common is GORD?
sx once or twice per month in about 1/3 of community
sx daily in 5% of community
T/F.. dismotility in oesophagus causes GORD
F...

seems to be a consequence and perpetuating factor rather than a cause
What is the relationship between hiatus hernia and GORD?
strong association; majority of those with GORD have sliding hiatus hernia, but many with hiatus hernia without GORD.

#knowhatimsayin?
What is the usual refluxed material in GORD?
gastric juice, food and sometimes duodenal content
What is the role of bile in GORD?
No one ******* knows- stomach acid way more important
What is the state of oesophageal mucosa in GORD?
usually normal, but in severe cases there can be erosions
How do strictures form?
erosion--> inflammation--> fibrous healing --> narrowing of oesophagus
How does Barrett's oesophagus form?
oesophagus mucosa changes from squamous to gastric/columnar mucosa
What does Barrett's oesophagus predispose people to?
adenocarcinoma in the gastro-oesophageal junction
What can Barrett's oesophagus do to GORD symptoms?
mask them
What are the two most important complications of GORD?
adenocarcinoma from Barrett's oesophagus
strictures
What is the most common complication of GORD?
chronic blood loss leading to iron-deficient anaemia
What other organ system can be affected by GORD?
respiratory
What investigation is used to find hiatus hernia?
barium swallow
What is a sliding hernia?
the viscus forms part of the wall of the hernial sac
What causes sliding hiatus hernia?
not fully known but thought to be a combination of:
attenuation of hiatial attachments
upward pull of longitudinal muscle of oesophagus
What is a para-oesophageal hernia?
gastro-oesophageal junction remains in normal position
part of anterior wall of stomach rolls up alongside oesophagus into mediastinum
T/F... para-oesophageal hernias have a complete peritoneal sac
T
What symptoms can accompany para-oesophageal hernia?
usually asymptomatic but can have
pain/discomfort after meals
acute pain usually due to twisting of stomach
What is an acute emergency from para-oesophageal hernia?
strangulation of the hernia
How is strangulation of hernia detected on CXR?
fluid level in mediastinum behind heart
What is a mixed hiatus hernia?
gastro-oesophageal junction slides up into chest together with para-oesophageal hernia
What foods can bring about heartburn?
pastries, sweet biscuits, tomato sauce, fatty food
What activities can cause heartburn?
stooping while gardening
lifting heavy objects
lying down (at night)
overeating
alcohol
Which GORD patients require endoscopy?
patients with:
atypical sx
requiring PPI for sx control
Which GORD patients need a pH profile?
those needing endoscopy but with normal finding
(monitor pH over 24h)
What are some PPis?
omeprazole
lanzoprazole
What are the pros/cons of drug therapy in GORD?
pros: low morbidity
cons: lifelong therapy (cost, unknown effect of drug over lifetime)
What do PPIs do in GORD?
reduce acid in the refluxed material
don't stop GORD occurring
What are pros/cons of surgery for GORD?
pros: cures condition
cons: morbidity of operation, leaves pt unable to belch properly, leading to post-prandial bloating, so have to modify eating habits
What are indications for GORD surgery?
severe dysphagia from stricture formation
recurrent respiratory problems from spillover into larynx
Which pt is not appropriate for GORD surgery?
those with short oesophagus (rare)
those who have had previous upper abdo surg in the area of oesophagus and stomach
What is the risk of conversation rate from laparoscopic to open surg for GORD surgery?
2%
What body sites can open GORD surgery be taken from?
thorax of abdo
What is fundoplication? (HINT: nothing to do with having fun with pelicans)
most common GORD operation
wrap fundus of stomach around behind oesophagus, then stitch it to itself
Why can fundoplication not be fun?
Stops vomiting and release of gas from stomach
What are complications specific to GORD surgery?
dysphagia
fundoplication wrap break down (15% cases)
What is the post-op mx of GORD surg?
oral fluids immediately
soft diet when tolerated
discharge 2-3 days laparoscopic, 6-8 days open surg
advise not to do anything that increases intrathoracic pressure (such as heavy lifting)
How long does GORD surgery take to heal?
8 weeks, else run risk of para-oesophageal hernia
What % of oesophageal tumours are benign?
<1%
List the oesophageal benign tumours from most common to least common
most common: leiomyoma

rarer: papilloma, fibrovascular polyps, granular cell tumour, adenoma, hemangioma, neurofibroma, lipoma
What are leiomyomas?
smooth-muscle tumours arising in the oesophageal wall

they are solitary, well-encapsulated with an intact overlying mucosa and grow slowly
What sized leiomyomas are asmyptomatic and how are they found?
small <5cm, found incidentally on barium swallow
How common is oesophageal ca?
9th most common ca worldwide
6th most frequent cause of ca death
What must a pt sign on consent form before surgery?
interpreter service reqs
cultural support reqs
condition and procedure
general risk of procedure: inf; bleed; AMI/CVA; DVT; death
specific risk of proc
sig risks
risks of not having proc
anaesthetic risk
consent signature
What can obtain consent?
AMO/VMO
registrar can do if deemed competent by above
What are NHMRC guidelines for what doctors should tell pts when informing them about procedure?
nature of illness
proposed tx, method, risks, benefits, who will do it
alternatives
degree of uncertainty
likely outcome if no tx
any long term outcome of tx
time and cost
What rx should be stopped for bowel prep?
excluding high residue foods for 48h and fluids 24h, therefore:
adjust insulin
risk of hyponatriemia if on diuretics
aggravation of constipation with opiates, anticholinergics, antidiarrhoeals, diet supps
stop iron 1 week prior to scoping (as it sticks to walls)
oral meds may be incompletely absorbed (ie OCP, antihypertensives)
What are the kinds of bowel preps?
phosphate preps - osmotic effect, can cause electrolyte imbalance
polyethylene glycol - poorly tolerated, as have to drink a fuckload of salty water, but safer than phosphate prep
diphenylmethanes such as bisacodyl or sodium picosulfate- stimulates perstalsis, need to replace fluid or risk electrolyte disturbance
magnesium - the sachet one. increase water and peristalsis in gut- contraindicated in heart/renal failure due to dehydration
What is the most well tolerated bowel prep by patients?
phosphate, but note the possibility of large electrolyte shift
WTF are TEDS?
thrombo embolic deterrent stockings
What are stockings good for?
reducing risk of DVT post-op (but they DON'T reduce risk of PE)
good for chronic venous insufficiency
peripheral oedema
varicose veins
lymphoedema
Which compressors are used before start or end of surgery?
graduated compression stockings
intermittent pneumatic compression stockings
What is the best stocking for DVT reduction while in hospital?
IPC reduce DVT risk by 60%
however, they work better when combined with anticoagulation
What are the NHMRC guidelines for compression stocking use?
GCS/IPC for hip replacement until pt fully mobile
IPC/footpump for hip replacement if anticoag not used
IPC/footpump for total knee replacement until mobile
GCS for all gen surg and abdo pts
GCS for gyne pt if coag CI
GCS/IPC for all ctx/vasc surg
IPC for neurosurg until mobile- no anticoag use
What is GCS first line tx for?
gen surg
abdo surg
CTX/vasc surg
total hip replacement
What is GCS second line for?
major gyne surg
What is IPC first line for?
neurosurg
THR
TKR
What is IPC second line for?
hip surg
When should anticoag be started to prevent DVT?
12h after surg to avoid risk of major bleed
continue for up to 1 week after surg or up to 35 for major joint replacement (hip/knee)
What is the mechanism of unfractionated heparin? How is it measured?
binds to antithrombin III, which
inactivates thrombin and factor Xa
measure with APTT
What is the mechanism of LMWH? What is benefit?
Inhibits Xa, not thrombin
better therapeutic index than heparin
reduced risk of thrombocytopenia and osteopenia
What is the mechanism of fondaparinux? What is benefit?
inhibits factor Xa
smaller size means less likely to bind to PF4, reducing risk of HIT
What is the mechanism of Rivaroxaban and apixaban? What is their benefit? CI?
direct Xa inhibitor
2x reduced risk of VTE compared to enoxaparin
renally secreted so CI in renal failure
What is the mechanism of Warfarin?
vit K antagonist, inhibiting synthesis of factors, II, VII, IX, X, proteins C and S
What is the warfarin paradox?
initial paradoxical thrombocytosis due to inhibition of proteins C and S compared to delayed inhibition of anticoag factors II, VII, IX, X
How long should heparin/LMSH be coadministered with warfarin to offset initial paradoxical thrombocytosis?
4-5 days
What is the mechanism of dabigatran?
direct thrombin inhibitor
non-reversible
inferior efficacy to enoxaparin for VTE reduction with similar bleeding risk
What are the side effects of heparin?
1. HIT (antibodies against heparin bind to platelet factor 4, forming IgG complex which activates plts to form thrombi: seen clinically as stroke, MI, leg ischaemia, PVT, PE. Treat with synth heparin eg danaparoid)
2. Elevated AST/ALT (80%)
3. Hyperkalaemia (10%)- heparin induced aldosterone suppression
4. osteoporosis
5. allopecia
What is major bleeding?
fatal bleeding
symptomatic bleeding in critical area or organ
fall in 2g/dL Hb or leading to xfusion of 2 or more units of blood
How common are surgical site infections?
2-5% of all surgeries
When is best time for antibiotic delivery around surgery?
60 mins pre-op
How do you confirm or exclude DVT?
confirm: doppler
exclude: d-dimer
How much fluid do adults have in body?
45-60% water
2/3 intracellular (25% plasma, 75% interstitial fluid)
1/3 extracellular
What % of body weight is plasma?
5%
What % of bodyweight is interstitial fluid?
15%
What % of body weight is intracellular fluid?
40%
What are the crystalloids?
solutions of sterile water and electrolytes

saline: NaCl and water, if given in large vol can cause hyperchloaemic metabolic acidosis
Ringer's lactate: balanced electrolyte solution with similar electrolyte comp to human plasma, preferred over saline in operations
What are the colloids?
human plasma derivatives or synthetics

hydroxyethyl starches: maintains intravascular vol by colloid pressure, but CI in renal failure/oliguria
FFP/cryoprecipitate: centrifuged whole blood/plasma
human/synth albumin: plasma derivates from fractionated plasma
whole blood: preferred for intraoperative blood loss
gelatins: good vol stabilising, but short in duration and may cause anaphylaxis
dextrans: used for VTE/PE prophylaxis and strong vol effect
What is preferred for operation and why (crystalloids or colloids)?
colloids, because they stay in blood longer
crystalloids move freely between blood and interstitial space, so 80% not in blood at equilibrium
What is good non-aggressive fluid management post-op?
1L of 0.9% isotonic saline
1-2L of 5% dextrose to max 2L/day
correct any electrolyte deficiencies by adding them
What are the 3 kinds of bleeding in surgery?
1. Primary- during operation
2. Reactionary- within 24h of surg
3. Secondary- 7-10d post-op
When is atelectasis seen post-op?
common after abdo/thoracoabdo surg
worst 2nd night post-op
lasts 4-5d
How is post-op atelectasis treated?
respiratory therapy
What is ventillator associated pneumonia?
occurs 48-72h after endotracheal intubation
What compartments of peritoneal cavity may develop abscess?
pelvic
right paracolic gutter
left paracolic gutter
infradiaphgramatic
lesser sac
interloop
How do pelvic abscesses present?
abdo pain
tnederness
spiking fever
prolonged ileus
leukocytosis
What Ix for pelvic abscess?
FBC, biochem, blood cultures

confirm diagnosis with
plain abdo xray
US (90% sensitivity)
CT (95% sensitivity)
How do you treat abscesses?
IV antibiotics before drainage
percutaneous CT guided drainage, or if abscess is complex, multilobulated or has enteric fistula
How does wound dehiscence occur?
When wound tension overcomes tissue or suture strength or knot security
When does wound dehiscence occur?
4-14d post-op
What is incidence of wound dehiscence?
0.4-3.5%
Why is early but not late wound dehiscence an emergency?
Early = risk of complete evisceration (guts falling out- FATALITY!)
Late: risk of incisional hernia
What are risk factors for dehiscence?
Age
Male
COPD
Ascites
Anaemia
Type of surg and closure
Post-op cough
Wound infn
Sepsis
Chronic Glucocorticoids
Malignancy
Obesity
Hypoalbuminemia
Malnuturiton
What are causes of suture failure?
Sutures too close to the edge (<1cm) cause wound necrosis and pull through the fascia
Total length of suture too short for incision (<4x length of incision)
How to diagnose dehiscence?
Profuse serosanguinous discharge
Popping or bulging exacerbated by valsalva
Absence of healing ridge at day 5
Use CT or US to confirm diagnosis
Define aseptic
free from contamination caused by harmful orgs or complete exclusion of harmful org
Define sterile
Free from all living bacteria or live orgs and their spores
What is monopolar diathermy?
current travels through pt
exits via path of least resistance- usually a pad applied to well perfused dry skin over large muscle and from bone, metal, hair
What are the diathermy modes of action?
Cut-to-cut: continuous low volt current, ablates tissue. hold just above tissue for highest density (concentrated area)

Coagulate: interrupted high volt current over large area (low density). Allows tissue to cool, resulting in dehydration. Seals vessels, but higher area means greater risk of complication

Blend: allows cutting currents to coag small vessels or coag currents to also dissect while providing hemostasis
What is dessication?
Current directly contacts tissue
Dehydration/degranulation occur
Tissue becomes white, nonconductive, then chars
What is vaporisation?
if tip of electrosurg equipment is held close to tissue surface cells near tip will vaporise without char
What is fulguration?
If tip of instrument held slightly further away, current jumps to tissue, charring it and stopping bleeding over wider area. good for surface of solid vascular organs, ie lungs
What are the common complications of electrosurg? How common is it?
2-5 in 1000
bowel perforation
ureteral perf
direct coupling (causing burns)
capacitative coupling (current passes through body structure)
insulation failure (breakdown of insulation leads to current leak)
What are the different kinds of IDCs?
Foley: common; double lumen catether in many sizes
Coude: bent tip, facilitates insertion through obstruction, ie BPH
Triple lumen: irrigation, or clot removal in haematuria
Low friction hydrophilic: don't req lube; useful intermittently; don't have balloon anchor
What are complications of catheterisation?
UTI
paraphigmosis
falses passages
urethra stricture
urethral perf
bleeding
What are CI to IV cannulation?
AV fistulas
hx of lymph node dissection or masectomy and lymphoedema
When is central IV cannulation req'd?
sclerosing chemo
vasopressive meds in vol depleted pt
if periph access can't be gained
hemodynamic monitoring
transvenous cardiac pacing
pulmonary artery catheterisation
plasmapheresis
apheresis
hemodialysis
What are the layers of vein a cannula has to penetrate?
internal endothelium
smooth muscle fibres
adventitia
Where can central IV cannula go?
IJV - through SCM triangle- risk of hitting carotid -lowest rate of malposition - optimal for emergencies
EJV - uncomfortable
subclavian vein - risk of ptx, easy to maintain
femoral- easy access but restricts mobilisation
Complications of IV periph cannulas?
phlebitis
extravisation of fluids
bruising
hematoma
thrombophlebitis
septicemia
septic discitis
venous air emboli
pneumocephalus
DVT
skin necrosis
compartment syndrome
arterial/vein injury
venous aneurysm formn
Complications of IV central cannula?
infection
thrombosis
arrythmia - ventricular, branch block
arterial puncture (3-15%)
pneumothorax
hemodynamic collapse
venous air embolus
bleeding
malposition
What are hte diagnostic uses for nasal cannula?
evaluate upper GI lavage bleed
aspirate gastric fluid content
identify oesophagus and stomach on CXR
administer oral contrast for imaging
What are the therapeutic uses for nasal cannula?
decompression of treating ileus or bowel obstruction
administering medications to dysphagic patients
enteral nutrition
aspiration of recently ingested toxic content
stomach lavage/whole bowel irrigation to remove blood, clots, toxins or to facilitate endoscopy
On blood film what do giant platelets mean?
Bernard-Soulier syndrome
What is pseudothrombocytopenia?
in vitro platelet agglutination by EDTA
What does prolonged PT indicate?
vit K deficiency
warfarin
liver disesae
factor deficiency ie inherited VII
antiphospholipid antibodies- lupus anticoagulant
What does APTT measure?
factor deficiencies XII, XI, IX, VIII, prekalikrein, HMW kininogen
heparin use
non-specific inhibitor, eg lupus
vWD
What does prolonged TT indicate?
heparin
fibrin degradation products
low fibrinogen
dysfibrinogenemia
What does prolonged bleeding time indicate?
thrombocytopenia
vWD
vascular purpura
severe fibrinogen deficiency
How do you treat Hemophilia A?
placement of factor VII in bleeds and prophylaxis
DDAVP induces factor VIII, so may be used alternatively to factor VIII in mild cases
How do you treat Hemophilia B?
Recombinant factor IX
How do you treat vWD?
DDAVP for those with minor bleeds
vWF+FVIII concentrate for those Type III absolute deficiency
How do you treat DIC?
Treat underlying condition
Plt xfusion if severely bleeding or at risk, ie surg
FFP or cryprecipitate if pt is bleeding with high INR or low fibrinogen
Heparin may be used if predominantly thrombotic manifestation
How do you treat ITP?
Glucocorticoids first line for mod-severe thrombocytopenia and bleeding
IV Ig or Anti-D is second line to achieve acute changes if persistent symptomatic thrombocytopenia
Splenectomy third line if glucocorticoids fail
Rituximab 4th line
What does FFP contain?
all factors
shelf life 12 months
transfuse quickly after thawing else lose all factors
What is FFP used for?
single factor deficiencies
warfarin effect
acute DIC
TTP
coag inhibitor deficiencies
following mass xfusion/cardiac bypass
liver disease
What is cryoprecipitate?
factor VIII, factor XIII, fibronectin
What is cryoprecipitate used for?
fibrinogen deficiency
DIC
What is an allergic rxn to blood xfusion and how is it treated?
rxn to non-cellular component in blood, ie allergens/ABs
treat with diphenhydramine/promethazine for mild
give hydrocortisone for moderate
give adrenaline for severe anaphylaxis
How can xfusing blood alter oxygen affinity?
stored blood has decreased 2-3DPG, resulting in increased O2 affinity and reduced O2 release into tissues
loses 2-3DPG after 7 days
Only an issue for infants, sickle cell, AMI, stroke, heart failure
What is TRALI and how is it treated?
transfusion related lung injury (TRALI)
anti-HLA or anti-granulocyte ABs from donor cause agglutination and degranulation of granulocytes in lung leading to pulmonary oedema

tx: immediately discontinue xfusion and give O2 therapy
What is graft v host disease and how is it treated?
host lymphocytes in an immunocompromised host cause widespread immune damage to all tissues

tx: irradiate all transfused products to prevent GvHD
no treatment. 90% mortality
What is paralytic ileus?
neurogenic failure of perstalsis to propel intestinal contents
How commonly do adhesions cause small bowel obstruction?
up to 75%
What does colicky pain with dilated small bowel on Xray mean?
complete mid/distal small bowel obstruction
What can be an early sign of strangulation obstruction?
shock
in the form of fever, vomitus, vague colicky pain
What are the causes of small bowel obstruction?
adhesion
neoplasms
hernia
intussuception
volvulus
forgein body
gallstone ileus (passage of large gallstone through cholecysteric fistula)
inflammatory bowel disease
stricture
cystic fibrosis (equivalent to meconium ileus in children)
hematoma (from anticoag)
What is the management for small bowel obstruction?
nasogastric suction (to relieve vomiting, reduce risk of aspiration and reduce air swallowed into abdomen re distention)
fluid and electrolyte resus (no surg until hypokalaemia corrected)
give antibiotics if strangulation suspected

possibly operate (lyse adhesion, remove foreign body, resect gangrene)
What is the prognosis of small bowel obstruction?
2% death rate (most in elderly)
8% for strangulating obstruction if operated on within 36h, 25% if operated after 36h
once adhesions lysed, recurrence uncommon
What are four mechanisms leading to mesenteric ischaemia?
arterial embolus
arterial thrombus
vasospasm
venous thrombosis
What is the prevalence of mesenteric ischaemia by each cause? What is their most likely anatomic origin? What are their comorbidities?
embolus- 50% of cases (up to 95% of pts with embolus ischaemia have heart disease) - 50% of these cases are embolus to SMA
thrombosis (25% of cases)- usually occur at proximal mesenteric arteries, superimposed on atherosclerotic lesions
vasospasm (20% of cases)- usually in critcally-ill pts receiving vasopressor agents
mesenteric venous thrombus (5-15% of cases) usually SMV. Assoc with portal HT, abdominal sepsis, hypercoag-states and trauma
What are the risk factors for mesenteric ischaemia?
acute arterial ischaemia: AF; recent MI; valvular heart disease; recent cardiac/vasc catheterisation
related to aging popn and incidence of athersclerosis
aortic valve repair has 5-9% chance of causing ischaemic colitis
mesenteric venous thrombosis: hypercoag states: protein C or S deficiency; anti-thrombin III deficiency; polycythaemia vera; carcinoma
What are the clinical features of mesenteric ischaemia?
severe, diffuse abdo pain (unresponsive to narcotics)
gross or occult intestinal bleeding
minimal phys findings
possible radiographic changes
operative findings
How is diagnosis made for mesenteric ischaemia?
angiography (sen 74-100%, spec ~100%), but invasive and time consuming

CT (sen 64-82%)
What is the ddx for mesenteric ischaemia?
acute pancreatitis (Ix: serum amylase, oedematous pancreas on CT)
strangulation obstruction (operate)
What is the treatment for mesenteric ischaemia?
arterial thrombosis/embolus: revasculise with thrombolytic therapy (reduced effectiveness >12h)
resection
angiography with stent
massive fluid replacement and anti-coag
second-look operation 24-48h post-op if marginally viable bowel left in
What is the prognosis for mesenteric ischaemia?
arterial vascular occlusion: 59-93% mortality
venous thrombosis: 20-50% mortality
30% recurrence rate within one month without anticoag

peri-operative rate 0-16%, recurrence generally <10%
Where does Crohn's disease affect?
distal ileum usually (75%), but can be anywhere in alimentary tract
small bowel alone (15-30%)
ileum+colon (40-60%)
colon alone (25-30%)
isolated perineal/anorectal disease (5-10%)
What is the incidence of infl bowel disease?
highest incidence in western countries
26-199 per 100k
slightly higher in females than males
median age of diagnosis is 30
higher SES has increased incidence
higher in smokers
lower in breast feeding
What are risk factors for Crohn's?
first degree relative = x4-20 risk
What is the pathology of Crohn's?
granuloma in 70% cases
aphthous ulcers coalesce in cobblestone pattern
can become transmural resulting in fibrosis, stricture formation, intra-abdo abscess, fistulas and free perforation
enroaching of mestenteric fat onto serosa
What are the clinical features of Crohns?
diarrhoea
abdo pain and palpable mass
low grade fever, lassitude, weight loss
anemia
radiographic finding of thickened, stenotic bowel with ulceration and intl fistula
malnutrition can = failure to thrive in children
How many pts with Crohn's have extra-intestinal manifestations?
25%
What are the extra-intestinal manifestations of Crohn's?
Dermatologic: erythema nodosum; pyoderma gangrenosum
rheumatologic: periph arthritis; ank spond; sacroilitis
Ocular: conjunctivitis; uveitis; episcleritis
Urologic: nephrolithiasis; ureteral obstruction
Misc: thromboembolic disease; vasculitis; OP; endocarditis; myocarditis; ILD; amyloidosis; pancreatitis
Hepatobiliary: hepatic steatosis; cholelithiasis; PSC
What are the ddx of Crohn's?
UC
appendicitis
tuberculosis
lyphoma
other: carcinoma, iscaemia, oesinophilic gastroenteritis, NSAID enteropathy
What is the treatment for Crohn's?
no cure
manage sx
sulfasalazine
oral glucocorticoids for mild-moderate
azathioprine/6MP help with gcorticoid tapering but can lead to bone marrow suppression and promote infectious complications
infliximab if no infection
antiotics if infection
What is the surg tx for Crohn's?
70-80% will need operation
if unresponsive to medical rx
if disease complicates
if med induced complications
if growth retardation in children (30%)
if GI haemorrhage/ca

usually tx obstruction
segmental resection is best choice
alternative is strictuloplasty- preserves intestine surface area
What is the prognosis for Crohn's?
Surg complication rate 15-30% mostly wound infn, post-op intra-abdo abscess, anastomotic leak
70% recurrence after 1 year bowel resection
most will have had resection by 15 years of having disease
What is a true AAA?
primary dilatation of all artery incl vessel wall layers (intima, media, aventitia). vessel also elongates as well as dilates
What is a false AAA?
disruption of artery wall
pulsatile hematoma not contained in artery but in fibrous capsule

a mycotic aneurysm is a false aneurysm caused by infn
Are AAAs usually true or false?
usually true
What are the most common arteries to have aneurysms?
most common top:
aorto-iliac
popliteal
common femoral
aortic arch
carotid
other periph arteries
What rate does AAA usually grow?
0.4cm/y
What is the risk of rupture of a 5cm AAA? a 7cm AAA?
5cm = 3-5% yearly rupture rate
7cm = 19% yearly rupture rate
What is perioperative mortality of AAA surg?
3-5%
What sized AAAs are operated on?
>5cm due to greater risk of rupture than harm from surg
What is prevalence of AAA?
6-9% >65yo
2% deaths
What are risk factors for AAA?
smoking
FHx
ethnicity (euro>asian/african #notracistyo)
coronary heart disease
elevated lipids, HT

DIABETES AIN'T NO RISK FACTOR YO
What triad of sx does infrarenal AAA give?
severe abdo/back pain
pulsatile mass
shock
What is the gold standard pre-op imaging study?
CT contrast
What is best imaging for yearly follow up of AAA?
US
What is best surg mx for AAA?
endovascular repair due to lower M&M
What are the criteria for endovascular repair?
adequate neck: >15mm length, diameter <32mm
not excessively angulated

adequate access vessels: size >8mm
not excessively tortuous
What is M&M for infrarenal abdominal aneuroplasty?
2-4% operative death
5-10% rate of complication
What are complications for endovascular repair?
trauma to access vessels
microembolisation
graft displacement/misplacement-graft may slip/ occlude renal aa
branch leak occlusion
endoleak- persistent filling of aneurysm sac
post-implantation syndrome
graft-limb compression, compression, stenosis
contrast-related nephrotoxicity
What is incidence of endoleak?
18-24% postop
What are the four types of endoleak?
1 attachment site leak
2 lumbar/IMA endoleak (most common)
3 junctional leak (junctions of overlapping segments)
4 transgraft
What are the treatment options for endoleak?
leave alone (type 2s seal by themselves)
coil embolisation, inject biological glue, direct access and ligation
What is prognosis of ruptured AAA?
50% make it to hospital
yet 50% die even if they make it
What % of bowel obstructions occur in large bowel?
15%
Where is the most common site in colon for obstruction?
sigmoid
What structure determines the presentation of the large bowel obstruction?
ileocaecal valve competence
What are the causes of large bowel obstruction (%s)?
carcinoma of colon (65%)
diverticulitis (20%)
volvulus (5%)
other (10%)
What is the best useful test for large bowel obstruction?
CT to determine aetiology
Contrast enema can determine its exact location
What is the ddx for large bowel obstruction?
small v large bowel obstruction (large bowel frequently slow in onset, cause less pain and may not cause vomiting despite sig distention)
paralytic ileus (may result from trauma to back/pelvis or peritonitis. abdomen is silent and no cramping. may be tenderness. plain films shows dilated abdomen)
pseudo-obstruction (Ogilvie's sydrome- massive distention in spite of no obstruction)
What is the mx for large bowel obstruction?
surgery to of necrotic bowel and decompression of obstructed segment to avoid perforation. removal of obstruction is secondary goal

stents are useful for depcompression or palliative pts with life expectancy less than 6mth (patent period of stent)
What is the surg strategy for large bowel obstruction?
resect affected portion
establish ileostomy/colostomy
second operation do anastomosis
What is the prognosis for large bowel obstruction?
mortality 20%
caecal perf = 40% mortality