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Walronds Sessions

Hernias ............................................................................................................................................................................................. 1

Thyroid ........................................................................................................................................................................................... 5

Peripheral Vascular Disease (Arterial Disease) ................................................................................................................8

Colon Cancer .............................................................................................................................................................................. 13

Rectal Cancer .............................................................................................................................................................................. 15

Pancreatitis .................................................................................................................................................................................. 15

Acute Appendicitis ................................................................................................................................................................... 19

Gallstones .................................................................................................................................................................................... 23

Breast ............................................................................................................................................................................................ 28

Intestinal Obstruction ............................................................................................................................................................ 32

Pancreatic Cancer .................................................................................................................................................................... 40

Pancreatitis ................................................................................................................................................................................. 42

Benign Breast Disease ............................................................................................................................................................ 43

Hernias

Definition

Hernia protrusion of an organ with its coverings through an abnormal opening

Types of External Hernias:

Inguinal hernia Direct/ Indirect

Umbilical

Incisional

Femoral

Spigelian

Lumbar

Epigastric (occurs anywhere superior to the umbilicus)

Obturator

Gluteal

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Examination of Hernias:

Introduction

Exposure

Inspection

General Inspection

Obvious/ visible lumps or swellings (?ask pt to stand)

Ask patient to cough does the swelling become more obvious?

Palpation

Ask patient if they are experiencing pain

Cough impulse?

Ask patient if they can push it back in. If no and the hernia is small, try to reduce it yourself

Determine if the inguinal hernia is indirect or direct:

o External inguinal ring halfway along the inguinal ligament between ASIS and pubic

tubercle and ~2cm above

o Reduce the hernia and occlude the external inguinal ring then ask the patient to cough:

o If controlled at the deep ring INDIRECT inguinal hernia

o If it protrudes ABOVE and MEDIALLY to the pubic tubercle DIRECT inguinal hernia

o IF it protrudes BELOW and LATERALLY to the pubic tubercle FEMORAL hernia

NB: Mid-inguinal point halfway between ASIS and pubic symphysis

Case Scenarios:

Case #1: Right Groin Swelling

Introduction

Exposure

Inspection

Ask patient to cough: No cough impulse visible.

Ask patient to cough again and palpate for cough impulse: Positive cough impulse

Ask patient if they can push it back in, if not and a small hernia, you try to reduce it.

RING OCCLUSION TEST:

Find pubic tubercle lateral and inferior to pubic symphysis then locate ASIS then go halfway

between ASIS and pubic tubercle and 2cm superiorly.

Occlude ring with 1-2 fingers not the thumb or palm and make sure the medial side is always

exposed in order to see the protrusion.

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HESSELBACHS TRIANGLE (direct hernias): triangle formed by the inguinal ligament, lacteral border of

rectus abdominis and inferior epigastric artery.

Case #2: Scrotal Mass

Introduction

Exposure

Inspection

Ask patient to cough: No cough impulse visible.

Ask patient to cough again and palpate for cough impulse: Absent cough impulse

Try to palpate above the mass (feel in line with pubic tubercle or just above it at the root of the

penis):

o YES scrotal

Palpate for cord structures. If in doubt, feel opposite side.

o NO Hernia

Ask patient if they can push it back in, if not and a small hernia, you try to

reduce it.

Then state that you cannot perform the ring occlusion test but you think it is

an INDIRECT INGUINAL hernia because these are more common and more

likely to extend into the scrotum.

Case #3: Large left scrotal swelling

Introduction

Exposure

Inspection

Ask patient to cough: No cough impulse visible.

Ask patient to cough again and palpate for cough impulse: Absent cough impulse

Try to palpate above the mass (feel in line with pubic tubercle or just above it at the root of the

penis):

o YES scrotal Palpate for cord structures (if in doubt, feel opposite side)

Transillumination:

o YES Hydrocoele

o NO Is it fluctuant? Are the testes palpable? NO. Consistency? FIRM

Testicular mass TESTICULAR CANCER (common in Caucasian population)

Case #4: Big swelling in scrotum on right side (inguinoscrotal mass)

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Introduction

Exposure

Inspection

Ask patient to cough: No cough impulse visible.

Ask patient to cough again and palpate for cough impulse: Yes at the top but not at the bottom

Ask patient if they can push it back in, if not and a small hernia, you try to reduce it.

(Make sure you do not try to reduce the testes {feel for them})

HERNIA testes palpable

After reducing the hernia the scrotal mass is still present:

Check for hydrocele (fluctuant, can be transilluminated and the testes are not palpable.

Case #5: Left indirect inguinal hernia

Introduction

Exposure

Inspection

Ask patient to cough: No cough impulse visible.

Ask patient to cough again and palpate for cough impulse: Positive cough impulse

Ask patient if they can push it back in, if not and a small hernia, you try to reduce it.

Reducible? YES

Treatment

Surgery:

Herniotomy: removes hernia sac but does nothing about the defect

o Only performed in children

o Persistence of processus vaginalis

o As the child grows, there is closure of the superficial and deep rings by external oblique

muscle

Hernioplasty: the defect is cover with mesh; tension free

Herniorraphy: the defect is sutured; associated with tension

Additional Notes

Irreducible: cough impulse present, no vomiting, usually caused by adhesions of the hernia sac;

NOT AN EMERGENCY

Obstructed: no cough impulse, non-tender, not erythematous and associated with mild pain

Strangulated: no cough impulse, tender, erythematous and painful

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Ricters hernia: hernia involving only a part of the muscle wall eg only the anterior wall is

involved eg Femoral Hernia

Pantaloon hernia: combination of indirect and direct hernia; separated by inferior epigastric

artery

Hydrocoele (fluid collects in the tunica vaginalis)

Jahboulays fluid is drained, excess sac of tunica vaginalis is turned on itself and ligated. Excess

tunica vaginalis is excised.

Thyroid

Examination:

Inspection of neck

Mass e.g. in anterior triangle

Ask patient to swallow. Moves with swallowing mass arising from thyroid

Ask patient to stick their tongue out. Moves with protrusion of tongue thyroglossal cyst

Palpation

Trachea central?

Palpate mass by behind the patient

o Diffuse or symmetric enlargement

o Multinodular symmetric or asymmetric

o Solitary nodule

Ask patient to swallow. Try to get your fingers below the mass as the thyroid moves superiorly

with swallowing. If your fingers get below it no retrosternal involvement

Percussion (for retrosternal extension of thyroid)

After this you can check for other features:

Eyes: Exopthalmos, Lid lag, Ophhalmoplegia (Graves Disease)

Tremors

Cervical lymphadenopathy

Hyperreflexia

Findings on Palpation:

Diffuse, multinodular Multinodular Goitre

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Diffuse, multinodular Graves disease

Thyroid neoplasm eg Toxic adenoma

Hyperthyroidism Graves disease, Thyroid adenoma, Toxic multinodular goitre (rare)

Thyroiditis eg Hashimotos thyroiditis

NB: At the end of the examination, state if the patient is euthyroid, hypothyroid or hyperthyroid.

Scenarios:

1. Diffuse goitre, exophthalmos, lid lag, other signs of hyperthyroidism Graves Disease

2. Big, asymmetric gland Multinodular goitre

3. Right side symmetrically enlarged, left side normal:

a. Clinically euthyroid Solitary nodule

b. Clinically hyperthyroid Toxic nodule

4. Diffuse swelling, euthyroid Physiologic goitre

Management

1. Graves Disease

Investigations: T4, T3 (elevated), TSH (decreased)

Treatment:

Medical: Carbemazole (S/E: agranulocytosis), Propylthiouracil for 1 year (until

euthyroid; NB: they dont stay euthyroid)

Radioactive iodine

o Avoid in young people because of uncertainty of teratogenicity

o Requires lifelong follow up

o Patient is rendered euthyroid but later develops hypothyroidism

Thyroidectomy

o Lifelong thyroxine use after.

2. Multinodular Goitre

Investigations:

Ultrasound

TFTs T4, TSH (normal)

Indications for surgery:

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1. Compressive symptoms:

Hoarseness compression of recurrent laryngeal nerve

Dysphagia compression of oesophagus

Coughing or stridor Compression of trachea 2. Cosmetic reasons

No compressive symptoms and no cosmetic reasons no surgery indicated.

If surgery is needed: Total or Subtotal Thyroidectomy

3. Solitary Nodule

Investigations: Ultrasound, TFTs

If normal do FNAC (malignant potential)

Limitation of FNAC: cannot differentiate follicular adenoma from follicular cancer

Can identify papillary, medullary and anaplastic cancer

4. Thyroid Neoplasms

Management: staging, thyroidectomy

Papillary (most common) Follicular Medullary Anaplastic

Best prognosis -----------------------------------------------------------> Worst prognosis

Commonly in young ----------------------------------------------------> More common in elderly

Cytology/Histology: papillary projections

Papillary cancer Orphan- Annie eyes, Psammoma bodies

Nodular process with hyperthyroidism Radionucleotide scan (otherwise useless)

If warm still need to do FNAC

Thyroidectomy

Preparation for Surgery:

Bloods: FBCs, U&Es, GXM, TFTs

CXR: Thoracic Inlet view for compression

o tracheal deviation, retrosternal extension

ECG: hyperthyroidism can cause arrhythmias

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Indirect laryngoscopy: use mirror to visualize vocal cords

o For comparison pre and post-op

If hyperthyroid:

o Render euthyroid prior to surgery:

o Carbemazole

o Beta blocker (blocks receptors thereby preventing thyroid storm)

Complications:

Haemorrhage haematoma which can cause compression of trachea

o Remove sutures- both superficial and deep ON THE WARD

o Cover with sterile gauze and inform senior

o Return patient to OT secure the bleeding vessel

Nerve damage to recurrent laryngeal nerve stridor, hoarseness

o Superior laryngeal nerve (vocal strength)

Hypoparathyroidism

o Removal of parathyroid glands during surgery hypocalcemia

o Damage to inferior thyroid artery (blood supply to parathyroids)

Tracheomalacia

Pneumothorax

o Caused by damage to apex of lung with removal of retrosternal thyroid

Peripheral Vascular Disease (Arterial Disease)

Presentation

Intermittent claudication/ claudication pain

Rarely: Rest pain, tissue necrosis

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Causes

Atherosclerosis

Buergers disease (in young male smokers, lower and upper limb disease)

Risk factors

Males

Cigarette smoking

Hypertension

Diabetes mellitus

Obesity

Dyslipidemia

Homocysteinemia

How to confirm claudication pain

Ask the patient if the pain goes away at rest.

o NB: can be confused with pain from osteoarthritis (pain at rest, pain made worse

during cold weather, morning stiffness, maybe relieved by walking)

o Another differential: sciatica (back pain shooting down the leg, worse on walking)

Can the pain be localized? (suggests site of the arterial disease/stenosis)

o Calf pain superficial femoral or popliteal arteries are affected

o Thigh pain common femoral, femoral profunda or iliac arteries are affected

o Buttocks Internal iliac artery affected

o Penis (impotence) both internal iliac arteries are compromised

Leriches syndrome: absent femoral pulses, intermittent claudication of the

buttocks muscles, pale cold legs and impotence

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Ask about history of cardiovascular disease eg previous MI, Angina, IHD

Ask about previous stroke, TIA

Ask about renal disease

Examination

General examination

CVS BP (HTN), Carotid bruits, displaced apex beat

ABD abdominal aortic aneurysms

Inspection of Lower limbs:

Hair loss

Shiny skin

Thickened nails

Ulcers

Muscle wasting/atrophy

Palpation:

Temperature

Pulses: dorsalis pedis, posterior tibial, popliteal, femoral

Investigations

Non-Invasive:

1. Ankle:Brachial Pressure Index (ABPI)

ABPI is a non-invasive test comparing the systolic blood pressure in the brachial artery and

the systolic pressure in the dorsalis pedis or posterior tibial artery.

Normal ABPI 0.9-1.0

Intermittent claudiation ABPI 0.5-0.9

Critical Limb ischaemia ABPI

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A 20 mmHg or greater reduction in pressure is considered significant if such a gradient is

present either between segments along the same leg or when compared to the same level of

the opposite leg.

Several blood pressure cuff positions have been employed to detect the level of peripheral

vascular disease. As examples, a significant reduction in pressure:

At the thigh, reflects aortoiliac or superficial femoral artery disease

At the calf, reflects distal superficial femoral artery or popliteal disease

At the ankle, reflects infrapopliteal disease.

In addition, a toe pressure of less than 60 percent of the ankle pressure indicates digital

artery occlusive disease.

3. Duplex Doppler ultrasound anatomy and assessment of floe in the arteries

4. Plethsymography assesses flow through arteries

Scenarios

1. Claudicant with ABPI of 0.6, duplex Doppler USS confirms blockage in superficial femoral artery

Management:

Initially conservative management

NB: 1/3 get worse, 1/3 get better, 1/3 remain the same

Address risk factors; factor modification helps to improve claudication

Control BP, DM, Cholesterol, cessation of smoking

Exercise increase claudication distance (neovascularization and

development of collateral circulation around the area of stenosis)

Drugs:

Antiplatelet agent: Aspirin (stops platelet aggregation)

Statin lipid lowering agent, plaque stabilization, anti-

inflammatory

Trental (Pentoxyphylline) improves flexibility of RBCs

Follow up: repeat ABPIs and monitor claudication distance

Improvement: no indication for surgery

Pain at rest or progression to critical limb ischaemia surgery indicated

If getting worse eg rest pain, do CT angiogram to determine the procedure to be done at

surgery

2. Critical limb ischaemia (CLI) ABPI

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Angiography

Types:

Conventional Angiogram with Digital Substraction (GOLD STANDARD) [requires

interventional radiologist]

CT Angiogram

MR Angiogram

CT Angiogram findings required for surgical intervention:

Good run in and run off good proximal and distal flow to the area of stenosis.

If CT angiogram shows run in but no off and in the presence of rest pain initially

ANALGESIA

Interventions to improve blood supply in atherosclerosis:

By pass grafting for long segment stenosis

o Long saphenous vein is used- is either revered or valvectomy is performed in

situ

Percutaneous Transluminal (Balloon) Angioplasty (PTA) + Stenting for short segment

stenoses

Endarterectomy (vessel is incised and plaque is removed

o Common done on carotid arteries

Indications for Amputation:

Intractable pain

Sepsis

Leg that is a nuisance

3. Dry gangrene of the great toe, angiogram shows no run off

Management:

Betadine dressings (to keep area dry)

Wait for auto-amputation of toe (If the toe is surgically removed, there is poor blood

supply and healing will no occur).

4. Dry gangrene progressing to wet gangrene

Management:

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Is there collateral circulation?

Transcutaneous oxygen insert needle and measure O2, if >60mmHg healing will

occur

Pulse volume recording

If no collateral circulation indication for amputation (determine level eg BKA or AKA)

5. Wet gangrene of the great toe

NB: Surgical Emergency

Management:

Amputate the toe to stop sepsis and cover with antibiotics

Then do CT angiogram to determine if further intervention is needed eg PTA

o If no further intervention is possible to save limb because of compromised

blood supply further amputation to level of adequate blood supply.

Colon Cancer

Investigations

Colonoscopy + Biopsy or Barium enema

Histology

Staging (e.g. tumour on left side of colon)

o CT abdomen

For: Enlarge lymph nodes, invasion into surrounding structures, distant

metastases

o CT pelvis

o CXR or CT chest (lung metastases)

Other tests

Abdominal USS

Bloods: FBC (anaemia), U&Es

Tumour Markers CEA (carcinoembryonic antigen)

Staging

1. TNM

T1 limited to submucosa

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T2 muscularis propria

T3 into the subserosa but not breeching visceral peritoneum or adjacent structures

T4 extending beyond visceral peritoneum and into adjacent structures

N- nodes

M metastases

2. Dukes Classification

A limited to bowel wall

B extending through the bowel wall

C- lymph nodes involved

Modified Dukes: D distant metastases

Scenarios

Tumour in:

1. Sigmoid colon, was confirmed by CT abdomen, no metastases, few local enlarged lymph nodes

Sx: Sigmoid colectomy with removal of regional lymph nodes (mesentery, blood supply and

lymph nodes are removed)

2. caecum Right hemicolectomy

3. Ascending colon Right hemicolectomy

4. Distal transverse and descending colon Left hemicolectomy

5. High rectum Anterior resection

6. Mid rectum Low anterior resection

7. Low rectum Abdominal Perineal Resection (APR) excise rectum and anus; needs permanent

colostomy

Preparation for Sigmoid Colectomy

Informed consent

Bloods: FBC, U&Es, GXM

CXR lung disease which may affect the patient under general anaesthesia while being

ventilated)

ECG Ischaemic heart disease, arrhythmias

DVT prophylaxis

Prophylactic antibiotics

Bowel prep: only if concerned that tumour is too small to be felt

Review the patient in SOPD (6/52 following the surgery)

Wound healed? No hernias

Assess bowel function

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Review staging of tumour (specimen from surgery was sent to histology/pathology)

o Determines need for adjuvant therapy

o Margins clear?

o Nodes that were harvested- were they involved?

o Determine how far the excised tumour had invaded the bowel wall.

If tumour is staged at T3 N1 M0 Adjuvant chemotherapy (if it can be tolerated)

Indications for Adjuvant chemotherapy

anybody that is node positive

controversial stage T3

T4 tumour

Chemotherapy agents

5- fluorouracil (5FU)

Combinations oxycisplatin + 5FU

Five FOX (?)

Radiotherapy

Radiation of the colon is not routinely used because of surrounding structures in abdomen. May be used

in rectal cancer.

Rectal Cancer Investigations: Same as for colon plus Transrectal USS or MRI(not available @QEH)

Adjuvant therapy is usually given before surgery because of difficulty access to tumour without

having to remove anus.

NB: Anal canal 3-5cm; APR 5-7cm

Scenarios:

T1 or T2 tumour with no nodes involved Local resection within the anal canal

Pancreatitis

Causes

(GET SMASHED)

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Gallstones

EtOH (alcohol)

Trauma

Viral Illness e.g. mumps

Drugs e.g. corticosteroids

ERCP

Dyslipidemia

Hyperperfusion states

Idiopathic

Congenital?

Presentation

Epigastric pain radiating to the back, worse on leaning forward

Vomiting, fever

Jaundice

Clinical Features:

Tenderness on palpation of RUQ or epigastrium

Guarding and rebound tenderness

Cullens sign periumbilical ecchymosis

Grey-Turners sign bruising in the flanks

Decreased bowel sounds

Obstructive jaundice (dark urine, pale stools)

Steatorrhea

General Examination

Jaundice, fever, dehydration

CVS: assess for haemodynamic stability tachycardia? Hypotension?

RESP: findings of pleural effusion- occurs due to irritation of diaphragm (may be larger on left than the

right)

Investigations

Bloods:

FBC- elevated white cell count

U&Es

LFTs

Bilirubin

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Alkaline phosphatase (elevated in presence of gallstones)

Serum amylase (Dx: elevated >3x ULN acute pancreatitis)

o Normal 120-130

o Dx: >400

o Severity not dependent on level of rise of serum amylase

Lipases (most specific for acute pancreatitis)

Blood glucose

Other investigations:

USS abdomen gallstones

Erect CXR

Abdominal xray colon cut off sign, sentinel loop (not specific or diagnostic)

CT scan to assess severity of pancreatitis

Ransons Criteria: (>3 severe pancreatitis- manage in ICU)

On Admission 48hrs Post Admission

Glucose > 11mmol/l Calcium < 2.0

Age > 55 Haematocrit- decrease >10%

LDH > 350 PaO2 16 BUN elevated >15%

AST > 250 Base deficit > -4

Sequestration fluid > 6L

Treatment

1. Analgesia NSAIDs (monitor urine output)

Narcotics except morphine (causes spasm of sphincter of Oddi)

2. IV fluids maintenance, deficit and insensible losses

Monitor urine output catheterize

Large fluid requirement CVP line

3. Bed rest, NPO, NG tube (rest the pancreas)

Pancreas stimulated by stomach distension and food passing through the duodenal complex)

4. Nutrition

Enteral vs parenteral

5. Severe pancreatitis antibiotics (prophylaxis against infective necrosis)

6. Treat underlying cause.

Gallstones cholecystectomy

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Stop alchohol use

Parathyroidectomy

7. Monitor for progress and complications.

Complications

Pancreatic insufficiency

Acute renal failure

ARDS

Infected pancreatic necrosis

Pseudocyst

Pancreatic abscess

Pancreatic fistula

UGIB (rare) {splenic vein thrombosis as a result of portal HTN}

Indications for Surgery

Infected pancreatic necrosis debridement

Pancreatic abscess incision & drainage

Treat underlying cause eg gallstones

Complications eg pseudocyst

Pseudocyst

Cyst not lined by epithelium, lined by fibrotic tissue

Cyst contains pancreatic fluid (enzymes enter 2nd part of duodenum and leak out into the

abdomen)

Treatment:

o Wait until they mature (4-6 weeks)

o If they get smaller: drain through through pancreatic duct

o Not resolving: Anastomose onto the back of the stomach

Cysto-gastrostomy or cystojejunostomy

Chronic pancreatitis

Pancreatic ducts become strictured increase pressure severe pain

Severe inflammation pancreatic insufficiency

Causes e.g. alcohol

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Acute Appendicitis Definition

Inflammation of the appendix caused by obstruction of the appendiceal lumen

History

Initially periumbilical pain radiating to the right iliac fossa (RIF)

Nausea, vomiting, anorexia, low-grade fever

Late: signs of dehydration

Examination

Inspection: lie still (because patient experiences pain on moving)

Palpation: RIF pain, rebound tenderness, guarding

DRE: pain (if appendix anterior and to the right of the Pouch of Douglas)

Obturator sign:

Psoas sign:

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Various anatomical locations of appendix

Preileal

Post ileal

Retrocecal

Subcecal

Pelvic

Terms to know

McBurneys point: one third the distance from the ASIS to the umbilicus

Rovsings sign: Palpation of the LLQ results in pain in the RLQ. This occurs because you push

the bowel which causes the appendix to touch the peritoneum.

Interesting points you should know

When would you consider Meckels Diverticulum as a differential diagnosis?

o Mainly in the children

o It is inflammation of the remnant of the vitello-intestinal duct

What is Mittelschmerz?

o Pain in ovulation or mid-cycle

What is Fitz-Hugh-Curtis Syndrome?

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o PID that tracts up the right side to the kidney

Case Scenarios

Case #1:

Hx: 22 year old female complaining of RIF, anorexia. There is no fever.

Exam: mild rebound tenderness and guarding. Normal bowel sounds. DRE- normal.

What is the next step?

o Vaginal exam because of the differential diagnoses of a 22 year old female.

o DDx: ovarian cysts, ovarian torsion, ectopic pregnancy, endometrisos, PID, salpingitis.

The PV exam was normal. What imaging modality would you do?

o Ultrasound of the abdomen

o DDx:

GI: Crohns, gastroenteritis, perforated ulcer, right sided diverticular disease,

perforated right sided colon

GU: UTI- pyleonephritis, cystitis, stones in the ureter, occasionally stones in

the kidneys

Hepatobiliary: cholecystitis, hepatitis, pancreatitis

What investigations would you do in this patient?

o Urinalysis- leukocytes (UTI), blood (stones)

o Pregnancy test

o Blood tests: FBC- WBC

o Radiology: Ultrasound

The ultrasound is mostly used to rule out conditions e.g. stones in kidneys,

cholecystitis, ovarian cysts.

Ultrasound findings of appendicitis: blind ended tubular structure which is

noncompressible. Thickening of the wall >6mm.

o Microbiology and histology

Suppose the ultrasound shows fluid in the RIF. What is the next step?

o CT Scan- more sensitive that ultrasound

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o The next step will then be laparoscopic exploration in females because the rate of

negative appendicitis is very high.

The ultrasound is normal. At laparoscopy you see an inflamed appendix and perform an

appendectomy. What is the main complication of this surgery?

o Early- wound infection- clean contaminated; if appendix ruptures- dirty

o Prevention of wound infection- prophylactic antibiotic to cover gram ve anaerobes

Case #2:

Hx: Young male complaining of a 6 days of umbilical pain which radiates to the RIF. He is complaining of

a fever, vomiting and generalized peritonitis.

How would you manage this patient?

Urinalysis

Blood test: FBC- WBC

Resuscitate and take to operation because this is a case of a ruptured appendicitis.

Case #3:

Hx: Male patient with a 2 week history of RIF noted to have a decreased appetite. Examination reveals a

lump in the right side of his tummy that is tender to touch. A FBC was done with a WBC of 17.

How would you manage this patient?

Imaging- CT scan of the abdomen. In this case the ultrasound would have problems visualizing

the abdominal contents with the matted bowel.

Appendix abscess- percutaneous drainage and antibiotics; 6 weeks later perform a colonoscopy

Of note: interval appendectomy is not necessary unless there are signs of recurrent appendicitis.

Operation is not done at same time because of the inflammatory process causes the vision at

surgery to be decreased.

Case #4:

20 year old male with generalized peritonitis and a WBC 20 is diagnosed with an appendicitis. A 20 year

old female also diagnosed with appendicitis based on history. No peritonitis. Her WBC is 10.

Who goes to theatre first?

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The female goes to theatre first because her appendix has not ruptured. If ruptured there is the

possibility of sepsis which increases the risk of wound infection, adhesions and infertility. In males the

ve appendicitis rate is ~8% while in females this rate is ~30%.

Appendix Tumors

Carcinoid tumor, adenocarcinoma (famous for pseudomyxoma peritoni)

Gallstones

What are the syndromes gallstones can cause?

1. Biliary colic

2. Acute cholecystitis

3. Chronic cholecystitis

4. Obstructive jaundice

5. Cholangitis

6. Pancreatitis

Biliary colic: there is a stone in the cystic duct that continuously lodges and dislodges. The clinical

features include epigastric pain, nausea and vomiting. The epigastric pain that is experienced is caused by

contraction of the gallbladder against the blockage. This pain can mimic that of gastritis and acid reflux.

Patients may experience nausea or vomiting.

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Acute cholecystitis: there is a stone lodged in the cystic duct which does not dislodge as quickly as that

in biliary colic. The gallbladder becomes distended as it is unable to empty bile into the cystic duct. This

affects the blood supply gallbladder with thick walls and distension stasis bacterial proliferation

and inflammation. N.B. Patient should not have jaundice (as the common bile duct is not obstructed)

Chronic cholecystitis: there is stone that is permanently lodged in the cystic duct. There will be recurrent

acute attacks as the stone is still able to dislodge until fibrosis occurs.

Obstructive jaundice: due to choledocholithiasis. There is a stone lodged in the common bile duct.

Clinical features include: icterus, pale stools, dark urine.

Cholangitis: There is stasis and subsequent infection of the common bile duct, due to the stone

remaining lodged in the CBD.

Pancreatitis: There is a stone lodged in the ampulla of vater which blocks the pancreatic duct.

What is the cause of gallstones?

Stasis and supersaturation of bile salts

What are the different types of gallstones?

Mixed (multifaceted)

Pigment (seen mainly in people with sickle cell / haemolytic process)

Cholesterol (seen mainly in people with dyslipidemia or FHH; usually a solitary stone is present)

Mixed > Pigment > Cholesterol

Who gets gallstones?

Five Fs: Fair, Fertile, Forty, Female, Fat (increased oestrogen delays gallbladder emptying)

N.B. Not hard and fast rule

Case Scenarios

Case #1: A patient presents with intermittent epigastric pain, nausea and vomiting due to biliary colic.

On ultrasound the gall bladder is full of stones, there is thickening of the wall and distension. Of note

there is also pericholecystic fluid. There is also a positive sonographic Murphys sign. What is the

management of this patient?

1. Discuss diet (less greasy foods, etc) with the patient

2. Advise patient about surgery (if symptomatic gallstones, do surgery).

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Before removal of the gall bladder check to see if there are stones in the CBD. This can be determined

based on 3 things: history + USS + LFTs (ALP and BILI are elevated).

Case #2: A patient presents with abdominal pain, rebound tenderness, guarding, and a positive Murphys

sign (halting inspiratory effort on palpation of the gallbladder) on examination. The patient is diagnosed

with acute cholecystitis. What is the management of this patient?

1. USS, FBCs, LFTs

2. If within 48 hours of symptoms, perform a cholecystectomy

3. If past 72 hours, the chance of the surgery being performed laparoscopically is decreased.

Administer antibiotics, NPO, perform cholecystectomy. Laparoscopic cholecystectomy may be

difficult and would require to open cholecystectomy.

Complications of acute cholecystitis:

1. Mucocele

2. Empyema

3. Gangrene

4. Perforation

5. Abscess (if walled off) or peritonitis (if not walled off)

Case #3: A patient presents with multiple attacks of acute cholecystitis. On USS the gallbladder wall is

contracted (due to fibrosis). What is the treatment?

1. Cholecystectomy.

Case #4: A patient presents with a history of years of GERD. It was recently realised that is was actually

gallstones. On USS the gallbladder was contracted with thickened walls. What is the management?

1. Make sure there are no stones in the CBD (Check using the history, USS, and blood

investigations FBC, U&Es, LFTs. If any of the 3 above are off, use a cholangiogram to check

(e.g. ERCP or MRCP; if no stones seen do lap. Cholecystectomy but if stones present will require

common bile duct exploration.)

2. At time of surgery, an intraoperative cholangiogram may also be performed

Case #5: A patient presents with a history of yellow eyes, dark urine and pale stools. What is the

management?

1. Bloods: LFTs increased direct bilirubin, increased ALP, increased GGT (more than ALT or

AST)

2. USS: dilatation of common bile duct (not very sensitive for gallstones)

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On ultrasound, stones were seen in the gallbladder but unable to visualize common bile duct. What

is the next step in the management of this patient?

Treatment:

1. ERCP to remove stones which are usually seen as a filling defect (via basket, or sphincterotomy

of ampulla of vater and use of Fogaherty catheter)

2. Then do cholecystectomy.

Case #6: A patient presents with right upper quadrant pain + fever (+/- chills and rigors) + jaundice

(Charcots triad). Patient is diagnosed with cholangitis. What is the management?

1. Most important things are rehydration of IVF and antibiotics (do blood cultures prior to starting

antibiotics)

2. Once the patient is better, perform ERCP and remove the stone

3. Perform cholecystectomy

4. If the patient is unstable, perform an urgent ERCP to decompress the gallbladder

Case #7: A patient presents with pain in the epigastric region, which radiates to the back and is relieved

on leaning forward. The patient is diagnosed with pancreatitis. What is the management?

1. There is NO indication for antibiotics because it is inflammatory and not infective (unlike

cholangitis)

2. Fluid resuscitation

3. Rest pancreas (NPO)

4. If it is mild, wait until it settles, investigate, then remove gallbladder

N.B. ERCP can worsen pancreatitis (do not use for the mild pancreatitis, use more in the severe type)

Additional

Normal size of common bile duct is 6mm.

Rokitansky Aschoff sinuses are pseudodiverticula in the wall of the gallbladder. They may be

microscopic or macroscopic. Histologically they are outpouchings of gallbladder mucosa into

the gall bladder muscle layer and serosal tissue. They are associated with cholelithiasis and

cholecystitis. They form as a result of increased pressure in the gallbladder and recurrent

damage to the wall of the gallbladder.

95% of gallbladders that are taken out are due to chronic cholecystitis.

USS is good at showing dilated ducts. It is also sensitive at differentiating between obstructive

jaundice and normal jaundice.

If the distal common bile duct cannot be visualised on USS, perform ERCP.

Pale stools are an important finding in obstructive jaundice.

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Pain differentiates between jaundice due to gallstones and jaundice due to pancreatic cancer.

There is pain in gallstone jaundice, while pancreatic cancer jaundice is painless.

Acute cholecystitis does not cause jaundice.

Charcots triad = RUQ pain + fever + jaundice

Raynauds pentad = Charcots triad + hypotension + confusion (basically adding the features of

shock)

Cholangitis causes septicaemia.

X-Rays

1. Pneumothorax

If mild, leave it alone and allow to settle. Do X-rays 6 hours apart. 20% of pneumothorax can

resolve on their own. If severe, use a chest tube. After placement of chest tube, it is important

to ensure that the pneumothorax has resolved. Also, ensure that the chest tube is placed

correctly (make sure all holes are inside the chest the last hold always breaks the radiopaque

line, so if this hole is seen on chest X-ray then all the holes are inside the chest)

2. Massive pleural effusion

Homogenous opacification seen on chest xray.

Management:

Thoracocentesis diagnostic (send pleural fluid for cytology, microscopy, culture and

sensitivity) and therapeutic

Insert chest tube

What is the most likely cause of this massive pleural effusion? MALIGNANCY

3. Small and large bowel obstruction

An xray showing both SBO and LBO suggests right colonic distension which is most likely due

to a malignancy.

Additional notes:

Always look at supine abdominal xray first as it allows you to see differentiating

features for small vs large bowel eg plicae circulares, central distribution in SBO.

The erect abdominal xray is good for seeing the air-fluid levels and in detecting

pneumo-peritoneum.

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Normally the liver is seen under the right hemidiaphragm. If a loop of bowel gets

between the diaphragm and liver, this is known as Chilaiditis sign.

Add images from your phone please tanz! (My pictures didnt come out very clear, Jamz has

better pics)

Breast

Risk Factors

ALL of the following must be asked in the history!

Prolonged uninterrupted estrogen cycle

o Age of 1st child

Ideally, first child should be before the age of 20

Ask patient the age of their first child

o No breast feeding

o Early menarche

o Late menopause

o Hormone replacement therapy (HRT)

Persons with 1st degree relatives who have breast cancer

BRCA1 and BRCA2 genes

Obesity

History of proliferative breast disease

o e.g. atypical ductal or lobular hyperplasia

o Ask about previous breast lumps or breast cancer

Examination

Size

Location

Features e.g. irregular, indistinct edges, fixed to skin or surrounding structures

Investigations

Imaging in the presence of clinically palpable lump is only useful for looking for other lesions.

The results of the mammogram wont affect the approach to the lump already discovered

because it should be biopsied regardless

FNAC

Core biopsy

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Incisional biopsy

Excisional biopsy

Vacuum-assisted biopsy (using image guidance such as X-ray, USS)

N.B. Most places in the world do FNAC over core needle because it is less painful.

Staging

If FNAC or core needle shows lump to be cancerous, the next step is to stage:

T1 < 2cm

T2 = 2-5cm

T3 > 5cm

T4 any tumour which is fixed to skin or other structures

Stages 1 and 2 are early disease while stages 3 and 4 are late disease.

N1 < 3 nodes

N2 = 3-10 nodes

Most important prognostic factor in breast cancer is the presence of affected lymph nodes

Ipsilateral lymph node involvement is not a metastasis (it is regional spread). Contralateral node

spread, supraclavicular and cervical nodes are considered metastatic disease???

Common sites of metastases for breast cancer (L2B2):

o Lung

o Liver

o Bone

o Brain

Investigations

CXR

Abdominal USS

o Liver metastases (uncommon in early disease)

Bone scan

o Not very useful in early disease

1 in 1 million positive in early disease

CT scan of chest and upper abdomen

o Covers liver, bone and chest

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CT scan of brain

Treatment

Treatment is locoregional (breast and axillary nodes) and systemic.

None of the tests mentioned previously can detect microscopic disease. Most cancer cells or

mets are only visible at sizes >1 cm, therefore systemic treatment is required to be on the safe

side.

Locoregional Therapy

Locoregional treatment +/- local radiotherapy:

o Breast conservative surgery

o Breast ablative surgery

Cons of breast conservative surgery

o It is well known that patients receiving breast conservative surgery have more recurrences,

have more procedures and are more likely to have future radiotherapy, etc. For these

reasons, most patients (in Barbados) pick breast ablative surgery.

??? Similar mortality rates between those treated with breast conservative and breast ablative

surgery

Resection:

o Small breasts, at least 1cm margin grossly, and 3mm microscopically should be resected

(remember fixation shrinks the tissue)

o Large breasts: aim for wider resection margins

Modified Radical Mastectomy:

o Level 1 Lateral to pectoralis minor

o Level 2 Posterior to pectoralis minor

o Level 3 Superomedial to pectoralis minor

Clinically, large axillary nodes will require axillary dissection (level 1 and 2 usually). For clinically

imperceptible small nodes consider SLNB??? (supposed to be right in 97% of cases (3% will

have skip lesions))

Toilet mastectomy is a palliative mastectomy for a fungating breast mass. It is not a treatment

but just for the purposes of relief (decrease odour, etc)

Systemic Therapy

Types of systemic therapy:

1. Hormonal therapy

2. Chemotherapy

3. Immunotherapy

Hormonal Therapy:

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N.B. Aromatase inhibitors are used in post menopausal women

Side effects of Tamoxifen

o Increased risk of endometrial cancer

o Increased risk for osteoporosis

o Increased risk of venous thromboembolism

o Increased risk of cardiac events

Chemotherapy:

1st line chemotherapy regimen - Adriamycin (Doxorubicin) + Cyclophosphamide

Chemotherapy candidates are those with poor prognostic factors:

o +ve lymph nodes

o High grade tumours

o Young patients (30s and 40s - more aggressive)

o Estrogen negative tumours

Immunotherapy:

Herceptin for Her 2 neu +ve tumours

Handling the non-palpable Lesion on Mammogram

Stereotactically guided core needle biopsy

Hook-wire wide local excision under the guidance of a hook wire placed by the aid of the

radiologist. The surgeon follows the end of this hook wire and does wide local excision.

N.B. Lobular carcinoma in situ is not visible on mammogram. It indicates very high risk for developing

ductal carcinoma in situ not just in original, but also in the contralateral breast.

Approach to high-risk Patient with non-palpable Mammography Finding

Surveillance

o Breast examination twice yearly by surgeon

o Self examination once monthly

o Mammography

Chemoprophylaxis with Tamoxifen

Bilateral mastectomy (drastic)

Additional

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Peau dorange is blockage of the skin lymphatics (there is no skin involvement). Sometimes,

peau dorange is considered T3 automatically.

Walrond: Much evidence to suggest locoregional foci wont metastasize. Some surgeons choose

to remove primary tumour without axillary clearing. Years later, axillary nodes enlarged and

upon subsequent resection there was no evidence of distant metastases, and this group of

patients survived just as long as those who received axillary clearance initially.

Be careful with giving Tamoxifen to patients who have had previous pulmonary embolism.

Doxorubicin is cardiotoxic, so do pretreatment echocardiogram and baseline cardiac function

Ductal carcinoma in situ is not invasive and therefore technically there is no role for axillary

dissection

Lobular carcinoma can be distinguished from ductal carcinoma on FNAC by examining the

appearance of the cells. What you cant tell from FNAC is whether or not it is invasive (biopsy

is needed in this case).

X-ray Session

Endoscopy is used to investigate esophageal cancer. Cannot comment on LES thickening unless

theres an ultrasound probe attached to the main probe. What they can say is that there was

difficulty passing the probe at the upper GI endoscopy from which they infer theres failure of

LES relaxation. Achalasia is diagnosed by manometry. DDx for appearance of achalation on

barium swallow acid reflus, esophageal cancer.

Intracapsular (subcapital) femoral fracture

o Austin Moore prosthesis

Lack of collateral vessels with visible filling defect is suggestive of an acute event such as

thrombosis

Intestinal Obstruction

Types

Gastric outlet obstruction (GOO)

Small bowel obstruction (SBO)

Large bowel obstruction (LBO)

Main symptoms of intestinal obstruction

Abdominal pain

Abdominal distension

Vomiting

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Constipation or obstipation (inability to pass feces or flatus)

Abdominal pain:

Gastric outlet obstruction epigastric pain

Small bowel obstruction periumbilical

Large bowel obstruction ???

Abdominal distension:

Gastric outlet obstruction The patient will more likely not complain about abdominal

distension, but on examination there may be fullness in the abdomen.

Small bowel obstruction There is central distension. If the obstruction is proximally, there is

less distension. If the obstruction is distally, there is more distension.

Large bowel obstruction There will always be distension because the entire small bowel will

also be backed up. Distension may also be seen in the flanks.

Vomiting:

The stomach makes 1.5 L of fluid/day

Gastric outlet obstruction constant vomiting, non-bilious, undigested food)

Small bowel obstruction early in history, constant vomiting, bilious vomiting (this bilious

vomiting is the only way to differentiate between GOO and SBO)

Large bowel obstruction late in history, not constant or often, begins as food, then bile, than

faeculent

Constipation or obstipation:

Patient will not come out and complain about constipation, therefore, ask about not passing

stool (and they may remember)

Small bowel obstruction constipation and obstipation are late features

Large bowel obstruction constipation and obstipation are early features

Gastric Outlet Obstruction

Occurs at the narrowest part

Causes:

o Chronic peptic ulcer disease (causing fibrosis and scarring)

o Gastric cancer

On examination:

o May feel fullness on left side

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o Succession splash (because stomach is full and big with fluid)

o May be associated with Virchows node, Bloomers shelf, Krukenburgs tumour, liver

mass/metastases, Sister Mary Joseph nodule

Investigations:

o FBC

o U&E (may show dehydration) decreased potassium, decreased sodium, decreased

chloride, and increased bicarbonate (metabolic alkalosis)

Treatment:

o Correct electrolyte abnormalities (bombard them with K+ - 60 mEq/L????)

o Rehydrate (normal saline IVF)

o NG tube

After rehydration, other investigation should include endoscopy and barium swallow. Endoscopy

is gold standard. It can differentiation between a malignancy and benign PUD.

o On endoscopy, if a tight stricture is at the pyloris from PUD, the treatment will be

surgery (gastrojejunostomy), PPi (long term Omeprazole), or vagotomy to decrease acid

production

o On endoscopy, if a malignant tumour is found, treatment involved surgery to remove

the tumour

Small Bowel Obstruction

Causes:

o Adhesions (look for scars from previous surgery)

o Hernia (check all hernial orifices femoral hernias are small and difficult to see)

On examination:

o Increased tinkling bowel sounds (if it becomes absent that it meant there is gangrenous

bowel)

Investigations:

o FBC

o U&E dehydration with no specific electrolyte abnormality

Radiological Investigations:

o X-ray supine (dilated loops of small bowel, centrally located with plica circularis) and

erect (air fluid levels)

o N.B. USS is useless as it does not image small bowel well

Treatment:

o Do not take patients to surgery if the cause is adhesions rehydrate and NGT

(decompression)

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o Volvulus surgery

o Intussusception surgery in adults, but no surgery in children. To reduce it, do an air

enema or contrast enema. Only if this fails, do surgery.

Large Bowel Obstruction

Causes:

o Malignancy in colon (more commonly on the left)

o Complicated chronic diverticular disease

o Volvulus of sigmoid colon

o Fecal impaction

o Ogilves syndrome pseduoobstruction seen in the elderly

On examination:

o Increased tinkling bowel sounds

Investigations:

o FBC

o U&E

o X-Ray dilated bowel seen at the periphery and haustra

o Sigmoidoscopy if there is no peritonitis

Treatment:

o Rehydrate

o Sigmoidoscopy can see a malignancy (remove the tumour) or volvulus (ability to

unravel the colon for a period of time)

o If caecum is extremely large on X-Ray (>12cm), take the patient straight to surgery

because there is a risk of perforation (N.B. Caecum will perforate usually in left sided

bowel obstruction)

Additional

The way to determine if it is bile that the person is vomiting, ask if it was green or yellow and

bitter to taste

Pyloris stenosis in children will give projectile vomiting

Paradoxical aciduria due to vomiting there is hypochloremic metabolic alkalosis. To

compensate, the kidney excretes low chloride with bicarbonate. Sodium is lost along with

bicarbonate. With time the patient becomes progressively dehydrated and hyponatremic.

Because of dehydration a phase of sodium retention follows. Sodium is conserved in exchange

for H+ and K+, leading to paradoxical aciduria and hypokalemia

How to localize pain there are two types of peritoneum:

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o Visceral not localized (more diffuse)

o Parietal localized

Foregut mouth 2nd part of the duodenum (ampulla of vater), Midgut 2nd part of

duodenum 3rd part of the transverse colon, Hindgut 3rd part of transverse colon to the end

????

GOO has an outlet so there will be no perforation because the patient is continuously vomiting

through the outlet

Femoral hernias are most common in thin, older women

Closed loop obstruction ISHA MORE

Volvulus know the signs

Features of intussusception red currant jelly stools, mass may be felt, USS can be used

because not much air is in the way (target sign)

X-Ray Session

Intravenous Pyelogram (IVP)

KUB plain X-Ray without contrast. Look for stones (seen as opacities, guided by the

transverse proceses).

Label minutes of time with contrast on each subsequent film

o At 0 mins, the one that lights up 1st is the kidney with good excretion

Know what the previous X-Ray would should before contrast

Round opacifications in kidneys signify dilated calyces

Diagnosis the patient had a hydronephrosis due to obstruction. The ureters are dilated

proximal to the obstruction. Possible causes include a stone in the ureter, ureter cancer,

retrocaval ureter, retroperitoneal fibrosis

Other more sensitive investigation CT pyelogram

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Ortho X-Ray #1

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X-Ray of left arm

Fracture to proximal 1/3 of ulna and dislocation of the radial head (Monteggia fracture)

Treatment open reduction and internal fixation (plate and screws)

Complications radial nerve damage (wrist drop) (posterior interosseus nerve)

Ortho X-Ray #2

X-Ray of knee joint

Gun shot wound

Worry about bleeding and compartment syndrome???

Main concern is blood vessel damage (popliteal artery)

Examine pulses distally to proximally (dorsalis pedis posterior tibial popliteal)

Treatment open reduction and internal fixation (IM rod and traction)

N.B. GSW dont tend to have a lot of infection

Pancreatic Cancer

Function of Pancreas

Endocrine: secretion of insulin, glucagon, somatostatin

Exocrine: trypsin, lipase, amyplase (which aid in digestion)

Tumours of the Pancreas

Adenocarcinoma (ducts arise from exocrine glands)

Insulinoma (islet cell tumour)

Glucagonoma (islet cell tumour)

Somatostatinoma (islet cell tumour)

Gastrinoma of the pancreas

Benign tumours:

o Cystadenoma (cystic or mucinous)

o Pseudopapillary tumours

Presentation of Adenocarcinoma

Weight loss

Jaundice

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o In head of pancreas

o Tail tumours do not have jaundiceusually have distant metastases with severe weight

loss

Yellowing of skin and sclera

Pruritis

Pale stools and dark urine

Steatorrhea (late feature)

Abdominal pain (mild)

Back pain (retroperitoneal location)

Examination

General:- jaundice, weight loss (cachexia), pale mucous membranes (anemia of chronic disease),

dehydration, supraclavicular lymphadenopathy

Abdomen:-

o May feel palpable mass

o RUQ mass (smooth, globular palpable gall bladder) (Courvosiers law in presence

of painless jaundice, a palpable gallbladder is not due to stones)

o Empyema palpable gallbladder, painful, no jaundice

o Obstructive jaundice with palpable gallbladder, painful, no jaundice

Investigations

Urinalysis:- increased bilirubin, decreased urobilinogen

Bloods:- FBC (WBC), U&Es (dehydration), LFTs (ALT, AST mildly increased, ALP, GGT

increased, direct bilirubin increased), PT, PTT (malabsorption of Vitamin K bile needed to

absorb Vitamin K), amylase (normal in cancer)

Radiology:- USS (pre- vs post-hepatic jaundice ducts), CT abdomen, MRCP/ERCP (biopsy from

ERCP brushings), percutaneous transhepatic cholangiography

Staging

Metastases or local invasion

10% or less respond to chemotherapy (Gencitabin)

Not a candidate for surgery palliative treatment

Palliative Treatment

Stenting across tumour using ERCP (to relieve jaundice)

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Growth of tumour blocks the third part of the duodenum stent with gastro-jejunostomy

Double bypass of CBD and duodenum

5% may be curative Whipples procedure

Preparation For Surgery If You Have Obstructive Jaundice

Hydration status hepatorenal syndrome (combined hepatic and renal failure post-op). Give

mannitol IV preop to flush kidneys

Normalize clotting indices (Vitamin K IV/IM or FFP)

ECG/CXR

Prophylactic antibiotics (to prevent infection)

DVT prophylaxis (pancreatic cancer migratory thrombophlebitis procoagulable state)

Pancreatitis

Causes

GET SMASHED

Drugs (steroids, sulfonylureas, Metformin, OCP, hyperlipidemia, increased Calcium

Clinical Examination

Epigastric pain radiating to the back, relieved by sitting forwards

Vomiting

Jaundice

Dehydration

CVS: shock (fluid loss, inflammatory mediators)

Respiratory: Left-sided pleural effusion

Abdomen: epigastric tenderness, rebound, guarding, Grey-Turners sign, Cullens sign (severe

pancreatitis)

Investigations

Urinalysis bilirubin, 12 hour urinary amylase (spot urine is useless)

Bloods FBC, U&Es, serum amylase (3x upper limit of normal (120-130) therefore > 400 is

pancreatitis or a salivary gland tumour), lipase, LFTs

Imaging Abdominal USS (looking for gallstonesdoesnt image pancreas very well. If there are

no gallstones, suspect pancreatitis epigastric pain)

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Management

IVF

Pain analgesia (Narcotic, NSAIDdont use Morphine, it causes a spasm of the sphincter of

Oddi)

Rest pancreas: NPO, NGT to decompress stomach

Where to manage? Depends on severity (Ransons Criteria takes 48 hours to complete)

o Mild < 3 ward

o Severe > 3 HDU/ICU

Nutritional enteral or parenteral

o Jejunostomy

o Nasojejunal tube

Antibiotics prophylaxis for severe pancreatitis

o Meropenem (best penetration) or Imipenem

Complications

Pseudocyst leaking of enzymes into lesser sac enclosed in fibrotic tissue

o Treatment: resolve if smallwait until they mature

Pancreatic abscess surgery of debridement

Infective pancreatic necrosis

Acute renal failure

ARDS

Upper GI bleed (splenic vein thrombosis)

Pancreatic ascites

Pancreatic fistula

Benign Breast Disease

Nipple Discharge

History: duration, colour, lactating, bilateral, number of ducts (benign/physiological,

prolactinoma)

One duct discharging:

o

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o Mammary duct ectasia (most common, green or variable)

Scenario: Brown discharge expressed from one duct. What is the management?:

o Aspirate for cytology

o Mammogram

o Ductogram (inject dye into duct system may visualize papilloma)

Surgery: Microdochectomy and histology

o Local anesthesia

o Cannulate duct with fine metal instrument

o Periareolar incision and removal of duct

Lumps

History: breast cancer

o Age > 35 years

o Family history of cancer

o Time and change in size of lump

o Painless

Risk factors:

o N.B. not OCP use or ionizing radiation (increased risk of thyroid cancernot risk

factors for breast cancer)

o Nulliparity

o Age of first child (ideally < 20 years)

o Family history of breast cancer

o HRT (e.g. Tamoxifen)

o Early menarche

o Late menopause

o Genetics (BRCA-1 or BRCA-2)

Inspection:

o Discharge, tethering, peau dorange, asymmetry

o Axillary nodes, supraclavicular nodes

Differentials:

o Fibroademona: firm, well-circumscribed, +/- lobulations, smooth surface, highly mobile

o Breast cancer: firm, hard, may be mobile, not well circumscribed (irregular borders)

o Cysts: firm, well-circumscribed, mobile (not as mobile as a fibroadenoma), multiple,

fluctuant

Scenario #1: 16 year old with lump in right breast for 4 months. The lump is 3cm and is firm,

lobulated and mobile

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o Diagnosis: fibroadenoma

o Investigations: FNAC, ultrasound

o Treatment: excision (+ histological confirmation)

Scenario #2: 16 year old with lump. On examination the lump is fluctuant

o Diagnosis: cyst

o Investigations: USS (confirms that it is a cyst)

o Management: aspirate the cyst (+ send for cytology)

o After aspiration, there is a risk of recurrence. If there is recurrence, offer excision

Scenario #3: 30 year old with lump in breast. No risk factors. Had for few months. Firm lump

in right upper outer quadrant, mobile, no axillary nodes

o Investigations: core needle biopsy (fibrocystic change may not be representative),

excisional biopsy: fibrocystic change, USS: multiple

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o Management of patient with previous excision biopsy, +ve margins DCIS

o Treatment: all lumps must be excised as there is a risk of developing cancer

Wide excision

Simple mastectomy

LCIS:

o Incidental finding no lump

o High risk of breast cancer

o Surgery: bilateral mastectomy

o Cancer: IDC

4