GENERAL SURGERY CRASH NOTES

PRINCIPLES OF SURGICAL CARE

Just…no

UPPER GIT SURGERY

Upper GIT haemorrhage [p. 45]
Aetiology  varices | Ulcers | cancers | MW tear | inflammatory conditions

Rockall risk score [>2]

Management

• Resus  ABCs | baseline bloods | INR & cross match

• Medical
o PPIs (↑pH prevents clot lysis)
o H. Pylori ABs [Amoxicillin, Clarithromycin]  prevention of rebleeding
• Endoscopic  diagnostic & therapeutic
o When
 Emergency  unstable & continued bleeding
 Urgent  suspected varices | high risk pt eg elderly | shocked
 Elective  stable
o Where  endoscopy unit if stable | theatre if unstable
o Therapeutic options
 Banding | sclerotherapy |Epinephrine injection | thermal coagulation
 Balloon tamponade if only option available [intubate 1st]
• Surgical
o To treat current bleed  if all else fails or there are complications
o To prevent future bleeds  TIPS (shunt) | liver transplant

Benign disease of the pharynx & oesophagus [p. 50]

Special Ix

• CXR/AXR  dilatation (wide mediastinum)  achalasia | oesophageal Ca

• Barium swallow/meal  pharyngeal pouch | motility d/o | diaphragmatic hernias
• Endoscopy  oesophagitis | malignancies [barium swallow 1st ideal]
 • CT/US  assess spread of known Ca
• Manometric studies (pressure studies)  motility d/o

GORD

• Sx  heartburn | chest Sx (coughing, pain, hoarseness)

• Ix  barium meal | endoscopy | motility Ix
• Complications  oesophagitis (+/- ulcers, bleeding) | Barrett’s metaplasia
• Mx  lifestyle mod | PPIs | surgery if all else fails [Nissen Fundoplication]

Types of diaphragmatic hernias  sliding vs para-oesophageal

• Sliding  worse GORD Sx

• PO  more likely to become strangulated

Achalasia  ↓Fx of the oesophageal muscles & ↓relaxation of the LOS

• Sx  regurg (w/ widening of the oesophagus) | complicated by aspiration

• Ix  bird’s beak appearance (tapering of the oesophagus as it enters the LOS)
• Mx  oesophago myotomy [Heller’s operation]

Diverticula

• Zenker’s (pharyngo-oesophageal)  Upper oesophagus; left posterior

o Elderly patients
o Sx  dysphagia | foul breath | noisy chewing | regurg
o Comp  LOW | aspiration | perf during endoscopy
• Traction  mid oesophagus
o Usually due to contiguous pathology eg TB
• Epiphrenic  lower oesophagus [RARE, don’t stress about it]

Oesophageal perforation

• Causes
o Instrumental  endoscopy | dilatation | stent placement | sclerotherapy for varices
o Non-instrumental  vomiting | trauma | foreign body | leaking anastomosis
• Sx  pain | resp distress | dysphagia | fever
o Severity depends on: Extent | localised vs free perf
• Ix  CXR (free air in retro-oesophageal space) | gastrografin swallow
• Mx
o Cervical  conservative [supportive & ABs], upscale if needed
o Thoracic  urgent thoracotomy if transmural perf

Oesophageal Ca [p. 60]

Risk factors

• AdenoCa  GORD w/ Barrett’s | Obesity | Relatively ↓Age compared to SCC

• SCC  Black | Male | Age > 65 | smoking (↑ w/ etOH) | Achalasia | diverticulae | HPV

Signs & symptoms

• Tumour related  dysphagia | Regurg | odynophagia | LOW | Bleeding | cough

 • Local spread  Resp fistula (cough on swallowing) | hoarseness (RL n) | constant pain
• Distant spread  ↑Ca | Direct effect of mets

Diagnosis

• Endoscopy [+/- Bx]  Direct visualisation

• Contrast swallow  disruption of smooth oesophageal lining | Constriction | fistula filling
• U/S  Local stage (and sometimes LNs)
• CT and/or PET  Staging (especially distant spread)

Management

• Surgery  esophagectomy (if resectable)

• Chemoradiation  mainly Palliative [brachytherapy option]
• Intubation (stent)  Rx for dysphagia and/or fistula

PUD [p. 72]

Medical Mx

• PPI  omeprazole
• 2 ABs  Amoxicillin | clarithromycin (or metronidazole)

Surgery only if PUD complicates  haemorrhage | Perforation

Small intestine [p. 78]

Small bowel obstruction prev epis

• Causes
o Extrinsic  Adhesions | Hernias | neoplastic | intra-abdo sepsis
o Wall
 Congenital  malrotation | CF | Meckel’s
 Inflammatory  Crohn’s
 Infectious  TB | Actinomycosis
 Traumatic  Haematoma | Ischaemic stricture
 Neoplastic  primary | Met
 Other  Intussusception | endometriosis | radiation stricture
o Lumen  gallstones | Bezoar | foreign body | enterolith
• Clinical
o Hx  prev surgeries | hernias | Sx of malignancy | IBD | prev episodes
o Sx  Colicky pain & discomfort | distension | N/V (+ bile) | Obstipation
o Ix  AXR: dilated loops of small bowel w/ air-fluid levels [may also find cause]

Complications  Perf | short bowel Sx after surgery | haemorrhage

Gastric Ca [p. 84]

Risk factors  H. pylori | EBV | FHx | Prev surgery Blood group A | smoking | etOH | salty foods |
pernicious anaemia

Pathology

• AdenoCa [95%]
 o Intestinal type (commoner)  Antrum | +Acini | ulceration | better prognosis
o Diffuse type  Fundus | -Acini | constricting
• other  stromal | lymphoma

Correa’s Hypothesis

Clinical

• Dysphagia & Dyspepsia [look for VT adenopathy]

• gastric outlet obstruction  vomiting | dehydration | succession splash | mass
• Constitutional  Anaemia | LOW | melena stools | mets

Ix  endoscope +/- Bx | Staging & met screen (bloods, CXR, US)

Mx if resectable  Total vs subtotal gastrectomy

 HEPATOBILIARY SURGERY
Acute pancreatitis [p. 93]
Aetiology  etOH | gallstones | Ca | idiopathic | viral | drugs | trauma | ERCP | ↑PTH | ↑chol

Pathogenesis: Trigger  proteolytic enzyme activation  autodigestion +/- inflammatory response

Types

• Interstitial oedematous  focal/diffuse swelling of the pancreas due to oedema (milder)

• Necrotising  necrosis of parenchyma and/or peripancreatic tissue (often severe)

Complications

• Local
o Fluid collections (IOP)  <4wks after onset | NO necrosis | NO defined wall NOTE:
o Pseudocyst (IOP)  >4wks | usually no necrosis | well defined wall
o Necrotic collection (NP)  fluid collection w/ necrotic tissue | NO wall Collections may be
o Walled off necrosis (NP)  walled off necrotic collection | usually >4wks sterile of infected

o Other organs affected  gastric outlet obs | portal v. thrombosis | intestinal necrosis
• Systemic  SIRS | ARDS | renal failure | DIC

Sx

• Mild  post prandial epigastric pain which radiates to back | N/V | fever
• Severe  severe form of above Sx | shock | ARDS | renal failure
• Insidious [↓immune | post-op]  unexplained cardio-resp failure | fever | ileus

Ix

• Bloods  serum Lipase and/or amylase [3× Normal]

o Also serum Ca | Lipid profile | blood gas
• Urine trypsinogen activation peptide (TAP) [not widely available]
• CXR/AXR  most useful to exclude other conditions; AP Sx non-specific
o Sx of ARDS | pleural effusion | colon cut-off Sx | sentinel bowel loops
• CT  peripancreatic collections or necrosis
• U/S and/or ERCP  gallstones

Grading of severity

• Mild  no organ failure | No local/systemic complications

• Moderate  + complications | transient organ failure (<48hr)
• Severe  ++ complications | persistent organ failure (>48hr)

Mx  mostly supportive/conservative | Rx cause | Rx local complications (eg collection drainage)

Chronic pancreatitis [p. 93]

Characteristics  chronic inflammation | irreversible morphological changes | Pain | loss of Fx

Aetiology  etOH | nutrition | CF | hereditary | autoimmune | obstructive | idiopathic

Pathophysiology  necrosis-inflammation-fibrosis sequence

Complications  DysFx | fluid collections | false aneurysms | splenic v thrombosis | pancreatic Ca

Presentation [2 common patterns]  usually after years of binge drinking

• Mild intermittent attacks  sometimes burns itself out

• Progressive course  progressively worsening & persistent

Ix  similar to acute pancreatitis

Management

• Conservative  good pain control | Rx of complications

• Surgery [for severe cases]  drainage | resection | Rx complications

Gallstones [p. 105]

Risk factors (all the Fs)  Fat | Fair | Female | Fertile | Forty

Types  Cholesterol | black pigment (bilirubin) | brown pigment (worms) | Mixed

Sx  Biliary colic [RUQ colicky pain; R to scapula] | Murphy’s Sx in acute cholecystitis

Ix  LFT | U/S (acoustic shadow) | ERCP | AXR (opacities if calcified)

• LFT normal if just gallstones, but may be ↑↑ if choledocholithiasis

Mx if symptomatic  cholecystectomy (open vs laparoscopic)

Complications  acute cholecystitis | choledocholithiasis | cholangitis

Courvoisier’s law  If palpable GB + jaundice, then NOT GALLSTONES

Pancreatic neoplasm [p. 110]

Ductal AdenoCa  85%

• Insidious, usually presents w/ advanced disease

• RFs  FHx | Age | smoking | chronic pancreatitis | ?DM | ?Obesity
• Sx  painless obstructive jaundice | Dyspepsia | upper abdo pain, R to back | LOW | late
onset DM | gastric outlet obstruction | ascites | abdo mass | cancer C/Ss | VT node
• Investigations
o Bloods  CA 19-9 | abnormal LFT [↑Bili, ↑GGT ↑ALP]
o U/S  peripancreatic pathology [Not very good for detect small pancreatic tumours]
o CT  good for detecting 1o tumour & surrounding vessels
o Other  MRCP (level of biliary obs) | ERCP (palliative stenting) | staging laparotomy
• Mx  surgery if resectable [Whipple’s] | Good palliation if not

Neuroendocrine tumours

• Non-functional  commonest | Sx of mass effect | often advanced disease

• Insulinomas  commonest functional NE tumour | 90% benign | usually small & solitary
o Sx of hypoglycaemia  anxiety | confusion | seizures | ↓LOC | weight gain
o Dx  Whipple’s triad | ↑C-peptide & insulin during hypoglycaemic episode
o Rx  Medical glucose control | Resection
• Gastrinomas  mostly sporadic, but some genetic influence | 60% malignant
o Sx  Fulminant & refractory PUD | Diarrhoea which responds to PPIs
 o Rx  high dose PPIs | exclude gene (MEN-1) | Surgical excision
• Glucagonoma  RARE | Sx of starvation & excessive gluconeogenesis
• Cystic neoplasms  serous | mucinous | intraductal papillary | solid pseudopapillary

Acinar cell tumours  RARE | Sx of ↑enzyme production

Portal HPT [p. 119]

Causes

• Pre-hepatic  portal vein thrombosis | external compression of PV | congenital PV atresia

• Intra-hepatic  Cirrhosis (etOH, HBV) | ALD | portal fibrosis | schistosomiasis | idiopathic
• Post-hepatic  Budd-Chiari Sx | veno-occlusive disease | constrictive pericarditis

Complications  variceal bleed | encephalopathy | Ascites | hepatorenal Sx | coagulopathy

Prognosis for chronic liver disease  Child-Pugh score

Surgical disease of the liver [p. 131]

Pyogenic liver abscess

• Aetiology
o Biliary tract [Ascending cholangitis]  stones | Ca | strictures | sclerosing cholangitis
o Hepatic artery  dental infection | IE | IVDU
o Portal vein  appendicitis | Diverticulitis | Crohn’s | pelvic sepsis
o Direct extension  gall bladder empyaema | perf PUD | perinephric abscess
o Other  Cryptogenic | Trauma | Iatrogenic | 2o infection of liver cyst
• Sx  Abdo pain | Fever | night sweats | LOA | LOW | N/V | liver enlarged & tender
• Investigations
o Bloods  ↑WCC | ↑↑ESR | ↓Hb (chronic inf) | ↑ALP | ↓Alb | ↑AST/ALT
o U/S  preferred 1st line Ix
 o CXR  +/- HPM | air-fluid level in abscess | elevated diaphragm w/ pleural RXN
o Other  CT (other intra-abdo abscesses) | ERCP (biliary pathology)
• Mx  early ABs | drainage (percutaneous, surgical)

Amoebic liver abscess

• Aetiology  faecal-oral  through colon wall  liver

• Pathology  Solitary | 80% R lobe | red/brown pus & necrotic liver tissue
• Sx & Ix similar to pyogenic abscess  serological tests key
o Indirect haemagglutinin titre [beware false +ve from prev infections]
o NO eosinophilia
• Rx  metronidazole | supportive | surgical drainage only if needed

Hydatid disease

• Aetiology  Usually Echinococcus granulosus [Dog tapeworm]

• Pathology  via gut wall  portal vein [occurs anywhere in the body, but 2/3 liver]
• Sx  gradual RUQ enlargement & pain | Sx of acute comp eg rupture
• Ix  serology | ↑↑eosinophilia
• Rx  surgery if symptomatic [to prevent complications]

Benign liver tumours

• Simple cyst  Normal, no Rx usually required | normal liver Fx etc

• Haemangioma  commonest benign solid tumour | Non-specific Sx
• Other  Liver cell adenoma (LCA) | Focal nodular hyperplasia (FNH)

Malignant liver tumours

• HCC  usually w/ cirrhotic livers (EtOH | HBV)

o Dx  Discreet mass surrounded by cirrhosis on U/S | ↑AFP [Bx unnecessary]
• Mets  usually 2o to GIT Ca [colorectal | stomach | pancreas], but many others as well
o Usually multiple tumours
o Occasionally resectable w/ colorectal cancers

The spleen [p. 147]

Splenic disorders

• Splenic cysts  Simple | Hydatid | pseudo (resolution after haematoma)

• Splenic abscesses  Sx of LUQ pain & Fever | similar RFs & pathophysiology as liver abscess
• Splenic artery aneurysms  commonest visceral aneurysm
o RFs  elderly w/ atherosclerosis | female w/ congenital lesion | comp of pancreatitis
o Surgery if >2cm or close to the hilum
• Splenic tumours
o Benign [RARE]  haemangiomas | lymphangiomas
o Malignant
 1o  NH lymphoma | non-lymphoid (RARE)
 2o  lung | breast | stomach | pancreas | colon | melanoma
• Trauma  graded by the 1994 spleen injury scale [grade I-V]
o Mx  Conservative | Splenectomy
Haematological conditions treated by splenectomy

• Haemolytic anaemias  surgery if symptomatic | Anaemic | hypersplenism | cholelithiasis

• Purpuras  Most commonly ITP [idiopathic thrombocytopenic purpura]
• Hypersplenism  defined as splenomegaly | Pancytopenia | Normal BM Bx
o 1o or 2o [RA, sarcoid, haem malignancies, malaria etc]
• Myoproliferative D/Os  proliferation of precursor myeloid cells
o Polycythaemia rubra vera (RBCs) | essential thrombocytosis (PLTS)
o BM failure  extramedullary haematopoiesis  massive splenomegaly

Major complication of splenectomy  overwhelming post-splenectomy infection [OPSI]

 COLORECTAL SURGERY
Acute appendicitis [p. 156]
Signs & symptoms  RIF Pain | Anorexia | N/V | Fever

• Pain: vague periumbilical  sharp localised RIF pain

• Peritonism (localised vs diffuse) may indicate perforation
• Specific signs
o Rovsing’s Sx  palpation of LLQ = pain in RLQ
o Obturator Sx  pain w. internal rotation of hip [pelvic appendix]
o Iliopsoas Sx  pain in the R hip on extension [retrocaecal appendix]

Investigations

• Bloods  ↑WCC
• Imaging [Only of Dx is unclear]  U/S | AXR | CT (mostly for excluding other things)

Management: admission  supportive & analgesia  appendectomy if secure Dx (open vs lap)

Basic stomatherapy [p. 159]

Types of colostomies

• End  Permanent | Single end | No bowel left distal to end

• Loop  often temp | Bowel not fully divided | active & inactive limb
• Divided  proximal & distal stomas brought out at separate points on the abdo
• Double-barrel (Mikulicz)  like divided but brought out at the same point on the abdo

Colonic volvulus [p. 163]

Sigmoid

• Sx  recurrent abdo distension | constipation | mild colicky pain

• Ex  MASSIVE abdo distension | usually NOT tender
• Ix
o AXR  bent inner tube | coffee bean Sx | summation line
o Other  Barium enema [bird’s beak Sx] | CT
• Mx
o Conservative  rigid sigmoidoscopy to relieve torsion [Temp measure]
o Surgery  resection of sigmoid colon vs non-resectional procedures
 Urgent  failed decompression | peritonitis | evidence of gangrene on scope
 Elective

Ileo-sigmoid knot  knotting of small & large bowel | Mx = surgical resection

Caecum

• Types - Axial ileo-colic [90%] | Caecal bascule [10%]

• Sx  non-specific, general bowel obstruction stuff
• Ix  AXR [single fluid level in caecum | distended small bowel loops]
• Mx  usually urgent surgery (laparotomy)
Other  transverse colon | splenic flexure | descending colon

Colorectal Ca [p. 172]

Pathogenesis  Adenoma-Ca sequence [normal  tumour initiation  tumour progression  Ca]

Aetiology & RFs  80% sporadic w/ no identified genetic predisposition

• Hereditary
o FAP  Auto dominant | APC gene | multiple polyps in colon | 100% lifetime Ca risk
o Attenuated FAP  less aggressive form of FAP w/ fewer polyps & later presentation
o HNPCC (Lynch Sx)  Auto dominant | ↑risk of colon Ca (80%) but also other cancers
o MAP (MUYTH as. polyposis)  Auto recessive | MUYTH gene | similar to att. FAP
• Diet  processed meat | Animal fat [Fibre = protective]
• Physical  Obesity (insulin resistance w/ ↑IGF)
• IBD  Risk dependant of age of onset & disease severity

Screening  reserved for high risk patients, not general population

Signs & symptoms

• Hx  Blood/mucus | tenesmus | perianal pain | ∆ bowel habits | obs Sx | met Sx

 Obs Sx more severe if on LHS due narrower lumen
• Ex  palpable mass on PR if rectal Ca | Mass | Anaemia

Diagnosis  Biopsy [colonoscopy | procto-sigmoidoscopy | barium enema]

Staging  TNM

• CXR  distant lung mets

• Abdo U/S  abdo mets (liver | LNs | ascites)
• CT  useful for local and distant staging [PET if unsure]
• MRI  useful for rectal CA, not routine for the others

Management  surgery if resectable on staging, but MDT involvement (oncology, palliative etc)

• Surgery can be curative or palliative

• Anatomy dependant  R/L hemicolectomy | sigmoid colectomy | Ant/AP resection

Colorectal polyps [p. 184]

Definition  localised elevation arising from the epithelial surface [sessile vs pedunculated]

Solitary Multiple
Neoplastic
Tubular | Villous | Tubulovillous | flat adenoma | AdenoCa FAP
(adenoma)
Juvenile polyposis
Hamartoma Juvenile (retention polyp)
Peutz-Jeghers
Inflammatory Inflam polyposis in
IBD | dysentery | diverticulitis | amoebiasis | Bilharzia
(pseudo-polyp) colitis
Multiple metaplastic
Unclassified Metaplastic (hyperplastic)
polyposis
Clinical

• Sx  Brigh/dark red bleeding +/- mucus | diarrhoea | prolapse through anus

• Dx  direct observation (scope) & Bx
• Mx  excision Bx & f/u

Diverticular disease of the colon [p. 190]

Definition  sac-like protrusion of the colonic wall

• True  all 3 layers of the gut wall

• False  mucosa + submucosa only [NB what “diverticular disease of the colon” refer to]

Weak points of the colonic wall

where BVs enter:

• Either side of the

mesenteric taenia
• Mesenteric side of the anti-
mesenteric taenia

Pathogenesis  ↓Fibre diet | Dense, large stools | ↑intraluminal pressure | herniation of mucosa

Presentation

• Asymptomatic [AKA diverticulosis]

• Symptomatic  ++ Sx but no signs of inflammation | Sx disappear on defecation
o Sx [mimics IBS]  colicky LIF pain | bloating | flatulence | ∆ bowel habits
o Mx  dietary change (FIBRE) | surgery not indicated
• Diverticular bleed  commonest cause of life-threatening lower GI bleeding
• Diverticulitis  pretty much the same as appendicitis but in LIF
o Comps  perforation (local vs gen) | Fistula (often bladder) | stricture

Surgery for IBD [p. 198]

Aetiology [largely unknown]  Genetic | infection (??) | Hypersensitivity to luminal contents

Pathology

• UC  Distal bowel | continuous disease starting from rectum | affects mucosa

• Crohn’s  Whole bowel | patchy w/ skip lesions | affects all bowel layers

Sx  Diarrhoea +/- blood | Urgency | can mimic other bowel disease (location dependant)

Mx for UC

• Make Dx  >6 stools/day + at least 2 of: pyrexia | anaemia | ↑HR

• Resus
 • Confirm Dx  sigmoidoscopy [NOT colonoscopy, risk of perf] | Exclude infectious diarrhoea
• Daily erect CXR/AXR w/ daily consults from med & surgical gastroenterologists
• High dose IV steroids | anti-TNF if failed | surgery thereafter
• Surgery
o Emergency  toxic megacolon | Perf | massive haemorrhage (rare)
o Urgent  failed medical Rx [colectomy & ileostomy]
o Elective  Chronic problems due to UC | frequent admissions | Risk of malignancy

Surgical Mx of Crohn’s  Mx of complications [anal disease | strictures | Perfs etc]

Large bowel obstruction [p. 202]

Aetiology  Colorectal Ca | volvulus | diverticular stricture | faecal impaction | foreign body | hernia

Sx  Obstipation | Abdo distension | mild pain | late vomiting

DDx  small bowel obs | HD | colonic pseudo obs | congenital leiomyopathy | toxic megacolon

Investigations

• AXR  peripherally enlarged loops of bowel | haustral markings

o Small bowel  centrally distended loops | lines that run across width of abdomen
• Water soluble contrast enema [NOT Barium] or CT scan

Management

• Resus  IV line | catheter | NGT | baseline bloods

• Surgery  extremely dependant on the cause of obstruction
o Hemicolectomy vs stent [palliative | bridging Mx while optimising pt]
o Different for volvulus, refer to chapter above

Colonic pseudo obstruction  clinical Sx w/ no mechanical cause [“Ileus” of the colon]

Lower GI bleeding [p. 208]

Definition  distal to the ligament of Treitz (basically the distal duodenum onwards)

Causes  Most commonly large bowel, small bowel much less common

• Diverticular disease  Acute, painless bright red blood

• Angiodysplasia  Degenerative vascular malformations | usually caecum & asc colon
• Colitis  Ischaemic colitis | IBD (dysentery) | infection (uncommon)
• Neoplasia  both polyps and Ca
• Anorectal disease  haemorrhoids | fissures (more spotting)
• Drug related  Anticoagulants | NSAIDs

Investigation

• Bloods  FBC | Baseline bloods | cross-match

• Imaging  AXR | CT w/ mesenteric CTA [Abdo U/S not useful]
• Technetium-labelled RBCs  nuclear medicine | expensive & limited
• Selective mesenteric angiography  therapeutic potential (CTA/MRA preferred for pure Dx)
• Endoscopy  upper and lower scopes [sigmoidoscopy vs colonoscopy]
Mx  Resus | Locate bleeding point | haemostasis

Peri-anal conditions [p. 212]

Anal sepsis  anorectal abscess | fistula [simple vs complex]

• Aetiology  IBD | hidradenitis suppurativa | Ca | TB | 2o to pelvic sepsis | foreign body

• DDx  fissure | haematoma | haemorrhoids | anal Ca | furuncle | infected cyst

Acute abscess

• Sx  throbbing pain | worse on defecation | +/- discharge or pus | +/- fever

• Ex  visible abscess +/- cellulitis [avoid PR if abscess clearly visible]
• Mx  I&D | Add ABs in some cases [↓immune | ↑↑size | systemically unwell etc]

Fistula in ano

• Sx  purulent d/c (continuous or intermittent) | possible surgical Hx

• Ex  clearly visible external opening
• Mx  surgery [open 1o tract | drain 2o tracts/abscesses | create easy to Mx wound]

Thrombosed perianal varix

• Sx  sudden onset & worsening throbbing pain | worse on walking or sitting

• Ex  perianal tender lump covered by skin | soft & rubbery
• Mx  analgesia | hygiene | laxative | surgery

Hernias [p. 219]

Pathology of contents: reducible  incarcerated  strangulated  ischaemia

Walls

• Anterior  ext oblique

• Floor  inguinal ligament
• Roof  int oblique & transversus abdominus
• Posterior  transversalis fascia

Contents

• 3 arteries  test a. | crem a. | vas a.

• 3 nerves  crem n. | genitofemoral n. | autonomic
• 3 fascia  int/ext spermatic | crem
• 3 others  vas deferens | lymphatics | pamp plexus
Groin

• Inguinal
o Direct  through Hesselbach’s triangle [usually elderly w/ weak abdo wall]
o Indirect  through int ring & canal itself, out ext ring
• Femoral  through femoral canal [inferior to inguinal ligament & medial]

Indirect inguinal Direct inguinal Femoral

Above inguinal ligament Above inguinal ligament Below inguinal ligament
Lateral Medial Even more medial
Along inguinal canal Hesselbach’s triangle Femoral canal
All ages (↑young) Elderly Elderly
↑Male M=F ↑Female
May enter scrotum Cannot enter scrotum Found in thigh
↑risk of incarceration ↓risk of incarceration ↑risk of incarceration

Abdominal wall

• Primary
o Midline  true umbilical | para-umbilical | epigastric
o Lateral  Spigelian | lumbar
• Incisional  sub-xiphoidal | epigastric | para-umbilical | suprapubic | subcostal | flank

Diaphragmatic  sliding vs para-umbilical

Management  surgery

• Reduce contents of sac & release adhesions [restore anatomy]

• Close defect [suture CT not muscles | use mesh]
 BREAST & ENDOCRINE SURGERY
Benign breast disease [p. 226]
Cysts  usually only present when large, tense and painful

• Mx  aspirate to impalpability [Bx if blood stained fluid | still palpable after all fluid is gone]

Mastalgia  pain | tenderness | fullness | aching

• Occurs in most women (usually premenstrual), unclear when it becomes pathological

• Mx  Exclude pathology if focal or abnormal Ex | reassurance | anti-oestrogen if severe

Breast infection  Sx of acute inflammation

• Small abscess [periductal mastitis]  Aspirate | ABs

• Large abscess [lactational]  I&D
• Chronic fistula [Ca, TB]  Biopsy | TB workup

Fibro-adenomas  endocrine-dependant fibrous overgrowths of a single lobule [not true neoplasm]

• Found in younger patients  between 15-50yo, usually early 20s

• Reach about 2cm in size and do not get bigger thereafter
• Sx  well-defined | painless | firm & rubbery | mobile

Suspicious for breast Ca  triple test [clinical assessment | imaging | anat path]

• Based mainly on age & size (but consider other RFs as well)
• DDx  sclerosing adenosis | fibrosis | radial scar | fibro-adenomatoid nodule

Nipple d/c  only really significant if spontaneous d/c

• Sites  bilateral or several ducts [LOW RISK] | single duct [HIGH RISK]
• Fluid  blood is most concerning, but clear fluid does not exclude Ca
• Ix  microdocotomy [DDx: Ca | papilloma | papillomatosis | ectasia]

Gynaecomastia  hormone-dependant male breast enlargement

• Physiological causes  neonatal | puberty | elderly

• Drugs  oestrogens | digoxin | steroids
• Other  liver failure | tumours (testicular, adrenal)

Malignant breast disease [p. 232]

Risk factors

• Major  Female | Age | Genetics (BRCA1/2) | contra-lateral disease | FHx | irradiation

• Minor  wide oestrogen window | parity | HRT & COC | smoking
• Controversial  no lactation | alcohol | diet

Clinical

• Sx  painless lump | ∆ breast appearance | nipple d/c (blood) | nipple changes (Paget’s)
• Ex  mass | thickening | overlying skin retraction & oedema | LNs | mets Sx

Diagnosis  triple assessment [clinical | imaging | anat path]

 • Clinical (as above)
• Radiology  mammogram (only useful >35yo) | U/S (solid vs cystic lesions)
• Tissue  FNAB (cytology) | Trucut/core Bx | excision Bx

Types

• Non-invasive epithelial (Ca in situ)  lobular | ductal

• Invasive epithelial  lobular | ductal (further named after diff features)
• Mixed CT & epithelial  carcinosarcoma | angiosarcoma | phylloides tumours

Staging  TNM (T stages below)

• Tis  Ca in situ
• Tx  cannot be assessed
• T0  no tumour
• T1  <2cm
• T2  2-5cm
• T3  >5cm
• T4  invades skin or chest wall

Management

• Met workup  CXR | LFT | bone scans | CT

• Hormone receptor analysis  certain tumours respond to hormonal manipulation
• Counselling
• Surgery if resectable  mastectomy vs wide local excision (WLE) +/- LN clearance
o Sentinel LN Bx  testing of 1st draining axillary LN
• Adjuvants  chemoradiation | endocrine (eg Tamoxifen) | Biologics

Thyroid gland disorders [p. 240]

Physiology

• Stimulation: TRH (hypothalamus)  TSH (pituitary)  thyroid gland

• Thyroid hormones: T3 (active form) | T4/thyroxine (precursor)
• Also produces calcitonin [C-cells]  acts to reduce blood Ca

Patterns of enlargement [symmetrical vs asymmetrical]

• Symmetrical (goitre)  whole gland involvement

• Asymmetrical (solitary nodule)  focal enlargement [NB must exclude cancer]

thyroid vs other cervical masses

• lower midline of neck

• moves on swallowing

causes of neck swelling in general

• midline  thyroid enlargement | submental LNs | thyroglossal cyst

• lateral  cervical LNs | salivary gland enlargement | branchial cyst | cystic hygroma

causes of goitre
 • physiological  puberty/pregnancy | soft & diffusely enlarged | conservative Mx
• non-nodular  due to poor iodine intake | Mx with dietary iodine
• multinodular  multiple adenomatous colloid nodules | from ↑↑TSH stimulation
• thyroiditis  inflammatory | Hasimoto’s (autoimmune) | Quervain | Riedel

causes of solitary nodule

• hyperplastic/adenomatous nodule [60%]

• follicular adenoma [20%]
• simple cyst [10%]
• thyroid Ca [5-15%]  must exclude despite relative rarity

Ix of nodular thyromegaly

• U/S  single nodule vs MNG | solid vs fluid filled | features of malignancy

• Aspiration cytology (FNAB)  reports risk of Ca [Bethesda classification]
• Radio-isotope scanning  “hot” (↑Fx nodules) vs “cold” (cancer)
• CT  assessment of retrosternal thyroid enlargement & airway compression
• Bloods  thyroid Fx | tumour markers (calcitonin) | thyroid ABs

Surgery for solitary nodules

• Ca Dx made (or cannot be excluded)

• Resected lobe sent for histology  further Mx depends on result

Surgery for multinodular goitre

• Not usually required  reassurance

• Indications  compression (dysphagia; resp Sx) | cosmetics | risk of Ca

Thyroid malignancies

• Well differentiated [85%]  indolent | good long-term survival | surgery & I131
• Papillary [40%]  small nodule | may be multifocal | LN spread common
• Follicular [30%]  large single nodule | haem spread (bone & lung) | I131 sensitive
• Mixed [30%]
• Medullary [5%]  C-cells | Aggressive | total thyroidectomy w/ LN dissection
• Anaplastic [5%]  Elderly Pts | Highly aggressive | Fatal (no response to Rx)
• Lymphoma [3%]  irresectable | Mx w/ chemoradiotherapy

Thyrotoxicosis (hyperthyroidism)

• Common  3 | toxic multinodular goitre (Plumber’s) | toxic solitary nodule

• Rare  pituitary tumour | paraneoplastic Sx | thyroiditis

Complications of thyroidectomy

• Structural  RLN damage | laryngeal oedema | haemorrhage | tracheomalacia

• Endocrine  hypothyroidism | hypoparathyroidism | thyroid crisis
 Endocrine disorders [p. 248]
Thyroid gland  above

Parathyroid gland  secretes PTH to ↑Ca

• 1o hyperparathyroidism  common | intrinsic PT gland abnormality

o Usually single gland (adenoma), but can be all 4 (hyperplasia)
o Usually sporadic, but can be associated w/ MEN Sx (genetic)
o Sx  Bones | stones | groans | moans | hypercalcaemic crisis
o Ix  bloods [↑Ca, ↑PTH] | ↑urine Ca | nuclear scan to localise lesion [sestaMIBI]
o Rx  parathyroidectomy if symptomatic
• 2o hyperparathyroidism  2o to ↓Ca levels, thus ↑PTH to compensate
o Causes of ↓Ca absorption  renal failure | gut malabsorption | ↓VitD
o Sx  osteopenia (path #) | pruritis | ectopic soft tissue calcs | vascular calcs
o Ix - Normal Ca | ↑↑↑PTH | ↑PO4
o Rx  remove 3.5 of the hyperplastic glands
• 3 hyperparathyroidism  after Rx of causative factor leading to 2o
o

o PT gland overaction persists despite Rx  ↑Ca again

Pancreatic islets

• Gastrinoma [D cells]  can occur in the duodenum as well

o Zollinger Ellison Sx  recurrent PUD | ↑acid secretion | islet tumour
o Ix  CT | surgical exploration
o Rx  surgery |PPIs
• Insulinoma [B cells]
o Sx  weakness | confusion | convulsions | visual dist | sweating | palpitations etc
 DDx  Anti-DM rugs | liver disease | etOH | post-gastrectomy
o Ix  adenoma visible on CT
• Glucagonoma [A cells]  RARE

Adrenals

• Cushing’s Sx (cortex)  ↑Cortisol

 o causes  steroids | pituitary adenoma (Cushing’s disease) | ectopic ACTH | adrenal Ca
o Ix  24hr urine cortisol | serum ACTH | dexamethasone suppression test | CT
o Rx  treat cause, eg resection of tumour
• Conn’s Sx (cortex)  aldosterone secreting adenoma
o Sx  sustained HPT | ↓K | Adrenergic attacks | CVD
o Ix  urine vs blood levels (K, ald) | ↓renin | CT
o Rx  cause dependant (bilateral hyperplasia vs solitary adenoma)
• Pheochromocytoma (medulla)  Adrenalin | noradrenalin
o Associations  MEN2 | NF | Von Hippel-lindau Sx
o Sx  young, rapidly progressing HPT | paroxysmal attacks | sympathetic overdrive
o Ix  CT | radio-iodine labelled MIBG
o Rx  alpha-blockade
• Addison’s disease  ↓Cortisol
o Causes (destruction of adrenals)  TB | auto-immune adrenalitis | mets
o Sx  fever | N/V | ↓↓BP | lethargy | chronic ill health
o Ix  ↓cortisol | ↑ACTH | ↓Na | ↑K | ↓Gluc | renal impairment
o Mx  Resus | Steroid replacement therapy
• Other
o Adrenal Ca  ↑↑secretion of all hormones [usually advanced, poor prognosis]
o Adrenogenital Sx  ↓adrenal steroid synthesis  ↑ACTH  ↑adrenal androgens
o Ganglioneuroma  encapsulated benign tumours arising from ganglion cells
o Neuroblastoma  malignant tumour found n children

MEN syndrome (multiple endocrine neoplasia)  most likely hereditary

• MEN 1 [Wermer’s Sx]  pituitary (GH, PRO) | pancreas (INS, GAST) | PT gland (PTH)
• MEN 2 [Sipple Sx]  medullary thyroid Ca | pheochromocytoma | ↑PTH
• MEN 3 [mucosal neuroma Sx]  medullary thyroid Ca | pheochromocytoma | marfanoid
habitus | mucosal neuromas

Carcinoid tumours/syndrome  indolent neuroendocrine tumours

• Sites  GIT (appendix, ileum) | lung | thymus | ovary

• Carcinoid Sx  when these tumours secrete hormones which bypass the liver (oft serotonin)
o usually asymptomatic otherwise, or cause complications of mass effect eg appendicitis
• Dx  24hr urine HIAA (serotonin metabolism product) | CT to localise
• Rx  MTD | conservative | medical | surgical resection
 VASCULAR SURGERY
Acute limb ischaemia [p. 262]
Definition  sudden loss of arterial supply to limb [<2 weeks since onset]

Aetiology

• Thrombosis  usually less severe, diseased vessels = more collaterals & progressive Sx
o Atherosclerotic disease  Progressive | diseased vessels
o Hypercoagulable state  Normal vessels | thrombocythemia | malignancy etc
o Arterial dissection  Back pain | renal dysFx if renal aa are affected
o Bypass graft occlusion  common complication of bypass graft
• Embolism  usually severe due to occlusion of normal arteries (no collaterals developed)
o Cardiac  AF | acute MI (mural thrombus) | IE (septic emboli) | atrial myxoma
o Arterial  atheroembolism (diseased vessels) | aortic mural thrombi (N vessels)
o Paradoxical  venous thrombus causing arterial occlusion [Cardiac defect]
• Trauma  blunt (eg knee dislocation) | penetrating (inter-personal violence)
• Iatrogenic  post-interventional radiology | surgery in region of vessels
• Malperfusion  systemic shock (problem in diseased vessels) | dissection

Clinical

• History
o Sx  Pain (claudication  resting pain) | sensorimotor loss
o RFs  Hx of heart disease eg AF | metabolic Sx | smoking | FHx
• Examination  rule of 6 Ps [Pulse | Pain | Pallor | Paralysis | Paraesthesia | Poikilothermic]
o Define level of occlusion  Aorto-iliac | Femoral-popliteal | Tibial-peroneal
o Look for potential cause  Vitals | full cardiac Ex etc
o ABI  normal range [0.9 – 1.3]
o Hand-held doppler  biphasic (good) | monophasic (↓flow) | absent (NO flow)
o Define severity [Rutherford classification]
• Investigation  Time dependant [ie don’t do on immediately threatened limb]
o Arteriography  Dx & therapeutic potential
o CTA  Ix of choice (quick & easy) [MRA also possible, but less favourable]
o Echo  controversial | can be useful in identifying cause

Management

• Initial  Heparin | O2 face mask | Fluids | Analgesia | catheter | baseline bloods

• Definitive  depends on expertise available, severity of limb ischaemia etc
o Anticoagulation  Heparin | stabilises clot to prevent 2o thrombosis
o Surgery  embolectomy catheter | bypass graft
o Endovascular
 Mechanical thrombectomy  aspiration embolectomy
 Thrombolysis  drugs injected into clot
 Arterial aneurysm [p. 274]
Definitions

• Aneurysm  Permanent focal dilatation >1.5 times the original diameter

• Ectasia  small version of aneurysm (ie <1.5 times diameter)
• Arteriomegaly  diffuse enlargement of entire arterial segment
• Aneurysmosis  several aorto-iliac/infra-inguinal aneurysms in the setting of arteriomegaly

Classification modalities

• Location
o Aortic  Abdominal aortic | Thoraco-abdominal Aortic | Thoraco-aortic
o Non-aortic  peripheral | renal | mesenteric | carotid | subclavian | neural etc
• Type  True (all 3 vessel wall layers) vs false (sequestered peri-vessel bleed)
• Morphology  Fusiform (spindle) vs Saccular (outpouching)
• Size  small (<5.5cm) vs large (>5.5cm)
• Aetiology
o Degenerative  fibromuscular dysplasia | intimo-medial mucoid degeneration
o Infective  Mycotic | TB | syphilis | Salmonella | HIV | HepB | fungal (rare)
o Inflammatory  SLE | Takayasu’s | giant cell arteritis | Kawasaki | Behcet’s etc etc
o CT d/o’s  Marfan’s | Berry aneurysms (cerebral) etc etc
o Other  Post-dissection | Post-stenotic | Trauma | Congential
• Presentation (below)

Complications  Rupture | Thrombosis | source of embolism | mass effect | fistula

Abdominal aortic aneurysm (AAA)

• RFs  ↑Age | Male | White | HPT | ↑Chol | protease vs anti-protease imbalance

• Classification  infra-renal | juxta-renal | par-renal | supra-renal | TAAA
• Clinical features [most are asymptomatic & found incidentally]
o Symptomatic  vague abdo pain | recurrent backache | compressive Sx (below)
 Vomiting (duodenum) | Constipation (colon) | flank pain (ureters)
o Rupture  sudden & severe back pain | Shock | pulsatile abdo mass
 • Ix  U/S | CTA | MRA | DSA (therapeutic potential)
• Screening (selective)  RFs | documented aneurysms which were too small to treat
• Management
o Lifestyle modification  smoking | metabolic Sx
o Surveillance [small aneurysms]  annual (<4.5cm) vs 6-monthly (>4.5cm)
 Intervene if  +Sx/comps | >5.5cm | rapid ↑size | saccular >3cm
o Surgery
 Open repair  current standard [5% mortality if healthy]
 Endovascular (EVAR)  better peri-op outcomes but ↑recurrence rate
• Deciding to treat ruptured AAA  Hardman risk index [100% mortality if 3 or more]
o Age > 79 | BP < 90 | Creat > 179 | Hb < 9 | ischaemic ECG

Others

• Popliteal aneurysm  commonest peripheral aneurysm | Often associated w/ AAA

• Femoral aneurysm  Usually pseudoaneurysms | Rx is only surgical
• Subclavian artery aneurysm  usually post-stenotic
• Extracranial carotid aneurysm  uncommon
• Mesenteric artery aneurysm  uncommon, but ↑↑mortality if rupture
• Renal artery aneurysm  RARE

Diabetic foot [p. 285]

Neuropathy

• Pathophysiology  microvascular vs metabolic injury (↑intracellular glucose) theories

• Sensory  glove & stocking [Numbness | paraesthesia | burning]
• Motor  wasting of intrinsic muscles
o Flexor domination  claw foot  ↓cushioning under metatarsal head  ulcer
• Autonomic  ↓sweating [leads to dryness & injury & ulceration]

Vascular disease & Ischaemia  refer to PAD chapter for more

• Usually tibio-peroneal occlusion (atherosclerosis)

• Often the claudication isn’t felt due to neuropathy

Other problems

• Oedema [vascular disease]  ↑risk of ulceration and/or infection

• CT changes  glycosylation of CT  stiffness  ↓mobility  ↑injury & ↓healing
• Charcot’s osteoarthropathy  RARE [foot deformity]
• Classification systems  Wagner classification1 | University of Texan classification2
Management

• Relief of pressure (off-loading) & debridement of necrotic tissue

• ABs if infected, and Rx of ischaemia as w/ normal PAD
• Medical control of glucose and Mx of RFs

DVT & PE [p. 294]

RFs  always think Virchow’s triad [flow | vessel wall | blood constituents]

• Major  Age | Obesity | varicosities | FHx | thrombophilia

• Minor  malignancy | hormone Rx | acute illness | trauma | immobility | pregnancy

Clinical  Pain | oedema | erythema | tenderness | fever | Homan’s Sx | peripheral cyanosis

• Sx can be non-specific & inaccurate, thus use Well’s score to assess DVT likelihood

Investigations

• D-dimer  ↑↑sensitivity for DVT, but ↓specificity [DIC | Ca | infection | trauma etc]
• Duplex U/S [current test of choice]  venous incompressibility | flow abnormalities

Prevention

• General  avoids RFs | early mobilisation after surgery etc

• Mechanical  compression stockings | intermittent pneumatic compression etc
• Drugs  Heparin (UFH vs LMWH) | oral VitK antagonists (eg warfarin)

Management of DVT  prevention of clot extension & complications eg PE

• Immobilisation & leg elevation  More relief of Sx than prevention of PE

• Anticoagulation  LMW heparin & warfarin
• Long-term Mx
o Continued warfarin use [INR between 2-3]
o Elastic stockings  to prevent post-thrombotic Sx
 o Vena cava filter  to prevent PE, not treat DVT

Complications

• Pulmonary embolism  potentially fatal acute complication, but can be chronic as well
o Sx  dyspnoea | ↑HR | pleuritic chest pain | cough +/- blood | ↓sats
o Dx  2-level PE Well’s Score
o Ix  pulmonary CTA | VQ scan
o Mx  Resus | heparin and/or warfarin
• Post-thrombotic Sx  late complication of DVT
o Sx  pain | oedema | heaviness | ↑pigmentation | ulcers

Upper limb DVTs  1o/2o subclavian-axillary vein [usually due to venous thoracic outlet Sx - TOS]

Extracranial cerebrovascular disease [p. 308]

Refer to neurosurgery things for more info

Pathology  atherosclerosis of carotid bifurcation | FMD | dissection | aneurysm | other

Clinical [often asymptomatic]

• Sx  Hx of stroke/TIAs | neurological fallout

• Ex  bruit (distinguish from radiating murmur)
• Ix  CVS (ECG, echo etc) | baseline bloods | vascular imaging | duplex doppler
• Recurrent stroke risk score (determines who needs a doppler)  ABCD2 score
RISK of CVA after 2/7:

• 0-3  1%
• 4-5  4.1%
• 6-7  8.1%
Management

• Optimise medical Rx  RFs

• Surgery  carotid endarterectomy (CEA) | endovascular (stent | angioplasty)

Vertebrobasilar insufficiency  supplies the cerebellum & posterior fossa

• Sx  cerebellar Sx | visual disturbances

• Ix & Mx similar to carotid pathology

Lower limb claudication [p. 315]

Refer to PAD chapter

Lower limb venous disease [p. 322]

RFs  Age | pregnancy | FHX | obesity | prolonged standing

Causes of venous insufficiency & HPT

• Reflux [90%]  superficial vs Deep (1o valvular regurg | post-DVT)

• Obstruction [10%]  DVT | external obstruction

Clinical

• Hx  prev DVT | Sx* | reason for presenting (eg cosmetic > Sx)
o Sx  often non specific w/ poor correlation to varicosities
 Aching | throbbing | itching | fatigue | heaviness | Sx of venous HPT
• Ex  pulses | morphology of lesion | veins involved (eg saphenous vv)
• Ix  Duplex doppler (C4-6 disease | suspected DVT) | CT | Venography

Management

• Compression  class I-III based on severity [CI w/ arterial insufficiency]

• Sclerotherapy  mainly for cosmetic Rx [telangiectasia & reticular vv]
 • Surgery  disconnection & ligation of varicose vv

Complications

• Of varicosities
o Thrombophlebitis  thrombosis + infection [RX symptomatic]
o Bleeding  bleeding usually easily controlled
• Venous HPT
o ulceration
o Other  oedema | skin ↑pigmentation | eczema

Mesenteric ischaemia [p. 328]

Aetiology

• Arterial embolism  usually cardiac [AF | mural thrombus after MI]

• Arterial thrombosis  atherosclerotic disease [SMA | coeliac trunk]
• Venous thrombosis  similar presentation to AMI but more insidious [Rx systemic anticoag]
• Non-occlusive mesenteric ischaemia (NOMI)  patent vessels but ↓perfusion [eg shock]
• Other  aortic dissection | aneurysmal disease | vasculitidies

Progression of disease (absolute ischaemia)

• 15min  villi changes

• 3hrs  mucosal sloughing
• 6hrs  transmural necrosis

Clinical

• Sx  sudden & severe central pain out of proportion w/ Ex

o Associations  N/V | diarrhoea +/- blood | Hx of potential cause eg AF
• Ex  Acutely ill | unstable | abdo distension | peritonitis (LATE Sx)
• Investigations
o Bloods (variable)  ↑WCC | ↑CRP | ↑amylase | metabolic acidosis w/ ↑lactate
o AXR  dilated, gas-filled loops of bowel | free air if perf
o CTA  filling defect in vessels | Sx of ischaemia & infarction

Management

• General  RESUS | IV Heparin

• Surgery  exploration laparotomy [remove necrotic bowel | treat occlusion etc]

Chronic mesenteric ischaemia

• Atherosclerotic disease  ”mesenteric angina” [post prandial]

• Sx  LOW (fear of food) | N/V | wasting
• Ix (aim to exclude other Dx)  Duplex doppler | CTA | MRA | DSA
• Mx  open surgery vs endovascular techniques
 Peripheral arterial disease [p. 332]
RFs (same as all atherosclerosis)  smoking | metabolic Sx | Age | obesity

• Young PAD  Look for discernible cause

o Precocious (<40) or Accelerated (50-55) atherosclerosis
o Hypercoagulable state (anti-phospholipid Sx | malignancy)
o Vasculitidies (RA | SLE | scleroderma | Takayasu’s)
o Other  compartment Sx | popliteal entrapment Sx | HIV | fibromuscular dysplasia

Classification

• Segmental  aorto-iliac | femoro-popliteal | tibio-peroneal

• Clinical  asymptomatic | symptomatic | complicated
• Severity  Rutherford vs Fontaine

Symptoms

• Intermittent claudication  exertional pain in the calf muscles [relieved by rest]

o Other types of claudication  Venous | Spinal | atypical
• Erectile dysFx  can be an early Sx
o Leriche Sx  Aorto-iliac occlusion | erectile dysFx | buttock claudication
• Rest pain (nocturnal ischaemic foot pain)  forefoot pain when lying down

Examination

• Pulses  identify most proximal level of occlusion (segmental classification above)

o Pulse grading  0 absent | + Diminished | ++ N | +++ Bounding | ++++ Visible
• Trophic changes  Dry/thin skin | toe hair loss | nail atrophy | foot intrinsic muscle wasting
• Neuropathy  Numbness | paraesthesia | Reflexes | Power | foot deformities
• Exclude other Dx  venous insufficiency | sickle-cell | RA | aneurysms
• Special tests
o Buerger’s test  Supine: elevated leg = pale | dangling leg = Red
 o Goldflam test  Supine: elevated leg N, but then wriggling toes = pale

Critical limb ischaemia  Rest pain for >2wks PLUS tissue loss (ulcer/gangrene)

Investigations

• Bloods  Baseline bloods | glucose | HbA1C

• Duplex doppler & U/S  character of signal | ABI [0.9-1.3]
o Claudication 0.5-0.9 | rest pain <0.4 | CLI <0.2 | PAD w/ Ca vessels >1.3
• Other  MRA | DSA (therapeutic potential)

Management

• Lifestyle  ↓RFs | foot care | stop smoking (offer bupropion)

• Medical  ↓RFs (Mx chronic illnesses) | anti-platelet (Aspirin) | claudication drugs [??]
• Surgical
o Indications  very limiting disease | rest pain | tissue loss | life-threatening
o Open surgery [bypass graft] vs endovascular [balloons & stents mainly]
o Amputation

Reno-vascular HPT [p. 234]

Definition  vascular pathology leading to ↓ renal perfusion resulting in HPT

Causes of 2o HPT in general

• Endocrine  refer to endocrine chapter

• Renal parenchymal d/o’s  Nephroblastoma (Wilm’s tumour)
• Renovascular d/o’s  RAS | coarctation of the aorta | middle aortic Sx

Sx of 2o HPT

• Early (<30yo) or very late onset

• Severe (>160/100) or malignant (>180/120) HPT
• Refractory HPT | uncontrolled of several agents
• Severe Sx  retinopathy | flash pulmonary oedema | refractory angina
• Other clinical evidence of endocrine d/o’s

Investigations

• Endocrine screen  refer to endocrine chapter

• Duplex U/S of kidneys  Tumours | discrepant renal lengths (evidence of RAS)
• MAG 3 renogram  measures renal uptake & individual kidney GFRs
o Captopril renogram if inconclusive
• Vascular imaging [aortic & renal]  CTA | MRA | DSA

Goldblatt models  effect of RAS in different states

• Single RAS w/ 2 kidneys  +HPT but no ↑volume [compensatory diuresis]

• Bilateral RAS  +HPT and ↑volume

Renal artery stenosis (RAS)  causes HPT by activation of the RAAS

• Classification modalities
 o Anatomical  ostial | Parostial | truncal | accessory | segmental | mixed
o Pathological
 Atherosclerotic  below
 Non-atherosclerotic  Fibromuscular dysplasia | RA dissection | Takayasu’s |
aneurysm | trauma | NF | iatrogenic | etc etc

Atherosclerotic RAS

• Sx  severe HPT | Ischaemic nephropathy [rapidly ↓renal Fx]

• RFs  all RFs for atherosclerosis | associated diseases eg PAD or CAD
• Management
o Medical  similar approach to PAD | Add ACEi
o Surgical  Endovascular (stent) vs open (bypass) | Nephrectomy

Fibromuscular dysplasia (FMD)

• Degenerative condition of branchless vessels (eg renal aa)

• Types  medial (medial vs Perimedial vs medial hyperplasia) | Adventitial | intimal
• Dx  DSA [string of beads appearance in middle/distal RA]
• Rx  percutaneous balloon angioplasty/stent | Open revascularisation

Takayasu’s  Vasculitis of large vessels [aorta & branches]

• 90% affecting young women

• Sx  Fever | headache | join pain | muscle aches | carotidynia
• Ex  ↓/- Upper limb pulses (subclavian stenosis) | reno-vascular HPT
• Rx  medical (steroids) | surgical

Coarctation of the aorta

• Young patients
• Sx  headache | syncope | claudication
• Ex  radio-radial delay | radio-femoral delay | bruit over precordium
• Dx  ECG | CXR | angiography | echo
• Rx  medical (B-blockers | Ca channel blockers) | surgical

Upper limb ischaemia [p. 353]

Large vessel disease  very similar to PAD & ALI tbh so just read that

• Acute upper limb ischaemia

• Chronic upper limb ischaemia

Small vessel disease  commonest manifestation of ULI

• Aetiology
o Vasospasm  Raynaud’s phenomenon [Cold | stress]
o CT d/o’s  scleroderma | SLE | RA
o Buerger’s disease  inflammatory condition of middle/small aa
o Occupational injury  repetitive trauma [Ball sports | construction]
o Vasculitis  inflammation of wall of small muscular arteries
o Other  blood d/o’s | DM | renal failure etc
• Dx  mainly looking for a cause
 • Mx  avoid trigger (eg cold) | treat cause

Assessment of pt w/ ULI

• Hx  RFs (FHx | atherosclerosis) | Sx | underlying cause (occupational) etc etc

• Ex
o Ischaemic Sx  pallor | cyanosis | splinter haem | tissue loss
o Sx of underlying CTD  RA | scleroderma
o Pulses  Grading | most proximal occlusion | AF | Allan’s test
o L vs R blood pressures
o Supraclavicular fossa  subclavian a palpable above clavicle | bruit
• Ix  bloods (underlying cause) | CXR & hand XR | vascular imaging

Venous ulcers [p. 362]

Refer to venous chapter for more info

Definition of chronic venous ulcer [CEAP]  full-thickness skin defect | >30 days | does not heal

Aetiology  CVI | arterial | DM | vasculitis | trauma | lymphoedema | mixed

Classical features

• Location [Gaiter area]  medial | between mid-calf to ankle

• Appearance  irregular shape | shallow | red granulation or yellow exudate [NOT black]
• Surrounding  hyperpigmented (secondary to hyperaemia)
• Consistency  lipodermatosclerosis (chronic fibrosis of dermis  thickening)
o Eventually leads to “inverted Champaign bottle” appearance
• Other skin changes  venous eczema | pitting oedema | varicose veins