SurgeryAtaGlance PDF

Surgery at a Glance
Pierce A. Grace
Neil R. Borley
Blackwell Science
Surgery at a Glance
Surgery at a Glance
PIERCE A. GRACE
MCh, FRCSI, FRCS
Professor of Surgical Science
University of Limerick
Midwestern Regional Hospital
Limerick
NEIL R. BORLEY
FRCS, FRCS (Ed)
Consultant Colorectal Surgeon
Cheltenham General Hospital
Gloucestershire
SECOND EDITION
Blackwell
Science
1999, 2002 by Blackwell Science Ltd
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First published 1999

Second edition 2002
Library of Congress Cataloging-in-Publication Data

Grace, P. A. (Pierce A.)
Surgery at a glance / Pierce A. Grace, Neil R. Borley.2nd ed.
p., cm.(At a glance series)
Includes index.
ISBN 0-632-05988-5 (pbk.)
1. Diagnosis, SurgicalHandbooks, manuals, etc.
2. Operations, SurgicalHandbooks, manuals, etc.
3. SurgeryHandbooks, manuals, etc.
I. Borley, Neil R. II. Title. III. Series.
[DNLM: 1. Surgical Procedures, OperativeHandbooks.
2. DiagnosisHandbooks.
WO 39 G729c 2002]
RD35 G68 2002
617.9dc21 2001052912
ISBN 0-632-05988-5
A catalogue record for this title is available from the British Library
Set in 9A/12 Times by Graphicraft Limited, Hong Kong

Printed and bound in Great Britain by MPG Books Ltd, Bodmin, Cornwall
For further information on Blackwell Science, visit our website:

www.blackwell-science.com
Contents
Preface 7 38 Peptic ulceration 88

List of abbreviations 8 39 Gastric carcinoma 90
40 Malabsorption 92
Part 1 Clinical presentations at a glance 41 Crohns disease 94
1 Neck lump 10 42 Acute appendicitis 96
2 Dysphagia 12 43 Diverticular disease 98
3 Haemoptysis 14 44 Ulcerative colitis 100
4 Breast lump 16 45 Colorectal carcinoma 102
5 Breast pain 18 46 Benign anal and perianal disorders 104
6 Nipple discharge 20 47 Intestinal obstruction 106
7 Haematemesis 22 48 Abdominal hernias 108
8 Dyspepsia 24 49 Gallstone disease 110
9 Vomiting 26 50 Pancreatitis 114
10 Acute abdominal pain 28 51 Pancreatic tumours 116
11 Chronic abdominal pain 30 52 Benign breast disease 118
12 Abdominal swellings (general) 32 53 Breast cancer 120
13 Abdominal swellings (localized): upper abdominal 34 54 Goitre 122
14 Abdominal swellings (localized): lower abdominal 38 55 Thyroid malignancies 124
15 Jaundice 40 56 Parathyroid disease 126
16 Rectal bleeding 42 57 Pituitary disorders 128
17 Diarrhoea 44 58 Adrenal disorders 130
18 Altered bowel habit/constipation 46 59 Skin cancer 132
19 Groin swellings 48 60 Ischaemic heart disease 134
20 Claudication 50 61 Valvular heart disease 136
21 Acute warm painful leg 52 62 Peripheral occlusive vascular disease 138
22 Acute cold leg 54 63 The diabetic foot 140
23 Leg ulceration 56 64 Aneurysms 142
24 Dysuria 58 65 Extracranial arterial disease 144
25 Urinary retention 60 66 Deep venous thrombosis 146
26 Haematuria 62 67 Varicose veins 148
27 Scrotal swellings 64 68 Pulmonary collapse and postoperative pneumonia 150
69 Bronchial carcinoma 152
Part 2 Surgical diseases at a glance 70 Urinary tract infection 154
28 Hypoxia 66 71 Benign prostatic hypertrophy 156
29 Shock 68 72 Renal calculi 158
30 SIRS 70 73 Renal cell carcinoma 160
31 Acute renal failure 72 74 Carcinoma of the bladder 162
32 Fractures 74 75 Carcinoma of the prostate 164
33 Burns 76 76 Testicular cancer 166
34 Major traumabbasic principles 78 77 Urinary incontinence 168
35 Head injury 80 78 Paediatric general surgery 170
36 Gastro-oesophageal reflux 84
37 Oesophageal carcinoma 86 Index 173
5
Preface
Since it was first published in 1999, Surgery at a Glance has Key Points and Key Investigations or Essential Management
become a favourite with medical students. The book was written boxes to each chapter; these provide the core information a stu-
primarily as a learning and revision aid for students studying dent should know for each topic. A number of new topics have
for the final MB examination. However, others who require an been added (e.g. trauma, general paediatric surgery) and some
overview of clinical surgery, for example, nursing students and old ones removed or amalgamated. In keeping with the format of
some postgraduate surgical students, have also found Surgery at the at a Glance series, each chapter is presented across a two-
a Glance useful. page spread, illustrations on the left-hand page and text on the
This new edition follows the same format as the previous right. The illustrations and text compliment each other to give an
edition but it has been revised extensively without significantly overview of a topic at a glance.
increasing its size. The book is presented in two parts: Part 1 We have had tremendous help from several people in putting
(Clinical presentations at a glance) concentrates on the symp- this book together. We would like to thank the many medical
toms and signs with which patients present, while Part 2 students who have read the book, or parts of the book, over the
(Surgical diseases at a Glance) is concerned with the common last five years and given us good suggestions. Books would
surgical diseases that one is likely to see in practice (or meet in never appear without publishers, and we would like to thank
an exam!). Each of the 27 chapters in Part 1 gives a breakdown the team at Blackwell Publishing including Andrew Robinson,
of the common causes of a particular clinical presentation, for Fiona Goodgame, Anita Lane and Karen Moore for their encour-
example, abdominal pain, and this section should be especially agement, patience and professionalism in bringing the project
useful when preparing for a clinical examination. Part 2 to fruition. We thank the illustrator especially for the excellent
comprises 51 chapters on the common diseases encountered in illustrations.
surgery and should be helpful when faced with questions such as
what do you know about carcinoma of the stomach?. Many of Pierce Grace
the illustrations have been reworked and the text has been Neil Borley
revised for this second edition. A new feature is the addition of
7
List of abbreviations
AAA abdominal aortic aneurysm Dop dopamine

AAT aspartate amino transferase DPTA diethylenetriaminepentaacetic acid
ABI anklebrachial pressure index DU duodenal ulcer
Ach acetylcholine DVT deep venous thrombosis
ACN acute cortical necrosis DXT deep X-ray therapy
ACTH adrenocorticotrophic hormone EAS external anal sphincter
ADH antidiuretic hormone EBV EpsteinBarr virus
Adr adrenaline ECG electrocardiogram
AF atrial fibrillation ER oestrogen receptor
AFP -fetoprotein ERCP endoscopic retrograde cholangiopancreatographic
Ag antigen (examination)
Alb albumin ESR erythrocyte sedimentation rate
ANCA anti-neutrophil cytoplasmic antibody ESWL extracorporeal shock-wave lithotripsy
ANDI abnormalities of the normal development and EUA examination under anaesthesia
involution (of the breast) FBC full blood count
AP anteroposterior FCD fibrocystic disease
APTT activated partial thromboplastin time FHx family history
ARDS adult/acute respiratory distress syndrome FNAC fine-needle aspiration cytology
ARF acute renal failure FSH follicle-stimulating hormone
ATN acute tubular necrosis 5-FU 5-fluorouracil
AVM arteriovenous malfunction -GT gamma glutamyl transpeptidase
AXR abdominal X-ray GA general anaesthetic
BCC basal cell carcinoma GCS Glasgow Coma Scale
BCG bacillus CalmetteGurin GFR glomerular filtration rate
BE base excess GH growth hormone
BP blood pressure GI gastrointestinal
BPH benign prostatic hypertrophy GORD gastro-oesophageal reflux disease
C&S culture and sensitivity GTN glyceryl trinitrate
CABG coronary artery bypass surgery GU genito-urinary
CBD common bile duct Hb haemoglobin
CCF congestive cardiac failure -HCG -human chorionic gonadotrophin
CD Clostridium difficile Hct haematocrit
CEA carcinoembryonic antigen HDU high-dependency unit
CK creatinine kinase HIDA imido-diacetic acid
CLO Campylobacter-like organism HLA human leucocyte antigen
CMV cytomegalovirus Hx history
CNS central nervous system IBS irritable bowel syndrome
COCP combined oral contraceptive pill ICP intracranial pressure
COPD chronic obstructive pulmonary disease ICS intercostal space
CPK-MB creatine phosphokinase (cardiac type) ICU intensive care unit
CRC colorectal carcinoma IgG immunoglobulin G
CRF chronic renal failure IPPV intermittent positive pressure ventilation
CRP C-reactive protein ITP idiopathic thrombocytopaenic purpura
CSF cerebrospinal fluid IVC inferior vena cava
CT computed tomography IVU intravenous urogram
CVA cerebrovascular accident JVP jugular venous pulse
CVP central venous pressure LA local anaesthetic
CXR chest X-ray LAD left anterior descending
D2 type 2 dopaminergic receptors LATS long-acting thyroid stimulating (factor)
DIC disseminated intravascular coagulation LCA left coronary artery
DMSA dimercaptosuccinic acid LDH lactate dehydrogenase
8
LFT liver function test PTC percutaneous transhepatic cholangiography
LH luteinizing hormone PTH parathyroid hormone
LH-RH LH-releasing hormone PUD peptic ulcer disease
LIF left iliac fossa PUO pyrexia of unknown origin
LOC loss of consciousness PV per vaginum
LOS lower oesophageal sphincter PVD peripheral vascular disease
LPS lipopolysaccharide RBC red blood cell
LSE left sternal edge RCC renal cell carcinoma
LSF lesser sciatica foramen RIA radioimmunoassay
LUQ left upper quadrant RIF right iliac fossa
LV left ventricle RLN recurrent laryngeal nerve
LVF left ventricular failure RPLND retroperitoneal lymph node dissection
MC+S microscopy cultures and sensitivity RUQ right upper quadrant
MCP metacarpophalangeal RV right ventricle
MEN multiple endocrine neoplasia RVF right ventricular failure
MI myocardial infarction Rx treatment
MIBG meta-iodo-benzyl guanidine SCC squamous cell carcinoma
MM malignant melanoma SFJ sapheno-femoral junction
MND motor neurone disease SGOT serum glutamic oxalacetic transaminase
MODS multiple organ dysfunction syndrome SIADH syndrome of inappropriate antidiuretic
MRCP magnetic resonance cholangio-pancreatography hormone
MRI magnetic resonance imaging SIRS systemic inflammatory response syndrome
MS multiple sclerosis SLE systemic lupus erythematosus
MSH melanocyte-stimulating hormone SLN superior laryngeal nerve
MSU mid-stream urine STD sodium tetradecyl
MT major trauma SVC superior vena cava
MTP metatarsophalangeal Sxr skull X-ray
MUGA multiple uptake gated analysis T3 tri-iodothyronine
NAdr noradrenaline T4 thyroxine
NG nasogastric TB tuberculosis
NSAID non-steroidal anti-inflammatory drug TCC transitional cell carcinoma
NSU non-specific urethritis TED thrombo-embolic deterrent
OA osteoarthritis TIA transient ischaemic attack
OGD oesophago-gastro-duodenoscopy TNM tumour, node, metastasis (staging)
OGJ oesophago-gastric junction t-PA tissue plasminogen activator
PA posteroanterior TPHA treponema pallidum haemagglutination (test)
PAF platelet activating factor TPR temperature, pulse, respiration
PCA patient-controlled analgesia TSH thyroid-stimulating hormone
PCV packed cell volume TURP transurethral resection of the prostate
PE pulmonary embolism TURT transurethral resection of tumour
PHx past history UC ulcerative colitis
PIP proximal interphalangeal UDT undescended testis
PL prolactin U+E urea and electrolytes
PMN polymorphonuclear leucocyte UTI urinary tract infection
POVD peripheral occlusive vascular disease VA visual acuity
PPI proton pump inhibitor VHL von HippelLindau
PPL postphlebitic limb VIP vasoactive intestinal peptide
PR per rectum VMA vanillyl mandelic acid
PSA prostate-specific antigen VSD ventricular septal defect
PT prothrombin time WCC white cell count
List of abbreviations 9
1 Neck lump
Moves on swallowing or
moves on tongue protrusion
Yes No
THYROID Many/multiple
Posterior triangle
Yes
Midline = thyroglossal cyst
Lateral (Bi) = thyroid mass No LYMPH NODES
Yes Cystic
Reactive
CYSTS No 1 Lymphoma
2 Metastases
Rock hard
Yes
Cystic hygroma (child)
Branchial cyst
(adult) No TUMOURS
OTHERS Salivary gland tumours

Sternocleidomastoid
tumour (torticollis)
Carotid body tumour

TB abscess
Subclavian artery
Aneurysm
Ectasia
10 Clinical presentations at a glance

Important diagnostic features
Definition
Children
A neck lump is any congenital or acquired mass arising in the
Congenital and inflammatory lesions are common.
anterior or posterior triangles of the neck between the clavicles
Cystic hygroma: in infants, base of the neck, brilliant transil-
inferiorly and the mandible and base of the skull superiorly.
lumination, come and go.
Thyroglossal or dermoid cyst: midline, discrete, elevates with
tongue protrusion.
KEY POINTS
Torticollis: rock-hard mass, more prominent with head flexed,
Thyroid swellings move upwards (with the trachea) on
associated with fixed rotation (a fibrous mass in the sternoclei-
swallowing.
Most abnormalities of the neck are visible as swellings.
domastoid muscle).
Ventral lumps attached to the hyoid bone, such as thyroglossal Branchial cyst: anterior to the upper third of the sternocleido-
cysts, move upwards with both swallowing and protrusion of the mastoid.
tongue. Viral/bacterial adenitis: usually affects jugular nodes, mul-
Multiple lumps are almost always lymph nodes. tiple, tender masses.
Dont forget a full head and neck examination, including the oral cavity, Neoplasms are unusual in children (lymphoma most common).
in all cases of lymphadenopathy.
Young adults
Inflammatory neck masses and thyroid malignancy are common.
Differential diagnosis Viral (e.g. infectious mononucleosis) or bacterial (tonsillitis/
50% of neck lumps are thyroid in origin. pharyngitis) adenitis.
40% of neck lumps are caused by malignancy (80% metastatic Papillary thyroid cancer: isolated, non-tender, thyroid mass,
usually from primary lesion above the clavicle; 20% primary possible lymphadenopathy.
neoplasms: lymphomas, salivary gland tumours).
10% of neck lumps are inflammatory or congenital in origin. Over-40s
Neck lumps are malignant until proven otherwise.
Thyroid Metastatic lymphadenopathy: multiple, rock-hard, non-
Goitre, cyst, neoplasm. tender, tendency to be fixed.
75% in primary head and neck (thyroid, nasopharynx, tonsils,
Neoplasm larynx, pharynx), 25% from infraclavicular primary (stomach,
Metastatic carcinoma. pancreas, lung).
Primary lymphoma. Primary lymphadenopathy (thyroid, lymphoma): fleshy, mat-
Salivary gland tumour. ted, rubbery, large size.
Sternocleidomastoid tumour. Primary neoplasm (thyroid, salivary tumour): firm, non-
Carotid body tumour. tender, fixed to tissue of origin.
Inflammatory K E Y I N V E S T I G AT I O N S
Acute infective adenopathy. All patientsFBC
Collar stud abscess.

Cystic hygroma. ?Thyroid LAD Primary tumours

Branchial cyst. U/S scan: Full examination: U/S scan.
Parotitis. Solid/cystic. Fundoscopy FNAC.
FNAC: Auroscopy
Congenital Colloid nodule Nasopharyngoscopy
Thyroglossal duct cyst. Follicular neoplasm Laryngoscopy
Dermoid cyst. Papillary carcinoma Bronchoscopy
Torticollis. Anaplastic carcinoma. Gastroscopy.
FNAC:
Vascular ?Lymphoma/carcinoma.
Subclavian aneurysm. Biopsy:
Subclavian ectasia. ?Lymphoma cell type.
CXR
CT scan:
Source of carcinoma.
Neck lump 11
2 Dysphagia
NEUROMUSCULAR EXTRALUMINAL
Tracheo-oesophageal fistula
CVA
MS Polio Large pharyngeal pouch
MND GuillainBarr
Neuropathy Arch aortic aneurysm
Carcinoma of the
Myasthenia gravis bronchus/trachea **
Mediastinal lymphadenopathy **
Left atrial dilatation
MURAL INTRALUMINAL
Scleroderma
Chagas' disease
Diffuse oesophageal spasm

Food bolus
Achalasia *
Carcinoma of the oesophagus ** Foreign body * (child)
GORD scarring **
Caustic stricture
** = common

Definition Caustic stricture: examination shows corrosive ingestion,
Dysphagia literally means difficulty with swallowing, which chronic dysphagia, onset may be months after.
may be associated with ingestion of solids or liquids or both. Scleroderma: slow onset, associated with skin and hair
changes.
KEY POINTS Intraluminal

Most causes of dysphagia are oesophageal in origin. Foreign body: acute onset, marked retrosternal discomfort, dys-
In children, foreign bodies and corrosive liquids are common causes. phagia even to saliva is characteristic.
In young adults, reflux stricture and achalasia are common.
In the middle aged and elderly, carcinoma and reflux are common. Extramural
Because the segmental nerve supply of the oesophagus corresponds Pulsion diverticulum: intermittent symptoms, unexpected
to the intercostal dermatomes, a patient with dysphagia can accurately regurgitation.
pinpoint the level of obstruction. External compression: mediastinal lymph nodes, left atrial
Any new symptoms of progressive dysphagia should be assumed to be hypertrophy, bronchial malignancy.
malignant until proven otherwise. All need endoscopic or radiological
investigation.
Tumour and achalasia may mimic each other. Endoscopy and biopsy
K E Y I N V E S T I G AT I O N S
are advisable unless the diagnosis is clear.
All
FBC: anaemia (tumours much more commonly cause this than reflux).
LFTs: (hepatic disease).

Mural OGD
Carcinoma of the oesophagus: progressive course, associated (moderate risk, specialist, good for differentiating tumour vs. achalasia
weight loss and anorexia, low-grade anaemia, possible small vs. reflux stricture, allows biopsy for tissue diagnosis,
haematemesis. allows possible treatment).
Reflux oesophagitis and stricture: preceded by heartburn, pro- Barium swallow
gressive course, nocturnal regurgitation. (low risk, easy, good for possible fistula, high tumour,
Achalasia: onset in young adulthood or old age, liquids dis- diverticulum, reflux).

proportionately difficult to swallow, frequent regurgitation,
recurrent chest infections, long history. If ?dysmotility If ?extrinsic compression

achalasia
Tracheo-oesophageal fistula-recurrent chest infections, cough-
neurogenic causes CXR (AP and lateral)
ing after drinking. Present in childhood (congenital) or late adult-

CT scan: low risk, good for

hood (post trauma, deep X-ray therapy (DXT) or malignant).
Video barium swallow extrinsic compression,
Chagas disease (Trypanosoma cruzi): South American preval-
Oesophageal manometry allows tumour staging
ence, associated with dysrhythmias and colonic dysmotility.
Dysphagia 13
3 Haemoptysis
SPURIOUS
Nose bleed
Trauma
Dental abscess
Tumours
LARYNX Carcinoma
TRACHEA
Trauma
Flecks
Foreign body Bright red
TB
Carcinoma Often alone without sputum or with mucus
Aspergilloma
Carcinoma
Adenoma Pulmonary hypertension
Abscess Bronchiectasis
BRONCHUS
Mitral stenosis
Pneumonia
Cardiac failure
Infarction
LUNG CARDIOVASCULAR
Episodic Episodic
Pronounced cough Faint
Clots + fresh blood if abscess or TB Streaked sputum
Mixed with sputum + frothy pink
if pneumonia or infarction

Definition True haemoptysis
Haemoptysis (blood spitting) is the symptom of coughing up Larynx and trachea
blood from the lungs. Blood from the nose, mouth or pharynx Foreign body: choking, stridor, pain.
that may also be spat out is termed spurious haemoptysis. Carcinoma: hoarse voice, bovine cough.
Bronchus
KEY POINTS Carcinoma: spontaneous haemoptysis, chest infections,
Blood from the proximal bronchi or trachea is usually bright red. It may weight loss, monophonic wheezing.
be frankly blood or mixed with mucus and debris, particularly from a Adenoma (e.g. carcinoid): recurrent chest infections, carci-
tumour. noid syndrome.
Blood from the distal bronchioles and alveoli is often pink and mixed Bronchiectasis: chronic chest infections, fetor, blood mixed
with frothy sputum. with purulent sputum, physical examination shows TB or severe
chest infections.
Foreign body: recurrent chest infections, sudden-onset inex-
Important diagnostic features plicable asthma.
The sources, causes and features are listed below.
Lung
Spurious haemoptysis TB: weight loss, fevers, night sweats, dry or productive cough.
Mouth and nose Pneumonia/lung abscess: features of acute chest sepsis,
Blood dyscrasias: associated nose bleeds, spontaneous swinging fever.
bruising. Pulmonary infarct (secondary to PE): pleuritic chest pain,
Scurvy (vitamin C deficiency): poor hair/teeth, skin bruising. tachypnoea, pleural rub.
Dental caries, trauma, gingivitis. Aspergilloma.
Oral tumours: painful intraoral mass, discharge, fetor.
Hypertensive/spontaneous: no warning, brief bleed, often Cardiac
recurrent. Mitral stenosis: frothy pink sputum, recurrent chest infections.
Nasal tumours (common in South-East Asia). LVF: frothy pink sputum, pulmonary oedema.
All
Clotting: blood dyscrasias.
FBC: infections, dyscrasias.
Chest X-ray (AP and lateral).

?Foreign body ?Cardiac cause ?Tumour ?Infection ?Infarction/PE

Bronchoscopy. ECG Sputum cytology Sputum MC+S V/Q scan
Echocardiography. CT scan ?CT scan. CT scan.
Bronchoscopy.
Haemoptysis 15
4 Breast lump
YOUNG OLD
Fibroadenoma Carcinoma
Localized benign (FCD) Localized benign (FCD)
Cyst Cyst
(Carcinoma) (Fibroadenoma)
Mass o/e
Image (ultrasound < 35

mammography > 35)
Clinical assessment
FNAC
FNAC = C5 FNAC = C3/4 FNAC benign = C2 FNAC = C2 (Benign)

(Definitely (Equivocal) Clinical, or suspicious Non-suspicious
carcinoma) radiologically (clinical or radiology)
Definitive carcinoma Diagnostic ? Review clinical

treatment plan excision biopsy findings 2/12 later
or repeat triple ? Repeat FNAC
assessment
Cyst Fibroadenoma
Normal Bloody Residual Age < 35 Age > 35

cyst fluid fluid lump
Review 2/52 ? Excision Repeat Patient Patient Excision

diagnostic investigations unconcerned concerned biopsy
biopsy as above
Rapid
recurrence Review
? Underlying malignancy 6/12 later

Cysts
Definition
Galactocele: commoner postpartum, tender but not inflamed,
A breast lump is defined as any palpable mass in the breast. A
milky contents.
breast lump is the most common presentation of both benign and
Fibrocystic disease: irregular, ill defined, often tender.
malignant breast disease. Enlargement of the whole breast can
occur either uni- or bilaterally, but this is not strictly a breast lump.
Solid lumps
Benign include:
KEY POINTS Fibroadenoma: discrete, firm, well defined, regular, highly
The commonest breast lumps occurring under the age of 35 years are mobile.
fibroadenomas and fibrocystic disease. Fat necrosis: irregular, ill defined, hard, ?skin tethering.
The commonest breast lumps occurring over the age of 50 years are Lipoma: well defined, soft, non-tender, fairly mobile.
carcinomas and cysts. Cystosarcoma phylloides: wide surgical excision (10% are
Pain is more characteristic of infection/inflammation than tumours. malignant).
Skin/chest wall tethering is more characteristic of tumours than benign
disease. Malignant include:
Multiple lesions are usually benign (cysts or fibrocystic disease). Carcinoma
early: ill defined, hard, irregular, skin tethering
late: spreading fixity, ulceration, fungation, peau dorange.
Differential diagnosis
Swelling of the whole breast Swellings behind the breast
Bilateral Rib deformities, chondroma, costochondritis (Tietzes
Pregnancy, lactation. disease).
Idiopathic hypertrophy.
Drug induced (e.g. stilboestrol, cimetidine).
Unilateral KEY INVESTIGATIONS

Enlargement in the newborn. FNAC: tumours, fibroadenoma, fibrocystic disease, fat necrosis, mastitis.
Puberty. Ultrasound: fibroadenoma, cysts, tumours (best for young women/
dense breasts).
Mammography: tumours, cysts, fibrocystic disease, fat necrosis.
Localized swellings in the breast
Biopsy (Trucut/open surgical): usually provides definitive
Mastitis/breast abscess
histology (may be radiologically guided if lump is small or
During lactation: red, hot, tender lump, systemic upset.
impalpablebdetected by mammography as part of breast screening
Tuberculous abscess: chronic, cold, recurrent, discharging
programme).
sinus.
Breast lump 17
5 Breast pain
Tietze's
disease
Angina
Bornholm's
disease
Non-breast pathology
Pleurisy
PAIN
Breast Breast pathology

Cyclical No overt pathology
Non-cyclical
Abscess Periductal mastitis
Fibrocystic Infected areolar

disease sebaceous cyst
Ectasia

Definition Non-lactational abscesses: recurrent, associated with smok-
Mastalgia is any pain felt in the breast. Cyclical mastalgia is ing, associated with underlying ductal ectasia.
pain in the breast which varies in association with the menstrual Treatment: aspirate or incise and drain abscess, give oral
cycle. Non-cyclical mastalgia is pain in the breast which follows antibiotics, stop smoking, prophylactic metronidazole for
no pattern or is intermittent. recurrent sepsis.
Infected sebaceous cyst

KEY POINTS Single lump superficially in the skin of the periareolar region,
Mastalgia is commonly due to disorders of the breast or nipple tissue previous history of painless cystic lump.
but may also be due to problems in the underlying chest wall or overlying Treatment: excise infected cyst.
skin.
Pain is an uncommon presenting feature of tumours but any Fibrocystic disease
underlying mass should be investigated as for a mass (see Chapter 4). Irregular, ill defined, may be associated lumps, tender more than
Always look for an associated infection in the breast. very painful.
Mammography should be routine in women presenting over the age of
45 years to help exclude occult carcinoma. Mastalgia without breast pathology
Pain often felt throughout the breast, often worse in the axil-
lary tail, moderately tender to examination.
Important diagnostic features Treatment for cyclical mastalgia: linoleic acid (evening
Non-breast conditions primrose oil), danazol, tamoxifen.
Tietzes disease (costochondritis): tenderness over medial Treatment for non-cyclical mastalgia: NSAIDs, linoleic acid.
ends of ribs, not limited to the breast area of the chest wall,
relieved by NSAIDs.
Bornholms disease (epidemic pleurodynia): marked pain KEY INVESTIGATIONS
with no physical signs in the breast, worse with inspiration, no Non-breast origin
chest disease underlying, relieved with NSAIDs. Chest X-ray, ECG (exercise)
Pleurisy: associated chest infection, pleural rub, may be bilateral.
Angina: usually atypical angina, may be hard to diagnose, Breast pathology
previous history of associated vascular disease. FNAC (MC+S): associated palpable lump, ?fibrocystic disease,
?mastitis/abscess.
Ultrasound (young women/dense breasts) or mammography (older
Mastalgia due to breast pathology
women/small breasts).
Mastitis/breast abscess
During lactation: red, hot, tender lump, systemic upset.
Mastalgia without breast pathology
Treatment: aspirate abscess (may need to be repeated), do not
Mammography in women over 45 years
stop breast feeding, oral antibiotics.
Breast pain 19
6 Nipple discharge
DISCHARGE
Single lump No lump
Investigate as for lump Mammography
+ve Normal
Investigate Bloody No blood

accordingly discharge
Recurrent, Multiple ducts, Lumpy breast,

1 duct tender yellowgreen discharge
? Intraductal ? Mammary ? Fibrocystic

papilloma duct ectasia disease
Green Yellow
Bloody Fibrocystic disease

Mammary duct
ectasia
Purulent
Carcinoma
Intraductal papilloma Mastitis

Definition Mammary duct ectasia: usually multiple ducts, intermittent,
Any fluid (which may be physiological or pathological) emanat- may be associated with low-grade mastitis.
ing from the nipple.
Bloody
Duct papilloma: single duct, ?retro-areolar, pea-sized lump.
KEY POINTS Carcinoma: ?palpable lump.
Milky discharge is rarely pathological. Mammary duct ectasia: usually multiple ducts, intermittent,
Purulent discharge is usually benign. may be associated with low-grade mastitis.
Bloody discharge is often associated with neoplasia.
If a lump is present, always investigate for the lump rather than for
Pus milk
the discharge.
Acute suppurative mastitis: tender, swollen, hot breast, mul-
tiple ducts discharging.
Differential diagnosis Tuberculous (rare): chronic discharge, periareolar fistulae,
Physiological discharges sterile cultures on normal media.
Milky or clear
Lactation.
KEY INVESTIGATIONS
Lactorrhoea in the newborn (witches milk).
MC+S: acute mastitis, TB (LowensteinJensen medium, ZiehlNeelsen
Lactorrhoea at puberty (may be in either sex).
stains).
Discharge cytology: carcinoma.
Pathological discharges
Mammography: tumours, fibrocystic disease, ?ectasia.
Serous yellow-green
Ductal excision: may be needed for exclusion of neoplasia.
Fibrocystic disease: cyclical, tender, lumpy breasts.
Nipple discharge 21
7 Haematemesis
Oesophageal carcinoma
Acute reflux oesophagitis
MalloryWeiss syndrome
OESOPHAGEAL VARICES**
Dieulafoy lesion
CARCINOMA
Hereditary haemorrhagic
OF THE STOMACH
GASTRIC ULCER** telangiectasia
Leiomyoma
DUODENAL ULCER**
ACUTE GASTRITIS**
Periampullary carcinoma
Aortoduodenal fistula
** Major causes

Definitions Stomach
GI bleeding is any blood loss from the GI tract (from the mouth Erosive gastritis: small volumes, bright red, may follow alco-
to the anus), which may present with haematemesis, melaena, hol or NSAID intake/stress, history of dyspeptic symptoms.
rectal bleeding or anaemia. Haematemesis is defined as vomiting Gastric ulcer: often larger-sized bleed, painless, possible her-
blood and is usually caused by upper GI disease. Melaena is the ald smaller bleeds, accompanied by altered blood (coffee
passage PR of a black treacle-like stool that contains altered grounds), history of PUD.
blood, usually as a result of proximal bowel bleeding. Gastric cancer: rarely large bleed, anaemia commoner, associ-
ated weight loss, anorexia, dyspeptic symptoms.
Gastric leiomyoma (rare): spontaneous-onset moderate-sized
KEY POINTS
bleed.
Haematemesis is usually caused by lesions proximal to the duodeno-
Dieulafoys disease (rare): younger patients, spontaneous
jejunal junction.
large bleed, difficult to diagnose.
Melaena may be caused by lesions anywhere from oesophagus to
colon (upper GI lesions can cause frank PR bleeding).
Duodenum
Most tumours more commonly cause anaemia than frank haematemesis.
In young adults, peptic ulcer disease (PUD), congenital lesions and
Duodenal ulcer: past history of duodenal ulcer, melaena often
varices are common causes.
also prominent, symptoms of back pain, hunger pains, NSAID use.
In the elderly, tumours, PUD and angiodysplasia are common causes. Aortoduodenal fistula (rare): usually infected graft post AAA
repair, massive haematemesis and PR bleed, usually fatal.

Oesophagus KEY INVESTIGATIONS
Reflux oesophagitis: small volumes, bright red, associated FBC: carcinomas, reflux oesophagitis.
with regurgitation. LFTs: liver disease (varices).
Oesophageal carcinoma (rare): scanty, blood-stained debris, Clotting: alcohol, bleeding diatheses.
rarely significant volume, associated with weight loss, anergia, OGD: investigation of choice. High diagnostic accuracy, allows
dysphagia. therapeutic manoeuvres also (varices: injection; ulcers:
injection/cautery).
Bleeding varices: sudden onset, painless, large volumes, dark
Angiography: rare duodenal causes, obscure recurrent bleeds.
red blood, history of (alcoholic) liver disease, physical findings
Barium meal and follow through: useful for patients who are unfit for
of portal hypertension.
OGD (respiratory disease) and ?proximal jejunal lesions.
Trauma during vomiting (MalloryWeiss syndrome): bright
red bloody vomit usually preceded by several normal but force-
ful vomiting episodes.
MANAGEMENT
Resuscitation

Minor bleed: Major bleed:

observation Continued resuscitation, urgent OGD

scheduled OGD

monitor haemoglobin and fluid balance. Peptic ulcer Varices Gastritis

Endoscopic therapy Endoscopic therapy i.v. PPI treatment

Re-bleed or high risk: surgery Sengstaken tube Early feeding
Surgery
Haematemesis 23
8 Dyspepsia
Carcinoma of the oesophagus
Oesophagitis
Carcinoma of
the stomach
Gallstones
Gastritis
Duodenal ulcer
Gastric ulcer
Dyspepsia
<45 >45 or suspicious symptoms
Treatment
with PPI OGD
Poor Success Carcinoma Oesophagitis Gastritis Normal

result Treatment
with PPI HP +ve HP ve
or H2 blocker Treatment Treatment Treatment
OGD with PPI with PPI (U/S)
(then as for
over 45) Eradication Treatment
treatment with PPI Poor Success
Success No success result Treatment
Treatment or PPI with PPI
with PPI dependence or H2 blocker
or H2 blocker 24-h PH
study
Consider antireflux ? GORD
surgery

Definition Gastric ulcer: typically chronic epigastric pain, worse with
Dyspepsia is the feeling of discomfort or pain in the upper food, food fear may lead to weight loss, exacerbated by smok-
abdomen or lower chest. Indigestion may be used by the patient ing/alcohol, occasionally relieved by vomiting.
to mean dyspepsia, regurgitation symptoms or flatulence. Carcinoma stomach: progressive symptoms, associated weight
loss/anorexia, iron-deficient anaemia common, early satiety,
epigastric mass.
KEY POINTS
Dyspepsia may be the only presenting symptom of upper GI Duodenum
malignancy. All older patients and patients with atypical history should Duodenal ulcer: epigastric and back pain, chronic exacerba-
have endoscopy. tions lasting several weeks, relieved by food especially milky
In young adults, gastro-oesophageal reflux and Helicobacter-positive drinks, relieved by bed rest, commoner in younger men, associ-
gastritis are common causes. ated with Helicobacter infection.
Dyspepsia is rarely the only symptom of gallstonesathey are more Duodenitis: often transient, mild symptoms only, associated
often incidental findings. with alcohol and smoking.
Gallstones
Differential diagnosis Dyspepsia is rarely the only symptom, associated RUQ pain,
Oesophagus needs normal OGD and positive ultrasound to be considered as
Reflux oesophagitis: retrosternal dyspepsia, worse after large cause for dyspeptic symptoms.
meal/lying down, associated symptoms of regurgitation, pain on
swallowing.
Oesophageal carcinoma: new-onset dyspepsia in older KEY INVESTIGATIONS
patient, associated symptoms of weight loss/dysphagia/hae- FBC: anaemia suggests malignancy.
matemesis, failure to respond to acid suppression treatment. OGD: tumours, PUD, assessment of oesophagitis.
24-hour pH monitoring: ?GORD.
Stomach Ultrasound: ?gallstones.
Gastritis: recurrent episodes of epigastric pain, transient or
short-lived symptoms, may be associated with diet, responds
well to antacids/acid suppression.
Dyspepsia 25
9 Vomiting
Ach Acetylcholine
CTz Chemoceptor trigger zone Psychological
D2 Type 2 dopaminergic receptors Sights
H2 Type 2 histamine receptors Smells
IVv Floor of 4th ventricle
NAdr Noradrenaline
VC Vomiting centre
5HT3 Type 3 5-HT receptors
NAdr Many drugs
CTz Cytotoxics
Uraemia
H2
Viraemia
VC D2
Motion
5HT3 Cerebral irritation
Menire's disease
Trauma Ach Meningitis
Epilepsy
IVv
Ach
Gonadal pain
Biliary pain
Myocardial pain Overdistension
Irritants
Toxins
Pancreatitis
5HT3
Peritonitis
Trauma Toxins
Pregnancy Drugs
Paralytic ileus

Definitions PUD: especially gastric ulcer; vomiting relieves the pain.
Vomiting is defined as the involuntary return to, and forceful Intestinal obstruction.
expulsion from, the mouth of all or part of the contents of the Hour-glass stomach (carcinoma of the stomach).
stomach. Waterbrash is the sudden secretion and accumulation Pyloric stenosisbinfant: hypertrophic pyloric stenosis, pro-
of saliva in the mouth as a reflex associated with dyspepsia. jectile vomiting; adult: pyloric outlet obstruction secondary to
Retching is the process whereby forceful contractions of the PUD or malignant disease.
diaphragm and abdominal muscles occur without evacuation of Small bowel obstruction: adhesions, hernia, neoplasm,
the stomach contents. Crohns disease.
Large bowel obstruction: malignancy, volvulus, diverticular
disease.
KEY POINTS
Inflammation: appendicitis, peritonitis, pancreatitis, cholecys-
Vomiting is initiated when the vomiting centre in the medulla oblongata
titis, biliary colic.
is stimulated, either directly (central vomiting) or via various afferent
fibres (reflex vomiting).
Vomiting of different origins is mediated by different pathways and
General causes (ACh and D2 mediatedbtreatment:
transmitters. Therapy is best directed according to cause. anticholinergics, antidopaminergics)
Consider mechanical causes (e.g. gastric outflow or intestinal Myocardial infarction.
obstruction) before starting therapy. Ovarian disease, ectopic pregnancy.
Severe pain (e.g. kick to the testis, gonadal torsion, blow to the
epigastrium).
Important diagnostic features Severe coughing (e.g. pulmonary TB, pertussis).
Central vomiting
Drugs, e.g. morphine sulphate, chemotherapeutic agents. CNS causes (NAdr and ACh mediatedbtreatment:
Uraemia. anticholinergics, sedatives)
Viral hepatitis. Raised intracranial pressure.
Hypercalcaemia of any cause. Head injury.
Acute infections, especially in children. Cerebral tumour or abscess.
Pregnancy. Hydrocephalus.
Meningitis.
Reflex vomiting Cerebral haemorrhage.
Gastrointestinal causes (5HT3 and Ach mediatedb Migraine.
treatment: promotilants, 5HT3 antagonists) Epilepsy.
Ingestion of irritants. Offensive sights, tastes and smells.
Bacteria, e.g. salmonella (gastroenteritis). Hysteria.
Emetics, e.g. zinc sulphate, ipecacuanha. Middle ear disorders (H2 mediatedbtreatment: antihistamines).
Drugs, e.g. alcohol, salicylates (gastritis). Menires disease.
Poisons, e.g. salt, arsenic, phosphorus. Travel/motion sickness.
Vomiting 27
10 Acute abdominal pain
RUQ EPIGASTRIC LUQ

Oesophagitis
Pneumonia
Pneumonia
Hepatic tumour Duodenal ulcer Gastritis Splenic
Hepatic
infarction
abscess Biliary colic
Hepatitis Gastric ulcer
Cholangitis Pancreatitis
Cholecystitis
Pancreatitis
Pyelonephritis Pyelonephritis
Renal colic Renal colic
Renal infarction Renal infarction
Retrocaecal
appendicitis
CENTRAL
Aortic
aneurysm
Meckel's Renal colic
Intussusception
Renal colic diverticulitis UTI
UTI
Sigmoid
Meckel's volvulus
Obstruction Colitis
diverticulitis
Infarction Enteritis
Crohn's disease Crohn's disease
Acute appendicitis Diverticulitis
Perforated
caecal carcinoma
Ovarian cyst Ovarian cyst

Salpingitis SUPRAPUBIC
Salpingitis
Ectopic pregnancy Ectopic pregnancy
Diverticulitis
RIF Pelvic LIF
appendicitis Uterine fibroid
Ovarian cyst
Salpingitis
Cystitis

Definitions KEY INVESTIGATIONS
Abdominal pain is a subjective unpleasant sensation felt in any FBC: leucocytosis, infective/inflammatory diseases, anaemia, occult
of the abdominal regions. Acute abdominal pain is usually used malignancy, PUD.
to refer to pain of sudden onset, and/or short duration. Referred LFTs: usually abnormal in cholangitis, may be abnormal in acute
pain is the perception of pain in an area remote from the site of cholecystitis.
origin of the pain. Amylase: serum level >1000 iu diagnostic of pancreatitis. Serum level
5001000 iu, ?pancreatitis, perforated ulcer, bowel ischaemia, severe
sepsis. Serum level raised <500 iu, non-specific indicator of pathology.
KEY POINTS -HCG (serum): ectopic pregnancy.
The level of abdominal pain generally relates to the origin: foregutb Arterial blood gases: metabolic acidosisb?bowel ischaemia,
upper; midgutbmiddle; hindgutblower. peritonitis, pancreatitis.
Generally, colicky (visceral) pain is caused by stretching or contracting MSU: urinary tract infection (++ve nitrites, blood, protein), renal stone
a hollow viscus (e.g. gallbladder, ureter, ileum). (++ve blood).
Generally, constant localized (somatic) pain is caused by peritoneal ECG: myocardial infarction.
irritation and indicates the presence of inflammation/infection Chest X-ray: perforated viscus (free gas), pneumonia.
(e.g. pancreatitis, cholecystitis, appendicitis). Abdominal X-ray:
Associated back pain suggests retroperitoneal pathology ischaemic bowel (dilated, thickened oedematous loops)
(aortic aneurysm, pancreatitis, posterior DU, pyelonephritis). pancreatitis (sentinel dilated upper jejunum)
Associated sacral or perineal pain suggests pelvic pathology cholangitis (air in biliary tree)
(ovarian cyst, PID, pelvic abscess). acute colitis (dilated, oedematous, featureless colon)
Generally, very severe pain indicates ischaemia or generalized acute obstruction (dilated loops, string of pearls sign)
peritonitis (e.g. mesenteric infarction, perforated duodenal ulcer). renal stones (radiodense opacity in renal tract).
Pain out of proportion to the physical signs suggests ischaemia Ultrasound:
without perforation. intra-abdominal abscesses (diverticular, appendicular, pelvic)
Remember referred causes of pain: pneumonia (right lower lobe), acute cholecystitis/empyema
myocardial infarction, lumbar nerve root pathology. ovarian pathology (cyst, ectopic pregnancy)
trauma (liver/spleen haematoma)
renal infections.
OGD:
PUD, gastritis.
CT scan:
pancreatitis, trauma (liver/spleen/mesenteric injuries), diverticulitis,
leaking aortic aneurysm.
IVU: renal stones, renal tract obstruction.
Acute abdominal pain 29

11 Chronic abdominal pain
RUQ EPIGASTRIC LUQ

Oesophagitis
Carcinoma
Hepatic tumour
Duodenal ulcer Gastritis
Hepatic
Pancreatitis
abscess
Hepatitis Empyema
Gastric ulcer
of
gallbladder
Pancreatitis
Pyelonephritis Pyelonephritis
Pancreatic cancer
Appendix
abscess
CENTRAL
Aortic
Meckel's aneurysm
diverticulum
Lymphoma
Colonic
ischaemia
Mesenteric Colitis
Crohn's disease ischaemia
Invasive Appendix abscess Crohn's disease
caecal Tuberculosis Retroperitoneal fibrosis Diverticulitis
carcinoma Adhesions
Irritable
bowel syndrome
Ovarian cyst
SUPRAPUBIC
Ovarian cyst
Diverticulitis
RIF LIF
Appendix Uterine fibroid
abscess Ovarian cyst

Definition signs or symptoms present, abdominal signs may be unremark-
Chronic abdominal pain is usually used to refer to pain which able, self limiting.
is either longstanding, of prolonged duration or of recurrent/
intermittent nature. Chronic pain may be associated with acute Mesenteric angina
exacerbations. Classically occurs shortly after eating in elderly patients, colicky
central abdominal pain, vomiting, food fear and weight loss.
Usually associated with other occlusive vascular disease.
KEY POINTS
Chronic abdominal pain of prolonged duration requires investigation.
Meckels diverticulum
Adhesions as a cause of chronic abdominal pain should be a diagnosis May cause undiagnosed central abdominal pain in young adults.
of exclusion. Occasionally associated with obscure PR bleeding, anaemia.
Irritable bowel syndrome is less common than supposedbany Best diagnosed by radionuclide scanning.
atypical bowel symptoms should be investigated fully before diagnosing
IBS.
Back pain suggests a retroperitoneal origin. KEY INVESTIGATIONS
Sacral pain suggests a pelvic origin. FBC: leucocytosisbchronic infective/inflammatory diseases,
Relationship to food strongly suggests a physical pathology and anaemiaboccult malignancy, PUD, lymphocytosisblymphoma.
requires investigation. LFTs: common bile duct gallstones, hepatitis, liver tumours
(primary/secondary).
MSU: urinary tract infection (++ve nitrites, blood, protein), renal stone
(++ve blood).
Important diagnostic features ECG: ischaemic heart disease.
Irritable bowel syndrome Abdominal X-ray: chronic pancreatitis (small calcification throughout
Syndrome of colicky abdominal pain, bloating, hard pellety or gland):
watery stools, sensation of incomplete evacuation, often associ- Ultrasound:
ated with frequency and urgency. intra-abdominal abscesses (diverticular, appendicular, pelvic, hepatic)
Blood, mucus, abdominal physical findings, weight loss or gallstones, chronic cholecystitis
recent onset of symptoms or onset in old age should suggest an ovarian pathology (cyst)
organic cause and require thorough investigation. aortic aneurysm renal tumours.
OGD: PUD, gastritis, gastric or oesophageal carcinoma.
Adhesions Colonoscopy: diverticular disease, chronic colonic ischaemia.
Associated with several syndromes of chronic or recurrent CT scan: chronic pancreatitis, pancreatic carcinoma, aortic aneurysm,
abdominal symptoms. retroperitoneal pathologies (fibrosis, lymphadenopathy, tumours).
Adhesional abdominal pain: difficult to diagnosis with any IVU: renal stones, renal tract tumours, renal tract obstruction.
Visceral angiography: mesenteric vascular disease.
confidence, usually a diagnosis of exclusion, may be suggested
ERCP: chronic pancreatitis, pancreatic carcinoma.
by small bowel enema showing evidence of delayed transit or
Small bowel enema: Crohns disease, small bowel tumours, Meckels
fixed strictures, rarely responds well to surgery.
diverticulum.
Recurrent incomplete small bowel obstruction: transient
Barium enema: ischaemic strictures, chronic colitis.
episodes of obstructive symptoms, often do not have all classical
Chronic abdominal pain 31

12 Abdominal swellings (general)
'FLIPPING BIG MASS'
Ovarian cyst Fibroid in uterus
Mesenteric cyst Lymphadenopathy
Massive Massive
hepatomegaly splenomegaly
CAUSES OF ASCITES
Congestive
ABDOMINAL WALL SWELLINGS
cardiac failure
Chronic liver failure
Incisional Ventral hernia

hernia
Lipoma Para-umbilical
hernia
Chyle leak Abscess
Chronic Spigelian hernia
renal failure
Rectus sheath
haematoma
Inguinal hernia
Carcinomatosis
Chronic peritonitis

Definition chronic peritonitis (e.g. tuberculosis, missed appendicitis)
An abdominal swelling is an abnormal protuberance that arises carcinomatosis (malignant deposits, especially ovary, stomach)
from the abdominal cavity or the abdominal wall and may be chronic liver disease (cirrhosis, secondary deposits, portal or
general or localized, acute or chronic, cystic or solid. hepatic vein obstruction, parasitic infections)
congestive heart failure (RVF)
chronic renal failure (nephrotic syndrome)
KEY POINTS chyle (lymphatic duct disruption).
Generalized abdominal swellings affect the entire abdominal cavity.
Localized swellings can be located in the various regions of the abdomen. Faeces
Abdominal wall swellings can be differentiated from intra-abdominal Chronic constipation: faeces accumulate in the colon producing
swellings by asking the patient to raise his or her head from the couch
abdominal distension. Congenital causes include spina bifida
(intraperitoneal swellings disappear while abdominal wall swellings
and Hirschsprungs disease. Acquired causes include emotional
persist).
disorders, chronic dehydration, drugs (opiates, anticholinergics,
Giant masses, other than ovarian cystadenocarcinoma, are rarely
phenothiazines) and hypothyroidism.
malignant.
Fetus
Important diagnostic features Pregnancy: swelling arises out of the pelvis.
Fat
Obesity: deposition of fat in the abdominal wall and intra- Flipping big mass
abdominally (extraperitoneal layer, omentum and mesentery). Usually cystic lesions: giant ovarian cystadenoma, mesenteric
Clinical obesity is present when a persons body weight is 120% cyst, retroperitoneal lymphadenopathy (lymphoma), giant uter-
greater than that recommended for their height, age and sex ine fibroid, giant splenomegaly, giant hepatomegaly, giant renal
(body mass index). tumour, desmoid tumour.
Flatus
Intestinal obstruction: swallowed air accumulates in the bowel KEY INVESTIGATIONS
causing distension. This gives a tympanic note on percussion FBC: lymphomas, infections.
and produces the characteristic air-fluid levels and ladder pat- LFTs: liver disease.
tern on an abdominal radiograph. Sigmoid or caecal volvulus U+Es: renal disease.
produces gross distension with characteristic features of dis- Abdominal X-ray:
tended loops on abdominal X-ray. ascites (ground glass appearance, loss of visceral outlines)
large mass (bowel gas pattern eccentric, paucity of gas in one quadrant)
fibroid (popcorn calcification).
Fluid
Ultrasound: ascites, may show cystic masses.
Intestinal obstruction: as well as air, fluid accumulates in the
CT scan: investigation of choice, differentiates origin and relationships.
obstructed intestine.
Paracentesis: MC+S (infections), cytology (tumours).
Ascites: fluid accumulates in the peritoneal cavity due to the
Liver biopsy: undiagnosed hepatomegaly.
6 Cs:
Abdominal swellings (general) 33

13 Abdominal swellings (localized): upper abdominal/1
Venous engorgement Cirrhosis

RIGHT
LIVER
Abscess
Hydatid cyst
Primary
tumour GALLBLADDER
Metastatic Mucocele
tumour Empyema
Carcinoma
Riedel's lobe
Cyst
Tuberculosis
Hydronephrosis
Abscess Faeces
Carcinoma
Tumours
Intussusception
Polycystic disease ASCENDING COLON
KIDNEY
SPLEEN
Infections
STOMACH
Lymphoma
Distension
Portal
Carcinoma hypertension
LEFT PANCREAS
Pseudocyst
Carcinoma
Tuberculosis
DESCENDING COLON Cyst
Hydronephrosis
Carcinoma
Abscess
Faeces
Tumours
Polycystic
disease
KIDNEY

Gallbladder
KEY POINTS
Generally: oval, smooth, projects towards RIF, beneath the tip
Hepatic mass: moves with respiration, dull to percussion, cannot get
above it, enlarges/descends towards RIF.
of the ninth rib, moves with respiration.
Splenic mass: moves with respiration, dull to percussion, cannot get Mucocele: large gallbladder, moderately tender, smooth
above it, enlarges/descends towards RIF, may have a notched border. walled.
Renal mass: moves somewhat with respiration, usually resonant due Empyema: acutely tender, difficult to palpate clearly because
to overlying bowel gas, bimanually palpable (ballotable). of pain.
Retroperitoneal mass: no movement with respiration, difficult to Carcinoma of gallbladder: nodular, hard, irregular.
delineate, resonant to percussion.
Bowel masses: often mobile, may be well defined. Renal masses
Perinephric abscess/pyonephrosis: acutely tender, systemic
signs, rarely large.
Liver Hydronephrosis: large, smooth, tense kidney. May be massive.
Riedels lobe: smooth, non-tender, lateral/right lobe:, tongue- Solitary cyst: smooth, non-tender, may be massive.
like, men < women. Polycystic disease: frequently very large, lobulated, smooth.
Infective hepatitis: smooth, tender, global enlargement. Renal carcinoma: irregular, nodular, often hard, ?fixed.
Liver abscess: usually one large abscess, ?amoebic, very ten- Nephroblastoma: large mass in children.
der, systemically unwell.
Hydatid cyst: smooth, may be loculated, ?history of tropical Suprarenal gland
travel. Generally: only palpable when large, moves with respiration,
Venous congestion: smooth, tender, pulsatile (slightly irregu- difficult to define borders.
lar (cirrhotic) if chronic). Adenomas: usually cystic if palpable.
Cirrhosis: irregular, firm, knobbly. Infections: ?chronic fungal infections, may be tender, sys-
Tumours: temic features.
primary: solitary, large, non-tender, ?lobulated Congenital hyperplasia: young children, endocrine disorders
secondary: often multiple, irregular, rock hard, centrally associated, smooth, non-tender.
umbilicated.
Abdominal swellings (localized): upper abdominal 35

Abdominal swellings (localized): upper abdominal/2
EPIGASTRIC STOMACH
Pyloric Gastric PANCREATIC

stenosis cancer
Pseudocyst
Carcinoma
TRANSVERSE COLON
Carcinoma
Faeces
Dermoid cyst
Aortic aneurysm
Lymphadenopathy
RETROPERITONEUM
UMBILICAL STOMACH
Tumour
Carcinoma
Leiomyoma
TRANSVERSE COLON
Faeces
Carcinoma
RETROPERITONEUM
OMENTUM
Lymphadenopathy
Secondary
Aortic aneurysm tumours
Mesenteric cyst
SMALL BOWEL
Tumour
Crohn's disease

Colon Dermoid cysts (rare): deep seated, smooth, recurrent after
Faeces: soft, putty-like mass, mobile, non-tender, can be surgery.
indented. Aortic aneurysm: smooth, fusiform, pulsatile, expansile, may
Carcinoma: firmhard, irregular, non-tender, may be mobile be tender.
(fixity strongly suggests carcinoma).
Intussusception: mobile, smooth, sausage-shaped mass. Omentum
Secondary carcinoma: hard, irregular, mobile, pancake like,
Stomach often ovarian carcinoma.
Gastric distension: soft, fluctuant, succussion splash present.
Neoplasm: irregular, hard, craggy, immobile, does not
descend on inspiration. KEY INVESTIGATIONS
FBC: anaemiabtumours.
Pancreas WCC: lymphomas, Crohns disease, appendicitis/diverticulitis.
Generally: does not move with respiration, fixed to retroperi- LFTs: liver lesions.
toneum, poorly defined. Ultrasound: pancreatic (pseudo)cysts, aortic aneurysm.
Pseudocyst/cyst: mildly tender (worse if infected), symptoms CT scan: pancreatic tumours, lymphadenopathy,
of gastric obstruction. retroperitoneal/mesenteric cysts, aortic aneurysm, omental deposits.
Carcinoma: hard, irregular, non-tender, fixed. Gastroscopy: stomach tumours.
Colonoscopy: colonic tumours.
Retroperitoneum Small bowel enema: small intestinal tumours.
Lymphadenopathy: solid, immobile, irregular, rubbery, may Barium enema: colonic tumours.
be massive, particularly if lymphomatous.
Abdominal swellings (localized): upper abdominal 37

14 Abdominal swellings (localized): lower abdominal
RIGHT ILIAC FOSSA SWELLING LEFT ILIAC FOSSA SWELLING
ASCENDING COLON SIGMOID COLON

Normal
SMALL BOWEL Diverticular
Tuberculous abscess
Crohn's
mass mass
Carcinoma
Faeces
Carcinoma Diverticular mass
Appendix mass/abscess
OVARIAN/TUBAL
Ovarian cyst
Pyosalpinx Pelvic kidney

Ovarian cyst
Ectopic pregnancy
Pelvic kidney
Pyosalpinx
OVARIAN/TUBAL
Ectopic pregnancy
SUPRAPUBIC SWELLING
RECTUM
Carcinoma
OVARIAN/TUBAL
Cyst
Pyosalpinx UTERUS
Fibroid
Ectopic pregnancy Pregnancy
Carcinoma
BLADDER
Urinary retention Transitional cell tumour

KEY POINTS
Retention of urine: stony dull to percussion, associated with
Retroperitoneal mass: no movement with respiration, difficult to desire to pass urine, disappears on voiding/catheterization.
delineate, resonant to percussion. Transitional cell carcinoma: hard, irregular, fixed, may be
Bowel masses: often mobile, may be well defined. associated with dysuria, haematuria and desire to pass urine on
Pelvic mass: difficult to get below, bimanually palpable on PR/PV examination.
examination.
Uterus
Pregnancy: smooth, regular, fetal heart sounds heard/
Sigmoid colon movements!
Diverticular mass: tender, ill defined, rubbery hard, non-mobile. Fibromyoma: usually smooth, may be pedunculated and
Paracolic abscess: acutely tender, ill defined, ?fluctuant, sys- mobile, non-tender, associated menorrhagia.
temic upset. Uterine carcinoma: firm uterus, may be tender, irregular only
Carcinoma: hard, craggy, non-tender unless perforated, immob- if tumour is extrauterine, associated PV bloody discharge.
ile, associated with altered bowel habit/obstructive symptoms.
Faeces: firm, indentable/malleable, mobile with colon. Rectum
Normal: only in a thin person, non-tender, chord like. Carcinoma: firm, irregular, non-tender, relatively immobile,
associated alteration in bowel habit/PR bleeding.
Caecum/ascending colon
Appendix mass/abscess: acutely tender, ill defined, ?fluctuant, Urachus (rare)
systemic upset. Cyst: small swelling in midline, ?associated umbilical discharge.
Carcinoma: hard, craggy, non-tender unless perforated, im-
mobile, associated with anaemia/weight loss and anergia. Other
Pelvic kidney: smooth, regular, non-tender, non-mobile.
Terminal ileum
Crohns mass: tender, ill defined, rubbery hard, non-mobile.
Tuberculous mass: mildly tender, ill defined, firm, associated KEY INVESTIGATIONS
with cutaneous sinuses, ?systemic TB. FBC: anaemiabtumours.
WCC: lymphomas, Crohns disease, appendicitis/diverticulitis.
Ovary/fallopian tube LFTs: liver lesions.
Cyst: may be massive, usually mobile, ?bimanually palpable Ultrasound: ovarian lesions, appendix/diverticular mass or abscess,
on PV examination. Crohns mass, pelvic kidney, ovarian lesions, pregnancy, uterine lesions,
Neoplasm. bladder tumours.
Ectopic pregnancy: very tender, associated with PV bleeding/ CT scan: retroperitoneal/mesenteric cysts, omental deposits,
intra-abdominal bleeding and collapse. appendix/diverticular mass or abscess, Crohns mass. Allows guided
Salpingo-oophoritis: very tender, bimanually palpable, asso- drainage of abscesses and biopsy of some tumours.
Colonoscopy: colonic tumours, diverticular disease.
ciated with PV discharge.
Small bowel enema: small intestinal tumours, ileal Crohns disease.
Barium enema: diverticular disease, colonic tumours.
Bladder
MSU: infected urinary retention.
Generally: midline swelling, extends up towards umbilicus,
-HCG: pregnancy.
dull to percussion, non-mobile, cannot get below it.
Abdominal swellings (localized): lower abdominal 39

15 Jaundice
Anatomy and normal bilirubin metabolism

120 days
New RBCs Effete RBCs Biochemical features of different types of jaundice
Hepatocellular
Reticuloendothelial Type of jaundice Haemolytic Early Late Obstructive
system
Hb Haem Serum bilirubin
KIDNEY Unconjugated N/ N/ N
Unconjugated bilirubin Conjugated N N
Urobilinogen (water insoluble) Urinary bilirubin N/
excreted bound to albumin
in urine Urobilinogen N/ N
LFTs
HEPATOCYTE
Bilirubin Alkaline phosphatase N N
Glucuronyl -GT transaminase N
transferase
Bilirubin glucuronide
Transaminases N N/
(conjugated bilirubin) Lactate dehydrogenase N N/
(water soluble) FBC
Enterohepatic
circulation Reticulocytes > 2% N N N
SMALL BOWEL
Conjugated bilirubin
Bacteria
Urobilinogen
Stercobilin
excreted in faeces CAUSES OF OBSTRUCTIVE JAUNDICE
MURAL / INTRINSIC
Liver cell transport abnormalities
Sclerosing cholangitis
Cholangiocarcinoma
Mirrizi syndrome (gallbladder mass INTRALUMINAL
associated with cholecystitis) Infestation
Benign stricture Clonorchis
Postinflammatory Schistosomiasis
Postoperative Gallstones
Postradiotherapy
EXTRINSIC
Portal lymphadenopathy
Chronic pancreatitis
Pancreatic tumour
Ampullary tumour
Duodenal tumour

Definitions Hepatic/hepatocellular jaundice
Jaundice (also called icterus) is defined as yellowing of the Hepatic unconjugated hyperbilirubinaemia
skin and sclera from accumulation of the pigment bilirubin Failure of transport of unconjugated bilirubin into the cell, e.g.
in the blood and tissues. The bilirubin level has to exceed Gilberts syndrome.
3540 mmol/l before jaundice is clinically apparent. Failure of glucuronyl transferase activity, e.g. CriglerNajjar
syndrome.
KEY POINTS Hepatic conjugated hyperbilirubinaemia

Jaundice can be classified simply as pre-hepatic (haemolytic), hepatic Hepatocellular injury. Hepatocyte injury results in failure of
(hepatocellular) and post-hepatic (obstructive). excretion of bilirubin, e.g.
Most of the surgically treatable causes of jaundice are post-hepatic infections: viral hepatitis;
(obstructive). poisons: CCl4, aflatoxin;
Painless progressive jaundice is highly likely to be due to malignancy. drugs: paracetamol, halothane.
Post-hepatic/obstructive jaundice
Differential diagnosis Post-hepatic conjugated hyperbilirubinaemia
The following list explains the mechanisms behind the causes of Anything that blocks the release of conjugated bilirubin from the
jaundice. hepatocyte or prevents its delivery to the duodenum.
Pre-hepatic/haemolytic jaundice Courvoisiers law

Haemolytic/congenital hyperbilirubinaemias A palpable gallbladder in the presence of jaundice is un-
Excess production of unconjugated bilirubin exhausts the capa- likely to be due to gallstones. It usually indicates the presence
city of the liver to conjugate the extra load, e.g. haemolytic of a neoplastic stricture (tumour of pancreas, ampulla,
anaemias (e.g. hereditary spherocytosis, sickle cell disease, duodenum, CBD), chronic pancreatitic stricture or portal
hypersplenism, thalassaemia). lymphadenopathy.
FBC: haemolysis.
LFTs: alkaline phosphatase (cholestasis), g-GT and transaminases (hepatocellular).
Clotting: PT (elevated in cholestatic and hepatocellular jaundice).
Urinary urobilinogen

Haemolytic Hepatocellular Obstructive

Blood film Viral titres: including hepatitis U/S CBD and gallbladder

Reticulocyte count A/B/C, CMV, EBV

Autoantibody screen Ultrasound: details of hepatic CBD dilated CBD dilated Other cause found

parenchyma. No gallstones Gallstones

Liver biopsy: hepatocellular ERCP

disease ?Ca pancreas/CBD ERCP CT scan

Surgery
ERCP +/ stent Surgery
CT scan/MRCP
Jaundice 41
16 Rectal bleeding
COLON
Ischaemic colitis
SMALL BOWEL Intussusception
Enteritis
Meckel's
diverticulum
Leiomyoma
Angiodysplasia Infarction
Carcinoma/polyps Ulcerative colitis
Carcinoma Crohn's
disease
PROXIMAL COLON
RECTUM
Carcinoma/
polyps Diverticular disease
Proctitis ANUS
Solitary ulcer
Fissure
Haemorrhoids
Carcinoma

Diverticular disease: spontaneous onset, painless, large vol-
KEY POINTS
ume, mostly fresh blood, previous history of constipation.
Anorectal bleeding is characteristically bright red, associated with
defaecation, not mixed with the stool and visible on toilet paperboften
Ulcerative colitis: blood mixed with mucus, associated with
associated with other symptoms of anorectal disease. systemic upset, long history, intermittent course, diarrhoea
Distal (left-sided/sigmoid) bleeding is characteristically dark red, with prominent.
clots, may be mixed with the stool. Ischaemic colitis: elderly, severe abdominal pain, AF, bloody
Proximal colonic or ileal bleeding is characteristically dark red, fully diarrhoea, collapse and shock later.
mixed with the stool or occultbunless heavy when it may appear as
distal or anorectal in type. Rectum
In children, Meckels diverticulum, intussusception and ileal tumours Carcinoma of the rectum: change in bowel habit common,
are common causes. rarely large volumes.
In young adults, colitis, Meckels diverticulum and haemorrhoids are Proctitis: bloody mucus, purulent diarrhoea in infected, peri-
common causes. anal irritation common.
In the elderly, neoplasia, diverticular disease and angiodysplasia are Solitary rectal ulcer: bleeding post-defaecation, small vol-
common causes. umes, feeling of lump in anus, mucus discharge.
Anus
Haemorrhoids: bright red bleeding post-defaecation, stops
Important diagnostic features spontaneously, perianal irritation.
Small intestine Fissure in ano: extreme pain post-defaecation, small volumes
Meckels diverticulum: young adults, painless bleeding, bright red blood on stool and toilet paper.
darker red/melaena common. Carcinoma of the anus: elderly, mass in anus, small volumes
Intussusception: young children, colicky abdominal pain, bloody discharge, anal pain, unhealing ulcers.
retching, bright red/mucus stool. Perianal Crohns disease.
Enteritis (infective/radiation/Crohns).
Ischaemic: severe abdominal pain, physical examination
shows mesenteric ischaemia or AF, few signs, later collapse and KEY INVESTIGATIONS
shock. FBC: anaemiabtumours/chronic colitis.
Tumours (leiomyoma/lymphoma): rare, intermittent history, Clotting: bleeding diatheses.
often modest volumes lost. PR/sigmoidoscopy: anorectal tumours, prolapse, haemorrhoids, distal
colitis.
Proximal colon Abdominal X-ray: intussusception.
Angiodysplasia: common in the elderly, painless, no warning, Colonoscopy: diverticular disease, colon tumours, angiodysplasia.
often large volume, fresh and clots mixed. Angiography: angiodysplasia, small bowel causes (especially
Carcinoma of the caecum: more often causes anaemia than PR Meckels). (Needs active bleeding 0.5 ml/min, highly accurate when
positive, invasive, allows embolization therapy.)
bleeding.
Labelled RBC scan: angiodysplasia, small bowel causes, obscure
colonic causes. (Needs active bleeding l ml/min, less accurate placement
Colon
of source, non-invasive, non-therapeutic.)
Polyps/carcinoma: may be large volume or small, ?associated
Small bowel enema: small bowel tumours.
change in bowel habit, blood often mixed with stool.
Rectal bleeding 43
17 Diarrhoea
UPPER GI CAUSES GENERAL CAUSES
Diabetes
Thyrotoxicosis
Chronic Uraemia
liver Drugs
disease
Rapid
gastric
emptying
Cholestasis
Pancreatic
exocrine
insufficiency
COLONIC CAUSES
SMALL BOWEL CAUSES
Coeliac disease
Pseudomembranous
colitis
Whipple's disease
Carcinoid Colitis
Vipoma
Irritable Constipation
bowel syndrome
Infective enteritis Diverticular disease
Crohn's disease
Carcinoma of the colon
Terminal
ileal resection

Definition Coeliac disease: history of wheat and cereals intolerance, may
Diarrhoea is defined as the passage of loose, liquid stool. present in adulthood with chronic diarrhoea and weight loss,
Urgency is the sensation of the need to defaecate without being abdominal pains.
able to delay. It may indicate rectal irritability but also occurs Blind loop syndrome: frothy, foul-smelling liquid stool, due
where the volume of liquid stool is too large, causing the rectum to bacterial overgrowth and fermentation, usually associated
to be overwhelmed as a storage vessel. Frequency merely with previous surgery, may complicate Crohns disease.
reflects the number of stools passed and may or may not be asso-
ciated with urgency or diarrhoea. Large bowel disease
Ulcerative colitis: intermittent, blood and mucus, colicky
pains, young adults. May be a short history in first presentations.
KEY POINTS
Rarely presents with acute fulminant colitis with acute abdom-
Bloody diarrhoea is always pathological and usually indicates colitis of
inal signs.
one form or another.
Colon cancer: older, occasional blood streaks and mucus,
Infective causes are common in acute transient diarrhoea.
change in frequency may be the only feature, positive faecal
In diarrhoea of uncertain origin, remember the endocrine causes.
occult blood, rectal mass.
Consider parasitic infections in a history of foreign travel.
Irritable bowel syndrome: diarrhoea and constipation mixed,
Alternating morning diarrhoea and normal/pellety stools later in the
day is rarely pathological.
bloating, colicky pain, small stool pellets, never blood.
Diarrhoea developing in hospitalized patients may be due to Spurious: impacted faeces in rectum, liquefied stool passes
Clostridium difficile infectionbcheck for CD toxin in the stool. around faecal obstruction, elderly, mental illness, constipating
drugs.
Polyps (villous) (rare): watery, mucoid diarrhoea, K+ loss,
Important diagnostic features commonest in rectum.
Acute diarrhoea Diverticular disease (rare).
Infections
Shigella/Salmonella: associated colicky abdominal pain, Systemic disease
vomiting. Thyrotoxicosis, anxiety, peptides from tumours (VIP, serotonin,
Dysentery: blood and mucus in motions, ulcers in rectum and substance P, calcitonin), laxative abuse.
Entamoeba histolytica in the stool, fever, sweating, tachycardia.
Cholera: severe diarrhoea, rice water stool, dehydration, his-
tory of foreign travel.
Giardiasis. KEY INVESTIGATIONS
FBC: leucocytosis (infective causes, colitis), anaemia
Antibiotics (colon cancer, ulcerative colitis, diverticular disease).
Short-lived, self-limiting, mild colicky pain. Anti -gliadin Abs: coeliac disease.
Thyroid function tests: hyperthyroidism.
Pseudomembranous colitis Stool culture: infections (remember microscopy for
Caused by Clostridium difficile infection, characterized by parasites).
severe diarrhoea which may be bloody but occasionally acute Proctoscopy/sigmoidoscopy: cancer, colitis, polyps (simple,
constipation may indicate severe disease. Characteristic features easy, cheap and safe; performed in outpatients).
on colonoscopy. Flexible sigmoidoscopy: cancer, polyps, colitis, infections
(relatively safe, well tolerated, high sensitivity).
Colonoscopy: colitis (extent and severity), pseudomembranous
Chronic diarrhoea
colitis.
Small bowel disease
Small bowel enema: Crohns disease, coeliac disease, Whipples
Crohns disease: diarrhoea, pain prominent, blood and mucus
disease.
less common, young adults, long history, chronic malnourish-
Faecal fat estimation/ERCP: pancreatic insufficiency.
ment and weight loss.
Diarrhoea 45
18 Altered bowel habit/constipation
Hypothyroidism Irritable
Drugs bowel syndrome
Infective enterocolitis
Ulcerative colitis
Diverticular
disease
Hirschsprung's disease
Colonic Crohn's disease
Constipation
Colorectal carcinoma
Rectal polyp

Definitions Perianal pain, e.g. fissure, perianal abscessbdue to spasm of
Normal bowel habit varies widely from person to person. the internal anal sphincter, common in children.
Alterations in bowel habit are common manifestations of GI dis-
ease. Constipation is defined as infrequent or difficult evacua- Adynamic bowel
tion of faeces and can be acute or chronic. Absolute constipation Hirschsprungs disease: constipation from birth, gross abdom-
is defined as the inability to pass either faeces or flatus. inal distension. Short-segment Hirschprungs disease (involving
Diarrhoea is an increase in the fluidity of stool. only the lower rectum) may present in adulthood with worsening
chronic constipation and megarectum/megasigmoid.
KEY POINTS Drugs: opiates, anticholinergics, antipsychotics, secondary to
Acute constipation often indicates intestinal obstruction. The cardinal chronic laxative abuse.
symptoms of obstruction are colicky abdominal pain, vomiting, Pregnancy: due to progesterone effects on smooth muscle of
constipation and distension. bowel wall.
Chronic constipation may be a lifelong problem or may develop slowly
in later life.
All alterations in bowel habit that persist must be investigated for an KEY INVESTIGATIONS
underlying causebcolorectal neoplasms are common causes, especially Rectal examination: rectal cancer, rectal adenoma.
in the elderly. FBC: anaemia from colon cancer, ulcerative colitis, diverticular disease.
Stool culture: infections (remember microscopy for parasites).
Proctoscopy/sigmoidoscopy: cancer, colitis, polyps (simple, easy,
Important diagnostic features cheap and safe; performed in outpatients).
Chronic constipation Flexible sigmoidoscopy: cancer, polyps, colitis, infections (relatively
Bowel disease safe, well tolerated, high sensitivity).
Colon cancer: gradual onset, colicky abdominal pain, associ- Barium enema: best for tumours of proximal colon.
ated weight loss, anergia, anaemia, positive faecal occult bloods, Colonoscopy: colitis (extent and severity).
abdominal mass. Rectal biopsy (full thickness): Hirschprungs disease.
Diverticular disease: associated LIF pains, inflammatory
episodes, rectal bleeding.
Altered bowel habit/constipation 47

19 Groin swellings
Ectopic or undescended
testis
Inguinal hernia
Psoas abscess
Femoral neuroma
Femoral artery Varicocele

aneurysm
Saphena varix
Femoral
hernia
Inguinal
lymphadenopathy
Cordal hydrocele
+ Sebaceous cyst
+ Lipoma

Definition Spermatic cord: cordal hydrocele, does not have a cough
Any swelling in the inguinal area or upper medial thigh. impulse, may be possible to define upper edge, fluctuates and
transilluminates.
Lipoma: soft, fleshy, does not transilluminate or fluctuate.
KEY POINTS
The groin crease does not mark the inguinal ligament in most people Femoral
and is an unreliable landmark. Femoral hernia: elderly women (mostly), may be tender and
Inguinal hernias are common, always start above and medial to the non-expansile, not reducible, groin crease often lost, high risk of
pubic tubercle, may be medial or lateral to it and usually emphasize the strangulation and obstruction.
groin crease on that side.
Saphena varix: expansile, cough impulse, thrill on percussion
Femoral hernias always start below and lateral to the pubic tubercle
of distal saphenous vein.
and usually flatten the skin crease on that side.
Lymphadenopathy: hard, discrete nodules, often multiple or
Femoral hernias are commoner in women, are high risk and need
an indistinct mass.
urgent attention.
Femoral artery aneurysm: expansile, pulsatile, thrill and bruit
Masses in the groin and scrotum together are inguinal hernias.
may be present.
Inguinal lymphadenopathy may be isolated or may be part of systemic
lymphadenopathy. A cause should always be sought.
Psoas abscess (rare): soft, fluctuant and compressible,
lateral to the femoral artery, may be cold abscesses caused by
TB.
Important diagnostic features Femoral neuroma (very rare): hard, smooth, moves laterally
The types, causes and features are listed below. but not vertically, pressure may cause pain in the distribution of
the femoral nerve.
Inguinal Hydrocele of femoral sac (very rare).
Direct inguinal hernia: not controlled by pressure over internal
ring, characteristically causes a forward bulge in the groin,
KEY INVESTIGATIONS
does not descend into the scrotum.
FBC: causes of lymphadenopathy.
Indirect inguinal hernia: controlled by pressure over internal
Ultrasound: femoral aneurysm, saphena varix, psoas abscess, ectopic
ring, slides through the inguinal canal, often descends into the
testicle. Also sometimes useful to identify small femoral hernias.
scrotum.
CT scan: cause of psoas abscess.
Undescended testis: often mass at the external ring or inguinal
Herniography: rarely needed to confirm presence of hernia if operative
canal, associated with hypoplastic hemi-scrotum, frequently indication not clear.
associated with indirect inguinal hernia.
Groin swellings 49
20 Claudication
CLAUDICATION
No evidence of vascular disease Evidence of vascular disease
? Cauda equina lesion Limb not acutely threatened Limb acutely threatened
Mildmoderate Severe Interventional treatment

symptoms symptoms
Stop smoking Radiology Surgery

Exercise
Consider
Angiography
Symptoms Symptoms
improve deteriorate
Angioplasty
Stenting
Aorto-iliac
MUSCLES LEVEL OF
AFFECTED BLOCKAGE
+++ Glutei Aorto-iliac

Ilio-femoral
+++ Quadriceps
Ilio-femoral
+ Hamstrings
(profunda femoris)
Femoro-distal
++ Gastrocnemius
+++ Soleus Femoro-popliteal
+ Peronei

Definition Iliac or common femoral stenosis: thigh and calf claudication,
Intermittent claudication is defined as an aching pain in the leg absent/weak femoral pulses in affected limb.
muscles, usually the calf, which is precipitated by walking and is Femoro-popliteal stenosis: calf claudication only, absent
relieved by rest. popliteal and distal pulses.
Neurological
KEY POINTS
Cauda equina
Claudication pain is always reversible and relieved by rest.
Elderly patients, history of chronic back pain, pain is bilateral
Claudication tends to improve with time and exercise due to the opening
and in the distribution of the S1S3 dermatomes, may be accom-
up of new collateral supply vessels and improved muscle function.
panied by paraesthesia in the feet and loss of ankle jerks, all
The site of disease is one level higher than the highest level of affected
peripheral pulses palpable and legs well perfused.
muscles.
Most patients with claudication have associated vascular disease and
investigation for occult coronary or cerebrovascular is mandatory.
Cauda equina ischaemia caused by osteoarthritis of the spine can also
KEY INVESTIGATIONS
cause intermittent claudication.
FBC: exclude polycythaemia.
Glucose: diabetes.
Differential diagnosis Lipids: hyperlipidaemia.
Vascular ABI: estimate of disease severity.
Atheroma ECG: coronary disease.
Typical patient: male, over 45 years, ischaemic heart disease, Angiography: precise location and extent of disease, pre-procedure
planning. Intravenousbeasier, safer, larger volume of dye. Intra-
smoker, diabetic, overweight.
arterialblower dye volume, better images, higher risk of complications.
Aortic occlusion: buttock, thigh and possibly calf claudica-
Digital subtractionbbest images of all.
tion, impotence in males, absent femoral pulses and below in
Duplex scanning beginning to be used instead of angiography.
both legs (Leriches syndrome).
Claudication 51
21 Acute warm painful leg
TRAUMA INFECTION
Hip dislocation
Cellulitis
DEGENERATIVE Osteomyelitis
'Sciatica'
Spondylitides
Entrapment neuropathy
Osteoarthritis
Knee dislocation
Cruciate rupture
Patellar fracture
Fracture
Ruptured
Baker's cyst
Ankle dislocation
Collateral ligament
rupture
TUMOURS
VASCULAR
Primary
Gout Deep vein thrombosis
Secondary

Definitions Joints: painful, limited movement, deformity if dislocated,
Acute leg pain is a subjective, unpleasant sensation felt some- locking and instability with knee injury.
where in the lower limb. Referred pain is the perception of pain
in an area remote from the site of origin of the pain, e.g. leg pain Degenerative
from lumbar disc herniation, knee pain from hip pathology. Gout: first MTP joint (big toe), males, associated signs of joint
Cramps are involuntary, painful contractions of voluntary mus- inflammation.
cles. Sciatica is a nerve pain caused by irritation of the sciatic Disc herniation (sciatica): pain in distribution of one or two
nerve roots characterized by lumbosacral pain radiating down nerve roots, sudden onset, back pain and stiffness, lumbar scol-
the back of the thigh, lateral side of the calf and into the foot. iosis due to muscle spasm.
Ruptured Bakers cyst: pain mostly behind the knee, previous
history of knee arthritis, calf may be hot and swollen.
KEY POINTS
May be due to pathology arising in any of the tissues of the leg. Tumours
Constant or lasting pain suggests local pathology. Bone: deep pain, worse in morning and after exercise, overlying
Transient or intermittent pain suggests referred pathology. muscle tenderness, pathological fractures, primary (e.g. osteo-
Systemic symptoms or upset suggests inflammation. sarcoma, osteoclastoma) or secondary (e.g. breast, prostate, lung
metastasis).
Important diagnostic features Vascular

Infection DVT: calf pain, swelling, redness, prominent superficial veins,
Infection of skin (cellulitis): painful, swollen, red, hot leg, tender on calf compression, low-grade pyrexia.
associated systemic featuresbpyrexia, rigors, anorexia, com-
monly caused by Streptococcus pyogenes.
Acute osteomyelitis: staphylococcal infection, effects meta- KEY INVESTIGATIONS
physes, acute pain, tenderness and oedema over the end of a long FBC: WCC in infection.
bone, common in children, may be history of skin infection or D-Dimers: suspected DVT.
trauma. Blood cultures: spreading cellulitis.
Clotting: DVT.
Plain X-ray: trauma, osteomyelitis, bone tumours, gout.
Trauma
MRI: suspected disc herniation.
Muscle: swollen, tender and painful, pain worse on attempted
Duplex ultrasound: DVT.
movement of the affected muscle.
Venography: DVT where duplex not available or precise extent
Bone: painful, tender. Swelling, deformity, discoloration,
needed.
bruising and crepitus suggest fracture.
Acute warm painful leg 53

22 Acute cold leg
AF
Valve disease
Sources
Myocardial infarction of emboli
(mural thrombus)
Proximal atheroma Thrombosis of

aneurysms
(popliteal )
Blunt
Trauma
Penetrating
Pressure/ Graft
compression Thrombosis of thrombosis
atheromatous
stenosis
Embolus Plaque embolus
PURE ACUTE ACUTE ON CHRONIC
Acute cold leg
Assessment (leg and patient) Embolus Look for cause
Terminal event Leg non viable Leg acutely threatened Leg viable
Fixed staining Sensory loss - chronically threatened
Woody muscles Motor loss Rest pain
Prolonged history Both
Treatment:
Treatment: Heparin
TLC Analgesia
O2
Treatment: Treatment: Treatment:
Amputation Surgery Surgery
TLC ? Thrombolysis

Definitions Direct injuries may be due to: complete division of the vessel,
The acute cold leg is a clinical syndrome of the sudden onset of distraction injury, damage and in situ thrombosis, foreign body,
symptoms indicative of the presence of ischaemia sufficient to false aneurysm.
threaten the viability of the limb or part of it.
Thrombosis (in situ)
Usually associated with underlying atheroma predisposing to
KEY POINTS thrombosis after minor trauma or immobility (after a fall or illness).
Remember the 6 Ps of acute ischaemiabpainful, pale, paraesthetic, May be subacute in onset, previous history of known vascular
paralysed, pulseless, perishingly cold. disease or intermittent claudication, associated risk factors for
All acute cold legs are a surgical emergency and require a prompt peripheral vascular disease, abnormal pulses in the unaffected
diagnosis. limb.
80% of acute cold legs presenting as an emergency have underlying Paradoxically, the limb may not be as acutely threatened as in
chronic vascular pathology. isolated arterial embolus since collateral vessels may already be
Fasciotomies should always be considered as part of treatment if a leg present due to underlying disease.
is being revascularized.
Graft thrombosis
Often subacute in onset, limb not acutely threatened, progressive
Important diagnostic features symptoms, loss of graft pulsation
Isolated arterial embolus
Sudden-onset, severe ischaemia, no previous symptoms of Aneurysm thrombosis
vascular disease, previous history of atrial fibrillation/recent Commonest sitebpopliteal aneurysms.
myocardial infarction, all peripheral pulses on the unaffected Sudden-onset limb ischaemia, acutely threatened, may be
limb normal (suggesting no underlying peripheral vascular dis- associated embolization as well, non-pulsatile mass in popliteal
ease [PVD]). fossa, many have contralateral asymptomatic popliteal aneurysm.
Limb usually acutely threatened due to complete occlusion
with no collateral supply.
Common sites of impaction are: popliteal bi(tri)furcation, dis- KEY INVESTIGATIONS
tal superficial femoral artery (adductor canal), origin of the pro- FBC: polycythaemia.
funda femoris. Saddle embolus at aortic bifurcation causes U+E: renal impairment, myonecrosis.
Clotting: thrombophilia.
bilateral acute ischaemic limbs.
ECG: atrial fibrillation, myocardial infarction, valve disease.
Duplex scanning: graft patency, popliteal aneurysm
Trauma
Angiography: wherever possiblebarterial embolism, thrombosis,
May be due to direct injury to the vessel or by secondary com-
underlying PVD.
pression due to bone fragments or haematoma.
Acute cold leg 55

23 Leg ulceration
ULCER
Not painful Painful
Diabetic Acute Chronic
No Yes
Trauma ?Signs and
Infection symptoms of
History Isolated ?Chronic ?Neuropathic
Vasculitis vascular disease
of DVT varicose veins injury ?Ischaemia
No Yes
Postphlebitic Varicose ulcer Squamous Treatment:
ulcer carcinoma Podiatry, ?Malignant ? Ischaemic
shoe care education
Treatment: Diagnosis:
Treatment: Surgery for Biopsy Associated infection Treatment for
4-layer varicose veins diagnosis Improve diabetic control ischaemic disease
compression (inc. strip to knee)
bandages 4-layer compression
bandages COMMON SITES
Anterior shin Vasculitis

Medial calf
Venous
Medial ankle
Lateral malleolus
Heel
Lateral foot Arterial
Neuropathic
(pressure points) Heads of 1st Between toes
and 5th Tips of toes
metatarsals Toes

Definition Malignant ulcers
An ulcer is defined as an area of discontinuity of the surface Squamous cell carcinoma: may arise de novo or malignant
epithelium. change in a chronic ulcer or burn (Marjolins ulcer). Large ulcer,
heaped up, everted edges. Lymphadenopathybhighly suspicious.
Basal cell carcinoma: uncommon on the leg, rolled edges,
KEY POINTS pearly white.
Pain suggests ischaemia or infection. Malignant melanoma: lower limb is a common site, consider
Neuropathic ulcers occur over points of pressure and trauma. malignant if increase in size or pigmentation, bleeding, itching
Marked worsening of a chronic ulcer suggests malignant or ulceration.
change.
The underlying cause must be treated first or the ulcer will Miscellaneous ulcers
not heal. Trauma: may be caused by minor trauma. Predisposing factors
Several precipitating causes may coexist (e.g. diabetes, PVD and are poor circulation, malnutrition or steroid treatment.
neuropathy). Vasculitis (rare), e.g. rheumatoid arthritis, SLE.
Underlying varicose veins must be treated for venous ulcers. Infections (rare): syphilis, TB, tropical infections.
Pyoderma gangrenosum: multiple necrotic ulcers over the legs
that start as nodules. Seen with ulcerative colitis and Crohns
Important diagnostic features disease.
Venous ulcers
Venous hypertension secondary to DVT or varicose veins:
ulceration on the medial side of the leg, above the ankle, any KEY INVESTIGATIONS
size, shallow with sloping edges, bleeds after minor trauma, FBC: infections.
weeps readily, associated dermatoliposclerosis. Glucose: diabetes.
If deep venous disease is suspected duplex scanning of the Special blood tests: TPHA (syphilis), ANCA (SLE), Rh factor.
veins or venography is indicated. Anklebrachial pressure index (ABI) measurement to exclude
underlying PVD.
Doppler ultrasound: assessment of venous disease, assessment of
Arterial ulcers
arterial disease (above the knee). Simple, cheap, highly sensitive, good
Occlusive arterial disease: painful ulcers, do not bleed, non-
screening test.
healing, lateral ankle, heel, metatarsal heads, tips of the toes,
Biopsy: malignancy. Melanomabalways excision biopsy. Others may
associated features of ischaemia, e.g. claudication, absent
be incision/punch.
pulses, pallor. Elderly patients may present with blue toe
Venography/angiography: extent and severity of disease. Planning
syndrome.
treatment.
Diabetic ulcers
Ischaemic: same as arterial ulcers.
Neuropathic: deep, painless ulcers, plantar aspect of foot or
toes, associated with cellulitis and deep tissue abscesses, warm
foot, pulses may be present.
Leg ulceration 57
24 Dysuria
Pyelonephritis
Renal abscess
Tuberculosis
Colovesical fistula Pyogenic cystitis

Bladder stone
Interstitial cystitis
Bladder tumour
Prostatitis
Urethritis

Definitions Urethritis
Dysuria is defined as a pain that arises from an irritation of the Causes are:
urethra and is felt during micturition. Frequency indicates Sexually transmitted diseases.
increased passage of urine during the daytime, while nocturia May be gonococcal, chlamydial or mycoplasmal.
indicates increased passage of urine during the night. Urgency is
an uncontrollable desire to micturate and may be associated with Features: Dysuria and meatal pruritus, occurs 310 days after
incontinence. sexual contact, yellowish purulent urethral discharge suggests
Gonococcus, thin mucoid discharge suggests Chlamydia.
KEY POINTS Other causes of dysuria

UTI is the commonest cause of dysuria in adults.
Urethral syndrome
Systemic upset and loin pain suggest an ascending UTI
A condition characterized by frequency, urgency and dysuria in
(pyelonephritis).
women with urine cultures showing no growth or low bacterial
Elderly men with recurrent UTIs often have an underlying problem of
counts.
bladder emptying due to prostate disease.
Recurrent infections require investigation to exclude an underlying
cause.
Vaginitis
Pneumaturia, bits in the urine and coliform infections suggest a
Condition characterized by dysuria, pruritus and vaginal dis-
colovesical fistula. charge. Urine cultures are negative, but vaginal cultures often
reveal Trichomonas vaginalis, Candida albicans or Haemo-
philus vaginalis.
Urinary tract infection Bladder tumours
Acute pyelonephritis Uncommon cause of dysuria, haematuria, sterile pyuria (no
Cause: Upper tract infection. growth on MSU).
Ultrasound: possible pyelonephritis/renal abscess, may show
Predisposing causes are: predisposing structural abnormality.
Outflow tract obstruction. DMSA scan: assesses renal function where renal damage sus-
Vesicoureteric reflux. pected from recurrent sepsis.
Renal or bladder calculi.
Diabetes mellitus.
Neuropathic bladder dysfunction. K E Y I N V E S T I G AT I O N S
FBC: ascending infections.
Features: Pyrexia, rigors, flank pain, dysuria, malaise, anorexia, Glucose: exclude diabetes.
leucocytosis, pyuria, bacteriuria, microscopic haematuria, C&S MSU MC + S: infection
>100 000 organisms per ml. (ZiehlNeelsen stain if ?TB).
Single UTI Recurrent UTI ?Interstitial

Acute cystitis or ? fistula cystitis

Causes are:
Lower tract infection. Treatment Renal U/S Cystoscopy
Usually coliform bacteria. Cystoscopy
Because of short urethra commoner in females. IVU
Proteus infections may indicate stone disease. DMSA
Features: Dysuria, frequency, urgency, suprapubic pain, low

back pain, incontinence and microscopic haematuria.
Dysuria 59
25 Urinary retention
EXTERNAL
Ovarian cyst
INTRALUMINAL Pregnancy
Blood clot
Stone
Prolapsing bladder tumour Fibroids
Urethral valves
Pelvic mass
INTRAMURAL
BPH
Prostatitis NEUROLOGICAL
Prostate carcinoma
Spinal injury
Urethral stricture
Urethral trauma
MS
Diabetes Polio
Drugs Prolapsed disc
Postoperative

Definitions Stones (rare): acute pain in penis and glans.
Urinary retention is defined as an inability to micturate. Acute Tumour (rare): TCC or squamous cell carcinoma, history of
urinary retention is the sudden inability to micturate in the haematuria, working in dye or rubber industry.
presence of a painful bladder. Chronic urinary retention is the
presence of an enlarged, full, painless bladder with or with- In the wall of the urethra
out difficulty in micturition. Overflow incontinence is an uncon- BPH: frequency, nocturia, hesitancy, poor stream, dribbling,
trollable leakage and dribbling of urine from the urethra in the urgency.
presence of a full bladder. Tumour: as above.
Stricture: history of trauma or serious infection, gradual onset
of poor stream.
KEY POINTS Trauma: blood at meatus.
Acute retention is characterized by pain, sensation of bladder fullness
and a mildly distended bladder. Outside the wall of the urethra
Remember common causes: Pregnancy.
childrenbabdominal pain, drugs Fibroids: palpable, bulky uterus, menorrhagia, dysmenorrhoea.
youngbpostoperative, drugs, acute UTI, trauma, haematuria Ovarian cyst: mobile iliac fossa mass.
elderlybacute on chronic retention with BPH, tumours, postoperative. Faecal impaction: spurious diarrhoea.
Chronic retention is characterized by symptoms of bladder irritation
(frequency, dysuria, small volume), or painless, marked distension, Neurological
overflow incontinence (often associated with secondary UTI). Postoperative: pain, drugs, pelvic nerve disturbance.
Remember common causes: Spinal cord injuries: acute phase is lower motor neurone type,
childrenbcongenital abnormalities late phase is upper motor neurone type.
youngbtrauma, postoperative
Drugs: narcotics, anticholinergics, antihistamines, anti-
elderlybBPH, strictures, prostatic carcinoma.
psychotics.
Neurogenic retention.
Diabetes: progressive lower motor neurone pattern.
Upper motor neurone causes produce chronic retention with reflex
Idiopathic: detrusor sphincter dyssynergia, ?bladder neurone
incontinence.
degeneration.
Lower motor neurone causes produce chronic retention with overflow
incontinence.
Urinary retention is uncommon in young adults and almost always
requires investigation to exclude underlying cause. KEY INVESTIGATIONS
Retention is common in elderly menboften due to prostate pathology. U+E: renal function.
MSU MC+S: associated infection, include cytology where tumour
suspected.
Differential diagnosis Cystography: urethral valves, strictures.
Mechanical IVU: renal/bladder stones.
Urodynamics: allows identification and assessment of neurological
In the lumen of the urethra
problems, assesses BPH.
Congenital valves (rare): neonates, males, recurrent UTIs.
Cystoscopy.
Foreign body (rare).
Urinary retention 61
26 Haematuria
RENAL
Pyelonephritis
Tuberculosis
Renal cell carcinoma
Renal adenoma
Renal cyst
Renal infarction
Arteriovenous malformation
Trauma
Glomerulonephritis
URETERAL
TCC
Stone
Appendicitis
BLADDER
TCC
Pyogenic cystitis
Trauma
URETHRAL
BPH
Prostate carcinoma
Stone
Trauma

Definitions Ureter
Haematuria is the passage of blood in the urine. Frank haema- Calculus: severe loin/groin pain, gross or microscopic, associ-
turia is the presence of blood on macroscopic examination, ated infection.
while microscopic haematuria indicates that RBCs are only seen TCC: see below.
on microscopy. Haemoglobinuria is defined as the presence of
free Hb in the urine. Bladder
Calculus: sudden cessation of micturition, pain in perineum
and tip of penis.
TCC: characteristically painless, intermittent haematuria, his-
KEY POINTS
tory of work in rubber or dye industries.
Haematuria always requires investigation to exclude an underlying
Acute cystitis: suprapubic pain, dysuria, frequency and
cause.
bacteriuria.
Initial haematuria (blood on commencing urination) suggests a
Interstitial cystitis (rare): may be autoimmune, drug or radia-
urethral cause.
tion induced, frequency and dysuria common.
Terminal haematuria (blood after passing urine) suggests a bladder
base or prostatic cause.
Schistosomiasis (very rare): history of foreign travel, espe-
Ribbon clots suggest a pelvi-ureteric cause. cially North Africa.
Renal bleeding can mimic colic due to clots passing down the
ureter. Prostate
BPH: painless haematuria, associated obstructive symptoms,
recurrent UTI.
Carcinoma (rare).
Kidney Urethra
Trauma: mild to moderate trauma commonly causes renal Trauma: blood at meatus, history of direct blow to perineum,
bleeding, severe injuries may not bleed (avulsed kidneyb acute retention.
complete disruption). Calculus (rare).
Tumours: may be profuse or intermittent. Urethritis (rare).
Renal cell carcinoma: associated mass, loin pain, clot colic
or fever, occasional polycythaemia, hypercalcaemia and
hypertension. K E Y I N V E S T I G AT I O N S
TCC: characteristically painless, intermittent haematuria. FBC: infection, chronic blood loss. Rouleaux
Calculus: severe loin/groin pain, gross or microscopic, associ- suggest glomerulonephritis.
ated infection. Clotting: exclude underlying bleeding cause.
Glomerulonephritis: usually microscopic, associated systemic U+E: renal function.
disease (e.g. SLE). MSU MC + S: infection, parasites.

Pyelonephritis (rare).
Renal tuberculosis (rare): sterile pyuria, weight loss, anorexia, ?Renal cause ?Bladder cause ?Glomerulonephritis

PUO, increased frequency of micturition day and night.
Polycystic disease (rare): palpable kidneys, hypertension, IVU Cystoscopy Autoimmune screen
CT scan or Renal U/S Renal Bx
chronic renal failure.
Renal U/S
Renal arteriovenous malformation or simple cyst (very rare):

painless, no other symptoms.

Angiography
Renal infarction (very rare): may be caused by an arterial
(?AVM)
embolus, painful tender kidney.
Haematuria 63
27 Scrotal swellings
SWELLING
On the scrotum In the scrotum
Sebaceous cyst Extends above the scrotum
Hernia
PAINFUL HARD + PAINLESS SOFT
Torsion of testis Tumour Varicocele
Torsion of
hydatid of
Morgagni Syphilis Epididymal cyst
Tuberculosis
Epididymitis
(Bacterial:
Coliform
NSU)
Orchitis Haematoma Hydrocele

(Viral:
Mumps
Glandular fever
Bacterial:
Coliform
Chlamydial)

Definition transillumination, later the whole testis becomes swollen, may
Any swelling in or on the scrotum or its contents. require explorative surgery to exclude full torsion.
Hard conditions
KEY POINTS Testicular tumour: painless swelling, younger adult men
Always evaluate scrotal swellings for extension to the groin. If present (2050 years), may have lax secondary hydrocele, associated
they are almost always inguinoscrotal hernias. abdominal lymphadenopathy.
Torsion is commonest in adolescence and in the early twenties. Haematocele: firm, does not transilluminate, testis cannot
Whenever the diagnosis is suspected, urgent assessment and usually usually be felt, history of trauma.
surgery are required. Syphilitic gummatabfirm, rubbery, usually associated with
Young adult men: tumours, trauma and acute infections are common. other features of secondary syphilis. TBbuncommon outside
Old men: hydrocele and hernia are common. developing world, usually associated with miliary disease.
Soft conditions
Differential diagnosis Hydrocele: soft, fluctuant, transilluminates brilliantly, testis
The causes and features are listed below. may be difficult to feel, new onset or rapidly recurrent hydrocele
suggests an underlying testicular cause.
Scrotum Epididymal cyst: separate and behind the testis, transillumin-
Sebaceous cyst: attached to the skin, just fluctuant, does not ates well, may be quite large.
transilluminate. Varicocele: a collection of dilated and tortuous veins in the
Infantile scrotal oedema: acute idiopathic scrotal swelling, spermatic cordbbag of worms on examination, commoner
hot, tender, bright red, testicle less tender than in torsion, com- on the left, associated with a dragging sensation, occasional
monest in young boys. haematospermia.
Testis
Painful conditions KEY INVESTIGATIONS
Orchitis: confined to testis, young men. FBC: infection.
Epididymo-orchitis: painful and swollen, epididymis more than Ultrasound: painless, non-invasive imaging of testicle. Allows
testis, associated erythema of scrotum, fever and pyuria, unusual underlying pathology to be excluded in hydrocele. High sensitivity and
below the age of 25 years, pain relieved by elevating the testis. specificity for tumours.
Torsion of the testis: rapid onset, pubertal males, often high Doppler ultrasound: may confirm presence of blood flow where torsion
is thought unlikely.
investment of tunica vaginalis on the cordbbellclapper testis,
CT scan: staging for testicular tumours.
testis may lie high and transversely in the scrotum, knot in the
Surgery: may be the only way to confirm or exclude torsion in a
cord may be felt.
high-risk group. Should not be delayed for any other investigation if
Torsion of appendix testis: mimics full torsion, early signs
required.
are a lump at the upper pole of the testis and a blue spot on
Scrotal swellings 65
28 Hypoxia
GENERAL CAUSES 1 CNS DEPRESSION

Drugs
Opiates
Alcohol
2 NEUROMUSCULAR FAILURE Benzodiazepines
CVA Hypercapnia
Multiple sclerosis Acidosis
Polio CVA
Neuropathies
Myasthenia gravis 3 AIRWAY OBSTRUCTION
Myopathy Facial fractures
Neck haematoma
5 LOSS OF FUNCTIONAL LUNG Foreign bodies
Collapse
Infection
ARDS 4 MECHANICAL INFLATION
Pulmonary embolism FAILURE
Pulmonary oedema Abdominal pain
Pneumothorax
Flail chest
Large pleural effusion
POSTOPERATIVE HYPOXIA
Smoking
( Production N2O/O2 more soluble
Opiates Cilial action) than O2/N2
( Cough) GASES
ABSORBED
Anaesthetics 100% O2 prior to
Secretion Absorption
( Production extubation very soluble
blocking collapse
Cough) airways
Anticholinergics
COPD Collapse
( Sticky
Cilial action) Age (Shunting
Inhaled Dynamic Available lung)
anaesthetics collapse
Hypoxia
Supine position Abdominal

Hypoventilation
pain
Recumbent
position Anaesthetic Opiates
( Depth agents Alcohol
Cough) ( Deep breaths
Rate)
66 Surgical diseases at a glance

Definitions Epidural: excellent for upper abdominal/thoracic surgery, can
Hypoxia is defined as a lack of O2 (usually meaning lack of O2 cause hypotension by relative hypovolaemia.
delivery to tissues or cells). Hypoxaemia is a lack of O2 in arter-
ial blood. Apnoea means cessation of breathing in expiration. Clinical features
In the unconscious patient
Common causes Central cyanosis.
Postoperative causes Abnormal respirations.
CNS depression, e.g. post-anaesthesia. Hypotension.
Airway obstruction, e.g. aspiration of blood or vomit.
Poor ventilation, e.g. abdominal pain, mechanical disruption In the conscious patient
to ventilation. Central cyanosis.
Loss of functioning lung, e.g. ventilationperfusion mismatch Anxiety, restlessness and confusion.
(pulmonary embolism, pneumothorax, collapse/consolidation). Tachypnoea.
Tachycardia, dysrhythmias (AF) and hypotension.
General causes
CNS depression, e.g. opiates, CVA, head injury. Key investigations
Airway obstruction, e.g. facial fractures, aspiration of blood or Pulse oximetry saturations: give a guide to arterial oxygena-
vomit, thyroid disease or cervical malignancy. tion.
Poor ventilation, e.g. pleural effusions, neuromuscular failure. Arterial blood gases (PCO2 PO2 pH base excess): respiratory
Loss of functioning lung, e.g. ventilationperfusion mismatch acidosis, metabolic acidosis later.
(pulmonary embolism, pneumothorax, collapse/consolidation), Chest X-ray: ?collapse/pneumothorax/consolidation.
right to left pulmonary shunt. ECG: AF.
KEY POINTS ESSENTIAL MANAGEMENT

80% of patients following upper abdominal surgery are hypoxic during Airway control.
the first 48 h postoperatively. Have a high index of suspicion and treat Triple airway manoeuvre, suction secretions, clear oropharynx.
prophylactically. Consider endotracheal intubation in CNS depression/exhausted
Adequate analgesia is more important than the sedative effects of patients (rising P CO2), neuromuscular failure.
opiatesbensure good analgesia in all postoperative patients. Consider surgical airway (cricothyroidotomy/mini-tracheostomy) in
Ensure the dynamics of respiration are adequatebupright position, facial trauma, upper airway obstruction.
abdominal support, humidified O2. Breathing.
Acutely confused (elderly) patients on a surgical ward are hypoxic until Position patientbupright.
proven otherwise. Adequate analgesia.
Pulse oximetry saturations of less than 85% equate to an arterial Supplemental O2bmask/bag/ventilation.
PO2 <8 kPa and are unreliable in patients with poor peripheral perfusion. Support respiratory physiologybphysiotherapy, humidified gases,
encouraging coughing, bronchodilators.
Circulatory support.
Maintain cardiac output.
Analgesia in postoperative patients
Ensure adequate fluid resuscitation.
Opiates: powerful, highly effective if given by correct route
Determine and treat the cause.
(e.g. PCA) but antitussive, sedative only in overdose.
Hypoxia 67
29 Shock
SEPTIC TYPE I
Neutrophils
Phospholipase A2 activation Warm
Flushed
Neutrophil degranulation Bounding pulse
Lipopolysaccharide Ags
Complement fixation Low diastolic BP
Cell surface Ags
Gram ve V/Q mismatch
Mast cell degranulation
organisms ( Capillary leak
Shunting
Vasodilatation
Redistribution of
blood flow)
TYPE II
Cold Worsening capillary leak
Pale Precapillary sphincter relaxation
Cyanosed Myocardial depression
Confused Lactic acidosis
Low systolic BP
Oliguria
HYPOVOLAEMIC
Minor haemorrhage without/with treatment
100
Major haemorrhage with prompt treatment
% of
normal Treatment
systolic Secondary effects of prolonged hypotension
Treatment
blood
pressure
Major haemorrhage with late treatment
Catastrophic haemorrhage Time

without control of source

Definitions Anaphylactic/distributive
Shock is defined as a state of acute inadequate or inappropriate Release of vasoactive substances when a sensitized individual is
tissue perfusion resulting in generalized cellular hypoxia and exposed to the appropriate antigen.
dysfunction.
Clinical features
Hypovolaemic and cardiogenic
KEY POINTS Pallor, coldness, sweating and restlessness.
Identify the cause early and begin treatment quickly. Tachycardia, weak pulse, low BP and oliguria.
Shock in surgical patients is often overlookedbunwell, confused,
restless patients may well be shocked. Septic
Unless a cardiogenic cause is obvious, treat shock with urgent fluid Initially warm, flushed skin and bounding pulse.
resuscitation. Later confusion and low output picture.
Worsening clinical status despite adequate volume replacement
suggests the need for intensive care. Investigations and assessment
Monitor pulse, BP, temperature, respiratory rate and urinary
output.
Common causes Establish good i.v. access and set up CVP line (possibly
Hypovolaemic SwanGanz catheter as well).
Blood loss (ruptured abdominal aortic aneurysm, upper GI ECG, cardiac enzymes, echocardiography.
bleed, multiple fractures, etc.). Hb, Hct, U+E, creatinine.
Plasma loss (burns, pancreatitis). Group and crossmatch blood: haemorrhage.
Extracellular fluid losses (vomiting, diarrhoea, intestinal fistula). Blood cultures: sepsis.
Arterial blood gases.
Cardiogenic
Myocardial infarction. Complications
Dysrhythmias (AF, VT, AFlutter). SIRS (see p. 70) may ensue if shock not corrected.
Pulmonary embolus. Acute renal failure (acute tubular necrosis).
Cardiac tamponade. Hepatic failure.
Valvular heart disease Stress ulceration.
Septic
Gram ve or, less often, Gram +ve infections.
ESSENTIAL MANAGEMENT
Airway and breathing: give 100% O2, sit up, consider ventilatory support if necessary.
Circulation: ensure good IV access, urinary catheter, monitor cardiac rate and rhythm.

Anaphylactic Cardiogenic Septic Hypovolaemic

i.v. fluids. Optimize rate and rhythm (e.g. Fluids to restore circulating Identify and arrest losses
i.v. adrenaline. cardioversion, drugs). volume. (may include surgery).
i.v. antihistamines. Optimize preload (e.g. adequate Antibiotics or surgery. Restore circulating volume
i.v. hydrocortisone. volume, diuretics). Support cardiac function (crystalloids, colloids or blood).
Optimize afterload (e.g. vasoconstrictors/dilators). (e.g. inotropes). Support cardiac function.
Optimize cardiac function (e.g. thrombolytic
therapy, inotropes, assist devices).
Deal with the cause of the shock: e.g. stop the bleeding, drain the abscess, remove the source of the anaphylactic antigen, etc.
Shock 69
30 SIRS
Sepsis
syndrome
Infection SIRS
Septic
shock
Shock Insult
Induction
Local cytokine
PROCESS OF SIRS activation Synthesis
Amplification
Lipopolysaccharide (LPS)
Amplification into
+
generalized cytokine
LPS binding protein LPS
activation
CD14 receptor Potentiation
+ +
SIRS Continued amplification
or failed downregulation
Macrophage Polymorphonuclear
+ + cell
MODS Organ specific RE cell
TNF activation and dysfunction
IL-1
IL-6
Chemokines Complement
+
iNOS Endothelial cell
iNOS Inducible nitric oxide synthetase

Activation Dysfunction IL-6 Interleukene 6
leak IL-1 Interleukene 1 beta
coagulopathy

Definitions Multiple trauma.
SIRS (systemic inflammatory response syndrome) is a systemic Massive blood transfusion.
inflammatory response characterized by the presence of two or Aspiration pneumonia.
more of the following: Ischaemia reperfusion injury.
hyperthermia >38C or hypothermia <36C
tachycardia >90 bpm Causation and treatments
tachypnoea >20 r.p.m. or PaCO2 <4.3 kPa
TNF
neutrophilia >12 109 l1 or neutropenia <4 109 l1. TNF is both released by and activates macrophages and neu-
Sepsis syndrome is a state of SIRS with proven infection. Septic trophils. It is cytotoxic to endothelial cells and parenchymal cells
shock is sepsis with systemic shock. of end organs. There is no clear evidence that anti-TNF therapy
MODS (multiple organ dysfunction syndrome) is a state of is effective in SIRS.
derangement of physiology such that organ function cannot
maintain homeostasis. Lipopolysaccharide (LPS)
The common terminal pathways for organ damage and dys- Released from Gram ve bacterial cell walls, activates
function are vasodilatation, capillary leak, intravascular coagu- macrophages via attachment of LPS binding protein and activa-
lation and endothelial cell activation. tion of CD14 molecules on the cell surface. There is no proven
value for anti-LPS antibody treatment.
KEY POINTS
Interleukines
SIRS is more common in surgical patients than is diagnosed.
IL-6 and IL-1 cause endothelial cell activation and damage.
Early treatment of SIRS may reduce the risk of MODS
They promote complement and chemokines release. High-dose
developing.
intravenous steroids have little role in established SIRS (prob-
The role of treatment is to eliminate any causative factor and support
ably because of multiple pathways of activation). Steroids for
the cardiovascular and respiratory physiology until the patient can
recover.
early SIRS are unproven.
Overall mortality is 7% for a diagnosis of SIRS, 14% for sepsis
syndrome and 40% for established septic shock. Platelet activating factor (PAF)
Implicated particularly in acute pancreatitis, no proven role for
anti-PAF antibody treatment.
Common surgical causes
Acute pancreatitis. Inducible nitric oxide synthetase (iNOS)
Perforated viscus with peritonitis. Synthesized by activated endothelial cells, activates endothelial
Fulminant colitis. cells and leucocytes, potent negative ionotrope.
SIRS 71
31 Acute renal failure
CAUSES RENAL
Any established cause
PRERENAL of prerenal or postrenal
Hypoperfusion Glomerular damage
Hypovolaemia Glomerulonephritis
Septicaemia Tubular damage
Hypoxaemia Toxins
Nephrotoxins Drugs
Pancreatitis Pyelonephritis
Liver cell dysfunction Vascular damage
Bilirubin Acute vasculitis
Other toxins Diabetes
Hypertension
POSTRENAL
Primary tumours
Secondary tumours invasion
Stones
Blood clots
Bladder obstruction
Infestations (worms)
FEATURES
Normal Prerenal Renal Postrenal
Uosmolality Approx 400500 mosm/kg > 500 <400 Normal
UNa+ 1020 mmol/l < 10 > 20 Normal
Uurea/Purea Approx 5/1 > 10/1 3/11/1 Normal
Uosm/Posm Approx 1.5/1 > 2/1 < 1.1/1 Normal
Findings Concentrated Casts Normal urine

urine RBCs ? Findings due
? Findings due to cause Protein to cause

Definitions Fluid retention: hypervolaemia, hypertension.
Acute renal failure is a sudden deterioration in renal function Hyperkalaemia: dysrrhythmias.
such that neither kidney is capable of excreting body waste prod- Acidosis.
ucts (e.g. urea, creatinine, potassium) that accumulate in the
blood. It is fatal unless treated. Anuria means no urine is passed. Polyuric (recovery) phase
Oliguria means that less than 0.5 ml/kg/h is passed. (May last days/weeks)
Polyuria: hypovolaemia, hypotension.
Hyponatraemia.
KEY POINTS Hypokalaemia.
Oliguria in a surgical patient is an emergency and the cause must be
identified and treated promptly. Investigations
Prompt correction of pre-renal causes may prevent the development of Urinalysis (see opposite page).
established renal failure. U+E (especially K+).
Ensure the oliguric patient is normovolaemic as far as possible before Creatinine estimation.
starting diuretics or other therapies.
ECG/chest X-ray.
Dont use blind, large fluid challenges, especially in the elderlybif
Arterial blood gases: metabolic acidosis (N PO2, Lo PCO2, Lo
necessary use a CVP line.
pH, Hi base deficit).
Established renal failure requires specialist support as electrolyte and
fluid imbalances can be rapid in onset and difficult to manage.
Prevention
Common causes
Keep at-risk patients (e.g. patients with obstructive jaundice) well
Pre-renal failure
hydrated pre- and perioperatively.
Shock causing reduced renal perfusion.
Protect renal function in selected patients with drugs such as
Pancreatitis.
dopamine and mannitol.
Monitor renal function regularly in patients on nephrotoxic drugs
Intrinsic renal failure (e.g. gentamicin).
Shock causing renal ischaemia (ATN).
Nephrotoxins (aminoglycosides, myoglobin). Identification
Acute glomerulonephritis. Exclude urinary retention as a cause of anuria by catheterization.
Severe pyelonephritis. Correct hypovolaemia as far as possible. Use appropriate fluid
Hypertension and diabetes mellitus. bolusesbif necessary guided by a CVP monitor.
A trial of bolus high-dose loop diuretics may be appropriate in a
Post-renal failure normovolaemic patient.
Urinary tract obstruction, e.g. prostatic hypertrophy. Dopamine infusions may be necessary but suggest the need for HDU
Obstructing renal calculi. or ICU care.
Clinical features Treatment of established renal failure

Specific to the cause Maintain fluid and electrolyte balance.
Hypovolaemia: cool peripheries, tachycardia, confusion, rest- Water intake 400 ml/day + measured losses.
lessness, dry mucous membranes. Na+ intake limited to replace loss only.
K+ intake nil (dextrose and insulin and/or ion-exchange resins are
Oliguric phase required to control hyperkalaemia).
(May last hours/days/weeks) Diet: high calorie, low protein in a small volume of fluid.
Acidosis: sodium bicarbonate.
Oliguria.
Treat any infection.
Uraemia: dyspnoea, confusion, drowsiness, coma.
Dialysis: peritoneal, ultrafiltration, haemodialysis
Nausea, vomiting, hiccoughs, diarrhoea.
(usually indicated for hypervolaemia, hyperkalaemia or acidosis).
Anaemia, coagulopathy, GI haemorrhage.
Acute renal failure 73

32 Fractures
COMPLICATIONS Infection
Tetanus
GENERAL Gangrene
Septicaemia
Shock
Neurogenic DVT
Hypovolaemic
Fat embolus
Crush syndrome ARDS DIC
ARF Myonecrosis
LOCAL BONY
Sepsis Non- or delayed union
Acute osteitis Causes
Acute osteomyelitis Infection
Chronic osteomyelitis Ischaemia
Distraction
Interposition of soft tissue
Epiphyseal injury Movement of bone ends
Type Malunion
'Salter Joint stiffness/ e.g. rotational deformity
Harris' early OA angulation
I II III IV V shortening
Avascular necrosis
LOCAL OTHER TISSUES
Vascular Compartment syndrome

Ischaemic Nerve damage
Injury Muscle damage
Oedema Ischaemia
Division Spasm
Tear Thrombosis
Non-ischaemic Pressure Blood flow
Hypotension
Tight casts
Nerves
Aneurysm AV fistula
Palsy (permanent)
(False or
Viscera Praxia (temporary)
real)
e.g. Heart ribs Muscles
Liver ribs Haematoma acute
Bladder pelvis Myositis ossificans chronic
Colon pelvis

Definitions ESSENTIAL MANAGEMENT
A fracture is a break in the continuity of a bone. General
Fractures may be transverse, oblique or spiral in shape. Look for shock/haemorrhage and check ABC (see p. 78).
In a greenstick fracture, only one side of the bone is fractured, Look for injury in other areas at risk (head and spine, ribs and
the other simply bends (usually immature bones). pneumothorax, femoral and pelvic injury).
A comminuted fracture is one in which there are more than two
fragments of bone. The fracture
In a complicated fracture, some other structure is also dam- Immediate
aged (e.g. a nerve or blood vessel). Relieve pain (opiates i.v., nerve blocks, splints, traction).
In a compound fracture, there is a break in the overlying skin Establish good i.v. access and send blood for group and
(or nearby viscera) with potential contamination of the bone crossmatch.
ends. Open (compound) fractures require debridement, antibiotics and
A pathological fracture is one through a bone weakened by tetanus prophylaxis.
disease, e.g. a metastasis.
Definitive
Reduction (closed or open).
Immobilization (casting, functional bracing, internal fixation, external
KEY POINTS
fixation, traction).
Always consider multiple injury in patients presenting with fractures.
Rehabilitation (aim to restore the patient to pre-injury level of function
Compound fractures are a surgical emergency and require appropriate
with physiotherapy and occupational therapy).
measures to prevent infection, including tetanus prevention.
Always image the joints above and below a long bone fracture.
Complications
Early
Common causes
Blood loss.
Fractures occur when excessive force is applied to a normal bone
Infection.
or moderate force to a diseased bone, e.g. osteoporosis.
Fat embolism.
DVT and PE.
Clinical features
Renal failure.
Pain.
Compartment syndrome.
Loss of function.
Deformity, tenderness and swelling.
Late
Discoloration or bruising.
Non-union.
(Crepitus, not to be elicited!)
Delayed union.
Malunion.
Investigations
Growth arrest.
Radiographs in two planes (look for lucencies and discontinu-
Arthritis.
ity in the cortex of the bone).
Post-traumatic sympathetic (reflex) dystrophy.
Tomography, CT scan, MRI scan (rarely).
Ultrasonography and radioisotope bone scanning. (Bone scan
is particularly useful when radiographs/CT scanning are negat-
ive in clinically suspect fracture.)
Fractures 75
33 Burns
WALLACE'S RULE OF 9's TYPES

9
Partial Full
9 Colour Red White
Blanching Yes None
9 Pain +++ None
Light touch Pain None
9 9 9 Hair Preserved Lost
9 1
Major burn = 20% surface area +
or
9 9 Age < 5 > 60
or
Airway burn
or
Perineal/ocular/hands burns
9 9
11 x 9 = 99%
COMPLICATIONS
LOCAL Treatment GENERAL/SYSTEMIC

O2 100% Laryngeal oedema
Neb adrenaline Bronchospasm
Corneal burns Protective tarsorrhaphy
Chloramphenicol ointment ARDS
IPPV Inhalational
O2 pneumonitis
Albumin-rich H Albumin i.v.
fluid loss
i.v. H2 blockers Acute gastric ulceration
Circumferential Naso-gastric sucralfate (Curling's ulcer)
Escharotomy
burns Naso-gastric tube Pancreatitis
Naso-gastric tube Paralytic ileus

Fluids i.v.
Acute renal failure
Antibiotics Sepsis
Perineal Catheterization
burns Heparin FFP Disseminated intravascular
coagulation
Nutritional C2H5OH Hypercatabolism
support NH4+ Proteolysis

Definitions Complications
A burn is the response of the skin and subcutaneous tissues to Immediate
thermal injury. A partial thickness burn is a burn which either Compartment syndrome from circumferential burns (limb burns
does not destroy the skin epithelium or destroys only part of it. limb ischaemia, thoracic burns hypoxia from restrictive
They usually heal with conservative management. A full thick- respiratory failure) (prevent by urgent escharotomy).
ness burn destroys all sources of skin epithelial regrowth and
may require excision and skin grafting if large. Early
Hyperkalaemia (from cytolysis in large burns). Treat with
insulin and dextrose.
KEY POINTS Acute renal failure (combination of hypovolaemia, sepsis, tis-
Start resuscitation immediately in major burns. sue toxins). Prevent by aggressive early resuscitation, ensuring
Calculate fluid requirement from the time of the burn. high GFR with fluid loading and diuretics, treat sepsis.
Be sure to assess for vital area burns (airway/hands/face/perineum/ Infection (beware of Streptococcus). Treat established infec-
circumferential). tion (106 organisms present in wound biopsy) with systemic
Consider referral to a specialist burns centre for all major burns. antibiotics.
Stress ulceration (Curlings ulcer) (prevent with antacid, H2-
blocker or proton pump inhibitor prophylaxis).
Common causes
Thermal injury from dry (flame, hot metal) or moist (hot liq- Late
uids or gases) heat sources. Contractures.
Electricity (deep burns at entry and exit sites, may cause car-
diac arrest). ESSENTIAL MANAGEMENT
Chemicals (usually industrial accidents with acid or alkali). General
Radiation (partial thickness initially, but may progress to Start resuscitation (ABC (see p. 78), set up good i.v. lines, give O2).
chronic deeper injury). Assess size of burn (Wallaces rule of 9s).
Clinical features Major burns (>20% burn in adult, >10% in child)

General Monitor pulse, BP, temperature, urinary output, give adequate
Pain. analgesia i.v., consider nasogastric tube, give tetanus prophylaxis.
Swelling and blistering. Give i.v. fluids according to MuirBarclay formula:
% burn wt in kg/2 = one aliquot of fluid.
Specific Give six aliquots of fluid over first 36 h in 4, 4, 4, 6, 6, 12-hour
Evidence of smoke inhalation (soot in nose or sputum, burns sequence from time of burn. Colloid, albumin or plasma solutions
in the mouth, hoarseness). are used.
Eye or eyelid burns (early ophthalmological opinion). The burn wound is treated as for minor burns (see below).
Circumferential burns (will need escharotomy). Consider referral to a burns centre.
Minor burns (<20% burn in adult, <10% in child)

Investigations
Treatment by exposurebdebride wound and leave exposed in special
FBC.
clean environment.
U+E.
Treatment by dressingsbcover with tulle gras impregnated with
If inhalation suspected: chest X-ray, arterial blood gases, CO
chlorhexidine or silver sulphadiazine under absorptive gauze
estimation.
dressings.
Blood group and crossmatch.
Debridement of eschar and split skin grafting.
ECG/cardiac enzymes with electrical burns.
Burns 77
34 Major traumacbasic principles
AIRWAY
Obtunded
HYPOXIA
Cyanosed
Stridor
Tracheal tug
Accessory muscles OBSTRUCTION
Intercostal recession
BREATHING
TENSION PNEUMOTHORAX LARGE HAEMOTHORAX FLAIL CHEST
Distended Tracheal deviation Distended Tracheal deviation
neck veins neck veins
Tachypnoea
Cyanosis
Hyperresonant Displaced apex Stony dull Displaced apex Paradoxical

BS Hypotension No BS Hypotension movement
Tachycardia Tachycardia
Cannula thoracostomy Chest drain thoracostomy Mechanical ventilation
Chest drain thoracostomy May need thoracotomy if resistant hypoxia
CIRCULATION
CARDIAC TAMPONADE AORTIC RUPTURE CARDIAC CONTUSION
Distended Chest X-ray Tachycardia
neck veins Displaced Pleural Hypotension
trachea capping JVP
Pulsus ECG
paradoxsus Widened
mediastinum AF
or
Muffled Loss of A-P
VEs
heart sounds in dent
or
Acute MI pattern
Hypotension
Tachycardia
Aspiration Sternotomy Supportive
Thoracotomy/sternotomy

Definition ESSENTIAL PRIMARY SURVEY MANAGEMENT
Major trauma (MT) can be defined as injury (or injuries) of Cervical spine
organs of severity sufficient to present an immediate threat to Stabilize with in-line manual traction. Lateral C spine/X-ray
life. MT often involves multiple injuries. The majority of Secure with hard collar, head supports (must include C7T1)
patients who reach hospital alive following MT have potentially and tape.
survivable injuries if detected and treated early. Can only be cleared by normal examination
in a fully conscious patient or normal X-rays.
KEY POINTS A Airway management (see opposite for major

Treat all MT patients as having a potentially unstable cervical spine. abnormalities)
Treat life-threatening injuries identified in the primary survey Clear obstructions by hand and lift chin
immediately upon discovery. (obtunded patients).
Undiagnosed hypotension is due to occult haemorrhage unless proven Secure airway with oropharyngeal or
otherwise. nasopharyngeal airway (obtunded patients).
Emergency surgery may be part of the resuscitation of patients Definitive airway (direct access to intratracheal
suffering from internal haemorrhage. oxygenation) indicated by:
Apnoea / (risk of) upper airway obstruction /
(risk of) aspiration / need for mechanical
Principles of management ventilation.
Orotracheal tube.
Management for MT is divided into two categories.
Nasotracheal tube.
First aidbroadside given by paramedics or on-site med-
Surgical airway (cricothyroidotomy)
ical teams. Aims to maintain life during extraction and evacua-
indicated by:
tion of patient.
Maxillofacial injuries / laryngeal disruption
Primary surveybin hospital performed by A&E or Trauma
/ failure to intubate.
Teams. Aims to identify and treat life-threatening injuries to
airways, respiratory and cardiovascular systems and perform B Breathing (see opposite for some major
major skeletal radiology. Known as the ABC(DE) secondary abnormalities)
surveybin hospital performed by A&E or Trauma Teams, pos- Administer supplemental O2.
sibly with specialist surgical staff. Aims to identify and assess all Assess respiratory rate / air entry (symmetry) / CXR
major injuries. chest wall motion (symmetry) / tracheal position.
Monitor with pulse oximetry and observations.
Patterns of injury
Some of the major injuries which may be encountered in the C Circulation (see opposite for some major
primary survey are shown opposite. Mechanisms of injury and abnormalities)
patterns of injury may be associated, e.g. Assess pulse rate and character / blood Pelvic X-ray
pressure / apex beat / JVP / heart sounds /
evidence of blood loss.
Restrained RTA Pedestrian collision Draw blood for Cross-match, FBC and U+E.
Cervical spine injury Long bone fractures

D Dysfunction of the CNS
Sternal fracture Knee ligamentous injury
Cardiac contusion Rib fractures Assess GCS (see p. 81) / pupil reactivity / limb
Liver laceration Pneumothorax gross motor and sensory function where
Facial fractures possible.
Head injury
E Exposure of extremities
Assess limbs for major long bone injuries and
sites of major blood loss.
35 Head injury/1
Blunt blow Crush Rotational/ Coup Penetrating

decelerational Contrecoup missile
Spiral shear
TYPES OF MECHANISM
1. Vascular injuries 2. Bony injuries 3. 'Secondary'

injuries
Intracerebral Simple
haematoma skull fracture Hypotension
Hypoxia
Infection
Subdural Depressed
haematoma skull fracture
Extradural Base of skull

haematoma fracture

Definitions Rotation/deceleration
A head injury is the process whereby direct or decelerating Neck flexion, extension or rotation results in the brain striking
trauma to the head results in skull and brain damage. bony points within the skull (e.g. the wing of the sphenoid bone).
Primary brain injury is the damage that occurs to the brain Severe rotation also causes shear injuries within the white matter
immediately as the result of the trauma. of the brain and brainstem, causing axonal injury and intracere-
Secondary brain injury is the damage that develops later as a bral petechial haemorrhages.
result of complications.
Crush
The brain is often remarkably spared direct injury unless severe
KEY POINTS (especially in children with elastic skulls).
Prevention of secondary brain injury is the most important objective of
head injury care. Missiles
A full trauma survey (p. 79) must be carried out on all patients with Tend to cause loss of tissue with injury proportionate. Brain
head injuries. swelling less of a problem due to the skull disruption automatic-
The Glasgow Coma Scale (GCS) provides a simple method of ally decompressing the brain!
monitoring global CNS function over a period rather than a precise index
The degree of primary brain injury is directly related to the
of brain injury at any one time.
amount of force applied to the head.
Secondary damage results from: respiratory complications
(hypoxia, hypercarbia, airway obstruction), hypovolaemic
Epidemiology shock (head injury does not cause hypovolaemic shockblook
Head injury is very common. A million patients each year pre- for another cause), intracranial bleeding, cerebral oedema,
sent to A&E departments in the UK with head injury and about epilepsy, infection and hydrocephalus.
5000 patients die each year following head injuries.
Clinical features
Pathophysiology History of direct trauma to head or deceleration.
Direct blow Patient must be assessed fully for other injuries.
May cause damage to the brain at the site of the blow (coup Level of consciousness determined by GCS.
injury) or to the side opposite the blow when the brain moves
within the skull and hits the opposite wall (contrecoup injury).
The Glasgow Coma Scale.
Eye opening Voice response Best motor response

Spontaneous 4 Alert and orientated 5 Obeys commands 6
To voice 3 Confused 4 Localizes pain 5
To pain 2 Inappropriate 3 Flexes to pain 4
No eye opening 1 Incomprehensible 2 Abnormal flexion to pain 3
No voice response 1 Extends to pain 2
No response to pain 1
Fully conscious: GCS = 15; deep coma: GCS = 3.
Pupillary inequalities or abnormal light reflex indicate intra- Investigations

cranial haemorrhage. Skull X-ray: AP, lateral and Townes views.
Headache, nausea, vomiting, a falling pulse rate and rising BP CT/MRI scan: show contusions, haematomas, hydrocephalus,
indicate cerebral oedema. cerebral oedema.
Head injury 81
Head injury/2
TREATMENTS TO CONTROL RISE IN INTRACRANIAL PRESSURE
Intrathoracic pressure
(negative phase ventilation)
PaCO2 (hyperventilation)
Oedema
Sedation (barbiturates)
Fluid + salt restriction

Hyperaemia Intravascular Fluid Mannitol
Loss of local blood Dexamethasone
control of blood
flow ICP
Evacuation of Extravascular Brain mass Treatment

haematoma blood Removal of frontal lobe apex
Removal of temporal lobe apex
Swelling
Haemorrhage

Complications
Trivial head injury Skull fractures
The patient is conscious, may be history of period of loss of Indicate severity of injury. No specific treatment required unless
consciousness (LOC). Retrograde amnesia for events prior to head injury compound, depressed or associated with chronic CSF loss (e.g.
is significant. anterior cranial fossa basal skull fracture).
Indications for skull X-ray Intracranial haemorrhage

LOC or amnesia. Extradural haemorrhage: tear in middle meningeal artery.
Neurological signs. Haematoma between skull and dura. Often a lucid interval
CSF leakage. before signs of raised intracranial pressure (ICP) ensue (falling
Suspected penetrating injury. pulse, rising BP, ipsilateral pupillary dilatation, contralateral
Alcohol intoxication. paresis or paralysis). Treatment is by evacuation of haematoma
Difficulty in assessing patient. via burr holes.
Acute subdural haemorrhage: tearing of veins between arach-
Indications for admission noid and dura mater. Usually seen in elderly. Progressive
Confusion or reduced GCS. neurological deterioration. Treatment is by evacuation but even
Skull fracture. then recovery may be incomplete.
Neurological signs or headache or vomiting.
Chronic subdural haematoma: tear in vein leads to subdural
Difficulty in assessing patient.
haematoma which enlarges slowly by absorption of CSF. Often
Coexisting medical problem.
the precipitating injury is trivial. Drowsiness and confusion,
Inadequate social conditions or lack of responsible adult to observe
headache, hemiplegia. Treatment is by evacuation of the clot.
patient.
Intracerebral haemorrhage: haemorrhage into brain substance
causes irreversible damage. Efforts are made to avoid secondary
Indications for neurosurgical referral
Skull fracture + confusion/decreasing GCS.
injury by ensuring adequate oxygenation and nutrition.
Focal neurological signs or fits.
Persistence of neurological signs or confusion for >12 h. Prognosis
Coma after resuscitation. Prognosis is related to level of consciousness on arrival in
Suspected open injury to skull. hospital.
Depressed skull fracture.
Deterioration.
GCS on admission Mortality
Severe head injury 15 1%

Patient will arrive unconscious in A&E department. Head injury may be 812 5%
<8 40%
part of a multiple trauma.
ABC (see p. 79). Intubate and ventilate unconscious patients to protect
airway and prevent secondary brain injury from hypoxia.
Resuscitate patient and look for other injuries, especially if the patient
is in shock. Head injury may be accompanied by cervical spine injury and
the neck must be protected by a cervical collar in these patients.
Treat life-threatening problems (e.g. ruptured spleen) and stabilize
patient before transfer to neurosurgical unit. Ensure adequate medical
supervision (anaesthetist + nurse) during transfer.
Head injury 83
36 Gastro-oesophageal reflux
CAUSES Grades of oesophagitis

I Erythema
PHYSIOLOGICAL ANATOMICAL II Erosions
Crural sling III Confluent erosions/ulcers
IV Stricture
Mucosal rosettes B Barrett's change
Gastro-oesophageal angle of His
+ve intra-abdominal
pressure
High pressure zone

(Lower oesophageal sphincter)
FUNCTIONAL
Sedatives
Alcohol
Drugs
Recumbent position
Overeating/distension Surgery
Poor gastric emptying
COMPLICATIONS
Aspiration
Barrett's Fundoplication
oesophagus Stricturing
Shortening
Perforation
Bleeding
Anaemia
Haemorrhage
Gastroplasty + fundoplication
(for shortening)

Definitions ESSENTIAL MANAGEMENT
Gastro-oesophageal reflux is a condition caused by the retro- General
grade passage of gastric contents into the oesophagus resulting Lose weight, avoid smoking, coffee, alcohol and chocolate.
in inflammation (oesophagitis), which manifests as dyspepsia. A Avoid tight garments and stooping.
hiatus hernia is an abnormal protrusion of the proximal stomach
through the oesophageal opening in the diaphragm resulting in a Medical
more proximal positioning of the oesophagogastric junction and Exclude carcinoma by OGD in patients over 45 years and with
predisposition to gastro-oesophageal reflux disease (GORD). symptoms suspicious of malignancy.
Sliding (common) and rolling or para-oesophageal (rare) hiatus Control acid secretion (H2 receptor antagonists (e.g. ranitidine)
hernias are recognized. or proton pump inhibitors (PPIs) (e.g. omeprazole)).
Minimize effects of reflux (give alginates to protect oesophagus).
Prokinetic agents (e.g. metoclopramide, cisapride) improve LOS
KEY POINTS tone and promote gastric emptying.
The majority of GORD is benign and uncomplicated.
Barretts oesophagus is an increasingly recognized association Surgical
predisposing to adenocarcinoma of the oesophagus. Anti-reflux surgery (e.g. Nissen fundoplication) which may be
Patients over the 45 years or with suspicious symptoms should have performed by laparotomy or laparoscopy. Indicated for:
malignancy excluded as a cause when first presenting with GORD complications of reflux;
symptoms. failed medical control of symptoms;
Surgery for GORD should be reserved for complications or patients ?long-term dependence on medical treatment;
resistant to medical therapy. ?large volume reflux.
Common causes Complications

Failure of normal mechanisms of gastro-oesophageal con- Benign stricture of the oesophagus.
tinence (LOS pressure, length of intra-abdominal LOS, angle Barretts oesophagus (see below).
of His, sling fibres around the cardia, the crural fibres of the Bleeding.
diaphragm, the mucosal rosette).
LOS pressure reduced by smoking, alcohol and coffee. Barretts oesophagus
Definition and aetiology
Clinical features >3 cm of columnar epithelium lining the lower anatomical
Retrosternal burning pain, radiating to epigastrium, jaw and oesophagus. May be related to eradication of H. pylori and
arms. (Oesophageal pain is often confused with cardiac pain.) increasing incidence of GORD.
Regurgitation of acid contents into the mouth (waterbrash).
Back pain (a penetrating ulcer in Barretts oesophagus). Diagnosis
Dysphagia from a benign stricture. Can only be confidently made by biopsy but appearances of red-
dish mucosa in the lower oesophagus are typical on OGD.
Investigations
Barium swallow and meal: sliding hiatus hernia, oesophageal Complications
ulcer, stricture. Risk of adenocarcinoma:
Oesophagoscopy: assess oesophagitis, biopsy for histology, 2%bno dysplasia present;
dilate stricture if present. 20%blow-grade dysplasia present;
24-hour pH monitoring: assess the degree of reflux. 50%bhigh-grade dysplasia present.
Oesophageal manometry.
Treatment
Follow-up OGD (close surveillance if low-grade dysplasia)
and PPI/H2 blockers.
Oesophagectomy if high-grade dysplasia due to risk of
carcinoma.
Gastro-oesophageal reflux 85
37 Oesophageal carcinoma
TYPES DISTRIBUTION
Postcricoid (10%) Squamous

Iron deficiency carcinoma
Malignant Malignant Invasive Smoking
stricture ulcer mass
Upper/middle 1/3 (40%) Squamous
Smoking carcinoma
EFFECTS/SPREAD Diet
Supraclavicular Achalasia
node (Virchow's)
Dyspnoea Lower 1/3 (50%) Squamous/adeno
Cough carcinoma
Haemoptysis Barrett's oesophagus
Mediastinal nodes
AF
Pericardial effusion
Gastric nodes
Pleural
effusion
Dysphagia
Dyspepsia
SURGICAL OPTIONS
Postcricoid
Lower 1/3 OGJ Lower/middle 1/3 Upper 1/3

(large stomach
element)
Pharyngo(laryngo)
oesophagectomy +
interposition graft
Total gastrectomy Oesophago- Oesophagectomy +

+ Roux-en-y loop gastrectomy interposition graft

Definition Weight loss and weakness.
Malignant lesion of the epithelial lining of the oesophagus. Aspiration pneumonia.
Investigations
KEY POINTS Barium swallow: narrowed lumen with shouldering.
All new symptoms of dysphagia should raise the possibility of Oesophagoscopy and biopsy: malignant stricture. (Trans-
oesophageal carcinoma. luminal ultrasound may help assess local invasion.)
Adenocarcinoma of the oesophagus is increasingly common. Bronchoscopy: assess bronchial invasion with upper third
Only a minority of tumours are successfully cured by surgery. lesions.
CT scanning (helical): assess degree of spread if surgery is
being contemplated.
Epidemiology Laparoscopy to assess liver and peritoneal involvement prior
Male/female 3 : 1, peak incidence 5070 years. High incid- to proceeding to surgery.
ence in areas of China, Russia, Scandinavia and among the
Bantu in South Africa.
Adenocarcinoma has the fastest increasing incidence of any
Palliation
carcinoma in the UK.
Intubation with Atkinson or Celestine tube or expanding
endoprosthesis.
Aetiology Intraluminal irradiation with iridium wires.
The following are predisposing factors.
Laser resection of the tumour to create lumen.
Alcohol consumption and cigarette smoking. Surgical excision of the tumour.
Chronic oesophagitis and Barretts oesophagus.
Stricture from corrosive (lye) oesophagitis. Curative treatment
Achalasia. Surgical resection is curative only if lymph nodes are not involved.
PlummerVinson syndrome (oesophageal web, mucosal Reconstruction is by gastric pull-up or colon interposition.
lesions of mouth and pharynx, iron deficiency anaemia).
Nitrosamines. Other treatment
Combination therapy with external beam radiation, chemotherapy
Pathology and surgery is under trial and probably indicated for squamous
Histological type: 90% squamous carcinoma (upper two- carcinoma.
thirds of oesophagus); 10% adenocarcinoma (lower third of
oesophagus).
Spread: lymphatics, direct extension, vascular invasion. Prognosis
Following resection, 5-year survival rates are about 15%, but
Clinical features overall 5-year survival (palliation and resection) is only about
Dysphagia progressing from solids to liquids. 4%.
Oesophageal carcinoma 87
38 Peptic ulceration
Mucus producers
Carbenoxolone
Local antacid
Sucralfate
Epithelial regeneration
ANTI-SECRETORIES H+ Methyl PGE2
Proton pump inhibitors

Omeprazole
Pantoprazole
Lansoprazole K+ ANTI -HELICOBACTER ANTACIDS
Metronidazole Aluminium- and
H2 blockers Amoxycillin magnesium-containing
Ranitidine Erythromycin compounds
Cimetidine Bismuth
AcH blockers
Gastrin receptor blockers ROLE OF H. PYLORI
Pirenzepine
Proglumide Ulcers
Beneficial to
H. pylori
H+
COMPLICATIONS
H. pylori in crypts
H+ production
Neutrophil ingress
Damage to
Cytotoxic cytokines inhibitory cells
? Primary released
malignancy
Perforation
Bleeding GU
Prepyloric stenosis
Postpyloric stenosis
Perforation DU
Bleeding

Definition Weight loss.
A peptic ulcer is a break in the epithelial surface of the oesopha- Nausea and vomiting.
gus, stomach or duodenum (rarely Meckels diverticulum) Anaemia from chronic blood loss.
caused by the action of gastric secretions (acid and pepsin) and,
in the case of duodenal ulceration, infection with H. pylori. Investigations
FBC: to check for anaemia.
U+E: rarely indicates ZollingerEllison syndrome.
KEY POINTS Faecal occult blood.
Not all dyspepsia is due to PUD. OGD: necessary to exclude malignant gastric ulcer in:
The majority of chronic duodenal ulcers are related to H. Pylori patients over 45 at first presentation;
infection and respond to eradication therapy. concomitant anaemia;
All patients over 45 at presentation or with suspicious symptoms short history of symptoms;
require endoscopy to exclude malignancy. other symptoms suggestive of malignancy.
Surgery is usually limited to complications of ulcer disease and failure Useful to obtain biopsy for Campylobacter-like organism
of compliant medical therapy. (CLO) (urease) test.
Barium meal: best for patients unable to tolerate OGD or
evaluation of the duodenum in cases of pyloric stenosis.
Common causes Urease breath test/H. pylori serology: non-invasive method
Imbalance between acid/pepsin secretion and mucosal defence. of assessing the presence of H. pylori infection. Used to direct
Acid hypersecretion occurs because of increased numbers of therapy or confirm eradication.
parietal cells (or rarely in response to gastrin hypersecretion in
the ZollingerEllison syndrome).
Defects in mucosal defence (e.g. mucus secretion). ESSENTIAL MANAGEMENT
NSAIDs and the usual suspects: alcohol, cigarettes and stress! Medical
Infection with H. pylori. Avoid smoking and foods that cause pain.
Antacids for symptomatic relief.
Clinical features H2 blockers (ranitidine, cimetidine).
Duodenal ulcer and type II gastric ulcer PPIs (omeprazole).
(i.e. prepyloric and antral) Colloidal bismuth.
Male/female 4 : 1, peak incidence 2550 years. Ampicillin or tetracycline + metronidazole.
Epigastric pain during fasting (hunger pain), relieved by (These are effective against Helicobacter pylori.)
food/antacids, typically exhibits periodicity. Re-endoscope patients with gastric ulcer after 6 weeks because of risk
Boring back pain if ulcer is penetrating posteriorly. of malignancy.
Haematemesis from ulcer penetrating gastroduodenal artery
posteriorly. Surgical
Peritonitis if perforation occurs with anterior duodenal ulcer. Only indicated for failure of medical treatment and complications.
Vomiting if gastric outlet obstruction (pyloric stenosis) occurs Elective for duodenal ulcer: highly selective vagotomy; rarely
performed now.
(note succussion splash and watch for hypokalaemic, hypochlo-
Elective for gastric ulcer: Billroth I gastrectomy.
raemic alkalosis).
Perforated duodenal/gastric ulcer: simple closure of perforation and
biopsy.
Type I gastric ulcer (i.e. body of stomach)
Haemorrhage: endoscopic control by sclerotherapy, undersewing
Male/female 3 : 1, peak incidence 50+ years.
bleeding vessel vagotomy.
Epigastric pain induced by eating.
Pyloric stenosis: gastroenterostomy truncal vagotomy.
Peptic ulceration 89
39 Gastric carcinoma
TNM STAGING PROGNOSIS

N1 (Local,~3 cm) N2(Regional, 3 cm+) N3 (Distant)
Stage 5-year survival
1 T12 N0 M0 75%
2 T14 N12 M0 35%
3 T13 N13 M0 10%
4 T4 N3 M1 2%
T1 T2 T3 T4
Mucosal invasion Into muscularis Across muscularis Onto serosa/

propria propria organ invasion
SITES OF SPREAD
Infiltrating mass
Diaphragm
TYPES OF TUMOUR Retro-
peritoneum Spleen
Oesophageal
obstruction
Malignant polyp Malignant Pylorus
ulcer Pancreas
Pyloric obstruction
Linitus plastica
Transverse
TYPES OF OPERATION colon Omentum
PALLIATIVE TREATMENT
Gastrojejunostomy
Extent of
resection
Total gastrectomy Bilroth I partial Polya partial Laser therapy (oesophageal obstruction)
+ Roux-en-y gastrectomy gastrectomy Chemotherapy
oesophagojejunostomy Alcohol injection (bleeding)

Definition Anaemia.
Malignant lesion of the stomach epithelium. Dysphagia.
Vomiting.
Weight loss.
KEY POINTS The presence of physical signs usually indicates advanced
The majority of tumours are unresectable at presentation. (incurable) disease.
Tumours considered candidates for resection should be staged with
CT and laparoscopy to reduce the risk of an open and shut laparotomy. Investigations
Most tumours are poorly responsive to chemotherapy. FBC.
U+E.
LFTs.
Epidemiology OGD (see the lesion and obtain biopsy to distinguish from
Male/female 2 : 1, peak incidence 50+ years. Incidence has benign gastric ulcer).
decreased in Western world over last 50 years. Still common in Barium meal (space-occupying lesion/ulcer with rolled edge).
Japan, Chile and Scandinavia. Best for patients unable to tolerate OGD.
CT scan (helical): stages disease locally and systemically.
Aetiology Laparoscopy: used to exclude undiagnosed peritoneal or liver
The following are predisposing factors. secondaries prior to consideration of resection.
Diet (smoked fish, pickled vegetables, benzpyrene,
nitrosamines).
Atrophic gastritis.
Pernicious anaemia. ESSENTIAL MANAGEMENT
Previous partial gastrectomy. Palliation (metastatic disease or gross distal nodal disease at
Familial hypogammaglobulinaemia. presentation):
gastrectomy: local symptoms, e.g. bleeding;
Gastric adenomatous polyps.
gastroenterostomy: malignant pyloric obstruction;
Blood group A.
intubation: obstructing lesions at the cardia.
Curative treatment (resectable primary and local nodes).
Pathology
Surgical excision with clear margins and locoregional lymph node
Histology: adenocarcinoma.
clearance (D2 gastrectomy).
Advanced gastric cancer (penetrated muscularis propria) may
Other treatment: combination chemotherapy with etoposide,
be polypoid, ulcerating or infiltrating (i.e. linitus plastica). adriamycin and cisplatin may induce regression.
Early gastric cancer (confined to mucosa or submucosa).
Spread: lymphatic (e.g. Virchows node); haematogenous to
liver, lung, brain; transcoelomic to ovary (Krukenberg tumour).
Prognosis
Clinical features Following curative resection, 5-year survival rates are approx-
History of recent dyspepsia (epigastric discomfort, postpran- imately 20%, but overall 5-year survival (palliation and resec-
dial fullness, loss of appetite). tion) is only about 5%.
Gastric carcinoma 91
40 Malabsorption
FEATURES OF MICRONUTRIENT DEFICIENCIES
Crohn's
Vitamin A: K+/Na+/Ca2+/Mg2+:
disease
Nyctalopia Lethargy
Keratomalacia Weakness
Cramps
Vitamin K:
Blind loop Purpura
bacterial
Fe B12 Folate:
overgrowth
Intestinal Anaemia
resection
Giardiasis
Vitamins B1
Whipple's intestinal and B6:
lipodystrophy Peripheral
neuritis
Dermatitis
GROSSLY DISORDERED Cardiomyopathy
ARCHITECTURE Cu2+/Zn2+/Se:
Vitamins D Weakness
and Ca2+: Cardiac failure
Osteomalacia Poor wound
Amino acids healing
Fats
Calories
Micronutrients
Electrolytes
VILLOUS ATROPHY WITH Fluid volume
CRYPT HYPOPLASIA
Ischaemia
Irradiation NORMAL INTESTINAL ARCHITECTURE
Drug-induced
Toxin damage
VILLOUS ATROPHY WITH
Inadequate exocrine Enzymatic deficiencies
CRYPT HYPERPLASIA
input to gut Dissacharidases
Chronic Proteases
Coeliac disease pancreatitis
Post-infective Pancreatectomy
Tropical sprue Liver disease

Definition Presents with steatorrhoea associated with arthralgia and
Malabsorption is the failure of the body to acquire and conserve malaise.
adequate amounts of one or more essential dietary elements. The
cause may be localized or generalized. Bacterial overgrowth
Malabsorption caused by bacterial metabolism of nutrients
and production of breakdown products such as CO2 and H2.
KEY POINTS Usually a result of exclusion of a loop of ileum (e.g. in Crohns
Malabsorption usually affects several nutrient groups. disease, postsurgery, intestinal fistulation) with consequent bac-
Coeliac disease is a common cause and may present with obscure, terial overgrowth, although can occur in chronically damaged or
vague abdominal symptoms. dilated bowel.
Always consider micronutrients and trace elements in malabsorption.
Radiation enteropathy
Slow onset, progressive global malabsorption. Usually only if
Differential diagnosis large areas of ileum affected.
Coeliac disease May occur many years after original radiotherapy exposure.
Classically presents as sensitivity to gluten-containing foods
with diarrhoea, steatorrhoea and weight loss in early adulthood. Chronic ischaemic enteropathy
Mild forms may present later in life with non-specific symp- Rare cause of malabsorption. Usually accompanied by chronic
toms of malaise, anaemia (including iron deficiency picture), intestinal ischaemia causing mesenteric angina/claudication
abdominal cramps and weight loss. upon eating.
Crohns disease Parasitic infection

Commonest presenting symptoms are colicky abdominal Common in tropics but rare in the UK.
pains with diarrhoea and weight loss.
Malabsorption is an uncommon presenting symptom but often Key investigations
accompanies stenosing or inflammatory complications of wide- FBC, U+E, LFTs: general nutritional status.
spread ileal disease. Trace elements (Zn, Se, Mg, Mn, Cu).
Anti a-gliadin antibodies (serum assay for coeliac disease).
Intestinal resection Small bowel meal or enema: best for Crohns disease, radia-
Global malabsorption may develop after small bowel resection or ischaemic enteropathy and blind loop formation.
tions leaving less than 50 cm of functional ileum. Water and
electrolyte balance is most disordered but fat, vitamin and other
nutrient absorption is also affected with lengths progressively ESSENTIAL MANAGEMENT
less than 50 cm. Major deficiencies should be corrected by supplementation (oral or
Specific malabsorption may result from relatively small re- parenteral).
section (e.g. fat and vitamin B12 malabsorption after terminal Infectious causes should be excluded or (consider probiotics) treated
ileal resection, vitamin B12 and iron malabsorption after promptly.
Coeliac disease: gluten-free diet.
gastrectomy).
Crohns disease: usually requires resection of affected segment.
Course of systemic steroids or immunosuppressive agents may help.
Whipples disease (intestinal lipodystrophy)
Radiation or ischaemic malabsorption rarely responds to any medical
Fat malabsorption caused by intestinal infection blocking the
therapyboften requires parenteral nutrition.
lacteals with macrophages and bacteria.
Malabsorption 93
41 Crohns disease
Treatment Treatment
Medical Resection closure
Treatment Treatment
Resection
Resection Resection
Inflammatory
mass Fistula
Free perforation Enteroenteric
Enterovaginal
Enterocutaneous
Enterovesical
Abscess formation
'INFLAMMATORY TYPE'
Thickened
Bluish Spiral serosal vessels
Fat wrapping
'Cobblestoned mucosa'
Thickened mesentery
Narrowed lumen
Fleshy lymph nodes
Rake ulcers
Acute toxic colitis Fissures
Panenteritis
Fibrosis Non-caseating granulomas
Treatment
Crypt abscesses
Colectomy
Ulcer-associated cell lineage
'FIBROSTENOSING TYPE'
Obstruction
?Cancer
Complete/incomplete
Acute/subacute intermittent
Treatment
Strictureplasty
Haemorrhage
Resection
Loss of terminal ileal function

B12 deficiency
Balloon dilatation Bile salt loss ( gallstones)
Diarrhoea

Definition Chronic presentations
Crohns disease is a chronic transmural inflammatory disorder Stricturesbintermittent colicky abdominal pains associated
of the alimentary tract. with eating.
Malabsorption (due to widespread disease often with previous
resections).
KEY POINTS Growth retardation in children (due to chronic malnutrition
May present with acute, subacute or chronic manifestations. and chronic inflammatory response suppressing growth).
Perianal disease is common and may be the presenting feature.
Surgery is common but never curative and should be used sparingly Extraintestinal features
when necessary. Eye: episcleritis, uveitis.
Acute phase proteins, e.g. C-reactive protein (CRP)
Joints: arthritis.
Epidemiology Skin: erythema nodosum, pyoderma gangrenosum.
Male/female 1 : 1.6. Young adults. High incidence among Liver: sclerosing cholangitis, cirrhosis.
Europeans and Jewish people.
Perianal disease
Aetiology Fissure in ano, fistula in ano, perianal sepsis.
Unknown.
Impaired cell-mediated immunity. Investigations
Genetic link probable but candidate genes unknown. FBC: macrocytic anaemia.
No proven link to mycobacterial infection or measles virus Acute phase proteins, e.g. C-reactive protein (CRP)
hypersensitivity. Small bowel enema: narrowed terminal ileum, string sign of
Smoking associated with recurrence. Kantor, stricture formation, fistulae.
Abdominal ultrasound: RIF mass, abscess formation.
Pathology CT scan: RIF mass, abscess formation.
Macroscopic Indium-labelled white-cell scan: areas of inflammation.
May affect any part of the alimentary tract.
Skip lesions in bowel (affected bowel wall and mesentery are
thickened and oedematous, frequent fistulae). ESSENTIAL MANAGEMENT
Affected bowel characteristically fat wrapped by mesenteric Medical
fat. Nutritional support (enteral and parenteral feeding).
Perianal disease characterized by perianal induration and Anti-inflammatory drugs (salazopyrin, steroids).
sepsis with fissure, sinus and fistula formation. Antibiotics (only for specific complicating bacterial infections).
Immunosuppressive agents (azathioprine, cyclosporin A).
Histology
Transmural inflammation in the form of lymphoid aggregates. Surgical
Non-caseating epithelioid cell granulomas with Langhans For
giant cells. Regional nodes may also be involved. Complications (peritonitis, obstruction, abscess, fistula).
Failure of medical treatment and persisting symptoms.
Clinical features Growth retardation in children.
Acute presentations (uncommon) Principlesbresect minimum necessary.
RIF peritonitis (like appendicitis picture).
Generalized peritonitis (due to free perforation).
Prognosis
Subacute presentations (common) Crohns disease is a chronic problem, and recurrent episodes
RIF inflammatory mass (usually associated with fistulae or of active disease are common.
abscess formation). 75% of patients will require surgery at some time.
Widespread ileal inflammationbgeneral ill health, malnutri- 60% of patients will require more than one operation.
tion, anaemia, abdominal pain. Life expectancy of Crohns disease patients is little different
from the normal population.
Crohns disease 95
42 Acute appendicitis
Normal
Resolution
Treatment
Drainage
Occasional Closed
phlegmonous Operation
Abscess Antibiotics
Acute appendicitis Gangrenous Perforation
Peritonitis
Treatment Phlegmonous
Operation Inflammatory mass Treatment
Operation
Treatment
Antibiotics
Operation
DIFFERENTIAL DIAGNOSIS
Gastrointestinal Other abdominal EXTRA-ABDOMINAL
1
2 2
3
1 1
4
6
7
5 3 5
8
2
9 4
10
1 Cholecystitis 1 Renal colic Diabetes ketoacidosis

2 Perforated duodenal ulcer 2 Pyelonephritis Acute intermittent porphyria
3 Pancreatitis 3 Ovarian cyst Alcohol
4 Mesenteric adenitis 4 Ectopic pregnancy 1 Right lower lobe pneumonia
5 Small bowel ischaemia 5 Pelvic inflammatory disease 2 Herpes zoster
6 Ileal Crohn's disease
7 Salmonella typhlitis
8 Perforated caecal carcinoma
9 Ileal tuberculosis
10 Diverticulitis

Definition Investigations
Acute appendicitis is an inflammation of the vermiform appendix. Diagnosis is a clinical diagnosis, but WCC (almost always
leucocytosis) and CRP (usually raised) are helpful.
Ultrasound for appendix mass and if in doubt to rule out other
KEY POINTS pelvic pathology (e.g. ovarian cyst).
7 out of 10 cases of RIF pain in children under 10 are non-specific and Laparoscopy commonly used to exclude ovarian pathology
self limiting. prior to appendicectomy in young women.
The commonest differential diagnosis in young women is ovarian CT scan (helical) in elderly patients or where other causes are
pathology.
considered possible.
RIF peritonism over 55 years should raise the suspicion of other causes.
Cross-sectional imaging (CT) should be obtained whenever there is
Differential diagnosis
real concern about the differential diagnosis to prevent inappropriate
Mesenteric lymphadenitis in children.
surgical exploration.
Pelvic disease in women (e.g. pelvic inflammatory disease,
UTIs, ectopic pregnancy, ruptured corpus luteum cyst).
More rarely: Crohns disease, cholecystitis, perforated duode-
Epidemiology
nal ulcer, right basal pneumonia, torsion of the right testis, dia-
Commonest surgical emergency in the Western world. Rare
betes mellitus in younger and middle-aged patients.
under 2 years, common in second and third decades, but can
Occasionally: perforated caecal carcinoma, sigmoid divertic-
occur at any age.
ulitis, caecal diverticulitis in elderly patients.
Pathology
Obstructivebinfection superimposed on luminal obstruction
from any cause. ESSENTIAL MANAGEMENT
Acute appendicitis: appendicectomy, open or laparoscopic.
Phlegmonousbviral infection, lymphoid hyperplasia, ulcera-
Appendix mass: i.v. fluids, antibiotics, close observation. Then:
tion, bacterial invasion without obvious cause.
If symptoms resolve: interval appendicectomy after a few months.
If symptoms progress: urgent appendicectomy drainage.
Clinical features
Periumbilical abdominal pain, nausea, vomiting.
Localization of pain to RIF.
Mild pyrexia. Complications
Patient is flushed, tachycardia, furred tongue, halitosis. Wound infection.
Tender (usually with rebound) over McBurneys point. Intra-abdominal abscess (pelvic, RIF, subphrenic).
Right-sided pelvic tenderness on PR examination. Adhesions.
Peritonitis if appendix perforated. Abdominal actinomycosis (rare!).
Appendix mass if patient presents late. Portal pyaemia.
Acute appendicitis 97
43 Diverticular disease
Treatment Treatment Treatment

Conservative Laxatives Abs
((Emergency colectomy))
To
Pulse
Anaemia (rare)
Haemorrhage Painful diverticular disease Acute diverticulitis
Treatment Fistula May

Elective colectomy
+ fistula closure
To
Pulse
?Mass
Postinflammatory
stricture Phlegmon/
DIVERTICULAR DISEASE pericolic abscess Treatment
Abs
To CT
Pulse May
Treatment
Elective colectomy May
Treatment Purulent peritonitis

Surgery resection To
Pulse
?Hartmann's Anastomosis
May
Mass
To
Paracolic abscess Treatment
Pulse
Treatment Faecal peritonitis Abs
Surgery resection Drainage
?Hartmann's Anastomosis Surgery Guided
Closed

Definition Large bowel obstruction: absolute constipation, distension,
Diverticular disease (or diverticulosis) is a condition in which colicky abdominal pain and vomiting.
many sac-like mucosal projections (diverticula) develop in the Fistula: to bladder (cystitis/pneumaturia/recurrent UTIs); to
large bowel, especially the sigmoid colon. Acute inflammation vagina (faecal discharge PV); to small intestine (diarrhoea).
of a diverticulum causes diverticulitis. Lower GI bleed: painless spontaneousbdistinguish from
angiodysplasia.
KEY POINTS Investigations

The majority of diverticular disease is asymptomatic. Diverticulosis: barium enema (colonoscopy).
The majority of acute attacks are resolved by non-surgical Diverticulitis: FBC, WCC, U+E, chest X-ray, CT scan.
treatment. ?Diverticular mass/paracolic abscess: CT scan.
Emergency surgery for complications has a high morbidity and ?Perforation: plain film of abdomen, CT scan.
mortality and often involves an intestinal stoma. ?Obstruction: gastrograffin or dilute barium enema, colon-
Elective surgery should be reserved for recurrent proven symptoms oscopy to exclude underlying malignancy.
and complications (e.g. stricture). ?Fistula:
Diverticular strictures should be biopsied in case of underlying colon colovesicalbMSU, cystoscopy, barium enema;
carcinoma. colovaginalbcolposcopy, flexible sigmoidoscopy.
Haemorrhage: colonoscopy, selective angiography.
Epidemiology
Male/female 1 : 1.5, peak incidence 40s and 50s onwards. High ESSENTIAL MANAGEMENT
incidence in the Western world where it is found in 50% of Medical
people over 60 years. Painful or asymptomatic
High-fibre diet (fruit, vegetables, wholemeal breads, bran). Increase fluid
Aetiology intake.
Low fibre in the diet causes an increase in intraluminal colonic
Acute diverticulitis
pressure, resulting in herniation of the mucosa through the
Antibiotics and bowel rest.
muscle coats of the wall of the colon.
Radiologically guided drainage for localized abscess.
Weak areas in wall of colon where nutrient arteries penetrate
to submucosa and mucosa.
Surgical
Usually for complications/recurrent, proven, acute attacks or (rarely)
Pathology failed medical treatment.
Macroscopic Elective left colon surgery without peritonitis: resect diseased colon
Diverticula mostly found in (thickened) sigmoid colon. and rejoin the ends (primary anastomosis).
Emerge between the taenia coli and may contain faecoliths. Emergency left colon surgery with diffuse peritonitis: resect diseased
segment, oversew distal bowel (i.e. upper rectum) and bring out
Histological proximal bowel as end-colostomy (Hartmanns procedure).
Projections are acquired diverticula as they contain only Emergency left colon surgery with limited or no peritonitis: resect
mucosa, submucosa and serosa and not all layers of intestinal diseased segment and rejoin the ends (primary anastomosis) may be
wall. safe.
Complicated left colon surgery (e.g. colovesical fistula): resection,
Clinical features primary anastomosis (may have defunctioning proximal stoma).
Mostly asymptomatic.
Painful diverticulosis: LIF pain, constipation, diarrhoea.
Acute diverticulitis: malaise, fever, LIF pain and tenderness Prognosis
palpable mass and abdominal distension. Diverticular disease is a benign condition, but there is sig-
Perforation: peritonitis + features of diverticulitis. nificant mortality and morbidity from the complications.
Diverticular disease 99
44 Ulcerative colitis
15%
Total colitis EXTRA-INTESTINAL MANIFESTATIONS
25%
Left-sided colitis
Iritis
Conjunctivitis Seronegative
Scleritis arthritis
30%
Distal colitis Ankylosing spondylitis
30%
Proctitis
Chronic active
hepatitis
FEATURES
Primary biliary
Confluent ulceration cirrhosis
Hyperaemic mucosa
Serosal oedema Gallstones
Thinned walls
Pyoderma gangrenosum
Erythema nodosum
Mucosal slough
Crypt branching + distortion
Crypt microabscesses
Pseudopolyps (islands of residual mucosa)
Neutrophils
COMPLICATIONS
Acute Chronic
Toxic dilatation Stricture

perforation
Hypokalaemia
Hypoalbuminaemia Dysplasia carcinoma
Acute haemorrhage
Chronic blood loss anaemia

Definition skin: erythema nodosum, pyoderma gangrenosum (10%);
A chronic inflammatory disorder of the colonic mucosa, usually liver: pericholangitis, fatty liver (3%);
beginning in the rectum and extending proximally to a variable blood: thromboembolic disease (rare).
extent.
Severe/fulminant disease
620 bloody bowel motions per day.
Fever, anaemia, dehydration, electrolyte imbalance.
KEY POINTS
Colonic dilatation/perforationbtoxic megacolon.
The majority of colitis is controlled by medical managementbsurgery
is usually only required for poor control of symptoms or complications.
Acute attacks require close scrutiny to avoid major complications. Investigations
Long-term colitis carries a risk of colonic malignancy. FBC: iron deficiency anaemia.
Ileoanal pouch reconstruction offers good function in the majority of Stool culture: exclude infective colitis before treatment.
cases where surgery is required. Plain abdominal radiograph: colonic dilatation or air under
diaphragm indicating perforation in fulminant colitis.
Barium enema: loss of haustrations, shortened lead pipe colon.
Sigmoidoscopy: inflamed friable mucosa, bleeds to touch.
Epidemiology Colonoscopy: extent of disease at presentation, evaluation of
Male/female 1 : 1.6, peak incidence 3050 years. High incid- response to treatment after exacerbations, screening of long-
ence among relatives of patients (up to 40%) and among standing disease for dysplasia.
Europeans and Jewish people. Biopsy: typical histological features.
Aetiology
Genetic origin: increased prevalence (10%) in relatives, asso- ESSENTIAL MANAGEMENT
ciated with HLA-B27 phenotype. Medical
May have autoimmune basis. Basic: high-fibre diet, antidiarrhoeal agents (codeine phosphate,
Smoking protects against relapse! loperamide).
First-line: anti-inflammatory drugs (salazopyrin, 5 aminosalicylic acid
Pathology (5-ASA), corticosteroids).
Disease confined to colon, rectum always involved, may be Second-line: other immunosuppressive agents (azathioprine,
backwash ileitis. cyclosporin A).
Use enemas if disease confined to rectum.
Oral preparations for more extensive disease.
Macroscopic
i.v. immunosuppressives for acute exacerbations.
Only the mucosa is involved with superficial ulceration, exuda-
tion and pseudopolyposis.
Surgical
Indications
Histological
Failure of medical treatment to control chronic symptoms.
Crypt abscess, inflammatory polyps and highly vascular granula-
Complications: profuse haemorrhage, perforation/toxic megacolon,
tion tissue. Epithelial dysplasia with longstanding disease. risk of cancer (greater with longer disease, more aggressive onset and
more extensive disease).
Clinical features Dysplasia or development of carcinoma
Proctitis
Mucus, pus and blood PR. Operations
Diarrhoea with urgency and frequency. For acute attacks/complicationsbtotal colectomy, end ileostomy and
preserved rectal stump.
Left-sided colitis total colitis Electivelybproctocolectomy with end (Brooke) ileostomy or
Symptoms of proctitis + increasing features of systemic upset, proctocolectomy with preservation of anal sphincter and creation of
abdominal pain, anorexia, weight loss and anaemia with more ileoanal pouch (e.g. J-shaped pouch).
extensive disease.
Extraintestinal features Prognosis

Percentage involved: Ulcerative colitis is a chronic problem that requires constant
joints: arthritis (25%); surveillance unless surgery, which is drastic but curative, is
eye: uveitis (10%); performed.
Ulcerative colitis 101

45 Colorectal carcinoma
Right-sided Right
Elective hemicolectomy
5% Anaemia (bleeding)
Weight loss
Right iliac fossa mass Emergency
(rarely small bowel
15% obstruction) Right
Caecal hemicolectomy
Left-sided
10% Altered bowel habit Elective Left/sigmoid
Altered blood per hemicolectomy
rectum
Emergency
1/3 large bowel
20% obstruction Hartmann's
Sigmoid procedure
Altered bowel habit Anterior

Fresh blood per rectum resection
Either
Mucus per rectum
Tenesmus
Mass per rectum Abdomino-perineal
50% excision of rectum
Rectal
TYPES DUKE'S STAGE

T1 T2 T3 T4 Mucosa
Polyp A Confined to wall Submucosa
Musc. propria
Ulcer Serosa
B Through bowel wall
Mass
C Involved lymph nodes
(whatever the state
of the primary tumour)
Stricture
D Distant metastases

Definition Bleeding or passage of mucus PR.
Colorectal carcinoma (CRC) is the occurrence of malignant Tenesmus (frequent or continuous desire to defaecate)brectal
lesions in the mucosa of the colon or rectum. lesions.
Investigations
KEY POINTS Digital rectal examination and faecal occult blood.
Genetic factors play an important role in risk of CRC. FBC: anaemia.
Most colorectal cancers are left sided and produce symptoms of U+E: hypokalaemia, LFTs: liver metastases.
bleeding or altered bowel habit. Sigmoidoscopy (rigid to 30 cm/flexible to 60 cm) and colon-
Prognosis depends mainly on stage at diagnosis. oscopy (whole colon)bsee the lesion, obtain biopsy.
Surgery is the only curative treatment but radiotherapy and Double-contrast barium enemabapple core lesion, polyp.
chemotherapy are both useful adjuncts. CEA is often raised in advanced disease.
Epidemiology ESSENTIAL MANAGEMENT

Male/female 1.3 : 1, peak incidence 50+ years. Incidence has Surgery (potentially curative)
increased in Western world over last 50 years. Resection of the tumour with adequate margins to include regional
lymph nodes.
Aetiology
Procedures
Predisposing factors in decreasing importance:
Right hemicolectomy (no bowel preparation) for lesions from caecum
a prior CRC or adenomatous polyps;
to splenic flexure.
hereditary polyposis syndromes;
Left hemicolectomy (bowel preparation) for lesions of descending and
family history of CRC; or
sigmoid colon.
chronic active ulcerative colitis;
Anterior resection for rectal tumours.
diet (low in indigestible fibre, high in animal fat); Abdomino-perineal resection and colostomy for very low rectal lesions.
increased faecal bile salts, selenium deficiency. Hartmanns procedure for emergency surgery to left colon.
Resection possible for liver metastases if fewer than five are present.
Pathology
Macroscopic Surgery/interventions (palliative)
Polypoid, ulcerating, annular, infiltrative. Open resection of the tumour (with anastomosis or stoma) for
75% of lesions are within 60 cm of the anal margin (rectum, obstructing or symptomatic cancers despite metastases.
sigmoid, left colon). Surgical bypass for obstructing inoperable cancers.
3% are synchronous (i.e. a second lesion will be found at the Transanal resection for inoperable rectal cancer.
same time) and 3% are metachronous (i.e. a second lesion will be Intraluminal stents for obstructing cancers.
found later).
Other treatment
Histological Radiotherapy may be used to shrink rectal cancers preoperatively or
Adenocarcinoma (1015% are mucinous adenocarcinoma). palliate inoperable rectal cancer.
Staging by Dukes classification and TNM. Adjuvant chemotherapy (5-FU levamisole) to reduce risk of systemic
Spread: lymphatic, haematogenous (via veins to liver), recurrence (Dukes C and some Dukes B) or palliate liver metastases.
peritoneal.
Clinical features Prognosis

Anaemiabcaecal cancers often present with anaemia. 5-year survival depends on staging: A, 80%; B, 60%; C, 35%;
Colicky abdominal painbtumours which are causing partial D, 5%.
obstruction, e.g. transverse or descending colonic lesions. 25% 5-year survival after successful resections of <5 liver
Alteration in bowel habitbeither constipation or diarrhoea. metastases.
Colorectal carcinoma 103

46 Benign anal and perianal disorders
DIFFERENTIAL DIAGNOSES
BLOOD PER RECTUM LUMP IN ANUS
Diverticular SMALL
Angiodysplasia Perianal haematoma
disease
Skin tag
Haemorrhoid Wart
Carcinoma
Colitis Polyp LARGE

Rectal
carcinoma Anal carcinoma
Fissure
Haemorrhoids Polyp/prolapse
ANAL DISCHARGE PAIN
Prolapse Proctalgia fugax
Proctitis
Abscess
Fistula Perianal
Infections haematoma Fissure
Haemorrhoids
Haemorrhoids Thrombosed
Strangulated
ITCH
50% Idiopathic
25% Dermatological 25% Anal
Psoriasis Infections Inflammatory
Eczema Worms Haemorrhoids
Allergic dermatitis Candida Fistula
Warts Ulcerative proctitis
Gonorrhoea Crohn's disease
Haemorrhoids (piles) Aetiology

Definition Increased venous pressure from straining (low-fibre diet) or
A submucosal swelling in the anal canal consisting of a dilated altered haemodynamics (e.g. during pregnancy) causes chronic
venous plexus, a small artery and areolar tissue. Internal: only dilation of submucosal venous plexus.
involves tissue of upper anal canal. External: involves tissue of Found at the 3, 7 and 11 oclock positions in the anal canal.
lower anal canal.
Clinical features Second-line: botulinum toxin injection, lateral internal
First degree (1): bleeding/itching only. sphincterotomy.
Second degree (2): prolapse during defaecation. Examination under anaesthesia (EUA) and biopsy for
Third degree (3): constantly prolapsed. atypical/suspicious abnormal fissures.
Treatment Perianal abscess

Simple treatmentbbulk laxatives and high-fibre diet. Aetiology
Bleeding internal pilesbinjection sclerotherapy, Barrons Focus of infection starts in anal glands (cryptoglandular
bands, cryosurgery. sepsis) and spreads into perianal tissues to cause:
Prolapsing externalbhaemorrhoidectomy (complications: perianal abscess: adjacent to anal margin;
bleeding, anal stenosis). ischiorectal abscess: in ischiorectal fossa;
para-rectal abscess: above levator ani.
Rectal prolapse
Definition Clinical features
The protrusion from the anus to a variable degree of the rectal Painful, red, tender, swollen mass fever, rigors, sweating,
mucosa (partial) or rectal wall (full thickness). tachycardia.
Aetiology Treatment
Rectal intussusception, poor sphincter tone, chronic straining, Incision and drainage, antibiotics.
pelvic floor injury.
Fistula in ano
Clinical features Definition and aetiology
Mucous discharge, bleeding, tenesmus, obvious prolapse. Abnormal communication between the perianal skin and the
anal canal, established and persisting following drainage of a
Treatment perianal abscess. May be associated with Crohns disease (mul-
Stool manipulation and biofeedback, Delormes perianal muco- tiple fistulae), UC or TB.
sal resection, abdominal rectopexy (rectum is hitched up onto Low: below 50% of the external anal sphincter (EAS).
sacrum). High: crossing 50% or more of the EAS.
Perianal haematoma Clinical features

Very painful subcutaneous haematoma caused by rupture of Chronic perianal discharge, external orifice of track with granula-
small blood vessel in the perianal area. Evacuation of the clot tion tissue seen perianally.
provides instant relief.
Treatment
Anal fissure Low: probing and laying open the track (fistulotomy).
Definition High: seton insertion, core removal of the fistula track.
Longitudinal tear in the mucosa of the anal canal, in the midline
posteriorly (90%) or anteriorly (10%). Pilonidal sinus
Definition
Aetiology A blind-ending track containing hairs in the skin of the natal cleft.
90% caused by local trauma during passage of constipated
stool and potentiated by spasm of the internal anal sphincter. Aetiology
Other causes: pregnancy/delivery, Crohns disease, sexually Movement of buttocks promotes hair migration into a (?congen-
transmitted infections (often lateral position). ital) sinus.
Clinical features Clinical features

Exquisitely painful on passing bowel motion, small amount of May present as: a natal cleft abscess, a discharging sinus in mid-
bright red blood on toilet tissue, severe sphincter spasm, skin tag line posterior to anal margin with hair protruding from orifice,
at distal end of tear (sentinel pile). natal cleft itch/pain.
Treatment Treatment
First-line: stool softeners/bulking agents, local anaesthetic Good personal hygiene. Incision and drainage of abscesses,
(LA) gels, GTN ointment. excision of sinus network.
Benign anal and perianal disorders 105

47 Intestinal obstruction
Stasis Altered food Air swallowing PATHOPHYSIOLOGY

Mixed bacterial NH4HS2 N2 from vessels
overgrowth
Toxins DISTENSION Wall pressure
Initially hyperactive
Toxaemia Hypotonia
Continued FLUID ACCUMULATION Ischaemia
Acidosis secretions ALBUMIN
Leaky epithelium
Hypovolaemia
Hypokalaemia
Ascites
Distal bowel
Collapsed and quiescent
CAUSES SIGNS SYMPTOMS

Wall Without Dehydrated Vomiting
Tumour * Adhesions ** Septic/toxic
Stricture * Hernia **
Diverticular Volvulus
Ischaemia Caecal
Crohn's Sigmoid
Intussusception Small bowel
Lymphoma/nodes
Distended Distension
Within Tympanitic Colic
Bowel sounds
Gallstone Visible peristalsis Constipation
Faeces
Bezoar Oliguria
Foreign body Acidosis
Meconium Hypokalaemia
Hypoalbuminaemia
* = common

Definitions Clinical features
Complete intestinal obstruction indicates total blockage of the Vomiting, colicky abdominal pain, abdominal distension,
intestinal lumen, whereas incomplete denotes only a partial absolute constipation (i.e. neither faeces nor flatus).
blockage. Obstruction may be acute (hours) or chronic (weeks), Dehydration and loss of skin turgor.
simple (mechanical), i.e. blood supply is not compromised, or Hypotension, tachycardia.
strangulated, i.e. blood supply is compromised. A closed loop Abdominal distension and increased bowel sounds.
obstruction indicates that both the inlet and outlet of a bowel Empty rectum on digital examination.
loop is closed off. Tenderness or rebound indicates peritonitis.
Investigations
KEY POINTS
Hb, PCV: elevated due to dehydration.
Small bowel obstruction is often rapid in onset and commonly due to
WCC: normal or slightly elevated.
adhesions or hernia.
Large bowel obstruction may be gradual or intermittent in onset, is
U+E: urea elevated, Na+ and Cl low.
often due to carcinoma or strictures and NEVER due to adhesions. Chest X-ray: elevated diaphragm due to abdominal distension.
All obstructed patients need fluid and electrolyte replacement. Abdominal supine X-ray:
The cause should be sought and confirmed wherever possible prior to (a) small bowel (central loops, non-anatomical distribution,
operation. valvulae conniventes shadows cross entire width of lumen)
Tachycardia, pyrexia and abdominal tenderness indicate the need to or large bowel obstruction (peripheral distribution/haustral
operate whatever the cause. shadows do not cross entire width of bowel).
(b) look for cause (gallstone, characteristic patterns of vol-
vulus, hernias).
Common causes Single contrast large bowel enemab?large bowel obstructionb-
Extramural: adhesions, bands, volvulus, hernias (internal and site and cause.
external), compression by tumour (e.g. frozen pelvis). CT scanb?small bowel obstructionbsite and cause, sigmoid-
Intramural: inflammatory bowel disease (Crohns disease), oscopy to show site of obstruction.
tumours, carcinomas, lymphomas, strictures, paralytic: (ady-
namic) ileus, intussusception.
Intraluminal: faecal impaction, foreign bodies, bezoars, gall-
stone ileus. ESSENTIAL MANAGEMENT
Decompress the obstructed gut: pass nasogastric tube.
Pathophysiology Replace fluid and electrolyte losses: give Ringers lactate or NaCl with
Bowel distal to obstruction collapses. K+ supplementation.
Bowel proximal to obstruction distends and becomes hyper- Monitor the patientbfluid balance chart, urinary catheter, regular
active. Distension is due to swallowed air and accumulating temperature, pulse, respiration (TPR) chart, blood tests.
intestinal secretions. Request investigations appropriate to likely cause.
The bowel wall becomes oedematous. Fluid and electrolytes Relieve the obstruction surgically if:
underlying causes need surgical treatment (e.g. hernia, colonic
accumulate in the wall and lumen (third space loss).
carcinoma);
Bacteria proliferate in the obstructed bowel.
patient does not improve with conservative treatment (e.g. adhesion
As the bowel distends, the intramural vessels become stretched
obstruction); or
and the blood supply is compromised, leading to ischaemia and
there are signs of strangulation or peritonitis.
necrosis.
Intestinal obstruction 107

48 Abdominal hernias
TYPES
Epigastric
Incisional
(Para)umbilical
Gluteal (GSF) Spigelian

Sciatic (LSF)
Inguinal
Femoral Obturator Lumbar
SORTS
Reducible Irreducible Strangulated

(incarcerated) = impaired blood supply
Sliding Littr's Richter's Maydl's Prevascular

(Retroperitoneal (Meckel's diverticulum (Strangulated (Strangulated (Femoral)
contents in sac) content) unobstructed) above defect)
PRINCIPLES OF REPAIR
1 Identify anatomy Inguinal Femoral
2 Isolate sac
Reduce contents
Remove sac
3 Repair defect or
Mesh repair Plication darn

(Lichtenstein) (Shouldice)

Definition Inguinal hernias start off above and medial to the pubic tub-
A hernia is the protrusion of a viscus or part of a viscus through ercle but may descend broadly when larger, they usually accentu-
an abnormal opening in its coverings. ate the groin crease. Most are benign and have a low risk of
complications.
(a) Indirect inguinal hernias can be controlled by digital pres-
sure over the internal inguinal ring, may be narrow necked and
KEY POINTS
are common in younger men (3% per annum present with
Abdominal wall hernias are common and cause many
complications).
symptoms.
(b) Direct inguinal hernias are poorly controlled by digital
Femoral hernias are commoner in women than men but inguinal
pressure, are often broad necked and are commoner in older
hernia is the commonest hernia in women.
men (0.3% per annum strangulate).
All femoral hernias require prompt repair due to the risk of
Incisional hernias bulge, are usually broad necked, poorly
complications.
Inguinal hernias may be repaired depending on symptoms.
controlled by pressure and are accentuated by tensing the recti.
Large, chronic incisional hernias may contain much of the small
bowel and may by irreducible/unrepairable due to the loss of the
right of abode in the abdomen of the contents.
Types True umbilical hernias are present from birth and are symmet-
Common rical defects in the umbilicus due to failure to close.
Umbilical/para-umbilical. Para-umbilical hernias develop due to an acquired defect in
Inguinal (direct and indirect). the periumbilical fascia.
Femoral.
Incisional.
Assess the hernia for: severity of symptoms, risk of complications (type,
Uncommon
size of neck), ease of repair (size, location), likelihood of success (size,
Epigastric.
loss of right of abode).
Gluteal, lumbar, obturator.
Assess the patient for: fitness for surgery, impact of hernia on lifestyle
(job, hobbies).
Pathophysiology Surgical repair is usually offered in suitable patients for:
The defect in the abdominal wall may be congenital (e.g. (a) hernias at risk of complications whatever the symptoms;
umbilical hernia, femoral canal) or acquired (e.g. an incision) (b) hernias with previous symptoms of obstruction;
and is lined with peritoneum (the sac). (c) hernias at low risk of complications but symptoms interfering with
Raised intra-abdominal pressure further weakens the defect lifestyle, etc.
allowing some of the intra-abdominal contents (e.g. omentum,
small bowel loop) to migrate through the opening. Principles of surgery
Entrapment of the contents in the sac leads to incarceration Herniotomy: excision of the hernial sac.
(unable to reduce contents) and possibly strangulation (blood Herniorrhaphy: repairing the defect.
supply to incarcerated contents is compromised).
Clinical features Complications of surgery

Patient presents with a lump over the site of the hernia. Haematoma (wound or scrotal).
Femoral hernias are below and lateral to the pubic tubercle, Acute urinary retention.
they usually flatten the groin crease and are 10 times more com- Wound infection.
mon in women than men. 50% present as a surgical emergency Chronic pain.
due to obstructed contents and 50% of these will require a small Testicular pain and swelling leading to testicular atrophy.
bowel resection. Femoral hernias are irreducible. Hernia recurrence (about 5%).
Abdominal hernias 109

49 Gallstone disease/1
Causes and Cardinal symptoms Structure involved (diagnosis)

symptoms and signs Gallbladder CBD Other
A Presence Pain Biliary Biliary
of stone Nausea colic (ductal)
Irritation Vomiting colic
Contraction Tender RUQ May
May
B Obstruction As above + Mucocele Obstructive
of structure Persistence jaundice
(simple) of pain etc.
Mass RUQ May
May
(jaundice)
C Obstruction As above + Empyema Cholangitis
of structure Swinging fever May
(+ infection) Tachycardia perforate
Neutrophilia Biliary
Rigors peritonitis
D Inflammation/ As for A + Cholecystitis (Cholangitis) Pancreatitis
infection Fever
Tachycardia
Neutrophilia
Other conditions associated with gallstones
Gallstone ileus CAUSES
Adenocarcinoma gallbladder
Abnormal
Infection/ anatomy
TYPES OF GALLSTONES stasis
Cholesterol 20%
Solitaire Mulberry Crystalline

Diabetes mellitus 100 0
structure
Pregnancy Cholesterol
Bile pigments 5% Diet Lecithin
%
Genetics %
Pigment 'Jacks'
0 Sol 100
Haematological disease 100 Bile acids % 0
Mixed 75%
Faceted Concentric Crohn's
structure Altered bile composition

Definition Stone obstruction at the gallbladder neck with superimposed
Gallstones are round, oval or faceted concretions found in the infection leads to cholecystitis.
biliary tract. They contain cholesterol, calcium carbonate, cal- Obstruction of the common bile duct (CBD) with superim-
cium bilirubinate or a mixture of these elements. posed infection leads to septic cholangitis.
Migration of a large stone into the gut may cause intestinal
obstruction (gallstone ileus).
KEY POINTS
Gallstones are common and not all causes of RUQ pain with an Clinical features
ultrasound scan showing stones are due to gallstones. 90% of gallstones are (probably) asymptomatic.
An episode of obstructive jaundice, deranged LFTs or acute Biliary colic: severe colicky upper abdominal pain radiating
pancreatitis or a dilated common bile duct on ultrasound scan suggests around the right costal margin vomiting. Periodicity of hours,
the presence of common bile duct stones. often onset at night spontaneously resolves after several hours.
An attack of acute pancreatitis, cholangitis or obstructive jaundice is Differential diagnosis includes myocardial infarction, peptic
usually an indication for prophylactic cholecystectomy. ulcer exacerbation, GORD.
Chronic cholecystitis: uncertain diagnosis suggested by vague,
intermittent right upper abdominal pain, distension, flatulence,
Epidemiology fatty food intolerance. May indicate recurrent mild episodes of
Male/female 1 : 2. Age 40s onwards. High incidence of mixed cholecystitis. Differential diagnosis includes chronic PUD, GORD.
stones in Western world. Pigment stones commoner in the Acute obstructive cholecystitis: constant right hypochondrial
East. pain, pyrexia, nausea jaundice. Tender in RUQ with positive
Murphys sign. Leucocytosis. Unresolved may lead to an
Pathogenesis empyema of the gallbladder. Differential diagnosis includes
Cholesterol stones: imbalance in bile between cholesterol, bile myocardial infarction, basal pneumonia, pancreatitis, appen-
salts and phospholipids, producing lithogenic bile. Associated dicitis, perforated peptic ulcer, pulmonary embolus.
with inflammatory bowel disease. Cholangitis: abdominal pain, high fever/rigors, obstructive
Bilirubinate stones: chronic haemolysis, infection with - jaundice (Charcots triad), severe RUQ tenderness. Differential
glucuronidase-producing bacteria. diagnosis includes myocardial infarction, basal pneumonia, pan-
Mixed stones: associated with anatomical abnormalities, creatitis, acute hepatitis.
stasis, previous surgery, previous infections. Obstructive jaundice: upper abdominal pain, pale/claylike
stools, dark brown urine, pruritus. May progress into cholangitis
Pathology if CBD remains obstructed.
Gallstones passing through the biliary system may cause bili- Pancreatitis (see p. 114): central/epigastric pain, back pain,
ary colic or pancreatitis. fever, tachycardia, epigastric tenderness.
Gallstone disease 111

Gallstone disease/2
GALLBLADDER COMMON BILE DUCT
IRRITATION ONLY Biliary (ductal) colic
Biliary colic
May
May
SIMPLE OBSTRUCTION
Obstructive jaundice
Mucocele
May
OBSTRUCTION
+ INFECTION May
Cholangitis
Empyema
SIMPLE INFECTION
Other:
Pancreatitis
Cholecystitis Gallstone ileus
Adenocarcinoma gallbladder

Investigations ESSENTIAL MANAGEMENT
FBC: acute inflammatory complications, picture of haemo- Asymptomatic: no treatment required unless diabetic or
lytic anaemias underlying. undergoing major immunosuppression (risk factors for cholecystitis).
U+E. Biliary colic: elective cholecystectomy, now usually performed
LFTs: obstructive jaundice pattern. laparoscopically, for classic symptoms with ultrasound-proven
Plain X-ray of the abdomen shows only 10% of gallstones. gallstones.
Ultrasound: 90% of gallstones will be detected on ultrasound Chronic cholecystitis: elective laparoscopic cholecystectomy only if no
examination. Assesses CBD size and possible presence of CBD evidence of PUD or other causes for symptoms.
stones. Acute cholecystitis: i.v. fluids, antibiotics, early or interval
Rarely are other investigations, such as oral cholecystography, cholecystectomy.
intravenous cholangiography or HIDA scanning, required Empyema: percutaneous (ultrasound- or CT-guided) drainage of the
(ultrasound impossible, e.g. obesity). gallbladder and interval cholecystectomy.
Endoscopic retrograde cholangiopancreatography (ERCP)b Ascending cholangitis: i.v. fluids, antibiotics, ductal drainage (now
suspected or proven CBD stones. Allows stones removal or stent usually by ERCP, sphincterotomy and extraction of stones).
to be placed to bypass any risk of obstruction from the stones.
OGD: to exclude PUD as a cause for uncomplicated disease Complications of cholecystectomy
Leakage of bile from cystic duct or gallbladder bed.
symptoms.
Jaundice due to retained ductal stones. (Retained stones can be
treated by ERCP or if a T-tube is in place by extraction with a Dormia
basket down the T-tube track (Burhenne manoeuvre).)
Injury to the CBD.
Gallstone disease 113

50 Pancreatitis
CBD obstruction Insulin diabetes mellitus Ranson's criteria ITU Death

1 WCC > 16 R1 02 2% 2%
Fibrosis pain 2 Hb 10% R2 34 20% 20%
3 Ur R3 56 50% 40%
4 Alb R4 78 100% 90%
Inflammation pain (post meals) 5 Ca < 2
weight loss 6 LDH > 350
CHRONIC Enzymes steatorrhoea 7 AAT > 250
8 Fluid > 6000 ml
9 Gluc > 10
Aspiration 10 BE < -4
Treatment
11 PaO2 < 8
O2
11 ARDS 12 Age > 55
Physiotherapy
Support Albumin 4
V/Q mismatch Collapse Calcium 5
Myocardial Glucose 9
Effusion depression Triglycerides
Cerebral dysfunction Acidosis 10
Biochemistry
Necrotic
3 ATN
Treatment
i.v. fluids
ACN Haemorrhagic
DIC
2 Anaemia DVT Abscess with
1 Leucocytosis infection
Liver dysfunction
6,7
Gastric stasis
8 Stress ulceration Chronic

Inflammatory ascites pseudocyst
Infection Treatment
Treatment Ileus Haemorrhage Endoscopic
Naso-gastric tube Gastric obstruction gastrocystectomy
H2 blockers Mesenteric thrombosis Failure to resolve Open
Nil by mouth gastrocystectomy
i.v. fluids Guided drainage

Definition Severe/necrotizing pancreatitis: severe upper abdominal pain,
An inflammatory condition of the exocrine pancreas that results signs of hypovolaemic shock, respiratory and renal impairment,
from injury to the acinar cells. It may be acute or chronic. silent abdomen, retroperitoneal bleeding with flank and umbil-
ical bruising (Grey Turners and Cullens signs).
KEY POINTS
Most pancreatitis is mild and spontaneously resolves. ESSENTIAL MANAGEMENT
All patients should have a cause sought by imaging and the severity Attempt to confirm diagnosis: (serum amylase > 1000 i diagnosticb
assessed by recognized criteria. may be clinical diagnosis).
A normal or mildly elevated serum amylase does NOT exclude Assess disease severity (Imrie/Ranson criteria).
pancreatitis. Severe is 3+ of the following: WBC >16 109/l, PaO2 <7.98 kPa, B
Severe or complicated pancreatitis may worsen rapidly and require ICU glucose > 11.2 mmol/l, LDH >350 IU/l, SGOT > 250 IU/l, PCV fall >
support. 10%, urea > 1.8, Ca2+ < 2.0 mmol/l.
Surgery has little place other than to treat severe complications. Resuscitate the patient:
Mild/moderate disease: i.v. fluids, analgesia, monitor progress with
pulse, BP, temperature.
Severe pancreatitis: full resuscitation in ICU with invasive
Aetiology monitoring.
Gallstones and alcohol abuse account for 95% of cases of Establish the cause: ultrasound to look for gallstones.
acute pancreatitis.
Other causes include: idiopathic, congenital structural abnorm- Further management
alities, drugs, viral infections, hypercalcaemia, hypothermia, No proven use for routine nasogastric tube or antibiotics.
hyperlipidaemia and trauma. ?Vitamin supplements and sedatives if alcoholic cause.
Proven CBD gallstones may require urgent ERCP.
Pathology Failure to respond to treatment or uncertain diagnosis warrants
Acute abdominal CT scan.
Mild injury: acinar(exocrine) cell damage with enzymatic Suspected/proven infection of necrotic pancreasbantibiotics
spillage, inflammatory cascade activation and localized oedema. surgical debridement.
Local exudate may also lead to increased serum levels of pan-
creatic enzymes (amylase, lipase, colipase).
Moderate injury: increasing local inflammation leads to intra- Complicationscacute pancreatitis
pancreatic bleeding, fluid collections and spreading local oedema Acute
involving the mesentery and retroperitoneum. Activation of the Pancreatic abscess: usually necrotic pancreas present.
systemic inflammatory response leads to progressive involve- Intra-abdominal sepsis.
ment of other organs. Necrosis of the transverse colon.
Severe injury: progressive pancreatic destruction leads to Respiratory (ARDS) or renal (ATN) failure.
necrosis, profound localized bleeding and fluid collections Pancreatic haemorrhage.
around the pancreas. Spread to local structures and the peritoneal
cavity may result in mesenteric infarction, peritonitis and intra- Subacute/chronic
abdominal fat saponification. Pseudocyst formation: may need to be drained internally or
A persisting accumulation of inflammatory fluid, usually in the externally.
lesser sac, is a pseudocyst, i.e. does not have an epithelial lining. Chronic pancreatitis.
Chronic Chronic pancreatitis

Recurrent episodes of acute inflammation lead to progressive Usually caused by chronic alcohol abuse.
destruction of acinar cells with healing by fibrosis. Incidental Presents with intractable abdominal pain and evidence of
islet cell damage may lead to endocrine gland failure. exocrine pancreatic failure (steatorrhoea) and eventually dia-
betes as well.
Clinical features Medical treatment is with analgesia and exocrine pancreatic
Mild/moderate pancreatitis: constant upper abdominal pain enzyme replacement. Surgical treatment is by drainage of
radiating to back, nausea, vomiting, pyrexia, tachycardia dilated pancreatic ducts or excision of the pancreas in some
jaundice. cases.
Pancreatitis 115
51 Pancreatic tumours
Treatment Pain (direct spread Metastases

Coeliac nerve to coeliac nerves)
ablation
Malabsorption
(loss of tissue)
Diabetes mellitus Anergia
Treatment (loss of islets) Anorexia
Enzyme supplements
Treatment
Presents Treatment
Insulin supplements
Presents Palliative (very rarely
opportunity to remove
early tumours)
Tail
Ampullary Body
Head
Presents Presents
Cholangitis Obstructive jaundice

Treatment Treatment
Potentially curable Potentially curable
Whipple's Rarely pancreatitis
pancreatico-duodenectomy Rarely duodenal
Obstructive jaundice obstruction
Rarely pancreatitis
Treatment
Palliative treatment Palliative treatment

for jaundice/cholangitis for jaundice
ERCP + stent insertion

or percutaneous
transhepatic stent insertion Gastroenterostomy

Definitions Occasionally duodenal obstruction causing vomiting.
Pancreatic adenocarcinoma is a malignant lesion of the head, Body: back pain, anorexia, weight loss, steatorrhoea.
body or tail of the pancreas. Periampullary carcinomas arise Tail: often presents with metastases, malignant ascites or
around the ampulla of Vater and include tumours arising from unexplained anaemia.
the pancreas, duodenum, distal bile duct and the ampulla itself.
Endocrine pancreatic tumours cause a variety of syndromes sec- Investigations
ondary to the secretion of active peptides. Ultrasound: may see mass in head of pancreas and distended
biliary tree, facilitates needle biopsy.
CT scan: demonstrates tumour mass, facilitates biopsy, assess
KEY POINTS involvement of surrounding structures and local lymph node
Most pancreatic cancer is not surgically curable. spread.
New, chronic back pain and vague symptoms may be the only ERCP: very accurate in making diagnosis; obtain specimen
presenting feature. or shed cells for cytology and stent may be placed to relieve
The best prognosis is for true periampullary cancers. jaundice.
Good palliation of jaundice is possible without surgery. Barium meal: widening of the duodenal loop with medial
filling defect, the reversed 3 sign.
Epidemiology
Male/female 2 : 1, peak incidence 5070 years. Incidence of ESSENTIAL MANAGEMENT
pancreatic carcinoma is increasing in the Western world. Palliation
Pancreatic adenocarcinoma is usually incurable at time of diagnosis.
Aetiology Jaundice can be relieved by placing a stent through the tumour either
Predisposing factors: smoking, diabetes, chronic pancreatitis. transhepatically or via ERCP.
Duodenal obstruction may be relieved by gastrojejunostomy.
Pathology Pain may be helped with a coeliac axis block.
Site: 55% involve head of pancreas, 25% body, 15% tail, 5%
periampullary region. Curative treatment
Macroscopic: growth is hard and infiltrating. Rarely surgical (Whipples) resection of small tumours of the head of the
Histology: 90% ductal carcinoma, 7% acinar cell carcinoma, pancreas is curative if lymph nodes are not involved.
2% cystic carcinoma, 1% connective tissue origins.
Spread: lymphatics to peritoneum and regional nodes, via
bloodstream to liver and lung. Metastases often present at time Prognosis
of diagnosis. 90% of patients with pancreatic adenocarcinoma are dead
within 12 months of diagnosis.
Clinical features It is important to obtain histology from tumours around the
Head or periampullary: painless, progressive jaundice with a head of the pancreas as the prognosis from non-pancreatic peri-
palpable gallbladder (Courvoisiers law: a palpable gallbladder ampullary cancers is considerably better (50% 5-year survival)
in the presence of jaundice is unlikely to be due to gallstones). following resection.
Pancreatic tumours 117

52 Benign breast disease
CAUSES OF GYNAECOMASTIA
Hormones Drugs
Teratoma -HCG Oestrogenic Anti-androgens Cytotoxics
Adrenal tumour E2 Digoxin Cyproterone Vincristine
Acromegaly GH Cannabis Cimetidine
Prolactinoma Prolactin Diamorphine Spironolactone
Cushing's Cortisol
Metabolic Liver
Thyroid Primary biliary cirrhosis
Hyper T4 Cirrhosis
Alcohol
Kidney
CRF
FEATURES OF FIBROCYSTIC DISEASE AND RELATIONSHIP TO PRESENTATIONS
Breast cysts Cyclical painful breasts Single breast lump

(Single or multiple) (mastalgia)
('Cystic mastopathy')
1/3 Single
1/3 24
1/3 5+
Adenosis
Generalized 'lumpy' breast
Cyst formation
Fibrocystic
disease
Lymphocytic infiltration
Fibrosis
Nipple discharge Ductal epitheliosis 'Radial scar' on

mammography

ANDI Treatment is with antibiotics (flucloxacillin) initially but, if
Definition an abscess develops, incision and drainage will be required.
Abnormalities of the Normal Development and Involution of the Lactation/breast feeding does not need to be suppressed while
breastba broad term covering benign conditions many of which the abscess is being treated.
have overlapping features.
Mammary duct ectasia
Abnormalities of development Dilated subareolar ducts are filled with cellular debris which
Fibroadenoma causes a periductal inflammatory response. Associated with
Benign breast lump caused by overgrowth of single breast smoking and recurrent non-lactational abscesses. The usual pre-
lobule. Manifests as one or more firm, mobile, painless lumps sentation is a green nipple discharge and a subareolar lump.
usually in women under 30 years. Treatment is by subareolar excision of the involved ducts.
Investigation: triple assessment (clinical/radiological/
cytological) (see p. 121). Duct papilloma
Treatment: Small papillomas arise in the major breast ducts. They cause a
age <30 either observe or excise if worried; bloody or serous nipple discharge.
age >30 excise to exclude malignancy. Treatment is by excision of the affected duct by
microdochectomy.
Abnormalities of cycles
Fibrocystic disease Fat necrosis
Usually presents age 2545 years. May present as breast pain, A fibrous scar in the breast tissue caused by injury, haematoma
tenderness, breast lump(s), breast cyst(s), especially during the and necrosis of breast fat with subsequent scarring. History of
second half of the menstrual cycle. trauma to the breast in 50% of cases. May be associated with
Investigation: triple assessment of all lumps. superficial ecchymoses. Histology: periductal cellular infiltrate
Treatment: patient reassurance, analgesics, -linoleic acid, and fibrosis.
hormone manipulation., cyst aspiration, excision of persistent Investigation: triple assessment.
localized masses after aspiration. Avoid xanthine-containing Treatment: usually surgical excision to exclude malignancy.
substances (coffee).
Abnormalities of involution KEY POINTS

Breast cyst Any breast lump should be evaluated by triple assessment for risk of
May be single or multiple. Firm, round discrete lump(s). malignancy whatever the likely diagnosis.
Investigation: aspiration mammography. Triple assessment ANDI disorders are common in younger, premenopausal women and
often cause considerable anxiety.
for any discrete associated lumps.
Gynaecomastia is usually physiological but often needs to be
Treatment: reassurance, aspiration (repeated), hormone
investigated for hormonal causes.
manipulation.
Other benign conditions

Breast abscess
Usually infection of the pregnant or lactating breast with
Staphylococcus aureus. Patient presents with redness, swelling,
heat and pain in the breast.
Benign breast disease 119

53 Breast cancer
PREDISPOSITIONS LOCATION
GENETIC HORMONAL
FHx Low, late parity
BrCa1 Anovulatory cycles
Cancer 15% 45%
BrCa2 Postmenopausal oestrogen
Caucasian
5% 10%
o
IRRADIATION
25%
retroalveolar
or central
STAGING
CARDINAL SIGNS
Lymph nodes
I Unfixed II Unfixed III Fixed IV Metastases

+ nodes + nodes
Painless
Fixed
Tumour Nodes Metastases Hard
IS In situ
0 Impalpable None None
1 < 2 cm Unfixed Present

Homolateral
NIPPLE CHANGES
2 25 cm Fixed IN BREAST CANCER
Homolateral
3 510 cm Contralateral Destroyed

or clavicular o
Deviated
4 > 10 cm
Displaced
Chest wall
fixed Depressed
Ulceration = T + 1 Discoloured
Discharging blood

Definition Radiological assessment: mammography (ultrasound in
Malignant lesion of (predominantly) the female breast. young women with dense or large breasts). Features on
mammography: irregular, spiculated, radio-opaque mass with
microcalcification.
KEY POINTS Cytological assessment: FNAC or core biopsy.
All breast lumps require triple assessment. Breast biopsy: excision biopsy occasionally required for
Early breast cancer can be effectively treated in many cases. diagnosis.
Early breast cancer treatment is aimed at local control/lymph node Staging investigations for proven carcinoma:
treatment and prevention of systemic relapse. all: chest X-ray, FBC, serum alkaline phosphatase, -glutamyl
Treatment of late breast cancer is usually palliative and mostly medical. transpeptidase, serum calciumb(suggest liver or bone
metastases);
if clinically indicated: isotope bone scan, ultrasound scan of
Epidemiology liver, brain CT scan.
Male/female 1 : 100. Any age (usually >30 years). High incid- Breast tissue for hormone receptor status (ER), important for
ence in Western world and in white population more than black treatment and prognosis.
population.
Aetiology
Predisposing factors:
Early breast cancer
strong family history of breast cancer (genetic factors);
(No evidence of distant spread at time of diagnosis.)
early menarche and late menopause, especially in nulliparous Local treatment is usually either:
women; lumpectomy + radiotherapy to breast; or
social class I and II. simple mastectomy.
Treatment for axillary lymph nodes is usually either:
Pathology axillary dissection (at time of surgery) and removal; or
Histology: adenocarcinomas arising from the glandular epi- radiotherapy to axilla.
thelium. Common types are invasive ductal or lobular carcinoma. Prevention of systemic spread is usually either:
Pagets disease is ductal carcinoma involving the nipple. hormonal therapy (e.g. tamoxifen); or
Spread: lymphatics, vascular invasion, direct extension; adjuvant chemotherapy (cyclophosphamide, methotrexate,
spreads to lung, liver, bone, brain, adrenal, ovary. 5-FU) if high risk (positive lymph nodes, bad histological features).
Staging: TNM classificationbimportant for treatment and Prognosis depends on lymph nodes status, tumour size and
prognosis. histological grade: overall 80% 10-year survival rate.
Clinical features Late breast cancer

Palpable, hard, irregular, fixed breast lump, usually painless. (Distant spread at time of diagnosis.)
Nipple retraction and skin dimpling. Local treatment is directed at controlling local recurrenceb
Nipple eczema in Pagets disease. lumpectomy/mastectomy/radiotherapy.
Distant metastases: radiotherapy to relieve pain from bony metastases,
Peau dorange (cutaneous oedema secondary to lymphatic
chemotherapy (tamoxifen, cytotoxics, aminoglutethamide) to control
obstruction).
tumour load.
Palpable axillary nodes.
Prognosis: poor, only 3040% respond to treatment with mean
survival of 2 years, by which time the non-responders have usually
Investigations died.
Triple assessment: clinical/radiological/cytological.
Breast cancer 121

54 Goitre
Poor concentration Lid lag

HYPERTHYROIDISM
Fine alopecia Lid retraction
Excitement Exophthalmos
SECONDARY Occulomotor palsies
Pituitary adenoma Blinking
Glitter eyes/chemosis
Thyroid bruit Tremor
Sweaty
Flushed
Atrial Tachycardia
fibrillation High pulse
PRIMARY pressure
Graves' disease Weight loss Hyper-reflexia
(TSAbs) Diarrhoea
Heat intolerance
Plummer's disease
(toxic nodule)
Adenoma
(Cyst)
((Carcinoma)) Pretibial mxyoedema
HYP0THYROIDISM
Poor work Hair loss
Lassitude Thin eyebrows
Slow mentation Puffy eyelids
Idiopathic senile atrophy
Coarse dry skin
Pallor
Hoarse voice
PRIMARY Bradycardia
Autoimmune Hypotension
(Hashimoto's)
Hyporeflexia
Weight gain Bradykinesia
SECONDARY Constipation
Pituitary failure
Cold intolerance
Proximal myopathy
TERTIARY
Hypothalamic failure
Peripheral oedema
Enzyme failures (congenital)

A goitre is an enlargement of the thyroid gland from any cause. Hyperthyroidism
Symptoms
Heat intolerance and excessive sweating.
KEY POINTS Increased appetite, weight loss, diarrhoea.
Toxic goitres are rarely malignant. Anxiety, tiredness, palpitations.
All solitary nodules need investigation to exclude carcinoma. Oligomenorrhoea.
Surgery is rarely necessary in autoimmune or inflammatory thyroid
disease. Signs
Goitre.
Exophthalmos, lid lag and retraction.
Warm moist palms, tremor.
Common causes
Atrial fibrillation.
Physiological: gland increases in size as a result of in-
Pretibial myxoedema.
creased demand for thyroid hormone at puberty and during
pregnancy.
Hypothyroidism
Iodine deficiency (endemic): deficiency of iodine results in
Symptoms
decreased T4 levels and increased TSH stimulation leading to a
Cold intolerance, decreased sweating.
diffuse goitre.
Hoarseness.
Primary hyperthyroidism (Graves disease): goitre and thyro-
Weight increase, constipation.
toxicosis due to circulating immunoglobulin LATS.
Slow cerebration, tiredness.
Adenomatous (nodular) goitre: benign hyperplasia of the thy-
Muscle pains.
roid gland.
Thyroiditis: autoimmune (Hashimotos); subacute (de
Signs
Quervains); Riedels (struma).
Pale/yellow skin, dry, thickened skin, thin hair.
Thyroid malignancies.
Periorbital puffiness, loss of outer third of eyebrow.
Dementia, nerve deafness, hyporeflexia.
Slow pulse, large tongue, peripheral oedema.
I N V E S T I G AT I O N S A N D E S S E N T I A L M A N A G E M E N T
Clinically toxic goitre: I123 scan

Single adenoma Diffuse usually = Graves disease Multinodular goitre

Medical treatment Medical: antithyroid drugs: carbimazole (side-effect Medical treatment: antithyroid drugs.
until euthyroid leucopenia), propranolol, radioactive iodine.

Subtotal thyroidectomy indicated

Lobectomy. Subtotal thyroidectomy indicated for: poor response or for: cosmesis, pressure symptoms.
contraindicated medical treatment, cosmesis, pressure symptoms.
Solitary nodule: FNAC

Colloid cyst

Simple cyst Follicular cells (adenoma or carcinoma) Papillary carcinoma

Repeat FNAC to confirm diagnosis. <4 cm: reassure. Lobectomy Treatment, see p. 125.

Surgery only for cosmesis of >4 cm: lobectomy

pressure symptoms (small risk of carcinoma). Proceed to completion total
thyroidectomy if follicular carcinoma.
Other causes
Physiological: reassurance.
I2 deficiency (endemic): supplemental iodine in the diet.
Thyroiditis.
Autoimmune (Hashimotos): anti-inflammatories, thyroid replacement therapy if becomes hypothyroid.
Subacute (de Quervains): simple analgesia, sometimes steroids.
Riedels (struma): resection only for compression symptoms.
Goitre 123
55 Thyroid malignancies
THE 'SOLITARY NODULE' COMPLICATIONS OF THYROIDECTOMY
Bleeding
Intraoperative Thyrotoxic storm
(toxic glands)
FNAC Laryngeal oedema
Pneumothorax
Colloid Follicular Papillary Simple

cyst neoplasm carcinoma cyst Hypocalcaemia
Early Haematoma
< 4cm Recurrent laryngeal
Repeat Consider See nerve palsy
FNAC lobectomy p.125 > 4cm
Lobectomy
Hypothyroidism
Surgery Late Recurrence of thyroid
only for disease
symptoms
or
cosmesis
SPREAD
SLN Liver
Weak voice
Pharynx Brain
Dysphagia
Lungs
Internal jugular Trachea Bone

Jugulodiagastric Stridor
RLN Adrenals
Para-aortic Haemoptysis
Weak voice
Cough
Lymph Local Blood

Malignant lesions of the thyroid gland. Papillary: solitary thyroid nodule.
Follicular: slow-growing thyroid mass, symptoms from dis-
tant metastases.
KEY POINTS
Anaplastic: rapidly growing thyroid mass causing tracheal and
Many thyroid tumours are tumours of young adults.
oesophageal compression.
Isolated thyroid lumps should always be investigated to confirm a cause.
Medullary: thyroid lump, may have MEN IIA (medullary
The prognosis is often good with surgical resection and medical
thyroid carcinoma, phaeochromocytoma, hyperparathyroid-
adjuvant treatment.
ism) or MEN IIB (medullary thyroid carcinoma, phaeochro-
mocytoma, multiple mucosal neuromas, Marfanoid habitus)
syndrome.
Epidemiology
Male/female 1 : 2. Peak incidence depends on histology (papil-
Investigations
lary: young adults; follicular: middle age; anaplastic: elderly;
Ultrasound of the thyroid gland.
medullary: any age).
FNAC: may give histological diagnosis.
Bone scan and radiographs of bones for secondary deposits.
Pathology Calcitonin levels as a marker for medullary carcinoma.
Histology of thyroid malignancies.
Type (% of total) Cell of origin Differentiation Spread

Papillary (60%) Epithelial Well Lymphatic
Follicular (25%) Epithelial Well Haematogenous
Anaplastic (10%) Epithelial Poor Direct, lymphatic and haematogenous
Medullary (5%) Parafollicular Moderate Lymphatic and haematogenous
Aetiology ESSENTIAL MANAGEMENT

The following are predisposing factors: Papillary
pre-existing goitre; Surgery: total thyroidectomy and removal of involved lymph nodes.
radiation of the neck in childhood. Adjunctive treatment: L-thyroxine postoperatively to suppress TSH
production (which stimulates papillary tumour growth).
Prognosis: excellent.
Follicular
Surgery: thyroid lobectomy or total thyroidectomy if metastases are
present.
Adjunctive treatment: radioactive iodine (131I) for distant metastases
and L-thyroxine for replacement therapy to suppress TSH.
Prognosis: no metastasesb90% 10-year survival; metastasesb30%
10-year survival.
Anaplastic
Surgery: only to relieve pressure symptoms.
Adjunctive treatment: neither radiotherapy nor chemotherapy is
effective.
Prognosis: dismalbmost patients will be dead within 12 months of
diagnosis.
Medullary
Exclude phaeochromocytoma before treating.
Surgery: total thyroidectomy and excision of regional lymph nodes.
Prognosis: overall 50% 5-year survival.
Thyroid malignancies 125

56 Parathyroid disease
CALCIUM METABOLISM
Ileum Vitamin D3 Calcitonin PTH
ECF
Ca2+
Calcitonin Vitamin D3
PTH Bone
Kidney
HYPERCALCAEMIA HYPOCALCAEMIA
(Hyperparathyroid)
'Moans' Facial nerve

Weakness hypersensitivity (Chvostek's)
Psychosis
Perioral paraesthesia
'Groans' Tetany
Peptic ulcer Cramps
Pancreatitis Hyper-reflexia
Abdominal pain Carpopedal spasm (Trousseau's)
QT
'Stones'
Renal stone T peak
Polyuria
'Bones'
Bone pain METHODS OF PARATHYROID LOCALIZATION
Pathological fractures
RIA
99mTc RP30
Surgical Radionuclide Methylene blue Peroperative

expertise scanning PTH blood
sampling

Hyperparathyroidism high-resolution ultrasound;
Definition CT and MRI scanning;
Hyperparathyroidism is a condition characterized by hypercal- dual isotope imaging (201Tl and 99mTc pertechnate).
caemia caused by excess production of parathyroid hormone. Selective vein catheterization and digital subtraction angio-
graphy in patients in whom exploration has been unsuccessful.
KEY POINTS
Hyperparathyroidism often presents with vague symptoms to many ESSENTIAL MANAGEMENT
different specialists. Primary and tertiary hyperparathyroidism are treated surgically: excise
Surgery is the treatment of choice for primary hyperparathyroidism. adenoma if present, remove 31/2 of 4 glands for hyperplasia.
Hypoparathyroidism postsurgery is rare and mostly transient. Secondary hyperplasia: vitamin D and/or calcium.
Causes Hypoparathyroidism
Primary hyperparathyroidism is usually due to a parathyroid Definition
adenoma (75%) or parathyroid hyperplasia (20%). Hypoparathyroidism is a rare condition characterized by hypo-
Secondary hyperparathyroidism is hyperplasia of the gland in calcaemia due to reduced production of parathormone.
response to hypocalcaemia (e.g. in chronic renal failure).
In tertiary hyperparathyroidism, autonomous secretion of Causes
parathormone occurs when the secondary stimulus has been Post-thyroid or parathyroid surgery.
removed (e.g. after renal transplantation). Idiopathic (often autoimmune).
MEN syndromes and ectopic parathormone production (e.g. Congenital enzymatic deficiencies.
oat cell carcinoma of the lung). Pseudohypoparathyroidism (reduced sensitivity to para-
thormone).
Pathology
Parathormone mobilizes calcium from bone, enhances renal Pathology
tubular absorption and, with vitamin D, intestinal absorption of Reduced serum calcium increases neuromuscular excitability.
calcium. The net result is hypercalcaemia.
Clinical features
Clinical features Perioral paraesthesia, cramps, tetany.
Renal calculi or renal calcification, polyuria. Chvosteks sign: tapping over facial nerve induces facial
Bone pain, bone deformity, osteitis fibrosa cystica, patholo- muscle contractions.
gical fractures. Trousseaus sign: inflating BP-cuff to above systolic pressure
Muscle weakness, anorexia, intestinal atony, psychosis. induces typical main daccoucheur carpal spasm.
Peptic ulceration and pancreatitis. Prolonged QT interval on ECG.
Diagnosis Diagnosis
Serum calcium (specimen taken on three occasions with Calcium and parathormone levels decreased.
patient fasting, at rest and without a tourniquet). Normal range
2.22.6 mmol/l. Calcium is bound to albumin and the level has
to be corrected when albumin levels are abnormal.
Parathormone level.
Calcium and vitamin D.
Imaging:
Parathyroid disease 127

57 Pituitary disorders
ACROMEGALY HYPERPROLACTINAEMIA
Somatomedins
Liver Tissue effects Milk production
GH
Direct anti-insulin effects Sex hormone effects
Eosinophil cells Eosinophil cells
(350 nm granules) (500 nm granules)
Large head Headaches

Prominent brow
Big nose Uncinate fits
Thick lips Bitemporal hemianopia
Teeth spaced
Overriding bite
Prominent chin Large hands
Hoarse voice Galactorrhoea or
gynaecomastia
Sweating
Gynaecomastia
Infertility
Coarse skin
Impotence Menstrual irregularity

Impotence
Diabetes Libido
Hypertension Headaches
Tumour
Acromegaly
GH Prol.
Normal Normal
Glucose Dopamine

Pituitary disorders are characterized either by a failure of secretion Pan-hypopituitarism: pallor (MSH), hypothyroid (TSH), fail-
of pituitary hormones or by tumours, which cause local pressure ure of lactation (PL), chronic adrenal insufficiency (ACTH),
effects or specific syndromes due to hormone overproduction. ovarian failure and amenorrhoea (FSH, LH).
Diabetes insipidus (ADH): polyuria (520 l/day), polydipsia.
Tumours: pressure effects: headache, bitemporal hemianopia.
KEY POINTS Acromegaly (excess GH): thickened skin, increased skull size,
Acromegaly is often insidious in onset and slow to be diagnosed. prognathism, enlarged tongue, goitre, osteoporosis, organo-
Deficiencies of pituitary function are generally tested for by stimulation megaly, spade-like hands and feet.
tests and overactivity by suppressions tests. Occasionally direct serum Cushings disease (excess ACTH): malaise, muscle weak-
hormone levels may be measured. ness, weight gain, bruising, moon facies, buffalo hump,
hirsutism, amenorrhoea, impotence, polyuria, diabetes, emo-
tional instability.
Common causes
Failure of anterior pituitary secretion, pan-hypopituitarism Investigations
(Simmonds disease): Pan-hypopituitarism: serum assay of pituitary and target gland
pressure from a tumour; hormones, dynamic tests of pituitary function.
infection; Diabetes insipidus: very low urinary specific gravity which
ischaemia; does not increase with water deprivation.
postpartum-induced infarction of the anterior pituitary Tumours: visual field measurements, hormone assay, CT or
(Sheehans syndrome). MRI scanning.
Failure of antidiuretic hormone production from the posterior
pituitary gland leads to diabetes insipidus:
trauma; ESSENTIAL MANAGEMENT
local haemorrhage; Pan-hypopituitarism: replacement therapybcyclical oestrogen
ischaemia; progesterone, hydrocortisone, thyroxine.
tumours. Diabetes insipidus: vasopressin analogue, desmopressin,
administered as nasal spray.
Tumours: bromocriptine suppresses PL release from prolactinomas,
Tumours (% of total) Cell type 90Y implant for pituitary ablation, surgery (hypophysectomy via nasal or
Endocrinologically active (75%) transcranial route).

Prolactinomas (35%) Acidophil
GH-secreting tumours (20%) Acidophil
Mixed PL and GH (10%) Acidophil
ACTH-secreting tumours (10%) Basophil
Endocrinologically inactive (25%) Chromophobe
Craniopharyngioma Rathkes pouch
Pituitary disorders 129

58 Adrenal disorders
Headache 90% Adrenal 10% Extra-adrenal

Sweating 90% Benign 10% Malignant
Mydriasis 90% Unilateral 10% Bilateral
Flushing
Panic attacks
Derealization attacks
VMA
Wheezing Dop.
NAdr.
Adr.
Abdominal pain PHAEOCHROMOCYTOMA
+++
Tachycardia
Dysrhythmias +++
Hypertension
CUSHING'S ADDISON'S
Poor hair Cataracts

Plethora Intra-oral pigmentation
Seborrhoea Moon face
Buffalo hump
Myalgia
Poor healing Fatigue
Wasting
Abdominal obesity
Bruising
Pigmented scars
Petechiae
Body hair loss
Poor nails Striae

Pigmented
Osteoporosis skin creases
Limb wasting Diabetes mellitus Hypotension
Hypertension Hyponatraemia
Hypernatraemia Hyperkalaemia
Hypokalaemia
Immunocompromise
Peripheral neuropathy

Adrenal gland disorders are characterized by clinical syndromes Basic principles
resulting from either a failure of secretion or excessive secretion Establish the endocrine diagnosis by serum levels or sup-
of adrenal cortical or medullary hormones. pressions/stimulation tests.
Cushings syndrome describes the clinical features irrespect- Correct the endocrine abnormalities.
ive of the cause; Cushings disease refers to a pituitary adenoma Localize the cause by investigation and imaging.
with secondary adrenal hyperplasia. Consider if definitive (surgical) treatment is necessary.
Addisons disease
KEY POINTS U+Es (Na+, K+), low plasma cortisol, short synacthen test to
Addisons disease is often insidious in onset and presents with vague confirm diagnosis. Long synacthen test to differentiate primary
symptomsbconsider in unexplained lethargy and weakness. (adrenal) from secondary (pituitary) insufficiency.
Phaeochromocytoma can mimic a wide range of acute surgical,
medical and psychiatric states. Cushings syndrome
Cushings syndrome is commonly caused by chronic exogenous Elevated plasma cortisol (taken at 24.00 hours) and loss of
steroid administration. diurnal variation, low-dose dexamethasone suppression test to
Treatment for most situations aims to normalize body physiology
confirm diagnosis, high-dose test to distinguish adrenal from
before any definitive/surgical treatment is considered.
pituitary disease, serum ACTH to identify secondary cause.
Conns syndrome
Common causes U+Es (K+, normal or Na+), raised serum aldosterone and nor-
Failure of secretion
mal renin levels.
Adrenal insufficiency, Addisons disease: bilateral adrenal
haemorrhage in sepsis (WaterhouseFriderichsen syndrome),
Adrenogenital syndrome
autoimmune disease, TB, pituitary insufficiency, metastatic
Elevated urinary 17 ketosteroids.
deposits.
Phaeochromocytoma
Excessive secretion
24-hour urinary VMA, serum dopamine, epinephrine (adrena-
Cushings syndrome: excess corticosteroid due to steroid ther-
line) and norepinephrine (noradrenaline).
apy, ACTH-producing pituitary tumour, adenoma or carcinoma
of the adrenal cortex, ectopic ACTH production, e.g. oat-cell
Localization imaging
carcinoma of lung.
Helical CT: excellent for adrenal gland, retroperitoneum.
Conns syndrome (primary hyperaldosteronism): excess
[123I] MIBG scan: neuroendocrine tumours (phaeochrom-
aldosterone due to adenoma or carcinoma of adrenal cortex,
ocytoma).
bilateral cortical hyperplasia.
Arteriography and venous sampling: occasionally required.
Adrenogenital syndrome: excess androgen: abnormal cortisol
synthesis causes excess ACTH production which boosts andro-
gen production, adrenal cortical tumour.
Phaeochromocytoma: excess catecholamines due to adrenal ESSENTIAL MANAGEMENT
medullary tumours, 95% are benign. Addisons disease: replacement therapy. Cortisol, fludrocortisone.
Increase dose at times of stress/surgery.
Clinical features Cushings syndrome: adrenalectomy for adenoma (rarely carcinoma).
Addisons disease: see opposite. Addisonian crisis: an acute Mitotane reduces steroid production in metastases.
collapse which may mimic an abdominal emergency. Conns syndrome: adrenalectomy for unilateral adenoma (rarely
Cushings syndrome: see opposite. carcinoma). Spironolactone or amiloride for bilateral adenomas or
Conns syndrome, primary hyperaldosteronism: muscle weak- hyperplasia. (Only if poor response, bilateral adrenalectomy with
replacement therapy.)
ness, tetany, polyuria, polydipsia, hypertension.
Adrenogenital syndrome: cortisol to suppress ACTH and provide
Adrenogenital syndrome: virilization in female children,
corticosteroids. Surgery to correct abnormalities of external genitalia.
pseudohermaphroditism, precocious puberty.
Phaeochromocytoma: surgery after fluid replacement and careful
Phaeochromocytoma: see opposite.
and adrenergic blockade.
Adrenal disorders 131

59 Skin cancer
BASAL CELL CARCINOMA
Waxy appearance of growing edge

Pearly
Central slough
Umbilicated
Raised rolled edge
Well circumscribed
Sites of predilection
SQUAMOUS CELL CARCINOMA
Other causes
Sun exposure Association with infection Skin infection
Osteomyelitis TB
Abscess Syphilis
Leprosy
Associated features Chronic irritation
'Solar' keratosis
'Weathered' skin
Sites of predilection Chronic trauma

Poorly defined edge
Deep penetration
Everted edge
Centrally necrotic
++ Friable
manual workers Bleeding
MALIGNANT MELANOMA
Principal features suggesting malignancy
Increase in size Change in Itching Bleeding Satellite lesions Lymphadenopathy

pigmentation

Definition Staging
Malignant lesions of epidermis of the skinbprincipally basal Clarkes levels IV, Breslows tumour thickness.
cell (BCC) and squamous cell (SCC) carcinomas and malignant
melanoma (MM). Clinical features
BCC
Recurring, ulcerated, umbilicated skin lesion on forehead or
KEY POINTS face. Ulcer has a raised, pearl-coloured edge. Untreated, large
Protection from sun exposure reduces the risk of all forms of skin areas of the face may be eroded (rodent ulcer).
cancer dramatically.
Not all MMs are pigmented. SCC
All moles with suspicious features should be excision biopsied. Lesions (ulcers, fungating lesions with heaped-up edges) on
The prognosis from early MM is excellent with surgery but late disease exposed areas of the body.
is usually fatal.
MM
Pigmented lesions (occasionally not pigmentedbamelanotic),
Epidemiology 1 cm in diameter on lower limbs, feet, head and neck. Usually
Male/female 2 : 1 for BCC and SCC. Elderly males. Equal sex present as a change in a pigmented lesion: increasing size or pig-
distribution and all adults for MM. All tumours common in areas mentation/bleeding/pain or itching/ulceration/satellite lesions.
of high annual sunshine (e.g. Australia, southern USA).
Investigations
Aetiology Biopsy (usually excisional) of the lesion unless clinically cer-
The following are predisposing factors. tain (definitive surgery).
Exposure to sunlight (especially in fair-skinned races). For MMbhelical CT scan for ?involved draining nodes,
Immunosuppression (high incidence after renal transplant). FNAC for palpable draining nodes, ?peroperative sentinel node
Radiation exposure (radiotherapy, among radiologists). biopsy using dye injection mapping.
Chemical carcinogens (hydrocarbons, arsenic, coal tar).
Inherited disorders (albinism, xeroderma pigmentosum).
Chronic irritation (Marjolins ulcer).
BCC
Naevi (50% of MM arise in pre-existing benign pigmented
Curettage/cautery/cryotherapy/topical chemotherapy (5-FU). These
lesions).
treatments are suitable for small lesions.
Bowens disease and erythroplasia of Queryat. Surgical excision/radiotherapy.
Pathology SCC
BCC Surgical excision/radiotherapy.
Arises from basal cells of epidermis.
Aggressive local spread but do not metastasize. MM
Surgical excision with 23 cm margin.
SCC Lymph node dissection if CT, FNAC or sentinel node biopsy +ve for
Arises from keratinocytes in the epidermis. metastases with no systemic disease.
Spreads by local invasion and metastases. Immunotherapy, chemotherapy (systemic and local limb perfusion),
radiotherapy disseminated disease (poor response).
MM
Arises from the melanocytes often in pre-existing naevi.
Superficial spreading and nodular types. Prognosis
Radial and vertical growth phases. Lymphatic spread is to BCC, SCC prognosis is usually excellent, but patients with
regional lymph nodes and haematogenous spread to liver, bone SCC should be followed for 5 years.
and brain. MM prognosis depends on staging:
Clarkes level 5-year survival (%) Tumour thickness (mm) 5-year survival (%)
I (epidermis) 100 <0.76 98
II (papillary dermis) 90100 0.761.49 95
III (papillary/reticular dermis) 8090 1.502.49 80
IV (reticular dermis) 6070 2.503.99 75
V (subcutaneous fat) 1530 4.007.99 60
>8.00 40
Skin cancer 133

60 Ischaemic heart disease
100%
ST dep + pain = Angina
Survival
1
> 1 mm Number of
Failure of 2 diseased
exercise
vessels
vasodilatation 3
Platelet Reduced
aggregation coronary 10 years
100%
flow
Treatment: OUTCOMES
Survival
Surgical
LCA
stenosis
COMPLICATIONS OF MYOCARDIAL Medical
INFARCTION
2 years
AF VF ANGINA
VSD LVF
Mural Papillary
rupture muscle
Mural rupture
thrombosis
ECG FEATURES MYOCARDIAL INFARCTION

T-wave
Seconds
'dome + spike' Troponins
concentration
CK
Minutes AAT LDH
Serum
ST elevation
ST + T-wave Minutes
inversion 1 3 Hours 8
Q-wave Hours
development Days
Patterns
ST returns Days I V1V3 Anterior
V2V4 Septal
V5V6 Lateral
T returns Weeks II III aVf Inferior

Definition Myocardial infarction
Ischaemic heart disease is a common disorder caused by acute Severe central chest pain for >30 min duration.
or chronic interruption of the blood supply to the myocardium, Radiates to neck, jaw, arms.
usually due to atherosclerosis of the coronary arteries, i.e. coron- Not relieved by GTN.
ary artery disease. Signs of cardiogenic shock.
Arrhythmias.

Angina alone is rarely managed surgically (CABG). Angina pectoris
Urgent treatment with thrombolysis, antiplatelet agents and FBC: anaemia.
cardioprotection reduces the risk of death from MI significantly. Thyroid function tests.
Serum troponins are highly sensitive and very specific for myocardial Chest X-ray: heart size.
injury. ECG ST segment changes.
Exercise ECG.
Coronary angiography.
Epidemiology
Myocardial infarction
Male > female before 65 years. Increasing risk with increasing
ECG: Q waves, ST segment and T-wave changes.
age up to 80 years. Commonest cause of death in the Western
Cardiac enzymes: troponins, LDH, CPK (MB).
world.
Chest X-ray: dissection.
FBC: associated anaemia.
Aetiology
U+E: kyperkalaemia.
Atherosclerosis and thrombosis.
Thromboemboli (especially plaque rupture).
Arteritis (e.g. periarteritis nodosa).
Coronary artery spasm.
Angina pectoris
Extension of aortic dissection/syphilitic aortitis.
Lose weight.
Avoid precipitating factors (e.g. cold).
Risk factors GTN (sublingual).
Family history. Calcium channel blockers.
Cigarette smoking. -blockers, nitrates, aspirin.
Hypertension. Treatment of hypertension and hyperlipidaemias.
Hyperlipidaemia. Coronary angioplasty or CABG.
Type A personality.
Obesity. Myocardial infarction
Bed rest, O2, analgesia.
Pathology Thrombolysis.
Reduction in coronary blood flow is critical when lumen is Aspirin.
decreased by 90%. Treatment of heart failure.
Angina pectoris results when the supply of O2 to the heart Treatment of arrhythmias.
muscle is unable to meet the increased demands for O2, e.g. dur-
ing exercise, cold, after a meal. Indications for CABG
Thrombotic occlusion of the narrowed lumen precipitates Left main stem disease.
acute ischaemia. Triple vessel disease.
The heart muscle in the territory of the occluded vessel dies, Two-vessel disease involving LAD.
i.e. MI. May be subendocardial or transmural. Chronic ischaemia + LV dysfunction.
Clinical features
Angina pectoris Complications of MI
Central chest pain on exertion, especially in cold weather, lasts Arrhythmias.
115 min. Cardiogenic shock.
Radiates to neck, jaw, arms. Myocardial rupture.
Relieved by GTN. Papillary muscle rupture causing mitral incompetence.
Usually no signs. Ventricular aneurysm.
Pericarditis.
Mural thrombosis and peripheral embolism.
Ischaemic heart disease 135

61 Valvular heart disease
Atrial Atrial
fibrillation fibrillation
Mid-diastolic Pansystolic
murmur apex murmur
S1 P2 Opening S3 Apex Axilla
Presystolic
Loud (rigid Loud snap accentuation lost Apex beat displaced
mitral valve) (pulmonary in AF (no atrial Infective
hypertension) boost to filling) Traumatic
Connective tissue
MITRAL MITRAL
disorders
STENOSIS INCOMPETENCE
Displaced apex
Tapping apex
RV heave
Rheumatic
Congenital Infective
AORTIC AORTIC Traumatic
STENOSIS INCOMPETENCE
High pulse
Slow rising pulse pressure
Head bobbing
Low pulse pressure 'De Musset's sign'
N 'Corrigan's' Nail bed pulsation
P2
A2 collapsing pulse 'Quincke's sign'
Ejection systolic
murmur R2 Neck N
Early diastolic
1 2 1 murmur
Opening Reversed splitting LSE Apex
click (severe LV dysfunction) 1 2 1
'Conway's' suprasternal thrill
Apex beat displaced

LV heave

Definition Mitral stenosis
Valvular heart disease is defined as a group of conditions char- Pulmonary hypertension.
acterized by damage to one or more of the heart valves, resulting Paroxysmal nocturnal dyspnoea.
in deranged blood flow through the heart chambers. Atrial fibrillation.
Loud first heart sound and opening snap.
Low-pitched diastolic murmur with presystolic accentuation
KEY POINTS at the apex.
Valve replacements are uncommon but offer excellent long-term function
with newer bioprosthetic valves. Mitral regurgitation
Chronic fatigue.
Pulmonary oedema.
Apex laterally displaced, hyperdynamic praecordium.
Epidemiology
Apical pansystolic murmur radiating to axilla.
Rheumatic fever is still a major problem in developing countries,
while congenital heart disease occurs in 810 cases per 1000 live
Tricuspid stenosis
births worldwide.
Fatigue.
Peripheral oedema.
Aetiology
Liver enlargement/ascites.
Congenital valve abnormalities.
Prominent JVP with large a waves.
Rheumatic fever.
Lung fields are clear.
Infective endocarditis.
Rumbling diastolic murmur (lower left sternal border).
Degenerative valve disease.
Tricuspid regurgitation
Pathology
Chronic fatigue.
Rheumatic feverbimmune-mediated acute inflammation affect-
Hepatomegaly/ascites.
ing the heart valves due to a cross-reaction between antigens of
Right ventricular heave.
group A -haemolytic Streptococcus and cardiac proteins.
Prominent JVP with large v waves.
Disease may make the valve orifice smaller (stenosis) or un-
Pansystolic murmur (subxiphoid area).
able to close properly (incompetence or regurgitation) or both.
Stenosis causes a pressure load while regurgitation causes a
Investigations
volume load on the heart chamber immediately proximal to it
ECG.
with upstream and downstream effects.
Chest X-ray.
Echocardiography and colour Doppler techniques.
Clinical features
Cardiac catheterization with measurement of transvalvular
Aortic stenosis
gradients.
Angina pectoris.
Syncope.
Left heart failure.
Slow upstroke arterial pulse.
Medical
Precordial systolic thrill (second right ICS). Treat cardiac failure, diuretics, restrict salt intake, reduce exercise,
Harsh midsystolic ejection murmur (second right ICS). digitalis for rapid atrial fibrillation and anticoagulation for peripheral
embolization.
Aortic regurgitation
Congestive cardiac failure. Surgical
Increased pulse pressure. Repair (possible in mitral and tricuspid valve only) or replace diseased
Water-hammer pulse. valve (requires cardiopulmonary bypass). Prosthetic (lifelong
Decrescendo diastolic murmur (lower left sternal edge). anticoagulation), bioprosthetic (animal tissue on prosthetic frame,
3 months anticoagulation) and biological (cadaveric homografts,
no anticoagulation) valves available.
Valvular heart disease 137

62 Peripheral occlusive vascular disease
CHRONIC ISCHAEMIA
AORTO-ILIAC FEMORO-POPLITEAL INFRA-POPLITEAL
Sites affected
Buttocks Thighs Calves
Thighs Calves Feet
Pelvis
(including sex organs)
+ + ++ ++
++
Pulses affected
Treatment options
Balloon angioplasty Balloon angioplasty Saphenous vein

in situ or reversed
5-year patency
Only for profunda <60%
origin disease
Intraluminal stent
Endarterectomy + profundaplasty Femoro-distal vein graft
5-year patency 90% Saphenous vein

in situ or reversed
5-year patency 7080%
Anatomical grafts
Aorto-bi-iliac Femoro-popliteal vein graft
Aorto-bifemoral
Gortex armoured
5-year patency 60%
5-year patency 6070%
Femoro-popliteal synthetic graft

Extra-anatomical grafts
Axillo-bifemoral
Femoro-femoral

Definition Paraesthesia.
Peripheral occlusive vascular disease (POVD) is a common Paralysis.
disorder caused by acute or chronic interruption of the blood Perishing cold.
supply to the limbs, usually due to atherosclerosis. Pistol shot onset.
Mottling.
Muscle rigidity.
KEY POINTS
All patients with POVD require screening for associated coronary or Investigations
carotid disease. Chronic ischaemia
The majority of POVD responds to conservative treatment. ABI (normal >1.0) at rest and postexercise on treadmill.
Surgery is confined to limb-threatening (critical) ischaemia or truly FBC (exclude polycythaemia).
disabling, refractory claudication. Doppler wave-form analysis.
Digital plethysmography (in diabetes).
Perfemoral angiography.
Epidemiology Acute ischaemia
Male > female before 65 years. Increased risk with increased
ECG, cardiac enzymes.
age.
Angiography (?), may be performed peroperatively.
Find source of embolism. Holter monitoring. Echocar-
Aetiology
diograph. Ultrasound aorta for AAA.
Atherosclerosis and thrombosis.
Embolism.
Vascular trauma.
Vasculitis (e.g. Buergers disease).
Non-disabling claudication
Stop smoking.
Risk factors Exercise programme.
Cigarette smoking. Avoid -blockers.
Hypertension. Aspirin 75 mg/day; clopidogril 75 mg/day.
Hyperlipidaemia. Pentoxifylline (?).
Diabetes mellitus. Lipid-lowering drug if hyperlipidaemia present.
Family history.
Disabling claudication/critical ischaemia
Pathology Balloon angioplasty intravascular stent.
Reduction in blood flow to the peripheral tissues results in Bypass surgery.
ischaemia which may be acute or chronic. Critical ischaemia is Amputation.
present when the reduction of blood flow is such that tissue viab- i.v. treatment: iloprost.
ility cannot be sustained (defined by tissue loss, rest pain for 2
weeks, ankle pressure <50 mmHg). Acute ischaemia
Heparin anticoagulation.
Clinical features Surgical embolectomy.
Chronic ischaemia (see p. 50) Thrombolytic therapy (t-PA, streptokinase, urokinase).
Intermittent claudication in calf (femoral), thigh (iliac) or but-
tock (aortoiliac).
Cold peripheries. Prognosis
Prolonged capillary refill time. Non-disabling claudication
Rest pain, especially at night. >65% respond to conservative management. The rest require
Venous guttering. more aggressive treatment.
Absent pulses.
Arterial ulcers, especially over pressure points (heels, toes). Disabling claudication/critical ischaemia
Knee contractures. Angioplasty and bypass surgery overall give good results.
The more distal the anastomosis the poorer the result.
Acute ischaemia (see p. 54)
Pain. Acute ischaemia
Pallor. Limb salvage 85%.
Pulselessness. Mortality 1015%.
Peripheral occlusive vascular disease 139

63 The diabetic foot
Treatment
Drain all sources of sepsis
Early intravenous antibiotics
Cellulitis Treatment
Major inflow arterial problems
treated as conventionally for
POVD
Treatment Disordered joints
Fitted shoes/footwear
Padded footwear Pulses
Poor skin (may be incompressible
or absent)
Hairless
Fungal nail infection
Chronic osteomyelitis
Paronychial infection (usually secondary to ulcers)
Pressure point ulcers

Treatment
Treatment
Antibiotics
Drain collection of pus
Treatment Amputation
Consider nail excision
Podiatry Control sepsis
Debride dead tissue
Consider local amputation
Amputations used in diabetes
Digital Ray Lisfranc/ Syme's

transmetatarsal

The term diabetic foot refers to a spectrum of foot disorders Non-invasive vascular tests: ABI, segmental pressure, digital
ranging from ulceration to gangrene occurring in diabetic people pressure. ABI may be falsely elevated due to medial sclerosis.
as a result of peripheral neuropathy or ischaemia, or both. X-ray of foot may show osteomyelitis.
Arteriography.
KEY POINTS
Prevention is everything in diabetic feet. ESSENTIAL MANAGEMENT
All infections should be treated aggressively to reduce the risk of tissue Should be undertaken jointly by surgeon and physician as diabetic foot
loss. may precipitate diabetic ketoacidosis.
Treat major vessel POVD as normalbimprove inflow to the foot.
Prevention
Do
Carefully wash and dry feet daily.
Pathophysiology
Inspect feet daily.
Three distinct processes lead to the problem of the diabetic foot.
Take meticulous care of toenails.
Ischaemia caused by macro- and microangiopathy.
Use antifungal powder.
Neuropathy: sensory, motor and autonomic.
Sepsis: the glucose-saturated tissue promotes bacterial Do not
growth. Walk barefoot.
Wear ill-fitting shoes.
Clinical features Use a hot water bottle.
Neuropathic features Ignore any foot injury.
Sensory disturbances.
Trophic skin changes. Neuropathic disease
Plantar ulceration. Control infection with antibiotics effective against both aerobes and
Degenerative arthropathy (Charcots joints). anaerobes.
Pulses often present. Wide local excision and drainage of necrotic tissue.
Sepsis (bacterial/fungal). These measures usually result in healing.
Ischaemic features Ischaemic disease

Formal assessment of the vascular tree by angiography and
Rest pain.
reconstitution of the blood supply to the foot (either by angioplasty
Painful ulcers over pressure areas.
or bypass surgery) must be achieved before the local measures will
History of intermittent claudication.
work.
Absent pulses.
After restoration of blood supply treat as for neuropathic disease.
Sepsis (bacterial/fungal).
The diabetic foot 141

64 Aneurysms
NON-AORTIC ANEURYSMS AORTIC ANEURYSMS Risk of rupture
Subclavian ~10% Ascending

aortic 5%
Risk of
surgery
Splenic <0.5%
Hepatic <0.5%
0 2 4 6 8 10
95% abdominal
Size (cm)
<2% above renal arteries
30% Involve iliac arteries

Femoral ~20% 20% Involve external iliac arteries
Popliteal 70%
Distal embolization Abdominal aortic

Ischaemic feet aneurysm
Bowel ischaemia
Treatment
Straight graft Straight graft Bifurcated

+ renal artery 'trouser' graft
Free rupture reimplantation
Collapse
Hypotension
Tachycardia
Back pain Haematemesis Plethora

Nausea Melaena Low body oedema
Vomiting Pulsatile JVP
Hypotension Haematuria
Abdominal bruit
Retroperitoneal rupture Aortoduodenal fistula Aortocaval fistula

('leak')

Definition Symptomatic
An aneurysm is a permanent localized dilatation of an artery to the Back pain from pressure on the vertebral column.
extent that the affected artery is 1.5 times its normal diameter. A Rapid expansion causes flank or back pain.
pseudo or false aneurysm is an expanding pulsating haematoma in Rupture causes collapse, back pain and an ill-defined mass.
continuity with a vessel lumen. It does not have an epithelial lining. Erosion into IVC causes CCF, loud abdominal bruit, lower
limb ischaemia and gross oedema.

All patients with other vascular disease should be examined for AAA. Detection of AAA
Regular monitoring of size helps determine timing for elective surgery. Physical examination: not accurate.
Mortality for elective surgery is reduced by careful patient evaluation Plain abdominal X-ray: aortic calcification.
for hidden coronary or pulmonary disease. Ultrasonography: best way of detecting and measuring
aneurysm size.
CT scan: provides good information regarding relationship
Sites between AAA and renal arteries.
Abdominal aorta, iliac, femoral and popliteal arteries. Cerebral Angiography: not routine for AAA.
and thoracic aneurysms are less common.
Determination of fitness for surgery
Aetiology History and examination.
Atherosclerosis. ECG stress testing.
Familial (abnormal collagenase or elastase activity). Radionuclide cardiac scanning (MUGA or stress thallium
Congenital (cerebral (berry) aneurysm). scan).
Bacterial aortitis (mycotic aneurysm). Pulmonary function tests.
Syphilitic aortitis (thoracic aneurysm). U+E and creatinine for renal assessment.
Risk factors
Cigarette smoking. ESSENTIAL MANAGEMENT
Hypertension. Surgical repair is the treatment of choice for AAA.
Hyperlipidaemia. AAA of 5.5 cm should be repaired electively as they have a high
rate of rupture (perioperative mortality for elective AAA repair is 5%).
Surgical repair with inlay of a synthetic graft is the standard method of
Pathology
repair.
Aneurysms increase in size in line with the law of Laplace (T
Endovascular repair with graft/stent devices is indicated in selected
= RP), T = tension on the arterial wall, R = radius of artery, P =
patients.
blood pressure. Increasing tension leads to rupture.
Ruptured AAA require immediate surgical repair (perioperative
Thrombus from within an aneurysm may be a source of
mortality 50%, but 70% of patients die before they get to hospital so that
peripheral emboli. overall mortality is 85%).
Popliteal aneurysms may undergo complete thrombosis lead-
ing to acute leg ischaemia.
Aneurysms may be fusiform (AAA, popliteal) or saccular
(thoracic, cerebral).
Prognosis
Most patients do well after surviving AAA repair and have an
excellent quality of life.
Clinical features of AAA
Asymptomatic
The vast majority have no symptoms and are found incidentally.
This has led to the description of an AAA as a U-boat in the belly.
Aneurysms 143
65 Extracranial arterial disease
Parietal lobe
Hemiparesis
Frontal lobe Occipital lobe
Personality changes Visual disturbances
Temporal lobe
Dysphasia Cerebellum
Ataxia
Ocular Vertigo
Brainstem
Amaurosis fugax Nystagmus
Carotid Paraparesis
Loss of consciousness
Vertebral
RISKS INVESTIGATIONS
70% Stenosis Angiography

? Overestimates stenosis
50% Stenosis + symptoms
Doppler velocities
Ulcerated plaque ? Indirect calculation
of stenosis
Duplex colour flow Doppler

Contralateral occlusion ? Most accurate against
anatomical calculation of
stenosis
SURGICAL OPTIONS MRA ? Best for confirming

Magnetic occlusion vs. very tight
Resonance stenosis
Angiography
Shunt (reduces risk of
peroperative stroke)
MEDICAL OPTIONS
vs.
Vein patch Dacron patch Primary Aspirin
enlargement enlargement closure Warfarin
Clopidogril
Intraoperative monitoring
? Allows control of risks for intraoperative stroke

Extracranial arterial disease is a common disorder character- Cerebral symptoms (contralateral):
ized by atherosclerosis of the carotid or vertebral arteries motor (weakness, clumsiness or paralysis of a limb);
resulting in cerebral-ocular (stroke, TIA, amaurosis fugax) or sensory (numbness, paraesthesia);
cerebellar (vertigo, ataxia, drop attacks) ischaemic symptoms. speech related (receptive or expressive dysphasia).
Ocular symptoms (ipsilateral): amaurosis fugax (transient loss
of vision described as a veil coming down over the visual field).
KEY POINTS Cerebral (or ocular) symptoms may be transitory (a transient
All patients with transient neurological symptoms should undergo ischaemic attack is a focal neurological or ocular deficit lasting
screening for carotid diseasebclinical examination is not accurate. not more than 24 hours) or permanent (a stroke).
Targeted carotid endarterectomy offers optimal risk benefit in stroke Vertebrobasilar symptoms: vertigo, ataxia, dizziness, syn-
prevention. cope, bilateral paraesthesia, visual hallucinations.
A bruit may be heard over a carotid artery, but it is an unreli-
able indicator of pathology.
Epidemiology
Male > female before 65 years. Increasing risk with increasing Investigations
age. Duplex scanning: B-mode scan and Doppler ultrasonic velocit-
ometry: method of choice for assessing degree of carotid stenosis.
Aetiology Carotid angiography: no longer essential prior to surgery.
Atherosclerosis and thrombosis. CT or MRI brain scan: demonstrate the presence of a cerebral
Thromboemboli. infarct.
Fibromuscular dysplasia.
Risk factors ESSENTIAL MANAGEMENT

Cigarette smoking. Medical
Hypertension. Aspirin (75 mg/day) inhibits platelet aggregation for the life of the
Hyperlipidaemia. platelet.
Clopidogril has a similar action to aspirin.
Pathophysiology Anticoagulation is indicated in patients with cardiac embolic disease.
The commonest extracranial lesion is an atherosclerotic
Surgical
plaque at the carotid bifurcation. Platelet aggregation and subse-
Carotid endarterectomy (+ aspirin).
quent platelet embolization cause ocular or cerebral symptoms.
Symptoms due to flow reduction are rare in the carotid territ-
Indications for carotid endarterectomy
ory, but vertebrobasilar symptoms are usually flow related.
Carotid distribution TIA or stroke with good recovery after 1-month delay:
Reversed flow in the vertebral artery in the presence of ipsilat-
>70% ipsilateral stenosis;
eral subclavian occlusion leads to cerebral symptoms as the
>50% ipsilateral stenosis with ulceration.
arm steals blood from the cerebellumbsubclavian steal Asymptomatic carotid stenosis >80% (controversial).
syndrome. Carotid endarterectomy has about 5% morbidity and mortality.
Carotid angioplasty stentingbcontroversial.
Extracranial arterial disease 145

66 Deep venous thrombosis
VIRCHOW'S TRIAD SIGNS OF DVT

Stasis
Immobility
Swollen calf
Long operation
Obesity Red
Heart failure Hot
Trauma Tender
Prominent
Clot
superficial veins
Endothelial injury Hypercoagulability Oedematous feet

Trauma Polycythaemia
Intraluminal cannula Thrombocythaemia (May be no signs at all)
Inflammation Leukaemia
Infection Sepsis
Major trauma
Diabetes
Pregnancy/COCP
Smoking
Malignancy
TREATMENT/PREVENTION OUTCOME
Improving flow Passive exercise Risk

Active exercise
TED stockings
Pneumatic compression boots Recannulization
Resolution
DVT Persistent obstruction
Reducing wall inflammation Reducing viscosity
Regular cannula changes Heparin Deep venous
Reducing fractures Warfarin reflux
Off COCP
Dextran Normal Postphlebitic limb
Definitions KEY POINTS

A deep venous thrombosis (DVT) is a condition in which the All patients in hospital should be considered for mechanical and
blood in the deep veins of the legs or pelvis clots. Embolization pharmacological DVT prophylaxis.
of the thrombus results in a pulmonary embolus (PE) while local Have a low threshold of investigation for DVT in bed-bound patients.
venous damage may lead to chronic venous hypertension and the Recurrent DVT may lead to chronic disabling postphlebitic limb.
postphlebitic limb (PPL). DVT may be the first manifestation of an occult malignancy.

Epidemiology Venous ulceration.
DVT is extremely common among medical and surgical Inverted bottle-shaped leg.
patients, affecting 1030% of all general surgical patients over
40 years who undergo a major operation. PE is a common cause Investigations
of sudden death in hospital patients (0.53.0% of patients die DVT
from PE). D-dimers.
Duplex imagingbsuprapopliteal thrombosis.
Aetiology Ascending venography.
Risk factors
Increasing age >40 years. PE
Immobilization. ECG: S1, Q3, T3.
Obesity. Chest X-ray: linear collapse.
Malignancy. Blood gases: hypoxia, hypocapnia.
Sepsis. Ventilation/perfusion lung scan.
Thrombophilia (e.g. antithrombin III/protein C/protein S Pulmonary angiography.
deficiency, Factor V leiden, anticardiolipin Ab).
Inflammatory bowel disease. PPL
Trauma. Ascending descending venography.
Heart disease. Duplex scanning.
Pregnancy/oestrogens. Plethysmography.
Ambulatory venous pressure.
Virchows triad
Stasis.
Endothelial injury. ESSENTIAL MANAGEMENT
Hypercoagulability. Prophylaxis against DVT
Indications
Presence of risk factors (see above).
Pathology
Aggregation of platelets in valve pockets (area of maximum
Methods
stasis or injury).
Mechanical compression (TED) stockings.
Activation of clotting cascade producing fibrin.
Pharmacological subcutaneous heparin 5000 iu s.c. b.d. (warfarin
Fibrin production overwhelms the natural anticoagulant/
1 mg/day, dextran 70 i.v., 500 ml/day).
fibrinolytic system.
Natural history. Definitive treatment
Complete resolution vs. PE vs. PPL. DVT
Anticoagulation for 68 weeks:
Clinical features i.v. heparin (check efficacy with APTT);
DVT warfarin (check efficacy with PT).
Asymptomatic. ( Thrombolysis.)
Calf tenderness, ankle oedema, mild pyrexia, ( Thrombectomy.)
Phlegmasia alba/caerulea dolens.
PE
PE Anticoagulation for 36 months.
Substernal chest pain. Thrombolysis.
Dyspnoea. Pulmonary embolectomy.
Circulatory arrest. IVC filters for recurrent PE despite treatment, anticoagulation
Pleuritic chest pain. treatment contraindicated, high risk DVTs.
Haemoptysis.
PPL
Limb elevation.
PPL
Compression.
History of DVT.
Four-layer bandaging to achieve ulcer healing.
Aching limb.
Graduated compression stockings to maintain limb compression.
Leg swelling.
( Venous valve reconstruction.)
Venous eczema.
Deep venous thrombosis 147

67 Varicose veins
FEATURES CAUSE TREATMENT

Saphena varix Sapheno-femoral 'High-tie'
cough thrill incompetence All branches tied
Sapheno-femoral
junction isolated
Saphenous vein
divided
Percussion thrill Mid-thigh valve Strip if there is also

incompetence mid-thigh valve
incompetence
'Blow-out' flares Perforating vein Perforator ligation

incompetence
Varicosities Avulsions
'Flare' veins Injection sclerotherapy
CHRONIC FEATURES
Venous eczema ULCERS
Haemosiderin deposits Healing edge
Onychogryposis
Malleolar 'flare' Slough ++
Trapped white cells
Bleed ++
Lipodermatosclerosis
Underlying
incompetent vein
Painless
Surrounding 'corona phlebectatica'
of varicose veins

Definition Dull aching leg pain. Symptoms worse in the evening
Varicose veins are tortuous, dilated prominent superficial veins Heaviness in the leg. or on standing for long periods.
in the lower limbs, often in the anatomical distribution of the Itching and eczema.
long and short saphenous veins. Superficial thrombophlebitis.
Bleeding.
Saphena varix.
KEY POINTS Ulceration.
Surgery for varicose veins aims to divide all incompetent perforators
and remove grossly diseased varicosities. Investigations
Smaller varicose veins are best treated by injection sclerotherapy Clinical assessment by Trendelenburg tourniquet tests.
alone. Doppler velocitometry: assess sapheno-femoral junction
Beware non-anatomical or atypical varicose veins in the young adult (SFJ)/short sapheno-popliteal junction (SSPJ).
(congenital causes). Duplex scanning: identify recurrence site (especially recurrent
Recurrent varicose veins require Duplex scanning assessment. varicose veins).
Epidemiology General
Very common in the Western world, affecting about 50% of the Avoid long periods of standing.
adult population. Elevate limbs.
Wear support hosiery.
Aetiology
Primary or familial varicose veins. Specific
Pregnancy (progesterone causes passive dilatation of veins). Injection sclerotherapy with sodium tetradecyl (STD)
Secondary to postphlebitic limb (perforator failure). Suitable for small veins and usually only below the knee.
Congenital: Patients are encouraged to walk several miles per day.
KlippelTrenaunay syndrome; Anaphylaxis and local ulceration may occur.
ParkesWeber syndrome.
Iatrogenic: following formation of an arteriovenous fistula. Surgical ablation
With the patient standing, the dilated veins are carefully marked with
Pathophysiology an indelible marker.
Venous valve failure, usually at the saphenofemoral junction The saphenous vein is surgically disconnected from the femoral vein
(and sometimes in perforating veins), results in increased venous and the perforators are also ablated.
pressure in the long saphenous vein with progressive vein dilata- The elongated veins are removed via multiple stab incisions and long
tion and further valve disruption. segments above the knee are removed using a vein stripper.
Postoperatively compression stockings are worn for several weeks and
exercise is encouraged.
Clinical features
Surgery is the most effective treatment for large varicose veins, but
Asymptomatic.
recurrence rates are high.
Cosmetic appearance.
Varicose veins 149

68 Pulmonary collapse and postoperative pneumonia
TYPES OF PNEUMONIA
Oedema Haemorrhage White cell infiltrate
(Congestion) ('Red hepatization') ('Grey hepatization')
Resolution
Broncho- Lobar Interstitial
Bacteria Bacteria Viral
Staphylococci Streptococcus Influenza
Haemophilus Klebsiella CMV
Coliforms Adenovirus
Fungi Pneumocystis
Aspergillus
COMPLICATIONS OF PNEUMONIA
Haemoptysis Hypoxia
Lung abscess Metastatic abscess
Pleural effusion
Chronic metabolic
SIADH compensation 8.0 PaCO2
Oliguria
Chronic Hyponatraemia HCO3 Acute 5.3
Thirst (mMol) respiratory
acidosis
Base 4.1
excess
Fibrosis
25
Empyema
Cor pulmonale 7.4 pH

Bronchiectasis (pulmonary hypertension) EFFECTS OF PNEUMONIA

Definitions Diabetes.
Pulmonary collapse or atelectasis results from alveolar hypo- Post-CVA.
ventilation such that the alveolar walls collapse and become Immunodeficiency states.
de-aerated. Pneumonia is an infection with consolidation of the Postsplenectomy.
pulmonary parenchyma. Atelectasis postsurgery.
Clinical features
Pulmonary collapse
KEY POINTS
Thoracoabdominal incisions are at high risk of postoperative
Pyrexia.
pulmonary collapse and infection. Tachypnoea.
Aggressive prophylaxis is key to prevention of complications. Diminished air entry.
Postoperative pneumonia is often due to mixed organisms. Bronchial breathing.
Pneumonia
Respiratory distress.
Aetiology/pathophysiology Painful dyspnoea.
Postoperatively patients frequently develop atelectasis, which Tachypnoea.
may develop into a pneumonia. Productive cough haemoptysis.
Hypoxiabconfusion.
Pulmonary collapse Diminished air entry.
Proximal bronchial obstruction. Consolidation.
Trapped alveolar air absorbed. Pleural rub.
Common in smokers. Cyanosis.
Common with chronic bronchitis.
Investigations
Pneumonia Chest X-ray: consolidation, pleural effusion, interstitial
Infection with microorganisms. infiltrates, air-fluid cysts.
Bacterial: Streptococcus pneumoniae, Staphylococcus, Hae- Sputum culture: essential for correct antibiotic treatment.
mophilus influenzae. Blood gas analysis: diagnosis of respiratory failure.
Viral: influenza, CMV.
Fungal: Candida, Aspergillus.
Protozoal: Pneumocystis, Toxoplasma. ESSENTIAL MANAGEMENT
Prophylaxis
Predisposing factors Preoperative deep-breathing exercises.
Secretional airway obstruction. Incentive spirometry.
Bronchorrhoea postsurgery. Adequate analgesia postoperatively.
Mucus plugs block bronchi. Early ambulation.
Impaired ciliary action.
Postoperative pain prevents effective coughing (especially Treatment
thoracotomy and upper laparotomies). Intensive chest physiotherapy.
Organic airway obstruction. Respiratory support: humidified O2 therapy; adequate hydration;
Bronchial neoplasm. bronchodilators if bronchospasm is present.
Specific antimicrobial therapy.
Patients prone to severe pneumonia
The elderly.
Alcoholics. Complications
Chronic lung and heart disease. Respiratory failure.
Debilitated patients. Lung abscess.
Pulmonary collapse and postoperative pneumonia 151

69 Bronchial carcinoma
COMPLICATIONS and EFFECTS Phrenic nerve palsy Recurrent laryngeal nerve palsy
Local direct spread Brachial plexus
palsy Horner's syndrome (T1)
Rib destruction Oesophageal obstruction

SVC obstruction
Local pulmonary
Pneumonia
Collapse Atrial fibrillation
Abscess
Pleurisy
Metastatic
Pleural effusion
Anorexia
Empyema
Anaemia
Cachexia
Endocrine
ACTH
Marantic PTH
endocarditis ADH
5HT
Nephrotic syndrome Thrombophlebitis migrans

(membranous
glomerulonephritis) Finger clubbing Encephalopathy
Cerebellar degeneration
Myelopathy
Hypertrophic Neuropathy
Pulmonary Myasthenic syndrome
Osteo Myopathy
Arthropathy Myositis
STAGING
T < 3 cm > 3 cm Carinal Heart

Segmental Central Chest wall Mediastinum
Parenchymal Subpleural Diaphragm Pleural effusion
1 2 3 4
N Ipsilateral Subcarinal Contralateral

Hilar Paratrachial Extrathoracic
Mediastinal
1 2 3
M 1 Present

Definition Neuropathy, myopathy, hypertrophic osteoarthropathy.
Malignant lesion of the respiratory tree epithelium. Endocrine syndromes (ACTH is secreted by oat-cell tumours,
parathormone is secreted by SCCbhypercalcaemia).
Pancoasts tumour (apical tumour invading sympathetic trunk
KEY POINTS and brachial plexus)bHomers syndrome, brachial neuralgia,
Symptoms may be masked by coexistent lung pathology (COPD). paralysis of upper limb.
Bronchial carcinoma often presents late and most are non-resectable. Dysphagia and broncho-oesophageal fistula.
Surgically resectable tumours have a fair prognosis. Superior vena caval obstruction.
Investigations
Epidemiology Diagnostic
Male/female 5 : 1. Uncommon before 50 years. Most patients Chest X-raybPA and lateral (lung opacity, hilar lym-
are in their 60s. Accounts for 40 000 deaths per annum in the phadenopathy).
UK. CT-guided lung biopsy.
Sputum cytology.
Aetiology Bronchoscopy and cytology of brushings or lavage fluid.
The following are predisposing factors.
Cigarette smoking. Assess operability
Air pollution. Helical CT scan of thorax/abdomen: involvement of adjacent
Exposure to uranium, chromium, arsenic, haematite and structures, hepatic metastases, multiple primary lesions.
asbestos. Bone scan: metastases.
Liver ultrasound: metastases.
Pathology Mediastinoscopy: involvement of mediastinal nodes.
Histology Lung function test: likely patient tolerance of pulmonary
Squamous carcinoma: 50%. resection.
Small-cell (oat-cell) carcinoma: 35%.
Adenocarcinoma: 15%.
Spread Surgical
Direct to pleura, recurrent laryngeal nerve, pericardium, Indicated only for non-small cell tumours when tumour is confined to
oesophagus, brachial plexus. one lobe or lung, no evidence of secondary deposits, carina is tumour
Lymphatic to mediastinal and cervical nodes. free on bronchoscopy.
Haematogenous to liver, bone, brain, adrenals. Operation: lobectomy or pneumonectomy.
Transcoelomic pleural seedlings and effusion.
Palliative
Clinical features Radiotherapy (small-cell carcinoma most radiosensitive): stop
haemoptysis, relieve bone pain from secondaries, relieve superior vena
History of tiredness, cough, anorexia, weight loss.
caval obstruction.
Productive cough with purulent sputum.
Haemoptysis.
Finger clubbing.
Bronchopneumonia (secondary infection of collapsed lung Prognosis
segment distal to malignant bronchial obstruction). Following curative resection 5-year survival rates are approx-
Pleuritic pain. imately 2030%, but overall 5-year survival is only about 6%.
Bronchial carcinoma 153

70 Urinary tract infection
Pyelonephritis
Renal abscess
Tuberculosis
Colovesical fistula Pyogenic cystitis

Bladder stone
Bladder tumour
Prostatitis

Definitions Investigations
A urinary tract infection (UTI) is a documented episode of Gram stain and culture of a clean-catch urine specimen before
significant bacteriuria (i.e. an infection with a colony count of antibiotics have been given. Usual organisms are E. coli, Entero-
>100 000 single organisms per ml) which may affect the upper bacter, Klebsiella, Proteus (suggests presence of urinary calculi).
( pyelonephritis, renal abscess) or the lower (cystitis) urinary
tract or both. Upper urinary tract infection
FBC.
U+E and serum creatinine: renal function.
KEY POINTS Renal ultrasound: swelling in pyelonephritis, stones, obstruc-
Lower UTI is usually harmless and simple to treat. tion/hydronephrosis, secondary abscess.
Upper UTI may be associated with renal damage and major IVU: stones, structural abnormalities, obstructed collecting
complications and requires prompt investigation and treatment. system.
Consider an underlying cause in all recurrent or atypical infections. CT scan: abscess/tumours.
Isotope scan (DPTA, DMSA): renal tubuloglomerular
function.
Epidemiology
UTI is a very common condition in general practice (usually Lower urinary tract infection
Escherichia coli) and accounts for 40% of hospital-acquired FBC.
(nosocomial) infections (often Enterobacter or Klebsiella). Cystoscopy only if haematuriabunderlying neoplasm or
stones.
Risk factors If obstruction is present ultrasound scan, IVU and cystoscopy
Urinary tract obstruction. may be needed.
Instrumentation of urinary tract (e.g. indwelling catheter).
Dysfunctional (neuropathic) bladder.
Immunosuppression. ESSENTIAL MANAGEMENT
Diabetes mellitus. Treat the infection with an appropriate antibiotic based on urine culture
Structural abnormalities (e.g. vesicoureteric reflux). results and deal with any underlying cause (e.g. relieve obstruction).
Pregnancy. High fluid intake should be encouraged and potassium citrate may relieve
dysuria.
Pathology
Upper tract UTIs, epididymo-orchitis and prostatitis
Ascending infection: most UTIs caused in this way (bacteria
i.v. antibiotic therapy (ciprofloxacin, gentamicin, cefuroxime,
from GI tract colonize lower urinary tract).
co-trimoxazole).
Haematogenous spread: infrequent cause of UTI (seen in i.v.
Relieve acute obstruction with internal (stent) or external
drug users, bacterial endocarditis and TB).
(nephrostomy) drainage (especially if acute severe sepsis).
An abscess will require drainage either radiologically or surgically.
Clinical features
Upper urinary tract infection Cystitis and uncomplicated lower UTI
Fever, rigors/chill. Oral antibiotics (trimethoprim, ciprofloxacin, nitrofurantoin,
Flank pain. cephradine).
Malaise. If there is a poor response to treatment consider unusual urinary
Anorexia. infections: tuberculosis (sterile pyuria), candiduria, schistosomiasis,
Costovertebral angle and abdominal tenderness. Chlamydia trachomatis, Neisseria gonorrhoeae.
Recurrent infections should raise the possibility of underlying
Lower urinary tract infection abnormalities requiring investigation.
Dysuria.
Frequency and urgency.
Suprapubic pain. Complications
Haematuria. Bacteraemia and septic shock.
Scrotal pain (epididymo-orchitis) or perineal pain (prostatitis). Renal, perinephric and metastatic abscesses.
Renal damage and acute/chronic renal failure.
Chronic and xanthogranulomatous pyelonephritis.
Urinary tract infection 155

71 Benign prostatic hypertrophy
DETRUSOR INSTABILITY PROBLEMS BLADDER FAILURE PROBLEMS

Frequency Dribbling
Low volume micturition Leakage Overflow
Urgency Infections
Vmax
Pronounced detrusor contractions
At lower pressure PB Weak/absent
Higher frequency detrusor activity
Higher tonicity Bladder
Atonic VB
Vmax
Insensitive
PB Weak
Dilated
VB
Prolonged P
Bladder Stasis
Hypertrophied
Trabeculated
Thickened RENAL PROBLEMS
Hydronephrosis
Pyonephrosis
Uraemia
Stones
Prolonged
resistance to flow
NORMAL
OUTFLOW PROBLEMS ONLY
Sustained
Poor stream
coordinated
Hesitancy Periods of detrusor
Terminal dribbling detrusor Vmax contraction
Bladder N activity
N Vmax
PBladder Voiding
Voiding normal
PB
slow
VBladder
VB

Definition Further investigations
Benign prostatic hypertrophy (BPH) is a condition of unknown Voiding diary.
aetiology characterized by an increase in size of the inner zone Uroflowmetry and residual volume measurement (normal
(periurethral glands) of the prostate gland. <100 ml): evidence of obstruction.
Ultrasonography of kidneys and bladder: structural
abnormalities.
KEY POINTS Transrectal ultrasound: to determine prostate size.
Symptoms of BPH are initially due to outflow problems, then bladder IVU: structural abnormalities.
instability, then bladder failure. Cystoscopy.
Early treatment of symptoms prevents/reverses bladder damage and
complications.
Surgical resection is safe but is associated with some significant ESSENTIAL MANAGEMENT
complications. Medical
Alter oral fluid intake, reduce caffeine intake.
-Adrenergic blockers (e.g. phenoxybenzamine, prazosin).
Epidemiology Anti-androgens acting selectively at prostatic cellular level (e.g.
Present in 50% of 6090-year-old-men. finasteride).
Intermittent self-catheterization if detrusor failure.
Pathophysiology Balloon dilatation and stenting of prostate (unfit patient).
Microscopic stromal nodules develop around the periurethral
glands. Surgical
Glandular hyperplasia originates around these nodules. Majority of patients are treated surgically.
As the gland increases in size, it compresses the urethra, lead- Surgical removal of the adenomatous portion of the prostate.
ing to urinary tract obstruction. TURP with electrocautery or laser.
Thermal ablation of prostate.
Open prostatectomy if large which may be transvesical or
Clinical features
retropubic.
Initially outlet obstruction:
Weak stream, hesitancy, intermittency, dribbling, straining to
void, acute urinary retention.
Subsequent detrusor instability: Complications of surgical treatment
Frequency, urgency, nocturia, dysuria, urge incontinence. Postoperative haemorrhage and clot retention.
Finally detrusor failure and chronic retention: UTI.
Palpable (or percussible) bladder, overflow incontinence. Retrograde ejaculation, impotence.
Enlarged smooth prostate on digital rectal examination. TURP syndrome: in 2% of patients absorption of irrigation
fluid via venous sinuses in the prostate causes hyponatraemia,
Investigations hypotension and metabolic acidosis.
Basic investigations Incontinence.
Urinalysis and urine culture for evidence of infection or Urethral stricture.
haematuria.
FBC: infection. Prognosis
U+E and serum creatinine: renal function. The majority of patients have a very good quality of life after
PSA: suspicion of underlying malignancy. prostatectomy (endoscopic or open).
Benign prostatic hypertrophy 157

72 Renal calculi
TYPES FEATURES
60% Oxalate Spiky

Hard Renal destruction
Discoloured by blood Pyonephrosis
Soft Pyelonephritis
30%+ Phosphate Chalky Hydronephrosis
Faceted Pelvi-ureteric obstruction
Large 'staghorn' fragile Renal colic
Haematuria
5% Urate Some pale yellow/brown
Hydronephrosis
Hard
Pyelonephritis
Bladder irritation
Haematuria
Frequency
Pain Vesico-ureteric obstruction
Renal colic
Bladder outflow obstruction Haematuria
Acute retention Hydronephrosis
Haematuria
NON-OPERATIVE TREATMENTS
Renal upper 1/3 ureter
Lower 1/3 ureter Percutaneous

Middle nephrostomy
1/3 ureter
Uretero-rhinoscopy
Bladder
Endoscopic Extracorporeal
retrieval/destruction shock wave lithotripsy

Definition Ureteric colicbsevere colicky pain radiating from the loin to
Renal calculi are concretions formed by precipitation of various the groin and into the testes or labia associated with gross or
urinary solutes in the urinary tract. They contain calcium oxalate microscopic haematuria.
(60%), phosphate as a mixture of calcium, ammonium and mag- Bladder calculi present with sudden interruption of urinary
nesium phosphate (triple phosphate stones are infective in ori- stream, perineal pain and pain at the tip of the penis.
gin) (30%), uric acid (5%) and cystine (1%).
Investigations
FBC, U+E, serum creatinine, calcium, phosphate, urate, pro-
KEY POINTS teins and alkaline phosphatase.
Calculi may develop because of or cause UTIs. Urine microscopy for haematuria and crystals.
Most stones pass without complication. Urine culture: secondary infection.
Most stones are managed non-surgically. Plain abdominal X-ray: 90% of renal calculi are radio-opaque.
IVU: confirms the presence and identifies the position of the
stone in the genito-urinary tract.
Epidemiology A renogram: may be indicated with staghorn calculi to assess
Male > female. Early adult life. Among Europeans prevalence is renal function.
3%. 24-hour urine collection when patient is at home in normal
environment.
Pathogenesis Stone analysis: origin.
Hypercalciuria: 65% of patients have idiopathic hypercalciuria.
Nucleation theory: a crystal or foreign body acts as a nucleus
for crystallization of supersaturated urine. ESSENTIAL MANAGEMENT
Stone matrix theory: a protein matrix secreted by renal tubu- Pain relief for ureteric colic: pethidine, diclofenac. High fluid intake.
lar cells acts as a scaffold for crystallization of supersaturated 80% of ureteric stones pass spontaneously. Stones of <4 mm in
diameter almost always pass, >6 mm almost never pass.
urine.
Indications for intervention:
Reduced inhibition theory: reduced urinary levels of naturally
kidney stones: symptomatic, obstruction, staghorn;
occurring inhibitors of crystallization.
ureteric stones: failure to pass, large stone, obstruction, infection;
Dehydration.
bladder stones: all to prevent complications;
Infection: staghorn triple phosphate calculi are formed by the
sepsis super-added: nephrostomy.
action of urease-producing organisms (Proteus, Klebsiella),
which produce ammonia and render the urine alkaline.
Schistosomiasis predisposes to bladder calculi (and cancer).
Interventional procedures
Pathology ESWL for small/medium kidney stones.
Staghorn calculi are large, fill the renal pelvis and calices, and Percutaneous nephrolithotomy for large kidney stones and
lead to recurring pyelonephritis and renal parenchymal damage. staghorn calculi.
Other stones are smaller, ranging in size from a few milli- ESWL or contact lithotrypsy for upper ureteric stones (above
metres to 12 cm. They cause problems by obstructing the urinary pelvic brim).
tract, usually the ureter. Calyceal stones may cause haematuria Contact lithotrypsy or extraction with a Dormia basket for
and bladder stones may cause infection. Chronic bladder stones lower ureteric stones.
predispose to the unusual squamous carcinoma of the bladder. Open surgery: ureterolithotomy or nephrolithotomy.
Mechanical lithotrypsy or open surgery for bladder stones.
Clinical features
Calyceal stones may be asymptomatic.
Staghorn calculi present with loin pain and upper-tract UTI.
Renal calculi 159

73 Renal cell carcinoma
METASTASES
Haemorrhage
Brain
Haemorrhagic areas Large foamy cells
Cystic Upper pole
Attempts at
Liver Yellow tubule formation
Smooth Vascular
Lung
('cannon ball'
solitary metastasis)
Pain Body wall invasion
Haematuria
Flank mass
DIFFERENTIAL DIAGNOSIS OF HAEMATURIA Renal vein invasion
Renal
Cyst
Infection
Stone
Infarction DIFFERENTIAL DIAGNOSIS OF FLANK MASS
Ureteric
Tumour
Splenomegaly Adrenal tumour
Stone
(left)
Retroperitoneal
Bladder tumours Renal cyst
Tumour
Stone Colonic
Cystitis tumour
Prostatic
BPH

Definitions Haematogenous to lung (large, cannon-ball metastases),
Malignant lesion (adenocarcinoma) of the kidney epithelium bones and contralateral kidney.
(also known as hypernephroma and Grawitz tumour).
Clinical features
Triad of haematuria (5060%), flank pain (3550%), palpable
KEY POINTS abdominal mass (2545%). All three are present in <10% of
New, significant haematuria always requires investigation and may patients.
represent renal cell carcinoma (RCC). Hypertension, polycythaemia (due to decreased blood flow to
Consider RCC in unexplained anaemia, vague abdominal symptoms JGA renin, erythropoietin).
and recurrent UTIs. Anaemia, weight loss, PUO.
Surgery offers the best hope of long-term survival. Hypercalcaemia, ectopic hormone production (ACTH, ADH).
Tumours are occasionally familial and a family history should be Liver dysfunction (raised enzymes and prolonged PT) in the
sought. absence of metastatic disease.
Renal carcinoma is one of the great mimics of medicine.
Epidemiology Investigations
Male/female 2 : 1. Uncommon before 40 years. Accounts for FBC: anaemia, polycythaemia.
23% of all tumours in adults and 85% of all renal tumours. (The ESR.
other renal tumours are urothelial tumours, Wilms tumour and U+E, creatinine: renal function.
sarcomas.) LFTs: metastases.
Urine culture: infection.
Aetiology Abdominal ultrasound: assess renal mass and IVC.
Predisposing factors Helical CT scan: assess renal mass, fixity, nodes.
Diet: high intake of fat, oil and milk. IVU: image renal outline.
Toxic agents: lead, cadmium, asbestos, petroleum by-products. Cavagram and echocardiogram: assess IVC and right atrium
Smoking. involvement.
Genetic factors: oncogene on short arm of chromosome 3,
HLA antigen BW-44 and DR-8.
Other diseases: von HippelLindau (VHL) syndrome, adult ESSENTIAL MANAGEMENT
polycystic disease, renal dialysis patients. Surgical
Offers best chance of long-term survival.
Pathology Partial: if Stage I and part of VHL presentation.
Histology Radical: aim to remove kidney, renal vessels, upper ureter, adrenal and
Adenocarcinoma (cell of origin is the proximal convoluted Gerotas fascia.
Isolated lung metastases may also be removed surgically with good
tubular cell).
results.
Staging
Palliative
TNM staging.
Renal artery embolization (may stop haematuria).
Robson stages IIV
Chemotherapy (only 10% response rate).
Stage I: tumour confined within renal capsule.
Hormone therapy (only 5% response rate).
Stage II: tumour confined by Gerotas fascia. Immunotherapy (currently under review).
Stage III: tumour to renal vein or IVC, nodes or through
Gerotas fascia.
Stage IV: distant metastases or invasion of adjacent organs.
Prognosis
Overall survival is 40% at 5 years.
Spread
Direct into renal vein and perirenal tissue.
Lymphatic to periaortic and hilar nodes.
Renal cell carcinoma 161

74 Carcinoma of the bladder
TYPES
'Polyp' Solid mass Infiltrating mass
Haematuria Sterile pyuria Infection Pneumaturia
STAGES
T0 T1 T2 T3a T3b T4a
Elderly Young
TURT ? CYSTECTOMY ? Palliative TURT/DXT
or + chemotherapy
DXT + TURT
30% 20% 25% 25%
0 Rec 1 Rec Infrequent Frequent
Rec Rec
TURT + chemotherapy

Definition Lymphatic to periaortic nodes.
Malignant lesion of the bladder epithelium. Haematogenous to liver and lung.
Clinical features
KEY POINTS Painless intermittent haematuria (95%).
Commonly presents with haematuria. Dysuria or frequency (10%).
Ranges from benign acting recurrent bladder polyps to rapidly
progressive infiltrating masses. Investigations
Transitional cell lesions are a field change and often multiple. Urine cytology.
IVU: occult upper tract tumours.
Cystourethroscopy.
Epidemiology FBC: anaemia.
Male > female. Uncommon before 50 years. Increasing incidence U+E creatinine: renal function.
of bladder cancer in recent years. Death rate is 7.6/100 000. Ultrasound: obstruction.
CT scan: local invasion, distant metastases.
Aetiology
Predisposing factors:
Exposure to carcinogens in rubber industry (1- and 2-naphthyl- ESSENTIAL MANAGEMENT
amine, benzidine, aminobiphenyl). Carcinoma in situ (TIS)
Smoking, tryptophan metabolites, phenacitan. Intravesical chemotherapy for isolated carcinoma-in-situ and
Bladder schistosomiasis, and chronic bladder stones (squam- associated with papillary tumours.
ous carcinoma). Cystourethrectomy for unresponsive lesions and malignant
Congenital abnormalities (extrophy of the bladder) cystitis.
(adenocarcinoma).
Superficial tumours (Ta, T1)
TURT and follow-up cystoscopy.
Pathology
If recurrences or increased risk of invasion (large tumours, multiple
Histology
tumours, severe dysplasia or carcinoma-in-situ) intravesical
Transitional cell carcinoma (TCC).
chemotherapy (mitomycin-C, BCG).
Squamous cell carcinoma (rare).
Persistent recurrences despite therapybcystourethrectomy.
Adenocarcinoma (rare).
Invasive tumours (T2, T3)
Staging for TCC TURT + radical radiotherapy; or
Radical cystectomy (and reconstruction or urinary diversion, e.g. by
TIS Carcinoma in situ ileal conduit).
Superficial tumours Ta Tumour confined to urothelium

Fixed tumours (T4)
T1 Lamina propria involved
Chemotherapy: MVAC (methotrexate, vinblastine, adriamycin,
Invasive tumours T2 Superficial muscle invasion cisplatin), CMV (cisplatin, methotrexate, vinblastine), Cisca (cisplatin,
T3a Deep muscle invasion cyclophosphamide, adriamycin).
T3b Serosal involvement
Radiotherapy and TURT for palliation.
Fixed tumours T4a Invasion of prostate, uterus or vagina
T4b Fixation to pelvic wall
Prognosis
Superficial tumours: 75% 5-year survival.
Spread Invasive tumours: 10% 5-year survival.
Direct into pelvic viscera (prostate, uterus, vagina, colon, Fixed tumours and metastases: median survival 1 year.
rectum). Long-term follow-up required for life.
Carcinoma of the bladder 163

75 Carcinoma of the prostate
FACTORS INVOLVED PRESENTATION
Testosterone Genetic ( in negro males)

Metastases (20%) Urinary tract
outflow symptoms
(70%)
Haematuria (10%)
Tumour of true
(para)urethral glands N2
Cadmium Age
T0 N1
N
T
T1
T2 M
T3
Lungs
T4 Bone
Spine
Pelvis
Long bones
Osteosclerotic
TREATMENT
T0 T1/2 early T3/4 late
or or
TURP + Radical Radical Local disease Metastasis
observation
Prostatectomy Radiotherapy Palliative radiotherapy

Hormonal therapy Hormonal therapy Palliative hormonal therapy
TURP for obstruction

Definition Spread
Malignant lesion of the prostate gland. Direct into remainder of gland and seminal vesicles.
Lymphatic to iliac and periaortic nodes.
Haematogenous to bone (usually osteosclerotic lesions), liver,
KEY POINTS lung.
Prostatic cancer is common and should be considered in all new
symptoms of lower urinary tract obstruction. Clinical features
Increasingly found (asymptomatic) by screening. Bladder outflow obstruction (poor stream, hesitancy,
Early treatment offers good 5-year survival with combined surgery and nocturia).
hormonal adjuvants. Symptoms of advanced disease (ureteric obstruction and hydro-
Late presentation disease is best managed medically and has a poor nephrosis or bone pain from metastases, classically worse at
outlook. night).
Nodule or mass detected on rectal examination.
Epidemiology Investigations
Uncommon before 60 years. 80% of prostate cancers are clinic- FBC: anaemia.
ally undetected (latent carcinoma) and are only discovered on U+E, creatinine: renal function.
autopsy. The true incidence of this disease is considerably higher Specific markers: PSA, alkaline and acid phosphatase.
than the clinical experience would indicate. Transrectal ultrasound and MRI: local staging.
Needle biopsy of the prostate: tissue diagnosis.
Aetiology Bone scan: metastases.
Increasing age.
More common in negro males.
Hormonal factors: prostate cancer growth is enhanced by ESSENTIAL MANAGEMENT
testosterone and inhibited by oestrogens or antiandrogens. T0: observation, repeated digital (or ultrasound) examination and PSA.
T1+2: radical prostatectomy or radical radiotherapy, or interstitial
radiation with 125I or 198Au.
Pathology
T3+4: external beam radiation hormonal therapy.
Prostatic tumours are often multicentric and located in the
Metastatic: hormonal manipulation, bilateral orchidectomy,
periphery of the gland.
stilboestrol, LH-RH agonists, antiandrogens (cyproterone acetate),
radiotherapy and strontium for bony metastases.
Histology
Adenocarcinoma arising from glandular epithelium.
Gleason grading (15) is used to grade differentiation.
Prognosis
Localized tumours: 80% 5-year survival.
Staging
Local spread: 40% 5-year survival.
Metastases: 20% 5-year survival.
T0 Unsuspected
Localized T1 Histological diagnosis only
(clinical, radiology ve)
T2 Palpablebconfined within prostate
Local spread T3 Spread to seminal vesicles
T4 Spread to pelvic wall
T14, M1 Metastatic disease
Carcinoma of the prostate 165

76 Testicular cancer
III Supradiaphragmatic
nodes or metastases
II Infradiaphragmatic
nodes
TD Teratoma differentiated
MTI Malignant T intermediate
MTU Malignant T undifferentiated
MTA Malignant T anaplastic
I Local tumour
Increasing risk
STAGES OF SPREAD of metastasis
SEMINOMA TYPES OF TERATOMA
Placental -fetoprotein
alkaline phosphatase -HCG
Homogeneous Non-seminoma teratoma

Smooth Heterogeneous
Sheets of similar cells Firm Haemorrhagic Wide cell variety
Small White/grey Soft Elements of varying morphology
Round Highly pleomorphic
Spermatogenic-like cells
TREATMENT
I II III I II III
+ + + + + +
? +
DXT DXT Chemotherapy Dissection Dissection + Chemotherapy

chemotherapy

Malignant lesion of the testis. Painless swelling of the testis, often discovered incidentally or
after trauma.
Vague testicular discomfort common, bleeding into tumour
KEY POINTS
may mimic acute torsion.
All newly discovered testicular lumps require investigation to exclude
Rarely evidence of metastatic disease or gynaecomastia.
malignancy.
Examination reveals a hard, irregular, non-tender testicular
Early tumours have an excellent prognosis with surgery alone.
mass.
Late tumours have a good prognosis with surgery and medical
therapy.
Orchidectomy for tumour should be via a groin incision.
Investigations
Blood for tumour markers, i.e. AFP and -HCG.
AFP is elevated in 75% of embryonal and 65% of teratocarci-
Epidemiology noma.
Age 2040 years. Commonest solid tumours in young males. AFP is not elevated in pure seminoma or choriocarcinoma.
-HCG is elevated in 100% choriocarcinoma, 60% embryonal
Aetiology carcinoma, 60% teratocarcinoma and 10% pure seminoma.
Cryptorchidismb50-fold increase in risk of developing tes- Scrotal ultrasound: diagnosis.
ticular cancer. Risk is unaffected by orchidopexy. Chest X-ray to assess lungs and mediastinum: metastases.
Higher incidence in white men. CT scan of chest and abdomen: to detect lymph nodes.
Laparoscopy (retroperitoneoscopy): to assess abdominal
Pathology nodes.
Classification of testicular tumours
Germ-cell tumours (90%) (secrete AFP and (-HCG)):
seminoma; ESSENTIAL MANAGEMENT
non-seminomabembryonal carcinoma, teratocarcinoma, Radical orchidectomy (via groin incision) and histological diagnosis.
choriocarcinoma. Further treatment depends on histology and staging.
Stromal tumours:
Leydig cell; Seminoma
Sertoli cell; Stage I: radiotherapy to abdominal nodes.
granulosa cell. Stage II: radiotherapy to abdominal nodes.
Metastatic tumours. Stage III: chemotherapy (bleomycin, etoposide, cisplatin).
Non-seminoma germ cell

Staging
Stage 1: Retroperitoneal lymph node dissection (RPLND).
Stage I: confined to scrotum.
Stage II: chemotherapy + RPLND.
Stage II: spread to retroperitoneal lymph nodes below the
Stage III: chemotherapy (+ RPLND if good response).
diaphragm.
Stage III: distant metastases.
Spread Prognosis
Germ-cell tumours metastasize to the para-aortic nodes, lung Overall cure rates are over 90% and node-negative disease has
and brain. almost 100% 5-year survival.
Stromal tumours rarely metastasize.
Testicular cancer 167

77 Urinary incontinence
TYPES
STRESS URGE NEUROPATHIC ANATOMICAL

Pelvic floor injury Detrusor instability Head injury Vesicovaginal fistula
Spinal injury
Peripheral nerve injury
FEATURES
Bladder
Volume infusion graphs
Lack of reflex
coordinated emptying
reflex
Detrusor Normal
contractions curve
Pressure
Pressure
Pressure
Pressure
Leak
Time Time Time Time

Cough Early Dripping
voiding leak
TREATMENT
Anti-UTI
Vaginal oestrogens
Anticholinergics
Ventral suspension
Burch
Catheter
Stamey
Indwelling Repair
Intermittent
Ant. vaginal repair

Urinary incontinence is defined as the involuntary loss of urine. Stress incontinence: loss of urine during coughing, straining,
etc. These symptoms are quite specific for stress incontinence.
Urge incontinence: inability to maintain urine continence in
KEY POINTS the presence of frequent and insistent urges to void.
A common and socially disabling condition. Nocturnal enuresis: 10% of 5-year-olds and 5% of 10-year-
Full assessment and investigation is required to elicit precise cause olds are incontinent during sleep. Bed wetting in older children
and tailor treatment properly. is abnormal and may indicate the presence of an unstable bladder.
Always assess if bladder full or empty (overflow or otherwise). Symptoms of urinary infection (frequency, dysuria, nocturia), ob-
struction (poor stream, dribbling), trauma (including surgery,
e.g. abdominoperineal resection), fistula (continuous dribbling),
Physiology neurological disease (sexual or bowel dysfunction) or systemic
Normal bladder capacity is 350400 ml. As the bladder fills with disease (e.g. diabetes) may point to an underlying cause.
urine, the detrusor muscle relaxes to accommodate the rise in
volume without a rise in pressure (plasticity). When the bladder Investigations
is full, stretch receptors in the bladder wall initiate a reflex con- Urine culture: to exclude infection.
traction (via S3,4) of the detrusor muscle and relaxation of the IVU: to assess upper tracts and obstruction or fistula.
urinary sphincter to empty the bladder. This spinal reflex is con- Urodynamics:
trolled by an inhibitory cortical mechanism, which allows con- uroflowmetry: measures flow rate;
scious control over micturition. Conscious control develops cystometry: demonstrates detrusor contractures;
during early childhood. video cystometry: shows leakage of urine on straining in
patients with stress incontinence;
Classification urethral pressure flowmetry: measures urethral and bladder
Urethral incontinence pressure at rest and during voiding.
Urethral abnormalities: obesity, multiparity, difficult delivery, Cystoscopy: if bladder stone or neoplasm is suspected.
pelvic fractures, postprostatectomy. Vaginal speculum examination cystogram if vesicovaginal
Bladder abnormalities: neuropathic or non-neuropathic detru- fistula suspected.
sor abnormalities, infection, interstitial cystitis, bladder stones
and tumours.
Non-urinary abnormalities: impaired mobility or mental Urge incontinence
function. Medical treatment: modify fluid intake, avoid caffeine, treat any
underlying cause (infection, tumour, stone); bladder training;
Non-urethral incontinence anticholinergic/smooth muscle relaxants (oxybutinin, tolterdine).
Urinary fistula: vesicovaginal. Surgical treatment: cystoscopy and bladder distension, augmentation
Ureteral ectopia: ureter drains into urethra (usually a duplex cystoplasty.
ureter).
Stress incontinence
Pathophysiology Medical treatment: pelvic floor exercises, oestrogens for atrophic
Stress incontinence: urine leakage occurs when infra-abdom- vaginitis.
inal pressure exceeds urethral pressure (e.g. coughing, straining Surgical treatment: retropubic or endoscopic urethropexy, vaginal
or lifting), usually in the presence of urethral incompetence. repair, artificial sphincter.
Urge incontinence: idiopathic detrusor instability causes a rise
in intravesical pressure and urine leakage. Overflow incontinence
Detrusor hypereflexia: loss of cortical control results in an If obstruction present: treat cause of obstruction, e.g. TURP.
uninhibited bladder with unstable detrusor contractions. The If no obstruction: short period of catheter drainage to allow detrusor
bladder fills, the sacral reflex is initiated and the bladder empties muscle to recover from overstretching, then short course of detrusor
muscle stimulants (bethanehol; distigmine). If all else fails, clean
spontaneously.
intermittent self-catheterization (neurogenic overflow incontinence).
Overflow incontinence: damage to the efferent fibres of the
sacral reflex causes bladder atonia. The bladder fills with urine
Urinary fistula
and becomes grossly distended with constant dribbling of urine,
Always requires surgical treatment.
e.g. chronic bladder distension from obstruction.
Urinary incontinence 169

78 Paediatric general surgery
Gastro-oesophageal reflux Management

Definition Correct dehydration and electrolyte imbalance with 0.45%
This is a common condition characterized by incompetence of NaCl in dextrose 5% with added K+. May take 2448 hours to
the lower oesophageal sphincter, resulting in retrograde passage become normal.
of gastric contents into the oesophagus, leading to vomiting. Ramstedts pyloromyotomy via transverse RUQ or per umbil-
ical incision. Normal feeding can commence within 24 hours.
Aetiology
Immaturity of lower oesophageal sphincter; short intra-abdom- Malrotation of the gut
inal oesophagus. Definition and aetiology
Malrotation describes a number of conditions that are caused by
Clinical features failure of the intestine to rotate into the correct anatomical posi-
Vomiting, usually bile-stained, not related to feeds, may con- tion during embryological development. Midgut volvulus, inter-
tain blood (indicates oesophagitis) and rarely is projectile. nal herniae and duodenal and colonic obstruction may occur.
Failure to thrive may indicate repeated episodes of aspiration
and pneumonia. Clinical features
Bile-stained vomiting in the newborn period is the commonest
Investigation presentation but older children may present with recurrent
If oesophagitis, stricture, anaemia or aspiration is suspected, a abdominal pain, abdominal distension and vomiting.
barium swallow, oesophagoscopy and biopsy, 24-hour pH mon-
itoring and oesophageal manometry are indicated. Management
Surgery is required to release the obstructions.
Treatment
As there is a natural tendency towards spontaneous improve- Meckels diverticulum
ment with age, a conservative approach is adopted initially: Definition
thickening of feeds, positioning infant in 30 head-up prone Meckels diverticulum is the remnant of the vitello-intestinal
position after feeds, antacids (e.g. Gaviscon), drugs to increase duct forming a blind-ending pouch on the antimesenteric border
gastric emptying and increase lower oesophageal sphincter tone of the terminal ileum and is present in 2% of the population.
(e.g. Cisapride).
Surgery (laparoscopic Nissen fundoplication) is reserved for Clinical features
failure for respond to conservative treatment with oesophageal Most are asymptomatic. May present with rectal bleeding,
stricture or severe pulmonary aspiration. mimic appendicitis (Meckels diverticulitis), be a lead point for
intussusception or cause a volvulus. Ectopic gastric mucosa in a
Infantile hypertrophic pyloric stenosis Meckels diverticulum is responsible for GI bleeding and may
Definition be detected by technetium pertechnate scan in 70% of cases.
This is a condition characterized by hypertrophy of the circular
muscle of the gastric pylorus that obstructs gastric outflow. Management
Surgical excision, even if found incidentally.
Aetiology
The aetiology is unknown but it affects 1 : 450 children; 85% Intussusception
male, often firstborn; 20% have family history. Definition
Intussusception is the invagination of one segment of bowel into
Clinical features an adjacent distal segment. The segment that invaginates is called
Non-bile-stained, projectile vomiting (after feeds) beginning the intussusceptum and the segment into which it invaginates the
at 26 weeks. intussuscepiens. The tip of the intussusceptum is called the apex
Baby is hungry, constipated and dehydrated. Loss of H+ and or lead point.
Cl from stomach and K+ from kidney causes hypochloraemic,
hypokalaemic alkalosis. Aetiology
Palpable pyloric tumour during a test feed or after vomiting. 90% are idiopathic.
Gastric peristalsis may be seen. Ultrasound or Barium meal if Viral infection can lead to hyperplasia of Peyers patches
diagnosis is uncertain. which become the apex of an intussusception.

Other lead points include Meckels diverticulum, a polyp or a Inguinal hernia and hydrocele
duplication cyst. Definition and aetiology
During the seventh month of gestation the testis descends from
Clinical features the posterior abdominal wall into the scrotum through a peri-
Commonest cause of intestinal obstruction in infants 312 toneal diverticulum called the processus vaginalis, which oblit-
months. Males > females. erates just before birth.
Presents with pain (attacks of colicky pain every 1520 min, An inguinal hernia in an infant is a swelling in the inguinal
lasting 23 min with screaming and drawing up of legs), pallor, area due to failure of obliteration of the processus vaginalis,
vomiting and lethargy between attacks. allowing bowel (rarely omentum) to descend within the hernial
Sausage-shaped mass in RUQ, empty RIF (sign de Dance). sac below the external inguinal ring.
Passage of blood and mucus (redcurrant jelly stool). A hydrocele is a collection of fluid around the testis that has
Tachycardia and dehydration. trickled down from the peritoneal cavity via a narrow, but patent,
processus vaginalis.
Diagnosis
Plain X-ray may show intestinal obstruction and sometimes Diagnosis
the outline of the intussusception. Diagnosis of a hydrocele is usually obvious: the scrotum con-
Ultrasonography may help showing RUQ mass. tains fluid and transilluminates brilliantly.
Definite diagnosis by air or (less common) barium enema. Diagnosis of a hernia may be entirely on the mothers given
history or a lump may be obvious.
Management Strangulation is a serious complication as it may compromise
i.v. fluids to resuscitate infant (shock is frequent because of bowel and/or the blood supply to the testis.
fluid sequesteration in the bowel).
Air or barium reduction of intussusception if no peritonitis Management
(75% of cases). Both hernia and hydrocele should be treated by operation to
Remainder require surgical reduction. obliterate the remaining processus vaginalis.
Inguinoscrotal conditions Undescended testis

Acute scrotum Definition and aetiology
Definition A congenital undescended testis (UDT) is one that has not
The acute scrotum is a red, swollen, painful scrotum caused by reached the bottom of the scrotum at 3 months post-term. A
torsion of the hydatid of Morgagni (60%), torsion of the testis retractile testis is one that can be manipulated to the bottom of
(30%), epididimo-orchitis (10%) and idiopathic scrotal oedema the scrotum. An ectopic testis is one that has strayed from the
(10%). normal path of descent.
Management Diagnosis
All cases of acute scrotum should be explored. Most UDTs are found at the superficial inguinal pouch and asso-
If true testicular torsion, treatment is bilateral orchidopexy ciated with hypoplastic hemiscrotum and inguinal hernia.
(orchidectomy of affected testis if gangrenous).
If torsion is hydatid of Morgagni, treatment is removal of Management
hydatid on affected side only. Treatment is by orchidopexy and should be performed at 612
months.
UDTs are at increased risk of developing malignancy, even
after orchidopexy and require long-term surveillance.
Paediatric general surgery 171

Index
Page numbers in italics indicate figures; those in appendix testis, torsion65 cardiac failure14, 15
bold indicate tables. arterial disease, extracranial144 5 cardiac tamponade78
arterial embolus54, 55 carotid artery disease144, 145
ABC trauma sequence78, 79 arterial thrombosis54, 55 carotid body tumour10, 11
abdominal hernias108 9 arterial ulcers56, 57 cauda equina lesion51
abdominal pain arteriovenous malformations, renal63 caustic oesophageal stricture12, 13
acute289 ascites32, 33 cellulitis53
chronic30 1 aspergilloma14, 15 central nervous system (CNS) depression66,
referred29 atelectasis150 1 67
abdominal swellings323 atheroma51 cervical lymphadenopathy10, 11
generalized33 cervical spine injury, potential79
giant32, 33 Bakers cyst, ruptured52, 53 Chagas disease12, 13
lower389 Barretts oesophagus85 chemical burns77
upper347 basal cell carcinoma (BCC), cutaneous57, 132, children170 1
abdominal wall swellings32, 33 133 cholangitis110, 111, 112, 113
achalasia12, 13 benign prostatic hypertrophy (BPH)61, 63, cholecystitis110, 112
acromegaly128, 129 156 7 acute111, 113
acute abdominal pain28 9 biliary colic110, 111, 112, 113 chronic111, 113
acute renal failure723, 77 bilirubin metabolism40 cholera45
Addisonian crisis131 bladder Chvosteks sign126, 127
Addisons disease130, 131 bleeding62, 63 cirrhosis of liver35
adhesions, intra-abdominal30, 31 masses38, 39 Clarkes levels133
adrenal (suprarenal) gland outflow obstruction60, 61, 156 claudication
disorders130 1 stones61, 63, 158, 159 intermittent50 1, 139
enlargement35 tumours (carcinoma)58, 59, 61, 63, 1623 neurological51
insufficiency131 blind loop syndrome (bacterial overgrowth)45, Clostridium difficile45
adrenogenital syndrome131 93 coeliac disease45, 93
airway obstruction66, 67, 78, 79 bone colon
amaurosis fugax145 fractures52, 53, 74 5 bleeding42, 43
amputations140 tumours52, 53 carcinoma39, 43, 45, 47, 1023
analgesia, postoperative67 Bornholms disease18, 19 masses34, 36, 37, 38, 39
aneurysms1423 bowel habit, altered46 7 polyps43
aortic37, 142, 143 see also constipation; diarrhoea colorectal carcinoma1023
false (pseudo)143 brain injury compartment syndrome74, 77
femoral artery48, 49 primary80, 81 Conns syndrome131
subclavian artery10, 11 secondary80, 81 constipation46
thrombosis54, 55 branchial cyst10, 11 absolute46
angina pectoris19, 134, 135 breast acute46
angiodysplasia41 abnormalities of normal development and chronic33, 46, 47
antibiotic-induced diarrhoea45 involution (ANDI)119 contrecoup injury80
antidiuretic hormone (ADH) deficiency129 abscess17, 19, 119 coronary artery disease135
anuria73 benign disease118 19 cor pulmonale150
anus carcinoma17, 21, 120 1 costochondritis (Tietzes disease)18, 19
benign disorders104 5 cysts17, 118, 119 Courvoisiers law41, 117
bleeding42, 43 fat necrosis17, 119 cramps, muscle53
carcinoma41 fibroadenoma16, 17, 119 Crohns disease45, 46, 93, 945
discharge104 fibrocystic disease (FCD)17, 19, 21, 118, 119 inflammatory mass39, 95
fissure41, 105 lumps16 17, 118 perianal43, 95
fistula105 pain18 19 cryptorchidism (undescended testis)48, 167,
lump104 bronchial adenoma14, 15 171
see also perianal disorders bronchial carcinoma14, 15, 1523 Curlings ulcers76, 77
aortic aneurysms37, 142, 143 bronchiectasis14, 15, 150 Cushings disease129, 131
abdominal (AAA)142, 143 burns76 7 Cushings syndrome130, 131
aortic incompetence (regurgitation)136, 137 full thickness76, 77 cystic hygroma10, 11
aortic rupture78 partial thickness76, 77 cystitis154
aortic stenosis136, 137 Wallaces rule of 9s76 acute58 9, 63
aortoduodenal fistula22, 23, 142 interstitial63
aorto-iliac occlusive disease50, 51, 138 caecum cystosarcoma phylloides17
apnoea67 carcinoma41, 42, 43, 102
appendicitis, acute28, 96 7 masses39 deep venous thrombosis (DVT)53, 1467
appendix mass/abscess38, 39, 96, 97 calcium metabolism126 dermoid cysts10, 11, 37
Index 173
detrusor gallstone ileus111 hypoxaemia67
hyperreflexia169 gallstones25, 110 13 hypoxia66 7, 78
instability156, 168, 169 gastric carcinoma23, 25, 37, 90 1
diabetes insipidus129 gastric ulcers23, 25, 88, 89 iliac artery stenosis50, 51
diabetes mellitus56, 57, 61 Curlings76, 77 incisional hernia109
diabetic foot140 1 gastritis23, 25 incontinence
diarrhoea44 5, 46 gastrointestinal (GI) bleeding22, 423 overflow60, 169
spurious45 gastro-oesophageal reflux84 5 urinary168 9
Dieulafoy lesion22, 23 in children170 indigestion25
diverticular disease42, 43, 47, 98 9 disease (GORD)12, 13, 85 infections
diverticular mass38, 39 see also oesophagitis, reflux in burned patients77
diverticulitis, acute98, 99 germ-cell tumours, testicular167 cervical lymphadenopathy11
Dukes staging system102 giardiasis45, 92 leg52, 53, 57
duodenal carcinoma, periampullary116, 117 Glasgow Coma Scale (GCS)80, 81, 83 urinary tract (UTI)58 9, 1545
duodenal ulcers23, 25, 88, 89 glomerulonephritis63 infective enterocolitis44, 45, 46
duodenitis25 gluten enteropathy (coeliac disease)45, 93 infra-popliteal occlusive disease138
dysentery45 goitre1223 inguinal hernia65, 108, 109
dyspepsia24 5 gout53 direct48, 109
dysphagia1213 Graves disease122, 123 indirect48, 109
dysuria589 Grawitz tumour (renal cell carcinoma)35, 63, in infants171
160 1 inguinal lymphadenopathy48, 49
ectopic pregnancy38, 39 groin swellings48 9 injuries see trauma
electric burns77 gynaecomastia118, 119 interleukins (IL-1 and IL-6)70, 71
endocrine pancreatic tumours117 intervertebral disc herniation53
enteritis41 haematemesis223 intestine
enuresis, nocturnal169 haematuria623, 160 lipodystrophy (Whipples disease)92,
epididymal cyst64, 65 haemoglobinuria63 93
epididymitis/epididymo-orchitis64, 65, 155 haemoptysis14 15 malrotation170
epidural analgesia67 spurious14, 15 obstruction33, 106 7
epiphyseal injuries74 haemorrhage68, 69, 79 resection93
escharotomy76, 77 intracranial80, 81, 823 see also large bowel; small bowel
extracranial arterial disease144 5 haemorrhoids41, 104 5 intracerebral haemorrhage80, 83
extradural haemorrhage80, 823 haemothorax78 intracranial haemorrhage80, 81, 823
eye, burns76, 77 head injury80 3 intracranial pressure, raised27, 82
heart disease intussusception37, 41, 1701
faeces33, 37, 39 ischaemic134 5 iodine deficiency123
fallopian tube, masses38, 39 valvular136 7 irritable bowel syndrome30, 31, 45, 46
fat heart valves, prosthetic137 ischaemia
malabsorption92, 93 Helicobacter pylori88, 89 acute54 5, 139
necrosis, breast17, 119 hepatitis, infective35 chronic51, 138
femoral artery hereditary haemorrhagic telangiectasia critical139
aneurysm48, 49 22 diabetic foot141
stenosis50, 51 hernias, abdominal108 9 ischaemic colitis42, 43
femoral hernia48, 49, 108, 109 hiatus hernia85 ischaemic enteropathy, chronic93
femoral neuroma48, 49 Hirschsprungs disease46, 47 ischaemic heart disease1345
femoro-popliteal arterial occlusion50, 51, 138 hydatid cyst35
fibroadenoma, breast16, 17, 119 hydatid of Morgagni, torsion64, 171 jaundice40 1
fibrocystic disease (FCD), breast17, 19, 21, hydrocele64, 65, 171 haemolytic40, 41
118, 119 cordal48 hepatic/hepatocellular40, 41
first aid79 femoral sac49 obstructive40, 41, 110, 111
fissure in ano41, 105 hydronephrosis35 joint trauma52, 53
fistula in ano105 hyperaldosteronism131
flail chest78 hyperbilirubinaemia kidney
flank mass160 congenital41 bleeding62, 63
foot, diabetic140 1 conjugated40, 41 cysts35, 63
foreign body unconjugated40, 41 masses34, 35
ingested12, 13 hypercalcaemia126, 127 pelvic38, 39
inhaled14, 15 hypercalciuria159
fractures52, 53, 74 5 hypernephroma (renal cell carcinoma)35, 63, lactorrhoea21
skull80, 82 160 1 Laplaces law143
frequency45, 58 hyperparathyroidism126, 127 large bowel
fungal nail infection140 hyperprolactinaemia128 bleeding42, 43
hyperthyroidism122, 123 causes of diarrhoea44, 45
galactocele17 hypocalcaemia126, 127 masses36, 37, 38, 39
gallbladder hypoparathyroidism127 obstruction27, 99, 107
empyema35, 110, 112, 113 hypopituitarism129 polyps42, 43, 45
enlargement34, 35 hypothyroidism122, 123 laryngeal carcinoma14, 15
mucocele35, 110, 112 hypovolaemia68, 69, 73 left atrial dilatation12
174 Index
leg obesity33 pneumothorax, tension78
acute cold (ischaemia)54 5 oesophagitis, reflux13, 23, 25, 84, 85 polycystic kidney disease35, 63
acute warm painful523 oesophagus popliteal aneurysms142, 143
postphlebitic (PPL)146, 147 Barretts85 postphlebitic limb (PPL)146, 147
referred pain53 carcinoma12, 13, 23, 25, 86 7 pregnancy33, 38, 39, 47
trauma52, 53, 54, 55 pulsion diverticulum13 ectopic38, 39
ulceration56 7, 140, 141 stricture12, 13 primary survey79
leiomyoma, stomach22, 23 varices, bleeding22, 23 processus vaginalis171
Leriches syndrome51 oliguria73 proctitis41, 101
lipoma17, 48 omentum, swellings36, 37 prostate
lipopolysaccharide (LPS)70, 71 opiate analgesia67 carcinoma63, 164 5
Lisfranc amputation140 oral tumours14, 15 hypertrophy, benign (BPH)61, 63,
Littrs hernia108 orchitis64, 65 156 7
liver osteomyelitis53, 140 prostatitis155
abscess35 ovary pruritus ani (anal itch)104
enlargement34, 35 cysts38, 39, 61 pseudomembranous colitis45
lung masses38, 39 psoas abscess48, 49
abscess14, 15, 150 overflow incontinence60, 169 pulmonary collapse150 1
cancer see bronchial carcinoma pulmonary embolus (PE)146, 147
empyema150 paediatric general surgery170 1 pulmonary hypertension14, 150
infarction14, 15 Pagets disease of nipple121 pyelonephritis58, 63, 154
loss of functioning66, 67 Pancoasts tumour153 pyloric stenosis27, 89
lymphadenopathy pancreas infantile hypertrophic170
cervical10, 11 abscess114, 115 pyoderma gangrenosum57
inguinal48, 49 carcinoma37, 116, 117 pyonephrosis35
mediastinal12, 13 endocrine tumours117 pyosalpinx38
retroperitoneal36, 37 masses34, 36, 37
pseudocyst/cyst37, 114, 115 radiation
malabsorption923, 95 tumours116 17 burns77
MalloryWeiss syndrome22, 23 pancreatitis111, 114 15 enteropathy93
malrotation of gut170 pan-hypopituitarism129 Ransons criteria114
mammary duct paracolic abscess39, 98 ray amputation140
ectasia20, 21, 119 parasitic infections93 rectum
papilloma20, 21, 119 parathormone127 bleeding423, 104
Marjolins ulcer57, 133 parathyroid gland carcinoma38, 39, 43, 1023
mastalgia18, 19 disease126 7 polyps45, 46
mastitis17, 19, 20, 21 localization126 prolapse105
Maydls hernia108 para-umbilical hernia109 solitary ulcer41
Meckels diverticulum31, 42, 170 peau dorange121 referred pain29, 53
mediastinal lymphadenopathy12, 13 pelvic masses38, 39 renal abscess58, 154
melaena22 peptic ulceration (PUD)27, 88 9 renal calculi63, 158 9
melanoma, malignant (MM)57, 132, 133 see also duodenal ulcers; gastric ulcers renal cell carcinoma (RCC)35, 63,
mesenteric angina31 periampullary carcinoma116, 117 160 1
micronutrient deficiencies92 perianal disorders104 5 renal colic28, 159
mitral incompetence (regurgitation)136, abscess105 renal failure, acute723, 77
137 in Crohns disease43, 95 respiratory failure, neuromuscular66
mitral stenosis15, 136, 137 haematoma105 retching26
mouth, bleeding15 itch104 retroperitoneal masses35, 36, 37, 39
multiple endocrine neoplasia (MEN) pain47, 104 rheumatic fever137
syndromes125, 127 see also anus Richters hernia108
multiple organ dysfunction syndrome pericolic abscess98 Riedels lobe35
(MODS)70, 71 perinephric abscess35 road traffic accident (RTA)79
muscle peripheral occlusive vascular disease51, 57,
cramps53 138 9 salivary gland tumours10, 11
trauma53 phaeochromocytoma130, 131 Salmonella infections45
myocardial infarction134, 135 piles (haemorrhoids)41, 104 5 salpingo-oophoritis39
pilonidal sinus105 saphena varix48, 49, 148
neck lumps10, 11 pituitary gland schistosomiasis63
nephroblastoma35 disorders128 9 sciatica53
neuropathic foot ulcers56, 57, 141 tumours128, 129 scleroderma12, 13
nipple platelet activating factor (PAF)71 scrotum
in breast cancer120 pleural effusion150 acute171
discharge20, 21, 118 pleurisy18, 19 infantile oedema65
Pagets disease121 Plummers disease122 swellings64 5
nitric oxide synthetase, inducible (iNOS)71 PlummerVinson syndrome87 scurvy15
nocturia58 pneumaturia58 sebaceous cyst19, 65
nocturnal enuresis169 pneumonia14, 15, 28 secondary survey79
nose bleed14, 15 postoperative150 1 seminoma166, 167
Index 175
sepsis70 telangiectasia, hereditary haemorrhagic ulcerative colitis43, 45, 1001
syndrome70 22 umbilical hernia109
septic shock68, 69, 70 teratoma, testicular166 urachal cyst39
Sheehans syndrome129 testis ureter
Shigella infections45 ectopic171 calculus63, 158, 159
shock689 haematocele65 ectopic169
anaphylactic69 retractile171 ureteric (renal) colic28, 159
cardiogenic69 torsion64, 65, 171 urethra
hypovolaemic68, 69 tumours64, 65, 166 7 calculus61, 63
septic68, 69, 70 undescended (UDT, cryptorchidism)48, 167, obstruction60, 61
Simmonds disease129 171 trauma63
skin cancer57, 1323 thrombosis54, 55 urethral syndrome59
skull fracture80, 82 aneurysm54, 55 urethritis59
small bowel deep venous (DVT)53, 146 7 urge incontinence168, 169
bacterial overgrowth (blind loop)45, 93 graft54, 55 urgency45, 58
bleeding423 thyroglossal cyst10, 11 urinary calculi63, 158 9
causes of diarrhoea44, 45 thyroid gland urinary fistula169
ischaemia41 benign hyperplasia123 urinary incontinence168 9
masses36, 38, 39 malignancies11, 124 5 urinary retention38, 39, 601
obstruction27, 31, 107 masses (swellings)10, 11 acute60
resection93 solitary nodule123, 124 chronic60
tumours41 thyroiditis122, 123 neurogenic61
smoke inhalation76, 77 Tietzes disease18, 19 urinary tract infection (UTI)589, 1545
spermatic cord48 torticollis11 uterus
spinal cord injuries61 trachea carcinoma38, 39
spleen, enlargement34, 35 bleeding14, 15 fibromyomas (fibroids)38, 39, 61
squamous cell carcinoma (SCC), cutaneous57, carcinoma12, 14, 15 masses38, 39
132, 133 tracheo-oesophageal fistula12, 13
staghorn calculi159 transient ischaemic attack (TIA)145 vaginitis59
sternocleidomastoid tumour10, 11 transitional cell carcinoma (TCC)38, 39, 63, valvular heart disease1367
stomach 163 varicocele64, 65
distension37 trauma varicose veins148 9
hour-glass27 head80 3 vascular disease, peripheral occlusive51, 57,
leiomyoma22, 23 kidney63 138 9
masses34, 36, 37 leg52, 53, 54, 55, 57 vascular trauma55, 74
see also gastric carcinoma; gastric ulcers major (MT)78 9 vasculitis56, 57
stress incontinence168, 169 tricuspid regurgitation137 venous thrombosis, deep (DVT)53, 1467
stroke145 tricuspid stenosis137 venous ulcers56, 57, 148
subclavian artery Trousseaus sign126, 127 ventilation, poor66, 67
aneurysm10, 11 Trypanosoma cruzi (Chagas disease)12, vertebrobasilar disease144, 145
ectasia10, 11 13 vesicovaginal fistula168, 169
subclavian steal syndrome145 tuberculosis (TB) Virchows triad146, 147
subdural haemorrhage80, 83 abdominal mass38, 39 vitamin C deficiency15
suprarenal gland see adrenal (suprarenal) breast abscess17, 21 vitamin deficiencies92
gland neck abscess10 vomiting26 7
Symes amputation140 pulmonary14, 15
syphilis64, 65 renal58, 63 Wallaces rule of 9s76
systemic inflammatory response syndrome testis65 waterbrash26
(SIRS)70 1 tumour necrosis factor (TNF)70, 71 Whipples disease92, 93
176 Index

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Surgery at a Glance

First published 1999

Library of Congress Cataloging-in-Publication Data

Set in 9A/12 Times by Graphicraft Limited, Hong Kong

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Preface 7 38 Peptic ulceration 88

AAA abdominal aortic aneurysm Dop dopamine

OTHERS Salivary gland tumours

Carotid body tumour

10 Clinical presentations at a glance

Cystic hygroma. ?Thyroid LAD Primary tumours

Neuropathy Arch aortic aneurysm

Left atrial dilatation

Diffuse oesophageal spasm

Carcinoma of the oesophagus ** Foreign body * (child)

12 Clinical presentations at a glance

KEY POINTS Intraluminal

CT scan: low risk, good for

14 Clinical presentations at a glance

?Foreign body ?Cardiac cause ?Tumour ?Infection ?Infarction/PE

Image (ultrasound < 35

FNAC = C5 FNAC = C3/4 FNAC benign = C2 FNAC = C2 (Benign)

Definitive carcinoma Diagnostic ? Review clinical

Normal Bloody Residual Age < 35 Age > 35

Review 2/52 ? Excision Repeat Patient Patient Excision

16 Clinical presentations at a glance

Unilateral KEY INVESTIGATIONS

Breast Breast pathology

Abscess Periductal mastitis

Fibrocystic Infected areolar

18 Clinical presentations at a glance

Infected sebaceous cyst

Single lump No lump

Investigate as for lump Mammography

Investigate Bloody No blood

Recurrent, Multiple ducts, Lumpy breast,

? Intraductal ? Mammary ? Fibrocystic

Bloody Fibrocystic disease

Intraductal papilloma Mastitis

20 Clinical presentations at a glance

Acute reflux oesophagitis

22 Clinical presentations at a glance

Important diagnostic features

observation Continued resuscitation, urgent OGD

Endoscopic therapy Endoscopic therapy i.v. PPI treatment

Carcinoma of the oesophagus

<45 >45 or suspicious symptoms

Poor Success Carcinoma Oesophagitis Gastritis Normal

24 Clinical presentations at a glance

26 Clinical presentations at a glance

RUQ EPIGASTRIC LUQ

Ovarian cyst Ovarian cyst

28 Clinical presentations at a glance

Acute abdominal pain 29

RUQ EPIGASTRIC LUQ

30 Clinical presentations at a glance

Chronic abdominal pain 31

'FLIPPING BIG MASS'

Ovarian cyst Fibroid in uterus