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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? |
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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
|
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What investigation is used to find hiatus hernia?
|
barium swallow
|
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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
|
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What symptoms can accompany para-oesophageal hernia?
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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?
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pros: low morbidity
cons: lifelong therapy (cost, unknown effect of drug over lifetime) |
|
What do PPIs do in GORD?
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reduce acid in the refluxed material
don't stop GORD occurring |
|
What are pros/cons of surgery for GORD?
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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?
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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
|
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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 |
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What is the treatment for Crohn's?
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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 |
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What is the surg tx for Crohn's?
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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 |
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What is the prognosis for Crohn's?
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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 |
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What is a true AAA?
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primary dilatation of all artery incl vessel wall layers (intima, media, aventitia). vessel also elongates as well as dilates
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What is a false AAA?
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disruption of artery wall
pulsatile hematoma not contained in artery but in fibrous capsule a mycotic aneurysm is a false aneurysm caused by infn |
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Are AAAs usually true or false?
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usually true
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What are the most common arteries to have aneurysms?
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most common top:
aorto-iliac popliteal common femoral aortic arch carotid other periph arteries |
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What rate does AAA usually grow?
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0.4cm/y
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What is the risk of rupture of a 5cm AAA? a 7cm AAA?
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5cm = 3-5% yearly rupture rate
7cm = 19% yearly rupture rate |
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What is perioperative mortality of AAA surg?
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3-5%
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What sized AAAs are operated on?
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>5cm due to greater risk of rupture than harm from surg
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What is prevalence of AAA?
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6-9% >65yo
2% deaths |
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What are risk factors for AAA?
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smoking
FHx ethnicity (euro>asian/african #notracistyo) coronary heart disease elevated lipids, HT DIABETES AIN'T NO RISK FACTOR YO |
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What triad of sx does infrarenal AAA give?
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severe abdo/back pain
pulsatile mass shock |
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What is the gold standard pre-op imaging study?
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CT contrast
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What is best imaging for yearly follow up of AAA?
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US
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What is best surg mx for AAA?
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endovascular repair due to lower M&M
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What are the criteria for endovascular repair?
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adequate neck: >15mm length, diameter <32mm
not excessively angulated adequate access vessels: size >8mm not excessively tortuous |
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What is M&M for infrarenal abdominal aneuroplasty?
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2-4% operative death
5-10% rate of complication |
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What are complications for endovascular repair?
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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 |
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What is incidence of endoleak?
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18-24% postop
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What are the four types of endoleak?
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1 attachment site leak
2 lumbar/IMA endoleak (most common) 3 junctional leak (junctions of overlapping segments) 4 transgraft |
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What are the treatment options for endoleak?
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leave alone (type 2s seal by themselves)
coil embolisation, inject biological glue, direct access and ligation |
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What is prognosis of ruptured AAA?
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50% make it to hospital
yet 50% die even if they make it |
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What % of bowel obstructions occur in large bowel?
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15%
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Where is the most common site in colon for obstruction?
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sigmoid
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What structure determines the presentation of the large bowel obstruction?
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ileocaecal valve competence
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What are the causes of large bowel obstruction (%s)?
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carcinoma of colon (65%)
diverticulitis (20%) volvulus (5%) other (10%) |
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What is the best useful test for large bowel obstruction?
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CT to determine aetiology
Contrast enema can determine its exact location |
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What is the ddx for large bowel obstruction?
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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) |
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What is the mx for large bowel obstruction?
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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) |
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What is the surg strategy for large bowel obstruction?
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resect affected portion
establish ileostomy/colostomy second operation do anastomosis |
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What is the prognosis for large bowel obstruction?
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mortality 20%
caecal perf = 40% mortality |